Date: June 29, 2018

To: Holders of EMS Policy and Procedure Manuals

From: Dustin Ballard, MD Grant Colfax, MD EMS Agency Medical Director DIRECTOR Subject: Update to Policy Manual

Emergency Medical Services Please find the 2018 update to the EMS Policy and Procedure Manual. These new and 1600 Los Gamos Drive revised policies and procedures are effective July 1, 2018. Suite 220 San Rafael, CA 94903 Revised Policies and Procedures include: 415 473 6871 T 415 473 3747 F • 415 473 3344 TTY 5003 Drug Security www.marinEMS.org • 5005 ALS Non-transport Equipment • 5006 ALS First Responder • 5010 Provider Equipment List • 5011 CCT Drug, Solution, and Equipment List • 5011a CCT Equipment Checklist • 5100 EMS Aircraft • 5200 Medical Mutual Aid • 5201 Non-Medical Mutual Aid • 5400 Ambulance Diversion • 7002 Communication Failure • 7003 Radio Communications • 7004 EMS Communications • 7006 PCR Policy • 7006b Medical Abbreviations • ALS PR 02 Adult Intraosseous Procedure • ALS PR 03 Oral Intubation • ALS PR 04 ETTI • ALS PR 09 Verification of Tube Placement • ALS PR 11 External Cardiac Pacing • ALS PR 14 King Procedure • ATG 2 Adult Pain Management • ATG 3 Adult Sedation • ATG 7 Adult Medications • BLS 1 RMC • BLS 2 Chest Pain • BLS PR3 Oral Glucose Administration • BLS PR6 Medical Emergencies • BLS PR 7 Environmental Emergencies • C 1 Ventricular Fibrillation/Pulseless Ventricular Tachycardia • C 2 Asystole/PEA • C 4 Bradydysrhythmias • C 8 Chest Pain • C 9 STEMI

PG. 2 OF 2

• E 1 Heat Illness • E 2 Cold Induced Injury • E 4 Envenomation • GPC Cardiac Arrest • GPC 2 AMA • GPC 4 Destination Guidelines • GPC 9 Suspected Abuse • M 1 Non-Traumatic Shock • M 3 Allergic Reaction • M 4 Poisons/Drugs • M 6 Sepsis • N 1 Coma • N 4 CVA • O 2 Imminent Delivery • P 1 Pediatric Pulseless Arrest • P 2 Newborn Resuscitation • P 3 Pediatric Respiratory Distress • P 4 Pediatric Bradycardia • P 8 Pediatric Allergic Reaction • P 11 Pediatric Toxic Exposure • P 12 Pediatric Burns • P 15 Pediatric Pain Management • P 18 Pediatric Medication List • P 18a Pediatric Dosing Guide • R 1 Respiratory Arrest • R 3 Acute Respiratory Distress • R 4 Bronchospasm / Asthma / COPD • R 5 Acute Pulmonary Edema

New Policies:

• BLS PR 10 Glucose Monitoring • BLS PR 11 Nasal Narcan Spray

COUNTY OF MARIN

DEPARTMENT OF HEALTH AND HUMAN SERVICES

Division of Public Health Services

Emergency Medical Services Agency

Policy and Procedure Manual

July 1, 2018

______Miles Julihn, EMS Administrator, EMS Agency

______Dustin Ballard, MD, Medical Director, EMS Agency

EMS Policy & Procedures Manual

Record of Change

Keep your policy manual current. After receiving and filing additional or revised policies/protocols, initial and date the block following the appropriate change.

There should not be any blank boxes between initialed blocks; this means you either failed to record the CHANGE NOTICE or have not received it. Notify the Marin County EMS Office if you did not receive a CHANGE NOTICE.

No. Initial Date No. Initial Date No. Initial Date 1 11/94 19 07/2003 37 07/2018 2 08/95 20 09/2003 38 3 01/96 21 02/2004 39 4 08/96 22 01/2005 40 5 01/97 23 01/2006 41 6 04/97 24 N/A 42 7 10/97 25 07/2006 43 8 01/98 26 01/2007 44 9 08/98 27 05/2008 45 10 03/99 28 06/2009 46 11 10/99 29 07/2010 47 12 11/99 30 07/2011 48 13 04/2000 31 07/2012 49 14 10/2000 32 07/2013 50 15 01/2001 33 07/2014 51 16 07/2001 34 07/2015 52 17 01/2002 35 07/2016 53 18 01/2003 36 07/2017 54

vi

EMS Policy & Procedures Manual

Errata Report

If any errors, (i.e.; typographical, grammatical, calculations or omissions) are noted in this manual, please inform this office immediately. To insure that the appropriate policy is changed, please make a copy of this form, fill in the required information and send it to us. Thank you.

Policy/Protocol Title Policy Number Page Number Correction

Policy/Protocol Title Policy Number Page Number Correction

Policy/Protocol Title Policy Number Page Number Correction

Policy/Protocol Title Policy Number Page Number Correction

vi EMS Program Policy & Procedure Manual

TABLE OF CONTENTS

Revised – 07/2018

2000 - Quality Assurance/Improvement 2000 Quality Assurance/Improvement References 2000 Quality Assurance/Improvement Reference DELETED 2003 Provider Medical Director Functions/Responsibilites 07/2017 2004 Quality Improvement, Provider Agency Responsibilities 07/2017 2005 Prehospital Care Record Audit 11/98 2010 EMS System Event Form 07/2016 2010a EMS Event Reporting Form 07/2016

3000 - Certification/Accreditation/Authorization 3100 General 07/94 3101 Fee Schedule 01/91 3102 Certificate Review Process for Prehospital Personnel 05/2008 3103 Continuing Education 01/2003 3200 EMT-I Certification/Recertification 01/2006 3300 EMT-P Accreditation 07/2017

4000 - Programs 4100 EMT/ First Responder Defibrillation 4100 EMT AED Service Provider 07/2014 4101 EMT/First Responder Defibrillation Provider Approval DELETED 4102 EMT/First Responder Defibrillation Medical Director DELETED 4103 EMT/First Responder Defibrillation Quality Assurance DELETED 4104 EMT/First Responder Defibrillation Performance Standards DELETED 4105 EMT/First Responder Defibrillation Treatment Protocol DELETED 4106 EMT/First Responder Defibrillation Records and Forms DELETED 4110 Public Safety Defibrillation Program 01/2017 4111 Public Safety Early Defibrillation – Provider Approval DELETED 4112 Public Safety Early Defibrillation – Medical Director DELETED 4113 Public Safety Early Defibrillation – Quality Assurance DELETED 4114 Public Safety Early Defibrillation – Performance Standards DELETED 4115 Public Safety Early Defibrillation – Treatment Protocol DELETED 4116 Public Safety Early Defibrillation – Records and Forms DELETED 4120 Public Access Early Defibrillation – Program 01/2017 4200 Emergency Medical Dispatch 4200 Emergency Medical Dispatch Policy 07/2017 4201 Emergency Medical Dispatch Certification 03/91 4202 Emergency Medical Dispatch Recertification 03/94 4203 Emergency Medical Dispatch Training Program Approval 03/91 4204 Emergency Medical Dispatch Quality Assurance 03/94

ii

4600 Trauma System 4600 Trauma System 07/2017 4602 Marketing and Advertising 01/2017 4603 Service Areas for Hospitals 07/2017 4604 EMS Dispatching DELETED 4605 EMS Communication DELETED 4606 Patient Transfer and Transportation 07/2017 4606A Trauma Re-Triage Adult 07/2015 4606B Trauma Re-Triage Pediatric 07/2015 4608 Training of Trauma System Personnel 07/2017 4609 Jurisdiction Coordination 07/2017 4610 Coordination with Non-medical Emergency Services 07/2017 4611 Trauma System Fees DELETED 4612 Medical Control and Accountability 07/2017 4613 Trauma Triage and Destination Guideline Policy 07/2017 4613A Marin County Trauma Triage Tool 07/2017 4614 Trauma Center Designation Process 07/2017 4615 Data Collection and Management (Trauma) 07/2016 4616 Quality Improvement and System Evaluation (Trauma) 07/2017 4618 System Organization and Management 07/2017

5000 - Providers 5000 Providers – General 5001 General System Operations 07/2017 5002 Ambulance Supply and Equipment Requirements 07/2017 5003 Drug Security 07/2018 5004 Description and Function of Basic, ALS and CCT Transport Units 07/2017 5005 ALS Nontransport Supply/ Equipment Requirements 07/2018 5006 ALS First Responder 07/2018 5007 Fireline Personnel 07/2017 5008 Paramedic Internships 07/2016 5010 Provider Equipment/Supplies 07/2018 5011 CCT Equipment/Supplies 07/2018 5012 Lifesquare Use - DELETED DELETED 5100 EMS Aircraft 07/2018 5200 Medical Mutual Aid 07/2018 5201 Non-Medical Mutual Aid Paramedic Function 07/2018 5202 Unified Response to Violent Incidents 07/2016 5203 Tactical Medic Personnel 07/2016 5300 Golden Gate Bridge and GGNRA Response 07/2017 5400 Ambulance Diversion Policy 07/2018 Deleted 5401 Neurosurgeon Coverage Not Available 5500 EMS Program Approvals 07/2017 5600 Specialty Care Center Designation 07/2017

7000 - Communications 7000 Communications 7001 Hospital Report / Consult 07/2017

iii 7002 Communication Failure 07/2018 7003 Radio Communications Policy 07/2018 7004 EMS Communications 07/2018 7005 Reddinet Policy 07/2017 7006 Prehospital Patient Care Record 01/2018 7006A Prehospital Field Transfer Form (FTF) 07/2018 7006B Approved Medical Abbreviations 07/2018 7007 Interim Policy Memo 07/2013

Patient Care GPC Adult Cardiac Arrest 07/2018 GPC 1 Cancellation Of ALS Response 05/2008 GPC 2 AMA 05/2018 GPC 3 RAS 05/2008 GPC 3A AMA / RAS Form 05/2008 GPC 4 Destination Guidelines 07/2018 GPC 5 Interfacility Transfer 05/2008 GPC 6 Medical Personnel On Scene 05/2008 GPC 6A Doctor On Scene Card 05/2008 GPC 7 DNR / POLST 07/2013 GPC 8 Anatomical Gift/Donor Card Search 05/2008 GPC 9 Suspected Abuse/ Neglect/ Human Trafficking 07/2018 GPC 9A Child Abuse Form 05/2008 GPC 9B Elder Abuse Form 05/2008 GPC 10 Sexual Assault 07/2015 GPC 11 Patient Restraint 05/2008 GPC 12 MCI 05/2008 GPC 13 Spinal Motion Restriction 07/2016 GPC 13A Spinal Injury Assessment 07/2014 GPC 14 Bariatric Patient Transports 07/2014 GPC 15 Specialty Patients 07/2014 BLS 1 Routine Medical Care BLS 07/2018 BLS 2 Chest Pain BLS 07/2018 BLS 3 Bronchospasm/Asthma/COPD BLS 05/2008 BLS 4 Seizure BLS 07/2017 BLS 5 Determination Of Death BLS 07/2017 BLS 6 Early Transport Decisions 05/2008 BLS PR 1 Authorized Procedures For EMT1 07/2017 BLS PR 2 BLS Oxygen Therapy 07/2014 BLS PR 3 Administration Of Oral Glucose 07/2018 BLS PR 4 Auto-Injector Epi-Pen 07/2010 BLS PR 5 Traumatic Emergencies 07/2014 BLS PR 6 Medical Emergencies 07/2018 BLS PR 7 Environmental Emergencies 07/2018 BLS PR 8 Obstetrical Emergencies 05/2008 BLS PR 9 Nerve Gas Auto-Injector 06/2009 BLS PR 10 Glucose Monitoring 07/2018 BLS PR 11 Nasal Narcan Spray 07/2018 ATG 1 Routine Medical Care ALS 07/2015 ATG 2 Adult Pain Management 07/2018

iv ATG 2A Adult Pain Addendum 05/2008 ATG 3 Adult Sedation 07/2018 ATG 4 Transfer Of Care 07/2011 ATG 5 Adult Intraosseous Infusion Policy 07/2012 ATG 6 Determination Of Death ALS 07/2017 ATG 7 Adult Medication List 07/2018 ATG 8 Ventricular Assist Device 07/2017 ALS PR 01 Expanded Scope Of Practice For EMT- P DELETED ALS PR 02 Adult Intraosseous 07/2018 ALS PR 03 Adult Oral Intubation 07/2018 ALS PR 04 ETTI 07/2018 ALS PR 05 Cricothyroidotomy DELETED ALS PR 06 Combitube DELETED ALS PR 07 Intranasal Meds (Versed / Narcan) 07/2016 ALS PR 08 Needle Thoracostomy Pleural Decompression 07/2011 ALS PR 09 Verification Of Tube Placement 07/2018 ALS PR 10 IV Access 05/2008 ALS PR 11 External Cardiac Pacing 07/2018 ALS PR 12 12-Lead ECG 07/2016 ALS PR 13 Continuous Positive Airway Pressure 07/2014 ALS PR 14 King Airway Procedure 07/2018 ALS PR 15 Impedance Threshold Device DELETED ALS PR 16 Metered Dose Inhaler 07/2010 C 1 Ventricular Fib/ Pulseless Ventricula Tach 07/2018 C 2 Asystole / PEA 07/2018 C 3 Asystole DELETED C 4 Bradydysrhythmia 07/2018 C 5 Ventricular Ectopy deleted C 6 Wide Complex Tachycardia 05/2016 C 7 Narrow Complex Tachycardia 05/2013 C 8 Chest Pain ALS 07/2018 C 9 STEMI 07/2018 C 10 Return of Spontaneous Circulation (ROSC) 07/2014 E 1 Heat Illness 07/2018 E 2 Cold Induced Injury 07/2018 E 3 Envenomation 07/2018 E 4 Burns 07/2017 E 5 Drowning / Near Drowning 07/2017 M 1 Non-Traumatic Shock 07/2018 M 2 GI Bleeding DELETED M 3 Allergic Reaction / Anaphylaxis 07/2018 M 4 Poisons / Drugs 07/2018 M 5 Severe Nausea/Vomiting 07/2017 M 6 Sepsis 07/2018 N 1 Coma / ALOC 07/2018 N 2 Seizure 07/2017 N 3 Syncope 07/2016 N 4 CVA / Stroke 07/2018 O 1 Vaginal Hemorrhage 07/2010 O 2 Imminent Delivery - Normal 07/2018

v O 3 Imminent Delivery - Complications 05/2008 O 4 Severe Eclampsia / Preeclampsia 07/2014 R 1 Respiratory Arrest 07/2018 R 2 Airway Obstruction 07/2012 R 3 Acute Respiratory Distress 07/2018 R 4 Bronchospasm/Asthma/COPD 07/2018 R 5 Acute Pulmonary Edema 07/2018 R 6 Pneumothorax 05/2008 R 7 Toxic Inhalation 07/2015 T 1 Traumatic Injury 07/2017 T 2 Head Trauma DELETED T 3 Crush Syndrome 05/2008 T 4 Management of Less-Than-Lethal-Interventions 07/2017 P 01 Pediatric Pulseless Arrest 07/2018 P 02 Newborn Resuscitation 07/2018 P 03 Pediatric Respiratory Distress 07/2018 P 04 Pediatric Bradycardia 07/2018 P 06 Pediatric Tachycardia Poor Perfusion 07/2016 P 07 Pediatric Shock 07/2016 P 08 Pediatric Allergic Reaction 07/2018 P 09 Pediatric Seizure 07/2016 P 10 Pediatric ALOC 07/2016 P 11 Pediatric Toxic Exposure 07/2018 P 12 Pediatric Burns 07/2018 P 13 Pediatric Trauma 07/2017 P 14 Pediatric BRUE 07/2017 P 15 Pediatric Pain Management 07/2018 P15A Pediatric Pain Addendum 05/2008 P 16 Pediatric Sexual Assault 07/2016 P 17 Pediatric IO Policy 05/2008 P 18 Pediatric Medications List 07/2018 P18A Pediatric Dosing Chart 07/2018 P PR 1 Pediatric IO Procedure 05/2016 P PR 2 Pediatric Oral Intubation DELETED

vi July 2018 COUNTY OF MARIN EMS 5003

DRUG SECURITY POLICY

PURPOSE To establish guidelines for controlled substances carried on ALS and CCT units.

POLICY A. Medications carried on ALS and CCT units must comply with the County approved drug list (See Policy # 5002, Appendix B). B. EMS approved controlled substance inventory checks must be done daily and permanent record of this count kept on file by the provider according to their department drug security policy. 1. One signature is required to confirm accuracy of inventory. 2. Any discrepancy must be reported to the Provider Medical Director for further investigation and an EMS Event form shall be completed and forwarded to the EMS Agency. C. Controlled substances must be kept secure by the following means: 1. Must be kept in a double-locked system when not in use. 2. When stored in the ALS or CCT unit, must be kept in a locked cabinet/compartment. 3. Shall be attended at all times by an authorized crew member when in use. D. If the unit is out of service, all controlled substances must be removed and secured. E. Security of and access to controlled medications must be consistent with current applicable laws and regulations.

Reviewed: May 2018 Page 1 of 1

July 2010 COUNTY OF MARIN EMS 5005

ALS NONTRANSPORT SUPPLY/EQUIPMENT REQUIREMENTS

PURPOSE To establish minimum requirements for supplies and equipment to be maintained by ALS staffed non- transport vehicles.

DEFINITION A. For the purposes of this policy, “ALS staffed non-transport vehicle” shall be defined as follows: 1. Vehicle must be owned and maintained by an approved provider agency 2. Vehicle must have the capability to respond Code 3 3. Vehicle must be staffed by an on-duty paramedic employed by an approved provider agency. 4. Vehicle must be responding to an incident in conjunction with an ALS transport vehicle.

POLICY A. Vehicle must carry equipment to enable communication with the County Communications Center, the appropriate receiving hospital, and the transport unit reasonably expected to arrive on-scene. B. ALS non-transport vehicles must reasonably expect to 1. Carry or have immediate access to supplies and equipment as listed in Policy 5010. 2. Have access to an ALS transport vehicle within 20 minutes. C. If an ALS vehicle cannot reasonably expect to meet the criteria listed, they must carry a full complement of ALS equipment and supplies as listed in Policy 5010.

Reviewed: April 2018 Page 1 of 1

July 2014 COUNTY OF MARIN EMS 5006

ALS FIRST RESPONDER

PURPOSE To define the role and function of the ALS First Responder within the Marin County EMS system.

DEFINITION A. The ALS First Responder is a licensed paramedic, accredited in Marin County and working for an ALS provider. This policy is applicable only when the paramedic is not staffing an ALS transport unit and is assigned to a first response vehicle. B. First Response vehicle refers to a fire department vehicle dispatched by an official dispatching agency in response to a request for medical assistance.

ROLE To augment the currently operating ALS system by initiating defined ALS skills prior to the arrival of the ALS transport unit.

POLICY A. The ALS First Responder will carry the ALS equipment as listed in Policy 5010 (ALS First Responder level). B. The ALS First Responder will comply with all Marin County ALS Treatment Guidelines and all pertinent EMS policies and procedures. If ALS skills are initiated prior to arrival of the ALS transport unit, the name of the ALS First Responder will be documented on the PCR as defined in the Prehospital Patient Care Record policy #7006.

Reviewed: April 2018 Page 1 of 1

Oct 2017 COUNTY OF MARIN EMS 5010 BLS ALS Fireline/ ALS First ALS Transport Tactical Responder Transport AIRWAY EQUIPMENT Airways: · Oropharyngeal (Sizes 0 – 6) 2 each 1 each 1 each 2 each · Nasopharyngeal, soft rubber (sizes 14Fr., 18Fr., 22Fr., 26Fr., 28Fr., 30Fr., 32Fr., 2 each 1 each 1 each 2 each 34Fr., 36Fr.) Atomizer for intranasal medication administration (MAD device) 2 2 2 3 Bite Stick 2 0 1 2 King Airway · Size 3 0 0 1 2 · Size 4 0 1 1 2 · Size 5 0 0 1 2 Continuous Positive Airway Pressure Device 0 0 (optional) 1 Intubation Equipment · Laryngoscope handle (battery powered) 0 1 1 1 · Additional batteries 0 0 2 2 · Blades (curved 1 - 4) 0 1 x #4 1 each 1 each · Blades (straight 0 – 4) 0 1 x #4 1 each 1 each · Bulbs (extra or disposable) 0 0 1 1 · Magill forceps (adult and pediatric) 0 0 1 1 each · Endotracheal tubes sizes 6.0-8.0 mm: cuffed 0 Size 7.5 = 1 1 each 2 each · Disposable stylets (adult) 0 1 1 2 · End-Tidal CO2 Detectors Adult – Colormetric 0 1 1 2 OR Capnograph or digital (optional) 0 0 1 1 · Esophageal Detector Device (optional if Capnometer is utilized) 0 1 1 1 · Endotracheal Tube Introducer (ETTI) 0 1 1 2 · ET Tube Holder (adult) 0 0 1 2 · Meconium Aspirator 0 0 1 1 Videolaryngoscopy (adult) 0 0 optional optional Nebulizer · Hand-held OR Patient activated 0 0 1 2 · In-line nebulizer equipment with T-piece 0 0 1 2

Page 1 of 5 Oct 2017 COUNTY OF MARIN EMS 5010 BLS ALS Fireline/ ALS First ALS Transport Tactical Responder Transport Oxygen Equipment and Supplies · Fixed tank in vehicle with regulator; M-tank or H-tank 1 0 0 1 · Regulator 1 0 1 1 · Portable tank (minimum D tank) 2 0 1 2 · Adult face masks: transparent, non-rebreathing; Child/infant: simple or 4 each 2, 2 0 1 each 4 each 2,2 non-rebreathing · Nasal cannulas (adult, child, infant) 4 each 2, 2 0 1 each 4 each 2,2 · Portable Pulse Oximetry Optional optional Optional 1 Pleural Decompression kit: ≥14g needle, ≥2 ¼ inches long; Heimlich valve; 0 1 1 1 occlusive dressing;10 ml syringe Resuscitation bag-valve-mask (BVM) Adult, pediatric, infant 1 each 1 adult 1 each 2,1,1 Suction Equipment and Supplies 1 portable 1 portable self · Suction apparatus – Portable / battery powered 1 self contained 1 contained unit unit · Suction apparatus – Wall Mount 1 0 0 1 · Pharyngeal tonsil tip (rigid) 2 equivalent equivalent 2 · Suction catheters: 6 Fr, 8 Fr, 10 Fr, 14 Fr, 16 Fr, 18 Fr 2 each 0 0 2 each · Suction canister (spares) 2 0 0 2 · Suction tubing 2 0 0 2 DRESSING MATERIALS Bandages · Bulk non-sterile 1 box / pkg 0 0 1 box · 4 x 4” sterile gauze pads 12 6 12 12 · 10 x 30” universal dressings 2 0 2 2 · ABD Pads 6 0 0 6 · 40” triangular bandage with safety pins 4 2 2 4 · Elastic bandage 3” (Ace) 2 2 2 2 · Occlusive dressing 4 2 2 4 * Hemostatic dressings (must be CA EMSA approved) optional optional optional optional · Roller bandages (2”, 3”, 4”, or 6”) 6 2 3 6 Band-Aids (Assorted) 1 box 0 1 box 1 box Burn Sheets (sterile) or commercial burn kit 2 2 2 2 Cold Packs / Hot Packs 4ea / 4ea 2 each 2 each 4ea / 4ea Tape (1” and 2”) 2 each 1” = 2 rolls 1 each 2 each Trauma shears 1 1 1 1

Page 2 of 5 Oct 2017 COUNTY OF MARIN EMS 5010 BLS ALS Fireline/ ALS First ALS Transport Tactical Responder Transport EQUIPMENT AND SUPPLIES Alcohol swabs 12 6 12 12 Bedpan OR Fracture Pan/Covered Urinal 1 0 0 1 Betadine swabs or solution 0 4 4 8 Blanket - disposable 2 2 1 2 1 x adult, thigh, Blood Pressure Cuffs (adult, large arm, thigh, pediatric, infant) 1 each 1 adult 1 each pedi Bulb Syringe 1 0 1 1 Drinking Water (one gallon) 1 0 0 1 Emesis basin/ disposable bag/ Covered waste container 2 0 1 2 EMS Field Manual Patient Care (8000) Series 1 1 1 Glucometer 1 1 1 1 Irrigation Equipment · Saline (sterile) 1000 ml 2 0 1 2 · Tubing for irrigation 2 0 1 2 Length based color-coded resuscitation tape (most current) 0 0 1 1 Lubricant, water soluable 4 0 4 packs 4 packs Monitor/defibrillator equipment 12-lead · Cardiac monitor – (portable) must have strip recorder, defibrillator/transcutaneous 0 0 optional 1 pacing ability for child / adult. May be biphasic or monophasic (biphasic preferred) (pacing · ECG electrodes 0 0 0 1 box · 12-lead ECG capability 0 0 0 1 set · A.E.D. 1 1 1 0 OB Delivery · Separate and sterile kit includes: Towels, 4” x 4” dressing, umbilical tape or clamp, 1 0 1 1 sterile scissors or other cutting utensil, bulb suction, sterile gloves, and blanket · Thermal absorbent blanket and head cover, aluminum foil roll, or appropriate heat- 1 0 1 1 reflective material (enough to cover newborn) · Appropriate heat source for ambulance compartment 1 0 0 1 Pen Light 1 1 1 1 Sharps container 1 1 1 2 Sheet, pillow case, blanket, towel 4 each 0 0 4 each 2 or Pillow 2 0 0 equivalent Stethoscope 1 1 1 1 Thermometer (with core temp capability) Optional 0 0 1 Triage tags 20 6 20 20 Biohazard bags (large and small) 4 each 2 small 2 each 4 each PPE kit (gloves, gown, booties, face shield, cap) 2 per person 0 1per person 2 per person Disposable gloves S/M/L Box 6 pair Box Box Page 3 of 5 Oct 2017 COUNTY OF MARIN EMS 5010 BLS ALS Fireline/ ALS First ALS Transport Tactical Responder Transport Face protection mask – N95 or P100 2 pp 0 1 pp 2 pp Stair chair or equivalent 1 0 0 1 Scoop stretcher or breakaway flat Optional 0 0 Optional Road Flares or Equivalent (30 min) 6 0 0 6 Flashlight 1 0 0 1 Marin County Map 1 0 Optional 1 Vehicle Emergency Lights Set 0 Optional Set MERA Radio 1 Optional Optional 1 Company Radio 1 Optional Optional 1 Spare Tire 1 0 Optional 1 Fire Extinguisher 1 0 Optional 1 IMMOBILIZATION and RESTRAINT DEVICES Cervical collars – adjustable Sizes to fit all patients over 1 yr old (adult/pedi) 4, 2 1 2, 1 4, 2 Head immobilization device 4 0 2 4 Spinal immobilization (radiolucent) backboard 2 0 1 2 · Strap system, adult 2 0 1 2 · K.E.D. or equivalent 1 0 0 1 Splints (vacuum/cardboard/equivalent) · Short, medium, long 2 each 1 moldable 1 each 2 each Traction splint, adult / pediatric 1 each 0 0 1 each Quick release synthetic soft restraints (or padded leather) 1 0 0 1 IV EQUIPMENT / SYRINGES / NEEDLES Arm board (Short) 0 0 1 2 Catheters – 1” long 14g, 16g, 18g, 20g, 22g, 24g 0 2 each 2 each 4 each Intraosseous Equipment – adult and pedi · IO needles and/or mechanical device 0 0 optional 1 · Extra batteries if needed by model 0 0 0 1 Intravenous Solutions - 0.9% NL Saline · 100 cc bag 0 1000 cc total 1 2 · 1000 cc bag 0 0 2 6 Glucose Paste, 15 gm/ tube 2 tubes 2 tubes 2 tubes 2 tubes Pressure Infusion Bags 0 0 0 1 Saline Lock 0 0 2 4 Syringes · 1 cc TB with removable needle 0 2 2 4 · 3 cc with 25 g x 5/8/” needle 0 0 0 4 · 10 cc without needle 0 2 1 2 · filter needle 0 2 2 2 · 30 cc without needle 0 0 0 2

Page 4 of 5 Oct 2017 COUNTY OF MARIN EMS 5010 BLS ALS Fireline/ ALS First ALS Transport Tactical Responder Transport Extension set (saline lock) 0 0 2 4 Constriction band 0 2 2 2 Three way stop cock 0 0 1 2 Tubing – with adjustable flow · macro drip (10gtt/cc – 15gtt/cc- adjustable) 0 2 2 each 4 each · micro drip (60 micro gtts/cc) 0 0 1 2 - vented (for Acetaminophen IV admin) 0 optional Optional 1 MEDICATIONS AND SOLUTIONS Acetaminophen (Tylenol/Ofirmev), 1000mg / 100ml 0 Optional Optional 2 Adenosine, 6 mg in 2 ml NS 0 0 18 mg 36 mg 1 MDI Albuterol Unit Dose 0 w/Spacer 3 9 Amiodarone, 150 mg in 3 cc NS 0 3 3 6 ASA (chewable), 81 mg 1 bottle 1 bottle 1 bottle 1 bottle Atropine, 1 mg in 10 ml 0 2 3 10 Calcium Chloride 10%, 1 gm in 10 ml 0 0 1 2 Check and Inject Kit (EMS Agency approved providers only) 2 0 0 0 Dextrose 10% 0 0 1 2 Diphenhydramine, 50 mg/1ml 0 4 2 4 Duo-Dote (Nerve Gas Auto-injector) See County policy Epinephrine 1 mg/1 ml (multidose) 0 4 1 2 Epinephrine 1 mg/10 ml 0 4 3 9 Glucagon, 1 mg 0 1 mg 1 mg 2 mg Ipratroprium (Atrovent), Unit Dose 0 0 1 4 Lidocaine 2% (20mg/ml) 0 0 0 2 Midazolam, 2 mg/2 ml 0 10 optional 4 Midazolam, 5 mg/1 ml 0 0 optional optional Morphine Sulfate, 10 mg/1 ml 0 6 optional 3 Naloxone (Narcan), 2 mg/ 5 ml 0 2 3 6 Narcan Nasal Spray 1 kit 0 0 0 Nitroglycerine, 0.4mg /tablet or spray 0 1 container 1 container 1 container Ondansetron (Zofran) 4mg PO tablet 0 6 4 8 Ondansetron (Zofran) 4mg/2ml 0 0 1 4 Sodium Bicarbonate, 50 mEq/ 50 ml 0 0 1 2

Page 5 of 5 July 2018 COUNTY OF MARIN EMS 5011

CRITICAL CARE TRANSPORT DRUG, SOLUTION, AND EQUIPMENT LIST

IN ADDITION TO ITEMS LISTED IN POLICY 5010 (ALS TRANSPORT), UNITS STAFFED TO PERFORM CRITICAL CARE TRANSPORTS MUST INCLUDE THE FOLLOWING: A. A minimum of two personnel, appropriate to individual patient care needs (refer to Interfacility Transfer policy # 8107) must be available to attend the patient. B. All transports must occur in accordance with federal and local laws, including the Consolidated Omnibus Budget Reconciliation Act (COBRA) and its amendments (OBRA). C. Communication equipment must be present that will allow contact between the transporting vehicle and the transferring and receiving hospitals. D. The equipment and medications listed in #5011a recommended by the Guidelines Committee of the American College of Critical Care Medicine; the Society of Critical Care Medicine and American Association of Critical Care Nurses Transfer Guidelines Task Force and is recommended for use in Marin County. E. Upon written request from a provider medical director, exceptions to the recommended equipment and medications may be made by the EMS Agency Medical Director. Equipment and medications shall be additionally tailored to meet all anticipated needs of the individual patient being transported.

Reviewed: April 2018 Page 1 of 1

CRITICAL CARE TRANSPORT DRUG, SOLUTION AND EQUIPMENT LIST The following items are required in addition to the BLS/ALS equipment. On a case by case basis, upon written request from a provider medical director, an exception may be made to a requirement by the EMS Agency Medical Director.

Description of Item On Unit Airway equipment : 50 ml flex tube with patient adapter Infant medication concentration mask with tubing Booted hemostat Heimlich valve Scalpel with blade for cricothyrotomy Positive end-expiratory pressure valve (PEEP) Pressure gauge with airway adapter tubing and test lung IV Administration sets: 3-way stopcocks with extensions Pedi-drip sets Blood tubing IV catheters up to 24 gauge Butterfly needles or IV Catheters, pediatric sizes Irrigating syringes Infusion pumps Arterial line tubing and monitoring equipment IV Solutions: 1000 Lactated Ringers solution 250 cc D5/W Equipment: Arm boards Pulse oximiter Salem sump nasogastric tubes, assorted sizes External pacing Infant, pediatric electrodes Transport ventilator Neonatal isolette Medications: Dexamethasone Diazepam Digoxin Heparin Lopressor Mannitol Magnesium Nitroglycerin for IV use Phenytoin Procainamide Solumedrol Verapamil

Reviewed: April 2018 Page 1 of 1

Reviewed: April 2018 Page 2 of 1

July 2018 COUNTY OF MARIN EMS 5100

EMS AIRCRAFT

PURPOSE To provide policy for integrating dispatch and utilization of aircraft into the Marin County EMS system as a specialized resource for prehospital response, transport, and care of patients. Aircraft utilization provides a valuable adjunct to the Marin County EMS System by minimizing the time to definitive care in prescribed circumstances.

RELATED POLICIES Emergency Medical Dispatch Policy, #4200; Trauma Triage and Destination Guideline Policy, #4613; Prehospital/Hospital Contact Policy, # 7001

AUTHORITY California Administrative Code, Title 22, Divisions 2.5 and 9.

APPLICABILITY All aircraft providing prehospital patient transport within the Marin County EMS System must be authorized by the EMS agency in their county of origin, or by the EMS Authority, or by a United States Government agency.

POLICY A. The patient’s condition, available ground resources, incident location in relation to receiving facility and call circumstances will be evaluated by caregivers in the field to determine if air transport is appropriate. B. The type of aircraft to be requested will be determined by the Incident Commander and/or the County Communications Center based on provider availability, response time criteria and nature of the service needed. See Appendix A.

PROCEDURE FOR AIRCRAFT DISPATCH A. Aircraft will be dispatched simultaneously with ground units for specific circumstances as follows: 1. Area of the call is inaccessible to ground unit(s) or ground access is compromised; 2. Air assistance may be needed with rescue activities; or 3. Ground transport time to the hospital is > 30 minutes and the applicable Emergency Medical Dispatch Protocol (policy #4200, Appendix A) recommends simultaneous dispatch. 4. Reported traumatic injury and Level III Trauma Center is on trauma diversion. B. Aircraft Dispatch may also occur in the following manner: 1. Upon request of the responding unit while en route to the scene. 2. Upon request of onscene personnel following patient assessment.

PROCEDURE FOR AIRCRAFT USE A. Consider use of an EMS aircraft where: 1. A patient meets Trauma Triage Tool anatomic or physiologic criteria and the time closest facility is a Level II Trauma Center. 2. Ground transport time is greater than 30 minutes.

Reviewed: May 2018 Page 1 of 3

July 2018 COUNTY OF MARIN EMS 5100

B. Procedural Considerations 1. EMS aircraft should not transport patients in cardiac arrest. Aircraft crew shall have discretion to transport patients receiving CPR in certain situations (refractory VF, unsafe scene conditions, hypothermia, etc.). 2. Marin County Communications Center will notify law enforcement and fire agencies with jurisdiction over the landing zone. 3. The EMS aircraft may be canceled by the on-scene Incident Commander. C. Medical control 1. Treatment decisions will be made according to medical control policies and procedures governing the provider agency having responsibility for care.

GENERAL AND RELATED PROCEDURES A. Marin County personnel may accompany a patient in an EMS aircraft during transport if all of the following conditions are met: 1. Personnel have been providing care for the patient prior to arrival of the aircraft; 2. Aircraft pilot and crew request that personnel accompany the patient during transport to assist with care. B. Patient care records will be kept as follows: 1. Marin County personnel will complete a Marin County PCR as per policy/procedure, and when known, forward it to the receiving hospital. 2. EMS aircraft crew will complete a PCR as required by policy/procedure within their county of origin, and forward a copy to Marin County EMS Agency. C. The following times, when available, will be relayed to and recorded by Marin County Communications Center: 1. ETA at time of original dispatch request 2. When airborne, en route to scene 3. Arrival at scene 4. Departure from scene 5. Destination hospital 6. Arrival at receiving hospital D. As part of the Quality Improvement Program, the EMS Agency will review all aircraft dispatches. E. Aircraft may be utilized by acute care hospitals for interfacility transfers. 1. Hospitals will contact EMS aircraft providers directly. 2. The hospital requesting an EMS aircraft will notify the Marin County Communications Center of aircraft activity so fire and law enforcement agencies can be notified of the probable aircraft landing site. 3. Hospitals shall notify the Marin County EMS Agency of interfacility transfers by EMS aircraft on an annual basis.

Reviewed: May 2018 Page 2 of 3

July 2018 COUNTY OF MARIN EMS 5100

APPENDIX A PROVIDER LIST AND CLASSIFICATION DEFINITIONS

Provider Name Classification Function Staffing Location Stanford University Air Ambulance Medical Pilot Palo Alto Hospital Helicopter Flight Nurses (2) (LIFEFLIGHT) California Air Ambulance Medical Pilot Concord Shock/Trauma Air Critical Care Nurses (2) Rescue (CALSTAR) Redwood Empire Air Air Ambulance Medical Pilot Santa Rosa care Helicopter Critical Care Nurse/EMT- and Concord (REACH) P Sonoma County ALS Rescue Law, Medical, Pilot Santa Rosa Sheriff's Department Long-line rescue Paramedic helicopter (Henry 1) EMT-I California Highway ALS Rescue Law, Medical Pilot Napa Patrol Helicopter (H- Paramedic 30) U.S. Coast Guard Auxiliary Water rescue, 2 Pilots San Helicopter Long-line rescue Crew includes 1 EMT-I Francisco rescue swimmer Airport

CLASSIFICATION DEFINITIONS

A. “Air Ambulance” means any aircraft specifically constructed, modified, or equipped and used for the primary purpose of responding to emergency calls and transporting critically ill or injured patients whose medical flight crew has at a minimum two attendants certified or licensed in advanced life support. B. “Rescue Craft” means an aircraft whose usual function is not prehospital emergency medical transport but which may be utilized for prehospital emergency patient transport when use of an air or ground ambulance is inappropriate or unavailable. C. “ALS Rescue Aircraft” means a rescue aircraft that is equipped to provide ALS service, staffed with a minimum of one ALS medical flight crew member. D. “Air Rescue Service” means an air service used for emergencies including search and rescue. E. “BLS Rescue Service” means a rescue aircraft whose medical crew has, at a minimum, one attendant certified as an EMT-1. F. “Auxiliary Aircraft” is a rescue aircraft which does not have a medical flight crew or whose flight crew does not meet the minimum requirements of a BLS Rescue Aircraft.

Reviewed: May 2018 Page 3 of 3

January 1997July 2018 COUNTY OF MARIN EMS 5200

MEDICAL MUTUAL AID POLICY

PURPOSE To establish guidelines and procedure to be used when medical mutual aid is requested by Marin County or of from Marin County by another county in the Bay AreaRegion.

POLICY It is the policy of the Marin County Emergency Medical Services Office Agency to respond to medical mutual aid requests from other counties, subject to maintaining normal ability to respond to prehospital medical emergencies within the county. The intent is to augment resources available to an impacted area on a short term basis.

GENERAL REQUIREMENTS A. Automatic medical mutual aid, defined as preset, automatic response to incidents from adjacent EMS systems is not addressed in this policy. This policy shall not affect any agreements or contracts currently in place. B. Local needs and resources shall be assessed before resources are requested from another county or committed to a request from another jurisdiction (see Procedure). C. The EMS Medical Director or designee shall authorize all personnel and equipment to be committed to a requesting county per Medical Mutual Aid Agreement approved by the Board of Supervisors. D. When an Incident Commander requests additional ALS and/or BLS units not available in Marin County, Comm Center will obtain authorization of the EMS Medical Director or designee to implement the request. E. County Communications Center will initiate procedures to request or to provide mutual aid on receipt of a request, attempting to obtain authorization as soon as possible during the process. See Procedure, Appendix A. F. Personnel will operate under home county standing orders or equivalent, allowing treatment without base contact. G. Patient transports will be to the closest Basic Emergency Facility unless otherwise directed by the appropriate person (e.g. Transportation Officer) within the incident command structure. H. Units responding will remain under the operational control of the requesting agency until specifically released. I. The requesting agency shall be responsible for providing all necessary operational and logistical support, including command and control, communications, maps, re supply, fuel, food, and lodging. J. Participation in medical mutual aid exercises or drills is not eligible for reimbursement. K. Services will be billed on a flat hourly rate as detailed in Appendix B.

Reviewed: Month Year April 2018 Page 1 of 4

January 1997July 2018 COUNTY OF MARIN EMS 5200

APPENDIX A PROCEDURE TO ACTIVATE MEDICAL MUTUAL AID

TO SEND MEDICAL MUTUAL AID: A. Obtain the following information from requesting EMS or Public Safety agency 1. Requesting agency 2. Requesting individual 3. Call back number 4. Nature of incident, including number and types of casualties 5. Number and type of aid requested 6. When aid is needed and/or response code 7. Reporting location (city, county, Thomas Brothers map coordinates) 8. On-scene contact person 9. Communications instructions B. Assess local needs and available resources using the following criteria: 1. Number of units currently operating within county 2. Assess current call volume, estimating needs within county 3. Assess provider ability to staff additional units and time frame for same C. Determine number of ALS/BLS ambulance units that could respond to request. D. Contact EMS Medical Director or designee to authorize response and approve number of units responding. E. Contact requesting agency to advise them of ability to answer their request and expected response time. Request that they confirm release time of units responding.

TO REQUEST MEDICAL MUTUAL AID: A. Receive request from Incident Commander at scene of incident. B. Assess other needs and available resources within county using the following criteria: 1. Number of units currently operating within county 2. Current call volume, estimate other needs within county 3. Assess provider ability to staff additional units and time frame for same C. Determine number of ALS/BLS ambulance units to be requested. D. Consult BAMMA directory for contact list and county requirements. E. Contact EMS Medical Director or designee to authorize request. F. Request mutual aid, supplying information as listed in I-A above.

Reviewed: Month Year April 2018 Page 2 of 4

January 1997July 2018 COUNTY OF MARIN EMS 5200

TO OBTAIN AUTHORIZATION FOR RESPONSE OR REQUEST: A. During normal business hours, contact Marin County EMS Office Ardith Hamilton, Program Administrator 415 499-6871 or Thomas Peters, Ph.D. Director, Department of Health and Human Services 415 499-3696 or Martin Nichols County Administrator 415 499-6358 or Senior Sheriff's officer on duty 415 499-7237 B. After business hours, on weekends or holidays, contact Marin County Sheriff's Office Communication Division 415 499-7237

Reviewed: Month Year April 2018 Page 3 of 4

January 1997July 2018 COUNTY OF MARIN EMS 5200

APPENDIX B

FOR SERVICES PROVIDED BY MARIN COUNTY: A. Services will be billed at a flat hourly rate as detailed below. This rate will be billed to the requesting county and will be requested in addition to items listed in III-H of the policy. B. Time will be calculated beginning with the time the unit begins the response (leaves quarters en route to destination) and terminating with the time the unit is released by the requesting agency. C. Times accepted for billing purposes will be those times recorded by Marin County Communications Center, provided by the responding agency (when it goes in service) and the release time (provided by the requesting county). D. Services provided for which billable and/or collectable information is available will be provided to the requesting county by the responding agency and will not be billed or collected independent of the requesting county. E. Hourly billable rate is as follows: 1. ALS unit $525 2. BLS unit $375 F. Reimbursement for services to be made within thirty (30) days of service.

FOR SERVICES PROVIDED TO MARIN COUNTY: A. Agencies providing mutual aid will provide services according to agreements on file in "OES Region II Emergency Medical Service Mutual Aid and Disaster Medical References Manual". B. Bills for services provided should be routed to the requesting agency (rather than to individual patients). If the patient in question is billable, according to the procedures in place within that area, the bill will be forwarded to the patient.

Reviewed: Month Year April 2018 Page 4 of 4

July 2018 COUNTY OF MARIN EMS 5201

NON-MEDICAL MUTUAL AID -- PREHOSPITAL PROVIDER RESPONSIBILITIES

PURPOSE To address the provision of ALS care by Marin County accredited paramedics when they are located outside Marin County, in response to a formal request for mutual aid in a non-medical situation.

RELATED POLICIES Medical Mutual Aid, #5200; Fireline Personnel #5007; Hospital Contact for Medical Direction, #7001

DEFINITIONS A. Non-medical mutual aid means that the purpose for which mutual aid has been requested and provided is for reasons other than the provision of medical care. For instance, mutual aid may be requested to assist in the fighting of a fire. B. “Having responded to a formal request for mutual aid” means that the paramedic has been sent to provide mutual aid by his or her employer following a request for mutual aid that meets established criteria for requesting that type of assistance.

POLICY A. If necessary, personnel may utilize the scope of practice for which they are trained and accredited according to the policies and procedures established by the Marin County EMS Agency. B. EMS personnel shall make every effort to inform the local EMS agency of their presence in that jurisdiction. C. A Marin County PCR or equivelent must be completed by the Marin County provider and must accompany the patient to his/her destination. D. Upon returning to the incident base, cover station, or back to Marin County, an electronic PCR shall be completed.

Reviewed: May 2018 Page 1 of 1

July 2018 COUNTY OF MARIN EMS 5400

AMBULANCE DIVERSION POLICY

PURPOSE

To define the circumstances under which ambulance traffic may be diverted from the intended receiving facility.

RELATED POLICIES

A. Trauma Triage and Destination, #4613 B. Destination Guidelines, GPC 04

AUTHORITY

"In the absence of decisive factors to the contrary, ambulance drivers shall transport emergency patients to the most accessible emergency medical facility equipped, staffed, and prepared to administer care appropriate to the needs of the patient." California Administrative Code, Title 13, Section 1105 (c).

DEFINITIONS

A. Full diversion means a rerouting of all ambulance traffic. B. Condition specific diversion may occur when a normally available service, procedure or piece of equipment is temporarily unavailable and results in the rerouting of specific patients, dependent on the reason for diversion. Condition specific diversion may include the following:

1. CT Scanner Inoperable 2. Neurosurgeon Not Available 3. Trauma Center Diversion 4. Emergency Department (ED) Saturation 5. Cath Lab Diversion

POLICY

A. Each receiving hospital shall establish an internal hospital plan, approved by and on file with the EMS Agency. The plan shall include, but not be limited to the following:

1. Definitions and standards for activation which are consistent with this policy/ procedure. 2. Identification of the internal approval process, including persons or positions that must be involved in the decision-making process.

Reviewed: May 2018 Page 1 of 4 July 2018 COUNTY OF MARIN EMS 5400

3. Mechanisms for notification, on-going monitoring, removal from diversion status; identification and activation of backup ED and ICU physical space per state licensing guidelines; call-in mechanism for additional staff; identification of patients who can be safely transferred within the facility; internal review of the diversion and reporting to the EMS Agency.

B. Full diversion may occur only if the receiving emergency department is incapacitated by a physical plant breakdown (i.e., fire, bomb threat, power outage, etc.) which renders patient care unsafe. In the event of a full diversion, all patients will be rerouted to other facilities as appropriate.

C. The need to institute a Condition Specific Diversion is determined per each facility's plan, consistent with the following:

1. The following patients may not be rerouted: a. Obstetrical patients in active labor b. Patients with respiratory distress and unmanageable airway c. Patients with uncontrolled external hemorrhage d. Patients requiring ALS, but having no paramedic in attendance e. Patients with CPR in progress f. Stable patients who insist on transport to a specific hospital. Ambulance personnel will inform the patient of the diversion status and document that the patient refused transport to an alternate facility. g. Destinations of all other patients will be determined in accordance with the type of diversion.

2. CT Scanner Inoperable: a. Patients who meet Physiologic and/or Anatomic Trauma Triage Criteria with signs and symptoms of head, neck or spinal cord injury will be transported to Level II Trauma Center; if conditions preclude air transport consult with Marin General Hospital Level III Trauma Center. b. Patients who meet Mechanism of Injury and/or Additional Factors will be transported to Kaiser Permanente San Rafael EDAT. c. Patients with the following get transported to closest facility with functioning CT scanner: 1. Signs or symptoms of a new CVA 2. Head injury patients not meeting trauma criteria with anticoagulant use and/or bleeding disorders

3. Neurosurgeon Not Available: a. Patients with signs and symptoms of head, neck or spinal cord trauma: transport to Level II Trauma Center; if conditions preclude air transport consult Level III Trauma Center (MGH). b. Patients with signs and symptoms of CVA and/or medical conditions that may require neurosurgical intervention: transport to the closest appropriate facility in Marin County with a functioning CT scanner for initial evaluation and stabilization. Transfer, if indicated, is the responsibility of the hospital, including the maintenance of formal transfer agreements with other facilities.

Reviewed: May 2018 Page 2 of 4 July 2018 COUNTY OF MARIN EMS 5400

4. Trauma Center Diversion: a. Trauma patients will be diverted from the trauma center when the trauma surgeon and back-up trauma surgeon are encumbered with the care of trauma patients either in the operating room or emergency department. b. Patients who meet Physiologic and/or Anatomic Trauma Triage Criteria shall be transported to the time-closest Level I or Level II Trauma Center by air or ground. c. Patients who meet “Mechanism of Injury” and/or “Additional Factors” Trauma Triage Criteria shall be transported to the EDAT. d. The following conditions DO NOT constitute acceptable grounds for Trauma Center Diversion: 1) A lack of clinical specialty backup, inpatient bed space, monitored beds, or inpatient nursing staff. 2) ED Saturation Diversion 3) Inoperable CT Scanner (see section C.2.)

5. ED Saturation Diversion: a. Ambulance traffic may be diverted due to emergency department saturation when emergency department resources are fully committed and unable to accept incoming ambulance traffic. b. Trauma, STEMI, and suspected CVA patients will NOT be rerouted. c. Under this policy, no diversion incident shall exceed two hours. At the end of a two-hour diversion period, a hospital must update ReddiNet to initiate another diversion status. d. Under no circumstance is lack of in-patient hospital beds, other than in the emergency department, grounds for diversion. Hospitals are expected to accept ALL ambulance patients and to provide emergency stabilization and appropriate transfer if necessary. e. In all cases of diversion, senior management or designee must be notified and must approve activation of the diversion status.

6. Cath Lab Diversion a. STEMI ambulance traffic will be diverted when a STEMI Receiving Center cath lab is unavailable because of physical plant or mechanical problems. b. Cath lab diversion will not be declared when the cath lab is encumbered by routine medical care.

D. If more than two receiving hospitals within Marin County meet their internal plan criteria and wish to activate diversion status at the same time, diversion status for all will be discontinued upon direction of the EMS Agency.

Reviewed: May 2018 Page 3 of 4

E. Initiating and terminating diversion status

1. Initiating diversion

a. The facility shall implement the internal plan prior to initiating diversion status. The request to initiate status must be approved by senior management. b. The facility shall update ReddiNet to indicate their status as being on diversion. c. Dispatch centers (public and private) shall monitor ReddiNet to inform providers of the hospital diversion status.

2. Termination of diversion

a. Diversion status will be terminated as soon as possible. b. Diversion status is terminated when the hospital updates their status in ReddiNet to indicate that they are no longer on diversion or two hours from initiation has passed. c. Dispatch centers (public and private) shall monitor ReddiNet to inform providers of the hospital diversion status.

3. The Communications Center shall notify the EMS Agency of changes in diversion status.

4. EMS Agency staff is available to assist with solving system-related problems and can be reached by contacting the Communications Center.

5. The EMS Agency will track the frequency and duration of diversion, making periodic reports to system participants.

Reviewed: May 2018 Page 4 of 4 July 2018 COUNTY OF MARIN EMS 7002

COMMUNICATION FAILURE

PURPOSE To provide guidelines for the prehospital provider in the event that voice communication cannot be established or maintained and a delay in treatment may jeopardize the patient.

RELATED POLICIES Hospital Report/Consult #7001; Radio Communications Policy #7003; Destination Guidelines, GPC 04, EMS Event Reporting #2010.

POLICY A. The ability to make and maintain voice communication with a hospital is a vital component of the prehospital patient care system. B. Hospital contact for the purpose of a physician consult shall be made when desired by the prehospital provider or when required by a treatment guideline.

PROCEDURE A. If, following assessment, evaluation, and initiation of patient care as appropriate and set forth in Marin County guidelines, the prehospital provider is required to or wishes to contact a hospital and is unable to establish contact, the prehospital provider shall: 1. Utilize the appropriate treatment guideline except for those items requiring a physician consult. 2. Accompany the patient to the hospital according to Marin County Destination Guidelines. 3. Make the appropriate verbal and written patient care reports on arrival at the receiving facility. 4. Complete an EMS Event Form per EMS Policy 2010, and include the following (or similar) information: "Communications failure, ____ protocol utilized. Please audit call." B. Followup action 1. EMS Event Form is forwarded to the CQI Coordinator within the provider agency for evaluation and appropriate action. a. If failure is determined to be the result of equipment malfunction or problem, report with provider comment is forwarded to Marin County Department of Public Works Communications Division (i.e, Radio Shop) or other appropriate agency. b. That agency will take appropriate action and advise provider of same within a reasonable period of time.

Reviewed: April 2018 Page 1 of 1

July 2018 COUNTY OF MARIN EMS 7003

RADIO COMMUNICATION POLICY

PURPOSE To provide guidance for the use of the MERA radio system

RELATED POLICIES Communications Failure, #7002; Marin Emergency Radio Authority (MERA) Mutual Aid and Communications Policy

POLICY A. Available Communications Resources 1. MERA Policy: Users should refer to the MERA Communications Policy for general directions for the use of the MERA system. 2. Templates: Users should refer to their Agency Templates or Fleetmap for the locations of specific talkgroups on their console, back-up control stations, mobile and portable radios. The Templates also contain the correct name (alias) for that talkgroup. 3. Permissions: Users shall only use talkgroups that have been assigned for their use. Users may use talkgroups that are assigned for temporary use by a Marin communications center or incident commander “I.C.”. Before users can use any talkgroup (other than those stated above) provided by another agency they must have a written agreement with that agency. 4. MERA Radio System: Field units can communicate directly to the hospital using the designated talkgroups on their mobile or portable MERA radio. On all EMS/ Fire radios, Zone A contains the EMS talkgroups; “mode” channels contain the following aliases or talkgroup names: a. EMS is to communicate with the County EMS Dispatcher b. HOSP is the MERA “All Hospital” talkgroup for large-scale incidents c. MGH 1 is for Marin General Hospital “MARIN REPORT” d. MGH 2 is for Marin General Hospital “MARIN CONSULT” e. KSR 1 is for Kaiser San Rafael Hospital “KAISER REPORT” f. KSR 2 is for Kaiser San Rafael Hospital “KAISER CONSULT” g. NCH 1 is for Novato Community Hospital “NOVATO REPORT” h. NCH 2 is for Novato Community Hospital “NOVATO CONSULT” i. EMS 10 is for EMS tactical operations and shall be assigned by the IC or Comm. Center j. LG CLL is for hailing a local government agency or units. Once contact is made, then go to LG TLK k. LG TLK is for conversations with local government agencies l. PD CLL is for hailing law enforcement units. Once contact is made go to PD TLK m. PD TLK is for conversations with law enforcement n. 911 is for emergency communications with a communications center

Reviewed: May 2018 Page 1 of 2

July 2018 COUNTY OF MARIN EMS 7003

6. Paging: The field units will be responsible to set the Page function on their radio for initial contact with the hospitals. Other units may be using the channel at the same time, please listen for broadcast traffic before beginning your transmission. A page may not be needed if the receiving hospital radio is staffed due to other broadcast traffic. 7. Initiating Communications: When making initial contact with a communications center, unit or hospital you should state the name of the entity you are calling first, then your identifier followed by the “alias” of the talkgroup you are on, i.e. “Marin Comm., Medic-1 on EMS Dispatch” or “Marin General Hospital, Medic-1 on MGH Consult.” 8. Consult: “Consult” talkgroups shall be used for physician consults and policy required consultations. 9. Report: “Report” talkgroups shall be used for routine hospital reports. 10. Hosp: The “All Hospital” talkgroup shall be used for hospital communications during large scale incidents or other urgent communications that may require multiple hospitals to share information simultaneously and during failures of normal communications systems. 11. Emergency Button Activations: Emergency Button Activations are authorized when an EMS Field Unit needs urgent or emergency assistance. It is not to be used for routine assistance requests. Field Units should expect an emergency response from other public safety units following an Emergency Button Activation. Please see the MERA Communications Policy for further information. Due to the system configuration the Emergency Buttons are not active for private EMS providers or hospitals. 12. Hospital Systems: Marin County hospitals are equipped with three radios. Console set 1 is for hospital reports and is labeled with the initials of the hospital -1, i.e. MGH 1. Console set 2 is for hospital consults and is labeled with the initials of the hospital -2, i.e. MGH 2. Console set 3 is for the all hospital talkgroup and is labeled HOSP this consol should be left on this talkgroup at all times. Console 3 is also able to receive and transmit on other talkgroups; hospitals should review their Templates and Trouble Shooting Guide for use of other talkgroups if urgent communications are required, i.e. using the 911 channel to request law enforcement during an emergency and no other forms of communication are available. 13. ALS / BLS Use: ALS and BLS users should both use the system in the same manner for hospital consultations, reports and multiple casualty incident activities. 14. Cellular telephone service: Field units can use the cellular telephone to communicate directly with the hospital emergency department. Cell phones should be a second choice during MCI operations due to the loss of information to other units involved in the incident. 15. Contact an alternative hospital: If contact cannot be made with the receiving hospital field units may contact an alternative hospital via the listed methods and request the information be relayed to the appropriate hospital by telephone. 16. If contact cannot be established: If contact cannot be established with any hospital emergency department, the Paramedic shall rely on the EMS Policy “Communication Failure #7002”. 17. Any major system failure should be reported to the Marin Communications Center and the Marin County Radio Shop. Hospitals should consult their Trouble Shooting Guide before calling for outside assistance; requests for repairs should be made by an authorized employee of the hospital or agency.

Reviewed: May 2018 Page 2 of 2

January 2001 2018 COUNTY OF MARIN EMS 7004

EMS COMMUNICATION

PURPOSE To provide an overview of EMS communication.

RELATED POLICIES Ambulance Supply and Equipment Requirements, #5002; ALS Non-transport Supply and Equipment Requirements, #5005; EMS Aircraft, #5100; Prehospital/Hospital Contact, #7001; Communication Failure, #7002; Trauma Triage and Destination Guidelines, #4613; BLS Treatment Guidelines 8200 series; ALS Treatment Guidelines 8300 series; Destination Guidelines, #8106GPC 04

POLICY A. The universal 9-1-1 emergency number is to be used by all system participants in an emergency. B. All system participants shall participate in efforts to educate the public on the appropriate use of the 9-1-1 system. C. System participants are required to have, maintain, and utilize designated communications equipment as may be detailed in policy, contract, MOU, or other written agreement. D. BLS and ALS Treatment Guidelines and the Trauma Triage and Destination Guideline will specify requirements for field to hospital contact, indicating the need for hospital consultation or receiving hospital notification and the point at which that contact should occur. E. In the Marin County EMS System, all radio or telephone contact between prehospital providers and hospital facilities is to be made with the intended receiving hospital unless that hospital is located in another county. (Refer to Destination Guidelines, #8106GPC 04.)

Reviewed: Month Year April 2018 Page 1 of 1

July 2018 COUNTY OF MARIN EMS 7006

PATIENT CARE RECORD (PCR)

I. PURPOSE To establish requirements for completion, reporting, and submission of Marin County approved Patient Care Records.

II. RELATED POLICIES ALS to BLS Transfer of Care, ATG 4 Against Medical Advise (AMA), GPC 2 Release at Scene (RAS), GPC 3 Trauma Re-Triage, 4606 A & B

III. DEFINITIONS A. Patient – someone who meets any one of the following criteria: 1. Has a chief complaint or has made a request for medical assistance 2. Has obvious symptoms or signs of injury or illness 3. Has been involved in an event when mechanism of injury would cause the responder to reasonably believe that an injury may be present 4. Appears to be disoriented or to have impaired psychiatric function 5. Has evidence of suicidal intent 6. Is dead B. Emergency Medical (EM)/Authorization Order (AO) – a number assigned by a Marin County Communication’s Center to identify each 9-1-1 call dispatched for medical assistance. C. Electronic Patient Care Record (ePCR) - the permanent record of prehospital patient evaluation, care, and treatment. D. Field Transfer Form (FTF) – a temporary, paper record of patient care E. Triage Tag – a paper record for multi-casualty incidents involving 6 or more patients

IV. POLICY A. An ePCR shall be completed for every call for which an EM/AO is issued. B. For all transported patients: 1. A completed ePCR must be available to the receiving facility within 15 minutes of transferring care. If this is not possible (e.g. unit must leave for another call), then a complete and legible FTF may be submitted to the patient’s nurse or doctor within 15 minutes of transferring care. 2. An FTF ALONE may not be left for any notification patients (e.g. sepsis, stroke, STEMI, trauma) or critical patients (e.g. cardiac arrest and/or airway emergency) with the exception being for a rapid re-triage patient that utilizes the same transport unit. 3. If a FTF was utilized at the time of transfer, an ePCR must be completed and available to the facility as soon as possible and no later than 3 hours after the transfer of care. 4. For all patients transported, the ePCR will be completed by the personnel assigned to the transport unit. C. For non-transported patients (e.g. AMA, RAS, Dead on Scene), the ePCR will be completed by the paramedic or EMT most involved in patient care and responsible for the patient's disposition.

Page 1 of 2

July 2018 COUNTY OF MARIN EMS 7006

D. For calls where there is no medical merit, the ePCR will be completed according to provider agency’s policy. E. The ePCR is the permanent PCR and will be filled out in a complete manner and will include all care provided in the prehospital setting. When possible, it shall include all 12 lead ECGs and any ECG other than normal sinus rhythm. F. The completed PCR includes all care rendered by the transporting providers as well as any care given prior to arrival of the transporting unit by bystanders and/or first responders. Documentation of care provided by first responders (of a different agency than the transport unit) may be required by their department policy. G. For ground transportations to an out-of-county facility, a FTF will be given to the receiving provider and a completed ePCR shall be produced and sent to that facility within 3 hours of transfer of care. H. For air ambulance transportations, a FTF will be given to the air ambulance personnel, and an ePCR will be created within 3 hours of transfer of care and sent to the receiving facility via ePCR program or FAX. I. Personnel assigned outside of the county to provide medical mutual aid (e.g. fire-line EMT/Paramedic), shall complete a FTF for each patient contact. The FTF will be created on site and a copy submitted to the provider agency as soon as possible after returning to the county. J. Willful omission, misuse, tampering, or falsification of documentation of patient care records is cause for formal investigative action under Section 1978.200 of the California Health and Safety Code.

V. GENERAL INSTRUCTIONS A. The patient care record is part of the patient’s permanent medical record and is used for, but not limited to, the following purposes: 1. Transfer of information to other healthcare providers 2. Medical legal documentation 3. Billing for services 4. Development of aggregate data reports for Continuous Quality Improvement (CQI), including specific quality indicators and identification of educational needs 5. EMS Agency case investigation B. Reference to a Marin County EMS Event Form or similar record should not be included on the patient care record. C. If ALS to BLS transfer of care is determined to be appropriate, documentation of assessments and all care rendered must be completed by both the ALS and the BLS units according to policy ATG 4. D. Provider agencies are responsible for training their employees in the initiation, completion, distribution of patient care records, HIPAA and any accompanying forms based on the EMS Agency’s currently approved training curriculum.

Page 2 of 2

Marin County EMS Pre-Hospital Field Transfer Form (FTF)

Last Name ______First Name ______Age ______DOB ______M F

Date ______/______/______Pt. Transferred Time______Unit #______Incident # ______

Pt. Address ______Phone (_____)______PMD______Ins. ID #______

Incident Address ______PT’s HOME SNF ASSISTED LIVING OTHER ______

Facility - Name ______Contact Person______Phone ______

Code Status Information: Full POLST Form DNR Form Hospice - Agency ______Phone______Person best able to provide history about current illness: Patient Facility Other: Name ______Phone______

(M) Chief Complaint ______ = WNL (I) PHYSICAL EXAM ______ Head______ Pupils______Signs & Symptoms ______ Neck ______ Chest______Medical History______ Abdomen ______ Back ______ Pelvis ______Medications ______ Extremities ______Time (T) Treatment Response ______Allergies______

(V) Time Position BP Pulse RR SpO2 BGL Temp Pain (# / 10) GCS ECG

/

/

/

E Spon 4 Voice 3 Pain 2 None 1 Notes V Orient 5 Con 4 Innap 3 Incomp 2 None 1

M Obey 6 Local 5 Withdrl 4 Flex 3 Exten 2 None 1

Lead Medic

Signature

Apr 2018

July 2018 COUNTY OF MARIN EMS 7006b

APPROVED MEDICAL ABBREVIATIONS

PURPOSE

To identify the abbreviations and symbols which an Emergency Medical Technician (EMT) or Paramedic may use for documentation purposes in Marin County.

ABBREVIATIONS

Abbreviation / Symbol Description female male + positive - negative °C degrees Celsius °F degrees Fahrenheit L left R right 1° primary 2° secondary < less than > greater than @ at ∆ change ↓ decrease(d) ↑ increase(d) ≈ approximately x times ā before A/O alert and oriented A/S at scene / arrived at scene abd abdomen AC antecubical AFIB atrial fibrillation AICD Automatic Internal Cardiac Defibrillator AKA above the knee amputation ALOC altered level of consciousness ALS Advanced Life Support AM morning AMA against medical advice AMI acute myocardial infarction AOS arrived on scene approx approximately ASA acetylsalicylic acid, aspirin ASAP as soon as possible ATF arrived to find B/C because BBB bundle branch block BG blood glucose BGL blood glucose level Page 1 of 6 July 2018 COUNTY OF MARIN EMS 7006b

Bilat bilateral BKA below the knee amputation BLS Basic Life Support BM bowel movement BP blood pressure bpm beats per minute

BSA burn surface area BVM bag valve mask c with C/C chief complaint C/O complain of C2 code two C3 code three CA cancer CAD coronary artery disease, computer assisted dispatch CHF congestive heart failure CHP California Highway Patrol CMPA Central Marin Police Authority CO complain of / carbon monoxide COPD chronic obstructive pulmonary disease CP chest pain CPAP continuous positive airway pressure CPR cardio pulmonary resuscitation CPSS Cincinnati prehospital stroke scale CSM circulation, sensation, movement CVA cerebral vascular accident DDM designated decision maker DKA diabetic ketoacidosis DM Diabetes mellitus DNI Do not intubate DNR do not resuscitate DVT deep vein thrombosis dx diagnosis ECG electrocardiogram ED emergency department EKG electrocardiogram EMD Emergency Medical Dispatch EMS Emergency Medical Service EMT Emergency Medical Technician EMT-P Paramedic ENRT enroute ER Emergency Room ESO electronic PCR software ET endotracheal ETA estimated time of arrival ETCO2 end-tidal carbon dioxide ETI endotracheal intubation ETOH alcohol ETT endotracheal tube F female Page 2 of 6 July 2018 COUNTY OF MARIN EMS 7006b

FTF Field transfer form fx fracture G Gram G gauge GCS Glasgow Coma Scale GI gastrointestinal gm gram GSW gunshot wound gtt(s) drop(s) GU genitourinary h hour H/N/B head, neck, back H2O water HA headache HHN hand-held nebulizer HOB Head of bed HR heart rate HTN hypertension Hwy highway hx history ICD Internal Cardiac Defibrillator ICU intensive care unit IM intramuscular IN intranasal IO intraosseous IV intravenous IVP intravenous push JVD jugular venous distension KED Kendrick Extrication Device kg kilograms KSR Kaiser San Rafael KTL Kaiser Terra Linda L liter L left lac laceration LKW Last known well LL left lateral LLQ left lower quadrant LOC loss of consciousness / level of consciousness LS lung sounds Lt left LVO Large vessel occlusion LUQ left upper quadrant LZ Landing zone m min M male m/o Month old mA Milliamp MAD mucosal atomization device MCSO Marin County Sheriff's Office (deputy) MD medical doctor Page 3 of 6 July 2018 COUNTY OF MARIN EMS 7006b mEq milliequilvalent mg milligram mg/Dl milligrams per deciliter MGH Marin General Hospital MI myocardial infraction MICU mobile intensive care unit MIN minimum / minute ml milliliter MOI mechanism of injury MPH miles per hour MS morphine sulfate / multiple sclerosis MSo4 morphine MVA motor vehicle accident MVC motor vehicle crash MVPD Mill Valley Police Department N&V or N/V or NV nausea and vomiting NaCL Sodium Chloride NAD no apparent distress NC nasal cannula NCH Novato Community Hospital NEG negative Neuro neurological NITRO nitroglycerin NKDA no known drug allergies NPA nasopharyngeal airway NPD Novato Police Department NRB non-rebreather mask NS normal saline NSR normal sinus rhythm NTG nitroglycerine NVD nausea, vomiting, diarrhea O2 oxygen O2 sat peripheral capillary oxygen saturation OD overdose ODT orally disintegrating tablet OPA oropharyngeal airway p after P/W/D pink warm dry PAC premature atrial contraction PALP palpitation PARA parity, e.g. gravid 2, para 1 means the patient has been pregnant twice and given birth once; also written G2P1 PCN penicillin PE pulmonary edema / pedal edema / patient exam PEA pulseless electrical activity PERL pupils equal reactive to light PERRL Pupils equal, round, reactive to light PJC premature junctional contraction PM evening PMD primary/personal/private medical doctor PO by mouth Page 4 of 6 July 2018 COUNTY OF MARIN EMS 7006b

POC position of comfort POLST Physician Orders for Life Sustaining Treatment PRN as needed PSYCH psychiatric PT patient PTA prior to arrival PTS patients PTSD post traumatic stress disorder Pulse Ox peripheral capillary oxygen saturation PVC premature ventricular contraction PVH Petaluma Valley Hospital PVT private PX pain q every R right RA room air RAS released at scene RLQ right lower quadrant RMC routine medical care RN registered nurse ROM range of motion ROSC return of spontaneous circulation RP reporting party RPM respirations per minute RR respiratory rate Rt right Rx prescription s without S. Brady sinus brady S. Tach sinus tachycardia S/NT/ND Soft, non-tender, no distention S/P status post S/S signs and symptoms SBP systolic blood pressure SC, SQ subcutaneous SL sublingual SM small SMR spinal motion restriction SNF skilled nursing facility SOB shortness of breath SPO2 peripheral capillary oxygen saturation SRC STEMI Receiving Center SRPD San Rafael PD STEMI ST Segment Elevation Myocardial Infarction SVT supraventricular tachycardia TACH tachycardia TB tuberculosis TEMP temperature TIA transient ischemic attack TKO to keep open TOC transfer of care Page 5 of 6 July 2018 COUNTY OF MARIN EMS 7006b

TRANS transport / transfer TTT Trauma Triage Tool TX treatment UCSF University California San Francisco UOA upon our arrival USGC United States Coast Guard UTI urinary tract infection UTL unable to locate UTO unable to obtain V victim V/S or VS vital sign VA Veteran's Administration VAD Ventricular Assist Device VF ventricular fibrillation VL Video laryngoscopy VT ventricular tachycardia W/ with w/c wheelchair w/o wide open WBC white blood count WNL within normal limits Y/O or YO Year(s) old

Page 6 of 6 July 2018 COUNTY OF MARIN EMS ALS PR 2

ADULT INTRAOSSEOUS PROCEDURE ALWAYS USE STANDARD PRECAUTIONS

INDICATIONS . Patient in extremis, cardiac arrest, profound hypovolemia, or septic and in need of immediate delivery of medications / fluids and immediate IV access is not possible CONTRAINDICATIONS . Absolute contraindications: . Recent fracture of involved bone (less than 6 weeks) . Vascular disruption proximal to insertion site . Inability to locate landmarks . Relative contraindications: . Infection or burn overlying the site . Congenital deformities of the bone . Metabolic bone disease EQUIPMENT . Intraosseous infusion needle and/ or mechanical device . Commercially prepared chlorhexidine with alcohol swab or ampule. If patient has allergy to chlorhexidine, use alcohol swab only. . Sterile gauze pads . 10-12 ml syringe filled with 10 ml saline . IV NS solution and tubing with 3-way stopcock . Supplies to secure infusion . Pressure bag . Lidocaine 2% (Preservative Free) PROCEDURE . Aseptic technique must be followed at all times . Position and stabilize chosen site . Prepare insertion site using aseptic technique . Air or gauze dry . Insert IO needle according to manufacturer’s directions . Confirm placement . Attach primed extension set and flush with 10 ml of saline . If patient awake and/or responsive to pain, infuse 2% Lidocaine 20-40 mg over 30-60 seconds. Wait 30-60 seconds before fluid infusion. May repeat Lidocaine in 15 minutes if needed. . If resistance is met, remove needle, apply pressure to site and attempt at secondary site . Attach pre-flooded IV tubing . Stabilize as recommended by manufacturer . Fluid administration requires pressure bag . Monitor insertion site and patient condition

Page 1 of 1 October 2017 COUNTY OF MARIN EMS ALS PR 3

ORAL ENDOTRACHEAL INTUBATION PROCEDURE ALWAYS USE STANDARD PRECAUTIONS

INDICATION . Severe ventilatory compromise where the airway cannot be adequately maintained by BLS techniques CONTRAINDICATION . Absolute . Patient whose height is less than the length of the color-coded resuscitation tape and <12 years of age . Epiglottitis . Relative . Spontaneous respirations are present . Responsive patient with intact gag reflex . Suspected opiate overdose . Profound hypoglycemia EQUIPMENT . Battery powered laryngoscope handle, extra batteries and bulbs or equivalent devices . Laryngoscope blades . Video Laryngoscopy (if available; refer to manufacturer’s recommendation for use) . McGill forceps . Cuffed endotracheal tubes . ETTI . Lubricating jelly . Disposable stylets . Suction . Pulse oximetry . End Tidal CO2 detector . Esophageal Detector Device (EDD) . Capnometer or capnograph when available PROCEDURE . Open airway and pre-oxygenate with BVM for 1-3 minutes with 100% O2. Avoid hyperventilation in cardiac arrest. . Select proper ETT . Insert stylet . Select proper sized blade and visualize the larynx . Suction as needed . If possible, provide continuous high flow oxygen during procedure . Under direct visualization insert ETT 2-3 cm past the cords. Each attempt should not exceed 30 seconds, hyperventilating between attempts. . Remove stylet . Inflate cuff . Verify placement using all of the following: . Rise and fall of chest

Page 1 of 2 October 2017 COUNTY OF MARIN EMS ALS PR 3

. Absence of epigastric sounds . Bilateral breath sounds . Capnometry/capnography or EDD and Colormetric Device . Secure the tube. Consider spinal immobilization to prevent extubation. Do NOT use C-collar. . Reassess tube placement after each patient movement. If any doubt about placement, confirm by capnography or direct visualization.

SPECIAL CONSIDERATION . Defibrillation should precede intubation in cardiac arrest VF / VT situations. . Limit intubation attempts (an attempt is defined as passing the device beyond the patient’s teeth). . Consider use of ETTI if difficult intubation. . If unable to intubate, manage airway with other airway adjunct.

RELATED POLICIES/ PROCEDURES . Endotracheal Tube Introducer (ETTI) Procedure ALS PR 4 . King Airway Procedure ALS PR 14 . Head Trauma T 2 . Pediatric Respiratory Distress P03

Page 2 of 2 October 2017 COUNTY OF MARIN EMS ALS PR 4

ENDOTRACHEAL TUBE INTRODUCER (ETTI) PROCEDURE ALWAYS USE STANDARD PRECAUTIONS

INDICATION . Airway structure or condition which prevents adequate visualization by standard tools of endotracheal intubation. May include: . Patients with Grade II through IV laryngeal views (Cormack-Lehane grade) . Patients with airway edema regardless of laryngeal view

CONTRAINDICATION . Endotracheal tubes smaller than 6.0 . Patient whose height is less than the length of the color-coded resuscitation tape and <12 years of age

EQUIPMENT . Intubation supplies . ETT Introducer

PROCEDURE . Perform laryngoscopy and obtain the best possible laryngeal view . Holding the ETTI in your right hand and the angled tip pointing upward, gently advance the ETTI anteriorly (under the epiglottis) to the glottic opening (cords). . For grade II views: . Direct through the cords . For all other situations: . Direct the ETTI to the area where the cords should lie and feel for washboard sensation as the tip ratchets on the tracheal rings. . Gently advance the ETTI until resistance is encountered at the carina. Because the ETTI can potentially cause pharyngeal/ tracheal perforation, NEVER FORCE IT. If no resistance is encountered and the entire length of the ETTI is inserted, the device is in the esophagus. . The ETTI is correctly placed when you see the device going through the cords, when the ratcheting of the tip on the trachea, and/or when resistance is met while advancing the device (ETTI is at the carina). . Once positioned, withdraw the ETTI until the 37 cm black line mark is aligned with the lip and advance an endotracheal tube over the ETTI and into the trachea. This indicates that the tip is well beyond the cords and the proximal end has enough length to slide the endotracheal tube over it. . If resistance is encountered – caused by the endotracheal tube catching on the arytenoids or aryepiglottic folds – withdraw the endotracheal tube slightly, rotate 90 degrees and reattempt. If this is unsuccessful, attempt with a smaller tube. . Once the endotracheal tube is in position, while holding the tube, remove the ETTI through the endotracheal tube. . Because this is a blind intubation, capnography should be utilized to confirm tracheal placement. SPECIAL CONSIDERATION . Use the confirmation methods standard for endotracheal intubation to verify placement of the endotracheal tube, both prior to and after initiating ventilation. RELATED POLICIES/ PROCEDURES . Oral Endotracheal Intubation ALS PR 3

Page 1 of 1 Oct 2017 COUNTY OF MARIN EMS ALS PR 9

VERIFICATION OF TUBE PLACEMENT PROCEDURE ALWAYS USE STANDARD PRECAUTIONS

INDICATION . To verify the placement of an endotracheal tube

EQUIPMENT . Esophageal Detector Device (EDD) . End Tidal Carbon Dioxide Detector (ETCO2 Detector) . Stethoscope . Capnography device

PROCEDURE . After tube placement, apply EDD prior to first ventilation. . Check for the following: . Auscultate the lungs; assess for presence and equality of breath sounds . Movement of air through the tube . Presence of condensation in the tube . Auscultate the stomach; assess for absence of air movement . Apply capnometer or capnography if available.

DOCUMENTATION . Response of EDD . Color change of ETCO2 Detector . Number and waveform of capnography

RELATED POLICIES/ PROCEDURES . Oral Endotracheal Intubation Procedure ALS PR 3

Page 1 of 1 July 2018 COUNTY OF MARIN EMS ALS PR 11

EXTERNAL CARDIAC PACING PROCEDURE ALWAYS USE STANDARD PRECAUTIONS

INDICATION . Symptomatic bradycardia which may include: HR < 50 with decreasing perfusion, chest pain, shortness of breath, decreased LOC, pulmonary congestion or congestive heart failure

 PHYSICIAN CONSULT . Concomitant administration of opioids (Morphine and Fentanyl) and Midazolam . If SBP < 80, obtain physician consult for Push-dose Epinephrine

CRITICAL INFORMATION . If patient is unstable, do not delay pacing for IV access

EQUIPMENT . Cardiac monitor/ defibrillator/ external pacemaker . Pacing capable electrode pads

PROCEDURE . ALS RMC . If patient is conscious, administer Midazolam 1 mg slow IV/IO. May repeat 1 mg every 3 minutes to desired degree of sedation. Maximum dose = 0.05 mg/kg. . If tolerated, position patient supine, applying pacing electrodes to bare chest according to manufacturers recommendations (anterior/ posterior or sternal/ apex). . Confirm and record ECG. . Set pacing rate at 60, turn on pacing module, and confirm pacer activity on monitor. May increase rate to 80. . Increase mA until capture occurs or maximum output is reached. . Once capture is confirmed, increase output by 10% . Confirm pulses with paced rhythm. . Monitor vital signs and need for further sedatives or pain control. . If SBP < 90, consider NS 250 ml bolus IV/IO .  Opioids for pain management if concomitant administration of Midazolam .  Physician consult for Push-dose Epinephrine for SBP < 80 . Mix 1mL Epinephrine (0.1mg/mL concentration) with 9mL Normal Saline in a 10mL syringe . Administer Push-dose Epinephrine 1mL IV/IO every 3-5 minutes . Titrate to maintain SBP >80mmHg . Monitor blood pressure every five minutes

DOCUMENTATION . mA needed for capture . Time pacing started/ discontinued

RELATED POLICIES/ PROCEDURES . Bradydysrhythmia C 4 . Adult Sedation ATG 3 . Adult Pain Management ATG 2

Page 1 of 1 October 2017 COUNTY OF MARIN EMS ALS PR 14

KING AIRWAY PROCEDURE ALWAYS USE STANDARD PRECAUTIONS

INDICATION . When ventilation cannot be adequately maintained by BVM or other BLS techniques and intubation is anticipated to be difficult or intubation is unsuccessful after no more than one attempt (cardiac arrest patients) or two attempts (respiratory arrest patients) CONTRAINDICATION . Responsive patient with an intact gag reflex . Patient with known esophageal disease . Patients who have ingested caustic substances . Tracheal stoma . Patient < 4 feet tall or < 12 years of age

EQUIPMENT . King Airway Size Patient Criteria Color Inflation Volume . Syringe 3 4 – 5 ft. Yellow 45 - 60 ml. . Water soluable lubricant 4 5 – 6 ft. Red 60 - 80 ml. . Portable suction device 5 > 6 ft. Purple 70 - 90 ml. . Capnometry/capnography or Colormetric Device . Stethoscope

PROCEDURE . Open airway and pre-oxygenate with BVM for 1-3 min. with 100% O2. Avoid hyperventilation in cardiac arrest. . Test cuff according to manufacturer’s instructions . Apply water soluble lubricant to the distal end of the tube. . Position the head into the “sniffing” position or neutral position if trauma is suspected . Remove dentures before placing tube to prevent laceration of the cuffs . Without exerting excessive force, advance tube until base of connector is aligned with teeth or gums . Inflate cuffs based on size of tube . Attach bag-valve to King Airway . While gently bagging the patient to assess ventilation, withdraw the airway until ventilation is easy and free flowing . Verify placement using all of the following: • Rise and fall of chest • Bilateral breath sounds • Absence of epigastric sounds • Capnometry/capnography or Colormetric Device . Secure the tube with tape or commercial tube holder, noting depth marking on tube SPECIAL CONSIDERATION . If there is any doubt about the proper placement of the King Airway, deflate the cuffs and remove device; ventilate the patient with BVM for 30 seconds and repeat sequence of steps . If unsuccessful on second attempt, resume BLS airway management

Page 1 of 1 July 2018 COUNTY OF MARIN EMS ATG 2

ADULT PAIN MANAGEMENT ALWAYS USE STANDARD PRECAUTIONS

Assess/document initial pain score and after each  PHYSICIAN CONSULT FOR OPIOIDS pain management intervention. Utilize non- . Patients with SBP < 100 pharmacological pain management as appropriate . Patients with ALOC (GCS < 15); (ice, splinting, repositioning, distraction). acute onset of severe headache; multi-system trauma that includes abdominal/thoracic trauma; decreased respirations; or women ALS RMC in active labor . > 20 mg Morphine Sulfate or > 200mcg of Fentanyl is needed for pain management Pt is > 50kg: NO . Pain > 6? Concomitant administration of Acetaminophen OPIOIDS and Midazolam

(Tylenol / Ofirmev) 1000 mg IV Infuse over 15-20 min. YES

Morphine Sulfate . IV/IO: 5 mg slowly; MR q 5 minutes, max. dose 20 mg. . IM: 5-10 mg; MR in 20 minutes, max. dose 20 mg

OR

Fentanyl . IV/IO: 50 mcg slowly; MR q 5 minutes, max. dose 200 mcg. . IN: 1 mcg/kg (administer ½ dose in each nare; max single dose = 100 mcg) . IM: 1 mcg/kg; max single dose = 100 mcg. MR in 30 min. at ½ initial dose.

If Morphine/Fentanyl unavailable or patient unable to tolerate, consider Acetaminophen IV or: Midazolam . IV/IO: 1 mg slowly; MR q 3 minutes to maximum dose 0.05 mg/kg . IN: 5 mg/1ml (2.5 mg in each nostril) . IM: 0.1 mg/kg; MR x 1 in 10 minutes

If nausea/vomiting, consider Ondansetron (Zofran ©) 4mg ODT/IM or slow IV/IO over 30 seconds; MR x 1 in 10 minutes

Page 1 of 1 July 2018 COUNTY OF MARIN EMS ATG 3

ADULT SEDATION ALWAYS USE STANDARD PRECAUTIONS

INDICATION . Cardioversion / Cardiac Pacing . Agitation / combativeness interfering with critical ALS interventions and airway control or that endangers patient or caregiver . Patients unable to tolerate opioids (e.g. Morphine Sulfate or Fentanyl) for pain management  PHYSICIAN CONSULT . Head injury (airway is stable) . Multiple system trauma (airway is stable) . Concomitant administration of opioids and Midazolam CRITICAL INFORMATION . Relative contraindications: . Nausea / vomiting . ALOC . Hypotension (SBP < 100) . Suspected drug / alcohol intoxication TREATMENT . ALS RMC, including ETCO2 . Cardioversion / cardiac pacing . If patient is conscious, administer Midazolam 1 mg slow IV/IO. May repeat 1 mg every 3 minutes to desired degree of sedation. Maximum dose = 0.05 mg/kg. . Opioids for pain management as needed per Adult Pain Management, ATG 2 . Agitation, combativeness or for patients unable to tolerate Morphine Sulfate- administer Midazolam . IV/IO: 1 mg slowly; MR q 3 minutes to maximum dose 0.05 mg/kg. . IN: 5 mg (2.5 mg in each nostril) . IM: 0.1 mg/kg; MR x 1 in 10 minutes . Patients receiving sedation for airway management who have long transport times may receive sedation maintenance doses of Midazolam 1 mg IV/IO every 15 minutes Midazolam for Sedation Weight Based Chart - MAXIMUM DOSE for IV/IO only Kg Lb Dose (0.05 mg/kg) 40 88 2 mg 45 99 2.25 mg 50 110 2.5 mg 55 121 2.75 mg 60 132 3 mg 65 143 3.25 mg 70 154 3.5 mg 75 165 3.75 mg 80 176 4 mg 85 187 4.25 mg 90 198 4.5 mg 95 209 4.75 mg >100 >220 5 mg

Page 1 of 2 July 2018 COUNTY OF MARIN EMS ATG 3

SPECIAL CONSIDERATION . Sedation for airway management does not mandate intubation, but may require airway/ventilation support . Patients receiving Midazolam may experience hypotension . Prior to arrival, prehospital personnel must notify the receiving facility of any patient with a known history of violence, or behavior which may pose a risk to staff (disruptive, uncooperative, aggressive, unpredictable).

RELATED POLICIES . Patient Restraint GPC11 . Continuous Positive Airway Pressure (CPAP) Procedure ALS PR 13 . External Cardiac Pacing Procedure ALS PR 11 . Adult Pain Management ATG 2

Page 2 of 2 July 2018 COUNTY OF MARIN EMS ATG 7

ADULT MEDICATIONS AUTHORIZED/ STANDARD DOSE

DRUG CONCENTRATION STANDARD DOSE Acetaminophen 1000 mg/ 100 ml Pain: 1000 mg IV over 15 – 20 min. (Tylenol / Ofirmev)

Adenosine 6 mg 1st dose, 12 mg 2nd dose (rapid IV/IO (Adenocard) 6 mg/ 2 ml push) followed by 20 ml saline flush after each dose Albuterol 2.5 mg/ 3ml NS 5 mg/ 6 ml NS; (MDI: Fireline only) Amiodarone 150 mg/ 3ml VFib or Pulseless VTach: 300 mg IV/ IO push followed by one 150MG push in 3-5 min. Perfusing/Recurrent VTach 150 mg IV/ IO over 10 min. (15 mg/ min); MR q 10 min. as needed Aspirin (chewable) Variable 162-325 mg PO Atropine 1 mg/ 10 ml Bradycardia: 0.5 mg IV/ IO, MR q 3-5 min. to max of 3 mg. Organophosphate Poisoning: 2.0 mg slowly IV/ IO; MR 2-5 min. until drying of secretions Calcium chloride 10% 1 GM/ 10 ml Crush syndrome: 1gm IV/ IO slowly over 5 min. for suspected hyperkalemia (flush line with NS before & after administration) Dextrose 10% 25 GM/250 ml 125 ml bolus IV/IO over 10 minutes; recheck BG and repeat as needed Diphenhydramine 50 mg/ 1ml Allergic reaction: 50 mg IV/ IO/ IM; max (Benadryl) 50 mg Phenothiazine reaction: 1 mg/ kg slowly IV/ IO; max 50 mg. Motion sickness: 1 mg/kg IM/IV to maximum dose of 50 mg; maximum IV rate is 25 mg/minute Epinephrine 1 mg/ 1ml Allergic Reaction/ Anaphylaxis: 0.3mg IM or EpiPen®; MR x 1 in 5 minutes EpiPen® (0.3mg) auto- Bronchospasm/ Asthma/ COPD: 0.3mg injector (or EMS Agency IM or EpiPen®; MR x 1 in 5 minutes approved equivalent)

Epinephrine 0.1mg/ 1ml Cardiac Arrest: 1mg (10 ml) IV/ IO followed by 20 ml NS flush q 3-5 min.

Page 1 of 2 July 2018 COUNTY OF MARIN EMS ATG 7

Epinephrine (Push-Dose) 0.1mg/ 1 ml SBP<80 in Pulmonary Edema, Pacing, Bradydysrhythmias, Non-Traumatic Shock, Anaphylaxis, Sepsis: Mix 1mL Epinephrine (0.1mg/mL concentration) with 9mL Normal Saline in a 10mL syringe. Administer 1mL IV/IO every 3-5 minutes, titrate to maintain a SBP >80mmHg Fentanyl 100 mcg/ 2 ml Pain Management: IV/IO: 50 mcg slowly; (Sublimaze) MR q 5 minutes, max. dose 200 mcg. IN: 1 mcg/kg (administer ½ dose in each nare; max. single dose = 100 mcg). IM: 1 * opioid mcg/kg; max. single dose = 100 mcg; MR in 30 minutes at ½ initial dose. Glucose Paste 15 GM / tube 30 GM PO Glucagon 1 mg/ vial 1 mg IM Ipratropium 500 mcg per unit dose (2.5 500 mcg (Atrovent) ml) Lidocaine 2% 20 mg / 1 ml IO insertion: infuse 20-40 mg IO over 30- (preservative free) 60 seconds Nerve gas Auto-Injector 2 mg (0.7 ml) Small Exposure to vapors/ liquids: 1 Kit contains: 600 mg (2 ml) dose of both medications (Atropine & 2- Atropine PAM), MR X1 in 10 minutes. Pralidoxime Chloride (2 Larger exposure to liquids/ vapors: PAM) 3 doses initially (both medications)

Midazolam 2 mg/2 ml (IV/IO/IM) Cardioversion/ Pacing/Seizure: 1 mg (Versed) 5 mg/1 ml (IN) slow IV/ IO; MR 1 mg q 3 min.; Max dose = 0.05 mg/kg For IN: 5 mg (2.5 mg in each nostril). For IM: 0.1 mg/kg; MR x 1 in 10 minutes. Sedation: see specific policy Morphine Sulfate 10 mg/ 1ml Chest Pain: 2-5 mg slow IV/IO; MR q 2-3 min. to max of 10 mg Pain Management/ Trauma Patient: * opioid 5 mg slow IV/ IO, MR q 5 min if SBP >100; max dose 20 mg

Naloxone (Narcan) 2 mg/ 2 ml 0.4 - 4.0mg IV/IO/IM/IN; MR as necessary

Nitroglycerine 0.4 mg/ tablet or spray 1 SL; MR q 5 min. if SBP > 100 Ondansetron (Zofran) 4 mg 4 mg ODT/IM or slow IV over 30 seconds; MR x 1 in 10 minutes Sodium Bicarbonate 50 mEq/ 50 ml 1 mEq/ kg IV/ IO

NOTE: If the above concentrations become unavailable, providers may use alternate available concentrations or packaging.

Page 2 of 2 July 2018 COUNTY OF MARIN EMS BLS 1

ROUTINE MEDICAL CARE (RMC) BLS ALWAYS USE STANDARD PRECAUTIONS

INDICATION . To define Routine Medical Care (RMC) in the pre-hospital setting

TREATMENT . Assess Airway, Breathing and Circulation (ABC) . Apneic and/ or pulseless: . Begin CPR in accordance with the standards established by the American Heart Association, including early defibrillation . Patient breathing with pulse present: . Administer oxygen per policy BLS PR 2, Oxygen Therapy Procedure. Use appropriate airway adjuncts indicated for signs and symptoms. . Control significant external bleeding using direct pressure. If bleeding remains uncontrolled, apply gauze or hemostatic dressing and/or tourniquet. . Limb with the tourniquet must remain exposed . Hemostatic dressing must be approved by California EMS Authority . Check vital signs – repeat q 5 min. for emergent patients and q 15 min. for non-emergent patients. . For ALOC, assess blood glucose and treat per protocol . Obtain: . Chief complaint . History of current event . Past medical history . Medications . Allergies . Code status / Designated Decision Maker . Perform full secondary patient exam . If indicated, apply spinal motion restriction . Place patient in position of comfort or in other positions as needed to maintain adequate breathing and/ or circulation

Page 1 of 1 July 2018 COUNTY OF MARIN EMS BLS 2

CHEST PAIN/ ACUTE CORONARY SYNDROME BLS ALWAYS USE STANDARD PRECAUTIONS

INDICATION . Chest discomfort or pain, suggestive of cardiac origin or other symptoms of ACS (Acute Coronary Syndrome) which may include weakness, nausea, vomiting, diaphoresis, dyspnea, dizziness, palpitations, “indigestion”

TREATMENT . BLS RMC . Limit patient’s physical activity . Administer ASA 162-325 mg (chewable) if no known aspirin allergy, even if patient has taken daily ASA dose. . Allow patient to self-administer own Nitroglycerin (NTG) as directed by their own physician only if SBP > 100

SPECIAL CONSIDERTIONS . Discomfort or pain: OPQRST, Previous episodes, 0-10 scale . Suspicion of ACS is based upon patient history. Be alert to patients likely to present with atypical symptoms or “silent MI’s” (women, elderly and diabetics). . If patient is having an MI, NTG may cause significant hypotension. . If the patient has taken erectile dysfunction (ED) medication within the last 24 hrs (Viagra/Levitra) or 36 hrs (Cialis) instruct patient not to take NTG.

DOCUMENTATION- ESSENTIAL ELEMENTS . Medical history (cardiac history; other medical problems including hypertension, diabetes or stroke) . OPQRST information . Vital signs before/after NTG administration . Erectile dysfunction medications taken . Level of pain . Medications administered . Code status / Designated Decision Maker

Page 1 of 1 July 2018 COUNTY OF MARIN EMS BLS PR 3

ADMINISTRATION OF ORAL GLUCOSE BLS PROCEDURE ALWAYS USE STANDARD PRECAUTIONS

INDICATIONS . Patients with blood glucose measurement of < 60

EQUIPMENT . Oral glucose and/ or juices that contain sugar (no diet drinks) . Glucose Paste

PROCEDURE . Responsive patients with a gag reflex: . Give sweetened fluids (orange/ fruit juice) to drink . Do not use “diet” preparations as they do not contain sugar . Lethargic patients unable to drink fluids: . Place patient in left or right lateral position . Place Glucose paste 30 gm PO between the dependent cheek and gum . Monitor airway, being prepared to suction if necessary . Transfer patient to higher level of care as soon as possible

Page 1 of 1 July 2018 COUNTY OF MARIN EMS BLS PR 6

MEDICAL EMERGENCIES BLS PROCEDURES ALWAYS USE STANDARD PRECAUTIONS

INDICATIONS . For the following emergencies: . Syncope/ Near Syncope/ Fainting . Abdominal pain (non-traumatic) . Allergic Reaction . ALOC . Unconscious/ Unresponsive . Cardiac Arrest . SOB . Seizure (active) . Post- Seizure (post-ictal) . Chest Pain

PROCEDURES . BLS RMC . Reassure patient . Transfer care to ALS unit as patient condition warrants . Syncope/ near syncope/ fainting: . Evaluate for need of spinal motion restriction if significant mechanism of injury . Abdominal pain (non-traumatic): . Nothing by mouth . Prepare for vomiting . Check bilateral BP, pedal pulses . Allergic reaction: . Loosen clothing . Advise patient to self-administer EpiPen (or equivalent) or provider to administer epinephrine per policy . ALOC/Unconscious/ Unresponsive: . If altered, place patient in recovery position . Assess blood glucose (BG) . If BG < 60 or immeasurable and patient can swallow, give sweetened drink or administer Glucose paste per policy . Ventilate with positive pressure devices . If opioid overdose is suspected, provide rescue breaths and administer Narcan Nasal Spray ▪ Record time of administration and place patient in recovery position ▪ May repeat every 2-3 minutes until patient responds. Multiple doses may be required. ▪ If no pulse, follow Cardiac Arrest algorithm (below) . Cardiac Arrest: . Place patient supine on firm surface and remove patient shirt . CPR

Page 1 of 2 July 2018 COUNTY OF MARIN EMS BLS PR 6

. Attach A.E.D. . Suction as needed . If ALS arrival time is longer than time to transport to the closest facility, begin transport and consider rendezvous with ALS unit enroute if appropriate. . Consider field determination of death

. SOB/Airway Obstruction: . Position of comfort, usually upright . Allow patient to self-administer any inhaled medications . Consider different causes of SOB with pediatric patients . Seizure (active): . Protect patient from injury (move furniture, etc.) . Consider possible treatment of diabetic patient (see ALOC) . If febrile seizure, initiate cooling measures . Post- Seizure (post-ictal): . Follow above treatment on seizures . Frequently evaluate patient’s level of consciousness and anticipate recurring seizures . Suction as needed . Chest Pain: . Limit patient’s physical activity . Administer ASA 162-325 mg (chewable) if no known allergy, even if patient has taken daily ASA dose. . Allow patient to self-administer own Nitroglycerin (NTG) as directed by their own physician only if SBP > 100 . Psychiatric Patient: . Protect self, others from combative or violent behavior . Prepare for rapid changes in behavior due to possible ingestion of poisons, alcohol and drugs. If possible, bring ingested substances to hospital for analysis.

RELATED POLICIES/ PROCEDURES . Administration of Oral Glucose BLS PR 3 . Administration of EpiPen Procedure BLS PR 4 and BLS PR 4A . Administration of Narcan Nasal Spray BLS PR 11 . Chest Pain / Acute Coronary Syndrome BLS 2 . Determination of Death First Responder BLS, BLS 5

Page 2 of 2 July 2018 COUNTY OF MARIN EMS BLS PR 7

ENVIRONMENTAL EMERGENCIES BLS PROCEDURES ALWAYS USE STANDARD PRECAUTIONS

INDICATION . For the following environmental emergencies: . Near Drowning . Bites/ Stings (animal/ snake) . Heat Injuries . Cold Injuries . Localized cold injuries EQUIPMENT . Airway management per patient condition . BP monitor . Suction . Dressings . Cold packs . Hot packs PROCEDURE . BLS RMC . Near Drowning . Consider spinal motion restriction . Keep patient warm . Prepare to log-roll if vomiting occurs . Frequent evaluation of lung sounds . Bites/ Stings . Restrict patient physical activity . Immobilize extremity . Apply cold pack to site . Advise patient to self-administer EpiPen (or equivalent) or provider to administer epinephrine per EMS Agency approved policy . Observe for allergic reactions and refer to Medical Emergencies Procedures BLS PR 6 . Animal Bites . Apply appropriate dressing . Re-evaluate size of swelling every 5-10 minutes . Snake Bites . Identify or provide description of snake if seen . Do not use ice or apply constricting bands . Remove rings, bracelets, or other constricting items from all extremities . Limit patient’s movement as much as possible . Mark extent of affected area, noting time on skin . Immobilize extremity in a position of comfort and monitor distal pulses

Page 1 of 2 July 2018 COUNTY OF MARIN EMS BLS PR 7

. Heat Injuries . Move to a cool environment and remove clothing . Rapid cooling measures: ▪ Apply wet towels and promote cooling by fanning ▪ Apply cold packs to axilla and groin . BLS RMC; treat hypoglycemia per policy . Replenish electrolytes by mouth if able to swallow . Recheck vital signs frequently . Transport all patients rapidly, even if in cardiac arrest . Cold Injuries . Remove wet clothing and patient from cold environment . Apply warming measures with blankets, heaters, etc. If patient is no longer shivering be less aggressive with re-warming efforts and minimize stimulation of patient. . Localized Cold Injuries . Gently remove clothing from injured area . Cover area with sterile dressing . Avoid direct contact with affected area

Page 2 of 2 July 2018 COUNTY OF MARIN EMS BLS PR 10

BLOOD GLUCOSE MONITORING BLS PROCEDURE ALWAYS USE STANDARD PRECAUTIONS

INDICATIONS . Patients with ALOC and / or suspected hypoglycemia as indicated by the following symptoms: . Diabetic history . Abnormal or combative behavior . Pale, moist skin

EQUIPMENT . Glucometer . Lancet . Test strip . Alcohol pad . Gauze pad/bandage

PROCEDURE . Turn glucometer on and insert test strip . Clean fingertip with alcohol pad. Gently squeeze fingertip to promote blood flow . Pierce fingertip with lancet . Apply blood sample to test strip . Record results . If blood glucose is < 60 or immeasurable, treat patient according to Administration of Oral Glucose Policy, BLS PR 3.

Page 1 of 1 July 2018 COUNTY OF MARIN EMS BLS PR 11

ADMINISTRATION OF NARCAN NASAL SPRAY BLS PROCEDURE ALWAYS USE STANDARD PRECAUTIONS

INDICATIONS . Patients with ALOC and suspicion of overdose as indicated by the following symptoms: . Overdose history or drug paraphernalia at scene . Pale, moist skin . Unable to respond . Respirations and/or pulse is slow, erratic, or absent . Pinpoint pupils

EQUIPMENT . Narcan Nasal Spray . BVM

PROCEDURE . Establish unresponsiveness; if pulseless and apneic start CPR . Place in supine position and tilt head back . Administer Narcan Nasal Spray . Insert tip of nozzle into one nostril until fingers are flush with skin/nose . Press firmly to fully depress the plunger . Place patient in recovery position . Record time of administration . Narcan Nasal Spray may be repeated every 2-3 minutes (alternate nostrils) if patient remains unresponsive . Monitor airway, suction as needed . If no response to Narcan, begin CPR . Transfer patient to higher level of care as soon as possible . Document type of overdose, if known

Page 1 of 1 July 2018 COUNTY OF MARIN EMS C1

VENTRICULAR FIBRILLATION/PULSELESS VENTRICULAR TACHYCARDIA ALWAYS USE STANDARD PRECAUTIONS

Critical Information: START CPR ● Give O2 • Witnessed vs Unwitnessed ● Attach monitor/defibrillator • Consider pre-cordial thump if witnessed and ● ALS RMC defibrillator not immediately available • Compress at 110 bpm. Use metronome or similar device • Manual CPR is preferred; mechanical CPR is an acceptable alternative Rhythm Yes No • Change compressors every 2 minutes Shockable? • Minimize interruptions • If hypothermic <95F, delay compressions for 3 minutes; focus on ventilations and active rewarming • Defibrillate per manufacturer’s recommendations. • Do not stop compressions while defibrillator is VF/pVT charging • Resume compressions immediately after shock BLS Airway Management: • BLS airway is preferred during the first 5 minutes CPR 2 min • Use two-person BLS airway management whenever IO/IV access ● possible • Avoid excessive ventilation • 30:2 compression/ventilation ratio

Rhythm No ALS Airway Management: Shockable? • King Airway / Video Laryngoscopy (VL) preferred • Laryngoscopy for ETT must occur with CPR in progress. Do not interrupt CPR for >10 seconds for Yes tube placement • Use continuous ETCO2 to monitor CPR CPR 2 min Go to Policy – effectiveness and advanced airway placement. • Epinephrine every 3-5 • Maintain O2 sat 94-99% min ● Asystole/PEA • 1 breath every 6 seconds • Consider advanced airway ● ROSC Drug Therapy: • Epinephrine 1mg (0.1mg/ml concentration) IV/IO q 3-5 minutes

Rhythm No • Amiodarone first dose: 300mg IV/IO; second dose Shockable? 150mg IV/IO in 3-5 minutes. If rhythm converts to ROSC after Amiodarone, consider infusion of Amiodarone drip (150mg in 100ml NS, 1mg/min = 40 gtts/min with 60 gtt/ml tubing) Yes Reversible Causes: • Hypovolemia CPR 2 min • Hypoxia • Amiodarone • Hydrogen Ion (Acidosis) • Treat reversible causes • Hypo-/Hyperkalemia • Hypothermia • Tension Pneumothorax • Tamponade (cardiac) For refractory Vfib >30 min, transport to nearest available • Toxins STEMI Receiving Center • Thrombosis, pulmonary • Thrombosis, coronary Page 1 of 1

July 2018 COUNTY OF MARIN EMS C2

ASYSTOLE / PULSELESS ELECTRICAL ACTIVITY ALWAYS USE STANDARD PRECAUTIONS

Critical Information: • Witnessed vs Unwitnessed • Determination of death can be made immediately if all are present (Medical patients): - Presenting rhythm is asystole - Event was unwitnessed - Effective bystander CPR was not initiated No Start CPR Does patient meet - No evidence of potentially reversible cause of ALS Determination ● Give O2 arrest (e.g. hyperkalemia or hypothermia) of Death criteria? ● Attach monitor/defibrillator ● ALS RMC - No AED or manual shock delivered • Determination of death can be made immediately if either are present (Trauma patients): Yes 1. MCI incident where triage principles preclude initiation of CPR . CPR for 2 minutes 2. Blunt, penetrating or profound multi-system Go to policy: . IV/IO access trauma with asystole or PEA . Epinephrine (0.1mg/ml Determination of concentration) 1 mg IV/IO every 3-5 • If hyperkalemia is suspected in renal dialysis Death ALS, ATG 6 i patients, administer 500mg of 10% Calcium Chloride and 1 mEq/kg of Sodium Bicarbonate IV/IO • If hypothermic <95F, delay compressions for 3 No minutes; focus on ventilations and active ROSC? Shockable rhythm? rewarming • Refer to Adult Cardiac Arrest Policy

BLS Airway Management Yes • BLS airway is preferred during the first 5 minutes Yes • Use two-person BLS airway management whenever possible • Avoid excessive ventilation Go to policy: Go to policy: • 30:2 compression/ventilation ratio

ROSC C10 VF/pVT C1 ALS Airway Management: • King Airway / Video Laryngoscopy (VL) preferred • Laryngoscopy for ETT must occur with CPR in progress. Do not interrupt CPR for >10 seconds for tube placement • Use continuous ETCO2 to monitor CPR effectiveness and advanced airway placement. • Maintain O2 sat 94-99% • 1 breath every 6 seconds

Reversible Causes • Hypovolemia • Hypoxia • Hydrogen Ion (acidosis) • Hypo/Hyperkalemia • Hypothermia • Tension Pneumothorax • Tamponade (cardiac) • Toxins • Thrombosis, pulmonary • Thrombosis, coronary

Page 1 of 1 July 2018 COUNTY OF MARIN EMS C 4

BRADYDYSRHYTHMIAS ALWAYS USE STANDARD PRECAUTIONS

INDICATION . HR < 50 with adequate or inadequate perfusion

 PHYSICIAN CONSULT . If SBP < 80, obtain physician consult for Push-dose Epinephrine

TREATMENT . Adequate perfusion . ALS RMC . Inadequate perfusion (acute altered mental status, ongoing chest pain, hypotension or other signs of shock) . ALS RMC . Atropine 0.5 mg IV/IO Repeat q 3-5 min. to total of 3 mg. (Atropine should not delay pacing for patients with inadequate perfusion). . Transcutaneous pacing for high-degree blocks (type II second-degree or third-degree) . Fluid bolus of 250-500 ml NS if hypotensive and lungs clear. Repeat as needed. If inadequate response .  If SBP < 80 obtain physician consult for Push-dose Epinephrine: ▪ Mix 1mL Epinephrine (0.1mg/mL concentration) with 9mL Normal Saline in a 10mL syringe . Administer Push-dose Epinephrine 1mL IV/IO every 3-5 minutes . Titrate to maintain SBP >80mmHg . Monitor blood pressure every five minutes

SPECIAL CONSIDERATIONS . Consider and treat possible contributing factors: . Hypovolemia . Toxins (overdoses) . Hypoxemia . Tamponade, cardiac . Hydrogen ion (acidosis) . Tension pneumothorax . Hypo/Hyperkalemia . Thrombosis (coronary / pulmonary) . Hypoglycemia . Trauma . Hypothermia

DOCUMENTATION / ESSENTIAL ELEMENTS . Time pacing started/ stopped RELATED POLICIES/ PROCEDURES . Adult Sedation Policy ATG 3 . External Cardiac Pacing Procedure ALS PR 11

Page 1 of 1 July 2018 COUNTY OF MARIN EMS C 8

CHEST PAIN/ ACUTE CORONARY SYNDROME ALS

ALWAYS USE STANDARD PRECAUTIONS INDICATION . Chest discomfort or pain, suggestive of cardiac origin. . Other symptoms of Acute Coronary Syndrome (ACS) which may include weakness, nausea, vomiting, diaphoresis, dyspnea, dizziness, palpitations, “indigestion” . Atypical symptoms or “silent MIs” (women, elderly, and diabetics)

 PHYSICIAN CONSULT . Additional treatment for ongoing pain when BP<100

TREATMENT . ALS RMC . ASA 162-325 mg (chewable), even if patient has taken daily ASA dose. . 12-lead ECG; if elevation in leads II, III, and AVF, suspect RVI and perform right-sided ECG. . For chest discomfort or pain, NTG 0.4 mg SL/ spray, MR q 5 min. if systolic BP > 100 . Withhold the NTG if the patient has RVI or has taken erectile dysfunction (ED) medication within the last 24 hrs (Viagra/Levitra) or 36 hrs (Cialis). . If pain persists, treat per Adult Pain Management Policy, ATG 2 . Consider NS 250cc IV fluid bolus if BP < 100. . For recurrent episodes of ventricular tachycardia with persistent chest pain, administer Amiodarone 150 mg in 100 ml NS, IV/IO; infuse over 10 minutes. May repeat q 10 minutes as needed. SPECIAL CONSIDERATION . IV access before NTG if any one of the following applies: . SBP <120 . Patient does not routinely take NTG . Consider other potential causes of chest pain: pulmonary embolus, pneumonia, aortic aneurysm and pneumothorax . Infarctions may be present with normal 12-leads . Routine administration of oxygen is not indicated if saturation is >93% DOCUMENTATION- ESSENTIAL ELEMENTS . OPQRST information . Vital signs before/after NTG administration . Cardiac rhythm documentation . ECG findings . Erectile dysfunction medications taken . Level of pain RELATED POLICIES/ PROCEDURES . 12-lead Electrocardiogram ALS PR 12 . Destination Guidelines GPC 4 . STEMI C 9 . Adult Pain Management ATG 2

Page 1 of 1 July 2018 COUNTY OF MARIN EMS C 9

ST ELEVATION MYOCARDIAL INFARCTION (STEMI) ALWAYS USE STANDARD PRECAUTIONS INDICATION . Patients with acute ST Elevation Myocardial Infarction (STEMI) as identified by machine read

 PHYSICIAN CONSULT . If patient is symptomatic for STEMI, but computer interpretation is not in agreement, transmit ECG and consult the STEMI Receiving Center (SRC) receiving physician. . If above findings occur, but transmission is not available, activate SRC with Early STEMI Notification. TREATMENT/ PROCEDURE . ALS RMC . Treat patient under appropriate protocol . Routine administration of oxygen is not indicated if saturation is >93% . Determine if patient is stable or unstable, and transport to appropriate facility . Provide Early STEMI Notification and identifying patient information . If elevation in leads II, III, and AVF, suspect RVI and perform right-sided ECG. . Transmit all STEMI ECGs to SRC if possible . To determine if patient is stable or unstable: Stable Unstable . Stable VS and no indication . SBP< 90 (prior to NTG and opioid administration) of shock . Signs of acute pulmonary edema . Ventricular tachyarrhythmia requiring defibrillation or antiarrhythmic therapy . Patient’s condition, based on paramedic judgment, requires immediate hospital intervention . Stable patient: . May go to preferred SRC if the estimated transport time is not more than 15 minutes longer than the nearest SRC . Preferred SRC defined: . Patient preference . SRC used by treating cardiologist. . Unstable patient: . Transport to the closest SRC SPECIAL CONSIDERATION . Early notification report to include: age, gender, patient identifying information, symptoms (including presence or absence of chest pain), and 12-lead findings DOCUMENTATION- ESSENTIAL ELEMENTS . 12-lead findings . How preferred SRC is determined RELATED POLICIES/ PROCEDURES . Destination Guidelines GPC 4 . 12-lead ECG Procedure ALS PR 12 . Chest Pain / ACS C8

Page 1 of 1 July 2018 COUNTY OF MARIN EMS E 1

HEAT ILLNESS ALWAYS USE STANDARD PRECAUTIONS

INDICATION . Exposure to unusually high temperatures, humidity, or vigorous exercise resulting in heat cramps, heat exhaustion, or heat stroke

CRITICAL INFORMATION

. The following categories of heat illness should be seen as a continuum rather than three distinct categories. Treat heat illness aggressively, particularly in at-risk populations: elderly, pediatric and patient taking certain medication such as vasoconstrictors, ADHD (i.e., Adderall or Ritalin), beta blockers, diuretics, antidepressants or antipsychotics. . Heat Cramps: . Severe painful cramping of fatigued muscles in the setting of heat stress, often following fluid replacement with hypotonic fluids . Heat Exhaustion: . Systemic symptoms, often vague and nonspecific, precipitated by significant hypovolemia under conditions of heat stress, and characterized by any of the following: weakness, fatigue, nausea, vomiting, headache, impaired judgment, vertigo, syncope, tachycardia, hypotension and dizziness, often orthostatic. Mental status is normal. . Heat Stroke: . Catastrophic life-threatening failure of homeostatic thermoregulatory mechanisms, manifested by extreme elevation of body temperature & severe CNS dysfunction, which may present as disorientation, delirium, seizure or coma.

TREATMENT . Move to a cool environment and remove clothing . Rapid cooling measures: ▪ Apply wet towels and promote cooling by fanning ▪ Apply cold packs to axilla and groin . ALS RMC . Replenish electrolytes by mouth or IV NS 1-liter bolus . Transport all patients rapidly, even if in cardiac arrest . Treat ALOC, seizures or shock per appropriate policy

Page 1 of 1 July 2018 COUNTY OF MARIN EMS E2

COLD INDUCED INJURY ALWAYS USE STANDARD PRECAUTIONS

Suspected cold induced injury Indication: exposure to cold or wet environment

Move patient to warm, protected area ASAP

Signs of life No signs of life

Start warming If submersion measures; ≤one hour , If submersion Handle gently obtain rectal ≥one hour temp

If ALOC, obtain rectal If rectal temp If rectal temp Determination

temp <95 F > 95 F of Death

Warming measures include: Begin During warming • Remove all wet clothes transport measures, • Cover entire body with auscultate HR Follow warm blankets for 1 minute & Adult Cardiac • Hot packs ventilate for 3 Arrest, GPC • Warm IV fluids minutes; assess electrical Symptoms can include: activity • Mild- shivering, increased RR & HR • Moderate/ Severe- ALOC, slurred speech, unsteady *Asystole *PEA * Vfib/pVT gait, slow HR & RR, low BP, (ventricular) dysrhythmias

Special Considerations: Defibrillate once @ highest Begin CPR Withhold CPR, • Subtler presentations exist focus on warming joule setting, then CPR in elderly, newborns, chronically ill and alcoholics

*Withhold ACLS meds if temp <86 F

Page 1 of 1 July 2018 COUNTY OF MARIN EMS E 3

ENVENOMATION ALWAYS USE STANDARD PRECAUTIONS

INDICATION . Unidentified and/or identified poisonous snake bite (physical evidence: puncture wound or symptoms of envenomation: local pain, swelling or numbness)

CRITICAL INFORMATION . Identify or provide description of snake if seen

TREATMENT . ALS RMC . Remove rings, bracelets, or other constricting items from all extremities . Limit patient’s movement as much as possible . Mark extent of affected area, noting time on skin . Immobilize extremity in a position of comfort and monitor distal pulses . Consider pain management. . If exhibiting signs of allergic reaction or shock, refer to Allergic Reaction Policy . Expedite transport

SPECIAL CONSIDERATION . Contact hospital early to allow preparation for treatment . Do not apply tourniquets, incise skin, apply ice, or suction

DOCUMENTATION- ESSENTIAL ELEMENTS . Estimated time of snake bite

RELATED POLICIES/ PROCEDURES . Allergic Reactions/ Anaphylaxis M 3 . Adult Pain Management ATG 2

Page 1 of 1 July 2018 COUNTY OF MARIN EMS GPC

ADULT CARDIAC ARREST ALWAYS USE STANDARD PRECAUTIONS

INDICATION . Unresponsive; no breathing or has agonal respirations; no pulse

Critical Information: Start CPR • Witnessed vs Unwitnessed 110 bpm – 2” depth & full recoil • Consider pre-cordial thump if witnessed and Give O2 via BVM defibrillator not immediately available Attach monitor/defibrillator • Compress at 110 bpm. Use metronome or similar device • Manual CPR is preferred; mechanical CPR is an acceptable alternative • Change compressors every 2 minutes Shockable • Minimize interruptions Rhythm? • If hypothermic < 95F, delay compressions for 3 minutes; focus on ventilations and YES active rewarming NO • Defibrillate per manufacturer’s recommendations. • Do not stop compressions while defibrillator is charging Vfib/pVT Asystole/PEA • Resume compressions immediately after shock

SHOCK BLS Airway Management • BLS airway is preferred during the first 5 min • Use two-person BLS airway management CPR 2 min whenever possible CPR 2 min • Avoid excessive ventilation SEE • 30:2 compression/ventilation ratio SEE VFIB / ASYSTOLE / PULSELESS VTACH PEA ALS Airway Management POLICY POLICY • King Airway/Video laryngoscopy (VL) preferred • Laryngoscopy for ETT must occur with CPR in progress. Do not interrupt CPR for >10 seconds for tube placement • Use continuous ETCO2 to monitor CPR effectiveness and advanced airway placement. • Maintain O2 sat 94-99% • 1 breath every 6 seconds

Special Considerations

• Movement of patient during CPR may be detrimental to outcome • Provide resuscitation on scene until ROSC or when patient meets Determination of Death criteria • Regardless of the above, transportation is warranted in the following situations: refractory VF, unsafe scene conditions, unstable airway, hypothermia/hyperthermia as a primary cause of arrest, any patient pulled from a fire in cardiac arrest • To assure ROSC continues, remain on scene for 5-10 minutes and then transport to a STEMI Receiving Center

Page 1 of 1 July 2018 COUNTY OF MARIN EMS GPC 2

AGAINST MEDICAL ADVICE (AMA) ALWAYS USE STANDARD PRECAUTIONS INDICATION . For patients or Designated Decision Maker (DDM) refusing medical care against the advice of the medical personnel on scene or of the receiving hospital

 PHYSICIAN CONSULT - required . Patient requests transport to a facility that is not the recommended destination, and that decision would create a life-threatening or high-risk situation . Patient requests an out of county transport when informed of the recommended destination within Marin County . Pediatric brief resolved unexplained event (BRUE)  PHYSICIAN CONSULT – strongly recommended, but not required . Patients ≥ 65 years requesting AMA with the following complaints: . Chest pain . SOB/ Dyspnea . Syncope . New onset of headache . New onset of seizure . TIA/ resolving stroke symptoms . Traumatic injuries (particularly head injury patients on anti-coagulants) . Pediatric complaints . Pregnancy related issues

CRITICAL INFORMATION . Patients who may legally give consent or refuse medical treatment are as follows: . At least 18 years of age . A minor (<18 years) who is lawfully married/ divorced, or on active duty with the armed forces . A minor who seeks prevention or treatment of pregnancy or sexual assault . A minor ≥12 years of age seeking treatment of rape, contagious diseases, alcohol or drug abuse . A self-sufficient minor, ≥ 15 year of age, caring for themselves . A legally emancipated minor . DDM is an individual to whom the patient or a court has given legal authority to make medical decisions concerning the patient’s healthcare (a parent or Durable Power of Attorney) . An AMA may be obtained by telephone consent from patients who do not have a DDM physically present TREATMENT/ PROCEDURE . All patients requesting medical attention will be offered treatment and/ or transportation after a complete assessment. . Mentally competent patients/ DDMs have the right to accept or refuse any or all pre-hospital care and transportation as long as medical personnel have explained the care and the patient /DDM understands by restating the nature and implications of such decisions. . The following information must be provided to the patient or DDM by the EMS personnel: . The recommended treatment and benefits for receiving care

Page 1 of 2 July 2018 COUNTY OF MARIN EMS GPC 2

. The risks and possible complications involved . Reasonable consequences for not seeking care and treatment for the condition . EMS personnel should advise the patient of alternative care and transport options which may include: . Private transport to a clinic, a physician’s office or an Emergency Department . Telephone consultation with a physician . Have patient/ DDM sign the AMA form SPECIAL CONSIDERATION . Consider early involvement of law enforcement if there is any threat to self, others or grave disability . Treat as necessary to prevent death or serious disability . If the patient cannot legally refuse care or is mentally incapable of refusing care, document on the PCR that the patient required immediate treatment and /or transport, and lacked the mental capacity to understand the risks / consequences of the refusal (implied consent) . Do not request a 5150 hold unless the patient presents a danger to self or others as an apparent result of a psychiatric problem. . At no time are field personnel to put themselves in danger by attempting to transport or treat a patient who refuses. At all times, good judgment should be used, appropriate assistance obtained, and supporting documentations completed. DOCUMENTATION- ESSENTIAL ELEMENTS . Who activated 911 and the reason for the call . Any medical care provided . The apparent competency of the patient/ DDM to sign out AMA . The ability of the patient/ DDM to verbalize understanding of his/her illness or injury, as well as any risks involved and potential outcomes for not receiving treatment or transport . Reasons given by the patient/DDM for refusing care/ transport and alternate plan for patient follow up if one has been stated . The presence or absence of any impairment such as drugs or alcohol . The patient/ DDM understanding that they may re-access 911 if needed . Signature of the patient/ DDM on the AMA form, or reason why signature was not obtained RELATED POLICIES/ PROCEDURES . Pediatric brief resolved unexplained event (BRUE) P14

Page 2 of 2 July 2018 COUNTY OF MARIN EMS GPC 4

DESTINATION GUIDELINES ALWAYS USE STANDARD PRECAUTIONS

INDICATION . To identify destination choices and appropriate facilities for patients in Marin County  PHYSICIAN CONSULT . Patient requests transport to a facility not capable of providing specific care for their needs CRITICAL INFORMATION . Destination choices: ▪ The destination for patients shall be based upon several factors including, but not limited to the clinical capabilities of the receiving hospital, the patient’s condition, and paramedic discretion. ▪ When the patient’s condition is unstable or life threatening, the patient should be transported to the time closest receiving facility: ▪ Patients with unmanageable airway . Uncontrolled external hemorrhage . CPR in progress . Patients requiring ALS but having no paramedic in attendance ▪ The following factors will be considered in determining patient destination: ▪ Patient condition ▪ Clinical capabilities of the receiving hospital ▪ Paramedic discretion ▪ Patient/family request ▪ Patient’s physician request or preference . Patients with return of spontaneous circulation post cardiac arrest will be transported to the nearest STEMI Receiving Center. . Burn patients, without other trauma mechanism, shall be transported by ground ambulance to the time closest emergency department. . Ventricular Assist Device patients: If patient is stable and complaint not related to VAD, transport per above guidelines. If VAD related: The patient may need to bypass local facilities and go to VAD center. If concerned about patient stability, refer to guidelines and request physician consult. . Prior to arrival, prehospital personnel must notify the receiving facility of any patient with a known history of violence, or behavior which may pose a risk to staff (disruptive, uncooperative, aggressive, unpredictable). . Marin County receiving facilities: . Marin General Hospital - Level III Trauma Center- Greenbrae . Neurological Emergencies- sudden, witnessed onset of coma or rapidly deteriorating GCS with high likelihood of intracranial bleed . Pregnant patients - 20 weeks or > with a complaint related to pregnancy . STEMI Receiving Center (SRC) . Primary Stroke Center . Kaiser Permanente San Rafael - Emergency Department Approved for Trauma (EDAT) - Terra Linda . STEMI Receiving Center (SRC) . Primary Stroke Center . Novato Community Hospital - Basic level receiving facility – Novato . Primary Stroke Center RELATED POLICIES/ PROCEDURES . Trauma Triage & Destination Guidelines Policy 4613 . STEMI Policy C 9 . Ambulance Diversion Policy 5400

Page 1 of 1 July 2018 COUNTY OF MARIN EMS GPC 4

. Adult and Pediatric Sexual Assault GPC 10 and P16 . Cerebrovascular Accident (Stroke) N 4 . Burns E4 and P12 . Ventricular Assist Device ATG 8

Page 2 of 1 July 2017 COUNTY OF MARIN EMS GPC 9

SUSPECTED ABUSE/NEGLECT/HUMAN TRAFFICKING ALWAYS USE STANDARD PRECAUTIONS

INDICATION . Identification and guidelines for reporting and treating suspected child abuse (persons < 18 years of age), dependent adults between the ages of 18 and 64 years (those with physical or mental limitations restricting their ability to carry out normal activities), domestic abuse (intimate partner violence, includes dating relationships), human trafficking, and elder adults (≥ 65 years) . Abuse is defined as harmful, wrongful, neglectful or improper treatment which may result in physical or mental injury.

TREATMENT . BLS/ ALS RMC . Treat and transport the patient per Destination Guidelines Policy GPC 4 . If patient or patient’s DDM (Designated Decision Maker) refuses transportation to the hospital and patient’s life is not in imminent danger: . Leave the scene, contact law enforcement, establish radio contact with the intended receiving hospital, describe situation including reasons for suspecting abuse. . If patient or patient’s DDM refuses transportation to the hospital and patient’s life is in imminent danger: . Stay on the scene, request local law enforcement agency to respond and place patient in protective custody. . If abuse is suspected in individuals other than the patient: . Follow the procedures stated above for imminent and/ or non-imminent danger. . Contact the local law enforcement agency and/or one of the following protective service agencies by phone within 24 hours and submit completed report within 36 hours of incidence: . Marin Children and Family Services Emergency Response, 415-473-7153. State of California Report of Suspected Child Abuse Report SS 8583 (see GPC 9A) . Marin County Adult Protective Services, 415-473-2774. State of California Report of Suspected Dependent Adult/ Elder Abuse Form SOC 341 (see GPC 9B)

CRITICAL INFORMATION . Common findings in victims of child abuse are as follows: . Suspicious fractures in children < 3 years . Multiple fractures . Unexplained bruising . Starvation/ dehydration . Common findings in parents/ guardian of abused child/ elder/ domestic partners/ human trafficking/ dependent adult are as follows: . Contradictory stories regarding patient’s injury . Evasive answers in questions . Anger directed towards or little concern for the patient . Drug use . Inability to locate guardian

RELATED POLICIES/ PROCEDURES . California Department of Social Services, Welfare & Institution Code (SS 15630, 15658 (a) (1), 8583 . Destination Guidelines Policy GPC 4

Page 1 of 1 July 2018 COUNTY OF MARIN EMS M1

NON-TRAUMATIC SHOCK ALWAYS USE STANDARD PRECAUTIONS

INDICATION . SBP < 90 and signs of shock, i.e., ALOC, severe vomiting, diarrhea, dark tarry stools, or vaginal bleeding

 PHYSICIAN CONSULT . If SBP < 80, obtain physician consult for Push-dose Epinephrine

CRITICAL INFORMATION . If rales present, see Acute Pulmonary Edema R 5

TREATMENT . ALS RMC; initiate two large bore IVs . Give 250 ml bolus. Repeat as needed up to two liters. .  If SBP < 80 obtain physician consult for Push-dose Epinephrine: . Mix 1mL Epinephrine (0.1mg/mL concentration) with 9mL Normal Saline in a 10mL syringe . Administer Push-dose Epinephrine 1mL IV/IO every 3-5 minutes . Titrate to maintain SBP >80mmHg . Monitor blood pressure every five minutes

DOCUMENTATION- ESSENTIAL ELEMENTS . 12-lead ECG finding . Vital signs pre/post fluid boluses . History of progression of illness

RELATED POLICIES/ PROCEDURES . Severe Nausea/Vomiting M 5

Page 1 of 1 July 2018 COUNTY OF MARIN EMS M 3

ALLERGIC REACTION & ANAPHYLAXIS ALS ALWAYS USE STANDARD PRECAUTIONS

INDICATION . Urticaria, wheezing or signs and/ or shock after exposure to common allergens (stings, drugs, nuts, seafood, medications)

 PHYSICIAN CONSULT . If SBP < 80, obtain physician consult for Push-dose Epinephrine

CRITICAL INFORMATION . Respiratory: wheezing, stridor, respiratory distress . Skin: itching, hives, rash . Symptoms indicating early shock such as nausea, weakness, anxiety . Past history of severe allergic reactions and hospitalizations TREATMENT . Mild: hives, rash . ALS RMC . Benadryl 50 mg IM/IV . Moderate: hives, rash, mild bronchospasm/ wheezes, normotensive . ALS RMC . Benadryl 50 mg IM/IV . Epinephrine 0.3mg IM (1mg/ml concentration); MR x 1 in 5 minutes . Albuterol 5 mg/6 ml NS via HHN, if indicated for respiratory symptoms . Severe (Anaphylaxis) . ALS RMC . Treat dysrhythmias per appropriate protocol . High flow O2; advanced airway as needed . Epinephrine 0.3mg IM (1mg/ml concentration); MR x 1 in 5 minutes . Large bore IV and fluid challenge 250-500 ml; MR .  If SBP < 80 obtain physician consult for Push-dose Epinephrine: . Mix 1mL Epinephrine (0.1mg/mL concentration) with 9mL Normal Saline in a 10mL syringe . Administer Push-dose Epinephrine 1mL IV/IO every 3-5 minutes . Titrate to maintain SBP >80mmHg . Monitor blood pressure every five minutes . If unresponsive/ no palpable BP /no palpable pulse: go to Cardiac Arrest Policy, GPC . Albuterol 5 mg/ 6ml NS via HHN, repeat if indicated . Benadryl 50 mg IV/IO/IM . If hypotension persists after two fluid challenges. Monitor BP every five (5) minutes. SPECIAL CONSIDERATION . Epinephrine may cause anxiety, tremors, palpitations, tachycardia, and headache in the elderly (> 50yrs), and may precipitate AMI, hypertensive crisis and dysrhythmias. . Edema of any of the soft structures of the upper airway may be lethal. Frequently assess and prepare for early intubation. DOCUMENTATION- ESSENTIAL ELEMENTS . Pulse oximetry . Level of distress (mild, moderate, severe) & associated respiratory distress findings

Page 1 of 1 July 2018 COUNTY OF MARIN EMS M 4

POISONS/DRUGS ALWAYS USE STANDARD PRECAUTIONS

INDICATION . Exposure to one or more toxic substances (ingestion, inhalation, or skin contact) CRITICAL INFORMATION . Avoid contamination of prehospital personnel . Identify substance/drug if possible and amount ingested . Time of ingestion and length of exposure . Risk of exposure to field providers; additional respiratory protection may be needed . Alert receiving facility of possible HAZMAT exposure TREATMENT . ALS RMC . Consider contacting Poison Control Center at 1(800) 404-4646 for additional information. If information from Poison Control is outside of scope of practice, contact the intended receiving facility for consult. . If level of consciousness diminishes, protect airway. . If skin or eye exposure, decontaminate patient, remove clothing, wash skin, continuous irrigation of eyes . Hydrocarbons or Petroleum distillates (kerosene, gasoline, lighter fluid, furniture polish): . Do not induce vomiting. . Transport immediately. . Caustic/ Corrosives (Ingestion of substances causing intra-oral burns, painful swallowing or inability to handle secretions): . Do not induce vomiting . Insecticides (organophosphates, carbonates; can cause cholinergic crisis characterized by bradycardia, increased salivation, lacrimation, sweating, muscle fasciculation, abdominal cramping, pinpoint pupils, incoherence or coma: . Atropine 2 mg IV slowly. Repeat 2-5 minutes until drying of secretions, reversal of bronchospasm and reversal of bradycardia. Maximum dose 10 mg. . If seizures, Midazolam (Versed) 1 mg IV slowly; MR in 3 minutes to maximum dose 0.05 mg/kg . For IN: 5 mg (2.5mg in each nostril) . For IM: 0.1mg/kg; MR x 1 in 10 minutes . Cyclic Antidepressants (frequently associated with respiratory depression, almost always tachycardic, widened QRS and ventricular arrhythmias generally indicate life-threatening ingestions). . In the presence of life-threatening dysrhythmias (hemodynamically significant supraventricular rhythms, ventricular dysrhythmias or QRS > 0.10): ▪ Hyperventilate if assisting ventilations or if intubated ▪ Sodium bicarbonate 1 mEq/kg IVP ▪ If seizures, Midazolam (Versed) 1 mg IV slowly; MR in 3 minutes to maximum dose 0.05 mg/kg . For IN: 5 mg (2.5 mg in each nostril) . For IM: 0.1mg/kg; MR x 1 in 10 minutes . Phenothiazine reactions (restlessness, muscle spasms of the neck, jaw, and back; oculogyric crisis, history of ingestion of phenothiazine, or unknown medication), give Benadryl 1mg/kg slow IVP to max of 50 mg. DOCUMENTATION- ESSENTIAL ELEMENTS . Obtain history of ingestion, substance, amount and time of ingestion, bring sample to hospital if possible . Vomiting prior to ED arrival RELATED POLICIES/ PROCEDURES . Seizures N2

Page 1 of 1 July 2018 COUNTY OF MARIN EMS M 6

SEPSIS ALWAYS USE STANDARD PRECAUTIONS

INDICATION Documented or suspected infection with at least TWO of the following: . HR > 90 . RR > 20 . SBP < 90 . Temperature >100.4 or <96 . AND ▪ ETCO2 ≤ 25 mmHG

 PHYSICIAN CONSULT . If SBP < 80, obtain physician consult for Push-dose Epinephrine

CRITICAL INFORMATION If rales present, see Acute Pulmonary Edema R5

TREATMENT . ALS RMC . ETCO2 . If patient meets above criteria, provide Sepsis Notification . Two large bore IVs or IOs (only one may be in antecubital fossa) . Administer 20cc/kg fluid bolus. May give up to two liters fluid. .  If SBP < 80 obtain physician consult for Push-dose Epinephrine: . Mix 1mL Epinephrine (0.1mg/mL concentration) with 9mL Normal Saline in a 10mL syringe . Administer Push-dose Epinephrine 1mL IV/IO every 3-5 minutes . Titrate to maintain SBP >80mmHg . Monitor blood pressure every five minutes

SPECIAL CONSIDERATION . Consider other causes of shock and treat as per specific protocols

DOCUMENTATION- ESSENTIAL ELEMENTS . Suspected infection . History of progression of illness . Full set of VS including temperature and ETCO2

Page 1 of 1 July 2018 COUNTY OF MARIN EMS N1

COMA/ ALTERED LEVEL OF CONSCIOUSNESS ALWAYS USE STANDARD PRECAUTIONS

INDICATION GCS < 15, etiology unclear (consider AEIOU TIPS); sudden onset of weakness, paralysis, confusion, speech disturbances, headache

TREATMENT . ALS RMC . Position patient with head elevated 30 degrees or left lateral recumbent if vomiting . If BG < 60 or immeasurable: . Dextrose 10% 25GM/250ml: . 125 ml bolus IV/IO over 10 minutes; recheck BG and repeat as needed . If BG < 60 or immeasurable and unable to start IV: . Glucagon 1 mg IM . Narcotic overdose: . Narcan 0.4-4.0 mg/kg, IV/IO/IM/IN . For IN administration: 2 mg (1 mg per nostril) . If respiratory depression persists, repeat as necessary. May need multiple doses.

SPECIAL CONSIDERATION . Consider indication for C-spine precautions; consider diabetes-related complications . If CVA suspected, see CVA/Stroke Policy N 4

DOCUMENTATION- ESSENTIAL ELEMENTS . Past medical history (i.e., seizures, diabetes) . Blood glucose level . Dosage of medications, times administered . Narcan administration by first responder, if known

RELATED POLICIES/ PROCEDURES . Intranasal Medications Midazolam(Versed) and Narcan Procedure ALS PR 7 . CVA / Stroke Policy N4

Page 1 of 1 July 2018 COUNTY OF MARIN EMS N 4

CEREBROVASCULAR ACCIDENT (STROKE) ALWAYS USE STANDARD PRECAUTIONS

INDICATION Sudden onset of weakness/paralysis, speech or gait disturbance TREATMENT . ALS RMC . Secure IV access (antecubital preferred) if patient meets Early Stroke Notification criteria . Elevate head of bed 20-30% elevation or place in left lateral decubitus . Provide Early Stroke Notification if all of the following are true: . Abnormal Cincinnati Prehospital Stroke Scale (CPSS) score . Last known well < 4.5 hours . Symptoms are most likely due to stroke and not a stroke mimic . Blood glucose level >60 . If the patient meets criteria for early notification . During radio report, provide patient identifying information – hospital medical record number if known and/or last name and DOB of patient . Rapidly transport to patient’s preferred Primary Stroke Center (PSC), as long as the estimated transport time is not > 15 minutes longer than the closest PSC. . Preferred PSC: patient’s preference or PSC with patient’s medical records . No preferred PSC: transport to the closest PSC . Notify family members/medical decision maker that their immediate presence at the hospital is critical for optimal care . Bring names and best phone numbers for the patient’s medical decision maker and whoever last saw the patient normal whenever possible . If high suspicion of rapidly progressive intracranial bleed (sudden, witnessed onset of coma or rapidly deteriorating GCS especially in setting of severe headache) transport to Marin General Hospital DOCUMENTATION- ESSENTIAL ELEMENTS . Criteria for Early Stroke Notification . Choose CVA as Primary Impression . Name and contact information for patient family member/decision maker and/or those who had last seen the patient normal (e.g., skilled nursing personnel) . Documentation of CPSS and hospital notification . Time last known well (document in military time). If time last known to be well is unknown or indeterminate, document and report . Blood glucose level . GCS . History of intracranial hemorrhage . Serious head injury within 2 months . Taking anticoagulant medications (e.g. Warfarin/ Coumadin, Pradaxa/Dabigatran, Xarelto/Rivaroxaban, Eliquis/Apixaban, Lovenox/Enoxaparin) . Improving neurological deficit

Page 1 of 2 July 2018 COUNTY OF MARIN EMS N 4

RELATED POLICIES/ PROCEDURES . Destination Guidelines GPC 4 . Prehospital / Hospital Contact Policy 7001 . Ambulance Diversion Policy 5400 . Coma/ALOC N1

Cincinnati Pre-Hospital Stroke Scale (CPSS) Facial Droop (the patient shows teeth or smiles) ___Normal: both sides of the face move equally ___Abnormal: Right side of the face does not move as well as the left ___Abnormal: Left side of the face does not move as well as the right

Arm Drift (the patient closes their eyes and extends both arms straight out for 10 seconds) ___Normal: both arms move the same, or both arms do not move at all ___Abnormal: Right arm either does not move, or drifts down compared to the left ___Abnormal: Left arm either does not move, or drifts down compared to the right

Speech (the patient repeats “The sky is blue in Cincinnati.” or another sentence) ___Normal: the patient says the correct words with no slurring of words ___Abnormal: the patient slurs words, says the wrong words, or is unable to speak

Page 2 of 2 July 2018 COUNTY OF MARIN EMS 0 2

IMMINENT DELIVERY (NORMAL) ALWAYS USE STANDARD PRECAUTIONS

INDICATION . Anticipated delivery as indicated by regular contractions, bloody show, low back pain, feels like bearing down, crowning of infant head

TREATMENT . ALS RMC . Provide reassurance to mother, provide instructions during delivery . Contact hospital and start IV NS TKO if time allows prior to delivery . As head is delivered, gently suction baby's mouth and nose keeping the head dependent . If the cord is around neck and can't be slipped over the head: . Double clamp and cut between clamps . Allow delivery, dry baby and keep warm, placing baby on mother's abdomen or breast . Delay cord clamping until 30-60 seconds after birth, then clamp and cut 6-8 inches from baby . Assess baby by Apgar score at 1 and 5 minutes . Allow delivery of placenta, save and bring to the hospital . If infant is premature (<36 weeks gestation), prepare for neonatal resuscitation and early transport

DOCUMENTATION- ESSENTIAL ELEMENTS . Determine gestational age, number of babies in utero . Gravida and Para . Apgar score at 1 and 5 minutes

APGAR SCORE

Sign 0 1 2

Heart rate (bpm) Absent Slow (<100) ≥100

Respirations Absent Slow, irregular Good, crying

Muscle tone Limp Some flexion Active motion

Reflex irritability No response Grimace Cough, sneeze, cry

Color Blue or pale Pink body with blue extremities Completely pink

RELATED POLICIES/ PROCEDURES . Destination Guidelines Policy GPC 4 . Neonatal Resuscitation P 2 . Obstetrical / Gynecology Emergencies BLS Procedure BLS PR 8

Page 1 of 1 October 2017 COUNTY OF MARIN EMS P1

PEDIATRIC CARDIAC ARREST ALWAYS USE STANDARD PRECAUTIONS

START CPR REFER TO P18 A • Give O2 via BVM 15:2 • Defibrillation • Attach monitor/defibrillator • Drug dosages • Prepare for immediate transport

CPR Ratios • Pedi One Rescuer – 30:2 • Pedi Two Rescuer – 15:2 Assess Rhythm BLS Airway Management • BVM is the preferred airway for pediatric patients • Avoid excessive ventilation. Deliver only the volume needed to VF/pVT Asystole/PEA make the chest rise • Place younger child in sniffing position for neutral airway CPR 2 min positioning CPR 2 min ● IO/IV access • IV/IO access ALS Airway Management • Epinephrine every 3-5 • Consider only if unable to ventilate min with BVM and patient is ≥12 years of age or height > length of the Rhythm color-coded resuscitation tape. Shockable? Rhythm • Laryngoscopy for ETT must occur No YES Shockable? with CPR in progress. Do not interrupt CPR for >10 seconds for YES tube placement No • May use VL (video laryngoscopy) if CPR 2 min CPR 2 min available • Epinephrine every 3-5 min • Treat reversible causes • May use King Airway if patient is • Consider advanced airway ≥12 years of age and 4 feet tall. • Use continuous ETCO2 to monitor CPR effectiveness and advanced airway placement. Rhythm • Maintain O2 sat 94-99% No Rhythm Shockable? • 1 breath every 6 seconds Shockable? Reversible causes: • Hypovolemia YES • Hypoxia • • Yes: follow VF/pVT Hydrogen Ion (acidosis) • Hypoglycemia • No: continue with • Hypo/Hyperkalemia Asystole/PEA CPR 2 min • Hypothermia • ROSC: Go to Policy C 10 • Amiodarone • Tension Pneumothorax • Treat reversible causes • Tamponade (cardiac) • Toxins • Thrombosis, pulmonary • Thrombosis, coronary

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July 2018 COUNTY OF MARIN EMS P2

Newborn Resuscitation ALWAYS USE STANDARD PRECAUTIONS

Critical Information: • Measure with color-coded resuscitation tape Birth • Compress at rate of 90 bpm. Use metronome or similar device • 3:1 compression/ventilation ratio w/2 two-person CPR • Change compressors every 2 minutes • For routine care, if mother stable then place infant on mother’s chest for skin-to-skin care • Peripheral cyanosis is considered a normal finding Crying and/or • Note if meconium present No Yes good muscle tone? • Delay cord clamping until 30-60 seconds after birth, and then clamp and cut 6-8 inches from baby • If cord is around neck and can’t be slipped over the head, double clamp and cut between claps Airway Management: • Ventilate at a rate of 60 breaths/min Dry, warm, stimulate: • Use two-person BLS airway management whenever Assess HR possible • Avoid excessive ventilation • If HR>100 but SpO2 not in target range or central cyanosis present, administer blow-by O2 at 10LPM HR <100? • Ventilation corrective actions No Yes M-mask adjustment R-reposition head S-suction mouth THEN nose O-open the mouth P-pressure increase PPV 15 sec A-alternative airway Monitor SpO2 Drug Therapy: Routine C are: • Epinephrine 0.01mg/kg (0.1mg/ml concentration) IV/IO q 3-5 minutes • Warm and maintain Fluid bolus 10ml/kg NS normal temperature, No HR <60? position airway, clear APGAR SCORE secretions if needed, Sign 0 1 2 dry, O2 prn, ongoing Heart rate Absent Slow (<100) ≥100 Yes evaluation (bpm) Respirations Absent Slow, irregular Good, crying Muscle tone Limp Some flexion Active motion Reflex No Grimace Cough, CPR 30 sec irritability response sneeze, cry Color Blue or Pink body with Completely pale blue pink extremities

Reversible Causes: • Hypovolemia ● Hypoglycemia No HR <60? • Hypoxia ● Hypothermia • Pneumothorax • Toxins (maternal drug exposure) Yes

SpO2 Normal Values After Birth (In Min) 1 min 60-65% CPR 1 min 2 min 65-70% 3 min 70-75% • Epinephrine q 3-5min 4 min 75-80% • Treat reversible causes 5 min 80-85%

10 min 85-95%

Page 1 of 1

July 2018 COUNTY OF MARIN EMS P 3

PEDIATRIC RESPIRATORY DISTRESS ALWAYS USE STANDARD PRECAUTIONS

INDICATION . Patient exhibits any of the following: . Wheezing . Stridor . Grunting . Nasal flaring . Apnea CRITICAL INFORMATION . Measure with color-coded resuscitation tape and treat according to the Pediatric Dosing Guide (P18A). Apply corresponding wrist band. . Neonate = birth to four weeks; infant = four weeks to 1 year; child = 1-14 years; adolescent = >14 years TREATMENT . ALS RMC . Position of comfort to maintain airway . Allow parent to administer oxygen if possible . Upper Airway/ Stridor: . Mild to moderate respiratory distress: 3ml NS via HHN . Moderate to severe respiratory distress: Epinephrine (1mg/1ml concentration) 5 mg in 5 ml via nebulizer . Lower Airway Obstruction/ Wheezing: . Albuterol 2.5 mg in 3 ml NS via HHN, mask, or bag-valve-mask; MR x 1 and . Ipratropium 500 mcg in 2.5 ml NS via HHN or bag-valve-mask . If response inadequate, Epinephrine IM 0.01mg/kg (1mg/1ml concentration); MR in 5 minutes; max. total dose 0.6 mg . Foreign Body Obstruction: . Attempt to clear airway: . < 1 year: 5 back blows and 5 chest thrusts . > 1 year: 5 abdominal thrusts . For foreign body airway obstruction refractory to above attempts, utilize laryngoscopy to visualize and remove foreign body with Magill forceps . Respiratory failure/ apnea/ complete obstruction: . Attempt positive pressure ventilation via bag-valve-mask . ET tube placement approved for patients who are 12yrs of age or older or height greater than the length of the color-coded resuscitation tape. . King Airway approved as a rescue airway for patients who are 12 years of age or older or 4 feet tall SPECIAL CONSIDERATIONS . Assess key history factors: recent hospitalizations, asthma, allergies, croup, and medication usage

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July 2018 COUNTY OF MARIN EMS P 4

PEDIATRIC BRADYCARDIA ALWAYS USE STANDARD PRECAUTIONS

INDICATION . HR< 60 causing cardio-respiratory compromise

CRITICAL INFORMATION . Treat according to length based color-coded resuscitation tape. Apply corresponding wrist band. . Neonate = birth to four weeks; infant = four weeks to 1 year; child = 1-14 years; adolescent = >14 years . History of exposure to substances or medications

TREATMENT . ALS RMC . 12-lead ECG . Obtain IV/IO access . If responsive and no signs of shock . Monitor and transport . If shock present: . Assist respirations with BVM prn . CPR if < 8 years and HR < 60 after effective ventilations . Epinephrine 0.01 mg/kg IV/IO (0.1mg/ml concentration); MR q 3-5 min. . If first degree block or Mobitz type I, Atropine 0.02 mg/kg IV/IO (max single dose: 0.5 mg; minimum single dose: 0.1 mg); MR x 1 . ET tube placement approved for patients who are 12 years of age or older or height greater than the length of the color-coded resuscitation tape. . King Airway approved as a rescue airway for patients who are 12 years of age or older and 4 feet tall . Consider cardiac pacing if no response to above treatment.

SPECIAL CONSIDERATIONS . Consider and treat possible contributing factors: . Hypovolemia . Toxins (overdoses) . Hypoxemia . Tamponade, cardiac . Hydrogen ion (acidosis) . Tension pneumothorax . Hypo/Hyperkalemia . Thrombosis (coronary / pulmonary) . Hypoglycemia . Trauma . Hypothermia

RELATED POLICIES/ PROCEDURES . External Cardiac Pacing Procedure ALS PR 11

Page 1 of 1 July 2018 COUNTY OF MARIN EMS P 8

PEDIATRIC ALLERGIC REACTION ALWAYS USE STANDARD PRECAUTIONS

INDICATION . Exposure to allergens causing airway, breathing and/or circulatory impairment

CRITICAL INFORMATION . Treat according to length based color-coded resuscitation tape and in conjunction with the Pediatric Dosing Guide (P18A). Apply corresponding wrist band. . Neonate = birth to four weeks; infant = four weeks to 1 year; child = 1-14 years; adolescent = >14 years . Exposure to common allergens (stings, drugs, nuts, seafood, meds), prior allergic reactions . Presence of respiratory symptoms (wheezing, stridor)

TREATMENT . ALS RMC . Mild (hives, rash) . Benadryl 1mg/kg IM (MR in 10 minutes; max. dose 50 mg) . Moderate / Severe . Epinephrine 0.01mg/kg IM (1mg/ml concentration); MR in 5 minutes; max. total dose is 0.6 mg . Benadryl 1mg/kg IM/IV/IO (MR in 10 minutes; max. dose 50 mg) . Albuterol 2.5 mg/3 ml NS HHN if bronchospasms present; MR X1 if no improvement . If hypotensive, fluid challenge NS 20 ml/kg IV/IO, MR . If unresponsive/ no palpable BP /no palpable pulse: go to Pediatric Cardiac Arrest Policy, P1

DOCUMENTATION- ESSENTIAL ELEMENTS . Allergen if known

Page 1 of 1 July 2018 COUNTY OF MARIN EMS P 11

PEDIATRIC TOXIC EXPOSURES ALWAYS USE STANDARD PRECAUTIONS

INDICATION . Probable ingestion and/or exposure to one or more toxic substances, including alcohol and medications  PHYSICIAN CONSULT . Calcium Channel Blocker, Beta-Blockers, and Tricyclic overdoses CRITICAL INFORMATION . Treat according to length based color-coded resuscitation tape. Apply corresponding wrist band. . Neonate = birth to four weeks; infant = four weeks to 1 year; child = 1-14 years; adolescent = >14 years . Avoid contamination of prehospital personnel . Identify substance/drug if possible and amount ingested; bring to hospital if appropriate . Time of ingestion and length of exposure . Risk of exposure to field providers – additional respiratory protection may be needed . Alert receiving facility of possible HAZMAT exposure TREATMENT . ALS RMC . Fluid bolus NS 20 ml/kg IV/IO as indicated . If suspected opiate overdose in patient > four weeks, administer Narcan 0.1 mg/kg IV/IO/IM/IN prior to advanced airway . Hydrocarbons or Petroleum Distillates . Do not induce vomiting . Transport immediately . Calcium Channel Blockers / Tricyclics / Beta-Blockers . Transport immediately .  Physician consultation for additional treatments (i.e., Calcium Chloride, Sodium Bicarb) . Caustics/Corrosives . Do not induce vomiting . Insecticides (organophosphates, carbonates; can cause cholinergic crisis characterized by bradycardia, increased salivation, lacramation, sweating, muscle fasciculation, abdominal cramping, pinpoint pupils, incoherence or coma): . Decontaminate patient and alert hospital of possible HAZMAT exposure . Atropine 0.05 mg/kg IV/IO slowly every 5-10 minutes until symptoms resolve. . If seizures, Midazolam (Versed): • IV / IO: 0.05 mg/kg (maximum 1 mg per dose). May repeat every 3 minutes until seizure stops and/or total dose of 5 mg is reached. • IM: 0.1 mg/kg; May repeat x 1 in 10 minutes if still seizing. • IN: 0.2 mg/kg (split dose in half for each nostril). Maximum dose = 5 mg . Phenothiazine Reactions . Benadryl 1 mg/kg IM/IV/IO to max. of 50 mg

SPECIAL CONSIDERATION . Early contact with Poison Control Center

Page 1 of 2 July 2018 COUNTY OF MARIN EMS P 11

DOCUMENTATION- ESSENTIAL ELEMENTS . Toxic substance identification . Approximate time of exposure / ingestion

RELATED POLICIES/ PROCEDURES . Intranasal Medications Midazolam(Versed) and Narcan ALS PR 7 . Pediatric Seizures P 9 . Pediatric Dosing Guide P18A

Page 2 of 2 October 2017 COUNTY OF MARIN EMS P 12

PEDIATRIC BURNS ALWAYS USE STANDARD PRECAUTIONS

INDICATION Damage to the skin or an inhalation injury caused by contact with fire, heat, electricity, or caustic material. CRITICAL INFORMATION . Measure with color-coded resuscitation tape and treat per the Pediatric Dosing Guide (P18A). Apply corresponding wrist band (do not apply over burned areas). Neonate = birth to four weeks; infant = four weeks to 1 year; child = 1-14 years; Adolescent = >14 years . Perform frequent airway assessments for inhalation injury, i.e., facial or chest burns, singed nasal hairs, soot/blisters in oropharynx. . Burns with trauma mechanism will be transported per the Marin County Trauma Triage Tool TREATMENT . Remove patient to safe area and stop the burning process . Remove offending agent, involved clothing and restrictive jewelry (unless adhered to skin) . Brush away dry chemicals . Flush with copious amounts of tepid water x 10-15 minutes to stop burning process or to decontaminate . Keep patient warm . Cover injuries with clean, dry linen . ALS RMC . High-flow oxygen for inhalation injuries, facial or chest burns . If wheezing, consider bronchodilator therapy Albuterol 2.5 mg HHN; MR x 1 . IV NS at TKO; do not administer fluid bolus . Keep patient warm to avoid hypothermia . Provide pain management as soon as possible . DOCUMENTATION- ESSENTIAL ELEMENTS . Estimated percentage of BSA affected . Airway assessments RELATED POLICIES/ PROCEDURES . Pediatric Pain Management P15 . Pediatric Shock P7 . Pediatric Dosing Guide P18A . Destination Guidelines GPC4 . Marin County Trauma Triage Tool, 4613a . Pediatric Respiratory Distress P3

Page 1 of 1 July 2018 COUNTY OF MARIN EMS P 15

PEDIATRIC PAIN MANAGEMENT ALWAYS USE STANDARD PRECAUTIONS

INDICATION . To provide analgesia for pediatric patients (6 months to 14 years or up to 45 kg), especially if anticipated extrication, movement, or transportation would exacerbate the patient’s level of pain

 PHYSICIAN CONSULT . Patients less than 6 months of age . Patients with head, chest, or abdominal trauma; decreased respirations; ALOC (GCS < 15) . Additional doses of narcotic after initial doses administered

CRITICAL INFORMATION . Measure with color-coded resuscitation tape and treat according to the Pediatric Dosing Guide (P18A). Apply corresponding wrist band. . Origin of pain (examples: isolated extremity trauma, chronic medical condition, burns, abdominal pain, multi-system trauma) . Mechanism of injury . Approximate time of onset . Complaints or obvious signs of discomfort . Use Visual Analog Scale (0-10) or Wong/Baker Faces Pain Rating Scale (see Appendix A). Express results as a fraction (i.e. 2/10 or 7/10).

TREATMENT . ALS RMC . Morphine Sulfate 0.1mg/kg IV/IO/IM; MR x 2 in 15 minutes following IV/IO administration, or in 30 minutes following IM administration.  Physician consult for additional doses OR . Fentanyl 1 mcg/kg slow IV/IO/IN; MR q 5 minutes; max dose 3 mcg/kg; for IN divide dose evenly between nares . Have Narcan available . If nausea/vomiting, consider Ondansetron (Zofran ©) ▪ Ages 2-3: 2mg ODT or slow IV/IO over 30 seconds; MR x1 in 10 minutes ▪ Age ≥4: 4mg ODT or slow IV/IO over 30 seconds; MR x 1 in 10 minutes

DOCUMENTATION- ESSENTIAL ELEMENTS . Initial and post treatment pain score, expressed in a measurable form (i.e. 7/10) . Interventions used for pain management (i.e. ice pack, splint, Morphine Sulfate or Fentanyl) . Reassessments made after interventions . Initial and post treatment vital signs (including GCS in patients with ALOC) . Physician consult if required

Page 1 of 1 July 2018 COUNTY OF MARIN EMS P 18

PEDIATRIC MEDICATIONS AUTHORIZED/ STANDARD INITIAL DOSE

DRUG CONCENTRATION STANDARD DOSE

Tachycardia Poor Perfusion: 0.1mg/kg; Adenosine 6 mg/ 2 ml max. first dose 6mg. MR x 1 (double (Adenocard) the dose); max. dose 12mg. (Rapid IV/IO push, each dose followed by 5 ml NS flush).

Albuterol 2.5 mg/ 3 ml NS 2.5 mg/ 3ml NS Pulseless Arrest: 5 mg/ kg IV/ IO Amiodarone 150 mg/ 3 ml followed by or diluted in 20-30 ml NS. Maximum single dose 300 mg.  Tachycardia with poor perfusion: 5mg/kg IV/IO over 20-60 min. Bradycardia: 0.02 mg/kg IV/ IO Atropine 1 mg/ 10 ml (minimum dose 0.1 mg.; single max. dose 0.5mg). MR X 1. Organophosphate Poisoning: 0.05 mg/kg IV/IO; MR q 5-10 min. max. dose 4mg or until relief of symptoms

Dextrose 10% D10% ALOC (Neonate): 2 ml/ kg IV/IO ALOC (>Neonate): 5 ml/ kg IV/IO

Diphenhydramine 50 mg/ 1 ml “or” 1 mg/ kg IV/IO/IM (Benadryl) 50 mg/ 10 ml IV/ IO max. dose 25 mg/ min. IM max. dose, 50 mg. Allergic Reaction moderate/ severe/ Epinephrine 1 mg/ 1ml anaphylaxis: 0.01 mg/ kg IM (0.01ml/ kg). Max. dose of 0.6 mg (0.6 ml). EpiPen Jr.® 0.15mg (or EpiPen Jr®.; repeat as needed in 5 min. equivalent) Upper Airway/ Stridor: 5mg in 5ml via nebulizer Bradycardia: 0.01mg/ kg (0.1ml/kg) Epinephrine 1 mg/ 10 ml IV/ IO. or Cardiac Arrest: 0.01 mg/kg (0.1ml/kg) 0.1mg/ml IV/ IO

Page 1 of 2 July 2018 COUNTY OF MARIN EMS P 18

Fentanyl 100 mcg/2 ml Pain Management: 1 mcg/kg slow IV/IO/IN; MR q 5 minutes; max dose 3 mcg/kg; for IN divide dose evenly between nares

Glucagon 1 mg/ 1 ml Hypoglycemia/Beta Blocker OD: 0.03 mg/kg IM (max. dose 1 mg)

Ipratropium 500 mcg per unit dose Unit dose (Atrovent) (2.5 ml)

Lidocaine 2% 20 mg/1 ml IO insertion for pts >3kg: (preservative free) Infuse 0.5mg/kg slowly (up to a maximum dose of 40mg). May repeat as needed x 1 using ½ of initial bolus. Cardioversion: 0.05 mg/kg slow Midazolam 2 mg/ 2ml IV/IO. Max. initial dose 1 mg (Versed) IN: 5 mg/1 ml Seizure (see policy for specifics): IV/IO=0.05 mg/kg; MR q 3’ (Max=5mg) IM=0.1mg/kg; MR in 10 minutes x1 IN= 0.2mg/kg; Max.= 5 mg. Pain Management: 0.1mg/ kg (0.1ml/ kg) Morphine Sulfate 10 mg/ 10 ml slow IV/ IO/ IM. MR X 1 in 15 min. if IV/ 10 mg/ 1 ml IO or 30 min if IM. Burns: 0.1 mg/kg IV/IO/IM in incremental doses up to 0.3mg/kg

Naloxone 2mg/2ml Suspected OD in non-neonate: 0.1 mg/ (Narcan) kg (0.25 ml/ kg) IV/ IO/ IM Ondansetron (Zofran) 4 mg Patients ≥ 4 yrs: 4 mg ODT or slow IV over 30 seconds Patients 2-4yrs: 2mg ODT or slow IV over 30 seconds. Tricyclic Antidepressant OD with Sodium Bicarbonate 50 mEq/ 50 ml significant dysrhythmias: 1mEq/ kg IV/ IO

NOTE: If the above concentrations become unavailable, providers may use alternate available concentrations or packaging.

Page 2 of 2 P18A MARIN COUNTY EMS PEDIATRIC DOSING GUIDE (PAGE 1) JULY 1,2018 Grey Pink Red Purple Yellow White Blue Orange Green kg 3 - 5 6 - 7 8 - 9 10 - 11 12 - 14 15 - 18 19 - 23 24 - 29 30 - 36 WEIGHT lbs 6 - 11 13 - 15 18 - 20 22 - 24 27 - 31 33 - 40 42 - 51 53 - 64 66 - 80 NS Fluid Bolus 60, 80, 100 ml 130 ml 170 ml 210 ml 260 ml 325 ml 420 ml 530 ml 660 ml Blade size for foreign body removal 0 0 1 1 2 2 2 2 3 1st 6 10J 13J 17J 20J 26J 33J 40J 53J 66J DEFIBRILLATION 2 4 J/kg 2nd 12 20J 26J 34J 40J 52J 66J 80J 106J 130J 1st 3 - 5J 7J 9J 10J 13J 17J 20J 27J 33J CARDIOVERSION 0.5 1 J/kg, 2 J/kg 2nd 6 - 10J 13J 17J 20J 26J 34J 40J 54J 66J ADENOSINE 0.1 mg/kg RIVP w/ 10ml NS flush 0.3 - 0.5 mg 0.7 mg 0.9 mg 1 mg 1.3 mg 1.7 mg 2.1 mg 2.7 mg 3.3 mg 1st MR x 1 double the dose 0.14 ml 0.2 ml 0.3 ml 0.3 ml 0.4 ml 0.6 ml 0.7 ml 0.9 ml 1.1 ml Max 1st dose 6 mg, Max 2nd dose 12 mg 0.6 - 1 mg 1.3 mg 1.7 mg 2.1 mg 2.6 mg 3.4 mg 4.2 mg 5.4 mg 6.6 mg 2nd Concentration: 6 mg/2 ml (3 mg/ml) 0.25 ml 0.4 ml 0.6 ml 0.7 ml 0.9 ml 1.1 ml 1.4 ml 1.8 ml 2.2 ml ALBUTEROL Unit Dose 2.5 mg/3 ml AMIODARONE (Pulseless Arrest) 5 mg/kg IV/IO followed by 20 ml NS flush. MR x 2 refractory rhythm 15 25 mg 32 mg 42 mg 50 mg 65 mg 80 mg 105 mg 130 mg 165 mg Max single dose 300 mg Concentration: 150 mg/3 ml (50 mg/ml) 0.3 0.5 ml 0.6 ml 0.8 ml 1 ml 1.3 ml 1.6 ml 2.1 ml 2.6 ml 3.3 ml ATROPINE (Bradycardia) 0.02 mg/kg IV/IO MR x 1 in 3 - 5 minutes 0.1 mg 0.1 mg 0.2 mg 0.2 mg 0.3 mg 0.3 mg 0.4 mg 0.5 mg 0.5 mg Min dose 0.1 mg, Max single dose 0.5 mg Concentration: 1 mg/10 ml (0.1 mg/ml) 1 ml 1 ml 2 ml 2 ml 3 ml 3 ml 4 ml 5 ml 5 ml ATROPINE (Organophosphate Poisoning) 0.15 0.25 mg 0.3 mg 0.4 mg 0.5 mg 0.7 mg 0.8 mg 1 mg 1.3 mg 1.7 mg 0.05 mg/kg IV/IO MR q 5 - 10 mins until symptoms resolve Concentration: (preload) 1 mg/10 ml (0.1 mg/ml) 1.5 - 2.5 ml 3 ml 4 ml 5 ml 7 ml 8 ml 11 ml 13 ml 17 ml Concentration: (multi dose vial) 0.4 mg/ml 0.4 - 0.6 ml 0.8 ml 1.1 ml 1.3 ml 1.6 ml 2.1 ml 2.6 ml 3.3 ml 4.1 ml BENADRYL 1 mg/kg IM/IV/IO 4 mg 6.5 mg 8.5 mg 10.5 mg 13 mg 16.5 mg 21 mg 26 mg 33 mg IV/IO Max dose 25 mg; IM Max dose 50 mg Concentration: 50 mg/ml 0.08 ml 0.1 ml 0.2 ml 0.2 ml 0.3 ml 0.3 ml 0.4 ml 0.5 ml 0.7 ml DEXTROSE 10% 8 ml 13 ml 42 ml 53 ml 65 ml 83 ml 105 ml 125 ml 125 ml Give over 10 minutes 2 ml/kg IV/IO 5 ml/kg IV/IO Max dose 125 ml EPINEPHRINE (Cardiac Arrest/Bradycardia) 0.03 0.05 mg 0.07 mg 0.09 mg 0.1 mg 0.1 mg 0.2 mg 0.2 mg 0.3 mg 0.3 mg 0.01 mg/kg IV/IO MR q 3 -5 mins Concentration: 1 mg/10 ml 0.3 - 0.5 ml 0.7 ml 0.9 ml 1 ml 1 ml 2 ml 2 ml 3 ml 3 ml EPINEPHRINE (Allergic Reaction & Asthma) 0.03 - 0.05 mg 0.1 mg 0.1 mg 0.1 mg 0.1 mg 0.2 mg 0.2 mg 0.3 mg 0.3 mg 0.01 mg/kg IM; MRx1 in 5 minutes Total max dose 0.6 mg Concentration: 1 mg/1 ml 0.03 - 0.05 ml 0.1 ml 0.1 ml 0.1 ml 0.1 ml 0.2 ml 0.2 ml 0.3 ml 0.3 ml EPINEPHRINE "Nebulized Epi" (Upper Airway/Stridor) 5 mg (5 ml) Via Nebulizer (1mg/1 ml concentration) P18A MARIN COUNTY EMS PEDIATRIC DOSING GUIDE (PAGE 2) draft May 2018 Grey Pink Red Purple Yellow White Blue Orange Green kg 3-5 6 - 7 8 - 9 10 - 11 12 - 14 15 - 18 19 - 22 24 - 28 30 - 36 WEIGHT lbs 6 - 11 13 - 15 18 - 20 22 - 24 27 - 31 33 - 40 42 - 51 53 - 64 66 - 80 FENTANYL (Pain) 1 mcg/kg IV/IO/IM/IN MR q 5 min 4 mcg 6.5 mcg 8.5 mcg 10.5 mcg 13.5 mcg 16.5 mcg 21 mcg 26.5 mcg 33 mcg for IN split dose evenly per nostril Max dose 3 mcg/kg; Concentration: 1 mg/1 ml 0.08 ml 0.13 ml 0.17 ml 0.21 ml 0.27 ml 0.33 ml 0.42 ml 0.53 ml 0.66 ml GLUCAGON (hypoglycemia/Beta blocker OD) 0.03 mg/kg IM 0.09 - 0.15 mg 0.2 mg 0.3 mg 0.3 mg 0.4 mg 0.5 mg 0.6 mg 0.8 mg 1 mg MR x 2 q 15 minutes Max dose 1 mg Concentration: 1 mg/1 ml 0.1 - 0.15 ml 0.2 ml 0.3 ml 0.3 ml 0.4 ml 0.5 ml 0.6 ml 0.8 ml 1 ml IPRATROPIUM - Atrovent 500 mcg / 2.5 ml 500 mcg per unit dose (2.5 ml) 1.5 - 2.5 mg 3 mg 4 mg 5 mg 6 mg 8 mg 10 mg 13 mg 17 mg LIDOCAINE 2% - (IO Insertion) 1st 0.06 - 0.13 ml 0.2 ml 0.2 ml 0.3 ml 0.3 ml 0.4 ml 0.5 ml 0.7 ml 0.8 ml 0.5 mg/kg slow IO Max dose 40 mg 0.75 - 1.25 mg 2 mg 2 mg 3 mg 3 mg 4 mg 5 mg 6 mg 8 mg 2nd Concentration: 20mg/1ml .04 - .06 ml 0.1 ml 0.1 ml 0.2 ml 0.2 ml 0.2 ml 0.3 ml 0.4 ml 0.4 ml MIDAZOLAM - Versed (Seizure & Cardioversion) 0.05 mg/kg slow IV/IO 0.15 - 0.25 mg 0.3 mg 0.4 mg 0.5 mg 0.7 mg 0.8 mg 1 mg 1 mg 1 mg Max 1st dose 1 mg, Total max dose 5 mg Concentration: 2mg/2ml (1 mg/ml) 0.15 - 0.25 ml 0.3 ml 0.4 ml 0.5 ml 0.7 ml 0.8 ml 1 ml 1 ml 1 ml MIDAZOLAM - Versed (Seizure) IN: 0.2 mg/kg 0.6 - 1.0 mg 1.3 mg 1.7 mg 2.1 mg 2.6 mg 3.3 mg 4.2 mg 5 mg 5 mg Split dose equally per nostril Max dose 5 mg Concentration: 5 mg/ml 0.12‐ - 0.2 ml 0.3 ml 0.3 ml 0.4 ml 0.5 ml 0.7 ml 0.8 ml 1 ml 1 ml MIDAZOLAM-Versed (Seizure) IM: 0.1 mg/kg 0.3 0.5 mg 0.7 mg 0.9 mg 1 mg 1.3 mg 1.7 mg 2.1 mg 2.6 mg 3.3 mg MR x 1 in 10 minutes Concentration: 5 mg/ml 0.06 - 0.1 ml 0.1 ml 0.2 ml 0.2 ml 0.3 ml 0.3 ml 0.4 ml 0.5 ml 0.7 ml MORPHINE (Pain/Burns) 0.1 mg/kg IV/IO/IM 0.3 0.5 mg 0.7 mg 0.9 mg 1 mg 1.3 mg 1.7 mg 2.1 mg 2.6 mg 3.3 mg MR x 2 in 15 minutes (IV/IO) or in 30 minutes (IM) Concentration: 10 mg/1 ml 0.03 -0.05 ml 0.1 ml 0.1 ml 0.1 ml 0.1 ml 0.2 ml 0.2 ml 0.3 ml 0.3 ml NARCAN- Naloxone 0.3 0.5 mg 0.7 mg 0.9 mg 1 mg 1.3 mg 1.7 mg 2 mg 2 mg 2 mg 0.1 mg/kg IV/IO/IM MR q 5 minutes up to 2 mg Concentration: 2 mg/2 ml 0.3 - 0.5 ml 0.7 ml 0.9 ml 1 ml 1.3 ml 1.7 ml 2 ml 2 ml 2 ml SODIUM BICARBONATE 1 mEq/kg IV/IO 3 5 mEq 6.5 mEq 8.5 mEq 10 mEq 13 mEq 17 mEq 21 mEq 26 mEq 33 mEq Concentration: 1 mEq/ml 3 5 ml 6.5 ml 8.5 ml 10 ml 13 ml 17 ml 21 ml 26 ml 33 ml ZOFRAN - Ondansetron Age 2 - 3 years: Give 2 mg ODT or slow IVP Age 4 and up: Give 4 mg ODT or slow IVP Concentration: 4 mg tab ODT, 4 mg/2 ml IV July 2018 COUNTY OF MARIN EMS R 1

RESPIRATORY ARREST ALWAYS USE STANDARD PRECAUTIONS

INDICATION . Absence of spontaneous ventilations; pulse present

TREATMENT . ALS RMC . If suspected narcotic overdose: . Assist breathing with BVM (do not insert advanced airway before Narcan) . Administer Narcan 0.4-4.0 mg/kg, IV/IO/IM/IN . For IN administration: 2 mg (1 mg per nostril) . If respiratory depression persists, repeat above doses q 2-3 minutes until patient responds. May need multiple doses.

RELATED POLICIES/ PROCEDURES . Intranasal Medication Midazolam (Versed) & Narcan Procedure ALS PR 7

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ACUTE RESPIRATORY DISTRESS ALWAYS USE STANDARD PRECAUTIONS

INDICATIONS . Increased respiratory rate or sensation of difficulty breathing that is not clearly due to the clinical entities specified in other guidelines. Symptoms may be due to pneumonia, inhalation of toxic substances, pulmonary embolus.

TREATMENT . ALS RMC . Position of comfort . If absent or diminished breath sounds due to severe bronchospasm, refer to Bronchospasm/Asthma/COPD, R4 . Consider CPAP with decreased oxygen saturation

DOCUMENTATION- ESSENTIAL ELEMENTS . Pulse oximetry

RELATED POLICIES/ PROCEDURES . CPAP Procedure ALS PR 13 . Bronchospasm/Asthma/COPD R4 . Toxic Inhalation R7

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BRONCHOSPASM/ ASTHMA/ COPD ALS ALWAYS USE STANDARD PRECAUTIONS

INDICATION . Acute or progressive shortness of breath, chest discomfort, wheezing, cyanosis

TREATMENT . ALS RMC . Mild to moderate (alert, may be unable to speak full sentences, limited accessory muscle use). . Albuterol 5 mg in 6 ml NS HHN, MR if necessary . Ipratropium (Atrovent) 500 mcg (2.5 ml) HHN . Severe (altered mental status, minimal air movement, inability to speak, significant desaturation <90%, cyanosis) . Consider CPAP . If Albuterol and Atrovent not effective: . Epinephrine 0.3mg IM (1mg/ml concentration); MR once in 5 minutes

SPECIAL CONSIDERATION . Do not repeat Albuterol / Ipratropium (Atrovent) if significant tachycardia or chest pain. . Epinephrine may cause anxiety, tremor, palpitation, tachycardia, hypertension and headache, and may precipitate AMI, hypertensive crisis and intracranial hemorrhage. . Consider use of patient actuated nebulizer with prolonged scene times and/or transport times over 10 minutes. . Suspect carbon monoxide in cases of exposure to fire or smoke in confined areas; pulse oximetry in these settings is not an accurate measure of respiratory status

DOCUMENTATION- ESSENTIAL ELEMENTS . Wheezing, decreased lung sounds . SAO2

RELATED POLICIES/ PROCEDURES . CPAP Procedure ALS PR 13

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ACUTE PULMONARY EDEMA ALWAYS USE STANDARD PRECAUTIONS

INDICATION . Acute onset of respiratory difficulty; associated with the following signs or symptoms: . Rales . Hypertension . Tachypnea . Diaphoresis . Chest discomfort . History of cardiac disease . Occasional wheezes . Near drowning

 PHYSICIAN CONSULT . Opioid administration . If SBP < 80, obtain physician consult for Push-dose Epinephrine

TREATMENT . ALS RMC . If tolerated, position patient in a sitting position, with legs dependent. . 12-lead ECG if available . If SBP > 100: . Apply CPAP . Nitroglycerin 0.4 mg SL; MR q 5 if SBP > 100 . If SBP < 100, consider NS 250-500 ml IV fluid challenge .  If SBP < 80 obtain physician consult for Push-dose Epinephrine: . Mix 1mL Epinephrine (0.1mg/mL concentration) with 9mL Normal Saline in a 10mL syringe . Administer Push-dose Epinephrine 1mL IV/IO every 3-5 minutes . Titrate to maintain a SBP >80mmHg . Monitor blood pressure every five minutes

SPECIAL CONSIDERATION . Do not give NTG if patient has taken erectile dysfunction medication (ED) within the previous 24 hours for Levitra/Viagra or 36 hours for Cialis.

DOCUMENTATION- ESSENTIAL ELEMENTS . SpO2

RELATED POLICIES/ PROCEDURES . CPAP Procedure ALS PR 13

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