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					   ANCHORAGE FIRE DEPARTMENT

Medical Operations Manual
          MOM 2006




     Michael Levy, M.D., FACEP, FACP
             Medical Director

         Soren Threadgill, MICP
    Deputy Fire Chief, EMS Operations

        Francis X. Nolan, Jr., MICP
           Chief Medical Officer


              Revision 3.0, 2006
Introduction to MOM 2006
The Medical Operations Manual (MOM) remains the basic document that describes the Anchorage Fire
Department’s protocols and standing medication orders as directed by the Medical Director for pre-
hospital care by AFD personnel. Version 2006 corrects typographical and content errors found in MOM
2004 and introduces revised protocols and drug orders. In most cases, off-line medical control using this
document’s content will allow for the care of the vast majority of our patients. On-line control, i.e. contact
with medical control, is strongly encouraged in situations that are outside the scope of these protocols.
The protocols in this document are based upon best available evidence for efficacy and safety. As new
information becomes available, protocols may change and the electronic version of the MOM will be
updated accordingly. EMS administration will make all personnel aware of the current standard version of
MOM. Please contact me or DC Threadgill with any questions regarding the MOM.

Michael Levy, MD
Medical Director AFD
Anchorage Fire Department                               Medical Operations Manual

                            Contact Telephone Numbers

Alaska Division of Family and Youth Services                    269-4000
(Child Abuse/Neglect Reporting)                           (fax) 269-3939
Alaska Native Medical Center Emergency                          729-1729
Department                                                (fax) 729-1759
Alaska Regional Hospital Emergency                              264-1222
Department                                                (fax) 264-2004
Elmendorf AFB Hospital Emergency Department                     580-5555
                                                          (fax) 580-2230
Providence Alaska Medical Center Emergency                      261-3111
Department                                                (fax) 261-3647
STEMI Line                                                      261-2920
Oregon Poison Control Center (24 hour                    1-800-222-1222
toxicology)
Anchorage Emergency Operations Center                            343-1414
Medical Operations Branch                                        343-1413
Fire/Rescue Operations Branch                              (fax) 343-1441
AFD Dispatch                                                     267-4950
                                                           (fax) 267-4989
AFD EMS 2                                                        267-4922
                                                          (cell) 317-3352
                                                           (fax) 267-4998
AFD EMS 1                                                        267-4912
                                                          (cell) 317-3353
                                                           (fax) 267-5081
AFD Medical Director                                    (pager) 762-2452
                                                          (cell) 632-0309
                                                           (fax) 696-7385
AFD Deputy Fire Chief, EMS Operations                            267-4932
                                                        (pager) 762-0495
                                                          (cell) 317-7244
                                                           (fax) 267-4984
AFD Chief Medical Officer, Editor                                267-4922




Treatment and Medications Protocol      3                           Revision 3.0, 2006
Anchorage Fire Department                                                                                                        Medical Operations Manual
   INTRODUCTION TO MOM 2006 ................................................................................................................ 2
   CONTACT T ELEPHONE NUMBERS ............................................................................................................ 3
   SECTION 1: OPERATIONS........................................................................................................................ 4
             EMS Incident Disposition ......................................................................................................................... 4
             Definition of Patient.................................................................................................................................. 4
             Destination of Patients with Psychiatric Problems ..................................................................................... 5
             Hospital Alerts ......................................................................................................................................... 5
             STEMI Alert (formerly Cardiac Alert)......................................................................................................... 7
             Hospital Disposition of Status 1, Status 2, and Post-Code 99 Pediatric Patients......................................... 7
             Hospital Radio Report Format/Patient Status............................................................................................ 8
             Incident Command and Mutual Aid........................................................................................................... 8
             Metropolitan Medical Response System ................................................................................................. 10
             Multiple Victim Incident (MVI) ................................................................................................................. 11
             Patient Transports ................................................................................................................................. 15
             Perimortal Policy.................................................................................................................................... 15
             START Triage ....................................................................................................................................... 18
             Transfer of Care/Return to Service Policy ............................................................................................... 19
             Direct Admit Patients ............................................................................................................................. 19
             Medication Use and Patient Safety......................................................................................................... 19
   SECTION 2: T REATMENT PROTOCOLS .................................................................................................... 21
             General Scene Guidelines: Treatment and Transport.............................................................................. 21
             General Patient Care ............................................................................................................................. 21
             All Providers .......................................................................................................................................... 21
             EMT-I/ETT Patient Care Protocol ........................................................................................................... 22
             EMT-II Patient Care Protocol.................................................................................................................. 22
             EMT-III Patient Care Protocol................................................................................................................. 23
             Airway/Oxygen ...................................................................................................................................... 23
             Airway Protocol ..................................................................................................................................... 23
             Inspiratory Impedance Device ................................................................................................................ 25
             CPR...................................................................................................................................................... 26
             Revivant Device .................................................................................................................................... 26
             Cardiac Monitoring ................................................................................................................................ 26
             12-Lead ECG ........................................................................................................................................ 27
             Combative Patient ................................................................................................................................. 27
             IV Therapy ............................................................................................................................................ 28
             Intraosseous (IO) Therapy ..................................................................................................................... 28
             Pain Management ................................................................................................................................. 29
      Specific Therapies........................................................................................................................ 31
             Medication Administration ...................................................................................................................... 31
             Blood Glucose Determination................................................................................................................. 31
             Inflatable Lower-Body Splint (MAST/PASG)............................................................................................ 32
             Transcutaneous Pacing ......................................................................................................................... 32
             Rapid Sequence Intubation with Neuromuscular Blockade...................................................................... 32
             Gastric Intubation .................................................................................................................................. 33
      Medical.......................................................................................................................................... 35
             Allergy and Anaphylaxis......................................................................................................................... 35
             Asthma, Wheezing, COPD..................................................................................................................... 35
             Chest Pain ............................................................................................................................................ 36
             Congestive Heart Failure ....................................................................................................................... 37
             Diabetic Emergencies ............................................................................................................................ 37
             Epistaxis ............................................................................................................................................... 38
             Hyperkalemia ........................................................................................................................................ 38
             Hypertension ......................................................................................................................................... 39
             Hypotension .......................................................................................................................................... 39
             Seizures, Status Epilepticus and Postictal States.................................................................................... 39
             Seizure Algorithm .................................................................................................................................. 40
             Stroke (CVA) ......................................................................................................................................... 41
             Tricyclic Antidepressant Overdose ......................................................................................................... 41
             Unconscious Patient Unknown Etiology.................................................................................................. 42
      Trauma .......................................................................................................................................... 43
        Amputations .......................................................................................................................................... 43
        Burn Management ................................................................................................................................. 43
        Eye Injuries ........................................................................................................................................... 44
        Pelvic Fracture ...................................................................................................................................... 44
        C-Spine Guidelines (Axial Spine Immobilization)..................................................................................... 44
        Clinical Criteria for Assessment of Spine Injury ....................................................................................... 45
Treatment and Medications Protocol                                         1                                                                     Revision 3.0, 2006
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             Spinal Immobilization Method................................................................................................................. 46
             Traumatic Brain Injury (TBI) ................................................................................................................... 47
      Obstetrics and Neonatal............................................................................................................... 48
             Newborn Care ....................................................................................................................................... 48
             Obstetrics.............................................................................................................................................. 49
             Third Trimester Hemorrhage .................................................................................................................. 49
             Pre-eclampsia and Eclampsia ................................................................................................................ 49
             Childbirth............................................................................................................................................... 50
             Postpartum Hemorrhage........................................................................................................................ 50
      Environmental............................................................................................................................... 51
             Hypothermia.......................................................................................................................................... 51
             Near Drowning ...................................................................................................................................... 51
      ACLS Algorithms.......................................................................................................................... 52
             Asystole ................................................................................................................................................ 52
             Bradycardia........................................................................................................................................... 53
             NCT (Narrow Complex Tachycardia) ...................................................................................................... 54
             PEA (Pulseless Electrical Activity).......................................................................................................... 55
             Perfusing WCT (Wide Complex Tachycardia) ......................................................................................... 56
             Pulseless VT/VF (Ventricular Tachycardia/Fibrillation) ............................................................................ 57
             Automatic External Defibrillator (AED) Protocol....................................................................................... 58
             Post Resuscitation Care......................................................................................................................... 59
             Post Resuscitation Care Algorithm ......................................................................................................... 60
             Basic Life Support Summary Sheet1 ....................................................................................................... 61
                                                                                                1
             Foreign Body Airway Obstruction (FBAO) Summary Sheet .................................................................... 62
      Appendix....................................................................................................................................... 63
             APGAR Scores...................................................................................................................................... 63
             Prehospital Index (PHI).......................................................................................................................... 63
             Glasgow Coma Scale ............................................................................................................................ 64
             Adult Burn Chart.................................................................................................................................... 65
             Child Burn Chart.................................................................................................................................... 66
             Infant Burn Chart ................................................................................................................................... 67
             Esophageal Tracheal Airway (Combitube and Combitube SA) ........................................................... 68
             Melker™ Cuffed Emergency Cricothyrotomy Catheter Set ...................................................................... 69
             Melker™ Procedure............................................................................................................................... 70
             ResQPOD® Circulatory Enhancer.......................................................................................................... 74
                    TM
             Turkel Safety Thoracentesis Catheter ................................................................................................. 75
             Oxylator EM-100 Protocols ................................................................................................................. 76
             FACES Pain Rating Scale ................................................................................................................... 77
             Precordial Lead Placement .................................................................................................................... 78
             12 Lead Waveforms............................................................................................................................... 79
             Capnography Waveform Elements ......................................................................................................... 80
             Capnography Waveform Analysis........................................................................................................... 81
             VentiSure™ ET CO2 Reference ............................................................................................................. 82
   SECTION 3: STANDING MEDICATION ORDERS ......................................................................................... 83
        adenosine ............................................................................................................................................. 83
        albuterol ................................................................................................................................................ 84
        amiodarone ........................................................................................................................................... 85
        aspirin ................................................................................................................................................... 86
        atropine sulfate...................................................................................................................................... 87
        calcium chloride..................................................................................................................................... 88
        dextrose 50% ........................................................................................................................................ 89
        diphenhydramine................................................................................................................................... 90
        dopamine .............................................................................................................................................. 91
        Dopamine Drip Chart for Adults.............................................................................................................. 92
        droperidol.............................................................................................................................................. 93
        epinephrine 1:1000................................................................................................................................ 94
        epinephrine 1:10,000 ............................................................................................................................. 95
        epinephrine 1:100,000 ........................................................................................................................... 96
        etomidate .............................................................................................................................................. 97
        fentanyl ................................................................................................................................................. 98
        furosemide ............................................................................................................................................ 99
        glucagon ............................................................................................................................................. 100
        glucose, oral........................................................................................................................................ 101
        lidocaine.............................................................................................................................................. 102
        lorazepam ........................................................................................................................................... 103
        magnesium sulfate .............................................................................................................................. 104
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           morphine sulfate.................................................................................................................................. 105
           naloxone ............................................................................................................................................. 106
           nitroglycerin......................................................................................................................................... 107
           nitrous oxide........................................................................................................................................ 108
           oxytocin............................................................................................................................................... 109
           phenylephrine HCL.............................................................................................................................. 110
           sodium bicarbonate ............................................................................................................................. 111
           succinylcholine .................................................................................................................................... 112
           tetracaine ............................................................................................................................................ 113
           vasopressin......................................................................................................................................... 114
    Pediatric Weight Pages .............................................................................................................. 115
  SECTION 4: ADMINISTRATIVE ............................................................................................................. 133
           Approved Abbreviations....................................................................................................................... 133
           State of Alaska Mandatory Reporting Requirements ............................................................................. 141
           Continuing Medical Education .............................................................................................................. 142
           Controlled Substances......................................................................................................................... 144
           HIPAA and Public Information Release Memo ...................................................................................... 148
           Infectious Disease ............................................................................................................................... 150
           Medical Control ................................................................................................................................... 160
           Medical Operations Manual.................................................................................................................. 162
  SPECIAL ANNEX: WMD MEDICAL STRIKE T EAM STANDING MEDICATION ORDERS AND PROTOCOLS .......... 164
           Nerve Agent Exposure......................................................................................................................... 164
           Standing Medication Orders for Nerve Agent Exposure......................................................................... 165
           Vesicant Exposure............................................................................................................................... 165
           Standing Medication Orders for Vesicant Exposure............................................................................... 166
           Cyanide Exposure ............................................................................................................................... 166
           Standing Medication Orders for Cyanide Exposure ............................................................................... 167
           Biological Agent Exposure ................................................................................................................... 167
           Standing Medication Orders for Biological Agent Exposure ................................................................... 167
           Nuclear Agent (Ionizing Radiation) Exposure........................................................................................ 168
           Standing Medication Orders for Nuclear Agent (Ionizing Radiation) Agent Exposure.............................. 168
  REVISION 2.0, AUGUST 2003 .............................................................................................................. 169
  REVISION 2.6, DECEMBER 2003 .......................................................................................................... 171
  REVISION 2.8, JANUARY 2004 ............................................................................................................ 172
  REVISION 3.0, 2006 ........................................................................................................................... 172
  NOTES .............................................................................................................................................. 174




Treatment and Medications Protocol                                              3                                                                  Revision 3.0, 2006
Anchorage Fire Department                                                            Medical Operations Manual

                                    Section 1: Operations
The Operations Section was added in MOM 2003. It is meant as a quick reference for some common
areas of emergency medical operations. It is not meant to replace a thorough knowledge of Anchorage
Fire Department Procedures and Instructions, Standard Operating Guidelines, various divisional memos,
or other pertinent documents.


                                    EMS Incident Disposition
DATE:              July 5, 2002                                             OPS 02-27

TO:                All Operations and Dispatch personnel

FROM:              Soren Threadgill, DC of EMS

Effective immediately, please begin using the following procedure when radioing dispatch with EMS
incident dispositions:

      1) When transporting a patient, the MICU should notify dispatch of the hospital transporting to, the
         transport status, and the number of patients being transported. The dispatcher must be certain to
         enter all of these data points, particularly the number of patients.
      2) If a patient refuses transport, the unit responsible for the patient report should notify dispatch of
         “patient refused transport”. The dispatcher should select this choice for the unit disposition.
      3) If the unit arrives and finds no patient, then they should notify dispatch of “location, no patient”.
         The dispatcher should select this choice for the unit disposition. Personnel are reminded to
         review P&I 900-22 for the definition of a “patient”. It is a violation of department policy to report
         “location, no patient” to avoid completion of a PCR.
      4) If the unit(s) are cancelled en route, the dispatcher should select as the disposition “canceled by
         agency on-scene” and include which agency canceled and the reason for the cancellation in the
         comments.

Your commitment to accuracy in data entry is very important for the department’s strategic planning and
budgetary justifications, and supports our collective mission. Additionally, this information will be used to
create a daily EPCR reconciliation report for the EMS statistician. Your effort in implementing these
changes is appreciated.

                                        Definition of Patient
A patient is defined as:

      •   Anyone who makes a first party call to 911 for EMS,

      •   anyone who claims to have an illness or injury to whom we have responded or otherwise
          encountered,

      •   and anyone who on examination either by the significance of mechanism or findings may have an
          injury or illness.

Note: A multi-person event will require best judgment of PM or EMS provider.

A Patient Care Report (PCR) is required for all patients except for a Public Assist that does not involve an
injury or potential for injury given mechanism or situation.




Treatment and Medications Protocol                     4                                           Revision 3.0, 2006
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                Destination of Patients with Psychiatric Problems
DATE:              June 4, 2002                                               OPS 02-22

TO:                All Personnel

THRU:              Soren Threadgill MICP, Chief of EMS

FROM:              Michael Levy MD, Medical Director

Providence Hospital now has a psychiatric emergency department. All non-native patients who are
transported by AFD for problems of a purely psychiatric nature should preferentially be taken to
Providence Hospital.

Included problems:
   - Severe depression with or without suicidal ideation
   - Severe anxiety not associated with substance abuse
   - Pure behavioral or emotional problems including apparent psychosis, mania, delusions, etc.
   - Stable suicide attempts

Excluded problems:
  - Drug dependency or withdrawal
  - Acute intoxication
  - Possible medical problem or trauma thought possibly responsible for an altered
      sensorium

ANMC would still like for its beneficiaries to be transported preferentially to ANMC.
Providence Hospital, Alaska Regional and ANMC ER’s will still handle the patients with “excluded
problems” as before.

Effective date: 6/1/02

                                           Hospital Alerts
DATE             June 6, 2003                                                   OPS 03-28

TO:              All FF/PM’s

FROM:            Deputy Fire Chief Soren Threadgill

Recently concern has been expressed by hospital staff and MDs in regard to the over use of the new
hospital alerts. The concern stems from the fact that each hospital has basic procedures and plans which
are placed into action when an alert is called from the field. In the case of a STEMI Alert a cardiologist is
called into the hospital, the cath lab is asked to clear the table and postpone all elective catheterizations,
a cardiac team is also called to the ER. During neuro (stroke) and trauma alerts similar protocols are
followed.

The disruption which is caused by an alert which is inappropriate or inaccurate may be more than an
inconvenience suffered by the hospital; it may lead to complications in patient care. The hospital alert
system was intended to be another adjunct in emergency patient care which should be a benefit for the
whole team – both pre-hospital providers and in-hospital providers. The alert system should not be used
when only a high index of suspicion is present. Care should be taken to only use the alert system when
the proper criteria are met.




Treatment and Medications Protocol                    5                                           Revision 3.0, 2006
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As a review, the hospital alert criteria are listed below:

Alert status is given to the hospital based on the AFD paramedic’s impression that a patient has a high
likelihood of requiring an intervention at the hospital due to the presence of a new stroke, severe trauma
or acute coronary syndrome with elevated ST segments. Radio reports to the hospital will start with the
type of alert, followed by the patient transport status.

STEMI*
         1. Age 35 or greater
         2. Acute onset of symptoms
         3.    Symptoms consistent with acute coronary syndrome (ACS) that must include the following:
                 a. “Visceral” chest pain: squeezing, pressure, aching, band-like, etc and may have
                      associated jaw or arm pain, diaphoresis, SOB
         4.    12 lead ECG showing >1mm of ST-segment elevation in at least 2 contiguous limb leads or
               >2mm in 2 or more contiguous precordial leads and that must have a “tombstone” or other
               definitive morphology
         Note the presence of Q-waves if seen.
            • QRS MUST be <0.12 (i.e. NO BUNDLE BRANCH BLOCK) unless it is definitively known
                 in a timely manner that the BBB is new.
            • LVH must be absent: measure largest major deflections at V1 or V2 (S wave) and V5 or
                 V6 (R wave). If >35, possible LVH: do not call cardiac alert

         *ALL FOUR REQUIRED

Trauma Alert
      1. Victim of a penetrating or blunt trauma that by mechanism of injury and/or physical findings
          suggesting a high likelihood of requiring immediate surgery or admission to the ICU for
          stabilization.
      2. Isolated head injuries, particularly those due to penetrating trauma will not usually require
          trauma alert.

Stroke Alert (Neuro Alert)
       1.     Field neurological exam is positive for focal neurological deficit suggestive of
              cerebrovascular accident (CVA).
       2.     Strong evidence that symptoms began within the preceding 2 hours.
       3.     Pt had no severe neurological conditions preceding this event.
       4.     The patient is alert.
       5.     There are no obvious signs of contraindications to the use of fibrinolytic agents such as:
                a.    Age less than or equal to 18 y/o
                b.    CVA or head trauma within the preceding 3 months
                c.    Major surgery in the last 14 days
                d.    History of intracranial hemorrhage
                e.    Systolic BP ≥ 185
                f.    Diastolic BP ≥ 110
                g.    Rapidly resolving symptoms of stroke
                h.    GI or GU bleeding within the preceding 21 days
                i.    Seizure at onset of stoke




Treatment and Medications Protocol                      6                                       Revision 3.0, 2006
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                              STEMI Alert (formerly Cardiac Alert)
DATE:                February 11, 2005                                            EMS- 05-06

TO:                  All AFD paramedics, All Areawide EMS providers

THRU:                Soren Threadgill, Chief of EMS

FROM:                Michael K. Levy, M.D., AFD Medical Director

      1. STEMI: Cardiac alert will now be called STEMI (pronounced “stemmy”) to relay the fact that the
          problem is ST-segment elevation MI.
      2. Dispatch pre-notification: alert dispatch at the earliest time to pre-alert the hospital that they will
          be receiving a STEMI unless you are ready to give a report.
      3. Dispatch pre-notification information:
              a. EKG shows STEMI and patient meets criteria for “cardiac alert” as previously defined.
              b. Note if cardiogenic shock or other severe symptomatology is present.
              c.   Gender
              d. Age
              e. Approximate ETA
      4. Minimize scene time: in patient with likely ACS and STEMI use your team to rapidly acquire data
          as you are treating the patient. Move to MICU as quickly as is deemed safe for the patient.
      5. Help minimize transfer to cath lab times: changeovers in the ED take a surprising amount of time.
          Simple maneuvers such as EMS removing the patient’s shirt prior to starting an IV shaves off
          time and lessens the chance of losing the IV. Other ways that we can help with a smooth handoff
          will be explored.

Hospital Disposition of Status 1, Status 2, and Post-Code 99 Pediatric
                               Patients
DATE: November 5, 2002                                                          OPS 02-52

TO:       All MICP Personnel
THRU: Soren Threadgill, MICP
          Chief of EMS
FROM: Michael Levy, M.D., FACEP, FACP
      AFD Medical Director

Pediatric patients 12 years old and under who are stable enough to bypass the closest hospital but who
are expected to require admission to a Pediatric Intensive Care Unit (PICU) should be transported to
either Providence Alaska Medical Center Hospital or to Alaska Native Medical Center, as appropriate,
rather than to Alaska Regional Hospital or Elmendorf Hospital. Critical care pediatric resources are
concentrated at Providence and ANMC and are thus more capable of providing the best in-patient care
for this patient population.

Pediatric patients requiring immediate life-saving interventions will, as per existing policy, be taken to the
closest appropriate Emergency Department. The exercise of good paramedic clinical judgment will be
the determining factor in distinguishing the proper disposition of these patients on a case-by-case basis.

This policy is effective immediately.

Treatment and Medications Protocol                       7                                            Revision 3.0, 2006
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                   Hospital Radio Report Format/Patient Status
1.      Report MICU designator and estimated time of arrival.
                               *
2.      Report patient status .

3.      Report patient age and sex.

4.      Report chief complaint/mechanism of injury and brief pertinent history.

5.      Report level of consciousness.

6.      Report respiratory rate, depth and effort.

7.      Report pulse rate and, if applicable, EKG rhythm.

8.      Report blood pressure.

9.      Report physical exam findings.

10.     Report treatment provided and patient response.

11.     State patient physician preference, if any.
                                              *
                                                  Patient Status

The patient status code is determined by the following guidelines:

        Code 99-Cardiac Arrest

        Status One- Unstable, immediate threat to life or limb.

        Status Two- Stable at this time, potential threat to life or limb.

        Status Three- Stable with no potential threat to life or limb.


Note: Vital signs may be abbreviated in the Status Three patient by stating that the patient is
“hemodynamically stable” or “vital signs are within normal limits”.

Radio reports should be as brief as possible while still conveying necessary information.

                            Incident Command and Mutual Aid
DATE: July 8, 2003                                                           OPS 03-35

TO:     Operations; Dispatch

FROM: Doug Schrage, Deputy Chief
      Soren Threadgill, Deputy Chief

A recurring problem that we’ve been experiencing is the establishment of multiple commands. This
happens most often when a unit without a company officer, such as a brush engine or MICU, arrives first
and establishes command. Then, when a company officer arrives on an engine, truck, or rescue, he or
she establishes command again. This has also been occurring when responding jointly with other
agencies whose members have established command.

Two of the most basic principles of incident management are unity of command and the clear and orderly
transfer of command. Neither of these exists when there are multiple incident commanders, and the
Treatment and Medications Protocol                      8                                         Revision 3.0, 2006
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result will be communication failures, poor coordination and interagency cooperation, and safety hazards.
Please be reminded of the following principles of command:

1. There can be only one incident commander, and the identity and location of the IC must be known by
   everybody on scene at all times.
2. If command has been established, you are subordinate to the incident commander (regardless of
   your rank or jurisdiction) until (a) command is passed, (b) command is transferred to you, or (c) you
   have exercised the authority of your rank or jurisdiction and assumed command of the incident.
3. If the incident is under the jurisdiction of another agency (e.g., Anchorage International Airport,
   Chugach State Park, Elmendorf AFB, Chugiak, Girdwood, etc.) and we have been requested as a
   resource, you must report to the officer in charge and be guided by the direction given, as in item 2
   above.
4. If the nature of the incident is such that multiple agencies share jurisdiction for it, the officer in charge
   for each organization should work closely together to resolve the incident (unified command).
Here are some representative examples of how this might work:

        Brush arrives first at a working brush fire The FFIII establishes command and orders a full
        response. He or she passes command and goes to work fighting the fire with his or her partner.
        The first arriving CO assumes command and resumes management of the incident.

        MICU arrives first at a MVI The FF/paramedic arrives first, establishes command, and declares
        an MVI. He or she assigns the FF/EMT to begin START triage and maintains command of the
        incident. The first arriving CO or BC reports to the IC, gets a briefing and either assumes
        command or lets command rest with the FF/PM and goes to work.

        APD and AFD respond jointly to a vehicle accident Since both agencies share jurisdiction for the
        incident, unified command is assumed. The OIC for each incident confer briefly and go to work.
        AFD is dispatched on automatic aid to Anchorage International Airport for an Alert II Barring a fire
        involving one of the facilities, crash/fire/rescue is AIA’s jurisdiction and we are there to support
        their operation. Command should not normally be established.
        AFD Rescue is requested by Girdwood VFD on scene of an entrapment Rescue reports to the
        GVFD IC and goes to work as requested. The Rescue officer recognizes that there is a
        command in place and does not also establish command.
        AFD is called to a back-country rescue in State Parks’ jurisdiction; no Parks representative on
        scene In the absence of a Parks representative, we would initiate command of the incident. Once
        a Ranger was on scene, we would offer to turn command over to the agency having jurisdiction.
        It is likely that he or she would ask us to remain in command.
        AFD is called to a brush fire on Ft. Richardson Since this is in their jurisdiction, we would not
        automatically establish command. However, if there is no discernible command in place, we
        would establish and declare command. Once contact was made with a Ft. Richardson
        commander, our IC would offer to turn command over and assume a supporting role.
        TransCare arrives first to a vehicle accident Since this is within our jurisdiction, we have clear
        responsibility and would automatically assume command of the incident.
There are many more variations, but these examples are intended to illustrate the relationships between
command and jurisdiction, rank, and authority. Being subordinate to another agency’s incident
commander does not mean you are relinquishing control of your crew; it means that you are using your
expertise and resources to support their incident strategy and objectives. In any case, each of you has
the duty and authority to exert command commensurate with your rank if you feel the incident is being
grossly mismanaged, or to refuse an order that is unsafe.
Numerous roles in the management of incidents share responsibility for ensuring that command is
established, recognized, and properly transferred, as follows:
1. Companies arriving on scene where there are already other units Arriving companies should be
   listening for the establishment of command, and should report to the IC or assignment upon arrival,
Treatment and Medications Protocol                     9                                            Revision 3.0, 2006
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      regardless of rank or jurisdiction. If the arriving officer intends to assume command, this should be
      accomplished after a face-to-face conference if possible. In any case, this must be communicated to
      all units on scene, and it must be clearly understood by the existing incident commander that he or
      she is being relieved of command.
2. When requesting additional resources The requesting officer should communicate 1) the nature of the
   request, 2) who to report to and where the command post, staging, or other assignment is located,
   and 3) on what channel to report on. This applies whether the requestor is a Chugiak officer
   requesting a dive response, or an AFD officer requesting a DOF resource or a second alarm.
3. Dispatch Dispatchers should be alert to multiple commands and should notify all units on scene of the
   situation so that it can be corrected. When receiving a request for resources, dispatchers should
   make sure to collect the information in item two above, and in turn provide it to the responding
   resources.
4. Competing commands If you have established command and another member also establishes
   command, it is your duty to communicate with him or her to identify the command. The ranking
   officer within jurisdiction will determine the command structure.
Our operating environment is becoming more complex and multi-jurisdictional. As this trend continues
and as the leading response agency in this part of the state, it will become increasingly important that we
set the benchmark for effective command and coordination. Your survival depends on it.


                             Metropolitan Medical Response System
TITLE:                      Metropolitan Medical Response System
                            Metropolitan Medical Strike Team Formation and Organization

SECTION: 905 – Emergency Operations

NUMBER: (P&I) 905-11

PREPARED BY:                F.X. Nolan, Wade Strahan, Tom Wells, Brian Wallace
                            Name

APPROVED:                   John Fullenwider
                            Fire Chief

EFFECTIVE DATE:             2/26/01

1.0       Procedure and Instruction

1.1       This is the general procedure when the AFD is providing a cohesive response to a NBC WMD event
          as an integral component of the national Metropolitan Medical Response System. The AFD provides
          the EMS, hazmat and fire components of the initial response system with APD providing the law
          enforcement component. The Metropolitan Medical Strike Team element is formed by allocating
          EMS, hazmat, fire, and law enforcement resources as necessary to effect the following objectives, in
          order of priority:
              1. Rescuer safety
              2. Victim rescue
              3. Victim triage and treatment
              4. Hazard stabilization and/or
              5. Area evacuation
              6. Victim decontamination and transport
              7. Rescuer decontamination
              8. Agent identification

1.2    Command is established using the ICS under a Unified Command with law enforcement. The
       general ICS structure will consist of a Medical Group, Hazmat Group, Fire Group, and Law Group
       operating under the IC or Operations Section Chief. Normal functions for each group will be
       maintained such as Triage, Treatment, and Transport Units under Medical and Entry and Decon
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        Units under Hazmat. In real terms, functional tasks, such as victim extraction and treatment, or
        treatment and decontamination, may be blended.
                                                                                            1
1.3     Initial dispatch for a suspected NBC incident requiring a Medical Strike Team is:
                  1 Chief Officer
                  1 BC
                  1 EMS BC (Note: Reads “EMS Supervisor” in existing P&I)
                  2 Engine Companies
                  2 ALS Units
                  1 Hazmat Unit
                  1 ISO
                  HMRT leader or HMRT coordinator
                  Hazmat Medical Group leader

1.4     Important command considerations:
        • staging area
        • plume direction/weather conditions
        • access routes
        • number of victims/signs and symptoms
        • EOC CAT activation
        • call for additional resource needs
        • hospital notifications
        • decontamination needs
        • sample and evidence preservation
        • FBI and lab notifications
        • witnesses

1.5     Consider requesting a MMST response if any of the following is suspected:
        • Explosion
        • Unexplained plume, gas, vapor
        • Unusual multiple casualties with no explosion
        • Suspect packages
        • Dissemination devices
        • Credible Threat

1.6     General operational timeline/checklist:
        • Establish command
        • Establish control zones
        • Establish triage/treatment area
        • Establish decontamination/plan
        • Make notifications

                                Multiple Victim Incident (MVI)
Conditions

A Multiple Victim Incident (MVI) is any situation which results in injury or illness to multiple persons and
which meets the following criteria:
                                                                           2
    1. 3 or more IMMEDIATE category patients based on the START triage system and
    2. potential to overload the immediate resources of a single hospital emergency room and
    3. exceeds the resource capabilities of the initial response but which
    4. can be managed in a relatively short time period without the need to activate the Anchorage
        Emergency Operations Center. (Generally, less than 12 patients)


1
  The Metropolitan Medical Strike Team Resources Unit will be added to the dispatch once it is placed into
service.
2
  Reference SOG T-3
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Procedures

An MVI response will be initiated under the following conditions:
   1. AFD Dispatch receives caller information that the incident involves 3 or more seriously injured or
       ill persons, or
   2. first-in AFD units declare an MVI based on their initial scene size-up.

MVI Response Profile

An MVI declaration will result in the dispatch of sufficient additional units beyond the initial response so
that the following reinforced response level is achieved:
    1. EMS Battalion Chief
    2. Fire Battalion Chief
    3. Incident Safety Officer
    4. 3 MICUs
    5. 3 three person companies (Engine, Truck or Squad)
    6. Rescue unit if entrapment is determined by AFD Dispatch or first-in AFD units

MVI Communications Procedure

Declaration of an MVI will initiate the following communications procedure:
1. Assignment of a Tac frequency for on-scene radio communications and
2. notification by AFD Dispatch to hospital emergency departments to put their radios on “monitor”
   status and
3. notification of the Fire Chief or designee.

Initial Response

Initial Incident Command
1. Initial Incident Command will be assumed by the first-in company officer who will perform scene size-
     up appropriate to the specific incident following existing Standard Operating Guidelines, where
                  3
     applicable. Size-up will, in all situations, prioritize safety considerations. Size-up will include a brief
     description of the situation relayed to AFD Dispatch.
2. Initial Incident Command will assign the triage function and relay the triage report to dispatch using
     START criteria.
3. In the event that the incident meets the conditions for declaration of an MVI, the first-in company
     officer will declare an MVI and establish an MVI Incident Command System structure. The first-in
                                                                                4
     officer will retain command until the arrival of the EMS Battalion Chief.
4. Initial Incident Command will assess the need for and request additional resources that are needed in
     addition to the MVI Reinforced Response.
5. The initial Incident Command will designate a staging area for incoming reinforced response units.
6. The initial Incident Commander will affect an orderly transfer of command upon the arrival of the EMS
     Battalion Chief and will brief the EMS Battalion Chief on the incident including the START triage
     report.

Safety
(See Safety under Reinforced Response)

Triage
1. Triage will be performed by the first-in FF/PM or FF/EMT utilizing the START Protocol.
2. Triage will account for and tag all patients.
3. Triage will assign immediate treatment needs to available personnel not otherwise assigned.
4. Triage will report number of patients and START categories to Initial Incident Command.

Treatment
1. Available personnel will be assigned to perform initial priority treatment as identified by Triage.

3
 SOG A-1, A-2, B-1, C-1, D-2, H-1, H-2, I-1, I-2, S-1, S-2, S-7, T-2, T-3
4
 If an MVI is declared by an MICU arriving first, the ICS will be initiated and command will immediately be
passed to the first due company officer.
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                                        Multiple Victim Incident

                                     Initial Response ICS Structure


                                  In c ide n t Co m m a nd
                                (F irs t c o m pa n y o ffic e r)


                                  T ria ge               T re a tm e nt
                                 (F F /P M )             (F F /E M T )

Reinforced Response

Incident Commander
1. The EMS Battalion Chief will assume command from the first-in company officer and reassign the
    company officer as needed.
2. The reinforced response Incident Commander will coordinate the staging area and all incoming
    personnel will report in through the Incident Commander.
3. Incident Command will designate a Medical Branch Director and support the Medical Branch Director
    by allocating needed personnel to the Medical Branch and by providing for any additional resource
    needs.
4. Incident Command will designate an Extrication Branch Director and support the Extrication Branch
    Director by allocating needed personnel to the Extrication Branch and by providing for any additional
    resource needs.
5. Incident Command will account for all personnel.
6. Incident Command will terminate command upon completion of treatment and transport objectives
    and will direct the return to service of non-transporting units.

Medical Branch Director
1. The Incident Commander will assign the Medical Branch Director position and brief them on the
   incident including the triage report.
2. The Medical Branch Director will obtain personnel resources from Incident Command and will form
   and direct Treatment Teams.
3. The Medical Branch Director will assign an ETT or EMT as Ground Ambulance Coordinator and, if
   needed, assign a Helispot Manager.
4. The Medical Branch Director will communicate with receiving facilities and determine patient
   disposition based on available hospital resources.
5. The Medical Branch Director may provide direct patient care and transport only upon termination of
   the Medical Branch.

Extrication Branch Director
1. The Incident Commander will assign the Extrication Branch Director position and brief them on the
    incident including the triage report and extrication priorities.
2. The Extrication Branch Director will obtain personnel resources from Incident Command and will form
    and direct Extrication Teams

Safety Officer
1. The Incident Safety Officer will identify and mitigate hazards.
2. The Incident Safety Officer will exercise the authority to prevent or stop unsafe actions.
3. The Incident Safety Officer will not engage in any task that precludes performing the safety function.

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Treatment Teams
1. Treatment Teams will be formed by the Medical Branch Director and assigned according to available
   resources and patient need.
2. Treatment Teams will assess and treat patients.
3. Treatment Teams will direct and assist with removal of patients to assigned MICUs or temporary
   treatment area.
4. Treatment Teams will obtain the hospital destination from the Ground Ambulance Coordinator and
   continue to assess and treat during transport.
5. A Treatment Team member will communicate necessary patient information to the appropriate
   receiving facility while enroute.
                                           5
Ground Ambulance Coordinator
1. The Ground Ambulance Coordinator will be assigned by the Incident Commander and will coordinate
   patient/ambulance disposition based on hospital availability as specified by the Medical Branch
   Director.
2. The Ground Ambulance Coordinator will direct MICUs to transport to the hospital designated by the
   Medical Branch Director.
3. The Ground Ambulance Coordinator will assure that patients are transported in an effective manner
   by assuring that there are adequate Treatment Team personnel with the patient(s) during transport.
4. The Ground Ambulance Coordinator will record MICU hospital disposition and accompanying
   personnel and will report this information to Incident Command after all patients have been
   transported.
5. The Ground Ambulance Coordinator will manage any temporary treatment area.
                   6
Helispot Manager
1. The Helispot Manager will          be assigned by the Incident Commander when helicopter transport is
    utilized.
2. The Helispot Manager will          establish and control a landing zone (including assuring a “tail guard”).
3. The Helispot Manager will          direct the landing and take-off of the aircraft.
4. The Helispot Manager will          direct patient loading in conjunction with the flight crew.

Extrication Group
1. The Extrication Group will consist of a Rescue Company and any other resources as determined by
    Incident Command.
2. The Extrication Group will be under the direct command of the Extrication Branch Director.
3. The Extrication Branch Director will coordinate heavy extrication and patient removal with the Medical
    Branch Director.
                                        Multiple Victim Incident
                                 Reinforced Response ICS Structure

                                                        Inc ide nt Com m a nd
                                                       (E M S Ba tta lion C hie f)


                                           S a fe ty                                   S ta ging


            Extrication Branch Director                                     M e dica l B ran c h Dire c tor


                E x tric a tion G ro up                  T re a tm e nt G ro up                     Tra n s portation G roup


               E x tric ation Te a m (s)                Tre a tm e nt T e a m (s)            G roun d Am bulanc e C oordina tor


                                                                                                       H e lis po t M a na ger




5
  The Ground Ambulance Coordinator and Helispot Manager functions should not be assigned to an
MICP.
6
  The Helispot Manager should obtain a radio from a Battalion Chief or State Trooper for communicating
with the aircraft.
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                                          Patient Transports
DATE:                April 26, 2002                                            OPS 02-16

TO:                  All AFD Personnel
THRU:                John Fullenwider, Fire Chief

FROM:                Soren Threadgill, EMS Chief

Various problems have been cropping up focused on our transport policies. To eliminate these problems,
and provide better customer service the following will become AFD policy effective immediately:

      • Dispatch shall continue to use current policies when deciding whether to send Transcare or an
         AFD medic unit.
      • Dispatch can confer with flight crews and, if the flight crew agrees to a longer wait for Transcare,
         this will be accommodated.
      • When an AFD medic unit arrives prior to Transcare, the AFD unit will transport.
      • Requests for patient transports from an airport will be dispatched 20 minutes prior to the
         rendezvous time.
      • Calls for critical patients considered to meet the criteria for a Transcare transport, a unit will be
         dispatched 20 minutes prior to the rendezvous time.
      • All routine facility transports will be scheduled with the least amount of waiting time as possible
         based on notification to dispatch and availability of transport units.
      • In the event that Transcare calls facilitate the need for an additional unit, Transcare will be notified
         of the need of that additional unit as soon as possible to prevent extended patient waiting times.
      • In the event that Transcare is not available for patient transports due to current call volume,
         dispatch will assign an AFD MICU to the call.


                                            Perimortal Policy
This section shall define AFD policy regarding situations that involve patients that have been determined
to be beyond resuscitation. Included are guidelines and information pertaining to SUID, obvious death,
those patients that do not respond to advanced life support resuscitation efforts, and expected home
death/Comfort-One patients

It is the policy of the AFD to assume that a reasonable chance of resuscitation exists unless otherwise
addressed in this document.

I. SUID (Sudden Unexpected Infant Deaths)

Policy: In recognition of CDC guidelines concerning death scene investigation for victims of SUID∗ it shall
be the policy of the Anchorage Fire Department not to transport those patients under twelve months of
age believed to have expired as a result of sudden infant death syndrome in circumstances when no
resuscitation efforts have been undertaken.

II. Obvious death/ Decision not to resuscitate

Policy: It is AFD policy for the first arriving crew to begin resuscitation on any patient without pulse or
respiration unless one or more of the following signs are present. If there is any doubt whether or not the

∗
  “Transportation of the child may disrupt investigation of the scene and is not recommended.” Excerpted from the
Guidelines for death scene investigation of sudden, unexplained infant deaths (SUID) Source: MMWR June 21, 1996
/Vol. 45 /No. RR-10.

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patient meets this criterion, then CPR with BLS adjuncts shall be initiated. Resuscitative efforts shall
continue until the first arriving MICP or EMT determines that the patient is beyond resuscitation and/or an
emergency department physician is contacted and consulted.
A. Evidence of non recent death. Including: 1) rigor mortis (NOTE: only valid if hypothermia clearly not a
   factor), 2) dependent lividity (NOTE: area to check depends upon position of patient), or 3) any
   evidence of decomposition.
B. Explosive gunshot wound(s) to the head.
C. Severe injury obviously incompatible with life.
D. Submersion greater than one hour.
E. Suspected death due to hypothermia with the following signs: 1) core temp < 60 degrees, 2) pt
   has ice in the airway, 3) generalized or total body frozen skin/tissue which is more than localized
   frostbite.

Procedure: The first arriving apparatus that determines the patient to be beyond resuscitation based
upon the above criteria shall advise dispatch of an “11-29“ and recommend the closest ALS unit amend to
code yellow; all other responding units shall be in service. The first arriving MICP or EMT will confirm the
initial assessment and complete all required documentation. In the case of dispatch advising 11-29 per
APD/AST then only the closest ALS unit will continue code yellow.

Documentation: The first arriving MICP or EMT shall complete a patient care report, specifically
recording the physical findings which support the decision not to resuscitate based on the criteria
established in this policy (NOTE: The assessment/impression portion of the narrative should be
documented as “Beyond resuscitation“ or “No chance of resuscitation“). Any decisions not to resuscitate
made upon consultation with a physician must have the time of contact and the name of the physician
included in the documentation.

Exceptions to this policy:
A. Triage decisions in multiple patient incidents.
B. An inability to gain access to the patient. This would include:
   1) Entrapment
   2) APD/AST denying access to the scene or patient. If this is the case attempt to obtain the name and
     badge number of the officer for documentation.
   3) Situations that would place rescuers/AFD personnel in grave danger.
C. Decisions based upon direct consultation with an emergency room physician, or with an identified MD
   on scene. Delays in Physician contact must be fully documented.

III. Patients unresponsive to CPR

Policy: Decisions by paramedics or EMTs to discontinue advanced life support resuscitation efforts
outside the hospital, once those efforts are underway, require consultation with an emergency department
physician. Contact must be made prior to discontinuing resuscitative efforts.

Documentation: The name of the consulted MD and the time of contact must be clearly documented on
the completed patient care report.

IV. Expected home death/Comfort-One

Policy: When AFD is called to respond to a confirmed expected home death or Comfort-One patient, the
nearest ALS engine or MICU will respond code yellow to confirm that the patient is without signs of life. If
another call of an emergency nature is received, and the unit responding is the closest available, that unit
will divert to the emergency call and an additional ALS Engine or MICU will be dispatched to the original
call. It is the responsibility of the EMT or MICP to assess the needs of the family for emotional support
and ascertain whether logistical assistance in dealing with the deceased is required. The APD chaplain
may be contacted through AFD dispatch to assist the family or caregivers of the patient at the discretion
of the AFD EMT or MICP.

Procedure: The responding EMT or MICP will carefully evaluate pulse and respiration before verbal
confirmation of death is reported to APD or the patient’s family. It should be noted that an EKG is not
required nor is it preferred. Physical findings must be documented completely on the patient care report.
If upon arrival, the family requests resuscitation or if there is a conflict among the family, resuscitation
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may be undertaken if no signs of non recent death are present. Additionally, if the patient still has
measurable vital signs and the family requests transport without resuscitation an AFD MICU will transport
to a receiving facility. Contact the patient’s personal physician or the receiving emergency department
physician if special requests are made or if there are questions regarding treatment.




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                                      START Triage


All Walking Wounded
                                RESPIRATIONS
        MINOR

                NO                                           YES

        Position Airway


   NO                     YES                Under                            Over
                                             30/Min                           30/Min

DECEASED           IMMEDIATE                                                IMMEDIATE




                                       PERFUSION

                                     Radial Pulse Present

                                     Radial Pulse Absent
                                             OR
                                       Capillary Refill

                          Over 2                             Under 2
                          Seconds                            Seconds



                Control
                Bleeding


            IMMEDIATE

                                                                     MENTAL STATUS


                                                             Can’t follow              Can Follow
                                                               Simple                    Simple
                                                             Commands                  Commands

                                                            IMMEDIATE                  DELAYED




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                       Transfer of Care/Return to Service Policy
MICU crews delivering a patient to a receiving facility have the following responsibilities:

1. Continue all necessary patient care until a full transfer of information has been made to ensure patient
   safety and continuity of care. This occasionally involves a short interim period if an emergency
   department is very busy.

2. Give a full, face-to-face verbal report to the receiving employee who will accept and continue care.

3. Deliver a written copy of the Patient Care Report before leaving, unless another response interrupts
   completion. Return a completed copy of the PCR at the earliest opportunity when it is not possible to
   leave one at the time of transfer.

4. Return the MICU to response-ready condition as soon as possible after completing necessary patient
   care and verbal reporting duties, and place the unit in service.

                                      Direct Admit Patients
The care of most patients will be transferred to hospital staff in the receiving facility Emergency
Department. This policy allows the MICU crew to rapidly return to service and be available for an
emergency response. There are situations, however, when it is in the best interest of the patient to
proceed directly to a specific area of the hospital other than the Emergency Department and effect the
transfer of patient care at that location. These situations include the following patient dispositions:

1. Patients directly admitted to Care Units.

2. Obstetric patients greater then 16 weeks gestation who are in active labor or where delivery is
   imminent or where there is any indication of fetal distress will be taken directly to Labor and Delivery.

3. Patients being directly admitted to other units whose comfort would be significantly compromised from
   excessive movement, e.g., multiple orthopedic injuries or extensive burns.

4. Cardiac cath lab patients when it can be determined either through AFD Dispatch or the receiving
   facility Emergency Department that the cath lab is ready to receive the patient without excessive delay
   (< 10 minutes).

Exceptions to this policy can be granted by the Chief Medical Officer on a case by case basis. Any
question regarding interpretation of this policy will be immediately referred to the Chief Medical Officer.

                            Medication Use and Patient Safety
DATE:            March 29, 2004                                             OPS 04-21

TO:              All EMTs and MICPs

THRU:            Soren Threadgill, Deputy Chief of EMS Operations

FROM:            Michael Levy, M.D., FACEP, FACP
                 Anchorage Area Wide EMS Medical Director

SUBJECT:         Medication Use and Patient Safety

Patient safety is the highest priority for the prehospital care providers of the Anchorage Fire Department
EMS. As part of a more comprehensive Error Free Drug Program, the Medication Use and Patient Safety
protocol will be one of several initiatives aimed at eliminating the chance of errors during the course of
drug administration to patients within the Anchorage Area Wide EMS System. This protocol will be
included within the MOM (Section 1: Operations).
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General:
   • Medication errors are a preventable cause of harm to patients.
   • Many medications appear similar and it is imperative that one confirm the name on the label.
   • The AFD will strive to avoid all medication errors through education, training and strict adherence
       to the best-demonstrated practice of medication administration.

Guidelines:
   • All personnel authorized to administer a given medication will be familiar with its indications,
       warnings and contraindications.
   • All personnel who are involved in patient care and in assisting providers with medication
       administration will be familiar with medications used by AFD and be able to accurately identify
       these agents and their packaging.
   • Such personnel will periodically demonstrate competence in this activity.

Administration of Medications:
   • Select medication based upon clinical setting as per MOM.
   • Select proper dose.
   • Reconfirm that proper medication and proper dose are to be given.
   • Review allergies and medication list to confirm that no contraindication to the medication exists.
   • If more than one provider is involved in drawing up medications, it is the responsibility of the
      provider administering the medication to visually reconfirm the safety checks listed above as well
      as to confirm that the medication in a syringe is the desired medication by checking the label of
      the bottle from which it was drawn.

Errors:
    • If a medication is given in error, the first priority is to assess any immediate adverse reaction to
        the patient as well as to anticipate other potentially delayed consequence.
    • Depending on the circumstance it may be appropriate to notify the patient at the time of the
        incident or later.
    • Notify the receiving physician of the error and any corrective action.
    • Notify your Battalion Chief of EMS.
    • Complete a FD-1 with notification to the Area Wide EMS Medical Director.




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                          Section 2: Treatment Protocols

               General Scene Guidelines: Treatment and Transport
Trauma

The goal is the shortest possible scene time. To the extent possible, after initial scene assessment and
necessary immobilization is performed, all other interventions are performed in the MICU enroute.

Cardiac Arrest

The goal is to obtain a perfusing rhythm and then to transport.

Medical

An overall focused evaluation of the patient to obtain the nature of the complaint and to assess the
patient’s initial stability may be undertaken at the scene. To the extent possible, all other interventions
should be done enroute to hospital. If immediate transport is not deemed safe, the MICU is generally the
best place to perform the necessary procedures.

All Patients

    1. The offer of transport will be extended to every patient.
    2. Transport offers will be extended in a neutral manner and without qualification.
    3. Any refusal of medical assistance, and/or transport, must be informed and competent.
    4. Informed and competent refusals of medical assistance, and/or AFD transport, must be
       thoroughly documented in the PCR. Patient or guardian signatures must be obtained. In cases
       where this is not possible, then the reason(s) for the absence of a signature must be explained in
       the PCR.
    5. Patients will only be transported to a hospital.


                                      General Patient Care
The following provides general guidelines for patient management. Refer to additional protocols as
appropriate for treatment of specific conditions.

                                            All Providers
Initial Size-up
1. Observe Body Substance Isolation precautions.
2. Ensure scene safety.
3. Determine number of patients.
4. Determine mechanism of injury/nature of illness.
5. Call for additional help or specialty resources as needed.
6. Consider need to provide spinal immobilization.
7. Form a general impression of the condition of the patient(s)
General Approach to the Patient
8. Establish patient responsiveness. If cervical spine trauma is suspected, manually stabilize the spine.
9. Assess the patient’s airway for patency, protective reflexes and the possible need for advanced
     airway management. Look for signs of airway obstruction.
10. Open the airway as necessary using head tilt/chin lift if no spinal trauma is suspected, or modified jaw
     thrust if spinal trauma is suspected.
11. Suction as necessary.


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12. Consider placing an oropharyngeal or nasopharyngeal airway adjunct if the airway cannot be
    maintained with positioning. EMTs may use Combitube® in a patient with no gag reflex and
    immediate need for airway control.
13. Assess for signs of respiratory distress, failure, inadequate tidal volume or arrest. If present, refer to
    the appropriate protocol for treatment options.
14. If breathing is adequate, place the patient in a position of comfort and administer high-flow,
    100%concentration oxygen as necessary. Use a partial nonrebreather mask.
15. Assess pulse/perfusion status.
16. Look for external hemorrhage if indicated and control using direct pressure or a pressure dressing.
17. Immediately treat imminent life threatening problems as they are found during the initial assessment.
18. Reassess the patient frequently.


                              EMT-I/ETT Patient Care Protocol
General:
• Follow General Patient Care as listed above.
• Determine chief complaint and level of distress.
• Measure and record vital signs.
• Perform physical exam specific to chief complaint.

Medical Emergencies:
• Code 99: Follow AED Protocol.
• Diabetic Emergencies: Suspected hypoglycemia: check blood sugar with Glucometer, if blood sugar
   <80 and patient has symptoms of hypoglycemia but is alert, administer oral glucose.
• Assist with patient’s nitroglycerin, metered dose inhaler, or epinephrine auto-injector per State of
   Alaska regulations.
• Chest Pain: ASA per Standing Medication Order and Chest Pain Protocol.
• All other: Follow General Patient Care and Oxygen Therapy guidelines in this document. Approved
   advanced airway is Combitube®.

Trauma Emergencies:
• Stabilize spine when indicated by mechanism of injury or signs and symptoms. (See C-Spine
   guidelines)
• Control external hemorrhage.
• Perform rapid head-to-toe exam.
• Follow General and Oxygen Therapy guidelines in this document.
• Approved advanced airway is Combitube®.

Multi-victim/Mass Casualty Incident:
• Follow Start Protocol.

                                 EMT-II Patient Care Protocol
General:
• Follow all guidelines per EMT-I/ETT Patient Care Protocol.

Additional Authorized Activities: An AFD EMT-II who has been authorized by the Medical Director
may:
• Initiate peripheral IV therapy per IV Therapy Protocol.
• Administer D50W per Diabetic Emergencies Protocol and D50W Standing Medication Order.
• Administer naloxone HCL (Narcan ®) per Standing Medication Order.
• Administer nebulized albuterol for bronchospasm per albuterol medication order when so directed by
   an incoming MICP.




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                                EMT-III Patient Care Protocol
General:
• Follow all guidelines per EMT-II/ETT Patient Care Protocol.

Additional Authorized Activities: An AFD EMT-III who has been authorized by the Medical Director
may:
• Apply electrodes and monitor cardiac activity.
• Manually defibrillate ventricular fibrillation and pulseless ventricular tachycardia.
• Administer specific medications according to Treatment Protocols and Standing Medication Orders
   when trained to those specific medications and under the direct supervision of a state licensed and
   municipally certified MICP.
• Administer lidocaine per Pulseless VT/VF Algorithm and lidocaine Standing Medication Order.
• Administer atropine per Asystole and Bradycardia Algorithms and atropine Standing Medication
   Order.
• Administer epinephrine 1:10,000 per Asystole and Pulseless VT/VF Algorithms and epinephrine
   1:10,000 Standing Medication Order.
• Administer epinephrine 1:1000 per Allergy and Anaphylaxis and Asthma Protocols and epinephrine
   1:1000 Standing Medication Order.
• Administer morphine sulfate per Pain Management and Chest Pain Protocols and morphine sulfate
   Standing Medication Order.
• Administer NTG for chest pain per Chest Pain Protocol and NTG Standing Medication Order.

                                           Airway/Oxygen
Oxygen therapy:
Oxygen will be administered as the paramedic and/or EMT/ETT deems appropriate according to clinical
signs and clinical situation. If pulse oximeter is used in addition to the clinical assessment, the Sa02
should be >95%.

•   COPD: a relatively small number of patients with this condition will react to supplemental oxygen by
    slowing their respiratory rate and eventually becoming obtunded. These patients have at baseline a
    compensated hypoxemia. This must be considered in all COPD patients and 02 should not be used
    routinely in such patients unless they are being treated for symptomatic hypoxemia. If a COPD
    patient is being treated for hypoxemia, carefully titrate oxygen to improve the patient’s clinical status.
    Carefully monitor these patients and if ventilatory drive is suppressed and the need for oxygen
    persists, then augment with BVM or other measures as required.


                                          Airway Protocol
General Airway and Oxygenation:
1. Head tilt/chin lift maneuver if unconscious; jaw thrust if suspected cervical spine injury or trauma.
2. Oropharyngeal or nasopharyngeal airway as indicated.
3. Suction as needed to maintain clear airway but limit each event to 15 seconds with re-oxygenation
   between attempts.
4. Oxygen will be delivered as deemed necessary. Use appropriate 02 delivery device and flow rate to
   achieve Sa02 of> 95%. If Sa02 not available, use clinical judgment for delivery method and
   concentration.
   a. 2-6 liters by nasal cannula.
   b. 10-15 liters by non-rebreather mask.
   c. 15-25 liters by bag-valve mask (depends on oxygen resources).

Endotracheal intubation:
Endotracheal intubation (oral or nasal) is recognized as the most direct and effective means of securing
and maintaining the airway. Orotracheal intubation is generally preferable, but the nasal route allows for a
definitive airway in persons who have a gag reflex (yet require an airway) or in whom an oral approach is
not possible.


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Indications:
1. Unprotected airway with danger of aspiration.
2. Need to support ventilation due to patient's inability to generate adequate tidal volumes.
3. Apnea (relative indication).
4. Inability to ventilate by other means.
5. Occasionally as the only means of drug delivery.

Contraindications:
1. Orotracheal intubation: none if the proper indications are present.
2. Nasotracheal intubation:
   a. Possible mid-face fracture.
   b. Nasal deformity or obstruction.
   c. Possibility of nasopharyngeal foreign body that could be blindly pushed into airway.
   d. When there is any consideration of increased intracranial pressure.

NOTE: Do not delay initial defibrillations for intubation!

NOTE: Apply cricoid pressure when patient is being BVM ventilated (if personnel are available) and
release pressure only after cuff of endotracheal tube is inflated with position confirmed!

Method: Orotracheal Intubation
1. One team member should oxygenate the patient with 100% 02.
2. If the patient is breathing spontaneously, DO NOT HYPERVENTILATE OR BVM AUGMENT. If
    patient is apneic or ventilating inadequately, bag at appropriate rate.
3. Assemble intubation equipment: check tube cuff, have suction ready, have Endostat® or other
    securing method ready.
4. Intubate.
5. Confirm placement in apneic patient with TubeChek®.
6. Apply capnography (if available).
7. Confirm placement in perfusing patient with VentiSure™ (if no capnography available).
8. Check breath sounds in both axillae and in the epigastrium, and check the tube’s distance at the
    teeth.
9. ETT tube should be inflated until no air is heard to escape around the tube, or, to a maximum of 10 ml
    of air in cuff.
10. Secure tube.
11. Intubation should be completed in no more than 2 attempts each by 2 providers MAXIMUM. Move to
    alternative airway if unable to intubate.

Method: Nasotracheal Intubation
1. Check patient for the larger or more patent nare.
2. Instill Neo-synephrine: administer 3 squirts of 0.5% Neo-synephrine spray prior to nasotracheal
   intubation when time and conditions permit.
3. Lubricate tube and/or nare and nasal passage well and insert the tube, advancing along the slightly
   downward path of the nasal cavity.
4. Listen for the approach of the tube to the glottis. Advance tube on inhalation. Success is often
   confirmed by a cough.
5. Check breath sounds, inflate cuff and secure tube.

NOTES:
1. CPR should not be interrupted for more than 30 seconds for the placement of airway adjuncts.
2. The patient should be oxygenated prior to placement attempts.
3. ETT placement will be re-evaluated after each time patient is moved and periodically throughout
   transport.
4. Secure the neck of intubated unresponsive patients with c-collar or other method to help avoid
   displacement of the tube by unintended head movement.
5. Measure pulse oximetry continuously. Pulse oximetry is a routine diagnostic tool used to measure
   oxygen saturation and response to oxygen therapy. It is generally reliable but, as always, clinical
   impression is the final determinant in whether to believe a given reading.
6. NGT may be placed in the intubated patient with distended abdomen as per Gastric Intubation
   Protocol.
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Combitube®:
The Combitube® or the Combitube®SA will be used by MICPs or EMTs when endotracheal intubation is
not possible, technically difficult or when the Combitube® is considered the best method to safely
expedite a critical patient’s care.

Indications:
1. Unprotected airway with danger of aspiration.
2. Need to support ventilation due to patient's inability to generate adequate tidal volumes.
3. Apnea (relative indication).
4. Inability to ventilate by other means.
5. In trauma: may be used initially as the most expedient method. Must be used if unsuccessful
    endotracheal intubation after two attempts.
6. General patient in need of airway intervention in which (at maximum) no more than two paramedics
    have made two attempts.

Contraindications:
1. Gag reflex present.
2. Height less than 4 feet.
3. Known or suspected esophageal disease.
4. Caustic oral ingestion.
5. Suspected foreign body in airway.

Method: Refer to training documents in Appendix.

Cricothyrotomy:
Cricothyrotomy is a last resort intervention available to MICPs for unrelieved airway obstruction or a
patient emergently requiring an airway who cannot be intubated.

Indications: Absolute need for an airway with no other practical option.

Contraindications: None in this setting.

Method: Refer to appendix: Melker™ Cuffed Emergency Cricothyrotomy Catheter Set

Bag-Valve-Mask Ventilation (BVM):
Deliver breaths slowly (1 ½-2 seconds) with a volume adequate to cause chest rise when ventilating the
apneic patient. Limit ventilations to 12 per minute in the adult cardiac arrest patient.

                               Inspiratory Impedance Device
                                    (ResQPOD® Circulatory Enhancer)

This device causes as brief impedance to inspiration and can lead to improved cardiac output in low flow
states.

Indications:
For temporary increase in blood circulation in patients receiving positive pressure ventilation by ETT or
BVM (Combitube excluded unless it is confirmed to be in the trachea)

Contraindications
   1. Known decompensated heart failure or CHF
   2. Pulmonary hypertension or aortic stenosis
   3. Flail chest
   4. Chest pain
   5. Patient with primary complaint of shortness of breath
   6. It is currently not indicated for pediatric use (<12 yo, <80lb)

Method
Refer to appendix for graphics on use of device

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    1. With facemask and BVM: apply ResQPOD between facemask and BVM. Provide ventilations in
       customary manner
    2. With ETT: apply ResQPOD between airway device and BVM and ventilate as per protocol.
    3. Be sure that all pieces fit tightly
    4. The device has a timing light that is activated by a switch on the upper face rim. This light directs
       the timing for delivering 12 breaths per minute with each breath lasting 1.0 seconds. AFD
       resuscitation protocols supercede this ventilation rate. However, in cases of other shock states
       when this device is applied, 12 breaths per minute will be used

                                                    CPR
Available evidence shows that high quality, uninterrupted cardiac compressions are of great importance
to victims of cardiopulmonary arrest. Compressions using an external device (Revivant® Autopulse)
show promise as an adjunct in this setting. AFD personnel are directed to institute CPR at the earliest
possible moment and to limit all interruptions to continuous CPR.

Ventilations for victims of cardiopulmonary arrest who are greater than 18 and for who the cause of the
cardiac arrest is believed not to be of a ventilatory/respiratory cause will have ventilations given at a 15:2
ratio while CPR is being performed. If cardiac arrest is considered secondary to ventilatory insufficiency
then ventilation is performed at 5:1 once two-man CPR is being performed.

                                          Revivant Device
The Zoll AutoPulse is a battery operated, non-invasive mechanical CPR pump. The AutoPulse device is
currently in limited use in the Municipality of Anchorage EMS system.

Indications:
    1. Non-traumatic cardiac arrest, to include PEA requiring CPR
    2. >age 18
    3. >90 lbs body weight

Contraindications:
   1. Cardiac arrest due to traumatic injury
   2. Confirmed Comfort One or DNR order
   3. Abdominal or chest surgery in previous 6 weeks

Usage guidelines:
   1. The AutoPulse device automatically sizes to fit a 32 to 54 inch chest diameter.
   2. The AutoPulse shall be used in accordance with the manufacturer’s recommendations.
   3. At the current time, the AutoPulse device is to be incorporated as soon as feasible into the
       treatment flow of a cardiac arrest without changing current Anchorage Fire Department protocols.
   4. The Autopulse is equipped with rate settings of:
       a) 15:2
       b) Continuous
The Anchorage Fire Department shall use the 15:2 rate settings

                                        Cardiac Monitoring
Initiate continuous monitoring in all of the following:
1. First time seizures and patients over 30 y/o with seizures.
2. Chest pain of all causes (including symptoms suggestive of Acute Coronary Syndrome).
3. Unconscious patients of any etiology.
4. Patients with a neurological deficiency of unknown etiology.
5. Any blunt or penetrating chest trauma.
6. Irregular or abnormal peripheral pulses.
7. Syncope.
8. Suspected overdoses*.
9. Patients who are hemodynamically unstable.
10. Asthmatic patients over 35 y/o receiving epinephrine.
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*Measure QRS and QT intervals.


                                            12-Lead ECG
Purpose: EMS-generated 12-lead ECG may hasten the restoration of vessel patency by speeding the
acquisition of that vital piece of data. In rhythm disturbances, the 12-lead gives additional information as
to the type of rhythm.

Method: EMS will obtain the 12-lead ECG for the indications listed below. In general, the leads will be
applied by EMT while the paramedic takes history, obtains IV access etc. The goal is to add no more than
one minute to scene time for ECG.

Indications:
1. NCT. Obtain pre-adenosine 12-lead. Try to get continuous strip during conversion with adenosine
    (leads I, II and V2).
2. Suspected AMI or acute coronary syndrome (symptoms may include indigestion, nausea, arm or jaw
    pain).
3. CHF, pulmonary edema, acute respiratory distress that might be due to cardiac etiology.
4. Unexplained diaphoresis (age appropriate).
5. Unexplained tachycardia or hypoxemia in a patient with known coronary artery disease.
6. Unexplained syncope or near-syncope in non-pregnant patient greater than age 40.

Contraindications: unstable patient.

Reporting: Paramedic will make a verbal report at earliest appropriate time alerting the receiving hospital
of the patient’s history, physical exam, response to therapy and ECG findings (rate, rhythm and evidence
of injury, ischemia or infarction). The paramedic shall report the findings by describing ST elevation or
depression, q-waves and other abnormalities in each lead in which the abnormality is seen.

Additional notes: Try to get the 12-lead before giving nitroglycerin to patients with cardiac chest pain. If
this will result in significant delay (>60sec), treat symptoms prior to 12-lead acquisition.


                                        Combative Patient
Applies to: All violent and combative patients thought to be a risk to themselves or AFD personnel during
transport. The usual etiology of this behavior would be secondary to cocaine or methamphetamine use,
but may be secondary to neuro-psychiatric disorders or other ingestions. It is important to exclude
hypoglycemia, hypovolemia, hypoxia, or head injury as the cause of the behavior.

Guidelines:
1. Protect yourself first, and then protect the patient from injury.
2. Be sure that you have the right kind (e.g. law enforcement) and number of personnel to handle the
   problem.
3. Always leave yourself, and the patient, escape routes.
4. Obtain vital signs, if possible.

Medical Support:
1. Maintain ABC’s.
2. Monitor vital signs, take history, and do physical assessment if possible.

Optional treatment modalities:
1. IV at a TKO rate.
2. Obtain glucometer reading if possible. If behavior is likely due to hypoglycemia (history or clinical)
   treat as per Diabetic Emergencies Protocol.
3. Restraints may be needed for patient and/or medical staff protection.
4. Consider droperidol 1.25-5.0 mg IM or 1-2mg IV.
5. For the intubated combative patient, refer to and utilize the Rapid Sequence Intubation Protocol.

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Transport:
1. Maintain ABC’s (this may include physical restraints in intubated and combative patients).
2. Monitor vital signs.
3. Bring samples of drugs, plants or other causative agents.
4. Patient management may interrupt radio communication.
5. PROTECT PATIENT AND PERSONNEL FROM INJURY.


                                               IV Therapy
Indications:
1. Patients in shock or impending shock requiring volume replacement.
2. Patients requiring IV drug therapy.
3. Pediatric IV placement at paramedic discretion.
4. Cardiac arrest.
Method:
1. Apply venous tourniquet.
2. Prep site with alcohol.
3. Perform venous catheterization with appropriate gauge IV.
4. Appropriate disposal of sharps
5. Chart site, gauge and number of attempts.
Guidelines:
1. Volume replacement: Start 1-2 large-bore IVs and infuse NS to maintain systolic blood pressure
   above 90 (adult) or to maintain perfusion (improved mentation, color, or capillary refill) in pediatric
   patients. * Monitor vital signs and lung sounds frequently.
2. Medications: Infuse medications through a running IV.
3. Saline lock: For stable patient with the potential to need IV access medication or fluid.
4. Cardiac arrest: large-bore IV.
*Vigorous fluid therapy in patients with internal bleeding may lead to further hemorrhage. Aim for SBP of
90 and signs of improved tissue perfusion (as above), then decrease rate. Refer to Traumatic Brain
Injury Protocol for additional pressures.

                                   Intraosseous (IO) Therapy
Indications:
1. An alternative to venipuncture in children <6 years of age when peripheral IV access cannot be
    quickly achieved within 2 attempts or 90 seconds.
2. Drug and fluid resuscitation of an infant or child who is unconscious and unresponsive, and in need of
    immediate life saving intervention.
3. Cardiac arrest.
***Note: The AFD is investigating the use of devices for adult IO therapy. If adopted, a revised policy will
be added.

Contraindications:
1. Insertion of an IO into a fractured bone.
2. Insertion of an IO distal to a fractured bone (i.e., tibial placement with a femur fracture).
3. Previous attempts at IO insertion in the same bone.

Relative Contraindications:
Infection or burns at the intended site (physician contact required)

Precautions:
1. The infusion rate may not be adequate for resuscitation of ongoing hemorrhage or severe shock. It is
   a good alternative route when venous access is difficult.
2. Extravasation of fluid is the most common problem secondary to improper initial placement or
   dislodgement of needle.
3. Other complications reported in the literature are rare, including fat embolism and osteomyelitis.

Method:
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    1. Infant or child is placed in the supine position.
    2. Identify and locate the bony landmarks:
        a) The site of choice is in the proximal tibia 1-2 finger breadths below the tibial tuberosity on the
            anteromedial surface.
        b) Alternate sites are:
            • The distal femur 2 finger breadths above the external condyles in the midline;
            • The distal tibia 1-2 finger breadths above the medial malleolus at the ankle.
    3. Prep the site with betadine.
    4. Direct and insert the needle with the stylet in place perpendicular to the bone or angled away
        from the joint, avoiding the epiphyseal plate.
    5. Insert with pressure and a boring or screwing motion until penetration into the marrow, which is
        marked by a sudden lack of resistance.
    6. Remove the stylet.
        a) Appropriate disposal of sharps.
    7. Attach a 5 ml syringe filled with saline. The IO is appropriately placed if the following are present:
        a) Aspiration with syringe yields blood with marrow particulate matter.
        b) Attempt at infusion of saline in syringe is not met with resistance or infiltration at the site.
        c) Needle stands without support.
    8. Attach stopcock to IO; attach IV tubing or use syringes directly to the stopcock for medication
        flushes/fluid replacement.
        a) IV flow rates to gravity may be unacceptably slow.
        b) Use 60 ml syringes for fluid boluses.
        c) Medications administered by IO must be followed by a flush of at least 5 ml to ensure that the
            drug is infused into the marrow.
    9. Stabilize needle on both sides with sterile gauze and secure with tape.
        a) Avoid tension on the needle.
    10. Chart site, gauge and number of attempts.

                                        Pain Management
Many of our patients experience acutely painful conditions. We can help many of them with medications
or other techniques. In general, we must balance our wish to ease their pain with the possibility of
complicating their care.
Pediatric patients experience pain that is as real as in older persons and should be offered pain control
when appropriate.

General Guidelines:
   1. A calm and supportive provider will help the injured person deal with the anxiety associated with
       an injury. Conversation used to distract from the situation is helpful.
   2. Fractures and sprains are generally more comfortable if splinted and iced. This is especially true
       for femur fractures that can be traction splinted.
Documentation:
Document by means of the FACES Pain Rating Scale the patient’s pain level at the onset of EMS care.
Document any change in that level after EMS intervention or at termination of EMS care.
Medical Therapy:
Patients with no contraindications who are experiencing moderate to severe pain should be offered pain
relief.
Absolute contraindications:
1. Allergy to proposed pain agent.
2. Hypotension.
3. Acute multi-system trauma with unstable vital signs.
4. Penetrating eye injury (tetracaine).
5. Significant impairment due to alcohol or other intoxicants.
Relative contraindications:
1. Pregnancy (N02).
2. Pneumothorax (N02).
3. Bowel obstruction (N02).
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Therapies:
1. Morphine sulfate, per standing orders. Note: See diphenhydramine regarding hypotension.
2. Fentanyl, preferred for situations where short action desired e.g. abdominal pain, head injury, multiple
   trauma or if patient has morphine allergy.
3. Nitrous oxide (NO2), per standing orders.
4. Tetracaine, per standing orders.
Important Note:
All patients given analgesics by AFD shall be transported to a receiving facility. The patient must be
aware of and agree to this before receiving therapy.




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                                      Specific Therapies
                                  Medication Administration
1. Route: in cardiac arrest or other critical resuscitation, IV is the preferred route when available. Give a
   20 ml flush after each IV injection. Use ETT or IO (age-appropriate) when IV is not available. IO
   doses are equivalent to IV.
2. Parental administration definitions:

     Route                              Method
     IN                                 Intra-nasal using mucosal administration device
     IM                                 Intra-muscular using approved technique.
     IO                                 Intraosseous.
     IVD                                IV drip.
     IVP                                IV push (bolus).
     IVPB                               IV piggy-back
     PO                                 Per Os, Orally.
     Rapid IV bolus                     Specific attention to rapid push and immediate follow up flush.
     RIVP                               Rapid IV push.
     SC                                 Subcutaneous.
     SIVP                               Slow IV push, over 1-2 minutes unless specified otherwise.
     SL                                 Sublingual.

3. Endotracheal doses , maximums: in all cases where ETT administration is allowed, the doses and
   maximums will be double those for IV administration.* When mixed IV and ETT doses are given,
   consider the doubled ETT dose to be equivalent to the standard IV dose.
4. Definitions – restricted situations:
   a. Contraindication - the drug cannot be given without physician contact. Deviation without contact
       requires immediate Special Medical Report (FD-1). Note: all medications are understood to be
       contraindicated when the patient has a known sensitivity or allergy.
   b. Relative contraindication - the drug is not normally recommended; physician contact preferred.

Note: Deviation in a restricted situation requires:
   a. Thorough charting of circumstances that support the decision.
   b. Notification and explanation to the receiving physician upon hospital arrival.
   c. FD-1 to be completed and submitted to Chief Medical Officer and to Medical Director for review.

*Except for pediatric endotracheal epinephrine: see Pediatric Weight Pages.

                               Blood Glucose Determination
Indications:
1. Before and after D50 administration, when possible, to evaluate response to therapy.
2. Suspected abnormal blood sugar values: diabetes, possible hypoglycemia.
3. Unconsciousness of unknown etiology.
4. Status seizures.
5. Symptoms/signs suggestive of CVA.

Method: Glucometer.




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                      Inflatable Lower-Body Splint (MAST/PASG)
Indications:
1. To splint pelvic and/or multiple leg fractures.
2. Can be considered as an option to treat traumatic shock, particularly in the setting "1" above or with
    suspected intra-abdominal bleeding but do not delay transport time to apply.
3. Suspected ruptured abdominal aortic aneurysm.

Contraindications: Pulmonary edema.

Relative contraindications:
1. Chest injury.
2. Evisceration.
3. Impaled object.
4. Pregnancy.
                                     Transcutaneous Pacing
Indications:
1. Witnessed asystole.
2. Consider as first approach to patient with anginal chest pain and symptomatic bradycardia.
3. Any of the following rhythms when they are symptomatic and either not responsive to atropine or are
    causing major instability requiring use before atropine.
    a. Sinus or junctional bradycardia.
    b. Sinus pause.
         nd     rd
    c. 2 or 3 degree AV block.
Current settings:
1. Cardiac arrest or mentation that makes pain problems unlikely: 20mA increments.
2. Mentation suggesting potential pain problems: 5mA increments with brief pauses for the patient to
    adjust.
Procedure: Pace @70/min. Increase current to electrical capture (consistent T waves) and check
perfusion signs carefully for mechanical response. Discontinue and retry later if perfusion clearly does not
improve.

Pain control: In conscious person pain control will most likely be paramount. MS and Lorazepam
preferred if neither is contraindicated; use Nitronox if neither is practical. Pain will increase the patient’s
ischemia.

          Rapid Sequence Intubation with Neuromuscular Blockade
Indications: To establish an airway in a patient in imminent danger because of an uncontrolled airway or
ventilatory insufficiency, in whom other methods for securing the airway have been unsuccessful or are
obviously impractical or impossible.

Contraindications:
1. Upper airway obstruction.
2. Probable inability to intubate afterward because of very unfavorable anatomical characteristics, or
   face or neck trauma.
3. History of malignant hyperthermia.
4. Patient who is 24 hours post-spinal cord injury, severe burn, or crush injury.
5. Known hyperkalemia.
6. Known myopathy (personal or family history of disease of muscles).

NOTE: If unable to intubate or use Combitube® and succinylcholine is contraindicated, proceed to
cricothyrotomy.




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Guidelines:
1. Prior to initiating RSI, reevaluate the patient for any obvious contraindications for paralysis
2. One paramedic and at least one other provider with advanced airway skills (approved by the medical
   director for field intubations) will directly attend the airway during and immediately after administration
   of the paralytic, until the following have been successfully completed:
   a. Intubation.
   b. Confirmation of tube placement as per Airway Protocol.
   c. Re-confirmation of tube placement with a C02 monitor or other recommended adjunct
        (mandatory).
   d. Tube is secured.

Procedure
1. Assemble personnel and equipment
    a. 2 providers with airway skills
    b. Intubation tools, check ETT cuff, suction
    c. IV access with running IV
    d. Check label and draw up succinylcholine 1.5 mg/kg and etomidate 0.3 mg/kg (if indicated)
2. Preoxygenate patient with 100% oxygen from BVM. If patient is spontaneously ventilating with
    adequate volume, DO NOT VENTILATE. If patient requires BVM ventilation, apply cricoid pressure.
3. Give succinylcholine. If neuromuscular blockade is required in the conscious patient, use etomidate
    0.3 mg/kg SIVP for sedation prior to succinylcholine.
4. Proceed with intubation as per Airway Protocol.
5. Maintain cricoid pressure from time of paralysis until tube is inflated. Must be fully prepared to
    ventilate and suction prior to administration, and to establish a surgical airway if necessary.
6. For sedation of combativeness after successful intubation and end of paralytic action, lorazepam 2
    mg (may give up to 4 mg) SIVP.
Pediatric Guidelines:
Pre-medicate with atropine (0.02 mg/kg) before giving succinylcholine (see atropine standing order).

Notes: Consider restraints during paralysis, after securing the airway and initiating ventilation, especially
in restless head injury patients.

                                         Gastric Intubation
Indications: Gastric decompression

Contraindications:
1. Ingestion of caustic substances.
2. Nasogastric: not used if there is facial trauma or significant head trauma.

Method: Nasogastric Insertion
1. Select tube size appropriate to patient size and age.
2. Examine for the more patent nare.
3. Measure the tube against the patient to get a rough idea of the length of tube that will be necessary to
   intubate the stomach.
4. Lubricate the tube with water-soluble lubricant.
5. Place the tube following the natural downward slope of the nose, trying to keep the tube on the floor
   of the nasal cavity.
6. The tube should move easily, do not use excessive force.
7. When the tube appears to be in position, place a stethoscope over the stomach, insufflate 20 ml of air
   with a syringe and auscultate for air in the stomach.
8. Place the tube to suction.

Method: Orogastric Insertion
1. Select tube size appropriate to patient size and age.
2. Measure the tube against the patient to get a rough idea of the length of tube that will be necessary to
   intubate the stomach.
3. Lubricate the tube with water-soluble lubricant.

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4. Insert the tube into the mouth.
5. The tube should move easily, do not use excessive force.
6. When the tube appears to be in position, place a stethoscope over the stomach, insufflate 20 ml of air
   with a syringe and auscultate for air in the stomach.
7. Place the tube to suction.




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                                               Medical

                                   Allergy and Anaphylaxis
Allergy and anaphylaxis are points along a continuum in the body s immune response. Allergy can be an
acute or chronic event. Anaphylaxis is a severe allergic reaction that manifests with sudden and
progressive symptoms that usually include angioedema (tissue swelling), bronchospasm, hives and
hypotension. A mixture of multiple endogenous agents causes the symptoms (not just histamine) and
true anaphylactic shock usually requires agents to support vascular tone (epinephrine, IV fluids),
bronchodilatation (epinephrine, albuterol), and membrane stabilizers (steroids), as well as antihistamines
(diphenhydramine).

Consider what may be causing the reaction and remove it from the patient or the patient from the
exposure, if possible. One such example would be a reaction to latex.

Stable reaction: (hives and/or pruritis, no airway problem, stable vitals).
1. Airway Protocol.
2. May need transport only.
3. If symptoms warrant field treatment:
   a. Diphenhydramine (Benadryl).
         I. Adult: 25 mg IV, may repeat to 50 mg if required; or 50 mg IM.
        II. Ped: 1 mg/kg IV or IM to a maximum of 50 mg/dose.

Moderate to Severe reaction: (complaint of throat constriction, some wheezing, stable vitals).
1. Airway Protocol.
2. IV Protocol.
3. Cardiac Monitoring Protocol.
4. Epinephrine: 1:1000 SC (unless contraindicated):
   a. Adult: 0.3-0.5 mg SC may repeat q15 min. times 3.
   b. Ped: 0.0 1mg/kg SC may repeat q15 min. to 0.3 mg max.
5. Diphenhydramine (Benadryl):
   a. Adult: 25-50 mg IV.
   b. Ped: 1 mg/kg IV (give IM if no IV) to a maximum of 50 mg/dose.
6. Albuterol: nebulize per albuterol standing order if there is wheezing, which does not clear after
   epinephrine.

Anaphylactic shock:
1. Airway Protocol.
2. IV Protocol.
3. Cardiac Monitoring Protocol.
4. Epinephrine: 1:100,000: Give as slow push from 10 ml syringe and titrate to symptoms. No dose
   limits in this setting if heart rate remains stable and no ectopy.
5. Diphenhydramine (Benadryl):
   a. Adult: 50 mg IV.
   b. Ped: 1 mg/kg IV (give IM if no IV) to a maximum of 50 mg/dose.
6. Albuterol: nebulize per albuterol standing order if there is wheezing, which does not clear after
   epinephrine.

                                  Asthma, Wheezing, COPD
Asthma, also referred to as reactive airway disease, and Chronic Obstructive Pulmonary Disease, are
conditions of obstructed outward airflow. These patients require substantial expiratory time in their
ventilatory cycle. If these patients require BVM or intubation with assisted breathing, it is crucial to give
sufficient time for the expiratory phase. They also require small tidal volumes, delivered slowly. Neglecting
this technique will result in a patient that is tight and “can’t be bagged.”


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Applies to: all patients being treated for known or presumed asthma (reactive airway disease), wheezing,
          or chronic obstructive pulmonary disease.

Guidelines:
1. Airway Protocol.
2. Supplemental oxygen by the method yielding the highest usable 02 delivery tolerated by the patient.
3. Cardiac Monitoring Protocol if patient:
   a. Is in moderate to severe respiratory distress.
   b. Has prior cardiac history.
   c. Is >50 years old.
   d. Patients >35 years old receiving epinephrine.

Mild Distress:
1. Albuterol inhaler, 3 breaths; Note: EMT-I may administer patient’s own inhaler/nebulizer.
2. Nebulized albuterol, 2.5 mg at 6-8 lpm.
Moderate Distress:
Nebulized albuterol, 5 mg at 6-8 lpm, may repeat once.
Severe Distress:
1. Nebulized albuterol, 5 mg at 6-8 lpm. Note: Continuous administration.
2. Epi 1:1000: 0.3-0.5mg SC; Note: May repeat q15 min. x3. Physician contact required for age >55.
3. Pediatric epi 1:1000: 0.01 mg/kg SC; max.0.3 mg/dose. Note: May repeat q15 min. x3. Albuterol
   unit dose nebulizer, blow by into face, PRN, in transport.
Note: Epinephrine is not indicated in the patient with COPD.
Oxygen administration is indicated for all symptomatic, hypoxemic patients. Those with severe COPD and
CO2 retention may be very sensitive to 02; high concentrations may cause further C02 retention.
Nevertheless, if these patients are having severe respiratory distress, they should be treated with 02 and
monitored carefully for changes in mental status. As they improve, the 02 should be titrated down to the
lowest comfortable level. Assist ventilations if respiratory distress does not improve and level of
consciousness deteriorates.

If a COPD patient is being treated for hypoxemia, carefully titrate oxygen to improve the patient¹s clinical
status. If available, apply capnography and monitor C02 level. If it begins to increase, consider
decreasing oxygen concentration. If ventilatory drive is suppressed and the need for oxygen
persists, then augment with BVM or other measures as required.

All patients treated for asthma or COPD by AFD must be transported to a receiving facility.

                                              Chest Pain
The new era of fibrinolytics and emergency angioplasty requires that patients with signs and symptoms
consistent with acute myocardial infarction be transported as quickly as possible.

Applies to: all patients with chest pain of possible cardiac origin. These orders may also be applied to
patients with symptoms that may represent an acute coronary syndrome including:

a. unexplained diaphoresis
b. pain in a typical cardiac referral pattern
c. indigestion in a suspicious clinical setting

Guidelines:
1. ABC’s, Airway Protocol, Hypotension Protocol, ACLS Protocols as required.
2. Oxygen, cardiac monitor, 12-lead-Protocol, IV.
3. ”OPQRST” and history of current events. Be sure to ask about aspirin and Viagra, Levitra, Cialis
   usage. Physical exam focusing on LOC, signs of pulmonary edema.

Medications:
1. Nitroglycerin, per standing orders.
2. Aspirin, 162 mg PO, per standing orders (do not re-administer if given within last 12h).
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3. Morphine, per standing orders.
4. Nitrous oxide, per standing orders (may be helpful if morphine allergy or hypotension).

Transport:
1. Transport code appropriate to the patients need.
2. If patient is a potential acute MI, notify the hospital that you have a patient with chest pain consistent
   with myocardial ischemia.
3. If the patient presents with contiguous lead ST segment elevations, initiate STEMI Alert. (See
   Operations Section.)

Note: Treat chest pain aggressively. Pain will increase the patient’s ischemia.


                                   Congestive Heart Failure
Guideline:
1. Airway Protocol. Note: Monitor closely, be prepared to assist ventilations or place advanced airway.
2. 02 at highest concentration tolerated by patient.
3. Cardiac monitor, obtain 12-Lead.
4. Monitor 02 saturation.
5. IV access, TKO.
6. Position patient upright with legs dependent, if possible.

Medications: (given in the following order unless contraindicated).
1. Nitroglycerin: 0.4 mg, SL, Note: PRN until max. amount determined by effects on symptoms and B/P.
   (Nitroglycerin is the primary and most important therapy.)
2. Furosemide: 40 mg, SIVP. If patient is on maintenance dosage, may increase dose to 80 mg SIVP.
   For repeat doses, physician contact required.
3. Albuterol nebulizer: may be used as an adjunct in pulmonary edema when wheezing is prominent,
   and in cases when the differential of CHF vs. exacerbation of COPD is uncertain.
4. Morphine Sulfate: 2-5 mg SIVP titrated to effect, max. of 15 mg. Note: Last line drug for pulmonary
   edema secondary to CHF. Nitro and Lasix are the preferred drugs in this setting. (May be most
   appropriate when the pulmonary edema is accompanied by chest pain.)
5. Aspirin: 162 mg, PO. Note: When an MI is suspected.

                                      Diabetic Emergencies
Adult Guidelines:
1. Provide general supportive care as required by patient’s status.
2. Check blood glucose with Glucometer.
3. If glucose <80 and patient has symptoms of hypoglycemia but is alert, administer oral glucose and
   monitor for improvement.
4. If patient has a significantly altered level of consciousness and blood glucose is <60, administer
   D50W: 25 gm IV. A running IV line is required.
5. If unable to establish IV, give glucagon: 1 mg (1 unit) SC/IM.
6. If patient does not improve, repeat glucometer and may repeat D50 x1. Re-evaluate and consider
   other etiologies.
7. All hypoglycemic patients taking an oral hypoglycemic must be transported and all others should be
   strongly encouraged to allow transport.

Pediatric Guidelines:
1. Provide general supportive care as required by patient status. Septic neonates and young infants
   may become hypoglycemic with serious infections.
2. Check blood glucose with Glucometer.
3. If glucose <80 and patient has symptoms of hypoglycemia but is alert, administer oral glucose and
   monitor for improvement.
4. If patient has a significantly altered level of consciousness and glucose is <60:
   a. Age ≤12: administer D25 IV or IO per Pediatric Weight Pages.
   b. Age >12, give as D50W per Pediatric Weight Pages.

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5. If unable to establish IV, give glucagon 1 mg (1 unit) SC/IM if >20 kg; if less than 20 kg then use .05
   mg/kg.*
6. If patient does not improve, repeat Glucometer and may repeat D50W x1.

*In neonates and infants, hypoglycemia may result from depletion of available liver glycogen due to
physiological stress. Since glucagon uses glycogen as the energy source, it is less likely to be effective in
this setting.

                                                Epistaxis
Epistaxis is a common problem and may arise spontaneously or from trauma. Although the lay public
strongly correlates elevated blood pressure with epistaxis, scientific evidence is lacking. There are two
basic types of epistaxis: those that arise from the anterior nasal cavity and those that arise from the
posterior. Anterior bleeding is usually controlled with direct pressure or pharmacological agents. Posterior
bleeding is generally imcompressible in the prehospital setting and is often the result of significant arterial
bleeding. Bleeding which does not respond to therapy for anterior epistaxis should be assumed to be of
posterior origin. Significant nasal arterial bleeding in the elderly should be considered to likely be of
posterior origin unless an anterior bleed is visualized.

Procedure, known or presumed posterior bleeding.
1. IV access.
2. Trial of compression of nares.
3. Trial of rolled 2x2 gauze firmly placed beneath upper lip(should resemble the size and shape of
   cigarette filter) in the midline between lip and gum, with pressure then applied in a direction toward
   the nasal spine(either with pressure applied from the skin surface of the upper lip or directly on the
   gauze).
4. 3 squirts of neosynephrine to each nare.
5. Positioning to allow blood to be expectorated by patient or suctioned by EMS.
6. Airway control if necessary.

Procedure, anterior bleeding.
If no current active bleeding, transport without further intervention.
1. Compression of nasal alae. This should include the entire cartilaginous area distal to nasal bone.
2. If bleeding persists: see 3 above.
3. If bleeding persists: have patient gently blow nose to try to evacuate all clot and use 3 squirts of
     neosynephrine to affected side.


                                            Hyperkalemia
Severe elevations of potassium cause progressive derangement of cardiac conduction. This eventually
leads to VTach or VFib, often preceded by a sinusoidal ECG pattern.

The prehospital provider will rarely have sufficient information to make this diagnosis since it generally
requires lab confirmation. It should be strongly suspected in a dialysis-dependent renal failure patient who
demonstrates a sinusoidal cardiac rhythm, suffers cardiac arrest after missing a dialysis session, or is
otherwise known to be hyperkalemic. Tall, peaked T waves in multiple leads are also suggestive, and
often diagnostic in a patient who is known to be at risk for hyperkalemia.

Applies to: unstable patient who is at risk for hyperkalemia.

Guidelines:
1. Airway Protocol.
2. IV Protocol.
3. Cardiac Monitoring Protocol.
4. Administer calcium chloride, 1 gm (10 ml) SIVP.
5. Administer sodium bicarbonate, 50 mEq IVP.

NOTE: do not co-administer these agents because precipitation will occur.

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                                             Hypertension
Severe hypertension requiring pre-hospital treatment is quite rare. Treatment is necessary only if the
hypertension clearly is causing a clinical condition to evolve or if there is documented end-organ damage
due to the hypertension (difficult to establish pre-hospital). The main examples of this are intracranial
hemorrhage, myocardial ischemia, or renal failure associated with severe elevations of blood pressure
(systolic >240,diastolic >140). This is a largely unstudied area. The danger in pre-hospital treatment is
that an agent may cause a precipitous change in blood pressure that creates a new, and potentially
worse, problem.

Guidelines:
Treat the underlying condition if it may be causing the elevated BP.
1. Pain: Pain Protocol.
2. Anxiety: Verbal calming techniques and reassurance.
3. Pulmonary edema: CHF Protocol.
4. NTG: not generally recommended; physician contact required.
5. Furosemide: at physician request only.

                                             Hypotension
Patients who present with symptomatic hypotension should be categorized as to their probable
intravascular volume status as well as the presumed mechanism for the hypotension (if known or
presumed). Therapy should then be directed accordingly.

Applies to: symptomatic hypotension unrelated to trauma.

Guidelines
Consider volume status: Is patient “dry” (hypovolemic), normally hydrated(euvolemic), or “wet”
(hypervolemic).

    •   If the patient is hypovolemic: use repeat boluses of normal saline titrated against clinical exam.
        Potential situations: gastrointestinal illness, dehydration of other causes
    •   Is the patient euvolemic? May need volume and dopamine. Potential causes: septic shock,
        neurogenic shock, anaphylactic shock.
    •   Is the patient hypervolemic? Use dopamine. This situation is generally cardiogenic shock.

                 Seizures, Status Epilepticus and Postictal States
Seizures are generally of short duration and, if self-limited, require no drug therapy in the field. Seizures
that are not self-limited, or that last longer than a few minutes, do require drug therapy. Always consider
possible etiologies, including hypoglycemia, hypoxemia, toxic ingestion, trauma, CNS infections, and
subarachnoid hemorrhage.

Observe the type of seizure that is occurring. If it is a motor seizure, observe whether it is general or focal.
If focal, communicate this to the receiving physician and record it on the PCR.

Adult Guideline:
Control all further seizure activity with lorazepam 1-2 mg repeated in 5 minutes if necessary. Apply
supplemental oxygen by NRB. Oxygen may be discontinued if patient returns to normal mentation and
has no more indication for oxygen. If further doses are required, physician contact required.

Pediatric Guideline:
1. Attention to ABCs and general supportive care.
2. Lorazepam 0.1 mg/kg SIVP. May give lorazepam IM 0.1 mg/kg.
3. Begin cooling if febrile.
Note: Transport at the level appropriate to patient’s status.



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                                       Seizure Algorithm


                                       Occurring, Postictal, or Tremulous



                                           ABC’s, IV, O2, Monitor, Blood
                                             Glucose Determination


           NO                          Evidence of correctable problem?                  YES


    Lorazepam, 1-2 mg SIVP*                       No seizure                Hypoglycemia: per protocol,
                                                                            D50W
                                                                            Arrhythmia
                                     YES                                    Hypotension
        Seizure controlled                        Transport                 Toxic Ingestion


           NO

    Re-evaluate for
    correctable problem.
    Found?

           NO

    Contact medical control
    for additional Lorazepam




* May repeat x1 per Lorazepam Standing Medication Order.




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                                            Stroke (CVA)
A stroke is a focal neurological change that occurs as a result of lack of blood flow to the brain. This is
typically the result of a clot in a blood vessel in or near the brain or from a bleeding blood vessel. EMS
treatment is supportive emphasizing protection against secondary insults such as hypoxemia. Although
blood pressure may be elevated in these patients, there is rarely (if ever) an indication for rapid blood
pressure lowering in the field. Recent advances have lead to an opportunity to use clot-busting drugs in a
select group of patients whom are suffering an acute stroke. Interventions must be initiated within 3 hours
of onset of symptoms so EMS time can be very critical.

Guidelines:
1. Airway Protocol. Attention to need for suctioning.
2. Apply O2.
3. Cardiac monitor.
4. IV saline lock.
5. If evidence of increased intracranial pressure, elevate head 15 degrees.
6. Perform 30 Second Stroke Exam. A positive on any of the three measures suggests stroke:
   a. Test upper extremity strength: have the patient close his/her eyes and extend both arms. Ask
        him/her to maintain this for 10 seconds. Downward drift with one (but not both) indicates unilateral
        weakness.
   b. Test facial strength: have the patient smile. If this is equivocal, have the patient blow up both
        cheeks with air and then gently tap on either cheek to see if air is released. A facial droop with
        smiling or inability to keep air in only one side of the face indicates facial weakness.
   c. Test speech: have the patient repeat a saying such as “the sun shines on the fearless in
        Fairbanks”. Inability to repeat this due to lack of articulation or due to not being able to form the
        words is a positive finding.

If Stroke Exam is positive and onset is within 3 hours, notify ED ASAP that patient may be a candidate for
stroke intervention.

CONTINUALLY REASSESS FOR NEURO CHANGES IN TRANSPORT.

                           Tricyclic Antidepressant Overdose
Tricyclic antidepressants (TCAs) are widely prescribed for a variety of conditions and are responsible for
more intentional drug overdose deaths than any other group of prescribed medications. These agents act
upon a number of physiologic systems and therefore have effects that are the net result of those actions.
Pupillary findings, for example, may range from dilated to constricted depending upon whether the
anticholinergic effects (dilation), or the adrenergic blockade (constriction) predominate.

Dose range: therapeutic ranges for most TCAs are 2-4 mg/kg. Life-threatening symptoms usually occur
with ingestions greater than 10 mg/kg. Fatalities often occur within 2hours and rarely >24 hours post-
ingestion. Serious toxicity is almost always seen within 6hours.

Clinical presentation:
CNS: Mild to moderate TCA toxicity may present as drowsiness, confusion, slurred speech, and ataxia
with increasing TCA toxicity, CNS depression progresses to coma and respiratory depression. Seizures
may occur and are usually brief and single (the tetracyclics, amoxapine and maprotiline may cause status
epilepticus).
Cardiovascular: cardiac conduction delays, supraventricular tachycardia, premature ventricular beats,
ventricular tachycardia, hypotension, and respiratory depression.
Electrocardiographic abnormalities are common, especially prolongation of the PR, QRS, and QT
intervals. Other ECG abnormalities include conduction blocks. The natural progression of ECG and
cardiac abnormalities occurs in the following order: sinus tachycardia, widening of the QRS complex,
decreased cardiac inotropy, increased PR interval, and finally, decreased heart rate.



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Pre-hospital focus points:
Consider TCA OD in all unconscious unknowns. If the patient has decreased LOC, ECG findings of
prolongation of QRS, or QT intervals, and OD are conceivable, initiate therapy for TCA OD as listed
below.
Death in TCA OD will be due to a lethal cardiac arrhythmia, poor peripheral perfusion due to decreased
cardiac output or respiratory embarrassment due to aspiration or decreased ventilatory effort.
Progression of neurological deterioration can occur remarkably quickly: anticipate that the patient may
require intubation.

Treatment:
Decreased LOC, poor gag reflex: intubate.
QRS abnormalities: QRS>.10 sec, QT>.35 sec at 100 bpm; or QT>.44 sec at 60 bpm: 50 mEq
NaHCO3, hyperventilate.
Ventricular arrhythmias: bursts of VT or frequent PVCs: 50 mEq NaHCO3, hyperventilate.
Hypotension: 50 mEq NaHCO3, hyperventilate, fluid bolus with careful attention to fluid overload.

Note: overaggressive use of NaHCO3 may result in severe base excess, which is very difficult to correct.
LIMIT TO: 50 mEq.

Tricyclic Antidepressants

 Generic Names                     Trade Names                                       Comments
 Amitriptyline                     Elavil, Endep, Etrafon, Limbritol, Triavil
 Amoxapine                         Asendin
 Clomipramine                      Anafranil
 Desipramine                       Norpramin
 Doxepin                           Adapin, Sinequan, Zonalon
 Imipramine                        Tofranil
 Maprotiline                       Ludiomil
 Nortriptyline                     Pamelor
 Protriptyline                     Vivactil
 Trimipramine                      Surmontil
 Cyclobenzaprine                   Flexeril                                          Treat as TCA OD
 Carbamazepine                     Tegretol                                          Treat as TCA OD.

                       Unconscious Patient Unknown Etiology
Guidelines:
Assess ABC’s.
Assess for signs of trauma.
Look for medic alert bracelet, pill bottles or other evidence for underlying medical condition.
Look for signs of drug abuse.
Look for treatable causes:
   • Consider metabolic etiology: check glucose and treat if significantly low: see Diabetic
        Emergencies Protocol.
   • If evidence of opiate narcotic overdose (including propoxyphene): treat with naloxone.

Observe for smells of alcohol, ketones, or other unusual odors.

Vital signs:
Hypotension: see Hypotension Protocol.
Bradycardia: see Bradycardia Algorithm.
Tachycardia: see tachycardia algorithms in ACLS Algorithms.

Physical exam: focus on potential causes including infection (fever, lung exam, skin etc), toxins (drugs,
carbon monoxide, others).
Neuro exam: Seizure, other? If evidence of focal findings on exam (and blood sugar wnl): treat as TBI.

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                                                 Trauma
Victims of severe trauma benefit most from very rapid transport to a facility capable of caring for their
injuries. Pre-hospital interventions that extend scene time, with the possible exception of those related to
airway and spine management, are detrimental to patient well being. Minimal scene times are more
difficult to achieve in blunt trauma, which may require extrication and immobilization, and this is
understood when applying the following standards. It is vital to give early notification to the receiving
hospital so that they can assemble their trauma team.

Applies to: all victims of serious trauma resulting in an unstable or potentially unstable patient.

Standards:
• Airway at the scene if emergently required.
• IVs en route.
• Scene time <8 minutes.
• Early notification of the receiving hospital.

Guidelines:
1. High-flow 02.
2. C-Spine and Spinal injury Protocol.
3. Cardiac monitor.
4. Large-bore IVs if possible.
5. For shock, IV NS at rapid flow rates through blood tubing.
6. Incompressible hemorrhage, e.g. bleeding into body cavities, may worsen with overly aggressive IV
   fluid therapy. In cases of suspected intracavitary bleeding, limit fluids to the amount required to bring
   SBP to 90 and/or alleviate the shock state as demonstrated by mental status, skin signs, and vital
   signs.
7. Keep patient warm.

                                             Amputations
Guidelines:
1. Amputated part shall be wrapped in sterile dressing, slightly moistened with NS (dressing should be
   damp, not wet).
2. Place the part in a plastic bag and seal.
3. Place bag in a cool solution.
4. Never immerse the part or put it directly on ice.
5. Transport amputated part with patient to hospital.
6. Stump care:
   a. Apply bulky dressing.
   b. Control extremity hemorrhage by direct pressure and elevation of the limb.
   c. If tourniquet is required due to ongoing bleeding uncontrolled by other measures note in writing
       the time of application.
   d. If tourniquet was applied in the field prior to EMS arrival, it is usually best to leave it in place. Note
       in writing as accurately as possible the time of application.

                                         Burn Management
Thermal trauma presents significant diagnostic challenges. The possibility of multi-system injury is very
high in patients rescued from burning structures, explosions, electrical burns or dermal chemical
exposures. Initially subtle airway compromise may become acutely life threatening. An explosion or
electrical injury may have thrown the victim some distance resulting in internal injuries, initially masked by
painful burns. The EMS provider should try to get a rapid size-up of all potentially injuring mechanisms
involved in the injury.
Guidelines:
1. Extinguish the fire. Remember: Molten plastics/tar should be rapidly cooled to stop further burning.
    NEVER try to pull such substances off of the skin. This can result in the loss of vital skin structures
    and convert the burn to one requiring a graft!
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2. Airway Protocol.
3. Remove clothing and jewelry as needed.
4. Cover with burn sheet or dry dressings.
5. Estimate percentage of total body surface involvement.
6. Estimate thickness of burn.
7. For second and third degree burns over 20% total body surface area, start IV with NS using large-
   bore catheter.
           • Refer to burn charts for estimation of BSA.
           • Use variation of Parkland formula: Fluids in 24h=TBSA burn x 4 ml x wt (kg) with 1st half
                in first 8 hours.
8. Treat for shock.
9. Pain Management Protocol.

PREHOSPITAL REMEMBER: TBSA burned x 2 x Wt (kg) = mls NS in first 8hrs.

                                               Eye Injuries
Chemical Exposures
Copiously irrigate the eye(s)right away. Use available fluid. Examples: a kitchen sink with the depth to
allow the patient to put the eye under running water; an eye wash station at an industrial site; irrigation
with IV fluid through an 18g catheter held at the nasal or temporal canthus, or through a nasal cannula
placed on the bridge of the nose. tetracaine may be used to facilitate this process.
Note: Bring the MSDS, chemical agent, or name of the agent to receiving facility with the patient.
UV Exposure
Manage pain with tetracaine and transport.
Trauma
1. Blunt trauma:
   a. Obtain basic visual acuity if possible (light/dark vision or ability to read newsprint or count
       fingers). Do this in children as well as adults.
   b. Protect eye from pressure or further injury, and transport. May apply eye shield if available but
       DO NOT patch.
   c. Elevate head and have patient avoid valsalva.
2. Penetrating:
   a. As with blunt trauma.
   b. Leave any penetrating object in place.

                                            Pelvic Fracture
Stabilize an unstable pelvis by the application of moderate circumferential pressure around the pelvic
girdle. This may be accomplished by the application of the abdominal section only of the MAST, using
the trunk portion of an inverted KED, binding the pelvic girdle with a folded sheet, or using the long
elastic straps packaged with the Sager traction splint.

                  C-Spine Guidelines (Axial Spine Immobilization)
The proper and timely application of axial immobilization to a patient with an unstable injury of the spine is
unquestionably one of the most important pre-hospital skills. It clearly reduces or eliminates the
potentially devastating effects of a spinal injury if it is applied prior to compression or laceration of nervous
structures by either active or passive movement.

These guidelines are provided to set a uniform standard for all AFD personnel. They may be
independently applied by ETT through MICP.




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Situations in which cervical and full spinal immobilization are indicated:

Categories:
1. Patient complaint /clinical signs and symptoms.
           a. All patients c/o pain or tenderness on palpation of the neck or midline back, following
              physical injury of sufficient magnitude that damage to ligaments or bone of the spinal
              column could have occurred.
           b. All patients with a cervical, thoracic or lumbar deformity or any form of neurological deficit
              following physical injury.
           c. All patients with altered or decreased level of consciousness and a major mechanism of
              injury, regardless of presence or absence of pain.
           d. Unconscious patients with significant penetrating trauma to the head, neck or trunk in
              which trajectory could include spinal column (T or L-spine).
           e. Any neurological deficit after penetrating trauma to the head, neck or trunk (T or L-spine)
           f. Any unconscious patient following significant trauma.

2. Suspicious mechanism of injury: spinal immobilization indicated.
            a) Ejection from a vehicle.
            b) Fall >15 feet.
            c) Pedestrian struck by a moving vehicle with evidence of significant impact with vehicle or
                 upon impact with ground.
            d) Any seriously injured multiple trauma patient.
Notes:
1. Use these as guidelines. If there is any doubt, immobilize the patient.
2. In certain circumstances spinal immobilization may be omitted even though a potential mechanism for
   spinal injury exists. The following algorithm, Clinical Criteria for Assessment of Spine Injury, explains
   the decision-making process for omitting spinal precautions in this setting.

                   Clinical Criteria for Assessment of Spine Injury

                                       Mechanism



        Negative                   Positive / Uncertain


                                       Spine Pain/
                                                                YES
                                       Tenderness
     Negative Spine
     Injury                      NO

                                 Motor / Sensory Exam                                      Possible Spine
                                                                ABNORMAL
                                                                                           Injury
                                NORMAL

          YES                    Reliable Patient /Exam          NO

             •   Calm                                            •    Acute Stress Reaction
             •   Cooperative                                          (ASR)
             •   Sober                                           •    Brain Injury
             •   Alert                                           •    Intoxication
                                                                 •    Abnormal Mental
                                                                      Status
                                                                 •    Distracting Injuries
                                                                 •    Communications
                                                                 •    Age<12
                                                                 •    Advanced age?

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                             Spinal Immobilization Method




Notes:
1. The cervical collar should contact the shoulders and securely support the chin.
2. Head movement should be restricted by: the cervical collar, blanket-roll, and 2” tape.
3. The occipital padding should position the head in a neutral or very slightly flexed position.
4. The popliteal padding should provide some flexion to the knees.
5. The Spyder™ strap should be snug enough to prevent lateral displacement of the patient if the board
   is tilted.
6. The chest strap should be high on the thorax so diaphragmatic movement is unrestricted.
7. Strap from the shoulders and chest working toward the feet. Secure the head last.
8. Use additional padding between legs or between legs and straps or flanks and straps as needed to
   prevent lateral movement when board is tipped.




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                                Traumatic Brain Injury (TBI)
TBI is a significant cause of morbidity and mortality in trauma. Scientific evidence exists showing how pre-
hospital care can improve outcome in TBI. Pre-hospital therapy should focus on limiting secondary brain
injury that can result from hypoxemia, hypoventilation, and hypo-perfusion. EMS must also try to limit
physical factors that can increase intracranial pressure.
Guidelines:
1. Assess ABC’s. Stabilize spine.
2. Oxygenate with 100% 02, or highest concentration available. Monitor 02 saturation.
3. Secure airway. If intubation is required, it should bbe done with minimal gag stimulation. Consider
   RSI if gag is present and patient requires airway.
4. Capnography if available. Maintain pC02 35-40 unless patient shows signs of herniation (see below)
5. Establish IV with NS. Treat hypotension with fluid infusion. If normotensive, TKO.
    AGE         SBP
    12-Adult    <90
    5-12        <80
    1-5         <75
    0-1         <65

Treatment:
1. Elevate head of stretcher or backboard 15 degrees if possible while maintaining spinal precautions.
2. Evaluate and record mental status; the patient’s level of consciousness is the best indicator of brain
   function. Use the Glasgow Coma Scale to assess patient’s status on EMS arrival and document.
   Frequently reevaluate vital signs and GCS (q5 min.).
3. Hyperventilation is indicated in an unconscious trauma patient who is deteriorating neurologically
   with:
   a. Decerebrate or decorticate posturing.
   b. Significantly different pupil size (>2 mm difference) in a comatose, head injury patient.
   c. Cushing’s reflex (bradycardia and hypertension associated with acute head injury).
   d. Lateralizing signs (one-sided neurological changes elsewhere on the body, i.e., other than just
       pupil differences).
   e. Decrease in GCS by 2 or more points.
Definition of hyperventilation: capnography reading of 32-35.
    Adult:      20 breaths per minute.
    Child:      25 breaths per minute.
    Infant:     30 breaths per minute.
Combative patients with TBI may suffer an increase in ICP if forcibly restrained. Such patients may
require chemical sedation if verbal calming methods are not effective. EMS providers must have some
certainty that the combativeness is not due to correctable causes such as hypoglycemia or hypoxemia
before initiating sedation. Lorazepam is the preferred agent (doses titrated to 4 mg SIVP).
Destination issues: The receiving facility must have a functioning CT scanner available as well as
neurosurgeon on staff; (as of this writing EAFB is the only receiving facility without a neurosurgeon).
Note: Evaluation of a patient with mental status changes is often complicated. The EMS provider must
consider TBI in cases without apparent mechanism and must also consider toxic/metabolic causes in
cases in which there is a trauma mechanism that does not seem sufficient to explain the patient’s exam.
Blood glucose determination should be used liberally when the cause of the change in mental status is
not obvious.




Treatment and Medications Protocol                  47                                          Revision 3.0, 2006
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                                 Obstetrics and Neonatal
                                           Newborn Care
1. Suction the infant’s airway using a bulb syringe as soon as the infant’s head is delivered and before
    delivery of the body. Suction the mouth first, then the nasopharynx.
2. Once the body is fully delivered, dry the baby, replace wet towels with dry ones, and wrap the baby in
    a thermal blanket or dry towel. Cover the infant’s scalp to preserve warmth.
3. Open and position the airway. Re-suction the infant’s airway. Suction the mouth first, then the
    nasopharynx.
4. If thick meconium is present, initiate endotracheal intubation before the infant takes a first breath.
5. Suction the airway using an appropriate suction adapter while withdrawing the endotracheal tube.
    Repeat this procedure until the endotracheal tube is clear of meconium. If the infant’s heart rate
    slows, discontinue suctioning immediately and provide ventilation until the infant recovers. Note: If the
    infant is already breathing or crying, this step may be omitted.
6. Assess breathing and adequacy of ventilation.
7. If ventilation is inadequate, stimulate the infant by gently rubbing the back and flicking the soles of
    the feet.
8. If ventilation is still inadequate, after brief stimulation, begin assisted ventilations at 40 to 60
    breaths per minute using a bag-valve-mask device with high-flow, 100% concentration oxygen.
9. If ventilation is adequate and the infant displays central cyanosis, administer high-flow, 100%
    concentration oxygen via blow-by. Hold the tubing 1 to 1-1/2 inches from the infant’s mouth and nose
    and cup a hand around the end of the tubing to help direct the oxygen flow toward the infant’s face.
10. Assess heart rate by auscultation or by palpation of the umbilical cord stump.
11. If the heart rate is slower than 60 beats per minute after 30 seconds of assisted ventilation with
    high-flow, 100% concentration oxygen, initiate the following actions:
    a. Continue assisted ventilation.
    b. Begin chest compressions at a combined rate of 120/minute (three compressions to each
         ventilation).
    c. If there is no improvement in heart rate after 30 seconds, perform endotracheal intubation.
    d. If there is no improvement in heart rate after intubation and ventilation, administer Epi. 1:1000
         solution at 0.1 mg/kg (maximum individual dose 1 mg) via endotracheal tube, or establish
         vascular access and administer 0.01mg/kg Epi 1:10,000 IVP (maximum individual dose 1 mg).
         Repeat epinephrine at the same dose every 3 to 5 minutes PRN.
    e. Initiate transport. Reassess heart rate and respirations en route.
12. If the heart rate is between 60 and 80 beats per minute, initiate the following actions:
    a. Continue assisted ventilation with high-flow, 100% concentration oxygen.
    b. If there is no improvement in heart rate after 30 seconds, initiate management sequence
         described in step 11b.
    c. Initiate transport. Reassess heart rate and respirations en route.
13. If the heart rate is between 80 and 100 beats per minute, initiate the following actions:
    a. Continue assisted ventilation with high-flow, 100% concentration oxygen.
    b. Stimulate as previously described.
    c. Initiate transport. Reassess heart rate after 15 to 30 seconds.
14. If the heart rate is faster than 100 beats per minute, initiate the following actions:
    a. Assess skin color. If central cyanosis is still present, continue blow-by oxygen.
    b. Initiate transport. Reassess heart rate and respirations en route.
    c. Clamp umbilical cord securely 8-10 inches from the infant.
    d. Do APGAR scores at one and five minutes, if possible. This can be done later. Do not delay
         resuscitative or warming measures to obtain APGAR.
    e. Reassess the patient frequently.

NOTE: Assess and support temperature (warm and dry), breathing (stimulate to cry), circulation (heart
rate and color).




Treatment and Medications Protocol                   48                                          Revision 3.0, 2006
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                                               Obstetrics
All EMS encounters with pregnant patients will proceed with the care directed toward the maternal-fetal
unit; all interventions are to be performed with an understanding of their potential effect on both the
mother and fetus. Provide supplemental O2 in all cases of trauma or hypoxemia. Position the mother to
maximize blood flow (15 degree left lateral tilt or manually displace the uterus).


                                 Third Trimester Hemorrhage
Applies to: all patients known or believed to be in the third trimester of pregnancy that is experiencing
vaginal bleeding. Possible causes of third trimester bleeding include placenta previa, abruptio placentae*,
and uterine rupture.
*In the presence of abruptio placentae, shock is likely to be out of proportion to the apparent volume of
blood loss.
Guidelines:
1. O2.
2. Position left lateral recumbent.
3. Begin emergency transport, code red.
4. Notify receiving facility immediately.
5. Establish at least one, preferably two, large-bore IVs. Titrate fluid rate to patient’s status. IV should be
   deferred until transport is underway.
Under no circumstances attempt to examine the patient internally

                                Pre-eclampsia and Eclampsia
Pre-eclampsia, characterized by hypertension, edema, and proteinuria develops after the twentieth week
of gestation. Eclampsia is pre-eclampsia with seizures.
Applies to: all patients with eclampsia, or one with symptoms of pre-eclampsia who appears likely to
have a seizure. These patients are expected to meet the minimum criteria of systolic BP >140 and
peripheral edema.
Guidelines:
1. ABC’s: Airway Protocol as required, supplemental 02, large bore IV, TKO.
2. Monitor.
3. Position left lateral recumbent.
4. Magnesium sulfate 1-4 gm IVPB.*
5. Unstable pre-eclamptic: handle and transport gently.
* Add 3 gm magnesium sulfate (50% solution) to a 1 gm/100ml bag (total 4 gm/100ml). Magnesium
  sulfate is hyperosmolar and will cause damage to red blood cells if not diluted, or if injected too quickly
  even when properly diluted.




Treatment and Medications Protocol                    49                                           Revision 3.0, 2006
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                                              Childbirth
Applies to: Women in active labor who desire transport to a hospital.
Policy: Complications of delivery that require immediate emergency transport are prolapsed cord,
breech, limb breech, shoulder, or face presentation. Specific history should include prenatal care,
expected complications, para, gravida, due date, personal MD, high risk factors, whether water has
broken, previous c-section, medical history, medications and allergies.
Guidelines:
1. Imminent Delivery:
   a. Prepare for delivery.
   b. Establish one large-bore IV.
   c. Deliver at home.
   d. Assess baby and mother.
   e. Attend to neonatal needs: ABCs, warmth, APGARs. (Newborn Care Protocol).
   f. If uncomplicated and neonate is OK, place at mother s breast.
   g. After delivery of intact placenta, add 10 units Pitocin* to 1000 ml NS and administer at a rate of
       125 ml/hr.
   h. If delivery is uncomplicated and mother and baby are stable, transport code yellow.
*If on-going, severe hemorrhage occurs, titrate to a firm uterus, and start a second, un-medicated, large-
 bore IV for fluid replacement.

2. Active labor, delivery NOT imminent:
   a. Exam and history.
   b. Saline lock.
   c. Transport left lateral recumbent to hospital of choice, code yellow.

                                  Postpartum Hemorrhage
Applies to: postpartum patient with more than 500 ml of blood loss.

Guidelines:
1. Establish large bore IV with NS.
2. Check perineum for any obvious source of bleeding from birth trauma. Apply direct pressure if site
   found.
3. Perform external uterine massage.
4. Give Pitocin (10u) by rapid infusion in IV fluid or by IM injection.
5. Rapid transport with frequent vital signs.




Treatment and Medications Protocol                  50                                          Revision 3.0, 2006
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                                         Environmental
The following material is consistent with current ACLS and State of Alaska guidelines. Complete copies of
both are available in station libraries.

                                            Hypothermia
1. Assessment: Severe hypothermia is present in a cold patient with any of the following signs:
   depressed vital signs, altered level of consciousness, core temperature of 90°F. (32°C) or lower,
   absence of shivering (less reliable in the presence of ETOH), or who has significant illness or injury.
   Mild to moderate hypothermia is assumed in the cold patient without any of these signs.
2. Basic treatment: Focus on preventing further heat loss. Add heat to the core surface areas (head,
   neck, chest, and groin), or re-warm internally with warm, moist air. Caution: warm packs must be
   wrapped and monitored, especially in the perfusion-impaired patient. Treat and transport in very
   warm air (80°F. or warmer) if possible.
3. Specific therapy: Indications for O2 are as usual for mild or moderate hypothermia; if severe,
   administer at 2-4 lpm via nasal cannula. Indications for oral airways and ETT tubes are the same as
   in warm patients. In severe patients attempt IV line of NS after other stabilization and give a 10 ml/kg
   bolus followed by 5 ml/kg/hr infusion. (Example: 70 kg pt and 10 gtt/ml dripset =1 gtt/sec).

In mild to moderate hypothermia, indications for IVs and medications are as usual. In severe
hypothermia, pacing is not indicated, nor are medications unless specifically ordered. Intubation may be
more difficult than usual and should be performed gently to reduce the risk of VF.

4. CPR setting: Do not resuscitate if: a) core temp is <60°F. b) patient has ice in airway, or c)
   generalized or total-body frozen skin/tissue is present (such that it is obviously more than localized
   frostbite). Provide basic treatment and specific therapy as above. Carefully assess absence of pulse
   and respirations for up to 45 seconds before beginning CPR. For patients with a core temperature
   >86°F, follow standing orders. For patients with a core temperature <86° F, VF, one series of three
   defibrillation attempts should be performed as indicated. If not successful, transport with CPR.
   Asystole or other pulseless rhythms: transport with CPR.

                                          Near Drowning
Treatment: No Heimlich unless evidence of foreign body airway obstruction. The “up to” 45 second pulse
check before CPR also applies here. Other therapy follows the hypothermia guidelines.




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                                       ACLS Algorithms
                                               Asystole

                                             Routine Medical Care



                                               CPR, Monitor, IV



                                             Confirm Asystole in 2
                                                    leads


                                     Transcutaneous pacing may be tried if
                                           arrest witnessed by EMS.


                                            Vasopressin 40 iu IVP
                                             Repeat in 3 minutes


                                             Epinephrine 1:10,000
                                              1 mg IV q 3-5 min.
                                                     -or-
                                             2 mg ETT q 3-5 min.


                                                  Atropine
                                       1 mg IV q 3-5 min. to max 3 mg.
                                                     -or-
                                      2 mg ETT q 3-5 min. to max. 6 mg.


                    If no response, may contact medical control to request cessation.


                                               Consider possible
                                                   causes


     Hypoxemia              Hyperkalemia            TCA OD              Hypothermia         βBeta-blocker OD

                            CaCl, 1 gm.


     Re-assess.                 Sodium Bicarbonate per                    Limit heat           Glucagon
    Oxygenation &                  TCA protocol or                          loss.               1 mg IV
     Ventilation                Hyperkalemia protocol.                  Handle gently.




Treatment and Medications Protocol                  52                                       Revision 3.0, 2006
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                                           Bradycardia


                                           Routine Medical Care


                                                Monitor, IV, O2



                                           Patient symptomatic?



                                 Definition of symptomatic bradycardia:
                               HR<60 bpm with at least one of the following:
                                             1. Chest pain.
                                             2. Altered LOC.
                                             3. Hypotension
                                             4. Difficulty breathing.


                         YES                                                   NO




                        Atropine
           0.5 mg IV q 3-5 min. to max. 3 mg.                      Monitor and transport.
                          -or-
           1 mg ETT q 3-5 min. to max. 6 mg.

                               OR



                Transcutaneous pacing




         Dopamine                Fluid challenge if
      5-20 µgm/kg/min.           no signs of CHF.




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                         NCT (Narrow Complex Tachycardia)

                                        Routine Medical Care



                                             Monitor, IV



                         YES               Patient stable?            NO



             Valsalva; 12-Lead ECG                             Etomidate 0.3 mg/kg SIVP
                (Continual I, II, V2                               If situation allows.
            printout during adenosine
                  administration.)
                                          Rhythm unchanged

                Adenosine 6 mg                                      Synchronized
                    RIVP                                            cardioversion
                                                                        100j

                                          Rhythm unchanged

               Adenosine 12 mg                                       Synchronized
                    RIVP                                             cardioversion
                                                                         200j
                                          Rhythm unchanged

               Adenosine 12 mg                                       Synchronized
                    RIVP                                             cardioversion
                                                                         300j
              Option: If adenosine        Rhythm unchanged
            antagonists are present
            (theophyllines), contact                                 Synchronized
                           rd
            Physician for 3 dose of                                  cardioversion
              18 mg (total 36 mg).                                       360j




            Definition of unstable:
             1. Chest pain
             2. Altered LOC
             3. Hypotension
             4. Difficulty breathing




Treatment and Medications Protocol              54                                     Revision 3.0, 2006
Anchorage Fire Department                                                            Medical Operations Manual


                            PEA (Pulseless Electrical Activity)




                                          Routine Medical Care



                                             CPR, Monitor, IV



                        YES                 Suspected cause?                    NO




                                                                         Epinephrine 1:10,000
                Cardiac Tamponade                                         1 mg IV q 3-5 min.
                 Cardiogenic Shock                                               -or-
                     Drug OD                                             2 mg ETT q 3-5 min.
               Hydrogen ion (acidosis)
                 Hyper/hypokalemia                               OPTION
                    Hypothermia
                   Hypovolemia
                      Hypoxia                                                Dopamine
                Pulmonary Embolism                                        5-20 µgm/kg/min.
               Tension Pneumothorax


                                                                  Rate<60

                                                                            Atropine
             Treat suspected condition(s)                        1 mg IV q 3-5 min. to max 3 mg.
               per appropriate protocol.                                       -or-
                                                                2 mg ETT q 3-5 min. to max. 6 mg.




                                         Fluid challenge option in all
                                                    cases.




Treatment and Medications Protocol                  55                                           Revision 3.0, 2006
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                  Perfusing WCT (Wide Complex Tachycardia)

                                                 Routine Medical Care
          If Pt. becomes unstable,
          move to appropriate point                  Monitor, IV, O2
             on “unstable” arm of
                  algorithm.
                                                    Patient Stable?
                                    YES                                           NO



  SVT               WCT:                       WCT:
                   Uncertain                Monomorphic                           Etomidate 0.3 mg/kg SIVP
                     Type                       VT                                    If situation allows.


                                                        Rhythm unchanged

                Amiodarone, 150 mg in NS 50 ml bag.                                  Sensing Adequate?
                 50 gtts/min. using 10 gtts/ml dripset.                           YES                NO


                                                        Rhythm unchanged

                                                                             Cardioversion           Defibrillation
Adenosine                         WCT:                                           100j                    200j
6 mg RIVP                   Polymorphic VT
                                                        Rhythm unchanged


 Adenosine                                                                   Cardioversion           Defibrillation
12 mg RIVP                           Suspected or known                          200j                    300j
                                     hypomagnesemia or
                                     prolonged QT (Torsades)

 Adenosine                                                                   Cardioversion           Defibrillation
12 mg RIVP                                                                       300j                    360j
                                 Magnesium
                                 1 gm IVPB

                                                                             Cardioversion
                                                                                 360j



                               Definition of unstable: Chest Pain, altered LOC,
                               hypotension, or difficulty breathing.




Treatment and Medications Protocol                   56                                       Revision 3.0, 2006
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             Pulseless VT/VF (Ventricular Tachycardia/Fibrillation)
                                                       Defibrillate 200j
                                                       Defibrillate 300j
                                                       Defibrillate 360j

                                                    Recurrent/Persistent          Conversion/Return of
                                                     Pulseless VT/VF             Spontaneous Circulation

                                                    60 seconds of CPR             Proceed to appropriate
                                                        Intubation                  Post Resuscitation
                                                            IV                       Care Algorithm

                                IV Established                               No IV Established

          Torsade de pointes: 1 gm          Epinephrine 1:10,000           Epinephrine 1:10,000
           Mag sulfate is first line if          1 mg IVP                       2 mg ETT
           known hypomagnesemia                q 3-5 minutes                  q 3-5 minutes
        or pre-existent prolonged QT.

                                            Recurrent/Persistent            60 seconds of CPR
                                             Pulseless VT/VF                  Defibrillate 360j

                                          Amiodarone 300 mg IVP             Recurrent/Persistent
                                            Magnesium 1 gm                   Pulseless VT/VF
                                               if Torsades

                                             60 seconds of CPR             Lidocaine 3 mg/kg ETT
                                               Defibrillate 360j

                                            Recurrent/Persistent            60 Seconds of CPR
                                             Pulseless VT/VF                  Defibrillate 360j

                                          Amiodarone 150 mg IVP            Continue Epi Regimen
                                                                           Continue IV attempts

                                            60 Seconds of CPR              Lidocaine 3 mg/kg ETT
                                              Defibrillate 360j               5-10 minutes after
                                           Continue Epi Regimen                    1st dose




                                    Note: Consider NaHCO3 in protracted resuscitation situations.




Treatment and Medications Protocol                       57                                            Revision 3.0, 2006
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                   Automatic External Defibrillator (AED) Protocol*
                                             Initial Assessment
                                 Verify Patient is UNRESPONSIVE and has
                                       NO Pulse and NO Respirations


                                              TURN ON AED


                                          APPLY ELECTRODES


                                            PRESS ANALYZE



                 NO SHOCK ADVISED                                                   SHOCK ADVISED


                         1 Minute CPR                                                 DEFIBRILLATE


                    PRESS ANALYZE                                                         ANALYZE


                                                                                      DEFIBRILLATE
       No Shock                      Shock Advised
        Advised                  Proceed to Right Column
                                                                                          ANALYZE


                                                                                      DEFIBRILLATE


                                                                                   ASSESS PATIENT
                                                                                     For Return of
                                                                             Spontaneous Circulation (ROSC)




                                                                            NO ROSC                   ROSC


                                                                           1 Minute CPR          Supportive Care


                                                                             ANALYZE



                                                        Shock Advised               No Shock Advised
                                                                                      Continue CPR



*
    Note: The AED is to be used only on persons 8 years of age or older.
Treatment and Medications Protocol                  58                                         Revision 3.0, 2006
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                                   Post Resuscitation Care
Applies to: care of patients who have the return of spontaneous circulation after a no-flow cardiac arrest.

Guidelines
       1. Work to optimize oxygenation and ventilation by reassessing these parameters frequently by
           clinical exam and monitoring of physiologic parameters such as oxygen saturation and
           capnography.
       2. Careful attention to the airway device regarding maintenance of its position and suctioning as
           necessary
       3. Work to optimize blood pressure while paying careful attention to the possibility of adversely
           increasing cardiac work. If there are no contraindications and rate is adequate, try bolus of
           250 ml saline and reevaluate. If evidence of “pump failure” then begin with dopamine.
       4. Consider precipitating cause of arrest: Obtain 12 lead ECG if possible.
       5. Treat bradycardia-associated hypotension with atropine, fluids, dopamine, or transcutaneous
           pacing as per the algorithm.
       6. Consider nasogastric tube.
       7. Consider aspirin therapy.
       8. If blood pressure adequate and ECG shows ST elevations, try to use NTG.
       9. Lorazepam titrate to a maximum of 4 mg SIVP for agitation or post-arrest seizure.
       10. Maintain normothermic body temperature




Treatment and Medications Protocol                  59                                          Revision 3.0, 2006
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                                           Post Resuscitation Care Algorithm


                                                                                                                   Manage airway as
                                                                                                                     appropriate


                                                                                                                Assess vital signs
                                                                                                               Obtain 12 lead ECG


                                                                    Symptomatic Treatment                                                                  Reversion to
                                                                                                                                                          Pulseless VT/VF


                         Hypotension                        Couplets, Runs of V-Tach          Frequent PVCs               Symptomatic Bradycardia     Return to Pulseless VT/VF
                                                                                                                                                              Algorithm


      Non-specific              Obvious Cardiogenic Shock     Amiodarone 150 mg.                 Lidocaine                  Atropine 0.5 mg IVP
  No Pulmonary Edema                Pulmonary Edema            IV Drip in 50 ml NS          (Per standing order)
                                                             over 10 minutes if max
                                                            dose not previously given


     Fluid Challenge                    Dopamine               If Amiodarone max                                          Symptomatic Bradycardia
 250 ml NS Rapid Infusion            Titrate to effect           previously given                                                Persists
                                   per Dopamine S.O.         Lidocaine 1 mg/kg IVP


   Hypotension Persists                                      Ventricular Arrhythmia                                           Fluid Challenge
                                                                    Persists                                              250 ml NS Rapid Infusion


     Fluid Challenge                                        Lidocaine 0.5 mg/kg IVP                                       Symptomatic Bradycardia
 250 ml NS Rapid Infusion                                      8-10 minutes after                                                Persists
                                                                   initial dose


    Hypotension Persists                                                                                                         Dopamine
                                                                                                                              Titrate to effect
                                                                                                                            per Dopamine S.O.


        Dopamine                                                                                                          Symptomatic Bradycardia
     Titrate to effect                                                                                                           Persists
   per Dopamine S.O.


                                                                                                                           Transcutaneous Pacing
                                                                                                                          (In severe bradycardia or
                                                                                                                               unstable patient,
                                                                                                                           implement immediately)




Treatment and Medications Protocol                                                60                                                                   Revision 3.0, 2006
                                                                                       Basic Life Support Summary Sheet1


                                         Procedure                                         Adult                      Child (1-8 years)                  Infant (1 year or less)2
                                                                                Head tilt/chin-lift              Head-tilt/chin lift                   Head-tilt/chin-lift
                                     Airway maneuver
                                                                                Jaw thrust                       Jaw thrust                            Jaw thrust
                                                                                                                                                                                    Anchorage Fire Department




                                     Rescue breathing rate                      12 breaths per minute            20 breaths per minute                 20 breaths per minute




Treatment and Medications Protocol
                                     Pulse location                             Carotid                          Carotid                               Brachial

                                                                                Lower half of the                Lower half of the                     1 fingerbreadth below
                                     Hand position
                                                                                sternum                          sternum                               intermammary line




61
                                     Compression method                         2 hands stacked                  Heel of 1 hand                        Middle and ring fingers

                                     Compression depth                          1½ to 2 inches                   1 to 1 ½ inches                       ½ to 1 inch

                                     Compression rate                           100 per minute                   100 per minute                        100+ per minute

                                                                                15:2, single rescuer             5:1, single rescuer
                                     CPR ratio                                                                                                         5:1
                                                                                15:2, two rescuers3              5:1, two rescuers

                                     Pause for ventilation?4                    Yes                              Yes                                   Yes
                                     ________________________________________
                                     1
                                       AFD/FXN – This summary sheet may be freely copied and distributed for educational purposes but not reprinted for sale.
                                     2
                                       Neonatal resuscitation should be performed at a rate of 120 compressions per minute and a ratio of 3:1.
                                     3
                                       5:1 if endotracheal tube in place.
                                     4
                                       A pause is not necessary in the intubated patient.
                                                                                                                                                                                    Medical Operations Manual




Revision 3.0, 2006
                                                                 Foreign Body Airway Obstruction (FBAO) Summary Sheet1

                                                                      Abdominal                  Chest                                              Blind         Visualize
                                             Condition                                                                      Backblows
                                                                        Thrust                Compressions2                                      Fingersweep       Mouth


                                         Conscious                      Repeated
                                                                                                   Alternate                      No                    N/A         N/A
                                                                                                                                                                              Anchorage Fire Department




                                         Adult                           Thrusts




Treatment and Medications Protocol
                                         Unconscious
                                                                              5                    Alternate                      No                    Yes         N/A
                                         Adult

                                         Conscious                      Repeated
                                         Child                                                     Alternate                      No                    N/A         N/A




62
                                                                         Thrusts
                                         (poor air exchange)


                                         Unconscious
                                                                              5                    Alternate                      No                     No         Yes
                                         Child

                                         Conscious
                                         Infant                              No                      Yes, 5                      Yes                     No         N/A
                                         (poor air exchange)


                                         Unconscious
                                                                             No                      Yes, 5                      Yes                     No         Yes
                                         Infant

                                     ________________________________________
                                     1
                                         AFD/FXN – This summary sheet may be freely copied and distributed for educational purposes but not reprinted for sale.
                                     2
                                         Pregnancy, obesity
                                                                                                                                                                              Medical Operations Manual




Revision 3.0, 2006
Anchorage Fire Department                                                           Medical Operations Manual

                                             Appendix

                                          APGAR Scores
Sign                         0                 1                               2


Heart rate                   Absent            <100                            >100

Resp effort                  Absent            Weak cry                        Strong cry
                                               Hypoventilation                 Good effort

Muscle tone                  Limp              Some flexion                    Active

Reflex                       None              Some motion                     Crying/active
irritability

Color                        Blue/pale         Body pink                       All pink
                                               Extremities blue

                                      Prehospital Index (PHI)
Components                       Value                                    Score

BP                               > 100                                         0
                                 86-100                                        1
                                 75-84                                         2
                                 0-74                                          5

Pulse                            > 120                                         3
                                 51-119                                        0
                                 < 50                                          5

Respirations                     Normal                                        0
                                 Labored / shallow                             3
                                 < 10/min / needs intubation                   5

Consciousness                    Normal                                        0
                                 Confused / combative                          3
                                 No intelligible words                         5

* Note: for penetrating chest or abdominal trauma: give 4 additional points.




Treatment and Medications Protocol                  63                                          Revision 3.0, 2006
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                                     Glasgow Coma Scale
Components                     Value                        Score

Best eye opening               Spontaneous                    4
                               To voice                       3
                               To pain                        2
                               None                           1

Best verbal                    Oriented                       5
                               Confused                       4
                               Inappropriate                  3
                               Moans / unintelligible         2
                               None                           1

Best motor                     Obeys commands                 6
                               Purposeful movement (pain)     5
                               Withdraw (pain)                4
                               Decorticate                    3
                               Decerebrate                    2
                               None                           1




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                                     Adult Burn Chart




Treatment and Medications Protocol          65                      Revision 3.0, 2006
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                                     Child Burn Chart




Treatment and Medications Protocol          66                      Revision 3.0, 2006
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                                     Infant Burn Chart




Treatment and Medications Protocol          67                       Revision 3.0, 2006
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Esophageal Tracheal Airway (Combitube and Combitube SA)

The Esophageal Tracheal Combitube and Combitube SA are
designed for emergency intubation and will provide sufficient ventilation
whether the airway is placed in the esophagus or the trachea. It will be
used in patients without gag reflex with whom endotracheal intubation is
unsuccessful or protracted.

Method
1. Determine appropriate size according to the following illustration:




2. Prepare Combitube for insertion by checking both balloon cuffs.
3. Lift the patient’s tongue and mandible upward and insert the
Combitube into the mouth and along the natural curvature of the
pharynx (A) until the black printed ring is aligned with the teeth.
4. Inflate Line 1, the blue pilot balloon, with 100ml of air using the large
syringe (B). This may cause slight anterior displacement of the tube.
5. Inflate Line 2, the white pilot balloon, with 15ml of air using the small
syringe.
6. Ventilate through the longer blue tube (C). If auscultation of breath
sounds is positive and epigastric sounds are negative the tube is placed
in the esophagus and ventilation should be continued. (Look for chest
rise.)
7. If auscultation of breath sounds is negative and gastric insufflation is
positive immediately switch ventilations to the shorter clear tube (D).
Confirm tracheal placement by auscultation and observation of chest
rise.
8. With normal esophageal placement the included suction catheter can
be passed through the shorter clear tube to reduce gastric insufflation.

Contraindications
1. Persons < 4’ tall.
2. Responsive patients with an intact gag reflex.
3. Patients with known esophageal disease.
4. Patients who have ingested caustic substances.
5. Suspected FBAO.

Precautions
When facial trauma has resulted in sharp broken teeth or dentures,
remove dentures and exercise extreme caution when passing the
Combitube into the mouth to prevent the cuffs from tearing.
Do not force insertion. If tube does not insert easily, redirect or
withdraw and reinsert.



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          Melker™ Cuffed Emergency Cricothyrotomy Catheter Set
Cricothyrotomy, using the Melker™ device, may be used as a last resort for the patient with unrelieved
total upper airway obstruction. The device consists of a scalpel, syringe, introducer needle, wire guide,
curved dilator, cuffed airway catheter, and cloth tape strip (not shown).




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                                     Melker™ Procedure
1. Locate and palpate the crycothyroid membrane between the thyroid and cricoid cartilages (Figure 1).




                                                Figure 1

2. While palpating the cricothyroid membrane and stabilizing the cartilage, use the #15 scalpel to make a
vertical incision over the membrane sufficient to allow passage of the catheter and dilator (Figure 2).




                                                Figure 2




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3. With the supplied syringe attached to the 18g introducer needle, advance the needle through the
                                                    °
incision and cricothyroid membrane midline at a 45 angle to the frontal plane in a caudad direction. The
needle is in the trachea when aspiration on the syringe provides free air return (Figure 3).




                                                Figure 3

4. Remove the syringe, leaving the needle in place. Advance the soft, flexible end of the wire guide
through the needle and several centimeters into the trachea (Figure 4).




                                                Figure 4




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5. Remove the needle, leaving the wire guide in place (Figure 5).




                                                Figure 5

6. Assemble the device by advancing the handled dilator fully into the connector end of the cuffed tube
(Figure 6).




                                                Figure 6




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7. Advance the wire guide through the distal end of the airway catheter until the wire is fully visible at the
handle end. While retaining control of the wire guide, advance the airway catheter completely into the
trachea using pressure on the dilator handle. A water soluble lubricant can be used to enhance fit and
ease placement of the cuffed airway into the trachea (Figure 7).




                                                  Figure 7

8. Remove the wire guide and dilator simultaneously. Inflate the cuff with 8-10 ml of air and secure the
airway with the cloth tape (Figure 8).




                                                  Figure 8




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                            ResQPOD® Circulatory Enhancer
                                     (Airway Impedance Device)




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                        TurkelTM Safety Thoracentesis Catheter
Pleural decompression will be performed on patients with life threatening, progressive respiratory distress
due to suspected tension pneumothorax by inserting a TurkelTM Thoracentesis Catheter into the second
intercostal space on the mid-clavicular line on the affected side.

    1. Prep the insertion site.
    2. Remove the cap from the end of the device
       handle.
    3. Hold the device between the thumb and
       middle finger with the index finger
       supporting the rest of the handle.
    4. Introduce the device into the chest wall
       using sufficient pressure to detect
       movement of the colored indicator within
       the handle. The indicator should change
       from green to red when the blunt cannula
       tip is retracted into the needle and the
       needle is cutting.
    5. Advance the device through the chest wall
       until the indicator changes back to green
       indicating that the tip is no longer
       encountering resistance. A click may be
       heard when this occurs.
    6. Advance the catheter into the pleural space
       and withdraw the needle assembly.
       Entrapped air will escape through the
       catheter sideport valves.

    NOTES: Insertion of the device should be
    made over the top of the third rib, avoiding
    vascular and neural structures within the
    intercostal space adjacent to the caudal edge
    of the second rib.

    If the function of the needle is in doubt, the
    device should be discarded.

    Do not attempt to reinsert the needle assembly
    into the catheter assembly after removal of the
    needle assembly.




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                                Oxylator EM-100 Protocols
Use of the EM-100 Oxylator:

Indications:    The EM-100 Oxylator is designed to be used at any time a Bag-Valve-Mask would be
used. It can be used in place of /or as an alternative to the BVM. The Oxylator can be used with a
cuffed facemask (BVM mask, pocket mask), ET tube, or Nu-trake type device. Both ALS and BLS
technicians may use the EM-100.

Procedure:
BLS   1. Connect the EM-100 directly to the facemask (BVM mask / “rigid” pocket mask).
      2. Assure that the setting of the Pressure release is at 25 cmH2O. ALWAYS RESET TO 25
      cmH2O after use.
      3. With the O2 tank FULLY turned on, depress the Oxygen Release button (the gold button
      marked O2), then turn ¼ turn “clockwise” to lock. This allows a constant flow of ~600 ml of 100%
      O2 / second.
      4. Place the mask on the patient’s face. Make sure that you have a good seal and an open
      airway. The Oxylator will ventilate the patient, and chest rise and fall will begin to occur. The
      Oxylator will cycle on and off. If a stuttering sound is heard or rapid cycling occurs, then turn the
      Oxygen Release button off (“counter-clockwise” ¼ turn), and check for airway blockage or head
      extension. You should then begin to adjust the pressure settings upward from 25 cmH2O in
      increments of 5 cmH2O, turning off the Oxylator between adjusted increments, until cycling
      occurs and the inhalation time achieves 1½ to 2 seconds. Observe for chest rise & fall, and
      color improvement.

ALS     1. Use established procedures to intubate the patient, confirm placement and secure the tube.
        2. Set the pressure Oxylator’s “pop-off” at 30-35 cmH2O to start. ALWAYS RESET TO 25
        cmH2O after use.
        3. OPTIONAL: Attach one end of a disposable extension (an extension that does not have a
        one-way valve) to the Oxylator and the other end to the ET tube. Note: Always make sure of a
        secure tube placement.
        4. Depress the gold button as above, then turn ¼ turn clockwise to lock. This allows a constant
        flow of ~ 600 ml of 100% O2 / second. The Oxylator will ventilate the patient, and chest rise and
        fall will begin to occur. The Oxylator will cycle on and off. If a stuttering sound is heard or rapid
        cycling occurs, then turn the Oxygen Release button off (counter-clockwise ¼ turn), and check
        for airway blockage or kinked tube. You should begin to adjust the pressure settings upward from
        30-35 cmH2O in increments of 5 cmH2O, turning off the Oxylator between adjusted increments,
        until stuttering ceases and/or the inhalation time achieves 1½ to 2 seconds for adults, and 1
        second for children down to 10 Kg. Observe for chest rise & fall, and color improvement, using
        manual ventilation mode, if necessary.
        5. Reconfirm a proper and secure tube placement.

Common Pitfalls
     1. Tank not turned on fully or               Results in longer than normal inhalation
        capacity below 50 PSI                              (I) time due to reduced flow.
     2. ET cuff not fully inflated                Results in longer than normal I time,
                                                  or no automatic cycling at all.
        3. Oxylator “speeds-up”                           Check lung fields, possible right
                                                  mainstem or developing tension-pneumothorax.
        4. Abdomen begins to swell                Check tube placement. If using Combitube, consider
                                                  changing to the other lumen.
        5. Won’t cycle in automatic               Uncuffed tube? If Oxylator will not cycle,
           mode on pediatric patient              then use gold button for manual ventilations.

CPR should be performed using a 15:2 ratio in both the intubated and non-intubated patient. The
Oxylator will not cycle during compressions, therefore, it is necessary to pause for ventilations even
when the patient is intubated. Always allow the Oxylator to fully inflate the lungs (1.5-2 seconds per
ventilation) before resuming compressions.

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Should the patient regain spontaneous respirations, turn the automatic mode off by turning the gold
button counter-clockwise. Immediately turn the black INH button all the way on by turning to the left until
it stops. This allows the Oxylator to deliver 15 LPM constant flow, similar to having the patient on a NRB.
You may assist the patient’s inhalation depth by using the Oxylator’s gold button. When the patient
inhales on his or her own, press the gold button for an assist of approximately one second. When the
patient begins to exhale, the Oxylator will shut down and allow passive exhalation, either when the O2
button is released or after pop-off pressure is attained.

If (while using the automatic or hands-free ventilation mode) the operator observes an inhalation phase
of greater than 2 seconds in an adult or greater than 1 second in a child, then the rescuer is instructed to
use the manually activated mode of ventilation.



                                 FACES Pain Rating Scale




From Wong D.L., Hockenberry-Eaton M., Wilson D., Winkelstein M.L., Schwartz P.: Wong's Essentials of
Pediatric Nursing, ed. 6, St. Louis, 2001, p. 1301. Copyrighted by Mosby, Inc. Reprinted by permission.




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                               Precordial Lead Placement




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                                     12 Lead Waveforms




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                            Capnography Waveform Elements




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                            Capnography Waveform Analysis




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                            VentiSure™ ET CO2 Reference




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                     Section 3: Standing Medication Orders

                                              adenosine
                                               (Adenocard®)

Actions:
A nucleoside found in all cells of the body. It slows conduction time through the AV junction, can interrupt
reentry pathways through the AV junction, and can restore normal sinus rhythm in patients with
paroxysmal supraventricular tachycardia (PSVT).

Indications:
1.Conversion of PSVT. (Will not convert AFib, Aflutter or most VT).

Contraindications:
1. Known hypersensitivity.
2. Second or third degree block (except if functioning pacemaker).
3. Sick sinus syndrome (except if functioning pacemaker).

Side effects and adverse reactions:
CV:     Facial flushing, chest pain, occasional prolonged asystole.
RESP: Shortness of breath, chest pressure. May exacerbate active asthma (contact physician if active
        wheezing).
CNS: Nausea.

Warnings:
1. Obtain 12-lead ECG prior to administration. Run continuous lead I, II, V2 printout during adenosine
   administration.
2. Effect potentiated by dipyridamole (Persantine) and carbamezapine (Tegretol).
3. Effect antagonized by theophyllines.

Adult dose:
IV:    6mg RAPID IVP at site as close to needle hub as possible followed immediately by rapid flush. If
       after 2 minutes second dose is required, increase to 12 mg. May repeat once at 12 mg to a total
       of 30mg. Option: NCT: If adenosine antagonists are present (Theophyllines), contact Physician
            rd
       for 3 dose of 18 mg (total 36 mg).
IM:    NOT given IM

Protocol reference:
ACLS algorithms:
1. NCT.
2. Perfusing WCT.

Pediatric dose:
IV:     0.1 mg/kg, dilute with 4 ml NS to 6 mg/6 ml if patient < 6 kg. May repeat to a total of 3 doses.
        See specific pediatric weight page.

How supplied:
6 mg in 2 ml vial.




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                                               albuterol
                                          (Ventolin®, Proventil®)

Actions:
Primarily a beta-2 sympathomimetic, it produces bronchodilation. Because it is more specific for beta-2
adrenergic receptors than isuprel, it produces fewer cardiovascular side effects and more prolonged
bronchodilation. Onset is within 15 minutes, and it peaks in 60-90 minutes. Therapeutic effects may last
up to 5 hours.

Indications:
Relief of bronchospasm in patients with reversible obstructive airway disease, including asthma.

Contraindications:
History of hypersensitivity.

Side effects and adverse reactions:
CNS: Nervousness, tremor, headache, dizziness, insomnia.
CV: Tachycardia, hypertension, angina.
GI: Drying of oropharynx, nausea, vomiting, and unusual taste.

Warnings:
1. Use cautiously in patients with coronary artery disease, hypertension, hyperthyroidism, and diabetes.
2. Should not be used at the same time as epinephrine. However, either may be used after failure of the
   other.
3. Administer cautiously to patients on MAO inhibitors∗ or tricyclic antidepressants.
4. Beta-blockers and albuterol will inhibit each other.

Adult dose:
2.5-5mg unit dose via nebulizer, as indicated by specific protocol. Add sodium chloride to medication to a
total of 3ml volume of medication and dilutent in nebulizer.

Protocol reference:
1. Asthma, Wheezing, COPD.
2. CHF.
3. Allergy/Anaphylaxis.

Pediatric dose:
Unit dose nebulizer, blow by into face, PRN, in transport.

How supplied:
3ml unit dose (2.5mg albuterol sulfate in 3ml), and/or 20ml multi-use 0.5%, (5mg/ml).




∗
    Common MAO inhibitors include Nardil® (phenilizine) and Parnate® (tranylcypromine).
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                                            amiodarone
                                             (Cordarone®)

Actions:
Amiodarone is a very complex drug with actions upon sodium, potassium and calcium channels as well
as alpha and beta-adrenergic blocking properties.

Indications:
1. Recurrent/Persistent Pulseless VT/VF after defibrillation and epinephrine.
2. Perfusing WCT.

Contraindications:
1. History of hypersensitivity.
2. Cardiogenic shock.
    nd     rd
3. 2 or 3 degree AV block in absence of functioning pacemaker.
4. Sinus Bradycardia

Side effects and adverse reactions:
CV: Hypotension / bradycardia.
Vessels: Can cause sclerosis / phlebitis.

Warnings:
1. Safety in pregnancy not established. May only be given in pregnancy if potential benefit outweighs
   risk to fetus.
2. Torsade des pointes is an uncommon pro-arrhythmic effect usually associated with QTc>450ms.

Adult dose:
IV:    Pulseless VT/VF: 300 mg IVP. May repeat 150 mg after five minutes if necessary for recurrent
       Pulseless VT/VF.
       Perfusing WCT, Torsades with perfusion: 150 mg in 50 ml bag NS administered over
         approximately 10 minutes (50 gtts/min using 10 gtts/ml dripset).
IM:    NOT given IM

Protocol reference:
1. Pulseless VT/VF.
2. Perfusing WCT.
3. Post Resuscitation Care Algorithm.

Pediatric dose:
1. Physician contact required.
2. Pulseless VT/VF: 5 mg/kg IV, IO, SIVP.
3. Perfusing WCT, Torsades with perfusion: 5 mg/kg IV/IO over 10 min. Dilute 150 mg with 50 ml NS.
   and infuse with a volumetric infusion device.

How supplied:
Glass ampule 150 mg total in 3 ml. The drug must be drawn slowly from the ampule directly into the
syringe without a needle to avoid foaming.




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                                                 aspirin
                                         (ASA, acetylsalicylic acid)

Actions:
Inhibits platelet aggregation.

Indications:
Chest pain with suspicion of myocardial infarction or unstable angina.

Contraindications:
1. Active peptic ulcer disease.
2. Sensitivity to aspirin or other nonsteroidal anti-inflammatory.
3. Patient who has already taken aspirin within last 12 hours.

Side effects and adverse reactions:
GI:     Upper GI bleeding, upset stomach.
RESP: Acute bronchospasm in susceptible individuals.

Warnings:
None.

Adult dose:
162mg PO, chewed well.

Protocol reference:
1. Chest pain.
2. CHF.
3. Post Resuscitation Algorithm.

Pediatric dose:
Not indicated.

How supplied:
81 mg chewable tablets.




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                                           atropine sulfate
                                                   (Atropine)

Actions:
Potent parasympatholytic (anticholinergic). By reducing vagal tone it increases automaticity in the SA
node and increases A-V conduction.

Indications:
1. Sinus bradycardia accompanied by hemodynamic compromise: hypotension (SBP < 90); confusion;
    frequent PVCs; pale, cold, clammy skin.
2. Second- and third-degree AV blocks (unless accompanied by wide QRS).
3. Asystole.
4. Pre-medication for pediatric succinylcholine administration.
5. Pesticide exposure and organophosphate exposure (physician contact required).

Contraindications:
None in emergency situations.

Side effects and adverse reactions:
CNS: Restlessness, agitation, confusion, psychotic reaction, pupil dilation, blurred vision, headache.
CV:     Increases heart rates; may worsen ischemia or increase area of infarction; ventricular fibrillation.
GI:     Dry mouth, difficulty swallowing.
GU:     Urinary retention.
Other: Can worsen pre-existing glaucoma.

Warnings:
1. Too small a dose (< 0.02 mg/kg), or normal dose pushed too slowly, may initially cause the heart rate
   to decrease.
2. Potentiated by antihistamines and antidepressants.
3. Do not use in tricyclic antidepressant overdose.
4. May worsen cardiac ischemia.
5. Do not exceed maximum dose of 3 mg IV (6 mg ETT).

Adult dose:
IV:
1. Perfusing bradycardias and blocks, 0.5 mg IV q 3-5 min. to max. 3 mg. ETT: give 1 mg q 3-5 min to
    max. 6 mg.
2. Asystole/PEA: 1 mg IV q 3-5 min, to max 3 mg. ETT: 2 mg q 3-5 min. to max. 6 mg.
3. Organophosphate poisoning may require large doses of atropine: contact medical control
IM: This route may be used in organophosphate exposure: contact medical control.

Protocol reference:
1. ACLS algorithms:
   a. Bradycardia.
   b. PEA.
   c. Asystole.
   d. Post Resuscitation Care Algorithm.

2.   Pediatric pre-medication for paralytic agent, field use.

Pediatric dose:
0.1 mg/kg IV or I0. Minimum dose: 0.1 mg. Maximum single dose 0.5 mg, maximum total 1.0 mg.

How supplied:
1 mg in 10 ml pre-filled syringe.




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                                        calcium chloride
                                                 (CaCl)

Actions:
Has multiple membrane actions in conducting and muscular tissue. Stabilizes irritable myocardium in the
setting of hyperkalemia.

Indications:
1. Unstable arrhythmia in a patient who may be hyperkalemic.
2. Calcium channel blocker overdose with hypotension.

Contraindications:
None in the setting of confirmed hyperkalemia with a sinusoidal cardiac rhythm.

Side effects and adverse reactions:
Integument: Pain at injection site.

Warnings:
1. Rapid injection may cause bradycardia.
2. May worsen digoxin toxicity.
3. Co-administration with sodium bicarbonate will cause precipitation.

Adult dose:
IV:    1 gm SIVP.
IM:    NOT given IM.

Protocol reference:
1. Hyperkalemia.

Pediatric dose:
Not indicated.

How supplied:
1 gm in 10 ml prefilled syringe.




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                                             dextrose 50%
                                             (D50W, D50, D25)

Actions:
A monosaccharide that provides calories for metabolic needs, and spares body proteins and loss of
electrolytes. Readily excreted by kidneys producing diuresis. Hypertonic solution.

Indications:
Hypoglycemia or suspected hypoglycemia.

Contraindications:
None.

Side effects and adverse reactions:
CV:     Thrombosis, sclerosis if given in small peripheral vein.
Integ: Tissue irritation if IV infiltrates. May cause skin necrosis
Other: Acidosis, alkalosis, hyperglycemia, and hypokalemia.

Warnings:
1. May theoretically cause Wernicke-Korsakoff syndrome in acute alcohol intoxication.
2. Theoretically may worsen cerebral edema if present.

Adult dose:
IV:    25 gm (50 ml) IV. Obtain a Glucometer reading (if possible) before administering. Administer with
       running IV fluid. May repeat once if required.
IM:    NOT given IM.

Protocol reference:
1. Unconscious patient unknown etiology.
2. Diabetic Emergencies.
3. Seizures.
4. Blood Glucose Determination.

Pediatric dose:
1 gm/kg SIVP.

Notes:
1. Give as D25 (2 ml/kg diluted with 2 ml/kg NS or sterile water) if weight less than 25 kg, as D50 (2
   ml/kg) if weight 25 kg or greater, to max of 25 gm.
2. Doses are the endpoint. If patient responds to smaller dose during a slow push, stop at that level and
   reassess.

How supplied:
25 gm in 50 ml pre-filled syringe.




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                                         diphenhydramine
                                               (Benadryl®)

Actions:
An antihistamine with anticholinergic (drying) and sedative side effects. Antihistamines appear to compete
with histamine for cell receptor sites on effector cells. Prevents, but does not reverse, histamine mediated
responses, particularly its effects on smooth muscle in the bronchial airways, GI tract, uterus, and blood
vessels.

Indications:
1. Allergy symptoms.
2. Anaphylaxis, as an adjunct to epinephrine.
3. Dystonic (extrapyramidal) and dysphoric reactions associated with use or overdose of phenothiazines
    and related drugs: droperidol, haloperidol, Thorazine, Compazine, Stelazine, metoclopromide
    (Reglan).
4. Adjunct to use of morphine in potentially hypotensive patient (give 12.5-25mg SIVP prior to
    morphine).

Contraindications:
1. Newborn or premature infants.
2. Nursing mothers.
3. Lower respiratory tract symptoms, including asthma.

Side effects and adverse reactions:
CNS: Drowsiness, confusion, insomnia, headache, vertigo, hyperactivity in children.
CV:     Palpitations, tachycardia, PVCs, hypotension.
GI:     Nausea, vomiting, diarrhea, dry mouth, constipation.
GU:     Dysuria, urinary retention.
RESP: Thickening of bronchial secretions, chest tightness, wheezing, nasal stuffiness.

Warnings:
1. In infants and children especially, OD may cause hallucinations, convulsions, or death.
2. May diminish mental alertness in adults and children. In young children, may produce excitation.
3. Have additive effects with alcohol and other CNS depressants (hypnotics, sedatives, tranquilizers,
   etc).
4. More likely to cause dizziness, sedation, and hypotension in the elderly (>60 y/o).

Adult dose:
IV:    25–50 mg IV or deep IM.
IM:    25–50 mg deep IM.

Protocol reference:
1. Allergy/anaphylaxis.
2. Pain management.

Pediatric dose:
IV:     1 mg/kg IV. Maximum: 50 mg per dose.
IM:     1 mg/kg deep IM. Maximum: 50 mg per dose.

How supplied:
50 mg in 1 ml ampule.




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                                              dopamine
                                                (Intropin®)

Actions:
Stimulates dopaminergic, alpha-adrenergic and beta-adrenergic receptors. Inotropic effect increases
cardiac output. Dilates renal and mesenteric vessels at low doses that may not increase heart rate or
blood pressure. Therapeutic doses have predominantly beta adrenergic effects that increase cardiac
output and vital organ perfusion without marked increases in pulmonary occlusive pressure. At high
doses, alpha-receptor stimulation causes peripheral vasoconstriction and marked increases in pulmonary
occlusive pressure.

Indications:
Cardiogenic or vasogenic shock.

Contraindications:
1. Hypovolemia.
2. Pheochromocytoma.

Side effects and adverse reactions:
CNS: Headache.
CV:     Ectopic beats, tachycardia, anginal pain, palpitations, hypotension.
GI:     Nausea, vomiting.
Local: Necrosis and tissue sloughing with extravasation.
Other: Piloerection, dyspnea.

Warnings:
1. Do not administer in the presence of uncorrected tachyarrhythmias or ventricular fibrillation.
2. Inactivated in alkaline solutions.
3. Patients taking monoamine oxidase (MAO)∗ inhibitors will require substantially reduced dosage.

Adult dose:
IV:    Mix 400mg of dopamine in 250ml of NS to yield a concentration of m1600mcg/ml. Begin infusion
       at 5mcg/kg/min and titrate to effect. Dosages of over 20mcg/kg/min have occasionally been
       required. Refer to Dopamine Drip Chart.
IM:       NOT given IM.

Protocol reference:
1. ACLS algorithms:
   a. Bradycardia.
   b. PEA.
2. Hypotension.
3. Post Resuscitation Care Algorithm.

Pediatric dose:
IV:     Mix 150mg (3.75ml) of dopamine in 250ml NS to yield a concentration of 600mcg/ml. Start at
        10mcg/kg/min.If not effective in 3-5 minutes, consider physician contact for permission to
        increase to 20mcg/kg/min.
IM:       NOT given IM

How supplied:
200mg in 5ml ampule.




∗
    Common MAO inhibitors include Nardil® (phenilizine) and Parnate® (tranylcypromine).
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                               Dopamine Drip Chart for Adults

FOR A CONCENTRATION OF 1600 µg of DOPAMINE PER MILLILITER SOLUTION:
400 mg dopamine in 250ml NS.
Body                    Wt. lbs.     110   121   132    143   154   165   176   187   198   209   230   231   242
                        Wt. kgs.     50    55    60     65    70    75    80    85    90    95    100   105   110

µg/min.                     5µg      10    11    11     12    13    14    15    16    17    18    19    20    21
                            6µg      11    13    14     15    16    17    18    19    21    22    23    24    25
                            7µg      13    15    16     17    19    20    21    23    24    25    27    28    29
                            8µg      15    17    18     20    21    23    24    26    28    29    31    32    34
                            9µg      17    19    21     22    24    26    28    29    31    33    34    36    38
                            10µg     19    21    23     25    27    29    31    32    34    36    38    40    42
                            11µg     21    23    25     27    29    32    34    36    38    40    42    44    46
                            12µg     23    25    28     30    32    34    37    39    41    44    46    48    50
                            13µg     25    27    30     32    35    37    40    42    45    47    50    52    55
                            14µg     27    29    32     35    37    40    43    45    48    51    53    56    59
                            15µg     29    32    34     37    40    43    46    49    52    54    57    60    63
                            16µg     31    34    37     40    43    46    49    52    55    58    61    64    67
                            17µg     32    36    39     42    45    49    52    55    58    62    65    68    71
                            18µg     34    38    41     45    48    52    55    58    62    65    69    72    76
                            19µg     36    40    44     47    51    54    58    62    65    69    73    76    80
                            20µg     38    42    46     50    53    57    61    65    69    73    76    80    84
  FLOW RATE IN DROPS PER MINUTE BASED ON A MICRODRIP CALLIBRATION OF 60 DROPS EQUAL 1.O
                                       MILLILITER.


Note: Refer to the Pediatric Weight Pages for pediatric drip rates.




Treatment and Medications Protocol                 92                                         Revision 3.0, 2006
Anchorage Fire Department                                                         Medical Operations Manual


                                              droperidol
                                                          ®
                                                 (Inapsine )

Actions:
Droperidol produces tranquilization and sedation with reduced motor activity and reduced anxiety.
Additionally, droperidol produces alpha adrenergic blockade, which can lead to hypotension.



Indications:
1. Combative patient without any other obvious, reversible reason for the behavior who threatens the
    safety of the crew or who may him/herself be injured in our physical attempts to contain the behavior.

Contraindications:
1. History of hypersensitivity to droperidol or haloperidol.

Side effects and adverse reactions:
CNS:      Extrapyramidal reactions
          Dysphoric reactions
CV:       Hypotension; tachycardia
Resp:     Increased respiratory depression if baseline status is decreased (particularly by other drugs)

Warnings:
1. Hypotensive effect potentiated by hypovolemia
2. Hypotensive effect due to alpha blockade more likely to occur at IV doses > 2mg
3. This drug will generally be given IM! Be sure to reduce dose for IV
4. Reduce dose for small body size, elderly, infirmity
5. Prolonged effect may occur with renal or hepatic failure

Adult dose:

Droperidol 1.25-5.0 mg IM or 1-2mg IV for combativeness. IM May repeat in 10 minutes if not effective.
IV may repeat in 5 minutes if not effective.

Protocol reference:
Combative Patient

Pediatric dose:
Not indicated; call medical control.

How supplied:
5 mg in 2 ml vial




Treatment and Medications Protocol                   93                                         Revision 3.0, 2006
Anchorage Fire Department                                                          Medical Operations Manual


                                       epinephrine 1:1000
                                               (Epi 1:1000)

Actions:
A sympathomimetic that stimulates both alpha and beta-adrenergic receptors. Causes immediate
bronchodilation, increase in heart rate, and increase in the force of cardiac contraction. Subcutaneous
dose lasts 5-15 minutes.

Indications:
1. Asthma.
2. Moderate to severe allergic reaction.
3. Angioneurotic edema.
4. Pediatric cardiac resuscitation.

Contraindications:
1. Hyperthyroidism.
2. Hypertension.
3. Elderly or debilitated patients with underlying cardiovascular disease.

Note: in anaphylaxis, there are no contraindications.

Side effects and adverse reactions:
CNS: Anxiety, headache, cerebral hemorrhage.
CV:     Tachycardia, ventricular dysrhythmias, hypertension, angina, palpitations.
GI:     Nausea and vomiting.

Warnings:
1. Asthmatic patients >55 years of age require Physician contact.
2. Inactivated by alkaline solutions; never mix with sodium bicarbonate.
3. Catecholamine action is depressed by acidosis; attention to ventilation and circulation is essential.
4. Antidepressants potentiate the effects of epinephrine.
5. Causes hyperglycemia.
6. Cannot be given intravenously at this strength.

Adult dose:
SC:    0.3-0.5mg (0.3-0.5ml) SC. May be repeated q15 minutes x 3. Can also be given SL.
IV:    NOT given IV.
IM:    NOT given IM.

Protocol reference:
1. Allergy/anaphylaxis.
2. Asthma.
3. Newborn Care.

Pediatric dose:
SC:     0.01mg/kg SC if patient > 4 kg. Maximum: 0.3mg.
IV:     NOT given IV.
IM:     NOT given IM.
ET      In cardiac resuscitation, 0.1 mg/kg flushed with 3-5 ml NS.

How supplied:
1mg in 1 ml ampule.




Treatment and Medications Protocol                  94                                          Revision 3.0, 2006
Anchorage Fire Department                                                          Medical Operations Manual

                                      epinephrine 1:10,000
                                              (Epi 1:10,000)

Actions:
A sympathomimetic that stimulates both alpha and beta-receptors. Increases myocardial and cerebral
blood flow during ventilation and chest compression. Increases systemic vascular resistance and thus
may enhance defibrillation.

Indications:
1. Asystole.
2. Ventricular fibrillation unresponsive to defibrillation.
3. Pulseless ventricular tachycardia (including pulseless WCT) unresponsive to defibrillation
4. PEA.
5. Anaphylaxis with cardiovascular collapse (diluted; see epi 1:100,000).
6. Additional pediatric indications:
    a. Hypotension with circulatory instability.
    b. Bradycardia unresponsive to atropine.
    c. Initial treatment of bradycardia in neonates.

Contraindications:
None in these situations.

Side effects and adverse reactions:
CNS: Anxiety, headache, cerebral hemorrhage.
CV:     Tachycardia, ventricular dysrhythmias, hypertension, angina, palpitations.
GI:     Nausea and vomiting.

Warnings:
1. Inactivated by alkaline solutions; never mix with sodium bicarbonate.
2. Catecholamine action is depressed by acidosis; attention to ventilation and circulation is essential.
3. Antidepressants potentiate the effects of epinephrine.
4. Causes hyperglycemia.

Adult dose:
IV:    1mg IV. By ETT, give double dose: 2mg . May repeat every 5 minutes.
IM:    NOT given IM.

Protocol reference:
1. Allergy/anaphylaxis (see epi 1:100,000).
2. ACLS algorithms:
   a. Asystole.
   b. PEA.
   c. Pulseless VT/VFib (including Pulseless WCT).
3. Newborn Care, Bradycardia.

Pediatric dose:
IV:     0.01mg/kg (0.1ml/kg) IV or I0. Repeat every 5 minutes as necessary.
IM:     NOT given IM.

How supplied:
1mg in 10ml prefilled syringe.




Treatment and Medications Protocol                  95                                          Revision 3.0, 2006
Anchorage Fire Department                                                          Medical Operations Manual

                                     epinephrine 1:100,000
                                              (Epi 1:100,000)

Actions:
Provides vascular tone, inotropic support, and bronchodilatation in the setting of an acute hypersensitivity
reaction with anaphylactic shock.

Indications:
Anaphylactic shock.

Contraindications:
None in this setting.

Side effects and adverse reactions:
CNS: Anxiety, headache, cerebral hemorrhage.
CV:     Tachycardia, ventricular dysrhythmias, hypertension, angina, palpitations.
GI:     Nausea and vomiting.
Integ: Skin sloughing if IV extravasates.

Warnings:
1. Epinephrine is inactivated by alkaline solutions; never mix with sodium bicarbonate.
2. Catecholamine action is depressed by acidosis; attention to ventilation and circulation is essential.
3. Antidepressants potentiate the effects of epinephrine.
4. Causes hyperglycemia.

Adult dose:
In a 10ml syringe, draw 1 ml from an epi 1:10,000 preload and 9ml of NS . Administer as slow, continuous
IV push, titrating against symptoms. May repeat dose as needed.

Protocol reference:
1. Allergy/anaphylaxis.

Pediatric dose:
Same as for adults.

How supplied:
1 mg in 10 ml prefilled syringe




Treatment and Medications Protocol                   96                                         Revision 3.0, 2006
Anchorage Fire Department                                   Medical Operations Manual

                                              etomidate
                                               (Amidate®)

Actions:
Ultrashort acting non-barbiturate hypnotic.

Indications:
1. Sedation prior to paralytic assisted intubation
2. Sedation prior to emergency synchronized cardioversion

Contraindications:
1. Known allergy to etomidate

Side effects and adverse reactions:
CV:     Usually no effect
RESP: Usually no effect
Neuro: Involuntary muscle movements
Other: Pain on injection
GI:     May cause GI discomfort; hiccoughs

Warnings:
1. For use for age>10

Adult dose:
IV:
1. 0.3mg/kg SIVP over 15-60 sec
IM: not recommended

Protocol reference:

1. Rapid Sequence Intubation
2. Narrow Complex Tachycardia Algorithm
3. Perfusing Wide Complex Tachycardia Algorithm

Pediatric dose:
0.3mg/kg for age >10

How supplied:
Injectable 2mg/ml




Treatment and Medications Protocol                97                    Revision 3.0, 2006
Anchorage Fire Department                                                          Medical Operations Manual

                                               fentanyl
                                               (Sublimaze®)

Actions:
Potent opiate analgesic with same mechanism of action as other narcotic analgesics. Onset of action is
almost immediate, duration of action is 30-60 minutes.
Indications:
1. Patients suffering from severe pain in whom a shorter duration of narcotic effect is desired, e.g.,
    patients suffering from multiple trauma, head injury and abdominal pain.

Contraindications:
1. History of hypersensitivity to opiates.

Side effects and adverse reactions:
CNS:      Sedation
CV:       Hypotension; bradycardia
Resp:     Respiratory depression, apnea

Warnings:
1. Rapid infusion can lead to chest wall spasm, muscle rigidity
2. Dosage units are MICROGRAMS
3. Do not use if patient is taking MAOI

Adult dose:
1 microgram/kg SIVP. May repeat x1 if ineffective after 5 minutes or effect wanes during transport.

Protocol reference:
Pain Management.

Pediatric dose:
1 microgram/kg SIVP (titrate to 1 microgram/kg total dose)

How supplied:
100 microgram in 2 ml




Treatment and Medications Protocol                  98                                          Revision 3.0, 2006
Anchorage Fire Department                                                          Medical Operations Manual

                                             furosemide
                                                  (Lasix®)

Actions:
A sulfonamide derivative and potent diuretic that inhibits the re-absorption of sodium and chloride in the
proximal and distal renal tubules, and in the Loop of Henle. With IV administration, onset of diuresis is
within 5 minutes, peak is in 30 minutes; and duration is 2 hours.

Indications:
1. Pulmonary edema.
2. Hypertension (at physician request only).

Contraindications:
1. Anuria.
2. Relative contraindications:
   a. Allergy to sulfa. If previous reaction was minor, consider the risks versus benefit to the patient.
   b. Pregnancy. Use only when benefits clearly outweigh risks.

Side effects and adverse reactions:
CNS: Dizziness, tinnitus, hearing loss, headache, blurred vision, weakness.
GI:     Anorexia, vomiting, nausea.
CV:     Hypotension.
Other: Pruritus, urticaria, muscle cramping.

Warnings:
1. Rapid infusion and high doses (>100 mg) can cause tinnitus and inner ear damage.
2. Should be stored to protect it from light.
3. Dehydration and electrolyte imbalance can result from excessive dosages.
4. Rapid diuresis can lead to hypotension.

Adult dose:
IV:    40 mg SIVP. If patient is on maintenance dosage, may increase dose to 80 mg SIVP. For repeat
       doses, physician contact required.
IM:    NOT given IM.

Protocol reference:
CHF.
Hypertension.

Pediatric dose:
IV:     0.5-1 mg/kg IV slowly over 1-2 minutes.
IM:     NOT given IM.

How supplied:
40 mg in 4 ml prefilled syringe.




Treatment and Medications Protocol                   99                                         Revision 3.0, 2006
Anchorage Fire Department                                                          Medical Operations Manual

                                              glucagon
                                                (Glucagon)

Actions:
Produced naturally in the pancreas by alpha cells in the islets of Langerhans. Acts only on liver glycogen,
converting it to glucose. Increases blood glucose concentrations. Effective in small doses. No toxicity
problems have been reported.

Indications:
1. Hypoglycemia when IV access is not available.
2. Symptomatic β-blocker overdose*
3. Symptomatic Calcium-channel blocker overdose*

Contraindications:
Hypersensitivity to glucagon.

Side effects and adverse reactions:
GI:     Occasionally causes nausea and vomiting.

Warnings:
1. Use caution in patients with a history of insulinoma or pheochromocytoma.
2. Response for hypoglycemia may take up to 20 minutes.
3. Depletes liver glycogen stores. Increased carbohydrate intake is important, as is transport after
   administration.

Adult dose:
IV, IM, SC: 1.0 unit of glucagon IV, IM, or SC. Can be repeated once. *

Protocol reference:
1. Diabetic Emergencies.
2. Asystole.
.
Pediatric dose:
IV, IM, SC: 0.05 mg/kg IV, IM, or SC. Maximum:1 mg.*

*Doses required for treatment of calcium channel blocker or β-blocker OD may be much higher than listed
here. Start with above listed doses and if OD is strongly suspected, contact medical control.

How supplied:
1 unit (1 mg) glucagon in dry powder form and 1ml diluting solution.




Treatment and Medications Protocol                  100                                         Revision 3.0, 2006
Anchorage Fire Department                                                      Medical Operations Manual

                                          glucose, oral
                                           (Insta-glucose ®)

Actions:
A monosaccharide that provides calories for metabolic needs, and spares body proteins and loss of
electrolytes. Readily excreted by kidneys producing diuresis. Hypertonic solution.

Indications:
Hypoglycemia or suspected hypoglycemia in alert patient.

Contraindications:
None.

Side effects and adverse reactions:
None

Warnings:
None

Dose:
Swallow one tube. If no improvement in 10 minutes, repeat.

Protocol reference:
Diabetic Emergencies.
Blood Glucose Determination.

How supplied:
Insta-Glucose containing 30 grams of glucose and 24 grams of carbohydrate.




Treatment and Medications Protocol               101                                        Revision 3.0, 2006
Anchorage Fire Department                                                               Medical Operations Manual

                                                lidocaine
                                                (Xylocaine®)

Actions:
Decreases ventricular automaticity and raises the ventricular fibrillation threshold.

Indications:
1. PVCs >6/min.,R-on T phenomenon, multifocal, or in bursts of 2 or more in setting of possible
    myocardial ischemia.
2. Ventricular fibrillation and pulseless WCT (second line to amiodarone).

Contraindications:
1. Heart blocks:
   a. Second-degree, Mobitz II.
   b. Complete AV block.
   c. Stokes-Adams syndrome.

2. Allergy to amide-type local anesthetics (not Novacaine [procaine ]).

Side effects and adverse reactions:
CV:     Rarely with toxic levels, causes hypotension, QRS widening, bradycardia, cardiac arrest.
RESP: At toxic levels, respiratory depression or arrest.

Warnings:
1. If PVCs occur in conjunction with symptomatic sinus bradycardia, treat the bradycardia first.
2. Metabolized in the liver. Note dosage for liver failure, low cardiac output, and patients >70 years of
   age.

Adult dose:
1. PVCs >6/min.,R-on T phenomenon, multifocal, or in bursts of 2 or more in setting of possible
   myocardial ischemia, 1.0mg/kg, repeat with 0.5 mg/kg q5-10 minutes if necessary to a total of 3
   mg/kg.
2. Pulseless VT/VF with NO IV established: 3mg/kg ETT, Rebolus 3mg/kg q 5-10min. Maximum 6mg/kg
   ETT.
3. Liver failure, low cardiac output, patient >70 y/o: give normal 1mg/kg IV bolus dose, but repeats are at
   0.25mg/kg.

IM: NOT given IM

Protocol reference:
1. Pulseless V Tach/V Fib Algorithm
2. Post Resuscitation Care Algorithm

Pediatric dose:
1mg/kg IV/IO bolus. Not allowed below 3 kg. Can be repeated twice.

How supplied:
100mg in 10ml (1%) or 100mg in 5ml (2%) prefilled syringe.




Treatment and Medications Protocol                   102                                            Revision 3.0, 2006
Anchorage Fire Department                                                          Medical Operations Manual

                                              lorazepam
                                                 (Ativan)

Actions:
A benzodiazepine that depresses the limbic system, thalamus, and hypothalamus, resulting in calming
effects. Produces an amnesic effect, suppresses seizures, is an antiemetic, and is also a muscle
relaxant.

Indications:
1. Status epilepticus.
2. Adjunct to cardiac pacing to alleviate anxiety in conscious patient.
3. Post-intubation sedation.
4. Sedation of TBI patient.


Contraindications:
(Relative): Alcohol or other sedatives may exaggerate and prolong sedative effect

Side effects and adverse reactions:
CNS:     Confusion, muscular weakness, blurred vision, slurred speech, drowsiness,
CV:      Respiratory depression can occur (1%). Hypotension is very rare (0.1%)


Adult dose:
IV: 1-2 mg diluted with 1 ml sodium chloride, SIVP.
Repeat up to additional 2 mg if seizure persists after 5 minutes
Additional dose of 2 mg can be given in the intubated patient if required due to agitation (must be first
verified that agitation is not due to correctable hypoxemia or complication of tube placement). Total for the
intubated patient not to exceed 4mg without physician contact.
IM: 2 mg, may repeat x1 as above

Protocol reference:
1. Seizures.
2. Traumatic Brain Injury.
3. Post Resuscitation Care Algorithm.


Pediatric dose:
IV:      0.05-0.1 mg/kg SIVP titrated to effect (max 2 mg).
         Repeat dose if seizure persists after 5 minutes.
IM:      0.1 mg/kg, may repeat x1 as above.

How Supplied:
2 mg/ml injectable




Treatment and Medications Protocol                  103                                          Revision 3.0, 2006
Anchorage Fire Department                                                           Medical Operations Manual

                                       magnesium sulfate
                                                  (MgS04)

Actions:
The mechanisms of action in arrhythmias and eclampsia are not fully understood. They are thought to be
caused in part by magnesium s effect on chronotropy and smooth muscle tone.

Indications:
1. Refractory VFib or pulseless WCT: last line.
2. Torsade de pointes: first line if known hypomagnesemia or preexistent prolonged QT.
3. Perfusing WCT.
4. Eclampsia.

Contraindications:
1. Heart block.
2. Hypermagnesemia.

Side effects and adverse reactions:
CV:     Heart block, flushing, bradycardia, hypotension.

Warnings:
1. May cause respiratory depression.
2. MgS04 is hyperosmolar and must be diluted to prevent red blood cell damage.

Adult dose:
IV:
1. Torsades, refractory VF/WCT: 1gm of MgS04 in 100 ml of NS (Pre-mix) Run drip at full flow. May
    repeat x1 in 2 min.
2. Eclampsia: 3 gms added to pre-mix (above) titrated to cessation or maximum of 4 gm.

IM: painful; absorption may not be fast enough to effect arrhythmia. Contact medical control if this route is
necessary.

Protocol reference:
1. Obstetrics: Pre-eclampsia and eclampsia.
2. ACLS algorithms:
   a. VT/VF
   b. Perfusing WCT

Pediatric dose:
Not indicated.

How supplied:
1. 1 gm in 100 ml pre-mix bag.
2. 5 gm in 10 ml vial.




Treatment and Medications Protocol                  104                                          Revision 3.0, 2006
Anchorage Fire Department                                                        Medical Operations Manual

                                        morphine sulfate
                                                  (MS)

Actions:
A narcotic analgesic that depresses the central nervous system and suppresses pain by binding at opioid
receptors in the brain. Increases venous capacitance, decreases venous return, and produces mild
peripheral vasodilatation. Also decreases myocardial oxygen demand.

Indications:
1. Pain from acute MI.
2. Pulmonary edema.
3. Pain from other sources.

Contraindications:
1. Acute abdomen.
2. Volume depletion or hypotension.
3. Head trauma (GCS<13).
4. Acute substance abuse.
5. Acute asthma.
6. History of hypersensitivity to opiates.
7. Multiple trauma: excluding isolated extremity fractures.

Side effects and adverse reactions:
CNS: Euphoria, drowsiness, pupillary constriction, respiratory arrest.
CV:     Bradycardia, hypotension.
GI:     Decreases gastric motility; may cause nausea and vomiting.
GU:     Urinary retention.
RESP: Bronchoconstriction, decreased cough reflex.

Warnings:
1. Detoxified by the liver.
2. Potentiated by alcohol, antihistamines, barbiturates, phenothiazines, and other sedatives.

Adult dose:
IV:    2-5 mg IV, slowly. Repeat with small increments every 5 minutes until desired response is
       achieved. Adult maximum 15 mg. Physician contact required for larger doses.
IM:     5 mg-15 mg IM. Adult maximum 15 mg. Physician contact required for larger doses.

Protocol reference:
1. Chest Pain.
2. CHF.
3. Pain Management.
4. Transcutaneous pacing.

Pediatric dose:
0.1 mg/kg SIVP. Can also be given IM or SC. Can be repeated once. Not given to patient under 4 kg in
weight.

How supplied:
10 mg in 2 ml Carpuject® (1 ml of solution).




Treatment and Medications Protocol                 105                                          Revision 3.0, 2006
Anchorage Fire Department                                                          Medical Operations Manual

                                               naloxone
                                                (Narcan®)

Actions:
The mechanism of action is not fully understood. It does appear that Narcan antagonizes the effects of
opiates by competing at the same receptor sites. When given IV, the action is apparent within two
minutes. IM or SC administration is slightly less rapid.

Indications:
1. Complete or partial reversal of respiratory depression secondary to narcotics or related drugs.
2. Suspected acute opiate overdose.

Contraindications:
Hypersensitivity.

Warnings:
1. Caution in newborns of mothers who are known or suspected to be physically dependent on opiates;
   may precipitate an acute abstinence syndrome.
2. Duration of action of some narcotics may exceed that of Narcan; may need to be repeated.
3. Not effective for respiratory depression caused by non-opioid drugs.
4. Patient may become violent as level of consciousness increases.
5. May precipitate acute narcotic withdrawal in opiate addicted patient. Symptoms could include:
   CNS: Tremor, agitation, belligerence, pupillary dilation, seizures, increased tear production, sweating.
   CV: Hypertension, hypotension, ventricular tachycardia, pulmonary edema, ventricular fibrillation.
   GI: Nausea, vomiting.
6. Large doses may be required in propoxyphene overdose (Darvon ®, Darvocet ®).

Adult dose:
IV, IN, IM, SC, SL: 2 mg IV, IM, SC or SL injection. May repeat in 2-3 minutes. If no response after 10mg,
then condition probably not due to narcotic.

Note:
If patient has a high likelihood a narcotic addiction (based upon physical stigmata, other informants at
scene, etc) and the situation is stable, consider using smaller doses of naloxone (e.g.0.4-0.8 mg) to
stimulate respirations yet avoid abrupt withdrawal.

Protocol reference:
1. Unconscious patient unknown etiology.

Pediatric dose:
IV, IM, SC: 0.1 mg/kg IV, I0, IM, or SC. Can be repeated as needed if no improvement is noted.

How supplied:
Ampules:
1. 0.4 mg in 1 ml (0.4 mg/ml).
2. 4 mg in 10 ml (0.4 mg/ml).
3. 2 mg in 1 ml (2.0 mg/ml).
4. 2 mg in 2 ml syringe.




Treatment and Medications Protocol                  106                                          Revision 3.0, 2006
Anchorage Fire Department                                                            Medical Operations Manual

                                             nitroglycerin
                                            (Nitrolingual® spray)

Actions:
A direct vasodilator that acts primarily on the venous system, although it also produces direct coronary
artery vasodilatation. Causes a decrease in venous return that also decreases workload on the heart and
thus myocardial oxygen demand. Sublingual spray is preferred over tablets because it is more reliably
absorbed and bio-available.

Indications:
1. Ischemic chest pain.
2. Pulmonary edema.
3. Severe hypertension (not generally recommended; physician contact required).

Contraindications:
1. Increased intracranial pressure.
2. SBP <90.
3. Children under 12.
4. Viagra (sildenafil), Levitra (vardenafil), or Cialis® (tadalafil) use in past 24 hours.

Side effects and adverse reactions:
CNS: Headache, dizziness, flushing, nausea, and vomiting.
CV: Hypotension, reflex tachycardia.

Warnings:
1. Because of an easily developed tolerance, patients on chronic nitrate therapy may require larger
   doses of nitroglycerin during acute anginal episodes.
2. Light, air and moisture inactivate Nitro tablets. Must be kept in amber glass containers with tight-fitting
   lids. Do not leave cotton in container. Once opened, nitroglycerine has a shelf life of 3 months.
3. Nitrospray has a shelf- life of 1 to 2 years.
4. Alcohol will accentuate vasodilating and hypotensive effects.

Adult dose:
1 metered dose sublingually (0.4mg). May repeat PRN at 3-5 minutes intervals. Hold canister upright. Do
not shake. At the onset of attack, 1 or 2 metered doses to be sprayed into mouth. Blood pressure and
relief of pain limit dosing, otherwise no upper limit to number of doses.

Notes:
Position the canister as close as possible, press button firmly to release spray onto or under tongue.
Advise patient not to inhale spray.
Establish IV access before or concurrent with NTG administration.

Protocol reference:
1. Chest pain.
2. CHF.
3. Hypertension.

Pediatric dose:
Not indicated.

How supplied:
0.4 mg (400 ug) per metered dose spray.




Treatment and Medications Protocol                   107                                          Revision 3.0, 2006
Anchorage Fire Department                                                          Medical Operations Manual

                                           nitrous oxide
                                             (Nitronox®, NO2)

Actions:
A colorless gas that acts on the central nervous system. When mixed with 50%oxygen and inhaled, it
produces an effect similar to a mild intoxicant. The patient laughs and talks but does not go to sleep.
When inhaled, nitrous has a potent analgesic effect that dissipates within 2-5 minutes after stopping
administration.

Indications:
Moderate to severe pain, such as that caused by trauma, acute MI, burns, acute abdomen.

Contraindications:
1. Any altered state of consciousness, such as alcohol ingestion, drug OD.
2. Trapped gas conditions: COPD patients, acute pulmonary pneumothorax, or suspected intestinal
   blockage.
3. Pregnancy.

Side effects and adverse reactions:
CNS: Light-headedness, confusion, drowsiness, nausea, vomiting.

Warnings:
Since nitrous is heavier than air, it may accumulate on floor of ambulance. During transports of more than
15 minutes, it may affect ambulance personnel.

Adult dose:
Self-administered through inhalation. Also apply 02 cannula at 4 -6 LPM to maintain 02 therapy when
Nitrous is not being administered.

Protocol reference:
1. Chest Pain.
2. Pain.
3. Transcutaneous Pacing.

Pediatric dose:
Same as adult.

How supplied:
Blended mixture of 50% nitrous oxide and 50% oxygen. One oxygen and one nitrous oxide cylinder fed
into a regulator that maintains the appropriate concentration.




Treatment and Medications Protocol                  108                                         Revision 3.0, 2006
Anchorage Fire Department                                                         Medical Operations Manual

                                              oxytocin
                                                (Pitocin®)

Actions:
Selectively affects uterine smooth muscle. Stimulates rhythmic contractions of the uterus, increases the
frequency of existing contractions, and raises the tone of uterine muscle.

Indications:
1. Uncontrolled postpartum hemorrhage.
2. To increase uterine tone after delivery.

Contraindications:
1. Not to be administered before delivery of both baby and placenta.
2. Cardiovascular disease.

Side effects and adverse reactions:
CNS: Cerebral hemorrhage.
CV:     Hypertensive crises.
OB:     Uterine rupture.
Neon: Fetal death.

Warnings:
None other than those above.

Adult dose:
IV:
1. Hemorrhage: add 10 u. to 1 liter NS and titrate to a firm uterus. Use second IV line for volume
    replacement.
2. Post-partum: add 10 u. to 1 liter NS and run at 125 ml/hr.
IM: 10 u.

Protocol reference:
1. OB: childbirth.
2. OB: Postpartum Hemorrhage.

Pediatric dose:
Not indicated.

How supplied:
10 units in 1 ml ampule.




Treatment and Medications Protocol                 109                                         Revision 3.0, 2006
Anchorage Fire Department                                                       Medical Operations Manual

                                       phenylephrine HCL
                                       (Neo-synephrine nasal spray)

Actions:
Topical vasoconstrictor.

Indications:
1. Epistaxis.
2. Pretreatment for nasal endotracheal intubation.


Contraindications:
1. Known sensitivity to the product.
2. Systolic BP>220 and/or Diastolic BP>110.
3. Severe coronary artery disease.
4. Use of monoamine oxidase inhibitor within 14 days.∗

Side effects and adverse reactions:
CV: Possible increase in blood pressure.


Warnings:
None.

Adult dose:
3 sprays to nostril(s).

Protocol reference:
1. Epistaxis.
2. Nasal endotracheal intubation.

Pediatric dose:
Not indicated below age12. Adult dose for age>12.

How supplied:
Spray bottle.




∗
    Common MAO inhibitors include Nardil® (phenilizine) and Parnate® (tranylcypromine).
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                                      sodium bicarbonate
                                                (NaHCO3)

Actions:
An alkalizing agent used to buffer acids. Bicarbonate combines with excess acid (usually lactic acid)
present in the body to form a weak, volatile acid. This acid is broken down into C02 and H20.

Indications:
1. Cardiac arrest, prolonged resuscitation.
2. Hyperkalemia (second line to CaCl2 if cardiac arrest or bizarre/sinusoidal rhythm).
3. Tricyclic overdose with cardiac manifestations.

Contraindications:
None in these settings.

Side effects and adverse reactions:
Other: Metabolic alkalosis, hypernatremia, cerebral acidosis, sodium and H20 retention that can lead to
CHF.

Warnings:
1. May inactivate catecholamines given at the same time.
2. Will precipitate if mixed with calcium chloride.

Adult dose:
Cardiac arrest:
1 mEq/kg IV. Repeat at 0.5 mEq/kg q 10 minutes, to a maximum of 250 mEq.
Hyperkalemia:
50 mEq IVP. Limit to single dose in hyperkalemia.
TCA OD:
50 mEq IVP. Limit to single dose in TCA OD.

Protocol reference:
1. ACLS algorithms:
   a. Asystole.
   b. PEA.
   c. VF (including Pulseless WCT).
2. Hyperkalemia.
3. Tricyclic OD.

Pediatric dose:
1 mEq/kg IV. Can repeat twice at 0.5 mEq/kg q 10 minutes. (Dilute to half strength in neonatal
resuscitation).

How supplied:
50 mEq in 50 ml prefilled syringe.




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                                         succinylcholine
                                         (Organon®, Anectine®)

Actions:
A short acting neuromuscular blocking agent that acts at the motor endplate.

Indications:
To establish an airway in a patient in imminent danger because of an uncontrolled airway or ventilatory
insufficiency, in whom other methods for securing the airway have been unsuccessful or are obviously
impractical or impossible.

Contraindications:
1. Upper airway obstruction.
2. Probable inability to intubate afterward because of very unfavorable anatomical characteristics, or
   face or neck trauma.
3. History of malignant hyperthermia.
4. Patient who is 24 hours post-spinal cord injury, severe burn or crush injury.
5. Known hyperkalemia.
6. Known myopathy (personal or family history of disease of muscles).

Side effects and adverse reactions:
CV:     Bradycardia; may be severe in pediatrics.
Neuro: Prolonged paralysis will occur in persons lacking pseudocholinesterase.

Warnings:
1. A second dose of succinylcholine is more likely to cause bradycardia.
2. Succinylcholine must be administered per the Rapid Sequence Intubation Protocol. Usage form must
   be sent to the medical director after each use.

Adult dose:
IV:    1.5 mg/kg IVP.
IM:    Do not give without IV access.

Protocol reference:
Rapid Sequence Intubation with Neuromuscular Blockade.

Pediatric dose:
2 mg/kg (to 35 kg as per Peds SO) IVP, after pre-medication with atropine (.02 mg/kg IV).

How supplied:
200 mg in 10 ml.




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                                              tetracaine
                                                (Alcaine®)

Actions:
A local anesthetic for topical ophthalmologic use.

Indications:
Short-term relief of pain caused by corneal injuries such as flash burns, corneal abrasions, and chemical
exposures.

Contraindications:
1. Penetrating eye injuries.
2. Allergy to local anesthetics.

Side effects and adverse reactions:
None.

Warnings:
1. Administer ONLY to patients who are being transported by AFD.
2. Use only on patients who can open the eye spontaneously.
3. Advise patient to avoid touching the eye while anesthetized.
4. Do NOT give unused portion to patient.

Adult dose:
2 drops in affected eye. May repeat once.

Protocol reference:
1. Eye injury.
2. Pain Management.

Pediatric dose:
2 drops in affected eye. May repeat once.

How supplied:
15 ml squeeze bottle of 0.5%solution.




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                                            vasopressin
                                              (Vasopressin®)

Actions:
Vasopressin (arginine vasopressin, AVP; antidiuretic hormone, ADH) is a hormone released from the
posterior pituitary. AVP has two principle sites of action: kidney and blood vessels. AVP increases
water reabsorption by the kidneys. This is the antidiuretic effect of AVP. This hormone also constricts
arterial blood vessels, contributing to an increase in systemic vascular resistance during heart failure,
thus increasing coronary perfusion without the beta adrenergic effects of epinephrine.

Indications:
Asystole.

Contraindications:
None in the above setting.

Side effects and adverse reactions:
None in the above setting.

Warnings:
No demonstrated benefits in pulseless VT/VF.

Adult dose:
40 iu IVP. Repeat in 3 minutes.

Protocol reference:
Asystole Algorithm.

Pediatric dose:
Not recommended.

How supplied:
20 iu in 1 ml vials.




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                                 Pediatric Weight Pages

                                                 2.2 pounds                                               1kg
Adenocard       dilute with 4 ml NS to 6 mg/6 ml, 0.1 mg = 0.1 ml
                rpt q 3 min x 2 @ 0.2 mg = 0.2 ml
Albuterol-neb   not allowed
Amiodarone      5 mg. Physician contact required.
Atropine        not allowed
Benadryl        not allowed
D50W            dilute 50%, 0.5 g = 2 ml D25W q 10 min x 1 rpt
Dopamine        10 mcg/min = 1 gtt/60 seconds (Mix 150mg (3.75ml) of dopamine in 250ml NS)
Epi 1:1,000     Asthma not allowed
                0.1 mg = 0.1 ml ET & Rpt ET dose in arrest q 3-5 min
Epi 1:10,000    0.01 mg = 0.1 ml IV/IO dose in arrest and bradycardia
Glucagon        0.05 mg = 0.05 ml
Lorazepam       0.05-0.1 mg (0.025-0.05 ml diluted in 0.025-0.05 ml NS) SIVP titrated to effect; repeat in 5
                min. if seizure persists. 0.1 mg IM (0.05 ml); repeat x 1 in 5 min. if seizure persists.
Lidocaine       not allowed
Morphine        not allowed
Narcan          0.1 mg = 0.25 ml q 3 min prn
Nitronox        not allowed
Tetracaine      not allowed
Sodium          dilute 50% ,1 mEq = 2ml, may repeat 0.5 mEq diluted 50% to 1ml q 10 minutes x 2
Bicarb
Sux             2 mg = 0.1ml
Fluid Bolus     10 ml q 5-10 min x 2 rpt
Synch CV        not allowed
Defib           5 joules rpt @ 5 joules
Pacing          140/min; begin @ 60 mA
ET tube         2.5 / ETCO2 Detector: not allowed
Gastric tube:   orogastric only
VS -->          HR: 110 - 160 BP: 36 /14 - 58/36         R: 30 - 60




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                                                  4.4 pounds                                    2 kg
Adenocard       dilute with 4 ml NS to 6 mg/6 ml, 0.2 mg = 0.2 ml
                rpt q 3 min x 2 @ 0.2 mg = 0.4 ml
Albuterol-neb   not allowed
Amiodarone      10 mg. Physician contact required.
Atropine        not allowed
Benadryl        not allowed
D50W            dilute 50%, 1 g = 4ml D25W q 10 min x 1 rpt
Dopamine        20 mcg/min = 1 gtt/ 30 seconds (Mix 150mg (3.75ml) of dopamine in 250ml NS)
Epi 1:1,000     Asthma not allowed
                0.2 mg = 0.2 ml initial ET & Rpt ET dose in arrest q 3-5 min
Epi 1:10,000    0.02 mg = 0.2 ml IV/IO dose in arrest and bradycardia
Glucagon        0.1 mg = 0.1 ml
Lorazepam       0.1-0.2 mg (0.05-0.1 ml diluted in 0.05-0.1 ml NS) SIVP titrated to effect; repeat in 5 min.
                if seizure persists. 0.2 mg IM (0.1 ml); repeat x 1 in 5 min. if seizure persists.
Lidocaine       not allowed
Morphine        not allowed
Narcan          0.2 mg = 0.5 ml q 3 min prn
Nitronox        not allowed
Sodium          dilute 50% , 2 mEq = 4ml, may repeat 0.5 mEq diluted 50% to 2ml q 10 minutes x 2
Bicarb
Sux             4 mg = 0.2 ml
Tetracaine      not allowed
Fluid Bolus     10 ml/kg = 20 ml q 5-10 min prn x 2 rpt
Synch CV        not allowed
Defib           5 joules rpt @ 10 joules
Pacing          140/ min; begin @ 60 mA
ET Tube         2.5 or 3.0 / ETCO2 Detector: Not allowed
Gastric tube    orogastric only
VS -->          HR: 110 - 160        BP: 44/22 - 66/42         R: 30 - 60




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                                                 7 pounds                                                3 kg
Adenocard       dilute with 4 ml NS to 6 mg/6 ml, 0.3 mg = 0.3 ml
                rpt q 3 min x 2 @ 0.6 mg = 0.6 ml
Albuterol-neb   not allowed
Amiodarone      15 mg. Physician contact required.
Atropine        not allowed
Benadryl        not allowed
D50W            dilute 50%,1.5 g = 6 ml D25W q 10 min x 1 rpt
Dopamine        30 mcg/min = 1 gtt/20 seconds (Mix 150mg (3.75ml) of dopamine in 250ml NS)
Epi 1:1,000     Asthma not allowed
                0.3 mg = 0.3 ml initial ET & Rpt ET dose in arrest q 3-5 min
Epi 1:10,000    0.03 mg = 0.3 ml IV/IO dose in arrest and bradycardia
Glucagon        0.15 mg = 0.15 ml
Lorazepam       0.15-0.3 mg (0.075-0.15 ml diluted in 0.075-0.15 ml NS) SIVP titrated to effect; repeat in 5
                min. if seizure persists. 0.3 mg IM (0.15 ml); repeat x 1 in 5 min. if seizure persists.
Lidocaine       3 mg = 0.15 ml Q 10 min x 2 rpt
Morphine        not allowed
Narcan          0.3 mg = 0.75 ml q 3 min prn
Nitronox        not allowed
Sodium          dilute 50% , 3 mEq = 6 ml, may repeat 0.5 mEq diluted 50% to 3ml q 10 minutes x 2
Bicarb
Sux             6mg=.3ml
Tetracaine      not allowed
Fluid Bolus     10 ml /kg = 30 ml q 5-10 min prn x 2 rpt
Synch CV        not allowed
Defib           5 joules rpt @ 10 joules
Pacing          140/ min; begin @ 60 mA
ET Tube         3.0 / ETCO2 Detector: not allowed
Gastric tube:   orogastric only
VS -->          HR: 110 - 160        BP: 42/26 - 66/48        R: 30 - 60




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                                                  9 pounds                                                 4 kg
Adenocard       dilute with 4 ml NS to 6 mg/6 ml, 0.4 mg = 0.4 ml rpt x 2 @ 0.8 mg = 0.8 ml
Albuterol-neb   not allowed
Amiodarone      20 mg. Physician contact required.
Atropine        0.1 mg = 1.0 ml q 5 min x 3 rpt
Benadryl        not allowed
D50W            dilute 50%, 2 g = 8 ml D25W q 10 min x 1 rpt
Dopamine        40 mcg/min = 1 gtt/15 seconds (Mix 150mg (3.75ml) of dopamine in 250ml NS)
Epi 1:1000      Asthma not allowed
                0.4 mg = 0.4 ml initial ET & Rpt ET dose in arrest q 3-5 min
Epi 1:10,000    0.04 mg = 0.4 ml IV/IO dose in arrest and bradycardia
Fentanyl        4 mcg (0.08 ml)
Glucagon        0.2 mg = 0.2 ml
Lorazepam       0.2-0.4 mg (0.1-0.2 ml diluted in 0.1-0.2 ml NS) SIVP titrated to effect; repeat in 5 min. if
                seizure persists. 0.4 mg IM (0.2 ml); repeat x 1 in 5 min. if seizure persists.
Lidocaine       4 mg = 0.2 ml q 10 min x 2 rpt
Morphine        0.4 mg = 0.04 ml q 20 min x 1 rpt
Narcan          0.4 mg = 1 ml q 3 min prn
Nitronox        not allowed
Sodium          dilute 50% , 4 mEq = 8 ml, may repeat 0.5 mEq diluted 50% to 4ml q 10 minutes x 2
Bicarb
Sux             8 mg = 0.4 ml
Tetracaine      not allowed
Fluid Bolus     80 ml q 5-10 min x 2 rpt
Synch CV        not allowed
Defib           10 joules rpt @ 20 joules
Pacing          140/ min; begin @ 60 mA
ET Tube         3.0 or 4.0 / ETCO2 Detector: not allowed
Gastric tube:   orogastric only
VS -->          HR: 110 - 160        BP: 56/30 - 80/50          R: 30 - 60




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                                                 11 pounds                                                5 kg
Adenocard            dilute with 4 ml NS to 6 mg/6 ml, 0.5 mg = 0.5 ml rpt q 3 min x 2 @ 1.0 ml
Albuterol-neb        Unit dose PRN via blow by into face
Amiodarone           25 mg. Physician contact required.
Atropine             0.1 mg = 1.0 ml q 5 min x 3 rpt
Benadryl             5 mg = 0.1 ml q 5 min x 1 rpt
D50W                 dilute 50%, 2.5 g = 10 ml D25W q 10 min x 1 rpt
Dopamine             50 mcg/min = 1 gtt/12 seconds (Mix 150mg (3.75ml) of dopamine in 250ml NS)
Epi 1:1,000          Asthma 0.05 mg = 0.05 ml q 10 min x 2 rpt
                     0.5 mg = 0.5 ml initial ET & Rpt dose in arrest q 3-5 min
Epi 1:10,000         0.05 mg = 0.5 ml IV/IO dose in arrest and bradycardia
Fentanyl             5 mcg (0.1 ml)
Glucagon             0.25 mg = 0.25 ml
Lidocaine            5 mg = 0.25 ml q 10 min x 2 rpt
Lorazepam            0.25-0.5 mg (0.125-0.25 ml diluted in 0.125-0.25 ml NS) SIVP titrated to effect;
                     repeat in 5 min. if seizure persists. 0.5 mg IM (0.25 ml); repeat x 1 in 5 min. if
                     seizure persists.
Morphine             0.5 mg = 0.05 ml q 20 min x 1 rpt
Narcan               0.5 mg = 1.25 ml q 3 min prn
Nitronox             not allowed
Sodium Bicarb        (do not dilute) 5mEq = 5 ml, may repeat 2.5 mEq q 10 min x 2
Sux                  10 mg = 0.5 ml
Tetracaine           not allowed
Fluid Bolus          100 ml q 5-10 min x 2 rpt
Synch CV             5 joules rpt @ 5 joules rpt @ 10 joules
Defib                10 joules rpt @ 20 joules
Pacing               120/ min; begin @ 60 mA
ET Tube              3.0 or 4.0 / ETCO2 Detector: not allowed
Gastric tube:        orogastric only
VS -->               HR: 110 - 160          BP: 56/30 - 80/50       R: 30 - 60




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                                                  13 pounds                                               6 kg
Adenocard       dilute with 4 ml NS to 6 mg/6 ml, 0.6 mg = 0.6 ml
                rpt q 3 min x 2 @ 1.2 mg = 1.2 ml
Albuterol-neb   Unit dose PRN via blow by into face
Amiodarone      30 mg. Physician contact required.
Atropine        0.12 mg = 1.2 ml q 5min x 3 rpt
Benadryl        6 mg = 0.12 ml q 5 min x 1 rpt
D50W            dilute 50%, 3 g = 12 ml D25W q 10 min x 1 rpt
Dopamine        60 mcg / min = 1 gtt/10 seconds (Mix 150mg (3.75ml) of dopamine in 250ml NS)
Epi 1:1,000     Asthma 0.06 mg = 0.06 ml q 10 min x 2 rpt
                0.6 mg = 0.6 ml initial ET & Rpt ET dose in arrest q 3-5 min
Epi 1:10,000    0.06 mg = 0.6 ml IV/IO dose in arrest and bradycardia
Fentanyl        6 mcg (0.12 ml)
Glucagon        0.3 mg = 0.3 ml
Lidocaine       6 mg = 0.3 ml q 10 min x 2 rpt
Lorazepam       0.3-0.6 mg (0.15-0.3 ml diluted in 0.15-0.3 ml NS) SIVP titrated to effect; repeat in 5 min.
                if seizure persists. 0.6 mg IM (0.3 ml); repeat x 1 in 5 min. if seizure persists.
Morphine        0.6 mg = 0.06 ml q 20 min x 1 rpt
Narcan          0.6 mg = 1.5 ml q 3min prn
Nitronox        not allowed
Sodium          (do not dilute) 6 mEq = 6 ml, may repeat 3 mEq q 10 min x 2
Bicarb
Sux             12 mg = 0.6 ml
Tetracaine      not allowed
Fluid Bolus     120 ml q 5- 10 min x 2 rpt
Synch CV        5 joules rpt @ 5 joules rpt @ 10 joules
Defib           10 joules rpt @ 20 joules
Pacing          120/ min; begin @ 60 mA
ET Tube         3.0 or 4.0 / ET CO2 Detector: not allowed
VS -->          HR: 120 - 160         BP: 74/50 - 100/70          R: 30 - 60




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                                                 15 pounds                                               7 kg
Adenocard       0.7 mg = 0.7 ml rpt q 3 min x 2 @ 1.4 mg = 1.4 ml
Albuterol-neb   Unit dose PRN via blow by into face
Amiodarone      35 mg. Physician contact required.
Atropine        0.14 mg = 1.4 ml q 5 min x 3 rpt
Benadryl        7 mg = 0.14 ml q 5 x 1 rpt
D50W            dilute 50%, 3.5 g = 14 ml D25W q 10 min x 1 rpt
Dopamine        70 mcg/ min = 7 gtts/ 60 seconds (Mix 150mg (3.75ml) of dopamine in 250ml NS)
Epi 1:1,000     Asthma 0.07 mg = 0.07 ml q 10 min x 2 rpt
                0.7 mg = 0.7 ml initial ET & Rpt ET doses in arrest q 3-5 min
Epi 1:10,000    0.07 mg = 0.7 ml IV dose in arrest and bradycardia
Fentanyl        7 mcg (0.14 ml)
Glucagon        0.35 mg = 0.35ml
Lidocaine       7 mg = 0.35 ml q 10 min x 2 rpt
Lorazepam       0.35-0.7 mg (0.175-0.35 ml diluted in 0.175-0.35 ml NS) SIVP titrated to effect; repeat in 5
                min. if seizure persists. 0.7 mg IM (0.35 ml); repeat x 1 in 5 min. if seizure persists.
Morphine        0.7 mg = 0.07 ml q 20 min x 1 rpt
Narcan          0.7 mg = 1 75 ml q 3 min prn
Nitronox        not allowed
Sodium          (do not dilute) 7 mEq = 7 ml, may repeat 3.5 mEq q 10 min x 2
Bicarb
Sux             14 mg = 0.7 ml
Tetracaine      not allowed
Fluid Bolus     140 ml q 5-10 min x 2 rpt (l. ringers)
Synch CV        5 joules rpt @ 5 joules rpt @ 10 joules
Defib           20 joules rpt @ 20 joules rpt @ 50 joules
Pacing          120/ min; begin @ 60 mA
ET Tube         3.0 or 4.0
VS -->          HR: 120 - 160        BP: 74/50 - 100/70        R: 30 - 60




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                                               17 pounds                                           8 kg
Adenocard       0.8 mg = 0.8 ml rpt q 3 min x 2 @ 1.6 mg = 1.6 ml
Albuterol-neb   Unit dose PRN via blow by into face
Amiodarone      40 mg. Physician contact required.
Atropine        0.16 mg = 1.6 ml q 5 min x 3 rpt
Benadryl        8 mg = 0.16 ml q 5 min x 1 rpt
D50W            dilute 50%, 4 g = 16 ml D25W q 10 min x 1 rpt
Dopamine        80 mcg/min = 2 gtts/15 seconds (Mix 150mg (3.75ml) of dopamine in 250ml NS)
Epi 1:1,000     Asthma 0.08 mg = 0.08 ml q 10 min x 2 rpt
                0.8 mg = 0.8 ml initial ET & Rpt ET doses in arrest q 3-5 min
Epi 1:10,000    0.08 mg = 0.8 ml IV/IO dose in arrest and bradycardia
Fentanyl        8 mcg (0.16 ml)
Glucagon        0.4 mg = 0.4 ml
Lidocaine       8 mg = 0.4 ml q 10 min x 2 rpt
Lorazepam       0.4-0.8 mg (0.2-0.4 ml diluted in 0.2-0.4 ml NS) SIVP titrated to effect; repeat in 5 min. if
                seizure persists. 0.8 mg IM (0.4 ml); repeat x 1 in 5 min. if seizure persists.
Morphine        0.8 mg = 0.08 ml q 20 min x 1 rpt
Narcan          0.8 mg = 2 ml q 3 min prn
Nitronox        not allowed
Sodium          (do not dilute) 8 mEq = 8 ml, may repeat 4 mEq q 10 min x 2
Bicarb
Sux             16 mg = 0.8 ml
Tetracaine      not allowed
Fluid Bolus     160 ml q 5-10 min x 2 rpt (l. ringers)
Synch CV        5 joules rpt @ 10 joules rpt @ 20 joules
Defib           20 joules rpt @ 50 joules
Pacing          120/ min; begin @ 60 mA
ET Tube         3.0 or 4.0
VS -->          HR: 120 - 160        BP: 74/50 - 100/70          R: 30 - 60




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                                                 20 pounds                                               9 kg
Adenocard       0.9 mg = 0.9 ml rpt q 3 min x 2 @ 1.8 mg = 1.8 ml
Albuterol-neb   Unit dose PRN via blow by into face
Amiodarone      45 mg. Physician contact required.
Atropine        0.18 mg = 1.8 ml q 5 min x 3 rpt
Benadryl        9 mg = 0.18 ml q 5 min x 1 rpt
D50W            dilute 50%, 4.5 g = 18 ml D25W, q 10 min x 1 rpt
Dopamine        90 mcg/min = 3 gtts/20 seconds (Mix 150mg (3.75ml) of dopamine in 250ml NS)
Epi 1:1,000     Asthma 0.09 mg = 0.09 ml q 10 min x 2 rpt
                0.9 mg = 0.9 ml initial ET & Rpt ET doses in arrest q 3-5 min
Epi 1:10,000    0.09 mg = 0.9 ml IV/IO dose in arrest and bradycardia
Fentanyl        9 mcg (0.18 ml)
Glucagon        0.45 mg = 0.45 ml
Lidocaine       9 mg = 0.45 ml q 10 min x 2 rpt
Lorazepam       0.45-0.9 mg (0.225-0.45 ml diluted in 0.225-0.45 ml NS) SIVP titrated to effect; repeat in 5
                min. if seizure persists. 0.45 mg IM (0.9 ml); repeat x 1 in 5 min. if seizure persists.
Morphine        0.9 mg = 0.09 ml q 20 min x 1 rpt
Narcan          0.9 mg = 2.25 ml q 3 min prn
Nitronox        not allowed
Sodium          (do not dilute) 9 mEq = 9 ml, may repeat 4.5 mEq q 10 min x 2
Bicarb
SUX             18 mg = 0.9 ml
Tetracaine      not allowed
Fluid Bolus     180 ml q 5-10 x 2 rpt (l. ringers)
Synch CV        5 joule rpt @ 10 joules rpt @ 20 joules
Defib           20 joules rpt @ 50 joules
Pacing          120/ min; begin @ 60 mA
ET Tube         3.0 or 4.0
VS -->          HR: 120 - 160        BP: 74/50 - 100/70        R: 30 - 60




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                                                  22 pounds                                             10 kg
Adenocard       1.0 mg = 1.0 ml rpt q 3 min x 2 @ 2.0 mg = 2.0 ml
Albuterol-neb   Unit dose PRN via blow by into face
Amiodarone      50 mg. Physician contact required.
Atropine        0.2 mg = 2 ml q 5 min x 3 rpt
Benadryl        10 mg = 0.2 ml q 5 min x 1 rpt
D50W            dilute 50%, 5 g = 20 ml D25W q 10 min x 1 rpt
Dopamine        100mcg/min = 1 gtt/6 seconds (Mix 150mg (3.75ml) of dopamine in 250ml NS)
Epi 1:1,000     Asthma 0.1 mg = 0.1 ml q 10 min x 2 rpt
                1.0 mg initial ET & Rpt ET doses in arrest q 3-5 min
Epi 1:10,000    0.1 mg = 1 ml IV/IO dose in arrest and bradycardia
Fentanyl        10 mcg (0.2 ml)
Glucagon        0.5 mg = 0.5 ml
Lidocaine       10 mg = 0.5 ml q 10 min x 2 rpt
Lorazepam       0.5-1 mg (0.25-0.5 ml diluted in 0.25-0.5 ml NS) SIVP titrated to effect; repeat in 5 min. if
                seizure persists. 1 mg IM (0.5 ml); repeat x 1 in 5 min. if seizure persists.
Morphine        1 mg = 0.1 ml q 20 min x 1 rpt
Narcan          1 mg = 2.5 ml q 3 min prn
Nitronox        not allowed
Sodium          (do not dilute) 10 mEq = 10 ml, may repeat 5 mEq q 10 min x 2
Bicarb
Sux             20 mg = 1.0 ml
Tetracaine      not allowed
Fluid Bolus     200ml q 5-10 min x 2 rpt (l. ringers)
Synch CV        5 joules rpt @ 10 joules rpt @ 20 joules
Defib           20 joules rpt @ 50
Pacing          120/ min; begin @ 60 mA
ET Tube         4.0 or 5.0
VS -->          HR: 120 - 160        BP: 74/50 - 100/70          R: 30 - 60




Treatment and Medications Protocol                  124                                           Revision 3.0, 2006
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                                                  26 pounds                                              12 kg
Adenocard       1.2 mg = 1.2 ml rpt q 3 min x 2 @ 2.4 mg = 2.4 ml
Albuterol-neb   Unit dose PRN via blow by into face
Amiodarone      60 mg. Physician contact required.
Atropine        0.24 mg = 2.4 ml q 5 min x 3 rpt
Benadryl        12 mg = 0.24 ml q 5 min x 1 rpt
D50W            dilute 50%, 6 g = 24 ml D25W q 10 min x 1 rpt
Dopamine        120 mcg/ min = 1 gtt/ 5 seconds (Mix 150mg (3.75ml) of dopamine in 250ml NS)
Epi 1:1,000     Asthma 0.12 mg = 0.12 ml q 10 min x 2 rpt
                1.2 mg = 1.2 ml initial ET & Rpt ET doses in arrest q 3-5 min
Epi 1:10,000    0.12 mg = 1.2 ml in arrest and bradycardia
Fentanyl        12 mcg (0.24 ml)
Glucagon        0.6 mg = 0.6 ml
Lidocaine       12 mg = 0.6 ml q 10 min x 2 rpt
Lorazepam       0.6-1.2 mg (0.3-0.6 ml diluted in 0.3-0.6 ml NS) SIVP titrated to effect; repeat in 5 min. if
                seizure persists. 1.2 mg IM (0.6 ml); repeat x 1 in 5 min. if seizure persists.
Morphine        1.2 mg = 0.12 ml q 20 min x 1 rpt
Narcan          1.2 mg= 3 ml q 3 min prn
Nitronox        not allowed
Sodium          (do not dilute) 12 mEq = 12 ml, may repeat 6 mEq q 10 min x 2
Bicarb
Sux             24 mg = 1.2 ml
Tetracaine      not allowed
Fluid Bolus     240 ml q 5-10 min x 2 rpt (l. ringers)
Synch CV        5 joules rpt @ 10 joules rpt @ 20 joules
Defib           20 joules rpt @ 50 joules
Pacing          120/ min; begin @ 60 mA
ET Tube         4.0 or 5.0
VS -->          HR: 120 - 160        BP: 74/50 - 100/70          R: 30 - 60




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                                                  31 pounds                                            14 kg
Adenocard       1.4 mg = 1.4 ml rpt q 3 min x 2 @ 2.8 mg = 2.8 ml
Albuterol-neb   Unit dose PRN via blow by into face
Amiodarone      70 mg. Physician contact required.
Atropine        0.28 mg = 2.8 ml q 5 min x 3 rpt max 1.0 mg
Benadryl        14 mg = 0.28 ml q 65 min x 1 rpt
D50W            dilute 50%, 7 g = 28 ml D25W, q 10 min x 1 rpt
Dopamine        140 mcg/min = 7 gtts/30 seconds (Mix 150mg (3.75ml) of dopamine in 250ml NS)
Epi 1:1,000     Asthma 0.14 mg = 0.14 ml q 10 min x 2 rpt
                1.4 mg = 1.4 ml initial ET & Rpt ET doses in arrest q 3-5 min
Epi 1:10,000    0.14 mg= 1.4 ml IV/IO dose in arrest and bradycardia
Fentanyl        14 mcg (0.28 ml)
Glucagon        0.7 mg = 0.7 ml
Lidocaine       14 mg = 0.7 ml q 10 min x 2 rpt
Lorazepam       0.7-1.4 mg (0.35-0.7 ml diluted in 0.35-0.7 ml NS) SIVP titrated to effect; repeat in 5 min.
                if seizure persists. 0.7 mg IM (0.35 ml); repeat x 1 in 5 min. if seizure persists.
Morphine        1.4 mg = 0.14 ml q 20 min x 1 rpt
Narcan          1.4 mg = 3.5 ml q 3 min prn
Nitronox        not allowed
Sodium          (do not dilute) 14 mEq = 14 ml, may repeat 7 mEq q 10 min x 2
Bicarb
Sux             28 mg = 1.4 ml
Tetracaine      not allowed
Fluid Bolus     280 ml q 5-10 min x 2 rpt (l. ringers)
Synch CV        5 joules rpt @ 10 joules rpt @ 20 joules
Defib           20 joules rpt @ 50 joules
Pacing          120/ min; begin @ 60 mA
ET Tube         4.0 or 5.0
VS -->          HR: 90 - 140         BP: 80/50 - 112/80         R: 24 - 40




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                                                  35 pounds                                              16 kg
Adenocard       1.6 mg = 1.6 ml rpt q 3 min x 2 @ 3.2 mg = 3.2 ml
Albuterol-neb   Unit dose PRN via blow by into face
Amiodarone      80 mg. Physician contact required.
Atropine        .32 mg = 3.2 ml q 5 min x 3 rpt max 1.0 mg
Benadryl        16 mg = 0.32 ml q 5 min x 1 rpt
D50W            dilute 50%, 8 g = 32 ml D25W, q 10 min x 1 rpt
Dopamine        160 mcg/min = 4 gtts/15 seconds (Mix 150mg (3.75ml) of dopamine in 250ml NS)
Epi 1:1,000     Asthma 0.16 mg = 0.16 ml q 10 min x 2 rpt
                1.6 mg = 1.6 ml initial ET & Rpt ET doses in arrest q 3-5 min
Epi 1:10,000    0.6 mg = 1.6 ml IV/IO dose in arrest and bradycardia
Fentanyl        16 mcg (0.32 ml)
Glucagon        0.8 mg = 0.8 ml
Lidocaine       16 mg = 0.8 ml q 10 min x 2 rpt
Lorazepam       0.8-1.6 mg (0.4-0.8 ml diluted in 0.4-0.8 ml NS) SIVP titrated to effect; repeat in 5 min. if
                seizure persists. 1.6 mg IM (0.8 ml); repeat x 1 in 5 min. if seizure persists.
Morphine        1.6 mg = 0.16 ml q 20 min x 1 rpt
Narcan          1.6 mg = 4 ml q 3 min prn
Nitronox        prn
Sodium          (do not dilute) 16 mEq = 16 ml, may repeat 8 mEq q 10 min x 2
Bicarb
Sux             32 mg = 1.6 ml
Tetracaine      1-2 gtts max
Fluid Bolus     320 ml q 5-10 min x 2 rpt (l. ringers)
Synch CV        10 joules rpt @ 20 joules rpt @ 50 joules
Defib           50 joules rpt @ 50 joules rpt @ 100 joules
Pacing          100/ min; begin @ 60 mA
ET Tube         5.0 or 6.0
VS -->          HR: 80 - 110         BP: 82/50 - 112/78          R: 22 - 34




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                                                  40 pounds                                            18 kg
Adenocard       1.8 mg = 1.8 ml rpt q 3 min x 2 @ 3.6 mg = 3.6 ml
Albuterol-neb   Unit dose PRN via blow by into face
Amiodarone      90 mg. Physician contact required.
Atropine        0.36 mg = 3.6 ml q 5 min x 3 rpt 1.0 mg max
Benadryl        18 mg = 0.36 ml q 5 min x 1 rpt
D50W            dilute 50%, 9 g = 36 ml D25W, q 10 min x 1 rpt
Dopamine        180 mcg/min = 9 gtts/30 seconds (Mix 150mg (3.75ml) of dopamine in 250ml NS)
Epi 1:1,000     Asthma 0.18 mg = 0.18 ml q 10 min x 2 rpt
                1.8 mg = 1.8 ml initial ET & Rpt ET doses in arrest q 3-5 min
Epi 1:10,000    0.18 mg = 1.8 ml IV/IO dose in arrest and bradycardia
Fentanyl        18 mcg (0.36 ml)
Glucagon        0.9 mg = 0.9 ml
Lidocaine       18 mg = 0.9 ml q 10 min x 2 rpt
Lorazepam       0.9-1.8 mg (0.45-0.9 ml diluted in 0.45-0.9 ml NS) SIVP titrated to effect; repeat in 5 min.
                if seizure persists. 0.9 mg IM (0.45 ml); repeat x 1 in 5 min. if seizure persists.
Morphine        1.8 mg = 0.18 ml q 20 min x 1 rpt
Narcan          1.8 mg = 4.5 ml q 3 min prn
Nitronox        prn
Sodium          (do not dilute) 18 mEq = 18 ml, may repeat 9 mEq q 10 min x 2
Bicarb
Sux             38 mg = 1.8 ml
Tetracaine      1-2 gtts max
Fluid Bolus     360 ml q 5-10 x 2 rpt (l. ringers)
Synch CV        10 joules rpt @ 20 joules rpt @ 50 joules
Defib           50 joules rpt @ 100 joules
Pacing          100/ min; begin @ 60 mA
ET Tube         5.0 or 6.0
VS -->          HR: 80 - 110        BP: 82/50 - 112/78          R: 22 - 34




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                                                  44 pounds                                                 20 kg
Adenocard       2.0 mg = 2.0 ml rpt q 3 min x 2 @ 4.0 mg = 4.0 ml
Albuterol-neb   Unit dose PRN via blow by into face
Amiodarone      100 mg. Physician contact required.
Atropine        0.4 mg = 4 ml q 5 min x 3 rpt max 1.0 mg
Benadryl        20 mg = 0.4 ml q 5 min x 1 rpt
D50W            dilute 50%, 10 g = 40 ml D25W, q 10 min x 1 rpt
Dopamine        200 mcg/min = 5 gtts/15 seconds (Mix 150mg (3.75ml) of dopamine in 250ml NS)
Epi1:1,000      Asthma 0.2 mg = 0.2 ml q 10 min x 2 rpt
                2.0 mg = 2.0 ml initial ET & Rpt ET doses in arrest q 3-5 min
Epi 1:10,000    0.2 mg = 2 ml IV/IO dose in arrest and bradycardia
Fentanyl        20 mcg (0.4 ml)
Glucagon        1.0 mg = 1.0 ml
Lidocaine       20 mg = 1 ml q 10 min x 2 rpt
Lorazepam       1-2 mg (0.5-1.0 ml diluted in 0.5-1.0 ml NS) SIVP titrated to effect; repeat in 5 min. if
                seizure persists. 2 mg IM (1 ml); repeat x 1 in 5 min. if seizure persists.
Morphine        2 mg = 0.2 ml q 20 min x 1 rpt
Narcan          2 mg = 5 ml q 3 min prn
Nitronox        prn
Sodium          (do not dilute) 20mEq = 20 ml, may repeat 10 mEq q 10 min x 2
Bicarb
Sux             40 mg = 2.0 ml
Tetracaine      1-2 gtts max
Fluid Bolus     400 ml q 5-10 min x 2 rpt (l. ringers)
Synch CV        10 joules rpt @ 20 joules rpt @ 50 joules
Defib           50 joules rpt @ 100 joules
Pacing          100/ min; begin @ 60 mA
ET Tube         5.0 or 6.0
VS -->          HR: 75 - 100         BP: 84/54 - 120/80          R: 18 - 30




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                                            55 pounds                                           25 kg
Adenocard       2.5 mg = 2.5 ml rpt q 3 min x 2 @ 5.0 mg = 5.0 ml
Albuterol-neb   Unit dose PRN via blow by into face
Amiodarone      125 mg. Physician contact required.
Atropine        0.5 mg = 5 ml q 5 min x 1 rpt
Benadryl        25 mg = 0.5 ml q 5 min x 1 rpt
D50W            (do not dilute) 12.5 g =25ml D50W, q 10 min x 1 rpt
Dopamine        250 mcg / min = 5 gtts/12 seconds (Mix 150mg (3.75ml) of dopamine in 250ml NS)
Epi 1:1,000     Asthma 0.25 mg = 0.25 ml, q 10 min x 2 rpt
                2.5 mg = 2.5 ml initial ET & Rpt ET doses in arrest q 3-5 min
Epi 1:10,000    0.25 mg= 2.5 ml IV/IO dose in arrest and bradycardia
Fentanyl        25 mcg (0.5 ml)
Glucagon        1.0 mg = 1.0 ml
Lorazepam       1-2 mg (0.5-1.0 ml diluted in 0.5-1.0 ml NS) SIVP titrated to effect; repeat in 5 min. if
                seizure persists. 2 mg IM (1 ml); repeat x 1 in 5 min. if seizure persists.
Lidocaine       25 mg = 1.25 ml q 10 min x 2 rpt
Morphine        2.5 mg = 0.25 ml q 20 min x 1 rpt
Narcan          2.0 mg = 5 ml q 3 min prn
Nitronox        prn
Sodium          (do not dilute) 25 mEq = 25 ml, may repeat 12.5 mEq q 10 min x 2
Bicarb
Sux             50 mg = 2.5 ml
Tetracaine      1-2 gtts max
Fluid Bolus     500 ml q 5-10 min x 2 rpt (l. ringers)
Synch CV        10 joules rpt @ 20 joules @ 50 joules
Defib           50 joules rpt @ 100 joules
Pacing          100/ min; begin @ 60 mA
ET Tube         5.0 or 6.0
VS -->          HR: 75 - 100         BP: 84/54 - 120/80         R: 18 - 30




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                                                  66 pounds                                                 30 kg
Adenocard       3.0 mg = 3.0 ml rpt q 3 min x 2 @ 6.0 mg = 6.0 ml
Albuterol-neb   Unit dose PRN via blow by into face
Amiodarone      150 mg. Physician contact required.
Atropine        0.5 mg = 5 ml q 5 x 1 rpt
Benadryl        30 mg = 0.6 ml q 5 min rpt x 1 @ 20 mg = 0.4 ml
D50W            (do not dilute) 15 g = 30 ml D50W, q 10 min x 1 rpt
Dopamine        300 mcg / min = 5 gtts/10 seconds (Mix 150mg (3.75ml) of dopamine in 250ml NS)
Epi 1:1,000     Asthma 0.3 mg = 0.3 ml q 10 min x 2 rpt
                3.0 mg = 3.0 ml initial ET & Rpt ET doses in arrest q 3-5 min
Epi 1:10,000    0.3 mg = 3 ml IV/IO dose in arrest and bradycardia
Fentanyl        30 mcg (0.6 ml)
Glucagon        1.0 mg = 1.0 ml
Lidocaine       30mg = 1.5 ml q 10 min x 2 rpt
Lorazepam       1-2 mg (0.5-1.0 ml diluted in 0.5-1.0 ml NS) SIVP titrated to effect; repeat in 5 min. if
                seizure persists. 2 mg IM (1 ml); repeat x 1 in 5 min. if seizure persists.
Morphine        3 mg = 0.3 ml q 20 min x 1 rpt
Narcan          2 mg = 5 ml q 3 min prn
Nitronox        prn
Sodium          (do not dilute) 30 mEq = 30 ml, may repeat 15 mEq q 10 min x 2
Bicarb
Sux             60 mg = 3.0 ml
Tetracaine      1-2 gtts max
Fluid Bolus     500 ml q 5-10 min x 2 rpt (l. ringers)
Synch CV        20 joules rpt @ 50 joules rpt @ 100 joules
Defib           50 joules rpt @ 100 joules
Pacing          100/ min; begin @ 60 mA
ET Tube         6.0 or 7.0
VS -->          HR: 75 - 100         BP: 84/54 - 120/80          R: 18 - 30




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                                                  77 pounds                                                 35 kg
Adenocard       3.5 mg = 3.5 ml rpt q 3 min x 2 @ 7.0 mg = 7.0 ml
Albuterol-neb   Unit dose PRN via blow by into face
Amiodarone      175 mg. Physician contact required.
Atropine        0.5 mg = 5 ml q 5 x 1 rpt
Benadryl        35 mg = 0.7 ml q 5 min x 1 rpt @15 mg = 0.3 ml
D50W            (do not dilute) 17.5 g =35ml D50W, q 10 min x 1 rpt
Dopamine        350 mcg/min = 7 gtts/12 seconds (Mix 150mg (3.75ml) of dopamine in 250ml NS)
Epi 1:1,000     Asthma 0.3 mg = 0.3 ml q 10 min x 2 rpt
                3.5 mg = 3.5 ml initial ET & Rpt ET doses in arrest q 3-5 min
Epi 1:10,000    0.35 mg = 3.5 ml IV/IO dose in arrest and bradycardia
Fentanyl        35 mcg (0.7 ml)
Glucagon        1.0 mg = 1.0 ml
Lidocaine       35 mg = 1.75 ml q 10 min x 2 rpt
Lorazepam       1-2 mg (0.5-1.0 ml diluted in 0.5-1.0 ml NS) SIVP titrated to effect; repeat in 5 min. if
                seizure persists. 2 mg IM (1 ml); repeat x 1 in 5 min. if seizure persists.
Morphine        3.5 mg = 0.35 ml q 20 min x 1 rpt
Narcan          2 mg = 5 ml q 3 min prn
Nitronox        prn
Sodium          (do not dilute) 35 mEq = 35 ml, may repeat 17.5 mEq q 10 min x 2
Bicarb
Sux             70 mg = 3.5 ml
Tetracaine      1-2 gtts max
Fluid Bolus     500 ml q 5-10 x 2 rpt ( LR )
Synch CV        20 joules rpt @ 50 joules rpt @ 100 joules
Defib           50 joules rpt @ 100 joules
Pacing          100/ min; begin @ 60 mA
ET Tube         6.0 or 7.0
VS -->          HR: 60 - 90        BP: 94 /62 - 140/88          R: 12 - 16




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                               Section 4: Administrative
The Administrative Section was added in MOM 2003. It is not intended to be a complete guide to
administrative Procedure and Instruction; however, it provides a ready reference for certain specific
information.
                                   Approved Abbreviations
A-

a                       before
AAOx3                   awake, alert, oriented x 3 [person/place/time]
A&O x 4 -               alert and oriented to person, place, time and event
ab                      abortion ,*SAB spontaneous AB
abd.                    abdomen
ABG                     arterial blood gas
abs.                    absent
ACLS                    advanced cardiac life support
ACS                     acute coronary syndromes
admin.                  administer
AED                     automatic external defibrillator
AICD                    automatic implanted cardioverter-defibrillator
AIDS                    acquired immune deficiency syndrome
ALS                     advanced life support
AMA                     against medical advice
AMI                     acute myocardial infarction
amp                     ampule
Amp.                    amputation
amt.                    amount
ant                     anterior
A&O                     alert and oriented
AOS                     arrived on scene
APAP                    acetominophen (Tylenol)
ASA                     aspirin (acetylsalicylic acid)
ASAP                    as soon as possible
AV                      atrial/ventricular

B-

BBP                     blood borne pathogen
BCP                     birth control pills
BG                      blood glucose
b.i.d                   twice a day
bilat.                  bilateral
BLS                     basic life support
BM                      bowel movement
BOW:                    bag of water
BP                      blood pressure
B/S                     breath sounds
BS                      blood sugar
BVM                     bag valve mask (Ambu Bag™)

C-

c                      with
CA                     cancer
Ca                     calcium
CABG                   coronary artery bypass graft ("cabbage")
CAD                    coronary artery disease
cal.                   caliber
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CC                     chief complaint
cc                     cubic centimeter
CCU                    Cardiac Care Unit
CHF                    congestive heart failure
cl.                    clear
cm.                    centimeter
cm3                    cubic centimeter
CT                     CAT scan
CNS                    central nervous system
CO2                    carbon dioxide
CO                     carbon monoxide
C/O                    complains of
conc.                  concentration
cond.                  condition
COPD                   chronic obstructive pulmonary disease
CPR                    cardiopulmonary resuscitation
CSF                    cerebral spinal fluid
CSM                    circulation, sensation and movement.
CVA                    cerebrovascular accident

D-

d                      day
D5W                    5% dextrose in water
D50                    50% dextrose
DBP                    diastolic blood pressure
DC                     disconnect
D/C                    discontinue
D&C                    Dilation and curettage
Defib.                 defibrillation
Deform.                deformity
DI                     diabetes insipidus
DIC                    disseminated intravascular coagulation
dig.                   digtalis
disloc.                dislocated
DM                     diabetes mellitus
DNR                    do not resuscitate
DOB                    date of birth
DOE                    dyspnea on exertion
dsg.                   dressing
DTR                    deep dendon reflexes
DT's                   delerium tremens
Dx                     diagnosis

E-

ea.                    each
EBL                    estimated blood loss
ECG                    electrocardiogram
ED                     Emergency Department
EDC                    estimated date of confinement
EEG                    electroencephalogram
EENT                   ears, eyes, nose and throat
e.g.                   for example
EKG                    electrocardiogram (old, from German electrokardiogram)
EMD                    Emergency Medical Dispatcher
EMS                    Emergency Medical Services
EMS-C                  Emergency Medical Services for Children
EMT                    Emergency Medical Technician
EMT-P                  Paramedic
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Epi.                    epinephrine
ER                      Emergency Room
ET                      endotracheal (tube)
ETA                     estimated time of arrival
ETCo2                   end-tidal Co2 (detector)
ETOH                    ethanol (ethyl alcohol)
ETT                     endotracheal tube
exam                    examination

F-

F                       Fahrenheit
FB                      foreign body
FD                      fire department
fem.                    femoral
FF                      firefighter
FH                      family history
FHT                     fetal heart tones
fl.                     fluid
flex.                   flexion
freq.                   frequency
FROM                    full range of motion
ft.                     foot, feet
Fx                      fracture

G-

gm                      gram
ga.                     gauge
gal.                    gallon
GB                      gallbladder
GC                      gonorrhea
gd.                     good
gen.                    general
gluc.                   glucose
GI                      gastrointestinal
GM seizure              grandmal seizure
gr.                     grain
G 0 1,2, etc.           gravida (must have number following)
grav.                   gravida
GOA                     gone on arrival
GSW                     gunshot wound
gtts                    drops
GU                      genito-urinary

H-

h                      hour
HA H/A                 headache
Hb                     hemoglobin
HEENT                  head, eyes, ears, nose, and throat
HEPA                   high efficiency particulate aspirator
Hep-B,HBV              Hepatitis B (or A, C, D)
Hg                     mecury
HIV                    human immunodeficiency virus
H&P                    history and physical
HPI                    history of present illness
HR                     heart rate
h.s.                   at bedtime
HTN                    hypertension
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Hx                     history

I-

ICP                    intracranial pressure
ICS                    Incident Command System
ICU                    Intensive Care Unit
IM                     intramuscular
info.                  information
inj.                   injury
irreg.                 irregular
iu                     international units
IUD                    intrauterine device
IV                     intravenous
IVD                    IV drip
IVDA                   IV drug abuse
IVP                    intravenous push
IVPB                   intravenous piggy back

J-

J.                     joule
jct.                   junction
JVD                    juglar venous distension

K-

K                      potassium
KCL                    potassium chloride
KED                    Kendricks Extrication Device™
kg                     kilogram
KVO                    keep vein open

L-

L.                     liter
L                      left
lac.                   laceration
lat.                   lateral
lb.                    pounds
LBBB                   left bundle branch block
LBP                    low back pain
L&D                    labor and delivery
lg.                    large
lig.                   ligament
liq.                   liquid
LLQ                    left lower quadrant
LMP                    last menstrual period
LOC                    level of consciousness (in Glasgow scale)
LOC                    loss of consciousness
LPM                    liters per minute (oxygen)
LPN                    Licensed Practical Nurse
LR                     lactated Ringers (IV solution)
L.                     left
LUQ                    left upper quadrant




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M-

m.                     meter
mA                     milliamps
MAE                    moves all extremities
mand.                  mandible
MAST                   Medical Anti Shock Trousers™ (see PASG)
mcg                    microgram
MCI                    mass casualty incident
MCL1                   modified chest lead 1
MCL 6                  modified chest lead 6
MD                     medical doctor
mEq                    milliequlivants
mg                     milligram
Mg                     magnesium
MI                     myocardial infarction
MICP                   Mobile Intensive Care Paramedic
MICU                   Mobile Intensive Care Unit
misc.                  miscellaneous
ml.                    milliliters
mm.                    millimeter
mo                     month
M/O                    months old
mod.                   moderate
MOI                    mechanism of injury
MRI                    magnetic resonance imaging
MS                     Morphine Sulfate
M/S                    motor and sensory (i.e.; M/S intact x4 ext)
MSDS                   Material Safety Data Sheet
multip.                multiparous
musc.                  muscle
MVA                    motor vehicle accident
MVI                    multi-victim incident

N-

NA                     not applicable (available)
Na                     sodium
NaCl                   sodium chloride
NAD                    no acute (apparent) distress
NaHCO3                 sodium bicarbonate
narc.                  narcotic
NC                     nasal cannula
NCT                    narrow complex tachycardia
neg.                   negative
Neuro.                 neurological
NG                     nasogastric
NKDA                   no known drug allergies
norm.                  normal
NP                     Nurse Practitioner
NPO                    nil per os (nil per mouth)
NRB                    non-rebreathing (mask)
NS                     normal saline
NSAID                  non-steroidal anti-inflammatory drug
NSR                    normal sinus rhythm
NTG                    nitroglycerin
N&V                    nausea and vomiting



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O-

O2                     oxygen
OB                     obstetrics
Ob/Gyn                 obstetrics/gynecology
occ.                   occasional
OCP                    oral contraceptive pill
OD.                    overdose
OTC                    over the counter
oz.                    ounce

P-

p                      after (superscript hyphen over p)
P 1,2, etc.            parity (must be followed by # and used with gravida)
PA, PA-C               Physician Assistant
palp.                  palpation
parox.                 paroxysmal
PASG                   pneumatic anti-shock garment
PAC                    premature atrial contraction/complex
PAT                    paroxysmal atrial tachycardia
PCN                    penicillin
PCR                    patient care record/report
PD                     police department
PE                     pulmonary embolus, or physical exam
PEA                    pulseless electrical activity (cardiac)
PERL                   pupils equal and reactive to light
PERLA                  pupils equal and reactive to light and accommodation
PERRL                  pupils equal, round, and reactive to light
PERRLA                 pupils equal, round, and reactive to light and accommodation
peds.                  pediatrics
PID                    pelvic inflammatory disease
PIH                    pregnancy induced hypertension
PMH                    past medical history
PMS                    pulse, motor, sensory
PMS                    premenstrual syndrome
PND                    paroxysmal nocturnal dyspnea
pneumo.,ptx            pneumothorax
p.o.                   by mouth
post.                  posterior
POV                    privately owned vehicle
PPE                    personal protective equipment
preg.                  pregnant
prep.                  prepare
PRN                    as necessary/needed
PROM                   premature rupture of membranes
prox.                  proximal
PT                     patient
PTCA                   percutaneous transluminal coronary angioplasty
PTOA                   prior to our arrival
PVC                    premature ventricular contraction

Q-

q                      each, every
q.d.                   each day
q.h.                   each hour
q.i.d.                 four times a day
qt.                    quart

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R-

R                      rate
R                      right
RBBB                   right bundle branch block
resp.                  respirations
RL                     Ringer’s lactate (IV solution)
RLQ                    right lower quadrant
Rm                     room
RMA                    refuse[s] medical assistance
RN                     Registered Nurse
ROM                    range of motion
RSI                    rapid sequence intubation
RT                     Respiratory Therapist
RUQ                    right upper quadrant
Rx                     prescription/medication

S-

s                      without
SABA                   supplied air breathing apparatus
sal.                   saline
SAR                    search and rescue
SBP                    systolic blood pressure
SCBA                   self contained breathing apparatus
SCUBA                  self contained underwater breathing apparatus
SUIDS                  sudden unexpected infant death syndrome
SA                     sinus node (sinoatrial)
SIVP                   slow intravenous push
SL                     sublingual
SOB                    shortness of breath
SOP                    standard operating procedure
SpO2                   oxygen saturation (peripheral/pulse)
SQ                     subcutaneous
S&S                    signs and symptoms
SR                     sinus rhythm
STAT                   immediately
STD                    sexually transmitted disease
std.                   standard
sup.                   superior
supp.                  suppository
Surg.                  surgery or surgeon
SVT                    supraventricular tachycardia
Sx                     symptoms/signs

T-

T                      temperature
tab.                   tablet
TB                     tuberculosis
TCA                    tricyclic anti-depressant
TIA                    transient ischemic attack
t.i.d.                 three times a day
TKO                    to Keep Open
TM                     tympanic Membrane
tol.                   tolerate(d)
TPR                    temperature, Pulse, Respirations
trach.                 tracheostomy
tract.                 traction
Tx                     treatment
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U-

ug                     micrograms
UOA                    upon our arrival
URI                    upper respiratory infection
UTI                    urinary tract infection

V-

Vv.                    vein
VA                     Veteran's Administration (US Government)
VD                     venereal disease
VF                     ventricular fibrillation
VFD                    volunteer fire department
V-fib                  ventricular fibrillation
vol.                   volume
vs                     vital signs
VT,V-tach              ventricular tachycardia

W-

WBC                    white blood count
WCT                    wide complex tachycardia
WD                     warm/dry
wk.                    week
WNL                    within normal limits
WPD                    warm, pink, dry (skin signs)
WPW                    Wolf-Parkinson-White
wt.                    weight

X-

X-fer                  transfer

Y-

Y/O, y.o.              years old




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              State of Alaska Mandatory Reporting Requirements

This document is based on Alaska Statutes and Regulations and represents the best interpretation
available from the Section of Community Health and EMS. Readers are encouraged to refer to the
applicable law when questions arise. The Alaska Statutes and Regulations are available on-line through
the Department of Law at: http://www.law.state.ak.us.

Reporting gunshot wounds, stab wounds, and severe burns to the Department of Public Safety.

AS 08.64.369 requires health care professionals to report 5 categories of injuries to the Department of
Public Safety (DPS):

(1) second or third degree burns to five percent or more of a patient's body;
(2) a burn to a patient's upper respiratory tract or laryngeal edema due to the inhalation of super-heated
air;
(3) a bullet wound, powder burn, or other injury apparently caused by the discharge of a firearm;
(4) an injury apparently caused by a knife, axe, or other sharp or pointed instrument, unless the injury was
clearly accidental; and
(5) an injury that is likely to cause the death of the patient, unless the injury was clearly accidental.

An oral report must be made 'promptly' to DPS of all five injuries; in addition, a WRITTEN report be must
made within three days on a DPS form for the burn injuries. To report non-burn and non-accidental
mortal injuries, call the police or troopers.

Obtaining a copy of the burn reporting form.

From the Division of Fire Prevention in Anchorage at 269-5491, the Section of Community Health and
Emergency Medical Services in Juneau at 465-3027 or you can download the form from our website at:
http://www.chems.alaska.gov/EMS/Assets/Downloads/DPS_Burn_Form.doc

Burn reports should be sent to:

Alaska Department of Public Safety
Division of Fire Prevention
5700 E. Tudor Road
Anchorage, AK 99507

Reporting suspected child or elder abuse or neglect.

Child abuse
EMTs and paramedics are considered to be required to report child abuse. Under AS 47.17.020 a report
of a suspicion of child abuse or neglect should be made directly to the Office of Children’s Services of the
Department of Health and Social Services (OCS). If you can’t reasonably contact OCS, a report must be
made to the nearest peace officer. Notifying your medical director, EMS supervisor or the receiving
facility is not sufficient to comply with the reporting requirements.

Statewide number: 1-800-478-4444

Vulnerable Adult Abuse
Under AS 47.24.010 you must report suspicions that a vulnerable adult suffers from abandonment,
exploitation, abuse, neglect, or self neglect. A vulnerable adult is a person 18 years of age or older who,
because of physical or mental impairment, is unable to meet his or her own needs or to seek help without
assistance. You must make the report to the Division of Senior Services within 24 hours after you first
suspect abuse. If the office is closed, contact the local law enforcement agency immediately and make
the report of harm to the Division of Senior Services the next business day.

Statewide number: 1-800-478-9996       Anchorage: 269-3666

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Liability for filing a report of suspected abuse.

The statutes provide immunity from civil or criminal liability for a person who makes a good faith report of
suspected abuse.
                                Continuing Medical Education
Extracted from P&I 902-7

Purpose
This procedure establishes guidelines for required and elective Continuing Medical Education (CME)
necessary to maintain medical licensure or certification and/or to meet Department standards.

Policy
The policy of the Anchorage Fire Department Training Division is to make available continuing medical
education and training for all personnel licensed as Mobile Intensive Care Paramedic (MICP) or certified
as Emergency Medical Technician (EMT) or Emergency Trauma Technician (ETT).

Authorities
AS 08.64.170, AS 18.08.082, 12 AAC 40.310 – 390, 7 AAC 050.0075, AMC 16.95.

Procedure & Instruction
1.0   Responsibilities
      1.1      The Chief of Training is responsible for ensuring compliance with this Procedure.
      1.2      The Anchorage Fire Department Training Division will provide continuing medical
      education specific to department operational needs as identified by the Medical Director, Mayor’s
      Emergency Medical Services Board, and department administration.
      1.3      The Municipality of Anchorage will provide sufficient on-duty training hours annually to
      maintain all certifications and licenses required as a condition of employment. Members who do
      not avail themselves of department training must recertify at their own time and expense.
      1.4      Individual AFD personnel are responsible for:
               1.4.1 Maintaining licenses and certifications required by job classification or
               department policy.
               1.4.2 Assuring that a current copy of those licenses or certifications are on file and
               available at the Fire Training Center with the Chief of Training.
               1.4.3 Reporting training that qualifies towards re-certification/license renewal and
               keeping personal records of the same.
2.0   Training
      2.1      Insofar as is practical, training provided by the department will be accomplished during
      regularly scheduled shifts.
               2.1.1 Personnel attending mandatory classes outside of regularly scheduled shifts will
               be compensated at the overtime rate as specified in the Labor Agreement.
      2.2      Absence from scheduled training classes designated as mandatory must be pre-
      approved by the Chief of Training. Such approval will only be granted in extraordinary situations
      to include annual leave and time off on Worker’s Compensation due to occupational illness or
      injury.
               2.2.1 To assure consistency in training for all personnel, every attempt will be made to
               duplicate classes that are mandatory. When two or more classes of the same
               instructional material are offered on different dates, only one of these classes need be
               attended. This information will be noted as part of the memorandum that announces the
               training.
               2.2.2 Personnel on "Kelly" for posted mandatory training dates may be mandated as to
               which date to attend when practical drills or other considerations require control of
               attendance.
               2.2.3 On-duty attendance at mandatory training scheduled for off-duty attendance is
               not allowed unless approved in advance for special circumstances relating to department
               need.
               2.2.4 Every attempt will be made to schedule mandatory training sessions at least two
               weeks in advance of the actual dates of such training.



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                 2.2.5 Insofar as possible, off-duty mandatory training will be scheduled in minimum
                 two-hour block periods. This two-hour minimum need not apply to periods scheduled
                 during normal duty hours.
       2.3       MICP personnel must attend three out of four shift meetings annually.
                 2.3.1 Attendance for the entire shift meeting is required for it to count toward the
                 minimum. Shift meeting absences will be excused (not counted against the total) if the
                 reason is submitted to the Chief of Training and approved. Approval will be reserved for
                 major emergencies only. Absences are not excused for shift trades, overtime or leave.
                 Worker's Compensation status and emergency leave are excusable; mandatory overtime
                 and late runs are also excusable; these latter two will be excused orally if the Chief of
                 Training is informed.
                 2.3.2 Overtime pay for shift meetings will be only for the time attended.
       2.4       All personnel must attend any class dealing with a new drug or procedure approved for
       use at their respective certification or license level.
       2.5       Meeting CME requirements for licensing or certification in excess of that identified in this
       document is the sole responsibility of the personnel referenced in this procedure
                 2.5.1 The Training Division/EMS Section will post announcements of training that may
                 be of interest or helpful in meeting licensing or certification requirements; however,
                 overtime pay will apply only to training designated as off-duty mandatory.
       2.6       Failure to meet department required CME and training standards as specified in this
       procedure will result in initiation of progressive discipline and may result in suspension or
       termination of employment on the Anchorage Fire Department.
3.0    Record-keeping
       3.1       It is the responsibility of the personnel referenced in this P&I to report training that
       qualifies towards re-certification/license renewal and to keep personal records of the same.
       3.2       All personnel must use the Application for Continuing Medical Education Hours form
       submitted to the EMS Training Specialist to request CME credit and record keeping for training
       not conducted or directly coordinated by the training division.
                 3.2.1 CME submissions made more than 30 days after the date of training may require
                 additional documentation to be accepted.
                 3.2.2 Applications for continuing medical education must provide itemization by topics
                 and hours when submitted for multiple topic training events, or for multiple date events.
                 Shotgun or lump-sum submissions do not allow for adequate record keeping and will be
                 returned for itemization.
                 3.2.3 Applications for CME Hours submitted for training occurring in the stations or
                 other venues must define objectives and a descriptive narrative detailing the training
                 activity.
                 3.2.4 Round training hours to the nearest tenth hour.
       3.3       Hours submitted that fall under special topic areas as described herein are subject to
       particular scrutiny before approval. Routine acting duties will not be accepted as training.
                 3.3.1 Likewise, observation and/or participation in one's own medical care or that of a
                 family member or friend will be accepted only if it is directly relevant to the EMS mission.
                 CME credit in this category will be limited to 7.5 hours annually. CME requests must
                 include notes and measurable objectives.
                 3.3.2 Other special categories will be evaluated for suitability on a case-by-case basis.
4.0    Activities Acceptable for CME
       4.1       Following are general guidelines about what is acceptable as CME. The most senior
       EMS Training Specialist will make final decisions and interpretations of details not mentioned
       either herein or in memos.
       4.2       Didactic training as defined by this department shall include, but not be limited to,
       classroom training and testing procedures that focus on cognitive learning objectives.
       4.3       Clinical training as defined by the department shall include, but not be limited to, that
       training obtained in a medical facility or a setting relevant to the needs of the department. Clinical
       training primarily applies to the application of psychomotor skills; thus, some of the best "hands-
       on" training is available after delivery of patients to a medical facility. All personnel are
       responsible for recognizing and acting on this type of clinical training opportunity in order to obtain
       this training while on duty. Participation in EMS related labs and drills generally qualifies as
       clinical training.
                 4.3.1 Pre-hospital field response activities do not qualify as training.

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        4.4      In order to be approved, CME must be referable to EMS core curricula. This refers to the
        knowledge base (primarily medical) necessary for independent, pre-hospital basic and advanced
        life support practice. This material shall be referable to the U.S./D.O.T National Standard
        Curriculum for Emergency Medical Technician-Paramedic or Emergency Medical Technician-
        Basic or First Responder (ETT) current at the time of training or other curriculum approved by the
        Chief of Training. Generally, the following venues provide core training:
                 4.4.1 Shift meetings and labs
                 4.4.2 EMS training lectures and mandatory training classes
                 4.4.3 EMS symposiums, conferences (submit program and objectives for approval)
                 4.4.4 Hospital in-service classes and EMS continuing education functions
                 4.4.5 Self-testing provided by the EMS training office
                 4.4.6 Independent learning of core curriculum material. You must take notes to submit
                 with the training sheet and identify learning objectives for inclusion in the records.
                 Approved materials only, either by numbered memo or special approval. This training
                 may use textual, videotaped, interactive or other media. Limited to 12 hours per year.
                 4.4.7 College and correspondence courses (one semester hour equals three training
                 hours, must be directly relevant to EMS). Advance approval recommended.
        4.5      Teaching – An annual maximum of 20 hours of CME credit will be granted to MICPs and
        15 hours for EMTs for teaching EMS related topics referable to the U.S./D.O.T. National Standard
        Curriculum for Emergency Medical Technician-Paramedic or Emergency Medical Technician-
        Basic or First Responder (ETT) or other curriculum approved by the Chief of Training.
        4.6      Special Topic Areas - A maximum of 15 hours annually will be granted for topics related
        to EMS but not immediately referable to core curriculum topics. Examples: EMS management
        and leadership courses, advanced vehicular extrication, river rescue, respiratory fitness and
        hazard communication. Other topics may be assigned to this category when they are judged not
        to be core EMS training. Pre-approval by the Chief of Training is required.
        4.7      The department recognizes the value of attending training which is pertinent to the job
        but which is not department sponsored. CME credit for training that is not department sponsored
        is at the discretion of the Chief of Training. This training must be relevant to the department's
        mission and needs. Pre-approval of non-department sponsored training is recommended.
        1. In-Station Drills and Exercises- A maximum of 15 hours annually. Refer to 3.2.3.

                                     Controlled Substances
Extracted from P&I 903-5
Purpose
This document established guidelines for the security and accountability of any AFD substances
considered a controlled substance.
Policy
The policy of the Anchorage Fire Department is to:
        Maintain sufficient levels of controlled substances to meet operational need.
        Assure control over the use, inventory, security and access to controlled substances.
        Prevent theft or diversion of controlled substances.
        Provide for the regular inventory of substances.
        Comply with federal regulations regarding controlled substances.
Procedure & Instruction
1.0     AFD Controlled Substances
        1.1      The following are considered controlled substances by the Drug Enforcement
        Administration (DEA) or the AFD and are subject to the requirements outlined in this procedure:
                 1.1.1 All Substances listed in 21 Code of Federal Regulations (CFR) Ch II §1308-
                 Schedule of Controlled Substances; the AFD currently stocks two Schedule II
                 substances; Morphine Sulfate and Fentanyl Citrate and Two Schedule IV substances;
                 Lorazepam and Valium (in NAAK Kits).
                 1.1.2 Nitrous Oxide
        1.2      Chief Medical Officers (CMOs) shall oversee and enforce compliance with this policy.
        The steward of this policy is referred to as the Narcotics Control Officer (NCO).
        1.3      Any discrepancy of count, loss, destruction or damage to containers involving controlled
        substances or controlled medication forms shall be reported to a CMO immediately.
        1.4      A CMO will immediately initiate an investigation into any discrepancies. Discrepancies
        that remain unresolved for more than two hours shall be referred to the NCO and the DC of EMS

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       for investigation. Confirmed medication discrepancies will be reported through the DC of EMS to
       the AFD Medical Director, Fire Chief and the DEA.
       1.5      Only MOA certified paramedics are authorized to assume control of controlled
       substances except for the emergency supplies contained in NAAK Kits. NAAK kits are authorized
       directly and solely to the custody and oversight of the individual in charge of an apparatus.
       1.6      The individual who has assumed control of a controlled substance has the responsibility
       for compliance with the elements of this policy and has authority over all access to the controlled
       substances in his/her custody.
       1.7      Audits:
                1.7.1 At least quarterly a CMO will conduct an audit. The scope of the audit will be
                determined by the CMO and or the Chief of EMS operations. These audits will be
                documented and the documentation retained at fire administration.
                1.7.2 Municipal Internal Audit will conduct unannounced audits from time to time
                coordinating timing and scope with the DC of EMS.
                1.7.3 A department wide biennial inventory will be conducted within 24 months of the
                previous inventory. This inventory will include all controlled substances present. This
                inventory will utilize unique forms denoting that it was conducted at the “close of
                business” or “beginning of business”.
                1.7.4 The controlled substances used by the AFD are purchased by the AFD Medical
                Director under his registration and made available for AFD operational use. The
                Schedule II and IV substances stocked by AFD remain his responsibility and under his
                direct control. The AFD Medical Director may take any such means as he deems
                necessary to regulate, audit, survey or monitor the department’s storage, use, inventory
                and safeguarding of those controlled substances.
                1.7.5 The Narcotics Control Officer shall report the result of the monthly reconciliation
                of inventory forms to the DC of Area Wide EMS and the Medical Director.
                1.7.6 From time to time DEA Investigators may request access to controlled
                substances in order to conduct inspections. All AFD personnel are to cooperate with
                DEA inspection requests after verifying the identity of the DEA Investigator. It will not be
                necessary for the DEA Investigator to present a DEA Form 82.
                1.8      Personnel shall be vigilant when handling controlled substances, to prevent theft,
                loss or diversion. Loss of controlled substances is an extremely serious offense and
                subject to discipline.
       1.9      Inventory Forms:
                1.9.1 All perpetual and biennial inventory forms will be retained at the AFD
                administration building for a minimum of two calendar years from the last date entered.
                Forms pertaining to Schedule II substances will be filed separately from all other
                controlled medication forms. Access to controlled substance forms filed at admin is
                restricted to the DC EMS’s designated support staff or personnel conducting audits.
                1.9.2 Instructions for inventory forms will be available on the “G” drive.
                1.9.3 Only a single sided copy of the current form is permissible. On the first day of
                every month all perpetual inventory forms (NAAK, Morphine, Fentanyl and Lorazepam)
                will be sent to the fire administration building via a red envelope. This will be the
                responsibility of the following persons on duty at 1000 hours on the first of the month:
                a.       Chief medical officers and paramedics for all controlled substances under their
                         direct control.
                b.       Chief and company officers for NAAK kits on their apparatus.
                c.       On those apparatus without an officer or paramedic, it will be the responsibility of
                         the station captain. On those apparatus without an officer or paramedic, it will be
                         the responsibility of the station captain.
                1.9.4 On forms completed prior to the first of the month:
                The last person to sign as “Controller” is responsible to:
                Place the form in a red envelope for courier pick up.
                Send an email to the “operations secretary” that specifies:
                What unit the form is from;
                Which form it is (NAAK, Schedule II or Lorazepam);
                Who is sending it;
                The beginning and ending dates of the form;
                The beginning and ending drug counts.
       1.10     Signatures:
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               1.10.1 Signatures for documentation must be in ink and legible.
               1.10.2 A legible employee number is required with any signature.
               1.10.3 No person may sign for another person.
               1.10.4 No person may sign as both controller and witness on the same line.
       1.11    Administration of Controlled Substances:
               1.11.1 Shall be logged on the inventory control sheet of the source apparatus by the
               controller and witnessed. Quantities (in mgs or mcgs) administered and wasted shall be
               logged with the run number.
               1.11.2 Remaining quantities of controlled substances from partially administered
               syringes shall be wasted in the presence of the person signing as a witness. Only
               partially administered tubexes of controlled substances are to be wasted. Tubexes with
               damage, a breached paper seal or an expired date must be surrendered to a CMO and
               not wasted.
               1.11.3 Prepackaged tamper resistant containers opened preparatory to administration
               but not administered shall be retained in inventory and shall be surrendered to a CMO at
               first opportunity.
       1.12    Inventory Transactions:
               1.12.1 Any controlled substance transferred from one person to another person is a
               transaction. All transactions require 2 signatures on each of two separate forms. Each
               surrender and issue of controlled substances will be logged as a unique transaction on
               separate lines, even if the net inventory effect is zero change. Transactions will not be
               conducted without all required signatures being completed.
               1.12.2 Required signatures:
               Person surrendering:
               Sign your form as “controller”;
               Sign the form of the person receiving as “witness”.
               Person receiving:
               Sign your form as “controller”.
               Sign the issuing persons form as “witness”.
       1.13    Operations Secretary:
               1.13.1 The “EMS Fire Office Associate” will:
               Collect and file all controlled substance inventories.
               Reconcile all forms assuring completeness, accuracy of the counts on the individual
               forms and continuity of dates on the forms. The “Operations Secretary” will assure
               continuity of dates to the preceding inventory for the unit. Individual transactions on the
               inventory will be verified back to the corresponding transaction on the CMO inventory
               monthly. Transactions on the CMO logs will be verified to the administration inventory
               form and to paramedic staffed apparatus (PSAs) inventories monthly. Administration
               inventory transactions will be verified to a form 222 source or to CMO inventories.
               Report to the Narcotics Control Officer on the reconciliation of inventory forms monthly.
               Contact a CMO to investigate any irregularities.
               The NCO will be notified of any transactions not in compliance with this policy.
               Inform the DC EMS immediately through the NCO if there are any missing logs or
               discontinuities of date. Notification shall be verbal and via email.
               Issue inventory forms to MICUs and paramedic staffed apparatus.
               Each controlled medication shall have a unique color inventory form.
               Forms shall have the month, apparatus designator and medication printed on them.
               NAAK/nitrous oxide inventory forms will be white and available on the “G” drive. The
               apparatus designator, month and year will be written in ink on the form.
       1.14    Combination Security:
               1.14.1 The combination to controlled substance lockers will be restricted to a minimum
               number of specifically authorized AFD personnel. The combination to CMO vehicles and
               the administration building’s safe will be unique from the other combinations and the
               combination to these areas will be further restricted. Combinations will be given out only
               by CMOs. The CMOs will maintain a list of all personnel that have been provided
               combinations. All other holders of the combination are prohibited from divulging it to
               anyone else. In the unlikely event it becomes necessary for someone other than a CMO
               to divulge the combination, contact a CMO, verbally and in writing, as soon as possible
               after the event.
2.0    Inventory of Nerve Agent Antidote Kits
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       2.1      Nerve Agent Antidote Kit (NAAK) and Nitrous Oxide Units assigned to an MICU
                2.1.1 The paramedic is responsible for complying with this section.
                2.1.2 NAAKs will not be left on MICUs that are not staffed.
                2.1.3 NAAKs will only be carried in the controlled substance locker.
                2.1.4 Every use of nitrous oxide: document run # in comments and reseal.
                2.1.5 Every Monday:
                Inspect the NAAK perpetual inventory form for discrepancies
                Assure the NAAK is present, locked, and locked to the vehicle
                Assure the NAAK has no evidence of tampering
                Assure the NAAK is sealed and the seal number matches the inventory form
                Inspect the seal on the Nitrous Oxide Unit to confirm it is sealed and the seal number
                matches the inventory.
                If no discrepancies are found, fill out the inventory and sign it.
                2.1.6 A chief medical officer shall be informed immediately of any discrepancy
                involving a NAAK, a Nitrous Oxide Unit, NAAK or nitrous inventory forms.
       2.2      Nerve Agent Antidote Kit (NAAK) assigned to vehicles other than an MICU
                2.2.1 The company officer is directly responsible for complying with this section. The
                vehicle operator is responsible when no company officer is assigned to a vehicle.
                2.2.2 A chief medical officer and the NCO, through the chain of command, shall be
                informed immediately of any discrepancy involving a NAAK or NAAK inventory forms.
                2.2.3 NAAKs will not be left on apparatus that are not staffed.
                2.2.4 NAAKs will not be carried on apparatus without the ability to secure them with a
                lock. The combination to this lock will be provided verbally to all operations personnel.
                All operations personnel shall commit this combination to memory.
                2.2.5 Every Monday:
                Inspect the NAAK perpetual inventory form for discrepancies
                Assure the NAAK is present, locked, and locked to the vehicle
                Assure the NAAK has no evidence of tampering
                Assure the NAAK is sealed and the seal number matches the inventory form
                If no discrepancies are found, fill out the inventory and sign it
3.0    Inventory of Other Controlled Substances
       3.1      The paramedic is responsible for all controlled substances on their assigned vehicle,
       except as noted in 2.2.1.
       3.2      At the beginning of a duty period and any time the controlled substance locker is
       accessed, the assigned paramedic will perform an inventory of that vehicle’s stock of controlled
       substances.
                3.2.1 Inventory will be accomplished as soon as possible after coming on duty, and will
                not be interrupted or delayed, except by responses or direction from a chief medical
                officer.
                3.2.2 Counts and signatures for changes of control will occur with oncoming and off
                going PM’s present.
       3.3      When a paramedic assumes responsibility for controlled substances, they shall:
                3.3.1 Inspect the perpetual inventory form for discrepancies.
                3.3.2 Inspect the controlled substances to assure that there is no evidence of
                tampering, seals damaged or broken, the proper amount is present and that they are not
                expired.
                3.3.3 If no discrepancies are found, fill out the inventory form and sign it.
                3.3.4 Remain on duty until another MOA certified paramedic signs for and assumes
                control of the controlled substances on their assigned vehicle.
       3.4      The controlled substance inventory form will remain with the controlled substances and
       controller regardless of the vehicle is being used. A controller (PM) will have only one inventory
       form for each type of controlled substances under his control.
       3.5      If an apparatus is transitioning to BLS status the controller will contact the CMO and
       assure arrangements to surrender the controlled substances inventory to the CMO or a designee
       before shift change.
                3.5.1 Controlled substances will be surrendered before the paramedic is relieved of
                duty.
                3.5.2 It is the responsibility of the company officer and the paramedic to ensure that
                the transfer of custody occurs in a timely fashion with a minimum of overtime.

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                3.5.3 When controlled substances are surrendered to a paramedic on another
                apparatus the log will show the surrender and result in stock levels of zero. The log
                showing zero stock will remain with the now BLS apparatus secured in the lock box. This
                is to minimize the number of logs and simplify accountability for controlled substances.
                3.5.4 Restocking apparatus with controlled substances will occur as soon as possible
                after start of shift when an apparatus transitions to PSA status. Contact the appropriate
                CMO to coordinate the reissue of controlled substances.
        3.6     Medic units and PSA are not to issue, exchange, surrender or accept controlled
        substances from any unit other than EMS 1 or EMS 2 unless directly authorized by a CMO. An
        email to the Narcotics Control Officer is required to document all such transactions.
        3.7     Controlled substances will not be left on out of service apparatus under any
        circumstances.
        3.8     Controlled substances are not to be carried on apparatus without a locking drug lock box.
        Controlled substances that are unable to be secured in a locking drug box may be transported on
        the person of the controller for a response or directly to a replacement apparatus with a
        functioning lock box.
        3.9     Stock levels on all apparatus except CMO vehicles:
                Fentanyl:          Minimum 2       Maximum 5
                Lorazepam:         Minimum 2       Maximum 5
                Morphine:          Minimum 2       Maximum 5
        a)      Stock levels may be exceeded temporarily by PSAs when recovering controlled
        substances from another PSAs transitioning to BLS status with the direct authorization of a chief
        medical officer. Inventory above stock level should be surrendered to the CMO as soon as
        possible.
        b)      Stock levels on CMO vehicles will be determined by the DC of EMS.

                   HIPAA and Public Information Release Memo
DATE:           05/20/05                                                                   EMS 05-15

TO:             All Personnel

THRU:           Soren Threadgill, Deputy Chief of EMS

FROM:           Stephen R Poggi, Chief Medical Officer

SUBJECT:        Designation of Hybrid Entity Status and Guidelines for Public Release of Private Medical
Information

The Municipality of Anchorage (“City”) has determined that it is a hybrid entity under the Health Insurance
Portability and Accountability Act of 1996 (“HIPAA” or the “Privacy Rule”). This determination was made
after a thorough analysis of the many and varied departments, programs and services at the City. As a
hybrid entity under HIPAA, the City as a whole is considered a covered entity whose business activities
include both covered and non-covered functions.

The City has designated the following programs as covered health care components within the hybrid
entity:
        • Anchorage Fire Department, with the exception of the Public Information Officer (PIO), Fire
            Prevention and Maintenance Shop; and[f1]
        • Department of Health and Human Services

In addition, the City’s self-insured group health plan is a covered entity for purposes of HIPAA. The City
included in its covered health care and health plan components those programs or services that would
satisfy the definition of a covered entity if each were operated as a separate legal entity.

No other City department, program or service is subject to HIPAA or this policy, including the Anchorage
Police Department.



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Determining that the City is a hybrid entity also means that the release of protected health information
(“PHI”) from a covered component to a non-covered component is considered a disclosure under HIPAA
and is not permitted unless there is a written individual authorization or a specific exemption allowing the
disclosure. The City has implemented safeguards to ensure that disclosures of PHI between covered and
non-covered departments, programs or services comply with HIPAA.

Anchorage Fire Department is Regulated

Specifically, the AFD is regulated as a covered health care provider under HIPAA. This determination
places stringent limits on the amount and type of information that AFD can release. For example, the
release of individually identifiable health information in response to requests from the media or the
general public involving all patients treated or evaluated by the AFD is now limited.

Covered AFD Operations
For covered AFD operations, information related to an individual’s medical condition or treatment is
confidential unless the individual signs a written authorization permitting public release. This applies to all
patients, including employees of AFD. PHI includes all information related to treatment, injuries, and any
physical or mental condition, including death. Any such information that can be identified with an
individual is protected by the Privacy Rule. AFD may not release or comment on this information without
the written authorization of the individual patient, unless a specific exemption exists under the Privacy
Rule. This policy applies even if the information is public knowledge or has been released by a non-
covered City department or program.

Non-covered AFD Operations
Non-covered members of AFD, which includes the PIO, are not subject to the Privacy Rule and may
release information obtained in the course of their work with the media or the general public as they deem
fit in their professional judgment. However, such individuals cannot have access to or release PHI
learned from those who work within the covered operations of the AFD.

Event Information
While an individual’s PHI is confidential, event information is not. For example, AFD is permitted to
describe a vehicle accident or building collapse to the media. It is also acceptable to describe rescue or
extrication of individuals in general terms; AFD may release a statement that three individuals were
rescued and transported to area hospitals.

However, in releasing event information, AFD will not release:
Descriptions of injuries.
Age, gender or any other identifying characteristics if there is a reasonable basis to believe the
information can be used to identify the individual

Private medical events are never acceptable for comment to neighbors, the general public or the media
unless the individual gives written authorization. AFD is unable to provide information about specific
medical events in private venues.

The public right to know about covered AFD operations is real but does not extend into the private
medical information of the people we care for.

The following guidelines summarize the new requirements as they relate to AFD operations and should
be helpful to you as you respond to information requests.

Events with No Release of Medical or Event Information:
Primarily medical events:
In private or public venues

Events involving Injury:
In private venues
As a result of apparent domestic violence or abuse
Apparent accidental origin
Not extending into the public domain

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Events with Information Acceptable for Release:
Traumatic or Catastrophic Events in a Public Venue:
Motor Vehicle Accidents
Fires, including fire origin, spread, extent of damage, displacement of occupants
Explosions
Evacuations, $ value of damage, activities to contain or control event
Rescues of persons and number of individuals transported to hospitals, sheltered or aided
Search and Rescue activities
Criminal or terrorist activities with or without casualties
Public hazardous material releases

Disaster Relief Efforts or Mass Casualty Events:
Method for patients’ personal representatives to locate them
Hotline numbers or collection point
Information sufficient to allow representatives to locate the missing

Releases to Family Members, Personal Representatives or Public Health Authority:
Location of patients
Available condition information
Information necessary to confirm identities or locate missing persons

Incident Information Released Publicly only with Individual Written Authorization or Exception under the
Privacy Rule:

Medical information:
        In conjunction with personally identifying information that could be combined with other commonly
available source information to identify patients
Medical information is the description of injuries, burns, death, or any condition relating to the health or
treatment of an individual.

The AFD cannot release patient’s medical condition to the media, even when the information is in the
public domain, without a written authorization from the patient. The release of registry type information,
including a one word condition, such as “good” or “critical,” does not typically apply to AFD operations.

                                        Infectious Disease
Extracted from P&I 901-2

Effective 11/04/97
1.0         Procedure and Instruction

1.1         The Anchorage Fire Department recognizes the inherent hazards of emergency work related
            to blood borne pathogens exposures.

1.1.2       The Department's goal is to minimize employee exposures to blood borne pathogens and
            other potentially infectious materials using recognized medical industry Exposure Control
            Plans.

1.1.3       The Department shall implement and maintain this Infectious Disease Control Standard for
            blood borne pathogen exposure using OSHA CFR 29, 1910.1030 as a guideline.

1.1.4       The EMS Operations Division & Health and Safety Officer (HSO) shall be responsible for
            implementing and maintaining all aspects of this Procedure, and Instruction (P & I).

1.2         Engineering & Work Practice Controls

1.2.1       Universal Precautions shall be observed to prevent contact with blood or other potentially
            infectious materials. Under circumstances in which differentiation between body fluid types is
            difficult or impossible, all body fluids shall be considered potentially infectious materials.
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           Where the risk of exposure remains in spite of controls, personal protective equipment shall
           also be used.

1.2.2      Engineering controls shall be examined and maintained or replaced on a regular schedule to
           ensure their effectiveness.

1.2.3      All procedures involving blood or other potentially infectious materials shall be performed in
           such a manner as to minimize splashing, spraying, spattering, and generation of droplets of
           these substances.

1.2.3.1    Techniques and equipment that require mouth suctioning of blood or other potentially
           infectious materials are prohibited.

1.2.3.2    Hand washing facilities which are readily accessible to employees will be provided by the
           Department. The Department shall ensure that employees wash hands and any other skin
           with soap and water or flush mucous membranes with water immediately or as soon as
           feasible following contact with blood or other potentially infectious materials and after removal
           of gloves or other personal protective equipment.

1.2.3.3    When provision of hand washing facilities is not feasible, an appropriate antiseptic hand
           cleanser in conjunction with clean cloth/paper towels or antiseptic towelettes will be provided.
           When antiseptic hand cleansers or towelettes are used, hands shall be washed with soap
           and running water as soon as feasible.

1.2.3.4    Contaminated needles and other contaminated sharps shall not be bent, recapped, or
           removed except where the Department can demonstrate that no alternative is feasible or that
           such action is required by a specific medical procedure. Shearing or breaking of
           contaminated needles is prohibited.

1.2.3.5    Such recapping or needle removal must be accomplished through the use of a mechanical
           device or a one-handed technique.

1.2.3.6    Immediately or as soon as possible after use, contaminated disposable sharps shall be
           placed in appropriate containers until properly processed. The containers shall be (1)
           puncture resistant, (2) appropriately labeled or color-coded as provided herein, (3) leak proof
           on the sides and bottom, and (4) closable.

1.2.4      Eating, drinking, smoking, applying cosmetics or lip balm, and handling contact lenses are
           prohibited in all Worksites or Work Areas or where there is a reasonable likelihood of
           occupational exposure.

1.2.4.1    Food and drink shall not be kept in refrigerators, freezers, shelves, cabinets or on
           countertops or bench tops where blood or other potentially infectious materials are present.

1.2.4.2    Specimens of blood or other potentially infectious materials shall be placed in a container
           which prevents leakage during collection, handling, processing, storage, transport, or
           shipping.

1.2.4.3    The container for storage, transport, or shipping shall be appropriately labeled or color-coded
           as provided herein, and closed prior to being stored, transported, or shipped. When universal
           precautions are used in the handling of all specimens, the labeling and color-coding of
           specimens is not necessary provided containers are recognizable as containing specimens.
           This exemption applies only while such specimens and/or containers remain within the
           Department's control.

1.2.4.4    If outside contamination of the primary container occurs, the primary container shall be
           placed within a second container which prevents leakage during handling, processing,
           storage, transport, or shipping and is appropriately labeled or color-coded.


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1.2.4.5    Equipment which may become contaminated with blood or other potentially infectious
           materials shall be examined prior to servicing or shipping and shall be decontaminated as
           necessary, unless the Department can demonstrate that decontamination of such equipment
           or portions of such equipment is not feasible.

1.2.4.6    An appropriate label as provided herein shall be attached to the equipment stating which
           portions remain contaminated.

1.2.5      Personal Protective Equipment

1.2.5.1    When there is risk of occupational exposure, the Department shall provide appropriate
           personal protective equipment such as, but not limited to, bunker coat and pants, AFD
           “personal protective equipment packs”, gloves of different sizes, gowns, arm protectors, face
           shields or masks and eye protection, mouthpieces, resuscitation bags, pocket masks, or
           other ventilation devices[F2].

1.2.5.2    Hypoallergenic gloves, glove liners, powderless gloves, or other similar alternatives shall be
           readily accessible to those employees who are allergic to the gloves normally provided.

1.2.5.3    The Department will clean, launder, and/or dispose of personal protective equipment as
           appropriate, or provide facilities for the employee to do so.

1.2.5.4    The Department will repair or replace personal protective equipment as needed to maintain
           its effectiveness. All re-supply of personal protective equipment carried in the AFD PPE
           packs shall be done by the AFD through AFD medical supply.

1.2.5.5    The Department shall ensure that each employee uses appropriate personal
           protective equipment unless it can be shown that the employee temporarily and
           briefly declined to use personal protective equipment when, under rare and
           extraordinary circumstances, it was the employee's professional judgment that in the
           specific instance its use would have prevented the delivery of health care or public
           safety services or would have posed an increased hazard to the safety of the worker
           or co-worker. When the employee makes this judgment, the circumstances shall be
           investigated and documented in order to determine whether changes can be
           instituted to prevent such occurrences in the future.

1.2.5.6    Personal protective equipment will be considered "appropriate" only if it does not permit blood
           or other potentially infectious materials to pass through to or reach the employee's uniforms,
           jumpsuits, undergarments, skin, eyes, mouth, or nose under normal conditions of use and for
           the duration of time which the protective equipment will be used.

1.2.5.7    All contaminated personal protective equipment shall be removed prior to leaving the Work
           Area and placed in a designated area or container for storage, washing, decontamination or
           disposal. Note: Turnout coats & pants should remain in the Work Area based on NFPA
           1581, Section 3-3.3, which states - “protective clothing, and protective equipment shall not be
           stored in kitchen, living, sleeping, or personal hygiene areas, nor shall it be stored in personal
           clothing lockers.”

1.2.5.8    If a personal protective equipment garment is penetrated by blood or other potentially
           infectious materials, the garment shall be removed immediately or as soon as feasible.

1.2.5.9    If soak-through occurs to jumpsuits, uniforms, or undergarments, they shall be removed prior
           to leaving the Work Area

1.2.6      Gloves are required to be worn in all situations of anticipated physical contact of any patient;
           and when handling or touching contaminated items or surfaces.

1.2.6.1    Disposable (single use) gloves such as surgical or examination gloves shall be replaced as
           soon as practical when contaminated or are torn, punctured, or when their ability to function

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           as a barrier maybe compromised. The department shall require gloves to be worn for all
           vascular access procedures. (i.e. starting IV’s)

1.2.6.2    Disposable (single use) gloves shall not be washed or decontaminated for re-use.

1.2.6.3    Utility gloves (reusable, heavy, plastic or rubber) may be decontaminated for re-use if the
           integrity of the glove is not compromised. However, they must be discarded if they are
           cracked, peeling, torn, punctured, or exhibits other signs of deterioration or when their ability
           to function as a barrier maybe compromised.

1.2.6.4    Masks in combination with eye protection devices, such as goggles or glasses with solid slide
           shields or chin-length face shields on helmets shall be worn whenever splashes, spray,
           spatter, or droplets of blood or other potentially infectious materials may be generated and
           eye, nose, or mouth contamination can be reasonably anticipated[F3]. When performing
           airway procedures such as, suctioning, oral, or nasal airway insertion, combitube insertion,
           intubation procedures, and bag valve mask (BVM) operations, it’s required that skin, eye, and
           respiratory PPE be worn at all times during theses procedures.

1.2.6.5    Additional protective clothing such as gowns, aprons, arm protectors or similar outer
           garments shall be worn in occupational exposure situations as required. The type
           and characteristics will depend upon the task and degree of exposure anticipated.

1.2.6.6    AFD “personal protective equipment packs” shall be worn by all personnel when working on
           MICU apparatus responding on all medical calls. AFD “PPE packs” shall be carried by all
           personnel when working on Fire Apparatus & shall be worn when responding on all medical
           calls. (Note: regardless of which apparatus personnel are working on, the “PPE pack” must
           be available at the site of patient care/contact in the field)

1.2.6.8    In addition to the above mentioned PPE, Jumpsuits shall be worn in all occupational
           exposure situations when bunker clothing is not worn. (e.g. all medical responses) Although
           this gear is not designated as personal protective equipment, it will give a limited measure of
           protection to other daily work uniforms, undergarments or skin on the majority of medical
           calls.

1.2.7      Housekeeping

1.2.7.1    Each Worksite and Work Area shall be maintained in a clean and sanitary condition. The
           Department shall implement an appropriate written schedule for cleaning and method of
           decontamination based upon the location within the facility, type of surface to be cleaned,
           type of soil present, and tasks or procedures being performed in the area.

1.2.7.2    Regulated waste shall be placed in containers which are (1) closable, (2) constructed to
           contain all contents and prevent leakage of fluids during handling, storage, transport, or
           shipping, (3) labeled or color-coded as provided herein, and (4) closed prior to removal to
           prevent spillage or protrusion of contents during handling, storage, transport, or shipping.

1.2.7.3    If outside contamination of the regulated waste container occurs, it shall be placed in a
           second container. The second container shall meet all of the requirements of the original
           container.

1.2.7.4    Contaminated sharps shall be placed immediately or as soon as feasible in containers that
           are (1) closable, (2) puncture resistant, (3) leak proof on its sides and bottom, and (4) labeled
           or color-coded as provided herein.

1.2.7.5    During use, containers for contaminated sharps shall be easily accessible to personnel and
           located as close as is feasible to the immediate area where sharps are used or can be
           reasonably anticipated to be found (e.g., ambulances , trauma kits, etc.). They shall be
           maintained upright throughout use and not be allowed to overfill.


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1.2.7.6     When moving containers of contaminated sharps from the area of use, the containers shall
            be closed immediately prior to removal or replacement to prevent spillage or protrusion of
            contents and placed in a secondary container if leakage is possible.

1.2.7.7     Contaminated laundry shall be handled as little as possible with a minimum of agitation.
            Contaminated laundry, if not laundered immediately, shall be bagged or containerized and at
            the location where it was used and shall not be sorted or rinsed in the location of use.

1.2.7.8     Contaminated laundry shall be placed and transported in bags or containers labeled or color-
            coded as provided herein. When a facility utilizes Universal Precautions in the handling of all
            soiled laundry, alternative labeling or color-coding is sufficient if it permits all employees to
            recognize the containers as requiring compliance with universal precautions.

1.2.7.9     Whenever contaminated laundry is wet and presents a reasonable likelihood of soak-through
            of or leakage from the bag or container, the laundry shall be placed in a second bag or
            container which prevents soak-through and/or leakage of fluids to the exterior before being
            transported.

1.2.8       Labels and Color-coding

1.2.8.1     Warning labels shall be affixed to containers of regulated waste, refrigerators and freezers
            containing blood or other potentially infectious material, and other containers used to store,
            transport or ship blood or other potentially infectious materials, except as provided below.

1.2.8.2     These labels shall be fluorescent orange or orange-red or predominantly so, with lettering or
            symbols in a contrasting color.

1.2.8.3     Labels are required to be affixed as close as feasible to the container by string, wire,
            adhesive, or other method that prevents their loss or unintentional removal.

1.2.8.4     Red bags or red containers may be substituted for labels.

1.2.8.5     Individual containers of blood or other potentially infectious materials that are placed in a
            labeled container during storage, transport, shipment or disposal are exempted from the
            labeling requirement.

1.2.8.6     Labels required for contaminated equipment shall also state which portions of the equipment
            remain contaminated, if any.

1.2.9       Records

1.2.9.1     Medical records shall be established and maintained by the Municipality's Central Files
            Division in accordance with 29 CFR 1910.1030 and other applicable regulations (ADA). The
            medical record shall include (1) the name and social security number of the employee, (2) a
            copy of the employee's hepatitis B vaccination status including the dates of all the hepatitis B
            vaccinations and any medical records relative to the employee's ability to receive
            vaccinations, (3) a copy of all results of examinations, medical testing, and follow-up
            procedures, (4) the Department's copy of the health care professional's written opinion, (5)
            and a copy of the information provided to the health care professional.

1.2.9.2     The Municipality of Anchorage shall ensure that employee medical records are kept
            confidential and are not disclosed or reported without the employee's express written consent
            to any person within or outside the workplace except as may be required by law.

1.2.9.3     The Municipality shall maintain medical records for at least the duration of employment plus
            30 years in accordance with CFR 29 1910.1030.

1.2.9.4     Training records relative to infectious disease control will be kept and maintained by the
            Anchorage Fire Department Training Division. Training records shall include (1) the dates of
            the training sessions, (2) contents or a summary of the training sessions, (3) names and
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                qualifications of persons conducting the training, and (4) the names and job titles of all
                persons attending the training sessions.

1.2.9.5         Training records shall be maintained for at least three years from the date on which the
                training occurred.

1.2.9.6         All records required to be maintained by this section shall be made available to the Assistant
                Secretary and the Director of OSHA for examination and copying.

1.2.9.7         Employee training records shall be provided upon request for examination and copying to
                employees, or employees' representatives.

1.2.9.8         Employee medical records shall be provided upon request for examination and copying to the
                subject employee, or to anyone having written consent of the subject employee.

1.2.9.9         The Anchorage Fire Department shall comply with the requirements involving transfer of
                records set forth in OSHA CFR 29, 1910.1030.

1.2.9.10        If the Department ceases to do business and there is no successor employer to receive and
                retain the records for the prescribed period, the department shall notify OSHA at least three
                months prior to their disposal and transmit them to their Director, if required by the Director to
                do so, within that three month period.

1.3             Hepatitis B Vaccination

1.3.1           The Department shall make available the hepatitis B vaccination series to all employees who
                are subject to occupational exposure, and post-exposure evaluation and follow-up to all
                employees who have had an exposure incident.

1.3.2           Hepatitis B vaccination shall be made available after the employee has received the required
                training and within 10 working days of initial assignment unless the employee has previously
                received the complete hepatitis B vaccination series and antibody testing has revealed that
                the employee is immune, or unless the vaccine is contraindicated for medical reasons.

1.3.3           The employer shall ensure that employees who decline to accept the vaccination offered by
                the employer sign a declination statement.

1.3.4           Following a report of a confirmed exposure incident, the Department shall make immediately
                available to the exposed employee a confidential medical evaluation and follow-up, including
                at least the following elements:

           1.   Documentation of the route(s) of exposure and the circumstances under which the
           exposure incident occurred using exposure forms 53-109 and 53-116.

           2.     Identification and documentation of the source individual, unless the Department can
           establish that identification is not feasible or prohibited by state or local law.

           3.       Collection and testing of blood for HBV and HIV serological status.

           4.    Post-exposure prophylaxis, when medically indicated, as recommended by the US Public
           Health Service.

           5.       Counseling.

           6.       Evaluation of reported illness.

1.3.5           The Department shall ensure that the health care professional responsible for the employee's
                Hepatitis B vaccination is provided a copy of this policy and the following information:

           1.  A copy of OSHA CFR 29, 1910.1030.
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          2.       A description of the exposed employee's duties as they relate to the exposure incident.

          3.    Documentation of the route(s) of exposure and circumstances under which exposure
          occurred using forms 53-109 and 53-116.

          4.       Results of the source individual's blood testing, if available.

          5.    All medical records relevant to the appropriate treatment of the employee including
          vaccination status.

1.3.6          The Department shall obtain and provide the employee with a copy of the evaluating health
               care professional's written opinion within 15 days of the completion of the evaluation.

1.3.6.1        The health care professional's written opinion for Hepatitis B vaccination shall be limited to
               whether Hepatitis B vaccination is indicated for an employee, and if the employee has
               received such vaccination.

1.3.6.2        The health care professional's written opinion for post-exposure evaluation and follow-up
               shall be limited to the following information:

          1.       That the employee has been informed of the results of the evaluation.

          2.    That the employee has been told about any medical conditions resulting from exposure to
          blood or other potentially infectious materials which require further evaluation or treatment.

1.3.6.3        All other findings or diagnoses shall remain confidential and shall not be included in the
               written report.

1.4            Tuberculosis

1.4.1          The Department will maintain active surveillance for tuberculosis and for skin-test
               conversions among its personnel. Its intended goal will be to prevent the occurrence of
               tuberculosis and its spread to other personnel, as well as the public which we serve.

1.4.2          At the time of employment all new personnel, including those with a history of “Bacillus of
               Calmette and Guerin” (BCG) vaccination, should receive a Mantoux tuberculin skin test
               unless a previously positive reaction can be documented or completion of adequate
               preventive therapy or adequate therapy for active disease can be documented.

1.4.3          Initial and follow-up tuberculin skin tests should be administered and interpreted according to
               current medical guidelines.

1.4.4          Current personnel with a documented history of a positive tuberculin test, or adequate
               treatment for disease of preventive therapy for infection, should be exempt from further
               screening unless they develop symptoms suggestive of tuberculosis.

1.4.4.1        Periodic retesting of PPD-negative personnel should be conducted to identify persons whose
               skin tests convert to positive. In general, the frequency of repeat testing should be based on
               the risk of developing new infection. Personnel should be retested at least annually.
               Personnel who are frequently exposed to patients with tuberculosis or who are involved with
               potentially high-risk procedures (e.g. bronchoscopy, sputum induction, endotracheal
               intubation and suctioning procedures) can be retested at least every six months. This can be
               done at the employee's request or if they develop symptoms suggestive of tuberculosis at the
               Department's request. Data on skin-test conversions should be periodically reviewed so that
               the risk of acquiring new infection may be estimated for various Department operations. On
               the basis of this analysis, the frequency of retesting may be altered accordingly.

1.4.5       In addition to periodic screening, personnel should be evaluated if they have been exposed to
            a potentially infectious tuberculosis patient (one who is confirmed to have tuberculosis
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           disease and is capable of spreading the germs to others) for whom the infection control
           procedures outlined (HEPA respirator) have not been followed.

1.4.5.1    Unless a negative test has been documented within the preceding three months, each
           exposed employee should receive a Mantoux Tuberculin Skin Test as soon as possible after
           exposure and should be managed in the same way as other contacts (except those already
           known to be positive reactors). If the initial skin test is negative, the test should be repeated
           12 weeks after the exposure ended.

1.4.5.2    Exposed persons with skin-test or with symptoms suggestive of tuberculosis should receive
           chest radiographs. Persons with previously known positive skin-test reactions who have been
           exposed to an infectious patient do not require a repeat skin test or a chest radiograph unless
           they have symptoms suggestive of tuberculosis.

1.4.5.3    Personnel with positive tuberculin skin tests or with skin-test conversions on repeat testing or
           after exposure should be clinically evaluated for active tuberculosis. Persons with symptoms
           suggestive of tuberculosis should be evaluated regardless of skin-test results.

1.4.5.4    Personnel with positive skin tests should be evaluated for risk of HIV infection. If HIV
           infection is considered a possibility, counseling and HIV-antibody testing should be strongly
           encouraged.

1.4.5.5    All personnel with a history of tuberculosis or positive tuberculin tests are at risk for
           contracting tuberculosis in the future. These people should be reminded periodically
           that they should promptly report any pulmonary symptoms. If symptoms of
           tuberculosis should develop; the person should be evaluated immediately.

1.4.5.6    Routine chest films are not required for asymptomatic, tuberculin-negative personnel. After
           the initial chest radiograph is taken, personnel with positive skin-test reactions do not need
           repeat chest radiographs unless symptoms develop that may be due to tuberculosis.

1.4.6      Personnel with current pulmonary or laryngeal tuberculosis pose a risk to patients and other
           personnel while they are infectious; therefore, stringent work restrictions for these persons
           are necessary. They should be removed from duty until adequate treatment is instituted,
           cough is resolved, and sputum is free of bacilli on three consecutive smears. AFD personnel
           with current tuberculosis at sites other than the lung or larynx usually do not need to be
           removed from duty if concurrent pulmonary tuberculosis has been ruled out.

1.4.6.1    Personnel who discontinue treatment before the recommended course of therapy has been
           completed should not be allowed to work until treatment is resumed, and adequate response
           to therapy is documented, and they have negative sputum smears on three consecutive
           days.

1.4.6.2    Personnel who are otherwise healthy and receiving preventive treatment for tuberculosis
           infection should be allowed to continued usual work activities.

1.4.6.3    Personnel who cannot take or do not except or complete a full course of preventive therapy
           should have their work situations evaluated to determine whether reassignment is indicated.
           Work restrictions may not be necessary for otherwise healthy persons who do not accept or
           complete preventive therapy.

1.4.6.4    These tuberculosis surveillance procedures are in accordance with the Dept. of Health &
           Human Services, Atlanta’s Center for Disease Control, and OSHA’s recommendations.

1.4.7      Training

1.4.7.1    The Department shall conduct information and training programs for all operations personnel
           and those at risk for occupational exposure. For new employees the information and training
           shall occur prior to their initial assignment. Refresher training will be given at least annually.

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1.4.7.2        The Department shall provide additional training when changes such as modification of tests
               or procedures or institution of new tasks or procedures affect the employee's risk of
               occupational exposure.

1.4.7.3        Material appropriate in content and vocabulary to educational level, literacy, and language of
               employees will be used. The person conducting the training shall be knowledgeable in the
               subject matter covered by the elements contained in the training program as it relates to the
               Department.

1.4.7.4        Information and education will include but not be limited to:

          A.       A copy and explanation of this P&I and OSHA CFR 29, 1910.1030.

          B.     Information and education on the epidemiology and symptoms of blood borne diseases,
          how blood borne diseases are transmitted, and prevention of diseases including, but not limited
          to, hepatitis A, B, and hepatitis non-A/non-B or hepatitis C, and human immunodeficiency virus.
          Information & education will also be given on airborne diseases such as meningitis,
          tuberculosis, and tetanus.

          C.     Information on the hepatitis B vaccine, including information on its efficacy, safety,
          method of administration, the benefits of being vaccinated, and that the vaccine and vaccination
          will be offered free of charge to the employee.

          D.     Information and explanation on record keeping requirements which will include medical
          and training records and transfer of those records.

          E.    An explanation of the appropriate methods for recognizing tasks and other activities that
          may involve exposure to blood and other potentially infectious materials.

          F.    An explanation of the methods (and limitations of those methods) that will prevent
          exposure to blood borne pathogens, including appropriate engineering & work practice controls
          (universal precautions, hand washing, needles & sharps, sharps disposal containers,
          environmental surfaces, food & beverages, mouth pipetting, blood samples & containers, body
          substance isolation, contaminated equipment).

          G.    Information and explanation on PPE requirements, types, proper use, location, removal,
          handling, decontamination and disposal, and the selection of appropriate PPE.

          H.    Information and explanation on housekeeping requirements which shall include work site
          decontamination, regulated waste containers, and laundry.

          I.     Information on the appropriate actions to take and persons to contact in an emergency
          involving blood or other potentially infectious materials which shall include an explanation of the
          procedure to follow if an exposure incident occurs, including the method of reporting the incident
          and the medical follow-up that will be made available, information on the post-exposure
          evaluation and follow-up that the Department is required to provide for the employee following
          an exposure incident.

          J.       An explanation of the signs and labels and/or color-coding requirements.

          K.     An opportunity for interactive questions and answers with the person conducting the
          training.

1.4.8          Definitions

               Blood: human blood, human blood components, and products made from human blood.

            Blood borne pathogens: pathogenic micro-organisms that are present in human blood and
            can cause disease in humans. These pathogens include hepatitis B virus (HBV) and human
            immunodeficiency virus (HIV).
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            Cerebrospinal: pertaining to the brain and spinal cord.

            Contaminated: the presence or the reasonably anticipated presence of blood or other
            potentially infectious material on an item or surface.

            Contaminated laundry: laundry which has been soiled with blood or other potentially
            infectious materials or may contain sharps.

            Contaminated sharps: any contaminated object that can penetrate the skin including
            needles, scalpels, disposable razors or broken glass.

            Decontamination: the use of physical or chemical means to remove, inactivate, or destroy
            blood borne pathogens on a surface or item to the point where they are no longer capable of
            transmitting infectious particles and the surface or item is rendered safe for handling, use, or
            disposal.

            Engineering controls: controls (e.g., sharps disposal containers, regulated waste containers)
            that isolate or remove the blood borne pathogens hazard from the workplace.

            Exposure incident: a specific eye, nose, mouth, non-intact skin, or parenteral contact with
            blood or other potentially infectious materials that results from the performance of an
            employee's duties.

            Gloves: disposable gloves are designed to provide limited protection for existing abrasions
            and cuts during emergency operations and station cleaning by providing a barrier against
            body fluids and disinfectants. Structural fire fighting gloves meet the requirements of NFPA
            1973, Standard on Gloves for Structural Fire Fighting.

            Hand washing facility: a facility providing an adequate supply of running potable water, soap
            and single use towels or hot air drying machines.

            Leak proof Bags: bags that are sufficiently sturdy to prevent tearing or breaking and can be
            sealed securely to prevent leakage. Such bags are red in color or display the universal
            biohazard symbol.

            Licensed health care professional: a person whose legally permitted scope of practice allows
            him or her to independently administer hepatitis B vaccination and post-exposure evaluation
            and follow-up.

            Occupational exposure: reasonably anticipated skin, eye, mucous membrane, or parenteral
            contact with blood or other potentially infectious materials that may result from the
            performance of an employee's duties.

            Other potentially infectious materials: semen; vaginal secretions; cerebrospinal, synovial,
            pleural, amniotic, or any other body fluid that is visibly contaminated with blood; any body
            fluid where it is difficult or impossible to differentiate between body fluids; any unfixed tissue
            or organ (other than intact skin) from a human (living or dead).

            Parenteral: piercing mucous membranes or the skin barrier through such events as needle
            sticks, bites, cuts, and abrasions.

            Pathogen: any disease-producing microorganism or material.

            Personal protective equipment (PPE): specialized clothing or equipment (e.g., gowns,
            aprons, lab coats, sterile arm/sleeve protectors, gloves, hoods, eye and face protection,
            bunker coats and pants) worn by an employee for protection against blood borne pathogens.
            General work clothes (e.g., jumpsuits, uniforms, pants, shirts, or blouses) not intended to
            function as protection against a hazard are not considered to be personal protective
            equipment.
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            PPE packs: A personal protective equipment bag worn around the waist that has as a
            minimum the following protective gear: safety glasses, full face shield, masks, multiple pairs
            of medical gloves, CPR one-way valve or blob mask, disposable sterile arm sleeve protector,
            disposable gowns, waterless anti-septic hand cleaner, & one small bio-hazard bag. Other
            medical supplies used for patient care as determined by the employee. (i.e., kerlex
            bandages, 4 X 4’s, etc.)

            Regulated medical waste: liquid or semi-liquid blood or other potentially infectious materials,
            contaminated items that would release blood or other potentially infectious materials in a
            liquid or semi-liquid state if compressed, items that are caked with dried blood or other
            potentially infectious materials and are capable of releasing these materials during handling,
            contaminated sharps, and pathological and micro-biological waste containing blood or other
            potentially infectious materials.

            Resuscitation equipment.: respiratory assist devices such as bag-valve masks, oxygen valve
            resuscitators, pocket masks, and other ventilation devices that are designed to provide
            artificial respiration or assist with ventilation of a patient.

            Splash-resistant eye wear: safety glasses, prescription eye wear (with side shields), goggles,
            or chin-length face shields that, when properly worn, provide limited protection against
            splashes, spray, spatter, droplets, or aerosols of body fluids or other potentially infectious
            material.

            Source individual: any individual, living or dead, whose blood or other potentially infectious
            materials may be a source of occupational exposure to the employee.

            Sterilization: the use of a physical or chemical procedure to destroy all microbial life including
            highly resistant bacterial endospores.

            Universal precautions: an approach to infection control in which all human blood and certain
            human body fluids are treated as if known to be infectious for HIV, HBV, and other blood
            borne pathogens.

            Work practice controls: controls that reduce the likelihood of exposure by altering the manner
            in which a task is performed (e.g., prohibiting recapping of needles by a two-handed
            technique).

            Worksite or Work area: apparatus rooms, fire apparatus, patient compartments of MICUs,
            and hospital areas in which employees deliver or pick up patients.

                                          Medical Control
Extracted from P&I 905-7 v 1.1

Purpose
This document establishes the authority of the Emergency Medical Services Board (EMSB) concerning
AFD EMS issues.

Policy
The policy of the Anchorage Fire Department is to provide for professional guidance and oversight of its
Emergency Medical Services. As such, the Emergency Medical Services Board (EMSB) is given
authority (in conjunction with the DC of EMS) in the area of medical practice by AFD members as
described.
Procedure & Instruction

Authority to Practice
Emergency Medical Service takes place by authority of the Fire Chief, and under the supervision of the
Anchorage Fire Department Deputy Chief of EMS.

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The authority of the EMS Board (through their agent, the Medical Director of the AFD) applies to any
response-related medical activity in fire suppression, communications, and other operations of the AFD
(AMC 16.95).

EMS Board authority over EMS practice is directly reflected in three forms:

        Provision of sponsorship, under State of Alaska medical licensing and certification regulations, for
        each:
                 Mobile Intensive Care Paramedic (MICP)
                 Emergency Medical Technician (EMT)
                 Emergency Trauma Technician (ETT)
        Certification of medical training.
        Oversight of written standing medication orders and treatment protocols.

Sponsorship
Sponsorship and medical control supervision is formally provided on a day to day basis under the
physician license of the Anchorage Fire Department Medical Director. In practice, however, sponsorship
policy and procedures are a function of the EMSB as a whole.

The sponsorship role of the EMS Board includes the authority and responsibility to investigate any
suspected problem brought before them by the Medical Director that could compromise medical care.

Examples of issues subject to investigation include, but are not limited to: medical proficiency or
performance, medical ethics, and substance abuse.

Such an investigation may result in limitation of practice or suspension of sponsorship.

Suspension of sponsorship or limitation of practice may be initiated by the Medical Director. Any such
suspension or limitation may be adjudicated by the EMS Board at their next full meeting.

Job suspension, limitation of practice, or disciplinary action may be initiated by the Department, and must
be consistent with the IAFF contract and MOA personnel rules.

The Medical Director is obligated to report any suspension (or other action related to an issue that could
potentially affect MICP license status) to the State Medical Board, or, in situations involving EMT or ETT
certification, to the State Community Health and Emergency Medical Services Section.

Present EMS Board policy is that sponsorship of both Anchorage Municipal certification and State of
Alaska licensure or certification cease when a MICP, EMT, or ETT leaves the Department.

Training and Certification
A MICP who is employed by the Department and sponsored by the EMS Board is granted municipal
paramedic certification. Renewal of municipal paramedic certification involves three elements:
1. Completion of annual training hour requirements.
2. Satisfactory participation in a multi-faceted on-going education and testing process conducted under
    supervision of the EMS Board.
3. The EMS Board’s continuing satisfaction that the paramedic meets proficiency standards.

An EMT or ETT who is employed by the Department and sponsored by the EMS Board is granted
municipal certification. Renewal of municipal certification involves three elements:
1. Completion of annual training hour requirements.
2. Satisfactory participation in a multi-faceted on-going education and testing process conducted under
   supervision of the Board.
3. The EMS Board’s continuing satisfaction that the technician meets proficiency standards.

MICPs, EMTs and ETTs are expected to maintain an acceptable level of medical proficiency. If a MICP,
EMT or ETT exhibits an unacceptable level of medical performance, an interim evaluation period may be
required. Unsatisfactory completion of this evaluation procedure may be grounds for action as described
herein.
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Standing Medication Orders and Treatment Protocols
MICP personnel are at all times responsible for complying with all current written standing medication
orders and protocols in the Medical Operations Manual.

EMT and ETT personnel are at all times responsible for complying with those sections of the Medical
Operations Manual pertinent to their respective level of certification, and for following those orders and
protocols.

Substantial deviation from the orders and protocols requires contact with the receiving physician. A
special medical report shall be submitted immediately after any deviation of treatment protocols or
medication standing orders. The special medical report will be sent through the CMO to the DC of EMS,
with a copy to the Medical Director. All special medical reports will be reviewed by the above recipients to
determine if further action is required.

EMS numbered memos may qualify or supercede protocols or Standing Medication Orders as written in
the Medical Operations Manual.

Knowledge of standing medication orders and treatment protocols is mandatory and is subject to periodic
written testing during the term of Anchorage Municipal certification.

Unsatisfactory test results will lead to counseling and re-testing. Unsatisfactory re-test results will serve
as cause for disciplinary action and/or loss of certification and sponsorship. Multiple test failures are also
cause for such action.

Lines of Medical Authority
While it is recognized that the emergency medical care provided by the AFD is generally carried out by
more than one individual, a clear delineation of medical authority is a vital aspect of the EMS system.
This is necessary, both to alleviate conflicts in opinion concerning appropriate medical care, and to
maintain a high quality of medical care by providing a mechanism for establishing accountability in patient
care decisions.

Medical authority is established in the following order:

1.   Medical Director, for patient care decisions, and DC of EMS, concerning operational issues.
2.   Chief Medical Officer
3.   FF/PM III
4.   FF/PM, Senior Captain PM, Captain/PM, Engineer PM
5.   Paramedic Intern
6.   EMT III
7.   EMT II
8.   EMT I
9.   ETT

The MICP that will complete the PCR, either directly or in supervision of the emergency care provider (for
example an EMT or FF/PM Intern), is the Provider of Record and retains authority and responsibility
regarding the treatment of the patient. In instances of conflict between two MICPs of equal authority, then
the Provider of Record may retain medical authority over the patient by accompanying the patient during
transport and completing the PCR.

                                  Medical Operations Manual
Extracted from P&I 905-9

Effective 12/15/00
Procedure and Instruction

The Medical Operations Manual will be developed and maintained under the direction of the Medical
Director.


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Any member who recognizes a situation for which an addendum to the MOM would be appropriate may
request through channels an update of the Medical Operations Manual.

The Medical Operations Manual will be reviewed and updated as necessary at least annually.

MOM Manuals will be maintained at each fire station and operations work site.




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         Special Annex: WMD Medical Strike Team Standing
                  Medication Orders and Protocols
                                     Nerve Agent Exposure

Nerve agents consist of organophosphate formulations developed specifically for use as weapons,
agents commercially formulated and available as pesticides and a chemically unrelated group known as
carbamates which produce the same biological effects as the organophosphate compounds.
Carbamates are commercially used both medically and as insecticides. Some typical agents are:

Organophosphate Compounds                          Carbamate Compounds
GA (Tabun)                                         Physostigmine (Antilirium)
GB (Sarin)                                         Neostigmine (Prostigmine)
GD (Soman)                                         Pyridostigmine (Mestinon)
VX                                                 Carbaryl (Sevin)
GF
Parathion
Malathion

Nerve agents are cholinesterase inhibitors which prevent the hydrolysis of the neurotransmitter
acetylcholine at the nerve end organ. The result is an accumulation of acetylcholine and constant
stimulation of the end organ. This occurs in the cholinergic nervous system at muscarinic sites (smooth
muscle and exocrine glands) and nicotinic sites (skeletal muscle and sympathetic pre-ganglia). Atropine,
the principle antidote for nerve agent toxicity, works by blocking acetylcholine primarily at the muscarinic
sites and has little effect on the nicotinic sites. Pralidoxime chloride (2PAM CL, Protopam) removes
nerve agent from acetylcholinesterase and thus allows the enzyme to once again hydrolize acetylcholine.
The effects of pralidoxime are seen primarily at the nicotinic sites.

Since it may be difficult or impossible to rapidly identify an agent used as a weapon, treatment for nerve
agent exposure must be based on presenting symptoms and a high index of suspicion that an exposure
has occurred.

Generally, nerve agents produced for military use are more highly toxic than those produced
commercially. It is important to note that nerve agents, like many other poisons, may be inhaled, ingested
or absorbed through the skin. Symptoms will vary in severity depending on the quantity of agent and
route of exposure.

Muscarinic effects will be seen as miosis, rhinorrhea, shortness of breath from pulmonary congestion and
the acronym SLUDGE which stands for salivation, lacrimation, urination, diarrhea, gastrointestinal
distress and emesis.

Nicotinic effects will be seen as tachy and brady arrhythmias, heart blocks, fasciculations, twitching,
seizures and, after muscle fatigue, flaccid paralysis.




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            Standing Medication Orders for Nerve Agent Exposure
Mild Effects

Miosis and severe rhinorrhea:

2mg atropine sulfate SIVP, time permitting or 2mg atropine sulfate via Mark I autoinjector in anterolateral
thigh if patient load exceeds resources.

Moderate Effects

Miosis, severe rhinorrhea, shortness of breath or vomiting and diarrhea:

2mg atropine sulfate and 600mg pralidoxime via Mark I autoinjector kit. Repeat as needed at 5-10 minute
intervals for up to 3 doses. Additional atropine may need to be administered if there is no improvement or
if prolonged field time is unavoidable.

Severe Effects

Symptoms as above plus convulsions, severe shortness of breath or apnea, unconsciousness,
fasciculations, severe gastrointestinal distress or any two combinations of these symptoms:

6mg atropine sulfate and 1800mg pralidoxime immediately via Mark I autoinjector kits and 10mg
diazepam via autoinjector (with or without seizure activity). Additional doses of all three may have to be
administered if prolonged field time is unavoidable.

                                       Vesicant Exposure
Vesicants are agents which produce erythema and vesicle formation on the skin. In addition to these
effects, vesicants can cause damage to the eyes, airway and internal organs. Military arsenals may
contain several types of liquid vesicant compounds, usually delivered as a vapor. It is important to note
that these agents may be mixed to lower vapor pressures so that they can be utilized in colder
temperatures. A common military formulation may contain both mustard and Lewisite.

Vesicants
H, HD, HS, HT (Sulfur mustard)
L (Lewisite)
CX (Phosgene oxime)

Mustard, which is not painful upon skin contact, is rapidly absorbed into the tissues upon skin or
pulmonary contact. In the tissues it forms a cyclic compound which is very reactive and which binds to
intra- and extracellular proteins, enzymes and other substances. Tissue damage probably occurs
because of alkylation of DNA which results in cellular death, including death in the marrow of precursor
cells. Mustard produces biochemical damage within minutes but does not present clinically until hours
later. Because of this, persons exposed to mustard may not realize that they have been exposed to a
potentially lethal chemical. There is no antidote for mustard absorption.

Lewisite is also rapidly absorbed upon skin or pulmonary contact. Unlike mustard, skin contact causes a
burning pain and visible early tissue damage presenting as grayish areas of necrotic skin. Lewisite does
not cause damage to marrow cells but it does cause increased capillary permeability and subsequent
third space fluid loss resulting in hypovolemia with subsequent predictable sequelae such as hypotension
and impaired renal and hepatic function. Lewisite contains a trivalent arsenic group that reacts with the
thiols of many enzymes to produce tissue damage by an unknown mechanism. Unlike mustard, Lewisite
has an antidote called BAL (British anti-Lewisite). It is used in clinical medicine as a chelating agent
known as dimercaprol for heavy metal poisoning. Because it has notable side effects, it is not suitable as
an immediate prehospital therapy.

Phosgene oxime is a vesicant agent of unclear biological mechanism. Like Lewisite, it is painful on skin
contact and rapidly produces skin blanching, erythema, urticaria and tissue necrosis. Pulmonary
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absorption results in pulmonary edema. It has no antidote and should not be confused with phosgene
gas, a pulmonary agent.

               Standing Medication Orders for Vesicant Exposure
None. Rapid decontamination is paramount with exposures to vesicant agents. Treatment is
symptomatic based on the regular Protocol and Standing Medication Orders section of the Medical
Operations Manual. Use fluids cautiously. Unlike thermal burns, vesicant burns do not require volume
fluid replacement. Systemic analgesics should be used liberally.

                                        Cyanide Exposure
Cyanide is a naturally occurring compound used in manufacturing and mining. It is also present in some
beans, fruit and fruit pits. In sufficient quantities it is a potent poison. Military use of cyanide has been
limited because it is highly volatile and requires relatively large amounts to induce dysfunction and death.
Most cyanides are salts which are solids. Large amounts of sodium cyanide (NaCN) are shipped through
Anchorage annually for use as an extraction agent in gold mines in the interior. Sodium cyanide is a
relatively stable compound but if it is combined with a strong acid (H) at normal environmental
temperatures it yields the salt (Na) and hydrogen cyanide (HCN), a highly poisonous liquid with a boiling
point of 73° F.

Cyanogen chloride is a liquid with a boiling point of 52° F which converts to cyanide upon entry into the
body. Vapors from cyanogen chloride are heavier than air and will settle in confined spaces. Vapors
from hydrogen cyanide are lighter than air and will rise, thus they are a threat mainly in enclosed spaces.
Military formulations of cyanide are:

Cyanides
AC (Hydrogen cyanide)
CK (Cyanogen chloride)

Cyanides produce their toxic effects at the cellular level by inhibiting one of the cytochrome oxidase
enzymes necessary for using oxygen in oxidative phosphorylation and ATP production. When oxygen
use within the cell is halted, cellular ATP production ceases and the cell dies. Prior to cellular death the
cell switches to short term anaerobic metabolism which results in a metabolic acidosis. Since cells within
the CNS are particular sensitive to hypoxia, most of the signs and symptoms of cyanide toxicity are CNS
related.

Large amounts of inhaled cyanide cause a rapid series of effects. About 15 seconds after inhalation the
exposed person will experience a series of deep breaths. About 30 seconds after inhalation loss of
consciousness and convulsions occur. Respiratory arrest occurs in 3-5 minutes and cardiac arrest in 5-8
minutes.

Cyanide ingestion produces slower effects that are dose related. Typical ingestion involves one of the
cyanide salts in solution. Symptoms may not occur for several minutes and death may take up to an hour
to occur. The cascade of symptoms includes agitation, vertigo, weakness, muscle trembling, decrease in
respiratory rate, convulsions, apnea, arrhythmics and death.




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               Standing Medication Orders for Cyanide Exposure
The treatment regimen is the same for inhaled or ingested cyanide. Persons who are apneic and
pulseless after exposure where multiple casualties are involved should be considered non-salvable .
Persons who are asymptomatic or only mildly symptomatic 5-10 minutes after exposure to cyanide vapors
generally do not require antidotal treatment.

Therapy, when indicated, involves a two pronged approach. The first step is the conversion of some of
the hemoglobin in the blood to methemoglobin. This is done by converting the iron in hemoglobin ,Fe++,
to Fe+++. Hemoglobin has an affinity to oxygen, methemoglobin has an affinity to cyanide and will draw it
out of the cells and bind it. A mild methemoglobinemia is induced with the use of nitrites to effect this
process.

The second step involves the administration of a sulfur compound to combine with the cyanide to form
thiocyanate which can be excreted by the kidneys.

Apneic Casualty Exposed to Cyanide Vapor

2 perls amyl nitrite broken and placed in BVM. Ventilate patient while other therapy is initiated.

300 mg sodium nitrite SIVP over several minutes.

12.5 gm sodium thiosulfate in 50 ml solution IV.

If symptoms persist for greater than 5 minutes after therapy, repeat ½ initial doses of all three
medications.

                                  Biological Agent Exposure
Biological agents include four classes. These are bacteria, rickettsia, toxins, and viruses. Most biological
agents are naturally occurring pathogens or toxins that can be cultured or extracted and used as
weapons. Because persons exposed to biological agents will not develop an acute symptomatology
immediately following the exposure, nor all at the same time, the need for acute intervention in the
prehospital arena is minimal and is based on symptomatic treatment. Appropriate protective work
practice measures must be employed whenever a potentially infectious patient is encountered.
Epidemiological monitoring, involving the recognition of disease trends among the population that are out
of the ordinary, is the best indicator that an unannounced biological attack has occurred.

         Standing Medication Orders for Biological Agent Exposure

None. Most bacterial biologicals can be treated prophylactically with antibiotics if known exposure has
occurred. In this event, rescuer prophylaxis will be ordered by the EMS and Public Health Medical
Directors.




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                   Nuclear Agent (Ionizing Radiation) Exposure
Exposure to ionizing nuclear radiation can occur in several ways. The least serious is exposure to alpha
particles which travel very short distances and do not penetrate intact skin. They are problematic as a
health risk only if ingested, inhaled or percutaneously absorbed in a lesion or wound where they may
cause localized tissue damage. Beta particles, in comparison, can travel for meters from the source and
may penetrate to the germinal layer of the skin where they can cause tissue damage. Like alpha
particles, they can also cause damage if ingested or inhaled. Gamma radiation (and x-rays) travels many
meters from the radioactive source and easily penetrates deeply into body tissues. Unlike alpha and beta
particles, gamma radiation penetrates through PPE and requires extremely dense material to shield the
rays.

Radioactive material varies in its particle content. Many materials contain more than isolated alpha, beta
or gamma emitters. Americium 241, used commercially in smoke detectors, contains both alpha and
gamma radiation. Cobalt 60, used in medicine, contains both beta and gamma radiation. Natural
uranium, used in reactors and weapons, contains all three.

Terrorist use of nuclear materials would most likely involve the use of a primarily alpha or beta material
dispersed in a way that would cause ingestion or inhalation in large numbers of people. Use of an
explosive nuclear device which would produce large amounts of gamma radiation during the explosion is
a less likely scenario.

   Standing Medication Orders for Nuclear Agent (Ionizing Radiation)
                          Agent Exposure
Treatment for radiation exposure consists of removing the patient from the emission source and
decontaminating particles. Patients who are exposed to high levels of gamma radiation do not become
“radioactive” or emitters in themselves. Except for particles which may be on the skin or in clothing, they
are not a threat to rescuers with PPE that protects against particles contacting the skin or entering the
body through the alimentary or respiratory routes.

In some cases of large scale exposure (e.g., leaky nuclear reactor upwind, nuclear explosion) the EMS or
Public Health Medical Director may order the oral administration of potassium iodide and/or prussian blue
as prophylaxis to protect the thyroid and parathyroid glands from absorbing radioactive isotopes of iodine
that would migrate to and seek receptors on these glands.




References:

Textbook of Military Medicine, Medical Aspects of Chemical and Biological Warfare, Siddell, Takafuji,
Franz
Jane’s Chem-Bio Handbook, Siddell, Patrick, Dashiell
Management of Chemical Warfare Agent Casualties, A Handbook for Emergency Medical Services,
Siddell
Managing Hazardous Materials Incidents Vol. III, Medical Management Guidelines for Acute Chemical
Exposures, U.S. D.H.H.S., P.H.S.
Medical Management of Biological Casualties Handbook, U.S. Army Medical Research Institute of
Infectious Diseases
Medical Management of Chemical Casualties Handbook, Chemical Casualty Care Office, Medical
Research Institute of Chemical Defense

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                             Revision 2.0, August 2003
                                     Change in
Introduction                         content             updated for dates
Contact telephone                    Change in
numbers                              content             Number changes; B4 added
Section 1, Ops Section               Addition            P&I SOG related to EMS Ops
MVI SOG                              Addition            Fire BC added to MVI response
                                                         General Scene Guidelines: Treatment
Section 2, Protocols                 Addition            and Transport
                                                         Pt. Meds per state regs and ASA per
EMT Patient Care Protocol            Addition            CP protocol
                                                         Nebulized albuterol at the direction of
EMT-II protocol                      Addition            incoming MICP
                                     Change in           Med administration under paramedic
EMT-III protocol                     content             supervision added
EMT-III Patient Care
Protocol                             Addition            NTG per CP protocol and ASA S.O.
                                     Change in           Droperidol added, lorazepam deleted
Combative Patient                    content             from Optional, #4
                                                         Added word "bradycardia" after
Transcutaneous Pacing                Text change         symptomatic in #2
Pain management                      Addition            Reference to diphenhydramine SO
                                                         Content clarified, renamed "Asthma,
Asthma Protocol                      Text Change         Wheezing, COPD"
                                                         Added word "albuterol" before "unit
Asthma Protocol                      Text change         dose" in #3 under Severe Distress
Asthma Protocol                      Addition            Repeat ped dosing added
                                                         Note added regarding capnography in
Asthma Protocol                      Addition            COPD
                                     Change in           Changed MS max dose from 10 to 15
Congestive Heart Failure             content             mg consistent with MS S.O.
                                                         Pediatric weight reference added under
Diabetic Emergencies                 Addition            Pediatric Guidelines #4, a.
                                                         Dosage wording changed to reflect
Seizures                             Change in text      lorazepam S.O.
                                     Change in           Lorazepam dosage made consistent
Seizure Algorithm                    content             with S.O.
Pre-eclampsia and                    Change in           SIVP changed to IVPB under
Eclampsia                            content             Guidelines, #4.
                                     Change in           Guidelines #1, g - Deleted reference to
Childbirth                           content             postpartum hemorrhage.
                                                         Deleted "causes" due to contradiction
                                     Change in           with oxytocin S.O. re: retained
Postpartum Hemorrhage                content             placenta.
                                                         References to post-resuscitation
                                                         lidocaine deleted consistent with
                                     Change in           lidocaine S.O. and Post-resuscitation
Environmental                        content             care algorithm
Asystole Algorithm                   Addition            CaCl added under hyperkalemia
                                     Change in           Cardioversion energy levels made
NCT Algorithm                        content             consistent with ACLS guidelines
PEA Algorithm                        Addition            Items added to "rule out" box


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                                                         The word "cardioversion" changed to
                                     Change in           "defibrillation" in the Sensing
Perfusing WCT Algorithm              content             Adequate?, NO column
                                     Change in           Lidocaine ET added per lidocaine S.O.
Pulseless VT/VF Algorithm            content             to No IV Established branch
                                     Change in           Reference to post-resuscitation
Pulseless VT/VF Algorithm            content             lidocaine omitted from footnote
                                     Change in           Guidelines, #5 changed to reflect PRC
Post-resuscitation Care              content             algorithm
                                                         Suspected FBAO added to
Combitube                            Addition            Contraindications
                                                         Third intercostal space in 1st
                                                         paragraph changed to second
Turkel Safety                        Change in           intercostal space consistent with
Thoracentesis Catheter               content             NOTES section
                                                         Communication with hospitals
                                     Change in           reassigned from IC to Medical Branch
MVI SOG                              content             Director-Moved to Ops Section
                                     Change in
Precordial Lead Placement            content             Addition
                                     Change in
12 Lead Waveforms                    content             Addition
Capnography Waveform                 Change in
Elements                             content             Addition
Capnography Waveform                 Change in
Analysis                             content             Addition
                                     Change in
VentiSure                            content             Addition
Section 3: Standing
Medication Orders
Albuterol                            Text change         How Supplied corrected
                                                         "Recurrent/Persistent" added to
                                                         Indications, #1 consistent with
Amiodarone                           Text change         Pulseless VT/VF Algorithm
                                                         "Buretrol type device" changed to
                                                         "volumetric infusion device" under
Amiodarone                           Text change         Pediatric dose, #3
                                     Change in           (unless accompanied by wide QRS)"
Atropine sulfate                     content             added to Indications, #2
                                                         dosage corrected in Note re: too small
Atropine sulfate                     Text change         a dose/bradycardia
                                     Change in
Atropine sulfate                     content             "or ETT" deleted from Pediatric dose
                                     Change in           Reference to Combative Patient
Diphenhydramine                      content             Protocol deleted
Dopamine                             Text change         mixing concentration corrected
                                     Change in           Starting dose changed from 2-5 to 5
Dopamine                             content             mcg/kg/min
                                                         how to mix preceding each chart
Dopamine Drip Charts                 Text change         simplified/clarified
                                     Change in           Updated to new adults and peds
Dopamine Drip Charts                 content             versions
                                     Change in
droperidol                           content             placed back in MOM


Treatment and Medications Protocol                 170                                       Revision 3.0, 2006
Anchorage Fire Department                                                        Medical Operations Manual

                                                       Word "diluted" changed to "flushed"
Epinephrine 1:1000                   Change in text    under ped ET dose
                                     Change in         Reference to pediatric ETT dose
Epinephrine 1:10000                  content           deleted
                                                       Adult ETT dose corrected from 3
Lidocaine                            Change in text    mg/min to 3 mg/kg
                                                       Warnings, #2 changed to correct dose
Lidocaine                            Change in text    consistent with Adult dose info below
                                     Change in         Protocol references to Perfusing WCT
Lidocaine                            content           and Pulseless VF/VT deleted
                                     Change in         References to Combative Patient
Lorazepam                            content           Protocol deleted
                                     Change in         Reference Post-resuscitation
Lorazepam                            content           algorithms added
                                                       Pediatric dose changed from .05 mg/kg
                                     Change in         to .05-.1 mg/kg consistent with weight
Lorazepam                            content           pages
                                     Change in         Note added to ped dose stating not
Morphine sulfate                     content           given under 4 kg
                                     Change in
Naloxone                             content           Additional "How supplied" line added
                                     Change in         Under Torsades, RIVP replaced with
Magnesium sulfate                    content           run drip at full flow
                                                       Words "with hypertension" deleted from
                                                       Indications, #2 to make consistent with
Nitroglycerin                        Change in text    CHF protocol
                                                       Words "from inhaler" deleted from How
Nitroglycerin                        Change in text    supplied
Nitroglycerin                        Addition          Note regarding IV added
                                                       400mcg added, 1/150 grain deleted in
Nitroglycerin                        Change in text    How Supplied
Phenylephrine                        Addition          MAO inhibitor footnote added
                                                       Epinephrine 1:10000 dosing revised to
                                                       remove word "initial" and x1-consistent
Pediatric Weight Pages               Change in text    with current PALS
Section 4, Admin                     Addition          Beginning Admin section-abbreviations

                            Revision 2.6, December 2003
Definition of Patient                Addition          Operations Section
                                                       Reference to Nelcor changed to
Endotracheal Intubation              Change            VentiSure
Pain Management                      Addition          Fentanyl added
                                     Change in
Rapid Sequence Intubation            content           Lorazepam changed to etomidate
NCT and Perfusing WCT                Change in
Algorithms                           content           Lorazepam replaced with etomidate
Etomidate                            Addition          Added to S.O. section
Fentanyl                             Addition          Added to S.O. section
                                                       Contraindication to MS standardized
                                                       with fentanyl, i.e., “hypersensitivity to
Morphine Sulfate                     Change            opiates”
                                                       Levitra and Cialis added as
Nitrolingual spray                   Addition          contraindications


Treatment and Medications Protocol               171                                           Revision 3.0, 2006
Anchorage Fire Department                                                      Medical Operations Manual

                                Revision 2.8, January 2004
                                                        Intranasal reference added to Medication
Medication Administration            Addition           Administration and Naloxone pages
Trauma                               Addition           Pelvic Fx Protocol
                                     Change in
Asystole Algorithm                   content/Addition   Vasopressin 1st line drug
NTG                                  Addition           Cialis added as contraindication
Vasopressin                          Addition           Vasopressin added to S.O. section
SOA reporting requirements           Addition           Administration section

                                     Revision 3.0, 2006
                                                         Dates
                                                         Delete BC Nolan replace with DC
 Introduction                        Change              Threadgill
                                                         Prov STEMI line
                                                         AFD Medical Director cell phone
 Contact telephone numbers           Addition            number
                                                         Operations Section-Cardiac changed to
 Cardiac alert                       Change, Addition    STEMI, Stemi memo added
                                                         Double negatives and incorrect info re:
                                                         Contraindications to fibrinolytics
 Neuro alert                         Change              removed
 Transfer of Care/Return to
 Service                             Addition            Operations Section
 Direct Admit                        Addition            Operations Section
 Airway Protocol                     Addition            Bag-Valve-Mask ventilation
 Medication Use and Safety           Addition            Operations Section
 Inspiratory Impedance
 Device                              Addition            Treatment Section
 CPR                                 Addition            Treatment Section
 Revivant                            Addition            Treatment Section
                                                         Delete any potentially unstable patient,
                                                         replaced with pediatric IV placement at
                                                         paramedic discretion
 IV Therapy                          Change, Addition    Reference to TBI
 Intraosseous (IO) Therapy           Addition            Treatment Section
 Chest Pain Protocol                 Addition            Reference to STEMI memo
 Deviation from protocol             Change              Routing of FD-1
                                                         Added Nitroglycerin is the primary and
 Congestive Heart Failure            Addition            most important therapy
                                                         Pediatric doses referred to Pediatric
 Diabetic emergencies                Change              Weight Pages
 Seizures, Status Epilepticus                            Under Adult Guideline: application of
 and Postictal States                Addition            supplemental oxygen
                                                         11.d. Endotracheal Epi changed to
 Newborn Care                        Change              1:1000, Epi 1:10,000 IV dose added
                                                         Pediatric weight pages made consistent
 Albuterol                           Change              with S.O.
                                                         Pediatric S.O. and weight pages doses
                                                         made concurrent with each other &
 Atropine sulfate                    Change              PALS

Treatment and Medications Protocol                172                                       Revision 3.0, 2006
Anchorage Fire Department                                                    Medical Operations Manual

                                                      References to Blood Glucose
                                                      Determination and Combative Patient
 Diphenhydramine                     Change           removed
 Dopamine                            Change           Concentrations of solutions corrected
 Pediatric Dopamine Drip
 Chart                               Change           Deleted-added reference to Wt. Pages
 Epinephrine 1:1000                  Addition         Reference to Newborn Care Protocol
 Fentanyl                            Addition         Pediatric Weight Pages
                                                      References to WCT deleted, protocol
 Lidocaine                           Change           references corrected
                                                      Indications and protocol references
 Lorazepam                           Change           updated
 Morphine sulfate                    Addition         "How supplied" clarified
                                                      Pediatric dose corrected to 0.1 mg/kg
 Naloxone                            Change           on S.O. page
                                                      Dilution note for neonatal resuscitation,
 Sodium Bicarbonate                  Change           weight pages corrected to reflect S.O.
 Continuing Medical
 Education P&I 902-7                 Addition         Administrative Section
 Controlled Medications
 Draft P&I 903-5                     Addition         Administrative Section
 HIPAA and Public
 Information Release memo            Addition         Administrative Section
 Infectious Disease P&I 901-
 2                                   Addition         Administrative Section
 Medical Control P&I 905-7           Addition         Administrative Section
 Medical Operations Manual
 P&I 905-9                           Addition         Administrative Section




Treatment and Medications Protocol              173                                       Revision 3.0, 2006
Anchorage Fire Department                    Medical Operations Manual

                                     Notes




Treatment and Medications Protocol    174                Revision 3.0, 2006

				
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