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`APReR nen
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`FIELD GUIDE
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`

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`Common EMSProtocols
`
`JONES AND BARTLETT PUBLISHERS
`Sudbury, Massachusetts
`BOSTON
`TORONTO
`LONDON
`SINGAPORE
`
`

`

`World Headquarters
`Jones and Bartlett Publishers
`40 Tall Pine Drive
`,
`
`Z
`:
`i
`info@jbpub.com
`www.jbpub.com
`
`Jones and Bartlett Publishers Canada
`2406 Nikanna Road
`Mississauga, ON LSC 2W6
`Canada
`Jones and Bartlett Publishers International
`Barb House, Barb Mews
`London W6 7PA
`United Kingdom
`
`AQUESTIVE EXHIBIT 1069 Page 0003
`
`2.1 Adult Initial Assessment & Management
`Protocols in Section 2.1 are designed to guide the EMT or paramedic in his or
`herinitial approach to assessment and managementof adultpatients. Support-
`ive Care is specified as EMT and Paramedic (BLS) and Paramedic Only (ALS).
`Protocol 2.1.1 should be used onall adult patients for initial assessment.
`During this assessment, if the EMT or paramedic determinesthatthereis a
`need for airway management, Protocol 2.1.2 should be used for the man-
`agementof the adult airway. These protocols are frequently referred to by
`other protocols, which may or may not override them in recommending
`morespecific therapy.
`Protocol 2.1.3 presents the basic components of preparation for trans-
`port of medical patients. Due to the significant differences in priorities and
`packaging in the pre-hospital care of trauma and hypovolemia cases, a sep-
`arate Trauma Supportive Care protocol has been developed. After follow-
`ing Protocol 2.1.1, this Medical Supportive Care protocol may be the only
`protocol used in medical emergency situations where a specific diagnostic
`impression and choice of additional protocol(s) cannot be made. Judgment
`must be used in determining whether patients require ALS or BLS level
`care. This protocolis frequently referred to by other protocols, which may
`or may not override it in recommending morespecific therapy.
`Protocol 2.1.4 presents the basic components of preparation for transport
`of traumapatients. Dueto the significant differencesin priorities and packag-
`ing in the pre-hospital care of medical cases, a separate Medical Supportive
`
`Copyright © 2005 by Jones and Bartlett Publishers, Inc., and Fire Chiefs Association of Broward
`County,Inc.
`ISBN:0-7637-3039-4
`
`Wong-Baker FACES Pain Rating Scale from Wong D.L., Hockenberry-Eaton M., Wilson D., Winkel-
`stein M.L., Schwartz P.: Wong's Essentials of Pediatric Nursing, ed. 6, St. Louis, 2001, Pp. 1301. Copy-
`righted by Mosby,Inc. Reprinted by permission.
`All rights reserved. No part of the material protected by this copyright may be reproducedoruti-
`lized in any form, electronic or mechanical, including photocopying,recording, or by any informa-
`tion storage andretrieval system, without written permission from the copyright owner.
`The procedures and protocols in this guide are based on the most current recommendations of
`responsible medical sources. The publisher, however, makes no guarantee as to, and assumes no
`responsibility for, the correctness, sufficiency, or completeness of such information or recommenda-
`tions. Other or additional safety measures may be required under particular circumstances. This
`guide is designedsolely as a guide to the appropriate procedures to be employed when rendering
`emergency care to the sick and injured. It is not intended as a statementof the standards of care
`required in any particular situation, because circumstances and the patient’s physical condition can
`vary widely from one emergency to another. Noris it intended that this guide shall in any way
`advise emergency personnel concerninglegal authority to perform the activities or procedures dis-
`cussed. Such local determinations should be made only with the aid of legal counsel.
`Production Credits
`Publisher, EMS & Aquatics: Lawrence D. Newell
`V.P., Manufacturing and Inventory Control:
`Therese Brauer
`Associate ManagingEditor: Jennifer Reed
`Associate Production Editor: Karen C. Ferreira
`Printed in Canada
`08 07 06 05 04 10987654321
`
`Photo Researcher: Kimberly Potvin
`Director of Marketing: Alisha Weisman
`Composition, Text Design, and Art: Shepherd,Inc.
`Printing and Binding: Transcontinental Printing
`
`Adult Protocols
`
`AQUESTIVE EXHIBIT 1069 Page 0003
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`

`

`2
`oreooe au snaneiee Field Guide”
`Care protocol has been developed.After following Protocol 2.1.1, this Trauma
`Supportive Care protocol may be the only protocol used in trauma or hypov-
`olemia situations where a specific diagnostic impression and choice of addi-
`tional protocol(s) cannot be made. Judgment must be used in determining
`whether patients require ALS or BLS level care. This protocol is frequently
`referred to by other protocols, which may or may not override it in recom-
`mending morespecific therapy.
`Protocol 2.1.5 should be used by paramedics only for pain management.
`
`2.1.1 Initial Assessment
`EMT and Paramedic
`
`onal Common EMSProtocals
`
`AQUESTIVE EXHIBIT 1069 Page 0004
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`I. Scene Size-up.
`. Review of Dispatch Information.
`. Assess Need for Body Substance Isolation.
`. Assessmentof Scene Safety.
`. Determine Mechanism ofInjury.
`. Determine Number and Locationof Patients.
`. Determine Need for Additional Resources.
`tial Assessment.
`. General Impressionof Patient.
`. Assess Mental Status (AVPU)—Maintain Spinal Immobilization PRN.
`. Assess Airway.
`. Assess Breathing.
`. Assess Circulation—Pulse, Major Bleeding, Skin Color and
`Temperature.
`. Assess Disability—Movementof Extremities /Defibrillation—
`VE/VT withoutpulse.
`. Expose and Examine Head, Neck, Chest, Abdomen,and Pelvis ©
`(check back when patientis rolled on side).
`H. Identify Priority Patients.
`. Initial Management(see Adult Protocol 2.1.3 - Medical Supportive
`Care or 2.1.4 - Trauma Supportive Care).
`- Secondary Assessment.
`A. Conduct a Head-to-Toe Survey.
`B. Neurological Assessment.
`1. Pupillary Response.
`2. Glasgow ComaScore.
`
`GEPEetePeh
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`

`

`C. Assess Vital Signs.
`. Respirations.
`. Pulse.
`. Blood Pressure.
`. Capillary Refill.
`. Skin Condition.
`a. Color.
`b. Temperature.
`c. Moisture.
`6. Lung sounds.
`. Obtain a Medical History.
`1. S- Symptoms- Assessment of Chief Complaint.
`a. O—Onset and Location.
`b. P—Provocation.
`c. Q—Quality.
`d. R—Radiation.
`e. R—Referred.
`f.
`. R—Relief.
`. S—Severity.
`. T—Time.
`
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`™
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`a
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`
`V. Other Assessment Techniques.
`A. Cardiac Monitoring.
`B. Pulse Oximetry.
`. Glucose Determination.
`. Monitor Core Temperature.
`. Capnography.
`
`AQUESTIVE EXHIBIT 1069 Page 0005
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`egional Common EMS Protocols Field Guide
`
`4
`
`
`
`O4gJINpYy
`
`&h
`
`. A- Allergies.
`. M- Medications.
`. P- Past Medical History.
`. L- Last OralIntake.
`. E- Events Leading to Ilness orInjury.
`
`Pgeereeesee
`
`=eeeeeeeen
`
`

`

`2.1.2 Airway Management
`Supportive Care
`EMT and Paramedic
`@ Initial Assessment Protocol2.1.1.
`If spontaneousbreathing is present without compromise:
`@ Monitor breathing during transport.
`@ Administer oxygen via nasal cannula (2-6 L/min) PRN.
`If spontaneousbreathing is present with compromise:
`Maintain airway (e.g. modified jaw thrust).
`Administer oxygen via non-rebreather mask (10-15 L/min).
`if unconscious, insert oropharyngeal or nasopharyngealairway PRN.
`Assist ventilations with BVM PRN.
`Suction PRN.
`Monitor pulse oximetry and capnography, as soonaspossible.
`Paramedic Only
`® If patient accepts oropharyngeal airway, consider need for intubation (see
`below: ALS Level
`|—Advanced Airway Management).
`EMT and Paramedic
`If spontaneousbreathing is absent or markedly compromised:
`® Maintain airway (e.g. modified jaw thrust).
`® If unconscious, insert oropharyngeal or nasopharyngeal airway.
`Assist ventilations with BVM.
`Suction PRN.
`
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`PEECECorElshd
`
`° ®
`
`® If unconscious and intubation is not available, insert LMA or Combitube(a).
`a
`Monitor pulse oximetry and capnography or ETCO, monitoring device, as
`soon as possible.
`
`ACiiRU NSTouROCsdance aCReni:Cag
`
`Paramedic Only
`Perform endotrachealintubation and documentthe following(a).
`|. Confirm ETT placement.
`a. Negative epigastric sounds.
`b. Positive bilateral breath sounds.
`2. Secure ETT with commercialdevice.
`a. Full spinal immobilization is recommended.
`3. Attach end-tidal CO, monitoring device.
`4. Monitor SpO, with pulse oximeter.
`If unable to intubate and patient cannotbe adequatelyventilatedby other
`means, perform cricothyroidotomy and transport rapidly to the hospital(b).
`
`StatenSPinitshsd
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`(a) Authorized IV routes includeall peripheral venoussites. External jugular
`veins may be utilized when other peripheralsite attempts have been unsuc-
`cessful or would be inappropriate. A large bore intracath should be used for
`unstable patients, avoid sites below the diaphragm.
`(b) An TV lock or medication access point (MAP) maybe usedin lieu of an IV
`bag in somepatients, when appropriate.
`(c) When unableto establish an IV in the adult patient that needsto be resuscitat-
`ed, an intraosseous line may be used by the Paramedic only.
`(d) An EMTthat has been authorized by their individual Medical Director may
`establish an IV.
`
`Florida Regional Common EMS Protocols Field Guide
`
`8
`
`NOTE
`(a) Other airway devices may be authorizedfor use by an individual medical
`director (e.g. COBRA Airway).
`(b) Follow Universal Airway Algorithm onall intubations.
`
`TeeterCePBellehed
`
`Universal Airway Algorithm
`r
`—_——-
`Grash
`Airway
`Algorithm
`=
`
`}i
`
`— Fails
`
`|
`—]
`]
`Unconscious,
`Critical Condition, -—— Yes ——-|
`| Gardiac Arrest
`|
`i od
`|No
`
`fess)
`
`
`
`—_
`Difficutt
`Algonitinm
`Airway
`eaie
`
`=p
`
`Sescco
`| Does the Patient
`|
`|
`rway?
`| vase Difficult
`+—— Yas —+
`[ae
`No
`
`
`
`|
`
`—N
`
`on-Paralytic
`| Rapid Sequence
`I
`Intubation
`
`Florida Regional Common EMSProtocols Field Guide
`
`2.1.3 Medical Supportive Care
`Supportive Care
`EMT and Paramedic
`@ Initial Assessment Protocol2.1.1.
`@ Airway Management Protocol2.1.2.
`@ Establish hospital contact for notification of incoming patient and for the
`Paramedic to obtain consultation for level 2 orders.
`
`EilosxenteMPeyalohed
`
`Paramedic Only
`Monitor ECG PRN.
`Paramedic and Authorized EMT
`Establish IV with Saline Lock (a)(b)(c)(d).
`
`or
`
`Establish IV of Normal Saline with regular infusion set (a)(b)(c)(d), unless
`overridden by other specific protocol.
`
`None
`
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`EypeeresCoPDelLitoked
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`Florida Regional Common EMS Protc
`
`NOTES
`THE FOLLOWING STEPS SHOULD NOT DELAY TRANSPORT
`® Complete bandaging, splinting and packaging PRN.
`@ Establish hospital contact for notification of incoming patient and for the
`Paramedic to obtain consultation for level 2 orders.
`
`Paramedic and Authorized EMT
`Establish IV of NormalSaline with regular infusion set (a)(b)({c), unless
`overridden by other specific protocol.
`Paramedic Only
`® Monitor ECG PRN.
`
`2.1.4 Trauma Supportive Care
`Supportive Care
`EMT and Paramedic
`@ Initial Assessment Protocol2.1.1. Initiate trauma alert, if applicable.
`@ Airway Management Protocol 2.1.2. (manually stabilize c-spine PRN).
`@ Correct any open wound/sucking chest wound (occlusive dressing).
`Paramedic Only
`@ Correct any massiveflail segment that causes respiratory compromise (intubate).
`@ Correct any tension pneumothorax.
`EMT and Paramedic
`@ Control hemorrhage.
`® Immobilize c-spine and secure patient to backboard PRN.
`@ Expedite transport.
`
`QUESTIVE EXHIBIT 1069
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`EEE
`PreTeiieintfh
`mF
`a
`|
`|
`i > ae 4 a
`SEEEEEES
`
`None
`
`oS Authorized IV routes includeall peripheral venous sites. External jugular
`veins maybe utilized when other peripheral site attempts have co
`cessful or would be inappropriate. TwoIVsusing large bore intracatns,
`shouldbe usedfor unstablepatients, avoid see diaphragm. Con-
`i
`‘no
`trauma tubing or blood infusion tubing
`;
`_
`(b) teotneblstoeaabuahonIV inthe adultpatientthatneedstobe resuscitat
`ed, an intraosseous line may be used by the Paramedic only.
`(©) An EMT that has been authorized bytheir individual Medical Director may
`establish an IV.
`
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`

`

`2.1.5 Pain Management
`Paramedic Only
`This entire protocol is ALS / Paramedic Only.
`Isocatep Extremity FRACTURE
`The purposeofthis procedure is to manage pain associated with isolated
`extremity fractures not associated with multi-system trauma or hemody-
`namic instability.
`
`or
`
`Hydromorphone Hydrochloride (Dilaudid®) | mg slow IV, may repeat
`once PRN (maximum total dose 2 mg),if available (a).
`
`or
`
`Nalbuphine Hydrochloride (Nubain®) 10 mg slow IV,if available(a).
`
`Patients should be asked to quantify their pain on an analogpain scale
`(O=least severe to !0=mostsevere). This number should be documented
`and used to measurethe effectiveness of analgesia.
`Distal circulation, sensation and movement should be noted and recorded
`in the injured extremity.
`The extremity should be immobilized as described in Adult Protocol 2.10.6 -
`Extremity Injuries. Nitrous Oxide self-administered analgesia should be
`given special consideration for pain managementduring this procedure,if
`available.
`Extremity fractures should be elevated,if possible, and cold applied.
`If pain persists and systolic BP >90 mmHg, choose oneofthe following:
`Morphine Sulfate may be given slow IV in 2 mg increments every 3-5 min-
`utes,titrated to pain and BP 290 mmHg, up to a maximum of 10 mg(a).
`
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`13
`
`Fentanyl (Sublimaze®) 250 mcg slowIV,if available (a).
`
`or
`
`Butorphanol (Stado!®) 2 mg slow IV,if available (a).
`
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`

`Acute Back STRAIN
`This procedure should be usedin the isolated back strain where an acute
`abdominalprocess is not suspected.
`
`Hydromorphone Hydrochloride (Dilaudid®) 1 mg slow IV, may repeat
`once PRN (maximum total dose 2 mg), if available (a).
`
`Nalbuphine Hydrochloride (Nubain®) 10 mg slow IV,if available (a).
`
`or
`
`or
`
`i Fentanyl (Sublimaze®) 250 meg slow IV,if available (a).
`or
`
`Butorphanol(Stadol®) 2 mg slow IV,if available (a).
`B'
`
`If pain persists and systolic BP 290 mmHg, Ketorolac Tromethamine
`(Toradol®) may be given 30 mg IV or 60 mg IM (if patient is >65 y/o limit
`dosage to 15 mg IV or 30 mg IM), if available (b).
`
`Patients should be asked to quantify their pain on an analogpain scale
`(0=least severe to 10=mostsevere). This number should be documented
`and used to measurethe effectiveness of analgesia.
`Nitrous Oxide self-administered, if available.
`:
`Secure patient to back board PRN.
`if pain persists and systolic BP >90 mmHg, choose oneofthe following:
`; Morphine Sulfate may be given slow IV in 2 mg increments every 3-5 min-
`utes, titrated to pain and BP >90 mmHg,up to a maximum of |0 mg(a).
`or
`
`QUESTIVE EXHIBIT 1069
`
`PATA AITAD
`eS ee
`SECCECEEEEE EES
`l
`a
`a
`
`J
`
`ommon EMSProt
`
`RENAL Cotic
`This procedureis used for flank pain associated with kidney stones where
`an acute abdominal process can beruledout.
`
`Patients should be asked to quantify their pain on an analog pain scale
`(O=least severe to 10=most severe). This number should be documented
`and used to measure the effectiveness of analgesia.
`Nitrous Oxide self-administered,if available.
`if pain persists and systolic BP 290 mmHg, choose one ofthe following:
`MorphineSulfate may be given slow IV in 2 mg increments every 3-5 min-
`utes,titrated to pain and BP >90 mmHg,up to a maximum of 10 mg (a).
`
`or
`
`Hydromorphone Hydrochloride (Dilaudid®) | mg stow IV, may repeat
`once PRN (maximum total dose 2 mg), if available (a).
`
`Nalbuphine Hydrochloride (Nubain®) 10 mg slow IV,if available (a).
`
`or
`
`or
`
`Fentanyl (Sublimaze®) 250 megslow IV,if available (a).
`
`or
`
`Butorphanol(Stadol®) 2 mg slow IV,if available(a).
`
`If pain persists and systolic BP >90 mmHg, Ketorolac Tromethamine
`(Toradol®) may be given 30 mg IV or 60 mg IM (if patient is >65 y/o limit
`dosage to 15 mg IV or 30 mg IM), if available {b).
`
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`16
`
`Sort Tissue Insuries, BurNs, BITES AND STINGS
`This procedure is used for pain associated with soft tissue injuries, burns,
`bites andstings not associated with multi-system trauma or hemodynam-
`ic instability.
`
`Patients should be asked to quantify their pain on an analog pain scale
`(0=least severe to 10=mostsevere). This number should be documented
`and used to measurethe effectiveness of analgesia.
`Nitrous Oxide self-administered,if available.
`If pain persists and systolic BP 290 mmHg,choose oneofthe following:
`MorphineSulfate maybe given slow IV in 2 mg increments every 3-5 min-
`utes, titrated to pain and BP 290 mmHg, up to a maximum of 10 mg(a).
`
`or
`
`or
`
`or
`
`or
`
`Hydromorphone Hydrochloride (Dilaudid®) | mg slow IV, may repeat
`once PRN (maximum total dose 2 mg),if available (a).
`
`Nalbuphine Hydrochloride (Nubain®) 10 mg slow lV,if available (a).
`
`Fentanyl (Sublimaze®) 250 mcg slow IV,if available (a).
`
`Butorphanol(Stadol®) 2 mg slow IV,if available (a).
`
`If pain persists and systolic BP 290 mmHg, Ketorolac Tromethamine
`(Toradol®) may be given 30 mg IV or 60 mg IM (if patient is >65 y/o limit
`dosage to 15 mg IV or 30 mg IM), if available (b).
`
`
`
`temresteePiriesd
`
`
`
`$j020304g3/NPY
`
`AQUESTIVE EXHIBIT 1069 Page 0011
`
`NOTE
`(a) Extreme caution should be used with administering narcotic analgesics to a
`patient with an SpO2 <95.
`(b) Toradol is contraindicated in the following patients:
`(1) Potential surgical candidate (e.g. Trauma patient)
`(2) Known allergies to nonsteroidal anti-inflammatory drugs(e.g. aspirin,
`ibuprophen)
`(3) History of nasal polyps
`(4) Angioedema
`(5) Bronchospastic reactivity (e.g. asthma)
`(6) Bleeding disorders(e.g. ulcers)
`(7) Kidney dysfunction
`(8) Older than 65 yearsof age
`
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`
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`118
`
`EoTeHPPetilhed
`
`4
`
`2.2 Adult Respiratory Emergencies
`Assessmentof the adult patient in respiratory distress requires specific
`attention to the function of the respiratory system. The EMT’s and para-
`medic’s assessment should be more concentrated in this area to include the
`following:
`|. Assessment of chest wall movement to include rate and depth of ventilation,
`as well as a symmetrical rise andfall.
`2. Assessment of accessory muscle use.
`3. Auscultation ofbilateral lung sounds.
`4. Use of pulse oximetry.
`The EMT and paramedic mustbe able to determine the adequacy of venti-
`lation and understandits relationship to respiration. If signs of hypoxia and
`respiratory distress are present, immediate airway and ventilatory manage-
`ment should be initiated. These signs include: altered mental status, tachyp-
`nea, use of accessory muscles, nasal flaring, pursed lips, abnormal lung
`sounds, tachycardia, and cyanosis. In addition, the general signs of shock may
`also be seen. Othersigns of respiratory insufficiency that should alert the para-
`medic to the need for immediate airway and ventilatory management, includ-
`ing intubation, are: respiratory rate <10 or >36 per minute, and SpO) <95.
`In patients with chronic respiratory disease, the paramedic must be able
`to differentiate between whatis chronic and what is acute, as it pertains to
`the respiratory assessment. Specific questions about the chief complaint and
`accompanying symptoms mayproveto be invaluablein this setting. Assess-
`mentof lung sounds should be combined with patient history. For example,
`a patient with a history of CHF that has wheezing on auscultation of lung
`sounds should not be automatically classified as an “asthmapatient”. The
`paramedic must remember that patients with CHF mayalso present with
`wheezing. If this patient does not have a history of asthma orallergic reac-
`tion, the more prudent assessment would be that of CHF.
`
`QUESTIVE EXHIBIT 1069 Page 0012
`
`gorerrerereerggys
`WULLLLLLLLLL
`
`BB
`
`EES
`
`feel adeiease soins
`Specific treatments for the different causes of respiratory distress are out-
`lined in the following protocols. When the paramedic is unsure as to which
`protocol to follow, he or she should follow the protocols in Section 2.1 and
`contact medical controlfor further direction.
`
`
`
`Beeterteerpeltedf
`
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`Florida Regional Common EMS ProtocolsField Guide 20
`
`2.2.1 Airway Obstruction
`Causes of upper airway obstruction include the tongue, foreign bodies,
`swelling of the upper airway due to angio-neurotic edema (see Adult
`Protocol 2.8.1 - Allergic Reactions/ Anaphylaxis) and traumato theair-
`way. Differentiation of the cause of upper airway obstruction is essential
`to determining the proper treatment.
`
`CELREeyiad
`
`Supportive Care
`@ Medical Supportive Care Protocol 2.1.3.
`@ if air exchange is inadequate and there is a reasonable suspicion of foreign
`body airway obstruction (FBAO), apply abdominal thrusts (a).
`
`ALSLevel |
`@ If unable to relieve FBAO,visualize with laryngoscope and extract foreign
`body with Magill forceps.
`® If obstruction is due to trauma and/or edema,orif uncontrollable bleeding
`into the airway causeslife-threatening ventilatory impairment, perform
`endotracheal intubation.
`@ If unable to intubate and patient cannot be adequately ventilated by other
`means, perform cricothyroidotomy.
`
`(a)
`
`Ifair exchangeis adequate with a partial airway obstruction,do notinterfere and
`encourage patient to cough up obstruction. Continue to monitor for adequacy ofair
`exchange.If air exchange becomes inadequate continue with protocol.
`
`ALS Level 2
`None
`SESPGTeereTESeTETSTT
`NOTE
`
`AQUESTIVE EXHIBIT 1069 Page 0013
`
`Flarida Regional Common EMSProtocols Field Guide 21
`
`2.2.2 Asthma/Bronchospasm
`This protocol is used for patients who are complaining of dypsnea and
`having wheezing. A patient with a history of CHF that has wheezing on
`auscultation of lung sounds should not be automatically classified as an
`“asthmapatient”. If the CHE patient does not have a history of asthma or
`allergic reaction, the more prudent assessment would be that of CHF
`(cardiac asthma) (see Adult Protocol 2.2.4 - Pulmonary Edema—CHF).
`
`
`
`PerestehPrevilehsd
`
`Supportive Care
`@ Medical Supportive Care Protocol 2.1.3, including pulse oximeter and
`capnography.
`
`ALS Level |
`© Choose one ofthe following bronchodilators:
`m Albuterol (Ventolin®) | nebulizer treatment containing 2.5 mg of Albuterol
`pre-mixed with 2.5 ml normalsaline. May repeat twice PRN (a).
`or
`
`m Levalbuterol (Xopenex®) | nebulizer treatment containing 0.63 mg
`(3 ml) of Levalbuterol. May repeat twice PRN.
`If bronchodilators are administered, may add Ipratropium Bromide (Atro-
`vent®) 0.5 mg (0.5 ml) to either Albuterol or Levalbuterol nebulizer treat-
`ment on first nebulizer treatment only.
`May give Terbutaline (Brethine®) 0.25 mg SQ,if available.
`Consider need for intubation.
`if patient has respiratory distress, choose oneof the following steroids:
`m Prednisone 60 mg PO,if available.
`or
`
`tt Methylprednisolone Sodium Succinate (Solu-Medrol®) 125 mg IV,if
`available.
`
`AQUESTIVE EXHIBIT 1069 Page 0013
`
`

`

`mon EMS Protocols
`
`or
`
`Dexamethasone (Decadron®) 10 mg IN,if available.
`For severe dyspnea, Epinephrine (1:1000) 0.3 mg SQ (b)(c).
`For severe dyspnea, Magnesium Sulfate 2 gm iV (mixed in 50 ml of D5W
`given over 5~10 minutes), PRN.
`
`Repeat Epinephrine (1:1000) 0.3 mg SQ (b)(c).
`
`Donotgive Albuterol or [pratropium Bromideif heart rate is 2140.
`Caution should be used whenthe patient is older than 40 years of age or
`has a history of hypertension or heart disease.
`if hypotensive with delayin capillary refill, consider Epinephrine (1:10,000)
`0.5 mg SLOWIV (over 3-4 minutes) or Epinephrine (1:10,000) Img ET.
`
`
`
`
`
`ElfeplorterItCaloh«A
`
`AQUESTIVE EXHIBIT 1069 Page 0014
`
`Levalbuterol (Xopenex®) | nebulizer treatment containing 0.63 mg
`(3 ml) of Levalbuterol. May repeat twice PRN.
`if bronchodilators are administered, may add Ipratropium Bromide (Atro-
`vent®) 0.5 mg (0.5 ml) to either Albuterol or Levalbuterol nebulizer treat-
`ment on first nebulizer treatmentonly.
`May give Terbutaline (Brethine®) 0.25 mgSQ,if available.
`Consider need for intubation.
`If patient has respiratory distress, choose one of the following steroids:
`Prednisone 60 mg PO,if available.
`or
`
`CUTTTTTT TTT TTT
`Lt 1
`» Oe
`OU
`| Bf
`|
`I
`:
`| i 1
`BECCECEECTETERELEECESES
`
`alvaleelntearelacMecounAMIodsy uSiancicecnasm Ciemeee)
`2.2.3 Chronic Obstructive Pulmonary Disease (COPD)
`This protocol is used for patients with a history of emphysema and/or
`chronic bronchitis that complain of dyspnea.If, at any point, the patient’s
`respiratory status deteriorates, consider intubation and administration of
`Albuterol via the ET tube as a mist, and transport immediately.
`
`IeteCOePPeload
`
`Supportive Care
`@ Medical Supportive Care Protocol 2.1.3, including pulse oximeter and
`capnography.
`
`Choose one of the following bronchodilators:
`Albuterol (Ventolin®) | nebulizer treatment containing 2.5 mg of
`Albuterol pre-mixed with 2.5 ml normalsaline. May repeat twice PRN (a).
`
`or
`
`Methylprednisolone Sodium Succinate (Solu-Medrol®) 125 mg IV,
`if available.
`
`or
`
`Dexamethasone (Decadron®) 10 mgIV,if available.
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`
`

`

`lorida Regional Common EMS Protocols Field Guide
`
`None
`
`NOTE
`(a) Do not give Albuterol or Ipratropium Bromideif heart rate is 2140.
`
`ponaaeaereeee
`
`|
`
`orida
`
`(eeticin sen aaens:
`
`QUESTIVE EXHIBIT 1069 Page 0015
`
`2.2.4 Pulmonary Edema - CHF
`This protocolis used for patients who are exhibiting signs of pulmonary - CHF
`‘including: dyspnea with rales and/or wheezing (cardiac asthma). The
`patient may also have diminished air exchange. Other treatmentfor the
`causes of pulmonary edema - CHF should be considered (e.g. supraventric-
`ular tachycardia, myocardial infarction and cardiogenic shock). A patient
`with a history of CHF that has wheezing on auscultation of lung sounds
`should not be automatically classified as an “asthma patient”. The para-
`medic must remember that patients with CHF may also present with
`wheezing. If the CHF patient does not have a history of asthmaoraller-
`gic reaction, the more prudent assessment would be that of CHF(cardiac
`asthma).
`
`Supportive Care
`@ Medical Supportive Care Protocol2.1.3, including pulse oximeter and
`capnography.
`Place patient in Fowler’s position, if tolerated andassist ventilations PRN.
`Administer CPAP with 10 cmH,0 PEEP,if available (a).
`if patient is hypotensive (systolic BP <90 mmHg), see Adult Protocol2.4.1 (b).
`
`If no improvementin patient’s pulse oximeter, capnography and mental
`status consider intubation.
`if systolic BP 290 mmHg, Nitroglycerin (Nitrostat® or Nitrolingual® Spray)
`0.4mg SL, repeat every 3 minutes (maximum dose 1.2 mg) (b)(c).
`If systolic BP 290 mmHg, Nitropaste (Nitro-Bid® Ointment) |-2 inch on
`chest wall (spread Nitropaste on chest to size of patient’s palm) (b).
`if systolic BP 290 mmHg, Furosemide (Lasix®) | mg/kg (or 80mg)IV (b).
`
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`

`Florida Regional Common EMS Protocols Field Guide
`Re-evaluate need for intubation.
`If no i
`i
`4s
`mprovementin patient’
`
`oximeter, capnography and mentalstatus consider ineulenase aia
`if patient is stable, see Adult Protocol2.4.2.
`,
`if systolic BP 290 mmHg, Morphine Sulfate may begiven slow IV in 2 m
`increments, may repeat every 3-5 minutes, titrated to BP >90 mmH ;
`to a maximum of [0 mg PRN (b)(d).
`-
`ae
`
`CoPeurekg
`
`Repeat Furosemide (Lasix®) | m
`:
`g/kg (or 80mg) IV (b).
`Nitroglycerin (Tridil®) infusion @ 5-20 meg/min., ' eal
`
`NOTE
`:
`(a) foo aebe tight fitting. Somepatients may nottolerate CPAPat
`cmH,O
`PEEP initially. In this instance, 7.5 cmH,O PEEP should be used
`to obtain tolerance
`and
`i
`whee
`e and
`then increased to 10 cmHO PEEP for therapeutic
`(b) Considerclinical presentation of patientfor signs of adequate perfusion.
`(c)
`It is preferred to have an IV in
`i
`:
`place prior to NTG administrati
`if unable to establish IV, NTG maybe administered with cactiand
`sate
`s
`If Morphine administration causes severe respiratory depression, consult with
`ie
`physician for possible reversal with Naloxon:e (N
`(ALS Level2 only).
`Ser
`
`d
`(d)
`
`27
`
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`
`Florida Regional Common EMS Protocols Field Guide
`2.2.5 Suspected Pneumonia
`Patients complaining of dyspnea should be suspected of having pneumo-
`nia when they present with fever, productive cough,possible pleuritic
`chest pain, history of being bedridden, known immuno-compromise, dia-
`betes, elderly and lung sounds indicative of consolidation (rales and/or
`thonchi with egophonyoverarea of consolidation).
`Supportive Care
`@ Medical Supportive Care Protocol2.1.3, including pulse oximeter and capnog-
`raphy; also check temperature.
`
`istePieishg
`
`Chooseone ofthe following bronchodilators:
`Albuterol (Ventolin®) | nebulizer treatment containing 2.5 mg of
`Albuterol pre-mixed with 2.5 ml normalsaline. May repeat twice PRN(a).
`
`or
`
`Levalbuterol (Xopenex®) | nebulizer treatment containing 0.63 mg
`(3 mi) of Levalbuterol. May repeat twice PRN.
`If bronchodilators are administered, may add Ipratropium Bromide (Atro-
`vent®) 0.5 mg (0.5 ml) to either Albuterol or Levalbuterol nebulizer treat-
`ment on first nebulizer treatmentonly.
`May give Terbutaline (Brethine®) 0.25 mg SQ,if available.
`Avoid use of diuretics.
`
`None
`
`NOTE
`(a) Donotgive Albuterolor Ipratropium Bromide if heart rate is 2140.
`
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`

`Fiorida Regional Common EMS Protocols Field Guide
`2.3 Adult Cardiac Dysrhythmias
`Protocols in Section 2.3 follow the ACLS guidelines. The EMT and para-
`medic should use these protocols to guide him/her through the treatment
`of cardiac patients with specific dysrhythmias and accompanying signs
`and symptoms. After stabilization of the patient, the paramedic may need
`to refer to additional protocols for continued treatment(e.g. other cardiac
`protocols).
`
`28
`
`2.3.1 Asystole
`Supportive Care
`@ Medical Supportive Care Protocol2.1.3, if applicable.
`@ CPR (check other leads to confirm asystole).
`® Hyperventilate.
`
`
`
`teersteePPeyiilshsd
`
`QUESTIVE EXHIBIT 1069 Page 0017
`
`External pacemaker.
`Epinephrine (1:10,000) | mg IV (a), repeat every 3-5 minutes for duration
`of pulselessness.
`Atropine | mg IV (b), repeat every 3—5 minutes (maximum total dose
`0.04 mg/kg or 3 mg).
`After maximum Atropine dose or known pre-existing metabolic acidosis,
`Sodium Bicarbonate (8.4%) | mEq/kg IV.
`> Perform glucose test with finger stick as soon as possible.If glucose is
`below 60 mg/dL, administer Dextrose 50% 25 gm (50 ml) slow IV.
`If patient is taking a calcium channel blocker or has knownrenalfailure,
`Calcium Chloride 10% 1000 mg (I g) or 10 mi IV.
`
`None
`
`NOTE
`(a)
`
`(b)
`
`I£IV is not established, administer Epinephrine via ETT at twice the [V dose
`(maximum 0.1 mg/kg).
`IfIV is not established, administer Atropine via ETT at twice the IV dose.
`
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`

`al Common EMSProt
`
`2.3.2 Bradycardia
`Supportive Care
`@ Medical Supportive Care Protocol 2.1.3.
`a
`
`or
`
`If patient displays severe symptoms refractory to ALS Level
`nephrine infusion @ 2-10 mcg/min.
`
`| care, Epi-
`
`Perform 12 Lead ECG. Transmit [2 Lead ECG to destination hospital, if
`available.If inferior wall Mlis identified, perform additional 12 lead ECG
`with V4R to confirm/rule out concurrent right ventricular MI (a).
`If symptomatic (b), Atropine 0.5—| mgIV, repeat every 3-5 minutes (c)
`(maximum total dose 0.04 mg/kg or 3 mg) (d).
`External pacemaker.
`If patient is conscious and awareofsituation during pacing, administer one
`of the following benzodiazepines:
`Diazepam (Valium®) 5 mg IV, may repeat once PRN (up to max. 10 mg).
`or
`Midazolam (Versed®) 2 mg lV, may repeat once PRN (up to max. 4 mg).
`Lorazepam (Ativan®) 2 mg IV, may repeat once PRN (up to max. 4 mg).
`If pacemakeris unavailable or ineffective, Dopamineinfusion @
`5-20mcg/kg/min (1600 meg/mlinfusion concentration =