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VOLUSIA COUNTY EMS SYSTEM CLINICAL PROTOCOLS TABLE OF CONTENTS

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VOLUSIA COUNTY EMS SYSTEM CLINICAL PROTOCOLS TABLE OF CONTENTS Powered By Docstoc
					Volusia County EMS System Protocols


                               VOLUSIA COUNTY EMS SYSTEM
                                  CLINICAL PROTOCOLS

                                         TABLE OF CONTENTS

Overview

100 .........................................General Principles/Measures for Medical Care
   101 .............................................................. Medical Transport Destination
   102 .....................................................................Physician/Nurse on Scene
   103 ........................... Patient Care During Transport Following a 911 Call
   104 ............................................. Initiation of CPR/Determination of Death
   105 ................................................. Determination of Hospital Destination
   106 ................................................................ Paramedic Scope of Practice
   107 .......................................... Certification and Education Requirements

200 Adult Guidelines
   201 ............................. General Patient Assessment (General Provisions)
   202 ............................................................................... Patient Assessment
   203 ................................................................. Abdominal Pain/GI Bleeding
   204 ..................................................................Airway Management – Adult
   205 .................................................................................. Allergic Reactions
   206 .............................................................................Altered Mental Status
   207 ........................................................................Behavioral Emergencies
   208 ............................ Carbon Monoxide Exposure and Toxic Inhalations
   209 ........................................................................................... Cardiac Alert
   210 ........................................................................... Cardiac Dysrhythmias
   211 ...............................................................................................Chest Pain
   212 ........................................................... Dyspnea – Respiratory Distress
   213 ............................................................Environmental/Thermal Injuries
           213(a) ......................................................................... Thermal Burns
           213(b) ....................................Decompression Sickness/Dysbarism
           213(c) ............................................................................ Hypothermia
           213(d) ........................................................................... Hyperthermia
   214 ............................................................................................. Eye Injuries
   215 ................................................... Hazardous Materials/Toxic Exposure
           215(a) ................................. Chemical Burns and Dermal Exposure
   216 ...................Hypertensive Emergencies (With or without Chest Pain)
   217 ................................................................Near Drowning (Submersion)
   218 ........................................................................ Obstetrics / Gynecology
           218(a) ................................................................................. Childbirth
           218(b) ... Prenatal Emergencies/Pregnancy Induced Hypertension
           218(c) ..................................................................... Vaginal Bleeding




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Volusia County EMS System Protocols


                VOLUSIA COUNTY EMS SYSTEM CLINCAL PROTOCOLS
                         TABLE OF CONTENTS (continued)


   219 .................................. Overdose and Poisonings – General Approach
           219(a) ............ Tricyclic and Tetracyclic Antidepressant Overdose
           219(b) .................... Anticholingeric Poisoning/Organophosphates
           219(c) ............................ Antipsychotics/Acture Dystonic Reaction
           219(d) ..............................................................Beta Blocker Toxicity
           219(e) ..................................................... Calcium Channel Blockers
           219(f) .............................Cocaine and Sympathomimetic Overdose
   220 ......................................................................Pain Management – Adult
   221 ..............................................................................Radio Report Format
   222 .........................................................................Refusal of Medical Care
           222(a) ...Guideline for Documenting the Determination of Medical
                           Competency to Refuse Care
           222(b) .................................................. Consent for Treating Minors
   223 .................................................................................................... Seizure
   224 ............................................................................................. Snake Bites
   225 ................................................................................ Stroke – Suspected
   226 ............................................................................... Syncope – Blackout
   227 ................................................................Trauma – General Guidelines
           227(a) .............................................................Chest Injuries/Trauma
           227(b) ............................................................ Cranial (Head) Injuries
           227(c) .................................................................... Extremity Trauma
           227(d) .............................................................. Trauma Amputations
           227(e) ....... Non-Resuscitation of Trauma Related Cardiac Arrests




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Volusia County EMS System Protocols


                 VOLUSIA COUNTY EMS SYSTEM CLINCAL PROTOCOLS
                          TABLE OF CONTENTS (continued)

300....................................................................... Pediatric Trauma Guidelines
       301 .......................................................Airway Management – Pediatric
       302 ...................................... Allergic Reaction/Anaphylaxis – Pediatric
       303 .....................................................Altered Mental Status – Pediatric
       304 ............................................................... Bronchospasm – Pediatric
       305 ...............................................................................Burns – Pediatric
       306 ........................................................ Cardiac Arrhythmia – Pediatric
                  306(a) .........................................................................Bradycardia
                  306(b) ........................................................................ Tachycardia
   307                                               Cardiac Arrest/Non Traumatic – Pediatric
       307(a)......................................................................................... Asystole
       307(b) ........................................................ Pulseless Electrical Activity
       307(c)...Ventricular Fibrillation or Pulseless Ventricular Tachycardia
   308 ................................ Drowning/Near Drowning/Submersion-Pediatric
   309 ..................................... Foreign Body Airway Obstruction – Pediatric
   310 ..........................................................................Newborn Resuscitation
   311 ...............................................................Precipitous Newborn Delivery
   312 .............................................................................. Abandoned Neonate
   313 .................................... Overdose, Poisoning, or Ingestion – Pediatric
   314 ................................................................Pain Management – Pediatric
   315 ............................ Respiratory Distress, Failure, or Arrest – Pediatric
   316 ............................................................................... Seizures – Pediatric
   317 .......................................................Shock (Non-Traumatic) – Pediatric
   318 ................................................................................. Trauma – Pediatric

400 – Procedural Protocols
   401 ......................................... Automatic External Defibrillator (AED) Use
   402 .......................................................................................Cricothyrotomy
   403 ........................................................................ Endotracheal Intubation
   404 ................................Epinephrine Auto Injector Administration Assist
   405 ........................................................................External Pacemaker Use
   406 ........................................................................... Femoral Venipuncture
   407 .................................................... Immobilization of the Cervical Spine
   408 ................................................................ Immunization Administration
   409 ..........................................................................................Inhaler Assist
   410 ...............................................................Internal Jugular Venipuncture
   411 ....................................................................... Intravenous Cannulation
   412 .............................................................Intravenous Fluid Management
   413 ............................................................................Needle Thoracostomy
   414 ............................................................................... Nitroglycerin Assist




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Volusia County EMS System Protocols


               VOLUSIA COUNTY EMS SYSTEM CLINCAL PROTOCOLS
                        TABLE OF CONTENTS (continued)

400 – Procedural Protocols Continued

   415 ................................................ Orogastric and Nasogastric Intubation
   416 .....................................................................................Patient Restraint
   417 ............................................................ Pediatric Intraosseous Infusion
   418 ................................................................................. Pericardiocentesis
   419 .......................................................................Subclavian Venipuncture
   420Suspected Bioterrorism Precautionary Measures & Decontamination
          of Patients/Environmental Surfaces
   421 ........................................................... Taser Deployment Management
   422 ........................................................ Triage in Multi-Casualty Incidents
   423 ........................................Use of the Esophageal Tracheal Combitube
   424 ........................................................................ Evidenciary Blood Draw

500    Authorized Pharmaceuticals

600    Medication Resume

       601 ..........................................................................Albuterol (Proventil)
       602 .................................................................................Atropine Sulfate
       603 ...............................................................................Calcium Chloride
       604 ............................................................Dextrose 50% in Water (D50)
       605 ............................................................................ Diazepam (Valium)
       606 ......................................................................... Diltiazem (Cardizem)
       607 ........................................................... Diphenhydramine (Benadryl)
       608 .......................................................................... Dopamine (Intropin)
       609 ........................................................................................Epinephrine
       610 ......................................................................... Etomidate (Amidate)
       611 ........................................................................... Furosemide (Lasix)
       612 ............................................................................................Glucagon
       613 ............................................................................................Lidocaine
       614 .................................................... Magnesium Sulfate 50% Solution
       615 ..................................Methylprednisolone Succinate (SoluMedrol)
       616 ............................................................................... Morphine Sulfate
       617 .............................................................................Naloxone (Narcan)
       618 ...................................................................................... Nitroglycerin
       619 ................................................................. Procainamide (Pronestyl)
       620 ......................................................................... Sodium Bicarbonate
       621 .......................................................................................... Tetracaine
       622 ..........................................................................................Phenergan
       623 .......................................................................................... Adenosine




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Volusia County EMS System Protocols


                 VOLUSIA COUNTY EMS SYSTEM CLINCAL PROTOCOLS
                          TABLE OF CONTENTS continued

700................................................................................... Toxi-Medic Protocols
701.......................................... Continuous Positive Airway Pressure (CPAP)
702.......................................................................................... Crush Syndrome




                                                                                        Effective Date: January 1, 2006
Volusia County EMS System Protocols



                                         Overview
       The Volusia County EMS Protocols contained within this document are intended to
provide and ensure uniform treatment for all patients who receive prehospital care within the
county. These protocols apply exclusively to EMS providers operating in the out-of-hospital
setting who are working under the Medical Direction of the Volusia County EMS System
Medical Director.   While attempts have been made to cover all patients who access our
system, the Medical Director realizes that unforeseen scenarios or situations may arise. We
suggest that for those instances that medical personnel will follow the general illness protocol
(or other appropriate protocol) exercise their own judgment and contact medical direction
should any questions or problems arise.
       Our goal is to provide care when appropriate, relieve pain and suffering and do no
harm. The patient’s best interest should be the final determinant for all decisions.
       This document contains the following sections:


       ♦ Overview/Authorization
       ♦ General Principles
       ♦ Adult Protocols
       ♦ Pediatric Protocols
       ♦ Procedural Protocols
       ♦ Authorized Pharmaceuticals




                                                     _____

                                         Authorization


These protocols were developed under the authorization of the below-signed Medical Director
in accordance with Florida Statute 401 and Chapter 64E of the Florida Administrative Code.
Changes to these protocols can be made only with the authorization of the Volusia County
EMS System Medical Director.




John G. Shedd, M.D., FACEP




                                                                         Effective Date: January 1, 2006
Volusia County EMS System Protocols
                                                                                       100


      General Principles/Measures for Medical Care
The following measures shall be applied to help promote speed and efficiency when
rendering emergency medical care to the sick, ill, injured or infirmed. They were
developed for the use of the paramedic in the field and the Emergency
Department/Medical Control physician.


1. The safety of EMS personnel is paramount to quality patient care. Each scene
   should be properly evaluated for hazardous materials, fire, violent patients, etc.
   Also, assess the need for additional EMS support.


2. The first agency on the scene of accident or illness shall establish command.
   Responsibility for management of the overall scene and medical command will be
   transferred to representatives of the authority having jurisdiction upon arrival as
   defined by State and National ICS guidelines. Fire/Rescue Departments shall
   routinely maintain responsibility for controlling incident scenes. It is the
   responsibility of the scene commander to insure the proper and timely utilization of
   resources to meet the goals of scene safety, quality patient care, and rapid
   movement to medical facilities.


3. Proper BSI MUST be utilized at all times.


4. For all calls, be prepared for immediate ALS interventions (e.g., defibrillation,
   airway management, drug therapy etc.) upon initial patient contact and patient
   transfer, if appropriate.


5. Notify your dispatcher or document the “patient contact time” for all calls, and at
   the time of initial defibrillation for all cardiac arrest patients, and patient care
   transfer time if appropriate.




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                                                                                        100.1

General Principles/Measures for Medical Care

6. Try to always obtain verbal consent prior to treatment. Respect the patient's right
   to privacy and dignity. Courtesy, concern and common sense will assure the
   patient of the best possible care.


7. The paramedic should be able to decide within 3 minutes after patient contact if
   advanced life support (ALS) measures will be needed and should be instituted
   almost simultaneously with the initial assessment.        A comprehensive exam is
   appropriate after the patient has been stabilized.


8. The initial assessment and initial therapy should be completed within the first 10
   minutes after patient contact. Except for extensive extrication, or other significantly
   atypical situations, the Trauma Alert patient should be enroute to a receiving facility
   within 10 minutes and the medical patient should be enroute to the receiving facility
   within 20 minutes. Additional therapy, if indicated, should be continued during
   transport.


9. For all calls where EMT’s and paramedics are involved in patient care, the
   paramedic is responsible for all patient care and shall be considered each
   agency’s lead care provider.       Patient care should be effectively and efficiently
   transferred to the transport agency.


10. All patients who are evaluated or receive treatment are to be transported by EMS
   to a receiving facility for further evaluation unless the refusal process is executed.


11. Please note that all medication dosages listed are for adults, for pediatric dosing
   see pediatric protocols and refer to Broselow tape.




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Volusia County EMS System Protocols
                                                                                          100.2

General Principles/Measures for Medical Care

12. For trauma situations, a pediatric patient has the anatomical and physical
   characteristics of a person fifteen (15) years or younger.

13. In cases of out of county, mutual aid response, Volusia County Emergency Medical
   Services agencies are directed to utilize these Protocols in conducting patient care.

14. An Approved EMS Patient Care Report (PCR) will be generated at the
   conclusion of each patient encounter. A complete copy of the full report or the
   approved abbreviated report must be left with the receiving facility at the time of
   transport. No copies or patient information will be given to anyone other than
   personnel authorized through Florida Statutes without written permission from the
   patient or via court order.

15. All patients are authorized only to be transported to state licensed hospital
   emergency departments. Details concerning which hospital is most appropriate
   based on clinical diagnostic category are outlined within the specific protocols.


16. For cases that do not fit exactly into a treatment category, perform general illness
   protocol and contact on-line Medical Control as needed.


17. According to Florida Chapter 64E, F.A.C., transporting vehicle personnel shall
   obtain information pertinent to the patient’s identification, patient assessment and
   care provided to the patient from the first responding agency.


18. Perform all procedures as per the Volusia County EMS System Protocols.


19. The following information (mini-SOAPP information) should be provided to the
   transporting agency:




                                                                    Effective Date: January 1, 2006
Volusia County EMS System Protocols
                                                                                        100.3

General Principles/Measures for Medical Care

          Subjective - the patient’s chief complaint(s), and history of present illness
          (including history of events surrounding call).
          Objective – vital signs, (normal and abnormal), normal and abnormal
          physical findings pertinent to chief complaint (e.g. document normal or
          abnormal heart and lung exam if chest pain, normal or abnormal abdominal
          exam if abdominal pain, normal or abnormal neurologic exam if neurologic
          complaint etc.).
          Assessment – what is the EMT/paramedic clinical impression (what is the
          working diagnosis. This can be the chief complaint – chest pain).
          Plan – what protocol(s) is/are followed or treatment is administered.
          Prehospital course – what assessment, management was performed and
          how did the patient respond?       The first response agency note may be
          abbreviated if transfer occurs quickly.


20. Document the contents of a SOAPP note, on a run report, for every patient.
   SOAPP note contents includes all pertinent Subjective patient information, all
   pertinent Objective information, a field Assessment, the Plan, (i.e. what was done
   for the patient), and the Prehospital course summarizing all events and changes
   during the entire patient encounter (see Documentation Standards in Procedures
   Manual for details).


21. The same information (SOAPP note information) shall also be documented and
   provided by the transporting agency to the ED in an expanded SOAPP format
   (more detail to include the first responder information and transporting agency
   information).


22. If any of the forms contained in these protocols (e.g. Cardiac Alert, Stroke Alert,
   Refusal of Care etc.) are going to be utilized electronically, the contents of the
   forms must be reproduced in their entirety.




                                                                  Effective Date: January 1, 2006
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                                                                                            101

                        Medical Transport Destination

1. Stable Patients

2. All patients will be transported to the hospital of their choice or closest appropriate
   facility unless patient is unstable.

3. Unstable patients

          All patients whose condition is judged to be unstable will be transported to
          the closest appropriate receiving facility.
          If several hospitals are within the same approximate distance from the
          scene, allow the patient and / or patient’s family to select the closest
          appropriate receiving facility of their choice.


For transport destination of TRAUMA ALERT or OB (> 18 week) PATIENTS, refer to
TRAUMA ALERT and OB TRANSPORT PROTOCOLS



  Medical Control
    Call Medical Control for any additional orders or questions.




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                                                                                        102


                         Physician/Nurse on Scene

   1. The control of the scene of an emergency should be the responsibility of the
      individual in attendance who is the most appropriately trained in providing pre-
      hospital stabilization and transport. As an agent of the System Medical Director
      of an EMS system, the Paramedic / EMT represents that individual.


   2. Occasions will arise when a physician on the scene will desire to direct pre-
      hospital care. A standardized method for dealing with these contingencies will
      optimize the care given to the patient.


   3. The physician desiring to assume care of the patient must:
      Be presented with the Volusia County EMS “Card”.
      Provide documentation of his/her status as a physician (M.D. or D.O.) to
      include a current copy of his/her license to practice medicine in Florida.
      Assumes care of patient and Allows Documentation of his or her assumption of
      care on the Patient Care Report.
      Agrees to transport with the patient unless the on-call medical director agrees
      that physician does not need to transport.


♦ Contact with Medical Control must be established as soon as possible. The
   Medical Control physician must relinquish control for the patient to the physician on
   scene for the scene physician to take control.




                                                                   Effective Date: January 1, 2006
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                                                                                              102

General Principles/Measures for Medical Care continued

♦ Orders provided by the physician assuming responsibility for the patient should be
   followed as long as they do not, in the judgment of the paramedic, endanger patient well
   being. The paramedic may request the physician to attend to the patient during transport if
   the suggested treatment varies significantly from Standing Orders.


♦ If the physician's care is judged by the paramedic to be potentially harmful to the patient,
   the paramedic should:
       Politely voice his or her objections.
       IMMEDIATELY place the physician on the scene in contact with Medical Control for
       resolution of the problem.
       When conflicts arise between the physician on the scene and Medical Control, EMS
       personnel should:
           Follow the directives of the Medical Control Physician.
           Offer no assistance in carrying out the order in question, but provide no resistance
           to the physician performing this care.
           If the physician on scene continues to carry out the order in question, offer no
           assistance and enlist aid from law enforcement.


♦ All interactions with physicians on the scene must be completely documented in the Patient
   Care Report with the Physician signing the run sheet.


♦ Should a Registered Nurse be present at an emergency scene and wish to participate in
   administering care for the patient he / she must function within the realm of F.S. 401 and
   F.S. Chapter 464.




                                                                        Effective Date: January 1, 2006
Volusia County EMS System Protocols
                                                                                                        102

General Principles/Measures for Medical Care continued

♦ Volusia County EMS “Card”



                        Volusia County, Florida
                     Office of the Medical Director
          Thank you for your offer of assistance. Be advised these Emergency Medical
          Technicians and Paramedics are operating under the authority of Florida Law and
          Volusia County Protocols developed by the County Medical Director. No
          physician or any other person may intercede in patient care without the Medical
          Command physician on duty relinquishing responsibility for patient care / treatment
          via radio or telephone. If responsibility is given to a physician at the scene, that
          physician is responsible for any and all care given at the scene, and must
          accompany the patient(s) to the hospital. Furthermore, the physician accepting the
          above responsibilities must sign the patient’s prehospital medical record.
          THANK YOU.

                                    John G. Shedd, M.D., FACEP
                                    Volusia County Medical Director




                                                                                  Effective Date: January 1, 2006
Volusia County EMS System Protocols
                                                                                               103

General Principles/Measures for Medical Care continued


            Patient Care During Transport Following a 911 Call


The following constitute those indications where > 1 attendant is required in the
back of the ALS unit.

♦ Assistance with patient transport from non-transport providers will be required only for
   critical patients. Critical patients will be defined as those in an unstable condition in which
   the danger of imminent and immediate death exists, such as, but not limited to:
       Cardiac arrest.
       Patients who are intubated via endotracheal tube, Combitube, or who are being bagged.
       Imminent childbirth.
       A 2nd attendant is not required if there will be an unacceptable delay in transport.
       Paced patient
       A non-EMT certified student is not defined as a crewmember.




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                                                                                                104

General Principles/Measures for Medical Care continued


   Initiation of Cardiopulmonary Resuscitation / Determination of Death


INITIATION OF CPR/DETERMINATION OF DEATH
   ♦ All patients found in cardiopulmonary arrest by EMS personnel will receive
      cardiopulmonary resuscitation with the following exceptions.
   ♦ Exceptions:
          The patient who has been decapitated or whose thorax has been transected.
          The patient who is apneic and pulseless, who exhibits no response to stimuli, no
          respiratory effort, is asystolic in two or more leads, and is not hypothermic,
          PROVIDED that one of the following is present:
              Rigor mortis.
              Decomposition of body tissues.
              Dependent lividity.
          The patient who, upon arrival of EMS personnel, is attended by a physician licensed
          in the State of Florida; AND where the physician is willing to write a statement of
          his relationship to the patient, a "do not resuscitate" order, and a rationale for this
          order on the run report. EMS personnel must attempt to verify the identity of the
          physician before withholding cardiopulmonary resuscitation.
          A patient whose personal physician communicates via telephone that resuscitative
          efforts should not to be initiated or resuscitative efforts should be discontinued.
          The physician must agree to accept the responsibility for pronouncing the patient
          dead to at least two (2) emergency personnel (EMT, paramedic, and law
          enforcement) via the telephone. The witnesses MUST sign the EMS Run Report.




                                                                           Effective Date: January 1, 2006
Volusia County EMS System Protocols
                                                                                              104

General Principles/Measures for Medical Care continued

          A patient with a Do Not Resuscitate Order (DNRO)
             A patient who has in his or her possession or at the bedside a completed Florida
             Prehospital Do Not Resuscitate Order (DH Form 1896 or equivalent) or the
             appropriate Do Not Resuscitate Order patient identification device (“wallet
             card”) may have the order honored by EMS personnel.
             A patient, on whose behalf a copy of a DNRO document is presented from a
             licensed nursing home facility, licensed home health care agency or hospice
             agency. For EMS personnel to honor a DNRO it shall:
             ♦ State that it is a DNRO and provide instructions that the patient is not to be
                 resuscitated in the event of cardiac or respiratory arrest
             ♦ Have an effective date
             ♦ Include the patient's full typed or printed legal name
             ♦ Be signed by the patient's attending physician, and include the physician's
                 medical license number, telephone number and date completed
             ♦ Be signed and dated by the patient, patient's health care surrogate, or proxy
                 (as appropriate)
             EMS personnel must verify the identity of the patient with a DNRO through a
             driver's license, other photo identification, or from a witness in the presence of
             the patient.
             If a witness is used to identify the patient, documentation in the run report must
             include the full name of the witness, address, telephone number, and
             relationship to the patient.
             EMS personnel must determine that the DNRO form is fully and properly
             executed in that it has the required signatures, has been witnessed, and has an
             effective date, which predates the date, the assistance is requested.
             A DNRO may be revoked at any time by the patient or designated health care
             surrogate. If any doubt exists as to the applicability or validity of a DNRO,
             EMS personnel will initiate resuscitation measures.




                                                                         Effective Date: January 1, 2006
Volusia County EMS System Protocols
                                                                                             104


General Principles/Measures for Medical Care continued

             Neither family nor law enforcement officers have the right to refuse
             resuscitative attempts for the patient.
             The presentation of a DNRO does not preclude comforting, pain relieving, and
             other medically indicated care short of resuscitative measures.
          A patient with a Living Will:
             A patient with a Living Will shall have this document honored UNLESS the
             patient or immediate family member(s) provide verbal or written instruction to
             the contrary. A Living Will may be revoked at any time by the patient or
             designated health care surrogate. If any doubt exists as to the applicability or
             validity of a Living Will, EMS personnel will initiate resuscitation measures.
             When presented with a Living Will, resuscitative efforts will not be initiated
             unless extenuating circumstances exist. If resuscitative efforts have already
             been initiated when prehospital staff is presented with a valid Living Will,
             resuscitative efforts may be ceased.
             Requirements for validity of a Living Will:
             ♦ The document must be signed by the principal.
             ♦ The document must be witnessed by two people (signatures do not have to
                 be notarized).
             The presentation of a Living Will does not preclude comforting, pain relieving,
             and other medically indicated care short of resuscitative measures.
             EMS personnel must verify the identity of the patient with a Living Will
             through a driver's license, other photo identification, or from a witness in the
             presence of the patient.
             If a witness is used to identify the patient, documentation in the run report must
             include the full name of the witness, address, telephone number, and
             relationship to the patient.




                                                                        Effective Date: January 1, 2006
Volusia County EMS System Protocols
                                                                                                  104

General Principles/Measures for Medical Care continued

              EMS personnel must determine that the Living Will form is fully and properly
              executed in that it has the required signatures, has been witnessed, and has an
              effective date, which predates the date, the assistance is requested.
              Neither family nor law enforcement officers have the right to refuse
              resuscitative attempts for the patient.
          The victim of blunt trauma who is pulseless, apenic, and without a palpable blood
          pressure or heart tones upon arrival of BLS or ALS providers.
          The victim of a multicasualty incident in cardiopulmonary arrest whose use of
          prehospital care resources would jeopardize the care, health, or well-being of other
          critically ill or injured patients at the scene of accident, injury, or illness.
   ♦ Cardiopulmonary resuscitation may be halted when:
          Effective spontaneous ventilation and circulation have been restored.
          Resuscitation efforts have been transferred to persons of no less skill than the initial
          providers.
          The rescuer is exhausted and physically unable to continue resuscitation.
          A patient in asystole who has received ALS care, including endotracheal intubation,
          combitube, external cardiopulmonary resuscitation, ventilation with 100% oxygen
          via positive pressure ventilation device (PPVD), and administration of two
          appropriate doses of epinephrine and one of atropine; exhibits no hypothermia; and
          demonstrates continuous asystole and no response to care.
   ♦ When prehospital personnel pronounce a patient dead on-scene, they must remain with
      the deceased until the arrival of appropriate law enforcement agencies.
          All invasive apparatus must be left in place, and the body and scene not further
          disturbed.
          In cases of possible homicide or suicide, do not remove or cut clothing unless
          absolutely necessary. Do not disturb the death scene unless absolutely required to
          do so. Do not dispose of clothing that has been removed.




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Volusia County EMS System Protocols
                                                                                                104

General Principles/Measures for Medical Care continued

SPECIAL CONSIDERATIONS


   ♦ EMTs and paramedics are responsible for the medical judgement as to whether a
       patient is obviously dead or resuscitation efforts should be initiated. This determination
       should be made by a Paramedic, if on scene. Otherwise, the senior field EMT (BLS
       response) can make this decision.
   ♦   If an EMT or paramedic has a question as to how to proceed with any EMS situation
       involving the start or termination of resuscitation, immediately contact the EDMCP.
       Provide the physician with a concise but comprehensive assessment of the situation.
   ♦ EMTs and paramedics are responsible for the medical judgment regarding the
       termination of resuscitative efforts for patients in public settings such as restaurants,
       sporting venues, or other areas where spectators are present.
          As a general guideline, patients in these types of settings should have resuscitative
          efforts continued and should be transported to the nearest receiving facility.




                                                                           Effective Date: January 1, 2006
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                                                                                                 105

General Principles/Measures for Medical Care continued

                      Determination of Hospital Destination

General patient considerations
   ♦ Determine acuity of the patient's chief complaint, illness, or injury.
   ♦ If non life-threatening:
          Transport the patient to hospital of the patient's choice.
          If the patient is unable to make such a judgment (minors, etc.), transport the patient
          to the hospital of choice of an appropriate party acting on behalf of the patient
          (parent, et al).
          If the patient expresses no choice and if no other appropriate party is available or
          has reason to act on behalf of the patient, transport the patient to the closest
          appropriate facility.
   ♦ If life-threatening:
          Transport the patient to the closest appropriate facility.
          If the closest appropriate facility conflicts with the choice of the patient or the party
          acting of behalf of the patient, contact the on-line medical control physician at the
          hospital of choice and request orders to transport the patient to the closest
          appropriate facility. Provide the receiving hospital with a complete patient report as
          soon as possible. Do not delay patient transport to the closest appropriate facility
          while waiting for a physician order to change destinations. Patient must be
          transported to the receiving facility dictated by the EDMCP.
   ♦ No pre-hospital care provider is to influence the choice of hospital by the patient in any
      way; nor is any pre-hospital care provider to assume that any hospital cannot offer its
      usual range of services and preferentially divert patients to selected facilities.
   ♦ The paramedic reserves the right to determine which facility is closest considering
      mileage, transport times, traffic patterns and density, and zone where incident occurred.




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General Principles/Measures for Medical Care continued

   ♦ The transporting paramedic will document specifics about this hospital destination
      selection in the run report, to include the EDMCP's authorization or refusal to bypass
      closer hospital(s).


Emergency Department Diversions - Hospital Request
   ♦ Hospitals desiring to be placed on diversion status shall make this request to the
      Volusia County EMS Medical Director, or his/her designee, through the county’s
      Emergency Communications Center (ECC).
          The requesting hospital shall provide the basis of the request and a contact person
          with contact telephone number at the hospital for the EMS Medical Director, or
          designee, to contact.
   ♦ The ECC shall contact the Medical Director who will then contact the hospital
      representative.
   ♦ If the diversion status is approved, the Medical Director, or designee, shall contact the
      ECC and advise of the hospital’s diversion status and projected length of the diversion.
   ♦ No pre-hospital provider shall honor a hospital diversion status unless informed of such
      by the Medical Director, or designee, through the ECC.


Emergency Department Diversions – Medical Director Initiated
   ♦ The Volusia County EMS Medical Director, or his/her designee, may place an
      emergency department on diversion status when he/she believes the patients serviced
      by the EMS system would be best served by bypassing the specific emergency
      department. Examples may include:
          Extensive delays in off loading patients from ambulances into the emergency
          department.
          Failure of critical infrastructure within the emergency department (CT scan
          capability, cardiac monitor availability, etc.)




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General Principles/Measures for Medical Care (continued)

   ♦ The EMS Medical Director, or designee, shall contact the emergency department
      physician at the emergency department being considered for diversion status and
      discuss the current status of the emergency department.
   ♦ If sufficient cause exists for the emergency department to be placed on diversion for the
      benefit of the patients being serviced by the EMS system, the hospital shall be placed
      on diversion status and the Medical Director shall communicate this to the ECC with an
      anticipated duration of the diversion status.
   ♦ Should the facility to which the patient would be transported be on diversion, identify
      patient wishes for transport.
          Explain nature and reason for hospital bypass.
          Explain potential wait times and wait status to patient.
          Explain risks of potential delays in medical attention due to facility congestion or
          lack of resources.
          Discussion with the patient should include a verbatim or summary recital of the
          following “diversion warning” text:
              “The hospital you have been requested to be transported to has informed _____
          (EMS Agency) that they are on a diversionary status. Diversions are initiated when
          hospital emergency department facilities are considered to be overwhelmed by
          excessive patient volume or by critical resource shortages to the extent where such
          volume or shortage may potentially compromise patient care. You may go to
          another hospital of your choice, where you may receive faster treatment. What do
          you choose to do?”
          Identify patient’s ability to make informed decisions regarding transport
          destination.
          Re-inquire of patient’s desire for transport to facility on diversion status.
          Identify closest appropriate facility for patient destination.




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   ♦ Should patient opt to continue to destination facility:
          Inform on-line medical control at receiving facility of patient’s decision.
          Document explanations of risks and benefits of transport to facility wishing to
          divert patient.
   ♦ Should patient opt for diversion:
          Provide patient report to new receiving facility, including notice of diversion
          Document explanations of risks and benefits of bypass to patient.
   ♦ Hospitals on diversion status will continue to accept the unstable, critically ill, or
      injured patient who requires transport to the closest facility to preserve life or limb.
   ♦ In the event of a mass casualty incident within Volusia County, all diversions may be
      nullified on direction of the Volusia County EMS Medical Director or his/her designee.


Trauma Alert
   ♦ For each trauma patient, prehospital providers will assess patient condition using the
      Florida trauma scorecard methodology criteria (64E-2.017) and local "high index of
      suspicion" criteria as established by the Volusia County Trauma Center at Halifax
      Medical Center.
   ♦ Adult trauma patients
          In accordance with F.A.C. Chapter 64E-2, upon arrival of a trauma incident,
          prehospital providers will assess the condition of each trauma patient.
              The Florida EMS Adult Trauma Scorecard will be utilized to determine the
              “Trauma Alert” status of the patient.
              If a trauma patient meets any single red-colored component or any two
              blue-colored components of the Adult Trauma Scorecard criteria, the patient
              will be designated a "Trauma Alert."




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          A trauma patient meeting ANY one or more of the local "high index of suspicion"
          criteria are NOT classified as Trauma Alert patients, but will be transported to
          Halifax Medical Center. Local criteria include:
             Electrocution with evidence of exit.
             Fall of 20 feet or more.
             Lightning injury.
             Pedestrian hit by a motor vehicle and thrown 20 feet or more.
             Paramedic discretion.
   ♦ Pediatric trauma patients:
          In accordance with F.A.C. Chapter 64E, upon arrival of a trauma incident,
          prehospital providers will assess the condition of each pediatric trauma patient.
          The term "pediatric trauma patient" applies to those injured persons with anatomical
          and physiological characteristics of a person fifteen (15) years of age or younger.
             If doubt exists if the patient is pediatric, prehospital staff will measure the
             patient using a length-based resuscitation tape.
             If patient length falls within maximum length (i.e., green zone or shorter) of the
             tape, the patient can be considered a pediatric patient.
          A pediatric trauma patient meeting the criteria listed below will be designated as a
          "Trauma Alert" patient:
             The Florida EMS Pediatric Trauma Scorecard will be utilized to determine the
             “Trauma Alert” status of the patient.
             If a pediatric trauma patient meets any single red-colored component or any two
             blue-colored components of the Pediatric Trauma Scorecard criteria, the patient
             will be designated a "Trauma Alert.”




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          Patients meeting local “high index of suspicion” criteria are NOT classified as
          Trauma Alert patients, but will be transported to Halifax Medical Center. These
          criteria include:
              Electrocution with evidence of exit.
              Fall of 20 feet or more.
              Lightning injury.
              Pedestrian hit by a motor vehicle and thrown 20 feet or more.
              Paramedic discretion.
   ♦ Notification of trauma-alert status
          Halifax Medical Center will be notified of the patient’s status and imminent arrival
          in one of the following fashions:
              Field personnel may directly notify Halifax Medical Center via medical control
              radio that a trauma patient meets the Trauma Alert criteria for Trauma center
              transport by using the words, “Trauma Alert” in the course of patient report; OR
              Field personnel may directly notify Halifax Medical Center via land line or cell
              phone at (386) 254-4183 that a trauma patient meets the Trauma Alert criteria
              for Trauma Center transport by using the words, “Trauma Alert” in the course
              of patient report. Prehospital staff must speak directly to the ED trauma
              physician or charge nurse; OR
              Field personnel may relay to the Volusia County Emergency Communications
              Center (ECC) or other communications center via radio that a trauma patient
              meets the Trauma Alert criteria and will be transported to Halifax Medical
              Center. The communications center will then notify Halifax Medical Center by
              radio or telephone of the incoming Trauma Alert patient, using the words,
              “Trauma Alert".




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          Radio communication from field EMS personnel will include the phrase "Trauma
          Alert", accompanied by the information below:
              Mechanism of injury, type of injury, and specific Trauma Alert criteria met by
              patient.
              Vital signs & GCS (itemized).
              ETA (Ground or Air).
              Second set of vital signs and GCS (when available).
              Presence of known DNRO (when patient is from a nursing home or other care
              facility).
   ♦ Patient destination
          An adult or pediatric trauma patient who meets any of the Trauma Alert criteria
          must be transported to Halifax Medical Center, unless one or more of the following
          circumstances are present:
              An acute airway management problem.
              Cardiopulmonary arrest due to trauma.
              Major uncontrollable hemorrhage.
              Logistics of mass casualty responses dictate alternate destinations.
          In the event the above circumstances exist, the patient may be transported to the
          closest appropriate hospital for stabilization.
          Any patient who has suffered a traumatic injury and is greater than 18 weeks gestation of
          pregnancy should only be transported to a hospital that possess obstetrical monitoring
          capabilities.
              If you are unsure if the patient’s anticipated receiving facility is able to provide OB
              monitoring, call Medical Control at the facility to assure the ability to provide these
              services.
              As per existing protocol, trauma patients exhibiting one or more of the following
              circumstances may be transported to the closest appropriate hospital for stabilization
              regardless of OB monitoring capabilities:
                          An acute airway management problem.
                          Cardiopulmonary arrest due to trauma.
                          Major uncontrollable hemorrhage.
                          Logistics of mass casualty responses dictate alternate destinations.



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Multiple Casualty Incidents (MCIs)
   ♦ Field personnel will notify the ECC of a patient count, along with a patient severity
      index (number of patients critical, serious, stable, walking wounded, etc.),
   ♦ ECC will contact Halifax Medical Center and those hospitals closest to the incident to
      determine each Emergency Department’s receiving capability.
   ♦ EMS must not inundate any single hospital with patients. Under most circumstances,
      no single hospital should receive more than one to two serious or critical patients and
      three to four stable patients.
   ♦ First arriving agencies will assess needs and capabilities and may call for assistance
      (i.e.: additional ground ambulances, EVAC, fire, police, FPL, etc.) by contacting the
      ECC for additional resources. If the first arriving agency on the scene does not have
      direct communications capability with the ECC, the information will be relayed
      through that agency's dispatch to the ECC.


Obstetric patient destinations
   ♦ Patients with a pregnancy-related problems of less than 20 weeks gestation may be
      transported to any receiving facility of the patient’s choice.
   ♦ Patients with pregnancy-related problems of greater than 20 weeks gestation,
      pregnancy-induced hypertension, pre-eclampsia, or high-risk obstetric status may be
      transported to the delivery facility of choice.
   ♦ If birth is impending (rupture of membranes has occurred and/or contractions are
      occurring at frequent intervals but crowning is NOT present), transport mother to the
      delivery facility of choice.
   ♦ If birth is imminent (crowning present), transport mother to closest receiving facility for
      emergent delivery.
   ♦ If birth has taken place in the field and a potentially life-threatening situation arises
      with mother or child, transport patients to the closest receiving facility.
   ♦ If birth has taken place in the field and both mother and child are stable, transport
      patients to delivery facility of choice.



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EMS must not inundate any single hospital with patients. Under most circumstances, no single
hospital should receive more than:
   -   one or two critical / serious patients
   -   three or four stable patients


The use of additional ground or air transport resources should be considered when:
   -   The needs at the scene currently or are anticipated to overwhelm current on-scene
       capabilities.
   -   One or more critical trauma patients are on the scene.
   -   A significant clinical difference exists between anticipated ground and air transport
       times.
   -   More than two patients require complete spinal immobilization.
   -   More than four ambulatory patients request transportation to a hospital.
   -   Additional resources may be requested for any other reason at the discretion of the first
       responding agency (police, fire, EMS) or scene commander.


Upon notification of an incident and when there are no emergency services personnel at the
scene, the ECC may initiate a multi-ambulance response to the scene and notify the Volusia
County Sheriff's Department Aviation Division.


When additional ground transport assistance is required; police, fire, and EMS personnel will
request such assistance from ECC via radio or telephone. If the first arriving agency on the
scene does not have direct communications capability with ECC, the information will be
relayed through that agency's dispatch to ECC.




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General Principles/Measures for Medical Care continued

Volusia County public safety agencies may request the Volusia County Sheriff's Office
helicopter (Air One) to respond to accident injury calls, fires with injuries, explosions,
watercraft or aircraft emergencies, or other emergencies with established or suspected
life-threatening illness or injury. Air transport time vs. ground transport time must be carefully
considered. The Sheriff's Office Aviation unit will provide priority dispatch for medical
emergencies.


When air transport assistance is required, public safety personnel will request such assistance
via radio or telephone to the ECC or to the Volusia County Sheriff's Department's
Communications Center, who in turn notifies ECC to ensure a coordinated response.


In the event more than one (1) patient at the scene requires air medical transport or when the
Volusia County Sheriff's Office Aviation Division is unable to respond, they will contact one
of the following services, based on proximity, availability and response times, to respond.
       Agency Name                                    Telephone Number
       Air One                                        (386) 248-1777 (Dispatch)
       Flagler County                                 (386) 437-7381
       Air Care (ORMC)                                (800) 895-4615
       Fire Star Orange County Fire Rescue            (407) 897-6380
       Florida Flight Florida South Orlando           (407) 897-1610 (Inter-facility only)
       First Flight Holmes Regional, Melbourne        (800) 541-1928
       Shands, Gainesville                            (800) 342-5365
       Lifenet-2, Palatka                             (800) 644-5242
       Air Rescue-3 Seminole County Fire Rescue       (407) 324-9685
       Trauma-1 University Hospital/Jacksonville      (800) 223-4878
       Aeromed Tampa, General                         (800) 727-2911
       Bayflight Tampa Bayfront Medical Center        (800) 223-4494
       Careflight Tamps St. Josephs                   (800) 234-6428
       Lifenet-5, Bartow                              (800) 223-4494
       Lifestar Martin County Fire Rescue             (772) 287-1662
       St. Lucie County Sheriff’s Air-1               (561) 465-5770
       TraumaHawk Palm Beach County EMS               (561) 478-3904




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Unavailability of Trauma Center services


When the Trauma Center notifies EMS personnel that they are temporarily unable to provide a
particular service (i.e.: CT scanner down), EMS personnel will determine transport destination
in the patient's best interest.


If the circumstances described in the paragraph above exist, the patient may be transported to
the closest appropriate hospital [a hospital that meets specified criteria in 64E-2.015(3)(a)] for
stabilization. A complete list of Volusia County EMS initial receiving hospitals can be found
in Section 500.06.


Interhospital trauma transports


A Volusia County receiving hospital can declare a trauma patient to be an emergency trauma
interhospital transfer if the patient's condition deteriorates to the Trauma Alert status based
upon Florida trauma alert criteria.


The initial receiving hospital must contact ECS at (386) 252-4911 or (800) 323-3822 to initiate
the trauma patient's emergency trauma interhospital transfer to the Volusia County Level II
Trauma Center, Halifax Medical Center.


The emergency trauma interhospital transfer will be assigned an "emergency" status for
patients meeting Trauma Alert criteria, life-threatening conditions, or when patients would
directly benefit from a more intensive level of patient care not available at the Volusia County
initial receiving hospital.


If an initial hospital requests an interhospital transfer for a stable patient for the sole purpose of
a desired procedure or specialty physician not available at the initial facility, that patient will
be handled as a routine non-emergency scheduled interhospital transfer.




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     VOLUSIA COUNTY
ADULT TRAUMA SCORECARD METHODOLOGY                                                      NAME
1.          The EMT or Paramedics shall assess the condition of each adult trauma
patient using the adult trauma scorecard methodology to determine the transport             INCIDENT #
destination, as provided in sec. 64-E, F.A.C. Each EMS provider shall transport,
or cause to be transported, every trauma alert patient to a SATC or SAPTC nearest to
the location of the incident, unless the distance is not relevant to the length of time for DATE
transport due to the use of an air ambulance.
2.          The EMT or paramedic shall assess all adult trauma patients using the following criteria:
COMPONENT                                      BLUE                                                   RED
 AIRWAY                                     Resp Rate ≥ 30                                          Airway Intervention (beyond the
                                                                                             B      administration of Oxygen)                  R
 CIRCULATION                                Sustained HR ≥ 120 per min.                             Lack of radial pulse with sustained HR >
                                                                                             B      120 per minute or BP < 90                  R
 BEST MOTOR RESPONSE                        BMR + 5                                                 BMR ≤ 4
                                                                                                    or paralysis or suspicion of spinal cord
                                                                                             B      Injury or loss of sensation                R
 CUTANEOUS                                  Soft tissue loss from either                            2nd or 3rd degree burns ≥ TBSA, or
                                            A major degloving injury:                               amputation proximal to the wrist or
                                            or major flap avulsion > 5 inches                       ankle, or penetrating injury to the head,
                                            or GSW to extremities                                   neck or torso (excluding superficial
                                                                                                    wounds where the depth of the wound
                                                                                             B      can be determined)                         R
 LONGBONE FRACTURE                          Single longbone fx from                                 Signs or symptoms of two or more
                                            Motor vehicle collision or                              Longbone fx sites (humerus, radius, Ulna,
                                            fall from ≥ 10 ft                                       femur, tibia, fibula) (excludes fx or radius
                                                                                                    and ulna on same extremity or tibia/fibula
                                                                                             B      on same extremity)                         R
 AGE                                        55 years of age or older
                                                                                   B
 MECHANISM OF INJURY                        Ejected from a motor vehicle
                                            (excluding motorcycle, moped, ATV, or
                                            open body of pickup truck) or steering
                                            wheel deformity by driver              B
 GCS                                                                       GCS ≤ 12 (excluding patients whose
                                                                           normal GCS is 12 or less, established by pt
                                                                           medical history or pre-existing medical
                                                                           condition when known)                     R
 PARAMEDIC JUDGEMENT                                                       EMT or paramedic can call a trauma alert if,
                                                                           in his or her judgement, the patient condition
                                                                           warrants such action.                    R
█       R = any one(1) – transport as a trauma alert       █      B = any two (2) – transport as a trauma alert
                                                 Glasgow Coma Scale
 EYES (open)                         BEST VERBAL RESPONSE            BEST MOTOR RESPONSE
 Spontaneous                    4 Oriented & converses           5 Obeys (verbal command)                              6
 To verbal command              3 Disoriented & converses        4 Localizes to pain                                   5
 To pain                        2 Inappropriate words            3 Flexion-withdrawal to pain                          4
 No response                    1 In comprehensible sounds       2 Flexion-abnormal to pain (decorticate rigidity) 3
                                     No response                 1 Extension to pain (decerebrate rigidity)            2
                                                                     No response                                       1




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Facilities to Which “Trauma Alert” Patients Will Be Transported
A.     SATC’s:
       Halifax Medical Center – Daytona, Volusia County
       If HMC unavailable, transport to nearest hospital.
Pediatric Trauma:
A.     A pediatric patient is a patient with the anatomical and physical characteristics of a
       person fifteen (15) years or younger.
B.     A pediatric trauma patient meeting any one of the criteria (one red or two blue criteria).




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      VOLUSIA COUNTY
PEDIATRIC TRAUMA SCORECARD METHODOLOGY                                                     NAME
The EMT or Paramedics shall assess the condition of those injured individuals with
anatomical and physical characteristics of a person fifteen (15) years of age or younger   INCIDENT #
for the presence of one or more of the following three (3) criteria to determine the
transport destination per 64E, Florida Administrative Code (F.A.C.)                        DATE


           1)          Pediatric Trauma Triage Checklist: The individual is assessed based on each of the six- (6) physiologic components listed below
                       (left column). The single, most appropriate criterion for each component is selected (along the row to the right). Refer to the color-
                       coding of each criteria and legend below to determine the transport destination:


    SIZE                                                                                                           WEIGHT ≤ Kg or
                                                                                                                   LENGTH ≤ INCHES ON A
                                     20 Kg (44+ lbs.)                   10-20 Kg (22-43 lbs.)
                                                                                                                   PEDIATRIC LENGTH
                                                                                                                   AND WEIGHT EMERGENCY TAPE
                                     1                                  1
                                                               G                                          G                                             B
    AIRWAY                           NORMAL                             SUPPLEMENTED O2                            ASSISTED OR INTUBATED1

                                     1                                  1                                          1                                    R
                                                               G                                          G
                                                                                                                                                   2
    CONSCIOUSNESS                    AWAKE                              AMNESIA or LOSS OF                         ALTERED MENTAL STATUS or
                                                                                                                   COMA or PRESENCE OF PARALYSIS
                                                                        ANY CONSCIOUSNESS                          or SUSPICION OF SPINAL CORD
                                                                                                                   1       INJURY or LOSS OF
                                     1                                  1                                                  SENSATION
                                                               G                                           B
                                                                                                                                        R
    CIRCULATION                      GOOD PERIPHERAL                    CAROTID or FEMORAL PULSES                  FAINT OR NON-PALPABLE
                                                                        PALPABLE, BUT THE RADIAL OR
                                     PULSES;                            PEDAL PULSE NOT PALPABLE
                                                                                                                   RADIAL or FEMORAL PULSE
                                     SBP > 90 mmHg                                                                 Or SBP <50 mmHg
                                     1                                  1                                          1
                                                   G                                                       B                            R
    FRACTURE                         NONE SEEN or                       SINGLE CLOSED LONG                         OPEN LONG BONE3 FRACTURE5
                                     SUSPECTED                          BONE3 FRACTURE4                            or MULTIPLE FRACTURE SITES
                                                                                                                   or MULTIPLE DISLOCATIONS5
                                     1                                  1                                          1
                                                     G                                     B                                                             r
    CUTANEOUS                        NO VISIBLE INJURY                  CONTUSION or ABRASION                      MAJOR SOFT TISSUE DISRUPTION6
                                                                                                                   or MAJOR FLAP AVULSION or 2° or
                                                                                                                   3° BURNS TO ≥ 10% TBSA or
                                     1                                  1                                          AMPUTATION7 or ANY
                                                                                                                   PENETRATING INJURY TO HEAD,
                                                               G                                          G        1     NECK or TORSO8
                                                                                                                                                R
█ R=any one (1) -                                        █    B=any two (2) -                                     █ G=follow local protocols
     transport as a trauma alert                                 transport as a trauma alert

     Patient does not meet any of the trauma criteria listed above, but the EMT or Paramedic can call a “Trauma Alert” if, in his or her
     judgement, the trauma patients’ condition warrants such action. Must be documented on run report pursuant to 64E (F.A.C.)
1
  Airway assistance includes manual jaw thrust, single or multiple suctioning, or use of other adjuncts to assist ventilatory efforts.
2
  Altered mental states include drowsiness, lethargy, inability to follow commands, unresponsiveness to voice, totally unresponsive.
3
  Long bones include the humerus, radius, ulna, femur, tibia or fibula.
4
  Long bone fractures to not include isolated wrist or ankle fractures.
5
  Long bone fractures do not include isolated wrist or ankle fractures or dislocations.
6
  Includes major degloving injury.
7
  Amputation proximal to wrist or ankle.
            8
              Excluding superficial wounds where the depth of the wound can be determined.




                                                                                                                          Effective Date: January 1, 2006
                Rev: April 2, 2003
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                            Paramedic Scope of Practice

Paramedic Scope of Practice
   ♦ Paramedics working with Volusia County prehospital agencies may, in the course of
      duty, be required to participate in patient care at locations outside of Volusia County.
          Participation in patient care outside of Volusia County may occur as a result of
          disaster responses, patient transport, or mutual aid agreements.
          Volusia County prehospital providers are authorized to perform within the scope of
          the Volusia County EMS Medical Protocols under these circumstances.
          Authorization is extended only to Volusia County paramedics working for a
          Volusia County agency during duty time.
   ♦ Providers working with Volusia County prehospital agencies may happen upon or be
      requested to assist at the scene of injury or illness outside of duty hours.
          Prehospital providers are authorized to perform within the scope of the Volusia
          County EMS Medical Protocols if the scene of illness or injury is fully within the
          confines of Volusia County.
          ALS certified providers responding as a volunteer for a BLS agency are authorized
          only to perform at the BLS level.
   ♦ Prehospital providers working with prehospital agencies external to Volusia County
      may, in the course of duty, be required to participate in patient care at locations within
      Volusia County.
          External prehospital providers may perform within the scope of EMS medical
          protocols established for their employing agency. This authorization is extended
          only for prehospital providers working within Volusia County during duty time.
          External prehospital providers outside of duty hours are not authorized to practice
          prehospital care within Volusia County.




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                   Certification and Education Requirements

FIRST RESPONDER
First Responders within Volusia County working under the auspices of the Volusia County
Medical Director will be required to meet certain educational and certification requirements.


Certified First Responders


First responders working with a fire/rescue agency will be considered as “certified first
responders.” Certified First Responders will be required to complete 20 hours of continuing
education every two years in order to maintain the ability to work within the Volusia County
EMS system. The content of these hours will consist of:


   ♦ 4 hours of SAED training for those First Responders who initiate care without
       concurrent BLS or ALS support (as agency-appropriate).
   ♦ 4 hours of CPR refresher training (or proof of maintenance of current CPR
       certification).
   ♦ 4 hours of training in AIDS/HIV and bloodborne pathogens (as required by statute).
   ♦ 4 hours of medical assessment and management.
   ♦ 4 hours of trauma assessment and management.


The medical and/or trauma modules will include training regarding the theory and practice of
oxygen therapy. The Volusia County Medical Director must certify continuing education
programs in order to be credited to this total.




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Non-Certified First Responders
Non-certified first responders are those working with agencies whose primary function is not
the provision of fire/rescue services, but whose medical operations fall under the auspices of
the EMS Medical Director. Non-Certified First Responders will be required to complete 10
hours of continuing education every two years in order to maintain the ability to work within
the Volusia County EMS system. The content of these hours will consist of:


    ♦ 4 hours of CPR refresher training (or proof of maintenance of current CPR
        certification).
    ♦ 2 hours of training in AIDS/HIV and bloodborne pathogens (as required by statute).
    ♦ 2 hours of medical assessment and management.
    ♦ 2 hours of trauma assessment and management.


The medical and/or trauma modules will include training regarding the theory and practice of
oxygen therapy. Modules may include other material as required by agency needs. The
Volusia County Medical Director must certify continuing education programs in order to be
credited to this total.




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EMERGENCY MEDICAL TECHNICIAN (EMT)


Emergency Medical Technicians (EMTs) working within Volusia County under the auspices
of the Medical Director will be required to meet certain educational and certification
requirements. These requirements are as follows:


   ♦ The EMT shall maintain current AHA CPR for the Healthcare Professional or
       equivalent.
   ♦ The EMT shall have attained a score of no less than 80% correct on a test of current
       EMS BLS protocols administered as part of the initial employment process and
       periodically as dictated by individual and/or systemic needs. If a score of less than
       80% is received, the EMT may be retested upon request.
   ♦ 16 hours of review of Medical Director inservice material, in person or by video, at a
       rate of 2 hours per calendar quarter.
   ♦ 24 hours of EMT or EMT-P refresher curriculum according to DOT standards or
       equivalent as approved by the Volusia County Medical Director. Refresher curriculum
       will place special emphasis on the role of the EMT in trauma care, in airway
       management, and in management of cardiac arrest.
   ♦ 4 hours of SAED training for those EMTs who initiate first response without
       concurrent ALS support (as agency-appropriate).
   ♦ The EMT shall maintain current EMT certification issued by the Florida Department of
       Health, Office of Emergency Medical Services.




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General Principles/Measures for Medical Care continued


PARAMEDIC (EMT-P)


Paramedics (EMT-Ps) working within Volusia County under the auspices of the Medical
Director will be required to meet certain educational and certification requirements. These
requirements are as follows:


♦ The EMT-P shall maintain current AHA CPR for the Healthcare Professional or
   equivalent.
♦ The EMT-P shall maintain a current Advanced Cardiac Life Support card issued by the
   AHA or equivalent.
♦ The EMT-P shall attend a 16-hour pediatric course (PALS, PEP, APLS, or equivalent as
   approved by the Medical Director) within one year from the date of new employment, or
   demonstrate certification in PALS, PEP, or APLS attained during paramedic training.
   Eight (8) hours of refresher training leading to recertification, or equivalent training as
   approved by the Medical Director, is required every two years.
♦ The EMT-P shall have attained a score of no less than 80% correct on a test of current ALS
   EMS protocols administered as part of the initial employment process and periodically as
   dictated by individual and/or systemic needs. If a score of less than 80% is received, the
   Paramedic may be retested upon request.
♦ The EMT-P shall attend a 16-hour trauma course (BTLS, PHTLS, or equivalent as
   approved by the Medical Director) within one year from the date of new employment, or
   demonstrate certification in BTLS or PHTLS attained during paramedic training. Eight (8)
   hours of refresher training leading to recertification, or equivalent training as approved by
   the Medical Director, is required every two years.
   ♦ The EMT-P shall attend either a 4-hour Volusia County Advanced Paramedic
       Procedure Course or a 4-hour EVAC Cadaver Laboratory Procedural Session within
       one year from the date of new employment, or demonstrate competency in these skills
       as attained during paramedic training. Such procedural course or laboratory attendance
       is required every two years.



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   ♦ 16 hours of review of Medical Director inservice material, in person or by video, at a
       rate of 2 hours per calendar quarter. EMT-Ps are required to attend one session per
       year in person.
   ♦ 16 hours of EMT-P refresher curriculum according to DOT standards or equivalent as
       approved by the Volusia County Medical Director.
   ♦ The EMT-P shall maintain a current Paramedic certification issued by the Florida
       Department of Health, Office of Emergency Medical Services.
   ♦ Flight paramedics working on Air-1 must complete a 32-hour Air Medical Crew
       Curriculum Course prior to assuming air medical duties.


SPECIAL CONSIDERATIONS


If any First Responder, EMT, or Paramedic is not in compliance with the above regulations,
the Paramedic or EMT shall not practice under the auspices of the Volusia County EMS
Medical Director until such time as these requirements are met. The Medical Director reserves
the right to waive any or all regulations due to extenuating circumstances.


The lead instructor for in-house courses at the EMT-P level must be certified as instructors in
the respective national disciplines. For example, lead instructors for PALS, PEP, APLS, or
“in-house” pediatric equivalent courses must be certified and maintain such certification as an
instructor in PALS, PEP, or APLS. Other instructors must be certified and maintain such
certification as providers in the discipline. To illustrate, instructors (other than the lead
instructor) for BTLS, PHTLS, or “in-house” trauma equivalent courses must be currently
certified as a BTLS or PHTLS provider. Instructors for courses at the EMT level must be
currently certified at the provider level in the area of focus to teach in the respective course.




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Instructors for EMT and EMT-P refresher courses, or other continuing education activities,
must be approved for teaching by the EMS officer of the appropriate agency. Whenever
possible, within the structure of an agency, instructors should be certified at a higher level than
the students (i.e. EMTs should receive instruction from and EMT-P as possible).


An EMT may receive credit for attendance at a combined EMT/EMT-P refresher course, in
congruence with the system philosophy of viewing EMS as a continuum of care and not as two
separate BLS and ALS systems. An EMT-P may not receive credit for attendance at an EMT
refresher course.


All EMS agencies within Volusia County are encouraged to consider the use of nationally
certified courses as a primary option to meet these requirements, and to utilize the resources of
local EMS educational institutions (such as Daytona Beach Community College) to fulfill
these needs.




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                             General Patient Assessment

                                   General Provisions


The following standards of care shall apply to all patients served by prehospital providers
within Volusia County:


   ♦ The Volusia County EMS Medical Protocols have been developed to aid Emergency
       Medical Technicians, Paramedics, and First Responders employed and on duty with
       licensed Volusia County BLS and ALS agencies to provide uniform excellence in
       prehospital medical care.
   ♦ Protocols are established and authorized exclusively by the Volusia County EMS
       Medical Director. Protocols may not be adapted, amended, or altered by any party
       without specific written consent from the Medical Director.
   ♦ The first agency on the scene of accident or illness shall establish command.
       Responsibility for management of the overall scene will be transferred to
       representatives of the authority having jurisdiction upon arrival. Command structures
       and procedures will adhere to accepted ICS standards and guidelines. Fire/Rescue
       Departments shall routinely maintain responsibility for controlling incident scenes. It is
       the responsibility of the scene commander to insure the proper and timely utilization of
       resources to meet the goals of scene safety, quality patient care, and rapid movement to
       medical facilities.
   ♦ The goal of the EMS system is to provide optimal patient care on scene and expedite
       patient transport to definitive care. Patient care may require transfer to other EMS
       providers to accomplish this mission.
           The EMT or EMT-P first “on scene” will assume responsibility for patient care
           until such care is transferred to another provider.




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          A prehospital provider certified at the First Responder level will transfer care to a
          Basic Life Support (BLS) provider.
          A prehospital provider certified at the BLS level will transfer care to a provider
          certified at the Advanced Life Support (ALS) level.
          A prehospital provider certified at the ALS level working with a non-transport
          agency will transfer care to an ALS level provider working with an air or ground
          transport agency.
          A prehospital provider certified at the ALS level working with a ground transport
          agency will transfer care to an ALS level provider working with an air transport
          agency.
          Under no circumstances may care be transferred from BLS care to that of First
          Responders, nor from ALS care to that of BLS staff.
          There are no medical conditions where delays on the scene benefit the patient.
          Transfer of patient care should begin in an effective and efficient manner upon
          arrival of the transporting agents.     Patients will be removed from hazardous
          situations as quickly as possible. Transfer of care in no way removes the obligation
          of initial responders to continue to act as integral members of the prehospital care
          team under the direction of the supervising provider.
          If disagreement exists between prehospital care providers of any level regarding
          patient treatment or transport, the EDMCP at the intended destination facility
          should be contacted for physician orders and conflict resolution.
   ♦ The prehospital provider will attempt to obtain verbal consent from the patient prior to
      treatment. The patient's rights to privacy and dignity will be continuously respected.
   ♦ Accurate documentation of the patient encounter is considered integral to these
      protocols. Documentation must include a description of the chief complaint, history of
      the present illness and of pertinent past problems, vital signs, mental status, and
      prehospital assessment and care. Failure to provide adequate documentation of the
      patient encounter will be considered to represent non-compliance with protocol.




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   ♦ Assistance with patient transport from non-transport providers will be required only for
      critical patients. Critical patients will be defined as those in an unstable condition in
      which the danger of imminent and immediate death exists. Assistance from non-
      transport providers will not be based upon the potential for patient deterioration.
   ♦ Paramedics who have successfully completed the Paramedic Procedural Recertification
      Course or the EVAC Advanced Procedure Cadaver Course are authorized to utilize
      advanced skills on resuscitation cases when other options have resulted in no response.
      Advanced procedures will be defined as cricothyrotomy, needle thoracentesis, central
      IV cannulation, pericardiocentesis, and intraosseous infusion.       All cases in which
      advanced procedures are performed will be reported to the Medical Director within 72
      hours.
   ♦ In accordance with F.A.C., emergency medical technicians may be authorized to
      perform certain advanced procedures.         Advanced procedures authorized by the
      Department of Health, Bureau of EMS and the Volusia County EMS Medical Director
      include oropharyngeal Combitube insertion, administration of epinephrine using an
      autoinjector, assistance with patient self-administration of nitroglycerin and inhaled
      bronchodilators, and initiation, monitoring, and maintenance of unmedicated
      intravenous lines under the supervision of a licensed paramedic (EMT-P). EMTs may
      be authorized to perform the above procedures after any prerequisites have been
      satisfied and qualified individuals are approved in writing by the Volusia County EMS
      Medical Director.
   ♦ Each patient will have vital signs continuously monitored. Vital signs include but are
      not limited to pulse, blood pressure, respiratory rate, cardiac rhythm, oxyhemoglobin
      saturation, and neurologic status. Vital signs will be recorded at least once at the scene
      and once during transport. Paramedics should record additional vital signs every five
      minutes during transport and at more frequent intervals as warranted.
   ♦ All patients will be transported facing backward in the vehicle in the position of
      comfort unless protocol or medical considerations dictate otherwise.



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   ♦ The medical control physician shall be defined as the emergency department-attending
      physician at the receiving facility.
   ♦ The ABC's (airway, breathing, and circulation) will always take priority in patient
      management. Maneuvers required to secure the airway, ensure sufficient air exchange,
      and establish adequate tissue perfusion always supersede specific protocol statements.
   ♦ Unless otherwise specified, patients should be continued on intravenous fluids,
      medications, and therapeutic devices initiated by referring agencies and institutions.
   ♦ Orders communicated directly from the on-line medical control physician accepting the
      patient to the paramedics caring for the patient may supersede established protocol.
   ♦ In order to insure protection of prehospital providers from communicable disease, all
      caregivers who anticipate exposure to patient blood or body fluids during transport
      should use appropriate precautions, including use of masks, gloves, and eye protection.
   ♦ Complications, problems, or requests for additional orders during care will be directed
      toward the on-line medical control physician. If orders are given for additional care
      and/or the use of controlled agents (diazepam, etomidate, and/or morphine sulfate), the
      name and hospital location of the EDMCP issuing the orders must be documented on
      the run report. The signature of the ordering physician is not required. Additional
      questions or problems should be directed to the EMS Medical Director after patient
      care has been completed.
   ♦ Volusia County prehospital services will adopt a philosophy of minimizing scene times
      in the care of prehospital patients. In general, on-scene activities should be limited to
      the primary survey and airway/cervical spine stabilization.




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   ♦ These protocols encompass both BLS and ALS levels of care. BLS providers are
       authorized to follow these protocols to the limits of their training, skill, resources, and
       certification. Providers may not provide care in excess of the level for which their
       employing agency is licensed (i.e. an ALS provider cannot provide ALS care while
       working for a BLS agency).
   ♦   Patient care is by nature unpredictable, and patients may require care derived from
       multiple protocols, protocols not yet devised, or in the absence of on-line medical
       control. The following protocols are written with this reality in mind. Deviations from
       protocol will be tolerated only when they are intended to further patient care. Such
       deviations must in no way detract from the high level of patient care expected from
       EMS personnel.




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                                 Patient Assessment


Approach to the Scene
The purpose of the initial assessment is to detect life-threatening problems. The primary
survey begins as you approach the scene.
   ♦ Survey the Scene and Location of the Patient
          The prime concern is the safety of one's self and for the patient.              Look for
          hazardous conditions that may be present, i.e., fire, electrical wires, possibility of
          explosion, etc.
          Look for signs that may identify the mechanisms of injury and suggest injured areas
          on the patient.
          Identify yourself and seek permission to examine and treat the patient.
   ♦ Simultaneously Survey the Patient
          Determine patient's level of consciousness.
          Determine rise and fall of patient's chest.
          Look for profuse bleeding and (or) blood soaked clothing.
          Look for obvious deformity or unnatural angulation of the extremities.


Initial Assessment

   ♦ All patient encounters will be characterized by use of the initial assessment (primary
       survey) and focused history and examination (secondary survey).
   ♦ Initial assessment (Primary survey)
          Scene survey
              Identify patient numbers, patient locations, and any hazardous conditions on the
              scene.
              Identify signs that may clarify mechanisms of injury of illness.
              Identify self to patient and seek permission for care.




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          Patient assessment
             Establish status of airway and cervical spine
             ♦ Maintain airway as required
                    Jaw thrust maneuver
                    Oral or nasal airways
                    Oropharyngeal Combitube
                    Endotracheal intubation
             ♦ Maintain cervical spine integrity
                    If cervical injury is suspected, do not move the head.
                    Cervical spine immobilization and stabilization should be performed
                    immediately. If patient is conscious, instruct not to move.
             Establish presence, rate, and quality of respirations.
             ♦ If respiration’s are absent, initiate ventilatory support
                    Secure airway
                    Bag-valve-mask ventilation
             ♦ If respiration’s are present, assess for presence of respiratory distress
                    Administer oxygen as appropriate
                               Nasal cannula
                               Simple face mask
                               Venturi mask
                               Non-rebreathing mask
                               Bag-valve ventilation
                    Identify and correct reversible causes of respiratory distress
                               Tension pneumothorax
                               Bronchospasm from asthma/COPD
                               Chest wound or flail chest




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              Establish presence of effective circulation
              ♦ Identify presence, rate, and quality of pulse
              ♦ If carotid pulse absent, initiate CPR
              ♦ If pulses present, assess systolic blood pressure
                      If carotid pulse present, SBP > 60 mmHg
                      If femoral pulse present, SBP > 70 mmHg
                      If radial pulse present, SBP > 80 mmHg
              ♦ Assess capillary refill. If capillary refill does not occur within two (2)
                  seconds, circulation may be impaired.
              ♦ Control external hemorrhage with direct pressure
              Assess neurologic function
              ♦ AVPU assessment of response
              ♦ Request motion of hands/feet
              ♦ Calculation of initial Glasgow Coma Score
              Expose and examine and site of patient injury or complaint
              Formally assess and record vital signs (pulse, respiratory rate, blood pressure,
              and oxyhemoglobin saturation)


The Focused History and Exam: Procedure
The objective of the focused history and examination (secondary survey) is to discover medical
and injury related problems that do not pose an immediate threat to patient survival, but may
do so if allowed to go untreated.      The secondary survey is composed of the subjective
interview and the objective examination. These tasks may be performed concurrently.
   ♦ Subjective Interview
   ♦ Gain essential information relative to the patient's condition, by questioning the patient,
       if conscious; or bystanders and/or relatives if the patient is unconscious.
   ♦ Objective Examination




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   ♦ This is a comprehensive hands-on head-to-toe survey. The findings are combined and
      related to allow you to make an assessment of your patient's condition and form a plan
      of emergency care.


Focused History and Exam: Procedures


   ♦ History (SAMPLE model)
   ♦ Physical examination
          Head
             Scalp (tenderness, deformities, foreign bodies, signs of trauma)
             Ears (CSF leakage, Battle sign)
          Face
             Eyes (pupil equality, diameter, reactivity, raccoon eyes)
             Nose (signs of trauma, CSF leak)
             Mouth (foreign bodies, trauma, blood, odor of breath)
          Neck
             Anterior (tracheal deviation, JVD, stomal openings, wounds, presence of Medic
             Alert tags)
             Posterior (vertebral tenderness, deformity, wounds)
          Trunk (signs of trauma, instability, respiratory excursion, respiratory effort,
          respiratory rate, lung sounds, paradoxical chest wall motion, subcutaneous
          emphysema)
          Abdomen (bowel sounds, tenderness, masses, rigidity, distension, signs of trauma)
          Pelvis and hips (pelvic stability, tenderness, signs of trauma, hip position and
          extremity rotation)
          Back and spine (signs of trauma, tenderness, deformity, instability)
          Extremities (deformity, edema, tenderness, signs of trauma, distal neurovascular
          and musculoskeletal function, presence of Medic Alert tags, constricting bands of
          clothing)



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           Neurologic (review AVPU status, GCS, ability to move extremities)
           Skin (color, warmth, dryness, diaphoresis, cyanosis, jaundice)


SPECIAL NOTES
General considerations
   ♦ The initial assessment takes precedence over all other procedures unless hazardous
       conditions are present. The primary survey should take no more than 30 seconds to
       complete.
   ♦ If the patient is suffering from a life-threatening condition, treat appropriately and
       transport immediately to an appropriate receiving facility. The focused history and
       examination may be initiated during transport.
   ♦ Always explain to the patient what is taking place. Request the patient inform the
       provider of any pain and/or discomfort. In patients who lack effective means of verbal
       communication, watch the face for reaction to pain.
   ♦ Answer patient inquires in a positive and reassuring fashion.             Do not frighten,
       intimidate, or judge the patient.
   ♦ Remove clothing as required for complete assessment. Discretion is encouraged, but
       exposure will always be dictated by clinical needs.
   ♦ Any foreign bodies should be stabilized in place. Removal is only indicated for foreign
       bodies in the airway.
   ♦ Patient transport may not be delayed in order to accomplish the complete secondary
       survey.
   ♦ The entire patient examination should take from one (1) to three (3) minutes.
   ♦ This protocol is meant to serve as a guideline for complete and comprehensive patient
       assessment. Rarely will a paramedic perform an examination of this depth. The
       paramedic will concentrate his or her examination based upon the complaint(s) of the
       patient.




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Examination points


   ♦ Components of the SAMPLE history
      S-      Symptoms
      A-      Allergies
      M-      Medications
      P-      Past medical history
      L-      Last meal
      E-      Events just prior to illness or injury
   ♦ Capillary refill may be falsely impaired by the presence of peripheral vascular disease,
      COPD, diabetes, carbon monoxide intoxication, and smoking; it may be falsely normal
      in patients with focal extremity vascular congestion.
   ♦ Components of the AVPU neurologic examination:
      Alert; speaks and moves spontaneously
      Responds to verbal stimuli
      Responds to painful stimuli
      Unresponsive
   ♦ Check for cerebrospinal fluid drainage from the ears and nose, indicating a basilar skull
      fracture. If present, do NOT stop drainage. Fluid may be clear or mixed with blood.
   ♦ Check pupils by shining light into each one. Check for equality and light reactivity.
      Check for any eye injuries. Note that up to 20% of people have pupils, which are
      normally unequal in size.
   ♦ Gently palpate on upper and lower abdomen. Check all four (4) quadrants. Check for
      rigidity, distension and (or) pain. Check for masses.
   ♦ Exert lateral pressure on hips by placing your hands on the patient's hips and gently
      pressing inward and downward toward the midline for pelvic fracture.




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General Patient Assessment continued

   ♦ To examine the lumbar and thoracic spine, reach as far under the patient as possible
       with palms upward. Curl fingers upward to exert pressure on the spinal region. If pain
       and (or) deformity is present, suspect an injury.
   ♦ Examine the extremities one at a time. Use both hands with thumbs together to encircle
       the limb. Exert firm pressure and feel for deformities and (or) pain; grasp proximal and
       distal ends of long bones and “rock” extremity to feel for crepitus or listen for
       complaints of pain.


Treatment priorities
   ♦ Two levels of treatment priorities are identified:
             Critical (life threatening) conditions must be treated immediately.
             Serious (potentially life-threatening or disabling) conditions must be managed as
             soon as critical conditions are stabilized.
Critical conditions often require cardiopulmonary resuscitation techniques and include the
following:
             Airway (compromise or obstruction)
             Breathing (respiratory failure or respiratory arrest)
             Circulation (problems with cardiac output or cardiac rhythm)
             Exsanguinating hemorrhage (massive bleeding, external or internal)
Serious conditions include the following:
             Disturbance of consciousness (coma or semi-coma)
             Respiratory distress (shortness of breath)
             Symptomatic cardiac dysrhythmias
             Active hemorrhage (bleeding)
             Toxic drug overdose or poisoning
             Active seizures
             Deforming injuries such as burns, penetrating wounds, fractures or other major
             trauma
             Chest pain



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                       Abdominal Pain/GI Bleeding
History

   ♦ Onset and duration
   ♦ Location and radiation
   ♦ Quality (crampy, sharp, intermittent, etc.)
   ♦ Menstrual history
   ♦ Previous trauma
   ♦ Current medications
   ♦ Medical illnesses
   ♦ Allergies
   ♦ Surgery
   ♦ Abnormal ingestion


Symptoms

   ♦ Nausea
   ♦ Vomiting (bloody, coffee-ground, etc.)
   ♦ Constipation
   ♦ Melena (bloody, tarry stools)
   ♦ Urinary problems
   ♦ Fever
   ♦ Diarrhea


Signs

   ♦ Vital Signs:    Vary
   ♦ Skin:           Diaphoresis; pallor
   ♦ GI:             Abdominal tenderness, guarding, distention, pulsatile mass, emesis




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Abdominal Pain/GI Bleeding continued



Basic Life Support
   ♦ Secure airway
   ♦ Administer supplemental oxygen, maintain saturation between 90-100%
   ♦ Record and monitor vital signs
   ♦ Nothing by mouth


Advanced Life Support
   ♦ Advanced airway/ventilatory management as needed
   ♦ If BP < 90 mmHG systolic, administer boluses of 0.9% NaCl at 250-500 cc to
       maintain systolic BP > 90 mmHg
              Contraindicated if evidence of congestive heart failure (e.g. rales)
   ♦ Record and evaluate 12-lead EKG as appropriate


  Medical Control
     For pain control, contact medical control.




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                       Airway Management - Adult
History
   ♦ Onset (acute or gradual)
   ♦ Duration
   ♦ Exacerbating or alleviating factors
   ♦ Oral exposure/foreign bodies (toys, drugs, alcohol, food, chemicals, etc.)
   ♦ Trauma
   ♦ Environmental exposure
   ♦ Smoking
   ♦ Medical illnesses (especially COPD, asthma, diabetes, CHF, thrombophlebitis)
   ♦ Current medications
   ♦ Allergies
   ♦ Home oxygen
   ♦ Drug or alcohol use


Common Causes
   ♦ Asthma
   ♦ Acute upper airway obstruction
   ♦ Acute bronchitis, pneumonia
   ♦ Drowning and asphyxiation
   ♦ Epiglottitis
   ♦ Overdose and poisoning
   ♦ Myocardial infarction (MI)
   ♦ CHF
   ♦ Chest trauma
   ♦ Pulmonary edema
   ♦ Diabetic Ketoacidosis
   ♦ Hyperventilation syndrome due to anxiety reaction




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Airway Management – Adult continued

Symptoms
   ♦ Chest pain (location, quality, position)
   ♦ Dyspnea
   ♦ Cough
   ♦ Sputum production or change
   ♦ Paresthesia in hands or mouth
   ♦ Calf pain (Homan's Sign)
   ♦ Fever


Signs
   ♦ Vital Signs:        Vary
   ♦ Skin:               Cyanosis, peripheral edema, hives, evidence of neck or chest trauma
   ♦ HEENT:              Upper airway, facial edema, drooling, nasal flaring
   ♦ Respiratory:       Stridor, rales, rhonchi, wheezing, decreased breath sounds, crepitus,
                        subcutaneous emphysema, accessory muscle usage
   ♦ Cardiovascular:     Neck vein distention, dysrhythmias
   ♦ Neurologic:         Decreased level of consciousness, restlessness, slurred speech



Basic Life Support
   ♦ If suspicion of trauma, maintain C-spine immobilization
   ♦ Suction all debris, secretions from airway
   ♦ Administer supplemental oxygen (100%), then BVM ventilate if indicated
   ♦ Place Combitube if unable to ventilate via BVM




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Airway Management – Adult continued

Advanced Life Support
   ♦ Apply cardiac monitor & obtain EKG rhythm strip (simultaneously if assistant
      available. Otherwise perform after airway management)
          Perform immediate defibrillation as soon as VF is identified
   ♦ Begin continuous oxygen saturation monitoring
   ♦ Follow algorithm below if patient has indication for Intubation
          Decreased level of consciousness with respiratory failure OR poor ventilatory effort
          (with hypoxia unresponsive to supplemental 100% oxygen) OR unable to maintain
          patent airway

                                                            Bag Mask Ventilate (BVM)1
                         •       Goal = keep oxygen saturation > 90-95% for 1-2 minutes pre-intubation if possible




                             •     Endotracheal Intubation, or
                             •     Continued BVM unless anticipated difficulty with continued BVM2




                                                               Endotracheal Intubation

                •     Reasonable attempts should be made for a medical patient and 2 attempts shall be made for a trauma
                      patient (repeated attempts are especially detrimental in head injury/stroke patients). Attempt to BVM
                      ventilate between intubation attempts to increase oxygen reserve.
                •     Stop any attempt if 30 seconds pass, or in case of a significant drop in oxygen saturation.



                                                               No success with attempt(s)                         Success
                                                                   BVM Ventilate1                            Confirm with
                                                                                                             • ETCO2 and
                                                                                                             • Exam
                                                          Place Laryngeal Mask Airway
                                                                    (LMA)3

                                                                                                               Continue to
                                                                                                               ventilate and
                         Success                           •     If unable to ventilate via                      monitor
                    Confirm with                                 LMA
                    • ETCO2 and                            •     Insert Combitube
                    • Exam



                                                         As a last resort, if unable to
                      Continue to                        ventilate by any other means
                      ventilate and
                                                            • Consider cricothyrotomy
                        monitor



            1
              At every step of airway algorithm, effective bag-valve-mask ventilation is an acceptable stopping point.
            2
               Examples where ETT may be attempted include limited manpower during transport (assistance with bagging),
               prolonged transport, increasing airway resistance, swelling, etc.
            3
              If LMA placement successful, training complete, and equipment available, may attempt intubation through LMA
               following successful LMA insertion.




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Airway Management – Adult continued

   ♦ Following intubation with ETT or Combitube, confirm proper placement:
          Examine for bowel sounds, breath sounds, and tube condensation.
          Record and monitor oxygen saturation and monitor continuously.
          Record end-tidal C02 and monitor continuously.
              Patients should not have a step down in the method used to record end-tidal
              C02. For instance, if the patient is initially monitored with a capnographic
              waveform (e.g. LifePak 12), this should not be switched to colorimetric device
              for monitoring end-tidal C02.
          Record depth of ET tube and secure airway.
              Utilize rigid cervical collar and long spine board immobilization as tolerated, to
              secure airway device in place.
              Record all airway documentation requirements as per Medical Procedures
              Manual (see Documentation Standards).
          Complete the Volusia County EMS Airway Management Reporting Form and
          submit to the appropriate EMS Coordinator.
   ♦ The use of paralytics in airway management is limited to paramedics who have been
       credentialed by the Medical Director after completion of the Volusia County Advance
       Airway Management Program (AAMP).
          See the AAMP Course Overview in the appendix.




  Medical Control
     Call Medical Control for any additional orders or questions.




                                                                        Effective Date: January 1, 2006
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                                                                                                 205

                                   Allergic Reactions
History

   ♦ Exposure, ingestion or contact (stings, drugs, foods, etc.)
   ♦ Prior allergic history
   ♦ Current medications


Symptoms

   ♦ Itching
   ♦ Rash
   ♦ Swelling
   ♦ Respiratory distress*
   ♦ Abdominal pain
   ♦ Nausea, vomiting
   ♦ Syncope
   ♦ Weakness
   ♦ Anxiety
   ♦ Choking sensation*
   ♦ Cough
        *
            Denotes moderate to severe allergic reaction

Signs

   ♦ Vital signs:        Vary (routine or shock*)
   ♦ Skin:               Rash, redness, urticaria (hives), generalized or local edema
   ♦ HEENT:              Tongue or upper airway (uvula) edema*
   ♦ Respiratory:        Wheezing, stridor, hoarseness*, cough, upper airway noise
   ♦ Neurologic:         Varies
        *
            Denotes moderate to severe allergic reaction




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Allergic Reactions continued


Basic Life Support
   ♦ Secure airway
   ♦ Administer supplemental oxygen, maintain saturation between 90-100%
   ♦ Record and monitor vital signs
   ♦ Assist patient in self-administration of previously prescribed SQ epinephrine (auto
      injector)
   ♦ Nothing by mouth


Advanced Life Support
   ♦ Advanced airway/ventilatory management as needed
   ♦ Initiate cardiac monitoring, record and evaluate EKG strip
   ♦ Record & monitor 02 saturation
   ♦ Microstream capnography (if available), if any acute respiratory symptoms
   ♦ If BP < 90 mmHG systolic, administer boluses of 0.9% NaCl at 250-500 ml to
      maintain systolic BP > 90 mmHg
             Contraindicated if evidence of congestive heart failure (e.g. rales)
   ♦ Mild Reaction (Itching/Hives)
          Diphenhydramine (Benadryl) 1 mg/kg IV (Maximum 50 mg)
             May be administered IM if no IV access available
   ♦ Moderate Reaction (Dyspnea, Wheezing, Chest tightness)
          Albuterol (Proventil) 2.5 mg/3 ml via aerosolized
             May repeat Albuterol (Proventil) X2
          Diphenhydramine (Benadryl) 1 mg/kg IV (Maximum 50 mg)
             May be administered IM if no IV access available
          Methylprednisolone (Solu-Medrol) 125mg, slow IV bolus




                                                                       Effective Date: January 1, 2006
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                                                                                          205

Allergic Reactions continued


   ♦ Severe systemic reaction (BP < 90 mmHG, stridor, severe respiratory distress)
          Epinephrine 1:1,000 0.3 mg SQ
          Albuterol (Proventil) 2.5 mg/3 ml via aerosolized
             May repeat X 2
          Methylprednisolone (Solu-Medrol) 125 mg, slow IV bolus
          Diphenhydramine (Benadryl) 1 mg/kg IV (Maximum 50 mg)
             May be administered IM if no IV access available


   ♦ Cardiopulmonary Arrest Imminent:
          Epinephrine 1:10,000 0.5 mg IVP (instead of 1:1,000 SQ)
          Albuterol (Proventil) 2.5 mg/3 ml via aerosolized
          Diphenhydramine (Benadryl) 1 mg/kg IV (Maximum 50 mg)
             May be administered IM if no IV access available




                                                                    Effective Date: January 1, 2006
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                                                                                            206

                             Altered Mental Status
History

   ♦ Onset (acute vs. gradual)
   ♦ Duration
   ♦ History of trauma
   ♦ Description of scene (pills found, notes, syringes, etc.)
   ♦ Unusual odor in residence or at scene
   ♦ Recent emotional trauma or crisis (including suicidal or homicidal ideation)
   ♦ Drug or alcohol ingestion
   ♦ Toxic exposure
   ♦ Exertion or heat exposure
   ♦ Psychiatric disorders
   ♦ Medical illnesses (diabetes, seizures, etc.)
   ♦ Current medications
   ♦ Allergies


Common Causes

   ♦ Head trauma
   ♦ Drug overdose
   ♦ Seizures
   ♦ CVA
   ♦ Diabetes
   ♦ Other metabolic disorders, such as kidney or liver failure
   ♦ Sepsis
   ♦ Psychiatric illness




                                                                      Effective Date: January 1, 2006
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                                                                                               206

Altered Mental Status continued


Symptoms

   ♦ Abrupt or bizarre behavior changes

Signs

   ♦ Vital Signs:     Vary
   ♦ Skin:            Needle tracks, cyanosis, diaphoresis
   ♦ HEENT:           Breath odor (alcohol, ketones), pupil size and reactivity
   ♦ Neck:            Suspect c-spine injury in the presence of head trauma; nuchal rigidity
                      (stiff neck)
   ♦ Respiratory:     Abnormal breathing patterns
   ♦ Neurologic:      Decreased level of consciousness, abnormal pupil size, abnormal pupil
                      symmetry and reactivity, seizures, focal deficits, hallucinations
   ♦ Other:           Evidence of trauma, medical alert tag


Basic Life Support

   ♦ Secure airway
   ♦ Administer supplemental oxygen, maintain saturation between 90-100%
   ♦ Record and monitor vital signs
   ♦ Nothing by mouth, unless patient is a known diabetic and is able to self-administer
        Glucose paste, orange or apple juice
   ♦ Assess for etiology


Advanced Life Support
   ♦ Advanced airway/ventilatory management as needed
   ♦ Initiate cardiac monitoring, record and evaluate EKG strip
   ♦ Record and evaluate 12-lead EKG
   ♦ Record & monitor 02 saturation & end-tidal C02 (if available)




                                                                         Effective Date: January 1, 2006
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Altered Mental Status continued



   ♦ If BP < 90 mmHG systolic, administer boluses of 0.9% NaCl at 250-500 cc to
       maintain systolic BP > 90 mmHg
              Contraindicated if evidence of congestive heart failure (e.g. rales)
   ♦ Obtain a Glucometer reading

If Hypoglycemic Blood glucose < 60 mg/dL, with IV access
   ♦ Dextrose 50% 25 Gm Slow IVP
           May repeat as needed every 5 or 10 minutes if Blood Glucose < 60 mg/dL
If Hypoglycemic (Blood glucose < 60 mg/dL), without IV access
   ♦ Glucagon 1 mg IM
If Hyperglycemic Blood glucose > 300 mg/dL, with IV access
   ♦ Administer boluses of 0.9% NaCl at 250-500 cc
              Contraindicated if evidence of congestive heart failure (e.g. rales)
If Drug (narcotic) overdose suspected
           Naloxone (Narcan) 2.0 mg IVP every 3 min as needed (Maximum 10 mg)
           If IV access has not been established, administer Naloxone (Narcan) 2.0mg IM.
           Consider IM injection site for its fluid capacity.
If Stroke suspected see Stroke Protocol

If Head Injury suspected see Trauma/Head Injury Protocol

DO NOT USE NARCAN IN SUSPECTED HEAD INJURY




  Medical Control
     Call Medical Control for any additional orders or questions.




                                                                        Effective Date: January 1, 2006
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                                                                                              207

                           Behavioral Emergencies
Basic Life Support
   ♦ Secure airway
   ♦ Administer supplemental oxygen, maintain saturation between 90-100%
   ♦ Record and monitor vital signs
   ♦ Restrain as needed for patient/crew safety


Advanced Life Support

   ♦ Advanced airway/ventilatory management as needed
   ♦ Begin cardiac monitoring, record and evaluate EKG strip
   ♦ Record & monitor 02 saturation
   ♦ If BP < 90 mmHG systolic, administer boluses of 0.9% NaCl at 250-500 cc to
      maintain systolic BP > 90 mmHg
              Contraindicated if evidence of congestive heart failure (e.g. rales)
   ♦ Blood glucose check
   ♦ If altered mental status, microstream capnography (if available by nasal cannula), if
      patient restrained


  Medical Control
     Call Medical Control if further sedation needed
     Diazepam (Valium) 5 to 10 mg IV




                                                                        Effective Date: January 1, 2006
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                                                                                             208

      Carbon Monoxide Exposure and Toxic Inhalations
History
   ♦ Description of scene (enclosed space, broken containers, distinctive odors, signs of fire
      or smoke, poor ventilation)
   ♦ Nature of inhalant or combustible material
   ♦ Duration of exposure
   ♦ Time since exposure
   ♦ Medical illnesses (especially prior cardiac or respiratory disease)
   ♦ Current medications
   ♦ Allergies


Symptoms
   ♦ Burning sensation in mouth, nose, throat, or chest
   ♦ Eye irritation or burning
   ♦ Cough/wheezing
   ♦ Dyspnea/labored breathing
   ♦ Loss of consciousness
   ♦ Nausea and vomiting
   ♦ Headache
   ♦ Dizziness
   ♦ Weakness




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Carbon Monoxide Exposure and Toxic Inhalations continued



Signs
   ♦ Vital Signs:      Vary - increased or labored respirations or hypoventilation
   ♦ Skin:             Thermal burns, particularly of face, mouth, throat, and chest, cyanosis
                       (cherry-red skin not reliable sign of CO poisoning)
   ♦ HEENT:            Singed nasal/facial hair, soot in mouth or sputum, pharyngeal
                       inflammation
   ♦ Respiratory:      Laryngeal edema (stridor, hoarseness, brassy cough), rales, rhonchi,
                       wheezing
   ♦ Neurologic:       Decreased level of consciousness, seizures, behavior changes


STABILIZATION


   ♦ Secure airway; administer 100% O2 via NRBM or BVM.
   ♦ Minimize patient motion.
   ♦ Prepare suction equipment for likely emesis.
   ♦ Monitor oxyhemoglobin saturation closely during transport (WARNING: SaO2
        readings may be falsely high in the presence of significantly elevated carbon monoxide
        levels. Don't be mislead by "normal" SaO2 readings. Apply 100% oxygen if any
        indication of toxic inhalation, significant flame or smoke exposure, or respiratory
        distress noted).
   ♦ Initiate IV NS to run at a “keep open” rate.
   ♦ Consider facility with hyperbaric services as primary destination.



  Medical Control
     Call medical control to determine transport destination, if burn center not available.




                                                                         Effective Date: January 1, 2006
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                                                                                               208

Carbon Monoxide Exposure and Toxic Inhalations continued


SPECIAL CONSIDERATIONS
   ♦ Multiple deaths commonly occur when improperly equipped persons attempt rescue in
      a confined space accident; do NOT attempt rescue unless properly trained and
      equipped.
   ♦ Inhalation of toxic products of combustion or chemical irritants produces varying
      damage, depending on nature and duration of exposure.
   ♦ Signs and symptoms may be minimal or absent initially; fatal burns to respiratory tract
      may occur with little or no external evidence; noncardiogenic pulmonary edema may
      develop as late as 24 to 72 hours after inhalation of some irritant substances.
   ♦ Suspect airway injury for burns sustained in confined space, if facial burns or singing
      are present. Airway edema usually does not become severe until after the first hour,
      but it may develop with dramatic rapidly in respiratory burns.
   ♦ Many irritant gases (ammonia, nitrogen oxide, sulfur dioxide, sulfur trioxide) combine
      with water to form corrosive acid or alkali that causes burns of the upper respiratory
      tract with potential early upper airway compromise.


Basic Life Support
   ♦ Remove the patient from the contamination source
   ♦ Secure airway
   ♦ Administer supplemental oxygen (100%), and note time oxygen started
   ♦ Record and monitor vital signs




                                                                         Effective Date: January 1, 2006
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                                                                                                   208

Carbon Monoxide Exposure and Toxic Inhalations continued


Advanced Life Support
   ♦ Advanced airway/ventilatory management as needed
   ♦ Begin cardiac monitoring, record and evaluate EKG strip
   ♦ Record and evaluate 12-lead EKG
   ♦ Record & monitor O2 saturation & end-tidal CO2 (if available by nasal cannula)
   ♦ IV 0.9% NaCl KVO or IV lock
              If BP < 90 mmHG systolic, administer boluses of 0.9% NaCl at 250-500 cc to
              maintain systolic BP > 90 mmHg
                  Contraindicated if evidence of congestive heart failure (e.g. rales)




  Medical Control
      Call Medical Control for determination of hyperbaric transport destination




                                                                             Effective Date: January 1, 2006
  Rev: April 2, 2003
Volusia County EMS System Protocols
                                                                                                 209

                                     Cardiac Alert
I. Purpose
       To provide a means by which patients eligible to receive thrombolytic therapy may be
       more rapidly identified in the pre-hospital setting. Emergency Departments (ED’s)
       receiving these patients may then decrease the time to initiation of thrombolytic
       therapy, thereby limiting the amount of cardiac damage and reducing morbidity and
       mortality of the patient with acute myocardial infarction (AMI).


A. Thrombolytic Therapy Cardiac - Alert
              1. Pre-hospital personnel should notify their receiving hospital as soon as
                  possible of the suspected AMI patient’s age, gender, and clinical findings,
                  including cardiac rhythm (or 12-lead electrocardiogram (ECG) if available)
                  and pertinent medical history.
                      a) If available, transmit 12 lead ECG to the receiving hospital.

              2. Information contained in the cardiac - alert checklist should also be relayed
                  to the receiving hospital in order to facilitate the initiation of thrombolytic
                  therapy in the ED. Ability of pre-hospital personnel to complete the
                  checklist will depend on patient condition, estimated time of arrival (ETA)
                  at the ED, and other factors.
                      Note: Scene time should not be delayed, nor should completion of the
                      checklist interfere with other patient care.

              3. It is recommended that the ED utilize the information from this checklist to
                  speed the delivery of thrombolytic therapy to eligible patients. Steps taken
                  might include, but are not limited to:
                             a) 12-lead EKG available in the ED upon patient arrival.
                             b) Free the ED physician from less critical patient care.
                             c) Prepare the thrombolytic agent and other medications (may
                                not include actually mixing the thrombolytic agent).
              4. Ideally, thrombolytic therapy should be initiated in every eligible patient
                  with AMI within thirty (30) minutes of their arrival in the ED.


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B. Thrombolytic Therapy Pre-Alert Checklist
            1. Inclusion Criteria:
                    a. Clinical findings consistent with AMI such as:
                           1) Chest pain > thirty (30) minutes - may be accompanied by
                               jaw, arm, or back pain.
                           2) Sudden onset shortness of breath.
                           3) Nausea/vomiting.
                           4) Pale, cool, diaphoretic skin.
                    b. Recent onset of AMI symptoms (< six (6) hours).


             2. Exclusion Criteria:
                    a. Active internal bleeding.
                    b. History of cerebrovascular accident (CVA).
                    c. Intracranial or intraspinal surgery or trauma within the past two (2)
                        months.
                    d. Known intracranial neoplasm, arteriovenous malformation, or
                        aneurysm.
                    e. Known bleeding disorder.
                    f. Severe uncontrolled hypertension.




                                                                        Effective Date: January 1, 2006
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                                                                                              210

                            Cardiac Dysrhythmias
History
   ♦ Onset (acute, gradual)
   ♦ Duration
   ♦ Precipitating events
   ♦ Medical illnesses (especially cardiac and respiratory disease)
   ♦ Current medications
   ♦ Allergies

Symptoms
   ♦ Chest pain
   ♦ Palpitations
   ♦ Dizziness (or syncope)
   ♦ Dyspnea
   ♦ Abdominal pain
   ♦ Fever
   ♦ Nausea
   ♦ Vomiting
   ♦ Weakness

Signs
   ♦ Vital Signs:             Vary
   ♦ Skin:                    Cool, clammy, pallor, cyanosis
   ♦ Neck:                    Flat or distended neck veins
   ♦ Respiratory:             Rales, rhonchi, respiratory distress
   ♦ Cardio-Vascular:         Dysrhythmias, pulses (thready, irregular, absent)
   ♦ Neurologic:              Decreased level of consciousness
   ♦ Extremity:               Peripheral edema
   ♦ Syncope:                 Sudden loss of consciousness




                                                                        Effective Date: January 1, 2006
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Cardiac Dysrhythmias continued


   ♦ Check pulse and respirations; assess and identify dysrhythmia as soon as possible.
      Refer to correct ACLS algorithm.
   ♦ Secure airway; Administer supplemental oxygen, maintain saturation between 90-
      100%. Use extra caution in administering oxygen to patients with COPD. Use rate and
      depth of respiration, mental status, and oxyhemoglobin saturation to observe for signs
      of hypercarbia via capnography, if available.
   ♦ Initiate IV access.
   ♦ CPR is vital.     In the pulseless and/or apneic patient, CPR must be continuously
      performed during the assessment phase and between any therapeutic measures.
   ♦ Cardiac rhythm and the presence of a pulse and/or blood pressure must be assessed
      prior to and between each therapeutic maneuver.
   ♦ If ventricular ectopy (ectopy shall be defined as > 6 PVC's/minute, couplets, multifocal
      PVC's, runs of ventricular tachycardia, or any ectopy in the patient with potential or
      confirmed myocardial infarction):
          Assess patient for chest pain, shortness of breath, palpitations, hypotension, or other
          symptoms of ischemic cardiac disease. If asymptomatic, observe frequency of
          PVC’s and monitor patient status.
          Administer lidocaine 1.5 mg/kg IVP over 1-2 minutes or via ETT (endotracheal
          tube) at 2-2.5 times usual dose.
              If ectopy diminished, begin lidocaine infusion 2.0 Gm in 500 cc 0.9 % to run at
              2 mg/min; titrate to further ectopy to maximum dose of 4 mg/min. Administer
              an additional 0.75 mg/kg bolus 10-15 minutes after initial dose to maintain
              adequate serum levels.
              If ectopy continues, repeat dose of 0.75 mg/kg IVP every 2-5 minutes until
              ectopy suppressed or total dose of 3 mg/kg has been given.                  If ectopy
              suppressed, initiate lidocaine drip as above. If not, continue with protocol.




                                                                         Effective Date: January 1, 2006
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Cardiac Dysrhythmias continued



      NOTE: IN PATIENTS SUSPECTED OF COCAINE INTOXICATION,
      LIDOCAINE SHOULD NOT BE USED AS A FIRST LINE DRUG WITH
      ANY DYSRHYTHMIA
   ♦ If ventricular tachycardia:
          Assess presence of pulse and stability of patient.
          If pulse present:
             If stable (pulse present, conscious, no chest pain, systolic BP > 90 mmHg):
             ♦ Administer lidocaine as above until dysrhythmia resolves. If no resolution;
             ♦ Administer Procainamide, 20-50mg/min slow IVP until; a) ectopy resolves,
                 b) QRS widens by 50% or c) hypotension ensues.
             ♦ If monitor indicates torsades des pointes as possible etiology of ventricular
                 tachycardia, administer 2 Gm slow IVP magnesium sulfate solution in 50 cc
                 of NS over 30 seconds.
             ♦ If ventricular tachycardia persists despite pharmacologic efforts, continue
                 with protocol.
             If unstable (hypotension, chest pain, dyspnea, pulmonary edema, decreased
             level of consciousness):
             ♦ Consider sedation with Diazepam (Valium) 5-10 mg slow IVP if patient
                 conscious (avoid in patients who are hemodynamically unstable or who are
                 in pulmonary edema).
             ♦ Perform synchronized cardioversion at 100 joules or biphasic equivalent.
             ♦ If dysrhythmia persists, perform synchronized cardioversion at 200 joules or
                 biphasic equivalent.
             ♦ If dysrhythmia unresolved, perform synchronized cardioversion at 300
                 joules or biphasic equivalent.
             ♦ If dysrhythmia unresolved, perform synchronized cardioversion at up to 360
                 joules or biphasic equivalent, repeat as necessary to halt rhythm.




                                                                       Effective Date: January 1, 2006
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Cardiac Dysrhythmias continued



              ♦ When dysrhythmia ceases, initiate lidocaine therapy as noted above to
                  suppress further ectopy.
              ♦ If ventricular tachycardia returns, begin therapy at last step, which was
                  successful in resolving the dysrhythmia.
          If no pulse:
              Refer immediately to ventricular fibrillation protocol.
   ♦ If ventricular fibrillation:
          If onset of dysrhythmia monitored, administer precordial thump.
          Confirm electrocardiographic rhythm. If rhythm is other than ventricular
          fibrillation or pulseless ventricular tachycardia, refer to appropriate protocol.
          Defibrillate with 200 joules or biphasic equivalent.
          If dysrhythmia persists, defibrillate with 300 joules or biphasic equivalent.
          If dysrhythmia has not resolved, defibrillate with 360 joules or biphasic equivalent.
          If ventricular fibrillation continues, restart BCLS maneuvers. Administer
          supplemental oxygen; maintain saturation between 90-100%. Initiate IV access.
          Administer epinephrine 1:10,000 1.0 mg IVP every 3-5 minutes for the duration of
          the dysrhythmia. If no IV access is available, administer epinephrine 2-2.5 mg via
          ETT as appropriate.
          If dysrhythmia continues, defibrillate with 360 joules or biphasic equivalent.
          Administer lidocaine 1.5 mg/kg via IV or ETT (2 to 2.5 times dose if given ETT).
          Administer repeat doses of lidocaine and institute infusion as above.
          If dysrhythmia persists, defibrillate with 360 joules or biphasic equivalent.
          Defibrillate again as above.
          Administer Procainamide 20-50 mg/min slow IVP or until ectopy resolved, QRS >
          50%, or 17 mg/kg administered and institute infusion.




                                                                          Effective Date: January 1, 2006
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Cardiac Dysrhythmias continued



          Continue alternate defibrillation and drug administration enroute to definitive care
          facility.
          If ventricular fibrillation prolonged or intractable, consider:
              Magnesium sulfate 2 Gm IVP in 50 cc MS slow IVP over 30 seconds (if no
              renal disease). Magnesium should be considered for use earlier in protocol if
              monitor indicates torsades des pointes.
              Sodium bicarbonate 1 meQ/kg IVP.
              Naloxone 2.0 mg IVP every 3 min as needed (maximum 10 mg).
              Check blood glucose. If < 60, administer Dextrose 50% 25 Gm slow IVP. May
              repeat as needed every 5 or 10 minutes if Blood Glucose < 60 mg/dL.
              Calcium chloride 10 cc of 10% solution IVP if calcium channel blocker toxicity
              or hyperkalemia suspected.
          When dysrhythmia resolves, initiate lidocaine or procainamide as described above.
   ♦ If asystole:
          Initiate CPR; utilize AutoPulse® if available as an alternate to manual CPR
          Secure airway; ventilate with 100% O2 via BVM.
          Confirm asystole in two different leads and/or increase gain to rule out fine
          ventricular fibrillation.
          Place external pacer pads on patient; monitor with pacing unit in line in preparation
          for restoration of ventricular complexes.
          Initiate IV access via peripheral, or central routes as appropriate.
          Administer epinephrine 1:10,000 1.0 mg IVP every 3-5 minutes for the duration of
          the dysrhythmia. If no IV access is available, administer epinephrine 2-2.5 mg via
          ETT.
          Administer atropine 1.0 mg via IV or ETT. This dose may be repeated in 3-5
          minutes to total dose of 0.04 mg/kg. The usual atropine dose should be doubled if
          given via the ET route.
          Consider sodium bicarbonate, naloxone, dextrose, or calcium chloride as above.




                                                                            Effective Date: January 1, 2006
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Cardiac Dysrhythmias continued



   ♦ Pulseless Electrical Activity (PEA):
          Initiate CPR; utilize AutoPulse® if available as an alternate to manual CPR
          Secure airway; ventilate with 100% O2 via BVM.
          Establish intravenous access.
          Determine likely etiology of PEA:
             If hypoxemia:
             ♦ Recheck position of ET tube.
             ♦ Insure adequacy of oxygen delivery and ventilations.
             ♦ If tension pneumothorax suspected, refer to appropriate protocol.
             If hypovolemia:
             ♦ Refer to shock (hypovolemia) protocol.
             If cardiogenic shock or pericardial tamponade suspected, refer to shock
             (cardiogenic) protocol.
          Administer epinephrine 1:10,000 1.0 mg IVP every 3-5 minutes for the duration of
          the dysrhythmia. If no IV access is available, administer epinephrine 2-2.5 mg via
          ETT.
          Start second large bore IV as possible; initiate IV infusion.          Provide 2 fluid
          challenges in increments of 500 cc.
          If fluid challenge does not restore pulse, begin dopamine infusion. Mix 400 mg in
          250 cc D5W or 0.9% Sodium Chloride (or equivalent concentration); run at 5-20
          mcg/kg/min, titrating to systolic blood pressure > 90 mmHg.
          Consider sodium bicarbonate, naloxone, dextrose, or calcium chloride as above.
          External pacing should be instituted as soon as possible to insure immediate capture
          of potential perfusing rhythms (refer to external pacing protocol).
          Atropine 1 mg IV if PEA rate < 60 bpm. May repeat 3-5 minutes as needed to total
          dose.




                                                                        Effective Date: January 1, 2006
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                                                                                              210

Cardiac Dysrhythmias continued

   ♦ Bradycardia
          Assess cardiac rate and rhythm. Identify mechanism as sinus, junctional, first
          degree, second degree (Mobitz I or II), or third degree atrioventricular block
          (complete heart block; CHB).
          Secure airway; administer supplemental oxygen, maintain saturation between 90-
          100%.
          Establish intravenous access.
          If sinus bradycardia, junctional bradycardia, first degree, or Mobitz Type I block:
             If asymptomatic, transport in position of comfort.
             If symptomatic (patient is hypotensive, in pulmonary edema, exhibits
             ventricular ectopy, or having chest pain or dyspnea):
             ♦ If external pacemaker not readily available, administer atropine 0.5-1.0 mg
                  via IV or ETT. This dose may be repeated in 3-5 minutes to total dose of
                  0.04 mg/kg.
             ♦ If pacemaker is readily available or signs or symptoms continue after
                  treatment with atropine, institute external pacing (refer to external pacing
                  protocol). Consider patient sedation with 5 mg of diazepam to total dose of
                  10 mg if external pacing instituted.
          If Mobitz type II or third degree atrioventricular block:
             Apply external pacer.
             If patient symptomatic:
             ♦ Administer atropine 1.0 mg via IV or ETT. This dose may be repeated in 3-
                  5 minutes to total dose of 0.04 mg/kg.
             ♦ If symptoms persist despite atropine therapy, proceed with external pacing
                  (refer to procedural protocol).
             If patient asymptomatic and hemodynamically stable set external pacer in
             demand mode at a rate of 20 - 40 and adjust based on patient’s condition.




                                                                        Effective Date: January 1, 2006
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Cardiac Dysrhythmias continued

   ♦ Paroxysmal Supraventricular Tachycardia (PSVT)/Atrial Fibrillation with Rapid
      Ventricular Response:
          Administer supplemental oxygen; maintain saturation between 90-100%.
          Assess for alternate causes of tachycardia (pain, fever, hypovolemia, etc.) and treat
          appropriately. Confirm diagnosis of PSVT; if ventricular tachycardia likely refer to
          appropriate protocol.
          Establish IV access.
          If patient stable (normotensive without dyspnea, chest pain, or decreased level of
          consciousness):
              Encourage patient in performance of the Valsalva maneuver.
          If no effect:
              Administer Adenosine (Adenocard) 6mg IV bolus over 1-3 seconds and flush
              with 20cc normal saline
              May repeat Adenosine (Adenocard) 12mg IV bolus over 1-3 seconds and flush
              with 20cc normal saline
          If no effect:
              Administer diltiazem 20-mg IV push over 1-2 minutes. Note that diltiazem may
              result in conversion of SVT, but rate control in atrial fibrillation or atrial flutter.
              If unresponsive to medications, continue with protocol.
          If patient unstable (patient has chest pain, dyspnea, hypotension, or decreased level
          of consciousness):
              Consider patient sedation with diazepam, 0.1 mg/kg IVP.
              Perform synchronized cardioversion with 50 joules or biphasic equivalent.
              If dysrhythmia persists, cardiovert with 100 joules or biphasic equivalent.
              If not resolved, cardiovert with 200 joules or biphasic equivalent.
              If dysrhythmia persists, cardiovert with 300 joules or biphasic equivalent.
              If not resolved, cardiovert with 360 joules or biphasic equivalent.
              If unresolved and symptoms continue, contact medical control physician.




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                                                                                               210

Cardiac Dysrhythmias continued

              If conversion occurs but PSVT recurs, again assess for symptomatology and
              follow appropriate protocol.


SPECIAL NOTES


Cardiopulmonary arrest
   ♦ Adequate airway, ventilation, oxygenation, chest compressions, and defibrillation are
      more important than administration of medications and take precedence over initiating
      an intravenous line or injecting pharmacological agents.
   ♦ The adult dosages of medications administered endotracheally are 2.0-2.5 times the
      intravenous dosage.
   ♦ When post-resuscitative patients present with hypotension, dopamine may be titrated to
      achieve a systolic blood pressure of 90 mmHg.
   ♦ Treat the patient, not the dysrhythmia.         Emergency treatment is not needed for
      bradydysrhythmias or tachydysrhythmias if the patient is perfusing well. Contact the
      EDMCP for clarification or guidance as required.
   ♦ Documentation of dysrhythmias is necessary. Mount ECG strips; attach to original or
      supplementary run reports.
   ♦ Electrically dangerous rhythms, including multifocal and multiple PVCs, ventricular
      tachycardia, Mobitz II second-degree block and 3rd degree block, may not cause poor
      perfusion, but can deteriorate. Careful patient monitoring is essential.
   ♦ It is inappropriate to discontinue efforts to resuscitate without thinking about the overall
      situation (patient age, hypothermia, etc.). When in doubt, contact the EDMCP.


Bradycardia and AV block
   ♦ Atropine may be administered as required for any form of AV block
   ♦ If the bradycardia is severe and/or the patient is clinically unstable, transcutaneous
      pacing may be implemented immediately.




                                                                         Effective Date: January 1, 2006
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                                                                                                210

Cardiac Dysrhythmias continued



Characteristics of unstable SVT
   ♦ Heart rate > 150 per minute
   ♦ QRS complex width < 0.12 sec
   ♦    Severe chest pain, profuse diaphoresis, respiratory distress, hypotension,
                altered mental status



  Medical Control
       Call Medical Control for any additional orders or questions




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                                                                                                210

Cardiac Dysrhythmias continued




                 AMERICAN HEART ASSOCIATION
                           ADVANCED CARDIAC LIFE SUPPORT
                                   ALGORITHMS


The American Heart Association algorithms listed on the next pages provide the Volusia County
paramedic with an illustrative method to summarize information pertaining to cardiac care. These
algorithms should not be considered "requirements" or "standards of care", but rather a guideline
from which the Volusia County treatment protocols were in part derived. As some patients may
require care not specified in protocol, contact with the EDMCP may be required.




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                                                            210

Cardiac Dysrhythmias continued




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                                                            210

Cardiac Dysrhythmias continued




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                                                            210

Cardiac Dysrhythmias continued




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                                                            210

Cardiac Dysrhythmias continued




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                                                            210

Cardiac Dysrhythmias continued




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                                                            210

Cardiac Dysrhythmias continued




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                                                            210

Cardiac Dysrhythmias continued




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                                                            210

Cardiac Dysrhythmias continued




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                                                            210

Cardiac Dysrhythmias continued




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                                                            210

Cardiac Dysrhythmias continued




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                                                            210

Cardiac Dysrhythmias continued




                                      Effective Date: January 1, 2006
Volusia County EMS System Protocols
                                                                                                211

                                        Chest Pain
History

   ♦ Onset and duration
   ♦ Location and radiation
   ♦ Quality (pleuritic, heavy, crushing, etc.)
   ♦ Precipitating (rest, exercise, emotional stress, etc.) and relieving factors (nitro, antacids,
         etc.)
   ♦ Medical illnesses (especially cardiac and respiratory disease)
   ♦ Smoking
   ♦ Recent cardiac-related surgery
   ♦ Current medications
   ♦ Allergies

Symptoms

   ♦ Diaphoresis
   ♦ Shortness of breath
   ♦ Cough and sputum production
   ♦ Nausea, vomiting
   ♦ Fever
   ♦ Chills

Signs
   ♦ Vital Signs:      Vary
   ♦ Skin:             Diaphoresis, cyanosis, peripheral edema
   ♦ Respiratory:      Rales, rhonchi, wheezing, chest wall tenderness
   ♦ Cardiac:          Neck vein distention, irregular pulse




  Rev: April 2, 2003


                                                                          Effective Date: January 1, 2006
Volusia County EMS System Protocols
                                                                                             211

Chest Pain continued


Basic Life Support

   ♦ Secure airway
   ♦ Administer supplemental oxygen, maintain saturation between 90-100%
   ♦ Record and monitor vital signs
   ♦ Assist patient in self-administration of previously prescribed Nitroglycerin
      (contraindicated if SBP < 90 mmHG)
   ♦ Repeat patient assisted Nitroglycerin administration every 3-5 minutes as needed for
      continued chest pain (provided SBP remains > 90 mmHG) with assessment of patient
      before and after each NTG dose
   ♦ Assist patient in self-administration of previously prescribed Aspirin if greater
      than 12 hours since last aspirin dose.
   ♦ Warning - NTG should be used only if the patient’s SBP is > 90 mmHg, the heart rate
      is > 60 beats per minute, and time of last medication for erectile dysfunction (e-d)
      usage > 24 hours (if Viagra has been taken < 24 hours prior to encounter, call EDMCP
      to request orders. If EDMCP contact is not possible, administer nitro with caution).


Advanced Life Support
   ♦ Advanced airway/ventilatory management as needed
   ♦ Initiate cardiac monitoring, record and evaluate EKG strip
   ♦ Record and evaluate 12-lead EKG if available
          Record duration of chest pain or ischemic equivalent symptoms
          Record presence or absence of thrombolytic criteria
          Notify receiving facility if Cardiac Alert
   ♦ Record & monitor O2 saturation & end-tidal CO2 (if available by nasal cannula)
   ♦ IV NaCl 0.9% KVO or IV Lock
          If BP < 90 mmHG systolic, administer boluses of 0.9% NaCl at 250-500 cc to
          maintain systolic BP > 90 mmHg
             Contraindicated if evidence of congestive heart failure (e.g. rales)



                                                                       Effective Date: January 1, 2006
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                                                                                               211

Chest Pain continued

          If condition worsens (i.e., SBP < 80 mmHG) and no improvement from fluid
          challenge, Dopamine infusion at 5-20 mcg/kg/min titrated to maintain systolic BP
          > 90 mmHg


For suspected cardiac chest pain or for myocardial ischemic equivalent symptoms:
   ♦ Administer two “baby” chewable aspirin tablets (81 mg/tablet) if patient is able to chew
       and swallow. Hold ASA if patient states allergic to aspirin, is currently taking
       Coumadin (warfarin), Plavix (clopidogel), or Ticlid (ticlopidine), or has had any aspirin
       product within 12 hours of patient encounter.
   ♦ Nitroglycerin 0.4 mg spray SL, every 3-5 minutes as needed for chest pain, or as
       long as ischemic equivalent symptoms and no contraindication develops
              Contraindicated if systolic BP < 90 mmHG
              Contraindicated if medication for the treatment of erectile dysfunction (e-d) has
              been taken in past 24 hrs
              Use with caution in acute Inferior Wall MI, or Right Ventricular Infarct (ST
              elevation in V4R)
          NOTE: Ensure IV line started, SBP > 90 mmHg. If BP < 90 mmHG systolic,
          administer boluses of 0.9% NaCl at 250-500 cc to maintain systolic BP > 90
          mmHg
              Contraindicated if evidence of congestive heart failure (e.g. rales)
   ♦ Morphine Sulfate 2 mg slow IVP, every 5 minutes (Maximum 10 mg) if no chest pain
       relief with 3 Nitroglycerin doses.
          Contraindicated if systolic BP < 90 mmHG
          Use with caution in suspected right ventricular infarct MI


  Medical Control
     Call Medical Control for additional orders.




                                                                         Effective Date: January 1, 2006
Volusia County EMS System Protocols
                                                                                            212

                     Dyspnea – Respiratory Distress
History
   ♦ Onset (acute or gradual)
   ♦ Duration
   ♦ Exacerbating or alleviating factors
   ♦ Oral exposure/foreign bodies (toys, drugs, alcohol, food, chemicals, etc.)
   ♦ Trauma
   ♦ Environmental exposure
   ♦ Smoking
   ♦ Medical illnesses (especially COPD, asthma, diabetes, CHF, thrombophlebitis)
   ♦ Current medications
   ♦ Allergies
   ♦ Home oxygen
   ♦ Drug or alcohol use


Common Causes
   ♦ Asthma
   ♦ Acute upper airway obstruction
   ♦ Acute bronchitis, pneumonia
   ♦ Drowning and asphyxiation
   ♦ Epiglottitis
   ♦ Overdose and poisoning
   ♦ Myocardial infarction (MI)
   ♦ CHF
   ♦ Chest trauma
   ♦ Pulmonary edema
   ♦ Diabetic Ketoacidosis
   ♦ Hyperventilation syndrome due to anxiety reaction




                                                                      Effective Date: January 1, 2006
Volusia County EMS System Protocols
                                                                                            212

Dyspnea – Respiratory Distress continued


Symptoms
   ♦ Chest pain (location, quality, position)
   ♦ Dyspnea
   ♦ Cough
   ♦ Sputum production or change
   ♦ Paresthesia in hands or mouth
   ♦ Calf pain (Homan's Sign)
   ♦ Fever



Signs
   ♦ Vital Signs:      Vary
   ♦ Skin:             Cyanosis, peripheral edema, hives, evidence of neck or chest trauma
   ♦ HEENT:            Upper airway, facial edema, drooling, nasal flaring
   ♦ Respiratory:      Stridor, rales, rhonchi, wheezing, decreased breath sounds, crepitus,
                       subcutaneous emphysema, accessory muscle usage
   ♦ Cardiovascular: Neck vein distention, dysrhythmias
   ♦ Neurologic:       Decreased level of consciousness, restlessness, slurred speech



Basic Life Support

   ♦ Secure airway
   ♦ Administer supplemental oxygen, maintain saturation between 90-100%
   ♦ Record and monitor vital signs
   ♦ Assist with self-administration with bronchodialators




                                                                      Effective Date: January 1, 2006
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                                                                                             212

Dyspnea – Respiratory Distress continued

Advanced Life Support
   ♦ Advanced airway/ventilatory management as needed
          If airway obstruction, remove using Magill Forceps
   ♦ Initiate cardiac monitoring, record and evaluate EKG strip
   ♦ Record and evaluate 12-lead EKG
   ♦ Record & monitor O2 saturation & end-tidal CO2 (if available by nasal cannula)
   ♦ IV 0.9% NaCl KVO or IV lock
          If BP < 90 mmHG systolic, administer boluses of 0.9% NaCl at 250-500 cc to
          maintain systolic BP > 90 mmHg
             Contraindicated if evidence of congestive heart failure (e.g. rales)
   ♦ If Acute Bronchospasm (wheezing)
          Albuterol (Proventil) 2.5 mg/3 ml via aerosolized
             May repeat Albuterol x 2
             Contact Medical Control if HR > 150 or systolic BP > 220 mmHG after 3rd
             aerosolization
          Epinephrine 1:1,000 at 0.3 mg subcutaneously
             May repeat either Albuterol or Epinephrine 2 additional doses (3 total)
             May administer at same time nebulizer is being administered
          Methylprednisolone (Solu-Medrol) 125mg IVP
          Intubate if decreased level of consciousness with respiratory failure OR poor
          ventilatory effort (with hypoxia unresponsive to supplemental 100% oxygen) OR
          unable to maintain patent airway
   ♦ If Acute Pulmonary Edema Suspected
          Nitroglycerin 0.4 mg spray SL every 3-5 minutes, as long as no contraindication
          develops
             Contraindicated if systolic BP < 90 mmHG
             Contraindicated if Viagra taken within 24 hrs
             Use with caution in acute Inferior Wall MI, or Right Ventricular Infarct
             ♦ NOTE: ensure IV line started, If BP < 90 mmHG systolic, administer
                 boluses of 0.9% NaCl at 250-500 cc to maintain systolic BP > 90 mmHg


                                                                       Effective Date: January 1, 2006
Volusia County EMS System Protocols
                                                                                              212

Dyspnea – Respiratory Distress continued

   ♦ If Acute Pulmonary Edema Suspected
          Nitroglycerin 0.4 mg spray SL every 3-5 minutes, as long as no contraindication
          develops
             Contraindicated if systolic BP < 90 mmHG
             Contraindicated if Viagra taken within 24 hrs
             Use with caution in acute Inferior Wall MI, or Right Ventricular Infarct
             ♦ NOTE: ensure IV line started, If BP < 90 mmHG systolic, administer
                 boluses of 0.9% NaCl at 250-500 cc to maintain systolic BP > 90 mmHg
                     Contraindicated if evidence of congestive heart failure (e.g. rales)




                                                                        Effective Date: January 1, 2006
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                                                                                             212

Dyspnea – Respiratory Distress continued



          Furosemide (Lasix) 1 mg/kg slow IVP (Minimum dose 40 mg).
          Albuterol (Proventil) 2.5 mg/3 ml via aerosolized if wheezing present
              May repeat x 2
              Contraindicated if HR > 150 or systolic BP > 220 mmHG
          Intubate if decreased level of consciousness with respiratory failure or poor
          ventilatory effort (with hypoxia unresponsive to supplemental 100% oxygen) or
          unable to maintain patent airway
          Administer morphine sulfate 2 mg IVP Q 5 minutes PRN in adults with severe
          shortness of breath unresponsive to nitroglycerin therapy (total dose 10 mg).
          Dopamine infusion at 5-20 mcg/kg/min titrated as needed if systolic BP < 90
          mmHg

  Medical Control
     Additional updrafts
     Magnesium Sulfate 2 Gm slow IVP in 50 cc of NS over 30 seconds for
     deteriorating or non-responding asthma patients (if no renal disease and CHF not
     suspected)
     Epinephrine, 1:1000, 0.3 cc SQ if no response to updrafts in Asthma patients




                                                                       Effective Date: January 1, 2006
Volusia County EMS System Protocols
                                                                                           213(a)

                    Environmental/Thermal Injuries

                                    Thermal Burns
History
   ♦ Description of scene
   ♦ Duration of exposure
   ♦ Time since exposure
   ♦ Medical illness (especially prior cardiac or respiratory disease)
   ♦ Current medications
   ♦ Allergies
   ♦ Chemical or toxic exposure - see "Chemical Burns", "Toxic Inhalation"
   ♦ Electrical contact - see "Electrocution"
   ♦ Enclosed space with steam or smoke - see "Confined Space Accidents"

Symptoms
   ♦ Pain
   ♦ Cough
   ♦ Respiratory distress
   ♦ Loss of consciousness
   ♦ Vomiting
   ♦ Headache

Signs
   ♦ Vital Signs:    Vary
   ♦ Skin:           Description of areas involved, depth of burn
   ♦ HEENT:          Singed nasal/facial hair; soot in mouth or sputum; hoarseness;
                     pharyngeal inflammation
   ♦ Respiratory:    Cough; stridor; wheezing; respiratory distress
   ♦ Neurologic:     Seizures




                                                                         Effective Date: January 1, 2006
Volusia County EMS System Protocols
                                                                                          213(a)

Environmental/Thermal Injuries continued



Severity of burn:

   Determined by depth and location of burn, body surface area (BSA) involved, age and
   health of patient, associated injuries.

   ♦ Major Burn:

           Partial thickness > 25% BSA in adults; > 20% BSA in children
           Full thickness > 5% BSA
           All burns of hands, feet, face, eyes, ears, genitalia
           Inhalation injury
           Electrical burns
           Burns complicated by fracture(s) or other major trauma
           Poor risk patients (very young, elderly, patients with chronic medical problems)

   ♦ Moderate Burn:

           Partial thickness 15% to 25% BSA in adults; 10% to 20% BSA in children
           Full thickness < 5% BSA

   ♦ Minor Burn:

           Partial thickness < 15% BSA in adults; < 10% BSA in children
           Full thickness < 2% BSA
Stabilization
   ♦ Assess type, depth, and extent of burn. Document area involved on chart using "Rule
       of Nines."
   ♦ Secure airway. Patients with known inhalational injury or with signs of potential
       airway burns (singed nasal hairs, soot in the pharynx, etc.) in respiratory distress should
       be intubated prior to transport with the largest endotracheal tube possible.




                                                                          Effective Date: January 1, 2006
Volusia County EMS System Protocols
                                                                                         213(a)

Environmental/Thermal Injuries continued

♦ Administer supplemental oxygen, maintain saturation between 90-100%
♦ Remove all clothing from patient; expose all burned areas.
♦ If burning agent still in contact with skin, remove gently after cooling with sterile water or
   NS.
          If burning agent is chemical, irrigate burned area with copious amounts (2 or more
          liters) of NS or sterile water.
          CAUTION: DO NOT USE WATER IRRIGATION IN CHEMICAL BURNS DUE
          TO LIME, CARBOLIC ACID, SOLID POTASSIUM OR SODIUM METALS, OR
          SULFURIC ACID. Contact Medical Control immediately.
   ♦ If patient has > 5% body surface area (BSA) second degree or any third degree burn,
       initiate IV access. Avoid starting lines in burned areas as possible.
   ♦ Dress burns:
           If less than 10-15% BSA involved, wrap burned areas with sterile cloths or sheets
           cooled in ambient temperature NS or sterile water.
           If greater than 15% BSA involved, wrap burned area in dry sterile cloths or sheets.
   ♦ Maintain temperature control. Keep patient warm; wrap in blankets as needed. DO
       NOT ALLOW PATIENT TO BECOME HYPOTHERMIC.
   ♦ Administer morphine sulfate 2 mg slow IVP for pain only if patient hemodynamically
       stable. Dose may be repeated Q 5-10 minutes as needed to total dose of 10 mg; titrate
       to pain relief, systolic blood pressure < 90 mmHg, respiratory depression, or change in
       mental status. If complications of morphine sulfate therapy occur, administer naloxone
       2.0 mg IVP every 3-5 min as needed (Maximum 10 mg). Naloxone dose may be
       repeated as needed to maintain adequate level of consciousness and respiratory rate.




                                                                         Effective Date: January 1, 2006
Volusia County EMS System Protocols
                                                                                          213(a)

Environmental/Thermal Injuries continued

   ♦ Calculation of IV fluids (NS) to be administered enroute:
          Fluids in first 24 hours = (4cc)(%BSA 2-3 degree)(body weight in kg)

          Administer 1/2 of this amount in first 8 hours; divide accordingly for hourly rate.

          Example of 70 kg patient with 20% second degree burns =
          (4cc)(20%)(70 kg) = 5600 cc first 24 hours;
          2800cc first 8 hours;
          350cc/hour first 8 hours
   ♦ Administer initial hour fluid requirement as bolus during transport.
   ♦ Consider transport to Burn Center for advanced burn care. Contact on-line medical
      control to verify Burn Center destination. Burn Center criteria include:
          Second degree burn involving > 20% BSA; third degree burn involving > 5% BSA.
          Burns of the hands, face, feet, or perineum, genitalia.
          Burns associated with inhalational injuries.
          Burns associated with multiple trauma.
          Electrical injuries.


Basic Life Support

   ♦ Secure airway
   ♦ Administer supplemental oxygen, maintain saturation between 90-100%
          High flow oxygen for inhalation injuries
   ♦ Record and monitor vital signs
   ♦ Remove or cool heat source if present (tar, clothing)
   ♦ Cool compress dressings on minor burns with sterile saline
   ♦ Dry, sterile burn sheet on 2° burns greater than 15% of Body Surface Area
   ♦ Spinal immobilization according to MOI




                                                                        Effective Date: January 1, 2006
Volusia County EMS System Protocols
                                                                                        213(a)

Environmental/Thermal Injuries continued


Advanced Life Support
   ♦ Advanced airway/ventilatory management as needed
   ♦ Initiate cardiac monitoring, record and evaluate EKG strip
   ♦ Record & monitor 02 saturation
   ♦ Microstream capnography (if available), if any acute respiratory symptoms
   ♦ IV 09% NaCl KVO or IV Lock
   ♦ If BP < 90 mmHG systolic, administer boluses of 0.9% NaCl at 250-500 cc to
      maintain systolic BP > 90 mmHg
              Contraindicated if evidence of congestive heart failure (e.g. rales)
          If moderate, severe pain
              Morphine Sulfate 2 mg IV every 5 minutes (Maximum of 10 mg)
              ♦ Contraindicated if allergic



  Medical Control
     Additional analgesics as needed




                                                                        Effective Date: January 1, 2006
Volusia County EMS System Protocols
                                                                                         213(b)

Environmental/Thermal Injuries continued


                   Decompression Sickness/Dysbarism




Definitions
   ♦ Dysbarism:                            A syndrome of illness/injury resulting from
                                           differences in pressure between the environment
                                           and tissues/organs either directly (barotrauma) or
                                           indirectly (decompression sickness).
   ♦ Barotrauma:                           Tissue damage directly related to the mechanism
                                           effects of pressure, including dysbaric air
                                           embolism (DAE) and direct trauma to gas filled
                                           spaces (e.g. ear, sinus "squeeze").
   ♦ Decompression Sickness:               Multi-system      disorder   resulting       from      the
                                           liberation of gas bubbles from solution when
                                           ambient pressure decreases, either Type I (skin,
                                           musculoskeletal      "bends")       or       Type        II
                                           (neurological, serious symptoms).


History

   ♦ Scuba Diving:    Air tank failure; rapid ascent; prolonged/repetitive dive profile
   ♦ Altitude:        Depressurization or inadequate pressurization while flying at high
                      altitude; high altitude exposure after scuba diving.




                                                                        Effective Date: January 1, 2006
Volusia County EMS System Protocols
                                                                                        213(b)

Environmental/Thermal Injuries continued


Symptoms

   ♦ Chest pain
   ♦ Dyspnea
   ♦ Cough
   ♦ Joint pain
   ♦ Cramps
   ♦ Headache
   ♦ Dizziness
   ♦ Fatigue
   ♦ Nausea & vomiting
   ♦ Paralysis


Signs

   ♦ Vital signs:    Hypotension (severe cases)
   ♦ Skin:           Tenderness, mottling, rash from bubble emboli, subcutaneous
   ♦ Respiratory:    Cough, respiratory distress without pneumothorax (decompression
                     illness), pneumothorax, tension pneumothorax (air embolism)
   ♦ Neurologic:     Confusion, coma, seizures, spinal deficits (hemi / para / multiplegias)


Basic Life Support

   ♦ Secure airway
   ♦ Administer supplemental oxygen, maintain saturation between 90-100%
   ♦ Record and monitor vital signs
   ♦ Spinal immobilization if suspected trauma
   ♦ Transport supine




                                                                       Effective Date: January 1, 2006
Volusia County EMS System Protocols
                                                                                                  213(b)

Environmental/Thermal Injuries continued


Advanced Life Support

   ♦ Advanced airway/ventilatory management as needed
   ♦ Initiate cardiac monitoring, record and evaluate EKG strip
   ♦ Record & monitor 02 saturation & end-tidal C02 (if available by nasal cannula)
   ♦ IV 0.9% NaCl KVO or IV lock
              If BP<90 mmHG systolic, administer boluses of 0.9% NaCl at 250-500 cc to
              maintain systolic BP > 90 mmHg
                       Contraindicated if evidence of congestive heart failure (e.g. rales)
   ♦ Observe for signs of tension pneumothorax
   ♦ Pleural decompression as needed
   ♦ Transport to nearest facility


  Medical Control
      Call Medical Control for any additional orders or questions




                                                                                 Effective Date: January 1, 2006
  Rev: April 2, 2003
Volusia County EMS System Protocols
                                                                                       213(c)

Environmental/Thermal Injuries continued


                                   Hypothermia

History
   ♦ Length of exposure
   ♦ Wet or dry
   ♦ Air/water temperature
   ♦ Wind
   ♦ History and timing of changes in mental status
   ♦ Drug or alcohol use
   ♦ Medical illnesses (cirrhosis, epilepsy, diabetes)
   ♦ Current medications
   ♦ Allergies


Symptoms
   ♦ Extremity pain
   ♦ Paresthesia (frostbite)
   ♦ Shivering (occurs between 89.6o F - 98.6o F)

Signs
   ♦ Vital Signs:     Rectal temperature < 95o F significant, bradycardia, hypotension,
                      decreased respiratory rate common
   ♦ Skin:            Evidence of local trauma (blanching, blistering) erythema of extremities,
                      ears, nose
   ♦ Neurologic:      Decreased level of consciousness, coma




                                                                       Effective Date: January 1, 2006
Volusia County EMS System Protocols
                                                                                       213(c)

Environmental/Thermal Injuries continued


Stabilization

   ♦ Determine temperature of patient as possible.
   ♦ Initiate IV access.
   ♦ Remove wet, cold, or constricting clothing; wrap patient in blankets. Protect from
      further exposure.
   ♦ Handle patient gently; the hypothermic heart is irritable, and roughness may result in
      ventricular arrythmias.
   ♦ If patient experiences dysrhythmias, please refer to dysrhythmia protocol.
      NOTE: ALS maneuvers have minimal effect in the hypothermic patient.
   ♦ Rewarming is the priority.
   ♦ If patient exhibits a decreased level of consciousness, administer naloxone and dextrose
      in accordance with protocol for same.
   ♦ If hypothermia injury is local (frostbite);
          Handle injured part gently; leave uncovered.
          Do not allow injured part to thaw if chance exists for refreezing before arrival at
          definitive care facility.
          Maintain core temperature of patient with blankets.


Basic Life Support
   ♦ Secure airway
   ♦ Administer supplemental oxygen, maintain saturation between 90-100%
   ♦ Record and monitor vital signs
   ♦ Remove wet garments
   ♦ Protect against heat loss and wind chill
   ♦ Maintain horizontal position
   ♦ Avoid rough movement and excess activity




                                                                       Effective Date: January 1, 2006
Volusia County EMS System Protocols
                                                                                        213(c)

Environmental/Thermal Injuries continued


Advanced Life Support

   ♦ Advanced airway/ventilatory management as needed
   ♦ Initiate cardiac monitoring, record and evaluate EKG strip
   ♦ Record & monitor 02 saturation & end-tidal C02 (if available by nasal cannula)
   ♦ IV NaCl 0.9% KVO or IV lock
          If BP < 90 mmHG systolic, administer boluses of 0.9% NaCl at 250-500 cc to
          maintain systolic BP > 90 mmHg
              Contraindicated if evidence of congestive heart failure (e.g. rales)
   ♦ Pain associated with frostbite administer Morphine Sulfate 2 mg slow IVP every 5
      minutes until pain relief achieved. Max 10 mg.
          systolic BP > 90 mmHg AND
          no allergy AND
          no airway or breathing difficulty.
          Contraindicated if systolic < 90 mmHg.
          Reassess patient frequently.




  Medical Control
     Call Medical Control for any additional orders or questions




                                                                        Effective Date: January 1, 2006
Volusia County EMS System Protocols
                                                                           213(d)

Environmental/Thermal Injuries continued

                                  Hyperthermia

History
   ♦ Onset and duration
   ♦ Patient age
   ♦ Patient attire
   ♦ Activity level (exercise induced?)
   ♦ Air temperature, humidity
   ♦ Drug or alcohol use
   ♦ Trauma
   ♦ Past medical history
   ♦ Current medications
   ♦ Allergies
   ♦ Obesity


Symptoms
   ♦ Chills
   ♦ Weakness
   ♦ Loss of consciousness, behavioral changes, delirium
   ♦ Sweats
   ♦ Muscle cramps
   ♦ Headache
   ♦ Thirst
   ♦ Nausea/vomiting
   ♦ Visual disturbances




                                                           Effective Date: January 1, 2006
Volusia County EMS System Protocols
                                                                                     213(d)

Environmental/Thermal Injuries continued


Signs

   ♦ Vital Signs:   Temperature (body temperature usually high)
   ♦ Skin:          Warm to hot, pallor or flushing, moist or dry
   ♦ Neck:          Stiff
   ♦ Respiratory:   Rales, wheezing
   ♦ Neurologic:    Restlessness, confusion, delirium, psychosis, coma, seizures




                                                                     Effective Date: January 1, 2006
Volusia County EMS System Protocols
                                                                                    213(d)

Environmental/Thermal Injuries continued


Basic Life Support

   ♦ Secure airway
   ♦ Administer supplemental oxygen, maintain saturation between 90-100%
   ♦ Record and monitor vital signs
   ♦ Move patient to cooler environment
   ♦ Heat Cramps (painful spasms of the extremities or abdominal muscles caused by salt
      depletion, patient A&O X 4, V/S normal)
          Oral fluids as tolerated
          Sponge with cool water
   ♦ Heat exhaustion (dizziness, light-headedness, headache, irritability caused by
      fluid/electrolyte loss and resulting Hypovolemia, normal or slightly decreased LOC,
      normal or decreased BP, tachycardia, normal or slightly elevated wave segment)
          Keep patient supine
          Remove clothing
          Sponge with cool water and fan
   ♦ Heat Stroke (Marked alteration in LOC, extremely high temperature [often > 104] with
      red/hot/dry skin, caused by hypothalamic imbalance)
          Semi-reclining with head elevated 15-30o
          Rapid cooling (Prevent shivering)
          Cold packs, sponge with cool water and fan




                                                                    Effective Date: January 1, 2006
Volusia County EMS System Protocols
                                                                                        213(d)

Environmental/Thermal Injuries continued


Advanced Life Support

   ♦ Advanced airway/ventilatory management as needed
   ♦ Initiate cardiac monitoring, record and evaluate EKG strip
   ♦ Record & monitor 02 saturation & end-tidal C02 (if available by nasal cannula)
   ♦ IV NaCl 0.9% KVO or IV lock
          If BP < 90 mmHG systolic, administer boluses of 0.9% NaCl at 250-500 cc to
          maintain systolic BP > 90 mmHg
              Contraindicated if evidence of congestive heart failure (e.g. rales)


  Medical Control
     Call Medical Control for any additional orders or questions




                                                                        Effective Date: January 1, 2006
Volusia County EMS System Protocols
                                                                                            214


                                       Eye Emergencies


History
   ♦ Mechanism of injury: blunt, penetrating, traumatic
   ♦ Description of scene
   ♦ Force involved
   ♦ Treatment prior to arrival
   ♦ Medical illness
   ♦ Current medications
   ♦ Allergies


Symptoms
   ♦ Areas of pain
   ♦    Visual problems


Signs
   ♦ Vital signs:    Vary
   ♦ Eyes:           Lid laceration, blood anterior to pupil, pupil abnormalities, abnormal
                     globe position or softness
   ♦ Head:           Evidence of trauma
   ♦ Neurologic:     Decreased level of consciousness




                                                                       Effective Date: January 1, 2006
Volusia County EMS System Protocols
                                                                                               214

Basic Life Support

♦ Assess nature of ophthalmologic emergency.

♦ If direct trauma:

           Patch both eyes without pressure to globes; place metal shield over affected eye.

           Transport patient in supine position. EXCEPTION: If blood noted in anterior
           chamber (hyphema), transport with head of bed elevated at least 60 degrees.

           Dim cabin lights for patient comfort.

♦ If chemical trauma:

           Irrigate affected eye with 2 liters NS. If patient remains symptomatic after initial
           care, continue irrigation throughout transport.

           Apply moist dressing to eyes.

           Dim cabin lights for patient comfort.

           If chemical trauma known inflicted by tear gas/pepper spray:

               Administer 2 drops tetracaine ophthalmic solution (as available) to each eye
               after irrigation.
               Dose may be repeated once as required.
               If patient is in custody of law enforcement officers, request authorization to
               treat from LEA officer in charge of patient.

♦ If atraumatic:

           Patch both eyes gently; apply raised cover (metal shield, styrofoam cup, etc.) to
           affected eye.

           Dim cabin lights for patient comfort.

♦ If patient is being transported for treatment of diagnosed central retinal artery occlusion:

           Administer 100% O2 via NRBM.

           Place patient in Trendelenburg position.




                                                                          Effective Date: January 1, 2006
Volusia County EMS System Protocols
                                                                                           214


    Medical Control
        Transport notification.



Special Considerations
♦ Be careful NOT to flush contaminated IV solution into the patient's uninjured eye.

♦ Do NOT apply pressure to the globe.

♦ Remove contact lenses, when applicable.




                                                                      Effective Date: January 1, 2006
  Rev: April 2, 2003
Volusia County EMS System Protocols
                                                                                             215

                 Hazardous Materials/Toxic Exposure
Consult your agency’s Hazardous Material Procedures before attempting to handle any toxic
chemical exposure patient

Report to the Incident Commander prior to approaching any Hazardous Materials incident


                                                                                        215(a)
                     Chemical Burns and Dermal Exposure

History

   ♦ Description of scene (lines/piping, pooling of chemicals around victim, victim
       immersed in agent, spurting agents from containers, toxic fumes/vapors, etc.)
   ♦ Type of chemical (acid, alkali, mixed, other, unknown)
   ♦ Duration of exposure
   ♦ Time since exposure
   ♦ Medical illnesses
   ♦ Current medications
   ♦ Allergies

Symptoms
   ♦ Skin pain
   ♦ Eye irritation or pain
   ♦ Excessive tearing
   ♦ Difficulty breathing




                                                                       Effective Date: January 1, 2006
Volusia County EMS System Protocols
                                                                                            215

Hazardous Materials-Chemical Burns and Dermal Exposure continued


Signs
   ♦ Vitals Signs: Vary
   ♦ Skin:            Description and extent of involved areas; burn depth
   ♦ HEENT:           Eye redness
   ♦ Respiratory:     Cough, stridor, wheezing, respiratory distress
   ♦ Neurologic:      Seizures


Basic Life Support

   ♦ Stop the burning process
           If a dry chemical is involved, brush it off, then flush with copious amounts of water
           Do not use water to flush the following chemicals
               Elemental metals (sodium, potassium, lithium), and phenols
               ♦ Remove obvious metallic fragments should be removed from skin
               ♦ Cover the burn with mineral oil or cooking oil
               Phenols penetrate the skin more readily when diluted with water
               ♦ Dilute with the following agents (listed in order of efficacy) depending on
                  agent availability
                      Polyethylene glycol (PEG) or
                      Gylcerol or
                      Vegetable oil or
                      As a last resort use extremely large amounts of soap and water with
                      continuous irrigation until all phenols are removed.
           If a caustic liquid is involved, flush with copious amounts of water
   ♦ Remove all patients clothing prior to irrigation
   ♦ Be prepared to treat hypothermia due to interventions
   ♦ For chemical burns with eye involvement, immediately begin flushing the eye with
        normal saline and continue throughout assessment and transport




                                                                         Effective Date: January 1, 2006
Volusia County EMS System Protocols
                                                                                         215(a)

Hazardous Materials-Chemical Burns and Dermal Exposure continued

   ♦ Establish patient responsiveness
   ♦ Stabilize spine if suspicion of trauma
   ♦ Assess airway/breathing, circulation and perfusion
   ♦ Assess mental status
   ♦ Apply a burn sheet or dry sterile dressing to burn areas. To prevent hypothermia, avoid
      moist, or cool dressing and do not leave wounds or skin exposed


Advanced Life Support

   ♦ Advanced airway/ventilatory management as needed
   ♦ Initiate cardiac monitoring, record and evaluate EKG strip
   ♦ Record & monitor O2 saturation & end-tidal CO2 (if available by nasal cannula)
   ♦ IV NaCl 0.9% KVO or IV lock
          If BP<90 mmHG systolic, administer boluses of 0.9% NaCl at 250-500 cc to
          maintain systolic BP > 90 mmHg
              Contraindicated if evidence of congestive heart failure (e.g. rales)
   ♦ Perform focused history and detailed physical examination en route to the hospital if
      patient status and management of resources permit
   ♦ Initiate transport to nearest SATC (State Approved Trauma Center) if patient meets
      Trauma Alert burn criteria
   ♦ Morphine Sulfate 2 mg IV every 5 min (Maximum 10 mg) until pain relief achieved
          systolic BP > 90 mmHg AND
          no allergy AND
          no airway or breathing difficulty
   ♦ Reassess patient frequently



  Medical Control
     Call Medical Control for any additional orders or questions




                                                                        Effective Date: January 1, 2006
Volusia County EMS System Protocols
                                                                                          216

 Hypertensive Emergencies (With or Without Chest Pain)
History
   ♦ Onset and duration
   ♦ History of hypertension
   ♦ Seizures
   ♦ Medical illnesses (especially DM, respiratory and cardiac disease, CVA, TIA)
   ♦ Pre-eclampsia
   ♦ Drug or alcohol use
   ♦ Head trauma
   ♦ Current medications
   ♦ Allergies

Symptoms

   ♦ Headache
   ♦ Nose bleed
   ♦ Dizziness
   ♦ Syncope
   ♦ Weakness
   ♦ Speech difficulties
   ♦ Abdominal pain
   ♦ Visual disturbances
   ♦ Projectile vomiting




                                                                    Effective Date: January 1, 2006
Volusia County EMS System Protocols
                                                                                               216

Hypertensive Emergencies continued


Signs
   ♦ Vital Signs:           Elevated blood pressure, bradycardia, bounding pulse
   ♦ Skin:                  Flushed, diaphoresis, pallor
   ♦ Cardio-Vascular:       Distended neck veins, extremity edema, pulmonary edema
   ♦ Neurologic:            Decreased level of consciousness, impaired movement, symmetry
                            of face and extremities, seizures, unequal pupils


Basic Life Support

   ♦ Secure airway
   ♦ Administer supplemental oxygen, maintain saturation between 90-100%
   ♦ Record and monitor vital signs


Advanced Life Support

   ♦ Advanced airway/ventilatory management as needed
   ♦ If available and appropriate, complete the following:
           Initiate cardiac monitoring, record and evaluate EKG strip
           Record and evaluate 12-lead EKG
           Record & monitor O2 saturation
           Microstream capnography (if available), if any acute respiratory symptoms
   ♦ IV 0.9% NaCl KVO or IV lock
           If BP < 90 mmHG systolic, administer boluses of 0.9% NaCl at 250-500 cc to
           maintain systolic BP > 90 mmHg
               Contraindicated if evidence of congestive heart failure (e.g. rales)
   ♦ If systolic BP > 220 mmHG and/or Diastolic BP > 120 mmHG and No chest pain, No
        pulmonary edema, and No altered mental status
           No treatment indicated




                                                                         Effective Date: January 1, 2006
Volusia County EMS System Protocols
                                                                                            216

Hypertensive Emergencies continued

   ♦ If Systolic BP > 220 mmHG and/or Diastolic BP > 120 mmHG and chest pain
          Nitroglycerin 0.4 mg spray SL, every 3-5 minutes as needed for chest pain or
          ischemic equivalent symptoms as long as no contraindication develops
             Contraindicated if systolic BP < 90 mmHG
             Contraindicated if Viagra use in past 24 hours
             Use with caution in inferior wall MI or acute Right Ventricular Infarct
             ♦ NOTE: IV line started and be prepared to administer IV NS boluses at 250-
                 500 ml if hypotension develops)
          ASA as per chest pain protocol if last dose was more than 12 hours.
          Morphine Sulfate 2 mg slow IVP every 5 minutes (Maximum 10 mg) until pain
          relief achieved only after Nitroglycerin administered X 3
             Contraindicated if systolic BP < 90 mmHG
          Use with caution if right ventricular (Posterior wall) MI
   ♦ If Systolic BP > 220 mmHG and/or Diastolic BP > 120 mmHG and pulmonary edema:
          Nitroglycerin 0.4 mg spray SL, every 3-5 minutes X 3, as long as no
          contraindication develops
             Contraindicated if systolic BP < 90 mmHG or Viagra use in past 24 hours
             Use with caution in inferior wall MI or acute Right Ventricular Infarct
             ♦ NOTE: IV line started and be prepared to administer IV NS boluses at 250-
                 500 ml if hypotension develops)
             Furosemide (Lasix) 1 mg/kg slow IVP (Minimum dose 40 mg)



  Medical Control
     If no response to NTG and Furosemide (Lasix) for Pulmonary Edema
     Call Medical Control for any additional MS orders or questions




                                                                      Effective Date: January 1, 2006
Volusia County EMS System Protocols
                                                                                           217

                      Near Drowning (Submersion)
History
   ♦ Length of submersion
   ♦ Fresh or salt water
   ♦ Warm or cold water
   ♦ Water depth
   ♦ Water contamination
   ♦ Trauma (diving accident, scuba diving, child abuse)
   ♦ Past medical history

Symptoms
   ♦ Cough
   ♦ Dyspnea
   ♦ Pleuritic chest pain
   ♦ Vomiting

Signs
   ♦ Vital Signs:   Vary
   ♦ Skin:          Cyanosis, pallor, cold
   ♦ HEENT:          Head or neck trauma
   ♦ Respiratory:   Rales, rhonchi, wheezing, frothy sputum, respiratory distress, airway
                    obstruction
   ♦ Cardiac:       Dysrhythmias
   ♦ Neurologic:    Seizures, decreased level of consciousness




                                                                     Effective Date: January 1, 2006
Volusia County EMS System Protocols
                                                                                              217

Near Drowning (Submersion) continued


Basic Life Support

   ♦ Secure airway
   ♦ Administer supplemental oxygen, maintain saturation between 90-100%
   ♦ Record and monitor vital signs
   ♦ Spinal immobilization with any suspicion of trauma
   ♦ Protect from heat loss


Advanced Life Support

   ♦ Advanced airway/ventilatory management as needed
   ♦ Initiate cardiac monitoring, record and evaluate EKG strip
   ♦ Record & monitor O2 saturation & end-tidal CO2 (if available by nasal cannula)
   ♦ IV 0.9% NaCl KVO
          If BP < 90 mmHG systolic, administer boluses of 0.9% NaCl at 250-500 cc to
          maintain systolic BP > 90 mmHg
              Contraindicated if evidence of congestive heart failure (e.g. rales)




  Medical Control
     Call Medical Control for any additional orders or questions




                                                                        Effective Date: January 1, 2006
Volusia County EMS System Protocols
                                                                      218(a)

                           Obstetrics / Gynecology

                                    Childbirth

History
   ♦ Due date
   ♦ Ruptured membranes
   ♦ Vaginal fluid drainage, bleeding
   ♦ Prenatal care
   ♦ Age
   ♦ Number of prior pregnancies (gravida)
   ♦ Number of live births (para)
   ♦ Problems with current pregnancy
   ♦ Problems with previous pregnancies
   ♦ Medical illnesses
   ♦ Current medications
   ♦ Allergies
   ♦ Last menstrual period

Symptoms
   ♦ Location of pain
   ♦ Regularity and timing of contractions
   ♦ Urge to push
   ♦ Bleeding
   ♦ Swelling of face or extremities




                                                     Effective Date: January 1, 2006
Volusia County EMS System Protocols
                                                                                         218(a)

Obstetrics / Gynecology continued


Signs
   ♦ Vital Signs:     Routine, hypertension (pre-eclampsia)
   ♦ Skin:            Facial, extremity edema
   ♦ GU:              Contraction and relaxation of uterus, vaginal bleeding or fluid (color,
                      odor), crowning, abnormal presentation (foot, arm, cord)


Basic Life Support
   ♦ Secure airway
   ♦ Administer supplemental oxygen, maintain saturation between 90-100%
   ♦ Record and monitor vital signs
   ♦ Delivery
           Slow, controlled delivery of head; apply gentle perineal pressure
           Observe for meconium staining
              If present, suction oral pharynx and nose as soon as head is delivered
              Following delivery, follow newborn resuscitation protocol
        Double clamp cord 7-10 inches from abdomen of the baby
        Cut cord between clamps
        Maintain body temperature
   ♦ Postpartum
           For neonate, see newborn resuscitation protocol
           Assess for postpartum hemorrhage
              Gently massage uterus until firm


Advanced Life Support
   ♦ Advanced airway/ventilatory management as needed
   ♦ Begin cardiac monitoring, record and evaluate EKG strip
   ♦ Record & monitor O2 saturation




                                                                        Effective Date: January 1, 2006
Volusia County EMS System Protocols
                                                                                          218(a)

Obstetrics / Gynecology continued

   ♦ IV 0.9% NaCl KVO or IV lock
          If BP < 90 mmHG systolic, administer boluses of 0.9% NaCl at 250-500 cc to
          maintain systolic BP > 90 mmHg
              Contraindicated if evidence of congestive heart failure (e.g. rales)
   ♦ Transport to nearest OB receiving facility
   ♦ See newborn resuscitation for care of neonate
   ♦ For imminent birth or complication, transport to nearest facility

FIRST STAGE: Dilation of the cervix:
   ♦ Frequency and duration of uterine contractions?
   ♦ Hemorrhage? Estimated blood loss?




                                                                         Effective Date: January 1, 2006
Volusia County EMS System Protocols
                                                                                     218(a)

Obstetrics / Gynecology continued


SECOND STAGE:                Expulsion of the fetus:

   ♦ Urge to push?
   ♦ Presentation of fetal parts (Cephalic? Breech? Limb?)
   ♦ Hemorrhage? Estimated blood loss?
   ♦ Umbilical cord? Wrapped around infant's neck?
   ♦ Injuries (tears) of external genitalia or vagina?
   ♦ Evaluate infant on delivery. Fetal distress: Cyanosis? Respirations?

THIRD STAGE:                 Expulsion of placenta:
   ♦ Evaluate and manage infant.
   ♦ Hemorrhage? Estimated blood loss?
   ♦ Evaluation of uterine tone.
   ♦ Injuries (tears) of external genitalia or vagina?
   ♦ Evaluate placenta on delivery for completeness.
   ♦ Placenta must be brought to the hospital for evaluation.




  Medical Control
     Call Medical Control for any additional orders or questions




                                                                    Effective Date: January 1, 2006
Volusia County EMS System Protocols
                                                                      218(b)

Obstetrics / Gynecology continued


           Prenatal Emergencies/Pregnancy Induced Hypertension


History
   ♦ Due date
   ♦ Ruptured membranes
   ♦ Vaginal fluid drainage, bleeding
   ♦ Prenatal care
   ♦ Age
   ♦ Number of prior pregnancies (gravida)
   ♦ Number of live births (para)
   ♦ Problems with current pregnancy
   ♦ Problems with previous pregnancies
   ♦ Medical illnesses
   ♦ Current medications
   ♦ Allergies
   ♦ Last menstrual period

Symptoms
   ♦ Location of pain
   ♦ Regularity and timing of contractions
   ♦ Urge to push
   ♦ Bleeding
   ♦ Swelling of face or extremities




                                                      Effective Date: January 1, 2006
Volusia County EMS System Protocols
                                                                                       218(b)

Obstetrics / Gynecology continued


Signs
   ♦ Vital Signs:     Routine, hypertension (pre-eclampsia)
   ♦ Skin:            Facial, extremity edema
   ♦ GU:              Contraction and relaxation of uterus, vaginal bleeding or fluid (color,
                      odor), crowning, abnormal presentation (foot, arm, cord)



NOTES ON HYPERTENSIVE STATES OF PREGNANCY

PRE-ECLAMPSIA -              Hypertension, edema and proteinuria developing during
                             pregnancy. Occurs in about 5% of the general (pregnant)
                             population. Usually develops after 20th week of pregnancy.

Mild Pre-eclampsia
   ♦ Blood pressure greater than 140 systolic.
   ♦ Blood pressure greater than 90 diastolic.
   ♦ Greater than 30 mmHg (systolic) higher than baseline blood pressure (during
        pregnancy).
   ♦ Greater than 15 mmHg (diastolic) higher than baseline blood pressure (during
        pregnancy).
   ♦ Non-dependent edema (facial or hand edema). Edema is not a reliable sign as it is
        often NOT present in preeclampsia/eclampsia.
   ♦ Persistent or recurring headache
   ♦ Vision changes (flashing lights, dots before eyes, dimming or blurring of vision)
   ♦ Abdominal pain
   ♦ Diminished or infrequent urination (oliguria)
   ♦ Weight gain > 2 lb/week




                                                                       Effective Date: January 1, 2006
Volusia County EMS System Protocols
                                                                                        218(b)

Obstetrics / Gynecology continued


Severe pre-eclampsia
   ♦ Blood pressure greater than 160/110
   ♦ Generalized edema
   ♦ Weight gain > 6 lb/week
   ♦ Persistent or recurring headache
   ♦ Vision changes (flashing lights, dots before eyes, dimming or blurring of vision)
   ♦ Abdominal pain
   ♦ Diminished or infrequent urination (oliguria)

Complications
Complications of preeclampsia include early delivery and fetal complications due to
prematurity as well as progression to eclampsia. Treatment of preeclampsia is bed rest and
delivery.


Eclampsia - The occurrence of grand mal seizures (or coma) with severe pre-eclampsia can
              occur up to 24 hours postpartum. Grave prognosis: maternal mortality from 1 -
              10%, perinatal mortality from 13-30%. Occurs in up to 0.5% of all deliveries.
              There is usually no aura preceding the seizure and the patient may have more
              than one. The patient hyperventilates after the tonic/clonic seizure to
              compensate for the respiratory and lactic acidosis. Prehospital treatment of
              eclampsia includes the use of both magnesium sulfate and diazepam as outlined
              in Section 221.3 (Seizures).
Basic Life Support
   ♦ Secure airway
   ♦ Administer supplemental oxygen, maintain saturation between 90-100%
   ♦ Record and monitor vital signs




                                                                        Effective Date: January 1, 2006
Volusia County EMS System Protocols
                                                                                        218(b)

Obstetrics / Gynecology continued


Advanced Life Support
   ♦ Advanced airway/ventilatory management as needed
   ♦ Begin cardiac monitoring, record and evaluate EKG strip
   ♦ Record & monitor O2 saturation & end-tidal CO2 (if available by nasal cannula)
   ♦ IV NaCl 0.9% KVO or IV lock
          If BP < 90 mmHG systolic, administer boluses of 0.9% NaCl at 250-500 cc to
          maintain systolic BP > 90 mmHg
              Contraindicated if evidence of congestive heart failure (e.g. rales)
   ♦ For active seizures,
          Diazepam (Valium) 5-10 mg slow IV titrated to control seizures, OR
          If no IV access available, give 10 mg IM
   ♦ Blood Glucose measurement
          If < 60 mg/dL, treat per Altered Mental Status/Hypoglycemia Protocol
   ♦ After seizure control, Magnesium Sulfate 4 Gm IV piggyback in 50 cc NS over 15-
      30 minutes
              Contraindicated if renal disease
   ♦ For Systolic BP > 160 mmHG on two readings,
          Magnesium Sulfate 4 Gm IV piggyback in 50 cc NS (if no renal disease) over
          15-30 minutes
              Contraindicated if renal disease




  Medical Control
     Call Medical Control for any additional orders or questions




                                                                        Effective Date: January 1, 2006
Volusia County EMS System Protocols
                                                                                   218(c)

Obstetrics / Gynecology continued


                               Vaginal Bleeding

History
   ♦ Onset
   ♦ Duration
   ♦ Amount (number of pads or tampons, clots and tissue fragments)
   ♦ Menstrual history
   ♦ Contraception
   ♦ Gravida, Para, Abortion (GPA)
   ♦ Pregnant (due date)
   ♦ Postpartum (time and place of delivery)
   ♦ Medical illnesses (bleeding disorders, etc.)
   ♦ Current medications
   ♦ Allergies

Symptoms
   ♦ Abdominal pain, cramping
   ♦ Weakness
   ♦ Passage of clots, tissue fragments (bring to ED)
   ♦ Nausea, vomiting
   ♦ Thirst
   ♦ Dizziness

Signs
   ♦ Vital Signs:    Orthostasis, tachycardia, hypotension
   ♦ Skin:           Cool, clammy, diaphoresis, pallor
   ♦ Abdominal:      Tenderness, distension, guarding, rebound
   ♦ Neurologic:     Decreased level of consciousness




                                                                  Effective Date: January 1, 2006
Volusia County EMS System Protocols
                                                                                         218(c)

Obstetrics / Gynecology continued


Basic Life Support
   ♦ Secure airway
   ♦ Administer supplemental oxygen, maintain saturation between 90-100%
   ♦ Record and monitor vital signs
   ♦ Apply pad to vaginal area
   ♦ 1st or 2nd Trimester or unknown pregnancy status
          Position of comfort
   ♦ 3rd Trimester Bleeding
          Left lateral recumbent position
          Mark fundal height and time of mark with pen; reassess frequently
   ♦ Pressure must be relieved from prolapsed cord. If prolapsed cord present, relieve
      pressure between the cord and the baby’s head with gloved hand.


Advanced Life Support
   ♦ Advanced airway/ventilatory management as needed
   ♦ Begin cardiac monitoring, record and evaluate EKG strip
   ♦ Record & monitor O2 saturation
   ♦ IV 0.9% NaCl KVO or IV lock
   ♦ If BP < 90 mmHG systolic, administer boluses of 0.9% NaCl at 250-500 ml until
      systolic BP > 90 mmHg
              Contraindicated if evidence of congestive heart failure (e.g. rales)


  Medical Control
     Call Medical Control for any further orders




                                                                        Effective Date: January 1, 2006
Volusia County EMS System Protocols
                                                                                          219

          Overdose and Poisonings – General Approach
History
   ♦ Route, type, time, quantity of exposure
   ♦ Accidental, intentional
   ♦ Bystander action prior to arrival
   ♦ Emesis (induced, spontaneous)
   ♦ Any antidote given
   ♦ Current medications
   ♦ Allergies
   ♦ Depression or suicidal
   ♦ Previous overdoses/poisonings
   ♦ History of drug/alcohol abuse


Common Causes
   ♦ CENTRAL NERVOUS SYSTEM AGENTS
          Sedatives:
             Barbiturates:       Seconal, Nembutal, Tuinal, etc.
             Non-Barbiturates: Quaalude, Sopors, Dalmane, Chloral hydrate, Placidyl, etc.
          Analgesics:
             Narcotics (opium derivates): Heroin, Morphine, Demerol, Codeine, Percodan,
                                           Paregoric, Methadone
             Non-Narcotics:                Talwin, Darvon, Acetaminophen, Salicylates,
                                           Phenylbutazone, Phenacetin
             Tranquilizers:                Valium, Librium, Meprobamate, Vistaril,
                                           Thorazine
          Alcohols:
             Ethanol, Methanol, Isopropyl alcohol




                                                                    Effective Date: January 1, 2006
Volusia County EMS System Protocols
                                                                                           219

Overdose and Poisonings – General Approach continued

          Hallucinogenics:
             Marijuana, LSD, Cocaine, STP, Hashish
          Amphetamines:
             Diet pills, Benzedrine, "Speed"
          Antidepressants:
             Elavil, Tofranil, Mellaril


♦     CARDIAC MEDICATIONS
      Digitalis, Quinidine, Propranolol


♦     HYPOGLYCEMIC AGENTS
          Orinase, Diabinese, Dymelor
          Insulins: Regular, NPH, Lente, Semilente)


♦     ANTCOAGULANTS
      Coumadin, Heparin


♦     ANTIBIOTICS
          Amoxil, Ceclor, Cefobid. Cleocin, EES, Erythromycin, Geocillin, Ultracef,
          Vibramycin, Duricef, Keflex, Penicillin, Tetracyline


♦ COMMON POISONOUS SUBSTANCES
      Parathion
      Arsenic
      Lead
      Strychnine
      Hydrocarbons
      Poisonous plants
      Acids and alkalines



                                                                     Effective Date: January 1, 2006
Volusia County EMS System Protocols
                                                                                                  219

Overdose and Poisonings – General Approach continued


Symptoms
   ♦ Mouth or throat pain
   ♦ Burns around the mouth
   ♦ Eye irritation/burning
   ♦ Dyspnea
   ♦ Sleepiness
   ♦ Nausea, vomiting
   ♦ Abdominal pain
   ♦ Diarrhea
   ♦ Headache
   ♦ Itching
   ♦ Chest pain
   ♦ Depression


Signs
        Vital Signs:     Vary
        Skin:            Cyanosis, rash, diaphoresis
        HEENT:           Abnormal breath odor, increased salivation, eye redness, excessive
                         tearing
        Respiratory:     Abnormal breathing patterns, labored respirations, wheezing
        CV:              Dysrhythmias
        GI:              Vomiting, abdominal tenderness
        Neurologic:      Decreased level of consciousness, coma, seizures


NOTE:         General considerations for any overdose or poisoning include determining the
              particular agent(s) involved, the time of the ingestion/exposure, and the amount
              ingested. Bring empty pill bottles, etc., to the receiving facility. See HAZMAT
              protocol for exposure to hazardous materials.




                                                                            Effective Date: January 1, 2006
Volusia County EMS System Protocols
                                                                                              219

Overdose and Poisonings – General Approach continued


Basic Life Support
   ♦ Secure airway while maintaining cervical spine immobilization, as necessary
   ♦ Administer supplemental oxygen, maintain saturation between 90-100%
   ♦ Record and monitor vital signs
   ♦ Nothing by mouth (depending on agent, patient may be at risk for seizure or rapid loss
      of consciousness with subsequent aspiration)


Advanced Life Support
   ♦ Advanced airway/ventilatory management as needed
   ♦ Initiate cardiac monitoring, record and evaluate EKG strip
   ♦ Record & monitor O2 saturation & end-tidal CO2 (if available)
   ♦ IV 0.9% NaCl KVO or IV lock
          If BP < 90 mmHG systolic, administer boluses of 0.9% NaCl at 250-500 cc to
          maintain systolic BP > 90 mmHg
              Contraindicated if evidence of congestive heart failure (e.g. rales)
   ♦ If patient has an altered level of consciousness: Obtain a Glucometer reading


If Hypoglycemic (Blood glucose < 60 mg/dL) with IV access
   ♦ Dextrose 50% 25 Gm Slow IVP
   ♦ May repeat as needed every 5 or 10 minutes if Blood Glucose < 60 mg/dL


If Hypoglycemic (Blood glucose < 60 mg/dL), without IV access
   ♦ Glucose paste (Glutose) or other oral glucose agent (e.g. orange juice) if patient alert
      enough to self administer oral agent or
   ♦ Glucagon 1 mg IM




                                                                        Effective Date: January 1, 2006
Volusia County EMS System Protocols
                                                                                             219

Overdose and Poisonings – General Approach continued

   ♦ If there is no change in mental status, administer Naloxone (Narcan)
          Naloxone (Narcan) 2.0 mg IVP every 3-5 min as needed (Max 10 mg). If IV
          access has not been established, administer Naloxone (Narcan) 2.0 mg, IM.
          Consider IM injection site for its fluid capacity.
              NOTE: If drug overdose is strongly suspected, administer Naloxone prior to
              Dextrose
   ♦ Refer to specific sub protocols when a specific agent has been identified or is strongly
      suspected.



  Medical Control
     Call Medical Control for any further orders




                                                                       Effective Date: January 1, 2006
Volusia County EMS System Protocols
                                                                                       219

Overdose and Poisonings – General Approach continued


                                  Antidepressants
          Category                     Drugs                     Overdose Effects
                         ♦ Amitriptyline (Elavil, Endep,     Hypotension
                           Etrafon, Vanatrip, Levate)        Anti-cholinergic effects
                         ♦ Clomipramine (Anafranil)          (tachycardia, seizures,
                         ♦ Doxepin (Sinequan, Zonalon,       altered mental status,
                           Triadapin)                        mydriasis)
         Tricyclic       ♦ Imipramine (Tofranil, Impril)     AV conduction blocks,
                                                             prolonged QT interval,
                         ♦ Nortriptyline (Aventyl;Pamelor,
   antidepressants                                           wide QRS, VT and VF
                           Norventyl)
                         ♦ Desipramine (Norpramin)
                         ♦ Protriptyline (Vivactil)
                         ♦ Trimipramine (Surmontil)
                         ♦ (Limbitrol) Amitriptyline +
                           chlordiazepoxide

                         ♦ Maprotiline (Ludiomil)            Ludiomil is similar to
                         ♦ Amoxapine (Asendin)               tricyclics, Asendin
     Other Cyclic                                            produces mostly seizures
                         ♦ Bupropion (Wellbutrin)            Minimal-moderate
  Antidepressants                                            seizures
                         ♦ Trazodone (Desyrel, Trazorel)     Less seizures and cardiac
                                                             effects than tricyclics
         Selective       ♦ Citalopram (Celexa)               Hypertension,
                                                             tachycardia, agitation,
        Serotonin        ♦ Fluoexitine (Prozac)              diaphoresis, shivering,
                         ♦ Fluvoxamine (Luvox)               tremor, muscle rigidity
        Reuptake                                             Malignant Hyperthermia
                         ♦ Paroxetine (Paxil)
 Inhibitors (SSRI’s)
                         ♦ Sertraline (Zoloft)




                                                                 Effective Date: January 1, 2006
  Rev: April 2, 2003
Volusia County EMS System Protocols
                                                                                    219(a)

Overdose and Poisonings continued

               Tricyclic and Tetracyclic Antidepressant Overdose


Basic Life Support
   ♦ Secure airway
   ♦ Administer supplemental oxygen, maintain saturation between 90-100%
   ♦ Record and monitor vital signs
Advanced Life Support
   ♦ Advanced airway/ventilatory management as needed
   ♦ Begin cardiac monitoring, record and evaluate EKG strip
   ♦ Record and evaluate 12-lead EKG
   ♦ Record & monitor O2 saturation & end-tidal CO2 (if available by nasal cannula)
   ♦ IV 0.9% NaCl KVO or IV lock
          If BP < 90 mmHG systolic, administer boluses of 0.9% NaCl at 250-500 cc to
          maintain systolic BP > 90 mmHg
   ♦ If Altered Mental Status
          See Altered Mental Status Protocol
   ♦ If Seizures
          See Seizure Protocol
   ♦ If wide complex (QRS ≥ 0.12 sec), hypotension, or any arrhythmias
          Sodium Bicarbonate 1 mEq/kg IV
   ♦ If Torsades de pointes
          Magnesium sulfate 2 Gm slow IVP in 50 cc MS slow IVP over 30 seconds (if no
          renal disease)

   Medical Control
      Call Medical Control for any further orders




                                                                    Effective Date: January 1, 2006
Volusia County EMS System Protocols
                                                                                         219(b)

Overdose and Poisonings continued

               Anticholingeric Poisoning/Organophosphates



Basic Life Support
   ♦ Wear protective clothing including masks, gloves, and eye protection.
          Toxicity to ambulance crew may result from inhalation or topical exposure.
          Any traces of contamination must be removed from the vehicle and/or equipment
          prior to the next transport.
   ♦ Secure airway
   ♦ Administer supplemental oxygen, maintain saturation between 90-100%
   ♦ Record and monitor vital signs
   ♦ Decontaminate patient
          Remove clothing
          Irrigate with normal saline -may also use soap and water
              Contain run-off of toxic chemicals when flushing


Advanced Life Support
   ♦ Advanced airway/ventilatory management as needed
   ♦ Begin cardiac monitoring, record and evaluate EKG strip
   ♦ Record and evaluate 12-lead EKG
   ♦ Record & monitor O2 saturation & end-tidal CO2 (if available by nasal cannula)
   ♦ IV 0.9% NaCl KVO or IV lock
          If BP 90 mmHG systolic, administer boluses of 0.9% NaCl at 250-500 cc to
          maintain systolic BP > 90 mmHg
              Contraindicated if evidence of congestive heart failure (e.g. rales)




                                                                        Effective Date: January 1, 2006
Volusia County EMS System Protocols
                                                                                          219(b)

Overdose and Poisonings continued

   ♦ If Altered Mental Status
          See Altered Mental Status Protocol
   ♦ If Seizures
          See Seizure Protocol
   ♦ If signs of severe toxicity, (severe respiratory distress, bradycardia, heavy respiratory
      secretions – do not rely on pupil constriction to diagnose or to titrate medications)
          Atropine 2.0 mg IVP every 5 min – titrate until respiratory secretions/distress
          begins to decrease




   Medical Control
      Call Medical Control for any further orders




                                                                         Effective Date: January 1, 2006
Volusia County EMS System Protocols
                                                                                      219(c)

Overdose and Poisonings continued

                     Antipsychotics/Acture Dystonic Reaction


Commonly used Antipsychotics - antipsychotic related medicines (e.g. antiemetics) in medical
practice include, but are not limited to the following:
               Prochlorperazine (Compazine)
               Promethazine (Phenergan)
               Thorazine
               Prolixin
               Haloperidol
Basic Life Support
   ♦ Secure airway
   ♦ Administer supplemental oxygen, maintain saturation between 90-100%
   ♦ Record and monitor vital signs
Advanced Life Support
   ♦ Advanced airway/ventilatory management as needed
   ♦ Begin cardiac monitoring, record and evaluate EKG strip
   ♦ Record and evaluate 12-lead EKG
   ♦ Record & monitor O2 saturation & end-tidal CO2 (if available by nasal cannula)
   ♦ IV 0.9% NaCl KVO or IV lock
           If BP < 90 mmHG systolic, administer boluses of 0.9% NaCl at 250-500 cc to
           maintain systolic BP > 90 mmHg
   ♦ For Dystonic reactions, administer
           Diphenhydramine (Benadryl) 25 mg, IV
           Repeat Diphenhydramine (Benadryl) 25 mg, IV or IM if inadequate response, in
           10 minutes

  Medical Control
     Call Medical Control for any further orders
Overdose and Poisonings continued



                                                                      Effective Date: January 1, 2006
Volusia County EMS System Protocols

                                                                                           219(d)
                               Beta Blocker Toxicity

Commonly used Beta Blockers in medical practice include but are not limited to the following:
       Propranolol (Inderal)
       Atenolol (Tenormin)
       Metroprolol (Lopressor)
       Nadolol (Corgard)
       Timolol (Blocadren)
       Labetolol (Trandate)
       Esmolol (Brevibloc)
       Acebatolol (Sectral)


In addition beta-blockers are contained in many combination drugs. It is the beta-blocker
component that leads to specific toxicity. Combination beta-blocker drugs include, but are not
limited to the following:
       Corzide (Nadolol/bendroflumethlazide
       Inderide (Propranolol/HCTZ)
       Inderide LA) Propranolol/HCTZ)
       Lopressor HCT (Metoprolol/HCTZ)
       Tenoretic (Atenolol/Chlorthalidone)
       Timolide (Timolol/HCTZ)
       Ziac (Bisoprolol/HCTZ)


Basic Life Support
   ♦ Secure airway
   ♦ Administer supplemental oxygen, maintain saturation between 90-100%
   ♦ Record and monitor vital signs




                                                                        Effective Date: January 1, 2006
Volusia County EMS System Protocols

                                                                                        219(d)
Overdose and Poisonings continued


Advanced Life Support
   ♦ Advanced airway/ventilatory management as needed
   ♦ Begin cardiac monitoring, record and evaluate EKG strip
   ♦ Record and evaluate 12-lead EKG
   ♦ Record & monitor O2 saturation & end-tidal CO2 (if available by nasal cannula)
   ♦ IV 0.9% NaCl KVO or IV lock
          If BP < 90 mmHG systolic administer boluses of 0.9% NaCl at 250-500 ml until
          systolic BP>90 mmHG
              Contraindicated if evidence of congestive heart failure (e.g. rales)
   ♦ For patients with cardiovascular toxicity (chest pain, syncope, SBP < 90 mmHG,
      altered mental mentation) with (1) bradycardia with rate < 60 or (2) Heart block,
      including third degree heart block and high grade second degree heart blocks i.e.
      Mobitz Type II second degree
          Administer the following agents
              Atropine 0.5 to 1.0 mg IV, may repeat to total max. of 0.04 mg/kg
              If no response, begin Transcutaneous Pacing



  Medical Control
     Dopamine infusion, or additional orders if cardiovascular toxicity persists




                                                                        Effective Date: January 1, 2006
Volusia County EMS System Protocols
                                                                                       219(e)

Overdose and Poisonings continued

                          Calcium Channel Blockers

Calcium Channel Blockers include:
      Amlodipine (Norvasc)
      Felodipine (Plendil, Renedil)
      Isradipine (DynaCirc)
      Nicardipine (Cardene)
      Nifedipine (Procardia, Adalat)
      Verapamil (Calan)
      Diltiazem (Cardizem)


Basic Life Support
   ♦ Secure airway
   ♦ Administer supplemental oxygen, maintain saturation between 90-100%
   ♦ Record and monitor vital signs


Advanced Life Support
   ♦ Advanced airway/ventilatory management as needed
   ♦ Begin cardiac monitoring, record and evaluate EKG strip
   ♦ Record and evaluate 12-lead EKG
   ♦ Record & monitor O2 saturation & end-tidal CO2 (if available by nasal cannula)
   ♦ IV 0.9% NaCl KVO or IV lock
          If BP < 90 mmHG administer boluses of 0.9% NaCl at 250-500 cc to maintain
          systolic BP > 90 mmHg
             Contraindicated if evidence of congestive heart failure (e.g. rales)




                                                                       Effective Date: January 1, 2006
Volusia County EMS System Protocols
                                                                                        219(e)

Overdose and Poisonings continued

   ♦ For patients with cardiovascular toxicity (chest pain, syncope, SBP < 90 mmHG,
      altered mental mentation) (1) bradycardia with rate < 60 or (2) Heart block, including
      third degree heart block and high grade second degree heart blocks i.e. - Mobitz Type II
      second degree
   ♦ Administer the following agents
          Atropine 0.5 mg to 1.0 mg IV, may repeat to total max. of 0.04 mg/kg
              If no response, Calcium Chloride 1 gram IVP
              ♦ Avoid if patient taking digoxin (Lanoxin)
              If no response, may repeat Calcium Chloride 1 gram IVP
              If no response, begin transcutaneous pacing


  Medical Control
     Dopamine infusion, or additional orders if cardiovascular toxicity persists




                                                                        Effective Date: January 1, 2006
Volusia County EMS System Protocols
                                                                                        219(f)

Overdose and Poisonings continued


                    Cocaine and Sympathomimetic Overdose


Basic Life Support
   ♦ Secure airway
   ♦ Administer supplemental oxygen, maintain saturation between 90-100%
   ♦ Record and monitor vital signs


Advanced Life Support
   ♦ Advanced airway/ventilatory management as needed
   ♦ Begin cardiac monitoring, record and evaluate EKG strip
   ♦ Record and evaluate 12-lead EKG
   ♦ Record & monitor O2 saturation & end-tidal CO2 (if available by nasal cannula)
   ♦ IV 0.9% NaCl KVO or IV lock
          If BP < 90 mmHG systolic, administer boluses of 0.9% NaCl at 250-500 cc to
          maintain systolic BP > 90 mmHg
              Contraindicated if evidence of congestive heart failure (e.g. rales)
   ♦ If seizures, refer to Seizure Protocol
   ♦ For patients with Sympathomimetic toxidrome (hypertension, tachycardia, agitation):
          Diazepam (Valium) 5-10 mg, slow IVP


  Medical Control
     Call Medical Control for any further orders




                                                                        Effective Date: January 1, 2006
Volusia County EMS System Protocols
                                                                                                  220

                           Pain Management - Adult
Basic Life Support
   ♦ Establish patient responsiveness
   ♦ If trauma suspected, stabilize spine
   ♦ Administer supplemental oxygen, maintain saturation between 90-100%
   ♦ Assess perfusion and circulation
   ♦ Assess mental status
   ♦ Assess baseline pain level (0-10 scale), (0 = no pain, 10 = worst pain)
   ♦ Administer nothing by mouth


Advanced Life Support
   ♦ Assess airway/breathing and ensure no airway intervention or ventilation needed
   ♦ Begin cardiac monitoring
   ♦ Record and monitor oxygen saturation and end-tidal CO2. (If available by nasal
      cannula)
   ♦ IV 0.9% NaCl KVO or IV lock
          If BP < 90 mmHG systolic, administer boluses of 0.9% NaCl at 250-500 cc to
          maintain systolic BP > 90 mmHg
              Contraindicated if evidence of congestive heart failure (e.g. rales)
   ♦ Obtain baseline blood pressure
   ♦ Perform a focused history and detailed physical examination enroute to the hospital if
      patient status and management of resources permit.
   ♦ Analgesic agents may be administered if patient has severe pain and one of following
          Isolated extremity injury
          Burn without airway, breathing, or circulatory compromise
          Sickle crisis with pain that is typical for that patient’s sickle cell disease
          Acute chest pain – see chest pain protocol for management




                                                                            Effective Date: January 1, 2006
Volusia County EMS System Protocols
                                                                                                220

Pain Management – Adult continued

   ♦ Agents for pain control
          Morphine Sulfate 2 mg slow IVP every 5 minutes until pain relief achieved
          (Maximum 10 mg)
              Contraindicated if systolic BP < 90 mmHg
              Use with caution if right ventricular (posterior wall) MI
   ♦ After drug administration
          Reassess the patient’s pain
          Note adequacy of ventilation and perfusion
          Monitor oxygen saturation & end-tidal C02
   ♦ Reassess the patient frequently



  Medical Control
     Contact medical control for questions concerning pain control in patients not meeting
     above criteria or for additional or higher dose of medications




                                                                          Effective Date: January 1, 2006
Volusia County EMS System Protocols
                                                                                                221

                                    Radio Report Format

The ideal radio report should relate all pertinent information regarding both the patient and the
plan for treatment in less than two minutes. The report itself must be prefaced with an
explanation of the type of report to follow. Reports must be described as emergent or non-
emergent. This statement must be followed by noting if on-line physician orders are to be
requested or if the report is for information only.


It is understood that some prehospital situations preclude providing a complete report to the
destination facility. However, paramedics should strive to furnish a complete report at the
earliest possible opportunity, and deviations from this standard must be for the benefit of the
patient.


Ambulance identification


    ♦ Vehicle identification


    ♦ Paramedic name or badge number


    ♦ Location of vehicle, including description of scene (if on site) and estimated time of
           arrival to the destination facility.


Patient data
    ♦ Patient's age, sex, and chief complaint
    ♦ Brief history of the present illness; include past medical history, medications, and
           allergies only if relevant to the chief complaint.
    ♦ Vital signs (to include pulse, respiratory rate and depth, blood pressure, cardiac rhythm,
           and oxyhemoglobin saturation as appropriate).




                                                                          Effective Date: January 1, 2006
Volusia County EMS System Protocols
                                                                                           221

Radio Report Format continued

   ♦ General appearance (including level of consciousness) and pertinent physical findings.
   ♦ Care in progress.
   ♦ Request for orders and confirmation of same.




                                                                     Effective Date: January 1, 2006
Volusia County EMS System Protocols
                                                                                               222

                   Refusal of Medical Care
        Determination of Medical Competency to Refuse
Indications
   ♦ For all calls whereby a basic or advanced life support unit is dispatched in response to
      activation of the 911 system, all patients will be offered transport to the nearest
      appropriate hospital.
   A patient shall be defined as

        Any individual who activates EMS for themselves
        Any individual with an injury or illness
        Any individual with a medical or traumatic complaint
        Any individual with a new altered level of consciousness
        Any individual where EMT/paramedic suspects injury due to mechanism


   ♦ The only patients authorized to not be transported to a hospital are patients who execute
      a complete refusal process (as per the refusal protocol below).


Procedure
   ♦ Obtain history from the patient and / or others in the area.
   ♦ Obtain and record
          At least one set of vital signs for each patient
          If unobtainable, justify reason on report
          Any improvement from initial complaint (e.g. improved blood glucose)
   ♦ Perform a physical examination
          Record that patient is awake & oriented to person, place, time, and events.
          Assess for any trauma or medical illness that may represent a threat to well- being
          of the patient or alter their ability to make decisions (hypoxia, hypoglycemia, prior
          stroke, or other neurologic disability)




                                                                         Effective Date: January 1, 2006
Volusia County EMS System Protocols
                                                                                                  222

Refusal of Medical Care continued

          Assess for psychiatric illness (suicidal/homicidal behavior, hallucinations,
          delusions)
          Assess for the presence of a toxic ingestion or exposure (e.g. alcohol, drugs,
          medications, narcotics or benzodiazepines), or carbon monoxide
   ♦ Assess the competency of the patient.
          For EMS purposes, a competent patient shall be defined as one who
              Is ≥18 years of age or a court certified emancipated minor, (a female with a
              baby, or a married person of either sex) AND
              Is awake, alert and fully oriented to time, person, place and situation AND
              Has no signs of injury or illness which may impair the ability to make an
              informed decision AND
              No recent history of drug/medication/alcohol ingestion or carbon monoxide
              exposure that might impair judgment AND
              Not suicidal or homicidal and does not want to hurt themselves.
   ♦ Care may be refused for a minor ONLY if ALL of the following are met
          The patient exhibits no historical or physical findings of potentially life or limb or
          organ threatening injury or illness.
          The patient is not intoxicated, and has no alterations in mental status, level of
          consciousness, or vital signs.
          The responsible parent/legal guardian is competent and present.
          If one of above is not met, transport patient
   ♦ If the patient (or parent or guardian) is judged NOT competent to refuse transport
          Explain to patient, (or parent or guardian) the need for transport.
          Reassure patient that no harm will result from transport but complications, up to
          and including death may result from a delay in treatment.
          If the patient (or parent or guardian) continues to refuse care
              enlist the aid of law enforcement personnel for patient and crew safety.
              Proceed with transport of the patient




                                                                            Effective Date: January 1, 2006
Volusia County EMS System Protocols
                                                                                                222

Refusal of Medical Care continued

   ♦ If the patient, (or parent/guardian), is judged competent to refuse transport, Emphasize
          The need for medical care
          The risks of refusal of care (including death and disability)
          The willingness of EMS to transport the patient
          The patient should call their primary care physician immediately or seek medical
          advice/council ASAP
   ♦ Document on a patient care report (or patient refusal sheet)
          All cases in which there is a refusal of care
          All cases where there is an assessment of competency
          The name and phone number of the patient refusing care
          Signature of patient
          Printed name and signature of competent witness
          The signature of the medic involved
   ♦ Complete the Outline for Documenting the Determination of Medical Competency to
      Refuse Care for every patient contact where transport to the hospital does not occur.
   ♦ Prisoners in Custody of Law Enforcement:
          Paramedics and Emergency Medical Technicians are not authorized to
          recommend whether or not a patient needs transportation to a medical
          facility for further care at this time. This is beyond their current scope of
          training and clinical expertise.

          Decisions relative to the further care and/or transportation to a medical
          facility rest solely with the patient or the patient’s legal guardian, including
          agencies in which the patient is in custody.



  Medical Control
     Contact Medical Control if there are any questions regarding a patient’s ability to
     refuse medical care of if assistance is needed to convince patient to be transported, or
     for any pediatric patient with any abnormality in vital signs.




                                                                          Effective Date: January 1, 2006
Volusia County EMS System Protocols
                                                                                            222(a)

Refusal of Medical Care continued

 Guideline for Documenting the Determination of Medical
               Competency to Refuse Care
       Patient is awake, alert and oriented to person, place, time and events
       Patient’ symptoms that prompted 911 call have disappeared (or improved)
       Patient is an adult who is not intoxicated, has ingested no drugs, and has not been
       exposed to carbon monoxide has no underlying neurologic or mental disorder (e.g.
       severe stroke, psychiatric illness, or suicidal ideation) and has no signs of injury or
       illness that limit ability to understand risks, or make informed decisions
       Patient is not suicidal, & has no evidence of a thought disorder (e.g. delusions,
       hallucinations)
       Patient (or guardian) has been advised of the risks of refusing medical care, including
       the risk of sudden death and severe disability
       Patient (or guardian) understands and accepts these risks of refusal
       Patient (or guardian) has been offered the opportunity to re-call 911 should he/she
       change their mind and desire transportation to the hospital
       Patient (or guardian) has been advised to call their primary care physician ASAP
       Must include following information:
   Patient Name, Guardian Name, Patient phone number (if possible), Medic/EMT Name and
   Signature, Witness Printed Name and Signature.
   If patient is a minor, include the following information:
   Parent, Guardian, or appropriate relative name and Signature.
If possible, attempt to leave competent refusing patients with a competent adult or encourage
patient in contacting such a person (not a requirement if patient is competent to make
decisions on own and understands risks)




                                                                           Effective Date: January 1, 2006
Volusia County EMS System Protocols
                                                                                            222(b)

                         Consent for Treating Minors

   ♦ Under Florida Statute 743.064 (as of November 2000) consent for minors is guided by
      the following rules.
          If medical personnel are concerned for the safety of a minor and the legal guardian
          as defined below refuses transport
                Contact Medical Control for assistance with convincing guardian
                Contact local police agency for assistance with transport
   ♦ Under Florida Statute 743.064 (November 2000), any of the following persons in order
      of priority listed may consent to the medical care or treatment of a minor who is not
      committed to the Department of Children and Family Services or the Department of
      Juvenile Justice or in their custody when, after a reasonable attempt, a person who has
      the power to consent as otherwise provided by law cannot be contacted by the treatment
      provider and actual notice to the contrary has not been given to the provider by that
      person.
          A person who possesses a power of attorney to provide medical consent for the
          minor
          The stepparent of the minor
          The grandparent of the minor
          An adult brother or sister of the minor
          An adult aunt or uncle of the minor




                                                                            Effective Date: January 1, 2006
Volusia County EMS System Protocols
                                                                                        222(b)

Consent for Treating Minors continued



   ♦ The Department of Children and Family Services or the Department of Juvenile Justice
      caseworker, juvenile probation officer, or person primarily responsible for the case
      management of the child, the administrator of any facility licensed by the department or
      the administrator of any state operated or state contracted delinquency residential
      treatment facility may consent to the medical care or treatment of any minor committed
      to it or in its custody when the person who has the power to consent as otherwise
      provided by law cannot be contacted and such person has not expressly objected to
      such consent. There shall be maintained in the records of the minor documentation that
      a reasonable attempt was made to contact the person who has the power to consent as
      otherwise provided by the law.




   Medical Control
      Call Medical Control for any additional orders or questions




                                                                        Effective Date: January 1, 2006
Volusia County EMS System Protocols
                                                                                           223

                                          Seizure
History
   ♦ Onset
   ♦ Duration
   ♦ Type (grand-mal, focal, petit mal)
   ♦ Recovery of consciousness
   ♦ Incontinence
   ♦ Medical illnesses (especially prior seizures, diabetes, CVA, fever)
   ♦ Current medications
   ♦ Allergies
   ♦ Drug or alcohol withdrawal
   ♦ Head trauma
   ♦ Pregnancy (eclampsia - see "Emergency Childbirth Protocol")


Symptoms
   ♦ Aura (visual or auditory hallucinations)
   ♦ Metallic taste in mouth


Signs
   ♦ Vital Signs:           Vary
   ♦ Skin:                  Cyanosis, pallor, clammy children - rash, hot
   ♦ HEENT:                 Head trauma, tongue biting/oral trauma
   ♦ Cardio-Vascular:       Check for pulses post seizure, as seizure may be first indication
                            of cardiac arrest or serious dysrhythmia
   ♦ Neurologic:            Seizures, decreased level of consciousness (postictal), focal
                            neurologic signs
   ♦ GU:                    Incontinence




                                                                       Effective Date: January 1, 2006
Volusia County EMS System Protocols
                                                                                         223

Seizure continued

Basic Life Support
   ♦ Secure airway
   ♦ Administer supplemental oxygen, maintain saturation between 90-100%
   ♦ Record and monitor vital signs
   ♦ Protect patient from injury


Advanced Life Support
   ♦ Advanced airway/ventilatory management as needed
   ♦ Begin cardiac monitoring, record and evaluate EKG strip
   ♦ Record and evaluate 12-lead EKG if seizure has stopped
   ♦ Record & monitor O2 saturation & end-tidal CO2 (if available by nasal cannula)
   ♦ Blood Glucose measurement
          If < 60 mg/dL, treat per Altered Mental Status/Hypoglycemia Protocol
   ♦ IV 0.9% NaCl KVO or IV lock (medications only for active seizures)
          Diazepam (Valium) 5-10 mg slow IVP OR
          Diazepam (Valium) rectally 10 mg if no IV
   ♦ If Hypoxic seizures, Drug induced seizures, Seizures from head trauma, stroke or
      eclampsia suspected:
          Treat as above AND
          See appropriate protocol for further treatment




   Medical Control
      Call Medical Control for any further orders




                                                                     Effective Date: January 1, 2006
Volusia County EMS System Protocols
                                                                                             224

                                      Snake Bites

History
   ♦ Type of snake
   ♦ Time of bite
   ♦ Age and size of patient
   ♦ Location of injury
   ♦ Treatment provided prior to EMS arrival
   ♦ Medical illnesses
   ♦ Current medications
   ♦ Allergies

Symptoms
   ♦ Paresthesis (numbness or tingling of mouth, tongue, other areas)
   ♦ Local pain
   ♦ Peculiar or metallic taste in mouth
   ♦ Chills
   ♦ Nausea, vomiting
   ♦ Headache
   ♦ Dysphagia (difficulty swallowing)

Signs
   ♦ Vital Signs:    Hypotension, fever
   ♦ Skin:           Bite wound location, configuration (1, 2, or 3 fang marks, entire jaw
                     imprint, none), local edema, discoloration




                                                                        Effective Date: January 1, 2006
Volusia County EMS System Protocols
                                                                                      224

Snake Bites continued

Basic Life Support

   ♦ Secure airway
   ♦ Administer supplemental oxygen, maintain saturation between 90-100%
   ♦ Evaluate for specific signs/symptoms:
          Distinct “fang marks” or puncture wounds
          Swelling and pain at the site
          Weakness, nausea, and vomiting
          Paresthesia, fasciculations
          Numbness and tingling around the face and head
          Metallic taste, change in taste sensation
          Hypotension and shock
          Allergic reactions/Anaphylaxis
   ♦ Irrigate/Cleanse wound with 0.9% NaCl (remove any large debris and formal
      cleansing can wait until ED arrival)
   ♦ Apply dry, sterile dressing
   ♦ Mark initial edematous area with pen and note time
   ♦ Immobilize affected part and remove distal jewelry
   ♦ Attempt to identify what caused bite and bring to Emergency Department if dead (be
      careful as dead snakes can still strike and bite)
   ♦ Record and monitor vital signs
   ♦ If constricting bands in place upon arrival, remove




                                                                 Effective Date: January 1, 2006
Volusia County EMS System Protocols
                                                                                             224

Snake Bites continued

Advanced Life Support

   ♦ Advanced airway/ventilatory management as needed
   ♦ Initiate cardiac monitoring, record and evaluate EKG strip
   ♦ Record & monitor O2 saturation
   ♦ IV 0.9% NaCl KVO or IV Lock in uninjured extremity
   ♦ If BP < 90 mmHG systolic, administer boluses of 0.9% NaCl at 250-500 cc to
       maintain systolic BP > 90 mmHg
          Contraindicated if evidence of congestive heart failure (e.g. rales)
   ♦ See Allergic Reaction protocol if signs or symptoms of allergic reaction.
   ♦ If condition worsens or no improvement from fluid challenge,
          Dopamine infusion at 5-20 mcg/kg/min titrated to maintain systolic BP > 90
          mmHg
   ♦ Transport to closest facility



  Medical Control
     Call Medical Control for further orders.




                                                                        Effective Date: January 1, 2006
Volusia County EMS System Protocols
                                                                                            225

                               Stroke - Suspected

History
   ♦ Onset and duration
   ♦ Where found
   ♦ Sequence of deficits
   ♦ Head or neck trauma
   ♦ Seizures
   ♦ Medical illnesses (especially diabetes, cardiovascular disease)
   ♦ Current medications
   ♦ Allergies


Symptoms
   ♦ Headache
   ♦ Confusion
   ♦ Seizures


Signs
   ♦ Vital Signs:    Vary
   ♦ Skin:           Diaphoresis, pallor
   ♦ Neurologic:     Decreased level of consciousness, impaired movement and symmetry of
                     face and extremities, tremors
   ♦ Other:          Medical alert tag




                                                                       Effective Date: January 1, 2006
Volusia County EMS System Protocols
                                                                                              225

Stroke – suspected continued

Basic Life Support
   ♦ Secure airway
   ♦ Do not administer any oral medications
   ♦ Administer supplemental oxygen, maintain saturation between 90-100%
   ♦ Record and monitor vital signs (obtain blood pressure in both arms)
   ♦ Keep head of stretcher at 30-45° elevation (if no trauma)
   ♦ Assess patient using the Florida Bureau of EMS Stroke Alert Checklist.
   ♦ Spinal immobilization if trauma.
   ♦ Note answers to following patient thrombolytic therapy screening questions:
          Is the onset of symptoms less than 3 hours from the time of response?
          Is the patient clinically stable (no evidence of head trauma, seizures, or bleeding)?
          Is the patient on any anticoagulant medication (Coumadin, warfarin, or heparin)?
          Is the blood pressure controlled (< 185/110 mmHg)?
   ♦ Notify receiving facility of “Stroke Alert” patient and transport emergency if screening
      criteria have been met (onset < 3 hours, clinically stable, no use of anticoagulants, and
      BP controlled).
   ♦ Transport Stroke Alert patients to the closest designated Primary or Comprehensive
      Stroke Center.


Advanced Life Support
   ♦ Advanced airway/ventilatory management as needed
   ♦ Begin cardiac monitoring, record and evaluate EKG strip
   ♦ Record & monitor O2 saturation & end-tidal CO2 (if available by nasal cannula)
   ♦ IV 0.9% NaCl KVO or IV lock
          If BP < 90 mmHG systolic, administer boluses of 0.9% NaCl at 250-500 cc to
          maintain systolic BP > 90 mmHg
              Contraindicated if evidence of congestive heart failure (e.g. rales)




                                                                         Effective Date: January 1, 2006
Volusia County EMS System Protocols
                                                                                              225

   ♦ If condition worsens or no improvement from fluid challenge, Dopamine infusion at
      5-20 mcg/kg/min titrated to maintain systolic BP > 90 mmHg (and DO NOT initiate
      stroke alert)


Stroke – suspected continued

If Hypoglycemic (< 60 mg/dL) with IV access
   ♦ Dextrose 50% 25 Gm Slow IVP
   ♦ May repeat as needed every 5 or 10 minutes to Blood Glucose < 60 mg/dL
If Hypoglycemic (< 60 mg/dL) without IV access
   ♦ Glucose paste (Gluctose) or other oral glucose agent (e.g. orange juice) if patient alert
      enough to self administer oral agent or
   ♦ Glucagon 1 mg IM If < 60 mg/dL
   ♦ If patient meets stroke alert criteria
          Immediately notify receiving facility and give Stroke Alert
          Consider air transportation only if time will be saved transporting the patient by this
          route
          Notify receiving facility of “Stroke Alert” patient and transport emergency if
          screening criteria have been met (onset < 3 hours, clinically stable, no use of
          anticoagulants, and BP controlled).



  Medical Control
     Call Medical Control for any additional orders or questions




                                                                         Effective Date: January 1, 2006
Volusia County EMS System Protocols




                                      Effective Date: January 1, 2006
Volusia County EMS System Protocols
                                                                               226

                               Syncope - Blackout

History
   ♦ Onset (gradual or abrupt)
   ♦ Duration
   ♦ Position (sitting, standing, lying down)
   ♦ Seizure activity
   ♦ Trauma
   ♦ Pregnancy
   ♦ Precipitating factors
   ♦ Medical illnesses (previous syncope, cardiac, CVA)
   ♦ Current medications (newly prescribed)
   ♦ Allergies


Symptoms
   ♦ Palpitations
   ♦ Chest pain
   ♦ Abdominal pain
   ♦ Back pain
   ♦ Nausea, vomiting
   ♦ Hematemesis, melena
   ♦ Headache
   ♦ Vertigo




                                                          Effective Date: January 1, 2006
Volusia County EMS System Protocols
                                                                                            226

Syncope – Blackout continued

Signs
   ♦ Vital Signs:       Orthostasis (significant if pulse change > 30 bpm or systolic BP
                        change > 15 mmHg from lying to sitting or standing)
   ♦ HEENT:             Evidence of head trauma
   ♦ Cardio-Vascular: Dysrhythmias
   ♦ Abdominal:         Tenderness, possible pulsatile mass
   ♦ GU:                Incontinence
   ♦ Neurologic:        Decreased level of consciousness, coma


Basic Life Support
   ♦ Secure airway
   ♦ Administer supplemental oxygen, maintain saturation between 90-100%
   ♦ Record and monitor vital signs
   ♦ Spinal immobilization if indicated


Advanced Life Support
   ♦ Advanced airway/ventilatory management as needed
   ♦ Begin cardiac monitoring, record and evaluate EKG strip
   ♦ Record and evaluate 12-lead EKG
          If acute changes present treat per Chest Pain/Acute MI Protocol
   ♦ Record & monitor O2 saturation & end-tidal CO2 (if available by nasal cannula)
   ♦ IV 0.9% NaCl KVO or IV lock
          If BP < 90 mmHG systolic, administer boluses of 0.9% NaCl at 250-500 ml until
          systolic BP > 90 mmHg
             Contraindicated if evidence of congestive heart failure (e.g. rales)
          If condition worsens or no improvement from fluid challenge, Dopamine infusion
          at 5-20 mcg/kg/min titrated to maintain systolic BP > 90 mmHg




                                                                       Effective Date: January 1, 2006
Volusia County EMS System Protocols
                                                                                         226

Syncope – Blackout continued

   ♦ Blood Glucose level
          If < 60 mg/dL, treat per Altered Mental Status/Hypoglycemia Protocol
   ♦ If EKG rhythm is Bradycardia/Heart Block
          See Chest Pain/Dysrhythmia/Bradycardia protocol
   ♦ If EKG shows dysrhythmia
          See specific dysrhythmia protocols
   ♦ If TIA/Stroke suspected
          See Altered Mental Status/Stroke Protocol




   Medical Control
      Call Medical Control for any further orders




                                                                    Effective Date: January 1, 2006
Volusia County EMS System Protocols
                                                                                             227

                                           Trauma

                                     General Guidelines


History
   ♦ Mechanism of injury (blunt or penetrating)
   ♦ Blunt trauma: amount and direction of force
   ♦ Penetrating trauma: weapon, size of object, bullet caliber, trajectory of bullet
   ♦ Motor vehicle accident: condition of vehicle, dashboard, and steering wheel, speed of
        impact, seat belt use, patient trajectory
   ♦ Description of scene
   ♦ Treatment prior to arrival (patient movement)
   ♦ Drug or alcohol use
   ♦ Medical illnesses
   ♦ Current medications
   ♦ Allergies


Symptoms
   ♦ Not applicable


Signs
   ♦ Vital Signs:      Vary
   ♦ Skin:             Cyanosis, pallor, mottling, entrance and exit wounds, cool, clammy
   ♦ Respiratory:      Apnea, abnormal chest wall movements (paradoxical, retractions),
                       abnormal breath sounds, tracheal shift, subcutaneous emphysema




                                                                        Effective Date: January 1, 2006
Volusia County EMS System Protocols
                                                                                            227

Trauma General Guidelines continued


Basic Life Support
   ♦ Secure airway/Spinal immobilization
   ♦ Assess Breath sounds and Respiratory effort
          Administer supplemental oxygen, maintain saturation between 90-100%
   ♦ Record and monitor vital signs
   ♦ Examine patient for obvious bleeding
          Compress bleeding sites
   ♦ Assess Disability – neurologic status/record Glasgow coma score
   ♦ Head to toe examination to assess for injuries
   ♦ Restrain as needed


Advanced Life Support
   ♦ Advanced airway/ventilatory management as needed
   ♦ Two attempts followed by Combi-tube
   ♦ Needle decompression for patient with tension pneumothorax as needed
   ♦ Begin cardiac monitoring, record and evaluate EKG strip
   ♦ Record & monitor 02 saturation
   ♦ IV 0.9% NaCl KVO or IV lock if condition warrants
          If BP < 90 mmHG systolic, administer boluses of 0.9% NaCl at 250-500 cc to
          maintain systolic BP > 90 mmHg
             Contraindicated if evidence of congestive heart failure (e.g. rales)
             Note: Do Not Delay Transport for IV insertion
   ♦ For cranial, chest, extremity, and ocular injuries see specific management
      protocols below
   ♦ Transport per Trauma Transport Protocols
          Goal is to have scene time < 10 minutes




                                                                       Effective Date: January 1, 2006
Volusia County EMS System Protocols
                                                                                       227

Trauma General Guidelines continued



          Do not delay transport inserting IV or performing procedures other than those
          that are immediately required to stabilize patient (e.g. airway management in
          apneic patient)



   Medical Control
      Call Medical Control for any further orders if necessary




                                                                  Effective Date: January 1, 2006
Volusia County EMS System Protocols
                                                                                        227(a)




                                Chest Injuries/Trauma

History
   ♦ Mechanism of injury (blunt or penetrating)
   ♦ Blunt trauma: amount and direction of force
   ♦ Penetrating trauma: weapon, size of object, bullet caliber, trajectory of bullet
   ♦ Motor vehicle accident: condition of vehicle, dashboard, and steering wheel, speed of
      impact, seat belt use, patient trajectory
   ♦ Description of scene
   ♦ Treatment prior to arrival (patient movement, etc.)
   ♦ Drug or alcohol use
   ♦ Medical illnesses
   ♦ Current medications
   ♦ Allergies


Symptoms
   ♦ Respiratory distress
   ♦ Chest pain
   ♦ Neck pain
   ♦ Hemoptysis




                                                                        Effective Date: January 1, 2006
Volusia County EMS System Protocols
                                                                                       227(a)

Chest Injuries/Trauma continued

Signs
   ♦ Vital Signs:  Vary - abnormal respiratory rates
   ♦ Skin:         Cyanosis, subcutaneous emphysema, presence or absence of chest
                   wound
   ♦ Respiratory: Abnormal chest wall movements (paradoxical movement, retractions),
                   chest wall tenderness, abnormal breath sounds, tracheal
   ♦ Cardiovascular: Muffled heart sounds, distended neck veins, narrowed pulse pressure,
                     EMD
   ♦ Neurologic:     Decreased level of consciousness, change in mental status (hypoxia)



Basic Life Support
   ♦ Spinal immobilization/Secure airway
   ♦ Administer supplemental oxygen, maintain saturation between 90-100%
   ♦ Record and monitor vital signs
   ♦ Evaluate breath sounds
          Reevaluate frequently
   ♦ For Open/Sucking Chest wounds, apply occlusive dressing sealed on three (3) sides
          Remove temporarily to vent air if any ventilatory deterioration
   ♦ For Flail segment
          Assess for ventilatory compromise and assist ventilation with B-V-M as needed
          Stabilize flail segment




                                                                       Effective Date: January 1, 2006
Volusia County EMS System Protocols
                                                                                          227(a)

Chest Injuries/Trauma continued



Advanced Life Support
   ♦ Advanced airway/ventilatory management as needed
   ♦ Begin cardiac monitoring, record and evaluate EKG strip
   ♦ Record and evaluate 12-lead EKG if applicable
   ♦ Record & monitor O2 saturation & end-tidal CO2 (if available by nasal cannula)
   ♦ IV 0.9% NaCl KVO or IV lock
   ♦ If systolic BP < 90 mmHG, administer boluses of 0.9% NaCl at 250-500 cc to
      maintain systolic BP > 90 mmHg
             Contraindicated if evidence of congestive heart failure (e.g. rales)
             NOTE: Total amount of IVF shall not exceed 3000 cc
   ♦ Assess for tension pneumothorax
          If suspicion of tension pneumothorax with respiratory distress, Perform Pleural
          decompression
   ♦ If flail segment present
          Intubate if poor ventilatory effort with unresponsive hypoxia



   Medical Control
      Call Medical Control for any further orders




                                                                          Effective Date: January 1, 2006
Volusia County EMS System Protocols
                                                                                     227(b)


                             Cranial (Head) Injuries


History
   ♦ Time of injury
   ♦ Mechanism of injury (blunt vs. penetrating)
   ♦ Estimate of force involved
   ♦ Helmet (motorcycle, bicycle)
   ♦ Loss of or change in consciousness (duration and progression)
   ♦ Amnesia for events
   ♦ Medical illnesses (especially diabetes, seizures, etc.)
   ♦ Current medications
   ♦ Allergies
   ♦ Drug or alcohol use


Symptoms
   ♦ Nausea, vomiting
   ♦ Neck pain
   ♦ Headache
   ♦ Diplopia (double vision) or blurred vision
   ♦ Abnormal gait
   ♦ Numbness or tingling of extremities
   ♦ Paralysis of extremities




                                                                     Effective Date: January 1, 2006
Volusia County EMS System Protocols
                                                                                         227(b)

Cranial (Head) Injuries continued

Signs
   ♦ Vital Signs:   Hypotension or tachycardia may be indicative of internal hemorrhage
   ♦ Skin:          Contusions, abrasions, lacerations
   ♦ HEENT:         Abnormal breath odor (especially ETOH), bleeding or CSF from nose
                    and ears
   ♦ Neck:          Tenderness (suspect neck injury in ALL head injured patients)
   ♦ Neurologic:    Decreased level of consciousness, restlessness, abnormal papillary size
                    and response, focal neuro deficits, seizures, coma


Basic Life Support
   ♦ Secure airway/Spinal immobilization
   ♦ Administer supplemental oxygen, maintain saturation between 90-100%
   ♦ Record and monitor vital signs
   ♦ Restrain as needed
   ♦ If Normotensive or Hypertensive
          Elevate head of backboard 15-30°


Advanced Life Support
   ♦ Advanced airway/ventilatory management as needed
   ♦ Begin cardiac monitoring, record and evaluate EKG strip
   ♦ IV 0.9% NaCl KVO or IV lock
          If BP < 90 mmHG systolic, administer boluses of 0.9% NaCl at 250-500 cc to
          maintain systolic BP > 90 mmHg
             Contraindicated if evidence of congestive heart failure (e.g. rales)
   ♦ Do not administer Narcan to a suspected head injury patient




                                                                         Effective Date: January 1, 2006
Volusia County EMS System Protocols
                                                                                        227(b)

Cranial (Head) Injuries continued

   ♦ Intubate ONLY IF
          Decreased level of consciousness with respiratory failure OR poor ventilatory effort
          (with hypoxia, unresponsive to supplemental 100% oxygen) OR unable to maintain
          patent airway (especially if GCS ≤ 8 AND unable to maintain supplemental oxygen
          saturation between 90-100 with non rebreather mask or BVM)
          If head injury suspected, administer 1.5 mg/kg lidocaine IVP two minutes prior to
          intubation as urgency permits.
          Airway interventions can be detrimental in patients with head injury by
          raising intracranial pressure, worsening hypoxia (and secondary brain injury)
          and increasing risk of aspiration
   ♦ Administer eucapneic (normal rate) ventilations
          Hyperventilate (rate = 20 per minute) only if signs of acute herniation:
              Acute unilateral blown (dilated and unreactive) pupil
              Abrupt deterioration in mental status
              Abrupt onset of motor posturing
          Hyperventilation is to be performed only as a temporizing measure:
              Discontinue as soon as signs of herniation cease
              If CO2 monitor available, ventilate to CO2 30-35



  Medical Control
     Call Medical Control for any further orders if necessary




                                                                        Effective Date: January 1, 2006
Volusia County EMS System Protocols
                                                                                         227(c)

Trauma General Guidelines continued

                                     Extremity Trauma
History
   ♦ Mechanism of injury
   ♦ Direction of force
   ♦ Description of scene (athletic event, motor vehicle accident, fall, etc.)
   ♦ Treatment prior to arrival (dislocation reduction, patient movement, etc.)
   ♦ Previous injury
   ♦ Drug or alcohol use
   ♦ Medical illnesses
   ♦ Current medications
   ♦ Allergies


Symptoms
   ♦ Pain or limited movement
   ♦ Deformity


Signs
   ♦ Vital Signs:            Routine
   ♦ Musculoskeletal:        Obvious deformity, swelling, tenderness, crepitus, ecchymosis,
                             discoloration, loss of function
   ♦ Neurovascular:          Weak or absent distal pulses and sensation


Basic Life Support
   ♦ Secure airway
   ♦ Administer supplemental oxygen, maintain saturation between 90-100%
   ♦ Record and monitor vital signs




                                                                         Effective Date: January 1, 2006
Volusia County EMS System Protocols
                                                                                            227(c)

Extremity Trauma continued

   ♦ Spinal immobilization if indicated
   ♦ Remove or cut away clothing to expose area of injury
   ♦ Control active bleeding by direct pressure and elevation
   ♦ Check distal pulses, capillary refill, sensation/movement prior to splinting
          If present, splint in position found if possible
          If absent, attempt to place the injury into anatomical position
   ♦ Open wounds/fractures should be covered with sterile dressings and immobilized in the
      presenting position
   ♦ Dislocations should be immobilized to prevent any further movement of the joint
   ♦ Check distal pulses, capillary refill, and sensation after splinting


Advanced Life Support
   ♦ Advanced airway/ventilatory management as needed
   ♦ Begin cardiac monitoring, record and evaluate EKG strip
   ♦ Record & monitor O2 saturation
   ♦ IV 0.9% NaCl KVO or IV lock if condition warrants
          If BP < 90 mmHG systolic, administer boluses of 0.9% NaCl at 250-500 cc to
          maintain systolic BP > 90 mmHg
               Contraindicated if evidence of congestive heart failure (e.g. rales)
   ♦ Morphine Sulfate 2 mg IV every 5 minutes until pain relief achieved (Maximum of
      10 mg)
          Contraindicated if head injury, thoracic or abdominal trauma, or systolic BP < 90
          mmHg



  Medical Control
     Call Medical Control for any additional orders or questions




                                                                            Effective Date: January 1, 2006
Volusia County EMS System Protocols
                                                                                      227(c)


                              Traumatic Amputations

History
   ♦ Time of injury
   ♦ Mechanism of injury
   ♦ Care for severed part
   ♦ Medical illnesses (especially bleeding problems, etc.)
   ♦ Current medications
   ♦ Allergies


Symptoms
   ♦ Not applicable


Signs
   ♦ Vital Signs:     Vary (hypotension, tachycardia)
   ♦ Skin:            Cyanosis, pallor, clammy
   ♦ Extremity:       Structural attachments in partial amputations
   ♦ Other:           Assess blood loss at scene and other injuries


Basic Life Support
   ♦ Secure airway
   ♦ Administer supplemental oxygen, maintain saturation between 90-100%
   ♦ Record and monitor vital signs
   ♦ Spinal Immobilization if indicated




                                                                      Effective Date: January 1, 2006
Volusia County EMS System Protocols
                                                                                        227(c)

Traumatic Amputations continued

   ♦ If amputation incomplete
          Attempt to stabilize with bulky pressure dressing
          Splint inline
   ♦ If amputation complete
          Cleanse amputated part with sterile saline
          Wrap in sterile dressing soaked in sterile saline
          Place in plastic bag if possible
          Attempt to cool with cool pack during transport
   ♦ Attempt to control blooding with direct pressure, elevations and ice
   ♦ If uncontrolled bleeding
          Apply tourniquet or BP cuff inflated 30-40 mmHG above systolic BP above
          amputation
          Note time tourniquet applied
          Do not release after application


Advanced Life Support
   ♦ Advanced airway/ventilatory management as needed
   ♦ Begin cardiac monitoring, record and evaluate EKG strip
   ♦ Record & monitor 02 saturation
   ♦ IV 0.9% NaCl KVO or IV lock
   ♦ If BP < 90 mmHG systolic, administer boluses of 0.9% NaCl at 250-500 cc to
      maintain systolic BP > 90 mmHg
              Contraindicated if evidence of congestive heart failure (e.g. rales)
   ♦ Morphine sulfate 2 mg IV every 5 minutes for pain control (Maximum of 10 mg)
          Contraindicated if head injury, thoracic or abdominal trauma, or systolic BP < 90
          mmHG.

  Medical Control
     Call Medical Control for any additional orders or questions




                                                                        Effective Date: January 1, 2006
Volusia County EMS System Protocols
                                                                                            227(d)

    Non-Resuscitation of Trauma Related Cardiac Arrests

The criteria required to not resuscitate in Trauma Related Cardiac Arrests include the
following:


   ♦ Evidence of injuries incompatible with life
   ♦ Patient is pulseless and apneic on initial assessment


In patients initially presenting with all of the above criteria, the paramedic is not required to
initiate or continue resuscitation and is not required to contact Medical Control.


A paramedic may decide to initiate or continue resuscitation despite the above criteria if scene
safety, location, patient age, or bystander input compels this decision.




  Medical Control
     All decisions concerning the withholding or cessation of resuscitation, not covered
  by the above rules, must be made in conjunction with Medical Control




                                                                            Effective Date: January 1, 2006
Volusia County EMS System Protocols
                                                                                                 300

                       Trauma – Pediatric Guidelines
General definition for child
       Neonate – Birth to < 30 days
       Pediatric – 31 days to 8 years
       Child – 8 – 12 years
       Adolescent – 12 – 15 years
       Over 15 years treat as adult


Basic Life Support
   ♦ Ensure scene safety
   ♦ Scene survey to determine environmental conditions, mechanism of illness or injury
       and potential for hazardous conditions
   ♦ Form general impression of patients condition
   ♦ Establish patient responsiveness
           Immobilize spine if cervical or other spine injury suspected
   ♦ Assess airway, breathing, circulation and administer oxygen if needed.
   ♦ Control hemorrhage using direct pressure or a pressure dressing.
   ♦ Assess circulation and perfusion by measuring heart rate, and observing skin color,
       temperature, capillary refill, and the quality of central/peripheral pulses.
   ♦ Measure BP only in children older than 3 years.
   ♦ For children with absent pulses initiate cardiopulmonary resuscitation
   ♦ Evaluate mental status, including pupillary reaction, distal function and sensation, and
       AVPU (alert, verbal, painful, unresponsive) assessment
   ♦ Expose the child only as necessary to perform further assessments. Maintain the child’s
       body temperature throughout the examination.




                                                                           Effective Date: January 1, 2006
Volusia County EMS System Protocols
                                                                                                  300

Trauma – Pediatric Guidelines continued



Advanced Life Support
   ♦ Suction airway as necessary
   ♦ Open and secure airway
   ♦ Obtain and record pulse oximetry reading
   ♦ Assist breathing and ventilation if needed
   ♦ Initiate cardiac monitoring
   ♦ If evidence of shock
              Obtain vascular access
              If IV access is required and it cannot be obtained, place intraosseous needle (IO)
              (this technique is especially useful < 6)
              Fluid bolus of 0.9% NaCl 20-ml/kg set to maximum flow rate.
              Reassess patient after bolus
              If shock persists, repeat bolus X 2 to a maximum total of 60 ml/kg.



    Medical Control
        Call Medical Control for any additional orders or questions




   ♦ If child’s condition is critical or unstable, initiate transport. Perform focused history and
         detailed physical examination en route to the hospital if patient status and management
         of resources permit.
   ♦ Please note that all medication dosages and equipment sizes should be calculated using
         the length based measuring device. Refer to specific protocols for pediatric doses.
   ♦ Reassess the patient frequently.




                                                                            Effective Date: January 1, 2006
  Rev: April 2, 2003
Volusia County EMS System Protocols
                                                                                          301

                     Airway Management–Pediatric
Basic Life Support
   ♦ If suspicion of trauma, maintain C-spine immobilization
   ♦ Suction all debris, secretions form airway
   ♦ Bag valve mask ventilate
   ♦ Administer supplemental oxygen, maintain saturation between 90-100%


Advanced Life Support
   ♦ Apply cardiac monitor and obtain EKG rhythm strip (simultaneously if assistant
      available or following airway management)
   ♦ Begin continuous oxygen saturation monitoring
   ♦ BVM ventilate at least 2 minutes with 100% oxygen so saturation is > 90
   ♦ Follow sequence listed below (use length based measuring device tape to select
      appropriate equipment)




                                                                    Effective Date: January 1, 2006
Volusia County EMS System Protocols
                                                                                              301

Trauma – Pediatric Guidelines continued


               Bag mask ventilate (BVM).
           Goals is to keep oxygen saturation > 90
                            Then
             Choose one of following techniques



                          Continued bagging                             Endotracheal
                                                                         intubation

                                          No success with              Stop if 02 <
                                          One attempt                  90%


                        Bag mask ventilate for 2 minutes
                                                                           success

                           If able to bag, or     If unable to          Confirm with
                           keep saturation        bag or keep sat       ETC02 device
                           90% - Continue         90%
                           bagging                                      Ventilate using
                                                                        ETT
                                                                         NG placement


   ♦ Following intubation with ETT
          Measure end-tidal CO2 (continuously)
          Record depth of ET tube and secure airway
             Consider padding and immobilization to maintain integrity of airway device.
             Record all airway documentation requirements as per Medical Procedures
             Manual (see Documentation Standards)




   Medical Control
      Call Medical Control for any further orders, questions, or assistance.




                                                                        Effective Date: January 1, 2006
Volusia County EMS System Protocols
                                                                                                 302

                  Allergic Reaction/Anaphylaxis–Pediatric

History
   ♦ Exposure, ingestion or contact (stings, drugs, foods, etc.)
   ♦ Prior allergic history
   ♦ Current medications


Symptoms
   ♦ Itching
   ♦ Rash
   ♦ Swelling
   ♦ Respiratory distress*
   ♦ Abdominal pain
   ♦ Nausea, vomiting
   ♦ Syncope
   ♦ Weakness
   ♦ Anxiety
   ♦ Choking sensation*
   ♦ Cough
        *
            Denotes moderate to severe allergic reaction


Signs
   ♦ Vital signs:        Vary (routine or shock*)
   ♦ Skin:               Rash, redness, urticaria (hives), generalized or local edema
   ♦ HEENT:              Tongue or upper airway (uvula) edema*
   ♦ Respiratory:        Wheezing, stridor, hoarseness*, cough, upper airway noise
   ♦ Neurologic:         Varies
        *
            Denotes moderate to severe allergic reaction




                                                                           Effective Date: January 1, 2006
Volusia County EMS System Protocols
                                                                                               302

Allergic Reaction/Anaphylaxis–Pediatric continued


Basic Life Support
   ♦ Establish responsiveness
   ♦ If trauma suspected, stabilize spine
   ♦ Airway/Breathing/Oxygenation
   ♦ Assess perfusion and circulation
   ♦ If evidence of anaphylactic present, administer or assist patient with auto injector


Advanced Life Support
   ♦ Assist breathing/ventilation if needed
   ♦ If patient meets criteria for anaphylaxic shock
          Epinephrine 1:1,000 solution of 0.01 mg/kg SQ (max individual dose 0.3 mg)
   ♦ If breathing adequate, place child in a position of comfort and
          Administer high-flow oxygen 100% with nonrebreather mask or blow-by as
          tolerated
   ♦ Initiate cardiac monitoring and determine rhythm
   ♦ If bronchospasm is present in a patient with adequate ventilation,
          Albuterol (Proventil) 2.5 mg/3 ml via aerosolized
   ♦ If bronchospasm persists,
          Continue Albuterol (Proventil) 2.5 mg/3 ml via aerosolized
   ♦ Reassess patient for signs of anaphylactic shock. If criteria are still present repeat
          Epinephrine 1:1,000 solution at 0.01 mg/kg (Maximum individual dose 0.3 mg)
          via subcutaneous injection.
   ♦ IV 0.9% NaCl KVO or IV lock




                                                                         Effective Date: January 1, 2006
Volusia County EMS System Protocols
                                                                                             302

Allergic Reaction/Anaphylaxis–Pediatric continued

   ♦ If evidence of shock,
          If IV access cannot be obtained and < 6 years, place intraosseous needle (IO).
          Administer fluid bolus of 0.9% NaCl at 20 ml/kg set to maximum flow rate IV or
          IO
          Reassess patient after bolus
          If shock persists, repeat bolus X 2 to a maximum total of 60 ml/kg.
          Reassess patient – if hypotension persists, administer epinephrine 0.1 cc/kg of
          1:10,000 Q 2-3 minutes until response noted (maximum individual dose is 0.1mg).
          If IV access is unavailable, administer via ETT or IO cannula.
          Diphenhydramine (Benadryl) 1.0 mg/kg IV or deep IM (maximum individual
          dose 50 mg)
          Methylprednisolone (SoluMedrol) 2.0 mg/kg IV
   ♦ Expose the child only as necessary to perform further assessments. Maintain the child’s
      body temperature throughout the examination
   ♦ Initiate transport, Perform focused history and detailed physical examination en route to
      the hospital if patient status and management of resources permit
   ♦ Reassess the patient frequently



   Medical Control
      Call Medical Control for any additional orders or questions




                                                                       Effective Date: January 1, 2006
Volusia County EMS System Protocols
                                                                                               303

                      Altered Mental Status–Pediatric
This protocol is intended for pediatric patients with an altered mental status of unknown
etiology.
History
   ♦ Onset (acute vs. gradual)
   ♦ Duration
   ♦ History of trauma
   ♦ Description of scene (pills found, notes, syringes, etc.)
   ♦ Unusual odor in residence or at scene
   ♦ Recent emotional trauma or crisis (including suicidal or homicidal ideation)
   ♦ Drug or alcohol ingestion
   ♦ Toxic exposure
   ♦ Exertion or heat exposure
   ♦ Psychiatric disorders
   ♦ Medical illnesses (diabetes, seizures, etc.)
   ♦ Current medications
   ♦ Allergies


Common Causes
   ♦ Head trauma
   ♦ Drug overdose
   ♦ Seizures
   ♦ CVA
   ♦ Diabetes
   ♦ Other metabolic disorders, such as kidney or liver failure
   ♦ Sepsis
   ♦ Psychiatric illness




                                                                         Effective Date: January 1, 2006
Volusia County EMS System Protocols
                                                                                              303

Altered Mental Status–Pediatric continued


Symptoms
   ♦ Abrupt or bizarre behavior changes
Signs
   ♦ Vital Signs:    Vary
   ♦ Skin:           Needle tracks, cyanosis, diaphoresis
   ♦ HEENT:          Breath odor (alcohol, ketones), pupil size and reactivity
   ♦ Neck:           Suspect c-spine injury in the presence off head trauma; nuchal rigidity
                     (stiff neck)
   ♦ Respiratory:    Abnormal breathing patterns
   ♦ Neurologic:     Decreased level of consciousness, abnormal pupil size, abnormal pupil
                     symmetry and reactivity, seizures, focal deficits, hallucinations
   ♦ Other:          Evidence of trauma, medical alert tag


Basic Life Support
   ♦ Establish responsiveness
   ♦ If trauma suspected, stabilize spine
   ♦ Airway/Breathing/Oxygenation
   ♦ Assess perfusion and circulation




                                                                        Effective Date: January 1, 2006
Volusia County EMS System Protocols
                                                                                                 303

Altered Mental Status–Pediatric continued


Advanced Life Support
   ♦ Assist airway, ventilation if needed
   ♦ If signs or respiratory distress, failure or arrest are present refer to the appropriate
      protocol
   ♦ If breathing adequate, place child in a position of comfort and administer high-flow
      oxygen 100% as necessary. Use a non rebreather mask or blowby as tolerated
   ♦ Initiate cardiac monitoring and determine rhythm
   ♦ IV 0.9% NaCl KVO or IV lock, if IV access cannot be obtained in a child < 6 years
      proceed with IO
          No more than two (2) IV attempts shall be completed.
          Placement of IV should not take longer than 90 seconds




                                                                           Effective Date: January 1, 2006
Volusia County EMS System Protocols
                                                                                              303

Altered Mental Status–Pediatric continued

   ♦ Determine blood glucose and treat glucose < 60 mg/dl
          D10W at 5 ml/kg for neonates
          D25W at 2 ml/kg for a child
          D50W at 1 ml/kg for an adolescent
          IF IV or IO access is unavailable
          Glucagon 0.1 mg/kg IM (Maximum dose 1.0 mg)
   ♦ Repeat Dextrose X 1 if
          Blood glucose remains < 60 mg/dl after treatment
          OR cannot determine blood glucose and no change in mental status
   ♦ If patient has continued altered mental status
          Naloxone at 0.1 mg/kg (Maximum individual dose 2.0 mg) via IV or IO route
          If IV or IO unavailable administer same dose endotracheally or IM
   ♦ If evidence of shock
          If IV access cannot be obtained, and < 6 years place intraosseous needle (IO)
              Fluid bolus 0.9% NaCl at 20 ml/kg (10 ml for neonate)
              If shock persists, repeat bolus X 2 to a maximum total of 60 ml/kg.
   ♦ Expose the child only as necessary to perform further assessments. Maintain the child’s
      body temperature throughout the examination
   ♦ Perform focused history and detailed physical examination en route to the hospital if
      patient status and management of resources permit.
   ♦ Consider causes of altered mental status such as chemical or drug intoxication, toxic
      exposure, head trauma or seizure.
   ♦ Reassess the patient frequently.


   Medical Control
      Call Medical Control for any further orders, questions, or assistance.




                                                                        Effective Date: January 1, 2006
Volusia County EMS System Protocols
                                                                                            304

                           Bronchospasm–Pediatric
History
   ♦ Onset (acute or gradual)
   ♦ Duration
   ♦ Exacerbating or alleviating factors
   ♦ Oral exposure/foreign bodies (toys, drugs, alcohol, food, chemicals, etc.)
   ♦ Trauma
   ♦ Environmental exposure
   ♦ Smoking
   ♦ Medical illnesses (especially COPD, asthma, diabetes, CHF, thrombophlebitis)
   ♦ Current medications
   ♦ Allergies
   ♦ Home oxygen
   ♦ Drug or alcohol use
Common Causes
   ♦ Asthma
   ♦ Acute upper airway obstruction
   ♦ Acute bronchitis, pneumonia
   ♦ Drowning and asphyxiation
   ♦ Epiglottitis
   ♦ Overdose and poisoning
   ♦ Myocardial infarction (MI)
   ♦ CHF
   ♦ Chest trauma
   ♦ Pulmonary edema
   ♦ Diabetic Ketoacidosis
   ♦ Hyperventilation syndrome due to anxiety reaction




                                                                      Effective Date: January 1, 2006
Volusia County EMS System Protocols
                                                                                             304

Bronchospasm–Pediatric continued


Symptoms
   ♦ Chest pain (location, quality, position)
   ♦ Dyspnea
   ♦ Cough
   ♦ Sputum production or change
   ♦ Paresthesia in hands or mouth
   ♦ Calf pain (Homan's Sign)
   ♦ Fever


Signs
   ♦ Vital Signs:      Vary
   ♦ Skin:             Cyanosis, peripheral edema, hives, evidence of neck or chest trauma
   ♦ HEENT:            Upper airway, facial edema, drooling, nasal flaring
   ♦ Respiratory:      Stridor, rales, rhonchi, wheezing, decreased breath sounds, crepitus,
                       subcutaneous emphysema, accessory muscle usage
   ♦ Cardiovascular: Neck vein distention, dysrhythmias
   ♦ Neurologic:       Decreased level of consciousness, restlessness, slurred speech


Basic Life Support
   ♦ Assess airway and breathing
   ♦ Administer supplemental oxygen, maintain saturation between 90-100
   ♦ Assess circulation and perfusion




                                                                       Effective Date: January 1, 2006
Volusia County EMS System Protocols
                                                                                                  304

Bronchospasm–Pediatric continued


Advanced Life Support
   ♦ Open and secure airway
   ♦ Obtain and record pulse oximetry reading
   ♦ Assist breathing/ventilation if needed
   ♦ If breathing adequate, place child in a position of comfort and administer high-flow
      oxygen 100% with nonrebreather mask or blow-by as tolerated
   ♦ If bronchospasm
          Albuterol (Proventil) 2.5 mg/3 ml via aerosolized over 10-15 minutes
          Continue Albuterol (Proventil) 2.5 mg/3 ml via aerosolized every 15 minutes
          (Max 3 treatments)
   ♦ If patient shows signs of respiratory distress or failure with clinical evidence of
      bronchospasm or a history of asthma and inadequate ventilation
          Epinephrine 1:1,000 at 0.01 mg/kg (max 0.3 mg) subcutaneously OR
              May repeat either Albuterol or Epinephrine 2 additional doses (3 total)
              May administer at same time nebulizer is being administered
   ♦ If patient shows signs of severe respiratory distress/failure/arrest
          IV 0.9% NaCl KVO or IV lock
          Methylprednisolone (SoluMedrol) 2.0 mg/kg IV




   Medical Control
      Call Medical Control for any further orders, questions, or assistance.




                                                                            Effective Date: January 1, 2006
Volusia County EMS System Protocols
                                                                                              305

                                    Burns–Pediatric

History
   ♦ Description of scene (lines/piping, pooling of chemicals around victim, victim
        immersed in agent, spurting agents from containers, toxic fumes/vapors, etc.)
   ♦ Type of chemical (acid, alkali, mixed, other, unknown)
   ♦ Duration of exposure
   ♦ Time since exposure
   ♦ Medical illnesses
   ♦ Current medications
   ♦ Allergies


Symptoms
   ♦ Skin pain
   ♦ Eye irritation or pain
   ♦ Excessive tearing
   ♦ Difficulty breathing


Signs
   ♦ Vitals Signs: Vary
   ♦ Skin:            Description and extent of involved areas; burn depth
   ♦ HEENT:           Eye redness
   ♦ Respiratory:     Cough, stridor, wheezing, respiratory distress
   ♦ Neurologic:      Seizures




                                                                        Effective Date: January 1, 2006
Volusia County EMS System Protocols
                                                                                              305

Burns–Pediatric continued


Basic Life Support
   ♦ Stop the burning process
          If dry chemical involved, brush it off, then flush with copious amounts water.
          Do not use water to flush the following chemicals
              Elemental metals (sodium, potassium, lithium)
              ♦ Remove obvious metallic fragments from skin
              ♦ Cover the burn with mineral oil or cooking oil (if readily available)
              Phenols penetrate the skin more readily when diluted with water
              ♦ Dilute with the following agents (listed in order of efficacy)
                     Polyethylene glycol (PEG), or Glycerol or Vegetable oil or
                     As a last resort use extremely large amounts of soap and water with
                     continuous irrigation until all phenols are removed
          If a caustic liquid is involved, flush with copious amounts of water
   ♦ Remove all clothing prior to irrigation and be prepared to treat hypothermia
   ♦ For chemical burns with eye involvement, immediately begin flushing the eye with
      normal saline and continue throughout assessment and transport
   ♦ Establish patient responsiveness and stabilize spine if suspicion of trauma
   ♦ Assess airway/breathing/oxygenation, circulation, perfusion and mental status
   ♦ Apply a burn sheet or dry sterile dressing to burn areas. Avoid moist, or cool dressing
      and do not leave wounds or skin exposed


Advanced Life Support
   ♦ Open and secure airway
   ♦ Obtain and record pulse oximetry reading
   ♦ Assist breathing and ventilation if needed
   ♦ If breathing adequate, place child in a position of comfort and administer high-flow
      oxygen 100% with nonrebreather mask or blow-by as tolerated




                                                                        Effective Date: January 1, 2006
Volusia County EMS System Protocols
                                                                                             305

Burns–Pediatric continued

   ♦ Initiate cardiac monitoring
   ♦ IV 0.9% NaCl KVO or IV lock
          Do not let this delay transport time and obtain enroute if needed
   ♦ If evidence of shock,
          If IV access cannot be obtained, and < 6 years place intraosseous needle.
          Administer fluid bolus of 0.9% NaCl at 20 ml/kg.
          Reassess patient after bolus
          If shock persists, repeat bolus X 2 to a maximum total of 60 ml/kg.
   ♦ Perform focused history and detailed physical examination enroute to the hospital
   ♦ Initiate transport to a SATC (State Certified Trauma Center) if patient meets Trauma
      Alert criteria
   ♦ Administer appropriate analgesic if needed
          Morphine Sulfate 0.1 mg/kg IV for severe pain if
              Systolic BP is > 70 + age X 2 AND no signs of shock (normal cap refill)
              No allergy and No airway or breathing difficulty



   Medical Control
      Repeated administration of Morphine sulfate




                                                                       Effective Date: January 1, 2006
Volusia County EMS System Protocols
                                                                                        306(a)

                        Cardiac Arrhythmia–Pediatric

                                     Bradycardia

Basic Life Support
   ♦ Establish responsiveness
   ♦ If spine trauma suspected stabilize spine
   ♦ Administer supplemental oxygen, maintain saturation between 90-100%
   ♦ Look for signs of obstruction
          Absent breath sounds, tachypnea, intercostal retractions, stridor or drooling,
          choking, bradycardia or cyanosis
   ♦ If foreign body obstruction is suspected refer to foreign body protocol
   ♦ Open airway using head tilt/chin lift if no spinal trauma is suspected and modified jaw
      thrust if spinal trauma suspected
   ♦ Assess circulation and perfusion


Advanced Life Support
   ♦ Open and secure airway
   ♦ Obtain and record pulse oximetry reading
   ♦ Assist breathing and ventilation
   ♦ Initiate cardiac monitoring and determine rhythm
   ♦ If signs of severe cardiopulmonary compromise are present in an infant (< 1 year) or
      neonate and the heart rate remains slower than 60 beats per minute despite oxygenation
      and ventilation
          Initiate chest compressions




                                                                        Effective Date: January 1, 2006
Volusia County EMS System Protocols
                                                                                         306(a)

Cardiac Arrhythmia–Pediatric continued

   ♦ If signs of severe cardiopulmonary compromise
          IV 0.9% NaCl KVO or IV lock
          If unable to establish IV, and < 6 years old, establish intraosseous access
          Do not delay transport to establish access
   ♦ Check blood glucose and treat glucose < 60 mg/dl
          D10W at 5 ml/kg IV for neonates
          D25W at 2 ml/kg IV for a child
          D50W at 1 ml/kg IV for an adolescent
   ♦ If signs of severe cardiopulmonary compromise persist;
          Please note that all medication dosages and equipment sizes should be calculated
          using the length based measuring device. Refer to specific protocols for pediatric
          doses.
          Reassess the patient frequently.
          Epinephrine 1:10,000 at 0.01 mg/kg (Max 1 mg) via IV/IO
          Or Epinephrine 1:1,000 at 0.1 mg/kg (Max 10 mg) diluted in 5 ml of NaCl via
          endotracheal tube and administer 5 manual ventilations after drug given.
          Use first route available
          Repeat dose every 3-5 minutes until either the bradycardia or severe
          cardiopulmonary compromise resolves
   ♦ Identify and treat possible causes of bradycardia
          If hypoxia open airway, assist breathing
          If hypothermic, rewarm
          If acutely deteriorating head injury, hyperventilate
          If heart block or post heart transplant, apply external transcutaneous pacer
          If toxin ingestion, see specific toxin




                                                                         Effective Date: January 1, 2006
Volusia County EMS System Protocols
                                                                                         306(a)

Cardiac Arrhythmia–Pediatric continued

   ♦ If signs of severe cardiopulmonary compromise persist despite epinephrine and above
      measures
          Atropine at 0.02 mg/kg via IV, IO, or Endotracheal tube (if given via ETT dilute
          in 5 ml of 0.9% NaCl and administer 5 ventilations after drug given)
              Minimum dose is 0.1 mg
              Maximum individual dose is 0.5 mg for a child and 1.0 mg for adolescent
              May repeat once after 3-5 minutes until maximum dose reached.
   ♦ If severe cardiopulmonary compromise persists despite epinephrine/atropine
          If weight is > 15 kilograms apply adult external pacemaker.
          If <15 kilograms use pediatric (small/medium electrodes) in the same configuration
          as per the <15-kilogram patient.
   ♦ If severe cardiopulmonary compromise persists despite pacing
          Dopamine infusion at 5-20 mcg/kg/minute IV
   ♦ If child’s condition is critical or unstable, initiate transport. Perform focused history and
      detailed physical examination enroute to the hospital if patient status and management
      of resources permit.
   ♦ If the child’s condition is stable, perform focused history and detailed physical
      examination on the scene, then initiate transport.
   ♦ Reassess the patient frequently.



   Medical Control
      Repeated administration of Epinephrine
      Repeated administration of Atropine




                                                                         Effective Date: January 1, 2006
Volusia County EMS System Protocols
                                                                                       306(a)

Cardiac Arrhythmia–Pediatric continued

   ♦ Please note that all medication dosages and equipment sizes should be calculated using
      the length based measuring device. Refer to specific protocols for pediatric doses.
   ♦ Reassess the patient frequently.




                                                                       Effective Date: January 1, 2006
Volusia County EMS System Protocols
                                                                                       306(b)

Cardiac Arrhythmia–Pediatric continued

                                Tachycardia
Basic Life Support
   ♦ Establish patient responsiveness
   ♦ Administer supplemental oxygen, maintain saturation between 90-100%
   ♦ If trauma suspected, stabilize spine
   ♦ Assess circulation and perfusion


Advanced Life Support
   ♦ Assist airway, ventilation if needed
   ♦ If breathing adequate, place child in a position of comfort and administer high-flow
      oxygen 100% with nonrebreather mask or blow-by as tolerated
   ♦ Initiate cardiac monitoring and determine rhythm
   ♦ IV 0.9% NaCl KVO or IV lock
          If IV cannot be obtained in a child ≤ 5 years old AND the patient shows signs of
          severe cardiopulmonary compromise, proceed with intraosseous access
          Do not delay transport to obtain vascular access
   ♦ Check blood glucose and treat glucose < 60 mg/dl
          D10W at 5 ml/kg IV for neonates
          D25W at 2 ml/kg IV for a child
          D50W at 1 ml/kg IV for an adolescent
   ♦ Sinus tachycardia
          Identify and treat possible causes.




                                                                      Effective Date: January 1, 2006
Volusia County EMS System Protocols
                                                                                          306(b)

Cardiac Arrhythmia–Pediatric continued

Supraventricular tachycardia with severe cardiopulmonary compromise
          Synchronized Cardioversion at 0.5-1.0 joules/kg
          See Medical Control box for possible sedation orders
          May repeat at double the energy to maximum of 4 joules/kg (max individual dose
          360 joules)
   ♦ Supraventricular tachycardia without severe cardiopulmonary compromise
          If vascular access is readily available AND if the patient has adequate perfusion
              Administer Adenosine 0.1mg/kg rapid IV bolus and immediately flush with 5cc
              of saline
   ♦ Ventricular tachycardia with a pulse
          If vascular access is readily available AND if the patient has adequate perfusion
              Administer Adenosine 0.1mg/kg rapid IV bolus and immediately flush with 5cc
              of saline
          If vascular access is not readily available AND the patient is poorly perfused
              Synchronized Cardioversion at 0.5 – 1.0 J/kg
              See Medical Control box for possible sedation orders
              If Ventricular Tachycardia persists, administer 1.0-2.0 J/kg (max 360 J)
   ♦ If torsades de pointes is suspected
          Magnesium Sulfate 2 Gm slow IV in 50 cc NS over 30 seconds (10 cc for
          neonate).
   ♦ Assess mental status
   ♦ If child’s condition is critical or unstable, initiate transport. Perform focused history and
       detailed physical examination en route to the hospital if patient status and management
       of resources permit.
   ♦ If the child’s condition is stable perform focused history and detailed physical
       examination on the scene, then initiate transport.
   ♦ Reassess the patient frequently.

    Medical Control
    Sedate the patient before Cardioversion as permitted by Medical Direction
       Diazepam (Valium) 0.2 mg/kg IV (Maximum individual dose 5.0 mg)

                                                                         Effective Date: January 1, 2006
Volusia County EMS System Protocols
                                                                                              307

               Cardiac Arrest/Non Traumatic–Pediatric

Basic Life Support
   ♦ Establish patient responsiveness
   ♦ If spine trauma suspected, stabilize spine
   ♦ Confirm apnea and pulselessness and administer CPR
   ♦ Apply AED as soon as available for > 8 years old


Advanced Life Support
   ♦ Confirm apnea and provide ventilation using bag valve mask device with high flow
      oxygen 100%
   ♦ Confirm absent pulse and begin chest compressions
   ♦ Initiate cardiac monitoring and determine rhythm
   ♦ Refer to appropriate protocol for further management actions
          Ventricular fibrillation/Pulseless Ventricular Tachycardia
          Asystole
          PEA
   ♦ Obtain Glucometer reading and treat if glucose < 60 mg/dl
          D10W at 5 ml/kg IV for neonates
          D25W at 2 ml/kg IV for a child
          D50W at 1 ml/kg IV for an adolescent
   ♦ IV 0.9% NaCl KVO, if no IV access available & < 6 year old obtain intraosseous
      access


   Medical Control
      Call Medical Control for any further orders, questions, or assistance.




                                                                        Effective Date: January 1, 2006
Volusia County EMS System Protocols
                                                                                          307(a)

Cardiac Arrest/Non Traumatic–Pediatric continued

                                     Asystole

Basic Life Support
   ♦ Establish patient responsiveness
   ♦ If spine trauma suspected, stabilize
   ♦ Confirm apnea and pulselessness and administer CPR
   ♦ Apply AED as soon as available for > 8 years old


Advanced Life Support
   ♦ Follow Nontraumatic Cardiac Arrest Protocol
   ♦ Confirm the presence of Asystole in two leads
   ♦ IV 0.9% NaCl KVO, if IV access unavailable & < 6 y old obtain IO access
   ♦ Using the most readily available route, administer
          Epinephrine 1:1,000 solution of 0.1 mg/kg endotracheal (Max. of 10 mg)
          Or Epinephrine 1:10,000 of 0.01 mg/kg IV or IO
          Repeat Epinephrine at 0.1 mg/kg ETT, IV, or IO every 3 to 5 min.
          Flush medication port with 10-20 ml of normal saline after each dose
   ♦ Initiate transport
   ♦ Expose the child only as necessary to perform further assessments. Maintain the child’s
      body temperature throughout the examination
   ♦ Perform focused history and detailed physical examination en route to the hospital if
      patient status and management of resources permit.
   ♦ See termination of resuscitation protocol if > 15 minutes of Asystole

  Medical Control
     Call Medical Control for any further orders, questions, or assistance.




                                                                        Effective Date: January 1, 2006
Volusia County EMS System Protocols
                                                                                     307(b)

Cardiac Arrest/Non Traumatic–Pediatric continued

                             Pulseless Electrical Activity

Basic Life Support
   ♦ Establish patient responsiveness
   ♦ If trauma suspected, stabilize spine
   ♦ Confirm apnea and pulselessness and administer CPR
   ♦ Apply AED as soon as available for > 8 years old


Advanced Life Support
   ♦ Follow Nontraumatic Cardiac Arrest Protocol
   ♦ Treat suspected cause of PEA if known
          If hypovolemia administer 0.9% NaCl 20 ml/kg IV, may repeat X 2 (to a
          maximum total of 60 ml/kg)
          If hypoxia, open airway and assist breathing
          If hypothermia, rewarming
          If hyperkalemia
              Calcium chloride (10%), 0.3 ml/kg IV (Max 5 ml), and
              Sodium Bicarbonate 1 mEq/kg IV
          If toxin ingestion, see specific toxin section
          If tension pneumothorax (severe cardiopulmonary compromise)
              Needle thoracostomy




                                                                     Effective Date: January 1, 2006
Volusia County EMS System Protocols
                                                                                        307(b)

Cardiac Arrest/Non Traumatic–Pediatric continued

   ♦ If PEA persists, using the most readily available route
          Epinephrine 1:10,000 of 0.01 mg/kg IV or IO
          Repeat Epinephrine 1:1000 at 0.1 mg/kg either ETT, IV, or IO every 3 to 5
          minutes (readdress dosing for subsequent doses)
          Flush medication port with 10-20 ml of normal saline after each dose
   ♦ Initiate transport
   ♦ Expose the child only as necessary to perform further assessments. Maintain the child’s
      body temperature throughout the examination
   ♦ Perform focused history and detailed physical examination en route to the hospital if
      patient status and management of resources permit.
   ♦ Reassess the patient frequently.



  Medical Control
     Call Medical Control for any further orders, questions, or assistance.




                                                                        Effective Date: January 1, 2006
Volusia County EMS System Protocols
                                                                                         307(c)

Cardiac Arrest/Non Traumatic–Pediatric continued

         Ventricular Fibrillation or Pulseless Ventricular Tachycardia


Basic Life Support
   ♦ Establish patient responsiveness
   ♦ If spinal trauma suspected, stabilize
   ♦ Confirm apnea and pulselessness and administer CPR
   ♦ Apply AED as soon as available for > 8 years old


Advanced Life Support
   ♦ Follow Nontraumatic Cardiac Arrest Protocol
   ♦ Confirm the presence of ventricular fibrillation/pulseless ventricular tachycardia
   ♦ Defibrillate at 2.0 j/kg (maximum of 200 joules) or equivalent biphasic
   ♦ Defibrillate at 4.0 j/kg (maximum of 360 joules) or equivalent biphasic
   ♦ Defibrillate at 4.0 j/kg (maximum of 360 joules) or equivalent biphasic
   ♦ Using the most readily available route
          Epinephrine 1:10,000 of 0.01 mg/kg IV or IO
          Or Epinephrine 1:1,000 solution of 0.1 mg/kg Endotracheal (max 10 mg)
          Repeat Epinephrine at 0.1 mg/kg ETT, IV, or IO every 3 to 5 min.
          Flush medication port with 10-20 ml of normal saline after each dose
   ♦ Defibrillate at 4.0 J/kg within 30-60 seconds after each medication bolus
   ♦ Lidocaine 1 mg/kg ET if no IV/IO available
   ♦ Magnesium 50 mg/kg IVP/IO over 1-2 minutes for torsades de pointes or
      hypomagnesaemia
   ♦ Defibrillate at 4.0 J/kg within 30-60 seconds after each medication
   ♦ IF VF or pulseless VT reoccurs after successful defibrillation, repeat defibrillation
      using the last energy level that restored perfusing rhythm




                                                                        Effective Date: January 1, 2006
Volusia County EMS System Protocols
                                                                                         307(c)

Cardiac Arrest/Non Traumatic–Pediatric continued

   ♦ Expose the child only as necessary to perform further assessments. Maintain the child’s
      body temperature throughout the examination
   ♦ Perform focused history and detailed physical examination en route to the hospital if
      patient status and management of resources permit
   ♦ Reassess the patient frequently.


   Medical Control
      Call Medical Control for any further orders, questions, or assistance.




                                                                        Effective Date: January 1, 2006
Volusia County EMS System Protocols
                                                                                        307(c)

Cardiac Arrest/Non Traumatic–Pediatric continued

   ♦ Please note that all medication dosages and equipment sizes should be calculated using
      the length based measuring device. Refer to specific protocols for pediatric doses.
   ♦ Reassess the patient frequently.




                                                                       Effective Date: January 1, 2006
Volusia County EMS System Protocols
                                                                                                  308

        Drowning/Near-Drowning/Submersion-Pediatric

Basic Life Support
   ♦ Establish responsiveness
   ♦ If trauma suspected, stabilize spine
   ♦ Administer supplemental oxygen, maintain saturation between 90-100%
   ♦ Assess perfusion and circulation
   ♦ Assess mental status


Advanced Life Support
   ♦ Assist airway, breathing/ventilation if needed
   ♦ If breathing adequate, place child in a position of comfort and administer high-flow
      oxygen 100% with nonrebreather mask or blow-by as tolerated
   ♦ Initiate cardiac monitoring and determine rhythm
          Consult the appropriate protocol for treatment of specific dysrhythmias
   ♦ IV 0.9% NaCl KVO or IV lock
   ♦ Expose the child only as necessary to perform further assessments. Maintain the
      child’s body temperature throughout the examination
   ♦ If the child’s condition is critical or unstable, initiate transport
   ♦ Perform focused history and detailed physical examination enroute to the hospital if
      patient status and management of resources permit
   ♦ Reassess the patient frequently




    Medical Control
        Call Medical Control for any further orders, questions, or assistance.




                                                                            Effective Date: January 1, 2006
Volusia County EMS System Protocols
                                                                                             309

           Foreign Body Airway Obstruction-Pediatric

Basic Life Support
   ♦ Confirm patient is unresponsive
   ♦ Open airway using a head tilt/chin lift (if no trauma)
   ♦ If < 1 year old, administer up to 5 back blows and 5 chest thrusts
   ♦ If < 8 years, administer abdominal thrusts until foreign body dislodged -
   ♦ After foreign body dislodged, assess circulation and perfusion
   ♦ Assess mental status
   ♦ Expose the child only as necessary to perform further assessments
   ♦ Maintain the child’s body temperature through the examination
   ♦ Attempt assisted ventilation using a bag valve mask device with high flow, 100%
      oxygen


Advanced Life Support
   ♦ If unsuccessful (perform each step in order, if unsuccessful advance to next step)
          Reposition airway and attempt bag valve mask assisted ventilation again.
          Establish direct view of object and attempt to remove it with Magill forceps
          Secure airway using laryngeal mask airway, or endotracheal tube
   ♦ Initiate transport and perform focused history and detailed physical examination
      enroute to the hospital if patient status and management of resources permit
   ♦ Reassess the patient frequently


    Medical Control
       Call Medical Control for any further orders, questions, or assistance.




                                                                       Effective Date: January 1, 2006
Volusia County EMS System Protocols
                                                                                                310

                             Newborn Resuscitation

Basic Life Support
   ♦ Note term gestation, and if twin gestation is known
   ♦ Assess for presence of meconium
   ♦ Assess breathing or presence of crying
   ♦ Assess muscle tone
   ♦ Assess color
   ♦ Provide warmth
   ♦ Position and clear airway
   ♦ Dry, stimulate and reposition
   ♦ Administer supplemental oxygen, maintain saturation between 90-100%
   ♦ Evaluate respirations, heart rate, and color
          If apnea, or HR < 100, provide positive-pressure ventilations
          If HR remains < 60, administer chest compressions
   ♦ Note APGAR scores at 1 and 5 minutes after birth and then sequentially every 5
      minutes until VS have stabilized


Advanced Life Support
   ♦ If the fluid contains meconium and the newborn has absent or depressed respirations,
      decreased muscle tone, or heart rate < 100 bpm,
          Perform direct laryngoscope immediately after birth for suctioning of residual
          meconium from the hypopharynx (under direct vision) and intubation/suction of the
          trachea
              Perform endotracheal intubation
              ♦ Apply suction directly to the endotracheal tube as it is withdrawn from the
                    airway




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Newborn Resuscitation continued

             Repeat intubation and suctioning X 1
             ♦ Apply positive pressure ventilation and do not re-intubate if patient with
                 severe respiratory failure or apnea or difficult intubation
             ♦ Avoid tracheal suctioning of the vigorous newborn with meconium-stained
                 fluid, unless the newborn develops apnea or respiratory distress
             If the vigorous newborn with meconium-stained fluid develops apnea or
             respiratory distress, perform tracheal suctioning before positive-pressure
             ventilation
   ♦ If apnea, or HR < 100, provide positive-pressure ventilations
          If HR remains < 60, administer chest compressions
          IV 0.9% NaCl KVO or IV lock
          If no IV access obtained after 2 attempts, or within 90 sec., obtain IO access
          Naloxone (Narcan) 0.1 mg/kg, IV or IO if respiratory depression in a newborn of a
          mother who received narcotics within 4 hours of delivery
          Repeat Naloxone (Narcan) dose as needed
          Epinephrine 0.1 to 0.3 cc/kg IV of a 1:10,000 solution
          Repeat Epinephrine (same dose) every 3 to 5 minutes as indicated
          Rapid transportation
   ♦ If no apnea, and HR > 100
          Clear airway
          Dry
          Provide warmth
          Apply cardiac monitor




    Medical Control
       Call Medical Control for any further orders, questions, or assistance.




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Newborn Resuscitation continued

                             Precipitous Newborn Delivery


   ♦ If meconium-stained fluid present
           Suction the mouth, pharynx, and nose as soon as the head is delivered
          Use either a large bore suction catheter (12F to 14F) or a bulb syringe
   ♦ See newborn resuscitation above after delivery
   ♦ Note APGAR scores at 1 and 5 minutes after birth and then sequentially every 5
      minutes until VS have stabilized
   ♦ Notify the closest appropriate receiving facility as early as possible so they can
      assemble their resuscitation team.




    Medical Control
       Call Medical Control for any further orders, questions, or assistance.




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Newborn Resuscitation continued




    Medical Control
       Call Medical Control for any further orders, questions, or assistance.




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                                Abandoned Neonate
Florida statue 383.50 allows for new parents to anonymously leave a neonate at a fire
station or a hospital.


    ♦ Assess neonate per neonatal/pediatric resuscitation protocols
    ♦ Transport neonate to nearest ED
    ♦ If possible record any physical description of parent (if available)
    ♦ Parents may leave behind information regarding medical, and social history regarding
        the newborn
            Attempt to obtain and record this history
            If any written information available bring with patient to the ED



  Medical Control
      Call Medical Control for any further orders, questions, or assistance.




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            Overdose, Poisoning, or Ingestion-Pediatric

Basic Life Support
   ♦ Establish responsiveness
   ♦ If trauma suspected, stabilize spine
   ♦ Administer supplemental oxygen, maintain saturation between 90-100%
   ♦ Assess perfusion and circulation


Advanced Life Support
   ♦ Assist airway, ventilation if needed
   ♦ If signs or respiratory distress, failure or arrest are present refer to the appropriate
      protocol.
   ♦ If breathing adequate, place child in a position of comfort
          Administer high-flow oxygen 100% with nonrebreather mask or blow-by as
          tolerated.
          Initiate cardiac monitoring and determine rhythm
          IV 0.9% NaCl KVO or IV lock
   ♦ If respiratory depression is present and a narcotic overdose is suspected,
          Administer Naloxone at 0.1 mg/kg (Maximum dose 2.0 mg) via IV, IO, or IM
          route
   ♦ Treatment for specific toxic exposures:
          Organophosphates
              High dose Atropine (goal is to improve respiratory difficulty and decrease
              secretions) Atropine 0.02 mg/kg IV (minimum dose 0.1 mg)
   ♦ Tricyclic overdose WITH hypotension OR arrhythmia OR wide QRS complex
          Sodium Bicarbonate 1 mEq/kg IV
              May be repeated in 10 minutes




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Overdose, Poisoning, or Ingestion-Pediatric continued

           Calcium channel and B-blocker overdose
               Atropine 0.02 mg/kg (minimum dose 0.1 mg) for symptomatic bradycardia, if
               inadequate response
               Calcium Chloride 0.3 ml/kg slow IV over 2 minutes for calcium channel
               blocker overdose
           Dystonic reactions – acute uncontrollable muscle contractions
               Diphenhydramine (Benadryl) 1 mg/kg) IV or deep IM (Maximum dose 50
               mg)
           Insulin overdose with hypoglycemia or unknown blood glucose and altered mental
           status
               Treat glucose < 60 mg/dl
               ♦ D10W at 5 ml/kg IV for neonates
               ♦ D25W at 2 ml/kg for IV for a child
               ♦ D50W at 1 ml/kg IV for an adolescent
   ♦ Expose the child only as necessary to perform further assessments. Maintain the
       child’s body temperature throughout the examination
   ♦ If the child’s condition is critical or unstable, initiate transport.
   ♦ Perform focused history and detailed physical examination en route to the hospital if
       patient status and management of resources permit.
   ♦ Reassess the patient frequently.



    Medical Control
        Call Medical Control for questions concerning individual toxic exposures and
    treatments.




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                          Pain Management-Pediatric

Basic Life Support
   ♦ Establish responsiveness
   ♦ If trauma suspected, stabilize spine
   ♦ Administer supplemental oxygen, maintain saturation between 90-100%
   ♦ Assess perfusion and circulation
   ♦ Assess mental status


Advanced Life Support
   ♦ Assist airway, ventilation if needed
   ♦ If signs or respiratory distress, failure or arrest are present refer to the appropriate
       protocol
   ♦ If breathing adequate, place child in a position of comfort and administer high-flow
       oxygen 100% with nonrebreather mask or blow-by as tolerated
   ♦ Obtain baseline blood pressure
   ♦ Initiate cardiac monitoring and determine rhythm
   ♦ IV 0.9% NaCl KVO or IV lock
   ♦ If the child’s condition is critical or unstable, initiate transport.
   ♦ Perform a focused history and detailed physical examination en route to the hospital if
       patient status and management of resources permit.
   ♦ If the child’s condition is stable, perform focused history and detailed physical
       examination on the scene, then initiate transport.
   ♦ Analgesic agents may be administered if patient has severe pain and one of following
           Isolated extremity injury
           Burn without airway, breathing, or circulatory compromise
           Typical sickle cell crisis for patient




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Pain Management-Pediatric continued

   ♦ Agents for pain control
          Morphine Sulfate 0.1 mg/kg IV or SC (Maximum individual dose 10 mg)
   ♦ After drug administration
          Reassess the patient’s pain
          Note adequacy of ventilation and perfusion
   ♦ Reassess the patient frequently



    Medical Control
       Call Medical Control for questions concerning control in children not meeting
       above criteria.




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       Respiratory Distress, Failure, or Arrest-Pediatric

Basic Life Support
   ♦ Establish responsiveness
   ♦ If spine trauma suspected stabilize spine
   ♦ Assess patient airway for patency, protective reflexes and need for advanced
      management
   ♦ Look for signs of airway obstruction
   ♦ If foreign body obstruction is suspected refer to foreign body protocol
   ♦ Open airway using head tilt/chin lift if no spinal trauma is suspected and modified jaw
      thrust if spinal trauma suspected


Advanced Life Support
   ♦ Open and secure airway
   ♦ If partial airway obstruction
          Do nothing to upset the child
          Perform critical assessments only
          Have parent administer blow by oxygen
          Place patient in position of comfort
          Do not obtain vascular access
   ♦ If complete airway obstruction, or respiratory distress, failure, or arrest
          Assist breathing/ventilation
          If unable to ventilate, refer to foreign body protocol
   ♦ Obtain and record pulse oximetry reading
   ♦ If bronchospasm is present refer to bronchospasm protocol




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Respiratory Distress, Failure, or Arrest-Pediatric continued

   ♦ Initiate cardiac monitoring
   ♦ If patient shows signs of severe respiratory failure/arrest,
           IV 0.9% NaCl KVO
   ♦ Initiate transport and perform focused history and detailed physical examination en
       route to the hospital if patient status and management of resources permit.
   ♦ Reassess the patient frequently



     Medical Control
        Contact Medical Control for and further orders, questions, or assistance.




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                                  Seizures-Pediatric

Basic Life Support
   ♦ Establish responsiveness
   ♦ If trauma suspected, stabilize spine
   ♦ Administer supplemental oxygen, maintain saturation between 90-100%
   ♦ Assess perfusion and circulation
Advanced Life Support
   ♦ Assist airway, ventilation if needed
   ♦ If signs of respiratory distress, failure or arrest refer to the appropriate protocol.
   ♦ If breathing adequate, place child in a position of comfort and administer high-flow
      oxygen 100% with nonrebreather mask or blow-by as tolerated.
   ♦ Initiate cardiac monitoring and determine rhythm
   ♦ IV 0.9% NaCl KVO or IV lock
          If IV access cannot be obtained administer anticonvulsants via rectal route
   ♦ Determine blood glucose and treat if glucose < 60 mg/dl
          D10W IV or IO at 5 ml/kg for neonates
          D25W IV or IO at 2 ml/kg for a child
          D50W IV or IO at 1 ml/kg to an adolescent
   ♦ Repeat dextrose X 1 if Blood glucose remains < 60 mg/dl after treatment
          OR cannot determine blood glucose and no change in mental status.
   ♦ If IV access cannot be obtained, administer Glucagon 0.1 mg/kg IM (Maximum dose
      1.0 mg)
   ♦ Administer anticonvulsants IV slowly over 1-2 minutes if patient in status epilepticus,
      more than 10 minute seizure, or > 1 seizure without awakening
          Be prepared for respiratory depression
          Diazepam (Valium) 0.2 mg/kg IV (Max. individual dose 5 mg)
          Diazepam (Valium) 0.5 mg/kg rectal (Max. individual dose 10 mg) if no IV




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Seizures-Pediatric continued

   ♦ If seizures persist, repeat any listed anticonvulsant at same dose
   ♦ Expose the child only as necessary to perform further assessments. Maintain the
      child’s body temperature throughout the examination
   ♦ Perform focused history and detailed physical examination en route to the hospital if
      patient status and management of resources permit.
   ♦ Consider causes of altered mental status such as chemical or drug intoxication, toxic
      exposure, head trauma or seizure.
   ♦ Reassess the patient frequently.




    Medical Control
       Contact Medical Control for and further orders, questions, or assistance.




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                        Shock (Non traumatic)-Pediatric

Basic Life Support
   ♦ Establish responsiveness
   ♦ If trauma suspected, stabilize spine
   ♦ Administer supplemental oxygen, maintain saturation between 90-100%
   ♦ Assess perfusion and circulation


Advanced Life Support
   ♦ Assist airway, ventilation if needed
   ♦ If signs of respiratory distress, failure or arrest are present refer to the appropriate
       protocol
   ♦ If breathing adequate, place child in a position of comfort and administer high-flow
       oxygen 100% with nonrebreather mask or blow-by as tolerated
   ♦ Initiate cardiac monitoring and determine rhythm
   ♦ IV 0.9% NaCl KVO or IV lock
           If IV access cannot be obtained and patient in shock, proceed with IO access if < 6
           years
If evidence of shock,
           If IV access cannot be obtained, place intraosseous needle.
           Fluid bolus of NS at 20 ml/kg set to maximum flow rate IV or IO.
           Reassess patient after bolus
           If shock persists, repeat bolus X 2 to a maximum total of 60 ml/kg
   ♦ Expose the child only as necessary to perform further assessments. Maintain the
       child’s body temperature throughout the examination
   ♦ Initiate transport, perform focused history and detailed physical examination en route to
       the hospital if patient status and management of resources permit.




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Shock (Non traumatic)-Pediatric continued

   ♦ Reassess the patient frequently.



    Medical Control
       Contact Medical Control for and further orders, questions, or assistance.




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                                Trauma-Pediatric

Basic Life Support
   ♦ Establish patient responsiveness
   ♦ Stabilize spine
   ♦ Assess airway and breathing
          Use modified jaw thrust (chin lift is contraindicated) if obstruction
          Administer supplemental oxygen, maintain saturation between 90-100%
   ♦ Control hemorrhage using direct pressure or pressure dressing
   ♦ Assess circulation and perfusion exposing patient so injuries can be identified
   ♦ Assess mental status
   ♦ Splint obvious fractures of long bones
   ♦ Maintain normal body temperature


Advanced Life Support
   ♦ Open and secure airway, assist ventilation and breathing
   ♦ Obtain and record pulse oximetry reading
   ♦ If unilateral absent breath sounds with hypotension, or signs of severe respiratory
      distress are noted with a mechanism of injury that could cause a tension pneumothorax
          Perform needle decompression procedure
   ♦ Initiate cardiac monitoring
   ♦ Initiate transport to an appropriate trauma facility no more than 10 minutes after
      arriving on the scene unless extenuating circumstances (extrication)
   ♦ IV 0.9% NaCl KVO or IV lock
          Do not let this delay scene time and obtain in route if needed




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Trauma-Pediatric continued

   ♦ If evidence of shock,
          If IV access cannot be obtained, place intraosseous needle (IO)(this technique is
          especially useful < 6 years but may be used if older)
          Fluid bolus of 0.9% NaCl at 20 ml/kg
          Reassess patient after bolus
          If shock persists, repeat bolus X 2 to a maximum total of 60 ml/kg
   ♦ Perform focused history and detailed physical examination en route to the hospital if
      patient status and management of resources permit
   ♦ Reassess patient frequently



    Medical Control
       Contact Medical Control for and further orders, questions, or assistance.




                                                                       Effective Date: January 1, 2006
Volusia County EMS System Protocols



                            Procedural Protocols



MUST CONTACT MEDICAL CONTROL BEFORE PERFORMING ANY
OF THE FOLLOWING PROCEDURES:


                            FEMORAL VENIPUNCTURE


                          SUBCLAVIAN VENIPUNCTURE


                      INTERNAL JUGULAR VENIPUNCTURE


                              PERICARDIOCENTESIS




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Procedural Protocols continued

                    Automatic External Defibrillator (AED) Use



PURPOSE
   ♦ This protocol has been established to provide a guideline for the First Responder to
      quickly and efficiently apply and operate the Automatic External Defibrillator.


BACKGROUND
   ♦ Studies have proven the importance of rapid defibrillation for the patient in cardiac
      arrest.


CERTIFICATION REQUIREMENTS
   ♦ Fire Department First Responders must successfully complete a DOT-approved First
      Responder course consisting of a minimum of 40 hours training and in addition,
      successfully complete the six (6) hour Volusia County (FL-state approved) training
      program. Certified in Heart Start AED or equivalent.
   ♦ First Responders must be certified in CPR prior to taking this course. CPR certification
      must remain current to operate a SAED.


ELIGIBLE CANDIDATES FOR AED USE
   ♦ Patients weighing more than eighty (80) pounds and greater than eight (8) years of age,
      pulseless and apneic.




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Procedural Protocols continued



INELIGIBLE CANDIDATES FOR AED USE
      -       Patients weighing less than 25 kg
      -       Patients who are less than 8 years of age
      -       Patients who are breathing.
      -       Patients with a carotid pulse.
      -       Patients who are conscious and/or have a pulse.


PROCEDURE


   ♦ Identify patient as candidate for AED use.
          Inclusion criteria include a weight of more than 25 kg, an age of greater than eight
          (8) years, ventricular fibrillation or pulseless ventricular tachycardia identified on
          the SAED monitor screen, and the presence of no pulse or of apnea.
   ♦ Begin CPR. Secure airway. Ventilate using 100% O2 bag-valve technique.
   ♦ Turn the AED to "ON". Check self-test message for warnings.
   ♦ Ensure the medical control module and microcassette are in place and functioning.
   ♦ Identify yourself and give a short explanation of the situation (patient age, sex, down
      time, pertinent history, and presence of bystander CPR).




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Procedural Protocols continued

                                   Cricothyrotomy

   ♦ Assess need for airway control with cricothyrotomy; select technique and insure needed
      equipment is nearby.
   ♦ Needle cricothyrotomy:
          Identify cricothyroid membrane; clean area with Betadine or alcohol swabs.
          Puncture cricothyroid membrane with 14 gauge Angiocath attached to 10-cc
          syringe; direct needle caudally at a 45-degree angle.
          Aspirate while advancing needle. When air returns, secure catheter and remove
          needle and syringe. If needle advanced > 2 inches without return of air, withdraw
          needle, reassess position, and re-attempt.
          Insert a 3.5 mm endotracheal tube adapter into the catheter hub, and ventilate the
          patient with 100% O2 via BVM.
          The needle cricothyrotomy provides adequate ventilation for 15 minutes. If patient
          transport to definitive care facility will be prolonged, convert to wire-guided
          cricothyrotomy.
  ♦ Wire-guided cricothyrotomy
          Identify and prepare cricothyroid area as above.
          Using needle attached to 10-cc syringe, advance needle through membrane caudally
          (towards the feet) at a 45-degree angle. When air is aspirated, secure needle and
          detach syringe.
          Pass guide wire through needle. Remove needle, holding end of guide wire until
          needle tip is clear from skin; then grasp guide wire at entrance to skin.
          Make a small vertical stab wound (5 mm wide) at base of guide wire. Incise
          through skin and subcutaneous tissue only.




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Procedural Protocols continued

          Place tracheal tube over silastic dilator (ET tube adapter end should be opposite
          from tapered end of dilator). Insert guide wire into tapered end of dilator and grasp
          at opposite end as wire emerges. Gently but firmly place dilator/tube assembly
          caudally through incision and into trachea.
          Remove dilator and guide wire, leaving tube in place.
          Secure tube. Attach ET tube adapter end to BVM; assist or perform ventilations
          with 100% O2 via BVM.


SPECIAL NOTES: NEEDLE CRICOTHYROTOMY


   ♦ Place the patient in the supine position.
   ♦ Palpate the cricothyroid membrane anteriorly, between the thyroid cartilage and the
      cricoid cartilage.
   ♦ Assemble a #12 or #14 8.5 cm, over the needle catheter, to a 6-12 cc syringe.
   ♦ Puncture the skin midline and directly over the cricothyroid membrane.
   ♦ Withdraw the stylet while gently advancing the teflon catheter downward into position,
      being careful not to perforate posterior wall of the trachea.
   ♦ Connect this cricothyroidotomy adapter to 3.5-mm pediatric ET adapter. The oxygen
      flow should be at least 15 liters per minute (50 PSI). Please note adequate oxygen
      levels to the patient can be maintained for only 30-45 minutes with this technique.
      Intermittent ventilation may be achieved by placing the thumb over the open end of the
      Y-connector using this rhythm for one second and then off, allowing the chest to
      decompress for four (4) seconds.




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Procedural Protocols continued

                            Endotracheal Intubation


   ♦ Assess need for endotracheal intubation.
   ♦ Select route of intubation (Note: Patient must have spontaneous respirations if nasal
      intubation will be attempted).
   ♦ Have airway supplies (including cricothyrotomy kit) nearby; have suction available for
      use prn.
   ♦ If patient has known or suspected head injury or stroke, administer 1.5 mg/kg lidocaine
      IVP prior to intubation as time allows.
   ♦ If orotracheal intubation:
          Maintain cervical spine immobilization by holding head in the neutral position if
          trauma is known or suspected. DO NOT HYPEREXTEND OR DISTRACT
          NECK.
          Hyperventilate patient with 100% O2 via BVM prior to intubation attempt.
          Insert laryngoscope blade into oropharynx; visualize vocal cords. Remove any
          obstructing secretions or foreign bodies with suction and/or Magill forceps.
          Insert endotracheal tube past vocal cords and inflate balloon; visually confirm
          placement before removing laryngoscope. A stylet may be used; it is removed after
          the tube has passed the cords. Confirm placement by listening for an absence of
          sounds over the epigastrium and the presence of breath sounds over both sides of
          the chest, or by use of end-tidal capnometry.
          Ventilate patient via ETT with 100% O2 using BVM. Prepare to continue with
          BVM ventilations during transport or place on mechanical ventilation.




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Procedural Protocols continued

          If intubation attempt is unsuccessful, remove laryngoscope and resume
          hyperventilation. Intubation attempts should be limited to 30 seconds if SaO2 is at
          or below 90%. If oxyhemoglobin saturation is >90%, the intubation attempt may
          be continued until SaO2 values fall below 90%. If intubation attempts continue to
          fail, consider alternate operator or alternate means of airway control (continued
          BVM if air exchange adequate, cricothyroidotomy, etc.).
   ♦ If nasotracheal intubation:
          Maintain cervical spine immobilization if trauma is known or suspected.
          Hyperventilate patient with 100% O2 prior to intubation attempt.
          Nasal anesthesia can be achieved by the placement of a nasal trumpet coated with
          2% lidocaine jelly 3-5 minutes prior to intubation. Coat external nares and tip of
          endotracheal tube with 2% lidocaine jelly as well.
          Insert tube with curve along floor of nose. Stylets cannot be used. As tube enters
          the pharynx, the patient is likely to cough or gag. Suction must be ready for use.
          Listen for patient breathing and/or vocalizations; feel the air exchange emanating
          from the tube. The vocal cords are widest apart upon inspiration. At that time,
          advance tube quickly through cords. Success is noted by an absence of further
          vocalizations and continued airflow through the tube.
          Inflate balloon. If possible, confirm tube placement with direct laryngoscopy.
          Ventilate patient via ETT with 100% O2 using BVM. Prepare to continue with
          BVM ventilations during transport.
          If unable to intubate after 30 seconds, pull tube back into oropharynx and
          hyperventilate before next attempt. Continued lack of success indicates the need
          for attempts by other operators or alternate means of airway control.




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Procedural Protocols continued



   ♦ If unable to perform oral or nasal intubation due to seizure, prominent gag reflex,
      increased muscle tone or patient combativeness:
          Premedicate patient with diazepam 5-10 mg (0.1 mg/kg in children. Diazepam use
          is focused on prevention of subsequent myoclonus, and should not be considered as
          a primary agent for intubation.
          Administer etomidate 0.3 mg/kg to total dose of 20 mg over 30-60 seconds IVP.
          Patients must be hyperventilated prior to use of sedating and relaxing agents; bag-
          valve mask ventilation with 100% O2 must be continued throughout the procedure.
   ♦ In all cases, confirmation of endotracheal tube position is mandatory. Confirmation
      techniques include, but are not limited to:
          Listening for breath sounds over both sides of the chest in conjunction with the
          absence of epigastric sounds.
          Visualization of tube placement by direct laryngoscopy.
          Confirmation of placement by capnometric colorimetry (FENEM device, et al).
   ♦ After tube placement confirmed, secure endotracheal tube to face with tape or tie.
   ♦ If a patient with known or suspected trauma vomits during airway procedures (or
      whenever immobilized), turn AS A UNIT on side and suction oral cavity. Maintain
      spinal immobilization throughout the turning maneuver.
   ♦ Following confirmation of successful endotracheal intubation, diazepam 5-10 mg (0.1
      mg/kg in children). Endotracheal tube placement must be confirmed immediately
      before and after each administration of diazepam for this purpose.




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Procedural Protocols continued

                Epinephrine Auto Injector Administration Assist

DESCRIPTION
   ♦ Epinephrine is a beta-agonist medication, which produces two major physiologic
      effects. Vasoconstriction results in a rise in blood pressure and improved tissue
      oxygenation and perfusion, while bronchodilation opens airways and improves
      respiration. As hypotension (shock) and bronchoconstriction (wheezing) are major
      symptoms of severe allergic reaction (“anaphylaxis”), epinephrine is a useful agent in
      the emergency management of these patients. Epinephrine is also a natural body
      hormone, produced by the adrenal glands and vital in mediating the body’s response to
      stress.


      Patients prone to severe allergic reactions may be in possession of an epinephrine auto-
      injector, which has been prescribed by their physician for home use. An adult auto-
      injector contains a dose of 0.3 mg of epinephrine; an infant/child autoinjector contains a
      dose of 0.15 mg. The EMT is allowed under Florida law to assist the patient in the use
      of their own autoinjector or perform autoinjection on the patient’s behalf.


      The EMS Medical Director may authorize BLS entities to carry and administer EPI
      auto injectors.




INDICATIONS
   ♦ Signs of severe allergic reaction or anaphylaxis, including generalized urticaria (hives),
      respiratory distress (wheezing), or shock (hypotension).




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Procedural Protocols continued



CONTRAINDICATIONS
   ♦ There are no absolute contraindications to the use of epinephrine in a life-threatening
      situation. Use cautiously in patients with known history of cardiovascular disease,
      angina, myocardial infarction, cardiac arrhythmia, and in the elderly.


SIDE EFFECTS AND COMPLICATIONS
   ♦ Tachycardia, pallor, dizziness, chest pain, headache, nausea and vomiting, restlessness,
      anxiety. Patients with severe cardiovascular disease are at risk of cardiac ischemia or
      infarction after injection; tachydysrhythmias may progress to ventricular tachycardia or
      fibrillation.


PROCEDURE
   ♦ Identify epinephrine autoinjector. If autoinjector is presented by the patient, verify that
      injector is for patient’s own use and that contents are not discolored.
   ♦ Remove cap from auto-injector
   ♦ Place tip of auto-injector against the lateral thigh, midway between the waist and knee.
   ♦ Push injector smoothly and firmly against thigh until injector activates
   ♦ Maintain injector firmly in place until medication fully injected (3-5 seconds)
   ♦ Dispose of injector in biohazardous waste container
   ♦ Monitor patient for response.




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Procedural Protocols continued

                               External Pacemaker Use

   ♦ Assess need for external pacing.
   ♦ Place pacer pads over apex/sternum position of chest walls just left of the sternum and
      spine, respectively.
   ♦ Hook pacer in line with defibrillator/monitor unit (if not built in to unit).
   ♦ Set pacer rate:
          In patients with electrocardiographic evidence of organized cardiac activity, set
          pacer rate at 20-30 bpm above patient's intrinsic rate.
          In patients without evidence of organized activity, set pacer at rate of 70-90 bpm.
   ♦ Set alarms appropriately and arm pacer.
   ♦ Turn on pacing element and set amperage:
          In patients with intrinsic cardiac function (pulses and blood pressure present), turn
          on pacing element with amperage at lowest setting; gradually increase until patient
          demonstrates electrical capture on EKG and mechanical capture as evidenced by
          pulses simultaneous with paced beat. Set amperage approximately 5 milliamps
          above capture point.
          In patients with no intrinsic cardiac function, set pacer at highest amperage and
          maintain until both electrical and mechanical capture achieved as described in (A)
          above. After capture occurs, amperage may be decreased for patient comfort,
          titrating to loss of mechanical capture or relief of discomfort. If loss of capture
          occurs, final amperage should be set approximately 5 milliamps above the capture
          point.
   ♦ When mechanical capture obtained, adjust heart rate to maintain systolic BP > 100
      mmHg. Do not exceed paced rate of 90 bpm.
   ♦ Awake patients requiring pacing, may be given diazepam 5-10 mg slow IVP. Titrate to
      patient comfort to a maximum dose of 10 mg or a systolic blood pressure of < 90
      mmHg.




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                                  Femoral Venipuncture

   ♦ Place the patient in a supine position.
   ♦ Cleanse the skin well around the venipuncture site and drape the area. Sterile gloves
      should be worn when performing this procedure.
   ♦ Locate the femoral vein by palpating the femoral artery. The vein lies directly medial
      to the femoral artery. A finger should remain on the artery to facilitate anatomical
      location and to avoid insertion of the catheter into the artery.
   ♦ If the patient is awake, use a local anesthetic at the venipuncture site.
   ♦ Introduce a large caliber over-the-needle catheter, attached to a 6- or 12-ml syringe.
      The needle, directed towards the patient’s head, should enter the skin directly over the
      femoral vein.
   ♦ The needle, with syringe attached, is held parallel to the frontal plane.
   ♦ Directing the needle cephalad and posteriorly, slowly advance the needle while gently
      withdrawing the plunger of the syringe.
   ♦ When a free flow of blood appears in the syringe, remove the syringe with needle while
      advancing the catheter and occlude the catheter hub with a finger to prevent air
      embolism.
   ♦ Connect the catheter to intravenous tubing.
   ♦ Affix the catheter in place (i.e., with suture or temporarily with tape), apply antibiotic
      ointment and dress the area.
   ♦ Tape the intravenous tubing in place.




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   ♦ Complications of Femoral Venipuncture
          Hematoma formation
          Cellulitis
          Thrombosis
          Phlebitis
          Nerve transection and/or puncture
          Arterial puncture
          Arteriovenous fistula
          Peripheral neuropathy
          Lost catheters




  Medical Control
     Must contact Medical Control before performing this procedure.




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                               Immobilization of the Cervical Spine


   ♦ Secure airway; evaluate and maintain respiratory and circulatory status as per
      appropriate protocol.
   ♦ C-spine immobilization must be performed in:
          Patients with head, facial, or cervical trauma
          Patients with decreased or altered levels of consciousness of unknown etiology.
          Patients with suspected deceleration injuries (auto or bicycle accidents, falls from
          any height, etc.).
          Patients with complaints of neck and/or back pain after trauma.
          Patients with mechanism of injury, subjective complaints, or objective findings
          suggestive of neck or back injury.
   ♦ Request assistance from bystanding EMS workers, fire fighters, LEA officers, or public
      in securing and moving patient. Maintain charge of activity by providing direction
      and standing at head end of patient.
   ♦ If patient found in sitting position:
          Place cervical collar.
          If patient found sitting in open space (sidewalk, roadside, etc), recline patient as a
          unit onto backboard. Secure patient to backboard, then place and secure lateral
          head supports.
          If patient found in closed or confined space (car seat, etc), place K.E.D. board
          behind patient and secure head and torso to board. Perform rapid extrication
          procedure ONLY when demanded by scene safety or patient severity. Extract
          patient from vehicle or seat. Recline on backboard, secure patient to board, and
          place and secure lateral head supports.




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   ♦ If patient found standing or ambulatory:
          Place cervical collar.
          Recline patient as a unit onto backboard. Secure patient to backboard, then place
          and secure lateral head supports.
   ♦ If patient found lying on ground:
          Place cervical collar.
          If patient lying on side, slip backboard under side of patient from back; roll patient
          as a unit onto backboard, secure to board, and place and secure lateral head
          supports.
          If patient lying prone, place backboard alongside patient. Roll patient as a unit onto
          backboard, secure to board, and place and secure lateral head supports.
          If patient lying supine, place backboard alongside patient. Roll patient as a unit
          away from board and slip board under side of patient. Proceed as directed above.




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                          Immunization Administration


   ♦ Assess patient age, general health status, allergies, and immunization history.
   ♦ Select immunizations to be administered based on age and immunization history (refer
      to most recent schedules proposed by the Advisory Committee on Immunization
      Practices (ACIP) of the United States Public Health service) as required by Florida
      immunization law (F.S. 232.032).
   ♦ Provide preimmunization counseling and answer any questions using Center for
      Disease Control Vaccine Information Statements (CDC VIS). Obtain consent for
      immunization from parent or guardian.
   ♦ Assess patient for contraindications to immunization (refer to MMWR current “Guide
      to Contraindications and Precautions to Vaccinations”).
   ♦ Administer immunizations
   ♦ Provide postimmunization instruction sheet to parent or guardian.
   ♦ If questions arise during the immunization procedure, contact the Volusia County
      Department of Health at 947-3458.
   ♦ All Volusia County Department of Health polices, procedures, and protocols
      concerning the acquisition, storage, reconstitution and wasting of vaccine are to be
      followed in the process of implementing this protocol. Adverse effects of
      immunizations will be reported to the Volusia County Department of Health at the
      contact noted above.




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                                      Inhaler Assist

DESCRIPTION


   ♦ Inhaled bronchodialators for the treatment of asthma, chronic obstructive pulmonary
      disease (COPD), and other respiratory conditions are known as beta agonist
      medications. Smooth muscle lining the bronchioles of the lung are richly innervated
      with these receptors. When the beta-receptors within the muscle are stimulated, the
      musculature relaxes, resulting in enlargement of the diameter of the bronchial tube
      (bronchodilation), decreased airway resistance, and improved airflow within the lung.


      Beta-agonist bronchodialators encompass a wide range of generic and brand names,
      including albuterol (Alupent, Ventolin), metaproterenol (Alupent), salmeterol
      (Serevent), and isoetharine (Bronkosol). Many patients on beta agonists will also be on
      inhaled atropine derivatives (ipratropium bromide, or Atrovent) or inhaled
      corticosteroids such as beclomethasone (Beclovet, Vanceril), flunisolide (AeroBid), or
      triamcinolone (Azmacort). These medications do not qualify for administration by
      prehospital personnel.


      Inhalers are often accompanied by spacers. A spacer is essentially a thick plastic tube,
      which attaches to the outlet of the inhaler and allows the particles of medication to be
      suspended within a small volume of air. This improves the ability of the patient to
      coordinate inhalations and enhances drug delivery to the lungs. If a patient has a spacer
      to use with his or her inhaler, it should be used whenever possible. The standard dose
      of inhaled bronchodialators is 2 sprays or puffs per dose.




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INDICATIONS
   ♦ Patients who require assist with inhalers must exhibit signs and symptoms of
      respiratory emergencies (please refer to Section 200.06, “Respiratory distress”), have a
      history consistent with respiratory disease, and have a physician-prescribed hand-held
      inhaler on their person.
CONTRAINDICATIONS
   ♦ As patient cooperation is essential, patients with altered level of consciousness or those
      who are otherwise unable to cooperate effectively cannot use hand-held inhalers.
      Inhalers provided for the use of others besides the patient cannot be used. Tachycardia
      (> 140 beats/min) and acute hypertension (SBP > 200 mmHg) are relative
      contraindications; use in these situations must be weighed against the patient’s degree
      of respiratory distress.
SIDE EFFECTS AND COMPLICATIONS
   ♦ The most common side effect is tachycardia. Tremors and a feeling of “nervousness”
      or “jitters” are common. Hypertension and nausea/vomiting may also result.
PROCEDURE
   ♦ Identify patient as requiring assist with inhaled bronchodialator
   ♦ Confirm medication belongs to patient and check expiration date. Insure that inhaler is
      at room temperature or warmer. Assess patient for an adequate level of consciousness
      to permit cooperation.
   ♦ Shake inhaler vigorously for fifteen seconds.
   ♦ Have patient exhale deeply, then place lips around the opening of the inhaler or spacer.
   ♦ Have patient depress the inhaler and begin a deep inhalation
   ♦ Instruct patient to hold breath for as long as possible to promote full deposition of
      medication; if using spacer, repeat inhalations from spacer tube five times with each
      depression of the inhaler.
   ♦ Repeat procedure for second spray.




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NOTES ON OXYGEN USE


   ♦ Inhalers may be used in conjunction with nasal cannula. If the patient is on a facemask
      for oxygen supplementation, the mask must be removed for inhalation therapy.
      Immediately replace mask after treatment or consider placement of nasal cannula as
      patient status allows.




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                         Internal Jugular Venipuncture


   ♦ Place the patient in a supine position and if possible, at least 15 degrees head-down to
      distend the neck veins and to prevent an air embolism. Turn the patient’s head away
      from the venipuncture site.
   ♦ Cleanse the skin well around the venipuncture site and drape the area. Sterile gloves
      should be worn when performing this procedure.
   ♦ If the patient is awake, use a local anesthetic at the venipuncture site.
   ♦ Introduce a large-caliber over-the-needle catheter, attached to a 6- or 12-ml syringe,
      into the center of the triangle formed by the two lower heads of the sternomastoid
      muscle and the clavicle.
   ♦ After the skin has been punctured, with the bevel of the needle upward, expel the skin
      plug that may occlude the needle.
   ♦ Direct the needle caudally, parallel to the sagittal plane, at a 30-degree posterior angle
      with the frontal plane.
   ♦ Slowly advance the needle while gently withdrawing the plunger of the syringe.
   ♦ When a free flow of blood appears in the syringe, remove the syringe with needle stylet
      attached while simultaneously advancing the catheter into the vein. After removing the
      stylet, occlude the catheter hub with a finger to prevent an air embolism. If the vein is
      not entered, withdraw the needle with catheter and redirect it 5 to 10 degrees laterally
      (towards the right nipple of the patient).
   ♦ Connect the catheter to the intravenous tubing.
   ♦ Affix the catheter in place, apply antibiotic ointment and dress the area.
   ♦ Tape the intravenous tubing in place.




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   ♦ Complications of Central Intravenous Venipuncture
          Hematoma formation
          Cellulitis
          Thrombosis
          Phlebitis
          Nerve transection
          Arterial puncture
          Pneumothorax
          Hemopheumothorax (e.g. with subclavian venipuncture)
          Nerve puncture
          Arteriovenous fistula
          Peripheral neuropathy
          Lost catheters




  Medical Control
     Must contact Medical Control before performing this procedure.




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                                 Intravenous Cannulation


   ♦ Assess need for intravenous catheterization; select peripheral site. Apply tourniquet to
      area just proximal to intended puncture site.
   ♦ Peripheral catheterization procedure:
          Prepare skin with Betadine or alcohol swabs.
          Secure vein with fingers; ask patient or assistant to secure extremity.
          Insert needle and catheter assembly into vein; watch for free blood return.
          When intraluminal placement confirmed by blood return, remove needle; insert
          catheter to hub. Remove tourniquet.
          Attach IV fluid line to catheter hub; insure patency by briefly running fluid WO.
          Fluid should continue to run at a rate indicated by the status of the patient.
          Secure catheter with tape, occlusive dressing, and/or Veniguard.




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                             Intravenous Fluid Management

   ♦ Normal saline will be the sole intravenous fluid used by prehospital providers within
      Volusia County.
   ♦ Fluid administration
          Unless otherwise specified or patient status mandates a change, patients on IV
          fluids upon arrival of EMS personnel should be continued on the same fluid at the
          same rate during transport.
          Unless otherwise specified, IV fluids started by EMS personnel should run at TKO
          (10 cc/hour). NOTE: Saline locks (heparin locks) do not require continuous fluid
          infusion to maintain patency.
          Saline lock if no fluid resuscitation.




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                            Needle Thoracostomy


   ♦ Assess need for needle thoracostomy.
   ♦ Identify puncture site:
          Second intercostal space on affected side in the mid-clavicular line (strongly
          preferred).
          Fourth intercostal space on affected side in anterior axillary line.
   ♦ Prepare skin at puncture site with Betadine or alcohol swabs.
   ♦ Insert 14-gauge Angiocath over top of inferior rib, perpendicular to skin at puncture site
      (remove any parts which may occlude the lumen from the catheter/needle assembly).
      Listen for a rush of air; if noted, the diagnosis of tension pneumothorax and proper
      needle placement is confirmed.
   ♦ Remove needle from catheter (even if escape of air not heard); secure catheter in place.
   ♦ If air collection reaccumulates, perform second needle thoracostomy on the same side.




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                                   Nitroglycerin Assist


DESCRIPTION
   ♦ Nitroglycerin (NTG) is a vasodilatory agent, which can improve blood flow to regions
      affected by narrowed or constricted blood vessels. Major effects occur in the coronary
      vasculature, where NTG seems to preferentially redirect and supplement blood flow to
      ischemic areas of the heart. Other major sites of action include the pulmonary vessels
      and the peripheral vasculature. These latter effects reduce the pressure that the heart
      has to “work against” to pump blood, and reduces the heart’s need for large quantities
      of oxygen.


      Patients with a history of coronary artery disease may be prescribed NTG by their own
      physician. NTG may come in tablet or spray form. EMT’s may assist patients in using
      their own medications as required. Patients are often instructed by their own physicians
      to use NTG in the event of chest pain, and to call EMS if no relief has been obtained.


♦ INDICATIONS
   ♦ Nitroglycerin use is indicated in the patient with chest pain and a history of cardiac
      problems. The NTG to be administered must be the patient’s own, and systolic blood
      pressure must be > 100 mmHg.


CONTRAINDICATIONS
   ♦ NTG is contraindicated when the patient’s systolic blood pressure is < 90 mmHg, the
      patient has a head injury, the patient’s pain is atypical or unusual for his or her known
      angina, or the patient is an infant or child. As patient cooperation is essential, the
      patient must be conscious and in possession of full airway reflexes.




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SIDE EFFECTS AND COMPLICATIONS
   ♦ Hypotension, headache and a “reflex tachycardia” (in response to decreases in blood
      pressure). Hypotension is best addressed by placing patient supine and (in the ALS
      setting) administering a fluid challenge.




PROCEDURE
   ♦ Perform cardiac assessment; note blood pressure.
   ♦ Verify medication belongs to patient and that medication is not expired (date usually on
      bottle or spray canister).
   ♦ Confirm patient is awake, alert, and cooperative. Explain means of administration
      (sublingual spray or tablet).
   ♦ Ask patient to lift tongue. Place tablet or spray dose of nitroglycerin under tongue in
      the sublingual space. Hand protection (gloves) should be worn during NTG
      administration.
   ♦ If tablet given, have patient close mouth until tablet absorbed and dissolved. Instruct
      patient not to swallow tablet.
   ♦ Reassess pulse rate, blood pressure, and patient’s level of pain.
   ♦ Record nitroglycerin administration, route, time, and effects on run report.
   ♦ Doses may be repeated every five minutes as required up to the patient’s maximum
      prescribed dose.




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                  Orogastric and Nasogastric Intubation


DESCRIPTION AND INDICATION
   ♦ Orogastric and nasogastric intubation is indicated to prevent vomiting with resultant
      aspiration of gastric contents. It is also indicated in cases of cardiopulmonary arrest to
      decompress the stomach, enhancing diaphragmatic excursion and allowing more
      effective ventilation and cardiac compressions.


CONTRAINDICATIONS
   ♦ Acute GI bleeding is a contraindication to orogastric or nasogastric intubation in the
      prehospital setting due to risk of rupture of esophageal varicies with resultant
      hemorrhage. Placement of nasogastric tubes are specifically contraindicated in the
      presence of facial trauma. Relative contraindications include known pregnancy,
      suspected aortic aneurysm or myocardial infarction, and the presence of head injury
      (passage of the tube through the pharynx may raise intracranial pressure).


SIDE EFFECTS AND COMPLICATIONS
   ♦ The most common problem encountered in nasogastric and orogastric intubation is
      coiling of tube in the posterior pharynx.


      Complications of orogastric and nasogastric tube placement include nasal hemorrhage,
      inadvertent endotracheal intubation, esophageal perforation, induction of
      gastrointestinal bleeding, and intracranial tube migration due to facial trauma.




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PROCEDURE
   ♦ Don personal protective equipment; prepare suction with rigid catheter. Determine
         appropriate size of tube. In general, adults should be intubated with an 18 F gauge
         device; tube diameter in pediatric patients should conform to that specified on the
         Broselow Tape.
   ♦ Examine nostrils and select the largest or least deviated for nasogastric tube placement
         (usually the right).
   ♦ Determine appropriate length for tube insertion. Length of nasogastric tubes should
         extend from the tip of the nose to the earlobe and then to the xiphoid process; length of
         orogastric tubes should extend from the earlobe to the xiphoid process.
   ♦ Coil 3-4 inches on tube around fingers to form a curve; lubricate coiled portions of
         tube.
   ♦ Position patient appropriately for insertion:
              If patient is the victim of trauma, maintain patient supine with cervical spine
              immobilized in the neutral position.
              If the patient is not a trauma victim:
                       If patient in unconscious, place patient supine or in the “sniffing” position.
                       If patient conscious, place in 45-90 degree head up, knees flexed position
                       (Fowler’s position).
   ♦ If performing nasogastric intubation, grasp tube with curve downward and insert into
         nostril. Advance tube downward towards the closest ear. If performing orogastric
         intubation, insert curved portion of tube into mouth and advance downward.
   ♦ Gently flex the head (in the non-trauma victim only!) as the tube proceeds past the
         pharynx to facilitate passage into the esophagus. Ask the patient to swallow as possible
         to facilitate passage.
              The gag reflex will often be stimulated by tube passage. If vomiting occurs,
              remove tube and suction vigorously.
              If patient exhibits any signs of respiratory distress, remove tube immediately.




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   ♦ Advance tube to premeasured position and tape securely in place.
   ♦ Confirm tube placement
          Aspirate gastric contents (if unable to aspirate initially, advance tube 1-2 inches and
          re-attempt).
          Place bell of stethoscope over patient’s stomach. Instill air into stomach via tube
          and auscultate for sounds of air motion within the stomach.
   ♦ Attach tube to low suction as possible; clamp tube if no suction available.
   ♦ Document details of tube placement and aspirated gastric contents in the run report.




  Medical Control
     Contact Medical Control for all cases other than cardiac arrest.




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                                  Patient Restraint


   ♦ Determine need for patient restraint.
   ♦ Assign personnel resources to initiate restraint. A minimum of five (5) people is often
      required to restrain an uncooperative patient.
   ♦ The patient's four (4) extremities and waist must be restrained to the ambulance
      stretcher.
          Soft restraints are the only form of mechanical restraint permitted.
          The head will not be restrained at any time. No restraints will be placed within the
          oral cavity. A facemask may be placed on the patient who exhibits biting or
          spitting behavior. Mask use must be supervised at all times by prehospital
          personnel, and removed immediately if patient exhibits impending emesis or any
          signs of airway compromise.
          Should a patient on backboard and collar require restraint, one edge of the board
          will be supported with pillows to place the patient in a lateral decubitus position.
   ♦ If the patient breaks restraints and attempts to escape, EMS personnel will take no
      action to subdue the patient. The appropriate law enforcement agency will be notified.
   ♦ All patients should have their airway and breathing closely monitored and assistance
      provided as necessary.
   ♦ Patients will not be restrained in a prone position.




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                           Pediatric Intraosseous Infusion


FLUID AND DRUG ACCESS IN THE UNSTABLE INFANT OR CHILD
   ♦ Intravenous access is always preferred.
   ♦ Drugs such as epinephrine, atropine, lidocaine, diazepam and naloxone may be given
      by the endotracheal route while attempting to establish peripheral vascular access.
   ♦ I/O access should be established if reliable venous access cannot be achieved within
      two (2) peripheral attempts or 90 seconds, whichever comes first. Patient Care Report
      documentation must reflect an explanation for I/O access.
   ♦ Volume replacement and administration of crystalloid solutions may occur via the
      peripheral vascular or intraosseous route.


CRITERIA FOR INTRAOSSEOUS INFUSION
   ♦ Patient < 6 years of age or younger.
   ♦ Patient assessment indicates immediate or imminent need for vascular access.
   ♦ Attempts at peripheral vascular access have been unsuccessful.
   ♦ Patient should be unconscious or unresponsive to justify intraosseous access due to the
      painful and invasive nature of this intervention.


ANATOMIC LANDMARKS
   ♦ Tibial tuberosity.
   ♦ External condyles of the distal femur.
   ♦ The site of choice for intraosseous access is in the proximal tibia, one (1) finger-breadth
      (1-2 cm) below the tibial tuberosity on the anteromedial surface.
   ♦ An alternate site is the distal femur, one (1) finger-breadth (1-2 cm) above the external
      condyles in the midline.




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CONTRAINDICATIONS
   ♦ Placement in a fractured bone.
   ♦ Placement distal to a fractured bone.
   ♦ Conscious (alert, lethargic, stuporous) pediatric patient. Contact EDMCP for
      instructions.
   ♦ Pediatric patients > 6 years of age or older. Contact EDMCP for instructions.
   ♦ Placement in an infected or burned area. Contact EDMCP for instructions.


COMPLICATIONS
   ♦ Extravasation of fluid is the most common problem secondary to improper initial
      placement or dislodgement of the needle.
   ♦ Fat embolism.
   ♦ Osteomyelitis.


PROCEDURE
   ♦ Assess need for intraosseous line.
   ♦ Select line site:
          2 finger breadths below the tibial tuberosity on medial side of tibia (1 finger breadth
          in children). The medial tibial site is the preferred site for intraosseous line
          placement.
          1 finger breadth above the external femoral condyle in the lateral midline.
          Avoid starting intraosseous lines in injured extremities.
   ♦ Prepare site with Betadine or alcohol swabs.
   ♦ Insert needle with the stylet in place perpendicular to bone, avoiding the epiphyseal
      plate. Insert with pressure and a boring or twisting motion until penetration into the
      marrow (marked by a sudden loss of resistance) is noted.
   ♦ Remove the stylet.




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   ♦ Confirm intraosseous needle placement:
          Assess stability of needle to insure placement in bone.
          Flush needle with 10 cc NS to insure patency. Minimal resistance to NS flush and
          no skin infiltration is expected with proper placement.
          If patency in question, attempt second flush; if unsuccessful, withdraw needle 1-2
          turns and attempt to flush again. If still unsuccessful, attempt second intraosseous
          needle placement or consider alternative means of vascular access.
   ♦ Connect IV fluid line to intraosseous needle and run at predetermined rate (NOTE:
      Flow rates to gravity may be unacceptably slow. Consider placing IV solution in a
      pressure bag inflated to 300 torr or "pushing" the fluid bolus from a syringe attached to
      the hub of the intraosseous needle).
   ♦ Secure the intraosseous needle using sterile gauze and tape (avoid tension on the
      needle).


FLUID RESUSCITATION
   ♦ Definitive therapy for shock involves fluid administration.
   ♦ Establishment of intravenous access is difficult in young children, especially in the face
      of dehydration or shock.
   ♦ The risks of prolonged scene time must be weighed against:
          transport time to the hospital
          patient's condition
          anticipated benefits of fluid administration during transport
   ♦ Only 0.9% sodium chloride solution (NS) should be used for volume resuscitation.
          initial bolus is 20 cc/kg
          repeat bolus 20 cc/kg, based upon reassessment of patient perfusion: patient's heart
          rate, quality of pulses, capillary refill, extremity warmth, level of consciousness,
          blood pressure.
          the most common error in fluid resuscitation in children is the reluctance to give
          adequate volume. A child with hypovolemic shock may require 60 cc/kg in the first
          hour.


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   ♦ Catecholamines - vassopressors (e.g., epinephrine, dopamine) are seldom indicated in
      the prehospital treatment of shock in children. Contact the EDMCP prior to
      administering catecholamines to the pediatric patient in shock.
   ♦ The treatment of hypovolemia is volume. Never give vasopressors to a patient with an
      "empty tank".
   ♦ Sodium bicarbonate and D50W must be diluted 50/50 with a sterile, isotonic solution
      (0.9% sodium chloride) prior to intravenous (IV) or intraosseous administration unless
      pediatric pre-filled syringes are utilized.




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                                  Pericardiocentesis

   ♦ Monitor the patient’s vital signs and cardiac monitor before, during and after the
      procedure.
   ♦ Prepare the xiphoid and subxiphoid areas, if time allows.
   ♦ Locally anesthetize the puncture site, if necessary.
   ♦ Using a 16- to 18-gauge, 6-inch over-the-needle catheter (spinal needle), attach a 35-ml
      syringe with a three-way stopcock.
   ♦ Assess the patient for any mediastinal shift that may have caused the heart to shift
      significantly.
   ♦ Puncture the skin 1 to 2 cm inferior to the left of the xiphochondral junction, at a 45-
      degree angle to the skin.
   ♦ Carefully advance the needle cephalad and aim toward the tip of the left scapula.
   ♦ If the needle is advanced too far (into the ventricular muscle), an injury pattern (e.g.
      extreme ST-T wave changes, or widened and enlarged QRS complex) will appear on
      the cardiac monitor. This pattern indicates that the pericardiocentesis needle should be
      withdrawn until the previous baseline cardiac rhythm reappears. Premature ventricular
      contractions may also occur, secondary to irritation of the ventricular myocardium.
   ♦ When the needle tip enters the blood-filled pericardial sac, withdraw as much non-
      clotted blood as possible.
   ♦ During the aspiration, the epicardium will reapproach the inner pericardial surface, as
      will the tip of the needle. This indicates that the needle should be withdrawn slightly.
      Should this injury pattern persist, withdraw the needle completely.
   ♦ After aspiration is completed, remove the syringe leaving the stopcock attached and in
      a closed position. Secure the needle in place with bulky dressings.
   ♦ Should the cardiac tamponade symptoms persist or recur, the stopcock may be opened
      and the pericardial sac reaspirated.




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   ♦ Complications of Pericardiocentesis
          Aspiration of left or right ventricular cavity blood instead of pericardial blood
          Cellulitis
          Laceration of coronary artery or vein
          Laceration of ventricular epicardium/myocardium
          New hemopericardium, secondary to lacerations of the coronary artery or vein,
          and/or ventricular epicardium/myocardium
          Local hematoma
          Pericarditis
          Ventricular Fibrillation
          Pneumothorax
          Aortic Puncture
          Puncture of inferior vena cava
          Puncture of esophagus
          Mediastinitis secondary to puncture of esophagus
          Puncture of peritoneum
          Peritonitis, secondary to puncture of peritoneum




  Medical Control
     Must contact Medical Control before performing this procedure.




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                                 Subclavian Venipuncture

   ♦ Place the patient in a supine position and, if possible, at least 15 degrees head-down to
      distend the neck veins and prevent air embolism. Turn the patient’s head away from
      the venipuncture site.
   ♦ Cleanse the skins well around the site and drape the area. Sterile gloves should be
      worn when performing this procedure.
   ♦ If the patient is awake, use a local anesthetic at the venipuncture site.
   ♦ Introduce a large-caliber over-the-needle catheter attached to a 6- or 12-ml syringe 1
      cm below the junction of the middle and medial thirds of the clavicle.
   ♦ After the skin has been punctured, with the bevel of the needle upward, expel the skin
      plug that may occlude the needle.
   ♦ The needle and syringe are held parallel to the frontal plane.
   ♦ Direct the needle medially, slightly cephalad, and posteriorly behind the clavicle
      toward the posterior, superior angle of the sternal end of the clavicle (toward finger
      placed in the suprasternal notch).
   ♦ Slowly advance the needle while gently withdrawing the plunger of the syringe.
   ♦ When a free flow of blood appears in the syringe, remove the needle stylet with syringe
      attached while simultaneously advancing the catheter into the vein. After removing the
      stylet, occlude the catheter hub with a finger to prevent an air embolism.
   ♦ Connect the catheter to the intravenous tubing.
   ♦ Affix the catheter (e.g. with suture or temporarily with tape), apply antibiotic ointment,
      and dress the area.
   ♦ Tape the intravenous tubing in place.


  Medical Control
     Must contact Medical Control before performing this procedure.




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                          Suspected Bioterrorism Precautionary
                            Measures & Decontamination of
                            Patients/environmental Surfaces

MUST CONTACT EDMCP OR HEALTH DEPARTMENT BEFORE TRANSPORT OF
ANY WMD/BIOTERRORISM AGENT.

This policy covers exposure to Biological Agents Only (Chemical contamination is not
included as part of this policy).


The goal of decontamination after a potential exposure to bioterrorism agents is to reduce the
extent of contamination by the patients and to contain the contamination to prevent further
spread of the disease. Decontamination of exposed individuals prior to delivery to a healthcare
facility may be necessary in the pre-hospital setting to ensure the safety of EMS personnel,
facility patients and staff.


GENERAL
    ♦ For many biological agents, patient decontamination may not be necessary.


        Depending on the agent, the likelihood for re-aerosolization, or a risk associated with
        cutaneous exposure, clothing of exposed persons may need to be promptly removed.
        Patient clothing should be handled only by personnel wearing appropriate personal
        protective equipment, and placed in an impervious biohazard (red) bag to prevent
        further environmental contamination. After removal of contaminated clothing, patients
        should be instructed (or assisted if necessary) to immediately shower with soap and
        water.    Potentially harmful practices, such as bathing patients with bleach
        solutions, are unnecessary and should not be done. Clean water or saline solution is
        recommended for rinsing eyes.




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   Patients with suspected exposure to anthrax powder require decontamination prior to
                                    ambulance transport.
               The destination hospital must be notified prior to ambulance
                                    arrival at that facility.


                    ** See Agent-Specific Recommendations – Anthrax


DEFINITIONS


   ♦ Standard precautions prevent direct contact with all body fluids (including blood),
      secretions, excretions, intact skin (including rashes), and mucous membranes. Standard
      precautions will be practiced by EMS personnel caring for patients with potentially
      transmissible infections including:
          Hand washing (before and after patient contact)
          Wearing disposable gloves
          Wearing masks with eye protection or face shields
          Wearing protective gowns
   ♦ Droplet precautions are used for patients suspected to be infected with microorganisms
      transmitted by large particle droplets, generally larger than 5u in size, that can be
      generated by the infected patient during coughing, sneezing, talking, or during
      respiratory-care procedures. Droplet precautions require EMS personnel to wear a
      surgical-type mask, especially when within 3 feet of the infected patient.
   ♦ Airborne precautions are used for patients suspected to be infected with
      microorganisms transmitted by airborne droplet nuclei (small particle residue, 5u, or
      smaller in size) of evaporated droplets containing microorganisms that can remain
      suspended in air and can be widely dispersed by air currents. Airborne precautions
      require EMS personnel to wear respiratory protection that meets the minimal NIOSH
      standard for particulate respirators, N95.



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AGENT-SPECIFIC RECOMMENDATIONS
   ♦ Anthrax
             Anthrax is an acute infectious disease caused by Bacillus anthracis, a spore-
      forming, and gram-positive bacillus. Associated disease occurs most frequently in
      sheep, goats, and cattle, which acquire spores through ingestion of contaminated soil.
      Humans can become infected through skin contact, ingestion, or inhalation.
          Transmission of anthrax infections, especially inhalation anthrax, from person-to-
      person is highly unlikely. Airborne transmission from one person to another does not
      occur, but direct contact with skin lesions may result in cutaneous infection.


          Isolation Precautions / Exposure to Suspicious Powder
             Standard and airborne precautions are used for the care of patients with
             exposure to suspicious powder (anthrax), until patients and environmental
             surfaces are properly decontaminated.
          Post-Exposure: Decontamination of Patients / Environment
             Instruct patient(s) to remove contaminated clothing.                Ensure patient
             privacy/modesty if at all possible.
             Handle clothing minimally to avoid agitation.
             Store patient clothing and/or items in labeled, biohazard plastic bags (double
             bag).
             Instruct patient(s) to shower thoroughly with soap and water (providing
             assistance if necessary).
             Provide patient with a disposable gown to wear.
             All potentially contaminated environmental surfaces should be decontaminated
             using an EPA-registered, germicidal agent or 0.5% hypochlorite solution (one
             part household bleach added to nine parts water). Reusable equipment should
             not be used for the care of another patient until it has been appropriately
             cleaned.




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   ♦ Botulism
             Food-borne botulism is the most common form of the natural disease in adults.
      An inhalational form of botulism is also possible, but unlikely.         Botulinum toxin
      exposure may possibly be seen in both forms as agents of bioterrorism.
             Individuals suspected to have been exposed to botulinum toxin should be
      carefully monitored for evidence of respiratory paralysis and decompensation.
             The goal of prehospital care of botulism is to expedite transport to the hospital
      for anti-toxin administration. Therefore, prehospital onscene times should be kept to an
      absolute minimum.


          Isolation Precautions
             Standard precautions are used for the care of patients with botulism.


          Post-Exposure: Decontamination of Patients / Environment
             Contamination with botulinum toxin does not place persons at risk for dermal
             exposure or risk associated with re-aerosolization. Therefore, decontamination
             of patients is not required.
             All potentially contaminated environmental surfaces should be decontaminated
             using an EPA-registered, germicidal agent or 0.5% hypochlorite solution (one
             part household bleach added to nine parts water).         Reusable patient care
             equipment should not be used for the care of another patient until it has been
             appropriately cleaned.




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   ♦ Plague
              Plague is an acute bacterial disease caused by a tiny gram-negative bacillus
      Yersinia pestis, which is usually transmitted by infected fleas when the disease is
      naturally occurring. A bioterrorism-related outbreak may be expected to be airborne,
      causing a pulmonary variant, pneumonic plague.
              Patients with pneumonic plague may have coughs productive of infectious
      particle droplets. Droplet precautions should be implemented by EMS, including at
      minimum, a surgical mask.


          Isolation Precautions
              Droplet and standard precautions are used for the care of patients with plague.


          Post-Exposure: Decontamination of Patients / Environment
              Patient decontamination after exposure to plague is not indicated.
              All potentially contaminated environmental surfaces should be decontaminated
              using an EPA-registered, germicidal agent or 0.5% hypochlorite solution (one
              part household bleach added to nine parts water). Reusable equipment should
              not be used for the care of another patient until it has been appropriately
              cleaned.
              EMS personnel should begin prophylactic antibiotic therapy ASAP if they
              provided care or were otherwise exposed to the patient prior to the patient
              receiving an appropriate antibiotic for plague or if the patient has been receiving
              antibiotic therapy for the plague for less than 72 hours.



  Medical Control
     Contact health department for permission to transport.




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   ♦ Smallpox
              Smallpox is an acute viral illness caused by Variola virus. Smallpox is a
      bioterrorism threat due to its potential to cause severe morbidity in a non-immune
      population (which exists in the USA today), and because it is highly contagious, and
      this respiratory agent can be transmitted via the airborne route. A single case is
      considered a public health emergency.
              Small pox is transmitted via both large and small respiratory droplets. Patient-
      to-patient transmission is likely from airborne and droplet exposure, and by contact
      with skin lesions or secretions. Patients are considered more infectious if coughing or
      if they have a hemorrhagic form of smallpox.


          Isolation Precautions
              Airborne and standard precautions are used for the care of patients with
              smallpox.


          Post-Exposure: Decontamination of Patients / Environment
              Patient decontamination after exposure to smallpox is not indicated.
              All potentially contaminated environmental surfaces should be decontaminated
              using an EPA-registered, germicidal agent or 0.5% hypochlorite solution (one
              part household bleach added to nine parts water). Reusable equipment should
              not be used for the care of another patient until it has been appropriately
              cleaned.
              All EMS personnel responsible for care should be vaccinated against smallpox
              ASAP or no later than 72 hours after exposure.


  Medical Control
     Must contact Medical Control for permission to transport.




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                                           REFERENCES

American Public Health Association. Control of communicable diseases in man.
       Washington DC: American Public Health Association; 1995.

Anonymous. Bioterrorism alleging the use of anthrax and interim guidelines for management – United
      States, 1998. MMWR Morb Mortal Wkly Rep 1999; 48:69-74.

Anonymous. Drugs and vaccines against biological weapons. Med Lett Drugs Ther 1999;
      41:15-6.

Centers for Disease Control and Prevention, Hospital Infection Control Practices Advisory Committee
        (HICPAC). Recommendations for isolation precautions in hospitals.
        Am J Infect Control 1996;24:24-52.

DOD DFFUaE. NBC Domestic Preparedness Response Workbook. 1998.

Federal Register. Respiratory protective devices; final rules and notice. 1995.

Franz D, Jahrling PB, Friedlander AM, McClain DJ, Hoover DL, Bryne WR, et al. Clinical recognition
       and management of patients exposed to biological warfare agents.
       JAMA 1997; 278:399-411.

Holloway HC, Norwood AE, Fullerton CS, Engel CC Jr, Ursano RJ. The threat of biological weapons.
       Prophylaxis and mitigation of psychological and social consequences.
       JAMA 1997;278:425-7.

Noah DL, Sovel AL, Ostroff SM, Kildew JA. Biological warfare training: Infectious disease outbreak
      differentiation criteria. Mil Med 1998;163:198-201.

Pile JC, Malone JD, Eitzen EM, Friedlander AM. Anthrax as a potential biological warfare agent.
        Arch Intern Med 1998;158:429-34.

Shapiro RL, Hatheway C, Becher J, Swerdlow DL. Botulism surveillance and emergency response.
       JAMA 1997;278:433-5.

Shapiro RL, Hatheway C, Swerdlow DL. Botulism in the United States: A clinical and epidemiological
        review. Arch Intern Med 1998;129:221-8.

Simon JD. Biological terrorism. JAMA 1997;278:428-30.

Tucker JB. National health and medical services response to incidents of chemical and biological
       terrorism. JAMA;1997;278:362-8.

U.S. Army medical research institute of infectious diseases. Medical management of biological
       casualties. Fort Detrick;USAMRIID; 1998.




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                         Taser Deployment Management


   ♦ The Advanced Taser is a widely used adjunct utilized by law enforcement in order to
      control dangerous or violent subjects without the use of deadly force. When the probes
      are shot and make contact with the subject, a five-second incapacitating electrical shock
      is delivered.
   ♦ When caring for patients’ post Taser shock, trauma protocols should be followed. The
      EMT or paramedic using gentle traction and universal precautions may remove probes
      that are embedded below the clavicle. If after the primary and secondary survey, the
      patient has no obvious injury, it will not be necessary to transport the patient to a care
      facility unless the patient requests further treatment and evaluation. Probes imbedded
      above the clavicles should be secured and the patient transported to the ED for care and
      removal.
   ♦ When called to a scene where a Taser has been deployed on a patient with an altered
      mental sate, or exhibiting highly erratic behavior or breathing patterns, cardiac
      monitoring and other supportive measures should be strongly considered.
   ♦ All patients must be fully evaluated and should be referred to the appropriate medical
      care protocol.




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                           Triage In Multiple-Casualty Incidents



   ♦ Multicasualty incidents are defined as events where sufficient personnel are not readily
      available to maintain adequate patient care.
   ♦ Triage is a system of identifying and prioritizing patients according to the severity of
      injury and need for treatment.       It is of special import in the classification and
      prioritization of patient care during mass casualty incidents.
   ♦ Patients triaged at the scene will be placed in 1 of 4 classifications.
          “DEAD/DYING” (black tag)
              DEAD/DYING patients are those who are obviously dead or whose wounds are
              so severe that death appears imminent, even if ALS treatment is initiated.
              Once tagged, DEAD/DYING patients should be covered, but not moved, unless
              it is necessary to treat other patients. If they must be moved, patients should be
              placed in an “out of the way” location. If possible, mark the location of the
              body prior to moving.
          “IMMEDIATE” (red tag)
              IMMEDIATE patients are those with treatable, life-threatening injuries and
              illnesses who will benefit most from immediate treatment and transport.
              IMMEDIATE patients should be considered as “load and go” and transported
              as early as feasible.
          “DELAYED” (yellow tag)
              DELAYED patients are those with serious, non-life threatening injuries who
              will ultimately require ambulance transport.
              DELAYED patients should be transported to the closest appropriate facilities
              not already inundated with patients.




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          “MINOR” (green tag) patients are those with minor, easily managed injuries.
          These patients may be ambulatory and / or able to care for themselves. The most
          common problem associated with these patients is the need to remove them from
          the scene so as not to interfere with more important tasks.
          If the patient’s medical status deteriorates resulting in a triage reclassification, place
          a new triage tag on the patient, which will better indicate the patient’s new status.
          Mark an “X” through the old tag, leaving it attached to the patient, and affix a new
          tag in the same location.
          It is key that patients be continually reassessed until all patients have been
          transported.
   ♦ Triage procedures will correspond to the elements of the patient assessment primary
      survey.
          Airway and breathing
                Assess the patient’s respiratory rate and adequacy
                If no respirations are present, reposition the airway as appropriate
                If the above procedure does not initiate spontaneous respiratory effort, TAG
                PATIENT “DEAD/DYING” (black tag)
                If respirations return and are less than 10 or more than 29, or respiratory effort
                is inadequate, TAG PATIENT “IMMEDIATE” (red tag)
          Circulation
                Assess vital signs. If carotid and / or femoral pulse is felt, but radial pulse is
                absent, systolic blood pressure is less than 80 mmHg.              TAG PATIENT
                “IMMEDIATE” (red tag), unless mortal injuries are present.
                If pulse is less than 60 or more than 150 BPM, TAG PATIENT
                “IMMEDIATE” (red tag)
                Check for capillary refill if time and conditions permit. If capillary refill is
                greater than 3 seconds, TAG PATIENT “IMMEDIATE” (red tag)
                If refill is less than 3 seconds, assess mental status




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             Neurologic status (disability)
             Ask the patient to “open and close your eyes” and to “move your         fingers      and
             toes”
             Ask patient their name
             If patient appears awake, but is unable to follow these commands, TAG
             PATIENT PRIORITY “IMMEDIATE” (red tag)
             If the patient can follow these commands, TAG PATIENT PRIORITY
             “DELAYED” (yellow tag) OR “MINOR” (green tag) according to severity of
             injuries
   ♦ The following information will be entered on the triage tag
          Date and time of triage
          Patient name and address
          Pertinent medical information (especially allergies)
          Triage providers name and certification number
          Vital signs and time of assessment
          Medication administered
          Patient injuries (per diagram on tag reverse)
   ♦ Triage providers will remove and retain any colored tabs required to identify triage
      level. Triage tags will be attached securely to the patient’s body in a fashion that is
      easily visible and does not compromise circulation.
   ♦ Treatment and transport procedures
          The sides of the triage tag are perforated to enable easy removal.
          Once the patient has been loaded into a transport vehicle, remove and retain one
          side of the triage tag. This side shall be given to the person in charge of the
          treatment sector upon completion of the multiple casualty incident.




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          Upon arrival at a receiving medical facility, the transporting crew shall remove and
          retain the other side of the triage tag. These sides shall be given to the person in
          charge of the transport sector upon completion of the multiple casualty incident.
          The main body of the triage tag will remain affixed to the patient throughout
          transport and delivery to the medical facility.
          All triage tags and removed portions (tabs, sides) shall be returned to the authority
          in charge of the multiple casualty incident once all persons have been treated and
          transported, and the incident considered complete.


SPECIAL CONSIDERATIONS


   ♦ Triage is a system of identifying and prioritizing patients according to the severity of
      injury and need for treatment.
   ♦ The first personnel to arrive on the scene are responsible for making initial patient
      assessments and should avoid committing themselves to treatment until all triage is
      completed. The initial arriving crews should rapidly assess the situation and determine
      the nature of the incident, the specific location of the incident, the estimated number of
      casualties, and the best routes of access to the scene. This information must be relayed
      immediately to supervisory/command personnel. The initial assessment should be
      made as soon as possible in order to mobilize additional responding units.
   ♦ Examples of “DEAD/DYING” (black tag) conditions:
          Decapitation or other obvious mortal injury (i.e., massive cranial, chest, or
          abdominal injury)
          No ventilations present, even after attempting to open the airway
          Cardiac arrest




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      “DEAD/DYING” patients are those who are obviously dead or whose wounds are so
      severe that death appears imminent, even if ALS treatment is initiated. There is an
      admittedly fine line between the dying patient and a seriously injured patient who may
      survive if treated aggressively. If only one of the patients on the scene appears mortally
      injured, enough manpower and equipment may be available to commit crews to this
      patient’s care.    However, as the number of seriously injured patients increases,
      manpower and equipment may become limited. Under these circumstances, mortally
      injured patients may need to be tagged “DEAD/DYING” with no treatment
      administered, while available resources concentrate on treating a large number of less
      critically injured persons.


      Once tagged, “DEAD/DYING”, patients should be covered, but not moved, unless it is
      necessary to do so to treat other patients. If they must be moved, patients should be
      placed in an “out of the way” location. If possible, mark the location of the body prior
      to moving.


      It should be noted that the designation of a patient as “DEAD/DYING” does not mean
      they cannot benefit from comfort care including removal from uncomfortable positions
      or sites, psychologic support, and the generous use of analgesics. Such comfort care is
      to be provided at the earliest opportunity given the needs of patients with Priority “I”
      status.
   ♦ Examples of “IMMEDIATE” (red tag) conditions:
          Ventilations present after repositioning the airway
          Severe or uncontrollable bleeding
          Severe shock
          Burns involving the respiratory tract or burns associated with fractures
          Major fractures (i.e., skull, pelvis, flail chest)
          Severe medical problems induced or exacerbated by the incident (i.e. heart attack)
          Any patient meeting Volusia County trauma alert criteria




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      “IMMEDIATE” patients are those with treatable, life-threatening injuries / illnesses,
      and those who will benefit most from immediate treatment / transport.
      “IMMEDIATE” patients should be considered as “load and go” and transported as
      early as possible.


   ♦ Examples of “DELAYED” (yellow tag) conditions:
          Moderate burns not involving the respiratory tract or fractures
          Moderate blood loss
          Multiple fractures without circulatory compromise
          Spinal injuries without deficit
          Injuries that could progress if left untreated
      “DELAYED” patients are those with serious, non life threatening injuries who will
      ultimately require ambulance transport. These patients should be transported to the
      hospitals that are the least inundated with patients.


   ♦ Examples of “MINOR” (green tag) conditions:
          Ambulatory patients
          Minor, uncomplicated fractures
          Minor, uncomplicated burns
          Minor soft tissue injuries
          Psychological or emotional problems
      “MINOR” patients are those with minor, easily managed injuries. These patients may
      or may not be ambulatory and / or able to care for themselves. The most common
      problem associated with these patients is the attempt to remove them from the scene so
      as not to interfere with the more important tasks at hand.


   ♦ Depending upon the extent of the incident and the manpower available, it is important
      for the individual(s) handling triage to continually reassess patients, until all
      “IMMEDIATE” patients have been transported. Triage personnel should circulate
      throughout the scene as opposed to having patients brought to them.


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                Use of the Esophageal Tracheal Combitube


DESCRIPTION
   ♦ The Esophageal-Tracheal Combitube (ETC, or “Combitube”) is a double-lumen airway
      featuring proximal and distal balloons. The proximal balloon is designed to lodge in
      and seal off the oropharynx and is inflated with 100-140 cc of air. The distal balloon
      seals the tube against the wall of the esophagus or trachea and holds 15 to 20 cc of air.
      One lumen is open at the distal end; the other is closed, but perforated along the
      midportion of the tube. The ETC is designed to function as either an endotracheal or
      esophageal gastric tube airway depending on the final position of the distal tube. The
      longer blue tube with perforations serves as an EGTA; the shorter clear, open-ended
      tube acts as an ET airway.


      If the tube passes into the esophagus, the patient can be ventilated using the side holes
      in the longer blue tube and the stomach aspirated. If it passes into the trachea, the
      patient can be ventilated through the open holes at the distal end of the clear tube.
      Studies in the hospital setting have shown oxygenation and ventilation equivalent to
      that of endotrahceal intubation in the operating suite using the ETC. One large
      prehospital study indicates that ventilation using the ETC is better than achieved
      through the use of an oral airway/bag-valve-mask combination; other small works
      indicate that ventilation can be as food as that achieved by endotrahceal intubation, but
      that reliability is variable and the complication rate is high.


INDICATIONS
   ♦ Use of the ETC is indicated when the patient requires invasive airway measures and
      providers are unable to perform endotracheal intubation.




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CONTRAINDICATIONS
   ♦ Patient age less than 16 years; presence of a gag reflex; patient conscious or
         semiconscious; known or suspected esophageal disease; known or suspected caustic
         ingestion; insufficient oropharyngeal size for passage of ETC complex into mouth. The
         presence of maxillofacial injuries is a relative contraindication.
COMPLICATIONS
   ♦ Esophageal perforation (2%); aspiration; prompting of gag reflex with loss of spinal
         immobilization and increased intracranial pressure; induction of pharyngeal, or
         esophageal, or laryngeal trauma with bleeding and further loss of airway integrity.


PROCEDURE FOR USE
   ♦ Place patient supine with head in the neutral position (may hyperextend neck slightly if
         cervical spine integrity not at issue)
   ♦ Grasp the tongue and lower jaw between the thumb and index finger; open mouth fully.
   ♦ Insert Combitube until printed rings aligned with teeth.
   ♦ Inflate blue pilot balloon (linked to pharyngeal balloon) with 100 cc air.
   ♦ Inflate white pilot balloon (linked to distal balloon) with 15 cc air.
   ♦ Ventilate the patient through the longer blue tube using PPVD. Assess for breath
         sounds over both sides of the chest, the absence of epigastric sounds, and watch for
         chest rise. If these signs are noted, continue to ventilate through this tube.
   ♦ If patient assessed not to be ventilated through longer blue tube, ventilate patient using
         shorter clear tube. Again assess for breath sounds over both sides of the chest, the
         absence of epigastria sounds, and watch for chest rise. If these signs are noted,
         continue to ventilate through this tube.
   ♦ Secure airway in position; continue to ventilate patient through appropriate tube using
         100% O2 via PPVD.
   ♦ If patient regains consciousness, remove Combitube. Extubation is likely to be
         followed by vomiting. Suction should be ready for immediate use.


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                               Evidenciary Blood Draw


1. Initiate medical care as per the appropriate protocol.

2. If the patient is in legal custody of law enforcement, blood samples can be obtained even if
        the patient does not consent. If the patient is NOT in custody of law enforcement, the
        patient can refuse to have blood drawn.

3. Determine if you can safely (without jeopardizing patient care) draw the blood and convey
      to officer requesting draw.

4. Draw blood as per procedure (see next page)

5. Record date on kit, officer’s name, and how you drew blood in your report.

6. Complete the appropriate sections of paperwork enclosed with the blood draw kit which
     pertain to EMS as directed by Law Enforcement Officer.


REFUSAL OF TREATMENT AND/OR TRANSPORT (for person that will be
treated and released)

1. Assess the patient’s mental ability to refuse.
      • If mentally incompetent, enlist law enforcement to aid transport.
      • If mentally competent, completely advise patient of possible complications (with
          witness present) and advise patient they will have to sign refusal.

2. Draw blood as per procedure (see next page).

3. Record date on kit, officer’s name, and how the blood was drawn in your report. Have the
      patient sign a refusal, if warranted, and have the same officer witness the refusal.

4. Complete the appropriate sections of paperwork enclosed with the blood draw kit which
     pertain to EMS as directed by Law Enforcement Officer.


Note: All patients from which evidenciary blood samples are drawn, regardless of patient
chief complaint, are considered ALS patients for the purpose of care & documentation. A
patient history and assessment that includes vital signs, blood glucose level, and ECG should
be obtained, on all patients that are having blood drawn.




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Procedure:
1.    Open needle cartridge. Twist to break the tamper-evident seal. Remove cap, exposing
      the back portion of the needle and threaded hub. Do not remove front needle cover.




2.    Assemble needle to holder. Thread needle into holder until firmly seated.




3.    Insert VACUTAINER tube into holder. Push straight onto needle, no further than the
      guideline on the holder.




4.    Apply tourniquet, prepare venipuncture site using only the non-alcoholic antiseptic
      pad provided in this kit. Position the arm in a downward or lowered altitude.




5.    Remove needle cover; perform venipuncture in the usual manner, keeping the tube in
      an upward position with the stopper upper-most.




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6.    Push VACUTAINER tube forward to end of holder, piercing the rubber stopper. When
      blood flows into tube, REMOVE TOURNIQUET AS SOON AS BLOOD BEGINS TO
      FILL TUBE. DURING THIS PROCEDURE, DO NOT ALLOW CONTENTS OF
      VACUTAINER TUBE TO CONTACT STOPPER. SPECIAL ATTENTION SHOULD
      BE GIVEN TO ARM POSITION, TUBE POSITION IN ORDER TO PREVENT
      POSSIBLE BACKFLOW FROM THE TUBE AND ITS ATTENDANT POSSIBILITY
      OF ADVERSE REACTION TO THE PATIENT.




7.    When the tube fill is complete and blood ceases to flow, remove the tube from the
      holder. Insert the second VACUTAINER tube straight into the holder until blood
      flows.




8.    When sampling is completed immediately remove the needle/holder assembly with the
      last VACUTAINER, then remove the tube from the assembly: Apply and hold a dry
      sterile compress to the venipuncture site. Elevate the arm.




9.    To assure proper mixing with anticoagulant powder, slowly invert the tubes at least
      five times immediately after blood collection. DO NOT SHAKE VIGOROUSLY!




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                        Authorized Pharmaceuticals
The following pharmaceuticals are authorized to be administered under the parameters set
forth in the Volusia County EMS System Protocols:

This list does not include specialized Hazardous Materials pharmaceuticals.

Albuterol (Proventil)                             Gluctose Paste
Aspirin (Baby)                                    Lidocaine 2%
Atropine Sulfate                                  Magnesium Sulfate
Calcium Chloride                                  Methylprednisone (SoluMedrol)
Dextrose 50%                                      Morphine Sulfate
Diazepam (Valium)                                 Naloxone (Narcan)
Diltiazem (Cardizem)                              Nitroglycerin
Diphenhydramine (Benadryl)                        Procainamide (Pronestyl)
Dopamine (Intropin)                               Promethazine (Phenergan)
Epinephrine 1,1000                                Sodium Bicarbonate
Epinephrine 1, 10,000                             Succinylcholine
Etomidate                                         Tetracaine
Furosemide (Lasix)
Glucagon




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                             Medication Resume (600)

                                 Albuterol (Proventil)

CLASSIFICATION
   ♦ A relatively selective Beta2 - adrenergic bronchodilator


ACTION
   ♦ Proventil has been shown to have effect on the respiratory tract, in the form of
       bronchial smooth muscle relaxation. Studies have shown Proventil can produce a
       significant cardiovascular effect in some patients, as measured by increased pulse rate,
       increased blood pressure, palpitations and/or ECG changes.
DOSAGE
   ♦ One unit dose (2.5 mg as 3 cc of 0.083% solution) by nebulizer. Flow rate is regulated
       to suit the particular nebulizer so that Proventil solution will be delivered in
       approximately 5 to 15 minutes.


ROUTE OF ADMINISTRATION
   ♦ Nebulizer


DIRECTIONS
   ♦ Twist open the top of one bottle and pour the contents into the nebulizer reservoir.
   ♦ Connect the nebulizer reservoir to the mouthpiece or facemask.
   ♦ Connect the nebulizer to compressed air.
   ♦ Place the mouthpiece in patient's mouth; and turn on compressed air to activate
       nebulizer.
   ♦ Have patient breath as calmly, deeply and evenly as possible until no more mist is
       formed in the nebulizer chamber.




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SIDE EFFECTS
   ♦ Tremors, headache, insomnia, hypertension, arrhythmias, palpitations, bronchospasm,
       cough, wheezing, sputum increase, dyspnea, nausea, malaise


CONTRAINDICATIONS
   ♦ In any patients with a history of hypersensitivity to any of it's components.


NOTES
   ♦ More frequent doses not recommended.          Caution should be used in patients with
       cardiovascular disorders, hypertension, convulsive disorders, hyperthyroidism,
       diabetes, and those with unusual response to sympathomimetic amines.




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Medication Resume continued


                                      Atropine Sulfate

CLASSIFICATION
   ♦ Parasympatholytic
   ♦ Vagal blocker
   ♦ Cholinergic blocking agent (inhibits action of acetylcholine and nerve endings)


ACTION
   ♦ Blocks vagal impulses, which may be responsible for brady-arrhythmias, such as sinus
       bradycardia, sinus arrhythmia, sinus block or arrest, high degree A/V heart blocks and
       slow ventricular rhythms. Onset of action is within one minute and the peak of action
       is within 2 - 5 minutes. By reducing vagal tone it accelerates the rate of discharge at
       the S/A node and speeds conduction through the A/V node, thus increasing the heart
       rate. Atropine should be used only in those situations in which a bradyarrhythmia is
       accompanied by hypotension, decreased level of consciousness, or by frequent
       ventricular irritability.


DOSAGE
   ♦ ADULT
           Asystole:
               1.0 mg IV, and repeated in 3 to 5 minutes up to a maximum dosage of 3.0 mg
               (0.04 mg/kg)
           Bradycardia:
               0.5 mg to 1.0 mg IV every 3 to 5 minutes to a total dose of 3.0 mg (0.04 mg/kg).




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   ♦ PEDIATRIC
               0.02 mg/kg of body weight. The dose may be repeated in 5 minutes, to a
               maximum total dose of 1.0 mg in a child and 2.0 mg in an adolescent.
               Minimum single dose 0.1 mg.
               Maximum single dose: 0.5 mg in child, 1.0 mg in adolescent.


ROUTE OF ADMINISTRATION
               Rapid IV push


SIDE EFFECTS
   ♦ Flushed, dry warm skin, dryness of the mouth, nose and throat, blurred vision, dilated
       pupils, rapid pulse and increased respiration. Toxic doses may produce stupor and
       coma.


NOTE
   ♦ Atropine dilates the pupils.
   ♦ An acceleration in the cardiac rate may result in increased myocardial O2 consumption
       in patients with acute MI or ischemia, which can be deleterious to the patient.
   ♦ Adult doses of atropine sulfate of less than 0.5 mg may be parasympathomimetic and
       further slow the cardiac rate.
   ♦ Organophosate and/or organphonte like poisoning may require mass doses, there will
       be no max dose.




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                                 Calcium Chloride

CLASSIFICATION
   ♦ Inotropic drug - increases contractility


ACTION
   ♦ Although calcium ions play a critical role in myocardial contractile performance and
       impulse formation, retrospective and prospective studies in the majority of patients with
       cardiac arrest have not demonstrated benefit from the use of calcium. In addition, there
       is considerable theoretical reason to believe that the high levels induced by calcium
       administration may be detrimental to cardiac and neurologic survival.           However,
       calcium therapy is very effective at combating the effects of hyperkalemia,
       hypocalcemia, and calcium channel blocker toxicity, and should be used in patients
       suspected to be suffering from these conditions, even if the patient is also in cardiac
       arrest.


DOSAGE
   ♦ Calcium chloride can be given in a dose of 2 to 4 mg/kg (10% solution) IVP and
       repeated as necessary at ten (10) minute intervals. The 10% solution contains 13.6
       mEq of calcium (100 mg = 1ml).


SIDE EFFECTS
   ♦ An excess of calcium chloride induces systolic arrest (calcium rigor), anorexia,
       weakness, depression, polyuria vomiting and diarrhea. Sudden death has occurred
       following IV injections of calcium. Calcium Chloride should be administered with
       caution in patients taking digoxin.




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Medication Resume continued



CONTRAINDICATIONS
   ♦ Calcium Chloride is contraindicated in the presence of high amplitude or coarse
       ventricular fibrillation.


NOTE
   ♦ ALWAYS FLUSH IV TUBING BEFORE ADMINISTRATION. It is not compatible
       with other drugs, especially sodium bicarbonate.




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                            Dextrose 50% in Water (D50)


CLASSIFICATION
   ♦ Hypertonic glucose solution.


ACTION
   ♦ Corrects hypoglycemia in patients displaying a variety of symptoms of insulin shock,
       such as trembling, diaphoresis, seizures, and coma.


DOSAGE
   ♦ ADULT
           50 ml (25 grams) IVP, may be repeated, as needed
   ♦ CHILDREN
           1 ml/kg initially, may be repeated as needed. Young children; dilute 50/50 with
           sterile water (D25W).


DILUTION PROCEDURE
       •   Dextrose 50% in water is a very hypertonic solution of 25 grams of Dextrose in
           50ml water.

       •   Create D25/W by removing 25ml from the 50ml syringe and drawing up 25ml of
           saline or sterile water into the D50 syringe.



ROUTE OF ADMINISTRATION
   ♦ Slow IV only.


SIDE EFFECTS
   ♦ Hyperglycemia, diuresis and spinal hemorrhage.



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CONTRAINDICATIONS                                                                         604
   ♦ Hyperglycemia, diabetic coma, delirium tremens, intracranial and spinal hemorrhage.


PRECAUTIONS
   ♦ Avoid extravasation. Check IV site frequently to prevent irritation, tissue sloughing,
       necrosis and phlebitis. Use cautiously in cardiac or pulmonary disease, hypertension or
       renal insufficiency.




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                                Diazepam (Valium)


CLASSIFICATION
   ♦ Central nervous system depressant, anticonvulsant, sedative, and skeletal muscle
       relaxant.


ACTION
   ♦ Valium will be used primarily in the field for severe recurrent convulsive seizures,
       especially during status epilepticus. It is indicated for sedation, anxiety, tension and
       severe muscle spasm, and for induction of relaxation prior to endotracheal intubation.


DOSAGE
   ♦ Administer diazepam 5-10 mg slow IVP, IO, or via ETT.


ROUTE OF ADMINISTRATION
   ♦ Extreme care should be taken especially in debilitative patients. Be prepared to support
       respirations. When used for induction prior to endotracheal intubation, the dose should
       be administered via rapid IV push.


SIDE EFFECTS
   ♦ Respiratory depression, fatigue, drowsiness, headache, weakness, slurred speech,
       blurred vision, etc. Skin sloughing, pain and phlebitis at site of injection. Overdosage
       may cause drowsiness, confusion, coma, diminished reflexes and respiratory
       depression.




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NOTES
   ♦ Rare instances of allergic reactions have occurred.
   ♦ Do not use small veins if possible.
   ♦ The onset of action is rapid following IV administration and effects of an IV dose may
       persist for as long as three (3) hours. However, the blood level falls relatively quickly,
       so patients may seize again within 10, 15 or 30 minutes following the administrative
       dose. Valium readily passes the placental barrier with the concentration of the drug in
       the fetal circulation approaching that in maternal circulation.


RECTAL ADMINISTRATION OF DIAZEPAM


   ♦ INDICATIONS
           Unable to establish peripheral IV access.
           Patient in status seizure activity.


   ♦ EQUIPMENT NEEDED FOR RECTAL ADMINISTRATION
           #16 or #18 needle
           10 cc or 12 cc syringe
           #l4 to #l6 gauge IV catheter
           Valium ampule


   ♦ PROCEDURE FOR RECTAL ADMINISTRATION
           Attach #16 or #18 needle to 10 cc or 12 cc syringe.
           Draw 10 mg diazepam (2 cc ampule/10 mg) into syringe
           Draw 8 cc 0.9% sodium chloride into same syringe. Resulting concentration of
           diazepam is 1 mg/cc.
           Remove #16 or #18 needle from syringe




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           Remove the needle (stylet) from a #14 or #16 gauge IV catheter (dispose of sharps
           properly)
           Attach the #14 or #16 IV catheter (without needle/stylet inside) to the same 10 cc or
           12 cc syringe
           Place the patient on side with knees bent forward, if possible.
           Insert catheter into rectum and slowly administer until seizure activity stops.




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                                  Diltiazem (Cardizem)

CLASSIFICATION
   ♦ Calcium channel blocker


ACTION
   ♦ Diltiazem blocks calcium and sodium flux across cell membranes in the AV node,
       slowing conduction and increasing refractory periods. Diltiazem may terminate re-
       entrant supraventricular tachycardias (PSVT), and will allow rate control in other
       supraventricular tachydysrhythmias (atrial fibrillation and atrial flutter).


INDICATION
   ♦ It is indicated for use in patients with all forms of narrow-complex tachydysrhythmias.


DOSAGE
   ♦ 20 mg IVP over 1-2 minutes as a single bolus dose.


ROUTE OF ADMINISTRATION
   ♦ Intravenous


SIDE EFFECTS
   ♦ Hypotension, bradycardia, flushing




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CONTRAINDICATIONS
   ♦ Known hypersensitivity, hypotension, bradycardia (absolute); AV block, congestive
       heart failure, concomitant use of beta-blockers (relative).


NOTES
   ♦ In the event of hypotension or bradycardia, 10 cc of calcium chloride 10% solution may
       be administered IVP. The dose may be repeated to effect.
   ♦ Diltiazem is not to be used with suspected wide-complex tachycardias. These are to be
       treated as if they are ventricular in origin (V-tach).
   ♦ Patients with PSVT may exhibit rate conversion after use of diltiazem. Diltiazem will
       not convert atrial fibrillation or atrial flutter, but will reduce ventricular rate.




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Medication Resume continued

                            Diphenhydramine (Benadryl)


CLASSIFICATION
   ♦ Antihistamine/Antipruritic


ACTION
   ♦ Benadryl is an antihistamine/antipruritic used to combat the mild and uncomplicated
       symptoms of urticaria and angioedema associated with allergic or anaphylactic reactions
       and as an adjunct to epinephrine.


INDICATION
   ♦ Allergic reaction and/or extra pyramidal symptoms.


CONTRAINDICATIONS
   ♦ Benadryl is contraindicated in acute asthmatic attacks. Use cautiously in narrow-angle
       glaucoma, prostatic hypertrophy, and stenosing peptic ulcers; in newborns; and in
       asthmatic, hypertensive, or cardiac patients.


SIDE EFFECTS
   ♦ Benadryl can cause hypotension, headache, palpitations, tachycardia, extrasystoles,
       dizziness, fatigue, confusion, restlessness, excitation, nervousness, tremor, irritability,
       insomnia, euphoria, paresthesias, vertigo, tinnitus, hysteria, neuritis, convulsions, blurred
       vision, diplopia, anorexia, vomiting, diarrhea, urinary retention, thickening of bronchial
       secretions, tightness in the chest and wheezing, chills, excessive perspiration, and dry
       mouth, nose and throat.




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DOSAGE
   ♦ ADULT
               25-50 mg IM (deeply) or IV.
   ♦ PEDIATRIC
               1 mg/kg, IM (deeply) or IV.


NOTES
   ♦ Use of Benadryl in conjunction with alcohol, tranquilizers, sedatives, hypnotics, and other
       CNS depressants increases CNS depression.
   ♦ Use of Benadryl in conjunction with MOA inhibitors causes an increase in
               anticholinergic effects (dry mouth, nose and throat).




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                                 Dopamine (Intropin)

CLASSIFICATION
   ♦ Chemical precursor of norepinephrine that stimulates dopaminergic, beta-2-adrenergic,
       and alpha-adrenergic receptors.


ACTION
   ♦ Dosage-related;
           5-10ug/kg/min stimulates both beta-1- and alpha-adrenergic receptors, resulting in
           increased cardiac output.
           > 10ug/kg/min stimulates alpha-adrenergic receptors, resulting in renal, mesenteric,
           and peripheral arterial and venous vasoconstriction.
           Indicated in cardiogenic shock and hemodynamically significant hypotension.


INDICATION
   ♦ Cardiogenic shock and hemodynamically significant hypotension.


DOSAGE
   ♦ Initially 5 ug/kg/min; titrate to systolic blood pressure > 90 mmHg. 400 mg in 500 cc
       0.9% NS yields a concentration of 800 ug/ml; 400 mg in 250 cc, 800 mg in 500 cc, and
       1600 mg in 1000 cc all yield a concentration of 1600 ug/cc. Note that “street rules” for
       calculation of dopamine dose in drops per minute (weight in pounds, drop last digit,
       then subtract 1) are applicable only with concentrations of 1600 mg/ml.


ROUTE OF ADMINISTRATION
   ♦ IV Drip (piggyback)




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SIDE EFFECTS
   ♦ Tachydysrhythmias may result from dopamine; ectopic beats, nausea and vomiting are
       more frequent adverse effects; may produce tissue necrosis and sloughing.


PRECAUTIONS
   ♦ Patients receiving monoamine oxidase inhibitors should receive no more than one-tenth
       of the normal dosage of dopamine. Dopamine should not be discontinued abruptly but
       should be tapered gradually.


CONTRAINDICATIONS
   ♦ Dopamine is contraindicated in patients with pheochromocytoma (causes serious acute
       hypertension).


NOTE
   ♦ Administration of dopamine should be titrated to the desired hemodynamic effect
       (usually low normal blood pressure).




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                                 Epinephrine

CLASSIFICATION
   ♦ Sympathomimetic (mimics sympathetic nervous system). Epinephrine is a hormone
       produced by the adrenal glands. Epinephrine stimulates both alpha and beta receptors
       and is an inotropic, chronotropic, and dromotropic agent.


ACTION
   ♦ It increases blood pressure, increases heart rate, causes peripheral vasoconstriction, has
       an effect on the smooth muscles, therefore relaxing constriction and spasms of the
       bronchi. It is used in the treatment of allergic conditions such as anaphylaxis, including
       angioneurotic edema and status asthmaticus. It also relieves local edema by direct
       action on small blood vessels. Epinephrine is a physiological antagonist to histamine.
   ♦
       Epinephrine elevates perfusion pressure generated during cardiac compression,
       improves myocardial contractility, stimulates spontaneous contractions (such as in
       ventricular standstill), and increases myocardial tone, which is accompanied by
       conversion of a fine fibrillation to a coarser one, thus more susceptible to termination to
       countershock. The following responses may be noted during resuscitation:


           Increased heart rate (chronotropic)
           Increased myocardial contractility (inotropic)
           Increased systematic vascular resistance (alpha response)
           Increased arterial blood pressure
           Increased pulse pressure
           Increased cardiac output
           Increased coronary blood flow




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           Increased myocardial oxygen consumption
           Increased muscle irritability
   Onset is immediate; peak action 1-2 minutes; duration 3-5 minutes. Administered every 3
   to 5 minutes during resuscitation.


INDICATION
   ♦ PEA asystole, cardiac arrest, tachycardia without a pulse, anaphylaxis, bronchospasm
       not associated with CHF.
   ♦
DOSAGE
   ♦ Allergic Reaction/Anaphylaxis
           ADULT:             0.3 cc 1:1,000 SQ = .3mg
           CHILDREN:          0.01 cc/kg 1:1,000 SQ = .01mg/kg


   ♦ Anaphylaxis with Hypotension
           ADULT:             3.0 cc 1:10,000 IVP = 0.3mg
           CHILDREN:          0.1 cc/kg 1:10,000 IVP = 0.01mg/kg


   ♦ Cardiac Arrest
           ADULT:             1 mg 1:10,000 IVP. Epinephrine is administered endotracheally
                              at 2-2.5 times the IV dose.
           CHILDREN:          Initial bolus of 0.01 mg/kg 1:10,000 IV/IO or 0.1 mg/kg 1:1000
                              via ETT; repeat bolus dose is 0.1 mg/kg 1:1000 IV/IO/ETT.




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ROUTE OF ADMINISTRATION
   ♦ May be given subcutaneous or intramuscular or IV to adults. Usually SQ is preferred
       for children. Brisk massage of the site of injection will hasten the action of the drug.
       Do not expose ampules to light for prolonged periods and do not use if a reddish or
       brownish discoloration has occurred.
   ♦ Epinephrine should be given early in the resuscitation effort IV or via the endotracheal
       tube. The IV route is preferred if immediately available.


SIDE EFFECTS
   ♦ Any of the physiological actions listed under epinephrine 1:10,000 are indicated. In
       addition, pallor, nervousness, palpitations, anxiety, headache, sweating, hypertension,
       elevated blood sugar, tachycardia, arrhythmias, and CVAs. May cause dilation of
       pupils and increased intraocular pressure, which may be harmful in patients with
       glaucoma. Hypertension may also be a secondary effect. Epinephrine will worsen
       such conditions as cerebral arteriosclerosis, hypertension, shock, ventricular
       arrhythmias, and angina.


CONTRAINDICATIONS
   ♦ Pregnancy is a relative contraindication.


NOTES
   ♦ Do not mix epinephrine with any other drug, especially bicarbonate for epinephrine
       will be neutralized.
   ♦ Do not use solution if reddish or brownish in color.
   ♦ Remember to correct acidosis prior to administering epinephrine, as it is less effective
       in an acidotic state.
   ♦ Monitor the patient's rhythm frequently.




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                              ETOMIDATE (Amidate)


CLASSIFICATION
   ♦ A non-narcotic, non-barbiturate sedative-hypnotic agent.


ACTION
   ♦ Etomidate’s main effect is the production of hypnosis, with a time of onset of 10-15
       seconds and a duration of action of 5-15 minutes.           It may lower intraocular and
       intracranial pressure, and lowers the rate of cerebral oxygen utilization. The elderly
       appear to be more sensitive to the effects of etomidate than are younger patients.


INDICATION
   ♦ The use of etomidate is indicated in the non-cardiac arrest patient requiring
       endotracheal intubation.


DOSAGE
   ♦ 0.3 mg/kg IV over 30-60 seconds. In the elderly, consider an initial bolus of 10 mg,
       followed by an additional 0.3 mg/kg up to a total dose of 20 mg, as required for effect.


ROUTE OF ADMINISTRATION
   ♦ Etomidate must be given IV. As the agent can be irritating to vascular walls, a large
       venous site (i.e. antecubital) is preferred for administration, but is not required.




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SIDE EFFECTS
   ♦ The most important side effect is myoclonus, or diffuse muscle contraction, which may
       be very painful after the patient awakens.      Other side effects include pain at the
       injection site, apnea, hypotension, tachycardia, nausea, and vomiting.            Adrenal
       suppression has been reported after use of chronic etomidate infusions, but this is not
       seen in single bolus dosing. It is important to note that etomidate does not cause
       analgesia; reflex sympathetic hypertension and tachycardia may be anticipated.



CONTRAINDICATIONS
   ♦ Known hypersensitivity to the agent.


NOTES
   ♦ While etomidate is not associated with increased intracranial pressure (and may, in fact,
       decrease ICP), the preintubation use of lidocaine in patients with suspected head injury
       or increased intracranial pressure is recommended (as time allows).
   ♦ To prevent the occurrence of painful myoclonus, the preintubation use of diazepam is
       recommended (as time allows).
   ♦ While adrenal suppression has not been reported after single doses of etomidate,
       methylprednisolone 125 mg should be considered for administration in patients on
       chronic oral corticosteroid therapy (Prednisone).




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                                   Furosemide (Lasix)

CLASSIFICATION
   ♦ Potent diuretic


ACTION
   ♦ Lasix inhibits the reabsorption of sodium at the proximal and distal tubules of the
       kidney thus promoting diuresis. Diuresis commences in five (5) minutes after IV
       injection, reaches peak in 30 minutes, and lasts up to two (2) hours.


INDICATION
   ♦ Lasix may be used in the treatment of acute pulmonary edema, congestive heart failure,
       drownings, and post-resuscitation to stimulate kidneys and decrease cerebral edema.


DOSAGE
   ♦ ADULT:            The usual initial dose is 40 to 100 mg.


   ♦ CHILDREN: 1 mg/kg (not frequently used in the field).


ROUTE OF ADMINISTRATION
   ♦ Slow IV push (1 to 2 minutes)


SIDE EFFECTS
   ♦ Dermatitis, flushing, blurred vision, postural hypotension, nausea and vomiting.
       Vascular thrombosis and embolism are possible, especially in elderly or debilitated
       patients.




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NOTES
   ♦ Hypersensitivity or allergic reactions are possible, especially in those patients who are
       allergic to sulfa drugs or thiazide diuretics, also those patients who are allergic to oral
       hypoglycemia agents
   ♦ Lasix is not to be used in dehydrated patients or those patients who have renal failure or
       bladder obstruction problems.
   ♦ Dehydration and blood volume depletion can result and can contribute to circulatory
       collapse.
   ♦ Potassium depletion may pose a serious threat to patients with acute coronary heart
       disease and as well as those patients on digitalis therapy.
   ♦ Remember: COPD-like pulmonary edema may be present with pulmonary basilar and
       pre-tibial edema.




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                                      Glucagon

CLASSIFICATION
   ♦ Antihypoglycemic


ACTION
   ♦ Glucagon is extracted from beef and pork pancreas. It causes an increase in blood
       glucose concentration and is used in the treatment of hypoglycemia. Glucagon acts
       only on liver glycogen, converting it to glucose.


INDICATION
       ♦ Hypoglycemia with no IV access


DOSAGE
   ♦ ADULT:                   1 - 2 mg IM or SQ
   ♦ PEDIATRIC:               0.5 - 1 mg IM or SQ


ROUTE OF ADMINISTRATION
   ♦ May be given intramuscularly or subcutaneously. The diluent is provided for use only
       in the preparation of Glucagon and is intended for no other use. Glucagon should not
       be used in concentrations greater than 1 mg (1 unit/ml).


SIDE EFFECTS
   ♦ Occasional nausea and/or vomiting. Generalized allergic reactions (hives, itching,
       respiratory distress) and hypotension have also been reported.




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NOTES
   ♦ The patient will usually awaken within 15 minutes.
   ♦ When the patient responds, give supplemental carbohydrate to restore the liver
       glycogen and to prevent secondary hypoglycemia.
   ♦ Glucagon solutions should not be used unless they are clear and of a water-like
       consistency.




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                                         Lidocaine

CLASSIFICATION
   ♦ Local anesthetic, depresses ventricular irritability
ACTION
   ♦ Lidocaine is most useful in the suppression of dysrhythmias of ventricular origin for it
       decreases automatically by slowing the rate of spontaneous phase for depolarization of
       the action potential of the myocardial cells. It reduces non-uniform recovery thus
       terminating re-entry to ventricular dysrhythmias.         A therapeutic blood level of
       Xylocaine increases the fibrillation threshold accompanying acute myocardial ischemia
       and ventricular premature beats. Lidocaine does not produce a significant fall in blood
       pressure, decreased myocardial contractility, or diminished cardiac output. Lidocaine
       appears to be a very stable drug when mixed with other drugs. Onset of action is
       approximately 2 minutes with a duration of approximately 10 to 20 minutes.
INDICATION
   ♦ In the presence of an acute infarct, the drug is effective in the control of a ventricular
       ectopic activities of several forms which would include more than five PVC's per
       minute, R on T phenomena, multifocal, back-to-back, and short runs of V-tach or salvo,
       also indicated for ventricular tachycardia and ventricular fibrillation.
DOSAGE: BOLUS
   ♦ ADULT
           V-fib & pulseless V-Tach: 1.5 mg/kg IV. Repeat in 3-5 minutes to total dose of 3
           mg/kg. V-Tach with a pulse or PVC’s: 1.0 - 1.5 mg/kg IV. Repeat every 5-10
           minutes at 0.5-0.75 mg/kg to a total of 3 mg/kg. Prior to endotracheal intubation in
           patients with known or suspected head injury or stroke, administer 1.5 mg/kg IVP
           as time allows.




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   ♦ CHILDREN
           1.5 mg/kg IV or IO route for all indications (give 2.0-2.5 times normal dose if given
           ET)


DOSAGE: INFUSION
   ♦ Adult
           1 to 4 mg per minute.
               Dilute 2 Gm of Lidocaine in 500 cc of 0.9% NS administer with a pedi-drip (60
               gtts/ml). This provides a concentration of 4 mg per ml.
   ♦ Children
           20 to 50 ug/kg/minute.
               This infusion can be prepared by adding 120 mg of lidocaine to the amount of
               0.9% NS needed to create a total solution volume of 100 ml. Administer with a
               pedi-drip (60 gtts/ml). An infusion rate of 1.0 to 2.5 ml/kg/hr will deliver 20 to
               50 ug/kg/minute. (10 gtts/min = 10 ml/hr)


SIDE EFFECTS
   ♦ High doses may produce convulsions and respiratory arrest. Usual doses may produce
       central nervous system reactions such as drowsiness, dizziness, visual disturbances,
       disorientation, euphoria, psychosis, etc. Overdoses may produce hypotension,
       conduction disorders, heart block, cardiovascular collapse, and bradycardia. Lidocaine
       should not be used in patients with third degree heart block or PVC's in presence of
       sinus bradycardia. Lidocaine is rapidly metabolized by the liver and excreted via the
       kidney. Therefore, such conditions as liver disease, severe renal disease, congestive
       heart failure, marked hypoxia, severe respiratory depression, hypovolemia, or shock
       will increase the risks of toxic effects and require reduction of dosage.




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CONTRAINDICATIONS
   ♦ If allergic to lidocaine, consider procainamide.


NOTES
   ♦ Allergic reactions have occurred with the use of Lidocaine.
   ♦ Only bolus therapy should be used in the cardiac arrest setting.
   ♦ After successful resuscitation, a continuous infusion should be initiated at 1 to 4
       mg/minutes.
   ♦ Observe for signs of Lidocaine toxicity.
   ♦ Lidocaine drip should be infused for up to 24 hours following ventricular
       tachycardia/fibrillation or until ventricular irritability has been terminated.
   ♦ Patient should be on the monitor
   ♦ Caution should be used on patients in congestive heart failure, with bundle branch
       blocks, hepatic disease, hypovolemic shock, and sinus bradycardia.
   ♦ REMEMBER: Only bolus therapy should be used in the cardiac arrest setting
   ♦ REMEMBER: After successful resuscitation, a Lidocaine drip should be administered.
   ♦ Observe the signs of lidocaine toxicity as mentioned in side effects.
   ♦ REMEMBER: Do not use in the presence of third degree heart block or in the presence
       of sinus bradycardia with PVCs.




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                          Magnesium Sulfate 50% Solution

CLASSIFICATION
   ♦ Anticonvulsant, antihypertensive, antiarrhythmic


ACTION
   ♦ Magnesium prevents or controls convulsions by blocking neuromuscular transmissions.
       Magnesium is said to have a depressant effect on the central nervous system, but it does
       not adversely affect the mother, fetus or neonate when used as directed in eclampsia or
       pre-eclampsia. Magnesium acts peripherally to produce vasodilation, and stabilizes
       cardiac membranes to decrease propagation of arrhythmias.


INDICATION
   ♦ Torsades, eclampsia, pre-eclampsia, bronchospasm


DOSAGE
           Condition                        Adult                          Pediatric
Torsades                        1-2 g IV diluted in 100 mL of N/A
                                D5W over 1-2 min


Eclampsia                       4 Gm IV piggyback in 50 cc       N/A
                                NS over 15-30 minutes

Bronchospasm                    2 Gm slow IVP in 50 cc of
                                NS over 30 seconds for
                                deteriorating or non-
                                responding asthma patients (if
                                no renal disease and CHF not
                                suspected)




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ROUTE OF ADMINISTRATION
       Both intravenous and intramuscular administration are appropriate. IV doses have the
       benefit of providing therapeutic plasma levels almost immediately.


SIDE EFFECTS
   ♦ Flushing, sweating, hypotension, depressed reflexes, flaccid paralysis, hypothermia,
       circulatory collapse, respiratory paralysis.




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CONTRAINDICATIONS
   ♦ IV magnesium should not be given to mothers with toxemia during the two hours
       preceding delivery.


NOTES
   ♦ Do not administer unless solution is clear.
   ♦ With IV administration, the onset of anticonvulsant action is immediate and lasts about
       30 minutes.
   ♦ IV use in eclampsia should be reserved for immediate control of life threatening
       convulsions.
   ♦ The antidote for magnesium sulfate overdose is 10 cc of 10% calcium chloride or
       calcium gluconate given IV.




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                    Methylprednisolone Succinate (SoluMedrol)

CLASSIFICATION
   ♦ Corticosteroid


ACTION
   ♦ While the exact mechanism of corticosteroid activity is unknown, these agents decrease
       inflammatory and immune responses by stabilizing membranes within white blood cells
       responding to a site of infection, injury, irritation, or inflammation.


INDICATION
   ♦ Anaphylaxis, airway disease, spinal cord injuries, and adrenal insufficiency.

DOSAGE
   ♦ The dosage in both respiratory and allergic conditions is 125 mg in adults (pediatric
       dose is 2 mg/kg).


ROUTE OF ADMINISTRATION
   ♦ Methylprednisolone is preferentially administered IV. It may also be administered IM
       in equivalent doses in adults.




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SIDE EFFECTS
   ♦ The majority of adverse reactions to corticosteriods are dose and duration dependent.
       In the EMS setting, look for euphoria, behavioral alterations, hypertension, and
       hyperglycemia. Effects of long-term use include edema, cataracts, peptic ulceration,
       pancreatitis, delayed wound healing, acne, the development of a “buffalo hump”(a
       subcutaneous fat deposit over the upper thoracic vertebrae), rounded “moon facies,”
       osteoporosis, hirsutism, hypokalemia, and increased susceptibility to infection.


CONTRAINDICATIONS
   ♦ Use of this agent is contraindicated in patients allergic to any component of the
       formulation, those with systemic fungal infections (ask about these in patients on
       chemotherapy or with AIDS), and in premature infants.


NOTES
   ♦ Methylprednisolone is also used in emergency care in the initial management of spinal
       trauma.   A dose of 30 mg/kg is administered over one hour followed by a 5.4
       mg/kg/hour drip. As this medication has a “window” of 3-8 hours after injury for
       administration, it is not in protocol for this agent to be used by Volusia County EMS
       personnel for this indication.
   ♦ There are a number of forms of methylprednisolone. Methylprednisolone acetate can
       be used IM or injected into joint spaces and is used in the management of chronic
       inflammatory conditions such as rheumatoid arthritis. Methylprednisolone itself is
       taken orally, and is found in medications such as Medrol Dose-Paks used in the follow-
       up care of patients with allergic reaction, asthma, and COPD.




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                                Morphine Sulfate

CLASSIFICATION
   ♦ Narcotic analgesic


ACTION
   ♦ Used to relieve severe pain, acts mainly as a CNS depressant to produce analgesia and
       sedation.


INDICATION
   ♦ It is the drug of choice in relieving pain of myocardial infarctions and extremely useful
       in patients with acute pulmonary edema for its cardiovascular effects in allaying
       anxiety. Morphine causes pooling thus reducing left ventricular stress and relieving
       pulmonary congestion. In addition, it decreases the myocardial oxygen requirement.


DOSAGE
   ♦ ADULT, pain control
           IV slow push 2-4 mg increments depending on patient requirements, titrating to
           response. Total dose not to exceed 10 mg.
   ♦ CHILDREN
           .1 mg/kg IVP (all indications), maximum dose .2 mg/kg


ROUTE OF ADMINISTRATION
   ♦ IV route used in severe pain requiring immediate relief. Peak analgesia occurs 50
       to 90 minutes after Sub-Q injection, 30 to 60 minutes after IM injection.




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SIDE EFFECTS
   ♦ In patients with myocardial infarction, Morphine may cause severe hypotension. To
       decrease the possibility of the development of hypotension, the patient's legs should be
       elevated.   Respiratory depression and, to a lesser degree, circulatory depression
       (including orthostatic hypotension) are the chief hazards of Morphine therapy.


   ♦ Respiratory arrest, shock, sinus bradycardia, and cardiac arrest have occurred. IV
       administration increases the risk of these hazards. Respiratory depression occurs in
       almost every case but in not usually significant with usual doses in patients with normal
       respiratory capacity. Other side effects include convulsions, nausea, vomiting and
       constricted pupils.


CONTRAINDICATIONS
   ♦ Not to be used in pulmonary edema resulting from chemical irritants. Not to be used in
       head injury patients for it obscures CNS and LOC evaluation.


NOTES
   ♦ Morphine can cause allergic reactions.
   ♦ Vital signs (blood pressure, pulse, and respirations) are to be taken before and after
       narcotic administration.
   ♦ Antidote for narcotics is Narcan, should always be on hand.
   ♦ In MI patients, Morphine is not used in the field to attain total pain relief, but to make
       pain tolerable and alley patient's fear.
   ♦ Should always be given IV route to suspected MI, burn patient (will not be absorbed
       effectively if given IM in face of possible hypotension and will adversely effect cardiac
       enzyme studies if intramuscular).
   ♦ Midazolam and morphine sulfate are compatible and may be administered together.




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                               Naloxone (Narcan)

CLASSIFICATION
   ♦ Opiate antagonist


ACTION
   ♦ Narcan is an antagonist of opium derivatives and synthetic narcotics such as Morphine,
       Demerol, Dilaudid, Codeine, Percodan, Heroin, Lomotil, Darvon, and Talwin. When
       given IM, the onset of action is approximately 2 minutes. Onset is slightly less rapid
       when given SubQ of IM.


INDICATION
   ♦ Narcan is used in the treatment of respiratory depression or unconsciousness induced
       by the above-mentioned drugs. It itself does not depress respirations nor constrict
       pupils.


CONTRAINDICATIONS
   ♦ Not to be used patients with a suspected head injury.


DOSAGE
   ♦ Administer naloxone 2 mg IVP every 3 minutes as needed (Maximum 10 mg). (0.1
       mg/kg in children).


ROUTE OF ADMINISTRATION
   ♦ Narcan is best-administered IV route in the field, for it has the most rapid onset and is
       recommended by this route in emergency situations. Narcan may also be administered
       via ETT, IO line, IM, or SQ.




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SIDE EFFECTS
   ♦ Rare cases of nausea and vomiting have been reported.           Otherwise, Narcan is
       essentially free of side effects in recommended doses.


NOTES
   ♦ Allergic reactions are a possibility. Can have withdrawal symptoms.
   ♦ All unconscious patients of unknown etiology should have Narcan administered.
   ♦ Narcan does not reverse barbiturate overdoses.
   ♦ Remember that airway management is first priority in any unconscious victim.
   ♦ Do not administer to patients with suspected head injury.




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                                      Nitroglycerin

CLASSIFICATION
   ♦ Smooth muscle relaxant and vasodilator


ACTION
   ♦ Nitroglycerin has a direct vasodilator effect on smooth muscles. Its onset of action is
       approximately 1 to 2 minutes and it has a duration of action of about 30 minutes.


INDICATION
   ♦ It is used in the treatment of angina pectoris and has a vasodilating effect upon
       coronary arteries, thus improving the blood deficiency to the myocardium. May also be
       used in congestive heart failure patients to decrease preload and afterload effects.


DOSAGE
   ♦ For anginal attacks and respiratory distress suspected to be due to pulmonary edema,
       0.4 mg (1/150 gr) may be administered sublingually. One (1) tablet or spray is given at
       3-5 minute intervals until the pain is relieved. Patient response to Nitroglycerin varies
       greatly.


ROUTE OF ADMINISTRATION
   ♦ Sublingual. Place under the tongue and allow to dissolve. A slight residue may remain
       due to the tablet filter. Spray is also permitted.




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SIDE EFFECTS
   ♦ Marked flushing and throbbing of the head. Two large a dose may cause violent
       headaches. Use with caution in patients with glaucoma or cerebral hemorrhage. May
       cause decrease in blood pressure and increase the pulse rate.


NOTES
   ♦ Tablets have an unstable shelf life and therefore must be kept in a tightly closed amber
       glass container to prevent loss to potency.
   ♦ If patient has history of angina, find out how many NTG tablets he has already taken
       and whether or not he has had relief.
   ♦ It is important to get a good history of the type of pain the patient is having.
   ♦ Treat all chest pain patients in the field as if they were MI's.
   ♦ REMEMBER: Nitroglycerin has been known to cause severe hypotension especially in
       the face of an acute MI. If this occurs, elevate legs and lie patient supine.
   ♦ If BP < 90, if patient used Viagra within 24 hours, call on-line medical control.




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                                Procainamide (Pronestyl)


CLASSIFICATION
   ♦ Sodium Channel Blocker


ACTIONUse-dependent block of sodium channels
   ♦ Blocks potassium channels
   ♦ Blocks alpha-adrenergic receptors
   ♦ Blocks muscarinic receptors


INDICATION
   ♦ For treating a wide variety of arrhythmias such as PSVT, stable wide-complex
       tachycardia and atrial fibrillation with a rapid ventricular response as is Wolff-
       Parkinson-White syndrome, or pulsless v-tach and/or v-fib.


DOSAGE
   ♦ 20mg – 50mg/min slow IVP until one of the following occurs:
           Arrythmia suppression
           Hypotension
           QRS widens by > 50%
           Total dose of 17mg/kg
   ♦ If ectopy resolves:
           Initiate maintenance drip of 1 – 4 mg/min titrated to desired effect




ROUTE OF ADMINISTRATION
   ♦ Intravenous infusion


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SIDE EFFECTS
   ♦ Vasodilation: Due to blocking of alpha-adrenergic receptors. Hypotension from this
       effect is usually only seen at high, quickly administered doses.
   ♦ Depressed vagal tone: Due to an antimuscarinic action. (The direct negative
       chromotropic and dromotrophic effects outweigh the reduction in vagal tone.)
   ♦ Lupus erythematosus: Procainamide can cause or aggravate this condition.
   ♦ Torsades de pointes: Class IA drugs can cause and aggravate this condition
   ♦ GI upset: Nausea, vomiting, etc.
   ♦ Adverse CNS effects: Giddiness, psychosis, depression, hallucinations.
   ♦ Hypersensitivity reactions: Fever, agranulocytosis, Raynaud's syndrome, myalgia,
       skin rashes, digital vasculitis.


NOTES
   ♦ If cardiac or renal dysfunction present, reduce maximum total dose to 12mg/kg.
   ♦ Proarrhythmic, especially in setting of AMI, hypokalemia, or hypomagnesemia.
   ♦ May induce hypotension in patients with impaired LV function.
   ♦ Use with caution with other drugs that prolong Q-T interval (eg.: amiodarone, sotalol).




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                                   Sodium Bicarbonate


CLASSIFICATION
   ♦ Base chemical


INDICATIONS
   o           Cardiac arrest, tricyclic anti-depressant overdose patients.


DOSAGE
   ♦ ADULT
           1 mEq/kg may be repeated every 8 to 10 minutes.
           Repeat doses:      1/2 original dose.
   ♦ Children
           1-2 Meq/kg may be repeated every in 8 to 10 minutes.
           Repeat doses:      1/2 original dose.


ROUTE OF ADMINISTRATION
   ♦ Direct IV injection ONLY.


SIDE EFFECTS
   ♦ Overdosage will cause alkalosis. Sodium bicarbonate is very irritating to veins at the
       site of injection. Sodium bicarbonate should not be mixed with any other drugs.
       Therefore, ALWAYS FLUSH IV TUBING WELL AFTER INJECTION. Because of
       the Ph of bicarb, it is well to avoid mixing of any drug with it.




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NOTES
   ♦ Prompt and effective ventilation of the lungs is essential for excretion of carbon dioxide
       and oxygenation.
   ♦ Bicarb and epinephrine mixed together-inactivates and epinephrine.
   ♦ Bicarb and CaCl mixed together will inactivate and possibly crystalize.
   ♦ Do not mix Bicarb and Dopamine-will inactivate.




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                                         Succinylcholine

CLASSIFICATION


   •   Non-competitive, depolarizing neuromuscular blocking agent


INDICATIONS
   •   Induction of temporary paralysis for advanced airway management / intubation.


CONTRAINDICATIONS
   •   Hypersensitivity to the agent
   •   Personal or familial history of malignant hyperthermia
   •   Skeletal muscle myopathies (Myasthemia Gravis, Amyotrophic Lateral Sclerosis
       [ALS], Multiple Sclerosis [MS])
   •   >3 days following crush injury
   •   >3 days following burns
   •   Pseudocholinesterase disease
   •   Polyneuropothy
   •   Disuse atrophy




DOSAGE
   ♦ ADULT
           1.5 mg/kg
   ♦ CHILD
           1.5-3 mg/kg


ROUTE OF ADMINISTRATION
   ♦ Direct IV injection ONLY.




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ONSET
       30-60 seconds


DURATION
       3-8 minutes


SIDE EFFECTS
       General
         o Hyperkalemia
         o Malignant hyperthermia
         o Masseter spasm
         o Increases in ICP, gastric pressure and intraoccular pressure

       Respiratory
         o Prolonged apnea/neuromuscular blockade (renal and hepatic dysfunction)

       Circulatory
         o Hypertension, hypotension, tachycardia, bradycardia and other dysrhythmias




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                                        Tetracaine

CLASSIFICATION
   ♦ Local anesthetic


ACTION
   ♦ Stabilizes membranes of conjunctival and corneal pain fibers to inhibit depolarization
       and perception of pain.


INDICATIONS
   ♦ Use for patient exposure to pepper spray.


DOSAGE
   ♦ 2 drops of 0.5% solution


ROUTE OF ADMINISTRATION
   ♦ Medication should be instilled into eye in lower conjunctival sac. Patient should be
       instructed to look up towards the top of the head while the paramedic pulls down the
       lower lid and instills the medication within the pouch formed by the inner surface of the
       lower lid and the conjunctiva.



SIDE EFFECTS
   ♦ Many patients experience a transient (< 60 seconds) stinging or burning in the eye after
       instillation of the medication. Long term use can result in softening and damage to the
       cornea and sensitization to the agent (with increased chances of future allergic
       reactions)




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CONTRAINDICATIONS
   o           The use of tetracaine is contraindicated in patients with known hypersensitivity
       to the drug. Tetracaine may cross-react in patients with allergy to procaine (Novocain)
       or chloroprocaine (Nesacaine) and is relatively      contraindicated in these patients as
       well.


NOTES
   ♦ Tetracaine does not dilate the pupil, paralyze gaze or accommodation, or increase
       intraocular pressure.
   ♦ Discolored solutions should not be used. Containers must be kept tightly closed.
   ♦ Warn patient not to touch or rub eye while cornea is anesthetized. This may cause
       corneal abrasion, further injury, and greater discomfort once tetracaine wears off.
   ♦ Dose may be repeated every 15 minutes under specific circumstances (refer to Section
       214 “Eye Emergencies”).
   ♦ Refer to Section 214, “Eye Emergencies, “ for use of tetracaine in the setting of law
       enforcement operations.




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                                      Phenergan

CLASSIFICATION
   ♦ Antihistamine
   ♦ Antiemetic


ACTION
   ♦ Promethazine hydrochloride, a phenothiazine derivative, possesses antihistaminic,
       sedative, antimotion-sickness, antiemetic, and anticholinergic effects. The duration of
       action is generally from four to six hours.


INDICATIONS
   ♦ Prevention and control of nausea and vomiting.


DOSAGE
   ♦ ADULT
           12.5 mg I.V.
           25mg I.M.
   ♦ CHILDREN
           Contraindicated for children under 2 years of age
           0.2mg/kg I.V. or I.M.


ROUTE OF ADMINISTRATION
   ♦ ADULT
           I.V. or I.M.
   ♦ CHILDREN
           I.V. or I.M.




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SIDE EFFECTS
   ♦ CNS Effects

       Drowsiness is the most prominent CNS effect of this drug. Extrapyramidal reactions
       may occur with high doses.

       Other reported reactions include dizziness, lassitude, tinnitus, incoordination, fatigue,
       blurred vision, euphoria, diplopia, nervousness, insomnia, tremors, convulsive seizures,
       oculogyric crises, excitation, catatonic-like states, and hysteria.


   ♦ Cardiovascular Effects

       Tachycardia, bradycardia, faintness, dizziness, and increases and decreases in blood
       pressure have been reported following the use of promethazine hydrochloride injection.
       Venous thrombosis at the injection site has been reported.



CONTRAINDICATIONS
   o           Drugs having anticholinergic properties should be used with caution in patients
       with asthmatic attack.



NOTES:




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                                      Adenosine

CLASSIFICATION
   ♦ Antiarrhythmic


ACTION
   ♦ Adenocard (adenosine) slows conduction time through the A-V node, can interrupt the
       reentry pathways through the A-V node, and can restore normal sinus rhythm in
       patients with paroxysmal supraventricular tachycardia (PSVT), including PSVT
       associated with Wolff-Parkinson-White Syndrome.


INDICATIONS
   ♦ Conversion to sinus rhythm of paroxysmal supraventricular tachycardia (PSVT),
       including that associated with accessory bypass tracts (Wolff-Parkinson-White
       Syndrome). When clinically advisable, appropriate vagal maneuvers (e.g., Valsalva
       maneuver), should be attempted prior to Adenocard administration.



ADULT DOSAGE
   ♦ Initial Dose:
           6 mg IV bolus over 1 – 3 seconds
   ♦ Repeat Dose:
           12 mg IV bolus over 1 – 3 seconds



PEDIATRIC DOSAGE
           0.1mg/kg IV bolus over 1 – 3 seconds to a maximum of 6mg



ROUTE OF ADMINISTRATION
   ♦ Intravenous only




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SIDE EFFECTS
       Cardiovascular: Facial flushing (18%), headache (2%), sweating, palpitations, chest
       pain, hypotension (less than 1%).

       Respiratory: Shortness of breath / dyspnea (12%), chest pressure (7%),
       hyperventilation, head pressure (less than 1%).

       Central Nervous System: Lightheadedness (2%), dizziness, tingling in arms,
       numbness (1%), apprehension, blurred vision, burning sensation, heaviness in arms,
       neck and back pain (less than 1%).

       Gastrointestinal: Nausea (3%), metallic taste, tightness in throat, pressure in groin
       (less than 1%).

       In post-market clinical experience with Adenocard, cases of prolonged asystole,
       ventricular tachycardia, ventricular fibrillation, transient increase in blood pressure,
       bradycardia, hypotension, atrial fibrillation, and bronchospasm, in association with
       Adenocard use, have been reported.

       .

CONTRAINDICATIONS
   o           Rarely, ventricular fibrillation has been reported following Adenocard
       administration, including both resuscitated and fatal events. In most instances, these
       cases were associated with the concomitant use of digoxin, and less frequently with
       digoxin and verapamil. Although no causal relationship or drug-drug interaction has
       been established, Adenocard should be used with caution in patients receiving digoxin
       or digoxin and verapamil in combination. Appropriate resuscitative measures should be
       available.



NOTES




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        VOLUSIA COUNTY HAZARDOUS MATERIALS
                           INCIDENT RESPONSE TEAM

                       TOXI-MEDICAL PROTOCOL
         FOR ANTIDOTAL TREATMENT OF HAZMAT POISONINGS


MEDICAL SURVELLANCE PROGRAM

I.     Composition of Annual Physical Examination for HazMat Team Members

       This exam shall include, but not be limited to, the following:

       A.      Documentation of medical history.

               1.     Cardiovascular
               2.     Gastrointestinal
               3.     Reproductive system
               4.     Respiratory system
               5.     Integumentary system
               6.     Nervous system
               7.     Muscular
               8.     Skeletal
               9.     Medication
               10.    Personal habits (social history)
               11.    Past injury/illness
               12.    Allergies
               13.    Recent medical complaints
               14.    Family history




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       B.      Physical examination:

               1.     Blood pressure (orthostatic measurements)
               2.     Pulse
               3.     Respiratory status including breath sounds
               4.     Heart sounds
               5.     Thoracic exam
               6.     Peripheral vascular status
               7.     Peripheral neurological status
               8.     General appearance and health of skin
               9.     Body weight and height
               10.    Stool exam for blood
               11.    Prostate exam (if applicable)
               12.    Endocrine system
               13.    Genitourinary examination
               14.    Abdominopelvic exam
               15.    Extremities
               16.    Full posterior exam

       C.      Diagnostic testing:

               1.     Hearing acuity
               2.     Visual acuity (to include color and depth perception)
               3.     Blood tests
                      a.      Renal (BUN, Creatinine)
                      b.      Thyroid function
                      c.      Hemotology composition (CBC)
                      d.      SGPT, GGTP, LDH, total protein, bilirubin, (direct and indirect)
                              and alkaline phosphatase
               4.     Urinalysis
                      (Appearance, color, bile, specific gravity, pH, proteins, blood, glucose,
                      uric acid, evidence of drug use)
               5.     X-ray of chest (PA & lateral)
               6.     Pulmonary function (every two years)
               7.     12 lead EKG (with an additional stress test every two years).




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Other tests may be required over the time of service to screen team members for exposure to
heavy metals and other contaminants.
Per OSHA requirements, all medical records will be maintained 30 years past the retirement
date of members.

II.    Cursory Physical

       This exam is used as a baseline assessment for HazMat team members at the scene of
       an incident prior to entering the hazardous environment. Personnel who require this
       exam at the scene of an incident include entry and back-up team members,
       decontamination teams, and EMS teams who receive contaminated patients. The exam
       will be used as a comparison tool in the event of possible exposure to a hazard. This
       exam should include, but not be limited to, the following observations and interactions:


               1.      Blood pressure, pulse, and respirations
               2.      Lung sounds
               3.      EKG leads 1, 2, and 3
               4.      Weight (5% to 8% weight loss during an incident indicates a sever loss
                       of body fluids).
               5.      Current allergies
               6.      Medical history to include present medications.
               7.      Body temperature (no entry allowed if temp. 100° F or greater)
               8.      Pulse oximetry
               9.      Baseline blood draw for possible CBC post-incident.

III.   Exit Physical

       This physical is identical to the cursory physical. If there is any questions as to the well
       being of personnel, (i.e. did the team member become contaminated or otherwise
       injured), the individual should be subject to a series of follow-up exams.




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IV.    Follow-up Physical

       This exam is required if personnel are believed to have been exposed to a toxic hazard.
       Conditions arising from a toxic exposure may take time to manifest. Follow-up
       examinations can track such development. Early discovery of a developing illness may
       speed patient recovery through early medical intervention. Follow-up physicals should
       be conducted every three months up to the time of the next annual physical, or until as
       deemed necessary by a toxicology physician.

       Follow-up physicals should include all aspects of the annual physical, as well as testing
       for specific toxins or developing illness.


       The follow-up exam is required if one or all of the following elements are present at an
       incident, or if a physician deems such an exam as necessary.


               1.     Aromatic Hydrocarbons
               2.     Asbestos
               3.     Dioxin
               4.     Halogenated aliphatic hydrocarbons
               5.     Organophosphate and carbamate pesticides
               6.     Polychlorinated biphenyl
               7.     Organochlorine insecticides
               8.     Extremee radiological exposure
               9.     Significant exposure to carcinogens
               10.    Significant exposure to mutagens
               11.    Significant exposure to teratogens




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TREATMENT FOR SPECIFIC INJURIES

I.     Specific treatments for injuries for the following are contained within this
       protocol.

       A.      Anhydrous Ammonia
       B.      Carbamate Poisoning
       C.      Carbon Monoxide Poisoning
       D.      Chlorine Poisoning
       E.      Cyanide Poisoning
       F.      Hydrofluoric Acid Burn and Poisoning
       G.      Hydrogen Sulfide Poisoning
       H.      Nitrite/Nitrate Poisoning
       I.      Organophosphate Poisoning
       J.      Phenol (Carbolic Acid) Poisoning

       The “Emergency Care for Hazardous Materials Exposure Handbook” should be utilized
       to research treatment of exposures not listed above. In many cases, the treatment for
       exposures will be comprised only of decontamination and supportive care.


       At all incidents, resources such as the NIOSH Pocket Guide to Hazardous Chemical
       and the Department of Transportation Emergency Response Guidebook should be used
       to properly identify the agents involved.




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ANYDROUS AMMONIA

A.     Presentation

       1.      History

               Anydrous Ammonia is commonly used as a commercial refrigerant. It is also
               used in water treatment plants and in other utilities. It is characterized by a
               strong pungent odor. It is considered colorless.


       2.      Symptoms/Signs


               a.      Cardiac arrhythmias
               b.      Hypotension
               c.      Pulmonary irritation
               d.      Pulmonary edema
               e.      Decreased LOC
               f.      Seizures may be present
               g.      Skin irritation and burns




B.     Stabilization


       1.      BLS


               a.      Remove patient from source of contaminant
               b.      Secure airway; provide 100% O2 NRB
               c.      Contact EDMCP
               d.      Monitor hemodynamics; provide supportive measures




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       2.      ALS


               a.     Place cardiac monitor
               b.     Start IV NaCL KVO
               c.     Treat pulmonary edema per Volusia County Protocol
               d.     Assess need for ET Intubation




D.     Decontamination


       1.      Protect personnel from exposure
       2.      Wash patient with copious amounts of water
       3.      Remove and bag patient’s clothing
       4.      Contain water run-off




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CARBAMATE

A.     Presentation


       1.      History


               Carbamates are insecticides derived from carbamic acid. They affect patients
               much the same way as organophosphate. Carbamates inhibit
               acetylcholinesterase and disrupt the parasympathetic nervous system.


       2.      Symptoms/Signs


               a.      Salivation
               b.      Lacrimation
               c.      Urination
               d.      Defecation
               e.      Gastric distress
               f.      Emesis


               CNS effects: Effects on the CNS system are not as severe as organophosphates
                    because of the inability of carbamates to penetrate the central nervous
                    system. Effects of carbamates usually last no more that 6-12 hours.




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B.     Stabilization


       1.      BLS


               a.      Remove patient from source of contaminant
               b.      Secure airway
               c.      Provide 100% O2 NRB
               d.      If patient is being assisted with BVM, give 100% O2
               e.      Contact EDMCP
               f.      Monitor hemodynamics
               g.      Provide supportive measures


       2.      ALS


               a.      Cardiac Monitor
               b.      Assess for need of ET Intubation
               c.      Start IV NaCL KVO
               d.      Administer Atropine 2 mg IV slow repeated every 15-30 minutes until
                       Atropinization occurs.
               e.      Protopam is not required

C.     Decontamination


       1.      Protect personnel from exposure
       2.      Remove solid product by dry decontaminate
       3.      Remove liquid contaminant by blotting
       4.      Remove patient’s clothing
       5.      Was patient with water
       6.      Patient should not be able to smell chemical after decontamination complete
       7.      Contain water run off




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CARBON MONOXIDE

A.     Presentation


       1. History


            Carbon Monoxide is a odorless, colorless, tasteless, non-irritating gas produced as a
            by-product of incomplete combustion. It crosses the alveolcapillary membrane and
            enters the bloodstream, where it combines with hemoglobin to form
            carboxyhemoglobin. This prevents oxygen from binding with the hemoglobin, and
            tissue cells become O2 deprived. Carbon Monoxide (CO) is classified as a
            chemical asphyxiant. Patient exposure may be accidental or intentional.

       2. Symptoms/Signs                                            Saturation %

            None………………………………………………………0-10%
            Tightness across forehead, headache…………………….10-20%
            Severe headache, nausea/vomiting
               Diminished vision……………………………………20-30%
            Coma, Convulsions, Red skin……………………………30-40%
            Cardiovascular collapse/
               Respiratory failure……………………………………60% +

B.     Stabilization


       1.      BLS


               a.      Remove patient to fresh air, Rescuer to wear Self-Contained Breathing
                       Apparatus during extrication of patient from scene.
               b.      Provide 100% O2
               c.      Provide supportive measures
               d.      If in respiratory arrest, ventilate patient with 100% O2 with BVM
               e.      Contact EDMCP



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       2.      ALS

                a.      Cardiac monitor
                b.      IV NaCL KVO
                c.      Administer 25g dextrose (if altered level of awareness)
                d.      Administer Narcan 2mg IVP (if altered level of awareness)
                e.      Consider ET intubation
                f.      Consider transport to Hyperbaric chamber
                g.      NOTE: Pulse Oximetry not dependable in CO poisonings

       3. Decontamination


            Chemical residue will not provide cross-contamination. Locate source of CO and
            monitor air quality to establish if treatment area is safe.




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CHLORINE

A.     Presentation


       1.      History


               Chlorine is utilized in industry as an oxidizer and a chlorinator. It is found in
               homes as well as in municipal water treatment facilities. It is a greenish yellow
               gas with a strong odor.


       2.      Symptoms/Signs
               a.      Cardiac dysrhythmia
               b.      Pulmonary irritation
               c.      Pulmonary edema
               d.      Skin irritation
               e.      Decreased LOC


B.     Stabilization


       1.      BLS
               a.      Remove patient from source of contaminant
               b.      Secure airway
               c.      Provide 100% O2 NRB
               d.      I patient is being assisted with BVM, give 100% O2
               e.      Contact EDMCP
               f.      Monitor hemodynamics
               g.      Provide supportive measures
               h.      Eye injuries:
                       1)      Use pontocaine to prevent blepherospasm
                       2)      Attach Morgan lens to a 100 cc bag of NaCl
                       3)      Irrigate eyes with moderate flow rate




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       2.      ALS


               a.     Cardiac monitor
               b.     Assess need for ET Intubation
               c.     Start IV NaCL KVO
               d.     Treat Pulmonary edema per Volusia County Protocol


C.     Decontamination


       1.      Protect personnel from exposure
       2.      Wash patient with water
       3.      Remove patient’s clothing
       4.      Patient should not be able to smell chemical after decontamination is complete
       5.      Contain water run-off




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CYANIDE

A.     Presentation

       1.      History
               One of the most rapidly acting poisons know, Cyanide is a chemical asphyxiant
               that impedes O2 absorption into tissues at a cellular level by binding with
               cytochrome oxidase. This chemical is found in industries such as metal plating,
               metal cleaning, plastics, and fertilizers. It is used as an insecticide and
               rodenticide, and is given off by materials after they are on fire or smoldering.
               Materials to Cyanide include polyurethane, polyacrylonitriles, nylon, wool, silk
               and many plants.


       2.      Symptoms/Signs
                                                                Serum Cyanide Levels
               Patients are:
               Normal (Non-Smoker)………………………………….0-0.2
               Normal (Smoker)……………………………………….0.1-0.4


               Patients with mild toxicity may present:
               Anxiety, confusion, unsteady, tachypnea………………0.5-1.0
               Signs & Symptoms of moderate toxicity include:
               Cardiac arrhythmia, dyspnea, depressed, LOC………..1.0-2.5


               Severe toxicity if:
               Loss of muscular coordination, convulsions, reflex bradycardia,
               Respiratory depression, coma………………………….2.5-3.0


               Exposure to ----- levels of Cyanide result in:
               Apnea, cardiovascular collapse, asystole………………3.0 +


               Ulcerations of the skin may be present. The patient is usually not cyanotic.



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B.     Stabilization
       1.      BLS
               a.      Secure airway
               b.      Provide 100% O2 NRB
               c.      If in respiratory arrest, ventilate patient with 100% O2 with BVM
               d.      Provide supportive measures
               e.      Remove source of contaminant
               f.      Monitor hemodynamics


       2.      ALS
               a.      Cardiac monitor
               b.      Assess for need of ET intubation
               c.      Start IV NaCL KVO
               d.      Administer 1 Amyl Nitrite aspirol to be broken and inhaled by patient
                       through nose for 15 seconds followed by a 15 second rest. This should
                       be repeated until Sodium Nitrite can be administered. If the patient is
                       apneic and ventilations are being assisted, and aspirol can be broken and
                       placed in a BVM to be administered as previously described.
               e.      When -- Nitrite availability, stop Amyl Nitrite aspirol treatments and
                       administer Sodium Nitrite, 300 mg NaNO3 IV over 5 minutes. Look for
                       hypotension.
               f.      Ped-dose - .33cc of 3% Sodium nitrite per kilogram up to 10 CC.
                       WATCH FOR HYPOTENSION.
                              Note: Contact Medical Control for Children who are anemic
                              as they may have lethal reactions to Sodium Nitrite infusion!
               g.      Administer Sodium Thiosulfate.
                       Adult dose:     12.5 g over 5 minute IV
                       Child dose:     1.65 cc/Kg of a 25% solution over 5 minutes

Methylene Blue should not be used for Cyanide since it can result in a lethal release of
bound cyanide ions!




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Decontamination


       1.      Protect personnel from exposure
       2.      Remove away dry product by brush or vacuum
       3.      Blot liquids
       4.      Remove patient’s clothing and jewelry
       5.      Wash with mild soap
       6.      Rinse thoroughly
       7.      Contain water run-off




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HYDROFLUROIC ACID

A.       Presentation

         1. History

                     Hydrofluoric acid is an inorganic acid in the same category as hydrochloric and
                     sulfuric acid. It is commonly used in water treatment as a chlorinator as well as
                     in the electronic manufacturing, plastics, pesticides, fire extinguisher, fertilizers,
                     and metals cleaning industries.


                     Hydrofluoric acid continues to injure the patient even after decontamination
                     because the fluoride ion penetrates the skin and bonds with calcium and
                     magnesium, causing continued injury with tissue and bone necrosis. Changes in
                     electrocardiographs may also be seen.

         2. Symptoms/Signs

                     After the corrosive burn stops, the skin may appear milky white to black. The
                     skin may be hardened with possible coagulation necrosis. The burn is very
                     painful.




New: March 1, 2004
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B.     Stabilization

       1.      BLS

               a.      Remove patient from source of contaminant
               b.      Secure airway
               c.      Provide 100% O2 NRB
               d.      If patient is being assisted with BVM, give 100% O2
               e.      Contact EDMCP
               f.      Monitor hemodynamics
               g.      Skin injuries:
                       1)     Flush exposed areas with copious amounts of water at low
                              pressure
                       2)     Apply calcium gluconate gel to effected area


                              a)        Mix 10cc of a 10% calcium gluconate solution into a 2
                                        ounce tube of K-Y jelly. This will provide a 2.5% gel.
                              b)        Contimnuously massage liberal amounts of gel into the
                                        burn site. Pain should be relieved with 30-45 seconds.
                       3)     Pain is an indicator that the injury is continuing. If pain
                              continues after gel is applied, then calcium gluconate injection is
                              necessary.
                              a)        5% Calcium gluconate is injected in a volume of 0.5ml
                                        every ¼ inch into the burn area. Treatment stops when
                                        the pain is releived.




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               h.     Eye injuries:
                      1)      Flush eyes with copious amounts of water at low pressure.
                      2)      Mix 50cc of a 10% solution of calcium gluconate into a 500cc
                              bag of NACL.
                      3)      Connect IV bag to Morgan lenses.
                      4)      Apply 1-2 drops of ponticaine to eyes to releive blepherospasms.
                      5)      Insert Morgan lens into affected eye and begin irrigation at
                              moderate rate.
                      6)      Protect patient from water run-off.
               i.     Inhalation injuries:
                      1)      Give O2 and ventilatory assistance.
                      2)      Mix 3cc of sterile water with 1.5 cc of a 10% solution of calcium
                              gluconate.
                      3)      Place solution in nebulizer and administer with O2 as an
                              adequate fog.


       2.      ALS


               a.     Cardiac monitor
               b.     Assess need for ET intubation
               c.     Establish IV NaCL KVO
               d.     Watch for dysrhythmia due to the effects of fluoride ion absorption.

C.     Decontamination

       1.      Protect personnel from exposure
       2.      Remove solid product by dry decontaminate
       3.      Remove liquid product by blotting
       4.      Remove patient’s clothing
       5.      Wash patient with water
       6.      Contain water run-off




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HYDROGEN SULFIDE

A. Presentation

       1. History

               Hydrogen sulfide is a toxic, irritating gas, generated by the decomposition of
               organic material. It is commonly found in the petrochemical industry, water
               treatment plants, mining operations and liquid manure systems. It is a chemical
               asphyxiant with a mechanism of action similar to cyanide.

       2. Symptoms/Signs                                     Concentration (ppm)

               Detectable odor                                      0.025

               Obvious unpleasant odor                              10

               Conjunctivitis                                       50

               Loss of ability to smell in 3-15 minutes of
               Exposure                                             100

               Olfactory nerve paralysis                            150

               Pulmonary edema                                      300-500

               Apnea                                                700

               Rapid decline, imminent death                        900+




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B.     Stabilization

       1. BLS

               a. Secure airway
               b. Provide 100% O2 NRB
               c. If in respiratory arrest ventilate patient with 100% O2 with BVM
               d. Provide supportive measures
               e. Monitor hemodynamics
               f. Contact EDMCP

       2. ALS

               a. Cardiac monitor
               b. Assess for need of intubation
               c. Start IV NaCL KVO
               d. Treat pulmonary edema per Volusia County protocol (Nitro administration
                       may adversely effect Sodium Nitrite therapy)
               e. Administer 1 Amyl Nitrite aspirol, broken and inhaled by patient through
                       nose for 15 seconds followed by a 15-second rest. This should be
                       repeated until Sodium Nitrite can be administered. If the patient is
                       apneic and is being assisted with a BVM, an aspirol can be broken and
                       placed in the BVM to be administered as previously described.
               f. Stop Amyl Nitrite aspirol treatments and administer Sodium Nitrite, 300 mg
                       IV over 5 minutes. Look for hypotension.

                       Sodium Nitrite –

                       Child dose:    If child’s Hemoglobin concentration is known.

                       Hemoglobin in grams     Initial dose
                        8………………………………………0.22cc (6.6mg)/Kg
                       10……………………………………...0.27cc (8.7mg)/Kg
                       12……………………………………...0.33cc (10 mg)/Kg
                       14……………………………………...0.39cc (11.6mg)/Kg




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                      If child’s hemoglobin count is not known - 0.33cc of 3% Sodium Nitrite
                      per kilogram up to 10 CC.


                      WATCH FOR HYPOTENSION. Children who are anemic may have
                      lethal reactions to Sodium Nitrite infusion!


                      Dose of Sodium Nitrite should not exceed 300 mg.


                      Do not use Sodium Thisulfate in treating Hydrogen Sulfide
                      poisonings!


C.     Decontamination


       1.      Protect personnel from exposure
       2.      Make sure atmosphere in patient treatment area is free from exposure
       3.      Wash patient with water
       4.      Contain water run-off




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NITRITE/NITRATE


A.     Presentation

       1.      History

               Nitrites and nitrates can be found in both solid and liquid states. Nitrites are
               often misused as a recreational drug. These chemicals are also commonly used
               as pharmaceutical because of their ability to cause vasodilation (i.e.
               nitroglycerin). Nitrites and nitrates are also found in fertilizers, the most
               common source of exposure. Other areas where these chemicals can be found
               are in polishes, photography, food preservation, dyes, and paints. Nitrites and
               nitrate can cause a change in the bloods ability to receive oxygen resulting in
               chemical asphyxiation.

       2.      Symptoms/Signs

               a.     Low doses

                      1)      Hypotension
                      2)      Flushed skin
                      3)      Headache
                      4)      Dizziness
                      5)      Diaphoresis
                      6)      Syncope
                      7)      Sinus tachycardia




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               b.      High doses (methemoglobemia)

                       1)     Cyanosis
                       2)     Headache
                       3)     Dizziness
                       4)     Dark brown blood (“chocolate”)
                       5)     Metabolic acidosis
                       6)     Lethargy
                       7)     Cardiovascular collapse
                       8)     Convulsions
                       9)     Death

B.     Stabilization

       1.      BLS

               a.      Remove patient from source of contaminant
               b.      Provide 100% O2 NRB
               c.      If in respiratory arrest ventilate patient with 100% O2 with BVM
               d.      Monitor hemodynamics
               e.      Provide supportive measures


       2.      ALS

               a.      Cardiac monitor
               b.      Assess need for ET intubation
               c.      Start IV NaCL KVO
               d.      Treat hypotension per Volusia County Protocol
               e.      Give Methylene Blue 2mg/kg over 5 minutes
               Note: Pulse oximetry not accurate with methemoglobemia patients




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C.     Decontamination

       1.      Remove solid material through dry decontaminate
       2.      Remove liquid contaminants through blotting
       3.      Use water
       4.      Capture water run-off




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ORGANOPHOSPHATE

A.     Presentation

       1.      History

               Organophosphate are responsible for the majority of treated insecticide
               poisonings. They can be in solid, liquid and gas states. The chemical bonds
               with acetylcholinesterase and inhibits normal function of the parasympathetic
               nervous system.

       2.      Symptoms/Signs

               a.      Salivation
               b.      Lacrimation
               c.      Urination
               d.      Defecation
               e.      Gastro discomfort
               f.      Emesis

               CNS effects: Anxiety, ataxia, convulsions, coma, absent reflexes, Cheyne-
                    Strokes respirations, circulatory collapse.



B.     Stabilization

       1.      BLS

               a.      Remove patient from source of contaminant
               b.      Secure airway
               c.      Provide 100% O2 NRB
               d.      If patient is assisted with BVM, Give 100% O2
               e.      Monitor hemodynamics
               f.      Provide supportive measures




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       2.      ALS

               a.     Cardiac monitor
               b.     Assess need for ET Intubation
               c.     Start IV NaCL KVO
               d.     Atropine 2 mg doses IV slowly until atropinization occurs
               e.     Protopam 1 g IV over 2 minutes

C.     Decontamination

       1.      Protect personnel from exposure
       2.      Remove solid product by dry decontaminate
       3.      Remove liquid contaminant by blotting
       4.      Remove patient’s clothing
       5.      Wash patient with water
       6.      Patient should not be able to smell chemical after decontamination complete
       7.      Contain water run-off




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                                                                                             700

PHENOL (CARBOLIC ACID)

A.     Presentation

       1.       History

       Phenol can be found in many products:

       Amyl phenol                     Germicide
       Creosol                         Antiseptic
       Creosote                        Wood preservative
       Quaiacol                        Dematologic treatments
       Hexachlorophene                 Disinfectant
       Medicinal tat                   Fungicide
       Phenol                          Anthelmintic
       Phenylphenol                    Tetrachlorophenol
       Thymol



       2.       Symptoms/Signs

                Phenol causes injury to tissues through saponification. It also adversely affects
                the central nervous system, resulting in seizures, cardiac dysrhythimias, and
                changes in level of consciousness.


B.     Stabilization

       1.       BLS

                a.     Remove patient from source of contaminant
                b.     Secure airway
                c.     Provide 100% O2 NRB
                d.     If patient is being assisted with BVM, give 100% O2
                e.     Monitor hemodynamics
                f.     Provide supportive measures




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       2.      ALS

               a.     Cardiac monitor
               b.     Establish IV NaCL KVO
               c.     Assess need for ET intubation
               d.     Treat for seizures per Volusia County Protocol

C.     Decontamination

       1.      Protect personnel from exposure
       2.      The principle treatment for assisting patients exposed to phenol is to remove the
               contaminant.
               a.     This can be done by applying olive oil, mineral oil, vegetable oil, or
                      isopropyl alcohol should be applied. Water should not be used as
                      Phenol is not water soluble.
               b.     After application of one of the aforementioned decontamination
                      solutions, rinse area with water and gentle soap.
       3.      Remove patient’s clothing
       4.      Contain water run-off




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        Use of Continuous Positive Airway Pressure (CPAP) Ventilation


DESCRIPTION
The continuous positive airway pressure (CPAP) instrumentation consists of an air pressure
generating source and a hose and mask assembly. The mask is placed on the patient and
increased air pressure is delivered directly to the respiratory system.


Goals of CPAP:
   1. Elimination of dyspnea
   2. Reduced Respiratory Rate
   3. Reduced Heart Rate
   4. Increased SpO2
   5. Stabilized blood pressure


If the patient fails to show improvement based on the above goals, endotracheal intubation should
be considered.


INDICATIONS
   o   Retractions of Chest
   o   Accessory muscle use
   o   Tachypnea (respiratory rate > 25/min)
   o   Pulse oximetry reading < 90%
   o   Bibasilar or diffuse rales OR medical history and presenting complaints consistent with
       cardiogenic pulmonary edema




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CONTRAINDICATIONS
   o   Respiratory or cardiac arrest
   o   Systolic blood pressure < 90mmHg
   o   Severely depressed level of consciousness
   o   Inability to maintain airway patency
   o   Major trauma, especially head injury with increased ICP or significant chest trauma
   o   Vomiting
   o   Signs and symptoms of pneumothorax
   o   Gastric distension


Endotracheal Intubation should be considered for any patient who exhibits one or more of the
above contraindications.




PROCEDURE FOR USE
   1. Place patient in a seated position with legs dependant
   2. Monitor ECG, Vital signs, (BP, HR, RR, SpO2) and lung sounds.
   3. While one member of the team is setting up the CPAP equipment, the second team member
       should treat the patient according to EMS treatment protocols.
   4. The patient must be reassessed frequently (every 5 minutes) for;
           a. Level of Consciousness
           b. Heart Rate
           c. Respiratory Rate
           d. Blood Pressure
           e. Pulse Oximetry
           f.   Lung Sounds


   5. Normally, the patient should improve in the first 5-10 minutes with CPAP as evidenced by;
           a. Decreased heart rate
           b. Decreased respiratory rate
           c. Decreased blood pressure
           d. Increased pulse oximetry readings




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    6. Should the patient fail to show improvement with CPAP as evidenced by:
             a. Sustained or increased heart rate
             b. Sustained or increased respiratory rate
             c. Sustained or increased blood pressure
             d. Sustained or decreasing pulse oximetry readings
             e. Decrease in level of consciousness


        Intubation should be considered




Setting up the System:


Connect the generator to a 50 psi oxygen source. This may be the power take-off of an oxygen regulator
on a cylinder or a quick connect to a wall outlet. Do not attach the generator to a flowmeter or it will
not function properly. It must be a 50 psi gas source!


Install a filter on the air entrainment port.


Select the WhisperFlow setup you are going to use. Assemble the patient interface, securing device,
tubing and CPAP valve. 7.5cm H2O CPAP Valve (YELLOW) for underlying COPD and 10.0cm H2O
CPAP Valve (GREEN) for all other Adult Patients




                                       Adjusting the Flow and FIO2


    •   Connect the WhisperFlow generator to the circuit and turn it on by rotating the ON/OFF knob
        fully counter-clockwise ¾ turn, to the ON position.


    •   Turn the Flow adjustment valve counter-clockwise to the completely open position to provide
        full flow.




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   •   In the closed position (completely clockwise) the unit will deliver a minimum 28% oxygen to
       the patient. You may deliver higher oxygen concentrations (up to 100%) by turning the valve
       counter-clockwise, ½ turn every two minutes. Start at the lowest FIO2 setting and then increase
       if necessary based on patient condition.


   •   Hold the mask or have the patient hold the mask to their face. If the patient seems anxious, it is
       all right to turn the generator on and have the gas flowing before placing the mask on the
       patients face. When the patient is comfortable, use the headstrap to hold the mask in place.
       Ensure that it is not too tight. Some air leakage is acceptable unless it is in the eye area.


   •   Make sure you are providing flow in excess of the patient’s inspiratory flow rate in order to
       maintain continuous pressure throughout the breathing cycle. This should be checked
       frequently during transport as the patient’s needs may change.
        There are 3 ways to determine whether your flow is set high enough.
           1. The CPAP valve should remain slightly open during the entire respiratory cycle.
           2. The anti-asphyxia valve on the mask should not open during normal operation.
           3. You should be able to feel some gas escaping from the exhalation port of the CPAP
               valve even during inspiration.


   •   For patient comfort you may turn the flow adjustment knob down to maintain the flow just
       above what the patient’s flow rate is. For example, if the patient is inspiring at a rate of 60 liters
       per minute, you only need a flow slightly above that to maintain CPAP. When fully open, the
       generator produces about 140 liters per minute flow. This is far in excess of what is needed and
       may be uncomfortable for the patient and in addition will waste oxygen.




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ADDITIONAL NOTES
   •     If you are using a portable tank, it is important to conserve your oxygen. For example, at 100%
         FIO2 and at full flow, a full tank will last approximately:
             o   “D” cylinder = 3.5 – 4 minutes
             o   “E” cylinder = 5.5 – 6 minutes
             o   “M” cylinder = 28 minutes
             o   “H” cylinder = 56 minutes


   •     At 28-30% FIO2 a full tank will last approximately:
             o   “D” cylinder = 28 minutes
             o   “E” cylinder = 45-50 minutes
             o   “M” cylinder = 236 minutes
             o   “H” cylinder = 472 minutes


Notes:
         o In pre-hospital use, it is not necessary to use an in-line oxygen analyzer, however
             you must insure that oxygen pressure is maintained at no less than 50 psi at all
             times. It is recommended that oximetry be used to monitor patient’s oxygen
             saturation.

         o If a pressure monitor is not used, you must insure that the correct CPAP pressure is
             being delivered at all times. The flow from the generator should always be in excess
             of the patients demand. Check to make sure that you feel excess flow coming out
             from the exhaust port of the CPAP valve at all times.

         o In the hospital it is recommended to set up the system with an oxygen analyzer
             and/or pressure monitor. In the pre-hospital setting this is not usually done since the
             patient’s vital signs and oxygen saturation are continuously monitored and the
             patient will not be left unattended.




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       o   In the hospital a pressure relief valve (CPAP valve) should be used at the flow
           outlet port if there is any chance of the exhalation valve becoming occluded. Select
           a valve at least 5 cmH2O higher than the expiratory CPAP valve. In pre-hospital
           application, this isn’t usually necessary as there is no opportunity for the exhalation
           port to become occluded when the patient is constantly monitored.


                                       DOCUMENTATION


   1. The use of CPAP must be documented on the Patient Care Report.
   2. Vital signs (BP, HR, RR, SpO2 and Lung Sounds) must be documented every 5 minutes.
   3. Narrative documentation should include a description of the patient’s response to CPAP. Refer
       to “Goals of CPAP” for descriptive terms that may be useful.
   4. Additional narrative documentation should include if the patient does not respond to CPAP and
       endotracheal intubation is required.




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                                        Crush Syndrome


History
All the effects Crush Syndrome are localized to the affected tissue until it is released from
compression, and is re-perfused by oxygenated blood.


Patients who are entrapped for days with a severe crush injury appear more or less stable when
reached by rescuers.


Upon release of compression, blood flow is restored to the crushed area and multiple processes
begin:
         Capillary leak leads to hypovolemia, hypotension and possibly hypovolemic shock.
         Severe metabolic acidosis causes an acute alteration in the ion gradients of cardiac
         cells, decreasing the fibrillatory threshold, making ventricular fibrillation more likely.
         Rapid increase in serum potassium concentration alters ionic concentration gradients,
         leading to cardiac arrhythmias.
         The release of myoglobin, uric acid and other toxins contribute both directly and
         indirectly to kidney failure.
         These toxins and others can cause reperfusion injury in all tissues, especially lung,
         liver, and kidney.



Morbidity and Mortality
Primary causes of death in crush syndrome include:
         Hypovolemia.
         Dysrhythmia.
         Renal failure.




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Other causes of death include:
       Adult Respiratory Distress Syndrome (ARDS)
       Sepsis
       Electrolyte disturbances
       Ischemic organ injury (gangrene)



Clinical Manifestations
Prior to release from entrapment:

       Generally there is a painless crushed extremity.
       There may be hyperesthesia or anesthesia.
       In some cases, the degree of pain seems inappropriate for the apparently little degree of
       tissue damage.
       Distal pulses may or may not be present. Generally, they are present.

After release from entrapment (if nothing is done):

       Agitation is common. This may represent toxins affecting the brain as well as
       alterations in cellular ionic gradients.
       There may be hyperesthesia or anesthesia, but mostly there is severe pain in the crushed
       extremity.
       Passive movement of the affected limb results in pain.
       Muscle function decreases rapidly, leading to limb paralysis. This is not due to nerve
       involvement though. It is due to direct muscular dysfunction.
       There is progressively marked swelling of the affected area.
       Systemic manifestations of crush syndrome begin to be seen in seconds to minutes to
       hours depending on the amount of muscle involved.




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Diagnosis
       There needs to be a high index of suspicion in order to make this diagnosis.
       Identify the potential crush mechanism.
       Look for subtle signs and symptoms.
       The most consistent clinical finding is loss of two-point discrimination.
       In a comatose patient, the only clue would be firm swelling of the affected muscle
       compartments.


Basic Life Support
   ♦ Secure airway/Spinal immobilization
   ♦ Assess Breath sounds and Respiratory effort
           Administer supplemental oxygen, maintain saturation between 90-100%
   ♦ Record and monitor vital signs
   ♦ Examine patient for obvious bleeding
           Compress bleeding sites if possible
   ♦ Assess Disability – neurologic status/record Glasgow coma score
   ♦   Head to toe examination to assess for injuries if possible
   ♦ Assess for crush injury potential, and traumatic mechanisms of injury
   ♦ Re-evaluate frequently while inside the rubble, and immediately upon extrication.
       Continue close monitoring outside of the rubble, and continue right up until transport


Advanced Life Support
   ♦ Advanced airway/ventilatory management as needed
   ♦ Needle decompression for patient with tension pneumothorax as needed
   ♦ Begin cardiac monitoring, record and evaluate EKG strip
   ♦ Record & monitor 02 saturation
   ♦ IV 0.9% NaCl KVO
           Fluid replacement should be initiated prior to lifting compression
           Administer 0.9% NaCl at infusion rate of 1500 cc/hr
               Contraindicated if evidence of congestive heart failure (e.g. rales)


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Medical Control

    Consider pre-alkalinizing with sodium bicarbonate
         The suggested initial maintenance fluid based on the available research is sodium
        chloride 70 mEq/L in 5% dextrose water with 5O mEq/L of sodium bicarbonate (D5
        1/2 NS with 1 amp bicarb per liter bag).
     Consider promotion of Renal Perfusion
        Renal dose dopamine should be used to promote diuresis if needed
        Dopamine 1-2 mcg/kg/min IV



                         CONTROVERSIAL INTERVENTIONS
               TO BE CONSIDERED BY ON-LINE MEDICAL CONTROL ONLY:

Field amputations:
Indications:
       Inability to extricate by ANY other means.
       Situation where the need for rapid extrication is paramount (hazmat, very unstable
       rubble, etc.).


Complications:
       Permanent loss of function.
       Inadequate anesthesia and analgesia.
       Difficulty controlling hemorrhage.
       Infection and sepsis.
       Difficult procedure in the field. Few emergency physicians ale trained in this
       procedure.




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Arterial tourniquets:
Indications:
       Patient in extremis resistant to therapy.
       Need for rapid extrication.


Complications:
       Inadequate analgesia (tourniquets are very painful!).
       Must monitor closely to prevent accidental (or patient) release.
       Increases injury to involved extremity.
       Only delays the necessary care.
       No studies demonstrating efficacy.


Field fasciotomies:
Indications are controversial:
       To prevent severe compartment syndrome and on-going rhabdomyolysis.
       Should not be used if mannitol infusion has not been given an adequate trial; generally
       eight hours.
       Compartment pressure measurements should be obtained. Consider fasciotomy if:
       Compartment pressure is 40 mmHg greater than systolic blood pressure.
       Compartment pressure is 30 mmHg greater than diastolic blood pressure.


Complications:
       Technically difficult in the field. Again, this is not something that emergency
       physicians are routinely taught.
       Infection almost unavoidable. This is especially true if dead muscle is exposed to the
       contaminated environment in the rubble.
       Inadequate analgesia for procedure and afterward.
       Severe bleeding from crushed tissue is common.


                      NOT RECOMMENDED unless there are no pulses,
                   ongoing rhabdomyolysis is severe, and help is far away.



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            Appendix 1: Advanced Airway Management Program




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