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Home My WebLink AboutItem C05 COUNTY of MONROE BOARD OF COUNTY COMMISSIONERS Mayor Michelle Lincoln,District 2 The Florida Keys Mayor Pro Tem David Rice,District 4 a e Craig Cates,District 1 e' Tames K. Scholl,District 3 � Holly Merrill Raschein,District 5 Regular Meeting April 15, 2026 Agenda Item Number: C5 26-0587 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 the Key Largo Volunteer Fire Department, Inc. for the operation of Advanced Life Support(ALS) and Basic Life Support (BLS) emergency medical non-transport services provided within the boundaries of the Key Largo Fire Rescue and Emergency Medical Services District for the period of May 16, 2026, through May 15, 2028. ITEM BACKGROUND: The Key Largo Volunteer Fire Department, Inc. (KLVFD) currently has a Class A COPCN for the period starting on May 16, 2024 and ending on May 15, 2026. In view of the foregoing, KLVFD has applied to renew this Class A COPCN which, if approved, will become effective starting on May 16, 2026 for a period of two years. This will enable KLVFD to continue performing ALS/BLS services within the legal boundaries of the special district known as the Key Largo Fire Rescue and Emergency Medical Services District. PREVIOUS RELEVANT BOCC ACTION: On 05/15/24, BOCC approved the application of Key Largo Volunteer Fire Department, Inc. for a new Class A COPCN for the period of 05/16/24 through 05/15/26. INSURANCE REQUIRED: Mandated by SOF. CONTRACT/AGREEMENT CHANGES: N/A. STAFF RECOMMENDATION: Approval. DOCUMENTATION: KLVFD COPCN Certificate_Legal Stamped KLVFD COPCN Application-Updated 3-19-2026_Redacted.pdf KLVFD Services Agreement with Key Largo Fire Rescue and Emergency Medical Services District 2024 Key Largo Fire Rescue and Emergency Medical Services District - Audit Report.pdf Key_Largo_Volunteer Fire_Department_Inc. COPCN_Expires_05.15.2028.pdf FINANCIAL IMPACT: Effective Date: 05/16/2026 Expiration Date: 05/15/2028 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. o a) Q) co a� Cd •N •N o 00 v� N a a� co 4t co 4-1 W O •N co COCO (J cd U cd Lo 'N Qq ." �;-, cd z 00 v pq p Lr) � N ON co o � � A 0) O ti � •N '� -� N L�'' � � U1 p O •U (l,4-5 o W A ° � `� � • o � U Cd cd W Q 0) r U O 4) ® N Ct co p 4) •N +, N Q U , cd � cd LJco N r co co a G� � 0 0 MONROE COUNTY, FLORIDA APPLICATION FOR CERTIFICATE OF PUBLIC CONVENIENCE AND NECESSITY (COPCN) CLASS A -EMERGENCY MEDICAL SERVICE (PRINT OR TYPE) INITIAL APPLICATION-$950.00 N RENEWAL APPLICATION-$475.00 'ALL APPLICATION FEES ARE NON-REFUNDABLE*** IF RENEWAL, PLEASE LIST NUMBER OF PREVIOUS CERTIFICATE: # al�n�nnnnf null ....................................... ..................... Part I: General Information KEY LARGO VOLUNTEER FIRE 1 DEPARTMENT IINC. LEGAL NAME OF SERVICE. 0 BUSINESS MAILING ADDRESS, I EAST DRIVE KEY LARGO,,FL,,33037 - 305-451-2700 305-451-2700 BUSINESS PHONE NUMBER. EMERGENCY PHONE NUMBER. -. HR@Keylargofire.org EMAIL ADDRESS (To be used for all correspondence.) 501 c3 NON-PROFIT 2 CORP. TYPE OF OWNERSHIP(Ii.e. .Sole Proprietor, Partnership,Corporation, ® DATE OF INCORPORATION OR FORMATION OF THE BUSINESS ASSOCIATION, 0512712013 NOTE.- NO 911 EMERGENCY SCENE RESPONSE WORK WITHIN MONROE COUNTY WILL BE PERMITTED FOR AGENCIES OTHER THAN MUNICIPALITIES AND SPECIAL TAXING DISTRICTS. IS THE ENTITY A MUNICIPALITY? No 4. IS THE ENTITY A SPECIAL TAXING DISTRICTi No ........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................... 3. LIST ALL OWNERS,OFFICERS,DIRECTORS,AND SHAREHOLDERS(Use separate sheet,if necessary),- NAME AGE ADDRESS TELEPHONE# EMAIL ADDDRESS POSITION/TITLE JASON MUMPER 44 1 East Didve Key Largio,FL 33037 305-451-2700 lboard.president@keylargofire,org President I East Ofive Key iLairgo,FL.33037 DONALD CONORD 74 305-451-2700 dconord24@g mail.coml Board Member TRAVIS WILSON 44 1 Easit Ddvia Key Largo,FL 33037 305-451-2700 twilson@keylargofire.org Vice President 4. LEVEL OF CARE TOBEPROVIDED, BLS only or ALS BLS or El ALS only IF ALS �E]TRANSPORT or NON TRANSPORT Elklr.Ambu.lance �5.. DESCRIBE THE GEOGRAPHIC AREAS OR ZONE(S)THATYOUR SERVICEDESIRES TO SERVE: (Use separate sheet if necessary) ILA D BST IE R LAN EISOUTH BAIR HAIR 130 R D IR 11V IE 1('195MM)IN 10 R T H TO MO R RI11-S ILAA E OR M 11 Allifil.-IDAIDE 0 IU N'rV IL 11 IN E('11.3M M AI LSO IF ROM C IR190 5 AIN ID US I IN 0 RTIH To THE 3 WAY STOP CRI0., Paige 11 'af-7 SUB-STATIONSwl LIST THE ADDRESS AND/OR DESCRIBE THE LOCATION OF YOUR BASE STATION LOCATED IN MONROE COUNTY,AND ALL BASE STATION 1 EAST DRIVE KEY LARGO, FL 33037 - STATION 24 - HEADQUARTERS '�,00f1A1P OID99io iiJ,IvJYi/ii� ,,,,,,,, ��..,.,., NAwnN(((RAfG(dtatatatatatatatatatau6fkGUUG�J4GJ4GJ4GJ4G�NlFmmiiiiwa( 'F(FrRlAll(A!A((fwlldwm�� mm �� SUB-STATION(S) �' �' + R ELF DRIVE KEY LARGO, FL 33 3 - STATION 2 ��^„^'�^^mnr" ^m,,. ,.,. .,,,.. s>eamla�nrrm»m»+»nimwm».r i,,,, ,,, ,,,,,,,,s,,,,,,,,,,,,,,;��„zr�rr:ar,,,,,,,,�drsr�crwrrscrwrrscrwrrscrwrrscrwrrscrwrrscrwrrr¢rarr�rcr�erwr�ruwraw�r�r�r[hr�✓c✓ ,,,�„�wsrraJurc�,!^ra�rrr�rrrer ��rt��ru�erwr„,.....,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,, rrwrr�i.,��ar�rru� .^...... M 7. DESCRIBE YOUR COMMUNICATION'f1 'TIJNICATIO SYSTEM(Attach copy of all FCC FIDE UE CIES CALL NUMBERS ##OF IFS OFFICE E24,T24,Al 24, E 5, L25, U 25, U'r V25 8. LIST THE NAMES AND ADDRESSES OF THREE(3) U.S. CITIZENS WHO WILL ACT AS REFERENCES FOR YOUR SERVICE: OWN NAME ADDRESS CAROL GRIECO 1632 MONMOUTH LANE KEY LARGO, FL 33037 THOMAS MORRISON 105030 OVERSEAS HIGHWAY KEY LARGO, FL 33037 ANTHONY ALLEN 101640 OVERSEAS HIGHWAY KEY LARGO, 9. ATTACH THE SCHEDULE OF RATES THAT YOUR SERVICE WILL CHARGE DURING THE COPCN PERIOD FOR ALL PROPOSED SERVICES. 10. PROVIDE VERIFICATION OF ADEQUATE INSURANCE COVERAGE DURING THE COPCN PERIOD. NOTE: Pursuant to Section 401.25, FL 33037 . certificate . required by DOH to 'issue an ALS/BLS license in the State of Florida. Currently, DOH has established MINIMUM insurance 11imialts for Bodaily Injury at $100,000/$300,00 and property damage at $50,000 for non-government owned . services. , 11. ATTACH A COPY OF YOUR SERVICE9S CONTRACT WITH A MEDICAL DIRECTOR FOR THE COPCN 12. ATTACH A COPY OF ALL STANDING ORDERS AS ISSUED BY YOUR MEDICAL DIRECTOR. 13. ATTACH A CHECK OR MONEY ORDER IN THE APPROPRIATE APPLICATION FEE AMOUNT,, MADE PAYABLE TO THE MONROE COUNTY BOARD OF COUNTY COMMISSIONERS. 14. ATTACH A COPY OF AN AUDIT PERFORMED BY AN INDEPENDENT CERTIFIED PUBLIC ACCOUNTANT OF THE ANNUAL OPERATING STATISTICS, ACCOUNTS, AND RECORDS OF THE SERVICE INVOLVED; SAID AUDIT IS TO BE DONE ANNUALLY TO COINCIDE WITH THE END OF THE BUSINESS YEAR OF THE medical malpractice/professiotial liability'insurance for all air medical crew members and medical director is required. BY COMPLETING AND SIGNING THIS APPLICATION, THE SERVICE, ACTING BY AND THROUGH ITS AUTHORIZED REPRESENTATIVE, HEREBY ACKNOWLEDGES, UNDERSTANDS, AND AGREES TO COMPLY WITH SECTIONS 11-151 THROUGH 11-178, MONROE COUNTY CODE, AS SAME MAY BE AMENDED FROM TIME TO TIME. A PENALTY FOR FAILURE TO COMPLY WITH THE LAW MAY INCLUDE, BUT IS NOT LIMITED TO,RECOVATION OF ANY COPCN PREVIOUSLY GRANTED. 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,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,m,,,,,,,,,,,,,,m,,,,�,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,, III"li'a ' ,(,i f PERSONNEL EMERGENCY MEDICAL TECHNICIANS NAME EMT CERTIFICAT10ii Firct-M*ddle Last SOCIAL SECURITY# CERTIFICATION# EXPIRATION DATE Andres Alvarez EMT583743 12/01/2026 Michael Baez EMT534281 12/01/2026 Gabriel Belgiovine EMT582324 12/01/2026 Jorge Braceras EMT593935 12/01/2026 ......................................................................... .�.�.�.�.�.�.�.�.�. Rodolfo Cabrera E MT58 1 94 2 12/01/2026 Frank Diaz EMT588402 12/01/2026 Carlos Ferreira EMT534281 12/01/2026 Chris Fischman EMT571728 12/01/2026 Nick Garcia EMT588112 12/01/2026 Joseph Hanna EMT537568 12/01/2026 Samuel Huttig EMT545732 12/01/2026 o�m Chris Martinez EMT574235 12/01/2026 ....... RodriguezSebastian Moreno EMT588027 12/01/2026 Christian Rico EMT586627 12/01/2026 Leonardo �. ... ..... .�.� �.�. ................................................................................................... *s Tucker EMT557593 12/01/2026 Curt Travis Wilson EMT582747 12/01/2026� ............. ................................................................................................................................,ate � �� ...................................................................................., ..... ................................................................................................................................................... ........................... ............................................... PERSONNEL DRIVERS m wwwwww ... .�w�w�w�wwwwwwwwwwwww vuU r.. nrmbn!mwnnram rinia,�c,hirmzvvrrmmromunnmmmmm99M,. ,.,.,.,.mm!.. av. ��ww�—nm�wo wwwwww �� „w.,� ,�m.,nm^^Rw mm mmrm....,.,.,.. ,,,mr;...........It, NAME TAT First, Maiddle,Last SOCIAL DATE OF DRIVER LICENSE# OF EXPIRATION SECURITV# BIRTH ISSUANCE DATE (ff�ffff� .� nnmo u f 7oq/2-0 2_A_ Andrew Bohl Florida 12/09/2029 Bradley Glvi n Florida w��www��w��ww•w��„ l rrda07/01/2028 Carlos Ferreira �� w�� Florida /10/2028 � � Christian i ��wo��'uw.mw.w��'w.www�.w�� Florida 12/08/2027 ��w�w�w�w�w�w�w�� w w Cww��w�� „.....................................w�w�.....� ww�,wwwwwwww�......................wwwwwwww�.w�ww�ww�w.................................................................................................................................................................� f ��„'w��w"w��w��www��www��www��wwrw�, • h ri tr i maM rr �� lord /15/e � wwwwww wwwwwww�w� 3 Enrique Abilleira Florida 08/19/2026 �w Gabriel w ■ Belgiovine �w w wow�ww�ww�ww�ww Florida �w Giuliano w w w w �wwwwwwwwwwwww wwwwwww Gonzalezi Florida � �w wwwwww Joseph Hanna Marcos Gonzales 4�wwwwwwwwwww w�w�w w Florid 1 wwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwww w w Michael Baez Florida04/01/2033 w•�� .,.mmu.I.—Iww...................................................................................Samuel j 6 * ��www �� Florida II 07/15/2033 Thoma Florida1 w w w wwww w mm��w ww w�www i �� Florida 01/08/2034 www�wmw wwwwww.w w�w�w�www w� www www .-wwwwww www . w� www I. w�w www„ www I.�i.�w•��iw,�imw'm��w.w'w w.w'w w.� iw•��i "ww�www��w��w•"w��w��www��www��w,�wwmww„w��www�� .ww��w wwwwwwwwwwwww��,�,� w ��w wwwwww wwwwww ��w� �.�n�., wwwwwwno ,� w, �---------oo�wwwww wwwwww��'itfilF(FlfilFlfilFlfildlitititititititititititititititillllllllllllllllllllllllitititilili!!!!llilililililllllllllli' Pursuant to Section' 2.525(2), Fla.Stat.,under penalties of perjury,I declare that I have read the foregoing list of named drivers,and I hereby certify that the above-named drivers, and any named on a separate sh et, meet all of the requirements of Sectlion 401.281, Fla.Stat.,and Rule 4J-1,01 ,F.A.C.,and that the facts stated herein are true. �i�mv��amimureoX�ixmr�Omm�.,u��im;�,,,,�a+mmrmn�^'w'wy�w� rnm^mmm�xn o.„�,�auu ,rrrrrr�rdrmrrrrrr�,rrsrdrrarRmr�, Chris i J" Jones - Captain w ,.,,,,. •,,,,, ,,,, ,,,,, ,,,,id lbbd„..:...,JI,WJ!/NId�1kW,iiwuWlk2'/h.G6!((i I✓Jame,wu(�iii6lRfR(��&tdkd4L((FG'�fG� PRINTED NAME&'TITLE 0 a"ti r 5 fir.) l? VEHICLES For Each Vehicle Operated Your Service,Please Provide the Followina In forma fi*oH_jKjE§gpMALe Sheet If Neces - ---------— .............. DOH Specify: LICENSE VEHICLE ALS or BLSI; VEHICLE TYPE MODEL YEAR MILEAGE CHASSIS# TAG PERMIT# Transport or NUMBER Non�Transjport E-ONE ENFORCER 2018 67711 4EN6AAA88H1001128 TE6997 0026266 NON-TRANSPORT ALS ------------ -------............-------------------------------- ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------.................................. E-ONE ' ENFORCER 2019 37477 4EN6AAA8XK1002031 TA3546 0026265 NON-TRANSPORT ALS ------------------------------------------- ---------------------------------L.-................. --------------------------------..............................................-....................................-....................................-.......................................... - - . . . ----------------------------------------------------------------------------------------------------------- ------------------------------- ----------------------- ---------------------------------------------------------------------------- ......................................... -------------------------------------------. ...,..............................--------------- -------------------------------------....................-------------------------------------------------- ------------------------------------------------I........................-........ --------------------------------------- .................................................................................------------------------ -----------------------------------------------------------------------------------------------------------..-..-...............-----------------------------------......................--------------- ------------------------------------------- .........................-...................... ------------------ ..............................--------------------------------------------------------------------------------------------------------------------------------------------------------------------- -.................ft........------------------------------------------------------.................. --------------------------------------......................................................I......................................-......................................------------------------------------------- --------- --------------------------------------- ................................. -------------------------------......................... `---------------------------------------------------I------------------------------------- ------------------------------------- ......................................... -...............-----------------------------__________________ -....................-.................................................................................................................... ........................................ -......................................I......-------------------------________-...............................-.........I---------------------------------__---------- -................................. .-.-..-.......................-......-..-.------------- Ill, THE UNDERSIGNED REPRESENTATIVE OF THE ABOVE-NAMED SERVICE, AM SOMEONE WHO POSSESSES THE REQUISITE LEGAL AUTHORITY TO SUBMIT THIS APPLICATION ON BEHALF OF THE SERVICE, AND I DO HEREBY ATTEST THAT THE SERVICE MEETS ALL OF THE REQUIREMENTS FOR OPERATION OF AN EMERGENCY MEDICAL SERVICES PROVIDER IN MONROE COUNTY AND THE STATE OF FLORIDA. I FURTHER ATTEST THAT ALL OF THE INFORMATION CONTAINED IN THIS APPLICATION,AND ALL INFORMATION PROVIDED IN ANY SEPARATE SHEETS RRE OF M ATTACHED HERETO,IS TRUE AND CO CT TO T E BEST 7 Y KNOWLEDGE. CHRIS"Clillill"JONES Printed Name CAPTAIN ADM�,,NISTRATION .....................................................................................................................................................................................................�lllllll'..............�lllllll,.......................... ................................................. .................................... STATE OF FLORIDA Title of authorized representative of company COUNTY OF ....................................................................... RUN20e; applicable ....................................................................................................................................... The foregoing document was acknowledged before me, by means of physical presence or online notarization, this l y of 2 0 2Jo, by 4 C M a s ............................................................ Person's Title] of [ENTITY], Florida (Not for ........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................... a profit / For profit) Corporation / LLC, if applicable. Who is personally known to me or has produced a Print tamp Commissioned Name of Notary: SIG NA' ,URE T W_ T"m T ryy� ...... Name of Notary.- State of Florida COOL GRECO Notlivy Public-sute of F*Ws Page '7 Cimmissfol 0 WN 731541 aill."I'vaill,04 INS, my com,uplivis Od is.2029 d@4 Ww*0400nall 010tarY MO. .".. u ...... .�x.� ovunmwxww.�.0 mw�wvzau�mxm�re� n . ........... urr�r �mowmm a�wmmovunmavm�i wmiovunmwwmmmmnn u w FOR USE BY MONROE COUNTY OFFICE STAFF 'The MonroeCounty Fire Rescue Department h, l perform a life safety inspection of each business location placed Can the application tion prior to the beginning of operations within Monroe County. 'The COPCN applicant is required to maintain a business location in Monroe County throughout the term the COPCN remains active. appli"cant/awardee is required to notify the days prior Administrator "' 1 , 1Administrator reduction su�ject to cancellationissued Notes of Inspection for each fac 1m ty 11 Location InspectionDate m Location Date Inspection occurred u Inspection [Add additional m m sheets for additional �^�^^_^^•••••ova....�•^^^�•n�^Wua—�s�^•^^^nrr;^m^.n^Rr^m�mnm�a�nmm�mrianz!amnrnrnr�a, .,.�,. ,rirmnm�m�nn,,,, ,. ,rcmrr�m�rmmmnrm�rr�nurmmmnnvmrmzrmm��n,��m..;�.�,na.�n�,a,,,> ..y��.�...�,�,�o��...a,.�..�.��...>.-��„ ,,,.�,.�..�.��,,;-�,- .,-,...�,-�-,.,-.�.--�;�„ ,,,,�,� �,;,,.,�,o�.,r n>o,>,o.�o� y r�o.�m>m>o,ao.�rrarimrwm�mrix v vrmmmomr ,..,rrernmm�.�ovwo,>o,�-,-.�; .��;,,,,...,.�.� RRg Serving the community since 1950 2 aw ,, KEY LARGO VOLUNTEER FIRE DEPARTEMENT 1►74,� 1 East Drive Phone : 305-451-2700 Key Largo, Florida, 33037 Fax : 305-451-2766 Info@kevlar�ofire.or g www.keylargofire.org February 17, 2026 Monroe County Board of County Commissioners 1100 Simonton Street Key West, Florida 33040 Monroe County Fire Rescue 490 63rd Street Ocean Marathon, Florida 33050 RE: FCC License Status and Radio Communications Operations To whom it may concern: This letter serves to formally clarify the radio communications status of the Key Largo Fire Department. The Key Largo Fire Department does not hold any Federal Communications Commission (FCC) licenses. Our agency operates exclusively within the Monroe County 911 communications system as the designated responding agency for fire rescue and emergency medical services in the Key Largo service area. All radio communications utilized by our personnel are conducted through infrastructure licensed to and maintained by Monroe County.This arrangement ensures seamless coordination with Monroe County 911 dispatch and interoperability with other emergency response agencies throughout the county. Should you require any additional information regarding our communications operations or designated response area, please do not hesitate to contact me. Sincerely, Chris "G"Jones Captain—Administration Key Largo Fire Department BOARD OF COUNTY COMMISSIONERS County of Monroe Mayor Michelle Lincoln,District 2 • The Florida Keys r Mayor Pro Tem David Rice,District 4 ` ' �� Craig Cates, District 1 ' James K. Scholl,District 3 Holly Merrill Raschein,District 5 Monroe County Fire Rescue 7280 Overseas Highway Marathon,FL 33050 Phone(305)289-6004 4 MEMORANDUM TO: Nicole Lyons FROM: Cara Johnson SUBJECT: Check for Deposit- COPCN DATE: January 26, 2026 Attached please find Check M dated January 12, 2026 in the amount of$475.00 per check to be deposited in revenue account 141-342000-RC 00345. This check has been issued for the renewal application of a Class A Certificate of Public Convenience for Key Largo Volunteer Fire Department, Inc. Thank you, Cara Johnson ...'.M�+ �io�..�..��ry m4Vm��,warwrtmN:NrrrYxNuuit�n1Va rvr,�:v�J!�reaw�fR�rtx4',�f�.r In'rvMr„�mw,x�,Im,,�1w,.R<drQNIf aUH�nvuX Y!fl.Nt��1NlloNrt ImWw W werMNrv.VH d„VN,N�1W�,.NIDN/�Na"u�y"�m"cM W�Ir.��I�vN1�,/w,N�V,db�rI ��l ':iiiiii„iirivu moo rmmv«ra ... ,,,.,.:,rrrn,un„i.i. r ry,. r ,fi r mR w.fI If Key# Larguo Volunteer Fire Department nt ..��. District Payroll Account wwwwmo Ank«Hm 1 East Drive 81-275/829 Key Largo,FL 33037 305 q 4 � a, PAY TO THE ORDER emA i' WO ClC44) O` S f, Ir 1, o 1 1� I V��N R �,�� n � MEAAC ►�" AUTHORIZED SIGNATURE I , f rea 2i Serving the community since 1950 aw KEY LARGO VOLUNTEER FIRE DEPARTEMENT 1 East Drive Phone : 305-451-2700 Key Largo, Florida, 33037 Fax : 305-451-2766 Info@keYlarRofire.orR www.keylargofire.org March 16, 2026 Monroe County Board of County Commissioners 1100 Simonton Street Key West, Florida 33040 Monroe County Fire Rescue 490 63rd Street Ocean Marathon, Florida 33050 RE: Non-Transport Fee's To whom it may concern: Key Largo Fire Department provides Advanced Life Support(ALS) services under a non-transport license issued by the Florida Department of Health.The Department does not transport patients and does not charge any fees for ALS medical services rendered. Sincerely, Chris "CJ"Jones Captain—Administration Key Largo Fire Department vii IrY 4+di49dV+w p i ppgg i NQ@ ilirlY�Irii'�i iYNi4jM il�i�'tlilq yll^ Il �IpY�lf��II�IiI�IiIII I i�IiIIIPiI�i��4>4r4f�Vl II I EER LAq% KPY LARIG,I II �� FIRE DEPAR7mwr Drive1 East Florida24 25 Key Largo, 305-451-2700 J M info@keylargofire.org 305-451-4699 fax March V, 202 Chris "CJ" Jones (captain of Administration) is duly authorized by Key Largo Volunteer Fire Department, Inc., by and through its President Jason Mumper, to execute contracts and other legal documents relating to any and all legal documents, agreements, contracts, instruments.. and other writings requiring execution or acknowledgment on behalf of the undersigned, on behalf of Ivey Largo 'Volunteer Fire Department, Inc. This authorization is valid as of March 9, 2026 and will remain in effect until revoked by currently seated President of Key Largo Volunteer Fire Department, Inc. on Mamp+er President STATE OF FLORIDA COUNTY OF F1 The foregoing instrument was acknowledged before me by means of V physical presence or V online notarization, this ,Q day of 21CIRG, President of Key Largo Volunteer Fire Department, by Inc., Florida (Not for profit/For profit) Corporation/ LLC. He/She is p rson /or ANIIII A. .2. n . has produced (type of identification) as 'Identification. AWI , A%,,$V*406,jrp% CAROLRECO SignatureofNotary Public .1 Notary Public-State of Florida V Colsion#HN 731548 Bonded through WatWnal Notify # (Print Commissioned Public) Name of Notary 2026 FLORIDA NOT FOR PROFIT CORPORATION ANNUAL REPORT FILED DOCUMENT# N13000004121 Mar 12, 2026 EntityName: KEY LARGO VOLUNTEER FIRE DEPARTMENT, INC. Secretary of State 2640497371 CC Current Principal Place of Business: 1 EAST DR STATION 24 KEY LARGO, FL 33037 Current Mailing Address: 1 EAST DR STATION 24 KEY LARGO, FL 33037 US FEI Number: 46-2821808 Certificate of Status Desired: Yes Name and Address of Current Registered Agent: MUMPER,JASON 1 EAST DR. KEY LARGO, FL 33037 US The above named entity submits this statement for the purpose of changing its registered office or registered agent,or both,in the State of Florida. SIGNATURE: JASON MUMPER 03/12/2026 Electronic Signature of Registered Agent Date Officer/Director Detail : Title PRESIDENT Title VP Name MUMPER,JASON Name WILSON,TRAVIS Address 1 EAST DR Address 1 EAST DR City-State-Zip: KEY LARGO FL 33037 City-State-Zip: KEY LARGO FL 33037 Title DIRECTOR Name CONORD, DONALD Address 1 EAST DR City-State-Zip: KEY LARGO FL 33037 1 hereby certify that the information indicated on this report or supplemental report is true and accurate and that my electronic signature shall have the same legal effect as if made under oath;that I am an officer or director of the corporation or the receiver or trustee empowered to execute this report as required by Chapter 617,Florida Statutes;and that my name appears above,or on an attachment with all other like empowered. SIGNATURE:JASON MUMPER PRESIDENT 03/12/2026 Electronic Signature of Signing Officer/Director Detail Date AGREEMENT FOR MEDICAL DIRECTOR SERVICES This Agreement for Medical Director Services is made and entered into as of the date last written below, by and between the Key Largo Fire Rescue and Emergency Medical Services District ("DISTRICT"), and TGM Medical Corp., 105030 Overseas Highway, Key Largo, FL 33037("DOCTOR"),licensed to practice medicine in the State of Florida with a principle location of Monroe County. In exchange for good and valuable consideration, the receipt and sufficiency of which are hereby acknowledged, the parties hereto agree as follows: WITNESSETH: I. Provision of Service. DISTRICT provides emergency services in the Key Largo area through its DISTRICT charter under Florida Law. DOCTOR is a medical doctor licensed and insured to practice medicine in the State of Florida. DISTRICT desires to enter into this Agreement with DOCTOR to serve as Medical Director and provide medical supervision and control for the DISTRICT, Key Largo Volunteer Ambulance Corps, and Key Largo Volunteer Fire Department, in Key Largo Florida, and DOCTOR is willing to accept such engagement upon the terms set forth in this Agreement. 2. Designation and Duties as Medical Director. By execution hereof, DISTRICT hereby designates DOCTOR as the Medical Director for DISTRICT operations within DISTRICT'S jurisdiction. In that capacity, DOCTOR will be responsible to provide all necessary and appropriate medical authority and direction for the Medical Teams operating in the area. DOCTOR shall be responsible for all medical aspects of, and all medical decisions and directions relating to, Basic Life Support, Advanced Life Support, and immunizations. DOCTOR shall meet at least once each month with the DISTRICT and Page I of 11 appropriate Medical Team(s) personnel on site to review, among other things, patient records for appropriateness of transport, patient care, and other areas of quality improvement. DOCTOR shall carry out training pursuant to the Proposed Training Program attached hereto as Attachment "A." DOCTOR shall meet all standards of the Florida Department of Health and the Commission on the Accreditation of Medical Transport Systems (CAMTS) for a Medical Director. DOCTOR will also be responsible for compliance with federal, state and other governmental requirements pertaining to the operation and provision of the emergency medical care services. DOCTOR shall also serve as liaison between DISTRICT and the various health care facilities or other health care providers for whom DISTRICT provides service in the area covered by this Agreement. Such liaison shall include coordinating the medical operations of DISTRICT to comply with the by-laws, policies, rules and regulations applicable to any such health care facility or health care provider for whom DISTRICT is providing services. DOCTOR shall also assist in evaluating the technical medical aspects of DISTRICT medical personnel working for DISTRICT who may assist in providing emergency medical assistance. DOCTOR will carry out and put into effect its improvement plan entitled Commitment to Clinical Performance and attached hereto as Attachment 66B.95 3. a. Insurance Requ ireme nts. The Parties shall provide, during the term of this Agreement, the following minimum insurance coverage and provide appropriate certificates of insurance to the other Party: i. DISTRICT will provide all risk insurance, as provided herein. ii. DISTRICT has liability insurance and to the extent that its existing policy will allow it, will provide coverage to DOCTOR. Page 2 of 1 I ii. DISTRICT will provide liability insurance to DOCTOR acting within the scope of his duties to the extent that its present policy allows. iv. Both Parties agree to provide workers' compensation insurance for their employees as required by law. b. Communications EquiDment. DISTRICT will provide all necessary communication equipment, upon approval of written request(s)presented to DISTRICT for review; including but not limited to: cellular phone, two-way radio, or pager. 4. Indemnification. DISTRICT shall indemnify and hold DOCTOR and his employees and agents harmless from and against claims, damages, liabilities and expenses (including reasonable attorneys' fees and costs) (collectively, "Losses") arising directly from DISTRICT'S performance of emergency services to the extent such Losses arise out of negligent or intentional act of omission of DISTRICT or its officers, directors, employees or agents, except and to the extent such Losses directly result from DOCTOR's failure to perform his duties as outlined in this agreement. DOCTOR shall indemnify and hold DISTRICT and its officers, directors, employees and agents harmless from and against Losses arising directly from DOCTOR'S performance of services hereunder to the extent such Losses arise out of negligent or intentional acts or omissions of DOCTOR, except and to the extent such Losses directly result from DISTRICT'S failure to comply with DOCTOR'S directives hereunder. DISTRICT and DOCTOR shall promptly notify the other of any event or circumstance that may lead to a request for indemnification hereunder, provided that, no failure to provide such notice shall prevent either party from obtaining Page 3 of I I indemnification hereunder unless and only to extent that the indemnifying party was demonstrably prejudiced by such failure to provide notice. 5. Relationship of the Parties. The relationship between DISTRICT and DOCTOR will be that of contractor and independent contractor. Nothing in this Agreement is intended or shall be construed as creating any kind of partnership,joint venture, employer-employee relationship or any other agency relationship between DOCTOR and DISTRICT. The parties shall be solely responsible for the method and manner in which they or their respective employees carry out the duties imposed by this Agreement, and neither party shall exercise any control or direction over the methods by which the other party performs their respective functions hereunder, except as may otherwise be provided in this Agreement. DOCTOR specifically acknowledges that he is not an employee of DISTRICT. 6. Compensation for Medical Director Services. DISTRICT agrees to pay to DOCTOR the sum of$67,000 per year during the term of this Agreement. A cost of living adjustment of 4(four)percent as determined by the DISTRICT will be added to the annual fee each year at the beginning of the respective budget year. Payment shall be made biweekly. 7. Payment of Ex-penses. DISTRICT agrees to reimburse DOCTOR for DOCTOR's reasonable and necessary travel and business expenses in accordance with state and federal law, and further, pursuant to any DISTRICT travel policies. Any conflict between requirements set out by law and a DISTRICT travel policy shall result in the provisions created by law controlling resolution of the conflict. A copy of any DISTRICT travel policy, whenever created if not already in existence at the time of this Agreement, will be provided to DOCTOR. DOCTOR may also be reimbursed for expenditures made on behalf of the DISTRICT program, with the prior approval of the DISTRICT. Bills or invoices for Page 4 of I I fees or compensation under this Agreement shall be submitted in detail sufficient for a proper pre-audit and post-audit thereof 8. Tenn of.Ageement. This Agreement shall commence on S eptember 22, 2025, and shall continue for a period of three (3) years, and will automatically renew an additional three (3)years,unless terminated by either party as contained in this paragraph. This Agreement may be terminated by either party by giving ninety (90) days written notice to the other party, termination effective upon the other party's receipt of the notice of termination, said receipt of the notice being documented by a return receipt other than via electronic mail. DOCTOR shall be entitled to compensation through the effective date of termination ®f this Agreement, provided services continue to be provided through such date as contained herein. 9. Limitation of Liabil In no event, whether as a result of contract, tort, strict liability or otherwise, shall either Party be liable to the other for any punitive, special, indirect,, incidental or consequential damages, including without limitation to of profits, loss of use or loss of contract. 10. Severability. In the event that any provision of this Agreement is determined to be unlawful or contrary to public policy, such provision shall be severed herefrom and shall be deemed null and void, but shall in no way affect the remaining provisions outlined herein. 11. Cony fete Apareement. This Agreement, inclusive of at sets forth the complete understanding of the parties hereto and any modification of the terms hereof must be in a writing signed by both parties hereto. Page 5 of 11 12. Governing Law. ri ne terms of this Agreement shall be governed by and interpreted in accordance with the laws of the State of Florida, with venue agreeably set in Monroe County, Florida. 13. Contract Records Retention. DOCTOR agrees to comply with all state and federal regulations governing contracts with public entities, including but not limited to cooperation with public records requests as provided by law, and cooperation with comptrollers and auditors as provided by law. 14. Waiver.Any act or lack thereof that is determined to be a waiver by either party of a breach or failure to perform hereunder shall not constitute a waiver of any subsequent breach or failure to perfor m- . 15. Re-Dresentations and Warranties. DOCTOR represents and warrants to DISTRICT, upon execution and throughout the ten-n of this Agreement that: a. DOCTOR is not bound by any contract or arrangement which would preclude him from entering into, or from fully performing the services required under this Agreement; b. None of DOCTOR'S agents, employees or officers have ever had his or her professional license or certification in the State of Florida, or of any other jurisdiction, denied, suspended, revoked, terminated and/or voluntarily relinquished under threat of disciplinary action, or restricted in any way; C. DOCTOR has not been convicted of a public entity crime as provided in F.S. §287.133; and d. DOCTOR and DOCTOR'S agents, employees and officers have, and shall maintain throughout the term of this Agreement, all appropriate licenses, Page 6 of I I certifications and insurance coverage that are required in order for DOCTOR to perform the functions assigned to him in connection with the provisions of this Agreement. 16. Assianment. Neither DISTRICT nor DOCTOR may assign or transfer any interest in this Agreement without the prior written consent of both parties. Should an assignment occur upon mutual written consent, this Agreement shall inure to the benefit of and be binding upon the parties hereto and their respective heirs, representatives, successors and assigns. 17. Sovereijim Immunity. Nothing in this Agreement shall be construed so as to waive negate or otherwise affect the immunities, exemptions, and limitations of liability of DISTRICT provided under Florida law, including but not limited to Section 768.28,, Florida Statutes, and other applicable state laws. I . E-verify . Pursuant to Florida Statute § 448.095, DOCTOR shall be required to register with and use the United States Department of Homeland Security's E-Verify system to verify the work authorization status of all employees hired after January 1, 2021. If DOCTOR enters into any contract with a subcontractor, DOCTOR shall be required to obtain an affidavit from the subcontractor confirming that the subcontractor does not employ, contract with, or subcontract with any person who is not authorized-under federal law to be employed in the United States. DOCTOR shall be required to maintain a copy of said affidavit for the duration of the Contract Term and shall produce said, affidavit to the DISTRICT upon request. Notwithstanding any other provision herein, DISTRICT reserves the right to immediately to mate this Contract upon notice to DOCTOR that the DISTRICT has developed a good faith belief that DOCTOR has knowingly violated this section. Page 7 of I I 19. Public records® Pursuant to section 119.0701, Florida Statutes, for any tasks performed by DOCTOR on behalf of the District, DOCTOR shall: (a) keep and maintain all public records, as that term is defined in chapter 119,Florida.Statutes("Public Records"),required by the District to perform the work contemplated by this Agreement; (b)upon request from the District's custodian of public records, provide the District with a copy of the requested Public Records or allow the Public Records to be inspected or copied within a reasonable time at a cost that does not exceed the costs provided in chapter 119, Florida Statutes, or as otherwise provided by law; (c) ensure that Public Records that are exempt or confidential and exempt from Public Records disclosure requirements are not disclosed except as authorized by law for the duration of the to of this Agreement and following completion or ten-nination of this Agreement, if DOCTOR does not transfer the records to the District in accordance with(d) below; and (d) upon completion or termination of this Agreement, (i) if the District, in its sole and absolute discretion, requests that all Public Records in possession of DOCTOR be transferred to the District, DOCTOR shall transfer, at no cost, to the District, all Public Records in possession of DOCTOR within thirty(30) days of such request or(ii) if no such request is made by the District, DOCTOR shall keep and maintain the Public Records required by the District to perform the work contemp lated by this ARreement. If DOCTOR transfers all Public Records to the District pursuant to (d)(i) above, DOCTOR shall destroy any duplicate Public Records that are exempt or confidential and exempt from Public Records disclosure requirements within thirty (30) days of transferring the Public Records to the District and provide the District with written confirmation.that such records have been destroyed within thirty (30) days of transferring the Public Records. If DOCTOR keeps and maintains Public Records pursuant to (d)(1i) above, DOCTOR shall meet all applicable requirements for retaining Public Records. All Page ofll Public Records stored electronically must be provided to the District, upon request from the District's custodian of public records, in a format that is compatible with the information technology of the District. If DOCTOR does not comply with a Public Records request, or does not comply with a Public Records request within a reasonable amount of time, the District may pursue any and all remedies available in law or equity including, but not limited to, specific performance. IF THE DOCTOR HAS QUESTIONS REGARDING THE APPLICATION OF CHAPTER 119, FLORIDA STATUTES, TO THE DOCTOR'S DUTY TO PROVIDE PUBLIC RECORDS RELATING TO THIS CONTRACT, CONTACT THE CUSTODIAN OF PUBLIC RECORDS AT, Telephone number, 305-664-4675 0 E-mai'l address* K9L L_C0kfl,.ordia-1a",,con1 Mailing Address.* 81990 Overseas Highway, 3rd Floor, Islamorada, FL 33036 20. Notices. All notices required by this Agreement, unless otherwise provided herein, by either party to the other shall be in writing, delivered personally, by certified or registered mail, return receipt requested, or by Federal Express or Express Mail, and shall be deemed to have been duly given when delivered personally or when deposited in the United States mail,postage prepaid, addressed as follows-, DISTRICT: ----------- Key Largo Fire Rescue & Emergency Medical. Services District P.O. Box 371023 Key Largo, Florida 33037-1023 Attention: District Clerk DOCTOR: TGM Medical Corporation c/o Thomas Morrison, M.D. 105030 Overseas Highway Key Largo, FL 33037 Page 9 of I I WHEREOF,IN WITNESS the parties hereto have executed this agreement, as of the day . d year first written above. Key Lan 0 ue an ency TGM MedicalCorp. Medi Services ,..,. : : Yr—int- nthony Allen Chairman riot: Thomas Morrison, MD DateDated: Attest: Iistrie er . Dated: w Approved as to f sufficiency: u District Legal Counsel Print: Dated: 2 Z/z f t A N C x Yi 3 i> Page 10 of �r w Affidavit Regarding the Use of Coercion for Labor and Services Respondent Vendor Name: vendor ---------- endor FETN: Oak + 5- 444? Vendor's Authorized Representative Name and Title: Address: City: State,ZIP: Phone Number: Email Address: +1 Section 787.06(13), Florida Statutes requires all nongovernmental entities executing, renewin 9,, or extending a contract with a governmental entity to provide an affidavit signed by an officer or representative of the nongovernmental entity under penalty of perjury that the nongovernmental entity does not use coercion for labor or services as defined in that statute. The Key Largo Fire Rescue and Emergency Medical Services District is a governmental entity for purposes of this statute. As the person authorized to sign on behalf of Respondent, I certify that the company identified does not: * Use or threaten to use physical force against any person, * Restrain, isolate, or confine or threaten to restrain', isolate, or confine any person without lawful authority and against her or his will; * Use lending or other credit methods to establish a debt by any person when labor or services are pledged as a security for the debt, if the value of the labor or services as reasonably assessed is not applied toward the liquidation of the debt, the length and nature of the labor or services are not respectively limited a nd defined; Destroy, conceal, remove, confiscate, withhold, or possess any actual or purported passport, visa, or other immigration document, or any other actual or purported government identification document, of any person; * Cause or threaten to cause financial harm to any person; * Entice or lure any person by fraud or deceit; or *Provide a controlled substance as outlined in Schedule I or Schedule 11 of s. 893.03 to any person for the purpose of exploitation of that person. 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Ln rO 0 4--J Ln C)......... 4--J (J.III Cu (A �Ln CD Nil Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC aw AW4, y, Illiv, Key Largo Fire Department 0 M Emergency IVIedicai rreatment Protocols u IU „ „ Version: 2025-001 10 Nam �m u ,EAkC�III i i�sl III .... ....... .........."I'll' r� I III I III I g o. v Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71 AEC 7- ow P) 24 2,Q' KEY LARGO FIRE DEPARTMENT EMERGENCY MEDICAL SERVICES PROTOCOLS & PROCEDURES EFFECTIVE DATE: 06/11/2025 VERSION: 2025-001 MEDICAL DIRECTOR Dr. Thomas Morrison MD/DO License#: M E79946 W FIRE CHIEF Donald Bock W CONFIDENTIAL This document contains confidential medical protocols and procedures for the Key Largo Fire Department. These protocols are to be used only by authorized emergency medical personnel operating under the department's license and medical direction. W DOCUMENT ID: KLFD-PROTOCOLS-2025-001 Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC ,A 2 FTC, KEY LARGO FIRE DEPARTMENT MEDICAL PROTOCOLS APPROVAL WUlUIYIIIU/d/G/Ff4/N/U///4/U/N11UlUl4ll/!//U/U/Ff4/U/U//l4/U/NllUlUIYIIIU/d/G/Ff4/N/U///4/U/N11UlUl4ll/!//U/U/Ff4/U/U//l4/U/NllUlUIYIIIU/d/G/Ff4/N/U///4/U/N11UlUl4ll/!//U/U/Ff4/U/U//l4/U/NllUlUIYIIIU/d/G/Ff4/N/U///4/U/N11UlUl4ll/!//U/U/Ff4/U/U//l4/U/NllUlUIYIIIU/d/G/Ff4/N/U///4/U/N11UlUl4ll/!//U/U/Ff4/U/U//l4/U/NllUlUIYIIIU/d/G/Ff4/N/U///4/U/N11UlUl4ll/!//U/U/Ff4/U/U//l4/U/NllUlUIYIIIU/d/G/Ff4/N/U///4/U/N11UlUl4ll/!//U/U/Ff4/U/U//l4/U/NllUlUIYIIIU/d/G/Ff4/N/U///4/U/N11UlUl4ll/!//U/U/Ff4/U/U//l4/U/NllUlUIYIIIU/d/G/Ff4/N/U///4/U/N11UlUl4ll/!//U/U/Ff4/U/U//l4/U/NllUlUIYIIIU/d/G/Ff4/N/U///4/U/N11UlUl4ll/!//U/U/Ff4/U/U//l4/U/NllUlUIYIIIU/d/G/Ff4/N/U///4/U/N11UlUl4ll/!//U/U/Ff4/U/U//l4/U/NllUlUIYIIIU/d/G/Ff4/N/U///4/U/N11UlUl4ll/!//U/U/Ff4/U/U//l4/U/NllUlUIYIIIU/d/G/Ff4/N/U///4/U/N11UlUl4ll/!//U/U/Ff4/U/U//l4/U/NllUlUIYIIIU/d/G/Ff4/N/U///4/U/N11UlUl4ll/!//U/U/Ff4/U/U//l4/U/NllUlUIYIIIU/d/G/Ff4/N/U///4/U/N11UlUl4ll/!//U/U/Ff4/U/U//l4/U/NllUlUIYIIIUINIV. MEDICAL DIRECTOR APPROVAL I, Dr. Thomas Morrison , MD, in my capacity as Medical Director for the Key Largo Fire Department, have reviewed and approved the attached medical protocols. These protocols are authorized for use by all properly trained and certified Emergency Medical Technicians and Paramedics operating under the license and authority of the Key Largo Fire Department. These protocols shall remain in effect until such time as they are formally revised or rescinded by the Medical Director. WUlUIYIIIU/d/G/Ff4/N/U///4/U/N11UlUl4ll/!//U/U/Ff4/U/U//l4/U/NllUlUIYIIIU/d/G/Ff4/N/U///4/U/N11UlUl4ll/!//U/U/Ff4/U/U//l4/U/NllUlUIYIIIU/d/G/Ff4/N/U///4/U/N11UlUl4ll/!//U/U/Ff4/U/U//l4/U/NllUlUIYIIIU/d/G/Ff4/N/U///4/U/N11UlUl4ll/!//U/U/Ff4/U/U//l4/U/NllUlUIYIIIU/d/G/Ff4/N/U///4/U/N11UlUl4ll/!//U/U/Ff4/U/U//l4/U/NllUlUIYIIIU/d/G/Ff4/N/U///4/U/N11UlUl4ll/!//U/U/Ff4/U/U//l4/U/NllUlUIYIIIU/d/G/Ff4/N/U///4/U/N11UlUl4ll/!//U/U/Ff4/U/U//l4/U/NllUlUIYIIIU/d/G/Ff4/N/U///4/U/N11UlUl4ll/!//U/U/Ff4/U/U//l4/U/NllUlUIYIIIU/d/G/Ff4/N/U///4/U/N11UlUl4ll/!//U/U/Ff4/U/U//l4/U/NllUlUIYIIIU/d/G/Ff4/N/U///4/U/N11UlUl4ll/!//U/U/Ff4/U/U//l4/U/NllUlUIYIIIU/d/G/Ff4/N/U///4/U/N11UlUl4ll/!//U/U/Ff4/U/U//l4/U/NllUlUIYIIIU/d/G/Ff4/N/U///4/U/N11UlUl4ll/!//U/U/Ff4/U/U//l4/U/NllUlUIYIIIU/d/G/Ff4/N/U///4/U/N11UlUl4ll/!//U/U/Ff4/U/U//l4/U/NllUlUIYIIIU/d/G/Ff4/N/U///4/U/N11UlUl4ll/!//U/U/Ff4/U/U//l4/U/NllUlUIYIIIU/d/G/Ff4/N/U///4/U/N11UlUl4ll/!//U/U/Ff4/U/U//l4/U/NllUlUIYIIIUINIV. PROTOCOL INFORMATION Protocol Title/Number: KLFD-MED-PROC-2025-001 Version: 2025-001 Effective Date: 06/11/2025 Supersedes: 03/20/2024 WUIUIYl11U/d/G//Ip/p/U///p/p/N11UlUlPll/U/u/4/FIG/U/u/Fl4//iiN11U1V1Y111U/U/u/F14/U/u///4/U/N1fU1Vl4ll/4/U/u//l4lU///l4/�2111U1UIYl11U/d/G//Ip/p/U///p/p/N11UlUlPll/U/u/4/FIG/U/u/Fl4//iiN11U1V1Y111U/U/u/F14/U/u///4/U/N1fU1Vl4ll/4/U/u//l4lU///l4/�2111U1UIYl11U/d/G//Ip/p/U///p/p/N11UlUlPll/U/u/4/FIG/U/u/Fl4//iiN11U1V1Y111U/U/u/F14/U/u///4/U/N1fU1Vl4ll/4/U/u//l4lU///l4/�2111U1UIYl11U/d/G//Ip/p/U///p/p/N11UlUlPll/U/u/4/FIG/U/u/Fl4//iiN11U1V1Y111U/U/u/F14/U/u///4/U/N1fU1Vl4ll/4/U/u//l4lU///l4/�2111U1UIYl11U/d/G//Ip/p/U///p/p/N11UlUlPll/U/u/4/FIG/U/u/Fl4//iiN11U1V1Y111U/U/u/F14/U/u///4/U/N1fU1Vl4ll/4/U/u//l4lU///l4/�2111U1UIYl11U/d/G//Ip/p/U///p/p/N11UlUlPll/U/u/4/FIG/U/u/Fl4//iiN11U1V1Y111U/U/u/F14/U/u///4/U/N1fU1Vl4ll/4/U/u//l4lU///l4/�2111U1UIYl11U/d/G//Ip/p/U///p/p/N11UlUlPll/U/u/4/FIG/U/u/Fl4//iiN11U1V1Y111U/U/u/F14/U/u///4/U/N1fU1Vl4ll/4/U/u//l4lU///l4/�2111U1UIYl11U/d/G//Ip/p/U///p/p/N11UlUlPll/U/u/4/FIG/U/u/Fl4//iiN11U1V1Yl11UlUlli, AUTHORIZATION I hereby authorize the implementation and use of these medical protocols by the Key Largo Fire Department personnel under my medical direction. Signed by: Medical Director Signature: 1- y* Aum'sbvu 3DE708ED44BNBA... Date: 6/16/2025 License Number: ME79946 Florida Medical License Expiration: 01/31/2026 WUIUIYl11U/d/G//Ip/p/U///G/p/N11U1GlPll/U/G/4/FIG/U/u/Fl4//iiN11U1G1G111U/G/u/FIG/U/u///4/U/N1fU1Gl4ll/4/G/u//l4lU///l4/�2111U1UIYl11U/d/G//Ip/p/U///G/p/N11U1GlPll/U/G/4/FIG/U/u/Fl4//iiN11U1G1G111U/G/u/FIG/U/u///4/U/N1fU1Gl4ll/4/G/u//l4lU///l4/�2111U1UIYl11U/d/G//Ip/p/U///G/p/N11U1GlPll/U/G/4/FIG/U/u/Fl4//iiN11U1G1G111U/G/u/FIG/U/u///4/U/N1fU1Gl4ll/4/G/u//l4lU///l4/�2111U1UIYl11U/d/G//Ip/p/U///G/p/N11U1GlPll/U/G/4/FIG/U/u/Fl4//iiN11U1G1G111U/G/u/FIG/U/u///4/U/N1fU1Gl4ll/4/G/u//l4lU///l4/�2111U1UIYl11U/d/G//Ip/p/U///G/p/N11U1GlPll/U/G/4/FIG/U/u/Fl4//iiN11U1G1G111U/G/u/FIG/U/u///4/U/N1fU1Gl4ll/4/G/u//l4lU///l4/�2111U1UIYl11U/d/G//Ip/p/U///G/p/N11U1GlPll/U/G/4/FIG/U/u/Fl4//iiN11U1G1G111U/G/u/FIG/U/u///4/U/N1fU1Gl4ll/4/G/u//l4lU///l4/�2111U1UIYl11U/d/G//Ip/p/U///G/p/N11U1GlPll/U/G/4/FIG/U/u/Fl4//iiN11U1G1G111U/G/u/FIG/U/u///4/U/N1fU1Gl4ll/4/G/u//l4lU///l4/�2111U1UIYl11U/d/G//Ip/p/U///G/p/N11U1GlPll/U/G/4/FIG/U/u/Fl4//iiN11U1GlGlllUlGlli, Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71 AEC LAItor 24 2 5 DEPARTMENT ACKNOWLEDGMENT e--DocuSigned by: Fire Chief Signature: rD �--913066CME944E... Name (Printed): Donald Bock Date: 6/16/2025 PROTOCOL REVIEW HISTORY Review Date Reviewer Changes Made Next Review Date Initial 06/04/2025 Dr. Morrison M Epi SQ 1:1,000 removed for 01/01/2026 IL allergic reactions Epi IM 1:1,000 added for 06/04/2025 Dr. Morrison allergic reactions 01/01/2026 Initial Adensione 6mg removed in 06/04/2025 Dr. Morrison cardiac related emergencies 01/01/2026 NOTES: This document shall be maintained as part of the official medical protocols of the Key Largo Fire Department and shall be retained according to department policy and applicable regulations. DOCUMENT ID: KLFD-MED-PROc-.2025-001 W Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC Table of Contents Foreword------------------------------------------------------------------------------------------------------------------------1 I. General Procedural Protocols 2 A. Scene and Patient Assessment Protocol 2 ------------------------------------------------------------------ B. Airway Management-------------------------------------------------------------------------------------------------,3 C. Emergency Incident Rehabilitation -------------------------------------9 -------------------------------------- II. Altered Mental Status and Unconsciousness 14 --------------------------------------------------------- A. Unconscious person--------------------------------------------------------------------------------------------------,14 B. Seizure 17 C. Diabetic Emergencies------------------------------------------------------------------------------------------------.20 D. Confusion, Agitation--------------------------------------------------------------------------------------------------23 III. Acute Respiratory Distress--------------------------------------------------------------------------------------25 A. Asthma 25 B. COPD (Chronic Bronchitis and/or Emphysema)-------------------------------------------------------27 C. Hyperventilation-------------------------------------------------------------------------------------------------------,29 IV. Behavioral Emergencies------------------------------------------------------------------------------------------.31 V. Burns---------------------------------------------------------------------------------------------------------------------------33 VI. Cardiac Emergencies------------------------------------------------------------------------------------------------37 A. Chest Pain (Angina, Acute Coronary Syndrome) -----------------------------------------------------37 B. Ca rd iogen is Shock-----------------------------------------------------------------------------------------------------39 C. Congestive Heart Failure (Pulmonary Edema) ------------------40 --------------------------------------- D. Cardiac Arrest 42 E. Other Cardiac Arrhythmias---------------------------------------------------------------------------------------49 VII. Childbirth and Newborn Care 58 A. Uncomplicated Delivery---------------------------------------------------------------------------------------------58 B. Complicated Delivery-------------------------------------------------------------------------------------------------.60 Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC C. Newborn Care------------------------------------------------------------------------------------------------------------64 VIII. Environmental Emergencies---------------------------------------------------------------------------------67 A. Dehydration ---------------------------------------------------------------------------------------------------------------.67 B. Drowning— Near Drowning---------------------------------------------------------------------------------------68 C. Heat-related Illness (Hyperthermia)-------------------------------------------------------------------------70 D. Hypothermia --------------------------------------------------------------------------------------------------------------73 E. Diving-related Emergencies---------------------------------------------------------------------------------------76 F. Decompression Sickness (DCS) ----------------------------------------------------------------------------------76 G. Arterial Gas Emboli (AGE) -----------------------------------------------------------------------------------------78 H. Barotrauma of the Ear-----------------------------------------------------------------------------------------------79 I. Envenomation 81 J. Marine Bites and Stings----------------------------------------------------------------------------------------------84 IX. Trauma 8.9 ---------------------------------------------------------------------------------------------------------------------- A. Extremity wound hemorrhage----------------------------------------------------------------------------------89 B. Amputations---------------------------------------------------------------------------------------------------------------91 C. Multi-system Trauma-------------------------------------------------------------------------------------------------92 D. Chest and Abdominal Injuries-----------------------------------------------------------------------------------95 E. Spinal Cord Injuries----------------------------------------------------------------------------------------------------97 F. Selective Spinal Immobilization ---------------------------------------------------------------------------------98 G. Electrical Burns and Lightning Injuries--- --------------------------------99 ---------------------------------- H. Orthopedic Bone and Joint Injuries--------------------------------------------------------------------------101 I. Head, Neck and Facial Injuries------------------------------------- ---------------------------------------------,103 X. Other Medical Emergencies-------------------------------------------------------------------------------------107 A. Allergic Reaction--------------------------------------------------------------------------------------------------------107 B. Hypertensive Crisis----------------------------------------------------------------------------------------------------.109 C. Epistaxis----------------------------------------------------------------------------------------------------------------------111 Docusign Envelope ID:D9C28060-04D5-4D4C-A898-A72C90C71AEC D. Nausea/Vomiting-------------------------------------------------------------------------------------------------------112 E. GI Bleeding------------------------------------------------------------------------------------------------------------------113 F. Abdominal Pain 115 G. Poisoning/Overdose--------------------------------------------------------------------------------------------------117 H. Stroke, TIA------------------------------------------------------------------------------------------------------------------119 I. Shock 120 ---------------------------------------------------------------------------------------------------------------------------- XI. Special Medical/Legal Protocols-----------------------------------------------------------------------------124 A. Documentation Requirements----------------------------------------------------------------------------------124 B. Abuse/Neglect------------------------------------------------------------------------------------------------------------125 C. Withholding or Terminating Resuscitation (Non-trauma).......................................127 D. Withholding or Terminating Resuscitation (Trauma) ...............................................128 E. Do Not Resuscitate (DNR)------------------------------------------------------------------------------------------129 F. Refusal of Care or Transport--------------------------------------------------------------------------------------130 XII. Specialty Skills---------------------------------------------------------------------------------------------------------132 A. 10 Procedures 132 B. i-Gel Device Procedure 134 ---------------------------------------------------------------------------------------------- C. Intranasal Administration Technique (Narcan) ........................................................137_137 D. Combat Application Tourniquet--------------------------------------------------------------------------------139 E. Full Spinal Immobilization Technique_______________________________________________________________________140 F. APGAR Scores 141 G. Rule of Nines 143 -------------------------------------------------------------------------------------------------------------- H. Adult Trauma Scorecard Methodology....................................................................144 I. Pediatric Trauma Scorecard Methodology________________________________________________________________145 J. RAD- 57 Pulse C Oximeter 146 K. Glasgow Coma Scales-------------------------------------------------------------------------------------------------149 L. Pediatric Vital Signs----------------------------------------------------------------------------------------------------150 Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC M. ETCO2 Waveforms----------------------------------------------------------------------------------------------------151 N. 12 Lead Quick Reference Guide 152 0. Synchronized Cardioversion -------------------------------------------------------------------------------------.153 P. Transcutaneous External Pacing--------------------------------------------------------------------------------153 Q. Cincinnati Prehospital Stroke Scale--------------------------------------------------------------------------154 XIII.Appendix A. Approved Drug List----------------------------------------------------------------------------------------------------1-21 B. Trauma Transport Protocols--------------------------------------------------------------------------------------1-14 Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC 1 1. General Procedural Protocols A. Scene Size-Up and Patient Assessment Protocol Scene Size-Up Conduct safety assessment of scene for hazards to EMS personnel. If the scene is unsafe and cannot be made safe, DO NOT enter. Patient Assessment BLS 1. Institute appropriate measures for prevention of infectious exposure as outlined in Protocol I.A. 2. If appropriate, begin triage and initiate Mass Casualty Incident (MCI). 3. Determine mechanisms of injury (MOI), nature of illness, and number of patients. 4. Perform primary assessment (airway, breathing, circulation). Then control serious bleeding and assess level of consciousness with "AVPU"—Alert and aware, Verbal stimuli, Painful stimuli, and Unresponsive—and the Glasgow Coma Scale (Refer to Protocol XII.L.). 5. Initiate BLS measures as outlined by the American Heart Association, including CPR, and use of automated electrical defibrillator (AED), for cardiac arrest. (Refer to Protocol VI.D.) 6. Be prepared to assist ventilation with a bag valve or mechanical ventilator 7. Administer oxygen at the appropriate flow rate via i-gel Supraglottic Airway if inserted by paramedic on scene, bag valve mask, non-rebreathing mask, or nasal cannula if indicated; 8. Apply pulse oximeter if available. 9. Correct other life-threatening problems if possible and according to protocol. 10. Monitor and repeat vital signs at 15-minute intervals for stable patients, and 5 minutes intervals for unstable patients. 11. Consider cervical immobilization if appropriate (see "Selective Spine Immobilization"). 12. Obtain full patient history in SAMPLE & OPQRST format. I I General Procedural Protocols KLFD BLS&ALS PROTOCOLS Docusign Envelope ID:D9C280B0-04D5-4D4C-A898-A72C90C71AEC 2 S—Signs/Symptoms O—Onset A—Allergies P—Provocation/Palliative M—Medications Q—Quality P—Past Med Hx/Past Surgical Hx R—Region/Radiation/Referral L— Last Oral Intake S—Severity E—Precipitating Events T—Timing 13. Perform focused exam. 14. Continue assessment employing (DCAPBTLS). a. D— Deformities b. C—Contusions c. A—Abrasions d. P— Punctures e. B— Burns f. T—Tenderness g. L— Laceration h. S—Swelling 15. Determine the patient's transport priority and whether paramedic care is required. Priority conditions include: a. Unable to obtain or maintain open airway. b. Clinical deterioration or death appears imminent. c. Altered mental status, includes not following commands. d. Difficulty breathing/inadequate ventilation and oxygenation. e. Hypoperfusion (Shock). f. Complicated childbirth. g. Chest pain with Systolic BP < 100 mm Hg. h. Uncontrolled bleeding. General Procedural Protocols KLFD BLS&ALS PROTOCOLS Docusign Envelope ID:D9C280B0-04D5-4D4C-A898-A72C90C71AEC 3 i. Severe pain. 16. Treat according to applicable protocols; transport, if capable. 17. Determine the need for ALS care, ground transport. 18. Consider the need for additional resources. 19. Document all findings and medical interventions on patient care report. 20. Continue supportive care and monitor vital signs until the patient is turned over to an ALS transport unit. ALS 1. Confirm completion of BLS steps 1-19. 2. Assess the need for advanced airway management. (Refer to Protocol I.B.). 3. Institute ALS measures for resuscitation as outlined in the most recent guidelines for Advanced Cardiac Life Support (ACES) by the American Heart Association. 4. Obtain 12-lead ECG and maintain cardiac monitoring, if appropriate. 5. Initiate fluid line of 0.9% Normal Saline IV/10 at KVO or saline lock or as required by local protocol. 6. Administer medications as required by local protocol. ALWAYS ask about allergies to medication before administering any drug to a patient. 7. Continue supportive care and monitor vital signs until the patient is turned over to a higher level of medical care. Consider the need for Aeromedical evacuation to the nearest Trauma Center. Pediatrics 1. Follow BLS guidelines, adjusting for patient age/size. 2. Adjust medication dosage, as appropriate, for patient age/size. (Refer to Protocol XIII.E.) B. Airway Management General Procedural Protocols KLFD BLS&ALS PROTOCOLS Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC 4 Review of Injury/Illness The obstruction or compromise of an airway can be caused by: (1) a variety of injuries and illnesses that result in narrowed air passages or excessive secretions or (2) the presence of solid foreign bodies that block air flow to the lungs. Signs and Symptoms * Wheezing * Stridor * Gasping- (when ineffective, sometimes called agonal respirations) * "Tripoding" or other positioning * Anxious * Skin color changes (cyanosis) * Nasal flaring, accessory muscle use, diminished or absent breath sounds * Difficulty swallowing—swollen tongue, and lips, drooling * Inability to breathe—weak respirations * Inability to speak * Abnormal respiratory rate * Rapid heart rate * Altered mental status Management BLS 1. Evaluate scene safety. DO NOT approach patient if scene cannot be rendered safe. 2. Institute appropriate Body Substance Isolation (BSI) measures/Universal Precautions, as outlined in Protocol I.A. 3. Perform patient assessment and initiate routine BLS care, as outlined in Protocol I.A., and as indicated by the patient's condition. 4. If choking, attempt Heimlich maneuver. I I General Procedural Protocols KLFD BLS&ALS PROTOCOLS Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC 5 5. Determine the need for ALS care and/or transport to hospital for further evaluation and treatment. 6. Assess adequacy of airway and ventilatory effort: a. Ability to speak. b. Color (note pallor or cyanosis) c. Vigor of cough/cry d. Rate and depth of respirations e. Unusual breath sounds on auscultation, including rales, wheezing, stridor f. Accessory muscle use and/or nasal flaring 7. For respiratory distress, apply pulse oximeter and administer 100% oxygen via non- rebreathing mask at high flow rate. 8. Assist ventilations with bag valve mask (BVM) as required. 9. Complete vital signs and determine likely cause of airway difficulty, such as: a. Potential aspiration of small objects or food b. Fever or cough c. Chest pain d. History of asthma, COPD, CHF e. In infants, a history of prematurity 10. Place patient in a position of comfort. 11. Continue supportive care and monitor vital signs until the patient is turned over to an ALS transport unit. ALS (Advanced Airways and Ventilation) 1. Confirm completion of BLS steps 1-11. These guidelines should be followed for all attempts at advanced airway management, or when assuming responsibility for an airway already established by another agency or provider. 2. The term "advanced airway" refers to devices such as the supraglottic i-Gel Airway. Securing an airway with these devices is a lifesaving measure that has the potential for devastating harm if not performed or maintained correctly. I I General Procedural Protocols KLFD BLS&ALS PROTOCOLS Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC 6 3. Advanced airways may be used ONLY by paramedics who have received training and been certified by local medical direction. Advanced airways should be attempted ONLY if BLS ventilatory support and oxygen are insufficient to sustain respirations. 4. i-Gel airway devices may be deployed as either preferred or "rescue" methods for airway control only after all providers have been trained on them according to the manufacturer's instructions and certified as "competent" in the technique by local medical direction. 5. Forceps (e.g., Magill) should be available during laryngoscopy of a choking patient so that a solid object obstructing the airway can be mechanically removed. If unable to remove an object obstructing airway using forceps, immediately consider surgical airway. 6. Mobile or portable suction devices should be available during placement of advanced airways to clear airway secretions present in the tube or oral pharynx. i-Gel Airways Indication 1. Unconscious patient who is not breathing without a gag reflex. 2. Apneic patient without a gag reflex 3. A difficult airway is anticipated: a. Small mouth which obstructs visualization b. Short neck c. Mallampati or Cormack- Lehane score > 3 d. Any obstruction that could impair visualization of the glottic opening. e. Impaired neck mobility f. Access to the airway is impeded (entrapment, helicopter cabin etc.) Contraindications 1. Responsive patients with an intact gag reflex 2. Esophageal tissue damage from trauma, chemical ingestion or thermal injury 3. Known esophageal disease or ingestion of caustic substances I I General Procedural Protocols KLFD BLS&ALS PROTOCOLS Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC 7 Procedure BLS A LS 1. Select appropriate size: a. #1 (Pink): Patient 2-5kg * No gastric Channel b. #1.5 (Blue): Patients 5-12kg NG Tube Size 10 Fr c. #2 (Grey): Patients 10-25kg NG Tube Size 10-12 Fr d. #2.5 (White): Patients 25-35kg NG Tube Size 10-12 Fr e. #3 (Yellow): Patients 30-60kg NG Tube Size 10-12 Fr f. #4 (Green): Patients 50-80kg NG Tube Size 12 Fr g. #5 (Orange): Patients 90+ kg NG Tube Size 12-14 Fr 2. Open and maintain the airway. Ventilate with 100% oxygen before attempting the i-Gel. 3. Open i-Gel package and take i-Gel out of the protective cradle. 4. Lubricate the back, sides, and front of the cuff by rubbing it on the smooth surface of the protective cradle containing the water- based lubricant. i" f 0" i%1 " / 0 r max° �11'A001 fr�/ rF F t;, 5. Remove dentures or removable plates from the mouth prior insertion. 6. Grasp the lubricated i-Gel firmly along the integral bite block. Position the device so that the i-Gel is facing towards the chin of the patient. 7. Maintain the head in a neutral position for trauma patients. For non-traumatic patients, the patient's head should be in the "sniffing" position with the head extended and neck flexed. The chin should be gently pressed down before proceeding to insert the i-Gel. 8. Introduce the leading soft tip into the mouth of the patient in a direction towards the hard palate. I I General Procedural Protocols KLFD BLS&ALS PROTOCOLS Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC 8 9. Glide the device downward and backward along the hard palate with continuous but gentle push until a definitive resistance is felt. 10. Attach the End-tidal CO2 device to the i-Gel and BVM and confirm placement. Location n of bite block lMA Tracheal opening 1 -sriir mmgQj�i�il�Oi�IVVI I''ir1 i H,o yiiwi^^^mr,7!vwUM Oesophageal opening Confirming Secure Airway 1. Confirmation of objective methods for tube placement (quantitative electronic capnography) must be used to continuously ensure that an advanced airway is positioned correctly. 2. The following steps are designed to assist the paramedic in verifying initial airway placement and maintaining the airway until the emergency department (ED) staff assumes patient care. a. The paramedic who initially establishes an advanced airway is responsible for maintaining it until the patient is transferred to transport paramedic. While mechanical ventilation may be delegated to another provider, the paramedic is responsible for all aspects of tube placement (lung sounds, capnography, and pulse oximetry). • The transporting paramedic should re-confirm tube placement before assuming responsibility for the patient. b. Quantitative ETCO2 confirmation and continuous monitoring are required for all field intubations (adult and pediatric and supraglottic devices). • Quantitative capnography should include continuous display of the ETCO2 waveform and numerical value (normal = 35-40 mm Hg). Documentation Documentation is a key component in protecting an EMT against claims of a misplaced airway device or inadequate respiratory care. The documentation should include initial and final assessment of airway placement, regardless of transportation decision (hospital transport or field termination). Documentation should also reflect a reassessment performed after each patient's movement and should be included in the patient care report. I I General Procedural Protocols KLFD BLS&ALS PROTOCOLS Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC 9 C. Emergency Incident Rehabilitation Review of Injury/Illness: This protocol describes the roles of Fire Department personnel in the process of rehabilitating firefighters. Rehab is designed to prevent, detect, and treat such conditions as heat exhaustion, hyperthermia, and dehydration among the workforce, and to remove operational personnel from duty if they cannot safely rotate back into emergency response efforts. 1. An Emergency Incident Rehabilitation (EIR) area: a. Should be designated by the incident commander (IC) or designated sector officer. It should be in a safe location, and upwind and uphill from the hot zone if the incident involves airborne or waterborne threats. b. The specific incident will dictate the type and configuration of the rehab area to be established. For example, if hazardous materials are involved, a decontamination corridor must separate the hot zone from the rehab area. 2. Responsibilities: a. Incident Commander: The incident commander has discretion as to how to implement formal emergency incident rehabilitation (EIR). The IC should consider the circumstances of each incident and make adequate provisions early in the incident for the rest and rehabilitation of all members operating at the scene. These provisions may include physical and mental rest; fluid and food replenishment; relief from extreme climatic conditions and other environmental parameters of the incident; and medical evaluation, treatment, and monitoring. b. Rehab Officer: An EMT B, EMT-P. should/may be assigned to the rehab area, and, if appropriate, may be designated by the IC as the Rehab Officer (RO). If available and practical, it is preferable that ALS-level personnel and equipment be present, as indicated in NFPA 1500. Rehab sector medical personnel and other assets should be dedicated to support of firefighters and other operational emergency responders and should be assigned no other responsibilities. c. Rehab Team: Should include sufficient personnel to perform rehab sector functions for the maximum number of personnel anticipated to be in the Rehab Area at any given time. A ratio of one Rehab Team member for every 10 personnel on scene is recommended. The team should include sufficient EMS personnel to perform medical monitoring tasks but may include non-EMS personnel also. d. Supervisors/Company Officers: All supervisors and company officers should maintain their awareness of the condition of all personnel operating within their span of control and ensure I I General Procedural Protocols KLFD BLS&ALS PROTOCOLS Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC 10 that adequate steps are taken to provide for each member's safety and health. The ICS structure should be used to request relief and/or reassignment of fatigued crews. e. Personnel: Any member who believes that fatigue or exposure to heat or cold is approaching a level that could affect his performance or the operation in which he/she is involved should advise his supervisor or company officer. Personnel should also remain aware of the health and safety of other members of the crew. 3. Establishing the Rehabilitation Sector: a. The IC should establish a Rehab Sector or Group when conditions indicate that rest and rehabilitation is needed for personnel operating at an incident scene or training exercise. This determination should be made based upon the anticipated duration of the operation, level of physical exertion, and environmental conditions, including temperature, humidity, and windchill. Guidelines to consider include: • Heat stress index > 90" F • Wind chill index< 100 F • Personnel have completed (or will complete) exertional work with second 30-minute SCBA cylinder, if firefighting involved • Personnel have used (or will use) SCBA or other protective breathing devices for > 45 minutes of physical exertion • It is recommended that an EMS vehicle, not otherwise involved in emergency operations at the scene, be positioned at the Rehab Area. If required, an additional ambulance should be requested to the scene for this purpose. Except under extreme circumstances, this ambulance should not be used for transport of civilian patients. b. The location of the Rehab Area will be designated by the IC and/or the RO, and should: • Be far enough from the scene to allow personnel to safely remove (and leave outside the area) SCBA and/or PPE, and remove personnel from the imminent dangers the scene presents, yet close enough to allow prompt re-entry completion • Provide adequate protection from environmental conditions and exhaust fumes • Be easily accessible by EMS units • Be large enough to accommodate several crew members. • For extreme heat conditions, have shaded areas, misting systems and/or fans, and an area to sit down I I General Procedural Protocols KLFD BLS&ALS PROTOCOLS Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC 11 • For extreme cold and/or wet conditions, have dry, protected, heated areas, and dry clothing • Be integrated with departmental system for personnel accountability, using a single entry and exit point when feasible. Sites that have been used include a nearby building, garage, or lobby; a school bus or large van; and an open, shaded area. 4. Rehab Operations: a. Resources: The RO should secure, through the IC or Logistics Officer, all necessary resources to properly supply the sector. These may include oral fluids, foods, medical supplies, paperwork, lighting, heaters, fans, a means of access to toilet facilities, and other assets as appropriate to the incident. b. Rotation of Personnel/Accountability: Working units will be assigned to the Rehab Sector by the IC or his designee (e.g., Operations Officer). When possible, the entire unit should be assigned to the Rehab Sector as a group. The crew designation, names of members, times of entry and exit, and appropriate medical information should be documented by the Rehab Officer or designee on a PCR form or similar document. Personnel rotated to the Rehab Sector should not leave until directed by the RO. If any member requires transport to a medical facility, the IC shall be notified immediately. c. Hydration: During exertional activity, in both hot and cold weather, personnel should consume at least one quart per hour of water, activity beverage, or combination. Carbonated and caffeinated beverages should be avoided. During a typical 20-minute rehab cycle, 12-32 ounces of fluids are recommended. d. Nutrition: Food should be provided whenever operations exceed 3 hours. Fatty and salty foods should be avoided. 5. Medical Evaluation: a. Ask members arriving at the Rehab Area if they have any symptoms of dehydration, heat/cold stress, physical exhaustion, cardiopulmonary abnormalities, or emotional/mental stress. b. Complete a medical evaluation, and appropriate treatment and/or transport, for all members who report such symptoms. c. A medical evaluation, with appropriate treatment and/or transport, should also be completed for any member meeting any of the following criteria: • The RO or Rehab Sector EMS staff observes evidence of one of the above conditions displayed by a member. • Another member, officer, or supervisor indicates he/she does not appear well. I I General Procedural Protocols KLFD BLS&ALS PROTOCOLS Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC 12 • The member had to leave an evolution for reasons of excessive fatigue or symptoms. d. Consider the possibility of toxic exposure in ill or injured responders at fi re, hazmat, and certain law enforcement operational scenes. e. Carbon monoxide levels can be determined non-invasively when pulse oximetry with this capability (CO-oximetry) is available. Management BLS 1. Evaluate scene safety. DO NOT approach patient if scene cannot be rendered safe. 2. Institute appropriate Body Substance Isolation (BSI) measures/Universal Precautions, as outlined in Protocol I.A. 3. Perform patient assessment and initiate routine BLS care, as outlined in Protocol I.A., and as indicated by the patient's condition. 4. Determine the need for ALS care and/or transport to hospital for further evaluation and treatment. 5. For personnel with signs or symptoms of dehydration or fatigue, check for toxic exposure, heat-related illness, chest pain, and/or change in mental status. These are medical emergencies; obtain ALS treatment if available and transport to a hospital emergency department. 6. For symptomatic personnel with no evidence of the conditions listed in step 5 and vital signs within the following ranges: a. Systolic BP > 90 and < 200 mm Hg b. Pulse rate > 50 and < 100 bpm c. Respirations > 12 and < 24 per minute d. Temperature < 100.5° F Then manage them in rehab as follows: a. Remove as much clothing as possible and minimize exposure to sun and wind. b. Limit as much energy exertion as possible. c. Oral hydration may be administered using a carbohydrate/electrolyte drink, diluted 1:4 with water. I I General Procedural Protocols KLFD BLS&ALS PROTOCOLS Docusign Envelope ID:D9C280B0-04D5-4D4C-A898-A72C90C71AEC 13 d. Place members in cool place and apply evaporative measures. Avoid shivering as this may raise the core temperature. (Apply cool—not cold—water-soaked towels to as much exposed skin as possible.) e. Administer oxygen and apply pulse oximetry. f. Continue supportive care and monitor vital signs until the patient is turned over to an ALS transport unit. ALS 1. Confirm the completion of BLS steps 1-6. 2. Initiate 0.9% Normal Saline via IV/10 at 10 ml/kg/hr., up to a maximum of 3 L if the patient is severely dehydrated. If the patient's condition does not improve or worsens at any time during the trial of rehydration, he/she should be transported to the hospital. Oral hydration may be administered using acarbohydrate/electrolyte drink, diluted 1:4 with water. 3. Continue to monitor vital signs, administer oxygen, and pulse oximetry. 4. Continue cold packs and maintain a cool environment. Avoid shivering, as this may raise body core temperature. 5. Obtain 12-lead ECG to check for myocardial ischemia and monitor cardiac rhythm, as necessary. 6. If elevated carbon monoxide levels are documented or suspected, ensure that the patient is on high flow oxygen via non-rebreathing mask (NRBM) and IV access is established. 7. If cyanide exposure is suspected advise on-line medical direction of the situation. 8. Continue supportive care and monitor vital signs until the patient is turned over to an ALS transport unit. General Procedural Protocols KLFD BLS&ALS PROTOCOLS Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC 14 Altered iiii t Review of Injury/Illness The term "altered mental status" (AMS) indicates a dysfunction of the central nervous system. Common causes of altered mental status in the field include seizures, shock, diabetic emergencies, drug or alcohol intoxication, medication overdose, stroke, infection, environmental exposure (heat or cold), and traumatic brain injuries. AMS may present anywhere on the spectrum from minimal impairment to unconsciousness. Signs and Symptoms * Slurring or other change in speech * Memory loss (inability to recall recent events) * Unsteady gait * Seizure activity * Impaired judgment * Inability to verbally respond or follow commands (unresponsiveness) * Unconsciousness A. Unconscious person Management BLS 1. Evaluate scene safety. DO NOT approach patient if scene cannot be rendered safe. 2. Institute appropriate Body Substance Isolation (BSI) measures/Universal Precautions, as outlined in Protocol I.A. 3. Perform patient assessment and initiate routine BLS care, as outlined in Protocol I.A., and as indicated by the patient's condition. 4. Determine the need for ALS care treatment. 5. Attempt to determine cause of altered mental status (e.g., overdose, intoxication, stroke, diabetes, trauma). 6. Check for hypoxia and provide supplemental oxygen via non-rebreathing mask at high concentration 7. Check blood sugar level with a glucometer, if available and part of the scope of practice: a. If hypoglycemic (blood sugar< 60 mg/dQ and conscious, administer glucose paste (10-15 gm) between cheek and teeth. May repeat x1 after 10 minutes, if no response. DO NOT give glucose 11 1 Altered Mental Status and Unconsciousness KLFD BLS&ALS PROTOCOLS Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC 15 paste to patients who are unconscious and/or do not have the capacity to swallow. Be cautious of vomiting/aspiration after administration and protect the airway. b. Recheck blood sugar after all interventions, every 30 minutes during transport, and with any change in mental status. 8. Check temperature, if a thermometer is available. 9. Continue supportive care and monitor vital signs until the patient is turned over to a higher level of medical care. ALS 1. Confirm completion of BLS steps 1-8. 2. Provide advanced airway support, if necessary. (Refer to Protocol I.B.). 3. Initiate 0.9% Normal Saline via IV/10 at KVO or saline lock. If hypotensive, administer a fluid bolus at 20 ml/kg of 0.9% Normal Saline via IV/10. 4. If hypoglycemic, administer D50W 50 ml (25 gm) slow IV push. a. Important to have free flowing IV access due to risk of vein sclerosis. 5. If unconscious, or with depressed respiratory function, consider narcotic overdose and administer naloxone 0.4-2.0 mg IV/10/IM every 2-3 minutes as needed, up to a maximum of 6 Mg. 6. Obtain 12-lead ECG and treat dysrhythmias, as appropriate. Continue monitoring cardiac rhythm. Pediatric BLS 1. Follow BLS guidelines. 2. Assess for possible closed head injury. 3. If hypoglycemic: Administer glucose paste (10-15 gm) between cheek and teeth, if awake and able to swallow. ALS 1. Follow BLS guidelines. 2. If hypoglycemic: 11 1 Altered Mental Status and Unconsciousness KLFD BLS&ALS PROTOCOLS Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC 16 a. Newborn-2 months: D1OW 2.0-4.0 ml/kg IV/10. b. 2 months-2 years: D25W 2.0-4.0 ml/kg IV/10. c. > 2 years: D5OW 1.0-2.0 m I/kg to max of 50 m I IV/10. 3. If overdose of narcotic is suspected, administer one dose of naloxone 0.1 mg/kg up to 2.0 mg IV/I M/I0. 4. If hypo perfusing, initiate 0.9% Normal Saline fluid therapy 20 ml/kg bolus IV/10, except in volume-sensitive children. Titrate to a systolic pressure of 100 mm Hg. a. Volume-sensitive children: Administer an initial fluid bolus of 10 ml/kg 0.9% Normal Saline via IV/10. If patient's condition does not improve, administer the second bolus of fluid at 10 ml/kg 0.9% Normal Saline via IV/10. Volume-sensitive children include neonates (0-28 days) and children with congenital heart disease, chronic lung disease, or chronic renal failure. b. If the patient's condition does not improve, and the lung sounds clear, administer the second bolus of fluid at 20 ml/kg 0.9% Normal Saline via IV/10. c. Administer third (and subsequent) fluid boluses at 10 ml/kg IV/10, while monitoring lung sounds. d. Consider additional fluid administration, up to a maximum of 3,000 ml, without consulting on-line medical directions. 5. Consider obtaining a blood sample, using a closed system. 6. If a patient has constricted pupils and respiratory depression, or is unresponsive, consider narcotic overdose. a. Administer naloxone 0.4-2.0 mg slow IV/IM/10/Intranasal (if delivery device is available). Titrate to adequate respiratory effort. b. If there is no improvement in respiratory function or level of consciousness, consider an additional dose of naloxone, every 2-3 minutes as needed, up to a maximum of 6 mg. 7. Continue supportive care and monitor vital signs until the patient is turned over to a higher level of medical care. 11 1 Altered Mental Status and Unconsciousness KLFD BLS&ALS PROTOCOLS Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC 17 B. Seizure Review of Injury/Illness: Seizures are caused by abnormal electrical bursts in the brain. Partial, or focal, seizures may cause uncontrolled movements of one or more limbs or the face, though patients typically remain conscious during focal seizure activity. Generalized seizures, sometimes referred to as "fits" or "convulsions," involve both sides of the brain, and therefore typically produce unconsciousness. Generalized seizures may involve tonic (rigid stretching of the body and limbs) and/or clonic (rhythmic jerking of the limbs and/or head) activity. Many, but not all, patients experience an "aura" of symptoms that warn them of a coming seizure, allowing them to sit or lie down to prevent injury. Others have no warning, and may be seriously injured by falls, blunt trauma, motor vehicle accidents, near drowning, or other incidents caused by their sudden loss of consciousness and body control. Seizures may be caused by head trauma, low blood sugar, infections, fevers, tumors, hypoxia, environmental exposure, toxic chemical exposure (e.g., a nerve agent, insecticide), or other metabolic abnormalities. They may also occur periodically in individuals without evidence of one of these causes—a condition called "epilepsy," which typically is controlled to some extent by medication. Febrile seizures in children do not predict underlying epilepsy and seldom last long enough to require treatment in the field but should always be evaluated by a physician when they occur. Epileptic seizures generally last from 30 seconds to a couple of minutes and may be followed by a postictal state of deep sleep or agitation lasting from a few minutes to several hours. Generalized seizures that last for 5 minutes, or more are considered "prolonged seizures." These may require treatment to be stopped, and the patient should be transported as expeditiously as possible. Continuous or recurrent generalized seizures without regaining consciousness over a period of 30 minutes is called "status epilepticus" or "status seizure." This is a true medical emergency, with the potential for permanent brain damage. Signs and Symptoms Focal seizures * Uncontrolled, rhythmic jerking of one or more limbs or facial muscles * Abnormal, but stereotyped behavior or sensations such as smells not related to the environment * Patients typically remain awake and may be variably responsive during focal seizures Generalized seizures 11 1 Altered Mental Status and Unconsciousness KLFD BLS&ALS PROTOCOLS Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC 18 * May be preceded by an aura * Patients are unconscious * Tonic/clonic muscle activity * Likely to have associated injuries Management BLS 1. Evaluate scene safety. DO NOT approach patient if scene cannot be rendered safe. 2. Institute appropriate Body Substance Isolation (BSI) measures/Universal Precautions, as outlined in Protocol I.A. 3. Perform patient assessment and initiate routine BLS care, as outlined in Protocol I.A., and as indicated by the patient's condition. 4. Determine the need for ALS care and/or transport to hospital for further evaluation and treatment. 5. For generalized (typically tonic-clonic) seizure, monitor airway: a. DO NOT attempt to restrain a patient that is actively seizing. b. DO NOT force any device into the patient's mouth, if the patient is still seizing. c. Position patient to maintain open airway; turn onto side if patient is at risk for aspirating excess secretions or is vomiting. 6. For prolonged seizures or status epilepticus (status seizure), request ALS support for medication, and/or transport to hospital ASAP. 7. When seizure activity has stopped: a. Identify and treat injuries. b. If the patient is a known diabetic, and patient is awake/able to control airway, glucose paste (10-15 gm) should be administered between the gum and cheek. Consider a single additional dose of glucose paste if condition does not improve after 10 minutes. 8. Continue supportive care and monitor vital signs until the patient is turned over to a higher level of medical care. 11 1 Altered Mental Status and Unconsciousness KLFD BLS&ALS PROTOCOLS Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC 19 ALS 1. Confirm completion of BLS steps 1-7. 2. Initiate 0.9% Normal Saline via IV/10 at KVO or saline lock. 3. Check blood sugar. 4. For prolonged seizure or status epilepticus, treat with the IV/10 benzodiazepine, according to local protocols: a. Midazolam: 5.0 mg IV/10, administer over 1-2 min b. Patients >_ 69 years: Reduce any of these medications by 50%. c. If IV is unavailable, check with on-line medical direction for alternative route and dosing. 5. Pregnant women require on-line medical consultation prior to the administration of any benzodiazepines. (Refer to Protocols VILA and VII.B.) 6. Continue supportive care and monitor vital signs until the patient is turned over to a higher level of medical care. Pediatric BLS 1. Follow BLS guidelines, adjusting for patient age/size. ALS 1. Follow BLS guidelines, adjusting for patient age/size. 2. Initiate 0.9% Normal Saline via IV/10 at KVO or saline lock. 3. Check blood sugar. 4. For prolonged seizure or status epilepticus, treat with the IV/10 benzodiazepine, according to local protocols: a. Midazolam: Administer 1.0-5.0 mg (0.05 mg/kg) IV/10/IM; repeat every 5 minutes, up to a maximum of 0.1 mg/kg, if needed. b. If medications are administered, monitor cardiac rhythm and pulse oximetry. 11 1 Altered Mental Status and Unconsciousness KLFD BLS&ALS PROTOCOLS Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC 20 C. Diabetic Emergencies Review of Illness/Injury Diabetes mellitus is a group of conditions in which the body does not produce enough or cannot properly use insulin. Insulin shock (hypoglycemia or low blood sugar) occurs when a patient has received more insulin than was needed. This causes low blood sugar levels, so metabolically active cells (e.g., brain) do not have enough energy to function normally. An altered mental status, including unconsciousness, may occur and is treated by administering glucose. Diabetic coma (hyperglycemia, diabetic ketoacidosis, and hyperosmolar coma) occurs when insulin is insufficient or not working. This results in excessive sugar circulating in the bloodstream, and other metabolic changes. Signs and Symptoms Insulin Shock * Rapid respirations and/or heartbeat * Dizziness * Sweating * Headache * Confusion * May progress to unresponsiveness Diabetic Coma * Drowsiness * Confusion * Thirst, dehydration * Change in level of consciousness * Sweet or fruity-smelling breath Management 1. Evaluate scene safety. DO NOT approach patient if scene cannot be rendered safe. 11 1 Altered Mental Status and Unconsciousness KLFD BLS&ALS PROTOCOLS Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC 21 2. Institute appropriate Body Substance Isolation (BSI) measures/Universal Precautions, as outlined in Protocol I.A. 3. Perform patient assessment and initiate routine BLS care, as outlined in Protocol I.A., and as indicated by the patient's condition. 4. Determine the need for ALS care and/or transport to hospital for further evaluation and treatment. 5. Determine blood sugar level using a glucometer, if available and usage permitted by local protocols. 6. If hypoglycemic (blood sugar< 60 mg/dL) and conscious, administer glucose paste (10-15 gm) between cheek and teeth. May repeat x1 after 10 minutes, if no response. DO NOT give glucose paste to patients who are unconscious and/or do not have the capacity to swallow. Be cautious of vomiting/aspiration after administration and protect the airway. 7. If a patient's condition improves, and he/she does not wish further evaluation, no medical direction is required, if all the following are present: a. This was an acute hypoglycemic event in a diabetic patient and he/she has returned to an alert and oriented mental status. b. Oral glucose was administered. c. The current glucose reading is >80 mg/dL. d. A responsible adult is present. e. Further caloric intake is assured. f. There are no clinical findings consistent with acute illness. 8. Continue supportive care and monitor vital signs until the patient is turned over to a higher level of medical care. Patients on oral hypoglycemic agents who have a hypoglycemic's episode must be transported for further monitoring. ALS 1. Confirm completion of BLS steps 1-8. 2. Initiate 0.9% Normal Saline via IV/10 at KVO or saline lock. 3. If hypoglycemic (blood sugar< 60 mg/d L): Administer Dextrose (D50W) 50 m I of 50% solution slow IV push. a. If unable to obtain IV/10 access, administer Glucagon (1.0 mg) IM. 11 1 Altered Mental Status and Unconsciousness KLFD BLS&ALS PROTOCOLS Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC 22 b. Patients on oral hypoglycemic agents who have a hypoglycemic's episode must be transported for further monitoring. 4. If hyperglycemic (blood sugar >400 mg/dL): Run IV 0.9% Normal Saline or open. a. Reassess bilateral lung sounds and pulse oximetry after each 250 ml of fluid. b. Do not exceed 2 L of IV fluid without consulting on-line medical direction. 5. Re-check glucometer reading every 30 minutes, or for altered mental status, during transport. 6. Refer to "Refusal of Further Evaluation" in this section, if patient does not wish further evaluation or transport. Pediatric BLS A LS 1. Follow BLS guidelines, adjusting for patient age/size. 2. Re-check glucometer reading: a. If hypoglycemic (blood sugar< 60 mg/dL): Administer glucose paste (10-15 gm) between cheek and teeth. May repeat x1 after 10 minutes, if no response. DO NOT give glucose paste to patients who are unconscious and/or do not have the capacity to swallow. Be cautious of vomiting/aspiration after administration and protect the airway. b. If hyperglycemic (blood sugar >400 mg/dL): Contact on-line medical direction. Refusal of Further Evaluation 1. If a patient's condition improves, and he/she does not wish further evaluation, no assistance from on-line medical direction is required if all the following are present: a. This was an acute hypoglycemic event in a diabetic patient and he/she has returned to an alert and oriented mental status. b. Oral glucose was administered. c. The current glucose reading is > 80 mg/dL. d. A responsible adult is present. e. Further caloric intake is assured. f. There are no clinical findings consistent with acute illness. g. The patient is not using prescribed oral hypoglycemic agents. 11 1 Altered Mental Status and Unconsciousness KLFD BLS&ALS PROTOCOLS Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC 23 D. Confusion, Agitation Review of Injury/Illness "Confusion" is a state in which a patient has difficulty both understanding his surroundings and ascertaining a response. "Agitation" suggests heightened anxiety and frequently includes combative behavior.There are many causes for acute onset of confusion and/or agitation. These include but are not limited to behavioral emergencies, metabolic emergencies including hypoxia and hypoglycemia, hypo/hyperthermia intoxication or over-medication, and head injury. All these conditions are covered elsewhere in these protocols, and all require transportation for full medical evaluation and treatment. Signs and Symptoms This protocol pertains to patients who are awake and alert, but present with an acute change from their normal mental status. It is important to establish and convey to the transport unit whether the patient is oriented (knows who and where he/she is and the day and date). This can only be established by asking these questions. Management BLS 1. Evaluate scene safety. DO NOT approach patient if scene cannot be rendered safe. 2. Institute appropriate Body Substance Isolation (BSI) measures/Universal Precautions, as outlined in Protocol I.A. 3. Perform patient assessment and initiate routine BLS care, as outlined in Protocol I.A., and as indicated by the patient's condition. 4. Determine the need for ALS care and/or transport to hospital for further evaluation and treatment. a. Restrain only if necessary for patient and staff safety, following local protocols for methods of restraint and documentation requirements. 5. Check for hypoxia and provide supplemental oxygen via a non-rebreathing mask at high concentration if present. 6. Assess patient for possible closed head injury and follow trauma protocol if appropriate. 7. Check blood sugar level. a. If hypoglycemic (blood sugar less than 60 mg/dQ, administer glucose paste. (Refer to Protocol II.C.) b. Recheck blood sugar after all interventions. 11 1 Altered Mental Status and Unconsciousness KLFD BLS&ALS PROTOCOLS Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC 24 8. Check for signs of dehydration and provide oral or IV rehydration. (Refer to Protocol VIII.A.) 9. Continue supportive care and monitor vital signs until the patient is turned over to a higher level of medical care. ALS 1. Confirm completion of BLS Steps 1-9 (above). 2. Initiate 0.9% Normal Saline via IV/10 at KVO or saline lock. If hypotensive, administer a fluid bolus at 20 ml/kg of 0.9% Normal Saline via IV/10. 3. If hypoglycemic, refer to Protocol II.C. 4. If a patient has constricted pupils and respiratory depression, or is unresponsive, consider narcotic overdose. a. Administer naloxone 0.4-2.0 mg slow IV/IM/10/Intranasal (if delivery device is available). Titrate to adequate respiratory effort. b. If there is no improvement in respiratory function or level of consciousness, consider an additional dose of naloxone, every 2-3 minutes as needed, up to a maximum of 6 mg. 5. Obtain 12-lead ECG and treat dysrhythmias, as appropriate. Continue monitoring cardiac rhythm. Pediatric BLS 1. Follow BLS guidelines, adjusting for patient age/size. 2. Assess for possible closed head injury. 3. If hypoglycemic: Administer glucose paste (10-15 gm) between cheek and gum, if awake and able to swallow. AILS 1. Follow BLS guidelines, adjusting for patient age/size 11 1 Altered Mental Status and Unconsciousness KLFD BLS&ALS PROTOCOLS Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC 25 111.. ii r ry Distiress, General Review A variety of conditions can cause acute difficulty breathing or inadequate oxygenation. Examples include asthma (including allergic reactions involving the airway or allergic bronchospasm), chronic obstructive pulmonary disease (including emphysema), congestive heart failure, respiratory tract infections, pulmonary emboli, and others. Any of these processes can lead to respiratory failure, or loss of the ability to inhale oxygen and exhale carbon dioxide. EMS care of patients in acute respiratory distress should determine what is causing the difficulty breathing and use the appropriate protocols to improve ventilation and oxygenation in the fi eld environment. A. Asthma Review of Injury/Illness Asthma is a chronic lung disease that causes inflammation and narrows the air passages (bronchospasm). It affects people of all ages but usually begins in childhood. In the fi eld, all causes of acute bronchospasm are treated essentially the same. Signs and Symptoms * Coughing * Wheezing * Difficulty exhaling * Shortness of breath * Chest tightness * Retractions and nasal flaring in pediatric patients Management BLS 1. Evaluate scene safety. DO NOT approach patient if scene cannot be rendered safe. 2. Institute appropriate Body Substance Isolation (BSI) measures/Universal Precautions, as outlined in Protocol I.A. 3. Perform patient assessment and initiate routine BLS care, as outlined in Protocol I.A., and as indicated by the patient's condition. III I Acute Respiratory Distress KLFD BLS&ALS PROTOCOLS Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC 26 4. Determine need for ALS care and/or transport to hospital for further evaluation 5. Provide supplemental oxygen. 6. Be prepared to assist ventilations with a bag valve mask (BVM), if necessary. 7. Allow patient to assume position of comfort. 8. If the patient has prescribed inhaler available, assist the patient to administer; repeat once in a 30-minute period, if difficulty breathing persists. 9. If a patient's asthma is historically precipitated by allergies, and he/she has an EpiPeno prescribed by a physician for that purpose, assistance may be offered for administration. 10. Continue supportive care and monitor vital signs until the patient is turned over to a higher level of medical care. ALS 1. Confirm the completion of BLS steps 1-9. 2. Administer Albuterol 2.5 mg in 3 ml 0.9% Normal Saline via nebulizer. Repeat nebulizer treatments, with Albuterol only, every 5 minutes as needed. 3. If ventilatory support is needed, continue nebulized Albuterol treatment via BVM or while assisting respirations through advanced airway. NOTE: Although sometimes needed, intubation further narrows the airway restriction in a severe asthma exacerbation, and this may worsen some cases. Aggressive use of bronchodilators is generally the most important therapy for severe asthma exacerbation. 4. Initiate 0.9% Normal Saline via IV/10 at KVO or saline lock. 5. Administer Epinephrine 1:1,000 solution (1mg/1ml) Intramuscular (IM) 0.3ml if there is no improvement with nebulizer treatment or if in extreme respiratory distress. III I Acute Respiratory Distress KLFD BLS&ALS PROTOCOLS Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC 27 Pediatric BLS 1. Follow BLS guidelines, adjusting to patient age/size. ALS 1. Follow BLS guidelines, adjusting to patient age/size. 2. Initiate 0.9% Normal Saline via IV/10 at KVO or saline lock. 3. Administer Albuterol adjusting for patient age/size, via nebulizer. Repeat nebulizer treatments, with Albuterol only, every 5 minutes as needed. 4. Administer Epinephrine 1:1,000 solution if there is no improvement with nebulizer treatment or if in extreme respiratory distress. Reference Handtevy guidelines for dosing. B. COPD (Chronic Bronchitis and/or Emphysema) Review of Injury/Illness Chronic obstructive pulmonary disease (COPD) comprises several problems that impede the flow of gases through the airways and gas exchange in the lungs. Most, but not all, cases result from smoking or long-time asthma. Acute exacerbations of COPD are frequently caused by bronchospasm, which may in turn be triggered by infections, changes in air quality, or other environmental factors. Signs and Symptoms * Shortness of breath * Wheezing, rhonchi, or sometimes severely decreased breath sounds * Chronic cough with large amounts of mucus * Frequent respiratory infections Management BLS 1. Evaluate scene safety. DO NOT approach patient if scene cannot be rendered safe. 2. Institute appropriate Body Substance Isolation (BSI) measures/Universal Precautions, as outlined in Protocol I.A. III Acute Respiratory Distress KLFD BLS&ALS PROTOCOLS Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC 28 3. Perform patient assessment and initiate routine BLS care, as outlined in Protocol I.A., and as indicated by the patient's condition. 4. Determine the need for ALS care and/or transport to hospital for further evaluation and treatment. 5. Provide supplemental oxygen. a. Administer oxygen at a high-flow rate to all patients in severe respiratory distress. b. COPD patients not in respiratory distress should be given oxygen to maintain adequate 02 saturation (e.g., > 90%). 6. Be prepared to assist ventilation, if necessary, with a bag valve mask. 7. Allow patient to assume position of comfort. 8. If the patient has a prescribed inhaler available, assist the patient to administer. 9. Continue supportive care and monitor vital signs until patient is turned over to an ALS transport unit. ALS 1. Confirm the completion of BLS steps 1-8. 2. Initiate 0.9% Normal Saline via IV/10 at KVO or saline lock. 3. Administer Albuterol adjusting for patient age/size, via nebulizer. Repeat nebulizer treatments, with Albuterol only, every 5 minutes as needed. 4. Provide advanced airway support, if necessary. (Refer to Protocol I.B.) 5. Obtain 12-lead ECG and treat dysrhythmias, as appropriate. Continue monitoring cardiac rhythm. 7. Monitor pulse oximetry. Pediatric BLS 1. Follow BLS guidelines, adjusting for patient age/size. ALS 1. Follow BLS guidelines, adjusting for patient age/size. 2. Provide advanced airway support, if necessary. (Refer to Protocol I.B.) III Acute Respiratory Distress KLFD BLS&ALS PROTOCOLS Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC 29 3. Epinephrine: Administer 0.01 mg/kg SQ, up to a maximum of 0.5 mg. 4. Monitor cardiac rhythm and pulse oximetry. C. Hyperventilation Review of Injury/Illness Hyperventilation is rapid, deep breathing. It may be seen in panic or anxiety attacks. Signs and Symptoms * Agitation * Weakness * Dizziness * Confusion * Numbness or parasthesia of fingers and around the mouth * Syncope Management 1. Evaluate scene safety. DO NOT approach patient if scene cannot be rendered safe. 2. Institute appropriate Body Substance Isolation (BSI) measures/Universal Precautions, as outlined in Protocol I.A. 3. Perform patient assessment and initiate routine BLS care, as outlined in Protocol I.A., and as indicated by the patient's condition. 4. Determine the need for ALS care and/or transport to hospital for further evaluation and treatment. 5. Allow patients to assume a position of comfort. 6. Administer oxygen via non-rebreathing mask, if needed. 7. Coach patient to slow breathing with a calm demeanor. 8. Continue supportive care and monitor vital signs until the patient is turned over to an ALS transport unit. ALS 1. Confirm the completion of BLS steps 1-8. III Acute Respiratory Distress KLFD BLS&ALS PROTOCOLS Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC 30 2. Initiate 0.9% Normal Saline via IV/10 at KVO or saline lock. 3. Confirm patient is not hypoxic with pulse oximetry, and coach to slow breathing. 4. Consider any of the following sedatives as a last resort: a. Midazolam: 2.0 mg IV/10, up to maximum of 4.0 mg; repeat once, if needed. b. If medications are administered, place them on cardiac monitor. Pediatric BLS A LS 1. Follow BLS guidelines, adjusting for patient age/size. 2. Confirm patient is not hypoxic with pulse oximetry, and coach to slow breathing. III Acute Respiratory Distress KLFD BLS&ALS PROTOCOLS Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC 31 h i ill I Einneirgeiricies Review of Injury/Illness Many factors can influence a person's behavior. A pattern of disruptive behavior can become an emergency at any time. Behavioral emergencies may be psychiatric or medical. Always search for underlying medical causes such as head trauma, hypoxia, drug overdose, postictal following a seizure, or hypoglycemia. Signs and Symptoms * Talking to imaginary person or object * Agitation * Threat of suicide or homicide * Inability to care for self * Threatening or violent behavior BLS 1. Evaluate scene safety. DO NOT approach patient if scene cannot be rendered safe. REQUEST LAW ENFORCEMENT. 2. Institute appropriate Body Substance Isolation (BSI) measures/Universal Precautions, as outlined in Protocol I.A. 3. Perform patient assessment and initiate routine BLS care, as outlined in Protocol I.A., and as indicated by the patient's condition. 4. Determine the need for ALS care and/or transport to hospital for further evaluation and treatment. 5. Maintain calm demeanor and respect the dignity of the patient. 6. Move slowly and deliberately. 7. Assess underlying medical issues. 8. Check blood sugar and monitor pulse oximetry, if possible. 9. If the patient is spitting, cover his/her face with a surgical mask or non-rebreathing mask (NRBM) with high flow oxygen. 10. Continue supportive care and monitor vital signs until the patient is turned over to an ALS transport unit. IV I Behavioral Emergencies KLFD BLS&ALS PROTOCOLS Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC 32 ALS 1. Confirm the completion of BLS steps 1-10. 2. Establish IV/10 of 0.9% Normal Saline via IV/10 at KVO or saline lock, if appropriate. 3. If patient remains combative, belligerent, or uncontrollable, consider any of the following sedatives as a last resort, according to local protocols: a. Midazolam: Administer 2.0 mg IV/10; repeat once, up to maximum of 4.0 mg. b. If medications are administered, place the patient on a cardiac monitor. Monitor cardiac rhythm and pulse oximetry. Pediatric BLS 1. Follow BLS guidelines, adjusting for patient age/size. 2. Attempt to locate parent or guardian, if not on scene. ALS 1. Follow BLS guidelines, adjusting for patient age/size. 2. Establish IV/10 of 0.9% Normal Saline via IV/10 at KVO or saline lock, if appropriate. 3. If patient remains combative, belligerent, or uncontrollable, consider any of the following sedatives as a last resort, according to local protocols: a. Midazolam: Administer 1.0-5.0 mg (0.05 mg/kg) IV/10/IM; repeat every 5 minutes, up to a maximum of 0.1 mg/kg, if needed. b. If medications are administered, place the patient on a cardiac monitor. Monitor cardiac rhythm and pulse oximetry. IV I Behavioral Emergencies KLFD BLS&ALS PROTOCOLS Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC 33 V. Burins, Review of Injury/Illness Aburn injury can result from direct or indirect contact with any heat source, including a flame, electrical, chemical, lightning, flammable liquid, flashes, radiation, or scalding liquids. Injuries can range from minor (1st and 2nd degree) to life-threatening (3rd and 4th degree burns). (Also refer to Protocol IX.G - Electrical Burns and Lightning Injuries.) Signs and Symptoms Inhalation (airway burns) * Difficulty breathing and/or swallowing * Hoarseness * Stridor * Wheezing * Soot/singed hairs * May or may not exhibit facial burns First degree (superficial thickness burn to skin) * Redness * Pain * Swelling Second degree (partial thickness burn to skin) * Redness * Pain * Swelling * Blistering Third degree (full thickness burn to skin) * May be white, leathery or charred appearance * Swelling * Underlying tissue is damaged * May or may not have pain V I Burns KLFD BLS&ALS PROTOCOLS Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC 34 Fourth degree (full thickness burn to skin; not universally used term) * Burns extend through skin and muscle, sometimes into bone. Management BLS 1. Evaluate scene safety. DO NOT approach patient if scene cannot be rendered safe. 2. Institute appropriate Body Substance Isolation (BSI) measures/Universal Precautions, as outlined in Protocol I.A. 3. Perform patient assessment and initiate routine BLS care, as outlined in Protocol I.A., and as indicated by the patient's condition. 4. Determine the need for ALS care and/or transport to hospital for further evaluation and treatment. 5. Provision of supplemental oxygen is crucial to patients with smoke inhalation due to possible carbon monoxide poisoning. Start with 100% 02 by non-rebreathing mask (NRBM) if patient has altered mental status. 6. Be prepared to assist ventilation with a bag-valve-mask, if necessary. 7. For singed nasal hair or burns around the mouth or nose, request ALS support and transport as quickly as possible, as airway burns, and edema can result in rapid loss of airway. 8. Evaluate burn surface area (BSA) using the "Rule of Nines" or estimate using the patient's palm as 1%. Measuring BSA does not predict severity of injury for electrical burns. 9. Determine if there is any associated traumatic injury. 10. Remove jewelry and any clothing that is not stuck to the wound. 11. Cool burned skin with room temperature saline, do not apply ice to burned tissues. 12. Cover burns with dry, sterile dressing if irrigation is discontinued. 13. Keep patient warm to protect against hypothermia. 14. For a chemical burn, wear protective equipment as needed, and consider fi eld decontaminant. Remove contaminated clothing and irrigate areas with copious amounts of water. If dry/powdered chemical, brush off prior to any irrigation. V I Burns KLFD BLS&ALS PROTOCOLS Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC 35 ALS 1. Confirm the completion of BLS steps 1-15. 2. Continue high flow 100% 02 by non-rebreathing mask (NRBM) if CO poisoning is possible or if it is documented by CO-oximetry. 3. Monitor airway as airway edema may progress rapidly to complete obstruction. Provide advanced airway support, if necessary. (Refer to Protocol I.B.) 4. Initiate 0.9% Normal Saline via IV/10 through unburned skin, if possible. If BSA> 20% second degree or higher burns, administer fluid bolus with 500 ml of 0.9% Normal Saline via IV/10. a. Check lung sounds after each 250 ml fluid bolus. b. If hypotensive, repeat fluid bolus, as needed. c. Use caution with IV fluids to avoid hypothermia and fluid overload. d. Calculate IV fluid resuscitation using Parkland formula. • Total IV fluid for first 24 hours =4 x% BSA x Weight (kg) • Deliver first half of IV fluids in the first 8 hours, second half in the following 16 hours. 5. Obtain 12-lead ECG and monitor cardiac rhythm. Pediatric BLS 1. Follow BLS guidelines, adjusting for patient age/size. 2. Adjust estimates of involved BSA for pediatric patients using the Lurd-Broaden chart for age- adjusted Rule of Nines. a. For patients < 1 year, head = 18% and each leg is 15%. b. Add 0.5%to each leg and subtract 1%from head for each year over age 1. 3. Suspect child abuse when injuries and/or story are inconsistent. Report to authorities, as required by state or local laws. 4. Consider Aeromedical evacuation to a Pediatric Trauma Center or Burn Center. V I Burns KLFD BLS&ALS PROTOCOLS Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC 36 ALS 1. Follow BLS guidelines, adjusting for patient age/size. 2. Adjust estimates of involved BSA for pediatric patients using the Lurd-Broaden chart for age- adjusted Rule of Nines. a. For patients < 1 year, head = 18% and each leg is 15%. b. Add 0.5%to each leg and subtract 1%from head for each year over age 1. 3. Initiate 0.9% Normal Saline IV/10 through unburned skin, if possible. If BSA > 20% second degree or higher burns, administer fluid bolus with 20 ml/kg of 0.9% Normal Saline via IV/10. a. Check lung sounds after each fluid bolus. b. If hypotensive, repeat fluid bolus 20 ml/kg, as needed. c. Use caution with IV fluids to avoid hypothermia and fluid overload. • Total IV fluid for first 24 hours =4 x% BSA x Weight (kg) • Deliver first half of IV fluids in the first 8 hours, second half in the following 16 hours. 4. Suspect child abuse when injuries and/or story are inconsistent. Report to authorities as required by state or local laws. 5. Consider the need for Aeromedical evacuation to the nearest Burn Center or Pediatric Trauma Center. V I Burns KLFD BLS&ALS PROTOCOLS Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC 37 I. Cardiac Emergencies A. Chest Pain (Angina,, Acute Coronary Syndrome) Review of Injury/Illness In addition to cardiac ischemia, chest pain may be caused by inflammation of the lungs or pleural linings, pneumothorax, pulmonary embolus, indigestion, gastric reflux, and other problems. It is sometimes difficult to distinguish cardiac chest pain from these other problems. "Acute coronary" syndrome (ACS) refers to a set of symptoms resulting from inadequate blood flow to the heart muscle. The blood supply for the myocardium is provided by the coronary arteries, and when one or more of the coronaries is narrowed or blocked, ACS results. ACS includes angina pectoris, or chest pain, indicating inadequate blood flow to the myocardium. Myocardial infarction (MI) occurs when the muscle has been deprived of blood and oxygen long enough for it to be permanently damaged. Electrocardiograms (ECG) of patients having acute MI may show elevation of the ST segment in leads corresponding to the part of the heart that is being damaged. This is called ST elevation, MI, or STEMI. NOTE: Many patients who are having acute MI do not show ST elevations. Signs and Symptoms * Chest pain/discomfort that may radiate to the left or right arm, shoulders,jaw, or back * Frequently described as pressure or a crushing pain * Shortness of breath, sweating, nausea, or vomiting * Diaphoresis * Women, elderly, and diabetic patients have a higher incidence of atypical presentations such as generalized weakness or fatigue, nausea, and epigastric pain Management 1. Evaluate scene safety. DO NOT approach patient if scene cannot be rendered safe. 2. Institute appropriate Body Substance Isolation (BSI) measures/Universal Precautions. as outlined in Protocol I.A. 3. Perform patient assessment and initiate routine BLS care, as outlined in Protocol I.A, and as indicated by the patient's condition. 4. Determine need for ALS care and/or transport to hospital for further evaluation and treatment VI I Cardiac Emergencies KLFD BLS&ALS PROTOCOLS Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC 38 5. Provide supplemental oxygen: a. 2.0-6.0 L/min via nasal cannula, if pulse oximetry is normal and the patient is not short of breath. b. 100% by non-rebreathing mask if 02 saturation is < 90% or if patient is subjectively short of breath. 6. Be prepared to assist ventilations with a bag valve mask (BVM), if necessary. 7. Allow patient to assume position of comfort. 8. If the patient has prescribed nitroglycerin, and there are no contraindications, assist the patient to administer nitroglycerin 0.4 mg sublingual (SQ; may repeat every 5 minutes up to a maximum of 3 doses, provided Systolic BP >_ 100 mm Hg and chest pain persists. a. Contraindications to first dose of SL nitroglycerin: • Use of erectile dysfunction medications in previous 24 hours • Systolic BP < 100 m m Hg 9. For chest pain consistent with ACS, administer aspirin 162-325 mg, after confirming the following: a. No history of ulcers or gastrointestinal bleeding b. No history of allergy or sensitivity to aspirin 10. Continue to assess pain level. 11. Assess and treat for hypotension or shock, if indicated. (Refer to Protocol X.I.) 12. Continue supportive care and monitor vital signs until the patient is turned over to an ALS transport unit. ALS 1. Confirm the completion of BLS steps 1-12. 2. Initiate 0.9% Normal Saline via IV/10 at KVO or saline lock. 3. Obtain a 12-lead ECG and monitor cardiac rhythm. 4. Administer aspirin (162-324 mg) orally, if patient is awake, able to swallow, and denies aspirin allergy. 5. If patient does not have a prescription or previous history of nitroglycerin use: VI I Cardiac Emergencies KLFD BLS&ALS PROTOCOLS Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC 39 a. Establish a 0.9% Normal Saline via IV/10 at KVO prior to administration. b. Administer nitroglycerin 0.4 mg sublingual (SQ; may repeat every 5 minutes up to a maximum of 3 doses, provided Systolic BP >_ 100 mm Hg and chest pain persists. c. If IV/10 or saline lock cannot be established, consult on-line medical direction before nitroglycerin use. 6. Withhold administration of nitroglycerin if the patient has an obvious inferior MI (> 1 mm ST segment elevation in at least 2 of the inferior leads 11, III, AVF) or with ECG evidence of a right ventricular infarct. 7. If Systolic BP < 90 mm Hg, place patient in supine position with legs elevated and administer 250 ml fluid bolus of 0.9% Normal Saline via IV/10. 8. Consider repeating ECG every 15 minutes, as indicated by changes in chest pain. 9. Monitor cardiac rhythm and treat any dysrhythmia according to current AHA/ACLS guidelines. B. Cardiogenic Shock Review of Injury/Illness Cardiogenic shock indicates failure of the heart's pump function. Like other forms of shock, it presents with low blood pressure and evidence of inadequate perfusion of the brain and other vital organs. It is caused by profound weakness of the left ventricular muscle, most often due to a large area of myocardial ischemia or infarct, or to a severe inflammatory process (myocarditis). In cardiogenic shock, the low blood pressure is due entirely to loss of pump function, not to hypovolemia. Therefore, patients are often in congestive heart failure with distended neck veins and pulmonary edema despite the hypotension. Other processes that impede cardiac pump function (e.g., tension pneumothorax, cardiac tamponade) may cause patient presentations similar to cardiogenic shock. Signs and Symptoms * Distended neck veins * Pulmonary edema (rales on auscultation) * Decreased heart sounds * Hypotension * Tachycardia * Electrocardiographic changes consistent with current or recent MI VI I Cardiac Emergencies KLFD BLS&ALS PROTOCOLS Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC 40 * Sudden deterioration in condition (respiratory failure, decreased mentation) Management 1. Evaluate scene safety. DO NOT approach patient if scene cannot be rendered safe. 2. Institute appropriate Body Substance Isolation (BSI) measures/Universal Precautions. as outlined in Protocol I.A. 3. Perform patient assessment and initiate routine BLS care, as outlined in Protocol I.A, and as indicated by the patient's condition. 4. Determine the need for ALS care and/or transport to hospital for further evaluation and treatment. 5. Provide supplemental oxygen (100% by non-rebreathing mask [NRBM]). 6. Be prepared to assist ventilations, if necessary, with a bag valve mask. 7. Continue supportive care and monitor vital signs until the patient is turned over to an ALS transport unit. ALS 1. Confirm the completion of BLS steps 1-6. 2. Initiate 0.9% Normal Saline via IV/10 at KVO or saline lock; titrate to achieve a Systolic BP >_ 100 mm Hg. 3. If Systolic BP < 90 mm Hg, administer 250 ml fluid bolus with 0.9% Normal Saline via IV/10, and re-assess both BP and lung sounds. If lung sounds are clear, repeat with a second 250 ml fluid bolus with 0.9% Normal Saline via IV/10. 4. Consider other causes of the patient's shock. 5. Obtain 12-lead ECG and monitor cardiac rhythm. 6. Provide advanced airway support, if necessary. (Refer to Protocol I.B.) C. Congestive Heart Failure (Pulmonary Edema) Review of Injury/Illness Congestive heart failure (CHF) occurs when the heart is not strong enough to pump the blood that returns to it via the venous system out to the rest of the body against the resistance produced by the arteries. This causes the body to retain fluid as it tries to build up enough "head pressure" to compensate for the failing pump. Eventually, the combination of increased VI I Cardiac Emergencies KLFD BLS&ALS PROTOCOLS Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC 41 circulating volume and ineffective pumping action causes fluid to build up in the limbs and abdomen (right-sided CHF), and the lungs (left-sided CHF, pulmonary edema). Patients may present with biventricular, or both right and left-sided CHF. This protocol deals primarily with pulmonary edema, a life-threatening emergency. The pump failure of CHF can be caused by long-standing hypertension, damage to the heart's valves, and loss of myocardial muscle strength due to inflammation or infarct. Signs and Symptoms * Edema, most often in legs and ankles * Fatigue * Difficulty breathing on exertion or when lying down * Pulmonary edema causes severe shortness of breath and hypoxia at rest; may be improved by sitting upright * Frothy sputum, may be pink-tinged Management 1. Evaluate scene safety. DO NOT approach patient if scene cannot be rendered safe. 2. Institute appropriate Body Substance Isolation (BSI) measures/Universal Precautions. as outlined in Protocol I.A. 3. Perform patient assessment and initiate routine BLS care, as outlined in Protocol LA, and as indicated by the patient's condition. 4. Determine the need for ALS care and/or transport to hospital for further evaluation and treatment. 5. Provide supplemental oxygen (100% by non-rebreathing mask [NRBM]). 6. Assist ventilations with a bag valve mask (BVM), if necessary. 7. If the patient has prescribed nitroglycerin, and there are no contraindications, assist the patient to administer nitroglycerin 0.4 mg sublingual (SQ; may repeat every 5 minutes up to a maximum of 3 doses, provided Systolic BP >_ 100 mm Hg and chest pain persists. a. Contraindications to first dose of SL nitroglycerin: • Use of erectile dysfunction medications in previous 24 hours • Systolic BP < 100 m m Hg VI I Cardiac Emergencies KLFD BLS&ALS PROTOCOLS Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC 42 8. Continue to monitor vital signs, including pulse oximetry, if available. 9. Continue supportive care and monitor vital signs until patient is turned over to an ALS transport unit. ALS 1. Confirm the completion of BLS steps 1-9. 2. Initiate 0.9% Normal Saline via IV/IO at KVO or saline lock. 3. Obtain a 12-lead ECG and monitor cardiac rhythm. Pediatric BLS 1. Follow BLS guidelines, adjusting for patient age/size. 2. Provide advanced airway support, if necessary. (Refer to Protocol I.B.) ALS 1. Follow BLS guidelines, adjusting for patient age/size. 2. Provide advanced airway support, if necessary. (Refer to Protocol I.B.) 3. Administer Albuterol 2.5 mg in3.0ml Normal Saline. 4. Monitor cardiac status and pulse oximetry. D. Cardiac Arrest Ventricular Fibrillation, Non-Perfusing Ventricular Tachycardia, Asystole, Pulseless Electrical Activit Review of Injury/Illness BLS and ALS protocols to resuscitate patients in cardiac arrest should be based on the most recent American Heart Association guidelines and approved by local medical direction. The protocols below require that all BLS providers be trained to use and have access to automatic or semi-automatic defibrillators (AED). Signs and Symptoms * Unresponsive * No palpable pulse VI I Cardiac Emergencies KLFD BLS&ALS PROTOCOLS Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC 43 * Electrical activity on ECG is absent or shows course/fi ne ventricular fibrillation or ventricular tachycardia * No respirations (possible agonal gasping in initial stage Management BLS 1. Evaluate scene safety. DO NOT approach patient if scene cannot be rendered safe. 2. Institute appropriate Body Substance Isolation (BSI) measures/Universal Precautions. as outlined in Protocol I.A. 3. Perform patient assessment and initiate routine BLS care, as outlined in Protocol I.A. and as indicated by the patient's condition. 4. Determine the need for ALS care and/or transport to hospital for further evaluation and treatment. 5. If witnessed arrest: Defibrillate one time prior to starting CPR. (Refer to step 6.) 6. If unwitnessed arrest: Start CPR according to current American Heart Association (AHA) guidelines. a. Resume 5 cycles of CPR (2 minutes) with minimal interruption (< 10 seconds). • Push hard and fast (chest compression of 2 inches at a ratio of 30:2 with a rate of 100 compressions/min. (DO NOT wait to check rhythm or pulses.) Apply an AED as soon as possible. • Change compressors every 2 minutes. • Ensure complete chest recoil during CPR b. Defibrillate one time, ASAP, if indicated; resume 5 cycles of CPR (2 minutes) with minimal interruption (< 10 seconds). c. Re-check rhythm on AED or cardiac monitor and check pulses. d. Defibrillate one time, ASAP, if indicated; resume 5 cycles of CPR (2 minutes) with minimal interruption (< 10 seconds). e. Re-check rhythm and pulses. f. Defibrillate one time, ASAP, if indicated; resume 5 cycles of CPR (2 minutes) with minimal interruption (< 10 seconds). g. Re-check rhythm and pulses. VI I Cardiac Emergencies KLFD BLS&ALS PROTOCOLS Docusign Envelope ID:D9C280B0-04D5-4D4C-A898-A72C90C71AEC 44 7. Manually ventilate with a bag valve mask (BVM) and high flow 02 every 6-8 seconds with minimal interruption (< 10 seconds) ASAP. Avoid excessive ventilation. 8. Continue CPR until the patient is turned over to an ALS transport unit. 9. If there is no return of spontaneous circulation, refer to Protocol XI.C. ALS (VF, Pulseless VT-Adult) 1. Confirm the completion of BLS steps 1-6. 2. Resume CPR, administer supplemental oxygen, attach manual defibrillator, and verify that VF/VT is present on the monitor. 3. Defibrillate one time. If a shockable rhythm (VF/VT) develops, resume 5 cycles of CPR (2 minutes) with minimal interruption (< 10 seconds). 4. Initiate intubation, or provide advanced airway support, and verify correct placement with capnography with minimal interruption of CPR (< 10 seconds). 5. Initiate 0.9% Normal Saline via IV/10 at KVO or saline lock with minimal interruption of CPR (< 10 seconds). 6. Administer epinephrine 1.0 mg IV/10/ET, every 3-5 minutes, with minimal interruption of CPR (< 10 seconds). 7. Defibrillate one time. If a shockable rhythm (VF/VT) develops, resume 5 cycles of CPR (2 minutes) with minimal interruption (< 10 seconds). 8. If refractory VF/VT: Administer Amiodarone 300 mg bolus IV/10; may repeat x1 at 150 mg bolus IV/10. 9. Defibrillate one time. If a shockable rhythm (VF/VT) develops, resume 5 cycles of CPR (2 minutes) with minimal interruption (< 10 seconds). 10. Identify and treat reversible causes: • Hypovolemia • Hypoxia • Hydrogen Ion (acidosis) • Hypo/hyperkalemia • Hypothermia • Tamponade, cardiac VI I Cardiac Emergencies KLFD BLS&ALS PROTOCOLS Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC 45 • Tension Pneumothorax • Thrombosis, coronary • Thrombosis, pulmonary • Toxins 13. If spontaneous circulation returns, monitor vital signs, support airway and breathing per local protocols. 14. If there is no return of spontaneous circulation, refer to Protocol XI.C. ALS (Asystole/PEA-Adult) 1. Confirm the completion of BLS steps 1-6. 2. Resume 5 cycles of CPR (2 minutes) with minimal interruption (< 10 seconds). 3. Administer supplemental oxygen, attach manual defibrillator, and verify that Asystole is present on the monitor. 4. Continue to monitor cardiac rhythms. 5. Defibrillate one time, if a shockable rhythm (VF/VT) develops. Follow the guidelines for "ALS (VF, Pulseless VT-Adult).J#I 6. Initiate intubation, or provide advanced airway support, and verify correct placement with capnography with minimal interruption of CPR (< 10 seconds). 7. Initiate 0.9% Normal Saline or via IV/10 at KVO or saline lock with minimal interruption of CPR (< 10 seconds). 8. Administer epinephrine 1.0 mg IV/10/ET, every 3-5 minutes, with minimal interruption of CPR (< 10 seconds). 9. Identify and treat reversible causes: • Hypovolemia • Hypoxia • Hydrogen Ion (acidosis) • Hypo/hyperkalemia • Hypothermia • Tamponade, cardiac VI I Cardiac Emergencies KLFD BLS&ALS PROTOCOLS Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC 46 • Tension Pneumothorax • Thrombosis, coronary • Thrombosis, pulmonary • Toxins 10. Give all medications with minimal interruption of CPR (< 10 seconds). 11. If spontaneous circulation returns, monitor vital signs, support airway and breathing, and provide medications appropriate for BP, heart rate, and rhythm per local protocol. 12. If there is no return of spontaneous circulation, refer to Protocol XI.C. Pediatric BLS 1. Follow BLS guidelines, adjusting for patient age/size. 2. Start CPR according to current American Heart Association (AHA) guidelines (30:2 with one rescuer [15:2 with two rescuers]): a. Compress chest at a rate of 100 compressions/min. • Neonates< 28 days: Compress lower third of the sternum 1/3 of the anterior-posterior diameter of the chest. • Infants 28 days-1 year: Compress chest 1% inches. • Children 1-8 years: Compress chest 2 inches. b. Manually ventilate with appropriate-sized bag valve mask (BVM), if available. If not, use a mouth-to-mask/barrier device. Administer supplemental oxygen. c. Defibrillate one time, if a shockable rhythm (VF/VT) develops; resume 5 cycles of CPR (2 minutes) with minimal interruption (< 10 seconds); if possible, use AED with pediatric pads. d. Defibrillate one time, if a shockable rhythm (VF/VT) develops; resume 5 cycles of CPR (2 minutes) with minimal interruption (< 10 seconds) 3. If spontaneous circulation returns, monitor vital signs, support airway and breathing per local protocols. 4. If there is no return of spontaneous circulation, refer to Protocol XI.C. ALS (VF, Pulseless VT- Pediatric) 1. Follow Pediatric BLS guidelines, adjusting for patient age/size. VI I Cardiac Emergencies KLFD BLS&ALS PROTOCOLS Docusign Envelope ID:D9C280B0-04D5-4D4C-A898-A72C90C71AEC 47 2. Attach manual defibrillator and verify that VF/VT is present on the monitor. 3. Defibrillate one time at 2 J/kg. If a shockable rhythm develops; resume 5 cycles of CPR (2 minutes) with minimal interruption (< 10 seconds). 4. Initiate intubation, or provide advanced airway support, and verify correct placement with capnography with minimal interruption of CPR (< 10 seconds). S. Initiate 0.9% Normal Saline or LR via IV/10 at KVO or saline lock with minimal interruption of CPR (< 10 seconds): a. IV/10: 0.01 mg/kg (0.1 ml/kg 1:10,000), up to a maximum of 1.0 mg b. ET: 0.01 mg/kg (0.1 ml/kg 1:1,000), up to a maximum of 2.5 mg. Flush with 5 ml of Normal Saline and follow with 5 ventilations. 7. Defibrillate one time at 4 J/kg. If a shockable rhythm develops; resume 5 cycles of CPR (2 minutes) with minimal interruption (< 10 seconds). 8. Defibrillate third and subsequent times at >_4 J/kg, up to a maximum of 10 J/kg or adult dose. 9. If refractory VF/VT: Administer Amiodarone 5 mg/kg IV/10; may repeat x2 at 15 mg/kg, up to a maximum single dose of 300 mg. 10. Identify and treat reversible causes: • Hypovolemia • Hypoxia • Hydrogen Ion (acidosis) • Hypo/hyperkalemia • Hypothermia • Tamponade, cardiac • Tension Pneumothorax • Thrombosis, coronary • Thrombosis, pulmonary • Toxins VI I Cardiac Emergencies KLFD BLS&ALS PROTOCOLS Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC 48 11. Give all medications with minimal interruption of CPR (< 10 seconds). 12. If spontaneous circulation returns, monitor vital signs, support airway and breathing, and provide medications appropriate for BP, heart rate, and rhythm per local protocols. 13. If there is no return of spontaneous circulation, refer to Protocol XI.C. ALS (Asystole/PEA- Pediatric) 1. Follow Pediatric BLS guidelines, adjusting for patient age/size. 2. Attach manual defibrillator and verify that Asystole is present on the monitor. 3. Defibrillate one time at 2 J/kg, if a shockable rhythm develops. Follow the guidelines for "ALS (VF, Pulseless VT- Pediatric)." 4. Initiate intubation, or provide advanced airway support, and verify correct placement with capnography with minimal interruption of CPR (< 10 seconds). 5. Initiate 0.9% Normal Saline via IV/10 at KVO or saline lock with minimal interruption of CPR (< 10 seconds). 6. Administer epinephrine, every 3-5 minutes, with minimal interruption of CPR (< 10 seconds): a. 1W10: 0.01 mg/kg (0.1 m I/kg 1:10,000), up to a maximum of 1.0 mg b. ET: 0.01 mg/kg (0.1 ml/kg 1:1,000), up to a maximum of 2.5 mg. Flush with 5 ml of Normal Saline and follow with 5 ventilations. 7. Identify and treat reversible causes: • Hypovolemia • Hypoxia • Hydrogen Ion (acidosis) • Hypo/hyperkalemia • Hypothermia • Tamponade, cardiac • Tension Pneumothorax • Thrombosis, coronary • Thrombosis, pulmonary VI I Cardiac Emergencies KLFD BLS&ALS PROTOCOLS Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC 49 • Toxins 8. Give all medications with minimal interruption of CPR (< 10 seconds). 9. If spontaneous circulation returns, monitor vital signs, support airway and breathing, and provide medications appropriate for BP, heart rate, and rhythm per local protocols. 10. If there is no return of spontaneous circulation, refer to Protocol XI.C. E. Other Cardiac Arrhythmias Premature Ventricular Contractions Review of Injury/Illness Premature ventricular complexes (PVCs) have three characteristics: • They occur earlier than the expected sinus beat. • They do not start with a positive P wave. • They have an abnormal QRS width (�! 0.12 seconds). PVCs in the presence of cardiac symptoms that are and that have the following characteristics are indications for treatment: • Near the "T" wave • Multi-focal (different shapes on the monitor tracing) • Sequential or closely coupled • Runs of ventricular tachycardia (5 or more consecutive beats) • Ventricular tachycardia with a pulse • Once successful electrical conversion from ventricular tachycardia • Ventricular fibrillation to a supraventricular rhythm Signs and Symptoms * Irregular heartbeat of ventricular origin (may or may not be felt by the patient) * Sensation of irregular heartbeats or pounding/fluttering in chest BLS 1. Evaluate scene safety. DO NOT approach patient if scene cannot be rendered safe. 2. Institute appropriate Body Substance Isolation (BSI) measures/Universal Precautions. as outlined in Protocol I.A. VI I Cardiac Emergencies KLFD BLS&ALS PROTOCOLS Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC 50 3. Perform patient assessment and initiate routine BLS care, as outlined in Protocol I.A. and as indicated by the patient's condition. 4. Determine the need for ALS care and/or transport to hospital for further evaluation and treatment. 5. Monitor airway, administer supplemental oxygen, if necessary, and monitor pulse oximetry. 6. Assess and treat for shock, if indicated. (Refer to Protocol X.I.) 7. Continue supportive care and monitor vital signs until the patient is turned over to an ALS transport unit. ALS 1. Confirm the completion of BLS steps 1-6. 2. Provide advanced airway support, if necessary. (Refer to Protocol I.B.) 3. Obtain a 12-lead ECG and monitor cardiac rhythm. Providers may perform a 15-lead ECG, if trained. 4. Initiate 0.9% Normal Saline via IV/10 at KVO or saline lock. 5. Patients who are symptomatic (e.g., hypotensive, syncope, dizziness): a. Administer Amiodarone 150 mg IV mixed in NS 50 cc on a macro drip. (Administer over 10 minutes using Dial-A-Flow set at 300 which yields 5cc/min). 6. Continue supportive care, monitoring cardiac status and 02 saturation, and transport. Bradycardia Review of Injury/Illness Patients may present with a slow heart rate and chest pain, shortness of breath, decreased level of consciousness, hypotension, hypoperfusion, pulmonary congestion, congestive heart failure, and/or acute myocardial infarction. It is not unusual for young, healthy athletes to have a resting heart rate below 60 beats per minute. Bradycardia has a number of causes, including damage to the conduction pathways in the heart, medications, hypoxia, and hypothermia. SijRns and Symptoms * Light-headedness * Syncope * Fatigue * Chest pain VI I Cardiac Emergencies KLFD BLS&ALS PROTOCOLS Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC 51 * Shortness of breath Management BLS 1. Evaluate scene safety. DO NOT approach patient if scene cannot be rendered safe. 2. Institute appropriate Body Substance Isolation (BSI) measures/Universal Precautions. as outlined in Protocol I.A. 3. Perform patient assessment and initiate routine BLS care, as outlined in Protocol I.A, and as indicated by the patient's condition. 4. Determine the need for ALS care and/or transport to hospital for further evaluation and treatment. 5. Assess and treat for shock, if indicated. (Refer to Protocol X.I.) 6. Monitor airway, administer supplemental oxygen, if necessary, and monitor pulse oximetry. 7. Continue supportive care and monitor vital signs until the patient is turned over to an ALS transport unit. ALS 1. Confirm the completion of BLS steps 1-6. 2. Obtain 12-lead ECG and monitor cardiac rhythm. 3. Initiate 0.9% Normal Saline via IV/10 at KVO or saline lock. 4. If hypotensive, and lungs are clear, initiate a 250 ml bolus of 0.9% Normal Saline or LR; repeat to bring Systolic BP > 90 mm Hg, as needed. 5. If symptomatic, with heart rate < 50 bpm, apply pacer pads and treat any underlying causes. 6. If symptomatic, administer atropine 1.0 mg slow IV/10 push; repeat every 3-5 minutes, up to a maximum total dose of 3.0 mg. a. DO NOT administer atropine to patients who have had cardiac transplants. b. Hypothermic patients with a pulse should generally be re-warmed before atropine or pacing is attempted. 7. If the patient is hemodynamically unstable, with NO response to atropine: a. Administer transcutaneous pacing (TCP). VI I Cardiac Emergencies KLFD BLS&ALS PROTOCOLS Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC 52 8. If patient is hemodynamically stable and in Type 11, second-degree AV Block or third-degree AV Block: a. Consider TCP after consulting on-line medical direction. • If the patient develops discomfort with TCP, and Systolic BP > 110 mm Hg: • Consider midazolam 0.1 mg/kg in 2.0 mg increments slow IV/10 push over 1-2 minutes, up to a maximum single dose of 5.0 mg to reduce pain/anxiety of pacing. Reduce dosage by 50%for patients >_ 69 years. Pediatric BLS 1. Follow BLS guidelines, adjusting for patient age/size. ALS 1. Follow BLS guidelines, adjusting for patient age/size. 2. Obtain 12-lead ECG and monitor cardiac rhythm. 3. Initiate 0.9% Normal Saline via IV/10 at KVO or saline lock. 4. Identify and treat any reversible causes. 5. If hypotensive, and lungs are clear, initiate a 20 mg/kg fluid bolus of 0.9% Normal Saline or LR; repeat to bring Systolic BP > 90 mm Hg, as needed. 6. If the patient is hemodynamically unstable (with a pulse and poor perfusion): a. Start CPR, if heart rate < 60 bpm, with poor perfusion, despite oxygenation and ventilation. b. Administer epinephrine, every 3-5 minutes, with minimal interruption of CPR (< 10 seconds): • IWIO: 0.01 mg/kg (0.1 m I/kg 1:10,000), up to a maximum of 1.0 mg • ET: 0.01 mg/kg (0.1 ml/kg 1:1,000), up to a maximum of 2.5 mg. Flush with 5 ml of Normal Saline and follow with 5 ventilations. c. If symptomatic, administer atropine 0.02 mg/kg IV/10 (minimum dose 0.1 mg); may repeat x1, up to a maximum single dose of 0.5 mg. • DO NOT administer atropine to patients who have had cardiac transplants. • Hypothermic patients with a pulse should generally be re-warmed before atropine or pacing is attempted. • If the patient DOES NOT respond to epinephrine and atropine, administer transcutaneous pacing (TCP) after consulting on-line medical direction. VI I Cardiac Emergencies KLFD BLS&ALS PROTOCOLS Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC 53 Tachycardia Review of Injury/Illness Tachycardia is defined as a heart rate > 100 bpm. Symptoms and potential hemodynamic compromise typically occur when heart rates > 150 bpm. The most common tachycardia is sinus tach, and it is treated by correcting the underlying causes. Atrial tachycardias require transport if they produce hypotension. Signs and Symptoms * Chest pain (may or may not be felt by the patient) * Shortness of breath * Decreased level of consciousness * Heart failure and/or acute myocardial infarction * Light-headedness * Syncope * Fatigue Management BLS 1. Evaluate scene safety. DO NOT approach patient if scene cannot be rendered safe. 2. Institute appropriate Body Substance Isolation (BSI) measures/Universal Precautions. as outlined in Protocol I.A. 3. Perform patient assessment and initiate routine BLS care, as outlined in Protocol I.A, and as indicated by the patient's condition. 4. Determine the need for ALS care and/or transport to hospital for further evaluation and treatment. 5. Monitor airway, administer supplemental oxygen, if necessary, and monitor pulse oximetry. 6. Assess and treat for shock, if indicated. (Refer to Protocol X.I.) 7. Continue supportive care and monitor vital signs (every 15 minutes, if stable; every 5 minutes, if unstable) until patient is turned over to an ALS transport unit. VI I Cardiac Emergencies KLFD BLS&ALS PROTOCOLS Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC 54 ALS 1. Confirm the completion of BLS steps 1-6. 2. Provide advanced airway support, if necessary. (Refer to Protocol I.B.) 3. Obtain a 12-lead ECG and monitor cardiac rhythm. Identify the rhythm and QRS duration. Providers may perform a 15-lead ECG, if trained. 4. Initiate 0.9% Normal Saline via IV/10 at KVO or saline lock. 5. If no pulse is present, treat as Asystole PEA. (Refer to Protocol VI.D "ALS [Asystole/PEA - AduN.") 6. If the patient is hemodynamically stable, identify the rhythm and treat according to current AHA/ACLS guidelines. 7. If patient is hemodynamically unstable with a ventricular rate > 150 bpm, identify and treat reversible causes: • Hypovolemia • Hypoxia • Hydrogen Ion (acidosis) • Hypo/hyperkalemia • Hypothermia • Tamponade, cardiac • Tension Pneumothorax • Thrombosis, coronary • Thrombosis, pulmonary • Toxins. 8. Consider vagal maneuvers. 9. If the QRS duration is a regular narrow complex: a. Consider administering adenosine 12mg rapid IV/10 push and follow with 20 ml Normal Saline flush. b. If the rhythm does not convert in 1-2 minutes, administer a second dose at 12mg IV/10. VI I Cardiac Emergencies KLFD BLS&ALS PROTOCOLS Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC 55 c. If the patient has a history of WPW, a defibrillator must be available when adenosine is administered. 10. Consider the following for sedation prior to synchronized cardioversion, after consulting on- line medical direction. DO NOT delay, if hemodynamically unstable, as low blood pressure may affect ability to administer sedative. a. Midazolam (Versed'): 2.0-5.0 mg slow IV/10 or 0.2 mg/kg IM, if no IV access. 11. Synchronized cardioversion doses: a. Narrow regular: 50-100 J b. Narrow irregular: 120-200 J c. Wide regular: 100 J d. Wide irregular: defibrillation dose (NOT synchronized) Pediatric BLS 1. Follow BLS guidelines, adjusting for patient age/size. ALS 1. Follow BLS guidelines, adjusting for patient age/size. 2. If the patient is hemodynamically stable (with a pulse and appears well perfused): a. Administer oxygen to obtain a saturation of 90-100%. b. Attach cardiac monitor and identify rhythm and QRS duration. c. Initiate 0.9% Normal Saline via IV/10 at KVO or saline lock. d. Identify and treat reversible causes. 3. If the patient is hemodynamically unstable (with a pulse and poor perfusion) with a heart rate > 220 bpm for an infant, or > 180 bpm for a child: a. Consider vagal maneuvers. b. Initiate 0.9% Normal Saline via IV/10 at KVO or saline lock. c. If cardiac rhythm is regular and narrow and the QRS duration <_ 0.09 seconds: VI I Cardiac Emergencies KLFD BLS&ALS PROTOCOLS Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC 56 • Administer Adenosine 0.1 mg/kg rapid IV/10 push, up to a maximum of 6.0 mg. Follow with 20 ml Normal Saline flush. • If the rhythm does not convert in 1-2 minutes, administer a second dose at 0.2 mg/kg rapid IV/10, up to a maximum of 12 mg. • If the rhythm does not convert in 1-2 minutes, administer a third dose at 0.2 mg/kg rapid IV/10, up to a maximum of 12 mg. • ET dosage is 2-2.5 times the IV/10 dosage. d. If the patient is not improved with Adenosine, or if IV/10 is unavailable, consider immediate synchronized cardioversion. • Consider the following for sedation prior to synchronized cardioversion, after consulting on- line medical direction. DO NOT delay, if hemodynamically unstable, as low blood pressure may affect ability to administer sedative. • Midazolam (VersedO): 0.1 mg/kg slow IV/10, up to a maximum of 4.0 mg or 0.2 mg/kg IM, up to a maximum of 4.0 mg, if no IV access. • Start cardioversion with 0.5-1.0 J/kg. If a patient's condition does not improve, or worsens, increase to 2.0 J/kg • If a calculated joule setting is lower than the cardioversion device is able to deliver, use the lowest power setting possible or consult on-line medical direction. • Be prepared for up to 40 seconds of Asystole after cardioversion. VI I Cardiac Emergencies KLFD BLS&ALS PROTOCOLS Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC 58 11. Childbirth and Newboilrin Care A. Uncomplicated Delivery Review of Injury/Illness Full-term gestation lasts 40 weeks. Babies may be born at any time before or after 40 weeks, but the earlier the birth occurs in the gestation process, the likelier it is that complications, including fetal demise, will arise. Signs and Symptoms * Abdominal, pelvic pain * Low back pain * Vaginal discharge—this may be the mucus plug or it may be a large volume of clear liquid from the amniotic sac * Urge to defecate Management BLS 1. Evaluate scene safety. DO NOT approach patient if scene cannot be rendered safe. 2. Institute appropriate Body Substance Isolation (BSI) measures/Universal Precautions, as outlined in Protocol I.A. 3. Perform patient assessment and initiate routine BLS care, as outlined in Protocol I.A., and as indicated by the patient's condition. 4. Determine the need for ALS care and/or transport to hospital for further evaluation and treatment. 5. Time the duration of contractions and the length of the interval between them. 6. Obtain pre-natal history, including the number of previous pregnancies and births. 7. Assess for crowning. 8. If crowning is not present, allow patient to assume position of comfort. 9. If crowning is present, delivery is imminent. 10. In addition to gloves, don splash protection garments, if possible, to assist delivery. 11. Alert medical direction and/or receiving hospital of procedure in progress if possible. VII I Childbirth and Newborn Care KLFD BLS&ALS PROTOCOLS Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC 59 12. Assist delivery: a. Apply gentle pressure to the baby's head to prevent tearing of perineum. b. Once the head is delivered, suction mouth and nose with bulb syringe. c. Check to see if the umbilical cord is wrapped around the baby's neck. d. Apply gentle pressure downward while supporting baby's head to ease delivery of superior (upper position) shoulder. e. Once superior shoulder is delivered, apply gentle pressure upward to ease delivery of inferior (lower) shoulder. f. Upon delivery of both shoulders, the rest of the baby should follow quickly. g. Keep the baby at the level of the vagina until the cord is clamped and cut. h. Once fully delivered, clamp the umbilical cord at 8" and 10" from baby, and cut the cord between the two clamps. i. After clamping and cutting the cord, wrap the baby in a warm blanket, place the baby on the mother's abdomen, and allow for delivery of placenta. j. Record time of delivery. k. Refer to "Newborn Care Protocol" (Protocol VII.C). I. Watch for excessive bleeding; perform uterine massage and apply pressure to any lacerations that may be bleeding. m. Encourage mothers to breastfeed to help control hemorrhage. 13. Continue supportive care and monitor vital signs until the patient is turned over to a higher level of medical care. ALS 1. Confirm the completion of BLS steps 1-12. 2. Administer oxygen and monitor pulse oximetry. 3. Resuscitate neonate, if needed. (Refer to Protocol VII.C). 4. Initiate 0.9% Normal Saline via IV/10 at KVO or saline lock. VII I Childbirth and Newborn Care KLFD BLS&ALS PROTOCOLS Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC 60 B. Complicated Delivery Review of Injury/Illness Labor and delivery can be complicated by abnormal presentation of the fetus, including: • Breech presentation • Prolapsed cord • Multiple births • Vaginal hemorrhage None of these is optimally handled in the fi eld, and every attempt must be made to move the patient to a higher level of care while EMS care is in progress. Breech Delivery Signs and Symptoms * Fetal buttocks visible at vaginal opening (breech presentation) * Prolapsed umbilical cord Management BLS 1. Evaluate scene safety. DO NOT approach patient if scene cannot be rendered safe. 2. Institute appropriate Body Substance Isolation (BSI) measures/Universal Precautions, as outlined in Protocol I.A. 3. Perform patient assessment and initiate routine BLS care, as outlined in Protocol I.A., and as indicated by the patient's condition. 4. Determine the need for ALS care and/or transport to hospital for further evaluation and treatment. 5. Provide supplemental oxygen. 6. Support the baby's body as it is delivered. 7. If the head delivers normally, refer to Protocol VII.A. 8. If the head does not deliver within 2 minutes, insert gloved hand into the vagina, keeping palm toward the baby's face and forming a "V" with your fingers. Push the vaginal wall away from the baby's face to allow room for an airway. VII I Childbirth and Newborn Care KLFD BLS&ALS PROTOCOLS Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC 61 9. Maintain this airway until the baby is delivered or turned over to an ALS transport unit. 10. Continue supportive care and monitor vital signs until the patient is turned over to an ALS transport unit. ALS 1. Confirm the completion of BLS steps 1-9. 2. Resuscitate neonate, if needed. (Refer to Protocol VII.C). 3. Initiate 0.9% Normal Saline via IV/10 at KVO or saline lock. Limb Presentation Signs and Symptoms * Fetal arm or foot visible at vaginal opening Management BLS 1. Evaluate scene safety. DO NOT approach patient if scene cannot be rendered safe. 2. Institute appropriate Body Substance Isolation (BSI) measures/Universal Precautions, as outlined in Protocol I.A. 3. Perform patient assessment and initiate routine BLS care, as outlined in Protocol I.A., and as indicated by the patient's condition. 4. Determine the need for ALS care and/or transport to hospital for further evaluation and treatment. 5. Administer oxygen and monitor pulse oximetry. 6. Place mother in the Trendelenburg position. 7. Continue supportive care and monitor vital signs until the patient is turned over to an ALS transport unit. ALS 1. Confirm the completion of BLS steps 1-6. 2. Initiate 0.9% Normal Saline via IV/10 at KVO or saline lock. VII I Childbirth and Newborn Care KLFD BLS&ALS PROTOCOLS Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC 62 Prolapsed Cord Signs and Symptoms * Cord presents first at vaginal opening Management BLS 1. Evaluate scene safety. DO NOT approach patient if scene cannot be rendered safe. 2. Institute appropriate Body Substance Isolation (BSI) measures/Universal Precautions, as outlined in Protocol I.A. 3. Perform patient assessment and initiate routine BLS care, as outlined in Protocol I.A., and as indicated by the patient's condition. 4. Determine the need for ALS care and/or transport to hospital for further evaluation and treatment. 5. Administer oxygen and monitor pulse oximetry. 6. Place the mother in the knee-to-chest position. 7. Wrap the cord in gauze moistened with saline. 8. Check the cord for a pulse. 9. If no pulse present, insert gloved hand into the vagina and push up on the baby until a pulse returns to the cord. 10. Continue supportive care and monitor vital signs until the patient is turned over to a higher level of medical care. ALS 1. Confirm the completion of BLS steps 1-9. 2. Initiate 0.9% Normal Saline via IV/10 at KVO or saline lock. Multiple Births Review of Injury/Illness Most patients can report whether the impending delivery involves twins or multiple births. VII I Childbirth and Newborn Care KLFD BLS&ALS PROTOCOLS Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC 63 Signs and Symptoms * Ongoing labor after first newborn delivered Management BLS 1. Evaluate scene safety. DO NOT approach patient if scene cannot be rendered safe. 2. Institute appropriate Body Substance Isolation (BSI) measures/Universal Precautions, as outlined in Protocol I.A. 3. Perform patient assessment and initiate routine BLS care, as outlined in Protocol I.A., and as indicated by the patient's condition. 4. Determine the need for ALS care and/or transport to hospital for further evaluation and treatment. 5. Administer oxygen and monitor pulse oximetry. 6. Follow normal delivery protocol for each neonate as it presents. (Refer to Protocol VII.A.) 7. Continue supportive care and monitor vital signs until the patient is turned over to an ALS transport unit. ALS 1. Confirm the completion of BLS steps 1-6. 2. Initiate 0.9% Normal Saline via IV/10 at KVO or saline lock. Vaginal Hemorrhage Review of Injury/Illness Vaginal hemorrhage can be a sign of miscarriage or can be a pre- or post-partum complication. Signs and Symptoms * Unusually heavy vaginal bleeding * May be hypotensive VII I Childbirth and Newborn Care KLFD BLS&ALS PROTOCOLS Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC 64 Management BLS 1. Evaluate scene safety. DO NOT approach patient if scene cannot be rendered safe. 2. Institute appropriate Body Substance Isolation (BSI) measures/Universal Precautions, as outlined in Protocol I.A. 3. Perform patient assessment and initiate routine BLS care, as outlined in Protocol I.A., and as indicated by the patient's condition. 4. Determine the need for ALS care and/or transport to hospital for further evaluation and treatment. 5. Administer oxygen and monitor pulse oximetry. 6. Apply bandages/dressings appropriate for bleeding control in the vaginal area. 7. If pre-delivery, place mother in the left lateral recumbent position for third trimester. Prior to third trimester, place in shock position. 8. If before 20 weeks gestation and baby delivers without vital signs, do not begin resuscitation. If> 20 weeks gestation and baby deliver without vital signs, begin CPR. If unsure of gestational age, begin CPR. (Refer to Protocol VI.D.) 9. If post-partum, begin fi rm uterine massage. 10. Continue supportive care and monitor vital signs until the patient is turned over to an ALS transport unit. AILS 1. Confirm the completion of BLS steps 1-9. 2. Initiate Normal Saline via IV/10 at KVO or saline lock. 3. Assess and treat for hypotension or shock, if indicated. (Refer to Protocol X.I.) C. Newborn Care Review of Injury/Illness EMS care for a newborn follows a delivery at which the providers have just assisted or may be initiated on arrival at the scene of a recent out-of-hospital birth. VII I Childbirth and Newborn Care KLFD BLS&ALS PROTOCOLS Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC 65 Management BLS 1. Evaluate scene safety. DO NOT approach patient if scene cannot be rendered safe. 2. Institute appropriate Body Substance Isolation (BSI) measures/Universal Precautions, as outlined in Protocol I.A. 3. Perform patient assessment and initiate routine BLS care, as outlined in Protocol I.A., and as indicated by the patient's condition. 4. Determine the need for ALS care and/or transport to hospital for further evaluation and treatment. 5. Warm and dry the newborn. 6. Stimulate breathing by tapping the heels of the feet or rubbing the newborn's back. 7. If breathing does not begin, or is labored, suction the airway with a bulb syringe to remove mucus and secretions. 8. If no spontaneous respirations occur: Begin manual respirations, as needed, with an appropriate-sized bag valve mask (BVM) at 40-60 breaths per minute with 100% 02. 9. Assess heart rate. 10. If heart rate is absent or < 60 bpm at 30 seconds, after assisted respirations and supplemental oxygen, begin resuscitation according to current American Heart Association (AHA) Neonatal Resuscitation guidelines. 11. Assess APGAR score at 1 minute and 5 minutes post birth. (Refer to chart.) 12. Continue supportive care and monitor vital signs until the patient is turned over to an ALS transport unit. ALS 1. Confirm the completion of BLS steps 1-9. 2. Provide advanced airway support, if necessary. (Refer to Protocol I.B.) 3. If heart rate remains < 60 bpm, despite adequate ventilation with 100% 02 and chest compressions, administer epinephrine (1:10,000) 0.01-0.03 mg/kg IV/10 or 0.05-0.1 mg/kg ET. 4. Consider hypovolemia and pneumothorax, if condition does not improve. VII I Childbirth and Newborn Care KLFD BLS&ALS PROTOCOLS Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC 66 D. APGAR Score Sign 0 1 2 Points Appearance(Color) Blue, pale Body pink, extremities Completely pink Blue or pink Pulse rate Not detectable Slow(below 100) Over 100 Grimace No response Grimace Crying Activity Limp Some flexion Active motion Respirations Absent Slow, irregular Good,crying (respiratory effort) Tota I Score Score Point total Infant's Condition Treatment Considerations 10 Very good Routine 7-9 Good Re-assess 4-6 Fair May need oxygen and stimulation 0-3 Poor Requires CPR VII I Childbirth and Newborn Care KLFD BLS&ALS PROTOCOLS Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC 67 111. Enveiroinilmein"tal Eirnergeincies A. Dehydration Review of Injury/Illness Dehydration can be caused by inadequate fluid intake, inapparent loss of fluids through sweating and evaporation, obvious fluid loss such as vomiting, diarrhea, excessive urination due to diuretic medication, or a combination of these factors. There is an increased risk of dehydration in both hot and cold climates and at high altitudes. Signs and Symptoms * Dry mucosa * Decreased urine output * Headache * loss of coordination * Altered mental status * Decreased blood pressure, increased heart rate * May progress to shock Management 1. Evaluate scene safety. DO NOT approach patient if scene cannot be rendered safe. 2. Institute appropriate Body Substance Isolation (BSI) measures/Universal Precautions, as outlined in Protocol I.A. 3. Perform patient assessment and initiate routine BLS care, as outlined in Protocol I.A, and as indicated by the patient's condition. 4. Determine the need for ALS care and/or transport to hospital for further evaluation and treatment. 5. If dehydration is associated with heat exposure, move the patient to a cool shaded area. 6. Loosen patient's clothing. 7. If possible, take orthostatic vital signs. If mental status or blood pressure are abnormal with the patient lying down, DO NOT attempt to take an orthostatic set of vital signs. VIII I Environmental Emergencies KLFD BLS&ALS PROTOCOLS Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC 68 8. Continue supportive care and monitor vital signs until the patient is turned over to an ALS transport unit. ALS 1. Confirm the completion of BLS steps 1-11. 2. Monitor for change in mental status. 3. Initiate 0.9% Normal Saline via IV/10 and administer 500 ml fluid bolus. a. If the patient's age is < 40, repeat 500 ml bolus as needed up to 3,000 ml. b. If the patient's age is >40, repeat 500 ml bolus as needed up to 2,000 ml. 4. After each bolus, monitor vital signs, including auscultation of lung sounds, and pulse oximetry, if available. 5. Obtain 12-lead ECG and monitor cardiac rhythm. (An electrolyte imbalance may cause dysrhythmia.) Pediatric BLS 1. Follow BLS guidelines, adjusting for age/size of patient. Expanded Scope BLS ALS 1. Follow Expanded Scope BLS guidelines, adjusting for age/size of patient. 2. Initiate 0.9% Normal Saline via IV/10. Infuse 20 ml/kg bolus. Reevaluate and repeat 20 ml/kg bolus, up to a maximum total infusion of 40 ml/kg. After each bolus, monitor vital signs, lung sounds, and pulse oximetry, if available. B. Drowning— Near Drowning Review of Injury/Illness Drowning and near drowning involve respiratory impairment due to submersion or immersion in liquid. Hypothermia and/or cervical spine injury are frequently associated with drowning and near drowning and should be considered when caring for such patients. Signs and Symptoms * Respiratory distress/arrest * Hypoxia VIII I Environmental Emergencies KLFD BLS&ALS PROTOCOLS Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC 69 * Cough with clear or frothy pink sputum * Decreased level or loss of consciousness * Decreased or absent pulses Management BLS 1. Evaluate scene safety. DO NOT approach patient if scene cannot be rendered safe. 2. Institute appropriate Body Substance Isolation (BSI) measures/Universal Precautions, as outlined in Protocol I.A. 3. Perform patient assessment and initiate routine BLS care, as outlined in Protocol I.A, and as indicated by the patient's condition. 4. Determine the need for ALS care and/or transport to hospital for further evaluation and treatment. 5. Administer oxygen and monitor pulse oximetry. 6. Assist respirations, if necessary, with a bag valve mask and high-flow 02. 7. Position patient on side to prevent aspiration if coughing/choking, with or without assisted ventilations. Otherwise, allow patients to assume a position of comfort. 8. Protect from hypothermia. (Refer to Protocol VIII.D.) 9. Evaluate for additional illness or injury including c-spine injury, diabetes, seizure, cardiac event, or stroke. 10. Continue supportive care and monitor vital signs until the patient is turned over to an ALS transport unit. ALS 1. Confirm the completion of BLS steps 1-9. 2. Provide advanced airway support, if necessary. (Refer to Protocol I.B.) 3. Initiate 0.9% Normal Saline via IV/10 at KVO or saline lock. Use warm fluids, if available. 4. Obtain 12-lead ECG and monitor cardiac rhythm and treat any dysrhythmia according to current American Heart Association (AHA) ACLS guidelines. 5. Start CPR according to current AHA guidelines, if indicated. VIII I Environmental Emergencies KLFD BLS&ALS PROTOCOLS Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC 70 6. If a patient is resuscitated from VF or Asystole cardiac arrest, consider therapeutic hypothermia and have receiving facility continue therapy, if available. 7. Continuously monitor vital signs and pulse oximetry. Pediatric BLS 1. Follow BLS guidelines, adjusting for patient age/size. ALS 1. Follow BLS guidelines, adjusting for patient age/size. 2. Provide advanced airway support, if necessary. (Refer to Protocol I.B.) 3. Initiate 0.9% Normal Saline via IV/10 at KVO or saline lock. Use warm fluids, if available. 4. Obtain 12-lead ECG and monitor cardiac rhythm and treat any dysrhythmia according to current American Heart Association (AHA) ACLS guidelines. S. Start CPR according to current AHA guidelines, if indicated. 6. If a patient is resuscitated from VF or Asystole cardiac arrest, consider therapeutic hypothermia and have receiving facility continue therapy, if available. 7. Continuously monitor vital signs and pulse oximetry. C. Heat-related Illness (Hyperthermia) Review of Injury/Illness Heat-related illness is a group of acute conditions in which the body produces or absorbs more heat than it can effectively dissipate into the environment, causing a dangerous increase in core body temperature. The two most common forms of heat-related illness that require EMS treatment are heat exhaustion and heat stroke. These conditions may be associated with dehydration and electrolyte abnormalities, rarely including life-threatening hypernatremia. Signs and Symptoms Heat exhaustion * Nausea * Clammy skin * Dizziness VIII I Environmental Emergencies KLFD BLS&ALS PROTOCOLS Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC 71 * Muscle cramps * Elevated core temperature Heat stroke * Altered mental status * Elevated core temperature (> 1050 F) * Skin may be hot and dry or sweaty * Dilated pupils * Rapid heart rate (sometimes with arrhythmia) Management BLS 1 . Evaluate scene safety. DO NOT approach patient if scene cannot be rendered safe. 2. Institute appropriate Body Substance Isolation (BSI) measures/Universal Precautions, as outlined in Protocol I.A. 3. Perform patient assessment and initiate routine BLS care, as outlined in Protocol I.A, and as indicated by the patient's condition. 4. Determine the need for ALS care and/or transport to hospital for further evaluation and treatment. 5. Have the patient stop doing any work or physical exertion. 6. Remove as much clothing from patients as possible. 7. Have the patient rest in shaded or cooler area. 8. Aggressively cool patient with tepid or cool (not cold or iced) water and/or towels soaked with tepid water; the more skin surface actively cooled, the better. a. Increase airflow over the moist skin to increase evaporation. b. Avoid inducing shivering, which is one of the body's mechanisms for warming itself. c. Monitor mental status and core body temperature (rectal) temperature to avoid over-cooling, if possible. d. Watch for rebound hyperthermia when measures are discontinued after initial cooling, and restart if core body temperature exceeds 1010 F. VIII I Environmental Emergencies KLFD BLS&ALS PROTOCOLS Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC 72 e. Provide supplemental oxygen to keep 02 saturation at a minimum of 94%. 9. Provide oral hydration with water, diluted fruit juice, or diluted sports drink (50:50 with water), if patient is awake and able to swallow and mental status is intact. 10. For heat stroke, consider ground transportation to the nearest hospital as rapidly as possible. 11. Monitor core body temperature, oxygen saturation, lung sounds, and mental status. 12. Continue supportive care and monitor vital signs until patient is turned over to an ALS transport unit. ALS 1. Confirm the completion of BLS steps 1-11. 2. Initiate 0.9% Normal Saline via IV/10 at 250 ml/hr., up to a maximum total of 3,000 ml. 3. Obtain 12-lead ECG and monitor cardiac rhythm and treat any dysrhythmia according to current American Heart Association (AHA) ACLS guidelines. 4. If patient is seizing or combative and Systolic BP > 100 mm Hg, consider Midazolam (Versed): 2.0-5.0 mg IV/10, up to a maximum of 10 mg. Pediatric BLS 1. Follow BLS guidelines, adjusting for age/size of patient. 2. Pediatric patients are more susceptible to heat extremes than adults. 3. Monitor core body temperature. ALS 1. Follow BLS guidelines, adjusting for age/size of patient. 2. Pediatric patients are more susceptible to heat extremes than adults. 3. Monitor core body temperature. 4. Initiate 0.9% Normal Saline via IV/I0at20ml/kg fluid bolus, uptoa maximum total infusion of 40 m I/kg. 5. Obtain 12-lead ECG and monitor cardiac rhythm and treat any dysrhythmia according to current American Heart Association (AHA) ACLS guidelines. VIII I Environmental Emergencies KLFD BLS&ALS PROTOCOLS Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC 73 7. If patient is combative, belligerent, or uncontrollable, consider any of the following sedative as a last resort, according to local protocols: a. Midazolam: Administer 1.0-5.0 mg (0.05 mg/kg) IV/10/IM; repeat every 5 minutes, up to a maximum of 0.1 mg/kg, if needed. d. If medications are administered, place them on cardiac monitor. Monitor cardiac rhythm and pulse oximetry. D. Hypothermia Review of Injury/Illness Hypothermia results when the body loses more heat to the environment than it can generate metabolically. Hypothermia is a cold injury of greatest significance. Signs and Symptoms Mild hypothermia (core body temperature 98.6-92° F) * Shivering * Unable to perform complex tasks with hands * Poor judgment * Amnesia Moderate hypothermia (core body temperature 91-86° F) * Violent shivering to potential loss of shivering reflex * Dazed consciousness, slurred speech, irrational behavior * loss of fine motor coordination * Dilated pupils * Mild to moderate hypotension * Diminished respiratory rate and effort Severe hypothermia (core body temperature <_ 850 F) * Shivering occurs in waves until it ceases as body temp drops * Severe altered mental status * Absent response to pain * Muscle rigidity, skin becomes pale VIII I Environmental Emergencies KLFD BLS&ALS PROTOCOLS Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC 74 * Pupils dilate, pulse rate decreases, breathing becomes erratic * Cardiac abnormalities, hypotension Hypothermia Management BLS 1. Evaluate scene safety. DO NOT approach patient if scene cannot be rendered safe. 2. Institute appropriate Body Substance Isolation (BSI) measures/Universal Precautions, as outlined in Protocol I.A. 3. Perform patient assessment and initiate routine BLS care, as outlined in Protocol I.A, and as indicated by the patient's condition. 4. Determine the need for ALS care and/or transport to hospital for further evaluation and treatment. S. Monitor core body temperature. 6. Assess for possible hypoglycemia and treat. (Refer to Protocol II.C.) 7. Move patient to warm place if feasible: a. Handle gently in moderate to severe hypothermia as jostling can precipitate cardiac arrhythmias. b. DO NOT massage or vigorously manipulate the patient. 8. Minimize patient's exposure to weather. 9. Replace wet clothing with dry, if possible. 10. Passive re-warming: a. Wrap in rescue blanket if available. b. Ensure adequate insulation between patient and ground. 11. Active re-warming: a. Hot packs to neck, groin, and armpits, if available. b. Discourage PO intake if hypothermia is moderate or severe. c. Assist ventilations with BVM and 02. VIII I Environmental Emergencies KLFD BLS&ALS PROTOCOLS Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC 75 d. Begin CPR if the patient deteriorates and loses spontaneous respiration or pulses. In general, CPR should not be considered unsuccessful and terminated until patient has been warmed (core body temperature > 95' F. 12. Continue supportive care and monitor vital signs, including core body temperature (rectal), until patient is turned over to a higher level of medical care. ALS 1. Confirm the completion of BLS steps 1-11. 2. Initiate 0.9% Normal Saline via IV/10. Administer initial bolus of 250 ml. Use warm fluids, if available. 3. Obtain 12-lead ECG and monitor cardiac rhythm and treat any dysrhythmia according to current American Heart Association (AHA) ACLS guidelines. 4. If hypoglycemic: a. Administer D50W: 25 gm IV/10. 5. If there is suspected opiate overdose, administer naloxone 0.4-2.0 mg slow IV/10/IM/Intranasal (if delivery device is available), up to a maximum of 6 mg, every 2-3 minutes. Titrate to adequate respiratory effort. 6. Continue re-warming and monitoring. Pediatric BLS 1. Follow BLS guidelines, adjusting for patient age/size. ALS 1. Follow BLS guidelines, adjusting for patient age/size. 2. Initiate 0.9% Normal Saline via IV/10. Administer initial bolus of 20 ml/kg. 3. Obtain 12-lead ECG and monitor cardiac rhythm and treat any dysrhythmia according to current American Heart Association (AHA) ACLS guidelines. 4. Continue re-warming and monitoring. E. Diving-related Emergencies Review of Injury/Illness VIII I Environmental Emergencies KLFD BLS&ALS PROTOCOLS Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC 76 The most common dive-related medical presentations involve minor ear disorders, but systemic and life-threatening emergencies occur every year. These include arterial gas emboli (AGE), decompression sickness (DCS), and barotraumas to the ears and other locations. 1. When dealing with a diving-related incident, it is important to transport the diver's equipment with him during evacuation, so it can be inspected and possibly analyzed. DO NOT clear patient's dive computer. The dive history obtained from a patient by an EMS provider should include at a minimum: the times, duration and depth of dives (includes bottom time), as well as the number of dives over the previous 3 days, surface intervals, activity performed while diving, and whether the dive(s) were complicated by events such as entrapment, running out of air, or rapid ascent. It is also important to record the time and rapidity of onset of symptoms. 2. Flying too soon after diving increases the risk of decompression sickness (DCS) and other dive-related problems. (Refer to Protocol VIII.F, Protocol VIII.G, Protocol VIII.H.) Minimum Flight Delay, Dive History 12 hrs Single, no-decompression dive 18 hrs Multi-day, no-decompression dives 24 hrs Decompression required dive(s) 3 days If treated for DCS or arterial embolis(AGE) F. Decompression Sickness (DCS) Review of Injury/Illness DCS, commonly known as "the Bends," is an emergency condition requiring treatment in a decompression chamber. DCS most often occurs within the first 1-6 hours after diving; further deterioration is unlikely to occur after 24 hours. The onset of symptoms is directly related to the severity of the DCS; in severe cases, symptoms occur more rapidly. Several forms of DCS primarily affect the nervous system, muscles,joints, skin, inner ear and cardiopulmonary system. At depth and under pressure (P), gas is absorbed into the tissues proportionate to depth and exposure time. Significant absorption most likely occurs following dives to depths > 33 feet of sea water (FSW). DCS results from the formation of bubbles of inert gas (e.g., nitrogen) within the intravascular and extravascular spaces as the diver ascends to the surface, when the ascent is too rapid to allow nitrogen to be released that is absorbed in the tissues during the dive. Signs and Symptoms Depending on the distribution of gas bubbles throughout the body, DCS may create a variety of symptoms: VIII I Environmental Emergencies KLFD BLS&ALS PROTOCOLS Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC 77 * Pruritus (early symptom), skin rash * Unusual fatigue * Joint pain, abdominal or thoracic pain ("girdling" pain) * Shortness of breath, frothy sputum, hemoptysis * Dizziness, vertigo, tinnitus, parasthesia, paralysis, seizures,tremors, staggering * Altered mental status, confusion, amnesia, behavioral changes Management BLS 1. Evaluate scene safety. DO NOT approach patient if scene cannot be rendered safe. 2. Institute appropriate Body Substance Isolation (BSI) measures/Universal Precautions, as outlined in Protocol I.A. 3. Perform patient assessment and initiate routine BLS care, as outlined in Protocol I.A. and as indicated by the patient's condition. 4. Determine the need for ALS care and/or transport to hospital for further evaluation and treatment. 5. Primary treatment is recompression in a hyperbaric chamber. 6. Keep patient supine. 7. Administer oxygen, if available: 10-15 L/min by non-rebreathing mask to keep 02 saturation at minimum of94%. 8. Transport diver's equipment with patient during evacuation for inspection and possible analysis. DO NOT clear patient's dive computer. AILS 1. Confirm the completion of BLS steps 1-8. 2. Initiate 0.9% Normal Saline via IV/10 at KVO or saline lock. 3. If seizures develop, consult medical control before administering IV benzodiazepines (e.g., midazolam). G. Arterial Gas Emboli (AGE) VIII I Environmental Emergencies KLFD BLS&ALS PROTOCOLS Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC 78 Review of Injury/Illness Arterial gas emboli (AGE) is the most common cause of sudden death in diving. Sudden collapse or loss of consciousness immediately or soon after surfacing should always be treated as AGE until proven otherwise. A complication of pulmonary barotrauma (PBT), AGE may cause near- drowning during ascent. It is most commonly seen in panicked or inexperienced divers making a rapid ascent while holding their breath, as the rapidly expanding air ruptures the pulmonary alveoli and allows gas bubbles to enter the blood stream across the capillary membranes. These bubbles may cause sudden loss of perfusion to the brain, heart, and other vital organs. Massive gas loading of the vasculature causes cardiac arrest that is refractory to resuscitation efforts. Signs and Symptoms * Abrupt onset of symptoms occurring during ascent or within 10 minutes after surfacing * Stupor, confusion, vertigo, coma, convulsions * Unilateral or bilateral motor or sensory deficits * Visual disturbances Symptoms may also include: * Aphasia * Headache * Chest pain related to myocardial ischemia * Cardiac arrhythmias, cardiac arrest * Symptoms of other barotrauma and decompression sickness (DCS) may also be present Management BLS 1. Evaluate scene safety. DO NOT approach patient if scene cannot be rendered safe. 2. Institute appropriate Body Substance Isolation (BSI) measures/Universal Precautions, as outlined in Protocol I.A. 3. Perform patient assessment and initiate routine BLS care, as outlined in Protocol I.A, and as indicated by the patient's condition. 4. Determine the need for ALS care and/or transport to hospital for further evaluation and treatment. VIII I Environmental Emergencies KLFD BLS&ALS PROTOCOLS Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC 79 5. Primary treatment is recompression in a hyperbaric chamber. 6. Keep patient supine. 7. Administer oxygen, if available: 10-15 L/min NRBM to keep 02 saturation at a minimum of 94%. 8. Transport diver equipment with patient during evacuation for inspection and possible analysis. DO NOT clear patient's dive computer. Urgently transport for decompression. ALS 1. Confirm the completion of BLS steps 1-9. 2. Initiate 0.9% Normal Saline via IV/10 at KVO or saline lock. a. DCS patients are often hypovolemic. 3. If seizures develop, consult medical control before administering IV benzodiazepines (e.g., midazolam). H. Barotrauma of the Ear Review of Injury/Illness There are 3 barotraumas related to the ear: 1. External ear barotrauma: Also known as barotitis externa media interna or "ear canal squeeze"; caused by air trapped in the external auditory canal (EAC) by: a. Cerumen impaction. b. Exocytoses (chronic narrowing of the EAC). c. The use of ear plugs or a tight wet suit hood. 2. Middle Ear Barotrauma: a. Barotitis media or "ear squeeze" and "reverse ear squeeze." b. Caused by failure of middle ear to equalize to ambient pressure (P). 3. Inner Ear Barotrauma (IEB): a. Also known as barotitis interna or labyrinthine window rupture. b. Caused by the pressure differential between the inner ear and ambient pressure. VIII I Environmental Emergencies KLFD BLS&ALS PROTOCOLS Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC 80 c. IEB may cause injury to the cochleovestibular system of the inner ear, may lead to permanent vestibular dysfunction or deafness. d. It is important to distinguish IEB from the dizziness, balance problems, nausea, and vomiting that are also symptoms of decompression sickness (DCS). Signs and Symptoms External Ear Barotrauma * Pain, swelling, and erythema to the EAC * Petechiae or hemorrhagic blebs may be seen on the walls of the EAC Middle Ear Barotrauma * Pain, begins as slight pain and progressively worsens on descent/ascent * Impaired hearing * Nasal congestion * Tympanic membrane (ear drum) rupture • Sudden severe pain • Vertigo, as water enters into the middle ear • Total loss of hearing in the affected ear * Blood may be seen around the mouth and nose as well as in the EAC Inner Ear Barotrauma * Sudden pain, dizziness, vertigo, may be extreme * Nausea and vomiting (vomiting underwater may lead to drowning) * "Roaring"tinnitus, hearing loss * Nystagmus, ataxia, facial nerve paralysis * Pallor, diaphoresis, disorientation * Ear may feel "blocked" or patient may relate a feeling of"fullness" in the ear * Differentiation from inner ear Decompression Sickness (DCS): • IEB is usually associated with ear pain and clearing difficulties upon descent • In IEB, evidence of other barotraumas may be seen on ear exam VIII I Environmental Emergencies KLFD BLS&ALS PROTOCOLS Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC 81 • In inner ear DCS, symptoms are often noted upon ascent or shortly after surfacing • Other symptoms of decompression sickness are often present with inner ear DCS Management BLS 1. Evaluate scene safety. DO NOT approach patient if scene cannot be rendered safe. 2. Institute appropriate Body Substance Isolation (BSI) measures/Universal Precautions, as outlined in Protocol I.A. 3. Perform patient assessment and initiate routine BLS care, as outlined in Protocol I.A, and as indicated by the patient's condition. 4. Determine the need for ALS care and/or transport to hospital for further evaluation and treatment. 8. Continue supportive care and monitor vital signs until the patient is turned over to an ALS transport unit. ALS 1. Confirm the completion of BLS steps. 2. Initiate 0.9% Normal Saline via IV/10 at KVO or saline lock. I. Envenomations Snakes and Spiders Review of Injury/Illness Snake and spider bites can cause damage to body tissue at the location of the bite and, if venomous, can cause both local tissue injury and systemic reactions. A snakebite, whether from a venomous or non-venomous snake, may cause severe fright reactions (e.g., nausea, tachycardia, diaphoresis), which may be difficult to distinguish from systemic manifestations of envenomation. Non -venomous snakebites cause only local injury, usually pain and 2-4 rows of scratches from the snake's upper jaw at the bite site. It is important to know and recognize all species of venomous snakes that are indigenous to areas of operation. Spiders are identified by location and markings. Black widow spiders live outdoors in protected spaces (e.g., rock piles, firewood cords, hay bales, outhouses) and have a red or orange hourglass marking on the ventral (upper side) abdomen. Brown recluse spiders live indoors in protected spaces (e.g., in clothing, behind furniture, under baseboards) and have a fiddle- or violin-like marking from the eyes to the abdomen.This marking may be difficult to recognize even in the intact spider. VIII I Environmental Emergencies KLFD BLS&ALS PROTOCOLS Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC 82 Signs and Symptoms * Local bite wound * Swelling, severe allergic reaction * Bleeding * Ecchymosis at site * Localized pain * Weakness * Tachycardia * Nausea * Shortness of breath * Respiratory arrest * Dim vision * Vomiting and/or shock Management BLS 1. Evaluate scene safety. DO NOT approach patient if scene cannot be rendered safe. 2. Institute appropriate Body Substance Isolation (BSI) measures/Universal Precautions, as outlined in Protocol I.A. 3. Perform patient assessment and initiate routine BLS care, as outlined in Protocol I.A, and as indicated by the patient's condition. 4. Determine the need for ALS care and/or transport to hospital for further evaluation and treatment. 5. Calm and reassure the patient. 6. Assess and treat for anaphylaxis. (Refer to Protocol X.A.) 7. Secure and maintain airway and administer supplemental oxygen via non-rebreathing mask (NRBM), as needed. 8. Assess and treat for shock. (Refer to Protocol X.I.) VIII I Environmental Emergencies KLFD BLS&ALS PROTOCOLS Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC 83 9. Prepare for immediate transport. (DO NOT delay transport for any first aid/treatment measures or wait for signs of envenomation to occur.) 9. DO NOT apply any constricting bands, ice, or suction to the bite. 10. Remove ALL watches, rings and jewelry, not just from affected limbs. 11. Mark the proximal edge of any discoloration or swelling in ink and write the time on the line. If signs increase during treatment, make new marks with the times, if possible. 12. Dress the wound and immobilize the extremity. 13. If the snake or spider is identified in the field, notify receiving facility of type of bite and patient's condition ASAP in case they need to initiate acquisition of antivenin. 14. Notify on-line medical direction of the situation so that antivenins can be obtained. 15. Continue supportive care and monitor vital signs until the patient is turned over to an ALS transport unit. ALS 1. Confirm completion of BLS steps 1-14. 2. Initiate 0.9% Normal Saline via IV/10 at KVO or saline lock 3. Monitor cardiac rhythm and treat any dysrhythmia according to current American Heart Association (AHA) ACLS guidelines. Pediatric BLS 1. Follow BLS guidelines, adjusting for patient age/size. ALS 1. Follow BLS guidelines, adjusting for patient age/size. 2. Initiate 0.9% Normal Saline via IV/10 at KVO or saline lock. 3. Monitor cardiac rhythm and treat any dysrhythmia according to current American Heart Association (AHA) ACLS guidelines. J. Marine Bites and Stings Corals and Jellyfish VIII I Environmental Emergencies KLFD BLS&ALS PROTOCOLS Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC 84 Review of Injury/Illness Most marine bites and stings are at least transiently painful, while some involve envenomation as well. All create wounds at risk of infection with marine organisms. The most common encounters are with a class of marine animals called Cnidaria and they include the following: • Corals • Sea anemones • Jellyfish (e.g., sea nettles) • Hydroids (e.g., Portuguese man-of-war) Cnidaria are responsible for more envenomation's than any other marine animal. However, of the 9,000 species, only about 100 are toxic to humans. The multiple, highly developed stinging units (nematocysts) on Cnidaria tentacles can penetrate human skin; one tentacle may fi re thousands of nematocysts into the skin on contact. Signs and Symptoms * Lesions vary with the type of Cnidaria. * Usually, lesions initially appear as small, linear, papular eruptions that develop rapidly in one or several discontinuous lines, at times surrounded by a raised erythematous zone. * Pain is immediate and may be severe; itching is common. * The papules may blister and proceed to formation of painful, raised pustules, hemorrhage, and eventual peeling of the skin. * Systemic manifestations include weakness, nausea, headache, muscle pain and spasms, tearing of the eyes and nasal discharge, increased perspiration, changes in pulse rate, and pleuritic chest pain. * Uncommonly, fatal injuries have been inflicted by the Portuguese man-of-war in North American waters and by the box jellyfish (sea wasp, Chironex fleckeri), in Indo-Pacific waters. Management BLS 1. Evaluate scene safety. DO NOT approach patient if scene cannot be rendered safe. 2. Institute appropriate Body Substance Isolation (BSI) measures/Universal Precautions, as outlined in Protocol I.A. VIII I Environmental Emergencies KLFD BLS&ALS PROTOCOLS Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC 85 3. Perform patient assessment and initiate routine BLS care, as outlined in Protocol LA, and as indicated by the patient's condition. 4. Determine the need for ALS care and/or transport to hospital for further evaluation and treatment. 5. Calm and reassure the patient. 6. Assess and treat for anaphylaxis. (Refer to Protocol X.A.) 7. Secure and maintain airway and administer supplemental oxygen via non-rebreathing mask (NRBM), as needed. 8. Assess and treat for shock. (Refer to Protocol X.I.) 9. For pain relief due to stings, administer hot water or cold packs (whichever feels better). 10. Pain caused by jellyfish, usually short-lived, can be relieved with baking soda in a 50:50 slurry applied to the skin, or by papain (meat tenderizer) applied as a paste for a period not to exceed 15 minutes. 11. Jellyfish-type sting treatment includes removal of adherent tentacles with forceps (preferably) or fingers (double-gloved if possible) and liberal rinsing to remove invisible stinging cells (nematocysts). The type of rinse varies by the stinging organism: a. For jellyfish stings sustained in non-tropical waters and for coral stings, seawater rinse can be used. b. For jellyfish stings sustained in tropical waters, vinegar rinse followed by seawater rinse should be used. Fresh water should not be used because it can activate undischarged nematocysts. c. For box jellyfish stings, vinegar inhibits nematocyst firing and is used as the initial rinse if available, followed by seawater rinse. Fresh water should not be used because it can activate undischarged nematocysts. Notify on-line medical direction of the situation so that antivenins can be obtained. (Antivenin is only available for C. fleckeri species.) d. For Portuguese man-of-war stings, saltwater rinse can be used. Vinegar should not be used because it can activate undischarged nematocysts. 13. Continue supportive care and monitor vital signs until the patient is turned over to an ALS transport unit. VIII I Environmental Emergencies KLFD BLS&ALS PROTOCOLS Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC 86 ALS 1. Confirm the completion of BLS Steps 1-12. 2. Provide advanced airway support, if necessary. (Refer to Protocol I.B.) 3. Initiate 0.9% Normal Saline via IV/10 at KVO or saline lock. Pediatric BLS 1. Follow BLS guidelines, adjusting for patient age/size. ALS 1. Follow BLS guidelines, adjusting for patient age/size. 2. Initiate 0.9% Normal Saline via IV/10 at KVO or saline lock. 3. Monitor cardiac rhythm and treat any dysrhythmia according to current American Heart Association (AHA) ACLS guidelines. Seabather's Eruption Review of Injury/Illness This condition affects swimmers in some Atlantic locales (e.g., Florida, Caribbean, Long Island). It is caused by hypersensitivity to stings from the larvae of the sea anemone (e.g., Edwardsiella lineate) or the thimble jellyfish (Linuche unguiculata). Signs and Symptoms * Itchy, stinging rash typically appearing where the bathing suit contacts the skin Management BLS 1. Evaluate scene safety. DO NOT approach patient if scene cannot be rendered safe. 2. Institute appropriate Body Substance Isolation (BSI) measures/Universal Precautions, as outlined in Protocol I.A. 3. Perform patient assessment and initiate routine BLS care, as outlined in Protocol I.A, and as indicated by the patient's condition. 4. Determine the need for ALS care and/or transport to hospital for further evaluation and treatment. VIII I Environmental Emergencies KLFD BLS&ALS PROTOCOLS Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC 87 5. Calm and reassure the patient. 6. Assess and treat for anaphylaxis. (Refer to Protocol X.A.) 7. Encourage patients to sit in a shaded area and wait for conditions to ease. 8. People exposed to these larvae should shower after taking off their bathing suit. 9. Cutaneous manifestations can be treated with hydrocortisone lotion and an oral antihistamine, if needed. 10. Continue supportive care and monitor vital signs until the patient is turned over to an ALS transport unit. ALS 1. Confirm the completion of BLS steps 1-9. 2. Initiate 0.9% Normal Saline via IV/10 at KVO or saline lock, if necessary. Pediatric BLS 1. Follow BLS guidelines, adjusting for patient age/size. AILS 1. Follow BLS guidelines, adjusting for patient age/size. 2. Initiate 0.9% Normal Saline via IV/10 at KVO or saline lock, if necessary. VIII I Environmental Emergencies KLFD BLS&ALS PROTOCOLS Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC 88 0 fl f y!/ b III � If ` I�� r✓ A i m. 141 wr fin" Brown Recluse Spider Black Widow Spider Highly venomous ScorpionThey have thick tails and thin pincers. Not usually in the Keys. III � I I Non-venomous Wolf Spider Brown Widow Spider Non-venomous Scorpion-They p have thin tails and broad, well- developed pincers. Common in the Keys- both black and brown VIII I Environmental Emergencies KLFD BLS&ALS PROTOCOLS Docusign Envelope ID:D9C280B0-04D5-4D4C-A898-A72C90C71AEC 89 IX. Trauma The following patients should be transported to a Trauma Center: • Trauma patients with unstable or abnormal vital signs • Patients with major and/or multiple system trauma • Complex or extensive injury to hands, tissues, and nerves of low extremity • Contraindication for Referral to Pediatric or Adult Trauma Center— Patients with toe amputation (partial or complete) A. Extremity wound hemorrhage Review of Injury/illness Uncontrolled bleeding from an extremity wound, especially one involving major or deep arteries, can result in life threatening blood loss. Massive, rapid swelling of an extremity following blunt trauma with or without bruising or discoloration may suggest bleeding even without obvious surface laceration. Personnel engaged in military and law enforcement operations are at increased risk for penetrating trauma and exsanguinating wounds. Tourniquets are sometimes the best way to manage life-threatening bleeding from an extremity. Tourniquets placed on conscious patients can be painful and pain management should be considered. Sins and Symptoms * Obvious bleeding at the site of wound * Deep scraping of extremity area (e.g., road rash from a motorcycle accident) with substantial, oozing blood * Swelling of the extremity, usually with obvious bruising * Altered mental status from blood loss and ensuing shock Management BLS 1. Evaluate scene safety. DO NOT approach patient if scene cannot be rendered safe. 2. Institute appropriate Body Substance Isolation (BSI) measures/Universal Precautions, as outlined in Protocol I.A. IX I Trauma KLFD BLS&ALS PROTOCOLS Docusign Envelope ID:D9C280B0-04D5-4D4C-A898-A72C90C71AEC 90 3. Perform patient assessment and initiate routine BLS care, as outlined in Protocol I.A, and as indicated by the patient's condition. 4. Determine the need for ALS care and/or transport to hospital for further evaluation and treatment. 5. Calm and reassure patient. 6. Secure and maintain airway and administer supplemental oxygen, as needed. 7. Assess and treat for shock. (Refer to Protocol X.I.) 8. Check for obvious glass or foreign body that could cause further injury, if pressed into wound. 9. Wrap bleeding area with trauma pads or dressing appropriate for the size and location of the wound. 10. Apply direct pressure and elevate until bleeding is controlled, if possible. If the patient is able, have him/her apply direct pressure after dressing the wound. 11. If bleeding CANNOT be controlled by direct pressure: a. Apply a tourniquet proximal to the wound. • Use a commercially available tourniquet, Combat Application Tourniquet (CAT), 2-4 inches proximal to the wound. b. DO NOT apply tourniquet directly over a joint. c. Tighten the tourniquet just enough to control/stop the bleeding. This is generally tight enough so that pulses distal to the tourniquet are not palpable. d. Document the time that the tourniquet was applied to the patient. NEVER skip these steps when a tourniquet is in place. e. Always leave the wound and tourniquet sites uncovered so that any additional bleeding can be observed and treated accordingly. 12. Continue supportive care and monitor vital signs until the patient is turned over to an ALS transport unit. Consider the need for Aeromedical evacuation. ALS 1. Confirm the completion of BLS Steps 1-11. 2. Initiate 0.9% Normal Saline via IV/10 at KVO or saline lock. IX JTrauma KLFD BLS&ALS PROTOCOLS Docusign Envelope ID:D9C280B0-04D5-4D4C-A898-A72C90C71AEC 91 3. Obtain 12-lead ECG and monitor cardiac rhythm and treat any dysrhythmia according to current American Heart Association (AHA) ACLS guidelines. Pediatric BLS 1. Follow BLS guidelines, adjusting for patient age/size. ALS 1. Follow BLS guidelines, adjusting for patient age/size. 2. Initiate 0.9% Normal Saline via IV/10 at KVO or saline lock. B. Amputations Review of Injury/illness Patients with severe bone and/or soft tissue injury at or distal to the level of the mid-humerus, including complete or incomplete amputations of the hand, crush or degloving injuries, and other trauma resulting in loss of perfusion or suspected nerve injury (e.g., compartment syndrome) should be referred to nearest Trauma Center if: • They are stable with an isolated upper extremity injury at or below the mid-humerus • They have complete/incomplete hand or upper extremity amputation • There is partial/complete finger or thumb amputation • There is degloving, crushing, or devascularization injuries of hand or upper extremity • There is high-pressure injection injury to hand or upper extremity • There is complicated nerve, vessel, or compartment syndrome (excessive swelling and pain of extremity with possible evolving nerve deficit) injury of the forearm and hand. Management BLS 1. Evaluate scene safety. DO NOT approach patient if scene cannot be rendered safe. 2. Institute appropriate Body Substance Isolation (BSI) measures/Universal Precautions. as outlined in Protocol I.A. 3. Perform patient assessment and initiate routine BLS care, as outlined in Protocol I.A, and as indicated by the patient's condition. IX I Trauma KLFD BLS&ALS PROTOCOLS Docusign Envelope ID:D9C280B0-04D5-4D4C-A898-A72C90C71AEC 92 4. Determine the need for ALS care and/or transport to hospital for further evaluation and treatment. 5. Calm and reassure patient. 6. Secure and maintain airway and administer supplemental oxygen, as needed. 7. Assess and treat for shock. (Refer to Protocol X.I.) 8. Control extremity wound hemorrhage. (Refer to Protocol IX.A.) 9. Package amputated extremity in sealed plastic bag (keep dry) and place on top of ice to keep cool. DO NOT submerge in water or freeze amputated part. 10. Continue supportive care and monitor vital signs until the patient is turned over to an ALS transport unit. Consider the need for Aeromedical evacuation to the nearest Trauma Center. ALS 1. Confirm the completion of BLS steps 1-9. 2. Initiate 0.9% Normal Saline via IV/10 250 ml fluid bolus, up to a maximum total infusion of 2,000 ml without consulting on-line medical direction. 3. Obtain 12-lead ECG and monitor cardiac rhythm and treat any dysrhythmia according to current American Heart Association (AHA) ACLS guidelines. Pediatric BLS 1. Follow BLS guidelines, adjusting for patient age/size. ALS 1. Follow BLS guidelines, adjusting for patient age/size. 2. Initiate 0.9% Normal Saline via IV/10 at 20 ml/kg fluid bolus, up to a maximum total infusion of 40 ml/kg. C. Multi-system Trauma Review of Injury/illness Multi-system trauma refers to injuries involving more than one organ system and/or more than one area of the body. A patient with limb fracture(s) and significant head/neck injury, or one with trauma to both the chest and abdomen are examples of multi-system trauma. It is associated with an injury severity score > 17 and increased likelihood of death or a complicated IX I Trauma KLFD BLS&ALS PROTOCOLS Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC 93 clinical course and protracted time to recovery. It is important that EMS providers report scene findings that help estimate the severity of the injury. Signs and Symptoms * Hypovolemic or neurogenic shock * Pain, bruising, bleeding * Hypertension * Rapid or slow heart rate * Shallow or absent respirations * Decreased distal pulses * Decreased motor and sensory function in extremities * Deformities or obvious f ractu res/lacerations * Altered mental states or unconsciousness * Intercranial herniation • Posturing (decerebrate or decorticate) • Unequal pupils • Paralysis • Decreasing Glasgow Coma Scale Scores Management BLS 1. Evaluate scene safety. DO NOT approach patient if scene cannot be rendered safe. 2. Institute appropriate Body Substance Isolation (BSI) measures/Universal Precautions. as outlined in Protocol I.A. 3. Perform patient assessment and initiate routine BLS care, as outlined in Protocol I.A, and as indicated by the patient's condition. 4. Determine the need for ALS care and/or transport to hospital for further evaluation and treatment. 5. Calm and reassure patient. IX I Trauma KLFD BLS&ALS PROTOCOLS Docusign Envelope ID:D9C280B0-04D5-4D4C-A898-A72C90C71AEC 94 6. Secure and maintain airway and administer supplemental oxygen via non-rebreathing mask (NRBM) at high concentration. Assist ventilations with a bag valve mask (BVM) device, as needed. 7. If patient exhibits signs of intercranial herniation, hyperventilate at 20 breaths/minute, after consulting on-line medical direction. 8. Control extremity wound hemorrhage. (Refer to Protocol IX.A.) 9. Assess and treat for shock. (Refer to Protocol X.I.) 10. Maintain appropriate spine immobilization, according to Protocol IX.E. (Any trauma patient with suspected spinal injuries based on mechanism of injury should have fullbody spinal immobilization.) 11. Consider pelvic stabilization, if indicated. 12. Continue supportive care and monitor vital signs until the patient is turned over to an ALS transport unit. Consider the need for Aeromedical evacuation to the nearest Trauma Center. ALS 1. Confirm the completion of BLS steps 1-9. 2. Provide advanced airway support, if necessary. (Refer to Protocol I.B.) 3. Initiate 0.9% Normal Saline IV/10 250-500 ml bolus, up to a maximum total infusion of 2,000 ml without consulting on-line medical direction.Titrate to a Systolic BP = 100 mm Hg. 4. Obtain 12-lead ECG and monitor cardiac rhythm and treat any dysrhythmia according to current American Heart Association (AHA) ACLS guidelines. Pediatric BLS 1. Follow BLS guidelines, adjusting for patient age/size. 2. If patient exhibits signs of intercranial herniation, hyperventilate at 30 breaths/minute (child) or 35 breaths/minute (infant), after consulting on-line medical direction. ALS 1. Follow the BLS guidelines, adjusting for patient age/size. 2. Provide advanced airway support, if necessary. (Refer to Protocol I.B.) IX JTrauma KLFD BLS&ALS PROTOCOLS Docusign Envelope ID:D9C280B0-04D5-4D4C-A898-A72C90C71AEC 95 3. If patient exhibits signs of intercranial herniation, hyperventilate at 30 breaths/minute (child) or 35 breaths/minute (infant), after consulting on-line medical direction. 4. Initiate 0.9% Normal Saline via IV/10 at 20 ml/kg fluid bolus, up to a maximum total infusion of 40 ml/kg. D. Chest and Abdominal Injuries Review of Injury/Illness Chest and abdominal injuries are caused by penetrating or blunt forces applied to the torso. Respiratory distress may indicate pneumothorax; hypotension suggests tension pneumothorax or internal bleeding, both of which can cause rapid death if not treated promptly. Myocardial contusion can result in sudden arrythmias, including ventricular tachycardia and ventricular fibrillation with cardiac arrest. Sins and Symptoms * Pain, bruising, deformity of chest/abdomen following rapid deceleration (impact) injuries * Evidence of penetrating wound to the chest/abdomen by knife, bullet, or sharp object * Difficulty breathing and/or hypotension/shock Management BLS 1. Evaluate scene safety. DO NOT approach patient if scene cannot be rendered safe. 2. Institute appropriate Body Substance Isolation (BSI) measures/Universal Precautions. as outlined in Protocol I.A. 3. Perform patient assessment and initiate routine BLS care, as outlined in Protocol I.A, and as indicated by the patient's condition. 4. Determine the need for ALS care and/or transport to hospital for further evaluation and treatment. 5. Calm and reassure patient. 6. Perform airway management for unconscious patients—Chin lift or jaw thrust maneuver NP or OP airway and ventilate if necessary. 7. Secure and maintain airway and administer supplemental oxygen via non-rebreathing mask (NRBM) at high concentration. Assist ventilations with a bag valve mask (BVM) device, as needed. IX I Trauma KLFD BLS&ALS PROTOCOLS Docusign Envelope ID:D9C280B0-04D5-4D4C-A898-A72C90C71AEC 96 8. All open and/or sucking chest wounds should be treated by immediately applying a Chest Seal (Entry/ Exit). Monitor lung sounds and trachea position for development of tension pneumothorax. 9. Control extremity wound hemorrhage. (Refer to Protocol IX.A.) 10. Assess and treat for shock. (Refer to Protocol X.I.) 11. Continue supportive care and monitor vital signs until the patient is turned over to an ALS transport unit. Consider the need for Aeromedical evacuation to the nearest Trauma Center. ALS 1. Confirm the completion of BLS steps 1-10. 2. Provide advanced airway support, if necessary. (Refer to Protocol I.B.) 3. Initiate 0.9% Normal Saline IV/10 250-500 ml bolus, up to a maximum total infusion of 2,000 ml without consulting on-line medical direction.Titrate to a Systolic BP = 100 mm Hg. 4. Obtain 12-lead ECG and monitor cardiac rhythm and treat any dysrhythmia according to current American Heart Association (AHA) ACLS guidelines. Pediatric BLS 1. Follow the BLS guidelines, adjusting for patient age/size. ALS 1. Follow the BLS guidelines, adjusting for patient age/size. 2. Provide advanced airway support, if necessary. (Refer to Protocol I.B.) 3. Initiate 0.9% Normal Saline via IV/10 at 20 ml/kg fluid bolus, up to a maximum total infusion of 40 ml/kg. 4. Obtain 12-lead ECG and monitor cardiac rhythm and treat any dysrhythmia according to current American Heart Association (AHA) ACLS guidelines. Apply pediatric pads. E. Spinal Cord Injuries Review of Injury/Illness EMS responders are most likely to see spinal cord injuries, resulting from motor vehicle crashes, diving accidents, and falls. Young children and the elderly are especially vulnerable. IX JTrauma KLFD BLS&ALS PROTOCOLS Docusign Envelope ID:D9C280B0-04D5-4D4C-A898-A72C90C71AEC 97 Sins and Symptoms * Paralysis, numbness, or tingling sensation in one or more extremities * Obvious head or facial trauma * Loss of consciousness (mayor may not be present) Management 1. Evaluate scene safety. DO NOT approach patient if scene cannot be rendered safe. 2. Institute appropriate Body Substance Isolation (BSI) measures/Universal Precautions. as outlined in Protocol I.A. 3. Perform patient assessment and initiate routine BLS care, as outlined in Protocol I.A. and as indicated by the patient's condition. 4. Determine the need for ALS care and/or transport to hospital for further evaluation and treatment. 5. Calm and reassure patient. 6. Secure and maintain airway and administer supplemental oxygen via non-rebreathing mask (NRBM) at high concentration. Assist ventilations with a bag valve mask (BVM) device, as needed. 7. Maintain appropriate spine immobilization, according to Protocol IX.E. (Any trauma patient with suspected spinal injuries based on mechanism of injury should have fullbody spinal immobilization.) 8. Consider pelvic stabilization, if indicated. 9. Assess and treat for shock. (Refer to Protocol X.I.) 10. Continue supportive care and monitor vital signs until the patient is turned over to an ALS transport unit. Consider the need for Aeromedical evacuation to the nearest Trauma Center. ALS 1. Confirm the completion of BLS steps 1-8. 2. Provide advanced airway support, if necessary. (Refer to Protocol I.B.) 3. Initiate 0.9% Normal Saline IV/10 250-500 ml bolus, up to a maximum total infusion of 2,000 ml without consulting on-line medical direction.Titrate to a Systolic BP = 100 mm Hg. IX I Trauma KLFD BLS&ALS PROTOCOLS Docusign Envelope ID:D9C280B0-04D5-4D4C-A898-A72C90C71AEC 98 4. Obtain 12-lead ECG and monitor cardiac rhythm and treat any dysrhythmia according to current American Heart Association (AHA) ACLS guidelines. Pediatric BLS 1. Follow the BLS guidelines, adjusting for patient age/size. ALS 1. Follow the BLS guidelines, adjusting for patient age/size. 2. Provide advanced airway support, if necessary. (Refer to Protocol I.B.) 3. Initiate 0.9% Normal Saline via IV/10 at 20 ml/kg fluid bolus, up to a maximum total infusion of 40 m I/kg. F. Selective Spinal Immobilization Review of Injury/illness In rescue situations,field evacuation of an immobilized patient on a backboard significantly extends the time required and increases the risk of further injury to both the patient and the rescuers. Under the circumstances, it is imperative that the patient's C-spine be evaluated and if possible, cleared, allowing the patient to participate more in the evacuation and reducing the travel time to definitive care. C-spine clearance can be performed in the fi eld with approximately 99%certainty, for all eligible and injured patients using the NEXUS protocol. Procedure (NEXUS Protocol) BLS ALS 1. Assess and treat for possible spinal cord injury. (Refer to Protocol IX.E.) 2. It is not necessary to immobilize the C-spine if the patient meets ALL the following criteria: a. The patient is conscious and not under the influence of drugs or alcohol. b. No other distracting injury that might mask the pain of a cervical injury is present. c. No neck pain is present. d. No cervical tenderness or bony "step off" of the cervical spine is present upon examination and palpation. e. The patient can move all four extremities. IX JTrauma KLFD BLS&ALS PROTOCOLS Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC 99 f. The patient denies numbness or parasthesia and has intact sensation to light touch in all four extremities. 3. Contact on-line medical direction for further guidance. 4. Continue supportive care and monitor vital signs until the patient is turned over to an ALS transport unit. Special Rescue Considerations 1. There may still be instances when the patient can or must be evacuated ambulatory, even though the patient cannot be cleared using the NEXUS protocol (e.g., neck pain with no other findings). 2. The medical provider must use good judgment and balance the clinical findings and mechanism of injury with the risks versus benefits of evacuating an immobilized patient on a backboard. G. Electrical Burns and Lightning Injuries Review of Injury/Illness Electrical burns may be associated with other traumatic injuries, due to being thrown clear of the source and severe muscle contraction, especially following high voltage DC contact. Longer exposure to lower energy current results in skin and deep tissue burns. Si,Rns and Symptoms * "Entry" and "exit" site burns * Confusion and/or amnesia, with or without temporary loss of consciousness * Ear drum rupture * Fractures * Cardiac dysrhythmias/arrest Lightning injuries can range from minor wounds to serious traumatic injuries that can result in death. IX I Trauma KLFD BLS&ALS PROTOCOLS Docusign Envelope ID:D9C280B0-04D5-4D4C-A898-A72C90C71AEC 100 Management BLS 1. Evaluate scene safety. DO NOT approach patient if scene cannot be rendered safe. 2. Institute appropriate Body Substance Isolation (BSI) measures/Universal Precautions. as outlined in Protocol I.A. 3. Perform patient assessment and initiate routine BLS care, as outlined in Protocol I.A, and as indicated by the patient's condition. 4. Determine the need for ALS care and/or transport to hospital for further evaluation and treatment. 5. Calm and reassure patient. 6. Secure and maintain airway and administer supplemental oxygen, if necessary. Assist ventilations with a bag valve mask (BVM) device, as needed. 7. Maintain appropriate spine immobilization, according to Protocol IX.E. 8. Splint any fractures. 9. Dress any open wounds and/or burns. (Refer to Protocol V.) 10. Assess and treat for shock. (Refer to Protocol X.I.) 11. Continue supportive care and monitor vital signs until the patient is turned over to an ALS transport unit. Consider the need for Aeromedical evacuation to the nearest Trauma or Burn Center. ALS 1. Confirm the completion of BLS steps 1-8. 2. Provide advanced airway support, if necessary. (Refer to Protocol I.B.) 3. Initiate 0.9% Normal Saline via IV/10 at KVO or saline lock. 4. Obtain 12-lead ECG and monitor cardiac rhythm and treat any dysrhythmia according to current American Heart Association (AHA) ACLS guidelines. Pediatric BLS 1. Follow the BLS guidelines, adjusting for patient age/size. IX I Trauma KLFD BLS&ALS PROTOCOLS Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC 101 ALS 1. Follow the BLS guidelines, adjusting for patient age/size. 2. Provide advanced airway support, if necessary. (Refer to Protocol I.B.) 3. If hypotensive, initiate 0.9% Normal Saline via IV/10 at 20 ml/kg fluid bolus, up to a maximum total infusion of 40 ml/kg. 4. Obtain 12-lead ECG and monitor cardiac rhythm and treat any dysrhythmia according to current American Heart Association (AHA) ACLS guidelines. Apply pediatric pads. H. Orthopedic Bone and Joint Injuries Review of Injury/Illness These injuries are a result of a traumatic direct force or twisting action on a bone or joint. Other than neck or back injuries involving the spinal cord, orthopedic injuries are often not life threatening. Signs and Symptoms * Pain near injury * Swelling and/or bruising near injury * Obvious bony deformity * Limited range of motion Identify any life-threatening injuries. Pelvic and femur fractures can cause severe internal and external hemorrhaging that can lead to death. Management 1. Evaluate scene safety. DO NOT approach patient if scene cannot be rendered safe. 2. Institute appropriate Body Substance Isolation (BSI) measures/Universal Precautions. as outlined in Protocol I.A. 3. Perform patient assessment and initiate routine BLS care, as outlined in Protocol I.A, and as indicated by the patient's condition. IX I Trauma KLFD BLS&ALS PROTOCOLS Docusign Envelope ID:D9C280B0-04D5-4D4C-A898-A72C90C71AEC 102 4. Determine the need for ALS care and/or transport to hospital for further evaluation and treatment. 5. Calm and reassure patient. 6. Secure and maintain airway and administer supplemental oxygen, as needed. 7. Control extremity wound hemorrhage. (Refer to Protocol IX.A.) 8. Apply ice or cold packs to sites of swelling/deformity. 9. Splint obvious fractures and dislocations after checking for pulses distal to the fracture site: a. Splint the joints above and below the fracture site. b. If fracture/dislocation is open (compound), cover the open area with sterile dressing. DO NOT push bone back in if it is protruding. c. If fracture is angulated and the distal limb is pulseless, attempt to realign to neutral position using mild traction. If significant resistance is met, stop immediately and splint in position found. d. If fracture/dislocation is angulated with pulse, splint in position found. e. Reassess distal circulation before and after splinting. 10. Treat cervical injury, if indicated. (Refer to Protocol IX.E.) 11. Treat pelvic injury with pelvic stabilization device, if available. 12. Treat femur fracture with a traction splint, if available. Traction splint is contraindicated if: a. Suspected pelvic fracture b. Femoral neck (hip) fracture c. Avulsion or amputation of the ankle and foot d. Fractures distal to knee 13. Treat clavicle injury by "sling and swathe" with the patient's arm in a position of comfort. 14. Assess and treat for shock. (Refer to Protocol X.I.) 15. Continue supportive care and monitor vital signs unfit the patient is turned over to an ALS transport unit. IX JTrauma KLFD BLS&ALS PROTOCOLS Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC 103 ALS 1. Confirm the completion of BLS Steps 1-14. 2. Initiate 0.9% Normal Saline via IV/10 at KVO or saline lock. Pediatric BLS 1. Follow BLS guidelines, adjusting for patient age/size. ALS 1. Follow BLS guidelines, adjusting for patient age/size. 2. Initiate 0.9% Normal Saline via IV/10 at KVO or saline lock. I. Head, Neck and Facial Injuries Review of Injury/Illness Head, neck, and facial injuries can also cause Traumatic Brain Injury (TBI), which can be life- threatening. TBIs can present with loss of consciousness or changes in mental status ranging from confusion and combativeness to lethargy. Signs and Symptoms Head * Visible Wounds * AMS * Unequal Pupils * "Raccoon Eyes" * CSF or blood drainage from ear, nose, throat * Convulsions/seizures * Paralysis * Bruising behind the ear Neck * Hemorrhage * AMS IX I Trauma KLFD BLS&ALS PROTOCOLS Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC 104 * Hoarseness * Dyspnea, strider * Head fixed in an abnormal position * Vomiting/spitting blood * Paralysis, weakness, or abnormal sensation in upper or lower extremities Facial * Lacerated gums * Misaligned/broken teeth * Nosebleed * Limited eye movements * Massive hemorrhage even with minor wounds * Facial asymmetry * Difficulty swallowing * CSF drainage from nose Management BLS 1. Evaluate scene safety. DO NOT approach patient if scene cannot be rendered safe. 2. Institute appropriate Body Substance Isolation (BSI) measures/Universal Precautions. as outlined in Protocol I.A. 3. Perform patient assessment and initiate routine BLS care, as outlined in Protocol I.A, and as indicated by the patient's condition. 4. Determine the need for ALS care and/or transport to hospital for further evaluation and treatment. 5. Calm and reassure patient. 6. Secure and maintain airway and administer supplemental oxygen, if necessary. Assist ventilations with a bag valve mask (BVM) device, as needed. 7. Maintain appropriate spine immobilization, according to Protocol IX.E. IX ITrauma KLFD BLS&ALS PROTOCOLS Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC 105 8. Assess and treat for shock. (Refer to Protocol X.I.) 9. If a penetrating eye injury is noted or suspected: a. Leave object in eye. b. Perform a rapid field test of visual acuity. c. If an object is protruding from the eye socket, stabilize the object with bulky dressings and tape; then surround object with cup to prevent jarring. d. If an object is not protruding, cover the eye with a soft patch that does not touch eye. e. Protruding Globe— DO NOT put eye back in socket—Apply bulky dressing around eye, moist gauze over globe, and cover with a cup. f. If CSF is found, do not pack or suction nose/ear and transport in upright position. g. Use extreme caution with head injury and esophageal injury. 10. In cases of nasal injury, DO NOT tilt head back to control bleeding. Pinch the patient's nostrils and apply ice to the bridge of nose. 11. If CNS injury, perform and record full neurological assessment, including the Glasgow Coma Scales. Repeat and record every 5-10 min. (Refer to Protocol XII.L.) 12. Resuscitation for victims of a blast or penetrating trauma who have no pulse, no respiration, and no other signs of life should not be initiated. (Refer to Protocol XI.D.) 13. Continue supportive care and monitor vital signs until the patient is turned over to an ALS transport unit. ALS 1. Confirm the completion of BLS steps 1-12. 2. Provide advanced airway support, if necessary. (Refer to Protocol I.B.) 3. Initiate 0.9% Normal Saline via IV/10 at KVO or saline lock. 4. Nasal Injury: DO NOT attempt nasal intubation. Pediatric BLS 1. Follow BLS guidelines, adjusting for patient age/size. IX I Trauma KLFD BLS&ALS PROTOCOLS Docusign Envelope ID:D9C280B0-04D5-4D4C-A898-A72C90C71AEC 106 ALS 1. Follow BLS guidelines, adjusting for patient age/size. 2. Provide advanced airway support, if necessary. (Refer to Protocol I.B.) 3. Initiate 0.9% Normal Saline via IV/10 at KVO or saline lock. IX I Trauma KLFD BLS&ALS PROTOCOLS Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC 107 X. Otheir Medical Emeirgeiricies A. Allergic Reaction Review of Injury/Illness The body's immune system normally helps it to recognize, inactivate and eliminate threats such as bacterial or viral infections. Sometimes the components of that system are activated by foods, medications, or environmental elements like pets, latex, or other chemicals causing allergic reactions. Allergic reactions range from mild cold-like symptoms and rashes to life- threatening airway emergencies and shock (acute anaphylaxis). Signs and Symptoms * Itching, Hives * Swelling * Difficulty breathing (hoarseness, stridor) * Difficulty swallowing * Chest pain * Weakness * Flushing/redness * Wheezing * Unconsciousness Management BLS 1. Evaluate scene safety. DO NOT approach patient if scene cannot be rendered safe. 2. Institute appropriate Body Substance Isolation (BSI) measures/Universal Precautions, as outlined in Protocol I.A. 3. Perform patient assessment and initiate routine BLS care, as outlined in Protocol I.A, and as indicated by the patient's condition. 4. Determine the need for ALS care and/or transport to hospital for further evaluation and treatment. 5. Calm and reassure patient X I Other Medical Emergencies KLFD BLS&ALS PROTOCOLS Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC 108 6. Acute Anaphylaxis: a. If a patient has signs of cardiovascular or respiratory compromise (e.g., difficulty breathing, stridor, hypotension) and has a prescribed epinephrine auto-injector (EpiPenO), assistance may be offered for administration; may repeat x1 after 3-5 minutes. b. If the patient is wheezing, and has a prescribed MDI, assistance may be offered for administration. c. Continue to monitor vital signs, including pulse oximetry, if available. 7. Continue supportive care and monitor vital signs until the patient is turned over to an ALS transport unit. ALS 1. Confirm the completion of BLS steps 1-6. 2. Secure and maintain airway and administer supplemental oxygen, if necessary. Assist ventilations with a bag valve mask (BVIVI) device, as needed. 3. Provide advanced airway support, if necessary. (Refer to Protocol I.B.) 4. Initiate 0.9% Normal Saline via IV/10 at KVO or saline lock. 5. Administer epinephrine 0.3-0.5 mg 1:1,000 solution SQ; may repeat x1 after 3-5 minutes with a maximum of 2 doses. 6. Administer diphenhydramine 25-50 mg IV/10/IM; may repeat x1 after 15-20 minutes. 7. If unresponsive, or with no palpable pulses, administer epinephrine 0.5 mg of 1:10,000 IV/10. Ensure that only the 1:10,000 formula is used for IV/10 administration. 8. Initiate 0.9% Normal Saline IV/10 250-500 ml bolus, up to a maximum total infusion of 2,000 ml without consulting on-line medical direction.Titrate to a Systolic BP = 100 mm Hg. 9. If patient is wheezing, administer Albuterol 2.5 ml in 5.0 ml 0.9% Normal Saline; nebulized every 15 minutes. 10. Obtain 12-lead ECG and monitor cardiac rhythm and treat any dysrhythmia according to current American Heart Association (AHA) ACLS guidelines. 11. For patients taking beta blockers, who are unresponsive to epinephrine, consider Glucagon 1.0 mg IV/10/1 M, every 5 minutes; may repeat x2. X I Other Medical Emergencies KLFD BLS&ALS PROTOCOLS Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC 109 Pediatric BLS 1. Follow BLS guidelines, adjusting for patient age/size. 2. If pediatric patient is in anaphylaxis, and has a prescribed EpiPen,° assistance may be offered for administration. a. Patients weighing< 30 kg may have been prescribed EpiPen Jr° (0.15 mg of epinephrine) for IM administration; may repeat x1. b. Patients weighing > 30 kg may have been prescribed an adult dose EpiPen° (0.3 mg of epinephrine); may repeat x1. ALS 1. Follow BLS guidelines, adjusting for patient age/size. 2. Secure and maintain airway and administer supplemental oxygen, if necessary. Assist ventilations with a bag valve mask (BVIVI) device, as needed. 3. Provide advanced airway support, if necessary. (Refer to Protocol I.B.) 4. Administer epinephrine 0.01 mg/kg 1:1,000 solution SQ, up to a maximum total dose of 0.5 Mg. 5. If patient is wheezing, administer Albuterol 0.03-0.05 ml/kg in 2.5 ml 0.9% Normal Saline; nebulized every 15 minutes. 6. Initiate 0.9% Normal Saline via IV/I0at20ml/kg fluid bolus, uptoa maximum total infusion of 40 m I/kg. B. Hypertensive Crisis Review of Illness/Injury A severe increase in blood pressure accompanied by evidence of an organ damage that can lead to a stroke or another neurological manifestation. Sijzns and Symptoms * Systolic BP usually> 180 mm Hg * Headache with or without AMS * Chest pain/ECG changes * Pulmonary edema X I Other Medical Emergencies KLFD BLS&ALS PROTOCOLS Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC 110 * Neurologic changes consistent with stroke Management BLS 1. Evaluate scene safety. DO NOT approach patient if scene cannot be rendered safe. 2. Institute appropriate Body Substance Isolation (BSI) measures/Universal Precautions, as outlined in Protocol I.A. 3. Perform patient assessment and initiate routine BLS care, as outlined in Protocol LA, and as indicated by the patient's condition. 4. Determine the need for ALS care and/or transport to hospital for further evaluation and treatment. 5. Calm and reassure patient. 6. Secure and maintain airway and administer supplemental oxygen, if necessary. Assist ventilations with a bag valve mask (BVIVI) device, as needed. 7. Continue supportive care and monitor vital signs until the patient is turned over to an ALS transport unit. ALS 1. Confirm the completion of BLS steps 1-6. 2. Initiate 0.9% Normal Saline via IV/10 at KVO or saline lock. 3. Obtain 12-lead ECG and monitor cardiac rhythm and treat any dysrhythmia according to current American Heart Association (AHA) ACLS guidelines. 4. If Systolic BP > 180 mm Hg or Diastolic BP >_ 110 mm Hg, monitor blood pressure every 5 minutes Pediatric BLS 1. Follow BLS guidelines, adjusting for patient age/size. 2. Contact on-line medical direction for further guidance. X I Other Medical Emergencies KLFD BLS&ALS PROTOCOLS Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC 111 ALS 1. Follow BLS guidelines, adjusting for patient age/size. 2. Initiate 0.9% Normal Saline via IV/10 at KVO or saline lock. 3. Obtain 12-lead ECG and monitor cardiac rhythm and treat any dysrhythmia according to current American Heart Association (AHA) ACLS guidelines. Apply pediatric pads. 4. Contact on-line medical direction for further guidance C. Epistaxis Review of Injury/Illness It is important to recognize when nose bleeds result from head or face trauma. (Refer to Protocol IX.I.) Signs and Symptoms * Bleeding from one or both nares Management BLS 1. Evaluate scene safety. DO NOT approach patient if scene cannot be rendered safe. 2. Institute appropriate Body Substance Isolation (BSI) measures/Universal Precautions, as outlined in Protocol I.A. 3. Perform patient assessment and initiate routine BLS care, as outlined in Protocol I.A, and as indicated by the patient's condition. 4. Determine the need for ALS care and/or transport to hospital for further evaluation and treatment. 5. Calm and reassure patient. 6. Secure and maintain airway and administer supplemental oxygen, as needed. 7. Assess and treat for shock. (Refer to Protocol X.I.) 8. With patient in seated position, and head neutral, squeeze nostrils together with a dressing. If patient is able, he/she can hold compression on the nostrils; monitor for compliance and assist as needed (Must hold constant pressure for a minimum of 5 minutes.) 9. Apply cold pack to forehead/nose bridge area, if possible. X I Other Medical Emergencies KLFD BLS&ALS PROTOCOLS Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC 112 10. Continue supportive care and monitor vital signs until the patient is turned over to an ALS unit. ALS 1. Confirm the completion of BLS steps 1-9. 2. Initiate 0.9% Normal Saline via IV/10 at KVO or saline lock. 3. DO NOT attempt nasal intubation. D. Nausea/Vomiting Review of Injury/Illness Patients can present with nausea and/or vomiting due to underlying injury, medical condition, active motion sickness, or medication side effect/complication. Sometimes, vomiting or intense nausea can complicate the existing injury or medical condition (e.g., penetrating eye injury, high risk for aspiration, side effects of narcotic administration). Signs and Symptoms * Vomiting or sensation of imminent vomiting * Inability to tolerate food or liquids * Retching or"dry heaves" Management BLS 1. Evaluate scene safety. DO NOT approach patient if scene cannot be rendered safe. 2. Institute appropriate Body Substance Isolation (BSI) measures/Universal Precautions, as outlined in Protocol I.A. 3. Perform patient assessment and initiate routine BLS care, as outlined in Protocol I.A, and as indicated by the patient's condition. 4. Determine the need for ALS care and/or transport to hospital for further evaluation and treatment. 5. Calm and reassure patient. 6. Secure and maintain the airway. X I Other Medical Emergencies KLFD BLS&ALS PROTOCOLS Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC 113 7. Place patient either in position of comfort or in left lateral position to prevent aspiration, if not contraindicated by spinal immobilization or packaging. 8. Continue supportive care and monitor vital signs until the patient is turned over to an ALS unit. ALS 1. Confirm the completion of BLS steps 1-7. 2. Initiate 0.9% Normal Saline via IV/10 at KVO or saline lock. Pediatric BLS 1. Follow BLS guidelines, adjusting for patient age/size. ALS 1. Follow BLS guidelines, adjusting for patient age/size. 2. Initiate 0.9% Normal Saline via IV/I0at20ml/kg fluid bolus, uptoa maximum total infusion of 40 ml/kg. E. GI Bleeding Review of Injury/Illness Upper or lower GI bleeding can rapidly become a life-threatening medical emergency as a result of substantial blood loss with hypotension and shock. There are many potential sources of GI bleeding; most commonly: • Upper • Lowe r • Peptic ulcer disease • Infectious diarrhea • Esophageal varices • Colon cancer • Esophageal tears due to vomiting • Diverticulitis • Rectal varices • Hemorrhoids X I Other Medical Emergencies KLFD BLS&ALS PROTOCOLS Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC 114 Signs and Symptoms * Vomiting bright red blood or material that resembles coffee grounds * Bloody diarrhea (may be infectious) * Blood visible on the outside of formed stool or noticed on toilet paper after wiping * Black, "tarry" stools (typically indicates upper GI source of bleed) * Occult blood loss—May present with fatigue, general weakness, or syncope due to bleeding into the GI tract which is only found after testing for occult fecal blood Management BLS 1. Evaluate scene safety. DO NOT approach patient if scene cannot be rendered safe. 2. Institute appropriate Body Substance Isolation (BSI) measures/Universal Precautions, as outlined in Protocol I.A. 3. Perform patient assessment and initiate routine BLS care, as outlined in Protocol I.A, and as indicated by the patient's condition. 4. Determine the need for ALS care and/or transport to hospital for further evaluation and treatment. 5. Bloody vomiting: a. DO NOT allow patients to eat or drink anything. b. Administer supplemental oxygen, as needed. c. Ensure the airway is not threatened by severe vomiting; use advanced airway to prevent aspiration, if needed. d. If dehydrated, refer to Protocol VIII.A. 6. Bloody diarrhea: a. Provide oral hydration with water, diluted fruit juice, or diluted sports drink (50:50 with water), if patient is awake, able to swallow and mental status is intact. b. If dehydrated, refer to Protocol VIII.A. 7. If possible, take orthostatic vital signs. If mental status or blood pressure are abnormal with the patient lying down, DO NOT attempt to take an orthostatic set of vital signs. X I Other Medical Emergencies KLFD BLS&ALS PROTOCOLS Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC 115 8. Continue supportive care and monitor vital signs until the patient is turned over to an ALS unit. ALS 1. Confirm the completion of BLS steps 1-7. 2. Initiate 0.9% Normal Saline via IV/10 250 ml fluid bolus, up to a maximum total infusion of 2,000 ml without consulting on-line medical direction. Pediatric BLS 1. Follow BLS guidelines, adjusting for patient age/size. ALS 1. Follow BLS guidelines, adjusting for patient age/size. 2. Initiate 0.9% Normal Saline via IV/IOat20ml/kg fluid bolus, uptoa maximum total infusion of 40 ml/kg. F. Abdominal Pain Abdominal pain can indicate many different conditions such as ulcers, appendicitis, colitis, inflammation of the gall bladder or pancreas, kidney stone and internal masses that cause obstruction. Any of these conditions generate moderate or severe abdominal pain. The acute (surgical) abdomen indicates an intra-abdominal emergency that requires urgent transport for immediate surgical intervention. Signs and Symptoms Peritoneal Inflammation * Abdominal pain,with or without vomiting * Tenderness with guarding * Rebound/percussive tenderness * "Rigid" abdomen * Patient lying perfectly still (movement causes severe pain) X I Other Medical Emergencies KLFD BLS&ALS PROTOCOLS Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC 116 Management BLS 1. Evaluate scene safety. DO NOT approach patient if scene cannot be rendered safe. 2. Institute appropriate Body Substance Isolation (BSI) measures/Universal Precautions, as outlined in Protocol I.A. 3. Perform patient assessment and initiate routine BLS care, as outlined in Protocol I.A, and as indicated by the patient's condition. 4. Determine the need for ALS care and/or transport to hospital for further evaluation and treatment. 5. Calm and reassure patient. 6. DO NOT allow patients to eat or drink anything. 7. Ensure the airway is not threatened by severe vomiting; use advanced airway to prevent aspiration, if needed. 8. Administer supplemental oxygen, if needed. 9. For suspected GI bleeding, refer to Protocol X.E. 10. Assess and treat for shock. (Refer to Protocol X.I.) 11. Continue supportive care and monitor vital signs until the patient is turned over to an ALS transport unit. AILS 1. Confirm completion of BLS steps 1-10. 2. Initiate 0.9% Normal Saline via IV/10 250 ml fluid bolus, up to a maximum total infusion of 2,000 ml without consulting on-line medical direction. Titrate to maintain Systolic BP > 90 mm Hg. 3. Obtain 12-lead ECG and monitor cardiac rhythm and treat any dysrhythmia according to current American Heart Association (AHA) ACLS guidelines. Pediatric BLS 1. Follow BLS guidelines, adjusting for patient age/size. X I Other Medical Emergencies KLFD BLS&ALS PROTOCOLS Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC 117 ALS 1. Follow BLS guidelines, adjusting for patient age/size. 2. Initiate 0.9% Normal Saline via IV/I0at20ml/kg fluid bolus, uptoa maximum total infusion of 40 ml/kg. G. Poisoning/Overdose Review of Illness/Injury Depression and other serious mental illness may cause a suicide attempt by overdose. Poisoning may occur by exposure to toxic substances via inhalation, injection, ingestion, or skin absorption. Children may be accidentally poisoned by medications, alcohol or household cleaners left unsecured. Poisoning may occur in the setting of a hazardous materials incident. Acute or chronic poisoning may also be a result of criminal and/or terrorist activity. Signs and Symptoms * Altered mental status (AMS) - Lethargy or unconsciousness vs. hyper-excitability * Vomiting and/or diarrhea * Tachycardia or bradycardia * Sweating * Dilated or constricted pupils * Difficulty breathing,with or without increased bronchial secretion * Cardiac dysrhythmias/arrest Management BLS 1. Evaluate scene safety. DO NOT approach patient if scene cannot be rendered safe. 2. Institute appropriate Body Substance Isolation (BSI) measures/Universal Precautions, as outlined in Protocol I.A. 3. Perform patient assessment and initiate routine BLS care, as outlined in Protocol LA, and as indicated by the patient's condition. 4. Determine the need for ALS care and/or transport to hospital for further evaluation and treatment. X I Other Medical Emergencies KLFD BLS&ALS PROTOCOLS Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC 118 5. Remove patient from the toxic environment, using appropriately trained personnel wearing proper level PPE, if necessary; decontaminate as appropriate. 6. In case of ingestion, identify the source, substance, medication and/or amount ingested or inhaled, if possible. 7. Administer supplemental oxygen and monitor pulse oximetry, as needed. 8. Contact Poison Control and follow their instructions 1-800-222-1222. 9. Continue supportive care and monitor vital signs until the patient is turned over to an ALS transport unit. ALS 1. Confirm the completion of BLS steps 1-9. 2. Secure and maintain airway and administer supplemental oxygen, as needed. 3. Provide advanced airway support, if necessary. (Refer to Protocol I.B.) 4. Initiate 0.9% Normal Saline via IV/10 at KVO or saline lock. 5. Obtain 12-lead ECG and monitor cardiac rhythm and treat any dysrhythmia according to current American Heart Association (AHA) ACLS guidelines. 6. Maintain contact with the Poison Control Center. Pediatric BLS 1. Follow BLS guidelines, adjusting for patient age/size. ALS 1. Follow BLS guidelines, adjusting for patient age/size. 2. Secure and maintain airway and administer supplemental oxygen, as needed. 3. Provide advanced airway support, if necessary. (Refer to Protocol I.B.) 4. Initiate 0.9% Normal Saline via IV/10 at KVO or saline lock. 5. Obtain 12-lead ECG and monitor cardiac rhythm and treat any dysrhythmia according to current American Heart Association (AHA) ACLS guidelines. Apply pediatric pads. 6. Maintain contact with the Poison Control Center. X I Other Medical Emergencies KLFD BLS&ALS PROTOCOLS Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC 119 H. Stroke, TIA Review of Injury/Illness A stroke is a loss of brain function due to insufficient blood flow and decreased oxygen reaching the affected area, usually caused by obstruction or rupture of one or more blood vessels in the brain. A TIA or Transient Ischemic Attack is a temporary disruption of function with stroke-like symptoms that typically resolves completely within 24 hours of onset. A TIA is generally considered a warning that a stroke could occur in the same distribution in the near future. Signs and Symptoms * Slurred speech * Facial droop * Unequal grips/arms drift or other extremity weakness * Change in mental status—as documented by friend or family member * Sudden change in vision * Sudden severe or unexplained headache * Syncope/vertigo * Ataxia Management BLS 1. Evaluate scene safety. DO NOT approach patient if scene cannot be rendered safe. 2. Institute appropriate Body Substance Isolation (BSI) measures/Universal Precautions, as outlined in Protocol I.A. 3. Perform patient assessment and initiate routine BLS care, as outlined in Protocol I.A, and as indicated by the patient's condition. 4. Determine the need for ALS care and/or transport to hospital for further evaluation and treatment. 5. Calm and reassure the patient. 6. Secure and maintain airway and administer supplemental oxygen, as needed. 7. Provide advanced airway support, if necessary. (Refer to Protocol I.B.) 8. Establish and relay time of symptom onset to receiving facility or transporting service. X I Other Medical Emergencies KLFD BLS&ALS PROTOCOLS Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC 120 9. Continue supportive care and monitor vital signs until the patient is turned over to an ALS transport unit. ALS 1. Confirm the completion of BLS steps 1-8. 2. Provide advanced airway support, if necessary. (Refer to Protocol I.B.) 3. Initiate 0.9% Normal Saline via IV/10 at KVO or saline lock. 4. Obtain 12-lead ECG and monitor cardiac rhythm and treat any dysrhythmia according to current American Heart Association (AHA) ACLS guidelines. 5. If seizures occur, treat according to seizure protocol. (Refer to Protocol II.B.) Pediatric BLS 1. Follow BLS guidelines, adjusting for patient age/size. 2. Evaluate for overdose (e.g., cocaine, methamphetamine, street drugs). If suspected, refer to Protocol X.G. ALS 1. Follow BLS guidelines, adjusting for patient age/size. 2. Evaluate for overdose (e.g., cocaine, methamphetamine, street drugs). If suspected, refer to Protocol X.G. 3. Provide advanced airway support, if necessary. (Refer to Protocol I.B.) 4. Initiate 0.9% Normal Saline via IV/10 at KVO or saline lock. 5. Obtain 12-lead ECG and monitor cardiac rhythm and treat any dysrhythmia according to current American Heart Association (AHA) ACLS guidelines. Apply pediatric pads. 6. If seizures occur, treat according to seizure protocol. (Refer to Protocol II.B.) I. Shock Review of Injury/Illness The body responds in various ways when blood flow cannot meet the oxygen demands of the cells, depending on the severity and duration of the decreased blood flow/oxygen delivery. X I Other Medical Emergencies KLFD BLS&ALS PROTOCOLS Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC 121 Some of the common causes of shock include gastrointestinal bleeding, sepsis, severe dehydration, cardiac dysfunction, or blunt/penetrating trauma. Signs and Symptoms * General weakness * Cool, clammy skin (diaphoresis) * Dilated pupils * Rapid, weak pulse * Shallow, labored respirations * Decreasing pulse pressure * Altered mental status * Multi-system organ failure Management 1. Evaluate scene safety. DO NOT approach patient if scene cannot be rendered safe. 2. Institute appropriate Body Substance Isolation (BSI) measures/Universal Precautions, as outlined in Protocol I.A. 3. Perform patient assessment and initiate routine BLS care, as outlined in Protocol I.A, and as indicated by the patient's condition. 4. Determine the need for ALS care and/or transport to hospital for further evaluation and treatment. 5. Calm and reassure patient. 6. Secure and maintain airway and administer supplemental oxygen via non-rebreathing mask (NRBM) at high concentration. Assist ventilations with a bag valve mask (BVIVI) device, as needed. 7. Provide advanced airway support, if necessary. (Refer to Protocol I.B.) 8. Initiate IV fluid resuscitation, if permitted by local protocol. (Refer to Protocol VIII.A.) 9. Control extremity wound hemorrhage, if necessary. (Refer to Protocol IX.A.) X I Other Medical Emergencies KLFD BLS&ALS PROTOCOLS Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC 122 10. Maintain appropriate spine immobilization, according to Protocol IKE, if indicated. (Any trauma patient with suspected spinal injuries based on mechanism of injury should have full- body spinal immobilization.) 11. Consider pelvic stabilization, if indicated. 12. Continue supportive care and monitor vital signs until the patient is turned over to an ALS transport unit. Consider Aeromedical evacuation to the nearest Trauma Center, if available. ALS 1. Confirm the completion of BLS steps 1-11. 2. Provide advanced airway support, if necessary. (Refer to Protocol I.B.) 3. Initiate 0.9% Normal Saline via IV/10 250 ml fluid bolus, up to a maximum total infusion of 2,000 ml without consulting on-line medical direction. Titrate to maintain Systolic BP > 90 mm Hg. If rales are present, infuse up to 250 ml. Additional fluid requires consulting on-line medical direction. 4. Obtain 12-lead ECG and monitor cardiac rhythm and treat any dysrhythmia according to current American Heart Association (AHA) ACLS guidelines. Pediatric The pediatric patient may present hemodynamically unstable or with hypoperfusion as evidenced by altered mental status, delayed capillary refi II (> 2 seconds), pallor, peripheral cyanosis, hypotension. Hypotension is defined as a Systolic BP < 60 mm Hg in neonates (patients < 28 days old), < 70 mm Hg in infants (patients < 1 year old), < [70+ (2 x years) = Systolic BP] for patients > 1 year old. BLS 1. Follow BLS guidelines, adjusting for patient age/size. 2. Consider Aeromedical evacuation to the nearest Trauma Center or Pediatric Trauma Center, if available. BLS Extended Scope/ALS 1. Follow BLS guidelines, adjusting for patient age/size. 2. If age-related vital signs and patient's condition indicate hypoperfusion, administer initial fluid bolus of 20 ml/kg0.9% Normal Saline via IV/10. (Refer to Protocol VIII.A.) 3. If patient's condition does not improve: X I Other Medical Emergencies KLFD BLS&ALS PROTOCOLS Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC 123 a. Administer the second bolus of fluid at 20 ml/kg 0.9% Normal Saline via IV/10. If patient's condition still does not improve, administer third and subsequent fluid boluses at 10 ml/kg. b. For volume sensitive children (e.g., neonates [0-28 days], children with congenital heart disease, chronic lung disease, or chronic renal failure), administer initial fluid bolus of 10ml/kg 0.9% Normal Saline IV/10. If a patient's condition still does not improve, contact on-line medical direction. 4. Consider Aeromedical evacuation to the nearest Trauma Center. X I Other Medical Emergencies KLFD BLS&ALS PROTOCOLS Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC 124 . i l el l ! lPirotocols A. Documentation Requirements The patient care report (ePCR), or run report, is an official report provided by pre-hospital personnel. All requests for emergency medical services require that an ePCR be completed. Documentation must accurately reflect observations, orders, treatments, and outcomes throughout the patient encounter. Proper documentation is critical to proving adherence to standards of care. 1. Each ePCR should contain the following information: a. Date and time of event b. Chief complaint includes: • Patient description of problem • Mechanism of injury if trauma related c. History includes: • Onset - When did symptoms begin? • Provocation/Palliation -What makes them worse? What makes them better? • Quality - What do these symptoms feel like? • Radiation - Can it be felt in any other body location? • Pain Severity- How bad does it hurt? (rate pain using a 0-10 scale) • Time - Is the pain constant or does it come and go? Have you had this occur before? How was it treated? • Pertinent past medical history, related to complaint • Past surgical history 2. Documentation of patient assessment should include a. Scene survey and mechanism of injury if trauma related. b. Initial primary survey, to include signs, symptoms and immediate interventions related to the following: • Airway • Breathing XI I Special Medical/Legal Protocols KLFD BLS&ALS PROTOCOLS Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC 125 • Circulation • Level of Consciousness • Spinal precautions (if appropriate) 3. Documentation of focused history and physical findings should include signs and symptoms of presenting problem and review of body systems as needed: a. Vital signs, including postural vital signs if indicated. b. Color, temperature, appearance of skin c. Blood pressure, both arms if indicated. d. Capillary refill e. Pupillary response f. Motor, sensory, circulatory status of extremities, if appropriate g. Orders received, treatment and/or drug therapy initiated and patient response to treatment. h. On-going assessment of patient 4. Transfer summary should include: a. Condition of patient on transfer b. Name and signature of receiving agency/person assuming care of the patient. c. Time of transfer d . Legible signature of EMS provider of record, and names of all personnel who performed care, especially if they performed or attempted any procedure. B. Abuse/Neglect Review of Injury/Illness Abuse may involve physical, verbal, sexual mistreatment and/or neglect. Abuse may cause serious injury to the patient's mental and/or physical well-being. Perpetrators will often try to cover up, hide or alter information related to the nature of the injury. Victims may have been coached to give an alternate story about how an injury occurred. Particularly at-risk populations include pediatric, elderly, and pregnant patients. XI I Special Medical/Legal Protocols KLFD BLS&ALS PROTOCOLS Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC 126 Signs and Symptoms * Bruising * Burns * Broken bones * Lethargy or other AMS * Dehydration, malnutrition * Injuries inconsistent with the history provided * Delay in seeking medical care * Information passed on by family friends * Information passed on by the victim's friend(s) Management BLS ALS 1. Evaluate scene safety. DO NOT approach patient if scene cannot be rendered safe. 2. Institute appropriate Body Substance Isolation (BSI) measures/Universal Precautions, as outlined in Protocol I.A. 3. Perform patient assessment and initiate routine BLS care, as outlined in Protocol I.A, and as indicated by the patient's condition. 4. Determine the need for ALS care and/or transport to hospital for further evaluation and treatment. 5. Triage and treat patient according to appropriate protocol for injuries sustained. 6. Do not confront suspected abuser. 7. Document all findings including visual inspection of location where patient was found, and any interaction between patient and caregiver. 8. Relay all findings upon transfer of care. 9. All suspected cases of abuse, exploitation, or neglect should be reported to appropriate Law Enforcement, Adult and/or Child Protective Services according to state and local laws or regulations. 10. If the individual or caregiver is refusing treatment and transport, authorities and on-line medical direction should be notified prior to clearing the scene. XI I Special Medical/Legal Protocols KLFD BLS&ALS PROTOCOLS Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC 127 11. Continue supportive care and monitor vital signs until the patient is turned over to an ALS transport unit, if indicated. C. Withholding or Terminating Resuscitation (Non-trauma) Review of Injury/Illness In the pre-hospital setting, there are times when it is appropriate or necessary to consider discontinuing cardiopulmonary resuscitation and other lifesaving interventions. Management BLS ALS 1. Discontinuation of cardiopulmonary resuscitation and other potentially lifesaving interventions may be considered when ALL of the following criteria have been met a. Arrest was not witnessed by an EMS provider or first responder. b. Adequate CPR has been administered according to current American Heart Association (AHA) guidelines. c. There is no spontaneous circulation (palpable pulse) and no neurological activity (e.g., spontaneous respiration, eye opening, or motor response) present after appropriate BLS resuscitation efforts. d. The patient is at least 18 years of age. e. Core body temperature is at least 950 F for a patient who was hypothermic due to cold exposure (e.g., submersion). f. All health care providers on scene agree with the decision to cease efforts. g. Family members and others present must be acknowledged and assisted in dealing with this death. h. Contact on-line medical direction prior to termination of efforts. Documentation 1. The following must be legibly documented (e.g., printed) in addition to documentation protocol requirements. (Refer to Protocol XI.A.): a. Time resuscitation was started and discontinued. b. Run Number c. Any procedures performed (e.g., shocks administered by AED, airway management) XI I Special Medical/Legal Protocols KLFD BLS&ALS PROTOCOLS Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC 128 d. Name, identifying number, and agency of law enforcement official and/or patient's private physician, and/or on-line medical direction contacted, and time of contact. D. Withholding or Terminating Resuscitation (Trauma) Review of Injury/Illness Early cardiac arrest in trauma patients is usually due to severe hypoxia, neurologic injury, or massive hemorrhage. If a trauma patient is unresponsive, pulseless, and apneic, the prognosis is generally very poor. As outlined below, there are circumstances where it is appropriate not to initiate resuscitation of a trauma patient, as well as criteria for discontinuing unsuccessful efforts in the fi eld. Signs and Symptoms * No response * No pulse * No respirations Management BLS ALS 1. For patients with penetrating trauma (e.g., stab or gunshot wounds) it is acceptable NOT to attempt resuscitation if the patient has: a. No respirations or respiratory effort; and b. No palpable pulses and no organized electrical activity on AED or ECG; and c. No papillary reflexes; and d. No spontaneous movement. 2. If ANY signs of life are present, or if mechanism of injury indicates blunt trauma, the patient should undergo aggressive attempts at resuscitation. (Refer to Protocol IX.C.) a. Continue supportive care and monitor vital signs until the patient is turned over to an ALS transport unit. Consider the need for Aeromedical evacuation to the nearest Trauma Center. 3. For patients with either blunt or penetrating trauma, it is acceptable NOT to attempt resuscitation if the patient has: a. Injuries such as decapitation, hemicorporectomy, incineration, or submersion > 12 hours, that are obviously incompatible with life, OR XI I Special Medical/Legal Protocols KLFD BLS&ALS PROTOCOLS Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC 129 b. Evidence that he/she has been pulseless and apneic for a prolonged period (e.g., dependent lividity, rigor mortis, or decomposition). 4. For patients in cardiac arrest, but without injuries or apparent mechanism of injury to account for death, resuscitate according to current American Heart Association (AHA) guidelines. 5. For patients with either blunt or penetrating trauma, it is acceptable to terminate resuscitation in the field if the patient: a. Remains in cardiac arrest (after 15 minutes of appropriate resuscitation efforts), OR b. Remains in cardiac arrest and is located more than 15 minutes from a trauma center. 6. Always document findings and leave scene under Law Enforcement control after presuming an out-of-hospital death. a. Include name, identifying number, and agency of law enforcement officer. E. Do Not Resuscitate (DNR) Review of Injury/Illness 1. A DNR or "Do Not Resuscitate Order" is a valid physician's order to forgo resuscitative efforts. The presence of a valid Withholding Care Form allows providers to withhold specified care on patients. 2. When such a document is produced by the patient, patient's guardian, or agent designated to act on the patient's behalf, it should conform to the relevant, state or local requirements. The form must be signed by a physician or medical provider with authority to do so. 3. An Advanced Directive, otherwise known as a living will or health care directive, is a letter to a physician from the patient or responsible party outlining what care they wish to receive or not receive in the event they are incapacitated. Management BLS A LS 1. If presented with a valid DNR form, do not begin resuscitative measures on a patient in or near cardiac or respiratory arrest. 2. If the EMS provider is unsure as to the validity of the DNR contact medical direction for orders. If unable to contact, resuscitative efforts should be initiated until clarification of the Directive is made by a medical direction authority. XI I Special Medical/Legal Protocols KLFD BLS&ALS PROTOCOLS Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC 130 3. Proper law enforcement agencies should be notified upon death of the patient when: a. Resuscitative efforts are cancelled by a medical direction authority. b. A valid DNR Form is presented, and resuscitative efforts are withheld. c. A patient is being left rather than transported after death has occurred. 4. Documentation regarding the validity of a Pre-hospital Medical Care Directive Form must be included in the patient care reporting document. 5. Take into consideration the sensitivities of family members, whether or not transporting the patient. Special Considerations 1. Emergency Medical Services (EMS) personnel are not required to accept or interpret medical care directives, if uncertain of their validity. 2. Authorization for the withholding of resuscitative efforts DOES NOT include withholding other medical interventions (e.g., IV fluids, pain control) prior to cardiac or respiratory arrest. F. Refusal of Care or Transport Review of Injury/Illness An adult patient with normal mental status and intact judgment (competent) has the right to refuse care if properly informed of the potential consequences of that refusal. A parent or legal guardian must refuse care on behalf of a minor. Signs and Symptoms * Patient refusing medical care or transport for illness or injury * Not under the influence of mind-altering substances (e.g., alcohol, drugs) * Not demented * Oriented x 4 (person, place, time, event) Management XI I Special Medical/Legal Protocols KLFD BLS&ALS PROTOCOLS Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC 131 BLS ALS 1. Evaluate scene safety. DO NOT approach patient if scene cannot be rendered safe. 2. Institute appropriate Body Substance Isolation (BSI) measures/Universal Precautions, as outlined in Protocol I.A. 3. Perform patient assessment and initiate routine BLS care, as outlined in Protocol I.A, and as indicated by the patient's condition. 4. Determine the need for ALS care and/or transport to hospital for further evaluation and treatment. 5. Upon determination of illness or injury, if patient is refusing care, has a GCS of 15 is oriented x4, explain the potential risks and dangers of not accepting medical intervention to the patient or other authorized responsible party, that could reasonably be expected to occur (e.g., infection of an open wound, pain, death from heart attack). 6. Have the patient verbalize understanding of the consequences, and then sign REFUSAL OF CARE form or patient care record (PCR) and obtain witness signature(s), if possible. XI I Special Medical/Legal Protocols KLFD BLS&ALS PROTOCOLS Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC 132 11® Specialty Slkills A. 10 Procedures Intraosseous Infusion EZ 10 Insertion The administration of fluids and medications via intraosseous infusion has long been known to be a relatively safe and effective procedure in the treatment of critically ill patients. Equipment needed: EZ-10 driver and appropriate needle, Betadine, NS with drip set, 10 cc syringe, EZ-10 connector tubing, pressure infuser and 2-inch tape. Indications Patients in which the following conditions are present: 1. Cardiac arrest, or 2. Profound hypovolemia, or 3. No available vascular access, or 4. Following two unsuccessful peripheral IV attempts for patients with any other life-threatening illness or injury requiring immediate pharmacological or volume intervention, or 5. In pediatric patients in cardiac arrest, go directly to 10 if no peripheral sites are obvious. Contraindications 1. Conscious patient with stable vital signs 2. Peripheral vascular access available 3. Suspected or known fractures in the extremity targeted for 10 infusion 4. Previous attempt in the same bone 5. Cellulitis at the intended site of procedure 6. Patient with known bone disorder 7. Prior knee or shoulder joint replacement Select appropriate needle: 1. Adult: >40 kg—there are two lengths: regular and long 2. Pediatric: 3-39 kg or patients that fit on the Broselow Tape (if child has excessive tissue, adult needle may be used) XII I Specialty Skills KLFD BLS&ALS PROTOCOLS Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC 133 Procedure 1. Locate landmarks: identify patella, approximately 2 fingers widths, below is the tibial tuberosity. Then 1 finger width medial is the final landmark. 2. Prepare the skin with antiseptic (Betadine)solution. 3. Select appropriate needle and prepare driver 4. Stabilize leg and power the needle set through the skin at a 90-degree angle to the surface of the bone until you feel the needle set tip encounter the bone itself 5. The 5 mm mark on the catheter (mark closest to the flange) should be visible 6. If 5 mm mark not visible abandon the procedure, the needle is not long enough 7. Apply firm and steady pressure on the driver and power through the cortex (hard, outer surface of the bone), ensuring the driver is maintained at a 90-degree angle 8. Stop when the flange touches the skin or sudden decrease in resistance is felt 9. Remove the driver from needle set and withdraw Stylet from catheter 10. If patient is unable to tolerate pain due to fluid pressure inside the bone, consider administering Lidocaine 25 mg 10, up to 50 mg to reduce the pain 11. Attach primed EZ-10 extension tubing and confirm placement with fluid bolus: failure to flush will result in no flow • Adults: 10 cc fluid bolus • Pediatrics: 5 cc fluid bolus Secure tubing and catheter with tape and document time of insertion as the EZ-10 is good for 24 hours. Pressure infuser may be used to maintain adequate flow rates. XII I Specialty Skills KLFD BLS&ALS PROTOCOLS Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC 134 EZ-10 LANDMARKS iil p ✓ r Ilp�r(r, ` r J ,n �,'r 1 li s *rPrr✓ �i�iy �^minb.............. NVf JI� °1e're!✓dr<�7ii 001 AI, ��V i41 nrWi6 ;�� yidj �'J��'�'r�6,,rIt" Jill' i A 1. 1' J W�u wr ,,,.,n�, ��a ✓N 1 Y+J I � 1 t Locate landmark. Clean insertion site. Power driver through the cortex. 0 f «,„m �, a y�r ior or ! P ' A I � r � `a r VJr �Iru j l � N, a r Remove needle. Attach tubing,flush,and Pressure infusion for adequate consider Lido(25 mg to 50 mg 10) flow rates for bone pain in conscious patients B.-i-Gel Airway Device Procedure The i-Gel is a supraglottic airway management device used as an alternate means of establishing an airway. I-Gel has a soft, gel-like, non-inflatable cuff, designed to provide an anatomical impression fit over the laryngeal inlet. Indication 1. Unconscious patient who is not breathing without a gag reflex. 2. Apneic patient without a gag reflex. 3. A difficult airway is anticipated: a. Small mouth which obstructs visualization b. Short neck c. Mallampatti or Cormack-Lehane score > 3 d. Any obstruction that could impair visualization of the glottic opening. e. Impaired neck mobility. 4. Access to the airway is impeded (entrapment, helicopter cabin etc.) XII I Specialty Skills KLFD BLS&ALS PROTOCOLS Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC 135 Contraindications 1. Patient has a gag reflex. 2. 2. Esophageal tissue damage from trauma, chemical ingestion or thermal injury. 3. Esophageal or airway obstruction. 4. Airway burns or chemical inhalation injury. Procedure Equipment 1. Appropriate i-Gel Size (SEE CHART BELOW) 2. Water based lubricant (surgilube) 3. Suction 4. Sp02 Monitor 5. ETCO2 detector Insertion Technique 1. Open and maintain the airway. Ventilate with 100% oxygen before attempting of the i-Gel. 2. Select the appropriately sized i-Gel based on weight. Open i-Gel package and take i-Gel out of the protective cradle. 3. Lubricate the back, sides, and front of the cuff by rubbing it on the smooth surface of the protective cradle containing the water-based lubricant. /rlltG�rf��r��rr�ord ,rr�Uiiura�9i rrrrryi� 4. Remove dentures or removable plates from the mouth prior insertion. 5. Grasp the lubricated i-Gel firmly along the integral bite block. Position the device so that the i-Gel cuff is facing towards the chin of the patient. XII I Specialty Skills KLFD BLS&ALS PROTOCOLS Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC 136 6. Maintain the head in a neutral position for trauma patients. For non-traumatic patients, the patient's head should be in the "sniffing" position with the head extended and neck flexed. The chin should be gently pressed down before proceeding to insert the i-Gel. F 10 l /l ? /p 7. Introduce the leading soft tip into the mouth of the patient in the direction towards the hard palate. 8. Glide the device downward and backward along the hard palate with continuous but gentle push until a definitive resistance is felt. 9. The front teeth should be resting on the integral bite block. (The black lineon the i-Gel). 10. Attach the End tidal CO2 Device to the i-Gel and BVM, and confirm placement. W( , N i ' � �,�'",,,d iudmumGewwiu«mvrvidf!mrmnNPP+"ixiurnktNW'w,ww.rureddVGGvwiuAiarvvixi"' Securing the Device 1. Secure the i-Gel with the airway support strap provided. XII I Specialty Skills KLFD BLS&ALS PROTOCOLS Docusign Envelope ID:D9C280B0-04D5-4D4C-A898-A72C90C71AEC 137 i-Gel Tube Sizing Chart: i-Gel size Patient's size Patient weight guidance (kg) 1 N�c�nate 2-� 1.5 Infant 5-12 21 Small Pediatric 10-25 2.5 Large Pediatric 25-35 3 Small adult 30-60 5 Lar � adult Basic Airway Management (BAM): is defined as follows: Assisted Ventilations while using basic airway adjuncts (OPA, NPA), and a Bag Valve Mask. Advanced Airway Management (AAM): Includes all Basic procedures with the addition of i-gel Supraglottic Airway. C. Intranasal Administration Technique (Narcan) CLASS Synthetic opioid antagonist DOSAGES Vial has 2mg of Naloxone in 2mL • Give 1mg (Iml) in each nostril, quickly • Medication is atomized and absorbed through vessels in the nasal cavity ACTIONS The mechanism of action is not fully understood. It does appear that Naloxone antagonizes the effects of opiates by competing at same receptor sites. When given IV,the action is apparent within two minutes. IM or SC administration is slightly slower. INDICATIONS Naloxone is indicated for the complete or partial reversal of opiate narcotic depression and respiratory depression secondary to opiate narcotics or related drugs. Cook for the Signs... Overdose on opioids typically: • Unconscious • Slow or not breathing (<10/min) XII I Specialty Skills KLFD BLS&ALS PROTOCOLS Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71 AEC 138 • Small "pinpoint" pupils (miosis) • Pulse variable CONTRAINDICATIONS Naloxone is contrainclicated in patients known to be hypersensitive to it. Use with extreme caution in na rcotic-de pendent patients who may experience withdrawal syndrome (including neonates of narcotic-dependent mothers). SIDE EFFECTS CNS: Tremor Agitation *Belligerence Papillary dilation Seizures Increased tear production Sweating Seizures secondary to withdrawal Cardio: Hypertension Hypotension Ventricular tachycardia Pulmonary edema, Ventricular fibrillation. GI: * Nausea, • WARNINGS X11 I Specialty Skills KLFD BLS&ALS PROTOCOLS Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC 139 Use caution during administration i t s level of consciousness increases. Intranasal Administration Technique • The tip of the syringe I I r or just inside ril Placement• ri r inside l cavity may traumatizel passage r cause epistaxis "WON i I rrr, Are, HOW TO GIVE NASAL SPRAY NARCAN ,,.:, ;riiovai r /i.,ue/,eel ele„eel,ele„eel ele„eel,ele„eel ele,eel ele„eel ele„eel,ele„eel ele„eel ele„eel ele„eel,ilc„eel,ile„eel,ile„eel,ile„eel,/i l,i/,arr Ginri ,//,/�% er�� // Lr/'1e�/ rnrirawua„®iiiiriirirm rr an"), �,,, [,,, � '�'II'wu; IVY liim nm r �o�o�o�o�o�o�Jio�o�uo�o�o�ooil�,, ,„ ,' (IIuJ�J��II �iri��r�l�r iota/il�ia�ir/ ;' "r. IVVIffI J ;''a�(„ /r r,riii,; ,� IU ,rP/ % r• Ilk J: ff � 4r u u IrWeill d �rt«u ,..:., � f%r i 110C/1011C I rwm w ul lotiff, , AN Pu 01 y j ? , r' % o r,,,,, f0Mr ,, Y �li/, o T ' III I r , o r r,l / o I / /, r , , r o r � o f r /r � r / o o, r i/rrrrrriii/rrrrrriierrrrriii/rrrrrriii/rrrrrriierrrrriii/rrrrrriii/rrrrrrri.. r , f 3 4 i r l r ( a f r lu;' , .. it r y f,; hNVIVNI�NVIVNIVINVNIVINVNIVINVNIVINVNIVINVNIVINVNIVINVNIVINVNIVINVNIVINVNIVINVNIVINVNIVINVNIVINVNIVIVNI➢Nu /r V JiMI Guf�rlu. �I� 0 „ rNk��lO, °i h mr--- r, 0 V" `�. III 0 1 /D. Combat Application Tourniquet The Combat Application Tourniquet (CAT) is an effective tool to help control severe blood loss from the body's extremities. If used correctly, the CAT can save lives. A general misconception of the CAT is that it will result in the patient requiring amputation of their extremity, THIS IS FALSE. Amputation is more often required as a result of the injury itself, not because of the tourniquet. The CAT as well as any other type of tourniquet should be as a LAST RESORT for blood control XII I Specialty Skills KLFD BLS&ALS PROTOCOLS Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC 140 management. Applying direct pressure to the injury and elevating the extremity above the heart should be attempted prior to utilizing the CAT. E. Full Spinal Immobilization Technique Equipment Needed: Long backboard, 3 immobilization straps, head stabilization device and cervical collar Adults • Determine need for spinal precautions • Assure and maintain manual c-spine immobilization • Assess pulses, motor and sensation of extremities • Apply appropriate sized C-collar and long backboard • Fill voids with padddings/towels as needed • Apply X4 straps using the chest cross-strap technique • Apply head stabilizing device • Reassess pulses, motor and sensation after immobilizing patient • DO NOT strap the patient directly over the abdomen Straprsecuring XII I Specialty Skills KLFD BLS&ALS PROTOCOLS Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC 141 Est of We l Y� ilt is eon the shoW4erss ,a,nA the upper th i�g hs,, p lace , rho sr.a ps rdingl . i e Use f u�V � 'Yyl'VI If i I ' the fore� �ead ur tap,, ,to nd the- chln area to the 4ackboatc1l. Pediatrics • Apply appropriate size c-collar • Pad under the shoulders using pillowcases or towels to prevent flexion of spine • Secure to long backboard Pregnant Patients • Immobilize as above and tilt the backboard Left lateral recumbent to a 20-degree angle • Assure patient comfort F. APGAR Scores Sign o 1 2 Points Appearance Blue, pale Body pink, extremities Completely pink (color) Blue or pale Pulse rate Not Slow (below 100) Over 100 detectable Grimace No response Grimace Crying Activity Limp Some flexion Active motion XII I Specialty Skills KLFD BLS&ALS PROTOCOLS Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC 142 Respirations (respiratory Absent Slow, irregular effort) Tota I co re Scare Infant's Condition Point total Treatment Consideration Very good 10 Routine Good 7-9 Re-assess Fair 4-6 May need oxygen and stimulation Poor 0-3 Requires CPR XII Specialty Skills KLFD BLS&ALS PROTOCOLS Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC 143 G. Rule of Nines I�rpp�J, INI.,. IV' IVI, III I r �� II tllp irll �I 9 II ',. % Yi¢ B"r�,118��4� r Vie,I ' P 4d �w II I r 1lIIV, �� II;IMm JI 4% I J I�IIy,I� If INh@ YY,. °'4, �r/I ,I^ mIi;, ° % nf'a,,r�: 1 IpI V I Y p I+I ,�,„MryIfNa �0 rII p' �"IIWII IMM 4� 'Yrr II: .WSW I, 10's y sN IN r; y � uulip nI I II P I NIHu� r "'1961h wlLl P � frf rl f1 �� II°�� Y r' Adult P I hd Nlllrlll� XII Specialty Skills KLFD BLS&ALS PROTOCOLS 000uaign Envelope ID: 1AEo 144 H. Ad~.t Trauma Scorecard Methodology Red, any one (1), transport as trauma alert; Blue, any two (2), transport as trauma alert Component =111111 IN' illi�illll Airway e Sustained respiratory rate e Active airway assistance (1) 30 Circulation e Sustained heart rate 120 No radial pulse and a sustained (B M R) e 13MR = 4 or less e Presence of paralysis e Suspicion of spinal cord injury e Loss of sensation Cutaneous Soft tissue loss (2) e 2o or 3o burns to 15% or more TBSA e Amputation proximal to the wrist or ankle e Any penetrating injury to the head, neck, or torso (3) Long bone Fracture (4) Sign or symptoms of a single e Sign or symptoms of a fracture site due to MVC or Fall fracture of two or more long 10' or more bone "sites" Age 9 >_ 55 years or older (7) Mechanism of Injury * Ejection from motor vehicle (5) Steering wheel deformity (6) Judgement e EMT or Paramedic discretion (8) 1. Airway assistance beyond administration of oxygen. 2. Deg|oving injuries, major flap avulsion (> S") 3. Excluding superficial wounds in which the depth can be easily determined. 4. Long bone including humerus, radius/ ulna, femur, tibia/fibu|a. 5. Excludes: motorcycles, mopeds, ATVs, bicycles or open body of a pick-up truck. 6. Only applies to driver ofvehicle. 7. Blunt head, chest, or abdominal trauma on blood thinners with high risk of bleeding or with history of bleeding disorder X|| I Specialty Skills KLFD BLS&ALS PROTOCOLS Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC 145 8. If patient does not meet any of the criteria listed above and the on scene EMT, Paramedic believes the patient may benefit from Trauma Alert criteria due to extenuating. circumstances surrounding the incident, the patient may be classified as a "Trauma Alert". I. Pediatric Trauma Scorecard Methodology Red, any one (1), transport as trauma alert Blue any two 2 transport as trauma alert follow local protocols Size > 20kg (44. (22 3 1111)s.) * Weight < 11kg (<22 lbs.) length-based tape Airway N o r ii ri a 1 9 oxygen 9 Assisted (1) Consciousness a ke * Amnesia e Altered mental status (2) paralysis9 Loss of consciousness e Coma e Presence of Suspicion i injury e Loss of sensation Circulation Good e Carotid or femoral * Faint or non-palpable carotid ° p hEl ra I pulses palpable but femoral pulse uJ a e�''��,� B lack of radial or pedal 9 SP < 50 mmHg rn rye g pulse Fracture Norie seeii * Sign or symptom of e Open long bone fracture Multipleor sus�peclLed single closed long bone * fracture (3)(4) * Multiple dislocations (3)(4) Cutaneous No visi[ Contk,jsion i nj u��ry e A[xrasion 9 2o or 3o burns to > 10%TBSA 9 Amputation (6) e Any penetrating i ® ury to head, neck or torso (7) Judgement e EMT or Paramedic discretion 1. Airway assistance includes manual jaw thrust, continuing suctioning, or use of adjuncts to assist ventilator efforts. 2. Altered mental status includes drowsiness, lethargy, inability to follow commands, unresponsiveness to voice, total unresponsive. 3. Long bone including humerus, radius/ ulna, femur, tibia/fibula. XII I Specialty Skills KLFD BLS&ALS PROTOCOLS Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC 146 4. Long bone fractures do not include isolated wrist or ankle fractures or dislocations. 5. Degloving injuries, major flap avulsions, or major soft tissue disruption. 6. Proximal to wrist or ankle. 7. Excluding superficial wounds in which the depth can be easily determined. 8. If the patient does not meet any of the criteria listed above and the on scene EMT, Paramedic believes the patient may benefit from Trauma Alert criteria due to extenuating circumstances surrounding the incident, the patient may be classified as a "Trauma Alert". J. RAD-57 Pulse CO- Oximeter g w ��r �, 4 m� ,i II u i Purpose Carboxyhemoglobin monitoringis used to determineif carboni levels re present i firefighters, patients and occupants with possibler rmonoxide. If levels r present, r ine the course of treatment . SpCO readings i ' I screening measuredetermine r carboni readings I l of inclusion/exclusion medical complaints to reduce risk undiagnosed rbon monoxide poisoning. is used in conjunctioni it giveshigher index of suspicion of hypoxi indicates need r aggressive treatment. XII I Specialty Skills KLFD BLS&ALS PROTOCOLS Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71 AEC 147 Indications SpCO monitoring shall be indicated for the following conditions: 1. Post-incident firefighter screening on all fires 2. Firefighter rehabilitation in accordance to NFPA 1584. 3. Extended time on or near fire-ground. 4. Multiple SCBA bottle use. 5. Suspected carbon monoxide exposure from work performed in confined spaces. 6. Carbon monoxide alarms/gas leaks without symptoms in conjunction with gas detectors to determine presence and exposure. 7. Multi-patient presentation. 8. Headache, dizziness, syncope, weakness, altered mental status, and/or lethargy. 9. Shortness of breath, chest pain. 10. Nauseal vomiting, abdominal complaints. 11. Any ill or injured patient with vague complaints. Recommended Usage. For use during firefighter rehabilitation and as a screening tool on occupants without complaints regardless of whether known or unknown exposure. The following guidelines will be used as a baseline for detecting SpCO levels: 1. 0 - 3% Nor mall no treatment required 2. 3 - 12%Yes - signs and symptoms or history of exposure TREAT 3. 3 -12% No - signs or symptoms, no history of exposure OBSERVE 4. 12% and higher TREAT and CONSIDER TRANSPORT Treatment: 100%oxygen by non-re-breather mask and transport to hospital is highly recommended. 1. Adults with an SpCO level 25% or higher 2. Pediatrics with an SpCO level 15% or higher 3. Pregnant females with an SpCO 15% or higher X11 I Specialty Skills KLFD BLS&ALS PROTOCOLS Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71 AEC 148 Procedure: 1. Apply probe to patient's middle finger or any other digit to center of fingernail as recommended by the device manufacturer. If near strobe lights, cover finger to avoid interference and/or move away from lights if possible. 2. Allow machine to register percent circulating carboxyhemoglobin. 3. Record Carboxy Hb procedure in patient care report or on the scene rehabilitation form. Also record Sao2 from RAD 57 4. Verify pulse rate on machine with actual pulse of the patient. 5. Monitor critical patients continuously until arrival at the hospital. If recording a one-time reading, monitor patients for a few minutes as oxygen saturation can vary. 6. Document percent of carboxyhemoglobin every time vital signs are recorded and in response to therapy to correct CO exposure. 7. Use the pulse oximetry feature of the device as an added tool for patient evaluation. Treat the patient, not the data provided by the device. 8. The pulse oximeter reading should never be used to withhold oxygen from a patient in respiratory distress or when it is the standard of care to apply oxygen despite good pulse oximetry readings, such as chest pain. 9. Factors is may reduce the reliability of the reading include: • Poor peripheral circulation (blood volume, hypotension, hypothermia and vasoconstrictors) • Excessive external lighting, particularly strobe/flashing lights • Excessive pulse oximeter sensor motion • Fingernail polish (may be removed with acetone pad) Irregular heart rhythms (atrial fibrillation, SVT etc.) Jaundice Placement of BP cuff on same extremity as pulse ox probe 0 -4% normal value > 5% possibly some exposure alarm will sound. High CO exposure and start treating patient appropriately and consider transport to the closest appropriate hospital. X11 I Specialty Skills KLFD BLS&ALS PROTOCOLS Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC 149 K. Glasgow Coma Scales Spontaneous 4 To Voice 3 To Pain 2 No Response 1 Obeys Command 6 Localizes Pain 5 Withdraws to Pain 4 Flexion to Pain 3 Extension to Pain 2 No Response 1 5 YEARS-ADULT Oriented and Converses 5 Disoriented and Converses 4 Inappropriate Words 3 Incomprehensible Sounds 2 No Response 1 2 YEARS-5 YEARS Appropriate Words 5 Inappropriate Words 4 Cries/Screams 3 Grunts 2 No Response 1 < 2 YEARS Smiles/Coos/Cries 5 Cries 4 Inappropriate Cries/Screams 3 Grunts 2 No Response 1 Glasgow Coma Score Total = XII I Specialty Skills KLFD BLS&ALS PROTOCOLS Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC 150 L. PEDIATRIC VITAL SIGNS Age Weight in kg Minimum Systolic Normal Heart Rate Normal Respiratory Rate BP Premature <2.5 40 120-170 40-60 Term 3.5 60 100-170 40-60 3 months 3.5 60 100-170 30-50 6 months 8 60 100-170 30-50 1 year 10 72 100-170 30-40 2 years 13 74 100-160 20-30 4 years 15 78 80-130 20 6 years 20 82 70-115 16 8 years 25 86 70-110 16 10 years 30 90 60-105 16 12 years 40 94 60-100 16 Typical BP in children 1-10 years of age: 80 mmHg+ (child's age in years x 2) Synchronized Cardioversion Initial 0.5 joules per kg followed by 1 joule/ kg then 2 joules/ kg Transcutaneous External Pacing Follow AHA recommendations. XII I Specialty Skills KLFD BLS&ALS PROTOCOLS Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC 151 M. ETCO2 Waveforms tidalnot,ate imprassive as,,eve ' ,, Y� ielse by !1, � Capnograp r d common,�on, r mu lump � rVIu�W�i'r,.. 'T r ^. �rrrramuur uuuuuuuuuuuuuuuuuuhnminnnni0000iu�>ri�� ".",_ III�1 _... uui�mmuuuumnrwmmu�mim�mmngn�r�rd�nrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrr f f+ �0�� r�lil�yl Ltibn 1 n4 P ration Exp/ common waves an r Yl�; "v v Y "„ ,,,; „ ( j u�eimr`Km mim im;v Ril°.a➢r oir i¢00M lilr�, "i�,,, I�'' a it r if m� m�r�ur m,�oi� a m� li t ,r�� ; :. r Of"'A"VI r�r,amnr aino,%.�r.rt„jvr n�i„ , i ,,. Y„,,;„,,, ,� �� 'd Y' � �'=„ ,;� ��) ;i��i�Y� III NQ I Gov RIM II OWN 1 Ape A '409 laiw10 C"m r o .. ..,. TINm4e""Omn W VOR ilurr r(mu Ii Wmamfu wlrormugm,e°.r,I'/4/Iyeme owl A.x WA:Ivm un mm im m i; Wmift ion l,4100"; iit 44 VI 00 u �r So '�%�! ,� _ ,ii{slll" "uil'7rui r" it's, >®Y;Ii1�1 a',tN rs0ht"I vu o P� Y z «w �� XII Specialty Skills KLFD BLS&ALS PROTOCOLS Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC 152 N. 12 LEAD QUICK REFERENCE GUIDE • ST elevation in the following leads include: a. Inferior wall MI — II, III, aVF— Perform V4R on all inferior wall MI (IF V411 IS POSITIVE, DO NOT GIVE NITRO TO PT.) b. Lateral wall MI — I, aVL, V5 thru V6 c. Anterior wall MI —V1 thru V6 d. Septal wall MI —V1 thru V3 • Inverted T waves and ST depression are indications of ischemia when found in aVL and V1 • Posterior wall MI —ST Depression in V1 thru V4 and a tall R wave; any R wave in V1 is suspicious • Indications for 12 Lead Include: a. Any suspected cardiac event b. Chest pain c. Abdominal pain d. Syncope e. Poor general appearance f. Hypotension g. Dysthymias h. Weakness i. Unexplained nausea, vomiting or diaphoresis. j. Unexplained arm,jaw, or back pain XII I Specialty Skills KLFD BLS&ALS PROTOCOLS Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC 153 O. SYNCHRONIZED CARDIOVERSION Hemodynamically unstable, unconscious or decreased mental status, hypotension, dyspnea, chest pain. If possible, sedate with Midazollarn 2.5 mg (up to 10 mg max). Biphasic: • Synchronized cardioversion 100 joules, if unsuccessful • Synchronized cardioversion 200 joules, if unsuccessful • Synchronized cardioversion 300 joules, if unsuccessful repeat subsequent shocks at 360 joules If patients' rhythm converts,then re-enters dysrhythmias, repeat cardioversion at last joule setting administered. P. TRANSCUTANEOUS EXTERNAL PACING • Apply Combo pads to patient's chest. Apply the first pad to anterior right chest,just below clavicle and second pad lower left lateral, mid axillary, or anterior/ posterior. • Connect the multifunction cable to the extremity leads. • Sedate the patient as needed with Midazollam 2.5 mg (up to 10 mg max) • Print an EKG rhythm strip prior to pacing • Turn on the external pacer and set the rate at 70 beats per minute • Turn milliamps to lowest amount and slowly increase until electrical capture is noted Electrical capture 'is noted when each pacer spike is followed by a wide R wave • If electrical capture is achieved, check central pulses at the femoral and carotid If palpable pulses are present,, mechanical capture has been achieved and pacingis successful • If both electrical and mechanical capture have not been achieved, pacing should be discontinued and the need for chest compressions assessed • If pacing has been successful the patient's mental status, perfusion and blood pressure should improve • Maintain pacing until transfer of care is given to an ALS transport unit and fully prepare to assume pacing efforts for the patient * it is imperative to have correct placement of pads and good contact to the chest wall to successfully pace. XII I Specialty Skills KLFD BLS&ALS PROTOCOLS Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71 AEC 154 Q. CINCINNATI PREHOSPITAL STROKE SCALE II r.It i i will, If any of t,,heisei 3 signs is,abnormlA thell Probability of a stroke, Facial Droop The 4MY", 1pa fien t,shows tee th o r smlile ........................ .......... ............. ..... Normal both sides of the 1 tj face move equally A, 1 V�J14 A. 21 fV one sid �, � e de of the face does not move „ti �°w, a; as well ante other side ji4 ........... 0. ................ Ar " Th le pa fien t clos,le:,,s le.yes a r7d exten ds,,bo th a,rmsi Abnormal Spelech sitrai'llght wt 'th Palms,i,ip for 110 sleconds Il The pa P"V 1"mpem t si " 0 ul can" tea ch an old My # Normal 1............. both arnis move the same or both dogriew tricks"If a,rms do not move(it all (other findings,such # Normal- patient uses correct words with as p ro n ato iflt a,y b e h ou I pl u 1) no slurring * Abnormal -one arm does not move or # A Orman -patient slurswords, uses the one a rm drifts ownwar r0 g words, Or is unable to speak, X11 I Specialty Skills KLFD BLS&ALS PROTOCOLS Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC 1 Adenosine Triphosphate (AdenocardO) NO o o� / i I� � i� ,, i` �iiiii��lllllllllllllllllllllllll Mechanism of Action PSVT: Slows conduction through AV node and interrupts AV reentry pathways, which restore normal sinus symptoms. Contraindications Hypersensitivity 2nd or3rd degree AV block(except those on pacemakers) Sinus node disease, such as sick sinus syndrome or symptomatic bradycardia (except in patients with a functioning artificial pacemaker) Adenoscan: Contraindicated in broncho constrictive or bronchospastic lung disease (eg, asthma) Cautions: Symptomatic bradycardia, cardiac arrest, heart block, heart transplant patients, HTN, hypotension, MI, proarrhythmic events, unstable angina Adenocard: Caution with broncho constrictive or bronchospastic lung disease (i.e asthma) IV Administration: Adenocard: given as a rapid injection (1-3 sec) by peripheral IV route directly into vein or into IV line close (proximal)to patient and is followed by rapid NS flush after each injection (20 mL for adults, 5 mL or more for pediatrics) Place patient in mild reverse Trendelenburg position before giving drug. Record rhythm strip during administration. IIII U III to IIIItIII • Adenosine dose • Flush Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC 2 • Attach both syringes to IV injection port nearest to patient • Clamp IV tubing above injection port • Avoid drug traveling retrograde • Push adenosine as fast as possible (1-3 sec) • While keeping pressure on adenosine syringe plunger, push NS flush as fast as possible • Unclamp IV tubing Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC 3 Albuterol (Proventil. ® Ventolin) ("7 liv AV o Mechanism of Action Beta2 receptor agonist with some beta1 activity; relaxes bronchial smooth muscle with little effect on heart rate. Contraindications Hypersensitivity to albuterol Cautions Some inhalers use hydrofluoroalkane (HFA) as propellant instead of chlorofluorocarbons (CFCs); otherwise, devices are equivalent. Immediate hypersensitivity reactions may occur after administration of albuterol sulfate, as demonstrated by rare cases of urticaria, angioedema, rash, bronchospasm, anaphylaxis, and oropharyngeal edema. Paradoxical bronchospasm may occur. The need for more doses than usual may be a sign of deterioration of asthma and requires reevaluation of treatment. Adverse Reactions and Side Effects: Cardiovascular: Tachycardia, hypertension, and angina. CNS: Nervousness, tremor, headache, dizziness, and insomnia. GI: Drying oforopharynx, nausea, and vomiting, unusual taste. Dosage: Nebulizer solution: If>1 year or< 10 kg: 2.5 in 3 ml of NS (0.083%)to nebulizer and flow oxygen at 6-8 liters/ min. (premixed) If< 1 year or< 10 kg: 1.5 in 3 ml of NS (0.083%)to nebulizer and flow oxygen at 3 liters/ min. (premixed). (2.5) mg divided in half). Delivered in over 5-15 minutes. Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC 4 Amiodarone (Cordarone) f, LY I Itau s u Il�I Mechanism of Action Class III antiarrhythmic agent, which inhibits adrenergic stimulation; affects sodium, potassium, and calcium channels; markedly prolongs action potential and repolarization; decreases AV conduction and sinus node function. Contraindications Hypersensitivity Severe sinus node dysfunction, 20/30 AV block or bradycardia causing syncope (except with functioning artificial pacemaker), cardiogenic shock. ACLS, Pulseless Ventricular Fibrillation/Ventricular Tachycardia 300 mg IV or intraosseous push after dose epinephrine if no initial response to defibrillation May follow initial dose with 150 mg IV q3-5min. Pediatric dosage: Pulseless Arrest: 5 mg/ kg may be repeated once. No single dose greater than 300 mg. 15 mg/ kg max) Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC 5 Aspirin (Bayer,O Bufferin) e ........ �51� �� nm Y iNr o a9.ry 1'7 3 io ll a t'Jr foie " u ms l i ,,y iWi lYu7meP9 laYy, 1tl"";u !wtl 0.ruiv�ijW Mechanism of Action Aspirin is a salicylate used to treat pain, fever, inflammation, migraines, and reducing the risk of major adverse cardiovascular events. Contraindications: A known allergy to Aspirin (i.e. urticaria, dyspnea, etc.), active GI ulceration or bleeding, hemophilia or other bleeding disorders, during pregnancy, children under 2 years of age. Indications: Aspirin is indicated in Acute Coronary Syndrome setting to prevent further clotting. Adverse Reactions and Side Effects: GI: Nausea,vomiting, heartburn, and stomach pain. OTC:Tinnitus Hypersensitivity: Bronchospasm, tightness in chest, angioedema, urticaria, and anaphylaxis. Dosage: Adult 324 mg(4) 81 mg chewable tablets)for Acute Coronary Syndromes Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC 6 Atropine Sulfate as Cardiac Agent ....................... /�� IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII III�I� i I/ 1� „ "� �, Mechanism of Action: Atropine is a potent anticholinergic (parasympathetic blocker, parasympatholytic)that reduces vagal tone and thus increases automatically the SA node and increases AV conduction. Indications: Sinus Bradycardia accompanied by hemodynamic compromise, (i.e. hypotension, confusion, frequent PVCs, pale cold, clammy skin). In children < 1year bradycardia of less than 60 beats/min should be treated if symptomatic even if BP is normal. Contraindications: None in emergency situations Warnings: Too small of a dose (< 0.5 mg) or if pushed too slowly, may initially cause the heart to decrease. Antihistamines and antidepressants potentiate Atropine.A maximum dose of 0.04 mg/kg should not be exceeded. For 2nd degree AV block Type II and 3rf degree AV block, omit Atropine and go to external pacer. Adverse Reactions and Side Effects: CNS: Restlessness, agitation, confusion, psychotic reaction, pupil dilation, blurred vision, and headache Cardiovascular: Increase heart rate, may worsen ischemia or increase area of infarction, ventricular fibrillation, ventricular tachycardia, angina, flushing of skin GI: Dry mouth, difficulty swallowing Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC 7 Other: Urinary retention. Can worsen pre-existing glaucoma. Dosage: Adult: 0.5-1 mg IV/ 10, may repeat every 3-5 minutes until improved or total of 2 mg is reached Pediatric: 0.02 mg/kg IV/10 (minimum dose is 01 mg maximum single dose is 0.5 mg child, 1 mg adolescent). May repeat once. Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC 8 Dextrose 50% and 25% (Pedi) DEXTROSE Injedoin,UP Ell III Wilihmal Mechanism of Action A monosaccharide, which provides calories for metabolic needs, spare body proteins and loss of electrolytes. Readily excreted by kidneys producing diuresis. Hypertonic solution. Indications • Hypoglycemia • Coma of unknown origin Contraindications • Intracranial or intraspinal hemorrhage (in a patient with normal BGL). • Blood glucose Level> 60 mg/dl. Adverse Reactions and Side Effects Cardiovascular: Thrombosis Sclerosing if given in peripheral vein. Local: Tissue irritation or necrosis if infiltrates Other:Acidosis, alkalosis, hyperglycemia, and hypokalemia Dosage Adult: (> 30 kg) 50 m l of a 50% solution; (25gm) IV/ 10. Pediatric (< 30 kg) 2 ml/ kg slow IV/ 10 of a 25% solution. Newborn: (< 10 kg or< 1 month of age) 5 ml/ kg IV/ 10 of 10% solution (dilute D50 4:1 with NS). Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC 9 * Note- Divide 50 by the type of dextrose solution to arrive at rate in ml/1<9 Adult (D50): 50/50 = 1 ml/kg Child (D25): 50/25= 2 ml/kg Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC 10 Diphenhydramine Hydrochloride (Benadryl) Vsk Mechanism of Actions Diphenhydramine is an antihistamine with anticholinergic (drying) and sedative side effects. Antihistamines appear to compete with histamines for cell receptor sites on effector cells. Diphenhydramine prevents, but does not reverse histamine mediated responses, particularly histamine effects on the smooth muscle of the bronchial airways, gastrointestinal tract, uterus, and blood vessels. Indications •Allergy symptoms, s n a p hylaxi s • Sedation of violent patients. • Dystonic reactions from phenothiazine overdose (i.e Haldol, Compazine, Thorazine, and Stelazine) Contraindications • Diphenhydramine is not to be used in newborn or premature infants. • Diphenhydramine is not to be used in patients with acute asthma attack. Warnings In infants and children especially, antihistamines in overdose may cause hallucinations, convulsions, or death. As in adults, antihistamines may diminish mental alertness in children. In young children, they may produce excitation. Diphenhydramine has additive effects with alcohol and other CNS depressants (hypnotics, sedatives, tranquilizers, etc.). Antihistamines are more likely to cause dizziness, sedation, and hypotension in the elderly (60 years or older) patients. Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC 11 Adverse Reactions and Side Effects CNS: Drowsiness, confusion, insomnia, headache, vertigo (especially in the elderly) Cardiovascular: Palpitations, tachycardia, PVCs, and hypotension Respiratory:Thickening of bronchial secretions, tightness of the chest, wheezing, nasal stuffiness. GI: Nausea,vomiting, diarrhea, dry mouth, and constipations GU: Dysuria, urinary retention Dosage Adult: 25- 50 mg IV/ 10 or 50 mg deep IM. Pediatric: 1 mg/ kg IV/ 10 or I (maximum 25 mg). Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC 12 Epinephrine 1 :1,000 ............,"l � a If �Gi/ ................. W/ 2 f0 fa II Mechanism of Actions Epinephrine is a sympathomimetic, which stimulates both alpha and beta-adrenergic receptors causing immediate bronchodilation, increase in heart rate and an increase in the force of cardiac contraction. Subcutaneous dose lasts 5-15 minutes. Indications •Asthma •An a p hylaxi s •Angioneurotic edema •All pulseless Arrest Contraindications None in the cardiac arrest situation. Hyperthyroidism, hypertension, cerebral arteriosclerosis in asthma. Caution should be used with Epi administration when the patient is older >40 years of age or history of heart disease. The benefit the risk. Do Not administer Epi if heart is > 150 beats per minute. Adverse Reactions and Side Effects CNS: Anxiety, headache, cerebral hemorrhage. Cardiovascular: Tachycardia, ventricular dysrhythmias, hypertension, angina, palpitations. GI: Nausea and vomiting. Dosage Adult: SQ 0.3 mg(0.3 cc). Repeat every 3-5 minutes (Asthma/Anaphylaxis may repeat once in 15 minutes). Pediatric: SQ 0.01 mg/ kg up to 0.5 mg. Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC 13 Epinephrine 1 :10,000 i ............ % /J11llY/IJi3YiWyl'i� ir'r%1 r i%i/1/Yr l��j ,:i�rl�I�� m+w✓nba imw'kMnu rmer LLN�6Yµti mm.w ua ��iw Nu Mechanism of Action Epinephrine is a sympathomimetic, which stimulates both Alpha and Beta-receptors. As a result of its effects, myocardial and cerebral blood flow are increased during ventilation and chest compression. Epi increases systemic vascular resistance and thus may enhance defibrillation. Indications •All Pulseless Arrest •Asystole •Ventricular Fibrillation to defibrillation • PEA • Other pediatric indications: hypotension in patients with circulatory instability, bradycardia (before Atropine). Contraindications None in the cardiac arrest situation. Warnings Epi is inactivated by alkaline solutions- Never Mix with Sodium Bicarbonate Adverse Reactions and Side Effects CNS: Anxiety, headache, cerebral hemorrhage. Cardiovascular: Tachycardia, ventricular dysrhythmias, hypertension, angina, palpitations. GI: Nausea and vomiting. Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC 14 Glucagon laoauy ar��erNuCaiqu � /�'1% , �ii� J i nk ririr i r Jl inuhMn nunm XYw;a 1JJ�J�ji Mechanism of Actions Glucagon, which is produced naturally in the pancreas by the alpha cells of the islets of Langerhans, causes an increase in blood glucose concentrations. It is effective in small doses, and no evidence of toxicity has been reported with its use. Glucagon acts only on the liver glycogen, converting it to glucose if the patient has adequate glycogen reserves. Glucagon possesses positive inotropic and chronotropic properties. Indications Documented hypoglycemia is a true medical emergency, IM glucagon should be administered rapidly if IV access is delayed. Glucagon is indicated for the treatment of hypoglycemia when IV cannot be established and oral glucose is contraindicated. It may be effective in a symptomatic beta-Mocker overdose. Contraindications • Pheochromocytoma • Insulinoma • Known hypersensitivity • Should not be routinely used to replace Dextrose when IV access has been obtained Warnings Glucagon should be administered with caution in patients with history of insulinoma and / or pheochromocytoma. Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC 15 Possible Adverse Reactions and Side Effects Occasional nausea and vomiting Dosage Adult: 1 mg slow IVP/IM (not less than 30 seconds) Pediatric <40 kg: 0.025 mg/kg slow IVP/IM (not as effective in children as in adults) Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC 16 Midazolarn (Versed °) FO i t I, Mechanism of Actions Depresses CNS, muscle relaxant, strong sedative, hypnotic, amnesia. Indications Control of seizures, sedation for cardioversion &pacing. Sedation for airway management. Contraindications Respiratory depression Hypotension ETO H and drugs Warnings Monitor patient for respiratory and CNS depression. Monitor vital signs after administration. Adverse Reactions and Side Effects: CNS: Retrograde amnesia altered mental status, dizziness. Cardiovascular: Bradycardia, hypotension, PVCs, tachycardia, nodal rhythms. GI: Nausea and vomiting, hiccoughs, coughing Respiratory: Respiratory depression, laryngospasm, bronchospasm. Dosage Adult: 2.5 mg increments up to 10 mg max Pediatric: > 1 years of age (0.1 mg/ kg) Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC 17 Naloxone Hydrochloride (NarcanO) LORIOC / r 't uq iwyd tiA lrel%f9N,+kt,er;ilJP.,w,.�j M«ua�hN,dfIISRxS',nll ...�/ III y r�trlfll,111111111rrfrlr rr�f�lr Jfllr,f�f Q� �j�//ji%i�/ Mechanism of Actions Naloxone antagonizes the effects of opiates by competing at the same receptor sites. When given IV, the action is apparent within two minutes. I or SC is slightly slower. Indications • Heroin • Methadone • Meperidine (Demerol) • Lomotil • Codeine • Hydromorphone (Dilaudid) • Morphine • Pentazocine (Talwin) • Propoxyphene (Darvon) • Percodan • Fentanyl (Subtimize) (Also Known As "White China") Contraindications Known hypersensitivity to Narcan. Warnings Naloxone should be administered cautiously to people including newborns of mothers who are known or suspected to be physically dependent on opiates, it may precipitate an acute abstinence syndrome. If the patient is intubated and the airway is controlled do not administer Narcan (excludes cardiac arrest). May repeat Narcan since duration of action of some narcotics may exceed that of Narcan. Naloxone is not effective against respiratory depression due to non-opiate drugs. Use caution during administration as patients may become violent as level of consciousness increases. Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC 18 Adverse Reactions and Side Effects CNS: Tremor, agitation, belligerence, pupillary dilation, seizures, increased tear production, sweating, and seizures secondary to withdrawal Cardiovascular: Hypertension, hypotension, ventricular tachycardia, pulmonary edema, ventricular fibrillation. GI: Nausea and vomiting. Dosage Adult: Initial dose 2 mg may administer IV/10/IM/ If no response after 4 mg, then the condition is probably not due to narcotic. (Fentanyl may require large doses of Naloxone to reverse effects). Pediatric: 0.1 mg/ kg IV/10/IM Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC 19 Nitroglycerin (NitrostatO, Nitrolingua[O Spray) Mechanism of Actions Nitroglycerin is a direct vasodilator, which acts principally on the venous system although it also produces direct coronary artery vasodilation as well.There is a decrease in venous return, which decreases the workload on the heart and thus, decreases myocardial oxygen demand. Sublingual nitroglycerin is rapidly absorbed. Pain relief occurs within one to two minutes and therapeutic effects can last up to 30 minutes. Indications • Chest pain or discomfort associated with suspected AMI. • Pulmonary edema with hypertension Contraindications • Systolic BP < 100 mmHg • Children under 12 • Patients on erectile dysfunction drugs that fall within time parameters, DO NOT administer Nitro if erectile dysfunction drug use <48 hours. • Known hypersensitivity to the drug • Evidence of a positive WR in the setting of an Inferior Wall MI Adverse Reactions and Side Effects CNS: Headache, dizziness, flushing, nausea and vomiting Cardiovascular: Hypotension, reflex tachycardia, bradycardia Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC 20 Dosage Adult: 0.4 mg(1 tablet or 1 spray sublingual). May repeat up to two additional times 3-5 minutes PRN. Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC 21 Oral Glucose (Insta Glucose) ,//0i ", u Mechanism of Actions Increases blood glucose levels slowly. Indications BS < 60 mgdl, patients who are altered but alert enough to take the command to swallow. Contraindications Patients unable to swallow or Stroke symptoms. Precautions None when patient can swallow, risk of aspiration if given improperly. Adverse Reactions and Side Effects Cardiovascular: Unknown' CNS: Unknown GI: Nausea Dosage Adult: 1 tube Pediatric: 1 tube Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71 AEC o � 1 (9 4 w I KeyLargo Fire e I. COMMUNICATION (DISPATCH) CENTER PROCEDURE A. All EMS systems utilize the E911-phone system in conjunction with Computer Aided Dispatch (CAD) and Emergency Medical Dispatch programs. The taker call confirms all emergency information, including address and callback data prior to the end of the telephone conversation; immediately transmits the emergency call request to the nearest available Fire-Rescue unit(s) for response; and provides all unit(s) with all available information concerning the incident. B. Call taker personnel/dispatcher shall make every attempt to obtain the following information from the 911 caller: 1. Nature of the emergency. 2. Location of the incident. 3. Call back number. 4. Number of patients. 5. Severity of the illness/ injury. 6. Name of the caller. C. Monroe County operates a consolidated communications system, encompassing all but the four self-dispatched fire rescue agencies. Should on-scene personnel recognize a need for other emergency agencies (e. g. law enforcement, fire, EMS, Coast Guard), they shall notify Dispatch immediately. On-scene personnel must identify the type of additional equipment/ staffing needed/ required. The communications center shall contact the appropriate services (mutual aid/automatic aid). II. ON SCENE PROCEDURE—GROUND XIII I Appendix B KLFD BLS&ALS PROTOCOLS Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC 2 A. Upon arrival at the scene, Fire Department personnel shall conduct a size up of the scene, to include, but not limited to, Trauma Alert Criteria (Section IV), safe entry, severity, and number of patients, the need for extrication, and the need for additional help. Dispatch will be notified, as soon as possible, of"Trauma Alert" patient(s). Dispatchers shall immediately transfer this information, using the words "Trauma Alert", for Aeromedical evacuation to nearest Trauma Center. B. Fire Department personnel shall submit the treatment data for each trauma patient to the EMS ground transport unit as required in 64J- 1. 014, F. A. C. and their respective agencies. III.TRANSPORT PROCEDURE (Aeromedical) Three steps to follow when requesting Aeromedical evacuation. The first two are directed toward the safety of the helicopter pilot and crew, ground personnel, patient, and bystanders; and the third is to establish operational guidelines as to when and /or the helicopter may be used to transport these patients. A. Severe weather at scene, helicopter hanger, landing zone (LZ), or Trauma Center reduces the use of the Aeromedical evacuation. B. Safety considerations for landing zone (if any of 5, move the landing zone): 1. Landing Zone (LZ) should be clear of obstacles (obstacles are any object >40 feet tall and within 100 feet of the LZ). 2. Optimum size of the LZ should be 100-foot square (or diameter). 3. The surface should be smooth and hard as possible and should not exceed a 10-degree slope. 4. Pedestrians and large gatherings of civilians in the area. 5. An expectation that area may not remain safe. C. Aeromedical evacuation may be used if: 1. Trauma transport. 2. Extrication time greater than twenty (20) minutes. 3. The helicopter is needed to gain access to a patient for transport from an inaccessible area. 4. Open water incidents (e.g. drowning, boat fires, explosions on the bay or offshore, etc.) XIII Appendix B KLFD BLS&ALS PROTOCOLS Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC 3 5. Large scale multiple casualty incidents. D. Operational Guidelines by ground Fire Department crews for Aeromedical evacuation use: 1. Secure a TAC radio channel through the County's dispatch center and keep it open until the helicopter has left scene. 2. Ground Crew PRE-ALERT Trauma Center. 3. Start respective agency's modified patient treatment form. 4. Airway- advise Air Crew on airway status and if airway assistance is or RSI (Rapid Sequence Intubation) is required. 5. Begin Packaging Patient (remove shoes and clothing from vital areas). Advise crew of weight of patient. 6. A pre-designated landing zone should be used first. For roadway landings traffic must be stopped in both directions. 7. LZ Command should ensure that EMS crew personnel are supplemented with an appropriate number of personnel to assist in the safe and efficient loading of patient into the helicopter. 8. Headlights should be turned off at night. 9. Only clear landing zone upon direction of LZ command and helicopter has left the scene. IV.TRAUMA ALERT CRITERIA The following guidelines are to be used to establish the criteria for a "Trauma Alert" patient and determine which patient(s) will be transported to a trauma center. Any patient that meets any one of the "RED" or any two "BLUE" criterion will be considered a trauma alert. A. ADULT TRAUMA SCORECARD METHODOLOGY XIII I Appendix B KLFD BLS&ALS PROTOCOLS Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC 4 1. Each Fire Department personnel shall ensure that upon arrival at the location of an incident, Fire Department personnel shall: a. Assess the condition of each adult trauma patient using the adult trauma scorecard methodology, as provided in this section to determine whether the patient should be a trauma alert. b. In assessing the condition of each adult trauma patient, the Fire Department personnel shall evaluate the patient's status for each of the following components: airway, circulation, best motor response (i.e. Glasgow Coma Scale), cutaneous, long bone fracture, patient's age, mechanism of injury. The patient's age and mechanism of injury (i.e. ejection from vehicle or deformed steering wheel) shall only be assessment factors when used in conjunction with assessment criteria included in #3 (Level 2) of this section. (NOTE: Glasgow Coma Scale included for quick reference.) 2. Fire Department personnel shall assess all adult trauma patients using the following "RED" criteria in the order presented and if any one of the following conditions is identified, the patient shall be considered a trauma alert. a. : Active ventilation assistance required due to injury(ies) causing ineffective or labored breathing beyond the administration of oxygen. b. : Patient lacks a radial pulse with a sustained heart rate greater than or equal to 120 beats per minute or has a blood pressure of less than 90mmHg systolic. d. LONGBONE FRACTURE: Patient reveals signs or symptoms of two or more long bone fracture sites (humerus, radius/ ulna, femur, or tibia/fibula). e. : 2nd or 3rd degree burns to 15 percent or greater of the total body surface area; electrical burns (high voltage/direct lighting) regardless of surface area calculations; an amputation proximal to the wrist or ankle; any penetrating injury to the head, neck, or torso (excluding superficial wounds where the depth of the wound can be determined.) f. : Patient exhibits a score of 4 or less on the motor assessment component of the Glasgow Comal Scale; exhibits the presence of paralysis; suspicion of a spinal cord injury; or the loss of sensation. g. .. XIII Appendix B KLFD BLS&ALS PROTOCOLS Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC 5 • PARAMEDIC JUDGEMENT— If none of the conditions are identified using the criteria above during the assessment of the adult trauma patient, the paramedic can call a trauma alert if, in his or her judgment,. the patient's condition warrants such action. • GLASGOW COMA SCORE— 12 OR less 3. Should the patient not be identified as a trauma alert using the "RED" criterion listed in #2 of this section, the trauma patient shall be further assessed using the "BLUE" criteria in this section and shall be considered a trauma alert patient when a condition is identified from any two of the seven components included in this section. a. AIRWAY: Respiratory rate of 30 or greater. b. CIRCULATION.- Sustained heart rate of 120 beats per minute or greater. E I:::I rU I;;;;;'@ Patient reveals signs or symptoms of a single long bone fracture resulting from a motor vehicle collision or a fall from an elevation of 10 feet or greater. d. CUTANEOUS.- Soft tissue loss from either a major degloving injury; or major flap avulsion greater than 5 inches; or has sustained a gunshot wound to the extremities of the body. e. BEST MOT01:1 F E I E (BMR)-. BMR of 5 on the motor component of the Glasgow Coma Scale. f. MECI,,,,,,I I F:,: I J I" : Patient has been ejected from a motor vehicle, (excluding any motorcycle, moped, all-terrain vehicle, bicycle or open body of a pick-up truck), or the driver of the motor vehicle has impacted with steering wheel causing steering wheel deformity. g. AGE: Anticoagulated Older Adult > 55 h. .m Blunt Abdominal Injury. 4. If the patient is not identified as a trauma alert after evaluation using the criteria in sections 2 or 3 above, the trauma patient will be evaluated using all elements of the Glasgow Coma Scale. If the score is 12 or less, the patient shall be considered a trauma alert (excluding patients whose normal Glasgow Coma Scale is 12 or less, as established by the medical history or pre-existing medical condition when known). XIII Appendix B KLFD BLS&ALS PROTOCOLS Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC 6 5. If paramedic judgement is used as the basis for calling a trauma alert, it shall be documented on all patient data record as required in section 64J-1.014, F.A C. 7. The results of the patient assessment shall be recorded and reported on all patient data records in accordance with the requirements of section 64J-1.014, F.A.C. B. PEDIATRIC TRAUMA SCORECARD METHODOLOGY Pediatric patients are those people age 15 or younger and will be transported to nearest Trauma Center. 1. Fire Department personnel shall assess all pediatric trauma patients using the following " criteria in the order presented and if any of the following conditions is identified, the patient shall be considered a pediatric trauma alert: a. : Active ventilation assistance required due to injury(ies) causing ineffective or labored breathing beyond the administration of oxygen. b. b. : Patient exhibits an altered mental status that includes drowsiness; lethargy; inability to follow commands; unresponsiveness to voice or painful stimuli; or suspicion of a spinal cord injury with /without the presence of paralysis or loss of sensation (can include reliable history of loss of consciousness). c. : Faint or non-palpable carotid or femoral pulse or the patient has a systolic blood pressure of less than 50mmHg. d. : Evidence of an open long bone (humerus, radius/ ulna, femur, or tibia/fibula) fracture or there are multiple fractures sites or multiple dislocations (except for isolated wrist or ankle fractures or dislocations). e. : Major soft tissue disruption, including major degloving injury; 2nd or 3rd degree burns to 10 percent or more of the total body surface area; electrical burns (high voltage/ direct lighting) regardless of surface area calculations; an amputation proximal to the wrist or ankle; any penetrating injury to the head, neck, or torso (excluding superficial wounds where the depth of the wound can be determined). f. PARAMEDIC JUDGEMENT: If none of the conditions are identified using the criteria above during the assessment of the pediatric trauma patient, the paramedic can call a trauma alert if, in his or her judgement, the patient's condition warrants such action. XIII Appendix B KLFD BLS&ALS PROTOCOLS Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC 7 2. In addition to the criteria listed above in (1) of this section, a pediatric trauma alert shall be called when "BLUE"' criteria are identified from any two of the components included below: a. I E : Exhibits symptoms of amnesia, or there is loss of consciousness. b. CIRCULA,,,rul\l: Carotid or femoral pulse is palpable, but the radial or pedal pulses are not palpable, or the systolic blood pressure is less than 90 mmHg. c. I::: T E: Reveals signs or symptoms of a single closed long bone fracture. Long bone fractures do not include wrist or ankle fractures. d. MI SC.: Blunt Abdominal Injury. e. SIZE: Pediatric trauma patients weighing 11 kilograms or less, or the body length is equivalent to his weight on a pediatric length and weight emergency tape (the equivalent of 33 inches in measurement or less). 3. In the event paramedic judgment is used as the basis for calling a Trauma Alert, it shall be documented as required in the 64J-1.014 F.A.C., on the patient care report. MedicalNOTE,:Anytime KLFD care provider believes a patient would benefitfrom transport via an Aeromedical evacuation, the patient will be transported by Aeromedical. The patient discussion may take place after the transport has been completed with notification of . V.TRANSFER PROCEDURES FOR EMERGENCY INTER-HOSPITAL TRAUMA TRANSFERS The Key Largo Fire Department is a non-transport agency and does not provide inter- facility transfers within Monroe County. This information is based on the official records and protocols of the Key Largo Fire Department as of 08/05/2024. VI. GLASGOW COMA SCALE SCORING The Glasgow Coma Score (GCS) measures cognitive abilities. It is composed of three parameters, (eye, verbal, and motor responses) and uses numerical scoring to assist in the correlation of brain injury. Those scores are as follows: XIII I Appendix B KLFD BLS&ALS PROTOCOLS Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC 8 Adult GCS: Best Eye Response: 1. No eye opening 2. Eye opening to pain. 3. Eye opening to verbal command. 4. Eyes open spontaneously. Best Verbal Response: 1. No verbal response. 2. Incomprehensive sounds. 3. Inappropriate words. 4. Confused. 5. Oriented. Best Motor Response 1. No motor response. 2. Extension to pain. 3. Flexion to pain. 4. Withdrawal from pain. 5. Localizing pain. 6. Obeys commands. A GCS score is between 3 and 15, 3 being the worst and 15 the best. A Coma score of 13 or higher correlates with a mild brain injury;9 to 12 is a moderate injury, and 8 or less a severe brain injury. (Note a phrase "GCS of 11"is essentially meaningless, and it is important to break the figure down into its components, such as eye 3 + verbal 3 + motor 5 = GCS 11) XIII Appendix B KLFD BLS&ALS PROTOCOLS Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC 9 Pediatric GCS: Eye Opening < 1 Year >1 Year 4 Spontaneously Spontaneously 3 To verbal To verbal command command 2 To pain To pain 1 No response No response Motor Response < 1 Year >1 Year 6 Obeys 5 Localizes pain Localizes pain 4 Flexion —normal Flexion withdrawal 3 Flexion — Flexion — abnormal abnormal (decorticate (decorticate rigidity) rigidity) 2 Extension Extension (clecerebrate (decerebrate rigidity) rigidity) 1 No response No response Verbal Response 0-23 Months < 2-5 Years >5 Years 5 Smiles, coos, cries, Appropriate words Oriented and appropriately and phrases converses 4 Cries Inappropriate Disoriented and words converses 3 Inappropriate Cries and/or Inappropriate crying and /or screams words screaming 2 Grunts Grunts Incomprehensive 1 No response No response No response A GCS score is between 3 and 15, 3 being the worst and 15 the best. A Coma score of 13 or higher correlates with a mild brain injury;9 to 12 is a moderate injury, and 8 or less a severe brain injury. (Note a phrase "GCS of 11"is essentially meaningless, and it is important to break the figure down into its components, such as eye 3 + verbal 3 +motor 5 = GCS 11) XIII Appendix B KLFD BLS&ALS PROTOCOLS Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC 10 VI I. DESIGNATED FACILITIES Trauma Alert patients will be transported to the nearest appropriate trauma center. Should Aeromedical evacuation not be available, or ETA exceeds more than 30 minutes, the patient will be transported to the next closest facility. Listed below are the closest Trauma Centers: Ryder Trauma Center 1800 NW 10th Ave Miami, Florida 33136 Ryder Trauma Center/Jackson South 9333 SW 152ND Street Miami, Florida 33157 HCA Florida Kendall Hospital 11750 SW 40t" Street Miami, Florida 33175 VIII. RUN REPORTS The Fire Department provider issuing the "Trauma Alert" shall provide the ALS Ground Unit with a copy of the Patient Care Run Report. Non-transport units are required to initiate protocols and procedures until a transport unit assumes treatment. This includes, but is not limited to, medical care, patient packaging and documentation of an ePCR. (See attached) XIII I Appendix B KLFD BLS&ALS PROTOCOLS Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC 11 KLFD — Patient Care "Evaluation" Report Date: Unit# Crew: / Incident Location: Incident#: TIME OF ONSET/ DISPATCH ENROUTE TO SCENE ARRIVAL AT PATIENT ALERT:TRAUMA UNIT AVAILABLE INJURY SCENE CONTACT PATIENT NAME DATE OF BIRTH AGE SEX WEIGHT ADDRESS CITY STATE ZIP PHONE# PATIENT HISTORY' CHIEF COMPLAINT MEDICATIONS SYMPTOMS PAST MEDICAL HISTORY ALLERGIES LAST MEAL EVENTS LEADING PATIENT ASSESSMENT TIME B/P PULSE RESP/MIN SA02 SKIN GCS GLUCOSE TIME B/P PULSE RESP/MIN SA02 SKIN GCS GLUCOSE INTERVENTIONS TIME OXYGEN/ADJUNCT/LPM TIME SPINAL IMMOBILIZATION TIME I.V./CATH#/SITE TIME OTHER ' f V TIME MED/DOSE/ROUTE TIME OTHER , AN D �u HEAD/NECK CHEST BACK ABDOMEN PELVIS EXTREMITIES NARRATIVE: XIII I Appendix B KLFD BLS&ALS PROTOCOLS Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71 AEC 12 Adult Trauma Scorecard Methodology Red, any one (1), transport as trauma alert; Blue, any two (2), transport as trauma alert Component Airway • Sustained respiratory rate e Active airway assistance (1) 30 Circulation • Sustained heart rate 120 No radial pulse and a sustained HR > 120 or Systolic < 90 mmHg Best Motor Response • BMR = 5 e GCS :5 12 (BMR) e 13MR = 4 or less e Presence of paralysis e Suspicion of spinal cord injury * Loss of sensation Cutaneous • Soft tissue loss (2) e 2o or 3o burns to 15% or more TBSA * Amputation proximal to the wrist or ankle e Any penetrating injury to the head, neck, or torso (3) Long bone Fracture (4) • Sign or symptoms of a single 9 Sign or symptoms of a fracture site due to MVC or Fall fracture of two or more long 10' or more bone " ites" Age • >- 55 years or older (7) Mechanism of Injury • Ejection from motor vehicle (5) • Steering wheel deformity (6) Judgement 9 EMT or Paramedic discretion (8) X111 I Appendix B KLFD BLS&ALS PROTOCOLS Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71 AEC 13 Pediatric Trauma Scorecard Methodology Red, any one (1), transport as trauma alert; Blue, any two (2) transport as trauma alert; Gr' ','en follow local protocols Size 2Ukg (44. kg (22 3 Hbs.) * Weight < 11kg (<22 lbs.) I b S * Length < 33 inches on pediatric length-based tape Airway N ir a oxyg&ri * Assisted (1) * Intubated Consciousness .e Amnesia e Altered mental status (2) Loss of consciousness e Coma 9 Presence of paralysis 9 Suspicion of spinal cord injury e Loss of sensation Circulation Good Carotid or femoral 9 Faint or non-palpable carotid or e r i I�i e ra I pulses palpable but femoral pulse 11 Alses; SBP > lack of radial or pedal e SP < 50 mmHg 9 0 iiry) g pulse * SBP < 90 mmHg Fracture Norie see��ri 9 Sign or symptom of 9 Open long bone fracture o -sus�pectd single closed long bone 9 Multiple fracture si��r e tes fracture (3)(4) e Multiple dislocations (3)(4) Cutaneous No visi ritt zion * Major soft tissue disruption (5) i rijAb. rasioin e 2o or 3o burns to > 10%TBSA * Amputation (6) 9 Any penetrating injury to head, neck or torso (7) Judgement EMT or Paramedic discretion (8) XIII I Appendix B KLFD BLS&ALS PROTOCOLS Docusign Envelope ID: D9C280B0-04D5-4D4C-A898-A72C90C71AEC 14 Attestation of Medical Director's Participation, Review., and Approval of Trauma Transport Protocols "As the Medical Director of Key Largo Fire Department, I developed and /or directed the development of the Trauma Transport Protocols presented in this document" Signed by: 1-�* hbM,Sb(& 6/16/202 5 Dr. Thomas Morrison 944,& �A _ Name of Medical Director Signature of Medical Director Approval Date ME79946 M.D. D. O. License Number XIII I Appendix B KLFD BLS&ALS PROTOCOLS AGREEMENT BETWEEN KEY LARGO FIRE RESCUE AND EMERGENCY MEDICAL SERVICES DISTRICT AND KEY LARGO VOLUNTEER FIRE DEPARTMENT INC. This AGREEMENT made this Cr1 day of March, 2026, by and between the Key Largo Fire Rescue and Emergency Medical Services District (tOADISTRICT") and Key Largo Volunteer Fire Department("FIRE DEPARTMENT") RECITALS WHEREAS,the DISTRICT has lawful authority granted to it in Chapter 2005-329, organized and existing under Chapters 189 and 191, Laws of Florida, to provide fire and rescue services (hereinafter "Fire Services$,%) either directly or by contract with the Key Largo Volunteer Fire Department. Florida, desire primarily for the benefit of the taxpayers residing within said DISTRICT- and WHEREAS., the DISTRICT is charged with responsibility for provision of Fire Services, and WHEREAS, the DISTRICT and the FIRE DEPARTMENT NOW, THEREFORE, in consideration of the covenants contained herein and other good and valuable considerations, the parties agree as follows: 1, TERM OF AGREEMENIT1 The term of this AGREEMENT shall commence on March 9, 20261, and terminate on July 11 2026, unless terminated earlier in accordance with the terms and conditions hereafter provided. The Parties may mutually agree in writing to extend the term of this AGREEMENT on a month-to-month basis. Unless otherwise terminated or extended as provided herein, this AGREEMENT shall not automatically renew. 2. TERMINATION,,,- The DISTRICT may terminate this AGREEMENT at any time during its term if the FIRE DEPARTMENT defaults under any provisions specified herein,or violates any standard specified in this AGREEMENT,or violates any other law,regulation or standard applicable to the fumishing of Fire Services in Monroe County. In such event the DISTRICT shall furnish the FIRE DEPARTMENT written notice of any such default or violation and the FIRE DEPARTMENT shall have thirty(30) days from receipt of said notice to correct or remedy such default or violation. However, if correction of the default or violation requires permitting or outside authorization from any State or Local Govenunental Agency,the FIRE DEPARTMENT shall apply for the required permit or authorization within thirty (30) days and the time period for correction of the violation shall commence on the date that the FIRE DEPARTMENT received the necessary permit or authorization. Additionally, if any act of nature should occur during the period of time within the time the FIRE DEPARTMENT was to correct the default or violation, the period of time within which correction is to occur shall be extended a reasonable amount of time, using the reasonable person standard for determination of what is a reasonable tirne. If such violation is not corrected or such default is not remedied,. within the aforesaid time, or is of such nature that it cannot be corrected or remedied, this AGREEMENT shall be considered void. This AGREEMENT may be tenninated unilaterally for the refusal of the FIRE DEPARTMENT to allow public access to all documents, papers, letters, or other material, as allowed or required by law, excluding any and all material protected under the Health Information Portability and Accountability Act (HIPAA), made or received by the contractor in conjunction with duti es. performed under this AGREEMENT, after 30 days wn'tten notice of request and opportunity to provide same by the DISTRICT,unless such records are exempt from public access under F.S. 119.07 and 24(a)of Art. I of the State Constitution. This AGREEMENT may be terminated by the DISTRICT for any reason upon at least sixty(60) days written notice to the FIRE DEPARTMENT at the addresses set forth below. If said AGR-EEMENT should be terminated as provided in this paragrapri of the Contract, the DISTRICT will be relieved of all obligations under said contract unless otherwise provided herein. Upon termination of the AGREEMENT,the DISTRICT will only be required to pay that amount of the 2 contract actually performed to the date of termination with no payment due for unperformed work or lost profits. 3, EFFECT OF DISTRICT POLICIIE15.16 The FIRE DEPARTMENT shall not create or enforce internal policies that conflict with any policies of the District Personnel Manual, as amended. Should such a conflict ariseV the policies of the District's Personnel Manual shall control, unless otherwise provided by law or by the District's Personnel Manual. The DISTRICT shall solicit comments from the FIRE DEPARTMENT regarding any proposed amendments to the Personnel Manual the DISTRICT deems might materially affect the FIRE DEPARTMENT. 4. RESPONSE AREA AND MUTUAL The FIRE DEPARTMENT shall be the exclusive provider of Fire Services within their response area. The FIRE DEPARTMENT shall also provide mutual aid response to any other emergency service upon request and/or in accordance with existing protocol, applicable laws, rules, regulations, and standards. 5. FIRE DEPARTMENT ORGANIZATION AND BY-LAE15.1 The FIRE DEPARTMENBT shall revisit its corporate roles, distribution of authority, and executive or administrative oversight and shall create an organizational structure that provides for checks and balances between executive/administrative oversight and operational functions. The structure shall also reflect the efficient assignment of responsibility and authority, allowing the FIRE DEPARTMENT to accomplish effectiveness by maximizing distribution of workload and allocate resources equitably and with emphasis on safety. The FIRE DEPARTMENT'S Board shall provide to the DISTRICT an organizational plan of the FIRE DEPARTMENT and shall review the structure as needed due to internal restructuring. If the FIRF, DEPARTMENT effects revisions to the organizational plan the FIRE DEPARTMENT shall notify the DISTRICT clerk and present the revised plan to the DISTRICT upon request.To the extent the DISTRICT board provides comments or advice on the organizational plan, the FIRE DEPARTMENT shall give significant weight and consideration to the DISTRICT's comments and advice. No revisions to the organizational plan that would have a significant fiscal impact on the DISTRICT shall be approved by the FIRE DEPARTMENT without first obtaining DISTRICT approval. The plan shall include an organizational chart indicating any subordinate(s) or supervisor(s) of each position. The chart shall be accompanied by thorough job descriptions for each position. The job descriptions shall clearly and adequately describe the primary functions and activities, critical tasks,levels of supervision,and accountability,as well as reasonable qualifications of each class or position within the FIRE DEPARTMENT. All persons working under accepted job descriptions will receive a performance appraisal, as outlined in FIRE DEPARTMENT Policies annually, without exception. 3 4 The plan shall also contain eligibility lists for required positions based on merit,, experience, O and qualifications. Selections shall be made based on merit and qualification and should include practice guidelines for a Drug Free Workplace and a Smoke Free Workplace. The FIRE DEPARTMENT shall maintain an active corporation status with the State of Florida, and shall produce evidence to the DISTRICT confirming its corporate standing under Florida law upon request. The FIRE DEPARTMENT'S membership shall, review and/or revise its by-laws as needed and shall present one dated,typed copy of its by-laws to the DISTRICT within thirty(30) days of such revisions being adopted by the FIRE DEPARTMENT. The FIRE DEPARTMENT shall confirm the enabling documents providing for the appointment of corporate officers.The FIRE DEPARTMENT shall provide the DISTRICT a dated, typed copy of its updated by-laws upon any update thereof Notwithstanding the requirements of this section, the FIRE DEPARTMENT shall conduct a job analysis of all Job Classifications to confin-n the incumbents are working within their job descriptions and expectations. 6. MISSION, VISION,,V.AL.UE.S.ST.RA.TE.GIC PLANNING OUTCOMES, GOALS, AND OBJECTIVES- The FIRE DEPARTMENT shall, with the DISTRICT, develop a Strategic Plan. The purpose of the Plan shall be to evaluate service improvement opportunities,develop goals for future service delivery, and to establish critical tasks and timelines to accomplish those goals. The Plan shall contain a critical tasking analysis for common community risk types and ensure that the number of personnel dispatched to calls equals the identified critical tasks. 7. FOUNDATIONAL POLICY OF FIRE DEPARTMENIII The FIRE DEPARTMENT shall create clear policies that lay the foundation for effective organizational culture. The policies shall take the form of Administrative Rules and Standard Operating Guidelines ("SOGs"). The FIRE DEPARTMENT shall within thirty (30) days promulgate its initial Administrative Rules and SOGs and provide a hardcopy of the same to the DISTRICT. The FIRE DEPARTMENT shall thereafter provide the DISTRICT an updated copy of the FIRE DEPARTMENT'S Administrative Rules and SOGs upon any modification or update thereof 7.1 Administrative Rules: q............. The FIRE DEPARTMENT'S Board shall adopt or approve,,with a review by the DISTRICT, Administrative Rules that personnel in the FIRE DEPARTMENT are required to comply with at all times. The FIRE DEPARTMENT shall present such proposed rules to the DISTRICT on a semi- annual basis, via written submission of all revised rules to the DISTRICT Clerk and report to the DISTRICT board at a regularly scheduled meeting. The FIRE DEPARTMENT shall additionally make such proposed rules available to the DISTRICT upon the request of any sitting District Commissioner. The FIRE DEPARTMENT shall give significant weight and consideration to the DISTRICT'S advice and comments and shall revise previously 4 enacted Administrative Rules to the extent such revisions are warranted following advice and comment from the DISTRICT board. The Administrative Rules shall govern all members of FIRE DEPARTMENT., whether paid, volunteer, or civilian, and including the Chief. The FIRE DEPARTMENT Board may delegate authority to the Chief to enforce Administrative Rules on FIRE DEPARTMENT personnel. Where rules and policies, by their nature, require different application or provisions for different classifications of members, these differences shall be clearly indicated and explained in writing. The Administrative Rules shall contain sections which address: 0 Public records access and retention in accordance with the DISTRICT's Record Retention Schedule'; s Contracting and purchasing authority; Safety and loss prevention, 0 Personal Protective Equipment program', 0 Hazard communication program; Harassment and discrimination,- • Personnel appointment and promotion; • Disciplinary and grievance procedures-, • Uniforms and personal appearance; and Other personnel management issues. 7.2'Standard Operating Guidelines J"SOGs'!h. The FIRE DEPARTMENT shall develop and i # , tinder the direction of the Fire Chief, enforce, SOGs. SOGs shall contain street-level operational standards of practice for personnel of the FIRE DEPARTMENT. The FIRE DEPARTMENT shall present such proposed rules to the DISTRICT on a semi-annual basis, via written submission of all revised rules to the DISTRICT Clerk and report to the DISTRICT board at a regularly scheduled meeting. The FIRE DEPARTMENT shall additionally make such proposed SOG's available to the DISTRICT upon the request of any sitting District Commissioner. The FIRE DEPARTMENT shall give significant weight and consideration to the DISTRICT'S advice and comments and shall revise previously enacted SOG's to the extent such revisions are warranted following advice and comment from the DISTRICT board. Unlike Administrative Rules, variances shall be allowed in unique or unusual circumstances where strict application of the SOG would be less effective. The FIRE DEPARTMENT shall develop a program for regular, systematic updating of SOGs to ensurc they remain current, practical, and relevantfi 7.3 Avai,labill"!j of Rules and SOGs. The FIRE DEPARTMENT shall make all Administrative Rules and SOGs readily available to all members of the FIRE DEPARTMENT and shall furnish each member with his/her copy. In doing so,the FIRE DEPARTMENT shall ensure that no confusion exists as to which Rules or SOGs are currently in force. Additionally, the FIRE DEPARTMENT shall develop a written procedure to ensure and to govern the distribution of all new Rules, SOGs, and other memos to members of the FIRE DEPARTMENT. The written procedure shall include a method to verify distribution. 8, INCIDENT REPORTS Within twenty-four (24) hours of the occurrence of the following types of incidents, the FIRE DEPARTMENT shall provide a written report to the DISTRICT clerk and Board Chair: • Any incident involving damage to property estimated to be equal to or greater than $5 000.00. • Any incident involving the hospitalization or death of any FIRE DEPARTMENT personnel; • Any incident likely to result in litigation agalinst the FIRE DEPARTMENT,, its personnel, or the DISTRICT- 9 Within thirty(30)days of the occurrence of(or at the next regularly scheduled meeting of the DISTRICT Board) any incident response which the Chief determines to have an inordinately or unusually long response time, the FIRE DEPARTMENT shall provide a written report to the DISTRICT clerk and Board Chair, 1P 9. PERSONNE,1L I*, The FIRE DEPARTMENT shall maintain volunteer and/or paid personnel so as to make sure a complement of personnel are available to provide Fire Services on a twenty-four(24) hour basis to the DISTRICT. In accordance with the current practices of the FIRE DEPARTMENT,, scheduling and assignment of personnel shall be arranged so as to ensure that all applicable legal requ i rements.are met at al I t imes.The F I RE DEPA RTM ENT shal I ensure that at a I I ti mes su ffic i ent personnel are scheduled to comply with the requirements of Florida Stawte Section 633 as may be amended from time to time. The backup shall perform to the ninety-fifth percentile (W�'O') of a 'lab'lity. Scheduling and assignment of personnel shall be arranged so as to utilize volunteer val I personnel to the maximum extent possible. Only in the event the FIRE DEPARTMENT deems it necessary to maintain coverage or to meet administrative needs and obtains pen-nission from the DISTRICT shall paid part-time or full-time employees be employed in addition to those approved in the budget. 10. MINIMUM STANDARD AND TRAINING: The FIRE DEPARTMENT shall require that all volunteer personnel engaged in Fire Services comply with the minimum training,education,and performance requirements of the State of Florida for fire department personnel.On the date of hire,all FIRE DEPARTMENT personnel shall meet the minimum state certification and eligibility standards required for that position. The FIRE DEPARTMENT shall establish and maintain training and continuing education program designed to maintain a high degree of competency and skill on the part of all volunteer and/or paid FIRE DEPARTMENT personnel. The FIRE DEPARTMENT shall also facilitate and encourage attendance by all volunteer and/or paid FIRE DEPARTMENT personnel at proficiency training programs provided by the FIRE DEPARTMENT or other agency deemed appropriate. The FIRE 6 DEPARTMENT shall maintain current and accurate training and proficiency records for all volunteer 4 and/or paid FIRE DEPARTMENT personnel evidencing compliance with this provision. The FIRE DEPARTMENT shall appoint a FIRE DEPARTMENT training officer. The FIRE DEPARTMENT shall develop and implement a comprehensive FIRE DEPARTMENT Training Plan including minimum training and certification requirements for members and employees. The Plan shall provide for regular training of, and implement a comprehensive, structured, skills maintenance training program for all of FIRE DEPARTMENT officers and employees. The FIRE DEPARTMENT shall design and implement a pre-promotion training program. The FIRE DEPARTMENT shall require lesson plans for all training sessions and immediately implement the requirement for an assigned safety officer in attendance at all manipulative training sessions, as applicable to the specific exercise. The FIRE DEPARTMENT shall continue multi-company and multi-agency drills and training as frequently as is required by Florida law to enhance mutual aid operations and improve relationships and planning efforts.The FIRE DEPARTMENT shall develop and implement a plan to evaluate member/employee technical and manipulative skills on a regular basis. The FIRE DEPARTMENT shall develop and implement a formal performance evaluation system for all members and ' employees The FIRE DEPARTMENT shall conduct an ongoing analysi. s of on-scene staffing strength to confin-n the FIRE DEPARTMENT'S standard of coverage. The FIRE DEPARTMENT shall continue the centralized, consistent', training data collection and shall maintain up-to-date records on training data collection and reporting under direct oversight of the training officer. The FIRE DEPARTMENT shall establish a training reference, 0 equipment and props inventory and member checkout procedure. The FIRE DEPARTMENT shall consider implementing a forinal competency-based approach to the FIRE DEPARTMENT'S training program. On at least a quarterly basis, the FIRE DEPARTMENT shall provide to the DISTRICT at a regularly scheduled DISTRICT Board meeting a written report detailing FIRE DEPARTMENT compliance with this paragraph, specifically with regard to the adequacy of on-scene staffing. 11. COMPLIANCE: At all times in the performance of its duties wider this AGREEMENT, the FIRE DEPARTMENT shall comply with all applicable State and Federal regulations, and all applicable local laws, ordinances and procedures pertaining to the operation of equipment,direction of personnel,transportation of patients, and medical care of persons. 12. DISCIPLINE: The FIRE DEPARTMENT has previously adopted a clearly identifiable, fori-nal, progressive disciplinary process with an appropn*ate appeal procedure. Within thirty(30)days of the adoption of 4 * revisions to this disciplinary procedure,the FIRE DEPARTMENT shall notify the DISTRICT clerk, and shall present such proposed modifications to the DISTRICT upon request. The FIRE DEPARTMENT shall give significant weight and consideration to the DISTRICT's advice and comments and shall revise the previously adopted disciplinary procedure to the extent such * 0 revisions are warranted following advice and comment from the DISTRICT Board. U. PAID EMPLOYEES$ Subject to the provisions of Section Nine (9), the FIRE DEPARTMENT may employ such part-time or full-time employees as it deten-nines is necessary to carry out its Fire Services. Part- time or full-time employees of the FIRE DEPARTMENT shall be compensated by the DISTRICT at a rate commensurate with that of other similarly trained and experienced personnel employed within Monroe County. 14. SELECTION OF NEW MEMBERSHIP: The FIRE DEPARTMENT shall make membership selections based on merit and qualifications. The FIRE DEPARTMENT shall maintain and update a list of active FIRE DEPARTMENT membership. 15. HARASSMENT POLICX'- The FIRE DEPARTMENT shall establish a disciplinary policy and procedure for reporting harassment that conforms to State and Federal law, including Title V11 of the Civil Rights Act of 1964, the Age Discrimination in Employment Act, and the Americans with Disabilities Act. The FIRE DEPARTMENT shall instruct employees/volunteers to report any complaints in accordance with the DISTRICT'S harassment policy. 16. EQUAL EMPLOYMENT OPPORTUNITIES AND HARASSMENT* The FIRE DEPARTMENT must comply with all State and Federal and local laws relating to nondi'scn"mination,including,but not limited to: (a)Title V1 of the Civil Rights Act of 1964(P.L. 88- 352)which prohibits discrimination on the basis of race, •color or national origin; (b)Title IX of the Education Amendments of 1972,as amended(20 U.S.C. Sections 1681-1683,and 16851686),which prohibits discrimination on the basis of sex; (c) Section 504 of the Rehabilitation Act of 1973, as amended (29 U.S.0 Section 794), which prohibits discriminati" . on on the basis of handicaps; (d)the Age Discri'mination Act of 1975, as amended (42 U.S.C. Sections 6101-6107), which prohibits discrimination on the basis of age- (e) the Drug Abuse Office and Treatment Act of 1972 (P.L. 92- 255), as amended, relating to nondiscrimination on the basis of drug abuse; (f) the Comprehensive Alcohol Abuse and Alcoholism Prevention',Treatment and Rehabilitation Act of 1970(P.L. as amended, relating to nondiscrimination on the basis of alcohol abuse or alcoholism; (g) Sections 523 and 527 of the Public Health Service Act of 1912(42 U.S.C.290-dd-3 and 290-ee-3),as amended, relating to confidentiality of alcohol and drug abuse patient records;(h)Title V111 of the Civil Rights Acts of 1968(42 U.S.,C, Section 3601 et seq.), as amended, relating to nondiscrimination in the sale, rental or financing of housing; (1)any other nondiscrimination provisions in the specific statute(s) under which application for Federal assistance is being made;and 0)the requirements of any other nondiscrimination statute(s)which may apply to the application. 17. DRUG-FREE WORKPLACE: The FIRE DEPARTMENT shall comply with the requirements of the Drug-Free Workplace Act of 1988,and implemented at 44 C.F.R. Part 17, Subpart F. 18. FREEDOM FROM POLITICAL COERCION*. No paid FIRE DEPARTMENT employee who exercises functions in connection with an activity financed in whole or in part by loans or grants made by the United States or a Federal agency shall (1) use his or her official authority or influence for the purpose of interfering with or affecting the result of an election or a nomination for office, (2) directly or indirectly coerce, command, or advise a State or local officer or employee to pay, lend, or contribute anything of value to a party, committee, organization, agency, or person for political purposes, provided, however, that an individual may be a candidate for elective office. Provided, farther, that an FIRE DEPARTMENT officer or employee may be a candidate for elective office in an election as *ded by 5 U.S.C. 1502(a)(3), as amended. provi This provision does not in any way limit the rights of an FIRE DEPARTMENT officer or employee to vote as he or she chooses and to express his or her opinions on political subjects and candidates. 19. POLITICAL ACTIVITIES- In consultation with the DISTRICT, the FIRE DEPARTMENT shall adopt a "Political Activity Policy" which requires its personnel to make reasonably clear that any personal political opinion expressed in a public forum is their own and not attributable to the FIRE DEPARTMENT. If the FIRE DEPARTMENT should revise, suspend, or revoke the Political Activity Policy, the FIRE DEPARTMENT shall notify the DISTRICT Clerk within thirty (30) days of such decision. To the extent that the DISTRICT board provides comments or advice on the revision, suspension,y+ or revocation of the Political Activity Policy, the FIRE DEPARTMENT shall give significant weight and consideration to the DISTRICT'S comments and advice. 20, MAINTENANCE OF FIRE DEPARTMENT HISTORY: The FIRE DEPARTMENT shall clearly assign responsibility for maintaining a Facebook or other social media page or flle containing items of historical significance, including pictures, newspaper articles, etc. Additionally, the FIRE DEPARTMENT shall prepare an annual report to be presented to the DISTRICT on August I st of each year. The annual report shall also be distributed to the community and made available on the FIR-E DEPARTMENT'S website. At minimuml each annual report shall include.- • Brief history of the FIRE DEPARTMENT; 1P • Summary of events and activities during the report year-, 9 Description of major incidents handled by the FIRE DEPARTMENT; Descriptions of new or improved services and programs,- List of people who served with the FIRE DEPARTMENT during the year, Awards received by the FIRE DEPARTMENT or individuals; Financial summary including revenues and expenditures,grants.,etc., and Statistical analysis, with trends, of key community service level indicators. 21. OVERALL ALERTNESS, INCLUDING VOLUNTEER ALERTNESS: The FIRE DEPARTMENT shall establish a duty officer system, including using volunteer officers, to ensure that an individual designated for incident command will be available 24 hours a day. 22, PUBLIC COMPLAIN1,1111"S"'; The F1 RE D E PARTM ENT shal I establ 1 sh a formal procedu re for handl 1 ng compl ai nts from the public. The FIRE DEPARTMENT shall immediately provide the DISTPJCT with a written description of any written complaints received from the public within twenty-four (24) hours of receiving such complaints, or as soon as is practicable thereafter. Notwithstanding the foregoing, the FIRE DEPARTMENT shall report any complaint,written or otherwise,that concerns any matter specified in Section 8 of this Agreement. Subsequent remedial actions relating to the complaint shall likewise be immediately provided to the DISTRICT. 23. VEHICLE, EQUIPMENT AND FACILITIES: The DISTRICT shall provide to the FIRE DEPARTMENT sufficient vehicles, equipment, and facilities to enable the FIRE DEPARTMENT to carry out its Fire Services with the DISTRICT as provided for in the Monroe County Year 2030 Comprehensive Plan or any other plans or documents relating to the Fire Services that are adopted by Monroe County.The DISTRICT shall be responsible for the general maintenance and repair of the vehicles,equipment,and facilities owned and/or leased by the DISTRICT as well as required periodic testing and certification of all equipment,as necessary, used by the FIRE DEPARTMENT in connection with its Fire Services. The FIRE DEPARTMENT shall be responsible for proper control of all assigned vehicles, equipment, and facilities and shall develop and implement an aggressive drivev"'operator annual training program and checkout program for all FIRE DEPARTMENT vehicles.The FIRE DEPARTMENT shall be responsible for notifying the Chair of the DISTRICT of needed repairs for vehicles, equipment,yi and facilities and shall assist in affangements for said repairs. The DISTRICT shall have the right to inspect the vehicles, equipment,or facilities at any time. 24. PROPERTY CONTROL: The FIRE DEPARTMENT shall provide a system for property control of the vehicles and equipment owned and/or leased by the DISTRICT and used by the FIRE DEPARTMENT to provide Fire Services. The FIRE DEPARTMENT shall assist in the performance of the annual inventory of the vehicles and equipment. 25. SUBCONTRACT,& The FIRE DEPARTMENT may subcontract its services when the DISTRICT determines such subcontracts are beneficial to the FIRE DEPARTMENT,, the DISTRICT, and/or the community. The FIRE DEPARTMENT may utilize equipment and vehicles owned and/or leased by the DISTRICT in conjunction with the above subcontractors provided that no reduction in the level of services to their respective service area results from the utilization of said equipment for s&, contracted services. Notice of intent to subcontract, when DISTRICT equipment and/or vehicles will be used,must be provided to the DISTRICT at least thirty(30)days prior to execution of said subcontract in order to allow for proper review and comment concerning same and to allow the DISTRICT to decide whether to approve or disapprove of the same. A signed copy of all subcontracts shall be provided to the DISTRICT. The FIRE DEPARTMENT shall comply with all regulations promulgated pursuant to 40 U.S.C. §3 145 re lating to contractors' and subcontractors' fum ish ing statements on the wages pai d each employee during the previous pay period. No FIRE DEPARTMENT employee shall receive kickbacks from public works employees, as provided by 18 U.S.C. §874. The FIRE DEPARTMENT shall comply with all applicable provisions of 40 USC §§ 3701-3708. 26. BUDGET REOUEST AND AGREEMENT-1 As requested by the DISTRICT as part of its annual budget adoption process, the FIRE DEPARTMENT shall submit a proposed budget appropriations request, by line item account in a format specified by the DISTRICT, for the forthcoming fiscal year. The FIRE DEPARTMENT budget request should include personnel, supplies, materials, utilities and other internal costs, charges,or expenditures necessary or incidental to the operation of the Fire Services, including a reasonable stipend for professional services contemplated within this AGREEMENT, which have not been previously specified herein as being provided by the DISTRICT. This budget request shall also include, based on statistical analysis of the usage, mileage, serviceability, and/or level of service, a five year plan for refurbishment, replacement, or additional apparatus to be provided to the FIRE DEPARTMENT by the DISTRICT. Once fonnally adopted by the DISTRICT prior to October I S' of each year, the budget establishes an initial limitation on expenditures by the FIRE DEPARTMENT by line item total. The DISTRICT and FIRE DEPARTMENT acknowledge that the annual budget may be amended from time to time to reflect increases in actual expenses, and to reflect the increase or decrease in the level of services provided to the District due to hurricanes,other emergencies or requirements for additional staffing. If subsequent to the passage and adoption of the budget, the FIRE DEPARTMENT determines that a line item will exceed its original allocation, the FIRE DEPARTMENT shall prepare for the DISTRICT' s approval a budget amendment request to reflect its additional funding requirements.The FIRE DEPARTMENT is not authorized to receive payment in excess of the budgeted line item amounts until the DISTRICT approves such an amendment. The FIRE DEPARTMENT may,however,make budget transfers which increase or decrease budgeted line item amounts without DISTRICT approval, provided that such line item changes do not require an increase to the adopted total amount of the FIRE DEPARTMENT budget and that such transfer is in accordance with the District's Budget Transfer Policy. Budget line items for capital expenditures and those line items which include personnel and payroll related costs may not be modified by the FIRE DEPARTMENT without DISTRICT Board approval. 27. CONTRACT PAYMENIS: The FIRE DEPARTMENT shall receive funding for budgeted expenditures incurred in the performance of this CONTRACT by the following methods: 27.1 Advances- The DISTRICT shall retain the option to provide the FIRE DEPARTMENT with advance funding for minor recurring expenditures. If such advance payments are made the FIRE DEPARTMENT will provide the DISTRICT with monthly financial reports, by the 150day of each month for the prior month in a format deemed acceptable by the DISTRICT, which show all costs incurred by the FIRE DEPARTMENT against this advance. At the end of each fiscal year, incurred costs will be reconciled with total advance payments made by the ' DISTRICT The DISTRICT. S external auditors will determine the final balance. If incurred costs exceed total payments, the DISTRICT will reimburse the FIRE DEPARTMENT for the excess costs, provided that such reimbursement does not exceed the total adopted budget for the FIRE DEPARTMENT. If total payments exceed incurred costs, the FIRE DEPARTMENT will reimburse the DISTRICT for the excess payment amount. 0. 27.2 Direct Payment, The DISTRICT can provide for direct payment of any expenses of the FIRE DEPARTMENT which are part of the approved budget. If desired by the FIRE DEPARTMENT, the DISTRICT will provide for direct payment of payroll prepared by a third party payroll service through withdrawal from a DISTRICT account. Direct payment for other expenses will be made by the DISTRICT based on the FIRE DEPARTMENT'S submittal of purchase orders and/or check requests in accordance with the DISTRICT's adopted Purchasing Policies and Procedures or Travel Authorization and Expense Policy as may be amended by the DISTRICT from time to time. 27.3 Reimbursemento., In the event that an expenditure which is part of the adopted budget must be incurred by the FIRE DEPARTMENT rather than paid directly by the DISTRICT,the FIRE DEPARTMENT can request reimbursement from the DISTRICT's fands by submitting a check request in accordance with the DISTRICT'S adopted Purchasing Policies and Procedures. The DISTRICT will notreimburse the FIRE DEPARTMENT for capital expenditures that were incurred prior to execution of an approved purchase order or contract in accordance with the DISTRICT's purchasing policies. 12 In no event shall the DISTRICT reimburse the FIRE DEPARTMENT for expenditures that exceed budgeted line item allocations or that were made in violation of the DISTRICT's Policies and Procedures. Travel expenses must be submitted in accordance with the DISTRICT's adopted Travel Authorization and Expense policy. 28. ANNUAL AUDIT REPORT: The FIRE DEPARTMENT shall allow the DISTRICT and its external auditors access to its records related to expenditures under this contract to conduct an annual audit report,in accordance with Florida Statutes. The DISTRICT will be responsible to procure the services of the auditor and the cost of such audit shall be a cost,charge, or expenditure of the DISTRICT. 29. DISTRICT INSURAN,ICB.- The DISTRICT shall provide the following insurance coverage on and for the volunteers of the FIRE DEPARTMENT: A. Workers Compensation Insurance as required by Florida Statutes Chapter 440, including minimum$1,000,000 Employer's Liability Coverage,; B. General Liability Insurance,with minimum limits of$2,000,000- and 9 C. Automobile Liability Insurance with minimum limits of $2,000,000 including Physical Damage Insurance on all vehicles owned or leased by the DISTRICT and used by the FIRE DEPARTMENT. The policy shall provide secondary coverage on private vehicies only during such time as they are operated in response to a call, and ending, either at such time as the volunteer returns to his/her home, or to the first location to which a volunteer stops on the way home,after completion of participation in the emergency services that were subject to the call, whichever occurs first. All DISTRICT liability insurance policies shall name the FIRE DEPARTMENT as an additional insured. Proof of all insurance in a form acceptable to the FIRE DEPARTMENT shall be provided by the DISTRICT upon request. 30. FIRE DEPARTMENT INSURANCE,,-, 30.1 Part-Time and Full TIme Emvlovees: The FIRE DEPARTMENT shall provide the following insurance on all part-time and full-time employees of the FIRE DEPARTMENT- A. Workers Compensation Insurance in compliance with Florida Statutes Chapter 440 including minimum$1,000,000 Employer's Liability Coverage; B. Unemployment Compensation in compliance with Florida Statutes Chapter 443; 1,�3 C. General Liability Insurance with minimum limits of$2,000,000 combined single limitio D. D 1 sabi I ity i ncome i nsurance for a m i n i mum o f th ree hundred do I lars($3 00.00)week ly upon total disability for the first thirty(30)days and thereafter, in an amount up to six hundred dollars($600.00)weekly,not to exceed the employee's net income. Said benefit shall continue until otherwise terminated according to the provisions of the applicable disability policyl and E. Death benefits insurance with a minimum amount of seventy-five thousand ity ($75000.00) death/pennanent disabil, benefits for the employee while engaged in the performance of his/her duties. F. Labor and Employment Practices Liability insurance with a minimum limit of one m i I I i on do I lars($1,000. The FIRE DEPARTMENT shall provide the following insurance on all volunteers of the FIRE DEPARTMENT- A. Disability income insurance for a minimum of three hundred dollars ($300.00) weekly upon total disability for the first thirty(30) days and thereafter, in an amount up to six hundred dollars ' ($600. ,00)weekly not to exceed the volunteers average reimbursement. Said benefit shall continue until otherwise terminated according to the provisions of the applicable disability policy; B. Death benefits insurance with a minimuiln amount of seventy-five thousand dollars ($75,000.00) death/permanent disability benefit for the employee while engaged in the performance of his/her duties; and C. Workers Compensation Insurance as required by Florida Statutes Chapter 440, including minimum$1,000, ' 000 Employers Liability Coverage. ■ 30.3 Vehicles.- The FIRE DEPARTMENT shall provide the following insurance on all vehicles owned and/or leased by the FIRE DEPARTMENT and used in providing Fire Services within the DISTRICT: Automobile Liability Insurance with minimum limits of$300,000 combined single limit. All liability policies are to name the DISTRICT as an additional insured, and shall provide for no less than thirty(30) days notice of cancellation, non-renewal,or reduction in coverage. Proof of all insurance in a form acceptable to the DISTRICT shall be provided by the FIRE DEPARTMENT upon request. 14 31. PRIVATE VEHICLE 1NSURAN,C,1E,,1- Any and all FIRE DEPARTMENT personnel who utilize a private vehicle in the course and scope of their duties shall keep in full force and effect a policy of li ti ability insurance on his/her private vehicle(s) in at least such minimum amounts of coverage as are required under Florida law. Proof of insurance in a form acceptable to the DISTRICT shall be provided by each volunteer and maintained on file in the business office of the FIRE DEPATMENT. The FIRE DEPARTMENT shall provide copies of proof of insurance to the DISTRICT upon request. 32. VOLUNTEER PERSONNEL.- The DISTRICT shall reimburse the FIRE DEPARTMENT for the volunteer personnel in accordance with an annual budget agreed upon by both parties, the failure of which results in the previous year schedule applying. The FIRE DEPARTMENT shall have the right to establish its own eligibility requirements for d isbursement of rel mbursement based on parti c ipati on i n F I R E DE PA RT M ENT act iv iti es. D I STR ICT funding for the reimbursement of volunteers shall not exceed the budgeted allocation for such reimbursement. Said amounts may be changed or adjusted by approval of the DISTRICT and the FIR-E DEPARTMENT, during the term of this AGREEMENT without cause to void, cancel, or violate this AGREEMENT. 33. MAINTENANCE AND RECORDS CUSTODIAN. The following shall be obligations of the FIRE DEPARTMENT: A. Maintaining of detailed, accurate, and current records of all maintenance and repairs performed on all vehicles and equipment used by the FIRE DEPARTMENT; B. Ensuring that detailed, accurate, and current records of all required testing and certification of rescue, emergency, and medical equipment testing and certification are maintained by the FIRE DEPARTMENT,- C. Maintaining of accurate and current records of training,testing, and certification of all volunteer personnel and part-time and fall-time employees. D. Keeping an accurate and current inventory of all vehicles and equipment used by the FIR.E DEPARTMENT; E. Preparing and maintaining complete and accurate records of incident details, such as response times. The FIRE DEPARTMENT shall develop a written procedure governing the methods by which to document and record incident details,o which procedure shall include a list of required information to be recorded about each incident. The FIRE DEPARTMENT shall rile with the State of Florida in a timely fashion,an incident report for each response by 15 the FIRE DEPARTMENT to all FIRE DEPARTMENT personnel rescue,mutual aid, or other miscellaneous calls as required by the State of Florida; and F. Preparing and maintaining complete and accurate personnel records, such as records on employment history, discipline, commendations, work assignments, injuries, exposures, and leave time. The FIRE DEPARTMENT, has developed a written procedure for maintaining the preceding records. Within thirty (30) days of a revised records maintenance procedure being adopted, the FIRE DEPARTMENT shall notify the DISTRICT clerk and present such procedure to the DISTRICT Board upon request. The FIRE DEPARTMENT has formalized its process of responding to public requests for access to records. It shall maintain a current version of this policy and procedure in writing and shall ensure that all legal requirements concerning maintenance of records are met. Within thirty(30)days of a revised records maintenance procedure being adopted,the FIRE DEPARTMENT shall notify the DISTRICT clerk and present such procedure to the DISTRICT Board upon request. IF FIRE DEPARTMENT HAS QUESTIONS REGARDING THE APPLICATION OF CHAPTER 119, FLORIDA STATUTES, TO THE AMBULANCE CORP'S DUTY TO PROVIDE PUBLIC RECORDS R-ELATING TO THIS CONTRACT, CONTACT THE DISTRICT RECORDS CUSTODIAN, CAROL GRECO, AT (305) 394-1719,,CLERK, .ORG The FIRE DEPARTMENT shall ensure proper security of its records by using passage and/or container locks with limited access as needed. The FIRE DEPARTMENT shall back up important computer files every month. The FIRE DEPARTMENT shall establish a written procedure designed to ensure that the FIRE DEPARTMENT facilities are adequately locked and secured from unauthorized entry. The FIRE DEPARTMENT shall limit public access to its facilities to business areas. 34. PUBLIC MEETINGS: The FIRE DEPARTMENT shall comply with public notice and Sunshine Law requirement regarding public access to information, as if the FIRE DEPARTMENT were a government entity,, excluding confidential protected medical information and employee records. Requests for information from the public shall be directed through the District and not directly to the FIRE DEPARTMENT, 35. RELATIONSHIP WITH MONROE COUNTY. The FIRIE DEPARTMENT shall cooperate and maintain a good relationship with Monroe County and other neighboring fire departments and municipalities, their officials, and their fire department members. 16 36, DISTRICT MEDICAL DIRECTOR- The DISTRICT, after consulting with the FIRE DEPARTMENT,, shall contract with a Florida licensed physician(s)to serve as the FIRE DEPARTMENT Medical Director.The Medical Director shall secure and provide to the DISTRICT medical malpractice insurance with minimum limits of $3 00,000 per occ urre nce,$1 0 00,000 ann ua I aggregate to c over t h e neg I i gent acts and/or orn i ss i ons of the Medical Director of the FIRE DEPARTMENT when said Director is acting within the scope and in furtherance of the duties of the Medical Director as set forth in Florida Statute 401.265. 37. ACCOUNTABILITY—,- The FIRE DEPARTMENT shall be accountable to the DISTRICT as required by this ' AGREEMENT The Monroe County Emergency Management Agency shall have the authon . ty to coordinate and control all Fire Services during a State of Local Emergency. The Monroe County Emergency Management Agency shall also have the authority to coordinate and control Fire Services during other major incidents if requested by the FIRE DEPARTMENT, or under any authority granted to the FIRE DEPARTMENT by any applicable laws and/or ordinances or under any protocols, rules, regulations, standards, plans, policies, and/or procedures approved by the DISTRICT. The FIRE DEPARTMENT shall have the duties and responsibilities in its respective service area which are applicable to Fire Services. The DISTRICT shall provide administrative and technical assistance, as requested, to the FIRE DEPARTMENT in matters relating to the operation of the Fire Services. Representatives of both the DISTRICT and the FIRE DEPARTMENT shall meet on a regular basis for discussions regarding the operation of the Fire Services contemplated within this AGREEMENT and other related matters; meeting dates to be jointly agreed upon. All administrative correspondence shall be sent to: To the DISIRICT: Attn,- Chairperson Key Largo Fire Rescue and EMS District P.O. Box 371023 Key Largo, FL 33037-1023 To the FIRE DEPARTMENT Attn: President Key Largo Volunteer Fire Department, Inc. 98600 Overseas Highway Key Largo, FL 33037 38. INDEMNIFICATION.11, The FIRE DEPARTMENT, to the fullest extent by law, shall indemnify and forever hold harmless the DISTRICT, its officers.,agents.,and employees, from all claims of any sort whatsoever that may arise from negligence, acts or omissions of the paid part-time and f, ' or full-time employees of the FIRE DEPARTMENT, not related to the provision of the Fire and Rescue Services. 1 7' 39. MISCELLANE101 The FIRE DEPARTMENT shall comply with all applicable environmental laws and regulations. The FIRE DEPARTMENT shall comply with all applicable provisions of the Federal Fair Labor Standards Act (29 U.S.C. 201). The FIRE DEPARTMENT shall perform all financial and compliance audits required by law. 40. NOTICES- Any notice required or permitted to be given hereunder shall be deemed properly given at the time it is personally delivered or mailed, properly addressed and postmarked to the respective address s if pecl ied below or to such other addresses as may be specified in writing.. To the DISIRICT: Attn.- Chairperson Key Largo Fire Rescue and EMS District P.O. Box 371023 Key Largo, FL 33037-1023 To the FIRE DEPARTMENT.- Attn.- President Key Largo Volunteer Fire Department, Inc. 98600 Overseas Highway Key Largo, FL 33037 All vehicles and equipment owned and/or leased by the DISTRICT and used by the FIRE DEPARTMENT to provide Fire Services shall be returned to the DISTRICT when requested upon expiration or termination of this AGREEMENT. During the interim period between expiration of this AGREEMENT and the execution of a new AGREEMENT, the FIRE DEPARTMENT shall be authorized to use the vehicles and equipment for continued provision of Fire Services. 41. CALL HANDLING AND PROCESSIN,G,1 The FIRE DEPARTMENT shall formally establish standards for call answering and call processing times and shall regularly monitor compliance with such standards. The FIRE DEPARTMENT shall provide the DISTRICT a written performance report identifying 90th percentile call handling and i processing times on at least a quarterly basis. 42. INVALIDITY: If any section, subsection, sentence, clause,or provision of this AGREEMENT is held invalid, the remainder of this AGREEMENT shall not be affected by such invalidity. 18 43. DISPUTE RESOLUTION: The DISTRICT and the FIRE DEPARTMENT agree that any dispute to this contract will be submitted to binding arbitration for resolution if the DISTRICT and FIRE DEPARTMENT are unable to come to agreement through informal means. However, the DISTRICT'S determination on the use of funds, and the FIRE DEPARTMENT determination on the Chief of the FIRE DEPARTMENT (subject to the provisions of Section 42) are not subject to binding arbitration. .0 44. CHIEFS OF FIRE DISTRICT. If the DISTRICT'S Board of Commissioners votes upon a duly noticed resolution to require the FIRE DEPARTMENT to terminate the employment of its Chief and such resolution passes with the votes of at least four (4) out of the five (5) Commissioners, the FIRE DEPARTMENT shall immediately and unconditionally terminate the employment of the same. Furthermore, the re-employment of any Chief terminated under this provision shall be forbidden absent express permission of the DISTRICT. Nothing herein shall prevent the FIRE DEPARTMENT on its own initiative, from terminating the employment of its Chief. IN WITNESS WHEREOF, the parties hereto have caused this AGREEMENT to be executed the day and year las executed below: KEY LARGO FIRE RESCUE AND EMERGENCY MEDICAL SERVICES KEY LARGO VOLUNTEER DISTRICT FIRE DEPARTMENT, INC. ""INS ........................................ e e s I An to', All .'i,, Chair Went r Date: Date: 3 0 DATE(MM/DD/YYYY) ACC)RL> CERTIFICATE OF LIABILITY INSURANCE 01/07/2026 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Jessica Conway NAME: Risk Management Associates,Inc. PH/CONE Ext: (386)252-6176 (mac,No): (386)239-4049 P.O.Box 2416 E-MAIL essica.conwa bbrown.com ADDRESS: jess,ca.conway@bbrown.com AFFORDING COVERAGE NAIC# Daytona Beach FL 32115 INSURERA: National Union Fire Insurance Company of Pittsburgh,Pa. 19445 INSURED INSURER B: Key Largo Volunteer Fire Department,Inc. INSURER C: 1 East Drive INSURER D: INSURER E: Key Largo FL 33037 INSURER F: COVERAGES CERTIFICATE NUMBER: CL261795351 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. I TR INSD WVD POLICY NUMBER POLICY EFF POLICY EXP LIMITS TYPE OF INSURANCE (MM/DD/YYYY) (MM/DD/YYYY) X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED 1,000,000 CLAIMS-MADE FX OCCUR PREMISES(Ea occurrence) $ MED EXP(Any one person) $ 5,000 A VFNU-TR-0019768-05/000 10/01/2025 10/01/2026 PERSONAL&ADV INJURY $ 1,000,000 GEN'LAGGREGATE LIMITAPPLIES PER: GENERAL AGGREGATE $ 2,000,000 JECT X POLICY ❑ PRO- F LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 (Ea accident) X ANY AUTO BODILY INJURY(Per person) $ A OWNED SCHEDULED VFNU-TR-0019768-05/000 10/01/2025 10/01/2026 BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY (Per accident) Medical Payments $ 5,000 UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 1,000,000 A X EXCESS LIAB CLAIMS-MADE VFNU-TR-0019768-05/000 10/01/2025 10/01/2026 AGGREGATE $ 2,000,000 DED RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE F-1 N/A E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ Management Liability Each Wrongful Act $1,000,000 A VFNU-TR-0019768-05/000 10/01/2025 10/01/2026 or Offense DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Certificate of Insurance issued as proof of coverage. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Key Largo Volunteer Fire Department,Inc. ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD