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`
`AQUESTIVE EXHIBIT 1069 Page 0001
`
`

`

`
`
`Common EMS Prohuols
`
`JONES AND BARTLETT PUBLISHERS
`Sudbury, i\-!u55uclmselts
`BOSTON
`TORONTO
`LONDON
`SINGAPORE
`
`AQUESTIVE EXHIBIT 1069 Page 0002
`A QUESTIVE EXHIBIT 1069 Page 0002
`
`

`

`World Headquarters
`Jones and Bartlett Publishers
`40 Tall Pine Drive
`' \{A 01?“?6
`g
`_
`_
`“@F‘Pub-L‘?”
`www.}bpub.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
`
`Copyright © 2005 by lanes 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.: Wang’s Essentials of Pediatric Nursing, ed. 6, St. Louis, 2001, p. 1301. Copy-
`righted by Mosby, Inc. Reprinted by permission.
`
`All rights reserved. No part of the material protected by this copyright may be reproduced or uti-
`lized in any form, elecuonic or mechanical, including photocopying, recording, or by any informa—
`tion storage and retrieval 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 designed solely 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 statement of the standards of care
`required in any particular situation, because circumstances and the pafient's physical condition can
`vary widely from one emergency to another. Nor is it intended that this guide shall in any way
`advise emergency personnel concerning legal 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 6r Aquatics: Lawrence D. Newell
`V.P., Manufacturing and Inventory Control:
`Therese Brauer
`Associate Production Editor: Karen C. Ferreira
`Associate Managing Editor: Jennifer Reed
`PrintedinCanada
`0807060504 10987654321
`
`Photo Researcher: Kimberly Potvin
`Director of Marketing: Alisha Weisman
`Composition, Text Design, and Art. Shepherd, Inc.
`Printing and Binding: Transcontinental Printing
`
`
`
`2A Adult Initial Assessment 8: Management
`Protocols in Section 2.1 are designed to guide the EMT or paramedic in his or
`her initial approach to assessment and management of adult patients. Support-
`ive Care is specified as EMT and Paramedic (BLS) and Paramedic Only (ALS).
`Protocol 2.1.1 should be used on all adult patients for initial assessment.
`During this assessment, if the EMT or paramedic determines that there is a
`need for airway management, Protocol 2.1.2 should be used for the man-
`agement of the adult airway. These protocols are frequently referred to by
`other protocols, which may or may not override them in recommending
`more specific 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 protocol is frequently referred to by other protocols, which may
`or may not override it in recommending more specific therapy.
`Protocol 2.1.4 presents the basic components of preparation for transport
`of trauma patients. Due to the significant differences in priorities and packag-
`ing in the pre-hospital care of medical cases, a separate Medical Supportive
`
`Adult fi‘flotocols
`
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`

`

`Fiend] chuwai Common EMS Protocols Frcid Gmde
`
`2
`
`Care protocol has been developed. After followmg 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 more specific therapy.
`Protocol 2.1.5 should be used by paramedics only for pain management.
`
`Initial Assessment
`2. l .l
`EMT and Paramedic
`
`Common EMS F”:
`
`l-
`
`
`
`syoaouud)lnpv
`
`1. Scene Size-up.
`Review of Dispatch Information.
`Assess Need for Body Substance Isolation.
`Assessment of Scene Safety.
`Determine Mechanism of Injury.
`Determine Number and Location of Patients.
`Determine Need for Additional Resources.
`. Initial Assessment.
`
`mmDOm?
`P1909”?
`
`
`
`General Impression of Patient.
`Assess Mental Status (AVPU)—Maintain Spinal Immobilization PRN.
`Assess Airway.
`Assess Breathing.
`Assess Circulation—Pulse, Major Bleeding, Skin Color and
`Temperature.
`Assess Disability—Movement of Extremities/Defibrillation—
`VF/VT without pulse.
`G. Expose and Examine Head, Neck, Chest, Abdomen, and Pelvis '
`(check back when patient is rolled on side).
`H. Identify Priority Patients.
`
`5'11
`
`. 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 Coma Score.
`
`AQUESTIVE EXHIBIT 1069 Page 0004
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`

`ruler-:11CommomEMS Pl’OEOCOlS Field (nude
`
`4
`
`maimpv
`
`C. Assess Vital Signs.
`. Respirations.
`. Pulse.
`. Blood Pressure.
`
`. Capillary Refill.
`. Skin Condition.
`a. Color.
`b. Temperature.
`c. Moisture.
`
`. Q—Quality.
`. R—Radiation.
`. R—Referred.
`. R—Relief.
`
`. S—Severity.
`. T—Tirne.
`
`— Allergies.
`.
`. M - Medications.
`
`. P — Past Medical History.
`. L - Last Oral Intake.
`
`. E - Events Leading to Illness or Injury.
`
`6. Lung sounds.
`. Obtain a Medical History.
`1. S - Symptoms — Assessment of Chief Complaint.
`. O—Onset and Location.
`. P—Provocation.
`
`
`
`.,;-.1:.
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`
`V. Other Assessment Techniques.
`A. Cardiac Monitoring.
`B. Pulse Oximetry.
`C. Glucose Determination.
`
`D. Monitor Core Temperature.
`E. Capnography.
`
`AQUESTIVE EXHIBIT 1069 Page 0005
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`

`

`
`
`sgonozoad:lnpv
`
`Florida Regional Common EMS Protocols Field Guide
`
`6
`
`2. l .2 Airway Management
`
`Supportive Care
`EMT and Paramedic
`9 Initial Assessment Protocol 2.l.|.
`If spontaneous breathing is present without compromise:
`9 Monitor breathing during transport.
`9 Administer oxygen via nasal cannula (2-6 L/min) PRN.
`If spontaneous breathing is present with compromise:
`0 Maintain airway (e.g. modified jaw thrust).
`Administer oxygen via non-rebreather mask (IO—I5 L/min).
`If unconscious, insert oropharyngeal or nasopharyngeal airway PRN.
`0 Assist ventilations with BVM PRN.
`O Suction PRN.
`
`O 9
`
`9 Monitor pulse oximetry and capnography, as soon as possible.
`Paramedic Only
`0 If patient accepts oropharyngeal airway, consider need for intubation (see
`below: ALS Level
`l—Advanced Airway Management).
`EMT ang Earamedic
`If spontaneous breathing is absent or markedly compromised:
`Maintain airway (eg. modified jaw thrust).
`If unconscious, insert oropharyngeal or nasopharyngeal airway.
`Assist ventilations with BVM.
`Suction PRN.
`
`If unconscious and intubation is not available, insert LMA or Combitube (a).
`Monitor pulse oximetry and capnography or ETCO1 monitoring device, as
`soon as possible.
`
`
`
`Florida Regional Common EMS Protocols Field Guide
`
`7
`
`Paramedic in1
`Perform endotracheal intubation and document the following(a).
`|. Confirm ETT placement.
`a. Negative epigastric sounds.
`'... Positive bilateral breath sounds.
`7.. Secure ETT with commercial device.
`a. Full spinal immobilization is recommended.
`2. Attach end-tidal C02 monitoring device.
`Monitor SpOz with pulse oximeter.
`lf unable to intubge and went cannot be adequatelmntilated by other
`means, perform cricothyroidotomy and transport rapidly to the hospital (b).
`
`510303044"an
`
`None
`
`AQUESTIVE EXHIBIT 1069 Page 0006
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`

`

`NOTE
`
`Florida Regonal Common EMS Protocols Field Gizidc
`
`8
`
`(a) Other airway devices may be authorized for use by an individual medical
`director (e.g. COBRA Airway).
`(b) Follow Universal Airway Algorithm on all intubations.
`
`Universal Airway Algorithm
`
`
`
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`
`Florida Regional Common EMS Protocols Field Gu1de
`
`2.l.3 Medical Supportive Care
`
`Supportive Care
`EMT and Earamedic
`6 initial Assessment Protocol 2. | .l.
`O Airway Management Protocol 2.|.2.
`9 Establish hospital contact for notification of incoming patient and for the
`Paramedic to obtain consultation for level 2 orders.
`
`
`
`unwoundunpv
`
`Paramedic Onlx
`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
`
`(a) Authorized IV routes include all peripheral venous sites. External jugular
`veins may be utilized when other peripheral site attempts have been unsuc-
`cessful or would be inappropriate. A large bore intracath should be used for
`unstable patients, avoid sites below the diaphragml
`(b) An IV lock or medication access point (MAP) may be used in lieu of an IV
`bag in some patients, when appropriate.
`(c) When unable to establish an IV in the adult patient that needs to be resuscitat—
`ed, an intraosseous line may be used by the Paramedic only.
`An EMT that has been authorized by their individual Medical Director may
`establish an IV.
`
`AQUESTIVE EXHIBIT 1069 Page 0007
`QUESTIVE EXHIBIT 1069 Page 0007
`
`

`

`Fur-run Regional Common EMS l-‘---:_::-:
`
`2. I .4 Trauma Supportive Care
`
`Supportive Care
`EMT and Paramedic
`0 initial Assessment Protocol 2.|.l. Initiate trauma alert, if applicable.
`9 Airway Management Protocol 2.|.2. (manually stabilize c-spine PRN).
`0 Correct any open wound/sucking chest wound (occlusive dressing).
`Paramedic Only
`6 Correct any massive flail segment that causes respiratory compromise (intu bate).
`9 Correct any tension pneumothorax.
`EMT and Paramedic
`9 Control hemorrhage.
`O lmmobilize c-spine and secure patient to backboard PRN.
`O Expedite transport.
`
`slooozoad“an
`
`NOTES
`THE FOLLOWING STEPS SHOULD NOT DELAY TRANSPORT
`9 Complete bandaging, splinting and packaging PRN.
`0 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 Normal Saline with regular infusion set (a)(b)(c), unless
`overridden by other specific protocol.
`Paramedic Only
`-.'- Monitor ECG PRN.
`
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`
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`'
`include all peripheral venous sites. External jugular
`NOTE
`(a) Authonzed IV rou when other peripheral site attempts have been unsuc
`ins ma be utilized
`‘
`'
`::ssful orywould be inappropriate. Two IVs usmg large bore mtracaths,
`should be used for unstable patients, avoid sites below the diaphragm. Con—
`'
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`PRN.
`'
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`.
`:lliheernujrllbileat: establishgan IV in the adult patient that needs to be resusc1tat
`'
`the Paramedic only.
`'
`d, an mtraosseous hne may be used by
`'
`'
`.
`.
`:m EMT that has been authorized by their ind1v1dual Medical Director may
`establish an IV.
`
`_
`
`—
`
`QUESTIVE EXHIBIT 1069 Page 0008
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`
`

`

`Extremity fractures should be elevated, if possible, and cold applied.
`If pain persists and systolic BP 290 mmHg. choose one of the 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 [0 mg (a).
`
`or
`
`Hydromorphone Hydrochloride (Dilaudid®) | mg slow lV, may repeat
`once PRN (maximum total dose 2 mg), if available (a).
`
`or
`
`Nalbuphine Hydrochloride (Nubain®) IO mg slow IV, if available (a).
`
`Florida Regional Common EMS Protocols Field Guide
`
`I3
`
`Fentanyl (Sublimaze®) 250 mcg slow IV, if available (a).
`
`or
`
`Butorphanol (Stadol®) 2 mg slow M if available (a).
`
`2. I .5 Pain Management
`Paramedic Only
`This entire protocol is ALS / Paramedic Only.
`ISOLATED EXTREMITY FRACTURE
`
`The purpose of this procedure is to manage pain associated with isolated
`extremity fractures not associated with multi—system trauma or hemody-
`namic instability.
`
`Patients should be asked to quantify their pain on an analog pain scale
`(0=|east severe to l0=most severe). This number should be documented
`and used to measure the 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. l 0.6 -
`Extremity Injuries. Nitrous Oxide self-administered analgesia should be
`given special consideration for pain management during this procedure, if
`available.
`
`
`
`AQUESTIVE EXHIBIT 1069 Page 0009
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`
`

`

`ACUTE BACK STRAIN
`
`This procedure should be used in the isolated back strain where an acute
`abdominal process is not suspected.
`
`Hydromorphone Hydrochloride (Dilaudid®) I mg slow IV, may repeat
`once PRN (maximum total dose 2 mg), if available (a).
`
`Nalbuphine Hydrochloride (Nubain®) l0 mg slow IV, if available (a).
`
`or
`
`or
`
`. Fentanyl (Sublimaze®) 250 mcg slow IV, if available (a).
`or
`
`Butorphanol (Stadol®) 2 mg slow IV, if available (a).
`3
`
`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 I5 mg IV or 30 mg IM), if available (b).
`
`nefififlflnfinfln
`|_
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`I
`
`3‘
`
`l“
`
`-
`
`3‘
`
`‘1‘ U U U
`
`:_-:-.-:n'u.:.:i'- EMS F:'l'-'.'.‘|:
`
`RENAL COLIC
`This procedure is used for flank pain associated with kidney stones where
`an acute abdominal process can be ruled out.
`
`Patients should be asked to quantify their pain on an analog pain scale
`(0=least severe to l0=most severe). This number should be documented
`and used to measure the effectiveness of analgesia.
`Nitrous Oxide self-administered, if available.
`Secure patient to back board PRN.
`If pain persists and systolic BP 290 mmHg, choose one of the 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 IO mg (a).
`or
`
`
`
`Patients should be asked to quantify their pain on an analog pain scale
`(0=least severe to I0=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 of the 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 IO mg (a).
`
`or
`
`or
`
`or
`
`or
`
`Hydromorphone Hydrochloride (Dilaudid®) I mg slow IV. may repeat
`once PRN (maximum total dose 2 mg), if available (a).
`
`Nalbuphine Hydrochloride (Nubain®) I0 mg slow IV, 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 I5 mg IV or 30 mg IM), if available (b).
`
`AQUESTIVE EXHIBIT 1069 Page 0010
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`
`

`

`Florloa Regions i.'_-:_'I|'ii":.I-' EMS PI our-cons Fieid Ciel-d8
`
`l6
`
`SOFT TISSUE INJURIES, Bums, Brres AND STINGS
`This procedure is used for pain associated with soft tissue injuries, bums,
`bites and stings not associated with multi-system trauma or hemodynam-
`ic instability.
`
`
`
`sloooaoad2“an
`
`Patients should be asked to quantify their pain on an analog pain scale
`(0=least severe to l0=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 of the 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 IO 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®) l0 mg slow lV, if available (a).
`
`Fentanyl (Sublimaze®) 250 mcg slow IV, if available (a).
`
`Butorphanol (Stadol®) 2 mg slow lV, if available (a).
`
`If pain persists and systolic BP 290 mmHg, Ketorolac Tromethamine
`(Toradol®) may be given 30 mg IV or 60 mg M (if patient is >65 y/o limit
`dosage to IE mg IV or 30 mg lM), if available (b).
`
`
`
`Florida Regional Common EMS Protocols Field Guide
`
`[7
`
`OTE
`(a) Extreme caution should be used with administering narcotic analgesics to a
`patient with an SpOz <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 (eg, 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 years of age
`
`
`
`“030::onJ|npv
`
`r N
`
`AQUESTIVE EXHIBIT 1069 Page 0011
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`

`
`
`5103010“qgnpv
`
`Florida Rnglonal Common EMS Pl 0:06:12; FiC‘ll'J Cu dc
`
`l8
`
`2.2 Adult Respiratory Emergencies
`Assessment of 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:
`I. Assessment of chest wall movement to include rate and depth of ventilation,
`as well as a symmetrical rise and fall.
`2. Assessment of accessory muscle use.
`3. Auscultation of bilateral lung sounds.
`4. Use of pulse oximetry.
`
`The EMT and paramedic must be able to determine the adequacy of venti-
`lation and understand its 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. Other signs 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 Sp02 <95.
`In patients with chronic respiratory disease, the paramedic must be able
`to differentiate between what is chronic and what is acute, as it pertains to
`the respiratory assessment. Specific questions about the chief complaint and
`accompanying symptoms may prove to be invaluable in this setting. Assess-
`ment of 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 ”asthma patient". The
`paramedic must remember that patients with CHF may also present with
`wheezing. If this patient does not have a history of asthma or allergic reac-
`tion, the more prudent assessment would be that of CHF.
`
`
`
`9999900
`:flf
`
`.
`
`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 control for further direction.
`
`
`
`sloiouud1|”PV
`
`AQUESTIVE EXHIBIT 1069 Page 0012
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`

`Florida Regionailgornmpn EMS Protocols-Field:Guide '20
`
`2.2.l 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 trauma to the air-
`way. Differentiation of the cause of upper airway obstruction is essential
`to determining the proper treatment.
`
`5.0mm“wipv
`
`Supportive Care
`9 Medical Supportive Care Protocol 2. | .3.
`0 if air exchange is inadequate and there is a reasonable suspicion of foreign
`body airway obstruction (FBAO). apply abdominal thrusts (a).
`
`ALS Level 2
`None
`
`W N
`
`OTE
`
`ALS Level I
`0 If unable to relieve FBAO, visualize with laryngoscope and extract foreign
`body with Magill forceps.
`6 If obstruction is due to trauma and/or edema, or if uncontrollable bleeding
`into the airway causes life-threatening ventilatory impairment, perform
`endotracheal intubation.
`0 If unable to intubate and patient cannot be adequately ventilated by other
`means, perform cricothyroidotomy.
`
`
`
`(a)
`
`If air exchange is adequate with a partial airway obstruction, do not interfere and
`encourage patient to cough up obstruction. Continue to monitor for adequacy of air
`exchange. If air exchange becomes inadequate confinue with protocol.
`
`Florida Regional Common_EM_S Protocols Field guide" 2|
`
`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
`"asthma patient”. If the CHF 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).
`
`
`
`§|(I)0)()Jdiinpv
`
`Supportive Care
`0 Medical Supportive Care Protocol 2.l.3, including pulse oximeter and
`capnography.
`
`ALS Level |
`0 Choose one of the following bronchodilators:
`l Albuterol (Ventolin®) | nebulizer treatment containing 2.5 mg of Albuterol
`pre-mixed with 2.5 ml normal saline. May repeat twice PRN (a).
`or
`
`I Lewlbuterol (Xopenex®) l nebulizer treatment containing 0.63 mg
`(3 ml) of Levalbuterol. May repeat twice PRN.
`If bronchodilators are administered, may add lpratropium 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 incubation.
`
`lf patient has respiratory distress, choose one of the following steroids:
`I Prednisone 60 mg PO, if available.
`or
`
`I Methylprednisolone Sodium Succinate (Solu-Medrol®) |25 mg lV, if
`available.
`
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`

`

`or
`
`non EMS Protoco =.
`
`Dexamethasone (Decadron®) l0 mg IV, if available.
`For severe dyspnea, Epinephrine (l:|000) 0.3 mg SQ (b)(c).
`For severe dyspnea, Magnesium Sulfate 2 gm IV (mixed in 50 mi of D5W
`given over 5—l0 minutes), PRN.
`
`
`
`-03010.4(,"an
`
`Repeat Epinephrine (|:|000) 0.3 mg SQ (b)(c).
`
`NOTE
`
`(a) Do not give Albuterol or Ipratropium Bromide if heart rate is 2140.
`(b) Caution should be used when the patient is older than 40 years of age or
`has a history of hypertension or heart disease.
`If hypotensive with delay in capillary refill, consider Epinephrine (1210,000)
`0.5 mg SLOW IV (over 3—4 minutes) or Epinephrine (1:10,000) 1mg ET.
`
`(c)
`
`Qwflwflfinnnnnnn\
`
`_.
`
`oouooooooooow
`
`Florida Regional Common EMS Protocols Field Guide
`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.
`
`23
`
`s|oaoaoad“an
`
`Supportive Care
`0 Medical Supportive Care Protocol 2.|.3, including pulse oximeter and
`capnography.
`
`Choose one of the following bronchodilators:
`Albuterol (Ventolin®) l nebulizer treatment containing 2.5 mg of
`Albuterol pre-mixed with 2.5 ml normal saline. May repeat twice PRN (a).
`
`or
`
`
`
`Lemlbuterol (Xopenex®) l nebulizer treatment containing 0.63 mg
`(3 ml) of Levalbuterol. May repeat twice PRN.
`If bronchodilators are administered, may add lpratropium 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 one of the following steroids:
`Prednisone 60 mg PO, if available.
`or
`
`Methylprednisolone Sodium Succinate (Solu-Medrol®) I25 mg IV,
`if available.
`
`or
`
`Dexamethasone (Decadron®) l0 mg IV. if available.
`
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`

`..::--:.:j.r: Regional Common EMS Protocols Fleld Gu cle
`
`(a) Do not give Albuterol or Ipratropium Bromide if heart rate is 2140.
`
`t|.:;---.-,_.-_i
`
`
`
`2.2.4 Pulmonary Edema - CHF
`This protocol is 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 treatment for 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 m); be automatically classified as an "asthma patien ”. The para-
`medic must remember that patients with CHF may also present with
`wheezing. If the CHF patient does not have a history of asthma or aller-
`gic reaction, the more prudent assessment would be that of CHF (cardiac
`asthma).
`
`“d”up"
`
`Supportive Care
`0 Medical Supportive Care Protocol 2.l.3, including pulse oximeter and
`capnography.
`Place patient in Fowler’s position, if tolerated and assist ventilations PRN.
`Administer CPAP with l0 cmH20 PEEP, if available (a).
`If patient is hypotensive (systolic BP <90 mmHg), see Adult Protocol 2.4.l (b).
`
`lf no improvement in 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 |.2 mg) (b)(c).
`If systolic BP 290 mmHg. Nitropaste (Nitro-Bid® Ointment) l-2 inch on
`chest wall (spread Nitropaste on chest to size of patient’s palm) (b).
`If systolic BP 290 mmHg, Furosemide (Lasix®) l mg/kg (or 80mg) IV (b).
`
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`

`Florida Regional Common EMS Protocols Field Gmdc
`Re-evaluate need for intubation If no ’
`.
`Improvement in
`atient’
`I
`-
`oxlmeter, capnography and mental status consider intullJation S PU se
`If patient IS stable, see Adult Protocol 2.4.2.
`.
`lf systolic BP 290 mmHg, Morphine Sulfate may be given slow IV in 2 mg
`increments, may repeat every 3—5 minutes t't
`t
`to a maximum of lo mg PRN (b)(d).
`,
`I 1‘3 ed ‘50 BP 290 mmHgl UP
`
`:mdW‘PV
`
`Repeat Furosemide (Lasix®) l m
`.
`.
`g/kg (or 80mg) N b .
`NItroglycerIn (Tridil®) infusion @ 5—20 mcg/min., ll a)vailable
`
`NOTE
`
`.—
`
`(a)
`
`d
`
`(
`
`)
`
`11\gask ngtFbe tight fitting. Some patients may not tolerate CPAP at
`cmHz
`EEP uu’ually. In this instance, 7.5 cmHZO PEEP should be used
`to obtain toleranc
`c1
`-
`Effects.
`e an then Increased to 10 cmHzO PEEP for therapeutic
`(b) Consider clinical presentation of patient for signs of adequate perfusion
`(c)
`It is preferred to have an IV in
`'
`'
`.
`place prior to NTG administr ti
`1f unable to estabhsh IV, NTG may be administered with eating: HOWEVGL
`.
`.
`.
`.
`If Morphine adnumsh'atlon causes severe respiratory depression, consult with
`®
`physician for possible reversal with Naloxone N
`(ALS Level 2 only).
`( “can ) 2mg N
`
`
`
`Florida Reglonal 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
`rhonchi with egophony over area of consolidation).
`
`
`
`ulnao'mnduripv
`
`Supportive Care
`0 Medical Supportive Care Protocol 2. | .3, including pulse oximeter and capnog-
`raphy; also check temperature.
`
`Choose one of the following bronchodilators:
`Albuterol (Ventolin®) l nebulizer treatment containing 2.5 mg of
`Albuterol prevmixed with 2.5 ml normal saline. May repeat twice PRN (a).
`
`or
`
`Levalbuterol (Xopenex®) I nebulizer treatment containing 0.63 mg
`(3 ml) of Levalbuterol. May repeat twice PRN.
`If bronchodilators are administered, may add lpratropium 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.
`Avoid use of diuretics.
`
`None
`
`NOTE
`
`(a) Do not give Albuterol or Ipratropium Bromide if heart rate is 2140.
`
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`Fior'irjn Regional Conmmn EMS Protocols Field Guide
`
`28
`
`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 dysrhythrnias and accompanying Slgns
`and symptoms. After stabilization of the patient, the paramedic may need
`to refer to additional protocols for continued treatment (e.g. other cardiac
`protocols).
`
`Florida Regional Common EMS Protocols Field Guide
`
`2.".
`
`2.3. I Asystole
`
`Supportive Care
`0 Medical Supportive Care Protocol 2.|.3, if applicable.
`6 CPR (check other leads to confirm asystole).
`O Hyperventilate.
`
`
`
`slozozcud1"an
`
`
`
`External pacemaker.
`Epinephrine (I:|0,000) | mg IV (a), repeat every 3—5 minutes for duration
`of pulselessness.
`Atropine l 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 known renal failure,
`Calcium Chloride |0% I000 mg (I g) or IO ml IV.
`
`None
`
`NOTE
`(a)
`
`(b)
`
`If IV is not established, administer Epinephrine via ETT at twice the IV dose
`(maximum 0.1 mg/kg).
`If IV is not established, administer Atropine via E’IT at twice the IV dose.
`
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`
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`

`i
`
`!'_I:.:-m:n:.'.n= i'l'-‘|";3. F“: -:'.-r
`
`2.3.2 Bradycardia
`
`Supportive Care
`9 Medical Supportive Care Protocol 2.I.3.
`1
`
`or
`
`Midazolam (Versed®) 2 mg IV, may repeat once PRN (up to max. 4 mg).
`
`Lorazepam (Ativan®) 2 mg IV, may repeat once PRN (up to max. 4 mg).
`If pacemaker is unavailable or ineffective, Dopamine infusion @
`5—20mcg/kg/min (I600 mcg/ml infusion concentration = l5—60 gtdmin).
`Titrate to maintain a minimum systolic BP of 90 mmHg with good capillary
`refill—maximum BP I 20 mmHg (maximum dose 20 mcg/kg/min).
`
`If patient displays severe symptoms refractory to ALS Level
`nephrine infusion @ 2—l0 mcg/min.
`
`I care, Epi-
`
`Perform I 2 Lead ECG. Transmit I2 Lead ECG to