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hƉĚĂƚĞĚ11/07/2019

ǇƉƌĞƐƐƌĞĞŬD^ System Policies and Treatment Guidelines

1 INTRODUCTION Revised 8/2016 Approved: Levon Vartanian, MD

Table of Contents Introduction ...... 8 General Protocols/Treatment Guidelines ...... 9 Approval of Protocols ...... 12 Definition of Terms ...... 13 Reference Values ...... 17 Delegation of Medical Practice ...... 18 Clinical Policies ...... 24 Air Medical Utilization ...... 25 Child/Elder Abuse Recognition and Reporting ...... 27 Criteria for Death/Withholding Resuscitation ...... 29 Do Not Resuscitate (DNR) Orders...... 30 Documentation Guidelines ...... 31 Field Termination ...... 35 Fire Standby Response/Fire Rehab ...... 36 Inter-facility Transfers ...... 37 Paramedic Initiated Referral ...... 38 Patient Determination/Non-Transportation ...... 42 Physician on Scene ...... 46 Quality Management Process ...... 47 Safe Transport of Pediatric Patients ...... 48 Self-Reporting of Clinical Incidents...... 49 Operational Policies...... 50 CCEMS First Responder ...... 51 Child Lockedin aVehicle ...... 54 Communications ...... 55 Controlled Medication Management ...... 57 Crime Scene Management ...... 61 Firearms Policy ...... 62 Forcible Entry ...... 63 Mandatory Supervisor Notification ...... 64 Partner Agencies First Responders ...... 65 Posting Plan ...... 66 Readiness for Response ...... 69 Scene Safety ...... 70 Span of Control ...... 73 Ambulance Staging ...... 74 Use of Lights and Sirens ...... 80 Transport Destination Determination ...... 81 General Transport Guidelines ...... 82 Pediatric Patients ...... 83

Cypress Creek EMS System Policies and Treatment Guidelines

2 INTRODUCTION Revised 8/2016 Approved: Levon Vartanian, MD

Post-Cardiac Arrest ...... 84 Trauma and Burns ...... 85 STEMI ...... 87 Stroke ...... 88 Adult Medical ...... 89 Cardiac Arrest ...... 90 Ventricular Fibrillation/Pulseless Ventricular Tachycardia ...... 92 Asystole/Pulseless Electrical Activity ...... 94 Post-Resuscitation Care ...... 95 Narrow Complex Tachycardia ...... 97 Wide Complex Tachycardia/Ventricular Ectopy ...... 98 Bradycardia ...... 99 Chest Pain: Cardiac/STEMI ...... 100 Respiratory Distress: CHF/Pulmonary Edema ...... 102 Respiratory Distress: COPD/Asthma ...... 103 Deceased Person (DOS) ...... 104 Abdominal Pain ...... 106 Allergic Reactions/Anaphylaxis ...... 108 Altered Mental Status ...... 110 Suspected Stroke ...... 111 Seizure ...... 113 Syncope ...... 114 Diabetic Emergency ...... 115 Dialysis/Renal Failure ...... 116 Adrenal Crisis ...... 117 Behavioral/Mental Health ...... 118 Excited Delirium ...... 121 Hypertension ...... 125 Pregnancy and Obstetrical Emergency ...... 126 Sickle Cell Crisis...... 129 Hypotension/Shock ...... 130 Sepsis ...... 133 Overdose/Poisoning ...... 135 Vomiting and Diarrhea ...... 138 Fever & Infectious Disease ...... 139 Epistaxis ...... 140 Dental Problems ...... 141 Emergencies involving Central Lines ...... 142 Tracheostomies and Ventilators ...... 144 Ventricular Assist Devices (LVADs) ...... 145 Pediatric Medical ...... 147 Newborn Resuscitation ...... 148

Cypress Creek EMS System Policies and Treatment Guidelines

3 INTRODUCTION Revised 8/2016 Approved: Levon Vartanian, MD

Pediatric Cardiac Arrest ...... 149 Pediatric Asystole/PEA ...... 151 Pediatric Ventricular Fibrillation/Pulseless Ventricular Tachycardia ...... 152 Pediatric Post-Arrest Care ...... 153 Pediatric Tachycardia ...... 155 Pediatric Bradycardia ...... 156 Pediatric Respiratory Distress ...... 157 Pediatric Diabetic Emergency ...... 159 Pediatric Seizure ...... 160 Pediatric Overdose ...... 161 Pediatric Hypotension/Shock ...... 164 Pediatric Allergic Reaction/Anaphylaxis ...... 167 Pediatric Vomiting/Diarrhea ...... 169 Children with Special Healthcare Needs ...... 170 Apparent Life Threatening Event (ALTE) ...... 171 Trauma/Environmental ...... 172 General Trauma Treatment ...... 173 Major/Multi-System Trauma ...... 174 Traumatic Arrest ...... 177 Amputation...... 179 Bites and Envenomations ...... 180 Blast Injury ...... 182 Burns: Thermal ...... 184 Burns: Chemical and Electrical ...... 187 Crush Syndrome and Compartment Syndrome ...... 188 Drowning ...... 190 Extremity Trauma ...... 191 Eye Injuries ...... 192 Head Trauma ...... 193 Hyperthermia ...... 194 Hypothermia ...... 195 Hypotension/Shock ...... 196 Sexual Assault ...... 199 Smoke Inhalation ...... 200 Procedures ...... 202 Assessment Model ...... 204 General Therapies ...... 206 Airway Management Overview ...... 207 Crash Airway ...... 211 Failed Airway ...... 212 King Vision Video Laryngoscopy ...... 213 Capnography Monitoring ...... 215

Cypress Creek EMS System Policies and Treatment Guidelines

4 INTRODUCTION Revised 8/2016 Approved: Levon Vartanian, MD

Rapid Sequence Induction ...... 216 BVM Ventilations ...... 221 Foreign Body Airway Obstruction ...... 222 PEEP ...... 224 Orotracheal Intubation ...... 225 CPAP ...... 226 i-gel Supraglottic Airway...... 229 King Supraglottic Airway ...... 232 Nasal Intubation ...... 234 Cricothyrotomy...... 235 Suctioning ...... 238 Impedance Threshold Device (ResQPod) ...... 239 ResQGard ...... 240 Pulse Oximetry ...... 242 Oxygen Administration ...... 243 Ventilator Operation ...... 244 Tracheostomy Tube Change ...... 247 12-Lead ECG ...... 248 Defibrillation ...... 252 CPR...... 253 External Pacing ...... 255 Synchronized Cardioversion ...... 256 Blood Glucose Analysis ...... 257 CO-Oximetry ...... 258 Hemoglobin Assessment ...... 260 Orthostatic Blood Pressure Assessment ...... 262 Stroke & Neurological Assessment ...... 263 Visual Acuity Assessment ...... 267 Ultrasound Exams ...... 268 Whole Blood & Blood Product Transfusion ...... 281 Fluid Warmer ...... 284 Chest Decompression ...... 287 Nasogastric/Orogastric Tube Insertion ...... 289 Childbirth ...... 290 Eye Irrigation ...... 291 Pain Management ...... 292 LifeGift Donor Referral ...... 294 Patient Decontamination ...... 295 Nasopharyngeal Medication Administration ...... 296 Pelvic Sling ...... 297 Restraint ...... 298 Sedation ...... 299

Cypress Creek EMS System Policies and Treatment Guidelines

5 INTRODUCTION Revised 8/2016 Approved: Levon Vartanian, MD

Splinting ...... 302 Instrument Thoracostomy ...... 304 Peripheral IV Access ...... 306 External Jugular Access ...... 307 Implanted Ports and Central Lines ...... 308 Intraosseous (IO) Access...... 309 Ruggedized Field IV (Ranger IV) ...... 313 Ultrasound Guided Peripheral IV ...... 314 Wound Care: General ...... 315 ECD Probe Removal ...... 318 iT Clamp ...... 319 Junctional Extremity Treatment Tool (JETT)...... 321 Tourniquet ...... 322 Wound Packing ...... 324 Respiratory Support for Animal Patients ...... 325 Medications ...... 327 Acetaminophen (Tylenol) ...... 329 Adenosine (Adenocard) ...... 330 Albuterol (Proventil) ...... 331 Amiodarone HCL (Cordarone) ...... 332 Aspirin ...... 333 Atropine Sulfate ...... 334 Calcium Chloride...... 336 Dexamethasone (Decadron)...... 337 Dextrose ...... 338 Diazepam (Valium) ...... 339 Diltiazem (Cardizem) ...... 340 Diphenhydramine (Benadryl) ...... 341 Dopamine ...... 342 Epinephrine HCL (Adrenaline) ...... 344 Etomidate (Amidate) ...... 346 Fentanyl (Sublimaze) ...... 347 Furosemide (Lasix) ...... 348 Glucagon (GlucaGen) ...... 349 Heparin ...... 350 Hydroxocobalamin (Cyanokit) ...... 351 Ibuprofen (Motrin) ...... 352 Ipratropium Bromide (Atrovent) ...... 353 Ketamine (Ketalar) ...... 354 Ketorolac (Toradol) ...... 355 Lidocaine HCL (Xylocaine, Lidocaine Jelly) ...... 356 Magnesium Sulfate ...... 357

Cypress Creek EMS System Policies and Treatment Guidelines

6 INTRODUCTION Revised 8/2016 Approved: Levon Vartanian, MD

Meperidine HCl (Demerol) ...... 358 Methylprednisolone (Solu-Medrol) ...... 359 Metoclopramide (Reglan)...... 360 Metoprolol (Lopressor) ...... 361 Midazolam (Versed) ...... 362 Morphine Sulfate ...... 363 Naloxone (Narcan) ...... 364 Nitroglycerin (Nitrostat, Nitrolingual Spray) ...... 365 Normal Saline ...... 366 Ondansetron HCL (Zofran) ...... 367 Oral Glucose ...... 368 Oxygen ...... 369 Oxytocin (Pitocin) ...... 370 Pancuronium (Pavulon) ...... 371 PlasmaLyte-A (Plasmalyte) ...... 372 Promethazine (Phenergan) ...... 373 Rocuronium (Zemuron) ...... 374 Sodium Bicarbonate ...... 375 Succinylcholine Chloride (Anectine) ...... 376 Tetracaine Ophthalmic Solution ...... 378 Thiamine ...... 379 Vecuronium (Norcuron) ...... 380 Whole Blood & Blood Products ...... 381 Appendices ...... 382 BVM Nebulizer Setup ...... 383 Capnography ...... 384 Chain of Command and Phone Directory ...... 386 Medication Calculation/ Drips ...... 387 Operative IQ Check Sheet User Guide ...... 388 Station Map ...... 397 Truck Swap Checklist ...... 398 Underhood Inspection ...... 399

Cypress Creek EMS System Policies and Treatment Guidelines

7 INTRODUCTION Revised 8/2016 Approved: Levon Vartanian, MD

/ŶƚƌŽĚƵĐƚŝŽŶ

ǇƉƌĞƐƐƌĞĞŬD^ǁĂƐĨŽƵŶĚĞĚŝŶϭϵϳϱĂƐĂĐŽŵŵƵŶŝƚǇͲďĂƐĞĚƐĞƌǀŝĐĞƚŽƉƌŽǀŝĚĞĞǆĐĞůůĞŶƚŵĞĚŝĐĂů ĐĂƌĞƚŽƚŚĞƌĞƐŝĚĞŶƚƐŽĨ^ƉƌŝŶŐĂŶĚƐƵƌƌŽƵŶĚŝŶŐĂƌĞĂƐ͘^ŝŶĐĞƚŚĞŶ͕ǇƉƌĞƐƐƌĞĞŬD^ŚĂƐŐƌŽǁŶƚŽďĞĂ ƉƌĞŵŝĞƌD^ĂŐĞŶĐǇŝŶƚŚĞ^ƚĂƚĞŽĨdĞǆĂƐĐŚĂƌĂĐƚĞƌŝǌĞĚďǇƉƌŽǀŝĚŝŶŐŚŝŐŚͲƋƵĂůŝƚǇŵĞĚŝĐĂůĐĂƌĞĂŶĚ ĐŽŵŵƵŶŝƚǇƐƵƉƉŽƌƚƚŽƚŚĞƌĞƐŝĚĞŶƚƐŽĨ,ĂƌƌŝƐŽƵŶƚǇŵĞƌŐĞŶĐǇ^ĞƌǀŝĐĞƐŝƐƚƌŝĐƚηϭϭ͘

dŚŝƐŵĂŶƵĂůĐŽŶƚĂŝŶƐƚŚĞŽƉĞƌĂƚŝŽŶĂůĂŶĚĐůŝŶŝĐĂůƉŽůŝĐŝĞƐ͕ĂůŽŶŐǁŝƚŚƚƌĞĂƚŵĞŶƚŐƵŝĚĞůŝŶĞƐĂŶĚ ƉƌŽĐĞĚƵƌĞƐ͘ZĞĨĞƌƚŽƚŚĞdĂďůĞŽĨŽŶƚĞŶƚƐĨŽƌĂƐƉĞĐŝĨŝĐůŝƐƚŽĨƐĞĐƚŝŽŶƐ͘ Standard of Care Statement ůŝŶŝĐĂůĐŽŵƉĞƚĞŶĐĞĂŶĚŚŝŐŚƐƚĂŶĚĂƌĚƐĂƌĞǀŝƚĂůĨƵŶĐƚŝŽŶƐŝŶƉƌŽǀŝĚŝŶŐƋƵĂůŝƚǇƉƌĞŚŽƐƉŝƚĂůĞŵĞƌŐĞŶĐǇ ŵĞĚŝĐĂůĐĂƌĞƚŽƚŚĞĐƵƐƚŽŵĞƌƐǁŚŽƌĞůǇŽŶŽƵƌƐĞƌǀŝĐĞƐ͘dŚĞƚƌĞĂƚŵĞŶƚƉƌŽƚŽĐŽůƐƌĞƉƌĞƐĞŶƚƚŚĞ ŵŝŶŝŵƵŵůĞǀĞůŽĨƉĂƚŝĞŶƚĐĂƌĞƚŚĂƚŝƐƚŽďĞƉƌŽǀŝĚĞĚƵƉŽŶƌĞƋƵĞƐƚĨŽƌƐĞƌǀŝĐĞ͘ǇƉƌĞƐƐƌĞĞŬD^ǁŝůů ĂůǁĂǇƐƉƌŽǀŝĚĞƚŚĞŚŝŐŚĞƐƚƋƵĂůŝƚǇŽĨĐĂƌĞƚŚĂƚŚĂƐĐŽŵĞƚŽďĞĞǆƉĞĐƚĞĚďǇƚŚĞƉĞŽƉůĞƚŽǁŚŝĐŚǁĞ ƉƌŽǀŝĚĞƐĞƌǀŝĐĞ͘

D^ĞŵďƌĂĐĞƐ͕ĂƐĨƵŶĚĂŵĞŶƚĂůĐŽŵƉŽŶĞŶƚƐŽĨŝƚƐƐƚĂŶĚĂƌĚŽĨĐĂƌĞ͕ƚŚĞĨŽůůŽǁŝŶŐĐŽŶĐĞƉƚƐ͗

x dŚĞĞŵĞƌŐĞŶƚƉĂƚŝĞŶƚďĞŶĞĨŝƚƐĨƌŽŵĞĂƌůǇŵĞĚŝĐĂůŝŶƚĞƌǀĞŶƚŝŽŶƐ͕ĞƐƉĞĐŝĂůůǇƚŚĞĞĂƌůǇĂŶĚĂŐŐƌĞƐƐŝǀĞ ĂƉƉůŝĐĂƚŝŽŶŽĨĂŝƌǁĂǇĞƐƚĂďůŝƐŚŵĞŶƚĂŶĚŵĂŝŶƚĞŶĂŶĐĞ͕ĞĂƌůǇĂĚŵŝŶŝƐƚƌĂƚŝŽŶŽĨŽǆǇŐĞŶĂŶĚĞĂƌůǇ ŝŶŝƚŝĂƚŝŽŶŽĨĚĞĨŝŶŝƚŝǀĞƚŚĞƌĂƉŝĞƐ͘ x dŚĞƉĂƚŝĞŶƚĚĞĨŝŶĞƐƚŚĞĞŵĞƌŐĞŶĐǇ͘ƐD^ƉĞƌƐŽŶŶĞů͕ǁĞĂƌĞŽĨƚĞŶĐĂůůĞĚƵƉŽŶƚŽĂƐƐŝƐƚǁŝƚŚƐŽĐŝĂů ŽƌƉƐǇĐŚŽůŽŐŝĐĂůƉƌŽďůĞŵƐĂŶĚǁĞŵƵƐƚƌĞƐƉŽŶĚĂƐƉƌŽĨĞƐƐŝŽŶĂůůǇĂŶĚƚŚŽƌŽƵŐŚůǇƚŽƚŚĞƐĞĂƐǁĞĚŽ ĨŽƌŵĞĚŝĐĂůŽƌƐƵƌŐŝĐĂůƉƌŽďůĞŵƐ͘ x KƵƌƌŽůĞĂƐD^ƉĞƌƐŽŶŶĞůŝƐƚŽĂĐƚĂƐƚŚĞĞǇĞƐ͕ĞĂƌƐ͕ĂŶĚŚĂŶĚƐŽĨƚŚĞƉŚǇƐŝĐŝĂŶ͘dŽƐƵĐĐĞƐƐĨƵůůǇĚŽ ƐŽƌĞƋƵŝƌĞƐƚŚĂƚǁĞĞĚƵĐĂƚĞŽƵƌƐĞůǀĞƐďĞǇŽŶĚĨŝƌƐƚĂŝĚƉƌŽĐĞĚƵƌĞƐĂŶĚĚĞĚŝĐĂƚĞŽƵƌƐĞůǀĞƐƚŽďĞŝŶŐ ĂŶŝŶƚĞŐƌĂůƉĂƌƚŽĨƚŚĞƚŽƚĂůŚĞĂůƚŚĐĂƌĞƚĞĂŵ͘ x ǆĐĞůůĞŶƚƉĂƚŝĞŶƚĐĂƌĞďĞŐŝŶƐǁŝƚŚĂƚŚŽƌŽƵŐŚƉĂƚŝĞŶƚĂƐƐĞƐƐŵĞŶƚ͘

Cypress Creek EMS System Policies and Treatment Guidelines

8 INTRODUCTION Revised 8/2016 Approved: Levon Vartanian, MD

'ĞŶĞƌĂůWƌŽƚŽĐŽůƐͬdƌĞĂƚŵĞŶƚ'ƵŝĚĞůŝŶĞƐ

dŚĞĨŽůůŽǁŝŶŐƉƌŽƚŽĐŽůƐĂƌĞŵĞĂŶƚƚŽƐĞƌǀĞĂƐŐĞŶĞƌĂůŐƵŝĚĞůŝŶĞƐŝŶƉĂƚŝĞŶƚĐĂƌĞ͘/ƚŝƐŝŵƉŽƐƐŝďůĞƚŽŽƵƚůŝŶĞ ƚƌĞĂƚŵĞŶƚƐĞƋƵĞŶĐĞƐĨŽƌĞǀĞƌǇƐŝƚƵĂƚŝŽŶƚŚĞD^DĞĚŝĐǁŝůůƌƵŶĂĐƌŽƐƐ͘ĂĐŚƉĂƚŝĞŶƚƐŚŽƵůĚďĞƚƌĞĂƚĞĚ ŝŶĚŝǀŝĚƵĂůůǇĂŶĚĂƉƉƌŽƉƌŝĂƚĞůǇ͕ƵƚŝůŝǌŝŶŐƐŽƵŶĚũƵĚŐŵĞŶƚ͕ĂůŽŶŐǁŝƚŚƚŚĞƉƌŽƚŽĐŽůƐĂƐŐĞŶĞƌĂůŐƵŝĚĞůŝŶĞƐ͘ dŚĞƌĞĐĞŝǀŝŶŐŚŽƐƉŝƚĂůƐŚŽƵůĚďĞŶŽƚŝĨŝĞĚĂƐƐŽŽŶĂƐƉŽƐƐŝďůĞ͖ŚŽǁĞǀĞƌ͕ƚŚŝƐƐŚŽƵůĚŶŽƚŝŶƚĞƌĨĞƌĞǁŝƚŚ ƉĂƚŝĞŶƚĐĂƌĞ͘ĂĐŚƉĂƚŝĞŶƚƌĞĐŽƌĚƐŚŽƵůĚďĞƚŚŽƌŽƵŐŚůǇĚŽĐƵŵĞŶƚĞĚ͘

x ĞŐŝŶĞĂĐŚƉĂƚŝĞŶƚĞŶĐŽƵŶƚĞƌǁŝƚŚĂƚŚŽƌŽƵŐŚƉƌŝŵĂƌǇƐƵƌǀĞǇ͕ĂƐĚĞƐĐƌŝďĞĚŝŶPatient Assessment ƉƌŽĐĞĚƵƌĞ͘dƌĞĂƚůŝĨĞͲƚŚƌĞĂƚĞŶŝŶŐĐŽŶĚŝƚŝŽŶƐďĞĨŽƌĞŵŽǀŝŶŐŽŶ͘ x WƌŝŽƌŝƚǇŽĨƚƌĞĂƚŵĞŶƚŝƐ͗ x Hemorrhage Control/Chest Compressions x Airway x Ventilation/Oxygenation x Circulation x hƚŝůŝǌĞďĂƐŝĐͬ>^ŵĂŶĞƵǀĞƌƐďĞĨŽƌĞĂĚǀĂŶĐĞĚͬ>^ŵĂŶĞƵǀĞƌƐ͘ x dƌĞĂƚŵĞŶƚŐƵŝĚĞůŝŶĞƐŵĂǇŽǀĞƌůĂƉǁŝƚŚŽŶĞĂŶŽƚŚĞƌ͖ǁŚĞŶĐŚĂŶŐŝŶŐĨƌŽŵŽŶĞƚŽĂŶŽƚŚĞƌ͕ĚŽŶŽƚ ĂĚŵŝŶŝƐƚĞƌŵŽƌĞƚŚĂŶƚŚĞŵĂǆŝŵƵŵƚŽƚĂůĚŽƐĞŽĨĂŵĞĚŝĐĂƚŝŽŶ͘ x hƐĞƐŽƵŶĚĐůŝŶŝĐĂůũƵĚŐĞŵĞŶƚďĂƐĞĚŽŶƚŚĞŝŶĚŝǀŝĚƵĂůƉĂƚŝĞŶƚ͘

Section & Protocol

Required Treatments dŽďĞĚŽŶĞŽŶĞǀĞƌǇ ƉĂƚŝĞŶƚǁŝƚŚƚŚŝƐ ƐƐĞƐƐŵĞŶƚ ĐŽŶĚŝƚŝŽŶ ZĞƋƵŝƌĞŵĞŶƚƐ͕ ^ŝŐŶƐΘ^ǇŵƉƚŽŵƐ͕ ĂŶĚWŽƐƐŝďůĞĂƵƐĞƐ Available Treatments hƐĞůŝŶŝĐĂů:ƵĚŐĞŵĞŶƚ ƚŽĚĞƚĞƌŵŝŶĞŵŽƐƚ

Pearls ĂƉƉƌŽƉƌŝĂƚĞƚƌĞĂƚŵĞŶƚƐ ĚĚŝƚŝŽŶĂůŝŶĨŽƌŵĂƚŝŽŶ͕ ĨŽƌƉĂƚŝĞŶƚ͘ ƵƐĞĨƵůĂĚǀŝĐĞ͕ ĂƉƉůŝĐĂƚŝŽŶƚŝƉƐ͕ĂŶĚ ƐƉĞĐŝĂůƐŝƚƵĂƚŝŽŶƐ͘

Cypress Creek EMS System Policies and Treatment Guidelines

9 INTRODUCTION Revised 8/2016 Approved: Levon Vartanian, MD

ĂĐŚŵĞĚŝĐĂůĂŶĚƚƌĂƵŵĂƉƌŽƚŽĐŽůŝƐĚŝǀŝĚĞĚŝŶƚŽƚŚƌĞĞƐĞĐƚŝŽŶƐ͘dŚĞƵƉƉĞƌŵŽƐƚƐĞĐƚŝŽŶŝŶĐůƵĚĞƐ͗

x Required Assessment:ƚĂŵŝŶŝŵƵŵ͕ĂƉƌŝŵĂƌǇƐƵƌǀĞǇŝƐĂůǁĂǇƐƌĞƋƵŝƌĞĚ͘/ĨƚŚĞƉĂƚŝĞŶƚŝƐĂǁĂŬĞ ĂŶĚĂůĞƌƚǁŝƚŚĂŶŝƐŽůĂƚĞĚĐŽŵƉůĂŝŶƚ͕ĂĨŽĐƵƐĞĚƉŚǇƐŝĐĂůĞǆĂŵŵĂǇďĞĂƉƉƌŽƉƌŝĂƚĞ͘/ŶŽƚŚĞƌĐĂƐĞƐ͕ ĂŶĚĂƐŵĂƌŬĞĚƚŚƌŽƵŐŚŽƵƚƚŚĞƐĞƉƌŽƚŽĐŽůƐ͕ĂĨƵůůŚĞĂĚͲƚŽͲƚŽĞĞǆĂŵŝƐŶĞĐĞƐƐĂƌǇ͘ĚĚŝƚŝŽŶĂů ĂƐƐĞƐƐŵĞŶƚĂŶĚŵŽŶŝƚŽƌŝŶŐŵŽĚĂůŝƚŝĞƐƌĞƋƵŝƌĞĚĨŽƌĚŝĨĨĞƌĞŶƚƐƉĞĐŝĨŝĐƉƌĞƐĞŶƚĂƚŝŽŶƐĂƌĞůŝƐƚĞĚŝŶƚŚŝƐ ďŽǆŽŶĞĂĐŚƉƌŽƚŽĐŽů͘ x “May present as” ŝƐƚŚĞĐĞŶƚĞƌďŽǆĂŶĚůŝƐƚƐƐŝŐŶƐĂŶĚƐǇŵƉƚŽŵƐƚŚĂƚĐŽƵůĚůĞĂĚƚŽƚŚĞĚŝƐĞĂƐĞ ƉƌŽĐĞƐƐďĞŝŶŐƚƌĞĂƚĞĚďǇƚŚĞƉƌŽƚŽĐŽů͘ x “Possible Causes” ŝƐĂůŝƐƚŽĨĚŝĨĨĞƌĞŶƚŝĂůĚŝĂŐŶŽƐĞƐƚŽĐŽŶƐŝĚĞƌĂƐĂŐƵŝĚĞƚŽĂƐƐŝƐƚŝŶŝĚĞŶƚŝĨǇŝŶŐĂŶĚ ƚƌĞĂƚŝŶŐƵŶĚĞƌůǇŝŶŐĐĂƵƐĞƐĨŽƌƉĂƚŝĞŶƚĐŽŵƉůĂŝŶƚ͘ dŚĞĐĞŶƚĞƌƐĞĐƚŝŽŶĚĞƐĐƌŝďĞƐRequiredĂŶĚAvailable Treatments͕WƌŽĐĞĚƵƌĞƐ͕ŽƌWůĂŶƐ͘dŚĞƐĞƌĞƉƌĞƐĞŶƚ ƚŚĞƉƌŽǀĞŶƉƌĂĐƚŝĐĞƐǁŚŝĐŚĂƌĞƚŚĞĨŽƵŶĚĂƚŝŽŶŽĨŽƵƌĐĂƌĞ͘dŚĞƐĞĂƌĞůĂďĞůĞĚǁŝƚŚĂƐĐŽƉĞŽĨƉƌĂĐƚŝĐĞŝŶ ƉĂƌĞŶƚŚĞƐĞƐ͕ĚĞŶŽƚŝŶŐƚƌĞĂƚŵĞŶƚƐŽƌƐŬŝůůƐƚŚĂƚĐĂŶďĞƉĞƌĨŽƌŵĞĚďǇ͗

x (B):DdͲĂƐŝĐƐŽƌĂďŽǀĞ͘ x (I): DdͲ/ŶƚĞƌŵĞĚŝĂƚĞͬDdͲĚǀĂŶĐĞĚŽƌĂďŽǀĞ͘ x (P):DdͲWĂƌĂŵĞĚŝĐƐĐƌĞĚĞŶƚŝĂůĞĚĂƐĂWϭŽƌĂďŽǀĞ͘ x (P2):DdͲWĂƌĂŵĞĚŝĐƐĐƌĞĚĞŶƚŝĂůĞĚĂƐĂWϮŽƌĂďŽǀĞ͘ x (P3 Consult):DdͲWĂƌĂŵĞĚŝĐƐĐƌĞĚĞŶƚŝĂůĞĚĂƐĂWϮŽƌĂďŽǀĞ͕ĨŽůůŽǁŝŶŐ ĚŝƌĞĐƚĐŽŶƚĂĐƚǁŝƚŚĂWϯŝŶ ƉĞƌƐŽŶŽƌǀŝĂĞůĞĐƚƌŽŶŝĐĐŽŵŵƵŶŝĐĂƚŝŽŶ͘ x (P3):DdͲWĂƌĂŵĞĚŝĐƐĐƌĞĚĞŶƚŝĂůĞĚĂƐĂWϯ͘ dŚĞPearlsƐĞĐƚŝŽŶŽŶƚŚĞďŽƚƚŽŵŽĨĞĂĐŚƉƌŽƚŽĐŽůƉƌŽǀŝĚĞƐĂĚĚŝƚŝŽŶĂůŝŶĨŽƌŵĂƚŝŽŶĂŶĚŐƵŝĚĂŶĐĞĨŽƌ ƉĂƚŝĞŶƚĐĂƐĞďĂƐĞĚŽŶŽƌŐĂŶŝǌĂƚŝŽŶĂůĞǆƉĞƌŝĞŶĐĞĂŶĚĐůŝŶŝĐĂůƌĞƐĞĂƌĐŚ͘dŚĞƉĞĂƌůƐŵĂǇŝŶĐůƵĚĞŶŽƚĞƐŽŶ ŵĞĚŝĐĂƚŝŽŶ͕ŐƵŝĚĂŶĐĞĨŽƌƐƉĞĐŝĂůĐŝƌĐƵŵƐƚĂŶĐĞƐ͕ŽƌĂĚǀŝĐĞŽŶƉŽƚĞŶƚŝĂůƐŝƚƵĂƚŝŽŶƐ͘WĞĂƌůƐƐŚŽƵůĚďĞ ƐƚƵĚŝĞĚĂůŽŶŐǁŝƚŚƚŚĞƌĞƐƚŽĨƚŚĞƉƌŽƚŽĐŽůƐĂŶĚĨŽůůŽǁĞĚŝĨĂƉƉůŝĐĂďůĞ͕ďƵƚŵĂǇŶŽƚĂƉƉůǇĨŽƌĞǀĞƌǇ ƉĂƚŝĞŶƚŽƌĐĂƐĞ͘

Bold TextŝƐƵƐĞĚƚŚƌŽƵŐŚŽƵƚƚŽƌĞĨĞƌƚŽŽƚŚĞƌƉƌŽƚŽĐŽůƐŽƌƚƌĞĂƚŵĞŶƚŽƉƚŝŽŶƐ͘ ,ŝŐŚůŝŐŚƚĞĚdĞǆƚŝƐƵƐĞĚƚŚƌŽƵŐŚŽƵƚƚŽĞŵƉŚĂƐŝǌĞĐƌŝƚŝĐĂůŝŶĨŽƌŵĂƚŝŽŶ͘

dŚĞProceduresƐĞĐƚŝŽŶůŝƐƚƐĞĂĐŚŽĨƚŚĞƚƌĞĂƚŵĞŶƚĂŶĚĂƐƐĞƐƐŵĞŶƚƚĞĐŚŶŝƋƵĞƐĂŶĚƚŽŽůƐƵƐĞĚďǇ ǇƉƌĞƐƐƌĞĞŬD^͘ĂĐŚƉƌŽĐĞĚƵƌĞŚĂƐƚŚƌĞĞƐĞĐƚŝŽŶƐ͕ƐŝŵŝůĂƌƚŽƚŚĞŵĞĚŝĐĂůĂŶĚƚƌĂƵŵĂƉƌŽƚŽĐŽůƐ͘dŚĞ ƵƉƉĞƌŵŽƐƚƐĞĐƚŝŽŶŝŶĐůƵĚĞƐ͗

x IndicationsĨŽƌƵƐĞŽĨƚŚĞƚĞĐŚŶŝƋƵĞŽƌƚŽŽů͘ x Equipment NeededůŝƐƚƐƚŚĞŵŝŶŝŵƵŵĞƋƵŝƉŵĞŶƚƌĞƋƵŝƌĞĚƚŽŝŵƉůĞŵĞŶƚƚŚĞƉƌŽĐĞĚƵƌĞ͘ x Assessment RequirementsŽƵƚůŝŶĞƐƚŚĞƌĞƋƵŝƌĞĚŝƚĞŵƐƚŚĂƚŵƵƐƚďĞĂƐƐĞƐƐĞĚĂŶĚĚŽĐƵŵĞŶƚĞĚ ǁŚĞŶƉĞƌĨŽƌŵŝŶŐƚŚĞƉƌŽĐĞĚƵƌĞĚĞƐĐƌŝďĞĚ͘ dŚĞƉƌŝŵĂƌǇƐĞĐƚŝŽŶŽĨĞĂĐŚƉƌŽĐĞĚƵƌĞůŝƐƚƐƚŚĞƐƚĞƉƐƚŽƉĞƌĨŽƌŵƚŚĞƚĞĐŚŶŝƋƵĞŽƌĂƐƐĞƐƐŵĞŶƚ͘

ĂĐŚƉƌŽĐĞĚƵƌĞŝŶĐůƵĚĞƐĂPearlsƐĞĐƚŝŽŶǁŝƚŚĂĚĚŝƚŝŽŶĂůŝŶĨŽƌŵĂƚŝŽŶ͕ƌĞĨĞƌĞŶĐĞƚŽŽůƐ͕ĂŶĚŐƵŝĚĂŶĐĞŽŶ ƉĂƚŝĞŶƚĐĂƌĞ͕ĞƋƵŝƉŵĞŶƚŵĂŝŶƚĞŶĂŶĐĞ͕ĂŶĚƐƉĞĐŝĂůĐĂƐĞƐ͘

Cypress Creek EMS System Policies and Treatment Guidelines

10 INTRODUCTION Revised 8/2016 Approved: Levon Vartanian, MD

dŚĞ MedicationsƐĞĐƚŝŽŶŝŶĐůƵĚĞƐĂĚĞƐĐƌŝƉƚŝŽŶŽĨĞĂĐŚŵĞĚŝĐĂƚŝŽŶƵƐĞĚďǇǇƉƌĞƐƐƌĞĞŬD^ĂŶĚ ŽƵƚůŝŶĞƐƚŚĞŵĞĐŚĂŶŝƐŵŽĨĂĐƚŝŽŶ͕ŝŶĚŝĐĂƚŝŽŶƐ͕ĐŽŶƚƌĂŝŶĚŝĐĂƚŝŽŶƐ͕ĚŽƐĂŐĞ͕ĂĚŵŝŶŝƐƚƌĂƚŝŽŶ͕ĂŶĚƐƉĞĐŝĂů ĐŽŶƐŝĚĞƌĂƚŝŽŶƐƚŽďĞĂǁĂƌĞŽĨ͘dŚƌŽƵŐŚŽƵƚƚŚĞƐĞƉƌŽƚŽĐŽůƐ͕ƚŚĞŐĞŶĞƌŝĐĨŽƌŵŽĨƚŚĞŵĞĚŝĐĂƚŝŽŶŶĂŵĞŝƐ ƉƌĞĨĞƌƌĞĚ͘

ůŝŶŝĐĂůĂŶĚKƉĞƌĂƚŝŽŶĂůWŽůŝĐŝĞƐƐĞĐƚŝŽŶƐĂƌĞŽƌĚĞƌĞĚĂůƉŚĂďĞƚŝĐĂůůǇďǇŶĂŵĞŽĨƉŽůŝĐǇ͘

dŚĞĚƵůƚDĞĚŝĐĂů͕WĞĚŝĂƚƌŝĐDĞĚŝĐĂů͕ĂŶĚdƌĂƵŵĂͬŶǀŝƌŽŶŵĞŶƚĂůƐĞĐƚŝŽŶƐĂƌĞŽƌĚĞƌĞĚďĂƐĞĚŽŶĂ ĐŽŵďŝŶĂƚŝŽŶŽĨƐĞǀĞƌŝƚǇŽĨĚŝƐĞĂƐĞ͕ƚǇƉŝĐĂůƉƌŝŽƌŝƚǇŽĨƚƌĞĂƚŵĞŶƚƐ͕ĂŶĚĨƌĞƋƵĞŶĐǇŽĨĐĂůůƚǇƉĞ͘

dŚĞWƌŽĐĞĚƵƌĞƐƐĞĐƚŝŽŶŝƐŽƌŐĂŶŝǌĞĚďǇƉƌŽĐĞĚƵƌĞĐĂƚĞŐŽƌǇ;ŝƌǁĂǇ͕ŝƌǁĂǇͬƌĞĂƚŚŝŶŐ͕ĂƌĚŝĂĐ͕ ƐƐĞƐƐŵĞŶƚ͕dƌĞĂƚŵĞŶƚ͕sĞŶŽƵƐĐĐĞƐƐ͕ĂŶĚtŽƵŶĚĂƌĞͿ͘

dŚĞDĞĚŝĐĂƚŝŽŶƐƐĞĐƚŝŽŶŝƐŽƌŐĂŶŝǌĞĚĂůƉŚĂďĞƚŝĐĂůůǇďǇƚŚĞŐĞŶĞƌŝĐŶĂŵĞŽĨƚŚĞŵĞĚŝĐĂƚŝŽŶ͘ References Used dŚĞƐĞƉƌŽƚŽĐŽůƐĚĞƌŝǀĞĨƌŽŵĂǀĂƌŝĞƚǇŽĨĐůŝŶŝĐĂůƉƌĂĐƚŝĐĞŐƵŝĚĞůŝŶĞƐ͕ƚĞǆƚďŽŽŬƐ͕ĂŶĚĐůŝŶŝĐĂůƌĞƐĞĂƌĐŚ͘

Selected references: ŵĞƌŝĐĂŶĐĂĚĞŵǇŽĨWĞĚŝĂƚƌŝĐƐ͘;ϮϬϭϰͿ͘Pediatric Education for Prehospital Professionals;ϯƌĚĚŝƚŝŽŶ ĞĚ͘Ϳ͘ƵƌůŝŶŐƚŽŶ͕D͗:ŽŶĞƐΘĂƌƚůĞƚƚ͘ ŵĞƌŝĐĂŶŽůůĞŐĞŽĨ^ƵƌŐĞŽŶƐŽŵŵŝƚƚĞĞŽŶdƌĂƵŵĂ͘;ϮϬϭϰͿ͘ŶǀŝĚĞŶĐĞĂƐĞĚWƌĞŚŽƐƉŝƚĂů'ƵŝĚĞůŝŶĞ ĨŽƌǆƚĞƌŶĂů,ĞŵŽƌƌŚĂŐĞŽŶƚƌŽů͘Prehospital Emergency Care, 18;ϮͿ͕ϭϲϯʹϭϳϯ͘ ŵĞƌŝĐĂŶ,ĞĂƌƚƐƐŽĐŝĂƚŝŽŶ͘;ϮϬϭϱͿ͘ϮϬϭϱ'ƵŝĚĞůŝŶĞƐĨŽƌWZΘ͘Circulation, 132;ϭϴͿ͕ϯϭϯʹϱϴϵ͘ EĂƚŝŽŶĂůƐƐŽĐŝĂƚŝŽŶŽĨŵĞƌŐĞŶĐǇDĞĚŝĐĂůdĞĐŚŶŝĐŝĂŶƐ͘;ϮϬϭϲͿ͘Prehospital Trauma Life Support;ϴƚŚ ĚŝƚŝŽŶĞĚ͘Ϳ͘ƵƌůŝŶŐƚŽŶ͕D͗:ŽŶĞƐΘĂƌƚůĞƚƚ͘ EĂƚŝŽŶĂůƐƐŽĐŝĂƚŝŽŶŽĨŵĞƌŐĞŶĐǇDĞĚŝĐĂůdĞĐŚŶŝĐŝĂŶƐ͘;ϮϬϭϳͿ͘Advanced Medical Life Support;sŽů͘ ϮŶĚͿ͘ƵƌůŝŶŐƚŽŶ͕D͗:ŽŶĞƐΘĂƌƚůĞƚƚ͘ WŽƌƚĞƌD͕Z͘^͘;Ě͘Ϳ͘;ϮϬϭϲͿ͘The Merck Manual, Professional Version.EĞǁ:ĞƌƐĞǇ͗DĞƌĐŬ͘

ǇƉƌĞƐƐƌĞĞŬD^ĂĐŬŶŽǁůĞĚŐĞƐĂŶĚĂƉƉƌĞĐŝĂƚĞƐƚŚĞĐŽŶƚƌŝďƵƚŝŽŶƐŽĨŵĂŶǇŽĨŽƵƌĚĞĚŝĐĂƚĞĚŵĞŵďĞƌƐ ĂŶĚƚŚĞŝŶƉƵƚĂŶĚƐƵƉƉŽƌƚŽĨƉĂƌƚŶĞƌD^ĂŐĞŶĐŝĞƐŝŶĚĞǀĞůŽƉŝŶŐƚŚĞƐĞƉƌŽƚŽĐŽůŐƵŝĚĞůŝŶĞƐ͘

Cypress Creek EMS System Policies and Treatment Guidelines

11 INTRODUCTION

Approval of Protocols

The clinical treatment guidelines and protocols contained in this document are approved effective October 7, 2016 by Dr. Levon Vartanian, M.D., the Medical Director of Cypress Creek EMS.

Signed ______(signatures on file) Date: ______

The system policies, procedures, and protocols contained in this document are approved effective October 7, 2016 by Bradley England, the Executive Director of Cypress Creek EMS:

Signed ______(signatures on file) Date: ______

Cypress Creek EMS System Policies and Treatment Guidelines Cypress Creek EMS 7111 Five Forks Dr Spring, TX 77379 Interim Updates Each individual update below was individually approved by Dr. Levon Vartanian, M.D., with approval signatures on file: • 2/23/2017: Addition of metoclopramide (Reglan) for nausea and vomiting. • 5/12/2017: Addition of pancuronium for RSI, modification of RSI and ketamine protocols in response to drug shortages. • 4/16/2018: Addition of meperidine (Demerol) for pain management. • 5/31/2018: Update to time and attendance, update to delegation for first responders. • 8/22/2018: Addition of vecuronium for RSI. • 11/27/2018: Update for whole blood & blood products, fluid warmer, transport destinations, addition of oral glucose, update to delegation for advanced practice providers • 12/19/2018: Addition of ultrasound assessment, ultrasound guided IVs, and inclusion of ultrasound in related protocols. • 08/13/2018: Addition of dextrose 10%, i-gel supraglottic airway, instrument thoracostomy, respiratory support for animal patients, and revision/change of pregnancy information. • 10/04/2019: Updated delegation for paramedic unit operator level, revised chest decompression to include pediatrics and SPEAR device, revise hemorrhage control to include hemostatic gauze.

Cypress Creek EMS System Policies and Treatment Guidelines © 2016 Cypress Creek EMS INTRODUCTION Revised 6/2019 Approved: Levon Vartanian, MD

ĞĨŝŶŝƚŝŽŶŽĨdĞƌŵƐ

A4C ;hůƚƌĂƐŽƵŶĚͿ͘ƉŝĐĂůϰͲĐŚĂŵďĞƌǀŝĞǁ ABC's ŝƌǁĂǇ͕ďƌĞĂƚŚŝŶŐĂŶĚĐŝƌĐƵůĂƚŝŽŶ͕ĚĞĨŝŶĞĚĂƐ͗ DĂŝŶƚĂŝŶŝŶŐĂŶopenĂŶĚpatentĂŝƌǁĂǇ WƌŽǀŝĚŝŶŐĂĚĞƋƵĂƚĞventilationĂŶĚoxygenation ^ƵƉƉŽƌƚŝŶŐĂĚĞƋƵĂƚĞperfusionďǇĐŽŶƚƌŽůůŝŶŐĞǆƚĞƌŶĂůŚĞŵŽƌƌŚĂŐĞ͕ƌĞƉůĂĐŝŶŐůŽƐƚ ďůŽŽĚǀŽůƵŵĞĂŶĚĐŽŵƉŽŶĞŶƚƐ͕ƉƌŽǀŝĚŝŶŐĐŚĞƐƚĐŽŵƉƌĞƐƐŝŽŶƐĂƐŶĞĞĚĞĚ͕ĐŽŶƚƌŽůůŝŶŐ ŚĞĂƌƚƌĂƚĞĂƐŶĞĞĚĞĚ͕ĂŶĚƚƌĞĂƚŝŶŐƐŚŽĐŬĂƐŶĞĞĚĞĚ Advanced Life Support dŚĞƌĂƉŝĞƐ ĂŶĚ ƉƌŽĐĞĚƵƌĞƐ ďĞǇŽŶĚ ďĂƐŝĐ ůŝĨĞ ƐƵƉƉŽƌƚ ŝŶĐůƵĚŝŶŐ ǀĂƐĐƵůĂƌ ĂĐĐĞƐƐ͕ (ALS) ŝŶƚƌĂŽƐƐĞŽƵƐĂĐĐĞƐƐ͕ŝŶƚƌĂǀĞŶŽƵƐͬŝŶƚƌĂŵƵƐĐƵůĂƌͬŝŶƚƌĂŶĂƐĂůŵĞĚŝĐĂƚŝŽŶĂĚŵŝŶŝƐƚƌĂƚŝŽŶ͕ ƚƌĂĐŚĞĂů ŝŶƚƵďĂƚŝŽŶ͕ ' ŵŽŶŝƚŽƌŝŶŐ͕ ĚĞĨŝďƌŝůůĂƚŝŽŶͬƐǇŶĐŚƌŽŶŝǌĞĚ ĐĂƌĚŝŽǀĞƌƐŝŽŶ͕ ƐƵƌŐŝĐĂůĂŝƌǁĂǇ͕ĐŚĞƐƚ ĚĞĐŽŵƉƌĞƐƐŝŽŶ͕ ĞǆƚĞƌŶĂů ĐĂƌĚŝĂĐ ƉĂĐŝŶŐ͕ ĞŶĚŽƚƌĂĐŚĞĂů ĂŶĚͬŽƌ ŐĂƐƚƌŝĐƐƵĐƚŝŽŶŝŶŐ͕ŐĂƐƚƌŝĐƚƵďĞƉůĂĐĞŵĞŶƚ͕ǀĞŶƚŝůĂƚŝŽŶǁŝƚŚŵĞĐŚĂŶŝĐĂůǀĞŶƚŝůĂƚŽƌ͕ŶŽŶͲ ŝŶǀĂƐŝǀĞƉŽƐŝƚŝǀĞƉƌĞƐƐƵƌĞǀĞŶƚŝůĂƚŝŽŶ;ŝŶĐůƵĚŝŶŐWWͿ͕dKϮŵŽŶŝƚŽƌŝŶŐ͕ƵůƚƌĂƐŽƵŶĚ ĞǆĂŵŝŶĂƚŝŽŶ͕ĂŶĚďůŽŽĚƚƌĂŶƐĨƵƐŝŽŶ AFIB ƚƌŝĂůĨŝďƌŝůůĂƚŝŽŶ Appropriate Facility ŚŽƐƉŝƚĂů;ŶŽƚŶĞĐĞƐƐĂƌŝůǇƚŚĞŶĞĂƌĞƐƚͿǁŝƚŚƚŚĞƌĞƐŽƵƌĐĞƐĂŶĚĐĂƉĂďŝůŝƚǇƚŽĐĂƌĞĨŽƌĂ ƉĂƚŝĞŶƚďĂƐĞĚƵƉŽŶƚŚĞƉĂƚŝĞŶƚ͛ƐŵĞĚŝĐĂůŶĞĞĚƐ APAP ĐĞƚĂŵŝŶŽƉŚĞŶ ASA ƐƉŝƌŝŶ BGL ůŽŽĚŐůƵĐŽƐĞůĞǀĞů b/p or BP ůŽŽĚƉƌĞƐƐƵƌĞ͘dǇƉŝĐĂůůǇ ŵĞĂƐƵƌĞĚĂƐĂƐǇƐƚŽůŝĐͬĚŝĂƐƚŽůŝĐ ŽƌƐ ǇƐƚŽůŝĐͬ͟ƉĂůƉ͟ ĨŽƌ ƉĂůƉĂƚĞĚ͖WŝƐƚŚĞŵŽƐƚĐŽŵŵŽŶŵĞĂƐƵƌĞŵĞŶƚŽĨƐǇƐƚĞŵŝĐƉĞƌĨƵƐŝŽŶ WсKǆ^sZ͕ǁŚĞƌĞKŝƐĐĂƌĚŝĂĐŽƵƚƉƵƚ;ƐĞĞďĞůŽǁͿĂŶĚ^sZŝƐƐǇƐƚĞŵŝĐǀĂƐĐƵůĂƌ ƌĞƐŝƐƚĂŶĐĞ;ƐĞĞďĞůŽǁͿ͖ƚŚŝƐŵŽƐƚĚŝƌĞĐƚůǇƚƌĂŶƐůĂƚĞƐƚŽĂŵĞĂŶĂƌƚĞƌŝĂůƉƌĞƐƐƵƌĞ;ƐĞĞ ďĞůŽǁͿ Basic Life Support dŚĞƌĂƉŝĞƐ ĂŶĚ ƉƌŽĐĞĚƵƌĞƐ ŝŶĐůƵĚŝŶŐ ǀŝƚĂů ƐŝŐŶƐ͕ ^WKϮ ŵŽŶŝƚŽƌŝŶŐ͕ ŽǆǇŐĞŶ (BLS) ĂĚŵŝŶŝƐƚƌĂƚŝŽŶ͕ ĂŝƌǁĂǇ ŵĂŝŶƚĞŶĂŶĐĞ͕ ŽƌĂůͬŶĂƐĂů ƐƵĐƚŝŽŶŝŶŐ͕ ďůĞĞĚŝŶŐ ĐŽŶƚƌŽů͕ ďĂŶĚĂŐŝŶŐ͕ ĨƌĂĐƚƵƌĞ ĐĂƌĞ ĂŶĚ ƐƉůŝŶƚŝŶŐ͕ ƐƉŝŶĂů ŝŵŵŽďŝůŝǌĂƚŝŽŶ͕ ƉĂƚŝĞŶƚ ĂƐƐĞƐƐŵĞŶƚ͕ ƐĞŵŝͲĂƵƚŽŵĂƚŝĐ ĚĞĨŝďƌŝůůĂƚŝŽŶ ;Ϳ͕ WZ͕ ŶĞďƵůŝǌĞĚ ďƌŽŶĐŚŽĚŝůĂƚŽƌ ƚƌĞĂƚŵĞŶƚƐ͕ ĂŶĚ ďůŽŽĚŐůƵĐŽƐĞůĞǀĞůĞǀĂůƵĂƚŝŽŶ;ŐůƵĐŽŵĞƚĞƌƵƐĞͿ BSA ŽĚǇƐƵƌĨĂĐĞĂƌĞĂ BVM ĂŐǀĂůǀĞŵĂƐŬ Bypass /ŶƚĞŶƚŝŽŶĂůŵŽǀĞŵĞŶƚŽĨĂƉĂƚŝĞŶƚĨƌŽŵƚŚĞƐĐĞŶĞƚŽĂƐƉĞĐŝĨŝĐŚŽƐƉŝƚĂů͕ŶŽƚŶĞĐĞƐƐĂƌŝůǇ ƚŚĞŶĞĂƌĞƐƚŚŽƐƉŝƚĂů͕ďĂƐĞĚƵƉŽŶƚŚĞƉĂƚŝĞŶƚ͛ƐŵĞĚŝĐĂůŶĞĞĚ Cardiac Output (CO) sŽůƵŵĞŽĨďůŽŽĚƉƵŵƉĞĚƉĞƌŵŝŶƵƚĞ͖Kс^sǆ,ZǁŚĞƌĞ^sŝƐƐƚƌŽŬĞǀŽůƵŵĞ͕ Ă ĨƵŶĐƚŝŽŶŽĨƉƌĞůŽĂĚ;ĨůƵŝĚǀŽůƵŵĞͿĂŶĚĐĂƌĚŝĂĐĐŽŶƚƌĂĐƚŝůŝƚǇĂŶĚ,ZŝƐŚĞĂƌƚƌĂƚĞ

Cypress Creek EMS System Policies and Treatment Guidelines

13 INTRODUCTION Revised 6/2019 Approved: Levon Vartanian, MD

COPD ŚƌŽŶŝĐŽďƐƚƌƵĐƚŝǀĞƉƵůŵŽŶĂƌǇĚŝƐĞĂƐĞ CO ĂƌďŽŶŵŽŶŽǆŝĚĞ ĂƌĚŝĂĐŽƵƚƉƵƚ CR ĂƉŝůůĂƌǇƌĞĨŝůůƚŝŵĞ Critical Burns ŶǇƉĂƚŝĞŶƚǁŝƚŚŽŶĞŽƌŵŽƌĞŽĨƚŚĞĨŽůůŽǁŝŶŐ͗ ^ĞĐŽŶĚĚĞŐƌĞĞхϯϬй^ dŚŝƌĚĚĞŐƌĞĞхϭϬй^ ŝƌĐƵŵĨĞƌĞŶƚŝĂůďƵƌŶƐ ƵƌŶƐǁŝƚŚĂƐƐŽĐŝĂƚĞĚƐŝŐŶŝĨŝĐĂŶƚŝŶũƵƌŝĞƐ ƵƌŶƐǁŝƚŚĂƐƐŽĐŝĂƚĞĚŝŶŚĂůĂƚŝŽŶŝŶũƵƌǇ ŶǇďƵƌŶƐŽĨƚŚĞĨĂĐĞ͕ĨĞĞƚ͕ŚĂŶĚƐ͕ŽƌŐĞŶŝƚĂůŝĂ C -Spine DŽƚŝŽŶ ƌĞƐƚƌŝĐƚŝŽŶ ĂŶĚ ƉƌŽƚĞĐƚŝŽŶ ŽĨ ƚŚĞ ƐƉŝŶĂů ĐŽůƵŵŶͬĐŽƌĚ ŝŶĐůƵĚŝŶŐ ŵĂŶƵĂů ƚĞĐŚŶŝƋƵĞƐ͕ĐĞƌǀŝĐĂůĐŽůůĂƌƐ͕ĞǆƚƌŝĐĂƚŝŽŶƚĞĐŚŶŝƋƵĞƐĂŶĚĚĞǀŝĐĞƐ͕ďĂĐŬďŽĂƌĚƐ͕ĐĞƌǀŝĐĂů ŵŽƚŝŽŶƌĞƐƚƌŝĐƚŝŽŶĚĞǀŝĐĞƐ͕ĂŶĚƐƚƌĂƉƉŝŶŐ DOS ĞĂƚŚŽŶƐĐĞŶĞ DVT ĞĞƉǀĞŝŶƚŚƌŽŵďŽƐŝƐ Glucometer ƉŽŝŶƚŽĨĐĂƌĞĚŝĂŐŶŽƐƚŝĐĚĞǀŝĐĞƚŽŵĞĂƐƵƌĞďůŽŽĚŐůƵĐŽƐĞůĞǀĞůƐ ECG ůĞĐƚƌŽĐĂƌĚŝŽŐƌĂŵ eFAST exam ;hůƚƌĂƐŽƵŶĚͿ ǆƚĞŶĚĞĚ &ŽĐƵƐĞĚ ƐƐĞƐƐŵĞŶƚ ^ŽŶŽŐƌĂƉŚǇ dĞĐŚŶŝƋƵĞ͕ see also FAST exam ETCO2 ŶĚ ƚŝĚĂů ĐĂƌďŽŶ ĚŝŽǆŝĚĞ͖ ŶŽƌŵĂů ǀĂůƵĞ ŝƐ ĂďŽƵƚ ϯϬʹϰϬ ŵŵ,Ő͘ ^ĞĞ Capnography ƐĞĐƚŝŽŶŝŶĂƉƉĞŶĚŝǆ Extremis /ŶĞǆƚƌĞŵĞĐŝƌĐƵŵƐƚĂŶĐĞƐ͖ĂƚƚŚĞƉŽŝŶƚŽĨĚĞĂƚŚ͖see also Peri-arrest FAST exam ;hůƚƌĂƐŽƵŶĚͿ&ŽĐƵƐĞĚƐƐĞƐƐŵĞŶƚ^ŽŶŽŐƌĂƉŚǇdĞĐŚŶŝƋƵĞ͖see also eFAST exam G 'ƌĂŵ;ƐͿ GCS 'ůĂƐŐŽǁĐŽŵĂƐĐĂůĞ H&H ,ĞŵŽŐůŽďŝŶĂŶĚŚĞŵĂƚŽĐƌŝƚ Hyperglycemia ůŽŽĚͲƐƵŐĂƌхϮϬϬŵŐͬĚů Hypertensive Crisis ^ǇƐƚŽůŝĐхϭϴϬŵŵ,ŐORĚŝĂƐƚŽůŝĐхϭϬϬŵŵ,ŐwithĞŶĚͲŽƌŐĂŶĐŽŵƉƌŽŵŝƐĞ Hypoglycemia ůŽŽĚͲƐƵŐĂƌфϲϬŵŐͬĚů ICP /ŶͲĐŚĂƌŐĞƉĂƌĂŵĞĚŝĐ͖ƉƌŽƚŽĐŽůĚĞƐŝŐŶĂƚŝŽŶďǇƚŚĞDĞĚŝĐĂůŝƌĞĐƚŽƌĂůůŽǁŝŶŐƉƌĂĐƚŝĐĞ up to ƚŚĂƚĚĞƐŝŐŶĂƚĞĚĨŽƌĂƉƉƌŽǀĞĚƉĂƌĂŵĞĚŝĐƐ;ƐĞĞĞůĞŐĂƚŝŽŶͿ IM /ŶƚƌĂŵƵƐĐƵůĂƌŵĞĚŝĐĂƚŝŽŶĂĚŵŝŶŝƐƚƌĂƚŝŽŶƌŽƵƚĞ IN /ŶƚƌĂŶĂƐĂůŵĞĚŝĐĂƚŝŽŶĂĚŵŝŶŝƐƚƌĂƚŝŽŶƌŽƵƚĞ IO /ŶƚƌĂŽƐƐĞŽƵƐĨůƵŝĚͬŵĞĚŝĐĂƚŝŽŶĂĚŵŝŶŝƐƚƌĂƚŝŽŶƌŽƵƚĞ IV /ŶƚƌĂǀĞŶŽƵƐĨůƵŝĚͬŵĞĚŝĐĂƚŝŽŶĂĚŵŝŶŝƐƚƌĂƚŝŽŶƌŽƵƚĞ

Cypress Creek EMS System Policies and Treatment Guidelines

14 INTRODUCTION Revised 6/2019 Approved: Levon Vartanian, MD

IVC /ŶĨĞƌŝŽƌǀĞŶĂĐĂǀĂ IVP /sƉƵƐŚŵĞĚŝĐĂƚŝŽŶĂĚŵŝŶŝƐƚƌĂƚŝŽŶƌŽƵƚĞ J or j :ŽƵůĞ;ƐͿ kg <ŝůŽŐƌĂŵ;ƐͿ LV >ĞĨƚǀĞŶƚƌŝĐůĞ MAP DĞĂŶĂƌƚĞƌŝĂůƉƌĞƐƐƵƌĞ͕ƚŚĞĂǀĞƌĂŐĞƉƌĞƐƐƵƌĞŝŶĂƉĂƚŝĞŶƚ͛ƐĂƌƚĞƌŝĞƐ͖ƐŚŽǁŶŽŶŵŽŶŝƚŽƌ͕ ŽƌŵĂǇďĞĐĂůĐƵůĂƚĞĚĂƐ͗ ௦௬௦௧௢௟௜௖஻௉ାሺௗ௜௔௦௧௢௟௜௖஻௉ൈଶሻ ܯܣܲ ൌ ଷ Major Burns ϮŶĚĂŶĚͬŽƌϯƌĚĚĞŐƌĞĞďƵƌŶƐŐƌĞĂƚĞƌƚŚĂŶϭϬйƚŽƚĂůďŽĚǇƐƵƌĨĂĐĞĂƌĞĂ mcg or Pg DŝĐƌŽŐƌĂŵ;ƐͿ mEq DŝůůŝĞƋƵŝǀĂůĞŶƚ;ƐͿ mg DŝůůŝŐƌĂŵ;ƐͿ min. or mins DŝŶƵƚĞ;ƐͿ M-Mode ;hůƚƌĂƐŽƵŶĚͿDŽƚŝŽŶŵŽĚĞ͖ŐƌĂƉŚƐĂƐŝŶŐůĞůŝŶĞĨƌŽŵƵůƚƌĂƐŽƵŶĚĚŝƐƉůĂǇŽǀĞƌƚŝŵĞ N/V EĂƵƐĞĂĂŶĚͬŽƌǀŽŵŝƚŝŶŐ Neonate ŶǇƉĂƚŝĞŶƚфϯϬĚĂǇƐŽůĚ NTG EŝƚƌŽŐůǇĐĞƌŝŶ

O2 KǆǇŐĞŶ;ĂĚŵŝŶŝƐƚƌĂƚŝŽŶͿ OOH-DNR KƵƚͲŽĨͲŚŽƐƉŝƚĂůĚŽŶŽƚƌĞƐƵƐĐŝƚĂƚĞŽƌĚĞƌ Pediatric Patient ƉĂƚŝĞŶƚфϭϲǇĞĂƌƐŽĨĂŐĞORǁĞŝŐŚŝŶŐфϲϬŬŐ Peri-arrest ƉĂƚŝĞŶƚŝŶĂƐĞǀĞƌĞůǇŚĞŵŽĚǇŶĂŵŝĐĂůůǇĐŽŵƉƌŽŵŝƐĞĚƐƚĂƚĞŝŶŝŵŵŝŶĞŶƚƌŝƐŬŽĨĨƵůů ĐĂƌĚŝĂĐĂƌƌĞƐƚ PACO2 DĞĂƐƵƌĞŵĞŶƚŽĨƉĂƌƚŝĂůƉƌĞƐƐƵƌĞŽĨĐĂƌďŽŶĚŝŽǆŝĚĞŝŶƚŚĞĂůǀĞŽůŝ PaCO2 DĞĂƐƵƌĞŵĞŶƚŽĨƉĂƌƚŝĂůƉƌĞƐƐƵƌĞŽĨĐĂƌďŽŶĚŝŽǆŝĚĞĚŝƐƐŽůǀĞĚŝŶĂƌƚĞƌŝĂůďůŽŽĚƐƚƌĞĂŵ dKϮŝƐĂůǁĂǇƐůŽǁĞƌƚŚĂŶWĂKϮ͕ĂŶĚƚŚĞŐĂƉŝƐĂĨƵŶĐƚŝŽŶŽĨƉĞƌĨƵƐŝŽŶƋƵĂůŝƚǇĂŶĚ ĚŝĨĨƵƐŝŽŶďĂƌƌŝĞƌƐ͘ PAO2 DĞĂƐƵƌĞŵĞŶƚŽĨƉĂƌƚŝĂůƉƌĞƐƐƵƌĞŽĨŽǆǇŐĞŶŝŶƚŚĞĂůǀĞŽůŝ PaO2 DĞĂƐƵƌĞŵĞŶƚŽĨƉĂƌƚŝĂůƉƌĞƐƐƵƌĞŽĨŽǆǇŐĞŶĚŝƐƐŽůǀĞĚŝŶĂƌƚĞƌŝĂůďůŽŽĚƐƚƌĞĂŵ PCR WĂƚŝĞŶƚĐĂƌĞƌĞƉŽƌƚ PDA WĂƚĞŶƚĚƵĐƚƵƐĂƌƚĞƌŝŽƐƵƐ PE WƵůŵŽŶĂƌǇĞŵďŽůƵƐͬĞŵďŽůŝƐŵ PFO WĂƚĞŶƚĨŽƌĂŵĞŶŽǀĂůĞ PLAX ;hůƚƌĂƐŽƵŶĚͿWĂƌĂƐƚĞƌŶĂů>ŽŶŐǆŝƐǀŝĞǁ PO KƌĂůŵĞĚŝĐĂƚŝŽŶĂĚŵŝŶŝƐƚƌĂƚŝŽŶƌŽƵƚĞ PUPH ;hůƚƌĂƐŽƵŶĚͿWƌĞŚŽƐƉŝƚĂůhůƚƌĂƐŽƵŶĚŝŶWĂƚŝĞŶƚǁŝƚŚ,ǇƉŽƚĞŶƐŝŽŶ

Cypress Creek EMS System Policies and Treatment Guidelines

15 INTRODUCTION Revised 6/2019 Approved: Levon Vartanian, MD

PPM WĂĐŝŶŐƉĞƌŵŝŶƵƚĞ PR ZĞĐƚĂůŵĞĚŝĐĂƚŝŽŶĂĚŵŝŶŝƐƚƌĂƚŝŽŶƌŽƵƚĞ Pre-term Delivery ĚĞůŝǀĞƌǇŽĐĐƵƌƌŝŶŐƉƌŝŽƌƚŽƚŚĞĞŶĚŽĨƚŚĞϯϳƚŚǁĞĞŬŽĨŐĞƐƚĂƚŝŽŶ prn ƐŶĞĞĚĞĚ q ǀĞƌǇ RUSH exam ;hůƚƌĂƐŽƵŶĚͿZĂƉŝĚhůƚƌĂƐŽƵŶĚĨŽƌ^ŚŽĐŬĂŶĚ,ǇƉŽƚĞŶƐŝŽŶ RV ZŝŐŚƚǀĞŶƚƌŝĐůĞ RVR ZĂƉŝĚǀĞŶƚƌŝĐƵůĂƌƌĞƐƉŽŶƐĞ SL ^ƵďůŝŶŐƵĂůŵĞĚŝĐĂƚŝŽŶĂĚŵŝŶŝƐƚƌĂƚŝŽŶƌŽƵƚĞ SLOW IVP ĚŵŝŶŝƐƚƌĂƚŝŽŶŽĨĂŶ/sŵĞĚŝĐĂƚŝŽŶŽǀĞƌƚŚĞƐƉĂŶŽĨϲϬƐĞĐŽŶĚƐŽƌůŽŶŐĞƌ SP02 or Sp02 WĞƌŝƉŚĞƌĂůĐĂƉŝůůĂƌǇŽǆǇŐĞŶƐĂƚƵƌĂƚŝŽŶ SUBX ;hůƚƌĂƐŽƵŶĚͿ^ƵďǆŝƉŚŽŝĚǀŝĞǁ SQ ^ƵďĐƵƚĂŶĞŽƵƐŵĞĚŝĐĂƚŝŽŶĂĚŵŝŶŝƐƚƌĂƚŝŽŶƌŽƵƚĞ SVR ^ǇƐƚĞŵŝĐǀĂƐĐƵůĂƌƌĞƐŝƐƚĂŶĐĞ͕ĂĨƵŶĐƚŝŽŶƉƌŝŵĂƌŝůǇŽĨƉĞƌŝƉŚĞƌĂůǀĂƐŽĐŽŶƐƚƌŝĐƚŝŽŶ TCA dƌŝĐǇĐůŝĐ ŶƚŝĚĞƉƌĞƐƐĂŶƚ͖ ĐŽŵŵŽŶůǇ ŝŶĐůƵĚĞƐ ŵĞĚŝĐĂƚŝŽŶ ƐƵĨĨŝǆĞƐ͞ͲƉƌĂŵŝŶĞ͕͟ ͞Ͳ ƚƌŝƉƚǇůŝŶĞ͟ĂŶĚŵĞĚŝĐĂƚŝŽŶƐƐƵĐŚĂƐĚŽǆĞƉŝŶĂŶĚĂŵŽǆĂƉŝŶĞ͘ Trauma Patient ŶǇŝŶĚŝǀŝĚƵĂůǁŚŽĞǆƉĞƌŝĞŶĐĞƐďůƵŶƚŽƌƉĞŶĞƚƌĂƚŝŶŐƐŝŶŐůĞŽƌŵƵůƚŝƉůĞŽƌŐĂŶƐǇƐƚĞŵ ŝŶũƵƌǇƌĞƐƵůƚŝŶŐŝŶƉŽƚĞŶƚŝĂůŵŽƌďŝĚŝƚǇĂŶĚͬŽƌŵŽƌƚĂůŝƚǇ Triage dŚĞĐůĂƐƐŝĨŝĐĂƚŝŽŶŽĨƉĂƚŝĞŶƚƐĂĐĐŽƌĚŝŶŐƚŽŵĞĚŝĐĂůŶĞĞĚƐ TQ dŽƵƌŶŝƋƵĞƚ

VE DŝŶƵƚĞǀĞŶƚŝůĂƚŝŽŶ͖ǀŽůƵŵĞŽĨĂŝƌŵŽǀĞĚďǇƉĂƚŝĞŶƚŝŶŽŶĞŵŝŶƵƚĞ

sсsdǆƌĞƐƉŝƌĂƚŽƌǇƌĂƚĞ͕ǁŚĞƌĞsdŝƐƚŝĚĂůǀŽůƵŵĞ͘ VF or VFIB sĞŶƚƌŝĐƵůĂƌĨŝďƌŝůůĂƚŝŽŶ Vital Signs or V/S ZĞƐƉŝƌĂƚŽƌǇƌĂƚĞ͕ďůŽŽĚƉƌĞƐƐƵƌĞ͕ƉƵůƐĞƌĂƚĞ͕ƉƵůƐĞŽǆŝŵĞƚƌǇ͕ƚĞŵƉĞƌĂƚƵƌĞ͕ĂŶĚďƌĞĂƚŚ ƐŽƵŶĚƐ VSD sĞŶƚƌŝĐƵůĂƌƐĞƉƚĂůĚĞĨĞĐƚ VT or VTach sĞŶƚƌŝĐƵůĂƌƚĂĐŚǇĐĂƌĚŝĂ

VT dŝĚĂůǀŽůƵŵĞ͖ǀŽůƵŵĞŽĨĂŝƌŝŶŚĂůĞĚŝŶŽŶĞďƌĞĂƚŚ Δ ŚĂŶŐĞ

Cypress Creek EMS System Policies and Treatment Guidelines

16 INTRODUCTION Revised 6/2019 Approved: Levon Vartanian, MD

ZĞĨĞƌĞŶĐĞsĂůƵĞƐ DĞĂƐƵƌĞŵĞŶƚ EŽƌŵĂůsĂůƵĞ DĞĂƐƵƌĞĚtŝƚŚ EŽƚĞƐ BGL ϲϬʹϮϬϬŵŐͬĚ> WK'ůƵĐŽŵĞƚĞƌ ZĞĨĞƌĞŶĐĞƌĂŶŐĞĨŽƌ ƵŶĨĂƐƚĞĚͬƵŶŬŶŽǁŶĨĂƐƚĞĚƐƚĂƚĞ ETCO2 ϯϬʹϰϬŵŵ,Ő ^ŝĚĞƐƚƌĞĂŵ ^ĞĞCapnographyƐĞĐƚŝŽŶŝŶĂƉƉĞŶĚŝǆ ĐĂƉŶŽŐƌĂƉŚǇ PaO2 ϴϬʹϭϬϬŵŵ,Ő ' ZĞĨĞƌĞŶĐĞƐƚĂŶĚĂƌĚŝƐϱϬϬŵŵ,Őǆ &ŝKϮ PaCO2 ϯϱʹϰϱŵŵ,Ő ' dKϮŝƐĂůǁĂǇƐůŽǁĞƌƚŚĂŶWĂKϮ Hemoglobin Male͗ϭϮʹϭϲŐͬĚ> WK,Θ,ŵĞƚĞƌ Female͗ϭϯ͘ϱʹϭϳ͘ϱŐͬĚ> Hematocrit Male:ϯϲ͘ϭʹϰϰ͘ϯй WK,Θ,ŵĞƚĞƌ ,ĞŵĂƚŽĐƌŝƚŵĂǇŶŽƚĂůǁĂǇƐďĞ Female:ϰϬ͘ϳʹϱϬ͘ϯй ŵĞĂƐƵƌĞĚŝĨŚĞŵŽŐůŽďŝŶŝƐůŽǁ͘ Child:ϯϭʹϰϯй

Cypress Creek EMS System Policies and Treatment Guidelines

17 INTRODUCTION Approved: Levon Vartanian, MD

Delegation of Medical Practice

Revised 10/29/2019 Overview of Credentialing at Cypress Creek EMS Members of Cypress Creek EMS may not practice past the level they are credentialed by the Medical Director and his representatives in the Clinical Department. This credentialing follows this structure:

Medical Emergency Care Attendants, EMT-Basics, EMT-Intermediates, and Paramedics may be Providers credentialed to perform skills at the level of their certification (as delegated below). Without further specific credentialing, medically-certified personnel may not be the lead patient care provider during transport to the hospital.

First First Responders from CCEMS and from partner agencies are able to provide response Responders assistance on EMS calls. These first responders may be certified as ECAs, EMT-Basics, Advanced EMTs, or EMT-Paramedics, but may only provide BLS level care, unless otherwise credentialed by the CCEMS Medical Director and approved through CCEMS.

Unit Operator EMT-Basics, Advanced EMTs, and Paramedics may be credentialed at this level to assist with patient care under the direction of a Basic In-Charge, PI, PII, PIII, or Field Supervisor. Unit Operators may perform procedures at the level of their training and certification; a paramedic unit operator may perform any procedures at the level of PI. A Unit Operator without in-charge or P1 credentialing may not be the sole provider of patient care during transport.

Basic In-Charge EMT-Basics, Advanced EMTs, and Paramedics may be credentialed at this level to function as the lead patient care provider during transport provided no advanced procedures were performed and a PII, PIII, or Field Supervisor is on board.

PI EMT-Paramedics credentialed as a PI may function as the lead patient provider at the level of their certification (as detailed below) provided a PII, PIII, or Field Supervisor is on board.

PII/In-Charge EMT-Paramedics credentialed as a PII may function as the lead patient provider and lead Paramedic crew member. The In-Charge Paramedic is ultimately responsible for all patient care and operational aspects of their assigned unit.

PIII EMT-Paramedics credentialed as a PIII are expected to be clinical subject matter experts and leaders. Certain procedures, such as Rapid Sequence Intubation, may only be performed under the direct supervision of a PIII on scene. PIIIs may also provide advice and authorization for other specific procedures such as sedation.

Field Supervisor A Field Supervisor is a PIII credentialed to provide operational oversight and direction of field crews.

Advanced Advanced Practice RNs and Physician Assistants credentialed by the Medical Director may Practice function to the full extent of these protocols, as well as additional duties as delegated Providers (APP) specifically by the Medical Director.

Cypress Creek EMS System Policies and Treatment Guidelines

18 INTRODUCTION Approved: Levon Vartanian, MD

Medical Director Authorization to Practice As a physician licensed to practice medicine in the State of Texas, and as the physician Medical Director for Cypress Creek EMS, I hereby authorize the following: Emergency Care Attendant: Those Members of Cypress Creek EMS that are certified as an Emergency Care Attendant by the Texas Department of State Health Services, and while operating as a Member in good standing with Cypress Creek EMS, may provide basic, non-invasive care for our patients as set forth by the United States Department of Transportation, National Highway Traffic Safety Administration, First Responder National Standard Curriculum, as adopted by the Texas Department of State Health Services. These providers may also use an impedance threshold device (ResQPod) during CPR and assist with the application of a mechanical compression device. EMT-Basic/First Responder: Those members of partner agencies that are certified as an EMT-Basic, Advanced EMT, or EMT- Paramedic by the Texas Department of State Health Services, and while operating as a member in good standing with their respective partner agency, may provide basic, non-invasive care for our patients as set forth by the United States Department of Transportation, National Highway Traffic Safety Administration, EMT-Basic National Standard Curriculum, as adopted by the Texas Department of State Health Services. Additionally, these EMT-Basic providers, when responding to medical emergency situations prior to the arrival of a CCEMS ambulance may perform the following as indicated: x Administration of aspirin according to the Chest Pain protocol. x King supraglottic airway insertion during cardiac arrest. x Utilization of impedance threshold device (ResQPod) during CPR. x Blood glucose assessment. x Oral glucose administration. x Assist patient in taking their prescribed nebulizer or inhaled bronchodilator medication (e.g. albuterol, Atrovent, Combivent, Xopenex, etc.). x Assist patient in taking their prescribed nitroglycerin. x Assist patient in utilizing their prescribed epinephrine auto-injector device (EpiPen). x Assist application of electrodes for ECG or 12-lead acquisition. Advanced EMT or Paramedic/ALS First Responder: Those members of partner agencies that are certified as an Advanced EMT or EMT-Paramedic by the Texas Department of State Health Services, and while operating as a member in good standing with Cypress Creek EMS or their respective partner agency, may provide basic, non-invasive care and invasive care for our patients as set forth by the United States Department of Transportation, National Highway Traffic Safety Administration, EMT-Basic National Standard Curriculum, as adopted by the Texas Department of State Health Services. Partner agencies and personnel from partner agencies must be credentialed and approved to provide invasive care through the CCEMS medical director and CCEMS. Furthermore, those providers certified as Advanced EMTs by the Texas Department of State Health Services and credentialed and approved by CCEMS, when responding to medical emergency situations prior to the arrival of a CCEMS ambulance may perform the following as indicated: x All procedures listed above (under EMT-Basic/First Responder). x IV insertion/therapy (saline lock and/or normal saline infusion).

Cypress Creek EMS System Policies and Treatment Guidelines

19 INTRODUCTION Approved: Levon Vartanian, MD

x Adult and pediatric EZ/IO intraosseous insertion/infusion. x King supraglottic airway insertion. x IV/IO medication administration in cardiac arrest care. Furthermore, those providers certified as EMT-Paramedics by the Texas Department of State Health Services and credentialed and approved by CCEMS, when responding to medical emergency situations prior to the arrival of a CCEMS ambulance may perform the following as indicated: x All procedures listed above. x IV/IO/IN/IM medication administration. x Endotracheal Intubation/Nasotracheal Intubation. x Nasogastric or Orogastric tube placement. EMT-Basic Unit Operator/Basic In-Charge: Those Members of Cypress Creek EMS that are certified as an EMT-Basic by the Texas Department of State Health Services, and while operating as a Member in good standing with Cypress Creek EMS, may provide basic, non-invasive care for our patients as set forth by the United States Department of Transportation, National Highway Traffic Safety Administration, EMT-Basic National Standard Curriculum, as adopted by the Texas Department of State Health Services. Additionally, these EMT-Basic providers may, under the direction and direct supervision of a PII, PIII, or Field Supervisor, as credentialed by me, may perform the following: x Administration of aspirin according to the Chest Pain protocol. x King supraglottic airway insertion during cardiac arrest. x Utilization of impedance threshold device during CPR. x Application of electrodes for ECG or 12-lead acquisition. x Blood glucose assessment. x Nebulized albuterol and/or ipratropium administration. x Oral acetaminophen (Tylenol) administration. x Oral glucose administration. x Oral ibuprofen (Motrin) administration. x Oral/sublingual nitroglycerin administration. When authorized by the PII/Paramedic In-Charge, those designated as a Basic In-Charge may be the lead patient care provider during transport to the receiving facility provided that an ECG or 12-lead was not performed, and no medication was administered except acetaminophen (Tylenol), ibuprofen (Motrin), or oral glucose. If a Basic In-Charge is not comfortable handling a BLS level call for any reason, they must inform the PII/In-Charge Paramedic, and the PII/In-Charge Paramedic should be the lead patient care provider during transport. An on-duty Field Supervisor may be contacted after patient care is complete to debrief the call and determine appropriateness of delegation. When operating as an approved CCEMS First Responder, members designated as an EMT-Basic Unit Operator or Basic In-Charge may initiate medical care as indicated. Members may provide care as outlined above for EMT-Basics, within the operating guidelines for the CCEMS First Responder program. Additional, CCEMS First Responders may assist patient in utilizing their prescribed epinephrine auto- injector device (EpiPen).

Cypress Creek EMS System Policies and Treatment Guidelines

20 INTRODUCTION Approved: Levon Vartanian, MD

Advanced EMT Unit Operator/Basic In-Charge: Those Members of Cypress Creek EMS that are certified as an Advanced EMT or EMT-Paramedic by the Texas Department of State Health Services, and while operating as a Member in good standing with Cypress Creek EMS, may provide basic, non-invasive, and invasive care for our patients as set forth by the United States Department of Transportation, National Highway Traffic Safety Administration, EMT- Advanced National Standard Curriculum, as adopted by the Texas Department of State Health Services. Furthermore, these Advanced EMT providers may, under the direction and direct supervision of a PII, PIII, or Field Supervisor, as credentialed by me, may perform the following: x All procedures listed above. x IV insertion/therapy (saline lock and/or normal saline infusion). x Adult and pediatric EZ/IO intraosseous insertion/infusion. x King supraglottic airway insertion. x IV/IO medication administration in cardiac arrest care. When authorized by the PII/Paramedic In-Charge, those designated as a Basic In-Charge may be the lead patient care provider during transport to the receiving facility provided that an ECG or 12-lead was not performed, and no medication was administered except acetaminophen (Tylenol), ibuprofen (Motrin), or oral glucose. If a Basic In-Charge is not comfortable handling a BLS level call for any reason, they must inform the PII/In-Charge Paramedic, and the PII/In-Charge Paramedic should be the lead patient care provider during transport. An on-duty Field Supervisor may be contacted after patient care is complete to debrief the call and determine appropriateness of delegation. When operating as an approved CCEMS First Responder, members designated as an Advanced EMT Unit Operator or Basic In-Charge may initiate medical care as indicated. Members may provide care as outlined above for Advanced EMTs, within the operating guidelines for the CCEMS First Responder program.

EMT-Paramedic Unit Operator: Those Members of Cypress Creek EMS that are certified or licensed as an EMT-Paramedic by the Texas Department of State Health Services, credentialed by me, and while operating as a Member in good standing with Cypress Creek EMS, may provide basic, non-invasive, and invasive care for our patients as set forth by the United States Department of Transportation, National Highway Traffic Safety Administration, EMT-Paramedic National Standard Curriculum, as adopted by the Texas Department of State Health Services. Furthermore, these EMT-Paramedic providers may, under the direction and direct supervision of a PII, PIII, or Field Supervisor, as credentialed by me, may perform the following: x All procedures listed above. x IV/IO/IN/IM medication administration. x Endotracheal Intubation/Nasotracheal Intubation. x Nasogastric or Orogastric tube placement. Those members designated as Paramedic Unit Operators may not be the lead patient care provider during transport. When operating as an approved CCEMS First Responder, members designated as a Paramedic Unit Operator may initiate medical care as indicated. Members may provide care as outlined above, within the operating guidelines for the CCEMS First Responder program.

Cypress Creek EMS System Policies and Treatment Guidelines

21 INTRODUCTION Approved: Levon Vartanian, MD

EMT-Paramedic I: Those Members of Cypress Creek EMS that are certified or licensed as an EMT-Paramedic by the Texas Department of State Health Services, credentialed by me, and while operating as a Member in good standing with Cypress Creek EMS, may provide basic, non-invasive, and invasive care for our patients as set forth by the United States Department of Transportation, National Highway Traffic Safety Administration, EMT-Paramedic National Standard Curriculum, as adopted by the Texas Department of State Health Services. Furthermore, these EMT-Paramedic providers may, under the direction and direct supervision of a PII, PIII, or Field Supervisor, as credentialed by me, may perform the following: x All procedures listed above. x IV/IO/IN/IM medication administration. x Endotracheal Intubation/Nasotracheal Intubation. x Nasogastric or Orogastric tube placement. When authorized by the PII/Paramedic In-Charge, those designated as a PI may be the lead patient care provider during transport to the receiving facility. If an EMT-Paramedic I is not comfortable handling the call for any reason, they must inform the PII/In-Charge Paramedic, and the PII/In-Charge Paramedic should be the lead patient care provider during transport. An on-duty Field Supervisor may be contacted after patient care is complete to debrief the call and determine appropriateness of delegation. When operating as an approved CCEMS First Responder, members designated as a P1 may initiate medical care as indicated. Members may provide care as outlined above, within the operating guidelines for the CCEMS First Responder program.

EMT-Paramedic II/Paramedic In-Charge: Those Members of Cypress Creek EMS that are certified or licensed as an EMT-Paramedic by the Texas Department of State Health Services, and while operating as a Member in good standing with Cypress Creek EMS, may provide basic, non-invasive, and invasive care for our patients as set forth by the United States Department of Transportation, National Highway Traffic Safety Administration, EMT-Paramedic National Standard Curriculum, as adopted by the Texas Department of State Health Services. Furthermore, these EMT-Paramedic II providers, as credentialed by me, henceforth the In-Charge Paramedic, may perform the following: x All procedures listed above. x May provide and direct patient care as set forth in these patient care protocols, with the exception of the Rapid Sequence Induction Procedure and Sedation protocol. When operating as an approved CCEMS First Responder, members designated as a P2 may initiate medical care as indicated. Members may provide care as outlined above, within the operating guidelines for the CCEMS First Responder program. EMT-Paramedic III: Those Members of Cypress Creek EMS that are certified or licensed as an EMT-Paramedic by the Texas Department of State Health Services, and while operating as a Member in good standing with Cypress Creek EMS, may provide basic, non-invasive, and invasive care for our patients as set forth by the United States Department of Transportation, National Highway Traffic Safety Administration, EMT-Paramedic

Cypress Creek EMS System Policies and Treatment Guidelines

22 INTRODUCTION Approved: Levon Vartanian, MD

National Standard Curriculum, as adopted by the Texas Department of State Health Services. Furthermore, these EMT-Paramedic III providers, as credentialed by me, may perform the following: x All procedures listed above x May provide and direct patient care as set forth in these patient care protocols in their entirety including the Rapid Sequence Induction Procedure and Sedation protocol. When operating as an approved CCEMS First Responder, members designated as a P3 may initiate medical care as indicated. Members may provide care as outlined above, within the operating guidelines for the CCEMS First Responder program. Advanced Practice Providers (APP): Those Members of Cypress Creek EMS that are licensed as an Advanced Practice Nurse by the Texas Board of Nursing or as Physician Assistant by the Texas Physician Assistant Board, credentialed by me, and while operating as a Member in good standing with Cypress Creek EMS, may provide and direct basic, non-invasive, and invasive care for our patients as set forth in these protocols in their entirety as well as delineated in any specific delegation agreement signed by me. When operating as an approved CCEMS First Responder, members designated as an APP may initiate medical care as indicated. Members may provide care as outlined above, within the operating guidelines for the CCEMS First Responder program.

Cypress Creek EMS System Policies and Treatment Guidelines

23 CLINICAL POLICIES Revised 8/2016 Approved: Levon Vartanian, MD

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Air Medical Utilization ...... 25 Child/Elder Abuse Recognition and Reporting ...... 27 Criteria for Death/Withholding Resuscitation ...... 29 Do Not Resuscitate (DNR) Orders...... 30 Documentation Guidelines ...... 31 Field Termination ...... 35 Fire Standby Response/Fire Rehab ...... 36 Inter-facility Transfers ...... 37 Paramedic Initiated Referral ...... 38 Patient Determination/Non-Transportation ...... 42 Physician on Scene ...... 46 Quality Management Process ...... 47 Safe Transport of Pediatric Patients ...... 48 Self-Reporting of Clinical Incidents...... 49

Cypress Creek EMS System Policies and Treatment Guidelines

24 Cypress Creek EMS COVID-19 Guidance for CCEMS Personnel COVID-19 Screening Tool Pay attention to call notes for positive Comm Center screening or Person Under Monitoring cautions. Consider COVID-19 screening for any call for “sick person”, fever, shortness of breath, or other respiratory complaint. Complete screening at a six-foot distance from patient.

Symptoms No Is the patient presenting with fever and/or new onset of cough or difficulty breathing? YES NEGATIVE Exposure Risk Factors screening; Has the patient Did the patient Did the patient have close Does the proceed with travelled outside have close contact contact with a person with acute patient have patient care. No to all the state in the 14 OR with a confirmed OR respiratory illness who has been OR a cough and days before the or probable case outside the state within 14 days complaint of onset of illness? of COVID-19? prior to their illness onset? fever? YES YES YES YES

POSITIVE Screening: Take precautions and follow guidelines below Guidelines for Suspected COVID-19 Patient Care Isolate • Wear gloves, N-95 or face mask, and safety glasses. • Wear a gown and N-95 mask if patient is heavily contaminated or if performing aerosolizing procedures (CPR, airway management, intubation, etc). • Place surgical mask on patient; use a B/V filter on BVM or ventilator. 1. • Family and friends of patient should not ride in ambulance if at all possible. If they are riding, they should wear a surgical mask and be in the patient compartment. • Close any pass-through windows/doors between cab and patient compartment before loading. • During transport, run the rear exhaust fan and open windows to increase air flow. • The driver should remove all PPE and perform hygiene before getting into the cab. • Document during call using “Cath tablet” and/or a notepad. Do not take PCR computer out of cab.

3. Inform hospital before leaving scene and follow ER handoff instructions. Disinfect and Document • Thoroughly wash hands, disinfect all equipment used, disinfect personal equipment, and clean and disinfect ambulance. Air 4. out the patient compartment as much as possible to dilute and remove viral particles. • Do not use PCR computer during response/transport. Complete PCR after call. • Include all personnel on scene and level of contact with patient in PCR. • Report call to on-duty field supervisor and [email protected]. Assess and Treat • Follow general clinical care guidelines for respiratory illness. 2. • Balance risk to providers from exposure vs. patient benefit when considering if a treatment is needed. • Do not use any CPAP or BiPAP (this is a high risk for aerosolizing droplets). • Avoid treatments that might trigger coughing, such as nebulizers.

Updated 3/16/2020 ADULT MEDICAL Revised 04/2020 Approved: Levon Vartanian, MD

Cardiac Arrest (Interim Disaster Guidance) Pearls • Make every attempt to wear the proper personal protective equipment (PPE). Your level of readiness is critical to both excellent clinical care and continued response to this pandemic. • Limit exposure to potentially infectious patients when possible; if call notes indicate very high probability that a patient is DOS, consider sending a single provider inside the residence to confirm. • Place a surgical mask on the patient before performing other interventions. • Prioritize early defibrillation and chest compressions. • Efficiently manage the airway by securing it with the fewest interventions possible. Consider an early supraglottic airway rather than multiple ET intubation attempts. • The goal of this approach to cardiac arrest is to reduce demand for manpower, as our resources are finite. Additionally, our hospital partners should be delivered patients that they have capacity to treat, rather than patients that simply need their resuscitation terminated. • This protocol may be further amended in escalating disasters.

DOS Criteria Ventilator Settings Disposition

DO NOT WORK THESE PATIENTS CARDIAC ARREST: AFTER 20 MINS

Apneic and pulseless AND FiO2: 100 Persistent asystole/agonal AND

Decapitation OR PIP: 60 (alarm) EtCO2 ≤ 20 mmHg AND Trigger: -6.0 Rigor mortis (w/o isolated >18 years of age AND trismus) OR PEEP: 0 Primary cardiac arrest AND Incineration OR Vt: 400 mL (adult) Without exclusions: Decomposition OR BPM: 12 • Pregnant patient • Dependent lividity OR Mode: AC (V) Patient in view of public • Neurological activity HIGH PRESSURE ALARM Head or trunk trauma OR • Any ROSC, even transiently LIKELY NORMAL DNR ROSC: Approach family/resp. party; with permission: FiO2: Titrate to SpO2 of 94-99% TERMINATE PIP: 30 (alarm) OR PEEP: 5 AFTER 20 MINS, TRANSPORT

Cypress Creek EMS System Policies and Treatment Guidelines MEDICAL Revised 05/2020 Approved: Levon Vartanian, MD

Respiratory Distress COVID-19 Response (all patients)

Assessment Requirements Treatment for Hypoxia ECG Nasal cannula ↑ 6 l/min Isolation mask on patient EtCO2 > 60 – RED FLAG NRB ↑ 15 l/min PPE (N-95, eye protection, gloves)

SpO2 < 90% – RED FLAG COVID-19 risk (mask on patient) CAUTION: AEROSOL-GENERATING* Isolation mask on patient or viral filter on mask/tube Temperature Nebulization/CPAP/BiPAP BVM/RSI PPE (N-95, glasses, face shield or *CALL FOR SUPERVISOR safety goggles, gown, gloves) Required Treatments Airway management Ventilation/Oxygenation Circulation

Available Treatments Refer to routine protocol(s) with the following guidance: Nebulization: Nebulization is permitted ONLY with the following devices: • Non-invasive ventilation with ventilator (in-line) • Supraglottic or subglottic airways PROHIBITED: Handheld nebulizer and aerosol mask CPAP/BiPAP: CPAP and BiPAP should be reserved for patients that present with relatively low-risk for COVID-19 (e.g. history of COPD/CHF without additional viral symptoms or risk factors). Nebulization is allowable with BiPAP on the ventilator. PROHIBITED: Nebulized medications with CPAP Usage of a viral filter is still imperative.

Combative Hypoxic Patient • (P3 consult) Ketamine (light sedation) 1.0 mg/kg SLOW IV OR 4 mg/kg IM Apnea/Respiratory Failure • BVM ventilation (with CPAP mask if possible) • i-gel or ET tube (Rapid Sequence Intubation if necessary, ventilator if possible) When in doubt, don proper PPE and treat the patient. COVID-19 Pearls • During time of airborne/droplet precautions, aerosol-generating procedures should be limited due to risk to EMS providers. Use immense caution when providing these treatments and avoid administration for precautionary reasons. A good mask seal (with minimal adjustment) is imperative to reduce exposure.

Cypress Creek EMS System Policies and Treatment Guidelines MEDICAL Revised 05/2020 Approved: Levon Vartanian, MD

• Most COVID-19 patients will tolerate significant hypoxemia without visible respiratory distress. Base intubation and treatment escalation decisions on O2 saturation, mental status, work of breathing, and high EtCO2. • Intubation is the highest risk intervention for EMS personnel; following the COVID-19 Intubation Checklist should ensure minimum risk.

Cypress Creek EMS System Policies and Treatment Guidelines COVID-19 PROCEDURES

COVID-19 Intubation Checklist Personal Protective Equipment (PPE) o N-95 mask o Eye protection and face shield o Gloves and gown o Stage empty biohazard trash can for immediate secured disposal of contaminated disposable equipment

Medications & Pre-Planned ETT Depth o Succinylcholine 1.5mg/kg o Ketamine 1.5mg/kg o Rocuronium 1 mg/kg o ET tube insertion depth 3 × diameter (e.g. 8.0 tube = 24 cm depth)

Equipment o Video laryngoscope & blade o BVM with the BVM filter and PEEP valve added o Nasal cannula o CPAP mask o Suction/iGel/surgical airway o Additional bacterial/viral filter on ventilator tubing (if utilizing ventilator) o Ventilator set-up and settings complete

Procedure o Most experienced P3 or supervisor should intubate, limit people in ambulance o Pre-oxygenation: o BVM with viral filter, PEEP valve, and nasal cannula (4lpm) o Apneic period (Post-Ketamine) o Hold BVM mask with PEEP valve on patient’s mouth to prevent decruitment but don’t actively bag the patient o Discontinue all O2 sources prior to removing mask to attempt intubation o Once ET tube is placed – inflate cuff prior to ventilation o Secure ET tube to pre-calculated depth

Post-Procedure o Place ventilator onto ET tube and administer post-intubation sedation/paralysis as needed o Notify incoming hospital of patient with suspected COVID-19 exposure o Continue to wear all PPE until transfer of care o Meticulous removal of PPE post-transfer of care o Wash hands thoroughly. o Don clean PPE, then complete disinfection of ambulance patient compartment and equipment.

Cypress Creek EMS System Policies and Treatment Guidelines COVID-19 PROCEDURES

BVM/viral filter/PEEP/CPAP mask ET tube, viral filter, ventilator tubing

Cypress Creek EMS System Policies and Treatment Guidelines CLINICAL POLICIES Revised 7/2020 Approved: Levon Vartanian, MD Non-Transport for Suspected COVID-19 Patients During the COVID-19 pandemic, this non-transport protocol should be used to identify patients that are safe for not transporting to the hospital in order to reduce exposures, potential disease spread, and impact on hospital saturation. This protocol may be utilized when activated by CCEMS leadership based on local outbreak conditions for the duration of the outbreak.This protocol may only be utilized by P2 or P3 credentialled paramedics.

1. Initial Assessment • If Comm Center advises that the patient is suspected of having COVID-19, don PPE before entering the scene. • Consider COVID-19 screening for any call for “sick person”, fever, shortness of breath, or other respiratory complaint. • Complete screening at a six-foot distance from patient. High suspicion of COVID-19 2. Patient Assessment (Inclusion criteria) • Age greater than 17 and less than 60 years old. • Fever > 100.4° F or patient reports feeling warm/feverish. • One or more viral symptoms present (Cough, nasal and chest congestion, sore throat, body aches, loss of taste or smell). NO to Any Exit to the appropriate • Vital signs: protocol. • HR < 120 • RR between 8 and 20 • SpO2 > 94% on room air. • Sys. BP ≥ 100 mmHg • GCS 15 YES to all

3. Exclusions? • Chest pain, other than mild with coughing, or • Shortness of breath with activity, or • Syncope, or YES to Any Exit to the appropriate • Cyanotic, or protocol • Immunocompromised, or poorly controlled comorbidities (diabetes, hypertension, cardiovascular disease, stroke, COPD, or chronic liver disease). NO to all 4. Non-Transport Process • Discuss non-transport, self-quarantine, and when to seek care using scripting tool on next page. • Ensure patient has an appropriate support system in place in case EMS needs to be called on the patient’s behalf. • Consult with MD2. If MD2 is unavailable, call the Clinical On-Call number. • Fill out and hand COVID-19 Non-Transport brochure to patient. • Have patient sign the COVID-19 Non-Transport signature. Transport or contact Medical Control/Clinical On-Call if patient doesnot meet criteria.

Cypress Creek EMS System Policies and Treatment Guidelines 34 CLINICAL POLICIES Revised 7/2020 Approved: Levon Vartanian, MD Scripting When you identify an eligible patient for non-transport, it’s important to communicate why this is a safe and desirable option for them. Most will be concerned about a possible COVID-19 infection, so it is important to: Reassure • That you’ve assessed them and did not find any immediate life threats. • The vast majority of COVID-19 patients have an uncomplicated course and recover completely. • If they develop worsening symptoms, they can call 911 and get an immediate ambulance response back to their address. Educate • There are no antibiotics or other medications to treat this illness and the key treatments for the vast majority of cases is fever control and hydration, which can safely be done at home. • Hospital COVID-19 testing is limited to the seriously ill patients or those with an increased risk of hospitalization or a bad outcome, and that if you did transport them to the ER, they are likely not to get a test for COVID-19. • Testing sites are available through Harris County Public Health and they can sign up for a testing site at covidcheck.hctx.net. • Instruct them to call for 911 assistance again or go to the hospital if they have: • Difficulty breathing • Fever daily for greater than 7 days • Unable to take oral fluids or medicines. Use of this language is encouraged: “During this pandemic, the local and national healthcare system is overwhelmed. Based on this fact, my assessment, and our Medical Director’s opinion, transport to a hospital may place you at a higher risk of exposure to infective sources.” Additional Information • This guidelines is intended to reduce exposure risk to EMS and to patient and reduce ED crowding during high volume times. • A consult is required with MD2. If MD2 is unavailable, contact the Clinical On-Call P3 for consult. • The goal of these guidelines is to identify patients who have signs and symptoms consistent with COVID-19 AND are a low risk for a serious disease that might require hospitalization. • Complete documentation as a “Patient Treated, Released (Per Protocol)” and describe the non- transport conversation, the patient’s support system, and any other relevant information in the narrative. • Patients must be competent and capable of understanding the provided instructions. Patients also must have a support system, which could include family members, caretakers, or close friends who will be able to help the patient meet their basic daily needs and complete outpatient COVID-19 testing.

Cypress Creek EMS System Policies and Treatment Guidelines 35 CLINICAL POLICIES Revised 7/2020 Approved: Levon Vartanian, MD

Paramedic Initiated Referral

During disasters, this protocol may be implemented to reduce ED overcrowding and improve the use of limited resources by identifying patients that do not require ambulance transport to an emergency room and providing or referring to an appropriate level of care. This protocol may only be utilized by P2 or P3 credentialled paramedics after being authorized during a specific disaster. Each referral requires a consult with MD2 or Clinical On-Call. Procedure 1. Perform an appropriate patient assessment and initial treatment on all patients. 2. If patient does not desire transportation to an emergency room, obtain a refusal of treatment/transport as usual. 3. If patient is eligible for PIR and meets one of the PIR inclusion criteria below, consult with MD2 or Clinical On-Call to receive authorization. 4. Discuss non-transport and referral instructions with patient using scripting guidance on next page. 5. Fill out and hand the patient a Prehospital Discharge Instruction handout. 6. Obtain patient signature on the Paramedic Initiated Referral form in ESO. 7. Fully document the patient encounter in the electronic patient care report, using the disposition “Treated, Released (Per Protocol)”

Eligible Patients • Patients must be able to adequately communicate with you. This excludes the very young and very old. Language barriers are not automatically an exclusion, provided patient is able to adequately answer questions through an interpreter. • Patient vital signs must be stable. HR must be less than 120, RR between 8 and 20, SBP ≥ 100 mmHg, and SpO2 ≥ 94% on room air.

Inclusion Criteria (patients who may be referred) • Patients who have no complaint and no significant mechanism of injury but request ambulance transportation. No follow-up care instructions are indicated; provide patient with Prehospital Discharge Instruction #1 • Patients seeking transportation for routine doctor visits, scheduled clinic or lab appointments, scheduled dialysis, or catheter insertions. No follow-up instructions are indicated. Provide the patient with Prehospital Discharge Instruction #1 • Patients with minor insect or animal bites, including lice and foreign objects in the ear or nose (without airway compromise). For animal/insect bites, provide the patient with Prehospital Discharge Instruction #2. For lice infestation, provide Instruction #3. For foreign object in ear/nose, provide with Instruction #4. • Patients with minor bruises, abrasions, or lacerations (including animal bites). Provide appropriate first aid, wound care, and bandaging as indicated. For minor bruises, abrasions, and lacerations,

Cypress Creek EMS System Policies and Treatment Guidelines CLINICAL POLICIES Revised 7/2020 Approved: Levon Vartanian, MD

provide Instruction #5. If there is a possibility the patient may also require sutures, provide with Instruction #6. • Patients with non-specific extremity pain, joint sprains, isolated toothache, or minor swelling due to trauma. Provide first aid for comfort which may include cold application and/or bandaging/splinting. For non-specific extremity pain or minor swelling due to trauma, provide the patient with Instruction #5. For isolated toothache, provide with Instruction #7. • Patients experiencing mild to moderate heat exhaustion and/or dehydration with no comorbidities. Perform assessment including blood glucose measurement, and if findings are consistent with heat exhaustion/dehydration, treat per the Hyperthermia protocol with appropriate fluid therapy for patients age/weight. Reevaluate and reassess patient, including all vital signs. If patient has not improved, transport the patient to the appropriate facility. If patient has improved (and no toxic vital signs are present), release the patient with Instruction #8.

Scripting It is important to communicate to the patient why this is a safe and desirable option. Reassure the patient that: • You have assessed them and did not find any immediate life threats. • If they develop worsening symptoms, they can call 911 and get an immediate ambulance response back to their address. Educate the patient regarding their condition and follow-up instructions using the handout. Pearls • This protocol may only be used during a disaster-type situation when authorized. Protocol implementation must be authorized by the CEO and the Medical Director. • A consult is required before referral. The consult provides a second opinion and double-check and aids in tracking PIR uses. The consult should be made with MD2 or MD1, but if unavailable, contact the Clinical On-Call P3 or EOC for consult. • Do not provide home care for the purpose of avoiding physician involvement. If patients receive care from EMS other than minor first aid, it should be with the intent that the patients will seek the care of a physician. Breathing treatments, reversal of hypoglycemia, and similar treatments are examples of patients that we should approach the full intent of transporting to a hospital. If the patient refuses transport after receiving advanced care, follow established policy for refusal against medical advice and provide the patient with Instruction #1.

Cypress Creek EMS System Policies and Treatment Guidelines CLINICAL POLICIES Revised 7/2020 Approved: Levon Vartanian, MD

Transport to Satellite/Freestanding Emergency Departments

Purpose Transport by CCEMS to freestanding emergency departments can reduce ED overcrowding and provide faster, more appropriate care for low-acuity patients. These guidelines provide criteria for which patients can be transported to these facilities and which facilities are eligible to receive patients. Eligible Facilities These freestanding EDs are licensed under a general hospital CCEMS routinely transports to and offer the same staffing, equipment, and capabilities as a general emergency department along with 24/7 rapid transfer and admission capabilities for urgent or ill patients. • CHI St. Luke’s Emergency Center – Springwoods Village • HCA Houston ER 24/7 – Cypress Fairbanks • HCA Houston ER 24/7 – Spring Cypress • Houston Methodist Emergency Care Center – Spring • Memorial Hermann Convenient Care Center Spring Eligible Patients for Freestanding ED Transport Stable patients who are experiencing minor uncomplicated injury or illness (see next page for examples). Exclusion criteria (must be transported to hospital) • Any patient with unstable vital signs or other life-threatening condition • Level 1, 2, or 3 trauma patients • Traumatic or medical cardiac arrest patients • Intubated patients • STEMI/Acute Coronary Syndrome (suspected or confirmed) • Suspected or confirmed CVA/TIA (onset within past 24 hours) • Status epilepticus • Pregnant women >20 weeks gestation • Pediatric patients <1 year • Combative, restrained, or patients with chief complaint of psychiatric problems • GI bleed patients • Dialysis patients • Hospice patients • COVID-19 (suspected or confirmed) that requires supplemental oxygen

Cypress Creek EMS System Policies and Treatment Guidelines CLINICAL POLICIES Revised 7/2020 Approved: Levon Vartanian, MD

Additional Information:

Free-standing EDs are licensed under but physically separate from a general hospital. They are required to meet the same standards as general hospital Emergency Departments. The approved freestanding EDs are in or near CCEMS’s response district and affiliated with general hospitals that CCEMS takes patients to. This ensures these facilities are participating in performance improvement processes with CCEMS, will accept CCEMS transports, and have appropriate measures in place to care for and transfer critically ill patients if needed. The goal of this guideline is to avoid transporting high-acuity or high-risk patients to these facilities and ensure patients are able to receive the most appropriate definitive care as quickly and safely as possible. Examples of conditions that can be taken to a freestanding ED include: • Abdominal pain • Fever • Shortness of breath • Flu-like symptoms • Sore throats • Respiratory infections • Rashes • Urinary symptoms • Uncomplicated/controlled nosebleeds • Chest pain with a normal/unremarkable EKG and normal vital signs • Febrile seizures (single episode, non-recurrent, with no history of seizures) • Simple injures such as bruises, lacerations, sprains, back pain, suspected closed fractures • Possible COVID-19 patient who is low acuity and does not require supplemental oxygen Freestanding ED phone numbers and addresses:

CHI St. Luke’s Emergency Center – Springwoods Village 999-999-9999 - 2255 E Mossy Oaks Road, Spring, TX 77389 — (Holzwarth Rd north of SH-99) HCA Houston ER 24/7 – Cypress Fairbanks 281-890-4285 - 10655 Steepletop Drive, Houston, TX 77065 (FM 1960 and Steepletop, west of Jones Rd) HCA Houston ER 24/7 – Spring Cypress 281-320-8500 – 22475 Tomball Parkway, Houston, TX 77070 (Hwy 249 south of Spring Cypress) Houston Methodist Emergency Care Center – Spring 936-270-4640 – 5303 FM 2920 Road, Spring, TX 77388 (corner of Gosling Rd and FM 2920) Memorial Hermann – Convenient Care Center Spring 281-374-5400 – 7474 Grand Parkway, Spring, TX 77389 (SH-99 west of Kuykendahl)

Cypress Creek EMS System Policies and Treatment Guidelines CLINICAL POLICIES Revised 8/2016 Approved: Levon Vartanian, MD

ŝƌDĞĚŝĐĂůhƚŝůŝǌĂƚŝŽŶ Indications ŝƌŵĞĚŝĐĂůƚƌĂŶƐƉŽƌƚ;ƌŽƚŽƌǁŝŶŐͿƐŚŽƵůĚďĞƵƚŝůŝǌĞĚǁŚĞŶ>>ŽĨƚŚĞĨŽůůŽǁŝŶŐĐƌŝƚĞƌŝĂĂƌĞƉƌĞƐĞŶƚ͗

x WĂƚŝĞŶƚŵĞĞƚƐĐƌŝƚĞƌŝĂĨŽƌ>ĞǀĞůϭdƌĂƵŵĂĞŶƚĞƌƚƌĂŶƐƉŽƌƚ;ƐĞĞTrauma and Burn Transport Destination Determination ŐƵŝĚĞůŝŶĞƐͿ͖ x dŚĞŐƌŽƵŶĚƚƌĂŶƐƉŽƌƚƚŝŵĞŝƐĂŶƚŝĐŝƉĂƚĞĚƚŽďĞŐƌĞĂƚĞƌƚŚĂŶϮϱŵŝŶƵƚĞƐ͖ x dŚĞƉĂƚŝĞŶƚŝƐŶŽƚŝŶƚƌĂƵŵĂƚŝĐĐĂƌĚŝĂĐĂƌƌĞƐƚ͘ ŚĞůŝĐŽƉƚĞƌŵĂǇďĞĐŽŶƐŝĚĞƌĞĚǁŚĞŶEzŽĨƚŚĞĨŽůůŽǁŝŶŐĂƌĞƉƌĞƐĞŶƚ͗

x dŚĞƉĂƚŝĞŶƚŝƐĞŶƚƌĂƉƉĞĚĂŶĚĞǆƚƌŝĐĂƚŝŽŶŝƐĞǆƉĞĐƚĞĚƚŽůĂƐƚŐƌĞĂƚĞƌƚŚĂŶϮϬŵŝŶƵƚĞƐ͖ x ĚŵŝŶŝƐƚƌĂƚŝŽŶŽĨďůŽŽĚƉƌŽĚƵĐƚƐŝŶƚŚĞƉƌĞͲŚŽƐƉŝƚĂůƐĞƚƚŝŶŐŵĂǇďĞŶĞĞĚĞĚĂŶĚĂƌĞŶŽƚĂǀĂŝůĂďůĞ ĨƌŽŵĂD^ĨŝĞůĚƐƵƉĞƌǀŝƐŽƌ͖ x ƐŝƚƵĂƚŝŽŶĂƉƉƌŽǀĞĚďǇƚŚĞDĞĚŝĐĂůŝƌĞĐƚŽƌŽƌŽŶƐĐĞŶĞ&ŝĞůĚ^ƵƉĞƌǀŝƐŽƌ͖ x DĂƐƐĂƐƵĂůƚǇ/ŶĐŝĚĞŶƚ;D/ͿŽƌĚŝƐĂƐƚĞƌƌĞƐƉŽŶƐĞ͖ x dŚĞƉĂƚŝĞŶƚŵĞĞƚƐďƵƌŶĐĞŶƚĞƌĐƌŝƚĞƌŝĂŽƌƌĞƋƵŝƌĞƐĂŶŽƚŚĞƌƐƉĞĐŝĂůƚǇƌĞƐŽƵƌĐĞĐĞŶƚĞƌƚŚĂƚǁŽƵůĚ ďĞŶĞĨŝƚĨƌŽŵĂŝƌŵĞĚŝĐĂůƚƌĂŶƐƉŽƌƚ Procedure: ϭ͘ dŚĞ/ŶͲŚĂƌŐĞWĂƌĂŵĞĚŝĐ;ŽƌŚŝŐŚĞƐƚŵĞĚŝĐĂůĂƵƚŚŽƌŝƚǇŽŶƐĐĞŶĞͿǁŝůůƌĞƋƵĞƐƚĂŝƌŵĞĚŝĐĂůƚƌĂŶƐƉŽƌƚ ;>ŝĨĞ&ůŝŐŚƚͿ͘ŶŽŶͲƐĐĞŶĞ&ŝƌĞĞƉĂƌƚŵĞŶƚĨŝƌƐƚƌĞƐƉŽŶĚĞƌŵĂǇĂůƐŽƌĞƋƵĞƐƚĂŚĞůŝĐŽƉƚĞƌƚŽĞǆƉĞĚŝƚĞ ŝƚƐĂƌƌŝǀĂů͘ Ϯ͘ ŽŵŵĞŶƚĞƌ ǁŝůů ĐŽŶƚĂĐƚ>ŝĨĞ&ůŝŐŚƚĂŶĚŽďƚĂŝŶůĂƵŶĐŚďĂƐĞĂŶĚĞƐƚŝŵĂƚĞĚƚŝŵĞŽĨĂƌƌŝǀĂů;dͿ ĂŶĚǁŝůůĐŽŵŵƵŶŝĐĂƚĞƚŚŝƐƚŽƚŚĞŽŶƐĐĞŶĞŵĞĚŝĐĂůĂƵƚŚŽƌŝƚǇ͘ ϯ͘ dŚĞŽŶͲƐĐĞŶĞŵĞĚŝĐĂůĂƵƚŚŽƌŝƚǇƐŚŽƵůĚĚĞƚĞƌŵŝŶĞƌŝƐŬƚŽďĞŶĞĨŝƚĨŽƌĂŝƌŵĞĚŝĐĂůƚƌĂŶƐƉŽƌƚďĂƐĞĚŽŶ dĂŶĚĐƌŝƚĞƌŝĂůŝƐƚĞĚĂďŽǀĞ͖ĂŶĚĞŝƚŚĞƌĐŽŶƚŝŶƵĞ>ŝĨĞ&ůŝŐŚƚƌĞƐƉŽŶƐĞŽƌĚŝƐƌĞŐĂƌĚ>ŝĨĞ&ůŝŐŚƚ ƌĞƐƉŽŶƐĞ͘ ϰ͘ ƐĂĨĞůĂŶĚŝŶŐǌŽŶĞ;>ͿƐŚŽƵůĚďĞĞƐƚĂďůŝƐŚĞĚďǇƚŚĞ&ŝƌĞĞƉĂƌƚŵĞŶƚŽŶƐĐĞŶĞ͘ ϱ͘ /ĨƚŚĞŚĞůŝĐŽƉƚĞƌĚŽĞƐŶŽƚĂƌƌŝǀĞƉƌŝŽƌƚŽƚŚĞ ĞǆƚƌŝĐĂƚŝŽŶŽĨ ƚŚĞ ƉĂƚŝĞŶƚ͕ ƚŚĞ ƉĂƚŝĞŶƚ ŵĂǇ ďĞ ŝŵŵĞĚŝĂƚĞůǇƉůĂĐĞĚŝŶƚŚĞĂŵďƵůĂŶĐĞĂŶĚƚƌĂŶƐƉŽƌƚďĞŐƵŶƚŽƚŚĞŶĞĂƌĞƐƚ>ĞǀĞůϭdƌĂƵŵĂĞŶƚĞƌ͘ Collaborative Care and Patient Hand Off tŚĞŶ>ŝĨĞ&ůŝŐŚƚƉĞƌƐŽŶŶĞůĂƌƌŝǀĞŽŶƐĐĞŶĞ͕ƉĂƚŝĞŶƚĐĂƌĞǁŝůůŶĞĞĚƚŽďĞƚƌĂŶƐŝƚŝŽŶĞĚŝŶŽƌĚĞƌƚŽ ĂĐĐŽŵŵŽĚĂƚĞƌĂƉŝĚƚƌĂŶƐƉŽƌƚƚŽĚĞĨŝŶŝƚŝǀĞĐĂƌĞ͘ďƌŝĞĨƉĂƚŝĞŶƚĐĂƌĞƌĞƉŽƌƚƐŚŽƵůĚďĞƉƌŽǀŝĚĞĚƚŽ ŽŶĐŽŵŝŶŐŵĞĚŝĐĂůƉĞƌƐŽŶŶĞů͘ŶǇŝŶƚĞƌǀĞŶƚŝŽŶƐ;Ğ͘Ő͘ĂŝƌǁĂǇŵĂŶĂŐĞŵĞŶƚͬZ^/ͿƚŚĂƚŵĂǇďĞŶĞĐĞƐƐĂƌǇ ƉƌŝŽƌƚŽŵŽǀĞŵĞŶƚƚŽƚŚĞŚĞůŝĐŽƉƚĞƌƐŚŽƵůĚďĞĚŝƐĐƵƐƐĞĚ͕ĂŶĚƌŝƐŬƚŽďĞŶĞĨŝƚĐŽŶƐŝĚĞƌĞĚĐŽůůĂďŽƌĂƚŝǀĞůǇ͘

/ŶĐĂƐĞƐǁŚĞƌĞƚŚĞĐƌĞǁ;ƐͿĚĞƚĞƌŵŝŶĞƐƚŚĂƚĨƵƌƚŚĞƌŽŶƐĐĞŶĞŝŶƚĞƌǀĞŶƚŝŽŶƐĂƌĞŶĞĞĚĞĚƉƌŝŽƌƚŽ ƚƌĂŶƐƉŽƌƚ͕ƚŚĞĨŽůůŽǁŝŶŐƐŚŽƵůĚďĞĐĂƌƌŝĞĚŽƵƚ͗

x ĞƚĞƌŵŝŶĞǁŚŽǁŝůůƚĂŬĞůĞĂĚĚƵƌŝŶŐĚƵĂůƚĞĂŵĐĂƌĞ͘

Cypress Creek EMS System Policies and Treatment Guidelines

25 CLINICAL POLICIES Revised 8/2016 Approved: Levon Vartanian, MD

x ĞůĞŐĂƚĞŝŶƚĞƌǀĞŶƚŝŽŶƐĂŶĚǁŽƌŬƚŽŐĞƚŚĞƌƚŽƚƌĞĂƚƉĂƚŝĞŶƚ͘ x ŽŵŵƵŶŝĐĂƚĞŽƉĞŶůǇǁŝƚŚĞĂĐŚŽƚŚĞƌ͘ x /ĨďŽƚŚĐƌĞǁƐŵŽŶŝƚŽƌŝŶŐĞƋƵŝƉŵĞŶƚĐĂŶŶŽƚďĞĂƉƉůŝĞĚĚƵƌŝŶŐƚŚŝƐĚƵĂůƚĞĂŵĐĂƌĞ͕ƚŚĞŶĐĂƌĞĨƵůůǇ ĚŽĐƵŵĞŶƚ>ŝĨĞ&ůŝŐŚƚ͛ƐŵŽŶŝƚŽƌĚĂƚĂŝŶƚŚĞD^ĞůĞĐƚƌŽŶŝĐƉĂƚŝĞŶƚĐĂƌĞƌĞƉŽƌƚ͘ x /ĨD^ŝƐĐŽŶĚƵĐƚŝŶŐĂĚǀĂŶĐĞĚĂŝƌǁĂǇŵĂŶĂŐĞŵĞŶƚ͕ŬĞĞƉƉĂƚŝĞŶƚŽŶD^ŵŽŶŝƚŽƌŝŶŐ ĞƋƵŝƉŵĞŶƚƵŶƚŝůĐŽŵƉůĞƚĞ͘ x ƐƐŝŐŶĂĐƌĞǁŵĞŵďĞƌƚŽŵŽŶŝƚŽƌƚŽƚĂůƐĐĞŶĞƚŝŵĞĂŶĚĂŶŶŽƵŶĐĞĂƚϱŵŝŶƵƚĞŝŶƚĞƌǀĂůƐ͖ƌĞĂƐƐĞƐƐ ǁŚŝĐŚŝŶƚĞƌǀĞŶƚŝŽŶƐŵĂǇďĞĐĂƌƌŝĞĚŽƵƚĚƵƌŝŶŐĨůŝŐŚƚŝŶŽƌĚĞƌƚŽĞǆƉĞĚŝƚĞĚĞƉĂƌƚƵƌĞƚŽĚĞĨŝŶŝƚŝǀĞ ĐĂƌĞ͘ x tŚĞŶƉŽƐƐŝďůĞ͕ĚŽĐƵŵĞŶƚƚŚĞƚŝŵĞƚŚĂƚƚŚĞƉĂƚŝĞŶƚŝƐŵŽǀĞĚƚŽƚŚĞ>ŝĨĞ&ůŝŐŚƚƐƚƌĞƚĐŚĞƌĂŶĚǁŚĞŶ ƚŚĞŚĞůŝĐŽƉƚĞƌůŝĨƚƐŽĨĨĨŽƌĚĞƉĂƌƚƵƌĞ͘ x /ĨƚŚĞƉĂƚŝĞŶƚŝƐƚƌĂŶƐƉŽƌƚĞĚĂŶǇĚŝƐƚĂŶĐĞƵƐŝŶŐƚŚĞĂŵďƵůĂŶĐĞ͕ĚŽĐƵŵĞŶƚŵŝůĞĂŐĞĂƐĂƉƉƌŽƉƌŝĂƚĞ͘

Cypress Creek EMS System Policies and Treatment Guidelines

26 CLINICAL POLICIES Revised 8/2016 Approved: Levon Vartanian, MD

ŚŝůĚͬůĚĞƌďƵƐĞZĞĐŽŐŶŝƚŝŽŶĂŶĚZĞƉŽƌƚŝŶŐ Purpose ǇůĂǁ͕ĂŶǇŽŶĞǁŚŽƚŚŝŶŬƐĂĐŚŝůĚ͕ŽƌƉĞƌƐŽŶϲϱǇĞĂƌƐŽƌŽůĚĞƌ͕ŽƌĂŶĂĚƵůƚǁŝƚŚĚŝƐĂďŝůŝƚŝĞƐŝƐďĞŝŶŐ ĂďƵƐĞĚ͕ŶĞŐůĞĐƚĞĚ͕ŽƌĞǆƉůŽŝƚĞĚŵƵƐƚƌĞƉŽƌƚŝƚƚŽƚŚĞĞƉĂƌƚŵĞŶƚŽĨ&ĂŵŝůǇWƌŽƚĞĐƚŝǀĞ^ĞƌǀŝĐĞƐ;&W^Ϳ͘ ƉĞƌƐŽŶǁŚŽƌĞƉŽƌƚƐĂďƵƐĞŝŶŐŽŽĚĨĂŝƚŚŝƐŝŵŵƵŶĞĨƌŽŵĐŝǀŝůŽƌĐƌŝŵŝŶĂůůŝĂďŝůŝƚǇ͘&W^ŬĞĞƉƐƚŚĞŶĂŵĞŽĨ ƚŚĞƉĞƌƐŽŶŵĂŬŝŶŐƚŚĞƌĞƉŽƌƚĐŽŶĨŝĚĞŶƚŝĂů͘ŶǇŽŶĞǁŚŽĚŽĞƐŶŽƚƌĞƉŽƌƚƐƵƐƉĞĐƚĞĚĂďƵƐĞĐĂŶďĞŚĞůĚ ůŝĂďůĞĨŽƌĂŵŝƐĚĞŵĞĂŶŽƌŽƌĨĞůŽŶǇ͘dŝŵĞĨƌĂŵĞƐĨŽƌŝŶǀĞƐƚŝŐĂƚŝŶŐƌĞƉŽƌƚƐĂƌĞďĂƐĞĚŽŶƚŚĞƐĞǀĞƌŝƚǇŽĨƚŚĞ ĂůůĞŐĂƚŝŽŶƐ͘ZĞƉŽƌƚŝŶŐƐƵƐƉĞĐƚĞĚĂďƵƐĞŵĂŬĞƐŝƚƉŽƐƐŝďůĞĨŽƌĂĨĂŵŝůǇƚŽŐĞƚŚĞůƉ͘ Definitions AbuseŝƐŵĞŶƚĂů͕ĞŵŽƚŝŽŶĂů͕ƉŚǇƐŝĐĂů͕ŽƌƐĞǆƵĂůŝŶũƵƌǇƚŽĂĐŚŝůĚ;ůĞƐƐƚŚĂŶϭϴǇĞĂƌƐŽĨĂŐĞͿŽƌƉĞƌƐŽŶϲϱ ǇĞĂƌƐŽƌŽůĚĞƌŽƌĂŶĂĚƵůƚǁŝƚŚĚŝƐĂďŝůŝƚŝĞƐŽƌĨĂŝůƵƌĞƚŽƉƌĞǀĞŶƚƐƵĐŚŝŶũƵƌǇ͘

Neglect ŽĨĂĐŚŝůĚŝŶĐůƵĚĞƐĨĂŝůƵƌĞƚŽƉƌŽǀŝĚĞĂĐŚŝůĚǁŝƚŚĨŽŽĚ͕ĐůŽƚŚŝŶŐ͕ƐŚĞůƚĞƌĂŶĚͬŽƌŵĞĚŝĐĂůĐĂƌĞ͖ ĂŶĚͬŽƌůĞĂǀŝŶŐĂĐŚŝůĚŝŶĂƐŝƚƵĂƚŝŽŶǁŚĞƌĞƚŚĞĐŚŝůĚŝƐĂƚƌŝƐŬŽĨŚĂƌŵ͘

NeglectŽĨĂƉĞƌƐŽŶϲϱǇĞĂƌƐŽƌŽůĚĞƌŽƌĂŶĂĚƵůƚǁŝƚŚĚŝƐĂďŝůŝƚŝĞƐƚŚĂƚƌĞƐƵůƚƐŝŶƐƚĂƌǀĂƚŝŽŶ͕ĚĞŚǇĚƌĂƚŝŽŶ͕ ŽǀĞƌͲŽƌƵŶĚĞƌͲŵĞĚŝĐĂƚŝŽŶ͕ƵŶƐĂŶŝƚĂƌǇůŝǀŝŶŐĐŽŶĚŝƚŝŽŶƐ͕ĂŶĚůĂĐŬŽĨŚĞĂƚ͕ƌƵŶŶŝŶŐǁĂƚĞƌ͕ĞůĞĐƚƌŝĐŝƚǇ͕ ŵĞĚŝĐĂůĐĂƌĞ͕ĂŶĚƉĞƌƐŽŶĂůŚǇŐŝĞŶĞ͘

ExploitationŝƐŵŝƐƵƐŝŶŐƚŚĞƌĞƐŽƵƌĐĞƐŽĨĂƉĞƌƐŽŶϲϱǇĞĂƌƐŽƌŽůĚĞƌŽƌĂŶĂĚƵůƚǁŝƚŚĚŝƐĂďŝůŝƚŝĞƐĨŽƌ ƉĞƌƐŽŶĂůŽƌŵŽŶĞƚĂƌǇďĞŶĞĨŝƚ͘dŚŝƐŝŶĐůƵĚĞƐƚĂŬŝŶŐ^ŽĐŝĂů^ĞĐƵƌŝƚǇŽƌ^^/;^ƵƉƉůĞŵĞŶƚĂů^ĞĐƵƌŝƚǇ/ŶĐŽŵĞͿ ĐŚĞĐŬƐ͕ĂďƵƐŝŶŐĂũŽŝŶƚĐŚĞĐŬŝŶŐĂĐĐŽƵŶƚ͕ĂŶĚƚĂŬŝŶŐƉƌŽƉĞƌƚǇĂŶĚŽƚŚĞƌƌĞƐŽƵƌĐĞƐ͘ Reporting CPS and APS Cases dŚĞdĞǆĂƐĞƉĂƌƚŵĞŶƚŽĨ&ĂŵŝůǇĂŶĚWƌŽƚĞĐƚŝǀĞ^ĞƌǀŝĐĞƐ;&W^ͿƌƵŶƐĂƚŽůůͲĨƌĞĞ͕ƐƚĂƚĞǁŝĚĞƚĞůĞƉŚŽŶĞ ŚŽƚůŝŶĞƚŽƚĂŬĞƌĞƉŽƌƚƐŽĨƐƵƐƉĞĐƚĞĚĂďƵƐĞŽƌŶĞŐůĞĐƚĨŽƌĐŚŝůĚƌĞŶĂŶĚĂĚƵůƚƐĐĂůůĞĚƚŚĞTexas Abuse Hotline.dŚŝƐŚŽƚůŝŶĞŐŝǀĞƐǇŽƵĂǁĂǇƚŽƌĞƉŽƌƚ͗

x ŚŝůĚĂďƵƐĞĂŶĚŶĞŐůĞĐƚ͘ x ďƵƐĞ͕ŶĞŐůĞĐƚ͕ĂŶĚĞǆƉůŽŝƚĂƚŝŽŶŽĨĂĚƵůƚƐǁŚŽĂƌĞϲϱǇĞĂƌƐŽĨĂŐĞŽƌŽůĚĞƌŽƌǇŽƵŶŐĞƌĂĚƵůƚƐǁŚŽ ŚĂǀĞĂĚŝƐĂďŝůŝƚǇ͘ x ďƵƐĞŽƌŶĞŐůĞĐƚŽĨƉĞƌƐŽŶƐůŝǀŝŶŐŝŶůŝĐĞŶƐĞĚƐƚĂƚĞƐĐŚŽŽůƐ͕ƐƚĂƚĞŚŽƐƉŝƚĂůƐ͕ƐƚĂƚĞĐĞŶƚĞƌƐĂŶĚ ĐŽŵŵƵŶŝƚǇͲďĂƐĞĚĐĞŶƚĞƌƐǁŚĞŶĞŵƉůŽǇĞĞƐŝŶƚŚŽƐĞĨĂĐŝůŝƚŝĞƐĂƌĞƚŚĞĂůůĞŐĞĚǁƌŽŶŐĚŽĞƌƐ͘

Cypress Creek EMS System Policies and Treatment Guidelines

27 CLINICAL POLICIES Revised 8/2016 Approved: Levon Vartanian, MD

Report child abuse or neglect in two ways: Telephone (for emergent reporting) Internet (for non-urgent reporting)

zŽƵŵĂǇĐĂůůƚŚĞdĞǆĂƐďƵƐĞ,ŽƚůŝŶĞĂƚϭͲϴϬϬͲϮϱϮͲ zŽƵŵĂǇƌĞƉŽƌƚǇŽƵƌĂůůĞŐĂƚŝŽŶƐƚŽƚŚĞdĞǆĂƐďƵƐĞ ϱϰϬϬƚŽƌĞƉŽƌƚĂďƵƐĞŽƌŶĞŐůĞĐƚ͘dŚĞŚŽƚůŝŶĞŝƐ ,ŽƚůŝŶĞƚŚƌŽƵŐŚƚŚĞ/ŶƚĞƌŶĞƚĂƚ ĂŶƐǁĞƌĞĚďǇ&W^/ŶƚĂŬĞ^ƉĞĐŝĂůŝƐƚƐ;ǁŚŽĂƌĞĂůů ŚƚƚƉ͗ͬͬǁǁǁ͘ƚǆĂďƵƐĞŚŽƚůŝŶĞ͘ŽƌŐ͘dŚŝƐƐĞĐƵƌĞǁĞďƐŝƚĞ ĚĞŐƌĞĞĚƉƌŽĨĞƐƐŝŽŶĂůƐͿϮϰŚŽƵƌƐĂĚĂǇ͕ϯϲϱĚĂǇƐĂ ƉƌŽǀŝĚĞƐĂǁĂǇƚŽĞǆƉůĂŝŶǇŽƵƌĐŽŶĐĞƌŶƐŝŶǁƌŝƚŝŶŐ͘ ǇĞĂƌ͘ zŽƵmust ƉƌŽǀŝĚĞǇŽƵƌŶĂŵĞĂŶĚĂǀĂůŝĚĞͲŵĂŝůĂĚĚƌĞƐƐ͘ zŽƵǁŝůůďĞĂƐŬĞĚƚŽƉƌŽǀŝĚĞǇŽƵƌŶĂŵĞĂŶĚĐŽŶƚĂĐƚ zŽƵƌŝĚĞŶƚŝƚǇƌĞŵĂŝŶƐĐŽŶĨŝĚĞŶƚŝĂůĂŶĚǁŝůůŶŽƚďĞ ŝŶĨŽƌŵĂƚŝŽŶ͘ ƉƌŽǀŝĚĞĚĚŝƌĞĐƚůǇƚŽƚŚĞĂĐĐƵƐĞĚƉĞƌƐŽŶďǇĂŶǇ&W^ ĞŵƉůŽǇĞĞ͘ zŽƵǁŝůůďĞĂƐŬĞĚƚŽĞǆƉůĂŝŶǇŽƵƌĐŽŶĐĞƌŶƐ͘dŚĞ /ŶƚĂŬĞ^ƉĞĐŝĂůŝƐƚŵŝŐŚƚĂƐŬĂĚĚŝƚŝŽŶĂůƋƵĞƐƚŝŽŶƐƚŽ KŶĐĞĂŶ/ŶƚĂŬĞ^ƉĞĐŝĂůŝƐƚƉƌŽĐĞƐƐĞƐǇŽƵƌƌĞƉŽƌƚ͕ǇŽƵǁŝůů ĚĞƚĞƌŵŝŶĞŝĨƚŚĞƐŝƚƵĂƚŝŽŶƚŚĂƚǇŽƵĚĞƐĐƌŝďĞŵĞĞƚƐ ƌĞĐĞŝǀĞĂĐŽŶĨŝƌŵĂƚŝŽŶĞͲŵĂŝůǁŝƚŚĂĂůů/ĚĞŶƚŝĨŝĐĂƚŝŽŶ ƚŚĞdĞǆĂƐ&ĂŵŝůǇŽĚĞΖƐĚĞĨŝŶŝƚŝŽŶƐŽĨĂďƵƐĞŽƌ EƵŵďĞƌ͘dŚĞĞͲŵĂŝůǁŝůůĂůƐŽƚĞůůǇŽƵǁŚĞƚŚĞƌŽƌŶŽƚ ŶĞŐůĞĐƚ͘ ǇŽƵƌƌĞƉŽƌƚǁĂƐĨŽƌǁĂƌĚĞĚƚŽĂůŽĐĂů&W^ŽĨĨŝĐĞĨŽƌ ĨƵƌƚŚĞƌŝŶǀĞƐƚŝŐĂƚŝŽŶ͘

Report Priorities ZĞƉŽƌƚƐŽĨĐŚŝůĚĂďƵƐĞŽƌŶĞŐůĞĐƚĂƌĞĐůĂƐƐŝĨŝĞĚŝŶŽŶĞŽĨƚǁŽƉƌŝŽƌŝƚǇŐƌŽƵƉƐĂŶĚƚŚĞƉƌŝŽƌŝƚǇŽĨƚŚĞ ŝŶƚĂŬĞĚĞƚĞƌŵŝŶĞƐŚŽǁƋƵŝĐŬůǇĂŶŝŶǀĞƐƚŝŐĂƚŝŽŶďĞŐŝŶƐ͘dƌĂŝŶĞĚŝŶƚĂŬĞƐƚĂĨĨĂƐƐŝŐŶƚŚĞĂƉƉƌŽƉƌŝĂƚĞ ƉƌŝŽƌŝƚǇďĂƐĞĚŽŶƚŚĞŝŶĨŽƌŵĂƚŝŽŶĂǀĂŝůĂďůĞĂƚƚŚĞƚŝŵĞƚŚĞǇŐĞƚƚŚĞƌĞƉŽƌƚ͘W^ĨŝĞůĚƐƵƉĞƌǀŝƐŽƌŵĂǇ ƐƉĞĐŝĨǇĂŵŽƌĞĞǆĂĐƚƚŝŵĞĨƌĂŵĞĨŽƌƐƚĂƌƚŝŶŐƚŚĞŝŶǀĞƐƚŝŐĂƚŝŽŶ͘

Priority I Reports: WƌŝŽƌŝƚǇ/ƌĞƉŽƌƚƐŝŶĐůƵĚĞĂůůƌĞƉŽƌƚƐŽĨĐŚŝůĚƌĞŶǁŚŽĂƉƉĞĂƌƚŽĨĂĐĞĂŶŝŵŵĞĚŝĂƚĞƌŝƐŬŽĨĂďƵƐĞŽƌŶĞŐůĞĐƚ ƚŚĂƚĐŽƵůĚƌĞƐƵůƚŝŶĚĞĂƚŚŽƌƐĞƌŝŽƵƐŚĂƌŵ͘/ŶǀĞƐƚŝŐĂƚŝŽŶƐŽĨƚŚĞƐĞƌĞƉŽƌƚƐŵƵƐƚƐƚĂƌƚǁŝƚŚŝŶϮϰŚŽƵƌƐŽĨ ƌĞĐĞŝǀŝŶŐƚŚĞĐĂůůƌĞƉŽƌƚ͘

Priority II Reports: WƌŝŽƌŝƚǇ//ƌĞƉŽƌƚƐŝŶĐůƵĚĞĂůůƌĞƉŽƌƚƐŽĨĂďƵƐĞŽƌŶĞŐůĞĐƚƚŚĂƚĂƌĞŶŽƚĂƐƐŝŐŶĞĚĂƐWƌŝŽƌŝƚǇ/͘dŚĞƐĞ ŝŶǀĞƐƚŝŐĂƚŝŽŶƐŵƵƐƚƐƚĂƌƚǁŝƚŚŝŶϳϮŚŽƵƌƐŽĨƌĞĐĞŝǀŝŶŐƚŚĞƌĞƉŽƌƚ͘^ŽŵĞƌĞƉŽƌƚƐĚŽŶŽƚŵĞĞƚƚŚĞůĞŐĂů ĚĞĨŝŶŝƚŝŽŶŽĨĂďƵƐĞŽƌŶĞŐůĞĐƚ͕ĂƐĚĞĨŝŶĞĚŝŶƚŚĞdĞǆĂƐ&ĂŵŝůǇŽĚĞ͕ĂŶĚĂƌĞŶŽƚĂƐƐŝŐŶĞĚĂƉƌŝŽƌŝƚǇŽƌ ŝŶǀĞƐƚŝŐĂƚĞĚ͘

Reasons for not assigning a report for investigation include: x ^ŝƚƵĂƚŝŽŶƐƚŚĂƚĚŽŶŽƚĂƉƉĞĂƌƚŽŝŶǀŽůǀĞĂƌĞĂƐŽŶĂďůĞůŝŬĞůŝŚŽŽĚƚŚĂƚĂĐŚŝůĚǁŝůůďĞĂďƵƐĞĚŽƌ ŶĞŐůĞĐƚĞĚŝŶƚŚĞĨŽƌĞƐĞĞĂďůĞĨƵƚƵƌĞ͘ x ůůĞŐĂƚŝŽŶƐƚŚĂƚĂƌĞƚŽŽǀĂŐƵĞŽƌŐĞŶĞƌĂůƚŽĚĞƚĞƌŵŝŶĞŝĨĂĐŚŝůĚŚĂƐďĞĞŶŽƌŝƐůŝŬĞůǇƚŽďĞĂďƵƐĞĚŽƌ ŶĞŐůĞĐƚĞĚ͘ x ZĞƉŽƌƚƐǁŝƚŚƚŽŽůŝƚƚůĞŝŶĨŽƌŵĂƚŝŽŶƚŽůŽĐĂƚĞƚŚĞĐŚŝůĚŽƌƚŚĞĐŚŝůĚΖƐĨĂŵŝůǇŽƌŚŽƵƐĞŚŽůĚ͘ x ^ŝƚƵĂƚŝŽŶƐƚŚĂƚĂƌĞĂůƌĞĂĚǇƵŶĚĞƌŝŶǀĞƐƚŝŐĂƚŝŽŶ͘

Cypress Creek EMS System Policies and Treatment Guidelines

28 CLINICAL POLICIES Revised 8/2016 Approved: Levon Vartanian, MD

ƌŝƚĞƌŝĂĨŽƌĞĂƚŚͬtŝƚŚŚŽůĚŝŶŐZĞƐƵƐĐŝƚĂƚŝŽŶ

/ƚŝƐĂĐĐĞƉƚĂďůĞ͕ƵŶĚĞƌƚŚĞĨŽůůŽǁŝŶŐĐŝƌĐƵŵƐƚĂŶĐĞƐ͕ĨŽƌǇƉƌĞƐƐƌĞĞŬD^ƉĞƌƐŽŶŶĞůƚŽĞůĞĐƚƚŽ ǁŝƚŚŚŽůĚƌĞƐƵƐĐŝƚĂƚŝǀĞŵĞĂƐƵƌĞƐĨƌŽŵĂŶĂƉŶĞŝĐͬƉƵůƐĞůĞƐƐƉĂƚŝĞŶƚŽƌĚŝƐĐŽŶƚŝŶƵĞĂŶǇĂƚƚĞŵƉƚƐŝŶŝƚŝĂƚĞĚ ďǇůĂǇƉĞŽƉůĞ͗

ϭ͘ ĞĐĂƉŝƚĂƚŝŽŶ Ϯ͘ ZŝŐŽƌDŽƌƚŝƐ ϯ͘ dŽƚĂůŝŶĐŝŶĞƌĂƚŝŽŶ ϰ͘ ĞĐŽŵƉŽƐŝƚŝŽŶ ϱ͘ ĞƉĞŶĚĞŶƚůŝǀŝĚŝƚǇ ϲ͘ sŝƐŝďůĞƚƌĂƵŵĂƚŽƚŚĞŚĞĂĚŽƌƚƌƵŶŬĐůĞĂƌůǇŝŶĐŽŵƉĂƚŝďůĞǁŝƚŚůŝĨĞ ϳ͘ DĂƐƐĐĂƐƵĂůƚǇŝŶĐŝĚĞŶƚǁŚĞƌĞƚƌŝĂŐĞƉƌŝŶĐŝƉůĞƐƉƌĞĐůƵĚĞWZĨƌŽŵďĞŝŶŐŝŶŝƚŝĂƚĞĚŽŶĞǀĞƌǇǀŝĐƚŝŵ ϴ͘ sĂůŝĚDo Not ResuscitateĚŝƌĞĐƚŝǀĞĞǆĞĐƵƚĞĚďǇƚŚĞƉĂƚŝĞŶƚ͛ƐƉŚǇƐŝĐŝĂŶƚŚƌŽƵŐŚƚŚĞĨŽůůŽǁŝŶŐ ŵĞĐŚĂŶŝƐŵ͗ x ŝƌĞĐƚƉŚŽŶĞĐŽŶƚĂĐƚǁŝƚŚƚŚĞƉĂƚŝĞŶƚ͛ƐƉŚǇƐŝĐŝĂŶ x ƵƌƌĞŶƚ;ǁŝƚŚŝŶŽŶĞŵŽŶƚŚͿ͕ǁƌŝƚƚĞŶ͕ŽƌŝŐŝŶĂů͞EZ͟ŽƌĚĞƌƐŝŐŶĞĚďǇƚŚĞƉĂƚŝĞŶƚ͛ƐƉŚǇƐŝĐŝĂŶ x ǀĂůŝĚ^ƚĂƚĞŽĨdĞǆĂƐKK,ͲEZ;WŚŽƚŽĐŽƉŝĞƐĂƌĞĂĐĐĞƉƚĂďůĞͿ x ŶŝŶƚĂĐƚ͕ƵŶĂůƚĞƌĞĚ͕ĞĂƐŝůǇŝĚĞŶƚŝĨŝĂďůĞƉůĂƐƚŝĐŝĚĞŶƚŝĨŝĐĂƚŝŽŶKK,EZďƌĂĐĞůĞƚǁŝƚŚƚŚĞǁŽƌĚ ΗdĞǆĂƐΗ;ŽƌĂƌĞƉƌĞƐĞŶƚĂƚŝŽŶŽĨƚŚĞŐĞŽŐƌĂƉŚŝĐĂůƐŚĂƉĞŽĨdĞǆĂƐĂŶĚƚŚĞǁŽƌĚΗ^dKWΗŝŵƉŽƐĞĚ ŽǀĞƌƚŚĞƐŚĂƉĞͿĂŶĚƚŚĞǁŽƌĚƐΗŽEŽƚZĞƐƵƐĐŝƚĂƚĞΗƐŚĂůůďĞŚŽŶŽƌĞĚďǇƋƵĂůŝĨŝĞĚD^ ƉĞƌƐŽŶŶĞůŝŶůŝĞƵŽĨĂŶŽƌŝŐŝŶĂůKK,EZKƌĚĞƌĨŽƌŵ͘ OR x ŶŝŶƚĂĐƚ͕ƵŶĂůƚĞƌĞĚ͕ĞĂƐŝůǇŝĚĞŶƚŝĨŝĂďůĞmetalďƌĂĐĞůĞƚŽƌŶĞĐŬůĂĐĞŝŶƐĐƌŝďĞĚǁŝƚŚƚŚĞǁŽƌĚƐ͕ ΗdĞǆĂƐŽEŽƚZĞƐƵƐĐŝƚĂƚĞͲKK,ΗshallďĞŚŽŶŽƌĞĚďǇƋƵĂůŝĨŝĞĚD^ƉĞƌƐŽŶŶĞůŝŶůŝĞƵŽĨĂŶ KK,EZKƌĚĞƌĨŽƌŵ͘ ϵ͘ &ĂŵŝůǇŵĞŵďĞƌƐĂƌĞĂŐĂŝŶƐƚĂŶǇĂƚƚĞŵƉƚƐƚŽƌĞƐƵƐĐŝƚĂƚĞ͕ĂŶĚƚŚĞǇĂƉƉĞĂƌƚŽďĞŽĨƐŽƵŶĚŵŝŶĚ͘dŚŝƐ ƐŚŽƵůĚĞƐƉĞĐŝĂůůǇďĞĐŽŶƐŝĚĞƌĞĚŝĨƚŚĞƉĂƚŝĞŶƚŚĂƐƐŝŐŶĞĚĂ͞ŝƌĞĐƚŝǀĞƚŽWŚǇƐŝĐŝĂŶƐ͟ĂŶĚƚŚĂƚ ĚŽĐƵŵĞŶƚŝƐƉƌĞƐĞŶƚ͘ On Scene Procedure x WƌŝŶƚĐĂƌĚŝĂĐƌŚǇƚŚŵƐŚŽǁŝŶŐĂƐǇƐƚŽůĞŝŶϯůĞĂĚƐ͕ĂƐĂƉƉƌŽƉƌŝĂƚĞ͘ x KďƚĂŝŶƉĂƚŝĞŶƚĚĞŵŽŐƌĂƉŚŝĐĂŶĚŵĞĚŝĐĂůŚŝƐƚŽƌǇŝŶĨŽƌŵĂƚŝŽŶĂƐƉŽƐƐŝďůĞ͘ x ^ĞĞŬƚŽƉƌĞƐĞƌǀĞƉŽƐƐŝďůĞĐƌŝŵĞƐĐĞŶĞĞǀŝĚĞŶĐĞĂŶĚĐŽŽƌĚŝŶĂƚĞǁŝƚŚůĂǁĞŶĨŽƌĐĞŵĞŶƚ͘ x &ŽůůŽǁLife Gift/Donor ReferralƉƌŽĐĞĚƵƌĞ͘ Documentation x ŽĐƵŵĞŶƚƐĐĞŶĞĨŝŶĚŝŶŐƐĂŶĚĂƐƐĞƐƐŵĞŶƚĐĂƌĞĨƵůůǇ͘ x /ŶĐůƵĚĞŵŽŶŝƚŽƌĚĂƚĂƐŚŽǁŝŶŐĂƐǇƐƚŽůĞ͘EŽƚĞƚŚĂƚƚŚĞĂƐǇƐƚŽůĞĐĂƌĚŝĂĐƌŚǇƚŚŵǁŝůůŶŽƚďĞƐĂǀĞĚƚŽ ĚĞǀŝĐĞŵĞŵŽƌǇƵŶůĞƐƐĂƐƚƌŝƉŝƐƉŚǇƐŝĐĂůůǇƉƌŝŶƚĞĚ͘

Cypress Creek EMS System Policies and Treatment Guidelines

29 CLINICAL POLICIES Revised 4/2019 Approved: Levon Vartanian, MD

ŽEŽƚZĞƐƵƐĐŝƚĂƚĞ;EZͿKƌĚĞƌƐ

/ƚŝƐĂĐĐĞƉƚĂďůĞ͕ƵŶĚĞƌƚŚĞĨŽůůŽǁŝŶŐĐŝƌĐƵŵƐƚĂŶĐĞƐ͕ĨŽƌǇƉƌĞƐƐƌĞĞŬD^ƉĞƌƐŽŶŶĞůƚŽĞůĞĐƚƚŽ ǁŝƚŚŚŽůĚƌĞƐƵƐĐŝƚĂƚŝǀĞŵĞĂƐƵƌĞƐĨƌŽŵĂŶǇƉĂƚŝĞŶƚŽƌĚŝƐĐŽŶƚŝŶƵĞĂŶǇĂƚƚĞŵƉƚƐŝŶŝƚŝĂƚĞĚďǇůĂǇƉĞŽƉůĞ͗ x sĂůŝĚථOut-of-Hospital Do-Not-Resuscitate ;EZͿKƌĚĞƌථĞǆĞĐƵƚĞĚďǇƚŚĞƉĂƚŝĞŶƚ͛ƐƉŚǇƐŝĐŝĂŶ ƚŚƌŽƵŐŚථANYථŽĨථƚŚĞĨŽůůŽǁŝŶŐŵĞĐŚĂŶŝƐŵƐ͗ x ŝƌĞĐƚƉŚŽŶĞĐŽŶƚĂĐƚǁŝƚŚƚŚĞƉĂƚŝĞŶƚ͛ƐƉŚǇƐŝĐŝĂŶ x ƵƌƌĞŶƚ;ǁŝƚŚŝŶŽŶĞŵŽŶƚŚͿ͕ǁƌŝƚƚĞŶ͕ŽƌŝŐŝŶĂůEZŽƌĚĞƌƐŝŐŶĞĚďǇƚŚĞƉĂƚŝĞŶƚ͛ƐƉŚǇƐŝĐŝĂŶ x ǀĂůŝĚ^ƚĂƚĞŽĨdĞǆĂƐKK,ͲEZKƌĚĞƌĨŽƌŵ;ƉŚŽƚŽĐŽƉŝĞƐĂƌĞĂĐĐĞƉƚĂďůĞͿǁŝƚŚƐŝŐŶĂƚƵƌĞŽĨƚŚĞ ƉĂƚŝĞŶƚ;ŽƌƚŚĞŝƌƌĞƉƌĞƐĞŶƚĂƚŝǀĞͿ͕ƉŚǇƐŝĐŝĂŶ͕ĂŶĚϮǁŝƚŶĞƐƐĞƐ͘;dŚĞƐŝŐŶĂƚƵƌĞƐŵƵƐƚĂƉƉĞĂƌǁŝƚŚŝŶ ƚŚĞďŽĚǇŽĨƚŚĞĚŽĐƵŵĞŶƚĂŶĚĂŐĂŝŶĂƚƚŚĞďŽƚƚŽŵŽĨƚŚĞƉĂŐĞ͘Ϳ x ŶŝŶƚĂĐƚ͕ƵŶĂůƚĞƌĞĚ͕ĞĂƐŝůǇŝĚĞŶƚŝĨŝĂďůĞ͕ƉůĂƐƚŝĐŝĚĞŶƚŝĨŝĐĂƚŝŽŶKK,ͲEZďƌĂĐĞůĞƚǁŝƚŚƚŚĞǁŽƌĚ ͞dĞǆĂƐ͟;ŽƌĂƌĞƉƌĞƐĞŶƚĂƚŝŽŶŽĨƚŚĞŐĞŽŐƌĂƉŚŝĐĂůƐŚĂƉĞŽĨdĞǆĂƐĂŶĚƚŚĞǁŽƌĚ͞^dKW͟ŝŵƉŽƐĞĚ ŽǀĞƌƚŚĞƐŚĂƉĞͿĂŶĚƚŚĞǁŽƌĚƐ͞ŽEŽƚZĞƐƵƐĐŝƚĂƚĞ͟ථshallථďĞŚŽŶŽƌĞĚďǇƋƵĂůŝĨŝĞĚD^ ƉĞƌƐŽŶŶĞůŝŶůŝĞƵŽĨĂŶŽƌŝŐŝŶĂůKK,ͲEZථKƌĚĞƌථĨŽƌŵ͘ x ŶŝŶƚĂĐƚ͕ƵŶĂůƚĞƌĞĚ͕ĞĂƐŝůǇŝĚĞŶƚŝĨŝĂďůĞ͕ථmetalථďƌĂĐĞůĞƚŽƌŶĞĐŬůĂĐĞŝŶƐĐƌŝďĞĚǁŝƚŚƚŚĞǁŽƌĚƐ͗ ͞dĞǆĂƐŽEŽƚZĞƐƵƐĐŝƚĂƚĞʹKK,ΗථshallථďĞŚŽŶŽƌĞĚďǇƋƵĂůŝĨŝĞĚD^ƉĞƌƐŽŶŶĞůŝŶůŝĞƵŽĨĂŶ KK,ͲEZKƌĚĞƌĨŽƌŵ͘ x EŽƚĞ͗zŽƵŵĂǇƌĞĨƵƐĞƚŽŚŽŶŽƌƚŚĞKK,ͲEZKƌĚĞƌŝĨƚŚĞƉĂƚŝĞŶƚŝƐƉƌĞŐŶĂŶƚ͕ŝƚŝƐĨŝůůĞĚŽƵƚ ŝŶĐŽƌƌĞĐƚůǇ͕ŽƌƚŚĞƌĞĂƌĞƵŶŶĂƚƵƌĂůŽƌƐƵƐƉŝĐŝŽƵƐĞǀĞŶƚƐƐƵƌƌŽƵŶĚŝŶŐƚŚĞĐƵƌƌĞŶƚƐŝƚƵĂƚŝŽŶ͘ WĞĂƌůƐථ x KƵƚͲŽĨͲ,ŽƐƉŝƚĂůŽͲEŽƚͲZĞƐƵƐĐŝƚĂƚĞ;KK,ͲEZͿKƌĚĞƌƐƉƌŽŚŝďŝƚWZ͕ƉĂĐŝŶŐ͕ĚĞĨŝďƌŝůůĂƚŝŽŶ͕ĂĚǀĂŶĐĞĚ ĂŝƌǁĂǇŵĂŶĂŐĞŵĞŶƚ͕ĂŶĚĂƌƚŝĨŝĐŝĂůǀĞŶƚŝůĂƚŝŽŶ͘,ŽǁĞǀĞƌ͕ĂEZŵĂǇďĞƌĞǀŽŬĞĚĂƚĂŶǇƚŝŵĞďǇƚŚĞ ƉĂƚŝĞŶƚŽƌƚŚĞŝƌƌĞƉƌĞƐĞŶƚĂƚŝǀĞ͘&ĂŵŝůǇƉƌŝŽƌŝƚǇŽŶĚĞĐŝƐŝŽŶͲŵĂŬŝŶŐŝƐĂƐĨŽůůŽǁƐ͗ƐƉŽƵƐĞ͕ĂĚƵůƚ ĐŚŝůĚƌĞŶ͕ƉĂƌĞŶƚƐ͕ĂŶǇůŝǀŝŶŐƌĞůĂƚŝǀĞ͘

Cypress Creek EMS System Policies and Treatment Guidelines

30 CLINICAL POLICIES Revised 8/2016 Approved: Levon Vartanian, MD

ŽĐƵŵĞŶƚĂƚŝŽŶ'ƵŝĚĞůŝŶĞƐ Purpose ĐĐƵƌĂƚĞ͕ƚŝŵĞůǇĚŽĐƵŵĞŶƚĂƚŝŽŶŝƐĞƐƐĞŶƚŝĂůĨŽƌƉƌŽǀŝĚŝŶŐĂĐůĞĂƌƉŝĐƚƵƌĞŽĨƚŚĞƉĂƚŝĞŶƚ͛ƐĐŽŶĚŝƚŝŽŶ ĚƵƌŝŶŐD^ĐĂƌĞĂŶĚƚŚĞƚƌĞĂƚŵĞŶƚ;ƐͿƉƌŽǀŝĚĞĚ͘dŚĞƉĂƚŝĞŶƚĐĂƌĞƌĞĐŽƌĚ;WZͿĐŽŶƚĂŝŶƐŝŶĨŽƌŵĂƚŝŽŶƚŚĂƚ ǁŝůůďĞƵƐĞĚďǇƚŚĞƌĞĐĞŝǀŝŶŐŚŽƐƉŝƚĂůƉƌŽǀŝĚĞƌƐ͕ƚŚĞD^ďŝůůŝŶŐĐŽŵƉĂŶǇ͕ĂŶĚŝŶƐŽŵĞĐĂƐĞƐ͕ ƌĞŐƵůĂƚŽƌǇĂŶĚůĞŐĂůĞŶƚŝƚŝĞƐ͘ Principles x WZŵƵƐƚďĞĐƌĞĂƚĞĚĨŽƌĞǀĞƌǇĚŝƐƉĂƚĐŚĞĚĐĂůůĂŶĚĞǀĞƌǇƉĂƚŝĞŶƚĐŽŶƚĂĐƚ͘ x ŽĐƵŵĞŶƚĂƚŝŽŶŝƐƵůƚŝŵĂƚĞůǇƚŚĞƌĞƐƉŽŶƐŝďŝůŝƚǇŽĨƚŚĞ/ŶͲŚĂƌŐĞWĂƌĂŵĞĚŝĐŽŶƚŚĞƵŶŝƚ͕ŚŽǁĞǀĞƌ͕ƚŚĞ ƌĞƉŽƌƚŵĂǇďĞĐŽŵƉůĞƚĞĚďǇĂŶǇĐƌĞĚĞŶƚŝĂůĞĚĂƐŝĐ/ŶͲŚĂƌŐĞ͕Wϭ͕WϮ͕ŽƌWϯŝĨƚŚĞǇĂƐƐƵŵĞĚ ƌĞƐƉŽŶƐŝďŝůŝƚǇĨŽƌƉĂƚŝĞŶƚĐĂƌĞĚƵƌŝŶŐƚƌĂŶƐƉŽƌƚ͘ x WZĐŚĂƌƚƐƐŚŽƵůĚďĞƐĂǀĞĚƚŽƚŚĞƐĞƌǀĞƌƉƌŝŽƌƚŽůĞĂǀŝŶŐƚŚĞŚŽƐƉŝƚĂů͘ x /ĚĞĂůůǇ͕WZĐŚĂƌƚƐƐŚŽƵůĚďĞĐŽŵƉůĞƚĞĚďĞĨŽƌĞůĞĂǀŝŶŐƚŚĞŚŽƐƉŝƚĂů͕ŽƌĂƐƐŽŽŶĂƐĐŝƌĐƵŵƐƚĂŶĐĞƐ ƉĞƌŵŝƚ͘ x WZĐŚĂƌƚƐƐŚŽƵůĚďĞĐŽŵƉůĞƚĞĚǁŝƚŚŝŶϮϰŚŽƵƌƐŽĨƚŚĞĐĂůů͘/ĨĐŝƌĐƵŵƐƚĂŶĐĞƐƉƌĞǀĞŶƚƚŚŝƐ͕ƚŚĞŽŶͲ ĚƵƚǇĨŝĞůĚƐƵƉĞƌǀŝƐŽƌƐŚŽƵůĚďĞĐŽŶƚĂĐƚĞĚǁŝƚŚĂŶĞǆƉůĂŶĂƚŝŽŶ͘ x D^ƵƐĞƐ^K,Z;ůĞĐƚƌŽŶŝĐ,ĞĂůƚŚZĞĐŽƌĚƐͿĞůĞĐƚƌŽŶŝĐĚŽĐƵŵĞŶƚĂƚŝŽŶĂƐŝƚƐƉƌŝŵĂƌǇŵĞĂŶƐŽĨ ĚŽĐƵŵĞŶƚŝŶŐĐĂůůƐ͘ĂĐŬͲƵƉĚŽĐƵŵĞŶƚĂƚŝŽŶŵĞƚŚŽĚƐĂƌĞĂǀĂŝůĂďůĞŝŶƚŚĞĞǀĞŶƚŽĨƐǇƐƚĞŵĚŽǁŶƚŝŵĞ ŽƌĚŝƐĂƐƚĞƌƐĐĞŶĂƌŝŽƐ͘ Minimum Requirements x ĞƚƌƵƚŚĨƵů͕ĂĐĐƵƌĂƚĞ͕ƉĞƌƚŝŶĞŶƚ͕ůĞŐŝďůĞ͕ĂŶĚĐŽŵƉůĞƚĞǁŝƚŚĂƉƉƌŽƉƌŝĂƚĞƐƉĞůůŝŶŐ͕ĂďďƌĞǀŝĂƚŝŽŶƐ͕ĂŶĚ ŐƌĂŵŵĂƌ͘ǀĞƌǇĐŚĂƌƚƐŚŽƵůĚƌĞĨůĞĐƚƚŚĞƉƌŽĨĞƐƐŝŽŶĂůŝƐŵŽĨƚŚĞD^ƉƌŽǀŝĚĞƌƐŐŝǀŝŶŐĐĂƌĞ͘ x ǀĞƌǇĐŚĂƌƚƐŚŽƵůĚ͞ƉĂŝŶƚƚŚĞƉŝĐƚƵƌĞ͟ƐŽƚŚĂƚƚŚŽƐĞŶŽƚŽŶƐĐĞŶĞĐĂŶƵŶĚĞƌƐƚĂŶĚǁŚĂƚŚĂƉƉĞŶĞĚ ĂŶĚƚŚĞĐŽŶƚĞǆƚďĞŚŝŶĚƚŚĞĚĞĐŝƐŝŽŶƐŵĂĚĞŽŶƐĐĞŶĞ͘ x ůĞĂƌůǇĚĞƐĐƌŝďĞĐŝƌĐƵŵƐƚĂŶĐĞƐĂŶĚĨŝŶĚŝŶŐƐĂƐƐŽĐŝĂƚĞĚǁŝƚŚĂŶǇĐŽŵƉůĞǆŽƌƵŶƵƐƵĂůĐĂůůŽƌƐŝƚƵĂƚŝŽŶ͘ x hƉŚŽůĚƉĂƚŝĞŶƚĐŽŶĨŝĚĞŶƚŝĂůŝƚǇĂŶĚƐŚĂƌĞƉĂƚŝĞŶƚŝŶĨŽƌŵĂƚŝŽŶŽŶůǇǁŝƚŚůĞŐĂůůǇĂĐĐĞƉƚĂďůĞĞŶƚŝƚŝĞƐ͘ x tŚĞŶĐĂƌĚŝĂĐŵŽŶŝƚŽƌŝŶŐŝƐĚŽŶĞŽƌϭϮͲůĞĂĚ<'ƐŽďƚĂŝŶĞĚ͕ƚŚĞŵŽŶŝƚŽƌĚĂƚĂƐŚŽƵůĚďĞĂƚƚĂĐŚĞĚƚŽ ƚŚĞWZ͘ Required Documentation for No Patient Calls x ZĞůĞǀĂŶƚƌĞƐƉŽŶƐĞƚŝŵĞƐ͕ůŽĐĂƚŝŽŶ͕ůŽĐĂƚŝŽŶĚĞƐĐƌŝƉƚŝŽŶ͘ x /ĨƚŚĞĐƌĞǁŵĂŬĞƐƚŚĞƐĐĞŶĞ͕ĂďƌŝĞĨďƵƚƚŚŽƌŽƵŐŚŶĂƌƌĂƚŝǀĞĚĞƐĐƌŝďŝŶŐƚŚĞƐĐĞŶĞͬƐŝƚƵĂƚŝŽŶĂŶĚ ĐŝƌĐƵŵƐƚĂŶĐĞƐŽĨƚŚĞŶŽƉĂƚŝĞŶƚŝƐƌĞƋƵŝƌĞĚ͘ x /ĨƚŚĞƌĞŝƐĂŶǇƉŽƐƐŝďŝůŝƚǇƚŚĂƚƚŚĞƉĞƌƐŽŶŝŶǀŽůǀĞĚŝŶƚŚĞĐĂůůĐŽƵůĚƋƵĂůŝĨǇĂƐĂƉĂƚŝĞŶƚ͕ƚŚĞǇ ƐŚŽƵůĚďĞĞǀĂůƵĂƚĞĚĂŶĚĚŽĐƵŵĞŶƚĞĚĂƐĂƉĂƚŝĞŶƚĐŽŶƚĂĐƚ͘ x KŶĐĂƐĞƐŝŶǀŽůǀŝŶŐWƵďůŝĐƐƐŝƐƚƐ;ƌĞĨĞƌƚŽPatient Determination\Non-Transport ŐƵŝĚĞůŝŶĞƐͿ͕ ĚĞŵŽŐƌĂƉŚŝĐŝŶĨŽƌŵĂƚŝŽŶĂďŽƵƚƚŚĞĐůŝĞŶƚƌĞĐĞŝǀŝŶŐĂƐƐŝƐƚĂŶĐĞŝƐƌĞƋƵŝƌĞĚ͘

Cypress Creek EMS System Policies and Treatment Guidelines

31 CLINICAL POLICIES Revised 8/2016 Approved: Levon Vartanian, MD

x ŽŵƉůĞƚĞĂůůZƵůĞƐǁŝůůŐƵŝĚĞƚŚĞŵĞĚŝĐƚŚƌŽƵŐŚĐŽŵƉůĞƚŝŶŐƚŚĞƌĞƋƵŝƌĞĚĨŝĞůĚƐ͘ Required Documentation for Patient Contacts ƚĂŵŝŶŝŵƵŵ͕ĂůůƉĂƚŝĞŶƚĐĂƌĞĚŽĐƵŵĞŶƚĂƚŝŽŶďǇĂŶǇĐƌĞĚĞŶƚŝĂůĞĚƉƌŽǀŝĚĞƌŝŶƚŚĞŽƌŐĂŶŝǌĂƚŝŽŶƐŚĂůů ŝŶĐůƵĚĞ͗

x ŽŵƉůĞƚĞĐĂůůƌƵůĞƐǁŝůůŐƵŝĚĞƚŚĞŵĞĚŝĐƚŚƌŽƵŐŚĐŽŵƉůĞƚŝŶŐƚŚĞƌĞƋƵŝƌĞĚĨŝĞůĚƐ͘ x ĐůĞĂƌŚŝƐƚŽƌǇŽĨƉƌĞƐĞŶƚŝůůŶĞƐƐŝŶĐůƵĚŝŶŐĐŚŝĞĨĐŽŵƉůĂŝŶƚ͕ŽŶƐĞƚ͕ĂƐƐŽĐŝĂƚĞĚƐǇŵƉƚŽŵƐ͕ŵĞĐŚĂŶŝƐŵ ŽĨŝŶũƵƌǇ͕ĂŶĚƚŚĞƐĞƋƵĞŶĐĞŽĨĞǀĞŶƚƐƚŚĂƚůĞĚƚŽƚŚĞŝƌĐƵƌƌĞŶƚƌĞƋƵĞƐƚŽƌŶĞĞĚĨŽƌĐĂƌĞ͘ x ĚĞƚĂŝůĞĚĂƐƐĞƐƐŵĞŶƚŽĨƚŚĞŶĂƚƵƌĞŽĨƚŚĞƉĂƚŝĞŶƚ͛ƐĐŽŵƉůĂŝŶƚƐƚŚĂƚƉƌŽǀŝĚĞƐĐŽŶƚĞǆƚĨŽƌƚŚĞ ĚŝĂŐŶŽƐƚŝĐĞǀĂůƵĂƚŝŽŶĂŶĚƚƌĞĂƚŵĞŶƚŵŽĚĂůŝƚŝĞƐĂĚŵŝŶŝƐƚĞƌĞĚƚŽƚŚĞƉĂƚŝĞŶƚ͘ x ĐĐƵƌĂƚĞƌĞĐŽƌĚŽĨŝŶŝƚŝĂůƉŚǇƐŝĐĂůĨŝŶĚŝŶŐƐ͕ĂĐŽŵƉůĞƚĞƐĞƚŽĨŝŶŝƚŝĂůǀŝƚĂůƐŝŐŶƐ͕ĂůůĚĞƚĂŝůƐŽĨƌĞůĞǀĂŶƚ ĂďŶŽƌŵĂůĨŝŶĚŝŶŐƐ;ŝŶĐůƵĚŝŶŐƉĞƌƚŝŶĞŶƚŶĞŐĂƚŝǀĞƐͿĂŶĚƐŝŐŶŝĨŝĐĂŶƚĐŚĂŶŐĞƐŝŵƉŽƌƚĂŶƚƚŽƉĂƚŝĞŶƚĐĂƌĞ͘ x sŝƚĂůƐŝŐŶƐ͗ o ĐŽŵƉůĞƚĞƐĞƚŽĨǀŝƚĂůƐŝŐŶƐŝŶĐůƵĚĞƐƉƵůƐĞ͕ƌĞƐƉŝƌĂƚŝŽŶƐ͕ďůŽŽĚƉƌĞƐƐƵƌĞ͕^ƉKϮ͕ƚĞŵƉĞƌĂƚƵƌĞ͕ ĂŶĚůĞǀĞůŽĨĐŽŶƐĐŝŽƵƐŶĞƐƐ͘ o &ŽƌĂůůŶŽŶͲƚƌĂŶƐƉŽƌƚƐ͕ĂƚůĞĂƐƚŽŶĞƐĞƚŽĨǀŝƚĂůƐŝŐŶƐŝƐƌĞƋƵŝƌĞĚ͘/ĨǀŝƚĂůƐŝŐŶƐĨĂůůŽƵƚƐŝĚĞŽĨ ŶŽƌŵĂůƌĂŶŐĞ͕ƚŚĞŶƐƵďƐĞƋƵĞŶƚƐĞƚƐƐŚŽƵůĚďĞŽďƚĂŝŶĞĚ͘ o &ŽƌĂůůƚƌĂŶƐƉŽƌƚĞĚƉĂƚŝĞŶƚƐ͕ĂƚůĞĂƐƚƚǁŽĨƵůůƐĞƚƐŽĨǀŝƚĂůƐŝŐŶƐĂƌĞƌĞƋƵŝƌĞĚ͖ĐƌŝƚŝĐĂůůǇŝůůƉĂƚŝĞŶƚƐ ƐŚŽƵůĚŚĂǀĞĚŽĐƵŵĞŶƚĞĚǀŝƚĂůƐŝŐŶƐĂƚůĞĂƐƚĞǀĞƌǇϱŵŝŶƵƚĞƐ͕ƵƌŐĞŶƚƉĂƚŝĞŶƚƐƐŚŽƵůĚŚĂǀĞ ĚŽĐƵŵĞŶƚĞĚǀŝƚĂůƐŝŐŶƐĂƚůĞĂƐƚĞǀĞƌǇϭϬŵŝŶƵƚĞƐ͘ x KďƚĂŝŶŝŶŐĂŶĂĐĐƵƌĂƚĞďůŽŽĚƉƌĞƐƐƵƌĞŝŶĐŚŝůĚƌĞŶфϯǇĞĂƌƐŽůĚŝƐƐŽŵĞƚŝŵĞƐĚŝĨĨŝĐƵůƚ͕ďƵƚƐŚŽƵůĚďĞ ĂƚƚĞŵƉƚĞĚ͘ĂƉŝůůĂƌǇZĞĨŝůůƐŚŽƵůĚďĞƐƵďƐƚŝƚƵƚĞĚŝĨďůŽŽĚƉƌĞƐƐƵƌĞĐĂŶŶŽƚďĞĂƐƐĞƐƐĞĚ͘ x tŚĞŶĐĂƌĚŝĂĐŵŽŶŝƚŽƌŝƐĂƉƉůŝĞĚ͕ƚŚĞǀŝƚĂůƐŝŐŶƐĚĂƚĂŵĂǇďĞƚƌĂŶƐĨĞƌƌĞĚĨƌŽŵƚŚĞĚĞǀŝĐĞƚŽƚŚĞWZ͘ ,ŽǁĞǀĞƌ͕ŝĨƵƉůŽĂĚĞĚǀŝƚĂůƐŝŐŶƐĚŽŶŽƚĂĐĐƵƌĂƚĞůǇƌĞƉƌĞƐĞŶƚƚŚĞƉĂƚŝĞŶƚĐŽŶĚŝƚŝŽŶĚƵĞƚŽŝŶĂĐĐƵƌĂƚĞ ƌĞĂĚŝŶŐ;ƐͿ͕ƚŚĞǇŵĂǇďĞĞĚŝƚĞĚƚŽƌĞĨůĞĐƚŵĂŶƵĂůůǇŽďƚĂŝŶĞĚǀŝƚĂůƐŝŐŶƐ͘ x ĂƌĚŝĂĐŵŽŶŝƚŽƌĂŶĚǀŝƚĂůƐŝŐŶƐƌĞĂƐƐĞƐƐŵĞŶƚƐƐŚŽƵůĚďĞĐŽŶƚŝŶƵĞĚƵŶƚŝůƚƌĂŶƐĨĞƌŽĨƉĂƚŝĞŶƚĐĂƌĞ͘ůů ǀŝƚĂůƐŝŐŶƐĂŶĚĂŶǇĐŚĂŶŐĞƐŝŶƉĂƚŝĞŶƚĐŽŶĚŝƚŝŽŶǁŚŝůĞĂǁĂŝƚŝŶŐƚƌĂŶƐĨĞƌŽĨĐĂƌĞŵƵƐƚďĞƌĞĐŽƌĚĞĚŝŶ ƚŚĞWZĂŶĚĐŽŵŵƵŶŝĐĂƚĞĚƚŽƚŚĞƌĞĐĞŝǀŝŶŐƐƚĂĨĨ͘ x ^ƵŵŵĂƌŝǌĞĂůůĂƐƐĞƐƐŵĞŶƚƐ͕ŝŶƚĞƌǀĞŶƚŝŽŶƐ͕ĂŶĚƚŚĞƌĞƐƵůƚƐŽĨƚŚĞŝŶƚĞƌǀĞŶƚŝŽŶƐǁŝƚŚƐƵĨĨŝĐŝĞŶƚĚĞƚĂŝů ƚŚĂƚƚŚĞƌĞĂĚĞƌŵĂǇƵŶĚĞƌƐƚĂŶĚĂŶĚƌĞĐƌĞĂƚĞƚŚĞĞǀĞŶƚƐ͘ x ĐŽŵƉůĞƚĞůŝƐƚŽĨŝŶƚĞƌǀĞŶƚŝŽŶƐƐŚŽƵůĚďĞŝŶĐůƵĚĞĚ͕ŝŶĐůƵĚŝŶŐĐůŝŶŝĐĂůŝŶĚŝĐĂƚŝŽŶƐĂŶĚĐŚĂŶŐĞƐŝŶ ƉĂƚŝĞŶƚĐŽŶĚŝƚŝŽŶĨŽůůŽǁŝŶŐƚŚĞŝŶƚĞƌǀĞŶƚŝŽŶ͘ x &ŽƌƉĂƚŝĞŶƚƐǁŝƚŚĞǆƚƌĞŵŝƚǇŝŶũƵƌŝĞƐ͕ĚŽĐƵŵĞŶƚƉƵůƐĞͲŵŽƚŽƌͲƐĞŶƐĂƚŝŽŶďĞĨŽƌĞĂŶĚĂĨƚĞƌĂŶǇ ƚƌĞĂƚŵĞŶƚƐ͘ x &ŽƌƉĂƚŝĞŶƚƐƌĞĐĞŝǀŝŶŐƐƉŝŶĂůŝŵŵŽďŝůŝǌĂƚŝŽŶ͕ĚŽĐƵŵĞŶƚƌĞĂƐŽŶƐƉŝŶĂůĐůĞĂƌĂŶĐĞǁĂƐŶŽƚƉĞƌĨŽƌŵĞĚ ĂŶĚĚŽĐƵŵĞŶƚƉƵůƐĞͲŵŽƚŽƌͲƐĞŶƐĂƚŝŽŶŝŶĂůůĞǆƚƌĞŵŝƚŝĞƐďĞĨŽƌĞĂŶĚĂĨƚĞƌ^DZǁĂƐƉĞƌĨŽƌŵĞĚ͘ x ĚĞƚĂŝůĞĚŶĂƌƌĂƚŝǀĞ͞ƉĂŝŶƚŝŶŐƚŚĞƉŝĐƚƵƌĞ͟ƐŚŽƵůĚďĞŝŶĐůƵĚĞĚĨŽƌĂůůƉĂƚŝĞŶƚĐŽŶƚĂĐƚƐ͘dŚĞ,ZdŽƌ ^KWĨŽƌŵĂƚŝƐƉƌĞĨĞƌƌĞĚƚŽĂĐĐƵƌĂƚĞůǇĚŽĐƵŵĞŶƚŝŵƉŽƌƚĂŶƚĂŶĚƌĞůĞǀĂŶƚŝŶĨŽƌŵĂƚŝŽŶ͘ x /ĨƉĂƚŝĞŶƚŝƐƚƌĂŶƐƉŽƌƚĞĚ͕ĂƚƌĂŶƐĨĞƌŽĨĐĂƌĞƚŝŵĞŵƵƐƚďĞƌĞĐŽƌĚĞĚ͘dŚŝƐƚŝŵĞƐŚŽƵůĚďĞƚŚĞƉŽŝŶƚ ǁŚĞƌĞƉĂƚŝĞŶƚŝƐŽĨĨƚŚĞD^ƐƚƌĞƚĐŚĞƌĂŶĚƌĞƉŽƌƚŚĂƐďĞĞŶŐŝǀĞŶƚŽƚŚĞZEŽƌDĂĐĐĞƉƚŝŶŐƉĂƚŝĞŶƚ ĐĂƌĞ͘

Cypress Creek EMS System Policies and Treatment Guidelines

32 CLINICAL POLICIES Revised 8/2016 Approved: Levon Vartanian, MD

x /ŶĐůƵĚĞĂŶĞǆƉůĂŶĂƚŝŽŶĨŽƌǁŚǇĂŶŝŶƚƵŝƚŝǀĞůǇŝŶĚŝĐĂƚĞĚĂŶĚĂƉƉƌŽƉƌŝĂƚĞĂƐƐĞƐƐŵĞŶƚ͕ŝŶƚĞƌǀĞŶƚŝŽŶ͕Žƌ ĂĐƚŝŽŶƚŚĂƚŝƐƉĂƌƚŽĨƚŚĞǇƉƌĞƐƐƌĞĞŬD^ƉƌŽƚŽĐŽůƐŽƌƐƚĂŶĚĂƌĚŽĨĐĂƌĞĚŝĚŶŽƚŽĐĐƵƌ͘ Narrative Charting ůĞĐƚƌŽŶŝĐĚŽĐƵŵĞŶƚĂƚŝŽŶƐŽĨƚǁĂƌĞŚĂƐŶƵŵĞƌŽƵƐ͞ĐŚĞĐŬďŽǆĞƐ͟ĂŶĚĚƌŽƉĚŽǁŶďŽǆĞƐ͘,ŽǁĞǀĞƌ͕ƚŚĞƐĞ ĚŽŶŽƚƉƌŽǀŝĚĞĚĞƚĂŝůƐŽƌĐŽŶƚĞǆƚĨŽƌƚŚĞƉĂƚŝĞŶƚ͛ƐĐŽŵƉůĂŝŶƚ͕ŚŝƐƚŽƌǇ͕ŽƌŝŶƚĞƌǀĞŶƚŝŽŶƐƉĞƌĨŽƌŵĞĚ͘/ƚŝƐ ĐƌŝƚŝĐĂůƚŽƉƌŽǀŝĚĞĂĚĞƚĂŝůĞĚǁƌŝƚƚĞŶŶĂƌƌĂƚŝǀĞĞǆƉůĂŝŶŝŶŐǁŚĂƚŽĐĐƵƌƌĞĚŽŶƚŚĞĐĂůů͘/ƚŝƐƉƌĞĨĞƌƌĞĚƚŚĂƚ ƚŚĞŶĂƌƌĂƚŝǀĞďĞƐƚƌƵĐƚƵƌĞĚĨŽůůŽǁŝŶŐ,ZdŽƌ^KWŝŶŽƌĚĞƌƚŽĂǀŽŝĚŵŝƐƐŝŶŐŝŵƉŽƌƚĂŶƚĚĞƚĂŝůƐ͘

dŚĞĨŝǀĞĐŽŵƉŽŶĞŶƚƐŽĨĂ,ZdŶĂƌƌĂƚŝǀĞĂƌĞ͗

x Chief Complaint;ǁŚĂƚƚŚĞƉĂƚŝĞŶƚ͛ƐĐŽŵƉůĂŝŶƚŝƐͿ͘dŚŝƐĐĂŶďĞƉůĂĐĞĚƵŶĚĞƌƚŚĞŚŝĞĨŽŵƉůĂŝŶƚ ƐĞĐƚŝŽŶŝŶ,Z͘ x History of Present IllnessĚĞƐĐƌŝďĞƐƚŚĞĞǀĞŶƚƐƚŚĂƚůĞĚƚŽƚŚĞƉĂƚŝĞŶƚ͛ƐĐƵƌƌĞŶƚƌĞƋƵĞƐƚŽƌŶĞĞĚĨŽƌ ĐĂƌĞ͘dŚŝƐƐŚŽƵůĚŝŶĐůƵĚĞĂůůĂƐƐŽĐŝĂƚĞĚƐǇŵƉƚŽŵƐĂŶĚƉĞƌƚŝŶĞŶƚŶĞŐĂƚŝǀĞƐƌĞůĂƚĞĚƚŽƚŚĞƉĂƚŝĞŶƚ͛Ɛ ĐŚŝĞĨĐŽŵƉůĂŝŶƚŽƌĐĂƌĚŝŶĂůƉƌĞƐĞŶƚĂƚŝŽŶ͘WĞƌƚŝŶĞŶƚŵĞĚŝĐĂůŚŝƐƚŽƌǇ͕ƐƵƌŐŝĐĂůŚŝƐƚŽƌǇ͕ƌĞůĞǀĂŶƚĨĂŵŝůǇ ĂŶĚƐŽĐŝĂůŚŝƐƚŽƌǇ͕ĂůŽŶŐǁŝƚŚĐƵƌƌĞŶƚŵĞĚŝĐĂƚŝŽŶƐĂŶĚĂůůĞƌŐŝĞƐ͕ĂƌĞĂůƐŽƌĞĐŽƌĚĞĚŚĞƌĞ͘ o KWYZ^dĂŶĚ^DW>ͲZĂƌĞŵŶĞŵŽŶŝĐƐƵƐĞĚƚŽĐĂƉƚƵƌĞƚŚĞƌĞůĞǀĂŶƚƉŽƌƚŝŽŶƐŽĨƚŚĞ,ŝƐƚŽƌǇŽĨ WƌĞƐĞŶƚ/ůůŶĞƐƐ͘ƐƉĞĐƚƐŽĨƚŚĞƐĞŵĂǇďĞĐĂƉƚƵƌĞĚƵƐŝŶŐƐƉĞĐŝĂůƚǇĨŽƌŵƐŽƌĐŚĞĐŬďŽǆĞƐ͘dŚĞ ĚĞƚĂŝůƐ͕ŚŽǁĞǀĞƌ͕ƐŚŽƵůĚďĞĐĂƉƚƵƌĞĚŝŶŶĂƌƌĂƚŝǀĞĨŽƌŵŝŶƚŚĞŐĞŶĞƌĂůŶĂƌƌĂƚŝǀĞƐĞĐƚŝŽŶŽĨƚŚĞ WZ͘ x AssessmentŝŶĐůƵĚĞƐƚŚĞŽďũĞĐƚŝǀĞĂƐƉĞĐƚƐŽĨƚŚĞƉƌŽǀŝĚĞƌ͛ƐĂƐƐĞƐƐŵĞŶƚ͘dŚŝƐŝŶĐůƵĚĞƐ͗ o sŝƚĂůƐŝŐŶƐ;ĂƚůĞĂƐƚƚǁŽĐŽŵƉůĞƚĞƐĞƚƐƉƌĞĨĞƌƌĞĚĨŽƌĂůůƉĂƚŝĞŶƚƐͿ o WƌŝŵĂƌǇ^ƵƌǀĞǇ;ͲͲͲͲͿĨŝŶĚŝŶŐƐ;ŝŶŝƚŝĂůĂŶĚĂƚůĞĂƐƚŽŶĞƌĞĂƐƐĞƐƐŵĞŶƚͿ o WŚǇƐŝĐĂůĞǆĂŵĨŝŶĚŝŶŐƐŝŶĐůƵĚŝŶŐŽŶĞĐŽŵƉůĞƚĞŚĞĂĚͲƚŽͲƚŽĞĂƐƐĞƐƐŵĞŶƚĂŶĚĨŽĐƵƐĞĚ ĂƐƐĞƐƐŵĞŶƚƐĂƐĂƉƉƌŽƉƌŝĂƚĞ͘ o ZĞƐƵůƚƐĨƌŽŵĚŝĂŐŶŽƐƚŝĐƐƐƵĐŚĂƐ'>͕dKϮ͕ĐĂƌĚŝĂĐŵŽŶŝƚŽƌŝŶŐ͕ϭϮͲůĞĂĚ<'͕ĞƚĐ͘ o KƚŚĞƌĨŝŶĚŝŶŐƐƐƵĐŚĂƐ͗ 'ĞŶĞƌĂůĂƉƉĞĂƌĂŶĐĞ;ĚŝƐƚƌĞƐƐ͕ƉŽƐƚƵƌĞ͕ǀŽŵŝƚŝŶŐ͕ŚǇŐŝĞŶĞ͕ŽĚŽƌƐ͕ĞƚĐ͘Ϳ ŵŽƚŝŽŶĂůŵŽŽĚͬĂĨĨĞĐƚ;ĨůŝŐŚƚŽĨŝĚĞĂƐ͕ƉĂƌĂŶŽŝĚĚĞůƵƐŝŽŶƐ͕ƚŚŽƵŐŚƚƐŽĨŐƌĂŶĚĞƵƌ͕ƐƵŝĐŝĚĂůŽƌ ŚŽŵŝĐŝĚĂůŝĚĞĂƚŝŽŶ͕ĂƵĚŝŽͬǀŝƐƵĂůͬƚĂĐƚŝůĞŚĂůůƵĐŝŶĂƚŝŽŶƐ͕ĚĞƉƌĞƐƐŝŽŶ͕ĞƚĐ͘Ϳ YƵĂůŝƚǇŽĨƐƉĞĞĐŚ DĞŶƚĂƚŝŽŶ;ŵĞŵŽƌǇƋƵĂůŝƚǇ͕ĚŝƐƚƌĂĐƚŝďŝůŝƚǇ͕ĞƚĐ͘Ϳ WĞĚŝĂƚƌŝĐĐŽŶƐŝĚĞƌĂƚŝŽŶƐ͗&ŽŶƚĂŶĞůůĞƐ͕ĐƌǇŝŶŐͬĨƵƐƐŝŶĞƐƐ͕ĚĞǀĞůŽƉŵĞŶƚ͕ŶƵƚƌŝƚŝŽŶ͕ǀŽŝĚŝŶŐ͕ĂŐĞͲ ĂƉƉƌŽƉƌŝĂƚĞĂƚƚĂĐŚŵĞŶƚƚŽƉĂƌĞŶƚͬĐĂƌĞŐŝǀĞƌ͕ĞƚĐ͘ x Rx/TreatmentsŝŶĐůƵĚĞƐƚŚĞŝŶƚĞƌǀĞŶƚŝŽŶƐƉƌŽǀŝĚĞĚĂŶĚŚŽǁƚŚĞƉĂƚŝĞŶƚƌĞƐƉŽŶĚƐ͘dŚĞĨůŽǁĐŚĂƌƚ ƐĞĐƚŝŽŶŽĨ,ZǁŝůůƉƌŽǀŝĚĞƚŚĞĂďŝůŝƚǇƚŽĚĞƐĐƌŝďĞƚŚĞƌĞƋƵŝƌĞĚĚĞƚĂŝůƐĂďŽƵƚĞĂĐŚƚƌĞĂƚŵĞŶƚ ŵŽĚĂůŝƚǇ͕ĂŶĚĚĞƐĐƌŝƉƚŝŽŶƐŽĨƚŚĞƉĂƚŝĞŶƚ͛ƐƌĞƐƉŽŶƐĞƚŽƚƌĞĂƚŵĞŶƚƐŚŽƵůĚďĞŝŶĐůƵĚĞĚŝŶƚŚĞŐĞŶĞƌĂů ŶĂƌƌĂƚŝǀĞ͘ o dƌĞĂƚŵĞŶƚƐƐŚŽƵůĚďĞĚŽĐƵŵĞŶƚĞĚŝŶ͞ƌĞĂůƚŝŵĞ͟ŝĨƉŽƐƐŝďůĞ͕ƵƚŝůŝǌŝŶŐƚŚĞYƵŝĐŬ>ŽŐĨĞĂƚƵƌĞŽĨ ,Z͘dŝŵĞĞŶƚƌŝĞƐĨŽƌĂůůŝŶƚĞƌǀĞŶƚŝŽŶƐƐŚŽƵůĚďĞĂĐĐƵƌĂƚĞůǇƌĞĐŽƌĚĞĚ͘

Cypress Creek EMS System Policies and Treatment Guidelines

33 CLINICAL POLICIES Revised 8/2016 Approved: Levon Vartanian, MD

x TransportŝŶĐůƵĚĞƐĂŐĞŶĞƌĂůƐƵŵŵĂƌǇŽĨƚŚĞƚƌĂŶƐƉŽƌƚŽĨƚŚĞƉĂƚŝĞŶƚŽƌƚŚĞŝƌĚŝƐƉŽƐŝƚŝŽŶŽŶƐĐĞŶĞ ĂŶĚƐŚŽƵůĚĂůƐŽĚĞƐĐƌŝďĞƚŚĞƚƌĂŶƐĨĞƌŽĨĐĂƌĞ͘dŚŝƐƐŚŽƵůĚďĞŝŶĐůƵĚĞĚŝŶƚŚĞŐĞŶĞƌĂůŶĂƌƌĂƚŝǀĞ ƐĞĐƚŝŽŶŽĨ,Z͘ dŚĞĨŽƵƌĐŽŵƉŽŶĞŶƚƐŽĨĂ^KWŶŽƚĞĂƌĞƐŝŵŝůĂƌƚŽ,Zd͗

x SubjectiveŝŶĐůƵĚĞƐƚŚĞChief Complaint ĂŶĚHistory of Present IllnessƐĞĐƚŝŽŶƐŽĨ,Zd͘ x ObjectiveŝŶĐůƵĚĞƐƚŚĞAssessmentƐĞĐƚŝŽŶŽĨ,Zd͘ x AssessmentŝƐƵƐĞĚƚŽĚĞƐĐƌŝďĞĂŶĚĚĞǀĞůŽƉƚŚĞĚŝĨĨĞƌĞŶƚŝĂůĚŝĂŐŶŽƐŝƐ͘dŚŝƐƐŚŽƵůĚďĞĚŽĐƵŵĞŶƚĞĚ ŝŶƚŚĞWƌŝŵĂƌǇŽƌ^ĞĐŽŶĚĂƌǇŝŵƉƌĞƐƐŝŽŶƐĨŝĞůĚƐŽĨ,Z͘ůůĂƐƐĞƐƐŵĞŶƚĂŶĚƚƌĞĂƚŵĞŶƚĚŽĐƵŵĞŶƚĂƚŝŽŶ ƐŚŽƵůĚƐƵƉƉŽƌƚƚŚĞĚĞǀĞůŽƉŵĞŶƚŽĨƚŚĞĚŝĨĨĞƌĞŶƚŝĂůĚŝĂŐŶŽƐŝƐ͘ x PlanŝŶĐůƵĚĞƐƚŚĞRx/TreatmentĂŶĚ TransportƐĞĐƚŝŽŶƐŽĨ,Zd͘ Required Signatures x dŚĞƉƌŝŵĂƌǇƉĂƚŝĞŶƚĐĂƌĞƉƌŽǀŝĚĞƌŽŶĂĐĂůůƐŚŽƵůĚƐŝŐŶĂƐ͞>ĞĂĚWƌŽǀŝĚĞƌ͟ŝŶ,Z͘ x WƵďůŝĐĂƐƐŝƐƚĐĂůůƐƌĞƋƵŝƌĞƚŚĞEŽƚŝĐĞŽĨWƌŝǀĂĐǇWƌĂĐƚŝĐĞƐƐŝŐŶĂƚƵƌĞďǇƚŚĞƉĂƚŝĞŶƚ͕ŽƌĂůĞŐĂů ŐƵĂƌĚŝĂŶͬƉŽǁĞƌŽĨĂƚƚŽƌŶĞǇ͕ĂƐĂƉƉƌŽƉƌŝĂƚĞ͘ x dƌĂŶƐƉŽƌƚĐĂůůƐƌĞƋƵŝƌĞƚŚĞĂƉƉƌŽƉƌŝĂƚĞŝůůŝŶŐƵƚŚŽƌŝǌĂƚŝŽŶƐŝŐŶĂƚƵƌĞ;WĂƚŝĞŶƚƵƚŚŽƌŝǌĂƚŝŽŶŝƐ ƉƌĞĨĞƌƌĞĚ͕ďƵƚŝĨƉĂƚŝĞŶƚĐĂŶ͛ƚƐŝŐŶ͕ƚŚĞƵƚŚŽƌŝǌĞĚZĞƉƌĞƐĞŶƚĂƚŝǀĞƐŝŐŶĂƚƵƌĞŝƐĂĐĐĞƉƚĂďůĞ͘/ĨŶŽ ĂƵƚŚŽƌŝǌĞĚƌĞƉƌĞƐĞŶƚĂƚŝǀĞŝƐĂǀĂŝůĂďůĞ͕ƚŚĞŶƚŚĞD^ƉĞƌƐŽŶŶĞůĂŶĚͬŽƌĂĨĂĐŝůŝƚǇƐƚĂĨĨŵĞŵďĞƌĐĂŶ ƐŝŐŶƚŚĞĂƉƉƌŽƉƌŝĂƚĞƐŝŐŶĂƚƵƌĞͿ͘ x WĂƚŝĞŶƚZĞĨƵƐĂůƐƌĞƋƵŝƌĞĂZĞĨƵƐĂůƐŝŐŶĂƚƵƌĞďǇƉĂƚŝĞŶƚŽƌůĞŐĂůŐƵĂƌĚŝĂŶͬƉŽǁĞƌŽĨĂƚƚŽƌŶĞǇ͕ĂƐ ĂƉƉƌŽƉƌŝĂƚĞ͘ŽŶƐŝĚĞƌŽďƚĂŝŶŝŶŐǁŝƚŶĞƐƐƐŝŐŶĂƚƵƌĞƐĨƌŽŵǁŝƚŶĞƐƐĞƐǁŚŽĂƌĞŶŽƚĂĨĨŝůŝĂƚĞĚǁŝƚŚ D^;ĞǆĂŵƉůĞ͗ďǇƐƚĂŶĚĞƌ͕ĨĂŵŝůǇŵĞŵďĞƌ͕ĞƚĐ͘Ϳ x ŶǇĐĂůůǁŚĞƌĞƚŚĞƉĂƚŝĞŶƚƌĞĨƵƐĞƐĂƐƉĞĐŝĨŝĐƚƌĞĂƚŵĞŶƚƌĞƋƵŝƌĞƐƚŚĞdƌĞĂƚŵĞŶƚZĞĨƵƐĂůƐŝŐŶĂƚƵƌĞĂƚ ƚŚĞƚŝŵĞŽĨƚŚĞƚƌĞĂƚŵĞŶƚƌĞĨƵƐĂůĂůŽŶŐǁŝƚŚĨƵůůĚŽĐƵŵĞŶƚĂƚŝŽŶŽĨƚŚĞĐŝƌĐƵŵƐƚĂŶĐĞƐĂŶĚ ĐŽŶǀĞƌƐĂƚŝŽŶƐƵƌƌŽƵŶĚŝŶŐƚŚŝƐƌĞĨƵƐĂůŝŶƚŚĞŶĂƌƌĂƚŝǀĞƐĞĐƚŝŽŶŽĨƚŚĞWZ͘ x ŶǇƚƌĂŶƐƉŽƌƚƚŽƚŚĞŚŽƐƉŝƚĂůƌĞƋƵŝƌĞƐĂ&ĂĐŝůŝƚǇ^ŝŐŶĂƚƵƌĞĨƌŽŵƚŚĞZEŽƌDĂĐĐĞƉƚŝŶŐƉĂƚŝĞŶƚĂƚ ƚŚĞŚŽƐƉŝƚĂů͘dŚŝƐƐŝŐŶĂƚƵƌĞƐŚŽƵůĚŝŶĐůƵĚĞĨŝƌƐƚĂŶĚůĂƐƚŶĂŵĞǁŝƚŚ͕͞ZE͟Žƌ͕͞DͬK͟ĨŽůůŽǁŝŶŐ ƚŚĞŶĂŵĞĂŶĚƚŚĞƐŝŐŶĂƚƵƌĞƐŚŽƵůĚďĞůĞŐŝďůĞ͘ x ƚŶŽƉŽŝŶƚƐŚŽƵůĚĂĐƌĞǁŵĞŵďĞƌƐŝŐŶŽŶďĞŚĂůĨŽĨĂƉĂƚŝĞŶƚŽƌĂĨĂĐŝůŝƚǇƐƚĂĨĨ͘/ŶƐƚĞĂĚ͕ƚŚĞǇƐŚŽƵůĚ ĚŽĐƵŵĞŶƚƚŚĞƐŝŐŶĂƚƵƌĞĂƐZĞĨƵƐĞĚĂŶĚƉƌŽǀŝĚĞƚŚĞƌĞĂƐŽŶƐƚŚĞƐŝŐŶĂƚƵƌĞĐŽƵůĚŶŽƚďĞŽďƚĂŝŶĞĚŝŶ ƚŚĞŶĂƌƌĂƚŝǀĞ͘ Unknown Patient Procedures x ŶǇƵŶŬŶŽǁŶƉĂƚŝĞŶƚƐƐŚŽƵůĚŚĂǀĞƚŚĞŝƌĨŝƌƐƚĂŶĚůĂƐƚŶĂŵĞƌĞĐŽƌĚĞĚĂƐ͞hE

Cypress Creek EMS System Policies and Treatment Guidelines

34 CLINICAL POLICIES Revised 12/2018 Approved: Levon Vartanian, MD

&ŝĞůĚdĞƌŵŝŶĂƚŝŽŶ Purpose /ŶƐŝƚƵĂƚŝŽŶƐŝŶǁŚŝĐŚĂĚƵůƚƉĂƚŝĞŶƚƐŚĂǀĞĞǆƉĞƌŝĞŶĐĞĚĂƉƌŝŵĂƌǇĐĂƌĚŝĂĐĂƌƌĞƐƚĂŶĚĂĚǀĂŶĐĞĚĐĂƌĚŝĂĐůŝĨĞ ƐƵƉƉŽƌƚĞĨĨŽƌƚƐŚĂǀĞďĞĞŶƵŶƐƵĐĐĞƐƐĨƵů͕ƉƌĞŚŽƐƉŝƚĂůƌĞƐƵƐĐŝƚĂƚŝŽŶŵĂǇďĞĚŝƐĐŽŶƚŝŶƵĞĚĂƚƚŚĞĚŝƌĞĐƚŝŽŶ ŽĨƚŚĞ&ŝĞůĚ^ƵƉĞƌǀŝƐŽƌŝŶĂĐĐŽƌĚĂŶĐĞǁŝƚŚƚŚĞƐƚĂŶĚŝŶŐŽƌĚĞƌƐƐĞƚĨŽƌƚŚďǇƚŚĞD^DĞĚŝĐĂůŝƌĞĐƚŽƌ͘

Note: Resuscitation and termination procedures for traumatic cardiac arrests are addressed under a separate protocol. Procedure ƌŝƚĞƌŝĂĨŽƌŝƐĐŽŶƚŝŶƵĂƚŝŽŶŽĨZĞƐƵƐĐŝƚĂƚŝŽŶ͗ WĂƚŝĞŶƚŵƵƐƚďĞϭϴǇĞĂƌƐŽĨĂŐĞŽƌŽůĚĞƌ͘ WĂƚŝĞŶƚŵƵƐƚŚĂǀĞĞǆƉĞƌŝĞŶĐĞĚĂƉƌŝŵĂƌǇĐĂƌĚŝĂĐĂƌƌĞƐƚ͘ WĂƚŝĞŶƚŵƵƐƚŚĂǀĞƌĞĐĞŝǀĞĚĂĚĞƋƵĂƚĞWZďǇD^ƉĞƌƐŽŶŶĞůĨŽƌĂƚůĞĂƐƚϮϬŵŝŶƵƚĞƐ͕ǁŝƚŚ͗ ĚǀĂŶĐĞĚŝƌǁĂǇŵĂŶĂŐĞŵĞŶƚ;ŝŶƚƵďĂƚŝŽŶ͕<ŝŶŐƐƵƉƌĂŐůŽƚƚŝĐĂŝƌǁĂǇ͕ŽƌĐƌŝĐŽƚŚǇƌŽƚŽŵǇͿ͘ sĂƐĐƵůĂƌĂĐĐĞƐƐǀŝĂĂŶ/sŽƌ/K͘ ƉƉƌŽƉƌŝĂƚĞĐĂƌĚŝĂĐŵĞĚŝĐĂƚŝŽŶƐĂĐĐŽƌĚŝŶŐƚŽƉƌŽƚŽĐŽů͘ WĞƌƐŝƐƚĞŶƚĂƐǇƐƚŽůĞŽƌĂŐŽŶĂůƌŚǇƚŚŵǁŝƚŚŶŽƌĞǀĞƌƐŝďůĞĐĂƵƐĞƐŝĚĞŶƚŝĨŝĞĚ͘ ŽĐƵŵĞŶƚĞĚƉĞƌƐŝƐƚĞŶƚdKϮчϮϬŵŵ,Ő͘ EŽĐĂƌĚŝĂĐŵŽƚŝŽŶǀŝƐŝďůĞƵƐŝŶŐƵůƚƌĂƐŽƵŶĚ͕ŝĨĂǀĂŝůĂďůĞ͘ Resuscitation efforts may not be discontinued in any patients with the following: x ĂƌĚŝĂĐĂƌƌĞƐƚƐĞĐŽŶĚĂƌǇƚŽĂŶŽƚŚĞƌĞǀĞŶƚ;ƚƌĂƵŵĂ͕ĚƌŽǁŶŝŶŐ͕ƌĞƐƉŝƌĂƚŽƌǇĨĂŝůƵƌĞ͕ĞƚĐ͘Ϳ͘ x WĞƌƐŝƐƚĞŶƚǀĞŶƚƌŝĐƵůĂƌĨŝďƌŝůůĂƚŝŽŶŽƌǀĞŶƚƌŝĐƵůĂƌƚĂĐŚǇĐĂƌĚŝĂ͘ x ŶǇŶĞƵƌŽůŽŐŝĐĂůĂĐƚŝǀŝƚǇ;ĞǇĞŽƉĞŶŝŶŐ͕ŵŽƚŽƌƌĞƐƉŽŶƐĞƐ͕ĞƚĐ͘Ϳ͘ x ŶǇƌĞƚƵƌŶŽĨƐƉŽŶƚĂŶĞŽƵƐƉƵůƐĞ͕ĞǀĞŶƚƌĂŶƐŝĞŶƚůǇ͘ x ĂƌĚŝĂĐĂƌƌĞƐƚǁŚŝůĞŝŶĐĂƌĞŽĨD^ƉĞƌƐŽŶŶĞů͘ x WĂƚŝĞŶƚƐǁŚŽĂƌĞƉƌĞŐŶĂŶƚ͘ x WĂƚŝĞŶƚƐŝŶǀŝĞǁŽĨƉƵďůŝĐ͘ ϭ͘ /ĨƚŚĞƉĂƚŝĞŶƚŵĞĞƚƐĐƌŝƚĞƌŝĂĨŽƌĚŝƐĐŽŶƚŝŶƵĂƚŝŽŶƚŚĞ/WŽƌ&ŝĞůĚ^ƵƉĞƌǀŝƐŽƌƐŚŽƵůĚĂƉƉƌŽĂĐŚƚŚĞ ĨĂŵŝůǇŽƌƌĞƐƉŽŶƐŝďůĞƉĂƌƚǇĂďŽƵƚĚŝƐĐŽŶƚŝŶƵĂƚŝŽŶŽĨƚŚĞƌĞƐƵƐĐŝƚĂƚŝǀĞĞĨĨŽƌƚƐ͘ Ϯ͘ /ŶƚŚĞĞǀĞŶƚƚŚĂƚĂŶǇĨĂŵŝůǇŵĞŵďĞƌŽƌƌĞƐƉŽŶƐŝďůĞƉĂƌƚǇŝŶĚŝĐĂƚĞƐƚŚĞŝƌŽďũĞĐƚŝŽŶƚŽƚŚĞĐŽŶĐĞƉƚŽĨ ĚŝƐĐŽŶƚŝŶƵĂƚŝŽŶŽĨƌĞƐƵƐĐŝƚĂƚŝŽŶĞĨĨŽƌƚƐ͕ƚŚĞƌĞƐƵƐĐŝƚĂƚŝŽŶĞĨĨŽƌƚƐƐŚĂůůĐŽŶƚŝŶƵĞƵŶƚŝůĐĂƌĞŝƐĂƐƐƵŵĞĚ ďǇƚŚĞƌĞĐĞŝǀŝŶŐĞŵĞƌŐĞŶĐǇƌŽŽŵƉŚǇƐŝĐŝĂŶ͘ ϯ͘ KŶĐĞƚŚĞĂƉƉƌŽǀĂůƚŽĚŝƐĐŽŶƚŝŶƵĞƚŚĞƌĞƐƵƐĐŝƚĂƚŝŽŶĞĨĨŽƌƚƐŝƐĂĐŬŶŽǁůĞĚŐĞĚďǇƚŚĞĨĂŵŝůǇŽƌ ƌĞƐƉŽŶƐŝďůĞƉĂƌƚǇ͕ƚŚĞD^ĐƌĞǁƐŚĂůůĚŝƐĐŽŶŶĞĐƚĂůů/sůŝŶĞƐĐůŽƐĞƚŽƚŚĞŝŶƐĞƌƚŝŽŶƐŝƚĞĂŶĚƌĞŵŽǀĞ ƚŚĞ/sĨůƵŝĚďĂŐĂŶĚĂŶǇŽƚŚĞƌƐƵƉƉůŝĞƐĂƚƚŚĞĐŽĚĞƐŝƚĞ͘dŚĞ/sĐĂƚŚĞƚĞƌƐĂŶĚĞŶĚŽƚƌĂĐŚĞĂůƚƵďĞƐŚĂůů ƌĞŵĂŝŶŝŶƉůĂĐĞ͘ ϰ͘ >ĂǁĞŶĨŽƌĐĞŵĞŶƚƐŚŽƵůĚďĞŶŽƚŝĨŝĞĚ͘ ϱ͘ D^ƉĞƌƐŽŶŶĞůƐŚĂůůďĞĂƚƚĞŶƚŝǀĞƚŽƚŚĞƉƐǇĐŚŽůŽŐŝĐĂůŶĞĞĚƐŽĨƚŚĞ͞ƐƵƌǀŝǀŽƌƐ͟ĂƚĂůůƚŝŵĞƐĂŶĚ ƉƌŽǀŝĚĞƐƵƉƉŽƌƚĂƐŶĞĞĚĞĚ͘ ϲ͘ ƐƵƉƉůĞŵĞŶƚĂůƌĞƉŽƌƚƐŚĂůůďĞĐŽŵƉůĞƚĞĚďǇƚŚĞ&ŝĞůĚ^ƵƉĞƌǀŝƐŽƌ͘

Cypress Creek EMS System Policies and Treatment Guidelines

35 CLINICAL POLICIES Revised 8/2016 Approved: Levon Vartanian, MD

&ŝƌĞ^ƚĂŶĚďǇZĞƐƉŽŶƐĞͬ&ŝƌĞZĞŚĂď Purpose dŽĞǆĂŵŝŶĞĂŶĚĞǀĂůƵĂƚĞƚŚĞƉŚǇƐŝĐĂůĂŶĚŵĞŶƚĂůƐƚĂƚƵƐŽĨĨŝƌĞĨŝŐŚƚĞƌƐĂŶĚŽƚŚĞƌĞŵĞƌŐĞŶĐǇƌĞƐƉŽŶĚĞƌƐ ǁŽƌŬŝŶŐĂƚĂŶĞŵĞƌŐĞŶĐǇŝŶĐŝĚĞŶƚŽƌĂƚƌĂŝŶŝŶŐĞǆĞƌĐŝƐĞĂŶĚĚĞƚĞƌŵŝŶĞǁŚĂƚƚƌĞĂƚŵĞŶƚ͕ŝĨĂŶǇ͕ŝƐ ŶĞĐĞƐƐĂƌǇ͘ Procedure ϭ͘ ZĞŵŽǀĞWW͕^͕dƵƌŶŽƵƚ'ĞĂƌ͕ŽƚŚĞƌĞƋƵŝƉŵĞŶƚĂƐŝŶĚŝĐĂƚĞĚ͘ Ϯ͘ ǀĂůƵĂƚĞǀŝƚĂůƐŝŐŶƐĂŶĚKͲKǆŝŵĞƚƌǇ;^ĞĞAssessment: CO-OximetryƉƌŽĐĞĚƵƌĞͿ ϯ͘ /ĨĂŶǇŽĨƚŚĞĨŽůůŽǁŝŶŐǁĂƌŶŝŶŐǀŝƚĂůƐŝŐŶƐĂƌĞŶŽƚĞĚ͕ƉƌŽǀŝĚĞŽƌĂůƌĞŚǇĚƌĂƚŝŽŶĂŶĚƌĞĂƐƐĞƐƐŵĞŶƚ͗ x WƵůƐĞƌĂƚĞхϴϱйŽĨE&WĂŐĞƉƌĞĚŝĐƚĞĚŵĂǆŝŵƵŵ;ƐĞĞƚĂďůĞͿ x ^ǇƐƚŽůŝĐWхϭϲϬŽƌŝĂƐƚŽůŝĐWхϭϬϬ NFPA Age Predicted 85 % x ZĞƐƉŝƌĂƚŽƌǇZĂƚĞфϴŽƌхϰϬ Maximum Heart Rate ϮϬͲϮϱ ϭϳϬ x ^ƉKϮфϵϬй ϮϲͲϯϬ ϭϲϱ x ^ƉKхϭϬй

x dĞŵƉĞƌĂƚƵƌĞхϭϬϬ͘ϱΣ& ϯϭͲϯϱ ϭϲϬ ϰ͘ WƌŽǀŝĚĞŽƌĂůƌĞŚǇĚƌĂƚŝŽŶ;ϭϮͲϯϮŽǌŽƌĂůĨůƵŝĚŽǀĞƌϮϬŵŝŶƵƚĞƐͿ͘ ϯϲͲϰϬ ϭϱϱ ϱ͘ ƐŶĞĐĞƐƐĂƌǇ͕ƵƚŝůŝǌĞĂĐƚŝǀĞĐŽŽůŝŶŐŽƌǁĂƌŵŝŶŐŵĞĂƐƵƌĞƐ͘ ϰϭͲϰϱ ϭϱϮ ϲ͘ /ĨŶŽŝŵƉƌŽǀĞŵĞŶƚĂĨƚĞƌϯϬŵŝŶƵƚĞƐŽĨĂĚĚŝƚŝŽŶĂůƌĞŚĂď͕ŶŽƚŝĨǇ ϰϲͲϱϬ ϭϰϴ ƐĐĞŶĞĐŽŵŵĂŶĚĂŶĚĐŽŶƐŝĚĞƌĨƵƌƚŚĞƌƚƌĞĂƚŵĞŶƚĂŶĚƚƌĂŶƐƉŽƌƚŽĨ ϱϭͲϱϱ ϭϰϬ ƉĂƚŝĞŶƚ͘ ϱϱͲϲϬ ϭϯϲ Pearls ϲϭͲϲϱ ϭϯϮ x dŚŝƐƉƌŽƚŽĐŽůƐŚŽƵůĚďĞƵƚŝůŝǌĞĚĨŽƌƉƵďůŝĐƐĂĨĞƚǇƌĞƐƉŽŶĚĞƌƐŽŶƚŚĞƐĐĞŶĞŽĨĂŶŝŶĐŝĚĞŶƚ͘ x ŽͲůŽĐĂƚĞǁŝƚŚ&ŝƌĞĞƉĂƌƚŵĞŶƚƌĞŚĂďƵŶŝƚŝŶĂůŽĐĂƚŝŽŶƚŚĂƚƉƌŽǀŝĚĞƐƐŚĞůƚĞƌ͕ƉƌŝǀĂĐǇ͕ĂŶĚ ƉƌŽƚĞĐƚŝŽŶĨƌŽŵƐŵŽŬĞĂŶĚŽƚŚĞƌƐĐĞŶĞŚĂǌĂƌĚƐ͘ x ZĞƐƉŽŶĚĞƌƐƚĂŬŝŶŐĂŶƚŝͲŚŝƐƚĂŵŝŶĞƐ͕ďůŽŽĚƉƌĞƐƐƵƌĞŵĞĚŝĐĂƚŝŽŶ͕ĚŝƵƌĞƚŝĐƐ͕ŽƌƐƚŝŵƵůĂŶƚƐĂƌĞĂƚĂŶ ŝŶĐƌĞĂƐĞĚƌŝƐŬĨŽƌĐŽůĚĂŶĚŚĞĂƚƐƚƌĞƐƐ͘ x dŚĞŽŶůǇƌĞƋƵŝƌĞĚĚŽĐƵŵĞŶƚĂƚŝŽŶĨŽƌŝŶĚŝǀŝĚƵĂůƐĞǀĂůƵĂƚĞĚŽŶůǇƵŶĚĞƌƚŚĞƐĞƌĞŚĂďŐƵŝĚĞůŝŶĞƐĂŶĚ ŶŽƚƌĞĐĞŝǀŝŶŐĂŶǇ>^ĐĂƌĞ͕ƚƌĂŶƐƉŽƌƚ͕ŽƌĐĂƌĚŝĂĐŵŽŶŝƚŽƌŝŶŐͬ<'ĂƐƐĞƐƐŵĞŶƚŝƐĂůŽŐĞŶƚƌǇŝŶƚŚĞ ƉĂƉĞƌĨŝƌĞƌĞŚĂďƚƌĂĐŬŝŶŐĨŽƌŵ;ƐĞĞĂƉƉĞŶĚŝǆͿ͘dŚŝƐĨŽƌŵƐŚŽƵůĚďĞƐĐĂŶŶĞĚĂŶĚĂƚƚĂĐŚĞĚƚŽƚŚĞĨŝƌĞ ƐƚĂŶĚďǇƌĞƉŽƌƚ͘ x ,ŽǁĞǀĞƌ͕ĂŶǇƌĞƐƉŽŶĚĞƌǁŝƚŚĂďŶŽƌŵĂůǀŝƚĂůƐŝŐŶƐ;ƐĞĞĂďŽǀĞͿŽƌƌĞƋƵŝƌŝŶŐĂĚǀĂŶĐĞĚŵĞĚŝĐĂů ƚƌĞĂƚŵĞŶƚŽƌĂƐƐĞƐƐŵĞŶƚďĞĐŽŵĞƐĂƉĂƚŝĞŶƚĂŶĚŵƵƐƚďĞĂƐƐĞƐƐĞĚĂŶĚĚŽĐƵŵĞŶƚĞĚĂƐĚĞƐĐƌŝďĞĚŝŶ ƚŚĞƐĞƉƌŽĐĞĚƵƌĞƐ͘

Cypress Creek EMS System Policies and Treatment Guidelines

36 CLINICAL POLICIES Revised 8/2016 Approved: Levon Vartanian, MD

/ŶƚĞƌͲĨĂĐŝůŝƚǇdƌĂŶƐĨĞƌƐ Purpose dŽƉƌŽǀŝĚĞŐƵŝĚĂŶĐĞĨŽƌƚŚĞƚƌĂŶƐƉŽƌƚŽĨĂƉĂƚŝĞŶƚĨƌŽŵĂŶŝŶƉĂƚŝĞŶƚ͕ŽƵƚƉĂƚŝĞŶƚ͕ŽƌƐƉĞĐŝĂůŝǌĞĚĐĂƌĞ ĨĂĐŝůŝƚǇƚŽĂƌĞĐĞŝǀŝŶŐŵĞƌŐĞŶĐǇĞƉĂƌƚŵĞŶƚ͘ Statement ǇƉƌĞƐƐƌĞĞŬD^ĚŽĞƐŶŽƚƌŽƵƚŝŶĞůǇƉƌŽǀŝĚĞĐŽŶƚƌĂĐƚĞĚƐĞƌǀŝĐĞƐǁŝƚŚĂŶǇůŽĐĂůĨĂĐŝůŝƚǇƚŽƉƌŽǀŝĚĞŝŶƚĞƌͲ ĨĂĐŝůŝƚǇƚƌĂŶƐƉŽƌƚ͘,ŽǁĞǀĞƌ͕ŝŶĐĂƐĞƐǁŚĞƌĞĂĨĂĐŝůŝƚǇĐĂůůƐϵϭϭƚŽƉƌŽǀŝĚĞƌĂƉŝĚƚƌĂŶƐƉŽƌƚǁŚĞŶƚŚĞŝƌ ƉƌŝŵĂƌǇĐŽŶƚƌĂĐƚĞĚƉƌŝǀĂƚĞD^ƉƌŽǀŝĚĞƌŝƐŶŽƚĂǀĂŝůĂďůĞŝŶĂƚŝŵĞůǇŵĂŶŶĞƌŽƌŶŽƚĂŶŽƉƚŝŽŶ͕D^ ǁŝůůƚƌĂŶƐƉŽƌƚƚŚĞƉĂƚŝĞŶƚƚŽƚŚĞƌĞƋƵĞƐƚĞĚŚŽƐƉŝƚĂů͛ƐŵĞƌŐĞŶĐǇĞƉĂƌƚŵĞŶƚ;ƐĞĞ'ĞŶĞƌĂůdƌĂŶƐƉŽƌƚ 'ƵŝĚĞůŝŶĞƐͿ͘ Procedure dŚĞ/ŶͲŚĂƌŐĞWĂƌĂŵĞĚŝĐŝƐƌĞƐƉŽŶƐŝďůĞĨŽƌ͗

x WĞƌĨŽƌŵŝŶŐĂĐŽŵƉƌĞŚĞŶƐŝǀĞƉĂƚŝĞŶƚĂƐƐĞƐƐŵĞŶƚ͕ƉĞƌŵĞĚŝĐĂůƉƌŽƚŽĐŽů x KďƚĂŝŶŝŶŐĂǀĞƌďĂůƌĞƉŽƌƚĨƌŽŵƚŚĞŵĞĚŝĐĂůƉĞƌƐŽŶŶĞůĂƐƐŝŐŶĞĚƚŽƚŚĞƉĂƚŝĞŶƚ x ĞƚĞƌŵŝŶŝŶŐƚŚĞůĞǀĞůŽĨĐĂƌĞŶĞĞĚĞĚĨŽƌƉĂƚŝĞŶƚƚƌĂŶƐƉŽƌƚ o sĞŶƚŝůĂƚŽƌƐ͕/sƉƵŵƉƐ͕ĂŶĚͬŽƌŽƚŚĞƌƐƉĞĐŝĂůŝǌĞĚĞƋƵŝƉŵĞŶƚŐĞŶĞƌĂůůǇƐŚŽƵůĚEKdďĞƵƐĞĚďǇ D^ƐƚĂĨĨƚŚĂƚŚĂǀĞŶŽƚďĞĞŶƚƌĂŝŶĞĚŽŶƚŚĞĞƋƵŝƉŵĞŶƚ o &ŝĞůĚ^ƵƉĞƌǀŝƐŽƌƐŚŽƵůĚďĞĐŽŶƚĂĐƚĞĚƚŽĂƐƐŝƐƚǁŝƚŚĐŽŵƉůĞǆƉĂƚŝĞŶƚƐ͕ĂƐŶĞĞĚĞĚ x ŽůůĞĐƚŝŶŐƉĂƚŝĞŶƚĐĂƌĞĚŽĐƵŵĞŶƚƐĨƌŽŵƚŚĞĨĂĐŝůŝƚǇƐƚĂĨĨǁŚŝĐŚŵĂǇŝŶĐůƵĚĞĚĞŵŽŐƌĂƉŚŝĐƐ͕ƉĂƐƚ ŵĞĚŝĐĂůŚŝƐƚŽƌǇ͕ŵĞĚŝĐĂƚŝŽŶůŝƐƚƐ͕ĐƵƌƌĞŶƚƚƌĞĂƚŵĞŶƚƌĞŐŝŵĞŶƐ͕DĞŵŽƌĂŶĚƵŵŽĨdƌĂŶƐĨĞƌ;DKdͿ ƉĂƉĞƌǁŽƌŬĂŶĚƚŽƉƌŽǀŝĚĞƚŚĞƐĞĚŽĐƵŵĞŶƚƐƚŽƚŚĞƌĞĐĞŝǀŝŶŐĨĂĐŝůŝƚǇ x ŽŵƉůĞƚŝŶŐƚŚĞĞůĞĐƚƌŽŶŝĐƉĂƚŝĞŶƚĐĂƌĞƌĞƉŽƌƚƚŽƌĞĨůĞĐƚĂůůĂƐƐĞƐƐŵĞŶƚƐ͕ŝŶƚĞƌǀĞŶƚŝŽŶƐ͕ƚƌĂŶƐƉŽƌƚ͕ ĂŶĚŶĂƌƌĂƚŝǀĞƉĞƌD^ĚŽĐƵŵĞŶƚĂƚŝŽŶŐƵŝĚĞůŝŶĞƐ Pearls x dŚĞƌĞŵĂǇďĞŝŶƐƚĂŶĐĞƐǁŚĞƌĞĂƐĂƚĞůůŝƚĞĐůŝŶŝĐŽĨĂůĂƌŐĞƌŚŽƐƉŝƚĂůƐǇƐƚĞŵƌĞƋƵĞƐƚƐƚƌĂŶƐƉŽƌƚŽĨĂŶ ƵƌŐĞŶƚƉĂƚŝĞŶƚƚŽĂĨĂĐŝůŝƚǇƚŚĂƚŝƐĨƵƌƚŚĞƌĂǁĂǇƚŚĂŶƚŚĞĐůŽƐĞƐƚ͕ĂƉƉƌŽƉƌŝĂƚĞĨĂĐŝůŝƚǇ͘&ŽƌĞǆĂŵƉůĞ͕ ƚŚĞƐĞŶĚŝŶŐĨĂĐŝůŝƚǇĂƐŬƐD^ƚŽƚƌĂŶƐƉŽƌƚĂ^dD/ƉĂƚŝĞŶƚƚŽƚŚĞŝƌĚĞƐŝŐŶĂƚĞĚĂƚŚ>Ăď͕ďƵƚD^ ŵĂǇƉĂƐƐĂĐůŽƐĞƌĂƚŚ>Ăď͘dŚŝƐŝƐĂĐĐĞƉƚĂďůĞƉƌĂĐƚŝĐĞĂƐůŽŶŐĂƐƚŚĞƌĞĐĞŝǀŝŶŐĨĂĐŝůŝƚǇŚĂƐƐĞĐƵƌĞĚ ĚĞĨŝŶŝƚŝǀĞĐĂƌĞĨŽƌƚŚĞƉĂƚŝĞŶƚ͕ĂŶĚƚŚĞ/ŶͲŚĂƌŐĞWĂƌĂŵĞĚŝĐƌĞĂƐŽŶĂďůǇĚĞƚĞƌŵŝŶĞƐƚŚĂƚƚŚĞƉĂƚŝĞŶƚ ǁŽƵůĚŶŽƚĚĞƚĞƌŝŽƌĂƚĞĚƵƌŝŶŐƚŚĞĞǆƚĞŶĚĞĚƚƌĂŶƐƉŽƌƚƚŝŵĞ͘ x /ŶĐĂƐĞƐǁŚĞƌĞĂĨĂĐŝůŝƚǇŝƐƌŽƵƚŝŶĞůǇĐŽŶƚĂĐƚŝŶŐϵϭϭĨŽƌŶŽŶͲƵƌŐĞŶƚƚƌĂŶƐƉŽƌƚŽĨƚŚĞŝƌƉĂƚŝĞŶƚƐ͕ ƉĂƌƚŝĐƵůĂƌůǇǁŚĞŶƚŚĂƚĨĂĐŝůŝƚǇ͛ƐĐŽŶƚƌĂĐƚĞĚƉƌŝǀĂƚĞD^ƉƌŽǀŝĚĞƌŝƐƵŶĂďůĞƚŽƌĞƐƉŽŶĚƚŽƚŚĞĐĂůů͕ƚŚĞ ĐƌĞǁƐŚŽƵůĚĐŽŵƉůĞƚĞƚŚĞƚƌĂŶƐƉŽƌƚƉĞƌƉƌŽƚŽĐŽů͕ďƵƚƐŚŽƵůĚŶŽƚŝĨǇƚŚĞŝƌ&ŝĞůĚ^ƵƉĞƌǀŝƐŽƌĂŶĚƚŚĞ ůŝŶŝĐĂůĞƉĂƌƚŵĞŶƚĨŽƌĨŽůůŽǁƵƉǁŝƚŚƚŚĞĨĂĐŝůŝƚǇĂĚŵŝŶŝƐƚƌĂƚŽƌ͘

Cypress Creek EMS System Policies and Treatment Guidelines

37 CLINICAL POLICIES Revised 8/2016 Approved: Levon Vartanian, MD

WĂƚŝĞŶƚĞƚĞƌŵŝŶĂƚŝŽŶͬEŽŶͲdƌĂŶƐƉŽƌƚĂƚŝŽŶ Purpose ůƚŚŽƵŐŚŵĞƌŐĞŶĐǇDĞĚŝĐĂů^ĞƌǀŝĐĞƐĂƌĞƌĞƋƵĞƐƚĞĚĨŽƌĂǀĂƌŝĞƚǇŽĨƌĞĂƐŽŶƐ͕ŶŽƚĂůůƌĞƋƵĞƐƚƐĨŽƌD^ ƌĞƐƵůƚŝŶƚƌĂŶƐƉŽƌƚĂƚŝŽŶ͘ĞƚĞƌŵŝŶŝŶŐǁŚŽŵĂǇƐĂĨĞůǇƌĞĨƵƐĞD^ĞǀĂůƵĂƚŝŽŶ͕ƚƌĞĂƚŵĞŶƚ͕ĂŶĚͬŽƌ ƚƌĂŶƐƉŽƌƚĂƚŝŽŶŝƐƚŚĞƌĞƐƉŽŶƐŝďŝůŝƚǇŽĨƚŚĞ/ŶͲŚĂƌŐĞWĂƌĂŵĞĚŝĐ͘ Definition of a Patient x ƉĞƌƐŽŶƚŚĂƚ͙ x ,ĂƐĂĐŽŵƉůĂŝŶƚƐƵŐŐĞƐƚŝǀĞŽĨƉŽƚĞŶƚŝĂůŝůůŶĞƐƐŽƌŝŶũƵƌǇ x ZĞƋƵĞƐƚƐĞǀĂůƵĂƚŝŽŶĨŽƌƉŽƚĞŶƚŝĂůŝůůŶĞƐƐŽƌŝŶũƵƌǇ x ,ĂƐŽďǀŝŽƵƐĞǀŝĚĞŶĐĞŽĨŝůůŶĞƐƐŽƌŝŶũƵƌǇ x ,ĂƐĞǆƉĞƌŝĞŶĐĞĚĂŶĂĐƵƚĞĞǀĞŶƚƚŚĂƚĐŽƵůĚƌĞĂƐŽŶĂďůǇůĞĂĚƚŽŝůůŶĞƐƐŽƌŝŶũƵƌǇ x /ƐŝŶĂĐŝƌĐƵŵƐƚĂŶĐĞŽƌƐŝƚƵĂƚŝŽŶƚŚĂƚĐŽƵůĚƌĞĂƐŽŶĂďůǇůĞĂĚƚŽŝůůŶĞƐƐŽƌŝŶũƵƌǇ Non-Patient/No Need for EMS Scenarios Cancelled/Disregard x DĂǇďĞƵƐĞĚǁŚĞŶƚŚĞŵĞĚŝĐƵŶŝƚŝƐĐĂŶĐĞůůĞĚͬĚŝƐƌĞŐĂƌĚĞĚďǇ͗ x The Comm CenterĨŽƌĂŶǇƌĞĂƐŽŶƉƌŝŽƌƚŽƚŚĞŝƌĂƌƌŝǀĂůŽŶƐĐĞŶĞ x A first responder on scene;&ŝƌĞĞƉĂƌƚŵĞŶƚ͕>ĂǁŶĨŽƌĐĞŵĞŶƚ͕D^&ŝƌƐƚZĞƐƉŽŶĚĞƌ͕D^ ^ƵƉĞƌǀŝƐŽƌͿŵĂǇĚŝƐƌĞŐĂƌĚͬĐĂŶĐĞůĂƵŶŝƚǁŚŝůĞĞŶƌŽƵƚĞŽƌƵƉŽŶĂƌƌŝǀĂůƚŽƚŚĞƐĐĞŶĞŝĨD^ŝƐŶŽƚ ŶĞĞĚĞĚ͘ x Automatic Medical AlarmͲĂŶD^ƵŶŝƚŵĂǇďĞĚŝƐƌĞŐĂƌĚĞĚĞŝƚŚĞƌƉƌŝŽƌƚŽĂƌƌŝǀĂůƚŽĂƐĐĞŶĞŽƌŽŶ ƐĐĞŶĞǁŚĞŶŵĞĚŝĐĂůĂůĂƌŵĂĐƚŝǀĂƚŝŽŶǁĂƐĂĐĐŝĚĞŶƚĂůƉĞƌƚŚĞŚŽŵĞŽǁŶĞƌ͕ƚŚĞĂůĂƌŵĐŽŵƉĂŶǇ͕ŽƌƚŚĞ ŵĞĚŝĐĂůĞƌƚŽǁŶĞƌƚŚĂƚƐƚĂƚĞƐƚŚĂƚD^ŝƐŽƚŚĞƌǁŝƐĞŶŽƚŶĞĞĚĞĚ͘ x /ĨĂŵĞĚŝĐƵŶŝƚŝƐĚŝƐƌĞŐĂƌĚĞĚǁŚŝůĞĞŶƌŽƵƚĞƚŽĂĐĂůůƚŚĂƚŝƐŚĂŶĚůĞĚďǇĂŶŽƚŚĞƌD^ƵŶŝƚƚŚĞŶƚŚĞ ƌĞƉŽƌƚŐĞŶĞƌĂƚĞĚĨƌŽŵƚŚĞŶĞĞĚƐƚŽďĞĐŽŵƉůĞƚĞĚĂƐ͞ĐĂŶĐĞůůĞĚ͟ǁŝƚŚƚŚĞƌĞĂƐŽŶŽĨ͞ŽƚŚĞƌƵŶŝƚ ĐůŽƐĞƌ͘͟ GOA/Unfounded x DĂǇďĞƵƐĞĚǁŚĞŶŵĞĚŝĐƵŶŝƚĐĂŶŶŽƚůŽĐĂƚĞĂƉĂƚŝĞŶƚŽƌĐĂůůŝŶŐƉĂƌƚǇĂĨƚĞƌƌĞĂƐŽŶĂďůĞĞĨĨŽƌƚƐƚŽ ůŽĐĂƚĞƚŚĞŝŶĐŝĚĞŶƚŚĂǀĞĨĂŝůĞĚKZǁŚĞŶĂƉĞƌƐŽŶƚŚĂƚŚĂƐƌĞƋƵĞƐƚĞĚD^ŚĂƐůĞĨƚƚŚĞƐĐĞŶĞƉƌŝŽƌƚŽ D^ĂƌƌŝǀĂů͘ No Injury/No Medical Emergency dŚĞĨŽůůŽǁŝŶŐƋƵĂůŝĨŝĞƌƐŵĂǇďĞƵƐĞĚƚŽĚĞŶŽƚĞƐŝƚƵĂƚŝŽŶƐǁŚĞŶD^ǁĂƐŶŽƚŶĞĞĚĞĚĂĨƚĞƌĂƌƌŝǀĂůƚŽƚŚĞ ƐĐĞŶĞ͗

Cypress Creek EMS System Policies and Treatment Guidelines

42 CLINICAL POLICIES Revised 8/2016 Approved: Levon Vartanian, MD

x MVI (Motor Vehicle Incident)͗EŽƌĞƉŽƌƚĞĚŽƌǁŝƚŶĞƐƐĞĚŝŶũƵƌŝĞƐ͘dŚĞĐŝƌĐƵŵƐƚĂŶĐĞƐŽĨƚŚĞŝŶŝƚŝĂů ĐĂůůĂŶĚƚŚĞĚĞƚĞƌŵŝŶĂƚŝŽŶƚŚĂƚD^ǁĂƐŶŽƚŶĞĞĚĞĚŵƵƐƚďĞĐůĞĂƌůǇĚŽĐƵŵĞŶƚĞĚŝŶƚŚĞŶĂƌƌĂƚŝǀĞ͘/Ĩ ĂŶǇƉĞƌƐŽŶƐŝŶǀŽůǀĞĚŝŶƚŚĞDs/ĞǆŚŝďŝƚĂŶǇǀŝƐŝďůĞŝŶũƵƌŝĞƐŽƌǀŽŝĐĞĂŶǇĐŽŵƉůĂŝŶƚƐƚŚĂŶĂ͞ƉĂƚŝĞŶƚ͟ ĞǆŝƐƚƐĂŶĚƚŚŝƐĚĞƚĞƌŵŝŶĂŶƚŵĂǇŶŽƚďĞƵƐĞĚ͘DK'ZW,/&/>^ZEKdZYh/Z͘ x Public Assist͗ĂĐĂůůĨŽƌĂƐƐŝƐƚĂŶĐĞǁŚĞƌĞƚŚĞƉĞƌƐŽŶĚŽĞƐŶŽƚƌĞƋƵŝƌĞĞǀĂůƵĂƚŝŽŶ͕ƚƌĞĂƚŵĞŶƚ͕Žƌ ƚƌĂŶƐƉŽƌƚĂƚŝŽŶďǇD^͘dŚĞƉĞƌƐŽŶD^ŚĂƐďĞĞŶĐĂůůĞĚĨŽƌĚŽĞƐŶŽƚŵĞĞƚƚŚĞ͞ƉĂƚŝĞŶƚ͟ĚĞĨŝŶŝƚŝŽŶ͘ dǇƉŝĐĂůůǇ͕ƚŚĞƐĞĐĂůůƐĂƌĞĨŽƌůŝĨƚĂƐƐŝƐƚĂŶĐĞŽƌĂƐƐŝƐƚĂŶĐĞǁŝƚŚĂĐƚŝǀŝƚŝĞƐŽĨĚĂŝůǇůŝǀŝŶŐ;>ƐͿ͘ DK'ZW,/&/>^ZZYh/Z͘ x Fire/EMS Standby͗ƚŽďĞƵƐĞĚǁŚĞŶD^ŝƐĐĂůůĞĚƚŽƚŚĞƐĐĞŶĞŽĨĂĨŝƌĞŽƌŽƚŚĞƌƐƉĞĐŝĂůĞǀĞŶƚĂŶĚ ŶŽƉĞƌƐŽŶƉƌĞƐĞŶƚǁŝƚŚĂƉĂƚŝĞŶƚƌĞůĂƚĞĚĐŽŵƉůĂŝŶƚŽƌƌĞƋƵĞƐƚĨŽƌƚŚĞĚƵƌĂƚŝŽŶŽĨƚŚĞĞǀĞŶƚ͘;^ĞĞ &ŝƌĞ^ƚĂŶĚďǇŐƵŝĚĞůŝŶĞƐͿ͘DK'ZW,/&/>^ZEKdZYh/Z͘ x Child Locked in a Vehicle͗ƚŚŝƐĚĞƚĞƌŵŝŶĂŶƚŵĂǇďĞƵƐĞĚǁŚĞŶĂĐŚŝůĚŝƐůŽĐŬĞĚŝŶĂǀĞŚŝĐůĞĂŶĚŚĂƐ ŶŽƚďĞĞŶĞǆƉŽƐĞĚƚŽĞǆƚƌĞŵĞƚĞŵƉĞƌĂƚƵƌĞƐǁŚĞƌĞĂ͞ƉĂƚŝĞŶƚ͟ƐĐĞŶĂƌŝŽĞǆŝƐƚƐ͘/ƚŝƐŝŵƉŽƌƚĂŶƚƚŽ ĚŽĐƵŵĞŶƚŝŶƚŚĞŶĂƌƌĂƚŝǀĞƚŚĂƚƚŚĞĐŚŝůĚ;ƌĞŶͿŚĂǀĞŶŽƚƐƵĨĨĞƌĞĚĂŶĞǆƉŽƐƵƌĞĂŶĚƚŚĂƚƚŚĞĐĂƌĞŐŝǀĞƌ ƐƚĂƚĞƐƚŚĂƚD^ŝƐŶŽůŽŶŐĞƌŶĞĞĚĞĚŽŶƐĐĞŶĞ͘;^ĞĞŚŝůĚ>ŽĐŬĞĚ/ŶsĞŚŝĐůĞŐƵŝĚĞůŝŶĞƐͿ DK'ZW,/&/>^ZEKdZYh/Z͘ x Law Enforcement Support͗D^ŝƐŽĨƚĞŶƚŝŵĞƐĐĂůůĞĚƚŽĂůĂǁĞŶĨŽƌĐĞŵĞŶƚƐĐĞŶĞǁŚĞŶŝƚŝƐŶŽƚ ĐůĞĂƌůǇŬŶŽǁŶĂƚƚŚĞƚŝŵĞŽĨƉŽůŝĐĞĂŶĚD^ĚŝƐƉĂƚĐŚŝĨD^ŝƐŶĞĞĚĞĚĨŽƌĂŶǇƌĞĂƐŽŶ͘/ĨD^ĂƌƌŝǀĞƐ ŽŶĂƐĐĞŶĞĂŶĚůĂǁĞŶĨŽƌĐĞŵĞŶƚƉĞƌƐŽŶŶĞůƐƚĂƚĞƚŚĂƚƚŚĞƌĞŝƐŶŽŶĞĞĚĨŽƌŵĞĚŝĐĂůĞǀĂůƵĂƚŝŽŶ͕ ƚƌĞĂƚŵĞŶƚ͕ŽƌƚƌĂŶƐƉŽƌƚĂƚŝŽŶŽƌŽƚŚĞƌǁŝƐĞĚŝƐƌĞŐĂƌĚƐD^ǁŚŝůĞŽŶƐĐĞŶĞƚŚĞŶƚŚĞŵĞĚŝĐŵĂǇ ĚŽĐƵŵĞŶƚĂŶŽ͞ƉĂƚŝĞŶƚ͟ƐĐĞŶĂƌŝŽŝŶƚŚĞŶĂƌƌĂƚŝǀĞ͘DK'ZW,/&/>^ZZYh/Z͘ x Third Party Welfare Check͗ŶƵŵĞƌŽƵƐĐĂůůƐĨŽƌD^ĂƌĞŵĂĚĞďǇĐŽŶĐĞƌŶĞĚƚŚŝƌĚƉĂƌƚǇĐĂůůĞƌƐ͘DĂŶǇ ƚŝŵĞƐƚŚĞƉĞƌƐŽŶƚŚĂƚŚĂĚD^ĐĂůůĞĚŽŶƚŚĞŝƌďĞŚĂůĨĚŽŶŽƚŬŶŽǁƚŚĂƚD^ǁĂƐĐŽŶƚĂĐƚĞĚĨŽƌƚŚĞŵ ĂŶĚƐƚĂƚĞƚŚĂƚƚŚĞǇĚŽŶŽƚƌĞƋƵŝƌĞD^ĞǀĂůƵĂƚŝŽŶ͕ƚƌĞĂƚŵĞŶƚ͕ŽƌƚƌĂŶƐƉŽƌƚĂƚŝŽŶ͘dŚĞŵĞĚŝĐŵƵƐƚ ŵĂŬĞĐĂƌĞĨƵůĂƐƐĞƐƐŵĞŶƚŽĨƚŚĞƐĐĞŶĞ͕ĐŝƌĐƵŵƐƚĂŶĐĞƐ͕ŵĞŶƚĂƚŝŽŶĂŶĚĐƵƌƌĞŶƚƐƚĂƚĞŽĨƚŚĞƉĞƌƐŽŶ ĂŶĚƵůƚŝŵĂƚĞůǇŵĂŬĞĂĚĞĐŝƐŝŽŶŝĨƚŚŝƐϵϭϭĐĂůůĨŽƌĂƐƐŝƐƚĂŶĐĞŵĞĞƚƐĐƌŝƚĞƌŝĂĨŽƌĂƉŽƐƐŝďůĞ͞ƉĂƚŝĞŶƚ͟ ƐĐĞŶĂƌŝŽ͘ůůŶĂƌƌĂƚŝǀĞĨŝĞůĚƐŝŶƚŚĞWZŵƵƐƚƌĞĨůĞĐƚƚŚŝƐĞǀĂůƵĂƚŝŽŶĂŶĚDK'ZW,/&/>^Z ZYh/Z͘ x Paramedic Initiated Referral͗ƚŚŝƐŽƵƚĐŽŵĞĚĞƚĞƌŵŝŶĂŶƚŝƐĚĞƐĐƌŝďĞĚŝŶĂƐĞƉĂƌĂƚĞƉŽůŝĐǇ Patient Refusals x DŝŶŽƌƉĂƚŝĞŶƚƐƐŚĂůůŶŽƚďĞƉĞƌŵŝƚƚĞĚƚŽĚĞĐůŝŶĞͬƌĞĨƵƐĞŵĞĚŝĐĂůĐĂƌĞŽƌD^ƚƌĂŶƐƉŽƌƚĂƚŝŽŶ͘ ŽŶƐĞŶƚŽƌĂƌĞĨƵƐĂůŵƵƐƚďĞŽďƚĂŝŶĞĚĨƌŽŵƚŚĞƉĂƌĞŶƚŽƌůĞŐĂůŐƵĂƌĚŝĂŶ͘ƉĂƌĞŶƚŽƌůĞŐĂůŐƵĂƌĚŝĂŶ ĐĂŶŶŽƚƌĞĨƵƐĞĞŵĞƌŐĞŶƚůŝĨĞͲƐĂǀŝŶŐŵĞĚŝĐĂůĐĂƌĞĨŽƌƚŚĞŝƌĐŚŝůĚƌĞŶ͘ x ŶǇƉĂƚŝĞŶƚ;ŽƌůĞŐĂůƉĂƚŝĞŶƚƌĞƉƌĞƐĞŶƚĂƚŝǀĞͿǁŚŽŝƐŝŵƉĂŝƌĞĚ;ďǇĂůĐŽŚŽů͕ŝůůŝĐŝƚĚƌƵŐ͕ƉƌĞƐĐƌŝďĞĚ ŵĞĚŝĐĂƚŝŽŶ͕ŽƌĂŶǇŽƚŚĞƌƌĞĂƐŽŶͿŽƌǁŚŽŚĂƐĂůƚĞƌĞĚŵĞŶƚĂůƐƚĂƚƵƐƐŚŽƵůĚŶŽƚďĞƉĞƌŵŝƚƚĞĚƚŽ ĚĞĐůŝŶĞͬƌĞĨƵƐĞŵĞĚŝĐĂůĐĂƌĞŽƌD^ƚƌĂŶƐƉŽƌƚĂƚŝŽŶ͘tŚĞŶĐŽŵƉĞƚĞŶĐĞŝƐƋƵĞƐƚŝŽŶĂďůĞĚƵĞƚŽ ŝŵƉĂŝƌŵĞŶƚďǇĚƌƵŐƐŽƌĂůĐŽŚŽů͕ĂůǁĂǇƐĞƌƌŽŶƚŚĞƐŝĚĞŽĨƉƌŽǀŝĚŝŶŐŵĞĚŝĐĂůĐĂƌĞĨŽƌƚŚĞƉĂƚŝĞŶƚďǇ ƚƌĞĂƚŝŶŐĂŶĚƚƌĂŶƐƉŽƌƚŝŶŐŚŝŵͬŚĞƌ͘ x ŶǇƉĂƚŝĞŶƚ;ŽƌůĞŐĂůƉĂƚŝĞŶƚƌĞƉƌĞƐĞŶƚĂƚŝǀĞͿƐŚŽƵůĚŶŽƚďĞƉĞƌŵŝƚƚĞĚƚŽĚĞĐůŝŶĞͬƌĞĨƵƐĞD^ ƚƌĂŶƐƉŽƌƚĂƚŝŽŶŝĨŝŶǀĂƐŝǀĞƚƌĞĂƚŵĞŶƚǁĂƐƌĞŶĚĞƌĞĚďǇǇƉƌĞƐƐƌĞĞŬD^ƉĞƌƐŽŶŶĞů͘/ƚŝƐƐƚƌŽŶŐůǇ ƌĞĐŽŵŵĞŶĚĞĚƚŚĂƚĂƐƵƉĞƌǀŝƐŽƌďĞĐŽŶƚĂĐƚĞĚŝŶĐĂƐĞƐǁŚĞƌĞŝŶǀĂƐŝǀĞĐĂƌĞǁĂƐƌĞŶĚĞƌĞĚĂŶĚĂ

Cypress Creek EMS System Policies and Treatment Guidelines

43 CLINICAL POLICIES Revised 8/2016 Approved: Levon Vartanian, MD

ƉĂƚŝĞŶƚ;ŽƌĐĂƌĞŐŝǀĞƌͿĚŽĞƐŶŽƚǁŝƐŚƚŽďĞƚƌĂŶƐƉŽƌƚĞĚƚŽƚŚĞŚŽƐƉŝƚĂů;ŝ͘Ğ͘/sƚŚĞƌĂƉǇ͕ŵĞĚŝĐĂƚŝŽŶ ĂĚŵŝŶŝƐƚƌĂƚŝŽŶ͕ĞƚĐ͘Ϳ͘ ϭ͘ ƚĂŶǇƚŝŵĞ͕ǇƉƌĞƐƐƌĞĞŬD^ƉĞƌƐŽŶŶĞůŵĂǇĞŶůŝƐƚƚŚĞĂƐƐŝƐƚĂŶĐĞŽĨƚŚĞ&ŝĞůĚ^ƵƉĞƌǀŝƐŽƌ͕ƚŚĞ ƉĂƚŝĞŶƚ͛ƐƉŚǇƐŝĐŝĂŶ͕ŽƌůĂǁĞŶĨŽƌĐĞŵĞŶƚŽĨĨŝĐŝĂůƐƚŽĞŶĐŽƵƌĂŐĞĂƉĂƚŝĞŶƚƚŽĂĐĐĞƉƚD^ƚƌĂŶƐƉŽƌƚƚŽ ƚŚĞŚŽƐƉŝƚĂů͘ Ϯ͘ WĂƚŝĞŶƚƐǁŚŽƉƌĞƐĞŶƚǁŝƚŚƚŚĞĨŽůůŽǁŝŶŐƐŝŐŶƐͬƐǇŵƉƚŽŵƐƐŚĂůůďĞƐƚƌŽŶŐůǇĚŝƐĐŽƵƌĂŐĞĚĨƌŽŵ ĚĞĐůŝŶŝŶŐͬƌĞĨƵƐŝŶŐD^ƚƌĂŶƐƉŽƌƚ͗ x ŚĞƐƚƉĂŝŶŽƌŽƚŚĞƌƐǇŵƉƚŽŵƐƐƵƐƉŝĐŝŽƵƐŽĨĐĂƌĚŝĂĐŝƐĐŚĞŵŝĂ x ^ŚŽƌƚŶĞƐƐŽĨďƌĞĂƚŚͬƌĞƐƉŝƌĂƚŽƌǇĚŝƐƚƌĞƐƐ x ,ǇƉĞƌƚĞŶƐŝŽŶ;ƐǇƐƚŽůŝĐďͬƉшϮϬϬŵŵ,ŐĂŶĚͬŽƌĚŝĂƐƚŽůŝĐďͬƉшϭϭϬŵŵ,ŐͿ x ďĚŽŵŝŶĂůƉĂŝŶǁŝƚŚƐŝŐŶŝĨŝĐĂŶƚĨŝŶĚŝŶŐƐ;ŽƌƚŚŽƐƚĂƐŝƐ͕ŐƵĂƌĚŝŶŐ͕ƌŝŐŝĚŝƚǇ͕ŚĞŵĂƚĞŵĞƐŝƐ͕ƌĞďŽƵŶĚ ƚĞŶĚĞƌŶĞƐƐ͕ĂďĚŽŵŝŶĂůƐƵƌŐĞƌǇǁŝƚŚŝŶůĂƐƚǇĞĂƌͿ x KǀĞƌĚŽƐĞ x ^ĞŝǌƵƌĞ x ůƚĞƌĞĚŵĞŶƚĂůƐƚĂƚƵƐŽƌŶĞƵƌŽůŽŐŝĐĂůĚĞĨŝĐŝƚ x ŶǇĐŽŵƉůĂŝŶƚŽƌĂďŶŽƌŵĂůĨŝŶĚŝŶŐƚŚĂƚĐŽƵůĚďĞƌĞůĂƚĞĚƚŽĂŬŶŽǁŶŽƌƐƵƐƉĞĐƚĞĚƉƌĞŐŶĂŶĐǇ ŝŶĐůƵĚŝŶŐĂďĚŽŵŝŶĂůƉĂŝŶŽĨƵŶŬŶŽǁŶĞƚŝŽůŽŐǇŝŶĂĨĞŵĂůĞŽĨĐŚŝůĚďĞĂƌŝŶŐƉŽƚĞŶƚŝĂů x ǀŝĚĞŶĐĞŽĨƉŽƐƐŝďůĞŝŶũƵƌǇƚŽƚŚĞŚĞĂĚ͕ƐƉŝŶĞ͕ĐŚĞƐƚ͕ĂďĚŽŵĞŶ͕ŽƌƉĞůǀŝƐ x <ŶŽǁŶŽƌƐƵƐƉĞĐƚĞĚĂďƵƐĞǀŝĐƚŝŵƐ Required Refusal Documentation /ŶĂůůĐĂƐĞƐǁŚĞƌĞƉĂƚŝĞŶƚĐŽŶƚĂĐƚŝƐĞƐƚĂďůŝƐŚĞĚĂŶĚƚŚĞƉĂƚŝĞŶƚ;ŽƌůĞŐĂůƉĂƚŝĞŶƚƌĞƉƌĞƐĞŶƚĂƚŝǀĞͿƌĞĨƵƐĞƐ D^ƚƌĂŶƐƉŽƌƚ͕ƚŚĞĨŽůůŽǁŝŶŐƐŚĂůůďĞƚŚŽƌŽƵŐŚůǇĚŽĐƵŵĞŶƚĞĚ͗

ϭ͘ WĂƚŝĞŶƚ͛ƐĐŽŵƉůĂŝŶƚĂŶĚǁŚǇD^ǁĂƐĂĐƚŝǀĂƚĞĚ Ϯ͘ >ĞǀĞůŽĨĐŽŶƐĐŝŽƵƐŶĞƐƐ;ŽƌŝĞŶƚĞĚƚŽƉĞƌƐŽŶ͕ƉůĂĐĞ͕ƚŝŵĞ͕ΘƐŝƚƵĂƚŝŽŶͿ͖ƚŚĞƉƌŽǀŝĚĞƌŵƵƐƚĚŽĐƵŵĞŶƚ ĨĂĐƚƐƐƵĨĨŝĐŝĞŶƚƚŽĚĞŵŽŶƐƚƌĂƚĞƚŚĞƉĂƚŝĞŶƚ͛ƐƉƌĞƐĞŶƚŵĞŶƚĂůĐĂƉĂĐŝƚǇĂŶĚƵŶĚĞƌƐƚĂŶĚŝŶŐŽĨŚŝƐͬŚĞƌ ĐŽŶĚŝƚŝŽŶĂŶĚƚŚĞĐŽŶƐĞƋƵĞŶĐĞƐŽĨƌĞĨƵƐŝŶŐƚƌĞĂƚŵĞŶƚĂŶĚͬŽƌƚƌĂŶƐƉŽƌƚ ϯ͘ WŚǇƐŝĐĂůĨŝŶĚŝŶŐƐ ϰ͘ sŝƚĂů^ŝŐŶƐ;ͬW͕ƉƵůƐĞ͕ƌĞƐƉŝƌĂƚŽƌǇƌĂƚĞΘƋƵĂůŝƚǇͿͲƉƌĞĨĞƌĂďůǇϮĐŽŵƉůĞƚĞƐĞƚƐ ϱ͘ KƚŚĞƌĚŝĂŐŶŽƐƚŝĐĨŝŶĚŝŶŐƐ;'͕ďůŽŽĚŐůƵĐŽƐĞůĞǀĞů͕^ƉKϮ͕ƚĞŵƉĞƌĂƚƵƌĞͿ ϲ͘ ϭϮͲůĞĂĚ'ƐŚŽƵůĚďĞĐŽŵƉůĞƚĞĚĂŶĚĚŽĐƵŵĞŶƚĞĚŽŶĂŶǇĚŝĂďĞƚŝĐƉĂƚŝĞŶƚǁŝƚŚĂĚŝĂďĞƚŝĐ ĐŽŵƉůĂŝŶƚ;ĂůƚĞƌĞĚŵĞŶƚĂůƐƚĂƚƵƐ͕ŚǇƉŽͬŚǇƉĞƌŐůǇĐĞŵŝĂ͕ƐŚŽƌƚŶĞƐƐŽĨďƌĞĂƚŚ͕ĞƚĐ͘Ϳ ϳ͘ ƚƚĞŵƉƚƐĂƚĞŶĐŽƵƌĂŐŝŶŐĂŶĚŽĨĨĞƌŝŶŐD^ƚƌĂŶƐƉŽƌƚĂƚŝŽŶŝŶĐůƵĚŝŶŐůĂǁĞŶĨŽƌĐĞŵĞŶƚĂŶĚͬŽƌ ƐƵƉĞƌǀŝƐŽƌŝŶǀŽůǀĞŵĞŶƚ ϴ͘ ŽŶĚŝƚŝŽŶŽĨƉĂƚŝĞŶƚƵƉŽŶĂƌƌŝǀĂůĂŶĚĚĞƉĂƌƚƵƌĞ ϵ͘ ZĞĂƐŽŶƉĂƚŝĞŶƚŝƐƌĞĨƵƐŝŶŐĂŶĚƵŶĚĞƌƐƚĂŶĚŝŶŐƚŚĞƌŝƐŬƐŽĨƐƵĐŚĂƌĞĨƵƐĂů ϭϬ͘ WĂƚŝĞŶƚ͛ƐƉůĂŶƐĨŽƌƐĞĞŬŝŶŐƉŚǇƐŝĐŝĂŶĞǀĂůƵĂƚŝŽŶ;ŚŽƐƉŝƚĂů͕ĞŵĞƌŐĞŶĐǇĐůŝŶŝĐ͕ƉĞƌƐŽŶĂůƉŚǇƐŝĐŝĂŶ͕ĞƚĐ͘Ϳ ϭϭ͘ EĂŵĞƐŽĨŽƚŚĞƌƉĞŽƉůĞƉƌĞƐĞŶƚǁŚŽǁŝƚŶĞƐƐĞĚƉĂƚŝĞŶƚ͛ƐƌĞĨƵƐĂůĂŶĚĂƚƚĞŵƉƚƐĂƚĞŶĐŽƵƌĂŐŝŶŐ ƉĂƚŝĞŶƚƚŽƐĞĞŬĨƵƌƚŚĞƌĐĂƌĞ

Cypress Creek EMS System Policies and Treatment Guidelines

44 CLINICAL POLICIES Revised 8/2016 Approved: Levon Vartanian, MD

ϭϮ͘ dŚĞƉĂƚŝĞŶƚŽƌůĞŐĂůŐƵĂƌĚŝĂŶƐŝŐŶĂƚƵƌĞŽŶƚŚĞWZ͕ŽƌŝĨĂƉĂƚŝĞŶƚƌĞĨƵƐĞƐƚŽƐŝŐŶƚŚĞZĞĨƵƐĂůĨŽƌŵ͕ ƚŚĞƉƌŽǀŝĚĞƌƐŚŽƵůĚĚŽĐƵŵĞŶƚƚŚĞĐŝƌĐƵŵƐƚĂŶĐĞƐƵŶĚĞƌǁŚŝĐŚƚŚĞƉĂƚŝĞŶƚƌĞĨƵƐĞĚƚŽƐŝŐŶ ϭϯ͘ ŶǇƚƌĞĂƚŵĞŶƚƌĞŶĚĞƌĞĚďǇD^ Pearls for Refusals x dŚĞƉĂƚŝĞŶƚƐŚŽƵůĚďĞŵĂĚĞĂǁĂƌĞƚŚĂƚĞǀĂůƵĂƚŝŽŶͬƚƌĞĂƚŵĞŶƚŝƐŝŶĐŽŵƉůĞƚĞĚƵĞƚŽůŝŵŝƚĂƚŝŽŶƐŽĨƚŚĞ ƉƌĞͲŚŽƐƉŝƚĂůĐĂƌĞĞŶǀŝƌŽŶŵĞŶƚ͖ĚŝĂŐŶŽƐƚŝĐƚĞƐƚƐƵƐĞĚŝŶƚŚĞĨŝĞůĚĂƌĞŶŽƚŝŶĚŝĐĂƚŝǀĞŽĨĂůůƵŶĚĞƌůǇŝŶŐ ĞƚŝŽůŽŐǇŽƌƉĂƚŚŽůŽŐǇ͘ x dŚĞƉĂƚŝĞŶƚƐŚŽƵůĚďĞĂĚǀŝƐĞĚƚŚĂƚƚŚĞǇŵĂǇĐĂůůϵϭϭĂŐĂŝŶĂƚĂŶǇƚŝŵĞŝĨƚŚĞǇǁŝƐŚƚŽďĞ ƚƌĂŶƐƉŽƌƚĞĚƚŽƚŚĞŚŽƐƉŝƚĂůŽƌŝĨƚŚĞŝƌĐŽŶĚŝƚŝŽŶĐŚĂŶŐĞƐŽƌǁŽƌƐĞŶƐ͘ x ĚĞƐĐƌŝƉƚŝǀĞŶĂƌƌĂƚŝǀĞƚŚĂƚŝůůƵƐƚƌĂƚĞƐƚŚĞĐŝƌĐƵŵƐƚĂŶĐĞƐŽĨƚŚĞĐĂůůĨŽƌD^ĂŶĚĂŶǇƉĞƌƚŝŶĞŶƚ ĚŝĂůŽŐƵĞďĞƚǁĞĞŶD^ĂŶĚƚŚĞƉĂƚŝĞŶƚŽƌŽƚŚĞƌƉĂƌƚŝĞƐŽŶƐĐĞŶĞ͘ x h^ydZDhd/KEǁŚĞŶƵƚŝůŝǌŝŶŐƚŚĞWd/EdZ&h^>ĨŽƌĂŶǇƉƐǇĐŚŝĂƚƌŝĐĐŽŵƉůĂŝŶƚƐ͘ ĐŽŵƉƌĞŚĞŶƐŝǀĞŶĂƌƌĂƚŝǀĞĂŶĚĂƐƐĞƐƐŵĞŶƚƐĂƌĞǀŝƚĂůƚŽĚĞƐĐƌŝďĞŝŶĐŝĚĞŶƚƐǁŚĞƌĞD^ǁĂƐĐĂůůĞĚĨŽƌĂ ƉƐǇĐŚŝĂƚƌŝĐƌĞůĂƚĞĚĐŽŵƉůĂŝŶƚĂŶĚƚŚĞƉĂƚŝĞŶƚŽƉƚĞĚƚŽĚĞĐůŝŶĞD^ĞǀĂůƵĂƚŝŽŶ͕ƚƌĞĂƚŵĞŶƚ͕Žƌ ƚƌĂŶƐƉŽƌƚĂƚŝŽŶ͘

Cypress Creek EMS System Policies and Treatment Guidelines

45 CLINICAL POLICIES Revised 8/2016 Approved: Levon Vartanian, MD

WŚǇƐŝĐŝĂŶŽŶ^ĐĞŶĞ ůůD^ƉƌŽǀŝĚĞƌƐŽƉĞƌĂƚĞƵŶĚĞƌƐƚĂŶĚŝŶŐƉƌŽƚŽĐŽůƐĂƐĂƵƚŚŽƌŝǌĞĚďǇƌ͘>ĞǀŽŶsĂƌƚĂŶŝĂŶ͕ƚŚĞ WŚǇƐŝĐŝĂŶDĞĚŝĐĂůŝƌĞĐƚŽƌ͘KŶŽĐĐĂƐŝŽŶ͕D^ŵĞĚŝĐƐŵĂǇĞŶĐŽƵŶƚĞƌĂŶŽƚŚĞƌƉŚǇƐŝĐŝĂŶŽŶƐĐĞŶĞƚŚĂƚ ŵĂǇǁŝƐŚƚŽŐŝǀĞŵĞĚŝĐĂůĚŝƌĞĐƚŝŽŶ͘D^ŵĞĚŝĐƐĞŶĐŽƵŶƚĞƌŝŶŐƚŚŝƐƐŝƚƵĂƚŝŽŶƐŚŽƵůĚĨŽůůŽǁƚŚŝƐĐůŝŶŝĐĂů ƉŽůŝĐǇ͘dŚŝƐƉŽůŝĐǇŝƐĐĞŶƚĞƌĞĚĂƌŽƵŶĚƉŚǇƐŝĐŝĂŶƐŽŶĂŶĞŵĞƌŐĞŶĐǇƐĐĞŶĞǁŝƐŚŝŶŐƚŽĚŝƌĞĐƚƉĂƚŝĞŶƚĐĂƌĞ ƚŚĂƚŝƐĐŽŶƚƌĂƌǇƚŽĂůƌĞĂĚǇĞƐƚĂďůŝƐŚĞĚĂŶĚĂƵƚŚŽƌŝǌĞĚD^ƉĂƚŝĞŶƚĐĂƌĞƉƌŽƚŽĐŽůƐ͘ x tŚĞŶĞŶĐŽƵŶƚĞƌŝŶŐĂƉŚǇƐŝĐŝĂŶŽŶƐĐĞŶĞ͕D^ŵĞĚŝĐƐŵƵƐƚĨŝƌƐƚĚĞƚĞƌŵŝŶĞƚŚĂƚƚŚĞƉŚǇƐŝĐŝĂŶŝƐ ĐƵƌƌĞŶƚůǇĂůŝĐĞŶƐĞĚDĞĚŝĐĂůŽĐƚŽƌ;DͿŽƌŽĐƚŽƌŽĨKƐƚĞŽƉĂƚŚŝĐDĞĚŝĐŝŶĞ;KͿ͘D^ŵĞĚŝĐƐ ŵĂǇŶŽƚƚĂŬĞŵĞĚŝĐĂůĚŝƌĞĐƚŝŽŶĨƌŽŵƉƌĂĐƚŝƚŝŽŶĞƌƐƚŚĂƚĂƌĞWŚ͕͘͘ŽĐƚŽƌŽĨŚŝƌŽƉƌĂĐƚŝĐ;Ϳ͕EƵƌƐĞ WƌĂĐƚŝƚŝŽŶĞƌ͕WŚǇƐŝĐŝĂŶƐƐŝƐƚĂŶƚ͕ŽƌŽƚŚĞƌƚǇƉĞŽĨŶŽŵĞŶĐůĂƚƵƌĞŽƌĂĚǀĂŶĐĞĚŵĞĚŝĐŝŶĞƉƌĂĐƚŝƚŝŽŶĞƌ͘ x dŚĞƉŚǇƐŝĐŝĂŶŵƵƐƚƚŚĞŶďĞĂďůĞƚŽƉƌŽǀŝĚĞĂǀĂůŝĚdĞǆĂƐŵĞĚŝĐĂůůŝĐĞŶƐĞ͘DĞĚŝĐĂůůŝĐĞŶƐĞƐĨƌŽŵ ƐƚĂƚĞƐŽƚŚĞƌƚŚĂŶdĞǆĂƐĂƌĞŶŽƚĂĐĐĞƉƚĂďůĞ͘ x dŚĞƉŚǇƐŝĐŝĂŶŵƵƐƚĂŐƌĞĞƚŽƚĂŬĞĨƵůůƌĞƐƉŽŶƐŝďŝůŝƚǇĨŽƌĂůůĐĂƌĞŽĨƚŚĞƉĂƚŝĞŶƚ͘D^ŵĞĚŝĐƐǁŝůů ŚĂǀĞƚŚĞƉŚǇƐŝĐŝĂŶƐŝŐŶƚŚĞ͞WŚǇƐŝĐŝĂŶ^ƚĂƚĞŵĞŶƚ͟ŽŶƚŚĞĞWZĂŐƌĞĞŝŶŐƚŽƚŚŝƐ͘DĞĚŝĐƐƐŚŽƵůĚĂůƐŽ ĚŽĐƵŵĞŶƚƚŚĞƉŚǇƐŝĐŝĂŶ͛ƐŶĂŵĞĂŶĚŵĞĚŝĐĂůůŝĐĞŶƐĞŶƵŵďĞƌŝŶƚŚĞĞWZ͘ x dŚĞƉŚǇƐŝĐŝĂŶŵƵƐƚĂůƐŽĂŐƌĞĞƚŽƌŝĚĞŝŶƚŚĞĂŵďƵůĂŶĐĞǁŝƚŚƚŚĞƉĂƚŝĞŶƚĂŶĚĐƌĞǁĞŶƌŽƵƚĞƚŽƚŚĞ ƌĞĐĞŝǀŝŶŐŚŽƐƉŝƚĂů͘ x ǀĞŶƵŶĚĞƌƚŚĞĚŝƌĞĐƚŝŽŶŽĨĂƉŚǇƐŝĐŝĂŶŽŶƐĐĞŶĞ͕D^ŵĞĚŝĐƐĂƌĞŶŽƚĂƵƚŚŽƌŝǌĞĚƚŽƉĞƌĨŽƌŵĂŶǇ ƉƌŽĐĞĚƵƌĞŽƌĂĚŵŝŶŝƐƚĞƌĂŶǇŵĞĚŝĐĂƚŝŽŶƐƚŚĂƚĂƌĞŽƵƚƐŝĚĞŽĨƚŚĞŝƌƐĐŽƉĞŽĨƉƌĂĐƚŝĐĞ͘ x /ĨĂƉŚǇƐŝĐŝĂŶŽŶƐĐĞŶĞŽƌĚĞƌƐĂŵĞĚŝĐĂƚŝŽŶƚŚĂƚŝƐŶŽƚƌŽƵƚŝŶĞůǇĐĂƌƌŝĞĚďǇD^͕ƚŚĞƉŚǇƐŝĐŝĂŶ ŵƵƐƚĂĚŵŝŶŝƐƚĞƌƚŚĞŵĞĚŝĐĂƚŝŽŶƚŚĞŵƐĞůǀĞƐ͘ x /ĨƚŚĞƌĞŝƐĂĐŽŶĨůŝĐƚǁŝƚŚD^ĐƌĞǁƐĂŶĚƚŚĞƉŚǇƐŝĐŝĂŶŽŶƐĐĞŶĞ͕ƚŚĞĐƌĞǁƐŚŽƵůĚĐŽŶƚĂĐƚƚŚĞŝƌ &ŝĞůĚ^ƵƉĞƌǀŝƐŽƌĨŽƌĂƐƐŝƐƚĂŶĐĞ͘ x ŽŵŵŽŶƐĞŶƐĞĂŶĚƚĂĐƚĨƵůĚŝƉůŽŵĂĐǇŝƐƚŽďĞƵƐĞĚǁŚĞŶD^ŝƐƌĞƐƉŽŶĚŝŶŐƚŽĂŵĞĚŝĐĂůĨĂĐŝůŝƚǇ ǁŝƚŚĂƉŚǇƐŝĐŝĂŶĂůƌĞĂĚǇĚŝƌĞĐƚŝŶŐĐĂƌĞ͘

Cypress Creek EMS System Policies and Treatment Guidelines

46 CLINICAL POLICIES Revised 8/2016 Approved: Levon Vartanian, MD

YƵĂůŝƚǇDĂŶĂŐĞŵĞŶƚWƌŽĐĞƐƐ Purpose /ŶŽƌĚĞƌƚŽĨĂĐŝůŝƚĂƚĞĐŽŶƚŝŶƵŽƵƐƋƵĂůŝƚǇŝŵƉƌŽǀĞŵĞŶƚͬƋƵĂůŝƚǇĂƐƐƵƌĂŶĐĞ͕D^ĞŵƉůŽǇƐƐĞǀĞƌĂů ŵĞĐŚĂŶŝƐŵƐƚŽƌĞǀŝĞǁƉĂƚŝĞŶƚĐĂƌĞ͕ďĞŶĐŚŵĂƌŬƋƵĂůŝƚǇŵĞĂƐƵƌĞƐ͕ĂŶĚƉƌŽǀŝĚĞƌĞŵĞĚŝĂůƚƌĂŝŶŝŶŐͬƌĞǀŝĞǁ ĂƐŶĞĞĚĞĚ͘ QA/QI Programs ϭ͘ ǀĞƌǇĐŚĂƌƚŵƵƐƚĐŽŵƉůǇǁŝƚŚƚŚĞŵŝŶŝŵƵŵƐƚĂŶĚĂƌĚƐĞŶĨŽƌĐĞĚďǇŽŵƉůĞƚĞĂůůZƵůĞƐ͘dŚĞƐĞ ĚĞĨŝŶĞƌĞƋƵŝƌĞĚĚŽĐƵŵĞŶƚĂƚŝŽŶĐŽŵƉŽŶĞŶƚƐĨŽƌĚŝĨĨĞƌĞŶƚƌĞƐƉŽŶƐĞŽƵƚĐŽŵĞƐĂŶĚƚƌĞĂƚŵĞŶƚ ƐŝƚƵĂƚŝŽŶƐ͘ Ϯ͘ ^ƉĞĐŝĨŝĐŚŝŐŚͲĂĐƵŝƚǇͬŚŝŐŚͲƌŝƐŬĐĂůůĐĂƚĞŐŽƌŝĞƐĂƌĞƌĞǀŝĞǁĞĚďǇůŝŶŝĐĂůĞƉĂƌƚŵĞŶƚĂŶĚ^ƉĞĐŝĂů KƉĞƌĂƚŝŽŶƐĚĞƉĂƌƚŵĞŶƚ͗ x ŝƌǁĂǇDĂŶĂŐĞŵĞŶƚ x ĂƌĚŝĂĐƌƌĞƐƚ x ^ƚƌŽŬĞ x ^dD/ x DĂũŽƌdƌĂƵŵĂ x EŽͲůŽĂĚƐ x ǆĐŝƚĞĚĞůŝƌŝƵŵ x ^ĞĚĂƚŝŽŶ ϯ͘ KƚŚĞƌĐĂůůĐĂƚĞŐŽƌŝĞƐĂƌĞƌĞǀŝĞǁĞĚďǇĚĞƐŝŐŶĂƚĞĚĐŚĂƌƚƌĞǀŝĞǁĞƌƐŝŶĐůƵĚŝŶŐ&ŝĞůĚ^ƵƉĞƌǀŝƐŽƌƐ͕&dKƐ͕ ĂŶĚ^ƚĂƚŝŽŶĂƉƚĂŝŶƐ͘ ϰ͘ WƌŽďůĞŵƐŝĚĞŶƚŝĨŝĞĚĚƵƌŝŶŐĐŚĂƌƚƌĞǀŝĞǁŵĂǇďĞƐĞŶƚďĂĐŬƚŽƚŚĞŽƌŝŐŝŶĂůĐƌĞǁĨŽƌĐŽƌƌĞĐƚŝŽŶ͕ ĐŽŵŵĞŶƚƐ͕ŽƌƌĞǀŝĞǁ͘ ϱ͘ WƌŽďůĞŵƐŝĚĞŶƚŝĨŝĞĚŵĂǇĂůƐŽďĞĞƐĐĂůĂƚĞĚƚŽůŝŶŝĐĂůĞƉĂƌƚŵĞŶƚĂŶĚƌĞƐƵůƚŝŶĂŶŽŶͲƉƵŶŝƚŝǀĞĐĂƐĞ ƌĞǀŝĞǁǁŝƚŚƚŚĞƉĞƌƐŽŶŶĞůŝŶǀŽůǀĞĚ͘ ϲ͘ KǀĞƌĂůůƐǇƐƚĞŵƉĞƌĨŽƌŵĂŶĐĞĂŶĚŝŶĚŝǀŝĚƵĂůƉƌŽǀŝĚĞƌƉĞƌĨŽƌŵĂŶĐĞĂƌĞŵŽŶŝƚŽƌĞĚŽŶĂƌŽƵƚŝŶĞďĂƐŝƐ ƚŽŝĚĞŶƚŝĨǇĂƌĞĂƐĨŽƌŝŵƉƌŽǀĞŵĞŶƚŝŶƉĂƚŝĞŶƚĐĂƌĞƋƵĂůŝƚǇ͘

Cypress Creek EMS System Policies and Treatment Guidelines

47 CLINICAL POLICIES Revised 8/2016 Approved: Levon Vartanian, MD

^ĂĨĞdƌĂŶƐƉŽƌƚŽĨWĞĚŝĂƚƌŝĐWĂƚŝĞŶƚƐ Purpose dŽƉƌŽǀŝĚĞĂƐĂĨĞŵĞƚŚŽĚŽĨƚƌĂŶƐƉŽƌƚŝŶŐƉĞĚŝĂƚƌŝĐƉĂƚŝĞŶƚƐǁŝƚŚŝŶĂŶĂŵďƵůĂŶĐĞĂŶĚƉƌŽƚĞĐƚƚŚĞD^ ƐǇƐƚĞŵĂŶĚƉĞƌƐŽŶŶĞůĨƌŽŵƉŽƚĞŶƚŝĂůŚĂƌŵĂŶĚůŝĂďŝůŝƚǇĂƐƐŽĐŝĂƚĞĚǁŝƚŚƚŚĞ ƚƌĂŶƐƉŽƌƚĂƚŝŽŶŽĨƉĞĚŝĂƚƌŝĐ ƉĂƚŝĞŶƚƐ͘ Statement x tŝƚŚŽƵƚƐƉĞĐŝĂůĐŽŶƐŝĚĞƌĂƚŝŽŶƐ͕ĐŚŝůĚƌĞŶĂƌĞĂƚƌŝƐŬŽĨŝŶũƵƌǇǁŚĞŶƚƌĂŶƐƉŽƌƚĞĚďǇD^͘ x D^ŵƵƐƚƉƌŽǀŝĚĞĂƉƉƌŽƉƌŝĂƚĞƐƚĂďŝůŝǌĂƚŝŽŶĂŶĚƉƌŽƚĞĐƚŝŽŶƚŽƉĞĚŝĂƚƌŝĐƉĂƚŝĞŶƚƐĚƵƌŝŶŐD^ƚƌĂŶƐƉŽƌƚ ŝŶŽƌĚĞƌƚŽƉƌĞǀĞŶƚĨŽƌǁĂƌĚŵŽƚŝŽŶͬĞũĞĐƚŝŽŶ͘ŶĚŵƵƐƚƐĞĐƵƌĞƚŚĞƚŽƌƐŽĂŶĚƉƌŽƚĞĐƚƚŚĞŚĞĂĚ͕ŶĞĐŬ͕ ĂŶĚƐƉŝŶĞŽĨĂůůĐŚŝůĚƌĞŶƚƌĂŶƐƉŽƌƚĞĚŝŶĞŵĞƌŐĞŶĐǇŐƌŽƵŶĚĂŵďƵůĂŶĐĞƐ͘ Procedure /ŶŽƌĚĞƌƚŽŝĚĞŶƚŝĨǇƚŚĞďĞƐƚŵĞƚŚŽĚŽĨƌĞƐƚƌĂŝŶƚ͕ĂƉƌĂĐƚŝƚŝŽŶĞƌŵƵƐƚĐŽŶƐŝĚĞƌƚŚĞĂŐĞĂŶĚƐƚĂƚƵƌĞŽĨƚŚĞ ĐŚŝůĚ͕ŝĨƚŚĂƚĐŚŝůĚŝƐŝŶũƵƌĞĚŽƌŝƐĂŶĂĐĐŽŵƉĂŶǇŝŶŐƉĂƐƐĞŶŐĞƌ͕ƚŚĞŵĞĚŝĐĂůƐƚĂďŝůŝƚǇŽĨƚŚĞƉĂƚŝĞŶƚ͕ĂŶĚ ƚŚĞĂǀĂŝůĂďůĞůŽĐĂƚŝŽŶƐǁŚĞƌĞƚŚĞĐŚŝůĚĐĂŶďĞƐĂĨĞůǇƌĞƐƚƌĂŝŶĞĚŝŶƐŝĚĞƚŚĞĂŵďƵůĂŶĐĞ͘

The following general rules apply to all pediatric transports: ϭ͘ ƌŝǀĞĐĂƵƚŝŽƵƐůǇĂƚƐĂĨĞƐƉĞĞĚƐŽďƐĞƌǀŝŶŐƚƌĂĨĨŝĐůĂǁƐ͘ Ϯ͘ dŝŐŚƚůǇƐĞĐƵƌĞĂůůŵŽŶŝƚŽƌŝŶŐĚĞǀŝĐĞƐĂŶĚŽƚŚĞƌĞƋƵŝƉŵĞŶƚ͘ ϯ͘ ŶƐƵƌĞƚŚĂƚĂůůƉĞĚŝĂƚƌŝĐƉĂƚŝĞŶƚƐůĞƐƐƚŚĂŶϰϬůďƐĂƌĞƌĞƐƚƌĂŝŶĞĚǁŝƚŚĂŶĂƉƉƌŽǀĞĚĐŚŝůĚ ƌĞƐƚƌĂŝŶƚĚĞǀŝĐĞƐĞĐƵƌĞĚĂƉƉƌŽƉƌŝĂƚĞůǇƚŽƚŚĞƐƚƌĞƚĐŚĞƌŽƌĐĂƉƚĂŝŶ͛ƐĐŚĂŝƌ͘ ϯ͘ ŶƐƵƌĞƚŚĂƚĂůůD^ƉĞƌƐŽŶŶĞůƵƐĞƚŚĞĂǀĂŝůĂďůĞƌĞƐƚƌĂŝŶƚƐǇƐƚĞŵƐĚƵƌŝŶŐƚŚĞƚƌĂŶƐƉŽƌƚ͘ ϰ͘ dƌĂŶƐƉŽƌƚĂĚƵůƚƐĂŶĚĐŚŝůĚƌĞŶǁŚŽĂƌĞŶŽƚƉĂƚŝĞŶƚƐ͕ƉƌŽƉĞƌůǇƌĞƐƚƌĂŝŶĞĚ͕ŝŶĂŶĂůƚĞƌŶĂƚĞ ƉĂƐƐĞŶŐĞƌǀĞŚŝĐůĞ͕ǁŚĞŶĞǀĞƌƉŽƐƐŝďůĞ͘ ϱ͘ ŽŶŽƚĂůůŽǁƉĂƌĞŶƚƐ͕ĐĂƌĞŐŝǀĞƌƐ͕ŽƌŽƚŚĞƌƉĂƐƐĞŶŐĞƌƐƚŽďĞƵŶƌĞƐƚƌĂŝŶĞĚĚƵƌŝŶŐƚƌĂŶƐƉŽƌƚ͘ ϲ͘ EsZĂƚƚĞŵƉƚƚŽŚŽůĚŽƌĂůůŽǁƚŚĞƉĂƌĞŶƚƐŽƌĐĂƌĞŐŝǀĞƌƐƚŽŚŽůĚƚŚĞƉĂƚŝĞŶƚĚƵƌŝŶŐƚƌĂŶƐƉŽƌƚ͘ ϳ͘ &ŽƌƉĂƚŝĞŶƚƐǁŝƚŚŵĞĚŝĐĂůĐŽŶĚŝƚŝŽŶƐƚŚĂƚŵĂǇďĞĂŐŐƌĂǀĂƚĞĚďǇƐƚƌĞƐƐ͕ŵĂŬĞĞǀĞƌǇĂƚƚĞŵƉƚƚŽ ŽƉƚŝŵŝǌĞƐĂĨĞƚǇǁŚĞŶĐŽŵĨŽƌƚŝŶŐƚŚĞĐŚŝůĚ͘

D^ƵƚŝůŝǌĞƐƚŚĞĨŽůůŽǁŝŶŐĚĞǀŝĐĞƐƚŽƉƌŽǀŝĚĞƐƚĂďŝůŝǌĂƚŝŽŶĂŶĚͬŽƌƉƌŽƚĞĐƚŝŽŶƚŽƉĞĚŝĂƚƌŝĐƉĂƚŝĞŶƚƐ ĚƵƌŝŶŐĂŵďƵůĂŶĐĞƚƌĂŶƐƉŽƌƚ͗ x ^ƚƌĞƚĐŚĞƌͬŽƚǁŝƚŚŚĂƌŶĞƐƐƐǇƐƚĞŵ x WĞĚŝDĂƚĞƐĞĐƵƌŝŶŐĚĞǀŝĐĞ;ƵƉƚŽϰϬůďƐŽŶůǇͿƐĞĐƵƌĞĚƚŽƐƚƌĞƚĐŚĞƌ x ZĞĂƌĨĂĐŝŶŐĐĂƌƐĞĂƚƐĞĐƵƌĞĚƚŽƐƚƌĞƚĐŚĞƌ͖ŶŽŶͲŵĞĚŝĐĂůƉĞĚŝĂƚƌŝĐƚƌĂŶƐƉŽƌƚƐŵĂǇďĞƐĞĐƵƌĞĚƚŽ ĐĂƉƚĂŝŶ͛ƐĐŚĂŝƌ x <ƐĞĐƵƌĞĚƚŽďĂĐŬďŽĂƌĚĂŶĚͬŽƌƐƚƌĞƚĐŚĞƌ x ĂĐŬďŽĂƌĚƐĞĐƵƌĞĚƚŽƐƚƌĞƚĐŚĞƌ **Do not transport the pediatric patient who is assessed as meeting trauma center criteria in a child seat that was involved in the collision that produced the child’s injury.

Cypress Creek EMS System Policies and Treatment Guidelines

48 CLINICAL POLICIES Revised 8/2016 Approved: Levon Vartanian, MD

^ĞůĨͲZĞƉŽƌƚŝŶŐŽĨůŝŶŝĐĂů/ŶĐŝĚĞŶƚƐ General Purpose dŽŝĚĞŶƚŝĨǇƚŚĞŵĂŶŶĞƌďǇǁŚŝĐŚD^ĨŝĞůĚƉĞƌƐŽŶŶĞůŵĂǇself-reportĐĞƌƚĂŝŶĐůŝŶŝĐĂůŝŶĐŝĚĞŶƚƐŝŶ ŽƌĚĞƌƚŽŝŶŝƚŝĂƚĞƚŚĞYͬY/ƉƌŽĐĞƐƐĂŶĚͬŽƌƚŽƉƌĞǀĞŶƚĨƵƚƵƌĞĞƌƌŽƌƐŝŶĐůŝŶŝĐĂůƉƌĂĐƚŝĐĞ͘ Definitions x Medication errors:ŵĂǇŝŶĐůƵĚĞǁƌŽŶŐŵĞĚŝĐĂƚŝŽŶ͕ǁƌŽŶŐĚŽƐĞ͕ǁƌŽŶŐƌŽƵƚĞ͕ǁƌŽŶŐŝŶĚŝĐĂƚŝŽŶ͕ ĐŽŶƚƌĂŝŶĚŝĐĂƚĞĚŵĞĚŝĐĂƚŝŽŶ͕ŽƌŽƚŚĞƌĂĚǀĞƌƐĞĞǀĞŶƚƌĞůĂƚĞĚƚŽŵĞĚŝĐĂƚŝŽŶĂĚŵŝŶŝƐƚƌĂƚŝŽŶ͘ x Medical Protocol variance/deviation:ƵƐĞĚƚŽĞǆƉůĂŝŶĂŶǇƉƵƌƉŽƐĞĨƵůŐƌŽƐƐĚĞǀŝĂƚŝŽŶĨƌŽŵŵĞĚŝĐĂů ƉƌŽƚŽĐŽů;ŝ͘Ğ͘ƐƉĞĐŝĂůƉĂƚŝĞŶƚĐŝƌĐƵŵƐƚĂŶĐĞͿORĂŵŝƐƐĞĚĚŝĂŐŶŽƐŝƐ;ŝ͘Ğ͘^dD/ͿǁŚĞƌĞŵĞĚŝĐĂů ƉƌŽƚŽĐŽůǁĂƐŶŽƚĂƉƉƌŽƉƌŝĂƚĞůǇƵƚŝůŝǌĞĚ͘ x Equipment failure:ĂŶǇĞƋƵŝƉŵĞŶƚĨĂŝůƵƌĞƚŚĂƚŽĐĐƵƌƐĚƵƌŝŶŐƉĂƚŝĞŶƚĐŽŶƚĂĐƚǁŚĞƌĞƉĂƚŝĞŶƚĐĂƌĞ ǁĂƐƐŝŐŶŝĨŝĐĂŶƚůǇĂĨĨĞĐƚĞĚŽƌĐŽŵƉƌŽŵŝƐĞĚ͘ x Procedural complication:ĂŶǇĂĚǀĞƌƐĞĞǀĞŶƚƌĞůĂƚĞĚƚŽĂŶŝŶǀĂƐŝǀĞƉƌŽĐĞĚƵƌĞƉĞƌĨŽƌŵĞĚŝŶƚŚĞĨŝĞůĚ ;Ğ͘Ő͘ĨĂŝůĞĚĂŝƌǁĂǇ͕ƵŶĚĞƚĞĐƚĞĚĞƐŽƉŚĂŐĞĂůŝŶƚƵďĂƚŝŽŶ͕/sͬ/KĐŽŵƉůŝĐĂƚŝŽŶƐͿ͘ Principles x ^ĞůĨͲƌĞƉŽƌƚŝŶŐƐŚŽƵůĚŽĐĐƵƌǁŝƚŚŝŶϮϰŚŽƵƌƐŽĨƚŚĞĞǀĞŶƚ͘ x dŚĞƉƵƌƉŽƐĞŽĨƐĞůĨͲƌĞƉŽƌƚŝŶŐŝƐƚŽĐƌĞĂƚĞĂŶŽŶͲƉƵŶŝƚŝǀĞĞŶǀŝƌŽŶŵĞŶƚĨŽƌƚŚĞĞŵƉůŽǇĞĞƚŽƌĞƉŽƌƚ ƵŶĂŶƚŝĐŝƉĂƚĞĚŽƵƚĐŽŵĞƐĚƵƌŝŶŐŽƌŝŵŵĞĚŝĂƚĞůǇĨŽůůŽǁŝŶŐƉĂƚŝĞŶƚĐĂƌĞ͘ x dŚĞYͬY/ƉƌŽĐĞƐƐ;ƐĞĞƐĞƉĂƌĂƚĞĐůŝŶŝĐĂůƉŽůŝĐǇͿǁŝůůďĞĐĂƌƌŝĞĚŽƵƚďǇƚŚĞůŝŶŝĐĂůĞƉĂƌƚŵĞŶƚĂƐĂ ƉĂƌƚŽĨƚŚĞĨŽůůŽǁͲƵƉĨŽƌƌĞƉŽƌƚĞĚĐůŝŶŝĐĂůŝŶĐŝĚĞŶƚƐ͘ x ^ĞŶƚŝŶĞůĞǀĞŶƚƐ;ŐƌŽƐƐŶĞŐůŝŐĞŶĐĞŽƌŐƌŽƐƐŵŝƐĐŽŶĚƵĐƚͿƚŚĂƚƌĞƐƵůƚŝŶƐŝŐŶŝĨŝĐĂŶƚƉĂƚŝĞŶƚŚĂƌŵŵĂǇ ĂůƐŽƌĞƐƵůƚŝŶĚŝƐĐŝƉůŝŶĂƌǇĂĐƚŝŽŶĂƚƚŚĞĚŝƐĐƌĞƚŝŽŶŽĨƚŚĞDĞĚŝĐĂůŝƌĞĐƚŽƌĂŶĚǆĞĐƵƚŝǀĞŝƌĞĐƚŽƌ͘ Procedure ϭ͘ dŚĞ/ŶͲŚĂƌŐĞWĂƌĂŵĞĚŝĐŽƌ&ŝĞůĚ^ƵƉĞƌǀŝƐŽƌƌĞĐŽŐŶŝǌĞƐĐůŝŶŝĐĂůŝŶĐŝĚĞŶƚ͘ Ϯ͘ ZĞĐĞŝǀŝŶŐŚŽƐƉŝƚĂůƐƚĂĨĨŝƐŶŽƚŝĨŝĞĚŽĨŝŶĐŝĚĞŶƚ͕ŝĨĂƉƉůŝĐĂďůĞ͘ ϯ͘ KŶĚƵƚǇ&ŝĞůĚ^ƵƉĞƌǀŝƐŽƌŝƐŶŽƚŝĨŝĞĚďǇƉŚŽŶĞ͕ŽƌŝŶƉĞƌƐŽŶ͕ĂŶĚƉƌŽǀŝĚĞĚĂďƌŝĞĨĂĐĐŽƵŶƚŝŶŐŽĨƚŚĞ ĞǀĞŶƚ͘ ϰ͘ dŚĞŵĞĚŝĐƚŚĂƚŝƐƐĞůĨͲƌĞƉŽƌƚŝŶŐĐŽŵƉůĞƚĞƐĂClinical Incident FormŽŶͲůŝŶĞƚŚƌŽƵŐŚsĂŝƌŬŬŽǁŝƚŚŝŶϮϰ ŚŽƵƌƐŽĨƚŚĞŽĐĐƵƌƌĞŶĐĞ͘ ϱ͘ dŚĞůŝŶŝĐĂůĞƉĂƌƚŵĞŶƚƌĞǀŝĞǁƐƚŚĞůŝŶŝĐĂů/ŶĐŝĚĞŶƚ&ŽƌŵƐƵďŵŝƐƐŝŽŶĂŶĚĐŽŶĚƵĐƚƐŶĞĐĞƐƐĂƌǇ ĨŽůůŽǁͲƵƉ;ĂƐĂƉƉůŝĐĂďůĞͿ͗ Ă͘ ĞďƌŝĞĨǁŝƚŚƉĞƌƐŽŶŶĞůŝŶǀŽůǀĞĚ͖ ď͘ ZĞͲƚƌĂŝŶŝŶŐŽĨŝŶĚŝǀŝĚƵĂů;ƐͿŝŶǀŽůǀĞĚŝŶŝŶĐŝĚĞŶƚ͖ Đ͘ ^ǇƐƚĞŵͲǁŝĚĞĞĚƵĐĂƚŝŽŶͬƚƌĂŝŶŝŶŐ͖ Ě͘ WƌŽĐĞƐƐŝŵƉƌŽǀĞŵĞŶƚ͖ Ğ͘ EŽƚŝĨŝĐĂƚŝŽŶŽĨDĞĚŝĐĂůŝƌĞĐƚŽƌ

Cypress Creek EMS System Policies and Treatment Guidelines

49 OPERATIONAL POLICIES Revised 8/2016 Approved: Levon Vartanian, MD

KƉĞƌĂƚŝŽŶĂůWŽůŝĐŝĞƐ

CCEMS First Responder ...... 51 Child Lockedin aVehicle ...... 54 Communications ...... 55 Controlled Medication Management ...... 57 Crime Scene Management ...... 61 Firearms Policy ...... 62 Forcible Entry ...... 63 Mandatory Supervisor Notification ...... 64 Partner Agencies First Responders ...... 65 Posting Plan ...... 66 Readiness for Response ...... 69 Scene Safety ...... 70 Span of Control ...... 73 Ambulance Staging ...... 74 Use of Lights andSirens ...... 80

Cypress Creek EMS System Policies and Treatment Guidelines

50 OPERATIONAL POLICIES Approved: Levon Vartanian, MD

D^&ŝƌƐƚZĞƐƉŽŶĚĞƌ Purpose D^&ŝƌƐƚͲZĞƐƉŽŶĚĞƌƐΖĨƵŶĐƚŝŽŶŝƐƚŽŝŶŝƚŝĂƚĞƉĂƚŝĞŶƚĐĂƌĞ;ŝŶĂĐĐŽƌĚĂŶĐĞǁŝƚŚD^WƌŽƚŽĐŽůƐͿƉƌŝŽƌ ƚŽƚŚĞĂƌƌŝǀĂůŽĨƚŚĞDĞĚŝĐhŶŝƚ Qualifications ĐƚŝǀĞŵĞŵďĞƌƐŝŶŐŽŽĚƐƚĂŶĚŝŶŐǁŚŽŚĂǀĞďĞĞŶƌŝĚŝŶŐǁŝƚŚŽƵƌŽƌŐĂŶŝǌĂƚŝŽŶŝŶĂŵĞĚŝĐĂůĐĂƉĂĐŝƚǇĂŶĚ ĂĐĐƵŵƵůĂƚĞĂŵŝŶŝŵƵŵŽĨϮϴϴŚŽƵƌƐ;ϭϮǆϮϰŚŽƵƌƐŚŝĨƚƐͿŽĨĂŵďƵůĂŶĐĞƚŝŵĞŵĂǇĂƉƉůǇ͘ Approval and Requirements dŽďĞĂƉƉƌŽǀĞĚĂƐĂD^&ŝƌƐƚZĞƐƉŽŶĚĞƌ͕ƚŚĞŵĞŵďĞƌǁŝůů͗ x ŽŵƉůĞƚĞϮϴϴŚŽƵƌƐŽĨƐĞƌǀŝĐĞ;ƉĂŝĚŽƌǀŽůƵŶƚĞĞƌͿĂŶĚŶŽƚŚĂǀĞƌĞĐĞŝǀĞĚĂŶǇĚŝƐĐŝƉůŝŶĂƌǇĂĐƚŝŽŶ ǁŝƚŚŝŶƚŚĞƉĂƐƚϲŵŽŶƚŚƐ x DĂŝŶƚĂŝŶĐƵƌƌĞŶƚdĞǆĂƐĞƉĂƌƚŵĞŶƚŽĨ^ƚĂƚĞ,ĞĂůƚŚ^ĞƌǀŝĐĞƐĐĞƌƚŝĨŝĐĂƚŝŽŶŽƌůŝĐĞŶƐĞĂƐĂŶŵĞƌŐĞŶĐǇ ĂƌĞWƌŽǀŝĚĞƌ;͕DdͲĂƐŝĐ͕ĚǀĂŶĐĞĚDd͕ŽƌDdͲWĂƌĂŵĞĚŝĐͿŝŶŐŽŽĚƐƚĂŶĚŝŶŐǁŝƚŚƚŚĞdĞǆĂƐ ĞƉĂƌƚŵĞŶƚŽĨ^ƚĂƚĞ,ĞĂůƚŚ^ĞƌǀŝĐĞƐ͘ x WĂŝĚĞŵƉůŽǇĞĞƐŶĞĞĚƚŽŚĂǀĞƚŚĞŝƌ^ƵƉĞƌǀŝƐŽƌĞŶĚŽƌƐĞƚŚĞŝƌĂƉƉůŝĐĂƚŝŽŶŝŶǁƌŝƚŝŶŐ x WƌĞƐĞŶƚƚǁŽůĞƚƚĞƌƐŽĨƌĞĐŽŵŵĞŶĚĂƚŝŽŶĨƌŽŵD^WĂƌĂŵĞĚŝĐ/ŶͲŚĂƌŐĞƐƚŽƚŚĞŝƌĞĐƚŽƌŽĨ^ƉĞĐŝĂů KƉĞƌĂƚŝŽŶƐ͘dŚĞƐĞůĞƚƚĞƌƐǁŝůůŝŶĐůƵĚĞƐƚĂƚĞŵĞŶƚƐƌĞŐĂƌĚŝŶŐƚŚĞŝƌƉƌŽĨŝĐŝĞŶĐǇŝŶƚŚĞƐŬŝůůƐŶĞĞĚĞĚƚŽ ƌĞŶĚĞƌďĂƐŝĐĞŵĞƌŐĞŶĐǇŵĞĚŝĐĂůĐĂƌĞǁŝƚŚŽƵƚĚŝƌĞĐƚƐƵƉĞƌǀŝƐŝŽŶ͘ x ůůŶĞǁĂƉƉůŝĐĂŶƚƐǁŝůůďĞƉƌĞƐĞŶƚĞĚƚŽƚŚĞ&ZŽŵŵŝƚƚĞĞĨŽƌĂƉƉƌŽǀĂůďǇŵĂũŽƌŝƚǇǀŽƚĞ͘ x EŽƚŝĨŝĐĂƚŝŽŶŽĨĂƉƉƌŽǀĂůŽƌĚĞŶŝĂůǁŝůůďĞŵĂĚĞƚŽƚŚĞĨŝƌƐƚƌĞƐƉŽŶĚĞƌĂƉƉůŝĐĂŶƚďǇƚŚĞŝƌĞĐƚŽƌŽĨ ^ƉĞĐŝĂůKƉĞƌĂƚŝŽŶƐ͘ hƉŽŶĂƉƉƌŽǀĂů͕ƚŚĞĨŝƌƐƚƌĞƐƉŽŶĚĞƌǁŝůů͗ x DĂŝŶƚĂŝŶĂĐƵƌƌĞŶƚdĞǆĂƐƌŝǀĞƌ͛Ɛ>ŝĐĞŶƐĞǁŝƚŚĂĚƌŝǀŝŶŐƌĞĐŽƌĚƚŚĂƚŵĞĞƚƐD^ƌĞƋƵŝƌĞŵĞŶƚƐ͘ DĂŝŶƚĂŝŶŽŶŐŽŝŶŐĂŶĚĐŽŶƐŝƐƚĞŶƚƉĂƌƚŝĐŝƉĂƚŝŽŶŝŶƚŚĞD^&ŝƌƐƚͲZĞƐƉŽŶĚĞƌWƌŽŐƌĂŵ͘ x DĂŝŶƚĂŝŶĂĐƚŝǀĞƌŝĚŝŶŐƐƚĂƚƵƐŽŶƚŚĞĂŵďƵůĂŶĐĞ;ϮϰŚƌƐƉĞƌŵŽŶƚŚͿ͘ x ƵƌŝŶŐĞĂĐŚƉŽůŝĐǇƉĞƌŝŽĚ͕ƉƌŽǀŝĚĞǀĞƌŝĨŝĐĂƚŝŽŶŽĨƉƌŝǀĂƚĞǀĞŚŝĐůĞůŝĂďŝůŝƚǇŝŶƐƵƌĂŶĐĞĐŽǀĞƌĂŐĞƚŚĂƚ ŵĞĞƚƐƚŚĞƌĞƋƵŝƌĞŵĞŶƚƐƐĞƚĨŽƌƚŚďǇ^ƚĂƚĞŽĨdĞǆĂƐůĂǁƐ͘ Paid Staff Participation WĂŝĚƐƚĂĨĨŵĞŵďĞƌƐŵĂǇƉĂƌƚŝĐŝƉĂƚĞŝŶƚŚĞ&ŝƌƐƚZĞƐƉŽŶĚĞƌƉƌŽŐƌĂŵĂƚƚŚĞŝƌĚŝƐĐƌĞƚŝŽŶ͘dŚĞŝƌ ƉĂƌƚŝĐŝƉĂƚŝŽŶǁŝůůďĞǀŽůƵŶƚĂƌǇĂŶĚŶŽƚĨŽƌĐŽŵƉĞŶƐĂƚŝŽŶ͘dŚĞǇǁŝůůďĞƌĞƋƵŝƌĞĚƚŽĨŽůůŽǁĂůůŽƚŚĞƌ&ŝƌƐƚ ZĞƐƉŽŶĚĞƌƉŽůŝĐŝĞƐĂƐŝŶĚŝĐĂƚĞĚďǇƚŚŝƐĚŽĐƵŵĞŶƚ͘ Revocation of First Responder Status &ŝƌƐƚƌĞƐƉŽŶĚĞƌƐƚĂƚƵƐŵĂǇďĞƐƵƐƉĞŶĚĞĚŽƌƌĞǀŽŬĞĚĨŽƌĐĂƵƐĞŽƌŝĨĨŝƌƐƚƌĞƐƉŽŶĚĞƌĂƐƐĞƚƐŶĞĞĚƚŽďĞ ƌĞůŽĐĂƚĞĚŝŶŽƌĚĞƌƚŽŵĞĞƚƚŚĞĐŚĂŶŐŝŶŐŶĞĞĚƐŽĨƚŚĞŽƌŐĂŶŝǌĂƚŝŽŶ͘

Cypress Creek EMS System Policies and Treatment Guidelines

51 OPERATIONAL POLICIES Approved: Levon Vartanian, MD

Responding Restrictions KŶůǇĚĞƐŝŐŶĂƚĞĚ&ŝƌƐƚZĞƐƉŽŶĚĞƌŵĞŵďĞƌƐǁŚŽŚĂǀĞD^ͲĂƉƉƌŽǀĞĚŵĞĚŝĐĂůĞƋƵŝƉŵĞŶƚ͕ŝƐƐƵĞĚďĂƐĞĚ ŽŶƚŚĞŝŶĚŝǀŝĚƵĂůΖƐĂďŝůŝƚǇƚŽƌĞƐƉŽŶĚ͕ŶĞĞĚĨŽƌĚŝƐƚƌŝĐƚĐŽǀĞƌĂŐĞ͕ĂŶĚƚŚĞĂǀĂŝůĂďŝůŝƚǇŽĨƚŚĞĞƋƵŝƉŵĞŶƚ͕ ĂƌĞƚŽƌĞƐƉŽŶĚǁŝƚŚŝŶƚŚĞƐĞŐƵŝĚĞůŝŶĞƐ͗ x &ŝƌƐƚZĞƐƉŽŶĚĞƌƐŵĂǇƌĞƐƉŽŶĚƚŽĂŶŝŶĐŝĚĞŶƚůŽĐĂƚŝŽŶŝŶƚŚĞŝƌƌĞƐƉĞĐƚŝǀĞĂƐƐŝŐŶĞĚĚŝƐƚƌŝĐƚǁŚĞŶ ŶŽƚŝĨŝĞĚďǇƚŚĞŽŵŵĞŶƚĞƌ͘ x &ŝƌƐƚZĞƐƉŽŶĚĞƌƐ͕ǁŚŽĂƌĞŝŶƚŚĞŝŵŵĞĚŝĂƚĞǀŝĐŝŶŝƚǇŽĨĂƐƉĞĐŝĨŝĐŝŶĐŝĚĞŶƚůŽĐĂƚŝŽŶĂŶĚŚĂǀĞƚŚĞ ŵĞĂŶƐƚŽŶŽƚŝĨǇƚŚĞŽŵŵĞŶƚĞƌ͕ƐŚŽƵůĚĂĚǀŝƐĞƚŚĞŽŵŵĞŶƚĞƌĚŝƐƉĂƚĐŚĞƌŽŶĚƵƚǇŽĨŚŝƐŽƌŚĞƌ ŝŶƚĞŶƚƚŽƌĞƐƉŽŶĚ͘ x &ŝƌƐƚZĞƐƉŽŶĚĞƌƐǁŝůůĂůǁĂǇƐǁĞĂƌD^ŝĚĞŶƚŝĨŝĐĂƚŝŽŶǁŚĞŶƌĞƐƉŽŶĚŝŶŐƚŽĐĂůůƐĂŶĚĂƉƉƌŽƉƌŝĂƚĞ WWƉĞƌƉŽůŝĐǇƚŽŝŶĐůƵĚĞƚƌĂĨĨŝĐƐĂĨĞƚǇǀĞƐƚƐ͘ x &ŝƌƐƚZĞƐƉŽŶĚĞƌƐǁŝůůĂĚǀŝƐĞƚŚĞŽŵŵĞŶƚĞƌǀŝĂƌĂĚŝŽǁŚĞŶƚŚĞǇĂƌĞƌĞƐƉŽŶĚŝŶŐƚŽĂĐĂůů͕ŽŶͲƐĐĞŶĞ ŽĨĂĐĂůůĂŶĚǁŚĞŶƚŚĞǇĂƌĞŝŶͲƐĞƌǀŝĐĞ͘ x &ŝƌƐƚZĞƐƉŽŶĚĞƌƐǁŝůůEKdƌĞƐƉŽŶĚƚŽĐĂůůƐŝŶŽƚŚĞƌĚŝƐƚƌŝĐƚƐƵŶůĞƐƐƚŚĞǇĂƌĞĐůĞĂƌĞĚďǇƚŚĞŽŵŵ ĞŶƚĞƌŽƌŚĂǀĞƉƌŝŽƌĂƵƚŚŽƌŝǌĂƚŝŽŶĨƌŽŵƚŚĞŝƌĞĐƚŽƌŽĨ^ƉĞĐŝĂůKƉĞƌĂƚŝŽŶƐ Emergency Driving in Privately Owned Vehicles (POVs) ƉƉƌŽǀĞĚĨŝƌƐƚƌĞƐƉŽŶĚĞƌƐǁŝƐŚŝŶŐƚŽƵƐĞƚŚĞŝƌWKs͛ƐĨŽƌĞŵĞƌŐĞŶĐǇƚƌĂĨĨŝĐƌĞƐƉŽŶƐĞƐǁŝůůŵĞĞƚƚŚĞ ĨŽůůŽǁŝŶŐĐŽŶĚŝƚŝŽŶƐ͗ x tŝůůďĞĐƵƌƌĞŶƚůǇĂƉƉƌŽǀĞĚĂƐĂD^ĞŵĞƌŐĞŶĐǇǀĞŚŝĐůĞŽƉĞƌĂƚŽƌĐŽŵƉůĞƚŝŶŐƚŚĞƌĞƋƵŝƌĞĚƚƌĂŝŶŝŶŐ ĐƵƌƌŝĐƵůƵŵŽƌĞƋƵŝǀĂůĞŶĐǇ͖ x tŝůůĂďŝĚĞďǇĂůůůĂǁƐĂŶĚƌĞŐƵůĂƚŝŽŶƐĂƐůŝƐƚĞĚŝŶƚŚĞdĞǆĂƐdƌĂŶƐƉŽƌƚĂƚŝŽŶŽĚĞ͘ x tŝůů͕ĚƵƌŝŶŐĞĂĐŚƉŽůŝĐǇƉĞƌŝŽĚ͕ƉƌŽǀŝĚĞǀĞƌŝĨŝĐĂƚŝŽŶŽĨĨƵůůͲĐŽǀĞƌĂŐĞƉƌŝǀĂƚĞǀĞŚŝĐůĞŝŶƐƵƌĂŶĐĞ͕ ŝŶĐůƵĚŝŶŐĂŶĞŶĚŽƌƐĞŵĞŶƚƐƉĞĐŝĨŝĐĂůůǇĂƵƚŚŽƌŝǌŝŶŐƚŚĞWKs͛ƐƵƐĞĂƐĂŶĞŵĞƌŐĞŶĐǇǀĞŚŝĐůĞ͘ x dŚĞWKsǁŝůůďĞĞƋƵŝƉƉĞĚǁŝƚŚǀŝƐŝďůĞĂŶĚĂƵĚŝďůĞǁĂƌŶŝŶŐĚĞǀŝĐĞƐƚŚĂƚĐŽŵƉůǇǁŝƚŚƚŚĞdĞǆĂƐ dƌĂŶƐƉŽƌƚĂƚŝŽŶŽĚĞ^ĞĐƚŝŽŶƐϱϰϳ͘ϯϬϱĂŶĚϱϰϳ͘ϳϬϮ͕ǁŝƚŚƚŚĞĨŽůůŽǁŝŶŐĞǆĐĞƉƚŝŽŶƐ͗ǆŚĂƵƐƚǁŚŝƐƚůĞƐ͕ ďĞůůƐ͕ĂŶĚƐŝŶŐůĞůĂŵƉƚĞŵƉŽƌĂƌŝůǇĂƚƚĂĐŚĞĚǁĂƌŶŝŶŐůŝŐŚƚƐĂƌĞŶŽƚĂƉƉƌŽǀĞĚďǇD^ĨŽƌƵƐĞĂƐ ĞŵĞƌŐĞŶĐǇĞƋƵŝƉŵĞŶƚ͘ x &ŝƌƐƚZĞƐƉŽŶĚĞƌƐǁŝůůŽďĞǇĂůůD^WŽůŝĐŝĞƐ͕ƐƉĞĐŝĨŝĐĂůůǇƉĞƌƚĂŝŶŝŶŐƚŽŵĞƌŐĞŶĐǇsĞŚŝĐůĞ KƉĞƌĂƚŝŽŶƐĚƵƌŝŶŐĂƌĞƐƉŽŶƐĞŽŶďĞŚĂůĨŽĨD^͘ Duties on Scene x &ŝƌƐƚZĞƐƉŽŶĚĞƌƐǁŝůůƉƌŽǀŝĚĞĂƐĐĞŶĞƐŝǌĞƵƉ͕ŝĚĞŶƚŝĨǇƚŚĞŶƵŵďĞƌŽĨƉĂƚŝĞŶƚƐĂŶĚƉĂƚŝĞŶƚĂĐƵŝƚǇ͕ĂŶĚ ƌĞƋƵĞƐƚĂĚĚŝƚŝŽŶĂůƌĞƐŽƵƌĐĞƐĂƐŶĞĞĚĞĚ͘ x &ŝƌƐƚZĞƐƉŽŶĚĞƌƐǁŝůůƉĞƌĨŽƌŵƉĂƚŝĞŶƚĂƐƐĞƐƐŵĞŶƚƐĂŶĚƚƌĞĂƚŵĞŶƚƐƉĞƌƉƌŽƚŽĐŽů͘ x &ŝƌƐƚZĞƐƉŽŶĚĞƌƐǁŝůůƉƌŽǀŝĚĞĂƉĂƚŝĞŶƚƌĞƉŽƌƚƚŽƚŚĞĨŝƌƐƚĂƌƌŝǀŝŶŐĂŵďƵůĂŶĐĞ/ŶͲŚĂƌŐĞWĂƌĂŵĞĚŝĐ ĂŶĚƚŚĞŶĂƐƐŝƐƚƚŚĞĐƌĞǁŝŶƉƌŽǀŝĚŝŶŐƚƌĞĂƚŵĞŶƚĂŶĚƚƌĂŶƐƉŽƌƚƚŽƚŚĞŚŽƐƉŝƚĂů͘ x &ŝƌƐƚZĞƐƉŽŶĚĞƌƐŵĂǇƌŝĚĞŝŶǁŝƚŚƚŚĞĂŵďƵůĂŶĐĞƚŽĞŝƚŚĞƌĂƐƐŝƐƚŝŶƉĂƚŝĞŶƚĐĂƌĞĂŶĚͬŽƌĚƌŝǀĞƚŚĞ ĂŵďƵůĂŶĐĞĂƚƚŚĞĚŝƌĞĐƚŝŽŶŽĨƚŚĞ/ŶͲŚĂƌŐĞWĂƌĂŵĞĚŝĐ͘

Cypress Creek EMS System Policies and Treatment Guidelines

52 OPERATIONAL POLICIES Approved: Levon Vartanian, MD

Disregarding Calls x &ŝƌƐƚͲZĞƐƉŽŶĚĞƌƐĐĂŶŶŽƚĚŝƐƌĞŐĂƌĚƵŶŝƚƐǁŚĞŶƚŚĞƌĞŝƐĂŶĂĐƚƵĂůƉĂƚŝĞŶƚŽŶůŽĐĂƚŝŽŶ͘&ŝƌƐƚͲ ZĞƐƉŽŶĚĞƌƐƐŚŽƵůĚĂĚǀŝƐĞƚŚĞŽŵŵĞŶƚĞƌ;ŝĨĂďůĞͿŽĨƚŚĞŶƵŵďĞƌŽĨƉĂƚŝĞŶƚƐĂŶĚƚŚĞŝƌĐŽŶĚŝƚŝŽŶ ;ƐƚĂďůĞ͕ƵƌŐĞŶƚ͕ŽƌĐƌŝƚŝĐĂůͿ͘ x dŚĞ&ŝƌƐƚͲZĞƐƉŽŶĚĞƌDzĚŽǁŶŐƌĂĚĞƚŚĞĞŵĞƌŐĞŶĐǇƌĞƐƉŽŶƐĞŽĨƚŚĞĂƐƐŝŐŶĞĚŵĞĚŝĐƵŶŝƚƚŽŶŽŶͲ ĞŵĞƌŐĞŶĐǇƉĞƌƉŽůŝĐǇ͘ x /ĨƚŚĞŝŶĐŝĚĞŶƚŝƐƵŶĨŽƵŶĚĞĚ͕ƚŚĞƌĞŝƐŶŽƉĂƚŝĞŶƚ͕ŽƌŝĨƚŚĞƌĞĂƌĞŶŽŝŶũƵƌŝĞƐĂƚƚŚĞůŽĐĂƚŝŽŶ͕ƚŚĞ&ŝƌƐƚ ZĞƐƉŽŶĚĞƌŵĂǇĚŝƐƌĞŐĂƌĚƚŚĞŵĞĚŝĐƵŶŝƚ͘ x dŚĞ&ŝƌƐƚͲZĞƐƉŽŶĚĞƌĚŝƐƌĞŐĂƌĚŝŶŐƚŚĞŵĞĚŝĐƵŶŝƚŝƐŶŽƚƌĞƐƉŽŶƐŝďůĞĨŽƌĚŽĐƵŵĞŶƚĂƚŝŽŶ͖ŝƚŝƐƚŚĞ ƌĞƐƉŽŶƐŝďŝůŝƚǇŽĨƚŚĞƌĞƐƉŽŶĚŝŶŐŵĞĚŝĐƵŶŝƚƚŽĐŽŵƉůĞƚĞƚŚĞƉĂƚŝĞŶƚĐĂƌĞƌĞƉŽƌƚ;WZͿ͕ĂůŽŶŐǁŝƚŚƚŚĞ ƌĞĂƐŽŶĨŽƌƚŚĞĚŝƐƌĞŐĂƌĚ͘

Cypress Creek EMS System Policies and Treatment Guidelines

53 OPERATIONAL POLICIES Revised 8/2016 Approved: Levon Vartanian, MD

ŚŝůĚ>ŽĐŬĞĚŝŶĂsĞŚŝĐůĞ Purpose tŚĞŶϵϭϭĚŝƐƉĂƚĐŚŐĞƚƐĂƌĞƉŽƌƚŽĨĂĐŚŝůĚůŽĐŬĞĚŝŶĂǀĞŚŝĐůĞ͕D^ĂŶĚůĂǁĞŶĨŽƌĐĞŵĞŶƚĂƌĞĚŝƐƉĂƚĐŚĞĚ ƚŽƚŚĞůŽĐĂƚŝŽŶ͘/ŶǁĂƌŵŽƌŚŽƚǁĞĂƚŚĞƌ͕ĞƐƉĞĐŝĂůůǇŝĨƚŚĞǀĞŚŝĐůĞŝƐŶŽƚƌƵŶŶŝŶŐ͕ƚŚŝƐƐŝƚƵĂƚŝŽŶƉůĂĐĞƐƚŚĞ ĐŚŝůĚĂƚŚŝŐŚƌŝƐŬĨŽƌŚĞĂƚŝŶũƵƌǇĂŶĚŝƐĂƚƌƵĞĞŵĞƌŐĞŶĐǇ͘ Procedure ϭ͘ hŶůĞƐƐĂĚǀŝƐĞĚďǇŽŵŵĞŶƚĞƌƚŽƐƚĂŐĞ͕ƚŚĞD^ƵŶŝƚƐŚŽƵůĚĨŝŶĚƚŚĞǀĞŚŝĐůĞĂŶĚĂƐƐĞƐƐĨŽƌƐĐĞŶĞ ƐĂĨĞƚǇďĞĨŽƌĞŵĂŬŝŶŐĐŽŶƚĂĐƚ͘ Ϯ͘ ĞƚĞƌŵŝŶĞŝĨƚŚĞǀĞŚŝĐůĞŝƐƌƵŶŶŝŶŐĂŶĚͬŽƌŝĨƚŚĞŽĐĐƵƉĂŶƚ;ƐͿĂƉƉĞĂƌƚŽďĞŝŶĚŝƐƚƌĞƐƐ͘ ϯ͘ ĞƚĞƌŵŝŶĞŝĨƚŚĞǀĞŚŝĐůĞŝƐŝŶĨĂĐƚůŽĐŬĞĚŽƌŝĨƚŚĞŽĐĐƵƉĂŶƚ;ƐͿĐŽƵůĚďĞĚŝƌĞĐƚĞĚƚŽƵŶůŽĐŬƚŚĞ ǀĞŚŝĐůĞ͘ ϰ͘ /ĨƚŚĞǀĞŚŝĐůĞŝƐŶŽƚƌƵŶŶŝŶŐĂŶĚͬŽƌƚŚĞŽĐĐƵƉĂŶƚ;ƐͿĂƉƉĞĂƌƚŽďĞŝŶĚŝƐƚƌĞƐƐ͕ĚŽŶŽƚĚĞůĂǇŐĂŝŶŝŶŐ ĂĐĐĞƐƐƚŽƚŚĞǀĞŚŝĐůĞ͘/ƚŝƐƉƌĞĨĞƌƌĞĚƚŽŚĂǀĞƚŚĞŬĞǇŚŽůĚĞƌƵŶůŽĐŬƚŚĞǀĞŚŝĐůĞ͕ďƵƚŝĨƚŚŝƐŝƐŶŽƚ ƉŽƐƐŝďůĞ͕ƵƚŝůŝǌĞŽƚŚĞƌƌĞƐŽƵƌĐĞƐ͕ǁŚŝĐŚŵĂǇŝŶĐůƵĚĞ͗ x tƌĞĐŬĞƌĚƌŝǀĞƌƐƵƐŝŶŐǀĞŚŝĐůĞƵŶůŽĐŬŝŶŐƚŽŽůƐ x &ŝƌĞƌĞƐŽƵƌĐĞƐƵƐŝŶŐǀĞŚŝĐůĞƵŶůŽĐŬŝŶŐƚŽŽůƐ͕ŐůĂƐƐďƌĞĂŬĞƌƐ͕ĞƚĐ͘ x D^ĐƌĞǁƵƚŝůŝǌŝŶŐŐůĂƐƐƉƵŶĐŚ͗tĞĂƌWWĂŶĚŚŝƚĐŽƌŶĞƌŽĨǁŝŶĚŽǁĨĂƌƚŚĞƐƚĨƌŽŵŽĐĐƵƉĂŶƚ ƵƐŝŶŐƚŚĞƉƵŶĐŚ͘ĞĐĂƌĞĨƵůƚŽĂǀŽŝĚŝŶũƵƌǇĨƌŽŵƐŚĂƌƉŐůĂƐƐ͘ ϱ͘ KŶĐĞĂĐĐĞƐƐŝƐŐĂŝŶĞĚ͕ĂƐƐĞƐƐƚŚĞŽĐĐƵƉĂŶƚ;ƐͿƚŚĂƚǁĞƌĞŝŶƚŚĞǀĞŚŝĐůĞĂŶĚĚĞƚĞƌŵŝŶĞŝĨƚŚĞŝŶƚĞƌŝŽƌ ƚĞŵƉĞƌĂƚƵƌĞŽĨƚŚĞǀĞŚŝĐůĞǁĂƐĞǆĐĞƐƐŝǀĞůǇǁĂƌŵ͘

Criteria for No Injury/No Medical Emergency: KĐĐƵƉĂŶƚ;ƐͿǁĞƌĞŶŽƚĞǆƉŽƐĞĚƚŽĞǆƚƌĞŵĞƚĞŵƉĞƌĂƚƵƌĞƐ KĐĐƵƉĂŶƚ;ƐͿĚŽŶŽƚĂƉƉĞĂƌƚŽďĞŝŶĚŝƐƚƌĞƐƐŽƌƚŽďĞŝůůŽƌŝŶũƵƌĞĚ KĐĐƵƉĂŶƚ;ƐͿĚŽŶŽƚŚĂǀĞĂŵĞĚŝĐĂůĐŽŵƉůĂŝŶƚ /ĨƚŚĞƐĞĐƌŝƚĞƌŝĂĂƌĞŶŽƚŵĞƚ͕ƚŚĞŽĐĐƵƉĂŶƚŝƐĂƉĂƚŝĞŶƚĂŶĚŵƵƐƚďĞĨƵůůǇĂƐƐĞƐƐĞĚĂƐƌĞƋƵŝƌĞĚƵŶĚĞƌƚŚĞ Patient DeterminationƉŽůŝĐǇ͘ Documentation /ĨŶŽƉĂƚŝĞŶƚǁĂƐŝĚĞŶƚŝĨŝĞĚ͕ĚŽĐƵŵĞŶƚĂƚŝŽŶƐŚŽƵůĚŝŶĐůƵĚĞƚŚĞĨŽůůŽǁŝŶŐ͗ x ĞƐĐƌŝƉƚŝŽŶŽĨŚŽǁƐĐĞŶĞǁĂƐĨŽƵŶĚŽŶD^ĂƌƌŝǀĂů͕ŝŶĐůƵĚŝŶŐůŽĐĂƚŝŽŶŽĨŽĐĐƵƉĂŶƚƐŝŶǀĞŚŝĐůĞ͕ ǁŚĞƚŚĞƌŽƌŶŽƚǀĞŚŝĐůĞǁĂƐƌƵŶŶŝŶŐ͕ĂŶĚŝŶƚĞƌŝŽƌƚĞŵƉĞƌĂƚƵƌĞŽĨĐĂƌ͘ x ĞƐĐƌŝƉƚŝŽŶŽĨŚŽǁǀĞŚŝĐůĞǁĂƐƵŶůŽĐŬĞĚŽƌĂĐĐĞƐƐĞĚ͘ x ĞƐĐƌŝƉƚŝŽŶŽĨŽĐĐƵƉĂŶƚĐŽŶĚŝƚŝŽŶ͕ĚŝƐƚƌĞƐƐůĞǀĞů͕ĂŶĚǁŚŽƚŚĞǇǁĞƌĞůĞĨƚǁŝƚŚ͘

Cypress Creek EMS System Policies and Treatment Guidelines

54 OPERATIONAL POLICIES Revised 8/2016 Approved: Levon Vartanian, MD

ŽŵŵƵŶŝĐĂƚŝŽŶƐ

D^ƵƚŝůŝǌĞƐŵƵůƚŝƉůĞŵĞƚŚŽĚƐŽĨĐŽŵŵƵŶŝĐĂƚŝŽŶƐ͕ĂŶĚĐƌĞǁŵĞŵďĞƌƐƐŚŽƵůĚďĞĐŽŵĨŽƌƚĂďůĞŝŶ ƵƚŝůŝǌŝŶŐĂůůŽĨƚŚĞŵŝŶĂŶĞĨĨĞĐƚŝǀĞŵĂŶŶĞƌ͘ZĞŐĂƌĚůĞƐƐŽĨǁŚŝĐŚĐŽŵŵƵŶŝĐĂƚŝŽŶŵĞƚŚŽĚŝƐďĞŝŶŐƵƚŝůŝǌĞĚ͕ ĂůůƉĞƌƐŽŶƐƐŚŽƵůĚŬĞĞƉƚŚĞŝƌŵĞƐƐĂŐĞƐƉŽůŝƚĞĂŶĚƉƌŽĨĞƐƐŝŽŶĂů͘ůůĐŽŵŵƵŶŝĐĂƚŝŽŶŵĞƚŚŽĚƐĂƌĞƐƵďũĞĐƚ ƚŽŵŽŶŝƚŽƌŝŶŐĂŶĚĐĂƌĞƐŚŽƵůĚďĞƚĂŬĞŶƚŽƌĞƉƌĞƐĞŶƚǇƉƌĞƐƐƌĞĞŬD^ĂŶĚŽƵƌƉƌŽĨĞƐƐŝŽŶŝŶƚŚĞďĞƐƚ ůŝŐŚƚƉŽƐƐŝďůĞƚŽŽƵƌĐŽůůĞĂŐƵĞƐ͕ƉĂƌƚŶĞƌĂŐĞŶĐŝĞƐ͕ĂŶĚƚŚĞŐĞŶĞƌĂůƉƵďůŝĐ͘ Radio Overview D^ƵƚŝůŝǌĞƐh,&ƌĂĚŝŽĐŽŵŵƵŶŝĐĂƚŝŽŶĂƐƚŚĞƉƌŝŵĂƌǇŵĞĂŶƐĨŽƌƚŚĞŽŵŵĞŶƚĞƌƚŽĚŝƐƉĂƚĐŚĂŶĚ ĚŝƌĞĐƚƵŶŝƚƐ͕ĨŽƌƵŶŝƚƐƚŽƵƉĚĂƚĞŽŵŵĞŶƚĞƌŽŶĐĂůůŝŶĨŽƌŵĂƚŝŽŶ͕ĂŶĚĨŽƌŽŶͲƐĐĞŶĞ;ƚĂĐƚŝĐĂůͿ ĐŽŵŵƵŶŝĐĂƚŝŽŶďĞƚǁĞĞŶƌĞƐƉŽŶĚŝŶŐĂŐĞŶĐŝĞƐ͘

x ŽŵŵƵŶŝĐĂƚŝŽŶŽŶƌĂĚŝŽƐŚŽƵůĚĂůǁĂǇƐďĞĚŽŶĞŝŶƉůĂŝŶŶŐůŝƐŚ͘ŽŵŵĞŶƚĞƌĚŝƐƉĂƚĐŚĞƐƵƐŝŶŐ ƐƚĂŶĚĂƌĚŝǌĞĚĚĞƚĞƌŵŝŶĂŶƚĐŽĚĞƐ͕ǁŚŝĐŚĐƌĞǁŵĞŵďĞƌƐƐŚŽƵůĚďĞĨĂŵŝůŝĂƌǁŝƚŚ͘ x dƌĂŶƐŵŝƐƐŝŽŶƐƐŚŽƵůĚďĞĐŽŶĐŝƐĞĂŶĚĨŽĐƵƐĞĚ͕ĂƉƉƌŽǆŝŵĂƚĞůǇϭϬʹϭϱƐĞĐŽŶĚƐƉĞƌƚƌĂŶƐŵŝƐƐŝŽŶ͘ x ZĂĚŝŽƚƌĂĨĨŝĐ/^ŵŽŶŝƚŽƌĞĚďǇŵĞŵďĞƌƐŽĨƚŚĞƉƵďůŝĐ͕ũŽƵƌŶĂůŝƐƚƐ͕ĂŶĚŽƚŚĞƌĂŐĞŶĐŝĞƐ͘<ĞĞƉ ĐŽŵŵƵŶŝĐĂƚŝŽŶƉƌŽĨĞƐƐŝŽŶĂů͕ĨŽĐƵƐĞĚ͕ĂŶĚĂǀŽŝĚĚŝƐĐƵƐƐŝŶŐƐĞŶƐŝƚŝǀĞŝŶĨŽƌŵĂƚŝŽŶŽŶƚŚĞƌĂĚŝŽ͘ x KEKdĐŽŵŵƵŶŝĐĂƚĞĂŶǇƉĂƚŝĞŶƚŝĚĞŶƚŝĨŝĞƌƐŽǀĞƌƚŚĞƌĂĚŝŽ͘ x /ƚŝƐƉƌĞĨĞƌƌĞĚƚŚĂƚŶŽŶͲĚƌŝǀĞƌƐŽƉĞƌĂƚĞƚŚĞƌĂĚŝŽǁŚĞŶĚƌŝǀŝŶŐŽƌƌĞƐƉŽŶĚŝŶŐƚŽĂĐĂůů͘ x ƌĞǁƐƐŚŽƵůĚŚĂǀĞƚŚĞŝƌƌĂĚŝŽƐǁŝƚŚƚŚĞŵĂƚĂůůƚŝŵĞƐŽŶĚƵƚǇ͘ ZĂĚŝŽŚĂŶŶĞůƐ D^ƌĂĚŝŽƐĂƌĞƉƌŽŐƌĂŵŵĞĚǁŝƚŚĂŶƵŵďĞƌŽĨĐŽŵŵƵŶŝĐĂƚŝŽŶĐŚĂŶŶĞůƐ͘ŽŵŵĞŶƚĞƌŵĂǇĚŝƌĞĐƚ ĐƌĞǁƐƌĞƐƉŽŶĚŝŶŐƚŽĂŶŝŶĐŝĚĞŶƚƚŽƐǁŝƚĐŚƚŽŽƌƵƐĞĂĚŝĨĨĞƌĞŶƚĐŚĂŶŶĞůĚĞƉĞŶĚŝŶŐŽŶƚŚĞĨŝƌĞ ĚĞƉĂƌƚŵĞŶƚƌĞƐƉŽŶĚŝŶŐĂŶĚƚŚĞƚĂĐƚŝĐĂůŶĞĞĚƐŽĨƚŚĞŝŶĐŝĚĞŶƚ͘

dŚĞƉƌŝŵĂƌǇD^ĐŽŵŵƵŶŝĐĂƚŝŽŶĐŚĂŶŶĞůŝƐŽŵŵϭ͘dŚĞƉƌŝŵĂƌǇĨŝƌĞĚĞƉĂƌƚŵĞŶƚĐŚĂŶŶĞůƐĂƌĞŽŵŵ Ϯʹϱ͘dŚĞƐĞĐŽǀĞƌƚŚĞĨŽůůŽǁŝŶŐĂƉƉƌŽǆŝŵĂƚĞŐĞŽŐƌĂƉŚŝĐĂƌĞĂƐ͗

Cypress Creek EMS System Policies and Treatment Guidelines

55 OPERATIONAL POLICIES Revised 8/2016 Approved: Levon Vartanian, MD

ĂĐŚ&ŝƌĞĞƉĂƌƚŵĞŶƚĂůƐŽŚĂƐdĐŚĂŶŶĞůƐĂǀĂŝůĂďůĞĨŽƌƵƐĞŽŶƐƉĞĐŝĨŝĐŝŶĐŝĚĞŶƚƐ͘dŚĞƐĞŵĂǇďĞ ĂƐƐŝŐŶĞĚďǇĨŝƌĞĐŽŵŵĂŶĚŽƌƚŚĞŽŵŵĞŶƚĞƌ͘D^ĐƌĞǁƐŵĂǇƌĞƋƵĞƐƚĂdĐŚĂŶŶĞůĨƌŽŵŽŵŵ ĞŶƚĞƌŝĨŶĞĞĚĞĚ͘ŽŵŵϱŝƐďŽƚŚĂƉƌŝŵĂƌǇĐŽŵŵƵŶŝĐĂƚŝŽŶƐĐŚĂŶŶĞůĂŶĚĂƚĂĐƚŝĐĂůĐŚĂŶŶĞů͘

TAC CHANNELS Comm 2 Area Comm 3 Area Comm 4 Area Comm 5 EŽƌƚŚ Žŵŵϳ EŽƌƚŚ Žŵŵϵ EŽƌƚŚ ŽŵŵϭϬ EŽƌƚŚ Žŵŵϭϰ ĞŶƚƌĂů Žŵŵϭϭ ĞŶƚƌĂů Žŵŵϭϭ ĞŶƚƌĂů ŽŵŵϭϬ ĞŶƚƌĂů Žŵŵϭϰ ^ŽƵƚŚ Žŵŵϴ ^ŽƵƚŚ Žŵŵϭϯ ^ŽƵƚŚ Žŵŵϲ ^ŽƵƚŚ Žŵŵϭϰ D^ƵƚŝůŝǌĞƐĂƌĞƉĞĂƚĞƌƐǇƐƚĞŵ͘dŚŝƐĞǆƚĞŶĚƐƚŚĞƌĂŶŐĞŽĨŚĂŶĚŚĞůĚĂŶĚŵŽďŝůĞƌĂĚŝŽƐďǇŚĂǀŝŶŐĂ ůĂƌŐĞďĂƐĞƐƚĂƚŝŽŶƌĞĐĞŝǀĞƚƌĂĨĨŝĐŽŶŽŶĞĨƌĞƋƵĞŶĐǇĂŶĚƌĞͲďƌŽĂĚĐĂƐƚŝƚŽŶĂŶŽƚŚĞƌ͘/ĨŽƵƚŽĨƚŚĞƌĂŶŐĞŽĨ ƚŚĞƌĞƉĞĂƚĞƌ͕ƚŚĞƌĂĚŝŽƐŵĂǇŶŽƚďĞĂďůĞƚŽĐŽŵŵƵŶŝĐĂƚĞ͘/ĨŶĞĞĚĞĚ͕ƚŚĞĐƌĞǁŵĂǇƵƚŝůŝǌĞĂŶĂůƚĞƌŶĂƚĞ ĐŽŵŵƵŶŝĐĂƚŝŽŶĐŚĂŶŶĞůŽƌĂƚĂĐĐŚĂŶŶĞů͘WƌŝŽƌƚŽƚƌĂŶƐŵŝƚƚŝŶŐ͕ƚŚĞĐƌĞǁŵƵƐƚůŝƐƚĞŶĂŶĚďĞƐƵƌĞƚŚĞ ĐŚĂŶŶĞůŝƐĐůĞĂƌĂŶĚƚŚĞŶƐŚŽƵůĚĐŽŵŵƵŶŝĐĂƚĞƚŽƚŚĞĐŽŵŵĐĞŶƚĞƌĂŶĚƌĞƋƵĞƐƚĐůĞĂƌĂŶĐĞƚŽƵƐĞŝƚ͘

ĂĐŚĐŚĂŶŶĞůŝƐĂůƐŽƉƌŽŐƌĂŵŵĞĚŝŶƚŽƚŚĞƌĂĚŝŽƐĂƐĂ^ŝŵƉůĞǆŽƌ͞ŝƌĞĐƚ͟ĐŚĂŶŶĞů;ŝ͘Ğ͘Žŵŵϭ͕Ă ƌĞƉĞĂƚĞƌĐŚĂŶŶĞů͕ŝƐĂůƐŽƉƌŽŐƌĂŵŵĞĚŝŶĂƐŽŵŵϭŝƌĞĐƚͿ͘dŚĞŝƌĞĐƚǀĞƌƐŝŽŶŽĨĞĂĐŚĐŚĂŶŶĞůĚŽĞƐŶŽƚ ďƌŽĂĚĐĂƐƚƚŽƚŚĞƌĞƉĞĂƚĞƌďƵƚŝŶƐƚĞĂĚǁŝůůƚƌĂŶƐŵŝƚƚŽĂŶǇƌĂĚŝŽǁŝƚŚŝŶƌĂŶŐĞŽŶĞŝƚŚĞƌƚŚĞƌĞƉĞĂƚĞƌ ǀĞƌƐŝŽŶŽƌƚŚĞŝƌĞĐƚǀĞƌƐŝŽŶŽĨƚŚĞĐŚĂŶŶĞů͘dŚĞƐĞĐŚĂŶŶĞůƐŵĂǇďĞƵƚŝůŝǌĞĚĨŽƌĐŽŵŵƵŶŝĐĂƚŝŽŶďĞƚǁĞĞŶ ƌĞƐƉŽŶĚĞƌƐŽŶƐĐĞŶĞĂŶĚŶŽƚŝŶƌĂŶŐĞŽĨƚŚĞƌĞƉĞĂƚĞƌ͘ ĞůůWŚŽŶĞ ĂĐŚƵŶŝƚŝƐŝƐƐƵĞĚĂĐĞůůƉŚŽŶĞ͕ǁŚŝĐŚŝƐƵƐĞĚƚŽƌĞĐĞŝǀĞƚĞǆƚŵĞƐƐĂŐĞƉĂŐĞƐĨƌŽŵŽŵŵĞŶƚĞƌĂŶĚƚŽ ĐŽŵŵƵŶŝĐĂƚĞŽŶͲĚƵƚǇĂƐŶĞĞĚĞĚ͘dŚĞƐĞƉŚŽŶĞƐĂƌĞĨŽƌŽĨĨŝĐŝĂůƵƐĞŽŶůǇĂŶĚƐŚŽƵůĚŶŽƚďĞƵƐĞĚĨŽƌ ƉĞƌƐŽŶĂůƵƐĞ͘ŽŶŽƚŐŝǀĞŽƵƚƚŚĞŶƵŵďĞƌƚŽĂŵďƵůĂŶĐĞƉŚŽŶĞƐ͘ĐƌĞǁŵĞŵďĞƌƐŚŽƵůĚŚĂǀĞƚŚĞƉŚŽŶĞ ŽŶŽƌŶĞĂƌƚŚĞŝƌƉĞƌƐŽŶƚŚƌŽƵŐŚŽƵƚƚŚĞƐŚŝĨƚĂŶĚƚŚĞƉŚŽŶĞƐŚŽƵůĚďĞŬĞƉƚĂĚĞƋƵĂƚĞůǇĐŚĂƌŐĞĚ͘Ğůů ƉŚŽŶĞƐƐŚŽƵůĚŶŽƚďĞƵƐĞĚďǇƚŚĞĚƌŝǀĞƌǁŚĞŶŽƉĞƌĂƚŝŶŐĂŶĂŵďƵůĂŶĐĞ͘ ŵĂŝů ƵĞƚŽƚŚĞĚŝƐƚƌŝďƵƚĞĚŶĂƚƵƌĞŽĨƚŚĞD^ǁŽƌŬĨŽƌĐĞ͕ĞŵĂŝůŝƐĂƉƌŝŵĂƌǇŵĞĂŶƐĨŽƌĐŽŵŵƵŶŝĐĂƚŝŶŐ ŝŶĨŽƌŵĂƚŝŽŶǁŝƚŚŝŶD^͕Ğ͘Ő͘ŽƉĞƌĂƚŝŽŶĂůƵƉĚĂƚĞƐͬĐŚĂŶŐĞƐ͕ƵƉĐŽŵŝŶŐƚƌĂŝŶŝŶŐ͕ĐůŝŶŝĐĂůĂŶĚƐĐŚĞĚƵůĞ ĐŚĂŶŐĞƐ͘ƌĞǁƐĂƌĞƌĞƋƵŝƌĞĚƚŽĐŚĞĐŬƚŚĞŝƌD^ĞŵĂŝůĂĐĐŽƵŶƚĂƚůĞĂƐƚŽŶĐĞƉĞƌƐŚŝĨƚ͘ƌĞǁƐƐŚŽƵůĚ ƌĞĐŽŐŶŝǌĞƚŚĂƚƐŽŵĞƚŝŵĞƐŽŶŐŽŝŶŐŝŶĨŽƌŵĂƚŝŽŶƵƉĚĂƚĞƐŵĂǇďĞĚŝƐƚƌŝďƵƚĞĚŵƵůƚŝƉůĞƚŝŵĞƐƚŚƌŽƵŐŚŽƵƚĂ ƐŚŝĨƚ͘tŚŝůĞŶŽƚƌĞƋƵŝƌĞĚ͕ŝƚŝƐďĞŶĞĨŝĐŝĂůĨŽƌŵĞŵďĞƌƐƚŽĂůƐŽĐŚĞĐŬƚŚĞŝƌĞŵĂŝůĚƵƌŝŶŐŽĨĨĚĂǇƐ͘ ŽŵƉƵƚĞƌƐΘ/ŶƚĞƌŶĞƚ ŽŵƉƵƚĞƌƐĂƌĞĂƐƐŝŐŶĞĚƚŽĞĂĐŚƐƚĂƚŝŽŶĂŶĚƵŶŝƚĨŽƌƵƐĞďǇD^ŵĞŵďĞƌƐƚŽĂĐĐŽŵƉůŝƐŚŽĨĨŝĐŝĂůǁŽƌŬ͕ ƐƵĐŚĂƐƉĂƚŝĞŶƚĐĂƌĞĚŽĐƵŵĞŶƚĂƚŝŽŶ͕ŝŶǀĞŶƚŽƌǇŵĂŶĂŐĞŵĞŶƚ͕ŵĂƉƉŝŶŐͬƌĞƐƉŽŶĚŝŶŐƚŽĐĂůůƐ͕ĚŽŝŶŐ ĐŽŶƚŝŶƵŝŶŐĞĚƵĐĂƚŝŽŶ͕ĂŶĚĐŚĞĐŬŝŶŐD^ĞŵĂŝů͘D^ƐƚĂƚŝŽŶƐŚĂǀĞƐĞĐƵƌĞĚǁŝƌĞůĞƐƐŶĞƚǁŽƌŬƐĨŽƌ ƚŚĞƐĞĐŽŵƉƵƚĞƌƐƚŽĐŽŶŶĞĐƚ͘D^ŵĞŵďĞƌƐƐŚŽƵůĚŶŽƚĐŽŶŶĞĐƚĂŶǇƉĞƌƐŽŶĂůĚĞǀŝĐĞƐƚŽƚŚĞƐĞ ŶĞƚǁŽƌŬƐ͘ŐƵĞƐƚǁŝƌĞůĞƐƐŶĞƚǁŽƌŬŝƐĂǀĂŝůĂďůĞŝŶƚŚĞƐƚĂƚŝŽŶƐĨŽƌƉĞƌƐŽŶĂůĚĞǀŝĐĞƵƐĞ͘ZĞĨĞƌƚŽƚŚĞ D^/ŶƚĞƌŶĞƚWŽůŝĐǇĨŽƌĚĞƚĂŝůƐŽŶĂĐĐĞƉƚĂďůĞƵƐĞ͘

Cypress Creek EMS System Policies and Treatment Guidelines

56 OPERATIONAL POLICIES Revised 8/2016 Approved: Levon Vartanian, MD

ŽŶƚƌŽůůĞĚDĞĚŝĐĂƚŝŽŶDĂŶĂŐĞŵĞŶƚ Purpose dŚĞƌƵŐŶĨŽƌĐĞŵĞŶƚĚŵŝŶŝƐƚƌĂƚŝŽŶĂŶĚdĞǆĂƐ^,^ƌĞƋƵŝƌĞƚŚĞDĞĚŝĐĂůŝƌĞĐƚŽƌƚŽĂƐƐƵƌĞƚŚĂƚĂůů ŵĞĚŝĐĂƚŝŽŶƐƉƵƌĐŚĂƐĞĚƵŶĚĞƌŚŝƐͬŚĞƌůŝĐĞŶƐĞĂƌĞƐƚŽƌĞĚ͕ƐĞĐƵƌĞĚĂŶĚĂĚŵŝŶŝƐƚĞƌĞĚĂĐĐŽƌĚŝŶŐƚŽůĂǁƐ ĂŶĚƌĞŐƵůĂƚŝŽŶƐ͘/ƚŝƐĂůƐŽŶĞĐĞƐƐĂƌǇƚŽƉƌŽǀŝĚĞĂŶĚĚŽĐƵŵĞŶƚĐŚĂŝŶŽĨĐƵƐƚŽĚǇŽĨĂůůĐŽŶƚƌŽůůĞĚ ŵĞĚŝĐĂƚŝŽŶƐĨƌŽŵƚŝŵĞŽĨƉƵƌĐŚĂƐĞƚŽƚŚĞƚŝŵĞŽĨĂĚŵŝŶŝƐƚƌĂƚŝŽŶŽƌĞǆƉŝƌĂƚŝŽŶ͘ ^ƚŽƌĂŐĞĂŶĚ^ĞĐƵƌŝƚǇ dŚĞ/ŶͲŚĂƌŐĞWĂƌĂŵĞĚŝĐŽƌƚŚĞŝƌ/WƚƌĂŝŶĞĞŝƐƌĞƐƉŽŶƐŝďůĞĨŽƌƚŚĞĐŚĂŝŶŽĨĐƵƐƚŽĚǇŽĨƚŚĞĐŽŶƚƌŽůůĞĚ ŵĞĚŝĐĂƚŝŽŶƐĂŶĚĨŽƌĐĂƌƌǇŝŶŐƚŚĞŬĞǇƐĨŽƌƚŚĞĐŽŶƚƌŽůůĞĚŵĞĚŝĐĂƚŝŽŶƐŽŶŚŝƐͬŚĞƌƉĞƌƐŽŶĂƚĂůůƚŝŵĞƐ ĚƵƌŝŶŐƚŚĞƐŚŝĨƚ͘

dŚĞĐŽŶƚƌŽůůĞĚŵĞĚŝĐĂƚŝŽŶƐǁŝůůƌĞŵĂŝŶůŽĐŬĞĚŝŶƚŚĞĂŵďƵůĂŶĐĞůŽĐŬďŽǆĂƚĂůůƚŝŵĞƐĞǆĐĞƉƚǁŚĞŶ ĂĚŵŝŶŝƐƚƌĂƚŝŽŶŝƐĂŶƚŝĐŝƉĂƚĞĚŽƌƌĞƋƵŝƌĞĚ͘/ŶĂĚĚŝƚŝŽŶ͕ƚŚĞĂŵďƵůĂŶĐĞǁŝůůƌĞŵĂŝŶůŽĐŬĞĚĂƚĂůůƚŝŵĞƐ ǁŚĞŶŶŽƚŽĐĐƵƉŝĞĚƚŽƉƌŽǀŝĚĞĂĚĚŝƚŝŽŶĂůƐĞĐƵƌŝƚǇ͘;tŚĞŶƚŚĞĂŵďƵůĂŶĐĞŝƐŝŶƚŚĞďĂǇĂŶĚƚŚĞďĂǇĚŽŽƌƐ ĂƌĞĐůŽƐĞĚƚŚĞƵŶŝƚŵĂǇďĞƵŶůŽĐŬĞĚͿdŚĞĐŽŶƚƌŽůůĞĚŵĞĚŝĐĂƚŝŽŶĨŽůĚĞƌǁŝƚŚĂůůĂƐƐŽĐŝĂƚĞĚ ĚŽĐƵŵĞŶƚĂƚŝŽŶǁŝůůƌĞŵĂŝŶǁŝƚŚƚŚĞŵĞĚŝĐĂƚŝŽŶƐŝŶƚŚĞůŽĐŬďŽǆ͘

ŽŶƚƌŽůůĞĚŵĞĚŝĐĂƚŝŽŶƐĂƌĞƚŽďĞƉŚǇƐŝĐĂůůǇĞǆĂŵŝŶĞĚďǇďŽƚŚƚŚĞŽĨĨͲŐŽŝŶŐ/ŶͲŚĂƌŐĞWĂƌĂŵĞĚŝĐĂŶĚ ƚŚĞŽŶͲĐŽŵŝŶŐ/ŶͲŚĂƌŐĞWĂƌĂŵĞĚŝĐĚƵƌŝŶŐƐŚŝĨƚĐŚĂŶŐĞ͘ĂĐŚĐŽŶƚƌŽůůĞĚŵĞĚŝĐĂƚŝŽŶŝƐƚŽďĞĞǆĂŵŝŶĞĚ ŝŶƚŚĞƉƌĞƐĞŶĐĞŽĨďŽƚŚƉĂƌĂŵĞĚŝĐƐĨŽƌƋƵĂŶƚŝƚǇ͕ŶƵŵďĞƌǀĞƌŝĨŝĐĂƚŝŽŶ͕ĞǆƉŝƌĂƚŝŽŶĚĂƚĞ͕ĂŶĚƚĂŵƉĞƌŝŶŐ͘ ĂĐŚĐŽŶƚƌŽůůĞĚŵĞĚŝĐĂƚŝŽŶǁŝůůďĞůŽŐŐĞĚŽŶƚŚĞ^ŚŝĨƚŚĂŶŐĞ>ŽŐĚƵƌŝŶŐƚŚĞƚƌĂŶƐĨĞƌŽĨĐƵƐƚŽĚǇ͘KĨĨͲ ŐŽŝŶŐĂŶĚŽŶͲĐŽŵŝŶŐ/ŶͲŚĂƌŐĞWĂƌĂŵĞĚŝĐƐŵƵƐƚƐŝŐŶƚŚĞ^ŚŝĨƚŚĂŶŐĞ>ŽŐŝŶƚŚĞĂƉƉƌŽƉƌŝĂƚĞůŽĐĂƚŝŽŶĂƚ ƚŚĞƚŝŵĞŽĨŝŶƐƉĞĐƚŝŽŶĂŶĚƚƌĂŶƐĨĞƌŽĨƚŚĞĐŽŶƚƌŽůůĞĚŵĞĚŝĐĂƚŝŽŶƐ͘/ŶĂĚĚŝƚŝŽŶ͕ĂůůĂƐƐŽĐŝĂƚĞĚ ĚŽĐƵŵĞŶƚĂƚŝŽŶƐŚŽƵůĚďĞĂĐĐŽƵŶƚĞĚĨŽƌŝŶƚŚĞĐŽŶƚƌŽůůĞĚŵĞĚŝĐĂƚŝŽŶĨŽůĚĞƌ͘

dŚĞĐŽŶƚƌŽůůĞĚŵĞĚŝĐĂƚŝŽŶŬĞǇƐĂƌĞƚŽƌĞŵĂŝŶǁŝƚŚƚŚĞ/ŶͲŚĂƌŐĞWĂƌĂŵĞĚŝĐĂƚĂůůƚŝŵĞƐĚƵƌŝŶŐŚŝƐͬŚĞƌ ƐŚŝĨƚ͘dŚĞƐĞŬĞǇƐĂƌĞƚŽďĞƚƌĂŶƐĨĞƌƌĞĚƚŽƚŚĞŽŶͲĐŽŵŝŶŐ/ŶͲŚĂƌŐĞWĂƌĂŵĞĚŝĐĚƵƌŝŶŐƐŚŝĨƚĐŚĂŶŐĞ͘/Ŷ ƚŚĞĞǀĞŶƚƚŚĂƚƚŚĞƐĞŬĞǇƐĂƌĞŶŽƚƚƌĂŶƐĨĞƌƌĞĚĚƵƌŝŶŐƐŚŝĨƚĐŚĂŶŐĞ͕ƚŚĞƉĞƌƐŽŶŝŶƉŽƐƐĞƐƐŝŽŶŽĨƚŚĞŬĞǇƐ ŵƵƐƚƌĞƚƵƌŶƚŚĞŵŝŵŵĞĚŝĂƚĞůǇƵƉŽŶĚŝƐĐŽǀĞƌǇŽƌŶŽƚŝĨŝĐĂƚŝŽŶ͘

ƵƉůŝĐĂƚŝŽŶŽĨƚŚĞĐŽŶƚƌŽůůĞĚŵĞĚŝĐĂƚŝŽŶŬĞǇƐĞƚŝƐŶŽƚĂůůŽǁĞĚƵŶĚĞƌĂŶǇĐŝƌĐƵŵƐƚĂŶĐĞ͘

/ƚŝƐƵŶĂĐĐĞƉƚĂďůĞĨŽƌƚŚĞ/ŶŚĂƌŐĞWĂƌĂŵĞĚŝĐŽŶƐŚŝĨƚƚŽƐŝŐŶŽƵƚ&KZƚŚĞĞŶĚŽĨƐŚŝĨƚ;ǇŽƵĐĂŶŶŽƚ ƐŝŐŶŝŶĂŶĚƐŝŐŶŽƵƚĂƚƚŚĞƐĂŵĞƚŝŵĞͿ͘&ĂŝůƵƌĞƚŽĐŽŵƉůǇŵĂǇƌĞƐƵůƚŝŶƉƌŽŐƌĞƐƐŝǀĞĚŝƐĐŝƉůŝŶĞƵƉƚŽĂŶĚ ŝŶĐůƵĚŝŶŐƚĞƌŵŝŶĂƚŝŽŶ͘ ŝƐƉŽƐŝƚŝŽŶƐĂŶĚŽĐƵŵĞŶƚĂƚŝŽŶ ůůĚŝƐƉŽƐŝƚŝŽŶƐ;ĂĚŵŝŶŝƐƚƌĂƚŝŽŶ͕ĞǆƉŝƌĂƚŝŽŶ͕ĚĂŵĂŐĞĚ͕ŽƌďƌŽŬĞŶƐĞĂůͿǁŝůůďĞĚŽĐƵŵĞŶƚĞĚŽŶĂ ĐŽŶƚƌŽůůĞĚŵĞĚŝĐĂƚŝŽŶƚƌĂĐŬŝŶŐĨŽƌŵĂƐƐŽŽŶĂƐƚŚĞĐĂůůŝƐĐŽŵƉůĞƚĞĚďǇƚŚĞƉĂƌĂŵĞĚŝĐĂĚŵŝŶŝƐƚĞƌŝŶŐƚŚĞ ŵĞĚŝĐĂƚŝŽŶ͘/ƚŝƐƚŚĞƌĞƐƉŽŶƐŝďŝůŝƚǇŽĨƚŚĞ/ŶͲŚĂƌŐĞWĂƌĂŵĞĚŝĐƚŽĂƐƐƵƌĞƚŚĂƚĂůůĚŽĐƵŵĞŶƚĂƚŝŽŶŝƐ ĐŽŵƉůĞƚĞŽŶƚŚĞWZĂŶĚƚŚĞĐŽŶƚƌŽůůĞĚŵĞĚŝĐĂƚŝŽŶĨŽƌŵďǇĞŶĚŽĨƐŚŝĨƚ͘dŚĞĨŽƌŵǁŝůůƌĞŵĂŝŶŝŶƚŚĞ

Cypress Creek EMS System Policies and Treatment Guidelines

57 OPERATIONAL POLICIES Revised 8/2016 Approved: Levon Vartanian, MD

ĐŽŶƚƌŽůůĞĚŵĞĚŝĐĂƚŝŽŶĨŽůĚĞƌĂůŽŶŐǁŝƚŚƚŚĞƐŚŝĨƚĐŚĂŶŐĞůŽŐƵŶƚŝůƚŚĞŵĞĚŝĐĂƚŝŽŶŝƐƌĞƉůĂĐĞĚ͘/ƚŝƐƚŚĞ ĚƵƚǇŽĨƚŚĞ^ƚĂƚŝŽŶĂƉƚĂŝŶƚŽǀĞƌŝĨǇĂůůĨŽƌŵƐĂŶĚWZƉƌŝŽƌƚŽƌĞƉůĂĐĞŵĞŶƚ͘

/ŶƐŽŵĞƐŝƚƵĂƚŝŽŶƐ͕ƚŚĞƉĂƚŝĞŶƚǁŝůůŶŽƚƌĞƋƵŝƌĞŽƌƌĞĐĞŝǀĞĂůůƚŚĞŵĞĚŝĐĂƚŝŽŶŝŶƚŚĞĐŽŶƚĂŝŶĞƌĂƐŝƚŚĂƐ ďĞĞŶƉĂĐŬĂŐĞĚďǇƚŚĞŵĂŶƵĨĂĐƚƵƌĞƌ͘dŚŝƐƐŝƚƵĂƚŝŽŶǁŝůůƌĞƐƵůƚŝŶƵŶƵƐĞĚŵĞĚŝĐĂƚŝŽŶǁŚŝĐŚǁŝůůƌĞƋƵŝƌĞ ƚŚĞƌĞŵĂŝŶŝŶŐŵĞĚŝĐĂƚŝŽŶƚŽďĞ͚ǁĂƐƚĞĚ͛ƐŽƚŚĂƚŝƚĐĂŶŶŽƚďĞĚŝǀĞƌƚĞĚ͘

/ŶƚŚĞĞǀĞŶƚĂĐŽŶƚƌŽůůĞĚŵĞĚŝĐĂƚŝŽŶƐĞĂůŝƐďƌŽŬĞŶ͕ďƵƚŶŽƚĂĚŵŝŶŝƐƚĞƌĞĚĚƵĞƚŽƉĂƚŝĞŶƚĐŽŶĚŝƚŝŽŶ͕ƚŚĞ ŵĞĚŝĐĂƚŝŽŶǁŝůůŶĞĞĚƚŽďĞ͚ǁĂƐƚĞĚ͛͘

dŚĞĐŽƌƌĞĐƚƉƌŽĐĞĚƵƌĞƚŽǁĂƐƚĞƚŚĞŵĞĚŝĐĂƚŝŽŶŝƐƚŽƐƋƵŝƌƚƚŚĞƌĞŵĂŝŶŝŶŐŵĞĚŝĐĂƚŝŽŶŽƵƚŽĨƚŚĞƐǇƌŝŶŐĞ ŝŶƚŽĂƐŚĂƌƉƐĐŽŶƚĂŝŶĞƌǁŝƚŚŝŶƚŚĞĂŵďƵůĂŶĐĞŽƌƚŚĞŚŽƐƉŝƚĂů͘dŚĞƵƐĞĚƐǇƌŝŶŐĞĂŶĚĐŽŶƚĂŝŶĞƌǁŝůůĂůƐŽďĞ ĚŝƐƉŽƐĞĚŽĨŝŶƚŚĞƐŚĂƌƉƐĐŽŶƚĂŝŶĞƌ͘dŚŝƐƉƌŽĐĞĚƵƌĞƐŚŽƵůĚďĞǁŝƚŶĞƐƐĞĚďǇĂƐĞĐŽŶĚƉĂƌƚǇ͖ĞŝƚŚĞƌĂ ŵĞĚŝĐĂůƉƌŽĨĞƐƐŝŽŶĂůĂƚƚŚĞŚŽƐƉŝƚĂůŽƌĂŶŽƚŚĞƌŵĞĚŝĐ͘dŚĞǁŝƚŶĞƐƐŵƵƐƚƐŝŐŶƚŚĞĐŽŶƚƌŽůůĞĚŵĞĚŝĐĂƚŝŽŶ ƚƌĂĐŬŝŶŐĨŽƌŵĂůŽŶŐǁŝƚŚƚŚĞĂĚŵŝŶŝƐƚĞƌŝŶŐƉĂƌĂŵĞĚŝĐ͘

/ŶƚŚĞĞǀĞŶƚĂŵĞĚŝĐĂƚŝŽŶǀŝĂů͕ĂŵƉƵůĞŽƌƐǇƌŝŶŐĞŝƐďƌŽŬĞŶŽƌĚĂŵĂŐĞĚǇŽƵƐŚŽƵůĚŶŽƚŝĨǇǇŽƵƌ&ŝĞůĚ ^ƵƉĞƌǀŝƐŽƌŝŵŵĞĚŝĂƚĞůǇ͘ŶŝŶĐŝĚĞŶƚƌĞƉŽƌƚǁŝůůďĞƐƵďŵŝƚƚĞĚďǇĂůůƉĂƌƚŝĞƐƚŽƚŚĞƐĞŶŝŽƌŽƉĞƌĂƚŝŽŶƐ ƐƵƉĞƌǀŝƐŽƌĂŶĚƐŚŽƵůĚĂůƐŽďĞĚŽĐƵŵĞŶƚĞĚŽŶƚŚĞĐŽŶƚƌŽůůĞĚŵĞĚŝĐĂƚŝŽŶƚƌĂĐŬŝŶŐĨŽƌŵ͘ĞƉĞŶĚŝŶŐŽŶ ƚŚĞĐŝƌĐƵŵƐƚĂŶĐĞƐ͕ƚŚĞĨŝĞůĚƐƵƉĞƌǀŝƐŽƌŵĂǇĂĚǀŝƐĞǇŽƵƚŽ͚ǁĂƐƚĞ͛ĂŶĚĚŝƐƉŽƐĞŽĨƚŚĞĐŽŶƚĂŝŶĞƌŽƌ ƐƵƌƌĞŶĚĞƌŝƚƚŽƚŚĞĨŝĞůĚƐƵƉĞƌǀŝƐŽƌ͘

ŽĐƵŵĞŶƚĂƚŝŽŶŽĨƚŚĞƵŶŝƋƵĞĐŽŶƚƌŽůŶƵŵďĞƌĂůŽŶŐǁŝƚŚĂĚŵŝŶŝƐƚƌĂƚŝŽŶŝŶĨŽƌŵĂƚŝŽŶŝƐƌĞƋƵŝƌĞĚ ĚŽĐƵŵĞŶƚĂƚŝŽŶŝŶƚŚĞWZƵŶĚĞƌƚŚĞƐƉĞĐŝĨŝĐŵĞĚŝĐĂƚŝŽŶĂĚŵŝŶŝƐƚƌĂƚŝŽŶ͘ ZĞƉůĂĐĞŵĞŶƚ tŚĞŶĂĐŽŶƚƌŽůůĞĚŵĞĚŝĐĂƚŝŽŶƌĞĂĐŚĞƐƚŚĞĚĞƚĞƌŵŝŶĞĚƌĞƉůĂĐĞŵĞŶƚůĞǀĞů͕ƚŚĞ/ŶͲŚĂƌŐĞWĂƌĂŵĞĚŝĐǁŝůů ŝŶĨŽƌŵƚŚĞŝƌ&ŝĞůĚ^ƵƉĞƌǀŝƐŽƌŽĨƚŚĞŶĞĞĚĨŽƌƌĞƉůĂĐĞŵĞŶƚŵĞĚŝĐĂƚŝŽŶƐ͘ƚƚŚŝƐƚŝŵĞ͕ĂůůĐŽŶƚƌŽůůĞĚ ŵĞĚŝĐĂƚŝŽŶƐǁŝůůďĞďƌŽƵŐŚƚƚŽƉĂƌ͘ůůĂƐƐŽĐŝĂƚĞĚĚŽĐƵŵĞŶƚĂƚŝŽŶŝƐƌĞƋƵŝƌĞĚƚŽďĞĨŝůůĞĚŽƵƚĐŽŵƉůĞƚĞůǇ ĂŶĚĂĐĐƵƌĂƚĞůǇďĞĨŽƌĞŵĞĚŝĐĂƚŝŽŶƐǁŝůůďĞŝƐƐƵĞĚ͘dŚĞĚŽĐƵŵĞŶƚĂƚŝŽŶǁŝůůďĞƚƵƌŶĞĚŽǀĞƌƚŽƚŚĞ&ŝĞůĚ ^ƵƉĞƌǀŝƐŽƌǁŚĞŶŶĞǁĐŽŶƚƌŽůůĞĚŵĞĚŝĐĂƚŝŽŶƐĂƌĞŝƐƐƵĞĚ͘ŽƚŚƚŚĞ&ŝĞůĚ^ƵƉĞƌǀŝƐŽƌĂŶĚƚŚĞ/ŶͲŚĂƌŐĞ WĂƌĂŵĞĚŝĐǁŝůůǀĞƌŝĨǇƚŚĞŶĞǁĐŽŶƚƌŽůŵĞĚŝĐĂƚŝŽŶƐƚŽŐĞƚŚĞƌĂŶĚĨŝůůŽƵƚĂŶĚƐŝŐŶƚŚĞŽŶƚƌŽůůĞĚ DĞĚŝĐĂƚŝŽŶdƌĂĐŬŝŶŐ&Žƌŵ͘ ǆƉŝƌĞĚŽŶƚƌŽůůĞĚDĞĚŝĐĂƚŝŽŶƐ ǆƉŝƌĞĚĐŽŶƚƌŽůůĞĚŵĞĚŝĐĂƚŝŽŶƐǁŝůůďĞĚŽĐƵŵĞŶƚĞĚŽŶƚŚĞŽŶƚƌŽůůĞĚDĞĚŝĐĂƚŝŽŶdƌĂĐŬŝŶŐ&Žƌŵ͘ ǆƉŝƌĞĚŵĞĚŝĐĂƚŝŽŶƐĂƌĞŶŽƚƚŽďĞǁĂƐƚĞĚ͕ďƵƚƌĞƚƵƌŶĞĚƚŽƚŚĞ&ŝĞůĚ^ƵƉĞƌǀŝƐŽƌĨŽƌƌĞǀĞƌƐĞĚŝƐƚƌŝďƵƚŝŽŶ͘ WĞĂŬdƌƵĐŬƐ WĞĂŬdƌƵĐŬƐĂƌĞƚǇƉŝĐĂůůǇϭϮŚŽƵƌƚƌƵĐŬƐǁŚĞƌĞĂĨĂĐĞͲƚŽͲĨĂĐĞĐŽŶƚƌŽůůĞĚŵĞĚŝĐĂƚŝŽŶĞǆĐŚĂŶŐĞǁŝůůŶŽƚ ƚĂŬĞƉůĂĐĞ͘ƚƚŚĞďĞŐŝŶŶŝŶŐĂŶĚĞŶĚŽĨĞĂĐŚƐŚŝĨƚ͕ƚŚĞ/ŶͲŚĂƌŐĞWĂƌĂŵĞĚŝĐĂŶĚƚŚĞƚƚĞŶĚĂŶƚǁŝůůďŽƚŚ ŝŶƐƉĞĐƚĂŶĚĂĐĐŽƵŶƚĨŽƌƚŚĞŽŶƚƌŽůůĞĚDĞĚŝĐĂƚŝŽŶƐĂŶĚĂůůĂƐƐŽĐŝĂƚĞĚĚŽĐƵŵĞŶƚĂƚŝŽŶ͘dŚĞǇǁŝůůĞĂĐŚ ƐŝŐŶŝŶƚŚĞKŶͲŽŵŝŶŐĂŶĚKĨĨͲ'ŽŝŶŐƐĞĐƚŝŽŶƐŽĨƚŚĞŽŶƚƌŽůůĞĚDĞĚŝĐĂƚŝŽŶ^ŚŝĨƚŚĂŶŐĞ>ŽŐ͘dŚĞ

Cypress Creek EMS System Policies and Treatment Guidelines

58 OPERATIONAL POLICIES Revised 8/2016 Approved: Levon Vartanian, MD

ŽŶƚƌŽůůĞĚDĞĚŝĐĂƚŝŽŶƐǁŝůůďĞůŽĐŬĞĚŝŶƚŚĞůŽĐŬďŽǆĂŶĚĂůůĂŵďƵůĂŶĐĞĚŽŽƌƐĂŶĚĐŽŵƉĂƌƚŵĞŶƚƐǁŝůůďĞ ůŽĐŬĞĚ͘

<ĞǇƐǁŝůůďĞƐĞĐƵƌĞĚĂĐĐŽƌĚŝŶŐƚŽƐƚĂƚŝŽŶƐƉĞĐŝĨŝĐŽƉĞƌĂƚŝŶŐŐƵŝĚĞůŝŶĞƐ͘

dŚĞ^ƚĂƚŝŽŶĂƉƚĂŝŶǁŚĞƌĞƚŚĞWĞĂŬdƌƵĐŬŝƐŚŽƵƐĞĚǁŝůůďĞƌĞƐƉŽŶƐŝďůĞĨŽƌĚŽĐƵŵĞŶƚĂƚŝŽŶǀĞƌŝĨŝĐĂƚŝŽŶ ĂŶĚƌĂŶĚŽŵŝŶƐƉĞĐƚŝŽŶƐ͘ ^ƉĞĐŝĂůKƉĞƌĂƚŝŽŶǀĞŶƚƐ D^ĞŵƉůŽǇĞĞƐĂƐƐŝŐŶĞĚƚŽĂƐƉĞĐŝĂůŽƉĞƌĂƚŝŽŶƐĞǀĞŶƚͬƵŶŝƚǁŝůůƌĞĐĞŝǀĞĂƐĞƚŽĨĐŽŶƚƌŽůůĞĚ ŵĞĚŝĐĂƚŝŽŶƐĨŽƌƚŚĞĞǀĞŶƚĨƌŽŵƚŚĞŽŶͲĚƵƚǇ&ŝĞůĚ^ƵƉĞƌǀŝƐŽƌŝĨƌĞƋƵŝƌĞĚĨŽƌƚŚĞƐƉĞĐŝĨŝĐĞǀĞŶƚ͘EŽƚĂůů ƐƉĞĐŝĂůĞǀĞŶƚƐǁŝůůƌĞƋƵŝƌĞƚŚĞŝƐƐƵĂŶĐĞŽĨĐŽŶƚƌŽůůĞĚŵĞĚŝĐĂƚŝŽŶƐ͘ŽƚŚƚŚĞ&ŝĞůĚ^ƵƉĞƌǀŝƐŽƌĂŶĚƚŚĞ/W ǁŝůůĂĐĐŽƵŶƚĨŽƌƚŚĞŵĞĚŝĐĂƚŝŽŶƐǁŚĞŶŝƐƐƵĞĚĂŶĚǁŚĞŶƌĞƚƵƌŶĞĚŽŶƚŚĞŽŶƚƌŽůůĞĚDĞĚŝĐĂƚŝŽŶ^ŚŝĨƚ ŚĂŶŐĞ>ŽŐ͘;/ĨĐŽŶƚƌŽůůĞĚŵĞĚŝĐĂƚŝŽŶƐŚĂǀĞĂůƌĞĂĚǇďĞĞŶƉůĂĐĞĚŽŶƚŚĞƐƉĞĐŝĂůŽƉĞƌĂƚŝŽŶƐƵŶŝƚ͕ƚŚĞŶ ĨŽůůŽǁƚŚĞWĞĂŬdƌƵĐŬWƌŽĐĞĚƵƌĞ͘Ϳ >ĂƚĞĂůů͕WŽƐƚŝŶŐƐƐŝŐŶŵĞŶƚƐĂŶĚ^ƉĞĐŝĂůŝƌĐƵŵƐƚĂŶĐĞƐ /ŶƚŚĞĞǀĞŶƚƚŚĂƚĂŵĞĚŝĐƵŶŝƚŝƐĂƐƐŝŐŶĞĚĂŶĞŵĞƌŐĞŶĐǇƌĞƐƉŽŶƐĞŽƌƉŽƐƚĂƐƐŝŐŶŵĞŶƚďĞĨŽƌĞƉƌŽƉĞƌ ĐŽŶƚƌŽůůĞĚŵĞĚŝĐĂƚŝŽŶƚƌĂŶƐĨĞƌĐĂŶƚĂŬĞƉůĂĐĞƚŚĞĨŽůůŽǁŝŶŐĂĐƚŝŽŶƐŚŽƵůĚďĞƚĂŬĞŶ͘dŚĞŽŶͲĐŽŵŝŶŐ/ŶͲ ŚĂƌŐĞWĂƌĂŵĞĚŝĐĂŶĚƚƚĞŶĚĂŶƚƐŚŽƵůĚǀĞƌŝĨǇĂůůĐŽŶƚƌŽůůĞĚŵĞĚŝĐĂƚŝŽŶƐĂŶĚĂƐƐŽĐŝĂƚĞĚƉĂƉĞƌǁŽƌŬ͘ dŚĞ/ŶͲŚĂƌŐĞWĂƌĂŵĞĚŝĐĂŶĚƚƚĞŶĚĂŶƚǁŝůůƐŝŐŶŝŶƚŚĞ͚KŶŽŵŝŶŐ/ŶŚĂƌŐĞ^ŝŐŶĂƚƵƌĞ͛ƐƉĂĐĞĂŶĚŝŶ ƚŚĞ͚KĨĨ'ŽŝŶŐ/ŶŚĂƌŐĞ͛ƐƉĂĐĞƚŚĞ/ŶƵŵďĞƌŽĨƚŚĞƌĞƐƉŽŶƐĞŽƌƚŚĞƉŽƐƚĂƐƐŝŐŶŵĞŶƚǁŝůůďĞ ĚŽĐƵŵĞŶƚĞĚ͘dŚŝƐǁŝůůŝŶĚŝĐĂƚĞƚŽƚŚĞ&ŝĞůĚ^ƵƉĞƌǀŝƐŽƌƐǁŚǇƚŚĞƐŝŐŶĂƚƵƌĞŝƐŵŝƐƐŝŶŐĂŶĚƚŚĂƚĚŝƐĐŝƉůŝŶĂƌǇ ĂĐƚŝŽŶŝƐƵŶŶĞĐĞƐƐĂƌǇ͘

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Cypress Creek EMS System Policies and Treatment Guidelines

59 OPERATIONAL POLICIES Revised 8/2016 Approved: Levon Vartanian, MD

WŽůŝĐǇsŝŽůĂƚŝŽŶ ŶǇǀŝŽůĂƚŝŽŶƐŽĨƚŚŝƐƉŽůŝĐǇǁŝůůďĞŚĂŶĚůĞĚĂĐĐŽƌĚŝŶŐƚŽD^ƉƌŽŐƌĞƐƐŝǀĞĚŝƐĐŝƉůŝŶĞƉŽůŝĐǇĂƐŽƵƚůŝŶĞĚ ďĞůŽǁ͗

ĐŬŶŽǁůĞĚŐĞŵĞŶƚŽĨƚŚŝƐƉŽůŝĐǇƐĞƌǀĞƐĂƐĂǀĞƌďĂůǁĂƌŶŝŶŐ

ϭƐƚŽĨĨĞŶƐĞ͗tƌŝƚƚĞŶŽƵŶƐĞůŝŶŐ

ϮŶĚŽĨĨĞŶƐĞ͗tƌŝƚƚĞŶŽƵŶƐĞůŝŶŐǁŝƚŚϮϰͲŚŽƵƌƐƵƐƉĞŶƐŝŽŶǁŝƚŚŽƵƚƉĂǇ

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ŝǀĞƌƐŝŽŶŽƌƚŚĞĨƚŽĨĂĐŽŶƚƌŽůůĞĚŵĞĚŝĐĂƚŝŽŶǁŝůůƌĞƐƵůƚŝŶŝŵŵĞĚŝĂƚĞƚĞƌŵŝŶĂƚŝŽŶŽĨĞŵƉůŽǇŵĞŶƚĂŶĚ ƉŽƐƐŝďůĞƉƌŽƐĞĐƵƚŝŽŶďǇůĂǁĞŶĨŽƌĐĞŵĞŶƚ͘

Cypress Creek EMS System Policies and Treatment Guidelines

60 OPERATIONAL POLICIES Revised 8/2016 Approved: Levon Vartanian, MD

ƌŝŵĞ^ĐĞŶĞDĂŶĂŐĞŵĞŶƚ Purpose dŚĞƉƵƌƉŽƐĞŽĨƚŚŝƐĚŽĐƵŵĞŶƚŝƐƚŽƉƌŽǀŝĚĞŐƵŝĚĞůŝŶĞƐǁŚĞŶŽƉĞƌĂƚŝŶŐǁŝƚŚ>ĂǁŶĨŽƌĐĞŵĞŶƚKĨĨŝĐĞƌƐ ĂŶĚĐƌŝŵĞƐĐĞŶĞƐ͘ZĞĨĞƌƚŽ^ĐĞŶĞ^ĂĨĞƚǇWŽůŝĐǇĨŽƌƐĂĨĞƚǇŵĞĂƐƵƌĞƐƚŽƚĂŬĞǁŚĞŶǁŽƌŬŝŶŐĐƌŝŵĞƐĐĞŶĞƐ͘ ^ĐĞŶĞƐǁŝƚŚ>ĂǁŶĨŽƌĐĞŵĞŶƚ x D^ƉĞƌƐŽŶŶĞůĂƌƌŝǀŝŶŐĂƚĂƉŽƚĞŶƚŝĂůŽƌĂĐƚƵĂůĐƌŝŵĞƐĐĞŶĞďĞĨŽƌĞƚŚĞĂƌƌŝǀĂůŽĨ>ĂǁŶĨŽƌĐĞŵĞŶƚ ŵƵƐƚĚĞƚĞƌŵŝŶĞƐĐĞŶĞƐĂĨĞƚǇƉƌŝŽƌƚŽƉĂƚŝĞŶƚĐŽŶƚĂĐƚ͘DĂŝŶƚĂŝŶƐŝƚƵĂƚŝŽŶĂůĂǁĂƌĞŶĞƐƐĂƚĂůůƚŝŵĞƐ͘ x EŽƚŚŝŶŐŝƐƚŽƵĐŚĞĚŝŶĂƉŽƚĞŶƚŝĂůŽƌĂĐƚƵĂůĐƌŝŵĞƐĐĞŶĞǁŝƚŚŽƵƚŐůŽǀĞƐŽŶ͘ x /ĨƉŽƚĞŶƚŝĂůĞǀŝĚĞŶĐĞŝƐŵŽǀĞĚ;ďŽĚŝĞƐ͕ǁĞĂƉŽŶƐŽĨĂŶǇƚǇƉĞ͕ƐƵŝĐŝĚĞŶŽƚĞƐ͕ƐƵŝĐŝĚĞƌĞůĂƚĞĚ ĞƋƵŝƉŵĞŶƚ͕ĞƚĐ͘ͿĂŶŝŶĐŝĚĞŶƚƌĞƉŽƌƚŵƵƐƚďĞƐƵďŵŝƚƚĞĚƚŽƚŚĞůŝŶŝĐĂůĞƉĂƌƚŵĞŶƚĨŽƌĂƚƚĂĐŚŵĞŶƚƚŽ ƚŚĞWZƌĞĐŽƌĚ͘dŚŝƐƌĞƉŽƌƚƐŚŽƵůĚĚĞƚĂŝůǁŚĂƚǁĂƐĨŽƵŶĚ͕ǁŚĞƌĞŝƚǁĂƐĨŽƵŶĚ͕ǁŚŽŵŽǀĞĚŝƚ͕ĂŶĚ ǁŚǇŝƚǁĂƐŵŽǀĞĚ͘ x 'ƵŶƐ͕ŬŶŝǀĞƐ͕ĂŶĚŽƚŚĞƌǁĞĂƉŽŶƐƚŚĂƚŵƵƐƚďĞŵŽǀĞĚƉƌŝŽƌƚŽƚŚĞĂƌƌŝǀĂůŽĨ>ĂǁŶĨŽƌĐĞŵĞŶƚĂƌĞƚŽ ďĞŵŽǀĞĚǁŝƚŚĞǆƚƌĞŵĞĐĂƵƚŝŽŶ͘ x >ĂǁŶĨŽƌĐĞŵĞŶƚŽĨĨŝĐĞƌƐĂƌĞƉĞƌŵŝƚƚĞĚƚŽƋƵĞƐƚŝŽŶƉĂƚŝĞŶƚƐĂƚƚŚĞƐĐĞŶĞĂƐůŽŶŐĂƐƚŚĞŝŶƚĞƌǀŝĞǁ ƉƌŽĐĞƐƐĚŽĞƐŶŽƚũĞŽƉĂƌĚŝǌĞƚŚĞƉĂƚŝĞŶƚ͛ƐǁĞůĨĂƌĞ͘ x WĂƚŝĞŶƚƐƚŚĂƚĂƉƉĞĂƌƚŽďĞŝŶƚŽǆŝĐĂƚĞĚĂŶĚƵŶĚĞƌƚŚĞŝŶĨůƵĞŶĐĞŽĨĂůĐŽŚŽůŽƌĂĐŽŶƚƌŽůůĞĚƐƵďƐƚĂŶĐĞ͕ ƚŚĂƚĚŽŶŽƚƌĞƋƵŝƌĞŵĞĚŝĐĂůƚƌĞĂƚŵĞŶƚ͕ĂƌĞƚŽďĞƌĞƉŽƌƚĞĚƚŽůĂǁĞŶĨŽƌĐĞŵĞŶƚ͘ x ůůƐƵŝĐŝĚĞƐŽƌĂƚƚĞŵƉƚĞĚƐƵŝĐŝĚĞƐŵƵƐƚďĞƌĞƉŽƌƚĞĚƚŽ>ĂǁŶĨŽƌĐĞŵĞŶƚ͘ x /ĨƚŚĞƉĂƚŝĞŶƚŝƐŝŶƚŚĞĐƵƐƚŽĚǇŽĨůĂǁĞŶĨŽƌĐĞŵĞŶƚ͕ĂůĂǁĞŶĨŽƌĐĞŵĞŶƚŽĨĨŝĐŝĂůŵƵƐƚĂĐĐŽŵƉĂŶǇƚŚĞ ƉĂƚŝĞŶƚ;ĞŝƚŚĞƌŝŶƚŚĞƵŶŝƚĚƵƌŝŶŐƚƌĂŶƐƉŽƌƚŽƌĨŽůůŽǁŝŶŐŝŵŵĞĚŝĂƚĞůǇďĞŚŝŶĚƚŚĞƵŶŝƚͿ͘ x /ĨĂƉĂƚŝĞŶƚŝƐŚĂŶĚĐƵĨĨĞĚĚƵƌŝŶŐƚƌĂŶƐƉŽƌƚ͕ĂůĂǁĞŶĨŽƌĐĞŵĞŶƚŽĨĨŝĐĞƌǁŝƚŚĂĐƵĨĨŬĞǇŵƵƐƚďĞƌŝĚŝŶŐ ŝŶƚŚĞƉĂƚŝĞŶƚĐŽŵƉĂƌƚŵĞŶƚ͘ x tĞĂƉŽŶƐĂƌĞŶŽƚƚƌĂŶƐƉŽƌƚĞĚǁŝƚŚƚŚĞƉĂƚŝĞŶƚƵŶĚĞƌĂŶǇĐŝƌĐƵŵƐƚĂŶĐĞ͘KŶĚƵƚǇůĂǁĞŶĨŽƌĐĞŵĞŶƚ ŽĨĨŝĐĞƌƐƐŚŽƵůĚďĞƚŽůĚƚŽƌĞŵŽǀĞĂŶĚͬŽƌƐĞĐƵƌĞĂǁĞĂƉŽŶŝŶĂƐĂĨĞĂŶĚƵŶůŽĂĚĞĚĐŽŶĚŝƚŝŽŶ ǁŚĞŶĞǀĞƌƉŽƐƐŝďůĞ͘/ĨůĂǁĞŶĨŽƌĐĞŵĞŶƚŝƐŶŽƚĂǀĂŝůĂďůĞ͕ĂĨŝĞůĚƐƵƉĞƌǀŝƐŽƌŵƵƐƚďĞĐŽŶƚĂĐƚĞĚ͘ >ĂǁŶĨŽƌĐĞŵĞŶƚKĨĨŝĐĞƌƐƚŚĂƚŶĞĞĚƚŽďĞƚƌĂŶƐƉŽƌƚĞĚďǇĂŵďƵůĂŶĐĞĂƐƉĂƚŝĞŶƚƐǁŝůůŶĞĞĚƚŽŚĂǀĞ ǁĞĂƉŽŶƐƐĞĐƵƌĞĚďǇĂŶŽƚŚĞƌůĂǁĞŶĨŽƌĐĞŵĞŶƚŽĨĨŝĐĞƌƉƌŝŽƌƚŽƚƌĂŶƐƉŽƌƚ͘

Cypress Creek EMS System Policies and Treatment Guidelines

61 OPERATIONAL POLICIES Revised 8/2016 Approved: Levon Vartanian, MD

&ŝƌĞĂƌŵƐWŽůŝĐǇ Purpose dŚĞƉƵƌƉŽƐĞŽĨƚŚŝƐĚŽĐƵŵĞŶƚŝƐƚŽƉƌŽǀŝĚĞĂĐůĞĂƌƉŽůŝĐǇƌĞŐĂƌĚŝŶŐĨŝƌĞĂƌŵƐŽŶD^ƉƌŽƉĞƌƚǇ͘ 'ĞŶĞƌĂů x &ŝƌĞĂƌŵƐĂƌĞŶŽƚĂůůŽǁĞĚŝŶD^ƐƚĂƚŝŽŶƐŽƌĨĂĐŝůŝƚŝĞƐ͘dŚĞƐƚŽƌĂŐĞĂŶĚƉŽƐƐĞƐƐŝŽŶŽĨĂĨŝƌĞĂƌŵ ǁŚŝůĞŽŶĚƵƚǇŵƵƐƚŶŽƚĐŽŶƚƌĂĚŝĐƚƐƚĂƚĞůĂǁ͘WŽƐƐĞƐƐŝŽŶŽĨĂƐƚĂƚĞŝƐƐƵĞĚ>ŝĐĞŶƐĞƚŽĂƌƌǇƉĞƌŵŝƚ ;>dͿĚŽĞƐŶŽƚĞǆĞŵƉƚǇŽƵĨƌŽŵĂĚŚĞƌŝŶŐƚŽƚŚŝƐƉŽůŝĐǇ͘D^ŝƐŶŽƚƌĞƐƉŽŶƐŝďůĞĨŽƌƚŚĞůŽƐƐŽĨ ǁĞĂƉŽŶƐŽƌĂŶǇŽƚŚĞƌƉĞƌƐŽŶĂůƉƌŽƉĞƌƚǇůĞĨƚŝŶƉĞƌƐŽŶĂůǀĞŚŝĐůĞƐ͘ x DĞŵďĞƌƐǁŚŽĂƌĞĐŽŵŵŝƐƐŝŽŶĞĚůĂǁĞŶĨŽƌĐĞŵĞŶƚŽĨĨŝĐĞƌƐĂƌĞĞǆĞŵƉƚĨƌŽŵƚŚĞD^&ŝƌĞƌŵƐ WŽůŝĐǇĂƚƚŚĞƐŽůĞĚŝƐĐƌĞƚŝŽŶŽĨƚŚĞǆĞĐƵƚŝǀĞŝƌĞĐƚŽƌ͘DĞŵďĞƌƐƚŚĂƚĂƌĞƌĞƋƵŝƌĞĚƚŽĐĂƌƌǇĂĨŝƌĞĂƌŵ ǁŚĞŶĨƵŶĐƚŝŽŶŝŶŐŝŶĂD^ĐĂƉĂĐŝƚǇŵƵƐƚŚĂǀĞĂƉƉƌŽǀĂůĨƌŽŵƚŚĞǆĞĐƵƚŝǀĞŝƌĞĐƚŽƌƉƌŝŽƌƚŽ ĐĂƌƌǇŝŶŐƚŚĞǁĞĂƉŽŶŽŶͲƐŚŝĨƚ͘ŶĞǆĞŵƉƚŝŽŶƌĞƋƵŝƌĞƐƚŚĞŽĨĨŝĐĞƌƚŽŬĞĞƉƚŚĞǁĞĂƉŽŶĐŽŶĐĞĂůĞĚĂƚĂůů ƚŝŵĞƐ͘ x ƵƚŚŽƌŝǌĞĚD^ƉĞƌƐŽŶŶĞůǁŚŽĂƌĞ^ƉĞĐŝĂůKƉĞƌĂƚŝŽŶƐŵĞŵďĞƌƐĂŶĚĐŽŵŵŝƐƐŝŽŶĞĚůĂǁ ĞŶĨŽƌĐĞŵĞŶƚŽĨĨŝĐĞƌƐ͕ǁŚŝůĞŝŶǀŽůǀĞĚŝŶƐƉĞĐŝĂůŽƉĞƌĂƚŝŽŶƐ͕ĂƌĞĞǆĞŵƉƚĨƌŽŵƚŚĞD^&ŝƌĞĂƌŵƐ WŽůŝĐǇĨŽƌƚŚĞĚƵƌĂƚŝŽŶŽĨƚŚĞŽƉĞƌĂƚŝŽŶŽƌůĞŶŐƚŚŽĨƚŚĞƚƌĂŝŶŝŶŐ͕ĂƐĂƵƚŚŽƌŝǌĞĚďǇƚŚĞ^ƉĞĐŝĂů KƉĞƌĂƚŝŽŶƐŝƌĞĐƚŽƌŽƌŚŝƐĚĞƐŝŐŶĞĞ͘ x hŶĚĞƌŶŽĐŝƌĐƵŵƐƚĂŶĐĞƐƐŚŽƵůĚĂƉĂƚŝĞŶƚďĞƚƌĂŶƐƉŽƌƚĞĚǁŝƚŚǁĞĂƉŽŶƐ͘/ĨĂƉĂƚŝĞŶƚŚĂƐǁĞĂƉŽŶƐ͕ĂŶ ŽŶͲĚƵƚǇůĂǁĞŶĨŽƌĐĞŵĞŶƚŽĨĨŝĐĞƌƐŚŽƵůĚƌĞŵŽǀĞĂŶĚͬŽƌƐĞĐƵƌĞĂǁĞĂƉŽŶŝŶĂƐĂĨĞĂŶĚƵŶůŽĂĚĞĚ ĐŽŶĚŝƚŝŽŶ͘/ĨůĂǁĞŶĨŽƌĐĞŵĞŶƚŝƐŶŽƚĂǀĂŝůĂďůĞ͕ĐŽŶƚĂĐƚĂ&ŝĞůĚ^ƵƉĞƌǀŝƐŽƌĨŽƌŝŶƐƚƌƵĐƚŝŽŶƐ͘ x /ĨĂŶŽŶͲĚƵƚǇůĂǁĞŶĨŽƌĐĞŵĞŶƚŽĨĨŝĐĞƌŝƐƌŝĚŝŶŐŝŶƚŚĞĂŵďƵůĂŶĐĞĚƵĞƚŽƉĂƚŝĞŶƚďĞŝŶŐŝŶĐƵƐƚŽĚǇŽƌ ƚŽĂƐƐŝƐƚĐƌĞǁǁŝƚŚƉĂƚŝĞŶƚŚĂŶĚůŝŶŐ͕ƚŚĞǇŵĂǇĐĂƌƌǇǁĞĂƉŽŶƐŝŶĂĐĐŽƌĚĂŶĐĞǁŝƚŚƚŚĞŝƌĂŐĞŶĐǇƉŽůŝĐǇ ĂŶĚĂƉƉůŝĐĂďůĞůĂǁƐ͘

Cypress Creek EMS System Policies and Treatment Guidelines

62 OPERATIONAL POLICIES Revised 8/2016 Approved: Levon Vartanian, MD

&ŽƌĐŝďůĞŶƚƌǇ

KŶŽĐĐĂƐŝŽŶ͕D^ĐƌĞǁƐŵĂǇĞŶĐŽƵŶƚĞƌĂŶŝŶĂĐĐĞƐƐŝďůĞƐĐĞŶĞ͘dŚĞ/ŶͲŚĂƌŐĞWĂƌĂŵĞĚŝĐŚĂƐƚŚĞ ĚŝƐĐƌĞƚŝŽŶŽŶǁŚĞŶƚŽŵĂŬĞĞŶƚƌǇŝŶƚŽĂďƵŝůĚŝŶŐĂŶĚƐŚŽƵůĚƵƚŝůŝǌĞƚŚŝƐƉŽůŝĐǇĨŽƌŐƵŝĚĂŶĐĞ͘

ŶD^ĐƌĞǁŵĂǇĨŽƌĐĞĞŶƚƌǇŝŶƚŽĂƐĐĞŶĞǁŚĞŶ͗

x ^ŽŵĞŽŶĞŝŶƐŝĚĞƚŚĞďƵŝůĚŝŶŐŵĂĚĞƚŚĞĞŵĞƌŐĞŶĐǇĐĂůůKZƐŽŵĞŽŶĞŽƵƚƐŝĚĞƚŚĞďƵŝůĚŝŶŐŵĂĚĞĂĐĂůů ĂŶĚďĞůŝĞǀĞƐƚŚĂƚƚŚĞƌĞŝƐĂƉĞƌƐŽŶŝŶƐŝĚĞƚŚĞďƵŝůĚŝŶŐƚŚĂƚƌĞƋƵŝƌĞƐŵĞĚŝĐĂůĂƚƚĞŶƚŝŽŶKZƚŚĞĐƌĞǁ ĐĂŶǀŝƐƵĂůŝǌĞŽƌŚĞĂƌƐŽŵĞŽŶĞŝŶƐŝĚĞƚŚĞďƵŝůĚŝŶŐǁŚŽŵĂǇƌĞƋƵŝƌĞŵĞĚŝĐĂůĂƚƚĞŶƚŝŽŶ͘ x ƌĞǁƐŚŽƵůĚŵĂŬĞƌĞĂƐŽŶĂďůĞĞĨĨŽƌƚƐƚŽƐŝŐŶĂůƚŚĞŝƌĂƌƌŝǀĂůĂƚƚŚĞďƵŝůĚŝŶŐ;ŬŶŽĐŬͬƌŝŶŐĚŽŽƌďĞůůͿ͘ x ƌĞǁƐƐŚŽƵůĚŵĂŬĞƌĞĂƐŽŶĂďůĞĞĨĨŽƌƚƐƚŽƐĞĂƌĐŚƚŚĞŽƵƚƐŝĚĞŽĨƚŚĞďƵŝůĚŝŶŐĨŽƌƐŝŐŶƐŽĨĐƵƌƌĞŶƚ ŽĐĐƵƉĂŶĐǇ;sĞŚŝĐůĞƐŝŶĚƌŝǀĞǁĂǇ͕ůŝŐŚƚƐŽŶŝŶƐŝĚĞŚŽƵƐĞ͕ŶŽŝƐĞƐĨƌŽŵŝŶƐŝĚĞͿ͘ x ĞĨŽƌĞĨŽƌĐŝŶŐĞŶƚƌǇ͕ĐƌĞǁƐƐŚŽƵůĚŵĂŬĞƌĞĂƐŽŶĂďůĞĞĨĨŽƌƚƐƚŽƐĞĂƌĐŚƚŚĞĞǆƚĞƌŝŽƌŽĨƚŚĞďƵŝůĚŝŶŐĨŽƌ ŽƉĞŶĚŽŽƌƐŽƌǁŝŶĚŽǁƐ͘ x /ĨĨŽƌĐĞĚĞŶƚƌǇŝƐǁĂƌƌĂŶƚĞĚ͕ůĂǁĞŶĨŽƌĐĞŵĞŶƚŵƵƐƚďĞŶŽƚŝĨŝĞĚ;ƚŚŝƐĐĂŶďĞĚŽŶĞďǇŽŵŵĞŶƚĞƌͿ͘ x DĂŬĞĂŶĞĨĨŽƌƚƚŽŵŝŶŝŵŝǌĞĚĂŵĂŐĞƚŽƚŚĞďƵŝůĚŝŶŐĂŶĚƉƌĞǀĞŶƚĐŽŵƉƌŽŵŝƐĞĚƐĞĐƵƌŝƚǇƚŽƚŚĞ ďƵŝůĚŝŶŐĂƚƚŚĞĐŽŶĐůƵƐŝŽŶŽĨƚŚĞĞŵĞƌŐĞŶĐǇ͘ x &ŝƌĞĚĞƉĂƌƚŵĞŶƚƐŚŽƵůĚďĞŶŽƚŝĨŝĞĚŽŶůǇŝĨD^ĐĂŶŶŽƚĐŽŵƉůĞƚĞƚŚĞĨŽƌĐĞĚĞŶƚƌǇŽŶƚŚĞŝƌŽǁŶ͘ x tŝƚŚŽƵƚŽƚŚĞƌƐƵƉƉŽƌƚŝŶŐĞǀŝĚĞŶĐĞĂŶ͞ƵƚŽŵĂƚŝĐDĞĚŝĐĂůůĂƌŵ͟ŝƐŶŽƚĂŶŝŶĚŝĐĂƚŝŽŶĨŽƌĨŽƌĐĞĚ ĞŶƚƌǇ͘

Cypress Creek EMS System Policies and Treatment Guidelines

63 OPERATIONAL POLICIES Revised 8/2016 Approved: Levon Vartanian, MD

DĂŶĚĂƚŽƌǇ^ƵƉĞƌǀŝƐŽƌEŽƚŝĨŝĐĂƚŝŽŶ

ŵƉůŽǇĞĞƐŽƌǀŽůƵŶƚĞĞƌƐŽƉĞƌĂƚŝŶŐĂƐĂD^ŵĞŵďĞƌĚŽƐŽƵŶĚĞƌƚŚĞĂƵƚŚŽƌŝƚǇŽĨƚŚĞDĞĚŝĐĂů ŝƌĞĐƚŽƌĂŶĚǆĞĐƵƚŝǀĞŝƌĞĐƚŽƌ͘ŶǇŝŶĐŝĚĞŶƚƚŚĂƚŚĂƐĂƉŽƚĞŶƚŝĂůůǇĂĚǀĞƌƐĞŽƌŶĞŐĂƚŝǀĞŝŵƉĂĐƚŽŶƚŚĞ ƉĂƚŝĞŶƚŽƌD^ƐŚŽƵůĚďĞƌĞƉŽƌƚĞĚŝŵŵĞĚŝĂƚĞůǇƚŽƚŚĞKŶͲƵƚǇ&ŝĞůĚ^ƵƉĞƌǀŝƐŽƌĂƐƐŽŽŶĂƐƉƌĂĐƚŝĐĂů ŽƌĂĨƚĞƌĐŽŵƉůĞƚŝŽŶŽĨƚŚĞĐĂůůƐŽƚŚĂƚĂŶŝŶǀĞƐƚŝŐĂƚŝŽŶŵĂǇďĞŝŶŝƚŝĂƚĞĚŝĨĚĞĞŵĞĚŶĞĐĞƐƐĂƌǇ͘

^ƵƉĞƌǀŝƐŽƌŶŽƚŝĨŝĐĂƚŝŽŶƐŚŽƵůĚŝŶĐůƵĚĞ͕ďƵƚŶŽƚůŝŵŝƚĞĚƚŽƚŚĞĨŽůůŽǁŝŶŐ͗

x ĂƌĚŝĂĐĂŶĚͬŽƌƌĞƐƉŝƌĂƚŽƌǇĂƌƌĞƐƚŽĐĐƵƌƌŝŶŐĂĨƚĞƌĂĚŵŝŶŝƐƚƌĂƚŝŽŶŽĨĂĐŽŶƚƌŽůůĞĚŵĞĚŝĐĂƚŝŽŶ͘ x ĂƌĚŝĂĐĂƌƌĞƐƚĚƵƌŝŶŐĂŝƌǁĂǇŵĂŶĂŐĞŵĞŶƚ͘ x ĂƌĚŝĂĐĂƌƌĞƐƚŽĐĐƵƌƌŝŶŐĂĨƚĞƌĂĚŵŝŶŝƐƚƌĂƚŝŽŶŽĨĂƉĂƌĂůǇƚŝĐĂŐĞŶƚ x ĂƌĚŝĂĐĂƌƌĞƐƚŽĐĐƵƌƌŝŶŐĂĨƚĞƌĂĚŵŝŶŝƐƚƌĂƚŝŽŶŽĨĂŶĂŶƚŝĂƌƌŚǇƚŚŵŝĐĂŐĞŶƚ x ĂƌĚŝĂĐĂƌƌĞƐƚĂĨƚĞƌĞůĞĐƚƌŝĐĂůƚŚĞƌĂƉǇŚĂƐďĞĞŶĂĚŵŝŶŝƐƚĞƌĞĚ x ŶǇĂƚƚĞŵƉƚ;ƐƵĐĐĞƐƐĨƵůŽƌƵŶƐƵĐĐĞƐƐĨƵůͿĂƚŶĞĞĚůĞĂŶĚͬŽƌƐƵƌŐŝĐĂůĂŝƌǁĂǇ͘ x /ŶĐŽƌƌĞĐƚŵĞĚŝĐĂƚŝŽŶĂĚŵŝŶŝƐƚƌĂƚŝŽŶŽƌƵƐĞ;ŝ͘Ğ͕͘ĞǆĐĞƐƐŝǀĞĂŵŽƵŶƚ͕ǁƌŽŶŐĚŽƐĞ͕ƌŽƵƚĞ͕ĞƚĐ͘Ϳ͘ x ŶǇĐĂƌĚŝĂĐĂŶĚͬŽƌƌĞƐƉŝƌĂƚŽƌǇĂƌƌĞƐƚŽƌƉĂƚŝĞŶƚŝŶũƵƌǇǁŚŝůĞĂƚƚĞŵƉƚŝŶŐƉŚǇƐŝĐĂůƌĞƐƚƌĂŝŶƚ͘ x ŶǇƵŶƵƐƵĂůĐŝƌĐƵŵƐƚĂŶĐĞŽƌŝŶƚĞƌǀĞŶƚŝŽŶƚŚĂƚƉŽƚĞŶƚŝĂůůǇĐĂƵƐĞƐŽƌĐĂƵƐĞĚƉĂƚŝĞŶƚŚĂƌŵ͘ x ƉƌŽǀŝĚĞƌŚĂƐŽƉĞƌĂƚĞĚŽƵƚƐŝĚĞŽĨŚŝƐͬŚĞƌůĞǀĞůŽĨĐĞƌƚŝĨŝĐĂƚŝŽŶ͕ƚƌĂŝŶŝŶŐ͕ĂŶĚͬŽƌůĞǀĞůŽĨ ĂƵƚŚŽƌŝǌĂƚŝŽŶ;ŝ͘Ğ͕͘ƉĂƌĂŵĞĚŝĐǁŚŽŝƐĂƵƚŚŽƌŝǌĞĚďǇŵĞĚŝĐĂůĚŝƌĞĐƚŽƌĂƚƚŚĞ/ůĞǀĞů͕ŝŶŝƚŝĂƚŝŶŐĂŶ/s ŽƌƉĞƌĨŽƌŵŝŶŐĞŶĚŽƚƌĂĐŚĞĂůŝŶƚƵďĂƚŝŽŶͿ x ŶǇĞǆƉŽƐƵƌĞŽƌƉŽƚĞŶƚŝĂůĞŵƉůŽǇĞĞĞǆƉŽƐƵƌĞ x ŶǇŝŶũƵƌǇƐƵƐƚĂŝŶĞĚƚŽĂƉĂƚŝĞŶƚ͕ďǇƐƚĂŶĚĞƌ͕ŽƌĞŵƉůŽǇĞĞǁŚŝůĞŽŶĂŶŝŶĐŝĚĞŶƚ͘ x ŶǇƵŶƵƐƵĂůŽĐĐƵƌƌĞŶĐĞƚŚĂƚĐŽƵůĚƉƵƚƚŚĞƉĂƚŝĞŶƚ͕ƚŚĞĞŵƉůŽǇĞĞ͕ŽƌD^ĂƚƌŝƐŬĨŽƌůŝƚŝŐĂƚŝŽŶ͘ x ŶǇƚŝŵĞĂŵĞŵďĞƌŝƐĐŽŶƚĂĐƚĞĚďǇƚŚĞƉƌĞƐƐĂďŽƵƚĂĐƵƌƌĞŶƚŽƌƉƌĞǀŝŽƵƐD^ƌĞƐƉŽŶƐĞ͘

/ĨĂŶǇŽĨƚŚĞĂďŽǀĞŝŶĐŝĚĞŶƚƐŽĐĐƵƌ͕ƚŚĞ&ŝĞůĚ^ƵƉĞƌǀŝƐŽƌŝƐƌĞƐƉŽŶƐŝďůĞĨŽƌĐŽŶƚĂĐƚŝŶŐƚŚĞĂƉƉƌŽƉƌŝĂƚĞ ĐůŝŶŝĐĂůŽƉĞƌĂƚŝŽŶƐƐƚĂĨĨ͘/ŶĂĚĚŝƚŝŽŶ͕ƚŚĞ&ŝĞůĚ^ƵƉĞƌǀŝƐŽƌŝƐƌĞƋƵŝƌĞĚƚŽǀĞƌŝĨǇĂŶĚͬŽƌĐŽůůĂďŽƌĂƚĞŽŶĂŶ ĂĐĐƵƌĂƚĞĂŶĚƚŝŵĞůǇWZƌĞĐŽƌĚŽĨƚŚĞŝŶĐŝĚĞŶƚ͘

Cypress Creek EMS System Policies and Treatment Guidelines

64 OPERATIONAL POLICIES Approved: Levon Vartanian, MD

WĂƌƚŶĞƌŐĞŶĐŝĞƐ&ŝƌƐƚZĞƐƉŽŶĚĞƌƐ Purpose WĂƌƚŶĞƌĂŐĞŶĐŝĞƐŽƉĞƌĂƚŝŶŐĂƐ&ŝƌƐƚZĞƐƉŽŶĚĞƌKƌŐĂŶŝǌĂƚŝŽŶƐĂƌĞĂďůĞƚŽƉƌŽǀŝĚĞĞŵĞƌŐĞŶĐǇŵĞĚŝĐĂůĐĂƌĞ ƚŽƉĂƚŝĞŶƚƐƉƌŝŽƌƚŽƚŚĞĂƌƌŝǀĂůŽĨĂŶĂŵďƵůĂŶĐĞ͘dŚŝƐĚŽĐƵŵĞŶƚĚĞƐĐƌŝďĞƐƚŚĞĂƉƉƌŽǀĂůĂŶĚĐƌĞĚĞŶƚŝĂůŝŶŐ ƉƌŽĐĞƐƐĨŽƌĨŝƌƐƚƌĞƐƉŽŶĚĞƌƐĂŶĚŐƵŝĚĞůŝŶĞƐĨŽƌƚŚĞŝƌƵƚŝůŝǌĂƚŝŽŶǁŝƚŚƚŚĞD^D^ƐǇƐƚĞŵ͘dŚŝƐ ĚŽĐƵŵĞŶƚĚŽĞƐŶŽƚƌĞƉůĂĐĞŽƌƐƵƉĞƌƐĞĚĞŝŶĚŝǀŝĚƵĂůĨŝƌƐƚƌĞƐƉŽŶĚĞƌŐƵŝĚĞůŝŶĞƐ͕ƐƚĂŶĚĂƌĚŽƉĞƌĂƚŝŶŐ ƉƌŽĐĞĚƵƌĞƐ͕ŽƌƉŽůŝĐŝĞƐƉƵƚŝŶƉůĂĐĞďǇŝŶĚŝǀŝĚƵĂůƉĂƌƚŶĞƌĂŐĞŶĐǇƉƌŽŐƌĂŵƐ͘ BLS First Responders WĂƌƚŶĞƌĂŐĞŶĐŝĞƐĂƉƉƌŽǀĞĚďǇƚŚĞǇƉƌĞƐƐƌĞĞŬD^DĞĚŝĐĂůŝƌĞĐƚŽƌĂŶĚǇƉƌĞƐƐƌĞĞŬD^ĐĂŶ ƉƌŽǀŝĚĞĞŵĞƌŐĞŶĐǇŵĞĚŝĐĂůĐĂƌĞĨŽƌD^ƉĂƚŝĞŶƚƐĂƐĂĨŝƌƐƚƌĞƐƉŽŶĚĞƌŽƌŐĂŶŝǌĂƚŝŽŶ͘WĞƌƐŽŶŶĞů ĐĞƌƚŝĨŝĞĚĂƐDdͲĂƐŝĐ͕ĚǀĂŶĐĞĚDd͕ŽƌDdͲWĂƌĂŵĞĚŝĐƐďǇƚŚĞdĞǆĂƐĞƉĂƌƚŵĞŶƚŽĨ^ƚĂƚĞ,ĞĂůƚŚ ^ĞƌǀŝĐĞƐĂŶĚǁŚŝůĞŽƉĞƌĂƚŝŶŐĂƐĂŵĞŵďĞƌŝŶŐŽŽĚƐƚĂŶĚŝŶŐǁŝƚŚƚŚĞŝƌƉĂƌƚŶĞƌƉƵďůŝĐƐĂĨĞƚǇĂŐĞŶĐŝĞƐĐĂŶ ƉƌŽǀŝĚĞĐĂƌĞĂƐŽƵƚůŝŶĞĚƵŶĚĞƌĞůĞŐĂƚŝŽŶŽĨWƌĂĐƚŝĐĞ͘ ALS First Responders WĂƌƚŶĞƌĂŐĞŶĐŝĞƐŵĂǇƉƌŽǀŝĚĞ>^ĐĂƌĞĂƐĨŝƌƐƚƌĞƐƉŽŶĚĞƌƐŝĨĂƉƉƌŽǀĞĚďǇƚŚĞǇƉƌĞƐƐƌĞĞŬD^DĞĚŝĐĂů ŝƌĞĐƚŽƌĂŶĚǇƉƌĞƐƐƌĞĞŬD^ǆĞĐƵƚŝǀĞŝƌĞĐƚŽƌ͘/ŶŽƌĚĞƌƚŽƉƌŽǀŝĚĞ>^ĐĂƌĞ͕ƉĂƌƚŶĞƌĂŐĞŶĐǇ ƉĞƌƐŽŶŶĞůŵƵƐƚĂĚŚĞƌĞƚŽƚŚĞD^ĐƌĞĚĞŶƚŝĂůŝŶŐƉƌŽĐĞƐƐĂŶĚŵĂŝŶƚĂŝŶĐƌĞĚĞŶƚŝĂůƐƚĂƚƵƐǁŝƚŚĂŶŶƵĂů ĐŽŶƚŝŶƵŝŶŐĞĚƵĐĂƚŝŽŶĂŶĚŵĂŶĚĂƚŽƌǇƚƌĂŝŶŝŶŐ͘ĚĚŝƚŝŽŶĂůůǇ͕>^&ŝƌƐƚZĞƐƉŽŶĚĞƌƐŵƵƐƚǁƌŝƚĞ ƐƵƉƉůĞŵĞŶƚĂůƌĞƉŽƌƚƐĂĨƚĞƌƉƌŽǀŝĚŝŶŐ>^ĐĂƌĞ͘ First Responder Supplies WĂƌƚŶĞƌĂŐĞŶĐŝĞƐƚŚĂƚƵƐĞĐŽŶƐƵŵĂďůĞƐƵƉƉůŝĞƐŵĂǇƌĞƐƵƉƉůǇƚŚŽƐĞŝŶĚŝǀŝĚƵĂůƐƵƉƉůŝĞƐĨƌŽŵƚŚĞD^ ŵĞĚŝĐƵŶŝƚƚŚĂƚƌĞƐƉŽŶĚƐƚŽƚŚĞƐĐĞŶĞ͘ƵůŬƐƵƉƉůŝĞƐ͕ŝŶĐůƵĚŝŶŐŐůŽǀĞƐ͕ƐŚŽƵůĚďĞƌĞƋƵĞƐƚĞĚďǇƚŚĞ ƉĂƌƚŶĞƌĂŐĞŶĐǇƚŚƌŽƵŐŚƚŚĞD^^ƵƉƉůǇDĂŶĂŐĞƌ͘

Cypress Creek EMS System Policies and Treatment Guidelines

65 OPERATIONAL POLICIES Revised 8/2016 Approved: Levon Vartanian, MD

WŽƐƚŝŶŐWůĂŶ Purpose ǇƉƌĞƐƐƌĞĞŬD^ŝƐĞǆƉĞĐƚĞĚƚŽƉƌŽǀŝĚĞƚŚĞŵŽƐƚƌĂƉŝĚƌĞƐƉŽŶƐĞƉŽƐƐŝďůĞǁŝƚŚŝŶŝƚƐƐĞƌǀŝĐĞĂƌĞĂ͘ƚ ƚŝŵĞƐǁŚĞŶƐǇƐƚĞŵƐƚĂƚƵƐŝƐůŽǁ͕ŵĞĚŝĐƵŶŝƚƐŵĂǇďĞĚŝƌĞĐƚĞĚƚŽƉŽƐƚŝŶĚĞƐŝŐŶĂƚĞĚĂƌĞĂƐŝŶŽƌĚĞƌƚŽ ƌĞĚƵĐĞƌĞƐƉŽŶƐĞƚŝŵĞƐ͘WĞĂŬƚƌƵĐŬƐƉŽƐƚĨŽƌƚŚĞĞŶƚŝƌĞƚǇŽĨƚŚĞŝƌƐŚŝĨƚ͘ Procedure x ŽŵŵĞŶƚĞƌǁŝůůĂůĞƌƚƚŚĞŵĞĚŝĐƵŶŝƚŽĨƚŚĞƉŽƐƚŝŶŐĂƐƐŝŐŶŵĞŶƚ x dŚĞŵĞĚŝĐƵŶŝƚŵƵƐƚĂĐŬŶŽǁůĞĚŐĞƚŚĞĂƐƐŝŐŶŵĞŶƚŽǀĞƌƚŚĞƌĂĚŝŽŽƌDd x dŚĞŵĞĚŝĐƵŶŝƚŝƐĞǆƉĞĐƚĞĚƚŽƉƌŽĐĞĞĚ;ŐŽĞŶƌŽƵƚĞͿƚŽƉŽƐƚǁŝƚŚŝŶϮŵŝŶƵƚĞƐŽĨƚŚĞĂƐƐŝŐŶŵĞŶƚ x dŚĞŵĞĚŝĐƵŶŝƚŵƵƐƚƌĞƉŽƌƚŽǀĞƌƚŚĞƌĂĚŝŽǁŚĞŶƚŚĞǇŚĂǀĞĂƌƌŝǀĞĚĂƚƚŚĞŝƌƉŽƐƚŝŶŐĂƐƐŝŐŶŵĞŶƚ x dŚĞŵĞĚŝĐƵŶŝƚŝƐĞǆƉĞĐƚĞĚƚŽƉŽƐƚdŽƌEZ;ǁŝƚŚŝŶЬŵŝůĞͿƚŚĞƉŽƐƚŝŶŐůŽĐĂƚŝŽŶƐůŝƐƚĞĚďĞůŽǁ͗ Posting Locations: WŽƐƚϭ t&DϭϵϲϬͬ<ƵǇŬĞŶĚĂŚůZĚ WŽƐƚϮ t&DϭϵϲϬͬEŽƌƚŚ&ƌǁǇ WŽƐƚϯ ǇƉƌĞƐƐǁŽŽĚƌͬ^,Ϯϰϵ WŽƐƚϰ >ŽƵĞƚƚĂZĚͬ^ƚƵĞďŶĞƌŝƌůŝŶĞZĚ WŽƐƚϱ t&DϭϵϲϬͬ^ƚƵĞďŶĞƌŝƌůŝŶĞZĚ WŽƐƚϲ &DϭϵϲϬͬǇƉƌĞƐƐǁŽŽĚƌ WŽƐƚϳ ^ƉƌŝŶŐǇƉƌĞƐƐZĚͬ^,Ϯϰϵ WŽƐƚϴ EŽƌƚŚ&ƌǁǇͬ,ĂƌĚǇdŽůůZĚ WŽƐƚϵ &DϮϵϮϬͬ<ƵǇŬĞŶĚĂŚůZĚ WŽƐƚϭϬ ŝƌƚĞǆƌͬEŽƌƚŚ&ƌǁǇ

x DƵƚƵĂůĂŝĚŵĂǇƌĞƋƵŝƌĞD^ŵĞĚŝĐƵŶŝƚƐƚŽƉŽƐƚŽƵƚƐŝĚĞŽĨƚŚĞƐĞƌǀŝĐĞƚĞƌƌŝƚŽƌǇ͖ŵƵƚƵĂůĂŝĚ ĂŐĞŶĐŝĞƐǁŝůůŽŶůǇďĞĐĂůůĞĚtoD^ƚĞƌƌŝƚŽƌǇŝĨƐǇƐƚĞŵƐƚĂƚƵƐŝƐ>ĞǀĞůϯŽƌďĞůŽǁ x dŚĞŵĞĚŝĐƵŶŝƚǁŝůůďĞĂůĞƌƚĞĚďǇŽŵŵĞŶƚĞƌǁŚĞŶƚŚĞǇĂƌĞƌĞůĞĂƐĞĚĨƌŽŵƉŽƐƚ x /ĨĂƋƵĂĚƌĂŶƚ;E͕^͕͕ŽƌtͿŝƐŶŽƚĐŽǀĞƌĞĚ͕ŽƌƐǇƐƚĞŵƐƚĂƚƵƐŝƐůĞǀĞůϰŽƌďĞůŽǁ͕dZh<^Dh^d ^EddKWK^d͕ŶŽƉŽƐƚŝŶŐĨƌŽŵĂƐƚĂƚŝŽŶǁŝůůďĞƉĞƌŵŝƚƚĞĚ͘

Cypress Creek EMS System Policies and Treatment Guidelines

66 OPERATIONAL POLICIES Revised 8/2016 Approved: Levon Vartanian, MD

Dispatcher discretion is allowed to determine which unit will be sent to post. The current posting plan is as follows:

ǇƉƌĞƐƐƌĞĞŬD^^ǇƐƚĞŵ^ƚĂƚƵƐDĂŶĂŐĞŵĞŶƚWůĂŶ0600-0000

Level Posting Location(s)

ϭ WŽƐƚϭ

Ϯ WŽƐƚϮ͕ϰ

ϯ WŽƐƚϮ͕ϯ͕ϵ

ϰ WŽƐƚϮ͕ϯ͕ϱ͕ϵ

ϱ ŽǀĞƌYƵĂĚƌĂŶƚƐ

Quadrants

EŽƌƚŚ ϱϰ͕ϱϲ͕ϱϭϯ͕WŽƐƚϵŽƌϱϵΘϱϭϮĂƌĞďŽƚŚŝŶƐĞƌǀŝĐĞ

^ŽƵƚŚ ϱϱ͕ϱϳ͕WŽƐƚϱ

ĂƐƚ ϱϭ͕ϱϬϭ͕ϱϮϭ͕ϱϮ͕WŽƐƚϮ

tĞƐƚ ϱϯ͕ϱϴ͕ϱϭϭWŽƐƚϯ

Other info:

ϱϭͬϱϬϭͬϱϮϭͬϱϮKƵƚÆ560͕528͕ŽƌϱϭϬƚŽWϮ

ϱϯͬϱϴͬϱϭϭKƵƚÆ560͕528͕ϱϱŽƌϱϵƚŽWϯ

ϱϰͬϱϲͬϱϵͬϱϭϯKƵƚ Æ 512 to P9

ϱϱͬϱϳKƵƚÆ528͕560͕ϱϵ͕ϱϯ͕ϱϴ͕ϱϮϭ͕ϱϭŽƌϱϬϭƚŽWϱ

DƵƚƵĂůĂŝĚĐĂŶŽŶůǇďĞƌĞƋƵĞƐƚĞĚƚŽďƌŝŶŐƐǇƐƚĞŵƐƚĂƚƵƐƚŽ ůĞǀĞůϯ

Cypress Creek EMS System Policies and Treatment Guidelines

67 OPERATIONAL POLICIES Revised 8/2016 Approved: Levon Vartanian, MD

ǇƉƌĞƐƐƌĞĞŬD^^ǇƐƚĞŵ^ƚĂƚƵƐDĂŶĂŐĞŵĞŶƚWůĂŶ0000-0600

Level Posting Location(s)

ϭ WŽƐƚϭ

Ϯ WŽƐƚϮ͕ϰ

ϯ WŽƐƚϮ͕ϯ͕ϵ

ϰ WŽƐƚϮ͕ϯ͕ϱ͕ϵ

ϱ ĂƐƚΘtĞƐƚYƵĂĚƌĂŶƚƐDh^dĞŽǀĞƌĞĚ

Quadrants

ĂƐƚ ϱϭ͕ϱϬϭ͕ϱϮϭ͕ϱϮ͕WŽƐƚϮ

tĞƐƚ ϱϯ͕ϱϴ͕ϱϭϭ͕WŽƐƚϯ

Other info:

ϱϭͬϱϬϭͬϱϮϭͬϱϮKƵƚÆϱϭϬƚŽWϮ

DƵƚƵĂůĂŝĚĐĂŶŽŶůǇďĞƌĞƋƵĞƐƚĞĚƚŽďƌŝŶŐƐǇƐƚĞŵƐƚĂƚƵƐƚŽ ůĞǀĞůϯ

Peak Truck Utilization x DƵƐƚďĞEZKhdƚŽƉŽƐƚĂƚĚĞƐŝŐŶĂƚĞĚŝŶͲƐĞƌǀŝĐĞƚŝŵĞ x ĂŶďĞƐĞŶƚƚŽĂŶǇE^^ZzƉŽƐƚ x WƌŝŵĂƌŝůǇĂƐƐŝŐŶĞĚƚŽƉŽƐƚŝŶƚŚĞPost 2-Post 5 corridor x WĞĂŬƚƌƵĐŬƐǁŝůůďĞƌĞůĞĂƐĞĚƚŽƚŚĞŝƌďĂƐĞƐƚĂƚŝŽŶŽŶĞŚŽƵƌďĞĨŽƌĞƚŚĞŝƌKK^ƚŝŵĞ͕ŝĨƉŽƐƐŝďůĞ

Cypress Creek EMS System Policies and Treatment Guidelines

68 OPERATIONAL POLICIES Revised 8/2016 Approved: Levon Vartanian, MD

ZĞĂĚŝŶĞƐƐĨŽƌZĞƐƉŽŶƐĞ

/ƚŝƐƚŚĞƌĞƐƉŽŶƐŝďŝůŝƚǇŽĨƚŚĞ/ŶͲŚĂƌŐĞWĂƌĂŵĞĚŝĐ͕ǁŝƚŚĂƐƐŝƐƚĂŶĐĞĨƌŽŵƚŚĞĐƌĞǁ͕ƚŽĞŶƐƵƌĞƚŚĂƚƚŚĞŝƌ ƵŶŝƚŝƐƌĞĂĚǇƚŽƌĞƐƉŽŶĚƚŽĂůůƉƌĂĐƚŝĐĂůŝŶĐŝĚĞŶƚƐĂƚĂůůƚŝŵĞƐ͘dŚŝƐĞŶƐƵƌĞƐƚŚĂƚƵŶŝƚƐĂŶĚĐƌĞǁƐĂƌĞ ƉƌĞƉĂƌĞĚƚŽŚĂŶĚůĞĞŵĞƌŐĞŶĐǇƌĞƐƉŽŶƐĞƐ͘

x ƌĞǁƐŵƵƐƚƉĞƌĨŽƌŵĂŶĚĚŽĐƵŵĞŶƚĂĐŽŵƉůĞƚĞƵŶŝƚŝŶǀĞŶƚŽƌǇĂƚƚŚĞďĞŐŝŶŶŝŶŐŽĨĞĂĐŚƐŚŝĨƚ͘dŚĞ ƌĞƋƵŝƌĞĚŵĞĚŝĐĂůƐƵƉƉůŝĞƐĂŶĚĞƋƵŝƉŵĞŶƚĂƌĞůŝƐƚĞĚŽŶƚŚĞKƉĞƌĂƚŝǀĞ/Y^ǇƐƚĞŵ͘ƚĂŵŝŶŝŵƵŵ͕ ĞĂĐŚĨƌŽŶƚůŝŶĞƵŶŝƚŵƵƐƚŚĂǀĞĂĐŽŵƉůĞƚĞŝŶƐƉĞĐƚŝŽŶĂƚůĞĂƐƚŽŶĐĞŝŶĂϮϰͲŚŽƵƌƉĞƌŝŽĚ͘ƌĞǁƐ ǁŽƌŬŝŶŐůŽŶŐĞƌƚŚĂŶϮϰŚŽƵƌƐǁŝůůďĞƌĞƋƵŝƌĞĚƚŽĐŽŵƉůĞƚĞĂƐĞĐŽŶĚĨƵůůŝŶǀĞŶƚŽƌǇĂƚƚŚĞĞŶĚŽĨƚŚĞ ϮϰŚŽƵƌƐ͘ x ƌĞǁƐƐŚŽƵůĚƌĞƐƚŽĐŬĂŶǇƵƐĞĚĞƋƵŝƉŵĞŶƚĂƚƚŚĞĐŽŶĐůƵƐŝŽŶŽĨĞĂĐŚĐĂůů͕ŽƌĂƐƐŽŽŶĂƐƉƌĂĐƚŝĐĂůĂĨƚĞƌ ĞĂĐŚĐĂůů͘dŚĞƵƐĞĚƐƵƉƉůŝĞƐƐŚŽƵůĚďĞĚŽĐƵŵĞŶƚĞĚŝŶƚŚĞKƉĞƌĂƚŝǀĞ/YƐǇƐƚĞŵ͘/ĨĂĐƌĞǁŝƐƵŶĂďůĞƚŽ ƌĞƉůĂĐĞĂŶǇƵƐĞĚĞƋƵŝƉŵĞŶƚ͕ƚŚĞǇƐŚŽƵůĚĐŽŶƚĂĐƚƚŚĞŝƌŽŶͲĚƵƚǇƐƵƉĞƌǀŝƐŽƌƚŽŽďƚĂŝŶƌĞƉůĂĐĞŵĞŶƚ͘ ^ƵƉƉůŝĞƐƐƚŽƌĞĚŽŶƚŚĞƚƌƵĐŬƐŚŽƵůĚďĞƵƐĞĚƚŽďĂĐŬĨŝůůƵƐĞĚƐƵƉƉůŝĞƐĨƌŽŵƚŚĞƉĂƚŝĞŶƚĐĂƌĞďĂŐƐ͘ x &ƵĞůůĞǀĞů͗ƌĞǁƐƐŚŽƵůĚƌĞĨƵĞůƚŚĞŝƌƚƌƵĐŬǁŚĞŶƚŚĞĨƵĞůůĞǀĞůĚƌŽƉƐďĞůŽǁЪƚĂŶŬ͘/ƚŝƐĐŽŶƐŝĚĞƌĞĚĂ ĐŽƵƌƚĞƐǇƚŽŶŽƚĞǆĐŚĂŶŐĞĐƌĞǁƐŽƌƚƌƵĐŬƐǁŚĞŶƚŚĞĨƵĞůůĞǀĞůŝƐďĞůŽǁвƚĂŶŬ͘/ŶƚŚĞĞǀĞŶƚƚŚĂƚĨƵĞů ůĞǀĞůĚƌŽƉƐƚŽЬƚĂŶŬŽƌďĞůŽǁ͕ƚŚĞĐƌĞǁƐŚŽƵůĚŝŵŵĞĚŝĂƚĞůǇĐŽŶƚĂĐƚƚŚĞŝƌŽŶͲĚƵƚǇƐƵƉĞƌǀŝƐŽƌĂŶĚ ƌĞƉŽƌƚ͞ƌŝƚŝĐĂů&ƵĞů͟ůĞǀĞů͘ x DĂŝŶƚĞŶĂŶĐĞ͗ŶǇŵĂŝŶƚĞŶĂŶĐĞŝƐƐƵĞƐ;ƚŽƚŚĞƚƌƵĐŬŽƌĞƋƵŝƉŵĞŶƚͿƚŚĂƚĚŝƌĞĐƚůǇĂĨĨĞĐƚƚŚĞƵŶŝƚ͛Ɛ ĂďŝůŝƚǇƚŽƌĞƐƉŽŶĚƚŽŽƌŵŝƚŝŐĂƚĞĞŵĞƌŐĞŶĐŝĞƐƐŚŽƵůĚďĞŝŵŵĞĚŝĂƚĞůǇƌĞƉŽƌƚĞĚƚŽƚŚĞŽŶͲĚƵƚǇ ƐƵƉĞƌǀŝƐŽƌ͘DĂŝŶƚĞŶĂŶĐĞŝƐƐƵĞƐƚŚĂƚĂƌĞŶŽŶͲƵƌŐĞŶƚƐŚŽƵůĚďĞƌĞƉŽƌƚĞĚǀŝĂƚŚĞ,ĞůƉĞƐŬƐǇƐƚĞŵ͘ x KǆǇŐĞŶ͗ĂĐŚDĞĚŝĐƵŶŝƚŝƐĞƋƵŝƉƉĞĚǁŝƚŚϭDƐŝǌĞ;ŵĂŝŶͿĂŶĚĂƚŽƚĂůŽĨϲƐŝǌĞ;WŽƌƚĂďůĞͿŽǆǇŐĞŶ ĐǇůŝŶĚĞƌƐ͘ĂĐŚƚĂŶŬƐŚŽƵůĚďĞƌĞƉůĂĐĞĚǁŝƚŚĂĨƵůůƚĂŶŬǁŚĞŶƚŚĞW^/ůĞǀĞůĚƌŽƉƐƚŽϮϬϬW^/ŽƌůŽǁĞƌ͘

Cypress Creek EMS System Policies and Treatment Guidelines

69 OPERATIONAL POLICIES Revised 8/2016 Approved: Levon Vartanian, MD

^ĐĞŶĞ^ĂĨĞƚǇ Purpose dŚĞƉƵƌƉŽƐĞŽĨƚŚŝƐĚŽĐƵŵĞŶƚŝƐƚŽƌĞŵŝŶĚŽƵƌƐƚĂĨĨŽĨƚŚĞŝŶŚĞƌĞŶƚƌŝƐŬƐĂŶĚĚĂŶŐĞƌƐĂƐƐŽĐŝĂƚĞĚǁŝƚŚ ŽƵƌũŽď͘tŝƚŚƉƌĂĐƚŝĐĞĚƐŝƚƵĂƚŝŽŶĂůĂǁĂƌĞŶĞƐƐǁĞĐĂŶƌĞĚƵĐĞĂŶĚŵŝƚŝŐĂƚĞƚŚĞƐĞƌŝƐŬƐĂůƚŚŽƵŐŚǁĞ ĐĂŶŶŽƚĐŽŵƉůĞƚĞůǇĞůŝŵŝŶĂƚĞƚŚĞŵ͘

Situational awareness is an active process. It does not just happen, but takes active participation in being aware of what normal is around you so that abnormal will be obvious. Do not become complacent about any part of your life. 'ĞŶĞƌĂů x KŶůǇǇŽƵĐĂŶĐƌĞĂƚĞĂŶĚƉƌĂĐƚŝĐĞĂĐƵůƚƵƌĞŽĨƐĂĨĞƚǇĂŶĚƐŝƚƵĂƚŝŽŶĂůĂǁĂƌĞŶĞƐƐ x ^ĞĞ^ŽŵĞƚŚŝŶŐ͕^ĂǇ^ŽŵĞƚŚŝŶŐ x sĞƌďĂůůǇĞǆƉƌĞƐƐƚŽǇŽƵƌƉĂƌƚŶĞƌƐƚŚĂƚ͞/ŐŽƚǇŽƵƌďĂĐŬ͟ĂŶĚ͞ĂůůŽĨƵƐĂƌĞŐŽŝŶŐŚŽŵĞƚŽŽƵƌ ĨĂŵŝůŝĞƐ͕ĨƌŝĞŶĚƐĂŶĚƉĞƚƐĂƚƚŚĞĞŶĚŽĨƚŚŝƐƐŚŝĨƚ͘͟/ƚƐĞƚƐƚŚĞŵĞŶƚĂůƚŽŶĞĂŶĚĞǆƉĞĐƚĂƚŝŽŶĨŽƌƚŚĞ ƐŚŝĨƚ x ĞE/ĂŶĚZ^Wd&h>ƚŽƉĞŽƉůĞ͘hƐĞŶŽŶͲƚŚƌĞĂƚĞŶŝŶŐ͕ǀĞƌďĂů͕ĚĞͲĞƐĐĂůĂƚŝŽŶƚĞĐŚŶŝƋƵĞƐ͘ĂůůĨŽƌ ůĂǁĞŶĨŽƌĐĞŵĞŶƚďĞĨŽƌĞƚŚŝŶŐƐŐĞƚŽƵƚŽĨĐŽŶƚƌŽů x KEKdW>zKWŝŶŚŽǁǇŽƵƚĂůŬƚŽƉĞŽƉůĞ͘KEKdd,ZdEƉĞŽƉůĞ x ŽŶŽƚĞŶŐĂŐĞŝŶŶŽƌƉƌŽǀŽŬĞĐŽŶĨƌŽŶƚĂƚŝŽŶʹǁĞĂƌĞŶŽƚƚŚĞƉŽůŝĐĞ͕ǁĞĂƌĞŶŽƚŚĞƌĞƚŽĞŶƐƵƌĞƚŚĂƚ ƉĞŽƉůĞĚŽƚŚĞƌŝŐŚƚƚŚŝŶŐ͕ǁĞĂƌĞŚĞƌĞƚŽŚĞůƉƚŚĞŵǁŚĞŶƚŚĞǇĚŽŶŽƚ x ŽƚŚƉĂƌƚŶĞƌƐƐŚŽƵůĚĐĂƌƌǇĂƌĂĚŝŽĂŶĚŚĂǀĞŝƚƚƵƌŶĞĚŽŶ͘D^ƉƌŽǀŝĚĞƐǇŽƵƚǁŽĨŽƌƚŚŝƐƌĞĂƐŽŶ x ĂƌƌǇǇŽƵƌĐĞůůƉŚŽŶĞĂƐĂĨŽƌŵŽĨďĂĐŬƵƉĐŽŵŵƵŶŝĐĂƚŝŽŶ x ,ĂǀĞĂĐŽĚĞƚŚĂƚŵĞĂŶƐ^WͬsŝŵŵĞĚŝĂƚĞůǇ͘dŚŝƐŵĞĂŶƐůĞĂǀĞĂůůǇŽƵƌƐƚƵĨĨĂŶĚƌƵŶƉĞŽƉůĞ ŽǀĞƌŝĨŶĞĐĞƐƐĂƌǇƚŽĞƐĐĂƉĞ͘hƐĞĨŽƌĐĞĂƐŶĞĐĞƐƐĂƌǇ͘^ŽŵĞƉĞŽƉůĞƵƐĞƚŚĞƚĞƌŵ͞ƉƵƌƉůĞďĂŐ͟ĂƐƚŚĞƌĞ ŝƐŶŽƉƵƌƉůĞďĂŐŽŶƚŚĞƚƌƵĐŬǁŚŝĐŚŵĞĂŶƐůĞĂǀĞŶŽǁ͕ƐĐĞŶĞŝƐƵŶƐĂĨĞ x ,ĂǀĞĐŽĚĞƚŽĞǆŝƚŽƌůĞĂǀĞĂƐŝĨĞǀĞƌǇƚŚŝŶŐŝƐŶŽƌŵĂů͘dŚŝƐŵĞĂŶƐůĞĂǀĞǁŝƚŚŽƵƚĨŽƌĐĞ͕ƵƐĞĂZh^͕ ƐĂǇŝŶŐǇŽƵďŽƚŚŶĞĞĚƚŽŐŽŐĞƚĂƉŝĞĐĞŽĨĞƋƵŝƉŵĞŶƚ x dŚŝƌƚǇͲĨŽŽƚƌƵůĞĨŽƌĂŶǇŽŶĞǁŝƚŚĂŶĞĚŐĞĚǁĞĂƉŽŶ͕^WĂŶĚs͊ x ĂůůĨŽƌŚĞůƉƐŽŽŶĞƌƚŚĂŶůĂƚĞƌ͘/ĨǇŽƵŚĂǀĞĂƐƵƐƉŝĐŝŽŶ͖ĐĂůůĞĂƌůǇĂŶĚŽĨƚĞŶĨŽƌŚĞůƉ͘hƐƵĂůůǇǇŽƵƌ ŝŶƐƚŝŶĐƚƐĂƌĞƌŝŐŚƚ x ŽŶ͛ƚǁŽƌƌǇĂďŽƵƚĞƋƵŝƉŵĞŶƚŝĨŶĞĞĚŝŶŐƚŽsĂŶĚ^W͖ŝƚ͛ƐƌĞƉůĂĐĞĂďůĞ͕ǇŽƵĂƌĞŶŽƚ͊ x ŽŶ͛ƚǁĞĂƌĐůŽƚŚŝŶŐƚŚĂƚŝĚĞŶƚŝĨŝĞƐǇŽƵĂƐĂĨŝƌƐƚƌĞƐƉŽŶĚĞƌǁŚŝůĞŽĨĨĚƵƚǇ x ĞƵŶƉƌĞĚŝĐƚĂďůĞ͖ǀĂƌǇǇŽƵƌƌŽƵƚŝŶĞ͕ƚŝŵĞƐĂŶĚƌŽƵƚĞƐ x &ƵĞůĚƵƌŝŶŐĚĂǇƚŝŵĞŚŽƵƌƐ͘hƐĞĂďƵĚĚǇƐǇƐƚĞŵŝĨĂǀĂŝůĂďůĞ x ,ĂǀĞŽƉĞŶĐŽŵŵƵŶŝĐĂƚŝŽŶǁŝƚŚƐƚĂĨĨ͕ǀŽůƵŶƚĞĞƌƐĂŶĚƐƚƵĚĞŶƚƐĂďŽƵƚƐŝƚƵĂƚŝŽŶĂůĂǁĂƌĞŶĞƐƐ͘ x <ĞĞƉǇŽƵƌĂŵďƵůĂŶĐĞĚŽŽƌƐĂŶĚĐŽŵƉĂƌƚŵĞŶƚƐůŽĐŬĞĚĂĐĐŽƌĚŝŶŐƚŽƉŽůŝĐǇ

Cypress Creek EMS System Policies and Treatment Guidelines

70 OPERATIONAL POLICIES Revised 8/2016 Approved: Levon Vartanian, MD

WƌĞͲ/ŶĐŝĚĞŶƚ x WŚǇƐŝĐĂůĂŶĚŵĞŶƚĂůƉƌĞƉĂƌĞĚŶĞƐƐ͗ĂƚƌŝŐŚƚ͕ŐĞƚƌĞƐƚ͕ĂŶĚŬĞĞƉǇŽƵƌďŽĚǇŚĞĂůƚŚǇƚŽĚĞĂůǁŝƚŚƚŚĞ ƐƚƌĞƐƐŽĨƚŚĞũŽď͘zŽƵƌŵĞŶƚĂůĂĐƵŝƚǇĂŶĚƌĞĂĐƚŝŽŶƚŝŵĞŝƐĚĞƉĞŶĚĞŶƚƵƉŽŶƚŚĞƐĞƚŚŝŶŐƐ͘ x dĂŬĞĂĨĞǁƐĞĐŽŶĚƐƚŽůŽŽŬĂƌŽƵŶĚďĞĨŽƌĞǇŽƵŐĞƚŝŶƚŽŽƌŽƵƚŽĨǇŽƵƌǀĞŚŝĐůĞ͘ĞĂǁĂƌĞŽĨƐƵƐƉŝĐŝŽƵƐ ĂĐƚŝǀŝƚǇƚŚĂƚĚŽĞƐŶŽƚ͚ůŽŽŬƌŝŐŚƚ͛ŽƌŝƐŽƵƚŽĨƉůĂĐĞ͘dƌƵƐƚǇŽƵƌŐƵƚŝŶƐƚŝŶĐƚ͘ x <ĞĞƉǇŽƵƌƐƚĂƚŝŽŶĂŶĚǇŽƵƌĂŵďƵůĂŶĐĞƐƐĞĐƵƌĞ͘>ŽĐŬĂůůĚŽŽƌƐĂŶĚĐůŽƐĞďĂǇĚŽŽƌƐ x <ŶŽǁǇŽƵƌůŽĐĂƚŝŽŶĂƚĂůůƚŝŵĞƐĂŶĚŬŶŽǁƚŚĞůŽĐĂƚŝŽŶŽĨĞĂĐŚĐƌĞǁŵĞŵďĞƌ ZĞƐƉŽŶƐĞ x >ĞĂǀĞĂĚĞƋƵĂƚĞƐƉĂĐŝŶŐďĞƚǁĞĞŶǇŽƵƌĂŵďƵůĂŶĐĞĂŶĚƚŚĞǀĞŚŝĐůĞŝŶĨƌŽŶƚŽĨǇŽƵǁŚŝůĞŝŶƚƌĂĨĨŝĐ x dƌǇƚŽůĞĂǀĞǇŽƵƌƐĞůĨŽƌĐƌĞĂƚĞĂǁĂǇƚŽ^WŝŶǇŽƵƌǀĞŚŝĐůĞ x /ĨƚŚĞƐƚƌĞĞƚŝƐĂĚĞĂĚĞŶĚͬĐƵůĚĞƐĂĐ͕ƚƵƌŶƚŚĞƚƌƵĐŬĂƌŽƵŶĚďĞĨŽƌĞŐĞƚƚŝŶŐŽƵƚƚŽŐŝǀĞǇŽƵƌƐĞůĨĂŶ ^WƌŽƵƚĞ͘dŚŝƐĂůƐŽĂůůŽǁƐǇŽƵƚŽƉĂƐƐƚŚĞƐƚƌƵĐƚƵƌĞĂŶĚƐĞĞƚŚƌĞĞƐŝĚĞƐŽĨŝƚ x >ĞĂǀĞĞŵĞƌŐĞŶĐǇůŝŐŚƚƐKE͘dŚŝƐŚĞůƉƐƚŽŝĚĞŶƚŝĨǇǇŽƵƌůŽĐĂƚŝŽŶĂŶĚĚƌĂǁƐĂƚƚĞŶƚŝŽŶĨƌŽŵŶĞŝŐŚďŽƌƐ x /ŶĐƌĞĂƐĞƐƚĂŐŝŶŐĚŝƐƚĂŶĐĞĂŶĚƌĞƉŽƌƚƚŚĞĞǆĂĐƚůŽĐĂƚŝŽŶƚŽĚŝƐƉĂƚĐŚ KŶͲ^ĐĞŶĞ x ŽŶ͛ƚƉĂƌŬŝŶĨƌŽŶƚŽĨƚŚĞĨƌŽŶƚĚŽŽƌ x ŚĞĐŬƚŚĞƐƵƌƌŽƵŶĚŝŶŐĂƌĞĂǀŝƐƵĂůůǇďĞĨŽƌĞĞŶƚĞƌŝŶŐ͘ĂƌŬŚŽƵƐĞƐƐŚŽƵůĚƌĂŝƐĞǇŽƵƌĐŽŶĐĞƌŶ͘Ăůů ŝŶĨŽƌŵĂƚŝŽŶŶŽƚŵĂƚĐŚŝŶŐƚŚĞůŽĐĂƚŝŽŶƐŚŽƵůĚƌĂŝƐĞĐŽŶĐĞƌŶ͘ x ŽŶΖƚƐƚĂŶĚŝŶĨƌŽŶƚŽĨĚŽŽƌƐŽƌǁŝŶĚŽǁƐĚƵƌŝŶŐƚŚĞŬŶŽĐŬĂŶĚĂŶŶŽƵŶĐĞ x /ĚĞŶƚŝĨǇǇŽƵƌƐĞůĨĂƐD/^ x ůǁĂǇƐůĞĂǀĞǇŽƵƌƐĞůĨĂǁĂǇŽƵƚ͕ĂŶĞŐƌĞƐƐŽƌ^WƌŽƵƚĞ x ƐŬǁŚŽĞůƐĞŝƐƉƌĞƐĞŶƚŝŶƚŚĞŚŽŵĞ͕ĞƚĐ͘ x ŽŶŽƚůĞƚƐŽŵĞŽŶĞůĞĂǀĞǇŽƵƌƐŝŐŚƚĂŶĚŐŽďĂĐŬŝŶƚŚĞďĞĚƌŽŽŵ͕ĞƚĐ͘ x ŽŶŽƚůĞƚƚŚĞƉĞƌƐŽŶŽƌƉĂƚŝĞŶƚŵŽǀĞǇŽƵŝŶƚŽĂƉŽƐŝƚŝŽŶŽĨĚŝƐĂĚǀĂŶƚĂŐĞǁŚĞƌĞƚŚĞǇĂƌĞŶŽǁ ďĞƚǁĞĞŶǇŽƵĂŶĚǇŽƵƌĞŐƌĞƐƐƌŽƵƚĞ x ŽŐŽŽĚƉŚǇƐŝĐĂůĂƐƐĞƐƐŵĞŶƚƐ͖ǇŽƵǁŝůůĨŝŶĚǁĞĂƉŽŶƐŝĨƚŚĞǇĂƌĞŽŶƚŚĞƉĂƚŝĞŶƚ x ƐŬůĂǁĞŶĨŽƌĐĞŵĞŶƚƚŽ͚ƐĞĂƌĐŚ͛ĂƉĂƚŝĞŶƚŝĨǇŽƵĂƌĞĐŽŶĐĞƌŶĞĚĂďŽƵƚǁĞĂƉŽŶƐ x dƵƌŶǀĞŚŝĐůĞƐŽĨĨďĞĨŽƌĞůĞĂŶŝŶŐŝŶƚŽƚŚĞŵŽƌŐĞƚƚŝŶŐŝŶƚŽƚŚĞŵƚŽĂƐƐĞƐƐƉĂƚŝĞŶƚƐ x WĂƌŬďĞŚŝŶĚǀĞŚŝĐůĞƐŶŽƚŝŶĨƌŽŶƚŽĨƚŚĞŵ͖ǁŝƚŚƌŽŽŵĨŽƌĞŐƌĞƐƐͲŵĂŶĚŽǁŶĐĂůůƐ x ^ƚĂǇŝŶƐŝŐŚƚŽĨǇŽƵƌƉĂƌƚŶĞƌ͖ƚŚŝƐŵĞĂŶƐďƌŝŶŐ>>ĞƋƵŝƉŵĞŶƚƚŽƚŚĞŚŽƵƐĞƐŽƚŚĂƚǇŽƵĚŽŶ͛ƚŚĂǀĞƚŽ ƌĞƚƵƌŶƚŽƚŚĞĂŵďƵůĂŶĐĞ x ŽŶŽƚŐĞƚƐŽĨŽĐƵƐĞĚŽŶĂƚĂƐŬƚŚĂƚǇŽƵĨŽƌŐĞƚĞǀĞƌǇƚŚŝŶŐĞůƐĞĂƌŽƵŶĚǇŽƵ͘hƐĞĂďƵĚĚǇƐǇƐƚĞŵƚŽ ĞŶƐƵƌĞϯϲϬͲĚĞŐƌĞĞĂǁĂƌĞŶĞƐƐĂƚĂůůƚŝŵĞƐ͘ x dŚŝŶŬĂďŽƵƚǁŚĂƚǇŽƵĐŽƵůĚƵƐĞĨŽƌĂ&E^/sǁĞĂƉŽŶŝĨŶĞĞĚĞĚ͘ dƌĂŶƐƉŽƌƚĂƚŝŽŶ x >ŽĐŬǇŽƵƌĚŽŽƌƐĂŶĚǁĞĂƌǇŽƵƌƐĞĂƚďĞůƚƐ x ƌŝǀĞǁŝƚŚĐŽƵƌƚĞƐǇĂŶĚĚƵĞƌĞŐĂƌĚ x ĞĂǁĂƌĞŽĨǀĞŚŝĐůĞƐĂƌŽƵŶĚǇŽƵĂŶĚƚŚĞŝƌďĞŚĂǀŝŽƌ͖ƌĞƉŽƌƚƐƵƐƉŝĐŝŽƵƐĂĐƚŝǀŝƚǇƚŽůĂǁĞŶĨŽƌĐĞŵĞŶƚ͘ x /ĨǇŽƵĐĂƌƌǇĂŵƵůƚŝƚŽŽů͕ŬŶŝĨĞŽƌƐĐŝƐƐŽƌƐ͕ĐŽŶĐĞĂůƚŚĞĨĂĐƚƚŚĂƚǇŽƵŚĂǀĞƚŚĞƐĞŝƚĞŵƐƚŚĂƚĐŽƵůĚďĞ ƵƐĞĚĂƐǁĞĂƉŽŶƐ

Cypress Creek EMS System Policies and Treatment Guidelines

71 OPERATIONAL POLICIES Revised 8/2016 Approved: Levon Vartanian, MD

x >ĞĂǀĞĂĚĞƋƵĂƚĞƐƉĂĐŝŶŐďĞƚǁĞĞŶǇŽƵƌĂŵďƵůĂŶĐĞĂŶĚƚŚĞǀĞŚŝĐůĞŝŶĨƌŽŶƚŽĨǇŽƵǁŚŝůĞŝŶƚƌĂĨĨŝĐ x dƌǇƚŽůĞĂǀĞǇŽƵƌƐĞůĨŽƌĐƌĞĂƚĞĂŶŽƵƚ͕ĂǁĂǇƚŽ^WŝŶǇŽƵƌǀĞŚŝĐůĞ x &ƵĞůĂƚD^ĨƵĞůŝŶŐůŽĐĂƚŝŽŶƐĚƵƌŝŶŐĚĂǇƚŝŵĞŚŽƵƌƐ WŽƐƚŝŶŐ x ŽEKdƐůĞĞƉĂƚƉŽƐƚ͊^ƚĂǇĂůĞƌƚĂŶĚĂǁĂƌĞŽĨǇŽƵƌƐƵƌƌŽƵŶĚŝŶŐƐ x ŽEKdŐŽŝŶƚŽƉůĂĐĞƐďǇǇŽƵƌƐĞůĨ͕ƵƐĞĂďƵĚĚǇƐǇƐƚĞŵ x ŚĞĐŬŽƵƚǁŝƚŚĐŽŵŵĐĞŶƚĞƌŝĨƐƚŽƉƉŝŶŐĨŽƌĨƵĞů͕ŵĞĂůŽƌďƌĞĂŬ x ŽŶƐŝĚĞƌŶŽƚĞĂƚŝŶŐŽƵƚ͖ďƌŝŶŐĨŽŽĚĂŶĚƐŶĂĐŬƐǁŝƚŚǇŽƵƚŽĞĂƚĂƚƚŚĞƐƚĂƚŝŽŶŽƌŝŶĐĂďŽĨƚƌƵĐŬ͘ x /ŶĐƌĞĂƐĞƐƚĂŐŝŶŐĚŝƐƚĂŶĐĞĂŶĚƌĞƉŽƌƚƚŚĞĞǆĂĐƚůŽĐĂƚŝŽŶƚŽĚŝƐƉĂƚĐŚ x WŽƐƚŝŶĂŶŽƉĞŶĂƌĞĂƚŚĂƚŐŝǀĞƐǇŽƵůŽƚƐŽĨ^WĂŶĚsƌŽŽŵ͘ŚĂŶŐĞůŽĐĂƚŝŽŶǁŝƚŚŝŶƚŚĞ ƉĂƌŬŝŶŐůŽƚĚƵƌŝŶŐƚŚĞƉŽƐƚŝŶŐƚŝŵĞ;Ğ͘Ő͘ůŽŶŐƉŽƐƚƐͿ x ŽŶ͛ƚƉŽƐƚŝŶĞǆĂĐƚůǇƚŚĞƐĂŵĞůŽĐĂƚŝŽŶĞĂĐŚƚŝŵĞ͖ƵƐĞĂĚŝĨĨĞƌĞŶƚƋƵĂĚƌĂŶƚ x ŽŶƐŝĚĞƌĂ͚ƌŽůůŝŶŐƉŽƐƚ͖͛ŬĞĞƉŵŽǀŝŶŐŝŶǇŽƵƌŐĞŶĞƌĂůƉŽƐƚŝŶŐĂƌĞĂ͘ĚǀŝƐĞƚŚĞĐŽŵŵĐĞŶƚĞƌŽĨǇŽƵƌ ŝŶƚĞŶƚŝŽŶƐ͘ x ŽŶŽƚĐŽŶĚƵĐƚĂĐƚŝǀŝƚŝĞƐƚŚĂƚƌĞĚƵĐĞĂǁĂƌĞŶĞƐƐŝŶĂƌĞĂƐŝŶǀŝĞǁŽĨƉƵďůŝĐ͘hƐĞĂďƵĚĚǇƐǇƐƚĞŵƚŽ ĞŶƐƵƌĞϯϲϬͲĚĞŐƌĞĞĂǁĂƌĞŶĞƐƐĂƚĂůůƚŝŵĞƐ͘ x ĞŵŝŶĚĨƵůŽĨĂŶǇƉĞƌƐŽŶŽƌǀĞŚŝĐůĞĂƉƉƌŽĂĐŚŝŶŐǇŽƵ x ŐĂŝŶ͕ŽEKdƐůĞĞƉǁŚŝůĞĂƚƉŽƐƚ͘^ƚĂǇĂůĞƌƚĂŶĚĂǁĂƌĞŽĨǇŽƵƌƐƵƌƌŽƵŶĚŝŶŐƐ

Cypress Creek EMS System Policies and Treatment Guidelines

72 OPERATIONAL POLICIES Revised 6/2016 Approved: Bradley J England

^ƉĂŶŽĨŽŶƚƌŽů

D^ƐƚĂƚŝŽŶƐĂŶĚŵĞĚŝĐƵŶŝƚƐŚĂǀĞďĞĞŶĂƐƐŝŐŶĞĚƚŽĂƉƌŝŵĂƌǇƐƵƉĞƌǀŝƐŽƌĨŽƌĂůůŽƉĞƌĂƚŝŽŶĂůŶĞĞĚƐ͘ dŚĞĨŽůůŽǁŝŶŐŝƐƚŚĞĐƵƌƌĞŶƚƐƉĂŶŽĨĐŽŶƚƌŽůĂŶĚǁŝůůďĞĂĚũƵƐƚĞĚĂƐƐǇƐƚĞŵĚĞŵĂŶĚƐĐŚĂŶŐĞ͘

ŝǀŝƐŝŽŶKŶĞ;ĂƐƚͿ ŝǀŝƐŝŽŶdǁŽ;tĞƐƚͿ ϱϭ;^ƵƉĞƌǀŝƐŽƌͿ ϱϮ;^ƵƉĞƌǀŝƐŽƌͿ Dϱϭ Dϱϯ DϱϬϭ Dϱϰ DϱϮϭ Dϱϱ DϱϮ DϱϴͬDϱϮϴ DϱϭϬ Dϱϵ Dϱϳ Dϱϭϭ DϱϭϯͬDϱϲϯ DϱϭϮ Dϱϲ Definitions WƌŝŵĂƌǇ^ƵƉĞƌǀŝƐŽƌ͗ dŚŝƐŝƐǇŽƵƌƉƌŝŵĂƌǇƐƵƉĞƌǀŝƐŽƌďĂƐĞĚŽŶǇŽƵƌƐŚŝĨƚͬƐƚĂƚŝŽŶĂƐƐŝŐŶŵĞŶƚ;ƐĞĞƚŚĞĂďŽǀĞĐŚĂƌƚͿ͘dŚŝƐŝƐƚŚĞ ƐƵƉĞƌǀŝƐŽƌƚŚĂƚǁŝůůĐŽŵƉůĞƚĞǇŽƵƌĂŶŶƵĂůĞǀĂůƵĂƚŝŽŶ͘ WƌŝŵĂƌǇ^ŚŝĨƚ^ƵƉĞƌǀŝƐŽƌ͗ dŚŝƐŝƐǇŽƵƌƐŚŝĨƚƐƵƉĞƌǀŝƐŽƌǁŚĞŶŽŶͲĚƵƚǇďĂƐĞĚŽŶǇŽƵƌƚƌƵĐŬĂƐƐŝŐŶŵĞŶƚĨŽƌƚŚĞƐŚŝĨƚ͘;^ĞĞƚŚĞĂďŽǀĞ ĐŚĂƌƚͿ

zŽƵĂƌĞĞǆƉĞĐƚĞĚƚŽĐŽŶƚĂĐƚǇŽƵƌprimary shift supervisor ĨŽƌĂŶǇŽƉĞƌĂƚŝŽŶĂůŶĞĞĚƐǁŚŝůĞŽŶĚƵƚǇ͘ ǆĂŵƉůĞƐŝŶĐůƵĚĞ͕ďƵƚĂƌĞŶŽƚůŝŵŝƚĞĚƚŽĨŽůůŽǁŝŶŐ͗

x ^ƵƉƉůŝĞƐĂŶĚĞƋƵŝƉŵĞŶƚ x ^ĐŚĞĚƵůŝŶŐ x ůŝŶŝĐĂůƋƵĞƐƚŝŽŶƐ /ĨǇŽƵŶĞĞĚƚŽƌĞĂĐŚĂƐƵƉĞƌǀŝƐŽƌǁŚĞŶŽĨĨĚƵƚǇ͕ǇŽƵĐŽŶƚĂĐƚƚŚĞƉƌŝŵĂƌǇƐŚŝĨƚƐƵƉĞƌǀŝƐŽƌŽŶĚƵƚǇƚŚĂƚ ǇŽƵĂƌĞĂƐƐŝŐŶĞĚ͘;ǆĂŵƉůĞ͗/ĨǇŽƵǁĞƌĞĂƐƐŝŐŶĞĚƚŽDϱϯĂŶĚŶĞĞĚƚŽĐĂůůŽĨĨǁŽƌŬ͕ǇŽƵǁŽƵůĚĐŽŶƚĂĐƚ ƚŚĞŽŶĚƵƚǇϱϮͿ͘

/ĨǇŽƵĂƌĞƵŶĂďůĞƚŽƌĞĂĐŚǇŽƵƌƐŚŝĨƚƐƵƉĞƌǀŝƐŽƌ͕ƉůĞĂƐĞůĞĂǀĞĂŵĞƐƐĂŐĞĂŶĚǇŽƵƌĐŽŵŵƵŶŝĐĂƚŝŽŶǁŝůůďĞ ƌĞƚƵƌŶĞĚĂƐƐŽŽŶĂƐƉŽƐƐŝďůĞ͘/ƚŝƐŶŽƚŶĞĐĞƐƐĂƌǇƚŽĐŽŶƚĂĐƚƚŚĞŽƚŚĞƌƐƵƉĞƌǀŝƐŽƌĨŽƌǇŽƵƌŶĞĞĚƐƵŶůĞƐƐŝƚ ŝƐĞǆƚƌĞŵĞůǇƚŝŵĞƐĞŶƐŝƚŝǀĞ;ĞǆĂŵƉůĞ͗ŝĨǇŽƵĂƌĞŽŶͲƐĐĞŶĞĂŶĚŚĂǀĞĂŶŝŵŵĞĚŝĂƚĞĐůŝŶŝĐĂůƋƵĞƐƚŝŽŶͿ͘

Cypress Creek EMS System Policies and Treatment Guidelines

73 OPERATIONAL POLICIES Revised 6/2019 Approved: Levon Vartanian, MD

ŵďƵůĂŶĐĞ^ƚĂŐŝŶŐ Purpose D^ŵĂǇŽĨƚĞŶďĞĐĂůůĞĚƚŽĂƐĐĞŶĞƚŚĂƚƌĞƋƵŝƌĞƐůĂǁĞŶĨŽƌĐĞŵĞŶƚ;>ͿĐůĞĂƌĂŶĐĞ͘tŚĞŶĂŶĂŵďƵůĂŶĐĞ ŝƐĚŝƐƉĂƚĐŚĞĚĞŵĞƌŐĞŶĐǇƚƌĂĨĨŝĐ;ǁŝƚŚůŝŐŚƚƐĂŶĚƐŝƌĞŶƐͿƚŽƐƚĂŐĞĨŽƌĂŶŝŶĚĞĨŝŶŝƚĞĂŵŽƵŶƚŽĨƚŝŵĞ͕ƵŶĚƵĞ ƌŝƐŬŝƐƉůĂĐĞĚŽŶďŽƚŚƚŚĞŽĐĐƵƉĂŶƚƐŽĨƚŚĞĂŵďƵůĂŶĐĞĂŶĚĚƌŝǀĞƌƐŽŶƚŚĞƌŽĂĚ͖ƚŚŝƐŵĂǇŬĞĞƉĂŶ ĂŵďƵůĂŶĐĞŽƵƚŽĨƐĞƌǀŝĐĞǁŚĞŶƐǇƐƚĞŵĚĞŵĂŶĚƐĂƌĞŚŝŐŚ͘ WƌŽĐĞĚƵƌĞ /ĨƐƚĂŐŝŶŐƉƌŽĐĞĚƵƌĞƐĂƌĞƌĞƋƵŝƌĞĚĨŽƌD^ƌĞƐƉŽŶƐĞ͕ƌĞƐƉŽŶĚŝŶŐƵŶŝƚƐǁŝůůďĞŶŽƚŝĨŝĞĚďǇƌĂĚŝŽ͖&ŝƌƐƚ ZĞƐƉŽŶĚĞƌƉĞƌƐŽŶŶĞůŵĂǇďĞĚŝƐƌĞŐĂƌĚĞĚĨƌŽŵƚŚĞĐĂůůĂƚƚŚŝƐŶŽƚŝĨŝĐĂƚŝŽŶ͘

D^ƵŶŝƚƐǁŝůůďĞĂĚǀŝƐĞĚƚŽƐƚĂŐĞĨŽƌŝŶĐŝĚĞŶƚƐƚŚĂƚŝŶĐůƵĚĞƚŚĞĨŽůůŽǁŝŶŐ͗

x tĞĂƉŽŶƐ;ŝŶǀŽůǀĞĚŽƌŵĞŶƚŝŽŶĞĚͿ x ŽŵĞƐƚŝĐĚŝƐƉƵƚĞ x dŚƌĞĂƚƐ;ŵĂĚĞƚŽĚŝƐƉĂƚĐŚĞƌŽƌD^ĐƌĞǁͿ x Excited Delirium x ŚĞŵŝĐĂůƐƵŝĐŝĚĞƐŽƌŚĂǌĂƌĚŽƵƐŵĂƚĞƌŝĂůƐƐĐĞŶĞƐŝŶŶĞĞĚŽĨĐůĞĂƌĂŶĐĞďǇƚŚĞĨŝƌĞĚĞƉĂƌƚŵĞŶƚ x ŐŐƌĞƐƐŝŽŶͬƉŚǇƐŝĐĂůĂůƚĞƌĐĂƚŝŽŶŝŶƚŚĞďĂĐŬŐƌŽƵŶĚ x EŽƚĞ͗ĂůůĞƌƐƐŽůĞůǇĨƌƵƐƚƌĂƚĞĚďǇĂŵďƵůĂŶĐĞĚĞůĂǇƐĂƌĞŶŽƚĂŶŝŶĚŝĐĂƚŝŽŶƚŽƐƚĂŐĞ͘ x ŶŝŵĂůĂƚƚĂĐŬ;ĂŶŝŵĂůŶŽƚƌĞƐƚƌĂŝŶĞĚͿ x WĂŶŝĐĂůĂƌŵƐ D^ƵŶŝƚƐǁŝůůnot ďĞĂĚǀŝƐĞĚƚŽƐƚĂŐĞĨŽƌŝŶĐŝĚĞŶƚƐƚŚĂƚŝŶĐůƵĚĞƚŚĞĨŽůůŽǁŝŶŐ͗ x ƐƐĂƵůƚƐ;ĂƚĂĚŝĨĨĞƌĞŶƚůŽĐĂƚŝŽŶŽƌŵŽƌĞƚŚĂŶϲŚŽƵƌƐĂŐŽͿ x ŽŵďĂƚŝǀĞĚŝĂďĞƚŝĐƉĂƚŝĞŶƚƐ x ŽŵďĂƚŝǀĞĚĞŵĞŶƚŝĂͬůǌŚĞŝŵĞƌ͛ƐƉĂƚŝĞŶƚƐŝŶĂŚĞĂůƚŚĐĂƌĞĨĂĐŝůŝƚǇ x KǀĞƌĚŽƐĞǁŝƚŚŽƵƚŝŶĚŝĐĂƚŝŽŶŽĨǀŝŽůĞŶĐĞ x WƐǇĐŚǁŝƚŚŽƵƚŝŶĚŝĐĂƚŝŽŶŽĨǀŝŽůĞŶĐĞ x WĞƌƐŽŶĚŽǁŶ;ŝŶĂǀĞŚŝĐůĞŽƌŽƚŚĞƌǁŝƐĞͿ ϭ͘ hŶŝƚ;ƐͿƐŚĂůůƌĞƐƉŽŶĚnon-emergencyƚŽƐƚĂŐŝŶŐĂƌĞĂ͘dŚĞŽŵŵĞŶƚĞƌŵĂǇƵƉŐƌĂĚĞƚŚĞƵŶŝƚ ƌĞƐƉŽŶƐĞƚŽĞŵĞƌŐĞŶĐǇƚƌĂĨĨŝĐĚĞƉĞŶĚŝŶŐƵƉŽŶƵƉĚĂƚĞĚĐĂůůŝŶĨŽƌŵĂƚŝŽŶ͘ Ϯ͘ tŚĞŶƵŶŝƚ;ƐͿĂƌĞĚŝƐƉĂƚĐŚĞĚ͕ƵŶŝƚƐĂƌĞƚŽƌĞƐƉŽŶĚƚŽĂƐƚĂŐŝŶŐĂƌĞĂǁŝƚŚŝŶĂƉƌŽǆŝŵŝƚǇŽĨϬ͘ϱŵŝůĞƐŽĨ ĚŝƐƉĂƚĐŚĞĚůŽĐĂƚŝŽŶ͘ ϯ͘ hŶŝƚ;ƐͿƐŚĂůůǀĞƌďĂůŝǌĞ͞ƐƚĂŐĞĚ͟ǀŝĂƌĂĚŝŽƵƉŽŶĂƌƌŝǀĂůĂƚƚŚĞƐƚĂŐŝŶŐĂƌĞĂŽƌďǇƐĞůĞĐƚŝŶŐƚŚĞƐƚĂŐĞĚ ďƵƚƚŽŶŽŶƚŚĞŝƌŵĂƉƉŝŶŐƐŽĨƚǁĂƌĞ͘ ϰ͘ hŶŝƚ;ƐͿƐŚĂůůƌĞŵĂŝŶĂƚƚŚĞƐƚĂŐŝŶŐĂƌĞĂƵŶƚŝůĐůĞĂƌĞĚƚŽƉƌŽĐĞĞĚďǇŽŵŵĞŶƚĞƌĂĨƚĞƌůĂǁ ĞŶĨŽƌĐĞŵĞŶƚŚĂƐĚĞĐůĂƌĞĚƚŚĞƐĐĞŶĞƐĂĨĞ͘;ŽŵŵĞŶƚĞƌƐŚĂůůďĞŝŶĐŽŶƚĂĐƚǁŝƚŚƚŚĞĂƉƉƌŽƉƌŝĂƚĞ ůĂǁĞŶĨŽƌĐĞŵĞŶƚĂŐĞŶĐǇƚŚƌŽƵŐŚŽƵƚƚŚĞŝŶĐŝĚĞŶƚ͘Ϳ ϱ͘ hƉŽŶŽŵŵĞŶƚĞƌƌĞĐĞŝǀŝŶŐĂ͞ĐůĞĂƌĞĚŝŶ͟ĨƌŽŵůĂǁĞŶĨŽƌĐĞŵĞŶƚĂŶĚĐŽŵŵƵŶŝĐĂƚŝŶŐǁŝƚŚƚŚĞ ƵŶŝƚ͕ƚŚĞƵŶŝƚǁŝůůƉƌŽĐĞĞĚƚŽƚŚĞƐĐĞŶĞĞŵĞƌŐĞŶĐǇƚƌĂĨĨŝĐ͘ĚĞƐŝŐŶĂƚĞĚĐƌĞǁŵĞŵďĞƌƐŚĂůů ĐŽŵƉůĞƚĞƌĞƋƵŝƌĞĚWZĚŽĐƵŵĞŶƚĂƚŝŽŶŝŶĐůƵĚŝŶŐĂĚĞƚĂŝůĞĚŶĂƌƌĂƚŝǀĞ͘

Cypress Creek EMS System Policies and Treatment Guidelines

74 OPERATIONAL POLICIES Revised 5/2018 Approved: Levon Vartanian, MD

dŝŵĞĂŶĚƚƚĞŶĚĂŶĐĞWŽůŝĐǇͲField Staff General WƵŶĐƚƵĂůĂŶĚƌĞŐƵůĂƌĂƚƚĞŶĚĂŶĐĞŝƐĂŶĞƐƐĞŶƚŝĂůƌĞƐƉŽŶƐŝďŝůŝƚǇŽĨĞĂĐŚĞŵƉůŽǇĞĞĂƚǇƉƌĞƐƐƌĞĞŬD^͘ ŶǇƚĂƌĚŝŶĞƐƐŽƌĂďƐĞŶĐĞĚŝƐƌƵƉƚƐĞĨĨŝĐŝĞŶƚŽƉĞƌĂƚŝŽŶƐĂŶĚƉůĂĐĞƐĂŶƵŶŶĞĐĞƐƐĂƌǇďƵƌĚĞŶĨŽƌĨĞůůŽǁ ĞŵƉůŽǇĞĞƐĂŶĚƐƵƉĞƌǀŝƐŽƌƐ͘

ŵƉůŽǇĞĞƐĂƌĞĞǆƉĞĐƚĞĚƚŽƌĞƉŽƌƚƚŽǁŽƌŬĂƐƐĐŚĞĚƵůĞĚ͕ŽŶƚŝŵĞ͕ĂŶĚƉƌĞƉĂƌĞĚƚŽƐƚĂƌƚǁŽƌŬ͘ ŵƉůŽǇĞĞƐĂůƐŽĂƌĞĞǆƉĞĐƚĞĚƚŽƌĞŵĂŝŶĂƚǁŽƌŬĨŽƌƚŚĞŝƌĞŶƚŝƌĞǁŽƌŬƐĐŚĞĚƵůĞ͘>ĂƚĞĂƌƌŝǀĂů͕ĞĂƌůǇ ĚĞƉĂƌƚƵƌĞ͕ŽƌŽƚŚĞƌĂďƐĞŶĐĞƐĨƌŽŵƐĐŚĞĚƵůĞĚŚŽƵƌƐĂƌĞĚŝƐƌƵƉƚŝǀĞĂŶĚŵƵƐƚďĞĂǀŽŝĚĞĚ͘dŚĞƉƵƌƉŽƐĞŽĨ ƚŚŝƐƉŽůŝĐǇŝƐƚŽƉƌŽŵŽƚĞƚŚĞĞĨĨŝĐŝĞŶƚŽƉĞƌĂƚŝŽŶŽĨƚŚĞĐŽŵƉĂŶǇĂŶĚŵŝŶŝŵŝǌĞƵŶƐĐŚĞĚƵůĞĚĂďƐĞŶĐĞƐ͘

ƚƚĞŶĚĂŶĐĞĂŶĚƉƵŶĐƚƵĂůŝƚǇǁŝůůďĞƌĞǀŝĞǁĞĚ͕ŵĞĂƐƵƌĞĚ͕ĂŶĚǀĂůƵĞĚĂƚĞŵƉůŽǇĞĞ͛ƐĂŶŶƵĂůĞǀĂůƵĂƚŝŽŶ͘ ďƐĞŶĐĞĞĨŝŶŝƚŝŽŶƐ͗ Ŷ AbsenceŝƐƚŚĞĨĂŝůƵƌĞŽĨĂŶĞŵƉůŽǇĞĞƚŽƌĞƉŽƌƚĨŽƌǁŽƌŬǁŚĞŶƚŚĞĞŵƉůŽǇĞĞŝƐƐĐŚĞĚƵůĞĚƚŽ ǁŽƌŬ͘ďƐĞŶĐĞƐĂƌĞŵĞĂƐƵƌĞĚǁŝƚŚŝŶĂƌŽůůŝŶŐϭϮͲŵŽŶƚŚƉĞƌŝŽĚ͘

Scheduled Absence ĂƌĞƉůĂŶŶĞĚďĞƚǁĞĞŶƚŚĞƐĐŚĞĚƵůĞƌĂŶĚƚŚĞĞŵƉůŽǇĞĞŝŶĂĚǀĂŶĐĞŽĨƚŚĞĚĂƚĞŽĨ ĂďƐĞŶĐĞ͘

Ŷ Unscheduled Absence ĂƌĞŶŽƚƉůĂŶŶĞĚŝŶĂĚǀĂŶĐĞĂŶĚƌĞƋƵŝƌĞƚŚĞĞŵƉůŽǇĞĞƚŽŐŝǀĞsufficient notice (see notice below) ŽĨƚŚĞĂďƐĞŶĐĞƚŽƚŚĞŝƌƐƵƉĞƌǀŝƐŽƌ͘ tŚĞŶĂďƐĞŶĐĞƐĞǆĐĞĞĚϮϰĐŽŶƐĞĐƵƚŝǀĞƐĐŚĞĚƵůĞĚŚŽƵƌƐďĞĐĂƵƐĞŽĨŝůůŶĞƐƐŽƌŝŶũƵƌǇĞŵƉůŽǇĞĞƐŵƵƐƚ ƉƌŽǀŝĚĞƉƌŽŽĨŽĨƉŚǇƐŝĐŝĂŶ͛ƐĐĂƌĞ͘/ĨĂŶŝůůŶĞƐƐŽƌŝŶũƵƌǇƉƌĞǀĞŶƚƐĂŶĞŵƉůŽǇĞĞĨƌŽŵƉĞƌĨŽƌŵŝŶŐƚŚĞŝƌ ƌĞŐƵůĂƌůǇƐĐŚĞĚƵůĞĚĚƵƚŝĞƐ͕ĂƉŚǇƐŝĐŝĂŶ͛ƐƐƚĂƚĞŵĞŶƚŵƵƐƚďĞƉƌŽǀŝĚĞĚǀĞƌŝĨǇŝŶŐƚŚĞĨŽůůŽǁŝŶŐ͗

x dŚĂƚƚŚĞĞŵƉůŽǇĞĞŝƐĐƵƌƌĞŶƚůǇƵŶĚĞƌĂƉŚǇƐŝĐŝĂŶ͛ƐĐĂƌĞ͖ x /ĨĂŶĚǁŚĞŶƚŚĞĞŵƉůŽǇĞĞǁŝůůďĞĂďůĞƚŽƌĞƚƵƌŶƚŽǁŽƌŬ͖ĂŶĚ͕ x tŚĞƚŚĞƌŽƌŶŽƚƚŚĞĞŵƉůŽǇĞĞŝƐĐĂƉĂďůĞŽĨƉĞƌĨŽƌŵŝŶŐƚŚĞŝƌƌĞŐƵůĂƌůǇƐĐŚĞĚƵůĞĚĚƵƚŝĞƐ͕ĂŶĚŝĨŶŽƚ͕ ǁŚĂƚƉŚǇƐŝĐĂůůŝŵŝƚĂƚŝŽŶƐĞǆŝƐƚ͘

dŚĞĞŵƉůŽǇĞĞŝƐƌĞƐƉŽŶƐŝďůĞĨŽƌƉƌŽǀŝĚŝŶŐƚŚĞƉƌŽŽĨŽĨƉŚǇƐŝĐŝĂŶ͛ƐĐĂƌĞƚŽŚƵŵĂŶƌĞƐŽƵƌĐĞƐďĞĨŽƌĞ ƌĞƚƵƌŶŝŶŐƚŽĚƵƚǇ͘

Excessive absences ǁŝƚŚŝŶĂƌŽůůŝŶŐϭϮͲŵŽŶƚŚƉĞƌŝŽĚŵĂǇĂůƐŽƌĞƐƵůƚŝŶŶĞŐĂƚŝǀĞĞŵƉůŽǇĞĞĂŶŶƵĂů ĞǀĂůƵĂƚŝŽŶ͘Unscheduled absencesƚŚĂƚŽĐĐƵƌŽŶǁĞĞŬĞŶĚƐŽƌŽŶĚĞƐŝŐŶĂƚĞĚŚŽůŝĚĂǇƐǁŝůůďĞƐĐƌƵƚŝŶŝǌĞĚ ƚŚŽƌŽƵŐŚůǇĂŶĚŵĂǇŝŶĐƵƌĂĚĚŝƚŝŽŶĂůƉƌŽŐƌĞƐƐŝǀĞĚŝƐĐŝƉůŝŶĞ͘

Progressive disciplineǁŝůůďĞĂĚŵŝŶŝƐƚĞƌĞĚĂĐĐŽƌĚŝŶŐƚŽƚŚĞƉĂƌĂŐƌĂƉŚůŝƐƚĞĚďĞůŽǁ͘ EŽƚŝĐĞ ^ƵĨĨŝĐŝĞŶƚŶŽƚŝĐĞŵƵƐƚďĞŐŝǀĞŶƚŽƚŚĞŽŶͲĚƵƚǇĨŝĞůĚƐƵƉĞƌǀŝƐŽƌ͕ŽƌĨŽƌƉůĂŶŶĞĚĂďƐĞŶĐĞ͕ƚŚĞƐĐŚĞĚƵůĞƌ͘ ^ƵĨĨŝĐŝĞŶƚŶŽƚŝĐĞŝƐ͗

Cypress Creek EMS System Policies and Treatment Guidelines

75 OPERATIONAL POLICIES Revised 5/2018 Approved: Levon Vartanian, MD

x /ĨŝƚŝƐŶĞĐĞƐƐĂƌǇĨŽƌĂŶĞŵƉůŽǇĞĞƚŽĐĂůůŽĨĨĨŽƌǁŽƌŬďĞĐĂƵƐĞŽĨŝůůŶĞƐƐŽƌĂŶĞŵĞƌŐĞŶĐǇ͕ƚŚĞ ĞŵƉůŽǇĞĞŵƵƐƚŶŽƚŝĨǇƚŚĞŽŶͲĚƵƚǇƐƵƉĞƌǀŝƐŽƌas soon as possible͕ĂŶĚƉƌŝŽƌƚŽƚŚĞĞŵƉůŽǇĞĞ͛Ɛ ƐĐŚĞĚƵůĞĚƐƚĂƌƚƚŝŵĞ͘/ĨƚŚĞĞŵƉůŽǇĞĞŝƐƵŶĂďůĞƚŽĐĂůů͕ŝƚŝƐƌĞƋƵŝƌĞĚƚŚĂƚĂŶŽƚŚĞƌƉĞƌƐŽŶĐĂůůŽŶƚŚĞ ĞŵƉůŽǇĞĞ͛ƐďĞŚĂůĨ;EŽƚĞǆƚŝŶŐ͕ĞŵĂŝů͕ŽƌůĞĂǀŝŶŐĂǀŽŝĐĞŵĂŝůǁŝůůďĞĂĐĐĞƉƚĞĚ͖ĂůŝǀĞƉĞƌƐŽŶŵƵƐƚďĞ ƌĞĂĐŚĞĚͿ͘ x ^ĐŚĞĚƵůĞĚWĂŝĚdŝŵĞKĨĨƌĞƋƵĞƐƚƐƌĞƋƵŝƌĞĂŶŽƚŝĐĞŽĨƚǁŽǁĞĞŬƐ;ϭϰĚĂǇƐͿŽƌŵŽƌĞ͘^ĞĞScheduled Paid Time OffƐĞĐƚŝŽŶďĞůŽǁ͘ x ƐŚŝĨƚƚƌĂĚĞŵĂǇďĞĂƉƉƌŽǀĞĚďǇƚŚĞƐĐŚĞĚƵůĞƌŽƌĚĞƐŝŐŶĞĞŝĨŝƚďĞŶĞĨŝƚƐŽƌŐĂŶŝǌĂƚŝŽŶĂůŶĞĞĚƐĂŶĚ ĐĂŶďĞĂĐĐŽŵŵŽĚĂƚĞĚƚŽƉƌĞǀĞŶƚĂŶunscheduled absence. ;ƐĞĞƐŚŝĨƚƚƌĂĚĞƐďĞůŽǁͿ x &ŽƌĂŶemergency unscheduled absenceŽĐĐƵƌƌŝŶŐĚƵƌŝŶŐƚŚĞĞŵƉůŽǇĞĞ͛ƐƐŚŝĨƚ͕ĞŵƉůŽǇĞĞƐŵƵƐƚ ŶŽƚŝĨǇƚŚĞŽŶͲĚƵƚǇƐƵƉĞƌǀŝƐŽƌŝŵŵĞĚŝĂƚĞůǇ͕ĂŶĚŽďƚĂŝŶĂƉƉƌŽǀĂůƉƌŝŽƌƚŽůĞĂǀŝŶŐƚŚĞƉƌĞŵŝƐĞƐ͘ x dŚĞŽŶͲĚƵƚǇƐƵƉĞƌǀŝƐŽƌ͕^ĐŚĞĚƵůĞƌ͕Žƌ,ƵŵĂŶZĞƐŽƵƌĐĞƐDĂŶĂŐĞƌŵƵƐƚĂƉƉƌŽǀĞĂŶǇĞǆĐĞƉƚŝŽŶƐƚŽ ƚŚŝƐƉƌŽǀŝƐŝŽŶ͕ŽƌĂŶǇĐŽŶĨůŝĐƚƐŝŶƐĐŚĞĚƵůŝŶŐ͘ WƌŽŐƌĞƐƐŝǀĞŝƐĐŝƉůŝŶĞĨŽƌďƐĞŶĐĞƐ x dŚĞĨŝƌƐƚƵŶƐĐŚĞĚƵůĞĚĂďƐĞŶĐĞǁŝůůƌĞƐƵůƚŝŶĐŽĂĐŚŝŶŐĨƌŽŵǇŽƵƌƐƵƉĞƌǀŝƐŽƌ x dŚĞƐĞĐŽŶĚƵŶƐĐŚĞĚƵůĞĚĂďƐĞŶĐĞǁŝƚŚŝŶĂƌŽůůŝŶŐϭϮŵŽŶƚŚƉĞƌŝŽĚǁŝůůƌĞƐƵůƚŝŶĂǀĞƌďĂůǁĂƌŶŝŶŐ x dŚĞƚŚŝƌĚƵŶƐĐŚĞĚƵůĞĚĂďƐĞŶĐĞǁŝƚŚŝŶĂƌŽůůŝŶŐϭϮŵŽŶƚŚƉĞƌŝŽĚǁŝůůƌĞƐƵůƚŝŶĂǁƌŝƚƚĞŶĐŽƵŶƐĞůŝŶŐ x dŚĞĨŽƵƌƚŚƵŶƐĐŚĞĚƵůĞĚĂďƐĞŶĐĞǁŝƚŚŝŶĂƌŽůůŝŶŐϭϮŵŽŶƚŚƉĞƌŝŽĚĂƌĞƐƵďũĞĐƚƚŽĂŶƵŶƉĂŝĚ ƐƵƐƉĞŶƐŝŽŶ͘ x ŶǇƵŶƐĐŚĞĚƵůĞĚĂďƐĞŶĐĞǁŝƚŚŝŶĂƌŽůůŝŶŐϭϮŵŽŶƚŚƉĞƌŝŽĚďĞǇŽŶĚƚŚĂƚŝƐƐƵďũĞĐƚƚŽƚĞƌŵŝŶĂƚŝŽŶ͘ x ŶǇĞŵƉůŽǇĞĞǁŚŽĨĂŝůƐƚŽƌĞƉŽƌƚƚŽǁŽƌŬǁŝƚŚŽƵƚŶŽƚŝĨŝĐĂƚŝŽŶƚŽƚŚĞŽŶͲĚƵƚǇƐƵƉĞƌǀŝƐŽƌĨŽƌƚǁŽ ĐŽŶƐĞĐƵƚŝǀĞǁŽƌŬĂƐƐŝŐŶŵĞŶƚƐ;ŽƌŵŽƌĞͿǁŝůůďĞĐŽŶƐŝĚĞƌĞĚƚŽŚĂǀĞǀŽůƵŶƚĂƌŝůǇƚĞƌŵŝŶĂƚĞĚƚŚĞŝƌ ĞŵƉůŽǇŵĞŶƚƌĞůĂƚŝŽŶƐŚŝƉ͘ĨŝƌƐƚƚŝŵĞŶŽĐĂůůͬŶŽƐŚŽǁǁŚŽƌĞƉŽƌƚƐƚŽǁŽƌŬŽƌŶŽƚŝĨŝĞƐƚŚĞƐƵƉĞƌǀŝƐŽƌ ǁŝůůƌĞĐĞŝǀĞĂǁƌŝƚƚĞŶĐŽƵŶƐĞůŝŶŐ͘ x dŚŝƐƉƌŽŐƌĞƐƐŝǀĞĚŝƐĐŝƉůŝŶĞƐĐŚĞĚƵůĞŝƐĨŽĐƵƐĞĚŽŶƚŚŽƐĞǁŽƌŬŝŶŐĂϮϰͲŚŽƵƌƌŽƚĂƚŝŶŐƐĐŚĞĚƵůĞ͘ ƋƵŝƚĂďůĞĐŽŶƐŝĚĞƌĂƚŝŽŶǁŝůůďĞŐŝǀĞŶƚŽƚŚŽƐĞƉƌŝŵĂƌŝůǇĂƐƐŝŐŶĞĚƚŽŽƚŚĞƌƐŚŝĨƚůĞŶŐƚŚƐĂŶĚƌŽƚĂƚŝŽŶƐ͘ KǀĞƌƚŝŵĞ^ŚŝĨƚƐ x &ŝĞůĚƐƚĂĨĨĂƌĞƌĞƋƵŝƌĞĚƚŽǁŽƌŬŽǀĞƌƚŝŵĞĂƐĂƉĂƌƚŽĨƚŚĞŝƌƌĞŐƵůĂƌƐŚŝĨƚǁŽƌŬƐĐŚĞĚƵůĞ;ƐŽŵĞƉĞĂŬ ƚƌƵĐŬƐĐŚĞĚƵůĞƐŵĂǇŶŽƚŚĂǀĞďƵŝůƚŝŶŽǀĞƌƚŝŵĞŚŽƵƌƐͿ͘ĚĚŝƚŝŽŶĂůŽǀĞƌƚŝŵĞŚŽƵƌƐŵĂǇďĞĂǀĂŝůĂďůĞ ƚŽƚŚĞĞŵƉůŽǇĞĞ͘,ŽǁĞǀĞƌ͕ŽŶĐĞĂŶŽǀĞƌƚŝŵĞƐŚŝĨƚŝƐĂƐƐŝŐŶĞĚ͕ƚŚĂƚƐŚŝĨƚŝƐƐƵďũĞĐƚƚŽƚŚĞƐĂŵĞ ƉŽůŝĐǇƌƵůĞƐĂƐĂƌĞŐƵůĂƌůǇĂƐƐŝŐŶĞĚƐŚŝĨƚ͘WdKŚŽƵƌƐǁŝůůŶŽƚďĞĂƉƉůŝĞĚĨŽƌĂŶĂďƐĞŶĐĞĨŽƌĂŶ ŽǀĞƌƚŝŵĞƐŚŝĨƚ͕ƵŶůĞƐƐƚŚĂƚƐŚŝĨƚŝƐĂƉĂƌƚŽĨƚŚĞĞŵƉůŽǇĞĞ͛ƐƌĞŐƵůĂƌůǇƐĐŚĞĚƵůĞĚŽǀĞƌƚŝŵĞ͘ǆĐĞƐƐŝǀĞ ĂďƐĞŶĐĞƐĨƌŽŵŽǀĞƌƚŝŵĞƐŚŝĨƚƐŵĂǇƌĞƐƵůƚŝŶƚŚĞĞŵƉůŽǇĞĞďĞŝŶŐƉƌŽŚŝďŝƚĞĚĨƌŽŵƉŝĐŬŝŶŐƵƉ ĂĚĚŝƚŝŽŶĂůŽǀĞƌƚŝŵĞŚŽƵƌƐ͘ WƵŶĐƚƵĂůŝƚǇ dŚĞĞŵƉůŽǇĞĞŝƐĞǆƉĞĐƚĞĚƚŽƌĞƉŽƌƚƚŽǁŽƌŬŽŶƚŝŵĞ͕ƉƌĞĨĞƌĂďůǇϭϱŵŝŶƵƚĞƐƉƌŝŽƌƚŽĂƐĐŚĞĚƵůĞĚƐŚŝĨƚ͘ dŚĞŽŶͲĚƵƚǇĨŝĞůĚƐƵƉĞƌǀŝƐŽƌDh^dďĞĐŽŶƚĂĐƚĞĚďǇƉŚŽŶĞŝĨƚŚĞĞŵƉůŽǇĞĞǁŝůůďĞůĂƚĞ͘dŚŝƐŶŽƚŝĨŝĐĂƚŝŽŶ ƐŚŽƵůĚďĞŵĂĚĞĂƐƐŽŽŶĂƐŝƚŝƐƌĞĂůŝǌĞĚ͕ďƵƚŶŽůĂƚĞƌƚŚĂŶƚŚĞƐĐŚĞĚƵůĞĚƐƚĂƌƚƚŝŵĞĨŽƌƚŚĞƐŚŝĨƚ͕ĂƐƚŚŝƐ ĂůůŽǁƐƚŚĞŽŶͲĚƵƚǇƐƵƉĞƌǀŝƐŽƌƚŽĂĚũƵƐƚƐƚĂĨĨŝŶŐĂƐŶĞĞĚĞĚ͘/ƚŝƐĐŽŶƐŝĚĞƌĞĚĐŽƵƌƚĞŽƵƐƚŽŶŽƚŝĨǇƚŚĞ ƉĞƌƐŽŶƚŚĂƚŝƐǁĂŝƚŝŶŐĨŽƌƌĞůŝĞĨŽĨƚŚĞĞŵƉůŽǇĞĞ͛ƐĞƐƚŝŵĂƚĞĚƚŝŵĞŽĨĂƌƌŝǀĂů͘

Cypress Creek EMS System Policies and Treatment Guidelines

76 OPERATIONAL POLICIES Revised 5/2018 Approved: Levon Vartanian, MD

WƌŽŐƌĞƐƐŝǀĞŝƐĐŝƉůŝŶĞĨŽƌdĂƌĚŝŶĞƐƐ x hŶƌĞƉŽƌƚĞĚƚĂƌĚŝŶĞƐƐŝƐƐƵďũĞĐƚƚŽĂǁƌŝƚƚĞŶĐŽƵŶƐĞůŝŶŐŽŶƚŚĞĨŝƌƐƚŽĐĐƵƌƌĞŶĐĞ x ǆĐĞƐƐŝǀĞƚĂƌĚŝŶĞƐƐǁŝůůďĞƌĞĨůĞĐƚĞĚŽŶĂŶŶƵĂůƉĞƌĨŽƌŵĂŶĐĞĞǀĂůƵĂƚŝŽŶƐĂŶĚŵĂǇƌĞƐƵůƚŝŶ͗ o sĞƌďĂůĂŶĚͬŽƌǁƌŝƚƚĞŶĐŽƵŶƐĞůŝŶŐŝĨ͖ x DƵůƚŝƉůĞƚĂƌĚŝĞƐŽĐĐƵƌǁŝƚŚŝŶĂƐŚŽƌƚƚŝŵĞĨƌĂŵĞĂŶĚͬŽƌ x dŚĞƚĂƌĚǇĐƌĞĂƚĞƐĂĚŝƐƌƵƉƚŝŽŶŝŶƚŚĞĐŽŶƚŝŶƵŝƚǇŽĨĨŝĞůĚŽƉĞƌĂƚŝŽŶƐĂŶĚͬŽƌ x dŚĞƚĂƌĚǇŝŶĐƵƌƐĂĚĚŝƚŝŽŶĂůŽǀĞƌƚŝŵĞĐŽƐƚƐĨŽƌƚŚĞĐŽŵƉĂŶǇ x dŝŵĞĚĞĚƵĐƚĞĚĨƌŽŵƉĂǇŽƌWdKďĂŶŬ;ŝŶŝŶĐƌĞŵĞŶƚƐŽĨϬ͘ϮϱŚŽƵƌƐͿ DĂŶĚĂƚŽƌǇDĞĞƚŝŶŐƐĂŶĚŽŶƚŝŶƵŝŶŐĚƵĐĂƚŝŽŶ D^ŵĂŶĚĂƚŽƌǇŵĞĞƚŝŶŐƐĂŶĚŵĂŶĚĂƚŽƌǇĐŽŶƚŝŶƵŝŶŐĞĚƵĐĂƚŝŽŶĂƌĞĚĞƐŝŐŶĞĚƚŽŐŝǀĞĞŵƉůŽǇĞĞƐƵƉͲ ƚŽͲĚĂƚĞŝŶĨŽƌŵĂƚŝŽŶĂŶĚĐŽŵŵƵŶŝĐĂƚŝŽŶƌĞŐĂƌĚŝŶŐŽƉĞƌĂƚŝŽŶƐĂŶĚĐůŝŶŝĐĂůƉƌĂĐƚŝĐĞ͘^ƵĨĨŝĐŝĞŶƚŶŽƚŝĐĞǁŝůů ďĞŐŝǀĞŶƚŽĞŵƉůŽǇĞĞƐƚŽŵĂŬĞŶĞĐĞƐƐĂƌǇĂƌƌĂŶŐĞŵĞŶƚƐĨŽƌĂƚƚĞŶĚĂŶĐĞ͘DĂŶǇƚŝŵĞƐ͕ŵƵůƚŝƉůĞ ŽƉƉŽƌƚƵŶŝƚŝĞƐǁŝůůďĞŵĂĚĞĂǀĂŝůĂďůĞƚŽĂĐĐŽŵŵŽĚĂƚĞŽƵƌŵƵůƚŝƉůĞƐŚŝĨƚƐ͘ƵĞƚŽƚŚĞŶĂƚƵƌĞŽĨƚŚĞƐĞ ŵĞĞƚŝŶŐƐ͕ŝƚŝƐŝŵƉŽƌƚĂŶƚĨŽƌĂůůĨŝĞůĚĞŵƉůŽǇĞĞƐƚŽƌĞĐĞŝǀĞƚŚŝƐŝŶĨŽƌŵĂƚŝŽŶ͘DĂŶĚĂƚŽƌǇŵĞĞƚŝŶŐƐĂƌĞƚŚĞ ƌĞƐƉŽŶƐŝďŝůŝƚǇŽĨƚŚĞĞŵƉůŽǇĞĞĂŶĚǁŝůůďĞƐƵďũĞĐƚƚŽƚŚĞƐĂŵĞƌƵůĞƐĂƐĂƌĞŐƵůĂƌƐŚŝĨƚ͘/ŶƐŽŵĞĐĂƐĞƐ͕ ŵĞĚŝĐĂůĐƌĞĚĞŶƚŝĂůƐĐĂŶďĞƐƵƐƉĞŶĚĞĚƵŶƚŝůƌĞƋƵŝƌĞĚĞĚƵĐĂƚŝŽŶŚĂƐďĞĞŶĂĐĐŽŵƉůŝƐŚĞĚ͘ ĞƐƚWƌĂĐƚŝĐĞƐĨŽƌ^ĐŚĞĚƵůŝŶŐ dŝŵĞŽĨĨŝƐŝŵƉŽƌƚĂŶƚƚŽŵĂŝŶƚĂŝŶĂŚĞĂůƚŚǇǁŽƌŬͲůŝĨĞďĂůĂŶĐĞŝŶƚŚĞĚĞŵĂŶĚŝŶŐĨŝĞůĚŽĨĞŵĞƌŐĞŶĐǇ ŵĞĚŝĐĂůƐĞƌǀŝĐĞƐ͚͘ĞƐƚWƌĂĐƚŝĐĞƐ͛ĨŽƌƐĐŚĞĚƵůŝŶŐŝƐĂŐƵŝĚĞƚŽƚŚĞƐĐŚĞĚƵůŝŶŐƉƌŽĐĞĚƵƌĞƐŽĨD^ĨŝĞůĚ ƐƚĂĨĨŽƉĞƌĂƚŝŽŶƐ͘/ƚŝƐĚĞƐŝŐŶĞĚƚŽďĞĨĂŝƌĂŶĚĐŽŶƐŝƐƚĞŶƚƚŽĂůůĨŝĞůĚƐƚĂĨĨǁŚŝůĞĂĐĐŽŵƉůŝƐŚŝŶŐƚŚĞŵŝƐƐŝŽŶ ŽĨŽƉĞƌĂƚŝŶŐĂůůƵŶŝƚƐĂĐĐŽƌĚŝŶŐƚŽƚŚĞĐƵƌƌĞŶƚƐƚĂĨĨŝŶŐƉůĂŶ͘ ^ĐŚĞĚƵůĞĚWĂŝĚdŝŵĞKĨĨ x WdKƌĞƋƵĞƐƚƐŵƵƐƚďĞƐƵďŵŝƚƚĞĚŝŶǁƌŝƚŝŶŐƚŽƚŚĞ^ĐŚĞĚƵůĞƌĂƚůĞĂƐƚϮǁĞĞŬƐŝŶĂĚǀĂŶĐĞ͕ďƵƚŶŽ ŵŽƌĞƚŚĂŶϲϬĚĂǇƐŝŶĂĚǀĂŶĐĞ x dŚĞĞŵƉůŽǇĞĞƐŚŽƵůĚƐƵďŵŝƚƚŚĞƚŝŵĞŽĨĨƌĞƋƵĞƐƚƚŚƌŽƵŐŚƚŚĞŽŶͲůŝŶĞƐĐŚĞĚƵůŝŶŐƉƌŽŐƌĂŵEƐĞŶĚ ĂŶĞŵĂŝůĚŝƌĞĐƚůǇƚŽƚŚĞ^ĐŚĞĚƵůĞƌǁŝƚŚƚŚĞŶĂƚƵƌĞĂŶĚĚƵƌĂƚŝŽŶŽĨƚŚĞƌĞƋƵĞƐƚĨŽƌWdK x 'ĞŶĞƌĂůůǇ͕ŽŶůǇϮ/WƐĂŶĚϮƚƚĞŶĚĂŶƚƐŵĂǇďĞŐƌĂŶƚĞĚWdKƉĞƌƐŚŝĨƚ͕ƐŽĞŵƉůŽǇĞĞƐĂƌĞƐƚƌŽŶŐůǇ ĞŶĐŽƵƌĂŐĞĚƚŽƌĞƋƵĞƐƚWdKĂƐĞĂƌůǇĂƐƉŽƐƐŝďůĞ x dŚĞ^ĐŚĞĚƵůĞƌǁŝůůŶŽƚŝĨǇƚŚĞĞŵƉůŽǇĞĞƚŚĂƚƚŚĞƚŝŵĞŽĨĨƌĞƋƵĞƐƚŚĂƐďĞĞŶƌĞĐĞŝǀĞĚĂŶĚǁŝůů ĐŽŵŵƵŶŝĐĂƚĞǁŚĞŶƚŚĞƌĞƋƵĞƐƚŝƐ͞ƉƉƌŽǀĞĚ͟Žƌ͞ĞŶŝĞĚ͕͟ŽƌŵĂǇŽĨĨĞƌĂŶĂůƚĞƌŶĂƚŝǀĞƐĐŚĞĚƵůĞƚŽ ĂĐĐŽŵŵŽĚĂƚĞƚŚĞƚŝŵĞŽĨĨƌĞƋƵĞƐƚ x dŚĞĞŵƉůŽǇĞĞŵĂǇĨŝŶĚƚŚĞŝƌŽǁŶĐŽǀĞƌĂŐĞĂŶĚͬŽƌƵƚŝůŝǌĞĂƐŚŝĨƚƚƌĂĚĞ͕KE>zǁŝƚŚƚŚĞĂƉƉƌŽǀĂůŽĨ ƚŚĞ^ĐŚĞĚƵůĞƌ x ŵƉůŽǇĞĞƐŵƵƐƚŚĂǀĞĂƐƵĨĨŝĐŝĞŶƚďĂŶŬŽĨWdKŚŽƵƌƐŝŶŽƌĚĞƌƚŽďĞŐƌĂŶƚĞĚƚŝŵĞŽĨĨǁŝƚŚŽƵƚƉĞŶĂůƚǇ͖ ĂŶĞŵƉůŽǇĞĞƚŚĂƚĚĞƉůĞƚĞƐƚŚĞŝƌWdKďĂŶŬĂŶĚŝƐƵŶĂďůĞƚŽǁŽƌŬƚŚĞŝƌŚŽƵƌƐƌĞƋƵŝƌĞĚĨŽƌĨƵůůƚŝŵĞ ĞŵƉůŽǇŵĞŶƚŝƐƐƵďũĞĐƚƚŽƉƌŽŐƌĞƐƐŝǀĞĚŝƐĐŝƉůŝŶĞ͕ƵƉƚŽĂŶĚŝŶĐůƵĚŝŶŐƚĞƌŵŝŶĂƚŝŽŶŽĨĞŵƉůŽǇŵĞŶƚ͘

Cypress Creek EMS System Policies and Treatment Guidelines

77 OPERATIONAL POLICIES Revised 5/2018 Approved: Levon Vartanian, MD

x Days Unavailable for Paid Time Off: ƵĞƚŽƚŚĞŽƉĞƌĂƚŝŽŶĂůĚĞŵĂŶĚƐŽĨƚŚĞŽƌŐĂŶŝǌĂƚŝŽŶ͕ƚŚĞƌĞǁŝůů ďĞĚĂǇƐƚŚĂƚĂƌĞĚĞƐŝŐŶĂƚĞĚĂƐ͚hŶĂǀĂŝůĂďůĞĨŽƌWdK͛͘dŚŝƐĐŽƵůĚŝŶĐůƵĚĞ͕ďƵƚŝƐŶŽƚůŝŵŝƚĞĚƚŽ͕ƚŚĞ ĚĞƐŝŐŶĂƚĞĚŚŽůŝĚĂǇƐůŝƐƚĞĚďĞůŽǁ͕ĂŶĚͬŽƌƐƉĞĐŝĂůĞǀĞŶƚƐŽƌƚƌĂŝŶŝŶŐƚŚĂƚƌĞƋƵŝƌĞĂĚĚŝƚŝŽŶĂůƐƚĂĨĨŝŶŐ ƌĞƐŽƵƌĐĞƐƚŽĂĐĐŽŵƉůŝƐŚƚŚĞŵŝƐƐŝŽŶ͘

,ŽůŝĚĂǇƐ x WdKǁŝůůŶŽƚďĞŽĨĨĞƌĞĚŽŶĚĞƐŝŐŶĂƚĞĚŚŽůŝĚĂǇƐ;ƐĞĞďĞůŽǁͿƵŶůĞƐƐĂůůƐŚŝĨƚƐĂƌĞĐŽǀĞƌĞĚĂŶĚ ŵĂŶĂŐĞŵĞŶƚŚĂƐopenedƚŚĞŚŽůŝĚĂǇĨŽƌWdKƌĞƋƵĞƐƚƐ o KŶĐĞWdKŚĂƐďĞĞŶŽƉĞŶĞĚ͕ĂĨŽƌŵĂůƌĞƋƵĞƐƚŝƐƌĞƋƵŝƌĞĚƚŚƌŽƵŐŚƚŚĞƐĐŚĞĚƵůŝŶŐƉƌŽŐƌĂŵ;ĂŶ ĞŵĂŝůƚŽƚŚĞ^ĐŚĞĚƵůĞƌŝƐĂůƐŽŶĞĞĚĞĚͿ o ^ĞŶŝŽƌŝƚǇǁŝůůďĞƵƐĞĚƚŽƉƌŝŽƌŝƚŝǌĞĂƉƉƌŽǀĂů o ŵƉůŽǇĞĞŵĂǇ͚ĨŝŶĚƚŚĞŝƌŽǁŶĐŽǀĞƌĂŐĞ͛ŝĨĂůůŽƚŚĞƌŽƉĞŶƐŚŝĨƚƐĂƌĞĐŽǀĞƌĞĚ**note: employees are not allowed to work greater than 36 consecutive hours o ŵƉůŽǇĞĞŵĂǇƵƚŝůŝǌĞĂ^ŚŝĨƚdƌĂĚĞŝĨĂƉƉƌŽǀĞĚďǇƚŚĞƐĐŚĞĚƵůŝŶŐŽĨĨŝĐĞ͕ĂŶĚŝĨƚŚĞƚƌĂĚĞĂĚŚĞƌĞƐ ƚŽƚŚĞƐŚŝĨƚƚƌĂĚĞŐƵŝĚĞůŝŶĞƐ

dŚĞĨŽůůŽǁŝŶŐŝƐĂůŝƐƚŽĨdesignated holidays͗

EĞǁzĞĂƌ͛ƐǀĞ;ĞĐĞŵďĞƌϯϭͿ EĞǁzĞĂƌΖƐĂǇ;:ĂŶƵĂƌǇϭͿ 'ŽŽĚ&ƌŝĚĂǇ;&ƌŝĚĂǇďĞĨŽƌĞĂƐƚĞƌͿ ĂƐƚĞƌ DĞŵŽƌŝĂůĂǇ;ůĂƐƚDŽŶĚĂǇŝŶDĂǇͿ /ŶĚĞƉĞŶĚĞŶĐĞĂǇ;:ƵůǇϰͿ >ĂďŽƌĂǇ;ĨŝƌƐƚDŽŶĚĂǇŝŶ^ĞƉƚĞŵďĞƌͿ dŚĂŶŬƐŐŝǀŝŶŐ;ĨŽƵƌƚŚdŚƵƌƐĚĂǇŝŶEŽǀĞŵďĞƌͿ ŚƌŝƐƚŵĂƐǀĞ;ĞĐĞŵďĞƌϮϰͿ ŚƌŝƐƚŵĂƐ;ĞĐĞŵďĞƌϮϱͿ

^ŚŝĨƚdƌĂĚĞ'ƵŝĚĞůŝŶĞƐ x ^ŚŝĨƚƚƌĂĚĞƐĂƌĞĞŶĐŽƵƌĂŐĞĚĂƐůŽŶŐĂƐƚŚĞǇŵĞĞƚƚŚĞĨŽůůŽǁŝŶŐŐƵŝĚĞůŝŶĞƐ͗ o ^ŚŝĨƚƚƌĂĚĞƐŵƵƐƚďĞŝŶƚŚĞƐĂŵĞƉĂǇǁĞĞŬ;^ƵŶĚĂǇͲ^ĂƚƵƌĚĂǇͿ o ZĞƋƵĞƐƚƐŵƵƐƚďĞŵĂĚĞƚŚƌŽƵŐŚƚŚĞŽŶͲůŝŶĞƐĐŚĞĚƵůŝŶŐƉƌŽŐƌĂŵ o ZĞƋƵĞƐƚƐŵƵƐƚďĞĂƉƉƌŽǀĞĚďǇƚŚĞƐĐŚĞĚƵůŝŶŐŽĨĨŝĐĞ o ^ŚŝĨƚƚƌĂĚĞƐĐĂŶŶŽƚďĞĂƉƉƌŽǀĞĚďǇƚŚĞŽŶͲĚƵƚǇƐƵƉĞƌǀŝƐŽƌǁŝƚŚŽƵƚĂĚĚŝƚŝŽŶĂůŵĂŶĂŐĞŵĞŶƚ ĂƉƉƌŽǀĂů o EKd͗ŵƉůŽǇĞĞƐĂƌĞŶŽƚĂůůŽǁĞĚƚŽǁŽƌŬŐƌĞĂƚĞƌƚŚĂŶϯϲĐŽŶƐĞĐƵƚŝǀĞŚŽƵƌƐ

Cypress Creek EMS System Policies and Treatment Guidelines

78 OPERATIONAL POLICIES Revised 5/2018 Approved: Levon Vartanian, MD

dŚĞ^ĐŚĞĚƵůĞƌĂŶĚ^ĐŚĞĚƵůŝŶŐWƌŽŐƌĂŵ x dŚĞ^ĐŚĞĚƵůĞƌ͕ǁŝƚŚŽǀĞƌƐŝŐŚƚĨƌŽŵƚŚĞ,ƵŵĂŶZĞƐŽƵƌĐĞƐDĂŶĂŐĞƌ͕ƐĞƌǀĞƐĂƐƚŚĞWZ/DZzƉŽŝŶƚŽĨ ĐŽŶƚĂĐƚĨŽƌĂůůƐĐŚĞĚƵůĞƌĞƋƵĞƐƚƐ x ůůƐĐŚĞĚƵůŝŶŐ͕^ŚŝĨƚdƌĂĚĞƐ͕ĂŶĚWdKƌĞƋƵĞƐƚƐǁŝůůďĞƌĞĐŽƌĚĞĚƚŚƌŽƵŐŚƚŚĞĂƉƉƌŽǀĞĚŽŶͲůŝŶĞ ƐĐŚĞĚƵůŝŶŐƉƌŽŐƌĂŵ x ĞƉĂƌƚŵĞŶƚDĂŶĂŐĞƌƐĂŶĚ&ŝĞůĚ^ƵƉĞƌǀŝƐŽƌƐŚĂǀĞĂĐĐĞƐƐƚŽǀŝĞǁĂŶĚĂĚũƵƐƚƐĐŚĞĚƵůĞƐĂƐŶĞĞĚĞĚĨŽƌ ĐƌŝƐŝƐƐĐŚĞĚƵůŝŶŐ

WĞĂƌůƐĨŽƌƚƚĞŶĚĂŶĐĞ͕WdK͕ĂŶĚWƵŶĐƚƵĂůŝƚǇ x <ĞĞƉǇŽƵƌƐĞůĨŚĞĂůƚŚǇ͖hƐĞWdKĨŽƌǀĂĐĂƚŝŽŶĚĂǇƐĂŶĚƉĞƌƐŽŶĂůĚĂǇƐŽĨĨ x hƐĞĂĐĂůĞŶĚĂƌƚŽŬĞĞƉƚƌĂĐŬŽĨƐŚŝĨƚǁŽƌŬ͕ŝŵƉŽƌƚĂŶƚĨĂŵŝůǇĂŶĚƉĞƌƐŽŶĂůĞǀĞŶƚƐ x ^ĐŚĞĚƵůĞĞŶƚŝƐƚ͕ŽĐƚŽƌ͕ĂŶĚŽƚŚĞƌƉĞƌƐŽŶĂůĂƉƉŽŝŶƚŵĞŶƚƐŽŶĚĂǇƐŽĨĨ x /ĨǇŽƵŶĞĞĚŽĨĨĨŽƌƉĞƌƐŽŶĂůͬĨĂŵŝůǇĂĐƚŝǀŝƚŝĞƐ͕ƚƌĂĚĞŽƌƌĞƋƵĞƐƚƚŝŵĞŽĨĨǁĞůůŝŶĂĚǀĂŶĐĞ x ŚĞĐŬƐĐŚĞĚƵůŝŶŐƉƌŽŐƌĂŵĨƌĞƋƵĞŶƚůǇĨŽƌĂŶǇĐŚĂŶŐĞƐ x ŚĞĐŬĐŽŵƉĂŶǇĞŵĂŝůĨŽƌŝŵƉŽƌƚĂŶƚĐŽŵŵƵŶŝĐĂƚŝŽŶƐǁŚŝĐŚĐŽƵůĚĂĨĨĞĐƚǇŽƵƌƐĐŚĞĚƵůĞ x ,ĂǀĞďĂĐŬƵƉƉůĂŶƐĨŽƌĚĂǇĐĂƌĞ x <ĞĞƉǀĞŚŝĐůĞŝŶŐŽŽĚǁŽƌŬŝŶŐŽƌĚĞƌ x >ĞĂǀĞϭϱŵŝŶƵƚĞƐĞĂƌůŝĞƌƚŚĂŶǇŽƵŶŽƌŵĂůůǇĞǆƉĞĐƚƚŽůĞĂǀĞ x ,ĂǀĞĂďĂĐŬͲƵƉĂůĂƌŵĐůŽĐŬ x ƌŝŶŐĂŶĞǆƚƌĂƵŶŝĨŽƌŵƚŽǁŽƌŬŝŶĐĂƐĞŽĨŐƌŽƐƐĚĞĐŽŶƚĂŵŝŶĂƚŝŽŶ

Cypress Creek EMS System Policies and Treatment Guidelines

79 OPERATIONAL POLICIES Revised 6/2016 Approved: Levon Vartanian, MD

hƐĞŽĨ>ŝŐŚƚƐĂŶĚ^ŝƌĞŶƐ

ůůD^ĞŵĞƌŐĞŶĐǇǀĞŚŝĐůĞƐĂƌĞĞƋƵŝƉƉĞĚǁŝƚŚĂŶĞŵĞƌŐĞŶĐǇůŝŐŚƚŝŶŐĂŶĚƐŝƌĞŶƐǇƐƚĞŵ͘dŚŝƐƉŽůŝĐǇŝƐ ĚĞƐŝŐŶĞĚƚŽƉƌŽǀŝĚĞŐƵŝĚĂŶĐĞĨŽƌƚŚĞƵƐĞŽĨƚŚĞƐĞĞŵĞƌŐĞŶĐǇƐǇƐƚĞŵƐ͘ tŚĞŶĚƌŝǀŝŶŐǁŝƚŚƚŚĞŝƌĞŵĞƌŐĞŶĐǇƐǇƐƚĞŵƐĂĐƚŝǀĂƚĞĚ͕ĂůůD^ƵŶŝƚƐƐŚŽƵůĚĚƌŝǀĞǁŝƚŚĚƵĞƌĞŐĂƌĚĂŶĚ ĞǆƚƌĞŵĞĐĂƵƚŝŽŶ͘ ZĞƐƉŽŶĚŝŶŐƚŽĂůů͗ x ŵĞƌŐĞŶĐǇZĞƐƉŽŶƐĞ͗/ƚŝƐĐƵƌƌĞŶƚƉŽůŝĐǇĨŽƌĂůůD^ƵŶŝƚƐƚŽƌĞƐƉŽŶĚǁŝƚŚƚŚĞŝƌůŝŐŚƚƐĂŶĚƐŝƌĞŶƐ ĂĐƚŝǀĂƚĞĚ;ĞŵĞƌŐĞŶĐǇͿǁŚĞŶƌĞƐƉŽŶĚŝŶŐƚŽĂůůϵϭϭĐĂůůƐŽƌƚŽĐĂůůƐĨŽƌĂƐƐŝƐƚĂŶĐĞǁŚĞƌĞĂƉĂƚŝĞŶƚ ƌĞƋƵŝƌŝŶŐŵĞĚŝĐĂůĂƚƚĞŶƚŝŽŶŝƐƚŚŽƵŐŚƚƚŽĞǆŝƐƚ͘ x ƵƌŝŶŐ͞ĞŵĞƌŐĞŶĐǇ͟ƚƌĂĨĨŝĐ;ƌĞƐƉŽŶĚŝŶŐƚŽĂĐĂůůŽƌĞŶƌŽƵƚĞƚŽŚŽƐƉŝƚĂůͿ͕ďŽƚŚƚŚĞůŝŐŚƚƐĂŶĚƐŝƌĞŶƐ ŵƵƐƚďĞŽƉĞƌĂƚĞĚƐŝŵƵůƚĂŶĞŽƵƐůǇ͘ x ŽǁŶŐƌĂĚĞ͗ŶD^ƵŶŝƚŵĂǇĚĞĂĐƚŝǀĂƚĞƚŚĞŝƌĞŵĞƌŐĞŶĐǇƐǇƐƚĞŵ;ŶŽŶͲĞŵĞƌŐĞŶĐǇͿĂƚƚŚĞ ĂĚǀŝƐĞŵĞŶƚŽĨĂƐĞƉĂƌĂƚĞĞŵĞƌŐĞŶĐǇƌĞƐƉŽŶĚĞƌĂůƌĞĂĚǇŽŶƐĐĞŶĞ͘dŚĞƐĞƉĂƌĂƚĞĞŵĞƌŐĞŶĐǇ ƌĞƐƉŽŶĚĞƌŵƵƐƚŚĂǀĞĂůƌĞĂĚǇŵĂĚĞƉĂƚŝĞŶƚĐŽŶƚĂĐƚĂŶĚŚĂǀĞƐƵĨĨŝĐŝĞŶƚƌĞĂƐŽŶƚŽďĞůŝĞǀĞƚŚĂƚƚŚĞ ƉĂƚŝĞŶƚ͛ƐŵĞĚŝĐĂůĐŽŶĚŝƚŝŽŶŝƐŽďǀŝŽƵƐůǇŶŽŶͲůŝĨĞƚŚƌĞĂƚĞŶŝŶŐĂŶĚŶŽŶͲƵƌŐĞŶƚ͘dŚĞĚĞĐŝƐŝŽŶƚŽ ĚŽǁŶŐƌĂĚĞŝƐƵůƚŝŵĂƚĞůǇƚŚĞĚĞĐŝƐŝŽŶŽĨƚŚĞ/ŶͲŚĂƌŐĞWĂƌĂŵĞĚŝĐ͘ x WĂƚŝĞŶƚZĞƋƵĞƐƚ͗KŶŽĐĐĂƐŝŽŶ͕D^ƌĞĐĞŝǀĞƐƌĞƋƵĞƐƚƐĨƌŽŵƉĂƚŝĞŶƚƐŽƌĨĂŵŝůǇŵĞŵďĞƌƐƌĞƋƵĞƐƚŝŶŐ D^ƚŽŶŽƚƌĞƐƉŽŶĚǁŝƚŚ͕ŽƌĚĞĂĐƚŝǀĂƚĞƚŚĞŝƌĞŵĞƌŐĞŶĐǇƐǇƐƚĞŵƐĂƐƚŚĞǇĂƉƉƌŽĂĐŚƚŚĞƐĐĞŶĞ͘ D^ĂƐƐƵŵĞƐƚŚĂƚŽŶĂĐƚŝǀĂƚŝŽŶŽĨϵϭϭ͕ĂƉĂƚŝĞŶƚŽƌĨĂŵŝůǇŵĞŵďĞƌǁŝƐŚĞƐĨŽƌD^ƚŽĂƌƌŝǀĞĂƐ ƋƵŝĐŬůǇĂƐƉŽƐƐŝďůĞ͘dŚŝƐĚĞĐŝƐŝŽŶƵůƚŝŵĂƚĞůǇůŝĞƐǁŝƚŚƚŚĞ/ŶͲŚĂƌŐĞWĂƌĂŵĞĚŝĐ͘,ŽǁĞǀĞƌ͕ƚŚĞD^ ƵŶŝƚƐŚŽƵůĚŶŽƚĚĞĂĐƚŝǀĂƚĞƚŚĞŝƌĞŵĞƌŐĞŶĐǇƐǇƐƚĞŵǁŚĞŶƚŚĞǇĂƌĞĨƵƌƚŚĞƌƚŚĂŶϱϬϬĨĞĞƚĨƌŽŵƚŚĞ ĞŵĞƌŐĞŶĐǇƐĐĞŶĞ͕ŽƌŝĨƚŚĞĚĞĂĐƚŝǀĂƚŝŽŶŽĨƚŚĞĞŵĞƌŐĞŶĐǇƐǇƐƚĞŵǁŽƵůĚĐĂƵƐĞĂŶŝŶĐƌĞĂƐĞĚ ƌĞƐƉŽŶƐĞƚŝŵĞƚŽƚŚĞƐĐĞŶĞ͘ x WƵďůŝĐZĞůĂƚŝŽŶƐZĞƋƵĞƐƚ͗&ƌĞƋƵĞŶƚůǇ͕ƚŚĞƉƵďůŝĐǁŝůůĐŽŶƚĂĐƚD^ĂŶĚƌĞƋƵĞƐƚƚŚĂƚĂŶĂŵďƵůĂŶĐĞ ďĞŝŶĂƚƚĞŶĚĂŶĐĞĂƚĂƐƚĂŶĚďǇŽƌĞĚƵĐĂƚŝŽŶĂůĞǀĞŶƚ͘D^ƵŶŝƚƐǁŝůůĂůǁĂǇƐƌĞƐƉŽŶĚƚŽƚŚĞƐĞ ůŽĐĂƚŝŽŶƐǁŝƚŚƚŚĞŝƌĞŵĞƌŐĞŶĐǇƐǇƐƚĞŵƐĚĞĂĐƚŝǀĂƚĞĚ͘ KŶ^ĐĞŶĞ͗ ŶD^ƵŶŝƚŽŶƚŚĞƐĐĞŶĞŽĨĂŶŝŶĐŝĚĞŶƚƐŚŽƵůĚĐŽŶƚŝŶƵĞƚŽŚĂǀĞƚŚĞŝƌĞŵĞƌŐĞŶĐǇůŝŐŚƚƐĂĐƚŝǀĂƚĞĚǁŚĞŶ͗ x dŚĞƵŶŝƚƉůĂĐĞŵĞŶƚŽŶƐĐĞŶĞƉƌĞǀĞŶƚƐƚŚĞƌĞŐƵůĂƌĨůŽǁŽĨƚƌĂĨĨŝĐ x dŚĞƵŶŝƚƉůĂĐĞŵĞŶƚŽŶƐĐĞŶĞŝƐŝŶĐŽŶĨůŝĐƚǁŝƚŚŽƚŚĞƌƉĂƌŬĞĚǀĞŚŝĐůĞƐŝŶƚŚĞĂƌĞĂ;ŶŽƚƉĂƌŬĞĚŝŶĂ ƉĂƌŬŝŶŐƐƉŽƚͿ x ƚŶŝŐŚƚƚŝŵĞŽƌĂŶǇƚŝŵĞǁŚĞƌĞŝŶĐƌĞĂƐĞĚǀŝƐŝďŝůŝƚǇŝƐŶĞĞĚĞĚ x tŚŝůĞŽŶĂŶĂĐƚŝǀĞƌŽĂĚǁĂǇ dƌĂŶƐƉŽƌƚŝŶŐƚŽƚŚĞ,ŽƐƉŝƚĂů͗ dŚĞƵƐĞŽĨĞŵĞƌŐĞŶĐǇůŝŐŚƚƐĂŶĚƐŝƌĞŶĚƵƌŝŶŐƚƌĂŶƐƉŽƌƚŽĨĂƉĂƚŝĞŶƚƚŽĂŚŽƐƉŝƚĂůƐŚŽƵůĚŽŶůǇďĞƵƚŝůŝǌĞĚ ǁŚĞŶĂůůŽĨƚŚĞĨŽůůŽǁŝŶŐĐŽŶĚŝƚŝŽŶƐĂƌĞŵĞƚ͘ x ŵĞƌŐĞŶĐǇƚƌĂŶƐƉŽƌƚǁŽƵůĚƐĂǀĞƚŝŵĞ x dŚĞƉĂƚŝĞŶƚƌĞƋƵŝƌĞƐĞŵĞƌŐĞŶƚƚƌĞĂƚŵĞŶƚĂƚƚŚĞŚŽƐƉŝƚĂůƚŚĂƚŝƐŶŽƚĂǀĂŝůĂďůĞŝŶƚŚĞĂŵďƵůĂŶĐĞ͘ x dŚĞƚŝŵĞƐĂǀĞĚĂŶĚŚŽƐƉŝƚĂůƚƌĞĂƚŵĞŶƚĂƌĞĂŶƚŝĐŝƉĂƚĞĚƚŽƉŽƐŝƚŝǀĞůǇĂĨĨĞĐƚƚŚĞƉĂƚŝĞŶƚ͛ƐŽƵƚĐŽŵĞ

Cypress Creek EMS System Policies and Treatment Guidelines

80 TRANSPORT DESTINATION DETERMINATION Revised 8/2016 Approved: Levon Vartanian, MD

dƌĂŶƐƉŽƌƚĞƐƚŝŶĂƚŝŽŶĞƚĞƌŵŝŶĂƚŝŽŶ

General Transport Guidelines ...... 82 Pediatric Patients ...... 83 Post-Cardiac Arrest ...... 84 Trauma and Burns ...... 85 STEMI ...... 87 Stroke ...... 88

Cypress Creek EMS System Policies and Treatment Guidelines

81 TRANSPORT DESTINATION DETERMINATION Revised 8/2016 Approved: Levon Vartanian, MD

'ĞŶĞƌĂůdƌĂŶƐƉŽƌƚ'ƵŝĚĞůŝŶĞƐ Purpose ůůƉĂƚŝĞŶƚƐƌĞƋƵĞƐƚŝŶŐĂŵďƵůĂŶĐĞƚƌĂŶƐƉŽƌƚƐŚŽƵůĚďĞƚƌĂŶƐƉŽƌƚĞĚďǇƚŚĞƌĞƐƉŽŶĚŝŶŐĂŵďƵůĂŶĐĞ͘dŚĞ ĨŽůůŽǁŝŶŐĂƌĞƚŚĞƉƌŽĐĞĚƵƌĞƐĨŽƌƚƌĂŶƐƉŽƌƚŝŶŐĐƌŝƚŝĐĂůĂŶĚŶŽŶͲĐƌŝƚŝĐĂůƉĂƚŝĞŶƚƐ͘ WůĂŶ x dŚĞŵĞĚŝĐĂůŶĞĞĚƐŽĨƚŚĞƉĂƚŝĞŶƚǁŝůůĂůǁĂǇƐďĞƚŚĞƉƌŝŵĂƌǇĐŽŶƐŝĚĞƌĂƚŝŽŶŝŶĚĞƚĞƌŵŝŶŝŶŐƚƌĂŶƐƉŽƌƚ ĚĞƐƚŝŶĂƚŝŽŶ͘ x ǆĐůƵĚŝŶŐŵƵůƚŝͲƉĂƚŝĞŶƚƐŝƚƵĂƚŝŽŶƐ,ƚƌĂŶƐƉŽƌƚŽĨƚŚĞŶŽŶͲƵƌŐĞŶƚƉĂƚŝĞŶƚƐŚĂůůďĞƚŽƚŚĞŚŽƐƉŝƚĂůŽĨƚŚĞ ƉĂƚŝĞŶƚ͛ƐĐŚŽŝĐĞ͕ǁŝƚŚĐŽŶƐŝĚĞƌĂƚŝŽŶŵĂĚĞƚŽƚŚĞƐǇƐƚĞŵƐƚĂƚƵƐĂƚƚŚĞƚŝŵĞŽĨƚƌĂŶƐƉŽƌƚ͘^ŚŽƵůĚƚŚĞ ƐǇƐƚĞŵďĞĂƚůĞǀĞůϯŽƌďĞůŽǁĂƚƚŚĞƚŝŵĞŽĨƚƌĂŶƐƉŽƌƚ͕ƚŚĞƉĂƚŝĞŶƚƐŚĂůůďĞŽĨĨĞƌĞĚƚƌĂŶƐƉŽƌƚƚŽĂ ŚŽƐƉŝƚĂůǁŝƚŚŝŶƚŚĞƐĞƌǀŝĐĞĂƌĞĂ͕ŽƌĂƉƌŝǀĂƚĞƚƌĂŶƐĨĞƌĂŵďƵůĂŶĐĞĐĂŶďĞƌĞƋƵĞƐƚĞĚƚŽƚƌĂŶƐƉŽƌƚƚŚĞ ƉĂƚŝĞŶƚƚŽƚŚĞŝƌŚŽƐƉŝƚĂůŽĨĐŚŽŝĐĞ͘/ĨƚŚĞƉĂƚŝĞŶƚƌĞĨƵƐĞƐƚƌĂŶƐƉŽƌƚƚŽĂůŽĐĂůŚŽƐƉŝƚĂů͕ŽƌƚŚĞƌĞŝƐŶŽ ƉƌŝǀĂƚĞƚƌĂŶƐĨĞƌĂŵďƵůĂŶĐĞĂǀĂŝůĂďůĞ͕ƚŚĞ&ŝĞůĚ^ƵƉĞƌǀŝƐŽƌƐŚŽƵůĚďĞĐŽŶƚĂĐƚĞĚĨŽƌĨƵƌƚŚĞƌĚŝƌĞĐƚŝŽŶ͘ dŚĞ&ŝĞůĚ^ƵƉĞƌǀŝƐŽƌƐŚŽƵůĚĐŽŶƐŝĚĞƌƚŚĞƉĂƚŝĞŶƚ͛ƐŶĞĞĚƐĂŶĚƚŚĞƐǇƐƚĞŵƐƚĂƚƵƐŝŶĚĞƚĞƌŵŝŶŝŶŐ ĨƵƌƚŚĞƌĂĐƚŝŽŶƐ͕ǁŚŝůĞĂůƐŽƌĞůǇŝŶŐŽŶƚŚĞũƵĚŐŵĞŶƚŽĨƚŚĞ/ŶͲŚĂƌŐĞWĂƌĂŵĞĚŝĐŽŶƚŚĞƐĐĞŶĞ͘ůů ƌĞĂƐŽŶĂďůĞĂƚƚĞŵƉƚƐƐŚŽƵůĚďĞŵĂĚĞƚŽĐŽŵƉůǇǁŝƚŚƚŚĞƉĂƚŝĞŶƚ͛ƐĚĞƐŝƌĞƐ͘ x hƌŐĞŶƚͬĐƌŝƚŝĐĂůŵĞĚŝĐŝŶĞƉĂƚŝĞŶƚƐƐŚŽƵůĚďĞƚƌĂŶƐƉŽƌƚĞĚƚŽƚŚĞŶĞĂƌĞƐƚĨĂĐŝůŝƚǇ͘ǆĐĞƉƚŝŽŶƐƚŽƚŚŝƐĐĂŶ ďĞŵĂĚĞŝĨƚŚĞƉĂƚŝĞŶƚƌĞƋƵŝƌĞƐƐƉĞĐŝĂůŝǌĞĚĐĂƌĞŶŽƚĂǀĂŝůĂďůĞĂƚƚŚĞŶĞĂƌĞƐƚĨĂĐŝůŝƚǇŽƌŝƚŝƐŝŶƚŚĞ ƉĂƚŝĞŶƚ͛ƐďĞƐƚŝŶƚĞƌĞƐƚƚŽďĞƚƌĂŶƐƉŽƌƚĞĚƚŽĂŚŽƐƉŝƚĂůŽƚŚĞƌƚŚĂŶƚŚĞŶĞĂƌĞƐƚŚŽƐƉŝƚĂů͘ x dƌĂŶƐƉŽƌƚĚĞƐƚŝŶĂƚŝŽŶŽĨƚŚĞƵƌŐĞŶƚͬĐƌŝƚŝĐĂůŵĞĚŝĐŝŶĞŽƌƐƵƌŐŝĐĂůƉĂƚŝĞŶƚƐŚĂůůďĞƚŚĞĚĞĐŝƐŝŽŶŽĨƚŚĞ /ŶͲŚĂƌŐĞĐĂƌŝŶŐĨŽƌƚŚĞƉĂƚŝĞŶƚ͘This decision can only be changed by a Field Supervisor or the Medical Director present at the scene. ŵĞƌŐĞŶĐǇdƌĂŶƐƉŽƌƚ hƐĞŽĨůŝŐŚƚƐĂŶĚƐŝƌĞŶƐ;ŵĞƌŐĞŶĐǇdƌĂŶƐƉŽƌƚͿƐŚŽƵůĚŽŶůǇďĞƵƚŝůŝǌĞĚǁŚĞŶallŽĨƚŚĞĨŽůůŽǁŝŶŐ ĐŽŶĚŝƚŝŽŶƐĂƌĞŵĞƚ͗

x ŵĞƌŐĞŶĐǇdƌĂŶƐƉŽƌƚǁŽƵůĚƐĂǀĞƚŝŵĞ͘ x dŚĞƉĂƚŝĞŶƚƌĞƋƵŝƌĞƐĞŵĞƌŐĞŶƚƚƌĞĂƚŵĞŶƚĂƚƚŚĞŚŽƐƉŝƚĂůƚŚĂƚŝƐŶŽƚĂǀĂŝůĂďůĞŝŶƚŚĞĂŵďƵůĂŶĐĞ͘ x dŚĞƚŝŵĞƐĂǀĞĚĂŶĚŚŽƐƉŝƚĂůƚƌĞĂƚŵĞŶƚĂƌĞĂŶƚŝĐŝƉĂƚĞĚƚŽƉŽƐŝƚŝǀĞůǇĂĨĨĞĐƚƚŚĞƉĂƚŝĞŶƚ͛ƐŽƵƚĐŽŵĞ͘

dƌĂǀĞůŝŶŐůŝŐŚƚƐĂŶĚƐŝƌĞŶƐŝƐŚŝŐŚͲƌŝƐŬĨŽƌƚŚĞĐƌĞǁ͕ƚŚĞƉĂƚŝĞŶƚ͕ĂŶĚƚŚĞƉƵďůŝĐ͘/ƚƐŚŽƵůĚŽŶůǇďĞƵƐĞĚ ǁŚĞŶƚŚĞďĞŶĞĨŝƚƚŽƚŚĞƉĂƚŝĞŶƚŝƐďĞůŝĞǀĞĚƚŽŽƵƚǁĞŝŐŚƚŚĞƐĞƐĂĨĞƚǇƌŝƐŬƐ͘

Cypress Creek EMS System Policies and Treatment Guidelines

82 TRANSPORT DESTINATION DETERMINATION Revised 8/2016 Approved: Levon Vartanian, MD

WĞĚŝĂƚƌŝĐWĂƚŝĞŶƚƐ dƌĂƵŵĂ͗ WĞĚŝĂƚƌŝĐƉĂƚŝĞŶƚƐŵĞĞƚŝŶŐĐƌŝƚĞƌŝĂĨŽƌ>ĞǀĞůϭŽƌ>ĞǀĞůϮƚƌĂƵŵĂƐŚŽƵůĚďĞƚƌĂŶƐƉŽƌƚĞĚƚŽĂĚĞƐŝŐŶĂƚĞĚ >ĞǀĞůϭWĞĚŝĂƚƌŝĐdƌĂƵŵĂĞŶƚĞƌ͗ x dĞǆĂƐŚŝůĚƌĞŶ͛Ɛ,ŽƐƉŝƚĂůͶdĞǆĂƐDĞĚŝĐĂůĞŶƚĞƌ x DĞŵŽƌŝĂů,ĞƌŵĂŶŶŚŝůĚƌĞŶ͛ƐͶdĞǆĂƐDĞĚŝĐĂůĞŶƚĞƌ x ĞŶdĂƵďĂůƐŽĂĐĐĞƉƚƐƉĞĚŝĂƚƌŝĐƚƌĂƵŵĂƉĂƚŝĞŶƚƐ͘ hŶƐƚĂďůĞ>ŝĨĞͲdŚƌĞĂƚĞŶŝŶŐŽŶĚŝƚŝŽŶ͗ WĞĚŝĂƚƌŝĐƉĂƚŝĞŶƚƐǁŝƚŚƚŚĞĨŽůůŽǁŝŶŐůŝĨĞͲƚŚƌĞĂƚĞŶŝŶŐĐŽŶĚŝƚŝŽŶƐƐŚŽƵůĚďĞƚƌĂŶƐƉŽƌƚĞĚĞŵĞƌŐĞŶƚůǇƚŽ ƚŚĞĐůŽƐĞƐƚĂƉƉƌŽƉƌŝĂƚĞĞŵĞƌŐĞŶĐǇĚĞƉĂƌƚŵĞŶƚ͘ x EŽŶͲƌĞƐƉŽŶƐŝǀĞƌĞƐƉŝƌĂƚŽƌǇĚŝƐƚƌĞƐƐ x ^ĞǀĞƌĞŚǇƉŽƚŚĞƌŵŝĂŽƌŚǇƉĞƌƚŚĞƌŵŝĂ x ^ƚĂƚƵƐĞƉŝůĞƉƚŝĐƵƐ x WŽƚĞŶƚŝĂůůǇĚĂŶŐĞƌŽƵƐĞŶǀĞŶŽŵĂƚŝŽŶ x >ŝĨĞͲƚŚƌĞĂƚĞŶŝŶŐŝŶŐĞƐƚŝŽŶͬĐŚĞŵŝĐĂůĞǆƉŽƐƵƌĞ hƌŐĞŶƚͬƌŝƚŝĐĂůůǇ/ůů͗ hƌŐĞŶƚͬĐƌŝƚŝĐĂůƉĞĚŝĂƚƌŝĐƉĂƚŝĞŶƚƐƐŚŽƵůĚďĞƚƌĂŶƐƉŽƌƚĞĚƚŽĂĨĂĐŝůŝƚǇĐĂƉĂďůĞŽĨĐĂƌŝŶŐĨŽƌĂĐƌŝƚŝĐĂůůǇŝůů ƉĞĚŝĂƚƌŝĐƉĂƚŝĞŶƚ͗ x dĞǆĂƐŚŝůĚƌĞŶ͛Ɛ,ŽƐƉŝƚĂů;ŵƵůƚŝƉůĞĐĂŵƉƵƐĞƐͿ x DĞŵŽƌŝĂů,ĞƌŵĂŶŶŚŝůĚƌĞŶ͛Ɛ;WĞĚŝĂƚƌŝĐZͬ/hͿ ^ƚĂďůĞ͗ dƌĂŶƐƉŽƌƚƚŽƚŚĞĞŵĞƌŐĞŶĐǇĚĞƉĂƌƚŵĞŶƚŽĨƉĂƌĞŶƚͬŐƵĂƌĚŝĂŶ͛ƐĐŚŽŝĐĞ͘ WĞĂƌůƐ x /ĨŝŶĚŽƵďƚ͕ĐŽŶƚĂĐƚƚŚĞŚŽƐƉŝƚĂůĐŚĂƌŐĞŶƵƌƐĞ͕Ă&ŝĞůĚ^ƵƉĞƌǀŝƐŽƌ͕ŽƌŽŵŵĞŶƚĞƌƚŽĚĞƚĞƌŵŝŶĞ ĂǀĂŝůĂďŝůŝƚǇŽĨƐƉĞĐŝĂůƚǇƉĞĚŝĂƚƌŝĐƌĞƐŽƵƌĐĞƐĂƚĂĚĞƐƚŝŶĂƚŝŽŶŚŽƐƉŝƚĂů͘

Cypress Creek EMS System Policies and Treatment Guidelines

83 TRANSPORT DESTINATION DETERMINATION Revised 7/2019 Approved: Levon Vartanian, MD

WŽƐƚͲĂƌĚŝĂĐƌƌĞƐƚ Purpose dŽĞŶƐƵƌĞƉŽƐƚͲĐĂƌĚŝĂĐĂƌƌĞƐƚĂŶĚƉŽƐƚͲƌĞƐƵƐĐŝƚĂƚŝŽŶƉĂƚŝĞŶƚƐĂƌĞƚƌĂŶƐƉŽƌƚĞĚƚŽĂŶĂƉƉƌŽƉƌŝĂƚĞ ƌĞĐĞŝǀŝŶŐĨĂĐŝůŝƚǇ͘

dŚŝƐŐƵŝĚĞůŝŶĞĂƉƉůŝĞƐƚŽƉĂƚŝĞŶƚƐŝŶǁŚŝĐŚƌĞƐƵƐĐŝƚĂƚŝŽŶǁĂƐĂƚƚĞŵƉƚĞĚďǇĂϵϭϭƌĞƐƉŽŶĚĞƌĂŶĚͬŽƌWZ ǁĂƐƉĞƌĨŽƌŵĞĚƉƌŝŽƌƚŽD^ĂƌƌŝǀĂůǁŝƚŚƌĞƐƚŽƌĂƚŝŽŶŽĨƉƵůƐĞƐ͘ WůĂŶ ϭ͘ /ĨŶŽƌĞƚƵƌŶŽĨƉƵůƐĞƐŚĂƐďĞĞŶĂĐŚŝĞǀĞĚ͕ƌĞĨĞƌƚŽDiscontinuation of ResuscitationŐƵŝĚĞůŝŶĞƐĂŶĚ ĐŽŶƐŝĚĞƌĐĞĂƐŝŶŐƌĞƐƵƐĐŝƚĂƚŝǀĞĞĨĨŽƌƚƐ͘ Ϯ͘ /ĨĂtraumatic arrest, ƚƌĂŶƐƉŽƌƚƚŽƚŚĞĐůŽƐĞƐƚĚĞƐŝŐŶĂƚĞĚdƌĂƵŵĂĞŶƚĞƌ͗ x ,,ĞĂůƚŚĐĂƌĞʹEŽƌƚŚǁĞƐƚ;>ĞǀĞů//ͲĂƉĂďůĞͿ x ,,ĞĂůƚŚĐĂƌĞʹdŽŵďĂůů x DĞŵŽƌŝĂů,ĞƌŵĂŶŶͶdŚĞtŽŽĚůĂŶĚƐ;>ĞǀĞů//Ϳ x DĞŵŽƌŝĂů,ĞƌŵĂŶŶͶdD;>ĞǀĞů/Ϳ x ĞŶdĂƵď;>ĞǀĞů/Ϳ ϯ͘ /ĨĂpediatric patient͕ƚƌĂŶƐƉŽƌƚƚŽĂƉĞĚŝĂƚƌŝĐƐƉĞĐŝĂůƚǇĐĞŶƚĞƌ͗ x dĞǆĂƐŚŝůĚƌĞŶ͛ƐͶdD x DĞŵŽƌŝĂů,ĞƌŵĂŶŶŚŝůĚƌĞŶ͛ƐͶdD ϰ͘ /ĨĂSTEMIŽƌƐƵƐƉĞĐƚĞĚĐĂƌĚŝĂĐĞǀĞŶƚ͕ƚƌĂŶƐƉŽƌƚƚŽĂĨĂĐŝůŝƚǇŽŶƚŚĞ^dD/ĂƉƉƌŽǀĞĚůŝƐƚ͘

Cypress Creek EMS System Policies and Treatment Guidelines

84 TRANSPORT DESTINATION DETERMINATION Revised 10/2018 Approved: Levon Vartanian, MD

dƌĂƵŵĂĂŶĚƵƌŶƐ Purpose dŽĞŶƐƵƌĞƉĂƚŝĞŶƚƐĞǆƉĞƌŝĞŶĐŝŶŐƐĞƌŝŽƵƐƚƌĂƵŵĂƚŝĐŝŶũƵƌǇĂƌĞƚƌĂŶƐƉŽƌƚĞĚƌĂƉŝĚůǇƚŽĂĨĂĐŝůŝƚǇƚŚĂƚĐĂŶ ƉƌŽǀŝĚĞŽƉƚŝŵĂůĐĂƌĞĨŽƌƚŚĞŝƌŝŶũƵƌŝĞƐ͘ WůĂŶ ^ĐĞŶĞdŝŵĞ ϭ͘ ZĂƉŝĚůǇĂƐƐĞƐƐĂŶĚŝĚĞŶƚŝĨǇĐƌŝƚŝĐĂůůǇŝŶũƵƌĞĚƉĂƚŝĞŶƚƐ͘ 2. Keep scene time to 10 minutes or less with a “load and go” approach* ϯ͘ KŶƐĐĞŶĞƚƌĞĂƚŵĞŶƚƐƐŚŽƵůĚďĞůŝŵŝƚĞĚƚŽlife-saving, critical interventions͕Ğ͘Ő͘^DZ͕ĂŝƌǁĂǇ ŵĂŶĂŐĞŵĞŶƚ͕ǀĞŶƚŝůĂƚŝŽŶͬŽǆǇŐĞŶĂƚŝŽŶƐƵƉƉŽƌƚ͕ƚŽƵƌŶŝƋƵĞƚƐ͕ĐŚĞƐƚƐĞĂůƐ͕ĐŚĞƐƚĚĞĐŽŵƉƌĞƐƐŝŽŶ͕ĞƚĐ͘ ϰ͘ KEKdĚĞůĂǇƚƌĂŶƐƉŽƌƚĨŽƌƚƌĞĂƚŵĞŶƚƐƚŚĂƚĂƌĞŶŽƚŝŵŵĞĚŝĂƚĞůǇŶĞĐĞƐƐĂƌǇƚŽƚƌĞĂƚůŝĨĞƚŚƌĞĂƚƐ͘ ϱ͘ ƐĞĂƌůǇĂƐƉŽƐƐŝďůĞ͕ŶŽƚŝĨǇƚŚĞŚŽƐƉŝƚĂůŽĨĂTrauma AlertĂŶĚƉƌŽǀŝĚĞĚĞƚĂŝůƐŽĨĂŐĞ͕DK/͕ǀŝƚĂůƐŝŐŶƐ͕ ĂŶĚƐƉĞĐŝĨŝĐŝŶũƵƌŝĞƐ͘ ϲ͘ /ĨƉĂƚŝĞŶƚĐŽŶĚŝƚŝŽŶĐŚĂŶŐĞƐĚƵƌŝŶŐƚƌĂŶƐƉŽƌƚ͕ŶŽƚŝĨǇŚŽƐƉŝƚĂů͘ ϳ͘ dƌĂŶƐƉŽƌƚƌĂƉŝĚůǇƚŽƚŚĞĂƉƉƌŽƉƌŝĂƚĞĨĂĐŝůŝƚǇďĂƐĞĚŽŶƚŚĞĐƌŝƚĞƌŝĂďĞůŽǁ͘ Level 1 Trauma Criteria: hŶƐƚĂďůĞsŝƚĂů^ŝŐŶƐͬWŚǇƐŝŽůŽŐŝĐWĂƌĂŵĞƚĞƌƐ x ^ŝŐŶƐͬƐǇŵƉƚŽŵƐŽĨƐŚŽĐŬ;ĂďƐĞŶƚͬǁĞĂŬƉĞƌŝƉŚĞƌĂůƉƵůƐĞƐ͕ŚǇƉŽƚĞŶƐŝŽŶ͕ƉĂůůŽƌ͕ƚĂĐŚǇĐĂƌĚŝĂ͕ ĚŝĂƉŚŽƌĞƐŝƐ͕ĞƚĐ͘Ϳ x ZĞƐƉŝƌĂƚŽƌǇĐŽŵƉƌŽŵŝƐĞ;ƌĂƚĞфϭϬŽƌхϮϵͿ x ůƚĞƌĞĚŵĞŶƚĂůƐƚĂƚƵƐ;'^фϭϯͿ x DƵůƚŝͲƐǇƐƚĞŵƚƌĂƵŵĂǁŝƚŚƵŶƐƚĂďůĞǀŝƚĂůƐŝŐŶƐ͘ ŶĂƚŽŵŝĐĂů/ŶũƵƌǇ x WĞŶĞƚƌĂƚŝŶŐŝŶũƵƌǇƚŽŚĞĂĚ͕ŶĞĐŬ͕ƚŽƌƐŽ͕ŽƌŐƌŽŝŶ x /ŶũƵƌǇŝŶĐŽŵďŝŶĂƚŝŽŶǁŝƚŚďƵƌŶƐхϭϬйd^ŽƌŝŶĐŽŵďŝŶĂƚŝŽŶǁŝƚŚďƵƌŶƐƚŽĨĂĐĞ͕ĂŝƌǁĂǇ͕ŚĂŶĚƐ͕ ĨĞĞƚ͕ŽƌŐĞŶŝƚĂůŝĂ x dŽƚĂůŽƌƉĂƌƚŝĂůĂŵƉƵƚĂƚŝŽŶŽĨĞǆƚƌĞŵŝƚǇĂďŽǀĞĚŝŐŝƚƐ x ǆƚƌĞŵŝƚǇŝŶũƵƌǇǁŝƚŚĂďƐĞŶĐĞŽĨĚŝƐƚĂůƉƵůƐĞŽƌŽƚŚĞƌƐƵƐƉĞĐƚĞĚŶĞƵƌŽǀĂƐĐƵůĂƌŝŶũƵƌǇ x ^ĞǀĞƌĞĐƌƵƐŚŝŶũƵƌǇǁŝƚŚŶƵŵďŶĞƐƐŽƌƐĞǀĞƌĞƉĂŝŶ x WĂƌĂůǇƐŝƐŽƌŽƚŚĞƌƐƵƐƉĞĐƚĞĚƐƉŝŶĂůŝŶũƵƌǇ x &ůĂŝůĐŚĞƐƚ x dǁŽŽƌŵŽƌĞůŽŶŐďŽŶĞĨƌĂĐƚƵƌĞƐ x KƉĞŶŽƌƐƵƐƉĞĐƚĞĚĚĞƉƌĞƐƐĞĚƐŬƵůůĨƌĂĐƚƵƌĞ x hŶƐƚĂďůĞƉĞůǀŝĐŽƌƐƵƐƉĞĐƚĞĚƉĞůǀŝĐĨƌĂĐƚƵƌĞ x hŶƐƚĂďůĞŽƌŝŶƚƵďĂƚĞĚĂŝƌǁĂǇ

Cypress Creek EMS System Policies and Treatment Guidelines

85 TRANSPORT DESTINATION DETERMINATION Revised 10/2018 Approved: Levon Vartanian, MD

dƌĂŶƐƉŽƌƚ>ĞǀĞůϭdƌĂƵŵĂƚŽĐůŽƐĞƐƚ>ĞǀĞůϭŽƌ>ĞǀĞůϮdƌĂƵŵĂĞŶƚĞƌ;DĞŵŽƌŝĂů,ĞƌŵĂŶŶdD͕ĞŶ dĂƵď͕DĞŵŽƌŝĂů,ĞƌŵĂŶŶƚŚĞtŽŽĚůĂŶĚƐ͕,ŽƵƐƚŽŶEŽƌƚŚǁĞƐƚDĞĚŝĐĂůĞŶƚĞƌ͕ŽŶƌŽĞZĞŐŝŽŶĂůͿ Level 3 Trauma Criteria: DĞĐŚĂŶŝƐŵŽĨ/ŶũƵƌǇ;ǁŝƚŚŽƵƚƵŶƐƚĂďůĞǀŝƚĂůƐŝŐŶƐŽƌĂŶĂƚŽŵŝĐĂůŝŶũƵƌŝĞƐĂďŽǀĞͿ x ƵƚŽͲƉĞĚĞƐƚƌŝĂŶŽƌďŝĐǇĐůĞĐƌĂƐŚхϭϬŵƉŚ x Ds/ǁŝƚŚŵĂũŽƌŝŶƚƌƵƐŝŽŶ͕ƉƌŽůŽŶŐĞĚĞǆƚƌŝĐĂƚŝŽŶ͕хϰϬŵƉŚ͕ĚĞĂƚŚŽĨŽĐĐƵƉĂŶƚŝŶƐĂŵĞǀĞŚŝĐůĞ͕ ƌŽůůŽǀĞƌ͕ĞũĞĐƚŝŽŶ x dsŽƌDŽƚŽƌĐǇĐůĞĐƌĂƐŚхϮϬŵƉŚŽƌǁŝƚŚƐĞƉĂƌĂƚŝŽŶŽĨƌŝĚĞƌĨƌŽŵǀĞŚŝĐůĞ x &ĂůůƐхϮϬĨĞĞƚĨŽƌĂĚƵůƚƐŽƌшϯǆƉĂƚŝĞŶƚ͛ƐŚĞŝŐŚƚĨŽƌƉĞĚŝĂƚƌŝĐƐ dƌĂŶƐƉŽƌƚƚŽĐůŽƐĞƐƚĚĞƐŝŐŶĂƚĞĚdƌĂƵŵĂĞŶƚĞƌ Burn Center Criteria: x WĂƌƚŝĂůƚŚŝĐŬŶĞƐƐďƵƌŶƐхϭϬй^ x ƵƌŶƐƚŚĂƚŝŶǀŽůǀĞƚŚĞĨĂĐĞ͕ŚĂŶĚƐ͕ĨĞĞƚ͕ŐĞŶŝƚĂůŝĂ͕ƉĞƌŝŶĞƵŵ͕ŽƌŵĂũŽƌũŽŝŶƚƐ x ŝƌĐƵŵĨĞƌĞŶƚŝĂůďƵƌŶƐŽĨĂŶǇĞǆƚƌĞŵŝƚǇ x dŚŝƌĚĚĞŐƌĞĞďƵƌŶƐŝŶĂŶǇĂŐĞŐƌŽƵƉ x ƵƌŶŝŶũƵƌǇŝŶƉĂƚŝĞŶƚƐǁŝƚŚƉƌĞͲĞǆŝƐƚŝŶŐŵĞĚŝĐĂůĚŝƐŽƌĚĞƌƐƚŚĂƚĐŽƵůĚĐŽŵƉůŝĐĂƚĞŵĂŶĂŐĞŵĞŶƚ͕ ƉƌŽůŽŶŐƌĞĐŽǀĞƌǇ͕ŽƌĞĨĨĞĐƚŵŽƌƚĂůŝƚǇ x ŶǇƉĂƚŝĞŶƚǁŝƚŚďƵƌŶƐĂŶĚĐŽŶĐŽŵŝƚĂŶƚƚƌĂƵŵĂ;ƐƵĐŚĂƐĨƌĂĐƚƵƌĞƐͿ dƌĂŶƐƉŽƌƚƚŽDĞŵŽƌŝĂů,ĞƌŵĂŶŶdD WĞĂƌůƐ x WĂƚŝĞŶƚƐŵĞĞƚŝŶŐƚŚĞĨŽůůŽǁŝŶŐĐƌŝƚĞƌŝĂĂƌĞŚŝŐŚƌŝƐŬĂŶĚƚƌĂŶƐƉŽƌƚƚŽĂŚŝŐŚĞƌůĞǀĞůƚƌĂƵŵĂĐĞŶƚĞƌ ƐŚŽƵůĚďĞĐŽŶƐŝĚĞƌĞĚ͗ o WƌĞŐŶĂŶĐǇхϮϬǁĞĞŬƐ o ŐĞфϱŽƌхϱϱ o WĂƚŝĞŶƚƐǁŝƚŚďůĞĞĚŝŶŐĚŝƐŽƌĚĞƌƐŽƌŽŶďůŽŽĚƚŚŝŶŶĞƌƐ x ůƚĞƌĞĚŵĞŶƚĂůƐƚĂƚƵƐŝŶƚŚĞƉƌĞƐĞŶĐĞŽĨŝŶƚŽǆŝĐĂƚŝŽŶŽƌĚƌƵŐŝŵƉĂŝƌŵĞŶƚƐŚŽƵůĚďĞĐŽŶƐŝĚĞƌĞĚ ƐĞƌŝŽƵƐƵŶƚŝůƉƌŽǀĞŶŽƚŚĞƌǁŝƐĞ x ůŽŽĚƉƌŽĚƵĐƚƐ͕ǁŚĞŶŝŶĚŝĐĂƚĞĚ͕ĂƌĞŵŽƌĞŝŵƉŽƌƚĂŶƚƚŚĂŶĂƌĂƉŝĚƐĐĞŶĞƚŝŵĞ x WĞĚŝĂƚƌŝĐƉĂƚŝĞŶƚƐƐŚŽƵůĚďĞƚƌĂŶƐƉŽƌƚĞĚƚŽĂĚĞƐŝŐŶĂƚĞĚƉĞĚŝĂƚƌŝĐƚƌĂƵŵĂĐĞŶƚĞƌ͗ o DĞŵŽƌŝĂů,ĞƌŵĂŶŶdĞǆĂƐDĞĚŝĐĂůĞŶƚĞƌ o dĞǆĂƐŚŝůĚƌĞŶ͛Ɛ,ŽƐƉŝƚĂů;dĞǆĂƐDĞĚŝĐĂůĞŶƚĞƌͿ x ZĞĨĞƌƚŽAir Medical UtilizationŐƵŝĚĞůŝŶĞƐ x ZĞĨĞƌƚŽLights and SirensƉŽůŝĐǇ x WĂƚŝĞŶƚƐƌĞĐĞŝǀŝŶŐďůŽŽĚƉƌŽĚƵĐƚƐƐŚŽƵůĚďĞƚƌĂŶƐƉŽƌƚĞĚƚŽĂ>ĞǀĞůϭŽƌϮƚƌĂƵŵĂĐĞŶƚĞƌ

Cypress Creek EMS System Policies and Treatment Guidelines

86 TRANSPORT DESTINATION DETERMINATION Revised 10/2018 Approved: Levon Vartanian, MD

^dD/ Purpose WƌŽǀŝĚĞƌĂƉŝĚŝĚĞŶƚŝĨŝĐĂƚŝŽŶŽĨ^dD/ƉĂƚŝĞŶƚƐĂŶĚƌĂƉŝĚĂĐƚŝǀĂƚŝŽŶŽĨĂƚŚ>ĂďƉĞƌƐŽŶŶĞůŝŶŽƌĚĞƌƚŽ ƌĞƐƚŽƌĞĐŝƌĐƵůĂƚŝŽŶƚŽƚŚĞŚĞĂƌƚƋƵŝĐŬůǇĂŶĚŵŝŶŝŵŝǌĞŚĞĂƌƚĚĂŵĂŐĞ͘ WĂƚŝĞŶƚƐ WĂƚŝĞŶƚƐŵĞĞƚŝŶŐ^dD/ͬĂƚŚůĞƌƚƉƌŽƚŽĐŽůĚĞĨŝŶŝƚŝŽŶƐ͗

x ^dĞůĞǀĂƚŝŽŶŽĨϮŵŵŽƌŐƌĞĂƚĞƌŝŶƚǁŽŽƌŵŽƌĞĐŽŶƚŝŐƵŽƵƐůĞĂĚƐ x ďƐĞŶĐĞŽĨ>͕ƉĂĐĞĚƌŚǇƚŚŵ͕ŽƌǁŝĚĞͲĐŽŵƉůĞǆƌŚǇƚŚŵƐ WƌŽĐĞĚƵƌĞ ϭ͘ KŶĂďŽǀĞĨŝŶĚŝŶŐƐ͕ŶŽƚŝĨǇƌĞĐĞŝǀŝŶŐĨĂĐŝůŝƚǇĐŚĂƌŐĞŶƵƌƐĞĂƐĞĂƌůǇĂƐƉŽƐƐŝďůĞǁŝƚŚƚŚĞĨŽůůŽǁŝŶŐ ŝŶĨŽƌŵĂƚŝŽŶ͗ x dŚĂƚǇŽƵŚĂǀĞĂ͞ĂƚŚ>ĂďůĞƌƚ͟ x WĂƚŝĞŶƚŶĂŵĞ͕K͕^^E͕ϭϮͲůĞĂĚ'ĨŝŶĚŝŶŐƐ͕ĂŶĚďƌŝĞĨŚŝƐƚŽƌǇ x WĂƚŝĞŶƚ͛ƐĂƌĚŝŽůŽŐŝƐƚ Ϯ͘ dƌĂŶƐŵŝƚƚŚĞϭϮͲůĞĂĚ'ƚŽƚŚĞƌĞĐĞŝǀŝŶŐĨĂĐŝůŝƚǇĂƐƐŽŽŶĂƐƉŽƐƐŝďůĞ ϯ͘ ŽŶŽƚĚĞůĂǇƚƌĞĂƚŵĞŶƚŝŶŽƌĚĞƌƚŽŶŽƚŝĨǇŽƌƚƌĂŶƐŵŝƚ͕ďƵƚĂƚƚĞŵƉƚƚŽŶŽƚŝĨǇĂƐƐŽŽŶĂƐƉŽƐƐŝďůĞ ĞƐƚŝŶĂƚŝŽŶƐ͗ dŚĞĨŽůůŽǁŝŶŐŚŽƐƉŝƚĂůƐĂƌĞŚĞƐƚWĂŝŶĞŶƚĞƌĂĐĐƌĞĚŝƚĞĚĂŶĚŚĂǀĞŝŶƚĞƌǀĞŶƚŝŽŶĂůĐĂƉĂďŝůŝƚǇ͗

x ,ŽƵƐƚŽŶEŽƌƚŚǁĞƐƚDĞĚŝĐĂůĞŶƚĞƌ x dŽŵďĂůůZĞŐŝŽŶĂůDĞĚŝĐĂů x ,ŽƵƐƚŽŶDĞƚŚŽĚŝƐƚtŝůůŽǁďƌŽŽŬ,ŽƐƉŝƚĂů x EŽƌƚŚǇƉƌĞƐƐDĞĚŝĐĂůĞŶƚĞƌ x ǇƉƌĞƐƐ&ĂŝƌďĂŶŬƐ,ŽƐƉŝƚĂů x DĞŵŽƌŝĂů,ĞƌŵĂŶŶEŽƌƚŚĞĂƐƚ x DĞŵŽƌŝĂů,ĞƌŵĂŶŶdŚĞtŽŽĚůĂŶĚƐ x ,ŽƵƐƚŽŶDĞƚŚŽĚŝƐƚdŚĞtŽŽĚůĂŶĚƐ x ^ƚ͘>ƵŬĞ͛ƐdŚĞsŝŶƚĂŐĞ

Cypress Creek EMS System Policies and Treatment Guidelines

87 TRANSPORT DESTINATION DETERMINATION Revised 10/2018 Approved: Levon Vartanian, MD

^ƚƌŽŬĞ Purpose WĂƚŝĞŶƚƐĞǆƉĞƌŝĞŶĐŝŶŐĂƐƵƐƉĞĐƚĞĚƐƚƌŽŬĞƐŚŽƵůĚďĞƌĂƉŝĚůǇƚƌĂŶƐƉŽƌƚĞĚƚŽĂĚĞƐŝŐŶĂƚĞĚƐƚƌŽŬĞĐĞŶƚĞƌ͘ ŽŵƉƌĞŚĞŶƐŝǀĞ^ƚƌŽŬĞĞŶƚĞƌdƌĂŶƐƉŽƌƚ ŽŵƉƌĞŚĞŶƐŝǀĞ^ƚƌŽŬĞĞŶƚĞƌƐĂůůŽǁĨŽƌŵŽƌĞƌĂƉŝĚĞǀĂůƵĂƚŝŽŶŽĨƉĂƚŝĞŶƚďǇĂŶĞƵƌŽůŽŐŝƐƚ͕ŵŽƌĞ ƚŚĞƌĂƉǇŽƉƚŝŽŶƐ͕ŶĞƵƌŽƐƵƌŐĞƌǇĐĂƉĂďŝůŝƚǇ͕ĂŶĚĞŶĚŽǀĂƐĐƵůĂƌŝŶƚĞƌǀĞŶƚŝŽŶĐĂƉĂďŝůŝƚŝĞƐ͘ ƌŝƚĞƌŝĂĨŽƌƚƌĂŶƐƉŽƌƚƚŽĂŽŵƉƌĞŚĞŶƐŝǀĞ^ƚƌŽŬĞĞŶƚĞƌ͗ x WĂƚŝĞŶƚƐǁŚŽƐĞƐǇŵƉƚŽŵŽŶƐĞƚĐĂŶŶŽƚďĞĚĞƚĞƌŵŝŶĞĚ;ŝ͘Ğ͘ĚƵƌŝŶŐƐůĞĞƉͿŽƌůĂƐƚƐĞĞŶŶŽƌŵĂůхϯ͘ϱ ŚŽƵƌƐŝŶĚƵƌĂƚŝŽŶ x WĂƚŝĞŶƚƐǁŝƚŚĂĐƵƚĞůǇĂůƚĞƌĞĚŵĞŶƚĂůƐƚĂƚƵƐŽƌĂZ^ƐĐŽƌĞŽĨшϱ;ƌĞĨĞƌƚŽStroke Assessment ProcedureͿ x WĂƚŝĞŶƚƐƐƵƐƉĞĐƚĞĚƚŽďĞĞǆƉĞƌŝĞŶĐŝŶŐĂhemorrhagic stroke;ĂĐƵƚĞŽŶƐĞƚŽĨƐĞǀĞƌĞĚĞĨŝĐŝƚƐĂŶĚͬŽƌ ŐĂǌĞƐŚŝĨƚͿ x ŶǇƐƚƌŽŬĞƉƌĞƐĞŶƚĂƚŝŽŶǁŝƚŚƵŶƌĞƐŽůǀŝŶŐŶĞƵƌŽĚĞĨŝĐŝƚƐǁŚĞƌĞŵĞĐŚĂŶŝĐĂůƚŚƌŽŵďĞĐƚŽŵǇ ;ŶĞƵƌŽƐƵƌŐĞƌǇͿŵĂǇďĞŶĞĞĚĞĚ ĞƐƚŝŶĂƚŝŽŶƐ͗ dŚĞĨŽůůŽǁŝŶŐŚŽƐƉŝƚĂůƐĂƌĞĂƉƉƌŽǀĞĚŽŵƉƌĞŚĞŶƐŝǀĞ^ƚƌŽŬĞĞŶƚĞƌƐ͗ x ^ƚ͘>ƵŬĞ͛ƐDĞĚŝĐĂůĞŶƚĞƌ x DĞŵŽƌŝĂů,ĞƌŵĂŶŶDĞĚŝĐĂůĞŶƚĞƌ x ,ŽƵƐƚŽŶDĞƚŚŽĚŝƐƚDĞĚŝĐĂůĞŶƚĞƌ x <ŝŶŐǁŽŽĚ x ^ƚ͘>ƵŬĞ͛ƐtŽŽĚůĂŶĚƐ x ,ŽƵƐƚŽŶDĞƚŚŽĚŝƐƚdŚĞtŽŽĚůĂŶĚƐ WƌŝŵĂƌǇ^ƚƌŽŬĞĞŶƚĞƌdƌĂŶƐƉŽƌƚ ƌŝƚĞƌŝĂĨŽƌƚƌĂŶƐƉŽƌƚƚŽĂWƌŝŵĂƌǇ^ƚƌŽŬĞĞŶƚĞƌ͗

ͻ WĂƚŝĞŶƚƐǁŝƚŚŽŶƐĞƚŽĨŶĞƵƌŽůŽŐŝĐĂůƐŝŐŶƐͬƐǇŵƉƚŽŵƐEK'ZdZƚŚĂŶϰŚŽƵƌƐ ͻ WĂƚŝĞŶƚƐƚŚĂƚŵĞĞƚĐƌŝƚĞƌŝĂƚŽƌĞĐĞŝǀĞƚŚƌŽŵďŽůǇƚŝĐƐĨŽƌŝƐĐŚĞŵŝĐƐƚƌŽŬĞ ĞƐƚŝŶĂƚŝŽŶƐ͗ ůůŚŽƐƉŝƚĂůƐǁŝƚŚŝŶƚŚĞD^ƚĞƌƌŝƚŽƌǇĞǆĐĞƉƚĨŽƌ^ƚ͘>ƵŬĞ͛ƐĂƚƚŚĞsŝŶƚĂŐĞĂŶĚ^ƚ͘>ƵŬĞ͛Ɛ^ƉƌŝŶŐǁŽŽĚƐ sŝůůĂŐĞĂƌĞĚĞƐŝŐŶĂƚĞĚĂƐWZ/DZz^ƚƌŽŬĞĞŶƚĞƌƐ

Cypress Creek EMS System Policies and Treatment Guidelines

88 ADULT MEDICAL Revised 12/2018 Approved: Levon Vartanian, MD

ĚƵůƚDĞĚŝĐĂů

Cardiac Arrest ...... 90 Ventricular Fibrillation/Pulseless VentricularTachycardia ...... 92 Asystole/Pulseless Electrical Activity ...... 94 Post-Resuscitation Care ...... 95 Narrow Complex Tachycardia ...... 97 Wide Complex Tachycardia/Ventricular Ectopy ...... 98 Bradycardia ...... 99 Chest Pain: Cardiac/STEMI ...... 100 Respiratory Distress: CHF/Pulmonary Edema ...... 102 Respiratory Distress: COPD/Asthma ...... 103 Deceased Person (DOS) ...... 104 Abdominal Pain ...... 106 Allergic Reactions/Anaphylaxis ...... 108 Altered Mental Status ...... 110 Suspected Stroke ...... 111 Seizure ...... 113 Syncope ...... 114 Diabetic Emergency ...... 115 Dialysis/Renal Failure ...... 116 Adrenal Crisis ...... 117 Behavioral/Mental Health ...... 118 Excited Delirium ...... 121 Hypertension ...... 125 Pregnancy and Obstetrical Emergency ...... 126 Sickle Cell Crisis...... 129 Hypotension/Shock ...... 130 Sepsis ...... 133 Overdose/Poisoning ...... 135 Vomiting and Diarrhea ...... 138 Fever & Infectious Disease ...... 139 Epistaxis ...... 140 Dental Problems ...... 141 Emergencies involving Central Lines ...... 142 Tracheostomies and Ventilators ...... 144 Ventricular Assist Devices (LVADs) ...... 145

Cypress Creek EMS System Policies and Treatment Guidelines

89 ADULT MEDICAL Revised 12/2018 Approved: Levon Vartanian, MD

ĂƌĚŝĂĐƌƌĞƐƚ Purpose &ŽƌƚŚĞƉƵůƐĞůĞƐƐĂŶĚĂƉŶĞŝĐƉĂƚŝĞŶƚ͕ƌĂƉŝĚĂƉƉůŝĐĂƚŝŽŶŽĨĞĨĨĞĐƚŝǀĞƌĞƐƵƐĐŝƚĂƚŝŽŶƚĞĐŚŶŝƋƵĞƐŝƐĐƌŝƚŝĐĂůĨŽƌ ƐƵƌǀŝǀĂů͘ǇƉƌĞƐƐƌĞĞŬD^ƵƚŝůŝǌĞƐĂWŝƚƌĞǁĐŽŶĐĞƉƚŝŶǁŚŝĐŚĞĂĐŚƚĞĂŵŵĞŵďĞƌŚĂƐĂĐůĞĂƌůǇĚĞĨŝŶĞĚ ƌŽůĞĂŶĚĐůĞĂƌŽďũĞĐƚŝǀĞƐ͘ ƐƐĞƐƐŵĞŶƚ &ŽůůŽǁƚŚĞĂƐƐĞƐƐŵĞŶƚŵŽĚĞůĂŶĚĚĞůĞŐĂƚĞŽƌƚƌĞĂƚůŝĨĞƚŚƌĞĂƚƐĂƐĨŽƵŶĚ͘

Circulation/Initial Impression—ŝĨƉĂƚŝĞŶƚŝƐƵŶƌĞƐƉŽŶƐŝǀĞ͕ŝŶŝƚŝĂƚĞĂƉƵůƐĞĐŚĞĐŬ͕ĂŶĚƐƚĂƌƚĐŽŵƉƌĞƐƐŝŽŶƐ ŝĨĂƉƵůƐĞŝƐŶŽƚĨŽƵŶĚǁŝƚŚŝŶϭϬƐĞĐŽŶĚƐ͘

Airway—WŽƐŝƚŝŽŶĂŝƌǁĂǇǁŝƚŚŚĞĂĚͲƚŝůƚͬĐŚŝŶͲůŝĨƚŽƌũĂǁƚŚƌƵƐƚĂŶĚƉůĂĐĞĂĚũƵŶĐƚƐas appropriate.

Breathing—ŝĨƉĂƚŝĞŶƚŝƐŶŽƚďƌĞĂƚŚŝŶŐŽƌŝƐŐĂƐƉŝŶŐ͕ŝŶŝƚŝĂƚĞǀĞŶƚŝůĂƚŝŽŶƐǁŝƚŚsDĂƚƚĂĐŚĞĚƚŽϭϱůƉŵ KϮ͘ŽŶƐŝĚĞƌƉůĂĐŝŶŐƐƵƉƌĂŐůŽƚƚŝĐĂŝƌǁĂǇ͘

Circulation—ŝĨƉĂƚŝĞŶƚŝƐ ƉƵůƐĞůĞƐƐ͕ƉƌŽǀŝĚĞŚŝŐŚͲƋƵĂůŝƚǇĐŚĞƐƚĐŽŵƉƌĞƐƐŝŽŶƐǁŝƚŚŵŝŶŝŵĂůŝŶƚĞƌƌƵƉƚŝŽŶƐ͘ WŝƚƌĞǁZŽůĞƐ Compressor (B/I/P) ZĞƐƉŽŶƐŝďůĞĨŽƌŝŵŵĞĚŝĂƚĞůǇŝŶŝƚŝĂƚŝŶŐŚŝŐŚƋƵĂůŝƚǇĐŚĞƐƚĐŽŵƉƌĞƐƐŝŽŶ͗ĞƉƚŚŽĨĂƚůĞĂƐƚϮŝŶĐŚĞƐ͕ƌĂƚĞŽĨ ĂƚůĞĂƐƚϭϬϬĐŽŵƉƌĞƐƐŝŽŶƐƉĞƌŵŝŶƵƚĞ͕ĂŶĚĂůůŽǁŝŶŐĨŽƌĨƵůůƌĞĐŽŝůŽĨƚŚĞĐŚĞƐƚ

Airway (B/I/P) ZĞƐƉŽŶƐŝďůĞĨŽƌŝŵŵĞĚŝĂƚĞůǇƉůĂĐŝŶŐƚŚĞ<ŝŶŐƐƵƉƌĂŐůŽƚƚŝĐĂŝƌǁĂǇ͕ĐŽŶĨŝƌŵŝŶŐƉůĂĐĞŵĞŶƚ͕ĂƚƚĂĐŚŝŶŐƚŚĞ /d;ZĞƐYWŽĚͿ͕ĂŶĚǀĞŶƚŝůĂƚŝŶŐƚŚĞƉĂƚŝĞŶƚƵƐŝŶŐĂsDĂƚƚĂĐŚĞĚƚŽϭϱůƉŵKϮ͘

Manager (P) ZĞƐƉŽŶƐŝďůĞĨŽƌŝŵŵĞĚŝĂƚĞůǇĂƉƉůǇŝŶŐƚŚĞĐĂƌĚŝĂĐŵŽŶŝƚŽƌĚĞĨŝďƌŝůůĂƚŝŽŶƉĂĚƐ͕ĂŶĂůǇǌŝŶŐƚŚĞƌŚǇƚŚŵ͕ĂŶĚ ƚŚĞŶĂƐĂƉƉƌŽƉƌŝĂƚĞ͕ŝŶŝƚŝĂƚŝŶŐƚƌĂŶƐŝƚŝŽŶƚŽ>h^ĚĞǀŝĐĞ͘DĂŶĂŐĞƌŝƐĂůƐŽƌĞƐƉŽŶƐŝďůĞĨŽƌŽǀĞƌƐĞĞŝŶŐ ƌĞƐƵƐĐŝƚĂƚŝŽŶĞĨĨŽƌƚƐĂŶĚŵŝŶŝŵŝǌŝŶŐŝŶƚĞƌƌƵƉƚŝŽŶŽĨĐŽŵƉƌĞƐƐŝŽŶƐ͘ 'ĞŶĞƌĂůdƌĞĂƚŵĞŶƚƐ x /ĨĂƌƌĞƐƚŝƐwitnessedŽƌďǇƐƚĂŶĚĞƌͬĨŝƌƐƚƌĞƐƉŽŶĚĞƌWZǁĂƐĚŽŶĞƉƌŝŽƌƚŽĂƌƌŝǀĂů͕ĂŶĚs&ͬsdŝƐ ĚŝƐĐŽǀĞƌĞĚ͕ĚĞůŝǀĞƌŽŶĞďŝƉŚĂƐŝĐϮϬϬ:ĚĞĨŝďƌŝůůĂƚŝŽŶŝŵŵĞĚŝĂƚĞůǇ͘&ŽůůŽǁǁŝƚŚϮŵŝŶƵƚĞƐŽĨ ĐŽŵƉƌĞƐƐŝŽŶƐĂŶĚǀĞŶƚŝůĂƚŝŽŶƐĂƚĞŝƚŚĞƌĂϯϬ͗ϮƌĂƚŝŽ;ŶŽĂĚǀĂŶĐĞĚĂŝƌǁĂǇƉůĂĐĞĚͿŽƌĐŽŶƚŝŶƵŽƵƐ ĐŽŵƉƌĞƐƐŝŽŶƐǁŝƚŚϴͲϭϬǀĞŶƚŝůĂƚŝŽŶƐƉĞƌŵŝŶƵƚĞ;<ŝŶŐƐƵƉƌĂŐůŽƚƚŝĐĂŝƌǁĂǇŽƌdƚƵďĞƉůĂĐĞĚͿ͘ x /ĨĂƌƌĞƐƚŝƐunwitnessedĂŶĚŶŽWZǁĂƐĚŽŶĞƉƌŝŽƌƚŽĂƌƌŝǀĂů͕ƉĞƌĨŽƌŵϮŵŝŶƵƚĞƐŽĨĐŽŵƉƌĞƐƐŝŽŶƐ ĂŶĚǀĞŶƚŝůĂƚŝŽŶƐďĞĨŽƌĞĂŶĂůǇǌŝŶŐƌŚǇƚŚŵ͘ x ZĞƐĐƵĞƌƐƉĞƌĨŽƌŵŝŶŐĐŚĞƐƚĐŽŵƉƌĞƐƐŝŽŶƐƐŚŽƵůĚďĞƌŽƚĂƚĞĚĞǀĞƌǇϮŵŝŶƵƚĞƐ͘

Cypress Creek EMS System Policies and Treatment Guidelines

90 ADULT MEDICAL Revised 12/2018 Approved: Levon Vartanian, MD

x DĞĚŝĐĂƚŝŽŶĂŶĚĞůĞĐƚƌŝĐĂůƚŚĞƌĂƉŝĞƐƐŚŽƵůĚĨŽůůŽǁƚŚĞƌŚǇƚŚŵƐƉĞĐŝĨŝĐŐƵŝĚĞůŝŶĞƐŶĞǆƚŝŶƚŚŝƐƐĞĐƚŝŽŶ͘ x ŝƌǁĂǇŵĂŶĂŐĞŵĞŶƚƐŚŽƵůĚďĞƉĞƌĨŽƌŵĞĚďǇƉůĂĐĞŵĞŶƚŽĨĂ<ŝŶŐƐƵƉƌĂŐůŽƚƚŝĐĂŝƌǁĂǇĚƵƌŝŶŐŝŶŝƚŝĂů ƉŚĂƐĞŽĨƌĞƐƵƐĐŝƚĂƚŝŽŶ͘dKϮǁĂǀĞĨŽƌŵĐĂƉŶŽŐƌĂƉŚǇ͕ďŝůĂƚĞƌĂůďƌĞĂƚŚƐŽƵŶĚƐ͕ĂŶĚĂĚĞƋƵĂƚĞĐŚĞƐƚ ƌŝƐĞĂƌĞĐŽŶĨŝƌŵĂƚŝŽŶŽĨƉƌŽƉĞƌƉůĂĐĞŵĞŶƚ͘ x /ĨĂĚĞƋƵĂƚĞǀĞŶƚŝůĂƚŝŽŶĐĂŶŶŽƚďĞĂĐŚŝĞǀĞĚǁŝƚŚƚŚĞ<ŝŶŐƐƵƉƌĂŐůŽƚƚŝĐĂŝƌǁĂǇ͕ŽƌƚŚĞƌĞĂƌĞ ĐŽŶƚƌĂŝŶĚŝĐĂƚŝŽŶƐƚŽŝƚƐƵƐĞ͕ĐŚĂŶŐĞƚŽďĂŐͲǀĂůǀĞͲŵĂƐŬǀĞŶƚŝůĂƚŝŽŶƐǁŝƚŚĂŝƌǁĂǇĂĚũƵŶĐƚƐŝŶƉůĂĐĞĂŶĚ ĂϯϬ͗ϮĐŽŵƉƌĞƐƐŝŽŶ͗ǀĞŶƚŝůĂƚŝŽŶƌĂƚŝŽ͘ZĞƉůĂĐĞ<ŝŶŐƐƵƉƌĂŐůŽƚƚŝĐĂŝƌǁĂǇǁŝƚŚĂŶdƚƵďĞŝĨ<ŝŶŐ ƐƵƉƌĂŐůŽƚƚŝĐĂŝƌǁĂǇǀĞŶƚŝůĂƚŝŽŶƐĂƌĞĚĞĞŵĞĚƚŽďĞŝŶĞĨĨĞĐƚŝǀĞĂŶĚŝŶƚƵďĂƚŝŽŶĐĂŶďĞĂĐĐŽŵƉůŝƐŚĞĚ ǁŝƚŚŽƵƚŝŶƚĞƌƌƵƉƚŝŶŐĐŽŵƉƌĞƐƐŝŽŶƐ͘ x hƐĞƋƵĂŶƚŝƚĂƚŝǀĞĐĂƉŶŽŐƌĂƉŚǇƚŽŐƵŝĚĞƌĞƐƵƐĐŝƚĂƚŝŽŶĞĨĨŽƌƚƐ͘/ĨdKϮŝƐфϭϬŵŵ,Ő͕ŝŵƉƌŽǀĞWZ ƋƵĂůŝƚǇ͘ x ĨƚĞƌŝŶŝƚŝĂůĐĂƌĚŝĂĐĂƌƌĞƐƚĐĂƌĞŝƐƵŶĚĞƌǁĂǇ͕ƵƚŝůŝǌĞƵůƚƌĂƐŽƵŶĚŝĨĂǀĂŝůĂďůĞ͗ ϭ͘ ^ĐĂŶůƵŶŐƐĨŽƌƉŶĞƵŵŽƚŚŽƌĂǆͶŝĨƉŽƐŝƚŝǀĞ͕ƉĞƌĨŽƌŵNeedle Decompression͘ Ϯ͘ hƐĞFAST examƚŽůŽŽŬĨŽƌĨƌĞĞĨůƵŝĚŝŶƚŚĞĂďĚŽŵĞŶͶŝĨƉŽƐŝƚŝǀĞĂŶĚƚƌĂƵŵĂŵĞĐŚĂŶŝƐŵ͕ ƚƌĂŶƐĨƵƐĞďůŽŽĚĂŶĚŝŶŝƚŝĂƚĞƌĂƉŝĚƚƌĂŶƐƉŽƌƚƚŽĂ>ĞǀĞů/Žƌ//ƚƌĂƵŵĂĐĞŶƚĞƌ͘ ϯ͘ ^ĐĂŶŚĞĂƌƚƚŽŝĚĞŶƚŝĨǇĐĂƌĚŝĂĐŵŽƚŝŽŶĂŶĚĐĂƌĚŝĂĐĐĂƵƐĞƐĨŽƌĂƌƌĞƐƚ͗ x /ĨƉĞƌŝĐĂƌĚŝĂůƚĂŵƉŽŶĂĚĞŝƐƉƌĞƐĞŶƚ͕ŝŶŝƚŝĂƚĞƌĂƉŝĚƚƌĂŶƐƉŽƌƚƚŽĐůŽƐĞƐƚƚƌĂƵŵĂĐĞŶƚĞƌ͘ x dŚĞŽůůWůƵƐŝƐĂĐĐĞƉƚĂďůĞĨŽƌƵƐĞŝŶƉĞĚŝĂƚƌŝĐƉĂƚŝĞŶƚƐĨƌŽŵϭƚŽϴǇĞĂƌƐŽĨĂŐĞƵƐŝŶŐƚŚĞŽůů WůƵƐpedixpadz II x dŚĞWŚŝůŝƉƐ,ĞĂƌƚ^ƚĂƌƚ&ZǆŝƐĂĐĐĞƉƚĂďůĞĨŽƌƵƐĞŝŶƉĞĚŝĂƚƌŝĐƉĂƚŝĞŶƚƐƵŶĚĞƌϴǇĞĂƌƐŽůĚŽƌϱϱƉŽƵŶĚƐ ;ϮϱŬŐͿǁŝƚŚƚŚĞ/ŶĨĂŶƚͬŚŝůĚŬĞǇ͘ x dŚĞWŚŝůŝƉƐ,ĞĂƌƚ^ƚĂƌƚ&ZǆĂŶĚƚŚĞŽůůWůƵƐĂƌĞĂĐĐĞƉƚĂďůĞƐĨŽƌƵƐĞŝŶĂĚƵůƚƉĂƚŝĞŶƚƐ͘ x It is imperative that compressions be interrupted only when absolutely necessary and that any interruptions are kept as short as possible x Make every effort to keep the time from last compression to defibrillation as short as possible x ďĞƐƚƉƌĂĐƚŝĐĞƚŽŵŝŶŝŵŝǌĞƚŚĞƐĞŝŶƚĞƌƌƵƉƚŝŽŶƐŝƐƚŽĐŚĂƌŐĞƚŚĞĚĞĨŝďƌŝůůĂƚŽƌďĞĨŽƌĞƐƚŽƉƉŝŶŐƚŽĚŽĂ ƉƵůƐĞĐŚĞĐŬ͘/ĨŶŽƐŚŽĐŬŝƐŶĞĞĚĞĚ͕ƚŚĞƐŚŽĐŬĐĂŶďĞ͞ĚƵŵƉĞĚ͟ƐĂĨĞůǇĂŶĚĐŽŵƉƌĞƐƐŝŽŶƐĐŽŶƚŝŶƵĞĚ͘ x /ĨĂƐŝŶŐůĞƌĞƐĐƵĞƌŝƐƵŶǁŝůůŝŶŐŽƌƵŶĂďůĞƚŽƉĞƌĨŽƌŵǀĞŶƚŝůĂƚŝŽŶƐ͕ƉĞƌĨŽƌŵŝŶŐĐŽŵƉƌĞƐƐŝŽŶƐŽŶůǇŝƐ ĂĐĐĞƉƚĂďůĞ x &ĂŵŝůǇŵĞŵďĞƌƐĂƌĞĂůůŽǁĞĚƚŽďĞƉƌĞƐĞŶƚĚƵƌŝŶŐƚŚĞƌĞƐƵƐĐŝƚĂƚŝŽŶƵŶůĞƐƐƚŚĞŝƌƉƌĞƐĞŶĐĞŝŶƚĞƌĨĞƌĞƐ ǁŝƚŚƉĂƚŝĞŶƚĐĂƌĞ͘/ĨƉŽƐƐŝďůĞ͕ĂƐƐŝŐŶĂƌĞƐƉŽŶĚĞƌĂƐĂůŝĂŝƐŽŶǁŚŽŝƐĂǀĂŝůĂďůĞƚŽĞǆƉůĂŝŶƚƌĞĂƚŵĞŶƚƐ ĂŶĚĂŶƐǁĞƌƋƵĞƐƚŝŽŶƐ͘

Cypress Creek EMS System Policies and Treatment Guidelines

91 ADULT MEDICAL Revised 8/2016 Approved: Levon Vartanian, MD

sĞŶƚƌŝĐƵůĂƌ&ŝďƌŝůůĂƚŝŽŶͬWƵůƐĞůĞƐƐsĞŶƚƌŝĐƵůĂƌ dĂĐŚǇĐĂƌĚŝĂ Assessment Requirements May Present As Consider Possible Causes ƐƐĞƐƐŵĞŶƚΘ&ƵůůŚĞĂĚͲƚŽͲ hŶƌĞƐƉŽŶƐŝǀĞƉĂƚŝĞŶƚ ,ǇƉŽǀŽůĞŵŝĂ ƚŽĞĞǆĂŵ ,ǇƉŽǆŝĂ 'DŽŶŝƚŽƌ ,ǇĚƌŽŐĞŶŝŽŶƐ;ĂĐŝĚŽƐŝƐͿ dKϮŵŽŶŝƚŽƌŝŶŐ ,ǇƉĞƌŬĂůĞŵŝĂŽƌ ŚǇƉŽŬĂůĞŵŝĂ ,ǇƉŽƚŚĞƌŵŝĂ dĂďůĞƚƐŽƌƚŽǆŝŶƐ ĂƌĚŝĂĐƚĂŵƉŽŶĂĚĞ dĞŶƐŝŽŶƉŶĞƵŵŽƚŚŽƌĂǆ dŚƌŽŵďŽƐŝƐ;ŵǇŽĐĂƌĚŝĂů ŝŶĨĂƌĐƚŝŽŶͿ dŚƌŽŵďŽĞŵďŽůŝƐŵ ;ƉƵůŵŽŶĂƌǇĞŵďŽůŝƐŵͿ dƌĂƵŵĂ ZĞƋƵŝƌĞĚdƌĞĂƚŵĞŶƚƐ x (B)CPRǁŝƚŚITD (ResQPod) x (B/I/P)Airway management ĂƉƉƌŽƉƌŝĂƚĞ ƚŽƉĂƚŝĞŶƚĐŽŶĚŝƚŝŽŶ;ƐĞĞCardiac ArrestͿ x (B)VentilationǁŝƚŚsDĂŶĚϭϬϬйŽǆǇŐĞŶ͘ x (P)DefibrillationĂƚϮϬϬ:ďŝƉŚĂƐŝĐ͕ƌĞƉĞĂƚĂƐŶĞĞĚĞĚĂĨƚĞƌϮŵŝŶƵƚĞƐŽĨWZ͘ x (I)Vascular accessǁŝƚŚ/sŽƌ/K x (P)ĚŵŝŶŝƐƚĞƌvasopressors:ƉŝŶĞƉŚƌŝŶĞϭ͗ϭϬ͕ϬϬϬϭŵŐ/sͬ/KĞǀĞƌǇϱŵŝŶƵƚĞƐƵŶƚŝůZK^ŝƐ ĂĐŚŝĞǀĞĚ͘ x (P)ĚŵŝŶŝƐƚĞƌĂŶƚŝĚǇƐƌŚǇƚŚŵŝĐƐ͗ o AmiodaroneϯϬϬŵŐ/sͬ/K͕ƌĞƉĞĂƚĞĚŽŶĐĞĂĨƚĞƌϱͲϭϬŵŝŶƵƚĞƐĂƚϭϱϬŵŐ o &ŽůůŽǁǁŝƚŚAmiodarone ŝŶĨƵƐŝŽŶŽĨϭϱϬŵŐŽǀĞƌϭϬŵŝŶƵƚĞƐĨŽůůŽǁŝŶŐƌŚǇƚŚŵĐŽŶǀĞƌƐŝŽŶ ǀĂŝůĂďůĞdƌĞĂƚŵĞŶƚƐ x (P)Magnesium Sulfate ϭͲϮ'/sͬ/KĨŽƌƌĞĨƌĂĐƚŽƌǇƐƚĂƚĞĂŶĚͬŽƌĨŽƌtorsades-de-pointes͕ŵĂǇƌĞƉĞĂƚ ŽŶĐĞ x (P)Lidocaine ϭ͘ϱŵŐͬŬŐ/sͬ/K͕ŵĂǇƌĞƉĞĂƚŽŶĐĞŝĨŶĞĞĚĞĚ x (P)Lidocaine /ŶĨƵƐŝŽŶϮͲϰŵŐͬŵŝŶ/sͬ/KƵƉŽŶĐŽŶǀĞƌƐŝŽŶ x (P)Sodium BicarbonateϭŵƋͬŬŐ/sͬ/K͕ƚŚĞŶĂƚϬ͘ϱŵƋͬŬŐƋϭϬŵŝŶͲŽŶůǇŝĨdͬ<ŝŶŐƚƵďĞ ƉůĂĐĞŵĞŶƚŝƐĐŽŶĨŝƌŵĞĚĂŶĚĂĚĞƋƵĂƚĞǀĞŶƚŝůĂƚŝŽŶŝƐďĞŝŶŐƉĞƌĨŽƌŵĞĚ͘^ŽĚŝƵŵŝĐĂƌďŽŶĂƚĞƐŚŽƵůĚ ďĞĐŽŶƐŝĚĞƌĞĚĨŽƌƉƌŽůŽŶŐĞĚĚŽǁŶͲƚŝŵĞ͕ƉƌŽůŽŶŐĞĚĂƌƌĞƐƚŝŶƚĞƌǀĂů͕ƌĞƚƵƌŶŽĨZK^ĨŽůůŽǁŝŶŐ ƉƌŽůŽŶŐĞĚĂƌƌĞƐƚ͕ƐƵƐƉĞĐƚĞĚƚƌŝĐǇĐůŝĐĂŶƚŝĚĞƉƌĞƐƐĂŶƚŽǀĞƌĚŽƐĞ͕<͕ŽƌƐƵƐƉĞĐƚĞĚŚǇƉĞƌŬĂůĞŵŝĂ͘

Cypress Creek EMS System Policies and Treatment Guidelines

92 ADULT MEDICAL Revised 8/2016 Approved: Levon Vartanian, MD

x (P)Calcium ChlorideϱϬϬʹϭϬϬϬŵŐ/sͬ/KƌĞƉĞĂƚĞĚŽŶĐĞŝŶϭϬŵŝŶƵƚĞƐŝĨŬŶŽǁŶƌĞŶĂůƉĂƚŝĞŶƚ͕ŽƌŝĨ ŚǇƉĞƌŬĂůĞŵŝĂŝƐƐƵƐƉĞĐƚĞĚ͘ WĞĂƌůƐ x Amiodarone͕ǁŚĞŶĂĚŵŝŶŝƐƚĞƌĞĚǁŝƚŚsĂƵŐŚĂŶtŝůůŝĂŵƐůĂƐƐ/ĂŶƚŝĂƌƌŚǇƚŚŵŝĐƐ;ŝ͘Ğ͘LidocaineĂŶĚ ProcainamideͿŚĂƐďĞĞŶƐŚŽǁŶƚŽƉƌĞĐŝƉŝƚĂƚĞƚŽƌƐĂĚĞƐͲĚĞͲƉŽŝŶƚĞƐ͕ĂŶĚͬŽƌƉŽƐƚͲĂƌƌĞƐƚŚǇƉŽƚĞŶƐŝŽŶ͘ ,ŽǁĞǀĞƌ͕ŝĨƚŚĞƉĂƚŝĞŶƚƌĞŵĂŝŶƐƌĞĨƌĂĐƚŽƌǇƚŽAmiodarone͕LidocaineƐŚŽƵůĚďĞĂĚŵŝŶŝƐƚĞƌĞĚ͘ x Magnesium Sulfate ŝƐƚŚĞĨŝƌƐƚͲůŝŶĞĂŶƚŝĂƌƌŚǇƚŚŵŝĐŵĞĚŝĐĂƚŝŽŶĨŽƌƐƵƐƉĞĐƚĞĚƚŽƌƐĂĚĞƐͲĚĞͲƉŽŝŶƚĞƐ͘ x /ĨƵŶĂďůĞƚŽĚĞƚĞƌŵŝŶĞŝĨƌŚǇƚŚŵŝƐVentricular Fibrillation ŽƌAsystole ʹƚƌĞĂƚĂƐAsystole.

Cypress Creek EMS System Policies and Treatment Guidelines

93 ADULT MEDICAL 3 Revised 8/2016 Approved: Levon Vartanian, MD

ƐǇƐƚŽůĞͬWƵůƐĞůĞƐƐůĞĐƚƌŝĐĂůĐƚŝǀŝƚǇ

Assessment Requirements May Present As Consider Possible Causes ƐƐĞƐƐŵĞŶƚΘ&ƵůůŚĞĂĚͲƚŽͲƚŽĞ hŶƌĞƐƉŽŶƐŝǀĞƉĂƚŝĞŶƚ ,ǇƉŽǀŽůĞŵŝĂ ĞǆĂŵ ,ǇƉŽǆŝĂ 'ŵŽŶŝƚŽƌ ,ǇĚƌŽŐĞŶŝŽŶƐ;ĂĐŝĚŽƐŝƐͿ dKϮŵŽŶŝƚŽƌŝŶŐ ,ǇƉĞƌŬĂůĞŵŝĂŽƌŚǇƉŽŬĂůĞŵŝĂ ZĞĐƚĂůƚĞŵƉĞƌĂƚƵƌĞ ,ǇƉŽƚŚĞƌŵŝĂ dĂďůĞƚƐŽƌƚŽǆŝŶƐ ĂƌĚŝĂĐƚĂŵƉŽŶĂĚĞ dĞŶƐŝŽŶƉŶĞƵŵŽƚŚŽƌĂǆ dŚƌŽŵďŽƐŝƐ;ŵǇŽĐĂƌĚŝĂů ŝŶĨĂƌĐƚŝŽŶͿ dŚƌŽŵďŽĞŵďŽůŝƐŵ;ƉƵůŵŽŶĂƌǇ ĞŵďŽůŝƐŵͿ dƌĂƵŵĂ ZĞƋƵŝƌĞĚdƌĞĂƚŵĞŶƚƐ x (B)CPRǁŝƚŚITD (ResQPod) x Airway management ĂƉƉƌŽƉƌŝĂƚĞ ƚŽƉĂƚŝĞŶƚĐŽŶĚŝƚŝŽŶ;ƐĞĞCardiac ArrestͿ x (B)VentilationǁŝƚŚsDĂŶĚϭϬϬйŽǆǇŐĞŶ͘ x (I)Vascular accessǁŝƚŚ/sŽƌ/K x (P)ĚŵŝŶŝƐƚĞƌvasopressors:ƉŝŶĞƉŚƌŝŶĞϭ͗ϭϬ͕ϬϬϬϭŵŐ/sͬ/KĞǀĞƌǇϱŵŝŶƵƚĞƐƵŶƚŝůZK^ŝƐ ĂĐŚŝĞǀĞĚ ǀĂŝůĂďůĞdƌĞĂƚŵĞŶƚƐ x (P)Sodium BicarbonateϭŵƋͬŬŐ/sͬ/K͕ƚŚĞŶĂƚϬ͘ϱŵƋͬŬŐƋϭϬŵŝŶͲŽŶůǇŝĨdͬ<ŝŶŐƚƵďĞ ƉůĂĐĞŵĞŶƚŝƐĐŽŶĨŝƌŵĞĚĂŶĚĂĚĞƋƵĂƚĞǀĞŶƚŝůĂƚŝŽŶŝƐďĞŝŶŐƉĞƌĨŽƌŵĞĚ͘^ŽĚŝƵŵŝĐĂƌďŽŶĂƚĞƐŚŽƵůĚ ďĞĐŽŶƐŝĚĞƌĞĚĨŽƌƉƌŽůŽŶŐĞĚĚŽǁŶƚŝŵĞ͕ƉƌŽůŽŶŐĞĚĂƌƌĞƐƚŝŶƚĞƌǀĂů͕ƌĞƚƵƌŶŽĨZK^ĨŽůůŽǁŝŶŐ ƉƌŽůŽŶŐĞĚĂƌƌĞƐƚ͕ƐƵƐƉĞĐƚĞĚƚƌŝĐǇĐůŝĐĂŶƚŝĚĞƉƌĞƐƐĂŶƚŽǀĞƌĚŽƐĞ͕<͕ŽƌƐƵƐƉĞĐƚĞĚŚǇƉĞƌŬĂůĞŵŝĂ x (P)Calcium ChlorideϱϬϬʹϭϬϬϬŵŐ/sͬ/KƌĞƉĞĂƚĞĚŽŶĐĞŝŶϭϬŵŝŶƵƚĞƐŝĨŬŶŽǁŶƌĞŶĂůƉĂƚŝĞŶƚ͕ŽƌŝĨ ŚǇƉĞƌŬĂůĞŵŝĂŝƐƐƵƐƉĞĐƚĞĚ WĞĂƌůƐ x PEAŝƐĂŶŝŶĚŝĐĂƚŝŽŶƚŚĂƚƚŚĞŚĞĂƌƚ͛ƐĞůĞĐƚƌŝĐĂůƐǇƐƚĞŵŝƐĨƵŶĐƚŝŽŶŝŶŐ͕ďƵƚƚŚĞŵƵƐĐůĞŝƐŶŽƚ ƌĞƐƉŽŶĚŝŶŐ͘&ŽĐƵƐŽŶŝĚĞŶƚŝĨǇŝŶŐƌĞǀĞƌƐŝďůĞĐĂƵƐĞƐ;^ĞĞƚŚĞHs and TsĂďŽǀĞͿǁŝƚŚĂƚŚŽƌŽƵŐŚ ĂƐƐĞƐƐŵĞŶƚĂŶĚŚŝƐƚŽƌǇ͕ƚƌĞĂƚŝŶŐƚŚĞŵ͕ĂŶĚŵĂŝŶƚĂŝŶŝŶŐŚŝŐŚƋƵĂůŝƚǇWZ x /ĨasystoleĚŽĞƐŶŽƚƌĞƐƉŽŶĚƚŽƋƵĂůŝƚǇƌĞƐƵƐĐŝƚĂƚŝŽŶĞĨĨŽƌƚƐ͕ĐŽŶƐŝĚĞƌDiscontinuation of Resuscitation͘

Cypress Creek EMS System Policies and Treatment Guidelines

94 ADULT MEDICAL Revised 8/2016 Approved: Levon Vartanian, MD

WŽƐƚͲZĞƐƵƐĐŝƚĂƚŝŽŶĂƌĞ Assessment Requirements May Present As Consider Possible Causes ƐƐĞƐƐŵĞŶƚΘ&ƵůůŚĞĂĚͲƚŽͲ ĂƌĚŝĂĐĂƌƌĞƐƚ ,ǇƉŽǀŽůĞŵŝĂ ƚŽĞĞǆĂŵ WZǁŝƚŚƌĞƚƵƌŶŽĨƉƵůƐĞ ,ǇƉŽǆŝĂ '͕^ƉKϮ͕ĂŶĚdKϮ ;ZK^ͿƉƌŝŽƌƚŽĂƌƌŝǀĂů ,ǇĚƌŽŐĞŶŝŽŶƐ;ĂĐŝĚŽƐŝƐͿ ŵŽŶŝƚŽƌŝŶŐ WZǁŝƚŚƌĞƚƵƌŶŽĨƉƵůƐĞ ,ǇƉĞƌŬĂůĞŵŝĂŽƌ ZĞĐƚĂůƚĞŵƉĞƌĂƚƵƌĞ ;ZK^ͿĨŽƌD^ ŚǇƉŽŬĂůĞŵŝĂ ůŽŽĚŐůƵĐŽƐĞ ,ǇƉŽƚŚĞƌŵŝĂ ϭϮͲ>ĞĂĚ' dĂďůĞƚƐŽƌƚŽǆŝŶƐ ĂƌĚŝĂĐƚĂŵƉŽŶĂĚĞ dĞŶƐŝŽŶƉŶĞƵŵŽƚŚŽƌĂǆ dŚƌŽŵďŽƐŝƐ;ŵǇŽĐĂƌĚŝĂů ŝŶĨĂƌĐƚŝŽŶͿ dŚƌŽŵďŽĞŵďŽůŝƐŵ ;ƉƵůŵŽŶĂƌǇĞŵďŽůŝƐŵͿ dƌĂƵŵĂ WŽƐƚͲZĞƐƵƐĐŝƚĂƚŝŽŶdƌĞĂƚŵĞŶƚWƌŝŽƌŝƚŝĞƐ Optimize ventilation & oxygenation x ;ͿDĂŝŶƚĂŝŶŽǆǇŐĞŶƐĂƚƵƌĂƚŝŽŶtϵϰʹϵϵй x ;ͿhƚŝůŝǌĞǁĂǀĞĨŽƌŵĐĂƉŶŽŐƌĂƉŚǇƚŽƚĂƌŐĞƚdKϮŽĨϯϬʹϰϬŵŵ,Ő x ;ͿZĞŵŽǀĞ/dŝĨƐƚŝůůŝŶƉůĂĐĞ x ;ͬ/ͬWͿŽŶƐŝĚĞƌĂĚǀĂŶĐĞĚĂŝƌǁĂǇŵĂŶĂŐĞŵĞŶƚŝĨŶĞĞĚĞĚ x ;WͿWƌŽǀŝĚĞƐĞĚĂƚŝŽŶĂƐŶĞĐĞƐƐĂƌǇ;ƌĞĨĞƌƚŽSedationƉƌŽƚŽĐŽůͿďƵƚƵƐĞĐĂƵƚŝŽŶŝŶĂĚŵŝŶŝƐƚĞƌŝŶŐ ƉĂƌĂůǇƚŝĐƐ Treat hypotension & provide antiarrhythmic (SBP < 90 mmHg or MAP < 65 mmHg)

x (P)Normal salineŽƌPlasmalyteĨůƵŝĚďŽůƵƐĞƐƵƉƚŽϮϬŵ>ͬŬŐ͘DĂǇƵƐĞĐŽůĚĨůƵŝĚŝĨŝŶĚƵĐŝŶŐ ŚǇƉŽƚŚĞƌŵŝĂ x (P)DopamineϱʹϭϬŵĐŐͬŬŐͬŵŝŶ/sͬ/KŝŶĨƵƐŝŽŶƚŝƚƌĂƚĞĚƚŽDWхϲϱŵŵ,Ő x (P)Epinephrine ϮʹϭϬŵĐŐͬŵŝŶ/sͬ/KŝŶĨƵƐŝŽŶƚŝƚƌĂƚĞĚƚŽDWхϲϱŵŵ,Ő x (P)Amiodarone ϭϱϬŵŐŽǀĞƌϭϬŵŝŶ/sͬ/KŝŶĨƵƐŝŽŶŝĨsĞŶƚƌŝĐƵůĂƌ&ŝďƌŝůůĂƚŝŽŶŽƌsĞŶƚƌŝĐƵůĂƌ dĂĐŚǇĐĂƌĚŝĂĚƵƌŝŶŐĂƌƌĞƐƚŵĂŶĂŐĞŵĞŶƚ Evaluate for STEMI

x ;WͿǀĂůƵĂƚĞϭϮͲůĞĂĚ'ĂŶĚĨŽůůŽǁCath Alert/STEMI ƉƌŽĐĞĚƵƌĞŝĨĂƉƉƌŽƉƌŝĂƚĞ WĞĂƌůƐ x dŚĞƉƌŝŵĂƌǇŽďũĞĐƚŝǀĞƐŽĨƉŽƐƚͲƌĞƐƵƐĐŝƚĂƚŝŽŶĐĂƌĞĂƌĞƚŽƉƌĞƐĞƌǀĞŶĞƵƌŽůŽŐŝĐĨƵŶĐƚŝŽŶďǇ ŵĂŝŶƚĂŝŶŝŶŐƐ͕ƚŽŝĚĞŶƚŝĨǇĂŶĚƚƌĞĂƚƚŚĞƉƌĞĚŝĐĂƚŝŶŐĐĂƵƐĞŽĨƚŚĞĐĂƌĚŝĂĐĂƌƌĞƐƚ͕ĂŶĚƚŽĚĞůŝǀĞƌ ƚŚĞƉĂƚŝĞŶƚƚŽĂŶĂƉƉƌŽƉƌŝĂƚĞĨĂĐŝůŝƚǇŝŶĂƐƐƚĂďůĞĂƉŚǇƐŝŽůŽŐŝĐƐƚĂƚĞĂƐƉŽƐƐŝďůĞ͘ŽŶƚŝŶƵŽƵƐ

Cypress Creek EMS System Policies and Treatment Guidelines

95 ADULT MEDICAL Revised 8/2016 Approved: Levon Vartanian, MD

ŵŽŶŝƚŽƌŝŶŐĂŶĚĨƌĞƋƵĞŶƚƌĞĂƐƐĞƐƐŵĞŶƚŽĨƚŚĞƉĂƚŝĞŶƚŝƐŶĞĐĞƐƐĂƌǇďĞĐĂƵƐĞŚĞŵŽĚǇŶĂŵŝĐƐƚĂƚƵƐ ŵĂǇǁŽƌƐĞŶ͘ x DŽƐƚĂĚƵůƚĐĂƌĚŝĂĐĂƌƌĞƐƚƐŚĂǀĞĂĐĂƌĚŝĂĐĞƚŝŽůŽŐǇ͕ĂŶĚƐŚŽƵůĚďĞƚƌĂŶƐƉŽƌƚĞĚƚŽĂW/ͲĐĂƉĂďůĞ ^dD/ĨĂĐŝůŝƚǇ͘ x ǀĞŶƐŚŽƌƚͲƚĞƌŵŚǇƉŽƚĞŶƐŝŽŶĐĂŶƐŝŐŶŝĨŝĐĂŶƚůǇĂĨĨĞĐƚƉĂƚŝĞŶƚŽƵƚĐŽŵĞƐĂŶĚďƌĂŝŶƐƵƌǀŝǀĂů͘ǀŽŝĚ ĂŶĚŝŵŵĞĚŝĂƚĞůǇƚƌĞĂƚŚǇƉŽƚĞŶƐŝŽŶ;^WфϵϬ͕DWфϲϱͿ͘ĞƐƚƉƌĂĐƚŝĐĞŝƐƚŽŚĂŶŐĂǀĂƐŽƉƌĞƐƐŽƌ ǁŝƚŚĂƐĞĐŽŶĚůŝŶĞƚŽƌĞĚƵĐĞƚŝŵĞƚŽƚƌĞĂƚŚǇƉŽƚĞŶƐŝŽŶ͘ĚĞĚŝĐĂƚĞĚůŝŶĞŵĂŬĞƐŝƚƐŝŵƉůĞƌƚŽ ƉƌĞĐŝƐĞůǇĐŽŶƚƌŽůĂŶĚƚŝƚƌĂƚĞŵĞĚŝĐĂƚŝŽŶĚŽƐĞƌĂƚĞĂŶĚŵĂŬĞƐŝƚĞĂƐŝĞƌƚŽĂĚŵŝŶŝƐƚĞƌĂĨůƵŝĚďŽůƵƐ͘ x WŽƐƚͲĂƌƌĞƐƚƉĂƚŝĞŶƚƐĂƌĞĂƚŚŝŐŚƌŝƐŬĨŽƌƐĞŝǌƵƌĞƐ͕ǁŚŝĐŚĂƌĞĚĞƚƌŝŵĞŶƚĂůƚŽďƌĂŝŶƐƵƌǀŝǀĂů͘dƌĞĂƚ ƐĞŝǌƵƌĞƐƵƐŝŶŐSeizureŐƵŝĚĞůŝŶĞƐ͘/ĨƉĂƚŝĞŶƚŝƐƉĂƌĂůǇǌĞĚǁŝƚŚŶĞƵƌŽŵƵƐĐƵůĂƌďůŽĐŬĂĚĞĚƌƵŐƐ͕ŝƚ ǁŽŶ͛ƚďĞƉŽƐƐŝďůĞƚŽŝĚĞŶƚŝĨǇƐĞŝǌƵƌĞƐŝŶƚŚĞĨŝĞůĚĂŶĚŽƵƚĐŽŵĞƐĐŽƵůĚďĞǁŽƌƐĞŶĞĚ͘ x KŶĐĞƌĞƐƵƐĐŝƚĂƚŝŽŶĚƌƵŐƐŚĂǀĞǁŽƌŶŽĨĨ͕ƉĂƚŝĞŶƚǁŝůůďĞƉƌŽŶĞƚŽŚǇƉŽƚĞŶƐŝŽŶ͘WƌĞƉĂƌŝŶŐ ǀĂƐŽƉƌĞƐƐŽƌĚƌƵŐƐĂŚĞĂĚŽĨƚŝŵĞŝƐƌĞĐŽŵŵĞŶĚĞĚƚŽŵŝŶŝŵŝǌĞƚŝŵĞƚŽƚƌĞĂƚŝŶŐŚǇƉŽƚĞŶƐŝŽŶ͘

Cypress Creek EMS System Policies and Treatment Guidelines

96 ADULT MEDICAL Revised 8/2016 Approved: Levon Vartanian, MD

EĂƌƌŽǁŽŵƉůĞǆdĂĐŚǇĐĂƌĚŝĂ Assessment Requirements May Present As Consider Possible Causes ƐƐĞƐƐŵĞŶƚΘ&ƵůůŚĞĂĚͲƚŽͲ ŚĞƐƚƉĂŝŶ͕ƉĂůƉŝƚĂƚŝŽŶƐ͕ ,ǇƉŽǀŽůĞŵŝĂ͕ĚĞŚǇĚƌĂƚŝŽŶ͕ ƚŽĞĞǆĂŵ ĚŝǌǌŝŶĞƐƐ͕ŶĞĂƌͲƐǇŶĐŽƉĞ͕ ŚĞĂƚĞǆƉŽƐƵƌĞ͕ŚǇƉŽǆŝĂ͕ 'ŵŽŶŝƚŽƌ ƐǇŶĐŽƉĞ͕ĚŝĨĨŝĐƵůƚǇďƌĞĂƚŚŝŶŐ ĨĞǀĞƌ͕ŝŶĨĞĐƚŝŽŶ͕^dD/͕ ϭϮͲůĞĂĚ' ĐĂƌĚŝĂĐĚǇƐƌŚǇƚŚŵŝĂ͕ƚŽǆŝŶƐ͕ ƐƚŝŵƵůĂŶƚͬĚƌƵŐĂďƵƐĞ͘ ZĞƋƵŝƌĞĚdƌĞĂƚŵĞŶƚƐ x Airway management ĂƉƉƌŽƉƌŝĂƚĞ ƚŽƉĂƚŝĞŶƚĐŽŶĚŝƚŝŽŶ͘ x VentilationĂŶĚoxygenation ĂƉƉƌŽƉƌŝĂƚĞƚŽƉĂƚŝĞŶƚĐŽŶĚŝƚŝŽŶ͘ x (I) Vascular accessǁŝƚŚ/sŽƌ/K ǀĂŝůĂďůĞdƌĞĂƚŵĞŶƚƐ x (B) Vagal maneuver͕ŵĂǇƌĞƉĞĂƚŽŶĐĞǁŝƚŚĚƵƌĂƚŝŽŶŶŽůŽŶŐĞƌƚŚĂŶϭϬƐĞĐŽŶĚƐ x (P) Adenosine ϲŵŐZW//s͕ŝĨŶŽĐŚĂŶŐĞƌĞƉĞĂƚǁŝƚŚϭϮŵŐZW//sƵƉƚŽƚǁŽĚŽƐĞƐ x (P) Diltiazem ϮϬʹϮϱŵŐ/sŽǀĞƌϮŵŝŶƵƚĞƐŝĨƌĞĨƌĂĐƚŽƌǇƚŽAdenosine͕ŽƌĨŽƌĐŽŶĨŝƌŵĞĚĂƚƌŝĂů ĨŝďƌŝůůĂƚŝŽŶǁŝƚŚZsZ;ƌĂƚĞхϭϯϬͬŵŝŶͿ x (P) AmiodaroneϭϱϬŵŐ/sŝŶĨƵƐŝŽŶŽǀĞƌϭϬŵŝŶƵƚĞƐ͕ĞƐƉĞĐŝĂůůǇŝĨŝŶĚŽƵďƚĂƐƚŽŽƌŝŐŝŶ;ĂƚƌŝĂůǀƐ͘ ǀĞŶƚƌŝĐƵůĂƌͿ x (P) Synchronized Cardioversion͗ x /ŶŝƚŝĂůĚŽƐĞĨŽƌŶĂƌƌŽǁĐŽŵƉůĞǆƚĂĐŚǇĐĂƌĚŝĂ͗50 Joules biphasic͘ x /ŶĐƌĞĂƐĞĚŽƐĞƐƚĞƉǁŝƐĞŝĨŝŶŝƚŝĂůĚŽƐĞĨĂŝůƐ x (P) ŽŶƐŝĚĞƌSedationŐƵŝĚĞůŝŶĞƐǁŝƚŚĐĂƌĚŝŽǀĞƌƐŝŽŶ͕ďƵƚĚŽŶŽƚĚĞůĂǇĐĂƌĚŝŽǀĞƌƐŝŽŶŝĨƉĂƚŝĞŶƚŝƐ ĞǆƚƌĞŵĞůǇƵŶƐƚĂďůĞ WĞĂƌůƐ x ZƵůĞŽƵƚŽƚŚĞƌƚƌĞĂƚĂďůĞĐĂƵƐĞƐŽĨƚĂĐŚǇĐĂƌĚŝĂ;ŚǇƉŽǀŽůĞŵŝĂ͕ŚǇƉŽǆŝĂ͕ĨĞǀĞƌ͕ĚĞŚǇĚƌĂƚŝŽŶ͕ĞƚĐ͘Ϳ ďĞĨŽƌĞƚƌĞĂƚŝŶŐƌŚǇƚŚŵͬƌĂƚĞǁŝƚŚĐĂƌĚŝĂĐŵĞĚŝĐĂƚŝŽŶƐŽƌĞůĞĐƚƌŝĐŝƚǇ͘'ĞŶĞƌĂůůǇ͕ƚĂĐŚǇĂƌƌŚǇƚŚŵŝĂƐ ŚĂǀĞĂƌĂƚĞхϭϱϬ;хϭϯϬĨŽƌƚƌŝĂůĨŝďƌŝůůĂƚŝŽŶǁŝƚŚZsZͿ x tŝƚŚŽƵƚĞǀŝĚĞŶĐĞŽĨĞŶĚͲŽƌŐĂŶĐŽŵƉƌŽŵŝƐĞ;ŚǇƉŽƚĞŶƐŝŽŶ͕ĂĐƵƚĞůǇĂůƚĞƌĞĚŵĞŶƚĂůƐƚĂƚƵƐ͕ƐŝŐŶƐŽĨ ƐŚŽĐŬ͕ŝƐĐŚĞŵŝĐĐŚĞƐƚĚŝƐĐŽŵĨŽƌƚ͕ĂŶĚͬŽƌĂĐƵƚĞŚĞĂƌƚĨĂŝůƵƌĞͿ͕ƐǇŶĐŚƌŽŶŝǌĞĚĐĂƌĚŝŽǀĞƌƐŝŽŶƐŚŽƵůĚŶŽƚ ďĞƉĞƌĨŽƌŵĞĚ x hƐĞĐĂƵƚŝŽŶŝŶĐŽŶǀĞƌƚŝŶŐĂƚƌŝĂůĨŝďƌŝůůĂƚŝŽŶ͕ǁĞŝŐŚŝŶŐďĞŶĞĨŝƚĂŐĂŝŶƐƚƚŚĞƌŝƐŬŽĨƌĞůĞĂƐŝŶŐĐůŽƚƐŝŶƚŽ ĐĞŶƚƌĂůĐŝƌĐƵůĂƚŝŽŶ

Cypress Creek EMS System Policies and Treatment Guidelines

97 ADULT MEDICAL Revised 8/2016 Approved: Levon Vartanian, MD

tŝĚĞŽŵƉůĞǆdĂĐŚǇĐĂƌĚŝĂͬsĞŶƚƌŝĐƵůĂƌĐƚŽƉǇ Assessment Requirements May Present As Consider Possible Causes ƐƐĞƐƐŵĞŶƚΘ&ƵůůŚĞĂĚͲƚŽͲ ŚĞƐƚƉĂŝŶ͕ƉĂůƉŝƚĂƚŝŽŶƐ͕ ,ǇƉŽǀŽůĞŵŝĂ͕ĚĞŚǇĚƌĂƚŝŽŶ͕ ƚŽĞĞǆĂŵ ĚŝǌǌŝŶĞƐƐ͕ŶĞĂƌͲƐǇŶĐŽƉĞ͕ ŚĞĂƚĞǆƉŽƐƵƌĞ͕ŚǇƉŽǆŝĂ͕ 'DŽŶŝƚŽƌ ƐǇŶĐŽƉĞ͕ĚŝĨĨŝĐƵůƚǇďƌĞĂƚŚŝŶŐ ĨĞǀĞƌ͕ŝŶĨĞĐƚŝŽŶ͕^dD/͕ ϭϮͲůĞĂĚ' ĐĂƌĚŝĂĐĚǇƐƌŚǇƚŚŵŝĂ͕ƚŽǆŝŶƐ͕ ƐƚŝŵƵůĂŶƚͬĚƌƵŐĂďƵƐĞ ZĞƋƵŝƌĞĚdƌĞĂƚŵĞŶƚƐ x Airway management ĂƉƉƌŽƉƌŝĂƚĞ ƚŽƉĂƚŝĞŶƚĐŽŶĚŝƚŝŽŶ x VentilationĂŶĚoxygenation ĂƉƉƌŽƉƌŝĂƚĞƚŽƉĂƚŝĞŶƚĐŽŶĚŝƚŝŽŶ x (I) Vascular accessǁŝƚŚ/sŽƌ/K x /ĨƉƵůƐĞůĞƐƐ͕ĨŽůůŽǁƚŚĞCardiac ArrestŐƵŝĚĞůŝŶĞƐ ǀĂŝůĂďůĞdƌĞĂƚŵĞŶƚƐ x (P) Amiodarone ϭϱϬŵŐ^>Kt/sĨŽƌƐǇŵƉƚŽŵĂƚŝĐǀĞŶƚƌŝĐƵůĂƌƚĂĐŚǇĐĂƌĚŝĂĨŽůůŽǁĞĚďǇϭϱϬŵŐ/s ŝŶĨƵƐŝŽŶŽǀĞƌϭϬŵŝŶƵƚĞƐ͘DĂǇƌĞƉĞĂƚďŽůƵƐŝĨƌĞĨƌĂĐƚŽƌǇƚŽĨŝƌƐƚĚŽƐĞ x (P) Adenosine ϲŵŐZW//s͕ŝĨŶŽĐŚĂŶŐĞƌĞƉĞĂƚǁŝƚŚϭϮŵŐZW//sƵƉƚŽƚǁŽĚŽƐĞƐ;ŵĂǆŝŵƵŵ ŽĨϯϬŵŐͿ x (P) Lidocaineϭʹϭ͘ϱŵŐͬŬŐ/s͕ŵĂǇƌĞƉĞĂƚĂƚϬ͘ϱʹϬ͘ϳϱŵŐͬŬŐƚŽĂŵĂǆŝŵƵŵŽĨϯŵŐͬŬŐ͕ĨŽůůŽǁĞĚďǇ ĂŶŝŶĨƵƐŝŽŶŽĨϮʹϰŵŐͬŵŝŶƵƚĞƐŝĨƌŚǇƚŚŵĐŽŶǀĞƌƚƐǁŝƚŚůŝĚŽĐĂŝŶĞ x (P) Magnesium SulfateϭʹϮŐ^>Kt/sĨŽƌƉŽůǇŵŽƌƉŚŝĐǀĞŶƚƌŝĐƵůĂƌƚĂĐŚǇĐĂƌĚŝĂ x (P) Synchronized Cardioversion͗ x /ŶŝƚŝĂůƌĞĐŽŵŵĞŶĚĞĚĚŽƐĞĨŽƌƌĞŐƵůĂƌͬŵŽŶŽŵŽƌƉŚŝĐsd͗100 Joules biphasic x /ŶĐƌĞĂƐĞĚŽƐĞƐƚĞƉǁŝƐĞŝĨŝŶŝƚŝĂůĚŽƐĞĨĂŝůƐ x WŽůǇŵŽƌƉŚŝĐ͕ŝƌƌĞŐƵůĂƌsdƵƐƵĂůůǇǁŝůůŶŽƚƉĞƌŵŝƚƐǇŶĐŚƌŽŶŝǌĂƚŝŽŶ͕ĂŶĚƐŚŽƵůĚďĞƚƌĞĂƚĞĚǁŝƚŚ ƵŶƐǇŶĐŚƌŽŶŝǌĞĚƐŚŽĐŬƐ;Ğ͘Ő͕͘ĚĞĨŝďƌŝůůĂƚŝŽŶͿĂƚ200 Joules biphasic x (P) ŽŶƐŝĚĞƌSedationŐƵŝĚĞůŝŶĞƐǁŝƚŚĐĂƌĚŝŽǀĞƌƐŝŽŶ͕ďƵƚĚŽŶŽƚĚĞůĂǇĐĂƌĚŝŽǀĞƌƐŝŽŶŝĨƉĂƚŝĞŶƚŝƐ ĞǆƚƌĞŵĞůǇƵŶƐƚĂďůĞ WĞĂƌůƐ x >>ǁŝĚĞͲĐŽŵƉůĞǆƚĂĐŚǇĐĂƌĚŝĂƐƐŚŽƵůĚďĞĐŽŶƐŝĚĞƌĞĚǀĞŶƚƌŝĐƵůĂƌŝŶŽƌŝŐŝŶƵŶƚŝůƉƌŽǀĞŶŽƚŚĞƌǁŝƐĞďǇ ĂϭϮͲůĞĂĚ'͘ x /ĨŚĞĂƌƚƌĂƚĞфϲϬͬŵŝŶ͕ĚŽŶŽƚĂĚŵŝŶŝƐƚĞƌLidocaineŽƌAmiodarone. x KŶůǇƚƌĞĂƚWsƐŝĨƉĂƚŝĞŶƚŝƐsymptomatic͗ŝ͘Ğ͕͘ŵƵůƚŝĨŽĐĂůWsƐ͕ĐŽƵƉůĞƚƐ͕ƚƌŝƉůĞƚƐ͕ŽƌƌƵŶƐŽĨsd ĐŽŵďŝŶĞĚǁŝƚŚĐŚĞƐƚƉĂŝŶ͕ƐŚŽƌƚŶĞƐƐŽĨďƌĞĂƚŚ͕ĂĐƵƚĞůǇĂůƚĞƌĞĚŵĞŶƚĂůƐƚĂƚƵƐ͕ĂŶĚͬŽƌŚǇƉŽƚĞŶƐŝŽŶ͘ x tŝƚŚŽƵƚĞǀŝĚĞŶĐĞŽĨĞŶĚͲŽƌŐĂŶĐŽŵƉƌŽŵŝƐĞ;ŚǇƉŽƚĞŶƐŝŽŶ͕ĂĐƵƚĞůǇĂůƚĞƌĞĚŵĞŶƚĂůƐƚĂƚƵƐ͕ƐŝŐŶƐŽĨ ƐŚŽĐŬ͕ŝƐĐŚĞŵŝĐĐŚĞƐƚĚŝƐĐŽŵĨŽƌƚ͕ĂŶĚͬŽƌĂĐƵƚĞŚĞĂƌƚĨĂŝůƵƌĞͿ͕ƐǇŶĐŚƌŽŶŝǌĞĚĐĂƌĚŝŽǀĞƌƐŝŽŶƐŚŽƵůĚŶŽƚ ďĞƉĞƌĨŽƌŵĞĚ͘

Cypress Creek EMS System Policies and Treatment Guidelines

98 ADULT MEDICAL Revised 8/2016 Approved: Levon Vartanian, MD

ƌĂĚǇĐĂƌĚŝĂ Assessment Requirements May Present As Consider Possible Causes ƐƐĞƐƐŵĞŶƚΘĨŽĐƵƐĞĚĞǆĂŵ ŚĞƐƚƉĂŝŶ͕ƉĂůƉŝƚĂƚŝŽŶƐ͕ ,ǇƉŽǀŽůĞŵŝĂ͕ŚǇƉŽǆŝĂ͕ 'DŽŶŝƚŽƌ ĚŝǌǌŝŶĞƐƐ͕ŶĞĂƌͲƐǇŶĐŽƉĞ͕ ^dD/͕ĐĂƌĚŝĂĐĚǇƐƌŚǇƚŚŵŝĂ͕ ϭϮͲůĞĂĚ' ƐǇŶĐŽƉĞ͕ĚŝĨĨŝĐƵůƚǇďƌĞĂƚŚŝŶŐ ƚŽǆŝŶƐ͕ŽǀĞƌĚŽƐĞ͕ĐůŽƐĞĚŚĞĂĚ ŝŶũƵƌǇ͕ŚǇƉŽƚŚĞƌŵŝĂ ZĞƋƵŝƌĞĚdƌĞĂƚŵĞŶƚƐ x Airway management ĂƉƉƌŽƉƌŝĂƚĞ ƚŽƉĂƚŝĞŶƚĐŽŶĚŝƚŝŽŶ͘ x VentilationĂŶĚoxygenation ĂƉƉƌŽƉƌŝĂƚĞƚŽƉĂƚŝĞŶƚĐŽŶĚŝƚŝŽŶ͘ x (I) Vascular accessǁŝƚŚ/sŽƌ/K x /ĨƉƵůƐĞůĞƐƐ͕ĨŽůůŽǁƚŚĞCardiac ArrestŐƵŝĚĞůŝŶĞƐ͘ x ŶǇƉĂƚŝĞŶƚƉƌĞƐĞŶƚŝŶŐǁŝƚŚϮqs//ŽƌϯqsǁŝƚŚǁŝĚĞYZ^ĐŽŵƉůĞǆĞƐŽƌǁŝƚŚďŝĨĂƐŝĐƵůĂƌďůŽĐŬ ƐŚŽƵůĚŚĂǀĞƚƌĂŶƐĐƵƚĂŶĞŽƵƐƉĂĐŝŶŐŽŶƐƚĂŶĚďǇ͘ ǀĂŝůĂďůĞdƌĞĂƚŵĞŶƚƐ x (P) AtropineϬ͘ϱŵŐ/sƌĞƉĞĂƚĞǀĞƌǇϯʹϱŵŝŶƵƚĞƐƚŽĂŵĂǆŝŵƵŵŽĨϯŵŐ/s͘ x (P) Transcutaneous pacing x (P)ŽŶƐŝĚĞƌSedationŐƵŝĚĞůŝŶĞƐǁŝƚŚƉĂĐŝŶŐ͕ďƵƚĚŽŶŽƚĚĞůĂǇƉĂĐŝŶŐŝĨƉĂƚŝĞŶƚŝƐĞǆƚƌĞŵĞůǇ ƵŶƐƚĂďůĞ͘ x (P) Epinephrine ϮʹϭϬŵĐŐͬŵŝŶ/sŝŶĨƵƐŝŽŶ͕ƚŝƚƌĂƚĞĚƚŽĞĨĨĞĐƚ͘ x (P) DopamineϱʹϭϬŵĐŐͬŬŐͬŵŝŶ/sŝŶĨƵƐŝŽŶ͕ƚŝƚƌĂƚĞĚƚŽĞĨĨĞĐƚ͘ WĞĂƌůƐ x ,ǇƉŽǆŝĂŝƐĂĐŽŵŵŽŶĐĂƵƐĞŽĨďƌĂĚǇĐĂƌĚŝĂ͘ƐƐĞƐƐĨŽƌŝŶĐƌĞĂƐĞĚǁŽƌŬŽĨďƌĞĂƚŚŝŶŐ͕ǀĞŶƚŝůĂƚŝŽŶ ƉƌŽďůĞŵƐ͕ĂŶĚŽǆǇŐĞŶĂƚŝŽŶƉƌŽďůĞŵƐ͕ĂŶĚƚƌĞĂƚƚŚŽƐĞƉƌŝŽƌƚŽĂĚŵŝŶŝƐƚĞƌŝŶŐĐĂƌĚŝĂĐŵĞĚŝĐĂƚŝŽŶƐŽƌ ĞůĞĐƚƌŝĐĂůƚŚĞƌĂƉǇĨŽƌďƌĂĚǇĐĂƌĚŝĂ͘ x WĂƚŝĞŶƚƐƉƌĞƐĞŶƚŝŶŐǁŝƚŚďŝĨĂƐŝĐƵůĂƌďůŽĐŬ;ŚĞŵŝďůŽĐŬн>ͿĂƌĞĂƚŚŝŐŚƌŝƐŬƚŽĚĞǀĞůŽƉĂŶsďůŽĐŬ ĂŶĚďƌĂĚǇĐĂƌĚŝĂ͘ x WĂƚŝĞŶƚƐƉƌĞƐĞŶƚŝŶŐǁŝƚŚĂϮqs//ŽƌϯqsƐŚŽƵůĚƌĞĐĞŝǀĞtranscutaneous pacingƉƌŝŽƌƚŽ ĂĚŵŝŶŝƐƚƌĂƚŝŽŶŽĨĂŶǇŵĞĚŝĐĂƚŝŽŶƐ͕ĂƐAtropineŵĂǇĂĐƚƵĂůůǇǁŽƌƐĞŶƚŚĞŚĞĂƌƚďůŽĐŬ͘ x ƌĂĚǇĐĂƌĚŝĂĚŽĞƐŶ͛ƚƌĞƋƵŝƌĞŝŵŵĞĚŝĂƚĞƚƌĞĂƚŵĞŶƚƵŶůĞƐƐƐǇŵƉƚŽŵĂƚŝĐ;ŚǇƉŽƚĞŶƐŝŽŶ͕ƐŝŐŶƐŽĨƐŚŽĐŬ͕ ŝƐĐŚĞŵŝĐĐŚĞƐƚĚŝƐĐŽŵĨŽƌƚ͕ĂĐƵƚĞůǇĂůƚĞƌĞĚŵĞŶƚĂůƐƚĂƚƵƐ͕ĂĐƵƚĞŚĞĂƌƚĨĂŝůƵƌĞ͕ĞƚĐ͘Ϳ͘

Cypress Creek EMS System Policies and Treatment Guidelines

99 ADULT MEDICAL Revised 8/2016 Approved: Levon Vartanian, MD

ŚĞƐƚWĂŝŶ͗ĂƌĚŝĂĐͬ^dD/ Assessment Requirements May Present As Consider Possible Causes ƐƐĞƐƐŵĞŶƚΘĨŽĐƵƐĞĚĞǆĂŵ ŚĞƐƚƉĂŝŶ͕ƉĂůƉŝƚĂƚŝŽŶƐ͕ ^dD/ͬE^dD/͕^͕ĐĂƌĚŝĂĐ 'DŽŶŝƚŽƌ ĚŝǌǌŝŶĞƐƐ͕ŶĞĂƌͲƐǇŶĐŽƉĞ͕ ƚĂŵƉŽŶĂĚĞ͕ƉƵůŵŽŶĂƌǇ ϭϮͲůĞĂĚ' ƐǇŶĐŽƉĞ͕ĚŝĨĨŝĐƵůƚǇďƌĞĂƚŚŝŶŐ͕ ĞŵďŽůŝƐŵ͕ƉŶĞƵŵŽŶŝĂ͕ ĂďĚŽŵŝŶĂůƉĂŝŶ͘ ƉĞƌŝĐĂƌĚŝƚŝƐ͕ƉůĞƵƌŝƐǇ ZĞƋƵŝƌĞĚdƌĞĂƚŵĞŶƚƐ x Airway management ĂƉƉƌŽƉƌŝĂƚĞ ƚŽƉĂƚŝĞŶƚĐŽŶĚŝƚŝŽŶ͘ x VentilationĂŶĚoxygenation ĂƉƉƌŽƉƌŝĂƚĞƚŽƉĂƚŝĞŶƚĐŽŶĚŝƚŝŽŶ͘ x (I) Vascular accessǁŝƚŚ/sŽƌ/K͘/ĨƉŽƐƐŝďůĞ^dD/͕ĂǀŽŝĚǁƌŝƐƚƐ͘WƌĞĨĞƌƌĞĚůŽĐĂƚŝŽŶŝƐůĞĨƚĨŽƌĞĂƌŵŽƌ ůĞĨƚ͘ x (B) Chewable Aspirin ϴϭŵŐǆϰ;ϯϮϰŵŐͿWKƵŶůĞƐƐĐŽŶƚƌĂŝŶĚŝĐĂƚĞĚ͘/ĨƚĂŬĞŶƉƌŝŽƌƚŽĂƌƌŝǀĂů͕ ĚŽĐƵŵĞŶƚ͘ x dƌĂŶƐƉŽƌƚƉĞƌSTEMIŐƵŝĚĞůŝŶĞƐĂŶĚĨŽůůŽǁCath AlertƉƌŽĐĞĚƵƌĞŝŶƉĂƚŝĞŶƚƐŵĞĞƚŝŶŐ^dD/ͬĂƚŚ ůĞƌƚĐƌŝƚĞƌŝĂ;ĚĞƚĂŝůƐŽŶĂƚŚůĞƌƚƉƌŽĐĞĚƵƌĞĂƌĞŝŶĐůƵĚĞĚŝŶƚŚĞ^dD/dƌĂŶƐƉŽƌƚŐƵŝĚĞůŝŶĞƐͿ͘ ǀĂŝůĂďůĞdƌĞĂƚŵĞŶƚƐ x (B) Nitroglycerin ϭŵĞƚĞƌĞĚĚŽƐĞ^>ĞǀĞƌǇϱŵŝŶƵƚĞƐĂƐůŽŶŐĂƐƐǇƐƚŽůŝĐWхϭϬϬŵŵ,ŐĂŶĚƉĂƚŝĞŶƚ ĐŽŶƚŝŶƵĞƐƚŽƐŚŽǁƐŝŐŶƐŽĨĐĂƌĚŝĂĐŝƐĐŚĞŵŝĂ͘ x (P) MorphineϮʹϱŵŐ/sƚŝƚƌĂƚĞĚƚŽƉĂŝŶƌĞůŝĞĨĂƐŶĞĞĚĞĚ͖ŵĂǆŝŵƵŵŽĨϭϱŵŐ͘ x (P) Fentanyl Ϭ͘ϱʹϭŵĐŐͬŬŐƐůŽǁ/sͬ/EƚŝƚƌĂƚĞĚƚŽƉĂŝŶƌĞůŝĞĨĂƐŶĞĞĚĞĚ͖ŵĂǆŝŵƵŵŽĨϯŵĐŐͬŬŐ͘ x (P) Normal SalineƵƉƚŽϮϬŵůͬŬŐŝĨƌŝŐŚƚǀĞŶƚƌŝĐƵůĂƌŝŶĨĂƌĐƚŝƐŝĚĞŶƚŝĨŝĞĚ͘ x (P) Heparin ϱϬϬϬh/sͬ/KŝĨ^dD/ŝƐŝĚĞŶƚŝĨŝĞĚ͘ x (P) Metoprolol ϱŵŐ^>Kt/sͬ/KŝĨƉĂƚŝĞŶƚŝƐŚǇƉĞƌƚĞŶƐŝǀĞ;^WхϭϴϬĂŶĚͬŽƌWхϭϬϬͿ͘DĂǇďĞ ƌĞƉĞĂƚĞĚŽŶĐĞŝĨŚǇƉĞƌƚĞŶƐŝŽŶŝƐƵŶƌĞƐŽůǀĞĚ͘ WĞĂƌůƐ x DĂǇǁŝƚŚŚŽůĚĂĚǀĂŶĐĞĚƚƌĞĂƚŵĞŶƚŝĨĐĂƌĚŝĂĐŝƐĐŚĞŵŝĂŝƐŶŽƚƐƵƐƉĞĐƚĞĚďĂƐĞĚŽŶŚŝƐƚŽƌǇ͕ ĞǆĂŵŝŶĂƚŝŽŶ͕ĂŶĚ'ĨŝŶĚŝŶŐƐ͘ x ĐƵƚĞŽƌŽŶĂƌǇ^ǇŶĚƌŽŵĞƐŵĂǇƉƌĞƐĞŶƚĂƚǇƉŝĐĂůůǇ;ǁŝƚŚŽƵƚĐŚĞƐƚƉĂŝŶͿ͕ĞƐƉĞĐŝĂůůǇŝŶĨĞŵĂůĞĂŶĚͬŽƌ ĚŝĂďĞƚŝĐƉĂƚŝĞŶƚƐ͘KƚŚĞƌƉƌĞƐĞŶƚĂƚŝŽŶƐƚŚĂƚŵĂǇƌĞƋƵŝƌĞĂϭϮͲůĞĂĚ'ŝŶĐůƵĚĞ͗ĚŝǌǌŝŶĞƐƐ͕ ƉĂůƉŝƚĂƚŝŽŶƐ͕^K͕ŶĂƵƐĞĂͬǀŽŵŝƚŝŶŐͬƉĂŝŶ͕ĂĐŝĚŝŶĚŝŐĞƐƚŝŽŶͬŚĞĂƌƚďƵƌŶ͕ƵƉƉĞƌĞǆƚƌĞŵŝƚǇͬŶĞĐŬͬũĂǁ ƉĂŝŶ͕ďĂĐŬŽƌƐŚŽƵůĚĞƌƉĂŝŶ͕ǁĞĂŬŶĞƐƐ͕ŐĞŶĞƌĂůŵĂůĂŝƐĞ͕ŽƌƐǇŶĐŽƉĞͬŶĞĂƌƐǇŶĐŽƉĞ͘ x KƌĂůĂŶƚŝĐŽĂŐƵůĂŶƚƚŚĞƌĂƉǇŝƐŶŽƚĂĐŽŶƚƌĂŝŶĚŝĐĂƚŝŽŶƚŽAspirin ĂĚŵŝŶŝƐƚƌĂƚŝŽŶ x MorphineŝƐƉƌĞĨĞƌƌĞĚƚŽFentanylĚƵĞƚŽďĞŶĞĨŝĐŝĂůĐŽƌŽŶĂƌǇĂƌƚĞƌǇĚŝůĂƚŝŽŶ͘ x NitroglycerinŝƐƚŚĞĚƌƵŐŽĨĐŚŽŝĐĞĨŽƌƌĞůŝĞǀŝŶŐŝƐĐŚĞŵŝĐĐŚĞƐƚƉĂŝŶĂŶĚƐŚŽƵůĚďĞĂĚŵŝŶŝƐƚĞƌĞĚƉƌŝŽƌ ƚŽŽƉŝĂƚĞƐ͘ x Nitroglycerin ƐŚŽƵůĚďĞƵƐĞĚǁŝƚŚĞǆƚƌĞŵĞĐĂƵƚŝŽŶŝŶĂƉĂƚŝĞŶƚŚĂǀŝŶŐĂƌŝŐŚƚǀĞŶƚƌŝĐƵůĂƌŝŶĨĂƌĐƚŝŽŶ͕ ĂŶĚŵĂǇďĞĂĚŵŝŶŝƐƚĞƌĞĚƉƌŝŽƌƚŽĂŶ/sďĞŝŶŐĞƐƚĂďůŝƐŚĞĚŽŶůǇǁŚĞŶĂϭϮͲůĞĂĚ'ƐŚŽǁƐŶŽ ŝŶĚŝĐĂƚŝŽŶŽĨƉŽƐƐŝďůĞƌŝŐŚƚǀĞŶƚƌŝĐƵůĂƌŝŶĨĂƌĐƚŝŽŶ͘ x Nitroglycerin ŵƵƐƚďĞƵƐĞĚǁŝƚŚĞǆƚƌĞŵĞĐĂƵƚŝŽŶŝŶƚŚĞƉĂƚŝĞŶƚǁŚŽŚĂƐƚĂŬĞŶĂƉŚŽƐƉŚŽĚŝĞƐƚĞƌĂƐĞ ŝŶŚŝďŝƚŽƌ;sŝĂŐƌĂ͕ŝĂůŝƐ͕>ĞǀŝƚƌĂ͕ĞƚĐ͙ͿǁŝƚŚŝŶϮϰŚŽƵƌƐ͘

Cypress Creek EMS System Policies and Treatment Guidelines

100 ADULT MEDICAL Revised 8/2016 Approved: Levon Vartanian, MD

x EĞǁ;ŽƌƉƌĞƐƵŵĂďůǇŶĞǁͿůĞĨƚďƵŶĚůĞďƌĂŶĐŚďůŽĐŬ;>ͿŝƐƚŽďĞƚƌĞĂƚĞĚůŝŬĞ^důĞǀĂƚŝŽŶ͕ĂŶĚ ŵĂŬĞƐƚŚĞƉĂƚŝĞŶƚĂĐĂŶĚŝĚĂƚĞĨŽƌĐĂƌĚŝĂĐĐĂƚŚĞƚĞƌŝǌĂƚŝŽŶĂŶĚͬŽƌƚŚƌŽŵďŽůǇƚŝĐƚŚĞƌĂƉǇ͘EŽƚŝĨǇƚŚĞ ƉĂƚŝĞŶƚĂŶĚƚƌĂŶƐŵŝƚƚŚĞϭϮͲůĞĂĚ'ŝĨƉŽƐƐŝďůĞ͘ŽŶŽƚĂĐƚŝǀĂƚĞĂ^dD/ůĞƌƚ͘ x /ĨĂƉĂƚŝĞŶƚŚĂƐƌĞĐƵƌƌŝŶŐƐǇŵƉƚŽŵƐ͕ƚŚĞƚŝŵĞŽĨŽŶƐĞƚŝƐĐŽŶƐŝĚĞƌĞĚƚŽďĞǁŚĞŶƚŚĞƐǇŵƉƚŽŵƐ ďĞĐĂŵĞĐŽŶƐƚĂŶƚ͘

Cypress Creek EMS System Policies and Treatment Guidelines

101 ADULT MEDICAL Revised 8/2016 Approved: Levon Vartanian, MD

ZĞƐƉŝƌĂƚŽƌǇŝƐƚƌĞƐƐ͗,&ͬWƵůŵŽŶĂƌǇĚĞŵĂ Assessment Requirements May Present As Consider Possible Causes ƐƐĞƐƐŵĞŶƚΘĨŽĐƵƐĞĚĞǆĂŵ ŝĨĨŝĐƵůƚǇďƌĞĂƚŚŝŶŐ͕ ^dD/ͬE^dD/͕^͕ŚĞĂƌƚ 'DŽŶŝƚŽƌ ƌĞƐƚůĞƐƐŶĞƐƐ͕ĂŶǆŝĞƚǇ͕ĐŽƵŐŚ͕ ĨĂŝůƵƌĞ͕ĐĂƌĚŝĂĐĚǇƐƌŚǇƚŚŵŝĂ͕ dKϮŵŽŶŝƚŽƌŝŶŐ ƉĂůůŽƌ͕ĐǇĂŶŽƐŝƐ͕ƐǇŶĐŽƉĞ͕ ŚǇƉĞƌƚĞŶƐŝǀĞĐƌŝƐŝƐ͕ƚŽǆŝĐ ϭϮͲůĞĂĚ' ŶĞĂƌͲƐǇŶĐŽƉĞ͕ĚŝǌǌŝŶĞƐƐ ĞǆƉŽƐƵƌĞ͕ƉŶĞƵŵŽŶŝĂ͕ dĞŵƉĞƌĂƚƵƌĞ ƉůĞƵƌĂůĞĨĨƵƐŝŽŶ͕ƉƵůŵŽŶĂƌǇ ĞŵďŽůŝƐŵ ZĞƋƵŝƌĞĚdƌĞĂƚŵĞŶƚƐ x Airway management ĂƉƉƌŽƉƌŝĂƚĞ ƚŽƉĂƚŝĞŶƚĐŽŶĚŝƚŝŽŶ͘ x VentilationĂŶĚoxygenation ĂƉƉƌŽƉƌŝĂƚĞƚŽƉĂƚŝĞŶƚĐŽŶĚŝƚŝŽŶ͘ x Vascular accessǁŝƚŚ/sŽƌ/K ǀĂŝůĂďůĞdƌĞĂƚŵĞŶƚƐ x (P) CPAPƉƌŽĐĞĚƵƌĞƐƚĂƌƚŝŶŐĂƚϳ͘ϱĐŵ,ϮKƉƌĞƐƐƵƌĞĂŶĚĞƐĐĂůĂƚŝŶŐƚŽĂŵĂǆŝŵƵŵŽĨϭϬĐŵ,ϮK x (B) AlbuterolϭŶĞďƵůŝǌĞĚĚŽƐĞ͕ŵĂǇƌĞƉĞĂƚŽŶĐĞ͕ĨŽƌǁŚĞĞǌŝŶŐ͘ x (B) NitroglycerinϭŵĞƚĞƌĞĚĚŽƐĞ^>ƐƉƌĂǇŵĂǇƌĞƉĞĂƚĂƐŶĞĞĚĞĚĞǀĞƌǇϱŵŝŶƵƚĞƐƚŽƉĂƚŝĞŶƚ͛Ɛ ĐŽŶĚŝƚŝŽŶŽƌŝŵƉƌŽǀĞŵĞŶƚ͖ŚŽůĚŝĨ^WфϭϬϬŵŵ,Ő͘Maximum of 5 doses. x (P) FurosemideϬ͘ϱʹϭŵŐͬŬŐ/s;ŵĂǆŝŵƵŵϭϮϬŵŐ/sͿ͘/ĨƉĂƚŝĞŶƚŝƐĂůƌĞĂĚǇƚĂŬŝŶŐĨƵƌŽƐĞŵŝĚĞ͕ ĐŽŶƐŝĚĞƌĚŽƵďůŝŶŐƚŚĞĚĂŝůǇĚŽƐĂŐĞ͘ x (P) Dopamine ϱʹϭϬŵĐŐͬŬŐͬŵŝŶ/sŝŶĨƵƐŝŽŶ͕ƚŝƚƌĂƚĞĚƚŽ^WшϵϬŵŵ,ŐŝĨƉĂƚŝĞŶƚƉƌĞƐĞŶƚƐǁŝƚŚ ĐĂƌĚŝŽŐĞŶŝĐƐŚŽĐŬ͘ WĞĂƌůƐ x NitroglycerinŵƵƐƚďĞƵƐĞĚǁŝƚŚĞǆƚƌĞŵĞĐĂƵƚŝŽŶŝŶƚŚĞƉĂƚŝĞŶƚǁŚŽŚĂƐƚĂŬĞŶĂƉŚŽƐƉŚŽĚŝĞƐƚĞƌĂƐĞ ŝŶŚŝďŝƚŽƌ;sŝĂŐƌĂ͕ŝĂůŝƐ͕>ĞǀŝƚƌĂ͕ĞƚĐ͙ͿǁŝƚŚŝŶϮϰŚŽƵƌƐ x /ĨƚŚĞƉĂƚŝĞŶƚŝƐĐƵƌƌĞŶƚůǇƚĂŬŝŶŐWK&ƵƌŽƐĞŵŝĚĞ͕ĐŽŶƐŝĚĞƌŐŝǀŝŶŐ/sFurosemideĂƚĚŽƵďůĞƚŚĞ ƉĂƚŝĞŶƚ͛ƐƚŽƚĂůĚĂŝůǇĚŽƐĞƵƉƚŽĂŵĂǆŝŵƵŵĚŽƐĞŽĨϭϮϬŵŐ/s͘ x FurosemideƐŚŽƵůĚŽŶůǇďĞŐŝǀĞŶƚŽƉĂƚŝĞŶƚƐĞǆŚŝďŝƚŝŶŐǀŽůƵŵĞŽǀĞƌůŽĂĚŝŶƚŚĞĐŽŶƚĞǆƚŽĨĐŽŶŐĞƐƚŝǀĞ ŚĞĂƌƚĨĂŝůƵƌĞĂƐĞǀŝĚĞŶĐĞĚďǇƉƌŽĨŽƵŶĚŚǇƉĞƌƚĞŶƐŝŽŶ͕ŽƌƚŚŽƉŶĞĂ͕ĂŶĚƉŽƐƐŝďůǇƉĞĚĂůĞĚĞŵĂ͘

Cypress Creek EMS System Policies and Treatment Guidelines

102 ADULT MEDICAL Revised 8/2016 Approved: Levon Vartanian, MD

ZĞƐƉŝƌĂƚŽƌǇŝƐƚƌĞƐƐ͗KWͬƐƚŚŵĂ Assessment Requirements May Present As Consider Possible Causes ƐƐĞƐƐŵĞŶƚΘĨŽĐƵƐĞĚĞǆĂŵ ^ŚŽƌƚŶĞƐƐŽĨďƌĞĂƚŚ͕ƉƵƌƐĞĚ ƐƚŚŵĂ͕ĂŶĂƉŚǇůĂǆŝƐ͕ 'DŽŶŝƚŽƌ ůŝƉďƌĞĂƚŚŝŶŐ͕ǁŚĞĞǌŝŶŐ͕ ĂƐƉŝƌĂƚŝŽŶ͕KW dKϮŵŽŶŝƚŽƌŝŶŐ ƌŚŽŶĐŚŝ͕ĨĞǀĞƌ͕ĐŽƵŐŚ͕ ;ĞŵƉŚǇƐĞŵĂ͕ďƌŽŶĐŚŝƚŝƐͿ͕ ƐǇŶĐŽƉĞ͕ŶĞĂƌͲƐǇŶĐŽƉĞ͕ ƉůĞƵƌĂůĞĨĨƵƐŝŽŶ͕ƉŶĞƵŵŽŶŝĂ͕ ĂůƚĞƌĞĚŵĞŶƚĂůƐƚĂƚƵƐ ƉƵůŵŽŶĂƌǇĞŵďŽůŝƐŵ͕ ŝŶŚĂůĞĚƚŽǆŝŶ͕ĐĂƌĚŝĂĐ ZĞƋƵŝƌĞĚdƌĞĂƚŵĞŶƚƐ x Airway management ĂƉƉƌŽƉƌŝĂƚĞ ƚŽƉĂƚŝĞŶƚĐŽŶĚŝƚŝŽŶ͘ x VentilationĂŶĚoxygenation ĂƉƉƌŽƉƌŝĂƚĞƚŽƉĂƚŝĞŶƚĐŽŶĚŝƚŝŽŶ͘ x Vascular accessǁŝƚŚ/sŽƌ/K ǀĂŝůĂďůĞdƌĞĂƚŵĞŶƚƐ x (B) AlbuterolϮƵŶŝƚĚŽƐĞƐŶĞďƵůŝǌĞĚƌĞƉĞĂƚĞĚĂƐŶĞĞĚĞĚ͘ x (B) Albuterol/Ipratropium CombiventŶĞďƵůŝǌĞƌϭƵŶŝƚĚŽƐĞŝĨƌĞĨƌĂĐƚŽƌǇƚŽAlbuterolĂůŽŶĞƌĞƉĞĂƚ ĞǀĞƌǇϭϬͲϭϱŵŝŶƵƚĞƐĂƐŶĞĞĚĞĚ͘ x (P) Methylprednisolone ϭϮϱŵŐ^>Kt/sŽƌ/D x (P) Normal SalineĨůƵŝĚďŽůƵƐƵƉƚŽϮϬŵůͬŬŐŝĨŶŽŽƚŚĞƌĐŽŶƚƌĂŝŶĚŝĐĂƚŝŽŶƐ͘ x (P) CPAP ƉƌŽĐĞĚƵƌĞƐƚĂƌƚŝŶŐĂƚϱĐŵ,ϮKŝĨŶŽĐŽŶƚƌĂŝŶĚŝĐĂƚŝŽŶƐ͕ƵƉƚŽϳ͘ϱĐŵ,ϮK͘EĞďƵůŝǌĞĚ ŵĞĚŝĐĂƚŝŽŶƐŵĂǇďĞĂĚŵŝŶŝƐƚĞƌĞĚǀŝĂŝŶͲůŝŶĞWWĐŝƌĐƵŝƚ x (P) Epinephrine Ϭ͘ϯŵŐϭ͗ϭϬϬϬŵŐ/DŝĨƌĞĨƌĂĐƚŽƌǇƚŽŽƚŚĞƌƚƌĞĂƚŵĞŶƚƐ͘ WĞĂƌůƐ x /ĨƉĂƚŝĞŶƚŚĂƐƵƐĞĚAlbuterol ĂƚŚŽŵĞǁŝƚŚŽƵƚƌĞůŝĞĨ͕ƉƌŽĐĞĞĚǁŝƚŚĐŽŵďŝŶĂƚŝŽŶƚŚĞƌĂƉǇĂƐƚŚĞŝŶŝƚŝĂů ŶĞďƵůŝǌĞƌƚƌĞĂƚŵĞŶƚ͘ x DŽŶŝƚŽƌĂůůƉĂƚŝĞŶƚƐĐĂƌĞĨƵůůǇĨŽƌƐŝŐŶƐŽĨƚĂĐŚǇĐĂƌĚŝĂ͕ŚǇƉĞƌƚĞŶƐŝŽŶ͕ŽƌĐŚĞƐƚƉĂŝŶ͕ĞƐƉĞĐŝĂůůǇƚŚŽƐĞ ƉĂƚŝĞŶƚƐǁŝƚŚŚŝƐƚŽƌǇŽĨĐŽƌŽŶĂƌǇĂƌƚĞƌǇĚŝƐĞĂƐĞ͘ x EĞďƵůŝǌĂƚŝŽŶƐŚŽƵůĚďĞĐŽŶƚŝŶƵĞĚƉŽƐƚŝŶƚƵďĂƚŝŽŶǁŝƚŚsDĂŶĚŶĞďƵůŝǌĞƌĂƚƚĂĐŚŵĞŶƚ͘ x hƐĞĐĂƵƚŝŽŶǁŝƚŚAlbuterolŝŶƉĂƚŝĞŶƚƐǁŝƚŚƉŽƐƐŝďůĞ^ͬD/͘ x ŽŶƐŝĚĞƌƉŽƐƐŝďůĞĂůůĞƌŐŝĐƌĞĂĐƚŝŽŶͬĂŶĂƉŚǇůĂǆŝƐĐĂƵƐĞĂŶĚƌĞĨĞƌƚŽƚŚĞŐƵŝĚĞůŝŶĞƐĨŽƌƚŚĂƚŝĨ ĂƉƉƌŽƉƌŝĂƚĞ͘

Cypress Creek EMS System Policies and Treatment Guidelines

103 ADULT MEDICAL Revised 6/2019 Approved: Levon Vartanian, MD

ĞĐĞĂƐĞĚWĞƌƐŽŶ;K^Ϳ Assessment Requirements May Present As Consider Possible Causes ƐƐĞƐƐŵĞŶƚΘĨƵůůŚĞĂĚͲƚŽͲƚŽĞ WƵůƐĞůĞƐƐĂŶĚĂƉŶĞŝĐ dƌĂƵŵĂƚŝĐŽƌŵĞĚŝĐĂůĚĞĂƚŚ ĞǆĂŵ ƉĂƚŝĞŶƚǁŝƚŚĐƌŝƚĞƌŝĂĨŽƌ 'ŵŽŶŝƚŽƌ ŽďǀŝŽƵƐĚĞĂƚŚ ϭϮͲůĞĂĚ';ƵƐŝŶŐůŝŵďůĞĂĚƐͿ ĂƌĚŝĂĐƵůƚƌĂƐŽƵŶĚ;ŝĨĂǀĂŝůĂďůĞͿ ZĞĐƚĂůƚĞŵƉĞƌĂƚƵƌĞ Criteria for Obvious Death x ƉŶĞŝĐĂŶĚƉƵůƐĞůĞƐƐƉĂƚŝĞŶƚƉƌĞƐĞŶƚŝŶŐǁŝƚŚĂƐǇƐƚŽůĞEŽŶĞŽƌŵŽƌĞŽĨƚŚĞĨŽůůŽǁŝŶŐĨŝŶĚŝŶŐƐ͗ x ĞĐĂƉŝƚĂƚŝŽŶ x ZŝŐŽƌŵŽƌƚŝƐ;ĞǆĐůƵĚŝŶŐŝƐŽůĂƚĞĚƚƌŝƐŵƵƐͿ x dŽƚĂůŝŶĐŝŶĞƌĂƚŝŽŶ x ĞĐŽŵƉŽƐŝƚŝŽŶ x ĞƉĞŶĚĞŶƚůŝǀŝĚŝƚǇ x sŝƐŝďůĞƚƌĂƵŵĂƚŽƚŚĞŚĞĂĚŽƌƚƌƵŶŬĐůĞĂƌůǇŝŶĐŽŵƉĂƚŝďůĞǁŝƚŚůŝĨĞ x DĂƐƐĂƐƵĂůƚǇ/ŶĐŝĚĞŶƚǁŝƚŚ^dZddƌŝĂŐĞ;^ĞĞWĞĂƌůƐͿ ZĞƋƵŝƌĞĚdƌĞĂƚŵĞŶƚƐ x (B)KďƚĂŝŶϭϮͲůĞĂĚ';ƚŚŝƐĞŶƐƵƌĞƐƚŚĂƚƚŚĞĚĂƚĂŝƐƌĞĐŽƌĚĞĚŝŶƚŚĞWZͿƚŽĐŽŶĨŝƌŵĂƐǇƐƚŽůĞŝŶϯ ůĞĂĚƐ;ŽŶůǇƚŚĞůŝŵďůĞĂĚƐŶĞĞĚďĞĂƉƉůŝĞĚƚŽƚŚĞƉĂƚŝĞŶƚͿ͘ x (P)ĂƌĚŝĂĐƵůƚƌĂƐŽƵŶĚ;ŝĨĂǀĂŝůĂďůĞͿ x (B)ZĞĐƚĂůƚĞŵƉĞƌĂƚƵƌĞ x (P2)KďƐĞƌǀĞĂŶĚĚŽĐƵŵĞŶƚƌŝŐŽƌŵŽƌƚŝƐ͕ĚĞƉĞŶĚĞŶƚůŝǀŝĚŝƚǇ͕ĂŶĚŽƚŚĞƌƉĞƌƚŝŶĞŶƚĨŝŶĚŝŶŐƐ͘ WƌŽĐĞĚƵƌĞ x EŽƚŝĨǇĨĂŵŝůǇ;ŝĨƉƌĞƐĞŶƚŽŶƐĐĞŶĞͿŽĨƚŚĞĚŝƐĐŽŶƚŝŶƵĂƚŝŽŶͬůĂĐŬŽĨƌĞƐƵƐĐŝƚĂƚŝŽŶĞĨĨŽƌƚƐ͘ x ŽŶƚĂĐƚŽŵŵĞŶƚĞƌĂŶĚŶŽƚŝĨǇƚŚĞŵŽĨK^ƚŽŐĞƚ>ƌĞƐƉŽŶƐĞ͘^ĞĞŬƚŽƉƌĞƐĞƌǀĞƉŽƐƐŝďůĞĐƌŝŵĞ ƐĐĞŶĞĞǀŝĚĞŶĐĞĂŶĚĐŽŽƌĚŝŶĂƚĞǁŝƚŚůĂǁĞŶĨŽƌĐĞŵĞŶƚ͘ x &ŽůůŽǁDonor Referral/LifeGiftƉƌŽĐĞĚƵƌĞ͘ x >ĞĂǀĞĂůůƉĂƚŝĞŶƚŵĞĚŝĐĂůĚĞǀŝĐĞƐŝŶƉůĂĐĞ͘WƌĞƐĞƌǀĞƐĐĞŶĞĂƐƉŽƐƐŝďůĞĐƌŝŵĞƐĐĞŶĞ͘ŝƐĐŽŶŶĞĐƚ' ůĞĂĚƐďƵƚůĞĂǀĞƐƚŝĐŬĞƌƐ͘ŝƐĐŽŶŶĞĐƚĚĞĨŝďƌŝůůĂƚŽƌŽƌƉĂĚƐďƵƚůĞĂǀĞĂƚƚĂĐŚĞĚƚŽƉĂƚŝĞŶƚ͘ ŝƐĐŽŶŶĞĐƚĂŶǇ/sͬ/KůŝŶĞƐ͕ďƵƚůĞĂǀĞƚŚĞĐĂƚŚĞƚĞƌƐĂŶĚĞǆƚĞŶƐŝŽŶƐŝŶƉůĂĐĞŝŶƉĂƚŝĞŶƚ͘>ĞĂǀĞĂŶǇ ĂŝƌǁĂǇĚĞǀŝĐĞƐ;dƚƵďĞƐ͕ƐƵƉƌĂŐůŽƚƚŝĐĂŝƌǁĂǇƐ͕KWƐ͕EWƐ͕ƚƌĂĐŚĞŽƐƚŽŵŝĞƐ͕ĞƚĐ͘ͿŝŶƉůĂĐĞ͘ x KďƚĂŝŶƚŚĞĨŽůůŽǁŝŶŐŬĞǇŝŶĨŽƌŵĂƚŝŽŶ͗ WĂƚŝĞŶƚĚĞŵŽŐƌĂƉŚŝĐƐ;ĂŐĞ͕ƐĞǆ͕K͕ƌĂĐĞͿ DĞĐŚĂŶŝƐŵŽĨŝŶũƵƌǇͬŚŝƐƚŽƌǇŽĨƉƌĞƐĞŶƚŝůůŶĞƐƐ WĂƐƚŵĞĚŝĐĂůŚŝƐƚŽƌǇ ƵƌƌĞŶƚŵĞĚŝĐĂƚŝŽŶƐ

Cypress Creek EMS System Policies and Treatment Guidelines

104 ADULT MEDICAL Revised 6/2019 Approved: Levon Vartanian, MD

EĞǆƚŽĨŬŝŶŽƌƌĞƐƉŽŶƐŝďůĞƉĂƌƚǇ;ŶĂŵĞ͕ƌĞůĂƚŝŽŶƐŚŝƉ͕ƉŚŽŶĞŶƵŵďĞƌͿ >ĂƐƚƚŝŵĞŬŶŽǁŶƚŽďĞĂůŝǀĞĂŶĚĐŝƌĐƵŵƐƚĂŶĐĞƐƐƵƌƌŽƵŶĚŝŶŐĚĞĂƚŚ WƌŝŵĂƌǇĐĂƌĞƉŚǇƐŝĐŝĂŶ͕ŝĨŬŶŽǁŶ x /ĨƉĂƚŝĞŶƚŝƐĂĐƵƌƌĞŶƚŚŽƐƉŝĐĞƉĂƚŝĞŶƚ͕ĐŽŶƚĂĐƚƚŚĞŚŽƐƉŝĐĞĐŽŶƚĂĐƚŝĨĂǀĂŝůĂďůĞ͘ x WƌŽǀŝĚĞƌĞƋƵĞƐƚĞĚŝŶĨŽƌŵĂƚŝŽŶƚŽ>ĂŶĚůĞĂǀĞƐĐĞŶĞĂŶĚďŽĚǇŝŶƚŚĞŝƌĐƵƐƚŽĚǇ͘ x KŶůǇĂWϮŽƌWϯŵĂǇĐŽŵƉůĞƚĞƚŚĞƉĂƚŝĞŶƚĐĂƌĞƌĞƉŽƌƚĨŽƌƚŚĞƐĞŝŶĐŝĚĞŶƚƐ͘ x ŽĐƵŵĞŶƚĂƚŝŽŶŵƵƐƚŝŶĐůƵĚĞ͗ WŚǇƐŝĐĂůĞǆĂŵĨŝŶĚŝŶŐƐƚŚĂƚƐƵƉƉŽƌƚƚŚĞĐƌŝƚĞƌŝĂĨŽƌŽďǀŝŽƵƐĚĞĂƚŚ ĂƌĚŝĂĐŵŽŶŝƚŽƌĨŝůĞ͕ŝŶĐůƵĚŝŶŐϭϮͲůĞĂĚ';ŽŶůǇŶĞĞĚƚŽĐŽŶŶĞĐƚůŝŵďůĞĂĚƐͿ &ůŽǁĐŚĂƌƚŝŶƚĞƌǀĞŶƚŝŽŶĨŽƌ>ŝĨĞ'ŝĨƚƌĞĨĞƌƌĂů ĞƐĐƌŝƉƚŝŽŶŽĨƐĐĞŶĞĂŶĚƐŝƚƵĂƚŝŽŶ tŚŝĐŚůĂǁĞŶĨŽƌĐĞŵĞŶƚĂŐĞŶĐǇŵĂŝŶƚĂŝŶĞĚĐƵƐƚŽĚǇŽĨƐĐĞŶĞĂŶĚďŽĚǇ ĞƐĐƌŝƉƚŝŽŶŽĨĐŽŶǀĞƌƐĂƚŝŽŶ;ƐͿǁŝƚŚĨĂŵŝůǇ;ŝĨƉƌĞƐĞŶƚͿ /ĨĂƉƉůŝĐĂďůĞ͕ĨůŽǁĐŚĂƌƚŝŶƚĞƌǀĞŶƚŝŽŶĨŽƌŚŽƐƉŝĐĞĐŽŶƚĂĐƚ;'ĞŶĞƌĂůŽŵŵĞŶƚƐͿ WĞĂƌůƐ x dŚŝƐƉƌŽƚŽĐŽůŝƐŵĞĂŶƚƚŽĨĂĐŝůŝƚĂƚĞĚŝƐĐŽŶƚŝŶƵĂƚŝŽŶͬůĂĐŬŽĨƌĞƐƵƐĐŝƚĂƚŝŽŶŽĨƚŚĞnon-viable patient ĂŶĚƐŚŽƵůĚŶŽƚďĞƵƐĞĚƚŽĂǀŽŝĚƌĞƐƵƐĐŝƚĂƚŝŽŶŽĨƚŚĞpossibly viableƉĂƚŝĞŶƚ͘^ĞĞCardiac Arrest Žƌ Traumatic Arrest͘ x hƐĞŐŽŽĚũƵĚŐŵĞŶƚǁŚĞŶĚŝƐĐŽŶƚŝŶƵŝŶŐƌĞƐƵƐĐŝƚĂƚŝŽŶƚŚĂƚŝƐĂůƌĞĂĚǇŝŶƉƌŽŐƌĞƐƐ͘ŽŵŵƵŶŝĐĂƚŝŽŶ ǁŝƚŚƚŚĞĨĂŵŝůǇŝƐŬĞǇ͘/ĨƌĞƐƵƐĐŝƚĂƚŝŽŶ;ŝŶĐůƵĚŝŶŐWZͿǁĂƐƐƚĂƌƚĞĚďǇďǇƐƚĂŶĚĞƌƐͬĨĂŵŝůǇŽƌŶŽŶͲ D^ĨŝƌƐƚƌĞƐƉŽŶĚĞƌƐ͕ĂƐƐĞƐƐƚŚĞƉĂƚŝĞŶƚďĞĨŽƌĞƐƚŽƉƉŝŶŐƌĞƐƵƐĐŝƚĂƚŝǀĞĞĨĨŽƌƚƐ͘/ĨƚŚĞƉĂƚŝĞŶƚŝƐ ŽďǀŝŽƵƐůǇĚĞĂĚ͕ďĂƐĞĚŽŶƚŚĞĐƌŝƚĞƌŝĂĂďŽǀĞ͕ƚŚĞŶD^ƉĞƌƐŽŶŶĞůŵĂǇƐƚŽƉƌĞƐƵƐĐŝƚĂƚŝǀĞĞĨĨŽƌƚƐ ĨŽůůŽǁŝŶŐƚŚŝƐƉƌŽĐĞĚƵƌĞ͘ x /ĨƌĞƐƵƐĐŝƚĂƚŝŽŶǁĂƐƐƚĂƌƚĞĚďǇD^ƉĞƌƐŽŶŶĞů͕ŝƚŵƵƐƚĐŽŶƚŝŶƵĞƵŶƚŝůĂ&ŝĞůĚ^ƵƉĞƌǀŝƐŽƌŽƌWϯ ĂƐƐĞƐƐĞƐƚŚĞƉĂƚŝĞŶƚĂŶĚĚĞƚĞƌŵŝŶĞƐƚŚĂƚĞŝƚŚĞƌ͗ o dŚĞƉĂƚŝĞŶƚŝƐŽďǀŝŽƵƐůǇĚĞĂĚďĂƐĞĚŽŶƚŚĞĐƌŝƚĞƌŝĂĂďŽǀĞĂŶĚƌĞƐƵƐĐŝƚĂƚŝŽŶƐŚŽƵůĚďĞƐƚŽƉƉĞĚ or o ZĞƐƵƐĐŝƚĂƚŝŽŶƐŚŽƵůĚďĞĐŽŶƚŝŶƵĞĚƵŶƚŝůƚĞƌŵŝŶĂƚĞĚĂĐĐŽƌĚŝŶŐƚŽƚŚĞField TerminationƉƌŽƚŽĐŽů or o ZĞƐƵƐĐŝƚĂƚŝŽŶƐŚŽƵůĚďĞĐŽŶƚŝŶƵĞĚƵŶƚŝůƉĂƚŝĞŶƚĐĂƌĞŝƐƚƌĂŶƐĨĞƌƌĞĚƚŽĂŚŝŐŚĞƌůĞǀĞůŽĨĐĂƌĞ͘ x TrismusŝƐĚĞĨŝŶĞĚĂƐĂƚĞŵƉŽƌĂƌǇŽƌƉĞƌŵĂŶĞŶƚƌĞĚƵĐĞĚŽƉĞŶŝŶŐŽĨƚŚĞũĂǁƐ͘/ƚŝƐĂůƐŽŬŶŽǁŶĂƐ ůŽĐŬũĂǁĂŶĚŵĂǇďĞĂƉƌĞĞǆŝƐƚŝŶŐĐŽŶĚŝƚŝŽŶ͘dƌŝƐŵƵƐŵĂǇďĞĐĂƵƐĞĚďǇŵƵůƚŝƉůĞĞƚŝŽůŽŐŝĞƐ͘ x Mass Casualty Incidents:WĞƌĨŽƌŵ^dZdƚƌŝĂŐĞĨŽƌĂĚƵůƚƐĂŶĚ:ƵŵƉ^dZddƌŝĂŐĞĨŽƌƉĞĚŝĂƚƌŝĐƐ͘&Žƌ ĂĚƵůƚƐ͕ŝĨƉĂƚŝĞŶƚŝƐƉƵůƐĞůĞƐƐĂŶĚĂƉŶĞŝĐĂĨƚĞƌĐŽŶƚƌŽůŽĨŵĂũŽƌŚĞŵŽƌƌŚĂŐĞ͕ŽƉĞŶŝŶŐŽĨĂŝƌǁĂǇ͕ĂŶĚ ĐŚĞƐƚĚĞĐŽŵƉƌĞƐƐŝŽŶ͕ƉĞƌĨŽƌŵĂŚĞĂĚͲƚŝůƚŵĂŶĞƵǀĞƌ͘tŝƚŚŽƵƚƐƉŽŶƚĂŶĞŽƵƐďƌĞĂƚŚƐ͕ƉĂƚŝĞŶƚŝƐ ůĂďĞůĞĚĞǆƉĞĐƚĂŶƚ;ďůĂĐŬͿ͘ŶĞǆĐĞƉƚŝŽŶƚŽƚŚŝƐƌƵůĞŝƐĂŵĂƐƐĐĂƐƵĂůƚǇůŝŐŚƚŶŝŶŐͲƐƚƌŝŬĞŝŶĐŝĚĞŶƚ͖ ƉĂƚŝĞŶƚƐŝŶƌĞƐƉŝƌĂƚŽƌǇŽƌĐĂƌĚŝĂĐĂƌƌĞƐƚƐŚŽƵůĚďĞƚƌĞĂƚĞĚĨŝƌƐƚ͘

Cypress Creek EMS System Policies and Treatment Guidelines

105 ADULT MEDICAL Revised 6/2019 Approved: Levon Vartanian, MD

ďĚŽŵŝŶĂůWĂŝŶ Assessment Requirements May Present As Consider Possible Causes ƐƐĞƐƐŵĞŶƚΘĨŽĐƵƐĞĚĞǆĂŵ WĂŝŶ͕ƚĞŶĚĞƌŶĞƐƐ͕ŶĂƵƐĞĂ͕ ƉƉĞŶĚŝĐŝƚŝƐ͕ŝǀĞƌƚŝĐƵůŝƚŝƐ͕ 'DŽŶŝƚŽƌĂƉƉƌŽƉƌŝĂƚĞƚŽ ǀŽŵŝƚŝŶŐ͕ĚŝĂƌƌŚĞĂ͕ĚǇƐƵƌŝĂ͕ ĐƚŽƉŝĐWƌĞŐŶĂŶĐǇ͕KǀĂƌŝĂŶ ƉĂƚŝĞŶƚĐŽŶĚŝƚŝŽŶ ĐŽŶƐƚŝƉĂƚŝŽŶ͕ǀĂŐŝŶĂů ĐǇƐƚƐ͕ŶĚŽŵĞƚƌŝŽƐŝƐ͕ ϭϮͲůĞĂĚ'ŝĨĐĂƌĚŝĂĐ ďůĞĞĚŝŶŐͬĚŝƐĐŚĂƌŐĞ͕ KǀƵůĂƚŝŽŶ͕DĞŶƐĞƐ͕ ĞƚŝŽůŽŐǇĐĂŶŶŽƚďĞƌƵůĞĚŽƵƚ ƉƌĞŐŶĂŶĐǇ WƌĞŐŶĂŶĐǇ͕WƌĞŵĂƚƵƌĞ>ĂďŽƌ͕ Associated symptoms: DŝƐĐĂƌƌŝĂŐĞ͕hd/ͬǇƐƚŝƚŝƐ͕ &ĞǀĞƌ͕ŚĞĂĚĂĐŚĞ͕ǁĞĂŬŶĞƐƐ͕ W/͕<ŝĚŶĞǇ^ƚŽŶĞƐ͕ŽǁĞů ŵĂůĂŝƐĞ͕ĐŽƵŐŚ͕ĚŝǌǌŝŶĞƐƐ͕ KďƐƚƌƵĐƚŝŽŶ͕ďĚŽŵŝŶĂů ĂůƚĞƌĞĚŵĞŶƚĂƚŝŽŶ ŽƌƚŝĐŶĞƵƌǇƐŵ͕>ŝǀĞƌ ƉƌŽďůĞŵƐͬĐŝƌƌŚŽƐŝƐ͕ WĂŶĐƌĞĂƚŝƚŝƐ͕ŚŽůĞĐǇƐƚŝƚŝƐ ;ŐĂůůďůĂĚĚĞƌͿ͕WĞƉƚŝĐhůĐĞƌ ŝƐĞĂƐĞͬ'ĂƐƚƌŝƚŝƐ͕sŝƌĂů /ůůŶĞƐƐͬ&ŽŽĚƉŽŝƐŽŶŝŶŐ͕ ƐĐŝƚĞƐ͕WĞƌĨŽƌĂƚĞĚ ƵůĐĞƌͬƉĞƌĨŽƌĂƚĞĚďŽǁĞů͕ ůŽĂƚŝŶŐͬ'ĂƐ͕ŽŶƐƚŝƉĂƚŝŽŶ͕ 'ĂƐƚƌŽĞŶƚĞƌŝƚŝƐ͕ ^ƉůĞĞŶĞŶůĂƌŐĞŵĞŶƚ͕ŽůŝƚŝƐ͕ ƌŽŚŶ͛ƐŝƐĞĂƐĞ͕/^͕dƌĂƵŵĂ͕ ^ƵƌŐĞƌǇͲƌĞůĂƚĞĚƉĂŝŶ͕ĐƵƚĞ D/ͬ^ ZĞƋƵŝƌĞĚdƌĞĂƚŵĞŶƚƐ x Airway management ĂƉƉƌŽƉƌŝĂƚĞ ƚŽƉĂƚŝĞŶƚĐŽŶĚŝƚŝŽŶ͘ x VentilationĂŶĚoxygenation ĂƉƉƌŽƉƌŝĂƚĞƚŽƉĂƚŝĞŶƚĐŽŶĚŝƚŝŽŶ͘ x Nothing by mouth ǀĂŝůĂďůĞdƌĞĂƚŵĞŶƚƐ x (I) Vascular accessǁŝƚŚ/sŽƌ/K x (P) Ondansetron ϰʹϴŵŐKdĨŽƌŶĂƵƐĞĂŵĂǇƌĞƉĞĂƚŽŶĐĞ;ŵĂǆŝŵƵŵĚŽƐĞϭϲŵŐͿ x (P) Promethazine ϭϮ͘ϱŵŐ^>Kt/s;ŵĂǇƌĞƉĞĂƚ/sŽŶĐĞͿŽƌϮϱŵŐ/DĨŽƌĐŽŶƚƌŽůŽĨŶĂƵƐĞĂĂŶĚ ǀŽŵŝƚŝŶŐ͘ x (P) Normal SalineŽƌPlasmalyteĨůƵŝĚďŽůƵƐŽĨϭϬʹϮϬŵůͬŬŐŝĨŶŽĐŽŶƚƌĂŝŶĚŝĐĂƚŝŽŶƐĂŶĚ ĂƉƉƌŽƉƌŝĂƚĞĨŽƌƉĂƚŝĞŶƚĐŽŶĚŝƚŝŽŶ͘ x (P) ŽŶƐŝĚĞƌPain ManagementƉƌŽĐĞĚƵƌĞ͘ x ZĞĨĞƌƚŽHypotension/ShockŐƵŝĚĞůŝŶĞƐŝĨĂƉƉƌŽƉƌŝĂƚĞ͘

Cypress Creek EMS System Policies and Treatment Guidelines

106 ADULT MEDICAL Revised 6/2019 Approved: Levon Vartanian, MD

WĞĂƌůƐ x ĚŵŝŶŝƐƚƌĂƚŝŽŶŽĨMorphineŽƌFentanylĂůŽŶŐǁŝƚŚPromethazineƚŽƚŚĞƐĂŵĞƉĂƚŝĞŶƚĐĂŶĐĂƵƐĞĂ ƉƌŽĨŽƵŶĚƌĞĚƵĐƚŝŽŶŝŶŵĞŶƚĂůƐƚĂƚƵƐĂŶĚƌĞƐƉŝƌĂƚŽƌǇĚƌŝǀĞ͘hƐĞĐĂƵƚŝŽŶǁŚĞŶƵƐŝŶŐƚŚĞŵƚŽŐĞƚŚĞƌ͕ ĂŶĚĐůŽƐĞůǇŵŽŶŝƚŽƌƚŚĞƉĂƚŝĞŶƚĨŽƌƚŚĞƐĞĞĨĨĞĐƚƐ͘ x ŽŶƐŝĚĞƌĂĚŵŝŶŝƐƚĞƌŝŶŐPromethazineĂƐĂŶŝŶĨƵƐŝŽŶŽĨϭϮ͘ϱŵŐŝŶϭϬϬŵ>ŶŽƌŵĂůƐĂůŝŶĞŽǀĞƌϭϬ ŵŝŶƵƚĞƐŝŶŽƌĚĞƌƚŽŵŝŶŝŵŝǌĞĂĚǀĞƌƐĞƐŝĚĞĞĨĨĞĐƚƐ͘ x PromethazineƐŚŽƵůĚďĞĂǀŽŝĚĞĚĨŽƌĐŚŝůĚƌĞŶĂŶĚƉĂƚŝĞŶƚƐǁŚŽĂƌĞƉƌĞŐŶĂŶƚ͘ŽŶƐŝĚĞƌ OndansetronŽƌMetoclopramideĂƐĂŶĂůƚĞƌŶĂƚŝǀĞ͘^ĞĞPregnancy and Obstetrical Emergency͘ x ďĚŽŵŝŶĂůƉĂŝŶĞƚŝŽůŽŐǇŝƐĚŝĨĨŝĐƵůƚƚŽĚĞƚĞƌŵŝŶĞŝŶƚŚĞƉƌĞͲŚŽƐƉŝƚĂůƐĞƚƚŝŶŐǁŝƚŚŽƵƚůĂďǁŽƌŬĂŶĚ ƌĂĚŝŽůŽŐŝĐĂůƐƚƵĚŝĞƐ͘ŽŶƐŝĚĞƌĂďŽǀĞůŝƐƚŽĨƉŽƐƐŝďůĞĚŝĨĨĞƌĞŶƚŝĂůĚŝĂŐŶŽƐĞƐĂŶĚƵƐĞĂƐƐĞƐƐŵĞŶƚ ĨŝŶĚŝŶŐƐƚŽĐĂƚĞŐŽƌŝǌĞĂƐƐƚĂďůĞǀƐ͘ƵƌŐĞŶƚ͘

Cypress Creek EMS System Policies and Treatment Guidelines

107 ADULT MEDICAL Revised 8/2016 Approved: Levon Vartanian, MD

ůůĞƌŐŝĐZĞĂĐƚŝŽŶƐͬŶĂƉŚǇůĂǆŝƐ Assessment Requirements May Present As Consider Possible Causes ƐƐĞƐƐŵĞŶƚΘĨŽĐƵƐĞĚĞǆĂŵ /ƚĐŚŝŶŐŽƌŚŝǀĞƐ͕ hƌƚŝĐĂƌŝĂů;ƌĂƐŚŽŶůǇͿ 'DŽŶŝƚŽƌĂƉƉƌŽƉƌŝĂƚĞƚŽ ĐŽƵŐŚŝŶŐͬǁŚĞĞǌŝŶŐ͕ ŶĂƉŚǇůĂǆŝƐ;ƐǇƐƚĞŵŝĐͿ ƉĂƚŝĞŶƚĐŽŶĚŝƚŝŽŶ ƌĞƐƉŝƌĂƚŽƌǇĚŝƐƚƌĞƐƐ͕ ŶŐŝŽĞĚĞŵĂ;ĚƌƵŐŝŶĚƵĐĞĚ dKϮŵŽŶŝƚŽƌĂƉƉƌŽƉƌŝĂƚĞ ĐŚĞƐƚͬƚŚƌŽĂƚĐŽŶƐƚƌŝĐƚŝŽŶ͕ ƐǁĞůůŝŶŐͿ͕ƐƉŝƌĂƚŝŽŶͬĂŝƌǁĂǇ ƚŽƉĂƚŝĞŶƚĐŽŶĚŝƚŝŽŶ ĚŝĨĨŝĐƵůƚǇƐǁĂůůŽǁŝŶŐ͕ ŽďƐƚƌƵĐƚŝŽŶ͕ĂƐƚŚŵĂͬKW͕ ƐǁĞůůŝŶŐͬĞĚĞŵĂ͕ ,& ŚǇƉŽƚĞŶƐŝŽŶͬƐŚŽĐŬ͕ ŶĂƵƐĞĂͬǀŽŵŝƚŝŶŐ ZĞƋƵŝƌĞĚdƌĞĂƚŵĞŶƚƐ x Airway management ĂƉƉƌŽƉƌŝĂƚĞ ƚŽƉĂƚŝĞŶƚĐŽŶĚŝƚŝŽŶ͘ x VentilationĂŶĚoxygenation ĂƉƉƌŽƉƌŝĂƚĞƚŽƉĂƚŝĞŶƚĐŽŶĚŝƚŝŽŶ͘ ǀĂŝůĂďůĞdƌĞĂƚŵĞŶƚƐ Mild symptoms

x (B) Cold packsĂƉƉůŝĞĚŝŶĚŝƌĞĐƚůǇƚŽƐŝƚĞ x (B) ElevateĂĨĨĞĐƚĞĚĂƌĞĂŝĨĂƉƉůŝĐĂďůĞ x (I) Vascular accessǁŝƚŚ/sŽƌ/K͕ŝĨŝŶĚŝĐĂƚĞĚ x (P) DiphenhydramineϱϬŵŐ/sŽƌ/D x (P) Methylprednisolone ϭϮϱŵŐ^>Kt/sŽƌ/D

Moderate symptoms x ŽŶƐŝĚĞƌĂďŽǀĞƚƌĞĂƚŵĞŶƚƐ͘ x (B) AlbuterolŶĞďƵůŝǌĞƌϭƵŶŝƚĚŽƐĞ͕ƌĞƉĞĂƚĂƐŶĞĞĚĞĚ͘ x (B) Albuterol/IpratropiumĐŽŵďŝǀĞŶƚϭƵŶŝƚĚŽƐĞŶĞďƵůŝǌĞĚŝĨƌĞĨƌĂĐƚŽƌǇƚŽAlbuterolĂůŽŶĞ͘ZĞƉĞĂƚ ĂƐŶĞĞĚĞĚ͘ x (P) Epinephrine ϭ͗ϭϬϬϬϬ͘ϯŵŐ/D Severe symptoms x ŽŶƐŝĚĞƌĂďŽǀĞƚƌĞĂƚŵĞŶƚƐ͘ x (P) Normal saline ŽƌPlasmalyteϱϬϬŵ>ĨůƵŝĚďŽůƵƐƵƉƚŽϮϬŵ>ͬŬŐ͕ĂƐĂƉƉƌŽƉƌŝĂƚĞĨŽƌƉĂƚŝĞŶƚ ĐŽŶĚŝƚŝŽŶ͘ x (P) Epinephrine 0.1mg IVďŽůƵƐĂƐĂůĂƐƚƌĞƐŽƌƚĨŽƌƉĞƌŝͲĂƌƌĞƐƚĂŶĂƉŚǇůĂǆŝƐ͘DĂǇƌĞƉĞĂƚǆϮĂƐŶĞĞĚĞĚ͘ x (P)Epinephrine ŝŶĨƵƐŝŽŶϮʹϭϬŵĐŐͬŬŐͬŵŝŶ͕ƚŝƚƌĂƚĞĚƚŽĞĨĨĞĐƚ͕ƚŽŵĂŝŶƚĂŝŶ^WхϵϬŵŵ,Ő͘ WĞĂƌůƐ x ŶĂƉŚǇůĂǆŝƐŝƐĂůŝĨĞͲƚŚƌĞĂƚĞŶŝŶŐ͕ŵƵůƚŝͲƐǇƐƚĞŵĂůůĞƌŐŝĐƌĞĂĐƚŝŽŶ͘EpinephrineŝƐƚŚĞĚƌƵŐŽĨĐŚŽŝĐĞ ĂŶĚƚŚĞĨŝƌƐƚĚƌƵŐƚŚĂƚƐŚŽƵůĚďĞĂĚŵŝŶŝƐƚĞƌĞĚŝŶĂĐƵƚĞĂŶĂƉŚǇůĂǆŝƐ;ŵŽĚĞƌĂƚĞͬƐĞǀĞƌĞƐǇŵƉƚŽŵƐͿ͘ /DƉŝŶĞƉŚƌŝŶĞƐŚŽƵůĚƚĂŬĞƉƌŝŽƌŝƚǇŽǀĞƌĂƚƚĞŵƉƚƐĂƚ/sŽƌ/KĂĐĐĞƐƐŽƌĐĂƌĚŝĂĐŵŽŶŝƚŽƌŝŶŐ͘

Cypress Creek EMS System Policies and Treatment Guidelines

108 ADULT MEDICAL Revised 8/2016 Approved: Levon Vartanian, MD

Symptom Severity Classification:

Mild Moderate Severe &ůƵƐŚŝŶŐ 2 or more of the following: ZĞƐƉŝƌĂƚŽƌǇĂŶĚͬŽƌ'/ ,ŝǀĞƐͬhƌƚŝĐĂƌŝĂͬ/ƚĐŚŝŶŐ͕ x Skin;&ůƵƐŚŝŶŐ͕ ƐǇŵƉƚŽŵƐ͘ ƌǇƚŚĞŵĂ ,ŝǀĞƐͬhƌƚŝĐĂƌŝĂͬ/ƚĐŚŝŶŐ͕ WithŚǇƉŽƚĞŶƐŝŽŶĂŶĚ EŽƌŵĂůWĂŶĚƉĞƌĨƵƐŝŽŶ͘ ƌǇƚŚĞŵĂͿ ƉŽŽƌƉĞƌĨƵƐŝŽŶ͘ x Respiratory ;^ŬŝŶƐǇŵƉƚŽŵƐŵĂǇŽƌ ;ǁŚĞĞǌŝŶŐͬĚǇƐƉŶĞĂͬŚǇƉŽǆŝĂͿ ŵĂǇŶŽƚďĞƉƌĞƐĞŶƚ x GI ;ŶĂƵƐĞĂͬǀŽŵŝƚŝŶŐͬŐĂƐƚƌŝĐ ĚĞƉĞŶĚŝŶŐŽŶ ƵƉƐĞƚͬĂďĚŽŵŝŶĂůƉĂŝŶͿ ƉĞƌĨƵƐŝŽŶ͘Ϳ x ůůĞƌŐŝĐƌĞĂĐƚŝŽŶƐĂŶĚĂŶĂƉŚǇůĂǆŝƐŵĂǇŽĐĐƵƌǁŝƚŚŶŽƐŬŝŶƐǇŵƉƚŽŵƐĂŶĚŽŶůǇ'/нZĞƐƉŝƌĂƚŽƌǇ͕Žƌ ǁŝƚŚŶŽƌĞƐƉŝƌĂƚŽƌǇƐǇŵƉƚŽŵƐĂŶĚŽŶůǇ^ŬŝŶн'/͘ x ŶŐŝŽĞĚĞŵĂŝƐƐĞĞŶŝŶŵŽĚĞƌĂƚĞƚŽƐĞǀĞƌĞƌĞĂĐƚŝŽŶƐĂŶĚŝƐƐǁĞůůŝŶŐƚŽĨĂĐĞ͕ůŝƉƐ͕ƚŚƌŽĂƚ͕ĂŶĚĂŝƌǁĂǇ͘ /ƚŵĂǇĂůƐŽďĞƐĞĞŶŝŶƉĂƚŝĞŶƚƐƚĂŬŝŶŐͲŝŶŚŝďŝƚŽƌƐ͘ x hƐĞĐĂƵƚŝŽŶǁŚĞŶŐŝǀŝŶŐĞƉŝŶĞƉŚƌŝŶĞƚŽƉĂƚŝĞŶƚƐхϱϬǇĞĂƌƐŽĨĂŐĞ͕ǁŝƚŚĂŚŝƐƚŽƌǇŽĨĐĂƌĚŝĂĐĚŝƐĞĂƐĞ͕ ƚĂŬŝŶŐďĞƚĂͲďůŽĐŬĞƌƐͬĚŝŐŽǆŝŶ͕ǁŝƚŚ,ZхϭϱϬ͘ŽŶƐŝĚĞƌŐŝǀŝŶŐĂŚĂůĨĚŽƐĞ͘ x ŶǇƉĂƚŝĞŶƚƌĞĐĞŝǀŝŶŐĞƉŝŶĞƉŚƌŝŶĞƐŚŽƵůĚŚĂǀĞĂϭϮͲůĞĂĚ'ŽďƚĂŝŶĞĚ͕ďƵƚĚŽŶ͛ƚĚĞůĂǇ ĂĚŵŝŶŝƐƚƌĂƚŝŽŶŽĨĞƉŝŶĞƉŚƌŝŶĞƚŽŽďƚĂŝŶϭϮͲůĞĂĚ͘ x dŚĞŵŽƌĞƌĂƉŝĚƚŚĞŽŶƐĞƚŽĨƐǇŵƉƚŽŵƐ͕ƚŚĞŵŽƌĞƐĞǀĞƌĞƚŚĞƌĞĂĐƚŝŽŶ͘

Cypress Creek EMS System Policies and Treatment Guidelines

109 ADULT MEDICAL Revised 8/2016 Approved: Levon Vartanian, MD

ůƚĞƌĞĚDĞŶƚĂů^ƚĂƚƵƐ Assessment Requirements May Present As Consider Possible Causes ƐƐĞƐƐŵĞŶƚΘ&ƵůůŚĞĂĚͲƚŽͲ >ĞƚŚĂƌŐǇ͕ĚĞĐƌĞĂƐĞĚůĞǀĞůŽĨ ,ǇƉŽŐůǇĐĞŵŝĂͬŚǇƉĞƌŐůǇĐĞŵŝĂ ƚŽĞĞǆĂŵ ĐŽŶƐĐŝŽƵƐŶĞƐƐ͕ ^ŚŽĐŬ;ŚǇƉŽǀŽůĞŵŝĐ͕ƐĞƉƚŝĐ͕ 'DŽŶŝƚŽƌ ƵŶƌĞƐƉŽŶƐŝǀĞŶĞƐƐ͕ĐŚĂŶŐĞƐŝŶ ĐĂƌĚŝŽŐĞŶŝĐ͕ŽƚŚĞƌͿ ϭϮͲůĞĂĚ' ďĂƐĞůŝŶĞŵĞŶƚĂůƐƚĂƚƵƐ͘ KǀĞƌĚŽƐĞͬƚŽǆŝŶƐ dKϮŵŽŶŝƚŽƌŝŶŐ ^ĞŝǌƵƌĞƐ '>ƐƐĞƐƐŵĞŶƚ sͬ^ƚƌŽŬĞͬŚĞĂĚƚƌĂƵŵĂ /ŶĨĞĐƚŝŽŶ;E^͕hd/͕ŽƌŽƚŚĞƌͿ dŚǇƌŽŝĚ;ŚǇƉĞƌͬŚǇƉŽͿ ,ǇƉŽǆŝĂ ůĞĐƚƌŽůǇƚĞĂďŶŽƌŵĂůŝƚǇ WƐǇĐŚŝĂƚƌŝĐĚŝƐŽƌĚĞƌ ,ŝŐŚĂŵŵŽŶŝĂůĞǀĞůƐƌĞůĂƚĞĚ ƚŽĐŝƌƌŚŽƐŝƐ͘ ZĞƋƵŝƌĞĚdƌĞĂƚŵĞŶƚƐ x Airway management ĂƉƉƌŽƉƌŝĂƚĞ ƚŽƉĂƚŝĞŶƚĐŽŶĚŝƚŝŽŶ͘ x VentilationĂŶĚoxygenation ĂƉƉƌŽƉƌŝĂƚĞƚŽƉĂƚŝĞŶƚĐŽŶĚŝƚŝŽŶ͘ x (I) Vascular accessǁŝƚŚ/sŽƌ/K ǀĂŝůĂďůĞdƌĞĂƚŵĞŶƚƐ x ǀĂůƵĂƚĞĨŽƌƌĞǀĞƌƐŝďůĞĐĂƵƐĞƐĂŶĚƚƌĞĂƚǁŝƚŚƐƉĞĐŝĨŝĐŐƵŝĚĞůŝŶĞƐ͘ x /ĨƵŶŬŶŽǁŶĞƚŝŽůŽŐǇ͕ƐƵƉƉŽƌƚĂŝƌǁĂǇͬǀĞŶƚŝůĂƚŝŽŶΘŽǆǇŐĞŶĂƚŝŽŶͬĐŝƌĐƵůĂƚŝŽŶ͘ WĞĂƌůƐ x WĂǇĐůŽƐĞƚŽĂƚƚĞŶƚŝŽŶƚŽƚŚĞŚĞĂĚĂŶĚĐŽŵƉůĞƚĞĂƚŚŽƌŽƵŐŚĂƐƐĞƐƐŵĞŶƚ͘ x ĞĂǁĂƌĞƚŚĂƚD^ŵĂǇďĞĂƐŝŐŶŽĨĂŶĞŶǀŝƌŽŶŵĞŶƚĂůŚĂǌĂƌĚĂŶĚĐŽŶƐŝĚĞƌWWĂƐĂƉƉƌŽƉƌŝĂƚĞ͘ x ŽŶƐŝĚĞƌRestraint ƉƌŽĐĞĚƵƌĞĂƐŶĞĐĞƐƐĂƌǇƚŽƉƌŽƚĞĐƚƉĂƚŝĞŶƚĂŶĚƌĞƐƉŽŶĚĞƌƐ͘ x ĞĐĂƌĞĨƵůŶŽƚƚŽůĞƚĂůĐŽŚŽůĚŝƐƚƌĂĐƚĨƌŽŵĂƚŚŽƌŽƵŐŚĂƐƐĞƐƐŵĞŶƚ͘ůĐŽŚŽůůĞĂĚƐƚŽĂŚŝŐŚĞƌƌŝƐŬŽĨ ŚĞĂĚŝŶũƵƌŝĞƐĂŶĚĂĐƵƚĞŵĞĚŝĐĂůĐŽŶĚŝƚŝŽŶƐƚŚĂƚǁŽƵůĚĐĂƵƐĞĂůƚĞƌĞĚŵĞŶƚĂůƐƚĂƚƵƐ͘

Cypress Creek EMS System Policies and Treatment Guidelines

110 ADULT MEDICAL Revised 8/2016 Approved: Levon Vartanian, MD

^ƵƐƉĞĐƚĞĚ^ƚƌŽŬĞ Assessment Requirements May Present As Consider Possible Causes ƐƐĞƐƐŵĞŶƚΘĨŽĐƵƐĞĚĞǆĂŵ ůƚĞƌĞĚŵĞŶƚĂůƐƚĂƚƵƐ͕ ^ĞĞAltered Mental Status ^ƚƌŽŬĞ^ĐƌĞĞŶŝŶŐĐŚĞĐŬůŝƐƚ ǁĞĂŬŶĞƐƐͬƉĂƌĂůǇƐŝƐ͕ǀŝƐŝŽŶ d/ Z^ĐŽƌĞ ĐŚĂŶŐĞƐ͕ƐĞŶƐŽƌǇůŽƐƐ͕ ^ĞŝǌƵƌĞ ůŽŽĚ'ůƵĐŽƐĞ ĂƉŚĂƐŝĂ͕ƐǇŶĐŽƉĞ͕ dŽĚĚ͛ƐWĂƌĂůǇƐŝƐ 'DŽŶŝƚŽƌ ĚŝǌǌŝŶĞƐƐͬǀĞƌƚŝŐŽ͕ Ğůů͛ƐWĂůƐǇ ϭϮͲůĞĂĚ' ŶĂƵƐĞĂͬǀŽŵŝƚŝŶŐ͕ŚĞĂĚĂĐŚĞ͕ ^ƚƌŽŬĞ ƐĞŝǌƵƌĞƐ͕ dŚƌŽŵďŽƚŝĐͬĞŵďŽůŝĐ ŚǇƉĞƌƚĞŶƐŝŽŶͬŚǇƉŽƚĞŶƐŝŽŶ ;уϴϱйͿ ,ĞŵŽƌƌŚĂŐŝĐ;уϭϱйͿ dƵŵŽƌ dƌĂƵŵĂ ŝĂůǇƐŝƐͬZĞŶĂů&ĂŝůƵƌĞ ZĞƋƵŝƌĞĚdƌĞĂƚŵĞŶƚƐ x Airway management ĂƉƉƌŽƉƌŝĂƚĞ ƚŽƉĂƚŝĞŶƚĐŽŶĚŝƚŝŽŶ͘ x VentilationĂŶĚoxygenation ĂƉƉƌŽƉƌŝĂƚĞƚŽƉĂƚŝĞŶƚĐŽŶĚŝƚŝŽŶ͘ x (I) Vascular accessǁŝƚŚ/sŽƌ/K͘ŽŶŽƚĚĞůĂǇƚƌĂŶƐƉŽƌƚĨŽƌ/sĂĐĐĞƐƐ͘/ĨƚŝŵĞƉĞƌŵŝƚƐĚƵƌŝŶŐ ƚƌĂŶƐƉŽƌƚ͕ĂϮŶĚ/sŝƐƐƵŐŐĞƐƚĞĚ͘ŶϭϴŐĂ͘ŽƌůĂƌŐĞƌ/sŝƐƉƌĞĨĞƌƌĞĚĨŽƌdĐŽŶƚƌĂƐƚĚǇĞ͘ x ůĞǀĂƚĞŚĞĂĚŽĨƐƚƌĞƚĐŚĞƌĂŶĚŬĞĞƉŚĞĂĚŝŶŵŝĚůŝŶĞƉŽƐŝƚŝŽŶ͘ x &ŽůůŽǁStroke AssessmentĐŚĞĐŬůŝƐƚƚŽƚƌĂŶƐƉŽƌƚƉĂƚŝĞŶƚƚŽĂWƌŝŵĂƌǇŽƌŽŵƉƌĞŚĞŶƐŝǀĞ^ƚƌŽŬĞ ĞŶƚĞƌĂƐŝŶĚŝĐĂƚĞĚ͘ ǀĂŝůĂďůĞdƌĞĂƚŵĞŶƚƐ x (P) /ĨWŝƐхϭϴϬŵŵͬ,ŐƐǇƐƚŽůŝĐĂŶĚͬŽƌϭϭϬŵŵͬ,ŐĚŝĂƐƚŽůŝĐ x DzĂĚŵŝŶŝƐƚĞƌLopressorϱŵŐ^ůŽǁ/sW;ŵĂǇƌĞƉĞĂƚŽŶĐĞŝŶϭϬƚŽϭϱŵŝŶƵƚĞƐŝĨWƌĞŵĂŝŶƐхϭϴϬ ŵŵͬ,ŐƐǇƐƚŽůŝĐĂŶĚͬŽƌϭϭϬŵŵͬ,ŐĚŝĂƐƚŽůŝĐͿ͘ WĞĂƌůƐ x /ĨŝŶƚƵďĂƚŝŽŶŝƐŶĞĐĞƐƐĂƌǇ͕ĂĐƚŝŽŶŵƵƐƚďĞƚĂŬĞŶƚŽƌĞĚƵĐĞƚŚĞƐƚŝŵƵůĂƚŝŽŶĂƐƐŽĐŝĂƚĞĚǁŝƚŚ ůĂƌǇŶŐŽƐĐŽƉǇ͘ x ŽŶƐŝĚĞƌĂĚŵŝŶŝƐƚĞƌŝŶŐЪĚŽƐĞƉŽƐƚŝŶƚƵďĂƚŝŽŶŶŽŶͲĚĞƉŽůĂƌŝǌŝŶŐƉĂƌĂůǇƚŝĐƐƚŽƌĞĚƵĐĞĚƵƌĂƚŝŽŶŽĨ ƉĂƌĂůǇƐŝƐƚŽĂůůŽǁĨŽƌŶĞƵƌŽĂƐƐĞƐƐŵĞŶƚďǇƚŚĞWŚǇƐŝĐŝĂŶ͘ x ŽŶŽƚĂĚŵŝŶŝƐƚĞƌĂƐƉŝƌŝŶ͘ x dƌĞĂƚhypoglycemiaĂŶĚseizuresĂĐĐŽƌĚŝŶŐƚŽƉƌŽƚŽĐŽůƐ͘ x hƐĞŽŶůǇƚŚĞĂŵŽƵŶƚŽĨoxygenƌĞƋƵŝƌĞĚƚŽĂĐŚŝĞǀĞĂĚĞƋƵĂƚĞŽǆǇŐĞŶĂƚŝŽŶ;ƚĂƌŐĞƚϵϰͲϵϵй^ƉKϮͿ͘ x /ƚŝƐĐƌŝƚŝĐĂůƚŽĚĞƚĞƌŵŝŶĞĂƐƉƌĞĐŝƐĞĂ>ĂƐƚ^ĞĞŶEŽƌŵĂůͬKŶƐĞƚƚŝŵĞĂƐƉŽƐƐŝďůĞ͘KŶƐĞƚŽĨƐǇŵƉƚŽŵƐ ŝƐĚĞĨŝŶĞĚĂƐƚŚĞůĂƐƚǁŝƚŶĞƐƐĞĚƚŝŵĞƚŚĞƉĂƚŝĞŶƚǁĂƐƐǇŵƉƚŽŵͲĨƌĞĞ͘ x /ŶƉĂƚŝĞŶƚƐǁŝƚŚĂĚƵƌĂƚŝŽŶŽĨƐǇŵƉƚŽŵƐůĞƐƐƚŚĂŶϭϮŚŽƵƌƐ͕ůŝŵŝƚƐĐĞŶĞƚŝŵĞƐƚŽфϭϬŵŝŶƵƚĞƐĂŶĚ ŶŽƚŝĨǇƌĞĐĞŝǀŝŶŐĨĂĐŝůŝƚǇĂƐĞĂƌůǇĂƐƉŽƐƐŝďůĞ͘

Cypress Creek EMS System Policies and Treatment Guidelines

111 ADULT MEDICAL Revised 8/2016 Approved: Levon Vartanian, MD

x ŽĐƵŵĞŶƚŝŶĐŝŶŶĂƚŝ^ƚƌŽŬĞ^ĐĂůĞ͕>WƌĞŚŽƐƉŝƚĂů^ƚƌŽŬĞ^ĐƌĞĞŶ͕ĂŶĚD^^ƚƌŽŬĞƐƐĞƐƐŵĞŶƚ ŚĞĐŬůŝƐƚŝŶ,Z͘ dŚƌŽŵďŽůǇƚŝĐŚĞĐŬ>ŝƐƚ͗ x ƵƌƌĞŶƚƵƐĞŽĨĂŶƚŝĐŽĂŐƵůĂŶƚƐ;ŝ͘Ğ͘ŽƵŵĂĚŝŶͿ x ,ĂƐďůŽŽĚƉƌĞƐƐƵƌĞĐŽŶƐŝƐƚĞŶƚůǇŽǀĞƌϭϴϬͬϭϭϬŵŵ,Ő x tŝƚŶĞƐƐĞĚƐĞŝǌƵƌĞĂƚƐǇŵƉƚŽŵŽŶƐĞƚ x ,ŝƐƚŽƌǇŽĨŝŶƚƌĂĐƌĂŶŝĂůŚĞŵŽƌƌŚĂŐĞ x ,ŝƐƚŽƌǇŽĨ'/Žƌ'hďůĞĞĚŝŶŐ͕ƵůĐĞƌ͕ǀĂƌŝĐĞƐ x /ƐǁŝƚŚŝŶϯŵŽŶƚŚƐŽĨƉƌŝŽƌƐƚƌŽŬĞ x /ƐǁŝƚŚŝŶϯŵŽŶƚŚƐŽĨƐĞƌŝŽƵƐŚĞĂĚƚƌĂƵŵĂ x /ƐǁŝƚŚŝŶϮϭĚĂǇƐŽĨĂĐƵƚĞŵǇŽĐĂƌĚŝĂůŝŶĨĂƌĐƚŝŽŶ x /ƐǁŝƚŚŝŶϮϭĚĂǇƐŽĨůƵŵďĂƌƉƵŶĐƚƵƌĞ x /ƐǁŝƚŚŝŶϭϰĚĂǇƐŽĨŵĂũŽƌƐƵƌŐĞƌǇŽƌƐĞƌŝŽƵƐƚƌĂƵŵĂ x /ƐƉƌĞŐŶĂŶƚ x ďŶŽƌŵĂůďůŽŽĚŐůƵĐŽƐĞůĞǀĞů;фϱϬŽƌхϰϬϬͿ ůƚŚŽƵŐŚƚŚĞƐĞŵĂǇƌƵůĞŽƵƚƚŚĞƵƐĞŽĨdW͕ŽƚŚĞƌƚƌĞĂƚŵĞŶƚŽƉƚŝŽŶƐƐƵĐŚĂƐŵĞĐŚĂŶŝĐĂůƚŚƌŽŵďĞĐƚŽŵǇ ŵĂǇďĞĞŵƉůŽǇĞĚĂƚĂĐŽŵƉƌĞŚĞŶƐŝǀĞƐƚƌŽŬĞĐĞŶƚĞƌ͘ Stroke ALERT Protocol ĂůůĞĂƌůǇĂƐƉŽƐƐŝďůĞĂŶĚĂĚǀŝƐĞ͞ƐƚƌŽŬĞĂůĞƌƚ͟ĂŶĚƉƌŽǀŝĚĞƚŚĞĨŽůůŽǁŝŶŐŝŶĨŽƌŵĂƚŝŽŶ͗

x WĂƚŝĞŶƚEĂŵĞ x WĂƚŝĞŶƚŐĞǁŝƚŚK x WĂƚŝĞŶƚ^^E x dŝŵĞŽĨKŶƐĞƚ x ĞĨŝĐŝƚƐΘŶĞƵƌŽůŽŐŝĐĂůĨŝŶĚŝŶŐƐ x sŝƚĂů^ŝŐŶƐ x ŶǇĂŶƚŝĐŽĂŐƵůĂŶƚƚŚĞƌĂƉǇ x ƌƌŝǀĞƚŽĨŽƌƋƵŝĐŬƉŚǇƐŝĐŝĂŶĂƐƐĞƐƐŵĞŶƚ͕ůĂďĚƌĂǁ͕ĂŶĚƉĂƚŝĞŶƚƌĞŐŝƐƚƌĂƚŝŽŶ;ŝĨŶŽƚĚŽŶĞWdͿ͘ x ƐƐŝƐƚǁŝƚŚƉĂƚŝĞŶƚŵŽǀĞŵĞŶƚƚŽd;ŝĨƌĞƋƵĞƐƚĞĚͿ

Cypress Creek EMS System Policies and Treatment Guidelines

112 ADULT MEDICAL Revised 6/2019 Approved: Levon Vartanian, MD

^ĞŝǌƵƌĞ Assessment Requirements May Present As Consider Possible Causes ƐƐĞƐƐŵĞŶƚΘĨƵůůŚĞĂĚͲƚŽͲ ĞĐƌĞĂƐĞĚŵĞŶƚĂůƐƚĂƚƵƐ͕ E^ͬ,ĞĂĚƚƌĂƵŵĂ ƚŽĞĞǆĂŵ͕ĂƐŝŶĚŝĐĂƚĞĚ ƐůĞĞƉŝŶĞƐƐͬůĞƚŚĂƌŐǇ͕ dƵŵŽƌ 'ŵŽŶŝƚŽƌ ŝŶĐŽŶƚŝŶĞŶĐĞ͕ƵŶĐŽŶƐĐŝŽƵƐ͕ DĞƚĂďŽůŝĐ͕ŚĞƉĂƚŝĐ͕ŽƌƌĞŶĂů '>ĂƐƐĞƐƐŵĞŶƚ ŽďƐĞƌǀĞĚƐĞŝǌƵƌĞĂĐƚŝǀŝƚǇ ĨĂŝůƵƌĞ ϭϮͲůĞĂĚ' ,ǇƉŽǆŝĂ ůĞĐƚƌŽůǇƚĞĂďŶŽƌŵĂůŝƚŝĞƐ DĞĚŝĐĂƚŝŽŶŶŽŶͲĐŽŵƉůŝĂŶĐĞ ƌƵŐƐͬdŽǆŝŶƐ /ŶĨĞĐƚŝŽŶͬĨĞǀĞƌ ůĐŽŚŽůͬĚƌƵŐǁŝƚŚĚƌĂǁĂů ĐůĂŵƉƐŝĂ ^ƚƌŽŬĞ ,ǇƉĞƌƚŚĞƌŵŝĂ ,ǇƉŽŐůǇĐĞŵŝĂ ZĞƋƵŝƌĞĚdƌĞĂƚŵĞŶƚƐ x Airway management ĂƉƉƌŽƉƌŝĂƚĞ ƚŽƉĂƚŝĞŶƚĐŽŶĚŝƚŝŽŶ x VentilationĂŶĚoxygenation ĂƉƉƌŽƉƌŝĂƚĞƚŽƉĂƚŝĞŶƚĐŽŶĚŝƚŝŽŶ x (I) Vascular accessǁŝƚŚ/sŽƌ/K͕ŝĨŝŶĚŝĐĂƚĞĚ ǀĂŝůĂďůĞdƌĞĂƚŵĞŶƚƐ x (P) Midazolam ϭʹϮŵŐ/sŽƌϱŵŐ/DŽƌϮŵŐ/EŝĨ/sĂĐĐĞƐƐŝƐŶŽƚĂǀĂŝůĂďůĞ͘ZĞƉĞĂƚĞǀĞƌǇϯƚŽϱ ŵŝŶƵƚĞƐĨŽƌĐŽŶƚŝŶƵĞĚƐĞŝǌƵƌĞĂĐƚŝǀŝƚǇƚŽĂŵĂǆŝŵƵŵŽĨϮϬŵŐ͘ x (P) DiazepamϮʹϭϬŵŐ/sƌĞƉĞĂƚĞǀĞƌǇϯʹϱŵŝŶƵƚĞƐĨŽƌĐŽŶƚŝŶƵĞĚƐĞŝǌƵƌĞĂĐƚŝǀŝƚǇƚŽĂŵĂǆŝŵƵŵŽĨ ϰϬŵŐ͘ x (P)ĐƚŝǀĞƐĞŝǌƵƌĞŝŶƉƌĞŐŶĂŶĐǇŽƌƉŽƐƚƉĂƌƚƵŵƉĞƌŝŽĚ͗Magnesium SulfateϰŐ^>Kt/s͕ŵĂǇƌĞƉĞĂƚ ŽŶĐĞ͘ZĞĨĞƌƚŽPregnancy and Obstetrical EmergencyŐƵŝĚĞůŝŶĞƐ͘ x dƌĞĂƚƌĞǀĞƌƐŝďůĞĐĂƵƐĞƐ͘ZĞĨĞƌƚŽAltered Mental StatusŐƵŝĚĞůŝŶĞƐ͘ x ŽŶƐŝĚĞƌAdvanced Airway ManagementŝŶƉĂƚŝĞŶƚƐƌĞĐĞŝǀŝŶŐůĂƌŐĞĚŽƐĞƐŽĨďĞŶǌŽĚŝĂǌĞƉŝŶĞƐ͘ WĞĂƌůƐ x EŽŶͲƐƚĂƚƵƐƐĞŝǌƵƌĞƐƵƐƵĂůůǇĚŽŶŽƚƌĞƋƵŝƌĞŵĞĚŝĐĂƚŝŽŶ͘ x ŽŶŽƚĚĞůĂǇ/DĂĚŵŝŶŝƐƚƌĂƚŝŽŶŽĨMidazolamƚŽŽďƚĂŝŶ/sĂĐĐĞƐƐŝŶƚŚĞĂĐƚŝǀĞůǇƐĞŝǌŝŶŐƉĂƚŝĞŶƚ͘ x &ŽƌƐĞŝǌƵƌĞƐƚŚĂƚďĞŐŝŶŝŶƚŚĞƉƌĞƐĞŶĐĞŽĨD^ŝŶƉĂƚŝĞŶƚǁŚŽǁĞƌĞƉƌĞǀŝŽƵƐůǇĐŽŶƐĐŝŽƵƐ͕ƚĂŬĞƚŝŵĞ ƚŽĂƐƐĞƐƐĂŶĚĐŽŶƐŝĚĞƌƉŽƐƐŝďůĞĐĂƵƐĞƐ͘dŚĞƐĞŝǌƵƌĞŵĂǇƐƚŽƉ͕ĞƐƉĞĐŝĂůůǇŝŶƉĂƚŝĞŶƚƐǁŝƚŚĂƐĞŝǌƵƌĞ ŚŝƐƚŽƌǇ͘,ŽǁĞǀĞƌ͕ĚŽŶŽƚŚĞƐŝƚĂƚĞƚŽƚƌĞĂƚƉƌŽůŽŶŐĞĚ;хϭŵŝŶƵƚĞͿŽƌƌĞĐƵƌƌĞŶƚƐĞŝǌƵƌĞĂĐƚŝǀŝƚǇ͘ x ĞƉƌĞƉĂƌĞĚƚŽĂƐƐŝƐƚǀĞŶƚŝůĂƚŝŽŶƐĂŶĚͬŽƌŵĂŶĂŐĞĂŝƌǁĂǇŝĨďĞŶǌŽĚŝĂǌĞƉŝŶĞƐŚĂǀĞďĞĞŶŐŝǀĞŶ͘

Cypress Creek EMS System Policies and Treatment Guidelines

113 ADULT MEDICAL Revised 8/2016 Approved: Levon Vartanian, MD

^ǇŶĐŽƉĞ Assessment Requirements May Present As Consider Possible Causes ƐƐĞƐƐŵĞŶƚΘĨƵůůŚĞĂĚͲƚŽͲ >ŽƐƐŽĨĐŽŶƐĐŝŽƵƐŶĞƐƐǁŝƚŚ sĂƐŽǀĂŐĂů͕ŽƌƚŚŽƐƚĂƚŝĐ ƚŽĞĞǆĂŵĂƐŝŶĚŝĐĂƚĞĚ ƌĞĐŽǀĞƌǇ ŚǇƉŽƚĞŶƐŝŽŶ͕ĐĂƌĚŝĂĐ 'DŽŶŝƚŽƌ >ŝŐŚƚŚĞĂĚĞĚŶĞƐƐͬĚŝǌǌŝŶĞƐƐ ĚǇƐƌŚǇƚŚŵŝĂƐ͕ĐĂƌĚŝĂĐ ϭϮͲůĞĂĚ' WĂůƉŝƚĂƚŝŽŶƐ ĚŝƐĞĂƐĞ͕ƉƐǇĐŚŝĂƚƌŝĐ͕ '>ƐƐĞƐƐŵĞŶƚ ,ǇƉŽƚĞŶƐŝŽŶ ŚǇƉŽŐůǇĐĞŵŝĂ͕ƐƚƌŽŬĞ͕ ƐĞŝǌƵƌĞ͕ƐŚŽĐŬ͕ƚŽǆŝŶƐ͕ ŵĞĚŝĐĂƚŝŽŶĞĨĨĞĐƚƐ͕ ƉƵůŵŽŶĂƌǇĞŵďŽůŝƐŵ͕͕ ŚǇƉŽĐĂƉŶŝĂĐĂƵƐĞĚďǇ ƚĂĐŚǇƉŶĞĂͬĂŶǆŝĞƚǇ ZĞƋƵŝƌĞĚdƌĞĂƚŵĞŶƚƐ x Airway management ĂƉƉƌŽƉƌŝĂƚĞ ƚŽƉĂƚŝĞŶƚĐŽŶĚŝƚŝŽŶ͘ x VentilationĂŶĚoxygenation ĂƉƉƌŽƉƌŝĂƚĞƚŽƉĂƚŝĞŶƚĐŽŶĚŝƚŝŽŶ͘ ǀĂŝůĂďůĞdƌĞĂƚŵĞŶƚƐ x ƐƐĞƐƐĨŽƌĂŶĚƚƌĞĂƚƌĞǀĞƌƐŝďůĞĐĂƵƐĞƐ͘ZĞĨĞƌƚŽAltered Mental StatusŐƵŝĚĞůŝŶĞƐĂŶĚ Hypotension/ShockŐƵŝĚĞůŝŶĞƐ͘ x (I) Vascular accessǁŝƚŚ/sŽƌ/K͕ĂƐŝŶĚŝĐĂƚĞĚ x (P) Normal Saline ŽƌPlasmalyteĨůƵŝĚďŽůƵƐƵƉƚŽϮϬŵ>ͬŬŐ͕ŝĨĂƉƉƌŽƉƌŝĂƚĞƚŽƉĂƚŝĞŶƚĐŽŶĚŝƚŝŽŶ͘ WĞĂƌůƐ x ^ǇŶĐŽƉĂůƉĂƚŝĞŶƚƐƐŚŽƵůĚďĞƚƌĂŶƐƉŽƌƚĞĚ͘^ǇŶĐŽƉĞ͕ƵŶƚŝůƉƌŽǀĞŶŽƚŚĞƌǁŝƐĞ͕ŝƐĂƐĞƌŝŽƵƐŵĞĚŝĐĂů ĐŽŶĚŝƚŝŽŶ͘ x DŽƌĞƚŚĂŶϮϱйŽĨŐĞƌŝĂƚƌŝĐƐǇŶĐŽƉĞŝƐƌĞůĂƚĞĚƚŽĐĂƌĚŝĂĐĚǇƐƌŚǇƚŚŵŝĂƐ͕ǁŚŝĐŚŵĂǇŽƌŵĂǇŶŽƚƐƚŝůůďĞ ƉƌĞƐĞŶƚǁŚĞŶD^ĞǀĂůƵĂƚĞƐƚŚĞŵ͘ x ƐƐĞƐƐĨŽƌƐŝŐŶƐĂŶĚƐǇŵƉƚŽŵƐŽĨƚƌĂƵŵĂĂŶĚͬŽƌŚĞĂĚŝŶũƵƌǇŝĨĂƐƐŽĐŝĂƚĞĚǁŝƚŚĂĨĂůůŽƌŝĨŝƚŝƐ ƋƵĞƐƚŝŽŶĂďůĞǁŚĞƚŚĞƌŽƌŶŽƚƚŚĞƉĂƚŝĞŶƚĨĞůů͘

Cypress Creek EMS System Policies and Treatment Guidelines

114 ADULT MEDICAL Revised 7/2019 Approved: Levon Vartanian, MD

ŝĂďĞƚŝĐŵĞƌŐĞŶĐǇ Assessment Requirements May Present As Consider Possible Causes ƐƐĞƐƐŵĞŶƚΘĨƵůůŚĞĂĚͲƚŽͲ ůƚĞƌĞĚŵĞŶƚĂůƐƚĂƚƵƐ͕ ,ǇƉŽŐůǇĐĞŵŝĂ ƚŽĞĞǆĂŵĂƐŝŶĚŝĐĂƚĞĚ ĐŽŵďĂƚŝǀĞͬŝƌƌŝƚĂďůĞ͕ < ϭϮͲůĞĂĚ' ĚŝĂƉŚŽƌĞƐŝƐ͕ƐĞŝǌƵƌĞƐ͕ ,,E^ 'ŵŽŶŝƚŽƌĂƉƉƌŽƉƌŝĂƚĞƚŽ ĂďĚŽŵŝŶĂůƉĂŝŶ͕ ůĐŽŚŽůͬĚƌƵŐƵƐĞͬƚŽǆŝĐ ƉĂƚŝĞŶƚĐŽŶĚŝƚŝŽŶ ŶĂƵƐĞĂͬǀŽŵŝƚŝŶŐ͕ǁĞĂŬŶĞƐƐ͕ ŝŶŐĞƐƚŝŽŶ dKϮŵŽŶŝƚŽƌŝŶŐ ĚĞŚǇĚƌĂƚŝŽŶ͕ĚĞĞƉͬƌĂƉŝĚ ^ĞŝǌƵƌĞ ĂƉƉƌŽƉƌŝĂƚĞƚŽƉĂƚŝĞŶƚ ďƌĞĂƚŚŝŶŐ͕ƐŚŽƌƚŶĞƐƐŽĨ s ĐŽŶĚŝƚŝŽŶ ďƌĞĂƚŚ '>ĂƐƐĞƐƐŵĞŶƚ

ZĞƋƵŝƌĞĚdƌĞĂƚŵĞŶƚƐ x Airway management ĂƉƉƌŽƉƌŝĂƚĞ ƚŽƉĂƚŝĞŶƚĐŽŶĚŝƚŝŽŶ͘ x VentilationĂŶĚoxygenation ĂƉƉƌŽƉƌŝĂƚĞƚŽƉĂƚŝĞŶƚĐŽŶĚŝƚŝŽŶ͘ ǀĂŝůĂďůĞdƌĞĂƚŵĞŶƚƐ x (B) Oral GlucoseĨŽƌŚǇƉŽŐůǇĐĞŵŝĂŝĨƉĂƚŝĞŶƚŝƐĐŽŶƐĐŝŽƵƐĂŶĚŚĂƐďŽƚŚĂŶŝŶƚĂĐƚŐĂŐĂŶĚƐǁĂůůŽǁ ƌĞĨůĞǆ͘DĂǇďĞŐŝǀĞŶĂůŽŶŐǁŝƚŚŽƌĂŶŐĞũƵŝĐĞŽƌĂŶŽƚŚĞƌƐǁĞĞƚͬŐůƵĐŽƐĞƐŽůƵƚŝŽŶ͘ x (I) Vascular accessǁŝƚŚ/sŽƌ/K x (P) DextroseĨŽƌŚǇƉŽŐůǇĐĞŵŝĂ͖ƌĞƉĞĂƚĂƐŶĞĐĞƐƐĂƌǇ͘ x (P) ThiamineϭϬϬŵŐ/sͬ/DƉƌŝŽƌƚŽDextroseŝĨƉĂƚŝĞŶƚĂƉƉĞĂƌƐŵĂůŶŽƵƌŝƐŚĞĚŽƌĞǀŝĚĞŶĐĞŽĨ ĂůĐŽŚŽůŝƐŵ͘ x (P) Glucagon ϭʹϮŵŐ/DŝĨƵŶĂďůĞƚŽŽďƚĂŝŶ/sĂĐĐĞƐƐ͘DĂǇƌĞƉĞĂƚŽŶĐĞĂĨƚĞƌϭϱŵŝŶƵƚĞƐŝĨŶĞĞĚĞĚ͘ x (P) Normal SalineŽƌPlasmalyteĨůƵŝĚďŽůƵƐƵƉƚŽϮϬŵ>ͬŬŐĨŽƌŚǇƉĞƌŐůǇĐĞŵŝĂŝĨŶŽƚĐŽŶƚƌĂŝŶĚŝĐĂƚĞĚ WĞĂƌůƐ x WĞƌĨŽƌŵ'>ĂŶĂůǇƐŝƐďĞĨŽƌĞĂŶĚĂĨƚĞƌĂĚŵŝŶŝƐƚĞƌŝŶŐOral Glucose͕Dextrose͕ŽƌGlucagon. ,ǇƉŽŐůǇĐĞŵŝĂŝƐĚĞĨŝŶĞĚĂƐ'>фϲϬŵŐͬĚ>͖ŚǇƉĞƌŐůǇĐĞŵŝĂŝƐ'>хϮϬϬŵŐͬĚ>͘ x /ƚŝƐŝŵƉĞƌĂƚŝǀĞƚŽĂůůŽǁGlucagonĞŶŽƵŐŚƚŝŵĞƚŽŚĂǀĞĂŶĞĨĨĞĐƚŽŶƚŚĞƉĂƚŝĞŶƚ͘dŚŝƐŝƐƚǇƉŝĐĂůůǇϭϱʹ ϮϬŵŝŶƵƚĞƐĨŽůůŽǁŝŶŐ/DŝŶũĞĐƚŝŽŶ͘ x ŽŶƐŝĚĞƌƚŽƚĂůĐůŝŶŝĐĂůƉŝĐƚƵƌĞ͖ŝƚŵĂǇďĞƐĂĨĞƌƚŽĂůůŽǁGlucagonƚŚĞƚŝŵĞƚŽǁŽƌŬǀƐ͘ĞƐƚĂďůŝƐŚŝŶŐIO ĂŶĚĂĚŵŝŶŝƐƚĞƌŝŶŐDextrose͘,ŽǁĞǀĞƌ͕ĐŽŶƐŝĚĞƌIOĂŶĚDextroseĞĂƌůǇŝŶƉĂƚŝĞŶƚƐǁŚŽĂƌĞĐƌŝƚŝĐĂůůǇ ŝůůĂŶĚŚǇƉŽŐůǇĐĞŵŝĐ͘ x ŶǇƉĂƚŝĞŶƚĞǆƉĞƌŝĞŶĐŝŶŐĂĚŝĂďĞƚŝĐĞŵĞƌŐĞŶĐǇƐŚŽƵůĚďĞĞŶĐŽƵƌĂŐĞĚƚŽďĞƚƌĂŶƐƉŽƌƚĞĚƚŽĨŽƌ ĞǀĂůƵĂƚŝŽŶ͘dŚĞƌĞŝƐĂŶŝŶĐƌĞĂƐĞĚƌŝƐŬŽĨƌĞĐƵƌƌĞŶƚŚǇƉŽŐůǇĐĞŵŝĂŝŶƉĂƚŝĞŶƚƐƚĂŬŝŶŐŽƌĂůĚŝĂďĞƚŝĐ ŵĞĚŝĐĂƚŝŽŶƐŽƌůŽŶŐͲĂĐƚŝŶŐŝŶƐƵůŝŶ͘WĂƚŝĞŶƚƐǁŚŽƌĞĨƵƐĞƚƌĂŶƐƉŽƌƚĂŐĂŝŶƐƚŵĞĚŝĐĂůĂĚǀŝĐĞƐŚŽƵůĚďĞ ĞŶĐŽƵƌĂŐĞĚƚŽĐŽŶƐƵŵĞĂŵĞĂůŝŵŵĞĚŝĂƚĞůǇǁŝƚŚĐŽŵƉůĞǆĐĂƌďŽŚǇĚƌĂƚĞƐĂŶĚƉƌŽƚĞŝŶ͕ĂŶĚƚŽ ĐŽŶƚĂĐƚƚŚĞŝƌƉĞƌƐŽŶĂůƉŚǇƐŝĐŝĂŶŝŵŵĞĚŝĂƚĞůǇ͘

Cypress Creek EMS System Policies and Treatment Guidelines

115 ADULT MEDICAL Revised 8/2016 Approved: Levon Vartanian, MD

ŝĂůǇƐŝƐͬZĞŶĂů&ĂŝůƵƌĞ Assessment Requirements May Present As Consider Possible Causes ƐƐĞƐƐŵĞŶƚΘĨŽĐƵƐĞĚĞǆĂŵ ,ǇƉŽƚĞŶƐŝŽŶ ,&͕ƉĞƌŝĐĂƌĚŝƚŝƐ͕ĚŝĂďĞƚŝĐ 'DŽŶŝƚŽƌ ůĞĞĚŝŶŐ ĞŵĞƌŐĞŶĐǇ͕ƐĞƉƐŝƐ͕ĐĂƌĚŝĂĐ ϭϮͲůĞĂĚ' &ĞǀĞƌ ƚĂŵƉŽŶĂĚĞ͕ŚǇƉĞƌŬĂůĞŵŝĂ dKϮŵŽŶŝƚŽƌŝŶŐ ůĞĐƚƌŽůǇƚĞŝŵďĂůĂŶĐĞ EĂƵƐĞĂͬǀŽŵŝƚŝŶŐ ůƚĞƌĞĚŵĞŶƚĂůƐƚĂƚƵƐ ^ĞŝǌƵƌĞ ƌƌŚǇƚŚŵŝĂ ZĞƋƵŝƌĞĚdƌĞĂƚŵĞŶƚƐ x Airway management ĂƉƉƌŽƉƌŝĂƚĞ ƚŽƉĂƚŝĞŶƚĐŽŶĚŝƚŝŽŶ͘ x VentilationĂŶĚoxygenation ĂƉƉƌŽƉƌŝĂƚĞƚŽƉĂƚŝĞŶƚĐŽŶĚŝƚŝŽŶ͘ ǀĂŝůĂďůĞdƌĞĂƚŵĞŶƚƐ Shunt/Fistula Bleeding

x (B)ŽŶƚƌŽůďůĞĞĚŝŶŐǁŝƚŚĨŝƌŵ͕ĚŝƌĞĐƚƉƌĞƐƐƵƌĞƚŽƌƵƉƚƵƌĞ͘ƉƉůǇĚƌĞƐƐŝŶŐďƵƚĚŽŶŽƚĐŽŵƉƌĞƐƐ ĨŝƐƚƵůĂͬƐŚƵŶƚŝƚƐĞůĨĂƐƚŚŝƐǁŝůůĐĂƵƐĞĐůŽƚƚŝŶŐĂŶĚĨĂŝůƵƌĞŽĨƐŚƵŶƚ͘ x (B)/ĨĚŝƌĞĐƚƉƌĞƐƐƵƌĞĂŶĚĚƌĞƐƐŝŶŐĂƌĞŶŽƚĞĨĨĞĐƚŝǀĞ͕ĐŽŶƐŝĚĞƌĂƉƉůǇŝŶŐĂŚŝŐŚƚŽƵƌŶŝƋƵĞƚ͘ Cardiac Arrest x (P) Sodium Bicarbonate ϭŵƋͬŬŐ/sͬ/KƌĞƉĞĂƚĞĚŽŶĐĞĂƚϬ͘ϱŵƋͬŬŐ͘ x (P) Calcium Chloride ϱϬϬʹϭϬϬϬŵŐ/sͬ/KƌĞƉĞĂƚĞĚŽŶĐĞŝŶϭϬŵŝŶƵƚĞƐ͘ x (P) Albuterol ŶĞďƵůŝǌĞĚĐŽŶƚŝŶƵŽƵƐůǇ͘ ^ĞƌŝŽƵƐƐŝŐŶƐͬƐǇŵƉƚŽŵƐ͗ x (I) Vascular accessǁŝƚŚ/sŽƌ/K x (P) Normal salineĨůƵŝĚďŽůƵƐϮϱϬŵ>ƌĞƉĞĂƚƚŽŵĂǆŽĨϮϬŵ>ͬŬŐĨŽƌŐŽĂůŽĨ^WхϵϬŵŵ,Ő͕ŝĨ ŚĞŵŽĚŝĂůǇƐŝƐŝŶƉĂƐƚϰŚŽƵƌƐ͕ƉĂƚŝĞŶƚŝƐŚǇƉŽƚĞŶƐŝǀĞ͕ĂŶĚůƵŶŐƐŽƵŶĚƐĂƌĞĐůĞĂƌ͘ x (P) Sodium Bicarbonate ϭŵƋͬŬŐ/sͬ/KŝĨƉĂƚŝĞŶƚŚĂƐƉĞĂŬĞĚdǁĂǀĞƐĂŶĚĂYZ^шϬ͘ϭϮƐĞĐ͘ x (P) Calcium Chloride ϱϬϬʹϭϬϬϬŵŐ/sͬ/KŝĨƉĂƚŝĞŶƚŚĂƐƉĞĂŬĞĚdǁĂǀĞƐĂŶĚĂYZ^шϬ͘ϭϮƐĞĐ͘ x (P) Albuterol ŶĞďƵůŝǌĞĚĐŽŶƚŝŶƵŽƵƐůǇ WĞĂƌůƐ

x CHF/Pulmonary Edema refer to CHF/Pulmonary Edema guidelines x EŽƚĞŚŝƐƚŽƌǇŽĨƌĞĐĞŶƚĚŝĂůǇƐŝƐĂƉƉŽŝŶƚŵĞŶƚƐ;ĚĂƚĞƐŵŝƐƐĞĚ͕ĨůƵŝĚƚĂŬĞŶŽĨĨ͕ĂŶǇĐŽŵƉůŝĐĂƚŝŽŶƐͿ͘ x ŽŶŽƚŵŝǆCalcium ChlorideĂŶĚSodium Bicarbonate. /ĚĞĂůůǇƵƐĞƚǁŽƐĞƉĂƌĂƚĞůŝŶĞƐ͘ĚŵŝŶŝƐƚĞƌ ^ŽĚŝƵŵŝĐĂƌďŽŶĂƚĞďĞĨŽƌĞĂůĐŝƵŵŚůŽƌŝĚĞ͘ x ^ĞƌŝŽƵƐƐŝŐŶƐĂŶĚƐǇŵƉƚŽŵƐŝŶĐůƵĚĞĂĐƵƚĞůǇĂůƚĞƌĞĚŵĞŶƚĂůƐƚĂƚƵƐ͕'ĐŚĂŶŐĞƐƐƵĐŚĂƐǁŝĚĞŶĞĚ YZ^ĂŶĚƉĞĂŬĞĚdǁĂǀĞƐ͕ĂĐƵƚĞƐŚŽƌƚŶĞƐƐŽĨďƌĞĂƚŚ͕ĂŶĚƐĞǀĞƌĞͬŐĞŶĞƌĂůŝǌĞĚƉĂŝŶĂŶĚǁĞĂŬŶĞƐƐ͘

Cypress Creek EMS System Policies and Treatment Guidelines

116 ADULT MEDICAL Revised 8/2016 Approved: Levon Vartanian, MD

ĚƌĞŶĂůƌŝƐŝƐ Assessment Requirements May Present As Consider Possible Causes ƐƐĞƐƐŵĞŶƚΘĨƵůůŚĞĂĚͲƚŽͲ tĞĂŬŶĞƐƐ͕ĨĂƚŝŐƵĞ͕ ĚĚŝƐŽŶ͛ƐŝƐĞĂƐĞ͕^ͬD/͕ ƚŽĞĞǆĂŵĂƐŝŶĚŝĐĂƚĞĚ ŽƌƚŚŽƐƚĂƚŝĐŚǇƉŽƚĞŶƐŝŽŶ͕ s͕ŚǇƉŽŐůǇĐĞŵŝĂ͕ 'DŽŶŝƚŽƌ ŚǇƉĞƌƉŝŐŵĞŶƚĂƚŝŽŶ͕ ŚǇƉŽƚŚĞƌŵŝĂ͕E^͕ŝŶĨĞĐƚŝŽŶ͕ ϭϮͲůĞĂĚ' ŶĂƵƐĞĂͬǀŽŵŝƚŝŶŐͬĚŝĂƌƌŚĞĂ͕ ƐĞƉƐŝƐ͕ŚǇƉŽƚŚǇƌŽŝĚŝƐŵ͕ ĞĐƌĞĂƐĞĚƚŽůĞƌĂŶĐĞƚŽĐŽůĚ͘ ƚƵŵŽƌ tĞŝŐŚƚůŽƐƐ͘ ŝǌǌŝŶĞƐƐͬƐǇŶĐŽƉĞ ,ǇƉŽƚĞŶƐŝŽŶ ůƚĞƌĞĚŵĞŶƚĂůƐƚĂƚƵƐ ZĞƋƵŝƌĞĚdƌĞĂƚŵĞŶƚƐ x Airway management ĂƉƉƌŽƉƌŝĂƚĞ ƚŽƉĂƚŝĞŶƚĐŽŶĚŝƚŝŽŶ͘ x VentilationĂŶĚoxygenation ĂƉƉƌŽƉƌŝĂƚĞƚŽƉĂƚŝĞŶƚĐŽŶĚŝƚŝŽŶ͘ ǀĂŝůĂďůĞdƌĞĂƚŵĞŶƚƐ x ŽŶƐŝĚĞƌƌĞǀĞƌƐŝďůĞĐĂƵƐĞƐ͘ZĞĨĞƌƚŽAltered Mental Status ŐƵŝĚĞůŝŶĞƐ͘ x (I) Vascular accessǁŝƚŚ/sŽƌ/K͕ĂƐĂƉƉƌŽƉƌŝĂƚĞƚŽƉĂƚŝĞŶƚĐŽŶĚŝƚŝŽŶ͘ x (P) Normal saline ĨůƵŝĚďŽůƵƐϮϬŵ>ͬŬŐ͕ƵŶůĞƐƐĐŽŶƚƌĂŝŶĚŝĐĂƚĞĚ͘ x (P) Acetaminophen Ϭ͘ϱʹϭŐWKĨŽƌĨĞǀĞƌхϭϬϱΣ&;ϰϬ͘ϲΣͿ x (P) Methylprednisolone ϭϮϱŵŐ^>Kt/sͬ/DĨŽƌĂĚƌĞŶĂůĐƌŝƐŝƐ WĞĂƌůƐ x ĚƌĞŶĂůĐƌŝƐŝƐ;ĚĚŝƐŽŶ͛ƐĚŝƐĞĂƐĞͿŝƐĂůŝĨĞͲƚŚƌĞĂƚĞŶŝŶŐĐŽŶĚŝƚŝŽŶĐĂƵƐĞĚďǇŝŶƐƵĨĨŝĐŝĞŶƚůĞǀĞůƐŽĨ ĐŽƌƚŝƐŽů͘ x ĚƌĞŶĂůĐƌŝƐŝƐŝƐƚǇƉŝĐĂůůǇĐĂƵƐĞĚďǇĂƐƵĚĚĞŶƐƚŽƉƉŝŶŐŽĨƚĂŬŝŶŐŐůƵĐŽĐŽƌƚŝĐŽƐƚĞƌŽŝĚƐ͕ŽƌďǇĂŶ ŝŶĨĞĐƚŝŽŶ͕ƚƌĂƵŵĂ͕ŽƌŽƚŚĞƌĂĐƚŝǀŝƚǇĐŚĂŶŐĞŝŶĂƉĂƚŝĞŶƚǁŝƚŚĂŚŝƐƚŽƌǇŽĨĚĚŝƐŽŶ͛ƐĚŝƐĞĂƐĞŽƌŽƚŚĞƌ ĨŽƌŵŽĨĂĚƌĞŶĂůŝŶƐƵĨĨŝĐŝĞŶĐǇ͘ x ĚƌĞŶĂůĐƌŝƐŝƐŵĂǇƉƌĞƐĞŶƚĂƐƐĞǀĞƌĞŚǇƉŽƚĞŶƐŝŽŶƚŚĂƚĚŽĞƐŶŽƚƌĞƐƉŽŶĚƚŽǀĂƐŽƉƌĞƐƐŽƌƐ͘ x &ĞǀĞƌŝŶĂĚƌĞŶĂůĐƌŝƐŝƐŝƐƐƉĞĐŝĨŝĐĂůůǇĐĂƵƐĞĚďǇŝŶĂƉƉƌŽƉƌŝĂƚĞŚŽƌŵŽŶĂůůĞǀĞůƐ͖ŐĞŶĞƌĂůůǇ͕ƚƌĞĂƚŵĞŶƚ ŽĨƚŚĞƵŶĚĞƌůǇŝŶŐĐĂƵƐĞǁŝůůƌĞƐŽůǀĞĨĞǀĞƌǁŝƚŚŽƵƚƌĞƋƵŝƌŝŶŐƚŚĞƵƐĞŽĨĂĐĞƚĂŵŝŶŽƉŚĞŶ͘/Ĩ ƚĞŵƉĞƌĂƚƵƌĞƐĂƌĞхϭϬϱΣ&;ϰϬ͘ϲΣͿ͕ĂĚŵŝŶŝƐƚĞƌĂĐĞƚĂŵŝŶŽƉŚĞŶ͘ x ĚƌĞŶĂůĐƌŝƐŝƐŝƐĂƚƌƵĞůŝĨĞͲƚŚƌĞĂƚĞŶŝŶŐĞŵĞƌŐĞŶĐǇǁŝƚŚŵƵůƚŝƉůĞĞůĞĐƚƌŽůǇƚĞĚŝƐƚƵƌďĂŶĐĞƐĂŶĚĞŶĚͲ ŽƌŐĂŶƉƌŽďůĞŵƐ͘dŚĞƐĞƉĂƚŝĞŶƚƐƌĞƋƵŝƌĞƌĂƉŝĚƚƌĂŶƐƉŽƌƚĂƚŝŽŶƚŽƚŚĞĐůŽƐĞƐƚ͘

Cypress Creek EMS System Policies and Treatment Guidelines

117 ADULT MEDICAL Revised 8/2016 Approved: Levon Vartanian, MD

ĞŚĂǀŝŽƌĂůͬDĞŶƚĂů,ĞĂůƚŚ Assessment Requirements May Present As Consider Possible Causes ƐƐĞƐƐŵĞŶƚΘƉŚǇƐŝĐĂůĞǆĂŵ ůƚĞƌĞĚŵĞŶƚĂůƐƚĂƚƵƐ ^ĞĞAltered Mental Status ĂƐŝŶĚŝĐĂƚĞĚ ŽŵďĂƚŝǀĞ͕ŝƌƌŝƚĂďůĞ ůĐŽŚŽůͬƐƵďƐƚĂŶĐĞ '>ƐƐĞƐƐŵĞŶƚ͕ŝĨŝŶĚŝĐĂƚĞĚ ^ƵŝĐŝĚĂůͬŚŽŵŝĐŝĚĂů ĂďƵƐĞͬƚŽǆŝŶƐ ŶǆŝĞƚǇ͕ĂŐŝƚĂƚŝŽŶ͕ĐŽŶĨƵƐŝŽŶ DĞĚŝĐĂƚŝŽŶĞĨĨĞĐƚͬK ĚĞůƵƐŝŽŶĂůƚŚŽƵŐŚƚƐ͕ďŝǌĂƌƌĞ tŝƚŚĚƌĂǁĂů ďĞŚĂǀŝŽƌ͕ŚĂůůƵĐŝŶĂƚŝŽŶƐ ĞƉƌĞƐƐŝŽŶ ŝƉŽůĂƌ;ŵĂŶŝĐͲĚĞƉƌĞƐƐŝǀĞ ^ĐŚŝǌŽƉŚƌĞŶŝĂ ,ǇƉŽŐůǇĐĞŵŝĂ ,ǇƉŽƚŚĞƌŵŝĂ ,ǇƉŽǆŝĂ ŶǆŝĞƚǇĚŝƐŽƌĚĞƌƐ ǆĐŝƚĞĚĞůŝƌŝƵŵ ZĞƋƵŝƌĞĚdƌĞĂƚŵĞŶƚƐ x ŝƌǁĂǇ management ĂƉƉƌŽƉƌŝĂƚĞ ƚŽƉĂƚŝĞŶƚĐŽŶĚŝƚŝŽŶ͘ x VentilationĂŶĚoxygenation ĂƉƉƌŽƉƌŝĂƚĞƚŽƉĂƚŝĞŶƚĐŽŶĚŝƚŝŽŶ͘ x ƐƐĞƐƐĨŽƌĂŶĚƚƌĞĂƚƌĞǀĞƌƐŝďůĞĐĂƵƐĞƐ x ŶƐƵƌĞƐĐĞŶĞƐĂĨĞƚǇƚŚƌŽƵŐŚŽƵƚƌĞƐƉŽŶƐĞďǇ͗ o DĂŝŶƚĂŝŶŝŶŐƐŝƚƵĂƚŝŽŶĂůĂǁĂƌĞŶĞƐƐ o ĞƚĞƌŵŝŶŝŶŐĂŶĚŵĂŝŶƚĂŝŶŝŶŐĂŶĞƐĐĂƉĞƌŽƵƚĞ o ŶƐƵƌŝŶŐƚŚĞƌĞĂƌĞĞŶŽƵŐŚƌĞƐƉŽŶĚĞƌƐŽŶƐĐĞŶĞƚŽŚĂŶĚůĞĂƉŽƚĞŶƚŝĂůůǇĐŽŵďĂƚŝǀĞƉĂƚŝĞŶƚ o hƚŝůŝǌŝŶŐRestraintƉƌŽĐĞĚƵƌĞŝĨĂƉƉƌŽƉƌŝĂƚĞ ǀĂŝůĂďůĞdƌĞĂƚŵĞŶƚƐ x ZĞĨĞƌƚŽExcited Delirium ŐƵŝĚĞůŝŶĞŝĨƉƌĞƐĞŶƚŝŶŐǁŝƚŚǆĐŝƚĞĚĞůŝƌŝƵŵƐǇŵƉƚŽŵƐͬƐŝŐŶƐ͘ ƐƐĞƐƐŵĞŶƚĂŶĚŽĐƵŵĞŶƚĂƚŝŽŶ͗ x ƉƉĞĂƌĂŶĐĞĂŶĚŐĞŶĞƌĂůŝŵƉƌĞƐƐŝŽŶ x ĨĨĞĐƚ;ĐĂůŵ͕ĐŽŽƉĞƌĂƚŝǀĞ͕ĂŐŝƚĂƚĞĚ͕ĐŽŵďĂƚŝǀĞ͕ƚĞĂƌĨƵů͕ĂŶŐƌǇ͕ǁŝƚŚĚƌĂǁŶ͕ĨůĂƚ͕ĞƚĐ͘Ϳ x dŚŽƵŐŚƚƉƌŽĐĞƐƐĞƐ;ŶŽƌŵĂů͕ƉĂƌĂŶŽŝĚ͕ĚĞůƵƐŝŽŶĂů͕ĞƚĐ͘Ϳ x ^ƉĞĞĐŚ;ŶŽƌŵĂů͕ƌĂƉŝĚ͕ƉƌĞƐƐƵƌĞĚ͕ƐůƵƌƌĞĚ͕ŶŽŶͲǀĞƌďĂů͕ĞƚĐ͘Ϳ x :ƵĚŐŵĞŶƚĂŶĚŝŶƐŝŐŚƚ;ĚŽĞƐƚŚĞƉĂƚŝĞŶƚƌĞƋƵĞƐƚŽƌĨĞĞůƚŚĂƚƚŚĞǇŶĞĞĚŚĞůƉ͍Ϳ x ŽĞƐƚŚĞƉĂƚŝĞŶƚǁĂŶƚƚŽŚĂƌŵƚŚĞŵƐĞůǀĞƐŽƌŽƚŚĞƌƐ͍ x ,ĂůůƵĐŝŶĂƚŝŽŶƐ;ĂƵĚŝƚŽƌǇ͕ǀŝƐƵĂů͕ƚĂĐƚŝůĞͿ x WƌŝŽƌƉƐǇĐŚŝĂƚƌŝĐĞƉŝƐŽĚĞƐŝŶĐůƵĚŝŶŐƐƵŝĐŝĚĞĂƚƚĞŵƉƚ͕ŚŽƐƉŝƚĂůŝǌĂƚŝŽŶƐ͕ŽƚŚĞƌƚƌĞĂƚŵĞŶƚ

Cypress Creek EMS System Policies and Treatment Guidelines

118 ADULT MEDICAL Revised 8/2016 Approved: Levon Vartanian, MD

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Cypress Creek EMS System Policies and Treatment Guidelines

119 ADULT MEDICAL Revised 8/2016 Approved: Levon Vartanian, MD

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Cypress Creek EMS System Policies and Treatment Guidelines

120 ADULT MEDICAL Revised 8/2016 Approved: Levon Vartanian, MD

ǆĐŝƚĞĚĞůŝƌŝƵŵ Assessment Requirements May Present As Consider Possible Causes ƐƐĞƐƐŵĞŶƚΘĨƵůůŚĞĂĚͲƚŽͲ ^ĞĞĨƵůůƐǇŵƉƚŽŵĐŚĞĐŬůŝƐƚ ƌƵŐŽǀĞƌĚŽƐĞͬƚŽǆŝŶ ƚŽĞĞǆĂŵ ďĞůŽǁ E^;ŝŶĨĞĐƚŝŽŶ͕ƚƌĂƵŵĂ͕ 'DŽŶŝƚŽƌ ƚƵŵŽƌͿ dKϮŵŽŶŝƚŽƌŝŶŐ ^ƚƌŽŬĞ '>ƐƐĞƐƐŵĞŶƚ ^ĞŝǌƵƌĞ ,ǇƉŽŐůǇĐĞŵŝĂ WƐǇĐŚŝĂƚƌŝĐ ZĞƋƵŝƌĞĚdƌĞĂƚŵĞŶƚƐ x Airway management ĂƉƉƌŽƉƌŝĂƚĞ ƚŽƉĂƚŝĞŶƚĐŽŶĚŝƚŝŽŶ͘ x VentilationĂŶĚoxygenation ĂƉƉƌŽƉƌŝĂƚĞƚŽƉĂƚŝĞŶƚĐŽŶĚŝƚŝŽŶ͘ x (P) SedationŽĨƉĂƚŝĞŶƚƚŽƐƚŽƉĐŽŵďĂƚŝǀĞďĞŚĂǀŝŽƌĂŶĚƉƌŽƚĞĐƚƌĞƐƉŽŶĚĞƌƐ͘ x (B) Physical restraintŽĨƉĂƚŝĞŶƚ͗ o WƌĞĨĞƌƌĞĚͲhƚŝůŝǌŝŶŐŵƵůƚŝƉůĞƐĞƚƐŽĨůĂǁĞŶĨŽƌĐĞŵĞŶƚŚĂŶĚĐƵĨĨƐ͕ĚĂŝƐǇĐŚĂŝŶĞĚƚŽŐĞƚŚĞƌǁŝƚŚ ůŽŶŐƐƉŝŶĞďŽĂƌĚďĞƚǁĞĞŶƉĂƚŝĞŶƚĂŶĚŚĂŶĚĐƵĨĨƐʹKEKdh&&ƉĂƚŝĞŶƚƚŽƐƚƌĞƚĐŚĞƌ͖KZ o ƉƉůǇƐŽĨƚƌĞƐƚƌĂŝŶƚƐƚŽĂůůĞǆƚƌĞŵŝƚŝĞƐĂŶĚƐĞĐƵƌĞƚŽƐƚƌĞƚĐŚĞƌŽƌďĂĐŬďŽĂƌĚ o ƉƉůǇŝŶŐƌĞƐƚƌĂŝŶƚƐǁŝƚŚŽƵƚĂĚĞƋƵĂƚĞƐĞĚĂƚŝŽŶŝŶĐƌĞĂƐĞƐƌŝƐŬŽĨŝŶũƵƌǇƚŽƉĂƚŝĞŶƚĂŶĚƌĞƐƉŽŶĚĞƌƐ͘ o dƌĂŶƐŝƚŝŽŶŝŶŐĨƌŽŵŚĂŶĚĐƵĨĨƐƚŽƐŽĨƚƌĞƐƚƌĂŝŶƚƐŽƌĨƌŽŵƐŽĨƚƌĞƐƚƌĂŝŶƚƐƚŽŚŽƐƉŝƚĂůƌĞƐƚƌĂŝŶƚƐ ŝŶĐƌĞĂƐĞƐƌŝƐŬƚŽƉĂƚŝĞŶƚĂŶĚƌĞƐĐƵĞƌƐǁŝƚŚŽƵƚĂĚĞƋƵĂƚĞƐĞĚĂƚŝŽŶ͘ o It is preferred to achieve adequate sedation prior to applying or transitioning restraints. x (I) Vascular accessǁŝƚŚ/sŽƌ/K͘Ranger IVƉƌĞĨĞƌƌĞĚ x Field Supervisor NotificationĂŶĚƐƵƉƉůĞŵĞŶƚĂůƌĞƉŽƌƚ͘ x ,ŽƐƉŝƚĂůŶŽƚŝĨŝĐĂƚŝŽŶŽĨŝŶŝƚŝĂƚŝŽŶŽĨƉƌŽƚŽĐŽů ǀĂŝůĂďůĞdƌĞĂƚŵĞŶƚƐ x (P) MidazolamϱŵŐ/DŽƌ/E͘DĂǇƌĞƉĞĂƚŽŶĐĞ;ŝĨƵƐŝŶŐ/E͕ƵƐĞĂůƚĞƌŶĂƚĞŶŽƐƚƌŝůĨŽƌƐĞĐŽŶĚĚŽƐĞͿ͘ x (P) Ketamine ϭʹϭ͘ϱŵŐͬŬŐ/sŽƌϱŵŐͬŬŐ/D͘DĂǇƌĞƉĞĂƚ/sĚŽƐĞŽŶĐĞ͘ x (P) PlasmalyteƵƉƚŽϮϬŵůͬŬŐĨůƵŝĚďŽůƵƐŽĨĐŽŽůͲĐŽůĚ;ϯϰΣͿƌƵŶǁŝĚĞŽƉĞŶ͘ x (B) Active CoolingǁŝƚŚĞǀĂƉŽƌĂƚŝǀĞĐŽŽůŝŶŐ͕ƚƵƌůĞǇƉĂĚ͕ĐŽůĚƉĂĐŬƐƉůĂĐĞĚŝŶƚŚĞŶĞĐŬ͕ĂǆŝůůĂĞ͕ĂŶĚ ŐƌŽŝŶ x (P3) Sodium BicarbonateϱϬŵƋŝŶϭϬϬϬŵůĐŽŽůͲĐŽůĚ;ϯϰΣͿPlasmalyteƌƵŶǁŝĚĞŽƉĞŶ͘ WĞĂƌůƐ x ǆĐŝƚĞĚĞůŝƌŝƵŵŝƐĚĞĨŝŶĞĚĂƐĂƐƚĂƚĞŽĨĞǆƚƌĞŵĞŵĞŶƚĂůĂŶĚƉƐǇĐŚŽůŽŐŝĐĂůĞǆĐŝƚĞŵĞŶƚ͕ƵƐƵĂůůǇ ĂƐƐŽĐŝĂƚĞĚǁŝƚŚĐŚƌŽŶŝĐŽƌŝůůŝĐŝƚĚƌƵŐƵƐĞ͕ĐŚĂƌĂĐƚĞƌŝǌĞĚďǇĞǆĐĞƉƚŝŽŶĂůĂŐŝƚĂƚŝŽŶĂŶĚŚǇƉĞƌĂĐƚŝǀŝƚǇ͕ ŚǇƉĞƌƚŚĞƌŵŝĂ͕ŚŽƐƚŝůŝƚǇ͕ĞǆĐĞƉƚŝŽŶĂůƐƚƌĞŶŐƚŚ͕ĂŐŐƌĞƐƐŝŽŶĂŶĚƉĂƌĂŶŽŝĂ x dŚĞƚƌĞĂƚŵĞŶƚŐŽĂůŝƐƚŽŝŶƚĞƌǀĞŶĞĂŶĚŵĂŶĂŐĞƚŚĞƉŚĂƌŵĂĐŽůŽŐŝĐĂůĂŶĚƉƐǇĐŚŽůŽŐŝĐĂůĐĂƵƐĞƐŽĨ ǆĐŝƚĞĚĞůŝƌŝƵŵƚŽƉƌĞǀĞŶƚƚŚĞĚŽǁŶǁĂƌĚƐƉŝƌĂůƚŽǁĂƌĚƐ^hEd,

Cypress Creek EMS System Policies and Treatment Guidelines

121 ADULT MEDICAL Revised 8/2016 Approved: Levon Vartanian, MD

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Cypress Creek EMS System Policies and Treatment Guidelines

122 ADULT MEDICAL Revised 8/2016 Approved: Levon Vartanian, MD

Excited Delirium Checklist WŚǇƐŝĐĂůŚĂƌĂĐƚĞƌŝƐƚŝĐƐ;^ŝŐŶƐĂŶĚ^ǇŵƉƚŽŵƐͿ WƌŽĨƵƐĞƐǁĞĂƚŝŶŐ;ƉŽƐƐŝďůĞƐŝŐŶŽĨŚŝŐŚďŽĚǇƚĞŵƉĞƌĂƚƵƌĞͿ ,ǇƉĞƌƚŚĞƌŵŝĂ͖,ŝŐŚĐŽƌĞďŽĚǇƚĞŵƉĞƌĂƚƵƌĞ;ϭϬϮΣ&ƚŽϭϭϬΣ&͖ϯϵ͘ϰϰΣƚŽϰϯ͘ϯϯΣͿ hŶĐŽŶƚƌŽůůĂďůĞƐŚĂŬŝŶŐ͕ƐŚŝǀĞƌŝŶŐ WƐǇĐŚŽůŽŐŝĐĂůĞŚĂǀŝŽƌƐŽĨǆĐŝƚĞĚĞůŝƌŝƵŵ ĞŵŽŶƐƚƌĂƚĞƐŝŶƚĞŶƐĞƉĂƌĂŶŽŝĂ;ĨĞĂƌĨƵů͕ŚŝĚŝŶŐͿĂŶĚĞǆƚƌĞŵĞĂŐŝƚĂƚŝŽŶ ZĂƉŝĚĞŵŽƚŝŽŶĂůĐŚĂŶŐĞƐ ŝƐŽƌŝĞŶƚĞĚĂďŽƵƚƉůĂĐĞ͕ƚŝŵĞ͕ƉƵƌƉŽƐĞĂŶĚƐĞůĨ;ǀŝƐŝŽŶƐŽĨŐƌĂŶĚĞƵƌͿ ,ĂůůƵĐŝŶĂƚŝŽŶƐ;ŚĞĂƌƐǀŽŝĐĞƐ͕ƚĂůŬƐƚŽŝŶǀŝƐŝďůĞƉĞŽƉůĞĂŶĚͬŽƌŝŶĂŶŝŵĂƚĞŽďũĞĐƚƐͿ ĞůƵƐŝŽŶĂů͖^ĐĂƚƚĞƌĞĚŝĚĞĂƐĂďŽƵƚƚŚŝŶŐƐ ĂƐŝůǇĚŝƐƚƌĂĐƚĞĚ;ĐĂŶŶŽƚĨŽůůŽǁĐŽŵŵĂŶĚƐͿ WƐǇĐŚŽƚŝĐŝŶĂƉƉĞĂƌĂŶĐĞ ĞƐĐƌŝďĞĚĂƐ͞ũƵƐƚƐŶĂƉƉĞĚ͟Žƌ͞ĨůŝƉƉĞĚŽƵƚ͟ DĂŬĞƐƉĞŽƉůĞĨĞĞůƵŶĐŽŵĨŽƌƚĂďůĞ;ŝŶĐůƵĚŝŶŐŽĨĨŝĐĞƌƐͿ ŽŵŵƵŶŝĐĂƚŝŽŶĞŚĂǀŝŽƌƐŽĨǆĐŝƚĞĚĞůŝƌŝƵŵ ^ĐƌĞĂŵŝŶŐĨŽƌŶŽĂƉƉĂƌĞŶƚƌĞĂƐŽŶ WƌĞƐƐƵƌĞĚ͕ůŽƵĚ͕ŝŶĐŽŚĞƌĞŶƚƐƉĞĞĐŚ;ŵƵŵďůŝŶŐͿ 'ƌƵŶƚŝŶŐ͖ŐƵƚƚƵƌĂůƐŽƵŶĚƐ /ƌƌĂƚŝŽŶĂůƐƉĞĞĐŚ͖dĂůŬƐƚŽŝŶǀŝƐŝďůĞƉĞŽƉůĞ͕ŝŶĂŶŝŵĂƚĞŽďũĞĐƚƐ WŚǇƐŝĐĂůĞŚĂǀŝŽƌƐŽĨǆĐŝƚĞĚĞůŝƌŝƵŵ ĞŵŽŶƐƚƌĂƚĞƐǀŝŽůĞŶƚďĞŚĂǀŝŽƌƚŽǁĂƌĚŽƚŚĞƌƐŽƌŽďũĞĐƚƐ ĞŵŽŶƐƚƌĂƚĞƐďŝǌĂƌƌĞďĞŚĂǀŝŽƌ ĞŵŽŶƐƚƌĂƚĞƐĂŐŐƌĞƐƐŝŽŶƚŽǁĂƌĚŝŶĂŶŝŵĂƚĞŽďũĞĐƚƐ ZƵŶŶŝŶŐŝŶƚŽƚƌĂĨĨŝĐ;ŽŶĐŽŵŝŶŐǀĞŚŝĐůĞƐͿŽƌĨŽƌŶŽĂƉƉĂƌĞŶƚƌĞĂƐŽŶ EĂŬĞĚ͕ƐƚƌŝƉƉŝŶŐŽĨĨĐůŽƚŚŝŶŐ;ƚƌǇŝŶŐƚŽŐĞƚĐŽŽůͿŽĨƚĞŶŝŶƉƵďůŝĐŽƌǁŚĞƌĞŝƚŝƐŝŶĂƉƉƌŽƉƌŝĂƚĞ ƉƉĂƌĞŶƚƐƵƉĞƌŚƵŵĂŶƐƚƌĞŶŐƚŚ ^ĞĞŵŝŶŐůǇƵŶůŝŵŝƚĞĚĞŶĚƵƌĂŶĐĞ ZĞƐŝƐƚƐǀŝŽůĞŶƚůǇĚƵƌŝŶŐĐĂƉƚƵƌĞ͕ĐŽŶƚƌŽůĂŶĚƌĞƐƚƌĂŝŶƚĞǀĞŶ&dZZ^dZ/Ed DƵƐĐůĞƌŝŐŝĚŝƚǇ ŝŵŝŶŝƐŚĞĚĂŶĚͬŽƌŝŶƐĞŶƐŝƚŝǀŝƚǇƚŽƉĂŝŶ ^ĞůĨͲŝŶĚƵĐĞĚŝŶũƵƌŝĞƐ ^ĂǇƐ͞/ĐĂŶ͛ƚďƌĞĂƚŚĞ͟;ŝŶĚŝĐĂƚŝǀĞŽĨƌĞƐƉŝƌĂƚŽƌǇĚŝƐƚƌĞƐƐ͕ĞƐĐĂůĂƚŝŶŐŝŶƚŽƌĞƐƉŝƌĂƚŽƌǇĂƌƌĞƐƚƐƉŝƌĂů ĞǆŚĂƵƐƚŝǀĞŵĂŶŝĂͿ

Cypress Creek EMS System Policies and Treatment Guidelines

123 ADULT MEDICAL Revised 8/2016 Approved: Levon Vartanian, MD

WŚǇƐŝĐĂůZĞƐƚƌĂŝŶƚŽĨǆĐŝƚĞĚĞůŝƌŝƵŵWĂƚŝĞŶƚ WŚǇƐŝĐĂůƌĞƐƚƌĂŝŶƚƵƐŝŶŐŵƵůƚŝƉůĞŚĂŶĚĐƵĨĨƐ;ƉƌŽǀŝĚĞĚďǇůĂǁĞŶĨŽƌĐĞŵĞŶƚͿŝƐĂĐĐĞƉƚĂďůĞKE>zǁŚĞŶ ƵƐĞĚŝŶĐŽŶũƵŶĐƚŝŽŶǁŝƚŚĂůŽŶŐƐƉŝŶĞďŽĂƌĚŬĞĞƉŝŶŐƚŚĞƉĂƚŝĞŶƚƐĂƌŵƐƌĞƐƚƌĂŝŶĞĚďǇƚŚĞŝƌƐŝĚĞ͕ ĂĐĐĞƐƐŝďůĞĨŽƌĂƐƐĞƐƐŵĞŶƚƐĂŶĚŝŶƚĞƌǀĞŶƚŝŽŶƐ;ƐĞĞƉŝĐƚƵƌĞƐďĞůŽǁͿ͘

hƐĞĐĂƵƚŝŽŶ͗ŶƐƵƌĞƚŚĞďĂĐŬďŽĂƌĚŝƐŶŽƚďŝŶĚŝŶŐƚŚĞƉĂƚŝĞŶƚ͛ƐǁƌŝƐƚďǇƚƵĐŬŝŶŐƚŚĞƉĂƚŝĞŶƚƐĂƌŵͬŚĂŶĚ ŝŶƐŝĚĞĂŶĚůŝĨƚŝŶŐƚŚĞƉĂƚŝĞŶƚƐůŝŐŚƚůǇƚŽĂǀŽŝĚŝŶũƵƌǇƚŽƚŚĞƉĂƚŝĞŶƚ͛ƐǁƌŝƐƚ͘

tŚĞŶƵƐŝŶŐŚĂŶĚĐƵĨĨƐĨŽƌƌĞƐƚƌĂŝŶ͕ĂŶŽĨĨŝĐĞƌDh^d;ƌŝĚŝŶŐŝŶƚŚĞĂŵďƵůĂŶĐĞƉƌĞĨĞƌƌĞĚďƵƚĨŽůůŽǁŝŶŐ ŝŵŵĞĚŝĂƚĞůǇďĞŚŝŶĚŝƐĂĐĐĞƉƚĂďůĞͿĂĐĐŽŵƉĂŶǇƚŚĞƉĂƚŝĞŶƚƚŽƚŚĞŚŽƐƉŝƚĂů

WĂƚŝĞŶƚ͛ƐƚŽƌƐŽĂŶĚůŽǁĞƌĞǆƚƌĞŵŝƚŝĞƐƐŚŽƵůĚďĞƐĞĐƵƌĞĚǁŝƚŚǁĞďďŝŶŐƚŽĨĂĐŝůŝƚĂƚĞůŽŐƌŽůůŝŶŐĂŶĚƚŚĞ ƐĂĨĞŵŽǀĞŵĞŶƚŽĨƚŚĞƉĂƚŝĞŶƚ͕ƚŚŝƐŝƐEKdĨŽƌƐƉŝŶĂůŵŽƚŝŽŶƌĞƐƚƌŝĐƚŝŽŶ͘

ŶǇƉĂƚŝĞŶƚƐƉŚǇƐŝĐĂůůǇƌĞƐƚƌĂŝŶĞĚƐŚŽƵůĚďĞŵŽŶŝƚŽƌĞĚĐůŽƐĞůǇĂŶĚŶĞǀĞƌůĞĨƚƵŶĂƚƚĞŶĚĞĚ͘

d^ZĞůĞĐƚƌŽŶŝĐĐŽŶƚƌŽůĚĞǀŝĐĞƐĂƌĞŽĨƚĞŶƵƐĞĚďǇůĂǁĞŶĨŽƌĐĞŵĞŶƚƚŽĐĂƉƚƵƌĞĂŶĚĐŽŶƚƌŽůƚŚĞƐĞ ƉĂƚŝĞŶƚƐĂŶĚƚŚĞƉƌŽďĞƐĐŽƵůĚŚĂǀĞďĞĞŶƌĞŵŽǀĞĚƉƌŝŽƌƚŽĂƌƌŝǀĂůŽĨD^͘ƐĐĞƌƚĂŝŶŝĨĂd^ZǁĂƐ ƵƐĞĚĂŶĚĚŽĐƵŵĞŶƚƉĞƌƉŽůŝĐǇ͘

ǆĐŝƚĞĚĞůŝƌŝƵŵƉĂƚŝĞŶƚƐŽĨƚĞŶĚŝĞƐƵĚĚĞŶůǇ͕ŝŵŵĞĚŝĂƚĞůǇĨŽůůŽǁŝŶŐĐĞƐƐĂƚŝŽŶŽĨƌĞƐŝƐƚĂŶĐĞ͕ŽĨƚĞŶ ƌĞĨĞƌƌĞĚƚŽĂƐĂƐƵĚĚĞŶƵŶĞǆƉĞĐƚĞĚĐĂůŵ͘ŽŶŽƚŵŝƐƚĂŬĞƚŚŝƐĨŽƌĐŽŵƉůŝĂŶĐĞ͘

Cypress Creek EMS System Policies and Treatment Guidelines

124 ADULT MEDICAL Revised 8/2016 Approved: Levon Vartanian, MD

,ǇƉĞƌƚĞŶƐŝŽŶ Assessment Requirements May Present As Consider Possible Causes ƐƐĞƐƐŵĞŶƚ ,ĞĂĚĂĐŚĞ͕ǀŝƐŝŽŶĐŚĂŶŐĞƐ͕ E^;ĞŶĐĞƉŚĂůŽƉĂƚŚǇͿ 'DŽŶŝƚŽƌ ĐŚĞƐƚƉĂŝŶ͕ĚǇƐƉŶĞĂ͕ĂůƚĞƌĞĚ ƵƐŚŝŶŐ͛ƐƌĞƐƉŽŶƐĞƚŽ ϭϮͲůĞĂĚ' ŵĞŶƚĂůƐƚĂƚƵƐ͕ƐĞŝǌƵƌĞƐ͕ ƉƌŝŵĂƌǇE^ŝŶũƵƌǇ ĚŝǌǌŝŶĞƐƐ͕ŶĂƵƐĞĂͬǀŽŵŝƚŝŶŐ D/ ŽƌƚŝĐĚŝƐƐĞĐƚŝŽŶͬĂŶĞƵƌǇƐŵ WƌĞͲĞĐůĂŵƉƐŝĂͬĞĐůĂŵƉƐŝĂ WƌŝŵĂƌǇŚǇƉĞƌƚĞŶƐŝŽŶ

,ǇƉĞƌƚĞŶƐŝŽŶŝƐĂĐŽŵŵŽŶĨŝŶĚŝŶŐŝŶĂŶĞŵĞƌŐĞŶĐǇƐĞƚƚŝŶŐ͕ďƵƚŝƐƵƐƵĂůůǇĂƚƌĂŶƐŝĞŶƚƌĞƐƉŽŶƐĞƚŽŽƚŚĞƌ ĨĂĐƚŽƌƐĂŶĚĚŽĞƐŶŽƚƌĞƋƵŝƌĞƚƌĞĂƚŵĞŶƚ͘hypertensive emergencyŝƐďĂƐĞĚŽŶĨŝŶĚŝŶŐƐŽĨĂƐǇƐƚŽůŝĐWх ϭϴϬŵŵ,ŐĂŶĚͬŽƌĂĚŝĂƐƚŽůŝĐWхϭϬϬŵŵ,ŐEĨŝŶĚŝŶŐƐŽĨĞŶĚͲŽƌŐĂŶĐŽŵƉƌŽŵŝƐĞ;ƐĞǀĞƌĞŚĞĂĚĂĐŚĞ͕ ĐŚĞƐƚƉĂŝŶ͕ĚǇƐƉŶĞĂ͕ĂĐƵƚĞůǇĂůƚĞƌĞĚŵĞŶƚĂůƐƚĂƚƵƐ͕ĐŽŶĨƵƐŝŽŶ͕ďůƵƌƌĞĚǀŝƐŝŽŶ͕ƌĂůĞƐ͕ŽƌƐĞŝǌƵƌĞͿ͘ ŐŐƌĞƐƐŝǀĞƉƌĞŚŽƐƉŝƚĂůƚƌĞĂƚŵĞŶƚŽĨŚǇƉĞƌƚĞŶƐŝŽŶĐĂŶƌĞƐƵůƚŝŶŚĂƌŵ͕ĂŶĚŵŽƐƚƉĂƚŝĞŶƚƐ͕ĞǀĞŶǁŝƚŚǀĞƌǇ ŚŝŐŚďůŽŽĚƉƌĞƐƐƵƌĞƐ͕ŽŶůǇŶĞĞĚƐƵƉƉŽƌƚŝǀĞĐĂƌĞ͘^ƉĞĐŝĨŝĐĐŽŵƉůĂŝŶƚƐƐƵĐŚĂƐ,&ͬƉƵůŵŽŶĂƌǇĞĚĞŵĂ͕ ĐŚĞƐƚƉĂŝŶ͕ŽƌĂůƚĞƌĞĚŵĞŶƚĂůƐƚĂƚƵƐƐŚŽƵůĚďĞƚƌĞĂƚĞĚďĂƐĞĚŽŶƚŚŽƐĞƐƉĞĐŝĨŝĐŐƵŝĚĞůŝŶĞƐ͘ ZĞƋƵŝƌĞĚdƌĞĂƚŵĞŶƚƐ x Airway management ĂƉƉƌŽƉƌŝĂƚĞ ƚŽƉĂƚŝĞŶƚĐŽŶĚŝƚŝŽŶ͘ x VentilationĂŶĚoxygenation ĂƉƉƌŽƉƌŝĂƚĞƚŽƉĂƚŝĞŶƚĐŽŶĚŝƚŝŽŶ͘ x ,ĞĂĚŽĨƐƚƌĞƚĐŚĞƌĞůĞǀĂƚĞĚ͘ ǀĂŝůĂďůĞdƌĞĂƚŵĞŶƚƐ x (I) Vascular accessǁŝƚŚ/sŽƌ/K͕ŝĨŝŶĚŝĐĂƚĞĚ͘ x (P) Nitroglycerin ϭŵĞƚĞƌĞĚĚŽƐĞ^>ƌĞƉĞĂƚĞǀĞƌǇϱŵŝŶƵƚĞƐƚŽƚĂƌŐĞƚĂϮϬйƌĞĚƵĐƚŝŽŶŝŶƐǇƐƚŽůŝĐW͘ x (P) MetoprololϱŵŐ^>Kt/sŽǀĞƌϭƚŽϮŵŝŶƵƚĞƐŝĨNitroglycerinŝƐĐŽŶƚƌĂŝŶĚŝĐĂƚĞĚŽƌƐƚƌŽŬĞŝƐ ƐƵƐƉĞĐƚĞĚ͘DĂǇƌĞƉĞĂƚŽŶĐĞŝŶϭϬƚŽϭϱŵŝŶƵƚĞƐŝĨWŚĂƐŶŽƚŵĞƚƚĂƌŐĞƚŽĨϮϬйƌĞĚƵĐƚŝŽŶ͘ WĞĂƌůƐ x ůĞǀĂƚĞĚWŵƵƐƚďĞďĂƐĞĚŽŶƚǁŽƚŽƚŚƌĞĞƐĞƚƐŽĨǀŝƚĂůƐŝŐŶƐ͕ĞĂĐŚƐĞǀĞƌĂůŵŝŶƵƚĞƐĂƉĂƌƚ͕ĂŶĚ ŝŶĐůƵĚŝŶŐĂŵĂŶƵĂůWŵĞĂƐƵƌĞŵĞŶƚ͘ x ŽŶŽƚĂƚƚĞŵƉƚƚŽƌĞĚƵĐĞWŵŽƌĞƚŚĂŶϮϬйŽĨďĞŐŝŶŶŝŶŐƐǇƐƚŽůŝĐƉƌĞƐƐƵƌĞ͘ x EŝƚƌŽŐůǇĐĞƌŝŶŵƵƐƚďĞƵƐĞĚǁŝƚŚĞǆƚƌĞŵĞĐĂƵƚŝŽŶŝŶƚŚĞƉĂƚŝĞŶƚǁŚŽŚĂƐƚĂŬĞŶĂƉŚŽƐƉŚŽĚŝĞƐƚĞƌĂƐĞ ŝŶŚŝďŝƚŽƌ;sŝĂŐƌĂ͕ŝĂůŝƐ͕>ĞǀŝƚƌĂ͕ĞƚĐ͙ͿǁŝƚŚŝŶϮϰŚŽƵƌƐ͘

Cypress Creek EMS System Policies and Treatment Guidelines

125 ADULT MEDICAL Revised 6/2019 Approved: Levon Vartanian, MD

WƌĞŐŶĂŶĐǇĂŶĚKďƐƚĞƚƌŝĐĂůŵĞƌŐĞŶĐǇ Assessment Requirements May Present As Consider Possible Causes ƐƐĞƐƐŵĞŶƚΘĨŽĐƵƐĞĚĞǆĂŵ sĂŐŝŶĂůďůĞĞĚŝŶŐͬĚŝƐĐŚĂƌŐĞ͕ WƌĞͲĞĐůĂŵƉƐŝĂͬĞĐůĂŵƉƐŝĂ '>ĂƐƐĞƐƐŵĞŶƚ͕ĂƐŝŶĚŝĐĂƚĞĚ ĂďĚŽŵŝŶĂůƉĂŝŶ͕ĐŚĞƐƚƉĂŝŶ͕ WůĂĐĞŶƚĂƉƌĞǀŝĂ 'ŵŽŶŝƚŽƌ͕ĂƐŝŶĚŝĐĂƚĞĚ ƉĞůǀŝĐƉĂŝŶͬďĂĐŬƉĂŝŶ͕ WůĂĐĞŶƚĂůĂďƌƵƉƚŝŽŶ dKϮŵŽŶŝƚŽƌŝŶŐ͕ĂƐ ŚǇƉĞƌƚĞŶƐŝŽŶ͕ŚĞĂĚĂĐŚĞ͕ ĐƚŽƉŝĐƉƌĞŐŶĂŶĐǇ ŝŶĚŝĐĂƚĞĚ ǀŝƐƵĂůĐŚĂŶŐĞƐ͕ĞĚĞŵĂŽĨ ^ƉŽŶƚĂŶĞŽƵƐĂďŽƌƚŝŽŶ ŚĂŶĚƐĂŶĚĨĞĞƚ͕ƉĂŝŶƵƉŽŶ ;ŵŝƐĐĂƌƌŝĂŐĞͿ ƐƐĞƐƐĂŶĚĚŽĐƵŵĞŶƚK ƵƌŝŶĂƚŝŽŶ͕ĨĂĐŝĂůƉĂƌĂůǇƐŝƐ͕ ďŽƌƚŝŽŶĐŽŵƉůŝĐĂƚŝŽŶƐ ŚŝƐƚŽƌǇ;ƐĞĞWĞĂƌůƐͿ ƌĂůĞƐ͕ƐĞŝǌƵƌĞƐ WƵůŵŽŶĂƌǇĞŵďŽůŝƐŵ ĞĞƉǀĞŝŶƚŚƌŽŵďŽƐŝƐ;sdͿ dŚŽƌĂĐŝĐĂŽƌƚŝĐĚŝƐƐĞĐƚŝŽŶ ,ĞĂƌƚďƵƌŶ ,ǇƉŽͬŚǇƉĞƌŐůǇĐĞŵŝĂ ZŽƵŶĚůŝŐĂŵĞŶƚƉĂŝŶ ^ĐŝĂƚŝĐŶĞƌǀĞƉĂŝŶ

Overview WƌĞŐŶĂŶƚƉĂƚŝĞŶƚƐŚĂǀĞ͗

x /ŶĐƌĞĂƐĞĚĐŝƌĐƵůĂƚŽƌǇǀŽůƵŵĞ;ƉƌŽŶĞƚŽƋƵŝĐŬĞƌĚĞĐŽŵƉĞŶƐĂƚŝŽŶͿ x /ŶĐƌĞĂƐĞĚŝŶƚƌĂƚŚŽƌĂĐŝĐƉƌĞƐƐƵƌĞ;ƉƌĞĚŝƐƉŽƐĞĚƚŽĐĂƌĚŝĂĐĂŶĚůƵŶŐĞŵĞƌŐĞŶĐŝĞƐͿ x /ŶĐƌĞĂƐĞĚĐůŽƚƚŝŶŐĂďŝůŝƚǇ;ƉƌĞĚŝƐƉŽƐĞĚƚŽƚŚƌŽŵďŝŽĨůƵŶŐĂŶĚůŝŵďͿ x EŽƌŵĂůƉĂƚŚŽůŽŐǇ;ĂǁŝĚĞƌĂŶŐĞŽĨĚŝĨĨĞƌĞŶƚŝĂůĚŝĂŐŶŽƐĞƐƐŚŽƵůĚďĞĐŽŶƐŝĚĞƌĞĚͿ Required Treatments x Airway management ĂƉƉƌŽƉƌŝĂƚĞ ƚŽƉĂƚŝĞŶƚĐŽŶĚŝƚŝŽŶ x VentilationĂŶĚoxygenation ĂƉƉƌŽƉƌŝĂƚĞƚŽƉĂƚŝĞŶƚĐŽŶĚŝƚŝŽŶ x (B) Left lateral recumbentƉŽƐŝƚŝŽŶŝŶŐ x (I) Vascular accessǁŝƚŚ/sŽƌ/KŝĨƉĂƚŝĞŶƚŝƐƵŶƐƚĂďůĞ Available Treatments ^ƵƐƉĞĐƚĞĚĐůĂŵƉƐŝĂ;ƐĞŝǌƵƌĞĂĐƚŝǀŝƚǇ͕ŚǇƉĞƌƚĞŶƐŝŽŶͿ ŶǇďůŽŽĚƉƌĞƐƐƵƌĞŽĨϭϰϬͬϵϬŽƌŐƌĞĂƚĞƌǁŝƚŚƉƵůŵŽŶĂƌǇĞĚĞŵĂĂŶĚƐĞǀĞƌĞŚĞĂĚĂĐŚĞŵĂǇŝŶĚŝĐĂƚĞ ƉŽƐƐŝďůĞĞĐůĂŵƉƐŝĂ͘

x (P) Magnesium ϰŐ^>Kt/s͕ŵĂǇƌĞƉĞĂƚŽŶĐĞ x &ŽůůŽǁSeizureŐƵŝĚĞůŝŶĞƐĨŽƌƐĞŝǌƵƌĞƐƌĞĨƌĂĐƚŽƌǇƚŽMagnesium ƚŽŝŶĐůƵĚĞďĞŶǌŽĚŝĂǌĞƉŝŶĞ ĂĚŵŝŶŝƐƚƌĂƚŝŽŶ͘ x (P)DŽŶŝƚŽƌĂŝƌǁĂǇͬǀĞŶƚŝůĂƚŝŽŶͬŽǆǇŐĞŶĂƚŝŽŶĐůŽƐĞůǇĂŶĚƉƌŽǀŝĚĞƌĂƉŝĚƚƌĂŶƐƉŽƌƚ͘

Cypress Creek EMS System Policies and Treatment Guidelines

126 ADULT MEDICAL Revised 6/2019 Approved: Levon Vartanian, MD

x (P) MetoprololϱŵŐƐůŽǁ/sŽǀĞƌϭƚŽϮŵŝŶƵƚĞƐĨŽƌŚǇƉĞƌƚĞŶƐŝǀĞĞŵĞƌŐĞŶĐǇ;ŵĂǇƌĞƉĞĂƚŽŶĐĞŝŶϭϬ ƚŽϭϱŵŝŶƵƚĞƐŝĨWƌĞŵĂŝŶƐĞůĞǀĂƚĞĚхϭϰϬŵŵͬ,ŐƐǇƐƚŽůŝĐĂŶĚͬŽƌϵϬŵŵͬ,ŐĚŝĂƐƚŽůŝĐt/d,ƐŝŐŶƐŽĨ ĞŶĚͲŽƌŐĂŶĐŽŵƉƌŽŵŝƐĞ΀ƉƵůŵŽŶĂƌǇĞĚĞŵĂĂŶĚƐĞǀĞƌĞŚĞĂĚĂĐŚĞ΁Ϳ x EŽƚĞ͗ĐůĂŵƉƐŝĂŵĂǇŽĐĐƵƌƵƉƚŽƐĞǀĞƌĂůǁĞĞŬƐĂĨƚĞƌĚĞůŝǀĞƌǇ͘ ,ǇƉŽƚĞŶƐŝŽŶͬWŽŽƌWĞƌĨƵƐŝŽŶ WŽƐƐŝďůǇĐĂƵƐĞĚďǇƉůĂĐĞŶƚĂƉƌĞǀŝĂ͕ƉůĂĐĞŶƚĂůĂďƌƵƉƚŝŽŶ͕ƵƚĞƌŝŶĞƌƵƉƚƵƌĞ͕ŽƌƐƉŽŶƚĂŶĞŽƵƐĂďŽƌƚŝŽŶ͘&ĞƚĂů ƚŝƐƐƵĞƐŚŽƵůĚďĞƌĞƚĂŝŶĞĚĂŶĚƚƌĂŶƐƉŽƌƚĞĚǁŝƚŚƚŚĞƉĂƚŝĞŶƚŝŶĂďŝŽŚĂǌĂƌĚďĂŐ;ĐŽŶƐŝĚĞƌƵƐŝŶŐŝŶƐŝĚĞĂ ƐƚŽƌĂŐĞďŽǆͿ͕ĂŶĚĐůĞĂƌůǇŝĚĞŶƚŝĨŝĞĚͬƚƌĂŶƐĨĞƌƌĞĚƚŽŚŽƐƉŝƚĂůƐƚĂĨĨ͘

x (B)/ŵŵĞĚŝĂƚĞƚƌĂŶƐƉŽƌƚĂŶĚŶŽƚŝĨŝĐĂƚŝŽŶŽĨŚŽƐƉŝƚĂů x (P) ResQGardƉƌŽĐĞĚƵƌĞ x (P) PlasmalyteĨůƵŝĚďŽůƵƐƵƉƚŽϮϬŵ>ͬŬŐƚŽŵĂŝŶƚĂŝŶ^WхϵϬŵŵ,Ő x (B) Fundal massageĨŽƌƉŽƐƚͲĚĞůŝǀĞƌǇĂĐƚŝǀĞďůĞĞĚŝŶŐ x (P) Oxytocin ϮϬƵŶŝƚƐŝŶϭϬϬϬŵ>PlasmalyteƌƵŶǁŝĚĞŽƉĞŶĨŽƌƉŽƐƚͲĚĞůŝǀĞƌǇŽƌƉŽƐƚͲĂďŽƌƚŝŽŶĂĐƚŝǀĞ ďůĞĞĚŝŶŐĂĨƚĞƌĚĞůŝǀĞƌǇŽĨƚŚĞƉůĂĐĞŶƚĂ x (P) Whole Blood EĂƵƐĞĂĂŶĚsŽŵŝƚŝŶŐ x (P) Ondansetron ϰʹϴŵŐKdĨŽƌŶĂƵƐĞĂŵĂǇƌĞƉĞĂƚŽŶĐĞ;ŵĂǆŝŵƵŵĚŽƐĞϭϲŵŐͿ x (P) Metoclopramide ϭϬŵŐƐůŽǁ/sƉƵƐŚŽŶĐĞĨŽƌǀŽŵŝƚŝŶŐ x (P) Normal SalineŽƌPlasmalyteĨůƵŝĚďŽůƵƐŽĨϭϬʹϮϬŵůͬŬŐŝĨŶŽĐŽŶƚƌĂŝŶĚŝĐĂƚŝŽŶƐĂŶĚĂƉƉƌŽƉƌŝĂƚĞ ĨŽƌƉĂƚŝĞŶƚĐŽŶĚŝƚŝŽŶ x ŽŶƐŝĚĞƌ12-lead ECGŝĨƵŶĂďůĞƚŽƌƵůĞŽƵƚĐĂƌĚŝĂĐĞƚŝŽůŽŐǇ ŝĂďĞƚĞƐͬ'ĞƐƚĂƚŝŽŶĂůŝĂďĞƚĞƐ WƌĞŐŶĂŶĐǇŝƐĂŬĞƚŽŐĞŶŝĐƐƚĂƚĞ͕ĂŶĚǁŽŵĞŶǁŝƚŚƚǇƉĞϭĚŝĂďĞƚĞƐĂŶĚƚŽĂůĞƐƐĞƌĞǆƚĞŶƚƚŚŽƐĞǁŝƚŚƚǇƉĞϮ ĚŝĂďĞƚĞƐĂƌĞĂƚƌŝƐŬĨŽƌĚŝĂďĞƚŝĐŬĞƚŽĂĐŝĚŽƐŝƐĂƚůŽǁĞƌďůŽŽĚƐƵŐĂƌůĞǀĞůƐƚŚĂŶŝŶƚŚĞŶŽŶƉƌĞŐŶĂŶƚƐƚĂƚĞ͘

x (B) Oral GlucoseĨŽƌŚǇƉŽŐůǇĐĞŵŝĂŝĨƉĂƚŝĞŶƚŝƐĐŽŶƐĐŝŽƵƐĂŶĚŚĂƐďŽƚŚĂŶŝŶƚĂĐƚŐĂŐĂŶĚƐǁĂůůŽǁ ƌĞĨůĞǆ͘DĂǇďĞŐŝǀĞŶĂůŽŶŐǁŝƚŚŽƌĂŶŐĞũƵŝĐĞŽƌĂŶŽƚŚĞƌƐǁĞĞƚͬŐůƵĐŽƐĞƐŽůƵƚŝŽŶ͘ x (P) Dextrose ĨŽƌŚǇƉŽŐůǇĐĞŵŝĂ͕ƌĞƉĞĂƚŝĨŶĞĐĞƐƐĂƌǇ x (P) ThiamineϭϬϬŵŐ/sͬ/DŝĨƉĂƚŝĞŶƚĂƉƉĞĂƌƐŵĂůŶŽƵƌŝƐŚĞĚŽƌĚŝƐƉůĂǇƐĞǀŝĚĞŶĐĞŽĨĂůĐŽŚŽůŝƐŵ x (P) GlucagonϭͲϮŵŐ/DŝĨƵŶĂďůĞƚŽŽďƚĂŝŶ/sĂĐĐĞƐƐ͘DĂǇƌĞƉĞĂƚŽŶĐĞĂĨƚĞƌϭϱŵŝŶƵƚĞƐŝĨŶĞĞĚĞĚ͘ WĂŝŶDĂŶĂŐĞŵĞŶƚ x (B) Acetaminophen Ϭ͘ϱʹϭŐŵWK͕ĞǀĞƌǇϰͲϲŚŽƵƌƐ͕ĨŽƌŵŝůĚƚŽŵŽĚĞƌĂƚĞƉĂŝŶ͘DĂǇďĞƵƐĞĚŝŶ ĐŽŶũƵŶĐƚŝŽŶǁŝƚŚŽƉŝŽŝĚƐ͘ &ŽƌƉĂŝŶĂƐƐŽĐŝĂƚĞĚǁŝƚŚŽƌƚŚŽƉĞĚŝĐŝŶũƵƌŝĞƐ͕ƌĞŶĂůĐŽůŝĐ͕ĐƵƚĞŽƌŽŶĂƌǇ^ǇŶĚƌŽŵĞƐ͕ĂŶĚďƵƌŶƐ͗ x (P) Fentanyl Ϭ͘ϱʹϭŵĐŐͬŬŐƐůŽǁ/sͬ/Kͬ/EƌĞƉĞĂƚĂƐŶĞĞĚĞĚƵƉƚŽĂŵĂǆŝŵƵŵƚŽƚĂůĚŽƐĞŽĨϯŵĐŐͬŬŐ x (P) MorphineϮʹϱŵŐƐůŽǁ/sͬ/Kͬ/DĂƐŶĞĞĚĞĚƵƉƚŽĂŵĂǆŝŵƵŵƚŽƚĂůĚŽƐĞŽĨϭϱŵŐ͘ x (P) KetamineϬ͘ϮʹϬ͘ϯŵŐͬŬŐƐůŽǁ/sͬ/Kͬ/E;ŽŶůǇĨŽƌŽƌƚŚŽƉĞĚŝĐŝŶũƵƌŝĞƐŝŶĐŽŶũƵŶĐƚŝŽŶǁŝƚŚĂŶ ŽƉŝŽŝĚŵĞĚŝĐĂƚŝŽŶͿ͘

Cypress Creek EMS System Policies and Treatment Guidelines

127 ADULT MEDICAL Revised 6/2019 Approved: Levon Vartanian, MD

Pearls x dŚĞďĞŶĞĨŝƚŽĨĂŶǇƚƌĞĂƚŵĞŶƚŝŶƚŚĞƉƌĞŐŶĂŶƚƉĂƚŝĞŶƚƐŚŽƵůĚďĞǁĞŝŐŚĞĚĂŐĂŝŶƐƚƚŚĞƌŝƐŬƚŽƚŚĞĨĞƚƵƐ ǁŚĞŶďĞŝŶŐĐŽŶƐŝĚĞƌĞĚ͘ƚŚŽƌŽƵŐŚĚŝĨĨĞƌĞŶƚŝĂůĚŝĂŐŶŽƐŝƐĂŶĚDK/ͬ,W/ƐŚŽƵůĚďĞĚŽĐƵŵĞŶƚĞĚĂŶĚ ůĞƐƐŝŶǀĂƐŝǀĞŽƉƚŝŽŶƐŝŵƉůĞŵĞŶƚĞĚĨŝƌƐƚ͘,ŽǁĞǀĞƌ͕ƚŚŝƐĚŽĞƐŶŽƚƉƌĞĐůƵĚĞƚƌĞĂƚŵĞŶƚƚŽƚŚĞƉĂƚŝĞŶƚŝŶ ĞǆƚƌĞŵŝƐ;ŝŶĐůƵĚŝŶŐƉĂŝŶŵĂŶĂŐĞŵĞŶƚͿ͘ x dŚĞ>ƵĐĂƐĚĞǀŝĐĞƐŚŽƵůĚŶŽƚďĞƵƐĞĚŝŶĂĚǀĂŶĐĞĚƉƌĞŐŶĂŶĐǇ;ƚŚŝƌĚƚƌŝŵĞƐƚĞƌͿ͘ x ZĞƐƵƐĐŝƚĂƚŝŽŶŽĨƚŚĞƉƌĞŐŶĂŶƚƉĂƚŝĞŶƚƐŚŽƵůĚŝŶĐůƵĚĞƵƚĞƌŝŶĞĚŝƐƉůĂĐĞŵĞŶƚƚŽŬĞĞƉƚŚĞŝŶĨĞƌŝŽƌǀĞŶĂ ĐĂǀĂĨƌŽŵďĞŝŶŐĐŽŵƉƌĞƐƐĞĚ͘ĞƉĞŶĚŝŶŐŽŶƚŚĞƉĂƚŝĞŶƚƉƌĞƐĞŶƚĂƚŝŽŶ͕ĐŽŶƐŝĚĞƌƉůĂĐŝŶŐƚŚĞƉĂƚŝĞŶƚ ŽŶĂƐĐŽŽƉƐƚƌĞƚĐŚĞƌǁŝƚŚƚŽǁĞůƌŽůůƐƵŶĚĞƌŶĞĂƚŚƚŚĞƌŝŐŚƚƐŝĚĞ͕ĂůůŽǁŝŶŐĂůĞĨƚůĂƚĞƌĂůƌĞĐƵŵďĞŶƚ ƉŽƐŝƚŝŽŶ͕ŽƌƉĞƌĨŽƌŵŝŶŐĐŽŶƚŝŶƵŽƵƐŵĂŶƵĂůƵƚĞƌŝŶĞĚŝƐƉůĂĐĞŵĞŶƚƚŽƚŚĞůĞĨƚ͘ x KďƐƚĞƚƌŝĐĂůŚŝƐƚŽƌǇƐŚŽƵůĚŝŶĐůƵĚĞĐŽŵƉůŝĐĂƚŝŽŶƐŝŶƚŚĞĐƵƌƌĞŶƚƉƌĞŐŶĂŶĐǇĂŶĚǁŚĞƚŚĞƌƚŚĞƉĂƚŝĞŶƚ ŚĂƐƌĞĐĞŝǀĞĚƉƌĞŶĂƚĂůĐĂƌĞŽƌŝƐŚŝŐŚͲƌŝƐŬ;ƌĞĐĞŶƚƚƌĂƵŵĂ͕ŵƵůƚŝƉůĞĨĞƚƵƐĞƐ͕ĚŝĂŐŶŽƐĞĚƐŚŽƌƚĐŽƌĚ͕ ƉƌŝŽƌĐĂĞƐĂƌĞĂŶƐĞĐƚŝŽŶ͕ĐĞƉŚĂůŽƉĞůǀŝĐĚŝƐƉƌŽƉŽƌƚŝŽŶ͕ĂŶĚͬŽƌƉƌĞͲĞĐůĂŵƉƐŝĂͬĞĐůĂŵƉƐŝĂ͕ĞƚĐ͘Ϳ/ƚ ƐŚŽƵůĚĂůƐŽŝŶĐůƵĚĞĂƐǇŶŽƉƐŝƐŽĨƉĂƐƚƉƌĞŐŶĂŶĐŝĞƐ;ŝŶĐůƵĚŝŶŐĐŽŵƉůŝĐĂƚŝŽŶƐŽĨƉƌĞŐŶĂŶĐǇĂŶĚďŝƌƚŚͿ͘ dŚŝƐƐŚŽƵůĚŝŶĐůƵĚĞĂŐƌĂǀŝĚͬƉĂƌĂŶƵŵďĞƌ͕ŝŶĐůƵĚŝŶŐĚŽĐƵŵĞŶƚŝŶŐƚŚĞĨŽůůŽǁŝŶŐ;'WͿ͗ o Gravid͗EƵŵďĞƌŽĨƉƌĞŐŶĂŶĐŝĞƐ o Para͗EƵŵďĞƌŽĨĚĞůŝǀĞƌŝĞƐ o Abortions͗dŽƚĂůŶƵŵďĞƌƐƉŽŶƚĂŶĞŽƵƐŽƌĞůĞĐƚŝǀĞ x /ĨƚŚĞƉĂƚŝĞŶƚŝƐĞǆƉĞƌŝĞŶĐŝŶŐĐŽŶƚƌĂĐƚŝŽŶƐ͕ĐŽŵƉůĂŝŶŝŶŐŽĨǀĂŐŝŶĂůŽƌĂŶĂůƉƌĞƐƐƵƌĞ͕ŽƌŝƐƵŶĂďůĞƚŽ ĐŽŵŵƵŶŝĐĂƚĞĞĨĨĞĐƚŝǀĞůǇ;ŝŶĐůƵĚŝŶŐĂůĂŶŐƵĂŐĞďĂƌƌŝĞƌͿ͕ǀŝƐƵĂůŝǌĂƚŝŽŶŽĨƚŚĞǀĂŐŝŶĂůĂƌĞĂƐŚŽƵůĚďĞ ƉĞƌĨŽƌŵĞĚĂŶĚĚŽĐƵŵĞŶƚĞĚƚŽƉƌĞǀĞŶƚƵŶĨŽƌĞƐĞĞŶĚĞůŝǀĞƌǇ͘^ĞĞChildbirth ƉƌŽĐĞĚƵƌĞ͘ x WĂůƉĂƚŝŽŶŽĨƚŚĞŐƌĂǀŝĚĂďĚŽŵĞŶƐŚŽƵůĚďĞƉĞƌĨŽƌŵĞĚ͕ĂƐŝƚŝƐĂǀĂůƵĂďůĞĂƐƐĞƐƐŵĞŶƚƚŽŽů͘ƚƚĞŵƉƚ ƚŽĚĂƚĞƚŚĞƉƌĞŐŶĂŶĐǇƵƐŝŶŐŝŶĨŽƌŵĂƚŝŽŶĨƌŽŵƚŚĞƉĂƚŝĞŶƚ;ŝŶĐůƵĚŝŶŐ>DW͕ƉƌĞǀŝŽƵƐƵůƚƌĂƐŽƵŶĚ͕ĞƚĐ͘Ϳ ŽŶƐŝĚĞƌĂƐŬŝŶŐĂďŽƵƚĨĞƚĂůŵŽǀĞŵĞŶƚƚŽĂƐƐŝƐƚŝŶĂƐƐĞƐƐŝŶŐǀŝĂďŝůŝƚǇ͘EŽƚĞ͗sŝĂďŝůŝƚǇŽĨƚŚĞĨĞƚƵƐ ŝƐĂĐŽŵƉůĞǆƋƵĞƐƚŝŽŶĂŶĚŶŽƚŽŶĞƚŚĂƚƚŚŝƐƉƌŽƚŽĐŽůŝƐĂƚƚĞŵƉƚŝŶŐƚŽĚĞĨŝŶĞ͘D^ƐŚŽƵůĚƌĞƐƵƐĐŝƚĂƚĞ any newborn delivered͕ŽŶůǇĞǆĐůƵĚŝŶŐƚŚĞǀĞƌǇŽďǀŝŽƵƐůǇĚĞĂĚ͘ZĞĨĞƌƚŽƚŚĞNewborn Resuscitation ƉƌŽƚŽĐŽů͘

Cypress Creek EMS System Policies and Treatment Guidelines

128 ADULT MEDICAL Revised 8/2016 Approved: Levon Vartanian, MD

^ŝĐŬůĞĞůůƌŝƐŝƐ Assessment Requirements May Present As Consider Possible Causes ƐƐĞƐƐŵĞŶƚΘĨŽĐƵƐĞĚĞǆĂŵ WĂŝŶ͕ŵǇĂůŐŝĂ͕ĚŝĨĨŝĐƵůƚǇ /ŶĨĞĐƚŝŽŶ͕ĚĞŚǇĚƌĂƚŝŽŶ͕ 'DŽŶŝƚŽƌ ďƌĞĂƚŚŝŶŐ͕ƉĂůůŽƌ͕ ĂĐŝĚŽƐŝƐ͕D/͕s͕ƉŶĞƵŵŽŶŝĂ ϭϮͲůĞĂĚ' ƚĂĐŚǇĐĂƌĚŝĂ͕ĨĂƚŝŐƵĞ͕

ZĞƋƵŝƌĞĚdƌĞĂƚŵĞŶƚƐ x Airway management ĂƉƉƌŽƉƌŝĂƚĞ ƚŽƉĂƚŝĞŶƚĐŽŶĚŝƚŝŽŶ͘ x VentilationĂŶĚoxygenation ĂƉƉƌŽƉƌŝĂƚĞƚŽƉĂƚŝĞŶƚĐŽŶĚŝƚŝŽŶ͘ x (I) Vascular accessǁŝƚŚ/sŽƌ/K x (B) ,ŝŐŚĨůŽǁŽǆǇŐĞŶďǇŵĂƐŬ͕ƵŶůĞƐƐŶŽƚƚŽůĞƌĂƚĞĚďǇƉĂƚŝĞŶƚ͘ ǀĂŝůĂďůĞdƌĞĂƚŵĞŶƚƐ x (P) Normal Saline ŽƌPlasmalyte ĨůƵŝĚďŽůƵƐƵƉƚŽϮϬŵ>ͬŬŐŝĨŶŽĐŽŶƚƌĂŝŶĚŝĐĂƚŝŽŶƐ x ZĞĨĞƌƚŽPain ManagementƉƌŽĐĞĚƵƌĞ͘

Cypress Creek EMS System Policies and Treatment Guidelines

129 ADULT MEDICAL Revised 12/2018 Approved: Levon Vartanian, MD

,ǇƉŽƚĞŶƐŝŽŶͬ^ŚŽĐŬ Assessment Requirements May Present As Consider Possible Causes ƐƐĞƐƐŵĞŶƚΘ&ƵůůŚĞĂĚͲƚŽͲ ZĞƐƚůĞƐƐŶĞƐƐ͕ĂŶǆŝĞƚǇ͕ ^ŚŽĐŬ ƚŽĞĞǆĂŵ͕ĂƐŝŶĚŝĐĂƚĞĚ ĐŽŶĨƵƐŝŽŶ͕ǁĞĂŬŶĞƐƐ͕ ,ǇƉŽǀŽůĞŵŝĐ;ǀŽůƵŵĞ ZĂƉŝĚůǇŝĚĞŶƚŝĨǇ ĚŝǌǌŝŶĞƐƐ͕ǁĞĂŬ͕ƌĂƉŝĚƉƵůƐĞ͕ ĚĞƉůĞƚĞĚͿ ĞǆƐĂŶŐƵŝŶĂƚŝŶŐŚĞŵŽƌƌŚĂŐĞ ƉĂůĞ͕ĐŽŽůĐůĂŵŵǇƐŬŝŶ͕ ,ǇƉŽǀŽůĞŵŝĐ 'DŽŶŝƚŽƌ ĚĞůĂǇĞĚĐĂƉŝůůĂƌǇƌĞĨŝůů͕ĐŽĨĨĞĞ ;ŚĞŵŽƌƌŚĂŐŝĐͿ dKϮŵŽŶŝƚŽƌŝŶŐ ŐƌŽƵŶĚĞŵĞƐŝƐ͕ƚĂƌƌǇƐƚŽŽůƐ͕ ĂƌĚŝŽŐĞŶŝĐ ϭϮͲůĞĂĚ'͕ĂƐŝŶĚŝĐĂƚĞĚ '/ďůĞĞĚŝŶŐ͘ ^ĞƉƚŝĐ ,Θ,ĂƐĂƉƉƌŽƉƌŝĂƚĞ EĞƵƌŽŐĞŶŝĐ hůƚƌĂƐŽƵŶĚŝĨĂǀĂŝůĂďůĞ ŶĂƉŚǇůĂĐƚŝĐ WƵůŵŽŶĂƌǇĞŵďŽůŝƐŵ dĞŶƐŝŽŶƉŶĞƵŵŽƚŚŽƌĂǆ WĞƌŝĐĂƌĚŝĂůƚĂŵƉŽŶĂĚĞ ĐƚŽƉŝĐƉƌĞŐŶĂŶĐǇ ǇƐƌŚǇƚŚŵŝĂƐ DĞĚŝĐĂƚŝŽŶĞĨĨĞĐƚͬK sĂƐŽǀĂŐĂů WŚǇƐŝŽůŽŐŝĐ;ƉƌĞŐŶĂŶĐǇ ƉŽƐŝƚŝŽŶͿ ZĞƋƵŝƌĞĚdƌĞĂƚŵĞŶƚƐ x Airway management ĂƉƉƌŽƉƌŝĂƚĞ ƚŽƉĂƚŝĞŶƚĐŽŶĚŝƚŝŽŶ͘ x VentilationĂŶĚoxygenation ĂƉƉƌŽƉƌŝĂƚĞƚŽƉĂƚŝĞŶƚĐŽŶĚŝƚŝŽŶ͘ x (I) Vascular accessǁŝƚŚ/sŽƌ/K͘ŽŶƐŝĚĞƌůŽŽĚͲz/sƚƵďŝŶŐ x (B) Control exsanguinating hemorrhage ǀĂŝůĂďůĞdƌĞĂƚŵĞŶƚƐ x (P) PlasmalyteĨůƵŝĚĐŚĂůůĞŶŐĞ;ĐŽŶƐŝĚĞƌtherapeutic hypotensionďĞůŽǁͿ͘DĂǆĚŽƐĞϮϬŵ>ͬŬŐ x ZĞĨĞƌƚŽHemorrhage ControlŐƵŝĚĞůŝŶĞƐƵŶĚĞƌdƌĂƵŵĂƐĞĐƚŝŽŶ x (P) ResQGardƉƌŽĐĞĚƵƌĞ x (P) Dopamine ϱͲϮϬŵĐŐͬŬŐͬŵŝŶ/sͬ/KŝŶĨƵƐŝŽŶĨŽƌƐŚŽĐŬƚŚĂƚŝƐŶŽƚŚǇƉŽǀŽůĞŵŝĐŝŶŶĂƚƵƌĞ͘ x (P) Epinephrine ϮͲϭϬŵĐŐͬŵŝŶ/sͬ/KŝŶĨƵƐŝŽŶĨŽƌƐŚŽĐŬƚŚĂƚŝƐŶŽƚŚǇƉŽǀŽůĞŵŝĐŝŶŶĂƚƵƌĞ͘ x (P) Whole Blood ŽƌBlood ProductsƉĞƌůŽŽĚΘůŽŽĚWƌŽĚƵĐƚƐdƌĂŶƐĨƵƐŝŽŶWƌŽĐĞĚƵƌĞ͘ WĞĂƌůƐ x /ŶƚŚĞƉƌĞƐĞŶĐĞŽĨƵŶĐŽŶƚƌŽůůĞĚŚĞŵŽƌƌŚĂŐĞ͕ƚĂƌŐĞƚĂ^WŽĨϳϬŵŵ,Ő;ƚŚĞƌĂƉĞƵƚŝĐŚǇƉŽƚĞŶƐŝŽŶͿ͘/Ĩ ŚĞŵŽƌƌŚĂŐĞŝƐĐŽŶƚƌŽůůĞĚ͕ƚĂƌŐĞƚĂ^WŽĨхϵϬŵŵ,Ő͘ x hƐĞĐĂƵƚŝŽŶŝŶĂĚŵŝŶŝƐƚĞƌŝŶŐĨůƵŝĚƐŝŶcardiogenic shock. x ŽŶƐŝĚĞƌǀĂƐŽƉƌĞƐƐŽƌƐŝŶƚƌĂƵŵĂƚŝĐŽƌŚǇƉŽǀŽůĞŵŝĐƐŚŽĐŬKE>zĂĨƚĞƌϮůŝƚĞƌĨůƵŝĚďŽůƵƐĂŶĚƉĂƚŝĞŶƚŝƐ ƉĞƌŝͲĂƌƌĞƐƚ͘

Cypress Creek EMS System Policies and Treatment Guidelines

130 ADULT MEDICAL Revised 12/2018 Approved: Levon Vartanian, MD

x /ĨƵŶĐŽŶƚƌŽůůĂďůĞďůĞĞĚŝŶŐĞǆŝƐƚƐ͕ƌĂƉŝĚƚƌĂŶƐƉŽƌƚƚŽƚŚĞĂƉƉƌŽƉƌŝĂƚĞŚŽƐƉŝƚĂůŝƐŶĞĐĞƐƐĂƌǇĂĨƚĞƌ ŝŵŵŽďŝůŝǌĂƚŝŽŶŽĨƐƉŝŶĞĂŶĚĂŝƌǁĂǇŵĂŶĂŐĞŵĞŶƚŚĂƐďĞĞŶĂĐĐŽŵƉůŝƐŚĞĚ͘ŽŶƐŝĚĞƌĞĂƌůǇĂĐƚŝǀĂƚŝŽŶ ŽĨŝƌDĞĚŝĐĂůdƌĂŶƐƉŽƌƚ;>ŝĨĞ&ůŝŐŚƚͿŝĨƚŚĞƉĂƚŝĞŶƚŵĂǇďĞŶĞĨŝƚĨƌŽŵƚŚĞĂĚŵŝŶŝƐƚƌĂƚŝŽŶŽĨǁŚŽůĞ ďůŽŽĚŽƌďůŽŽĚƉƌŽĚƵĐƚƐĂŶĚĂƐƵƉĞƌǀŝƐŽƌŝƐŶŽƚĂǀĂŝůĂďůĞ͘ x EŽĂƚƚĞŵƉƚĂƚĞƐƚĂďůŝƐŚŝŶŐ/sĐĐĞƐƐƐŚŽƵůĚďĞĚŽŶĞǁŚŝůĞŽŶƐĐĞŶĞƵŶůĞƐƐƚƌĂŶƐƉŽƌƚŝƐĚĞůĂǇĞĚŽƌŝƚ ŝƐƌĞƋƵŝƌĞĚĨŽƌĂŝƌǁĂǇŵĂŶĂŐĞŵĞŶƚ x /ŶƚƵďĂƚŝŽŶƐŚŽƵůĚďĞƉĞƌĨŽƌŵĞĚŽŶƐĐĞŶĞŽŶůǇŝĨƚŚĞƉĂƚŝĞŶƚŝƐƵŶĂďůĞƚŽƉƌŽƚĞĐƚƚŚĞŝƌĂŝƌǁĂǇŽƌŝĨ ƚŚĞƉĂƚŝĞŶƚŝƐŚǇƉŽǆŝĐĂŶĚĚŽĞƐŶŽƚƌĞƐƉŽŶĚƚŽŽǆǇŐĞŶ x /ŶƚŚĞĂďƐĞŶĐĞŽĨŚĞĂĚŝŶũƵƌǇ͕ĂůƚĞƌĞĚŵĞŶƚĂůƐƚĂƚƵƐĐĂŶďĞƵƐĞĚĂƐĂŶŝŶĚŝĐĂƚŝŽŶĨŽƌĨůƵŝĚďŽůƵƐ ŝŶƐƚĞĂĚŽĨƐǇƐƚŽůŝĐďůŽŽĚƉƌĞƐƐƵƌĞфϳϬŵŵ,Ő͘ x /ĨƵůƚƌĂƐŽƵŶĚŝƐĂǀĂŝůĂďůĞ͕ƵƚŝůŝǌĞƚŚĞĨŽůůŽǁŝŶŐĞǆĂŵƐƚŽĞǀĂůƵĂƚĞĨŽƌƉŽƐƐŝďůĞĐĂƵƐĞƐŽĨŚǇƉŽƚĞŶƐŝŽŶ͗

Use this exam To evaluate for Treatment Indicated ĂƌĚŝĂĐdĂŵƉŽŶĂĚĞ /ŶŝƚŝĂƚĞƌĂƉŝĚƚƌĂŶƐƉŽƌƚƚŽĐůŽƐĞƐƚƚƌĂƵŵĂĐĞŶƚĞƌ͘ WŽŽƌŵŽƚŝŽŶƐƵƉƉŽƌƚƐƵƐĞŽĨƉƌĞƐƐŽƌƐ͘ ĂƌĚŝĂĐǆĂŵ;W>yͬ^hyͿ ĂƌĚŝĂĐ&ƵŶĐƚŝŽŶ ,ǇƉĞƌĚǇŶĂŵŝĐŵŽƚŝŽŶƐƵŐŐĞƐƚƐŚǇƉŽǀŽůĞŵŝĂ͖ ƉƌŽǀŝĚĞĨůƵŝĚďŽůƵƐ͘ &ůƵŝĚ /&/sŝƐĐŽůůĂƉƐŝďůĞ͕ĐŽŶƐŝĚĞƌƐĞƉƐŝƐŽƌ ƌĞƐƉŽŶƐŝǀĞŶĞƐƐͬƉƌĞůŽĂĚ ŚǇƉŽǀŽůĞŵŝĂĂŶĚƉƌŽǀŝĚĞĨůƵŝĚďŽůƵƐ /sĞǆĂŵ /sŝƐůĂƌŐĞ;ĚŽĞƐŶŽƚǀĂƌǇǁŝƚŚƌĞƐƉŝƌĂƚŝŽŶƐͿĂŶĚ WƵůŵŽŶĂƌǇĞŵďŽůŝƐŵ ĐĂƌĚŝĂĐĞǆĂŵƐŚŽǁƐĞŶůĂƌŐĞĚZs͘/ŶŝƚŝĂƚĞƌĂƉŝĚ ƚƌĂŶƐƉŽƌƚƚŽĐůŽƐĞƐƚĂƉƉƌŽƉƌŝĂƚĞŚŽƐƉŝƚĂů͘ WŶĞƵŵŽƚŚŽƌĂǆ WĞƌĨŽƌŵNeedle Decompression WƵůŵŽŶĂƌǇĞǆĂŵ /ŶƉƌĞƐĞŶĐĞŽĨƚƌĂƵŵĂ͕ƚƌĂŶƐĨƵƐĞďůŽŽĚĂŶĚ ďĚŽŵŝŶĂůĨƌĞĞ &^dĞǆĂŵ ŝŶŝƚŝĂƚĞƌĂƉŝĚƚƌĂŶƐƉŽƌƚƚŽĂ>ĞǀĞů/ͬ//ƚƌĂƵŵĂ ĨůƵŝĚͬďůŽŽĚ ĐĞŶƚĞƌ͘

Shock Differential Diagnosis ŚŽŽƐŝŶŐƚŚĞďĞƐƚƚŚĞƌĂƉǇŝƐĚĞƉĞŶĚĞŶƚŽŶŝĚĞŶƚŝĨǇŝŶŐƚŚĞƚǇƉĞĂŶĚŶĂƚƵƌĞŽĨƐŚŽĐŬƉƌĞƐĞŶƚ͘'ĞŶĞƌĂůůǇ ƐƉĞĂŬŝŶŐ͕ƐŚŽĐŬŝƐŝŶĂĚĞƋƵĂƚĞƉĞƌĨƵƐŝŽŶĂŶĚŝƚĐĂŶďĞĐĂƵƐĞĚďǇĨŽƵƌƉƌŝŵĂƌǇƉƌŽďůĞŵƐǁŝƚŚ͗ ,ǇƉŽǀŽůĞŵŝĐ^ŚŽĐŬŝƐĐĂƵƐĞĚďǇůŽƐƐŽĨďůŽŽĚǀŽůƵŵĞ͘ ^ŝŐŶƐͬƐǇŵƉƚŽŵƐŝŶĐůƵĚĞƚĂĐŚǇĐĂƌĚŝĂ͕ƚĂĐŚǇƉŶĞĂ͕ƌĞƐƚůĞƐƐŶĞƐƐ͕ĂůƚĞƌĞĚŵĞŶƚĂƚŝŽŶ͕ƉĂůĞͬĐŽŽůͬĐůĂŵŵǇ ƐŬŝŶ͕ĂŶĚŝƚůĞĂĚƐƚŽŚǇƉŽƚĞŶƐŝŽŶĂŶĚƵůƚŝŵĂƚĞůǇĚĞĂƚŚ͘

dŚŝƐŵĂǇďĞhemorrhagicŝŶŶĂƚƵƌĞ͕ǁŚĞƌĞƚŚĞƌĞŝƐĂůŽƐƐŽĨƌĞĚďůŽŽĚĐĞůůƐ͘dƌĞĂƚŵĞŶƚĨŽƌƚŚŝƐƐŚŽƵůĚ ŝŶĐůƵĚĞŚĞŵŽƌƌŚĂŐĞĐŽŶƚƌŽů͕ƵƐĞŽĨǁŚŽůĞďůŽŽĚŽƌďůŽŽĚƉƌŽĚƵĐƚƐ͕ĂŶĚƵƐĞŽĨĐƌǇƐƚĂůůŽŝĚƐĂƐŶĞĐĞƐƐĂƌǇ ;ǁŝƚŚƉĞƌŵŝƐƐŝǀĞŚǇƉŽƚĞŶƐŝŽŶŝŶŵŝŶĚͿ͘

Non-hemorrhagic hypovolemic shockŵĂǇďĞĐĂƵƐĞĚďǇĚĞŚǇĚƌĂƚŝŽŶŽƌŽƚŚĞƌĨůƵŝĚůŽƐƐ͘&ůƵŝĚ ƌĞƉůĂĐĞŵĞŶƚƵƐŝŶŐĂĐƌǇƐƚĂůůŽŝĚŝƐƚŚĞƉƌĞĨĞƌƌĞĚƚƌĞĂƚŵĞŶƚ͘

hƐĞŽĨǀĂƐŽƉƌĞƐƐŽƌƐĨŽƌŚǇƉŽǀŽůĞŵŝĐƐŚŽĐŬŝƐŶŽƚĂĚǀŝƐĂďůĞƵŶůĞƐƐƉĂƚŝĞŶƚŝƐƉĞƌŝͲĂƌƌĞƐƚĂŶĚŚĂƐƌĞĐĞŝǀĞĚ ĂŵŝŶŝŵƵŵŽĨϮůŝƚĞƌƐŽĨĨůƵŝĚďŽůƵƐ͘

Cypress Creek EMS System Policies and Treatment Guidelines

131 ADULT MEDICAL Revised 12/2018 Approved: Levon Vartanian, MD

ĂƌĚŝŽŐĞŶŝĐ^ŚŽĐŬŝƐĐĂƵƐĞĚďǇƉƵŵƉĨĂŝůƵƌĞ;ŚĞĂƌƚĨĂŝůƵƌĞͿ͘ ^ŝŐŶƐͬƐǇŵƉƚŽŵƐŵĂǇŝŶĐůƵĚĞŝƐĐŚĞŵŝĐĐŚĞƐƚĚŝƐĐŽŵĨŽƌƚ͕ĚǇƐƉŶĞĂ͕ƚĂĐŚǇĐĂƌĚŝĂ͕ĐĂƌĚŝĂĐĚǇƐƌŚǇƚŚŵŝĂƐ͕ ƚĂĐŚǇƉŶĞĂ͕ŚǇƉŽƚĞŶƐŝŽŶ͕ƉƵůŵŽŶĂƌǇĞĚĞŵĂ;ĐƌĂĐŬůĞƐͿ͕ĂůƚĞƌĞĚŵĞŶƚĂƚŝŽŶ͕ƉĂůĞͬĐŽŽůͬĐůĂŵŵǇƐŬŝŶ͕ĂŶĚ 'ĐŚĂŶŐĞƐ͘

dŚŝƐŵĂǇďĞĐĂƵƐĞĚďǇ rate problemsƐƵĐŚĂƐďƌĂĚǇĐĂƌĚŝĂ͕^sd͕ǀĞŶƚƌŝĐƵůĂƌĚǇƐƌŚǇƚŚŵŝĂƐ; mechanical problemsƐƵĐŚĂƐǀĂůǀĞĚŝƐƌƵƉƚŝŽŶƐ͖Žƌcontractility problemsĐĂƵƐĞĚďǇD/͕ŵƵƐĐůĞĚĂŵĂŐĞ͕ĞůĞĐƚƌŽůǇƚĞ ĂďŶŽƌŵĂůŝƚŝĞƐ͕ŽƌŽǀĞƌĚŽƐĞͬƚŽǆŝĐĞǆƉŽƐƵƌĞ͘

dƌĞĂƚŵĞŶƚƐŚŽƵůĚĨŽĐƵƐŽŶĨŝǆŝŶŐƚŚĞƵŶĚĞƌůǇŝŶŐƉƌŽďůĞŵĂŶĚƚƌĞĂƚŝŶŐƌĂƚĞ͕ƌŚǇƚŚŵ͕ďůŽŽĚƉƌĞƐƐƵƌĞŝŶ ƚŚĂƚŽƌĚĞƌ͘/ĨƌĂƚĞĂŶĚƌŚǇƚŚŵĂƌĞĂƉƉƌŽƉƌŝĂƚĞ͕ĐŽŶƐŝĚĞƌƵƐŝŶŐDopamineŝŶƚŚĞϱʹϭϬŵĐŐͬŬŐͬŵŝŶƌĂŶŐĞ ŽƌEpinephrineϮʹϭϬŵĐŐͬŬŐͬŵŝŶ͘ǀŽŝĚĨůƵŝĚƐƵŶůĞƐƐŚǇƉŽǀŽůĞŵŝĂŝƐĂůƐŽƐƵƐƉĞĐƚĞĚ͘ ŝƐƚƌŝďƵƚŝǀĞ^ŚŽĐŬŝƐĐĂƵƐĞĚďǇƐǇƐƚĞŵŝĐǀĂƐŽĚŝůĂƚŝŽŶ͘ dŚŝƐŵĂǇďĞĐĂƵƐĞĚďǇanaphylaxis͕sepsis͕Žƌneurogenic shock͘dƌĞĂƚSepsisƵƐŝŶŐ^ĞƉƐŝƐƉƌŽƚŽĐŽůĂŶĚ ĂůĂƌŐĞ;ϯϬŵ>ͬŬŐͿĨůƵŝĚďŽůƵƐĨŽůůŽǁĞĚďǇĂǀĂƐŽƉƌĞƐƐŽƌ͘dƌĞĂƚanaphylaxisĂŐŐƌĞƐƐŝǀĞůǇǁŝƚŚ Epinephrine Ϭ͘ϯŵŐϭ͗ϭ͕ϬϬϬ/D;ŽƌϬ͘ϭŵŐϭ͗ϭϬ͕ϬϬϬ/sŝĨƉĂƚŝĞŶƚŝƐƐĞǀĞƌĞůǇŚǇƉŽƚĞŶƐŝǀĞͿ͘dƌĞĂƚ neurogenicƐŚŽĐŬ͕ŽƌĂŶĂƉŚǇůĂǆŝƐĂŶĚƐĞƉƐŝƐƚŚĂƚĂƌĞƌĞĨƌĂĐƚŽƌǇƚŽŽƚŚĞƌƚƌĞĂƚŵĞŶƚƐ͕ǁŝƚŚŚŝŐŚͲĂůƉŚĂͲ ĂĚƌĞŶĞƌŐŝĐǀĂƐŽƉƌĞƐƐŽƌƐƐƵĐŚĂƐDopamine ŝŶƚŚĞϭϬʹϮϬŵĐŐͬŬŐͬŵŝŶƌĂŶŐĞŽƌEpinephrineϮʹϭϬ ŵĐŐͬŬŐͬŵŝŶ͘ KďƐƚƌƵĐƚŝǀĞ^ŚŽĐŬŝƐĐĂƵƐĞĚďǇĂƉŚǇƐŝĐĂůŽďƐƚƌƵĐƚŝŽŶƚŽďůŽŽĚĨůŽǁ͘ dŚŝƐŵĂǇďĞĂtension pneumothorax͕Ăpulmonary embolism͕Žƌpericardial tamponade͘dƌĞĂƚĂ ƚĞŶƐŝŽŶƉŶĞƵŵŽƚŚŽƌĂǆǁŝƚŚŶĞĞĚůĞĚĞĐŽŵƉƌĞƐƐŝŽŶ͘hƌŐĞŶƚůǇƚƌĂŶƐƉŽƌƚƐƵƐƉĞĐƚĞĚƉĞƌŝĐĂƌĚŝĂů ƚĂŵƉŽŶĂĚĞŽƌƉƵůŵŽŶĂƌǇĞŵďŽůŝƐŵƐĂŶĚƵƐĞĨůƵŝĚďŽůƵƐĞƐĂůŽŶŐǁŝƚŚǀĂƐŽƉƌĞƐƐŽƌƐĂƐŶĞĞĚĞĚƚŽ ŵĂǆŝŵŝǌĞďůŽŽĚƉƌĞƐƐƵƌĞ͘tŝƚŚŽƵƚĚĞĨŝŶŝƚŝǀĞƚƌĞĂƚŵĞŶƚŝŶƚŚĞZ͕ƚŚĞƐĞĐŽŶĚŝƚŝŽŶƐĂƌĞƚǇƉŝĐĂůůǇĨĂƚĂů͘

Cypress Creek EMS System Policies and Treatment Guidelines

132 ADULT MEDICAL Revised 8/2016 Levon Vartanian, MD

^ĞƉƐŝƐ

Assessment Requirements May Present As Consider Possible Causes ƐƐĞƐƐŵĞŶƚΘ&ŽĐƵƐĞĚŽƌ&Ƶůů ,ǇƉŽƚĞŶƐŝŽŶ͕ƐŚŽĐŬ͕ĨĞǀĞƌ͕ /ŶĨĞĐƚŝŽŶ͕ƉŶĞƵŵŽŶŝĂ͕hd/͕ ŚĞĂĚͲƚŽͲƚŽĞĞǆĂŵ͕ĂƐ ĂůƚĞƌĞĚŵĞŶƚĂůƐƚĂƚƵƐ͕ ĐĞůůƵůŝƚŝƐ͕ƐĞƉƐŝƐ ĂƉƉƌŽƉƌŝĂƚĞ͘ ŚǇƉŽƚŚĞƌŵŝĂ͕ƚĂĐŚǇĐĂƌĚŝĂ

'ĂŶĚdKϮŵŽŶŝƚŽƌŝŶŐ ϭϮͲůĞĂĚ' dĞŵƉĞƌĂƚƵƌĞĂƐƐĞƐƐŵĞŶƚ '>ĂƐƐĞƐƐŵĞŶƚ ƐƐĞƐƐĨŽƌ^/Z^ͬ^ĞƉƐŝƐĐƌŝƚĞƌŝĂ ^/Z^ͬ^ĞƉƐŝƐƌŝƚĞƌŝĂ SIRS Criteria Sepsis Severe Sepsis dǁŽŽƌŵŽƌĞŽĨƚŚĞĨŽůůŽǁŝŶŐ͗ ^/Z^ĐƌŝƚĞƌŝĂнƐƵƐƉĞĐƚĞĚŽƌ ,ǇƉŽƚĞŶƐŝŽŶŽƌŚǇƉŽƉĞƌĨƵƐŝŽŶ x TemperatureŐƌĞĂƚĞƌƚŚĂŶ ŬŶŽǁŶƐŽƵƌĐĞŽĨinfection͘ ĞǀŝĚĞŶĐĞĚďǇŽŶĞŽƌŵŽƌĞ͗ ϭϬϬ͘ϰΣ&;ϯϴΣͿŽƌůŽǁĞƌƚŚĂŶ x >ĂĐƚŝĐĂĐŝĚŽƐŝƐ ϵϲ͘ϴΣ&;ϯϲΣͿ͘ x ^WфϵϬ x PulseхϵϬ x DWфϲϱ x RRхϮϬ͕ŵĞĐŚĂŶŝĐĂůůǇ ǀĞŶƚŝůĂƚĞĚ͕ŽƌdKϮфϯϬ x WBCхϭϮ<͕фϰ<͕ŽƌϭϬй ďĂŶĚƐ

ZĞƋƵŝƌĞĚdƌĞĂƚŵĞŶƚƐ x Airway management ĂƉƉƌŽƉƌŝĂƚĞ ƚŽƉĂƚŝĞŶƚĐŽŶĚŝƚŝŽŶ͘ x VentilationĂŶĚoxygenation ĂƉƉƌŽƉƌŝĂƚĞƚŽƉĂƚŝĞŶƚĐŽŶĚŝƚŝŽŶ͘ x Vascular accessǁŝƚŚ/sŽƌ/K x (P) PlasmalyteĨůƵŝĚďŽůƵƐŽĨϯϬŵ>ͬŬŐ͘;ZĞĐŽŵŵĞŶĚĞĚƚŽƐƚĂƌƚĂƚůĞĂƐƚƚǁŽůŝŶĞƐ͕ǁŝĚĞŽƉĞŶͿ͘ x Sepsis Alert ƉƌŽĐĞĚƵƌĞ ǀĂŝůĂďůĞdƌĞĂƚŵĞŶƚƐ x (P) Dopamine ϱʹϮϬŵĐŐͬŬŐͬŵŝŶ/sͬ/KŝŶĨƵƐŝŽŶƚŝƚƌĂƚĞĚƚŽDWхϲϱŵŵ,Ő͕ŝĨƌĞĨƌĂĐƚŽƌǇƚŽϯϬŵ>ͬŬŐ ĨůƵŝĚďŽůƵƐ͘ x (P) Epinephrine ϮʹϭϬŵĐŐͬŬŐͬŵŝŶ/sͬ/KŝŶĨƵƐŝŽŶƚŝƚƌĂƚĞĚƚŽDWхϲϱŵŵ,Ő͕ŝĨƌĞĨƌĂĐƚŽƌǇƚŽϯϬ ŵ>ͬŬŐĨůƵŝĚďŽůƵƐ͘ x (P) CPAPƉƌŽĐĞĚƵƌĞƐƚĂƌƚŝŶŐĂƚϳ͘ϱĐŵ,ϮKĨŽƌƉƵůŵŽŶĂƌǇĞĚĞŵĂͬŚǇƉŽǆŝĂ͘ x (P) ŽŶƐŝĚĞƌAdvanced Airway ManagementŝĨŚǇƉŽǆŝĐŽƌŝŶĂĐƚƵĂůŽƌŝŵƉĞŶĚŝŶŐƌĞƐƉŝƌĂƚŽƌǇĨĂŝůƵƌĞ͘

Cypress Creek EMS System Policies and Treatment Guidelines

133 ADULT MEDICAL Revised 8/2016 Levon Vartanian, MD

WĞĂƌůƐ x ^ĞƉƐŝƐŝƐĂůŝĨĞͲƚŚƌĞĂƚĞŶŝŶŐ͕ƌĂƉŝĚůǇƉƌŽŐƌĞƐƐŝŶŐĚŝƐĞĂƐĞƉƌŽĐĞƐƐĚƵĞƚŽĂƐǇƐƚĞŵŝĐŝŶĨĞĐƚŝŽŶ͕ĂŶĚŵƵƐƚ ďĞƌĞĐŽŐŶŝǌĞĚĂŶĚƚƌĞĂƚĞĚĞĂƌůǇƚŽƉƌĞǀĞŶƚĚĞĂƚŚ͘ x ^ĞƉƐŝƐƉĂƚŝĞŶƚƐŽĨƚĞŶƌĞƋƵŝƌĞƐŝŐŶŝĨŝĐĂŶƚĨůƵŝĚƌĞƐƵƐĐŝƚĂƚŝŽŶ;ϯϬŵ>ͬŬŐŽƌŵŽƌĞͿĂŶĚŵĂǇĂůƐŽƌĞƋƵŝƌĞ ǀĂƐŽƉƌĞƐƐŽƌŝŶĨƵƐŝŽŶƐŝŶŽƌĚĞƌƚŽŵĂŝŶƚĂŝŶƉƌĞƐƐƵƌĞ͘dŝŵĞƐƉĞŶƚǁŝƚŚĂůŽǁďůŽŽĚƉƌĞƐƐƵƌĞŝƐĚŝƌĞĐƚůǇ ůŝŶŬĞĚǁŝƚŚŵŽƌƚĂůŝƚǇ͘ x ,ĞĂƌƚĨĂŝůƵƌĞƉĂƚŝĞŶƚƐŵĂǇƐŚŽǁƐŝŐŶƐŽĨĨůƵŝĚŽǀĞƌůŽĂĚ;ƉĞĚĂůĞĚĞŵĂ͕ƉƵůŵŽŶĂƌǇĞĚĞŵĂͿďƵƚƐƚŝůů ƌĞƋƵŝƌĞĨůƵŝĚƌĞƐƵƐĐŝƚĂƚŝŽŶ͘/ŶƚŚĞƐĞƉĂƚŝĞŶƚƐ͕ĐŽŶƐŝĚĞƌWWŽƌƉŽƐŝƚŝǀĞƉƌĞƐƐƵƌĞǀĞŶƚŝůĂƚŝŽŶŝĨƉĂƚŝĞŶƚ ŝƐŚǇƉŽǆŝĐŽƌŝŶƌĞƐƉŝƌĂƚŽƌǇĚŝƐƚƌĞƐƐ͘ x sĂƐŽƉƌĞƐƐŽƌƐƐŚŽƵůĚŽŶůǇďĞƐƚĂƌƚĞĚĂĨƚĞƌϮůŝƚĞƌƐŽĨĨůƵŝĚŚĂǀĞďĞĞŶŐŝǀĞŶ͘

Cypress Creek EMS System Policies and Treatment Guidelines

134 ADULT MEDICAL Revised 7/2019 Approved: Levon Vartanian, MD

KǀĞƌĚŽƐĞͬWŽŝƐŽŶŝŶŐ Assessment Requirements May Present As Consider Possible Causes ƐƐĞƐƐŵĞŶƚΘ&ƵůůŚĞĂĚͲƚŽͲ ůƚĞƌĞĚŵĞŶƚĂůƐƚĂƚƵƐ͕ dƌŝĐǇĐůŝĐŶƚŝĚĞƉƌĞƐƐĂŶƚƐ ƚŽĞĞǆĂŵĂƐĂƉƉƌŽƉƌŝĂƚĞ ŚǇƉŽƚĞŶƐŝŽŶͬŚǇƉĞƌƚĞŶƐŝŽŶ͕ ;dƐͿ 'DŽŶŝƚŽƌ ďƌĂĚǇͬƚĂĐŚǇĐĂƌĚŝĂ͕ĚĞĐƌĞĂƐĞĚ ĐĞƚĂŵŝŶŽƉŚĞŶ ϭϮͲůĞĂĚ' ƌĞƐƉŝƌĂƚŽƌǇƌĂƚĞ͕ƐĞŝǌƵƌĞƐ͕ ƐƉŝƌŝŶ dKϮŵŽŶŝƚŽƌŝŶŐ ĂďŶŽƌŵĂůďĞŚĂǀŝŽƌ͕ ĞƉƌĞƐƐĂŶƚƐ '>ĂƐƐĞƐƐŵĞŶƚ ǁĞĂŬŶĞƐƐ͕ŶĂƵƐĞĂͬǀŽŵŝƚŝŶŐ͕ ^ƚŝŵƵůĂŶƚƐ ĂďĚŽŵŝŶĂůƉĂŝŶ͕ŚĞĂĚĂĐŚĞ͕ ŶƚŝĐŚŽůŝŶĞƌŐŝĐ ĐŚĞƐƚƉĂŝŶ͕ǀŝƐƵĂůĐŚĂŶŐĞƐ ĂƌĚŝĂĐDĞĚŝĐĂƚŝŽŶƐ ^>h' ^ŽůǀĞŶƚƐ͕ĂůĐŽŚŽůƐ͕ĐůĞĂŶŝŶŐ hD>^ ĂŐĞŶƚƐ /ŶƐĞĐƚŝĐŝĚĞƐ ;ŽƌŐĂŶŽƉŚŽƐƉŚĂƚĞƐͿ ,ǇƉŽͬŚǇƉĞƌŐůǇĐĞŵŝĂ ůĞĐƚƌŽůǇƚĞĂďŶŽƌŵĂůŝƚŝĞƐ ,ǇƉŽͬŚǇƉĞƌƚŚĞƌŵŝĂ s Required Treatments x Airway management ĂƉƉƌŽƉƌŝĂƚĞ ƚŽƉĂƚŝĞŶƚĐŽŶĚŝƚŝŽŶ͘ x VentilationĂŶĚoxygenation ĂƉƉƌŽƉƌŝĂƚĞƚŽƉĂƚŝĞŶƚĐŽŶĚŝƚŝŽŶ͘ x (I) Vascular accessǁŝƚŚ/sŽƌ/K Available Treatments x Contact Poison Control ϭ;ϴϬϬͿϮϮϮͲϭϮϮϮĨŽƌƐƉĞĐŝĨŝĐĂĚǀŝĐĞĂďŽƵƚƚŚĞƐƵďƐƚĂŶĐĞ;ƐͿŝŶǀŽůǀĞĚŝŶƚŚĞ ĞǀĞŶƚŽĨƚŽǆŝĐĞǆƉŽƐƵƌĞŽƌŝŶŐĞƐƚŝŽŶ͘ KƉŝĂƚĞKǀĞƌĚŽƐĞ x (P) NaloxoneϬ͘ϰͲϮŵŐ^>Kt/sͬ/Dͬ/EĂƐŶĞĞĚĞĚǁŝƚŚŶĂƌĐŽƚŝĐŽǀĞƌĚŽƐĞĂŶĚƉĂƚŝĞŶƚŝƐ ĞǆƉĞƌŝĞŶĐŝŶŐƌĞƐƉŝƌĂƚŽƌǇĚĞƉƌĞƐƐŝŽŶ͕ƚŝƚƌĂƚĞĚƚŽĂĐŚŝĞǀĞĂĚĞƋƵĂƚĞǀĞŶƚŝůĂƚŝŽŶĂŶĚŽǆǇŐĞŶĂƚŝŽŶ͘ ŽĐĂŝŶĞKǀĞƌĚŽƐĞ x (P) Diazepam ϮͲϭϬŵŐ/s;ŽǀĞƌϮͲϱŵŝŶͿĂƐŶĞĞĚĞĚĨŽƌĐŽŶĨŝƌŵĞĚĐŽĐĂŝŶĞŽǀĞƌĚŽƐĞǁŝƚŚĂŶǆŝĞƚǇ͕ ƚƌĞŵŽƌƐ͕ƌĞƐƚůĞƐƐŶĞƐƐ͕ĂŶĚƚĂĐŚǇĐĂƌĚŝĂ͘ x (P) ŽŶƐŝĚĞƌ Normal SalineŝŶĨƵƐŝŽŶƵƉƚŽϮϬŵůͬŬŐŝŶƚŚĞƐǇŵƉƚŽŵĂƚŝĐƉĂƚŝĞŶƚŽŶůǇ͘ x ƐƐŽĐŝĂƚĞĚĐŚĞƐƚƉĂŝŶƐŚŽƵůĚďĞƚƌĞĂƚĞĚƵƐŝŶŐƚŚĞĐƵƚĞŽƌŽŶĂƌǇ^ǇŶĚƌŽŵĞƉƌŽƚŽĐŽů͘ x ŽŶŽƚƵƚŝůŝǌĞďĞƚĂďůŽĐŬĞƌƐŝŶƚƌĞĂƚŝŶŐĐŽĐĂŝŶĞͲƌĞůĂƚĞĚĐŚĞƐƚƉĂŝŶŽƌŚǇƉĞƌƚĞŶƐŝŽŶ͘ǇŽŶůǇůŝŵŝƚŝŶŐ ƚŚĞǀĂƐŽĚŝůĂƚŝŽŶĐĂƵƐĞĚďǇďĞƚĂͲĂĚƌĞŶĞƌŐŝĐĞĨĨĞĐƚƐŽĨĐŽĐĂŝŶĞĂŶĚŶŽƚůŝŵŝƚŝŶŐƚŚĞĂůƉŚĂͲĂĚƌĞŶĞƌŐŝĐ ĞĨĨĞĐƚƐĂƚĂůů͕ƚŚŝƐĐĂŶůĞĂĚƚŽƵŶĐŽŶƚƌŽůůĞĚƉĞƌŝƉŚĞƌĂůǀĂƐŽĐŽŶƐƚƌŝĐƚŝŽŶĂŶĚĂǁŽƌƐĞŶŝŶŐŽĨ ŚǇƉĞƌƚĞŶƐŝŽŶ͘

Cypress Creek EMS System Policies and Treatment Guidelines

135 ADULT MEDICAL Revised 7/2019 Approved: Levon Vartanian, MD

WŚĞŶŽƚŚŝĂǌŝŶĞKǀĞƌĚŽƐĞĂŶĚǇƐƚŽŶŝĐZĞĂĐƚŝŽŶƐ x (P) DiphenhydramineϱϬŵŐ/sŽƌϮϱŵŐ/sͬϮϱŵŐ/DĨŽƌƚŚĞƚƌĞĂƚŵĞŶƚŽĨĚǇƐƚŽŶŝĂĂƐƐŽĐŝĂƚĞĚǁŝƚŚ ƉŚĞŶŽƚŚŝĂǌŝŶĞŝŶŐĞƐƚŝŽŶ dƌŝĐǇĐůŝĐŶƚŝĚĞƉƌĞƐƐĂŶƚKǀĞƌĚŽƐĞ x (P) Sodium BicarbonateϭͲϮŵƋͬŬŐ^>Kt/sǁŝƚŚĐŽŶĨŝƌŵĞĚƚƌŝĐǇĐůŝĐŽǀĞƌĚŽƐĞǁŝƚŚĐŽƌƌĞůĂƚŝŶŐ ŚǇƉĞƌĐĂƉŶŝĂ͖ŝŶƚƵďĂƚŝŽŶǁŝƚŚŚǇƉĞƌǀĞŶƚŝůĂƚŝŽŶƐŚŽƵůĚďĞĐŽŶƐŝĚĞƌĞĚ x (P) Sodium Bicarbonate iŶĨƵƐŝŽŶϱϬŵƋŝŶϭϬϬϬŵůEĂůǁŝƚŚĐŽŶĨŝƌŵĞĚƚƌŝĐǇĐůŝĐŽǀĞƌĚŽƐĞĂŶĚYZ^ х Ϭ͘ϭϮƐĞĐŽŶĚƐ x (P) Epinephrine /ŶĨƵƐŝŽŶƚŽŵĂŝŶƚĂŝŶďůŽŽĚƉƌĞƐƐƵƌĞǁŝƚŚĐŽŶĨŝƌŵĞĚƚƌŝĐǇĐůŝĐŽǀĞƌĚŽƐĞ ĞƚĂůŽĐŬĞƌĂŶĚĂůĐŝƵŵŚĂŶŶĞůůŽĐŬĞƌKǀĞƌĚŽƐĞ x (P) ŽŶƐŝĚĞƌExternal PacingĞĂƌůǇĨŽƌƐĞǀĞƌĞĐĂƐĞƐ͘ x (P) Epinephrine iŶĨƵƐŝŽŶƚŽŵĂŝŶƚĂŝŶďůŽŽĚƉƌĞƐƐƵƌĞǁŝƚŚĐŽŶĨŝƌŵĞĚďĞƚĂďůŽĐŬĞƌŽƌĐĂůĐŝƵŵĐŚĂŶŶĞů ďůŽĐŬĞƌŽǀĞƌĚŽƐĞ x (P) Glucagon ϮŵŐ /s͕ƌĞƉĞĂƚĞĚĂƐŶĞĞĚĞĚ͕ĨŽƌƐǇŵƉƚŽŵĂƚŝĐďĞƚĂďůŽĐŬĞƌŽǀĞƌĚŽƐĞǁŝƚŚďƌĂĚǇĐĂƌĚŝĂ ĂŶĚͬŽƌŚǇƉŽƚĞŶƐŝŽŶ x (P) Calcium ChlorideϱϬϬͲϭϬϬϬŵŐ/sͬ/KĨŽƌĐŽŶĨŝƌŵĞĚĐĂůĐŝƵŵĐŚĂŶŶĞůďůŽĐŬĞƌŽǀĞƌĚŽƐĞ͘ x (P) Dextrose ĨŽƌŚǇƉŽŐůǇĐĞŵŝĂƌĞůĂƚĞĚƚŽďĞƚĂďůŽĐŬĞƌŽǀĞƌĚŽƐĞ KƌŐĂŶŽƉŚŽƐƉŚĂƚĞWŽŝƐŽŶŝŶŐ x (P) AtropineϮͲϱŵŐ/sĨŽƌŽƌŐĂŶŽƉŚŽƐƉŚĂƚĞƉŽŝƐŽŶŝŶŐĂƐŶĞĞĚĞĚƵŶƚŝůŚĞĂƌƚƌĂƚĞŝƐхϭϬϬƉĞƌ ŵŝŶƵƚĞĂŶĚůƵŶŐƐŽƵŶĚƐĂƌĞĐůĞĂƌ x (P) Consider CPAP ĨŽƌƉƵůŵŽŶĂƌǇĞĚĞŵĂŝĨŶŽƚĐŽŶƚƌĂŝŶĚŝĐĂƚĞĚ͘ Pearls x KƉŝĂƚĞŽǀĞƌĚŽƐĞƐƉƌĞƐĞŶƚǁŝƚŚĚĞĐƌĞĂƐĞĚ>K͕ŚǇƉŽǀĞŶƚŝůĂƚŝŽŶ͕ŚǇƉŽǆŝĂ͕ĂŶĚĐŽŶƐƚƌŝĐƚĞĚƉƵƉŝůƐ͘ x ŽĐĂŝŶĞŝƐĂƉŽƚĞŶƚĂĚƌĞŶĞƌŐŝĐƐƚŝŵƵůĂŶƚĂŶĚĐĂŶĐĂƵƐĞƚĂĐŚǇĂƌƌŚǇƚŚŵŝĂƐ͕ŚǇƉĞƌƚĞŶƐŝŽŶ͕ĂŐŝƚĂƚŝŽŶ͕ ĂŶĚŵĞŶƚĂůĐŚĂŶŐĞƐ͘/ƚĐĂŶĂůƐŽŝŶĚƵĐĞĂĐƵƚĞĐŽƌŽŶĂƌǇƐǇŶĚƌŽŵĞƚŚƌŽƵŐŚĂǀĂƌŝĞƚǇŽĨŵĞĐŚĂŶŝƐŵƐ͕ ůĞĂĚŝŶŐƚŽĐĂƌĚŝĂĐŝƐĐŚĞŵŝĂĂŶĚƉŽƐƐŝďůǇĂ^dD/͘ x dƌŝĐǇĐůŝĐŶƚŝĚĞƉƌĞƐƐĂŶƚ;dͿĚƌƵŐƐĂƌĞƵƐĞĚƉƌŝŵĂƌŝůǇƚŽƚƌĞĂƚŵŽŽĚĚŝƐŽƌĚĞƌƐĂŶĚŝŶĐůƵĚĞĂǀĂƌŝĞƚǇ ŽĨĚƌƵŐƐĞŶĚŝŶŐŝŶ͞ͲƚǇůŝŶĞ͕͟͞ͲĂŵŝŶĞ͕͟ĂŶĚ͞ͲĞƉŝŶ͘͟dŽǀĞƌĚŽƐĞƉƌĞƐĞŶƚƐǁŝƚŚĂŶƚŝĐŚŽůŝŶĞƌŐŝĐ ĞĨĨĞĐƚƐƚŚĂƚƉƌŽŐƌĞƐƐĞƐƚŽĂůƚĞƌĞĚŵĞŶƚĂůƐƚĂƚƵƐ͕ĐŽŵĂ͕ƐĞŝǌƵƌĞƐ͕ĂŶĚĐĂƌĚŝĂĐĐŚĂŶŐĞƐƐƵĐŚĂƐĂ ǁŝĚĞŶŝŶŐŽĨƚŚĞYZ^ĂŶĚƉƌŽůŽŶŐĂƚŝŽŶŽĨYdŝŶƚĞƌǀĂůƐ͘ x ĞƚĂďůŽĐŬĞƌĂŶĚĐĂůĐŝƵŵĐŚĂŶŶĞůďůŽĐŬĞƌŽǀĞƌĚŽƐĞƐĐĂƵƐĞďƌĂĚǇĐĂƌĚŝĂƐ͕ŚǇƉŽƚĞŶƐŝŽŶ͕ĂůƚĞƌĞĚ ŵĞŶƚĂůƐƚĂƚƵƐ͕ĂŶĚŵĂǇĐĂƵƐĞŚǇƉŽŐůǇĐĞŵŝĂ͘ x KƌŐĂŶŽƉŚŽƐƉŚĂƚĞƐŝŶĐůƵĚĞĐŽŵŵŽŶŝŶƐĞĐƚŝĐŝĚĞƐ͕ƉĞƐƚŝĐŝĚĞƐ͕ĐĞƌƚĂŝŶŵƵƐŚƌŽŽŵƐ͕ĂŶĚŶĞƌǀĞĂŐĞŶƚƐ͘ KƌŐĂŶŽƉŚŽƐƉŚĂƚĞƉŽŝƐŽŶŝŶŐƉƌĞƐĞŶƚƐǁŝƚŚƚŚĞ͞^>h'ͬ͟͟hD>^͟ƚŽǆŝĚƌŽŵĞ͘ x /ŶĂƚƌƵĞŽƌŐĂŶŽƉŚŽƐƉŚĂƚĞƉŽŝƐŽŶŝŶŐ͕ůĂƌŐĞƋƵĂŶƚŝƚŝĞƐŽĨAtropineŵĂǇďĞƌĞƋƵŝƌĞĚƚŽĐŽƵŶƚĞƌĂĐƚ ƚŚĞƚŽǆŝĐĞĨĨĞĐƚƐŽĨƚŚĞƐƵďƐƚĂŶĐĞ͘

Cypress Creek EMS System Policies and Treatment Guidelines

136 ADULT MEDICAL Revised 7/2019 Approved: Levon Vartanian, MD

x NaloxoneƐŚŽƵůĚŶŽƚďĞƵƐĞĚŝŶƚŚĞĐŽŶƐĐŝŽƵƐƉĂƚŝĞŶƚ͘NaloxoneƐŚŽƵůĚŽŶůǇďĞƵƐĞĚƚŽƐƚŝŵƵůĂƚĞ ƌĞƐƉŝƌĂƚŽƌǇĞĨĨŽƌƚƐĂŶĚͬŽƌŝŵƉƌŽǀĞŚĞŵŽĚǇŶĂŵŝĐƐŝŶƚŚĞƵŶĐŽŶƐĐŝŽƵƐƉĂƚŝĞŶƚŝŶǁŚŝĐŚĂŶŽƉŝĂƚĞ ŽǀĞƌĚŽƐĞŝƐŬŶŽǁŶŽƌƐƵƐƉĞĐƚĞĚĚƵĞƚŽƌĞƐƉŝƌĂƚŽƌǇĚĞƉƌĞƐƐŝŽŶ͕ĐŽŶƐƚƌŝĐƚĞĚƉƵƉŝůƐ͕ĂŶĚͬŽƌŽŶͲƐĐĞŶĞ ĞǀŝĚĞŶĐĞ͘/ĨƚŚĞƉĂƚŝĞŶƚŝƐŝŶƚƵďĂƚĞĚĂŶĚŚĞŵŽĚǇŶĂŵŝĐĂůůǇƐƚĂďůĞ͕ĚŽŶŽƚĂĚŵŝŶŝƐƚĞƌNaloxone͘ NaloxoneƐŚŽƵůĚďĞƚŝƚƌĂƚĞĚƚŽƌĞƐƉŝƌĂƚŽƌǇĞĨĨŽƌƚĂŶĚŝƐŶŽƚŐŝǀĞŶƚŽƌĞƐƚŽƌĞĐŽŶƐĐŝŽƵƐŶĞƐƐ͘ x SLUDGE/DUMBBELSĂƌĞƚŚĞƐǇŵƉƚŽŵƐ ŽĨŽƌŐĂŶŽƉŚŽƐƉŚĂƚĞƉŽŝƐŽŶŝŶŐ͗ o ^ĂůŝǀĂƚŝŽŶ͕ůĂĐƌŝŵĂƚŝŽŶ͕ƵƌŝŶĂƚŝŽŶ͕ĚĞĨĞĐĂƚŝŽŶ͕ŐĂƐƚƌŝĐƵƉƐĞƚ͕ĞŵĞƐŝƐ͘ o ŝĂƌƌŚĞĂ͕ƵƌŝŶĂƚŝŽŶ͕ŵŝŽƐŝƐͬŵƵƐĐůĞǁĞĂŬŶĞƐƐ͕ďƌŽŶĐŚŽƌƌŚĞĂ͕ďƌĂĚǇĐĂƌĚŝĂ͕ĞŵĞƐŝƐ͕ůĂĐƌŝŵĂƚŝŽŶ͕ ƐĂůŝǀĂƚŝŽŶͬƐǁĞĂƚŝŶŐ͘

Cypress Creek EMS System Policies and Treatment Guidelines

137 ADULT MEDICAL Revised 8/2016 Approved: Levon Vartanian, MD

sŽŵŝƚŝŶŐĂŶĚŝĂƌƌŚĞĂ Assessment Requirements May Present As Consider Possible Causes ƐƐĞƐƐŵĞŶƚΘĨŽĐƵƐĞĚĞǆĂŵ ďĚŽŵŝŶĂůƉĂŝŶ͕ŶĂƵƐĞĂ͕ E^;ŝŶĐƌĞĂƐĞĚ/W͕ '>ĂƐƐĞƐƐŵĞŶƚ ǀŽŵŝƚŝŶŐ͕ĚŝĂƌƌŚĞĂ͕ ŚĞĂĚĂĐŚĞ͕ƐƚƌŽŬĞ͕ƚƌĂƵŵĂ͕ ϭϮͲůĞĂĚ'ŝĨĂƉƉƌŽƉƌŝĂƚĞ ĐŽŶƐƚŝƉĂƚŝŽŶ͕ĨĞǀĞƌ͕ ƚƵŵŽƌͿ ŚĞĂĚĂĐŚĞ͕ŵĞŶƚĂůƐƚĂƚƵƐ D/ ĐŚĂŶŐĞƐ͕ŵĂůĂŝƐĞ͕ŵǇĂůŐŝĂƐ͕ ƌƵŐƐŝĚĞĞĨĨĞĐƚƐ ǁĞĂŬŶĞƐƐ '/ͬƌĞŶĂůĚŝƐŽƌĚĞƌƐ < 'ǇŶĞĐŽůŽŐŝĐĚŝƐĞĂƐĞ /ŶĨĞĐƚŝŽŶƐ ůĞĐƚƌŽůǇƚĞĂďŶŽƌŵĂůŝƚŝĞƐ &ŽŽĚŽƌƚŽǆŝŶŝŶĚƵĐĞĚ DĞĚŝĐĂƚŝŽŶŽƌƐƵďƐƚĂŶĐĞ ĂďƵƐĞ WƌĞŐŶĂŶĐǇ WƐǇĐŚŽůŽŐŝĐĂů ZĞƋƵŝƌĞĚdƌĞĂƚŵĞŶƚƐ x Airway management ĂƉƉƌŽƉƌŝĂƚĞ ƚŽƉĂƚŝĞŶƚĐŽŶĚŝƚŝŽŶ͘ x VentilationĂŶĚoxygenation ĂƉƉƌŽƉƌŝĂƚĞƚŽƉĂƚŝĞŶƚĐŽŶĚŝƚŝŽŶ͘ ǀĂŝůĂďůĞdƌĞĂƚŵĞŶƚƐ x (I) Vascular access ǁŝƚŚ/sŽƌ/K x (P) Ondansetron ϰʹϴŵŐKdĨŽƌŶĂƵƐĞĂŵĂǇƌĞƉĞĂƚŽŶĐĞ;ŵĂǆŝŵƵŵĚŽƐĞϭϲŵŐͿ x (P) Promethazine ϭϮ͘ϱŵŐ^>Kt/s;ŵĂǇƌĞƉĞĂƚ/sŽŶĐĞͿŽƌϮϱŵŐ/DĨŽƌĐŽŶƚƌŽůŽĨŶĂƵƐĞĂĂŶĚ ǀŽŵŝƚŝŶŐ͘ x (P) Normal SalineŽƌPlasmalyteĨůƵŝĚďŽůƵƐŽĨϭϬʹϮϬŵůͬŬŐŝĨŶŽĐŽŶƚƌĂŝŶĚŝĐĂƚŝŽŶƐĂŶĚĂƉƉƌŽƉƌŝĂƚĞ ĨŽƌƉĂƚŝĞŶƚĐŽŶĚŝƚŝŽŶ͘ x ZĞĨĞƌƚŽHypotension/ShockŐƵŝĚĞůŝŶĞƐŝĨĂƉƉƌŽƉƌŝĂƚĞ͘ x ŽŶƐŝĚĞƌ12-lead ECGŝĨƵŶĂďůĞƚŽƌƵůĞŽƵƚĐĂƌĚŝĂĐĞƚŝŽůŽŐǇ͘ WĞĂƌůƐ x ŽŶƐŝĚĞƌĂĚŵŝŶŝƐƚĞƌŝŶŐPromethazineĂƐĂŶŝŶĨƵƐŝŽŶŽĨϭϮ͘ϱŵŐŝŶϭϬϬŵ>ŶŽƌŵĂůƐĂůŝŶĞŽǀĞƌϭϬ ŵŝŶƵƚĞƐ͘ x OndansetronƐŚŽƵůĚďĞĐŽŶƐŝĚĞƌĞĚŽǀĞƌPromethazineĨŽƌĐŚŝůĚƌĞŶĂŶĚƉĂƚŝĞŶƚƐǁŚŽĂƌĞƉƌĞŐŶĂŶƚ͕ ŝĨƚŚĞƌĞĂƌĞŶŽĐŽŶƚƌĂŝŶĚŝĐĂƚŝŽŶƐ͘

Cypress Creek EMS System Policies and Treatment Guidelines

138 ADULT MEDICAL Revised 8/2016 Approved: Levon Vartanian, MD

&ĞǀĞƌΘ/ŶĨĞĐƚŝŽƵƐŝƐĞĂƐĞ Assessment May Present As Consider Possible Causes Requirements ƐƐĞƐƐŵĞŶƚΘƉŚǇƐŝĐĂů tĂƌŵͬĨůƵƐŚĞĚͬƐǁĞĂƚǇͬĐŚŝůůƐͬƌŝŐŽƌ͕ /ŶĨĞĐƚŝŽŶƐͬ^ĞƉƐŝƐ ĞǆĂŵ ŵǇĂůŐŝĂ͕ĐŽƵŐŚ͕ĐŚĞƐƚƉĂŝŶ͕ ĂŶĐĞƌͬdƵŵŽƌƐͬ>ǇŵƉŚŽŵĂƐ dĞŵƉĞƌĂƚƵƌĞ ĂďĚŽŵŝŶĂůƉĂŝŶ͕ŚĞĂĚĂĐŚĞ͕ DĞĚŝĐĂƚŝŽŶŽƌĚƌƵŐƌĞĂĐƚŝŽŶ ĂƐƐĞƐƐŵĞŶƚ ĚǇƐƵƌŝĂ͕ŵĞŶƚĂůƐƚĂƚƵƐĐŚĂŶŐĞƐ͕ ,ǇƉĞƌƚŚǇƌŽŝĚŝƐŵ ƌĂƐŚ ,ĞĂƚƐƚƌŽŬĞ DĞŶŝŶŐŝƚŝƐ ZĞƋƵŝƌĞĚdƌĞĂƚŵĞŶƚƐ x Airway management ĂƉƉƌŽƉƌŝĂƚĞ ƚŽƉĂƚŝĞŶƚĐŽŶĚŝƚŝŽŶ͘ x VentilationĂŶĚoxygenation ĂƉƉƌŽƉƌŝĂƚĞƚŽƉĂƚŝĞŶƚĐŽŶĚŝƚŝŽŶ͘ x Contact, droplet, ĂŶĚairborneƉƌĞĐĂƵƚŝŽŶƐĂƐĂƉƉƌŽƉƌŝĂƚĞ ǀĂŝůĂďůĞdƌĞĂƚŵĞŶƚƐ x (I) Vascular accessǁŝƚŚ/sŽƌ/K x (B) AcetaminophenϱϬϬʹϭ͕ϬϬϬŵŐWK͕ŝĨхϰŚŽƵƌƐƐŝŶĐĞůĂƐƚĂĐĞƚĂŵŝŶŽƉŚĞŶĚŽƐĞ͘ x (B) Ibuprofen ϰϬϬʹϴϬϬŵŐWK͕ŝĨхϲŚŽƵƌƐƐŝŶĐĞůĂƐƚĂĐĞƚĂŵŝŶŽƉŚĞŶĚŽƐĞ͘ x (B) Active Cooling ŵĞĂƐƵƌĞƐ;ĞǀĂƉŽƌĂƚŝǀĞĐŽŽůŝŶŐ͕ĐŽůĚƉĂĐŬƐƚŽĂǆŝůůĂĞͬŐƌŽŝŶ͕ĞƚĐ͘Ϳ x (P) Normal SalineŽƌPlasmalyteĨůƵŝĚďŽůƵƐƵƉƚŽϮϬŵ>ͬŬŐĂƐĂƉƉƌŽƉƌŝĂƚĞĨŽƌƉĂƚŝĞŶƚĐŽŶĚŝƚŝŽŶ͘ WĞĂƌůƐ x ŽŶŽƚĂĚŵŝŶŝƐƚĞƌWKŵĞĚŝĐĂƚŝŽŶƐƚŽƉĂƚŝĞŶƚƐǁŚŽĂƌĞƉŽƐƚͲŝĐƚĂůŽƌĂŶĂƐƉŝƌĂƚŝŽŶƌŝƐŬ͘ x &ĞǀĞƌŐĞŶĞƌĂůůǇĚŽĞƐŶŽƚƌĞƋƵŝƌĞƚƌĞĂƚŵĞŶƚƵŶůĞƐƐƚĞŵƉĞƌĂƚƵƌĞŝƐ> 100.4°F (38°C). x ŽŶƐŝĚĞƌǁŚĞƚŚĞƌƚĞŵƉĞƌĂƚƵƌĞŝƐĚƵĞƚŽŝŶĨĞĐƚŝŽŶŽƌĚƵĞƚŽƉŽƐƐŝďůĞĞŶǀŝƌŽŶŵĞŶƚĂůŚĞĂƚ ĞŵĞƌŐĞŶĐǇ͘ x WĂƚŝĞŶƚƐǁŝƚŚĂŚŝƐƚŽƌǇŽĨůŝǀĞƌĨĂŝůƵƌĞƐŚŽƵůĚŶŽƚƌĞĐĞŝǀĞĂĐĞƚĂŵŝŶŽƉŚĞŶ͘ x ZĞŚǇĚƌĂƚŝŽŶǁŝƚŚĨůƵŝĚƐŝŵƉƌŽǀĞƐƉĂƚŝĞŶƚ͛ƐĂďŝůŝƚǇƚŽƐǁĞĂƚĂŶĚĐŽŶƚƌŽůƚŚĞŝƌďŽĚǇƚĞŵƉĞƌĂƚƵƌĞ͘ ůǁĂǇƐƵƐĞƵŶŝǀĞƌƐĂůƉƌĞĐĂƵƚŝŽŶƐŝĨĂŶŝŶĨĞĐƚŝŽŶŝƐƐƵƐƉĞĐƚĞĚ͘

Cypress Creek EMS System Policies and Treatment Guidelines

139 ADULT MEDICAL Revised 8/2016 Approved: Levon Vartanian, MD

ƉŝƐƚĂǆŝƐ Assessment Requirements May Present As Consider Possible Causes ƐƐĞƐƐŵĞŶƚΘĨŽĐƵƐĞĚĞǆĂŵ ůĞĞĚŝŶŐĨƌŽŵŶĂƐĂůƉĂƐƐĂŐĞ͕ dƌĂƵŵĂ͕ŝŶĨĞĐƚŝŽŶ;ǀŝƌĂůhZ/ ƉĂŝŶ͕ŶĂƵƐĞĂ͕ǀŽŵŝƚŝŶŐ ŽƌƐŝŶƵƐŝƚŝƐͿ͕ĂůůĞƌŐŝĐƌŚŝŶŝƚŝƐ͕ ůĞƐŝŽŶƐ͕ŚǇƉĞƌƚĞŶƐŝŽŶ

ZĞƋƵŝƌĞĚdƌĞĂƚŵĞŶƚƐ x Airway management ĂƉƉƌŽƉƌŝĂƚĞ ƚŽƉĂƚŝĞŶƚĐŽŶĚŝƚŝŽŶ͘ x VentilationĂŶĚoxygenation ĂƉƉƌŽƉƌŝĂƚĞƚŽƉĂƚŝĞŶƚĐŽŶĚŝƚŝŽŶ͘ ǀĂŝůĂďůĞdƌĞĂƚŵĞŶƚƐ x (B)Compress nostrilsǁŝƚŚĚŝƌĞĐƚƉƌĞƐƐƵƌĞ͕ŚĞĂĚƚŝůƚĨŽƌǁĂƌĚ͕ƉŽƐŝƚŝŽŶŽĨĐŽŵĨŽƌƚ͘ x (B) Apply cold packŝŶĚŝƌĞĐƚůǇŽǀĞƌďƌŝĚŐĞŽĨŶŽƐĞ͘ x ŽŶƐŝĚĞƌHypotension/ShockŐƵŝĚĞůŝŶĞƐ͕ŝĨĂƉƉůŝĐĂďůĞ͘ x ŽŶƐŝĚĞƌŝŵƉĞŶĚŝŶŐŶĞĞĚĨŽƌAirway Management͕ŝĨĂƉƉůŝĐĂďůĞ͘ x (P) OndansetronϰʹϴŵŐKdŵĂǇƌĞƉĞĂƚŽŶĐĞ;ŵĂǆŝŵƵŵ͗ϭϲŵŐͿĨŽƌŶĂƵƐĞĂ͘ WĞĂƌůƐ x ůĞĞĚŝŶŐŵĂǇďĞŽĐĐƵƌƌŝŶŐƉŽƐƚĞƌŝŽƌůǇ͘ǀĂůƵĂƚĞƉŽƐƚĞƌŝŽƌŽƌŽƉŚĂƌǇŶǆĨŽƌďůŽŽĚůŽƐƐ͘ x ^ŝŐŶŝĨŝĐĂŶƚƉŽƐƚĞƌŝŽƌďůĞĞĚŝŶŐƉůĂĐĞƐƉĂƚŝĞŶƚĂƚƌŝƐŬĨŽƌŶĂƵƐĞĂ͕ǀŽŵŝƚŝŶŐ͕ĂŶĚƉŽƐƐŝďůĞĂƐƉŝƌĂƚŝŽŶ͘

Cypress Creek EMS System Policies and Treatment Guidelines

140 ADULT MEDICAL Revised 8/2016 Approved: Levon Vartanian, MD

ĞŶƚĂůWƌŽďůĞŵƐ ƐƐĞƐƐŵĞŶƚZĞƋƵŝƌĞŵĞŶƚƐ DĂǇWƌĞƐĞŶƚƐ ŽŶƐŝĚĞƌWŽƐƐŝďůĞĂƵƐĞƐ ƐƐĞƐƐŵĞŶƚΘĨŽĐƵƐĞĚĞǆĂŵ ůĞĞĚŝŶŐ͕ƉĂŝŶ͕ĨĞǀĞƌ͕ ĞĐĂǇ͕ŝŶĨĞĐƚŝŽŶ͕ĨƌĂĐƚƵƌĞ͕ ƐǁĞůůŝŶŐ͕ŵŝƐƐŝŶŐŽƌĨƌĂĐƚƵƌĞĚ ĂǀƵůƐŝŽŶ͕ĂďƐĐĞƐƐ͕ĨĂĐŝĂů ƚŽŽƚŚ ĐĞůůƵůŝƚŝƐ͕ŝŵƉĂĐƚĞĚƚŽŽƚŚ͕ dD:ƐǇŶĚƌŽŵĞ͕acute Myocardial Infarction Required Treatments x Airway management ĂƉƉƌŽƉƌŝĂƚĞ ƚŽƉĂƚŝĞŶƚĐŽŶĚŝƚŝŽŶ͘ x VentilationĂŶĚoxygenation ĂƉƉƌŽƉƌŝĂƚĞƚŽƉĂƚŝĞŶƚĐŽŶĚŝƚŝŽŶ͘ x 12-lead ECG͕ŝĨƵŶĂďůĞƚŽƌƵůĞŽƵƚĐĂƌĚŝĂĐĐĂƵƐĞƐ Available Treatments ůĞĞĚŝŶŐ x (B) Control bleedingǁŝƚŚĚŝƌĞĐƚƉƌĞƐƐƵƌĞ͘^ŵĂůůŐĂƵǌĞƌŽůůĐĂŶďĞƉůĂĐĞĚŝŶƚŽƐŽĐŬĞƚĂŶĚƉƌĞƐƐƵƌĞ ĂƉƉůŝĞĚďǇƉĂƚŝĞŶƚďŝƚŝŶŐĚŽǁŶŽŶŝƚ͘ ĞŶƚĂůǀƵůƐŝŽŶ x (B) Place toothŝŶŵŝůŬͬŶŽƌŵĂůƐĂůŝŶĞͬĐŽŵŵĞƌĐŝĂůƉƌĞƉĂƌĂƚŝŽŶ͘ŽŶŽƚƌƵďŽƌƐĐƌƵďƚŽŽƚŚ͖ŵĂǇ ůŝŐŚƚůǇƌŝŶƐĞŐƌŽƐƐĐŽŶƚĂŵŝŶĂƚŝŽŶ͘ 'ĞŶĞƌĂůdƌĞĂƚŵĞŶƚƐ x (B)Cold packĂƉƉůŝĞĚŝŶĚŝƌĞĐƚůǇƚŽĂƌĞĂŽĨƉĂŝŶ͘ x (P)ŽŶƐŝĚĞƌPain ManagementƉƌŽĐĞĚƵƌĞ͕ŝĨŝŶĚŝĐĂƚĞĚ͘ Pearls x ^ŝŐŶŝĨŝĐĂŶƚƐǁĞůůŝŶŐƚŽĨĂĐĞ͕ũĂǁ͕ŶĞĐŬ͕ŽƌŽƌĂůĐĂǀŝƚǇĐĂŶƌĞƉƌĞƐĞŶƚĐĞůůƵůŝƚŝƐŽƌĂŶĂďƐĐĞƐƐ͘hŶƚŝů ƉƌŽǀĞŶŽƚŚĞƌǁŝƐĞ͕ƚŚŝƐŝƐĂlife-threateningemergencyƚŚĂƚĐŽƵůĚůĞĂĚƚŽƐŝŐŶŝĨŝĐĂŶƚĂŝƌǁĂǇ ŽďƐƚƌƵĐƚŝŽŶŽƌĞŶĐĞƉŚĂůŝƚŝƐͬŵĞŶŝŶŐŝƚŝƐ͘

Cypress Creek EMS System Policies and Treatment Guidelines

141 ADULT MEDICAL Revised 8/2016 Approved: Levon Vartanian, MD

ŵĞƌŐĞŶĐŝĞƐŝŶǀŽůǀŝŶŐĞŶƚƌĂů>ŝŶĞƐ ƐƐĞƐƐŵĞŶƚZĞƋƵŝƌĞŵĞŶƚƐ DĂǇWƌĞƐĞŶƚƐ ŽŶƐŝĚĞƌWŽƐƐŝďůĞĂƵƐĞƐ ƐƐĞƐƐŵĞŶƚΘĨŽĐƵƐĞĚĞǆĂŵ ǆƚĞƌŶĂůĐĂƚŚĞƚĞƌ &ĞǀĞƌ͕ŚĞŵŽƌƌŚĂŐĞ͕ƌĞĂĐƚŝŽŶƐ ĚŝƐůŽĚŐĞŵĞŶƚ ĨƌŽŵĞŶƚĞƌĂůƚƵďĞŶƵƚƌŝƚŝŽŶ ŽŵƉůĞƚĞĐĂƚŚĞƚĞƌ ŽƌŵĞĚŝĐĂƚŝŽŶƐ͕ƌĞƐƉŝƌĂƚŽƌǇ ĚŝƐůŽĚŐĞŵĞŶƚ ĚŝƐƚƌĞƐƐ͕ƐŚŽĐŬ ĂŵĂŐĞĚĐĂƚŚĞƚĞƌ ůĞĞĚŝŶŐĂƚĐĂƚŚĞƚĞƌƐŝƚĞ /ŶƚĞƌŶĂůďůĞĞĚŝŶŐ ůŽŽĚĐůŽƚƐ ŝƌĞŵďŽůŝ ƌǇƚŚĞŵĂ͕ǁĂƌŵƚŚ͕Žƌ ĚƌĂŝŶŝŶŐĂƌŽƵŶĚƐŝƚĞ ŝŶĚŝĐĂƚŝŶŐŝŶĨĞĐƚŝŽŶ͘ Treating Specific Emergencies ŝƌǁĂǇͬƌĞĂƚŚŝŶŐͬŝƌĐƵůĂƚŝŽŶƉƌŽďůĞŵ x Airway management ĂƉƉƌŽƉƌŝĂƚĞ ƚŽƉĂƚŝĞŶƚĐŽŶĚŝƚŝŽŶ͘ x VentilationĂŶĚoxygenation ĂƉƉƌŽƉƌŝĂƚĞƚŽƉĂƚŝĞŶƚĐŽŶĚŝƚŝŽŶ͘ x dƌĞĂƚǁŝƚŚƐƉĞĐŝĨŝĐŐƵŝĚĞůŝŶĞƐ͘ ĂŵĂŐĞƚŽĂƚŚĞƚĞƌ x (I) Clamp catheterƉƌŽǆŝŵĂůƚŽĚĂŵĂŐĞ͘DĂǇƵƐĞŚĞŵŽƐƚĂƚǁƌĂƉƉĞĚŝŶŐĂƵǌĞ͘^ƚŽƉŝŶĨƵƐŝŽŶŝĨ ŽŶŐŽŝŶŐ͘ ĂƚŚĞƚĞƌŝƐůŽĚŐĞĚ;WĂƌƚŝĂůůǇͬŽŵƉůĞƚĞůǇͿŽƌ,ĞŵŽƌƌŚĂŐĞĂƚĂƚŚĞƚĞƌ^ŝƚĞ x ;B) Apply direct pressureĂƌŽƵŶĚĐĂƚŚĞƚĞƌ͘ x (I) Stop infusionŝĨŽŶŐŽŝŶŐ͘ ^ƵƐƉĞĐƚĞĚŝƌŵďŽůŝƐŵ (Tachypnea, dyspnea, chest pain) x (B)WůĂĐĞƉĂƚŝĞŶƚŽŶleft sideŝŶŚĞĂĚĚŽǁŶƉŽƐŝƚŝŽŶ͘ x (I) Stop infusionŝĨŽŶŐŽŝŶŐ͘ x (I) Clamp catheter͘ KŶŐŽŝŶŐ/ŶĨƵƐŝŽŶ x (I) Continue infusion͖ŶŽƚƚŽĞǆĐĞĞĚϮϬŵ>ͬŬŐĂĚŵŝŶŝƐƚĞƌĞĚĚƵƌŝŶŐD^ĐĂƌĞ͘ ĐĐĞƐƐŝŶŐĞŶƚƌĂů>ŝŶĞƐ x (P)/ŶƚŚĞĞǀĞŶƚŽĨĐĂƌĚŝĂĐĂƌƌĞƐƚǁŝƚŚŶŽŽƚŚĞƌǀĂƐĐƵůĂƌŽƉƚŝŽŶƐ;ŝŶĐůƵĚŝŶŐ/KͿ͕ĂĐĐĞƐƐĐĞŶƚƌĂů ĐĂƚŚĞƚĞƌĂŶĚƵƚŝůŝǌĞŝĨĨƵŶĐƚŝŽŶŝŶŐƉƌŽƉĞƌůǇ͘

Cypress Creek EMS System Policies and Treatment Guidelines

142 ADULT MEDICAL Revised 8/2016 Approved: Levon Vartanian, MD

Pearls x Always talk to family/caregivers as they may have specific knowledge and skills. x hƐĞƐƚƌŝĐƚƐƚĞƌŝůĞƚĞĐŚŶŝƋƵĞǁŚĞŶĂĐĐĞƐƐŝŶŐͬŵĂŶŝƉƵůĂƚŝŶŐĂŶŝŶĚǁĞůůŝŶŐĐĂƚŚĞƚĞƌ͘ x ^ŽŵĞŝŶĨƵƐŝŽŶƐŵĂǇďĞĚĞƚƌŝŵĞŶƚĂůƚŽƐƚŽƉ͘ƐŬĨĂŵŝůǇĂŶĚĐĂƌĞŐŝǀĞƌŝĨŝƚŝƐĂƉƉƌŽƉƌŝĂƚĞƚŽƐƚŽƉŽƌ ĐŚĂŶŐĞŝŶĨƵƐŝŽŶ͘ x /Ĩ/sŽƌĞŶƚĞƌĂůŶƵƚƌŝƚŝŽŶŝƐƐƚŽƉƉĞĚĨŽƌĂŶǇƌĞĂƐŽŶ͕ŵŽŶŝƚŽƌƉĂƚŝĞŶƚĨŽƌŚǇƉŽŐůǇĐĞŵŝĂ͘ ŽŵŵŽŶĞŶƚƌĂů>ŝŶĞƐ A Quinton catheter is a dual-lumen catheter typically used for dialysis. It is inserted into the chest and “tunneled” to its placement point in a central vein. Both lumens are in the vein, but typically have ports situated to minimize recycling of blood from one lumen into another.

Simple central venous line with three lumens. PICC (Peripherally Inserted Central Catheter) Line appears similarly to a peripheral IV line/lock.

Cypress Creek EMS System Policies and Treatment Guidelines

143 ADULT MEDICAL Revised 8/2016 Approved: Levon Vartanian, MD

dƌĂĐŚĞŽƐƚŽŵŝĞƐĂŶĚsĞŶƚŝůĂƚŽƌƐ ƐƐĞƐƐŵĞŶƚZĞƋƵŝƌĞŵĞŶƚƐ DĂǇWƌĞƐĞŶƚƐ ŽŶƐŝĚĞƌWŽƐƐŝďůĞĂƵƐĞƐ ƐƐĞƐƐŵĞŶƚΘĨŽĐƵƐĞĚĞǆĂŵ ZĞƐƉŝƌĂƚŽƌǇĚŝƐƚƌĞƐƐ ůůĞƌŐŝĐƌĞĂĐƚŝŽŶ͕ĂƐƚŚŵĂ͕ 'DŽŶŝƚŽƌ ůƚĞƌĞĚŵĞŶƚĂůƐƚĂƚƵƐ ĂƐƉŝƌĂƚŝŽŶ͕ƐĞƉƐŝƐ͕ĨŽƌĞŝŐŶ dKϮŵŽŶŝƚŽƌŝŶŐ ^ĞĐƌĞƚŝŽŶƐĐŽŵŝŶŐŽƵƚŽĨ ďŽĚǇ͕ƉŶĞƵŵŽŶŝĂ͕ŝŶĨĞĐƚŝŽŶ͕ ƚƵďĞ ĐŽŶŐĞŶŝƚĂůŚĞĂƌƚĚŝƐĞĂƐĞ͕ ŝŵŝŶŝƐŚĞĚďƌĞĂƚŚƐŽƵŶĚƐ ŵĞĚŝĐĂƚŝŽŶŽƌƚŽǆŝŶ͕ƚƌĂƵŵĂ͕ ǇĂŶŽƐŝƐ ĐĂƌĚŝĂĐĂƌƌĞƐƚ͘ dƌĂŶƐƉŽƌƚƌĞƋƵŝƌŝŶŐ ŵĂŝŶƚĞŶĂŶĐĞŽĨŵĞĐŚĂŶŝĐĂů ǀĞŶƚŝůĂƚŽƌ WŽǁĞƌŽƌĞƋƵŝƉŵĞŶƚĨĂŝůƵƌĞ ĂƚƌĞƐŝĚĞŶĐĞ͘ dƌĞĂƚŝŶŐ^ƉĞĐŝĨŝĐŵĞƌŐĞŶĐŝĞƐ x Tracheostomy Tube Removed:(P)WůĂĐĞĂƉƉƌŽƉƌŝĂƚĞůǇƐŝǌĞĚƚƌĂĐŚĞŽƐƚŽŵǇƚƵďĞŽƌdƚƵďĞŝŶƐƚŽŵĂ͘ ŽŶƐŝĚĞƌƵƐŝŶŐƉĞĚŝĂƚƌŝĐƐŝǌĞĚďŽƵŐŝĞ͕ƚƌĂĐŚĞĂůŚŽŽŬ͕ĂŶĚdƌŽƵƐƐĞĂƵĚŝůĂƚŽƌƐĂƐĂĚũƵŶĐƚƚŽŽůƐŝĨ ŶĞĞĚĞĚ͘ x Tracheostomy Tube in Place but Obstructed: x (P)ŚĞĐŬƚŚĂƚƚŚĞŽďƚƵƌĂƚŽƌ͕ƐƉĞĂŬŝŶŐǀĂůǀĞĚĞĐĂŶŶƵůĂƚŝŽŶƉůƵŐ͕ĂŶĚŝŶŶĞƌĐĂŶŶƵůĂ;ŝĨƉƌĞƐĞŶƚͿĂƌĞ ƌĞŵŽǀĞĚ͘ x (I) SuctionƚƌĂĐŚĞŽƐƚŽŵǇƚƵďĞ x Continued respiratory distress: (B)ƐƐŝƐƚǀĞŶƚŝůĂƚŝŽŶƐǀŝĂƚƵďĞͬdd͘ x Detached oxygen or ventilator circuit͗ŽƌƌĞĐƚƉƌŽďůĞŵ͘ dƌĂŶƐƉŽƌƚŝŶŐŽŶWĂƚŝĞŶƚ͛ƐsĞŶƚŝůĂƚŽƌ x (P)/ĨSpO2is > 94%ŽƌĂƚďĂƐĞůŝŶĞ͕ĂŶĚETCO2is between 30 and 40 mmHg͕ƚŚĞŶƚƌĂŶƐƉŽƌƚŽŶ ƉĂƚŝĞŶƚ͛ƐǀĞŶƚŝůĂƚŽƌǁŝƚŚĐƵƌƌĞŶƚƐĞƚƚŝŶŐƐ͘ x (P)/ĨƵŶĂďůĞƚŽŵĂŝŶƚĂŝŶĂĚĞƋƵĂƚĞǀĞŶƚŝůĂƚŝŽŶĂŶĚŽǆǇŐĞŶĂƚŝŽŶ͕ƌĞŵŽǀĞƉĂƚŝĞŶƚĨƌŽŵǀĞŶƚŝůĂƚŽƌĂŶĚ manually ventilate with BVM and oxygen͘dĂŬĞƉĂƚŝĞŶƚ͛ƐǀĞŶƚŝůĂƚŽƌƚŽŚŽƐƉŝƚĂůĞǀĞŶŝĨŝƚŝƐŶŽƚ ĨƵŶĐƚŝŽŶŝŶŐƉƌŽƉĞƌůǇ͘ WĞĂƌůƐ x Always talk to family/caregivers as they have specific knowledge and skills. x hƐĞƉĂƚŝĞŶƚĞƋƵŝƉŵĞŶƚŝĨĂǀĂŝůĂďůĞĂŶĚĨƵŶĐƚŝŽŶŝŶŐƉƌŽƉĞƌůǇ͘ x ƐƚŝŵĂƚĞƐƵĐƚŝŽŶĐĂƚŚĞƚĞƌƐŝǌĞďǇĚŽƵďůŝŶŐƚŚĞƚƌĂĐŚĞŽƐƚŽŵǇŝŶŶĞƌĚŝĂŵĞƚĞƌĂŶĚƌŽƵŶĚŝŶŐĚŽǁŶ͘ x ^ƵĐƚŝŽŶĚĞƉƚŚ͗ĂƐŬĐĂƌĞŐŝǀĞƌ͘EŽŵŽƌĞƚŚĂŶϯƚŽϲĐŵ͘/ŶƐƚŝůůϮʹϯŵ>ŽĨE^ďĞĨŽƌĞƐƵĐƚŝŽŶŝŶŐ͘ x ŽŶŽƚĨŽƌĐĞƐƵĐƚŝŽŶĐĂƚŚĞƚĞƌ͘/ĨƵŶĂďůĞƚŽƉĂƐƐ͕ƚŚĞŶƚƌĂĐŚĞŽƐƚŽŵǇƚƵďĞƐŚŽƵůĚďĞĐŚĂŶŐĞĚ͘ x hƚŝůŝǌĞDOPE ŵŶĞŵŽŶŝĐĂŶǇƚŝŵĞƚŚĞƌĞŝƐĂƉƌŽďůĞŵǁŝƚŚĂǀĞŶƚŝůĂƚŽƌŽƌĂŝƌǁĂǇĚĞǀŝĐĞ͗ DisplacedƚƵďĞ ObstructionŝŶƚƵďĞ͕ŝŶĂŝƌǁĂǇ͕ŽƌŝŶǀĞŶƚŝůĂƚŽƌĐŝƌĐƵŝƚƐ͘ Pneumothorax ĐĂŶĚĞǀĞůŽƉǀĞƌǇƌĂƉŝĚůǇŝŶƉŽƐŝƚŝǀĞƉƌĞƐƐƵƌĞǀĞŶƚŝůĂƚĞĚƉĂƚŝĞŶƚƐ͘ EquipmentĨĂŝůƵƌĞ͘

Cypress Creek EMS System Policies and Treatment Guidelines

144 ADULT MEDICAL Revised 8/2016 Approved: Levon Vartanian, MD

sĞŶƚƌŝĐƵůĂƌƐƐŝƐƚĞǀŝĐĞƐ;>sƐͿ ƐƐĞƐƐŵĞŶƚZĞƋƵŝƌĞŵĞŶƚƐ DĂǇWƌĞƐĞŶƚƐ ŽŶƐŝĚĞƌWŽƐƐŝďůĞĂƵƐĞƐ ƐƐĞƐƐŵĞŶƚΘĨŽĐƵƐĞĚĞǆĂŵ ůƚĞƌĞĚŵĞŶƚĂůƐƚĂƚƵƐ͕ ^ƚƌŽŬĞ͕ĐĂƌĚŝĂĐĂƌƌĞƐƚ͕ 'DŽŶŝƚŽƌ ŚǇƉŽǆŝĂ͕ƉƵůƐĞůĞƐƐƉĂƚŝĞŶƚ͘ ĚǇƐƌŚǇƚŚŵŝĂ͕ŝŶĨĞĐƚŝŽŶ͕ dKϮŵŽŶŝƚŽƌŝŶŐ dŚĞĨůŽǁƚŚƌŽƵŐŚƚŚĞƐĞ ďůĞĞĚŝŶŐ͕ĚĞŚǇĚƌĂƚŝŽŶ͕ ϭϮͲůĞĂĚ' ĚĞǀŝĐĞƐŝƐŶŽƚƉƵůƐĂƚŝůĞĂŶĚ ĐĂƌĚŝĂĐƚĂŵƉŽŶĂĚĞ͕ ƚŚĞƉĂƚŝĞŶƚŵĂǇŶŽƚŚĂǀĞĂ ŵĞĐŚĂŶŝĐĂůĚĞǀŝĐĞƉƌŽďůĞŵ ƉƵůƐĞĂƚďĂƐĞůŝŶĞ͘dŚƵƐ^ƉKϮ ;ƐƵĐŚĂƐůŽǁďĂƚƚĞƌǇŽƌ ƌĞĂĚŝŶŐƐŵĂǇďĞŝŶĂĐĐƵƌĂƚĞ͘ ĚŝƐĐŽŶŶĞĐƚĞĚĐĂďůĞͿ͘ VAD Summary: What is a Ventricular Assistance Device? ŵĞĐŚĂŶŝĐĂůƉƵŵƉƚŚĂƚŝƐƵƐĞĚƚŽƐƵƉƉŽƌƚŚĞĂƌƚĨƵŶĐƚŝŽŶĂŶĚďůŽŽĚĨůŽǁŝŶƉĞŽƉůĞǁŚŽŚĂǀĞǁĞĂŬĞŶĞĚ ŚĞĂƌƚƐ͘ How does a VAD work? dŚĞĚĞǀŝĐĞƚĂŬĞƐďůŽŽĚĨƌŽŵĂůŽǁĞƌĐŚĂŵďĞƌŽĨƚŚĞŚĞĂƌƚĂŶĚŚĞůƉƐƉƵŵƉŝƚƚŽƚŚĞďŽĚǇĂŶĚǀŝƚĂů ŽƌŐĂŶƐ͕ũƵƐƚĂƐĂŚĞĂůƚŚǇŚĞĂƌƚǁŽƵůĚ͘ What are the parts of a VAD? dŚĞďĂƐŝĐƉĂƌƚƐŽĨĂsŝŶĐůƵĚĞ͗ĂƐŵĂůůƚƵďĞƚŚĂƚĐĂƌƌŝĞƐďůŽŽĚŽƵƚŽĨǇŽƵƌŚĞĂƌƚŝŶƚŽĂƉƵŵƉ͖ĂŶŽƚŚĞƌ ƚƵďĞƚŚĂƚĐĂƌƌŝĞƐďůŽŽĚĨƌŽŵƚŚĞƉƵŵƉƚŽǇŽƵƌďůŽŽĚǀĞƐƐĞůƐ͕ǁŚŝĐŚĚĞůŝǀĞƌƐƚŚĞďůŽŽĚƚŽǇŽƵƌďŽĚǇ͖ĂŶĚ ĂƉŽǁĞƌƐŽƵƌĐĞ͘ What is the power source? ŝƚŚĞƌďĂƚƚĞƌŝĞƐŽƌƉŽǁĞƌ͘dŚĞƉŽǁĞƌƐŽƵƌĐĞŝƐĐŽŶŶĞĐƚĞĚƚŽĂĐŽŶƚƌŽůƵŶŝƚƚŚĂƚŵŽŶŝƚŽƌƐƚŚĞs͛Ɛ ĨƵŶĐƚŝŽŶƐ͘dŚĞďĂƚƚĞƌŝĞƐĂƌĞĐĂƌƌŝĞĚŝŶĂĐĂƐĞƵƐƵĂůůǇůŽĐĂƚĞĚŝŶĂŚŽůƐƚĞƌŝŶĂǀĞƐƚǁƌĂƉƉĞĚĂƌŽƵŶĚƚŚĞ ƉĂƚŝĞŶƚ͛ƐƐŚŽƵůĚĞƌƐ͘ What does the controller unit or controller do? /ƚŐŝǀĞƐǁĂƌŶŝŶŐƐŽƌĂůĂƌŵƐŝĨƚŚĞƉŽǁĞƌŝƐůŽǁŽƌŝƚƐĞŶƐĞƐƚŚĂƚƚŚĞĚĞǀŝĐĞŝƐŶŽƚǁŽƌŬŝŶŐƌŝŐŚƚ͘/ƚŝƐĂ ĐŽŵƉƵƚĞƌ͘ ƐƐĞƐƐŵĞŶƚ x ŐŽŽĚƉŚǇƐŝĐĂůƉƌŝŵĂƌǇƐƵƌǀĞǇŝƐĐƌŝƚŝĐĂůĂƐƚŚĞƐĞƉĂƚŝĞŶƚƐŵĂǇŶŽƚŚĂǀĞƉƵůƐĞƐĂŶĚƉƵůƐĞ ŽǆŝŵĞƚƌǇͬďůŽŽĚƉƌĞƐƐƵƌĞŵĞĂƐƵƌĞŵĞŶƚŵĂǇŶŽƚďĞĨƵŶĐƚŝŽŶ͘Assess mental status, skin condition, and lip colorĂƐƚŚŝƐǁŝůůŐŝǀĞǇŽƵƚŚĞďĞƐƚŝŶĚŝĐĂƚŝŽŶŽĨƉĞƌĨƵƐŝŽŶƐƚĂƚƵƐ͘ x ƐƐĞƐƐĨŽƌƉƵŵƉĨƵŶĐƚŝŽŶďǇĂƵƐĐƵůƚĂƚŝŶŐŽǀĞƌƉƵŵƉƉŽĐŬĞƚĂƚůŽǁĞƌůĞĨƚƌŝďŵĂƌŐŝŶŽŶƚŚĞĂŶƚĞƌŝŽƌ ĐŚĞƐƚ. A distinct hum or whirling sound will be heard if pump is running. WƌŽĐĞĚƵƌĞ x Contact the VAD Coordinator assigned to your patient͘dŚĞǇǁŝůůďĞĂďůĞƚŽƉƌŽǀŝĚĞǀĂůƵĂďůĞ ŝŶĨŽƌŵĂƚŝŽŶƌĞŐĂƌĚŝŶŐƚƌĞĂƚŵĞŶƚĂŶĚƚƌĂŶƐƉŽƌƚĚĞĐŝƐŝŽŶƐ͘ŽEKdĚĞůĂǇůŝĨĞͲƐĂǀŝŶŐŝŶƚĞƌǀĞŶƚŝŽŶƐ͘ x Treat specific disease processesƌĞůĂƚĞĚƚŽƚŚĞƉĂƚŝĞŶƚ͛ƐĐŚŝĞĨĐŽŵƉůĂŝŶƚ͘ x Transport to the closest VAD centerŽƌƉĞƌƚŚĞsŽŽƌĚŝŶĂƚŽƌŝŶƐƚƌƵĐƚŝŽŶƐ͘ƌŝŶŐĂůůŽĨƚŚĞ ƉĂƚŝĞŶƚ͛ƐĞƋƵŝƉŵĞŶƚĂŶĚĂĨĂŵŝůǇŵĞŵďĞƌƚŚĂƚĐĂŶĂŶƐǁĞƌƋƵĞƐƚŝŽŶƐ͘

Cypress Creek EMS System Policies and Treatment Guidelines

145 ADULT MEDICAL Revised 8/2016 Approved: Levon Vartanian, MD

x Confirm complete cardiac arrestďĞĨŽƌĞƐƚĂƌƚŝŶŐWZ͘dŚŝƐŝŶĐůƵĚĞƐŝĚĞŶƚŝĨǇŝŶŐƉŽŽƌƉĞƌĨƵƐŝŽŶŽĨ ƐŬŝŶ͕ĐŽŵƉůĞƚĞůĂĐŬŽĨƌĞƐƉŽŶƐŝǀĞŶĞƐƐ͕ĂŶĚƐŽŵĞŝŶĚŝĐĂƚŝŽŶƚŚĂƚƚŚĞƉƵŵƉŝƐŶŽƚĨƵŶĐƚŝŽŶŝŶŐ͘&ŽůůŽǁ ƚŚĞŐƵŝĚĂŶĐĞŽĨƚŚĞVAD CoordinatorďĞĨŽƌĞŝŶŝƚŝĂƚŝŶŐWZ͘ WĞĂƌůƐ x WĂƚŝĞŶƚƐǁŝƚŚĂsĂƌĞƚǇƉŝĐĂůůǇŽŶĂŶƚŝͲĐŽĂŐƵůĂŶƚƚŚĞƌĂƉǇƚŽƉƌĞǀĞŶƚĐůŽƚƚŝŶŐǁŝƚŚŝŶƚŚĞsĂŶĚ ƚŚĞďůŽŽĚƐƚƌĞĂŵ͘ŽŵƉůŝĐĂƚŝŽŶƐĨƌŽŵsƐƵƐƵĂůůǇƌĞƐƵůƚĨƌŽŵĂŶƚŝĐŽĂŐƵůĂƚŝŽŶ;ĞǆĐĞƐƐŝǀĞďůĞĞĚŝŶŐͿ ŽƌƉƵŵƉƚŚƌŽŵďŽƐŝƐ;ĐůŽƚͿ͘ x sƉĂƚŝĞŶƚƐĂƌĞƉƌĞůŽĂĚĚĞƉĞŶĚĞŶƚ͘ĨůƵŝĚďŽůƵƐĐĂŶŽĨƚĞŶƌĞǀĞƌƐĞŚǇƉŽƉĞƌĨƵƐŝŽŶ͘ x tŚĞŶƚƌĂŶƐƉŽƌƚŝŶŐƚŚĞsƉĂƚŝĞŶƚ͕ďĞƐƵƌĞƚŽďƌŝŶŐƚŚĞƉĂƚŝĞŶƚ͛ƐĞŵĞƌŐĞŶĐǇƚƌĂǀĞůƉĂĐŬǁŝƚŚƚŚĞŵ ǁŚŝĐŚĐŽŶƚĂŝŶƐĞǆƚƌĂďĂƚƚĞƌŝĞƐĂŶĚĂďĂĐŬͲƵƉĐŽŶƚƌŽůůĞƌ͘ x ƉĂƚŝĞŶƚŵĂǇďĞŝŶsĞŶƚƌŝĐƵůĂƌ&ŝďƌŝůůĂƚŝŽŶŽƌsĞŶƚƌŝĐƵůĂƌdĂĐŚǇĐĂƌĚŝĂĂŶĚƌĞŵĂŝŶĂǁĂŬĞĂŶĚĂůĞƌƚŝĨ ƚŚĞƉƵŵƉŝƐǁŽƌŬŝŶŐƉƌŽƉĞƌůǇ͘/ĨƚŚĞƉĂƚŝĞŶƚƌĞƋƵŝƌĞƐĚĞĨŝďƌŝůůĂƚŝŽŶŽƌĐĂƌĚŝŽǀĞƌƐŝŽŶ͕ƚŚĞƐĞĐĂŶďĞ ƉĞƌĨŽƌŵĞĚĂƐŶŽƌŵĂů͕ŚŽǁĞǀĞƌ͕ĚŽŶŽƚƉůĂĐĞƚŚĞĚĞĨŝďƌŝůůĂƚŝŽŶƉĂĚƐŽǀĞƌƚŚĞƉƵŵƉ͘ x /ŶƚŚĞĞǀĞŶƚŽĨĂƉƵŵƉĨĂŝůƵƌĞ͕ĐŽŶƚĂĐƚƚŚĞsĐŽŽƌĚŝŶĂƚŽƌĨŽƌŐƵŝĚĂŶĐĞĂŶĚŝŶƐƚƌƵĐƚŝŽŶ͘ZĞƐƚĂƌƚŝŶŐ ĂƉƵŵƉƚŚĂƚŚĂƐďĞĞŶƐƚŽƉƉĞĚŝƐŶŽƚƌĞĐŽŵŵĞŶĚĞĚďĞĐĂƵƐĞŝƚǁŝůůŝŶĐƌĞĂƐĞƚŚĞƉĂƚŝĞŶƚ͛ƐƌŝƐŬŽĨ ƐƚƌŽŬĞŽƌƚŚƌŽŵďŽĞŵďŽůŝƐŵ͘dŚŝƐŝƐĚƵĞƚŽƚŚĞƐƚĂŐŶĂŶƚďůŽŽĚƚŚĂƚŵĂǇŚĂǀĞĚĞǀĞůŽƉĞĚŝŶƚŚĞ ƐǇƐƚĞŵǁŚŝůĞƚŚĞƉƵŵƉǁĂƐŽĨĨ͘ x ůů>^ĚƌƵŐƐŵĂǇďĞŐŝǀĞŶƚŽĂƉĂƚŝĞŶƚǁŝƚŚĂs͘

Cypress Creek EMS System Policies and Treatment Guidelines

146 PEDIATRIC MEDICAL Revised 8/2016 Approved: Levon Vartanian, MD

WĞĚŝĂƚƌŝĐDĞĚŝĐĂů

Newborn Resuscitation ...... 148 Pediatric Cardiac Arrest ...... 149 Pediatric Asystole/PEA ...... 151 Pediatric VentricularFibrillation/Pulseless VentricularTachycardia ...... 152 Pediatric Post-Arrest Care ...... 153 Pediatric Tachycardia ...... 155 Pediatric Bradycardia ...... 156 Pediatric Respiratory Distress ...... 157 Pediatric Diabetic Emergency ...... 159 Pediatric Seizure ...... 160 Pediatric Overdose ...... 161 Pediatric Hypotension/Shock ...... 164 Pediatric Allergic Reaction/Anaphylaxis ...... 167 Pediatric Vomiting/Diarrhea ...... 169 Children with Special Healthcare Needs ...... 170 Apparent Life Threatening Event (ALTE) ...... 171

Cypress Creek EMS System Policies and Treatment Guidelines

147 PEDIATRIC MEDICAL Revised 8/2016 Approved: Levon Vartanian, MD

EĞǁďŽƌŶZĞƐƵƐĐŝƚĂƚŝŽŶ

ƐƐĞƐƐŵĞŶƚZĞƋƵŝƌĞŵĞŶƚƐ DĂǇWƌĞƐĞŶƚƐ ŽŶƐŝĚĞƌWŽƐƐŝďůĞĂƵƐĞƐ ƐƐĞƐƐŵĞŶƚΘ&ƵůůŚĞĂĚͲƚŽͲƚŽĞ ŚŝůĚďŝƌƚŚ ŝƌǁĂǇŽďƐƚƌƵĐƚŝŽŶ ĞǆĂŵ ͞ůƵĞ͟ďĂďǇ ZĞƐƉŝƌĂƚŽƌǇĂƌƌĞƐƚ WƵůƐĞ͕ƌĞƐƉŝƌĂƚŝŽŶƐ͕ƚĞŵƉĞƌĂƚƵƌĞ hŶƌĞƐƉŽŶƐŝǀĞ͕ƉŽƐƐŝďůǇ ,ǇƉŽǆŝĂ W'ZĂƐƐĞƐƐŵĞŶƚĂƚϭΘϱŵŝŶ ƉƵůƐĞůĞƐƐͬĂƉŶĞŝĐŝŶĨĂŶƚ͘ ,ǇƉŽŐůǇĐĞŵŝĂ ƌŽƐĞůŽǁƚĂƉĞ ŽŶŐĞŶŝƚĂůĚĞĨĞĐƚ 'ŵŽŶŝƚŽƌŝŶŐ ůŽŽĚŐůƵĐŽƐĞ

ZĞƋƵŝƌĞĚdƌĞĂƚŵĞŶƚƐ x (B/P)Airway managementĂŶĚoxygen therapyĂƉƉƌŽƉƌŝĂƚĞƚŽƉĂƚŝĞŶƚĐŽŶĚŝƚŝŽŶ x (B)^ƵĐƚŝŽŶŽƌĂůƚŚĞŶŶĂƐĂůƉŚĂƌǇŶǆƚŽƐƚŝŵƵůĂƚĞďƌĞĂƚŚŝŶŐ;ĞǆĐĞƉƚŝŽŶ͗ŵĞĐŽŶŝƵŵƐƚĂŝŶŝŶŐͿ x (B)ƌǇŶĞǁďŽƌŶǀŝŐŽƌŽƵƐůǇĂŶĚ<WEtKZEtZD x (B)WƌŽǀŝĚĞ͞ďůŽǁͲďǇ͟ŽǆǇŐĞŶ͘ĞĐĂƌĞĨƵůƚŽĂǀŽŝĚďůŽǁŝŶŐĚŝƌĞĐƚůǇŝŶƚŽŶĞǁďŽƌŶΖƐĞǇĞƐ x (P)/ĨĂŵŶŝŽƚŝĐĨůƵŝĚŝƐŵĞĐŽŶŝƵŵƐƚĂŝŶĞĚ͕ƚŚĞŶĂƐƐŽŽŶĂƐƚŚĞŚĞĂĚĚĞůŝǀĞƌƐ͕ŚĂǀĞƚŚĞŵŽƚŚĞƌƐƚŽƉ ƉƵƐŚŝŶŐĂŶĚƐƵĐƚŝŽŶŵŽƵƚŚͬŶŽƐĞ͕EƉĞƌĨŽƌŵůĂƌǇŶŐŽƐĐŽƉǇĂŶĚƐƵĐƚŝŽŶďĞůŽǁƚŚĞǀŽĐĂůĐŽƌĚƐ ƉƌŝŽƌƚŽĂŶǇĞĨĨŽƌƚƐƚŚĂƚŵĂǇƐƚŝŵƵůĂƚĞďƌĞĂƚŚŝŶŐ͘ x (B)DĞĐŚĂŶŝĐĂůǀĞŶƚŝůĂƚŝŽŶǁŝƚŚsDƐŚŽƵůĚďĞŐŝŶŝĨĂŶǇŽĨƚŚĞĨŽůůŽǁŝŶŐĐŽŶĚŝƚŝŽŶƐĞǆŝƐƚ͗ĂƉŶĞĂ͕ ďƌĂĚǇĐĂƌĚŝĂ;,ZфϭϬϬͬŵŝŶͿ͕ŽƌĐĞŶƚƌĂůĐǇĂŶŽƐŝƐƵŶƌĞƐƉŽŶƐŝǀĞƚŽƚĂĐƚŝůĞƐƚŝŵƵůĂƚŝŽŶĂŶĚ ƐƵƉƉůĞŵĞŶƚĂůKϮ͘ x (B)WZΘŝŶƚƵďĂƚŝŽŶŝĨŚĞĂƌƚƌĂƚĞфϲϬͬŵŝŶĂĨƚĞƌϭϱͲϯϬƐĞĐŽŶĚƐŽĨƉŽƐŝƚŝǀĞƉƌĞƐƐƵƌĞǀĞŶƚŝůĂƚŝŽŶĂŶĚ ŚĞĂƌƚƌĂƚĞŝƐŶŽƚŝŶĐƌĞĂƐŝŶŐ ǀĂŝůĂďůĞdƌĞĂƚŵĞŶƚKƉƚŝŽŶƐ x /sĂĐĐĞƐƐ x dƌĞĂƚƉĂƚŝĞŶƚĂƉƉƌŽƉƌŝĂƚĞůǇĂĐĐŽƌĚŝŶŐƚŽƉĂƚŝĞŶƚĐŽŶĚŝƚŝŽŶĨŽůůŽǁŝŶŐƚŚĞƉƌŽƉĞƌƉƌŽƚŽĐŽů WĞĂƌůƐ x ĞƚĞƌŵŝŶĞƉƵůƐĞƌĂƚĞďǇƉĂůƉĂƚŝŽŶĂƚƚŚĞďĂƐĞŽĨƚŚĞƵŵďŝůŝĐĂůĐŽƌĚŽƌĂƵƐĐƵůƚĂƚĞĂŶĂƉŝĐĂůƉƵůƐĞ͘ x /ĨƐƵĐƚŝŽŶŝƐƵƐĞĚ͕ƉƌĞƐƐƵƌĞƐŚŽƵůĚŶŽƚĞǆĐĞĞĚϭϬϬŵŵͬ,ŐĂŶĚĂƉƉůŝĐĂƚŝŽŶŽĨƐƵĐƚŝŽŶƐŚŽƵůĚůĂƐƚŶŽ ůŽŶŐĞƌƚŚĂŶϱƐĞĐŽŶĚƐ͘ĞĞƉƐƵĐƚŝŽŶŝŶŐĐĂŶĐĂƵƐĞůĂƌǇŶŐŽƐƉĂƐŵĂŶĚďƌĂĚǇĐĂƌĚŝĂ͘

Cypress Creek EMS System Policies and Treatment Guidelines

148 PEDIATRIC MEDICAL Revised 8/2016 Approved: Levon Vartanian, MD

WĞĚŝĂƚƌŝĐĂƌĚŝĂĐƌƌĞƐƚ ƐƐĞƐƐŵĞŶƚZĞƋƵŝƌĞŵĞŶƚƐ DĂǇWƌĞƐĞŶƚƐ ŽŶƐŝĚĞƌWŽƐƐŝďůĞĂƵƐĞƐ ƐƐĞƐƐŵĞŶƚΘ&ƵůůŚĞĂĚͲƚŽͲ hŶƌĞƐƉŽŶƐŝǀĞ͕ƉŽƐƐŝďůǇ ŝƌǁĂǇŽďƐƚƌƵĐƚŝŽŶ ĞǆĂŵ ƉƵůƐĞůĞƐƐͬĂƉŶĞŝĐĐŚŝůĚ͘ ZĞƐƉŝƌĂƚŽƌǇĂƌƌĞƐƚ WƵůƐĞ͕ƌĞƐƉŝƌĂƚŝŽŶƐ͕ ,ǇƉŽǆŝĂ ƚĞŵƉĞƌĂƚƵƌĞ ,ǇƉŽŐůǇĐĞŵŝĂ ƌŽƐĞůŽǁƚĂƉĞ ŽŶŐĞŶŝƚĂůĚĞĨĞĐƚ 'ŵŽŶŝƚŽƌŝŶŐ ůŽŽĚŐůƵĐŽƐĞ Overview DĂŶĂŐĞŵĞŶƚŽĨƚŚĞWĞĚŝĂƚƌŝĐĂƌĚŝĂĐƌƌĞƐƚ;ƉĂƚŝĞŶƚфϭϲǇĞĂƌƐŽůĚͿƐŚŽƵůĚĨŽůůŽǁƚŚĞƐĂŵĞŐĞŶĞƌĂůƉŝƚ ĐƌĞǁƐƚƌƵĐƚƵƌĞŽĨƚŚĞĚƵůƚĂƌĚŝĂĐƌƌĞƐƚ͕ǁŝƚŚĂĨĞǁŵŽĚŝĨŝĐĂƚŝŽŶƐ͘ ƐƐĞƐƐŵĞŶƚ &ŽůůŽǁƚŚĞĂƐƐĞƐƐŵĞŶƚŵŽĚĞůĂŶĚĚĞůĞŐĂƚĞŽƌƚƌĞĂƚůŝĨĞƚŚƌĞĂƚƐĂƐĨŽƵŶĚ͘

Airway—WŽƐŝƚŝŽŶĂŝƌǁĂǇĂŶĚŽƉĞŶǁŝƚŚŚĞĂĚͲƚŝůƚͬĐŚŝŶͲůŝĨƚ͘WůĂĐĞĂĚũƵŶĐƚƐas needed͘

Breathing—/ĨďƌĞĂƚŚŝŶŐŝƐĂďƐĞŶƚŽƌŐĂƐƉŝŶŐ͕ƉƌŽǀŝĚĞǀĞŶƚŝůĂƚŝŽŶƐĂƚĂƌĂƚĞŽĨϭϮʹϮϬďƌĞĂƚŚƐͬŵŝŶƵƚĞ ďĂƐĞĚŽŶĂŐĞ͘

Circulation—/ĨƉƵůƐĞŝƐŶŽƚĨĞůƚǁŝƚŚŝŶϭϬƐĞĐŽŶĚƐ͕ŽƌƉƵůƐĞŝƐчϲϬͬŵŝŶǁŝƚŚƐŝŐŶƐŽĨƉŽŽƌƉĞƌĨƵƐŝŽŶ͕ ŝŶŝƚŝĂƚĞĐŚĞƐƚĐŽŵƉƌĞƐƐŝŽŶƐ͘hƐĞĂϭϱ͗ϮƌĂƚŝŽŽĨĐŽŵƉƌĞƐƐŝŽŶƐ͗ǀĞŶƚŝůĂƚŝŽŶƐƵŶƚŝůĂŶĂĚǀĂŶĐĞĚĂŝƌǁĂǇŝƐ ƉůĂĐĞĚ͘

ReassessĞǀĞƌǇƚǁŽŵŝŶƵƚĞƐǁŝƚŚĂƉƵůƐĞĐŚĞĐŬ͘ WŝƚƌĞǁZŽůĞƐ Compressor (B/I/P)—ZĞƐƉŽŶƐŝďůĞĨŽƌŝŶŝƚŝĂƚŝŶŐŚŝŐŚƋƵĂůŝƚǇĐŚĞƐƚĐŽŵƉƌĞƐƐŝŽŶƐ͘

Airway (B/I/P)—ZĞƐƉŽŶƐŝďůĞĨŽƌǀĞŶƚŝůĂƚŝŶŐƉĂƚŝĞŶƚǁŝƚŚsDĂƚƚĂĐŚĞĚƚŽϭϱůƉŵKϮ͘ĨĨĞĐƚŝǀĞ ǀĞŶƚŝůĂƚŝŽŶŵĂǇƌĞƋƵŝƌĞƚǁŽƉĞƌƐŽŶŶĞůŝŶƚŚŝƐƌŽůĞ͘

Manager (P)—ZĞƐƉŽŶƐŝďůĞĨŽƌŝŵŵĞĚŝĂƚĞůǇĂƉƉůǇŝŶŐĐĂƌĚŝĂĐŵŽŶŝƚŽƌĚĞĨŝďƌŝůůĂƚŝŽŶƉĂĚƐ͕ĂŶĂůǇǌŝŶŐƚŚĞ ƌŚǇƚŚŵ͕ĂŶĚƚƌĞĂƚŝŶŐƚŚĞƉĂƚŝĞŶƚ͛ƐĐŽŶĚŝƚŝŽŶĂƐĂƉƉƌŽƉƌŝĂƚĞ͘ 'ĞŶĞƌĂůdƌĞĂƚŵĞŶƚƐ x /ĨĂƌƌĞƐƚŝƐwitnessedŽƌďǇƐƚĂŶĚĞƌͬĨŝƌƐƚƌĞƐƉŽŶĚĞƌWZǁĂƐĚŽŶĞƉƌŝŽƌƚŽĂƌƌŝǀĂů͕ĂŶĚs&ͬsdŝƐ ĚŝƐĐŽǀĞƌĞĚ͕ĚĞůŝǀĞƌŽŶĞďŝƉŚĂƐŝĐϮ:ͬŬŐĚĞĨŝďƌŝůůĂƚŝŽŶŝŵŵĞĚŝĂƚĞůǇ͘&ŽůůŽǁǁŝƚŚϮŵŝŶƵƚĞƐŽĨ ĐŽŵƉƌĞƐƐŝŽŶƐĂŶĚǀĞŶƚŝůĂƚŝŽŶƐĂƚĞŝƚŚĞƌĂϭϱ͗ϮƌĂƚŝŽ;ŶŽĂĚǀĂŶĐĞĚĂŝƌǁĂǇƉůĂĐĞĚͿŽƌĐŽŶƚŝŶƵŽƵƐ ĐŽŵƉƌĞƐƐŝŽŶƐǁŝƚŚϭϬͲϭϮǀĞŶƚŝůĂƚŝŽŶƐƉĞƌŵŝŶƵƚĞ;<ŝŶŐ>d^ͲŽƌdƚƵďĞƉůĂĐĞĚͿ͘

Cypress Creek EMS System Policies and Treatment Guidelines

149 PEDIATRIC MEDICAL Revised 8/2016 Approved: Levon Vartanian, MD

x /ĨĂƌƌĞƐƚŝƐunwitnessedĂŶĚŶŽWZǁĂƐĚŽŶĞƉƌŝŽƌƚŽĂƌƌŝǀĂů͕ƉĞƌĨŽƌŵϮŵŝŶƵƚĞƐŽĨĐŽŵƉƌĞƐƐŝŽŶƐ ĂŶĚǀĞŶƚŝůĂƚŝŽŶƐďĞĨŽƌĞĂŶĂůǇǌŝŶŐƌŚǇƚŚŵ͘ x ZĞƐĐƵĞƌƐƉĞƌĨŽƌŵŝŶŐĐŚĞƐƚĐŽŵƉƌĞƐƐŝŽŶƐƐŚŽƵůĚďĞƌŽƚĂƚĞĚĞǀĞƌǇϮŵŝŶƵƚĞƐ͘ x DĞĚŝĐĂƚŝŽŶĂŶĚĞůĞĐƚƌŝĐĂůƚŚĞƌĂƉŝĞƐƐŚŽƵůĚĨŽůůŽǁƚŚĞƌŚǇƚŚŵƐƉĞĐŝĨŝĐŐƵŝĚĞůŝŶĞƐŶĞǆƚŝŶƚŚŝƐƐĞĐƚŝŽŶ͘ x hƐĞƋƵĂŶƚŝƚĂƚŝǀĞĐĂƉŶŽŐƌĂƉŚǇƚŽŐƵŝĚĞƌĞƐƵƐĐŝƚĂƚŝŽŶĞĨĨŽƌƚƐ͘/ĨdKϮŝƐфϭϬŵŵ,Ő͕ŝŵƉƌŽǀĞWZ ƋƵĂůŝƚǇ͘ x dŚĞŽůůWůƵƐŝƐĂĐĐĞƉƚĂďůĞĨŽƌƵƐĞŝŶƉĞĚŝĂƚƌŝĐƉĂƚŝĞŶƚƐĨƌŽŵϭƚŽϴǇĞĂƌƐŽĨĂŐĞƵƐŝŶŐƚŚĞŽůů WůƵƐpedixpadz II x dŚĞWŚŝůŝƉƐ,ĞĂƌƚ^ƚĂƌƚ&ZǆŝƐĂĐĐĞƉƚĂďůĞĨŽƌƵƐĞŝŶƉĞĚŝĂƚƌŝĐƉĂƚŝĞŶƚƐƵŶĚĞƌϴǇĞĂƌƐŽůĚŽƌϱϱƉŽƵŶĚƐ ;ϮϱŬŐͿǁŝƚŚƚŚĞ/ŶĨĂŶƚͬŚŝůĚŬĞǇ͘ x dŚĞWŚŝůŝƉƐ,ĞĂƌƚ^ƚĂƌƚ&ZǆĂŶĚƚŚĞŽůůWůƵƐĂƌĞĂĐĐĞƉƚĂďůĞƐĨŽƌƵƐĞŝŶĂĚƵůƚƉĂƚŝĞŶƚƐ͘ x It is imperative that compressions be interrupted only when absolutely necessary and that any interruptions are kept as short as possible x Make every effort to keep the time from last compression to defibrillation as short as possible x /ĨĂƐŝŶŐůĞƌĞƐĐƵĞƌŝƐƵŶǁŝůůŝŶŐŽƌƵŶĂďůĞƚŽƉĞƌĨŽƌŵǀĞŶƚŝůĂƚŝŽŶƐ͕ƉĞƌĨŽƌŵŝŶŐĐŽŵƉƌĞƐƐŝŽŶƐŽŶůǇŝƐ ĂĐĐĞƉƚĂďůĞ͘ x &ĂŵŝůǇŵĞŵďĞƌƐĂƌĞĂůůŽǁĞĚƚŽďĞƉƌĞƐĞŶƚĚƵƌŝŶŐƚŚĞƌĞƐƵƐĐŝƚĂƚŝŽŶƵŶůĞƐƐƚŚĞŝƌƉƌĞƐĞŶĐĞŝŶƚĞƌĨĞƌĞƐ ǁŝƚŚƉĂƚŝĞŶƚĐĂƌĞ͘/ĨƉŽƐƐŝďůĞ͕ĂƐƐŝŐŶĂƌĞƐƉŽŶĚĞƌĂƐĂůŝĂŝƐŽŶǁŚŽŝƐĂǀĂŝůĂďůĞƚŽĞǆƉůĂŝŶƚƌĞĂƚŵĞŶƚƐ ĂŶĚĂŶƐǁĞƌƋƵĞƐƚŝŽŶƐ͘ WĞĂƌůƐ x WĞĚŝĂƚƌŝĐĐĂƌĚŝĂĐĂƌƌĞƐƚƐĂƌĞƌĂƌĞůǇĐĂƵƐĞĚďǇĐĂƌĚŝŽǀĂƐĐƵůĂƌĚŝƐĞĂƐĞĂŶĚĂƌĞŽĨƚĞŶƌĞůĂƚĞĚƚŽŚǇƉŽǆŝĂ ŽƌƌĞƐƉŝƌĂƚŽƌǇĨĂŝůƵƌĞ͘DĂŝŶƚĂŝŶŝŶŐĂƉĂƚĞŶƚĂŝƌǁĂǇĂŶĚƉƌŽǀŝĚŝŶŐĂĚĞƋƵĂƚĞǀĞŶƚŝůĂƚŝŽŶƐĂƌĞĐƌŝƚŝĐĂů͘ x sDǀĞŶƚŝůĂƚŝŽŶƐĂƌĞŵŽƐƚĞĨĨĞĐƚŝǀĞŝĨĚŽŶĞǁŝƚŚƚǁŽͲƉĞƌƐŽŶƚĞĐŚŶŝƋƵĞ͘ x ŝƌǁĂǇŵĂŶĂŐĞŵĞŶƚƐŚŽƵůĚďĞĚŽŶĞƵƐŝŶŐŵŽƐƚĞĨĨĞĐƚŝǀĞƚŽŽůƐŐŝǀĞŶƉĂƚŝĞŶƚƐŝǌĞĂŶĚĐŽŶĚŝƚŝŽŶ͘ ^ŵĂůůĞƌKing supraglottic airwaysĂŶĚEndotracheal IntubationĂƌĞĂǀĂŝůĂďůĞŽƉƚŝŽŶƐ͘

Cypress Creek EMS System Policies and Treatment Guidelines

150 PEDIATRIC MEDICAL Revised 8/2016 Approved: Levon Vartanian, MD

WĞĚŝĂƚƌŝĐƐǇƐƚŽůĞͬW ƐƐĞƐƐŵĞŶƚZĞƋƵŝƌĞŵĞŶƚƐ DĂǇWƌĞƐĞŶƚƐ ŽŶƐŝĚĞƌWŽƐƐŝďůĞĂƵƐĞƐ ƐƐĞƐƐŵĞŶƚΘĨƵůůŚĞĂĚͲƚŽͲ hŶƌĞƐƉŽŶƐŝǀĞ͕ƉŽƐƐŝďůǇ ŝƌǁĂǇŽďƐƚƌƵĐƚŝŽŶ ƚŽĞĞǆĂŵ ƉƵůƐĞůĞƐƐͬĂƉŶĞŝĐĐŚŝůĚ͘ ZĞƐƉŝƌĂƚŽƌǇĂƌƌĞƐƚ WƵůƐĞ͕ƌĞƐƉŝƌĂƚŝŽŶƐ͕ ,ǇƉŽǆŝĂ ƚĞŵƉĞƌĂƚƵƌĞ ,ǇƉŽŐůǇĐĞŵŝĂ ƌŽƐĞůŽǁƚĂƉĞ ŽŶŐĞŶŝƚĂůĚĞĨĞĐƚ '͕^ƉKϮ͕ĂŶĚdKϮ ŵŽŶŝƚŽƌŝŶŐ ůŽŽĚŐůƵĐŽƐĞ ZĞƋƵŝƌĞĚdƌĞĂƚŵĞŶƚƐ x (B)CPR ǁŝƚŚITD ;ŝĨƉĂƚŝĞŶƚŝƐхϭͲǇĞĂƌͲŽůĚͿ x ;BͿŝƌǁĂǇŵĂŶĂŐĞŵĞŶƚĂƉƉƌŽƉƌŝĂƚĞƚŽƉĂƚŝĞŶƚĐŽŶĚŝƚŝŽŶ͘ x (I)IV/IOĂĐĐĞƐƐ x (P) Epinephrine ϭ͗ϭϬ͕ϬϬϬ Ϭ͘ϬϭʹϬ͘ϬϯŵŐͬŬŐ/sͬ/KƋϯʹϱŵŝŶƵƚĞƐ͘ x /ĚĞŶƚŝĨǇƚƌĞĂƚĂďůĞĐĂƵƐĞƐ͘ ǀĂŝůĂďůĞdƌĞĂƚŵĞŶƚƐ x (P)Sodium Bicarbonate ϭŵƋͬŬŐ/sͬ/KĨŽƌĞǆƚĞŶĚĞĚĚŽǁŶƚŝŵĞŽƌĐĂƌĚŝĂĐĂƌƌĞƐƚ͘DĂǇďĞƌĞƉĞĂƚĞĚ ĂĨƚĞƌϭϬŵŝŶƵƚĞƐĂƚϬ͘ϱŵƋͬŬŐ͘ x hƐĞSodium Bicarbonate 4.2%ŝĨƉĂƚŝĞŶƚŝƐфϭǇĞĂƌŽůĚ͘

Cypress Creek EMS System Policies and Treatment Guidelines

151 PEDIATRIC MEDICAL Revised 8/2016 Approved: Levon Vartanian, MD

WĞĚŝĂƚƌŝĐsĞŶƚƌŝĐƵůĂƌ&ŝďƌŝůůĂƚŝŽŶͬWƵůƐĞůĞƐƐ sĞŶƚƌŝĐƵůĂƌdĂĐŚǇĐĂƌĚŝĂ ƐƐĞƐƐŵĞŶƚZĞƋƵŝƌĞŵĞŶƚƐ DĂǇWƌĞƐĞŶƚƐ ŽŶƐŝĚĞƌWŽƐƐŝďůĞĂƵƐĞƐ ƐƐĞƐƐŵĞŶƚΘĨƵůůŚĞĂĚͲƚŽͲ hŶƌĞƐƉŽŶƐŝǀĞ͕ƉŽƐƐŝďůǇ ŝƌǁĂǇŽďƐƚƌƵĐƚŝŽŶ ƚŽĞĞǆĂŵ ƉƵůƐĞůĞƐƐͬĂƉŶĞŝĐĐŚŝůĚ͘ ZĞƐƉŝƌĂƚŽƌǇĂƌƌĞƐƚ WƵůƐĞ͕ƌĞƐƉŝƌĂƚŝŽŶƐ͕ ,ǇƉŽǆŝĂ ƚĞŵƉĞƌĂƚƵƌĞ ,ǇƉŽŐůǇĐĞŵŝĂ ƌŽƐĞůŽǁƚĂƉĞ ŽŶŐĞŶŝƚĂůĚĞĨĞĐƚ '͕^ƉKϮ͕ĂŶĚdKϮ ŵŽŶŝƚŽƌŝŶŐ ůŽŽĚŐůƵĐŽƐĞ ZĞƋƵŝƌĞĚdƌĞĂƚŵĞŶƚƐ x (B)CPR ǁŝƚŚITD ;ŝĨƉĂƚŝĞŶƚŝƐхϭͲǇĞĂƌͲŽůĚͿ x ;BͿŝƌǁĂǇŵĂŶĂŐĞŵĞŶƚĂƉƉƌŽƉƌŝĂƚĞƚŽƉĂƚŝĞŶƚĐŽŶĚŝƚŝŽŶ͘ x (I)IV/IOĂĐĐĞƐƐ x (P) Epinephrine ϭ͗ϭϬ͕ϬϬϬ Ϭ͘ϬϭʹϬ͘ϬϯŵŐͬŬŐ/sͬ/KƋϯʹϱŵŝŶƵƚĞƐ͘ x (P) DefibrillationĂƚϮ:ͬŬŐĨŽƌĨŝƌƐƚĂƚƚĞŵƉƚĂŶĚϰ:ͬŬŐĨŽƌĞĂĐŚƐƵďƐĞƋƵĞŶƚĂƚƚĞŵƉƚ͘ x (P) AmiodaroneϱŵŐͬŬŐ;ƚŽŵĂǆŽĨϯϬϬŵŐͿ/sͬ/K͖ŵĂǇƌĞƉĞĂƚŽŶĐĞĂĨƚĞƌϱŵŝŶƵƚĞƐĂƚϱŵŐͬŬŐ;ŵĂǆ ƐĞĐŽŶĚĚŽƐĞŽĨϭϱϬŵŐͿ͘ŽŶŽƚĞǆĐĞĞĚϮϱŵŐͬŬŐŽƌϮ͘ϮŐŽĨŵŝŽĚĂƌŽŶĞŝŶϮϰŚŽƵƌƐ͘ x /ĚĞŶƚŝĨǇƚƌĞĂƚĂďůĞĐĂƵƐĞƐ͘ ǀĂŝůĂďůĞdƌĞĂƚŵĞŶƚKƉƚŝŽŶƐ x (P)Sodium Bicarbonate ϭŵƋͬŬŐ/sͬ/KĨŽƌĞǆƚĞŶĚĞĚĚŽǁŶƚŝŵĞŽƌĐĂƌĚŝĂĐĂƌƌĞƐƚ͘DĂǇďĞƌĞƉĞĂƚĞĚ ĂĨƚĞƌϭϬŵŝŶƵƚĞƐĂƚϬ͘ϱŵƋͬŬŐ͘ x hƐĞSodium Bicarbonate 4.2%ŝĨƉĂƚŝĞŶƚŝƐфϭǇĞĂƌŽůĚ͘ x (P)Magnesium SulfateϮϱʹϱϬŵŐͬŬŐ;ŵĂǆŝŵƵŵŽĨϮŐͿĨŽƌƌĞĨƌĂĐƚŽƌǇƐƚĂƚĞĂŶĚͬŽƌĨŽƌƚŽƌƐĂĚĞƐͲĚĞͲ ƉŽŝŶƚĞƐ͕ŵĂǇƌĞƉĞĂƚ͘ x (P) LidocaineϭŵŐͬŬŐ/sͬ/KĨŽƌƌĞĨĂĐƚŽƌǇƐƚĂƚĞ͘/ĨĐŽŶǀĞƌƐŝŽŶ͕ĨŽůůŽǁǁŝƚŚĂLidocaineŝŶĨƵƐŝŽŶĂƚϮϬʹ ϱϬŵĐŐͬŬŐͬŵŝŶ͘ WĞĂƌůƐ x AmiodaroneǁŚĞŶĂĚŵŝŶŝƐƚĞƌĞĚǁŝƚŚLidocaineŚĂƐďĞĞŶƐŚŽǁŶƚŽƉƌĞĐŝƉŝƚĂƚĞƚŽƌƐĂĚĞƐͲĚĞͲƉŽŝŶƚĞƐ ĂŶĚͬŽƌƉŽƐƚͲĂƌƌĞƐƚŚǇƉŽƚĞŶƐŝŽŶ͘,ŽǁĞǀĞƌ͕ŝĨƚŚĞƉĂƚŝĞŶƚƌĞŵĂŝŶƐƌĞĨƌĂĐƚŽƌǇƚŽAmiodarone͕ Lidocaine ƐŚŽƵůĚďĞĂĚŵŝŶŝƐƚĞƌĞĚ͘ x Magnesium SulfateŝƐƚŚĞĨŝƌƐƚͲůŝŶĞĂŶƚŝĂƌƌŚǇƚŚŵŝĐŵĞĚŝĐĂƚŝŽŶĨŽƌƐƵƐƉĞĐƚĞĚƚŽƌƐĂĚĞƐͲĚĞͲƉŽŝŶƚĞƐ͘ x /ĨƵŶĂďůĞƚŽĚĞƚĞƌŵŝŶĞŝĨƌŚǇƚŚŵŝƐVentricular FibrillationŽƌAsystole͕ƚƌĞĂƚĂƐAsystole͘

Cypress Creek EMS System Policies and Treatment Guidelines

152 PEDIATRIC MEDICAL Revised 8/2016 Approved: Levon Vartanian, MD

WĞĚŝĂƚƌŝĐWŽƐƚͲƌƌĞƐƚĂƌĞ ƐƐĞƐƐŵĞŶƚZĞƋƵŝƌĞŵĞŶƚƐ DĂǇWƌĞƐĞŶƚƐ ŽŶƐŝĚĞƌWŽƐƐŝďůĞĂƵƐĞƐ ƐƐĞƐƐŵĞŶƚΘĨƵůůŚĞĂĚͲƚŽͲ ĂƌĚŝĂĐĂƌƌĞƐƚŝŶĂƉĞĚŝĂƚƌŝĐ ŝƌǁĂǇŽďƐƚƌƵĐƚŝŽŶ ƚŽĞĞǆĂŵ ƉĂƚŝĞŶƚ ZĞƐƉŝƌĂƚŽƌǇĂƌƌĞƐƚ ƌŽƐĞůŽǁƚĂƉĞ WZǁŝƚŚƌĞƚƵƌŶŽĨƉƵůƐĞ ,ǇƉŽǆŝĂ '͕^ƉKϮ͕ĂŶĚdKϮ ;ZK^ͿƉƌŝŽƌƚŽĂƌƌŝǀĂů ,ǇƉŽŐůǇĐĞŵŝĂ ŵŽŶŝƚŽƌŝŶŐ WZǁŝƚŚƌĞƚƵƌŶŽĨƉƵůƐĞ ŽŶŐĞŶŝƚĂůĚĞĨĞĐƚ ůŽŽĚŐůƵĐŽƐĞ ;ZK^ͿĨŽƌD^ ZĞĐƚĂůƚĞŵƉĞƌĂƚƵƌĞ ϭϮͲůĞĂĚ' Post-Arrest Treatment Priorities ϭ͘ KƉƚŝŵŝǌĞsĞŶƚŝůĂƚŝŽŶΘKǆǇŐĞŶĂƚŝŽŶ x (B)DĂŝŶƚĂŝŶŽǆǇŐĞŶƐĂƚƵƌĂƚŝŽŶϵϰʹϵϵй͘ x (B)hƚŝůŝǌĞǁĂǀĞĨŽƌŵĐĂƉŶŽŐƌĂƉŚǇƚŽƚĂƌŐĞƚdKϮŽĨϯϬʹϰϬŵŵ,Ő x (B)ZĞŵŽǀĞ/dŝĨƐƚŝůůŝŶƉůĂĐĞ͘ x (B/I/P)ŽŶƐŝĚĞƌĂĚǀĂŶĐĞĚĂŝƌǁĂǇŵĂŶĂŐĞŵĞŶƚŝĨŶĞĞĚĞĚ͘ x (P)WƌŽǀŝĚĞƐĞĚĂƚŝŽŶĂƐŶĞĐĞƐƐĂƌǇ;ƌĞĨĞƌƚŽSedationƉƌŽƚŽĐŽůͿďƵƚƵƐĞĐĂƵƚŝŽŶŝŶĂĚŵŝŶŝƐƚĞƌŝŶŐ ƉĂƌĂůǇƚŝĐƐ͘ Ϯ͘ dƌĞĂƚ,ǇƉŽƚĞŶƐŝŽŶ x ,ǇƉŽƚĞŶƐŝŽŶŝƐĚĞĨŝŶĞĚĂƐSBP < (2 x age in years) + 65 mmHgŽƌMAP < (1.5 x age in years) + 40 mmHg.dŚĞƐĞŶƵŵďĞƌƐĂƌĞďĂƐĞĚŽŶĂǀĞƌĂŐĞŚĞŝŐŚƚĨŽƌĂŐĞĂŶĚŵĂǇŚĂǀĞĂƐŵƵĐŚĂƐϮŵŵ,Ő ǀĂƌŝĂƚŝŽŶ͘ x (P)Normal salineŽƌPlasmalyteĨůƵŝĚďŽůƵƐĞƐƵƉƚŽϮϬŵ>ͬŬŐ͘DĂǇƵƐĞĐŽůĚĨůƵŝĚŝĨŝŶĚƵĐŝŶŐ ŚǇƉŽƚŚĞƌŵŝĂ͘ x (P)DopamineϮʹϮϬŵĐŐͬŬŐͬŵŝŶ/sŝŶĨƵƐŝŽŶƚŝƚƌĂƚĞĚƚŽďůŽŽĚƉƌĞƐƐƵƌĞ͘ x (P)Epinephrine Ϭ͘ϬϱʹϬ͘ϭŵĐŐͬŬŐͬŵŝŶ/sŝŶĨƵƐŝŽŶƚŝƚƌĂƚĞĚƚŽďůŽŽĚƉƌĞƐƐƵƌĞ͘ x (P)Amiodarone ϭϱϬŵŐŽǀĞƌϭϬŵŝŶ/sŝŶĨƵƐŝŽŶŝĨsĞŶƚƌŝĐƵůĂƌ&ŝďƌŝůůĂƚŝŽŶŽƌsĞŶƚƌŝĐƵůĂƌdĂĐŚǇĐĂƌĚŝĂ ĚƵƌŝŶŐĂƌƌĞƐƚŵĂŶĂŐĞŵĞŶƚ͘ ϯ͘ KƚŚĞƌdƌĞĂƚŵĞŶƚWƌŝŽƌŝƚŝĞƐ x (P)ǀĂůƵĂƚĞϭϮͲůĞĂĚ'ĂŶĚĨŽůůŽǁCath Alert/STEMI ƉƌŽĐĞĚƵƌĞŝĨĂƉƉƌŽƉƌŝĂƚĞ͘ x (P)ǀĂůƵĂƚĞƌĞĐƚĂůƚĞŵƉĞƌĂƚƵƌĞĂŶĚĂŐŐƌĞƐƐŝǀĞůǇƚƌĞĂƚĨĞǀĞƌ;хϭϬϬ͘ϰǑ&Ϳ ϰ͘ dƌĂŶƐƉŽƌƚƚŽWĞĚŝĂƚƌŝĐ^ƉĞĐŝĂůƚǇ&ĂĐŝůŝƚǇ x (P)dƌĂŶƐƉŽƌƚǁŝƚŚĐŽŶƚŝŶƵŽƵƐŵŽŶŝƚŽƌŝŶŐĂŶĚĨƌĞƋƵĞŶƚƌĞĂƐƐĞƐƐŵĞŶƚƚŽĂƉĞĚŝĂƚƌŝĐƐƉĞĐŝĂůƚǇƚĞƌƚŝĂƌǇ ĐĂƌĞĨĂĐŝůŝƚǇ;Ğ͘Ő͘Texas Children’s HospitalͶdDŽƌMemorial Hermann Children’s—TMC)͘ Pearls x dŚĞƉƌŝŵĂƌǇŽďũĞĐƚŝǀĞƐŽĨƉŽƐƚͲƌĞƐƵƐĐŝƚĂƚŝŽŶĐĂƌĞĂƌĞƚŽƉƌĞƐĞƌǀĞŶĞƵƌŽůŽŐŝĐĨƵŶĐƚŝŽŶďǇŵĂŝŶƚĂŝŶŝŶŐ Ɛ͕ƚŽŝĚĞŶƚŝĨǇĂŶĚƚƌĞĂƚƚŚĞƉƌĞĚŝĐĂƚŝŶŐĐĂƵƐĞŽĨƚŚĞĐĂƌĚŝĂĐĂƌƌĞƐƚ͕ĂŶĚƚŽĚĞůŝǀĞƌƚŚĞƉĂƚŝĞŶƚƚŽ

Cypress Creek EMS System Policies and Treatment Guidelines

153 PEDIATRIC MEDICAL Revised 8/2016 Approved: Levon Vartanian, MD

ĂŶĂƉƉƌŽƉƌŝĂƚĞĨĂĐŝůŝƚǇŝŶĂƐƐƚĂďůĞĂƉŚǇƐŝŽůŽŐŝĐƐƚĂƚĞĂƐƉŽƐƐŝďůĞ͘ŽŶƚŝŶƵŽƵƐŵŽŶŝƚŽƌŝŶŐĂŶĚ ĨƌĞƋƵĞŶƚƌĞĂƐƐĞƐƐŵĞŶƚŽĨƚŚĞƉĂƚŝĞŶƚŝƐŶĞĐĞƐƐĂƌǇďĞĐĂƵƐĞŚĞŵŽĚǇŶĂŵŝĐƐƚĂƚƵƐŵĂǇǁŽƌƐĞŶ͘ x ǀĞŶƐŚŽƌƚͲƚĞƌŵŚǇƉŽƚĞŶƐŝŽŶĐĂŶƐŝŐŶŝĨŝĐĂŶƚůǇĂĨĨĞĐƚƉĂƚŝĞŶƚŽƵƚĐŽŵĞƐĂŶĚďƌĂŝŶƐƵƌǀŝǀĂů͘ǀŽŝĚĂŶĚ ŝŵŵĞĚŝĂƚĞůǇƚƌĞĂƚŚǇƉŽƚĞŶƐŝŽŶ;^WфϵϬ͕DWфϲϱͿ͘ĞƐƚƉƌĂĐƚŝĐĞŝƐƚŽŚĂŶŐĂǀĂƐŽƉƌĞƐƐŽƌǁŝƚŚĂ ƐĞĐŽŶĚůŝŶĞƚŽƌĞĚƵĐĞƚŝŵĞƚŽƚƌĞĂƚŚǇƉŽƚĞŶƐŝŽŶ͘ x WŽƐƚͲĂƌƌĞƐƚƉĂƚŝĞŶƚƐĂƌĞĂƚŚŝŐŚƌŝƐŬĨŽƌƐĞŝǌƵƌĞƐ͕ǁŚŝĐŚĂƌĞĚĞƚƌŝŵĞŶƚĂůƚŽďƌĂŝŶƐƵƌǀŝǀĂů͘dƌĞĂƚ ƐĞŝǌƵƌĞƐƵƐŝŶŐSeizureŐƵŝĚĞůŝŶĞƐ͘/ĨƉĂƚŝĞŶƚŝƐƉĂƌĂůǇǌĞĚǁŝƚŚŶĞƵƌŽŵƵƐĐƵůĂƌďůŽĐŬĂĚĞĚƌƵŐƐ͕ŝƚǁŽŶ͛ƚ ďĞƉŽƐƐŝďůĞƚŽŝĚĞŶƚŝĨǇƐĞŝǌƵƌĞƐŝŶƚŚĞĨŝĞůĚĂŶĚŽƵƚĐŽŵĞƐĐŽƵůĚďĞǁŽƌƐĞŶĞĚ͘ x KŶĐĞƌĞƐƵƐĐŝƚĂƚŝŽŶĚƌƵŐƐŚĂǀĞǁŽƌŶŽĨĨ͕ƉĂƚŝĞŶƚǁŝůůďĞƉƌŽŶĞƚŽŚǇƉŽƚĞŶƐŝŽŶ͘WƌĞƉĂƌŝŶŐǀĂƐŽƉƌĞƐƐŽƌ ĚƌƵŐƐĂŚĞĂĚŽĨƚŝŵĞŝƐƌĞĐŽŵŵĞŶĚĞĚƚŽŵŝŶŝŵŝǌĞƚŝŵĞƚŽƚƌĞĂƚŝŶŐŚǇƉŽƚĞŶƐŝŽŶ͘ x dŚĞ/ŶͲŚĂƌŐĞWĂƌĂŵĞĚŝĐĚĞĐŝĚĞƐŚŽǁƚŚĞƉĂƚŝĞŶƚ͛ƐĨĂŵŝůǇŵĞŵďĞƌƐǁŝůůƌŝĚĞƚŽƚŚĞŚŽƐƉŝƚĂů͘/Ĩ ƉŽƐƐŝďůĞ͕ĂƉĂƌĞŶƚŽƌŐƵĂƌĚŝĂŶƐŚŽƵůĚƌŝĚĞǁŝƚŚƚŚĞƉĂƚŝĞŶƚƚŽƚŚĞŚŽƐƉŝƚĂů͘

Cypress Creek EMS System Policies and Treatment Guidelines

154 PEDIATRIC MEDICAL Revised 8/2016 Approved: Levon Vartanian, MD

WĞĚŝĂƚƌŝĐdĂĐŚǇĐĂƌĚŝĂ ƐƐĞƐƐŵĞŶƚZĞƋƵŝƌĞŵĞŶƚƐ DĂǇWƌĞƐĞŶƚƐ ŽŶƐŝĚĞƌWŽƐƐŝďůĞĂƵƐĞƐ ƐƐĞƐƐŵĞŶƚΘĨƵůůŚĞĂĚͲƚŽͲ ŚĞƐƚƉĂŝŶ͕ƉĂůƉŝƚĂƚŝŽŶƐ͕ ,ǇƉŽǀŽůĞŵŝĂ͕ĚĞŚǇĚƌĂƚŝŽŶ͕ ƚŽĞĞǆĂŵ ĚŝǌǌŝŶĞƐƐ͕ŶĞĂƌͲƐǇŶĐŽƉĞ͕ ŚĞĂƚĞǆƉŽƐƵƌĞ͕ĨĞǀĞƌ͕ ƌŽƐĞůŽǁƚĂƉĞ ƐǇŶĐŽƉĞ͕ĚŝĨĨŝĐƵůƚǇďƌĞĂƚŚŝŶŐ͕ ŚǇƉŽǆŝĂ͕ĐŽŶŐĞŶŝƚĂůŚĞĂƌƚ 'Θ^ƉKϮŵŽŶŝƚŽƌŝŶŐ͘ ĚŝƐĞĂƐĞ͕ƚŽǆŝŶƐ͕ ϭϮͲůĞĂĚ' ƐƚŝŵƵůĂŶƚͬĚƌƵŐĂďƵƐĞ͘

ǀĂŝůĂďůĞdƌĞĂƚŵĞŶƚƐ x (B) Vagal maneuver͕ŵĂǇƌĞƉĞĂƚŽŶĐĞǁŝƚŚĚƵƌĂƚŝŽŶŶŽůŽŶŐĞƌƚŚĂŶϭϬƐĞĐŽŶĚƐ͘ x If rhythm is regular and QRS is narrow or monomorphic: (P) AdenosineϬ͘ϭŵŐͬŬŐZW//s;ŵĂǆŝŵƵŵϭƐƚĚŽƐĞŽĨϲŵŐͿ͖ŝĨŶŽĐŚĂŶŐĞ͕ƌĞƉĞĂƚǁŝƚŚϬ͘ϮŵŐͬŬŐ ZW//s;ŵĂǆŝŵƵŵŽĨϭϮŵŐϮŶĚĚŽƐĞͿ͘ x (P) Amiodarone ϱŵŐͬŬŐŝŶϭϬϬŵ>/sŝŶĨƵƐŝŽŶŽǀĞƌϭϬʹϮϬŵŝŶƵƚĞƐ;ŵĂǆŽĨϭϱϬŵŐͿ͕ŵĂǇƌĞƉĞĂƚϯǆ ƚŽĂŵĂǆŝŵƵŵĚŽƐĞŽĨϮϬŵŐͬŬŐŽƌϲϬϬŵŐ͘ x (P) Normal SalineŽƌPlasmalyteĨůƵŝĚĐŚĂůůĞŶŐĞƵƉƚŽϮϬŵůͬŬŐ͕ŝĨфϯϬǁĞĞŬƐŽůĚ͕ϭϬŵ>ŬŐ͘ x (P) Synchronized Cardioversion Ϭ͘ϱʹϭ:ͬŬŐ͕ŝĨŶŽƚĞĨĨĞĐƚŝǀĞƌĞƉĞĂƚĂƚϮ:ͬŬŐ͘ x (P) ŽŶƐŝĚĞƌsedationǁŝƚŚĐĂƌĚŝŽǀĞƌƐŝŽŶ͘ tŝĚĞŽŵƉůĞǆdĂĐŚǇĐĂƌĚŝĂ x (B) Vagal maneuver͕ŵĂǇƌĞƉĞĂƚŽŶĐĞǁŝƚŚĚƵƌĂƚŝŽŶŶŽůŽŶŐĞƌƚŚĂŶϭϬƐĞĐŽŶĚƐ͘ WĞĂƌůƐ x ZƵůĞŽƵƚŶŽŶͲĚǇƐƌŚǇƚŚŵŝĐƐŝŶƵƐƚĂĐŚǇĐĂƌĚŝĂďĞĨŽƌĞƚƌĞĂƚŝŶŐĨŽƌĚǇƐƌŚǇƚŚŵŝĂ͘^ŝŶƵƐƚĂĐŚǇĐĂƌĚŝĂŝƐ ĐŚĂƌĂĐƚĞƌŝǌĞĚďǇĂŶŝĚĞŶƚŝĨŝĂďůĞƵŶĚĞƌůǇŝŶŐĐĂƵƐĞ͕ƉƌĞƐĞŶƚͬŶŽƌŵĂůWǁĂǀĞƐ͕ǀĂƌŝĂďůĞZͲZǁŝƚŚĂ ĐŽŶƐƚĂŶƚWͲZ͕ĂŶĚƌĂƚĞŝƐƵƐƵĂůůǇфϭϴϬͬŵŝŶŝŶĐŚŝůĚƌĞŶĂŶĚфϮϮϬŝŶŝŶĨĂŶƚƐ͘ x KŶůǇƉĞƌĨŽƌŵƐǇŶĐŚƌŽŶŝǌĞĚĐĂƌĚŝŽǀĞƌƐŝŽŶŝŶƉĂƚŝĞŶƚƐǁŝƚŚĞǀŝĚĞŶĐĞŽĨŚǇƉŽƚĞŶƐŝŽŶ;^Wф;ϮǆĂŐĞŝŶ ǇĞĂƌƐͿнϲϱŵŵ,ŐͿ͕ĂĐƵƚĞůǇĂůƚĞƌĞĚŵĞŶƚĂůƐƚĂƚƵƐ͕ŽƌƐŝŐŶƐŽĨƐŚŽĐŬ;ƉĂůůŽƌ͕ĚĞůĂǇĞĚĐĂƉŝůůĂƌǇƌĞĨŝůů͕ ƚĂĐŚǇƉŶĞĂͿ͘ x tŚĞŶĂƚƚĞŵƉƚŝŶŐǀĂŐĂůƐƚŝŵƵůĂƚŝŽŶŽŶĂŶŝŶĨĂŶƚ͕ĂƉƉůǇŝĐĞƚŽƚŚĞĨĂĐĞǁŝƚŚŽƵƚĐĂƵƐŝŶŐĂŝƌǁĂǇ ĐŽŵƉƌŽŵŝƐĞͬŽĐĐůƵƐŝŽŶ͘

Cypress Creek EMS System Policies and Treatment Guidelines

155 PEDIATRIC MEDICAL Revised 8/2016 Approved: Levon Vartanian, MD

WĞĚŝĂƚƌŝĐƌĂĚǇĐĂƌĚŝĂ ƐƐĞƐƐŵĞŶƚZĞƋƵŝƌĞŵĞŶƚƐ DĂǇWƌĞƐĞŶƚƐ ŽŶƐŝĚĞƌWŽƐƐŝďůĞĂƵƐĞƐ ƐƐĞƐƐŵĞŶƚΘĨƵůůŚĞĂĚͲƚŽͲ ŚĞƐƚƉĂŝŶ͕ƉĂůƉŝƚĂƚŝŽŶƐ͕ ŝƌǁĂǇĐŽŵƉƌŽŵŝƐĞ͕ ƚŽĞĞǆĂŵ ĚŝǌǌŝŶĞƐƐ͕ŶĞĂƌͲƐǇŶĐŽƉĞ͕ ƌĞƐƉŝƌĂƚŽƌǇĚŝĨĨŝĐƵůƚǇ͕ĂƉŶĞĂ͕ ƌŽƐĞůŽǁƚĂƉĞ ƐǇŶĐŽƉĞ͕ĚŝĨĨŝĐƵůƚǇďƌĞĂƚŚŝŶŐ͕ ŚǇƉŽǆŝĂ͕ŚǇƉŽŐůǇĐĞŵŝĂ͕ 'Θ^ƉKϮŵŽŶŝƚŽƌŝŶŐ͘ ŝŶĨĞĐƚŝŽŶ͕ŚǇƉŽͲ ϭϮͲůĞĂĚ' ͬŚǇƉĞƌƚŚĞƌŵŝĂ͕ĐŽŶŐĞŶŝƚĂů ŚĞĂƌƚĚŝƐĞĂƐĞ͕ƉŽƐƚͲĐĂƌĚŝĂĐ ƐƵƌŐĞƌǇĐŽŵƉůŝĐĂƚŝŽŶ͘ ZĞƋƵŝƌĞĚdƌĞĂƚŵĞŶƚƐ x (B)WƌŽǀŝĚĞĂŐŐƌĞƐƐŝǀĞairway managementĂŶĚventilation/oxygenation͘WĞĚŝĂƚƌŝĐďƌĂĚǇĐĂƌĚŝĂŝƐ ĂůŵŽƐƚĞǆĐůƵƐŝǀĞůǇƚŚĞƌĞƐƵůƚŽĨĂŝƌǁĂǇŽƌƌĞƐƉŝƌĂƚŽƌǇĐŽŵƉƌŽŵŝƐĞĂŶĚƌĞƐƵůƚŝŶŐŚǇƉŽǆŝĂ͘ x (B) Start chest compressions if heart rate is < 60/minǁŝƚŚƉŽŽƌƉĞƌĨƵƐŝŽŶ;ƉĂůůŽƌ͕ĚĞůĂǇĞĚĐĂƉŝůůĂƌǇ ƌĞĨŝůů͕ĂĐƵƚĞůǇĂůƚĞƌĞĚŵĞŶƚĂůƐƚĂƚƵƐ͕ĞƚĐ͘ͿĚĞƐƉŝƚĞŽǆǇŐĞŶĂƚŝŽŶĂŶĚǀĞŶƚŝůĂƚŝŽŶ͘ ǀĂŝůĂďůĞdƌĞĂƚŵĞŶƚƐ /ĨďƌĂĚǇĐĂƌĚŝĂƉĞƌƐŝƐƚƐ͗ x (P) Epinephrine Ϭ͘ϬϭŵŐͬŬŐ/sͬ/KĞǀĞƌǇϯʹϱŵŝŶƵƚĞƐ x (P) Atropine SulfateϬ͘ϬϮŵŐͬŬŐ/sͬ/K;ŵŝŶĚŽƐĞϬ͘ϭŵŐ͕ŵĂǆƐŝŶŐůĞĚŽƐĞϬ͘ϱŵŐĨŽƌĐŚŝůĚͬϭŵŐĨŽƌ ĂĚŽůĞƐĐĞŶƚͿ͘DĂǇƌĞƉĞĂƚŽŶĐĞ͘ x (P) Transcutaneous pacing x (P) ŽŶƐŝĚĞƌSedationĂŶĚͬŽƌPain ManagementǁŝƚŚƉĂĐŝŶŐ͘ x /ĨƉƵůƐĞůĞƐƐĂƌƌĞƐƚĚĞǀĞůŽƉƐ͕ƚƌĞĂƚǁŝƚŚAsystole/PEA ŐƵŝĚĞůŝŶĞƐ͘

Cypress Creek EMS System Policies and Treatment Guidelines

156 PEDIATRIC MEDICAL Revised 8/2016 Approved: Levon Vartanian, MD

WĞĚŝĂƚƌŝĐZĞƐƉŝƌĂƚŽƌǇŝƐƚƌĞƐƐ ƐƐĞƐƐŵĞŶƚZĞƋƵŝƌĞŵĞŶƚƐ DĂǇWƌĞƐĞŶƚƐ ŽŶƐŝĚĞƌWŽƐƐŝďůĞĂƵƐĞƐ ƐƐĞƐƐŵĞŶƚΘĨƵůůŚĞĂĚͲƚŽͲ ŝĨĨŝĐƵůƚǇďƌĞĂƚŚŝŶŐ͕ŶĂƐĂů hƉƉĞƌĂŝƌǁĂǇŝŶĨĞĐƚŝŽŶ ƚŽĞĞǆĂŵ ĨůĂƌŝŶŐ͕ƌĞƚƌĂĐƚŝŽŶƐ͕ďĞůůǇ ƉŝŐůŽƚƚŝƚŝƐ ƌŽƐĞůŽǁƚĂƉĞ ďƌĞĂƚŚŝŶŐ͕ƐƚƌŝĚŽƌ͘ ƌŽŶĐŚŝŽůŝƚŝƐͬZ^s 'Θ^ƉKϮŵŽŶŝƚŽƌŝŶŐ͘ ƌŽƵƉ dĞŵƉĞƌĂƚƵƌĞ ƐƚŚŵĂ ŽŶŐĞŶŝƚĂůĂŝƌǁĂǇĚŝƐĞĂƐĞ ŽŶŐĞŶŝƚĂůĐĂƌĚŝĂĐĚŝƐĞĂƐĞ Available Treatments x (B)WƌŽǀŝĚĞairway managementĂŶĚventilation/oxygenation ĂƐĂƉƉƌŽƉƌŝĂƚĞ͘ x (P)Normal SalineŽƌPlasmalyteĨůƵŝĚďŽůƵƐ/sͬ/KĂƚϮϬŵ>ͬŬŐ;ϭϬŵ>ͬŬŐĨŽƌĂŐĞфϯϬĚĂǇƐͿĨŽƌ ƉĂƚŝĞŶƚƐǁŝƚŚƐŝŐŶƐŽĨƉŽŽƌƉĞƌĨƵƐŝŽŶ;ƉĂůůŽƌͬƉĂůĞƐŬŝŶ͕ĚĞĐƌĞĂƐĞĚĐĂƉŝůůĂƌǇƌĞĨŝůů͕ĂĐƵƚĞůǇĂůƚĞƌĞĚ ŵĞŶƚĂůƐƚĂƚƵƐͿ͘ ƉŝŐůŽƚƚŝƚŝƐ dǇƉŝĐĂůůǇŚĂƐĂŶĂĐƵƚĞŽŶƐĞƚĂŶĚƚŽǆŝĐĂƉƉĞĂƌĂŶĐĞ͕ŝƐĐŽŵŵŽŶŝŶĐŚŝůĚƌĞŶĂŐĞƐϮʹϴǇĞĂƌƐ͕ĂŶĚƌĂƌĞůǇŚĂƐ ĂĐŽƵŐŚ͘/ƚŝƐĐŚĂƌĂĐƚĞƌŝǌĞĚďǇĚƌŽŽůŝŶŐ͘ƉŝŐůŽƚƚŝƚŝƐĐĂŶƌĞƉƌĞƐĞŶƚĂƚƌƵĞĂŝƌǁĂǇĞŵĞƌŐĞŶĐǇĂŶĚĐĂůŵ͕ ƌĂƉŝĚƚƌĂŶƐƉŽƌƚƚŽĂƉĞĚŝĂƚƌŝĐĞŵĞƌŐĞŶĐǇƌŽŽŵƐŚŽƵůĚďĞĚŽŶĞǁŝƚŚĂŵŝŶŝŵĂůĂŵŽƵŶƚŽĨƐƚŝŵƵůĂƚŝŽŶƚŽ ƚŚĞƉĂƚŝĞŶƚ͘ĞƉƌĞƉĂƌĞĚƚŽƉƌŽǀŝĚĞBVM ventilationŝĨƌĞƐƉŝƌĂƚŽƌǇĂƌƌĞƐƚĚĞǀĞůŽƉƐ͘ ƌŽƵƉ dǇƉŝĐĂůůǇŚĂƐĂŐƌĂĚƵĂůŽŶƐĞƚ͕ŝƐĐŚĂƌĂĐƚĞƌŝǌĞĚďǇĂďĂƌŬŝŶŐĐŽƵŐŚĂŶĚŝƐĐŽŵŵŽŶŝŶĐŚŝůĚƌĞŶĂŐĞƐϲʹϯϲ ŵŽŶƚŚƐ͘

x (B) Humidified OxygenĂƉƉƌŽƉƌŝĂƚĞƚŽƉĂƚŝĞŶƚĐŽŶĚŝƚŝŽŶ x (P)Dexamethasone ϰŵŐĂŶĚEpinephrine 0.25 mgŶĞďƵůŝǌĞĚǁŝƚŚϮŵ>ŶŽƌŵĂůƐĂůŝŶĞ͘ ƌŽŶĐŚŝŽůŝƚŝƐͬZ^s dŚŝƐŝƐĂŶĂĐƵƚĞǀŝƌĂůŝŶĨĞĐƚŝŽŶŽĨƚŚĞůŽǁĞƌƌĞƐƉŝƌĂƚŽƌǇƐǇƐƚĞŵƚǇƉŝĐĂůůǇĂĨĨĞĐƚŝŶŐƉĂƚŝĞŶƚƐфϮǇĞĂƌƐ͘ dǇƉŝĐĂůůǇĐĂƵƐĞĚďǇZ^s͘WƌĞƐĞŶƚƐǁŝƚŚƌĞƐƉŝƌĂƚŽƌǇĚŝƐƚƌĞƐƐ͕ǁŚĞĞǌŝŶŐ͕ĐƌĂĐŬůĞƐ͕ĂŶĚĂǁŚĞĞǌǇŽƌŚĂĐŬŝŶŐ ĐŽƵŐŚ͘ ƐƚŚŵĂ tŚĞĞǌŝŶŐŝƐĐŽŵŵŽŶŝŶĐŚŝůĚƌĞŶĂŶĚŵĂǇŽƌŵĂǇŶŽƚŚĂǀĞĂĚŝĂŐŶŽƐŝƐŽĨĂƐƚŚŵĂ͘

x (B) Albuterol Ϯ͘ϱŵŐͬϯŵ>ƵŶŝƚĚŽƐĞŶĞďƵůŝǌĞĚ͘DĂǇďĞƌĞƉĞĂƚĞĚ͘ x (B) Ipratroprium ϱϬϬŵĐŐͬϮ͘ϱŵ>ƵŶŝƚĚŽƐĞŵŝǆĞĚǁŝƚŚAlbuterolƵŶŝƚĚŽƐĞŝĨǁŚĞĞǌŝŶŐŝƐƌĞĨƌĂĐƚŽƌǇ ƚŽAlbuterolĂůŽŶĞ

Cypress Creek EMS System Policies and Treatment Guidelines

157 PEDIATRIC MEDICAL Revised 8/2016 Approved: Levon Vartanian, MD

x DĂǇƐƚĂƌƚǁŝƚŚIpratroprium/AlbuterolĐŽŵďŝŶĂƚŝŽŶŝĨƉĂƚŝĞŶƚŚĂƐďĞĞŶƌĞĨƌĂĐƚŽƌǇƚŽ ŶĞďƵůŝǌĞĚͬŝŶŚĂůĞĚĂĚŵŝŶŝƐƚƌĂƚŝŽŶŽĨĂůďƵƚĞƌŽů;WƌŽŝƌ͕WƌŽǀĞŶƚŝů͕sĞŶƚŽůŝŶͿ͕ůĞǀĂůďƵƚĞƌŽů;yŽƉĞŶĞǆͿ͕ ŽƌƉŝƌďƵƚĞƌŽů;DĂǆŝƌͿƉƌŝŽƌƚŽĂƌƌŝǀĂů x (P) Methylprednisolone (Solu-Medrol)2 mg/kgƐůŽǁ/sͬ/KŽƌ/D

Cypress Creek EMS System Policies and Treatment Guidelines

158 PEDIATRIC MEDICAL Revised 7/2019 Approved: Levon Vartanian, MD

WĞĚŝĂƚƌŝĐŝĂďĞƚŝĐŵĞƌŐĞŶĐǇ ƐƐĞƐƐŵĞŶƚZĞƋƵŝƌĞŵĞŶƚƐ DĂǇWƌĞƐĞŶƚƐ ŽŶƐŝĚĞƌWŽƐƐŝďůĞĂƵƐĞƐ ƐƐĞƐƐŵĞŶƚΘĨƵůůŚĞĂĚͲƚŽͲ ůƚĞƌĞĚŵĞŶƚĂůƐƚĂƚƵƐ͕ ,ǇƉŽŐůǇĐĞŵŝĂ ƚŽĞĞǆĂŵ ĐŽŵďĂƚŝǀĞͬŝƌƌŝƚĂďůĞ͕ < ƌŽƐĞůŽǁƚĂƉĞ ĚŝĂƉŚŽƌĞƐŝƐ͕ƐĞŝǌƵƌĞƐ͕ ,,E^ 'Θ^ƉKϮŵŽŶŝƚŽƌŝŶŐ ĂďĚŽŵŝŶĂůƉĂŝŶ͕ ůĐŽŚŽůͬĚƌƵŐƵƐĞͬƚŽǆŝĐ '>ĂƐƐĞƐƐŵĞŶƚ ŶĂƵƐĞĂͬǀŽŵŝƚŝŶŐ͕ǁĞĂŬŶĞƐƐ͕ ŝŶŐĞƐƚŝŽŶ dĞŵƉĞƌĂƚƵƌĞ ĚĞŚǇĚƌĂƚŝŽŶ͕ĚĞĞƉͬƌĂƉŝĚ ^ĞŝǌƵƌĞ ďƌĞĂƚŚŝŶŐ͕ƐŚŽƌƚŶĞƐƐŽĨ s ďƌĞĂƚŚ ZĞƋƵŝƌĞĚdƌĞĂƚŵĞŶƚƐ x Airway management ĂƉƉƌŽƉƌŝĂƚĞ ƚŽƉĂƚŝĞŶƚĐŽŶĚŝƚŝŽŶ x VentilationĂŶĚoxygenation ĂƉƉƌŽƉƌŝĂƚĞƚŽƉĂƚŝĞŶƚĐŽŶĚŝƚŝŽŶ ǀĂŝůĂďůĞdƌĞĂƚŵĞŶƚƐ x (B) Oral GlucoseĨŽƌŚǇƉŽŐůǇĐĞŵŝĂŝĨƉĂƚŝĞŶƚŝƐĐŽŶƐĐŝŽƵƐĂŶĚŚĂƐďŽƚŚĂŶŝŶƚĂĐƚŐĂŐĂŶĚƐǁĂůůŽǁ ƌĞĨůĞǆ͘DĂǇďĞŐŝǀĞŶĂůŽŶŐǁŝƚŚŽƌĂŶŐĞũƵŝĐĞŽƌĂŶŽƚŚĞƌƐǁĞĞƚͬŐůƵĐŽƐĞƐŽůƵƚŝŽŶ͘ x (I) Vascular accessǁŝƚŚ/sŽƌ/K

/ĨƉĂƚŝĞŶƚŝƐŚǇƉŽŐůǇĐĞŵŝĐĂŶĚƐǇŵƉƚŽŵĂƚŝĐ͗ x (P) Dextrose 50% (D50)/sϬ͘ϱŐƌĂŵƐͬŬŐ x (P)Dextrose 25% (D25)/sϬ͘ϱŐƌĂŵƐͬŬŐ;ƉĂƚŝĞŶƚƐфϭǇͬŽͿ x (P)Dextrose 10% (D10)/sϮ͘ϱŵůͬŬŐ͕ŵĂǇƌĞƉĞĂƚŽŶĐĞŝĨŶĞĞĚĞĚ͘hƚŝůŝǌĞƵƌĞƚƌŽůĨŽƌĂĚŵŝŶŝƐƚƌĂƚŝŽŶ͘ x (P) Glucagon Ϭ͘ϯŵŐͬŬŐ/DŽŶůǇŝĨƵŶĂďůĞƚŽŽďƚĂŝŶ/sĂĐĐĞƐƐ͘ x (P) Normal SalineŽƌPlasmalyteĨůƵŝĚďŽůƵƐƵƉƚŽϮϬŵ>ͬŬŐ;ϭϬŵ>ͬŬŐŝĨĂŐĞфϯϬǁĞĞŬƐͿĨŽƌ ŚǇƉĞƌŐůǇĐĞŵŝĂŝĨŶŽƚĐŽŶƚƌĂŝŶĚŝĐĂƚĞĚ͘ WĞĂƌůƐ x WĞƌĨŽƌŵ'>ĂŶĂůǇƐŝƐďĞĨŽƌĞĂŶĚĂĨƚĞƌĂĚŵŝŶŝƐƚĞƌŝŶŐOral Glucose͕Dextrose͕ŽƌGlucagon. ,ǇƉŽŐůǇĐĞŵŝĂŝƐĚĞĨŝŶĞĚĂƐ'>фϲϬŵŐͬĚ>͖ŚǇƉĞƌŐůǇĐĞŵŝĂŝƐ'>хϮϬϬŵŐͬĚ>͘ x /ƚŝƐŝŵƉĞƌĂƚŝǀĞƚŽĂůůŽǁGlucagonĞŶŽƵŐŚƚŝŵĞƚŽŚĂǀĞĞĨĨĞĐƚŽŶƉĂƚŝĞŶƚ͘dŚŝƐŝƐƚǇƉŝĐĂůůǇϭϱʹϮϬ ŵŝŶƵƚĞƐĨŽůůŽǁŝŶŐ/DŝŶũĞĐƚŝŽŶ͘ x ŽŶƐŝĚĞƌƚŽƚĂůĐůŝŶŝĐĂůƉŝĐƚƵƌĞ͖ŝƚŵĂǇďĞƐĂĨĞƌƚŽĂůůŽǁGlucagonƚŚĞƚŝŵĞƚŽǁŽƌŬǀƐ͘ĞƐƚĂďůŝƐŚŝŶŐIO ĂŶĚĂĚŵŝŶŝƐƚĞƌŝŶŐDextrose͘,ŽǁĞǀĞƌ͕ĐŽŶƐŝĚĞƌIOĂŶĚDextroseĞĂƌůǇŝŶƉĂƚŝĞŶƚƐǁŚŽĂƌĞĐƌŝƚŝĐĂůůǇ ŝůůĂŶĚŚǇƉŽŐůǇĐĞŵŝĐ͘ x ŶǇƉĂƚŝĞŶƚĞǆƉĞƌŝĞŶĐŝŶŐĂĚŝĂďĞƚŝĐĞŵĞƌŐĞŶĐǇƐŚŽƵůĚďĞĞŶĐŽƵƌĂŐĞĚƚŽďĞƚƌĂŶƐƉŽƌƚĞĚƚŽĨŽƌ ĞǀĂůƵĂƚŝŽŶ͘dŚĞƌĞŝƐĂŶŝŶĐƌĞĂƐĞĚƌŝƐŬŽĨƌĞĐƵƌƌĞŶƚŚǇƉŽŐůǇĐĞŵŝĂŝŶƉĂƚŝĞŶƚƐƚĂŬŝŶŐŽƌĂůĚŝĂďĞƚŝĐ ŵĞĚŝĐĂƚŝŽŶƐŽƌůŽŶŐĂĐƚŝŶŐŝŶƐƵůŝŶ͘WĂƚŝĞŶƚƐǁŚŽƌĞĨƵƐĞƚƌĂŶƐƉŽƌƚĂŐĂŝŶƐƚŵĞĚŝĐĂůĂĚǀŝĐĞƐŚŽƵůĚďĞ ĞŶĐŽƵƌĂŐĞĚƚŽŝŵŵĞĚŝĂƚĞůǇĐŽŶƐƵŵĞĂŵĞĂůǁŝƚŚĐŽŵƉůĞǆĐĂƌďŽŚǇĚƌĂƚĞƐĂŶĚƉƌŽƚĞŝŶĂŶĚƚŽ ĐŽŶƚĂĐƚƚŚĞŝƌƉĞƌƐŽŶĂůƉŚǇƐŝĐŝĂŶŝŵŵĞĚŝĂƚĞůǇ͘

Cypress Creek EMS System Policies and Treatment Guidelines

159 PEDIATRIC MEDICAL Revised 8/2016 Approved: Levon Vartanian, MD

WĞĚŝĂƚƌŝĐ^ĞŝǌƵƌĞ ƐƐĞƐƐŵĞŶƚZĞƋƵŝƌĞŵĞŶƚƐ DĂǇWƌĞƐĞŶƚƐ ŽŶƐŝĚĞƌWŽƐƐŝďůĞĂƵƐĞƐ ƐƐĞƐƐŵĞŶƚΘĨƵůůŚĞĂĚͲƚŽͲ ůƚĞƌĞĚŵĞŶƚĂůƐƚĂƚƵƐ͕ &ĞǀĞƌ ƚŽĞĞǆĂŵ ĐŽŵďĂƚŝǀĞͬŝƌƌŝƚĂďůĞ͕ ,ĞĂƚĞǆƉŽƐƵƌĞ

ƌŽƐĞůŽǁƚĂƉĞ ĚŝĂƉŚŽƌĞƐŝƐ͕ƐĞŝǌƵƌĞƐ͕ E^ͬ,ĞĂĚƚƌĂƵŵĂͬŝŶĨĞĐƚŝŽŶƐ ĂďĚŽŵŝŶĂůƉĂŝŶ͕ 'Θ^ƉKϮŵŽŶŝƚŽƌŝŶŐ͘ DĞĚŝĐĂƚŝŽŶŶŽŶͲĐŽŵƉůŝĂŶĐĞ ŶĂƵƐĞĂͬǀŽŵŝƚŝŶŐ͕ǁĞĂŬŶĞƐƐ͕ '>ƐƐĞƐƐŵĞŶƚ ĚĞŚǇĚƌĂƚŝŽŶ͕ĚĞĞƉͬƌĂƉŝĚ DĞƚĂďŽůŝĐ͕ŚĞƉĂƚŝĐ͕ŽƌƌĞŶĂů ZĞĐƚĂůdĞŵƉĞƌĂƚƵƌĞ ďƌĞĂƚŚŝŶŐ͕ƐŚŽƌƚŶĞƐƐŽĨ ĨĂŝůƵƌĞ ďƌĞĂƚŚ ƌƵŐƐͬƚŽǆŝŶƐ ,ǇƉŽǆŝĂ ,ǇƉŽŐůǇĐĞŵŝĂ ůĞĐƚƌŽůǇƚĞĚŝƐƚƵƌďĂŶĐĞƐ ZĞƋƵŝƌĞĚdƌĞĂƚŵĞŶƚƐ x Airway management ĂƉƉƌŽƉƌŝĂƚĞ ƚŽƉĂƚŝĞŶƚĐŽŶĚŝƚŝŽŶ͘ x VentilationĂŶĚoxygenation ĂƉƉƌŽƉƌŝĂƚĞƚŽƉĂƚŝĞŶƚĐŽŶĚŝƚŝŽŶ͘ x (I) Vascular accessǁŝƚŚ/sŽƌ/K͕ŝĨŝŶĚŝĐĂƚĞĚ͘ ǀĂŝůĂďůĞdƌĞĂƚŵĞŶƚƐ x (B) Acetaminophen ϭϱŵŐͬŬŐWKŝĨƉĂƚŝĞŶƚŝƐĂǁĂŬĞĂŶĚƌĞƐƉŽŶƐŝǀĞ͘ x (B) IbuprofenϭϬŵŐͬŬŐWKŝĨĐŚŝůĚŝƐĂǁĂŬĞĂŶĚƌĞƐƉŽŶƐŝǀĞĂŶĚхϲŵŽŶƚŚƐ͘ x (B) Active coolingŝĨƉĂƚŝĞŶƚŝƐĨĞďƌŝůĞ;ƚĞŵƉĞƌĂƚƵƌĞхϭϬϬ͘ϰǑ&Ϳ͘ x (P) Diazepam Ϭ͘ϮϱŵŐͬŬŐƐůŽǁ/sͬ/KĨŽƌƐƚĂƚƵƐĞƉŝůĞƉƚŝĐƵƐ͘ZĞƉĞĂƚĂƐŶĞĞĚĞĚ͘ x (P) Midazolam Ϭ͘ϬϱʹϬ͘ϭŵŐͬŬŐ/sͬ/Dͬ/Eͬ/K͘ZĞƉĞĂƚĞǀĞƌǇϱŵŝŶƵƚĞƐĂƐŶĞĞĚĞĚ͘hƐĞMidazolamŝĨ ƐĞŝǌƵƌĞƐĂƌĞƌĞĨƌĂĐƚŽƌǇƚŽŝĂǌĞƉĂŵ͕ŝĨŝĂǌĞƉĂŵŝƐƵŶĂǀĂŝůĂďůĞ͕ŽƌŝĨǀĂƐĐƵůĂƌĂĐĐĞƐƐĐĂŶŶŽƚďĞ ĞƐƚĂďůŝƐŚĞĚ͘ WĞĂƌůƐ x /ŶƉĂƚŝĞŶƚƐфϮǇĞĂƌƐ͕ƐĞŝǌƵƌĞƐĂƌĞŵŽƐƚĐŽŵŵŽŶůǇĐĂƵƐĞĚďǇĨĞǀĞƌ͕ďŝƌƚŚͬĚĞǀĞůŽƉŵĞŶƚĂůĚĞĨĞĐƚƐ͕Žƌ ŵĞƚĂďŽůŝĐĚŝƐŽƌĚĞƌƐ͘ x /ŶƉĂƚŝĞŶƚƐϮʹϭϰǇĞĂƌƐ͕ƐĞŝǌƵƌĞƐĂƌĞŵŽƐƚĐŽŵŵŽŶůǇĐĂƵƐĞĚďǇĂƐĞŝǌƵƌĞĚŝƐŽƌĚĞƌ͘ x ^ĞŝǌƵƌĞƐŝŶƉĞĚŝĂƚƌŝĐƉĂƚŝĞŶƚƐƚǇƉŝĐĂůůǇĚŽŶŽƚŶĞĞĚƚŽďĞĐŽŶƚƌŽůůĞĚǁŝƚŚĂďĞŶǌŽĚŝĂǌĞƉŝŶĞĞǆĐĞƉƚĨŽƌ ƐƚĂƚƵƐĞƉŝůĞƉƚŝĐƵƐ͗dŽŶŝĐͲĐůŽŶŝĐƐĞŝǌƵƌĞĂĐƚŝǀŝƚǇůĂƐƚŝŶŐхϱʹϭϬŵŝŶƵƚĞƐŽƌ侔ϮƐĞŝǌƵƌĞƐǁŝƚŚŽƵƚ ƌĞŐĂŝŶŝŶŐĐŽŶƐĐŝŽƵƐŶĞƐƐ͘ x ŽŶŽƚĂĚŵŝŶŝƐƚĞƌIbuprofenŝĨŝƚŚĂƐďĞĞŶĂĚŵŝŶŝƐƚĞƌĞĚǁŝƚŚŝŶƉĂƐƚϲŚŽƵƌƐ͘/ďƵƉƌŽĨĞŶƐŚŽƵůĚďĞ ĂĚŵŝŶŝƐƚĞƌĞĚĞǀĞƌǇϲʹϴŚŽƵƌƐ͘ x ŽŶŽƚĂĚŵŝŶŝƐƚĞƌAcetaminophenŝĨŝƚŚĂƐďĞĞŶĂĚŵŝŶŝƐƚĞƌĞĚǁŝƚŚŝŶƉĂƐƚϰŚŽƵƌƐ͘ĐĞƚĂŵŝŶŽƉŚĞŶ ƐŚŽƵůĚďĞĂĚŵŝŶŝƐƚĞƌĞĚĞǀĞƌǇϰʹϲŚŽƵƌƐ͘ x Do NOT give anything by mouth to a postictal patient. x DĂŬĞĞǀĞƌǇĞĨĨŽƌƚƚŽƚƌĂŶƐƉŽƌƚƉĂƚŝĞŶƚƚŽĂƉĞĚŝĂƚƌŝĐĞŵĞƌŐĞŶĐǇƌŽŽŵĨŽƌĨƵƌƚŚĞƌĞǀĂůƵĂƚŝŽŶ͘

Cypress Creek EMS System Policies and Treatment Guidelines

160 PEDIATRIC MEDICAL Revised 7/2019 Approved: Levon Vartanian, MD

WĞĚŝĂƚƌŝĐKǀĞƌĚŽƐĞ ƐƐĞƐƐŵĞŶƚZĞƋƵŝƌĞŵĞŶƚƐ DĂǇWƌĞƐĞŶƚƐ ŽŶƐŝĚĞƌWŽƐƐŝďůĞĂƵƐĞƐ ƐƐĞƐƐŵĞŶƚΘĨƵůůŚĞĂĚͲƚŽͲƚŽĞ ůƚĞƌĞĚŵĞŶƚĂůƐƚĂƚƵƐ͕ dƌŝĐǇĐůŝĐŶƚŝĚĞƉƌĞƐƐĂŶƚƐ;dƐͿ ĞǆĂŵ ĐŽŵďĂƚŝǀĞͬŝƌƌŝƚĂďůĞ͕ ĐĞƚĂŵŝŶŽƉŚĞŶ ƌŽƐĞůŽǁƚĂƉĞ ĚŝĂƉŚŽƌĞƐŝƐ͕ƐĞŝǌƵƌĞƐ͕ ƐƉŝƌŝŶ 'Θ^ƉKϮŵŽŶŝƚŽƌŝŶŐ ĂďĚŽŵŝŶĂůƉĂŝŶ͕ ĞƉƌĞƐƐĂŶƚƐ ϭϮͲůĞĂĚ' ŶĂƵƐĞĂͬǀŽŵŝƚŝŶŐ͕ǁĞĂŬŶĞƐƐ͕ ^ƚŝŵƵůĂŶƚƐ '>ĂƐƐĞƐƐŵĞŶƚ ĚĞŚǇĚƌĂƚŝŽŶ͕ĚĞĞƉͬƌĂƉŝĚ ŶƚŝĐŚŽůŝŶĞƌŐŝĐ dĞŵƉĞƌĂƚƵƌĞ ďƌĞĂƚŚŝŶŐ͕ƐŚŽƌƚŶĞƐƐŽĨďƌĞĂƚŚ ĂƌĚŝĂĐDĞĚŝĐĂƚŝŽŶƐ ^ŽůǀĞŶƚƐ͕ĂůĐŽŚŽůƐ͕ĐůĞĂŶŝŶŐ ĂŐĞŶƚƐ /ŶƐĞĐƚŝĐŝĚĞƐ;ŽƌŐĂŶŽƉŚŽƐƉŚĂƚĞƐͿ ,ǇƉŽͬŚǇƉĞƌŐůǇĐĞŵŝĂ ůĞĐƚƌŽůǇƚĞĂďŶŽƌŵĂůŝƚŝĞƐ ,ǇƉŽͬŚǇƉĞƌƚŚĞƌŵŝĂ s Required Treatments x Airway management ĂƉƉƌŽƉƌŝĂƚĞ ƚŽƉĂƚŝĞŶƚĐŽŶĚŝƚŝŽŶ x VentilationĂŶĚoxygenation ĂƉƉƌŽƉƌŝĂƚĞƚŽƉĂƚŝĞŶƚĐŽŶĚŝƚŝŽŶ x (I) Vascular accessǁŝƚŚ/sŽƌ/K͕ŝĨŝŶĚŝĐĂƚĞĚ Available Treatments x Contact Poison Control ϭ;ϴϬϬͿϮϮϮͲϭϮϮϮĨŽƌƐƉĞĐŝĨŝĐĂĚǀŝĐĞĂďŽƵƚƚŚĞƐƵďƐƚĂŶĐĞ;ƐͿŝŶǀŽůǀĞĚŝŶƚŚĞ ĞǀĞŶƚŽĨƚŽǆŝĐĞǆƉŽƐƵƌĞŽƌŝŶŐĞƐƚŝŽŶ͘ Overview of Medication Dosages for Pediatric Overdoses Toxin/Overdose Medication Pediatric Dose KƉŝĂƚĞ EĂůŽǆŽŶĞ Ϭ͘ϭŵŐͬŬŐ/sͬ/Dͬ/E ŽĐĂŝŶĞ ŝĂǌĞƉĂŵ Ϭ͘ϮϱŵŐͬŬŐ/s EŽƌŵĂů^ĂůŝŶĞ ϮϬŵ>ͬŬŐ;ϭϬŵ>ͬŬŐŝĨĂŐĞфϯϬǁĞĞŬƐͿ WŚĞŶŽƚŚŝĂǌŝŶĞͬǇƐƚŽŶŝĐZĞĂĐƚŝŽŶ ŝƉŚĞŶŚǇĚƌĂŵŝŶĞ ϭʹϮŵŐͬŬŐ/sŽƌĚĞĞƉ/D;ŵĂǆĚŽƐĞϱϬŵŐͿ dƌŝĐǇĐůŝĐŶƚŝĚĞƉƌĞƐƐĂŶƚ ^ŽĚŝƵŵ ϭʹϮŵƋͬŬŐƐůŽǁ/s ŝĐĂƌďŽŶĂƚĞ ϱϬŵƋŝŶϭϬϬϬŵ>EĂ>ŝŶĨƵƐŝŽŶ ƉŝŶĞƉŚƌŝŶĞ Ϭ͘ϭʹϬ͘ϮŵĐŐͬŬŐͬŵŝŶ ĞƚĂůŽĐŬĞƌ 'ůƵĐĂŐŽŶ Ϭ͘ϯŵŐͬŬŐ/s;ŵĂǆĚŽƐĞϮŵŐͿ ĞǆƚƌŽƐĞϱϬй Ϭ͘ϱŐͬŬŐ/s;ƵƐĞϮϱŝĨĂŐĞфϭǇĞĂƌͿ ĞǆƚƌŽƐĞϭϬй Ϯ͘ϱŵůͬŬŐ/s ƉŝŶĞƉŚƌŝŶĞ Ϭ͘ϭʹϬ͘ϮŵĐŐͬŬŐͬŵŝŶ ĂůĐŝƵŵŚĂŶŶĞůůŽĐŬĞƌ ĂůĐŝƵŵŚůŽƌŝĚĞ ϮϬŵŐͬŬŐ ƉŝŶĞƉŚƌŝŶĞ Ϭ͘ϭʹϬ͘ϮŵĐŐͬŬŐͬŵŝŶ *See below for specific indications for above medications.

Cypress Creek EMS System Policies and Treatment Guidelines

161 PEDIATRIC MEDICAL Revised 7/2019 Approved: Levon Vartanian, MD

Opiate Overdose x (P) NaloxoneϬ͘ϭŵŐͬŬŐ^>Kt/sͬ/Dͬ/EĂƐŶĞĞĚĞĚǁŝƚŚŶĂƌĐŽƚŝĐŽǀĞƌĚŽƐĞŝĨƉĂƚŝĞŶƚŝƐĞǆƉĞƌŝĞŶĐŝŶŐ ƌĞƐƉŝƌĂƚŽƌǇĚĞƉƌĞƐƐŝŽŶ͕ƚŝƚƌĂƚĞĚƚŽĂĐŚŝĞǀĞĂĚĞƋƵĂƚĞǀĞŶƚŝůĂƚŝŽŶĂŶĚŽǆǇŐĞŶĂƚŝŽŶ͘ Cocaine Overdose x (P) Diazepam Ϭ͘ϮϱŵŐͬŬŐ/s;ŽǀĞƌϮͲϱŵŝŶͿĂƐŶĞĞĚĞĚĨŽƌĐŽŶĨŝƌŵĞĚĐŽĐĂŝŶĞŽǀĞƌĚŽƐĞǁŝƚŚĂŶǆŝĞƚǇ͕ ƚƌĞŵŽƌƐ͕ƌĞƐƚůĞƐƐŶĞƐƐĂŶĚƚĂĐŚǇĐĂƌĚŝĂ͘ x (P) ŽŶƐŝĚĞƌ Normal SalineŝŶĨƵƐŝŽŶƵƉƚŽϮϬŵůͬŬŐ;ϭϬŵ>ͬŬŐŝĨĂŐĞфϯϬǁĞĞŬƐͿŝŶƚŚĞƐǇŵƉƚŽŵĂƚŝĐ ƉĂƚŝĞŶƚŽŶůǇ͘ x ƐƐŽĐŝĂƚĞĚĐŚĞƐƚƉĂŝŶƐŚŽƵůĚďĞƚƌĞĂƚĞĚƵƐŝŶŐƚŚĞĐƵƚĞŽƌŽŶĂƌǇ^ǇŶĚƌŽŵĞƉƌŽƚŽĐŽů͘ x ŽŶŽƚƵƚŝůŝǌĞďĞƚĂďůŽĐŬĞƌƐŝŶƚƌĞĂƚŝŶŐĐŽĐĂŝŶĞͲƌĞůĂƚĞĚĐŚĞƐƚƉĂŝŶŽƌŚǇƉĞƌƚĞŶƐŝŽŶ͘ Phenothiazine Overdose / Dystonic Reaction x (P) DiphenhydramineϭʹϮŵŐͬŬŐ/sŽƌĚĞĞƉ/D;ŵĂǆĚŽƐĞϱϬŵŐ)ĨŽƌƚŚĞƚƌĞĂƚŵĞŶƚŽĨĚǇƐƚŽŶŝĂ ĂƐƐŽĐŝĂƚĞĚǁŝƚŚƉŚĞŶŽƚŚŝĂǌŝŶĞŝŶŐĞƐƚŝŽŶ Tricyclic Antidepressant Overdose x (P) Sodium BicarbonateϭͲϮŵƋͬŬŐ^>Kt/sǁŝƚŚĐŽŶĨŝƌŵĞĚƚƌŝĐǇĐůŝĐŽǀĞƌĚŽƐĞǁŝƚŚĐŽƌƌĞůĂƚŝŶŐ ŚǇƉĞƌĐĂƉŶŝĂ͖ŝŶƚƵďĂƚŝŽŶǁŝƚŚŚǇƉĞƌǀĞŶƚŝůĂƚŝŽŶƐŚŽƵůĚďĞĐŽŶƐŝĚĞƌĞĚ͘ x (P) Sodium Bicarbonate ŝŶĨƵƐŝŽŶϱϬŵƋŝŶϭϬϬϬŵůEĂůǁŝƚŚĐŽŶĨŝƌŵĞĚƚƌŝĐǇĐůŝĐŽǀĞƌĚŽƐĞĂŶĚYZ^ хϬ͘ϭϮƐĞĐŽŶĚƐ͘ x (P) Epinephrine /ŶĨƵƐŝŽŶĂƚϬ͘ϭʹϬ͘ϮŵĐŐͬŬŐͬŵŝŶƚŽŵĂŝŶƚĂŝŶďůŽŽĚƉƌĞƐƐƵƌĞǁŝƚŚĐŽŶĨŝƌŵĞĚƚƌŝĐǇĐůŝĐ ŽǀĞƌĚŽƐĞ͘ Beta Blocker and Calcium Channel Blocker Overdose x (P) ŽŶƐŝĚĞƌExternal PacingĞĂƌůǇĨŽƌƐĞǀĞƌĞĐĂƐĞƐ͘ x (P) Epinephrine /ŶĨƵƐŝŽŶĂƚϬ͘ϭʹϬ͘ϮŵĐŐͬŬŐͬŵŝŶƚŽŵĂŝŶƚĂŝŶďůŽŽĚƉƌĞƐƐƵƌĞǁŝƚŚĐŽŶĨŝƌŵĞĚďĞƚĂ ďůŽĐŬĞƌŽƌĐĂůĐŝƵŵĐŚĂŶŶĞůďůŽĐŬĞƌŽǀĞƌĚŽƐĞ͘ x (P) Glucagon Ϭ͘ϯŵŐͬŬŐ /s;ŵĂǆĚŽƐĞϮŵŐͿƌĞƉĞĂƚĞĚĂƐŶĞĞĚĞĚĨŽƌƐǇŵƉƚŽŵĂƚŝĐďĞƚĂďůŽĐŬĞƌ ŽǀĞƌĚŽƐĞǁŝƚŚďƌĂĚǇĐĂƌĚŝĂĂŶĚͬŽƌŚǇƉŽƚĞŶƐŝŽŶ͘ x (P) Calcium ChlorideϮϬŵŐͬŬŐƐůŽǁ/sĨŽƌĐŽŶĨŝƌŵĞĚĐĂůĐŝƵŵĐŚĂŶŶĞůďůŽĐŬĞƌŽǀĞƌĚŽƐĞ͘ x (P) Dextrose 50%Ϭ͘ϱŐͬŬŐ;ϭʹϮŵ>ͬŬŐͿ/sĨŽƌŚǇƉŽŐůǇĐĞŵŝĂƌĞůĂƚĞĚƚŽďĞƚĂďůŽĐŬĞƌŽǀĞƌĚŽƐĞ͘ hƐĞĞǆƚƌŽƐĞϮϱй;ϮϱͿĨŽƌƉĂƚŝĞŶƚƐфϭǇͬŽ͘ŽƐĞŝƐϬ͘ϱŐͬŬŐ;Ϯʹϰŵ>ͬŬŐͿ͘ x (P) Dextrose 10%;ϭϬͿϮ͘ϱŵůͬŬŐĨŽƌŚǇƉŽŐůǇĐĞŵŝĂƌĞůĂƚĞĚƚŽďĞƚĂďůŽĐŬĞƌŽǀĞƌĚŽƐĞ͖ŵĂǇƌĞƉĞĂƚ ŽŶĐĞŝĨŶĞĞĚĞĚ͘hƚŝůŝǌĞƵƌĞƚƌŽůĨŽƌĂĚŵŝŶŝƐƚƌĂƚŝŽŶ͘ Organophosphate Poisoning x (P) AtropineϮͲϱŵŐ/sĨŽƌŽƌŐĂŶŽƉŚŽƐƉŚĂƚĞƉŽŝƐŽŶŝŶŐƉƌŶƵŶƚŝůŚĞĂƌƚƌĂƚĞŝƐŐƌĞĂƚĞƌƚŚĂŶϭϬϬƉĞƌ ŵŝŶƵƚĞĂŶĚůƵŶŐƐŽƵŶĚƐĂƌĞĐůĞĂƌ͘ x (P) Consider CPAP ŝĨŶŽƚĐŽŶƚƌĂŝŶĚŝĐĂƚĞĚĨŽƌƉƵůŵŽŶĂƌǇĞĚĞŵĂ

Cypress Creek EMS System Policies and Treatment Guidelines

162 PEDIATRIC MEDICAL Revised 7/2019 Approved: Levon Vartanian, MD

Pearls x KƉŝĂƚĞŽǀĞƌĚŽƐĞƐƉƌĞƐĞŶƚǁŝƚŚĚĞĐƌĞĂƐĞĚ>K͕ŚǇƉŽǀĞŶƚŝůĂƚŝŽŶ͕ŚǇƉŽǆŝĂ͕ĂŶĚĐŽŶƐƚƌŝĐƚĞĚƉƵƉŝůƐ͘ x ŽĐĂŝŶĞŝƐĂƉŽƚĞŶƚĂĚƌĞŶĞƌŐŝĐƐƚŝŵƵůĂŶƚĂŶĚĐĂŶĐĂƵƐĞƚĂĐŚǇĂƌƌŚǇƚŚŵŝĂƐ͕ŚǇƉĞƌƚĞŶƐŝŽŶ͕ĂŐŝƚĂƚŝŽŶ͕ ĂŶĚŵĞŶƚĂůĐŚĂŶŐĞƐ͘/ƚĐĂŶĂůƐŽŝŶĚƵĐĞĂĐƵƚĞĐŽƌŽŶĂƌǇƐǇŶĚƌŽŵĞƚŚƌŽƵŐŚĂǀĂƌŝĞƚǇŽĨŵĞĐŚĂŶŝƐŵƐ͕ ůĞĂĚŝŶŐƚŽĐĂƌĚŝĂĐŝƐĐŚĞŵŝĂĂŶĚƉŽƐƐŝďůǇĂ^dD/͘ x dƌŝĐǇĐůŝĐŶƚŝĚĞƉƌĞƐƐĂŶƚ;dͿĚƌƵŐƐĂƌĞƵƐĞĚƉƌŝŵĂƌŝůǇƚŽƚƌĞĂƚŵŽŽĚĚŝƐŽƌĚĞƌƐĂŶĚŝŶĐůƵĚĞĂǀĂƌŝĞƚǇ ŽĨĚƌƵŐƐĞŶĚŝŶŐŝŶ͞ͲƚǇůŝŶĞ͕͟͞ͲĂŵŝŶĞ͕͟ĂŶĚ͞ͲĞƉŝŶ͘͟dŽǀĞƌĚŽƐĞƉƌĞƐĞŶƚƐǁŝƚŚĂŶƚŝĐŚŽůŝŶĞƌŐŝĐ ĞĨĨĞĐƚƐƚŚĂƚƉƌŽŐƌĞƐƐĞƐƚŽĂůƚĞƌĞĚŵĞŶƚĂůƐƚĂƚƵƐ͕ĐŽŵĂ͕ƐĞŝǌƵƌĞƐ͕ĂŶĚĐĂƌĚŝĂĐĐŚĂŶŐĞƐƐƵĐŚĂƐ ǁŝĚĞŶŝŶŐŽĨYZ^ĂŶĚƉƌŽůŽŶŐĂƚŝŽŶŽĨYdŝŶƚĞƌǀĂůƐ͘ x ĞƚĂďůŽĐŬĞƌĂŶĚĐĂůĐŝƵŵĐŚĂŶŶĞůďůŽĐŬĞƌŽǀĞƌĚŽƐĞƐĐĂƵƐĞďƌĂĚǇĐĂƌĚŝĂƐ͕ŚǇƉŽƚĞŶƐŝŽŶ͕ĂůƚĞƌĞĚ ŵĞŶƚĂůƐƚĂƚƵƐ͕ĂŶĚŵĂǇĐĂƵƐĞŚǇƉŽŐůǇĐĞŵŝĂ͘ x KƌŐĂŶŽƉŚŽƐƉŚĂƚĞƐŝŶĐůƵĚĞĐŽŵŵŽŶŝŶƐĞĐƚŝĐŝĚĞƐ͕ƉĞƐƚŝĐŝĚĞƐ͕ĐĞƌƚĂŝŶŵƵƐŚƌŽŽŵƐ͕ĂŶĚŶĞƌǀĞĂŐĞŶƚƐ͘ KƌŐĂŶŽƉŚŽƐƉŚĂƚĞƉŽŝƐŽŶŝŶŐƉƌĞƐĞŶƚƐǁŝƚŚƚŚĞ͞^>h'ͬ͟͟hD>^͟ƚŽǆŝĚƌŽŵĞ͘ x /ŶĂƚƌƵĞŽƌŐĂŶŽƉŚŽƐƉŚĂƚĞƉŽŝƐŽŶŝŶŐ͕ůĂƌŐĞƋƵĂŶƚŝƚŝĞƐŽĨAtropineŵĂǇďĞƌĞƋƵŝƌĞĚƚŽĐŽƵŶƚĞƌĂĐƚ ƚŚĞƚŽǆŝĐĞĨĨĞĐƚƐŽĨƚŚĞƐƵďƐƚĂŶĐĞ͘ x NaloxoneƐŚŽƵůĚŶŽƚďĞƵƐĞĚŝŶƚŚĞĐŽŶƐĐŝŽƵƐƉĂƚŝĞŶƚ͘NaloxoneƐŚŽƵůĚŽŶůǇďĞƵƐĞĚƚŽƐƚŝŵƵůĂƚĞ ƌĞƐƉŝƌĂƚŽƌǇĞĨĨŽƌƚƐĂŶĚͬŽƌŝŵƉƌŽǀĞŚĞŵŽĚǇŶĂŵŝĐƐŝŶƚŚĞƵŶĐŽŶƐĐŝŽƵƐƉĂƚŝĞŶƚŝŶǁŚŝĐŚĂŶŽƉŝĂƚĞ ŽǀĞƌĚŽƐĞŝƐŬŶŽǁŶŽƌƐƵƐƉĞĐƚĞĚĚƵĞƚŽƌĞƐƉŝƌĂƚŽƌǇĚĞƉƌĞƐƐŝŽŶ͕ĐŽŶƐƚƌŝĐƚĞĚƉƵƉŝůƐ͕ĂŶĚͬŽƌŽŶͲƐĐĞŶĞ ĞǀŝĚĞŶĐĞ͘/ĨƚŚĞƉĂƚŝĞŶƚŝƐŝŶƚƵďĂƚĞĚĂŶĚŚĞŵŽĚǇŶĂŵŝĐĂůůǇƐƚĂďůĞ͕ĚŽŶŽƚĂĚŵŝŶŝƐƚĞƌNaloxone͘ NaloxoneƐŚŽƵůĚďĞƚŝƚƌĂƚĞĚƚŽƌĞƐƉŝƌĂƚŽƌǇĞĨĨŽƌƚĂŶĚŝƐŶŽƚŐŝǀĞŶƚŽƌĞƐƚŽƌĞĐŽŶƐĐŝŽƵƐŶĞƐƐ͘

Cypress Creek EMS System Policies and Treatment Guidelines

163 PEDIATRIC MEDICAL Revised 12/2018 Approved: Levon Vartanian, MD

WĞĚŝĂƚƌŝĐ,ǇƉŽƚĞŶƐŝŽŶͬ^ŚŽĐŬ

ƐƐĞƐƐŵĞŶƚZĞƋƵŝƌĞŵĞŶƚƐ DĂǇWƌĞƐĞŶƚƐ ŽŶƐŝĚĞƌWŽƐƐŝďůĞĂƵƐĞƐ ZĂƉŝĚůǇŝĚĞŶƚŝĨǇĞǆƐĂŶŐƵŝŶĂƚŝŶŐ ZĞƐƚůĞƐƐŶĞƐƐ͕ĂŶǆŝĞƚǇ͕ ^ŚŽĐŬ ŚĞŵŽƌƌŚĂŐĞ͘ ĐŽŶĨƵƐŝŽŶ͕ǁĞĂŬŶĞƐƐ͕ĚŝǌǌŝŶĞƐƐ͕ ,ǇƉŽǀŽůĞŵŝĐ;ǀŽůƵŵĞ ƐƐĞƐƐŵĞŶƚΘĨƵůůŚĞĂĚͲƚŽͲƚŽĞ ǁĞĂŬ͕ƌĂƉŝĚƉƵůƐĞ͕ƉĂůĞ͕ĐŽŽů ĚĞƉůĞƚĞĚͿ ĞǆĂŵ ĐůĂŵŵǇƐŬŝŶ͕ĚĞůĂǇĞĚĐĂƉŝůůĂƌǇ ,ǇƉŽǀŽůĞŵŝĐ;ŚĞŵŽƌƌŚĂŐŝĐͿ ƌŽƐĞůŽǁƚĂƉĞ ƌĞĨŝůů͕ĐŽĨĨĞĞŐƌŽƵŶĚĞŵĞƐŝƐ͕ ĂƌĚŝŽŐĞŶŝĐ ƚĂƌƌǇƐƚŽŽůƐ͕'/ďůĞĞĚŝŶŐ͘ ^ĞƉƚŝĐ 'Θ^ƉKϮŵŽŶŝƚŽƌŝŶŐ͘ EĞƵƌŽŐĞŶŝĐ

ϭϮͲůĞĂĚ'ĂƐŝŶĚŝĐĂƚĞĚ ŶĂƉŚǇůĂĐƚŝĐ dĞŵƉĞƌĂƚƵƌĞ WƵůŵŽŶĂƌǇĞŵďŽůŝƐŵ hůƚƌĂƐŽƵŶĚ͕ŝĨĂǀĂŝůĂďůĞ dĞŶƐŝŽŶƉŶĞƵŵŽƚŚŽƌĂǆ WĞƌŝĐĂƌĚŝĂůƚĂŵƉŽŶĂĚĞ ǇƐƌŚǇƚŚŵŝĂƐ DĞĚŝĐĂƚŝŽŶĞĨĨĞĐƚͬK sĂƐŽǀĂŐĂů

ZĞƋƵŝƌĞĚdƌĞĂƚŵĞŶƚƐ x Airway management ĂƉƉƌŽƉƌŝĂƚĞ ƚŽƉĂƚŝĞŶƚĐŽŶĚŝƚŝŽŶ͘ x VentilationĂŶĚoxygenation ĂƉƉƌŽƉƌŝĂƚĞƚŽƉĂƚŝĞŶƚĐŽŶĚŝƚŝŽŶ͘ x (I) Vascular accessǁŝƚŚ/sŽƌ/K͘ŽŶƐŝĚĞƌůŽŽĚͲz/sƚƵďŝŶŐ͘ x (B) Control exsanguinating hemorrhage. ǀĂŝůĂďůĞdƌĞĂƚŵĞŶƚƐ x (P) Plasmalyte ĨůƵŝĚĐŚĂůůĞŶŐĞϮϬŵ>ͬŬŐ;ϭϬŵ>ͬŬŐŝĨĂŐĞфϯϬǁĞĞŬƐͿ͘ x (P) Dopamine ϱͲϮϬŵĐŐͬŬŐͬŵŝŶ/sͬ/KŝŶĨƵƐŝŽŶĨŽƌƐŚŽĐŬƚŚĂƚŝƐŶŽƚŚǇƉŽǀŽůĞŵŝĐŝŶŶĂƚƵƌĞ͘ x (P) Epinephrine Ϭ͘ϬϱʹϬ͘ϭŵĐŐͬŬŐͬŵŝŶ/sͬ/KŝŶĨƵƐŝŽŶĨŽƌƐŚŽĐŬƚŚĂƚŝƐŶŽƚŚǇƉŽǀŽůĞŵŝĐŝŶŶĂƚƵƌĞ͘ x (P) Whole Blood ŽƌBlood ProductsƉĞƌůŽŽĚΘůŽŽĚWƌŽĚƵĐƚƐdƌĂŶƐĨƵƐŝŽŶWƌŽĐĞĚƵƌĞ͘ WĞĂƌůƐ x dƌĞĂƚƐŝŐŶƐŽĨƐŚŽĐŬ;ƚĂĐŚǇĐĂƌĚŝĂ͕ƚĂĐŚǇƉŶĞĂ͕ƉĂůĞƐŬŝŶ͕ĚĞĐƌĞĂƐĞĚĐĂƉŝůůĂƌǇƌĞĨŝůů͕ĂĐƵƚĞůǇĂůƚĞƌĞĚ ŵĞŶƚĂůƐƚĂƚƵƐ͕ĞƚĐ͘ͿĞǀĞŶŝĨďůŽŽĚƉƌĞƐƐƵƌĞŝƐŶŽƌŵĂů͘ x ,ǇƉŽƚĞŶƐŝŽŶŝƐĚĞĨŝŶĞĚĂƐSBP < (2 x age in years) + 65 mmHgŽƌMAP < (1.5 x age in years) + 40 mmHg.dŚĞƐĞŶƵŵďĞƌƐĂƌĞďĂƐĞĚŽŶĂǀĞƌĂŐĞŚĞŝŐŚƚĨŽƌĂŐĞĂŶĚŵĂǇŚĂǀĞĂƐŵƵĐŚĂƐϮŵŵ,Ő ǀĂƌŝĂƚŝŽŶ͘ x ŽŶƐŝĚĞƌǀĂƐŽƉƌĞƐƐŽƌƐŝŶƚƌĂƵŵĂƚŝĐŽƌŚǇƉŽǀŽůĞŵŝĐƐŚŽĐŬKE>zĂĨƚĞƌϮϬŵ>ͬŬŐ;ϭϬŵ>ͬŬŐŝĨĂŐĞфϭ ǇĞĂƌͿĨůƵŝĚďŽůƵƐĂŶĚƉĂƚŝĞŶƚŝƐƉĞƌŝͲĂƌƌĞƐƚ͘ x /ĨƵŶĐŽŶƚƌŽůůĂďůĞďůĞĞĚŝŶŐĞǆŝƐƚƐ͕ƌĂƉŝĚƚƌĂŶƐƉŽƌƚƚŽƚŚĞĂƉƉƌŽƉƌŝĂƚĞŚŽƐƉŝƚĂůŝƐŶĞĐĞƐƐĂƌǇĂĨƚĞƌ ŝŵŵŽďŝůŝǌĂƚŝŽŶŽĨƐƉŝŶĞĂŶĚĂŝƌǁĂǇŵĂŶĂŐĞŵĞŶƚŚĂƐďĞĞŶĂĐĐŽŵƉůŝƐŚĞĚ͘ŽŶƐŝĚĞƌĞĂƌůǇĂĐƚŝǀĂƚŝŽŶ

Cypress Creek EMS System Policies and Treatment Guidelines

164 PEDIATRIC MEDICAL Revised 12/2018 Approved: Levon Vartanian, MD

ŽĨŝƌDĞĚŝĐĂůdƌĂŶƐƉŽƌƚ;>ŝĨĞ&ůŝŐŚƚͿŝĨƚŚĞƉĂƚŝĞŶƚŵĂǇďĞŶĞĨŝƚĨƌŽŵƚŚĞĂĚŵŝŶŝƐƚƌĂƚŝŽŶŽĨǁŚŽůĞ ďůŽŽĚŽƌďůŽŽĚƉƌŽĚƵĐƚƐ͘ x /ĨƵůƚƌĂƐŽƵŶĚŝƐĂǀĂŝůĂďůĞ͕ƵƚŝůŝǌĞƚŚĞĨŽůůŽǁŝŶŐĞǆĂŵƐƚŽĞǀĂůƵĂƚĞĨŽƌƉŽƐƐŝďůĞĐĂƵƐĞƐŽĨŚǇƉŽƚĞŶƐŝŽŶ͗

Use this exam To evaluate for Treatment Indicated ĂƌĚŝĂĐdĂŵƉŽŶĂĚĞ /ŶŝƚŝĂƚĞƌĂƉŝĚƚƌĂŶƐƉŽƌƚƚŽĐůŽƐĞƐƚƚƌĂƵŵĂĐĞŶƚĞƌ͘ WŽŽƌŵŽƚŝŽŶƐƵƉƉŽƌƚƐƵƐĞŽĨƉƌĞƐƐŽƌƐ͘ ĂƌĚŝĂĐǆĂŵ;W>yͬ^hyͿ ĂƌĚŝĂĐ&ƵŶĐƚŝŽŶ ,ǇƉĞƌĚǇŶĂŵŝĐŵŽƚŝŽŶƐƵŐŐĞƐƚƐŚǇƉŽǀŽůĞŵŝĂ͖ ƉƌŽǀŝĚĞĨůƵŝĚďŽůƵƐ͘ &ůƵŝĚ /&/sŝƐĐŽůůĂƉƐŝďůĞ͕ĐŽŶƐŝĚĞƌƐĞƉƐŝƐŽƌ ƌĞƐƉŽŶƐŝǀĞŶĞƐƐͬƉƌĞůŽĂĚ ŚǇƉŽǀŽůĞŵŝĂĂŶĚƉƌŽǀŝĚĞĨůƵŝĚďŽůƵƐ /sĞǆĂŵ /sŝƐůĂƌŐĞ;ĚŽĞƐŶŽƚǀĂƌǇǁŝƚŚƌĞƐƉŝƌĂƚŝŽŶƐͿĂŶĚ WƵůŵŽŶĂƌǇĞŵďŽůŝƐŵ ĐĂƌĚŝĂĐĞǆĂŵƐŚŽǁƐĞŶůĂƌŐĞĚZs͘/ŶŝƚŝĂƚĞƌĂƉŝĚ ƚƌĂŶƐƉŽƌƚƚŽĐůŽƐĞƐƚĂƉƉƌŽƉƌŝĂƚĞŚŽƐƉŝƚĂů͘ WŶĞƵŵŽƚŚŽƌĂǆ WĞƌĨŽƌŵNeedle Decompression /ŶƉƌĞƐĞŶĐĞŽĨƚƌĂƵŵĂ͕ƚƌĂŶƐĨƵƐĞďůŽŽĚĂŶĚ WƵůŵŽŶĂƌǇĞǆĂŵ ďĚŽŵŝŶĂůĨƌĞĞ ŝŶŝƚŝĂƚĞƌĂƉŝĚƚƌĂŶƐƉŽƌƚƚŽĂ>ĞǀĞů/ͬ//ƚƌĂƵŵĂ &^dĞǆĂŵ ĨůƵŝĚͬďůŽŽĚ ĐĞŶƚĞƌ͘ Shock Differential Diagnosis ŚŽŽƐŝŶŐƚŚĞďĞƐƚƚŚĞƌĂƉǇŝƐĚĞƉĞŶĚĞŶƚŽŶŝĚĞŶƚŝĨǇŝŶŐƚŚĞƚǇƉĞĂŶĚŶĂƚƵƌĞŽĨƐŚŽĐŬƉƌĞƐĞŶƚ͘'ĞŶĞƌĂůůǇ ƐƉĞĂŬŝŶŐ͕ƐŚŽĐŬŝƐŝŶĂĚĞƋƵĂƚĞƉĞƌĨƵƐŝŽŶĂŶĚŝƚĐĂŶďĞĐĂƵƐĞĚďǇĨŽƵƌƉƌŝŵĂƌǇƉƌŽďůĞŵƐǁŝƚŚ͗ Hypovolemic Shock ŝƐĐĂƵƐĞĚďǇůŽƐƐŽĨďůŽŽĚǀŽůƵŵĞ͘ ^ŝŐŶƐͬ^ǇŵƉƚŽŵƐŝŶĐůƵĚĞƚĂĐŚǇĐĂƌĚŝĂ͕ƚĂĐŚǇƉŶĞĂ͕ƌĞƐƚůĞƐƐŶĞƐƐ͕ĂůƚĞƌĞĚŵĞŶƚĂƚŝŽŶ͕ƉĂůĞͬĐŽŽůͬĐůĂŵŵǇ ƐŬŝŶ͕ĂŶĚŝƚůĞĂĚƐƚŽŚǇƉŽƚĞŶƐŝŽŶĂŶĚƵůƚŝŵĂƚĞůǇĚĞĂƚŚ͘ dŚŝƐŵĂǇďĞhemorrhagicŝŶŶĂƚƵƌĞ͕ǁŚĞƌĞƚŚĞƌĞŝƐĂůŽƐƐŽĨƌĞĚďůŽŽĚĐĞůůƐ͘dƌĞĂƚŵĞŶƚĨŽƌƚŚŝƐƐŚŽƵůĚ ŝŶĐůƵĚĞŚĞŵŽƌƌŚĂŐĞĐŽŶƚƌŽů͕ƵƐĞŽĨǁŚŽůĞďůŽŽĚŽƌďůŽŽĚƉƌŽĚƵĐƚƐ͕ĂŶĚƵƐĞŽĨĐƌǇƐƚĂůůŽŝĚƐĂƐŶĞĐĞƐƐĂƌǇ ;ǁŝƚŚƉĞƌŵŝƐƐŝǀĞŚǇƉŽƚĞŶƐŝŽŶŝŶŵŝŶĚͿ͘ Non-hemorrhagic hypovolemic shockŵĂǇďĞĐĂƵƐĞĚďǇĚĞŚǇĚƌĂƚŝŽŶŽƌŽƚŚĞƌĨůƵŝĚůŽƐƐ͘&ůƵŝĚ ƌĞƉůĂĐĞŵĞŶƚƵƐŝŶŐĂĐƌǇƐƚĂůůŽŝĚŝƐƚŚĞƉƌĞĨĞƌƌĞĚƚƌĞĂƚŵĞŶƚ͘ hƐĞŽĨǀĂƐŽƉƌĞƐƐŽƌƐĨŽƌŚǇƉŽǀŽůĞŵŝĐƐŚŽĐŬŝƐŶŽƚĂĚǀŝƐĂďůĞƵŶůĞƐƐƉĂƚŝĞŶƚŝƐƉĞƌŝͲĂƌƌĞƐƚĂŶĚŚĂƐƌĞĐĞŝǀĞĚ ĂŵŝŶŝŵƵŵŽĨϮůŝƚĞƌƐŽĨĨůƵŝĚďŽůƵƐ͘ Cardiogenic ShockŝƐĐĂƵƐĞĚďǇƉƵŵƉĨĂŝůƵƌĞ;ŚĞĂƌƚĨĂŝůƵƌĞͿ. ^ŝŐŶƐͬƐǇŵƉƚŽŵƐŵĂǇŝŶĐůƵĚĞŝƐĐŚĞŵŝĐĐŚĞƐƚĚŝƐĐŽŵĨŽƌƚ͕ĚǇƐƉŶĞĂ͕ƚĂĐŚǇĐĂƌĚŝĂ͕ĐĂƌĚŝĂĐĚǇƐƌŚǇƚŚŵŝĂƐ͕ ƚĂĐŚǇƉŶĞĂ͕ŚǇƉŽƚĞŶƐŝŽŶ͕ƉƵůŵŽŶĂƌǇĞĚĞŵĂ;ĐƌĂĐŬůĞƐͿ͕ĂůƚĞƌĞĚŵĞŶƚĂƚŝŽŶ͕ƉĂůĞͬĐŽŽůͬĐůĂŵŵǇƐŬŝŶ͕ĂŶĚ 'ĐŚĂŶŐĞƐ͘ dŚŝƐŵĂǇďĞĐĂƵƐĞĚďǇ rate problemsƐƵĐŚĂƐďƌĂĚǇĐĂƌĚŝĂ͕^sd͕ǀĞŶƚƌŝĐƵůĂƌĚǇƐƌŚǇƚŚŵŝĂƐ; mechanical problemsƐƵĐŚĂƐǀĂůǀĞĚŝƐƌƵƉƚŝŽŶƐ͖Žƌcontractility problemsĐĂƵƐĞĚďǇD/͕ŵƵƐĐůĞĚĂŵĂŐĞ͕ĞůĞĐƚƌŽůǇƚĞ ĂďŶŽƌŵĂůŝƚŝĞƐ͕ŽƌŽǀĞƌĚŽƐĞͬƚŽǆŝĐĞǆƉŽƐƵƌĞ͘ dƌĞĂƚŵĞŶƚƐŚŽƵůĚĨŽĐƵƐŽŶĨŝǆŝŶŐƚŚĞƵŶĚĞƌůǇŝŶŐƉƌŽďůĞŵĂŶĚƚƌĞĂƚŝŶŐƌĂƚĞ͕ƌŚǇƚŚŵ͕ďůŽŽĚƉƌĞƐƐƵƌĞŝŶ ƚŚĂƚŽƌĚĞƌ͘/ĨƌĂƚĞĂŶĚƌŚǇƚŚŵĂƌĞĂƉƉƌŽƉƌŝĂƚĞ͕ĐŽŶƐŝĚĞƌƵƐŝŶŐDopamineŝŶƚŚĞϱʹϭϬŵĐŐͬŬŐͬŵŝŶƌĂŶŐĞ ŽƌEpinephrineϮʹϭϬŵĐŐͬŬŐͬŵŝŶ͘ǀŽŝĚĨůƵŝĚƐƵŶůĞƐƐŚǇƉŽǀŽůĞŵŝĂŝƐĂůƐŽƐƵƐƉĞĐƚĞĚ͘

Cypress Creek EMS System Policies and Treatment Guidelines

165 PEDIATRIC MEDICAL Revised 12/2018 Approved: Levon Vartanian, MD

Distributive ShockŝƐĐĂƵƐĞĚďǇƐǇƐƚĞŵŝĐǀĂƐŽĚŝůĂƚŝŽŶ. dŚŝƐŵĂǇďĞĐĂƵƐĞĚďǇanaphylaxis͕sepsis͕Žƌneurogenic shock͘dƌĞĂƚSepsisƵƐŝŶŐ^ĞƉƐŝƐƉƌŽƚŽĐŽůĂŶĚ ĂůĂƌŐĞ;ϯϬŵ>ͬŬŐͿĨůƵŝĚďŽůƵƐĨŽůůŽǁĞĚďǇĂƉƌĞƐƐŽƌ͘dƌĞĂƚanaphylaxisĂŐŐƌĞƐƐŝǀĞůǇǁŝƚŚEpinephrine Ϭ͘ϯ ŵŐϭ͗ϭ͕ϬϬϬ/D;ŽƌϬ͘ϭŵŐϭ͗ϭϬ͕ϬϬϬ/sŝĨƉĂƚŝĞŶƚŝƐƐĞǀĞƌĞůǇŚǇƉŽƚĞŶƐŝǀĞͿ͘dƌĞĂƚneurogenicƐŚŽĐŬ͕Žƌ ĂŶĂƉŚǇůĂǆŝƐĂŶĚƐĞƉƐŝƐƚŚĂƚĂƌĞƌĞĨƌĂĐƚŽƌǇƚŽŽƚŚĞƌƚƌĞĂƚŵĞŶƚƐ͕ǁŝƚŚŚŝŐŚͲĂůƉŚĂͲĂĚƌĞŶĞƌŐŝĐǀĂƐŽƉƌĞƐƐŽƌƐ ƐƵĐŚĂƐDopamine ŝŶƚŚĞϭϬʹϮϬŵĐŐͬŬŐͬŵŝŶƌĂŶŐĞŽƌEpinephrineϮʹϭϬŵĐŐͬŬŐͬŵŝŶ͘ Obstructive ShockŝƐĐĂƵƐĞĚďǇĂƉŚǇƐŝĐĂůŽďƐƚƌƵĐƚŝŽŶƚŽďůŽŽĚĨůŽǁ. dŚŝƐŵĂǇďĞĂtension pneumothorax͕Ăpulmonary embolism͕Žƌpericardial tamponade͘dƌĞĂƚĂ ƚĞŶƐŝŽŶƉŶĞƵŵŽƚŚŽƌĂǆǁŝƚŚŶĞĞĚůĞĚĞĐŽŵƉƌĞƐƐŝŽŶ͘hƌŐĞŶƚůǇƚƌĂŶƐƉŽƌƚƐƵƐƉĞĐƚĞĚƉĞƌŝĐĂƌĚŝĂů ƚĂŵƉŽŶĂĚĞŽƌƉƵůŵŽŶĂƌǇĞŵďŽůŝƐŵƐĂŶĚƵƐĞĨůƵŝĚďŽůƵƐĞƐĂůŽŶŐǁŝƚŚǀĂƐŽƉƌĞƐƐŽƌƐĂƐŶĞĞĚĞĚƚŽ ŵĂǆŝŵŝǌĞďůŽŽĚƉƌĞƐƐƵƌĞ͘tŝƚŚŽƵƚĚĞĨŝŶŝƚŝǀĞƚƌĞĂƚŵĞŶƚŝŶƚŚĞZ͕ƚŚĞƐĞĐŽŶĚŝƚŝŽŶƐĂƌĞƚǇƉŝĐĂůůǇĨĂƚĂů͘

Cypress Creek EMS System Policies and Treatment Guidelines

166 PEDIATRIC MEDICAL Revised 8/2016 Approved: Levon Vartanian, MD

WĞĚŝĂƚƌŝĐůůĞƌŐŝĐZĞĂĐƚŝŽŶͬŶĂƉŚǇůĂǆŝƐ ƐƐĞƐƐŵĞŶƚZĞƋƵŝƌĞŵĞŶƚƐ DĂǇWƌĞƐĞŶƚƐ ŽŶƐŝĚĞƌWŽƐƐŝďůĞĂƵƐĞƐ ƐƐĞƐƐŵĞŶƚΘĨƵůůŚĞĂĚͲƚŽͲ /ƚĐŚŝŶŐŽƌŚŝǀĞƐ͕ hƌƚŝĐĂƌŝĂů;ƌĂƐŚŽŶůǇͿ ƚŽĞĞǆĂŵ ĐŽƵŐŚŝŶŐͬǁŚĞĞǌŝŶŐ͕ ŶĂƉŚǇůĂǆŝƐ;ƐǇƐƚĞŵŝĐͿ ƌŽƐĞůŽǁƚĂƉĞ ƌĞƐƉŝƌĂƚŽƌǇĚŝƐƚƌĞƐƐ͕ ŶŐŝŽĞĚĞŵĂ;ĚƌƵŐŝŶĚƵĐĞĚ

'Θ^ƉKϮŵŽŶŝƚŽƌŝŶŐ͘ ĐŚĞƐƚͬƚŚƌŽĂƚĐŽŶƐƚƌŝĐƚŝŽŶ͕ ƐǁĞůůŝŶŐͿ͕ƐƉŝƌĂƚŝŽŶͬĂŝƌǁĂǇ ĚŝĨĨŝĐƵůƚǇƐǁĂůůŽǁŝŶŐ͕ ŽďƐƚƌƵĐƚŝŽŶ͕ĂƐƚŚŵĂͬKW͕ ϭϮͲůĞĂĚ'ĂƐŝŶĚŝĐĂƚĞĚ ƐǁĞůůŝŶŐͬĞĚĞŵĂ͕ ,& ŚǇƉŽƚĞŶƐŝŽŶͬƐŚŽĐŬ͕ ŶĂƵƐĞĂͬǀŽŵŝƚŝŶŐ

Required Treatments x Airway management ĂƉƉƌŽƉƌŝĂƚĞ ƚŽƉĂƚŝĞŶƚĐŽŶĚŝƚŝŽŶ͘ x VentilationĂŶĚoxygenation ĂƉƉƌŽƉƌŝĂƚĞƚŽƉĂƚŝĞŶƚĐŽŶĚŝƚŝŽŶ͘ Available Treatments DŝůĚƐǇŵƉƚŽŵƐ x (B) Cold packsĂƉƉůŝĞĚŝŶĚŝƌĞĐƚůǇƚŽƐŝƚĞ x (B)ůĞǀĂƚĞĂĨĨĞĐƚĞĚĂƌĞĂŝĨĂƉƉůŝĐĂďůĞ x (I) Vascular accessǁŝƚŚ/sŽƌ/K͕ŝĨŝŶĚŝĐĂƚĞĚ x (P) DiphenhydramineϭʹϮŵŐͬŬŐ^>Kt/sŽƌ/D;ŵĂǆĚŽƐĞϱϬŵŐͿ x (P) Methylprednisolone ϮŵŐͬŬŐ ^>Kt/sŽƌ/D;ŵĂǆĚŽƐĞϭϮϱŵŐͿ DŽĚĞƌĂƚĞƐǇŵƉƚŽŵƐ x ŽŶƐŝĚĞƌĂďŽǀĞƚƌĞĂƚŵĞŶƚƐ͘ x (B) AlbuterolŶĞďƵůŝǌĞƌϭƵŶŝƚĚŽƐĞ͕ƌĞƉĞĂƚĂƐŶĞĞĚĞĚ͘ x (B) Albuterol/IpratropiumĐŽŵďŝǀĞŶƚϭƵŶŝƚĚŽƐĞŶĞďƵůŝǌĞĚŝĨƌĞĨƌĂĐƚŽƌǇƚŽAlbuterolĂůŽŶĞ͘ZĞƉĞĂƚ ĂƐŶĞĞĚĞĚ͘ x (P) Epinephrine ϭ͗ϭϬϬϬϬ͘ϬϭŵŐͬŬŐ/D ^ĞǀĞƌĞƐǇŵƉƚŽŵƐ x ŽŶƐŝĚĞƌĂďŽǀĞƚƌĞĂƚŵĞŶƚƐ͘ x (P) Normal saline ŽƌPlasmalyteϱϬϬŵ>ĨůƵŝĚďŽůƵƐƵƉƚŽϮϬŵ>ͬŬŐ͕ĂƐĂƉƉƌŽƉƌŝĂƚĞĨŽƌƉĂƚŝĞŶƚ ĐŽŶĚŝƚŝŽŶ͘ x (P) Epinephrine 1:10,000 0.01 mg/kg IVďŽůƵƐĂƐĂůĂƐƚƌĞƐŽƌƚĨŽƌƉĞƌŝͲĂƌƌĞƐƚĂŶĂƉŚǇůĂǆŝƐ͘DĂǇƌĞƉĞĂƚ ǆϮĂƐŶĞĞĚĞĚ͘ x (P)Epinephrine ŝŶĨƵƐŝŽŶϬ͘ϬϱʹϬ͘ϭŵĐŐͬŬŐͬŵŝŶ͕ƚŝƚƌĂƚĞĚƚŽĞĨĨĞĐƚ͕ƚŽŵĂŝŶƚĂŝŶ^Wх;ϮǆĂŐĞŝŶǇĞĂƌƐͿ нϲϱŵŵ,Ő͘

Cypress Creek EMS System Policies and Treatment Guidelines

167 PEDIATRIC MEDICAL Revised 8/2016 Approved: Levon Vartanian, MD

Pearls x ŶĂƉŚǇůĂǆŝƐŝƐĂůŝĨĞͲƚŚƌĞĂƚĞŶŝŶŐ͕ŵƵůƚŝͲƐǇƐƚĞŵĂůůĞƌŐŝĐƌĞĂĐƚŝŽŶ͘EpinephrineŝƐƚŚĞĚƌƵŐŽĨĐŚŽŝĐĞ ĂŶĚƚŚĞĨŝƌƐƚĚƌƵŐƚŚĂƚƐŚŽƵůĚďĞĂĚŵŝŶŝƐƚĞƌĞĚŝŶĂĐƵƚĞĂŶĂƉŚǇůĂǆŝƐ;ŵŽĚĞƌĂƚĞͬƐĞǀĞƌĞƐǇŵƉƚŽŵƐͿ͘ /DƉŝŶĞƉŚƌŝŶĞƐŚŽƵůĚƚĂŬĞƉƌŝŽƌŝƚǇŽǀĞƌĂƚƚĞŵƉƚƐĂƚ/sŽƌ/KĂĐĐĞƐƐŽƌĐĂƌĚŝĂĐŵŽŶŝƚŽƌŝŶŐ͘ Symptom Severity Classification:

Mild Moderate Severe &ůƵƐŚŝŶŐ 2 or more of the following: ZĞƐƉŝƌĂƚŽƌǇĂŶĚͬŽƌ'/ ,ŝǀĞƐͬhƌƚŝĐĂƌŝĂͬ/ƚĐŚŝŶŐ͕ x Skin;&ůƵƐŚŝŶŐ͕ ƐǇŵƉƚŽŵƐ͘ ƌǇƚŚĞŵĂ ,ŝǀĞƐͬhƌƚŝĐĂƌŝĂͬ/ƚĐŚŝŶŐ͕ WithŚǇƉŽƚĞŶƐŝŽŶĂŶĚƉŽŽƌ EŽƌŵĂůWĂŶĚƉĞƌĨƵƐŝŽŶ͘ ƌǇƚŚĞŵĂͿ ƉĞƌĨƵƐŝŽŶ͘ x Respiratory ;^ŬŝŶƐǇŵƉƚŽŵƐŵĂǇŽƌŵĂǇ ;ǁŚĞĞǌŝŶŐͬĚǇƐƉŶĞĂͬŚǇƉŽǆŝĂͿ ŶŽƚďĞƉƌĞƐĞŶƚĚĞƉĞŶĚŝŶŐ x GI ;ŶĂƵƐĞĂͬǀŽŵŝƚŝŶŐͬŐĂƐƚƌŝĐ ŽŶƉĞƌĨƵƐŝŽŶ͘Ϳ ƵƉƐĞƚͬĂďĚŽŵŝŶĂůƉĂŝŶͿ x ůůĞƌŐŝĐƌĞĂĐƚŝŽŶƐĂŶĚĂŶĂƉŚǇůĂǆŝƐŵĂǇŽĐĐƵƌǁŝƚŚŶŽƐŬŝŶƐǇŵƉƚŽŵƐĂŶĚŽŶůǇ'/нZĞƐƉŝƌĂƚŽƌǇ͕Žƌ ǁŝƚŚŶŽƌĞƐƉŝƌĂƚŽƌǇƐǇŵƉƚŽŵƐĂŶĚŽŶůǇ^ŬŝŶн'/͘ x ŶŐŝŽĞĚĞŵĂŝƐƐĞĞŶŝŶŵŽĚĞƌĂƚĞƚŽƐĞǀĞƌĞƌĞĂĐƚŝŽŶƐĂŶĚŝƐƐǁĞůůŝŶŐƚŽĨĂĐĞ͕ůŝƉƐ͕ƚŚƌŽĂƚ͕ĂŶĚĂŝƌǁĂǇ͘ /ƚŵĂǇĂůƐŽďĞƐĞĞŶŝŶƉĂƚŝĞŶƚƐƚĂŬŝŶŐŝŶŚŝďŝƚŽƌƐ͘ x ŶǇƉĂƚŝĞŶƚƌĞĐĞŝǀŝŶŐĞƉŝŶĞƉŚƌŝŶĞƐŚŽƵůĚŚĂǀĞĂϭϮͲůĞĂĚ'ŽďƚĂŝŶĞĚ͕ďƵƚĚŽŶ͛ƚĚĞůĂǇ ĂĚŵŝŶŝƐƚƌĂƚŝŽŶŽĨĞƉŝŶĞƉŚƌŝŶĞƚŽŽďƚĂŝŶϭϮͲůĞĂĚ͘ x dŚĞŵŽƌĞƌĂƉŝĚƚŚĞŽŶƐĞƚŽĨƐǇŵƉƚŽŵƐ͕ƚŚĞŵŽƌĞƐĞǀĞƌĞƚŚĞƌĞĂĐƚŝŽŶ͘

Cypress Creek EMS System Policies and Treatment Guidelines

168 PEDIATRIC MEDICAL Revised 8/2016 Approved: Levon Vartanian, MD

WĞĚŝĂƚƌŝĐsŽŵŝƚŝŶŐͬŝĂƌƌŚĞĂ ƐƐĞƐƐŵĞŶƚZĞƋƵŝƌĞŵĞŶƚƐ DĂǇWƌĞƐĞŶƚƐ ŽŶƐŝĚĞƌWŽƐƐŝďůĞĂƵƐĞƐ ƐƐĞƐƐŵĞŶƚΘĨƵůůŚĞĂĚͲƚŽͲ /ƚĐŚŝŶŐŽƌŚŝǀĞƐ͕ /ŶĨĞĐƚŝŽŶ ƚŽĞĞǆĂŵ ĐŽƵŐŚŝŶŐͬǁŚĞĞǌŝŶŐ͕ 'ĂƐƚƌŽĞŶƚĞƌŝƚŝƐ ƌŽƐĞůŽǁƚĂƉĞ ƌĞƐƉŝƌĂƚŽƌǇĚŝƐƚƌĞƐƐ͕ WŽŝƐŽŶŝŶŐͬƚŽǆŝĐŝŶŐĞƐƚŝŽŶ

'Θ^ƉKϮŵŽŶŝƚŽƌŝŶŐ͘ ĐŚĞƐƚͬƚŚƌŽĂƚĐŽŶƐƚƌŝĐƚŝŽŶ͕ /ŶƚĞƐƚŝŶĂůŽďƐƚƌƵĐƚŝŽŶ ĚŝĨĨŝĐƵůƚǇƐǁĂůůŽǁŝŶŐ͕ /ŶƚƵƐƐƵƐĐĞƉƚŝŽŶ ϭϮͲůĞĂĚ'ĂƐŝŶĚŝĐĂƚĞĚ ƐǁĞůůŝŶŐͬĞĚĞŵĂ͕ ŚǇƉŽƚĞŶƐŝŽŶͬƐŚŽĐŬ͕ ,ŝƐƚŽƌǇŽĨŽƌĂůŝŶƚĂŬĞ͕ƵƌŝŶĞ ŶĂƵƐĞĂͬǀŽŵŝƚŝŶŐ ŽƵƚƉƵƚͬηŽĨďŽǁĞů ŵŽǀĞŵĞŶƚƐ͕ηŽĨĚŝĂƉĞƌ ĐŚĂŶŐĞƐ͕ŵŽŝƐƚƵƌĞŽĨŵƵĐŽƐĂ ZĞƋƵŝƌĞĚdƌĞĂƚŵĞŶƚƐ x Airway management ĂƉƉƌŽƉƌŝĂƚĞ ƚŽƉĂƚŝĞŶƚĐŽŶĚŝƚŝŽŶ͘ x VentilationĂŶĚoxygenation ĂƉƉƌŽƉƌŝĂƚĞƚŽƉĂƚŝĞŶƚĐŽŶĚŝƚŝŽŶ͘ ǀĂŝůĂďůĞdƌĞĂƚŵĞŶƚƐ x (P) Normal Saline ŽƌPlasmalyteϮϬŵ>ͬŬŐ;ϭϬŵ>ͬŬŐŝĨĂŐĞфϯϬǁĞĞŬƐͿŝĨƐŝŐŶƐŽĨƐŚŽĐŬ ;ƚĂĐŚǇĐĂƌĚŝĂ͕ƚĂĐŚǇƉŶĞĂ͕ƉĂůĞƐŬŝŶ͕ĚĞĐƌĞĂƐĞĚĐĂƉŝůůĂƌǇƌĞĨŝůů͕ĂĐƵƚĞůǇĂůƚĞƌĞĚŵĞŶƚĂůƐƚĂƚƵƐ͕ĞƚĐ͘Ϳ͘ x (P) OndansetronϬ͘ϭϱŵŐͬŬŐKd;ƐƚĂƌƚǁŝƚŚϮŵŐͿ͘DĂǇƌĞƉĞĂƚĂƐŶĞĞĚĞĚƚŽŵĂǆŝŵƵŵĚŽƐĞŽĨϴ ŵŐ͘ŽŶŽƚĂĚŵŝŶŝƐƚĞƌƚŽĐŚŝůĚƌĞŶфϰǇĞĂƌƐ͘ x (P) Promethazine 0.25ŵŐͬŬŐ/s͕ŵĂǇƌĞƉĞĂƚŽŶĐĞ͖ŽƌϬ͘ϱŵŐͬŬŐĚĞĞƉ/D͕ŵĂǇƌĞƉĞĂƚŽŶĐĞ͘ŽŶŽƚ ĂĚŵŝŶŝƐƚĞƌƚŽĐŚŝůĚƌĞŶфϮǇĞĂƌƐ͘ WĞĂƌůƐ x ŝĂƌƌŚĞĂĂŶĚͬŽƌǀŽŵŝƚŝŶŐǁŝƚŚƚŚĞĨŽůůŽǁŝŶŐƐŝŐŶƐͬƐǇŵƉƚŽŵƐĂƌĞhigh–riskĂŶĚŵƵƐƚďĞƚƌĂŶƐƉŽƌƚĞĚ ƚŽƚŚĞĞŵĞƌŐĞŶĐǇƌŽŽŵĨŽƌĞǀĂůƵĂƚŝŽŶ͘ŽŶƚĂĐƚĂƐƵƉĞƌǀŝƐŽƌŝĨƚŚĞƉĂƚŝĞŶƚ͛ƐƉĂƌĞŶƚƐŽƌŐƵĂƌĚŝĂŶƐĂƌĞ ƌĞĨƵƐŝŶŐƚƌĂŶƐƉŽƌƚ͘ x dĂĐŚǇĐĂƌĚŝĂ͕ŚǇƉŽƚĞŶƐŝŽŶ͕ĂŶĚĂĐƵƚĞůǇĂůƚĞƌĞĚŵĞŶƚĂůƐƚĂƚƵƐ͘ x ůŽŽĚǇƐƚŽŽůƐ x ŝůŝŽƵƐ;ĚĂƌŬŐƌĞĞŶͿǀŽŵŝƚŝŶŐ x ďĚŽŵŝŶĂůƚĞŶĚĞƌŶĞƐƐĂŶĚͬŽƌĚŝƐƚĞŶƚŝŽŶ x ZĂƐŚĞƐ x WĂůůŽƌ x /ŶĐŽŶƐŽůĂďŝůŝƚǇĂŶĚďƵůŐŝŶŐĨŽŶƚĂŶĞůůĞŝŶŝŶĨĂŶƚ x EƵĐŚĂůƌŝŐŝĚŝƚǇ͕ƉŚŽƚŽƉŚŽďŝĂ͕ĂŶĚĨĞǀĞƌŝŶŽůĚĞƌĐŚŝůĚ

Cypress Creek EMS System Policies and Treatment Guidelines

169 PEDIATRIC MEDICAL Revised 8/2016 Approved: Levon Vartanian, MD

ŚŝůĚƌĞŶǁŝƚŚ^ƉĞĐŝĂů,ĞĂůƚŚĐĂƌĞEĞĞĚƐ Required Treatments x Airway management ĂƉƉƌŽƉƌŝĂƚĞ ƚŽƉĂƚŝĞŶƚĐŽŶĚŝƚŝŽŶ͘ x VentilationĂŶĚoxygenation ĂƉƉƌŽƉƌŝĂƚĞƚŽƉĂƚŝĞŶƚĐŽŶĚŝƚŝŽŶ͘ Specific Situations Ventilator x /ĨƉĂƚŝĞŶƚĚŽĞƐŶŽƚŚĂǀĞƌĞƐƉŝƌĂƚŽƌǇŽƌǀĞŶƚŝůĂƚŽƌƉƌŽďůĞŵƐ͕ĐŽŶƐŝĚĞƌƵƚŝůŝǌŝŶŐǀĞŶƚŝůĂƚŽƌŝŶƉůĂĐĞ͘ dƌĂŶƐƉŽƌƚŝŶŐƉĂƌĂŵĞĚŝĐƐŚŽƵůĚĨĂŵŝůŝĂƌŝǌĞƚŚĞŵƐĞůǀĞƐǁŝƚŚƚŚĞƉĂƚŝĞŶƚ͛ƐǀĞŶƚŝůĂƚŽƌƵƐŝŶŐĐĂƌĞŐŝǀĞƌƐ ŽƌĨĂŵŝůǇŵĞŵďĞƌƐŝĨƉŽƐƐŝďůĞ͘ZĞĨĞƌƚŽWƌŽĐĞĚƵƌĞƐƐĞĐƚŝŽŶĨŽƌƐƉĞĐŝĨŝĐĚĞƚĂŝůƐ͘ x /ĨƉĂƚŝĞŶƚŝƐŚĂǀŝŶŐƌĞƐƉŝƌĂƚŽƌǇŽƌǀĞŶƚŝůĂƚŽƌƉƌŽďůĞŵƐ͕ĚŝƐĐŽŶŶĞĐƚƚŚĞǀĞŶƚŝůĂƚŽƌĂŶĚǀĞŶƚŝůĂƚĞƵƐŝŶŐĂ sD͘ǀĂůƵĂƚĞĨŽƌƉŽƐƐŝďůĞĚŝƐƉůĂĐĞŵĞŶƚŽĨďƌĞĂƚŚŝŶŐƚƵďĞƐ͕ŽďƐƚƌƵĐƚŝŽŶŽĨƚƵďĞƐ͕ƚĞŶƐŝŽŶ ƉŶĞƵŵŽƚŚŽƌĂǆ͕ĂŶĚĞƋƵŝƉŵĞŶƚĨĂŝůƵƌĞƐ͘ Tracheostomy Tube x ^ƵĐƚŝŽŶƚƌĂĐŚĞŽƐƚŽŵǇƚƵďĞƵƐŝŶŐĨůĞǆŝďůĞͲƚŝƉĐĂƚŚĞƚĞƌ͘/ĨŶĞĐĞƐƐĂƌǇ͕ŝŶƐƚŝůůϭʹϮŵ>ŽĨŶŽƌŵĂůƐĂůŝŶĞ ĂŶĚƌĞƉĞĂƚƐƵĐƚŝŽŶŝŶŐ͘ x /ĨƚƵďĞŝƐŽďƐƚƌƵĐƚĞĚĂŶĚĚŽĞƐŶŽƚĐůĞĂƌǁŝƚŚƐƵĐƚŝŽŶŝŶŐ͕ĐŽŶƐŝĚĞƌƌĞƉůĂĐŝŶŐ͘ZĞĨĞƌƚŽWƌŽĐĞĚƵƌĞƐ ƐĞĐƚŝŽŶĨŽƌƐƉĞĐŝĨŝĐĚĞƚĂŝůƐ͘ Sickle Cell Disease x DĂǇƉƌĞƐĞŶƚǁŝƚŚƐĞǀĞƌĞƉĂŝŶ͕ƉĂůůŽƌ͕ƚĂĐŚǇƉŶĞĂ͕ĂŶĚͬŽƌƚĂĐŚǇĐĂƌĚŝĂ͘ x dƌĞĂƚƉĂŝŶƵƐŝŶŐƉĞĚŝĂƚƌŝĐPain ManagementŐƵŝĚĞůŝŶĞƐ͘ x ŝĨĨĞƌĞŶƚŝĂƚĞďĞƚǁĞĞŶƐĞƉƐŝƐĂŶĚƐĞǀĞƌĞĂŶĞŵŝĂŝŶƚŚĞƉƌĞƐĞŶĐĞŽĨƚĂĐŚǇĐĂƌĚŝĂĂŶĚƉĂůůŽƌ͘ o ^ĞƉƐŝƐƉƌĞƐĞŶƚƐǁŝƚŚĂůƚĞƌĞĚŵĞŶƚĂůƐƚĂƚƵƐ͕ĨĞǀĞƌ͕ĂŶĚƉŽƐƐŝďůǇǁĞĂŬĞŶĞĚƉƵůƐĞƐ͘ŚŝůĚƌĞŶǁŝƚŚ ƐŝĐŬůĞĐĞůůĚŝƐĞĂƐĞĂƌĞĂƚŝŶĐƌĞĂƐĞĚƌŝƐŬĨŽƌƐĞƉƐŝƐĂŶĚŽƚŚĞƌŝŶĨĞĐƚŝŽŶƐ͘ o ŶĞŵŝĂƉƌĞƐĞŶƚƐǁŝƚŚŶŽĨĞǀĞƌ͕ŶŽƌŵĂůŵĞŶƚĂůƐƚĂƚƵƐ͕ĂŶĚŶŽƌŵĂůƉƵůƐĞƐ͘ x sĂƐŽͲŽĐĐůƵƐŝǀĞĐƌŝƐĞƐĂƌĞƚŚĞŵŽƐƚĐŽŵŵŽŶĨŽƌŵŽĨƐŝĐŬůĞĐĞůůĐƌŝƐŝƐ͘dƌĞĂƚŵĞŶƚŝƐƉĂŝŶŵĂŶĂŐĞŵĞŶƚ ĂŶĚĨůƵŝĚďŽůƵƐĞƐŝĨƉĂƚŝĞŶƚƐŚŽǁƐƐŝŐŶƐŽĨƐŚŽĐŬŽƌĚĞŚǇĚƌĂƚŝŽŶ͘ Pearls x /ŶǀŽůǀĞĐĂƌĞŐŝǀĞƌƐĂŶĚͬŽƌĨĂŵŝůǇŵĞŵďĞƌƐ͘dŚĞǇǁŝůůďĞĨĂŵŝůŝĂƌǁŝƚŚƚŚĞĐŚŝůĚ͛ƐĚŝĂŐŶŽƐŝƐ͕ŽƉĞƌĂƚŝŶŐ ĂƐƐŝƐƚŝǀĞĞƋƵŝƉŵĞŶƚ͕ĂŶĚŚŽǁƚŽďĞƐƚŝŶƚĞƌĂĐƚǁŝƚŚĐŚŝůĚ͘ x ƐƚĂďůŝƐŚĐŚŝůĚ͛ƐďĂƐĞůŝŶĞǀŝƚĂůƐŝŐŶƐĂŶĚŵĞŶƚĂůƐƚĂƚƵƐ͘ƐŬĐĂƌĞŐŝǀĞƌƐĂŶĚͬŽƌĨĂŵŝůǇŝĨƉĂƚŝĞŶƚŝƐ ĂĐƚŝŶŐ͞ŶŽƌŵĂů͘͟ǀĞŶƐŵĂůůĐŚĂŶŐĞƐĨƌŽŵďĂƐĞůŝŶĞŵĂǇďĞĂƐŝŐŶŽĨƐŝŐŶŝĨŝĐĂŶƚƉƌŽďůĞŵƐ͘ x D^ƉƌŽǀŝĚĞƌƐŵĂǇĐŽŶƚĂĐƚƚŚĞĐŚŝůĚ͛ƐƉŚǇƐŝĐŝĂŶĨŽƌĂƐƐŝƐƚĂŶĐĞǁŝƚŚƐƉĞĐŝĨŝĐĐŽŶĚŝƚŝŽŶƐ͕ŵĞĚŝĐĂů ĞƋƵŝƉŵĞŶƚ͕ĂŶĚĨŽƌĂĚǀŝĐĞƌĞŐĂƌĚŝŶŐƚƌĞĂƚŵĞŶƚĂŶĚƚƌĂŶƐƉŽƌƚ͘ x dƌĂŶƐƉŽƌƚĐŚŝůĚƚŽŵŽƐƚĂƉƉƌŽƉƌŝĂƚĞŚŽƐƉŝƚĂů͕ƌĞŐĂƌĚůĞƐƐŽĨƐǇƐƚĞŵƐƚĂƚƵƐ͘dŚŝƐŵĂǇŝŶǀŽůǀĞ ďǇƉĂƐƐŝŶŐĂĐůŽƐĞƌĨĂĐŝůŝƚǇ͘

Cypress Creek EMS System Policies and Treatment Guidelines

170 PEDIATRIC MEDICAL Revised 8/2016 Approved: Levon Vartanian, MD

ƉƉĂƌĞŶƚ>ŝĨĞdŚƌĞĂƚĞŶŝŶŐǀĞŶƚ;>dͿ

ƐƐĞƐƐŵĞŶƚZĞƋƵŝƌĞŵĞŶƚƐ DĂǇWƌĞƐĞŶƚƐ ŽŶƐŝĚĞƌWŽƐƐŝďůĞĂƵƐĞƐ 'Z ƐƐĞƐƐŵĞŶƚΘĨƵůůŚĞĂĚͲƚŽͲƚŽĞ ^ƵĚĚĞŶĞǀĞŶƚƚŚĂƚŝƐĨƌŝŐŚƚĞŶŝŶŐ >ĂƌǇŶŐŽƐƉĂƐŵ ĞǆĂŵ ƚŽƚŚĞŽďƐĞƌǀĞƌĂŶĚ ƐƉŝƌĂƚŝŽŶ ƌŽƐĞůŽǁƚĂƉĞ ĐŚĂƌĂĐƚĞƌŝǌĞĚďǇĂĐŽŵďŝŶĂƚŝŽŶ EĞƵƌŽůŽŐŝĐĚŝƐŽƌĚĞƌƐ 'Θ^ƉKϮŵŽŶŝƚŽƌŝŶŐ͘ ŽĨĂƉŶĞĂ;ƌĞƐƉŝƌĂƚŽƌǇƉĂƵƐĞхϭϱ ZĞƐƉŝƌĂƚŽƌǇŝŶĨĞĐƚŝŽŶ ƐĞĐŽŶĚƐͿ͕ĚĞĐƌĞĂƐĞĚŵĞŶƚĂů ϭϮͲůĞĂĚ'ĂƐŝŶĚŝĐĂƚĞĚ ĂƌĚŝĂĐĚŝƐŽƌĚĞƌƐ ƐƚĂƚƵƐ͕ĐŽůŽƌĐŚĂŶŐĞ;ƉĂůůŽƌŽƌ '>ĂƐƐĞƐƐŵĞŶƚ hƉƉĞƌĂŝƌǁĂǇŽďƐƚƌƵĐƚŝŽŶ ĐǇĂŶŽƐŝƐͿ͕ĂůƚĞƌĂƚŝŽŶŝŶŵƵƐĐůĞ dĞŵƉĞƌĂƚƵƌĞ ďƵƐĞ ƚŽŶĞ;ƌŝŐŝĚŝƚǇŽƌůŝŵƉŶĞƐƐͿ͕ ĂŶĚͬŽƌĐŚŽŬŝŶŐ͘

Required Treatments x Airway management ĂƉƉƌŽƉƌŝĂƚĞ ƚŽƉĂƚŝĞŶƚĐŽŶĚŝƚŝŽŶ͘ x VentilationĂŶĚoxygenation ĂƉƉƌŽƉƌŝĂƚĞƚŽƉĂƚŝĞŶƚĐŽŶĚŝƚŝŽŶ͘ x KďƚĂŝŶĂƚŚŽƌŽƵŐŚŚŝƐƚŽƌǇĂŶĚƉŚǇƐŝĐĂůĞǆĂŵŝŶĂƚŝŽŶ͘ĞƚĞƌŵŝŶĞŶĂƚƵƌĞ͕ĚƵƌĂƚŝŽŶ͕ĂŶĚƐĞǀĞƌŝƚǇŽĨ ŝŶĐŝĚĞŶƚ͘ x EŽƚĞĂŶǇŝŶƚĞƌǀĞŶƚŝŽŶƐƚĂŬĞŶ;ƐƚŝŵƵůĂƚŝŽŶ͕ŵŽƵƚŚͲƚŽͲŵŽƵƚŚ͕WZ͕ĞƚĐ͘Ϳ x EŽƚĞĂŶǇƉƌĞŶĂƚĂůĂŶĚĐƵƌƌĞŶƚĨĂŵŝůǇƵƐĞŽĨĚƌƵŐƐ͕ƚŽďĂĐĐŽ͕ĂŶĚĂůĐŽŚŽů͘ x EŽƚĞƉĂƚŝĞŶƚ͛ƐƌĞĐĞŶƚĨĞĞĚŝŶŐŚĂďŝƚƐ͘ x EŽƚĞĂŶǇĐŽŵƉůŝĐĂƚŝŽŶƐŽĨƉĂƚŝĞŶƚ͛ƐďŝƌƚŚ;ƉƌĞͲƚĞƌŵ͕ƐŝǌĞ͕ĞƚĐ͘Ϳ͘ x Patients with an ALTE incident require transport for evaluation. x ŽŶƐŝĚĞƌƐƵƉĞƌǀŝƐŽƌĐŽŶƐƵůƚŝĨƉĂƚŝĞŶƚ͛ƐĐĂƌĞŐŝǀĞƌ͕ƉĂƌĞŶƚ͕ĂŶĚͬŽƌŐƵĂƌĚŝĂŶŝƐƌĞĨƵƐŝŶŐĐĂƌĞ͘ Pearls x tŝƚŶĞƐƐĞƐƐŚŽƵůĚďĞƚŚŽƌŽƵŐŚůǇƋƵĞƐƚŝŽŶĞĚĂďŽƵƚƚŚĞĚĞƚĂŝůƐŽĨƚŚĞ>d͘ x dŚĞŵĂũŽƌŝƚǇŽĨĐŚŝůĚƌĞŶǁŝůůŚĂǀĞĂŶŽƌŵĂůƉƌĞƐĞŶƚĂƚŝŽŶ͘ x DŽƐƚĐŽŵŵŽŶůǇŽĐĐƵƌƐŝŶĐŚŝůĚƌĞŶďĞƚǁĞĞŶƚŚĞĂŐĞƐŽĨϮͲϯŵŽŶƚŚƐ͕ďƵƚŚĂǀĞďĞĞŶƐĞĞŶƵƉƚŽϭ ǇĞĂƌ͘ x ƉƌŽďĂďůĞĐĂƵƐĞĨŽƌĂŶ>dĐĂŶďĞĨŽƵŶĚŝŶϱϬйŽĨƉĂƚŝĞŶƚƐ͕ůĞĂǀŝŶŐƚŚĞƌĞŵĂŝŶŝŶŐϱϬйǁŝƚŚĂŶ ƵŶĞǆƉůĂŝŶĞĚ>d͘ x >dƐĂƌĞĂƐƐŽĐŝĂƚĞĚǁŝƚŚĂƐŝŐŶŝĨŝĐĂŶƚƌŝƐŬĨŽƌĚĞĂƚŚĂŶĚŽĨƚĞŶĂƌĞƚŚĞŽŶůǇƐŝŐŶŽĨĂƐŝŐŶŝĨŝĐĂŶƚ ŵĞĚŝĐĂůĚŝƐŽƌĚĞƌ͘

Cypress Creek EMS System Policies and Treatment Guidelines

171 TRAUMA/ENVIRONMENTAL Revised 8/2016 Approved: Levon Vartanian, MD

dƌĂƵŵĂͬŶǀŝƌŽŶŵĞŶƚĂů

General Trauma Treatment ...... 173 Major/Multi-System Trauma ...... 174 Traumatic Arrest ...... 177 Amputation...... 179 Bites and Envenomations ...... 180 Blast Injury ...... 182 Burns:Thermal ...... 184 Burns: Chemical and Electrical ...... 187 Crush Syndrome and Compartment Syndrome ...... 188 Drowning ...... 190 Extremity Trauma ...... 191 Eye Injuries ...... 192 Head Trauma ...... 193 Hyperthermia ...... 194 Hypothermia ...... 195 Hypotension/Shock ...... 196 Sexual Assault ...... 199 Smoke Inhalation ...... 200

Cypress Creek EMS System Policies and Treatment Guidelines

172 TRAUMA/ENVIRONMENTAL Revised 8/2016 Approved: Levon Vartanian, MD

'ĞŶĞƌĂůdƌĂƵŵĂdƌĞĂƚŵĞŶƚ ƐƐĞƐƐŵĞŶƚ x ĞĂǁĂƌĞŽĨƐĐĞŶĞƐĂĨĞƚǇĐŽŶƐŝĚĞƌĂƚŝŽŶƐ͖ǁŚĂƚŝŶũƵƌĞĚƚŚĞƉĂƚŝĞŶƚĐŽƵůĚŝŶũƵƌĞǇŽƵ͘ x ŽŶĚƵĐƚĂƚŚŽƌŽƵŐŚPrimary SurveyĂŶĚĂFocused ŽƌFull Head-to-ToeƉŚǇƐŝĐĂůĞǆĂŵ͕ĂƐ ĂƉƉƌŽƉƌŝĂƚĞ͘ x dƌĞĂƚůŝĨĞƚŚƌĞĂƚƐŝŵŵĞĚŝĂƚĞůǇ͘ x ZĂƉŝĚůǇĚĞƚĞƌŵŝŶĞŝĨĂ͞>ŽĂĚĂŶĚ'Ž͟ƐŝƚƵĂƚŝŽŶĞǆŝƐƚƐ͘/ĨƚŚĞƉĂƚŝĞŶƚŝƐƵƌŐĞŶƚ͕ƐĐĞŶĞƚŝŵĞƐŚŽƵůĚďĞ ůĞƐƐƚŚĂŶϭϬŵŝŶƵƚĞƐ͘ x WƌĞƐĞƌǀĞĐƌŝŵĞƐĐĞŶĞΘƉŽƚĞŶƚŝĂůĞǀŝĚĞŶĐĞďǇďĞŝŶŐĂǁĂƌĞŽĨƐƵƌƌŽƵŶĚŝŶŐƐ͕ĂǀŽŝĚŝŶŐŵŽǀŝŶŐ ĂŶǇƚŚŝŶŐŽŶƐĐĞŶĞƵŶůĞƐƐĂďƐŽůƵƚĞůǇŶĞĐĞƐƐĂƌǇ͕ĂŶĚůŝŵŝƚŝŶŐŶƵŵďĞƌŽĨƉĞƌƐŽŶŶĞůĂŶĚĂŵŽƵŶƚŽĨ ĞƋƵŝƉŵĞŶƚŵŽǀĞĚŝŶƚŽĐƌŝŵĞƐĐĞŶĞ͘ŽĐƵŵĞŶƚŝŶũƵƌŝĞƐ͕ƐƚĂƚĞŵĞŶƚƐďǇƉĂƚŝĞŶƚ͕ĂŶĚƐĐĞŶĞ ƉƌĞƐĞŶƚĂƚŝŽŶĂƐƚŚŽƌŽƵŐŚůǇĂŶĚĂĐĐƵƌĂƚĞůǇĂƐƉŽƐƐŝďůĞ͘ 'ĞŶĞƌĂůdƌĞĂƚŵĞŶƚ x Airway management ĂƉƉƌŽƉƌŝĂƚĞ ƚŽƉĂƚŝĞŶƚĐŽŶĚŝƚŝŽŶ͘ x VentilationĂŶĚoxygenation ĂƉƉƌŽƉƌŝĂƚĞƚŽƉĂƚŝĞŶƚĐŽŶĚŝƚŝŽŶ͘ x (I) Vascular accessǁŝƚŚ/sŝĨŝŶĚŝĐĂƚĞĚ͘ x (P) ŽŶƐŝĚĞƌPain Management ƉƌŽĐĞĚƵƌĞ͕ŝĨĂƉƉƌŽƉƌŝĂƚĞ͘ x (B) ŽŶƐŝĚĞƌSpinal Motion RestrictionŝĨŝŶĚŝĐĂƚĞĚ͘ x dƌĞĂƚŚǇƉŽƚĞŶƐŝŽŶͬƐŚŽĐŬǁŝƚŚHypotension/ShockŐƵŝĚĞůŝŶĞƐ͘

Cypress Creek EMS System Policies and Treatment Guidelines

173 TRAUMA/ENVIRONMENTAL Revised 8/2016 Approved: Levon Vartanian, MD

DĂũŽƌͬDƵůƚŝͲ^ǇƐƚĞŵdƌĂƵŵĂ ƐƐĞƐƐŵĞŶƚZĞƋƵŝƌĞŵĞŶƚƐ DĂǇWƌĞƐĞŶƚƐ ŽŶƐŝĚĞƌWŽƐƐŝďůĞĂƵƐĞƐ ƐƐĞƐƐŵĞŶƚΘ&ƵůůŚĞĂĚͲƚŽͲ WĂŝŶ͕ƐǁĞůůŝŶŐ Life Threats: ƚŽĞĞǆĂŵ ĞĨŽƌŵŝƚǇ͕ůĞƐŝŽŶƐ͕ďůĞĞĚŝŶŐ ŚĞƐƚ͗dĞŶƐŝŽŶ DĞĐŚĂŶŝƐŵŽĨŝŶũƵƌǇ ůƚĞƌĞĚŵĞŶƚĂůƐƚĂƚƵƐ ƉŶĞƵŵŽƚŚŽƌĂǆ͕ĨůĂŝůƐĞŐŵĞŶƚ͕ 'DŽŶŝƚŽƌŝŶŐ;ĚŽŶŽƚĚĞůĂǇ ,ǇƉŽƚĞŶƐŝŽŶͬƐŚŽĐŬ ƉĞƌŝĐĂƌĚŝĂůƚĂŵƉŽŶĂĚĞ͕ŽƉĞŶ ƚƌĂŶƐƉŽƌƚͿ ƌƌĞƐƚ ĐŚĞƐƚǁŽƵŶĚƐ͕ŚĞŵŽƚŚŽƌĂǆ͘ dKϮŵŽŶŝƚŽƌŝŶŐ;ĚŽŶŽƚ /ŶƚƌĂͲĂďĚŽŵŝŶĂůďůĞĞĚŝŶŐ͘ ĚĞůĂǇƚƌĂŶƐƉŽƌƚͿ WĞůǀŝƐͬĨĞŵƵƌĨƌĂĐƚƵƌĞ ^ƉŝŶĂůĨƌĂĐƚƵƌĞͬĐŽƌĚŝŶũƵƌǇ ,ĞĂĚŝŶũƵƌǇ ǆƚƌĞŵŝƚǇ ĨƌĂĐƚƵƌĞͬĚŝƐůŽĐĂƚŝŽŶͬǁŽƵŶĚ ŝƌǁĂǇŽďƐƚƌƵĐƚŝŽŶ ,ǇƉŽƚŚĞƌŵŝĂ Major/Urgent Trauma Criteria hŶƐƚĂďůĞsŝƚĂů^ŝŐŶƐͬWŚǇƐŝŽůŽŐŝĐWĂƌĂŵĞƚĞƌƐ x ^ŝŐŶƐͬƐǇŵƉƚŽŵƐŽĨƐŚŽĐŬ;ďƐĞŶƚͬǁĞĂŬƉĞƌŝƉŚĞƌĂůƉƵůƐĞƐ͕ŚǇƉŽƚĞŶƐŝŽŶ͕ƉĂůůŽƌ͕ƚĂĐŚǇĐĂƌĚŝĂ͕ ĚŝĂƉŚŽƌĞƐŝƐ͕ĞƚĐ͘Ϳ x ZĞƐƉŝƌĂƚŽƌǇĐŽŵƉƌŽŵŝƐĞ;ƌĂƚĞфϭϬŽƌхϮϵͿ x ůƚĞƌĞĚŵĞŶƚĂůƐƚĂƚƵƐ;'^фϭϯͿ x DƵůƚŝͲƐǇƐƚĞŵƚƌĂƵŵĂǁŝƚŚƵŶƐƚĂďůĞǀŝƚĂůƐŝŐŶƐ͘ ŶĂƚŽŵŝĐĂů/ŶũƵƌǇ x WĞŶĞƚƌĂƚŝŶŐŝŶũƵƌǇƚŽŚĞĂĚ͕ŶĞĐŬ͕ƚŽƌƐŽ͕ŽƌŐƌŽŝŶ x /ŶũƵƌǇŝŶĐŽŵďŝŶĂƚŝŽŶǁŝƚŚďƵƌŶƐхϭϬйd^ŽƌŝŶĐŽŵďŝŶĂƚŝŽŶǁŝƚŚďƵƌŶƐƚŽĨĂĐĞ͕ĂŝƌǁĂǇ͕ŚĂŶĚƐ͕ ĨĞĞƚ͕ŽƌŐĞŶŝƚĂůŝĂ x dŽƚĂůŽƌƉĂƌƚŝĂůĂŵƉƵƚĂƚŝŽŶŽĨĞǆƚƌĞŵŝƚǇĂďŽǀĞĚŝŐŝƚƐ x ǆƚƌĞŵŝƚǇŝŶũƵƌǇǁŝƚŚĂďƐĞŶĐĞŽĨĚŝƐƚĂůƉƵůƐĞŽƌŽƚŚĞƌƐƵƐƉĞĐƚĞĚŶĞƵƌŽǀĂƐĐƵůĂƌŝŶũƵƌǇ x ^ĞǀĞƌĞĐƌƵƐŚŝŶũƵƌǇǁŝƚŚŶƵŵďŶĞƐƐŽƌƐĞǀĞƌĞƉĂŝŶ x WĂƌĂůǇƐŝƐŽƌŽƚŚĞƌƐƵƐƉĞĐƚĞĚƐƉŝŶĂůŝŶũƵƌǇ x &ůĂŝůĐŚĞƐƚ x dǁŽŽƌŵŽƌĞůŽŶŐďŽŶĞĨƌĂĐƚƵƌĞƐ x KƉĞŶŽƌƐƵƐƉĞĐƚĞĚĚĞƉƌĞƐƐĞĚƐŬƵůůĨƌĂĐƚƵƌĞ x hŶƐƚĂďůĞƉĞůǀŝĐŽƌƐƵƐƉĞĐƚĞĚƉĞůǀŝĐĨƌĂĐƚƵƌĞ x hŶƐƚĂďůĞŽƌŝŶƚƵďĂƚĞĚĂŝƌǁĂǇ

Cypress Creek EMS System Policies and Treatment Guidelines

174 TRAUMA/ENVIRONMENTAL Revised 8/2016 Approved: Levon Vartanian, MD

General Treatments for Urgent/Major Trauma x /ĨƉĂƚŝĞŶƚŚĂƐƵŶƐƚĂďůĞsͬ^͕ŚǇƉŽƉĞƌĨƵƐŝŽŶ͕ĚĞĐƌĞĂƐĞĚ'^͕ƌĂƉŝĚůǇƚƌĂŶƐƉŽƌƚƵƐŝŶŐƚŚĞTrauma and BurnsdƌĂŶƐƉŽƌƚĞƐƚŝŶĂƚŝŽŶƉůĂŶ͘Limit scene time to < 10 minutes. x ŽŶƐŝĚĞƌAir MedicalƵƚŝůŝǌĂƚŝŽŶĨŽƌĂŶǇŽĨƚŚĞĨŽůůŽǁŝŶŐ͗ x ĞůĂǇŽŶƐĐĞŶĞ;Ğ͘Ő͕͘ĞǆƚƌŝĐĂƚŝŽŶͿ͘ x dƌĂŶƐƉŽƌƚĂƚŝŽŶŵĂǇďĞĚĞůĂǇĞĚďǇŚĞĂǀǇƚƌĂĨĨŝĐŽƌĚŝƐƚĂŶĐĞ͘ x WĂƚŝĞŶƚŵĂǇďĞŶĞĨŝƚĨƌŽŵďůŽŽĚƉƌŽĚƵĐƚƐ;ŝŶƚĞƌŶĂůďůĞĞĚŝŶŐ͕ŚǇƉŽƚĞŶƐŝŽŶ͕ƚĂĐŚǇĐĂƌĚŝĂͿ͘ KŶ^ĐĞŶĞĂƌĞ x (B) Control exsanguinating hemorrhage;dŽƵƌŶŝƋƵĞƚƐ͕Hemorrhage ControlƉƌŽĐĞĚƵƌĞͿ͘ x Airway management ĂƉƉƌŽƉƌŝĂƚĞ ƚŽƉĂƚŝĞŶƚĐŽŶĚŝƚŝŽŶ͘ x VentilationĂŶĚoxygenation ĂƉƉƌŽƉƌŝĂƚĞƚŽƉĂƚŝĞŶƚĐŽŶĚŝƚŝŽŶ͘ x (B)CoverĂŶǇŽƉĞŶĐŚĞƐƚͬƚŽƌƐŽǁŽƵŶĚƐǁŝƚŚŽĐĐůƵƐŝǀĞĚƌĞƐƐŝŶŐ x (P)Needle decompressƚĞŶƐŝŽŶƉŶĞƵŵŽƚŚŽƌĂǆ;ƵŶŝůĂƚĞƌĂůĂďƐĞŶƚďƌĞĂƚŚƐŽƵŶĚƐ͕ĂůƚĞƌĞĚŵĞŶƚĂů ƐƚĂƚƵƐ͕ĂŶĚǁĞĂŬͬĂďƐĞŶƚƌĂĚŝĂůƉƵůƐĞͿ͘ x (B) Spinal Motion RestrictionŝĨŝŶĚŝĐĂƚĞĚ͘ŽŶŽƚ^DZƉĞŶĞƚƌĂƚŝŶŐƚƌĂƵŵĂ͕ƵŶůĞƐƐƐƉĞĐŝĨŝĐĨŽĐĂů ŶĞƵƌŽůŽŐŝĐĂůĚĞĨŝĐŝƚƐĂƌĞŝĚĞŶƚŝĨŝĞĚ͘ x &ŽĐƵƐŽŶŽŶůǇƚŚĞĞƐƐĞŶƚŝĂůůŝĨĞƐĂǀŝŶŐŝŶƚĞƌǀĞŶƚŝŽŶƐŽŶƐĐĞŶĞ͘>ĞĂǀĞƐĐĞŶĞĂƐƋƵŝĐŬůǇĂƐƉŽƐƐŝďůĞ͘ x KEKdĚĞůĂǇƚƌĂŶƐƉŽƌƚƚŽƉůĂĐĞ/sůŽĐŬƐ͕ƉůĂĐĞƉĂƚŝĞŶƚŽŶĐĂƌĚŝĂĐŵŽŶŝƚŽƌ͕ŽƌƉĞƌĨŽƌŵĂŶǇŽƚŚĞƌ ƚƌĞĂƚŵĞŶƚŶŽƚƐƉĞĐŝĨŝĐĂůůǇŶĞĐĞƐƐĂƌǇƚŽŝŵŵĞĚŝĂƚĞůǇƚƌĞĂƚĂůŝĨĞƚŚƌĞĂƚ͘ ĂƌĞĚƵƌŝŶŐdƌĂŶƐƉŽƌƚ x (I) Vascular accessǁŝƚŚ/sŽƌ/K͘/ĨƉŽƐƐŝďůĞ͕ĞƐƚĂďůŝƐŚƚǁŽůĂƌŐĞͲďŽƌĞ/sƐ͘ x Trauma Hypotension/ShockŐƵŝĚĞůŝŶĞƐ͕ŝĨŝŶĚŝĐĂƚĞĚ x Head Injury ŐƵŝĚĞůŝŶĞƐ͕ŝĨŝŶĚŝĐĂƚĞĚ͘ x (B) SplintƐƵƐƉĞĐƚĞĚĨƌĂĐƚƵƌĞƐ͘ x (B) ŽŶƐŝĚĞƌpelvic binding x (B)ControlĞǆƚĞƌŶĂůŚĞŵŽƌƌŚĂŐĞ͘ x (B)CoverĂŶǇŽƉĞŶĐŚĞƐƚͬƚŽƌƐŽǁŽƵŶĚƐǁŝƚŚŽĐĐůƵƐŝǀĞĚƌĞƐƐŝŶŐ x (P)Needle decompressƚĞŶƐŝŽŶƉŶĞƵŵŽƚŚŽƌĂǆ;ƵŶŝůĂƚĞƌĂůĂďƐĞŶƚďƌĞĂƚŚƐŽƵŶĚƐ͕ĂůƚĞƌĞĚŵĞŶƚĂů ƐƚĂƚƵƐ͕ĂŶĚǁĞĂŬͬĂďƐĞŶƚƌĂĚŝĂůƉƵůƐĞͿ͘ x (B)<ĞĞƉƉĂƚŝĞŶƚǁĂƌŵ͘ x ReassessĞǀĞƌǇϱŵŝŶƵƚĞƐŽƌĂĨƚĞƌĂŶǇĐŚĂŶŐĞŝŶƉĂƚŝĞŶƚĐŽŶĚŝƚŝŽŶ͘ ĂƌĞĂƚ,ŽƐƉŝƚĂů General Treatment for Multi-system, Non-Urgent Trauma x ZĞĨĞƌƚŽTrauma and Burn Transport Destination DeterminationŐƵŝĚĞůŝŶĞƐ͘ x dƌĞĂƚƐƉĞĐŝĨŝĐŝŶũƵƌŝĞƐĂƐŝŶĚŝĐĂƚĞĚ͘ x Airway management ĂƉƉƌŽƉƌŝĂƚĞ ƚŽƉĂƚŝĞŶƚĐŽŶĚŝƚŝŽŶ͘ x VentilationĂŶĚoxygenation ĂƉƉƌŽƉƌŝĂƚĞƚŽƉĂƚŝĞŶƚĐŽŶĚŝƚŝŽŶ͘

Cypress Creek EMS System Policies and Treatment Guidelines

175 TRAUMA/ENVIRONMENTAL Revised 8/2016 Approved: Levon Vartanian, MD

Pearls x /ĨŵĂŶĂŐŝŶŐĂŝƌǁĂǇ͕ĐŽŶƐŝĚĞƌSedationŐƵŝĚĞůŝŶĞƐĂŶĚKing supraglottic airwayƉůĂĐĞŵĞŶƚƚŽ ŵŝŶŝŵŝǌĞĚĞůĂǇŝŶƚƌĞĂƚŵĞŶƚ͘ x /ƚŝƐĂĐĐĞƉƚĂďůĞƚŽŵĂŶĂŐĞĂŝƌǁĂǇƵƐŝŶŐŽŶůǇďĂƐŝĐĂŝƌǁĂǇŵĂŶĞƵǀĞƌƐŝĨ^ƉKϮĐĂŶďĞŵĂŝŶƚĂŝŶĞĚ ĂďŽǀĞϵϬй͘

Cypress Creek EMS System Policies and Treatment Guidelines

176 TRAUMA/ENVIRONMENTAL Revised 8/2016 Approved: Levon Vartanian, MD

dƌĂƵŵĂƚŝĐƌƌĞƐƚ ƐƐĞƐƐŵĞŶƚZĞƋƵŝƌĞŵĞŶƚƐ DĂǇWƌĞƐĞŶƚƐ ŽŶƐŝĚĞƌWŽƐƐŝďůĞĂƵƐĞƐ ƐƐĞƐƐŵĞŶƚǁŝƚŚĨƵůůŚĞĂĚͲ WƵůƐĞůĞƐƐ͕ĂƉŶĞŝĐƉĂƚŝĞŶƚƐ Medical conditionƉƌĞĐĞĚŝŶŐ ƚŽͲƚŽĞĞǆĂŵ͘ ǁŝƚŚĞǀŝĚĞŶĐĞŽĨƉĞŶĞƚƌĂƚŝŶŐ ƚƌĂƵŵĂƚŝĐĞǀĞŶƚ͕ĐĂƵƐŝŶŐ 'ŵŽŶŝƚŽƌŝŶŐ ŽƌďůƵŶƚƚƌĂƵŵĂ͘ ĂƌƌĞƐƚ͘ dKϮŵŽŶŝƚŽƌŝŶŐ Tension pneumothorax ŽƌĞƚĞŵƉĞƌĂƚƵƌĞ Airway obstruction ŵĞĂƐƵƌĞŵĞŶƚ Open chest wounds '>ƐƐĞƐƐŵĞŶƚ Pericardial tamponade Hypovolemic shock: x ǆƚĞƌŶĂůŚĞŵŽƌƌŚĂŐĞ x /ŶƚĞƌŶĂůŚĞŵŽƌƌŚĂŐĞ x hŶƐƚĂďůĞƉĞůǀŝĐĨƌĂĐƚƵƌĞ x ŝƐƉůĂĐĞĚůŽŶŐďŽŶĞ ĨƌĂĐƚƵƌĞƐ͘ Do Not Attempt Resuscitation x WĂƚŝĞŶƚƐǁŝƚŚ/ŶũƵƌŝĞƐŝŶĐŽŵƉĂƚŝďůĞǁŝƚŚůŝĨĞŝŶĐůƵĚĞĚĞĐĂƉŝƚĂƚŝŽŶ͕ŵĂƐƐŝǀĞůǇĚĞĨŽƌŵŝŶŐŚĞĂĚŽƌĐŚĞƐƚ ŝŶũƵƌŝĞƐ͕ĚĞƉĞŶĚĞŶƚůŝǀŝĚŝƚǇ͕ƌŝŐŽƌŵŽƌƚŝƐ͕ĞǆƚĞŶĚĞĚĚŽǁŶƚŝŵĞǁŝƚŚĐŽŽůͬĐŽůĚƐŬŝŶEŽďǀŝŽƵƐ ƉĞŶĞƚƌĂƚŝŶŐŽƌƐŝŐŶŝĨŝĐĂŶƚďůƵŶƚĨŽƌĐĞŝŶũƵƌǇƚŽŚĞĂĚŽƌƚŽƌƐŽ͘ x WĂƚŝĞŶƚƐƉƌĞƐĞŶƚŝŶŐŝŶĂƐǇƐƚŽůĞ͘ Do Attempt Resuscitation /ŶĐĂƌĚŝĂĐĂƌƌĞƐƚƉĂƚŝĞŶƚƐǁŝƚŚsĞŶƚƌŝĐƵůĂƌ&ŝďƌŝůůĂƚŝŽŶͬsĞŶƚƌŝĐƵůĂƌdĂĐŚǇĐĂƌĚŝĂŽƌW͕ĂƚƚĞŵƉƚ ƌĞƐƵƐĐŝƚĂƚŝŽŶǁŝƚŚƚŚĞƐĞŐƵŝĚĞůŝŶĞƐ͗ x ^ƵƌǀŝǀĂůĨƌŽŵƚƌĂƵŵĂƚŝĐĐĂƌĚŝĂĐĂƌƌĞƐƚŝƐƌĂƌĞĂŶĚĚĞƉĞŶĚƐŽŶƐƵĐĐĞƐƐĨƵůůǇƌĞǀĞƌƐŝŶŐƚŚĞĐĂƵƐĞŽĨƚŚĞ ĂƌƌĞƐƚ͘dŚĞƌĞĂƌĞĂƐŵĂůůŶƵŵďĞƌŽĨŝŶũƵƌŝĞƐƚŚĂƚĂƌĞƌĞǀĞƌƐŝďůĞ͕ĂŶĚŝŶŝƚŝĂůƌĞƐƵƐĐŝƚĂƚŝŽŶŝŶƚŚĞ ƚƌĂƵŵĂƉĂƚŝĞŶƚŶĞĞĚƐƚŽƚƌĞĂƚĂůůŽĨƚŚĞƐĞƋƵŝĐŬůǇ͘ x ZĂƉŝĚƚƌĂŶƐƉŽƌƚƚŽĂĚĞƐŝŐŶĂƚĞĚ>ĞǀĞůϰŽƌĂďŽǀĞƚƌĂƵŵĂĐĞŶƚĞƌƌĞƉƌĞƐĞŶƚƐƚŚĞďĞƐƚĐŚĂŶĐĞŽĨ ƚƌĞĂƚŝŶŐĂůůƌĞǀĞƌƐŝďůĞĐĂƵƐĞƐŽĨĐĂƌĚŝĂĐĂƌƌĞƐƚ͘ŽŶŽƚĚĞůĂǇƐĐĞŶĞƚŝŵĞƵŶŶĞĐĞƐƐĂƌŝůǇ͘ ϭ͘ (B) Spinal Immobilization Procedure ŝĨŝŶĚŝĐĂƚĞĚ͘ Ϯ͘ (B) ControlƐƵďƐƚĂŶƚŝĂůĞǆƐĂŶŐƵŝŶĂƚŝŶŐŚĞŵŽƌƌŚĂŐĞǁŝƚŚĂƚŽƵƌŶŝƋƵĞƚ͕ŝĨŝŶĚŝĐĂƚĞĚ͘ ϯ͘ (B)/ŶŝƚŝĂƚĞĐŚĞƐƚĐŽŵƉƌĞƐƐŝŽŶƐŵĂŶƵĂůůǇŽƌǁŝƚŚ>ƵĐĂƐĞǀŝĐĞ͘ ϰ͘ (B) ^ĞĐƵƌĞĂŝƌǁĂǇƵƐŝŶŐĂ<ŝŶŐƐƵƉƌĂŐůŽƚƚŝĐĂŝƌǁĂǇŽƌĐůĞĂƌĂŝƌǁĂǇŽďƐƚƌƵĐƚŝŽŶƐ͕ĂƐŝŶĚŝĐĂƚĞĚ͘ ϱ͘ (B) sĞŶƚŝůĂƚĞΘŽǆǇŐĞŶĂƚĞƉĂƚŝĞŶƚƵƐŝŶŐsDǁŝƚŚϭϬϬй&ŝKϮ͘ ϲ͘ (P) /ĨĂŶǇƉŽƐƐŝďŝůŝƚǇŽĨĂĐŚĞƐƚŝŶũƵƌǇ͕ƉĞƌĨŽƌŵďŝůĂƚĞƌĂůNeedle DecompressionƐƚŽƚƌĞĂƚƉŽƐƐŝďůĞ ƚĞŶƐŝŽŶƉŶĞƵŽŵŽƚŚŽƌĂǆ͘ ϳ͘ (B)^ĞĐƵƌĞĐŚĞƐƚƐĞĂůƐŽŶĂŶǇŽƉĞŶǁŽƵŶĚƐďĞƚǁĞĞŶƵŵďŝůŝĐƵƐĂŶĚŶĞĐŬ͘ ϴ͘ (P) /ĨŝŶĚŝĐĂƚĞĚ͕ƉĞƌĨŽƌŵĚĞĨŝďƌŝůůĂƚŝŽŶ͘ ϵ͘ (I) ƐƚĂďůŝƐŚǀĂƐĐƵůĂƌĂĐĐĞƐƐǁŝƚŚ/K;WƌĞĨĞƌƌĞĚͿŽƌ/s

Cypress Creek EMS System Policies and Treatment Guidelines

177 TRAUMA/ENVIRONMENTAL Revised 8/2016 Approved: Levon Vartanian, MD

ϭϬ͘ (P) /ĨďůŽŽĚƉƌŽĚƵĐƚƐĂƌĞŽŶƐĐĞŶĞĂŶĚĂǀĂŝůĂďůĞ͕ŝŶŝƚŝĂƚĞďůŽŽĚƚƌĂŶƐĨƵƐŝŽŶ͘ ϭϭ͘ (P) ^ƚĂƌƚWůĂƐŵĂůǇƚĞĨůƵŝĚďŽůƵƐǁŝĚĞŽƉĞŶƵƉƚŽϮϬŵ>ͬŬŐ͘ ϭϮ͘ Rapidly transport to nearest designated (Level 4 or above) trauma center. ŽŶŽƚƚƌĂŶƐƉŽƌƚƚŽĂ ŶŽŶͲĚĞƐŝŐŶĂƚĞĚƚƌĂƵŵĂĐĞŶƚĞƌ͘ŽŶŽƚďǇƉĂƐƐĂ>ĞǀĞůϯͬϰƚƌĂƵŵĂĐĞŶƚĞƌƚŽŐŽƚŽĂŚŝŐŚĞƌůĞǀĞůŽĨ ĐĂƌĞ͘KŶůǇƵƚŝůŝǌĞĂŝƌŵĞĚŝĐĂůƚƌĂŶƐƉŽƌƚŝŶĐĂƐĞƐǁŚĞƌĞŝƚŝƐƚŚĞĨĂƐƚĞƐƚƌŽƵƚĞƚŽĂĚĞƐŝŐŶĂƚĞĚƚƌĂƵŵĂ ĐĞŶƚĞƌ͕ƐƵĐŚĂƐĞǆƚĞŶĚĞĚĞǆƚƌŝĐĂƚŝŽŶƚŝŵĞ͕ĚŝƐĂƐƚĞƌƐ͕ŽƌŚŝŐŚƚƌĂĨĨŝĐ͘ ϭϯ͘ Return of Pulse/ROSC: &ŽůůŽǁZĞƚƵƌŶŽĨWƵůƐĞŐƵŝĚĞůŝŶĞƐĂŶĚŵƵůƚŝͲƐǇƐƚĞŵƚƌĂƵŵĂŐƵŝĚĞůŝŶĞƐ͘Ğ ĐĂƵƚŝŽƵƐŝŶƵƚŝůŝǌŝŶŐǀĂƐŽƉƌĞƐƐŽƌƐ͘ Pearls x ŽŶƐŝĚĞƌƵƐŝŶŐŵĞĚŝĐĂůĐĂƌĚŝĂĐĂƌƌĞƐƚŐƵŝĚĞůŝŶĞƐŝĨƵŶĐĞƌƚĂŝŶĂďŽƵƚŵĞĚŝĐĂůŽƌƚƌĂƵŵĂƚŝĐĐĂƵƐĞŽĨ ĂƌƌĞƐƚ͘ x dƌĂŶƐƉŽƌƚƐŚŽƵůĚŶŽƚďĞĚĞůĂǇĞĚĨŽƌƚŚĞƐĞƉĂƚŝĞŶƚƐ͘

Cypress Creek EMS System Policies and Treatment Guidelines

178 TRAUMA/ENVIRONMENTAL Revised 8/2016 Approved: Levon Vartanian, MD

ŵƉƵƚĂƚŝŽŶ ƐƐĞƐƐŵĞŶƚZĞƋƵŝƌĞŵĞŶƚƐ DĂǇWƌĞƐĞŶƚƐ ŽŶƐŝĚĞƌWŽƐƐŝďůĞĂƵƐĞƐ ƐƐĞƐƐŵĞŶƚΘĨŽĐƵƐĞĚŽƌĨƵůů WĂŝŶ͕ƐǁĞůůŝŶŐ͕ďůĞĞĚŝŶŐ͘ >ŝĨĞƚŚƌĞĂƚƐ͗ ŚĞĂĚͲƚŽͲƚŽĞĞǆĂŵĂƐ ǆƐĂŶŐƵŝŶĂƚŝŶŐŚĞŵŽƌƌŚĂŐĞ ŝŶĚŝĐĂƚĞĚ͘

dƌĞĂƚŵĞŶƚƐ x (B) Control exsanguinating hemorrhageǁŝƚŚdŽƵƌŶŝƋƵĞƚ;ƐͿ͘;ZĞĨĞƌƚŽHemorrhage Control ƉƌŽĐĞĚƵƌĞͿ͘ x Airway management ĂƉƉƌŽƉƌŝĂƚĞ ƚŽƉĂƚŝĞŶƚĐŽŶĚŝƚŝŽŶ x VentilationĂŶĚoxygenation ĂƉƉƌŽƉƌŝĂƚĞƚŽƉĂƚŝĞŶƚĐŽŶĚŝƚŝŽŶ x (I) Vascular accessǁŝƚŚ/sŽƌ/K͕ŝĨŝŶĚŝĐĂƚĞĚ x (P) Trauma Hypotension/ShockŐƵŝĚĞůŝŶĞƐ͕ŝĨŝŶĚŝĐĂƚĞĚ x (P) Pain ManagementƉƌŽĐĞĚƵƌĞ͕ŝĨŝŶĚŝĐĂƚĞĚ x (P) Blood Products͕ŝĨŝŶĚŝĐĂƚĞĚ WĞĂƌůƐ x ^ŽŵĞĂŵƉƵƚĂƚŝŽŶƐƉƌĞƐĞŶƚǁŝƚŚǁŚĂƚĂƉƉĞĂƌƐƚŽďĞĐŽŶƚƌŽůůĞĚŚĞŵŽƌƌŚĂŐĞ͘ŽEKdďĞĨŽŽůĞĚďǇ ƚŚŝƐ͕WW>zĂƚŽƵƌŶŝƋƵĞƚŝĨƚŚĞƐŝƚĞŝƐĂŵĞŶĂďůĞ͘ x ǁĞůůƉůĂĐĞĚdƚŽƵƌŶŝƋƵĞƚĐĂŶŚĞůƉƚŽĐŚĂŶŐĞĚŝƌĞĐƚŝŽŶŽĨďĂŶĚĂŐĞĂƉƉůŝĐĂƚŝŽŶǁŚĞŶƵƐŝŶŐƚŚĞ /ƐƌĂĞůŝdƌĂƵŵĂƌĞƐƐŝŶŐ͕ĂůůŽǁŝŶŐĨŽƌĂŵŽƌĞĞĨĨŝĐŝĞŶƚƉƌĞƐƐƵƌĞĚƌĞƐƐŝŶŐƚŚĂƚĂĚŚĞƌĞƐƚŽƚŚĞ ĂŵƉƵƚĂƚĞĚƐƚƵŵƉ͘ x ŵƉƵƚĂƚĞĚƉĂƌƚƐƐŚŽƵůĚEKdďĞƐŽĂŬĞĚŽƌƉůĂĐĞĚŝŶǁĂƚĞƌ͕ĐŽǀĞƌĞĚǁŝƚŚǁĞƚŐĂƵǌĞŽƌƚŽǁĞůƐ͕Žƌ ƉůĂĐĞĚĚŝƌĞĐƚůǇŽŶŝĐĞŽƌŝĐĞƉĂĐŬƐ͘ x WƌĞƐĞƌǀĞĐƌŝŵĞƐĐĞŶĞĂŶĚƉŽƚĞŶƚŝĂůĞǀŝĚĞŶĐĞďǇďĞŝŶŐĂǁĂƌĞŽĨƐƵƌƌŽƵŶĚŝŶŐƐ͕ĂǀŽŝĚŝŶŐŵŽǀŝŶŐ ĂŶǇƚŚŝŶŐŽŶƐĐĞŶĞƵŶůĞƐƐĂďƐŽůƵƚĞůǇŶĞĐĞƐƐĂƌǇĂŶĚůŝŵŝƚŝŶŐŶƵŵďĞƌŽĨƉĞƌƐŽŶŶĞůĂŶĚĂŵŽƵŶƚŽĨ ĞƋƵŝƉŵĞŶƚŵŽǀĞĚŝŶƚŽĐƌŝŵĞƐĐĞŶĞ͘ŽĐƵŵĞŶƚŝŶũƵƌŝĞƐ͕ĂŶǇƐƚĂƚĞŵĞŶƚƐďǇƉĂƚŝĞŶƚĂŶĚƐĐĞŶĞ ƉƌĞƐĞŶƚĂƚŝŽŶĂƐƚŚŽƌŽƵŐŚůǇĂŶĚĂĐĐƵƌĂƚĞůǇĂƐƉŽƐƐŝďůĞ͘

Cypress Creek EMS System Policies and Treatment Guidelines

179 TRAUMA/ENVIRONMENTAL Revised 8/2016 Approved: Levon Vartanian, MD

ŝƚĞƐĂŶĚŶǀĞŶŽŵĂƚŝŽŶƐ ƐƐĞƐƐŵĞŶƚZĞƋƵŝƌĞŵĞŶƚƐ DĂǇWƌĞƐĞŶƚƐ ŽŶƐŝĚĞƌWŽƐƐŝďůĞĂƵƐĞƐ ƐƐĞƐƐŵĞŶƚĂŶĚĨŽĐƵƐĞĚ ZĂƐŚ͕ƐŬŝŶďƌĞĂŬ͕ǁŽƵŶĚ ŶŝŵĂůďŝƚĞ ƉŚǇƐŝĐĂůĞǆĂŵ ^ǁĞůůŝŶŐ͕ƉĂŝŶ͕ƌĞĚŶĞƐƐ ,ƵŵĂŶďŝƚĞ 'ŵŽŶŝƚŽƌŝŶŐŝĨŝŶĚŝĐĂƚĞĚ ǀŝĚĞŶĐĞŽĨŝŶĨĞĐƚŝŽŶ ^ŶĂŬĞďŝƚĞ ^ŚŽƌƚŶĞƐƐŽĨďƌĞĂƚŚĂŶĚ ^ƉŝĚĞƌďŝƚĞ ǁŚĞĞǌŝŶŐ /ŶƐĞĐƚƐƚŝŶŐͬďŝƚĞ;ĞĞ͕ǁĂƐƉ͕ ůůĞƌŐŝĐƌĞĂĐƚŝŽŶ͕ŚŝǀĞƐ͕ ĂŶƚ͕ƚŝĐŬͿ ŝƚĐŚŝŶŐ /ŶĨĞĐƚŝŽŶƌŝƐŬ ,ǇƉŽƚĞŶƐŝŽŶŽƌƐŚŽĐŬ ZĂďŝĞƐƌŝƐŬ dĞƚĂŶƵƐƌŝƐŬ Treatments x dƌĞĂƚǁŝƚŚHypotension/Shock͕Anaphylaxis/Allergic Reaction, Seizure ŐƵŝĚĞůŝŶĞƐŝĨŝŶĚŝĐĂƚĞĚ͘ x (P) ŽŶƐŝĚĞƌPain ManagementŝĨŝŶĚŝĐĂƚĞĚ͘ x /ĚĞŶƚŝĨǇĂŶŝŵĂůͬŽƌŐĂŶŝƐŵŝĨƉŽƐƐŝďůĞ͘ ^ƉŝĚĞƌͬtĂƐƉͬĞĞ x (B) ImmobilizeŝŶũƵƌǇ͕elevateŝĨĂďůĞ͕ĂƉƉůǇcold packsŝŶĚŝƌĞĐƚůǇ͕ĂŶĚƌĞŵŽǀĞĂŶǇĐŽŶƐƚƌŝĐƚŝŶŐ ĐůŽƚŚŝŶŐͬďĂŶĚƐͬũĞǁĞůƌǇ͘ x (P) dƌĞĂƚŵƵƐĐůĞƐƉĂƐŵƐǁŝƚŚĂďĞŶǌŽĚŝĂǌĞƉŝŶĞƐƵĐŚĂƐMidazolamŽƌValium͕ƵƐŝŶŐĂƉƉƌŽƉƌŝĂƚĞ ĚŽƐŝŶŐ;ƌĞĨĞƌƚŽŵĞĚŝĐĂƚŝŽŶƉĂŐĞƐĨŽƌƐƉĞĐŝĨŝĐĂĚƵůƚĂŶĚƉĞĚŝĂƚƌŝĐĚŽƐĞƐͿ͘ ^ŶĂŬĞŝƚĞ x Do not apply ice or cold packs. x (B) ImmobilizeŝŶũƵƌǇ͕elevateŝĨĂďůĞĂŶĚƌĞŵŽǀĞĂŶǇĐŽŶƐƚƌŝĐƚŝŶŐĐůŽƚŚŝŶŐͬďĂŶĚƐͬũĞǁĞůƌǇ͘ x (B) MarkŵĂƌŐŝŶŽĨƐǁĞůůŝŶŐͬƌĞĚŶĞƐƐĂŶĚƚŝŵĞ͘ x (B) /ĨĐŽƌĂůƐŶĂŬĞŝƐŝĚĞŶƚŝĨŝĞĚ͕ŝƌƌŝŐĂƚĞǁŽƵŶĚǁŝƚŚĐŽƉŝŽƵƐĂŵŽƵŶƚƐŽĨǁĂƚĞƌ͘ x ĞŶdĂƵďŽƌDĞŵŽƌŝĂů,ĞƌŵĂŶŶdĞǆĂƐDĞĚŝĐĂůĞŶƚĞƌĂƌĞƚŚĞŵŽƐƚĂƉƉƌŽƉƌŝĂƚĞĚĞƐƚŝŶĂƚŝŽŶƐĨŽƌ ƐĞƌŝŽƵƐƐŶĂŬĞĞŶǀĞŶŽŵĂƚŝŽŶƐ͘ ŶŝŵĂůͬ,ƵŵĂŶŝƚĞ x (B) Extremity Trauma ŐƵŝĚĞůŝŶĞƐŝĨŝŶĚŝĐĂƚĞĚ͘ x EŽƚŝĨǇůĂǁĞŶĨŽƌĐĞŵĞŶƚ͘ x dƌĂŶƐƉŽƌƚƌĞĐŽŵŵĞŶĚĞĚĨŽƌƉŽƐƐŝďůĞŝŶĨĞĐƚŝŽŶĐŽŶƚƌŽů͕ĂŶƚŝďŝŽƚŝĐƐ͕ĂŶĚͬŽƌƌĂďŝĞƐͬƚĞƚĂŶƵƐǀĂĐĐŝŶĞ͘ DĂƌŝŶĞƌĞĂƚƵƌĞ;:ĞůůǇ&ŝƐŚ͕ŶĞŵŽŶĞ͕DĂŶͲKͲtĂƌ͕ĞƚĐ͘Ϳ x (B) Immobilize ŝŶũƵƌǇ͕ůŝĨƚĂǁĂǇƚĞŶƚĂĐůĞƐͬďĂƌŶƐ;ĚŽŶŽƚƌƵďͿ͘ x (P) &ŽƌƐĞǀĞƌĞŵƵƐĐůĞƐƉĂƐŵƐ͕Calcium Chloride 1Ő/sͬ/KŽǀĞƌϯŵŝŶƵƚĞƐ;WĞĚŝĂƚƌŝĐϮϬŵŐͬŬŐ/sͬ/KͿ͘ Pearls x ,ƵŵĂŶďŝƚĞƐŚĂǀĞŚŝŐŚĞƌŝŶĨĞĐƚŝŽŶƌĂƚĞƐƚŚĂŶĂŶŝŵĂůďŝƚĞƐĚƵĞƚŽŵŽƵƚŚďĂĐƚĞƌŝĂ͘

Cypress Creek EMS System Policies and Treatment Guidelines

180 TRAUMA/ENVIRONMENTAL Revised 8/2016 Approved: Levon Vartanian, MD

Cypress Creek EMS System Policies and Treatment Guidelines

181 TRAUMA/ENVIRONMENTAL Revised 8/2016 Approved: Levon Vartanian, MD

ůĂƐƚ/ŶũƵƌǇ ƐƐĞƐƐŵĞŶƚZĞƋƵŝƌĞŵĞŶƚƐ DĂǇWƌĞƐĞŶƚƐ ŽŶƐŝĚĞƌWŽƐƐŝďůĞĂƵƐĞƐ ƐƐĞƐƐŵĞŶƚΘ&Ƶůů,ĞĂĚƚŽ ƵƌŶƐ͕ƉĂŝŶ͕ƐǁĞůůŝŶŐ ƵƌŶƐ͕ĂŝƌǁĂǇďƵƌŶƐ͕ƚŚĞƌŵĂů dŽĞĞǆĂŵ ^ŽĨƚƚŝƐƐƵĞǁŽƵŶĚƐ ďƵƌŶƐ͕ƌĂĚŝĂƚŝŽŶĞǆƉŽƐƵƌĞ 'ŵŽŶŝƚŽƌŝŶŐ ŝǌǌŝŶĞƐƐ͕ůŽƐƐŽĨ WŶĞƵŵŽƚŚŽƌĂǆ dKϮŵŽŶŝƚŽƌŝŶŐ ĐŽŶƐĐŝŽƵƐŶĞƐƐ ,ĞĂĚŝŶũƵƌǇ dŝŶŶŝƚƵƐŽƌůŽƐƐŽĨŚĞĂƌŝŶŐ ,ĞŵŽƌƌŚĂŐĞ ŝĨĨŝĐƵůƚǇďƌĞĂƚŚŝŶŐ͕ ,ǇƉŽǀŽůĞŵŝĐƐŚŽĐŬ ŚŽĂƌƐĞŶĞƐƐ͕ǁŚĞĞǌŝŶŐ dĞŶƐŝŽŶƉŶĞƵŵŽƚŚŽƌĂǆ ,ǇƉŽƚĞŶƐŝŽŶͬƐŚŽĐŬ ĂƌĚŝĂĐƚĂŵƉŽŶĂĚĞ ,ĞŵŽƚŚŽƌĂǆ ƌƵƐŚŝŶũƵƌǇͬĐŽŵƉĂƌƚŵĞŶƚ ƐǇŶĚƌŽŵĞ dǇŵƉĂŶŝĐŵĞŵďƌĂŶĞƌƵƉƚƵƌĞ Treatments x dƌĞĂƚƐƉĞĐŝĨŝĐŝŶũƵƌŝĞƐĂƐŝŶĚŝĐĂƚĞĚ͘ ůĂƐƚ>ƵŶŐ/ŶũƵƌǇ x ^ƵƐƉĞĐƚŝŶĂŶǇŽŶĞǁŝƚŚĂĐŽƵŐŚ͕ĚǇƐƉŶĞĂ͕ŚĞŵŽƉƚǇƐŝƐ͕ŽƌĐŚĞƐƚƉĂŝŶĨŽůůŽǁŝŶŐďůĂƐƚĞǀĞŶƚ͘ x (B) ^ƵƉƉŽƌƚventilationĂŶĚoxygenationĂƐŝŶĚŝĐĂƚĞĚ͘ x &ůƵŝĚƌĞƐƵƐĐŝƚĂƚĞĂƐŝŶĚŝĐĂƚĞĚďƵƚďĞĐĂƵƚŝŽƵƐŽĨĨůƵŝĚŽǀĞƌůŽĂĚ͘ x (P) ŽŶƐŝĚĞƌAdvanced Airway ManagementŝŶƉƌĞƐĞŶĐĞŽĨŵĂƐƐŝǀĞŚĞŵŽƉƚǇƐŝƐ͕ŽƌŝŵƉĞŶĚŝŶŐ ĂŝƌǁĂǇͬƌĞƐƉŝƌĂƚŽƌǇĨĂŝůƵƌĞ͘ x dŚĞƐĞƉĂƚŝĞŶƚƐĂƌĞĂƚŵƵĐŚŐƌĞĂƚĞƌƌŝƐŬĨŽƌďĂƌŽƚƌĂƵŵĂ;ĂŝƌĞŵďŽůŝƐŵŽƌĂůǀĞŽůĂƌƌƵƉƚƵƌĞͿĨƌŽŵ ƉŽƐŝƚŝǀĞƉƌĞƐƐƵƌĞǀĞŶƚŝůĂƚŝŽŶ͘>ŝŵŝƚƚŝĚĂůǀŽůƵŵĞƐĂŶĚƉƌĞƐƐƵƌĞ͖ŝƚŝƐďĞƚƚĞƌĨŽƌƉĂƚŝĞŶƚƚŽďĞ ŚǇƉĞƌĐĂƉŶŝĐƚŚĂŶŽǀĞƌƉƌĞƐƐƵƌĞĚ͘ x (P) WĞƌĨŽƌŵŝŵŵĞĚŝĂƚĞNeedle DecompressionŝĨƉĂƚŝĞŶƚĚĞǀĞůŽƉƐƐŝŐŶƐŽĨĂtension pneumothorax ;ƵŶŝůĂƚĞƌĂůĂďƐĞŶƚďƌĞĂƚŚƐŽƵŶĚƐ͕ǁĞĂŬŽƌĂďƐĞŶƚƌĂĚŝĂůƉƵůƐĞ͕ĂĐƵƚĞůǇĂůƚĞƌĞĚŵĞŶƚĂůƐƚĂƚƵƐͿ͘ Pearls x ƐƐĞƐƐĨŽƌ͗ x Nature of Device/Event: ŐĞŶƚͬĂŵŽƵŶƚ͕ŝŶĚƵƐƚƌŝĂůĂĐĐŝĚĞŶƚ͕ŝŶƚĞŶƚŝŽŶĂů͕ƚĞƌƌŽƌŝƐƚŝŶĐŝĚĞŶƚ͕ ŝŵƉƌŽǀŝƐĞĚĞǆƉůŽƐŝǀĞĚĞǀŝĐĞ;/Ϳ͕ĞƚĐ͘ x Method of Delivery:/ŶĐĞŶĚŝĂƌǇͬǆƉůŽƐŝǀĞ x Nature of Environment:KƉĞŶͬĐůŽƐĞĚ x Distance from device:ŶǇƉƌŽƚĞĐƚŝǀĞďĂƌƌŝĞƌƐ͍KƚŚĞƌĞŶǀŝƌŽŶŵĞŶƚĂůŚĂǌĂƌĚƐ͍ x ǆƉůŽƐŝŽŶƐŝŶĐŽŶĨŝŶĞĚƐƉĂĐĞƐ;ďƵŝůĚŝŶŐƐ͕ůĂƌŐĞǀĞŚŝĐůĞƐ͕ĞƚĐ͘ͿĂŶĚͬŽƌƐƚƌƵĐƚƵƌĂůĐŽůůĂƉƐĞĂƌĞ ĂƐƐŽĐŝĂƚĞĚǁŝƚŚŵŽƌĞƐĞǀĞƌĞŝŶũƵƌŝĞƐĂŶĚĂŐƌĞĂƚĞƌĐŚĂŶĐĞŽĨĚĞĂƚŚ͘ x ^ŽŵĞďůĂƐƚŝŶũƵƌŝĞƐŵĂǇŶŽƚĚĞǀĞůŽƉƐǇŵƉƚŽŵƐĨŽƌƵƉƚŽϰϴŚŽƵƌƐĂĨƚĞƌĞǀĞŶƚ͘ x WƌĞƐĞƌǀĞĐƌŝŵĞƐĐĞŶĞΘƉŽƚĞŶƚŝĂůĞǀŝĚĞŶĐĞďǇďĞŝŶŐĂǁĂƌĞŽĨƐƵƌƌŽƵŶĚŝŶŐƐ͕ĂǀŽŝĚŝŶŐŵŽǀŝŶŐ ĂŶǇƚŚŝŶŐŽŶƐĐĞŶĞƵŶůĞƐƐĂďƐŽůƵƚĞůǇŶĞĐĞƐƐĂƌǇ͕ĂŶĚůŝŵŝƚŝŶŐŶƵŵďĞƌŽĨƉĞƌƐŽŶŶĞůĂŶĚĂŵŽƵŶƚŽĨ

Cypress Creek EMS System Policies and Treatment Guidelines

182 TRAUMA/ENVIRONMENTAL Revised 8/2016 Approved: Levon Vartanian, MD

ĞƋƵŝƉŵĞŶƚŵŽǀĞĚŝŶƚŽĐƌŝŵĞƐĐĞŶĞ͘ŽĐƵŵĞŶƚŝŶũƵƌŝĞƐ͕ƐƚĂƚĞŵĞŶƚƐďǇƉĂƚŝĞŶƚ͕ĂŶĚƐĐĞŶĞ ƉƌĞƐĞŶƚĂƚŝŽŶĂƐƚŚŽƌŽƵŐŚůǇĂŶĚĂĐĐƵƌĂƚĞůǇĂƐƉŽƐƐŝďůĞ͘ ĂƚĞŐŽƌŝĞƐŽĨůĂƐƚ/ŶũƵƌŝĞƐ x Primary:/ŶũƵƌŝĞƐĨƌŽŵƉƌĞƐƐƵƌĞǁĂǀĞ͕ĂĨĨĞĐƚŝŶŐƉƌŝŵĂƌŝůǇŚŽůůŽǁŽƌŐĂŶƐ͗ƚǇŵƉĂŶŝĐŵĞŵďƌĂŶĞ ƌƵƉƚƵƌĞ͕ƉƵůŵŽŶĂƌǇĚĂŵĂŐĞ͕ĂŝƌĞŵďŽůŝ͘WƌĞĚŽŵŝŶĂŶƚůǇƐĐĞŶĞŝŶĐŽŶĨŝŶĞĚƐƉĂĐĞĞǆƉůŽƐŝŽŶƐ͘ x Secondary: /ŶũƵƌŝĞƐĨƌŽŵƉƌŽũĞĐƚŝůĞƐ;ĚĞďƌŝƐ͕ďŽŵďĨƌĂŐŵĞŶƚƐͿ͘ĂƵƐĞƐƉĞŶĞƚƌĂƚŝŶŐƚƌĂƵŵĂ͘ x Tertiary: /ŶũƵƌŝĞƐĨƌŽŵǀŝĐƚŝŵĚŝƐƉůĂĐĞŵĞŶƚ;ƉĂƚŝĞŶƚƚŚƌŽǁŶĂŐĂŝŶƐƚŽďũĞĐƚƐͿ͘ĂƵƐĞƐďůƵŶƚƚƌĂƵŵĂ͕ ĨƌĂĐƚƵƌĞƐ͕ĂŶĚĂŵƉƵƚĂƚŝŽŶƐ͘ x Quaternary: ůůŽƚŚĞƌŝŶũƵƌŝĞƐĨƌŽŵďůĂƐƚ͗ƌƵƐŚŝŶũƵƌŝĞƐ͕ďƵƌŶƐ͕ĂƐƉŚǇǆŝĂ͕ƚŽǆŝĐĞǆƉŽƐƵƌĞƐ͕ĞƚĐ͘ ^ƉĞĐŝĨŝĐůĂƐƚ/ŶũƵƌŝĞƐďǇKƌŐĂŶ^ǇƐƚĞŵ x Blast Lung Injury: ^ƵƐƉĞĐƚǁŝƚŚĐŽƵŐŚ͕ĚǇƐƉŶĞĂ͕ŚĞŵŽƉƚǇƐŝƐ͕ŽƌĐŚĞƐƚƉĂŝŶĨŽůůŽǁŝŶŐďůĂƐƚĞǀĞŶƚ͘ x Abdominal Injury: ^ƵƐƉĞĐƚǁŝƚŚĂďĚŽŵŝŶĂůƉĂŝŶ͕ŶĂƵƐĞĂ͕ǀŽŵŝƚŝŶŐ͕ƌĞĐƚĂůƉĂŝŶ͕ƚĞƐƚŝĐƵůĂƌƉĂŝŶ͕Žƌ ƵŶĞǆƉůĂŝŶĞĚŚǇƉŽǀŽůĞŵŝĂĨŽůůŽǁŝŶŐďůĂƐƚĞǀĞŶƚ͘ x Ear Injury:ZƵƉƚƵƌĞĚƚǇŵƉĂŶŝĐŵĞŵďƌĂŶĞŝƐƚŚĞŵŽƐƚĐŽŵŵŽŶƉƌŝŵĂƌǇďůĂƐƚŝŶũƵƌǇ͘^ǇŵƉƚŽŵƐ ŝŶĐůƵĚĞŚĞĂƌŝŶŐůŽƐƐ͕ƚŝŶŶŝƚƵƐ͕ǀĞƌƚŝŐŽ͕ďůĞĞĚŝŶŐĨƌŽŵĞǆƚĞƌŶĂůĞĂƌĐĂŶĂů͘ x Eye Injury:DĂǇƉƌĞƐĞŶƚǁŝƚŚǀŝƐŝŽŶůŽƐƐͬďůƵƌƌŝŶŐ͕ĞǇĞƉĂŝŶ͕ĐŽŶũƵŶĐƚŝǀŝƚŝƐ͕ƉĞƌŝŽƌďŝƚĂůƐǁĞůůŝŶŐ͕Žƌ ŽĐĐƵůƚƚƌĂƵŵĂƚŽŐůŽďĞ͘

Cypress Creek EMS System Policies and Treatment Guidelines

183 TRAUMA/ENVIRONMENTAL Revised 8/2016 Approved: Levon Vartanian, MD

ƵƌŶƐ͗dŚĞƌŵĂů ƐƐĞƐƐŵĞŶƚZĞƋƵŝƌĞŵĞŶƚƐ DĂǇWƌĞƐĞŶƚƐ ŽŶƐŝĚĞƌWŽƐƐŝďůĞĂƵƐĞƐ ƐƐĞƐƐŵĞŶƚΘ&ŽĐƵƐĞĚͬĨƵůů ƵƌŶƐ͕ƉĂŝŶ͕ƐǁĞůůŝŶŐ ^ƵƉĞƌĨŝĐŝĂůďƵƌŶƐ;ƌĞĚŽƌ ĞǆĂŵĂƐĂƉƉƌŽƉƌŝĂƚĞ͘ ,ŽĂƌƐĞŶĞƐƐ͕ƐƚƌŝĚŽƌ͕ ƉĂŝŶĨƵůͿ 'ŵŽŶŝƚŽƌŝŶŐĂƐŝŶĚŝĐĂƚĞĚ͘ ǁŚĞĞǌŝŶŐ͕ĚŝĨĨŝĐƵůƚǇďƌĞĂƚŚŝŶŐ WĂƌƚŝĂůƚŚŝĐŬŶĞƐƐ͗ůŝƐƚĞƌŝŶŐ dKϮŵŽŶŝƚŽƌŝŶŐĂƐ ,ǇƉŽƚĞŶƐŝŽŶͬƐŚŽĐŬ &ƵůůƚŚŝĐŬŶĞƐƐ͗WĂŝŶůĞƐƐ͕ ŝŶĚŝĐĂƚĞĚ͘ ĐŚĂƌƌĞĚ͕ŽƌůĞĂƚŚĞƌǇƐŬŝŶ͘ ŝƌǁĂǇďƵƌŶƐ KƚŚĞƌŝŶũƵƌŝĞƐƐƵƐƚĂŝŶĞĚ ĚƵƌŝŶŐĞǀĞŶƚ͘ Required Treatments ůůƵƌŶƐ x ;Ϳ^ƚŽƉƚŚĞďƵƌŶŝŶŐƉƌŽĐĞƐƐ x Airway management ĂƉƉƌŽƉƌŝĂƚĞ ƚŽƉĂƚŝĞŶƚĐŽŶĚŝƚŝŽŶ͘ x VentilationĂŶĚoxygenation ĂƉƉƌŽƉƌŝĂƚĞƚŽƉĂƚŝĞŶƚĐŽŶĚŝƚŝŽŶ͘ x ;ͿZĞŵŽǀĞƌĞƐƚƌŝĐƚŝŶŐŝƚĞŵƐ x ;ͿƉƉůǇƐƚĞƌŝůĞĚƌĞƐƐŝŶŐ x tĞƚ;ĚĂƉƚŝĐͿĨŽƌŵŝŶŽƌďƵƌŶƐ x ƌǇĨŽƌŵĂũŽƌďƵƌŶƐ;hƐŝŶŐŵŽŝƐƚĚƌĞƐƐŝŶŐƐŽŶůĂƌŐĞĂƌĞĂƐĐĂŶůĞĂĚƚŽŚǇƉŽƚŚĞƌŵŝĂͿ x (B) Water-Jel dressing͕ĂƐŝŶĚŝĐĂƚĞĚ͘ x (I) Vascular AccessǁŝƚŚ/sŽƌ/K;ƌĞƋƵŝƌĞĚĨŽƌŵĂũŽƌďƵƌŶƐŽŶůǇͿ x ;Ϳ<ĞĞƉƉĂƚŝĞŶƚǁĂƌŵƚŽĂǀŽŝĚŚǇƉŽƚŚĞƌŵŝĂ͘ x ƐƐĞƐƐĨŽƌƐŵŽŬĞŝŶŚĂůĂƚŝŽŶĂŶĚĨŽůůŽǁSmoke InhalationŐƵŝĚĞůŝŶĞƐ͘ x (P) Pain ManagementƉƌŽĐĞĚƵƌĞŝĨŝŶĚŝĐĂƚĞĚ͘ DĂũŽƌƵƌŶƐ x ďŽǀĞƚƌĞĂƚŵĞŶƚƐ͘ x (P) PlasmalyteĨůƵŝĚĐŚĂůůĞŶŐĞϬ͘Ϯϱŵ>ͬŬŐǆйd^ͬŚŽƵƌ;ƐĞĞŝŶĨŽďĞůŽǁͿ Pearls ƵƌŶƐƌĞƋƵŝƌŝŶŐĂďƵƌŶĨĂĐŝůŝƚǇĂƌĞ͗ x хϭϬйŽĚǇ^ƵƌĨĂĐĞƌĞĂƉĂƌƚŝĂůŽƌĨƵůůƚŚŝĐŬŶĞƐƐďƵƌŶƐ͘ x ^ƵƐƉĞĐƚĞĚŝŶŚĂůĂƚŝŽŶŽƌĂŝƌǁĂǇŝŶũƵƌǇ x ,ǇƉŽƚĞŶƐŝŽŶŽƌ'^фϭϯ x ƵƌŶƐǁŝƚŚŵƵůƚŝͲƐǇƐƚĞŵƚƌĂƵŵĂ x ƵƌŶƐŝŶǀŽůǀŝŶŐĨĂĐĞ͕ŚĂŶĚƐ͕ĨĞĞƚ͕ŐĞŶŝƚĂůŝĂ͕ƉĞƌŝŶĞƵŵ͕ŽƌŵĂũŽƌũŽŝŶƚƐ͘ x ŶǇĨƵůůͲƚŚŝĐŬŶĞƐƐďƵƌŶƐ͘

Cypress Creek EMS System Policies and Treatment Guidelines

184 TRAUMA/ENVIRONMENTAL Revised 8/2016 Approved: Levon Vartanian, MD

Rule of Nines

Cypress Creek EMS System Policies and Treatment Guidelines

185 TRAUMA/ENVIRONMENTAL Revised 8/2016 Approved: Levon Vartanian, MD

Fluid Infusion Rate Table &ŽƌƚŚĞĨŝƌƐƚĞŝŐŚƚŚŽƵƌƐ͕ĂĚŵŝŶŝƐƚĞƌϬ͘Ϯϱŵ>ͬŬŐͬйd^ƉĞƌŚŽƵƌ͘йd^ŝƐƉĞƌĐĞŶƚĂŐĞŽĨďŽĚǇǁŝƚŚ ƉĂƌƚŝĂůĂŶĚĨƵůůͲƚŚŝĐŬŶĞƐƐďƵƌŶƐ͘

%TBS 10 kg 20 kg 30 kg 50 kg 80 kg 100 kg 120 kg 140 kg 150 kg A 5% ϭϯŵ>ͬŚƌ Ϯϱŵ>ͬŚƌ ϯϴŵ>ͬŚƌ ϲϯŵ>ͬŚƌ ϭϬϬ ϭϮϱ ϭϱϬ ϭϳϱ ϭϴϴ ŵ>ͬŚƌ ŵ>ͬŚƌ ŵ>ͬŚƌ ŵ>ͬŚƌ ŵ>ͬŚƌ 10% Ϯϱŵ>ͬŚƌ ϱϬŵ>ͬŚƌ ϳϱŵ>ͬŚƌ ϭϮϱ ϮϬϬ ϮϱϬ ϯϬϬ ϯϱϬ ϯϳϱ ŵ>ͬŚƌ ŵ>ͬŚƌ ŵ>ͬŚƌ ŵ>ͬŚƌ ŵ>ͬŚƌ ŵ>ͬŚƌ 20% ϱϬŵ>ͬŚƌ ϭϬϬ ϭϱϬ ϮϱϬ ϰϬϬ ϱϬϬ ϲϬϬ ϳϬϬ ϳϱϬ ŵ>ͬŚƌ ŵ>ͬŚƌ ŵ>ͬŚƌ ŵ>ͬŚƌ ŵ>ͬŚƌ ŵ>ͬŚƌ ŵ>ͬŚƌ ŵ>ͬŚƌ 30% ϳϱŵ>ͬŚƌ ϭϱϬ ϮϮϱ ϯϳϱ ϲϬϬ ϳϱϬ ϵϬϬ ϭϬϱϬ ϭϭϮϱ ŵ>ͬŚƌ ŵ>ͬŚƌ ŵ>ͬŚƌ ŵ>ͬŚƌ ŵ>ͬŚƌ ŵ>ͬŚƌ ŵ>ͬŚƌ ŵ>ͬŚƌ 40% ϭϬϬ ϮϬϬ ϯϬϬ ϱϬϬ ϴϬϬ ϭϬϬϬ ϭϮϬϬ ϭϰϬϬ ϭϱϬϬ ŵ>ͬŚƌ ŵ>ͬŚƌ ŵ>ͬŚƌ ŵ>ͬŚƌ ŵ>ͬŚƌ ŵ>ͬŚƌ ŵ>ͬŚƌ ŵ>ͬŚƌ ŵ>ͬŚƌ 50% ϭϮϱ ϮϱϬ ϯϳϱ ϲϮϱ ϭϬϬϬ ϭϮϱϬ ϭϱϬϬ ϭϳϱϬ ϭϴϳϱ ŵ>ͬŚƌ ŵ>ͬŚƌ ŵ>ͬŚƌ ŵ>ͬŚƌ ŵ>ͬŚƌ ŵ>ͬŚƌ ŵ>ͬŚƌ ŵ>ͬŚƌ ŵ>ͬŚƌ 60% ϭϱϬ ϯϬϬ ϰϱϬ ϳϱϬ ϭϮϬϬ ϭϱϬϬ ϭϴϬϬ ϮϭϬϬ ϮϮϱϬ ŵ>ͬŚƌ ŵ>ͬŚƌ ŵ>ͬŚƌ ŵ>ͬŚƌ ŵ>ͬŚƌ ŵ>ͬŚƌ ŵ>ͬŚƌ ŵ>ͬŚƌ ŵ>ͬŚƌ 70% ϭϳϱ ϯϱϬ ϱϮϱ ϴϳϱ ϭϰϬϬ ϭϳϱϬ ϮϭϬϬ ϮϰϱϬ ϮϲϮϱ ŵ>ͬŚƌ ŵ>ͬŚƌ ŵ>ͬŚƌ ŵ>ͬŚƌ ŵ>ͬŚƌ ŵ>ͬŚƌ ŵ>ͬŚƌ ŵ>ͬŚƌ ŵ>ͬŚƌ 80% ϮϬϬ ϰϬϬ ϲϬϬ ϭϬϬϬ ϭϲϬϬ ϮϬϬϬ ϮϰϬϬ ϮϴϬϬ ϯϬϬϬ ŵ>ͬŚƌ ŵ>ͬŚƌ ŵ>ͬŚƌ ŵ>ͬŚƌ ŵ>ͬŚƌ ŵ>ͬŚƌ ŵ>ͬŚƌ ŵ>ͬŚƌ ŵ>ͬŚƌ Calculations based on Parkland/Consensus Burn Formula: 4 mL/kg/%TBSA over 24 hours with half in first 8 hours.

Cypress Creek EMS System Policies and Treatment Guidelines

186 TRAUMA/ENVIRONMENTAL Revised 8/2016 Approved: Levon Vartanian, MD

ƵƌŶƐ͗ŚĞŵŝĐĂůĂŶĚůĞĐƚƌŝĐĂů ƐƐĞƐƐŵĞŶƚZĞƋƵŝƌĞŵĞŶƚƐ DĂǇWƌĞƐĞŶƚƐ ŽŶƐŝĚĞƌWŽƐƐŝďůĞĂƵƐĞƐ ƐƐĞƐƐŵĞŶƚĂŶĚŚĞĂĚͲƚŽͲƚŽĞ ƵƌŶƐ͕ƉĂŝŶ͕ƐǁĞůůŝŶŐ ŚĞŵŝĐĂůďƵƌŶƐ ĞǆĂŵ ŝǌǌŝŶĞƐƐ͕ůŽƐƐŽĨ ůĞĐƚƌŝĐĂůďƵƌŶƐ 'ŵŽŶŝƚŽƌŝŶŐŝĨ ĐŽŶƐĐŝŽƵƐŶĞƐƐ ůĞĐƚƌŽĐƵƚŝŽŶ ĂƉƉƌŽƉƌŝĂƚĞ WĂůƉŝƚĂƚŝŽŶƐ dŽǆŝŶͬƉŽŝƐŽŶŝŶŐ ,ǇƉŽƚĞŶƐŝŽŶͬƐŚŽĐŬ dƌĂƵŵĂƚŝĐŝŶũƵƌŝĞƐĂƐƐŽĐŝĂƚĞĚ ŝƌǁĂǇŽďƐƚƌƵĐƚŝŽŶ͕ ǁŝƚŚĞǀĞŶƚ ŚŽĂƌƐĞŶĞƐƐ͕ǁŚĞĞǌŝŶŐ͕ ŚǇƉŽǆŝĂ ŝƐŽƌŝĞŶƚĂƚŝŽŶ͕ƉĂŝŶ͕ ŶƵŵďŶĞƐƐĂŶĚƚŝŶŐůŝŶŐ ǇƐƵƌŝĂ dƌĞĂƚŵĞŶƚƐ x ƐƐƵƌĞĐŚĞŵŝĐĂůͬĞůĞĐƚƌŝĐĂůƐŽƵƌĐĞŝƐEKdŚĂǌĂƌĚŽƵƐƚŽƌĞƐƉŽŶĚĞƌƐ͘/ĨŶĞĐĞƐƐĂƌǇ͕ƵƚŝůŝǌĞ,ĂǌĂƌĚŽƵƐ DĂƚĞƌŝĂůƐƵŶŝƚƚŽĚĞĐŽŶƚĂŵŝŶĂƚĞƉĂƚŝĞŶƚĂŶĚƐĐĞŶĞ͘ Chemical Burns x ƌƵƐŚĚƌǇƉŽǁĚĞƌƐŽĨĨƉĂƚŝĞŶƚďĞĨŽƌĞĂƉƉůǇŝŶŐǁĂƚĞƌ͘ x &ůƵƐŚĐŚĞŵŝĐĂůĐŽŶƚĂŵŝŶĂƚŝŽŶŽĨĨĨŽƌĂƚůĞĂƐƚƚǁĞŶƚǇŵŝŶƵƚĞƐ͘ x EŽƚŝĨǇŚŽƐƉŝƚĂůĞĂƌůǇƚŽĂůůŽǁĨŽƌĂĐƚŝǀĂƚŝŽŶŽĨĞĐŽŶƚĂŵŝŶĂƚŝŽŶdĞĂŵ͘ x ƐƐĞƐƐƐĞǀĞƌŝƚǇŽĨďƵƌŶƐĂŶĚƚƌĞĂƚǁŝƚŚThermal Burns ŐƵŝĚĞůŝŶĞƐ͘ x (B)&ůƵƐŚĞǇĞďƵƌŶƐƵƐŝŶŐMorgan LensƉƌŽĐĞĚƵƌĞĨŽƌĂƚůĞĂƐƚƚǁĞŶƚǇŵŝŶƵƚĞƐ͘ x (P) ŽŶƐŝĚĞƌĨůƵƐŚŝŶŐĞǇĞƐǁŝƚŚLidocaine ϭϬϬŵŐŝŶPlasmalyteϭϬϬϬŵ>ƵƐŝŶŐMorgan Lens͘ x (P) /ŶƐƚŝůůTetracaine 0.5%ϭʹϮĚƌŽƉƐŽĨŽƉŚƚŚĂůŵŝĐƐŽůƵƚŝŽŶƚŽĂĨĨĞĐƚĞĚĞǇĞƐ͘ x (P) &Žƌhydrofluoric acidďƵƌŶƐ͕ŵŝǆŽŶĞĂŵƉŽĨCalcium ChlorideǁŝƚŚǁĂƚĞƌͲďĂƐĞĚůƵďƌŝĐĂŶƚĂŶĚ ĂƉƉůǇĚŝƌĞĐƚůǇƚŽďƵƌŶĂƌĞĂƚŽŶĞƵƚƌĂůŝǌĞĂĐŝĚ Electrical Injuries x ůĞĐƚƌŝĐĂůďƵƌŶƐĨŽůůŽǁƉĂƚŚĐƵƌƌĞŶƚƚĂŬĞƐƚŚƌŽƵŐŚďŽĚǇ͘ƐƐĞƐƐĨŽƌĞŶƚƌǇĂŶĚŐƌŽƵŶĚǁŽƵŶĚƐ͘ ĂŵĂŐĞŵĂǇŽĐĐƵƌŝŶƚĞƌŶĂůůǇĂŶĚĐŽƵůĚĐĂƵƐĞƌŚĂďĚŽŵǇŽůǇƐŝƐŽƌĐŽŵƉĂƌƚŵĞŶƚƐǇŶĚƌŽŵĞ͘ x (P) Pain ManagementŝĨŝŶĚŝĐĂƚĞĚ x (P) PlasmalyteĨůƵŝĚďŽůƵƐƵƉƚŽϮϬŵ>ͬŬŐ WĞĂƌůƐ x ƚƚĞŵƉƚƚŽĚĞƚĞƌŵŝŶĞŶĂƚƵƌĞŽĨĞůĞĐƚƌŝĐĂůƐŽƵƌĐĞ;ͬͿ͕ĂŵŽƵŶƚŽĨǀŽůƚĂŐĞĂŶĚĂŵƉĞƌĂŐĞ͕ĂŶĚ ĚƵƌĂƚŝŽŶŽĨĞǆƉŽƐƵƌĞ͘ x ŶƚŝĐŝƉĂƚĞƌŚǇƚŚŵĂďŶŽƌŵĂůŝƚŝĞƐǁŝƚŚĞůĞĐƚƌŽĐƵƚŝŽŶ͘ůůĞůĞĐƚƌŝĐĂůŝŶũƵƌǇƉĂƚŝĞŶƚƐƐŚŽƵůĚďĞ ƚƌĂŶƐƉŽƌƚĞĚĂŶĚĞǀĂůƵĂƚĞĚ͕ĞǀĞŶŝĨĂƐǇŵƉƚŽŵĂƚŝĐŝŶŝƚŝĂůůǇ͘ x WƵůƐĞůĞƐƐ͕ĂƉŶĞŝĐƉĂƚŝĞŶƚƐĨŽůůŽǁŝŶŐĂůŝŐŚƚŶŝŶŐƐƚƌŝŬĞŚĂǀĞĂŚŝŐŚůŝŬĞůŝŚŽŽĚŽĨZK^ŝĨŝŵŵĞĚŝĂƚĞ ƌĞƐƵƐĐŝƚĂƚŝŽŶŝƐĂƚƚĞŵƉƚĞĚ͘/ŶŵƵůƚŝƉůĞƉĂƚŝĞŶƚƐŝƚƵĂƚŝŽŶƐ͕ĂǀŽŝĚƉůĂĐŝŶŐƚŚĞƐĞƉĂƚŝĞŶƚƐŝŶ͞ǆƉĞĐƚĂŶƚ͟ ĐĂƚĞŐŽƌǇĂƐƌĞƐƵƐĐŝƚĂƚŝŽŶŝƐůŝŬĞůǇƚŽďĞǀĞƌǇĞĨĨĞĐƚŝǀĞĨŽƌƚŚĞŵ͘

Cypress Creek EMS System Policies and Treatment Guidelines

187 TRAUMA/ENVIRONMENTAL Revised 8/2016 Approved: Levon Vartanian, MD

ƌƵƐŚ^ǇŶĚƌŽŵĞĂŶĚŽŵƉĂƌƚŵĞŶƚ^ǇŶĚƌŽŵĞ

ƐƐĞƐƐŵĞŶƚZĞƋƵŝƌĞŵĞŶƚƐ DĂǇWƌĞƐĞŶƚƐ ŽŶƐŝĚĞƌWŽƐƐŝďůĞĂƵƐĞƐ ƐƐĞƐƐŵĞŶƚΘ&ŽĐƵƐĞĚͬ&Ƶůů Crush Syndrome ŶƚƌĂƉŵĞŶƚǁŝƚŚŽƵƚĐƌƵƐŚ ďŽĚǇĞǆĂŵĂƐŝŶĚŝĐĂƚĞĚ ƌƵƐŚŝŶŐŝŶũƵƌǇнŚǇƉŽƚĞŶƐŝŽŶ͕ ŝŶũƵƌǇ ĚǇƐƵƌŝĂ͕ĂůƚĞƌĞĚůĞǀĞůŽĨ ZŚĂďĚŽŵǇŽůǇƐŝƐĨƌŽŵĂŶŽƚŚĞƌ 'DŽŶŝƚŽƌŝŶŐ ĐŽŶƐĐŝŽƵƐŶĞƐƐ͕ĐĂƌĚŝĂĐ ĐĂƵƐĞ ϭϮͲůĞĂĚ' ĚǇƐƌŚǇƚŚŵŝĂƐ͕ĐĂƌĚŝĂĐĂƌƌĞƐƚ ůƚĞƌĞĚŵĞŶƚĂůƐƚĂƚƵƐ dƌĂƵŵĂƚŝĐďƌĂŝŶŝŶũƵƌǇ Compartment Syndrome ĂƌĚŝĂĐŝŶũƵƌǇ WĂŝŶ ZĞŶĂůĨĂŝůƵƌĞ WĂƐƐŝǀĞŵŽǀĞŵĞŶƚƉĂŝŶ WƌĞƐƐƵƌĞ WĂƌĂůǇƐŝƐŽƌǁĞĂŬŶĞƐƐ WĂƌĞƐƚŚĞƐŝĂ WĂůůŽƌ WƵůƐĞůĞƐƐŶĞƐƐ;ůĂƚĞͿ Treatments Entrapped and crushed under load for > 30 minutes:

ĞĨŽƌĞĞǆƚƌŝĐĂƚŝŽŶ͗ x (I) Vascular accessǁŝƚŚ/sŽƌ/K͘ x (P) Normal Saline ŽƌPlasmalyte-A ĨůƵŝĚďŽůƵƐŽĨϭ>ĨŽůůŽǁĞĚďǇϱϬϬŵ>ͬŚŽƵƌ͘;WĞĚŝĂƚƌŝĐƐ͗ϮϬŵ>ͬŬŐ ƚŚĞŶϯǆŵĂŝŶƚĞŶĂŶĐĞĨůƵŝĚƌĂƚĞͿ͘ x (B) Tourniquet ŝĨƵŶĂďůĞƚŽĨůƵŝĚƌĞƐƵƐĐŝƚĂƚĞ͘dŽƵƌŶŝƋƵĞƚƐĂƌĞŶŽƚƉƌĞĨĞƌƌĞĚŽƉƚŝŽŶ͘

/Ĩ'ƐŚŽǁƐƉĞĂŬĞĚdǁĂǀĞƐ͕YZ^хϭϮϬŵƐ͕YdхϰϲϬŵƐ͕ŽƌůŽƐƐŽĨWǁĂǀĞƐ;ďĞĨŽƌĞŽƌĂĨƚĞƌĞǆƚƌŝĐĂƚŝŽŶͿ͗ x (P) Sodium Bicarbonate ϱϬŵƋ/sͬ/K;WĞĚŝĂƚƌŝĐƐ͗ϭŵƋͬŬŐ/sͬ/KͿ͕ŝĨŶŽƚŐŝǀĞŶďĞĨŽƌĞ͘ x (P) Calcium Chloride ϭŐ/sͬ/K;WĞĚŝĂƚƌŝĐƐϮϬŵŐͬŬŐ/sͬ/KͿŐŝǀĞŶŽǀĞƌϯŵŝŶƵƚĞƐ͘

/ŵŵĞĚŝĂƚĞůǇƉƌŝŽƌƚŽĞǆƚƌŝĐĂƚŝŽŶ͗ x (P) Sodium Bicarbonate ϱϬŵƋ/sͬ/K;WĞĚŝĂƚƌŝĐƐ͗ϭŵƋͬŬŐ/sͬ/KͿ͕ŝĨŶŽƚŐŝǀĞŶďĞĨŽƌĞ͘ x (P) Pain ManagementƉƌŽĐĞĚƵƌĞ͘ZĞƉĞĂƚŵĞĚŝĐĂƚŝŽŶƐĂƐŶĞĞĚĞĚ͘ x (P) ŽŶƐŝĚĞƌKetamineϭŵŐͬŬŐ/sͬ/K͕ŐŝǀĞŶƐůŽǁůǇŽǀĞƌϮͲϯŵŝŶƵƚĞƐ͘ĞƉƌĞƉĂƌĞĚƚŽŵĂŶĂŐĞĂŝƌǁĂǇ ŝĨŶĞĐĞƐƐĂƌǇ͘

/ĨƉĂƚŝĞŶƚŐŽĞƐŝŶƚŽs&ͬsdͬƐǇƐƚŽůĞͬW͗ x (P) Sodium Bicarbonate ϱϬŵƋ/sͬ/K;WĞĚŝĂƚƌŝĐƐ͗ϭŵƋͬŬŐ/sͬ/KͿ͕ŝĨŶŽƚŐŝǀĞŶďĞĨŽƌĞ͘ x (P) Calcium Chloride ϭŐ/sͬ/K;WĞĚŝĂƚƌŝĐƐϮϬŵŐͬŬŐ/sͬ/KͿŐŝǀĞŶŽǀĞƌϯŵŝŶƵƚĞƐ͘ x ZĞĨĞƌƚŽTraumatic Cardiac ArrestƉƌŽƚŽĐŽů͘

Cypress Creek EMS System Policies and Treatment Guidelines

188 TRAUMA/ENVIRONMENTAL Revised 8/2016 Approved: Levon Vartanian, MD

Compartment Syndrome x (B) ImmobilizeĂĨĨĞĐƚĞĚĞǆƚƌĞŵŝƚǇĂŶĚelevateŝĨƉŽƐƐŝďůĞ͘ x ƐƐĞƐƐĚŝƐƚĂůŶĞƵƌŽͬĐŝƌĐƵůĂƚŝŽŶ͘ŽŶƐŝĚĞƌƵƐŝŶŐZͲϱϳƉĞƌĨƵƐŝŽŶŵĞĂƐƵƌĞŵĞŶƚƐ͘ x (P) Pain ManagementƉƌŽĐĞĚƵƌĞĂƐĂƉƉƌŽƉƌŝĂƚĞ͘ x dƌĂŶƐƉŽƌƚƌĂƉŝĚůǇƚŽŶĞĂƌĞƐƚƚƌĂƵŵĂĐĞŶƚĞƌ͘ Pearls x Crush injury ŝƐĐĂƵƐĞĚďǇĐŽŵƉƌĞƐƐŝŽŶĨŽƌĐĞƐŽŶƚŚĞďŽĚǇ;ƚǇƉŝĐĂůůǇĞǆƚƌĞŵŝƚŝĞƐͿƌĞƐƵůƚŝŶŐŝŶŵƵƐĐůĞ ƐǁĞůůŝŶŐĂŶĚͬŽƌŶĞƌǀĞĚĂŵĂŐĞ͘Crush syndromeŝƐƐǇƐƚĞŵŝĐĞĨĨĞĐƚƐĐĂƵƐĞĚďǇĂůŽĐĂůŝǌĞĚĐƌƵƐŚ ŝŶũƵƌǇ͘ĨĨĞĐƚƐŝŶĐůƵĚĞƌŚĂďĚŽŵǇŽůǇƐŝƐ͕ƚŽǆŝŶƌĞůĞĂƐĞ͕ĂĐŝĚŽƐŝƐ͕ŚǇƉŽĐĂůĐĞŵŝĂ͕ĂŶĚͬŽƌŚǇƉĞƌŬĂůĞŵŝĂ͘ Compartment syndromeŝƐĐŚĂƌĂĐƚĞƌŝǌĞĚďǇƐǁĞůůŝŶŐǁŝƚŚŝŶĂĐůŽƐĞĚĂŶĂƚŽŵŝĐĂůĐŽŵƉĂƌƚŵĞŶƚ ƌĞƐƵůƚŝŶŐŝŶƚŝƐƐƵĞĚĞĂƚŚ͕ŶĞƌǀĞĚĂŵĂŐĞ͕ĂŶĚĐƵƚƚŝŶŐŽĨĨďůŽŽĚĨůŽǁĚŝƐƚĂůƚŽƚŚĞĐŽŵƉĂƌƚŵĞŶƚ͘ x ^ƵĚĚĞŶƌĞůĞĂƐĞŽĨĂĐƌƵƐŚĞĚŽƌƚƌĂƉƉĞĚĞǆƚƌĞŵŝƚǇŵĂǇƌĞƐƵůƚŝŶreperfusion syndrome͕ ĐŚĂƌĂĐƚĞƌŝǌĞĚďǇŚǇƉŽǀŽůĞŵŝĂ͕ŵĞƚĂďŽůŝĐĂďŶŽƌŵĂůŝƚŝĞƐ͕ĐĂƌĚŝĂĐĂďŶŽƌŵĂůŝƚŝĞƐ͕ĂŶĚƌĞŶĂůĨĂŝůƵƌĞ͕ ĂůŽŶŐǁŝƚŚƐĞĐŽŶĚĂƌǇĐŽŵƉĂƌƚŵĞŶƚƐǇŶĚƌŽŵĞ͘ x dŚĞŵŽƐƚĞĨĨĞĐƚŝǀĞƚƌĞĂƚŵĞŶƚƚŽƉƌĞǀĞŶƚƌĞƉĞƌĨƵƐŝŽŶƐǇŶĚƌŽŵĞŝƐƚŽŵŝůĚůǇĨůƵŝĚŽǀĞƌůŽĂĚƚŚĞ ƉĂƚŝĞŶƚ͘WĞƌŵŝƐƐŝǀĞŚǇƉŽƚĞŶƐŝŽŶŽƌďĞŝŶŐŚǇƉŽǀŽůĞŵŝĐŝƐĚĞĂĚůǇƚŽƚŚĞƐĞƉĂƚŝĞŶƚƐ͘

Cypress Creek EMS System Policies and Treatment Guidelines

189 TRAUMA/ENVIRONMENTAL Revised 8/2016 Approved: Levon Vartanian, MD

ƌŽǁŶŝŶŐ ƐƐĞƐƐŵĞŶƚZĞƋƵŝƌĞŵĞŶƚƐ DĂǇWƌĞƐĞŶƚƐ ŽŶƐŝĚĞƌWŽƐƐŝďůĞĂƵƐĞƐ ƐƐĞƐƐŵĞŶƚΘĨƵůůŚĞĂĚͲƚŽͲ hŶĐŽŶƐĐŝŽƵƐ͕ĂůƚĞƌĞĚŵĞŶƚĂů dƌĂƵŵĂ ƚŽĞĞǆĂŵ ƐƚĂƚƵƐ WƌĞͲĞǆŝƐƚŝŶŐŵĞĚŝĐĂů 'ŵŽŶŝƚŽƌŝŶŐ͕ŝĨŝŶĚŝĐĂƚĞĚ͘ ,ǇƉŽƚĞŶƐŝŽŶ͕ďƌĂĚǇĐĂƌĚŝĂ͕ ĐŽŶĚŝƚŝŽŶƐ dKϮŵŽŶŝƚŽƌŝŶŐ͕ŝĨ ŚǇƉŽǆŝĂ͕ĐǇĂŶŽƐŝƐ WƌĞƐƐƵƌĞŝŶũƵƌǇ;ĚŝǀŝŶŐͿ͗ ŝŶĚŝĐĂƚĞĚ͘ sŽŵŝƚŝŶŐ ĞĐŽŵƉƌĞƐƐŝŽŶ͕ĂƌŽƚƌĂƵŵĂ ŽƵŐŚŝŶŐ͕ǁŚĞĞǌŝŶŐ͕ƌĂůĞƐ͕ WŽƐƚͲŝŵŵĞƌƐŝŽŶƐǇŶĚƌŽŵĞ ƌŚŽŶĐŚŝ͕ƐƚƌŝĚŽƌ WŽƐƐŝďůĞƐƉŝŶĂůŝŶũƵƌǇ ,ǇƉŽƚŚĞƌŵŝĂ dƌĞĂƚŵĞŶƚƐ x (B) ŽŶƐŝĚĞƌSpinal Motion RestrictionĂƐĂƉƉƌŽƉƌŝĂƚĞ͘ Unresponsive, pulseless patients x &ŽůůŽǁdƌĂƵŵĂƚŝĐĂƌĚŝĂĐƌƌĞƐƚŐƵŝĚĞůŝŶĞƐ͘ x ůůǀŝĐƚŝŵƐŝŶĐŽůĚǁĂƚĞƌƐŚŽƵůĚďĞƌĞƐƵƐĐŝƚĂƚĞĚ͘dŚĞƐĞƉĂƚŝĞŶƚƐŚĂǀĞĂŶŝŶĐƌĞĂƐĞĚĐŚĂŶĐĞŽĨƐƵƌǀŝǀĂů͘ Altered mental status patients x &ŽůůŽǁAltered Mental StatusƉƌŽƚŽĐŽůƐŝĨŝŶĚŝĐĂƚĞĚ͘ x (B)ZĞŵŽǀĞǁĞƚĐůŽƚŚŝŶŐ͘ƌǇ͕ǁĂƌŵƉĂƚŝĞŶƚ͘ x (I) Vascular Access ǁŝƚŚ/sŽƌ/K x dƌĞĂƚƌĞƐƉŝƌĂƚŽƌǇĚŝƐƚƌĞƐƐǁŝƚŚŵĞĚŝĐĂůRespiratory DistressŐƵŝĚĞůŝŶĞƐ͘WŽƐƚͲĚƌŽǁŶŝŶŐƉĂƚŝĞŶƚƐǁŚŽ ĂƌĞĂǁĂŬĞĂŶĚĐŽŽƉĞƌĂƚŝǀĞŵĂǇďĞŶĞĨŝƚĨƌŽŵCPAP ƉƌŽĐĞĚƵƌĞ͘ Awake and Alert Patients x (B)ZĞŵŽǀĞǁĞƚĐůŽƚŚŝŶŐ͘ƌǇ͕ǁĂƌŵƉĂƚŝĞŶƚ͘ x DŽŶŝƚŽƌĂŶĚƌĞĂƐƐĞƐƐ͘ŶĐŽƵƌĂŐĞƚƌĂŶƐƉŽƌƚ͘ x Asymptomatic drowning survivors should be observed in the ED/Hospital setting for 4 to 6 hours for development of symptoms. There is potential for them to worsen over the next several hours post-incident. x dƌĞĂƚƌĞƐƉŝƌĂƚŽƌǇĚŝƐƚƌĞƐƐǁŝƚŚŵĞĚŝĐĂůRespiratory DistressŐƵŝĚĞůŝŶĞƐ͘WŽƐƚͲĚƌŽǁŶŝŶŐƉĂƚŝĞŶƚƐǁŚŽ ĂƌĞĂǁĂŬĞĂŶĚĐŽŽƉĞƌĂƚŝǀĞŵĂǇďĞŶĞĨŝƚĨƌŽŵCPAP ƉƌŽĐĞĚƵƌĞ͘ WĞĂƌůƐ x ƌŽǁŶŝŶŐŝƐƚŚĞƉƌŽĐĞƐƐŽĨĞǆƉĞƌŝĞŶĐŝŶŐƌĞƐƉŝƌĂƚŽƌǇŝŵƉĂŝƌŵĞŶƚĨƌŽŵƐƵďŵĞƌƐŝŽŶͬŝŵŵĞƌƐŝŽŶŝŶ ůŝƋƵŝĚ͘dŚĞƚĞƌŵ͞ŶĞĂƌͲĚƌŽǁŶŝŶŐ͟ŝƐŶŽůŽŶŐĞƌƵƐĞĚ͖ƌŽǁŶŝŶŐĚĞƐĐƌŝďĞƐƚŚĞƌĂŶŐĞŽĨŽƵƚĐŽŵĞƐĨƌŽŵ ĚĞĂƚŚ;ŶŽƐƵƌǀŝǀĂůͿ͕ŵŽƌďŝĚŝƚǇ;ƐƵƌǀŝǀĂůŽĨŝŶĐŝĚĞŶƚǁŝƚŚƌĞƐƵůƚŝŶŐĚĞĂƚŚŝŶƚŚĞĚĂǇƐƚŽǁĞĞŬƐ ĨŽůůŽǁŝŶŐͿ͕ĂŶĚŶŽŵŽƌďŝĚŝƚǇ;ƐƵƌǀŝǀĂůŽĨŝŶĐŝĚĞŶƚǁŝƚŚŽƌǁŝƚŚŽƵƚůŽŶŐͲƚĞƌŵŚĞĂůƚŚĞĨĨĞĐƚƐͿ͘ x ,ĂǀĞĂŚŝŐŚŝŶĚĞǆŽĨƐƵƐƉŝĐŝŽŶĨŽƌƐƉŝŶĂůŝŶũƵƌŝĞƐ͘ x ŶƐƵƌĞƐĐĞŶĞƐĂĨĞƚǇ͘ƌŽǁŶŝŶŐŝƐŽŶĞŽĨƚŚĞůĞĂĚŝŶŐĐĂƵƐĞƐŽĨĚĞĂƚŚĂŵŽŶŐǁŽƵůĚͲďĞƌĞƐĐƵĞƌƐ͘,ĂǀĞ ƚƌĂŝŶĞĚƌĞƐĐƵĞƌƐƌĞŵŽǀĞǀŝĐƚŝŵƐƚŽĂƌĞĂŽĨƐĂĨĞƚǇ͘ x ,ǇƉŽƚŚĞƌŵŝĂŝƐŽĨƚĞŶĂƐƐŽĐŝĂƚĞĚǁŝƚŚĚƌŽǁŶŝŶŐĂŶĚŽƚŚĞƌǁĂƚĞƌͲƌĞůĂƚĞĚŝŶũƵƌŝĞƐ͘ x ŽŶƐŝĚĞƌƉůĂĐĞŵĞŶƚŽĨĂŶĂĚǀĂŶĐĞĚĂŝƌǁĂǇĂŶĚƉƌŽǀŝĚŝŶŐWW͘

Cypress Creek EMS System Policies and Treatment Guidelines

190 TRAUMA/ENVIRONMENTAL Revised 8/2016 Approved: Levon Vartanian, MD

ǆƚƌĞŵŝƚǇdƌĂƵŵĂ ƐƐĞƐƐŵĞŶƚZĞƋƵŝƌĞŵĞŶƚƐ DĂǇWƌĞƐĞŶƚƐ ŽŶƐŝĚĞƌWŽƐƐŝďůĞĂƵƐĞƐ ƐƐĞƐƐŵĞŶƚΘĨŽĐƵƐĞĚĞǆĂŵ WĂŝŶ͕ƐǁĞůůŝŶŐ͕ŚĞŵŽƌƌŚĂŐĞ ďƌĂƐŝŽŶ ĂƐŝŶĚŝĐĂƚĞĚ ĞĨŽƌŵŝƚǇ͕ĐƌĞƉŝƚƵƐ ŽŶƚƵƐŝŽŶ ŝƐƚĂůWƵůƐĞͲDŽƚŽƌͲ^ĞŶƐĂƚŝŽŶ ůƚĞƌĞĚƐĞŶƐĂƚŝŽŶͬŵŽƚŽƌ >ĂĐĞƌĂƚŝŽŶ ĂƐƐĞƐƐŵĞŶƚ ĨƵŶĐƚŝŽŶ ^ƉƌĂŝŶͬƐƚƌĂŝŶ ŽŶƐŝĚĞƌZͲϱϳƉĞƌĨƵƐŝŽŶ ŝŵŝŶŝƐŚĞĚĐĂƉŝůůĂƌǇ ŝƐůŽĐĂƚŝŽŶ ĂƐƐĞƐƐŵĞŶƚ͘ ƌĞĨŝůůͬĚĞĐƌĞĂƐĞĚƉƵůƐĞ &ƌĂĐƚƵƌĞ WĂůůŽƌ͕ĐŽŽůƐŬŝŶ ŵƉƵƚĂƚŝŽŶ ŽŵƉĂƌƚŵĞŶƚ^ǇŶĚƌŽŵĞ dƌĞĂƚŵĞŶƚƐ x Hemorrhage ControlĂƐŶĞĐĞƐƐĂƌǇ͘ x (B) Wound CareĂŶĚĚƌĞƐƐŝŶŐĂƐŶĞĐĞƐƐĂƌǇ͘ x (B)/ŵŵŽďŝůŝǌĞ;ƐůŝŶŐͬƐǁĂƚŚͬƐƉůŝŶƚͿŝŶũƵƌĞĚĞǆƚƌĞŵŝƚŝĞƐĂƐŶĞĐĞƐƐĂƌǇ͕ĂŶĚĞůĞǀĂƚĞŝĨƉŽƐƐŝďůĞ͘ x (B)ƉƉůǇĐŽůĚƉĂĐŬƐŝŶĚŝƌĞĐƚůǇƚŽŝŶũƵƌǇƐŝƚĞ͘ x (P) &ŽůůŽǁ,ǇƉŽƚĞŶƐŝŽŶͬ^ŚŽĐŬŐƵŝĚĞůŝŶĞƐĂƐŶĞĐĞƐƐĂƌǇ͘ x (P) Pain Management ĂƐŶĞĐĞƐƐĂƌǇ͘ x hƌŐĞŶƚůǇƚƌĂŶƐƉŽƌƚĂŶǇƉĂƚŝĞŶƚǁŝƚŚŶĞƵƌŽǀĂƐĐƵůĂƌĐŽŵƉƌŽŵŝƐĞĂŶĚĂŶǇĂŵƉƵƚĂƚŝŽŶ͘ x >ĂĐĞƌĂƚŝŽŶƐƐŚŽƵůĚďĞĞǀĂůƵĂƚĞĚĨŽƌƌĞƉĂŝƌǁŝƚŚŝŶϲŚŽƵƌƐƚŽŵŝŶŝŵŝǌĞĐŽŵƉůŝĐĂƚŝŽŶƐ͘ x (B) Apply traction splintĨŽƌĐůŽƐĞĚŵŝĚͲƐŚĂĨƚĨĞŵƵƌĨƌĂĐƚƵƌĞƐ͘ŽŶŽƚĚĞůĂǇƚƌĂŶƐƉŽƌƚŽĨƉĂƚŝĞŶƚƐ ǁŝƚŚůŝĨĞͲƚŚƌĞĂƚĞŶŝŶŐŝŶũƵƌŝĞƐ͖ĐŽŶƐŝĚĞƌĐŽŵƉůĞƚŝŶŐĞŶƌŽƵƚĞ͘ x (B) /ĨĂŶŐƵůĂƚĞĚĞǆƚƌĞŵŝƚǇĨƌĂĐƚƵƌĞǁŝƚŚŶŽĚŝƐƚĂůĐŝƌĐƵůĂƚŝŽŶ͕ĂƚƚĞŵƉƚƚŽƐƚƌĂŝŐŚƚĞŶǁŝƚŚŐĞŶƚůĞ ƚƌĂĐƚŝŽŶŽŶůǇƚŽƚŚĞƉŽŝŶƚŶĞĐĞƐƐĂƌǇƚŽƌĞƐƚŽƌĞĐŝƌĐƵůĂƚŝŽŶ͘

Cypress Creek EMS System Policies and Treatment Guidelines

191 TRAUMA/ENVIRONMENTAL Revised 8/2016 Approved: Levon Vartanian, MD

ǇĞ/ŶũƵƌŝĞƐ ƐƐĞƐƐŵĞŶƚZĞƋƵŝƌĞŵĞŶƚƐ DĂǇWƌĞƐĞŶƚƐ ŽŶƐŝĚĞƌWŽƐƐŝďůĞĂƵƐĞƐ ƐƐĞƐƐŵĞŶƚΘĨŽĐƵƐĞĚĞǆĂŵ WĂŝŶ͕ƐǁĞůůŝŶŐ͕ďůŽŽĚ ďƌĂƐŝŽŶͬůĂĐĞƌĂƚŝŽŶ sŝƐƵĂůĂĐƵŝƚǇĂƐƐĞƐƐŵĞŶƚ ĞĨŽƌŵŝƚǇ͕ĐŽŶƚƵƐŝŽŶ 'ůŽďĞƌƵƉƚƵƌĞ sŝƐƵĂůĚĞĨŝĐŝƚƐŽƌůŽƐƐ ZĞƚŝŶĂůŶĞƌǀĞĚĂŵĂŐĞ >ĞĂŬŝŶŐĂƋƵĞŽƵƐͬǀŝƚƌĞŽƵƐ ŚĞŵŝĐĂůͬƚŚĞƌŵĂůďƵƌŶ ŚƵŵŽƌ KƌďŝƚĂůĨƌĂĐƚƵƌĞ hƉǁĂƌĚůǇĨŝǆĞĚĞǇĞ EĞƵƌŽůŽŐŝĐĂů sŝƐŝďůĞĐŽŶƚĂŵŝŶĂŶƚƐ ĞǀĞŶƚͬƐƚƌŽŬĞͬŚĞĂĚŝŶũƵƌǇ >ĂĐƌŝŵĂƚŝŽŶ dƌĞĂƚŵĞŶƚƐ x (B)ZĞŵŽǀĞĐŽŶƚĂĐƚůĞŶƐĞƐǁŚĞŶƉŽƐƐŝďůĞ͘ x (B)ŽǀĞƌďŽƚŚĞǇĞƐƚŽƉƌĞǀĞŶƚĨƵƌƚŚĞƌŝŶũƵƌǇ͘hƐĞĞǇĞƐŚŝĞůĚŽŶĂĨĨĞĐƚĞĚĞǇĞ͖ŵĂǇƵƐĞƉĂĚŽŶ ƵŶĂĨĨĞĐƚĞĚĞǇĞ͘ x ŽŶŽƚƌĞŵŽǀĞŝŵƉĂůĞĚŽďũĞĐƚƐ͘ x dƌĂŶƐƉŽƌƚƐŝŐŶŝĨŝĐĂŶƚĞǇĞŝŶũƵƌŝĞƐƚŽ>ĞǀĞůϭdƌĂƵŵĂĞŶƚĞƌĨŽƌĂǀĂŝůĂďŝůŝƚǇŽĨĞǇĞƐƵƌŐĞƌǇƐƉĞĐŝĂůƚŝĞƐ͘ x (B)&ůƵƐŚĞǇĞďƵƌŶƐͬĐŽŶƚĂŵŝŶĂŶƚƐƵƐŝŶŐMorgan LensƉƌŽĐĞĚƵƌĞĨŽƌĂƚůĞĂƐƚƚǁĞŶƚǇŵŝŶƵƚĞƐ͘ x (P) ŽŶƐŝĚĞƌĨůƵƐŚŝŶŐĞǇĞƐǁŝƚŚNormal SalineϭϬϬϬŵ>ƵƐŝŶŐMorgan Lens͘ x (P) /ŶƐƚŝůůTetracaine 0.5%ϭʹϮĚƌŽƉƐŽĨŽƉŚƚŚĂůŵŝĐƐŽůƵƚŝŽŶƚŽĂĨĨĞĐƚĞĚĞǇĞƐ͘ŽŶŽƚĂĚŵŝŶŝƐƚĞƌ dĞƚƌĂĐĂŝŶĞŝŶĐĂƐĞƐŽĨĚŝƐƌƵƉƚĞĚŐůŽďĞ͘

Cypress Creek EMS System Policies and Treatment Guidelines

192 TRAUMA/ENVIRONMENTAL Revised 8/2016 Approved: Levon Vartanian, MD

,ĞĂĚdƌĂƵŵĂ ƐƐĞƐƐŵĞŶƚZĞƋƵŝƌĞŵĞŶƚƐ DĂǇWƌĞƐĞŶƚƐ ŽŶƐŝĚĞƌWŽƐƐŝďůĞĂƵƐĞƐ ƐƐĞƐƐŵĞŶƚΘĨŽĐƵƐĞĚͬĨƵůů WĂŝŶ͕ƐǁĞůůŝŶŐ͕ďůĞĞĚŝŶŐ ^ŬƵůůĨƌĂĐƚƵƌĞ ďŽĚǇĞǆĂŵĂƐĂƉƉƌŽƉƌŝĂƚĞ ůƚĞƌĞĚŵĞŶƚĂůƐƚĂƚƵƐ ƌĂŝŶŝŶũƵƌǇ;ĐŽŶĐƵƐƐŝŽŶ͕ ƌĂŶŝĂůŶĞƌǀĞƐĂƐ ŚĂŶŐĞƐƚŽƉƵƉŝůƐ ĐŽŶƚƵƐŝŽŶ͕ŚĞŵŽƌƌŚĂŐĞͿ ĂƉƉƌŽƉƌŝĂƚĞ ZĞƐƉŝƌĂƚŽƌǇĚŝƐƚƌĞƐƐͬĨĂŝůƵƌĞ ƉŝĚƵƌĂůͬ^ƵďĚƵƌĂůͬ^ƵďĂƌĂĐŚŶŽŝĚ 'ŵŽŶŝƚŽƌŝŶŐ ZĞƐƉŝƌĂƚŽƌǇƉĂƚƚĞƌŶĐŚĂŶŐĞƐ ŚĞŵĂƚŽŵĂ dKϮŵŽŶŝƚŽƌŝŶŐ sŽŵŝƚŝŶŐ ^ƉŝŶĂůŝŶũƵƌǇ '>ƐƐĞƐƐŵĞŶƚ ^ĞŝǌƵƌĞ ,ǇƉĞƌƚĞŶƐŝŽŶ͕ďƌĂĚǇĐĂƌĚŝĂ ;ƵƐŚŝŶŐ͛ƐZĞƐƉŽŶƐĞͿ dƌĞĂƚŵĞŶƚƐ x (B)ƉƉůǇSpinal Motion RestrictionŝĨĂƉƉƌŽƉƌŝĂƚĞ x ZĞĨĞƌƚŽAltered Mental StatusŐƵŝĚĞůŝŶĞƐ͘ x (P) dƌĞĂƚƐĞŝǌƵƌĞƐƵƐŝŶŐSeizure ŐƵŝĚĞůŝŶĞƐ͘ x /Ĩ'^фϴĂŶĚƉĂƚŝĞŶƚƵŶĂďůĞƚŽĐŽƵŐŚŽƌƉƌŽƚĞĐƚĂŝƌǁĂǇ͕ƉƌŽƚĞĐƚĂŝƌǁĂǇĨŽůůŽǁŝŶŐAdvanced Airway ManagementƉƌŽĐĞĚƵƌĞ͘ x ŽŶŽƚƌŽƵƚŝŶĞůǇŚǇƉĞƌǀĞŶƚŝůĂƚĞ͗ o DĂŝŶƚĂŝŶdKϮϯϱʹϰϱŵŵ,ŐǁŝƚŚǀĞŶƚŝůĂƚŝŽŶƌĂƚĞŽĨϴʹϭϬďƌĞĂƚŚƐͬŵŝŶƵƚĞ͘ x /ĨƐŝŐŶƐŽĨŚĞƌŶŝĂƚŝŽŶ;ƵŶŝůĂƚĞƌĂůŽƌďŝůĂƚĞƌĂůƉƵƉŝůĚŝůĂƚŝŽŶͬƉŽƐƚƵƌŝŶŐͿ͗ o ,ǇƉĞƌǀĞŶƚŝůĂƚĞĂƚƌĂƚĞŽĨϭϰʹϭϲďƌĞĂƚŚƐͬŵŝŶƵƚĞĨŽƌdKϮŽĨϯϬʹϯϱŵŵ,Ő͘ o ZĂƚĞĨŽƌŝŶĨĂŶƚƐфϭǇĞĂƌ͗ϯϱďƌĞĂƚŚƐͬŵŝŶ͘ o ZĂƚĞĨŽƌĐŚŝůĚƌĞŶхϭǇĞĂƌ͗ϮϱďƌĞĂƚŚƐͬŵŝŶ͘ x (P) PlasmalyteĨůƵŝĚďŽůƵƐĞƐƵƉƚŽϮϬŵ>ͬŬŐĨŽƌŚǇƉŽƚĞŶƐŝǀĞƉĂƚŝĞŶƚ͘ o >ŝŵŝƚ/sĨůƵŝĚƐƵŶůĞƐƐƉĂƚŝĞŶƚŝƐŚǇƉŽƚĞŶƐŝǀĞ͘ o dŝƚƌĂƚĞĨůƵŝĚĨŽƌŵŝŶŝŵƵŵƐǇƐƚŽůŝĐWŽĨϵϬŵŵ,ŐŝŶĂĚƵůƚƐ͘ o dŝƚƌĂƚĞĨůƵŝĚĨŽƌŵŝŶŝŵƵŵƐǇƐƚŽůŝĐWŽĨϳϬŵŵ,ŐнϮǆƚŚĞĂŐĞŝŶǇĞĂƌƐŽĨƉĞĚŝĂƚƌŝĐ͘ WĞĂƌůƐ x ,ĞĂĚŝŶũƵƌǇƉĂƚŝĞŶƚƐĞǆƉĞƌŝĞŶĐĞĚŽƵďůĞƚŚĞĐŚĂŶĐĞŽĨĚĞĂƚŚŝĨ͗ o ^ǇƐƚŽůŝĐWĨĂůůƐďĞůŽǁϵϬŵŵ,ŐEVEN ONCE o ^ƉKϮĨĂůůƐďĞůŽǁϵϬй o '^фϵ x ,ǇƉĞƌǀĞŶƚŝůĂƚŝŽŶƌĞĚƵĐĞƐŝŶƚƌĂĐƌĂŶŝĂůƉƌĞƐƐƵƌĞďǇĐĂƵƐŝŶŐŚǇƉŽĐĂƉŶŝĂĂŶĚĐŽŶƐƚƌŝĐƚŝŶŐĐĞƌĞďƌĂů ďůŽŽĚǀĞƐƐĞůƐ͘dŚŝƐŵĂǇƚĂŬĞƉƌĞƐƐƵƌĞŽĨĨŚĞƌŶŝĂƚŝŶŐďƌĂŝŶƐƚƌƵĐƚƵƌĞƐ͕ďƵƚŝƚĂůƐŽƌĞĚƵĐĞƐĐĞƌĞďƌĂů ďůŽŽĚĨůŽǁ͕ĐĂƵƐŝŶŐďƌĂŝŶƚŽďĞĐŽŵĞŽǆǇŐĞŶͲĚĞƉƌŝǀĞĚ͘ x ůĐŽŚŽůŝƐŽĨƚĞŶĂƐƐŽĐŝĂƚĞĚǁŝƚŚŚĞĂĚŝŶũƵƌŝĞƐ͘ŽŶŽƚďĞĨŽŽůĞĚďǇĞǀŝĚĞŶĐĞŽĨĂůĐŽŚŽů͖ĂƐƐƵŵĞ ƉĂƚŝĞŶƚǁŝƚŚƐǇŵƉƚŽŵƐĨŽůůŽǁŝŶŐĂƚƌĂƵŵĂƚŝĐĞǀĞŶƚŚĂƐĂŚĞĂĚŝŶũƵƌǇƵŶƚŝůĚŝƐƉƌŽǀĞŶ͘ x ŽŶŽƚƵƐĞƉĞƌŵŝƐƐŝǀĞŚǇƉŽƚĞŶƐŝŽŶŽŶƚŚĞƐĞƉĂƚŝĞŶƚƐ͘ x ŽŶƐŝĚĞƌƌĞƐƚƌĂŝŶƚƐŝĨŶĞĐĞƐƐĂƌǇ͘

Cypress Creek EMS System Policies and Treatment Guidelines

193 TRAUMA/ENVIRONMENTAL Revised 8/2016 Approved: Levon Vartanian, MD

,ǇƉĞƌƚŚĞƌŵŝĂ

ƐƐĞƐƐŵĞŶƚZĞƋƵŝƌĞŵĞŶƚƐ DĂǇWƌĞƐĞŶƚƐ ŽŶƐŝĚĞƌWŽƐƐŝďůĞĂƵƐĞƐ ƐƐĞƐƐŵĞŶƚΘĨƵůůŚĞĂĚͲƚŽͲƚŽĞ ůƚĞƌĞĚŵĞŶƚĂů &ĞǀĞƌ;ŝŶĨĞĐƚŝŽŶͿ ĞǆĂŵ ƐƚĂƚƵƐͬĐŽŶĨƵƐŝŽŶͬĐŽŵĂ ĞŚǇĚƌĂƚŝŽŶ 'ŵŽŶŝƚŽƌŝĨĂƉƉƌŽƉƌŝĂƚĞ ,Žƚ͕ĚƌǇ͕ŽƌƐǁĞĂƚǇƐŬŝŶ DĞĚŝĐĂƚŝŽŶƐ dĞŵƉĞƌĂƚƵƌĞĂƐƐĞƐƐŵĞŶƚ ,ǇƉŽƚĞŶƐŝŽŶ ,ǇƉĞƌƚŚǇƌŽŝĚŝƐŵ;^ƚŽƌŵͿ ŝǌǌŝŶĞƐƐ͕ǁĞĂŬŶĞƐƐ ĞůŝƌŝƵŵƚƌĞŵĞŶƐ;dƐͿ EĂƵƐĞĂ ,ĞĂƚĐƌĂŵƉƐ͕ĞǆŚĂƵƐƚŝŽŶ͕ƐƚƌŽŬĞ ^ĞŝǌƵƌĞƐ E^ůĞƐŝŽŶƐŽƌƚƵŵŽƌƐ

Required Treatments x ŐŐƌĞƐƐŝǀĞůǇĐŽŽůƉĂƚŝĞŶƚ͗ o ZĞŵŽǀĞĐůŽƚŚŝŶŐ o WŽƵƌĐŽůĚĨůƵŝĚƐŽǀĞƌƉĂƚŝĞŶƚ;ĞǀĂƉŽƌĂƚŝǀĞĐŽŽůŝŶŐͿ o WƌŽŵŽƚĞĐŽŶǀĞĐƚŝŽŶĂŶĚĞǀĂƉŽƌĂƚŝŽŶŝĨƉŽƐƐŝďůĞǁŝƚŚƵŶŝƚͬŽƌĨĂŶ o ƉƉůǇŝĐĞŽƌĐŽůĚƉĂĐŬƐƚŽĂǆŝůůĂ͕ŐƌŽŝŶ͕ŶĞĐŬ͕ŽƌŽƚŚĞƌĂƉƉƌŽƉƌŝĂƚĞĂƌĞĂƐ͘ o ƉƉůǇdƵƌůĞǇƉĂĚƚŽƉŽƐƚĞƌŝŽƌƐƵƌĨĂĐĞŽĨƉĂƚŝĞŶƚ͘ Available Treatments Heat Cramps EŽƌŵĂůƚŽĞůĞǀĂƚĞĚďŽĚǇƚĞŵƉĞƌĂƚƵƌĞƐ͖ǁĞĂŬŶĞƐƐ͕ŵƵƐĐůĞĐƌĂŵƉŝŶŐ͘ x (B) Oral fluidsĂƐƚŽůĞƌĂƚĞĚ͘ Heat Exhaustion ůĞǀĂƚĞĚďŽĚǇƚĞŵƉĞƌĂƚƵƌĞ͖ĐŽŽů͕ŵŽŝƐƚƐŬŝŶ͖ǁĞĂŬ͕ĂŶǆŝŽƵƐ͕ƚĂĐŚǇƉŶĞĂ͘ x (I) Vascular AccessǁŝƚŚ/sŽƌ/K x (P) Normal SalineďŽůƵƐƵƉƚŽϮϬŵ>ͬŬŐ͕ƌĞƉĞĂƚĂƐŶĞĞĚĞĚ͘hƐĞǁŝƚŚĐĂƵƚŝŽŶŝŶƉĂƚŝĞŶƚƐǁŝƚŚƌĞŶĂů ĨĂŝůƵƌĞŽƌ,&͘ Heat Stroke ,ŝŐŚďŽĚǇƚĞŵƉĞƌĂƚƵƌĞŽĨϭϬϱΣ&;ϰϬ͘ϲΣͿĂŶĚĂůƚĞƌĞĚŵĞŶƚĂůƐƚĂƚƵƐͬĐŽŵĂ͘ x (I) Vascular AccessǁŝƚŚ/sŽƌ/K x (P) Cold Normal Saline ďŽůƵƐƵƉƚŽϮϬŵ>ͬŬŐ͕ƌĞƉĞĂƚĂƐŶĞĞĚĞĚ͘hƐĞǁŝƚŚĐĂƵƚŝŽŶŝŶƉĂƚŝĞŶƚƐǁŝƚŚ ƌĞŶĂůĨĂŝůƵƌĞŽƌ,&͘ Pearls x ǆƚƌĞŵĞƐŽĨĂŐĞĂƌĞŵŽƌĞƉƌŽŶĞƚŽŚĞĂƚĞŵĞƌŐĞŶĐŝĞƐ͘ x WƌĞĚŝƐƉŽƐĞĚďǇƵƐĞŽĨdƐ͕ƉŚĞŶŽƚŚŝĂǌŝŶĞƐ͕ĂŶƚŝĐŚŽůŝŶĞƌŐŝĐŵĞĚŝĐĂƚŝŽŶƐ͕ĂŶĚĂůĐŽŚŽů͘ x ŽĐĂŝŶĞ͕ĂŵƉŚĞƚĂŵŝŶĞƐ͕ĂŶĚƐĂůŝĐǇůĂƚĞƐŵĂǇĞůĞǀĂƚĞďŽĚǇƚĞŵƉĞƌĂƚƵƌĞƐ͘

Cypress Creek EMS System Policies and Treatment Guidelines

194 TRAUMA/ENVIRONMENTAL Revised 8/2016 Approved: Levon Vartanian, MD

,ǇƉŽƚŚĞƌŵŝĂ ƐƐĞƐƐŵĞŶƚZĞƋƵŝƌĞŵĞŶƚƐ DĂǇWƌĞƐĞŶƚƐ ŽŶƐŝĚĞƌWŽƐƐŝďůĞĂƵƐĞƐ ƐƐĞƐƐŵĞŶƚΘ&ƵůůŚĞĂĚͲƚŽͲ ŽŶĨƵƐŝŽŶ͕ĂůƚĞƌĞĚŵĞŶƚĂů ŶǀŝƌŽŶŵĞŶƚĂůĞǆƉŽƐƵƌĞ ƚŽĞĞǆĂŵ ƐƚĂƚƵƐ͕ĚŝǌǌŝŶĞƐƐ ,ǇƉŽŐůǇĐĞŵŝĂ 'ŵŽŶŝƚŽƌŝŶŐ ^ŚŝǀĞƌŝŶŐ ,ǇƉŽƚŚǇƌŽŝĚŝƐŵ ŽƌĞƚĞŵƉĞƌĂƚƵƌĞ WĂŝŶŽƌƐĞŶƐŽƌǇĂďŶŽƌŵĂůŝƚŝĞƐ ^ĞƉƐŝƐ ĂƐƐĞƐƐŵĞŶƚ ƌĂĚǇĐĂƌĚŝĂ͕ĐĂƌĚŝĂĐ E^ĚǇƐĨƵŶĐƚŝŽŶ '>ĂƐƐĞƐƐŵĞŶƚ ĚǇƐƌŚǇƚŚŵŝĂƐ ϭϮͲůĞĂĚ' ĂƌĚŝĂĐĂƌƌĞƐƚ Treatments x (B) Active warming measures:,ĞĂƚƉĂĐŬƐĂƌŽƵŶĚĂǆŝůůĂĞ͕ŐƌŽŝŶ͕ŶĞĐŬ͕ĂŶĚŽƚŚĞƌĂƉƉƌŽƉƌŝĂƚĞƉůĂĐĞƐ͘ ůĂŶŬĞƚƐ͘tĂƌŵĞŶǀŝƌŽŶŵĞŶƚ͘ZĞŵŽǀĞĂŶǇǁĞƚĐůŽƚŚŝŶŐ͘ x &ŽůůŽǁAltered Mental StatusŐƵŝĚĞůŝŶĞƐĂƐŝŶĚŝĐĂƚĞĚ͘ x (I) Vascular accessǁŝƚŚ/sŽƌ/K x (P) dƌĞĂƚŚǇƉŽƚĞŶƐŝŽŶĂƐŶĞĐĞƐƐĂƌǇƵƐŝŶŐHypotension/Shock ŐƵŝĚĞůŝŶĞƐ͘ ĂƌĚŝĂĐƌƌĞƐƚ WĂƚŝĞŶƚďĞůŽǁϴϲΣ&;ϯϬΣͿ͗

x ĞĨŝďƌŝůůĂƚĞϭƚŝŵĞŝĨĚĞĨŝďƌŝůůĂƚŝŽŶŝƐƌĞƋƵŝƌĞĚ͘&ŽůůŽǁŝŶŐƚŚŝƐ͕ĚŽWZĂŶĚƌĞǁĂƌŵƉĂƚŝĞŶƚďĞĨŽƌĞ ĨƵƌƚŚĞƌĚĞĨŝďƌŝůůĂƚŝŽŶĂƚƚĞŵƉƚƐ͘ x ŶƚŝĂƌƌŚǇƚŚŵŝĐƐǁŝůůŶŽƚǁŽƌŬ͘sĂƐŽƉƌĞƐƐŽƌƐĐĂŶďĞĂĚŵŝŶŝƐƚĞƌĞĚ͘WĂĐŝŶŐƐŚŽƵůĚŶŽƚďĞĚŽŶĞ͘ x ŽŶƚŝŶƵĞƌĞƐƵƐĐŝƚĂƚŝŽŶƵŶƚŝůƉĂƚŝĞŶƚ͛ƐĐŽƌĞƚĞŵƉĞƌĂƚƵƌĞŝƐŶŽƌŵĂů͘ Pearls x /ŶƚƵďĂƚŝŽŶĐĂŶĐĂƵƐĞǀĞŶƚƌŝĐƵůĂƌĨŝďƌŝůůĂƚŝŽŶ͘DŽƐƚĞǆƉĞƌŝĞŶĐĞĚƉƌŽǀŝĚĞƌƐŚŽƵůĚĚŽŝƚŝĨŶĞĐĞƐƐĂƌǇ͘ x ůĐŽŚŽů͕ĚƌƵŐƵƐĞ͕ĞǆƚƌĞŵĞƐŽĨĂŐĞ͕ĂŶĚŵĂůŶƵƚƌŝƚŝŽŶĂůůŝŶĐƌĞĂƐĞƌŝƐŬ͘ x ,ǇƉŽƚŚĞƌŵŝĂĐĂŶŽĐĐƵƌĞǀĞŶŝŶ͞ǁĂƌŵ͟ƚĞŵƉĞƌĂƚƵƌĞƐŝĨƉĂƚŝĞŶƚŝƐŝŶĐŽŶƚĂĐƚǁŝƚŚǁĂƚĞƌŽƌŝƐƵŶĂďůĞ ƚŽĐŽŶƚƌŽůƚŚĞŝƌƚĞŵƉĞƌĂƚƵƌĞĚƵĞƚŽŝŵƉĂŝƌŵĞŶƚŽƌŝŶũƵƌǇ͘

Cypress Creek EMS System Policies and Treatment Guidelines

195 TRAUMA/ENVIRONMENTAL Revised 12/2018 Approved: Levon Vartanian, MD

,ǇƉŽƚĞŶƐŝŽŶͬ^ŚŽĐŬ ƐƐĞƐƐŵĞŶƚZĞƋƵŝƌĞŵĞŶƚƐ DĂǇWƌĞƐĞŶƚƐ ŽŶƐŝĚĞƌWŽƐƐŝďůĞĂƵƐĞƐ ƐƐĞƐƐŵĞŶƚΘ&ƵůůŚĞĂĚͲƚŽͲ ZĞƐƚůĞƐƐŶĞƐƐ͕ĂŶǆŝĞƚǇ͕ ^ŚŽĐŬ ƚŽĞĞǆĂŵ͕ĂƐŝŶĚŝĐĂƚĞĚ ĐŽŶĨƵƐŝŽŶ͕ǁĞĂŬŶĞƐƐ͕ ,ǇƉŽǀŽůĞŵŝĐ;ǀŽůƵŵĞ ZĂƉŝĚůǇŝĚĞŶƚŝĨǇ ĚŝǌǌŝŶĞƐƐ͕ǁĞĂŬ͕ƌĂƉŝĚƉƵůƐĞ͕ ĚĞƉůĞƚĞĚͿ ĞǆƐĂŶŐƵŝŶĂƚŝŶŐŚĞŵŽƌƌŚĂŐĞ ƉĂůĞ͕ĐŽŽůĐůĂŵŵǇƐŬŝŶ͕ ,ǇƉŽǀŽůĞŵŝĐ 'DŽŶŝƚŽƌ ĚĞůĂǇĞĚĐĂƉŝůůĂƌǇƌĞĨŝůů͕ĐŽĨĨĞĞ ;ŚĞŵŽƌƌŚĂŐŝĐͿ dKϮŵŽŶŝƚŽƌŝŶŐ ŐƌŽƵŶĚĞŵĞƐŝƐ͕ƚĂƌƌǇƐƚŽŽůƐ͕ ĂƌĚŝŽŐĞŶŝĐ ϭϮͲůĞĂĚ'͕ĂƐŝŶĚŝĐĂƚĞĚ ĨƌĂŶŬ'/ďůĞĞĚŝŶŐ͘ ^ĞƉƚŝĐ ,Θ,ĂƐĂƉƉƌŽƉƌŝĂƚĞ EĞƵƌŽŐĞŶŝĐ hůƚƌĂƐŽƵŶĚ͕ŝĨĂǀĂŝůĂďůĞ ŶĂƉŚǇůĂĐƚŝĐ WƵůŵŽŶĂƌǇĞŵďŽůŝƐŵ dĞŶƐŝŽŶƉŶĞƵŵŽƚŚŽƌĂǆ WĞƌŝĐĂƌĚŝĂůƚĂŵƉŽŶĂĚĞ ĐƚŽƉŝĐƉƌĞŐŶĂŶĐǇ ǇƐƌŚǇƚŚŵŝĂƐ DĞĚŝĐĂƚŝŽŶĞĨĨĞĐƚͬK sĂƐŽǀĂŐĂů WŚǇƐŝŽůŽŐŝĐ;ƉƌĞŐŶĂŶĐǇ ƉŽƐŝƚŝŽŶͿ ZĞƋƵŝƌĞĚdƌĞĂƚŵĞŶƚƐ x Airway management ĂƉƉƌŽƉƌŝĂƚĞ ƚŽƉĂƚŝĞŶƚĐŽŶĚŝƚŝŽŶ͘ x VentilationĂŶĚoxygenation ĂƉƉƌŽƉƌŝĂƚĞƚŽƉĂƚŝĞŶƚĐŽŶĚŝƚŝŽŶ͘ x (I) Vascular accessǁŝƚŚ/sŽƌ/K͘ŽŶƐŝĚĞƌůŽŽĚͲz/sƚƵďŝŶŐ x (B) Control exsanguinating hemorrhage ǀĂŝůĂďůĞdƌĞĂƚŵĞŶƚƐ x (P) PlasmalyteĨůƵŝĚĐŚĂůůĞŶŐĞ;ĐŽŶƐŝĚĞƌtherapeutic hypotensionďĞůŽǁͿ͘DĂǆĚŽƐĞϮϬŵ>ͬŬŐ x ZĞĨĞƌƚŽHemorrhage ControlŐƵŝĚĞůŝŶĞƐƵŶĚĞƌdƌĂƵŵĂƐĞĐƚŝŽŶ x (P) ResQGardƉƌŽĐĞĚƵƌĞ x (P) Dopamine ϱͲϮϬŵĐŐͬŬŐͬŵŝŶ/sͬ/KŝŶĨƵƐŝŽŶĨŽƌƐŚŽĐŬƚŚĂƚŝƐŶŽƚŚǇƉŽǀŽůĞŵŝĐŝŶŶĂƚƵƌĞ͘ x (P) Epinephrine ϮͲϭϬŵĐŐͬŵŝŶ/sͬ/KŝŶĨƵƐŝŽŶĨŽƌƐŚŽĐŬƚŚĂƚŝƐŶŽƚŚǇƉŽǀŽůĞŵŝĐŝŶŶĂƚƵƌĞ͘ x (P) Whole Blood ŽƌBlood ProductsƉĞƌůŽŽĚΘůŽŽĚWƌŽĚƵĐƚƐdƌĂŶƐĨƵƐŝŽŶWƌŽĐĞĚƵƌĞ͘ WĞĂƌůƐ x /ŶƚŚĞƉƌĞƐĞŶĐĞŽĨƵŶĐŽŶƚƌŽůůĞĚŚĞŵŽƌƌŚĂŐĞ͕ƚĂƌŐĞƚĂ^WŽĨϳϬŵŵ,Ő;ƚŚĞƌĂƉĞƵƚŝĐŚǇƉŽƚĞŶƐŝŽŶͿ͘/Ĩ ŚĞŵŽƌƌŚĂŐĞŝƐĐŽŶƚƌŽůůĞĚ͕ƚĂƌŐĞƚĂ^WŽĨхϵϬŵŵ,Ő͘ x hƐĞĐĂƵƚŝŽŶŝŶĂĚŵŝŶŝƐƚĞƌŝŶŐĨůƵŝĚƐŝŶcardiogenic shock. x ŽŶƐŝĚĞƌǀĂƐŽƉƌĞƐƐŽƌƐŝŶƚƌĂƵŵĂƚŝĐŽƌŚǇƉŽǀŽůĞŵŝĐƐŚŽĐŬKE>zĂĨƚĞƌϮ>ŝƚĞƌĨůƵŝĚďŽůƵƐĂŶĚƉĂƚŝĞŶƚ ŝƐƉĞƌŝͲĂƌƌĞƐƚ͘

Cypress Creek EMS System Policies and Treatment Guidelines

196 TRAUMA/ENVIRONMENTAL Revised 12/2018 Approved: Levon Vartanian, MD

x /ĨƵŶĐŽŶƚƌŽůůĂďůĞďůĞĞĚŝŶŐĞǆŝƐƚƐ͕ƌĂƉŝĚƚƌĂŶƐƉŽƌƚƚŽƚŚĞĂƉƉƌŽƉƌŝĂƚĞŚŽƐƉŝƚĂůŝƐŶĞĐĞƐƐĂƌǇĂĨƚĞƌ ŝŵŵŽďŝůŝǌĂƚŝŽŶŽĨƐƉŝŶĞĂŶĚĂŝƌǁĂǇŵĂŶĂŐĞŵĞŶƚŚĂƐďĞĞŶĂĐĐŽŵƉůŝƐŚĞĚ͘ŽŶƐŝĚĞƌĞĂƌůǇĂĐƚŝǀĂƚŝŽŶ ŽĨŝƌDĞĚŝĐĂůdƌĂŶƐƉŽƌƚ;>ŝĨĞ&ůŝŐŚƚͿŝĨƚŚĞƉĂƚŝĞŶƚŵĂǇďĞŶĞĨŝƚĨƌŽŵƚŚĞĂĚŵŝŶŝƐƚƌĂƚŝŽŶŽĨǁŚŽůĞ ďůŽŽĚŽƌďůŽŽĚƉƌŽĚƵĐƚƐ͘ x EŽĂƚƚĞŵƉƚĂƚĞƐƚĂďůŝƐŚŝŶŐ/sĐĐĞƐƐƐŚŽƵůĚďĞĚŽŶĞǁŚŝůĞŽŶƐĐĞŶĞƵŶůĞƐƐƚƌĂŶƐƉŽƌƚŝƐĚĞůĂǇĞĚŽƌŝƚ ŝƐƌĞƋƵŝƌĞĚĨŽƌĂŝƌǁĂǇŵĂŶĂŐĞŵĞŶƚ x /ŶƚƵďĂƚŝŽŶƐŚŽƵůĚďĞƉĞƌĨŽƌŵĞĚŽŶƐĐĞŶĞŽŶůǇŝĨƚŚĞƉĂƚŝĞŶƚŝƐƵŶĂďůĞƚŽƉƌŽƚĞĐƚƚŚĞŝƌĂŝƌǁĂǇŽƌŝĨ ƚŚĞƉĂƚŝĞŶƚŝƐŚǇƉŽǆŝĐĂŶĚĚŽĞƐŶŽƚƌĞƐƉŽŶĚƚŽŽǆǇŐĞŶ x /ŶƚŚĞĂďƐĞŶĐĞŽĨŚĞĂĚŝŶũƵƌǇ͕ĂůƚĞƌĞĚŵĞŶƚĂůƐƚĂƚƵƐĐĂŶďĞƵƐĞĚĂƐĂŶŝŶĚŝĐĂƚŝŽŶĨŽƌĨůƵŝĚďŽůƵƐ ŝŶƐƚĞĂĚŽĨƐǇƐƚŽůŝĐďůŽŽĚƉƌĞƐƐƵƌĞфϳϬŵŵ,Ő͘ x /ĨƵůƚƌĂƐŽƵŶĚŝƐĂǀĂŝůĂďůĞ͕ƵƚŝůŝǌĞƚŚĞĨŽůůŽǁŝŶŐĞǆĂŵƐƚŽĞǀĂůƵĂƚĞĨŽƌƉŽƐƐŝďůĞĐĂƵƐĞƐŽĨŚǇƉŽƚĞŶƐŝŽŶ͗

Use this exam To evaluate for Treatment Indicated ĂƌĚŝĂĐdĂŵƉŽŶĂĚĞ /ŶŝƚŝĂƚĞƌĂƉŝĚƚƌĂŶƐƉŽƌƚƚŽĐůŽƐĞƐƚƚƌĂƵŵĂĐĞŶƚĞƌ͘ WŽŽƌŵŽƚŝŽŶƐƵƉƉŽƌƚƐƵƐĞŽĨƉƌĞƐƐŽƌƐ͘ ĂƌĚŝĂĐǆĂŵ;W>yͬ^hyͿ ĂƌĚŝĂĐ&ƵŶĐƚŝŽŶ ,ǇƉĞƌĚǇŶĂŵŝĐŵŽƚŝŽŶƐƵŐŐĞƐƚƐŚǇƉŽǀŽůĞŵŝĂ͖ ƉƌŽǀŝĚĞĨůƵŝĚďŽůƵƐ͘ &ůƵŝĚ /&/sŝƐĐŽůůĂƉƐŝďůĞ͕ĐŽŶƐŝĚĞƌƐĞƉƐŝƐŽƌ ƌĞƐƉŽŶƐŝǀĞŶĞƐƐͬƉƌĞůŽĂĚ ŚǇƉŽǀŽůĞŵŝĂĂŶĚƉƌŽǀŝĚĞĨůƵŝĚďŽůƵƐ /sĞǆĂŵ /sŝƐůĂƌŐĞ;ĚŽĞƐŶŽƚǀĂƌǇǁŝƚŚƌĞƐƉŝƌĂƚŝŽŶƐͿĂŶĚ WƵůŵŽŶĂƌǇĞŵďŽůŝƐŵ ĐĂƌĚŝĂĐĞǆĂŵƐŚŽǁƐĞŶůĂƌŐĞĚZs͘/ŶŝƚŝĂƚĞƌĂƉŝĚ ƚƌĂŶƐƉŽƌƚƚŽĐůŽƐĞƐƚĂƉƉƌŽƉƌŝĂƚĞŚŽƐƉŝƚĂů͘ WŶĞƵŵŽƚŚŽƌĂǆ WĞƌĨŽƌŵNeedle Decompression WƵůŵŽŶĂƌǇĞǆĂŵ /ŶƉƌĞƐĞŶĐĞŽĨƚƌĂƵŵĂ͕ƚƌĂŶƐĨƵƐĞďůŽŽĚĂŶĚ ďĚŽŵŝŶĂůĨƌĞĞ &^dĞǆĂŵ ŝŶŝƚŝĂƚĞƌĂƉŝĚƚƌĂŶƐƉŽƌƚƚŽĂ>ĞǀĞů/ͬ//ƚƌĂƵŵĂ ĨůƵŝĚͬďůŽŽĚ ĐĞŶƚĞƌ͘

^ŚŽĐŬŝĨĨĞƌĞŶƚŝĂůŝĂŐŶŽƐŝƐ

ŚŽŽƐŝŶŐƚŚĞďĞƐƚƚŚĞƌĂƉǇŝƐĚĞƉĞŶĚĞŶƚŽŶŝĚĞŶƚŝĨǇŝŶŐƚŚĞƚǇƉĞĂŶĚŶĂƚƵƌĞŽĨƐŚŽĐŬƉƌĞƐĞŶƚ͘'ĞŶĞƌĂůůǇ ƐƉĞĂŬŝŶŐ͕ƐŚŽĐŬŝƐŝŶĂĚĞƋƵĂƚĞƉĞƌĨƵƐŝŽŶĂŶĚŝƚĐĂŶďĞĐĂƵƐĞĚďǇĨŽƵƌƉƌŝŵĂƌǇƉƌŽďůĞŵƐǁŝƚŚ͗

Hypovolemic Shock ŝƐĐĂƵƐĞĚďǇůŽƐƐŽĨďůŽŽĚǀŽůƵŵĞ͘ ^ŝŐŶƐͬ^ǇŵƉƚŽŵƐŝŶĐůƵĚĞƚĂĐŚǇĐĂƌĚŝĂ͕ƚĂĐŚǇƉŶĞĂ͕ƌĞƐƚůĞƐƐŶĞƐƐ͕ĂůƚĞƌĞĚŵĞŶƚĂƚŝŽŶ͕ƉĂůĞͬĐŽŽůͬĐůĂŵŵǇ ƐŬŝŶ͕ĂŶĚŝƚůĞĂĚƐƚŽŚǇƉŽƚĞŶƐŝŽŶĂŶĚƵůƚŝŵĂƚĞůǇĚĞĂƚŚ͘

dŚŝƐŵĂǇďĞhemorrhagicŝŶŶĂƚƵƌĞ͕ǁŚĞƌĞƚŚĞƌĞŝƐĂůŽƐƐŽĨƌĞĚďůŽŽĚĐĞůůƐ͘dƌĞĂƚŵĞŶƚĨŽƌƚŚŝƐƐŚŽƵůĚ ŝŶĐůƵĚĞŚĞŵŽƌƌŚĂŐĞĐŽŶƚƌŽů͕ƵƐĞŽĨǁŚŽůĞďůŽŽĚŽƌďůŽŽĚƉƌŽĚƵĐƚƐ͕ĂŶĚƵƐĞŽĨĐƌǇƐƚĂůůŽŝĚƐĂƐŶĞĐĞƐƐĂƌǇ ;ǁŝƚŚƉĞƌŵŝƐƐŝǀĞŚǇƉŽƚĞŶƐŝŽŶŝŶŵŝŶĚͿ͘

Non-hemorrhagic hypovolemic shockŵĂǇďĞĐĂƵƐĞĚďǇĚĞŚǇĚƌĂƚŝŽŶŽƌŽƚŚĞƌĨůƵŝĚůŽƐƐ͘&ůƵŝĚ ƌĞƉůĂĐĞŵĞŶƚƵƐŝŶŐĂĐƌǇƐƚĂůůŽŝĚŝƐƚŚĞƉƌĞĨĞƌƌĞĚƚƌĞĂƚŵĞŶƚ͘

hƐĞŽĨǀĂƐŽƉƌĞƐƐŽƌƐĨŽƌŚǇƉŽǀŽůĞŵŝĐƐŚŽĐŬŝƐŶŽƚĂĚǀŝƐĂďůĞƵŶůĞƐƐƉĂƚŝĞŶƚŝƐƉĞƌŝͲĂƌƌĞƐƚĂŶĚŚĂƐƌĞĐĞŝǀĞĚ ĂŵŝŶŝŵƵŵŽĨϮůŝƚĞƌƐŽĨĨůƵŝĚďŽůƵƐ͘

Cypress Creek EMS System Policies and Treatment Guidelines

197 TRAUMA/ENVIRONMENTAL Revised 12/2018 Approved: Levon Vartanian, MD

Cardiogenic ShockŝƐĐĂƵƐĞĚďǇƉƵŵƉĨĂŝůƵƌĞ;ŚĞĂƌƚĨĂŝůƵƌĞͿ ^ŝŐŶͬƐǇŵƉƚŽŵƐŵĂǇŝŶĐůƵĚĞŝƐĐŚĞŵŝĐĐŚĞƐƚĚŝƐĐŽŵĨŽƌƚ͕ĚǇƐƉŶĞĂ͕ƚĂĐŚǇĐĂƌĚŝĂ͕ĐĂƌĚŝĂĐĚǇƐƌŚǇƚŚŵŝĂƐ͕ ƚĂĐŚǇƉŶĞĂ͕ŚǇƉŽƚĞŶƐŝŽŶ͕ƉƵůŵŽŶĂƌǇĞĚĞŵĂ;ĐƌĂĐŬůĞƐͿ͕ĂůƚĞƌĞĚŵĞŶƚĂƚŝŽŶ͕ƉĂůĞͬĐŽŽůͬĐůĂŵŵǇƐŬŝŶ͕ĂŶĚ 'ĐŚĂŶŐĞƐ͘

dŚŝƐŵĂǇďĞĐĂƵƐĞĚďǇ rate problemsƐƵĐŚĂƐďƌĂĚǇĐĂƌĚŝĂ͕^sd͕ǀĞŶƚƌŝĐƵůĂƌĚǇƐƌŚǇƚŚŵŝĂƐ; mechanical problemsƐƵĐŚĂƐǀĂůǀĞĚŝƐƌƵƉƚŝŽŶƐ͖Žƌcontractility problemsĐĂƵƐĞĚďǇD/͕ŵƵƐĐůĞĚĂŵĂŐĞ͕ĞůĞĐƚƌŽůǇƚĞ ĂďŶŽƌŵĂůŝƚŝĞƐ͕ŽƌŽǀĞƌĚŽƐĞͬƚŽǆŝĐĞǆƉŽƐƵƌĞ͘

dƌĞĂƚŵĞŶƚƐŚŽƵůĚĨŽĐƵƐŽŶĨŝǆŝŶŐƚŚĞƵŶĚĞƌůǇŝŶŐƉƌŽďůĞŵ͕ƚƌĞĂƚŝŶŐƌĂƚĞ͕ƌŚǇƚŚŵ͕ďůŽŽĚƉƌĞƐƐƵƌĞŝŶƚŚĂƚ ŽƌĚĞƌ͘/ĨƌĂƚĞĂŶĚƌŚǇƚŚŵĂƌĞĂƉƉƌŽƉƌŝĂƚĞ͕ĐŽŶƐŝĚĞƌƵƐŝŶŐDopamineŝŶƚŚĞϱʹϭϬŵĐŐͬŬŐͬŵŝŶƌĂŶŐĞŽƌ EpinephrineϮʹϭϬŵĐŐͬŬŐͬŵŝŶ͘ǀŽŝĚĨůƵŝĚƐƵŶůĞƐƐŚǇƉŽǀŽůĞŵŝĂŝƐĂůƐŽƐƵƐƉĞĐƚĞĚ͘ Distributive ShockŝƐĐĂƵƐĞĚďǇƐǇƐƚĞŵŝĐǀĂƐŽĚŝůĂƚŝŽŶ dŚŝƐŵĂǇďĞĐĂƵƐĞĚďǇanaphylaxis͕sepsis͕Žƌneurogenic shock͘dƌĞĂƚSepsisƵƐŝŶŐ^ĞƉƐŝƐƉƌŽƚŽĐŽůĂŶĚ ĂůĂƌŐĞ;ϯϬŵ>ͬŬŐͿĨůƵŝĚďŽůƵƐĨŽůůŽǁĞĚďǇĂƉƌĞƐƐŽƌ͘dƌĞĂƚanaphylaxisĂŐŐƌĞƐƐŝǀĞůǇǁŝƚŚEpinephrine Ϭ͘ϯ ŵŐϭ͗ϭ͕ϬϬϬ/D;ŽƌϬ͘ϭŵŐϭ͗ϭϬ͕ϬϬϬ/sŝĨƉĂƚŝĞŶƚŝƐƐĞǀĞƌĞůǇŚǇƉŽƚĞŶƐŝǀĞͿ͘dƌĞĂƚneurogenicƐŚŽĐŬ͕Žƌ ĂŶĂƉŚǇůĂǆŝƐĂŶĚƐĞƉƐŝƐƚŚĂƚĂƌĞƌĞĨƌĂĐƚŽƌǇƚŽŽƚŚĞƌƚƌĞĂƚŵĞŶƚƐ͕ǁŝƚŚŚŝŐŚͲĂůƉŚĂǀĂƐŽƉƌĞƐƐŽƌƐƐƵĐŚĂƐ Dopamine ŝŶƚŚĞϭϬʹϮϬŵĐŐͬŬŐͬŵŝŶƌĂŶŐĞŽƌEpinephrineϮʹϭϬŵĐŐͬŬŐͬŵŝŶ͘ Obstructive ShockŝƐĐĂƵƐĞĚďǇĂƉŚǇƐŝĐĂůŽďƐƚƌƵĐƚŝŽŶƚŽďůŽŽĚĨůŽǁ dŚŝƐŵĂǇďĞĂtension pneumothorax͕Ăpulmonary embolism͕Žƌpericardial tamponade͘dƌĞĂƚĂ ƚĞŶƐŝŽŶƉŶĞƵŵŽƚŚŽƌĂǆǁŝƚŚŶĞĞĚůĞĚĞĐŽŵƉƌĞƐƐŝŽŶ͘hƌŐĞŶƚůǇƚƌĂŶƐƉŽƌƚƐƵƐƉĞĐƚĞĚƉĞƌŝĐĂƌĚŝĂů ƚĂŵƉŽŶĂĚĞŽƌƉƵůŵŽŶĂƌǇĞŵďŽůŝƐŵƐĂŶĚƵƐĞĨůƵŝĚďŽůƵƐĞƐĂůŽŶŐǁŝƚŚǀĂƐŽƉƌĞƐƐŽƌƐĂƐŶĞĞĚĞĚƚŽ ŵĂǆŝŵŝǌĞďůŽŽĚƉƌĞƐƐƵƌĞ͘tŝƚŚŽƵƚĚĞĨŝŶŝƚŝǀĞƚƌĞĂƚŵĞŶƚŝŶƚŚĞZ͕ƚŚĞƐĞĐŽŶĚŝƚŝŽŶƐĂƌĞƚǇƉŝĐĂůůǇĨĂƚĂů͘

Cypress Creek EMS System Policies and Treatment Guidelines

198 TRAUMA/ENVIRONMENTAL Revised 8/2016 Approved: Levon Vartanian, MD

^ĞǆƵĂůƐƐĂƵůƚ ƐƐĞƐƐŵĞŶƚZĞƋƵŝƌĞŵĞŶƚƐ DĂǇWƌĞƐĞŶƚƐ ŽŶƐŝĚĞƌWŽƐƐŝďůĞĂƵƐĞƐ ƐƐĞƐƐŵĞŶƚΘĨŽĐƵƐĞĚĞǆĂŵ WĂŝŶ͕ďůĞĞĚŝŶŐ͕ƐǁĞůůŝŶŐ͘ /ŶƚĞƌŶĂůŝŶũƵƌŝĞƐ ĂƐĂƉƉƌŽƉƌŝĂƚĞ ,ĞŵŽƌƌŚĂŐĞ WƌŽǀŝĚĞƉƌŝǀĂĐǇĨŽƌ KƚŚĞƌĞǆƚĞƌŶĂůƚƌĂƵŵĂĨƌŽŵ ĂƐƐĞƐƐŵĞŶƚ ĂƐƐĂƵůƚ ,ĂǀĞƐĂŵĞͲƐĞǆƉƌŽǀŝĚĞƌ ĂƐƐĞƐƐŝĨƉŽƐƐŝďůĞĂŶĚ ĐŽŵĨŽƌƚĂďůĞĨŽƌƉĂƚŝĞŶƚ͘ dƌĞĂƚŵĞŶƚƐ x dƌĞĂƚƐƉĞĐŝĨŝĐŝŶũƵƌŝĞƐǁŝƚŚŐĞŶĞƌĂůƚƌĞĂƚŵĞŶƚŐƵŝĚĞůŝŶĞƐ͘ x /ƚŝƐĐƌŝƚŝĐĂůƚŚĂƚƚŚĞƉĂƚŝĞŶƚĨĞĞůĂĐĐĞƉƚĞĚĂŶĚƐƵƉƉŽƌƚĞĚ͕ƌĞŐĂƌĚůĞƐƐŽĨŚŝƐͬŚĞƌĞŵŽƚŝŽŶĂůƌĞƐƉŽŶƐĞ͘ /ĚĞŶƚŝĨǇǇŽƵƌƐĞůĨƚŽƉĂƚŝĞŶƚĂŶĚĂƐƐƵƌĞƚŚĞŵƚŚĂƚƚŚĞǇĂƌĞƐĂĨĞ͘ x /ĨŶŽůŝĨĞƚŚƌĞĂƚƐĂƌĞƉƌĞƐĞŶƚ͕ƌĞŵĂŝŶŽŶƐĐĞŶĞĨŽƌ>ĂǁŶĨŽƌĐĞŵĞŶƚƚŽƐĞĐƵƌĞƉŽƚĞŶƚŝĂůĐƌŝŵĞƐĐĞŶĞ ĂŶĚĨŽƌĞŶƐŝĐĞǀŝĚĞŶĐĞ͘ x dƌǇƚŽŵĂŝŶƚĂŝŶĨŽƌĞŶƐŝĐĞǀŝĚĞŶĐĞ͘ǀŽŝĚĐƵƚƚŝŶŐƚŚƌŽƵŐŚƚĞĂƌƐŽƌƐƚĂŝŶƐŽŶĐůŽƚŚŝŶŐ͘ŽŶŽƚĐůĞĂŶƐĞ ĂŶǇƐŬŝŶĂƌĞĂŵŽƌĞƚŚĂŶŶĞĐĞƐƐĂƌǇ͘ŽŶŽƚƉůĂĐĞĐůŽƚŚŝŶŐŝƚĞŵƐŝŶƉůĂƐƚŝĐďĂŐ;ƵƐĞƉĂƉĞƌďĂŐŝĨ ĂǀĂŝůĂďůĞͿ͘ x ĚǀŝƐĞƉĂƚŝĞŶƚŶŽƚƚŽĞĂƚ͕ĚƌŝŶŬ͕ƐŵŽŬĞ͕ďĂƚŚĞ͕ƐŚŽǁĞƌ͕ĐŚĂŶŐĞĐůŽƚŚŝŶŐ͕ŽƌŐŽƚŽƚŚĞďĂƚŚƌŽŽŵ͕ŝĨĂƚ ĂůůƉŽƐƐŝďůĞ͕ƚŽƉƌĞƐĞƌǀĞĨŽƌĞŶƐŝĐĞǀŝĚĞŶĐĞ͘/ĨƚŚĞǇŵƵƐƚƵƌŝŶĂƚĞ͕ƌĞƋƵĞƐƚƚŚĂƚƚŚĞǇŶŽƚǁŝƉĞ͘ x /ĨƉŽƐƐŝďůĞ͕ƐƵŐŐĞƐƚƉĂƚŝĞŶƚƚĂŬĞĂĐŚĂŶŐĞŽĨĐůŽƚŚĞƐƚŽŚŽƐƉŝƚĂů͘ x EŽƚŝĨǇƚŚĞŚŽƐƉŝƚĂůĂŚĞĂĚŽĨƚŝŵĞ͘ x tŚĞŶĂƐƐĞƐƐŝŶŐĂŶĚƚƌĂŶƐƉŽƌƚŝŶŐƉĂƚŝĞŶƚ͕ŝĨƉŽƐƐŝďůĞ͕ŚĂǀĞĂƐĂŵĞͲƐĞǆƉƌŽǀŝĚĞƌĂƐƚŚĞƉƌŝŵĂƌǇ ƉƌŽǀŝĚĞƌ͘/ĨƚŚĞĂƐƐĂƵůƚǁĂƐĂƐĂŵĞͲƐĞǆĂƐƐĂƵůƚ͕ĂƉƌŽǀŝĚĞƌŽĨƚŚĞŽƉƉŽƐŝƚĞƐĞǆŵĂǇďĞƉƌĞĨĞƌĂďůĞƚŽ ƚŚĞƉĂƚŝĞŶƚ͘dŚĞƉƌŝŽƌŝƚǇŝƐĞŶƐƵƌŝŶŐƚŚĞƉĂƚŝĞŶƚĨĞĞůƐĐŽŵĨŽƌƚĂďůĞĂŶĚƐĂĨĞ͘ x /ĨƉŽƐƐŝďůĞ͕ƚƌĂŶƐƉŽƌƚƚŽĂĨĂĐŝůŝƚǇƚŚĂƚŚĂƐƚŚĞĐĂƉĂďŝůŝƚǇŽĨƉĞƌĨŽƌŵŝŶŐƐĞǆƵĂůĂƐƐĂƵůƚĨŽƌĞŶƐŝĐ ĞǆĂŵŝŶĂƚŝŽŶ;ŚĂƐĂ^EͶ^ĞǆƵĂůƐƐĂƵůƚEƵƌƐĞǆĂŵŝŶĞƌͶŶƵƌƐĞͬƉƌŽŐƌĂŵͿ͘

Cypress Creek EMS System Policies and Treatment Guidelines

199 TRAUMA/ENVIRONMENTAL Revised 6/2019 Approved: Levon Vartanian, MD

^ŵŽŬĞ/ŶŚĂůĂƚŝŽŶ ƐƐĞƐƐŵĞŶƚZĞƋƵŝƌĞŵĞŶƚƐ DĂǇWƌĞƐĞŶƚƐ ŽŶƐŝĚĞƌWŽƐƐŝďůĞĂƵƐĞƐ ƐƐĞƐƐŵĞŶƚĂŶĚĨŽĐƵƐĞĚ tŚĞĞǌŝŶŐ͕ƐƚƌŝĚŽƌ͕ƌĂůĞƐ͕ ŝƌǁĂǇďƵƌŶƐ ĞǆĂŵĂƐŝŶĚŝĐĂƚĞĚ ĐŽƵŐŚŝŶŐ͕ĚǇƐƉŶĞĂ͕ ĐƵƚĞůƵŶŐŝŶũƵƌǇ 'ŵŽŶŝƚŽƌŝŶŐ ƐĞŝǌƵƌĞƐ͕ĂůƚĞƌĞĚŵĞŶƚĂů WƵůŵŽŶĂƌǇĞĚĞŵĂ dKϮŵŽŶŝƚŽƌŝŶŐ ƐƚĂƚƵƐ͕ĐŽŶĨƵƐŝŽŶ͕ŚĞĂĚĂĐŚĞ͕ ĂƌďŽŶŵŽŶŽǆŝĚĞƉŽŝƐŽŶŝŶŐ KͲŽǆŝŵĞƚƌǇĂƐƐĞƐƐŵĞŶƚ ŶĂƵƐĞĂ ǇĂŶŝĚĞƉŽŝƐŽŶŝŶŐ ϭϮͲůĞĂĚ'ŝĨĂƉƉƌŽƉƌŝĂƚĞ ĐŚĞƐƚƚŝŐŚƚŶĞƐƐͬƉĂŝŶ͕ ,ǇƉŽǆŝĂ ĐĂƌĚŝĂĐĚǇƐƌŚǇƚŚŵŝĂƐ͕ĐĂƌĚŝĂĐ ĂƌƌĞƐƚ͕ŵǇĚƌŝĂƐŝƐ ZĞƋƵŝƌĞĚdƌĞĂƚŵĞŶƚƐ x Airway managementĂƉƉƌŽƉƌŝĂƚĞƚŽƉĂƚŝĞŶƚĐŽŶĚŝƚŝŽŶ x ^ƵƉƉŽƌƚventilation ĂŶĚoxygenationĂƉƉƌŽƉƌŝĂƚĞƚŽƉĂƚŝĞŶƚĐŽŶĚŝƚŝŽŶ͘ x (I) Vascular accessǁŝƚŚ/sŽƌ/K͖ǇĂŶŽŬŝƚƌĞƋƵŝƌĞƐĂĚĞĚŝĐĂƚĞĚ/sůŝŶĞ͖ĞƐƚĂďůŝƐŚĂϮŶĚůŝŶĞŝĨŽƚŚĞƌ ŵĞĚŝĐĂƚŝŽŶƐŽƌĨůƵŝĚŶĞĞĚƐĂĚŵŝŶŝƐƚĞƌĞĚ x (B) High flow ŽǆǇŐĞŶǀŝĂEZĂƚϭϱůƉŵĨŽƌƐƵƐƉĞĐƚĞĚͬŬŶŽǁŶKŽƌǇĂŶŝĚĞƉŽŝƐŽŶŝŶŐ ǀĂŝůĂďůĞdƌĞĂƚŵĞŶƚƐ x (P) PlasmalyteĨůƵŝĚďŽůƵƐŝŶϮϱϬŵ>ŝŶĐƌĞŵĞŶƚƐƵƉƚŽϮϬŵ>ͬŬŐŽƌĂŵŽƵŶƚƉĞƌŽŶƐĞŶƐƵƐ&ŽƌŵƵůĂ ;ƌĞĨĞƌƚŽBurnŐƵŝĚĞůŝŶĞƐͿ x (P) Cyanokit;ŚǇĚƌŽǆŽĐŽďĂůĂŵŝŶͿϱŐŝŶĨƵƐŝŽŶŽǀĞƌϭϱŵŝŶƵƚĞƐ͕ƌĞƉĞĂƚǆϭ;ϭϱŵŝŶƵƚĞƐĂĨƚĞƌŝŶŝƚŝĂů ŝŶĨƵƐŝŽŶŝƐĐŽŵƉůĞƚĞ͕ŝĨƉĂƚŝĞŶƚŝƐƐƚŝůůƐĞǀĞƌĞůǇƐǇŵƉƚŽŵĂƚŝĐͿ ϭ͘ Reconstitute͗WůĂĐĞƚŚĞǀŝĂůŝŶĂŶƵƉƌŝŐŚƚƉŽƐŝƚŝŽŶ͘ĚĚϮϬϬŵůŽĨϬ͘ϵй^ŽĚŝƵŵŚůŽƌŝĚĞ͘/ŶũĞĐƚ ŝŶƚŽƚŚĞǀŝĂůƵƐŝŶŐƚŚĞƚƌĂŶƐĨĞƌƐƉŝŬĞŝŶĐůƵĚĞĚ͖ĨŝůůƚŽƚŚĞůŝŶĞŽŶƚŚĞǀŝĂů͕ǁŚŝĐŚĐŽƌƌĞƐƉŽŶĚƐƚŽ ϮϬϬŵů͘ Ϯ͘ Mix͗dŚĞǀŝĂůƐŚŽƵůĚďĞƌĞƉĞĂƚĞĚůǇŝŶǀĞƌƚĞĚŽƌƌŽĐŬĞĚ͕ŶŽƚƐŚĂŬĞŶ͕ĨŽƌĂƚůĞĂƐƚϲϬƐĞĐŽŶĚƐƉƌŝŽƌ ƚŽŝŶĨƵƐŝŽŶ͘ ϯ͘ Infuse vial͗hƐĞǀĞŶƚĞĚŝŶƚƌĂǀĞŶŽƵƐƚƵďŝŶŐŝŶĐůƵĚĞĚŝŶƚŚĞŬŝƚ͕ŚĂŶŐĂŶĚŝŶĨƵƐĞŽǀĞƌϭϱŵŝŶƵƚĞƐ͘ /ŶĨƵƐĞƚŚĞĞŶƚŝƌĞϱŐǀŝĂůƵŶůĞƐƐĂŶĂůůĞƌŐŝĐƌĞĂĐƚŝŽŶŝƐŶŽƚĞĚ͘ x (P) CPAPƉƌŽĐĞĚƵƌĞŝĨƉĂƚŝĞŶƚŝƐŚǇƉŽǆŝĐŽƌŚĂƐƐĞǀĞƌĞƌĞƐƉŝƌĂƚŽƌǇĚŝƐƚƌĞƐƐ x (B) AlbuterolϭƵŶŝƚŶĞďƵůŝǌĞĚ͕ŵĂǇƌĞƉĞĂƚŽŶĐĞ͕ĨŽƌǁŚĞĞǌŝŶŐͬďƌŽŶĐŚŽĐŽŶƐƚƌŝĐƚŝŽŶ WĞĂƌůƐ x WƌĞŐŶĂŶĐǇ͗ŽŶƐŝĚĞƌƌŝƐŬǀĞƌƐƵƐďĞŶĞĨŝƚ͘ x ^ŵŽŬĞŝŶŚĂůĂƚŝŽŶƐŚŽƵůĚďĞƐƵƐƉĞĐƚĞĚŝŶĂŶǇƉĂƚŝĞŶƚǁŝƚŚƐŝŐŶƐŽĨĨĂĐŝĂůŽƌƵƉƉĞƌĐŚĞƐƚďƵƌŶƐ͕ƐŝŶŐĞĚ ŚĂŝƌͬĞǇĞďƌŽǁƐ͕ĂůƚĞƌĞĚŵĞŶƚĂůƐƚĂƚƵƐ͕ĂŶĚͬŽƌƌĞƐƉŝƌĂƚŽƌǇĚŝƐƚƌĞƐƐĨŽůůŽǁŝŶŐĞǆƉŽƐƵƌĞƚŽƐŵŽŬĞŽƌ ĞǆĐĞƐƐŝǀĞŚĞĂƚ͘ x ^ŵŽŬĞŝŶŚĂůĂƚŝŽŶƉƌĞƐĞŶƚƐƚŚƌĞĞƉƌŝŵĂƌǇƚŚƌĞĂƚƐ͗airway burns͕carbon monoxide poisoning, ĂŶĚ cyanide poisoning.

Cypress Creek EMS System Policies and Treatment Guidelines

200 TRAUMA/ENVIRONMENTAL Revised 6/2019 Approved: Levon Vartanian, MD

x ǇĂŶŝĚĞƉŽŝƐŽŶŝŶŐŵĂǇƌĞƐƵůƚĨƌŽŵŝŶŚĂůĂƚŝŽŶ͕ŝŶŐĞƐƚŝŽŶ͕ŽƌĚĞƌŵĂůĞǆƉŽƐƵƌĞ͘KƉŽŝƐŽŶŝŶŐŵŽƐƚ ĐŽŵŵŽŶůǇŽĐĐƵƌƐĨƌŽŵŝŶŚĂůĂƚŝŽŶ͘dŚĞƐĞƚǁŽƚŽǆŝŶƐŐĞŶĞƌĂůůǇĂĐĐŽŵƉĂŶǇĞĂĐŚŽƚŚĞƌĞƐƉĞĐŝĂůůǇ ǁŚĞŶƐŵŽŬĞŝŶŚĂůĂƚŝŽŶŝƐƉƌĞƐĞŶƚ͘ x ^ŵŽŬĞŝŶŚĂůĂƚŝŽŶǀŝĐƚŝŵƐƐŚŽƵůĚďĞĂƐƐĞƐƐĞĚĨŽƌƚŚĞĨŽůůŽǁŝŶŐƉƌŝŽƌƚŽǇĂŶŽŬŝƚƵƚŝůŝǌĂƚŝŽŶ͗ o ǆƉŽƐƵƌĞƚŽĨŝƌĞŽƌƐŵŽŬĞŝŶĂŶĞŶĐůŽƐĞĚĂƌĞĂ o WƌĞƐĞŶĐĞŽĨƐŽŽƚĂƌŽƵŶĚƚŚĞŵŽƵƚŚ͕ŶŽƐĞ͕ŽƌŽƌŽƉŚĂƌǇŶǆ o ůƚĞƌĞĚŵĞŶƚĂůƐƚĂƚƵƐ;ĐŽŶĨƵƐŝŽŶ͕ĚŝƐŽƌŝĞŶƚĂƚŝŽŶ͕ƐĞŝǌƵƌĞƐͿ x /ŶĂĚĚŝƚŝŽŶƚŽǇĂŶŽŬŝƚ͕ƚƌĞĂƚŵĞŶƚŽĨĐǇĂŶŝĚĞͬKƉŽŝƐŽŶŝŶŐŵƵƐƚŝŶĐůƵĚĞŝŵŵĞĚŝĂƚĞĂƚƚĞŶƚŝŽŶƚŽ ĂŝƌǁĂǇƉĂƚĞŶĐǇ͕ĂĚĞƋƵĂĐǇŽĨŽǆǇŐĞŶĂƚŝŽŶ͕ŚǇĚƌĂƚŝŽŶ͕ĐĂƌĚŝŽǀĂƐĐƵůĂƌƐƵƉƉŽƌƚ͕ĂŶĚŵĂŶĂŐĞŵĞŶƚŽĨ ĂŶǇƐĞŝǌƵƌĞĂĐƚŝǀŝƚǇ͘ x /ĨĂƐĞŝǌƵƌĞŽƌĂůůĞƌŐŝĐƌĞĂĐƚŝŽŶŽĐĐƵƌƐĚƵƌŝŶŐŝŶĨƵƐŝŽŶƌĞĨĞƌƚŽĂƉƉƌŽƉƌŝĂƚĞƉƌŽƚŽĐŽů x ^ƵďƐƚĂŶƚŝĂůŝŶĐƌĞĂƐĞƐŝŶďůŽŽĚƉƌĞƐƐƵƌĞŵĂǇŽĐĐƵƌĨŽůůŽǁŝŶŐǇĂŶŽŬŝƚƚŚĞƌĂƉǇ͘ x ,ǇƉĞƌďĂƌŝĐƚŚĞƌĂƉǇŝƐŐĞŶĞƌĂůůǇŽŶůǇŶĞĞĚĞĚŝŶǀĞƌǇƐĞǀĞƌĞĐĂƐĞƐŽĨKƉŽŝƐŽŶŝŶŐ͖ĐƵƌƌĞŶƚůŝƚĞƌĂƚƵƌĞ ŝƐŝŶĐŽŶĐůƵƐŝǀĞĂƐƚŽŝƚƐďĞŶĞĨŝƚ͘ x Treatment for isolated CO poisoning unrelated to smoke inhalationƐŚŽƵůĚĨŽĐƵƐŽŶ ŚǇƉĞƌŽǆǇŐĞŶĂƚŝŽŶĂŶĚƌĂƉŝĚƚƌĂŶƐƉŽƌƚ͖ƚŚĞƐĞƉĂƚŝĞŶƚƐƐŚŽƵůĚŶŽƚƌĞĐĞŝǀĞŚǇĚƌŽǆŽĐŽďĂůĂŵŝŶ͘

Cypress Creek EMS System Policies and Treatment Guidelines

201 TRAUMA/ENVIRONMENTAL Revised 8/2016 Approved: Levon Vartanian, MD

Spinal Injuries/SMR/Clearance Indications for Spinal Motion Restriction (SMR) • Blunt trauma with: o Midline neck or back pain and/or tenderness o Acutely altered level of consciousness (e.g. GCS < 15, evidence of intoxication) o Focal neurologic signs and/or symptoms (e.g. numbness or motor weakness) o Acute anatomic deformity of the spine (to exclude chronic scoliosis or kyphosis) o Distracting circumstances or injury that impairs the patient’s ability to contribute to a reliable examination • High voltage electrical shock Treatments Application of Spinal Motion Restriction (SMR) 1. (B) Provide manual cervical spine motion restriction until the patient is secured to an SMR device or further assessment reveals no need for SMR. 2. (B) Apply a rigid cervical collar of the correct size as soon as possible. • If a patient’s neck is angulated and the patient expresses pain (or the neck does not easily straighten during attempts to move to a midline position) the neck should be motion restricted in the position found. 3. (B) Place patient on backboard, scoop stretcher, or ambulance stretcher and restrict motion with webbing or strap/buckles in a manner consistent with minimizing spinal motion. Secure head to backboard, scoop stretcher, or ambulance stretcher with commercial device or towel rolls. 4. (B) Assess peripheral distal pulse/motor/sensation and reassess after intervention and transport. 5. (B) Pad device and fill in any voids to minimize discomfort and tissue damage. 6. (P) Consider Sedation procedure if patient is agitated and will potentially injure themselves further. SMR Clearance 1. Assess NEXUS criteria. See SMR Clearance Procedure (see below) Pearls: • Do not use SMR on a patient with penetrating trauma. • SMR is a harmful treatment and its side effects include exacerbation of muscle pain, skin breakdown, respiratory difficulty, and the possibility of injury from patient manipulation. Always consider risk to benefit when applying SMR to patients. Perform SMR in cases where a cervical injury is suspected or likely based on assessment findings. • Patients >65 years of age are a special population due to decreased pain perception and other disease processes common to aging. Avoid SMR Clearance in the elderly. • Pediatric patients: Utilize above guidelines. Young children pose a communication barrier, but this should not mandate SMR purely based on age. Consider additional padding behind shoulders. • Patients that have been motion-restricted on the ambulance stretcher should be moved by use of a slide board or similar device with a sufficient number of properly trained individuals.

Cypress Creek EMS System Policies and Treatment Guidelines TRAUMA/ENVIRONMENTAL Revised 8/2016 Approved: Levon Vartanian, MD

SMR Clearance • P2 and P3 paramedics may perform this procedure. • The purpose of this procedure is to minimize application of SMR to trauma patients with a low risk for cervical spinal fracture. • ALL of the following conditions must be met in order to perform SMR clearance:

SMR Clearance Checklist  No posterior midline cervical spine tenderness to palpation  No evidence of alcohol/drug intoxication  No altered mental status (GCS <14)  No focal neurologic deficit  No painful distracting injury  No communications difficulties (language barrier, non-verbal patient)  No evidence of significant MOI (use clinical judgment and weigh risk vs. benefit).

If any positive findings above, apply Spinal Motion Restriction. If all conditions met, proceed with the following exam.

1. Inspect the head and neck for any abnormalities. The head should be perpendicular to the shoulders and held erect. There should not be any signs of trauma (bruising, scars, step-offs) 2. Palpate the posterior spinous processes and just laterally to each cervical bone/joint. There should not be any tenderness to palpation. 3. Assess Range of Motion (ROM) by asking the patient to: a. Flex (place chin to chest) and extend (look straight up to ceiling) b. Rotate the head side to side so that the chin is aligned with the shoulder c. Bend head laterally from side to side (about 45º) 4. Check for neurological function (motor, sensation) of upper extremities and lower extremities

If any deficits or abnormalities are noted at any point during the hands on exam, apply Spinal Motion Restriction.

Cypress Creek EMS System Policies and Treatment Guidelines TRAUMA/ENVIRONMENTAL Revised 8/2016 Approved: Levon Vartanian, MD

Anatomical Landmarks

Cypress Creek EMS System Policies and Treatment Guidelines PROCEDURES Revised 12/2018 Approved: Levon Vartanian, MD

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Assessment Model ...... 204 General Therapies ...... 206 Airway Management Overview ...... 207 Crash Airway ...... 211 Failed Airway ...... 212 King Vision Video Laryngoscopy ...... 213 Capnography Monitoring ...... 215 Rapid Sequence Induction ...... 216 BVM Ventilations ...... 221 Foreign Body Airway Obstruction ...... 222 PEEP ...... 224 Orotracheal Intubation ...... 225 CPAP ...... 226 i-gel Supraglottic Airway...... 229 King Supraglottic Airway ...... 232 Nasal Intubation ...... 234 Cricothyrotomy...... 235 Suctioning ...... 238 Impedance Threshold Device (ResQPod) ...... 239 ResQGard ...... 240 Pulse Oximetry ...... 242 Oxygen Administration ...... 243 Ventilator Operation ...... 244 Tracheostomy Tube Change ...... 247 12 - Lead ECG ...... 248 Defibrillation ...... 252 CPR...... 253 External Pacing ...... 255 Synchronized Cardioversion ...... 256 Blood Glucose Analysis ...... 257 CO-Oximetry ...... 258 Hemoglobin Assessment ...... 260 Orthostatic Blood Pressure Assessment ...... 262 Stroke & Neurological Assessment ...... 263 Visual Acuity Assessment ...... 267 Ultrasound Exams ...... 268 Whole Blood & Blood ProductTransfusion ...... 281 Fluid Warmer ...... 284 Chest Decompression ...... 287 Nasogastric/Orogastric Tube Insertion ...... 289

202 PROCEDURES Revised 12/2018 Approved: Levon Vartanian, MD

Childbirth ...... 290 Eye Irrigation ...... 291 Pain Management ...... 292 LifeGift Donor Referral ...... 294 Patient Decontamination ...... 295 Nasopharyngeal Medication Administration ...... 296 Pelvic Sling ...... 297 Restraint ...... 298 Sedation ...... 299 Splinting ...... 302 Instrument Thoracostomy ...... 304 Peripheral IV Access ...... 306 External Jugular Access ...... 307 Implanted Ports and Central Lines ...... 308 Intraosseous (IO) Access...... 309 Ruggedized Field IV (Ranger IV) ...... 313 Ultrasound Guided Peripheral IV ...... 314 Wound Care: General ...... 315 ECD Probe Removal ...... 318 iT Clamp ...... 319 Junctional Extremity Treatment Tool (JETT)...... 321 Tourniquet ...... 322 WoundPacking ...... 324 Respiratory Support for Animal Patients ...... 325

Cypress Creek EMS System Policies and Treatment Guidelines

203 PROCEDURES Revised 12/2018 Approved: Levon Vartanian, MD

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Cypress Creek EMS System Policies and Treatment Guidelines

204 PROCEDURES Revised 12/2018 Approved: Levon Vartanian, MD

Pearls x ůůƉĂƚŝĞŶƚƐƐŚŽƵůĚďĞŝŶŝƚŝĂůůǇĂƐƐĞƐƐĞĚǁŝƚŚĂŚĂŶĚƐͲŽŶƉƌŝŵĂƌǇƐƵƌǀĞǇĐŽǀĞƌŝŶŐĂŝƌǁĂǇ͕ďƌĞĂƚŚŝŶŐ ;ŝŶĐůƵĚŝŶŐďƌĞĂƚŚƐŽƵŶĚƐͿ͕ĐŝƌĐƵůĂƚŝŽŶ;ŝŶĐůƵĚŝŶŐƉƵůƐĞĐŚĞĐŬ͕ƐŬŝŶƚĞŵƉĞƌĂƚƵƌĞͬĐŽůŽƌͬĐŽŶĚŝƚŝŽŶ͕ ƉĞƌĨƵƐŝŽŶͿ͕ĂŶĚĚŝƐĂďŝůŝƚǇ;'^ĂŶĚŐƌŽƐƐŵŽƚŽƌͬƐĞŶƐŽƌǇͿ͘ x /ĨůŝĨĞƚŚƌĞĂƚƐĂƌĞĨŽƵŶĚĚƵƌŝŶŐƉƌŝŵĂƌǇƐƵƌǀĞǇ͕ƚŚĞƐĞƐŚŽƵůĚďĞĂĚĚƌĞƐƐĞĚŝŵŵĞĚŝĂƚĞůǇ͘ x ŶǇĐƌĞĚĞŶƚŝĂůĞĚŵĞĚŝĐĂůƉĞƌƐŽŶŶĞů;ĂƐŝĐͬ/ŶƚĞƌŵĞĚŝĂƚĞͬWĂƌĂŵĞĚŝĐͿĐĂŶĚŽƚŚĞŝŶŝƚŝĂůƉƌŝŵĂƌǇ ƐƵƌǀĞǇ͘

Cypress Creek EMS System Policies and Treatment Guidelines

205 PROCEDURES Revised 7/2019 Approved: Levon Vartanian, MD

'ĞŶĞƌĂůdŚĞƌĂƉŝĞƐ

dŚĞĨŽůůŽǁŝŶŐƉƌŽĐĞĚƵƌĞƐ͕ƚŚĞƌĂƉŝĞƐ͕ĂŶĚŵĞĚŝĐĂƚŝŽŶƐĂƌĞĂƵƚŚŽƌŝǌĞĚďĞǇŽŶĚƚŚŽƐĞŶŽƚĞĚŝŶƐƉĞĐŝĨŝĐ ƉƌŽƚŽĐŽůƐĨŽƌƵƐĞĂƚƚŚĞD^ƉƌŽǀŝĚĞƌ͛ƐĚŝƐĐƌĞƚŝŽŶ͘ /sĐĐĞƐƐ hŶůĞƐƐƐƉĞĐŝĨŝĐĂůůǇůŝŵŝƚĞĚŽƌƉƌŽŚŝďŝƚĞĚďǇĂƉĂƌƚŝĐƵůĂƌƉƌŽƚŽĐŽů/WƐŵĂǇŝŶŝƚŝĂƚĞĂŶ/sͬ/KŽŶĂŶǇƉĂƚŝĞŶƚ ĂƚƚŚĞŝƌĚŝƐĐƌĞƚŝŽŶ͘ /sDĞĚŝĐĂƚŝŽŶĚŵŝŶŝƐƚƌĂƚŝŽŶ x hŶůĞƐƐƐƉĞĐŝĨŝĐĂůůǇŶŽƚĞĚǁŝƚŚŝŶƚŚĞƉƌŽƚŽĐŽů͕Ăůů/sŵĞĚŝĐĂƚŝŽŶƐ;ĞǆĐůƵĚŝŶŐ>^ŵĞĚŝĐĂƚŝŽŶƐͿƐŚŽƵůĚďĞ ĚŝůƵƚĞĚŝŶϱͲϭϬŵůŽĨEĂůĂŶĚĨŽůůŽǁĞĚďǇĂƐĂůŝŶĞĨůƵƐŚ͘ x Best Practice:dŚĞƉƌŽǀŝĚĞƌƚŚĂƚĚƌĂǁƐƵƉƚŚĞŵĞĚŝĐĂƚŝŽŶĨŽƌŝŶũĞĐƚŝŽŶƐŚŽƵůĚďĞƚŚĞƉĞƌƐŽŶƚŚĂƚ ĂĚŵŝŶŝƐƚĞƌƐƚŚĞŵĞĚŝĐĂƚŝŽŶŝŶŽƌĚĞƌƚŽƌĞĚƵĐĞͬĞůŝŵŝŶĂƚĞŵĞĚŝĐĂƚŝŽŶĞƌƌŽƌƐ͘ /KDĞĚŝĐĂƚŝŽŶĚŵŝŶŝƐƚƌĂƚŝŽŶ ůůŵĞĚŝĐĂƚŝŽŶƐĂĚŵŝŶŝƐƚĞƌĞĚďǇ/sŵĂǇĂůƐŽďĞŐŝǀĞŶ/K͘ /DDĞĚŝĐĂƚŝŽŶĚŵŝŶŝƐƚƌĂƚŝŽŶ x /ĨƉƌŽƚŽĐŽůŝŶĚŝĐĂƚĞƐƚŚĂƚ͞ĞĞƉ/D͟ŝƐƌĞƋƵŝƌĞĚ͕ƚŚĞŶĂŵƵƐĐůĞůĂƌŐĞƌƚŚĂŶƚŚĞĚĞůƚŽŝĚƐŚŽƵůĚďĞ ƐĞůĞĐƚĞĚĨŽƌŝŶũĞĐƚŝŽŶ;Ğ͘Ő͘ŐůƵƚĞĂůͬŚŝƉͿ͘ x ŶǇ/DŝŶũĞĐƚŝŽŶƐƚŚĂƚĂƌĞŵŽƌĞƚŚĂŶϭ͘ϱŵůƐŚŽƵůĚďĞŐŝǀĞŶŝŶĂůĂƌŐĞƌŵƵƐĐůĞ;ĚƵĞƚŽĚŝƐĐŽŵĨŽƌƚͿ͘ x ŶǇŵĞĚŝĐĂƚŝŽŶƚŚĂƚŝƐŬŶŽǁŶƚŽďĞŝƌƌŝƚĂƚŝŶŐƚŽƐƵƌƌŽƵŶĚŝŶŐƚŝƐƐƵĞƐ;ŝ͘Ğ͘WŚĞŶĞƌŐĂŶͿƐŚŽƵůĚďĞ ĂĚŵŝŶŝƐƚĞƌĞĚŝŶĂůĂƌŐĞƌŵƵƐĐůĞ͘ x ŚƌŽŶŝĐĂůĐŽŚŽůƵƐĞƌƐŽƌƚŚĞĐŚƌŽŶŝĐĂůůǇŝůůͬĞŵĂĐŝĂƚĞĚƉĂƚŝĞŶƚƐŵĂǇŶŽƚŚĂǀĞƐƵĨĨŝĐŝĞŶƚŵƵƐĐůĞŵĂƐƐĨŽƌ /DŝŶũĞĐƚŝŽŶƐ͘ůǁĂǇƐƐĞůĞĐƚƚŚĞůĂƌŐĞƐƚŵƵƐĐůĞĨŽƌŵĞĚŝĐĂƚŝŽŶĂĚŵŝŶŝƐƚƌĂƚŝŽŶ͘ x WĞĚŝĂƚƌŝĐƉĂƚŝĞŶƚƐƚŚĂƚĂƌĞŶŽƚǁĂůŬŝŶŐǇĞƚǁŝůůŶŽƚŚĂǀĞĂĚĞƋƵĂƚĞŵƵƐĐůĞĚĞǀĞůŽƉŵĞŶƚĨŽƌĂŐůƵƚĞĂůͬŚŝƉ ƐŝƚĞŝŶũĞĐƚŝŽŶ͘hƚŝůŝǌĞƚŚĞǀĂƐƚƵƐůĂƚĞƌĂůŝƐŵƵƐĐůĞŽĨƚŚĞƚŚŝŐŚŝŶƐƚĞĂĚ͘ dŚŝĂŵŝŶĞ dŚŝĂŵŝŶĞŵĂǇďĞĂĚŵŝŶŝƐƚĞƌĞĚƚŽĂŶǇĂĚƵůƚƉĂƚŝĞŶƚŝŶǁŚŽŵƚŚĞ/WŚĂƐĂŶǇƌĞĂƐŽŶƚŽƐƵƐƉĞĐƚŵĂůŶƵƚƌŝƚŝŽŶ ŽƌĂůĐŽŚŽůĂďƵƐĞ͘dŚŝĂŵŝŶĞƐŚŽƵůĚďĞŐŝǀĞŶĂƐϱϬŵŐ/DĂŶĚϱϬŵŐ/s͘,ŽǁĞǀĞƌ͕ŝŶƚŚĞƉĂƚŝĞŶƚǁŝƚŚ ŝŶĂĚĞƋƵĂƚĞŵƵƐĐůĞŵĂƐƐƚŽƌĞĐĞŝǀĞ/DŝŶũĞĐƚŝŽŶƐ͕ƚŚĞĞŶƚŝƌĞĚŽƐĞŵĂǇďĞŐŝǀĞŶ/s͘ŽŶǀĞƌƐĞůǇ͕ŝĨĂŶ/s ĐĂŶŶŽƚďĞĞƐƚĂďůŝƐŚĞĚ͕ƚŚĞƉƌŽǀŝĚĞƌŵĂǇĂĚŵŝŶŝƐƚĞƌƚŚĞĞŶƚŝƌĞĚŽƐĞ/D͘

ĞǆƚƌŽƐĞ ĞǆƚƌŽƐĞŵĂǇďĞĂĚŵŝŶŝƐƚĞƌĞĚƚŽĂŶǇƉĂƚŝĞŶƚŝĨƚŚĞ/WƐƵƐƉĞĐƚƐŚǇƉŽŐůǇĐĞŵŝĂ͘/ŶƚŚĞŚǇƉŽŐůǇĐĞŵŝĐ;Žƌ ƐƵƐƉĞĐƚĞĚŚǇƉŽŐůǇĐĞŵŝĐͿƉĂƚŝĞŶƚǁŝƚŚĂŶŝŶƚĂĐƚŐĂŐƌĞĨůĞǆŝŶǁŚŽŵĂŶ/sĐĂŶŶŽƚďĞĞƐƚĂďůŝƐŚĞĚ͕ĚĞǆƚƌŽƐĞ ŵĂǇďĞŐŝǀĞŶŽƌĂůůǇ͘;KƌĂůĚĞǆƚƌŽƐĞƐŚŽƵůĚďĞĂĚŵŝŶŝƐƚĞƌĞĚǀŝĂƚŚĞƉƌĞͲƉĂĐŬĂŐĞĚŐůƵĐŽƐĞƉĂƐƚĞ͘Ϳ

Cypress Creek EMS System Policies and Treatment Guidelines

206 PROCEDURES Revised 8/2016 Airway Approved: Levon Vartanian, MD

ŝƌǁĂǇDĂŶĂŐĞŵĞŶƚKǀĞƌǀŝĞǁ

ŝƌǁĂǇŵĂŶĂŐĞŵĞŶƚŝƐŶĞĐĞƐƐĂƌǇĨŽƌƉĂƚŝĞŶƚƐǁŝƚŚ͗ x ŝƌǁĂǇŽďƐƚƌƵĐƚŝŽŶƐ x sĞŶƚŝůĂƚŝŽŶƉƌŽďůĞŵƐ;ƉƌĞƐĞŶƚŽƌŝŵƉĞŶĚŝŶŐͿ x KǆǇŐĞŶĂƚŝŽŶƉƌŽďůĞŵƐ;ƉƌĞƐĞŶƚŽƌŝŵƉĞŶĚŝŶŐͿ

Is the airway patent? x hƐĞďĂƐŝĐŵĂŶĞƵǀĞƌƐƚŽŽƉĞŶĂŶĚĐůĞĂƌĂŝƌǁĂǇ͘ A x hƐĞĂŝƌǁĂǇĂĚũƵŶĐƚƐƚŽŵĂŝŶƚĂŝŶĂŝƌǁĂǇŝĨƉĂƚŝĞŶƚŝƐŽďƚƵŶĚĞĚ͘ x /ĨƐƚŝůůŽďƐƚƌƵĐƚĞĚ͕ƵƐĞůĂƌǇŶŐŽƐĐŽƉǇ͕ŵĂŐŝůůĨŽƌĐĞƉƐ͕ĂŶĚͬŽƌƐƵĐƚŝŽŶƚŽĐůĞĂƌŝƚ͘ x /ĨĂŝƌǁĂǇŝƐĐŽŵƉůĞƚĞůǇŽďƐƚƌƵĐƚĞĚĂŶĚĂůůĞĨĨŽƌƚƐƚŽĐůĞĂƌŝƚŚĂǀĞďĞĞŶƵŶƐƵĐĐĞƐƐĨƵů, consider cricothyrotomy͘

Is breathing adequate? x ƐƐĞƐƐďƌĞĂƚŚŝŶŐĂƐVENTILATIONĂŶĚOXYGENATION͘ B x hƐĞƉŚǇƐŝĐĂůĂƐƐĞƐƐŵĞŶƚ͕ĂƵƐĐƵůƚĂƚŝŽŶ͕ĂŶĚdKϮƚŽĂƐƐĞƐƐǀĞŶƚŝůĂƚŝŽŶƌĂƚĞ͕ĚĞƉƚŚ͕ĂŶĚƋƵĂůŝƚǇ͘ x hƐĞƉŚǇƐŝĐĂůĂƐƐĞƐƐŵĞŶƚ͕ĐĂƉŝůůĂƌǇƌĞĨŝůů͕ĂƵƐĐƵůƚĂƚŝŽŶ͕ŵĞŶƚĂůƐƚĂƚƵƐ͕ĂŶĚ^ƉKϮƚŽĂƐƐĞƐƐŽǆǇŐĞŶĂƚŝŽŶ͘ x ŽŶƐŝĚĞƌĂŶĚƚƌĞĂƚƵŶĚĞƌůǇŝŶŐĐĂƵƐĞƐŽĨĨĂŝůƵƌĞƚŽǀĞŶƚŝůĂƚŝŽŶ͗ŚǇƉŽŐůǇĐĞŵŝĂ͕ƐĞŝǌƵƌĞƐ͕ŶĂƌĐŽƚŝĐĚƌƵŐŽǀĞƌĚŽƐĞƐ͕ĂŶĚŚǇƉŽǆŝĂ͘ x ŽŶƐŝĚĞƌĂŶĚƚƌĞĂƚƵŶĚĞƌůǇŝŶŐĐĂƵƐĞƐŽĨĨĂŝůƵƌĞƚŽŽǆǇŐĞŶĂƚĞ͗ŚǇƉŽǀĞŶƚŝůĂƚŝŽŶ͕ĂƐƚŚŵĂͬKW͕,&͕ƉƵůŵŽŶĂƌǇĞĚĞŵĂ͕ ĂůůĞƌŐŝĐƌĞĂĐƚŝŽŶƐͬĂŶĂƉŚǇůĂǆŝƐ͕ĐĂƌďŽŶŵŽŶŽǆŝĚĞ͕ĐǇĂŶŝĚĞƉŽŝƐŽŶŝŶŐ͕ĂŶĚƐŚŽĐŬ͘ x ĚŵŝŶŝƐƚĞƌƐƵƉƉůĞŵĞŶƚĂůŽǆǇŐĞŶƚŽĂŐŽĂůŽĨϵϰʹϵϵй^ƉKϮ͘ x ŽŶƐŝĚĞƌĞƐĐĂůĂƚŝŶŐƚŽWWƚŚĞƌĂƉǇƚŽƐƵƉƉŽƌƚǀĞŶƚŝůĂƚŝŽŶƐŝŶĐŽŶƐĐŝŽƵƐƉĂƚŝĞŶƚƐ͘ x ŽŶƐŝĚĞƌƵƚŝůŝǌŝŶŐsDƚŽƐƵƉƉŽƌƚǀĞŶƚŝůĂƚŝŽŶƐĂŶĚŝŶĐƌĞĂƐĞŽǆǇŐĞŶĚĞůŝǀĞƌǇŝĨŶĞĐĞƐƐĂƌǇ͘ x ŽŶƐŝĚĞƌƵƚŝůŝǌŝŶŐWWǁŝƚŚĂsDŽƌǀĞŶƚŝůĂƚŽƌƚŽŝŶĐƌĞĂƐĞŽǆǇŐĞŶĚĞůŝǀĞƌǇ;ƉĂƌƚŝĂůƉƌĞƐƐƵƌĞͿĂŶĚƐƵƉƉŽƌƚǀĞŶƚŝůĂƚŝŽŶƐ͘

Does airway need protected? x /ĨƉĂƚŝĞŶƚƌĞƋƵŝƌĞƐĂsD͕ĐŽŶƐŝĚĞƌƉƌŽƚĞĐƚŝŶŐƚŚĞĂŝƌǁĂǇǁŝƚŚĂŶĂĚǀĂŶĐĞĚĂŝƌǁĂǇ͘ x /ĨƉĂƚŝĞŶƚĐŽŶĚŝƚŝŽŶŝƐĞǆƉĞĐƚĞĚƚŽǁŽƌƐĞŶ͕ĂŶĚƚŚĞƌĞŝƐĂĐŽŶĐĞƌŶĨŽƌƉŽƐƐŝďůĞĂƐƉŝƌĂƚŝŽŶ͕ĐŽŶƐŝĚĞƌƉƌŽƚĞĐƚŝŶŐƚŚĞ ĂŝƌǁĂǇǁŝƚŚĂŶĂĚǀĂŶĐĞĚĂŝƌǁĂǇ͘ x King supraglottic airway͕ĐŽŶĨŝƌŵĞĚǁŝƚŚďƌĞĂƚŚƐŽƵŶĚƐĂŶĚdKϮ͕ŝƐĂŶĂĐĐĞƉƚĂďůĞŵĞĂŶƐŽĨƉƌŽƚĞĐƚŝŶŐĂŶ ĂŝƌǁĂǇ͘

zĞƐ ŽĞƐƉĂƚŝĞŶƚŚĂǀĞŝŶƚĂĐƚƌĞĨůĞǆĞƐ EŽ ĂŶĚͬŽƌƌĞƐƉŽŶƐŝǀĞŶĞƐƐ͍

&ŽůůŽǁCrash Airway Protocol &ŽůůŽǁ RSI Protocol x Intubate ŝŵŵĞĚŝĂƚĞůǇ͕Žƌ x WƌĞƉĂƌĞĞƋƵŝƉŵĞŶƚ͕ŵŽŶŝƚŽƌŝŶŐ͕ĂŶĚďĂĐŬƵƉ͕ĂŶĚ x WůĂĐĞĂKing supraglottic airway͘

WƉůĂŶ͘ x /ĨƵŶƐƵĐĐĞƐƐĨƵů͕ƵƐĞĂBVM. x WƌĞŽǆǇŐĞŶĂƚĞ͘ x ^ĞĚĂƚĞǁŝƚŚEtomidateϬ͘ϯŵŐͬŬŐŽƌKetamineϭʹ ϭ͘ϱŵŐͬŬŐ Failed Airway x WĂƌĂůǇǌĞǁŝƚŚSuccinylcholine ϭʹϭ͘ϱŵŐͬŬŐ͘ hŶĂďůĞƚŽǀĞŶƚŝůĂƚĞŽƌŽǆǇŐĞŶĂƚĞĂĚĞƋƵĂƚĞůǇĚƵƌŝŶŐŽƌĂĨƚĞƌŽŶĞŽƌ x WůĂĐĞŵĞŶƚǁŝƚŚƉƌŽŽĨ ŵŽƌĞƵŶƐƵĐĐĞƐƐĨƵůŝŶƚƵďĂƚŝŽŶĂƚƚĞŵƉƚƐEĚŝĨĨŝĐƵůƚĂŝƌǁĂǇ x WŽƐƚͲŝŶƚƵďĂƚŝŽŶ͗^ĞĐƵƌĞddƵďĞ͕^ĞĚĂƚĞǁŝƚŚ ĨŝŶĚŝŶŐƐ͖KZƚŚƌĞĞƚŽƚĂůƵŶƐƵĐĐĞƐƐĨƵůĂƚƚĞŵƉƚƐ͘ VersedϭʹϮŵŐŽƌKetamineϭʹϭ͘ϱŵŐͬŬŐ͖WĂƌĂůǇǌĞ x sĞŶƚŝůĂƚĞƉĂƚŝĞŶƚƵƐŝŶŐsDǁŝƚŚŐŽŽĚŵĂƐŬƐĞĂůĂŶĚ ǁŝƚŚRocuroniumϭŵŐͬŬŐ͘ KWͬEWƐƉůĂĐĞĚ͘ x ŽŶƐŝĚĞƌƉůĂĐŝŶŐŽŶǀĞŶƚŝůĂƚŽƌ͘ x WůĂĐĞKing supraglottic airwayƵŶůĞƐƐĐŽŶƚƌĂŝŶĚŝĐĂƚĞĚ͘ x /ĨǀĞŶƚŝůĂƚŝŽŶŝƐŝŵƉŽƐƐŝďůĞǁŝƚŚsDĂŶĚͬŽƌ<ŝŶŐ ƐƵƉƌĂŐůŽƚƚŝĐĂŝƌǁĂǇ͕ŝŵŵĞĚŝĂƚĞĐƌŝĐŽƚŚǇƌŽƚŽŵǇƐŚŽƵůĚďĞ ƉĞƌĨŽƌŵĞĚĂĐĐŽƌĚŝŶŐƚŽƉƌŽƚŽĐŽů͘

Cypress Creek EMS System Policies and Treatment Guidelines

207 PROCEDURES Revised 8/2016 Airway Approved: Levon Vartanian, MD

'ĞŶĞƌĂůŽŶƐŝĚĞƌĂƚŝŽŶƐ x All endotracheal intubations are considered high risk.ŽŶƐŝĚĞƌĂƚŝŽŶƐŚŽƵůĚďĞŐŝǀĞŶƚŽ ƚƌĂŶƐƉŽƌƚŝŶŐƚŚĞƉĂƚŝĞŶƚŝĨŽǆǇŐĞŶĂƚŝŽŶĂŶĚǀĞŶƚŝůĂƚŝŽŶĂƌĞĂĚĞƋƵĂƚĞ͘/ĨŝŶĂĚĞƋƵĂƚĞ͕ƉƌŝŽƌŝƚǇƐŚŽƵůĚ ďĞŐŝǀĞŶƚŽĞĨĨĞĐƚŝǀĞBag Valve Mask ventilationǁŝƚŚBLS airway maneuversĂŶĚĂĐĂƵƚŝŽƵƐƉůĂŶ ƐŚŽƵůĚďĞĨŽůůŽǁĞĚƚŽƐĂĨĞůǇŵĂŶĂŐĞƚŚĞƉĂƚŝĞŶƚ͛ƐĂŝƌǁĂǇ͘ x dŚĞƉƌŽĐĞĚƵƌĞƐĨŽƌŵĂŝŶƚĂŝŶŝŶŐƚŚĞĂŝƌǁĂǇŝŶĐůƵĚĞďƵƚƐŚĂůůŶŽƚďĞůŝŵŝƚĞĚƚŽƚŚĞĨŽůůŽǁŝŶŐ͗ďĂŐͲ ǀĂůǀĞͲŵĂƐŬǀĞŶƚŝůĂƚŝŽŶǁŝƚŚŽƌǁŝƚŚŽƵƚĂŶŽƌŽƉŚĂƌǇŶŐĞĂůĂŝƌǁĂǇĂŶĚͬŽƌŶĂƐŽƉŚĂƌǇŶŐĞĂůĂŝƌǁĂǇ͕ ŽƌŽƉŚĂƌǇŶŐĞĂůƐƵĐƚŝŽŶŝŶŐ͕ŽƌĂůĞŶĚŽƚƌĂĐŚĞĂůŝŶƚƵďĂƚŝŽŶƵƐŝŶŐĚŝƌĞĐƚŽƌǀŝĚĞŽůĂƌǇŶŐŽƐĐŽƉǇĂŶĚǁŝƚŚ ŽƌǁŝƚŚŽƵƚƚŚĞƐĐŚŵĂŶŶdƌĂĐŚĞĂůdƵďĞŝŶƚƌŽĚƵĐĞƌ;ďŽƵŐŝĞͿ͕ŶĂƐŽƚƌĂĐŚĞĂůŝŶƚƵďĂƚŝŽŶ͕ŝŶƐĞƌƚŝŽŶŽĨ ƚŚĞ<ŝŶŐƐƵƉƌĂŐůŽƚƚŝĐĂŝƌǁĂǇ͕ŶĞĞĚůĞĐƌŝĐŽƚŚǇƌŽƚŽŵǇǁŝƚŚŽƌǁŝƚŚŽƵƚũĞƚǀĞŶƚŝůĂƚŝŽŶ͕ĂŶĚƐƵƌŐŝĐĂů ĐƌŝĐŽƚŚǇƌŽƚŽŵǇ͘ x dŚĞƉĂƌĂŵĞĚŝĐƐŚĂůůĞŶƐƵƌĞĂĚĞƋƵĂƚĞŵŽŶŝƚŽƌŝŶŐŽĨƉĂƚŝĞŶƚ͛ƐƌĞƐƉŝƌĂƚŽƌǇƐƚĂƚƵƐŝŶĐůƵĚŝŶŐ'͕ďůŽŽĚ ƉƌĞƐƐƵƌĞ͕ƉƵůƐĞŽǆŝŵĞƚƌǇ͕ĂŶĚdKϮͬǁĂǀĞĨŽƌŵĐĂƉŶŽŐƌĂƉŚǇǁŚĞŶĂĚŵŝŶŝƐƚĞƌŝŶŐĂŶǇŵĞĚŝĐĂƚŝŽŶ ƚŚĂƚŵĂǇĂůƚĞƌƌĞƐƉŝƌĂƚŽƌǇƐƚĂƚƵƐ͘/ĨŝŶĚŝĐĂƚĞĚ͕ƉĂƚŝĞŶƚƐƐŚŽƵůĚďĞŽǆǇŐĞŶĂƚĞĚͬǀĞŶƚŝůĂƚĞĚǁŝƚŚϭϬϬй ŽǆǇŐĞŶ͘ x dŚĞ/ŶͲŚĂƌŐĞWĂƌĂŵĞĚŝĐŝƐƵůƚŝŵĂƚĞůǇƌĞƐƉŽŶƐŝďůĞĨŽƌĞŶƐƵƌŝŶŐŚŝŐŚƋƵĂůŝƚǇĂŝƌǁĂǇŵĂŶĂŐĞŵĞŶƚ͕ ŝŶĐůƵĚŝŶŐǁŚĞŶBLS airway managementŝƐďĞŝŶŐƉĞƌĨŽƌŵĞĚ͘tŚŝůĞĂŶǇĐƌĞĚĞŶƚŝĂůĞĚŵĞĚŝĐĂů ƉƌŽǀŝĚĞƌŵĂǇĂƐƐŝƐƚǁŝƚŚBag Valve Mask ventilationĂŶĚŽƚŚĞƌ>^ŵĂŶĞƵǀĞƌƐ͕ƚŚĞ/ŶͲŚĂƌŐĞ WĂƌĂŵĞĚŝĐŵƵƐƚƚĂŬĞĐĂƌĞƚŚĂƚĂĚĞƋƵĂƚĞǀĞŶƚŝůĂƚŝŽŶĂŶĚŽǆǇŐĞŶĂƚŝŽŶĂƌĞƉƌŽǀŝĚĞĚ͘ x Nasotracheal intubation ƐŚŽƵůĚďĞƌĞƐĞƌǀĞĚĨŽƌƚŚŽƐĞƉĂƚŝĞŶƚƐǁŚŽŵŽƌĂůĞŶĚŽƚƌĂĐŚĞĂůŝŶƚƵďĂƚŝŽŶ ǁŽƵůĚƉƌŽǀĞƚŽďĞŽǀĞƌůǇĚŝƐƚƌĞƐƐŝŶŐĂŶĚͬŽƌŶĞƵƌŽŵƵƐĐƵůĂƌƌĞůĂǆĂƚŝŽŶŝƐŶŽƚŝŶĚŝĐĂƚĞĚ͕ŽƌŶŽƚ ĂǀĂŝůĂďůĞ͘ x dŚĞKing supraglottic airway ƐŚŽƵůĚďĞƵƚŝůŝǌĞĚĂĨƚĞƌĂfailed intubation ĂŶĚŵĂǇďĞĐŽŶƐŝĚĞƌĞĚ ǁŚĞŶĂĚŝĨĨŝĐƵůƚŝŶƚƵďĂƚŝŽŶŝƐĂŶƚŝĐŝƉĂƚĞĚ͘ x Surgical cricothyrotomyĂŶĚͬŽƌƚŚĞMelker Emergency Cricothyrotomy KitŵĂǇďĞƵƐĞĚǁŚĞŶĂůů ŽƚŚĞƌŵĞĂŶƐŽĨĂŝƌǁĂǇĐŽŶƚƌŽůŚĂǀĞĨĂŝůĞĚ͘ x ŶŝŶƚƵďĂƚŝŽŶĂƚƚĞŵƉƚŝƐĚĞĨŝŶĞĚĂƐƉĂƐƐŝŶŐƚŚĞůĂƌǇŶŐŽƐĐŽƉĞďůĂĚĞŽƌdƚƵďĞƉĂƐƚƚŚĞƚĞĞƚŚŽƌŝŶƚŽ ƚŚĞŶĂƐĂůƉĂƐƐĂŐĞ͘ x /ŶƚƌĂƵŵĂƉĂƚŝĞŶƚƐƌĞƋƵŝƌŝŶŐƐƉŝŶĂůŵŽƚŝŽŶƌĞƐƚƌŝĐƚŝŽŶ͕ƉƌŽǀŝĚĞŝŶͲůŝŶĞĐĞƌǀŝĐĂůƐƚĂďŝůŝǌĂƚŝŽŶĚƵƌŝŶŐ intubation͕BVM͕ŽƌƉůĂĐĞŵĞŶƚŽĨa supraglottic airway͘ƵƌŝŶŐintubationŽƌƉůĂĐĞŵĞŶƚŽĨĂ Ɛupraglottic airway͕ƚŚĞĐĞƌǀŝĐĂůĐŽůůĂƌƐŚŽƵůĚďĞŽƉĞŶĞĚ͘ZĞƉůĂĐĞĐĞƌǀŝĐĂůĐŽůůĂƌĂĨƚĞƌƉƌŽĐĞĚƵƌĞŝƐ ĐŽŵƉůĞƚĞĚ͘ ŝƌǁĂǇƐƐĞƐƐŵĞŶƚ ŶĂŝƌǁĂǇĂƐƐĞƐƐŵĞŶƚƐŚŽƵůĚďĞĐŽŵƉůĞƚĞĚƉƌŝŽƌƚŽƉĞƌĨŽƌŵŝŶŐĂŶǇĂĚǀĂŶĐĞĚĂŝƌǁĂǇŵĂŶĂŐĞŵĞŶƚ ƉƌŽĐĞĚƵƌĞƐ͘dŚŝƐĂƐƐĞƐƐŵĞŶƚǁŝůůŚĞůƉƉƌĞĚŝĐƚĚŝĨĨŝĐƵůƚĂŝƌǁĂǇƐĂƐǁĞůůĂƐƉƌŽǀŝĚĞŝŶƐŝŐŚƚŝŶƚŽǁŚŝĐŚƚŽŽůƐ ŽƌƚĞĐŚŶŝƋƵĞƐĂƌĞďĞƐƚƐƵŝƚĞĚƚŽŵĂŶĂŐŝŶŐƚŚĞŝŶĚŝǀŝĚƵĂůƉĂƚŝĞŶƚ͘

Cypress Creek EMS System Policies and Treatment Guidelines

208 PROCEDURES Revised 8/2016 Airway Approved: Levon Vartanian, MD

LEMONS MOANS RODS SHORT ;ĚŝĨĨŝĐƵůƚůĂƌǇŶŐŽƐĐŽƉǇͿ ;ĚŝĨĨŝĐƵůƚsDͿ ;ĚŝĨĨŝĐƵůƚƐƵƉƌĂŐůŽƚƚŝĐ ;ĚŝĨĨŝĐƵůƚ ĂŝƌǁĂǇͿ ĐƌŝĐŽƚŚǇƌŽƚŽŵǇͿ LŽŽŬĞǆƚĞƌŶĂůůǇ MĂƐŬƐĞĂů RĞƐƚƌŝĐƚĞĚŵŽƵƚŚ SƵƌŐĞƌǇŽƌĚŝƐƚŽƌƚĞĚ EǀĂůƵĂƚĞϯͲϯͲϮƌƵůĞ OďĞƐĞ ŽƉĞŶŝŶŐ ĂŝƌǁĂǇ MĂůůĂŵƉĂƚŝ AŐĞхϱϱ OďƐƚƌƵĐƚŝŽŶͬŽďĞƐĞ HĞŵĂƚŽŵĂŽǀĞƌŶĞĐŬ OďƐƚƌƵĐƚŝŽŶͬŽďĞƐĞ NŽƚĞĞƚŚ DŝƐƚŽƌƚĞĚͬĚŝƐƌƵƉƚĞĚ OďĞƐĞ NĞĐŬŵŽďŝůŝƚǇ SƚŝĨĨ ĂŝƌǁĂǇ RĂĚŝĂƚŝŽŶƚƌĞĂƚŵĞŶƚƐ SĂƚƵƌĂƚŝŽŶƐ SƚŝĨĨ TƵŵŽƌŽǀĞƌŶĞĐŬ͘

ĂŐͲsĂůǀĞͲDĂƐŬsĞŶƚŝůĂƚŝŽŶ x dŚĞŝŶŝƚŝĂůƌĂƚĞĨŽƌsDǀĞŶƚŝůĂƚŝŽŶƐŚŽƵůĚďĞϴͲϭϮǀĞŶƚŝůĂƚŝŽŶƐƉĞƌŵŝŶƵƚĞ͘ x dŚĞďĞƐƚŵĞƚŚŽĚĨŽƌĚĞƚĞƌŵŝŶŝŶŐsDƌĂƚĞŝƐǁŝƚŚĐĂƉŶŽŐƌĂƉŚǇ͘dŚĞƚĂƌŐĞƚdKϮƌĞĂĚŝŶŐƐŚŽƵůĚ ďĞϯϱͲϰϱŵŵ,Ő͘ x dŚĞŽƉƚŝŵĂůƚŝĚĂůǀŽůƵŵĞĨŽƌƉĂƚŝĞŶƚƐǁŝƚŚŶŽƌŵĂůƉĞƌĨƵƐŝŽŶŝƐϱͲϴŵůͬŬŐ͘ Bag-Valve-Mask Ventilation Best Practices: x hƚŝůŝǌĞĂƚůĞĂƐƚƚǁŽƉƌŽǀŝĚĞƌƐ͕ŽŶĞƚŽƉƌŽǀŝĚĞǀĞŶƚŝůĂƚŝŽŶƐĂŶĚŽŶĞƚŽĞŶƐƵƌĞĂŐŽŽĚƐĞĂů͘ x ŶĞǆƉĞƌŝĞŶĐĞĚƉƌŽǀŝĚĞƌƐŚŽƵůĚďĞĚŝƌĞĐƚůǇƌĞƐƉŽŶƐŝďůĞĨŽƌďĂŐͲǀĂůǀĞͲŵĂƐŬǀĞŶƚŝůĂƚŝŽŶƐ͘ x WĂǇĐůŽƐĞĂƚƚĞŶƚŝŽŶƚŽƉƌŽǀŝĚŝŶŐĂŶĂƉƉƌŽƉƌŝĂƚĞƌĂƚĞĂŶĚƚŝĚĂůǀŽůƵŵĞ͘ x hƚŝůŝǌĞĂĨŝůƚĞƌůŝŶĞƚŽŵŽŶŝƚŽƌǁĂǀĞĨŽƌŵĐĂƉŶŽŐƌĂƉŚǇ͘ ŶĚŽƚƌĂĐŚĞĂů/ŶƚƵďĂƚŝŽŶ x EŽŵŽƌĞƚŚĂŶƚŚƌĞĞƚŽƚĂůŝŶƚƵďĂƚŝŽŶĂƚƚĞŵƉƚƐƐŚŽƵůĚďĞƉĞƌĨŽƌŵĞĚ͘ x /ĨĂŶŝŶƚƵďĂƚŝŽŶĂƚƚĞŵƉƚŝƐƵŶƐƵĐĐĞƐƐĨƵů͕ĐŚĂŶŐĞsomething;ďůĂĚĞĐŚŽŝĐĞ͕ĞƋƵŝƉŵĞŶƚ͕ƚƵďĞƐŝǌĞ͕ ƉŽƐŝƚŝŽŶŝŶŐ͕ůĂƌǇŶŐŽƐĐŽƉŝƐƚ͕ĞƚĐ͘ͿEŵĂǆŝŵŝǌĞ^ƉKϮďĞĨŽƌĞŵĂŬŝŶŐĂƌĞƉĞĂƚĂƚƚĞŵƉƚ͘ ŶĚŽƚƌĂĐŚĞĂůdƵďĞsĞƌŝĨŝĐĂƚŝŽŶ x &ŽůůŽǁŝŶŐƉůĂĐĞŵĞŶƚŽĨĂŶĞŶĚŽƚƌĂĐŚĞĂůƚƵďĞ͕ƉůĂĐĞŵĞŶƚŵƵƐƚďĞǀĞƌŝĨŝĞĚ͘ZĞƉĞĂƚĂůůǀĞƌŝĨŝĐĂƚŝŽŶ ƐƚĞƉƐĞǀĞƌǇϱŵŝŶƵƚĞƐ͕ĂŶĚĂĨƚĞƌĞǀĞƌǇƉĂƚŝĞŶƚŵŽǀĞ͘/ĨĂǀĂŝůĂďůĞ͕ĂƌĞĐŽƌĚŝŶŐƉĂƚŝĞŶƚŵŽŶŝƚŽƌŝŶŐ ĚĞǀŝĐĞ;ŝ͘Ğ͘ŽůůyͲ^ĞƌŝĞƐͿǁŝůůďĞƵƐĞĚĐŽŶƚŝŶƵŽƵƐůǇĂŶĚƚŚĞĚĂƚĂƚƌĂŶƐĨĞƌƌĞĚƚŽƚŚĞĞůĞĐƚƌŽŶŝĐƉĂƚŝĞŶƚ ƌĞĐŽƌĚ͘dŚĞĨŽůůŽǁŝŶŐŝƚĞŵƐŵƵƐƚďĞĐŚĞĐŬĞĚĂŶĚĚŽĐƵŵĞŶƚĞĚŽŶƚŚĞƉĂƚŝĞŶƚƌĞĐŽƌĚ͗ x /ĨƚƵďĞǁĂƐǀŝƐƵĂůŝǌĞĚƉĂƐƐŝŶŐƚŚĞǀŽĐĂůĐŽƌĚƐ x dKϮǁĂǀĞĨŽƌŵƌĞĂĚŝŶŐƐ;ƉƌŝŵĂƌǇŵĞƚŚŽĚͿ x ďƐĞŶĐĞŽĨĂŝƌŵŽǀĞŵĞŶƚĚƵƌŝŶŐĂƵƐĐƵůƚĂƚŝŽŶŽĨƚŚĞĂďĚŽŵĞŶ x WƌĞƐĞŶĐĞŽĨĂŝƌŵŽǀĞŵĞŶƚĚƵƌŝŶŐĂƵƐĐƵůƚĂƚŝŽŶŽĨƚŚĞĐŚĞƐƚ x sŝƐŝďůĞƌŝƐĞĂŶĚĨĂůůŽĨƚŚĞĐŚĞƐƚ x WƵůƐĞŽǆŝŵĞƚĞƌƌĞĂĚŝŶŐƐ;ŝŶƚŚĞƉĂƚŝĞŶƚǁŝƚŚĂƉƵůƐĞͿ x /ĨƉƌŽƉĞƌƚƵďĞƉůĂĐĞŵĞŶƚĐĂŶŶŽƚďĞĐŽŶĨŝƌŵĞĚǁŝƚŚĂďƐŽůƵƚĞĐĞƌƚĂŝŶƚǇƚŚĞƚƵďĞƐŚŽƵůĚďĞƌĞŵŽǀĞĚ ŝŵŵĞĚŝĂƚĞůǇĂŶĚƚŚĞĂŝƌǁĂǇŵĂŶĂŐĞĚďǇŽƚŚĞƌŵĞĂŶƐ͘ x ĨƚĞƌĐŽŶĨŝƌŵŝŶŐƉƌŽƉĞƌƉůĂĐĞŵĞŶƚ͕ƚŚĞĞŶĚŽƚƌĂĐŚĞĂůƚƵďĞƐŚŽƵůĚďĞƐĞĐƵƌĞĚŝŶƉůĂĐĞĂŶĚƚŚĞĚĞƉƚŚ ƐŚŽƵůĚďĞŶŽƚĞĚĂŶĚŵŽŶŝƚŽƌĞĚ͘ x dŚĞƵƐĞŽĨĂĐĞƌǀŝĐĂůĐŽůůĂƌƚŽƌĞƐƚƌŝĐƚŵŽǀĞŵĞŶƚŽĨƚŚĞŚĞĂĚĂŶĚŶĞĐŬƚŽĂƐƐŝƐƚŝŶƉƌĞǀĞŶƚŝŶŐƚƵďĞ ĚŝƐƉůĂĐĞŵĞŶƚŝƐƌĞĐŽŵŵĞŶĚĞĚ͘

Cypress Creek EMS System Policies and Treatment Guidelines

209 PROCEDURES Revised 8/2016 Airway Approved: Levon Vartanian, MD

WĞĚŝĂƚƌŝĐŝƌǁĂǇDĂŶĂŐĞŵĞŶƚ x WĞĚŝĂƚƌŝĐŝŶƚƵďĂƚŝŽŶŝƐhigh risk͘ƉĞĚŝĂƚƌŝĐƉĂƚŝĞŶƚŚĂƐůŝŵŝƚĞĚƌĞƐĞƌǀĞƐĂŶĚŝƐĂƵƚŽŵĂƚŝĐĂůůǇĂ ĚŝĨĨŝĐƵůƚŝŶƚƵďĂƚŝŽŶ͘ĂƵƚŝŽŶƐŚŽƵůĚďĞĞǆĞƌĐŝƐĞĚǁŚĞŶĐŽŶƐŝĚĞƌŝŶŐĂŶĞůĞĐƚŝǀĞŝŶƚƵďĂƚŝŽŶ͘ x /ĨĂŶĞĨĨĞĐƚŝǀĞĂŝƌǁĂǇŝƐďĞŝŶŐŵĂŝŶƚĂŝŶĞĚǁŝƚŚĂBVMǁŝƚŚĐŽŶƚŝŶƵŽƵƐ^ƉKϮŽĨшϵϬйŽƌ ƐƚĂďůĞͬŝŵƉƌŽǀŝŶŐǀŝƚĂůƐŝŐŶƐĐŽŶƐŝƐƚĞŶƚǁŝƚŚĐůŝŶŝĐĂůĐŽŶĚŝƚŝŽŶ͕ŝƚŝƐĂĐĐĞƉƚĂďůĞƚŽĐŽŶƚŝŶƵĞǁŝƚŚďĂƐŝĐ ĂŝƌǁĂǇŵĞĂƐƵƌĞƐŝŶƐƚĞĂĚŽĨƵƐŝŶŐĂ supraglottic airwayŽƌintubation͘ x sĞŶƚŝůĂƚŝŽŶƌĂƚĞƐƐŚŽƵůĚŐĞŶĞƌĂůůǇďĞϯϬďƌĞĂƚŚƐƉĞƌŵŝŶƵƚĞĨŽƌŶĞŽŶĂƚĞƐ͕ϮϱĨŽƌƚŽĚĚůĞƌƐ͕ϮϬĨŽƌ ƐĐŚŽŽůĂŐĞ͕ĂŶĚϴʹϭϮ;ŶŽƌŵĂůĂĚƵůƚƌĂƚĞͿĨŽƌĂĚŽůĞƐĐĞŶƚƐ͖ƚŚĞdKϮŝƐƚŚĞďĞƐƚŐƵŝĚĞĂŶĚƐŚŽƵůĚďĞ ŵĂŝŶƚĂŝŶĞĚďĞƚǁĞĞŶϯϱĂŶĚϰϬ͘ǀŽŝĚŚǇƉĞƌǀĞŶƚŝůĂƚŝŽŶ͕ƵŶůĞƐƐďĞŝŶŐĚŽŶĞĂƐŝŶĚŝĐĂƚĞĚŝŶƐĞǀĞƌĞ͕ ĚĞƚĞƌŝŽƌĂƚŝŶŐŚĞĂĚƚƌĂƵŵĂ͘ &ŽƌĨƵƌƚŚĞƌŝŶĨŽƌŵĂƚŝŽŶŽŶǇƉƌĞƐƐƌĞĞŬD^ĞƐƚWƌĂĐƚŝĐĞƐ͕ƉůĞĂƐĞƌĞĨĞƌƚŽ Manual of Emergency Airway Management;ϰƚŚĞĚŝƚŝŽŶͿďǇZŽŶD͘tĂůůƐ

Cypress Creek EMS System Policies and Treatment Guidelines

210 PROCEDURES Revised 8/2016 Airway Approved: Levon Vartanian, MD

ƌĂƐŚŝƌǁĂǇ Indications Equipment Needed Assessment Requirements hŶĐŽŶƐĐŝŽƵƐ͕ƵŶƌĞƐƉŽŶƐŝǀĞ sD͕KWͬEWƐ͕ĂŐĞů WƌŝŵĂƌǇƐƵƌǀĞǇ ƉĂƚŝĞŶƚƵŶĂďůĞƚŽƉƌŽƚĞĐƚƚŚĞŝƌ ^ƵĐƚŝŽŶ ƐƐĞƐƐĨŽƌůĞǀĞůŽĨĐŽŶƐĐŝŽƵƐŶĞƐƐ ŽǁŶĂŝƌǁĂǇ͘ <ŝŶŐƐƵƉƌĂŐůŽƚƚŝĐ '>ĂƐƐĞƐƐŵĞŶƚ ŝƌǁĂǇŬŝƚ ŝƌǁĂǇĂƐƐĞƐƐŵĞŶƚ ǆĂŵƉůĞƐŝŶĐůƵĚĞ͗ <ŝŶŐsŝƐŝŽŶůĂƌǇŶŐŽƐĐŽƉĞн ƐƐŽŽŶĂƐƉŽƐƐŝďůĞ͕ŝŶŝƚŝĂƚĞ x ĂƌĚŝĂĐĂƌƌĞƐƚ ďůĂĚĞ ĐŽŶƚŝŶƵŽƵƐŵŽŶŝƚŽƌŝŶŐŽĨ͗ x ZĞƐƉŝƌĂƚŽƌǇĂƌƌĞƐƚ ŽƵŐŝĞ x ^ƉKϮ ^ƵƌŐŝĐĂůĐƌŝĐŽƚŚǇƌŽƚŽŵǇŬŝƚ x dKϮ /ĨƉĂƚŝĞŶƚŚĂƐĂŝƌǁĂǇƌĞĨůĞǆĞƐŽƌ x ' ƌĞƐƉŽŶĚƐƚŽƉĂŝŶͬǀŽŝĐĞ͕ƌĞĨĞƌƚŽ ƐƐĞƐƐĨŽƌĂŶĚƚƌĞĂƚƌĞǀĞƌƐŝďůĞ ƚŚĞZ^/ƉƌŽĐĞĚƵƌĞ͘ ĐĂƵƐĞƐ͕ŝŶĐůƵĚŝŶŐŚǇƉŽŐůǇĐĞŵŝĂ͕ ŶĂƌĐŽƚŝĐŽǀĞƌĚŽƐĞ͕ĂŶĚŚǇƉŽǆŝĂ͘ WƌŽĐĞĚƵƌĞ ϭ͘ KƉĞŶĂŝƌǁĂǇƵƐŝŶŐhead-tilt/chin-liftŽƌjaw thrust͘ Ϯ͘ WůĂĐĞĂŝƌǁĂǇĂĚũƵŶĐƚƐĂƐŝŶĚŝĐĂƚĞĚ͘ ϯ͘ WƌŽǀŝĚĞŚŝŐŚͲƋƵĂůŝƚǇBag-Valve-Mask ventilationsǁŝƚŚϭϬϬйŽǆǇŐĞŶ͘ ϰ͘ ŽŶƐŝĚĞƌƌĞǀĞƌƐŝďůĞĐĂƵƐĞƐ͘ ϱ͘ /ĨƚŚĞĂŝƌǁĂǇŝƐŽďƐƚƌƵĐƚĞĚ͕ƌĞŵŽǀĞƚŚĞŽďƐƚƌƵĐƚŝŽŶƵƐŝŶŐForeign Body ObstructionƉƌŽĐĞĚƵƌĞ͘ ϲ͘ /ĨƚŚĞĐŽŵƉůĞƚĞůǇŽďƐƚƌƵĐƚĞĚĂŝƌǁĂǇĐĂŶŶŽƚďĞĐůĞĂƌĞĚƋƵŝĐŬůǇ͕ĐŽŶƐŝĚĞƌCricothyrotomy. ϳ͘ KŶĐĞĂŶĂŝƌǁĂǇĂƐƐĞƐƐŵĞŶƚŚĂƐďĞĞŶĐŽŵƉůĞƚĞĚĂŶĚĂůůĞƋƵŝƉŵĞŶƚŝƐƉƌĞƉĂƌĞĚ͕intubateƚŚĞƉĂƚŝĞŶƚ ŽƌƉůĂĐĞĂ supraglottic airway͘ ϴ͘ /ĨƚŚŝƐŝƐƵŶƐƵĐĐĞƐƐĨƵů͕ĐŽŶƚŝŶƵĞƚŽǀĞŶƚŝůĂƚĞǁŝƚŚĂBVM͘ WĞĂƌůƐ x DĂŝŶƚĂŝŶŝŶŐĂŶŽƉĞŶĂŝƌǁĂǇĂŶĚƉƌŽǀŝĚŝŶŐĂĚĞƋƵĂƚĞŽǆǇŐĞŶĂƚŝŽŶĂŶĚǀĞŶƚŝůĂƚŝŽŶĂƌĞĂŚŝŐŚĞƌ ƉƌŝŽƌŝƚǇƚŚĂŶƉůĂĐŝŶŐĂŶĂĚǀĂŶĐĞĚĂŝƌǁĂǇ͘ x EŽŵŽƌĞƚŚĂŶŽŶĞĂƚƚĞŵƉƚĂƚŝŶƚƵďĂƚŝŽŶƐŚŽƵůĚďĞƉĞƌĨŽƌŵĞĚǁŝƚŚŽƵƚĂĚĞƋƵĂƚĞŽǆǇŐĞŶƌĞƐĞƌǀĞƐ ;^ƉKϮшϵϬйͿ͘EŽŵŽƌĞƚŚĂŶƚŚƌĞĞƚŽƚĂůŝŶƚƵďĂƚŝŽŶĂƚƚĞŵƉƚƐƐŚŽƵůĚďĞƉĞƌĨŽƌŵĞĚ͘ x /ĨƚŚĞƉĂƚŝĞŶƚŝƐĂƉƌĞĚŝĐƚĞĚĚŝĨĨŝĐƵůƚĂŝƌǁĂǇŽƌŝĨŝŶƚƵďĂƚŝŽŶǁŽƵůĚƚĂŬĞƚŝŵĞĂǁĂǇĨƌŽŵŵŽƌĞĐƌŝƚŝĐĂů ƚĂƐŬƐ͕Ăsupraglottic airwayŵĂǇďĞƵƐĞĚƚŽĞƐƚĂďůŝƐŚĂŶĂŝƌǁĂǇĂŶĚǀĞŶƚŝůĂƚĞƚŚĞƉĂƚŝĞŶƚ͘ x tŚĞŶĂĚĞƋƵĂƚĞƌĞƐŽƵƌĐĞƐďĞĐŽŵĞĂǀĂŝůĂďůĞ͕Ăsupraglottic airwayƐŚŽƵůĚďĞĞǆĐŚĂŶŐĞĚĨŽƌĂŶET tube͕ƵŶůĞƐƐƚŚĞinitial airwayŝƐƉƌŽǀŝĚŝŶŐĂĚĞƋƵĂƚĞĂŝƌǁĂǇƉƌŽƚĞĐƚŝŽŶĂŶĚǀĞŶƚŝůĂƚŝŽŶĂŶĚƉƌŽďůĞŵƐ ǁŝƚŚŝŶƚƵďĂƚŝŽŶĂƌĞĂŶƚŝĐŝƉĂƚĞĚ͘ x /ĨƉĂƚŝĞŶƚ͛ƐůĞǀĞůŽĨĐŽŶƐĐŝŽƵƐŶĞƐƐŝŵƉƌŽǀĞƐĨŽůůŽǁŝŶŐĐƌĂƐŚĂŝƌǁĂǇ͕ƉƌŽǀŝĚĞƐĞĚĂƚŝŽŶǁŝƚŚ MidazolamϮ͘ϱʹϱŵŐ/sͬ/Eͬ/Dͬ/K;ƉĞĚŝĂƚƌŝĐĚŽƐĞ͗Ϭ͘ϬϱʹϬ͘ϭŵŐͬŬŐ/sͬ/Eͬ/Dͬ/KŵĂǆŝŵƵŵŽĨϱŵŐͿ ŽƌǁŝƚŚKetamineϭʹϭ͘ϱŵŐͬŬŐ/sͬ/KŽƌKetamineϱŵŐͬŬŐ/D͘/ĨŶĞĐĞƐƐĂƌǇ͕ĐŽŶƐŝĚĞƌƉĂƌĂůǇƐŝƐǁŝƚŚ RocuroniumϭŵŐͬŬŐ/sͬ/K͘ x ŽŶŽƚƉĂƌĂůǇǌĞĂƉĂƚŝĞŶƚǁŝƚŚĂƐƵƉƌĂŐůŽƚƚŝĐĂŝƌǁĂǇƉůĂĐĞĚ͘ŽŶŽƚƉĂƌĂůǇǌĞĂƉĂƚŝĞŶƚǁŝƚŚŽƵƚ ĞŶƐƵƌŝŶŐĂĚĞƋƵĂƚĞƐĞĚĂƚŝŽŶŚĂƐďĞĞŶƉƌŽǀŝĚĞĚ

Cypress Creek EMS System Policies and Treatment Guidelines

211 PROCEDURES 5 Revised 8/2016 Airway Approved: Levon Vartanian, MD

&ĂŝůĞĚŝƌǁĂǇ Indications Equipment Needed Assessment Requirements &ĂŝůƵƌĞƚŽŽǆǇŐĞŶĂƚĞĂĚĞƋƵĂƚĞůǇ sDǁŝƚŚKWͬEWƐ ŝƌǁĂǇĂƐƐĞƐƐŵĞŶƚ ĚƵƌŝŶŐŝŶƚƵďĂƚŝŽŶ͗ <ŝŶŐƐƵƉƌĂŐůŽƚƚŝĐĂŝƌǁĂǇ ƐƐŽŽŶĂƐƉŽƐƐŝďůĞ͕ŝŶŝƚŝĂƚĞ ĂŐĞů x ^ƉKϮĨĂůůƐƚŽфϵϬй;ŝĨ ĐŽŶƚŝŶƵŽƵƐŵŽŶŝƚŽƌŝŶŐŽĨ͗

ĂĚĞƋƵĂƚĞƚŽďĞŐŝŶͿ ^ƵƌŐŝĐĂůĐƌŝĐŽƚŚǇƌŽƚŽŵǇŬŝƚ ^ƵĐƚŝŽŶ x ^ƉKϮ x ^ƉKϮĨĂůůƐŵŽƌĞƚŚĂŶϱʹϭϬ x dKϮ ƉŽŝŶƚƐ;ŝĨŝŶĂĚĞƋƵĂƚĞ x ' ƌĞƐĞƌǀĞƐƚŽďĞŐŝŶͿ orƚŚƌĞĞƚŽƚĂůƵŶƐƵĐĐĞƐƐĨƵů ŝŶƚƵďĂƚŝŽŶĂƚƚĞŵƉƚƐ͘

WƌŽĐĞĚƵƌĞ ϭ͘ sĞŶƚŝůĂƚĞƉĂƚŝĞŶƚƵƐŝŶŐsDǁŝƚŚŐŽŽĚŵĂƐŬƐĞĂůĂŶĚKWͬEWƐƉůĂĐĞĚ͘ Ϯ͘ WůĂĐĞsupraglottic airwayƵŶůĞƐƐĐŽŶƚƌĂŝŶĚŝĐĂƚĞĚ͘ ϯ͘ /ĨƵŶĂďůĞƚŽǀĞŶƚŝůĂƚĞǁŝƚŚBVMĂŶĚͬŽƌĂ supraglottic airway, ŝŵŵĞĚŝĂƚĞsurgical cricothyrotomy ƐŚŽƵůĚďĞƉĞƌĨŽƌŵĞĚ͘ WĞĂƌůƐ x Conditions which define a failed airway: o &ĂŝůƵƌĞƚŽŵĂŝŶƚĂŝŶĂĚĞƋƵĂƚĞŽǆǇŐĞŶƐĂƚƵƌĂƚŝŽŶĂĨƚĞƌŽŶĞŽƌŵŽƌĞĨĂŝůĞĚŝŶƚƵďĂƚŝŽŶĂƚƚĞŵƉƚƐ͕ KZ o dŚƌĞĞtotalĨĂŝůĞĚĂƚƚĞŵƉƚƐĂƚŝŶƚƵďĂƚŝŽŶ͕KZ o hŶĂďůĞƚŽǀĞŶƚŝůĂƚĞĂŶĚŽǆǇŐĞŶĂƚĞĂĚĞƋƵĂƚĞůǇǁŝƚŚsDƚĞĐŚŶŝƋƵĞĂŶĚŝŶƐƵĨĨŝĐŝĞŶƚƚŝŵĞƚŽ ĂƚƚĞŵƉƚĂůƚĞƌŶĂƚŝǀĞŵĂŶĞƵǀĞƌƐ͘ x WĂƚŝĞŶƚƐǁŝƚŚĂĨĂŝůĞĚĂŝƌǁĂǇĂƌĞŶĞĂƌͲĚĞĂƚŚŽƌĂĐƚƵĂůůǇŝŶĐĂƌĚŝĂĐͬƌĞƐƉŝƌĂƚŽƌǇĂƌƌĞƐƚ͕ŶŽƚƐƚĂďůĞ͘ WĂƚŝĞŶƚƐǁŝƚŚƐƚĂďůĞŽƌŝŵƉƌŽǀŝŶŐǀŝƚĂůƐŝŐŶƐĚŽŶŽƚŶĞĐĞƐƐĂƌŝůǇŚĂǀĞĂĨĂŝůĞĚĂŝƌǁĂǇ͕ĂŶĚŵĂǇďĞĂďůĞ ƚŽďĞŵĂŶĂŐĞĚǁŝƚŚŽƵƚĂŐŐƌĞƐƐŝǀĞŝŶƚĞƌǀĞŶƚŝŽŶ͘

“A ‘Failed Airway’ is not a failure. It is a diagnosis, not an accusation.” —Dr. Bill Hinckle

Cypress Creek EMS System Policies and Treatment Guidelines

212 PROCEDURE Revised 8/2016 Airway Approved: Levon Vartanian, MD

<ŝŶŐsŝƐŝŽŶsŝĚĞŽ>ĂƌǇŶŐŽƐĐŽƉǇ Indications Equipment Needed Assessment Requirements ůƚĞƌŶĂƚŝǀĞƚŽĚŝƌĞĐƚ sD͕KWͬEW ŝƌǁĂǇĂƐƐĞƐƐŵĞŶƚ ;ƚƌĂĚŝƚŝŽŶĂůͿůĂƌǇŶŐŽƐĐŽƉǇ͘ ŝƌǁĂǇŬŝƚ ƐƐŽŽŶĂƐƉŽƐƐŝďůĞ͕ŝŶŝƚŝĂƚĞ &ŝƌƐƚͲůŝŶĞůĂƌǇŶŐŽƐĐŽƉǇ <ŝŶŐsŝƐŝŽŶĐĂŵĞƌĂƵŶŝƚĂŶĚ ĐŽŶƚŝŶƵŽƵƐŵŽŶŝƚŽƌŝŶŐŽĨ͗ ŵĞƚŚŽĚĨŽƌĞŶĚŽƚƌĂĐŚĞĂů ůĂƌǇŶŐŽƐĐŽƉǇďůĂĚĞƐ ŝŶƚƵďĂƚŝŽŶ͘ ZŝŐŝĚƐƚǇůĞƚ x ^ƉKϮ x Contraindications: dKϮ ŝĂŵĞƚĞƌŽĨŵŽƵƚŚǁŝůůŶŽƚ x ' ĂĐĐŽŵŵŽĚĂƚĞďůĂĚĞƐŝǌĞ ;ŵŝŶŝŵƵŵŽĨϭϯŵŵĨŽƌ ƐƚĂŶĚĂƌĚďůĂĚĞŽƌϭϴŵŵĨŽƌ ĐŚĂŶŶĞůĞĚͿ͘ Procedure ϭ͘ ^ĞůĞĐƚďůĂĚĞƐƚǇůĞĂŶĚĂƚƚĂĐŚƚŽĚŝƐƉůĂǇ͘>ŝƐƚĞŶĂŶĚĨĞĞůĨŽƌĂƉŽƐŝƚŝǀĞ͞ĐůŝĐŬ͟ƚŽĐŽŶĨŝƌŵĐŽŶŶĞĐƚŝŽŶ͘ Ϯ͘ >ƵďƌŝĐĂƚĞďůĂĚĞĂŶĚdƚƵďĞŬĞĞƉŝŶŐůƵďƌŝĐĂŶƚĂǁĂǇĨƌŽŵŝŵĂŐŝŶŐƐĞŶƐŽƌ͘ x ŚĂŶŶĞůĞĚďůĂĚĞʹdƚƵďĞƐŚŽƵůĚďĞƉƌĞůŽĂĚĞĚŝŶƚŽƚŚĞĐŚĂŶŶĞů͘ x EŽŶͲĐŚĂŶŶĞůĞĚďůĂĚĞʹƌŝŐŝĚƐƚǇůĞƚƐŚŽƵůĚďĞƉůĂĐĞĚŝŶƚŽƚŚĞdƚƵďĞ͘A rigid stylet is preferred͕ďƵƚŝĨƵŶĂǀĂŝůĂďůĞĂŵĂůůĞĂďůĞƚǇƉĞƐƚǇůĞƚŵƵƐƚďĞĨŽƌŵĞĚƚŽƚŚĞƐŚĂƉĞŽĨƚŚĞďůĂĚĞ ϯ͘ WŽǁĞƌĚĞǀŝĐĞŽŶĂŶĚĐŚĞĐŬĨŽƌĂĨƵŶĐƚŝŽŶĂůŵŽǀŝŶŐŝŵĂŐĞ͘ ϰ͘ /ĨĂƐƚĂƚŝĐ͕ƐƉůŝƚ͕ŽƌĨƌŽǌĞŶŝŵĂŐĞŝƐĚŝƐƉůĂǇĞĚƉŽǁĞƌƚŚĞĚĞǀŝĐĞŽĨĨ͖ĂƐƐƵƌĞƚŚĞďůĂĚĞŝƐƐĞĂƚĞĚ ĐŽƌƌĞĐƚůǇƚŽƚŚĞĚŝƐƉůĂǇĂŶĚƉŽǁĞƌďĂĐŬŽŶ͘ ϱ͘ WůĂĐĞƉĂƚŝĞŶƚƐŚĞĂĚŝŶĂŶĞƵƚƌĂůŽƌƐŶŝĨĨŝŶŐƉŽƐŝƚŝŽŶ͘ ϲ͘ hƚŝůŝǌŝŶŐĂƐƚĂŶĚĂƌĚƐĐŝƐƐŽƌƚĞĐŚŶŝƋƵĞƚŽŽƉĞŶƚŚĞŵŽƵƚŚ͕ƉůĂĐĞƚŚĞďůĂĚĞŝŶƚŽƚŚĞŽƌŽƉŚĂƌǇŶǆǁŝƚŚĂ ŵŝĚͲůŝŶĞĂƉƉƌŽĂĐŚ͖ĨŽůůŽǁƚŚĞĐƵƌǀĂƚƵƌĞŽĨƚŚĞƚŽŶŐƵĞůŽŽŬŝŶŐĨŽƌƚŚĞƵǀƵůĂĂŶĚƚŚĞŶĞƉŝŐůŽƚƚŝƐ ϳ͘ WůĂĐĞƚŚĞďůĂĚĞƚŝƉŝŶƚŽƚŚĞǀĂůůĞĐƵůĂǁŚŝůĞůŝĨƚŝŶŐƐƚƌĂŝŐŚƚƵƉ;ŶŽƚϰϱĚĞŐƌĞĞŽƌ͞ĐŽƌŶĞƌŽĨƚŚĞƌŽŽŵ͟ ĂŶŐůĞͿĂŶĚĚŝƐƉůĂĐĞƚŚĞŵĂŶĚŝďůĞĂŶƚĞƌŝŽƌůǇƚŽĞǆƉŽƐĞƚŚĞŐůŽƚƚŝĐĂƉĞƌƚƵƌĞ;DĂĐŝŶƚŽƐŚĂƉƉƌŽĂĐŚͿ͘ x ŶĂůƚĞƌŶĂƚŝǀĞĂƉƉƌŽĂĐŚŝƐƚŽůŝĨƚƚŚĞĞƉŝŐůŽƚƚŝƐĚŝƌĞĐƚůǇƚŽĞǆƉŽƐĞƚŚĞŐůŽƚƚŝĐĂƉĞƌƚƵƌĞ;DŝůůĞƌ ĂƉƉƌŽĂĐŚͿ͘ ϴ͘ ĚǀĂŶĐĞƚŚĞdƚƵďĞƚŚƌŽƵŐŚƚŚĞǀŽĐĂůĐŽƌĚƐƚŽƚŚĞƉƌŽƉĞƌĚĞƉƚŚŝŶƚŚĞƚƌĂĐŚĞĂ͘ x ŚĂŶŶĞůĞĚůĂĚĞ dƚƵďĞĐĂŶďĞƚǁŝƐƚĞĚǁŝƚŚŝŶĐŚĂŶŶĞůĨŽƌůĂƚĞƌĂůĂĚũƵƐƚŵĞŶƚ /ĨdƚƵďĞŝŵƉĂĐƚƐƌŝŐŚƚĂƌǇƚĞŶŽŝĚƐƌĞƚƌĂĐƚƚƵďĞĂŶĚƚǁŝƐƚƚŽƚŚĞůĞĨƚ ŽƵŐŝĞĐĂŶďĞƵƚŝůŝǌĞĚĨŽƌĂĚĚŝƚŝŽŶĂůĂŶƚĞƌŝŽƌĚĞĨůĞĐƚŝŽŶ x EŽŶͲŚĂŶŶĞůĞĚůĂĚĞ &ŽůůŽǁďůĂĚĞĐƵƌǀĞǁŝƚŚdƚƵďĞƚŝƉƚŽĂǀŽŝĚůŽƐŝŶŐƚŝƉŝŶƚŚĞŽƌŽƉŚĂƌǇŶǆ ůŝŐŶdƚƵďĞƚŝƉǁŝƚŚǀŽĐĂůĐŽƌĚƐ ZĞƚƌĂĐƚƐƚǇůĞƚĂƐdƚƵďĞŝƐĂĚǀĂŶĐĞĚ

Cypress Creek EMS System Policies and Treatment Guidelines

213 PROCEDURE Revised 8/2016 Airway Approved: Levon Vartanian, MD

ϵ͘ ^ƚĂďŝůŝǌĞĂŶĚŚŽůĚƚŚĞdƚƵďĞůĂƚĞƌĂůůǇǁŚŝůĞǁŝƚŚĚƌĂǁŝŶŐďůĂĚĞĨƌŽŵƚŚĞŵŽƵƚŚ͘ ϭϬ͘ ŝƐĐŽŶŶĞĐƚƚŚĞďůĂĚĞĨƌŽŵĚŝƐƉůĂǇ͖ĚŝƐƉŽƐĞŽĨďůĂĚĞĂŶĚĐůĞĂŶͬĚŝƐŝŶĨĞĐƚĚŝƐƉůĂǇ͘ Pearls x ƵƌŝŶŐƉůĂĐĞŵĞŶƚŽĨƚŚĞďůĂĚĞ͕ŵĂŝŶƚĂŝŶĂƐĂŶƚĞƌŝŽƌĂŶĂƉƉƌŽĂĐŚĂƐƉŽƐƐŝďůĞƚŽĂǀŽŝĚƉŽŽůĞĚ ƐĞĐƌĞƚŝŽŶƐŝŶƚŚĞƉŽƐƚĞƌŝŽƌƉŚĂƌǇŶǆ͘^ƵĐƚŝŽŶƐŚŽƵůĚďĞƌĞĂĚŝůǇĂǀĂŝůĂďůĞƚŽŵĂŶĂŐĞƐĞĐƌĞƚŝŽŶƐ͕ďůŽŽĚ͕ ŽƌǀŽŵŝƚƵƐ͘ x /ĨƐƵĐƚŝŽŶŝŶŐŝƐĂŶƚŝĐŝƉĂƚĞĚƚŚĞƉƌŽǀŝĚĞƌŵĂǇĞůĞĐƚƚŽƵƚŝůŝǌĞƚŚĞŶŽŶͲĐŚĂŶŶĞůĞĚďůĂĚĞ͕ǁŚŝĐŚĐĂŶďĞ ŵŽƌĞĞĂƐŝůǇƵƐĞĚŝŶĐŽŶũƵŶĐƚŝŽŶǁŝƚŚĂzĂŶŬĂƵĞƌƐƵĐƚŝŽŶ͘ x ŝƌǁĂǇĂǆŝƐĂůŝŐŶŵĞŶƚŝƐŐĞŶĞƌĂůůǇŶŽƚŶĞĐĞƐƐĂƌǇďƵƚŵĂǇďĞĞŵƉůŽǇĞĚĂƐƉƌŽǀŝĚĞƌĚĞĞŵƐ ĂƉƉƌŽƉƌŝĂƚĞ x ĞǀŝĐĞĐĂŶďĞƵƚŝůŝǌĞĚǁŝƚŚĂĐͲĐŽůůĂƌŝŶƉůĂĐĞ x ĞǀŝĐĞƐŚŽƵůĚďĞŚĞůĚďĞůŽǁƚŚĞƉƵƌƉůĞƌŝŶŐĚƵƌŝŶŐƵƐĞƚŽĂǀŽŝĚŝŶĂĚǀĞƌƚĞŶƚĚŝƐĐŽŶŶĞĐƚŝŽŶǁŚŝĐŚ ĐĂŶŽĐĐƵƌďǇůŝĨƚŝŶŐŽŶĚŝƐƉůĂǇĚƵƌŝŶŐƵƐĞ͘ x dŚĞĨŽůůŽǁŝŶŐƚĞĐŚŶŝƋƵĞƐĐĂŶďĞƵƚŝůŝǌĞĚƚŽĂǀŽŝĚƚŚĞĐŚĞƐƚŝŶůĂƌŐĞďŽĚǇŚĂďŝƚƵƐƉĂƚŝĞŶƚƐ͗ x /ŶƐĞƌƚďůĂĚĞƐŝĚĞǁĂǇƐ;ůŝŬĞĂŶKWͿĂŶĚƌŽƚĂƚĞŝŶƚŽĂŵŝĚůŝŶĞƉŽƐŝƚŝŽŶ͘ x /ŶƐĞƌƚďůĂĚĞǁŝƚŚŽƵƚĚŝƐƉůĂǇĂƚƚĂĐŚĞĚ͕ƚŚĞŶĂƚƚĂĐŚĚŝƐƉůĂǇǁŚŝůĞďůĂĚĞŝƐŝŶƚŚĞŵŽƵƚŚĂŶĚƉŽǁĞƌŽŶ͘ x ZĂŵƉŝŶŐŵĂǇĂůƐŽďĞĞĨĨĞĐƚŝǀĞŝŶƚŚĞƐĞƐŝƚƵĂƚŝŽŶƐ͘ x ůĂĚĞŵƵƐƚďĞĐŽŶŶĞĐƚĞĚƚŽĚŝƐƉůĂǇďĞĨŽƌĞƉŽǁĞƌŝŶŐĚĞǀŝĐĞŽŶ͘ x ŚĂŶŶĞůĞĚďůĂĚĞǁŝůůĂĐĐŽŵŵŽĚĂƚĞϲ͘Ϭʹϴ͘ϬdƚƵďĞ͘ x ůĞĂŶŝŶŐĂŶĚĚŝƐŝŶĨĞĐƚŝŶŐ͗ ϭ͘ ůĂĚĞŝƐĚŝƐƉŽƐĂďůĞ Ϯ͘ ŝƐƉůĂǇƐŚŽƵůĚďĞĐůĞĂŶĞĚĂŶĚĚŝƐŝŶĨĞĐƚĞĚǁŝƚŚ/WǁŝƉĞƐŽƌĐŽŵŵĞƌĐŝĂůůǇĂǀĂŝůĂďůĞĚŝƐŝŶĨĞĐƚŝŶŐ ǁŝƉĞƐ͘ ϯ͘ ŝƐƉůĂǇƐŚŽƵůĚŶŽƚďĞƐƵďŵĞƌƐĞĚĂŶĚĞůĞĐƚƌŝĐĂůĐŽŶŶĞĐƚŝŽŶƐĂƚƚŚĞďŽƚƚŽŵƐŚŽƵůĚďĞŬĞƉƚĚƌǇĂƚ ĂůůƚŝŵĞƐ͘ ϰ͘ ^ƚǇůĞƚĐůĞĂŶŝŶŐŝŶƐƚƌƵĐƚŝŽŶƐ͗ ϱ͘ ZĞŵŽǀĞǀŝƐŝďůĞĐŽŶƚĂŵŝŶĂŶƚƐǁŝƚŚŐĞƌŵŝĐŝĚĂůǁŝƉĞƐ ϲ͘ ůůŽǁƐƚǇůĞƚƚŽĂŝƌĚƌǇ ϳ͘ ZŝŶƐĞƐƚǇůĞƚǁŝƚŚǁĂƚĞƌ ϴ͘ ^ƵďŵĞƌƐĞƐƚǇůĞƚŝŶ^ƉŽƌŽǆďĂƚŚ ϵ͘ ůůŽǁƚŽƌĞŵĂŝŶƐƵďŵĞƌƐĞĚϭϬͲϮϬŵŝŶƵƚĞƐ ϭϬ͘ ůůŽǁƐƚǇůĞƚƚŽĂŝƌĚƌǇ ϭϭ͘ ZŝŶƐĞǁŝƚŚǁĂƚĞƌ ϭϮ͘ ZĞƚƵƌŶƚŽ<ŝŶŐsŝƐŝŽŶ<ŝƚ

Cypress Creek EMS System Policies and Treatment Guidelines

214 PROCEDURES Revised 8/2016 Airway/Breathing Approved: Levon Vartanian, MD

ĂƉŶŽŐƌĂƉŚǇDŽŶŝƚŽƌŝŶŐ Indications Equipment Needed DŽŶŝƚŽƌƐƉĂƚŝĞŶƚdKϮůĞǀĞůƐĂŶĚǁĂǀĞĨŽƌŵĂƐĂ Žůůy^ĞƌŝĞƐDŽŶŝƚŽƌ ĚŝĂŐŶŽƐƚŝĐĂŝĚĂŶĚǀĞŶƚŝůĂƚŝŽŶĂƐƐĞƐƐŵĞŶƚƚŽŽů͘ ^ŵĂƌƚĂƉŶŽ>ŝŶĞĐĂŶŶƵůĂ ŽŶƚŝŶƵŽƵƐdKϮŵŽŶŝƚŽƌŝŶŐƐŚŽƵůĚďĞƉĞƌĨŽƌŵĞĚŽŶ͗ Kƌ x ůůƉĂƚŝĞŶƚƐǁŝƚŚĂŶĂĚǀĂŶĐĞĚĂŝƌǁĂǇŝŶƉůĂĐĞ &ŝůƚĞƌ>ŝŶĞƐĞƚ ;dƚƵďĞŽƌ<ŝŶŐ>d^ͲͿ x ůůƉĂƚŝĞŶƚƐŝŶĐĂƌĚŝĂĐĂƌƌĞƐƚ x ĐƚŝǀĞůǇƐĞŝǌŝŶŐƉĂƚŝĞŶƚƐ x ůůƉĂƚŝĞŶƚƐƐƵĨĨĞƌŝŶŐĨƌŽŵĂƉŽŝƐŽŶŝŶŐŽƌƚŽǆŝĐ ĞǆƉŽƐƵƌĞ x ŶǇƉĂƚŝĞŶƚǁŝƚŚƐŝŐŶƐͬƐǇŵƉƚŽŵƐŽĨ ƌĞƐƉŝƌĂƚŽƌǇĚŝƐƚƌĞƐƐŽƌĚŝĨĨŝĐƵůƚǇďƌĞĂƚŚŝŶŐ͘ dKϮŵŽŶŝƚŽƌŝŶŐŵĂǇďĞƵƐĞĚŽŶŽƚŚĞƌƉĂƚŝĞŶƚƐ ŝĨƚŚĞƉĂƌĂŵĞĚŝĐĚĞĞŵƐŶĞĐĞƐƐĂƌǇ͘ Procedure x tŝƚŚŽƵƚĂĚǀĂŶĐĞĚĂŝƌǁĂǇ͗ x ƚƚĂĐŚƚŚĞ^ŵĂƌƚĂƉŶŽ>ŝŶĞƚŽƚŚĞĐĂƉŶŽŐƌĂƉŚǇƉŽƌƚŽŶƚŚĞŵŽŶŝƚŽƌĂŶĚƚƵƌŶŽŶƚŚĞ ĐĂƉŶŽŐƌĂƉŚǇŵŽĚƵůĞŽŶƚŚĞŵŽŶŝƚŽƌ͘ x WůĂĐĞĐĂŶŶƵůĂŽŶƉĂƚŝĞŶƚ͘/ƚŝƐŶŽƚŶĞĐĞƐƐĂƌǇƚŽĂĚŵŝŶŝƐƚĞƌŽǆǇŐĞŶƵŶůĞƐƐŝƚŝƐŶĞĞĚĞĚĨŽƌƚŚĞ ƉĂƚŝĞŶƚ͘ x tŝƚŚĂĚǀĂŶĐĞĚĂŝƌǁĂǇ͗ x ŽŶŶĞĐƚƚŚĞ&ŝůƚĞƌ>ŝŶĞƐĞƚƚŽƚŚĞĐĂƉŶŽŐƌĂƉŚǇƉ ŽƌƚŽŶƚŚĞŵŽŶŝƚŽƌĂŶĚƚƵƌŶŽŶƚŚĞ ĐĂƉŶŽŐƌĂƉŚǇŵŽĚƵůĞ͘ x ƚƚĂĐŚƚŚĞ&ŝůƚĞƌ>ŝŶĞϭϱͲϮϮŵŵĂĚĂƉƚĞƌƚŽƚŚĞĞŶĚŽƚƌĂĐŚĞĂůƚƵďĞ͕<ŝŶŐƚƵďĞ͕ŽƌsD ĨĂĐĞŵĂƐŬ͘ x /ĨƵƐŝŶŐĂŶ/d;ZĞƐYWŽĚͿ͕ƉůĂĐĞŝƚĐůŽƐĞƐƚƚŽƚŚĞƉĂƚŝĞŶƚĂŶĚƚŚĞ&ŝůƚĞƌ>ŝŶĞĂĚĂƉƚĞƌĂďŽǀĞŝƚ ;ĨƵƌƚŚĞƌĨƌŽŵƚŚĞƉĂƚŝĞŶƚͿ͘ Pearls x tĂǀĞĨŽƌŵdKϮŝƐĂƵƐĞĨƵůĂƐƐĞƐƐŵĞŶƚĨŽƌĂƐƐĞƐƐŝŶŐĨŽƌĂŝƌǁĂǇƐƚĂƚƵƐ͕ŝŶĐůƵĚŝŶŐĚĞƚĞĐƚŝŽŶŽĨ ĞƐŽƉŚĂŐĞĂůŝŶƚƵďĂƚŝŽŶŽƌĂĚŝƐůŽĚŐĞĚĞŶĚŽƚƌĂĐŚĞĂůƚƵďĞ͘ x ŚĂŶŐĞƐŝŶdKϮǀĂůƵĞƐĂŶĚǁĂǀĞĨŽƌŵƐŝŶƉĂƚŝĞŶƚƐǁŝƚŚŽďƐƚƌƵĐƚŝǀĞĂŝƌǁĂǇĚŝƐĞĂƐĞ;KW͕ĂƐƚŚŵĂ͕ ĞƚĐͿĐĂŶŚĞůƉĚĞƚĞƌŵŝŶĞŝĨďƌŽŶĐŚŽĚŝůĂƚŽƌƚŚĞƌĂƉǇŝƐĞĨĨĞĐƚŝǀĞŽƌŝĨƚŚĞƉĂƚŝĞŶƚƌĞƋƵŝƌĞƐĞŶĚŽƚƌĂĐŚĞĂů ŝŶƚƵďĂƚŝŽŶ͘/ŶƚŚĞƐĞƉĂƚŝĞŶƚƐ͕ŝŶŝƚŝĂůdKϮǀĂůƵĞƐфϮϴŵŵ,ŐŽƌхϱϬŵŵ,ŐĂƌĞĂƉŽƐŝƚŝǀĞƉƌĞĚŝĐƚŽƌ ŽĨŶĞĞĚŝŶŐĞŶĚŽƚƌĂĐŚĞĂůŝŶƚƵďĂƚŝŽŶ͘ x dKϮƌĞŵĂŝŶŝŶŐфϭϬŵŵ,ŐŝŶĐĂƌĚŝĂĐĂƌƌĞƐƚƉĂƚŝĞŶƚƐƉƌĞĚŝĐƚƐϬйƐƵƌǀŝǀĂů͘

Cypress Creek EMS System Policies and Treatment Guidelines

215 PROCEDURES Revised 8/2016 Airway Approved: Levon Vartanian, MD

ZĂƉŝĚ^ĞƋƵĞŶĐĞ/ŶĚƵĐƚŝŽŶ Indications Equipment Needed Assessment Requirements ƌŝƚŝĐĂůŶĞĞĚĨŽƌ sD͕KWͬEWƐ͕ĂŐĞů WƌŝŵĂƌǇƐƵƌǀĞǇ ĞŶĚŽƚƌĂĐŚĞĂůŝŶƚƵďĂƚŝŽŶ͗ ^ƵĐƚŝŽŶ ƐƐĞƐƐĨŽƌůĞǀĞůŽĨ <ŝŶŐƐƵƉƌĂŐůŽƚƚŝĐĂŝƌǁĂǇ x WĂƚŝĞŶƚĐĂŶŶŽƚƉƌŽƚĞĐƚ ĐŽŶƐĐŝŽƵƐŶĞƐƐ ƚŚĞŝƌŽǁŶĂŝƌǁĂǇ ŝƌǁĂǇŬŝƚ '>ĂƐƐĞƐƐŵĞŶƚ x ĐƚƵĂůŽƌŝŵƉĞŶĚŝŶŐ <ŝŶŐsŝƐŝŽŶůĂƌǇŶŐŽƐĐŽƉĞн ŽǆǇŐĞŶĂƚŝŽŶĨĂŝůƵƌĞ ďůĂĚĞ ŝƌǁĂǇĂƐƐĞƐƐŵĞŶƚ x ĐƚƵĂůŽƌŝŵƉĞŶĚŝŶŐ ŽƵŐŝĞ ŽŶƚŝŶƵŽƵƐŵŽŶŝƚŽƌŝŶŐŽĨ͗ ǀĞŶƚŝůĂƚŽƌǇĨĂŝůƵƌĞ͘ ^ƵƌŐŝĐĂůĐƌŝĐŽƚŚǇƌŽƚŽŵǇŬŝƚ x ^ƉKϮǁŝƚŚƐŝŶŐůĞͲƉĂƚŝĞŶƚ ƵƐĞƐƚŝĐŬĞƌƐĞŶƐŽƌ͘ ůŽŶŐǁŝƚŚŝŶƚĂĐƚĂŝƌǁĂǇ x dKϮ ƌĞĨůĞǆĞƐĂŶĚͬŽƌ x ' ƌĞƐƉŽŶƐŝǀĞŶĞƐƐ͘ ƐƐĞƐƐĨŽƌĂŶĚƚƌĞĂƚ ƌĞǀĞƌƐŝďůĞĐĂƵƐĞƐ͘ Purpose dŚŝƐƉƌŽĐĞĚƵƌĞŝƐĂƵƚŚŽƌŝǌĞĚďǇƚŚĞŵĞĚŝĐĂůĚŝƌĞĐƚŽƌƚŽďĞƉĞƌĨŽƌŵĞĚďǇĂƉƉƌŽǀĞĚƉĂƌĂŵĞĚŝĐƐŽŶůǇ͘ dŚŽƐĞĂƵƚŚŽƌŝǌĞĚĂƐW/ŽƌW//ƉĂƌĂŵĞĚŝĐƐŵĂǇƉĞƌĨŽƌŵƚŚŝƐƉƌŽĐĞĚƵƌĞŽŶůǇƵŶĚĞƌƚŚĞĚŝƌĞĐƚŝŽŶŽĨĂW/// ƉĂƌĂŵĞĚŝĐ͘ZĂƉŝĚ^ĞƋƵĞŶĐĞ/ŶĚƵĐƚŝŽŶŝƐĚĞƐŝŐŶĞĚƚŽƐĞĐƵƌĞƚŚĞĂŝƌǁĂǇŝŶĂŶǇƉĂƚŝĞŶƚƌĞƋƵŝƌŝŶŐ ĞŶĚŽƚƌĂĐŚĞĂůŝŶƚƵďĂƚŝŽŶǁŚŝĐŚĐĂŶŶŽƚďĞƉĞƌĨŽƌŵĞĚǁŝƚŚŽƵƚƉƌŽƉĞƌƐĞĚĂƚŝŽŶĂŶĚƉĂƌĂůǇƐŝƐ͕ďǇ ĂĚŵŝŶŝƐƚĞƌŝŶŐŶĞƵƌŽŵƵƐĐƵůĂƌďůŽĐŬŝŶŐĂŐĞŶƚƐŝŶĐŽŵďŝŶĂƚŝŽŶǁŝƚŚƐĞĚĂƚŝǀĞͬŚǇƉŶŽƚŝĐĂŐĞŶƚƐ͘ Indications dŚŝƐƉƌŽĐĞĚƵƌĞŵĂǇďĞƵƐĞĚǁŚĞŶĂĐƌŝƚŝĐĂůŶĞĞĚĨŽƌĞŶĚŽƚƌĂĐŚĞĂůŝŶƚƵďĂƚŝŽŶĞǆŝƐƚƐĂŶĚƚŚĞƉĂƚŝĞŶƚ ƌĞƋƵŝƌĞƐƐĞĚĂƚŝŽŶĂŶĚͬŽƌƉĂƌĂůǇƐŝƐƚŽĂĐĐŽŵƉůŝƐŚƚŚŝƐ͘ĂƐŝĐĂŝƌǁĂǇŵĂŶĞƵǀĞƌƐƐŚŽƵůĚĂůǁĂǇƐďĞ ƉĞƌĨŽƌŵĞĚǁĞůůƉƌŝŽƌƚŽZĂƉŝĚ^ĞƋƵĞŶĐĞ/ŶƚƵďĂƚŝŽŶ͘

^ŽŵĞĞǆĂŵƉůĞƐŽĨƉŽƚĞŶƚŝĂůĐĂŶĚŝĚĂƚĞƐĨŽƌZ^/ŝŶĐůƵĚĞ͗ x WĂƚŝĞŶƚƐ ǁŝƚŚ ĂŝƌǁĂǇ ĂŶĚͬŽƌ ǀĞŶƚŝůĂƚŽƌǇ ĐŽŵƉƌŽŵŝƐĞ ƚŚĂƚ ĐĂŶŶŽƚ ƚŽůĞƌĂƚĞ ĂŶ ĂǁĂŬĞ ŝŶƚƵďĂƚŝŽŶ͘ x ŽŵďĂƚŝǀĞƉĂƚŝĞŶƚƐǁŝƚŚĂŝƌǁĂǇĐŽŵƉƌŽŵŝƐĞŽƌƚŚĞƉŽƚĞŶƚŝĂůĨŽƌĂŝƌǁĂǇĐŽŵƉƌŽŵŝƐĞĞǆŝƐƚƐ͘ x ůŽƐĞĚ ŚĞĂĚ ŝŶũƵƌǇ ƉĂƚŝĞŶƚƐ Žƌ ƚŚŽƐĞ ǁŝƚŚ ĂůƚĞƌĞĚ ŵĞŶƚĂů ƐƚĂƚƵƐ ǁŝƚŚ ĂŝƌǁĂǇͬǀĞŶƚŝůĂƚŝŽŶ ĐŽŵƉƌŽŵŝƐĞ͕ŽƌƚŚĞƉŽƚĞŶƚŝĂůĨŽƌĂŝƌǁĂǇĐŽŵƉƌŽŵŝƐĞĞǆŝƐƚƐ͘ x WĂƚŝĞŶƚƐǁŝƚŚŚǇƉŽǆŝĂƌĞĨƌĂĐƚŽƌǇƚŽϭϬϬйŽǆǇŐĞŶĂĚŵŝŶŝƐƚƌĂƚŝŽŶŽƌWW͘ x DƵůƚŝͲƐǇƐƚĞŵƐƚƌĂƵŵĂƉĂƚŝĞŶƚƐƚŚĂƚƌĞƋƵŝƌĞĂƐĞĐƵƌĞĂŝƌǁĂǇ͘ x ^ƚĂƚƵƐĞƉŝůĞƉƚŝĐƵƐ͘ x ZĞƐƉŝƌĂƚŽƌǇĨĂŝůƵƌĞŽƌŝŵƉĞŶĚŝŶŐƌĞƐƉŝƌĂƚŽƌǇĨĂŝůƵƌĞ͘

Cypress Creek EMS System Policies and Treatment Guidelines

216 PROCEDURES Revised 8/2016 Airway Approved: Levon Vartanian, MD

Contraindications Z^/ƐŚŽƵůĚďĞŶŽƚďĞƉĞƌĨŽƌŵĞĚŝŶ͗

x WĂƚŝĞŶƚƐŝŶǁŚŽŵĂƐƵƌŐŝĐĂůĂŝƌǁĂǇǁŽƵůĚďĞĚŝĨĨŝĐƵůƚŽƌŝŵƉŽƐƐŝďůĞ;ŝ͘Ğ͘ŵĂƐƐŝǀĞƐǁĞůůŝŶŐŽƌ ƐŝŐŶŝĨŝĐĂŶƚŶĞĐŬŝŶũƵƌǇͿ͘ x WĂƚŝĞŶƚƐ ƚŚĂƚ ǁŽƵůĚ ďĞ ĚŝĨĨŝĐƵůƚ͕ Žƌ ŝŵƉŽƐƐŝďůĞ ƚŽ ŝŶƚƵďĂƚĞ Žƌ ǀĞŶƚŝůĂƚĞ Ă ĨƚĞƌ ƉĂƌĂůǇƐŝƐ ;ŝ͘Ğ͘ ƵŶƌĞƐŽůǀĞĚƵƉƉĞƌĂŝƌǁĂǇŽďƐƚƌƵĐƚŝŽŶŽƌĂĐƵƚĞĞƉŝŐůŽƚƚŝƚŝƐͿ͘ Modified RSI /ŶƐŽŵĞĐĂƐĞƐ͕RocuroniumƐŚŽƵůĚďĞĐŽŶƐŝĚĞƌĞĚĂƐĂŶŝŶŝƚŝĂůƉĂƌĂůǇƚŝĐŝŶƐƚĞĂĚŽĨSuccinylcholineďĂƐĞĚ ŽŶĂƌŝƐŬͲďĞŶĞĨŝƚĂŶĂůǇƐŝƐ͗

x WƌĞͲĞǆŝƐƚŝŶŐŚǇƉĞƌŬĂůĞŵŝĂŽƌƌŝƐŬĨŽƌŚǇƉĞƌŬĂůĞŵŝĂ͕ƐƵĐŚĂƐ͗ x ZĞŶĂůĨĂŝůƵƌĞͬĚŝĂůǇƐŝƐƉĂƚŝĞŶƚƐ x ƌƵƐŚŝŶũƵƌǇхϭǁĞĞŬĂŐŽ x DĂũŽƌďƵƌŶƐхϮϰŚŽƵƌƐĂŐŽ x ^ƉŝŶĂůĐŽƌĚŝŶũƵƌǇďĞƚǁĞĞŶϭǁĞĞŬƚŽϲŵŽŶƚŚƐĂŐŽ x EĞƵƌŽŵƵƐĐƵůĂƌĚŝƐŽƌĚĞƌƐƐƵĐŚĂƐDƵůƚŝƉůĞ^ĐůĞƌŽƐŝƐ͕DƵƐĐƵůĂƌǇƐƚƌŽƉŚǇ͕ĂŵǇŽƚƌŽƉŚŝĐůĂƚĞƌĂů ƐĐůĞƌŽƐŝƐ;>^Žƌ>ŽƵ'ĞŚƌŝŐ͛ƐĚŝƐĞĂƐĞͿ͕ŽƌDǇĂƐƚŚĞŶŝĂ'ƌĂǀŝƐ͘ x ,ŝƐƚŽƌǇŽĨŵĂůŝŐŶĂŶƚŚǇƉĞƌƚŚĞƌŵŝĂ Procedure—the Seven “P’s” of RSI PƌĞƉĂƌĂƚŝŽŶ ϭ͘ Monitor: ƉƉůǇĂůůŵŽŶŝƚŽƌŝŶŐĚĞǀŝĐĞƐ;^ƉKϮǁŝƚŚƐŝŶŐůĞͲƉĂƚŝĞŶƚƵƐĞƐƚŝĐŬĞƌ͕'͕dKϮ͕E/WͿ͘/Ĩ ĂǀĂŝůĂďůĞ͕ĚĞĚŝĐĂƚĞĂƐŝŶŐůĞƉƌŽǀŝĚĞƌƚŽŵŽŶŝƚŽƌƚŚĞƐĞƉĂƌĂŵĞƚĞƌƐ͘ Ϯ͘ Airway Assessment: hƐĞLEMONSƚŽĂƐƐĞƐƐĨŽƌƉŽƚĞŶƚŝĂůĚŝĨĨŝĐƵůƚŝŶƚƵďĂƚŝŽŶ͘ ϯ͘ Vascularaccess͗ŶƐƵƌĞƉĂƚĞŶƚ/sĂĐĐĞƐƐ͘ ϰ͘ PACE Plan: sĞƌďĂůŝǌĞƉůĂŶĨŽƌĂŝƌǁĂǇŵĂŶĂŐĞŵĞŶƚ͗ x PrimaryĂŝƌǁĂǇŵĂŶĂŐĞŵĞŶƚƉůĂŶ;Ğ͘Ő͘ďůĂĚĞƚǇƉĞͬƐŝǌĞ͕ƚƵďĞƐŝǌĞ͕ůĂƌǇŶŐŽƐĐŽƉŝƐƚ͕ĂŶǇĂĚũƵŶĐƚƐͿ͘ x AlternateĂŝƌǁĂǇŵĂŶĂŐĞŵĞŶƚƉůĂŶ x ContingencyƉůĂŶ͕Ğ͘Ő͘<ŝŶŐdƵďĞ x EmergencyƉůĂŶ͕Ğ͘Ő͘ƐƵƌŐŝĐĂůŽƌŶĞĞĚůĞĐƌŝĐŽƚŚǇƌŽƚŽŵǇ͘ ϱ͘ AssembleĂŶĚĐŚĞĐŬůĂƌǇŶŐŽƐĐŽƉĞ͕ďůĂĚĞƐ͕sD͕ǁŝƚŚƐƵĐƚŝŽŶŽŶĂŶĚƌĞĂĚŝůǇĂǀĂŝůĂďůĞ͘ ϲ͘ PreparedƚƵďĞ͕ĐŚĞĐŬĐƵĨĨĨŽƌŝŶƚĞŐƌŝƚǇ͕ƐƚǇůĞƚ͕ƐǇƌŝŶŐĞ͕ĂŶĚůƵďƌŝĐĂŶƚ͘ ϳ͘ Draw upĂůůŵĞĚŝĐĂƚŝŽŶƐŝŶƚŽůĂďĞůĞĚƐǇƌŝŶŐĞƐŽƌƉƌĞƉĂƌĞƉƌĞĨŝůůĞĚƐǇƌŝŶŐĞƐ͘ ϴ͘ ArrangeďŽƵŐŝĞ͕<ŝŶŐdƵďĞ͕ĂŶĚƐƵƌŐŝĐĂůĂŝƌǁĂǇŬŝƚƐǁŝƚŚŝŶƌĞĂĐŚĂŶĚƌĞĂĚǇƚŽƵƐĞ͘ ϵ͘ PositionƉĂƚŝĞŶƚŽƉƚŝŵĂůůǇǁŝƚŚŝŶƚƵďĂƚŝŽŶďĂŐĞůďĞŚŝŶĚŚĞĂĚ͕ƌĂŵƉŝŶŐͬƉĂĚĚŝŶŐĂƐĂƉƉůŝĐĂďůĞ͘<ĞĞƉ ĐĞƌǀŝĐĂůƐƉŝŶĞŝŶͲůŝŶĞŝĨŝŶĚŝĐĂƚĞĚ͘ PƌĞŽǆǇŐĞŶĂƚŝŽŶ ϭϬ͘ WƌĞŽǆǇŐĞŶĂƚĞǁŝƚŚϭϬϬйŽǆǇŐĞŶƚŽĂĐŚŝĞǀĞŶŝƚƌŽŐĞŶǁĂƐŚŽƵƚĂŶĚŽƉƚŝŵĂů^ƉKϮ͘

Cypress Creek EMS System Policies and Treatment Guidelines

217 PROCEDURES Revised 8/2016 Airway Approved: Levon Vartanian, MD

x Ŷ^ƉKϮхϵϬйŝƐĚĞƐŝƌĞĚƉƌŝŽƌƚŽŝŶƚƵďĂƚŝŽŶ͘ x /ĚĞĂůůǇ͕ĂĐŚŝĞǀĞĂŶ^ƉKϮŽĨϵϵͲϭϬϬй͘ x dŚŝƐŵĂǇŶŽƚďĞƉŽƐƐŝďůĞŽŶĂůůƉĂƚŝĞŶƚƐ͘hƐĞĐůŝŶŝĐĂůũƵĚŐĞŵĞŶƚĂŶĚĐŽŶƐŝĚĞƌƉĂƚŝĞŶƚƐǁŝƚŚ^ƉKϮ фϵϬйƚŽďĞĚŝĨĨŝĐƵůƚͬĐŚĂůůĞŶŐŝŶŐĂŝƌǁĂǇƐ͘ ϭϭ͘ /Ĩ^ƉKϮƉĞƌƐŝƐƚƐĂƚϵϬйŽƌůĞƐƐǁŝƚŚϭϬϬйŽǆǇŐĞŶĂƚŝŽŶĂŶĚĞĨĨĞĐƚŝǀĞsDǀĞŶƚŝůĂƚŝŽŶ͕ƚŚĞŶĂĐƌĂƐŚ ĂŝƌǁĂǇĞǆŝƐƚƐ͘/ĨďĞůŝĞǀĞĚƚŽďĞƵŶĐŽŵƉůŝĐĂƚĞĚ͕ƉƌŽĐĞĞĚǁŝƚŚŝŶƚƵďĂƚŝŽŶ͘/ĨďĞůŝĞǀĞĚƚŽďĞ ĐŽŵƉůŝĐĂƚĞĚŽƌŝĨŶŽƚƐƵĐĐĞƐƐĨƵůǁŝƚŚŝŶƚŚƌĞĞĂƚƚĞŵƉƚƐ͕ƉƌŽĐĞĞĚƚŽƐƵƉƌĂŐůŽƚƚŝĐĂŝƌǁĂǇŝŶƐĞƌƚŝŽŶ͘ ϭϮ͘ ŽŶƐŝĚĞƌĂĚŵŝŶŝƐƚĞƌŝŶŐKetamineƚŽĂƐƐŝƐƚǁŝƚŚsDǀĞŶƚŝůĂƚŝŽŶĂŶĚƉƌĞŽǆǇŐĞŶĂƚŝŽŶĂŶĚĚĞůĂǇŝŶŐ ĂĚŵŝŶŝƐƚƌĂƚŝŽŶŽĨƉĂƌĂůǇƚŝĐƵŶƚŝů^ƉKϮŝƐŵĂǆŝŵŝǌĞĚ͘ PƌĞƚƌĞĂƚŵĞŶƚ͗ ϭϯ͘ ŽŶƐŝĚĞƌAtropine0.02 mg/kg IV x DĂǆŝŵƵŵtotalĂĚƵůƚĚŽƐĞ͗3mg/kg x DŝŶŝŵƵŵsingleĚŽƐĞ͗0.1 mg x DĂǆŝŵƵŵsingleĚŽƐĞ;ĐŚŝůĚͿ͗0.5 mg x DĂǆŝŵƵŵsingleĚŽƐĞ;ĂĚŽůĞƐĐĞŶƚͿ͗1 mg ϭϰ͘ ŽŶƚŝŶƵĞϭϬϬйŽǆǇŐĞŶĂƚŝŽŶĂŶĚǀĞŶƚŝůĂƚŝŽŶĂƐƌĞƋƵŝƌĞĚ ϭϱ͘ WŽƐŝƚŝŽŶůĂƌǇŶŐŽƐĐŽƉŝƐƚĨŽƌďĞƐƚĂƚƚĞŵƉƚĂƚŝŶƚƵďĂƚŝŽŶ͘ PĂƌĂůǇƐŝƐ ϭϲ͘ ĚŵŝŶŝƐƚĞƌinduction agent: x EtomidateϬ͘ϯŵŐͬŬŐ/sͬ/Kor x Ketamine ϭʹϭ͘ϱŵŐͬŬŐ/sͬ/K x tŝƚŚŝŶϯϬƐĞĐŽŶĚƐ͕ƚŚĞƉĂƚŝĞŶƚƐŚŽƵůĚďĞĐŽŵĞĐŽŵƉůĞƚĞůǇƐĞĚĂƚĞĚ;^dƐĐŽƌĞͲϯ͕ŶŽƌĞƐƉŽŶƐĞƚŽ ƐƚŝŵƵůĂƚŝŽŶͿ͘ ϭϳ͘ ĚŵŝŶŝƐƚĞƌparalytic: x Succinylcholineϭʹϭ͘ϱŵŐͬŬŐ/sͬ/Kor x RocuroniumϭŵŐͬŬŐ/sͬ/KŝĨƵƐŝŶŐŵŽĚŝĨŝĞĚZ^/ĚƵĞƚŽƌĞůĂƚŝǀĞĐŽŶƚƌĂŝŶĚŝĐĂƚŝŽŶƐƚŽ Succinylcholine͘ x Never administer paralytics without ensuring sedation x tŝƚŚŝŶϯϬƐĞĐŽŶĚƐ͕ƚŚĞƉĂƚŝĞŶƚƐŚŽƵůĚďĞĐŽŵĞĐŽŵƉůĞƚĞůǇĨůĂĐĐŝĚĂŶĚƉĂƌĂůǇǌĞĚ͘ PƌŽƚĞĐƚŝŽŶ ϭϴ͘ ŽŶƐŝĚĞƌƵƚŝůŝǌŝŶŐĐƌŝĐŽŝĚƉƌĞƐƐƵƌĞƵŶƚŝůdƚƵďĞƉůĂĐĞŵĞŶƚŝƐĂƐƐƵƌĞĚĂŶĚĐƵĨĨŝƐŝŶĨůĂƚĞĚ͘ ϭϵ͘ sĞŶƚŝůĂƚĞǁŝƚŚϭϬϬйKϮĂŶĚsDŝĨŝŶĚŝĐĂƚĞĚĂŶĚŝĨƉŽƐƐŝďůĞƚŽŝŶĐƌĞĂƐĞ^ƉKϮ͘ŽŶƐŝĚĞƌWW͘ ϮϬ͘ WŽƐŝƚŝŽŶƚŚĞƉĂƚŝĞŶƚĨŽƌŝŶƚƵďĂƚŝŽŶ͗EĞƵƚƌĂůƐƉŝŶĞĂůŝŐŶŵĞŶƚĂŶĚƉƌĞĐĂƵƚŝŽŶƐŝĨŝŶĚŝĐĂƚĞĚ͖͞ƐŶŝĨĨŝŶŐ͟ ŚĞĂĚͲĞůĞǀĂƚĞĚĂŝƌǁĂǇĂůŝŐŶŵĞŶƚŽƚŚĞƌǁŝƐĞ͘ PůĂĐĞŵĞŶƚǁŝƚŚWƌŽŽĨ Ϯϭ͘ hƐĞůĂƌǇŶŐĞĂůŵĂŶŝƉƵůĂƚŝŽŶŝĨŶĞĞĚĞĚƚŽŝŵƉƌŽǀĞǀŝĞǁŽĨŐůŽƚƚŝĐŽƉĞŶŝŶŐ͘

Cypress Creek EMS System Policies and Treatment Guidelines

218 PROCEDURES Revised 8/2016 Airway Approved: Levon Vartanian, MD

ϮϮ͘ WĞƌĨŽƌŵŝŶƚƵďĂƚŝŽŶĂŶĚŝŶĨůĂƚĞĐƵĨĨ͘ Ϯϯ͘ ŽŶĨŝƌŵƉůĂĐĞŵĞŶƚďǇǀŝƐƵĂůŝǌŝŶŐdƚƵďĞƉĂƐƐƚŚƌŽƵŐŚĐŽƌĚƐ͕dKϮĚĞƚĞĐƚŝŽŶĂŶĚǁĂǀĞĨŽƌŵ ĐĂƉŶŽŐƌĂƉŚǇ͕ĂƵƐĐƵůƚĂƚŝŽŶŽĨďƌĞĂƚŚƐŽƵŶĚƐĂŶĚĂďƐĞŶĐĞŽĨĞƉŝŐĂƐƚƌŝĐďƌĞĂƚŚƐŽƵŶĚƐ͕ĂŶĚ^WKϮ ŵŽŶŝƚŽƌŝŶŐ͘ Ϯϰ͘ /Ĩ^ƉKϮĚƌŽƉƐƐŝŐŶŝĨŝĐĂŶƚůǇ;фϵϬйŽƌŵŽƌĞƚŚĂŶϭϬйŝĨƉƌĞŽǆǇŐĞŶĂƚŝŽŶĐŽƵůĚŶ͛ƚŐĞƚĂďŽǀĞϵϬйƚŽ ƐƚĂƌƚͿƚŚĞŶƚŚĞŝŶƚƵďĂƚŝŽŶĂƚƚĞŵƉƚƐŚŽƵůĚĐĞĂƐĞĂŶĚƚŚĞƉĂƚŝĞŶƚƐŚŽƵůĚďĞǀĞŶƚŝůĂƚĞĚǁŝƚŚĂsD ƵŶƚŝůŽǆǇŐĞŶůĞǀĞůƐĂƌĞƌĞƐƚŽƌĞĚ͘ Ϯϱ͘ /ĨƚŚƌĞĞƚŽƚĂůŝŶƚƵďĂƚŝŽŶĂƚƚĞŵƉƚƐĂƌĞƵŶƐƵĐĐĞƐƐĨƵů͕ƉƌŽĐĞĞĚƚŽKing supraglottic airwayƉůĂĐĞŵĞŶƚ͘ /ĨƚŚŝƐŝƐƵŶƐƵĐĐĞƐƐĨƵů͕ĂƚƚĞŵƉƚsDǀĞŶƚŝůĂƚŝŽŶǁŝƚŚĂĚũƵŶĐƚƐ͕ŐŽŽĚĂŝƌǁĂǇƉŽƐŝƚŝŽŶŝŶŐ͕ĂŶĚŐŽŽĚ ŵĂƐŬƐĞĂů͘ Ϯϲ͘ /ĨKing tubeƉůĂĐĞŵĞŶƚĂŶĚsDǀĞŶƚŝůĂƚŝŽŶĂƌĞƵŶƐƵĐĐĞƐƐĨƵů͕Ă͞ĐĂŶ͛ƚŝŶƚƵďĂƚĞ͕ĐĂŶ͛ƚǀĞŶƚŝůĂƚĞ͟ ƐŝƚƵĂƚŝŽŶĞǆŝƐƚƐĂŶĚŝŵŵĞĚŝĂƚĞĐƌŝĐŽƚŚǇƌŽƚŽŵǇŝƐŝŶĚŝĐĂƚĞĚ͘ PŽƐƚ/ŶƚƵďĂƚŝŽŶDĂŶĂŐĞŵĞŶƚ Ϯϳ͘ ŽŶƚŝŶƵĞǀĞŶƚŝůĂƚŝŽŶĂŶĚϭϬϬйŽǆǇŐĞŶĂƚŝŽŶǁŝƚŚsD͘ Ϯϴ͘ ŽŶƚŝŶƵĞƚŽŵŽŶŝƚŽƌ'͕^ƉKϮ͕dKϮ͕ĂŶĚďůŽŽĚƉƌĞƐƐƵƌĞ͘ Ϯϵ͘ ^ĞĐƵƌĞdƚƵďĞǁŝƚŚĐŽŵŵĞƌĐŝĂůdƚƵďĞŚŽůĚĞƌ͘ ϯϬ͘ ŶƐƵƌĞĐŽŶƚŝŶƵĞĚ͕ĂĚĞƋƵĂƚĞƐĞĚĂƚŝŽŶ͘ŽŶƐŝĚĞƌMidazolam (Versed) 1–2 mg IV/IOŐŝǀĞŶƐůŽǁůǇĂŶĚ ƚŝƚƌĂƚĞĚĨŽƌĞĨĨĞĐƚŝĨŶĞĞĚĞĚĂŶĚŝĨ^WƌĞŵĂŝŶƐхϭϬϬŵŵ,Ő͕ƚŽĂƚŽƚĂůŵĂǆŝŵƵŵĚŽƐĂŐĞŽĨϬ͘ϭ ŵŐͬŬŐ͘ŽŶƐŝĚĞKetamine (Ketalar) 1–1.5 mg/kg IV/IOĨŽƌƉĂƚŝĞŶƚǁŝƚŚďƌŽŶĐŚŽƐƉĂƐŵ͘ ϯϭ͘ ZĞͲƉĂƌĂůǇǌĞŝĨŶĞĞĚĞĚ͘ŽŶƐŝĚĞƌVecuronium (Norcuron) 0.05–0.1 mg/kg IV/IO ŽƌRocuronium1 mg/kg IV/IO͘Never administer these medications without ensuring deep sedation. ϯϮ͘ WůĂĐĞŽŶmechanical ventilatorŝĨĂǀĂŝůĂďůĞĂŶĚĂƉƉƌŽƉƌŝĂƚĞĨŽƌƉĂƚŝĞŶƚ͘ DŽŶŝƚŽƌŝŶŐ͕ZĞƐƵƉƉůǇ͕ĂŶĚŽĐƵŵĞŶƚĂƚŝŽŶ ϯϯ͘ ŽŶƚŝŶƵĞĨƵůůŵŽŶŝƚŽƌŝŶŐ;dKϮ͕'͕^ƉKϮ͕ƌĞƉĞĂƚWŵĞĂƐƵƌĞŵĞŶƚƐͿƚŚƌŽƵŐŚŽƵƚƚƌĂŶƐƉŽƌƚĂŶĚ ƵƉƵŶƚŝůƚƌĂŶƐĨĞƌŽĨĐĂƌĞĂƚŚŽƐƉŝƚĂůŽƌƚŽƚƌĂŶƐƉŽƌƚĐƌĞǁ͘ ϯϰ͘ ŽĐƵŵĞŶƚZ^/ƚŚŽƌŽƵŐŚůǇĂŶĚĂĐĐƵƌĂƚĞůǇŝŶWZƌĞƉŽƌƚ͕ŝŶĐůƵĚŝŶŐƌĂƚŝŽŶĂůĞĨŽƌƉĞƌĨŽƌŵŝŶŐŝƚ͘/ŶĐůƵĚĞ ĨƵůůĚĂƚĂĨŝůĞĨƌŽŵŽůůyͲ^ĞƌŝĞƐĐŽǀĞƌŝŶŐĞŶƚŝƌĞĐĂƐĞƚŚƌŽƵŐŚƚŽƚƌĂŶƐĨĞƌŽĨĐĂƌĞ͘ ϯϱ͘ Wϯͬ&ŝĞůĚ^ƵƉĞƌǀŝƐŽƌƐŚŽƵůĚĐŽŵƉůĞƚĞƚŚĞ^ƵƉƉůĞŵĞŶƚĂůƌĞƉŽƌƚŽŶƌĞĞŬƉŽŝŶƚ͘ ϯϲ͘ ZĞƐƵƉƉůǇŽĨƉĂƌĂůǇƚŝĐƐĂŶĚƐĞĚĂƚŝǀĞƐͬŝŶĚƵĐƚŝŽŶĂŐĞŶƚƐƐŚŽƵůĚďĞƉĞƌĨŽƌŵĞĚǁŝƚŚ&ŝĞůĚ^ƵƉĞƌǀŝƐŽƌĂƐ ƐŽŽŶĂƐĨĞĂƐŝďůĞ͘ Pearls for Rapid Sequence Intubation x KŶĐĞĂŶĞƵƌŽŵƵƐĐƵůĂƌďůŽĐŬŝŶŐĂŐĞŶƚŝƐŐŝǀĞŶ͕ǇŽƵĂƐƐƵŵĞĐŽŵƉůĞƚĞƌĞƐƉŽŶƐŝďŝůŝƚǇƚŽŵĂŝŶƚĂŝŶƚŚĞ ĂŝƌǁĂǇĂŶĚƉƌŽǀŝĚĞĂĚĞƋƵĂƚĞǀĞŶƚŝůĂƚŝŽŶĂŶĚŽǆǇŐĞŶĂƚŝŽŶ͘tŝƚŚĂĚŵŝŶŝƐƚƌĂƚŝŽŶŽĨƚŚĞƐĞĂŐĞŶƚƐ͕ǇŽƵ ŚĂǀĞƚĂŬĞŶĂǁĂǇƚŚĞƉĂƚŝĞŶƚ͛ƐǁŝůůĂŶĚĂďŝůŝƚǇƚŽďƌĞĂƚŚĞ͘ x /ŶĂƉĂƚŝĞŶƚǁŝƚŚĂĚĞƋƵĂƚĞŽǆǇŐĞŶĂƚŝŽŶ͕ǀĞŶƚŝůĂƚŝŽŶ͕ĂŶĚƉƵůŵŽŶĂƌǇĨƵŶĐƚŝŽŶ͕ƚŚĞƉĂƌĂŵĞĚŝĐƐŚŽƵůĚ ŚĂǀĞƐĞǀĞƌĂůŵŝŶƵƚĞƐŽĨůĂƌǇŶŐŽƐĐŽƉǇƚŝŵĞ͘dŚŝƐŵĂǇŶŽƚďĞƚŚĞĐĂƐĞǁŝƚŚǇŽƵƌƉĂƚŝĞŶƚ͘You must monitor the SpO2 continuously and cease laryngoscopy and initiate BVM ventilation if SpO2 drops

Cypress Creek EMS System Policies and Treatment Guidelines

219 PROCEDURES Revised 8/2016 Airway Approved: Levon Vartanian, MD

below 90% (provided you were able to pre-oxygenate patient to an SpO2 > 90%). If unable to initially pre-oxygenate above 90%, stop laryngoscopy if SpO2 drops more than 5–10 points. x /ƚŝƐŝŵƉĞƌĂƚŝǀĞƚŚĂƚƚŚĞĨŝƌƐƚĂƚƚĞŵƉƚŝƐƚŚĞďĞƐƚĂƚƚĞŵƉƚ͘WƌŽƉĞƌƉŽƐŝƚŝŽŶŝŶŐŽĨƚŚĞƉĂƚŝĞŶƚ͕ĂŶĚƚŚĞ ůĂƌǇŶŐŽƐĐŽƉŝƐƚ͕ĂŶĚŚĂǀŝŶŐĂůůƉŽƚĞŶƚŝĂůĞƋƵŝƉŵĞŶƚ;ĞƐƉĞĐŝĂůůǇƐƵĐƚŝŽŶͿƌĞĂĚŝůǇĂǀĂŝůĂďůĞŝƐ ƉĂƌĂŵŽƵŶƚ͘ x ŽŶƚŝŶƵĂůůǇŵŽŶŝƚŽƌ^ƉKϮĂŶĚdKϮĂĨƚĞƌŝŶƚƵďĂƚŝŽŶĂŶĚƌĞĐŽŶĨŝƌŵƉůĂĐĞŵĞŶƚĞĂĐŚƚŝŵĞƚŚĞ ƉĂƚŝĞŶƚŝƐŵŽǀĞĚ͘ŽĐƵŵĞŶƚĐŽŶĨŝƌŵĂƚŝŽŶŽĨƚƵďĞƉůĂĐĞŵĞŶƚĞĂĐŚƚŝŵĞƉĂƚŝĞŶƚŝƐŵŽǀĞĚ͘ x ĨƚĞƌƉĂƌĂůǇƐŝƐĂŶĚŝŶƚƵďĂƚŝŽŶĂƌĞĂĐĐŽŵƉůŝƐŚĞĚ͕ĐŽŶƚŝŶƵĞĚƉĂƌĂůǇƐŝƐŵĂǇďĞŶĞĐĞƐƐĂƌǇƚŽŵĂŶĂŐĞ ƚŚĞƉĂƚŝĞŶƚ͘ŶƐƵƌĞƉƌŽƉĞƌƐĞĚĂƚŝŽŶŝƐƉƌŽǀŝĚĞĚƚŚƌŽƵŐŚŽƵƚĂŶĚƉƌŽǀŝĚĞĂĚĚŝƚŝŽŶĂůƐĞĚĂƚŝŽŶŝĨƐŝŐŶƐ ŽĨƌĞĐŽǀĞƌǇĂƌĞŽďƐĞƌǀĞĚƐƵĐŚĂƐŝŶĐƌĞĂƐŝŶŐ,Z͕ŝŶĐƌĞĂƐŝŶŐW͕ŽƌůĂĐƌŝŵĂƚŝŽŶ͘^ŽŵĞƐŝŐŶƐŽĨ ƌĞĐŽǀĞƌǇĨƌŽŵƚŚĞŝŶŝƚŝĂůƉĂƌĂůǇƚŝĐĚŽƐĞƐŚŽƵůĚďĞŽďƐĞƌǀĞĚ͕ƐƵĐŚĂƐƐŬĞůĞƚĂůŵƵƐĐůĞŵŽǀĞŵĞŶƚŽƌ ĐŽƵŐŚŝŶŐ͕ďĞĨŽƌĞĂĚŵŝŶŝƐƚĞƌŝŶŐĂƌĞƉĞĂƚĚŽƐĞŽĨƉĂƌĂůǇƚŝĐ͘ x dŚĞWϯƉƌĞƐĞŶƚĨŽƌƚŚĞZ^/ƉƌŽĐĞĚƵƌĞĚŽĞƐŶŽƚŚĂǀĞƚŽďĞƚŚĞůĂƌǇŶŐŽƐĐŽƉŝƐƚ͕ŚŽǁĞǀĞƌ͕ƚŚĞǇĂƌĞ ƵůƚŝŵĂƚĞůǇƌĞƐƉŽŶƐŝďůĞƚŽĞŶƐƵƌĞďĞƐƚƉƌĂĐƚŝĐĞƐĂƌĞĨŽůůŽǁĞĚĂŶĚƉƌŽƉĞƌĐĂƌĞŝƐƉƌŽǀŝĚĞĚƚŽƚŚĞ ƉĂƚŝĞŶƚ͘

Cypress Creek EMS System Policies and Treatment Guidelines

220 PROCEDURE Revised 8/2016 Airway/Breathing Approved: Levon Vartanian, MD

sDsĞŶƚŝůĂƚŝŽŶƐ Indications Equipment Needed Assessment Requirements ŶǇƉĂƚŝĞŶƚǁŝƚŚŝŶĂĚĞƋƵĂƚĞ sD͕EWͬKW DŽŶŝƚŽƌdKϮĂƐƐŽŽŶĂƐ ǀĞŶƚŝůĂƚŝŽŶ͘ ƉŽƐƐŝďůĞ͘

Procedure x hƚŝůŝǌĞƚŚĞĐŽƌƌĞĐƚƐŝǌĞsDĨŽƌƉĂƚŝĞŶƚƐŝǌĞ͘ x /ĨƵƐŝŶŐǁŝƚŚĨĂĐĞŵĂƐŬ͕ƵƚŝůŝǌĞĂŶ͞Ͳ͟ĐůĂŵƉƚĞĐŚŶŝƋƵĞƚŽůŝĨƚũĂǁĂŶĚƉŽƐŝƚŝŽŶĂŝƌǁĂǇ͘ x /ĨƉĂƚŝĞŶƚŝƐƐƉŽŶƚĂŶĞŽƵƐůǇďƌĞĂƚŚŝŶŐ͕ĂƐƐŝƐƚǀĞŶƚŝůĂƚŝŽŶƐŐĞŶƚůǇ͕ďĞŝŶŐĐĂƌĞĨƵůŶŽƚƚŽĞǆĐĞĞĚƐĂĨĞ ƉƌĞƐƐƵƌĞůŝŵŝƚƐ͘ x /ĨƉĂƚŝĞŶƚŝƐŶŽƚďƌĞĂƚŚŝŶŐĂĚĞƋƵĂƚĞůǇ͕ƉƌŽǀŝĚĞǀĞŶƚŝůĂƚŝŽŶƐĐĂƌĞĨƵůůǇĂƚĂƌĂƚĞŽĨϭϬʹϭϮ ďƌĞĂƚŚƐͬŵŝŶƵƚĞ;ĨŽƌĂŶĂĚƵůƚͿ͘ x /ĨƉŽƐƐŝďůĞ͕ƵƚŝůŝǌĞĂƚǁŽͲƉƌŽǀŝĚĞƌƚĞĐŚŶŝƋƵĞƵƚŝůŝǌŝŶŐ͞ƚǁŽƚŚƵŵďƐĚŽǁŶ͟ƚĞĐŚŶŝƋƵĞƚŽŝŶĐƌĞĂƐĞŵĂƐŬ ƐĞĂů͘ x tŚĞŶƵƚŝůŝǌŝŶŐĂsD͕ƉůĂĐĞĂŝƌǁĂǇĂĚũƵŶĐƚƐ;EWͬKWͿŝĨƉĂƚŝĞŶƚĐĂŶƐĂĨĞůǇĂĐĐĞƉƚƚŚĞŵ͘ Pearls x ƵƌƌĞŶƚůǇƐƵƉƉůŝĞĚsDƐĐŽŵĞŝŶƚŚƌĞĞƐŝǌĞƐ͗ x ĚƵůƚ͕ĨŽƌƉĂƚŝĞŶƚƐхϰϬŬŐĂŶĚƉƌŽǀŝĚŝŶŐĂŵĂǆŝŵƵŵƚŝĚĂůǀŽůƵŵĞŽĨϵϱϬʹϵϲϬŵ>͘ x WĞĚŝĂƚƌŝĐ͕ĨŽƌƉĂƚŝĞŶƚƐϭϬʹϰϬŬŐĂŶĚƉƌŽǀŝĚŝŶŐĂŵĂǆŝŵƵŵƚŝĚĂůǀŽůƵŵĞŽĨϲϬϬʹϲϯϬŵ>͘ x /ŶĨĂŶƚ͕ĨŽƌƉĂƚŝĞŶƚƐdϭϬŬŐĂŶĚƉƌŽǀŝĚŝŶŐĂŵĂǆŝŵƵŵƚŝĚĂůǀŽůƵŵĞŽĨϭϱϬʹϭϳϬŵ>͘ x EŽƌŵĂůƚŝĚĂůǀŽůƵŵĞŝƐϱʹϴŵ>ͬŬŐŽĨŝĚĞĂůďŽĚǇǁĞŝŐŚƚ͕ƚŽĂŵĂǆŝŵƵŵŽĨϴʹϭϬŵ>ͬŬŐ͘ x ďŽǀĞƚŚĞƉĂƚŝĞŶƚŵĂƐŬĐŽŶŶĞĐƚŝŽŶŝƐĂƉƌĞƐƐƵƌĞŐĂƵŐĞ͖ƚŚĂƚƉƌŽǀŝĚĞƐĨĞĞĚďĂĐŬŽŶǀĞŶƚŝůĂƚŝŽŶ ĚĞůŝǀĞƌǇ͘ŝŵƚŽŬĞĞƉǀĞŶƚŝůĂƚŽƌƉƌĞƐƐƵƌĞƐŝŶƚŚĞŐƌĞĞŶĂƌĞĂ͘ x dŚĞĞǆŚĂůĂƚŝŽŶƉŽƌƚŝƐůŽĐĂƚĞĚŽƉƉŽƐŝƚĞƚŚĞďĂŐĐŽŶŶĞĐƚŝŽŶ͘dŚŝƐŝƐƚŚĞƉůĂĐĞƚŽĨŝƚƚŚĞWWǀĂůǀĞŝĨ ďĞŝŶŐƵƐĞĚ͖ƚŚŝƐŝƐĂůƐŽƚŚĞƉůĂĐĞƚŽĨŝƚƚŚĞƉƌŽǀŝĚĞĚďĂĐƚĞƌŝĂůͬǀŝƌĂůĨŝůƚĞƌƚŽƉƌŽƚĞĐƚĐůŝŶŝĐŝĂŶƐĨƌŽŵ ĞǆŚĂůĞĚƉĂƚŝĞŶƚĚƌŽƉůĞƚƐ͘

dǁŽͲdŚƵŵďƐŽǁŶƚĞĐŚŶŝƋƵĞ;ϮƉĞƌƐŽŶͿ ͲĐůĂŵƉƚĞĐŚŶŝƋƵĞ;ϭƉĞƌƐŽŶͿ

Cypress Creek EMS System Policies and Treatment Guidelines

221 PROCEDURES Revised 8/2016 Airway Approved: Levon Vartanian, MD

&ŽƌĞŝŐŶŽĚǇŝƌǁĂǇKďƐƚƌƵĐƚŝŽŶ Indications Equipment Needed Assessment Requirements WĂƌƚŝĂůŽƌĐŽŵƉůĞƚĞĂŝƌǁĂǇ sD͕KWͬEWƐ͕ĂŐĞů WƌŝŵĂƌǇƐƵƌǀĞǇ ŽďƐƚƌƵĐƚŝŽŶĚƵĞƚŽ ^ƵĐƚŝŽŶ ƐƐĞƐƐĨŽƌůĞǀĞůŽĨ <ŝŶŐ>d^Ͳ ƐĞĐƌĞƚŝŽŶƐ͕ďůŽŽĚ͕ǀŽŵŝƚƵƐ͕Žƌ ĐŽŶƐĐŝŽƵƐŶĞƐƐ ĨŽƌĞŝŐŶďŽĚǇ͘ ŝƌǁĂǇŬŝƚ

<ŝŶŐsŝƐŝŽŶůĂƌǇŶŐŽƐĐŽƉĞн '>ĂƐƐĞƐƐŵĞŶƚ DĂǇƉƌĞƐĞŶƚǁŝƚŚƐƚƌŝĚŽƌ͕ ďůĂĚĞ ŝƌǁĂǇĂƐƐĞƐƐŵĞŶƚ ĂůƚĞƌĞĚŵĞŶƚĂůƐƚĂƚƵƐ͕ ŽƵŐŝĞ ŽŶƚŝŶƵŽƵƐŵŽŶŝƚŽƌŝŶŐŽĨ͗ ĐǇĂŶŽƐŝƐ͕ĚǇƐƉŶĞĂ͕ĂŶĚͬŽƌ ^ƵƌŐŝĐĂůĐƌŝĐŽƚŚǇƌŽƚŽŵǇŬŝƚ x ^ƉKϮǁŝƚŚƐŝŶŐůĞͲƉĂƚŝĞŶƚ ĂƉŶĞĂ͘ ƵƐĞƐƚŝĐŬĞƌƐĞŶƐŽƌ͘ x dKϮ ZŝƐŬĨĂĐƚŽƌƐŝŶĐůƵĚĞƉŚǇƐŝĐĂů x ' ŽƌŵĞŶƚĂůŝŵƉĂŝƌŵĞŶƚ͕ ƐƐĞƐƐĨŽƌĂŶĚƚƌĞĂƚ ĞůĚĞƌůǇ͕ǀĞƌǇǇŽƵŶŐ͕Žƌ ƌĞǀĞƌƐŝďůĞĐĂƵƐĞƐ͘ ŝŶƚŽǆŝĐĂƚĞĚƉĂƚŝĞŶƚƐ͘ WĂƌƚŝĂůKďƐƚƌƵĐƚŝŽŶƐ x /ĨƚŚĞŽďƐƚƌƵĐƚŝŽŶŝƐƉĂƌƚŝĂůĂŶĚƚŚĞƉĂƚŝĞŶƚĐĂŶǀĞŶƚŝůĂƚĞĂŶĚŽǆǇŐĞŶĂƚĞĂĚĞƋƵĂƚĞůǇ͕ƚƌĂŶƐƉŽƌƚƚŽƚŚĞ ĨŽƌĞǀĂůƵĂƚŝŽŶĂŶĚƌĞŵŽǀĂůŽĨŽďũĞĐƚ͘,ĂǀĞĞŵĞƌŐĞŶĐǇĂŝƌǁĂǇŵĂŶĂŐĞŵĞŶƚĞƋƵŝƉŵĞŶƚƌĞĂĚǇ ĂŶĚŵŽŶŝƚŽƌ'͕dKϮ͕ĂŶĚ^ƉKϮƚŚƌŽƵŐŚŽƵƚƚƌĂŶƐƉŽƌƚ͘ ŽŵƉůĞƚĞKďƐƚƌƵĐƚŝŽŶƐ ϭ͘ /ĨƉĂƚŝĞŶƚŝƐĐŽŶƐĐŝŽƵƐ͕ƵƚŝůŝǌĞĂďĚŽŵŝŶĂůƚŚƌƵƐƚƐƚŽĂƚƚĞŵƉƚƚŽĐůĞĂƌƚŚĞŽďƐƚƌƵĐƚŝŽŶ͘hƚŝůŝǌĞĐŚĞƐƚ ƚŚƌƵƐƚƐŽŶƚŚĞŐƌĂǀŝĚŽƌŽďĞƐĞƉĂƚŝĞŶƚ͘ Ϯ͘ /ĨƉĂƚŝĞŶƚŝƐ;ŽƌďĞĐŽŵĞƐͿƵŶĐŽŶƐĐŝŽƵƐ͕ƉƌŽǀŝĚĞĂƌĂƉŝĚƐĞƌŝĞƐŽĨĐŚĞƐƚƚŚƌƵƐƚƐ͘ ϯ͘ /ĨƵŶƐƵĐĐĞƐƐĨƵů͕ƉƌŽĐĞĞĚƚŽŝŵŵĞĚŝĂƚĞĚŝƌĞĐƚŽƌǀŝĚĞŽůĂƌǇŶŐŽƐĐŽƉǇ͘ŽŶŽƚĂƚƚĞŵƉƚsD ǀĞŶƚŝůĂƚŝŽŶ͕ĂƐƚŚŝƐŵĂǇǁŽƌƐĞŶƚŚĞŽďƐƚƌƵĐƚŝŽŶ͘ ϰ͘ /ĨĂĨŽƌĞŝŐŶďŽĚǇĐĂŶďĞǀŝƐƵĂůŝǌĞĚĂďŽǀĞƚŚĞŐůŽƚƚŝƐ͕ƵƚŝůŝǌĞƐƵĐƚŝŽŶŽƌDĂŐŝůůĨŽƌĐĞƉƐƚŽƌĞŵŽǀĞƚŚĞ ĨŽƌĞŝŐŶďŽĚǇ͘ ϱ͘ ĨƚĞƌƌĞŵŽǀŝŶŐĨŽƌĞŝŐŶďŽĚǇ͕ƵƐĞůĂƌǇŶŐŽƐĐŽƉǇƚŽŝŶƐƉĞĐƚůĂƌǇŶǆĨŽƌĂŶǇƌĞŵĂŝŶŝŶŐŵĂƚĞƌŝĂů͘ ϲ͘ /ĨƉĂƚŝĞŶƚĚŽĞƐŶ͛ƚďĞŐŝŶďƌĞĂƚŚŝŶŐƐƉŽŶƚĂŶĞŽƵƐůǇ͕ŝŵŵĞĚŝĂƚĞŝŶƚƵďĂƚŝŽŶĂŶĚǀĞŶƚŝůĂƚŝŽŶŝƐŝŶĚŝĐĂƚĞĚ͘ dŚŝƐŵĂǇďĞĚŽŶĞĚƵƌŝŶŐƚŚĞƐĂŵĞůĂƌǇŶŐŽƐĐŽƉǇ͘ ϳ͘ /ĨǀĞŶƚŝůĂƚŝŽŶƌĞŵĂŝŶƐĐŽŵƉůĞƚĞůǇŽďƐƚƌƵĐƚĞĚ;ƚŽƚĂůƌĞƐŝƐƚĂŶĐĞ͕ŶŽĂŝƌŵŽǀĞŵĞŶƚǁŝƚŚsDͿĨŽůůŽǁŝŶŐ ŝŶƚƵďĂƚŝŽŶ͕ƉƌĞƐƵŵĞƚŚĞŽďƐƚƌƵĐƚŝŽŶŝƐďĞůŽǁƚŚĞŐůŽƚƚŝƐ͘WůĂĐĞďŽƵŐŝĞŝŶdƚƵďĞ͕ĚĞĨůĂƚĞĐƵĨĨ͕ĂŶĚ ĂĚǀĂŶĐĞƚƵďĞĨƵůůǇƚŽĂƚƚĞŵƉƚƚŽƉƵƐŚƚƌĂĐŚĞĂůĨŽƌĞŝŐŶďŽĚǇŝŶƚŽĂŵĂŝŶƐƚĞŵďƌŽŶĐŚƵƐ͘tŝƚŚĚƌĂǁ ƚƵďĞƚŽŶŽƌŵĂůůĞǀĞů͕ƌĞŝŶĨůĂƚĞĐƵĨĨ͕ĂŶĚĂƚƚĞŵƉƚǀĞŶƚŝůĂƚŝŽŶĂŐĂŝŶ͘ ϴ͘ /ĨǀĞŶƚŝůĂƚŝŽŶƌĞŵĂŝŶƐĐŽŵƉůĞƚĞůǇŽďƐƚƌƵĐƚĞĚ͕ƉƌĞƐƵŵĞƚŚĂƚƚŚĞƉĂƚŝĞŶƚŚĂƐĂƚĞŶƐŝŽŶƉŶĞƵŵŽƚŚŽƌĂǆ ŝŶĂĚĚŝƚŝŽŶƚŽĂŵĂŝŶƐƚĞŵŽďƐƚƌƵĐƚŝŽŶĂŶĚƉĞƌĨŽƌŵďŝůĂƚĞƌĂůneedle decompression͘

Cypress Creek EMS System Policies and Treatment Guidelines

222 PROCEDURES Revised 8/2016 Airway Approved: Levon Vartanian, MD

ϵ͘ KŶĐĞdƚƵďĞŝƐŝŶƉůĂĐĞĂŶĚǀĞŶƚŝůĂƚŝŽŶŝƐƵŶŽďƐƚƌƵĐƚĞĚ͕ƉƌŽǀŝĚĞĂƉƉƌŽƉƌŝĂƚĞpost-intubation managementŝŶĐůƵĚŝŶŐƐĞĚĂƚŝŽŶ͕ŝĨŶĞĐĞƐƐĂƌǇ͘ ϭϬ͘ /ĨŽďƐƚƌƵĐƚŝŽŶŝƐĂƚŽƌĂďŽǀĞƚŚĞǀŽĐĂůĐŽƌĚƐĂŶĚĐĂŶŶŽƚďĞƌĞŵŽǀĞĚƌĞĂĚŝůǇ͕ƉƌŽĐĞĞĚƚŽĂƐƵƌŐŝĐĂů ĂŝƌǁĂǇ͘ WĞĂƌůƐ x DŽƐƚƵƉƉĞƌĂŝƌǁĂǇŽďƐƚƌƵĐƚŝŽŶƐĂƌĞŶŽƚůŝĨĞͲƚŚƌĞĂƚĞŶŝŶŐĂŶĚĂƌĞĐůĞĂƌĞĚƌĞĂĚŝůǇƵƐŝŶŐ>^ ŵĂŶĞƵǀĞƌƐ͘ x ĂƌĞƐŚŽƵůĚďĞƚĂŬĞŶƚŽŶŽƚǁŽƌƐĞŶŽďƐƚƌƵĐƚŝŽŶƚŚƌŽƵŐŚŵĂŶĞƵǀĞƌƐ͘ x hŶůŝŬĞŽƚŚĞƌĂŝƌǁĂǇŵĂŶĂŐĞŵĞŶƚ͕ĐŽŵƉůĞƚĞĂŝƌǁĂǇŽďƐƚƌƵĐƚŝŽŶƐƌĞƋƵŝƌĞƌĂƉŝĚ͕ƚŝŵĞůǇƚƌĞĂƚŵĞŶƚ͘ dŚĞŵŽƐƚĞǆƉĞƌŝĞŶĐĞĚƉƌŽǀŝĚĞƌŽŶƐĐĞŶĞƐŚŽƵůĚŝŵŵĞĚŝĂƚĞůǇĂŶĚƌĂƉŝĚůǇĂƚƚĞŵƉƚƚŽĐůĞĂƌ ŽďƐƚƌƵĐƚŝŽŶ͘ x /ĨĂŝƌǁĂǇŝƐĐŽŵƉůĞƚĞůǇŽďƐƚƌƵĐƚĞĚĂŶĚŝŶŝƚŝĂůĂƚƚĞŵƉƚƐƚŽĐůĞĂƌŽďƐƚƌƵĐƚŝŽŶĂƌĞƵŶƐƵĐĐĞƐƐĨƵů͕ƌĂƉŝĚůǇ ƉƌŽŐƌĞƐƐƚŽĂƐƵƌŐŝĐĂůĂŝƌǁĂǇƚŽƉƌŽǀŝĚĞǀĞŶƚŝůĂƚŝŽŶĂŶĚŽǆǇŐĞŶĂƚŝŽŶƚŽƚŚĞƉĂƚŝĞŶƚ͘

Cypress Creek EMS System Policies and Treatment Guidelines

223 PROCEDURE Revised 8/2016 Airway/Breathing Approved: Levon Vartanian, MD

WW Indications Equipment Needed Assessment Requirements WĂƚŝĞŶƚƐǁŚŽƌĞŵĂŝŶŚǇƉŽǆĞŵŝĐ sD DŽŶŝƚŽƌ^ƉKϮ͕dKϮ͕ĂŶĚ ĂĨƚĞƌƉƌŽǀŝƐŝŽŶŽĨϭϬϬйŽǆǇŐĞŶ WWsĂůǀĞĨŽƌsD '͘ ĂŶĚĂƐƐŝƐƚĞĚǀĞŶƚŝůĂƚŝŽŶƐ͘ Or &ƌĞƋƵĞŶƚůǇƌĞĂƐƐĞƐƐE/W͘ WĂƌĂWĂĐǀĞŶƚŝůĂƚŽƌǀĞŶƚŝůĂƚŽƌ Contraindications: ĐŝƌĐƵŝƚ DŽŶŝƚŽƌǀĞŶƚŝůĂƚŽƌƉƌĞƐƐƵƌĞƐ x ^ǇƐƚŽůŝĐWфϵϬŵŵ,Ő WĂƌĂWĂĐWWǀĂůǀĞ ĂŶĚůƵŶŐĐŽŵƉůŝĂŶĐĞ͘ x >ŽǁĐĂƌĚŝĂĐŽƵƚƉƵƚƐƚĂƚĞƐ WƌŽĐĞĚƵƌĞ ϭ͘ WůĂĐĞƚŚĞWWǀĂůǀĞŽŶƚŚĞĞǆŚĂƵƐƚƉŽƌƚŽĨƚŚĞsD;ŽƌƚŚĞĞǆŚĂƵƐƚƉŽƌƚŽĨƚŚĞWĂƌĂWĂĐǀĞŶƚŝůĂƚŽƌ ĐŝƌĐƵŝƚͿ͘ Ϯ͘ ^ĞƚŝŶŝƚŝĂůWWďĂƐĞĚŽŶĐĂƚĞŐŽƌǇŽĨƌĞƐƉŝƌĂƚŽƌǇƉƌŽďůĞŵ͘ ϯ͘ /ŶĐƌĞĂƐĞWWƚŽĂĐŚŝĞǀĞ^ƉKϮшϵϰй͘ŽŶŽƚĞǆĐĞĞĚŵĂǆŝŵƵŵǀĂůƵĞƐĨŽƌƚŚĞŝƌƌĞƐƉŝƌĂƚŽƌǇĐĂƚĞŐŽƌǇ͘ ϰ͘ /ĨWŝƐƐŝŐŶŝĨŝĐĂŶƚůǇĚĞĐƌĞĂƐĞĚďǇWW͕ĚĞĐƌĞĂƐĞĂŵŽƵŶƚŽƌĚŝƐĐŽŶƚŝŶƵĞ͘

For bronchoconstriction (COPD/Asthma): ^ĞƚŝŶŝƚŝĂůǀĂůƵĞƚŽϱĐŵ,ϮKĂŶĚĚŽŶŽƚĞǆĐĞĞĚϳ͘ϱĐŵ,ϮK͘

To shift fluid (sepsis/pulmonary edema/CHF): ^ĞƚŝŶŝƚŝĂůǀĂůƵĞϳ͘ϱĐŵ,ϮKĂŶĚĚŽŶŽƚĞǆĐĞĞĚϭϬĐŵ,ϮK͘ WĞĂƌůƐ x WWŝŵƉƌŽǀĞƐŽǆǇŐĞŶĂƚŝŽŶŝŶƉĂƚŝĞŶƚƐǁŝƚŚƉƵůŵŽŶĂƌǇĞĚĞŵĂŽƌŽƚŚĞƌĨůƵŝĚƐŝŶƚŚĞůƵŶŐƐ;ƐƵĐŚĂƐ ƉŶĞƵŵŽŶŝĂͿĂŶĚƌĞĚƵĐĞƐĂƚĞůĞĐƚĂƐŝƐ͕ǁŚŝĐŚŝƐĐŽŵŵŽŶŝŶƉĂƚŝĞŶƚƐǁŝƚŚĂƐƐŝƐƚĞĚǀĞŶƚŝůĂƚŝŽŶƐ͘ x /ĨƚƌĂŶƐƉŽƌƚŝŶŐĂƉĂƚŝĞŶƚĨƌŽŵŽŶĞŵĞĚŝĐĂůĨĂĐŝůŝƚǇƚŽĂŶŽƚŚĞƌ;ĨŽƌŝŶƐƚĂŶĐĞ͕ĂŶŽƵƚƉĂƚŝĞŶƚƐƵƌŐĞƌǇ ĐĞŶƚĞƌƚŽĂŚŽƐƉŝƚĂůͿĂŶĚWWŚĂƐĂůƌĞĂĚǇďĞĞŶĞƐƚĂďůŝƐŚĞĚĂŶĚƚŚĞƉĂƚŝĞŶƚŝƐƚŽůĞƌĂƚŝŶŐŝƚ͕ĐŽŶƚŝŶƵĞ ĂƚƚŚĞƉƌĞǀŝŽƵƐůǇĞƐƚĂďůŝƐŚĞĚůĞǀĞů͘/ĨWWŚĂƐŶŽƚďĞĞŶĞƐƚĂďůŝƐŚĞĚĂŶĚƚŚĞƚƌĂŶƐĨĞƌƌŝŶŐƉŚǇƐŝĐŝĂŶ ƌĞƋƵĞƐƚƐƚŚĂƚŝƚďĞĞƐƚĂďůŝƐŚĞĚĂƚĂƉĂƌƚŝĐƵůĂƌůĞǀĞůŶŽƚĨŽůůŽǁŝŶŐƚŚĞĂďŽǀĞŐƵŝĚĞůŝŶĞƐ͕ƚŚĞƉŚǇƐŝĐŝĂŶ ƐŚŽƵůĚĂĐĐŽŵƉĂŶǇƚŚĞƉĂƚŝĞŶƚƚŽƚŚĞƌĞĐĞŝǀŝŶŐĨĂĐŝůŝƚǇ͘ x WWĚĞĐƌĞĂƐĞƐƉƌĞůŽĂĚĂŶĚŝŶƉĂƚŝĞŶƚƐǁŚŽĂƌĞǀŽůƵŵĞĚĞƉůĞƚĞĚ͕ŚǇƉŽƚĞŶƐŝǀĞ͕ŽƌĞǆƉĞƌŝĞŶĐŝŶŐ ŚĞĂƌƚĨĂŝůƵƌĞ͕WWĐĂŶŚĂǀĞĚƌĂƐƚŝĐŶĞŐĂƚŝǀĞĞĨĨĞĐƚƐŽŶƚŚĞƉĂƚŝĞŶƚ͛ƐŚĞŵŽĚǇŶĂŵŝĐƐ͘

Cypress Creek EMS System Policies and Treatment Guidelines

224 PROCEDURES Revised 8/2016 Airway Approved: Levon Vartanian, MD

KƌŽƚƌĂĐŚĞĂů/ŶƚƵďĂƚŝŽŶ Indications Equipment Needed Assessment Requirements dŽƉƌŽƚĞĐƚƚŚĞĂŝƌǁĂǇĂŶĚ sD͕KWͬEWƐ͕ĂŐĞů WƌŝŵĂƌǇƐƵƌǀĞǇ ŽǆǇŐĞŶĂƚĞͬǀĞŶƚŝůĂƚĞŝŶĂƉĂƚŝĞŶƚ ^ƵĐƚŝŽŶ ƐƐĞƐƐĨŽƌůĞǀĞůŽĨ ǁŚŽŝƐƵŶĐŽŶƐĐŝŽƵƐĂŶĚͬŽƌŚĂƐ <ŝŶŐ>d^Ͳ ĐŽŶƐĐŝŽƵƐŶĞƐƐ ŶŽŐĂŐƌĞĨůĞǆ͘ ŝƌǁĂǇŬŝƚ ŽƵŐŝĞ '>ĂƐƐĞƐƐŵĞŶƚ <ŝŶŐsŝƐŝŽŶs>ǁŝƚŚĐŚĂŶŶĞůĞĚ ŝƌǁĂǇĂƐƐĞƐƐŵĞŶƚ ŽƌƵŶĐŚĂŶŶĞůĞĚďůĂĚĞ ŽŶƚŝŶƵŽƵƐŵŽŶŝƚŽƌŝŶŐŽĨ͗ x ^ƉKϮǁŝƚŚƐŝŶŐůĞͲƉĂƚŝĞŶƚƵƐĞ ƐƚŝĐŬĞƌƐĞŶƐŽƌ͘ x dKϮ x ' ƐƐĞƐƐĨŽƌĂŶĚƚƌĞĂƚƌĞǀĞƌƐŝďůĞ ĐĂƵƐĞƐ͘ Procedure ϭ͘ sĞŶƚŝůĂƚĞǁŝƚŚϭϬϬйŽǆǇŐĞŶ͘ Ϯ͘ ^ĞůĞĐƚĂŶĂƉƉƌŽƉƌŝĂƚĞƐŝǌĞĚdƚƵďĞ͘>ƵďƌŝĐĂƚĞĐƵĨĨĂŶĚĚŝƐƚĂůĞŶĚŽĨĐƵĨĨ͘ZĞŵŽǀĞƐƚǇůĞƚŝĨƵƐŝŶŐ ǀŝĚĞŽůĂƌǇŶŐŽƐĐŽƉǇŽƌĂďŽƵŐŝĞ͘ ϯ͘ sŝƐƵĂůŝǌĞƚŚĞǀŽĐĂůĐŽƌĚƐƵƐŝŶŐĚŝƌĞĐƚŽƌǀŝĚĞŽůĂƌǇŶŐŽƐĐŽƉǇ͘ ϰ͘ /ĨƵƐŝŶŐĂďŽƵŐŝĞ͕ƉĂƐƐƚŚƌŽƵŐŚǀŽĐĂůĐŽƌĚƐ͘zŽƵƐŚŽƵůĚĨĞĞůƚŚĞ͞ĐůŝĐŬ͟ŽĨƚŚĞĐŽƵĚĞƚŝƉĂŐĂŝŶƐƚƚŚĞ ƚƌĂĐŚĞĂůƌŝŶŐƐ͘ ϱ͘ WĂƐƐƚŚĞdƚƵďĞƚŚƌŽƵŐŚƚŚĞǀŽĐĂůĐŽƌĚƐ͘/ŶƐĞƌƚƵŶƚŝůďůĂĐŬƌĞĨĞƌĞŶĐĞůŝŶĞŚĂƐũƵƐƚƉĂƐƐĞĚĐŽƌĚƐ͘ ϲ͘ /ŶĨůĂƚĞĐƵĨĨ͕ŶŽƚĞƚƵďĞĚĞƉƚŚ͕ĂŶĚĐŽŶĨŝƌŵƉůĂĐĞŵĞŶƚƵƐŝŶŐďƌĞĂƚŚƐŽƵŶĚƐĂŶĚdKϮǁĂǀĞĨŽƌŵ͘ ϳ͘ ^ĞĐƵƌĞƚƵďĞŝŶƉůĂĐĞĂŶĚƌĞĐŚĞĐŬƉůĂĐĞŵĞŶƚĨƌĞƋƵĞŶƚůǇ͘ Pearls x hƚŝůŝǌĞƚŚĞůĂƌŐĞƐƚƚƵďĞƐŝǌĞƚŚĂƚǁŝůůĂƉƉƌŽƉƌŝĂƚĞůǇĨŝƚƚŚĞƉĂƚŝĞŶƚ͘^ŵĂůůĞƌƚƵďĞƐŝǌĞƐĂƌĞĂƐƐŽĐŝĂƚĞĚ ǁŝƚŚůŽŶŐĞƌĚƵƌĂƚŝŽŶŽŶĂǀĞŶƚŝůĂƚŽƌĂŶĚŵŽƌĞĐŽŵƉůŝĐĂƚŝŽŶƐŝŶǁĞĂŶŝŶŐƉĂƚŝĞŶƚŽĨĨŽĨƚŚĞǀĞŶƚŝůĂƚŽƌ͘

Cypress Creek EMS System Policies and Treatment Guidelines

225 PROCEDURE Revised 8/2016 Airway/Breathing Approved: Levon Vartanian, MD

WW Indications Equipment Needed Assessment Requirements DŽĚĞƌĂƚĞŽƌƐĞǀĞƌĞƌĞƐƉŝƌĂƚŽƌǇĚŝƐƚƌĞƐƐƌĞůĂƚĞĚƚŽ WWŵĂƐŬƐŝǌĞĚ ^ƉKϮ͕dKϮ͕ ƉƵůŵŽŶĂƌǇĞĚĞŵĂ͕ďƌŽŶĐŚŽĐŽŶƐƚƌŝĐƚŝŽŶ͕Žƌ ĨŽƌƉĂƚŝĞŶƚ ZZ͕'͕ ĂƚĞůĞĐƚĂƐŝƐ͖ ĨƌĞƋƵĞŶƚůǇ ZĞƐƉŝƌĂƚŽƌǇĨĂŝůƵƌĞĂŶĚŵƵƐĐƵůĂƌĨĂƚŝŐƵĞ͖ ƌĞĂƐƐĞƐƐW͕ WŽŽƌƌĞƐƉŽŶƐĞƚŽŵĞĚŝĐĂůƚƌĞĂƚŵĞŶƚĨŽƌƌĞƐƉŝƌĂƚŽƌǇ ůĞǀĞůŽĨ ĚŝƐƚƌĞƐƐ͖ ĐŽŶƐĐŝŽƵƐŶĞƐƐ /ŶĐƌĞĂƐĞĚdKϮĂŶĚͬŽƌĚĞĐƌĞĂƐĞĚ^ƉKϮ;фϵϮйͿ͖ hƐĞŽĨĂĐĐĞƐƐŽƌǇƌĞƐƉŝƌĂƚŽƌǇŵƵƐĐůĞƐ͖ ůŽŶŐǁŝƚŚĂďŝůŝƚǇƚŽƚŽůĞƌĂƚĞĨĂĐĞŵĂƐŬĂŶĚŶŽƚ ŶĞĞĚŝŶŐŝŵŵĞĚŝĂƚĞŝŶƚƵďĂƚŝŽŶ;ƌĂƐŚĂŝƌǁĂǇͿ͘

Contraindications:

x KďǀŝŽƵƐƌĞƐƉŝƌĂƚŽƌǇĨĂŝůƵƌĞƚŚĂƚƌĞƋƵŝƌĞƐŝŵŵĞĚŝĂƚĞŝŶƚƵďĂƚŝŽŶ͖ x ĞĐƌĞĂƐĞĚůĞǀĞůŽĨĐŽŶƐĐŝŽƵƐŶĞƐƐƚŚĂƚĐĂŶŶŽƚĐŽŽƉĞƌĂƚĞǁŝƚŚŽƌƚŽůĞƌĂƚĞWW͖ x ĂƌĚŝĂĐŽƌƌĞƐƉŝƌĂƚŽƌǇĂƌƌĞƐƚ͖ x DĂũŽƌƚƌĂƵŵĂ͕ĞƐƉĞĐŝĂůůǇĨĂĐŝĂůŽƌŚĞĂĚŝŶũƵƌǇĂŶĚͬŽƌǁŝƚŚƐŝŐŶƐŽĨŝŶĐƌĞĂƐĞĚ/W͖ x /ŶĂďŝůŝƚǇƚŽŵĂŝŶƚĂŝŶƉĂƚĞŶƚĂŝƌǁĂǇ͖ x WĞŶĞƚƌĂƚŝŶŐĐŚĞƐƚƚƌĂƵŵĂ͖ x WƌĞƐĞŶĐĞŽƌƐƵƐƉŝĐŝŽŶŽĨƉŶĞƵŵŽƚŚŽƌĂǆ͖ x sŽŵŝƚŝŶŐŽƌĂĐƚŝǀĞƵƉƉĞƌ'/ďůĞĞĚŝŶŐ x KďǀŝŽƵƐƐŝŐŶƐĂŶĚͬŽƌƐǇŵƉƚŽŵƐŽĨŝŶĨĞĐƚŝŽŶĂŶĚͬŽƌƐĞƉƐŝƐ;Ğ͘Ő͘ƉŶĞƵŵŽŶŝĂͿ x 'ĂƐƚƌŝĐĚŝƐƚĞŶƚŝŽŶ x ĐƵƚĞĂďĚŽŵŝŶĂůƉƌŽĐĞƐƐĞƐ͕ƌĞĐĞŶƚ'/ŽƌĞƐŽƉŚĂŐĞĂůƐƵƌŐĞƌǇ͕ƌĞĐĞŶƚĨĂĐŝĂůŽƌEdƐƵƌŐĞƌǇ͕ ĨĂĐŝĂůĚĞĨŽƌŵŝƚŝĞƐŽƌƚƌĂƵŵĂ͘ x Patients less than 8 years of age WƌŽĐĞĚƵƌĞ ϭ͘ ^ĞƚWWǀĂůǀĞƚŽϳ͘ϱĐŵ,ϮK Ϯ͘ ŽŶŶĞĐƚKŚŝŽǀĂůǀĞƚŽĂƉƉƌŽƉƌŝĂƚĞŽǆǇŐĞŶƐŽƵƌĐĞ͘ ϯ͘ ŶƐƵƌĞƚŚĞŽǆǇŐĞŶƐŽƵƌĐĞŝƐƚƵƌŶĞĚŽŶĂŶĚƉŽƐŝƚŝŽŶƚŚĞŵĂƐŬŽŶƚŚĞƉĂƚŝĞŶƚĂŶĚĂĚũƵƐƚŚĞĂĚƐƚƌĂƉƐ ĨŽƌƐĞĂůĂŶĚĐŽŵĨŽƌƚ͘;^ĞĞĐůŝŶŝĐĂůWZ>^ďĞůŽǁ͘Ϳ ϰ͘ /ƚŝƐŝŵƉĞƌĂƚŝǀĞƚŽĂĐŚŝĞǀĞĂŵĂƐŬƚŽĨĂĐĞƐĞĂůĨŽƌƉƌŽƉĞƌŽƉĞƌĂƚŝŽŶ͘

ϱ͘ tŚĞŶƉƌŽƉĞƌůǇĐŽŶŶĞĐƚĞĚƚŚĞWWŐĞŶĞƌĂƚŽƌǁŝůůĚĞůŝǀĞƌĂŶ&iKϮŽĨϬ͘ϯϬ;ϯϬйͿ͘

ϲ͘ ŚŝŐŚĞƌƉƌĞƐƐƵƌĞƐĞƚƚŝŶŐŽĨϭϬĐŵ,ϮKŵĂǇďĞƵƐĞĚŝĨƚŚĞƉƌŝŵĂƌǇWWǀĂůǀĞƐĞƚƚŝŶŐĂƚϳ͘ϱĐŵ,ϮK ĚŽĞƐŶŽƚƉƌŽǀŝĚĞĨŽƌĂĚĞƋƵĂƚĞƉĂƚŝĞŶƚŝŵƉƌŽǀĞŵĞŶƚ͘

Cypress Creek EMS System Policies and Treatment Guidelines

226 PROCEDURE Revised 8/2016 Airway/Breathing Approved: Levon Vartanian, MD

ϳ͘ &ĂŝůƵƌĞŽĨƚŚĞƉĂƚŝĞŶƚƚŽŝŵƉƌŽǀĞǁŝƚŚWWƚŚĞƌĂƉǇŵĂǇďĞĞǀŝĚĞŶĐĞĚďǇ͗ x ĞĐƌĞĂƐŝŶŐůĞǀĞůŽĨĐŽŶƐĐŝŽƵƐŶĞƐƐ x /ŶĐƌĞĂƐŝŶŐǁŽƌŬŽĨďƌĞĂƚŚŝŶŐ x /ŶĐƌĞĂƐŝŶŐŚĞĂƌƚƌĂƚĞ;ďƌĂĚǇĐĂƌĚŝĂŝŶůĂƚĞƐƚĂŐĞƐͿ x /ŶĐƌĞĂƐŝŶŐƌĞƐƉŝƌĂƚŽƌǇƌĂƚĞ x /ŶĐƌĞĂƐŝŶŐďůŽŽĚƉƌĞƐƐƵƌĞ;ŚǇƉŽƚĞŶƐŝŽŶŝŶůĂƚĞƐƚĂŐĞƐͿ x ĞĐƌĞĂƐŝŶŐ^ƉKϮ x /ŶĐƌĞĂƐŝŶŐKϮ 8. Consider endotracheal intubation for the patients that do not respond within 5 minutes of beginning CPAP therapy. 9. In-line nebulization may be used with the CPAP Pulmodyne circuit to administer bronchodilators during CPAP use. ŝƐĐŽŶƚŝŶƵĂƚŝŽŶƌŝƚĞƌŝĂ ŝƐĐŽŶƚŝŶƵĞWWŝĨƚŚĞƉĂƚŝĞŶƚĞǆŚŝďŝƚƐƚŚĞĨŽůůŽǁŝŶŐƐǇŵƉƚŽŵƐ͗ ͻ ĞƚĞƌŝŽƌĂƚŝŶŐŵĞŶƚĂůƐƚĂƚƵƐ͕ďĞĐŽŵĞƐůĞƚŚĂƌŐŝĐǁŝƚŚǁŽƌƐĞŶŝŶŐŚǇƉĞƌĐĂƉŶŝĂŽƌĂŐŝƚĂƚĞĚǁŝƚŚ ŚǇƉŽǆĞŵŝĂ͖ ͻ /ŶĂďŝůŝƚǇƚŽƚŽůĞƌĂƚĞŵĂƐŬĚƵĞƚŽƉĂŝŶŽƌĚŝƐĐŽŵĨŽƌƚ͖ ͻ /ŶĂďŝůŝƚǇƚŽŝŵƉƌŽǀĞƌĞƐƉŝƌĂƚŽƌǇĨƵŶĐƚŝŽŶ͖ ͻ ,ĞŵŽĚǇŶĂŵŝĐŝŶƐƚĂďŝůŝƚǇ͖ ͻ ůĞĐƚƌŝĐŝŶƐƚĂďŝůŝƚǇ;ǁŝƚŚŝƐĐŚĞŵŝĂŽƌŵĂůŝŐŶĂŶƚǀĞŶƚƌŝĐƵůĂƌĂƌƌŚǇƚŚŵŝĂͿ͖ĂŶĚͬŽƌ ͻ ^ƵƐƉŝĐŝŽŶŽĨƉŶĞƵŵŽƚŚŽƌĂǆ͘ EŽƚĞ͗dŚĞƉĂƚŝĞŶƚŵĂǇĂůƐŽƌĞƋƵĞƐƚĚŝƐĐŽŶƚŝŶƵĂƚŝŽŶ͘ WĞĂƌůƐ WWŵĂǇďĞƵƚŝůŝǌĞĚĨŽƌŝŵƉĞŶĚŝŶŐƌĞƐƉŝƌĂƚŽƌǇĨĂŝůƵƌĞĚƵĞƚŽǀĂƌŝŽƵƐĐŽŶĚŝƚŝŽŶƐƐƵĐŚĂƐƉƵůŵŽŶĂƌǇĞĚĞŵĂͬŚĞĂƌƚ ĨĂŝůƵƌĞ͕KW͕ĂƐƚŚŵĂ͕ŶĞĂƌĚƌŽǁŶŝŶŐ͕ƐŵŽŬĞͬƚŽǆŝŶŝŶŚĂůĂƚŝŽŶǁŝƚŚĂĐƵƚĞďƌŽŶĐŚŽƐƉĂƐŵ͕ŽƌŽƚŚĞƌƌĞƐƉŝƌĂƚŽƌǇ ĐŽŶĚŝƚŝŽŶƐǁŚĞƌĞǀĞŶƚŝůĂƚŝŽŶĂŶĚͬŽƌŐĂƐĞǆĐŚĂŶŐĞŝƐŝŵƉĂŝƌĞĚ͘WWŵĂǇŝŵƉƌŽǀĞƚŚĞƐĞĐŽŶĚŝƚŝŽŶƐƚŚƌŽƵŐŚƚŚĞ ĨŽůůŽǁŝŶŐƉƌŝŶĐŝƉůĞƐ͗ x ZĞĚƵĐƚŝŽŶŽĨŝŶƐƉŝƌĂƚŽƌǇŵƵƐĐůĞƌĞĐƌƵŝƚŵĞŶƚĂŶĚ͕ƚŚĞƌĞĨŽƌĞ͕ĂǀŽŝĚĂŶĐĞŽĨŵƵƐĐƵůĂƌĨĂƚŝŐƵĞ͘dŚŝƐ ĞĨĨĞĐƚĐĂŶďĞŽďƐĞƌǀĞĚŝŶĂƐůŽǁŝŶŐŽĨƌĞƐƉŝƌĂƚŽƌǇƌĂƚĞĂŶĚĂŶŝŶĐƌĞĂƐĞŝŶƚŝĚĂůǀŽůƵŵĞ͘WWƐŚŽƵůĚ ĐŽƵŶƚĞƌĂĐƚƚŚĞĞĨĨĞĐƚƐŽĨŝŶƚƌŝŶƐŝĐWW͘ x ĂƌůǇŝŵƉƌŽǀĞŵĞŶƚŽĨŐĂƐĞǆĐŚĂŶŐĞ͘dŚŝƐŝƐĚƵĞƚŽĂŶŝŶĐƌĞĂƐĞŝŶǀĞŶƚŝůĂƚŝŽŶĂŶĚƚŽĂŐƌĞĂƚĞƌ ƚŽůĞƌĂŶĐĞƚŽŚŝŐŚĞƌŽǆǇŐĞŶĐŽŶĐĞŶƚƌĂƚŝŽŶƐ;ǁŝƚŚŽƵƚŚǇƉŽǀĞŶƚŝůĂƚŝŽŶͿ͘dŚĞƐŚƵŶƚĞĨĨĞĐƚĂŶĚƚŚĞ ǀĞŶƚŝůĂƚŝŽŶͲƉĞƌĨƵƐŝŽŶŵŝƐŵĂƚĐŚƐĞĐŽŶĚĂƌǇƚŽWWĂůƐŽĚĞĐƌĞĂƐĞ͘ x ,ĞŵŽĚǇŶĂŵŝĐĞĨĨĞĐƚƐ͘dŚĞƐĞŵĂǇďĞďĞŶĞĨŝĐŝĂůŽƌŚĂƌŵĨƵů͘/ŶƉĂƚŝĞŶƚƐǁŝƚŚĨůƵŝĚŽǀĞƌůŽĂĚĂŶĚĂ ĚĞĐƌĞĂƐĞŝŶƐǇƐƚŽůŝĐĨƵŶĐƚŝŽŶƉĞƌĨŽƌŵĂŶĐĞ͕ĂŶŝŶĐƌĞĂƐĞŝŶŝŶƚƌĂƚŚŽƌĂĐŝĐƉƌĞƐƐƵƌĞĐĂƵƐĞĚďǇWW ƉƌŽĚƵĐĞƐĂĚĞĐƌĞĂƐĞŝŶƌŝŐŚƚǀĞŶƚƌŝĐƵůĂƌƉƌĞůŽĂĚĂŶĚĂĨƚĞƌůŽĂĚ͘dŽĂǀŽŝĚƚŚŝƐĂĚǀĞƌƐĞĞĨĨĞĐƚ͕ĂǀŽŝĚ ĂƉƉůŝĐĂƚŝŽŶŽĨWWƚŽƉĂƚŝĞŶƚƐǁŝƚŚĂƐǇƐƚŽůŝĐƉƌĞƐƐƵƌĞďĞůŽǁϭϬϱŵŵ,Ő͘/ĨŚǇƉŽƚĞŶƐŝŽŶŽĐĐƵƌƐ͕ ĞŝƚŚĞƌĚŝƐĐŽŶƚŝŶƵĞWWŽƌƵƐĞĂůŽǁĞƌƉƌĞƐƐƵƌĞ͘

Cypress Creek EMS System Policies and Treatment Guidelines

227 PROCEDURE Revised 8/2016 Airway/Breathing Approved: Levon Vartanian, MD

x WWůĞǀĞůƐŽĨϳ͘ϱĐŵ,ϮKĂŶĚďĞůŽǁĂƌĞƵƐĞĚĨŽƌďƌŽŶĐŚŽĚŝůĂƚŝŽŶ͕ƐĞƚƚŝŶŐƐŐƌĞĂƚĞƌƚŚĂŶϳ͘ϱĐŵ,ϮK ĂƌĞƵƐĞĚƚŽĚŝƐƉůĂĐĞĂůǀĞŽůĂƌĨůƵŝĚ͘ x tŚĞŶďĞŐŝŶŶŝŶŐƚŚŝƐƉƌŽĐĞĚƵƌĞĂƉƉƌŽĂĐŚƚŚĞƉĂƚŝĞŶƚǁŝƚŚƚŚĞŵĂƐŬƐůŽǁůǇĂŶĚŚŽůĚŝƚĂĨĞǁ ĐĞŶƚŝŵĞƚĞƌƐĂǁĂǇĨƌŽŵƚŚĞŝƌĨĂĐĞƉƌŝŽƌƚŽĂƉƉůŝĐĂƚŝŽŶĂŶĚƐĞĐƵƌŝŶŐƚŚĞŚĞĂĚƐƚƌĂƉƐ͘dŚŝƐǁŝůůĂůůŽǁ ƚŚĞƉĂƚŝĞŶƚƚŽďĞĐŽŵĞĂĐĐƵƐƚŽŵĞĚƚŽƚŚĞŵĂƐŬ͘ x WƌŽǀŝĚŝŶŐĞŵŽƚŝŽŶĂůƐƵƉƉŽƌƚŝƐŶĞĐĞƐƐĂƌǇĂŶĚƐŚŽƵůĚďĞŽĨĨĞƌĞĚǁŝƚŚĂŶĞǆƉůĂŶĂƚŝŽŶŽĨƚŚŝƐ ƉƌŽĐĞĚƵƌĞǁŚĞŶďĞŐŝŶŶŝŶŐƚƌĞĂƚŵĞŶƚ͕ĂŶĚƵŶƚŝůƚŚĞƉĂƚŝĞŶƚĐĂŶƚŽůĞƌĂƚĞƚŚĞŵĂƐŬĂŶĚƚŚĞ ŝŶƐƉŝƌĂƚŽƌǇƉƌĞƐƐƵƌĞƐŝŶǀŽůǀĞĚ͘

x ŽŶŽƚĞǆĐĞĞĚϭϬĐŵ,ϮKǁŚĞŶĂĚŵŝŶŝƐƚĞƌŝŶŐWW͘ x Complications of CPAP may include: x ďĚŽŵŝŶĂůĚŝƐƚĞŶƚŝŽŶ x ĂƌŽƚƌĂƵŵĂƐ x ,ǇƉŽƚĞŶƐŝŽŶ x ^ĞĐƌĞƚŝŽŶƌĞƚĞŶƚŝŽŶ x &ĂĐŝĂůŶĞĐƌŽƐŝƐĐĂƵƐĞĚďǇƉƌĞƐƐƵƌĞĂŶĚͬŽƌŝŶĐƌĞĂƐŝŶŐĨĂƚŝŐƵĞĂŶĚƌĞƐƉŝƌĂƚŽƌǇĨĂŝůƵƌĞ͘

Cypress Creek EMS System Policies and Treatment Guidelines

228 PROCEDURE Revised 6/2019 Airway Approved: Levon Vartanian, MD ŝͲŐĞů^ƵƉƌĂŐůŽƚƚŝĐŝƌǁĂǇ Indications Equipment Needed Assessment Requirements ŝƌǁĂǇƉƌŽƚĞĐƚŝŽŶͬǀĞŶƚŝůĂƚŝŽŶŝŶ sD dKϮ ƚŚĞƵŶĐŽŶƐĐŝŽƵƐƉĂƚŝĞŶƚŽƌ ŝͲŐĞů^ƵƉƌĂŐůŽƚƚŝĐŝƌǁĂǇ ƉĂƚŝĞŶƚǁŝƚŚŶŽŐĂŐƌĞĨůĞǆ ƉƌĞƉĂĐŬĂŐĞĚŬŝƚǁŝƚŚƚƵďĞĂŶĚ /ŶŝƚŝĂůĂŝƌǁĂǇŝŶĐĂƌĚŝĂĐĂƌƌĞƐƚ ůƵďĞ ZĞƐĐƵĞĂŝƌǁĂǇ;ĨĂŝůĞĚ ŝŶƚƵďĂƚŝŽŶͿ

WƌŽĐĞĚƵƌĞ ϭ͘ WƌĞƉĂƌĞĂůůĞƋƵŝƉŵĞŶƚ͗^ĞůĞĐƚĂƉƉƌŽƉƌŝĂƚĞŝͲŐĞůƚƵďĞĨŽƌƉĂƚŝĞŶƚƐŝǌĞĂŶĚůƵďƌŝĐĂƚĞƚŚĞďĂĐŬ͕ƐŝĚĞƐ ĂŶĚĨƌŽŶƚŽĨĐƵĨĨǁŝƚŚĂƚŚŝŶůĂǇĞƌŽĨůƵďƌŝĐĂŶƚ͘;ŽŶĨŝƌŵƚŚĞƌĞĂƌĞŶŽĨŽƌĞŝŐŶďŽĚŝĞƐŽƌĂďŽůƵƐŽĨ ůƵďƌŝĐĂŶƚŽďƐƚƌƵĐƚŝŶŐƚŚĞĚŝƐƚĂůŽƉĞŶŝŶŐ͘ͿǀŽŝĚƚŽƵĐŚŝŶŐƚŚĞĐƵĨĨŽĨƚŚĞĚĞǀŝĐĞ͘ Ϯ͘ WŽƐŝƚŝŽŶƉĂƚŝĞŶƚ͛ƐŚĞĂĚĂŶĚŶĞĐŬŝŶƚŚĞƐŶŝĨĨŝŶŐƉŽƐŝƚŝŽŶ͘ ϯ͘ 'ĞŶƚůǇƉƌĞƐƐĚŽǁŶĐŚŝŶĂŶĚŝŶƐĞƌƚƚŚĞůĞĂĚŝŶŐƐŽĨƚƚŝƉŽĨƚŚĞƚƵďĞŝŶƚŽƚŚĞŵŽƵƚŚƚŽǁĂƌĚƐƚŚĞŚĂƌĚ ƉĂůĂƚĞ͘ ϰ͘ 'ůŝĚĞƚŚĞĚĞǀŝĐĞĚŽǁŶǁĂƌĚƐĂŶĚďĂĐŬǁĂƌĚƐĂůŽŶŐƚŚĞŚĂƌĚƉĂůĂƚĞǁŝƚŚĂĐŽŶƚŝŶƵŽƵƐďƵƚŐĞŶƚůĞƉƵƐŚ ƵŶƚŝůĚĞĨŝŶŝƚŝǀĞƌĞƐŝƐƚĂŶĐĞŝƐĨĞůƚ͘;dŚĞŝŶĐŝƐŽƌƐƐŚŽƵůĚďĞƌĞƐƚŝŶŐŽŶƚŚĞŝŶƚĞŐƌĂůďŝƚĞďůŽĐŬͿ ϱ͘ ŽŶĨŝƌŵƉůĂĐĞŵĞŶƚƵƐŝŶŐsDǀĞŶƚŝůĂƚŝŽŶĂŶĚǀĞƌŝĨǇŝŶŐƉƌĞƐĞŶĐĞŽĨdKϮǁĂǀĞĨŽƌŵĂŶĚ ƉƵůŵŽŶĂƌǇďƌĞĂƚŚƐŽƵŶĚƐǁŝƚŚĂďƐĞŶĐĞŽĨĞƉŝŐĂƐƚƌŝĐďƌĞĂƚŚƐŽƵŶĚƐ͘ ϲ͘ ^ĞĐƵƌĞƚŚĞŝͲŐĞůǁŝƚŚƚŚĞƉƌŽǀŝĚĞĚƐĞĐƵƌŝŶŐƐƚƌĂƉŽƌĂĐŽŵŵĞƌĐŝĂůƐĞĐƵƌŝŶŐĚĞǀŝĐĞ͘ ϳ͘ /ĨǀĞŶƚŝůĂƚŝŽŶĐŽŶƚŝŶƵĞƐƚŽďĞƵŶƐƵĐĐĞƐƐĨƵů͕ƉƌŽĐĞĞĚĂĐĐŽƌĚŝŶŐƚŽƚŚĞFailed AirwayƉƌŽƚŽĐŽů͘ ZĞŵŽǀĂů ϭ͘ WƌŝŽƌƚŽƌĞŵŽǀĂů͕ƵƐĞĂŐĂƐƚƌŝĐƚƵďĞ;ƐĞĞĐŚĂƌƚͿƚŚƌŽƵŐŚƚŚĞŐĂƐƚƌŝĐĐŚĂŶŶĞůŽĨƚŚĞŝͲŐĞůƚŽ ƐƵĐƚŝŽŶͬĚĞĐŽŵƉƌĞƐƐƚŚĞƐƚŽŵĂĐŚƚŽůŝŵŝƚƌĞŐƵƌŐŝƚĂƚŝŽŶͬĂƐƉŝƌĂƚŝŽŶƌŝƐŬĚƵƌŝŶŐŝŶƚƵďĂƚŝŽŶ;ĚŽĞƐŶŽƚ ĂƉƉůǇƚŽŝͲŐĞůŝŶƐŝǌĞϭͿ͘ Ϯ͘ WƵůůŝͲŐĞůŽƵƚĂŶĚƉƌĞƉĂƌĞĨŽƌƐƵĐƚŝŽŶŝŶŐŝĨŶĞĐĞƐƐĂƌǇ͘ ϯ͘ WƌŽĐĞĞĚǁŝƚŚĞŶĚŽƚƌĂĐŚĞĂůŝŶƚƵďĂƚŝŽŶŝĨŝŶĚŝĐĂƚĞĚ͘ ^ĞůĞĐƚƚŚĞĂƉƉƌŽƉƌŝĂƚĞƐŝǌĞŽĨŶĂƐŽŐĂƐƚƌŝĐ;E'ͿƚƵďĞ͗

Cypress Creek EMS System Policies and Treatment Guidelines

229 PROCEDURE Revised 6/2019 Airway Approved: Levon Vartanian, MD

i-gel Size Maximum Size of Nasogastric Tube ϭ Eͬ ϭ͘ϱ ϭϬ Ϯ Ϯ͘ϱ ϭϮ ϯ ϰ ϱ ϭϰ Contraindications x dƌŝƐŵƵƐ͕ůŝŵŝƚĞĚŵŽƵƚŚŽƉĞŶŝŶŐ͕ůĂƌǇŶŐĞĂůĂďƐĐĞƐƐ͕ƚƌĂƵŵĂŽƌŵĂƐƐ͘ x WĂƚŝĞŶƚƐǁŝƚŚĂŶǇĐŽŶĚŝƚŝŽŶǁŚŝĐŚŵĂǇŝŶĐƌĞĂƐĞƚŚĞƌŝƐŬŽĨĂĨƵůůƐƚŽŵĂĐŚĞ͘Ő͘ŚŝĂƚƵƐŚĞƌŶŝĂ͕ƐĞƉƐŝƐ͕ ŵŽƌďŝĚŽďĞƐŝƚǇ͕ƉƌĞŐŶĂŶĐǇŽƌĂŚŝƐƚŽƌǇŽĨƵƉƉĞƌŐĂƐƚƌŽͲŝŶƚĞƐƚŝŶĂůƐƵƌŐĞƌǇ͕ĞƚĐ͘ x hƐĞŽŶĂĐŽŶƐĐŝŽƵƐͬƐĞŵŝͲĐŽŶƐĐŝŽƵƐƉĂƚŝĞŶƚ Considerations x ŽŶŽƚĂůůŽǁƉĞĂŬĂŝƌǁĂǇƉƌĞƐƐƵƌĞŽĨǀĞŶƚŝůĂƚŝŽŶƚŽĞǆĐĞĞĚϰϬĐŵ,ϮK͘ x ŽŶŽƚƵƐĞĞǆĐĞƐƐŝǀĞĨŽƌĐĞƚŽŝŶƐĞƌƚƚŚĞĚĞǀŝĐĞŽƌŶĂƐŽŐĂƐƚƌŝĐƚƵďĞ͘ x ŽŶŽƚůĞĂǀĞƚŚĞĚĞǀŝĐĞŝŶƐŝƚƵĨŽƌŵŽƌĞƚŚĂŶĨŽƵƌŚŽƵƌƐ͘ x ŽŶŽƚƌĞƵƐĞŽƌĂƚƚĞŵƉƚƚŽƌĞƉƌŽĐĞƐƐƚŚĞŝͲŐĞůƐƵƉƌĂŐůŽƚƚŝĐĂŝƌǁĂǇ͘ Pearls x tŚĞŶĐŚŽŽƐŝŶŐƚŚĞƚŚĞĂƉƉƌŽƉƌŝĂƚĞŝͲŐĞůƐƵƉƌĂŐůŽƚƚŝĐĂŝƌǁĂǇ͕ĐŽŶƐŝĚĞƌĂŶĂƚŽŵŝĐĂůǀĂƌŝĂƚŝŽŶ͗ o ǇůŝŶĚƌŝĐĂůŶĞĐŬŽƌǁŝĚĞƚŚǇƌŽŝĚͬĐƌŝĐŽŝĚĐĂƌƚŝůĂŐĞʹůĂƌŐĞƌƐŝǌĞ o ƌŽĂĚŽƌƐƚŽĐŬǇŶĞĐŬŽƌŶĂƌƌŽǁƚŚǇƌŽŝĚͬĐƌŝĐŽŝĚĐĂƌƚŝůĂŐĞʹƐŵĂůůĞƌƐŝǌĞ o ĞŶƚƌĂůŽďĞƐŝƚǇʹƐŝǌĞĨŽƌŝĚĞĂůďŽĚǇǁĞŝŐŚƚ x ůƚŚŽƵŐŚƚŚĞŝͲŐĞůƉƌŽĐĞĚƵƌĞŝƐĂ͞ďůŝŶĚŝŶƐĞƌƚŝŽŶ͕͟ŝƚŝƐŶŽƚĂ͞ďůŝŶĚƚĞĐŚŶŝƋƵĞ͘͟ŝͲŐĞůƉůĂĐĞŵĞŶƚŵƵƐƚ ďĞĐŽŶĨŝƌŵĞĚĂŶĚƌĞĂƐƐĞƐƐĞĚŝŶƚŚĞƐĂŵĞŵĂŶŶĞƌĂƐĂŶdƚƵďĞ͘ x ŽŶŽƚĂƉƉůǇůƵďƌŝĐĂŶƚƚŽŽůŽŶŐďĞĨŽƌĞŝŶƐĞƌƚŝŽŶŽƌƉůĂĐĞƚŚĞĚĞǀŝĐĞŽŶƚŽĂƉŝůůŽǁŽƌƚŚĞƉĂƚŝĞŶƚ͛Ɛ ĐŚĞƐƚ͘ x /ƚŝƐŶŽƚŶĞĐĞƐƐĂƌǇƚŽŝŶƐĞƌƚĨŝŶŐĞƌƐŽƌƚŚƵŵďƐŝŶƚŽƚŚĞƉĂƚŝĞŶƚ͛ƐŵŽƵƚŚǁŚŝůĞŝŶƐĞƌƚŝŶŐƚŚĞĚĞǀŝĐĞ͘/Ĩ ƚŚĞƌĞŝƐĞĂƌůǇƌĞƐŝƐƚĂŶĐĞĚƵƌŝŶŐŝŶƐĞƌƚŝŽŶ͕ĂũĂǁƚŚƌƵƐƚŽƌŝŶƐĞƌƚŝŽŶǁŝƚŚĚĞĞƉƌŽƚĂƚŝŽŶŝƐ ƌĞĐŽŵŵĞŶĚĞĚ͘/ĨƚŚĞƚĞĞƚŚŽƌůŽĐĂƚĞĚůŽǁĞƌƚŚĂŶƚŚĞĚŝƐƚĂůƚŝƉŽĨƚŚĞďŝƚĞďůŽĐŬ͕ƚŚĞŶŝƚŝƐůŝŬĞůǇƚŚĞ ĚĞǀŝĐĞŚĂƐďĞĞŶŝŶĐŽŵƉůĞƚĞůǇŝŶƐĞƌƚĞĚ͘/ŶƚŚŝƐŝŶƐƚĂŶĐĞ͕ƌĞŵŽǀĞƚŚĞŝͲŐĞůĂŶĚƌĞŝŶƐĞƌƚǁŝƚŚĂŐĞŶƚůĞ ũĂǁƚŚƌƵƐƚĂƉƉůŝĞĚďǇĂŶĂƐƐŝƐƚĂŶƚ͘/ĨƚŚĂƚĚŽĞƐŶŽƚƌĞƐŽůǀĞƚŚĞƉƌŽďůĞŵ͕ƵƐĞŽŶĞƐŝǌĞƐŵĂůůĞƌŝͲŐĞů͘ dŚĞƉĞĚŝĂƚƌŝĐƐŝǌĞƐŽĨƚŚĞŝͲŐĞůĚŽŶŽƚŚĂǀĞĂŚŽƌŝǌŽŶƚĂůůŝŶĞŽŶƚŚĞŝŶƚĞŐƌĂůďŝƚĞďůŽĐŬ͘ x tŚĞŶŝŶƐĞƌƚŝŶŐƚŚĞŝͲŐĞů͕ƐŽŵĞƚŝŵĞƐĂĨĞĞůŽĨ͞ŐŝǀŝŶŐǁĂǇ͟ŝƐĨĞůƚďĞĨŽƌĞƚŚĞĞŶĚƉŽŝŶƚƌĞƐŝƐƚĂŶĐĞŝƐ ŵĞƚ͘dŚŝƐŝƐĚƵĞƚŽƚŚĞƉĂƐƐĂŐĞŽĨƚŚĞďŽǁůŽĨƚŚĞŝͲŐĞůƚŚƌŽƵŐŚƚŚĞĨĂĐŝĂůƉŝůůĂƌƐ͘ x /ŶŽƌĚĞƌƚŽĂǀŽŝĚƚŚĞƉŽƐƐŝďŝůŝƚǇŽĨƚŚĞĚĞǀŝĐĞŵŽǀŝŶŐƵƉŽƵƚŽĨƉŽƐŝƚŝŽŶƉƌŝŽƌƚŽďĞŝŶŐƐĞĐƵƌĞĚŝŶ ƉůĂĐĞ͕ĂƐƐŽŽŶĂƐŝŶƐĞƌƚŝŽŶŚĂƐďĞĞŶƐƵĐĐĞƐƐĨƵůůǇĐŽŵƉůĞƚĞĚƚŚĞŝͲŐĞůŵƵƐƚďĞŚĞůĚŝŶƚŚĞĐŽƌƌĞĐƚ ƉŽƐŝƚŝŽŶƵŶƚŝůĂŶĚǁŚŝůĞƚŚĞĚĞǀŝĐĞŝƐƐĞĐƵƌĞĚŝŶƉůĂĐĞ͘ x ŽŶŽƚƵƐĞƚŚĞŐĂƐƚƌŝĐĐŚĂŶŶĞůŝĨƚŚĞƌĞŝƐĂŶĞǆĐĞƐƐŝǀĞĂŝƌůĞĂŬƚŚƌŽƵŐŚƚŚĞŐĂƐƚƌŝĐĐŚĂŶŶĞůŽƌƉĂƚŝĞŶƚ ŚĂƐĞƐŽƉŚĂŐĞĂůǀĂƌŝĐĞƐ͕ĞǀŝĚĞŶĐĞŽĨƵƉƉĞƌ'/ďůĞĞĚ͕ĞƐŽƉŚĂŐĞĂůƚƌĂƵŵĂ͕ŚŝƐƚŽƌǇŽĨƵƉƉĞƌ'/ƐƵƌŐĞƌǇ͕ ŽƌĂŚŝƐƚŽƌǇŽĨďůĞĞĚŝŶŐͬĐůŽƚƚŝŶŐĂďŶŽƌŵĂůŝƚŝĞƐ͘

Cypress Creek EMS System Policies and Treatment Guidelines

230 PROCEDURE Revised 6/2019 Airway Approved: Levon Vartanian, MD

x /ŶĂĚĞƋƵĂƚĞůĞǀĞůƐŽĨĂŶĞƐƚŚĞƐŝĂŵĂǇůĞĂĚƚŽĐŽƵŐŚŝŶŐ͕ďƵĐŬŝŶŐ͕ĞǆĐĞƐƐŝǀĞƐĂůŝǀĂƚŝŽŶ͕ƌĞƚĐŚŝŶŐ͕ ůĂƌǇŶŐŽƐƉĂƐŵŽƌďƌĞĂƚŚŚŽůĚŝŶŐǁŚŝůĞƚŚĞŝͲŐĞůƐƵƉƌĂŐůŽƚƚŝĐĂŝƌǁĂǇŝƐŝŶƐĞƌƚĞĚ͘

i-gel Size Patient Size Patient Weight Age ϭ EĞŽŶĂƚĞ ϮʹϱŬŐ WƌĞĞŵŝĞ͕EĞǁďŽƌŶ ϭ͘ϱ /ŶĨĂŶƚ ϱʹϭϮŬŐ ϰŵŽʹϮǇƌ Ϯ ^ŵĂůůŚŝůĚ ϭϬʹϮϱŬŐ ϭʹϳǇƌ Ϯ͘ϱ >ĂƌŐĞŚŝůĚ ϮϱʹϯϱŬŐ ϳʹϭϬǇƌ ϯ ^ŵĂůůĚƵůƚ ϯϬʹϲϬŬŐ ϭϬʹϭϯǇƌͬĚƵůƚ ϰ DĞĚŝƵŵĚƵůƚ ϱϬʹϵϬŬŐ ĚƵůƚ ϱ >ĂƌŐĞĚƵůƚ хϵϬŬŐ ĚƵůƚ

Cypress Creek EMS System Policies and Treatment Guidelines

231 PROCEDURE 10 Revised 8/2016 Airway Approved: Levon Vartanian, MD

<ŝŶŐ^ƵƉƌĂŐůŽƚƚŝĐŝƌǁĂǇ Indications Equipment Needed Assessment Requirements x dŽƉƌŽƚĞĐƚƚŚĞĂŝƌǁĂǇĂŶĚ sD WƌŝŵĂƌǇƐƵƌǀĞǇ ŽǆǇŐĞŶĂƚĞͬǀĞŶƚŝůĂƚĞŝŶƚŚĞ <ŝŶŐ^ƵƉƌĂŐůŽƚƚŝĐŝƌǁĂǇ ƐƐĞƐƐĨŽƌůĞǀĞůŽĨ ƵŶĐŽŶƐĐŝŽƵƐƉĂƚŝĞŶƚŽƌƉĂƚŝĞŶƚ ƉƌĞƉĂĐŬĂŐĞĚŬŝƚǁŝƚŚƚƵďĞ͕ůƵďĞ͕ ĐŽŶƐĐŝŽƵƐŶĞƐƐ ǁŝƚŚŶŽŐĂŐƌĞĨůĞǆ͘ ĂŶĚƐǇƌŝŶŐĞ͘ x /ŶŝƚŝĂůĂŝƌǁĂǇĨŽƌŶŽŶͲƚƌĂƵŵĂƚŝĐ ŝƌǁĂǇĂƐƐĞƐƐŵĞŶƚ ĐĂƌĚŝĂĐĂƌƌĞƐƚ͘ ŽŶƚŝŶƵŽƵƐŵŽŶŝƚŽƌŝŶŐŽĨ͗ x ZĞƐĐƵĞĂŝƌǁĂǇŝŶĨĂŝůĞĚ x ^ƉKϮǁŝƚŚƐŝŶŐůĞͲƉĂƚŝĞŶƚƵƐĞ ŝŶƚƵďĂƚŝŽŶ͘ ƐƚŝĐŬĞƌƐĞŶƐŽƌ͘ x dKϮ Contraindications: x ' x /ŶƚĂĐƚŐĂŐƌĞĨůĞǆ x <ŶŽǁŶĞƐŽƉŚĂŐĞĂůĚŝƐĞĂƐĞ ƐƐĞƐƐĨŽƌĂŶĚƚƌĞĂƚƌĞǀĞƌƐŝďůĞ x ĂƵƐƚŝĐƐƵďƐƚĂŶĐĞŝŶŐĞƐƚŝŽŶ ĐĂƵƐĞƐ͘ x hƉƉĞƌĂŝƌǁĂǇŽďƐƚƌƵĐƚŝŽŶ ƐĞĐŽŶĚĂƌǇƚŽĨŽƌĞŝŐŶďŽĚǇ ĂƐƉŝƌĂƚŝŽŶ͕ůĂƌǇŶŐĞĂůĞĚĞŵĂ͕Žƌ ĞƉŝŐůŽƚƚŝƚŝƐ͘ x ^ĞǀĞƌĞŽƌŽƉŚĂƌǇŶŐĞĂůƚƌĂƵŵĂ WƌŽĐĞĚƵƌĞ ϭ͘ WƌĞƉĂƌĞĂůůĞƋƵŝƉŵĞŶƚ͗^ĞůĞĐƚĂƉƉƌŽƉƌŝĂƚĞ<ŝŶŐƚƵďĞĨŽƌƉĂƚŝĞŶƚƐŝǌĞ͕ĂƚƚĂĐŚƐǇƌŝŶŐĞƚŽĐŽŶŶĞĐƚŝŽŶ͕ ĂŶĚůƵďƌŝĐĂƚĞƚƵďĞ͘ Ϯ͘ WŽƐŝƚŝŽŶƉĂƚŝĞŶƚ͛ƐŚĞĂĚĂŶĚŶĞĐŬŝŶĂŶĞƵƚƌĂůƉŽƐŝƚŝŽŶ͘ ϯ͘ >ŝĨƚƚŽŶŐƵĞĂŶĚũĂǁ͕ĂŶĚŝŶƐĞƌƚƚƵďĞŝŶĂĐƵƌǀĞĚĚŽǁŶǁĂƌĚŵŽǀĞŵĞŶƚ͘ŽŶŽƚĨŽƌĐĞ͘ ϰ͘ /ŶƐĞƌƚƵŶƚŝůƚŚĞĐŽŶŶĞĐƚŽƌŝƐƉĂƌĂůůĞůǁŝƚŚƚŚĞƚĞĞƚŚ͘ ϱ͘ /ŶĨůĂƚĞĐƵĨĨƐǁŝƚŚĂƉƉƌŽƉƌŝĂƚĞĂŵŽƵŶƚŽĨĂŝƌ;ĂƐŝŶĚŝĐĂƚĞĚŽŶƉĂĐŬĂŐŝŶŐͿ͘ ϲ͘ ŽŶĨŝƌŵƉůĂĐĞŵĞŶƚǁŝƚŚsDǀĞŶƚŝůĂƚŝŽŶƵƐŝŶŐdKϮǁĂǀĞĨŽƌŵĂŶĚďƌĞĂƚŚƐŽƵŶĚƐ͘ ϳ͘ /ĨǀĞŶƚŝůĂƚŝŽŶŝƐƵŶƐƵĐĐĞƐƐĨƵů͕ĚĞĨůĂƚĞĐƵĨĨƐďǇϭϬй͕ǁŝƚŚĚƌĂǁ<ŝŶŐƚƵďĞďĂĐŬϮͲϯĐŵ͕ŝŶĨůĂƚĞĐƵĨĨƐ͕ĂŶĚ ƚĞƐƚĂŐĂŝŶ͘sĞƌŝĨǇƚŚĂƚƚƵďĞŝƐĂƉƉƌŽƉƌŝĂƚĞůǇƐŝǌĞĚĨŽƌƉĂƚŝĞŶƚ͘ ϴ͘ /ĨǀĞŶƚŝůĂƚŝŽŶĐŽŶƚŝŶƵĞƐƚŽďĞƵŶƐƵĐĐĞƐƐĨƵů͕ƉƌŽĐĞĞĚĂĐĐŽƌĚŝŶŐƚŽƚŚĞFailed AirwayƉƌŽƚŽĐŽů͘ ZĞŵŽǀĂů ϭ͘ WƌŝŽƌƚŽƌĞŵŽǀĂů͕ƵƐĞĂŶϭϴĨƌŽƌƐŵĂůůĞƌŐĂƐƚƌŝĐƚƵďĞƚŚƌŽƵŐŚƚŚĞƉŽƐƚĞƌŝŽƌƉŽƌƚŽĨƚŚĞ<ŝŶŐ>d^ͲƚŽ ƐƵĐƚŝŽŶͬĚĞĐŽŵƉƌĞƐƐƚŚĞƐƚŽŵĂĐŚƚŽůŝŵŝƚƌĞŐƵƌŐŝƚĂƚŝŽŶͬĂƐƉŝƌĂƚŝŽŶƌŝƐŬĚƵƌŝŶŐŝŶƚƵďĂƚŝŽŶ;ĚŽĞƐŶŽƚ ĂƉƉůǇƚŽ<ŝŶŐ>dƚƵďĞƐͿ͘ Ϯ͘ ĞĨůĂƚĞĐƵĨĨŽĨ<ŝŶŐƚƵďĞ͘ ϯ͘ WƵůůŽƵƚĂŶĚƉƌĞƉĂƌĞĨŽƌƐƵĐƚŝŽŶŝŶŐŝĨŶĞĐĞƐƐĂƌǇ͘ ϰ͘ WƌŽĐĞĞĚǁŝƚŚĞŶĚŽƚƌĂĐŚĞĂůŝŶƚƵďĂƚŝŽŶ͘

Cypress Creek EMS System Policies and Treatment Guidelines

232 PROCEDURE Revised 8/2016 Airway Approved: Levon Vartanian, MD

WĞĂƌůƐ x ůƚŚŽƵŐŚƚŚĞ<ŝŶŐƚƵďĞƉƌŽĐĞĚƵƌĞŝƐĂ͞ďůŝŶĚŝŶƐĞƌƚŝŽŶ͟ŝƚŝƐŶŽƚĂ͞ďůŝŶĚƚĞĐŚŶŝƋƵĞ͘͟<ŝŶŐƚƵďĞ ƉůĂĐĞŵĞŶƚŵƵƐƚďĞĐŽŶĨŝƌŵĞĚĂŶĚƌĞĂƐƐĞƐƐĞĚŝŶƚŚĞƐĂŵĞŵĂŶŶĞƌĂŶdƚƵďĞ͘ x dŚŝƐƉƌŽĐĞĚƵƌĞŵĂǇďĞƉĞƌĨŽƌŵĞĚďǇĂŶǇD^ĐƌĞĚĞŶƚŝĂůĞĚŵĞĚŝĐĂůƉƌŽǀŝĚĞƌ͘ x tŚĞŶĨĂĐŝĂůƚƌĂƵŵĂŚĂƐƌĞƐƵůƚĞĚŝŶďƌŽŬĞŶƚĞĞƚŚŽƌĚĞŶƚƵƌĞƐ͕ƌĞŵŽǀĞƚŚĞĚĞďƌŝƐĂŶĚƵƐĞĞǆƚƌĞŵĞ ĐĂƵƚŝŽŶǁŚĞŶŝŶƐĞƌƚŝŶŐ<ŝŶŐƚƵďĞƚŽƉƌĞǀĞŶƚƚŚĞĐƵĨĨƐĨƌŽŵƚĞĂƌŝŶŐ͘ x tŚĞŶŝŶĨůĂƚŝŶŐƚŚĞďĂůůŽŽŶ͕ƚŚĞ<ŝŶŐƚƵďĞŵĂǇŵŽǀĞƉƌŽǆŝŵĂůůǇĂĨĞǁĐĞŶƚŝŵĞƚĞƌƐ͘dŚŝƐŝƐŶŽƌŵĂů͘ x /ĨƵŶĂďůĞƚŽǀĞŶƚŝůĂƚĞǁŝƚŚƚŚĞ<ŝŶŐƚƵďĞ͕ƌĞƚƵƌŶƚŽƵƐŝŶŐBVM Ventilations. ^ŝǌĞŚĂƌƚ ^ŝǌĞ 2 2.5 3 4 5 ŽůŽƌ 'ƌĞĞŶ KƌĂŶŐĞ zĞůůŽǁ ZĞĚ WƵƌƉůĞ WĂƚŝĞŶƚ^ŝǌĞ ϯϱʹϰϱŝŶĐŚĞƐ ϰϭʹϱϭŝŶĐŚĞƐ ϰʹϱĨĞĞƚ ϱʹϲĨĞĞƚ хϲĨĞĞƚ ŽƌϭϮʹϮϱŬŐ ŽƌϮϱʹϯϱŬŐ ƵĨĨsŽůƵŵĞ Ϯϱʹϯϱŵ> ϯϬʹϰϬŵ> ϰϬʹϱϱŵ> ϱϬʹϳϬŵ> ϲϬʹϴϬŵ> ƌŽƐĞůŽǁ zĞůůŽǁ KƌĂŶŐĞ ƚĂƉĞ tŚŝƚĞ 'ƌĞĞŶ ůƵĞ EŽƚĞ͗/ĨƉĞĚŝĂƚƌŝĐƉĂƚŝĞŶƚĨĂůůƐďĞůŽǁϭϮŬŐ͕ƚŚĞηϮ<ŝŶŐƚƵďĞŵĂǇƐƚŝůůďĞ ĐŽŶƐŝĚĞƌĞĚďĂƐĞĚŽŶƉĂƚŝĞŶƚƐŝǌĞĂŶĚƉŚǇƐŝĐĂůĞǆĂŵ͘ ŝƌǁĂǇƐƐĞƐƐŵĞŶƚ ŶĂŝƌǁĂǇĂƐƐĞƐƐŵĞŶƚƐŚŽƵůĚďĞĐŽŵƉůĞƚĞĚƉƌŝŽƌƚŽƉĞƌĨŽƌŵŝŶŐĂŶǇĂĚǀĂŶĐĞĚĂŝƌǁĂǇŵĂŶĂŐĞŵĞŶƚ ƉƌŽĐĞĚƵƌĞƐ͘dŚŝƐĂƐƐĞƐƐŵĞŶƚǁŝůůŚĞůƉƉƌĞĚŝĐƚĚŝĨĨŝĐƵůƚĂŝƌǁĂǇƐĂƐǁĞůůĂƐƉƌŽǀŝĚĞŝŶƐŝŐŚƚŝŶƚŽǁŚŝĐŚƚŽŽůƐ ŽƌƚĞĐŚŶŝƋƵĞƐĂƌĞďĞƐƚƐƵŝƚĞĚƚŽŵĂŶĂŐŝŶŐƚŚĞŝŶĚŝǀŝĚƵĂůƉĂƚŝĞŶƚ͘

LEMONS MOANS RODS SHORT ;ĚŝĨĨŝĐƵůƚ ;ĚŝĨĨŝĐƵůƚsDͿ ;ĚŝĨĨŝĐƵůƚ<ŝŶŐƚƵďĞͿ ;ĚŝĨĨŝĐƵůƚĐƌŝĐŽƚŚǇƌŽƚŽŵǇͿ ůĂƌǇŶŐŽƐĐŽƉǇͿ LŽŽŬĞǆƚĞƌŶĂůůǇ MĂƐŬƐĞĂů RĞƐƚƌŝĐƚĞĚŵŽƵƚŚ SƵƌŐĞƌǇŽƌĚŝƐƚŽƌƚĞĚ EǀĂůƵĂƚĞϯͲϯͲϮƌƵůĞ OďĞƐĞ ŽƉĞŶŝŶŐ ĂŝƌǁĂǇ MĂůůĂŵƉĂƚŝ AŐĞхϱϱ OďƐƚƌƵĐƚŝŽŶͬŽďĞƐĞ HĞŵĂƚŽŵĂŽǀĞƌŶĞĐŬ OďƐƚƌƵĐƚŝŽŶͬŽďĞƐĞ NŽƚĞĞƚŚ DŝƐƚŽƌƚĞĚͬĚŝƐƌƵƉƚĞĚ OďĞƐĞ NĞĐŬŵŽďŝůŝƚǇ SƚŝĨĨ ĂŝƌǁĂǇ RĂĚŝĂƚŝŽŶƚƌĞĂƚŵĞŶƚƐ SĂƚƵƌĂƚŝŽŶƐ SƚŝĨĨ TƵŵŽƌŽǀĞƌŶĞĐŬ͘

Cypress Creek EMS System Policies and Treatment Guidelines

233 PROCEDURE Revised 8/2016 Airway Approved: Levon Vartanian, MD

EĂƐĂů/ŶƚƵďĂƚŝŽŶ Indications Equipment Needed Assessment Requirements dŽƉƌŽƚĞĐƚƚŚĞĂŝƌǁĂǇĂŶĚ sD͕KWͬEWƐ͕ĂŐĞů WƌŝŵĂƌǇƐƵƌǀĞǇ ŽǆǇŐĞŶĂƚĞͬǀĞŶƚŝůĂƚĞǁŚĞŶ ^ƵĐƚŝŽŶ ƐƐĞƐƐĨŽƌůĞǀĞůŽĨ <ŝŶŐƐƵƉƌĂŐůŽƚƚŝĐĂŝƌǁĂǇ ŽƌŽƚƌĂĐŚĞĂůŝŶƚƵďĂƚŝŽŶŝƐŶŽƚ ĐŽŶƐĐŝŽƵƐŶĞƐƐ ƉŽƐƐŝďůĞŽƌŶŽƚĚĞƐŝƌĂďůĞ͘ ŝƌǁĂǇŬŝƚ '>ĂƐƐĞƐƐŵĞŶƚ ŝƌǁĂǇĂƐƐĞƐƐŵĞŶƚ ŽŶƚŝŶƵŽƵƐŵŽŶŝƚŽƌŝŶŐŽĨ͗ x ^ƉKϮǁŝƚŚƐŝŶŐůĞͲƉĂƚŝĞŶƚ ƵƐĞƐƚŝĐŬĞƌƐĞŶƐŽƌ͘ x dKϮ x ' ƐƐĞƐƐĨŽƌĂŶĚƚƌĞĂƚ ƌĞǀĞƌƐŝďůĞĐĂƵƐĞƐ͘ WƌŽĐĞĚƵƌĞ ϭ͘ sĞŶƚŝůĂƚĞǁŝƚŚϭϬϬйŽǆǇŐĞŶ Ϯ͘ ^ĞůĞĐƚĂŶĂƉƉƌŽƉƌŝĂƚĞĞŶĚŽƚƌĂĐŚĞĂůƚƵďĞƐŝǌĞƚŚĂƚĂƉƉƌŽǆŝŵĂƚĞƐƉĂƚŝĞŶƚ͛ƐŶĂƌĞƐ ϯ͘ /ŶƚƵďĂƚĞƵƐŝŶŐƌŝŐŚƚŶĂƐĂůƉĂƐƐĂŐĞŝĨƉŽƐƐŝďůĞ ϰ͘ >ƵďƌŝĐĂƚĞĐƵĨĨĂŶĚĚŝƐƚĂůĞŶĚŽĨƚƵďĞǁŝƚŚǁĂƚĞƌͲƐŽůƵďůĞũĞůůǇŽƌ2% Lidocaine Jelly ϱ͘ ƉƉůǇDǁŚŝƐƚůĞƚŽĂƐƐŝƐƚŝŶůŝƐƚĞŶŝŶŐĨŽƌŝŶƐƉŝƌĂƚŝŽŶ ϲ͘ WůĂĐĞďĞǀĞůĂŐĂŝŶƐƚĨůŽŽƌŽƌƐĞƉƚƵŵŽĨŶĂƐĂůĐĂǀŝƚǇĂŶĚĂĚǀĂŶĐĞƚƵďĞƵŶƚŝůƚŚĞƚŝƉƌĞĂĐŚĞƐƚŚĞ ƉŽƐƚĞƌŝŽƌƉŚĂƌǇŶŐĞĂůǁĂůů ϳ͘ dǁŝƐƚƚƵďĞĐŽƵŶƚĞƌĐůŽĐŬǁŝƐĞ;ĐůŽĐŬǁŝƐĞŝĨŝŶƚŚĞůĞĨƚŶĂƌĞͿƐůŝŐŚƚůǇĂƐƚƵďĞĂĚǀĂŶĐĞƐ ϴ͘ >ŝƐƚĞŶĨŽƌďƌĞĂƚŚƐŽƵŶĚƐĂŶĚĂĚǀĂŶĐĞƚƵďĞƚŚƌŽƵŐŚĂƐƚŚĞĐŽƌĚƐŽƉĞŶ;ŝŶƐƉŝƌĂƚŝŽŶͿ ϵ͘ dƵďĞƐŚŽƵůĚďĞƉůĂĐĞĚĂƚϮϳͲϮϴĐŵŵĂƌŬĂƚƚŚĞŶĂƌĞƐŝŶŵŽƐƚĂĚƵůƚƉĂƚŝĞŶƚƐ ϭϬ͘ >ŝƐƚĞŶĨŽƌĂŝƌĞƐĐĂƉŝŶŐŽƵƚŽĨƚŚĞƚƵďĞƵƉŽŶĞǆŚĂůĂƚŝŽŶĂĨƚĞƌŝŶĨůĂƚŝŶŐƚŚĞĐƵĨĨĂŶĚƐĞĂůŝŶŐƚŚĞŵŽƵƚŚ ΘŶŽƐĞ͘ ϭϭ͘ ŽŶĨŝƌŵƚƵďĞƉůĂĐĞŵĞŶƚƵƐŝŶŐdKϮĂŶĚďǇĂƵƐĐƵůƚĂƚŝŽŶŽĨďƌĞĂƚŚƐŽƵŶĚƐ ϭϮ͘ ^ĞĐƵƌĞƚƵďĞĂŶĚƌĞĐŚĞĐŬƉůĂĐĞŵĞŶƚĨƌĞƋƵĞŶƚůǇ WĞĂƌůƐ x ŽŶŽƚƉĞƌĨŽƌŵŝĨ͗ ϭ͘ WĂƚŝĞŶƚŚĂƐŵĂũŽƌĨĂĐŝĂůƚƌĂƵŵĂ Ϯ͘ ƌĂŝŶŵĂƚƚĞƌŝƐƉƌĞƐĞŶƚŝŶƚŚĞŶŽƐĞ ϯ͘ ǆĐĞƐƐŝǀĞĨŽƌĐĞŝƐŶĞĞĚĞĚŝŶŽƌĚĞƌƚŽƉĂƐƐƚŚĞƚƵďĞ ϰ͘ WĂƚŝĞŶƚŝƐĞǆŚŝďŝƚŝŶŐƐŝŐŶƐĂŶĚƐǇŵƉƚŽŵƐŽĨǀŽĐĂůĐŽƌĚƐƉĂƐŵƐ x WĞƌĨŽƌŵĂŶĐĞŽĨĂ^ĞůůŝĐŬ͛ƐDĂŶĞƵǀĞƌŵĂǇŝŵƉƌŽǀĞƚŚĞĐŚĂŶĐĞŽĨƉĂƐƐĂŐĞŝŶƚŽƚŚĞƚƌĂĐŚĞĂ x hƐĞŽĨĂĚŝƌĞĐƚŝŽŶĂůůǇĐŽŶƚƌŽůůĞĚƚŝƉdƚƵďĞ;ŝ͘Ğ͘ŶĚŽƚƌŽůͿŝƐďĞŶĞĨŝĐŝĂůǁŚĞŶƉĞƌĨŽƌŵŝŶŐŶĂƐĂů ŝŶƚƵďĂƚŝŽŶ

Cypress Creek EMS System Policies and Treatment Guidelines

234 PROCEDURES Revised 8/2016 Airway Approved: Levon Vartanian, MD

ƌŝĐŽƚŚǇƌŽƚŽŵǇ Indications Equipment Needed Assessment Requirements ĂŶ͛ƚŝŶƚƵďĂƚĞ͕ĐĂŶ͛ƚ ĞƉĞŶĚŝŶŐŽŶƚĞĐŚŶŝƋƵĞ͗ ŝƌǁĂǇĂƐƐĞƐƐŵĞŶƚ ǀĞŶƚŝůĂƚĞ ^ƵƌŐŝĐĂůĂŝƌǁĂǇŬŝƚ ƐƐŽŽŶĂƐƉŽƐƐŝďůĞ͕ŝŶŝƚŝĂƚĞ ^ĞǀĞƌĞŵŝĚͲĨĂĐĞƚƌĂƵŵĂ ŚůŽƌĂƉƌĞƉƐǁĂď ĐŽŶƚŝŶƵŽƵƐŵŽŶŝƚŽƌŝŶŐŽĨ͗ ƉƌĞǀĞŶƚŝŶŐĂŝƌǁĂǇĂĐĐĞƐƐ ^ĐĂůƉĞů͕ďŽƵŐŝĞ͕ĂŶĚϲ͘Ϭd hƉƉĞƌĂŝƌǁĂǇƐǁĞůůŝŶŐ ƚƵďĞǁŝƚŚƐǇƌŝŶŐĞ x ^ƉKϮ ;ĂŶĂƉŚǇůĂǆŝƐ͕ůĂƌǇŶŐĞĂů DĞůŬĞƌŬŝƚ x dKϮ ĞĚĞŵĂ͕ƵŶƌĞƐŽůǀŝŶŐ x ' ůĂƌǇŶŐŽƐƉĂƐŵͿ Contraindications: /ŶĂďŝůŝƚǇƚŽŝĚĞŶƚŝĨǇ ůĂŶĚŵĂƌŬƐ ŶĂƚŽŵŝĐĂůĂďŶŽƌŵĂůŝƚŝĞƐŽĨ ŶĞĐŬ dƌĂĐŚĞĂůƚƌĂŶƐĞĐƚŝŽŶ ^ƵƌŐŝĐĂůĐƌŝĐŽƚŚǇƌŽƚŽŵǇŶŽƚ ĨŽƌĐŚŝůĚƌĞŶфϴǇĞĂƌƐŽĨĂŐĞ EĞĞĚůĞĐƌŝĐŽƚŚǇƌŽƚŽŵǇŶŽƚ ĨŽƌĐŚŝůĚƌĞŶфϮǇĞĂƌƐŽĨĂŐĞ Chinook Surgical Procedure &ŽƌƵƐĞŝŶƉĂƚŝĞŶƚƐϴǇĞĂƌƐŽƌŽůĚĞƌ͘

ϭ͘ WƌĞƉĂƌĞĂŶĚĂƐƐĞŵďůĞĂůůĞƋƵŝƉŵĞŶƚ Ϯ͘ /ĚĞŶƚŝĨǇĂŶĂƚŽŵǇ ϯ͘ WƌĞƉĂƌĞůŽĐĂƚŝŽŶǁŝƚŚĂĐŚůŽƌĂƉƌĞƉƐǁĂď ϰ͘ DĂŬĞƐŬŝŶŝŶĐŝƐŝŽŶŽǀĞƌĐƌŝĐŽƚŚǇƌŽŝĚŵĞŵďƌĂŶĞƵƐŝŶŐƐĐĂůƉĞů͘/ŶĐŝƐŝŽŶƐŚŽƵůĚďĞƐŝǌĞĚƚŽ ĂƉƉƌŽǆŝŵĂƚĞůǇƚǁŽŽĨƚŚĞƉĂƚŝĞŶƚ͛ƐĨŝŶŐĞƌǁŝĚƚŚƐ͘ ϱ͘ ůƵŶƚůǇĚŝƐƐĞĐƚƐŬŝŶĂŶĚĨĂƚƚǇƚŝƐƐƵĞƚŽǀŝƐƵĂůŝǌĞƚŚĞĐƌŝĐŽƚŚǇƌŽŝĚŵĞŵďƌĂŶĞ͘ ϲ͘ DĂŬĞĂŚŽƌŝǌŽŶƚĂůŝŶĐŝƐŝŽŶƚŚƌŽƵŐŚŵĞŵďƌĂŶĞƵƐŝŶŐĂ͞ƉƵŶĐƚƵƌŝŶŐ͟ŵŽƚŝŽŶ͘ ϳ͘ 'ƌĂƐƉƚŚǇƌŽŝĚĐĂƌƚŝůĂŐĞǁŝƚŚƚƌĂĐŚĞĂůĂŶĚŚŽŽŬĂŶĚŚĂǀĞĂƐƐŝƐƚĂŶƚŚŽůĚŝŶƉůĂĐĞ͘ ϴ͘ hƐĞƚŚĞĚŝůĂƚŽƌƐƚŽƐƉƌĞĂĚƚŚĞĐƌŝĐŽŝĚƌŝŶŐĂŶĚƚŚǇƌŽŝĚĐĂƌƚŝůĂŐĞŽƉĞŶĂŶĚĚŝůĂƚĞƚŚĞŝŶĐŝƐŝŽŶ ŚŽƌŝǌŽŶƚĂůůǇ͘ ϵ͘ /ŶƐĞƌƚƚŚĞ^ŚŝůĞǇƚƵďĞǁŝƚŚŽďƚƵƌĂƚŽƌŝŶƉůĂĐĞ;ĂůƚĞƌŶĂƚŝǀĞůǇŝŶƐĞƌƚϲ͘ϬddƚƵďĞƵŶƚŝůĐƵĨĨŝƐĨƵůůǇ ŝŶƐŝĚĞƚƌĂĐŚĞĂͿ͘ ϭϬ͘ /ŶĨůĂƚĞĐƵĨĨ͕ƌĞŵŽǀĞŽďƚƵƌĂƚŽƌ͕ĂŶĚŝŶĨůĂƚĞĐƵĨĨ͘ ϭϭ͘ ŽŶĨŝƌŵƉůĂĐĞŵĞŶƚǁŝƚŚďƌĞĂƚŚƐŽƵŶĚƐĂŶĚdKϮǁĂǀĞĨŽƌŵ͘ ϭϮ͘ ^ĞĐƵƌĞŝŶƉůĂĐĞ͘

Cypress Creek EMS System Policies and Treatment Guidelines

235 PROCEDURES Revised 8/2016 Airway Approved: Levon Vartanian, MD

Finger-Scalpel-Bougie Procedure &ŽƌƵƐĞŝŶƉĂƚŝĞŶƚƐϴǇĞĂƌƐŽƌŽůĚĞƌǁŝƚŚŶŽĂŶƚŝĐŝƉĂƚĞĚĚŝĨĨŝĐƵůƚŝĞƐ;ƐĞĞWĞĂƌůƐĨŽƌĂƐƐĞƐƐŵĞŶƚŽĨƐƵƌŐŝĐĂů ĂŝƌǁĂǇĚŝĨĨŝĐƵůƚŝĞƐͿ͘

ϭ͘ WƌĞƉĂƌĞĂŶĚĂƐƐĞŵďůĞĂůůĞƋƵŝƉŵĞŶƚ͘ x ^ĐĂůƉĞů x ŚůŽƌĂƉƌĞƉƐǁĂď x ŽƵŐŝĞ x ϲ͘ϬdƚƵďĞǁŝƚŚϭϬĐĐƐǇƌŝŶŐĞ Ϯ͘ /ĚĞŶƚŝĨǇĂŶĂƚŽŵǇ ϯ͘ WƌĞƉĂƌĞůŽĐĂƚŝŽŶǁŝƚŚĂĐŚůŽƌĂƉƌĞƉƐǁĂď͘ ϰ͘ DĂŬĞƐŬŝŶŝŶĐŝƐŝŽŶŽǀĞƌĐƌŝĐŽƚŚǇƌŽŝĚŵĞŵďƌĂŶĞƵƐŝŶŐƐĐĂůƉĞů͘/ŶĐŝƐŝŽŶƐŚŽƵůĚďĞƐŝǌĞĚƚŽ ĂƉƉƌŽǆŝŵĂƚĞůǇƚǁŽŽĨƚŚĞƉĂƚŝĞŶƚ͛ƐĨŝŶŐĞƌǁŝĚƚŚƐ͘ ϱ͘ ůƵŶƚůǇĚŝƐƐĞĐƚƐŬŝŶĂŶĚĨĂƚƚǇƚŝƐƐƵĞƚŽǀŝƐƵĂůŝǌĞƚŚĞĐƌŝĐŽƚŚǇƌŽŝĚŵĞŵďƌĂŶĞ͘ ϲ͘ DĂŬĞĂŚŽƌŝǌŽŶƚĂůŝŶĐŝƐŝŽŶƚŚƌŽƵŐŚŵĞŵďƌĂŶĞƵƐŝŶŐĂ͞ƉƵŶĐƚƵƌŝŶŐ͟ŵŽƚŝŽŶ͘ ϳ͘ /ŶƐĞƌƚŐůŽǀĞĚĨŝŶŐĞƌƚŚƌŽƵŐŚĐƌŝĐŽƚŚǇƌŽŝĚŵĞŵďƌĂŶĞĂŶĚĚŝůĂƚĞŝŶĐŝƐŝŽŶ͘ ϴ͘ /ŶƐĞƌƚďŽƵŐŝĞĂůŽŶŐƐŝĚĞĨŝŶŐĞƌ͕ĂŝŵŝŶŐĐĂƵĚĂůůǇ͘zŽƵƐŚŽƵůĚĨĞĞůƚŚĞĐŽƵĚĞƚŝƉ͞ĐůŝĐŬ͟ŽŶƚŚĞƚƌĂĐŚĞĂů ƌŝŶŐƐ͘ ϵ͘ ZĞŵŽǀĞĨŝŶŐĞƌ͕ĂŶĚŝŶƐĞƌƚdƚƵďĞŝŶƚŽŝŶĐŝƐŝŽŶŽǀĞƌďŽƵŐŝĞƵŶƚŝůĐƵĨĨŝƐĨƵůůǇŝŶƚƌĂĐŚĞĂ͘ ϭϬ͘ ZĞŵŽǀĞďŽƵŐŝĞĂŶĚŝŶĨůĂƚĞĐƵĨĨŽŶdƚƵďĞ͘ ϭϭ͘ ŽŶĨŝƌŵƉůĂĐĞŵĞŶƚǁŝƚŚďƌĞĂƚŚƐŽƵŶĚƐĂŶĚdKϮǁĂǀĞĨŽƌŵ͘ ϭϮ͘ ;KƉƚŝŽŶĂůͿdƌŝŵdƚƵďĞũƵƐƚĂďŽǀĞƉŝůŽƚďĂůůŽŽŶƚƵďŝŶŐ͘zŽƵŵĂǇŶĞĞĚƚŽƵƐĞϱ͘ϬdƚƵďĞĂĚĂƉƚĞƌƚŝƉ ŝŶƚƌŝŵŵĞĚƚƵďĞ͘ Melker Cricothyrotomy Procedure &ŽƌƵƐĞŝŶƉĂƚŝĞŶƚƐϮǇĞĂƌƐŽƌŽůĚĞƌ͘ŽŶƐŝĚĞƌƵƐŝŶŐŝŶĂĚƵůƚƉĂƚŝĞŶƚƐǁŝƚŚĂŶƚŝĐŝƉĂƚĞĚĚŝĨĨŝĐƵůƚŝĞƐ;ƐĞĞ WĞĂƌůƐͿ͘

ϭ͘ KƉĞŶƚŚĞDĞůŬĞƌŬŝƚĂŶĚƉƌĞƉĂƌĞĞƋƵŝƉŵĞŶƚ͘ Ϯ͘ /ĚĞŶƚŝĨǇƚŚĞĂŶĂƚŽŵǇ͘ ϯ͘ WƌĞƉĂƌĞƚŚĞƐŝƚĞǁŝƚŚĂĐŚůŽƌĂƉƌĞƉƐǁĂď͘ ϰ͘ tŝƚŚƚŚĞƐƵƉƉůŝĞĚϲĐĐƐǇƌŝŶŐĞĂƚƚĂĐŚĞĚƚŽƚŚĞϭϴŐĂ͘ŝŶƚƌŽĚƵĐĞƌĐĂƚŚĞƚĞƌŶĞĞĚůĞ͕ĂĚǀĂŶĐĞƚŚĞŶĞĞĚůĞ ƚŚƌŽƵŐŚƚŚĞĐƌŝĐŽƚŚǇƌŽŝĚŵĞŵďƌĂŶĞĂƚĂϰϱĚĞŐƌĞĞĂŶŐůĞĂůŽŶŐƚŚĞŵŝĚůŝŶĞƚŽǁĂƌĚƐƚŚĞĨĞĞƚ͘ ϱ͘ tŚĞŶĂĚǀĂŶĐŝŶŐƚŚĞŶĞĞĚůĞ͕ǀĞƌŝĨǇĞŶƚƌĂŶĐĞŝŶƚŽƚŚĞƚƌĂĐŚĞĂǁŝƚŚĂĨƌĞĞƌĞƚƵƌŶŽĨĂŝƌƚŽƚŚĞƐǇƌŝŶŐĞ͘ ϲ͘ ZĞŵŽǀĞƚŚĞƐǇƌŝŶŐĞĂŶĚŶĞĞĚůĞ͕ůĞĂǀŝŶŐƚŚĞĐĂƚŚĞƚĞƌŝŶƉůĂĐĞ͘ ϳ͘ ĚǀĂŶĐĞƚŚĞƐŽĨƚ͕ĨůĞǆŝďůĞĞŶĚŽĨƚŚĞǁŝƌĞŐƵŝĚĞƚŚƌŽƵŐŚƚŚĞĐĂƚŚĞƚĞƌĂŶĚŝŶƚŽƚŚĞĂŝƌǁĂǇƐĞǀĞƌĂů ĐĞŶƚŝŵĞƚĞƌƐ͘ ϴ͘ ZĞŵŽǀĞƚŚĞĐĂƚŚĞƚĞƌůĞĂǀŝŶŐƚŚĞǁŝƌĞŐƵŝĚĞŝŶƉůĂĐĞ͘ ϵ͘ ĚǀĂŶĐĞƚŚĞŚĂŶĚůĞĚĚŝůĂƚŽƌŝŶƚŽƚŚĞ^ŚŝůĞǇƚƵďĞƵŶƚŝůƚŚĞŚĂŶĚůĞŝƐƐƚŽƉƉĞĚĂŐĂŝŶƐƚƚŚĞƚƵďĞ͘ ϭϬ͘ ĚǀĂŶĐĞƚŚĞĂƐƐĞŵďůǇŽǀĞƌƚŚĞǁŝƌĞŐƵŝĚĞĂŶĚŝŶƚŽƚŚĞƚƌĂĐŚĞĂ͘

Cypress Creek EMS System Policies and Treatment Guidelines

236 PROCEDURES Revised 8/2016 Airway Approved: Levon Vartanian, MD

ϭϭ͘ DĂŬĞĂƐŵĂůů;Ϭ͘ϱʹϭĐŵͿŝŶĐŝƐŝŽŶŚŽƌŝǌŽŶƚĂůůǇƚŚƌŽƵŐŚƚŚĞƐŬŝŶŽŶĞŝƚŚĞƌƐŝĚĞŽĨƚŚĞĚŝůĂƚŽƌǁŚĞŶŝƚ ŵĞĞƚƐƌĞƐŝƐƚĂŶĐĞ͘ ϭϮ͘ KŶĐĞƚŚĞĂŝƌǁĂǇĂƐƐĞŵďůǇŝƐĐŽŵƉůĞƚĞůǇŝŶƚŚĞƚƌĂĐŚĞĂ͕ƌĞŵŽǀĞƚŚĞǁŝƌĞŐƵŝĚĞĂŶĚĚŝůĂƚŽƌ ƐŝŵƵůƚĂŶĞŽƵƐůǇ͘ ϭϯ͘ ^ĞĐƵƌĞƚŚĞ^ŚŝůĞǇƚƵďĞŝŶƉůĂĐĞĂŶĚĐŽŶŶĞĐƚƚŽsD͘ ϭϰ͘ ŽŶĨŝƌŵƉůĂĐĞŵĞŶƚǁŝƚŚsDĂŶĚdKϮǁĂǀĞĨŽƌŵ͘ Pearls x dŚĞƌĞŵĂǇďĞŵŝŶŝŵĂůŽƌƐŝŐŶŝĨŝĐĂŶƚďůĞĞĚŝŶŐ͘hƐĞϰǆϰŐĂƵǌĞƚŽĂďƐŽƌďƐŝŐŶŝĨŝĐĂŶƚďůĞĞĚŝŶŐĂŶĚ ĐŽŶƐŝĚĞƌƵƐŝŶŐĐŽŶƚŝŶƵŽƵƐƐƵĐƚŝŽŶĂƚƐƵƌŐŝĐĂůƐŝƚĞŝĨŶĞĐĞƐƐĂƌǇ͘ x dŚĞƌĞĂƌĞŶŽĂďƐŽůƵƚĞĐŽŶƚƌĂŝŶĚŝĐĂƚŝŽŶƐƚŽĂŶĞŵĞƌŐĞŶĐǇĐƌŝĐŽƚŚǇƌŽƚŽŵǇ͘,ŽǁĞǀĞƌ͕ƚŚĞƉĂƚŝĞŶƚ ƐŚŽƵůĚƐƚŝůůďĞĂƐƐĞƐƐĞĚĨŽƌƉŽƐƐŝďůĞĐŚĂůůĞŶŐĞƐƚŽƚŚĞƉƌŽĐĞĚƵƌĞ͘hƐĞƚŚĞŵŶĞŵŽŶŝĐ^DZdĨŽƌ ĂƐƐĞƐƐŝŶŐĨŽƌĂŶǇďĂƌƌŝĞƌƐƚŽĐƌŝĐŽƚŚǇƌŽƚŽŵǇ͗ x ^ƵƌŐĞƌǇ;ƌĞĐĞŶƚŽƌƌĞŵŽƚĞͿ x DĂƐƐ x ĐĐĞƐƐͬĂŶĂƚŽŵǇ x ZĂĚŝĂƚŝŽŶĂŶĚŽƚŚĞƌĚĞĨŽƌŵŝƚǇŽƌƐĐĂƌƌŝŶŐ x dƵŵŽƌ

Cypress Creek EMS System Policies and Treatment Guidelines

237 PROCEDURES Revised 8/2016 Airway/Breathing Approved: Levon Vartanian, MD

^ƵĐƚŝŽŶŝŶŐ Indications Equipment Needed ŝƌǁĂǇŽďƐƚƌƵĐƚŝŽŶƐĞĐŽŶĚĂƌǇƚŽƐĞĐƌĞƚŝŽŶƐ͕ĞŵĞƐŝƐ͕ ^ƵĐƚŝŽŶŵĂĐŚŝŶĞ;ƉŽƌƚĂďůĞŽƌĂŵďƵůĂŶĐĞͲ ďůŽŽĚ͕ŽƌŽƚŚĞƌƐƵďƐƚĂŶĐĞƐŝŶĂƉĂƚŝĞŶƚǁŚŽĐĂŶŶŽƚ ŵŽƵŶƚĞĚͿ ŵĂŝŶƚĂŝŶĂƉĂƚĞŶƚĂŝƌǁĂǇ͘ ^ƵĐƚŝŽŶĐĂŶŝƐƚĞƌǁŝƚŚůŝĚ zĂŶŬĂƵĞƌƐƵĐƚŝŽŶĐĂƚŚĞƚĞƌǁŝƚŚƚƵďŝŶŐ Possibly&ƌĞŶĐŚͲƚŝƉƉĞĚƐƵĐƚŝŽŶĐĂƚŚĞƚĞƌƐŝǌĞĚ ĨŽƌƉĂƚŝĞŶƚ͘

;Ϳ KƌŽƉŚĂƌǇŶŐĞĂů^ƵĐƚŝŽŶŝŶŐWƌŽĐĞĚƵƌĞ x KƌŽƉŚĂƌǇŶŐĞĂůƐƵĐƚŝŽŶŝŶŐŵĂǇďĞƉĞƌĨŽƌŵĞĚƵƐŝŶŐĂzĂŶŬĂƵĞƌ;ƌŝŐŝĚƚŝƉͿƐƵĐƚŝŽŶĐĂƚŚĞƚĞƌŽƌ͕ŝĨ ĂƉƉƌŽƉƌŝĂƚĞ͕Ă&ƌĞŶĐŚĐĂƚŚĞƚĞƌ͘ x WƌĞŽǆǇŐĞŶĂƚĞƉĂƚŝĞŶƚŝĨƉŽƐƐŝďůĞ x sŝƐƵĂůůǇŝŶƐƉĞĐƚŽƌŽƉŚĂƌǇŶǆĂŶĚƌĞŵŽǀĞĂŶǇĨŽƌĞŝŐŶďŽĚŝĞƐŽƌŵĂƚĞƌŝĂůǀŝƐŝďůĞ͘ x ŶƐƵƌĞƐƵĐƚŝŽŶĚĞǀŝĐĞŝƐĨƵŶĐƚŝŽŶĂůƉƌŝŽƌƚŽƉƌŽĐĞĚƵƌĞ͘ x hƐĞƐƵĐƚŝŽŶĚĞǀŝĐĞƚŽĐůĞĂƌƐĞĐƌĞƚŝŽŶƐ͕ďůŽŽĚ͕ĞƚĐ͖͘ƚŚĞĂůĞƌƚƉĂƚŝĞŶƚŵĂǇďĞĂďůĞƚŽĂƐƐŝƐƚǁŝƚŚƚŚŝƐ ƉƌŽĐĞĚƵƌĞ͘ x ĞĐĂƵƚŝŽƵƐƚŽĂǀŽŝĚƚƌŝŐŐĞƌŝŶŐƚŚĞŐĂŐƌĞĨůĞǆĂŶĚďĞĐĂƌĞĨƵůƚŽŶŽƚĐĂƵƐĞǀĂŐĂůƐƚŝŵƵůĂƚŝŽŶďǇŚŝƚƚŝŶŐ ďĂĐŬŽĨƚŚƌŽĂƚ͘ x /ŶƉĞĚŝĂƚƌŝĐƉĂƚŝĞŶƚƐŽƌƉĂƚŝĞŶƚƐǁŝƚŚĐůĞŶĐŚĞĚƚĞĞƚŚŽƌŽƚŚĞƌŽďƐƚƌƵĐƚŝŽŶƐ͕ĐŽŶƐŝĚĞƌƵƐŝŶŐĂ&ƌĞŶĐŚͲ ƚŝƉƉĞĚƐƵĐƚŝŽŶĐĂƚŚĞƚĞƌĨŽƌŽƌŽƉŚĂƌǇŶŐĞĂůƐƵĐƚŝŽŶŝŶŐ͘

;/ͬWͿdƌĂĐŚĞĂůdƵďĞ^ƵĐƚŝŽŶŝŶŐWƌŽĐĞĚƵƌĞ x ^ƵĐƚŝŽŶŝŶŐŽĨĂŶĞŶĚŽƚƌĂĐŚĞĂůƚƵďĞ͕ŶĂƐŽƚƌĂĐŚĞĂůƚƵďĞ͕ƐƵƉƌĂŐůŽƚƚŝĐĂŝƌǁĂǇ͕Žƌ ƚƌĂĐŚĞŽƐƚŽŵǇͬĐƌŝĐŽƚŚǇƌŽƚŽŵǇƚƵďĞŵĂǇďĞŶĞĐĞƐƐĂƌǇƚŽĐůĞĂƌĞǆĐĞƐƐƐĞĐƌĞƚŝŽŶƐ͕ŵƵĐƵƐ͕ďůŽŽĚ͕Žƌ ŽƚŚĞƌŽďƐƚƌƵĐƚŝŽŶƐ͘ x hƐĞĂƐĞƉƚŝĐƚĞĐŚŶŝƋƵĞƚŚƌŽƵŐŚŽƵƚƉƌŽĐĞĚƵƌĞĂŶĚŵŝŶŝŵŝǌĞĐŽŶƚĂŵŝŶĂƚŝŽŶŽĨĞƋƵŝƉŵĞŶƚ͘ x ŶƐƵƌĞƐƵĐƚŝŽŶĚĞǀŝĐĞŝƐŝŶǁŽƌŬŝŶŐŽƌĚĞƌĂŶĚƐƵĐƚŝŽŶĐĂƚŚĞƚĞƌĂƉƉƌŽƉƌŝĂƚĞůǇƐŝǌĞĚĨŽƌƚƵďĞ ĚŝĂŵĞƚĞƌ͘ x WƌĞŽǆǇŐĞŶĂƚĞƉĂƚŝĞŶƚŝĨƉŽƐƐŝďůĞ͘DĂŝŶƚĂŝŶƉƵůƐĞŽǆŝŵĞƚƌǇĂŶĚĐĂƌĚŝĂĐŵŽŶŝƚŽƌŝŶŐƚŚƌŽƵŐŚŽƵƚ ƉƌŽĐĞĚƵƌĞ͘ x ƐƚŝŵĂƚĞƐƵĐƚŝŽŶĚĞƉƚŚƵƐŝŶŐƐƵƉƌĂƐƚĞƌŶĂůŶŽƚĐŚƚŽĞĂƌůŽďĞƚŽĞŶĚŽĨĂŝƌǁĂǇĚĞǀŝĐĞĂƐĂŐƵŝĚĞ͘ x tŝƚŚƚŚĞƚŚƵŵďƉŽƌƚŽĨƚŚĞĐĂƚŚĞƚĞƌƵŶĐŽǀĞƌĞĚ͕ŝŶƐĞƌƚĐĂƚŚĞƚĞƌŝŶƚŽĂŝƌǁĂǇƚƵďĞƚŽĚĞƐŝƌĞĚĚĞƉƚŚ͘ x KĐĐůƵĚĞƚŚƵŵďƉŽƌƚĂŶĚǁŝƚŚĚƌĂǁĐĂƚŚĞƚĞƌƐůŽǁůǇŽǀĞƌŶŽŵŽƌĞƚŚĂŶϭϬƐĞĐŽŶĚƐ͘ x /ĨĚĞƐŝƌĞĚ͕ĂƐŵĂůůĂŵŽƵŶƚ;ŶŽŵŽƌĞƚŚĂŶϭϬŵ>ͿŽĨŶŽƌŵĂůƐĂůŝŶĞŵĂǇďĞŝŶƐƚŝůůĞĚŝŶƚŽĂŝƌǁĂǇƚƵďĞ ƚŽůŽŽƐĞŶƐĞĐƌĞƚŝŽŶƐĨŽƌƐƵĐƚŝŽŶŝŶŐ͘

Cypress Creek EMS System Policies and Treatment Guidelines

238 PROCEDURES Revised 8/2016 Airway/Breathing Approved: Levon Vartanian, MD

/ŵƉĞĚĂŶĐĞdŚƌĞƐŚŽůĚĞǀŝĐĞ;ZĞƐYWŽĚͿ

Indications Equipment Needed WĂƚŝĞŶƚхϭǇĞĂƌŽůĚŝŶĐĂƌĚŝĂĐĂƌƌĞƐƚ͘ ZĞƐYWŽĚ sD Relative Contraindications: Optional^ƵƉƌĂŐůŽƚƚŝĐŽƌĂĚǀĂŶĐĞĚĂŝƌǁĂǇ x ŝůĂƚĞĚĐĂƌĚŝŽŵǇŽƉĂƚŚǇ x ŽŶŐĞƐƚŝǀĞŚĞĂƌƚĨĂŝůƵƌĞ x WƵůŵŽŶĂƌǇŚǇƉĞƌƚĞŶƐŝŽŶ x ŽƌƚŝĐƐƚĞŶŽƐŝƐ

Absolute contraindication:&ůĂŝůŚĞƐƚ WƌŽĐĞĚƵƌĞ x ^ĞůĞĐƚƚŚĞĂŝƌǁĂǇĂĚũƵŶĐƚ;ŵĂƐŬ͕dƚƵďĞ͕<ŝŶŐ ƐƵƉƌĂŐůŽƚƚŝĐĂŝƌǁĂǇ͕ĞƚĐͿ x ƚƚĂĐŚZĞƐYWŽĚƚŽĂŝƌǁĂǇ͕ƚŚĞŶƉůĂĐĞƚŚĞdKϮ BVM ĚĞƚĞĐƚŽƌ͕ĨŽůůŽǁĞĚďǇƚŚĞsD͘ x ĞŐŝŶWZĂƚƉƌŽƉĞƌƌĂƚĞĂŶĚĚĞƉƚŚĂŶĚĂůůŽǁĨŽƌ ĐŽŵƉůĞƚĞĐŚĞƐƚƌĞĐŽŝů͘ x /ĨƉĂƚŝĞŶƚĚŽĞƐŶŽƚŚĂǀĞĂŶĂĚǀĂŶĐĞĚĂŝƌǁĂǇ͕ĨŽůůŽǁĂ ϯϬ͗Ϯ;Žƌϭϱ͗ϮŝĨƉĞĚŝĂƚƌŝĐƉĂƚŝĞŶƚͿ ETCO2 ĐŽŵƉƌĞƐƐŝŽŶ͗ǀĞŶƚŝůĂƚŝŽŶƌĂƚŝŽĂŶĚĚŽŶŽƚƵƐĞƚŝŵŝŶŐ FilterLine ůŝŐŚƚ͘ x /ĨƉĂƚŝĞŶƚŚĂƐĂŶĂĚǀĂŶĐĞĚĂŝƌǁĂǇĂŶĚŝƐĂŶĂĚƵůƚ͕ƵƐĞ ƚŚĞƚŝŵŝŶŐůŝŐŚƚƚŽŐƵŝĚĞƉƌŽƉĞƌǀĞŶƚŝůĂƚŽƌƌĂƚĞ͘ x ŝƐĐŽŶŶĞĐƚĚĞǀŝĐĞǁŚĞŶZK^ŚĂƐďĞĞŶĂĐŚŝĞǀĞĚŽƌŝĨ WZŝƐŶŽůŽŶŐĞƌŶĞĐĞƐƐĂƌǇ͘ ResQPod WĞĂƌůƐ dŚĞZĞƐYWŽĚŝŵƉĞĚĂŶĐĞƚŚƌĞƐŚŽůĚĚĞǀŝĐĞƐĞůĞĐƚŝǀĞůǇ ŝŵƉĞĚĞƐŝŶƐƉŝƌĂƚŽƌǇŐĂƐĞƐĨƌŽŵĞŶƚĞƌŝŶŐƚŚĞůƵŶŐƐĚƵƌŝŶŐ Pt. Airway ƚŚĞĚĞĐŽŵƉƌĞƐƐŝŽŶƉŚĂƐĞ;ƵƉƐƚƌŽŬĞͿŽĨWZ͘dŚŝƐ Device ŐĞŶĞƌĂƚĞƐĂŐƌĞĂƚĞƌŶĞŐĂƚŝǀĞƉƌĞƐƐƵƌĞŝŶƚŚĞƚŚŽƌĂǆ͕ ĂůůŽǁŝŶŐĨŽƌĂŶĞŶŚĂŶĐĞĚǀĞŶŽƵƐƌĞƚƵƌŶƚŽƚŚĞŚĞĂƌƚ͘Ɛ ĂƌĞƐƵůƚŽĨŐƌĞĂƚĞƌǀĞŶŽƵƐƌĞƚƵƌŶŝŶĐƌĞĂƐĞĚƉƌĞůŽĂĚŝƐ ĂĐĐŽŵƉůŝƐŚĞĚǁŚŝĐŚŐĞŶĞƌĂƚĞƐĂŐƌĞĂƚĞƌƐƚƌŽŬĞǀŽůƵŵĞ ĚƵƌŝŶŐƚŚĞƐƵďƐĞƋƵĞŶƚĐŽŵƉƌĞƐƐŝŽŶƉŚĂƐĞ;ĚŽǁŶƐƚƌŽŬĞͿ ŽĨWZ͕ǁŚŝĐŚůĞĂĚƐƚŽŝŶĐƌĞĂƐĞĚďůŽŽĚĨůŽǁ͘

Cypress Creek EMS System Policies and Treatment Guidelines

239 PROCEDURES Revised 8/2016 Airway/Breathing Approved: Levon Vartanian, MD

ZĞƐY'ĂƌĚ Indications Equipment Needed ^ƉŽŶƚĂŶĞŽƵƐůǇďƌĞĂƚŚŝŶŐƉĂƚŝĞŶƚƐŝŶŶŽŶͲĐĂƌĚŝŽŐĞŶŝĐƐŚŽĐŬ͘ ZĞƐY'ĂƌĚ WŽƐƐŝďůĞĐĂƵƐĞƐŝŶĐůƵĚĞ͗ KǆǇŐĞŶ x ŶĂƉŚǇůĂǆŝƐ x ůŽŽĚůŽƐƐ x &ůƵŝĚůŽƐƐƐĞĐŽŶĚĂƌǇƚŽĚĞŚǇĚƌĂƚŝŽŶ͕ĚŝĂůǇƐŝƐ͕ďƵƌŶƐ͕ĞƚĐ͘ x ƌƵŐŽǀĞƌĚŽƐĞ x KƌƚŚŽƐƚĂƚŝĐŚǇƉŽƚĞŶƐŝŽŶ x WƌĞŐŶĂŶĐǇ x ^ĞƉƐŝƐ x EĞƵƌŽŐĞŶŝĐ^ŚŽĐŬ Contraindications: x WĞŶĞƚƌĂƚŝŶŐĐŚĞƐƚƚƌĂƵŵĂ x &ůĂŝůĐŚĞƐƚ x ^ŚŽƌƚŶĞƐƐŽĨďƌĞĂƚŚŽƌƌĞƐƉŝƌĂƚŽƌǇŝŶƐƵĨĨŝĐŝĞŶĐǇ x ŚĞƐƚƉĂŝŶ x ŝůĂƚĞĚĐĂƌĚŝŽŵǇŽƉĂƚŚǇ x ŽŶŐĞƐƚŝǀĞŚĞĂƌƚĨĂŝůƵƌĞ x WƵůŵŽŶĂƌǇŚǇƉĞƌƚĞŶƐŝŽŶ x ŽƌƚŝĐƐƚĞŶŽƐŝƐ WƌŽĐĞĚƵƌĞ ϭ͘ KďƚĂŝŶďĂƐĞůŝŶĞǀŝƚĂůƐŝŐŶƐĂŶĚŵŽŶŝƚŽƌĐĂƌĚŝĂĐƌŚǇƚŚŵ͘ Ϯ͘ ǆƉůĂŝŶŚŽǁĚĞǀŝĐĞǁŽƌŬƐƚŽƉĂƚŝĞŶƚĂŶĚƉƌŽǀŝĚĞǀĞƌďĂůƌĞĂƐƐƵƌĂŶĐĞ͘ ϯ͘ ƉƉůǇZĞƐY'ĂƌĚǁŝƚŚĨĂĐĞŵĂƐŬƚŽŶŽƐĞĂŶĚŵŽƵƚŚ͘ƐƚĂďůŝƐŚĂƚŝŐŚƚƐĞĂů͘ ϰ͘ hƐĞƚŚĞŚĞĂĚƐƚƌĂƉƚŽƐĞĐƵƌĞŝŶƉůĂĐĞĂŶĚŵĂŝŶƚĂŝŶƐĞĂů͘ ϱ͘ ,ĂǀĞƉĂƚŝĞŶƚďƌĞĂƚŚŝŶƐůŽǁůǇ;ϮͲϯƐĞĐŽŶĚƐͿĂŶĚĚĞĞƉůǇ͕ĂŶĚĞǆŚĂůĞŶŽƌŵĂůůǇ͘ ϲ͘ /ĨƵƐŝŶŐƐƵƉƉůĞŵĞŶƚĂůŽǆǇŐĞŶ͕ĂƚƚĂĐŚƚƵďŝŶŐƚŽŽǆǇŐĞŶƉŽƌƚŽĨZĞƐY'ĂƌĚ͘ŽŶŽƚĞǆĐĞĞĚϭϱůƉŵ ĚĞůŝǀĞƌǇ͘ ϳ͘ ZĞĂƐƐĞƐƐǀŝƚĂůƐŝŐŶƐĨƌĞƋƵĞŶƚůǇ͘ ϴ͘ /ĨƉĂƚŝĞŶƚĐĂŶŶŽƚƚŽůĞƌĂƚĞZĞƐY'ĂƌĚ͕ƌĞŵŽǀĞĂŶĚĚŽĐƵŵĞŶƚƚŝŵĞŽĨƌĞŵŽǀĂů͘ ϵ͘ /ĨƉĂƚŝĞŶƚĚĞǀĞůŽƉƐƌĞƐƉŝƌĂƚŽƌǇĚŝƐƚƌĞƐƐŝŵŵĞĚŝĂƚĞůǇĚŝƐĐŽŶƚŝŶƵĞƵƐĞŽĨZĞƐY'ĂƌĚ͘ ϭϬ͘ /ĨƉĂƚŝĞŶƚĐŽŵƉůĂŝŶƐŽĨŶĂƵƐĞĂĐŽŶƐŝĚĞƌƵƐŝŶŐZĞƐY'ĂƌĚǁŝƚŚŽƵƚŚĞĂĚƐƚƌĂƉƚŽĂůůŽǁĨŽƌĞĂƐǇ ƌĞŵŽǀĂůŝŶƚŚĞĞǀĞŶƚŽĨǀŽŵŝƚŝŶŐ͘ WĞĂƌůƐ x dŚĞZĞƐY'ĂƌĚŝƐĂŶŝŵƉĞĚĂŶĐĞƚŚƌĞƐŚŽůĚĚĞǀŝĐĞ;/dͿƚŚĂƚƉƌŽǀŝĚĞƐƚŚĞƌĂƉĞƵƚŝĐƌĞƐŝƐƚĂŶĐĞƚŽ ŝŶƐƉŝƌĂƚŝŽŶŝŶƐƉŽŶƚĂŶĞŽƵƐůǇďƌĞĂƚŚŝŶŐƉĂƚŝĞŶƚƐ͘ƵƌŝŶŐŝŶƐƉŝƌĂƚŝŽŶ͕ĂŶĞŐĂƚŝǀĞƉƌĞƐƐƵƌĞ;ĐƌĞĂƚĞĚ ĨƌŽŵĞǆƉĂŶƐŝŽŶŽĨƚŚĞƚŚŽƌĂǆͿĚƌĂǁƐĂŝƌŝŶƚŽƚŚĞůƵŶŐƐ͘tŚĞŶŝŶƐƉŝƌĂƚŽƌǇŝŵƉĞĚĂŶĐĞŝƐĂĚĚĞĚƚŽƚŚĞ ǀĞŶƚŝůĂƚŝŽŶĐŝƌĐƵŝƚ͕ŝƚĞŶŚĂŶĐĞƐƚŚĞŶĞŐĂƚŝǀĞƉƌĞƐƐƵƌĞ;ǀĂĐƵƵŵͿŝŶƚŚĞĐŚĞƐƚ͕ǁŚŝĐŚƉƵůůƐŵŽƌĞďůŽŽĚ

Cypress Creek EMS System Policies and Treatment Guidelines

240 PROCEDURES Revised 8/2016 Airway/Breathing Approved: Levon Vartanian, MD

ďĂĐŬƚŽƚŚĞŚĞĂƌƚ͕ƌĞƐƵůƚŝŶŐŝŶŝŶĐƌĞĂƐĞĚƉƌĞůŽĂĚĂŶĚƚŚƵƐ͕ĞŶŚĂŶĐĞĚĐĂƌĚŝĂĐŽƵƚƉƵƚŽŶƚŚĞ ƐƵďƐĞƋƵĞŶƚĐĂƌĚŝĂĐĐŽŶƚƌĂĐƚŝŽŶ͘ x /ŶĂƉĂƚŝĞŶƚǁŝƚŚŽƵƚ/sĂĐĐĞƐƐ͕ƚŚĞZĞƐY'ĂƌĚŵĂǇŵĂŬĞŝƚĞĂƐŝĞƌƚŽĞƐƚĂďůŝƐŚĂŶ/sĚƵĞƚŽ ŝŵƉƌŽǀĞŵĞŶƚŝŶďůŽŽĚƉƌĞƐƐƵƌĞ͘ x dŚĞZĞƐY'ĂƌĚƐŚŽƵůĚďĞƵƐĞĚŝŶĐŽŶũƵŶĐƚŝŽŶǁŝƚŚŽƚŚĞƌŝŶĚŝĐĂƚĞĚƚƌĞĂƚŵĞŶƚƐĨŽƌƐŚŽĐŬͬŚǇƉŽƚĞŶƐŝŽŶ ;Ğ͘Ő͕͘ĨůƵŝĚƐ͕ǀĂƐŽƉƌĞƐƐŽƌƐ͕ƉĂƚŝĞŶƚƉŽƐŝƚŝŽŶŝŶŐͿ͘ x /ŶĐĂƐĞƐŽĨŚĞŵŽƌƌŚĂŐŝĐƐŚŽĐŬǁŝƚŚŽƵƚďůĞĞĚŝŶŐĐŽŶƚƌŽů͕ƚŚĞZĞƐY'ĂƌĚŵĂǇďĞĂƌĞĂƐŽŶĂďůĞƚŚĞƌĂƉǇ ƚŽŵĂŝŶƚĂŝŶ͞ƉĞƌŵŝƐƐŝǀĞŚǇƉŽƚĞŶƐŝŽŶ͘͟ x dŚĞZĞƐY'ĂƌĚŵĂǇďĞƵƐĞĚŝŶĐŽŶũƵŶĐƚŝŽŶǁŝƚŚĂsDďǇƉůĂĐŝŶŐƚŚĞŽƌĂŶŐĞƉƌĞƐƐƵƌĞĐŽŶƚƌŽůƉŝĞĐĞ ŝŶďĞƚǁĞĞŶƚŚĞsDŵĂƐŬĂŶĚƚŚĞsDďĂŐ͘dŚŝƐŝƐƵƐĞĨƵůŝŶƉĂƚŝĞŶƚƐǁŚŽĂƌĞƉƌĞůŽĂĚĚĞƉůĞƚĞĚĂŶĚ ŚĞŵŽĚǇŶĂŵŝĐĂůůǇƵŶƐƚĂďůĞĂŶĚǁŚŽƌĞƋƵŝƌĞǀĞŶƚŝůĂƚŽƌƐƵƉƉŽƌƚŽƌĂƐƐŝƐƚĂŶĐĞ͘hƐĞĐůŝŶŝĐĂůĂƐƐĞƐƐŵĞŶƚ ĂŶĚũƵĚŐĞŵĞŶƚƚŽĚŝĨĨĞƌĞŶƚŝĂƚĞďĞƚǁĞĞŶŚĞŵŽĚǇŶĂŵŝĐŝŶƐƚĂďŝůŝƚǇĂŶĚƌĞƐƉŝƌĂƚŽƌǇĨĂƚŝŐƵĞĐĂƵƐĞĚďǇ ůŽǁƉƌĞůŽĂĚ;ǁŚŝĐŚǁŽƵůĚďĞŶĞĨŝƚĨƌŽŵZĞƐY'ĂƌĚͿǀƐ͘ŚĞŵŽĚǇŶĂŵŝĐŝŶƐƚĂďŝůŝƚǇĂŶĚƌĞƐƉŝƌĂƚŽƌǇ ĨĂƚŝŐƵĞĐĂƵƐĞĚďǇĂƌĞƐƉŝƌĂƚŽƌǇĚŝƐĞĂƐĞƉƌŽĐĞƐƐ;ǁŚŝĐŚǁŽƵůĚďĞŚĂƌŵĞĚǁŝƚŚZĞƐY'ĂƌĚͿ͘

Cypress Creek EMS System Policies and Treatment Guidelines

241 PROCEDURES Revised 8/2016 Airway/Breathing Approved: Levon Vartanian, MD

WƵůƐĞKǆŝŵĞƚƌǇ WƵƌƉŽƐĞ WƵůƐĞŽǆŝŵĞƚƌǇŝƐƵƐĞĨƵůĨŽƌŵĞĂƐƵƌŝŶŐĂŶĚŵŽŶŝƚŽƌŝŶŐƚŚĞƉĞƌĐĞŶƚĂŐĞŽĨŚĞŵŽŐůŽďŝŶƐĂƚƵƌĂƚĞĚǁŝƚŚ ŽǆǇŐĞŶŝŶƚŚĞĐĂƉŝůůĂƌǇĐŝƌĐƵůĂƚŝŽŶ͘dŚŝƐƌĞůĂƚĞƐƚŽƚŚĞĂǀĂŝůĂďŝůŝƚǇŽĨŽǆǇŐĞŶƚŽĞŶĚŽƌŐĂŶƚŝƐƐƵĞƐĂŶĚŝƐĂ ƵƐĞĨƵůĂƐƐĞƐƐŵĞŶƚƚŽŽůĨŽƌĞǀĂůƵĂƚŝŶŐƉĞƌĨƵƐŝŽŶĂŶĚŽǆǇŐĞŶĂƚŝŽŶ͘ WƌŽĐĞĚƵƌĞ x ƉƉůǇƉƌŽďĞƚŽĨŝŶŐĞƌŽƌƚŽĞǁŝƚŚƚŚĞ>ƐŝĚĞŽĨƚŚĞƉƌŽďĞĂƉƉůŝĞĚƚŽƚŚĞŶĂŝůďĞĚ͘ x hƚŝůŝǌĞĚŝƐƉŽƐĂďůĞ͕ƐƚŝĐŬĞƌͲƚǇƉĞƉƌŽďĞƐŽŶĂŶǇĐƌŝƚŝĐĂůƉĂƚŝĞŶƚǁŚĞƌĞŽŶŐŽŝŶŐƉƵůƐĞŽǆŝŵĞƚƌǇ ŵŽŶŝƚŽƌŝŶŐŝƐĐƌŝƚŝĐĂů͘ WĞĂƌůƐ x hƐĞŽĨƚŚĞƉƵůƐĞŽǆŝŵĞƚƌǇǁĂǀĞĨŽƌŵ;ƉůĞƚŚͿŝƐƵƐĞĨƵůĨŽƌĂƐƐĞƐƐŝŶŐƋƵĂůŝƚǇŽĨƉĞƌĨƵƐŝŽŶĂŶĚƐŝŐŶĂůƚŽ ƚŚĞƉƌŽďĞ͘/ĨƚŚĞǁĂǀĞĨŽƌŵŝƐĐůĞĂƌůǇĚĞĨŝŶĞĚĂŶĚĐŽŶƐŝƐƚĞŶƚ͕ƚŚĞƉƌŽďĞŝƐǁĞůůͲƉĞƌĨƵƐĞĚĂŶĚƚŚĞ ƌĞĂĚŝŶŐŚĂƐĂŚŝŐŚůĞǀĞůŽĨĂĐĐƵƌĂĐǇ͘/ĨƚŚĞǁĂǀĞĨŽƌŵŝƐƐůŽƉƉǇĂŶĚŝŶĐŽŶƐŝƐƚĞŶƚ͕ƚŚĞŶƚŚĞƉĞƌĨƵƐŝŽŶ ƋƵĂůŝƚǇŝƐůŽǁĂŶĚƚŚĞƉƌŽďĞƌĞĂĚŝŶŐŝƐǀĞƌǇŝŶĂĐĐƵƌĂƚĞ͘ x ƉƉůŝĐĂƚŝŽŶƚŽƉƵůƐĞůĞƐƐŽƌĐŽůĚĞǆƚƌĞŵŝƚŝĞƐǁŝůůƌĞƐƵůƚŝŶŝŶĂĐĐƵƌĂƚĞĚĞƚĞƌŵŝŶĂƚŝŽŶƐŽĨŚĞŵŽŐůŽďŝŶ ƐĂƚƵƌĂƚŝŽŶ͘ x &ĂůƐĞƌĞĂĚŝŶŐƐŵĂǇďĞŝŶĚŝĐĂƚĞĚďǇĞǆƚƌĞŵĞůǇƌĂƉŝĚĐŚĂŶŐŝŶŐŽƌĨůƵĐƚƵĂƚŝŶŐƌĞĂĚŝŶŐƐĂƐǁĞůůĂƐ ŝŶĂďŝůŝƚǇŽĨƚŚĞŵŽŶŝƚŽƌƚŽĞƐƚŝŵĂƚĞƚŚĞƉƵůƐĞĂĐĐƵƌĂƚĞůǇ͘ x dŚĞŚĞĂƌƚƌĂƚĞŵĂǇŶŽƚĂĐĐƵƌĂƚĞůǇƌĞĨůĞĐƚƚŚĞƉƵůƐĞƌĂƚĞŝŶƚŚĂƚŝƚŝƐƉŽƐƐŝďůĞƚŽŚĂǀĞĂůŽǁĞƌƉƵůƐĞ ƌĂƚĞƚŚĂŶŚĞĂƌƚƌĂƚĞ͘ x KǆǇŐĞŶƐĂƚƵƌĂƚŝŽŶƌĞĂĚŝŶŐƐĂƌĞƵŶƌĞůŝĂďůĞŝŶƚŚĞƉĂƚŝĞŶƚƐƵĨĨĞƌŝŶŐĨƌŽŵĐĂƌďŽŶŵŽŶŽǆŝĚĞƉŽŝƐŽŶŝŶŐ͘ dŚĞƉƵůƐĞŽǆŝŵĞƚĞƌĐĂŶŶŽƚĚŝƐƚŝŶŐƵŝƐŚĐĂƌďŽǆǇŚĞŵŽŐůŽďŝŶĨƌŽŵŽǆǇŚĞŵŽŐůŽďŝŶ͘ >ŝŵŝƚĂƚŝŽŶƐŽĨWƵůƐĞKǆŝŵĞƚƌǇ x KǆǇŐĞŶŝƐƚƌĂŶƐƉŽƌƚĞĚƚŚƌŽƵŐŚŽƵƚƚŚĞďŽĚǇďǇďŝŶĚŝŶŐƚŽŚĞŵŽŐůŽďŝŶŵŽůĞĐƵůĞƐŝŶƌĞĚďůŽŽĚĐĞůůƐ͘/ƚ ƐƚĂƌƚƐďǇďĞŝŶŐĚĞůŝǀĞƌĞĚƚŽƚŚĞůƵŶŐƐĂƐĂŐĂƐ͕ĂŶĚĐĂŶďĞŵĞĂƐƵƌĞĚŝŶƚŚĞĂůǀĞŽůŝĂƐĞŝƚŚĞƌ&ŝKϮ ;ĨƌĂĐƚŝŽŶͬƉĞƌĐĞŶƚĂŐĞŽĨĂŝƌƚŚĂƚŝƐŽǆǇŐĞŶͿŽƌĂƐWKϮ;ƉĂƌƚŝĂůƉƌĞƐƐƵƌĞŽĨĂůǀĞŽůĂƌŽǆǇŐĞŶͿ͘ x KǆǇŐĞŶƚŚĞŶĚŝĨĨƵƐĞƐĂĐƌŽƐƐŝŶƚŽƚŚĞĂůǀĞŽůĂƌĐĂƉŝůůĂƌŝĞƐ͘ŝƐƐŽůǀĞĚĂƐĂŐĂƐŝŶďůŽŽĚƉůĂƐŵĂ͕ŝƚĐĂŶďĞ ŵĞĂƐƵƌĞĚĂƐWĂKϮ;ƉĂƌƚŝĂůƉƌĞƐƐƵƌĞŽĨĂƌƚĞƌŝĂůŽǆǇŐĞŶͿ͘ x ƐŚĞŵŽŐůŽďŝŶŚĂǀĞŽƉĞŶ͞ƐůŽƚƐ͕͟ƚŚĞǇǁŝůůƉŝĐŬƵƉŽǆǇŐĞŶĨƌŽŵƚŚĞďůŽŽĚƉůĂƐŵĂĂŶĚƚŚĞŶĐĂƌƌǇŝƚ͘ ^ƉKϮŵĞĂƐƵƌĞƐǁŚĂƚƉĞƌĐĞŶƚĂŐĞŽĨƚŽƚĂůŚĞŵŽŐůŽďŝŶŚĂǀĞŽǆǇŐĞŶďŽƵŶĚƚŽƚŚĞŵ͘ x dŚĞƉƌŝŵĂƌǇůŝŵŝƚĂƚŝŽŶŽĨ^ƉKϮŝƐƚŚĂƚŝƚǁŝůůŶŽƚŵĞĂƐƵƌĞďĞǇŽŶĚϭϬϬйͶŝĨĂůůŽĨƚŚĞŚĞŵŽŐůŽďŝŶĂƌĞ ƐĂƚƵƌĂƚĞĚ͕ƚŚĞƌĞŝƐĂŶƵŶŬŶŽǁŶĂĚĚŝƚŝŽŶĂůĂŵŽƵŶƚŽĨŽǆǇŐĞŶĚŝƐƐŽůǀĞĚŝŶƚŚĞďůŽŽĚƉůĂƐŵĂ͘tŝƚŚŽƵƚ ĂǁĂǇƚŽŵĞĂƐƵƌĞWĂKϮ͕ŝƚŝƐĚŝĨĨŝĐƵůƚƚŽĚĞƚĞƌŵŝŶĞŝĨƚŚĞƉĂƚŝĞŶƚŚĂƐƚŽŽŵƵĐŚŽǆǇŐĞŶ;ŽǆǇŐĞŶ ƚŽǆŝĐŝƚǇͿ͘ x dŚĞƐĞĐŽŶĚĂƌǇůŝŵŝƚĂƚŝŽŶŝƐƚŚĂƚ^ƉKϮĚŽĞƐŶŽƚƌĞĨůĞĐƚƚŚĞƚŽƚĂůŶƵŵďĞƌŽĨŚĞŵŽŐůŽďŝŶ͘ƉĂƚŝĞŶƚ ǁŝƚŚůŽǁŚĞŵŽŐůŽďŝŶŵĂǇďĞϭϬϬйƐĂƚƵƌĂƚĞĚďƵƚǁŝůůƐƚŝůůďĞŚǇƉŽǆŝĐĚƵĞƚŽďĞŝŶŐĂŶĞŵŝĐ͘ ƐĞƉĂƌĂƚĞŚĞŵŽŐůŽďŝŶŵĞĂƐƵƌĞŵĞŶƚĐĂŶŵŝƚŝŐĂƚĞƚŚŝƐůŝŵŝƚĂƚŝŽŶ͘ x dŚĞƚŚŝƌĚůŝŵŝƚĂƚŝŽŶŝƐƚŚĂƚƐƚĂŶĚĂƌĚ^ƉKϮƐĞŶƐŽƌƐǁŝůůŶŽƚĚŝĨĨĞƌĞŶƚŝĂƚĞďĞƚǁĞĞŶŚĞŵŽŐůŽďŝŶ ƐĂƚƵƌĂƚĞĚǁŝƚŚŽǆǇŐĞŶĂŶĚŚĞŵŽŐůŽďŝŶƐĂƚƵƌĂƚĞĚǁŝƚŚĐĂƌďŽŶŵŽŶŽǆŝĚĞ͘

Cypress Creek EMS System Policies and Treatment Guidelines

242 PROCEDURES Revised 8/2016 Airway/Breathing Approved: Levon Vartanian, MD

KǆǇŐĞŶĚŵŝŶŝƐƚƌĂƚŝŽŶ WƵƌƉŽƐĞ KǆǇŐĞŶĂĚŵŝŶŝƐƚƌĂƚŝŽŶŝƐƵƐĞĚƚŽƌĞǀĞƌƐĞŚǇƉŽǆĞŵŝĂĐĂƵƐĞĚďǇƌĞƐƉŝƌĂƚŽƌǇŝŶƐƵĨĨŝĐŝĞŶĐǇ͕ĐĂƌĚŝĂĐ ŝŶƐƵĨĨŝĐŝĞŶĐǇ͕ŽƌƚŚĞĞĨĨĞĐƚƐŽĨĐĞƌƚĂŝŶƚŽǆŝŶƐĂƚƚŚĞĐĞůůƵůĂƌůĞǀĞů͘ /ŶĚŝĐĂƚŝŽŶƐ x ŶǇƉĂƚŝĞŶƚǁŝƚŚƐƵƐƉĞĐƚĞĚŽƌĐŽŶĨŝƌŵĞĚŚǇƉŽǆŝĂ;^ƉKϮфϵϰйͿ x /ƐĐŚĞŵŝĐĐŚĞƐƚĚŝƐĐŽŵĨŽƌƚ͕ŝĨ^ƉKϮфϵϰй x ZĞƐƉŝƌĂƚŽƌǇŝŶƐƵĨĨŝĐŝĞŶĐǇ;ĐĂƵƐĞĚďǇŚǇƉŽǀĞŶƚŝůĂƚŝŽŶŽƌĂĚŝĨĨƵƐŝŽŶƉƌŽďůĞŵͿ x ^ƵƐƉĞĐƚĞĚŽƌĐŽŶĨŝƌŵĞĚKƉŽŝƐŽŶŝŶŐ x ^ƵƐƉĞĐƚĞĚŽƌĐŽŶĨŝƌŵĞĚĐǇĂŶŝĚĞƉŽŝƐŽŶŝŶŐ x ŶǇĐŽŶĚŝƚŝŽŶŽĨĚĞĐƌĞĂƐĞĚƚŝƐƐƵĞŽǆǇŐĞŶĂƚŝŽŶ x ĞĐƌĞĂƐĞĚůĞǀĞůŽĨĐŽŶƐĐŝŽƵƐŶĞƐƐ ĚŵŝŶŝƐƚƌĂƚŝŽŶΘŽƐĂŐĞ x KǆǇŐĞŶƐŚŽƵůĚďĞĂĚŵŝŶŝƐƚĞƌĞĚĂƚϭϬϬй&ŝKϮ͕ϭϱůƉŵĨůŽǁƌĂƚĞĨŽƌĂŶǇƉĂƚŝĞŶƚŝŶĐĂƌĚŝĂĐĂƌƌĞƐƚŽƌ ǁŝƚŚĐĂƌďŽŶŵŽŶŽǆŝĚĞŽƌĐǇĂŶŝĚĞƉŽŝƐŽŶŝŶŐ͘ x KǆǇŐĞŶƐŚŽƵůĚďĞƉƌŽǀŝĚĞĚƚŽĂŶǇƉĂƚŝĞŶƚĞǆƉĞƌŝĞŶĐŝŶŐŚǇƉŽǆŝĂ͕ƚŝƚƌĂƚĞĚƚŽĚĞƐŝƌĞĚĞĨĨĞĐƚ͘ x KǆǇŐĞŶƐŚŽƵůĚŶŽƚďĞǁŝƚŚŚĞůĚĨƌŽŵƚƌĂƵŵĂƉĂƚŝĞŶƚƐ͘ x WĂƚŝĞŶƚƐĞǆƉĞƌŝĞŶĐŝŶŐŝƐĐŚĞŵŝĐĐŚĞƐƚĚŝƐĐŽŵĨŽƌƚƐŚŽƵůĚƌĞĐĞŝǀĞŽǆǇŐĞŶƚŝƚƌĂƚĞĚƚŽĂŶ^ƉKϮŽĨϵϰͲ ϵϳй͘KǆǇŐĞŶƐŚŽƵůĚŶŽƚďĞƌŽƵƚŝŶĞůǇĂĚŵŝŶŝƐƚĞƌĞĚƚŽƉĂƚŝĞŶƚƐǁŝƚŚŝƐĐŚĞŵŝĐĐŚĞƐƚĚŝƐĐŽŵĨŽƌƚƵŶůĞƐƐ ƚŚĞ^ƉKϮŝƐфϵϰй͘ x WŽƐŝƚŝǀĞƉƌĞƐƐƵƌĞĂƐƐŝƐƚĂŶĐĞ;WW͕WW͕sDͿŵĂǇďĞŶĞĐĞƐƐĂƌǇƚŽĂĐŚŝĞǀĞŚŝŐŚĞƌĐŽŶĐĞŶƚƌĂƚŝŽŶƐ ŽĨŽǆǇŐĞŶŝŶƉĂƚŝĞŶƚƐǁŝƚŚǀĞŶƚŝůĂƚŽƌĐŽŵƉƌŽŵŝƐĞ͘

Cypress Creek EMS System Policies and Treatment Guidelines

243 PROCEDURES 22 Revised 8/2016 Airway/Breathing Approved: Levon Vartanian, MD

sĞŶƚŝůĂƚŽƌKƉĞƌĂƚŝŽŶ

Indications Equipment Needed Assessment Requirements /ŶƚƵďĂƚĞĚƉĂƚŝĞŶƚƐŶŽƚŝŶĐĂƌĚŝĂĐ ŽůůssĞŶƚŝůĂƚŽƌ;ŽŶ ĂƌĚŝĂĐŵŽŶŝƚŽƌŝŶŐ ĂƌƌĞƐƚĂŶĚƌĞƋƵŝƌŝŶŐǀĞŶƚŝůĂƚŽƌǇ ƐƵƉĞƌǀŝƐŽƌǀĞŚŝĐůĞƐͿ dKϮǁĂǀĞĨŽƌŵŵŽŶŝƚŽƌŝŶŐ ƐƵƉƉŽƌƚ͘ ^ƉKϮŵŽŶŝƚŽƌŝŶŐ KǆǇŐĞŶĐǇůŝŶĚĞƌǁŝƚŚKŚŝŽǀĂůǀĞ ƌĞĂƚŚƐŽƵŶĚƐ͕ƌĞĂƐƐĞƐƐĞĚ Contraindications: ĨƌĞƋƵĞŶƚůǇ͘ x Cardiac Arrest May also use WĂƌĂWĂĐsĞŶƚŝůĂƚŽƌ x Patients weighing < 5 kg ŝĨŽůůsŝƐƵŶĂǀĂŝůĂďůĞ͘

WƌŽĐĞĚƵƌĞĨŽƌŽůůssĞŶƚŝůĂƚŽƌ ϭ͘ hƚŝůŝǌĞsDǁŚŝůĞƐĞƚƚŝŶŐƵƉǀĞŶƚŝůĂƚŽƌĂŶĚŬĞĞƉsDǁŝƚŚŝŶƌĞĂĐŚĨŽƌĚƵƌĂƚŝŽŶŽĨƉĂƚŝĞŶƚĐĂƌĞ͘ Ϯ͘ ^ĞƚƵƉǀĞŶƚŝůĂƚŽƌĐŝƌĐƵŝƚĂŶĚĂƚƚĂĐŚĂŝƌŚŽƐĞƚŽǀĞŶƚŝůĂƚŽƌŽƵƚƉŽƌƚ͕ĂƚƚĂĐŚĐůĞĂƌƐĞŶƐŽƌͬĐŽŶƚƌŽůƚƵďŝŶŐ ƚŽƐŝůǀĞƌƉŽƌƚ͕ĂŶĚĂƚƚĂĐŚŐƌĞĞŶƐĞŶƐŽƌͬĐŽŶƚƌŽůƚƵďŝŶŐƚŽŐƌĞĞŶƉŽƌƚ͘ ϯ͘ ƚƚĂĐŚǀĞŶƚŝůĂƚŽƌƚŽŽǆǇŐĞŶƵƐŝŶŐKŚŝŽǀĂůǀĞĐŽŶŶĞĐƚŽƌ͘ ϰ͘ dƵƌŶŽŶǀĞŶƚŝůĂƚŽƌ͕ĐŽŶĨŝƌŵŵŽĚĞĂƐ;sͿ͕ĂŶĚƐĞƚŝŶŝƚŝĂůƐĞƚƚŝŶŐƐ;ƐĞĞŶĞǆƚƉĂŐĞͿ͘ ϱ͘ ƚƚĂĐŚǀĞŶƚŝůĂƚŽƌĐŝƌĐƵŝƚƚŽdƚƵďĞ͘ ϲ͘ sĞƌŝĨǇƉůĂĐĞŵĞŶƚǁŝƚŚdKϮǁĂǀĞĨŽƌŵĂŶĚĐŚĞƐƚƌŝƐĞ͘ ϳ͘ DŽŶŝƚŽƌǀĞŶƚŝůĂƚŝŽŶƉƌĞƐƐƵƌĞƐĂŶĚĂĚũƵƐƚǀĞŶƚŝůĂƚŝŽŶƐĞƚƚŝŶŐƐĂƐŶĞĞĚĞĚ͘ ϴ͘ ZĞĂƐƐĞƐƐďƌĞĂƚŚƐŽƵŶĚƐ͕ǀĞŶƚŝůĂƚŽƌƐĞƚƚŝŶŐƐ͕ĂŶĚƚƵďĞƉůĂĐĞŵĞŶƚĨƌĞƋƵĞŶƚůǇ;ĂƚůĞĂƐƚĞǀĞƌǇĨŝǀĞ ŵŝŶƵƚĞƐ͕ĞǀĞƌǇƚŝŵĞƉĂƚŝĞŶƚŝƐŵŽǀĞĚ͕ĂŶĚĂŶǇƚŝŵĞƉĂƚŝĞŶƚǀŝƚĂůƐŝŐŶƐŽƌĐŽŶĚŝƚŝŽŶĐŚĂŶŐĞƐͿ͘ 9. Ventilator must be monitored throughout transport by a provider credentialed for Zoll Ventilator operations by the Clinical Department. WƌŽĐĞĚƵƌĞĨŽƌWĂƌĂWĂĐǀĞŶƚŝůĂƚŽƌ ϭ͘ hƚŝůŝǌĞsDǁŚŝůĞƐĞƚƚŝŶŐƵƉǀĞŶƚŝůĂƚŽƌĂŶĚŬĞĞƉsDǁŝƚŚŝŶƌĞĂĐŚĨŽƌĚƵƌĂƚŝŽŶŽĨƉĂƚŝĞŶƚĐĂƌĞ͘ Ϯ͘ ^ĞƚƵƉǀĞŶƚŝůĂƚŽƌĐŝƌĐƵŝƚĂŶĚĂƚƚĂĐŚƚŽǀĞŶƚŝůĂƚŽƌŽƵƚƉŽƌƚ͘ ϯ͘ ƚƚĂĐŚǀĞŶƚŝůĂƚŽƌƚŽŽǆǇŐĞŶƵƐŝŶŐKŚŝŽǀĂůǀĞĐŽŶŶĞĐƚŝŽŶ͘ ϰ͘ ^ĞƚŝƌDŝǆĚŝĂůƚŽϭϬϬйĂŶĚƌĞůŝĞĨƉƌĞƐƐƵƌĞĂůĂƌŵƚŽϯϱ͘ ϱ͘ ^ĞƚŝŶŝƚŝĂůƐĞƚƚŝŶŐƐƵƐŝŶŐĂƉƉƌŽƉƌŝĂƚĞƐƚƌĂƚĞŐǇ;ƐĞĞďĞůŽǁͿ͘ ϲ͘ ƚƚĂĐŚWW͕ŝĨĂƉƉƌŽƉƌŝĂƚĞĨŽƌƉĂƚŝĞŶƚ͕ƚŽĞǆŚĂƵƐƚƉŽƌƚŽĨǀĞŶƚŝůĂƚŽƌĐŝƌĐƵŝƚ͘ ϳ͘ dƵƌŶŽŶǀĞŶƚŝůĂƚŽƌĂŶĚďƌŝĞĨůǇŽĐĐůƵĚĞƉĂƚŝĞŶƚĐŽŶŶĞĐƚŽƌƚŽǀĞƌŝĨǇǀĞŶƚŝůĂƚŽƌŽƉĞƌĂƚŝŽŶĂŶĚƉƌĞƐƐƵƌĞ ƌĞůŝĞĨĂůĂƌŵĨƵŶĐƚŝŽŶ͘ ϴ͘ ŽŶŶĞĐƚǀĞŶƚŝůĂƚŽƌĐŝƌĐƵŝƚƚŽĞŶĚŽƚƌĂĐŚĞĂůƚƵďĞ͘ ϵ͘ sĞƌŝĨǇƉůĂĐĞŵĞŶƚǁŝƚŚdKϮǁĂǀĞĨŽƌŵĂŶĚĐŚĞƐƚƌŝƐĞ͘ ϭϬ͘ DŽŶŝƚŽƌǀĞŶƚŝůĂƚŝŽŶƉƌĞƐƐƵƌĞƐĂŶĚƵƚŝůŝǌĞƉƌĞƐƐƵƌĞƐĂůŽŶŐǁŝƚŚdKϮƚŽĚĞƚĞƌŵŝŶĞŝĨǀĞŶƚŝůĂƚŝŽŶŝƐ ĂĚĞƋƵĂƚĞŽƌŶĞĞĚƐƚŽďĞĂĚũƵƐƚĞĚ͘ ϭϭ͘ ZĞĂƐƐĞƐƐďƌĞĂƚŚƐŽƵŶĚƐ͕ǀĞŶƚŝůĂƚŽƌƐĞƚƚŝŶŐƐ͕ĂŶĚƚƵďĞƉůĂĐĞŵĞŶƚĨƌĞƋƵĞŶƚůǇ;ĂƚůĞĂƐƚĞǀĞƌǇĨŝǀĞ ŵŝŶƵƚĞƐ͕ĞǀĞƌǇƚŝŵĞƉĂƚŝĞŶƚŝƐŵŽǀĞĚ͕ĂŶĚĂŶǇƚŝŵĞƉĂƚŝĞŶƚǀŝƚĂůƐŝŐŶƐŽƌĐŽŶĚŝƚŝŽŶĐŚĂŶŐĞƐͿ͘

Cypress Creek EMS System Policies and Treatment Guidelines

244 PROCEDURES 22 Revised 8/2016 Airway/Breathing Approved: Levon Vartanian, MD

WƌŽĐĞĚƵƌĞĨŽƌhƐŝŶŐWĂƚŝĞŶƚ͛ƐsĞŶƚŝůĂƚŽƌ WĂƚŝĞŶƚƐǁŝƚŚĂůŽŶŐͲƚĞƌŵŝůůŶĞƐƐŵĂǇďĞŽŶĂǀĞŶƚŝůĂƚŽƌŽĨƚŚĞŝƌŽǁŶĂƚŚŽŵĞ͘dƌĂŶƐƉŽƌƚƚŽŚŽƐƉŝƚĂůŵĂǇ ďĞĂĐĐŽŵƉůŝƐŚĞĚǁŝƚŚƚŚĞŝƌǀĞŶƚŝůĂƚŽƌƵƐŝŶŐƚŚĞĨŽůůŽǁŝŶŐŐƵŝĚĞůŝŶĞƐ͗ x WƌŽǀŝĚĞƌƐƐŚŽƵůĚƌĞǀŝĞǁŽƉĞƌĂƚŝŽŶŽĨƚŚĞǀĞŶƚŝůĂƚŽƌǁŝƚŚƚŚĞƚƌĞĂƚŝŶŐƉĞƌƐŽŶŶĞů;ƉŚǇƐŝĐŝĂŶ͕ŶƵƌƐĞ͕ ƌĞƐƉŝƌĂƚŽƌǇƚŚĞƌĂƉŝƐƚ͕ŽƌƉĂƌĞŶƚͿƉƌŝŽƌƚŽƚƌĂŶƐƉŽƌƚŝĨƉŽƐƐŝďůĞ͘ x ZĞĐŽƌĚĂůůǀĞŶƚŝůĂƚŽƌƐĞƚƚŝŶŐƐŝŶĐůƵĚŝŶŐƌĞƐƉŝƌĂƚŽƌǇƌĂƚĞ͕&ŝKϮ͕ǀĞŶƚŝůĂƚŽƌŵŽĚĞ͕ƚŝĚĂůǀŽůƵŵĞƐ͕ĂŶĚ ƉƌĞƐƐƵƌĞƐƉƌŝŽƌƚŽďĞŐŝŶŶŝŶŐƚƌĂŶƐƉŽƌƚ͘ x sĞƌŝĨǇƚŚĂƚǀĞŶƚŝůĂƚŽƌŚĂƐƐƵĨĨŝĐŝĞŶƚďĂƚƚĞƌǇůŝĨĞĂŶĚͬŽƌƉŽǁĞƌƉůƵŐĐŽŶŶĞĐƚŝŽŶƐƚŽĂĐĐŽŵƉůŝƐŚ ƚƌĂŶƐƉŽƌƚ͘ŶƐƵƌĞŽǆǇŐĞŶƐƵƉƉůǇŝƐĂĚĞƋƵĂƚĞĂŶĚǀĞŶƚŝůĂƚŽƌŝƐĐŽƌƌĞĐƚůǇĐŽŶŶĞĐƚĞĚƚŽŽǆǇŐĞŶ͘ x ,ĂǀĞsDǁŝƚŚŝŶƌĞĂĐŚƚŚƌŽƵŐŚŽƵƚƚƌĂŶƐƉŽƌƚ͘ dƌŽƵďůĞƐŚŽŽƚŝŶŐsĞŶƚŝůĂƚŽƌ x /ĨƉĞĂŬƉƌĞƐƐƵƌĞĂůĂƌŵƐŽƌŽƚŚĞƌƉƌŽďůĞŵƐĂƌĞĞŶĐŽƵŶƚĞƌĞĚǁŚŝůĞĂƉĂƚŝĞŶƚŝƐŽŶƚŚĞWĂƌĂWĂĐ ǀĞŶƚŝůĂƚŽƌ͕ƐƚĂƌƚƚƌŽƵďůĞƐŚŽŽƚŝŶŐďǇĚŝƐĐŽŶŶĞĐƚŝŶŐǀĞŶƚŝůĂƚŽƌĐŝƌĐƵŝƚĂŶĚƌĞƐƵŵŝŶŐǀĞŶƚŝůĂƚŝŽŶƐǁŝƚŚ ŵĂŶƵĂůďĂŐͲǀĂůǀĞĚĞǀŝĐĞ͘ x /ĨĂůĂƌŵƐĂƌĞĞŶĐŽƵŶƚĞƌĞĚǁŚŝůĞĂƉĂƚŝĞŶƚŝƐŽŶƚŚĞŽůůsǀĞŶƚŝůĂƚŽƌ͕ĨŽůůŽǁƚŚĞŽŶͲƐĐƌĞĞŶĐŚĞĐŬůŝƐƚ ĚŽƚƌŽƵďůĞƐŚŽŽƚ͘/ĨƉƌŽďůĞŵŝƐŶ͛ƚƌĞƐŽůǀĞĚ͕ĚŝƐĐŽŶŶĞĐƚǀĞŶƚŝůĂƚŽƌĐŝƌĐƵŝƚĂŶĚƌĞƐƵŵĞǀĞŶƚŝůĂƚŝŽŶƐǁŝƚŚ ŵĂŶƵĂůďĂŐͲǀĂůǀĞĚĞǀŝĐĞ͘ x hƐĞDOPEƚŽƚƌŽƵďůĞƐŚŽŽƚƉƌŽďůĞŵƐ͗ o ŚĞĐŬĨŽƌƚƵďĞdisplacementďǇĐŚĞĐŬŝŶŐdKϮǁĂǀĞĨŽƌŵĂŶĚďƌĞĂƚŚƐŽƵŶĚƐ͘ o ŚĞĐŬĨŽƌobstructionŝŶƚƵďĞ͕ǀĞŶƚŝůĂƚŽƌĐŝƌĐƵŝƚ͕ŽƌůƵŶŐƐ͘ o ŚĞĐŬĨŽƌpneumothoraxǁŝƚŚďƌĞĂƚŚƐŽƵŶĚƐĂŶĚsDĐŽŵƉůŝĂŶĐĞ͘dƌĞĂƚŝĨŝŶĚŝĐĂƚĞĚ͘ o ŚĞĐŬĨŽƌequipmentƉƌŽďůĞŵƐŝŶǀĞŶƚŝůĂƚŽƌĐŝƌĐƵŝƚ͘ sĞŶƚŝůĂƚŽƌDĂŶĂŐĞŵĞŶƚ^ƚƌĂƚĞŐŝĞƐ Lung Injury Strategy—For Most Patients x VT;ƚŝĚĂůǀŽůƵŵĞͿĂĚũƵƐƚĞĚƚŽƉƌŽƚĞĐƚůƵŶŐƐĨƌŽŵŽǀĞƌͲƉƌĞƐƐƵƌĞƐ͘^ƚĂƌƚĂƚϲͲϴŵ>ͬŬŐŽĨŝĚĞĂůďŽĚǇ ǁĞŝŐŚƚĂŶĚĂĚũƵƐƚƚŽƚĂƌŐĞƚǀĞŶƚŝůĂƚŝŽŶƉƌĞƐƐƵƌĞƐфϯϬʹϯϱ͘DŝŶŝŵƵŵŽĨϰŵ>ͬŬŐ͘ x RR͗ĚũƵƐƚĞĚĨŽƌǀĞŶƚŝůĂƚŝŽŶ͘^ƚĂƌƚĂƚϭϬͲϭϮďƌĞĂƚŚƐͬŵŝŶƵƚĞĨŽƌƚŚĞĂǀĞƌĂŐĞĂĚƵůƚ͕ĂĚũƵƐƚƚŽdKϮ ǁŝƚŚŝŶϯϱʹϰϬŵŵ,ŐƌĂŶŐĞ͘ĚũƵƐƚƌĂƚĞĨŽƌƉĞĚŝĂƚƌŝĐƉĂƚŝĞŶƚƐĂƐĂƉƉƌŽƉƌŝĂƚĞ͘ x FiO2:^ƚĂƌƚĂƚϭϬϬй͕ƚŝƚƌĂƚĞĂƚϱʹϭϬŵŝŶƵƚĞŝŶƚĞƌǀĂůƐƚŽĚĞƐŝƌĞĚ^ƉKϮ͘ x PEEP͗ĚĚĞĚƚŽƐƵƉƉŽƌƚŽǆǇŐĞŶĂƚŝŽŶŝĨŶĞĞĚĞĚ͖ďĞĐĂƵƚŝŽƵƐŽĨŚǇƉŽƚĞŶƐŝŽŶ͘ x Relief Pressure (Parapac): ϯϱ͘ Obstructive Disease Strategy—For patients with COPD, asthma, etc. x <ĞǇŐŽĂůŝƐĂůůŽǁŝŶŐĞŶŽƵŐŚƚŝŵĞĨŽƌĨƵůůĞǆŚĂůĂƚŝŽŶƚŽƉƌĞǀĞŶƚĂŝƌƚƌĂƉƉŝŶŐ͘ x VT: ^ƚĂƌƚĂƚϴŵ>ͬŬŐ͕ĚƌŽƉƚŽĂŵŝŶŝŵƵŵŽĨϲŵ>ͬŬŐŝĨƉůĂƚĞĂƵ;ǀĞŶƚŝůĂƚŝŽŶͿƉƌĞƐƐƵƌĞƐĂƌĞƚŽŽŚŝŐŚ͘ x RR:^ƚĂƌƚĂƚϭϬďƌĞĂƚŚƐͬŵŝŶƵƚĞĨŽƌƚŚĞĂǀĞƌĂŐĞĂĚƵůƚĂŶĚůŽǁĞƌƚŽĂůůŽǁƚŝŵĞĨŽƌĞǆŚĂůĂƚŝŽŶ͘ĚũƵƐƚ ƌĂƚĞĨŽƌƉĞĚŝĂƚƌŝĐƉĂƚŝĞŶƚƐĂƐĂƉƉƌŽƉƌŝĂƚĞ͘ x FiO2:^ƚĂƌƚĂƚϭϬϬй͕ƚŝƚƌĂƚĞĂƚϱʹϭϬŵŝŶƵƚĞŝŶƚĞƌǀĂůƐƚŽĚĞƐŝƌĞĚ^ƉKϮ͘ x PEEP:Ϭ x Permissive hypercapniaŵĞĂŶƐĂůůŽǁŝŶŐŚŝŐŚĞƌdKϮŝĨŶĞĞĚĞĚƚŽĂǀŽŝĚĂŝƌƚƌĂƉƉŝŶŐ͘ x /ŶĐƌĞĂƐĞI:EƌĂƚŝŽĂƐŶĞĞĚĞĚƚŽĞŶƐƵƌĞĨƵůůĞǆŚĂůĂƚŝŽŶ͘

Cypress Creek EMS System Policies and Treatment Guidelines

245 PROCEDURES 22 Revised 8/2016 Airway/Breathing Approved: Levon Vartanian, MD

WĞĂƌůƐ x tŚĞŶƵƐŝŶŐĂŶǇŵĂŶĚĂƚŽƌǇǀĞŶƚŝůĂƚŝŽŶŵŽĚĞ;͕^/Ds͕Ds͕ĞƚĐ͘ͿĞŶƐƵƌĞƉĂƚŝĞŶƚŚĂƐĂĚĞƋƵĂƚĞ ƐĞĚĂƚŝŽŶ͘^ŝŐŶƐŽĨƉŽŽƌƐĞĚĂƚŝŽŶŝŶĐůƵĚĞƚƌĞŶĚŝŶŐƚĂĐŚǇĐĂƌĚŝĂ͕ƚĞĂƌĨŽƌŵĂƚŝŽŶ͕ĨŝŐŚƚŝŶŐǀĞŶƚŝůĂƚŝŽŶ ďƌĞĂƚŚƐ͕ĂŶĚĨŝŐŚƚŝŶŐƚƵďĞ͘ x dĂƌŐĞƚƉĞĂŬ;W/WͿƉƌĞƐƐƵƌĞƐƵŶĚĞƌϯϱĐŵ,ϮKĂŶĚƉůĂƚĞĂƵƉƌĞƐƐƵƌĞƐŽĨϯϬĐŵ,ϮKŽƌůĞƐƐ͘ x 'ĞŶĞƌĂůůǇ͕ǀŽůƵŵĞͲƚĂƌŐĞƚĞĚǀĞŶƚŝůĂƚŝŽŶ;;sͿͿŝƐĂĚĞƋƵĂƚĞ͘,ŽǁĞǀĞƌ͕ŝĨƚŚĞƉĂƚŝĞŶƚ͛ƐƉĞĂŬŽƌ ƉůĂƚĞĂƵƉƌĞƐƐƵƌĞƐĂƌĞŝŶĐƌĞĂƐŝŶŐĂďŽǀĞϯϱŽƌϯϬ͕ƌĞƐƉĞĐƚŝǀĞůǇ͕ĐŽŶƐŝĚĞƌƐǁŝƚĐŚŝŶŐƚŽƉƌĞƐƐƵƌĞͲ ƚĂƌŐĞƚĞĚǀĞŶƚŝůĂƚŝŽŶ;;WͿͿ͘

Cypress Creek EMS System Policies and Treatment Guidelines

246 PROCEDURES Revised 8/2016 Airway/Breathing Approved: Levon Vartanian, MD

dƌĂĐŚĞŽƐƚŽŵǇdƵďĞŚĂŶŐĞ Indications Equipment Needed Assessment Requirements WĂƚŝĞŶƚǁŝƚŚƚƌĂĐŚĞŽƐƚŽŵǇƐŝƚĞ͗ ŝƌǁĂǇŬŝƚ DŽŶŝƚŽƌdKϮ͕^ƉKϮ͕ĂŶĚ x dƵďĞŚĂƐďĞĐŽŵĞ ^ƵƌŐŝĐĂůĂŝƌǁĂǇŬŝƚ 'ĂƐƐŽŽŶĂƐƉŽƐƐŝďůĞ͘ ĚŝƐůŽĚŐĞĚ͘ sD x dƵďĞŚĂƐŽďƐƚƌƵĐƚŝŽŶƚŚĂƚ ^ƵĐƚŝŽŶ ǁŝůůŶŽƚĐůĞĂƌǁŝƚŚƐƵĐƚŝŽŶ͘ WĞĚŝĂƚƌŝĐďŽƵŐŝĞ x /ŶĂďŝůŝƚǇƚŽ ŽǆǇŐĞŶĂƚĞͬǀĞŶƚŝůĂƚĞ ƉĂƚŝĞŶƚ͘ WƌŽĐĞĚƵƌĞ;WͿ ϭ͘ ,ĂǀĞĂůůĂŝƌǁĂǇĞƋƵŝƉŵĞŶƚƉƌĞƉĂƌĞĚĂŶĚƌĞĂĚǇ͕ŝŶĐůƵĚŝŶŐďĂĐŬƵƉĂŶĚĞŵĞƌŐĞŶĐǇĂŝƌǁĂǇƉůĂŶƐ͘ Ϯ͘ WƌĞƉĂƌĞĂŝƌǁĂǇĚĞǀŝĐĞŽĨƐĂŵĞƐŝǌĞĂƐƉĂƚŝĞŶƚ͛ƐĞǆŝƐƚŝŶŐĚĞǀŝĐĞ͕ĂƐǁĞůůĂƐŽŶĞĂŚĂůĨƐŝǌĞƐŵĂůůĞƌ͘ hƐŝŶŐĂ^ŚŝůĞǇƚƵďĞŝƐƉƌĞĨĞƌƌĞĚ͕ďƵƚŝĨƵŶĂǀĂŝůĂďůĞ͕ĂŶdƚƵďĞŽĨƐĂŵĞƐŝǌĞŵĂǇďĞƵƐĞĚ͘ ϯ͘ >ƵďƌŝĐĂƚĞƌĞƉůĂĐĞŵĞŶƚĂŝƌǁĂǇĚĞǀŝĐĞƐ͘ ϰ͘ ZĞŵŽǀĞĂŶǇŵĞĐŚĂŶŝĐĂůǀĞŶƚŝůĂƚŽƌƐĂŶĚǀĞŶƚŝůĂƚĞƉĂƚŝĞŶƚƵƐŝŶŐsDƚŽƉƌĞŽǆǇŐĞŶĂƚĞ͘ ϱ͘ ZĞŵŽǀĞĚĞǀŝĐĞƐƐĞĐƵƌŝŶŐƚƌĂĐŚĞŽƐƚŽŵǇƚƵďĞ͘ ϲ͘ ĞĨůĂƚĞĐƵĨĨŽŶƚƌĂĐŚĞŽƐƚŽŵǇƚƵďĞ͘ ϳ͘ /ŶƐĞƌƚƌĞƉůĂĐĞŵĞŶƚƚƵďĞĂŶĚŝŶĨůĂƚĞĐƵĨĨ͘ŽŶĨŝƌŵƉůĂĐĞŵĞŶƚƵƐŝŶŐďƌĞĂƚŚƐŽƵŶĚƐĂŶĚdKϮ ǁĂǀĞĨŽƌŵ͘^ĞĐƵƌĞƉƌŽƉĞƌůǇ͘ ϴ͘ /ĨĚŝĨĨŝĐƵůƚǇŝƐĞŶĐŽƵŶƚĞƌĞĚ͕ƌĞͲĂƚƚĞŵƉƚƉůĂĐĞŵĞŶƚǁŝƚŚƐŵĂůůĞƌƚƵďĞƐŝǌĞ͘ ϵ͘ /ĨƐƚŝůůƵŶƐƵĐĐĞƐƐĨƵů͕ĐŽŶƐŝĚĞƌƵƐŝŶŐƚƌĂĐŚĞĂůŚŽŽŬĂŶĚďŽƵŐŝĞĂƐĂĚũƵŶĐƚƐƚŽƚƵďĞƉůĂĐĞŵĞŶƚ͘ WĞĂƌůƐ x ŽŶƐŝĚĞƌƵƐŝŶŐďŽƵŐŝĞƉĂƐƐĞĚƚŚƌŽƵŐŚĞǆŝƐƚŝŶŐƚƵďĞĂƐĂŐƵŝĚĞĨŽƌƌĞƉůĂĐĞŵĞŶƚƚƵďĞ͘ x ŽŶƐŝĚĞƌƵƐŝŶŐǁŝƌĞŐƵŝĚĞĨƌŽŵDĞůŬĞƌŬŝƚĂƐĂŐƵŝĚĞĨŽƌƌĞƉůĂĐĞŵĞŶƚƚƵďĞ͘ x /ĨƵƐŝŶŐĂŶdƚƵďĞ͕ŝŶƐĞƌƚũƵƐƚƵŶƚŝůďůĂĐŬƌĞĨĞƌĞŶĐĞůŝŶĞŚĂƐƉĂƐƐĞĚƐŬŝŶƐƵƌĨĂĐĞƚŚĞŶŝŶĨůĂƚĞĐƵĨĨ͘/ƚŝƐ ĂĐĐĞƉƚĂďůĞƚŽƚƌŝŵƚƵďĞƚŽůĞǀĞůũƵƐƚĂďŽǀĞƉŝůŽƚďĂůůŽŽŶƚƵďŝŶŐ͘ x ,ĂǀĞƐƵƌŐŝĐĂůĂŝƌǁĂǇĞƋƵŝƉŵĞŶƚƌĞĂĚŝůǇĂǀĂŝůĂďůĞĂƐƵƐĞĨƵůĂĚũƵŶĐƚƐĨŽƌƚƵďĞƉůĂĐĞŵĞŶƚ͘ x EĞǁƚƌĂĐŚĞŽƐƚŽŵǇƐŝƚĞƐ;ůĞƐƐƚŚĂŶƚǁŽǁĞĞŬƐŽůĚͿĂƌĞůŝŬĞůǇƚŽŚĂǀĞŵƵĐŚŵŽƌĞĚŝĨĨŝĐƵůƚǇǁŝƚŚƚƵďĞ ƌĞƉůĂĐĞŵĞŶƚĂŶĚĐĂƵƚŝŽŶƐŚŽƵůĚďĞĞǆĞƌĐŝƐĞĚ͘ x /ĨƉŽƐƐŝďůĞ͕ƚƌĂŶƐƉŽƌƚŽůĚĂŝƌǁĂǇĚĞǀŝĐĞǁŝƚŚƉĂƚŝĞŶƚƚŽŚŽƐƉŝƚĂů͘ŽĐƵŵĞŶƚƐŝǌĞĂŶĚĐŽŶĚŝƚŝŽŶŽĨ ĚĞǀŝĐĞ͘

Cypress Creek EMS System Policies and Treatment Guidelines

247 PROCEDURES Revised 8/2016 Cardiac Approved: Levon Vartanian, MD

ϭϮͲ>ĞĂĚ' Indications Equipment Needed ŶǇƉĂƚŝĞŶƚǁŝƚŚƐƵƐƉĞĐƚĞĚĐĂƌĚŝĂĐŝƐĐŚĞŵŝĂŽƌ Žůůy^ĞƌŝĞƐDŽŶŝƚŽƌ ĚǇƐƌŚǇƚŚŵŝĂ͕ǁŚŝĐŚŵĂǇŝŶĐůƵĚĞ͗ ϯDZĂǌŽƌ x /ƐĐŚĞŵŝĐĐŚĞƐƚƉĂŝŶ ůĐŽŚŽů x ZĞĨĞƌƌĞĚƉĂŝŶƚŽƐŚŽƵůĚĞƌ͕ŶĞĐŬ͕ŽƌũĂǁ ϰǆϰ'ĂƵǌĞWĂĚ x ZĞĨĞƌƌĞĚƉĂŝŶƚŽĂďĚŽŵĞŶ x ^ŚŽƌƚŶĞƐƐŽĨďƌĞĂƚŚ x ůƚĞƌĞĚŵĞŶƚĂůƐƚĂƚƵƐ x ^ƵƐƉĞĐƚĞĚŽǀĞƌĚŽƐĞ x ^ƵƐƉĞĐƚĞĚĐĂƌĚŝĂĐŝŶǀŽůǀĞŵĞŶƚ x ůĞĐƚƌŝĐĂůŝŶũƵƌŝĞƐ x ^ǇŶĐŽƉĞ WƌŽĐĞĚƵƌĞ ϭ͘ ŶǇĐƌĞǁŵĞŵďĞƌŵĂǇƉůĂĐĞϭϮͲůĞĂĚ'ĞůĞĐƚƌŽĚĞƐĂŶĚƉƌŽŐƌĂŵŵŽŶŝƚŽƌƚŽƉƌŽĚƵĐĞϭϮͲůĞĂĚ͘dŚĞ ƉĂƌĂŵĞĚŝĐ;ƐͿŽŶƐĐĞŶĞƐŚŽƵůĚƌĞĂĚĂŶĚŝŶƚĞƌƉƌĞƚϭϮͲůĞĂĚƉƌŝŶƚŽƵƚ͘ Ϯ͘ WƌĞƉĂƌĞƚŚĞƐŬŝŶďǇǁŝƉŝŶŐǁŝƚŚĂůĐŽŚŽůĂŶĚĂďƌĂĚŝŶŐƚŚĞƐŬŝŶǁŝƚŚĂϰǆϰ͘ ϯ͘ WůĂĐĞůŝŵďůĞĂĚƐŽŶƌĞƐƉĞĐƚŝǀĞůŝŵď͘WƌĞĨĞƌƌĞĚƉůĂĐĞŵĞŶƚ;ĨŽƌŵŽƐƚĂĐĐƵƌĂƚĞϭϮͲůĞĂĚƌĞƐƵůƚƐͿŝƐŽŶ ĚŝƐƚĂůĞŶĚƐŽĨůŝŵďƐ͕ŚŽǁĞǀĞƌ͕ŝĨƚŚŝƐŝƐŶŽƚƉŽƐƐŝďůĞŽƌƚŚĞ'ŝƐƵŶƌĞĂĚĂďůĞĚƵĞƚŽĂƌƚŝĨĂĐƚͬůŽǁ ǀŽůƚĂŐĞ͕ƚŚĞDĂƐŽŶͲ>ŝŬĞƌǀĂƌŝĂƚŝŽŶŵĂǇďĞƵƚŝůŝǌĞĚǁŝƚŚůŝŵďůĞĂĚƐƉůĂĐĞĚƉƌŽǆŝŵĂůƚŽƚŽƌƐŽ͘ ϰ͘ dŚĞƉƌĞĐŽƌĚŝĂůůĞĂĚƐĂƌĞƉůĂĐĞĚĂƐĨŽůůŽǁƐ͗ DĂƐŽŶ>ŝŬĞƌsĂƌŝĂƚŝŽŶ x sϭͲϰƚŚŝŶƚĞƌĐŽƐƚĂůƐƉĂĐĞũƵƐƚƚŽƚŚĞƌŝŐŚƚŽĨƚŚĞ ƐƚĞƌŶƵŵ x sϮͲϰƚŚŝŶƚĞƌĐŽƐƚĂůƐƉĂĐĞũƵƐƚƚŽƚŚĞůĞĨƚŽĨƚŚĞ ƐƚĞƌŶƵŵ x sϰͲϱƚŚŝŶƚĞƌĐŽƐƚĂůƐƉĂĐĞĂƚƚŚĞŵŝĚĐůĂǀŝĐƵůĂƌůŝŶĞ x sϯͲϱƚŚŝŶƚĞƌĐŽƐƚĂůƐƉĂĐĞŵŝĚǁĂǇďĞƚǁĞĞŶsϮĂŶĚsϰ x sϱͲϱƚŚŝŶƚĞƌĐŽƐƚĂůƐƉĂĐĞĂƚƚŚĞĂŶƚĞƌŝŽƌĂǆŝůůĂƌǇůŝŶĞ x sϲͲϱƚŚŝŶƚĞƌĐŽƐƚĂůƐƉĂĐĞĂƚƚŚĞŵŝĚĂǆŝůůĂƌǇůŝŶĞ ϱ͘ /ŶƚŚĞĨĞŵĂůĞƉĂƚŝĞŶƚ͕ƚŚĞƉƌĞĐŽƌĚŝĂůůĞĂĚƐŵƵƐƚďĞ ƉŽƐŝƚŝŽŶĞĚƵŶĚĞƌƚŚĞďƌĞĂƐƚ͕ĂŐĂŝŶƐƚƚŚĞĐŚĞƐƚǁĂůů͘hƐŝŶŐ ƚŚĞƉŽƐƚĞƌŝŽƌĂƐƉĞĐƚŽĨĂŐůŽǀĞĚŚĂŶĚƚŽĚŝƐƉůĂĐĞƚŚĞďƌĞĂƐƚĨŽƌĞůĞĐƚƌŽĚĞƉůĂĐĞŵĞŶƚŝƐƚŚĞůĞĂƐƚ ƚŚƌĞĂƚĞŶŝŶŐŵĞĂŶƐĨŽƌĂƉƉůŝĐĂƚŝŽŶ͘ ϲ͘ WŽƐŝƚŝŽŶƚŚĞƉĂƚŝĞŶƚƚŽŵŝŶŝŵŝǌĞŵŽǀĞŵĞŶƚĂŶĚŵƵƐĐůĞƚĞŶƐŝŽŶ͘^ƵƉŝŶĞŝƐƉƌĞĨĞƌƌĞĚŝĨƚŚĞƉĂƚŝĞŶƚ ǁŝůůƚŽůĞƌĂƚĞŝƚ͘ ϳ͘ ƉĂƚŝĞŶƚǁŚŽƉƌĞƐĞŶƚƐǁŝƚŚĞǀŝĚĞŶĐĞŽĨŝŶĨĞƌŝŽƌǁĂůůD/;^ͲdƐĞŐŵĞŶƚĞůĞǀĂƚŝŽŶŝŶůĞĂĚƐ//͕///͕Žƌ

Ăs&͖ƌĞĐŝƉƌŽĐĂůĐŚĂŶŐĞƐŝŶůĞĂĚƐ/ŽƌĂs>ͿŽƌĂƌŝŐŚƚǀĞŶƚƌŝĐƵůĂƌŝŶĨĂƌĐƚŝƐƐƵƐƉĞĐƚĞĚ͕ĂĐƋƵŝƌĞsϰZ͕sϱZ͕

Cypress Creek EMS System Policies and Treatment Guidelines

248 PROCEDURES Revised 8/2016 Cardiac Approved: Levon Vartanian, MD

ĂŶĚsϲZůĂďĞůŝŶŐĂĐĐŽƌĚŝŶŐůǇ͘^ŝŵƉůǇŵŽǀĞsϰ͕sϱ͕ĂŶĚsϲƚŽƚŚĞƐĂŵĞůŽĐĂƚŝŽŶŽŶƚŚĞƌŝŐŚƚƐŝĚĞŽĨ ƚŚĞĐŚĞƐƚ;ϱƚŚŝŶƚĞƌĐŽƐƚĂůƐƉĂĐĞͿĂŶĚĂĐƋƵŝƌĞĂŶŽƚŚĞƌϭϮͲůĞĂĚ͘ ϴ͘ ƉĂƚŝĞŶƚǁŚŽƉƌĞƐĞŶƚƐǁŝƚŚĞǀŝĚĞŶĐĞŽĨĂƉŽƐƚĞƌŝŽƌǁĂůůD/;ƚǁŽĐŽŶƚŝŐƵŽƵƐůĞĂĚƐŽĨ^ͲdƐĞŐŵĞŶƚ

ĚĞƉƌĞƐƐŝŽŶŝŶůĞĂĚƐsϭ͕sϮ͕sϯ͕ŽƌsϰͿƐŚŽƵůĚŚĂǀĞĂŶ<'ƉĞƌĨŽƌŵĞĚƵƚŝůŝǌŝŶŐsϳ͕sϴ͕ĂŶĚsϵŝĨƚŝŵĞ ƉĞƌŵŝƚƐ͘ ϵ͘ KďƚĂŝŶƚŚĞϭϮͲůĞĂĚ'ĂƚƚŚĞĞĂƌůŝĞƐƚŽƉƉŽƌƚƵŶŝƚǇǁŝƚŚŽƵƚŝŶƚĞƌĨĞƌŝŶŐǁŝƚŚƚŚĞƵƌŐĞŶƚŶĞĞĚƐŽĨƚŚĞ ƉĂƚŝĞŶƚ͘ ϭϬ͘ KĐĐĂƐŝŽŶĂůůǇ͕ƐŝƚƵĂƚŝŽŶƐŵĂǇĂƌŝƐĞǁŚĞƌĞǁĂŝǀĞƌŽĨĂϭϮͲůĞĂĚ'ŝƐŶĞĐĞƐƐĂƌǇ͘ZĞĂƐŽŶĂďůĞũƵĚŐŵĞŶƚ ƐŚŽƵůĚŐƵŝĚĞƚŚŝƐĚĞĐŝƐŝŽŶĂŶĚƚŚŽƌŽƵŐŚĚŽĐƵŵĞŶƚĂƚŝŽŶƚŽƚŚĂƚĞĨĨĞĐƚŝƐƌĞƋƵŝƌĞĚ͘ 11. >ĞĂǀĞĂĐŽƉǇ;ŽƌƐĞĐŽŶĚƉƌŝŶƚŝŶŐͿŽĨĂůůƌŚǇƚŚŵƐƚƌŝƉƐĂŶĚϭϮͲůĞĂĚƐĂƚƚŚĞĚĞƐƚŝŶĂƚŝŽŶĨĂĐŝůŝƚǇĂůŽŶŐ ǁŝƚŚƚŚĞƉĂƚŝĞŶƚƌĞƉŽƌƚ͘ 12. ϭϮͲůĞĂĚƐŵĂǇďĞƚƌĂŶƐŵŝƚƚĞĚƚŽƚŚĞĚĞƐƚŝŶĂƚŝŽŶĨĂĐŝůŝƚǇŝĨ^dD/ŽƌE^dD/ŝƐŝĚĞŶƚŝĨŝĞĚ͕ŽƌŝĨ ŝŶƚĞƌƉƌĞƚĂƚŝŽŶŝƐƋƵĞƐƚŝŽŶĂďůĞ͘ 13. ϭϮͲůĞĂĚƐŵĂǇďĞƚƌĂŶƐŵŝƚƚĞĚƚŽŽŶͲĚƵƚǇ&ŝĞůĚ^ƵƉĞƌǀŝƐŽƌͬůŝŶŝĐĂůĞƉĂƌƚŵĞŶƚƐƚĂĨĨĨŽƌĂƐƐŝƐƚĂŶĐĞ ǁŝƚŚŝŶƚĞƌƉƌĞƚĂƚŝŽŶŽƌĐůŝŶŝĐĂůƋƵĞƐƚŝŽŶƐ͘ 14. ŶǇĂďŶŽƌŵĂůϭϮͲůĞĂĚƐŚŽƵůĚďĞƌĞƉĞĂƚĞĚďĞĨŽƌĞĂƌƌŝǀĂůƚŽŚŽƐƉŝƚĂů͘ ϭϮͲ>ĞĂĚ'ZĞĨĞƌĞŶĐĞ ^ƚĞƉƐƚŽ/ŶƚĞƌƉƌĞƚĂƚŝŽŶ ϭ͘ Rate Ϯ͘ Rhythm ϯ͘ Conduction Ă͘ sůŽĐŬƐ ŝ͘ ϭ϶s WZхϬ͘ϮƐĞĐŽŶĚƐ ŝŝ͘ Ϯ϶sdǇƉĞ/ WZƉƌŽŐƌĞƐƐŝǀĞůǇůŽŶŐĞƌƵŶƚŝůďĞĂƚĚƌŽƉƉĞĚ ŝŝŝ͘ Ϯ϶sdǇƉĞ// EŽŶͲĐŽŶĚƵĐƚĞĚWǁĂǀĞƌĞƐƵůƚŝŶŐŝŶĚƌŽƉƉĞĚYZ^ ŝǀ͘ ϯ϶s ŽŵƉůĞƚĞsďůŽĐŬ ď͘ ƵŶĚůĞďƌĂŶĐŚďůŽĐŬ ŝ͘ Z Z^Z͛ŝŶsϭĂŶĚsϮ ŝŝ͘ > Z^Z͛ŝŶsϱĂŶĚsϲ Đ͘ ,ĞŵŝďůŽĐŬƐ ŝ͘ ůŽĐŬĂŐĞŽĨĂŶƚĞƌŝŽƌŽƌƉŽƐƚĞƌŝŽƌĚŝǀŝƐŝŽŶŽĨůĞĨƚďƵŶĚůĞ͘ ŝŝ͘ >ĞĨƚŶƚĞƌŝŽƌŚĞŵŝďůŽĐŬ͗ ϭ͘ >ĞĨƚĂǆŝƐĚĞǀŝĂƚŝŽŶ;ͲϰϱʹͲϵϬĚĞŐƌĞĞƐͿ Ϯ͘ ƋZĐŽŵƉůĞǆƐŝŶůĞĂĚƐ/ĂŶĚĂs> ϯ͘ ƌ^ĐŽŵƉůĞǆĞƐŝŶůĞĂĚƐ//͕///͕ĂŶĚĂs& ϰ͘ /ŶĐƌĞĂƐĞĚYZ^ǀŽůƚĂŐĞ ŝŝŝ͘ >ĞĨƚƉŽƐƚĞƌŝŽƌŚĞŵŝďůŽĐŬ͗ ϭ͘ ZŝŐŚƚĂǆŝƐĚĞǀŝĂƚŝŽŶ;нϵϬĚĞŐƌĞĞƐͿ Ϯ͘ ƌ^ĐŽŵƉůĞǆĞƐŝŶůĞĂĚƐ/ĂŶĚĂs> ϯ͘ ƋZĐŽŵƉůĞǆƐŝŶůĞĂĚƐ//͕///͕ĂŶĚĂs&

Cypress Creek EMS System Policies and Treatment Guidelines

249 PROCEDURES Revised 8/2016 Cardiac Approved: Levon Vartanian, MD

ϰ͘ EŽĞǀŝĚĞŶĐĞŽĨƌŝŐŚƚǀĞŶƚƌŝĐƵůĂƌŚǇƉĞƌƚƌŽƉŚǇ͘ Ě͘ ŝĨĂƐĐŝƵůĂƌďůŽĐŬ͗,ĞŵŝďůŽĐŬнZ͘ Ğ͘ ǆŝƐ͗ ŝ͘ EŽƌŵĂůĂǆŝƐ͗ͲϯϬƚŽнϵϬĚĞŐƌĞĞƐ ŝŝ͘ >ĞĨƚĂǆŝƐ͗ͲϯϬƚŽͲϵϬĚĞŐƌĞĞƐ ŝŝŝ͘ ZŝŐŚƚĂǆŝƐ͗нϵϬƚŽнϭϴϬĚĞŐƌĞĞƐ ŝǀ͘ ǆƚƌĞŵĞƌŝŐŚƚĂǆŝƐ͗ͲϵϬƚŽͲϭϴϬĚĞŐƌĞĞƐ ǀ͘ ǆŝƐƐŚŝĨƚƐdKtZ^ŚǇƉĞƌƚƌŽƉŚǇĂŶĚtzĨƌŽŵD/ͬŝƐĐŚĞŵŝĂ ϰ͘ Hypertrophy ϱ͘ Infarction dͲtĂǀĞďŶŽƌŵĂůŝƚŝĞƐ dŚĞ'ŝĂŶƚdǁĂǀĞƌĞƉƌĞƐĞŶƚƐƚŚĞƌĞůĞĂƐĞŽĨƉŽƚĂƐƐŝƵŵ ĨŽƌŵĐĞůůƵůĂƌƚŝƐƐƵĞĂƐƐŽĐŝĂƚĞĚǁŝƚŚĂƌĞĂƐŽĨŚǇƉŽǆĞŵŝĂ ĂŶĚŝŶĨĂƌĐƚ͘dŚĞ^dĞůĞǀĂƚŝŽŶƌĞƉƌĞƐĞŶƚƐƚŚĞĚĂŵĂŐĞ ĂƐƐŽĐŝĂƚĞĚǁŝƚŚĚĞƉŽůĂƌŝǌĂƚŝŽŶĂŶĚŝƐŝŶĚŝĐĂƚŝǀĞŽĨƚŝƐƐƵĞ ĚĞĂƚŚ͘dŚĞYǁĂǀĞĂŶĚůŽƐƐŽĨZǁĂǀĞŚĞŝŐŚƚƌĞƉƌĞƐĞŶƚƐ ƚŚĞďĞŐŝŶŶŝŶŐƐŽĨĂƉĂƚŚŽůŽŐŝĐĂůY;хϭŵŵǁŝĚĞŽƌ ĚĞĞƉĞƌƚŚĂŶϭͬϯŚĞŝŐŚƚŽĨZǁĂǀĞͿĂŶĚƌĞƉƌĞƐĞŶƚƐ ƉĞƌŵĂŶĞŶƚĐŚĂŶŐĞƐŝŶĚĞƉŽůĂƌŝǌĂƚŝŽŶ͘dŚĞ^dƐĞŐŵĞŶƚ ƚŚĞŶƌĞƚƵƌŶƐƚŽŶŽƌŵĂůĂŶĚĂĚĞĞƉƉĂƚŚŽůŽŐŝĐĂůYǁĂǀĞ ĚĞǀĞůŽƉƐƚŚĂƚƌĞƉƌĞƐĞŶƚƐƚŚĞŽůĚD/͘

^ŐĂƌďŽƐƐĂƌŝƚĞƌŝĂ;D/ǁŝƚŚ>Ϳ hƚŝůŝǌĞ^ŐĂƌďŽƐƐĂĐƌŝƚĞƌŝĂƚŽŝĚĞŶƚŝĨǇD/ŝŶƚŚĞƉƌĞƐĞŶĐĞŽĨĂůĞĨƚďƵŶĚůĞďƌĂŶĐŚďůŽĐŬ͘

Ă͘ ŽŶĐŽƌĚĂŶƚ^dĞůĞǀĂƚŝŽŶхϭŵŵŝŶůĞĂĚƐǁŝƚŚĂƉŽƐŝƚŝǀĞ YZ^ĐŽŵƉůĞǆснϱƉŽŝŶƚƐ ď͘ ŽŶĐŽƌĚĂŶƚ^dĚĞƉƌĞƐƐŝŽŶхϭŵŵŝŶsϭʹsϯснϯƉŽŝŶƚƐ Đ͘ ǆĐĞƐƐŝǀĞůǇĚŝƐĐŽƌĚĂŶƚ^dĞůĞǀĂƚŝŽŶŝŶůĞĂĚƐǁŝƚŚĂ ŶĞŐĂƚŝǀĞYZ^снϮƉŽŝŶƚƐ шϯƉŽŝŶƚƐсϵϬйƐƉĞĐŝĨŝĐŝƚǇŽĨ^dD/

Cypress Creek EMS System Policies and Treatment Guidelines

250 PROCEDURES Revised 8/2016 Cardiac Approved: Levon Vartanian, MD

>ŽĐĂůŝǌŝŶŐ'ŚĂŶŐĞƐ Area Leads Reciprocal Contiguous Coronary Arteries Problems >ĞĨƚŶƚĞƌŝŽƌ sϮ͕sϯ͕sϰ sϳ͕sϴ V2Ͳsϭ͕sϯ͕s>͕/ > ^ƵĚĚĞŶĞĂƚŚ sĞŶƚƌŝĐůĞ V3ͲsϮ͕s>͕/͕sϰ >ƉƌŽǆŝŵĂů ,ǇƉŽƚĞŶƐŝŽŶ^sͬK V4Ͳsϯ͕sϱ͕sϲ͕// >ĚŝƐƚĂů ,ǇƉŽƚĞŶƐŝŽŶ^sͬK >ĞĨƚƉĞǆĂŶĚ //͕sϱ͕sϲ s&͕/// IIͲsϱ͕s&͕sϰ >ĚŝƐƚĂů ,ǇƉŽƚĞŶƐŝŽŶ^sͬK >Žǁ>ĂƚĞƌĂů V5Ͳ//͕sϲ͕sϰ ŝĂŐŽŶĂůͬ>ĚŝƐƚĂů WŽŽƌũĞĐƚŝŽŶ&ƌĂĐƚŝŽŶ ǀĞŶƚƌŝĐůĞ V6Ͳsϱ͕/͕sϰ ŝĂŐŽŶĂů WŽŽƌũĞĐƚŝŽŶ&ƌĂĐƚŝŽŶ >ĞĨƚ,ŝŐŚ>ĂƚĞƌĂů s>͕/ s&͕/// AVLͲ/sϮ͕sϯ >y DsƌĞŐƵƌŐŝƚĂƚŝŽŶ sĞŶƚƌŝĐůĞ IͲ s>͕sϲ͕sϮ͕sϯ >y WƵůŵŽŶĂƌǇĚĞŵĂ

>ĞĨƚWŽƐƚĞƌŝŽƌ sϳ͕sϴ sϮ͕sϯ͕sϰ V7Ͳsϲ͕sϴ ZŝŐŚƚWŽƐƚĞƌŝŽƌ ZŝŐŚƚƐŝĚĞĞǆƚĞŶƐŝŽŶ sĞŶƚƌŝĐůĞ V8Ͳsϳ DŝŶŽƌĚĞĐƌĞĂƐĞŝŶ^s

ZŝŐŚƚ/ŶĨĞƌŝŽƌ ///͕s&͕// s>͕/͕sϲ IIIͲs&͕sϰZ ZŝŐŚƚDĂƌŐŝŶĂů ĨĨĞĐƚƐWƌĞůŽĂĚŝŶ>s sĞŶƚƌŝĐůĞ AVFͲ///͕// ƉƌŽǆŝŵĂů ,ǇƉŽƚĞŶƐŝŽŶ IIͲ s&͕sϱ͕sϰ ZŝŐŚƚDĂƌŐŝŶĂůŽĚǇ WŽŽƌWƵůŵŽŶĂƌǇŐĂƐy ZŝŐŚƚDĂƌŐŝŶĂůŝƐƚĂů ZŝŐŚƚŶƚĞƌŝŽƌ sϭ͕sϰZ EŽŶĞ V1ͲsϮ͕sϰZ Z KǆǇŐĞŶĂƚĞƐsĂŶĚ^ sĞŶƚƌŝĐůĞ V4RͲsϭ͕/// ZĂŶƚĞƌŝŽƌ ŶŽĚĞƐ sůŽĐŬƐĂŶĚŝƐĐŚĞŵŝĂ

Cypress Creek EMS System Policies and Treatment Guidelines

251 PROCEDURES Revised 8/2016 Cardiac Approved: Levon Vartanian, MD

ĞĨŝďƌŝůůĂƚŝŽŶ Indications Equipment Needed WƵůƐĞůĞƐƐǀĞŶƚƌŝĐƵůĂƌƚĂĐŚǇĐĂƌĚŝĂŽƌǀĞŶƚƌŝĐƵůĂƌ Žůůy^ĞƌŝĞƐ ĨŝďƌŝůůĂƚŝŽŶ ĞĨŝďƌŝůůĂƚŝŽŶƉĂĚƐ

WƌŽĐĞĚƵƌĞ ϭ͘ Ensure that high quality chest compressions are being done with minimal interruptions. Ϯ͘ WůĂĐĞƉĂĚƐŽŶƉĂƚŝĞŶƚ͘WƌĞĨĞƌƌĞĚƉůĂĐĞŵĞŶƚŝƐŶƚĞƌŝŽƌͲWŽƐƚĞƌŝŽƌ͕ĂůƚŚŽƵŐŚŵŽĚŝĨŝĞĚƉůĂĐĞŵĞŶƚŽĨ ŶƚĞƌŝŽƌͲ>ĂƚĞƌĂůŵĂǇďĞƵƐĞĚŝĨƉĂƚŝĞŶƚƉŽƐŝƚŝŽŶŽƌĂŶĂƚŽŵǇĚŽĞƐŶ͛ƚĂůůŽǁĨŽƌŶƚĞƌŝŽƌͲWŽƐƚĞƌŝŽƌ ƉůĂĐĞŵĞŶƚ͘ ϯ͘ ^ĞƚƚŚĞĂƉƉƌŽƉƌŝĂƚĞĞŶĞƌŐǇůĞǀĞů͗ x Adult: ϮϬϬ:ŝƉŚĂƐŝĐ x Pediatric:/ŶŝƚŝĂůƐŚŽĐŬ͗Ϯ:ͬŬŐ͘^ƵďƐĞƋƵĞŶƚƐŚŽĐŬƐĂƚϰ:ͬŬŐ͘ ϰ͘ ŚĂƌŐĞƚŚĞĚĞĨŝďƌŝůůĂƚŽƌ͘Continue chest compressions while defibrillator is charging. ϱ͘ ^ƚŽƉĐŽŵƉƌĞƐƐŝŽŶƐĂŶĚĞŶƐƵƌĞĞǀĞƌǇŽŶĞŝƐĐůĞĂƌŽĨƉĂƚŝĞŶƚ͘ ϲ͘ ĞůŝǀĞƌƐŚŽĐŬďǇĚĞƉƌĞƐƐŝŶŐƐŚŽĐŬďƵƚƚŽŶĂŶĚŚŽůĚŝŶŐƵŶƚŝůƐŚŽĐŬŝƐĚĞůŝǀĞƌĞĚ͘ ϳ͘ &ŽůůŽǁŝŶŐƐŚŽĐŬ͕ŝŵŵĞĚŝĂƚĞůǇƌĞƐƵŵĞĐŚĞƐƚĐŽŵƉƌĞƐƐŝŽŶƐǁŝƚŚŽƵƚŝŶƚĞƌƌƵƉƚŝŽŶĨŽƌƚǁŽŵŝŶƵƚĞƐ͘ ϴ͘ ĨƚĞƌƚǁŽŵŝŶƵƚĞƐŚĂǀĞĞůĂƉƐĞĚ͕ƐĞůĞĐƚĞŶĞƌŐǇůĞǀĞůĂŶĚĐŚĂƌŐĞĚĞĨŝďƌŝůůĂƚŽƌ͘ ϵ͘ tŚĞŶĚĞĨŝďƌŝůůĂƚŽƌŝƐĐŚĂƌŐĞĚ͕ƐƚŽƉĐŽŵƉƌĞƐƐŝŽŶƐĂŶĚĂŶĂůǇǌĞƌŚǇƚŚŵ͘/ĨƐŚŽĐŬŝƐŝŶĚŝĐĂƚĞĚ͕ĚĞůŝǀĞƌ ƐŚŽĐŬĂŶĚƌĞƉĞĂƚĂďŽǀĞƉƌŽĐĞĚƵƌĞ͘/ĨƐŚŽĐŬŝƐŶŽƚŝŶĚŝĐĂƚĞĚ͕ĚĞͲĐŚĂƌŐĞƚŚĞŵŽŶŝƚŽƌĂŶĚƌĞƐƵŵĞ WZ͘ WĞĂƌůƐ x <ĞĞƉĐŚĞƐƚĐŽŵƉƌĞƐƐŝŽŶŝŶƚĞƌƌƵƉƚŝŽŶƐĂƐďƌŝĞĨĂŶĚĨĞǁĂƐƉŽƐƐŝďůĞ͘ x /ĨƉĂƚŝĞŶƚŚĂƐĂŶŝŵƉůĂŶƚĞĚƉĂĐĞŵĂŬĞƌͬĚĞĨŝďƌŝůůĂƚŽƌ͕ƚƌǇƚŽĂǀŽŝĚƉůĂĐŝŶŐƉĂĚƐĚŝƌĞĐƚůǇŽǀĞƌŝƚ͘ x WĂĚƐƐŚŽƵůĚŶŽƚƚŽƵĐŚĞĂĐŚŽƚŚĞƌ͘

Cypress Creek EMS System Policies and Treatment Guidelines

252 PROCEDURES Revised 8/2016 Cardiac Approved: Levon Vartanian, MD

WZ Indications Equipment Needed WƵůƐĞůĞƐƐĂĚƵůƚƉĂƚŝĞŶƚ ŽůůyͲ^ĞƌŝĞƐDŽŶŝƚŽƌǁŝƚŚ&ĞĞĚďĂĐŬƉĂĚƐ WĞĚŝĂƚƌŝĐƉĂƚŝĞŶƚǁŝƚŚ,ZфϲϬͬŵŝŶ ;ŽƉƚŝŽŶĂůͿ͗>ƵĐĂƐĚĞǀŝĐĞ

DĂŶƵĂůWZ ϭ͘ hƚŝůŝǌĞĂWZĨĞĞĚďĂĐŬĚĞǀŝĐĞƚŽĂŝĚŝŶĂĐŚŝĞǀŝŶŐĂĚĞƋƵĂƚĞĚĞƉƚŚĂŶĚƌĂƚĞ͘ Ϯ͘ ,ĂŶĚƉůĂĐĞŵĞŶƚƐŚŽƵůĚďĞůŽǁĞƌƚŚŝƌĚŽĨƚŚĞƐƚĞƌŶƵŵ͘ ϯ͘ ŽŵƉƌĞƐƐƚŚĞĐŚĞƐƚƚŽĂĚĞƉƚŚŽĨĂƚůĞĂƐƚϮ͟;ŝŶĂĚƵůƚƐͿŽƌϭͬϯƚŚĞĂŶƚĞƌŝŽƌͲƉŽƐƚĞƌŝŽƌĚŝĂŵĞƚĞƌŽĨƚŚĞ ĐŚĞƐƚ;ŝŶƉĞĚŝĂƚƌŝĐƐͿ ϰ͘ ŶƐƵƌĞƚŚĞĐŚĞƐƚǁĂůůĨƵůůǇƌĞĐŽŝůƐďĞƚǁĞĞŶĐŽŵƉƌĞƐƐŝŽŶƐ͘ ϱ͘ ŽŵƉƌĞƐƐĂƚĂƌĂƚĞŽĨϭϬϬͬŵŝŶƵƚĞƚŽϭϮϬͬŵŝŶƵƚĞ͘ ϲ͘ /ĨŶŽĂĚǀĂŶĐĞĚĂŝƌǁĂǇŝƐŝŶƉůĂĐĞ͕ƐǇŶĐŚƌŽŶŝǌĞĐŽŵƉƌĞƐƐŝŽŶƐǁŝƚŚǀĞŶƚŝůĂƚŝŽŶƐĂƚϯϬ͗Ϯ;ĨŽƌĂĚƵůƚƐͿŽƌ ϭϱ͗Ϯ;ĨŽƌƉĞĚŝĂƚƌŝĐƐͿ͘ ϳ͘ DŝŶŝŵŝǌĞŝŶƚĞƌƌƵƉƚŝŽŶƐ͘ >ƵĐĂƐĞǀŝĐĞ ŽŶƚƌĂŝŶĚŝĐĂƚŝŽŶƐ dŚĞ>ƵĐĂƐĚĞǀŝĐĞƐŚŽƵůĚŶŽƚďĞƵƐĞĚŝŶƚŚĞĨŽůůŽǁŝŶŐĐŝƌĐƵŵƐƚĂŶĐĞƐ͗

x ĚƵůƚƉĂƚŝĞŶƚƐƚŽŽƐŵĂůůŽƌƚŽŽůĂƌŐĞĨŽƌƚŚĞƉŝƐƚŽŶƚŽĨƵŶĐƚŝŽŶ;ŝƚǁŝůůĂůĂƌŵƚŽǁĂƌŶŽĨƚŚĞƐŝǌĞ ĚŝƐĐƌĞƉĂŶĐǇͿ͘ x WĞĚŝĂƚƌŝĐƉĂƚŝĞŶƚ x ĚǀĂŶĐĞĚƉƌĞŐŶĂŶĐǇ WƌŽĐĞĚƵƌĞ ϭ͘ KƉĞŶďĂŐĂŶĚƌĞŵŽǀĞĚĞǀŝĐĞ͘dƵƌŶŽŶƉŽǁĞƌĂŶĚƉƌĞƐƐŶƵŵďĞƌϭďƵƚƚŽŶƚŽƉůĂĐĞŝŶ͞ĚũƵƐƚ͟ŵŽĚĞ͘ Ϯ͘ WůĂĐĞďĂĐŬƉůĂƚĞƵŶĚĞƌďĂĐŬďĞůŽǁĂƌŵƉŝƚƐ͘ZĞƐƵŵĞWZŝŵŵĞĚŝĂƚĞůǇ͘ ϯ͘ ƚƚĂĐŚĚĞǀŝĐĞƚŽďĂĐŬƉůĂƚĞŽŶĞƐŝĚĞĂƚĂƚŝŵĞ͕ŵŝŶŝŵŝǌŝŶŐŝŶƚĞƌƌƵƉƚŝŽŶƐƚŽŵĂŶƵĂůWZ͘ ϰ͘ WŽƐŝƚŝŽŶƐƵĐƚŝŽŶĐƵƉŽǀĞƌůŽǁĞƌƚŚŝƌĚŽĨƚŚĞƐƚĞƌŶƵŵ͘ ϱ͘ WůĂĐĞWZƋƵĂůŝƚǇ͞ƉƵĐŬ͟ŝŶǀĞƌƚĞĚŝŶƐŝĚĞƐƵĐƚŝŽŶĐƵƉ͘ ϲ͘ >ŽǁĞƌƉŝƐƚŽŶƐŽƚŚĂƚƐƵĐƚŝŽŶĐƵƉƚŽƵĐŚĞƐƉĂƚŝĞŶƚ͛ƐĐŚĞƐƚ͘/ĨŝƚĚŽĞƐŶ͛ƚĨŝƚ͕ĐŽŶƚŝŶƵĞŵĂŶƵĂů ĐŽŵƉƌĞƐƐŝŽŶƐ͘ ϳ͘ ^ƚĂƌƚĐŽŵƉƌĞƐƐŝŽŶƐďǇƉƵƐŚŝŶŐďƵƚƚŽŶϮƚŽůŽĐŬƉŝƐƚŽŶŝŶƉůĂĐĞƚŚĞŶƉƌĞƐƐŝŶŐƚŚĞŶƵŵďĞƌϯĂĐƚŝǀĂƚŝŶŐ ďƵƚƚŽŶ͕ĐŚŽŽƐŝŶŐĞŝƚŚĞƌĐŽŶƚŝŶƵŽƵƐŽƌϯϬ͗ϮŵŽĚĞ͘ ϴ͘ ƚƚĂĐŚƐƚĂďŝůŝǌĂƚŝŽŶƐƚƌĂƉďĞŚŝŶĚƉĂƚŝĞŶƚ͛ƐŶĞĐŬ͘ ϵ͘ WĂƵƐĞĨŽƌƌŚǇƚŚŵĂŶĂůǇƐŝƐƉĞƌŝŽĚŝĐĂůůǇƵƐŝŶŐƚŚĞŶƵŵďĞƌϮďƵƚƚŽŶ͘

Cypress Creek EMS System Policies and Treatment Guidelines

253 PROCEDURES Revised 8/2016 Cardiac Approved: Levon Vartanian, MD

WĞĂƌůƐ x DŝŶŝŵŝǌĞŝŶƚĞƌƌƵƉƚŝŽŶƐŽĨĐŚĞƐƚĐŽŵƉƌĞƐƐŝŽŶƐ͘ x ĞĨŝďƌŝůůĂƚŝŽŶŵĂǇďĞƵƐĞĚǁŝƚŚĚĞǀŝĐĞŝƐŝŶƵƐĞ͘ŶƐƵƌĞƚŚĂƚĚĞĨŝďƌŝůůĂƚŝŽŶƉĂĚƐͬĞůĞĐƚƌŽĚĞƐĂƌĞŶŽƚ ƵŶĚĞƌƚŚĞƐƵĐƚŝŽŶĐƵƉ͘ x hƐĞŽĨƚŚŝƐĚĞǀŝĐĞŵƵƐƚďĞĚŝƐĐŽŶƚŝŶƵĞĚŽŶĐĞZ^KŚĂƐďĞĞŶĂĐŚŝĞǀĞĚ͕ŽƌǁŚĞŶWZŝƐŶŽůŽŶŐĞƌ ŶĞĐĞƐƐĂƌǇ͘ x hƚŝůŝǌŝŶŐWZĨĞĞĚďĂĐŬŚĞůƉƐƚŽĚĞƚĞƌŵŝŶĞWZŝŶƚĞƌƌƵƉƚŝŽŶƐĂŶĚĂŝĚƐŝŶŝŵƉƌŽǀŝŶŐƋƵĂůŝƚǇWZ ƋƵĂůŝƚǇ͘

Cypress Creek EMS System Policies and Treatment Guidelines

254 PROCEDURES Revised 8/2016 Cardiac Approved: Levon Vartanian, MD

ǆƚĞƌŶĂůWĂĐŝŶŐ Indications Equipment Needed hŶƐƚĂďůĞďƌĂĚǇĐĂƌĚŝĂ͗ ŽůůyͲ^ĞƌŝĞƐDŽŶŝƚŽƌ ,ZфϱϬͬŵŝŶǁŝƚŚĂŶǇŽĨƚŚĞĨŽůůŽǁŝŶŐ ƐŝŐŶƐͬƐǇŵƉƚŽŵƐŽĨƐŚŽĐŬ͗ĐŽŽůͬĐůĂŵŵǇͬƉĂůĞ ƐŬŝŶ͕ĂĐƵƚĞůǇĂůƚĞƌĞĚŵĞŶƚĂůƐƚĂƚƵƐ͕^WфϵϬ͕ ŝƐĐŚĞŵŝĐĐŚĞƐƚĚŝƐĐŽŵĨŽƌƚ͕ŽƌĂĐƵƚĞŚĞĂƌƚ ĨĂŝůƵƌĞ͘ WƌŽĐĞĚƵƌĞ ϭ͘ ŽŶŶĞĐƚŵŽŶŝƚŽƌŝŶŐĞůĞĐƚƌŽĚĞƐ;ϰͲůĞĂĚͿƚŽƉĂƚŝĞŶƚĂŶĚĂƚƚĂĐŚĞůĞĐƚƌŽĚĞƐƚŽƉĂƚŝĞŶƚ͘ Ϯ͘ ƉƉůǇƉĂĐŝŶŐƉĂĚƐƚŽƚŚĞƉĂƚŝĞŶƚ͘;ŶƚĞƌŝŽƌͬƉŽƐƚĞƌŝŽƌƉŽƐŝƚŝŽŶŝƐƉƌĞĨĞƌƌĞĚďƵƚĂƉĞǆͬƐƚĞƌŶƵŵŵĂǇďĞ ƵƚŝůŝǌĞĚŝĨĂŶƚĞƌŝŽƌͬƉŽƐƚĞƌŝŽƌŝƐĚŝĨĨŝĐƵůƚŽƌƉŽƐƐŝďůǇŚĂƌŵĨƵů͘ ϯ͘ ŶƐƵƌĞƚŚĂƚƚŚĞƉĂĚƐĚŽŶŽƚŵĂŬĞĐŽŶƚĂĐƚǁŝƚŚĂŶǇŽƚŚĞƌ'ĞůĞĐƚƌŽĚĞƐ͘ ϰ͘ ^ĞůĞĐƚĂ>ĞĂĚǀŝĞǁƚŚĂƚƉƌŽǀŝĚĞƐƚŚĞůĂƌŐĞƐƚĂŵƉůŝƚƵĚĞYZ^ǁĂǀĞĨŽƌŵ͖ǀĞƌŝĨǇƚŚĂƚZǁĂǀĞƐĂƌĞďĞŝŶŐ ƉƌŽƉĞƌůǇĚĞƚĞĐƚĞĚďǇƚŚĞŵŽŶŝƚŽƌ͘ ϱ͘ dƵƌŶŽŶƚŚĞWĂĐĞƌĂŶĚƐĞƚƚŽ&/yŵŽĚĞ ϲ͘ ^ĞůĞĐƚĂƌĂƚĞŝƐϭϬͲϮϬƉƉŵŚŝŐŚĞƌƚŚĂŶƚŚĞƉĂƚŝĞŶƚ͛ƐŝŶƚƌŝŶƐŝĐŚĞĂƌƚƌĂƚĞ͘/ĨŶŽŝŶƚƌŝŶƐŝĐŚĞĂƌƚƌĂƚĞ ĞǆŝƐƚƐ͕ƚŚĞŶƵƐĞϴϬƉƉŵ͘ ϳ͘ dŚĞƚǇƉŝĐĂůƌĂŶŐĞĨŽƌŵŝůůŝĂŵƉ;ŵͿŽƵƚƉƵƚŝƐďĞƚǁĞĞŶϰϬʹϴϬŵ͘dŚĞůŽǁĞƐƚǀĂůƵĞƚŚĂƚĂĐŚŝĞǀĞƐ ĞůĞĐƚƌŝĐĂůĂŶĚŵĞĐŚĂŶŝĐĂůĐĂƉƚƵƌĞƐŚŽƵůĚďĞƵƐĞĚ͘ x /ŶĐƌĞĂƐĞƚŚĞƉĂĐĞƌŽƵƚƉƵƚŝŶϭϬŵŝŶĐƌĞŵĞŶƚƐƵŶƚŝůĞůĞĐƚƌŝĐĂůĐĂƉƚƵƌĞŝƐĂĐŚŝĞǀĞĚ͘ x ĞĐƌĞĂƐĞďǇϱŵŝŶĐƌĞŵĞŶƚƐŝŶŽƌĚĞƌƚŽƵƐĞƚŚĞůĞĂƐƚĂŵŽƵŶƚŽĨĞůĞĐƚƌŝĐŝƚǇŶĞĐĞƐƐĂƌǇƚŽ ŵĂŝŶƚĂŝŶĐĂƉƚƵƌĞ͘ x KŶĐĞƚŚŝƐƚŚƌĞƐŚŽůĚŝƐƐĞƚ͕ĐŚĞĐŬĨŽƌĂƉĂůƉĂďůĞƉƵůƐĞǀŝĂƚŚĞĨĞŵŽƌĂůĂƌƚĞƌǇŽƌƚŚĞƌŝŐŚƚďƌĂĐŚŝĂů ŽƌƌŝŐŚƚƌĂĚŝĂůĂƌƚĞƌǇ͖ĐŽƌƌĞůĂƚĞƉƵůƐĞƐǁŝƚŚ^WKϮĂŶĚƚKϮǁĂǀĞĨŽƌŵƐ x /ĨƚŚĞƌĞŝƐŶŽŵĞĐŚĂŶŝĐĂůĐĂƉƚƵƌĞ͕ŝŶĐƌĞĂƐĞƚŚĞŵŝůůŝĂŵƉƐ;ŵĂǇŶĞĞĚƚŽĨƵƌƚŚĞƌƐĞĚĂƚĞƉĂƚŝĞŶƚ ƉƌŝŽƌƚŽŝŶĐƌĞĂƐŝŶŐƚŚƌĞƐŚŽůĚͿĂƐŶĞĐĞƐƐĂƌǇƵƉƚŽϭϮϬŵ x KŶĐĞŵĞĐŚĂŶŝĐĂůĐĂƉƚƵƌĞŝƐĂĐŚŝĞǀĞĚ͕ƌĞĐŚĞĐŬďůŽŽĚƉƌĞƐƐƵƌĞĂŶĚƉĞƌĨƵƐŝŽŶ͘,ĞĂƌƚƌĂƚĞŵĂǇďĞ ĂĚũƵƐƚĞĚďĂƐĞĚŽŶƉĞƌĨƵƐŝŽŶŶĞĞĚƐ͘

Cypress Creek EMS System Policies and Treatment Guidelines

255 PROCEDURES Revised 8/2016 Cardiac Approved: Levon Vartanian, MD

^ǇŶĐŚƌŽŶŝǌĞĚĂƌĚŝŽǀĞƌƐŝŽŶ Indications Equipment Needed hŶƐƚĂďůĞƚĂĐŚǇĂƌƌŚǇƚŚŵŝĂ͗ ŽůůyͲ^ĞƌŝĞƐDŽŶŝƚŽƌ EĂƌƌŽǁĐŽŵƉůĞǆƚĂĐŚǇĐĂƌĚŝĂхϭϱϬͬŵŝŶ sĞŶƚƌŝĐƵůĂƌƚĂĐŚǇĐĂƌĚŝĂ ƚƌŝĂů&ŝďƌŝůůĂƚŝŽŶǁŝƚŚZsZхϭϯϬͬŵŝŶ

tŝƚŚĂŶǇŽĨƚŚĞĨŽůůŽǁŝŶŐƐŝŐŶƐͬƐǇŵƉƚŽŵƐŽĨ ƐŚŽĐŬ͗ĐŽŽůͬĐůĂŵŵǇͬƉĂůĞƐŬŝŶ͕ĂĐƵƚĞůǇ ĂůƚĞƌĞĚŵĞŶƚĂůƐƚĂƚƵƐ͕^WфϵϬ͕ŝƐĐŚĞŵŝĐ ĐŚĞƐƚĚŝƐĐŽŵĨŽƌƚ͕ŽƌĂĐƵƚĞŚĞĂƌƚĨĂŝůƵƌĞ͘ WƌŽĐĞĚƵƌĞ ϭ͘ ŽŶŶĞĐƚŵŽŶŝƚŽƌŝŶŐĞůĞĐƚƌŽĚĞƐ;ϰͲůĞĂĚͿƚŽƉĂƚŝĞŶƚĂŶĚĂƚƚĂĐŚĞůĞĐƚƌŽĚĞƐƚŽƉĂƚŝĞŶƚ͘ Ϯ͘ ƉƉůǇĚĞĨŝďƌŝůůĂƚŝŽŶƉĂĚƐƚŽƚŚĞƉĂƚŝĞŶƚ͘;ŶƚĞƌŝŽƌͬƉŽƐƚĞƌŝŽƌƉŽƐŝƚŝŽŶŝƐƉƌĞĨĞƌƌĞĚďƵƚĂƉĞǆͬƐƚĞƌŶƵŵ ŵĂǇďĞƵƚŝůŝǌĞĚŝĨĂŶƚĞƌŝŽƌͬƉŽƐƚĞƌŝŽƌŝƐĚŝĨĨŝĐƵůƚŽƌƉŽƐƐŝďůǇŚĂƌŵĨƵů͘ ϯ͘ ŶƐƵƌĞƚŚĂƚƚŚĞƉĂĚƐĚŽŶŽƚŵĂŬĞĐŽŶƚĂĐƚǁŝƚŚĂŶǇŽƚŚĞƌ'ĞůĞĐƚƌŽĚĞƐ͘ ϰ͘ dƵƌŶŽŶƚŚĞ^zEŵŽĚĞĂŶĚĐŽŶĨŝƌŵƐǇŶĐŝŶŐŽŶĚŝƐƉůĂǇŽĨŵŽŶŝƚŽƌ ϱ͘ ^ĞůĞĐƚĞŶĞƌŐǇůĞǀĞů͗ x EĂƌƌŽǁĐŽŵƉůĞǆƚĂĐŚǇĐĂƌĚŝĂ͗^ƚĂƌƚǁŝƚŚϱϬ:;ĂĚƵůƚͿŽƌϬ͘ϱʹϭ:ͬŬŐ;ƉĞĚŝĂƚƌŝĐͿ x ZĞŐƵůĂƌ͕ǁŝĚĞĐŽŵƉůĞǆƚĂĐŚǇĐĂƌĚŝĂ͗^ƚĂƌƚǁŝƚŚϭϬϬ:;ĂĚƵůƚͿŽƌϭ:ͬŬŐ;ƉĞĚŝĂƚƌŝĐͿ x /ƌƌĞŐƵůĂƌ͕ǁŝĚĞĐŽŵƉůĞǆƚĂĐŚǇĐĂƌĚŝĂ͗hƚŝůŝǌĞDefibrillation ƉƌŽĐĞĚƵƌĞĂƚϮϬϬ:ƵŶƐǇŶĐŚƌŽŶŝǌĞĚ ;ĂĚƵůƚͿŽƌϮ:ͬŬŐƵŶƐǇŶĐŚƌŽŶŝǌĞĚ;ƉĞĚŝĂƚƌŝĐͿ͘ ϲ͘ ŚĂƌŐĞ͕ĞŶƐƵƌĞƉĂƚŝĞŶƚŝƐĐůĞĂƌ͕ƚŚĞŶƉƌĞƐƐĂŶĚŚŽůĚƚŚĞƐŚŽĐŬďƵƚƚŽŶƵŶƚŝůƐŚŽĐŬŝƐĚĞůŝǀĞƌĞĚ͘ ϳ͘ ZĞĂƐƐĞƐƐƉĂƚŝĞŶƚ͘/ĨŶĞĐĞƐƐĂƌǇ͕ƌĞƉĞĂƚƐǇŶĐŚƌŽŶŝǌĞĚƐŚŽĐŬƐĂƚĞƐĐĂůĂƚĞĚĚŽƐĞƐƵŶƚŝůĐŽŶǀĞƌƐŝŽŶŝƐ ĂĐŚŝĞǀĞĚ͘ WĞĂƌůƐ x ŽŶƐŝĚĞƌSedationƉƌŽĐĞĚƵƌĞǁŝƚŚĐĂƌĚŝŽǀĞƌƐŝŽŶ͕ďƵƚĚŽŶŽƚƵŶŶĞĐĞƐƐĂƌŝůǇĚĞůĂǇĐĂƌĚŝŽǀĞƌƐŝŽŶŝŶ ƵŶƐƚĂďůĞƉĂƚŝĞŶƚƐ͘ x ŽŶƐŝĚĞƌPain ManagementĨŽůůŽǁŝŶŐĐĂƌĚŝŽǀĞƌƐŝŽŶ͘ x tŝƚŚŽƵƚĞǀŝĚĞŶĐĞŽĨŚǇƉŽƉĞƌĨƵƐŝŽŶŽƌĞŶĚŽƌŐĂŶĐŽŵƉƌŽŵŝƐĞ͕ƚĂĐŚǇĂƌƌŚǇƚŚŵŝĂƐĚŽŶŽƚƌĞƋƵŝƌĞ ĐĂƌĚŝŽǀĞƌƐŝŽŶ͘

Cypress Creek EMS System Policies and Treatment Guidelines

256 PROCEDURES Revised 8/2016 Assessment Approved: Levon Vartanian, MD

ůŽŽĚ'ůƵĐŽƐĞŶĂůǇƐŝƐ Indications Equipment Needed ůƚĞƌĞĚŵĞŶƚĂůƐƚĂƚƵƐ 'ůƵĐŽŵĞƚĞƌ͕ĂůĐŽŚŽůƐǁĂď͕ŐĂƵǌĞƉĂĚ͕ůĂŶĐĞƚ͕ ďĚŽŵŝŶĂůƉĂŝŶ ďůŽŽĚŐůƵĐŽƐĞĂŶĂůǇƐŝƐƐƚƌŝƉƐ͘ ĞŚĂǀŝŽƌĂůĞŵĞƌŐĞŶĐǇ ^ƵƐƉĞĐƚĞĚďůŽŽĚŐůƵĐŽƐĞĚŝƐƚƵƌďĂŶĐĞ WƌŽĐĞĚƵƌĞ &ŽƌĐĂƉŝůůĂƌǇƚĞƐƚŝŶŐ͗ ϭ͘ ůĞĂŶƐĞƐŝƚĞƵƐŝŶŐĂƐĞƉƚŝĐƚĞĐŚŶŝƋƵĞ͘ Ϯ͘ WůĂĐĞĂŶĂůǇƐŝƐƐƚƌŝƉŝŶŐůƵĐŽŵĞƚĞƌ͘ ϯ͘ ƌĂǁďůŽŽĚƐĂŵƉůĞƵƐŝŶŐůĂŶĐĞƚ͘ŝƐƉŽƐĞŽĨůĂŶĐĞƚŝŶĂƐŚĂƌƉƐĐŽŶƚĂŝŶĞƌ͘ ϰ͘ ƉƉůǇďůŽŽĚƐĂŵƉůĞƚŽĂŶĂůǇƐŝƐƐƚƌŝƉ͘ ϱ͘ /ŶƚĞƌƉƌĞƚƌĞƐƵůƚƐ͘ Venous blood may not be used for blood glucose analysis. It is not acceptable to collect blood from the used IV needle or safety sheath, as this significantly increases risk for needlestick exposure. WĞĂƌůƐ hŶĚĞƌƐƚĂŶĚŝŶŐůŽŽĚ'ůƵĐŽƐĞdĞƐƚZĞƐƵůƚƐ

dŚĞŐůƵĐŽŵĞƚĞƌĚŝƐƉůĂǇƐƌĞƐƵůƚƐĨƌŽŵϮϬʹϲϬϬŵŐͬĚ>͘

tŚĞŶƚŚĞŵĞƚĞƌĚŝƐƉůĂǇƐLO͕ƚŚĞŶƚŚĞƌĞƐƵůƚŝƐфϮϬŵŐͬĚ>͘ŽĐƵŵĞŶƚƚŚŝƐĨŝŶĚŝŶŐŝŶŶĂƌƌĂƚŝǀĞ͕ŽƌŝŶƚŚĞ ĐŽŵŵĞŶƚƐƐĞĐƚŝŽŶŽĨƚŚĞǀŝƚĂůƐŝŐŶƐ͘

tŚĞŶƚŚĞŵĞƚĞƌĚŝƐƉůĂǇƐHIǁŚĞŶƚŚĞƌĞƐƵůƚŝƐхϲϬϬŵŐͬů͘dŚŝƐŝŶĚŝĐĂƚĞƐĞŝƚŚĞƌƐĞǀĞƌĞŚǇƉĞƌŐůǇĐĞŵŝĂ ŽƌĂƉƌŽďůĞŵǁŝƚŚƚŚĞƚĞƐƚƐƚƌŝƉ͘ZĞƉĞĂƚƚŚĞƚĞƐƚǁŝƚŚĂŶĞǁƐƚƌŝƉ͖ĚŽĐƵŵĞŶƚƚŚŝƐĨŝŶĚŝŶŐŝŶƚŚĞŶĂƌƌĂƚŝǀĞ ŽƌŝŶƚŚĞĐŽŵŵĞŶƚƐƐĞĐƚŝŽŶŽĨƚŚĞǀŝƚĂůƐŝŐŶƐ͘

Er1 ƵƐĞĚƚĞƐƚƐƚƌŝƉǁĂƐŝŶƐĞƌƚĞĚ͘ZĞƉůĂĐĞ Er2 ůŽŽĚǁĂƐĂƉƉůŝĞĚƚŽŽƐŽŽŶ͘ZĞƉĞĂƚǁŝƚŚ ǁŝƚŚĂŶĞǁƚĞƐƚƐƚƌŝƉ͘ ŶĞǁƐƚƌŝƉĂŶĚǁĂŝƚĨŽƌŵĞƚĞƌƚŽŝŶĚŝĐĂƚĞ ƌĞĂĚŝŶĞƐƐĨŽƌďůŽŽĚ͘ Er4 ůŽŽĚƐĂŵƉůĞŚĂƐŝŶƐƵĨĨŝĐŝĞŶƚǀŽůƵŵĞŽƌ Er5 tƌŽŶŐďůŽŽĚŐůƵĐŽƐĞƚĞƐƚƐƚƌŝƉ͘ZĞƉĞĂƚ ĂďŶŽƌŵĂůůǇŚŝŐŚǀŝƐĐŽƐŝƚǇ͘ZĞƉĞĂƚƚĞƐƚǁŝƚŚ ǁŝƚŚĂƐƚƌŝƉĚĞƐŝŐŶĞĚĨŽƌƚŚŝƐŵĞƚĞƌ͘ ŶĞǁƐƚƌŝƉ͘ Er6 WƌŽďůĞŵǁŝƚŚŵĞƚĞƌ͘ŽŶŽƚƵƐĞŵĞƚĞƌ͖ ĐŽŶƚĂĐƚĨŝĞůĚƐƵƉĞƌǀŝƐŽƌĨŽƌƌĞƉůĂĐĞŵĞŶƚ͘ HiF dĞŵƉĞƌĂƚƵƌĞƚŽŽŚŝŐŚ;хϭϬϰ϶&Ϳ͘ LoF dĞŵƉĞƌĂƚƵƌĞƚŽŽůŽǁ;фϱϬ϶&Ϳ͘

Cypress Creek EMS System Policies and Treatment Guidelines

257 PROCEDURES Revised 8/2016 Assessment Approved: Levon Vartanian, MD

KͲKǆŝŵĞƚƌǇ Indications Equipment Needed ^ƵƐƉĞĐƚĞĚKƉŽŝƐŽŶŝŶŐ͘^ǇŵƉƚŽŵƐŝŶĐůƵĚĞ͗ ZͲϱϳ ,ĞĂĚĂĐŚĞ͕ĚŝǌǌŝŶĞƐƐ͕ŶĂƵƐĞĂ͕ǀŽŵŝƚŝŶŐ͕ŽƌĐŚĞƐƚ KƌZĂŝŶďŽǁͲĞƋƵŝƉƉĞĚŽůůyͲ^ĞƌŝĞƐ ƉĂŝŶ͘ x hƚŝůŝǌĞKͲKǆŝŵĞƚƌǇƚŽŵĞĂƐƵƌĞůĞǀĞůƐŽĨĐĂƌďŽŶŵŽŶŽǆŝĚĞǁŚĞŶKƉŽŝƐŽŶŝŶŐŝƐƐƵƐƉĞĐƚĞĚ͘ x ůĞǀĂƚĞĚKůĞǀĞůƐǁŝůůĐĂƵƐĞĨĂůƐĞůǇŚŝŐŚƉƵůƐĞŽǆŝŵĞƚƌǇƌĞĂĚŝŶŐƐ͘ x KͲKǆŝŵĞƚƌǇƐĞŶƐŽƌƐĂƌĞŵŽƌĞƐĞŶƐŝƚŝǀĞƚŽĂŵďŝĞŶƚůŝŐŚƚ͘&ŽůůŽǁŵĂŶƵĨĂĐƚƵƌĞƌƌĞĐŽŵŵĞŶĚĂƚŝŽŶƐŝŶ ƵƚŝůŝǌŝŶŐĚĞǀŝĐĞƐ͘ x ŽŶƐŝĚĞƌƉŽƐƐŝďůĞĐǇĂŶŝĚĞƉŽŝƐŽŶŝŶŐŝŶƉĂƚŝĞŶƚƐǁŝƚŚĞůĞǀĂƚĞĚ^ƉKůĞǀĞůƐĨŽůůŽǁŝŶŐĞǆƉŽƐƵƌĞƚŽĂ ĨŝƌĞŝŶĂŶĞŶĐůŽƐĞĚƐƉĂĐĞ͘ /ŶƚĞƌƉƌĞƚĂƚŝŽŶŽĨZĞƐƵůƚƐ SpCO Interpretation фϯй EŽƌŵĂů фϭϮй ǀĂůƵĂƚĞĂŶĚƚƌĞĂƚďĂƐĞĚŽŶƐǇŵƉƚŽŵƐ͘ ϭϮʹϮϱй WƌŽǀŝĚĞϭϬϬй&ŝKϮĂŶĚƚƌĂŶƐƉŽƌƚƚŽĨŽƌĞǀĂůƵĂƚŝŽŶ͘ х Ϯϱй;ŽƌůŽƐƐŽĨ WƌŽǀŝĚĞϭϬϬй&ŝKϮĂŶĚƵƌŐĞŶƚůǇƚƌĂŶƐƉŽƌƚƚŽĨĂĐŝůŝƚǇĐĂƉĂďůĞŽĨ ĐŽŶƐĐŝŽƵƐŶĞƐƐͿ ŚǇƉĞƌďĂƌŝĐŽǆǇŐĞŶƚŚĞƌĂƉǇ͘ x ^ĞĞƚŚĞĂůŐŽƌŝƚŚŵďĞůŽǁĨŽƌĚĞƚĂŝůƐŽŶĂƉƉƌŽĂĐŚŝŶŐKƉŽŝƐŽŶŝŶŐ͘ x WƌĞŐŶĂŶƚƉĂƚŝĞŶƚƐƐŚŽƵůĚďĞĐŽŶƐŝĚĞƌĞĚĂƐŚŝŐŚĞƌƌŝƐŬĨŽƌĞĂĐŚĐĂƚĞŐŽƌǇ͘

Cypress Creek EMS System Policies and Treatment Guidelines

258 PROCEDURES Revised 8/2016 Assessment Approved: Levon Vartanian, MD

Cypress Creek EMS System Policies and Treatment Guidelines

259 PROCEDURES Revised 8/2016 Assessment Approved: Levon Vartanian, MD

,ĞŵŽŐůŽďŝŶƐƐĞƐƐŵĞŶƚ Indications Equipment Needed dƌĂƵŵĂŽƌŵĞĚŝĐĂůƉĂƚŝĞŶƚǁŝƚŚƐƵƐƉĞĐƚĞĚďůŽŽĚ >/ǁĂŝǀĞĚƉŚŽƚŽŵĞƚĞƌ͕ĂůĐŽŚŽůƐǁĂď͕ ůŽƐƐ ŐĂƵǌĞƉĂĚ͕ůĂŶĐĞƚ͕ĂƉŝůůĂƌǇdƌĂŶƐĨĞƌdƵďĞ͕ dĞƐƚĐĂƌƚƌŝĚŐĞƐ WƌŽĐĞĚƵƌĞ ϭ͘ DĂŬĞƐƵƌĞƚŚĞŵĞƚĞƌŝƐƌĞĂĚǇĨŽƌƵƐĞ͘dƵƌŶŵĞƚĞƌŽŶ͕ĂŶĚǁŚĞŶƚŚĞŽŶͲƐĐƌĞĞŶĚŝƐƉůĂǇŝŶĚŝĐĂƚĞƐ͕ ŝŶƐĞƌƚƚŚĞƚĞƐƚŝŶŐƐƚƌŝƉĂůůƚŚĞǁĂǇŝŶ͘ Ϯ͘ ůĞĂŶƐĞƐŝƚĞĨŽƌĐĂƉŝůůĂƌǇƉƵŶĐƚƵƌĞƵƐŝŶŐĂůĐŽŚŽůƉĂĚĂŶĚĂůůŽǁƚŽĚƌǇ͘ ϯ͘ >ĂŶĐĞƐŝĚĞŽĨĨŝŶŐĞƌƚŝƉ͘ůŽƚĂǁĂǇĨŝƌƐƚĚƌŽƉŽĨďůŽŽĚ͘ ϰ͘ WƌĞƐƐŐĞŶƚůǇŽŶĐĞĂŐĂŝŶƚŽŐĞƚĂϮŶĚĚƌŽƉŽĨďůŽŽĚ͘ ϱ͘ WůĂĐĞƚŚĞƚŝƉŽĨƚŚĞĐĂƉŝůůĂƌǇĐŽůůĞĐƚŝŽŶƚƵďĞĂŐĂŝŶƐƚƚŚĞĚƌŽƉŽĨ ďůŽŽĚ͘DO NOT squeeze capillary collection tube. ϲ͘ ůůŽǁĐĂƉŝůůĂƌǇĐŽůůĞĐƚŝŽŶƚƵďĞƚŽĚƌĂǁƵƉďůŽŽĚƚŽƚŚĞůĞǀĞůŽĨ ƚŚĞďůĂĐŬůŝŶĞ͘ ϳ͘ ƉƉůǇďůŽŽĚƐĂŵƉůĞƚŽƚŚĞƐƉĞĐŝŵĞŶĂƌĞĂŽŶƚŚĞƚĞƐƚƐƚƌŝƉ͘/ƚ ƐŚŽƵůĚĨŝůůƚŚĞĞŶƚŝƌĞƚĞƐƚĂƌĞĂǁŝƚŚďůŽŽĚ͘ ϴ͘ dŚĞŵĞƚĞƌǁŝůůƚŚĞŶƌĞĂĚŚĞŵŽŐůŽďŝŶĂŶĚŚĞŵĂƚŽĐƌŝƚǀĂůƵĞƐ͘ ϵ͘ ŽĐƵŵĞŶƚĨŝŶĚŝŶŐƐŝŶWZ͘ŝƐƉŽƐĞŽĨŵŝĐƌŽĐƵǀĞƚƚĞĂŶĚůĂŶĐĞƚŝŶƚŽƐŚĂƌƉƐĐŽŶƚĂŝŶĞƌ͘ WĞĂƌůƐ x dŚĞŵĞƚĞƌƌĞƋƵŝƌĞƐĂĐŽĚĞĐŚŝƉƉĂĐŬĂŐĞĚǁŝƚŚĞĂĐŚďŽǆŽĨƚĞƐƚŝŶŐƐƚƌŝƉƐ͘dŚŝƐĐŚŝƉŵƵƐƚďĞŝŶƐĞƌƚĞĚ ŽŶƚŚĞůĞĨƚŚĂŶĚƐŝĚĞŽĨƚŚĞŵĞƚĞƌŝŶƐůŽƚƉƌŽǀŝĚĞĚ͘ x KŶůǇĐĂƉŝůůĂƌǇďůŽŽĚŵĂǇďĞƚĞƐƚĞĚ͘ŽŶŽƚƵƐĞĂƌƚĞƌŝĂůŽƌǀĞŶŽƵƐďůŽŽĚ͘ x ^ĂŵƉůĞƐƐŚŽƵůĚďĞŝŵŵĞĚŝĂƚĞůǇƚĞƐƚĞĚ͘ x ,ĞŵĂƚŽĐƌŝƚǀĂůƵĞƐǁŝůůŶŽƚĚŝƐƉůĂǇŝĨŚĞŵŽŐůŽďŝŶǀĂůƵĞƐĂƌĞŽƵƚƐŝĚĞŽĨƚŚĞƌĂŶŐĞϭϮ͘ϯʹϭϳ͘ϱŐͬů͘ x DĞƚĞƌǁŝůůƌĞĂĚ>KŝĨƚĞƐƚƌĞƐƵůƚŝƐфϰ͘ϱŐͬůKZŝĨŝŶƐƵĨĨŝĐŝĞŶƚďůŽŽĚǁĂƐĂƉƉůŝĞĚ͘ZĞƉĞĂƚƚĞƐƚďĞĨŽƌĞ ŵĂŬŝŶŐƚƌĞĂƚŵĞŶƚĚĞĐŝƐŝŽŶƐďĂƐĞĚŽŶƌĞƐƵůƚ͘ x DĞƚĞƌǁŝůůƌĞĂĚ,/ŝĨƚĞƐƚƌĞƐƵůƚŝƐхϮϱ͘ϲŐͬů͘ x ŽŶŽƚƵƐĞďůĞĂĐŚŽƌĂůĐŽŚŽůƚŽĐůĞĂŶŵĞƚĞƌƐĞŶƐŽƌĂƌĞĂ͖ƚŚĞƐĞǁŝůůĚĂŵĂŐĞƚŚĞƐĞŶƐŽƌ͘ x ǆƉĞĐƚĞĚǀĂůƵĞƐ͗ x ĚƵůƚŵĂůĞƐ͗ ϭϯͲϭϴŐͬĚ> x ĚƵůƚĨĞŵĂůĞƐ͗ ϭϭͲϭϲŐͬĚ> x ŚŝůĚƌĞŶ͗ ϭϭͲϭϲŐͬĚ> x /ŶĨĂŶƚƐ;ƉŽƐƚͲŶĂƚĂůͿ͗ ϭϬͲϭϰŐͬĚ>

Cypress Creek EMS System Policies and Treatment Guidelines

260 PROCEDURES Revised 8/2016 Assessment Approved: Levon Vartanian, MD

ƌƌŽƌŽĚĞƐĂŶĚdƌŽƵďůĞƐŚŽŽƚŝŶŐ DISPLAY CAUSE SOLUTION Ͳϭ ^ĞŶƐŽƌĂƌĞĂŝƐĚĂŵĂŐĞĚ͕ĚŝƌƚǇ͕Žƌ ŶƐƵƌĞƐĞŶƐŽƌĂƌĞĂŝƐĐůĞĂŶ͘hƐĞĂƐŽĨƚ ďůŽĐŬĞĚ͘ ĐŽƚƚŽŶŐĂƵǌĞƉĂĚŽƌĐŽƚƚŽŶĂƉƉůŝĐĂƚŽƌ ƚŽĐůĞĂŶŝĨŶĞĐĞƐƐĂƌǇ͘ZĞƐƚĂƌƚŵĞƚĞƌ͘ ͲϮ dĞƐƚĐĂƌƚƌŝĚŐĞǁĂƐƌĞŵŽǀĞĚĚƵƌŝŶŐ ZĞƉĞĂƚƚŚĞƚĞƐƚ͘ŶƐƵƌĞƚŚĞƚĞƐƚ ƚŚĞƚĞƐƚ͘ ĐĂƌƚƌŝĚŐĞƌĞŵĂŝŶƐŝŶƉůĂĐĞ͘ Ͳϯ ^ƉĞĐŝŵĞŶǁĂƐĂƉƉůŝĞĚƚŽƚŚĞƚĞƐƚ ZĞƉĞĂƚƚĞƐƚ͘tĂŝƚĨŽƌƚŚĞďůŽŽĚĚƌŽƉ ĐĂƌƚƌŝĚŐĞƚŽŽƐŽŽŶ͘ ƐǇŵďŽůďĞĨŽƌĞĂƉƉůǇŝŶŐƐƉĞĐŝŵĞŶ Ͳϰ ĂƚƚĞƌŝĞƐĂƌĞƚŽŽůŽǁ͘ ZĞƉůĂĐĞďĂƚƚĞƌŝĞƐ Ͳϱ /ŶƐƵĨĨŝĐĞŶƚƐƉĞĐŝŵĞŶ ZĞƉĞĂƚƚĞƐƚ͕ĂŶĚĂƉƉůǇĞŶŽƵŐŚďůŽŽĚ͘ Ͳϲ ǆƉŝƌĞĚƚĞƐƚĐĂƌƚƌŝĚŐĞKZĚĂƚĞ ŚĞĐŬƚĞƐƚĐĂƌƚƌŝĚŐĞĞǆƉŝƌĂƚŝŽŶĚĂƚĞ ƉƌŽŐƌĂŵŵĞĚŽŶŵĞƚĞƌŝŶĐŽƌƌĞĐƚůǇ͘ ƉƌŝŶƚĞĚŽŶĐĂŶŝƐƚĞƌůĂďĞů͘ ^ĞƚƵƉŵĞƚĞƌĂŐĂŝŶǁŝƚŚĐŽƌƌĞĐƚĚĂƚĞ͘ Ͳϳ ŽĚĞĐŚŝƉǁĂƐƌĞŵŽǀĞĚĚƵƌŝŶŐ ŽŶĨŝƌŵĐŚŝƉĐŽĚĞŵĂƚĐŚĞƐƚĞƐƚƐƚƌŝƉƐ ƚĞƐƚŝŶŐ ;ƐĞĞĐĂŶŝƐƚĞƌůĂďĞůͿĂŶĚŝŶƐĞƌƚĐŽĚĞ ĐŚŝƉĂŐĂŝŶ͘

Cypress Creek EMS System Policies and Treatment Guidelines

261 PROCEDURES Revised 8/2016 Assessment Approved: Levon Vartanian, MD

KƌƚŚŽƐƚĂƚŝĐůŽŽĚWƌĞƐƐƵƌĞƐƐĞƐƐŵĞŶƚ Indications Equipment Needed ^ƵƐƉĞĐƚĞĚŽƌƚŚŽƐƚĂƚŝĐŚǇƉŽƚĞŶƐŝŽŶ͘^ǇŵƉƚŽŵƐ ŽůůyͲ^ĞƌŝĞƐŵŽŶŝƚŽƌ ĐŽƵůĚŝŶĐůƵĚĞĚŝǌǌŝŶĞƐƐ͕ƐǇŶĐŽƉĞ͕ǁĞĂŬŶĞƐƐ͕Žƌ WĐƵĨĨ ŚǇƉŽƚĞŶƐŝŽŶĂŶĚŵĂǇďĞƉŽƐŝƚŝŽŶĂů͘ WƌŽĐĞĚƵƌĞ ϭ͘ ŶƐƵƌĞƉĂƚŝĞŶƚŝƐŝŶĂƐĂĨĞĂƌĞĂĂŶĚƚŚĂƚĂŶǇĨĂůůƐ͕ƐǇŶĐŽƉĞ͕ŽƌƐƵĚĚĞŶǁĞĂŬŶĞƐƐĐĂŶďĞŵŝƚŝŐĂƚĞĚ ǁŝƚŚŽƵƚĐĂƵƐŝŶŐŝŶũƵƌǇƚŽƉĂƚŝĞŶƚ͘ Ϯ͘ ŽŶŶĞĐƚƉĂƚŝĞŶƚƚŽĐĂƌĚŝĂĐŵŽŶŝƚŽƌŝŶŐ͘ ϯ͘ DĞĂƐƵƌĞĂŶĚƌĞĐŽƌĚďůŽŽĚƉƌĞƐƐƵƌĞĂŶĚŚĞĂƌƚƌĂƚĞǁŝƚŚƉĂƚŝĞŶƚƐƵƉŝŶĞ͘ ϰ͘ ^ŝƚƉĂƚŝĞŶƚĨƵůůǇƵƉƌŝŐŚƚĂŶĚƌĞƉĞĂƚďůŽŽĚƉƌĞƐƐƵƌĞĂŶĚ,ZŵĞĂƐƵƌĞŵĞŶƚƐ͘ ϱ͘ ƐƐŝƐƚƉĂƚŝĞŶƚƚŽƐƚĂŶĚŝŶŐƉŽƐŝƚŝŽŶĂŶĚƌĞƉĞĂƚďůŽŽĚƉƌĞƐƐƵƌĞĂŶĚ,ZŵĞĂƐƵƌĞŵĞŶƚƐ͘ x /ĨĂƚĂŶǇƉŽŝŶƚ͕ƉĂƚŝĞŶƚďĞĐŽŵĞƐĚŝǌǌǇ͕ůŽƐĞƐĐŽŶƐĐŝŽƵƐŶĞƐƐ͕ŽƌŚĂƐĂƐƵĚĚĞŶĚĞƚĞƌŝŽƌĂƚŝŽŶŝŶ ƐǇŵƉƚŽŵƐ͕ƐƚŽƉƚŚĞƚĞƐƚŝŵŵĞĚŝĂƚĞůǇĂŶĚĐŽŶƐŝĚĞƌŝƚĂƐĂƉŽƐŝƚŝǀĞƌĞƐƵůƚ͘ x dŝŵĞƐŚŽƵůĚďĞŐŝǀĞŶďĞƚǁĞĞŶĞĂĐŚƉŽƐŝƚŝŽŶĐŚĂŶŐĞƚŽĂůůŽǁǀŝƚĂůƐŝŐŶƐƚŽƐƚĂďŝůŝǌĞ;ϯϬƐĞĐŽŶĚƐʹ ϮŵŝŶƵƚĞƐͿ͘ x ƉŽƐŝƚŝǀĞŽƌƚŚŽƐƚĂƚŝĐƚĞƐƚŝƐǁŚĞŶƚŚĞ,ZŝŶĐƌĞĂƐĞƐŵŽƌĞƚŚĂŶϮϬƉŽŝŶƚƐŽƌƐǇƐƚŽůŝĐWĚƌŽƉƐ ŵŽƌĞƚŚĂŶϭϬƉŽŝŶƚƐŽŶĂĐŚĂŶŐĞŝŶĂƉŽƐŝƚŝŽŶ͘ x ZĞĐŽƌĚŽƌƚŚŽƐƚĂƚŝĐƚĞƐƚĨŝŶĚŝŶŐƐŝŶŶĂƌƌĂƚŝǀĞƉŽƌƚŝŽŶŽĨƌĞƉŽƌƚ͘

Cypress Creek EMS System Policies and Treatment Guidelines

262 PROCEDURES Revised 8/2016 Assessment Approved: Levon Vartanian, MD

^ƚƌŽŬĞΘEĞƵƌŽůŽŐŝĐĂůƐƐĞƐƐŵĞŶƚ /ŶĚŝĐĂƚŝŽŶƐ ^ŝŐŶƐΘƐǇŵƉƚŽŵƐĐŽŶƐŝƐƚĞŶƚǁŝƚŚĂsŽƌŶĞƵƌŽůŽŐŝĐĂůŝŶũƵƌǇ͕ƉŽƐƐŝďůǇŝŶĐůƵĚŝŶŐ͗ x ^ƵĚĚĞŶŶƵŵďŶĞƐƐŽƌǁĞĂŬŶĞƐƐ͕ĞƐƉĞĐŝĂůůǇŽŶŽŶĞƐŝĚĞŽĨƚŚĞďŽĚǇ͘ x ^ƵĚĚĞŶĐŽŶĨƵƐŝŽŶ͕ƚƌŽƵďůĞƐƉĞĂŬŝŶŐ͕ŽƌƵŶĚĞƌƐƚĂŶĚŝŶŐ͘ x ^ƵĚĚĞŶƚƌŽƵďůĞǁĂůŬŝŶŐ͕ĚŝǌǌŝŶĞƐƐ͕ůŽƐƐŽĨďĂůĂŶĐĞŽƌĐŽŽƌĚŝŶĂƚŝŽŶ͘ x ^ƵĚĚĞŶůŽƐƐŽƌĐŚĂŶŐĞŝŶǀŝƐŝŽŶŝŶŽŶĞŽƌďŽƚŚĞǇĞƐ͘ x ^ƵĚĚĞŶƐĞǀĞƌĞŚĞĂĚĂĐŚĞǁŝƚŚŶŽŬŶŽǁŶĐĂƵƐĞ͘ Stroke Screening (Cincinnati Stroke Scale/FAST) Check if abnormal: F (Face) Facial Droop͗,ĂǀĞƉĂƚŝĞŶƚƐŵŝůĞŽƌƐŚŽǁƚĞĞƚŚ͘>ŽŽŬĨŽƌĂŶǇĂƐǇŵŵĞƚƌǇ͘ A (Arm) Motor weakness͗ƐƐĞƐƐarm strength, arm drift, ĂŶĚ grip strength͘ S (Speech) Speaking͗,ĂǀĞƉĂƚŝĞŶƚƌĞƉĞĂƚƉŚƌĂƐĞ͞zŽƵĐĂŶ͛ƚƚĞĂĐŚĂŶŽůĚĚŽŐŶĞǁƚƌŝĐŬƐ͘͟ ďŶŽƌŵĂůŝƐǁŽƌĚƐƐůƵƌƌĞĚ;ĚǇƐĂƌƚŚƌŝĂͿ͕ĂďŶŽƌŵĂů;ĂƉŚĂƐŝĂͿ͕ŽƌŶŽŶĞ͘ T (Time) Last seen normal time? /ĨĂŶǇďŽǆŝƐĐŚĞĐŬĞĚĂďŽǀĞ͕ƚŚŝƐŝƐĂƉŽƐƐŝďůĞStroke Alert͘ŽŶƚŝŶƵĞƚŽ^ƚƌŽŬĞůĞƌƚZƵůĞKƵƚƐ͗ Check all appropriate boxes: ZĞƐŽůƵƚŝŽŶŽĨƐƚƌŽŬĞƐǇŵƉƚŽŵƐƉƌŝŽƌƚŽĂƌƌŝǀĂůŝŶƚŚĞ;ƉŽƐƐŝďůĞd/Ϳ͘ ůŽŽĚŐůƵĐŽƐĞůĞƐƐƚŚĂŶϱϬĂŶĚƐǇŵƉƚŽŵƐŝŵƉƌŽǀĞǁŝƚŚĂĚŵŝŶŝƐƚƌĂƚŝŽŶŽĨϱϬ ƌĞĂŶǇŝƚĞŵƐĂďŽǀĞĐŚĞĐŬĞĚ͍ YES:WĂƚŝĞŶƚis notĂ^ƚƌŽŬĞůĞƌƚ͘TRANSPORT TO NEAREST STROKE CENTER. NO: dŚŝƐŝƐĂStroke Alert͘ /ƐƚŚĞƉĂƚŝĞŶƚƉĞƌŵĂŶĞŶƚůǇďĞĚŽƌǁŚĞĞůĐŚĂŝƌĐŽŶĨŝŶĞĚ͕ĚŽƚŚĞǇƌĞƋƵŝƌĞĐŽŶƐƚĂŶƚĐĂƌĞKZŝƐ ĂƐƐŝƐƚĂŶĐĞĞƐƐĞŶƚŝĂůĨŽƌĂĐƚŝǀŝƚŝĞƐŽĨĚĂŝůǇůŝǀŝŶŐƉƌŝŽƌƚŽƚŽĚĂǇ͛ƐĞǀĞŶƚ͍ YES: TRANSPORT TO NEAREST STROKE CENTER. NO: ŽŵƉůĞƚĞRACE Score ;ƐĞĞŶĞǆƚƉĂŐĞͿ͘ RACEScore ≥ 5: >ŝŬĞůǇ>sK͕TRANSPORT TO COMPREHENSIVE STROKE CENTER RACE Score 1–3: >ŝŬĞůǇƐƚƌŽŬĞ͕TRANSPORT TO NEAREST STROKE CENTER RACE Score 4: ŚĞĐŬ ƚŚĞĨŽůůŽǁŝŶŐďŽǆ;ĞƐͿĂƐĂƉƉƌŽƉƌŝĂƚĞ͗ ƐƚŝŵĂƚĞĚdƚŽĞŵĞƌŐĞŶĐǇĚĞƉĂƌƚŵĞŶƚхϯ͘ϱŚŽƵƌƐƐŝŶĐĞůĂƐƚƐĞĞŶŶŽƌŵĂů͘ ^ĞŝǌƵƌĞ;ĂƚŽŶƐĞƚͿ WĂƚŝĞŶƚŝƐŽŶĂŶǇŽĨƚŚĞĨŽůůŽǁŝŶŐďůŽŽĚƚŚŝŶŶĞƌƐ͗ŽƵŵĂĚŝŶ;ǁĂƌĨĂƌŝŶͿ͕WƌĂĚĂǆĂ;ĚĂďŝŐĂƚƌĂŶͿ͕ ƌŝůŝŶƚĂ;ƚŝĐĂŐƌĞůŽƌͿ͕yĂƌĞůƚŽ;ƌŝǀĂƌŽǆĂďĂŶͿ͕>ŽǀĞŶŽǆ;ĞŶŽǆĂƉĂƌŝŶͿŽƌ&ƌĂŐŵŝŶ;ĚĂůƚĞƉĂƌŝŶͿ͘ ZĞĐĞŶƚ;ǁŝƚŚŝŶϭϰĚĂǇƐͿŽƌĐƵƌƌĞŶƚďůĞĞĚŝŶŐ͕ƚƌĂƵŵĂ͕ƐƵƌŐĞƌǇ͕ŽƌŝŶǀĂƐŝǀĞƉƌŽĐĞĚƵƌĞ ůĞĞĚŝŶŐͬůŽƚƚŝŶŐĚŝƐŽƌĚĞƌƐ;ŚŝƐƚŽƌǇŽĨ'/'hďůĞĞĚŝŶŐǁŝƚŚŝŶůĂƐƚϮϭĚĂǇƐͿ WƌĞŐŶĂŶĐǇŽƌŽŵƉůĞƚŝŽŶͬdĞƌŵŝŶĂƚŝŽŶŽĨƉƌĞŐŶĂŶĐǇůĞƐƐƚŚĂŶϯϬĚĂǇƐ /ŶƚƌĂĐƌĂŶŝĂůƉĂƚŚŽůŽŐǇ;dƵŵŽƌ͕ŶĞƵƌǇƐŵ͕ƌƚĞƌŝŽsĞŶŽƵƐDĂůĨŽƌŵĂƚŝŽŶ;sDͿ͕/ŶƚƌĂĐƌĂŶŝĂů ŚĞŵŽƌƌŚĂŐĞͿ ^ƵĚĚĞŶŽŶƐĞƚŽĨǁŽƌƐƚŚĞĂĚĂĐŚĞĞǀĞƌ /ĨĂŶǇŽĨƚŚĞƐĞŝƚĞŵƐĂƌĞĐŚĞĐŬĞĚ͕TRANSPORT TO A COMPREHENSIVE STROKE CENTER KƚŚĞƌǁŝƐĞ͕TRANSPORT TO THE NEAREST STROKE CENTER

Cypress Creek EMS System Policies and Treatment Guidelines

263 PROCEDURES Revised 8/2016 Assessment Approved: Levon Vartanian, MD

RACE Score Evaluation (Rapid Artery Occlusion Evaluation)

Item Instruction Result Score Face ƐŬƉĂƚŝĞŶƚƚŽƐŵŝůĞ͘ Absent ;^ǇŵŵĞƚƌŝĐĂůŵŽǀĞŵĞŶƚͿ 0 Mild ;^ůŝŐŚƚĂƐǇŵŵĞƚƌǇͿ 1 Moderate to Severe ;ĐŽŵƉůĞƚĞůǇĂƐƐǇŵĞƚƌŝĐͿ͘ 2 Arm ,ĂǀĞƉĂƚŝĞŶƚĞǆƚĞŶĚ NormalƚŽMild;>ŝŵďƵƉŚĞůĚхϭϬƐͿ 0 ƚŚĞŝƌĂƌŵ͘ Moderate;>ŝŵďŚĞůĚфϭϬƐͿ 1 Severe;WĂƚŝĞŶƚƵŶĂďůĞƚŽƌĂŝƐĞĂƌŵͿ 2 Leg ,ĂǀĞƉĂƚŝĞŶƚƌĂŝƐĞůĞŐ NormalƚŽMild ;>ŝŵďƵƉŚĞůĚхϱƐͿ 0 Moderate;>ŝŵďƵƉŚĞůĚфϱƐͿ 1 Severe;WĂƚŝĞŶƚƵŶĂďůĞƚŽƌĂŝƐĞůĞŐͿ 2 Gaze KďƐĞƌǀĞĞǇĞƐĂŶĚŚĞĂĚ Absent;ǇĞŵŽǀĞŵĞŶƚƐƚŽďŽƚŚƐŝĚĞƐǁĞƌĞƉŽƐƐŝďůĞĂŶĚ 0 ĚĞǀŝĂƚŝŽŶƚŽŽŶĞƐŝĚĞ͘ ŶŽŚĞĂĚĚĞǀŝĂƚŝŽŶǁĂƐŽďƐĞƌǀĞĚͿ͘ Present;ǇĞƐĂŶĚŚĞĂĚĚĞǀŝĂƚŝŽŶƚŽŽŶĞƐŝĚĞǁĂƐ 1 ŽďƐĞƌǀĞĚͿ Choose the appropriate option based on what side unilateral weakness is observed on: Aphasia ƐŬƚŚĞƉĂƚŝĞŶƚƚŽĨŽůůŽǁ Normal;WĞƌĨŽƌŵƐďŽƚŚƚĂƐŬƐĐŽƌƌĞĐƚůǇͿ 0 (R Side) ĐŽŵŵĂŶĚƐ͗ Moderate;WĞƌĨŽƌŵƐŽŶůǇϭƚĂƐŬŽƵƚŽĨϮĐŽƌƌĞĐƚůǇͿ 1 ϭ͘ ůŽƐĞďŽƚŚĞǇĞƐ͘ Severe;ĂŶŶŽƚƉĞƌĨŽƌŵĞŝƚŚĞƌƚĂƐŬĐŽƌƌĞĐƚůǇͿ 2 Ϯ͘ DĂŬĞĂĨŝƐƚ;ŽŶ ƵŶĂĨĨĞĐƚĞĚƐŝĚĞͿ Agnosia ƐŬƉĂƚŝĞŶƚ͗ Normal;WĂƚŝĞŶƚƌĞĐŽŐŶŝǌĞƐĂƌŵͿ 0 (L Side) ϭ͘ ͞tŚŽƐĞĂƌŵŝƐƚŚŝƐ͍͟ Moderate;ŽĞƐŶŽƚƌĞĐŽŐŶŝǌĞĂƌŵŽƌŝƐƵŶĂǁĂƌĞŽĨĂƌŵͿ 1 Ϯ͘ ͞ĂŶǇŽƵŵŽǀĞǇŽƵƌ Severe;ŽĞƐŶŽƚƌĞĐŽŐŶŝǌĞĂƌŵĂŶĚŝƐƵŶĂǁĂƌĞŽĨĂƌŵͿ 2 Ăƌŵ͍͟ Add up total score (maximum score of 9): ^ĐŽƌĞхϭŝƐĂůŝŬĞůǇƐƚƌŽŬĞ͘^ĐŽƌĞшϱŝƐĂůŝŬĞůǇ>ĂƌŐĞsĞƐƐĞůKĐĐůƵƐŝŽŶƚŚĂƚƐŚŽƵůĚďĞƚƌĂŶƐƉŽƌƚĞĚƚŽĂ ĐŽŵƉƌĞŚĞŶƐŝǀĞƐƚƌŽŬĞĐĞŶƚĞƌ͘

Cypress Creek EMS System Policies and Treatment Guidelines

264 PROCEDURES Revised 8/2016 Assessment Approved: Levon Vartanian, MD

Cranial Nerves Assessment ƌĂŶŝĂůEĞƌǀĞĂƐƐĞƐƐŵĞŶƚŝƐƵƐĞĨƵůƚŽŝĚĞŶƚŝĨǇŶĞƵƌŽůŽŐŝĐĂůĚŝƐŽƌĚĞƌƐ͕Ğůů͛ƐWĂůƐǇ͕ĂŶĚĐĞƌƚĂŝŶƐƚƌŽŬĞƐ ƚŚĂƚĚŽŶ͛ƚƉƌĞƐĞŶƚǁŝƚŚŶĞƵƌŽůŽŐŝĐĂůĐŚĂŶŐĞƐŝŶďŽĚǇ͘

Cypress Creek EMS System Policies and Treatment Guidelines

265 PROCEDURES Revised 8/2016 Assessment Approved: Levon Vartanian, MD

Spinal Nerve Assessment

Cypress Creek EMS System Policies and Treatment Guidelines

266 PROCEDURES 34 Revised 8/2016 Assessment Approved: Levon Vartanian, MD

sŝƐƵĂůĐƵŝƚǇƐƐĞƐƐŵĞŶƚ Indications ƐƐĞƐƐŝŶŐǀŝƐƵĂůĂĐƵŝƚǇĨŽůůŽǁŝŶŐĞǇĞŝŶũƵƌǇ͕ǀŝƐƵĂůĐŚĂŶŐĞƐ͕ŽƌŽƚŚĞƌƐƵƐƉĞĐƚĞĚĐŽŶĚŝƚŝŽŶƐƚŚĂƚǁŽƵůĚĂĨĨĞĐƚ ƚŚĞĞǇĞƐ͘

WƌŽĐĞĚƵƌĞ ϭ͘ ,ŽůĚ^ŶĞůůĞŶǇĞŚĂƌƚƐŝǆ;ϲͿĨĞĞƚĂǁĂǇĨƌŽŵƉĂƚŝĞŶƚ͛ƐĞǇĞƐ͘ Ϯ͘ ŚĞĐŬĞǇĞƐƐĞƉĂƌĂƚĞůǇďǇŚĂǀŝŶŐƉĂƚŝĞŶƚĐŽǀĞƌĞĂĐŚĞǇĞ͘ ϯ͘ ŚĞĐŬďŽƚŚĞǇĞƐƚŽŐĞƚŚĞƌ ϰ͘ ŽĐƵŵĞŶƚƌŝŐŚƚĞǇĞ;KͿ͕ůĞĨƚĞǇĞ;K^Ϳ͕ĂŶĚďŽƚŚĞǇĞƐ;KhͿǀŝƐƵĂůĂĐƵŝƚŝĞƐďǇƌĞĨĞƌĞŶĐŝŶŐƚŚĞ ƐŵĂůůĞƐƚůŝŶĞŽŶƚŚĞ^ŶĞůůĞŶĐŚĂƌƚƚŚĂƚǁĂƐĐŽƌƌĞĐƚůǇƌĞĂĚǁŝƚŚŽŶĞŽƌůĞƐƐĞƌƌŽƌƐ;ϮŽƌŵŽƌĞŝŶĐŽƌƌĞĐƚ ƌĞĂĚŝŶŐƐŽŶĂǀŝƐŝŽŶůŝŶĞĐŽŶƐƚŝƚƵƚĞƐĂ͞ĨĂŝů͟ĂŶĚƚŚĞƉƌĞǀŝŽƵƐƐƵĐĐĞƐƐĨƵůůŝŶĞƐŚŽƵůĚďĞƵƐĞĚƚŽ ĚŽĐƵŵĞŶƚĂĐƵŝƚǇͿ͘ WĞĂƌůƐ x /ƚŵĂǇďĞĚŝĨĨŝĐƵůƚƚŽŽďƚĂŝŶĂǀŝƐƵĂůĂĐƵŝƚǇƵƐŝŶŐƚŚĞ^ŶĞůůĞŶŚĂƌƚĚƵĞƚŽĞŶǀŝƌŽŶŵĞŶƚ͖ŝĨĂƚƌƵĞ ǀŝƐƵĂůĂĐƵŝƚǇĐĂŶŶŽƚďĞŽďƚĂŝŶĞĚ͕ƚŚĞŵĞĚŝĐƐŚŽƵůĚĚŽĐƵŵĞŶƚĂŐƌŽƐƐǀŝƐƵĂůĂĐƵŝƚǇͬĂďŝůŝƚǇ;ŝ͘Ğ͘͞ƚŚĞ ƉĂƚŝĞŶƚŝƐĂďůĞƚŽĐůĞĂƌůǇŝĚĞŶƚŝĨǇĂŶĚǀĞƌďĂůŝǌĞŽďũĞĐƚƐŝŶƚŚĞŝƌĨŝĞůĚŽĨǀŝƐŝŽŶ͟Ϳ͘ x /ĨƉĂƚŝĞŶƚŚĂƐĚŝĨĨŝĐƵůƚǇĐŽŵƉůĞƚŝŶŐĂƐƐĞƐƐŵĞŶƚĚƵĞƚŽĞǇĞŝŶũƵƌǇŽƌƉĂŝŶ͕ĐŽŶƐŝĚĞƌĂĚŵŝŶŝƐƚĞƌŝŶŐ TetracaineĂŶĚƌĞƉĞĂƚŝŶŐĂƐƐĞƐƐŵĞŶƚŽŶĐĞƉĂƚŝĞŶƚŝƐŵŽƌĞĐŽŵĨŽƌƚĂďůĞ͘

Cypress Creek EMS System Policies and Treatment Guidelines

267 PROCEDURES Revised 12/2018 Approved: Levon Vartanian, MD

hůƚƌĂƐŽƵŶĚǆĂŵƐ tions Required Equipment ǆƚĞŶƐŝŽŶŽĨƉŚǇƐŝĐĂůĞǆĂŵƚŽĞǀĂůƵĂƚĞĨŽƌ͗ WŚŝůŝƉƐ>ƵŵŝĨǇhůƚƌĂƐŽƵŶĚƐǇƐƚĞŵ x ďĚŽŵŝŶĂůĨƌĞĞĨůƵŝĚͬďůŽŽĚ >ƵŵŝĨǇ^ϰ^ĞĐƚŽƌƌƌĂǇƉƌŽďĞ x ĂƌĚŝĂĐĨƵŶĐƚŝŽŶ >ƵŵŝĨǇ>ϭϮ>ŝŶĞĂƌƌƌĂǇƉƌŽďĞ x ĂƌĚŝĂĐdĂŵƉŽŶĂĚĞ dĂďůĞƚĚĞǀŝĐĞ x &ůƵŝĚƌĞƐƉŽŶƐŝǀĞŶĞƐƐͬƉƌĞůŽĂĚ hůƚƌĂƐŽƵŶĚŐĞů x WƵůŵŽŶĂƌǇŵďŽůŝƐŵ x WŶĞƵŵŽƚŚŽƌĂǆ

General Principles hůƚƌĂƐŽƵŶĚŵĂǇďĞƵƐĞĚĂƐĂŶĞǆƚĞŶƐŝŽŶŽĨƚŚĞĨŽĐƵƐĞĚƉŚǇƐŝĐĂůĞǆĂŵƚŽƐƵƉƉŽƌƚŽƌĨĂůƐŝĨǇĨŝĞůĚ ĚŝĂŐŶŽƐĞƐĂŶĚŐƵŝĚĞĨŝĞůĚƚƌĞĂƚŵĞŶƚŽĨƚŚĞŝůůŽƌŝŶũƵƌĞĚƉĂƚŝĞŶƚ͘hůƚƌĂƐŽƵŶĚƐŚŽƵůĚďĞƵƐĞĚďǇƉƌŽǀŝĚĞƌƐ ǁŚŽĂƌĞƚƌĂŝŶĞĚŝŶĞǆĂŵƚĞĐŚŶŝƋƵĞƐ͘WƌŽǀŝĚĞƌƐƐŚŽƵůĚĐŚŽŽƐĞƚŚĞĂƉƉƌŽƉƌŝĂƚĞƵůƚƌĂƐŽƵŶĚĞǆĂŵ ƚĞĐŚŶŝƋƵĞƐƚŽŐƵŝĚĞĐůŝŶŝĐĂůĚĞĐŝƐŝŽŶŵĂŬŝŶŐ͖ŶŽƚĞǀĞƌǇƉĂƚŝĞŶƚŶĞĞĚƐĞǀĞƌǇƵůƚƌĂƐŽƵŶĚǁŝŶĚŽǁ ĞǆĂŵŝŶĞĚ͘ǆĂŵĨŝŶĚŝŶŐƐĂŶĚƐƵƉƉŽƌƚŝŶŐŝŵĂŐĞƐĂŶĚͬŽƌǀŝĚĞŽƐƐŚŽƵůĚďĞĚŽĐƵŵĞŶƚĞĚĨŽƌYͬY/ ƉƵƌƉŽƐĞƐĂŶĚĂƐƉĂƌƚŽĨƚŚĞƉĂƚŝĞŶƚĐĂƌĞƌĞĐŽƌĚ͘

dŚŝƐƉƌŽĐĞĚƵƌĞŐƵŝĚĞƵƚŝůŝǌĞƐŝŶĨŽƌŵĂƚŝŽŶĨƌŽŵƚŚĞĨŽůůŽǁŝŶŐƐŽƵƌĐĞƐ͗ WŚŝůŝƉƐhůƚƌĂƐŽƵŶĚ͕/ŶĐ͘Lumify Ultrasound System User Manual͘ŽƚŚĞůů͕t͗WŚŝůŝƉƐhůƚƌĂƐŽƵŶĚ͖ϮϬϭϴ ŽǁŵĂŶ:͕ŽŝƚŶŽƚƚ:͕DŝĞƐĞŵĞƌ͘The Point of Care Ultrasound Handbook͘DŝĚĚůĞƚŽǁŶ͕͗D^WKh^͖ϮϬϭϴ ůŝŶŝĐĂůhůƚƌĂƐŽƵŶĚdƌĂŝŶŝŶŐƉƌŽǀŝĚĞĚďǇƌ͘:ŽŚŶ<ŶŝŐŚƚĂŶĚƌ͘ƌŝĐŚŝŶĂƚǇƉƌĞƐƐƌĞĞŬD^͘ hůƚƌĂƐŽƵŶĚĚŝĂŐƌĂŵƐĂŶĚŝŵĂŐĞƐĂƌĞĐŽƉǇƌŝŐŚƚΞϮϬϭϳD^WKh^͕>>ĂŶĚƵƐĞĚǁŝƚŚƉĞƌŵŝƐƐŝŽŶ͘ WŚŝůŝƉƐ>ƵŵŝĨǇhůƚƌĂƐŽƵŶĚ^ǇƐƚĞŵ

S4 Sector Array Probe L12 Linear Array Probe

ĞƐƚĨŽƌĂƌĚŝĂĐĞǆĂŵƐ͘ ĞƐƚĨŽƌ/sƐ͕sdƐ͕ƐŽĨƚ 'ŽŽĚĨŽƌ/s͕ďĚŽŵŝŶĂů͕'Ž ŵŝŶĂů͕ ƚŝƐƚŝƐƐƐƵĞ͕ĂƉƉĞŶĚŝǆ͘ >Ƶ>ƵŶŐƐ͕ĂŶĚKͬ'zE͘ 'ŽŽĚĨŽƌůƵŶŐƐ͘'Ž

Additional Equipment: x dĂďůĞƚĞǀŝĐĞ x hůƚƌĂƐŽƵŶĚ'ĞůŽƚƚůĞ x ^ƚĞƌŝůĞůƵďƌŝĐĂŶƚƉŽƵĐŚĞƐ ΘdĞŐĂĚĞƌŵ;ĨŽƌĂƐĞƉƚŝĐ ƉƌŽĐĞĚƵƌĞƐͿ

Cypress Creek EMS System Policies and Treatment Guidelines

268 PROCEDURES Revised 12/2018 Approved: Levon Vartanian, MD

General Exam Procedure ϭ͘ ĞĨŽƌĞƚƵƌŶŝŶŐŽŶƚŚĞĚĞǀŝĐĞ͕ĚŝƐĐŽŶŶĞĐƚĂůůƚƌĂŶƐĚƵĐĞƌƐ͘ Ϯ͘ dƵƌŶŽŶĚĞǀŝĐĞĂŶĚŽƉĞŶ>ƵŵŝĨǇĂƉƉ͘ŽŶŶĞĐƚƚŚĞĂƉƉƌŽƉƌŝĂƚĞƚƌĂŶƐĚƵĐĞƌƉƌŽďĞĨŽƌƚŚĞĚĞƐŝƌĞĚ ĞǆĂŵ͘ ϯ͘ &ƌŽŵƚŚĞ͞EĞǁǆĂŵ͟ƐĐƌĞĞŶ͕ƐĞůĞĐƚƚŚĞĚĞƐŝƌĞĚĞǆĂŵƉƌĞƐĞƚĂŶĚƚŚĞŶƚĂƉ͞ƌĞĂƚĞWĂƚŝĞŶƚ͟ ϰ͘ ŶƚĞƌƚŚĞŝŶĐŝĚĞŶƚŶƵŵďĞƌĨŽƌ͞>ĂƐƚEĂŵĞ͟ĂŶĚƚŚĞŶĂŵĞŽĨƚŚĞƉĞƌƐŽŶƉĞƌĨŽƌŵŝŶŐƚŚĞĞǆĂŵ͘/Ĩ ŵƵůƚŝƉůĞƉĂƚŝĞŶƚƐŽŶƐŝŶŐůĞŝŶĐŝĚĞŶƚ͕ĞŶƚĞƌƚŚĞƉĂƚŝĞŶƚŶĂŵĞƵŶĚĞƌ͞&ŝƌƐƚŶĂŵĞ͘͟ ϱ͘ dĂƉ͞^ƚĂƌƚǆĂŵ͘͟ ϲ͘ ƉƉůǇŐĞůƚŽƉƌŽďĞĂŶĚƉĂƚŝĞŶƚĂƚƐŝƚĞŽĨĞǆĂŵ͘ ϳ͘ WƌĞƐƐŚĂƌĚŝŶƚŽƉĂƚŝĞŶƚƐŬŝŶ͕ĂŶĚƵƐĞůĂƌŐĞĐŝƌĐƵůĂƌŵŽƚŝŽŶƐƚŽĨŝŶĚƚĂƌŐĞƚ͕ƚŚĞŶƐŵĂůůĞƌŵŽƚŝŽŶƐƚŽ ĨŝŶĞͲƚƵŶĞŝŵĂŐĞ͘ ϴ͘ /ĨǇŽƵĐŽŶƚŝŶƵĞŚĂǀŝŶŐƚƌŽƵďůĞĨŝŶĚŝŶŐůĂŶĚŵĂƌŬƐĂĨƚĞƌƚǁŽŵŝŶƵƚĞƐ͕ƐĞƚƉƌŽďĞĚŽǁŶĂŶĚƚĂŬĞĂ ďƌĞĂŬ͖ĂƚƚĞŶĚƚŽŽƚŚĞƌƉĂƚŝĞŶƚĐĂƌĞƉƌŝŽƌŝƚŝĞƐĂŶĚƚŚĞŶĞŝƚŚĞƌƌĞƚƌǇĞǆĂŵŽƌŵŽǀĞŽŶ͘ ϵ͘ dŽĐŚĂŶŐĞĞǆĂŵƉƌĞƐĞƚƐ͕ƚŽƵĐŚƚŚĞ ŵĞŶƵďƵƚƚŽŶĂŶĚƐĞůĞĐƚĂƉƌĞƐĞƚƵŶĚĞƌ͞ƵƌƌĞŶƚǆĂŵ͘͟ ϭϬ͘ dŽĞĚŝƚƉĂƚŝĞŶƚĚĂƚĂ͕ƚŽƵĐŚƚŚĞ ŵĞŶƵďƵƚƚŽŶĂŶĚƚŚĞŶ͞ĚŝƚWĂƚŝĞŶƚ/ŶĨŽ͘͟dŽƵĐŚ͞^ĂǀĞĂŶĚ ƌĞƚƵƌŶ͟ƚŽƐĂǀĞŝŶĨŽƌŵĂƚŝŽŶ͘ ϭϭ͘ dŽĐĂƉƚƵƌĞƐƚŝůůŝŵĂŐĞĚƵƌŝŶŐĞǆĂŵ͕ŐŽƚŽƐĞĐŽŶĚƉĂŐĞŽĨĐŽŶƚƌŽůƐĂŶĚƚĂƉ͞^ĂǀĞ/ŵĂŐĞ͘͟dŚĞƐǇƐƚĞŵ ďĞĞƉƐǁŚĞŶƚŚĞŝŵĂŐĞŚĂƐďĞĞŶƐĂǀĞĚ͘ ϭϮ͘ dŽĐĂƉƚƵƌĞůŽŽƉĚƵƌŝŶŐĐƵƌƌĞŶƚĞǆĂŵ͕ƚĂƉƚŚĞ͞^ĂǀĞ>ŽŽƉ͟ďƵƚƚŽŶĚƵƌŝŶŐĞǆĂŵ͘dŽƐƚŽƉƚŚĞůŽŽƉ ĐĂƉƚƵƌĞ͕ƚŽƵĐŚƚŚĞďƵƚƚŽŶĂŐĂŝŶŽƌǁĂŝƚĨŽƌŝƚƚŽƐƚŽƉĂƵƚŽŵĂƚŝĐĂůůǇ͘dŚĞƐǇƐƚĞŵďĞĞƉƐǁŚĞŶƚŚĞ ůŽŽƉŚĂƐďĞĞŶƐĂǀĞĚ͘ ϭϯ͘ tŚĞŶĨŝŶŝƐŚĞĚǁŝƚŚƉĂƚŝĞŶƚĐĂƌĞ͕ƚŽƵĐŚƚŚĞ͞ŶĚǆĂŵ͟ďƵƚƚŽŶƚŽƐĂǀĞƚŚĞĞǆĂŵ͘ ϭϰ͘ ŝƐĐŽŶŶĞĐƚƚƌĂŶƐĚƵĐĞƌĨƌŽŵĚĞǀŝĐĞĂŶĚĐůĞĂŶƚƌĂŶƐĚƵĐĞƌƐƚŚŽƌŽƵŐŚůǇƵƐŝŶŐĂƚŽǁĞůƚŽƌĞŵŽǀĞ ĞǆĐĞƐƐŐĞůĂŶĚƚŚĞŶĚŝƐŝŶĨĞĐƚƵƐŝŶŐƐĂŶŝƚŝǌŝŶŐǁŝƉĞƐ͘ ϭϱ͘ dŽĞǆƉŽƌƚƚŚĞĞǆĂŵ͛ƐŝŵĂŐĞƐ͕ƚŽƵĐŚƚŚĞ ŵĞŶƵďƵƚƚŽŶ͕ƚŚĞŶƚŽƵĐŚ͞^ĂǀĞĚǆĂŵƐ͘͟dŽƵĐŚĂŶ ĞǆĂŵƚŽŽƉĞŶŝƚŝŶƌĞǀŝĞǁ͕ƚŚĞŶƚŽƵĐŚ͞ǆƉŽƌƚǆĂŵ͟ƚŽĞǆƉŽƌƚĂůůŝŵĂŐĞƐ͘ŚŽŽƐĞƚŚĞ͞>ƵŵŝĨǇ͟ ĨŽůĚĞƌĂƐĂĚĞƐƚŝŶĂƚŝŽŶ͘ ϭϲ͘ ŽŶŶĞĐƚƚĂďůĞƚĚĞǀŝĐĞƚŽĐŽŵƉƵƚĞƌĂŶĚďƌŽǁƐĞƚŽƚŚĞ͞>ƵŵŝĨǇ͟ĨŽůĚĞƌƵŶĚĞƌ͞dŚŝƐW͟Žƌ͞DǇ ŽŵƉƵƚĞƌ͘͟&ŝŶĚƚŚĞŝŵĂŐĞƐĨŽƌǇŽƵƌƉĂƚŝĞŶƚŽƌŐĂŶŝǌĞĚďǇĨŽůĚĞƌĂŶĚĐŽƉǇƚŚĞƐĞƚŽƚŚĞƌŽƉďŽǆ ĨŽůĚĞƌ͘ƚƚĂĐŚƌĞůĞǀĂŶƚŝŵĂŐĞƐƚŽƚŚĞ^KWĂƚŝĞŶƚĂƌĞZĞĐŽƌĚĂŶĚĂĚĚĂŶĂĚĚĞŶĚƵŵƚŽƚŚĞ ŶĂƌƌĂƚŝǀĞĚĞƐĐƌŝďŝŶŐƵůƚƌĂƐŽƵŶĚĞǆĂŵƵƐĂŐĞĂŶĚĨŝŶĚŝŶŐƐ͘ hůƚƌĂƐŽƵŶĚ'ƵŝĚĞĚsĂƐĐƵůĂƌĐĐĞƐƐ hůƚƌĂƐŽƵŶĚŵĂǇďĞƵƐĞĚĂƐĂŶĂĚũƵŶĐƚĨŽƌƉůĂĐŝŶŐƉĞƌŝƉŚĞƌĂů/sƐĂŶĚĐĞŶƚƌĂůůŝŶĞƐ;ŝŶĐůƵĚŝŶŐĂƌƚĞƌŝĂů ůŝŶĞƐͿ͘ZĞĨĞƌƚŽUltrasound Guided Vascular AccessĨŽƌĚĞƚĂŝůƐŽŶƵůƚƌĂƐŽƵŶĚŐƵŝĚĞĚƉƌŽĐĞĚƵƌĞƐ͘

Cypress Creek EMS System Policies and Treatment Guidelines

269 PROCEDURES Revised 12/2018 Approved: Levon Vartanian, MD

Imaging Display Reference

A WĂƚŝĞŶƚ/ŶĨŽƌŵĂƚŝŽŶƌĞĂ Save Image:^ĂǀĞƐĂƐƚŝůůŝŵĂŐĞ͘ B ŽŶƚƌŽůƐƌĞĂ Power: ^ǁŝƉĞƚŽŝŶĐƌĞĂƐĞŽƌĚĞĐƌĞĂƐĞƉŽǁĞƌ ŽƵƚƉƵƚ͘ C /ŵĂŐĞĂƌĞĂ Fast Flow: dŽƵĐŚƚŽĚŝƐƉůĂǇĂĐŽůŽƌďŽǆǁŝƚŚ ŚŝŐŚĐŽůŽƌƐĐĂůĞĨŽƌĂƌƚĞƌŝĂůĨůŽǁ͘ D ^ĞĐŽŶĚƉĂŐĞŽĨĐŽŶƚƌŽůƐ Slow Flow: dŽƵĐŚƚŽĚŝƐƉůĂǇĂĐŽůŽƌďŽǆǁŝƚŚ ůŽǁĐŽůŽƌƐĐĂůĞĨŽƌǀĞŶŽƵƐĨůŽǁ͘ 1 WƌŽďĞKƌŝĞŶƚĂƚŝŽŶDĂƌŬĞƌ M-Mode: dŽƵĐŚƚŽĂĐƚŝǀĂƚĞDͲDŽĚĞ͘ 2 ĚǀĂŶĐĞĚƵůƚƌĂƐŽƵŶĚƉŽǁĞƌǀĂůƵĞƐ Save Loop: dŽƵĐŚƚŽƐĂǀĞĂůŽŽƉŽĨƚŚĞŝŵĂŐĞ ŽŶƐĐƌĞĞŶ͘ 3 /ŵĂŐĞŝŶĨŽƌŵĂƚŝŽŶ Gain: ^ǁŝƉĞƚŽŝŶĐƌĞĂƐĞŽƌĚĞĐƌĞĂƐĞƚŚĞŝŵĂŐĞ ŐĂŝŶ;ďƌŝŐŚƚŶĞƐƐͿ͘ 4 &ƵůůͲƐĐƌĞĞŶďƵƚƚŽŶ Depth: ^ǁŝƉĞƚŽŝŶĐƌĞĂƐĞŽƌĚĞĐƌĞĂƐĞƚŚĞ ŝŵĂŐĞĚĞƉƚŚ͘ 5 ĞŶƚĞƌůŝŶĞĐŽŶƚƌŽů Other functions: 6 &ŽĐĂůŝŶĚŝĐĂƚŽƌͬĚĞƉƚŚŵĞĂƐƵƌĞ WŝŶĐŚŽƌƐƉƌĞĂĚǁŝƚŚĨŝŶŐĞƌƐƚŽŵĂŐŶŝĨǇĂ 7 WĂŐĞŝŶĚŝĐĂƚŽƌ;ƚŽƵĐŚŝŶĚŝĐĂƚŽƌŽƌ ƉŽƌƚŝŽŶŽĨƚŚĞŝŵĂŐĞ͘ ƐǁŝƉĞƚŽŐŽƚŽŶĞǆƚƉĂŐĞŽĨĐŽŶƚƌŽůƐͿ ^ƉƌĞĂĚŽƌƉŝŶĐŚŝŶƐŝĚĞĐŽůŽƌďŽǆƚŽƌĞƐŝǌĞďŽǆ͖ 8 ZĞǀŝĞǁĂŶĚƐĞƚƚŝŶŐƐŵĞŶƵ ĚƌĂŐƚŽƌĞƉŽƐŝƚŝŽŶ͘ /Ŷ͞&ƌŽǌĞŶ͟ŵŽĚĞ͕ǇŽƵĐĂŶĂĚĚĂŶŶŽƚĂƚŝŽŶƐŽƌ ƉĞƌĨŽƌŵŵĞĂƐƵƌĞŵĞŶƚƐ͘

Cypress Creek EMS System Policies and Treatment Guidelines

270 PROCEDURES Revised 12/2018 Approved: Levon Vartanian, MD

Ultrasound Modes ͲDŽĚĞ ͲDŽĚĞ;͞ƌŝŐŚƚŶĞƐƐDŽĚĞ͟ͿŝƐƚŚĞŶŽƌŵĂůƵůƚƌĂƐŽƵŶĚŵŽĚĞƐĞĞŶŝŶƚŚĞŝŵĂŐŝŶŐĚŝƐƉůĂǇĂďŽǀĞ͘ͲDŽĚĞ ĚŝƐƉůĂǇƐƚŚĞĞĐŚŽĞƐŽĨƵůƚƌĂƐŽƵŶĚǁĂǀĞƐƚŚƌŽƵŐŚƚŚĞďŽĚǇ͘&ůƵŝĚƐƐŚŽǁĂƐďůĂĐŬ;͞ĂŶĞĐŚŽŝĐ͟ͿĂŶĚƐŽůŝĚ ŽďũĞĐƚƐƐŚŽǁƵƉĂƐǁŚŝƚĞ;͞ŚǇƉĞƌĞĐŚŽŝĐ͟Ϳ͘ ŽůŽƌŽƉƉůĞƌ

ŽůŽƌŽƉƉůĞƌƐŚŽǁƐĨůƵŝĚĨůŽǁƵƐŝŶŐŽƉƉůĞƌƵůƚƌĂƐŽƵŶĚǁĂǀĞƐƚŚĂƚĂƌĞĐŽůŽƌĐŽĚĞĚĨŽƌǀĞůŽĐŝƚǇĂŶĚ ĚŝƌĞĐƚŝŽŶŽĨĨůŽǁ͘Fast FlowŝƐƵƐĞĚĨŽƌƌĂƉŝĚůǇŵŽǀŝŶŐŽďũĞĐƚƐ͕ƐƵĐŚĂƐĐĂƌĚŝĂĐǀĂůǀĞƐ͕ĂŶĚSlow FlowŝƐ ƵƐĞĚĨŽƌƐůŽǁĞƌŵŽǀŝŶŐĨůƵŝĚƐƐƵĐŚĂƐďůŽŽĚŝŶĂƌƚĞƌŝĞƐĂŶĚǀĞŝŶƐ͘

dŚĞĐŽůŽƌĚŝƌĞĐƚŝŽŶĐĂŶďĞƌĞŵĞŵďĞƌĞĚǁŝƚŚƚŚĞĂĐƌŽŶǇŵB.A.R.T.ͶůƵĞǁĂǇ͕ZĞĚdŽǁĂƌĚƐ͘,ŽǁĞǀĞƌ͕ ĚŽŶŽƚƌĞůǇŽŶĐŽůŽƌƐĂůŽŶĞĨŽƌĚŝĨĨĞƌĞŶƚŝĂƚŝŶŐĂƌƚĞƌŝĞƐĂŶĚǀĞŝŶƐ͗dŚĞƉƌŽďĞĂŶŐůĞĂŶĚŽƌŝĞŶƚĂƚŝŽŶĐĂŶ ĨůŝƉƚŚĞĐŽůŽƌƐ͘

ŽůŽƌŽƉƉůĞƌŝƐĞƐƉĞĐŝĂůůǇƵƐĞĨƵůĨŽƌŝĚĞŶƚŝĨǇŝŶŐďůŽŽĚǀĞƐƐĞůƐ͘

Cypress Creek EMS System Policies and Treatment Guidelines

271 PROCEDURES Revised 12/2018 Approved: Levon Vartanian, MD

DͲDŽĚĞ DͲDŽĚĞƐŚŽǁƐĂƐŝŶŐůĞǀĞƌƚŝĐĂůƐůŝĐĞŽĨƚŚĞͲDŽĚĞŝŵĂŐĞŐƌĂƉŚĞĚŽǀĞƌƚŝŵĞ;ƐŝŵŝůĂƌƚŽĂŶ' ǁĂǀĞĨŽƌŵͿ͘ĨƚĞƌĂĐƚŝǀĂƚŝŶŐDͲDŽĚĞ͕ ƉŝĐŬƚŚĞĂŶŐůĞŽĨƚŚĞƐůŝĐĞĂŶĚƚŚĞŶ ĂĐƚŝǀĂƚĞ͘dŚĞĚŝƐƉůĂǇǁŝůůƐŚŽǁĂƐƚŝůů ŝŵĂŐĞ;ƚŽƉͿŝŶĚŝĐĂƚŝŶŐǁŚĞƌĞƚŚĞƐůŝĐĞ ŝƐ͕ĂŶĚĂŵŽǀŝŶŐŝŵĂŐĞ;ďŽƚƚŽŵͿ ƉůŽƚƚŝŶŐŵŽƚŝŽŶŽǀĞƌƚŝŵĞ͘

dŚŝƐĨŝŐƵƌĞ;ƚŽƚŚĞƌŝŐŚƚͿƐŚŽǁƐŵŝƚƌĂů ǀĂůǀĞŵŽƚŝŽŶŽǀĞƌƚŝŵĞ͘

DͲDŽĚĞŝƐĞƐƉĞĐŝĂůůǇƵƐĞĨƵůĨŽƌ ĞǀĂůƵĂƚŝŶŐůƵŶŐŵŽƚŝŽŶ͕/sƉƵůƐĂƚŝŽŶ͘

Cypress Creek EMS System Policies and Treatment Guidelines

272 PROCEDURES Revised 12/2018 Approved: Levon Vartanian, MD

Ultrasound Assessment Exams hƐĞƵůƚƌĂƐŽƵŶĚĞǆĂŵƚŽĂŶƐǁĞƌƐƉĞĐŝĨŝĐĐůŝŶŝĐĂůƋƵĞƐƚŝŽŶƐ;͞zĞƐ͟Žƌ͞EŽ͟Ϳ͘

For this patient… Use this exam To evaluate for WƵůŵŽŶĂƌǇǆĂŵ WŶĞƵŵŽƚŚŽƌĂǆ &^d;ZhY͕>hY͕ ďĚŽŵŝŶĂůĨƌĞĞĨůƵŝĚͬďůŽŽĚ Cardiac Arrest ůĂĚĚĞƌͬWĞůǀŝƐͿ ĂƌĚŝĂĐǆĂŵ;W>yĂŶĚͬŽƌ ĂƌĚŝĂĐdĂŵƉŽŶĂĚĞ ^hyͿ ĂƌĚŝĂĐ&ƵŶĐƚŝŽŶ ĂƌĚŝĂĐdĂŵƉŽŶĂĚĞ ĂƌĚŝĂĐǆĂŵ;W>yĂŶĚͬŽƌ ĂƌĚŝĂĐ&ƵŶĐƚŝŽŶ ^hyͿ WƵůŵŽŶĂƌǇĞŵďŽůŝƐŵ &ůƵŝĚƌĞƐƉŽŶƐŝǀĞŶĞƐƐͬƉƌĞůŽĂĚ Hypotension /s WƵůŵŽŶĂƌǇĞŵďŽůŝƐŵ WƵůŵŽŶĂƌǇǆĂŵ WŶĞƵŵŽƚŚŽƌĂǆ &^dǆĂŵ ďĚŽŵŝŶĂůĨƌĞĞĨůƵŝĚͬďůŽŽĚ Blunt or ďĚŽŵŝŶĂůĨƌĞĞĨůƵŝĚͬďůŽŽĚ Penetrating &^dǆĂŵ ĂƌĚŝĂĐƚĂŵƉŽŶĂĚĞ Thoracic Trauma WŶĞƵŵŽƚŚŽƌĂǆ &^d;&ŽĐƵƐĞĚƐƐĞƐƐŵĞŶƚǁŝƚŚ^ŽŶŽŐƌĂƉŚǇĨŽƌdƌĂƵŵĂͿ ^ĞǀĞƌĞƚƌĂƵŵĂƉĂƚŝĞŶƚƐƐŚŽƵůĚŚĂǀĞĂ&^dĞǆĂŵƉĞƌĨŽƌŵĞĚĂĨƚĞƌŽƚŚĞƌŝŶƚĞƌǀĞŶƚŝŽŶƐŚĂǀĞďĞĞŶ ĐŽŵƉůĞƚĞĚ͘ƉŽƐŝƚŝǀĞ&^dĞǆĂŵŝƐĂĐƌŝƚĞƌŝŽŶĨŽƌďůŽŽĚĂĚŵŝŶŝƐƚƌĂƚŝŽŶ͘EKd͗/ƚĐĂŶƚĂŬĞƵƉƚŽϱϬϬŵ> ŽĨďůŽŽĚĨŽƌĂ&^dƚŽďĞƉŽƐŝƚŝǀĞ͖ĂŶĞŐĂƚŝǀĞ&^dĞǆĂŵĚŽĞƐŶŽƚĞǆĐůƵĚĞďůĞĞĚŝŶŐ͘ ϭ͘ Cardiac͗>ŽŽŬĨŽƌĐĂƌĚŝĂĐƚĂŵƉŽŶĂĚĞƵƐŝŶŐƐƵďǆŝƉŚŽŝĚǀŝĞǁ͘ Ϯ͘ Morison’s͗/ĚĞŶƚŝĨǇŚĞŵŽƚŚŽƌĂǆĂŶĚĨƌĞĞĨůƵŝĚĂƌŽƵŶĚůŝǀĞƌ͘ 3. Bladder:/ĚĞŶƚŝĨǇĨƌĞĞĨůƵŝĚŝŶĂďĚŽŵĞŶĂďŽǀĞĂŶĚĂƌŽƵŶĚďůĂĚĚĞƌ͘ ϰ͘ Spleen͗ /ĚĞŶƚŝĨǇĨƌĞĞĨůƵŝĚĂƌŽƵŶĚƐƉůĞĞŶ͘ ϱ͘ Pulmonary: /ĚĞŶƚŝĨǇƉŶĞƵŵŽƚŚŽƌĂǆ͘ hůƚƌĂƐŽƵŶĚdƌŽƵďůĞƐŚŽŽƚŝŶŐ x hƐĞůŽƚƐŽĨGelͶďĞƋƵŝĐŬƚŽĂĚĚŵŽƌĞŝĨŚĂǀŝŶŐƚƌŽƵďůĞŐĞƚƚŝŶŐĂĐůĞĂƌŝŵĂŐĞ͘ x Press HardͶ'ŽŽĚƉƌŽďĞĐŽŶƚĂĐƚŝƐĞƐƐĞŶƚŝĂůƚŽŐĞƚƚŝŶŐĂĐůĞĂƌŝŵĂŐĞ͘ x Big Moves, Small Moves ͶDĂŬĞůĂƌŐĞŵŽƚŝŽŶƐǁŚŝůĞƐĐĂŶŶŝŶŐƚŽĨŝŶĚǇŽƵƌƚĂƌŐĞƚ͕ƚŚĞŶƵƐĞ ƐŵĂůůŵŽƚŝŽŶƐƚŽĨŝŶĞƚƵŶĞ͘ x Time OutͶŝĨǇŽƵĐĂŶŶŽƚŐĞƚĂŐŽŽĚŝŵĂŐĞĂĨƚĞƌϭ ʹϮŵŝŶƵƚĞƐ͕ƚĂŬĞĂďƌĞĂŬ͕ƐĞƚƚŚĞƉƌŽďĞĚŽǁŶ͕ ƚŚĞŶƌĞƚƌǇ͘

Cypress Creek EMS System Policies and Treatment Guidelines

273 PROCEDURES Revised 12/2018 Approved: Levon Vartanian, MD

ĂƌĚŝĂĐ&ƵŶĐƚŝŽŶǆĂŵ Probe ^ϰ^ĞĐƚŽƌƌƌĂǇ Preset ĂƌĚŝĂĐŽƌ&^d Starting Depth ϭϲĐŵ ǀĂůƵĂƚĞĨŽƌ͗ x Cardiac Tamponade:ŝĚĞŶƚŝĨŝĞĚďǇĨƌĞĞĨůƵŝĚĂƌŽƵŶĚŚĞĂƌƚ͘Don’t mistake the anterior fat pad for free fluid. If fluid is found, evaluate RV for signs of tamponade. x Cardiac Function: ŵŽƐƚĐůĞĂƌůǇŝŶĚŝĐĂƚĞĚďǇŵŝƚƌĂůǀĂůǀĞŵŽƚŝŽŶŝŶƚŚĞW>yǀŝĞǁ͘ x Right vs Left͗/ĨZsŝƐůĂƌŐĞƌƚŚĂŶ>s͕ĐŽŶƐŝĚĞƌƉĂƚŝĞŶƚŚŝƐƚŽƌǇ͘/ŶĐŚƌŽŶŝĐKWŽƌƉƵůŵŽŶĂƌǇ,dE͕Zs ŵĂǇďĞĚŝůĂƚĞĚĐŚƌŽŶŝĐĂůůǇ͘/ĨŶĞǁŽŶƐĞƚĚǇƐƉŶĞĂ͕ĚŝůĂƚĞĚZsŵĂǇďĞƐŝŐŶŽĨĂĐƵƚĞƉƵůŵŽŶĂƌǇ ĞŵďŽůŝƐŵ͘ǀĂůƵĂƚĞ/sĂŶĚĐŽŶƐŝĚĞƌsdĞǆĂŵ͘ WĂƌĂƐƚĞƌŶĂů>ŽŶŐǆŝƐ;W>yͿsŝĞǁ ^ƚĂƌƚĂƚ>ĞĂĚsϮ͘tŚĞŶƵƐŝŶŐƚŚĞĂƌĚŝĂĐƉƌĞƐĞƚ͕ŽƌŝĞŶƚƉƌŽďĞŵĂƌŬĞƌƚŽǁĂƌĚƐƉĂƚŝĞŶƚ͛ƐƌŝŐŚƚƐŚŽƵůĚĞƌ͘ tŚĞŶƵƐŝŶŐ&^dƉƌĞƐĞƚ͕ŽƌŝĞŶƚƉƌŽďĞŵĂƌŬĞƌƚŽǁĂƌĚƐƉĂƚŝĞŶƚ͛ƐůĞĨƚĞůďŽǁ͘

PLAX is most useful for:ĞǀĂůƵĂƚŝŶŐĐĂƌĚŝĂĐĨƵŶĐƚŝŽŶďǇŶŽƚŝŶŐŵŝƚƌĂůǀĂůǀĞŵŽƚŝŽŶĂŐĂŝŶƐƚƐĞƉƚƵŵ͘

Key Findings: x DŝƚƌĂůǀĂůǀĞŵŽƚŝŽŶƚŽǁĂƌĚƐƚŚĞƐĞƉƚƵŵŝƐĂƐŝŐŶŽĨŐŽŽĚĐĂƌĚŝĂĐĨƵŶĐƚŝŽŶ͘ x >sĐŽŶƚƌĂĐƚŝŶŐŵŝĚǁĂǇƚŚƌŽƵŐŚƚŚĞǀĞŶƚƌŝĐůĞŝƐĂƐŝŐŶŽĨŐŽŽĚĐĂƌĚŝĂĐĨƵŶĐƚŝŽŶ͘ x ZsƐŚŽƵůĚďĞƐŵĂůůĞƌƚŚĂŶƚŚĞ>s͘ ^ƵďǆŝƉŚŽŝĚ;^hyͿsŝĞǁ ^ĐŽŽƉƉƌŽďĞƵŶĚĞƌŶĞĂƚŚǆŝƉŚŽŝĚĂŶĚůĂǇĂƐĨůĂƚĂƐƉŽƐƐŝďůĞ͘tŚĞŶƵƐŝŶŐƚŚĞĂƌĚŝĂĐƉƌĞƐĞƚ͕ŽƌŝĞŶƚƉƌŽďĞ ŵĂƌŬĞƌƚŽǁĂƌĚƐƉĂƚŝĞŶƚůĞĨƚ͘tŚĞŶƵƐŝŶŐ&^dƉƌĞƐĞƚ͕ŽƌŝĞŶƚƉƌŽďĞŵĂƌŬĞƌƚŽǁĂƌĚƐƉĂƚŝĞŶƚƌŝŐŚƚ͘

SUBX is most useful for:/ĚĞŶƚŝĨǇŝŶŐƚĂŵƉŽŶĂĚĞ͘

Cypress Creek EMS System Policies and Treatment Guidelines

274 PROCEDURES Revised 12/2018 Approved: Levon Vartanian, MD

ƉŝĐĂůϰŚĂŵďĞƌ;ϰͿsŝĞǁ ^ƚĂƌƚĂƚ>ĞĂĚsϰ͘hƐĞƚŚĞĂƌĚŝĂĐƉƌĞƐĞƚ͕ĂŶĚŽƌŝĞŶƚƉƌŽďĞŵĂƌŬĞƌƚŽǁĂƌĚƐƉĂƚŝĞŶƚƌŝŐŚƚƐŝĚĞ͘dŝůƚƉƌŽďĞ ƚŽ͞Ăŝŵ͟ĂƚƌŝŐŚƚƐŚŽƵůĚĞƌďůĂĚĞ͘

A4C is not as useful as PLAX or SUBX. <ĞǇ&ŝŶĚŝŶŐƐǁŝƚŚĂƌĚŝĂĐǆĂŵ Cardiac Tamponade ĂƌĚŝĂĐƚĂŵƉŽŶĂĚĞĐĂŶďĞŝĚĞŶƚŝĨŝĞĚďǇĨƌĞĞĨůƵŝĚĂƌŽƵŶĚŚĞĂƌƚ͕ƉĂƌƚŝĐƵůĂƌůǇ͞ĂďŽǀĞ͟ŚĞĂƌƚďǇůŝǀĞƌŝŶƚŚĞ ƐƵďǆŝƉŚŽŝĚǀŝĞǁ͘ĂƌĚŝĂĐƚĂŵƉŽŶĂĚĞĐĂŶďĞĐŽŶĨŝƌŵĞĚďǇĞǀĂůƵĂƚŝŶŐƚŚĞƌŝŐŚƚƐŝĚĞŽĨƚŚĞŚĞĂƌƚ͗ƵƌŝŶŐ ĚŝĂƐƚŽůĞ͕ƚŚĞƌŝŐŚƚĂƚƌŝƵŵǁŝůůĐŽůůĂƉƐĞ;ǀĂůǀĞƐĐůŽƐĞĚͿĂŶĚĚƵƌŝŶŐƐǇƐƚŽůĞƚŚĞƌŝŐŚƚǀĞŶƚƌŝĐůĞǁŝůůĐŽůůĂƉƐĞ ;sĂůǀĞƐŽƉĞŶͿ͘

Systole ZsĐŽůůĂƉƐĞĚǁŚĞŶǀĂůǀĞƐĂƌĞ ŽƉĞŶ͘

ŝĂƐƚŽůĞ ZĐŽůůĂƉƐĞĚǁŚĞŶǀĂůǀĞƐĂƌĞ ĐŽůůĂƉƐĞĚ͘

Cypress Creek EMS System Policies and Treatment Guidelines

275 PROCEDURES Revised 12/2018 Approved: Levon Vartanian, MD

Pulmonary Embolism &ŝŶĚŝŶŐƐƐƵŐŐĞƐƚŝǀĞŽĨĂWĂƌĞĐŽŶƐŝƐƚĞŶƚǁŝƚŚĐŽƌƉƵůŵŽŶĂůĞ;ĞŶůĂƌŐĞĚZsͿ͘ŚƌŽŶŝĐKWŽƌƉƵůŵŽŶĂƌǇ ŚǇƉĞƌƚĞŶƐŝŽŶǁŝůůĂůƐŽůĞĂĚƚŽĞŶůĂƌŐĞĚZs͕ƐŽĐŽŶƐŝĚĞƌƉĂƚŝĞŶƚŚŝƐƚŽƌǇ͘

WŵĂǇƉƌĞƐĞŶƚǁŝƚŚZsůĂƌŐĞƌƚŚĂŶ>s͖ŝŶϰǀŝĞǁ͕ZsŵĂǇďĞĚŝůĂƚĞĚĂŶĚŶŽŶͲŵŽďŝůĞ͘dŽĐŽŶĨŝƌŵW ĚŝĂŐŶŽƐŝƐ͕ƚŚĞ/sŵƵƐƚĂůƐŽďĞĞŶůĂƌŐĞĚ͘

Cardiac Function /ĚĞŶƚŝĨǇƚŚĞĞǆƚƌĞŵĞƐŽĨĐĂƌĚŝĂĐĞũĞĐƚŝŽŶĨƌĂĐƚŝŽŶƵƐŝŶŐŵŝƚƌĂůǀĂůǀĞŵŽƚŝŽŶ;ŵŽƐƚǀŝƐŝďůĞŝŶƚŚĞW>y ǀŝĞǁͿ͘>ŽǁŵŽƚŝŽŶǁŝƚŚǀĂůǀĞŶŽƚƚŽƵĐŚŝŶŐǁĂůůƐƐƵŐŐĞƐƚƐŚĞĂƌƚĨĂŝůƵƌĞĂŶĚůŽǁĐĂƌĚŝĂĐŽƵƚƉƵƚ͘ ,ǇƉĞƌĚǇŶĂŵŝĐŵŽƚŝŽŶǁŝƚŚǀĞŶƚƌŝĐƵůĂƌǁĂůůƐƚŽƵĐŚŝŶŐĚƵƌŝŶŐƐǇƐƚŽůĞƐƵŐŐĞƐƚƐŚǇƉŽǀŽůĞŵŝĂŽƌƐĞƉƐŝƐ͘ Poor Function DŝŶŝŵĂůŵŽƚŝŽŶŽĨƚŚĞŵŝƚƌĂůǀĂůǀĞ͘ DŝŶŝŵĂůĐŽŶƚƌĂĐƚŝŽŶŽĨƚŚĞůĞĨƚǀĞŶƚƌŝĐůĞ͘ Consider heart failure.

Cypress Creek EMS System Policies and Treatment Guidelines

276 PROCEDURES Revised 12/2018 Approved: Levon Vartanian, MD

Normal Function DŝƚƌĂůǀĂůǀĞŝƐŵŽǀŝŶŐƚŽǁĂƌĚƐƚŚĞƐĞƉƚƵŵ͘ >ĞĨƚǀĞŶƚƌŝĐůĞŝƐĐŽŶƚƌĂĐƚŝŶŐŶŽƌŵĂůůǇ͘

Hyperdynamic Function DŝƚƌĂůǀĂůǀĞŝƐŵŽǀŝŶŐĚǇŶĂŵŝĐĂůůǇ͘ sĞŶƚƌŝĐƵůĂƌǁĂůůƐĂƌĞƚŽƵĐŚŝŶŐĚƵƌŝŶŐƐǇƐƚŽůĞ͘ Consider sepsis or hypovolemia. Assess IVC.

Cypress Creek EMS System Policies and Treatment Guidelines

277 PROCEDURES Revised 12/2018 Approved: Levon Vartanian, MD

/sǆĂŵ Probe ^ϰ^ĞĐƚŽƌƌƌĂǇ Preset &^d Starting Depth ϭϲĐŵ WƌŽǀŝĚĞƐŝŶĨŽƌŵĂƚŝŽŶŽŶĨůƵŝĚƐƚĂƚƵƐ͕ZsĂŶĚĐĂƌĚŝĂĐĨƵŶĐƚŝŽŶ͖ĞƐƚŝŵĂƚĞƐŽĨĐĞŶƚƌĂůǀĞŶŽƵƐ͕ƌŝŐŚƚĂƚƌŝĂů͕ ĂŶĚƌŝŐŚƚǀĞŶƚƌŝĐƵůĂƌĞŶĚĚŝĂƐƚŽůŝĐƉƌĞƐƐƵƌĞƐ͘

ϭ͘ WůĂĐĞƉƌŽďĞďĞůŽǁƌŝďƐŽŶƌŝŐŚƚƐŝĚĞŽĨŵŝĚůŝŶĞ͕ǁŝƚŚŵĂƌŬĞƌƚŽǁĂƌĚƐƚŚĞŚĞĂĚ͘ Ϯ͘ dŝůƚƵƉǁĂƌĚƐĂŶĚŝĚĞŶƚŝĨǇ/s͖ĂůŝŐŶƉƌŽďĞůĞŶŐƚŚǁŝƐĞ͘ ϯ͘ ůůŽǁƉĂƚŝĞŶƚƚŽďƌĞĂƚŚĞŶŽƌŵĂůůǇ͘ ϰ͘ /Ĩ/sŝƐůĂƌŐĞƌ͕ŚĂǀĞƉĂƚŝĞŶƚƐŶŝĨĨϯƚŝŵĞƐƚŽĂƐƐĞƐƐĨŽƌĐŽůůĂƉƐŝďŝůŝƚǇ͘ ϱ͘ ŽŶƐŝĚĞƌƵƐŝŶŐDͲDŽĚĞƚŽĂƐƐĞƐƐǀĂƌŝĂƚŝŽŶƐǁŝƚŚƌĞƐƉŝƌĂƚŝŽŶƐ͘

Findings Large Normal Collapsed EŽƌĞƐƉŝƌĂƚŽƌǇǀĂƌŝĂƚŝŽŶ ZĞƐƚŝŶŐ /ŶƐƉŝƌĂƚŝŽŶ ŽůůĂƉƐĞĚ

ŽŶƐŝĚĞƌƉŽƐƐŝďůĞW͕,&͕ ;ƚŚĞƐĞŝŵĂŐĞƐĂƌĞƌĞǀĞƌƐĞĚǁŝƚŚƉŽƐŝƚŝǀĞƉƌĞƐƐƵƌĞ ŽŶƐŝĚĞƌ^ĞƉƐŝƐŽƌŚǇƉŽǀŽůĞŵŝĂ͘ ŽƌƚĂŵƉŽŶĂĚĞ͘ ǀĞŶƚŝůĂƚŝŽŶͿ

Be sure to distinguish between IVC and aorta:

/s ŽƌƚĂ >ŽĐĂƚĞĚƚŽƚŚĞƌŝŐŚƚ >ŽĐĂƚĞĚŽŶƚŚĞ ŽĨŵŝĚůŝŶĞ͘ ŵŝĚůŝŶĞ͘ 'ŽĞƐĚŝƌĞĐƚůǇŝŶƚŽ 'ŽĞƐďĞŚŝŶĚŚĞĂƌƚ͘ ƚŚĞƌŝŐŚƚĂƚƌŝƵŵ ĂŶǀŝƐƵĂůŝǌĞƚŝƐƐƵĞ ^ƉŝŶĞƐŚĂĚŽǁďůŽĐŬƐ ƵŶĚĞƌŶĞĂƚŚ ĂŶǇƚŝƐƐƵĞ ƵŶĚĞƌŶĞĂƚŚ͘

Cypress Creek EMS System Policies and Treatment Guidelines

278 PROCEDURES Revised 12/2018 Approved: Levon Vartanian, MD

WƵůŵŽŶĂƌǇǆĂŵ Probe ^ϰ^ĞĐƚŽƌƌƌĂǇ Preset >ƵŶŐ Starting Depth ϲĐŵ Or>ϭϮ>ŝŶĞĂƌƌƌĂǇ ϭ͘ WůĂĐĞƉƌŽďĞŝŶϮŶĚŽƌϯƌĚŝŶƚĞƌĐŽƐƚĂůƐƉĂĐĞŽŶŵŝĚĐůĂǀŝĐƵůĂƌůŝŶĞ;ǁŚĞƌĞŶĞĞĚůĞĚĞĐŽŵƉƌĞƐƐŝŽŶŝƐ ƉĞƌĨŽƌŵĞĚͿǁŝƚŚŵĂƌŬĞƌƚŽǁĂƌĚƐŚĞĂĚ͘ Ϯ͘ ^ůŝĚĞŽƌƚŝůƚƉƌŽďĞƚŽĐĞŶƚĞƌŽŶƐƉĂĐĞďĞƚǁĞĞŶƌŝďƐ͘>ŽŽŬĨŽƌƐůŝĚŝŶŐůƵŶŐƐŝŐŶŝŶďŽƚŚϮŵŽĚĞĂŶĚ DͲŵŽĚĞĂŶĚƐĂǀĞĂůŽŽƉ͘ ϯ͘ ZĞƉĞĂƚĞǆĂŵŽŶŽƚŚĞƌƐŝĚĞ͘ ϰ͘ ;KƉƚŝŽŶĂůůǇͿdŽĐŽŶĨŝƌŵĂƉŶĞƵŵŽƚŚŽƌĂǆ͕ůŽŽŬĨŽƌ͞>ƵŶŐWŽŝŶƚ͟ďǇƐůŝĚŝŶŐƉƌŽďĞŝŶĨĞƌŝŽƌůǇĚŽǁŶ ĐŚĞƐƚƵŶƚŝůƉƌŽďĞŝƐŽǀĞƌĞĚŐĞŽĨƉŶĞƵŵŽƚŚŽƌĂǆ͘ƵƌŝŶŐŝŶƐƉŝƌĂƚŝŽŶ͕ƚŚĞůƵŶŐǁŝůůĞǆƉĂŶĚƵŶĚĞƌƚŚĞ ƉƌŽďĞ͘ƵƌŝŶŐĞǆŚĂůĂƚŝŽŶ͕ƚŚĞůƵŶŐǁŝůůĐŽŶƚƌĂĐƚĂŶĚƉŶĞƵŵŽƚŚŽƌĂǆǁŝůůďĞǀŝƐŝďůĞĂŐĂŝŶ͘ĞĐĂƵƚŝŽƵƐ ŽĨůĞĨƚƵƉƉĞƌĐŚĞƐƚ͕ĂƐŚĞĂƌƚĐĂŶŵŝŵŝĐůƵŶŐƉŽŝŶƚ͘

Normal Sliding Lung Sign Pneumothorax /ĚĞŶƚŝĨǇƐƚƌƵĐƚƵƌĞƐ͗ DͲDŽĚĞƐŚŽǁŝŶŐ͞ĞĂĐŚƐŝŐŶ͟ ͞ĂƌĐŽĚĞƐŝŐŶ͟

ďĚŽŵŝŶĂůǆĂŵ Probe ^ϰ^ĞĐƚŽƌƌƌĂǇ Preset ďĚŽŵĞŶŽƌ Starting Depth ϭϳʹϭϵĐŵ &^d ůŽŽĚǁŝůůƐŚŽǁƵƉĂƐĨƌĞĞĨůƵŝĚŽƵƚƐŝĚĞŽĨĂďĚŽŵŝŶĂůŽƌŐĂŶƐ͘ƐŵƵĐŚĂƐϱϬϬŵ>ŽĨĨƌĞĞĨůƵŝĚŝƐƌĞƋƵŝƌĞĚ ĨŽƌĂƉŽƐŝƚŝǀĞ&^dĞǆĂŵ͖ĂŶĞŐĂƚŝǀĞ&^dĞǆĂŵĚŽĞƐŶŽƚŵĞĂŶƚŚĞƉĂƚŝĞŶƚŝƐŶŽƚďůĞĞĚŝŶŐ͘&ůƵŝĚĨƌŽŵ ĐŽŶĚŝƚŝŽŶƐƐƵĐŚĂƐĂƐĐŝƚĞƐĚƵĞƚŽůŝǀĞƌĨĂŝůƵƌĞĐĂŶĂůƐŽĂƉƉĞĂƌĂƐĨƌĞĞĨůƵŝĚ͘ ZhY;DŽƌŝƐŽŶ͛ƐWŽƵĐŚͿ ϭ͘ WůĂĐĞƉƌŽďĞŽŶƌŝŐŚƚŵŝĚĂǆŝůůĂƌǇǁŝƚŚŵĂƌŬĞƌƚŽǁĂƌĚƐŚĞĂĚ͘ Ϯ͘ ŶŐůĞƚŚĞƉƌŽďĞ͞ƵƉ͟ƚŽǁĂƌĚƐĨƌŽŶƚŽĨƉĂƚŝĞŶƚ͕ĚƌŽƉƉŝŶŐǇŽƵƌŚĂŶĚƐĚŽǁŶƚŽǁĂƌĚƐĐŽƚ͘ ϯ͘ /ĚĞŶƚŝĨǇƚŚĞƌŝŐŚƚŬŝĚŶĞǇĂŶĚDŽƌŝƐŽŶƐ͛ƉŽƵĐŚ͘^ĂǀĞĂůŽŽƉ͘

Cypress Creek EMS System Policies and Treatment Guidelines

279 PROCEDURES Revised 12/2018 Approved: Levon Vartanian, MD

ϰ͘ ^ůŝĚĞƉƌŽďĞŝŶĨĞƌŝŽƌůǇƚŽǁĂƌĚƐĨĞĞƚƚŽǀŝƐƵĂůŝǌĞƚŝƉŽĨůŝǀĞƌ͘^ĂǀĞĂůŽŽƉ͘

ůĂĚĚĞƌͬWĞůǀŝƐ dŚĞƉĞůǀŝĐǀŝĞǁŝƐƚŚĞŵŽƐƚƐĞŶƐŝƚŝǀĞĨŽƌĚĞƚĞĐƚŝŶŐĨƌĞĞĨůƵŝĚ͘

ϭ͘ WůĂĐĞƉƌŽďĞũƵƐƚƐƵƉĞƌŝŽƌƚŽƉƵďŝĐƐǇŵƉŚǇƐŝƐǁŝƚŚƚŚĞŵĂƌŬĞƌƚŽǁĂƌĚƐƚŚĞŚĞĂĚ͘ Ϯ͘ ŶŐůĞƚŚĞƉƌŽďĞƵƉ;ƚŽǁĂƌĚƐŚĞĂĚͿƵŶƚŝůďůĂĚĚĞƌŝƐůĂƌŐĞƐƚƚŚĞŶĐŽŶƚŝŶƵĞƚŝůƚŝŶŐƚŽǁĂƌĚƐŚĞĂĚƚŽůŽŽŬ ũƵƐƚƐƵƉĞƌŝŽƌƚŽďůĂĚĚĞƌ͘^ǁĞĞƉƐŝĚĞƚŽƐŝĚĞůŽŽŬŝŶŐĨŽƌĨƌĞĞĨůƵŝĚ͘^ĂǀĞĂůŽŽƉ͘ ϯ͘ ZŽƚĂƚĞƚŚĞƉƌŽďĞϵϬǑǁŝƚŚŵĂƌŬĞƌƚŽƉĂƚŝĞŶƚƌŝŐŚƚ͘^ǁĞĞƉƵƉĂŶĚĚŽǁŶ͕ƐĂǀĞĂůŽŽƉ͘ ϰ͘ /ĨďůĂĚĚĞƌĐĂŶŶŽƚďĞĨŽƵŶĚ͕ĂŶŐůĞƉƌŽďĞĚŽǁŶ;ƚŽǁĂƌĚƐĨĞĞƚͿƚŽĨŝŶĚƚŚĞƉƵďŝĐƐǇŵƉŚǇƐŝƐ͘^ǁĞĞƉ ƐŝĚĞƚŽƐĂǀĞĂŶĚƐĂǀĞĂůŽŽƉ͘ >hY;^ƉůĞŶŽƌĞŶĂůͿ ϭ͘ WůĂĐĞƉƌŽďĞŽŶƉĂƚŝĞŶƚ͛ƐůĞĨƚƐŝĚĞƉŽƐƚĞƌŝŽƌƚŽŵŝĚĂǆŝůůĂƌǇůŝŶĞ͕ǁŝƚŚƚŚĞŵĂƌŬĞƌƚŽǁĂƌĚƐƚŚĞŚĞĂĚ͘ <ĞĞƉŬŶƵĐŬůĞƐŽŶĐŽƚ͘ Ϯ͘ ŶŐůĞƚŚĞƉƌŽďĞƚŽŝĚĞŶƚŝĨǇƚŚĞŬŝĚŶĞǇĂŶĚƐƉůĞĞŶ͘>ŽŽŬŽŶĂůůƐŝĚĞƐŽĨƐƉůĞĞŶ͘^ĂǀĞĂůŽŽƉ͘ ϯ͘ ^ůŝĚĞƉƌŽďĞƚŽǁĂƌĚƐŚĞĂĚƚŽǀŝƐƵĂůŝǌĞƚŚĞĚŝĂƉŚƌĂŐŵĂŶĚĞǀĂůƵĂƚĞĨŽƌƐƉŝŶĞƐŝŐŶ;ŝŶĚŝĐĂƚŝŶŐĨůƵŝĚŝŶ ůĞĨƚůƵŶŐĐĂǀŝƚǇͿ͘^ĂǀĞĂůŽŽƉ͘ ϰ͘ ƐƉĂƚŝĞŶƚďƌĞĂƚŚĞƐ͕ůŽŽŬĨŽƌĨůƵŝĚďĞƚǁĞĞŶƐƉůĞĞŶĂŶĚĚŝĂƉŚƌĂŐŵ͘

Cypress Creek EMS System Policies and Treatment Guidelines

280 PROCEDURES Treatment Approved: Levon Vartanian, MD tŚŽůĞůŽŽĚΘůŽŽĚWƌŽĚƵĐƚdƌĂŶƐĨƵƐŝŽŶ Indications Equipment Required Assessment Requirements dƌĂƵŵĂŽƌŵĞĚŝĐĂůƉĂƚŝĞŶƚǁŝƚŚ WůĂƐŵĂůǇƚĞ/sĨůƵŝĚ ůŽŽĚƉƌĞƐƐƵƌĞ͕ĐĂƌĚŝĂĐ ƐƵƐƉĞĐƚĞĚďůŽŽĚůŽƐƐ͘ ůŽŽĚͲzƚƵďŝŶŐ ŵŽŶŝƚŽƌŝŶŐ͕dKϮ DƵƐƚďĞĂƚůĞĂƐƚϭǇĞĂƌƐŽůĚ͘ /sĂƚŚĞƚĞƌtϮϬŐĂ͘yϮ ŵŽŶŝƚŽƌŝŶŐ͘ DƵƐƚŚĂǀĞtwo or moreŽĨƚŚĞ &ůƵŝĚǁĂƌŵĞƌ ,Θ,;ĨŽƌŵĞĚŝĐĂůƉĂƚŝĞŶƚƐͿ ĨŽůůŽǁŝŶŐ͗ ,Θ,DĞƚĞƌ dĞŵƉĞƌĂƚƵƌĞŵŽŶŝƚŽƌŝŶŐ ;ƉƌĞͲŽƌƉĞƌŝͲƚƌĂŶƐĨƵƐŝŽŶĂŶĚ x ,ZхϭϮϬďƉŵ tŚŽůĞďůŽŽĚŽƌďůŽŽĚ ƉƌŽĚƵĐƚƐ ƉŽƐƚͲƚƌĂŶƐĨƵƐŝŽŶďĞĨŽƌĞ x ^ǇƐ͘WdϵϬŵŵ,Ő ƚƌĂŶƐĨĞƌŽĨĐĂƌĞͿ͘ x WĞŶĞƚƌĂƚŝŶŐŝŶũƵƌǇŽƌ sŝƚĂůƐŝŐŶƐƉƌĞͲĂŶĚƉŽƐƚͲ ƐŝŐŶŝĨŝĐĂŶƚďůƵŶƚƚƌĂƵŵĂƚŝĐ ƚƌĂŶƐĨƵƐŝŽŶ͕ŝŶĐůƵĚŝŶŐ'^͘ ŝŶũƵƌǇ x ,ĞŵŽŐůŽďŝŶŽĨϳŽƌůĞƐƐ x WŽƐŝƚŝǀĞFAST exam

WƵƌƉŽƐĞ x tŚŽůĞďůŽŽĚĂŶĚďůŽŽĚƉƌŽĚƵĐƚƐĂƌĞƚŚĞƉƌĞĨĞƌƌĞĚĨůƵŝĚĨŽƌƚƌĞĂƚŵĞŶƚŽĨŚĞŵŽƌƌŚĂŐŝĐƐŚŽĐŬĐĂƵƐĞĚ ďǇďůŽŽĚůŽƐƐ͘tŚŽůĞďůŽŽĚĂŶĚďůŽŽĚƉƌŽĚƵĐƚƐĐĂŶŝŵƉƌŽǀĞƉĞƌĨƵƐŝŽŶ͕ŽǆǇŐĞŶĚĞůŝǀĞƌǇ͕ĂŶĚ ŚĞŵŽƌƌŚĂŐĞĐŽŶƚƌŽů͘WĂĐŬĞĚƌĞĚďůŽŽĚĐĞůůƐƌĞƉůĂĐĞŚĞŵŽŐůŽďŝŶ;ĞŶŚĂŶĐŝŶŐŽǆǇŐĞŶĚĞůŝǀĞƌǇĂŶĚKϮ ƌĞŵŽǀĂůͿ͕ĂŶĚĨƌĞƐŚůŝƋƵŝĚƉůĂƐŵĂƌĞƉůĂĐĞƐĨůƵŝĚǀŽůƵŵĞ͕ƉůĂƐŵĂƉƌŽƚĞŝŶƐ͕ĂŶĚĞůĞĐƚƌŽůǇƚĞƐǁŝƚŚŽƵƚ ƐŚŝĨƚŝŶŐŝŶƚŽŝŶƚĞƌƐƚŝƚŝĂůƐƉĂĐĞůŝŬĞĐƌǇƐƚĂůůŽŝĚƐ͘tŚŽůĞďůŽŽĚƌĞƉůĂĐĞƐŚĞŵŽŐůŽďŝŶ͕ĨůƵŝĚǀŽůƵŵĞ͕ ƉůĂƐŵĂƉƌŽƚĞŝŶƐ͕ĞůĞĐƚƌŽůǇƚĞƐ͕ĂƐǁĞůůĂƐƉůĂƚĞůĞƚƐĂŶĚĐůŽƚƚŝŶŐĨĂĐƚŽƌƐ͘&ŽƌƚŚŝƐƌĞĂƐŽŶ͕ǁŚŽůĞďůŽŽĚŝƐ ƉƌĞĨĞƌƌĞĚƚŽďůŽŽĚƉƌŽĚƵĐƚƐĂůŽŶĞ͘ x ŵĞƌŐĞŶĐǇŵĂƐƐƚƌĂŶƐĨƵƐŝŽŶŽĨƵŶͲĐƌŽƐƐͲŵĂƚĐŚĞĚďůŽŽĚŽƌďůŽŽĚƉƌŽĚƵĐƚƐŚĂƐĂƌŝƐŬŽĨŵŝŶŽƌ ƚƌĂŶƐĨƵƐŝŽŶƌĞĂĐƚŝŽŶƐ͖ůŽǁͲƚŝƚĞƌǁŚŽůĞďůŽŽĚŚĂƐƚŚĞůŽǁĞƐƚƌŝƐŬĂŶĚƚǇƉĞKŚĂƐƵŶŝǀĞƌƐĂůƚǇƉĞ ĐŽŵƉĂƚŝďŝůŝƚǇ͘ x dŚĞZŚͲĨĂĐƚŽƌ;ŶĞŐĂƚŝǀĞŽƌƉŽƐŝƚŝǀĞͿĚŽĞƐŶŽƚŚĂǀĞƚŽďĞĂĚŝƌĞĐƚŵĂƚĐŚĨŽƌĞŵĞƌŐĞŶĐǇƚƌĂŶƐĨƵƐŝŽŶƐ͕ ŚŽǁĞǀĞƌ͕ŝĨĂŶZŚͲŶĞŐĂƚŝǀĞĨĞŵĂůĞƉĂƚŝĞŶƚƌĞĐĞŝǀĞƐZŚͲƉŽƐŝƚŝǀĞďůŽŽĚ͕ƚŚĞǇĐĂŶĚĞǀĞůŽƉĂŶƚŝďŽĚŝĞƐ ůĞĂĚŝŶŐƚŽƉŽƚĞŶƚŝĂůĐŽŵƉůŝĐĂƚŝŽŶƐĚƵƌŝŶŐƉƌĞŐŶĂŶĐǇ͘dŚĞƐĞƉĂƚŝĞŶƚƐŵĂǇƌĞĐĞŝǀĞĂŵĞĚŝĐĂƚŝŽŶƚŽ ƚƌĞĂƚƚŚŝƐĂƚƚŚĞŚŽƐƉŝƚĂů͘ x Low titer type O-positive whole bloodǁŝůůďĞƚŚĞƉƌŝŵĂƌǇďůŽŽĚƉƌŽĚƵĐƚĨŽƌƵƐĞŽŶALLƉĂƚŝĞŶƚƐŝĨ ĂǀĂŝůĂďůĞ͘ x /ĨƐƵƉƉůǇŝƐĂǀĂŝůĂďůĞ͕low titertype O-negative whole bloodŵĂǇďĞƵƐĞĚŝŶƐƚĞĂĚŽĨlow titer type O-positive whole blood. x /ĨƚŚĞƌĞŝƐĂŶĂǀĂŝůĂďůĞƐƵƉƉůǇŽĨďŽƚŚůŽǁƚŝƚĞƌƚǇƉĞKͲŶĞŐĂƚŝǀĞĂŶĚƚǇƉĞKͲƉŽƐŝƚŝǀĞǁŚŽůĞďůŽŽĚ͕ ƌĞƐĞƌǀĞKͲŶĞŐĂƚŝǀĞĨŽƌƉĞĚŝĂƚƌŝĐƉĂƚŝĞŶƚƐ;ĂŐĞƐϭʹϭϴͿĂŶĚĨĞŵĂůĞƐфϱϬǇĞĂƌƐŽůĚŽƌŽĨĐŚŝůĚďĞĂƌŝŶŐ ĂŐĞ͘ x /ĨŶŽǁŚŽůĞďůŽŽĚŝƐĂǀĂŝůĂďůĞ͕ĐŽŶƐŝĚĞƌƚŚĞƵƐĞŽĨpacked red blood cellsĂŶĚfresh liquid plasma͘ x dŚĞYŝŶ&ůŽǁtĂƌƌŝŽƌǁĂƌŵĞƌŝƐƚŚĞƉƌĞĨĞƌƌĞĚĨůƵŝĚǁĂƌŵĞƌĨŽƌĐŽůĚǁŚŽůĞďůŽŽĚĂŶĚďůŽŽĚ ƉƌŽĚƵĐƚƐ͘

Cypress Creek EMS System Policies and Treatment Guidelines

281 PROCEDURES Treatment Approved: Levon Vartanian, MD

WĂƚŝĞŶƚZĞĨƵƐĂůŽĨdƌĂŶƐĨƵƐŝŽŶ͗ ϭ͘ ƉĞƌƐŽŶŵĞĞƚŝŶŐƚŚĞĐƌŝƚĞƌŝĂŵĂǇƌĞĨƵƐĞƚŚĞďůŽŽĚƚƌĂŶƐĨƵƐŝŽŶĨŽƌƌĞůŝŐŝŽƵƐ͕ƐŽĐŝĂů͕ŽƌƉĞƌƐŽŶĂů ƌĞĂƐŽŶƐŝĨŚĞͬƐŚĞŝƐĂǁĂŬĞ͕ĂůĞƌƚĂŶĚŽƌŝĞŶƚĞĚ͘dŚĞƌĞĂƐŽŶĨŽƌƌĞĨƵƐĂůŵƵƐƚďĞĐůĞĂƌůǇĚŽĐƵŵĞŶƚĞĚ ŝŶƚŚĞWZ͘ Ϯ͘ /ŶƚŚĞĐĂƐĞŽĨĂƌĞĨƵƐĂůŽĨďůŽŽĚƚƌĂŶƐĨƵƐŝŽŶ͕ĂĚŵŝŶŝƐƚĞƌPlasmalyteĂĐĐŽƌĚŝŶŐƚŽƉƌŽƚŽĐŽů͘ dƌĂŶƐĨƵƐŝŽŶWƌŽĐĞĚƵƌĞ ϭ͘ ƐƚĂďůŝƐŚǀĂƐĐƵůĂƌĂĐĐĞƐƐǁŝƚŚĂƚůĞĂƐƚĂϮϬŐĂ͘/sĐĂƚŚĞƚĞƌ͘tŚŽůĞďůŽŽĚĂŶĚďůŽŽĚƉƌŽĚƵĐƚƐŵĂǇ ĂůƐŽďĞƚƌĂŶƐĨƵƐĞĚƵƐŝŶŐĂŶ/K͘ƐƚĂďůŝƐŚĂƐĞĐŽŶĚǀĂƐĐƵůĂƌĂĐĐĞƐƐůŝŶĞĂƐƚŝŵĞƉĞƌŵŝƚƐĨŽƌ ĂĚŵŝŶŝƐƚƌĂƚŝŽŶŽĨŵĞĚŝĐĂƚŝŽŶƐŽƌŽƚŚĞƌĨůƵŝĚƐ͘ Ϯ͘ ŽŶŶĞĐƚĚŝƌĞĐƚůǇƚŽĂůŽŽĚͲzĂĚŵŝŶŝƐƚƌĂƚŝŽŶƐĞƚǁŝƚŚWůĂƐŵĂůǇƚĞĂƐƚŚĞďĂƐĞĨůƵŝĚ͘/ĨǁŚŽůĞďůŽŽĚŽƌ ďůŽŽĚƉƌŽĚƵĐƚƐĂƌĞƌĞĂĚŝůǇĂǀĂŝůĂďůĞ͕ŵŝŶŝŵŝǌĞĐƌǇƐƚĂůůŽŝĚĂĚŵŝŶŝƐƚƌĂƚŝŽŶ͘ ϯ͘ ŶƐƵƌĞŝŶƚƌĂǀĞŶŽƵƐŽƌŝŶƚƌĂŽƐƐĞŽƵƐůŝŶĞƉĂƚĞŶĐǇďǇĨůƵƐŚŝŶŐƐŝƚĞǁŝƚŚϭϬŵůŽĨŶŽƌŵĂůƐĂůŝŶĞ͘ ϰ͘ ZĞĐŽƌĚďĂƐĞůŝŶĞǀŝƚĂůƐŝŐŶƐ͘ ϱ͘ WĞƌĨŽƌŵ,Θ,͕ŝĨĂǀĂŝůĂďůĞ͕ĂŶĚƌĞĐŽƌĚŝŶWZ;ĚŽŶŽƚĚĞůĂǇƚƌĂŶƐĨƵƐŝŽŶͿ͘ ϲ͘ dǁŽ;ϮͿD^ƉĞƌƐŽŶŶĞůŵƵƐƚĐŽŶĨŝƌŵƚŚĞƚĂŐĂŶĚďůŽŽĚƉƌŽĚƵĐƚŵĂƚĐŚŝŶĐůƵĚŝŶŐŶƵŵďĞƌ͕ďůŽŽĚ ƚǇƉĞ͕ZŚĨĂĐƚŽƌ͕ĂŶĚĞǆƉŝƌĂƚŝŽŶĚĂƚĞ͘ŽĐƵŵĞŶƚƚĂŐŶƵŵďĞƌĂŶĚďůŽŽĚƚǇƉĞŝŶWZ͘ ϳ͘ 'ĞŶƚůǇĂŐŝƚĂƚĞďůŽŽĚŽƌďůŽŽĚƉƌŽĚƵĐƚƐƚŽĞŶƐƵƌĞĂĚĞƋƵĂƚĞĨůŽǁƌĂƚĞƐ͘ ϴ͘ ŽŶŶĞĐƚůŽŽĚͲzƚŽǁĂƌŵĞƌĐŝƌĐƵŝƚĂŶĚƉƌŝŵĞǁŝƚŚďůŽŽĚŽƌďůŽŽĚƉƌŽĚƵĐƚ͘ DO NOT TRANSFUSE COLD BLOOD. ϵ͘ hƚŝůŝǌĞĂƉƌĞƐƐƵƌĞŝŶĨƵƐĞƌŝŶĨůĂƚĞĚƚŽĂŵĂǆŝŵƵŵŽĨϮϴϬŵŵ,ŐĂŶĚƚƌĂŶƐĨƵƐĞƵƐŝŶŐĚŽƐĂŐĞŐƵŝĚĞůŝŶĞƐ ďĞůŽǁ͘dŚĞŝŶŝƚŝĂůŝŶĨƵƐŝŽŶƌĂƚĞǁŝůůďĞƐůŽǁƚŽŽďƐĞƌǀĞĨŽƌdƌĂŶƐĨƵƐŝŽŶZĞĂĐƚŝŽŶ͘/ĨŶŽƌĞĂĐƚŝŽŶŝƐ ŶŽƚĞĚ͕ĨůŽǁǁŝĚĞŽƉĞŶĂŶĚĐŽŶƚŝŶƵĞƚŽŵŽŶŝƚŽƌǀŝƚĂůƐŝŐŶƐĂŶĚƌĞĂƐƐĞƐƐĨŽƌƌĞƐƉŽŶƐĞƚŽƚŚĞƌĂƉǇŽƌ ĂĚǀĞƌƐĞƌĞĂĐƚŝŽŶƐ͘ ϭϬ͘ ĨƚĞƌƚƌĂŶƐĨƵƐŝŽŶŽĨlow titer type O-positive whole bloodŚĂƐďĞĞŶƐƚĂƌƚĞĚ͕ĂƚƚĂĐŚƚŚĞŐƌĞĞŶ ŝĚĞŶƚŝĨŝĐĂƚŝŽŶǁƌŝƐƚďĂŶĚŽŶƚŚĞǁƌŝƐƚŽĨƚŚĞĂƌŵǁŚĞƌĞƚŚĞƚƌĂŶƐĨƵƐŝŽŶůŝŶĞŝƐůŽĐĂƚĞĚ͘

ϭϭ͘ /Ĩlow titer type O-positive whole bloodŚĂƐďĞĞŶƚƌĂŶƐĨƵƐĞĚ͕ƚŚĞD^ĐƌĞǁŝƐƌĞƋƵŝƌĞĚƚŽŶŽƚŝĨǇƚŚĞ ƌĞĐĞŝǀŝŶŐŚŽƐƉŝƚĂůŶƵƌƐĞĂŶĚŽďƚĂŝŶĂƐŝŐŶĂƚƵƌĞŝŶƚŚĞĂƉƉůŝĐĂďůĞ^K,ZƐŝŐŶĂƚƵƌĞďŽǆ;ƵŶĚĞƌ ƵƐƚŽŵ^ŝŐŶĂƚƵƌĞƐͿŝŶĚŝĐĂƚŝŶŐƚŚĂƚƚŚĞD^ĐƌĞǁŚĂƐƉƌŽǀŝĚĞĚŶŽƚŝĨŝĐĂƚŝŽŶƚŽƚŚĞƌĞĐĞŝǀŝŶŐŶƵƌƐĞ ƚŚĂƚƚŚĞƉĂƚŝĞŶƚǁĂƐƚƌĂŶƐĨƵƐĞĚǁŝƚŚƚǇƉĞKͲƉŽƐŝƚŝǀĞďůŽŽĚ͘

Cypress Creek EMS System Policies and Treatment Guidelines

282 PROCEDURES Treatment Approved: Levon Vartanian, MD

ŽƐĂŐĞ Adults (Age > 12 years): Whole Blood: dƌĂŶƐĨƵƐĞŽŶĞƵŶŝƚŽĨůŽǁƚŝƚĞƌƚǇƉĞͲKďůŽŽĚ͘ZĞĂƐƐĞƐƐƉĂƚŝĞŶƚ͕ĂŶĚƚƌĂŶƐĨƵƐĞƐĞĐŽŶĚ ƵŶŝƚŝĨƉĂƚŝĞŶƚĐŽŶƚŝŶƵĞƐƚŽŵĞĞƚƚƌĂŶƐĨƵƐŝŽŶŝŶĚŝĐĂƚŝŽŶĐƌŝƚĞƌŝĂ͘ Blood Products: dƌĂŶƐĨƵƐĞŽŶĞƵŶŝƚŽĨĨƌĞƐŚůŝƋƵŝĚƉůĂƐŵĂĨŽůůŽǁĞĚďǇŽŶĞƵŶŝƚƉĂĐŬĞĚƌĞĚďůŽŽĚĐĞůůƐ͘ ZĞƉĞĂƚŝŶůŝŬĞƉĂŝƌƐŝĨƉĂƚŝĞŶƚĐŽŶƚŝŶƵĞƐƚŽŵĞĞƚƚƌĂŶƐĨƵƐŝŽŶŝŶĚŝĐĂƚŝŽŶĐƌŝƚĞƌŝĂ͘

Pediatric (Age 1–12 years): Whole Blood: dƌĂŶƐĨƵƐĞŝŶϱϬŵ>ďŽůƵƐĞƐƵƉƚŽϭϬŵ>ͬŬŐ͘ZĞĂƐƐĞƐƐƉĂƚŝĞŶƚĂŶĚƌĞƉĞĂƚŽŶĐĞŝĨƉĂƚŝĞŶƚ ĐŽŶƚŝŶƵĞƐƚŽŵĞĞƚƚƌĂŶƐĨƵƐŝŽŶŝŶĚŝĐĂƚŝŽŶĐƌŝƚĞƌŝĂ͘ Blood Products: dƌĂŶƐĨƵƐĞŝŶƉĂŝƌƐŽĨϱϬŵ>ďŽůƵƐĞƐ͕ǁŝƚŚĨƌĞƐŚůŝƋƵŝĚƉůĂƐŵĂƚŚĞŶƉĂĐŬĞĚƌĞĚďůŽŽĚ ĐĞůůƐ͕ƵƉƚŽϭϬŵ>ͬŬŐŽĨĞĂĐŚ͘ZĞƉĞĂƚŽŶĐĞŝĨƉĂƚŝĞŶƚĐŽŶƚŝŶƵĞƐƚŽŵĞĞƚƚƌĂŶƐĨƵƐŝŽŶ ŝŶĚŝĐĂƚŝŽŶĐƌŝƚĞƌŝĂ͘ WĞĂƌůƐ x tĂƚĐŚĨŽƌƚƌĂŶƐĨƵƐŝŽŶƌĞĂĐƚŝŽŶ͖ŝĨƉƌĞƐĞŶƚ͕ƐƚŽƉƚƌĂŶƐĨƵƐŝŽŶ͕ĐŚĂŶŐĞĂůůůŝŶĞƐĂŶĚƵƚŝůŝǌĞŶŽƌŵĂůƐĂůŝŶĞ͘ĂŐ ďůŽŽĚŽƌďůŽŽĚƉƌŽĚƵĐƚƐĨŽƌƌĞƚƵƌŶƚŽďůŽŽĚďĂŶŬ͕ĂŶĚŝĨŶĞĐĞƐƐĂƌǇ͕ƚƌĞĂƚǁŝƚŚAllergic ReactionŐƵŝĚĞůŝŶĞƐ͘ x dƌĂŶƐĨƵƐŝŽŶZĞĂĐƚŝŽŶŝƐĚĞĨŝŶĞĚĂƐĂŶĂĚǀĞƌƐĞĞǀĞŶƚĞǆƉĞƌŝĞŶĐĞĚďǇĂƉĂƚŝĞŶƚŝŶĂƐƐŽĐŝĂƚŝŽŶǁŝƚŚĂƚƌĂŶƐĨƵƐŝŽŶ ƚŚĂƚŝƐŶŽƚĞǆƉůĂŝŶĞĚďǇƚŚĞƉĂƚŝĞŶƚ͛ƐƵŶĚĞƌůǇŝŶŐĐŽŶĚŝƚŝŽŶ͘ x /ĨƐŝŐŶƐĂŶĚƐǇŵƉƚŽŵƐŽĨĂdƌĂŶƐĨƵƐŝŽŶZĞĂĐƚŝŽŶŽĐĐƵƌ^dKWƚŚĞƚƌĂŶƐĨƵƐŝŽŶŝŵŵĞĚŝĂƚĞůǇ͘ĞŐŝŶ WůĂƐŵĂůǇƚĞŝŶĨƵƐŝŽŶƚŚƌŽƵŐŚŶĞǁƚƵďŝŶŐĂƚƚŚĞĚĞƐŝƌĞĚƌĂƚĞĂŶĚƌĞĨĞƌƚŽůůĞƌŐŝĐZĞĂĐƚŝŽŶΘŶĂƉŚǇůĂǆŝƐ ŐƵŝĚĞůŝŶĞƐ x dŚĞďůŽŽĚŽƌďůŽŽĚƉƌŽĚƵĐƚƵŶŝƚ͕ĨŝůƚĞƌ͕ƚƵďŝŶŐĂŶĚ/sƐŽůƵƚŝŽŶďĂŐŶĞĞĚƚŽďĞƐƵďŵŝƚƚĞĚƚŽƚŚĞĐůŝŶŝĐĂů ĚĞƉĂƌƚŵĞŶƚ͘ x /ĨŽŶůǇŽŶĞůŝŶĞĐĂŶďĞƐƚĂƌƚĞĚ͕ƚƌĂŶƐĨƵƐĞĨƌĞƐŚůŝƋƵŝĚƉůĂƐŵĂĨŝƌƐƚ͕ĨŽůůŽǁĞĚďǇƉĂĐŬĞĚƌĞĚďůŽŽĚĐĞůůƐ͘&ƌĞƐŚ ůŝƋƵŝĚƉůĂƐŵĂĂŶĚƉĂĐŬĞĚƌĞĚďůŽŽĚĐĞůůƐŵĂǇďĞƚƌĂŶƐĨƵƐĞĐŽŶĐƵƌƌĞŶƚůǇƵƐŝŶŐƚǁŽǀĂƐĐƵůĂƌĂĐĐĞƐƐƐŝƚĞƐ͘ x ŽŶƚŝŶƵĞƚƌĂŶƐĨƵƐŝŽŶƐƵŶƚŝůƌĞƐƵƐĐŝƚĂƚŝŽŶƌĞĂĐŚĞƐƉĞƌŵŝƐƐŝǀĞŚǇƉŽƚĞŶƐŝŽŶƌĂŶŐĞ;ƐǇƐƚŽůŝĐϳϬŵŵ,ŐĨŽƌ ƵŶĐŽŶƚƌŽůůĞĚŚĞŵŽƌƌŚĂŐĞ͖ϵϬŵŵ,ŐĨŽƌĐŽŶƚƌŽůůĞĚͿ͘ x /ĨŐŝǀŝŶŐŵĞĚŝĐĂƚŝŽŶƐǁŝƚŚŽƵƚĂĚĚŝƚŝŽŶĂů/sͬ/KƐŝƚĞ͕ƐƚŽƉĨůŽǁ͕ĨůƵƐŚǁŝƚŚϭϬĐĐŽĨE^͕ŐŝǀĞŵĞĚŝĐĂƚŝŽŶƐ͕ĨůƵƐŚ ǁŝƚŚĂŶŽƚŚĞƌϭϬĐĐŽĨE^͕ƚŚĞŶƌĞƐƵŵĞďůŽŽĚŽƌďůŽŽĚƉƌŽĚƵĐƚĨůŽǁ͘ŽŶƐŝĚĞƌĞƐƚĂďůŝƐŚŝŶŐĂĚĚŝƚŝŽŶĂů/sƐŝƚĞ ǁŝƚŚůŽĐŬĨŽƌŵĞĚŝĐĂƚŝŽŶƐ͘ x ŽEKdŵŝǆŵĞĚŝĐĂƚŝŽŶƐǁŝƚŚďůŽŽĚŽƌďůŽŽĚƉƌŽĚƵĐƚƐŝŶƚŚĞďĂŐ x ŽŶŽƚĚĞůĂǇƚƌĂŶƐƉŽƌƚƚŽŝŶŝƚŝĂƚĞďůŽŽĚŽƌďůŽŽĚƉƌŽĚƵĐƚƐ͘/ŶŝƚŝĂƚĞĞŶƌŽƵƚĞŝĨƉĂƚŝĞŶƚŝƐƵŶƐƚĂďůĞͬƵƌŐĞŶƚ͘ x EŽƚŝĨǇƌĞĐĞŝǀŝŶŐĨĂĐŝůŝƚǇĂďŽƵƚďůŽŽĚŽƌďůŽŽĚƉƌŽĚƵĐƚƐƚƌĂŶƐĨƵƐŝŽŶĞĂƌůǇ͘ x dƌĂƵŵĂƉĂƚŝĞŶƚƐƌĞĐĞŝǀŝŶŐďůŽŽĚŽƌďůŽŽĚƉƌŽĚƵĐƚƐƐŚŽƵůĚďĞƚƌĂŶƐƉŽƌƚĞĚƚŽĂ>ĞǀĞů/Žƌ>ĞǀĞů//dƌĂƵŵĂ ĞŶƚĞƌ͘/ĨƚŚŝƐŝƐƵŶĂǀĂŝůĂďůĞ͕ƉƌŽĐĞĞĚƚŽƚŚĞŶĞǆƚŚŝŐŚĞƐƚůĞǀĞůƚƌĂƵŵĂĐĞŶƚĞƌĂǀĂŝůĂďůĞ͘ x DĞĚŝĐĂůƉĂƚŝĞŶƚƐƌĞĐĞŝǀŝŶŐďůŽŽĚŽƌďůŽŽĚƉƌŽĚƵĐƚƐƐŚŽƵůĚďĞƚƌĂŶƐƉŽƌƚĞĚƚŽƚŚĞĐůŽƐĞƐƚŵŽƐƚĂƉƉƌŽƉƌŝĂƚĞ ĨĂĐŝůŝƚǇ͘ DĂŶĚĂƚŽƌǇŽĐƵŵĞŶƚĂƚŝŽŶ ůŽŽĚƉƌĞƐƐƵƌĞ͕ƉƵůƐĞ͕dKϮ͕^WKϮĂŶĚ'^ƉƌĞĂŶĚƉŽƐƚďůŽŽĚŽƌďůŽŽĚƉƌŽĚƵĐƚƚƌĂŶƐĨƵƐŝŽŶ͘ WĂƚŝĞŶƚĚĞŵŽŐƌĂƉŚŝĐƐ͗ŐĞ͕ƐĞǆ͕ĂŶǇĐŽŵŽƌďŝĚŝƚŝĞƐŽƌŽƚŚĞƌƌŝƐŬĨĂĐƚŽƌƐ͘ dŝŵĞŽĨ/ŶũƵƌǇƚŽƚŝŵĞƚŚĂƚƚƌĂŶƐĨƵƐŝŽŶǁĂƐŝŶŝƚŝĂƚĞĚ͘;'ŽĂůŝƐůĞƐƐƚŚĂŶϯϲŵŝŶƵƚĞƐĨƌŽŵŝŶũƵƌǇƚŽt ĂĚŵŝŶŝƐƚƌĂƚŝŽŶͿ EƵŵďĞƌĂŶĚƚǇƉĞŽĨƵŶŝƚƐƚƌĂŶƐĨƵƐĞĚ͘ dŝŵĞǁŚĞŶƚƌĂŶƐĨƵƐŝŽŶǁĂƐĐŽŵƉůĞƚĞĚ͕ŽƌŝĨƐƚŝůůŝŶƉƌŽĐĞƐƐĂƚƚƌĂŶƐĨĞƌŽĨĐĂƌĞ͕ǁŚĞƚŚĞƌŽƌŶŽƚŚŽƐƉŝƚĂů ĐŽŶƚŝŶƵĞĚƚƌĂŶƐĨƵƐŝŽŶ͘ ŽŵƉůĞƚĞĂŶǇĂĚĚŝƚŝŽŶĂůƐƵƉƉůĞŵĞŶƚĂůƌĞƉŽƌƚƐƚŚĂƚĂƌĞƌĞƋƵŝƌĞĚ͘ ŽŵƉůĞƚŝŽŶŽĨWZǁŝƚŚ^ƵƉĞƌǀŝƐŽƌƌĞǀŝĞǁƉƌŝŽƌƚŽĐĂůůĐůŽƐŝŶŐ͘

Cypress Creek EMS System Policies and Treatment Guidelines

283 PROCEDURE Fluid Warmer Approved: Levon Vartanian, MD

&ůƵŝĚtĂƌŵĞƌ Indications Equipment Needed &ůƵŝĚǁĂƌŵĞƌƐŵĂǇďĞƵƐĞĚƚŽǁĂƌŵ/sĨůƵŝĚƐ͕ YŝŶ&ůŽǁtĂƌƌŝŽƌĚĞǀŝĐĞĂŶĚďĂƚƚĞƌǇǁŝƚŚ ǁŚŽůĞďůŽŽĚ͕ŽƌďůŽŽĚƉƌŽĚƵĐƚƐƚŽďŽĚǇ ĚŝƐƉŽƐĂďůĞƵŶŝƚͬĐŝƌĐƵŝƚ͘ ƚĞŵƉĞƌĂƚƵƌĞ͘ or ƵĚĚǇ>ŝƚĞĚĞǀŝĐĞĂŶĚďĂƚƚĞƌǇǁŝƚŚ ůŽŽĚĂŶĚďůŽŽĚƉƌŽĚƵĐƚƐDh^dďĞǁĂƌŵĞĚ ĚŝƐƉŽƐĂďůĞĐŝƌĐƵŝƚ͘ ƉƌŝŽƌƚŽƚƌĂŶƐĨƵƐŝŽŶ͘

dŚĞYŝŶ&ůŽǁtĂƌƌŝŽƌŵĂǇďĞƵƐĞĚƚŽƌĂƉŝĚůǇ ǁĂƌŵ/sĨůƵŝĚƐĂŶĚͬŽƌďůŽŽĚƉƌŽĚƵĐƚƐƚŽĂƐĞƚ ƚĞŵƉĞƌĂƚƵƌĞŽĨϭϬϬ͘ϰΣ&ǁŝƚŚŝŶƐĞĐŽŶĚƐ QinFlow Warrior dŚĞYŝŶ&ůŽǁtĂƌƌŝŽƌŝƐƚŚĞƉƌĞĨĞƌƌĞĚĚĞǀŝĐĞĨŽƌǁĂƌŵŝŶŐďůŽŽĚĂŶĚďůŽŽĚƉƌŽĚƵĐƚƐŝŶƚƌĂŶƐĨƵƐŝŽŶ͘dŚĞtĂƌƌŝŽƌ ƉƌŽǀŝĚĞƐďĞƚƚĞƌĨůƵŝĚǁĂƌŵŝŶŐƉĞƌĨŽƌŵĂŶĐĞ͕ĞƐƉĞĐŝĂůůǇǁŝƚŚǀĞƌǇĐŽůĚĨůƵŝĚƐĂŶĚŚŝŐŚĨůŽǁƌĂƚĞƐ͘ YŝŶ&ůŽǁtĂƌƌŝŽƌWƌŽĐĞĚƵƌĞ͗ ϭ͘ ^ƉŝŬĞ/sĨůƵŝĚďĂŐǁŝƚŚůŽŽĚzƚƵďŝŶŐ͖ƉƌŝŵĞůŝŶĞƚŽĐůĞĂƌĂŝƌ Ϯ͘ ŽŶŶĞĐƚďĂƚƚĞƌǇƚŽďĂƐĞƵŶŝƚ ϯ͘ >ŽĐŬďĂƚƚĞƌǇŝŶƉůĂĐĞǁŝƚŚƐŝĚĞůĂƚĐŚĞƐ ϰ͘ KƉĞŶĚŝƐƉŽƐĂďůĞƵŶŝƚĂŶĚĐŽŶŶĞĐƚƚŽďĂƐĞƵŶŝƚ by cable;ƚŚĞ^ƚǇƌŽĨŽĂŵƵŶŝƚĚŽĞƐŶŽƚŶĞĞĚƚŽƐĞĂƚĚŝƌĞĐƚůǇŽŶ ƚŚĞďĂƐĞͲŝƚĐĂŶďĞƉůĂĐĞĚĐůŽƐĞƌƚŽƚŚĞƉĂƚŝĞŶƚďǇĞǆƚĞŶĚŝŶŐƚŚĞĐŽŶŶĞĐƚŝŶŐĐĂďůĞͿ ϱ͘ ŽŶŶĞĐƚ/sƚƵďŝŶŐƚŽŝŶůĞƚůƵĞƌŽŶƚŚĞĚŝƐƉŽƐĂďůĞƵŶŝƚ ϲ͘ WƌŝŵĞƚŚĞ/sůŝŶĞƚŽĨůƵƐŚĂůůŽĨƚŚĞĂŝƌŽƵƚŽĨƚŚĞůŝŶĞ*DO NOT CONNECT TO PATIENT UNLESS FLUSHED* ϳ͘ ŽŶŶĞĐƚƚŚĞŽƵƚůĞƚůƵĞƌŽŶƚŚĞĚŝƐƉŽƐĂďůĞƵŶŝƚƚŽƚŚĞƉĂƚŝĞŶƚ͛ƐƐĂůŝŶĞůŽĐŬ ϴ͘ dƵƌŶŽŶƐǇƐƚĞŵ Ă͘ dŚĞƐǇƐƚĞŵǁŝůůŝŶŝƚŝĂůŝǌĞ ď͘ &ůƵŝĚƐǁŝůůǁĂƌŵƚŽϵϭ͘ϰʹϵϲ͘ϴΣ&ͬϯϯʹϯϲΣǁŝƚŚŝŶĂĨĞǁƐĞĐŽŶĚƐ Đ͘ ŽŶĨŝƌŵƚĞŵƉĞƌĂƚƵƌĞŽŶƐĐƌĞĞŶ ϵ͘ ^Ğƚ/sĨůŽǁƌĂƚĞǀŝĂƚŚĞƌŽůůĞƌĐůĂŵƉ͘*Recommended flow rate is 160-180ml/min* (can deliver 200- 290ml/min and will support a pressure bag of 300mmHg)

CypressCypress CCreekreek EMEMSS Systemstem PoliPPPololollcllliiiicccies and TreatmentTreatment GuGuiidelineiness

284 PROCEDURE Fluid Warmer Approved: Levon Vartanian, MD

The system works on gravity; it is NOT A PUMP! YŝŶ&ůŽǁtĂƌƌŝŽƌdƌŽƵďůĞƐŚŽŽƚŝŶŐ͗ x ŽŵŵŽŶƌƌŽƌŽĚĞƐŝŶĐůƵĚĞ͗ x ͞ŚĂŶŐĞŝŶ&ůŽǁ͟ʹƵƐƵĂůůǇĚƵĞƚŽĂŝƌŝŶůŝŶĞ͖ŵĂŬĞƐƵƌĞůŝŶĞŝƐĐůĞĂƌ͕ďƵƚǁŝůůŽĨƚĞŶĐůĞĂƌŽŶŝƚƐŽǁŶ x ͞ĂƚƚĞƌǇ>Žǁ͟ʹŝŶĚŝĐĂƚĞƐƚŚĂƚƚŚĞďĂƚƚĞƌǇŝƐĂƚϯϬйĂŶĚĐĂŶŽŶůǇŝŶĨƵƐĞϭŵŽƌĞůŝƚĞƌĨůƵŝĚ x ͞&ůƵŝĚŝƐ,Kd͟ʹƵƐƵĂůůǇĚƵĞƚŽĂŝƌĨůŽǁͬĨůƵŝĚĨůŽǁŝƌƌĞŐƵůĂƌŝƚŝĞƐ;ĐŚĂŶŐĞƐŝŶĨůŽǁƌĂƚĞͿ͖ŝĨŝƚĚŽĞƐŶ͛ƚ ĐůĞĂƌŽŶŝƚƐŽǁŶƚŚĞŶƐǁŝƚĐŚŽƵƚƚŚĞĚŝƐƉŽƐĂďůĞƵŶŝƚ x ͞DĂůĨƵŶĐƚŝŽŶ͟ʹĂůŵŽƐƚĂůǁĂǇƐĚƵĞƚŽŶŽƚƉƌŝŵŝŶŐƚŚĞůŝŶĞ͖ƚƵƌŶŽĨĨƵŶŝƚ͕ĚŝƐĐŽŶŶĞĐƚ͕ĨůƵƐŚůŝŶĞ͕ ƌĞƐƚĂƌƚ x EK/^W>zʹĐŚĞĐŬƚŽŵĂŬĞƐƵƌĞƚŚĞƵŶŝƚŝƐƉŽǁĞƌĞĚKEŽƌƐǁŝƚĐŚŽƵƚďĂƚƚĞƌǇ x ***Always watch the LCD display as not all errors will have an audible beep*** x dŽĐŚĞĐŬƚŚĞĂƐĞhŶŝƚŝƐƉƌŽƉĞƌůǇĐŽŵŵƵŶŝĐĂƚŝŶŐǁŝƚŚƚŚĞŝƐƉŽƐĂďůĞhŶŝƚ;ŝ͘Ğ͕͘ŝŶĐĂƐĞƚŚĞƐǇƐƚĞŵ ŝƐŶŽƚŚĞĂƚŝŶŐƚŚĞĨůƵŝĚͬďůŽŽĚͿ͕ƵƐĞƚŚĞ“Self-Test”ĨĞĂƚƵƌĞďǇƉƌĞƐƐŝŶŐƚŚĞŐƌĞĞŶƉƵƐŚďƵƚƚŽŶĨŽƌϯ ƐĞĐŽŶĚƐ͘ x In “Self-Test” mode the blood or fluid flows through the system but is not warmed YŝŶ&ůŽǁtĂƌƌŝŽƌĞǀŝĐĞDĂŝŶƚĞŶĂŶĐĞ Charging: x ƚƚĂĐŚĐŚĂƌŐŝŶŐĂĚĂƉƚŽƌƚŽďĂƚƚĞƌǇŝŶŽƌĚĞƌƚŽĐŽŶŶĞĐƚƚŽƚŚĞĐŚĂƌŐĞƌ͖ƉůƵŐĐŚĂƌŐĞƌŝŶƚŽƚŚĞǁĂůů ŽƵƚůĞƚ x ůůŽǁďĂƚƚĞƌŝĞƐƚŽ&h>>zĐŚĂƌŐĞ;ĂŶĞŵƉƚǇďĂƚƚĞƌǇǁŝůůƚĂŬĞϰͲϱŚŽƵƌƐƚŽĐŚĂƌŐĞͿ x ŚĂƌŐĞƐƚŽƌĞĚďĂƚƚĞƌŝĞƐĞǀĞƌǇϯŵŽŶƚŚƐ Cleaning: x tŝƉĞĚŽǁŶŶŽŶͲĚŝƐƉŽƐĂďůĞƉĂƌƚƐǁŝƚŚĂǀŝǁŝƉĞƐ͖ĚŽŶŽƚƐĂƚƵƌĂƚĞƵŶŝƚ x WůĂĐĞĚŝƐƉŽƐĂďůĞƵŶŝƚŝŶďŝŽŚĂǌĂƌĚƌĞĐĞƉƚĂĐůĞ YŝŶ&ůŽǁtĂƌƌŝŽƌEŽƚĞƐ͗ x tŚŽůĞďůŽŽĚƉƌŽĚƵĐƚƐǁŝůůƐĞƉĂƌĂƚĞĚƵƌŝŶŐƐƚŽƌĂŐĞĂŶĚƐŚŽƵůĚďĞŐĞŶƚůǇŵŝǆĞĚƉƌŝŽƌƚŽŝŶĨƵƐŝŽŶŝŶ ŽƌĚĞƌƚŽĞŶƐƵƌĞĨůŽǁƌĂƚĞƐ͘ x ƐŝŶŐůĞďĂƚƚĞƌǇǁŝůůĚĞůŝǀĞƌϯͲϱůŝƚĞƌƐŽĨǁĂƌŵĞĚĨůƵŝĚͬďůŽŽĚƉƌŽĚƵĐƚ͖battery life is not TIME dependent; it is VOLUME dependent (3-5 L may be infused over 30 minutes or 3 hours…the battery will be depleted when the max volume is reached). ĂƚƚĞƌǇůŝĨĞŝƐŝŵƉĂĐƚĞĚďǇƚĞŵƉĞƌĂƚƵƌĞŽĨĨůƵŝĚƐ ƚŽďĞǁĂƌŵĞĚƵƉĂŶĚĨůŽǁƌĂƚĞ͘ x Do NOT push ANY medications through the system. x dŚĞĚĞǀŝĐĞŵĂǇďĞƉůĂĐĞĚŚŽƌŝǌŽŶƚĂůůǇŽƌǀĞƌƚŝĐĂůůǇ͘ x zŽƵĚŽŶŽƚŚĂǀĞƚŽƌĞƉůĂĐĞƚŚĞĚŝƐƉŽƐĂďůĞƵŶŝƚǁŚĞŶƌĞƉůĂĐŝŶŐƚŚĞďůŽŽĚŽƌĨůƵŝĚďĂŐ͘ x zŽƵĚŽŶŽƚŚĂǀĞƚŽƐŚƵƚŽĨĨƚŚĞƵŶŝƚǁŚĞŶƌĞƉůĂĐŝŶŐƚŚĞĨůƵŝĚďĂŐ x zŽƵĐĂŶĂĚŵŝŶŝƐƚĞƌƐĞǀĞƌĂůĨůƵŝĚďĂŐƐƵƐŝŶŐƚŚĞƐĂŵĞĚŝƐƉŽƐĂďůĞƵŶŝƚ;ƐŝŶŐůĞƉĂƚŝĞŶƚƵƐĞŽŶůǇͿ

Cypress Creek EMS System Policies and Treatment Guidelines

285 PROCEDURE Fluid Warmer Approved: Levon Vartanian, MD

BuddyLite Fluid Warmer ƵĚĚǇ>ŝƚĞWƌŽĐĞĚƵƌĞ ϭ͘ ZĞŵŽǀĞĚŝƐƉŽƐĂďůĞƉŽƌƚŝŽŶŽĨĐŝƌĐƵŝƚĨƌŽŵƉĂĐŬĂŐĞ͕ŽƉĞŶ ŚĞĂƚĞƌ͕ĂŶĚŝŶƐƚĂůůĐŝƌĐƵŝƚŝŶŚĞĂƚĞƌ;ZĞĚƌŝŶŐŽŶĐŝƌĐƵŝƚůŝŶĞƐƵƉ ǁŝƚŚƌĞĚŵĂƌŬŝŶŐŽŶŚĞĂƚĞƌĂƐƐŚŽǁŶŝŶFigure 1ƚŽƌŝŐŚƚͿ͘ Ϯ͘ ůŝŐŶŽƌŝĞŶƚĂƚŝŽŶŶŽƚĐŚĞƐŽŶĚĞǀŝĐĞǁŝƚŚƉŝŶƐŽŶƚŚĞŚĞĂƚĞƌƵŶŝƚ ϯ͘ ůŽƐĞůĂƚĐŚĂŶĚŚĞĂƚĞƌĐĂƐĞ ϰ͘ ƚƚĂĐŚĨůƵŝĚǀŝĂĂĚŵŝŶŝƐƚƌĂƚŝŽŶƐĞƚƚŽƚŚĞĚŝƐƉŽƐĂďůĞůƵĞƌĨŝƚƚŝŶŐ ǁŝƚŚďůƵĞƐůŝĚĞĐůĂŵƉ ϱ͘ WƌŝŵĞƚŚĞƵŶŝƚǁŝƚŚŶŽƌŵĂůƐĂůŝŶĞŽƌWůĂƐŵĂůǇƚĞͲ͕ĞŶƐƵƌŝŶŐŶŽ ǀŝƐŝďůĞĂŝƌďƵďďůĞƐ͕ƚĂƉƉŝŶŐŽŶƚŚĞŚĞĂƚĞƌƵŶŝƚƚŽĞŶƐƵƌĞŶŽĂŝƌ ďƵďďůĞƐ ϲ͘ dƵƌŶŽŶŚĞĂƚĞƌƵŶŝƚ ϳ͘ dŚĞ>h>ƚƵƌŶƐŽŶĂŶĚƌĞĚĨůĂƐŚĞƐŽŶĐĞ;ŝĨŶŽƚƚŚĞĚĞǀŝĐĞŝƐŶŽƚǁŽƌŬŝŶŐƉƌŽƉĞƌůǇͿ ϴ͘ ƚƚĂĐŚŵĂůĞůƵĞƌĨŝƚƚŝŶŐƚŽƚŚĞĞǆƚĞŶƐŝŽŶƐĞƚĂŶĚĂĚũƵƐƚƌŽůůĞƌĐůĂŵƉƐƚŽĚĞƐŝƌĞĚĨůŽǁƌĂƚĞ ϵ͘ ^ĞĐƵƌĞƚŚĞƐǇƐƚĞŵĂƚŽƌďĞůŽǁƚŚĞůĞǀĞůŽĨƚŚĞŝŶƐĞƌƚŝŽŶƐŝƚĞ ϭϬ͘ DŽŶŝƚŽƌĚĞǀŝĐĞĂŶĚŵĂŬĞĐŽƌƌĞĐƚŝŽŶƐĂƐŶĞĞĚĞĚ ƵĚĚǇ>ŝƚĞWĞĂƌůƐ x hƐĞŽŶůǇWůĂƐŵĂůǇƚĞ͕ŶŽƌŵĂůƐĂůŝŶĞ͕ŽƌĂŶƚŝĐŽĂŐƵůĂƚĞĚďůŽŽĚŝŶƚŚĞĚĞǀŝĐĞ͘>ĂĐƚĂƚĞĚZŝŶŐĞƌƐŵĂǇŶŽƚ ďĞŵŝǆĞĚǁŝƚŚďůŽŽĚƉƌŽĚƵĐƚƐŝŶƚŚŝƐŚĞĂƚĞƌĚĞǀŝĐĞ͘ x ŽŶƐŝĚĞƌĐŽǀĞƌŝŶŐďĂƚƚĞƌǇƉĂĐŬŚŽƵƐŝŶŐǁŝƚŚĂƉůĂƐƚŝĐďĂŐƚŽůŝŵŝƚďŽĚǇƐƵďƐƚĂŶĐĞĐŽŶƚĂŵŝŶĂƚŝŽŶ͘ x ĞƐƚŝŶĨƵƐŝŽŶƌĂƚĞƐĨŽƌŚĞĂƚĞĚĨůƵŝĚƐ x ŚŝůůĞĚĨůƵŝĚƐ ϱϬŵůͬŵŝŶƵƚĞ x ZŽŽŵƚĞŵƉĞƌĂƚƵƌĞĨůƵŝĚƐ ϴϬŵůͬŵŝŶƵƚĞ x WƌĞƐƐƵƌĞďĂŐŵĂǇďĞƵƐĞĚ͕ĚŽŶŽƚŝŶĨůĂƚĞŽǀĞƌϮϴϬŵŵ,Ő

Cypress Creek EMS System Policies and Treatment Guidelines

286 PROCEDURES Revised 10/2019 Treatment Approved: Levon Vartanian, MD

Chest Decompression Revised 10/2019 Indications Equipment Needed Tension pneumothorax as evidenced by: SPEAR or ARS Needle x Hemodynamic compromise evidenced by weak or absent radial Decompression device pulse, hypotension, or other evidence of diminished perfusion (such as pale/cool/clammy skin or acutely altered mental status). 14 ga. × 1 ¼ in. IV catheter Along with one or more of: for pediatrics. x Respiratory distress or poor compliance with assisted ventilations. x Markedly diminished or absent breath sounds. Chlorhexidine swab x Ultrasound identification of pneumothorax with hemodynamic compromise.

Procedure 1. Provide airway management and oxygen therapy appropriate to patient condition. 2. Locate Site: The preferred site for the catheter insertion is the anterior approach through the second or third intercostal space on the mid-clavicular line. The alternate site is the lateral approach through the fifth intercostal space on the anterior axillary line. 3. Cleanse site with the chlorhexidine swab. 4. Insert decompression needle through skin at a 90϶ angle over the superior border of the rib below the selected insertion site. Insert needle into thoracic cavity. At this point, tension may release. If using the SPEAR Needle Decompression device, a whistling sound may be heard as air escapes. If using the ARS Needle Decompression device or 14 ga. IV catheter, listen for a rush of air. 5. Release catheter from needle (if using SPEAR Needle Decompression device, disconnect the spin lock a ¼ turn). 6. Advance catheter towards middle of clavicle using the needle as a station guide. 7. Remove needle when catheter has been fully inserted. 8. If using the SPEAR Needle Decompression device, remove the one-way valve from the proximal end of the needle and attach to catheter. 9. Secure catheter in place, if necessary, using tape. 10. Breath sounds and hemodynamic status should be re-evaluated frequently after inserting and securing the device. 11. If patient’s condition does not improve or deteriorates after the initial treatment, evaluate the catheter for a possible obstruction by flushing 1 ml of normal saline into the catheter. 12. If needed, a second needle decompression device may be inserted in the chest wall adjacent to the first or at an alternate site. 13. If patient is peri-arrest, consider Instrument Thoracostomy.

Cypress Creek EMS System Policies and Treatment Guidelines

287 PROCEDURES Revised 10/2019 Treatment Approved: Levon Vartanian, MD

Pearls x During a traumatic arrest if any possibility of chest trauma is present, perform bilateral chest decompressions or Instrument Thoracostomy. x For any pediatric patients under 13 years old, utilize 14 ga. × 1 ¼ in. IV catheter. x Consider utilizing a syringe and/or extension set as adjuncts to assist in placing, securing, and maintaining needle decompression. x For patients who have sustained blunt or penetrating trauma to the chest in the past twenty-four hours, evaluate for tension pneumothorax and reassess throughout care. x Any patient receiving positive pressure ventilation (with a BVM or a ventilator) is at risk for rapidly developing a tension pneumothorax. Close monitoring and frequent reassessments of patient are critical to recognition and rapid treatment. x Simple pneumothorax does not require chest decompression; however, these patients should be monitored closely for potential deterioration. x Pulmonary ultrasound may be used to confirm pneumothorax, evidenced by absent lung sliding, a lung point finding, and barcode sign on M-Mode. However, do not delay treatment for this exam or rely solely on this exam.

Needle Decompression Device Sizes Device Diameter Length SPEAR Needle Decompression Device 10 ga. 3.75 in (preferred) IV catheter (pediatrics < 13 years old) 14 ga. 1.25 in ARS Needle Decompression Device 14 ga. 3.25 in

Parts of SPEAR Needle Decompression Device

Cypress Creek EMS System Policies and Treatment Guidelines

288 PROCEDURES Revised 8/2016 Treatment Approved: Levon Vartanian, MD

EĂƐŽŐĂƐƚƌŝĐͬKƌŽŐĂƐƚƌŝĐdƵďĞ/ŶƐĞƌƚŝŽŶ Indications Equipment needed WĂƚŝĞŶƚǁŝƚŚĂĚǀĂŶĐĞĚĂŝƌǁĂǇƉůĂĐĞĚĂŶĚ ƉƉƌŽƉƌŝĂƚĞůǇƐŝǌĞĚŐĂƐƚƌŝĐƚƵďĞ;ŵĂǆŝŵƵŵƐŝǌĞ ƌŝƐŬŽĨŽƌƐƵƐƉĞĐƚĞĚŐĂƐƚƌŝĐĚŝƐƚĞŶƚŝŽŶ͘ ŽĨϭϴ&ƌŝĨƵƐŝŶŐ<ŝŶŐ>d^ͲŐĂƐƚƌŝĐĂĐĐĞƐƐ Contraindications: ĐŚĂŶŶĞůͿ͘ tĂƚĞƌͲƐŽůƵďůĞůƵďƌŝĐĂŶƚŽƌ>ŝĚŽĐĂŝŶĞϮйũĞůůǇ͘ x ^ŝŐŶƐŽĨĂďĂƐŝůĂƌƐŬƵůůĨƌĂĐƚƵƌĞ͘ >ĂƌŐĞĐĂƚŚĞƚĞƌͲƚŝƉƉĞĚƐǇƌŝŶŐĞ x DŝĚͲĨĂĐĞͬ>Ğ&ŽƌƚĨƌĂĐƚƵƌĞƐ ^ƵĐƚŝŽŶĚĞǀŝĐĞ x ƐŽƉŚĂŐĞĂůďůĞĞĚŝŶŐŽƌĚŝƐĞĂƐĞ

/ŶƐĞƌƚŝŶŐEĂƐŽŐĂƐƚƌŝĐdƵďĞ ϭ͘ ^ĞůĞĐƚŵŽƐƚĂƉƉƌŽƉƌŝĂƚĞŶŽƐƚƌŝůĨŽƌŝŶƐĞƌƚŝŽŶ͘ Ϯ͘ DĞĂƐƵƌĞƚƵďĞĨƌŽŵƚŝƉŽĨƚŚĞŶŽƐĞƚŽƚŚĞĞĂƌůŽďĞ͕ƚŚĞŶƚŽǆŝƉŚŽŝĚƉƌŽĐĞƐƐƚŽĚĞƚĞƌŵŝŶĞĂƉƉƌŽƉƌŝĂƚĞ ůĞŶŐƚŚ͘DĂƌŬƚŚĞĚĞƉƚŚƉƌŝŽƌƚŽŝŶƐĞƌƚŝŽŶ͘ ϯ͘ >ƵďƌŝĐĂƚĞĨŝƌƐƚĨŽƵƌŝŶĐŚĞƐŽĨƚŚĞƚƵďĞǁŝƚŚǁĂƚĞƌͲƐŽůƵďůĞůƵďƌŝĐĂŶƚŽƌ>ŝĚŽĐĂŝŶĞϮйũĞůůǇ͘ ϰ͘ /ŶƐĞƌƚƚƵďĞĂŝŵĞĚƉŽƐƚĞƌŝŽƌůǇƚŽďĂĐŬŽĨƚŚƌŽĂƚ͕ƚŚĞŶĐŽŶƚŝŶƵĞŝŶƐĞƌƚŝŶŐĐĂƵĚĂůůǇƚŽŵĂƌŬĞĚĚĞƉƚŚ͘ ϱ͘ ŚĞĐŬĨŽƌƉƌŽƉĞƌƉůĂĐĞŵĞŶƚďǇŝŶũĞĐƚŝŶŐϮϬʹϯϬĐĐŽĨĂŝƌƵƐŝŶŐƐǇƌŝŶŐĞǁŚŝůĞĂƵƐĐƵůƚĂƚŝŶŐŽǀĞƌ ĞƉŝŐĂƐƚƌŝƵŵ͘ ϲ͘ ^ĞĐƵƌĞŝŶƉůĂĐĞďǇƚĂƉŝŶŐƚŽŶŽƐĞŽƌƚŽĂĚǀĂŶĐĞĚĂŝƌǁĂǇĚĞǀŝĐĞ͘ ϳ͘ ƚƚĂĐŚͬĂƉƉůǇƐƵĐƚŝŽŶƚŽƌĞůŝĞǀĞŐĂƐƚƌŝĐĚŝƐƚĞŶƚŝŽŶŝĨŶĞĞĚĞĚ͘ /ŶƐĞƌƚŝŶŐKƌŽŐĂƐƚƌŝĐdƵďĞ ϭ͘ DĞĂƐƵƌĞƚƵďĞĨƌŽŵĐŽƌŶĞƌŽĨƚŚĞŵŽƵƚŚ;ŽƌƚŝƉŽĨ<ŝŶŐ>d^ͲƐƵƉƌĂŐůŽƚƚŝĐĂŝƌǁĂǇͿƚŽƚŚĞĞĂƌůŽďĞ͕ ƚŚĞŶƚŽǆŝƉŚŽŝĚƉƌŽĐĞƐƐƚŽĚĞƚĞƌŵŝŶĞĂƉƉƌŽƉƌŝĂƚĞůĞŶŐƚŚ͘DĂƌŬƚŚĞĚĞƉƚŚƉƌŝŽƌƚŽŝŶƐĞƌƚŝŽŶ͘ Ϯ͘ >ƵďƌŝĐĂƚĞĨŝƌƐƚĨŽƵƌŝŶĐŚĞƐŽĨƚŚĞƚƵďĞǁŝƚŚǁĂƚĞƌͲƐŽůƵďůĞůƵďƌŝĐĂŶƚ͘ ϯ͘ /ŶƐĞƌƚƚƵďĞĂŝŵĞĚƉŽƐƚĞƌŝŽƌůǇƚŽďĂĐŬŽĨƚŚƌŽĂƚ͕ƚŚĞŶĐŽŶƚŝŶƵĞŝŶƐĞƌƚŝŶŐĐĂƵĚĂůůǇƚŽŵĂƌŬĞĚĚĞƉƚŚ͘ ϰ͘ ůƚĞƌŶĂƚŝǀĞůǇ͕ŝŶƐĞƌƚƚƵďĞƚŚƌŽƵŐŚŐĂƐƚƌŝĐĂĐĐĞƐƐĐŚĂŶŶĞůŽĨ<ŝŶŐ>d^ͲƐƵƉƌĂŐůŽƚƚŝĐĂŝƌǁĂǇ͘ ϱ͘ ŚĞĐŬĨŽƌƉƌŽƉĞƌƉůĂĐĞŵĞŶƚďǇŝŶũĞĐƚŝŶŐϮϬʹϯϬĐĐŽĨĂŝƌƵƐŝŶŐƐǇƌŝŶŐĞǁŚŝůĞĂƵƐĐƵůƚĂƚŝŶŐŽǀĞƌ ĞƉŝŐĂƐƚƌŝƵŵ͘ ϲ͘ ^ĞĐƵƌĞŝŶƉůĂĐĞďǇƚĂƉŝŶŐƚŽŶŽƐĞŽƌƚŽĂĚǀĂŶĐĞĚĂŝƌǁĂǇĚĞǀŝĐĞ͘ ϳ͘ ƚƚĂĐŚͬĂƉƉůǇƐƵĐƚŝŽŶƚŽƌĞůŝĞǀĞŐĂƐƚƌŝĐĚŝƐƚĞŶƚŝŽŶŝĨŶĞĞĚĞĚ͘ WĞĂƌůƐ x ^ƵƐƉĞĐƚŐĂƐƚƌŝĐĚŝƐƚĞŶƚŝŽŶŝŶĂŶǇƉĂƚŝĞŶƚǁŚŽŚĂƐƌĞĐĞŝǀĞĚƉŽƐŝƚŝǀĞƉƌĞƐƐƵƌĞǀĞŶƚŝůĂƚŝŽŶƐǁŝƚŚĂĂŐͲ sĂůǀĞͲDĂƐŬĚĞǀŝĐĞ͘

Cypress Creek EMS System Policies and Treatment Guidelines

289 PROCEDURES Revised 8/2016 Treatment Approved: Levon Vartanian, MD

ŚŝůĚďŝƌƚŚ Indications Equipment Needed /ŵŵŝŶĞŶƚĚĞůŝǀĞƌǇǁŝƚŚĐƌŽǁŶŝŶŐ K<ŝƚ

WƌŽĐĞĚƵƌĞ ϭ͘ ƐůŽǁ͕ĐŽŶƚƌŽůůĞĚĚĞůŝǀĞƌǇŝƐŝŵƉŽƌƚĂŶƚƚŽƉƌĞǀĞŶƚŝŶũƵƌǇƚŽŵŽƚŚĞƌĂŶĚŝŶĨĂŶƚ͘ Ϯ͘ ^ƵƉƉŽƌƚƚŚĞŝŶĨĂŶƚ͛ƐŚĞĂĚ͘ ϯ͘ ŚĞĐŬƚŽƐĞĞŝĨƵŵďŝůŝĐĂůĐŽƌĚŝƐĂƌŽƵŶĚŶĞĐŬ;ŶƵĐŚĂůĐŽƌĚͿ͘/ĨƉƌĞƐĞŶƚ͕ƐůŝƉŽǀĞƌŚĞĂĚ͖ŝĨƚŚŝƐŝƐŶ͛ƚ ƉŽƐƐŝďůĞ͕ĚŽƵďůĞĐůĂŵƉĐŽƌĚĂŶĚĐƵƚďĞƚǁĞĞŶĐůĂŵƉƐďĞĨŽƌĞƉƌŽĐĞĞĚŝŶŐǁŝƚŚĚĞůŝǀĞƌǇ͘ ϰ͘ ^ƵĐƚŝŽŶĂŝƌǁĂǇǁŝƚŚďƵůďƐǇƌŝŶŐĞǁŚĞŶŝƚƉƌĞƐĞŶƚƐ ϱ͘ 'ƌĂƐƉŝŶŐŚĞĂĚ͕ƉƵůůĚŽǁŶŐĞŶƚůǇƚŽĚĞůŝǀĞƌĂŶƚĞƌŝŽƌƐŚŽƵůĚĞƌ͘ ϲ͘ WƵůůƵƉŐĞŶƚůǇƚŽĚĞůŝǀĞƌƉŽƐƚĞƌŝŽƌƐŚŽƵůĚĞƌ͘ ϳ͘ ^ůŽǁůǇĚĞůŝǀĞƌƌĞŵĂŝŶĚĞƌŽĨŝŶĨĂŶƚ͘ ϴ͘ ƌǇŝŶĨĂŶƚŽĨĨĂŶĚǁƌĂƉŝŶǁĂƌŵďůĂŶŬĞƚ͘WůĂĐĞǁĂƌŵŚĂƚŽŶŝŶĨĂŶƚ͘ ϵ͘ ůĂŵƉƚŚĞĐŽƌĚϮŝŶĐŚĞƐĨƌŽŵƚŚĞŝŶĨĂŶƚ͛ƐĂďĚŽŵĞŶǁŝƚŚƚǁŽĐůĂŵƉƐĂŶĚĐƵƚƚŚĞĐŽƌĚďĞƚǁĞĞŶƚŚĞ ƚǁŽĐůĂŵƉƐ͘ ϭϬ͘ ZĞĐŽƌĚW'ZƐĐŽƌĞƐĂƚϭĂŶĚϱŵŝŶƵƚĞƐ͘ ϭϭ͘ &ŽůůŽǁnewborn resuscitationŝĨŶĞĞĚĞĚ͘ ϭϮ͘ dŚĞƉůĂĐĞŶƚĂǁŝůůƚǇƉŝĐĂůůǇĚĞůŝǀĞƌƐƉŽŶƚĂŶĞŽƵƐůǇ͘ŽŶŽƚĨŽƌĐĞŝƚƚŽĚĞůŝǀĞƌ͘dƌĂŶƐƉŽƌƚƉůĂĐĞŶƚĂǁŝƚŚ ŵŽƚŚĞƌ͘ ϭϯ͘ DĂƐƐĂŐŝŶŐƚŚĞƵƚĞƌƵƐ;ĨƵŶĚĂůŵĂƐƐĂŐĞͿŵĂǇĨĂĐŝůŝƚĂƚĞĚĞůŝǀĞƌǇŽĨƉůĂĐĞŶƚĂĂŶĚĚĞĐƌĞĂƐĞďůĞĞĚŝŶŐ͘ ϭϰ͘ /ĨƐĞǀĞƌĞŚĞŵŽƌƌŚĂŐĞĐŽŶƚŝŶƵĞƐĂĨƚĞƌĚĞůŝǀĞƌǇŽĨƉůĂĐĞŶƚĂ͕ĂĚŵŝŶŝƐƚĞƌOxytocin (Pitocin) 20 units in 1000 mL NS rapid infusion IV/IO. ϭϱ͘ WƌŽǀŝĚĞƐĂĨĞ͕ƌĂƉŝĚƚƌĂŶƐƉŽƌƚƚŽƚŚĞŚŽƐƉŝƚĂů͘ŶƐƵƌĞŵŽƚŚĞƌĂŶĚŝŶĨĂŶƚĂƌĞƉƌŽƉĞƌůǇƐĞĐƵƌĞĚĨŽƌ ƚƌĂŶƐƉŽƌƚ͘

Cypress Creek EMS System Policies and Treatment Guidelines

290 PROCEDURES Revised 8/2016 Treatment Approved: Levon Vartanian, MD

ǇĞ/ƌƌŝŐĂƚŝŽŶ Indications Equipment Needed ŚĞŵŝĐĂůĐŽŶƚĂŵŝŶĂƚŝŽŶŝŶĞǇĞ DŽƌŐĂŶůĞŶƐ ƵƌŶƚŽĞǇĞ EŽƌŵĂů^ĂůŝŶĞϭϬϬϬŵ>ďĂŐ ϭϬŐƚƚĚƌŝƉƐĞƚ WƌŽĐĞĚƵƌĞ ϭ͘ ZĞŵŽǀĞĂŶǇĐŽŶƚĂĐƚůĞŶƐĞƐ͕ŝĨƉƌĞƐĞŶƚ͘ Ϯ͘ ƉƉůǇdĞƚƌĂĐĂŝŶĞƚŽĂĨĨĞĐƚĞĚĞǇĞ;ƐͿƉĞƌƉƌŽƚŽĐŽů͘ ϯ͘ ƚƚĂĐŚDŽƌŐĂŶ>ĞŶƐĚĞůŝǀĞƌǇƐĞƚƚŽ/sůŝŶĞĂŶĚƐƚĂƌƚĨůŽǁ͘ ϰ͘ ,ĂǀĞƉĂƚŝĞŶƚůŽŽŬĚŽǁŶ͕ŝŶƐĞƌƚůĞŶƐƵŶĚĞƌƵƉƉĞƌůŝĚ͘ ϱ͘ ,ĂǀĞƉĂƚŝĞŶƚůŽŽŬƵƉĂŶĚĚƌŽƉůĞŶƐŝŶƉůĂĐĞ͘ ϲ͘ ZĞůĞĂƐĞůŽǁĞƌůŝĚŽǀĞƌůĞŶƐĂŶĚĂĚũƵƐƚĨůŽǁ͘ ϳ͘ dĂƉĞƚƵďŝŶŐƚŽƉĂƚŝĞŶƚ͛ƐĨŽƌĞŚĞĂĚƚŽƉƌĞǀĞŶƚĂĐĐŝĚĞŶƚĂůůĞŶƐƌĞŵŽǀĂů͘ ϴ͘ ďƐŽƌďŽƵƚĨůŽǁǁŝƚŚƚŽǁĞůŽƌŽƚŚĞƌĂďƐŽƌďĞŶƚŵĂƚĞƌŝĂů͘ ϵ͘ ŽŶŽƚƌƵŶĚƌǇ͘ ϭϬ͘ /ƌƌŝŐĂƚĞǁŝƚŚĂƚůĞĂƐƚϭůŝƚĞƌ;ϭϬϬϬŵ>ͿŽĨƐƚĞƌŝůĞƐŽůƵƚŝŽŶ͘ ZĞŵŽǀĂů ϭ͘ ŽŶƚŝŶƵĞĨůŽǁĂŶĚŚĂǀĞƉĂƚŝĞŶƚůŽŽŬƵƉ Ϯ͘ ZĞƚƌĂĐƚůŽǁĞƌůŝĚĂŶĚŚŽůĚƉŽƐŝƚŝŽŶ ϯ͘ ^ůŝĚĞůĞŶƐŽƵƚĂŶĚƚĞƌŵŝŶĂƚĞĨůŽǁ

Cypress Creek EMS System Policies and Treatment Guidelines

291 PROCEDURES Revised 6/2019 Treatment Approved: Levon Vartanian, MD

WĂŝŶDĂŶĂŐĞŵĞŶƚ Indications Assessment Requirements ĐƵƚĞƉĂŝŶƌĞůĂƚĞĚƚŽ͗ WƌŝŵĂƌǇƐƵƌǀĞǇ DƵƐĐƵůŽƐŬĞůĞƚĂůŝŶũƵƌǇ͕ sŝƚĂůƐŝŐŶƐ DƵůƚŝͲƐǇƐƚĞŵƚƌĂƵŵĂ͕ '͕^ƉKϮĂŶĚdKϮŵŽŶŝƚŽƌŝŶŐ <ŝĚŶĞǇƐƚŽŶĞƐ͕ WĂŝŶƐĐŽƌĞ;ƉƌĞĂŶĚƉŽƐƚŝŶƚĞƌǀĞŶƚŝŽŶͿ ĂƌĚŝĂĐͲƌĞůĂƚĞĚĐŽŶĚŝƚŝŽŶƐ͕ ůĞĐƚƌŝĐĂůƚŚĞƌĂƉŝĞƐ;Ğ͘Ő͘ƉĂĐŝŶŐŽƌ ĚĞĨŝďƌŝůůĂƚŝŽŶͿ͕ ŚƌŽŶŝĐŝůůŶĞƐƐͬĚŝƐĞĂƐĞ;Ğ͘Ő͘ĐĂŶĐĞƌ͕ƐŝĐŬůĞĐĞůů ĐƌŝƐŝƐͿ͕ KƚŚĞƌĂĐƵƚĞŝůůŶĞƐƐŽƌŝŶũƵƌǇǁŝƚŚŽďǀŝŽƵƐ ƐŝŐŶƐŽĨƐĞǀĞƌĞƉĂŝŶ 'ŽĂůƐŽĨWĂŝŶDĂŶĂŐĞŵĞŶƚ x ĞĐƌĞĂƐŝŶŐůĞǀĞůƐŽĨƉĂŝŶĨŽƌĂĐƵƚĞŝŶũƵƌǇŽƌŝůůŶĞƐƐ x WƌŽǀŝĚŝŶŐĐŽŵĨŽƌƚĂŶĚƉĂŝŶƌĞĚƵĐƚŝŽŶƌĞůĂƚĞĚƚŽD^ŝŶƚĞƌǀĞŶƚŝŽŶƐ͕ƚƌĂŶƐƉŽƌƚĂƚŝŽŶ͕ĂŶĚĨŽƌ ĐŽŶƚŝŶƵŝƚǇŽĨĐĂƌĞĂƚƚŚĞŚŽƐƉŝƚĂů WŚĂƌŵĂĐŽůŽŐŝĐĂůƉĂŝŶŵĂŶĂŐĞŵĞŶƚƐŚŽƵůĚďĞƵƐĞĚĂĨƚĞƌŽƌŝŶĐŽŶũƵŶĐƚŝŽŶǁŝƚŚďĂƐŝĐƉĂŝŶŵĂŶĂŐĞŵĞŶƚ ƚŚĞƌĂƉŝĞƐƐƵĐŚĂƐ͗

x ZĞĂƐƐƵƌĂŶĐĞĂŶĚĞŵƉĂƚŚǇ x WůĂĐŝŶŐƉĂƚŝĞŶƚŝŶƉŽƐŝƚŝŽŶŽĨĐŽŵĨŽƌƚ x WĂĚĚŝŶŐ͕ƉŝůůŽǁƐ͕ďůĂŶŬĞƚƐ͕ĂŶĚƚŽǁĞůƌŽůůƐ x ŽůĚͬŚŽƚƉĂĐŬƐ x ^ƉůŝŶƚŝŶŐͬŝŵŵŽďŝůŝǌĂƚŝŽŶ;ŝŶĐůƵĚŝŶŐƚƌĂĐƚŝŽŶƐƉůŝŶƚͿ ŽŶƚƌĂŝŶĚŝĐĂƚŝŽŶƐĨŽƌWĂŝŶDĂŶĂŐĞŵĞŶƚ WĂƚŝĞŶƚƐĞǆƉĞƌŝĞŶĐŝŶŐƐĞǀĞƌĞƉĂŝŶƌĞůĂƚĞĚƚŽĂŶĂĐƵƚĞŝůůŶĞƐƐŽƌŝŶũƵƌǇƐŚŽƵůĚƌĞĐĞŝǀĞƉĂŝŶŵĂŶĂŐĞŵĞŶƚ͘ ,ŽǁĞǀĞƌ͕ĐĂƵƚŝŽŶƐŚŽƵůĚďĞƵƐĞĚǁŚĞŶĐŽŶƐŝĚĞƌŝŶŐƉĂŝŶŵĞĚŝĐĂƚŝŽŶƐĨŽƌƚŚĞĨŽůůŽǁŝŶŐƉĂƚŝĞŶƚƐ͗ x ůĐŽŚŽůŽƌĚƌƵŐŝŶƚŽǆŝĐĂƚŝŽŶ x ůƚĞƌĞĚŵĞŶƚĂůƐƚĂƚƵƐ x /ƐŽůĂƚĞĚŚĞĂĚŝŶũƵƌǇ x ^ƵƐƉĞĐƚĞĚƐƚƌŽŬĞ x /ƐŽůĂƚĞĚŚĞĂĚĂĐŚĞ x ďĚŽŵŝŶĂůƉĂŝŶŽĨƵŶŬŶŽǁŶĞƚŝŽůŽŐǇΎ x WƌĞŐŶĂŶĐǇΎΎ ΎZƵůĞŽƵƚŽƚŚĞƌƉŽƐƐŝďůĞĐĂƵƐĞƐŽĨĂďĚŽŵŝŶĂůƉĂŝŶ͖ĚŽĐƵŵĞŶƚĂƚŝŽŶŵƵƐƚƐƵƉƉŽƌƚĂƐƉĞĐŝĨŝĐĚŝĨĨĞƌĞŶƚŝĂů ĚŝĂŐŶŽƐŝƐǁŚĞŶƚƌĞĂƚŝŶŐĨŽƌĂƉƌŽďĂďůĞĐĂƵƐĞŽĨĂďĚŽŵŝŶĂůƉĂŝŶ

Cypress Creek EMS System Policies and Treatment Guidelines

292 PROCEDURES Revised 6/2019 Treatment Approved: Levon Vartanian, MD

ΎΎ^ĞĞPregnancy and Obstetrical Emergency ƉƌŽƚŽĐŽů ǀĂŝůĂďůĞdƌĞĂƚŵĞŶƚKƉƚŝŽŶƐ x (P) Vascular access ǁŝƚŚ/sͬ/KĂƐĂƉƉƌŽƉƌŝĂƚĞ x (B) Acetaminophen Ϭ͘ϱʹϭŐŵWK͕ĞǀĞƌǇϰͲϲŚŽƵƌƐ͕ĨŽƌŵŝůĚƚŽŵŽĚĞƌĂƚĞƉĂŝŶ͘DĂǇďĞƵƐĞĚŝŶ ĐŽŶũƵŶĐƚŝŽŶǁŝƚŚŽƉŝŽŝĚƐ͘ x (P) Ketorolac (for mild to moderate pain level) x ĚƵůƚ͗ϭϱʹϯϬŵŐ/sŽƌϯϬʹϲϬŵŐ/D x WĞĚŝĂƚƌŝĐ;хϭϬǇĞĂƌƐͿ͗ϭϬʹϭϱŵŐ/DŽƌ/s x ŽŶŽƚĂĚŵŝŶŝƐƚĞƌƚŽƉĂƚŝĞŶƚƐǁŝƚŚƉŽƚĞŶƚŝĂůďůĞĞĚŝŶŐ͘ x (P) Morphine Sulfate (for moderate to severe pain) x ĚƵůƚ͗ϮʹϱŵŐ/s͕ƌĞƉĞĂƚĂƐŶĞĞĚĞĚƵƉƚŽĂŵĂǆŝŵƵŵĚŽƐĞŽĨϭϱŵŐƚŽƚĂů x WĞĚŝĂƚƌŝĐ͗Ϭ͘ϬϱʹϬ͘ϭŵŐͬŬŐ/s͕ƌĞƉĞĂƚĂƐŶĞĞĚĞĚ x (P) Fentanyl (for moderate to severe pain) x ĚƵůƚ͗Ϭ͘ϱʹϭŵĐŐͬŬŐƐůŽǁ/sͬ/E͕ƌĞƉĞĂƚĂƐŶĞĞĚĞĚƵƉƚŽĂŵĂǆŝŵƵŵƚŽƚĂůĚŽƐĞŽĨϯŵĐŐͬŬŐ x WĞĚŝĂƚƌŝĐ͗Ϭ͘ϱŵĐŐͬŬŐƐůŽǁ/sͬ/E͕ƌĞƉĞĂƚĂƐŶĞĞĚĞĚƵƉƚŽĂŵĂǆŝŵƵŵƚŽƚĂůĚŽƐĞŽĨϮŵĐŐͬŬŐŽƌ ϭϬϬŵĐŐ x (P) Ketamine (for severe pain caused by traumatic injuries not relieved by Fentanyl or Morphine) x Ϭ͘ϯʹϬ͘ϱŵŐͬŬŐ/sͬ/Eͬ/K WĞĂƌůƐ x ŽŶƐŝĚĞƌĂĚŵŝŶŝƐƚĞƌŝŶŐPromethazineŽƌOndansetronĨŽƌƉƌŽĨŽƵŶĚŶĂƵƐĞĂŽƌǀŽŵŝƚŝŶŐƌĞůĂƚĞĚƚŽ ĂĚŵŝŶŝƐƚƌĂƚŝŽŶŽĨƉĂŝŶŵĂŶĂŐĞŵĞŶƚŵĞĚŝĐĂƚŝŽŶƐ͘ x ĞǁĂƌĞŽĨƐǇŶĞƌŐŝƐƚŝĐĞĨĨĞĐƚǁŚĞŶĐŽŵďŝŶŝŶŐPromethazineǁŝƚŚMorphine or FentanylǁŚŝĐŚŵĂǇ ĐĂƵƐĞƐŝŐŶŝĨŝĐĂŶƚĚĞĐƌĞĂƐĞŝŶůĞǀĞůŽĨĐŽŶƐĐŝŽƵƐŶĞƐƐ͕ƌĞƐƉŝƌĂƚŽƌǇĚĞƉƌĞƐƐŝŽŶ͕ĂŶĚͬŽƌŚǇƉŽƚĞŶƐŝŽŶ͘ x FentanylŝƐƚŚĞƉƌĞĨĞƌƌĞĚĚƌƵŐĨŽƌƚƌĂƵŵĂƚŝĐŝŶũƵƌŝĞƐĚƵĞƚŽŝƚƐƌĂƉŝĚŽŶƐĞƚĂŶĚƐŚŽƌƚĚƵƌĂƚŝŽŶŽĨ ĂĐƚŝŽŶ͘ x Morphine ŝƐƚŚĞƉƌĞĨĞƌƌĞĚĚƌƵŐĨŽƌďƵƌŶƐ͘ x FentanylŵĂǇďĞĂĚŵŝŶŝƐƚĞƌĞĚƚŽƉĂƚŝĞŶƚƐƚŚĂƚĂƌĞĂůůĞƌŐŝĐƚŽMorphine͕ŚŽǁĞǀĞƌ͕ƌĞŵĂŝŶƉƌĞƉĂƌĞĚ ĨŽƌĂƉŽƐƐŝďůĞĂůůĞƌŐŝĐƌĞĂĐƚŝŽŶ͘ x WĂŝŶŵĂŶĂŐĞŵĞŶƚŵĂǇďĞŝŶĚŝĐĂƚĞĚĂŶĚƉƌŽǀŝĚĞĚŝŶŵƵůƚŝƉůĞƐǇƐƚĞŵƚƌĂƵŵĂ͖ƵƐĞĞǆƚƌĞŵĞĐĂƵƚŝŽŶ ǁŚĞŶĂĚŵŝŶŝƐƚĞƌŝŶŐƚŽĂƉĂƚŝĞŶƚǁŝƚŚĂƉŽƐƐŝďůĞŚĞĂĚŝŶũƵƌǇ͘ x /ŶƚƵďĂƚŝŽŶĞƋƵŝƉŵĞŶƚĂŶĚNaloxone ŵƵƐƚďĞƌĞĂĚŝůǇĂǀĂŝůĂďůĞǁŚĞŶĂĚŵŝŶŝƐƚĞƌŝŶŐŶĂƌĐŽƚŝĐƉĂŝŶ ŵĞĚŝĐĂƚŝŽŶƐ͘ x KetamineĂƚĂŶĂůŐĞƐŝĐĚŽƐĞƐƐŚŽƵůĚƌĞĚƵĐĞƉĂŝŶǁŝƚŚŽƵƚƌĞĚƵĐŝŶŐůĞǀĞůŽĨĐŽŶƐĐŝŽƵƐŶĞƐƐ͘ x ŽŶŽƚĂĚŵŝŶŝƐƚĞƌKetorolacƚŽƉĂƚŝĞŶƚƐǁŝƚŚƐƵƐƉĞĐƚĞĚĂĐƚŝǀĞďůĞĞĚŝŶŐ͕ŝŶĐůƵĚŝŶŐƉŽƐƐŝďůĞ '/ͬĂďĚŽŵŝŶĂůďůĞĞĚŝŶŐ͕ůŽŶŐďŽŶĞͬƉĞůǀŝĐĨƌĂĐƚƵƌĞƐ͕ŽƌŝŶũƵƌŝĞƐƚŽƚŚĞŚĞĂĚŽƌƐĐĂůƉ͘ x ŽŶŽƚĂĚŵŝŶŝƐƚĞƌKetamine ĨŽƌƉĂŝŶŵĂŶĂŐĞŵĞŶƚƚŽƉĂƚŝĞŶƚƐǁŝƚŚĂůƚĞƌĞĚŵĞŶƚĂůƐƚĂƚƵƐŽƌŚĞĂĚ ŝŶũƵƌŝĞƐ͘

Cypress Creek EMS System Policies and Treatment Guidelines

293 PROCEDURES Revised 8/2016 Treatment Approved: Levon Vartanian, MD

>ŝĨĞ'ŝĨƚŽŶŽƌZĞĨĞƌƌĂů Indications WĂƚŝĞŶƚŵĞĞƚŝŶŐĐƌŝƚĞƌŝĂƚŽǁŝƚŚŚŽůĚƌĞƐƵƐĐŝƚĂƚŝŽŶ͘ WĂƚŝĞŶƚĨŽůůŽǁŝŶŐField Termination͘ WƵƌƉŽƐĞ ŽŶŽƌƌĞĨĞƌƌĂůĐƌĞĂƚĞƐĂƉŽƐŝƚŝǀĞƐŝƚƵĂƚŝŽŶĨƌŽŵĂĚĞĂƚŚĂŶĚŝƐĂŶŽƉƉŽƌƚƵŶŝƚǇƚŽŝŵƉƌŽǀĞƚŚĞůŽŶŐͲƚĞƌŵ ŚĞĂůƚŚŽĨŽƵƌĐŽŵŵƵŶŝƚǇ͘ WƌŽĐĞĚƵƌĞ ϭ͘ dŚĞĨĂŵŝůǇŵĞŵďĞƌƐƐŚŽƵůĚďĞŶŽƚŝĨŝĞĚŽĨƚŚĞůĂĐŬŽĨƌĞƐƵƐĐŝƚĂƚŝŽŶĞĨĨŽƌƚƐ;ŝĨƚŚĞǇĂƌĞƉƌĞƐĞŶƚͿ͘ Ϯ͘ dŚĞ/ŶͲŚĂƌŐĞWĂƌĂŵĞĚŝĐ;Žƌ&ŝĞůĚ^ƵƉĞƌǀŝƐŽƌͿƐŚŽƵůĚĐĂůů>ŝĨĞ'ŝĨƚĂƚ;ϴϬϬͿϲϯϯͲϲϱϲϮĂŶĚŐŝǀĞƚŚĞŵ ƚŚĞĨŽůůŽǁŝŶŐŝŶĨŽƌŵĂƚŝŽŶ͗ x dŚĞůŽĐĂƚŝŽŶŽĨƚŚĞŝŶĐŝĚĞŶƚ x WĂƚŝĞŶƚŝŶĨŽƌŵĂƚŝŽŶʹŶĂŵĞ͕ĂŐĞ͕ƐĞǆ͕ƌĂĐĞ x DĞĐŚĂŶŝƐŵŽĨŝŶũƵƌǇͬŚŝƐƚŽƌǇŽĨƉƌĞƐĞŶƚŝůůŶĞƐƐ x WĂƐƚŵĞĚŝĐĂůŚŝƐƚŽƌǇ x EĞǆƚŽĨŬŝŶŽƌƌĞƐƉŽŶƐŝďůĞƉĂƌƚǇʹŶĂŵĞĂŶĚƉŚŽŶĞŶƵŵďĞƌ x ŶǇŽƚŚĞƌƌĞůĞǀĂŶƚŽƌƌĞƋƵĞƐƚĞĚŝŶĨŽƌŵĂƚŝŽŶ ϯ͘ 'ŝǀĞ>ŝĨĞ'ŝĨƚǇŽƵƌĐŽŶƚĂĐƚŝŶĨŽƌŵĂƚŝŽŶ͘hƐĞ;ϮϴϭͿϰϰϬͲϬϬϳϵĨŽƌǇŽƵƌĐĂůůďĂĐŬŶƵŵďĞƌ͘ ϰ͘ /ƚŝƐƌĞĐŽŵŵĞŶĚĞĚƚŚĂƚǇŽƵĚŽŶŽƚŶŽƚŝĨǇƚŚĞĨĂŵŝůǇĂďŽƵƚƚŚĞĚŽŶŽƌƌĞĨĞƌƌĂů͘ 5. A donor referral should be done in every situation. ϲ͘ >ŝĨĞ'ŝĨƚǁŝůůƉƌŽǀŝĚĞĨŽůůŽǁƵƉďǇƉŚŽŶĞ;ǁŝƚŚŝŶϮϰŚŽƵƌƐͿĂŶĚďǇůĞƚƚĞƌ;ǁŝƚŚŝŶϯϬĚĂǇƐͿ͘

Cypress Creek EMS System Policies and Treatment Guidelines

294 PROCEDURES Revised 8/2016 Treatment Approved: Levon Vartanian, MD

WĂƚŝĞŶƚĞĐŽŶƚĂŵŝŶĂƚŝŽŶ Indications ŶǇƉĂƚŝĞŶƚǁŚŽŚĂƐďĞĞŶĞǆƉŽƐĞĚƚŽƐŝŐŶŝĨŝĐĂŶƚŚĂǌĂƌĚŽƵƐŵĂƚĞƌŝĂůƐ͘

WƌŽĐĞĚƵƌĞ ϭ͘ ŽŽƌĚŝŶĂƚĞǁŝƚŚ,ĂǌDĂƚ͕&ŝƌĞĞƉĂƌƚŵĞŶƚ͕ĂŶĚŽƚŚĞƌĞŵĞƌŐĞŶĐǇŵĂŶĂŐĞŵĞŶƚƚŽĞƐƚĂďůŝƐŚŚŽƚ͕ ǁĂƌŵ͕ĂŶĚĐŽůĚǌŽŶĞƐŽĨŽƉĞƌĂƚŝŽŶ͘,ĂǌDĂƚǁŝůůŚĂǀĞůĞĂĚŝŶĚĞƚĞƌŵŝŶŝŶŐƚŚĞďĞƐƚĚĞĐŽŶƚĂŵŝŶĂƚŝŽŶ ƉƌŽĐĞĚƵƌĞƐĨŽƌĂŶŝŶĚŝǀŝĚƵĂůŝŶĐŝĚĞŶƚ͘ Ϯ͘ ŶƐƵƌĞƉĞƌƐŽŶŶĞůŚĂǀĞƉƌŽƉĞƌWWĂŶĚĂĚĞƋƵĂƚĞƚƌĂŝŶŝŶŐ͘D^ƉĞƌƐŽŶŶĞůƐŚŽƵůĚŶŽƚĞŶƚĞƌǁĂƌŵ ĂŶĚŚŽƚǌŽŶĞƐƵŶůĞƐƐƚŚĞǇŚĂǀĞƚŚĞƐƉĞĐŝĨŝĐ͕ƌĞůĞǀĂŶƚƚƌĂŝŶŝŶŐ;,tKWZǁĂƌĞŶĞƐƐͬKƉĞƌĂƚŝŽŶƐ͕ ĞƚĐ͘ͿĂŶĚWWƚŽĚŽƐŽƐĂĨĞůǇ͘ ϯ͘ ĂĐŚƉĂƚŝĞŶƚĨƌŽŵƚŚĞŚŽƚǌŽŶĞƐŚŽƵůĚƵŶĚĞƌŐŽŝŶŝƚŝĂůĚĞĐŽŶƚĂŵŝŶĂƚŝŽŶ͕ǁŚŝĐŚŵĂǇŝŶĐůƵĚĞ͗ x ^ŝŵƉůĞƌĞŵŽǀĂůŽĨĐůŽƚŚŝŶŐ x /ƌƌŝŐĂƚŝŽŶŽĨĞǇĞƐ x tĂƚĞƌďĂƚŚ x ^ĐƌƵďďŝŶŐͬǁĂƚĞƌƐŚŽǁĞƌƐ ϰ͘ WĂƚŝĞŶƚƚƌŝĂŐĞŵĂǇŽĐĐƵƌĂĨƚĞƌƚŚŝƐŝŶŝƚŝĂůĚĞĐŽŶƚĂŵŝŶĂƚŝŽŶƐƚĞƉ͘ ϱ͘ DŽŶŝƚŽƌƉĂƚŝĞŶƚƐĂŶĚƌĞƐƉŽŶĚĞƌƐĨŽƌŚĞĂƚͲƌĞůĂƚĞĚŝůůŶĞƐƐĂŶĚĚĞŚǇĚƌĂƚŝŽŶ͘ZĞŚĂďƉƌŽĐĞĚƵƌĞƐŵĂǇďĞ ŶĞĞĚĞĚ͘

Cypress Creek EMS System Policies and Treatment Guidelines

295 PROCEDURES Revised 8/2016 Treatment Approved: Levon Vartanian, MD

EĂƐŽƉŚĂƌǇŶŐĞĂůDĞĚŝĐĂƚŝŽŶĚŵŝŶŝƐƚƌĂƚŝŽŶ

/ŶĚŝĐĂƚŝŽŶƐ ƋƵŝƉŵĞŶƚEĞĞĚĞĚ

ĚŵŝŶŝƐƚƌĂƚŝŽŶŽĨƐƉĞĐŝĨŝĐŵĞĚŝĐĂƚŝŽŶƐǁŚĞŶ/sŽƌ ϭŵ>Žƌϯŵ>^ǇƌŝŶŐĞǁŝƚŚůƵĞƌͲůŽĐŬƚŝƉ ŽƚŚĞƌŵĞĚŝĐĂƚŝŽŶƌŽƵƚĞƐĂƌĞƵŶĂǀĂŝůĂďůĞŽƌ DƵĐŽƐĂůƚŽŵŝǌĂƚŝŽŶĞǀŝĐĞ;DͿ ŝŶĂƉƉƌŽƉƌŝĂƚĞ

WƌŽĐĞĚƵƌĞ ϭ͘ WůĂĐĞƚŚĞƉĂƚŝĞŶƚŝŶĂƐƵƉŝŶĞƉŽƐŝƚŝŽŶ͘/ĨƚŚĞƉĂƚŝĞŶƚŵƵƐƚƌĞŵĂŝŶƐŝƚƚŝŶŐ͕ĐŽŵƉƌĞƐƐƚŚĞŶĂƌĞƐĨŽƌϭʹϮ ŵŝŶƵƚĞƐĂĨƚĞƌŵĞĚŝĐĂƚŝŽŶĂĚŵŝŶŝƐƚƌĂƚŝŽŶ͘ Ϯ͘ ƌĂǁŵĞĚŝĐĂƚŝŽŶŝŶƚŽƐǇƌŝŶŐĞ͕ĂŶĚĞǆƉĞůĂŶǇĂŝƌƌĞŵĂŝŶŝŶŐŝŶƚŚĞƐǇƌŝŶŐĞ͘ ϯ͘ ƚƚĂĐŚƚŚĞDƚŽƚŚĞƐǇƌŝŶŐĞ͘ ϰ͘ sŝƐƵĂůůǇŝŶƐƉĞĐƚƚŚĞŶĂƌĞƐ͕ĐŚŽŽƐŝŶŐƚŚĞůĂƌŐĞƐƚŶĂƌĞ͕ŽƌƚŚĞŽŶĞǁŝƚŚƚŚĞůĞĂƐƚŽďƐƚƌƵĐƚŝŽŶ͘ ϱ͘ /ŶƐĞƌƚƚŚĞƐǇƌŝŶŐĞŝŶƚŽƚŚĞŶĂƌĞƵŶƚŝůƚŚĞDŝƐƐĞĂƚĞĚĨŝƌŵůǇĂŐĂŝŶƐƚƚŚĞĞǆƚĞƌŶĂůƐƵƌĨĂĐĞŽĨƚŚĞ ŶĂƌĞ͘ ϲ͘ ĐƚƵĂůĂĚŵŝŶŝƐƚƌĂƚŝŽŶƐŚŽƵůĚŽĐĐƵƌĂĨƚĞƌĞǆŚĂůĂƚŝŽŶĂŶĚũƵƐƚƉƌŝŽƌƚŽƚŚĞƉĂƚŝĞŶƚŝŶŚĂůŝŶŐ͘ ϳ͘ ^ǇƌŝŶŐĞƉůƵŶŐĞƌƐŚŽƵůĚďĞƉƵƐŚĞĚĂƐƌĂƉŝĚůǇĂƐƉŽƐƐŝďůĞ͘ ϴ͘ dŚĞŵĂǆŝŵƵŵǀŽůƵŵĞŽĨŵĞĚŝĐĂƚŝŽŶǀŽůƵŵĞƉĞƌŶĂƌĞĨŽƌĞĂĐŚĂĚŵŝŶŝƐƚƌĂƚŝŽŶŝƐ1 cc. ϵ͘ dŚĞĨŽůůŽǁŝŶŐŵĞĚŝĐĂƚŝŽŶƐĂƌĞĂƉƉƌŽǀĞĚĨŽƌ/EĂĚŵŝŶŝƐƚƌĂƚŝŽŶĂƚƚŚĞĚŽƐĞƐƉƌĞƐĐƌŝďĞĚŝŶƚŚĞŝƌ ƌĞƐƉĞĐƚŝǀĞƉƌŽƚŽĐŽůƐ͗ x sĞƌƐĞĚ x &ĞŶƚĂŶǇů x EĂƌĐĂŶ x <ĞƚĂŵŝŶĞĨŽƌĂŶĂůŐĞƐŝĐƉƵƌƉŽƐĞƐ

WĞĂƌůƐ x KŶĐĞĂŵŽƌĞĚĞĨŝŶŝƚŝǀĞƌŽƵƚĞŽĨŵĞĚŝĐĂƚŝŽŶĂĚŵŝŶŝƐƚƌĂƚŝŽŶŝƐŽďƚĂŝŶĞĚ͕ƵƚŝůŝǌĂƚŝŽŶŽĨƚŚĞ/EƌŽƵƚĞ ƐŚŽƵůĚďĞĚŝƐĐŽŶƚŝŶƵĞĚ͘ x /EŵĞĚŝĐĂƚŝŽŶĂĚŵŝŶŝƐƚƌĂƚŝŽŶŝŶƉĂƚŝĞŶƚƐǁŚŽŚĂǀĞĞƉŝƐƚĂǆŝƐ͕ŶĂƐĂůƚƌĂƵŵĂ͕ŽƌŬŶŽǁŶƐĞƉƚĂů ĂďŶŽƌŵĂůŝƚŝĞƐͬŽďƐƚƌƵĐƚŝŽŶŵĂǇŶŽƚďĞĨĞĂƐŝďůĞ͘ x /ĨŝŶŝƚŝĂů/EĚŽƐĞƐĂƌĞŶŽƚĞĨĨĞĐƚŝǀĞ͕ĨŽůůŽǁͲƵƉǁŝƚŚĂůƚĞƌŶĂƚĞƌŽƵƚĞƐŽĨĂĚŵŝŶŝƐƚƌĂƚŝŽŶ;/s͕/D͕ĞƚĐ͘Ϳ x dŚĞDĚĞǀŝĐĞŝƐƌĞƵƐĂďůĞŽŶƚŚĞƐĂŵĞƉĂƚŝĞŶƚ͘ x sŽůƵŵĞƐŽǀĞƌϭŵůƉĞƌŶŽƐƚƌŝůƉĞƌĂĚŵŝŶŝƐƚƌĂƚŝŽŶĂƌĞůŝŬĞůǇƚŽĚŝůƵƚĞĂŶĚŵĂǇƌĞƐƵůƚŝŶƌƵŶŽĨĨŽƵƚŽĨ ƚŚĞŶŽƐƚƌŝů͘ x DĞĚŝĐĂƚŝŽŶĂĚŵŝŶŝƐƚĞƌĞĚŝŶƚƌĂŶĂƐĂůůǇŵĂǇƚĂŬĞƵƉƚŽϲͲϴŵŝŶƵƚĞƐƚŽƚĂŬĞĞĨĨĞĐƚ͘

Cypress Creek EMS System Policies and Treatment Guidelines

296 PROCEDURE Revised 8/2016 Treatment Approved: Levon Vartanian, MD

WĞůǀŝĐ^ůŝŶŐ Indications Equipment Needed ^ƵƐƉĞĐƚĞĚƵŶƐƚĂďůĞƉĞůǀŝĐĨƌĂĐƚƵƌĞǁŝƚŚ x ^DWĞůǀŝĐ^ůŝŶŐ// ƐŝŐŶŝĨŝĐĂŶƚŵĞĐŚĂŶŝƐŵŽĨŝŶũƵƌǇ͘ ƉƉůŝĐĂƚŝŽŶWƌŽĐĞĚƵƌĞ ϭ͘ ƐƐĞƐƐĂŶĚĚŽĐƵŵĞŶƚĚŝƐƚĂůƉƵůƐĞ͕ŵŽƚŽƌ͕ĂŶĚƐĞŶƐĂƚŝŽŶ͘ Ϯ͘ ZĞŵŽǀĞĐůŽƚŚŝŶŐĂƌŽƵŶĚŚŝƉƐͬƉĞůǀŝƐ͘ ϯ͘ WůĂĐĞƉĞůǀŝĐƐůŝŶŐďĞŶĞĂƚŚƉĂƚŝĞŶƚĂƚůĞǀĞůŽĨƚƌŽĐŚĂŶƚĞƌƐ;ŚŝƉƐ͕ ƐĞĞĚŝĂŐƌĂŵͿ͘ ϰ͘ ZŽƵƚĞ><^dZWƚŚƌŽƵŐŚƚŚĞůĂƌŐĞĐĞŶƚĞƌŚŽůĞŝŶƚŚĞďƵĐŬůĞ͘ ϱ͘ ,ŽůĚKZE'^dZWĂŶĚƉƵůů><^dZWŝŶŽƉƉŽƐŝƚĞĚŝƌĞĐƚŝŽŶƵŶƚŝůǇŽƵŚĞĂƌĂŶĚĨĞĞůƚŚĞďƵĐŬůĞ ĐůŝĐŬ͘ ϲ͘ DĂŝŶƚĂŝŶƚĞŶƐŝŽŶĂŶĚƉƌĞƐƐ><^dZWŽŶƚŽƐƵƌĨĂĐĞŽĨƉĞůǀŝĐ ƐůŝŶŐƚŽƐĞĐƵƌĞ͘ ϳ͘ ƐƐĞƐƐĂŶĚĚŽĐƵŵĞŶƚĚŝƐƚĂůƉƵůƐĞ͕ŵŽƚŽƌ͕ĂŶĚƐĞŶƐĂƚŝŽŶ͘ ϴ͘ ŽŶŽƚƌĞŵŽǀĞƉĞůǀŝĐƐůŝŶŐ͘ WĞĂƌůƐ x WĞůǀŝĐƐůŝŶŐŵĂǇďĞƉŽƐŝƚŝŽŶĞĚŽŶĂďĂĐŬďŽĂƌĚĂŶĚƉůĂĐĞĚĚƵƌŝŶŐĂůŽŐƌŽůů͕ŽƌŵĂǇďĞƐůŝĚŝŶƚŽƉůĂĐĞĨƌŽŵ ƚŚĞĨĞĞƚƵƉ͘ x WĞůǀŝĐƐůŝŶŐĐĂŶďĞůĞĨƚŽŶĨŽƌǆͲƌĂǇƐ͕DZ/Ɛ͕ĂŶĚƐŚŽƵůĚŶŽƚďĞƌĞŵŽǀĞĚƵŶůĞƐƐďǇĚŝƌĞĐƚŽƌĚĞƌƐŽĨƚŚĞ ƉŚǇƐŝĐŝĂŶŽƌƚƌĂƵŵĂƐƵƌŐĞŽŶ͘ WĞůǀŝĐ^ůŝŶŐ^ŝǌŝŶŐ ,ŝƉŝƌĐƵŵĨĞƌĞŶĐĞ EŽƚĞƐ ^D>> Ϯϳ͟ʹϰϳ͟ ^ƵƉĞƌǀŝƐŽƌƵŶŝƚƐŽŶůǇ ^dEZ ϯϮ͟ʹϱϬ͟ &ŝƚƐϵϴйŽĨƉŽƉƵůĂƚŝŽŶ͘KŶĂŵďƵůĂŶĐĞ͘ >Z' ϯϲ͟ʹϱϬ͟ ^ƵƉĞƌǀŝƐŽƌƵŶŝƚƐŽŶůǇ

Cypress Creek EMS System Policies and Treatment Guidelines

297 PROCEDURE Revised 8/2016 Treatment Approved: Levon Vartanian, MD

ZĞƐƚƌĂŝŶƚ Indications Equipment needed Assessment Requirements ZĞƐƚƌĂŝŶƚŝƐŝŶĚŝĐĂƚĞĚǁŚĞŶ ^ŽĨƚƌĞƐƚƌĂŝŶƚƐ WƌŝŵĂƌǇ^ƵƌǀĞǇ ŶĞĐĞƐƐĂƌǇĨŽƌƉĂƚŝĞŶƚĐĂƌĞ͕ DĞĚŝĐĂƚŝŽŶĂĚŵŝŶŝƐƚƌĂƚŝŽŶ sŝƚĂůƐŝŐŶƐ ƉŽƐƐŝďůǇĚƵĞƚŽƚŚĞĨŽůůŽǁŝŶŐ͗ ƐƵƉƉůŝĞƐ͕ŝŶĐůƵĚŝŶŐsĂŶŝƐŚWŽŝŶƚ '> ƐǇƌŝŶŐĞ͕ŝĨŶĞĞĚĞĚ '͕^ƉKϮ͕ĂŶĚdKϮ x dŽƉƌŽƚĞĐƚƚŚĞƉĂƚŝĞŶƚĨƌŽŵ /ŶǀŽůǀĞůĂǁĞŶĨŽƌĐĞŵĞŶƚŝĨ ŵŽŶŝƚŽƌŝŶŐĂƐ ŚĂƌŵŝŶŐƚŚĞŵƐĞůǀĞƐŽƌ ƉŽƐƐŝďůĞ ĂƉƉƌŽƉƌŝĂƚĞ ŽƚŚĞƌƐ͘ WƵůƐĞͬŵŽƚŽƌͬƐĞŶƐĂƚŝŽŶ x ůůŽǁĂƐƐĞƐƐŵĞŶƚĂŶĚ ŝŶĂůůĞǆƚƌĞŵŝƚŝĞƐďĞĨŽƌĞ ƚƌĞĂƚŵĞŶƚŽĨǀŝŽůĞŶƚŽƌ ĂŶĚĂĨƚĞƌƌĞƐƚƌĂŝŶƚ ƵŶĐŽŽƉĞƌĂƚŝǀĞƉĂƚŝĞŶƚƐ͘ ƉůĂĐĞŵĞŶƚ͘ x WƌĞǀĞŶƚĞůŽƉĞŵĞŶƚŽĨ ƐƉŽƐƐŝďůĞ͕ĚĞƚĂŝůĞĚ ƉĂƚŝĞŶƚƐƚŚĂƚŵĂǇƉŽƐĞĂ ŚŝƐƚŽƌǇĂŶĚƉŚǇƐŝĐĂů ƚŚƌĞĂƚƚŽƚŚĞŵƐĞůǀĞƐŽƌ ĞǆĂŵ͘ ŽƚŚĞƌƐ͘

ǀĂŝůĂďůĞdƌĞĂƚŵĞŶƚƐ x (B) ^ŽĨƚƌĞƐƚƌĂŝŶƚƐĂƉƉůŝĞĚƚŽĂůůĞǆƚƌĞŵŝƚŝĞƐĂŶĚƐĞĐƵƌĞĚƚŽƐƚƌĞƚĐŚĞƌ;ŽƌďĂĐŬďŽĂƌĚŝĨ^DZŝƐ ŝŶĚŝĐĂƚĞĚͿ͘ x Sedation procedureĂƐŶĞĞĚĞĚ͘ WĞĂƌůƐ x WƌŝŽƌƚŽƉĞƌĨŽƌŵŝŶŐƌĞƐƚƌĂŝŶƚ͕ĞƐƚĂďůŝƐŚƉůĂŶĂŶĚĐŽŽƌĚŝŶĂƚĞǁŝƚŚŽƚŚĞƌƌĞƐƉŽŶĚĞƌƐ͘ x sD͕ĂŝƌǁĂǇĂĚũƵŶĐƚƐ͕<ŝŶŐ>d^Ͳ͕ĂŶĚŝŶƚƵďĂƚŝŽŶĞƋƵŝƉŵĞŶƚŵƵƐƚďĞƌĞĂĚŝůǇĂǀĂŝůĂďůĞǁŚĞŶ ĂĚŵŝŶŝƐƚĞƌŝŶŐĂŶǇƐĞĚĂƚŝǀĞŵĞĚŝĐĂƚŝŽŶƐ͘ x EĞǀĞƌƌĞƐƚƌĂŝŶĂƉĂƚŝĞŶƚŝŶƚŚĞƉƌŽŶĞƉŽƐŝƚŝŽŶ͘ x /ƚŝƐŝŵƉĞƌĂƚŝǀĞƚŽƌĞĐŽŐŶŝǌĞƉĂƚŝĞŶƚƐǁŝƚŚĞǆĐŝƚĞĚĚĞůŝƌŝƵŵƐǇŶĚƌŽŵĞĂŶĚďĞǀŝŐŝůĂŶƚĂŐĂŝŶƐƚ ƉŽƐŝƚŝŽŶĂůĂŶĚƌĞƐƚƌĂŝŶƚĂƐƉŚǇǆŝĂ͘ x ŽŶƚŝŶƵŽƵƐŵŽŶŝƚŽƌŝŶŐŽĨƚŚĞƉĂƚŝĞŶƚ͛ƐĂŝƌǁĂǇ͕ǀĞŶƚŝůĂƚŝŽŶ͕ŽǆǇŐĞŶĂƚŝŽŶ͕ĂŶĚŚĞŵŽĚǇŶĂŵŝĐƐƚĂƚƵƐ ĂƌĞĞƐƐĞŶƚŝĂů͘ x /ĨƉŽƐƐŝďůĞ͕ĚŝĨĨĞƌĞŶƚŝĂƚĞďĞƚǁĞĞŶƉƐǇĐŚŝĂƚƌŝĐĂŶĚŶŽŶͲƉƐǇĐŚŝĂƚƌŝĐ;ŽƌŐĂŶŝĐͿĐĂƵƐĞƐ͘ǆĂŵƉůĞƐŽĨ ŽƌŐĂŶŝĐĐĂƵƐĞƐŝŶĐůƵĚĞŶĞƵƌŽůŽŐŝĐĂůĚŝƐĞĂƐĞƐ͕ĚƌƵŐŝŶƚŽǆŝĐĂƚŝŽŶͬƉŽŝƐŽŶŝŶŐ͕ǁŝƚŚĚƌĂǁĂůƐǇŵƉƚŽŵƐ͕ ŚǇƉŽǆŝĂ͕ŚǇƉŽŐůǇĐĞŵŝĂ͕ĞƚĐ͘/ĨƉŽƐƐŝďůĞ͕ƚƌĞĂƚƌĞǀĞƌƐŝďůĞĐĂƵƐĞƐŝŶƐƚĞĂĚŽĨƐĞĚĂƚŝŶŐƉĂƚŝĞŶƚ͘ x WĂƚŝĞŶƚƐƐŚŽƵůĚŶŽƚďĞƚƌĂŶƐƉŽƌƚĞĚŝŶŚĂŶĚĐƵĨĨƐǁŝƚŚŽƵƚĂůĂǁĞŶĨŽƌĐĞŵĞŶƚŽĨĨŝĐĞƌŽŶƚŚĞƵŶŝƚ͘ x ŽŶŽƚƌĞŵŽǀĞŚĂŶĚĐƵĨĨƐƵŶůĞƐƐĞǆƉƌĞƐƐůǇĂƵƚŚŽƌŝǌĞĚďǇůĂǁĞŶĨŽƌĐĞŵĞŶƚŽƌƚŚĞƉĂƚŝĞŶƚŐŽĞƐŝŶƚŽ ĐĂƌĚŝĂĐĂƌƌĞƐƚ͘

Cypress Creek EMS System Policies and Treatment Guidelines

298 PROCEDURES Revised 6/2019 Treatment Approved: Levon Vartanian, MD

^ĞĚĂƚŝŽŶ Indications Equipment needed Assessment Requirements DĂǆŝŵŝǌŝŶŐƉĂƚŝĞŶƚƐĂĨĞƚǇĂŶĚ ^ŽĨƚƌĞƐƚƌĂŝŶƚƐ WƌŝŵĂƌǇƐƵƌǀĞǇ ŵŝŶŝŵŝǌŝŶŐĚŝƐĐŽŵĨŽƌƚĂŶĚƉĂŝŶ sĂŶŝƐŚWŽŝŶƚƐǇƌŝŶŐĞĂƐŶĞĞĚĞĚ sŝƚĂůƐŝŐŶƐ ĂƐƐŽĐŝĂƚĞĚǁŝƚŚ͗ /ŶǀŽůǀĞůĂǁĞŶĨŽƌĐĞŵĞŶƚŝĨ '> ϭ͘ ůĞĐƚƌŝĐĂůƚŚĞƌĂƉŝĞƐ ƉŽƐƐŝďůĞ '͕^ƉKϮĂŶĚdKϮ Ϯ͘ DĂŝŶƚĂŝŶŝŶŐĂĚǀĂŶĐĞĚĂŝƌǁĂǇ ŵŽŶŝƚŽƌŝŶŐ ĚĞǀŝĐĞƐ Sedation Risk ϯ͘ ^ĂĨĞƚƌĂŶƐƉŽƌƚŽĨƚŚĞ Assessment ĐŽŵďĂƚŝǀĞ͕ĂŐŝƚĂƚĞĚ SAT score (pre and post ďĞŚĂǀŝŽƌĂůĞŵĞƌŐĞŶĐǇ intervention) ƉĂƚŝĞŶƚ ϰ͘ ŐŝƚĂƚŝŽŶƉƌĞǀĞŶƚŝŶŐůŝĨĞͲ ƐĂǀŝŶŐƚƌĞĂƚŵĞŶƚƐ;ƐĞĞ ďĞůŽǁͿ Overview ^ĞĚĂƚŝŽŶƐŚŽƵůĚďĞƵƐĞĚƚŽŵŝŶŝŵŝǌĞĚŝƐĐŽŵĨŽƌƚĂŶĚƉĂŝŶǁŚĞŶƉĞƌĨŽƌŵŝŶŐƉƌŽĐĞĚƵƌĞƐƐƵĐŚĂƐ ĞůĞĐƚƌŝĐĂůƚŚĞƌĂƉŝĞƐ;ƉĂĐŝŶŐ͕ƐǇŶĐŚƌŽŶŝǌĞĚĐĂƌĚŝŽǀĞƌƐŝŽŶͿĂŶĚŵĂŝŶƚĂŝŶŝŶŐĂĚǀĂŶĐĞĚĂŝƌǁĂǇƐ;<ŝŶŐ>d^Ͳ͕ ĞŶĚŽƚƌĂĐŚĞĂůƚƵďĞ͕ĞƚĐ͘Ϳ͘^ĞĚĂƚŝŽŶŵĂǇĂůƐŽďĞŶĞĞĚĞĚƚŽĂĐĐŽŵƉůŝƐŚƐĂĨĞƚƌĂŶƐƉŽƌƚŽĨĂŶĂŐŝƚĂƚĞĚŽƌ ĐŽŵďĂƚŝǀĞďĞŚĂǀŝŽƌĂůĞŵĞƌŐĞŶĐǇƉĂƚŝĞŶƚ͘/ŶƐƉĞĐŝĂůĐŝƌĐƵŵƐƚĂŶĐĞƐ͕ƐĞĚĂƚŝŽŶŵĂǇďĞŶĞĐĞƐƐĂƌǇƚŽ ŵŝŶŝŵŝǌĞƉĂƚŝĞŶƚĚŝƐĐŽŵĨŽƌƚĚƵƌŝŶŐWZ;ƌĞĨĞƌƚŽCardiac Arrest ƉƌŽƚŽĐŽůͿ͘/ŶůŝŵŝƚĞĚĐŝƌĐƵŵƐƚĂŶĐĞƐ͕ŝĨ ƉĂƚŝĞŶƚĂŐŝƚĂƚŝŽŶƉƌĞǀĞŶƚƐĂƚŚŽƌŽƵŐŚĂƐƐĞƐƐŵĞŶƚĂŶĚͬŽƌƚƌĞĂƚŵĞŶƚƐĂŶĚƚŚĞWϮͬWϯŽŶƐĐĞŶĞďĞůŝĞǀĞƐ ƚŚĞƉĂƚŝĞŶƚŵĂǇŚĂǀĞĂƐĞƌŝŽƵƐ͕ůŝĨĞͲƚŚƌĞĂƚĞŶŝŶŐĐŽŶĚŝƚŝŽŶ͕ƐĞĚĂƚŝŽŶŵĂǇďĞƵƐĞĚƚŽĂĐŚŝĞǀĞĂŵŽƌĞ ŵĂŶĂŐĞĂďůĞƉĂƚŝĞŶƚ͖ƚŚŝƐƐŚŽƵůĚŽŶůǇďĞĚŽŶĞĨŽůůŽǁŝŶŐĐŽŶƐƵůƚĂƚŝŽŶǁŝƚŚĂWϯ͘

^ĞĚĂƚŝŽŶƐŚŽƵůĚďĞĚŽŶĞcarefully͕ĂĨƚĞƌĂƚŚŽƌŽƵŐŚĂƐƐĞƐƐŵĞŶƚ͕ĨŽůůŽǁŝŶŐĂplan͕ĂŶĚtargetingĂ ƐƉĞĐŝĨŝĐŐŽĂůĨŽƌŚŽǁƐĞĚĂƚĞĚƚŚĞƉĂƚŝĞŶƚƐŚŽƵůĚďĞ͘dŽƚĂů͞ůŽƐƐŽĨĐŽŶƐĐŝŽƵƐŶĞƐƐ͟ƐŚŽƵůĚŶŽƚŐĞŶĞƌĂůůǇ ďĞƚŚĞŐŽĂů͖ƌĂƚŚĞƌƚŚĞƉƌŽǀŝĚĞƌƐŚŽƵůĚƵƐĞƚŚĞŵŝŶŝŵƵŵĂŵŽƵŶƚŽĨƐĞĚĂƚŝŽŶŶĞĐĞƐƐĂƌǇƚŽĂĐĐŽŵƉůŝƐŚ ŽƚŚĞƌƚƌĞĂƚŵĞŶƚŐŽĂůƐ͘'ĞŶĞƌĂůůǇƐƉĞĂŬŝŶŐ͕ƚŚĞƉĂƚŝĞŶƚƐŚŽƵůĚŵĂŝŶƚĂŝŶĂŝƌǁĂǇƌĞĨůĞǆĞƐĂŶĚƌĞƐƉŝƌĂƚŽƌǇ ĚƌŝǀĞ͘

sedation planƐŚŽƵůĚĂůƐŽƉƌĞƉĂƌĞĨŽƌǁŚĞŶƐŽŵĞƚŚŝŶŐŐŽĞƐǁƌŽŶŐ͕ŝŶĐůƵĚŝŶŐŚĂǀŝŶŐƚŚĞĂďŝůŝƚǇƚŽ ŵĂŝŶƚĂŝŶĂƉĂƚĞŶƚĂŝƌǁĂǇĂŶĚƉƌŽǀŝĚĞŽǆǇŐĞŶĂƚŝŽŶĂŶĚǀĞŶƚŝůĂƚŝŽŶŝĨŶĞĐĞƐƐĂƌǇ͘

ŶǇƚŝŵĞƐĞĚĂƚŝŽŶŝƐĂĚŵŝŶŝƐƚĞƌĞĚ͕ƚŚĞƉĂƚŝĞŶƚŵƵƐƚŚĂǀĞĐŽŶƚŝŶƵŽƵƐŵŽŶŝƚŽƌŝŶŐďǇĂƚůĞĂƐƚŽŶĞ ƉĂƌĂŵĞĚŝĐͲůĞǀĞůƉƌŽǀŝĚĞƌ;WϭͬWϮͬWϯͿǁŚŝĐŚƐŚŽƵůĚŝŶĐůƵĚĞĚŝƌĞĐƚǀŝƐƵĂůŝǌĂƚŝŽŶŽĨƚŚĞƉĂƚŝĞŶƚĂŶĚ͕ĂƐ ƐŽŽŶĂƐƉŽƐƐŝďůĞ͕ĐŽŶƚŝŶƵŽƵƐŵŽŶŝƚŽƌŝŶŐŽĨ'ůĞĂĚ;ƐͿ͕^ƉKϮ͕ĂŶĚǁĂǀĞĨŽƌŵdKϮĐĂƉŶŽŐƌĂƉŚǇ͘dŚĞ ƉĂƚŝĞŶƚƐŚŽƵůĚďĞĐŽŶƚŝŶƵŽƵƐůǇŵŽŶŝƚŽƌĞĚƵŶƚŝůƚƌĂŶƐĨĞƌŽĨĐĂƌĞƚŽƐƚĂĨĨĂŶĚƐŚŽƵůĚŚĂǀĞĂĨƵůů ƌĞĂƐƐĞƐƐŵĞŶƚĨƌĞƋƵĞŶƚůǇ͘

Cypress Creek EMS System Policies and Treatment Guidelines

299 PROCEDURES Revised 6/2019 Treatment Approved: Levon Vartanian, MD

dŚĞƌĞĂƐŽŶŝŶŐĨŽƌƐĞĚĂƚŝŽŶ͕ƉůĂŶĂŶĚƉƌĞƉĂƌĂƚŝŽŶƐŚŽƵůĚďĞĚŽĐƵŵĞŶƚĞĚŝŶƚŚĞWZ͘^dƐĐŽƌĞƐƐŚŽƵůĚ ĂůƐŽďĞĚŽĐƵŵĞŶƚĞĚĂƐďŽƚŚƉƌĞͲĂŶĚƉŽƐƚͲƐĞĚĂƚŝŽŶŝŶƚĞƌǀĞŶƚŝŽŶƐ͘

dŚĞƉƌĞĨĞƌƌĞĚŵĞĚŝĐĂƚŝŽŶĨŽƌƐĞĚĂƚŝŽŶŝƐMidazolam (Versed)ƚŝƚƌĂƚĞĚƚŽĞĨĨĞĐƚŝŶƐŵĂůůĐŽŶƚƌŽůůĞĚĚŽƐĞƐ ;ƐĞĞďĞůŽǁĨŽƌƐƉĞĐŝĨŝĐĚĞƚĂŝůƐͿ͘,ŽǁĞǀĞƌ͕ŝĨDŝĚĂǌŽůĂŵŝƐŶŽƚĞĨĨĞĐƚŝǀĞŽƌŝƐĐŽŶƚƌĂŝŶĚŝĐĂƚĞĚ͕Ketamine ŵĂǇďĞƵƚŝůŝǌĞĚĂĨƚĞƌĐŽŶƐƵůƚŝŶŐǁŝƚŚĂWϯ͘ Assessment & Plan WƌŝŽƌƚŽƐĞĚĂƚŝŽŶ͕ƚŚĞƉĂƚŝĞŶƚŵƵƐƚďĞĂƐƐĞƐƐĞĚĂŶĚĂƉůĂŶŵƵƐƚďĞĚĞǀĞůŽƉĞĚ͘ ^ĞĚĂƚŝŽŶZŝƐŬƐƐĞƐƐŵĞŶƚ Low Risk Medium Risk High Risk &ĂƐƚĞĚ;хϲŚŽƵƌƐĨƌŽŵĨŽŽĚŽƌ hŶĨĂƐƚĞĚŽƌƵŶŬŶŽǁŶĂŝƌǁĂǇ WƌĞĚŝĐƚĞĚĚŝĨĨŝĐƵůƚĂŝƌǁĂǇ х ϮŚŽƵƌƐĨƌŽŵĐůĞĂƌůŝƋƵŝĚƐͿ ^ƉKϮϵϬʹϵϰй;ǁŝƚŚ ĂŶŶŽƚŵĂŝŶƚĂŝŶ^ƉKϮшϵϬй ĂŝƌǁĂǇǁŝƚŚƉƌĞĚŝĐƚĞĚĞĂƐǇ ƐƵƉƉůĞŵĞŶƚĂůKϮͿ ^ŝŐŶŝĨŝĐĂŶƚŵĞĚŝĐĂůƉƌŽďůĞŵƐ ĂŝƌǁĂǇ;>DKE^ͿĂŶĚĞĂƐǇ KďƐƚƌƵĐƚŝǀĞĂŝƌǁĂǇĚŝƐĞĂƐĞ ;Ğ͘Ő͘KW͕,&͕ŽďĞƐŝƚǇ͕ŽůĚ͕ sD;KE^Ϳ ;ĂƐƚŚŵĂŽƌKWͿ ĞƚĐ͘Ϳ ^ƉKϮшϵϰй ^ŝŐŶŝĨŝĐĂŶƚůǇƵŶƐƚĂďůĞsͬ^ ^ƚĂďůĞsͬ^ WƌŽĐĞĞĚǁŝƚŚƐĞĚĂƚŝǀĞƐĂŶĚ ĞĐĂƵƚŝŽƵƐǁŝƚŚƐĞĚĂƚŝǀĞƐĂŶĚ ǀŽŝĚƐĞĚĂƚŝǀĞƐŝĨƉŽƐƐŝďůĞ ĂŶĂůŐĞƐŝĂŝĨŝŶĚŝĐĂƚĞĚ͘ ĂŶĂůŐĞƐŝĂ͖ƵƐĞŵŝŶŝŵƵŵĚŽƐĞƐ ŽŶƐŝĚĞƌĂŶĂůŐĞƐŝĂǁŝƚŚ ŝŵĨŽƌ^dŽĨϬƚŽͲϭ ŝŵĨŽƌ^dŽĨϬ FentanylĨŽƌƉƌŽĐĞĚƵƌĞƐ ,ĂǀĞƌĞǀĞƌƐĂůĂŐĞŶƚƐĂŶĚ ,ĂǀĞƌĞǀĞƌƐĂůĂŐĞŶƚƐĂŶĚ ,ĂǀĞƌĞǀĞƌƐĂůĂŐĞŶƚƐĂŶĚ ĂŝƌǁĂǇĞƋƵŝƉŵĞŶƚƌĞĂĚǇ ĂŝƌǁĂǇĞƋƵŝƉŵĞŶƚƌĞĂĚŝůǇ ĂŝƌǁĂǇĞƋƵŝƉŵĞŶƚƌĞĂĚŝůǇ ĂǀĂŝůĂďůĞ ĂǀĂŝůĂďůĞĂŶĚďĞƌĞĂĚǇĨŽƌZ^/ ĞƉƌĞƉĂƌĞĚĨŽƌƉŽƐƐŝďůĞZ^/ ǁŝƚŚWϯŽŶƐĐĞŶĞ /ĨƐĞĚĂƚŝŽŶŝƐƵŶĂǀŽŝĚĂďůĞ͕ ĐŽŶƐŝĚĞƌKetamineǁŝƚŚƉůĂŶ ƚŽZ^/ŝĨƌĞƋƵŝƌĞĚ͘WϯŽŶƐĐĞŶĞ͘ ^ĞĚĂƚŝŽŶƐƐĞƐƐŵĞŶƚdŽŽů;^dͿ^ĐŽƌŝŶŐ Score Responsiveness Speech нϯ ŽŵďĂƚŝǀĞ͕ǀŝŽůĞŶƚ͕ŽƵƚŽĨĐŽŶƚƌŽů ŽŶƚŝŶƵĂůůŽƵĚŽƵƚďƵƌƐƚƐ нϮ sĞƌǇĂŶǆŝŽƵƐĂŶĚĂŐŝƚĂƚĞĚ >ŽƵĚŽƵƚďƵƌƐƚƐ нϭ ŶǆŝŽƵƐͬƌĞƐƚůĞƐƐ EŽƌŵĂůͬƚĂůŬĂƚŝǀĞ Ϭ ǁĂŬĞĂŶĚĐĂůŵͬĐŽŽƉĞƌĂƚŝǀĞ ^ƉĞĂŬƐŶŽƌŵĂůůǇ ʹϭ ƐůĞĞƉďƵƚƌŽƵƐĞƐŝĨŶĂŵĞŝƐĐĂůůĞĚ ^ůƵƌƌŝŶŐŽƌƉƌŽŵŝŶĞŶƚƐůƵƌƌŝŶŐ ʹϮ ZĞƐƉŽŶĚƐƚŽƉŚǇƐŝĐĂůƐƚŝŵƵůĂƚŝŽŶ &ĞǁƌĞĐŽŐŶŝǌĂďůĞǁŽƌĚƐ ʹϯ EŽƌĞƐƉŽŶƐĞƚŽƐƚŝŵƵůĂƚŝŽŶ Eŝů

Cypress Creek EMS System Policies and Treatment Guidelines

300 PROCEDURES Revised 6/2019 Treatment Approved: Levon Vartanian, MD

WƌĞƉĂƌĂƚŝŽŶ x WůĂŶĂŶĚĐŽŽƌĚŝŶĂƚĞǁŝƚŚŽƚŚĞƌƌĞƐƉŽŶĚĞƌƐĂŶĚůĂǁĞŶĨŽƌĐĞŵĞŶƚƉƌŝŽƌƚŽĂƉƉƌŽĂĐŚŝŶŐƉĂƚŝĞŶƚ͘ x WƌĞƉĂƌĞƐŽĨƚƌĞƐƚƌĂŝŶƚƐŽŶƐƚƌĞƚĐŚĞƌ;ŽƌďĂĐŬďŽĂƌĚŝĨ^DZŝƐŝŶĚŝĐĂƚĞĚͿ͘ x ,ĂǀĞsD͕ĂŝƌǁĂǇĂĚũƵŶĐƚƐ͕<ŝŶŐƐƵƉƌĂŐůŽƚƚŝĐĂŝƌǁĂǇ͕ƐƵĐƚŝŽŶ͕ĂŶĚŝŶƚƵďĂƚŝŽŶĞƋƵŝƉŵĞŶƚƌĞĂĚŝůǇ ĂǀĂŝůĂďůĞǁŚĞŶĂĚŵŝŶŝƐƚĞƌŝŶŐĂŶǇƐĞĚĂƚŝǀĞŵĞĚŝĐĂƚŝŽŶƐ͘ x ĚŵŝŶŝƐƚĞƌ/DŵĞĚŝĐĂƚŝŽŶƐƵƐŝŶŐsĂŶŝƐŚWŽŝŶƚƐǇƌŝŶŐĞĨŽƌƐĂĨĞƚǇ͘ x ŽŶƐŝĚĞƌƌĞƋƵĞƐƚŝŶŐĂWϯƚŽƚŚĞƐĐĞŶĞ͘ WƌŽĐĞĚƵƌĞ x (P2) Midazolam Ϭ͘ϬϱʹϬ͘ϭŵŐͬŬŐ/Dͬ/EƚŽĂĐŚŝĞǀĞ/sŽƌĂŵŽƌĞŵĂŶĂŐĞĂďůĞƉĂƚŝĞŶƚ͘ x (P2) &ŽůůŽǁŝŶŐ/Dͬ/EĂĚŵŝŶŝƐƚƌĂƚŝŽŶ͕MidazolamŵĂǇďĞĂĚŵŝŶŝƐƚĞƌĞĚ/sŝĨŶĞĞĚĞĚŝŶϭʹϮŵŐĚŽƐĞƐ ŶŽƚƚŽĞǆĐĞĞĚĂƚŽƚĂůŽĨϱŵŐǀŝĂƚŚĞ/sƌŽƵƚĞ͘ x (P3 consult) /ĨsĞƌƐĞĚŝƐĐŽŶƚƌĂŝŶĚŝĐĂƚĞĚŽƌŶŽƚĞĨĨĞĐƚŝǀĞ͕ĐŽŶƐŝĚĞƌĂĚŵŝŶŝƐƚĞƌŝŶŐKetamine ϭʹϭ͘ϱ ŵŐͬŬŐ/sŽƌϱŵŐͬŬŐ/D͘ x (B) ŶƐƵƌĞĂƉĂƚĞŶƚĂŝƌǁĂǇŝƐŵĂŝŶƚĂŝŶĞĚĂŶĚƉĂƚŝĞŶƚŝƐƉƌŽƉĞƌůǇǀĞŶƚŝůĂƚĞĚĂŶĚŽǆǇŐĞŶĂƚĞĚ͘ x (B) DŽŶŝƚŽƌ'͕dKϮ͕ĂŶĚ^ƉKϮĂƐƋƵŝĐŬůǇĂƐƉŽƐƐŝďůĞĂŶĚĐŽŶƚŝŶƵŽƵƐůǇƵŶƚŝůƚƌĂŶƐĨĞƌŽĨĐĂƌĞƚŽ ƐƚĂĨĨ͘ x (B) ZĞĂƐƐĞƐƐĚŝƐƚĂůƉƵůƐĞͬŵŽƚŽƌͬƐĞŶƐĂƚŝŽŶ͕'^͕ǀŝƚĂůƐŝŐŶƐ͕ĞƚĐ͘ĨƌĞƋƵĞŶƚůǇ͘ WĞĂƌůƐ x /ƚŝƐŝŵƉĞƌĂƚŝǀĞƚŽƌĞĐŽŐŶŝǌĞƉĂƚŝĞŶƚƐǁŝƚŚĞǆĐŝƚĞĚĚĞůŝƌŝƵŵƐǇŶĚƌŽŵĞĂŶĚďĞǀŝŐŝůĂŶƚĂŐĂŝŶƐƚ ƉŽƐŝƚŝŽŶĂůĂŶĚƌĞƐƚƌĂŝŶƚĂƐƉŚǇǆŝĂ͘^ĞĞExcited Delirium͘ x /ĨƉŽƐƐŝďůĞ͕ĚŝĨĨĞƌĞŶƚŝĂƚĞďĞƚǁĞĞŶƉƐǇĐŚŝĂƚƌŝĐĂŶĚŶŽŶͲƉƐǇĐŚŝĂƚƌŝĐ;ŽƌŐĂŶŝĐͿĐĂƵƐĞƐ͘ǆĂŵƉůĞƐŽĨ ŽƌŐĂŶŝĐĐĂƵƐĞƐŝŶĐůƵĚĞŶĞƵƌŽůŽŐŝĐĂůĚŝƐĞĂƐĞƐ͕ĚƌƵŐŝŶƚŽǆŝĐĂƚŝŽŶͬƉŽŝƐŽŶŝŶŐ͕ǁŝƚŚĚƌĂǁĂůƐǇŵƉƚŽŵƐ͕ ŚǇƉŽǆŝĂ͕ŚǇƉŽŐůǇĐĞŵŝĂ͕ĞƚĐ͘/ĨƉŽƐƐŝďůĞ͕ƚƌĞĂƚƌĞǀĞƌƐŝďůĞĐĂƵƐĞƐŝŶƐƚĞĂĚŽĨƐĞĚĂƚŝŶŐƉĂƚŝĞŶƚ͘

Cypress Creek EMS System Policies and Treatment Guidelines

301 PROCEDURES Revised 8/2016 Treatment Approved: Levon Vartanian, MD

^ƉůŝŶƚŝŶŐ Indications Equipment needed /ŵŵŽďŝůŝǌŝŶŐĂŶĞǆƚƌĞŵŝƚǇǁŝƚŚƐƵƐƉĞĐƚĞĚ sĂĐƵƵŵƐƉůŝŶƚƐǁŝƚŚƉƵŵƉ ŝŶũƵƌǇ;ƐƉƌĂŝŶŽƌĨƌĂĐƚƵƌĞͿ WĂĚĚĞĚďŽĂƌĚƐƉůŝŶƚ /ŵŵŽďŝůŝǌŝŶŐĂŶĞǆƚƌĞŵŝƚǇƚŽƐĞĐƵƌĞ dƌĂĐƚŝŽŶ^ƉůŝŶƚ ŵĞĚŝĐĂůĚĞǀŝĐĞƐƐƵĐŚĂƐ/sĐĂƚŚĞƚĞƌ͘ ZŽůůĞĚ'ĂƵǌĞ dĂƉĞ dƌŝĂŶŐƵůĂƌďĂŶĚĂŐĞƐ sĂĐƵƵŵ^ƉůŝŶƚƐ ϭ͘ ƐƐĞƐƐĂŶĚĚŽĐƵŵĞŶƚĚŝƐƚĂůƉƵůƐĞ͕ŵŽƚŽƌ͕ĂŶĚƐĞŶƐŽƌǇĨƵŶĐƚŝŽŶƉƌŝŽƌƚŽƐƉůŝŶƚĂƉƉůŝĐĂƚŝŽŶ͘ x /ĨŶŽƉƵůƐĞƐĂƌĞƉƌĞƐĞŶƚĂŶĚƐŝŐŶŝĨŝĐĂŶƚĚĞĨŽƌŵŝƚǇŽƌƐǁĞůůŝŶŐŝƐƉƌĞƐĞŶƚ͕ƐƉůŝŶƚŝŶƉŽƐŝƚŝŽŶĨŽƵŶĚ ĂŶĚƌĂƉŝĚůǇƚƌĂŶƐƉŽƌƚƉĂƚŝĞŶƚƚŽĞŵĞƌŐĞŶĐǇĚĞƉĂƌƚŵĞŶƚ͘&ŝĞůĚƌĞĚƵĐƚŝŽŶƐŚŽƵůĚďĞĂǀŽŝĚĞĚ͘ Ϯ͘ ZĞŵŽǀĞĂůůĐůŽƚŚŝŶŐĨƌŽŵĞǆƚƌĞŵŝƚǇ͘ ϯ͘ WůĂĐĞƐƉůŝŶƚĂƌŽƵŶĚĞǆƚƌĞŵŝƚǇďŽƚŚƉƌŽǆŝŵĂůĂŶĚĚŝƐƚĂůƚŽƚŚĞŝŶũƵƌǇ͘ ϰ͘ ^ĞĐƵƌĞŝŶƉůĂĐĞǁŝƚŚƚĂƉĞ͘ ϱ͘ hƐĞƉƵŵƉƚŽĞǀĂĐƵĂƚĞĂŝƌĂŶĚŚĂƌĚĞŶƐƉůŝŶƚĂƌŽƵŶĚĞǆƚƌĞŵŝƚǇ͘ ϲ͘ ƐƐĞƐƐƐƉůŝŶƚĂŶĚƐůŝŶŐŽƌƐǁĂƚŚĞǆƚƌĞŵŝƚǇĂƐŶĞĞĚĞĚ͘ ϳ͘ ZĞĂƐƐĞƐƐĂŶĚĚŽĐƵŵĞŶƚĚŝƐƚĂůƉƵůƐĞ͕ŵŽƚŽƌ͕ĂŶĚƐĞŶƐŽƌǇĨƵŶĐƚŝŽŶĂĨƚĞƌƐƉůŝŶƚĂƉƉůŝĐĂƚŝŽŶĂŶĚŽŶĂŶ ŽŶŐŽŝŶŐďĂƐŝƐƚŚƌŽƵŐŚŽƵƚƚƌĂŶƐƉŽƌƚ͘ x /ĨĂŶǇĚĞƚĞƌŝŽƌĂƚŝŽŶŝƐŶŽƚĞĚ͕ůŽŽƐĞŶƐƉůŝŶƚĂŶĚƌĞĂƐƐĞƐƐ͘ ŽĂƌĚ^ƉůŝŶƚƐ ϭ͘ ƐƐĞƐƐĂŶĚĚŽĐƵŵĞŶƚĚŝƐƚĂůƉƵůƐĞ͕ŵŽƚŽƌ͕ĂŶĚƐĞŶƐŽƌǇĨƵŶĐƚŝŽŶƉƌŝŽƌƚŽƐƉůŝŶƚĂƉƉůŝĐĂƚŝŽŶ͘ x /ĨŶŽƉƵůƐĞƐĂƌĞƉƌĞƐĞŶƚĂŶĚƐŝŐŶŝĨŝĐĂŶƚĚĞĨŽƌŵŝƚǇŽƌƐǁĞůůŝŶŐŝƐƉƌĞƐĞŶƚ͕ƐƉůŝŶƚŝŶƉŽƐŝƚŝŽŶĨŽƵŶĚ ĂŶĚƌĂƉŝĚůǇƚƌĂŶƐƉŽƌƚƉĂƚŝĞŶƚƚŽĞŵĞƌŐĞŶĐǇĚĞƉĂƌƚŵĞŶƚ͘&ŝĞůĚƌĞĚƵĐƚŝŽŶƐŚŽƵůĚďĞĂǀŽŝĚĞĚ͘ Ϯ͘ ZĞŵŽǀĞĂůůĐůŽƚŚŝŶŐĨƌŽŵĞǆƚƌĞŵŝƚǇ͘ ϯ͘ WůĂĐĞƐƉůŝŶƚĂƌŽƵŶĚĞǆƚƌĞŵŝƚǇďŽƚŚƉƌŽǆŝŵĂůĂŶĚĚŝƐƚĂůƚŽƚŚĞŝŶũƵƌǇŽƌƐŝƚĞŽĨŵĞĚŝĐĂůŝŶƚĞƌǀĞŶƚŝŽŶ͘ ϰ͘ ^ĞĐƵƌĞŝŶƉůĂĐĞǁŝƚŚƌŽůůĞĚŐĂƵǌĞ͘ ϱ͘ ƐƐĞƐƐƐƉůŝŶƚĂŶĚƐůŝŶŐŽƌƐǁĂƚŚĞǆƚƌĞŵŝƚǇĂƐŶĞĞĚĞĚ͘ ϲ͘ ZĞĂƐƐĞƐƐĂŶĚĚŽĐƵŵĞŶƚĚŝƐƚĂůƉƵůƐĞ͕ŵŽƚŽƌ͕ĂŶĚƐĞŶƐŽƌǇĨƵŶĐƚŝŽŶĂĨƚĞƌƐƉůŝŶƚĂƉƉůŝĐĂƚŝŽŶĂŶĚŽŶĂŶ ŽŶŐŽŝŶŐďĂƐŝƐƚŚƌŽƵŐŚŽƵƚƚƌĂŶƐƉŽƌƚ͘ x /ĨĂŶǇĚĞƚĞƌŝŽƌĂƚŝŽŶŝƐŶŽƚĞĚ͕ůŽŽƐĞŶƐƉůŝŶƚĂŶĚƌĞĂƐƐĞƐƐ͘ dƌĂĐƚŝŽŶ^ƉůŝŶƚƐ ϭ͘ /ĨĂĨĞŵƵƌĨƌĂĐƚƵƌĞŝƐƐƵƐƉĞĐƚĞĚĂŶĚƚŚĞƌĞŝƐŶŽĞǀŝĚĞŶĐĞŽĨƉĞůǀŝĐŝŶƐƚĂďŝůŝƚǇŽƌĨƌĂĐƚƵƌĞ͕ƵƚŝůŝǌĞĂ ƚƌĂĐƚŝŽŶƐƉůŝŶƚ͘ Ϯ͘ ƐƐĞƐƐĂŶĚĚŽĐƵŵĞŶƚĚŝƐƚĂůƉƵůƐĞ͕ŵŽƚŽƌ͕ĂŶĚƐĞŶƐŽƌǇĨƵŶĐƚŝŽŶƉƌŝŽƌƚŽƐƉůŝŶƚĂƉƉůŝĐĂƚŝŽŶ͘ x /ĨŶŽƉƵůƐĞƐĂƌĞƉƌĞƐĞŶƚĂŶĚƐŝŐŶŝĨŝĐĂŶƚĚĞĨŽƌŵŝƚǇŽƌƐǁĞůůŝŶŐŝƐƉƌĞƐĞŶƚ͕ƐƉůŝŶƚŝŶƉŽƐŝƚŝŽŶĨŽƵŶĚ ĂŶĚƌĂƉŝĚůǇƚƌĂŶƐƉŽƌƚƉĂƚŝĞŶƚƚŽĞŵĞƌŐĞŶĐǇĚĞƉĂƌƚŵĞŶƚ͘&ŝĞůĚƌĞĚƵĐƚŝŽŶƐŚŽƵůĚďĞĂǀŽŝĚĞĚ͘

Cypress Creek EMS System Policies and Treatment Guidelines

302 PROCEDURES Revised 8/2016 Treatment Approved: Levon Vartanian, MD

ϯ͘ &ŽůůŽǁŵĂŶƵĨĂĐƚƵƌĞƌ͛ƐŝŶƐƚƌƵĐƚŝŽŶƐƚŽƉůĂĐĞƚƌĂĐƚŝŽŶƐƉůŝŶƚĂŶĚƐĞĐƵƌĞƚŽĂŶŬůĞ͘ ϰ͘ ǆƚĞŶĚƚŚĞĚŝƐƚĂůĞŶĚŽĨƚŚĞƐƉůŝŶƚĂƚůĞĂƐƚƐŝǆ;ϲͿŝŶĐŚĞƐďĞǇŽŶĚĨŽŽƚ͘ ϱ͘ ƉƉůǇƚƌĂĐƚŝŽŶƚŽϭϬйŽĨƚŚĞƉĂƚŝĞŶƚ͛ƐǁĞŝŐŚƚŽƌĂŵĂǆŝŵƵŵŽĨϭϱůďƐ͘ ϲ͘ ZĞĂƐƐĞƐƐĂŶĚĚŽĐƵŵĞŶƚĚŝƐƚĂůƉƵůƐĞ͕ŵŽƚŽƌ͕ĂŶĚƐĞŶƐŽƌǇĨƵŶĐƚŝŽŶĂĨƚĞƌƐƉůŝŶƚĂƉƉůŝĐĂƚŝŽŶĂŶĚŽŶĂŶ ŽŶŐŽŝŶŐďĂƐŝƐƚŚƌŽƵŐŚŽƵƚƚƌĂŶƐƉŽƌƚ͘ x /ĨĂŶǇĚĞƚĞƌŝŽƌĂƚŝŽŶŝƐŶŽƚĞĚ͕ůŽŽƐĞŶƐƉůŝŶƚĂŶĚƌĞĂƐƐĞƐƐ͘

Cypress Creek EMS System Policies and Treatment Guidelines

303 PROCEDURES Revised 7/2019 Treatment Approved: Levon Vartanian, MD

/ŶƐƚƌƵŵĞŶƚdŚŽƌĂĐŽƐƚŽŵǇ Indications Equipment needed ŚůŽƌĂWƌĞƉ ^ƵƐƉĞĐƚĞĚƚĞŶƐŝŽŶƉŶĞƵŵŽƚŚŽƌĂǆŝŶƉĞƌŝͲĂƌƌĞƐƚƚƌĂƵŵĂƉĂƚŝĞŶƚ͘ ηϭϬƐĐĂůƉĞů ^ƵƐƉĞĐƚĞĚŚĞŵŽƚŚŽƌĂǆƉƌĞǀĞŶƚŝŶŐĞĨĨĞĐƚŝǀĞǀĞŶƚŝůĂƚŝŽŶ͘ ZŽĐŚĞƐƚĞƌͲWĞĂŶĨŽƌĐĞƉƐ dƌĂƵŵĂƚŝĐĐĂƌĚŝĂĐĂƌƌĞƐƚ;ƉĞƌĨŽƌŵ&KZƉůĂĐŝŶŐ>ƵĐĂƐĚĞǀŝĐĞŽŶ WĞƌŵĂŶĞŶƚŵĂƌŬĞƌ ƉĂƚŝĞŶƚͿ ďƐŽƌďĞŶƚƉĂĚ ^ŝŐŶƐΘ^ǇŵƉƚŽŵƐŽĨdĞŶƐŝŽŶWŶĞƵŵŽƚŚŽƌĂǆ x ǇƐƉŶĞĂ x ŶǆŝĞƚǇ x dĂĐŚǇƉŶĞĂ x ^ƵďĐƵƚĂŶĞŽƵƐĞŵƉŚǇƐĞŵĂ x ďƐĞŶƚďƌĞĂƚŚƐŽƵŶĚƐ x ,ǇƉĞƌƌĞƐŽŶĂŶĐĞŽŶƉĞƌĐƵƐƐŝŽŶ x ĂƌĐŽĚĞƐŝŐŶŽŶƵůƚƌĂƐŽƵŶĚ x ŝƐƚĞŶĚĞĚŶĞĐŬǀĞŝŶƐ;>d^/'EͿ x ĞƌǀŝĐĂůƚƌĂĐŚĞĂůĚĞǀŝĂƚŝŽŶ;ŽĨƚĞŶĚŽĞƐŶŽƚŽĐĐƵƌͲͲ>d^/'EͿ ŽŶƚƌĂŝŶĚŝĐĂƚŝŽŶƐ x EŽĂďƐŽůƵƚĞĐŽŶƚƌĂŝŶĚŝĐĂƚŝŽŶŝĨƉĂƚŝĞŶƚŝƐƉĞƌŝͲĂƌƌĞƐƚǁŝƚŚƐŝŐŶƐŽĨƐŚŽĐŬ͕ŚǇƉŽǆŝĂ͕ŽƌŝŶĂďŝůŝƚǇƚŽ ǀĞŶƚŝůĂƚĞ͘ x ŽŶƚƌĂŝŶĚŝĐĂƚĞĚǁŚĞŶƉĂƚŝĞŶƚŚĂƐĂƉĂůƉĂďůĞƌĂĚŝĂůƉƵůƐĞŽƌďůŽŽĚƉƌĞƐƐƵƌĞ͘ x ŽŶƚƌĂŝŶĚŝĐĂƚĞĚǁŚĞŶŝŶũƵƌŝĞƐĂƌĞŝŶĐŽŵƉĂƚŝďůĞǁŝƚŚůŝĨĞ;ƐĞĞCriteria for DeathͿ͘ x ĂƵƚŝŽŶǁŚĞŶƉĂƚŝĞŶƚŝƐƚĂŬŝŶŐďůŽŽĚƚŚŝŶŶĞƌƐ͘ x ǀŽŝĚŝŶĐŝƐŝŽŶƚŚƌŽƵŐŚĂŶŽǀĞƌůǇŝŶŐƐŬŝŶŝŶĨĞĐƚŝŽŶ͘ WƌŽĐĞĚƵƌĞͶWϯŽŶůǇ ϭ͘ /ĚĞŶƚŝĨǇŝŶĚŝĐĂƚŝŽŶƐĂŶĚƉůĂĐĞƉĂƚŝĞŶƚŝŶĂƉƉƌŽƉƌŝĂƚĞƉŽƐŝƚŝŽŶŝŶŐ͘WůĂĐĞĂďƐŽƌďĞŶƚƉĂĚƵŶĚĞƌ ƉĂƚŝĞŶƚ͛ƐƐŝĚĞƚŽĂďƐŽƌďĂŶǇĚƌĂŝŶĂŐĞ͘ Ϯ͘ ůĞĂŶƐĞĐŚĞƐƚǁĂůůǁŝƚŚŚůŽƌĂWƌĞƉĂŶĚĚŽŶƐƚĞƌŝůĞŐůŽǀĞƐ͘ ϯ͘ hƐŝŶŐŶŽŶͲĚŽŵŝŶĂŶƚŚĂŶĚ͕ŝĚĞŶƚŝĨǇůĂŶĚŵĂƌŬƐĂƚƚŚĞϰͬϱƚŚŝŶƚĞƌĐŽƐƚĂůƐƉĂĐĞĂƚƚŚĞĂŶƚĞƌŝŽƌƚŽŵŝĚĚůĞ ĂǆŝůůĂƌǇůŝŶĞ͘;>ĞǀĞůŽĨŶŝƉƉůĞƐŝŶŵĞŶŽƌŝŶĨƌĂŵĂŵŵĂƌǇĨŽůĚŝŶǁŽŵĞŶͿ͘ ϰ͘ DĂŬĞĂƚǁŽͲŝŶĐŚ;Ϯ͟ͿƐŬŝŶŝŶĐŝƐŝŽŶƉĂƌĂůůĞůƚŽƚŚĞƌŝďƐĂůŽŶŐƚŚĞƚŽƉďŽƌĚĞƌŽĨƚŚĞŝŶĨĞƌŝŽƌƌŝď͘ŽŶŽƚ ĐƵƚƚŚƌŽƵŐŚďƌĞĂƐƚƚŝƐƐƵĞŝĨƉŽƐƐŝďůĞ͘ ϱ͘ hƐŝŶŐZŽĐŚĞƐƚĞƌͲWĞĂŶĨŽƌĐĞƉƐ͕ďůƵŶƚůǇĚŝƐƐĞĐƚƐƵďĐƵƚĂŶĞŽƵƐĨĂƚƚŽŝĚĞŶƚŝĨǇƌŝďďŽƌĚĞƌƐĂŶĚĞŶƐƵƌĞ ƚŚĞǇĂƌĞŶŽƚďƌŽŬĞŶ͘ ϲ͘ WĞŶĞƚƌĂƚĞƚŚŽƌĂĐŝĐĐĂǀŝƚǇǁŝƚŚZŽĐŚĞƐƚĞƌͲWĞĂŶĨŽƌĐĞƉƐ;ĚŽŶŽƚƵƐĞƐĐĂůƉĞůͿ͘WůĂĐĞƚŚƵŵďŽǀĞƌŚŝŶŐĞ͕ ĂƉƉůǇĨŝƌŵ͕ƐƚĞĂĚǇƉƌĞƐƐƵƌĞ͕ĂŶĚƉŽƉƚŚƌŽƵŐŚƚŚĞĐŚĞƐƚǁĂůů͘ŽǀĞƌŝŶĐŝƐŝŽŶǁŝƚŚŚĂŶĚƚŽĂǀŽŝĚďĞŝŶŐ ƐƉƌĂǇĞĚďǇďůŽŽĚ͘

Cypress Creek EMS System Policies and Treatment Guidelines

304 PROCEDURES Revised 7/2019 Treatment Approved: Levon Vartanian, MD

ϳ͘ KƉĞŶƚŚĞZŽĐŚĞƐƚĞƌͲWĞĂŶĨŽƌĐĞƉƐƉĂƌĂůůĞůƚŽƚŚĞƌŝďƐƚŽƚĞĂƌŝŶƚĞƌĐŽƐƚĂůŵƵƐĐůĞƐĂŶĚĞŶůĂƌŐĞ ƚŚŽƌĂĐŽƐƚŽŵǇƐŝƚĞ͘ ϴ͘ WĞƌĨŽƌŵĂůƵŶŐƐǁĞĞƉǁŝƚŚĂŐůŽǀĞĚĨŝŶŐĞƌďǇŝŶƐĞƌƚŝŶŐĨŝŶŐĞƌĂŶĚƐǁĞĞƉŝŶŐĂůŽŶŐŝŶƚĞƌŶĂůĐŚĞƐƚǁĂůů ƚŽĞŶƐƵƌĞƚŚĞƌĞĂƌĞŶŽůƵŶŐĂĚŚĞƐŝŽŶƐƉƌĞǀĞŶƚŝŶŐĚƌĂŝŶĂŐĞŽĨďůŽŽĚŽƌĂŝƌ͘ ϵ͘ DŽŶŝƚŽƌďůŽŽĚŽƵƚƉƵƚĂŶĚŶŽƚĞƚŽƚĂůĂŵŽƵŶƚŽĨďůŽŽĚ;ŝĨĂŶǇͿƌĞŵŽǀĞĚĨƌŽŵƚŚĞƚŚŽƌĂĐŝĐĐĂǀŝƚǇ͘ ϭϬ͘ ŽŶŽƚƉĂĐŬƚŚĞǁŽƵŶĚ͕ŝŶƐĞƌƚĂŶǇƚƵďĞƐ͕ŽƌĐŽǀĞƌƚŚĞŽƐƚŽŵǇ;ǁŽƵŶĚͿǁŝƚŚŐĂƵǌĞ͕ŚĞŵŽƐƚĂƚŝĐ ĚƌĞƐƐŝŶŐ͕ŽƌŽĐĐůƵƐŝǀĞĚƌĞƐƐŝŶŐ͘ ϭϭ͘ >ĂďĞůŝŶĐŝƐŝŽŶ͞D^͟ĂŶĚĐŝƌĐůĞǁŽƵŶĚƵƐŝŶŐĂƉĞƌŵĂŶĞŶƚŵĂƌŬĞƌ͘

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Cypress Creek EMS System Policies and Treatment Guidelines

305 PROCEDURES Revised 8/2016 Venous Access Approved: Levon Vartanian, MD

WĞƌŝƉŚĞƌĂů/sĐĐĞƐƐ Indications Equipment Needed EĞĐĞƐƐŝƚǇĨŽƌĂĚŵŝŶŝƐƚƌĂƚŝŽŶŽĨŵĞĚŝĐĂƚŝŽŶƐŽƌ /s^ƚĂƌƚŬŝƚ ĨůƵŝĚ͘ ǆƚĞŶƐŝŽŶƐĞƚ ŶƚŝĐŝƉĂƚĞĚŶĞĐĞƐƐŝƚǇĨŽƌǀĞŶŽƵƐĂĐĐĞƐƐĂƚ ƉƉƌŽƉƌŝĂƚĞůǇƐŝǌĞĚ/sĐĂƚŚĞƚĞƌ ŵĞƌŐĞŶĐǇĞƉĂƌƚŵĞŶƚ ^ŚĂƌƉƐĐŽŶƚĂŝŶĞƌŽƌƐŚĂƌƉƐƐŚƵƚƚůĞǁŝƚŚŝŶ ƌĞĂĐŚ WƌŽĐĞĚƵƌĞ ϭ͘ ^ĞůĞĐƚƉƌŽƉĞƌĞƋƵŝƉŵĞŶƚĂŶĚŝŶƐƉĞĐƚĨŽƌƐƚĞƌŝůŝƚǇ͕ĞǆƉŝƌĂƚŝŽŶĚĂƚĞ͕ĂŶĚĐůĂƌŝƚǇŽĨƐŽůƵƚŝŽŶƐ͘ Ϯ͘ ƐƚĂďůŝƐŚ/sƵƐŝŶŐƉƌŽƉĞƌĂƐĞƉƚŝĐƚĞĐŚŶŝƋƵĞĂŶĚƐĞĐƵƌĞŝŶƉůĂĐĞĂƉƉƌŽƉƌŝĂƚĞůǇ͘ ϯ͘ ŽŶŶĞĐƚĂŶĞǆƚĞŶƐŝŽŶƐĞƚŽƌĚŝƌĞĐƚůǇĐŽŶŶĞĐƚ/sŝŶĨƵƐŝŽŶƐĞƚ͘ WĞĂƌůƐ x /ŶƚƌĂǀĞŶŽƵƐĂĐĐĞƐƐĐĂŶďĞĂĐĐŽŵƉůŝƐŚĞĚǁŝƚŚĂƐĂůŝŶĞůŽĐŬ͕ƉĞƌŝƉŚĞƌĂůǀĞŶŽƵƐŝŶĨƵƐŝŽŶ͕ŝŵƉůĂŶƚĞĚ ƉŽƌƚĂĐĐĞƐƐ͕ŽƌǀŝĂ/KĂĐĐĞƐƐ͕ĂƚƚŚĞĚŝƐĐƌĞƚŝŽŶŽĨƚŚĞƉĂƌĂŵĞĚŝĐ/W;WϮͬWϯͿ͘ x ĐĐĞƐƐǀŝĂĞǆƚĞƌŶĂůũƵŐƵůĂƌ͕ŝŵƉůĂŶƚĞĚƉŽƌƚͬĐĞŶƚƌĂůůŝŶĞ͕ŽƌŝŶƚƌĂŽƐƐĞŽƵƐƐŚŽƵůĚďĞƌĞƐĞƌǀĞĚĨŽƌ ƉĂƚŝĞŶƚƐǁŚŽĂƌĞŝŶŝŵŵŝŶĞŶƚŶĞĞĚŽĨ/sĨůƵŝĚŽƌŵĞĚŝĐĂƚŝŽŶŽƌĂƌĞƉŽƚĞŶƚŝĂůůǇƵŶƐƚĂďůĞ͕ĂŶĚŝŶ ǁŚŽŵŽƚŚĞƌ/sĂĐĐĞƐƐŝƐŶŽƚƉŽƐƐŝďůĞ͘ZĞĨĞƌƚŽƚŚŽƐĞŝŶĚŝǀŝĚƵĂůƉƌŽĐĞĚƵƌĞƐ͘ x /ŶĂůůƉĞĚŝĂƚƌŝĐƉĂƚŝĞŶƚƐǁŝƚŚ/sƐĐŽŶŶĞĐƚĞĚƚŽĨůƵŝĚƐĞƚƐ͕ƵƚŝůŝǌĞĂƵƌĞƚƌŽůŽƌŵŝĐƌŽͲĚƌŝƉŝŶĨƵƐŝŽŶƐĞƚ ĂŶĚĐĂƌĞĨƵůůǇŵŽŶŝƚŽƌƚŚĞĚĞůŝǀĞƌǇŽĨĨůƵŝĚƐ͘ x ƐĞƉƚŝĐƚĞĐŚŶŝƋƵĞƐŚĂůůďĞƵƐĞĚĂƚĂůůƚŝŵĞƐ͘ x An IV catheter is a SINGLE use device and should never be used to puncture the skin more than once. If an IV attempt is unsuccessful for any reason, a new IV catheter must be used on any subsequent attempt and documented in the medical record.

Cypress Creek EMS System Policies and Treatment Guidelines

306 PROCEDURES Revised 12/2018 Venous Access Approved: Levon Vartanian, MD

ǆƚĞƌŶĂů:ƵŐƵůĂƌĐĐĞƐƐ Indications Equipment Needed /ŵŵŝŶĞŶƚŶĞĞĚĨŽƌ/sĨůƵŝĚŽƌŵĞĚŝĐĂƚŝŽŶ /s^ƚĂƌƚŬŝƚ ĂĚŵŝŶŝƐƚƌĂƚŝŽŶ͘ ǆƚĞŶƐŝŽŶƐĞƚ KƚŚĞƌ/sͬ/KĂĐĐĞƐƐŶŽƚƉŽƐƐŝďůĞ ƉƉƌŽƉƌŝĂƚĞůǇƐŝǌĞĚ/sĐĂƚŚĞƚĞƌ ^ŚĂƌƉƐĐŽŶƚĂŝŶĞƌŽƌƐŚĂƌƉƐƐŚƵƚƚůĞǁŝƚŚŝŶ ƌĞĂĐŚ WƌŽĐĞĚƵƌĞ ϭ͘ WůĂĐĞƉĂƚŝĞŶƚŝŶƐƵƉŝŶĞƉŽƐŝƚŝŽŶǁŝƚŚŚĞĂĚĚŽǁŶ͘ Ϯ͘ dƵƌŶƉĂƚŝĞŶƚ͛ƐŚĞĂĚĂǁĂǇĨƌŽŵƐĞůĞĐƚĞĚƐŝĚĞŝĨŶŽƌŝƐŬŽĨĐĞƌǀŝĐĂůŝŶũƵƌǇ͘ ϯ͘ WƌĞƉĂƌĞƐŝƚĞƵƐŝŶŐĂƐĞƉƚŝĐƚĞĐŚŶŝƋƵĞ͘ ϰ͘ ŽŵƉƌĞƐƐǀĞŝŶůŝŐŚƚůǇĂƚĐůĂǀŝĐůĞ͕ƉƵŶĐƚƵƌĞǀĞŝŶŵŝĚǁĂǇďĞƚǁĞĞŶĂŶŐůĞŽĨũĂǁĂŶĚĐůĂǀŝĐůĞ͕ĂŶĚ ĐĂŶŶƵůĂƚĞǀĞŝŶ͘ ϱ͘ ƚƚĂĐŚ/sĂŶĚƐĞĐƵƌĞĐĂƚŚĞƚĞƌ͘hƐĞĂůĂƌŐĞ;ϰ͟ͿƚĞŐĂĚĞƌŵƚŽĐŽǀĞƌĐĂƚŚĞƚĞƌƐŝƚĞ͘ ϲ͘ ǀŽŝĚĐŝƌĐƵŵĨĞƌĞŶƚŝĂůĚƌĞƐƐŝŶŐŽƌƚĂƉŝŶŐ͘ŽŶŽƚƚĂƉĞĞǆĐĞƐƐŝǀĞůǇŽǀĞƌĐĂƚŚĞƚĞƌ͘ ϳ͘ ZĞĂƐƐĞƐƐ/sƐŝƚĞĨƌĞƋƵĞŶƚůǇĨŽƌĞǆƚƌĂǀĂƐĂƚŝŽŶŽƌŽƚŚĞƌĐŽŵƉůŝĐĂƚŝŽŶƐ͘ WĞĂƌůƐ x ǆƚĞƌŶĂůũƵŐƵůĂƌ/sŵĂǇŽŶůǇďĞĂƚƚĞŵƉƚĞĚŽŶŽŶĞƐŝĚĞŽĨƚŚĞƉĂƚŝĞŶƚ͛ƐŶĞĐŬ͘ x hƐĞĐĂƵƚŝŽŶƚŽĂǀŽŝĚĂůůŽǁŝŶŐĂŝƌŝŶƚŽ/sƐŝƚĞĂŶĚĐĂƵƐĞĂŶĂŝƌĞŵďŽůŝƐŵ͘ x /ĨĂƚƚĞŵƉƚŝƐƵŶƐƵĐĐĞƐƐĨƵůŽƌ/sĐĂƚŚĞƚĞƌďĞĐŽŵĞƐĚŝƐůŽĚŐĞĚ͕ĂƉƉůǇĨŝƌŵƉƌĞƐƐƵƌĞĨŽƌĂƚůĞĂƐƚϮʹϯ ŵŝŶƵƚĞƐƚŽĐŽŶƚƌŽůďůĞĞĚŝŶŐĂŶĚƉƌĞǀĞŶƚŚĞŵĂƚŽŵĂĨƌŽŵĨŽƌŵŝŶŐŝŶŶĞĐŬ͘ x External jugular access has a higher complication rate than IO access; consider IO placement in patients when evaluating for external jugular placement.

Cypress Creek EMS System Policies and Treatment Guidelines

307 PROCEDURES Revised 8/2016 Venous Access Approved: Levon Vartanian, MD

/ŵƉůĂŶƚĞĚWŽƌƚƐĂŶĚĞŶƚƌĂů>ŝŶĞƐ Indications Equipment Needed /ŵŵŝŶĞŶƚŶĞĞĚĨŽƌ/sĨůƵŝĚŽƌŵĞĚŝĐĂƚŝŽŶ ^ƚĞƌŝůĞŐůŽǀĞƐ ĂĚŵŝŶŝƐƚƌĂƚŝŽŶ͘ ^ƚĞƌŝůĞĂĐĐĞƐƐŬŝƚ KƚŚĞƌ/sͬ/KĂĐĐĞƐƐŶŽƚƉŽƐƐŝďůĞ͘ ϭϬĐĐ^ǇƌŝŶŐĞƐ ĞŶƚƌĂůǀĞŶŽƵƐĂĐĐĞƐƐŝŶĐĂƌĚŝĂĐĂƌƌĞƐƚ ^ƚĞƌŝůĞƐĂůŝŶĞĨůƵƐŚ ƉĂƚŝĞŶƚ͘ ĐĐĞƐƐŝŶŐǆŝƐƚŝŶŐĂƚŚĞƚĞƌƐͶĂƌĚŝĂĐƌƌĞƐƚ ϭ͘ ŽŶŽƚĂĐĐĞƐƐĚŝĂůǇƐŝƐĨŝƐƚƵůĂƐŽƌƐŚƵŶƚƐ͘ Ϯ͘ hƐĞŽĨĐĞŶƚƌĂůǀĞŶŽƵƐůŝŶĞƐ͕W/ůŝŶĞƐ͕ŽƌŝŵƉůĂŶƚĞĚƉŽƌƚůŝŶĞƐŝƐĂƉƉƌŽƉƌŝĂƚĞŝĨƉĂƚŝĞŶƚŝƐŝŶĐĂƌĚŝĂĐ ĂƌƌĞƐƚĂŶĚĂŶ/sŽƌ/KĐĂŶŶŽƚďĞƌĂƉŝĚůǇĞƐƚĂďůŝƐŚĞĚ͘ ϯ͘ hƐĞĐůĞĂŶ͕ĂƐĞƉƚŝĐ;ŝĨŶŽƚƐƚĞƌŝůĞͿƚĞĐŚŶŝƋƵĞ͘ ϰ͘ ůĞĂŶƚŚĞƉŽƌƚŽĨƚŚĞĐĂƚŚĞƚĞƌƚŚŽƌŽƵŐŚůǇǁŝƚŚĂůĐŽŚŽůǁŝƉĞ͘ ϱ͘ hƐŝŶŐƐƚĞƌŝůĞƚĞĐŚŶŝƋƵĞ͕ǁŝƚŚĚƌĂǁϱͲϭϬŵ>ŽĨďůŽŽĚĂŶĚĚŝƐĐĂƌĚƐǇƌŝŶŐĞŝŶƐŚĂƌƉƐĐŽŶƚĂŝŶĞƌ͘ ϲ͘ hƐŝŶŐƐƚĞƌŝůĞƚĞĐŚŶŝƋƵĞ͕ŐĞŶƚůǇĂƚƚĞŵƉƚƚŽĨůƵƐŚϱŵ>ŽĨŶŽƌŵĂůƐĂůŝŶĞ͘ ϳ͘ /ĨƚŚĞƌĞŝƐŶŽƌĞƐŝƐƚĂŶĐĞĂŶĚŶŽĞǀŝĚĞŶĐĞŽĨŝŶĨŝůƚƌĂƚŝŽŶ͕ďĞŐŝŶĂĚŵŝŶŝƐƚƌĂƚŝŽŶŽĨŵĞĚŝĐĂƚŝŽŶƐŽƌ/s ĨůƵŝĚƐ͘ ϴ͘ /ĨƚŚĞƌĞŝƐƌĞƐŝƐƚĂŶĐĞŽƌĞǀŝĚĞŶĐĞŽĨŝŶĨŝůƚƌĂƚŝŽŶ͕ŽƌĂŶǇĐŽŶĐĞƌŶƚŚĂƚƚŚĞĐĂƚŚĞƚĞƌŵĂǇďĞĚŝƐůŽĚŐĞĚŽƌ ĐůŽƚƚĞĚ͕ĚŽŶŽƚƵƐĞƚŚĞĐĂƚŚĞƚĞƌ͘ ĐĐĞƐƐŝŶŐ/ŵƉůĂŶƚĞĚWŽƌƚƐ ϭ͘ dŚŝƐŝƐĂƐƚĞƌŝůĞƉƌŽĐĞĚƵƌĞĂŶĚƵƐĞŽĨĂŶĂƐƐŝƐƚĂŶƚŝƐŶĞĐĞƐƐĂƌǇ͘ Ϯ͘ >ŽĐĂƚĞƚŚĞǀĞŶŽƵƐĂĐĐĞƐƐĚĞǀŝĐĞĂŶĚĐůĞĂŶƐĞƚŚĞĂƌĞĂǁŝƚŚĂĐŚůŽƌŚĞǆŝĚŝŶĞƐǁĂď͘ ϯ͘ ŽŶƐƚĞƌŝůĞŐůŽǀĞƐĂŶĚŚĂǀĞĂŶĂƐƐŝƐƚĂŶƚŽƉĞŶƚŚĞ,ƵďĞƌŶĞĞĚůĞƉĂĐŬĂŐĞĂŶĚĂϭϬĐĐƐƚĞƌŝůĞƐĂůŝŶĞ ƐǇƌŝŶŐĞ͘ ϰ͘ ŽŶŶĞĐƚƚŚĞϭϬĐĐƐǇƌŝŶŐĞƚŽƚŚĞ,ƵďĞƌŶĞĞĚůĞĂŶĚĨůƵƐŚ͘ ϱ͘ ^ƚĂďŝůŝǌĞƚŚĞƐŬŝŶŽǀĞƌƚŚĞƉŽƌƚƚĂŬŝŶŐĐĂƌĞŶŽƚƚŽĐŽŶƚĂŵŝŶĂƚĞƚŚĞĂƌĞĂ͘ ϲ͘ 'ƌĂƐƉŝŶŐƚŚĞǁŝŶŐƐŽĨƚŚĞ,ƵďĞƌŶĞĞĚůĞ͕ŐĞŶƚůǇďƵƚĨŝƌŵůǇŝŶƐĞƌƚƚŚĞŶĞĞĚůĞƚŽŝƚƐƐƚŽƉƉŝŶŐƉŽŝŶƚ͘ ϳ͘ ƐƉŝƌĂƚĞĨŽƌƌĞƚƵƌŶŽĨďůŽŽĚĂŶĚĨůƵƐŚǁŝƚŚϭϬŵůŶŽƌŵĂůƐĂůŝŶĞ͘ ϴ͘ ůĂŵƉƉŽƌƚĂŶĚĞǆĐŚĂŶŐĞƐĂůŝŶĞƐǇƌŝŶŐĞĨŽƌŚĞƉĂƌŝŶĨůƵƐŚ ϵ͘ ŽŶŶĞĐƚŚĞƉĂƌŝŶĨůƵƐŚ;ϭϬϬƵŶŝƚƐͬŵůͿĂŶĚĨůƵƐŚǁŝƚŚϱŵů;ϱϬϬƵŶŝƚƐͿ͘ ϭϬ͘ ŽŶŶĞĐƚ/sƚƵďŝŶŐĂŶĚĞŶƐƵƌĞƉƌŽƉĞƌŝŶĨƵƐŝŽŶ͘ĞĐĞƌƚĂŝŶƚŚĞůŝŶĞĐŽŶƚŝŶƵĞƐƚŽĨůŽǁ͘ ϭϭ͘ /ŶƐĞƌƚƐƚĞƌŝůĞ͕ƐůŽƚƚĞĚϮǆϮ͛ƐƵŶĚĞƌƚŚĞǁŝŶŐƐŽĨƚŚĞ,ƵďĞƌŶĞĞĚůĞ͘ ϭϮ͘ ^ĞĐƵƌĞŝŶƉůĂĐĞǁŝƚŚůĂƌŐĞƚƌĂŶƐƉĂƌĞŶƚĚƌĞƐƐŝŶŐ͘

Cypress Creek EMS System Policies and Treatment Guidelines

308 PROCEDURES Revised 6/2019 Venous Access Approved: Levon Vartanian, MD

/ŶƚƌĂŽƐƐĞŽƵƐ;/KͿĐĐĞƐƐ Indications Equipment Needed /ŵŵŝŶĞŶƚŶĞĞĚĨŽƌ/sĨůƵŝĚŽƌŵĞĚŝĐĂƚŝŽŶ Ͳ/KĚƌŝǀĞƌĂŶĚŶĞĞĚůĞƐĞƚ ĂĚŵŝŶŝƐƚƌĂƚŝŽŶ͕ĂŶĚ ŚůŽƌĂƉƌĞƉ KƚŚĞƌ/sͬ/KĂĐĐĞƐƐŶŽƚƉŽƐƐŝďůĞŽƌ Ͳ/KƐĞĐƵƌŝŶŐĚĞǀŝĐĞŽƌƌŽůůĞĚŐĂƵǌĞ ƵŶƐƵĐĐĞƐƐĨƵůĂĨƚĞƌϮĂƚƚĞŵƉƚƐŽƌϵϬƐĞĐŽŶĚƐ Ͳ/KĞǆƚĞŶƐŝŽŶĂŶĚĨůƵƐŚ Contraindications >ŝĚŽĐĂŝŶĞ͕ŝĨŶĞĞĚĞĚ x ^ƵƐƉĞĐƚĞĚĨƌĂĐƚƵƌĞŽĨƚŚĞƚŝďŝĂŽƌĨĞŵƵƌŝĨ ĂĐĐĞƐƐŝŶŐƚŝďŝĂůƐŝƚĞ x ^ƵƐƉĞĐƚĞĚĨƌĂĐƚƵƌĞŽĨƚŚĞŚƵŵĞƌƵƐŝĨ ĂĐĐĞƐƐŝŶŐŚƵŵĞƌĂůŚĞĂĚ x WƌĞǀŝŽƵƐŽƌƚŚŽƉĞĚŝĐƉƌŽĐĞĚƵƌĞƐƐƵĐŚĂƐ ŬŶĞĞƌĞƉůĂĐĞŵĞŶƚĂƚƐŝƚĞ x /ŶĨĞĐƚŝŽŶŽǀĞƌŝŶƐĞƌƚŝŽŶƐŝƚĞ x /ŶĂďŝůŝƚǇƚŽůŽĐĂƚĞĂŶĂƚŽŵŝĐĂůůĂŶĚŵĂƌŬƐ x ŽŵƉƌŽŵŝƐĞĚĞǆƚƌĞŵŝƚǇĚƵĞƚŽƉƌĞĞǆŝƐƚŝŶŐ ŵĞĚŝĐĂůĐŽŶĚŝƚŝŽŶ x WĂƚŝĞŶƚƐĂƚƌŝƐŬĨŽƌŶŽŶͲƚƌĂŶƐƉŽƌƚ x ZĞĐĞŶƚ/KŝŶƐĞƌƚŝŽŶŝŶƚŚĞƐĂŵĞďŽŶĞ ǁŝƚŚŝŶƚŚĞƉĂƐƚϮϰŚŽƵƌƐ WƌŝŵĂƌǇĐĐĞƐƐ^ŝƚĞ͗WƌŽǆŝŵĂůdŝďŝĂ ϭ͘ >ŽĐĂƚĞƚŚĞƉĂƚĞůůĂ͘/ĚĞŶƚŝĨǇƚŚĞƚŝďŝĂůƚƵďĞƌŽƐŝƚǇ ;ϮĨŝŶŐĞƌͲǁŝĚƚŚƐŝŶĨĞƌŝŽƌƚŽƚŚĞƉĂƚĞůůĂͿ͘ Ϯ͘ /ĚĞŶƚŝĨǇƚŚĞƚŝďŝĂůƉůĂƚĞĂƵ ;ϭʹϮĨŝŶŐĞƌͲǁŝĚƚŚƐŵĞĚŝĂůƚŽƚŚĞƚŝďŝĂůƚƵďĞƌŽƐŝƚǇ ŽŶƚŚĞƉƌŽǆŝŵĂůƚŝďŝĂͿ͘ ϯ͘ ŝŵŶĞĞĚůĞƐĞƚƚŽǁĂƌĚƚŚĞĐĞŶƚĞƌŽĨƚŚĞďŽŶĞĂƚĂ ϵϬͲĚĞŐƌĞĞĂŶŐůĞ͘ ^ĞĐŽŶĚĂƌǇĐĐĞƐƐ^ŝƚĞ͗ŝƐƚĂů&ĞŵƵƌ ;/ŶĨĂŶƚͬŚŝůĚKŶůǇͿ ϭ͘ ^ĞĐƵƌĞƚŚĞůĞŐŽƵƚƐƚƌĞƚĐŚĞĚƚŽĞŶƐƵƌĞƚŚĞŬŶĞĞ ĚŽĞƐŶŽƚďĞŶĚ͘ Ϯ͘ /ĚĞŶƚŝĨǇƚŚĞƉĂƚĞůůĂďǇƉĂůƉĂƚŝŽŶ͘dŚĞŝŶƐĞƌƚŝŽŶƐŝƚĞ ŝƐũƵƐƚƉƌŽǆŝŵĂůƚŽƚŚĞƉĂƚĞůůĂ;ŵĂǆŝŵƵŵϭĐŵͿĂŶĚ ĂƉƉƌŽǆŝŵĂƚĞůǇϭʹϮĐŵŵĞĚŝĂůƚŽŵŝĚůŝŶĞ͘ ϯ͘ ŝŵŶĞĞĚůĞƐĞƚƚŽǁĂƌĚƚŚĞĐĞŶƚĞƌŽĨƚŚĞďŽŶĞĂƚĂ ϵϬͲĚĞŐƌĞĞĂŶŐůĞ͘ ŝƐƚĂů&ĞŵƵƌ^ŝƚĞ

Cypress Creek EMS System Policies and Treatment Guidelines

309 PROCEDURES Revised 6/2019 Venous Access Approved: Levon Vartanian, MD

^ĞĐŽŶĚĂƌǇĐĐĞƐƐ^ŝƚĞ͗,ƵŵĞƌĂů,ĞĂĚ

ϭ͘ ǆƉŽƐĞƐŚŽƵůĚĞƌĂŶĚĂĚĚƵĐƚŚƵŵĞƌƵƐ;ƉůĂĐĞĂƌŵĂŐĂŝŶƐƚƉĂƚŝĞŶƚ͛ƐďŽĚǇͿ͘ Ϯ͘ /ĚĞŶƚŝĨǇƚŚĞŐƌĞĂƚĞƌƚƵďĞƌĐůĞŝŶƐĞƌƚŝŽŶƐŝƚĞ;ǁŚŝůĞƉŝŶĐŚŝŶŐƚŚĞĂŶƚĞƌŝŽƌĂŶĚƉŽƐƚĞƌŝŽƌĂƐƉĞĐƚƐŽĨƚŚĞ ŚƵŵĞƌĂůŚĞĂĚ͕ƉĂůƉĂƚĞƚŚĞŵŝĚͲƐŚĂĨƚŽĨƚŚĞŚƵŵĞƌƵƐƚŚĞŶŐƌĂĚƵĂůůǇŵŽǀĞǇŽƵƌĨŝŶŐĞƌƐƚŽǁĂƌĚƚŚĞ ƉƌŽǆŝŵĂůĂƐƉĞĐƚŽĨƚŚĞŚƵŵĞƌĂůŚĞĂĚĂŶĚĐŽŶĨŝƌŵŝĚĞŶƚŝĨŝĐĂƚŝŽŶŽĨƚŚĞŐƌĞĂƚĞƌƚƵďĞƌĐůĞͿ͘ ϯ͘ ŽŶĨŝƌŵƐŝƚĞĂƐĞĐŽŶĚƚŝŵĞ͗ŝĚĞŶƚŝĨǇƚŚĞĐŽƌĂĐŽŝĚƉƌŽĐĞƐƐĂŶĚĂĐƌŽŵŝŽŶďǇŵŽǀŝŶŐǇŽƵƌŝŶĚĞǆĂŶĚ ŵŝĚĚůĞĨŝŶŐĞƌĂůŽŶŐƚŚĞĐůĂǀŝĐůĞƚŽƚŚĞƐŚŽƵůĚĞƌƐůĂƚĞƌĂůĞŶĚ͘/ĚĞŶƚŝĨǇƚŚĞŐƌĞĂƚĞƌƚƵďĞƌĐůĞŝŶƐĞƌƚŝŽŶ ƐŝƚĞǁŚŝĐŚŝƐĂƉƉƌŽǆŝŵĂƚĞůǇƚǁŽĨŝŶŐĞƌǁŝĚƚŚƐŝŶĨĞƌŝŽƌƚŽƚŚĞĐŽƌĂĐŽŝĚƉƌŽĐĞƐƐĂŶĚƚŚĞĂĐƌŽŵŝŽŶ ĂůŽŶŐƚŚĞŚƵŵĞƌĂůŵŝĚůŝŶĞ͘ ϰ͘ ŝŵŶĞĞĚůĞƐĞƚĂƚĂϰϱͲĚĞŐƌĞĞĂŶŐůĞƚŽƚŚĞĂŶƚĞƌŝŽƌƉůĂŶĞĂŶĚƉŽƐƚĞƌŽŵĞĚŝĂů͘

Cypress Creek EMS System Policies and Treatment Guidelines

310 PROCEDURES Revised 6/2019 Venous Access Approved: Levon Vartanian, MD

WƌŽĐĞĚƵƌĞ

ϭ͘ /ĚĞŶƚŝĨǇƐŝƚĞƵƐŝŶŐƚĞĐŚŶŝƋƵĞƐĂďŽǀĞ͘ Ϯ͘ ůĞĂŶƐĞƐŝƚĞǁŝƚŚĐŚůŽƌĂƉƌĞƉƉƌŝŽƌƚŽĂŶǇŝŶƐĞƌƚŝŽŶĂƚƚĞŵƉƚƐ͘ ϯ͘ ^ĞůĞĐƚĂƉƉƌŽƉƌŝĂƚĞůǇƐŝǌĞĚͲ/KŶĞĞĚůĞƐĞƚ͗ Color Size Weight Range/Site Blue Ϯϱŵŵ ϯʹϯϵŬŐ Yellow ϰϱŵŵ х ϰϬŬŐ͕ŚƵŵĞƌĂůŚĞĂĚĂƉƉůŝĐĂƚŝŽŶ͘ ϰ͘ ƚƚĂĐŚŶĞĞĚůĞƐĞƚƚŽĚƌŝǀĞƌĂŶĚƌĞŵŽǀĞƐĂĨĞƚǇĐĂƉ͘ ϱ͘ ŝŵŶĞĞĚůĞƵƐŝŶŐŝŶƐƚƌƵĐƚŝŽŶƐĂďŽǀĞ͘ ϲ͘ WƵƐŚŶĞĞĚůĞƚŚƌŽƵŐŚƐŬŝŶƚŝƉƚŽƵĐŚĞƐďŽŶĞ͘5 mm of the catheter (at least one black line) must be visible outside the skin. ϳ͘ ^ƋƵĞĞǌĞƚƌŝŐŐĞƌĂŶĚĂƉƉůǇŵŽĚĞƌĂƚĞƐƚĞĂĚǇƉƌĞƐƐƵƌĞ͘In the event of driver failure, disconnect driver and advance needle set by hand while twisting. ϴ͘ ZĞůĞĂƐĞƚƌŝŐŐĞƌǁŚĞŶĞŶƚƌǇŝƐĨĞůƚŝŶƚŽƚŚĞŵĞĚƵůůĂƌǇƐƉĂĐĞ͘/ŶƉĞĚŝĂƚƌŝĐƐ͕ƚŚŝƐǁŝůůďĞǁŚĞŶĂƐƵĚĚĞŶ ͞ƉŽƉ͟Žƌ͞ŐŝǀĞ͟ŝƐĨĞůƚ͘/ŶĂĚƵůƚƐ͕ĂĚǀĂŶĐĞĂƉƉƌŽǆŝŵĂƚĞůǇϭʹϮĐŵĂĨƚĞƌĞŶƚƌǇŽƌƵŶƚŝůŚƵďŝƐĨůƵƐŚ ĂŐĂŝŶƐƚƐŬŝŶ͘ ϵ͘ ^ƚĂďŝůŝǌĞŶĞĞĚůĞŚƵď͕ĚŝƐĐŽŶŶĞĐƚĚƌŝǀĞƌ͕ĂŶĚƌĞŵŽǀĞƐƚǇůĞƚ͘^ĞĐƵƌĞƐƚǇůĞƚŝŶƐŚĂƌƉƐĐŽŶƚĂŝŶĞƌŽƌ ƐŚĂƌƉƐƐĞĐƵƌŝŶŐĚĞǀŝĐĞ͘ ϭϬ͘ WůĂĐĞͲ^ƚĂďŝůŝǌĞƌŽǀĞƌŚƵď͘ ϭϭ͘ ^ĞĐƵƌĞƉƌŝŵĞĚĞǆƚĞŶƐŝŽŶƐĞƚƚŽŚƵď͘(if patient is responsive to pain, prime with lidocaine). ϭϮ͘ &ŽƌƉĂƚŝĞŶƚƐƌĞƐƉŽŶƐŝǀĞƚŽƉĂŝŶ͕ĂĚŵŝŶŝƐƚĞƌϮϬʹϱϬŵŐŽĨLidocaine 2%;Ϭ͘ϮϱʹϬ͘ϱŵŐͬŬŐĨŽƌƉĞĚŝĂƚƌŝĐ ƉĂƚŝĞŶƚƐͿSLOWLYŝŶƚŽŵĞĚƵůůĂƌǇƐƉĂĐĞ͘tĂŝƚϭʹϮŵŝŶƵƚĞƐďĞĨŽƌĞŵŽǀŝŶŐƚŽŶĞǆƚƐƚĞƉ͘ ϭϯ͘ &ůƵƐŚͲ/KǁŝƚŚƌĂƉŝĚŝŶĨƵƐŝŽŶŽĨŶŽƌŵĂůƐĂůŝŶĞ͘ x ƐƉŝƌĂƚĞƐůŝŐŚƚůǇƉƌŝŽƌƚŽĨůƵƐŚĨŽƌǀŝƐƵĂůĐŽŶĨŝƌŵĂƚŝŽŶŽĨďŽŶĞŵĂƌƌŽǁ͘ x &ůƵƐŚǁŝƚŚϭϬŵ>ŽĨŶŽƌŵĂůƐĂůŝŶĞŝŶĂĚƵůƚƐ͖Ϯʹϱŵ>ŝŶŝŶĨĂŶƚƐͬƉĞĚŝĂƚƌŝĐƐ͘ ϭϰ͘ ^ƚĂďŝůŝǌĞŝŶƉůĂĐĞĂŶĚƐĞĐƵƌĞŝĨŶŽƚƵƐŝŶŐͲ^ƚĂďŝůŝǌĞƌ ϭϱ͘ ĚŵŝŶŝƐƚĞƌĨůƵŝĚƐŽƌŵĞĚŝĐĂƚŝŽŶƐĂƐŝŶĚŝĐĂƚĞĚ͘ Ͳ/KZĞŵŽǀĂů x /ŶŵŽƐƚĐĂƐĞƐ͕ƚŚĞͲ/KĚĞǀŝĐĞǁŝůůŶŽƚŶĞĞĚƚŽďĞƌĞŵŽǀĞĚŝŶƚŚĞĨŝĞůĚ͘,ŽǁĞǀĞƌ͕ŝĨƌĞŵŽǀĂůŝƐ ŝŶĚŝĐĂƚĞĚ͗ x ZĞŵŽǀĞĞǆƚĞŶƐŝŽŶƐĞƚ͘ x >ŝĨƚĂŶĚƌĞŵŽǀĞƐƚĂďŝůŝǌĞƌ͘ x ƚƚĂĐŚůƵĞƌͲůŽĐŬƐǇƌŝŶŐĞƚŽŚƵď͘ x tŝƚŚĚƌĂǁĐĂƚŚĞƚĞƌďǇĂƉƉůǇŝŶŐƚƌĂĐƚŝŽŶǁŚŝůĞƌŽƚĂƚŝŶŐƐǇƌŝŶŐĞĐůŽĐŬǁŝƐĞ͘ŽŶŽƚƌŽĐŬŽƌďĞŶĚ ĐĂƚŚĞƚĞƌ͘ x KŶĐĞƌĞŵŽǀĞĚ͕ŝŵŵĞĚŝĂƚĞůǇƉůĂĐĞƐǇƌŝŶŐĞĂŶĚĐĂƚŚĞƚĞƌŝŶƐŚĂƌƉƐĐŽŶƚĂŝŶĞƌ͘ x ƌĞƐƐǁŽƵŶĚƐŝƚĞĂƐĂƉƉƌŽƉƌŝĂƚĞ͘

Cypress Creek EMS System Policies and Treatment Guidelines

311 PROCEDURES Revised 6/2019 Venous Access Approved: Levon Vartanian, MD

WĞĂƌůƐ x ĨƚĞƌŝŶƐĞƌƚŝŽŶŽĨƚŚĞĚĞǀŝĐĞŝĨĂŶŽͲĨůŽǁƐŝƚƵĂƚŝŽŶŽĐĐƵƌƐŐĞŶƚůǇďĂĐŬƚŚĞĐĂƚŚĞƚĞƌŽƵƚĂƉƉƌŽǆ͘ϭŵŵ ǁŚŝůĞƚǁŝƐƚŝŶŐƐůŝŐŚƚůǇ͘KŶĐĞƚŚĞĐĂƚŚĞƚĞƌŚĂƐďĞĞŶďĂĐŬĞĚŽƵƚ͕ĨůƵƐŚƚŚĞ/KƐƉĂĐĞǁŝƚŚĂŶŽƚŚĞƌϭϬ ŵ>ŽĨEĂů͘ x ƉƌĞƐƐƵƌĞďĂŐŽƌWĐƵĨĨŵĂǇďĞĂƉƉůŝĞĚĂƐŶĞĞĚĞĚƚŽŝŶĨƵƐĞƚŚĞƐŽůƵƚŝŽŶĂƚƚŚĞĚĞƐŝƌĞĚĨůŽǁƌĂƚĞ͘ x tŚŝůĞĂŶǇ/sŵĞĚŝĐĂƚŝŽŶD^ĐĂƌƌŝĞƐŵĂǇďĞŐŝǀĞŶ/K͕ŝƚŝƐƉƌĞĨĞƌĂďůĞƚŽĂĚŵŝŶŝƐƚĞƌŵĞĚŝĐĂƚŝŽŶ ŝŶĨƵƐŝŽŶƐǀŝĂĂƉĞƌŝƉŚĞƌĂů/s͘/KƐĂƌĞůĞƐƐƉƌĞĚŝĐƚĂďůĞ͕ŵŽƌĞĐŚĂůůĞŶŐŝŶŐǁŝƚŚǁŚŝĐŚƚŽƐĞƚĂ ĐŽŶƐŝƐƚĞŶƚĂĚĞƋƵĂƚĞƌĂƚĞĂŶĚƚĂŬĞůŽŶŐĞƌƚŽƌĞĂĐŚĐĞŶƚƌĂůĐŝƌĐƵůĂƚŝŽŶ͘ x /ĨƚŚĞŝŶŝƚŝĂů/KŝŶƐĞƌƚŝŽŶĨĂŝůƐĚŽŶŽƚĂƚƚĞŵƉƚĂƐĞĐŽŶĚŝŶƐĞƌƚŝŽŶŝŶƚŽƚŚĞƐĂŵĞďŽŶĞ͘/ĨĂƐĞĐŽŶĚ ĂƚƚĞŵƉƚŝƐƌĞƋƵŝƌĞĚƵƚŝůŝǌĞƚŚĞƉĂƚŝĞŶƚƐŽƉƉŽƐŝƚĞďŽŶĞŽƌƚŚĞĂůƚĞƌŶĂƚĞŝŶƐĞƌƚŝŽŶƐŝƚĞ͘ x tĂƚĐŚĨŽƌĞǆƚƌĂǀĂƐĂƚŝŽŶĂŶĚƉŽƚĞŶƚŝĂůĐŽŵƉůŝĐĂƚŝŽŶƐĂƐƐŽĐŝĂƚĞĚǁŝƚŚŝŶƚĞƌƐƚŝƚŝĂůĨůƵŝĚĂĐĐƵŵƵůĂƚŝŽŶ ůĞĂĚŝŶŐƚŽĐŽŵƉĂƌƚŵĞŶƚƐǇŶĚƌŽŵĞ͘ x tŚĞŶĂĚŵŝŶŝƐƚĞƌŝŶŐŵĞĚŝĐĂƚŝŽŶƐĂůǁĂǇƐƵƚŝůŝǌĞƚŚĞĞǆƚĞŶƐŝŽŶƐĞƚƉƌŽǀŝĚĞĚǁŝƚŚƚŚĞĚĞǀŝĐĞ͘ ƚƚĂĐŚŝŶŐĂƐǇƌŝŶŐĞĚŝƌĞĐƚůǇƚŽƚŚĞĐĂƚŚĞƚĞƌŝŶĐƌĞĂƐĞƐƚŚĞƉŽƚĞŶƚŝĂůĨŽƌĚŝƐůŽĚŐĞŵĞŶƚĂŶĚ ĞǆƚƌĂǀĂƐĂƚŝŽŶ͘ x ƵƌŝŶŐƚƌĂŶƐĨĞƌŽĨĐĂƌĞƚŚĞƌĞĐĞŝǀŝŶŐĨĂĐŝůŝƚŝĞƐƐƚĂĨĨŵƵƐƚďĞŝŶĨŽƌŵĞĚĂďŽƵƚƚŚĞƉůĂĐĞŵĞŶƚŽĨƚŚĞ/K ĚĞǀŝĐĞ͕ĂŶĚƚŚĞŶĞĐĞƐƐŝƚǇĨŽƌŝƚƚŽďĞƌĞŵŽǀĞĚŶŽůĂƚĞƌƚŚĂŶϮϰŚŽƵƌƐĂĨƚĞƌŝŶŝƚŝĂƚŝŽŶ͘ x The larger needle is recommended when there is excessive tissue over any insertion site or if you are accessing the humeral head insertion site.

Cypress Creek EMS System Policies and Treatment Guidelines

312 PROCEDURES Revised 8/2016 Venous Access Approved: Levon Vartanian, MD

ZƵŐŐĞĚŝǌĞĚ&ŝĞůĚ/s;ZĂŶŐĞƌ/sͿ Indications Equipment Needed /sĂĐĐĞƐƐŝŶĚŝĐĂƚĞĚ /sƐƚĂƌƚƐƵƉƉůŝĞƐ WĂƚŝĞŶƚŝƐĂŐŝƚĂƚĞĚŽƌŽƚŚĞƌƉŽƚĞŶƚŝĂůĞǆŝƐƚƐĨŽƌ dǁŽŽĨƐĞůĞĐƚĞĚ/sĐĂƚŚĞƚĞƌƐ ĚŝƐůŽĚŐŝŶŐĐĂƚŚĞƚĞƌ͘ ZĂƉƚŽƌƐĞĐƵƌŝŶŐďĂŶĚ WĞĚŝĂƚƌŝĐƉĂƚŝĞŶƚƐǁŝƚŚƌŝƐŬĨŽƌĚŝƐůŽĚŐŝŶŐ >ĂƌŐĞdĞŐĂĚĞƌŵĚƌĞƐƐŝŶŐ ĐĂƚŚĞƚĞƌ͘ EĞĞĚůĞůĞƐƐƐĂůŝŶĞůŽĐŬ WƌŽĐĞĚƵƌĞ ϭ͘ /ĚĞŶƚŝĨǇƐŝƚĞ͕ƉůĂĐĞƚŽƵƌŶŝƋƵĞƚ͕ĂŶĚĐůĞĂŶƐĞƐŝƚĞĂƐŝĨƐƚĂƌƚŝŶŐŶŽƌŵĂůƉĞƌŝƉŚĞƌĂů/s͘ Ϯ͘ WůĂĐĞ/sĐĂƚŚĞƚĞƌ͘ZĞŵŽǀĞŶĞĞĚůĞĂŶĚƐĞĐƵƌĞƐŚĂƌƉŝŶƐŚĂƌƉƐĐŽŶƚĂŝŶĞƌ͘ ϯ͘ ^ĞĐƵƌĞŶĞĞĚůĞůĞƐƐƐĂůŝŶĞůŽĐŬƚŽĐĂƚŚĞƚĞƌŚƵď͘ ϰ͘ ƉƉůǇdĞŐĂĚĞƌŵĐŽǀĞƌŝŶŐďŽƚŚĐĂƚŚĞƚĞƌĂŶĚƐĂůŝŶĞůŽĐŬĐŽŶŶĞĐƚŽƌ͘ ϱ͘ /ĨŶŽƚƐƚĂƌƚŝŶŐŝŶĨƵƐŝŽŶŝŵŵĞĚŝĂƚĞůǇ͕ĨůƵƐŚĐĂƚŚĞƚĞƌǁŝƚŚϱŵ>ŽĨƐƚĞƌŝůĞŶŽƌŵĂůƐĂůŝŶĞƵƐŝŶŐƐǇƌŝŶŐĞ ŶĞĞĚůĞƚŚƌŽƵŐŚdĞŐĂĚĞƌŵĂŶĚƐĂůŝŶĞůŽĐŬ͘ ϲ͘ /ĨƐƚĂƌƚŝŶŐ/sŝŶĨƵƐŝŽŶ͕ŝŶƐĞƌƚƐĞĐŽŶĚ/sĐĂƚŚĞƚĞƌƚŚƌŽƵŐŚdĞŐĂĚĞƌŵĂŶĚƐĂůŝŶĞůŽĐŬ͕ƚŚĞŶƌĞŵŽǀĞ ŶĞĞĚůĞůĞĂǀŝŶŐĐĂƚŚĞƚĞƌŝŶƉůĂĐĞ͘^ĞĐƵƌĞƐŚĂƌƉŝŶƐŚĂƌƉƐĐŽŶƚĂŝŶĞƌ͘ ϳ͘ ƚƚĂĐŚ/sůŝŶĞƚŽ/sĐĂƚŚĞƚĞƌĂŶĚďĞŐŝŶŝŶĨƵƐŝŽŶ͘ ϴ͘ ^ĞĐƵƌĞ/sůŝŶĞƚŽƉĂƚŝĞŶƚ͛ƐĨŽƌĞĂƌŵƵƐŝŶŐZĂƉƚŽƌƐĞĐƵƌŝŶŐďĂŶĚ͘

Cypress Creek EMS System Policies and Treatment Guidelines

313 PROCEDURE Revised 12/2018 Venous Access Approved: Levon Vartanian, MD

hůƚƌĂƐŽƵŶĚ'ƵŝĚĞĚWĞƌŝƉŚĞƌĂů/s Indications Equipment Needed EĞĐĞƐƐŝƚǇĨŽƌĂĚŵŝŶŝƐƚƌĂƚŝŽŶŽĨŵĞĚŝĐĂƚŝŽŶƐŽƌ hůƚƌĂƐŽƵŶĚĚĞǀŝĐĞǁŝƚŚůŝŶĞĂƌƉƌŽďĞ ĨůƵŝĚ͘ dĞŐĂĚĞƌŵ ^ƚĞƌŝůĞůƵďƌŝĐĂŶƚũĞůůǇ /s^ƚĂƌƚŬŝƚ ǆƚĞŶƐŝŽŶƐĞƚ ƉƉƌŽƉƌŝĂƚĞůǇƐŝǌĞĚ/sĐĂƚŚĞƚĞƌ ^ŚĂƌƉƐĐŽŶƚĂŝŶĞƌŽƌƐŚĂƌƉƐƐŚƵƚƚůĞǁŝƚŚŝŶ ƌĞĂĐŚ WƌŽĐĞĚƵƌĞ Probe >ϭϮ>ŝŶĞĂƌƌƌĂǇ Preset sĂƐĐƵůĂƌ Starting Depth ϰĐŵ ϭ͘ ^ĞůĞĐƚƉƌŽƉĞƌĞƋƵŝƉŵĞŶƚĂŶĚŝŶƐƉĞĐƚĨŽƌƐƚĞƌŝůŝƚǇ͕ĞǆƉŝƌĂƚŝŽŶĚĂƚĞ͕ĂŶĚĐůĂƌŝƚǇŽĨƐŽůƵƚŝŽŶƐ͘ Ϯ͘ WůĂĐĞƐƚĞƌŝůĞdĞŐĂĚĞƌŵŽǀĞƌĐůĞĂŶƉƌŽďĞƚŽĞŶƐƵƌĞƉƌŽďĞƐƵƌĨĂĐĞƌĞŵĂŝŶƐĂƐĞƉƚŝĐ͘ ϯ͘ ůĞĂŶŝŶƐĞƌƚŝŽŶƐŝƚĞ͖ƵƐĞĐůĞĂŶƉƌŽďĞĂŶĚƐƚĞƌŝůĞůƵďƌŝĐĂŶƚũĞůůǇ͘ ϰ͘ hƐĞƐŚŽƌƚĂǆŝƐƚŽŝĚĞŶƚŝĨǇďĞƐƚǀĞƐƐĞů͘ Short Axis Technique ϭ͘ /ĚĞŶƚŝĨǇǀĞƐƐĞů Ϯ͘ hƐĞ͞^ƚŽƉĂŶĚ'Ž͟ƚĞĐŚŶŝƋƵĞďǇĂůƚĞƌŶĂƚŝŶŐďĞƚǁĞĞŶĂĚǀĂŶĐŝŶŐƚŚĞŶĞĞĚůĞĂŶĚĂĚǀĂŶĐŝŶŐƚŚĞƉƌŽďĞ ƵŶƚŝůĐĂƚŚĞƚĞƌŝƐƉůĂĐĞĚ͘ ϯ͘ ZŽƚĂƚĞƚŚĞƉƌŽďĞƚŽůŽŶŐĂǆŝƐĂŶĚƐĂǀĞŝŵĂŐĞŽĨĐĂƚŚĞƚĞƌŝŶǀĞƐƐĞů͘ ϰ͘ ŽŶŶĞĐƚĞǆƚĞŶƐŝŽŶƐĞƚŽƌĚƌŝƉƐĞƚĂŶĚƐĞĐƵƌĞŝŶƉůĂĐĞ͘ Long Axis Technique ϭ͘ /ĚĞŶƚŝĨǇǀĞƐƐĞůŝŶƐŚŽƌƚĂǆŝƐ͘ Ϯ͘ ZŽƚĂƚĞϵϬĚĞŐƌĞĞƐǁŝƚŚŵĂƌŬĞƌƚŽǁĂƌĚƐǇŽƵ͘ ϯ͘ ůŝŐŶƉƌŽďĞǁŝƚŚǀĞƐƐĞůĂŶĚĂůŝŐŶŶĞĞĚůĞǁŝƚŚƉƌŽďĞ͘ ϰ͘ ĚǀĂŶĐĞŶĞĞĚůĞŝŶƚŽǀĞƐƐĞů͕ĨůĂƚƚĞŶŝŶŐŽƵƚĂƚĞŶĚ͘ ϱ͘ ^ĂǀĞŝŵĂŐĞŽĨĐĂƚŚĞƚĞƌŝŶǀĞƐƐĞů͘ ϲ͘ ŽŶŶĞĐƚĞǆƚĞŶƐŝŽŶƐĞƚŽƌĚƌŝƉƐĞƚĂŶĚƐĞĐƵƌĞŝŶƉůĂĐĞ͘ WĞĂƌůƐ x hůƚƌĂƐŽƵŶĚŐƵŝĚĞĚƉĞƌŝƉŚĞƌĂů/sƉůĂĐĞŵĞŶƚƐŚŽƵůĚŽŶůǇďĞƉĞƌĨŽƌŵĞĚďǇWϯƐǁŚŽŚĂǀĞĐŽŵƉůĞƚĞĚ D^ͲĂƉƉƌŽǀĞĚƚƌĂŝŶŝŶŐ͘ x /ŶĂůůƉĞĚŝĂƚƌŝĐƉĂƚŝĞŶƚƐǁŝƚŚ/sƐĐŽŶŶĞĐƚĞĚƚŽĨůƵŝĚƐĞƚƐ͕ƵƚŝůŝǌĞĂƵƌĞƚƌŽůŽƌŵŝĐƌŽͲĚƌŝƉŝŶĨƵƐŝŽŶƐĞƚ ĂŶĚĐĂƌĞĨƵůůǇŵŽŶŝƚŽƌƚŚĞĚĞůŝǀĞƌǇŽĨĨůƵŝĚƐ͘ x ƐĞƉƚŝĐƚĞĐŚŶŝƋƵĞƐŚĂůůďĞƵƐĞĚĂƚĂůůƚŝŵĞƐ͘ x An IV catheter is a SINGLE use device and should never be used to puncture the skin more than once. If an IV attempt is unsuccessful for any reason, a new IV catheter must be used on any subsequent attempt and documented in the medical record.

Cypress Creek EMS System Policies and Treatment Guidelines

314 PROCEDURES Revised 8/2016 Wound Care Approved: Levon Vartanian, MD

tŽƵŶĚĂƌĞ͗'ĞŶĞƌĂů Indications Equipment Needed KƉĞŶǁŽƵŶĚ WĞƌƐŽŶĂůƉƌŽƚĞĐƚŝǀĞĞƋƵŝƉŵĞŶƚ͕ŝŶĐůƵĚŝŶŐ ŐůŽǀĞƐ͕ĞǇĞƉƌŽƚĞĐƚŝŽŶ͕ŐŽǁŶ͕ŵĂƐŬ͕ĞƚĐ͘ĂƐ ĂƉƉƌŽƉƌŝĂƚĞ͘

^ƚĞƌŝůĞŐĂƵǌĞ͕ƌŽůůĞĚŐĂƵǌĞ͕ĂďƐŽƌďĞŶƚŐĂƵǌĞ͕ ƚƌĂƵŵĂƉĂĚƐ͕ĞƚĐ͘ĂƐĂƉƉƌŽƉƌŝĂƚĞ͘

dĂƉĞĂƐĂƉƉƌŽƉƌŝĂƚĞ͘

^ĂůŝŶĞ;ŝŶƐǇƌŝŶŐĞĨůƵƐŚŽƌŝŶďŽƚƚůĞͿ͘ WƌŽĐĞĚƵƌĞ ϭ͘ ŶƐƵƌĞůŝĨĞͲƚŚƌĞĂƚĞŶŝŶŐŝŶũƵƌŝĞƐĂŶĚĐŽŶĚŝƚŝŽŶƐĂƌĞƚƌĞĂƚĞĚďĞĨŽƌĞŵĂŶĂŐŝŶŐŶŽŶͲůŝĨĞͲƚŚƌĞĂƚĞŶŝŶŐ ǁŽƵŶĚƐ͘ Ϯ͘ /ĨĂĐƚŝǀĞďůĞĞĚŝŶŐ͕ĨŽůůŽǁƚŚĞHemorrhage ControlǁŽƵŶĚĐĂƌĞƉƌŽĐĞĚƵƌĞ͘ ϯ͘ KŶĐĞďůĞĞĚŝŶŐŝƐĐŽŶƚƌŽůůĞĚ͕ŝƌƌŝŐĂƚĞĐŽŶƚĂŵŝŶĂƚĞĚǁŽƵŶĚƐǁŝƚŚƐĂůŝŶĞĂƐĂƉƉƌŽƉƌŝĂƚĞ͘dŚŝƐŵĂǇŶŽƚ ďĞƉŽƐƐŝďůĞĚƵĞƚŽƉĂŝŶŽƌĚŝĨĨŝĐƵůƚƚŽĐŽŶƚƌŽůďůĞĞĚŝŶŐ͘ŽŶƐŝĚĞƌĂŶĂůŐĞƐŝĂƉƌŝŽƌƚŽŝƌƌŝŐĂƚŝŽŶ͘ ϰ͘ ŽǀĞƌǁŽƵŶĚƐǁŝƚŚƐƚĞƌŝůĞŐĂƵǌĞͬĚƌĞƐƐŝŶŐƐ͘ŚĞĐŬĚŝƐƚĂůƉƵůƐĞ͕ƐĞŶƐŽƌǇ͕ĂŶĚŵŽƚŽƌĨƵŶĐƚŝŽŶŝĨĂŶǇ ĐŝƌĐƵŵĨĞƌĞŶƚŝĂůĚƌĞƐƐŝŶŐƐǁĞƌĞĂƉƉůŝĞĚ͘ ϱ͘ ZĞĂƐƐĞƐƐĂŶǇǁŽƵŶĚƐƚŚƌŽƵŐŚŽƵƚĚƵƌĂƚŝŽŶŽĨĐĂƌĞƚŽĐŚĞĐŬĨŽƌďůĞĞĚŝŶŐ͕ƐǁĞůůŝŶŐ͕ĂŶĚƉŽƚĞŶƚŝĂů ĐŽŵƉƌŽŵŝƐĞŽĨĚŝƐƚĂůƉƵůƐĞ͕ƐĞŶƐŽƌǇ͕ĂŶĚŵŽƚŽƌĨƵŶĐƚŝŽŶ͘

Cypress Creek EMS System Policies and Treatment Guidelines

315 PROCEDURES Revised 10/2019 Wound Care Approved: Levon Vartanian, MD

External Hemorrhage Control 1 Apply Direct Pressure to injury. 2 If bleeding is uncontrolled, stop the bleeding now:

Extremity Injuries: Junctional Injuries: Scalp and Neck Injuries: Apply a tourniquet Utilize the JETT Junctional Place hemostatic gauze over placed high on limb Tourniquet if available. surface of wound. Do not pack and tight. or scalp and anterior neck wounds. Apply firm direct pressure on Pack wound, using hemostatic wound for at least 3 minutes or gauze if available. until bleeding stops. Apply firm direct pressure on For scalp injuries, secure a wound for at least 3 minutes Do not apply a or until bleeding stops. pressure dressing. pressure dressing to neck injuries. Secure a pressure dressing. Consider utilizing iT Clamp.

3 Once bleeding is controlled, consider splinting to immobilize the area and limit potential to re-open wound site or dislodge gauze packing material. 4 Keep patient warm. 5 Limit crystalloid to < 1,000 mL. 6 Initiate blood transfusion if hemorrhagic shock. 7 Monitor wounds and dressings during transport for bleeding.

Cypress Creek EMS System Policies and Treatment Guidelines

316 PROCEDURES Revised 10/2019 Wound Care Approved:Approved: Levon Levon Vartanian, Vartanian, MDMD

Pearls Uncontrolled, significant external hemorrhage is an immediate life threat. Control exsanguinating hemorrhage immediately. Do not delay application of a tourniquet in patients with major bleeding. Junctional areas are those areas between the proximal extremities and the abdominal and thoracic cavities. These areas are not amenable to tourniquet placement and do not have hollow internal body cavities. Wound packing and iT Clamp should not be utilized when the wound tract may potentially penetrate into the abdominal or thoracic cavity. Neck wounds may be treated with wound packing and/or iT Clamp if they are posterior to the airway and carotid arteries. Treatment Principles: • Hemorrhagic shock may not present initially with hypotension and blood loss is usually underestimated. • Avoid large infusions of crystalloids (normal saline or plasmalyte, more than 1,000 mL), which may worsen the patient’s condition even if bleeding has been controlled. • Early transfusion of blood in hemorrhagic shock will limit damage from the “Trauma Triad”: coagulopathy, acidosis, and hypothermia. • Keep patients warm: Hypothermia will worsen coagulopathy and acidosis. Patients in hemorrhagic shock have limited ability to maintain body temperature. • Permissive hypotension: If hemorrhage is uncontrolled, target a lower systolic blood pressure of 80–90 mmHg (or MAP > 80 mmHg in head injury). This avoids dislodging clots and diluting clotting factors in the blood. Wound Packing Using a gloved finger, firmly pack sterile gauze into the wound, aiming to fill the wound cavity and apply direct pressure to the disrupted blood vessels inside. Continue to pack gauze into the wound space until full. Apply firm direct pressure on top of the wound using a gloved hand for at least 3 minutes or longer until bleeding stops. Secure a pressure dressing over wound prior to patient movement. Utilize hemostatic gauze if available; however, wound packing will work with any sterile gauze.

Cypress Creek EMS System Policies and Treatment Guidelines

317 PROCEDURES Revised 8/2016 Wound Care Approved: Levon Vartanian, MD

WƌŽďĞZĞŵŽǀĂů Indications Equipment Needed Assessment Requirements

ŵďĞĚĚĞĚƉƌŽďĞ;ƐͿĨƌŽŵĂŶ 'ĞŶĞƌĂůǁŽƵŶĚĐĂƌĞƐƵƉƉůŝĞƐ͘ WƌŝŵĂƌǇƐƵƌǀĞǇĂŶĚĨŽĐƵƐĞĚ ůĞĐƚƌŽŶŝĐŽŶƚƌŽůĞǀŝĐĞ;Ğ͘Ő͘ ĞǆĂŵ͘ dĂƐĞƌͿ sŝƚĂůƐŝŐŶƐ ĞƚĞƌŵŝŶĞŶƵŵďĞƌĂŶĚ ĚƵƌĂƚŝŽŶŽĨĂĐƚŝǀĂƚŝŽŶƐ͘ ϭϮͲůĞĂĚ'ŝĨĂŶǇĂĐƚŝǀĂƚŝŽŶ͘ WƌŽĐĞĚƵƌĞ ϭ͘ /ĨƉƌŽďĞŝƐĞŵďĞĚĚĞĚŝŶĂŶǇƐĞŶƐŝƚŝǀĞĂƌĞĂ;ŶĞĐŬ͕ĨĂĐĞ͕ŐƌŽŝŶ͕ŽƌďƌĞĂƐƚͿ͕ƚƌĞĂƚĂƐĂŶŝŵƉĂůĞĚŽďũĞĐƚ ĂŶĚƚƌĂŶƐƉŽƌƚ͘ Ϯ͘ ŶƐƵƌĞƐĐĞŶĞŝƐƐĂĨĞĂŶĚƉƌŽďĞĐĂƌƚƌŝĚŐĞŝƐŶŽůŽŶŐĞƌĐŽŶŶĞĐƚĞĚƚŽƚŚĞĚĞǀŝĐĞ͘ ϯ͘ ,ŽůĚƐŬŝŶƚĂƵƚǁŚŝůĞĂƐƐƵƌŝŶŐŚĂŶĚƐĂƌĞƚǁŽŝŶĐŚĞƐĂǁĂǇĨƌŽŵƉƌŽďĞ͘ ϰ͘ 'ƌĂƐƉƉƌŽďĞďĞƚǁĞĞŶƚŚƵŵďĂŶĚĨŽƌĞĨŝŶŐĞƌ͘ ϱ͘ WƵůůƐƚƌĂŝŐŚƚŽƵƚ͘ ϲ͘ WƌŽǀŝĚĞǁŽƵŶĚĐĂƌĞĂƐŶĞĞĚĞĚ͘ WĞĂƌůƐ x ƉƌŽďĞƐƐŚŽƵůĚŶŽƚďĞƌĞŵŽǀĞĚŝĨĞŵďĞĚĚĞĚŝŶƚŚĞŶĞĐŬ͕ĨĂĐĞ͕ŐƌŽŝŶ͕ďƌĞĂƐƚ͕ŽƌǁŚĞŶĂĐůŽƐĞ ƉƌŽǆŝŵŝƚǇĚĞƉůŽǇŵĞŶƚŚĂƐƌĞƐƵůƚĞĚŝŶŽǀĞƌͲƉĞŶĞƚƌĂƚŝŽŶŽĨƚŚĞƉƌŽďĞ͘dŚŝƐĐĂŶĐƌĞĂƚĞĂƐŝƚƵĂƚŝŽŶ ǁŚĞƌĞƚŚĞƉƌŽďĞŝƐůŽĚŐĞĚŝŶƚŝƐƐƵĞͬďŽŶĞďĞǇŽŶĚƚŚĞďĂƌďƐ͘ x ĞĂǁĂƌĞŽĨƐƚĂƚĞƐŽĨExcited Delirium: ƚŚĞƐĞĂƌĞĐŚĂƌĂĐƚĞƌŝǌĞĚďǇĞǆƚƌĞŵĞĂŐŝƚĂƚŝŽŶͬĞǆĐŝƚĞŵĞŶƚ͕ ŚŽƐƚŝůŝƚǇ͕ĞǆĐĞƉƚŝŽŶĂůƐƚƌĞŶŐƚŚͬĞŶĚƵƌĂŶĐĞ͕ĂŶĚŚǇƉĞƌƚŚĞƌŵŝĂ͘WĂƚŝĞŶƚƐĞǆŚŝďŝƚŝŶŐĂŶǇŽĨƚŚĞƐĞƐŝŐŶƐ ĂƌĞĂƚĂŚŝŐŚƌŝƐŬĨŽƌƐƵĚĚĞŶƵŶĞǆƉĞĐƚĞĚĚĞĂƚŚĂŶĚŵƵƐƚďĞƚƌĂŶƐƉŽƌƚĞĚ͘ x ZĞĨĞƌƚŽƚŚĞExcited Delirium SyndromeƉƌŽƚŽĐŽůĨŽƌƉĂƚŝĞŶƚƐĞǆŚŝďŝƚŝŶŐƚŚƌĞĞŽƌŵŽƌĞĐƵĞƐ ;ƉŚǇƐŝĐĂů͕ƉƐǇĐŚŽůŽŐŝĐĂů͕ĐŽŵŵƵŶŝĐĂƚŝŽŶͿŽĨǆĐŝƚĞĚĞůŝƌŝƵŵ x ZĞĨĞƌƚŽƌĞƐƚƌĂŝŶƚƉƌŽĐĞĚƵƌĞĨŽƌƉĂƚŝĞŶƚƐǁŚŽƐĞĐŽŵďĂƚŝǀĞƐƚĂƚĞƉŽƐĞƐĂƉŽƚĞŶƚŝĂůƚŚƌĞĂƚƚŽ ƚŚĞŵƐĞůǀĞƐŽƌŽƚŚĞƌƐ x /ƚŝƐŝŵƉĞƌĂƚŝǀĞƚŚĂƚƚŚĞŚŝƐƚŽƌǇďĞŚŝŶĚƚŚĞĚĞƉůŽǇŵĞŶƚďĞƚŚŽƌŽƵŐŚůǇƵŶĚĞƌƐƚŽŽĚĂŶĚĚŽĐƵŵĞŶƚĞĚ x dŚĞŶƵŵďĞƌŽĨƚŝŵĞƐƚŚĞǁĂƐĂĐƚŝǀĂƚĞĚ;ƚƌŝŐŐĞƌĂĐƚŝǀĂƚĞĚͿŵƵƐƚĂůƐŽďĞĚŽĐƵŵĞŶƚĞĚĂůŽŶŐǁŝƚŚ ĂŶĞƐƚŝŵĂƚĞĚƚŽƚĂůůĞŶŐƚŚŽĨĞǆƉŽƐƵƌĞ x dŚĞƉƌŽďĞĂŶĚǁŽƵŶĚŵƵƐƚďĞĞǆĂŵŝŶĞĚƚŚŽƌŽƵŐŚůǇƚŽĐŽŶĨŝƌŵƚŚĂƚƚŚĞďĂƌďŝƐŝŶƚĂĐƚĂŶĚĚŝĚŶŽƚ ĨƌĂŐŵĞŶƚƵƉŽŶŝŵƉĂĐƚͬƌĞŵŽǀĂů x dŚĞƉƌŽďĞƐĂŶĚǁŝƌĞƐĂƌĞĞǀŝĚĞŶĐĞ͘ŽŶŽƚĐƵƚŽƌďƌĞĂŬǁŝƌĞƐ͘ŽŶŽƚƉůĂĐĞďĂƌďƐŝŶĂƐŚĂƌƉƐ ƐŚƵƚƚůĞͬĐŽŶƚĂŝŶĞƌ͘WůĂĐĞďĂƌďƐďĂĐŬŝŶƚŚĞĐĂƌƚƌŝĚŐĞďŽĚǇĂŶĚƚƵƌŶŽǀĞƌĂůůƉĂƌƚƐƚŽĂůĂǁ ĞŶĨŽƌĐĞŵĞŶƚŽĨĨŝĐĞƌĂŶĚĚŽĐƵŵĞŶƚƚŚĞĚĞƉĂƌƚŵĞŶƚŶĂŵĞ͕ŽĨĨŝĐĞƌŶĂŵĞ͕ĂŶĚďĂĚŐĞŶƵŵďĞƌŝŶƚŚĞ WZ͘ x ƵƌŶŚĂǌĂƌĚʹtŚĞŶĂdĂƐĞƌŝƐƵƐĞĚŝŶƚŚĞƉƌĞƐĞŶĐĞŽĨĐĞƌƚĂŝŶƉĞƉƉĞƌƐƉƌĂǇƉƌŽƉĞůůĂŶƚƐƚŚĞƌĞŝƐĂ ďƵƌŶŚĂǌĂƌĚ͘ůĞĐƚƌŝĐĂůĂƌĐŝŶŐĨƌŽŵŝŵƉĞƌĨĞĐƚ;ďƵƚĞĨĨĞĐƚŝǀĞͿĚĂƌƚĐŽŶƚĂĐƚĐĂŶŝŐŶŝƚĞƚŚĞƉƌŽƉĞůůĂŶƚ dŚĞƌĞƐƵůƚŝŶŐĐŽŵďƵƐƚŝŽŶŵĂǇŶŽƚďĞǀŝƐŝďůĞ͕ďƵƚĐĂŶůĞĂĚƚŽĐŽŵƉůĂŝŶƚƐŽĨŚĞĂƚĂŶĚďƵƌŶŝŶŐ͘ /ĨĂ ƉĂƚŝĞŶƚĐŽŵƉůĂŝŶƐŽĨŚĞĂƚŽƌďƵƌŶŝŶŐ͕ĞǀĂůƵĂƚĞĨŽƌƉŽƐƐŝďůĞŵŝŶŽƌďƵƌŶƐ͘

Cypress Creek EMS System Policies and Treatment Guidelines

318 PROCEDURES Revised 8/2016 Wound Care Approved: Levon Vartanian, MD

ŝdůĂŵƉ Indications Equipment needed ^ĞǀĞƌĞƵŶĐŽŶƚƌŽůůĞĚŚĞŵŽƌƌŚĂŐĞĨƌŽŵ ŝdůĂŵƉ ƐĐĂůƉŽƌũƵŶĐƚŝŽŶĂůǁŽƵŶĚ͘ Contraindications: hƚŝůŝǌĂƚŝŽŶŝŶŶŽŶͲĐŽŵƉƌĞƐƐŝďůĞůŽĐĂƚŝŽŶ ƐƵĐŚĂƐƚŚĞĐŚĞƐƚŽƌĂďĚŽŵŝŶĂůƌĞŐŝŽŶƐ͘ hƚŝůŝǌĂƚŝŽŶŽŶŽƌŝŶĐůŽƐĞƉƌŽǆŝŵŝƚǇƚŽĞǇĞƐ͕ ĞĂƌƐ͕ůŝƉƐ͕ŶŽƐĞ͕ĂŶĚŐĞŶŝƚĂůŝĂ͘ WƌŽĐĞĚƵƌĞ ϭ͘ ƚƚĞŵƉƚƚŽĐŽŶƚƌŽůďůĞĞĚŝŶŐƵƐŝŶŐĚŝƌĞĐƚƉƌĞƐƐƵƌĞ͘ Ϯ͘ &ŽƌůĂƌŐĞĐĂǀŝƚǇǁŽƵŶĚƐ͕ŝƚŵĂǇďĞŶĞĐĞƐƐĂƌǇƚŽƉĂĐŬƚŚĞǁŽƵŶĚƉƌŝŽƌƚŽĂƉƉůŝĐĂƚŝŽŶ͘ ϯ͘ WůĂĐĞƚŚĞŶĞĞĚůĞƐĂƉƉƌŽǆŝŵĂƚĞůǇϭͲϮĐŵďĞǇŽŶĚƚŚĞĞĚŐĞƐŽĨƚŚĞǁŽƵŶĚ͘ ϰ͘ &ŽƌůĂƌŐĞǁŽƵŶĚƐ͗ x &ŝƌƐƚĚĞƉůŽǇŽŶĞƐŝĚĞŽĨƚŚĞĐůĂŵƉƚŽƚŚĞŽƵƚƐŝĚĞĞĚŐĞŽĨƚŚĞǁŽƵŶĚĂŶĚƚŚĞŶƉƵůůƚŚĞŽƚŚĞƌƐŝĚĞ ŽĨƚŚĞǁŽƵŶĚƚŽŐĞƚŚĞƌĐŽŵƉƌĞƐƐŝŶŐƚŚĞǁŽƵŶĚĞĚŐĞƐ͘ x dŚĞǁŽƵŶĚĞĚŐĞƐĐĂŶĂůƐŽďĞĂƉƉƌŽǆŝŵĂƚĞĚďǇŚĂŶĚǁŚŝůĞƉƵůůŝŶŐͬƉƵƐŚŝŶŐƚŚĞƐŬŝŶƚŽŐĞƚŚĞƌ͘ ϱ͘ ƉŝŶĐŚŝŶŐƉƌĞƐƐƵƌĞƐŚŽƵůĚďĞĂƉƉůŝĞĚƚŽƚŚĞĐůĂŵƉƵŶƚŝůƚŚĞƐĂĨĞƚǇƐƚŝĐŬĞƌďƌĞĂŬƐĨƌĞĞĂŶĚƚŚĞ ĚĞǀŝĐĞĐůŽƐĞƐ;ĂƉƉƌŽǆŝŵĂƚĞůǇϱůďƐƉƌĞƐƐƵƌĞͿĂŶĚĂƉƉƌŽǆŝŵĂƚĞƐƚŚĞǁŽƵŶĚĞĚŐĞƐ͘ ϲ͘ KŶĐĞĂƉƉůŝĞĚǁŝƉĞĨƌĞĞďůŽŽĚĂǁĂǇĨƌŽŵƚŚĞǁŽƵŶĚƚŽĂƐƐĞƐƐĨŽƌĐŽŶƚŝŶƵĞĚĞǆƚĞƌŶĂůďůĞĞĚŝŶŐĂŶĚ ƚŚĞŶĞĞĚĨŽƌƌĞƉŽƐŝƚŝŽŶŝŶŐ͘ ϳ͘ /ĨƌĞƉŽƐŝƚŝŽŶŝŶŐŽƌƌĞŵŽǀĂůŝƐƌĞƋƵŝƌĞĚ͗ x ZĞůĞĂƐĞĐůĂŵƉďǇƉƌĞƐƐŝŶŐƚŚĞĚĞǀŝĐĞĨƵƌƚŚĞƌĐůŽƐĞĚ͕ǁŚŝůĞƐŝŵƵůƚĂŶĞŽƵƐůǇƉƌĞƐƐŝŶŐƚŚĞƐŝůǀĞƌŽƌ ƌĞĚůŽĐŬďƵƚƚŽŶƐǁŝƚŚǇŽƵƌŝŶĚĞǆĨŝŶŐĞƌĂŶĚƚŚƵŵď͘ x KƉĞŶƚŚĞĚĞǀŝĐĞƐůŽǁůǇĂŶĚƌĞŵŽǀĞĨƌŽŵƚŚĞƐŬŝŶ͘ **The greatest risk for a needle stick to the user occurs during repositioning and/or removal** ϴ͘ /ĨǁŽƵŶĚŝƐůĂƌŐĞƌƚŚĂŶĂƐŝŶŐůĞĐůĂŵƉ͕ĂĚĚŝƚŝŽŶĂůĐůĂŵƉ;ƐͿĐĂŶďĞƉůĂĐĞĚ͘ůĂŵƉƐƐŚŽƵůĚďĞƉůĂĐĞĚĂƐ ĐůŽƐĞƚŽŐĞƚŚĞƌĂƐƉŽƐƐŝďůĞ͕ƐƚĂƌƚŝŶŐĨƌŽŵŽŶĞǁŽƵŶĚĞĚŐĞĂŶĚǁŽƌŬŝŶŐƚŽǁĂƌĚƐƚŚĞŽƚŚĞƌ͘ ϵ͘ ĨƚĞƌĚĞǀŝĐĞĂƉƉůŝĐĂƚŝŽŶŝĨƚŚĞǁŽƵŶĚĐŽŶƚŝŶƵĞƐƚŽĞǆƉĂŶĚĂŶĚͬŽƌƐǁĞůůƐŝŐŶŝĨŝĐĂŶƚůǇ͕ĂŶĂƚƚĞŵƉƚĂƚ ƌĞĂĚũƵƐƚŵĞŶƚƚŽĐŽŶƚƌŽůŚĞŵŽƌƌŚĂŐĞƐŚŽƵůĚďĞŵĂĚĞ͘/ĨďůĞĞĚŝŶŐĐŽŶƚŝŶƵĞƐƚŚĞĚĞǀŝĐĞƐŚŽƵůĚďĞ ƌĞŵŽǀĞĚĂŶĚŽƚŚĞƌƚĞĐŚŶŝƋƵĞƐĨŽƌŚĞŵŽƌƌŚĂŐĞĐŽŶƚƌŽůƐŚŽƵůĚďĞƵƚŝůŝǌĞĚ͘ WĞĂƌůƐ x ŶƐƵƌĞŚŽƐƉŝƚĂůƐƚĂĨĨƌĞĐĞŝǀŝŶŐƉĂƚŝĞŶƚĂƌĞĨĂŵŝůŝĂƌǁŝƚŚŽƉĞƌĂƚŝŽŶĂŶĚƌĞŵŽǀĂůŽĨĚĞǀŝĐĞ͘ x /ĨǁŽƵŶĚƉĂĐŬŝŶŐŝƐƵƐĞĚ͕ĞŶƐƵƌĞƚŚĞƉĂĐŬŝŶŐĚŽĞƐŶŽƚƉƌŽƚƌƵĚĞĨƌŽŵƚŚĞǁŽƵŶĚǁŚĞŶƚŚĞĐůĂŵƉŝƐ ƉůĂĐĞĚ͘dŚĞĚĞǀŝĐĞƐŚŽƵůĚďĞĂƉƉůŝĞĚŝŵŵĞĚŝĂƚĞůǇĂĨƚĞƌƉĂĐŬŝŶŐƚŚĞǁŽƵŶĚ͘ x dŚĞĐůĂŵƉŵĂǇďĞƵƚŝůŝǌĞĚŝŶĐŽŶũƵŶĐƚŝŽŶǁŝƚŚĐůŽƚƚŝŶŐĂŐĞŶƚƐ;ŝ͘Ğ͘YƵŝĐŬůŽƚ͕ĐŽŵďĂƚŐĂƵǌĞͿ͕ ƚŽƵƌŶŝƋƵĞƚƐ͕ƚƌĂĚŝƚŝŽŶĂůďĂŶĚĂŐŝŶŐ͕ĞƚĐ͘

Cypress Creek EMS System Policies and Treatment Guidelines

319 PROCEDURES Revised 8/2016 Wound Care Approved: Levon Vartanian, MD

x &ŽƌƐŵĂůůĞƌůĂĐĞƌĂƚŝŽŶƐŽƌůĂĐĞƌĂƚŝŽŶƐǁŝƚŚŵŝŶŝŵĂůƐŬŝŶ;ŝ͘Ğ͘ƐĐĂůƉůĂĐĞƌĂƚŝŽŶƐͿ͕ƚŚĞĐůĂŵƉŵĂǇŶĞĞĚ ƚŽďĞƉĂƌƚŝĂůůǇĐůŽƐĞĚďĞĨŽƌĞĐůĂŵƉŝŶŐƚŚĞƐŬŝŶ͘ůĂŵƉŝŶŐƚŽŽŵƵĐŚƐŬŝŶ;хϭͲϮĐŵͿŵĂǇƌĞƐƵůƚŝŶ ŝŶĞĨĨĞĐƚŝǀĞŚĞŵŽƌƌŚĂŐĞĐŽŶƚƌŽů͘ x ĞƉůŽǇŵĞŶƚŽĨƚŚŝƐĚĞǀŝĐĞĐƌĞĂƚĞƐĂŚŝŐŚƉŽƚĞŶƚŝĂůĨŽƌŶĞĞĚůĞƐƚŝĐŬŝŶũƵƌŝĞƐƚŽƚŚĞĐĂƌĞŐŝǀĞƌ͘dŚĞ ŐƌĞĂƚĞƐƚƌŝƐŬŽĐĐƵƌƐĚƵƌŝŶŐƌĞƉŽƐŝƚŝŽŶŝŶŐŽƌƌĞŵŽǀĂů͘ x dŚĞŝdůĂŵƉŝƐĂƐŝŶŐůĞƵƐĞƐŚĂƌƉƐĚĞǀŝĐĞĂŶĚƐŚŽƵůĚďĞŚĂŶĚůĞĚĂŶĚĚŝƐƉŽƐĞĚŽĨĂĐĐŽƌĚŝŶŐůǇ͘ x /ŶĞǆƚƌĞŵĞĐĂƐĞƐ͕ƚŚĞĐůĂŵƉŵĂǇďĞůĞĨƚŝŶƉůĂĐĞĨŽƌƵƉƚŽϮϰŚŽƵƌƐ͕ŚŽǁĞǀĞƌƚŝŵĞƐůŽŶŐĞƌƚŚĂŶϭϮ ŚŽƵƌƐĂƌĞŶŽƚƌĞĐŽŵŵĞŶĚĞĚďǇƚŚĞŵĂŶƵĨĂĐƚƵƌĞƌ͘

Cypress Creek EMS System Policies and Treatment Guidelines

320 PROCEDURES Revised 8/2016 Wound Care Approved: Levon Vartanian, MD

:ƵŶĐƚŝŽŶĂůǆƚƌĞŵŝƚǇdƌĞĂƚŵĞŶƚdŽŽů;:ddͿ Indications Equipment Needed ^ŝŐŶŝĨŝĐĂŶƚͬǆƐĂŶŐƵŝŶĂƚŝŶŐŚĞŵŽƌƌŚĂŐĞĨƌŽŵ :ddƚŽƵƌŶŝƋƵĞƚ ǁŽƵŶĚƐŶŽƚĂŵĞŶĂďůĞƚŽƚŽƵƌŶŝƋƵĞƚ ƉůĂĐĞŵĞŶƚ͘ WƌŽǆŝŵĂůĂŵƉƵƚĂƚŝŽŶƚŚĂƚĚŽĞƐŶŽƚůĞĂǀĞ ĞŶŽƵŐŚĞǆƚƌĞŵŝƚǇƐƚƵŵƉƚŽĂƉƉůǇĂ ƚŽƵƌŶŝƋƵĞƚ͘ /ŶĚŝĐĂƚŝŽŶƐ dŚĞ:ƵŶĐƚŝŽŶĂůǆƚƌĞŵŝƚǇdƌĞĂƚŵĞŶƚdŽŽů;:ddͿŝƐŝŶƚĞŶĚĞĚƚŽŽĐĐůƵĚĞĨĞŵŽƌĂůĂƌƚĞƌŝĞƐĂŶĚĐŽŶƚƌŽů ĞǆƐĂŶŐƵŝŶĂƚŝŶŐŚĞŵŽƌƌŚĂŐĞĨƌŽŵŽŶĞŽƌďŽƚŚůŽǁĞƌůŝŵďƐƚŚĂƚĐĂŶŶŽƚďĞĐŽŶƚƌŽůůĞĚǁŝƚŚĂƚŽƵƌŶŝƋƵĞƚ͘ ƉƉůŝĐĂƚŝŽŶWƌŽĐĞĚƵƌĞ;ůŽǁĞƌĞǆƚƌĞŵŝƚǇͿ ϭ͘ ZĞŵŽǀĞĂŶǇŝƚĞŵƐŝŶƉŽĐŬĞƚƐŽƌĂŶǇ ĐůŽƚŚŝŶŐƚŚĂƚŵĂǇŝŶƚĞƌĨĞƌĞǁŝƚŚ ƉůĂĐĞŵĞŶƚŽĨ:dd͘/ƚŝƐŶŽƚŶĞĐĞƐƐĂƌǇƚŽ ƌĞŵŽǀĞĂůůĐůŽƚŚŝŶŐ͘ Ϯ͘ ^ůŝĚĞďĞůƚǁŝƚŚ͞dŚŝƐ^ŝĚĞdŽǁĂƌĚƐ ĂƐƵĂůƚǇ͟ĨĂĐŝŶŐƵƉƵŶĚĞƌƚŚĞďŽĚǇĂƚ ƚŚĞůŽǁĞƌďĂĐŬ͘ ϯ͘ >ŽĐĂƚĞƚŚĞƐƵƉĞƌŝŽƌŝůŝĂĐĐƌĞƐƚĂŶĚƉƵďŝĐ ďŽŶĞ͕ǁŚŝĐŚĂƌĞĐŽŶŶĞĐƚĞĚďǇƚŚĞ ŝŶŐƵŝŶĂůůŝŐĂŵĞŶƚ͘WŽƐŝƚŝŽŶďĞůƚƐŽƚŚĂƚ ďƵƚƚŽĐŬƐƉĂĚŝƐĐĞŶƚĞƌĞĚďĞŚŝŶĚƚŚĞ ƉĂƚŝĞŶƚĂŶĚƉƌĞƐƐƵƌĞƉĂĚƐĂƌĞĚŝƌĞĐƚůǇ ŝŶĨĞƌŝŽƌƚŽƚŚĞŝŶŐƵŝŶĂůůŝŐĂŵĞŶƚ͘ ϰ͘ ŶŐůĞƉƌĞƐƐƵƌĞƉĂĚƐƉĂƌĂůůĞůƚŽƚŚĞŝŶŐƵŝŶĂůůŝŐĂŵĞŶƚ͕ĂƉƉƌŽǆŝŵĂƚĞůǇϯϬ϶͕ƉŽŝŶƚŝŶŐŵŝĚůŝŶĞƚŽǁĂƌĚƐ ƚŚĞĨĞĞƚ͘ŶƐƵƌĞƚŚĂƚƉĂƚŝĞŶƚ͛ƐŐĞŶŝƚĂůƐĂƌĞĐůĞĂƌŽĨƚŚĞĂƌĞĂǁŚĞƌĞƚŚĞƉĂĚŝƐƉŽƐŝƚŝŽŶĞĚ͘ ϱ͘ ƵĐŬůĞďĞůƚĂŶĚĨŝƌŵůǇƚŝŐŚƚĞŶ͕ƌĞŵŽǀŝŶŐĂůůƐůĂĐŬ͘ ϲ͘ ZĞĂƐƐĞƐƐƉĂĚƉůĂĐĞŵĞŶƚƚŚĞŶƚŝŐŚƚĞŶƉĂĚƐ;ĂƐĂƉƉƌŽƉƌŝĂƚĞƚŽŝŶũƵƌǇƐŝĚĞͿ͘/ŶĐƌĞĂƐĞƉƌĞƐƐƵƌĞƵŶƚŝů ďůĞĞĚŝŶŐƐƚŽƉƐĂŶĚĐŚĞĐŬƚŽĐŽŶĨŝƌŵƚŚĂƚĚŝƐƚĂůƉƵůƐĞŚĂƐďĞĞŶŽĐĐůƵĚĞĚ͘ ϳ͘ /ŶƐĞƌƚƚŽŐŐůĞŝŶƚŽdͲŚĂŶĚůĞĂŶĚĐŝŶĐŚŝƚƚŝŐŚƚƚŽƐĞĐƵƌĞĚĞǀŝĐĞ͘ ϴ͘ ZĞĂƐƐĞƐƐĨƌĞƋƵĞŶƚůǇ;ƋϱŵŝŶƵƚĞƐͿĂŶĚĂĨƚĞƌĞǀĞƌǇŵŽǀĞ͘ WĞĂƌůƐ x dŚĞ:ddŵĂǇďĞƵƐĞĚŝŶĐŽŶũƵŶĐƚŝŽŶǁŝƚŚǁŽƵŶĚƉĂĐŬŝŶŐ;ĂƉƉůǇǁŽƵŶĚƉĂĐŬŝŶŐďĞĨŽƌĞƉůĂĐŝŶŐ:dd ĚĞǀŝĐĞͿ͘ x :ddĚĞǀŝĐĞĐĂŶĂůƐŽďĞƵƐĞĚĂƐĂƉĞůǀŝĐďŝŶĚĞƌǁŝƚŚŽƵƚƚŚĞƉƌĞƐƐƵƌĞƉĂĚƐ x ŽEKdƌĞŵŽǀĞƚŚŝƐĚĞǀŝĐĞŽŶĐĞŝƚŝƐŝŶƉůĂĐĞ͘/ƚƐŚŽƵůĚŽŶůǇďĞƌĞŵŽǀĞĚďǇĂƉŚǇƐŝĐŝĂŶ x DĂǆŝŵƵŵĂƉƉůŝĐĂƚŝŽŶƚŝŵĞŝƐϰŚŽƵƌƐ

Cypress Creek EMS System Policies and Treatment Guidelines

321 PROCEDURES Revised 8/2016 Wound Care Approved: Levon Vartanian, MD

dŽƵƌŶŝƋƵĞƚ Indications Equipment needed ^ĞǀĞƌĞƵŶĐŽŶƚƌŽůůĞĚŚĞŵŽƌƌŚĂŐĞĨƌŽŵ ͲͲdƚŽƵƌŶŝƋƵĞƚ ĞǆƚƌĞŵŝƚǇǁŽƵŶĚ͘ WĂƌƚŝĂůŽƌĐŽŵƉůĞƚĞĂŵƉƵƚĂƚŝŽŶŽĨ ĞǆƚƌĞŵŝƚǇ͘ ^ĞǀĞƌĞĐƌƵƐŚŝŶũƵƌŝĞƐǁŝƚŚůĞŶŐƚŚůǇ ĞǆƚƌŝĐĂƚŝŽŶ hƉƉĞƌǆƚƌĞŵŝƚǇŽƌKŶĞͲ,ĂŶĚĞĚƉƉůŝĐĂƚŝŽŶ ϭ͘ /ŶƐĞƌƚǁŽƵŶĚĞĚĞǆƚƌĞŵŝƚǇƚŚƌŽƵŐŚƚŚĞůŽŽƉŽĨƚŚĞƐĞůĨͲĂĚŚĞƌŝŶŐďĂŶĚ͞ŚŝŐŚĂŶĚƚŝŐŚƚ͟ĂďŽǀĞƚŚĞ ďůĞĞĚŝŶŐƐŝƚĞ͘ Ϯ͘ WƵůůƚŚĞƐĞůĨͲĂĚŚĞƌŝŶŐďĂŶĚsZzd/',dĂŶĚƐĞĐƵƌĞůǇĨĂƐƚĞŶďĂŶĚŽŶŝƚƐĞůĨ͘ ϯ͘ &ĂƐƚĞŶƚŚĞďĂŶĚĂƌŽƵŶĚƚŚĞĞǆƚƌĞŵŝƚǇ͕ďƵƚŶŽƚƉĂƐƚƚŚĞǁŝŶĚůĂƐƐĐůŝƉ͘ ϰ͘ dǁŝƐƚƚŚĞǁŝŶĚůĂƐƐƌŽĚƵŶƚŝůďƌŝŐŚƚƌĞĚďůĞĞĚŝŶŐŚĂƐƐƚŽƉƉĞĚĂŶĚƚŚĞĚŝƐƚĂůƉƵůƐĞŝƐĞůŝŵŝŶĂƚĞĚ;ŝĨƚŚĞ ďĂŶĚǁĂƐƚŝŐŚƚĞŶŽƵŐŚďĞĨŽƌĞƚƵƌŶŝŶŐƚŚĞǁŝŶĚůĂƐƐ͕ƚŚŝƐƐŚŽƵůĚŶŽƚƚĂŬĞŵŽƌĞƚŚĂŶƚŚƌĞĞƚƵƌŶƐͿ͘ ϱ͘ WůĂĐĞǁŝŶĚůĂƐƐƌŽĚŝŶƐŝĚĞĐůŝƉƚŽůŽĐŬŝƚŝŶƉůĂĐĞ͘ ϲ͘ ĚŚĞƌĞƚŚĞďĂŶĚŽǀĞƌƚŚĞƌŽĚ;ŝŶƐŝĚĞƚŚĞĐůŝƉͿĂŶĚĂƌŽƵŶĚƚŚĞĞǆƚƌĞŵŝƚǇ͘ ϳ͘ ^ĞĐƵƌĞƌŽĚǁŝƚŚǁŚŝƚĞƐƚƌĂƉ͘ŽĐƵŵĞŶƚĂƉƉůŝĐĂƚŝŽŶƚŝŵĞŽŶǁŚŝƚĞƐƚƌĂƉ͘ ϴ͘ ŚĞĐŬĨŽƌďůĞĞĚŝŶŐĂŶĚĚŝƐƚĂůƉƵůƐĞ͘/ĨďůĞĞĚŝŶŐŝƐŶŽƚĐŽŶƚƌŽůůĞĚ͕ĐŽŶƐŝĚĞƌĂĚĚŝƚŝŽŶĂůƚŝŐŚƚĞŶŝŶŐŽƌ ĂƉƉůǇĂƐĞĐŽŶĚƚŽƵƌŶŝƋƵĞƚƉƌŽǆŝŵĂůƚŽƚŚĞĨŝƌƐƚĂŶĚƌĞĂƐƐĞƐƐ͘ >ŽǁĞƌĂŶĚͬŽƌdƌĂƉƉĞĚǆƚƌĞŵŝƚǇƉƉůŝĐĂƚŝŽŶ ϭ͘ ƉƉůǇƚŽƵƌŶŝƋƵĞƚ͞ŚŝŐŚĂŶĚƚŝŐŚƚ͟ĂďŽǀĞƚŚĞďůĞĞĚŝŶŐƐŝƚĞ͕ƌŽƵƚĞďĂŶĚĂƌŽƵŶĚƚŚĞĞǆƚƌĞŵŝƚǇ͕ĂŶĚ ƉĂƐƐƚŚĞƌĞĚƚŝƉ;ĨƌĞĞƌƵŶŶŝŶŐĞŶĚͿƚŚƌŽƵŐŚƚŚĞŝŶƐŝĚĞĂŶĚŽƵƚƐŝĚĞƐůŽƚƐŽĨƚŚĞďƵĐŬůĞ͘ Ϯ͘ WƵůůƚŚĞƐĞůĨͲĂĚŚĞƌŝŶŐďĂŶĚsZzd/',dĂŶĚƐĞĐƵƌĞůǇĨĂƐƚĞŶďĂŶĚŽŶŝƚƐĞůĨ͘ ϯ͘ &ĂƐƚĞŶƚŚĞďĂŶĚĂƌŽƵŶĚƚŚĞĞǆƚƌĞŵŝƚǇ͕ďƵƚŶŽƚƉĂƐƚƚŚĞǁŝŶĚůĂƐƐĐůŝƉ͘ ϰ͘ dǁŝƐƚƚŚĞǁŝŶĚůĂƐƐƌŽĚƵŶƚŝůďƌŝŐŚƚƌĞĚďůĞĞĚŝŶŐŚĂƐƐƚŽƉƉĞĚĂŶĚƚŚĞĚŝƐƚĂůƉƵůƐĞŝƐĞůŝŵŝŶĂƚĞĚ;ŝĨƚŚĞ ďĂŶĚǁĂƐƚŝŐŚƚĞŶŽƵŐŚďĞĨŽƌĞƚƵƌŶŝŶŐƚŚĞǁŝŶĚůĂƐƐ͕ƚŚŝƐƐŚŽƵůĚŶŽƚƚĂŬĞŵŽƌĞƚŚĂŶƚŚƌĞĞƚƵƌŶƐͿ͘ ϱ͘ WůĂĐĞǁŝŶĚůĂƐƐƌŽĚŝŶƐŝĚĞĐůŝƉƚŽůŽĐŬŝƚŝŶƉůĂĐĞ͘ ϲ͘ ĚŚĞƌĞƚŚĞďĂŶĚŽǀĞƌƚŚĞƌŽĚ;ŝŶƐŝĚĞƚŚĞĐůŝƉͿĂŶĚĂƌŽƵŶĚƚŚĞĞǆƚƌĞŵŝƚǇ͘ ϳ͘ ^ĞĐƵƌĞƌŽĚǁŝƚŚǁŚŝƚĞƐƚƌĂƉ͘ŽĐƵŵĞŶƚĂƉƉůŝĐĂƚŝŽŶƚŝŵĞŽŶǁŚŝƚĞƐƚƌĂƉ͘ ϴ͘ ŚĞĐŬĨŽƌďůĞĞĚŝŶŐĂŶĚĚŝƐƚĂůƉƵůƐĞ͘/ĨďůĞĞĚŝŶŐŝƐŶŽƚĐŽŶƚƌŽůůĞĚ͕ĐŽŶƐŝĚĞƌĂĚĚŝƚŝŽŶĂůƚŝŐŚƚĞŶŝŶŐŽƌ ĂƉƉůǇĂƐĞĐŽŶĚƚŽƵƌŶŝƋƵĞƚƉƌŽǆŝŵĂůƚŽƚŚĞĨŝƌƐƚĂŶĚƌĞĂƐƐĞƐƐ͘ ZĞŵŽǀĂůŽĨdŽƵƌŶŝƋƵĞƚ x ZĞŵŽǀĂůŽĨƚŚĞƚŽƵƌŶŝƋƵĞƚƐŚŽƵůĚŶŽƚŽĐĐƵƌŝŶƚŚĞƉƌĞŚŽƐƉŝƚĂůƐĞƚƚŝŶŐĞǆĐĞƉƚŝŶĞǆƚƌĞŵĞĐĂƐĞƐ͘ x /ĨƚŚĞƌĞŝƐĂƋƵĞƐƚŝŽŶĂƐƚŽƚŚĞŶĞĐĞƐƐŝƚǇĨŽƌƚŚĞƚŽƵƌŶŝƋƵĞƚĂĨƚĞƌĨƵƌƚŚĞƌĞǀĂůƵĂƚŝŽŶŽĨƚŚĞǁŽƵŶĚ͕ ůŽŽƐĞŶƚŚĞƚŽƵƌŶŝƋƵĞƚďǇƵŶǁŝŶĚŝŶŐƚŚĞǁŝŶĚůĂƐƐďƵƚĚŽŶŽƚƉƵůůƚŚĞƐĞůĨͲĂĚŚĞƌŝŶŐƐƚƌĂƉŽƌƌĞŵŽǀĞ ƚŚĞƚŽƵƌŶŝƋƵĞƚĨƌŽŵƚŚĞĞǆƚƌĞŵŝƚǇ͘

Cypress Creek EMS System Policies and Treatment Guidelines

322 PROCEDURES Revised 8/2016 Wound Care Approved: Levon Vartanian, MD

x ^ŽŵĞĞŵĞƌŐĞŶĐǇĚĞƉĂƌƚŵĞŶƚƐƚĂĨĨŵĂǇŶŽƚďĞĨĂŵŝůŝĂƌǁŝƚŚƚŚŝƐĚĞǀŝĐĞ͘ĂƵƚŝŽŶƌĞĐĞŝǀŝŶŐƉĞƌƐŽŶŶĞů ĂďŽƵƚƌĞŵŽǀŝŶŐƚŚĞƚŽƵƌŶŝƋƵĞƚĂŶĚĂĚǀŝƐĞƚŽƵŶǁŝŶĚƚŚĞǁŝŶĚůĂƐƐƌŽĚƚŽĂƐƐĞƐƐĨŽƌďůĞĞĚŝŶŐ͘ Pearls x /ƚŝƐŝŵƉĞƌĂƚŝǀĞƚŚĂƚƚŚĞĚĞǀŝĐĞďĞƉůĂĐĞĚĂƐŚŝŐŚ;ƉƌŽǆŝŵĂůͿŽŶƚŚĞĞǆƚƌĞŵŝƚǇĂƐƉŽƐƐŝďůĞƚŽƉƌĞǀĞŶƚ ŵŝƐƐŝŶŐĂƌĞƚƌĂĐƚĞĚǀĞƐƐĞůǁŝƚŚŝŶƚŚĞĞǆƚƌĞŵŝƚǇ͘ x /ĨƚŚĞǁŝŶĚůĂƐƐƌŽĚŝƐƚƵƌŶĞĚхϯƚŝŵĞƐ͕ƚŚĞƚŽƵƌŶŝƋƵĞƚŝƐŶŽƚŽŶĐŽƌƌĞĐƚůǇŽƌƚŝŐŚƚĞŶĞĚĞŶŽƵŐŚ ŝŶŝƚŝĂůůǇ͘ZĞŵŽǀĞƐůĂĐŬĨƌŽŵĐŝƌĐƵŵĨĞƌĞŶƚŝĂůďĂŶĚ͕ƌĞͲƚǁŝƐƚƚŽƵƌŶŝƋƵĞƚ͕ĂŶĚͬŽƌĂĚĚĂƐĞĐŽŶĚ ƚŽƵƌŶŝƋƵĞƚ͘ x ƐĞĐŽŶĚƚŽƵƌŶŝƋƵĞƚŵĂǇďĞŶĞĐĞƐƐĂƌǇƚŽĂĐŚŝĞǀĞĂƌƚĞƌŝĂůŽĐĐůƵƐŝŽŶŽŶĂůŽǁĞƌĞǆƚƌĞŵŝƚǇ͘ x ZĞĂƐƐĞƐƐƚŚĞƚŽƵƌŶŝƋƵĞƚĂĨƚĞƌŵŽǀĞŵĞŶƚŽĨƚŚĞƉĂƚŝĞŶƚ͘ x EĞǀĞƌƉůĂĐĞƚŚĞĚĞǀŝĐĞŽǀĞƌĂũŽŝŶƚ͘ x WůĂĐĞŵĞŶƚŽĨƚŚĞĚĞǀŝĐĞprecedesƌĞŵŽǀĂůŽĨĐůŽƚŚŝŶŐ͘/ŶƚŚĞĂŵŽƵŶƚŽĨƚŝŵĞŝƚƚĂŬĞƐƚŽƌĞŵŽǀĞ ĐůŽƚŚŝŶŐ͕ƚŚĞƉĂƚŝĞŶƚĐĂŶĞǆƐĂŶŐƵŝŶĂƚĞ͘ůŽƚŚŝŶŐŵĂǇďĞĐƵƚĂǁĂǇĂƌŽƵŶĚƚŚĞƚŽƵƌŶŝƋƵĞƚƚŽĞǆƉŽƐĞ ƚŚĞĞǆƚƌĞŵŝƚǇĂĨƚĞƌďůĞĞĚŝŶŐŚĂƐďĞĞŶĐŽŶƚƌŽůůĞĚ͘ x /ĨƚŚĞƐĞůĨͲĂĚŚĞƌŝŶŐďĂŶĚďĞĐŽŵĞƐĞǆĐĞƉƚŝŽŶĂůůǇĚŝƌƚǇ͕ƵƐĞƚŚĞďƵĐŬůĞƚŽůŽĐŬƚŚĞďĂŶĚŝŶƉůĂĐĞǁŝƚŚ ĨƌŝĐƚŝŽŶ͘ x ŶǇƉƌĞͲĞǆŝƐƚŝŶŐĚŝƐƚĂůƉƵůƐĞƐŚŽƵůĚďĞĂďƐĞŶƚĂĨƚĞƌĂƉƉůŝĐĂƚŝŽŶ͘ x ƌĞƐƐǁŽƵŶĚ;ƐͿĂƐĂƉƉƌŽƉƌŝĂƚĞĨŽůůŽǁŝŶŐĂƉƉůŝĐĂƚŝŽŶŽĨƚŽƵƌŶŝƋƵĞƚ͘ x dŝƐƐƵĞĚĂŵĂŐĞŵĂǇŽĐĐƵƌŝĨƚŽƵƌŶŝƋƵĞƚŝƐŝŶƉůĂĐĞŵŽƌĞƚŚĂŶƐŝǆŚŽƵƌƐ͘

Cypress Creek EMS System Policies and Treatment Guidelines

323 PROCEDURES Revised 8/2016 Airway Approved: Levon Vartanian, MD

tŽƵŶĚWĂĐŬŝŶŐ Indications Equipment Needed KƉĞŶǁŽƵŶĚŝŶũƵŶĐƚŝŽŶĂůĂƌĞĂƐŶŽƚĂŵĞŶĂďůĞ x WĞƌƐŽŶĂůƉƌŽƚĞĐƚŝǀĞĞƋƵŝƉŵĞŶƚ͕ ƚŽƚŽƵƌŶŝƋƵĞƚƉůĂĐĞŵĞŶƚ͘ ŝŶĐůƵĚŝŶŐŐůŽǀĞƐ͕ĞǇĞƉƌŽƚĞĐƚŝŽŶ͕ŐŽǁŶ͕ ŵĂƐŬ͕ĞƚĐ͘ĂƐĂƉƉƌŽƉƌŝĂƚĞ͘ x ^ƚĞƌŝůĞŐĂƵǌĞ͕ƌŽůůĞĚŐĂƵǌĞ͕ĂďƐŽƌďĞŶƚ ŐĂƵǌĞ͕ƚƌĂƵŵĂƉĂĚƐ͕ĞƚĐ͘ĂƐĂƉƉƌŽƉƌŝĂƚĞ͘ x ,ĞŵŽƐƚĂƚŝĐŐĂƵǌĞĂƐĂƉƉƌŽƉƌŝĂƚĞ When to Wound Pack x tŽƵŶĚƉĂĐŬŝŶŐŝƐĂƉƉƌŽƉƌŝĂƚĞĨŽƌƐŝŐŶŝĨŝĐĂŶƚ͕ĞǆƐĂŶŐƵŝŶĂƚŝŶŐŚĞŵŽƌƌŚĂŐĞŝŶũƵŶĐƚŝŽŶĂůĂƌĞĂƐ͘ x /ĨǁŽƵŶĚŝƐĂŵĞŶĂďůĞƚŽTourniquet ƉůĂĐĞŵĞŶƚ͕ƵƚŝůŝǌĞĂƚŽƵƌŶŝƋƵĞƚ͘ x Do not ƉĂĐŬǁŽƵŶĚƐŝŶƚŚĞĂďĚŽŵĞŶŽƌƚŽƌƐŽ͘ x ǆĞƌĐŝƐĞĞǆƚƌĞŵĞĐĂƵƚŝŽŶŝŶƉĂĐŬŝŶŐǁŽƵŶĚƐƚŽƚŚĞŶĞĐŬ͘ŽŶŽƚƉĂĐŬƚŚĞĂŶƚĞƌŝŽƌƉŽƌƚŝŽŶŽĨƚŚĞ ŶĞĐŬ͕ĂƐŝƚŵĂǇŽĐĐůƵĚĞĐĂƌŽƚŝĚĂƌƚĞƌŝĞƐ͕ũƵŐƵůĂƌǀĞŝŶƐ͕ŽƌƚŚĞĂŝƌǁĂǇ͘ How to Wound Pack ϭ͘ ǆƉŽƐĞǁŽƵŶĚ͘ZĞŵŽǀĞĞǆĐĞƐƐƉŽŽůĞĚďůŽŽĚĂŶĚͬŽƌĚĞďƌŝƐǁŚŝůĞƉƌĞƐĞƌǀŝŶŐĂŶǇĐůŽƚƐƚŚĂƚŚĂǀĞ ĂůƌĞĂĚǇĨŽƌŵĞĚ͘ Ϯ͘ >ŽĐĂƚĞƚŚĞƐŽƵƌĐĞŽĨƚŚĞŵŽƐƚĂĐƚŝǀĞďůĞĞĚŝŶŐǁŝƚŚǇŽƵƌŐůŽǀĞĚĨŝŶŐĞƌ͘ ϯ͘ /ŶƐĞƌƚŐĂƵǌĞǁŝƚŚŽƚŚĞƌŚĂŶĚ͕ƐůŝĚŝŶŐĚŽǁŶŝŶƐĞƌƚĞĚĨŝŶŐĞƌ͕ƵƐŝŶŐŝƚĂƐĂŐƵŝĚĞ͘WĂĐŬŐĂƵǌĞ ;ŚĞŵŽƐƚĂƚŝĐŽƌƐƚĞƌŝůĞͿƚŝŐŚƚůǇŝŶƚŽǁŽƵŶĚĂŶĚĚŝƌĞĐƚůǇŽŶƚŽƐŽƵƌĐĞŽĨďůĞĞĚŝŶŐ͘ ϰ͘ ZĞƉĞĂƚηϯ͕ĂĚũƵƐƚ͕ŽƌĂĚĚŐĂƵǌĞĂƐŶĞĞĚĞĚƵŶƚŝůǁŽƵŶĚĐĂǀŝƚǇŝƐŽǀĞƌĨƵůůŽĨŐĂƵǌĞ͘ ϱ͘ ƉƉůǇĨŝƌŵŵĂŶƵĂůƉƌĞƐƐƵƌĞĨŽƌĂƚůĞĂƐƚϯŵŝŶƵƚĞƐ͘Do not ůĞƚƵƉƉƌĞƐƐƵƌĞƵŶƚŝůĨƵůůϯŵŝŶƵƚĞƐŚĂƐ ƉĂƐƐĞĚ͘ ϲ͘ ZĞĂƐƐĞƐƐƚŽĞŶƐƵƌĞďůĞĞĚŝŶŐŝƐĐŽŶƚƌŽůůĞĚ͘ ϳ͘ /ĨŝŶŝƚŝĂůĂƉƉůŝĐĂƚŝŽŶĨĂŝůƐƚŽƉƌŽǀŝĚĞŚĞŵŽƐƚĂƐŝƐ͕ƌĞŵŽǀĞ ĂŶĚƌĞƉĞĂƚƉƌŽĐĞĚƵƌĞǁŝƚŚŶĞǁŐĂƵǌĞ͘ ϴ͘ ƉƉůǇƉƌĞƐƐƵƌĞďĂŶĚĂŐĞŽǀĞƌƉĂĐŬĞĚǁŽƵŶĚ͘ ϵ͘ ŽŶŽƚƌĞŵŽǀĞƉƌĞƐƐƵƌĞďĂŶĚĂŐĞŽƌǁŽƵŶĚƉĂĐŬĞĚ ŐĂƵǌĞ͘ ϭϬ͘ Reassess frequently for bleeding͘ Pearls x >ĂƌŐĞ͕ƵŐůǇǁŽƵŶĚƐǁŝůůƌĞƋƵŝƌĞůŽƚƐŽĨŐĂƵǌĞ͘^ŵĂůůĞƌŚŽůĞƐǁŝůůďĞŚĂƌĚĞƌƚŽƉĂĐŬĂŶĚǁŝůůƌĞƋƵŝƌĞ ďŽƚŚŚĂŶĚƐͬĨŝŶŐĞƌƐƚŽƉĂĐŬŐĂƵǌĞŝŶƚŽǁŽƵŶĚ͘ x tŽƵŶĚƐŽŶůĂƚĞƌĂůĂŶĚƉŽƐƚĞƌŝŽƌĂƐƉĞĐƚƐŽĨŶĞĐŬĐĂŶďĞƉĂĐŬĞĚ͘ŽŶŽƚƉĂĐŬƚŚĞĂŶƚĞƌŝŽƌŶĞĐŬŽƌ ǁŽƵŶĚƐƚŚĂƚŵĂǇƉƌŽĐĞĞĚŝŶƚŽƚŚĞĐŚĞƐƚĐĂǀŝƚǇ͘ x DĂǇďĞƵƐĞĚŝŶĐŽŶũƵŶĐƚŝŽŶǁŝƚŚƚŚĞ^DWĞůǀŝĐ^ůŝŶŐ͕:dd͕ŽƌŝdůĂŵƉ͘

Cypress Creek EMS System Policies and Treatment Guidelines

324 PROCEDURES Revised 6/2019 Miscellaneous Approved: Levon Vartanian, MD

ZĞƐƉŝƌĂƚŽƌǇ^ƵƉƉŽƌƚĨŽƌŶŝŵĂůWĂƚŝĞŶƚƐ Indications Equipment Needed Assessment Requirements ŶǇĂŶŝŵĂůƉĂƚŝĞŶƚŝŶĚŝƐƚƌĞƐƐ sD͕ĂŶŝŵĂůŽǆǇŐĞŶƌĞĐŽǀĞƌǇ ŵĂƐŬ͕ŽǆǇŐĞŶ

Procedure x hƚŝůŝǌĞƚŚĞĐŽƌƌĞĐƚƐŝǌĞŵĂƐŬĨŽƌƉĂƚŝĞŶƚ͘ x ^ƵƉƉůĞŵĞŶƚĂůŽǆǇŐĞŶ͗ϱͲϳůŝƚĞƌƐͬŵŝŶƵƚĞ x /ĨƵŶĐŽŶƐĐŝŽƵƐ͕ƐĞĐƵƌĞƚŽŶŐƵĞĨŽƌǁĂƌĚƵƐŝŶŐĚŝĂƉŚƌĂŐŵŽĨŵĂƐŬ x &ŽƌĂƌƚŝĨŝĐŝĂůƌĞƐƉŝƌĂƚŝŽŶƐ;sDͿ͕ƌĞŵŽǀĞƚŚĞĂƚƚĂĐŚĞĚŵĂƐŬĨƌŽŵƚŚĞsDĂŶĚƵƐĞĂŶĂŶŝŵĂůŵĂƐŬ͘ ŽǀĞƌǀĞŶƚƐǁŝƚŚĨŝŶŐĞƌƐĂŶĚĂĚŵŝŶŝƐƚĞƌϭϬͲϭϮďƌĞĂƚŚƐͬŵŝŶƵƚĞ͘ Pearls x EŽƌŵĂůƚŝĚĂůǀŽůƵŵĞĨŽƌƐŵĂůůƚŽŵĞĚŝƵŵĚŽŐƐĂŶĚĐĂƚƐŝƐϭϱŵ>ͬŬŐ͖ƚŝĚĂůǀŽůƵŵĞĨŽƌŵĞĚŝƵŵƚŽ ůĂƌŐĞĚŽŐƐĂŶĚĐĂƚƐŝƐϭϬŵ>ͬŬŐ x ƵƌƌĞŶƚůǇƐƵƉƉůŝĞĚsDƐĐŽŵĞŝŶƚŚƌĞĞƐŝǌĞƐ͗ x ĚƵůƚ͕ĨŽƌƉĂƚŝĞŶƚƐхϰϬŬŐĂŶĚƉƌŽǀŝĚŝŶŐĂŵĂǆŝŵƵŵƚŝĚĂůǀŽůƵŵĞŽĨϵϱϬʹϵϲϬŵ> x WĞĚŝĂƚƌŝĐ͕ĨŽƌƉĂƚŝĞŶƚƐϭϬʹϰϬŬŐĂŶĚƉƌŽǀŝĚŝŶŐĂŵĂǆŝŵƵŵƚŝĚĂůǀŽůƵŵĞŽĨϲϬϬʹϲϯϬŵ> x /ŶĨĂŶƚ͕ĨŽƌƉĂƚŝĞŶƚƐфϭϬŬŐĂŶĚƉƌŽǀŝĚŝŶŐĂŵĂǆŝŵƵŵƚŝĚĂůǀŽůƵŵĞŽĨϭϱϬʹϭϳϬŵ> x KŶƚŚĞsDĂďŽǀĞƚŚĞƉĂƚŝĞŶƚŵĂƐŬĐŽŶŶĞĐƚŝŽŶŝƐĂƉƌĞƐƐƵƌĞŐĂƵŐĞƚŚĂƚƉƌŽǀŝĚĞƐĨĞĞĚďĂĐŬŽŶ ǀĞŶƚŝůĂƚŝŽŶĚĞůŝǀĞƌǇ͘ŝŵƚŽŬĞĞƉǀĞŶƚŝůĂƚŽƌƉƌĞƐƐƵƌĞƐŝŶƚŚĞŐƌĞĞŶĂƌĞĂ͘ x dŚĞĂŶŝŵĂůŽǆǇŐĞŶƌĞĐŽǀĞƌǇŵĂƐŬƐĂƌĞƌĞƵƐĂďůĞ͘ŽŶŽƚĚŝƐĐĂƌĚ͘ŝƐŝŶĨĞĐƚĂƐĂƉƉƌŽƉƌŝĂƚĞ͘

Cypress Creek EMS System Policies and Treatment Guidelines

325 PROCEDURES Revised 6/2019 Miscellaneous Approved: Levon Vartanian, MD

Cypress Creek EMS System Policies and Treatment Guidelines

326 MEDICATIONS Revised 8/2016 Approved: Levon Vartanian, MD

DĞĚŝĐĂƚŝŽŶƐ

Acetaminophen (Tylenol) ...... 329 Adenosine (Adenocard) ...... 330 Albuterol (Proventil) ...... 331 Amiodarone HCL (Cordarone) ...... 332 Aspirin ...... 333 Atropine Sulfate ...... 334 Calcium Chloride...... 336 Dexamethasone (Decadron)...... 337 Dextrose ...... 338 Diazepam (Valium) ...... 339 Diltiazem (Cardizem) ...... 340 Diphenhydramine (Benadryl) ...... 341 Dopamine ...... 342 Epinephrine HCL (Adrenaline) ...... 344 Etomidate (Amidate) ...... 346 Fentanyl (Sublimaze) ...... 347 Furosemide (Lasix) ...... 348 Glucagon (GlucaGen) ...... 349 Heparin ...... 350 Hydroxocobalamin (Cyanokit) ...... 351 Ibuprofen (Motrin) ...... 352 Ipratropium Bromide (Atrovent) ...... 353 Ketamine (Ketalar) ...... 354 Ketorolac (Toradol) ...... 355 Lidocaine HCL (Xylocaine, Lidocaine Jelly) ...... 356 Magnesium Sulfate ...... 357 Meperidine HCl (Demerol) ...... 358 Methylprednisolone (Solu-Medrol) ...... 359 Metoclopramide (Reglan)...... 360 Metoprolol (Lopressor) ...... 361 Midazolam (Versed) ...... 362 Morphine Sulfate ...... 363 Naloxone (Narcan) ...... 364 Nitroglycerin (Nitrostat, Nitrolingual Spray) ...... 365 Normal Saline ...... 366 Ondansetron HCL (Zofran) ...... 367 Oral Glucose ...... 368 Oxygen ...... 369 Oxytocin (Pitocin) ...... 370 Pancuronium (Pavulon) ...... 371

Cypress Creek EMS System Policies and Treatment Guidelines

327

Thiamine ...... 379 Vecuronium (Norcuron) ...... 380 Whole Blood & BloodProducts ...... 381 MEDICATIONS Revised 8/2016 Approved: Levon Vartanian, MD

PlasmaLyte-A (Plasmalyte) ...... 372 Promethazine (Phenergan) ...... 373 Rocuronium (Zemuron) ...... 374 Sodium Bicarbonate ...... 375 Succinylcholine Chloride (Anectine) ...... 376 Tetracaine Ophthalmic Solution ...... 378 Thiamine ...... 379 Vecuronium (Norcuron) ...... 380 Whole Blood & BloodProducts ...... 381

Cypress Creek EMS System Policies and Treatment Guidelines

328 MEDICATIONS Revised 8/2016 Approved: Levon Vartanian, MD

ĐĞƚĂŵŝŶŽƉŚĞŶ;dǇůĞŶŽůͿ DĞĚŝĐĂƚŝŽŶ x ŶĂŶĂůŐĞƐŝĐͬĂŶƚŝƉǇƌĞƚŝĐƚŚĂƚŚĂƐǁĞĂŬĂŶƚŝͲŝŶĨůĂŵŵĂƚŽƌǇĂĐƚŝǀŝƚǇĂŶĚŶŽĞĨĨĞĐƚƐŽŶƉůĂƚĞůĞƚƐŽƌ ďůĞĞĚŝŶŐƚŝŵĞ DĞĐŚĂŶŝƐŵŽĨĐƚŝŽŶ x ZĞĚƵĐĞƐĨĞǀĞƌďǇĂĐƚŝŶŐĚŝƌĞĐƚůǇŽŶƚŚĞŚĞĂƚƌĞŐƵůĂƚŝŶŐĐĞŶƚĞƌŽĨƚŚĞŚǇƉŽƚŚĂůĂŵƵƐ /ŶĚŝĐĂƚŝŽŶƐ x &ĞǀĞƌŽĨĂŶǇĞƚŝŽůŽŐǇ ŽŶƚƌĂŝŶĚŝĐĂƚŝŽŶƐ x EŽŶĞ ^ŝĚĞĨĨĞĐƚƐ x ZĂƌĞůǇ͕ŐĂƐƚƌŝĐŝƌƌŝƚĂƚŝŽŶ ŽƐĂŐĞΘĚŵŝŶŝƐƚƌĂƚŝŽŶ x Pediatric͗ϭϱŵŐͬŬŐďǇŵŽƵƚŚ͕ƋϰͲϲŚŽƵƌƐ x Adult͗Ϭ͘ϱʹϭŐƌĂŵďǇŵŽƵƚŚ͕ƋϰͲϲŚŽƵƌƐ ^ƉĞĐŝĂůŽŶƐŝĚĞƌĂƚŝŽŶƐ x ŽŶŽƚĂĚŵŝŶŝƐƚĞƌŝĨůĂƐƚĂĚŵŝŶŝƐƚƌĂƚŝŽŶŽĨĂĐĞƚĂŵŝŶŽƉŚĞŶǁĂƐфϰŚŽƵƌƐĂŐŽ͘ x ŽŶŽƚĂĚŵŝŶŝƐƚĞƌŽƌĂůŵĞĚŝĐĂƚŝŽŶƐƚŽƉŽƐƚŝĐƚĂůƉĂƚŝĞŶƚƐŽƌƚŚŽƐĞĂƚƌŝƐŬĨŽƌĂƐƉŝƌĂƚŝŽŶ͖ƵƐĞŽƚŚĞƌ ĐŽŽůŝŶŐŵĞĂƐƵƌĞƐ͕ŝĨŶĞĞĚĞĚ;ƵŶĚƌĞƐƐ͕ĐŽůĚƉĂĐŬƐ͕/sĨůƵŝĚƐ͕ĞƚĐ͘ͿĨŽƌĨĞǀĞƌ͘ x DĂǇĂůƐŽďĞĂƵƚŚŽƌŝǌĞĚĨŽƌƵƐĞĂƐĂŶĂŶĂůŐĞƐŝĐĨŽƌƐƉĞĐŝĂůĞǀĞŶƚƐ;Ğ͘Ő͘/ƌŽŶŵĂŶƌĂĐĞƐ͕ĞƚĐ͘Ϳ͘

Cypress Creek EMS System Policies and Treatment Guidelines

329 MEDICATIONS Revised 6/2016 Approved: Levon Vartanian, MD

ĚĞŶŽƐŝŶĞ;ĚĞŶŽĐĂƌĚͿ DĞĚŝĐĂƚŝŽŶ ŶĂƚƵƌĂůůǇŽĐĐƵƌƌŝŶŐ͕ƌĂƉŝĚĂĐƚŝŶŐ͕ĂŶƚŝĂƌƌŚǇƚŚŵŝĐĂŐĞŶƚĞĨĨĞĐƚŝǀĞŝŶƚŚĞƚƌĞĂƚŵĞŶƚŽĨƉĂƌŽǆǇƐŵĂů ƐƵƉƌĂǀĞŶƚƌŝĐƵůĂƌƚĂĐŚǇĐĂƌĚŝĂ;W^sdͿ͘ DĞĐŚĂŶŝƐŵŽĨĐƚŝŽŶ x ^ůŽǁƐĞůĞĐƚƌŝĐĂůĐŽŶĚƵĐƚŝŽŶĂŶĚĐĂŶŝŶƚĞƌƌƵƉƚƚŚĞƌĞͲĞŶƚƌǇƉĂƚŚǁĂǇƐƚŚƌŽƵŐŚƚŚĞsŶŽĚĞ x ŶƚĂŐŽŶŝǌĞĚďǇŵĞƚŚǇůǆĂŶƚŚŝŶĞƐ;ĐĂĨĨĞŝŶĞ͕ƚŚĞŽƉŚǇůůŝŶĞ͕ĂŵŝŶŽƉŚǇůůŝŶĞͿ x ĚĞŶŽƐŝŶĞŝƐŶŽƚďůŽĐŬĞĚďǇĂƚƌŽƉŝŶĞ /ŶĚŝĐĂƚŝŽŶƐ x EĂƌƌŽǁͲĐŽŵƉůĞǆƚĂĐŚǇĐĂƌĚŝĂ;W^sdͿ x tŝĚĞͲĐŽŵƉůĞǆƚĂĐŚǇĐĂƌĚŝĂ ŽŶƚƌĂŝŶĚŝĐĂƚŝŽŶƐ x ϮqŽƌϯqsďůŽĐŬ;ĞǆĐĞƉƚŝŶƉĂƚŝĞŶƚƐǁŝƚŚĂĨƵůůĨƵŶĐƚŝŽŶŝŶŐĂƌƚŝĨŝĐŝĂůƉĂĐĞŵĂŬĞƌͿ x ^ŝĐŬƐŝŶƵƐƐǇŶĚƌŽŵĞ;ĞǆĐĞƉƚŝŶƉĂƚŝĞŶƚƐǁŝƚŚĂĨƵůůĨƵŶĐƚŝŽŶŝŶŐĂƌƚŝĨŝĐŝĂůƉĂĐĞŵĂŬĞƌͿ x <ŶŽǁŶŚǇƉĞƌƐĞŶƐŝƚŝǀŝƚǇ x ^ŚŽƵůĚďĞƵƐĞĚǁŝƚŚĐĂƵƚŝŽŶŝŶƉƌĞŐŶĂŶƚǁŽŵĞŶ x ^ŚŽƵůĚďĞƵƐĞĚǁŝƚŚĐĂƵƚŝŽŶŝŶƉĂƚŝĞŶƚƐǁŚŽĂƌĞǁŚĞĞǌŝŶŐ ^ŝĚĞĞĨĨĞĐƚƐ x DĂǇƉƌŽĚƵĐĞĂƚĞŵƉŽƌĂƌǇϭq͕Ϯq͕ŽƌϯqsǁŚŝĐŚƐŚŽƵůĚďĞƚƌĞĂƚĞĚǁŝƚŚƚŚĞĂƉƉƌŽƉƌŝĂƚĞƉƌŽƚŽĐŽů͘ WĂƚŝĞŶƚƐǁŚŽĚĞǀĞůŽƉĂŚŝŐŚͲŐƌĂĚĞďůŽĐŬĂĨƚĞƌŽŶĞĚŽƐĞƐŚŽƵůĚŶŽƚďĞŐŝǀĞŶĂĚĚŝƚŝŽŶĂůĚŽƐĞƐ͘ x &ĂĐŝĂůĨůƵƐŚŝŶŐ͕ŚĞĂĚĂĐŚĞ͕ƐŚŽƌƚŶĞƐƐŽĨďƌĞĂƚŚͬĚǇƐƉŶĞĂ͕ůŝŐŚƚŚĞĂĚĞĚŶĞƐƐ͕ǀĞƌƚŝŐŽ͕ĂŶĚŶĂƵƐĞĂ x ƵĞƚŽƚŚĞǀĞƌǇƐŚŽƌƚŚĂůĨͲůŝĨĞŽĨĂĚĞŶŽƐŝŶĞ;|ϭϬƐĞĐ͘Ϳ͕ƚŚĞƐĞƐŝĚĞĞĨĨĞĐƚƐƐŚŽƵůĚďĞƐŚŽƌƚůĂƐƚŝŶŐ ŽƐĂŐĞΘĚŵŝŶŝƐƚƌĂƚŝŽŶ ĚĞŶŽƐŝŶĞƐŚŽƵůĚďĞŐŝǀĞŶĂƐĂƌĂƉŝĚďŽůƵƐ/s;ŽǀĞƌϭͲϮƐĞĐŽŶĚƐͿ͘/ƚƐŚŽƵůĚďĞŐŝǀĞŶĂƐƉƌŽǆŝŵĂůĂƐ ƉŽƐƐŝďůĞĂŶĚĨŽůůŽǁĞĚďǇĂƌĂƉŝĚĨůƵŝĚĨůƵƐŚ;ĂƚůĞĂƐƚϭϬŵůͿ͘

x /ŶŝƚŝĂů͗ĂĚƵůƚͲ6.0 mg͕ƉĞĚŝĂƚƌŝĐͲ0.1 mg/kg x ^ƵďƐĞƋƵĞŶƚ͗ĂĚƵůƚͲ12.0 mg͖ŵĂǇďĞƌĞƉĞĂƚĞĚŽŶĐĞŵŽƌĞ͕ƉĞĚŝĂƚƌŝĐͲ0.2 mg/kg x DĂǆŝŵƵŵƐŝŶŐůĞĚŽƐĞ͗12 mg x DĂǆŝŵƵŵƚŽƚĂůĚŽƐĞ͗30 mg ^ƉĞĐŝĂůŽŶƐŝĚĞƌĂƚŝŽŶƐ x dŚĞŵĞĚŝĐĂƚŝŽŶƐŚŽƵůĚďĞŝŶƐƉĞĐƚĞĚĨŽƌƉĂƌƚŝĐƵůĂƚĞŵĂƚƚĞƌƉƌŝŽƌƚŽĂĚŵŝŶŝƐƚƌĂƚŝŽŶ͘ x /ĨĐƌǇƐƚĂůůŝǌĂƚŝŽŶŽĐĐƵƌƐ͕ĚŝƐƐŽůǀĞĐƌǇƐƚĂůƐďǇǁĂƌŵŝŶŐƚŽƌŽŽŵƚĞŵƉĞƌĂƚƵƌĞ͘ x ĞĐĂƵƐĞƚŚĞŚĂůĨͲůŝĨĞŽĨĂĚĞŶŽƐŝŶĞŝƐ|ϭϬƐĞĐŽŶĚƐ͕ĂĚǀĞƌƐĞĞĨĨĞĐƚƐĂƌĞŐĞŶĞƌĂůůǇƌĂƉŝĚůǇƐĞůĨͲůŝŵŝƚŝŶŐ͘ x dƌĞĂƚŵĞŶƚŽĨĂŶǇƉƌŽůŽŶŐĞĚĂĚǀĞƌƐĞĞĨĨĞĐƚƐƐŚŽƵůĚďĞŝŶĚŝǀŝĚƵĂůŝǌĞĚĂŶĚĚŝƌĞĐƚĞĚƚŽǁĂƌĚƐƚŚĞ ƐƉĞĐŝĨŝĐĞǀĞŶƚ͘

Cypress Creek EMS System Policies and Treatment Guidelines

330 MEDICATIONS Revised 8/2016 Approved: Levon Vartanian, MD

ůďƵƚĞƌŽů;WƌŽǀĞŶƚŝůͿ DĞĚŝĐĂƚŝŽŶ

ůďƵƚĞƌŽůŝƐĂƌĞůĂƚŝǀĞůǇƐĞůĞĐƚŝǀĞEϮĂĚƌĞŶĞƌŐŝĐďƌŽŶĐŚŽĚŝůĂƚŽƌ͘ DĞĐŚĂŶŝƐŵŽĨĐƚŝŽŶ ůďƵƚĞƌŽůƉƌŽĚƵĐĞƐďƌŽŶĐŚŝĂůƐŵŽŽƚŚŵƵƐĐůĞƌĞůĂǆĂƚŝŽŶĂŶĚůŝŬĞŽƚŚĞƌEĂĚƌĞŶĞƌŐŝĐĂŐŽŶŝƐƚƐ͕ŝƚĐĂŶ ƉƌŽĚƵĐĞƐŝŐŶŝĨŝĐĂŶƚĐĂƌĚŝŽǀĂƐĐƵůĂƌĞĨĨĞĐƚƐŝŶƐŽŵĞƉĂƚŝĞŶƚƐ͕ĂƐŵĞĂƐƵƌĞĚďǇƉƵůƐĞƌĂƚĞ͕ďůŽŽĚƉƌĞƐƐƵƌĞ͕ ĂŶĚͬŽƌ'ĐŚĂŶŐĞƐ͘ /ŶĚŝĐĂƚŝŽŶƐ x ůďƵƚĞƌŽůŵĂǇďĞĂĚŵŝŶŝƐƚĞƌĞĚĨŽƌƚŚĞƌĞůŝĞĨŽĨďƌŽŶĐŚŽƐƉĂƐŵŝŶĂĚƵůƚƐĂŶĚĐŚŝůĚƌĞŶǁŝƚŚƌĞǀĞƌƐŝďůĞ ŽďƐƚƌƵĐƚŝǀĞĂŝƌǁĂǇĚŝƐĞĂƐĞĂŶĚĂĐƵƚĞĂƚƚĂĐŬƐŽĨďƌŽŶĐŚŽƐƉĂƐŵ͘ ŽŶƚƌĂŝŶĚŝĐĂƚŝŽŶƐ ůďƵƚĞƌŽůƐŚŽƵůĚŶŽƚďĞĂĚŵŝŶŝƐƚĞƌĞĚƚŽƉĂƚŝĞŶƚƐǁŝƚŚŬŶŽǁŶŚǇƉĞƌƐĞŶƐŝƚŝǀŝƚǇƚŽĂŶǇŽĨŝƚƐĐŽŵƉŽŶĞŶƚƐ͘ /ƚƐŚŽƵůĚďĞƵƐĞĚǁŝƚŚĐĂƵƚŝŽŶŝŶƉĂƚŝĞŶƚƐǁŝƚŚ͗ x ĂƌĚŝŽǀĂƐĐƵůĂƌĚŝƐŽƌĚĞƌƐ͕ĞƐƉĞĐŝĂůůǇĐŽƌŽŶĂƌǇŝŶƐƵĨĨŝĐŝĞŶĐǇ x ĂƌĚŝĂĐĂƌƌŚǇƚŚŵŝĂƐĂŶĚŚǇƉĞƌƚĞŶƐŝŽŶ x ŽŶǀƵůƐŝǀĞĚŝƐŽƌĚĞƌƐ x ,ǇƉĞƌƚŚǇƌŽŝĚŝƐŵĂŶĚͬŽƌĚŝĂďĞƚĞƐ ^ŝĚĞĨĨĞĐƚƐ dŚĞĨŽůůŽǁŝŶŐĂƌĞƉŽƐƐŝďůĞ͕ďƵƚŽĐĐƵƌŝŶĨƌĞƋƵĞŶƚůǇŝŶƉĂƚŝĞŶƚƐŐŝǀĞŶĂůďƵƚĞƌŽůďǇŝŶŚĂůĂƚŝŽŶ͗ x ŽĚǇƚƌĞŵŽƌƐ͕ŚĞĂĚĂĐŚĞ͕ŝŶƐŽŵŶŝĂ x ,ǇƉĞƌƚĞŶƐŝŽŶ͕ĂƌƌŚǇƚŚŵŝĂƐ x ƌŽŶĐŚŽƐƉĂƐŵ x hƌƚŝĐĂƌŝĂ͕ĂŶŐŝŽĞĚĞŵĂ͕ƌĂƐŚ ŽƐĂŐĞΘĚŵŝŶŝƐƚƌĂƚŝŽŶ x ůďƵƚĞƌŽůŝƐƐƵƉƉůŝĞĚŝŶƐŝŶŐůĞƵŶŝƚĚŽƐĞƉůĂƐƚŝĐ͞ďƵůůĞƚƐ͟ŽĨ2.5 mg/3.0 ml ĂŶĚŝƐĂĚŵŝŶŝƐƚĞƌĞĚǀŝĂ ŚĂŶĚŚĞůĚŽƌĨĂĐĞŵĂƐŬŶĞďƵůŝǌĞƌ͘EĞďƵůŝǌĂƚŝŽŶǁŝƚŚĂůďƵƚĞƌŽůŵĂǇďĞĐŽŶƚŝŶƵĞĚƵŶƚŝůƌĞƐƉŝƌĂƚŽƌǇ ƐƚĂƚƵƐŝŵƉƌŽǀĞƐ͘ x ŽƐĂŐĞŝƐϱŵŐ;ϮƵŶŝƚĚŽƐĞƐͿĨŽƌĂĚƵůƚƐ͕ĂŶĚϮ͘ϱŵŐ;ϭƵŶŝƚĚŽƐĞͿĨŽƌƉĞĚŝĂƚƌŝĐƐ͘ ^ƉĞĐŝĂůŽŶƐŝĚĞƌĂƚŝŽŶƐ

x ŶǇEϮĂĚƌĞŶĞƌŐŝĐĂŐŽŶŝƐƚŵĂǇŚĂǀĞĂĐůŝŶŝĐĂůůǇƐŝŐŶŝĨŝĐĂŶƚĐĂƌĚŝĂĐĞĨĨĞĐƚ͘ x ŽĐƵŵĞŶƚĂƚŝŽŶŽĨƉƵůƐĞƌĂƚĞďĞĨŽƌĞ͕ĚƵƌŝŶŐ͕ĂŶĚĂĨƚĞƌŶĞďƵůŝǌĂƚŝŽŶƚƌĞĂƚŵĞŶƚŵƵƐƚďĞŶŽƚĞĚ͘ x WĂƚŝĞŶƚƐĞǆƉĞƌŝĞŶĐŝŶŐƌĞƐƉŝƌĂƚŽƌǇĐŽŵƉƌŽŵŝƐĞǁŝƚŚĚĞĐƌĞĂƐĞĚƚŝĚĂůǀŽůƵŵĞŵƵƐƚďĞĐŽĂĐŚĞĚŽƌ ĂƐƐŝƐƚĞĚƚŽŝŵƉƌŽǀĞĚĞƉƚŚŽĨǀĞŶƚŝůĂƚŝŽŶƚŽĞŶƐƵƌĞŵĞĚŝĐĂƚŝŽŶƌĞĂĐŚĞƐƌĞĐĞƉƚŽƌƐŝƚĞƐĞĨĨĞĐƚŝǀĞůǇ͘ x dŚĞƌĂƉĞƵƚŝĐůĞǀĞůƐŵƵƐƚďĞĂƐƐƵƌĞĚƉƌŝŽƌƚŽĐŽŵďŝŶŝŶŐǁŝƚŚĂĚĚŝƚŝŽŶĂůŵĞĚŝĐĂƚŝŽŶƐƐƵĐŚĂƐ /ƉƌĂƚƌŽƉŝƵŵ͘

Cypress Creek EMS System Policies and Treatment Guidelines

331 MEDICATIONS Revised 8/2016 Approved: Levon Vartanian, MD

ŵŝŽĚĂƌŽŶĞ,>;ŽƌĚĂƌŽŶĞͿ DĞĚŝĐĂƚŝŽŶ x ŶƚŝĂƌƌŚǇƚŚŵŝĐ DĞĐŚĂŶŝƐŵŽĨĐƚŝŽŶ ZĞůĂƚŝǀĞŽŶƚƌĂŝŶĚŝĐĂƚŝŽŶƐ x ^ǇŵƉĂƚŚŽůǇƚŝĐ x <ŶŽǁŶŚǇƉĞƌƐĞŶƐŝƚŝǀŝƚǇ x ůŽĐŬƐEĂнĂŶĚ<нĐŚĂŶŶĞůƐ x ,ǇƉŽƚĞŶƐŝŽŶ x EĞŐĂƚŝǀĞŝŶŽƚƌŽƉĞĂŶĚĐŚƌŽŶŽƚƌŽƉĞ x ƌĂĚǇĐĂƌĚŝĂŽƌŚŝŐŚͲĚĞŐƌĞĞs x ^ůŽǁƐĐŽŶĚƵĐƚŝŽŶͬƉƌŽůŽŶŐƐƌĞĨƌĂĐƚŽƌŝŶĞƐƐ x sĂƐŽĚŝůĂƚŝŽŶ ^ŝĚĞĨĨĞĐƚƐ /ŶĚŝĐĂƚŝŽŶƐ x ,ǇƉŽƚĞŶƐŝŽŶ x ƌĂĚǇĐĂƌĚŝĂΘs x s&/ͬWƵůƐĞůĞƐƐsd, x >ŝǀĞƌĞŶǌǇŵĞĞůĞǀĂƚŝŽŶƐ x tŝĚĞŽŵƉůĞǆdĂĐŚǇĐĂƌĚŝĂ x EĂƵƐĞĂ x sĞŶƚƌŝĐƵůĂƌĐƚŽƉǇ x sŽŵŝƚŝŶŐ x &ĞǀĞƌ ŽƐĂŐĞĂŶĚĚŵŝŶŝƐƚƌĂƚŝŽŶ ĚƵůƚ͗

x Ventricular EctopyŽƌWide Complex Tachycardia: ϭϱϬŵŐ/sͬ/KŝŶĨƵƐŝŽŶŽǀĞƌϭϬŵŝŶƵƚĞƐ͘WůĂĐĞϭϱϬ ŵŐŵŝŽĚĂƌŽŶĞŝŶƚŽϭϬϬŵ>ďĂŐŽĨEŽƌŵĂů^ĂůŝŶĞĂŶĚƚŚĞŶĂĚŵŝŶŝƐƚĞƌĂƚĂƌĂƚĞŽĨϭϬŵ>ͬŵŝŶƵƚĞ͘ x Ventricular Fibrillation: ϯϬϬŵŐ^>Kt/sͬ/K͕ŵĂǇƌĞƉĞĂƚĂĨƚĞƌϱʹϭϬŵŝŶƵƚĞƐĂƚϭϱϬŵŐ/sͬ/K x Maintenance Dose: /ĨsĞŶƚƌŝĐƵůĂƌ&ŝďƌŝůůĂƚŝŽŶĐŽŶǀĞƌƚĞĚǁŝƚŚŵŝŽĚĂƌŽŶĞ͕ĂĚŵŝŶŝƐƚĞƌϭϱϬŵŐ/sͬ/K ŝŶĨƵƐŝŽŶŽǀĞƌϭϬŵŝŶƵƚĞƐ͘WůĂĐĞϭϱϬŵŐŵŝŽĚĂƌŽŶĞŝŶƚŽϭϬϬŵ>ďĂŐŽĨEŽƌŵĂů^ĂůŝŶĞĂŶĚƚŚĞŶ ĂĚŵŝŶŝƐƚĞƌĂƚĂƌĂƚĞŽĨϭϬŵ>ͬŵŝŶƵƚĞ͘ x Maximum Adult Dose: ŽŶŽƚĞǆĐĞĞĚϲϬϬŵŐ;ϯϬϬŵŐнϭϱϬŵŐнϭϱϬŵŐŽƌϭϱϬŵŐǆϰͿ͘

WĞĚŝĂƚƌŝĐ͗

x Ventricular Fibrillation:ϱŵŐͬŬŐ;ŵĂǆϯϬϬŵŐͿ^>Kt/sͬ/K͕ƌĞƉĞĂƚĂƚϱŵŐͬŬŐǁŝƚŚĂŵĂǆŝŵƵŵĚŽƐĞ ŽĨϭϱϬŵŐ͘dŽƚĂůĚŽƐĞƐŚŽƵůĚŶŽƚĞǆĐĞĞĚϮϱŵŐͬŬŐŽƌϮ͘ϮŐŝŶϮϰŚŽƵƌƐ͘ x Narrow/Wide Complex Tachyardia:ϱŵŐͬŬŐŝŶϭϬϬĐĐŽǀĞƌϭϬͲϮϬŵŝŶƵƚĞƐ/sͬ/K;ŵĂǆϭϱϬŵŐͿ͕ŵĂǇ ƌĞƉĞĂƚǆϯƚŽĂŵĂǆĚŽƐĞŽĨϮϬŵŐͬŬŐŽƌϲϬϬŵŐ/sͬ/K ^ƉĞĐŝĂůŽŶƐŝĚĞƌĂƚŝŽŶƐ x /ŶĨƵƐŝŽŶŶĞĞĚƐƚŽďĞƐƚĂƌƚĞĚǁŝƚŚŝŶϮϬͲϮϱŵŝŶƵƚĞƐĂĨƚĞƌďŽůƵƐĂĚŵŝŶŝƐƚƌĂƚŝŽŶ x ŽŶŽƚĂĚŵŝŶŝƐƚĞƌAmiodarone ĂƚƚŚĞƐĂŵĞƚŝŵĞŽƌƚŚƌŽƵŐŚƚŚĞƐĂŵĞ/sůŝŶĞĂƐSodium Bicarbonate ǁŝƚŚŽƵƚĨůƵƐŚŝŶŐƚŚĞůŝŶĞĂĚĞƋƵĂƚĞůǇ

Cypress Creek EMS System Policies and Treatment Guidelines

332 MEDICATIONS Revised 6/2019 Approved: Levon Vartanian, MD

ƐƉŝƌŝŶ DĞĚŝĐĂƚŝŽŶ x ƐƉŝƌŝŶ;ĂĐĞƚǇůƐĂůŝĐǇůŝĐĂĐŝĚͿŝƐĂŶĂŶĂůŐĞƐŝĐ͕ĂŶƚŝƉǇƌĞƚŝĐĂŶĚĂŶƚŝͲŝŶĨůĂŵŵĂƚŽƌǇŵĞĚŝĐĂƚŝŽŶ͘/ƚĂůƐŽ ŝŶŚŝďŝƚƐƉůĂƚĞůĞƚĂŐŐƌĞŐĂƚŝŽŶŵĂŬŝŶŐŝƚĂďĞŶĞĨŝĐŝĂůĂŶƚŝƚŚƌŽŵďŽƚŝĐ͘ DĞĐŚĂŶŝƐŵŽĨĐƚŝŽŶ

x ƐƉŝƌŝŶŝŶŚŝďŝƚƐƚŚĞƐǇŶƚŚĞƐŝƐŽĨƚŚƌŽŵďŽǆĂŶĞϮǁŚŝĐŚŝŶĚƵĐĞƐƉůĂƚĞůĞƚĂŐŐƌĞŐĂƚŝŽŶďǇŝŶŚŝďŝƚŝŶŐĂ ŵĞƚĂďŽůŝĐĞŶǌǇŵĞŶĞĐĞƐƐĂƌǇĨŽƌŝƚƐƉƌŽĚƵĐƚŝŽŶ͘ x /ŶƉĂƚŝĞŶƚƐǁŝƚŚĐŽƌŽŶĂƌǇďůŽĐŬĂŐĞĂƐƉŝƌŝŶŝŶĐƌĞĂƐĞƐďůŽŽĚĨůŽǁƚŚƌŽƵŐŚĐŽůůĂƚĞƌĂůĂŶĚĂŶĂƐƚŽŵŽƚŝĐ ĐŝƌĐƵůĂƚŝŽŶƌĞĚƵĐŝŶŐŵǇŽĐĂƌĚŝĂůĚĂŵĂŐĞ͘ /ŶĚŝĐĂƚŝŽŶƐ x ĐƵƚĞĐŽƌŽŶĂƌǇƐǇŶĚƌŽŵĞƐ ŽŶƚƌĂŝŶĚŝĐĂƚŝŽŶƐ x <ŶŽǁŶŚǇƉĞƌƐĞŶƐŝƚŝǀŝƚǇ x ĐƚŝǀĞ'/ďůĞĞĚŝŶŐĂƐĞǀŝĚĞŶĐĞďǇŚĞŵĂƚĞŵĞƐŝƐ͕ďůŽŽĚǇͬƚĂƌƌǇƐƚŽŽů͕ŽƌĨƌĂŶŬďůŽŽĚŝŶƐƚŽŽů͘ x ,ŝŐŚŝŶĚĞǆŽĨƐƵƐƉŝĐŝŽŶĨŽƌƐƚƌŽŬĞ x ŚŝůĚƌĞŶƵŶĚĞƌϮǇĞĂƌƐŽĨĂŐĞ ^ŝĚĞĨĨĞĐƚƐ x WƌŽůŽŶŐĞĚďůĞĞĚŝŶŐƚŝŵĞ x 'ĂƐƚƌŝĐŝƌƌŝƚĂƚŝŽŶ x EĂƵƐĞĂĂŶĚͬŽƌǀŽŵŝƚŝŶŐ ŽƐĂŐĞĂŶĚĚŵŝŶŝƐƚƌĂƚŝŽŶ x 324mg Ͳ;ϰͿϴϭŵŐĐŚĞǁĂďůĞƚĂďůĞƚƐWK;ďĂďǇĂƐƉŝƌŝŶͿ ^ƉĞĐŝĂůŽŶƐŝĚĞƌĂƚŝŽŶƐ x WƌĞŐŶĂŶĐǇ͗ŽŶƐŝĚĞƌƌŝƐŬǀĞƌƐƵƐďĞŶĞĨŝƚ͘ x /ĨƉĂƚŝĞŶƚƚŽŽŬĂƉĂƌƚŝĂůĚŽƐĞŽƌƚŽŽŬĞŶƚĞƌŝĐĂůůǇĐŽĂƚĞĚĂƐƉŝƌŝŶƉƌŝŽƌƚŽĂƌƌŝǀĂů͕ƌĞĚŽƐĞǁŝƚŚƚŚĞĂďŽǀĞ ĚŽƐĂŐĞ͘ x ƐƉŝƌŝŶĐĂŶŝŶŚŝďŝƚŝŶŚŝďŝƚŽƌƐďǇĂĨĨĞĐƚŝŶŐƌĞŶŝŶͲĂŶŐŝŽƚĞŶƐŝŶĐŽŶǀĞƌƐŝŽŶƉĂƚŚǁĂǇƐĐĂƵƐŝŶŐ ǀĂƐŽĐŽŶƐƚƌŝĐƚŝŽŶŝŶƉĂƚŝĞŶƚƐĐƵƌƌĞŶƚůǇƚĂŬŝŶŐŝŶŚŝďŝƚŽƌƐ͘ x ^ŽŵĞƉĂƚŝĞŶƚƐŵĂǇďĞŝŶƐƚƌƵĐƚĞĚďǇƚŚĞŝƌƉŚǇƐŝĐŝĂŶƚŽŶŽƚƚĂŬĞĂƐƉŝƌŝŶƌŽƵƚŝŶĞůǇĚƵĞƚŽ'/ŝƐƐƵĞƐŽƌ ďĞŝŶŐŽŶďůŽŽĚƚŚŝŶŶĞƌƐ͘hŶůĞƐƐƚŚĞƐĞƉĂƚŝĞŶƚƐŚĂǀĞĂĐŽŶƚƌĂŝŶĚŝĐĂƚŝŽŶŶŽƚĞĚĂďŽǀĞĂƐƉŝƌŝŶƐŚŽƵůĚ ƐƚŝůůďĞĂĚŵŝŶŝƐƚĞƌĞĚŝĨĂĐƵƚĞĐŽƌŽŶĂƌǇƐǇŶĚƌŽŵĞŝƐƐƵƐƉĞĐƚĞĚ͘

Cypress Creek EMS System Policies and Treatment Guidelines

333 MEDICATIONS Revised 8/2016 Approved: Levon Vartanian, MD

ƚƌŽƉŝŶĞ^ƵůĨĂƚĞ DĞĚŝĐĂƚŝŽŶ x ƚƌŽƉŝŶĞŝƐĂŶĂƚƵƌĂůůǇŽĐĐƵƌƌŝŶŐĂƵƚŽŶŽŵŝĐŶĞƌǀŽƵƐƐǇƐƚĞŵŝŶŚŝďŝƚŽƌĞǆƚƌĂĐƚĞĚĨƌŽŵƚŚĞĂƚƌŽƉĂ ďĞůůĂĚŽŶŶĂƉůĂŶƚ;ĚĞĂĚůǇŶŝŐŚƚƐŚĂĚĞͿ͘ DĞĐŚĂŶŝƐŵŽĨĐƚŝŽŶ x ůŽĐŬƐƉĂƌĂƐǇŵƉĂƚŚĞƚŝĐ;ǀĂŐĂůͿĂĐƚŝŽŶŽĨƚŚĞŚĞĂƌƚ x /ŵƉƌŽǀĞƐĐĂƌĚŝĂĐŽƵƚƉƵƚďǇŝŶĐƌĞĂƐŝŶŐƌĂƚĞŽĨƐŝŶƵƐŶŽĚĞĚŝƐĐŚĂƌŐĞ͕ĞŶŚĂŶĐĞƐĐŽŶĚƵĐƚŝŽŶƚŚƌŽƵŐŚ ƚŚĞͲsũƵŶĐƚŝŽŶ͕ĂŶĚŝŶĐƌĞĂƐĞƐŚĞĂƌƚƌĂƚĞ x ǇŝŶĐƌĞĂƐŝŶŐŚĞĂƌƚƌĂƚĞƚŽŶŽƌŵĂůƌĂŶŐĞ͕ĂƚƌŽƉŝŶĞĚĞĐƌĞĂƐĞƐƚŚĞĐŚĂŶĐĞŽĨĞĐƚŽƉŝĐĂĐƚŝǀŝƚǇŝŶƚŚĞ ǀĞŶƚƌŝĐůĞƐ͘ /ŶĚŝĐĂƚŝŽŶƐ x ^ŝŶƵƐďƌĂĚǇĐĂƌĚŝĂǁŚĞŶĂĐĐŽŵƉĂŶŝĞĚďǇWsƐŽƌŚǇƉŽƚĞŶƐŝŽŶ x ϮŶĚqŽƌϯƌĚqsǁŚĞŶĂĐĐŽŵƉĂŶŝĞĚďǇďƌĂĚǇĐĂƌĚŝĂ x EĞƵƌŽŐĞŶŝĐƐŚŽĐŬǁŚĞŶƚŚĞƉĂƚŝĞŶƚ͛ƐŚĞĂƌƚƌĂƚĞŝƐфϲϬ x KƌŐĂŶŽƉŚŽƐƉŚĂƚĞƉŽŝƐŽŶŝŶŐ ŽŶƚƌĂŝŶĚŝĐĂƚŝŽŶƐ x ƚƌŽƉŝŶĞƐŚŽƵůĚŶŽƚďĞƵƐĞĚŝŶƉĂƚŝĞŶƚƐƉƌĞƐĞŶƚŝŶŐǁŝƚŚĂƚƌŝĂůĨůƵƚƚĞƌŽƌĂƚƌŝĂůĨŝďƌŝůůĂƚŝŽŶǁŚĞƌĞƚŚĞƌĞ ŝƐƌĂƉŝĚǀĞŶƚƌŝĐƵůĂƌƌĞƐƉŽŶƐĞ͘ x WĂƚŝĞŶƚƐǁŝƚŚŬŶŽǁŶŚŝƐƚŽƌǇŽĨŐůĂƵĐŽŵĂƐŚŽƵůĚŶŽƚďĞŐŝǀĞŶĂƚƌŽƉŝŶĞ͘ x WĂƚŝĞŶƚƐǁŝƚŚĂŚĞĂƌƚƚƌĂŶƐƉůĂŶƚǁŝůůŶŽƚƌĞƐƉŽŶĚƚŽĂƚƌŽƉŝŶĞ͘ ^ŝĚĞĨĨĞĐƚƐ x ůƵƌƌĞĚǀŝƐŝŽŶ͕ŚĞĂĚĂĐŚĞ͕ƉƵƉŝůůĂƌǇĚŝůĂƚŝŽŶ x ƌǇŵŽƵƚŚ͕ƚŚŝƌƐƚ x ǇƐƵƌŝĂ ŽƐĂŐĞĂŶĚĚŵŝŶŝƐƚƌĂƚŝŽŶ Adult

x Bradycardia/AVB͗Ϭ͘ϱŵŐ/sͬ/Kͬ/DƋϱŵŝŶ͘ƵŶƚŝůĚĞƐŝƌĞĚŚĞĂƌƚƌĂƚĞŝƐĂĐŚŝĞǀĞĚ͘ŽŶŽƚĞǆĐĞĞĚϯŵŐ x Organophosphate poisoning:ϭŵŐ/sͬ/Kͬ/DƌĞƉĞĂƚĞĚĂƐŶĞĞĚĞĚƚŽŵĂŝŶƚĂŝŶŚĞĂƌƚƌĂƚĞхϭϬϬͬŵŝŶ͘ ĂŶĚͬŽƌĐůĞĂƌůƵŶŐƐŽƵŶĚƐ͘

Pediatric

x Bradycardia/AVB: Ϭ͘ϬϮŵŐͬŬŐƋϱŵŝŶƵŶƚŝůĚĞƐŝƌĞĚŚĞĂƌƚƌĂƚĞŝƐĂĐŚŝĞǀĞĚ͘ DŝŶŝŵƵŵƐŝŶŐůĞĚŽƐĞŝƐϬ͘ϭŵŐ͘DĂǆŝŵƵŵƐŝŶŐůĞĚŽƐĞĨŽƌĐŚŝůĚŝƐϬ͘ϱŵŐ͕ĨŽƌĂĚŽůĞƐĐĞŶƚŝƐϭŵŐ͘Ž ŶŽƚĞǆĐĞĞĚϭŵŐĨŽƌĐŚŝůĚ͕ϮŵŐĨŽƌĂĚŽůĞƐĐĞŶƚ͘ x Organophosphate poisoning:Ϭ͘ϬϱŵŐͬŬŐƌĞƉĞĂƚĞĚĂƐŶĞĞĚĞĚƵŶƚŝůŚĞĂƌƚƌĂƚĞхϭϬϬͬŵŝŶĂŶĚͬŽƌ ĐůĞĂƌůƵŶŐƐŽƵŶĚƐ͘

Cypress Creek EMS System Policies and Treatment Guidelines

334 MEDICATIONS Revised 8/2016 Approved: Levon Vartanian, MD

WĞĂƌůƐ Thoughts prior to atropine use in non-cardiac arrest situations:

x tŚǇŝƐŵǇƉĂƚŝĞŶƚďƌĂĚǇĐĂƌĚŝĐ͍ x Is it hypoxia͍/ĨǇĞƐ͕ĐŽƌƌĞĐƚƚŚĞŚǇƉŽǆŝĂƚŚƌŽƵŐŚŽǆǇŐĞŶĂƚŝŽŶĂŶĚŐŽŽĚǀĞŶƚŝůĂƚŝŽŶ͕ĂƐŶĞĞĚĞĚ͘ x Is it due to an MI͍ŐĂŝŶ͕ĨŝƌƐƚĂƌĞǁĞŵĂǆŝŵŝǌŝŶŐŽǆǇŐĞŶĂƚŝŽŶ͍dŚĞŶĞǀĂůƵĂƚĞƚŚĞƌŝƐŬƚŽďĞŶĞĨŝƚ ĨŽƌƚŚĞƉĂƚŝĞŶƚ͘ x Is it due to acidosis? WĂƚŝĞŶƚƐǁŝƚŚŝŶĂĚĞƋƵĂƚĞǀĞŶƚŝůĂƚŝŽŶĂŶĚͬŽƌƉĞƌĨƵƐŝŽŶǁŝůůďĞĂĐŝĚŽƚŝĐĂŶĚ ƐǇŵƉĂƚŚĞƚŝĐͬĐĂƚĞĐŚŽůĂŵŝŶĞƌĞƐƉŽŶƐĞǁŝůůďĞďůƵŶƚĞĚ͘ x Is it due to sepsis?WĂƚŝĞŶƚƐǁŝƚŚƐĞƉƐŝƐŵĂǇŚĂǀĞƉŽŽƌƉĞƌĨƵƐŝŽŶƌĞƐƵůƚŝŶŐŝŶďƌĂĚǇĐĂƌĚŝĂ͘ x /ĨďůŽŽĚƉƌĞƐƐƵƌĞŝƐĂĚĞƋƵĂƚĞ͕ŶŽŶĞĞĚĨŽƌĂƚƌŽƉŝŶĞ͘ x /ĨďůŽŽĚƉƌĞƐƐƵƌĞŝƐůŽǁ͕ĐĂŶǁĞĨůƵŝĚƌĞƐƵƐĐŝƚĂƚĞ͍dŚŝƐŝƐƉƌĞĨĞƌƌĞĚĂƐĂŶǇƚŝŵĞǁĞŝŶĐƌĞĂƐĞƚŚĞƌĂƚĞ ǁŝƚŚĂƚƌŽƉŝŶĞĚƵƌŝŶŐĂŶD/͕ǁĞŝŶĐƌĞĂƐĞƚŚĞŽǆǇŐĞŶĚĞŵĂŶĚŽŶƚŚĞŚĞĂƌƚƚŚĞƌĞďǇŝŶĐƌĞĂƐŝŶŐ ŝƐĐŚĞŵŝĂ͘ x /ĨƚŚĞƉĂƚŝĞŶƚŝƐŝŶĂŚĞĂƌƚďůŽĐŬ͕ŝƚŝƐƉƌŽďĂďůǇŵŽƌĞďĞŶĞĨŝĐŝĂůƚŽƉĂĐĞ͕ďƵƚƚŚĂƚĚĞĐŝƐŝŽŶŝŶǀŽůǀĞƐ ĚĞƚĞƌŵŝŶŝŶŐƚŚĞƚǇƉĞŽĨďůŽĐŬ͘,ŝŐŚĞƌĞŶĚďůŽĐŬƐŵĂǇƌĞƐƉŽŶĚƚŽĂƚƌŽƉŝŶĞ͕ďƵƚůŽǁĞƌĞŶĚďůŽĐŬƐǁŝůů ŶŽƚƌĞƐƉŽŶĚƚŽƚŚŝƐƚŚĞƌĂƉǇĚƵĞƚŽƚŚĞůĂĐŬŽĨǀĂŐĂůŝŶŶĞƌǀĂƚŝŽŶŝŶƚŚŝƐĂƌĞĂŽĨƚŚĞ ŵǇŽĐĂƌĚŝƵŵ͘ZĞŵĞŵďĞƌĂƚƌŽƉŝŶĞŝƐĂǀĂŐŽůǇƚŝĐĂŶĚŝƚŝŶĐƌĞĂƐĞƐŚĞĂƌƚƌĂƚĞďǇĚĞĐƌĞĂƐŝŶŐǀĂŐĂů ƐƚŝŵƵůĂƚŝŽŶ͘ x ƚƌŽƉŝŶĞŵĂǇƉƌĞĐŝƉŝƚĂƚĞǀĞŶƚƌŝĐƵůĂƌĂƌƌŚǇƚŚŵŝĂƐĂŶĚƚŚĞƌĞĨŽƌĞƐŚŽƵůĚďĞƵƐĞĚǁŝƚŚĐĂƵƚŝŽŶŝŶƚŚĞ ƐĞƚƚŝŶŐŽĨĂŶD/͘ x ŽƐĞƐф0.5 mg ŝŶĂŶĂĚƵůƚ;0.1 mg ŝŶƉĞĚŝĂƚƌŝĐƐͿŽƌĂĚŽƐĞŐŝǀĞŶƚŽŽƐůŽǁůǇŵĂǇĚĞĐƌĞĂƐĞƌĂƚŚĞƌ ƚŚĂŶŝŶĐƌĞĂƐĞƚŚĞŚĞĂƌƚƌĂƚĞ͘ x ZŽƵƚŝŶĞƵƐĞŽĨĂƚƌŽƉŝŶĞĚƵƌŝŶŐWŽƌĂƐǇƐƚŽůĞŝƐƵŶůŝŬĞůǇƚŽŚĂǀĞĂƚŚĞƌĂƉĞƵƚŝĐďĞŶĞĨŝƚ͘

Cypress Creek EMS System Policies and Treatment Guidelines

335 MEDICATIONS Revised 7/2019 Approved: Levon Vartanian, MD

ĂůĐŝƵŵŚůŽƌŝĚĞ DĞĚŝĐĂƚŝŽŶ ƐĂůƚƐŽůƵƚŝŽŶƵƐĞĚƚŽŝŶĐƌĞĂƐĞƚŚĞĐĂůĐŝƵŵĐŽŶƚĞŶƚŽĨƚŚĞďůŽŽĚŝŶĚŝƐŽƌĚĞƌƐƌĞƐƵůƚŝŶŐĨƌŽŵĂůĂĐŬŽĨ ƐƵĨĨŝĐŝĞŶƚĐĂůĐŝƵŵƐƵĐŚĂƐŚǇƉŽĐĂůĐĞŵŝĐƚĞƚĂŶǇ͘ĂůĐŝƵŵĐŚůŽƌŝĚĞŝƐĂĚŵŝŶŝƐƚĞƌĞĚŝŶƚƌĂǀĞŶŽƵƐůǇ͘ DĞĐŚĂŶŝƐŵŽĨĐƚŝŽŶ ĂůĐŝƵŵŝƐĂŶĞĐĞƐƐĂƌǇĞůĞĐƚƌŽůǇƚĞĨŽƌĐŽŶƚƌĂĐƚŝůĞĨƵŶĐƚŝŽŶŽĨŵƵƐĐůĞĐĞůůƐ͘/ŶĐƌĞĂƐŝŶŐĐĂůĐŝƵŵ ĐŽŶĐĞŶƚƌĂƚŝŽŶŚĂƐŝŶŽƚƌŽƉŝĐ͕ĐŚƌŽŶŽƚƌŽƉƌŝĐ͕ĚƌŽŵŽƚƌŽƉŝĐ͕ĂŶĚŝŶŽƚƌŽƉŝĐĞĨĨĞĐƚƐ͘ĂůĐŝƵŵŝƐďĞŶĞĨŝĐŝĂůŝŶ ŚǇƉĞƌŬĂůĞŵŝĐƉĂƚŝĞŶƚƐďǇŶĞƵƚƌĂůŝǌŝŶŐĞǆƚƌĂĐĞůůƵůĂƌƉŽƚĂƐƐŝƵŵŝŽŶƐ͘ /ŶĚŝĐĂƚŝŽŶƐ x ĂůĐŝƵŵĐŚĂŶŶĞůďůŽĐŬĞƌ͕ďĞƚĂͲďůŽĐŬĞƌ͕ŽƌŵĂŐŶĞƐŝƵŵƐƵůĨĂƚĞŽǀĞƌĚŽƐĞ͘ x ĂƌĚŝĂĐĂƌƌĞƐƚŽƌƐĞƌŝŽƵƐƐŝŐŶͬƐǇŵƉƚŽŵ;ƐͿŝŶĂƉĂƚŝĞŶƚǁŝƚŚĂŚŝƐƚŽƌǇŽĨƌĞŶĂůĨĂŝůƵƌĞŽƌŽƚŚĞƌ ƐƵƐƉĞĐƚĞĚŚǇƉĞƌŬĂůĞŵŝĐƐƚĂƚĞ͘ ŽŶƚƌĂŝŶĚŝĐĂƚŝŽŶƐ x ĂůĐŝƵŵĐŚůŽƌŝĚĞƐŚŽƵůĚďĞŐŝǀĞŶǁŝƚŚĞǆƚƌĞŵĞĐĂƵƚŝŽŶĂŶĚŝŶƌĞĚƵĐĞĚĚŽƐĂŐĞƚŽƉĂƚŝĞŶƚƐƚĂŬŝŶŐ ĚŝŐŝƚĂůŝƐ͖ŐŝǀĞŶƚŽŽƌĂƉŝĚůǇ͕ĐĂůĐŝƵŵĐĂŶĐĂƵƐĞƐƵĚĚĞŶĚĞĂƚŚĨƌŽŵs&/͘ ^ŝĚĞĨĨĞĐƚƐ x ĂůĐŝƵŵĐŚůŽƌŝĚĞŵĂǇĐĂƵƐĞŝƌƌŝƚĂďŝůŝƚǇŝŶƚŚĞƉƌĞƐĞŶĐĞŽĨĚŝŐŝƚĂůŝƐĂŶĚƉƌĞĐŝƉŝƚĂƚĞƐǁŚĞŶŵŝǆĞĚǁŝƚŚ ƐŽĚŝƵŵďŝĐĂƌďŽŶĂƚĞ͘ ŽƐĂŐĞΘĚŵŝŶŝƐƚƌĂƚŝŽŶ KǀĞƌĚŽƐĞ;DĂŐŶĞƐŝƵŵƐƵůĨĂƚĞ͕ďĞƚĂͲďůŽĐŬĞƌ͕ĐĂůĐŝƵŵĐŚĂŶŶĞůďůŽĐŬĞƌͿ x Adult:ϮϬŵŐͬŬŐ^>Kt/sͬ/K͖ŵĂǇƌĞƉĞĂƚŝŶϭϬŵŝŶƵƚĞƐ͘DĂǆĚŽƐĞϭŐƌĂŵ͘ x Pediatric:ϮϬŵŐͬŬŐ^>Kt/sͬ/K͖ŵĂǇƌĞƉĞĂƚŝŶϭϬŵŝŶƵƚĞƐ͕ŶŽƚƚŽĞǆĐĞĞĚϭŐƌĂŵŝŶĂƐŝŶŐůĞĚŽƐĞ͘ ,ǇƉĞƌŬĂůĞŵŝĂ;ĂƌĚŝĂĐĂƌƌĞƐƚŽƌƐĞƌŝŽƵƐƐŝŐŶƐͬƐǇŵƉƚŽŵƐͿ x Adult:Ϭ͘ϱʹϭŐƌĂŵ/sͬ/K x Pediatric:ϮϬŵŐͬŬŐ;Ϭ͘ϲŵůͬŬŐͿ/sͬ/K͖ŶŽƚƚŽĞǆĐĞĞĚϭŐƌĂŵŝŶĂƐŝŶŐůĞĚŽƐĞ ^ƉĞĐŝĂůŽŶƐŝĚĞƌĂƚŝŽŶƐ x WƌĞŐŶĂŶĐǇ͗ŽŶƐŝĚĞƌƌŝƐŬǀĞƌƐƵƐďĞŶĞĨŝƚ͘ x ^ŚŽƵůĚŶŽƚďĞĂĚŵŝŶŝƐƚĞƌĞĚ/DŽƌ^Y x ĂƵƐĞƐƚŝƐƐƵĞŝƌƌŝƚĂƚŝŽŶĂŶĚŶĞĐƌŽƐŝƐŝĨŝŶĨŝůƚƌĂƚĞĚ x DƵƐƚĨůƵƐŚďĞƚǁĞĞŶĂĚŵŝŶŝƐƚƌĂƚŝŽŶŽĨĐĂůĐŝƵŵĂŶĚƐŽĚŝƵŵďŝĐĂƌďŽŶĂƚĞ͖ďĞƐƚƉƌĂĐƚŝĐĞŝƐƚŽƐƚĂƌƚĂ ƐĞƉĂƌĂƚĞ/sͬ/KŝĨǇŽƵŶĞĞĚƚŽĂĚŵŝŶŝƐƚĞƌƚŚĞƐĞƚǁŽŵĞĚŝĐĂƚŝŽŶƐ͘ x DĂǇĐĂƵƐĞďƌĂĚǇĐĂƌĚŝĂŝĨĂĚŵŝŶŝƐƚĞƌĞĚƚŽŽƌĂƉŝĚůǇ

Cypress Creek EMS System Policies and Treatment Guidelines

336 MEDICATIONS Revised 8/2016 Approved: Levon Vartanian, MD

ĞǆĂŵĞƚŚĂƐŽŶĞ;ĞĐĂĚƌŽŶͿ DĞĚŝĐĂƚŝŽŶ ƐǇŶƚŚĞƚŝĐŐůƵĐŽĐŽƌƚŝĐŽŝĚƚŚĂƚůŝŵŝƚƐŝŶĨůĂŵŵĂƚŝŽŶ DĞĐŚĂŶŝƐŵŽĨĐƚŝŽŶ ZĞĚƵĐĞƐŝŶĨůĂŵŵĂƚŝŽŶďǇƌĞĚƵĐŝŶŐĐĞƌƚĂŝŶĂƐƉĞĐƚƐŽĨƚŚĞŝŵŵƵŶĞĨƵŶĐƚŝŽŶƌĞƐƉŽŶƐĞ /ŶĚŝĐĂƚŝŽŶƐ x ƌŽƵƉ ŽŶƚƌĂŝŶĚŝĐĂƚŝŽŶƐ x <ŶŽǁŶŚǇƉĞƌƐĞŶƐŝƚŝǀŝƚǇ x EĞŽŶĂƚĞƐ x ^ǇƐƚĞŵŝĐĨƵŶŐĂůŝŶĨĞĐƚŝŽŶƐ ^ŝĚĞĨĨĞĐƚƐ ŐŝƚĂƚŝŽŶ͕ĂŶǆŝĞƚǇ͕ďůƵƌƌĞĚǀŝƐŝŽŶ͕ĚŝǌǌŝŶĞƐƐ͕ŚĞĂĚĂĐŚĞ͕ŶĞƌǀŽƵƐŶĞƐƐ͕ŶƵŵďŶĞƐƐ͕ŶĂƵƐĞĂ͕ƐĞŝǌƵƌĞ͘

ĂŶĞǆĂĐĞƌďĂƚĞŚǇƉŽŬĂůĞŵŝĂŝŶƉĂƚŝĞŶƚƐƚĂŬŝŶŐƉŽƚĂƐƐŝƵŵͲĚĞƉůĞƚŝŶŐĚŝƵƌĞƚŝĐƐ͘ ŽƐĂŐĞΘĚŵŝŶŝƐƚƌĂƚŝŽŶ x Pediatric:ϰŵŐŶĞďƵůŝǌĞĚ

Cypress Creek EMS System Policies and Treatment Guidelines

337 MEDICATIONS Revised 7/2019 Approved: Levon Vartanian, MD

ĞǆƚƌŽƐĞ DĞĚŝĐĂƚŝŽŶ ŵŽŶŽƐĂĐĐŚĂƌŝĚĞƐƵŐĂƌƚŚĂƚŽĐĐƵƌƐŶĂƚƵƌĂůůǇŝŶƉůĂŶƚƐĂŶĚŝŶƚŚĞďŽĚǇĨůƵŝĚƐŽĨĂŶŝŵĂůƐ͖ŝƚŝƐĨŽƌŵĞĚŝŶ ƚŚĞĚŝŐĞƐƚŝǀĞƚƌĂĐƚďǇƚŚĞĂĐƚŝŽŶŽĨĞŶǌǇŵĞƐŽŶĐĂƌďŽŚǇĚƌĂƚĞƐ͘ DĞĐŚĂŶŝƐŵŽĨĐƚŝŽŶ dŚĞĂĚŵŝŶŝƐƚƌĂƚŝŽŶŽĨĚĞǆƚƌŽƐĞƌĂŝƐĞƐĐŝƌĐƵůĂƚŝŶŐďůŽŽĚƐƵŐĂƌůĞǀĞůƐ͘/ƚĂůƐŽĂĐƚƐƚƌĂŶƐŝĞŶƚůǇĂƐĂĚŝƵƌĞƚŝĐ͘ /ŶĚŝĐĂƚŝŽŶƐ x ,ǇƉŽŐůǇĐĞŵŝĂ;'>фϲϬŵŐͬĚůͿ ŽŶƚƌĂŝŶĚŝĐĂƚŝŽŶƐ ĞǆƚƌŽƐĞƐŚŽƵůĚŶŽƚďĞĂĚŵŝŶŝƐƚĞƌĞĚƚŽĂŶǇƉĂƚŝĞŶƚƉƌĞƐĞŶƚŝŶŐǁŝƚŚƐŝŐŶƐĂŶĚƐǇŵƉƚŽŵƐŽĨĐĞŶƚƌĂů ŶĞƌǀŽƵƐƐǇƐƚĞŵƉĂƚŚŽůŽŐǇ;ŝ͘Ğ͘ƐƚƌŽŬĞŽƌĐůŽƐĞĚŚĞĂĚŝŶũƵƌǇͿƵŶůĞƐƐƉĂƚŝĞŶƚŝƐƐŝŐŶŝĨŝĐĂŶƚůǇŚǇƉŽŐůǇĐĞŵŝĐ͘ ^ŝĚĞĨĨĞĐƚƐ x ĚŵŝŶŝƐƚƌĂƚŝŽŶŽĨĚĞǆƚƌŽƐĞŵĂǇƉƌĞĐŝƉŝƚĂƚĞƐĞǀĞƌĞŶĞƵƌŽůŽŐŝĐƐǇŵƉƚŽŵƐŝŶƚŚĞĂůĐŽŚŽůŝĐƉĂƚŝĞŶƚ͘ dŚŝĂŵŝŶĞƐŚŽƵůĚďĞĂĚŵŝŶŝƐƚĞƌĞĚƉƌŝŽƌƚŽϱϬŝŶƉĂƚŝĞŶƚƐƉƌĞƐĞŶƚŝŶŐǁŝƚŚƉŽƐƐŝďůĞĂůĐŽŚŽůĂďƵƐĞŽƌ ǁŚŽĂƉƉĞĂƌŵĂůŶŽƵƌŝƐŚĞĚ͘ ŽƐĂŐĞΘĚŵŝŶŝƐƚƌĂƚŝŽŶ x ŚĞĐŬďůŽŽĚŐůƵĐŽƐĞůĞǀĞůƉƌŝŽƌƚŽĂĚŵŝŶŝƐƚƌĂƚŝŽŶ͘ x DƵƐƚďĞĂĚŵŝŶŝƐƚĞƌĞĚƚŚƌŽƵŐŚĂƉĂƚĞŶƚ/sůŝŶĞƚŽƉƌĞǀĞŶƚƚŝƐƐƵĞŶĞĐƌŽƐŝƐĚƵĞƚŽĞǆƚƌĂǀĂƐĂƚŝŽŶ͘ x ZĞĐŚĞĐŬĂďůŽŽĚŐůƵĐŽƐĞůĞǀĞůϭϬŵŝŶƵƚĞƐĂĨƚĞƌĂĚŵŝŶŝƐƚƌĂƚŝŽŶ͘ ϱϬйĞǆƚƌŽƐĞ;ϱϬͿ

x Do not administer D50 via the oral route. x Adult:ϮϱŐƌĂŵƐ/s ;ϱϬŵůŽĨϱϬͿ;ŵĂǇĂůƐŽďĞŐŝǀĞŶ/KŝĨŶĞĞĚĞĚͿ x Pediatric:Ϭ͘ϱŐƌĂŵƐͬŬŐ ;ĚŝůƵƚĞƚŽϮϱйĞǆƚƌŽƐĞĨŽƌŝŶĨĂŶƚƐфϭͲǇĞĂƌͲŽůĚͿ ϭϬйĞǆƚƌŽƐĞ;ϭϬͿ o Adult:ϭϬϬŵů͕ŵĂǇƌĞƉĞĂƚŽŶĐĞŝĨŶĞĞĚĞĚ͘ o Pediatric:Ϯ͘ϱŵůͬŬŐ͕ŵĂǇƌĞƉĞĂƚŽŶĐĞŝĨŶĞĞĚĞĚ͘hƚŝůŝǌĞƵƌĞƚƌŽůĨŽƌĂĚŵŝŶŝƐƚƌĂƚŝŽŶ͘ ^ƉĞĐŝĂůŽŶƐŝĚĞƌĂƚŝŽŶƐ x ϱϬйĞǆƚƌŽƐĞŝƐĂƌĞůĂƚŝǀĞůǇƚŚŝĐŬƐŽůƵƚŝŽŶĂŶĚƐŚŽƵůĚďĞĂĚŵŝŶŝƐƚĞƌĞĚƚŚƌŽƵŐŚĂůĂƌŐĞďŽƌĞĐĂƚŚĞƚĞƌ ŝŶĂůĂƌŐĞƌǀĞŝŶǁŝƚŚĨƌĞĞͲĨůŽǁŝŶŐƐĂůŝŶĞŽƌƐĂůŝŶĞĨůƵƐŚƚŽĞŶƐƵƌĞƉĂƚĞŶĐǇƚŚƌŽƵŐŚŽƵƚĂĚŵŝŶŝƐƚƌĂƚŝŽŶ͘ x ĞǆƚƌŽƐĞŝƐƌĂƉŝĚůǇŵĞƚĂďŽůŝǌĞĚ͕ĂŶĚƉĂƚŝĞŶƚƐĂĚŵŝŶŝƐƚĞƌĞĚĚĞǆƚƌŽƐĞĨŽƌŚǇƉŽŐůǇĐĞŵŝĂĂƌĞĂƚƌŝƐŬĨŽƌ ƌĞďŽƵŶĚŚǇƉŽŐůǇĐĞŵŝĂ͘/ĨƉŽƐƐŝďůĞ͕ƚƌĂŶƐƉŽƌƚƉĂƚŝĞŶƚƚŽƚŚĞŚŽƐƉŝƚĂůĨŽƌĨƵƌƚŚĞƌĞǀĂůƵĂƚŝŽŶĂŶĚ ŽďƐĞƌǀĂƚŝŽŶ͘/ĨƉĂƚŝĞŶƚƌĞĨƵƐĞƐƚƌĂŶƐƉŽƌƚ͕ĞŶĐŽƵƌĂŐĞƉĂƚŝĞŶƚĂŶĚĐĂƌĞŐŝǀĞƌƐͬĨĂŵŝůǇŵĞŵďĞƌƐƚŽ ƉƌŽǀŝĚĞĂďĂůĂŶĐĞĚŵĞĂůƚŽĞŶƐƵƌĞďůŽŽĚƐƵŐĂƌůĞǀĞůƐĂƌĞŵĂŝŶƚĂŝŶĞĚ͘

Cypress Creek EMS System Policies and Treatment Guidelines

338 MEDICATIONS Revised 8/2016 Approved: Levon Vartanian, MD

ŝĂǌĞƉĂŵ;sĂůŝƵŵͿ DĞĚŝĐĂƚŝŽŶ ůŽŶŐĞƌĂĐƚŝŶŐďĞŶǌŽĚŝĂǌĞƉŝŶĞǁŝƚŚƐĞĚĂƚŝǀĞ͕ƐŬĞůĞƚĂůŵƵƐĐůĞͲƌĞůĂǆĂŶƚ͕ĂŶĚĂŶƚŝĐŽŶǀƵůƐĂŶƚƉƌŽƉĞƌƚŝĞƐ͘ DĞĐŚĂŶŝƐŵŽĨĐƚŝŽŶ /ŶĚƵĐĞƐĐĂůŵŝŶŐĞĨĨĞĐƚƐďǇŝƚƐĂĐƚŝŽŶŽŶƚŚĞƚŚĂůĂŵƵƐĂŶĚŚǇƉŽƚŚĂůĂŵƵƐ͕ĂŶĚŚĂƐŶŽĚĞŵŽŶƐƚƌĂďůĞ ƉĞƌŝƉŚĞƌĂůĂƵƚŽŶŽŵŝĐďůŽĐŬŝŶŐĂĐƚŝŽŶ͘ŝĂǌĞƉĂŵĞŶŚĂŶĐĞƐƚŚĞĂĐƚŝŽŶŽĨƚŚĞŝŶŚŝďŝƚŽƌǇŶĞƵƌŽƚƌĂŶƐŵŝƚƚĞƌ 'ďǇĂĐƚŝŶŐĂƚƚŚĞ'ƌĞĐĞƉƚŽƌĂŶĚŝŶŚŝďŝƚŝŶŐŵŽƚŽƌĂĐƚŝǀŝƚǇ͘ /ŶĚŝĐĂƚŝŽŶƐ x ^ƚĂƚƵƐĞƉŝůĞƉƚŝĐƵƐĂŶĚƐĞǀĞƌĞ͕ƌĞĐƵƌƌĞŶƚĐŽŶǀƵůƐŝǀĞƐĞŝǌƵƌĞƐ x DŝůĚƐĞĚĂƚŝŽŶǁŝƚŚWϯĐŽŶƐƵůƚ ŽŶƚƌĂŝŶĚŝĐĂƚŝŽŶƐ x ůĐŽŚŽůŽƌƐĞĚĂƚŝǀĞŝŶŐĞƐƚŝŽŶ x 'ůĂƵĐŽŵĂ x ^ŚŽĐŬ͕ĐŽŵĂ͕ŽƌĂĐƵƚĞĂůĐŽŚŽůŝĐŝŶƚŽǆŝĐĂƚŝŽŶǁŝƚŚpsͬ^ x ĂƵƚŝŽŶŝŶƉƌĞŐŶĂŶĐǇ͕ĞƐƉĞĐŝĂůůǇƚŚĞϭƐƚƚƌŝŵĞƐƚĞƌ;ŵĂǇƵƐĞŝĨĞĐůĂŵƉƐŝĂŝƐƌĞĨƌĂĐƚŽƌǇƚŽDĂŐŶĞƐŝƵŵ ^ƵůĨĂƚĞͿ ^ŝĚĞĨĨĞĐƚƐ x ƌŽǁƐŝŶĞƐƐ͕ĐŽŶĨƵƐŝŽŶ͕ƐƚƵƉŽƌ͕ĨĂƚŝŐƵĞ͕ĂƚĂǆŝĂĂŶĚͬŽƌŚǇƉŽƚĞŶƐŝŽŶ x DĂǇĐĂƵƐĞƌĞƐƉŝƌĂƚŽƌǇĂŶĚͬŽƌĐĂƌĚŝĂĐĂƌƌĞƐƚŝŶƐŽŵĞƉĂƚŝĞŶƚƐ͕ĞƐƉĞĐŝĂůůǇƚŚĞĞůĚĞƌůǇ͕ƚŚĞǀĞƌǇŝůů͕ĂŶĚ ƚŚŽƐĞǁŝƚŚƉƵůŵŽŶĂƌǇĚŝƐĞĂƐĞ͘ ŽƐĂŐĞĂŶĚĚŵŝŶŝƐƚƌĂƚŝŽŶ x dŚĞĚŽƐĂŐĞƐŚŽƵůĚďĞŝŶĚŝǀŝĚƵĂůŝǌĞĚĨŽƌŵĂǆŝŵƵŵďĞŶĞĨŝĐŝĂůĞĨĨĞĐƚĂŶĚŐŝǀĞŶSLOW IV͘ x dŚĞƵƐƵĂůƚŽƚĂůĚŽƐĂŐĞĨŽƌŽůĚĞƌchildren and adultsƌĂŶŐĞƐĨƌŽŵ2-20 mg ĚĞƉĞŶĚŝŶŐŽŶƚŚĞ ŝŶĚŝĐĂƚŝŽŶĂŶĚŝƚƐƐĞǀĞƌŝƚǇ͘dŽƚĂůĚŽƐĂŐĞƐƵƉƚŽ40 mg ŵĂǇďĞŶĞĐĞƐƐĂƌǇĨŽƌĐŽŶƚƌŽůŽĨƐĞŝǌƵƌĞĂĐƚŝǀŝƚǇ x ůĚĞƌůǇŽƌĚĞďŝůŝƚĂƚĞĚƉĂƚŝĞŶƚƐŽƌǁŚĞŶŽƚŚĞƌƐĞĚĂƚŝǀĞĚƌƵŐƐĂƌĞĂĚŵŝŶŝƐƚĞƌĞĚ͗2-5 mg x Pediatric͗0.25 mg/kg SLOW IV ^ƉĞĐŝĂůŽŶƐŝĚĞƌĂƚŝŽŶƐ x /ŶŽƌĚĞƌƚŽƌĞĚƵĐĞƚŚĞƉŽƐƐŝďŝůŝƚǇŽĨǀĞŶŽƵƐƚŚƌŽŵďŽƐŝƐ͕ƉŚůĞďŝƚŝƐ͕ůŽĐĂůŝƌƌŝƚĂƚŝŽŶ͕ƐǁĞůůŝŶŐ͕ĂŶĚ ƌĂƌĞůǇ͕ǀĂƐĐƵůĂƌŝŵƉĂŝƌŵĞŶƚ͕ƐŚŽƵůĚďĞŝŶũĞĐƚĞĚƐůŽǁůǇĂŶĚƐŵĂůůǀĞŝŶƐ͕ƐƵĐŚĂƐƚŚŽƐĞŽŶƚŚĞĚŽƌƐƵŵ ŽĨƚŚĞŚĂŶĚŽƌǁƌŝƐƚ͕ƐŚŽƵůĚŶŽƚďĞƵƐĞĚ͘ǆƚƌĞŵĞĐĂƌĞƐŚŽƵůĚďĞƚĂŬĞŶƚŽĂǀŽŝĚĞǆƚƌĂǀĂƐĂƚŝŽŶ͘ x ^ŚŽƵůĚŶŽƚďĞŵŝǆĞĚŽƌĚŝůƵƚĞĚǁŝƚŚŽƚŚĞƌƐŽůƵƚŝŽŶƐŽƌŵĞĚŝĐĂƚŝŽŶƐ͘ x /ŶƚƌĂǀĞŶŽƵƐŝĂǌĞƉĂŵƐŚŽƵůĚďĞŝŶũĞĐƚĞĚƐůŽǁůǇƚŚƌŽƵŐŚƚŚĞŝŶĨƵƐŝŽŶƚƵďŝŶŐĂƐƉƌŽǆŝŵĂůĂƐƉŽƐƐŝďůĞ ƚŽƚŚĞĐĂƚŚĞƚĞƌŝŶƐĞƌƚŝŽŶƉŽŝŶƚ͘ ƐƉŝƌĂƚŝŽŶŽĨďůŽŽĚŝŶƚŽƚŚĞ/sƚƵďŝŶŐƐŚŽƵůĚďĞƉĞƌĨŽƌŵĞĚƉƌŝŽƌƚŽŝŶũĞĐƚŝŽŶƚŽĞŶƐƵƌĞƉĂƚĞŶĐǇŽĨ ƚŚĞ/sůŝŶĞ͘

Cypress Creek EMS System Policies and Treatment Guidelines

339 MEDICATIONS Revised 8/2016 Approved: Levon Vartanian, MD

ŝůƚŝĂǌĞŵ;ĂƌĚŝǌĞŵͿ DĞĚŝĐĂƚŝŽŶ ĂůĐŝƵŵĐŚĂŶŶĞůďůŽĐŬĞƌ DĞĐŚĂŶŝƐŵŽĨĐƚŝŽŶ /ŶŚŝďŝƚƐĐĂůĐŝƵŵŝŶĨůƵǆĚƵƌŝŶŐĐĂƌĚŝĂĐĐĞůůƵůĂƌĚĞƉŽůĂƌŝǌĂƚŝŽŶĐĂƵƐŝŶŐ͗

x ^ůŽǁĞƌĐŽŶĚƵĐƚŝŽŶƚŚƌŽƵŐŚƚŚĞͲsŶŽĚĞ x sĂƐŽĚŝůĂƚŝŽŶ x ĞĐƌĞĂƐĞĚƌĂƚĞŽĨǀĞŶƚƌŝĐƵůĂƌƌĞƐƉŽŶƐĞ x ĞĐƌĞĂƐĞĚŵǇŽĐĂƌĚŝĂůŽǆǇŐĞŶĚĞŵĂŶĚ /ŶĚŝĐĂƚŝŽŶƐ dĂĐŚǇĐĂƌĚŝĂǁŝƚŚƐŝŐŶƐĂŶĚͬŽƌƐǇŵƉƚŽŵƐŽĨŝƐĐŚĞŵŝĐĐŚĞƐƚĚŝƐĐŽŵĨŽƌƚ͕ƉƵůŵŽŶĂƌǇĞĚĞŵĂ͕ŚǇƉŽƚĞŶƐŝŽŶ͕ ƉŽŽƌƉĞƌĨƵƐŝŽŶ͕ŽƌĂĐƵƚĞůǇĂůƚĞƌĞĚŵĞŶƚĂůƐƚĂƚƵƐ͗

x EĂƌƌŽǁͲĐŽŵƉůĞǆƚĂĐŚǇĐĂƌĚŝĂƌĞĨƌĂĐƚŽƌǇƚŽĚĞŶŽƐŝŶĞ x &/ǁͬZsZ;хϭϯϬŵŝŶͿ ŽŶƚƌĂŝŶĚŝĐĂƚŝŽŶƐ x ,ǇƉŽƚĞŶƐŝŽŶ x tŝĚĞͲĐŽŵƉůĞǆƚĂĐŚǇĐĂƌĚŝĂ x ŽŶĚƵĐƚŝŽŶƐǇƐƚĞŵĚŝƐƚƵƌďĂŶĐĞƐ x tŽůĨĨͲWĂƌŬŝŶƐŽŶͲtŚŝƚĞ^ǇŶĚƌŽŵĞ x ƌĂĚǇĐĂƌĚŝĂ x ĐƚŝǀĞD/ x sďůŽĐŬƐ x ŽŵƉƌŽŵŝƐĞĚŵǇŽĐĂƌĚŝƵŵĂƐĞǀŝĚĞŶĐĞĚďǇƐĞǀĞƌĞ,&ͬ>,&͕ĂĐƚŝǀĞD/͕ŽƌĐĂƌĚŝŽŵǇŽƉĂƚŚǇ͘ ^ŝĚĞĨĨĞĐƚƐ x EĂƵƐĞĂ x sŽŵŝƚŝŶŐ x ,ǇƉŽƚĞŶƐŝŽŶ x ŝǌǌŝŶĞƐƐ ŽƐĂŐĞĂŶĚĚŵŝŶŝƐƚƌĂƚŝŽŶ x 20-25 mg;Ϭ͘ϮϱŵŐͬŬŐͿ^>Kt/sW ^ƉĞĐŝĂůŽŶƐŝĚĞƌĂƚŝŽŶƐ x ĚŵŝŶŝƐƚƌĂƚŝŽŶƐŚŽƵůĚďĞŽǀĞƌƚǁŽŵŝŶƵƚĞƐ͘ x ZƵůĞŽƵƚŽƚŚĞƌĐĂƵƐĞƐĨŽƌƚĂĐŚǇĐĂƌĚŝĂ;Ğ͘Ő͘ŚǇƉŽǆŝĂ͕ŚǇƉŽǀŽůĞŵŝĂ͕ƉĂŝŶ͕ĞĐ͘ͿďĞĨŽƌĞƚƌĞĂƚŝŶŐǁŝƚŚ ĚŝůƚŝĂǌĞŵ͘

Cypress Creek EMS System Policies and Treatment Guidelines

340 MEDICATIONS Revised 8/2016 Approved: Levon Vartanian, MD

ŝƉŚĞŶŚǇĚƌĂŵŝŶĞ;ĞŶĂĚƌǇůͿ DĞĚŝĐĂƚŝŽŶ ŶĂŶƚŝŚŝƐƚĂŵŝŶĞĂŐĞŶƚǁŝƚŚĂŶƚŝĐŚŽůŝŶĞƌŐŝĐĂŶĚƐĞĚĂƚŝǀĞĞĨĨĞĐƚƐ͘ DĞĐŚĂŶŝƐŵŽĨĐƚŝŽŶ x WƌŽĚƵĐĞƐĂŶƚŝĐŚŽůŝŶĞƌŐŝĐ;ĚƌǇŝŶŐͿĂŶĚƐĞĚĂƚŝǀĞĞĨĨĞĐƚƐŽŶƉĂƚŝĞŶƚƐ͘/ƚƐĂŶƚŝŚŝƐƚĂŵŝŶĞĐŚĂƌĂĐƚĞƌŝƐƚŝĐƐ ĂƉƉĞĂƌƚŽĐŽŵƉĞƚĞǁŝƚŚŚŝƐƚĂŵŝŶĞƐĨŽƌĐĞůůƌĞĐĞƉƚŽƌƐŝƚĞƐŽŶĞĨĨĞĐƚŽƌĐĞůůƐ͘ x ůŽĐŬƐŚŝƐƚĂŵŝŶĞĞĨĨĞĐƚƐƚŚĂƚĂƌĞĐĂƵƐĞĚďǇĂůůĞƌŐŝĐƌĞĂĐƚŝŽŶƐ͘ x /ƚƌĞǀĞƌƐĞƐƚŚĞƐŝĚĞĞĨĨĞĐƚƐŽĨƉŚĞŶŽƚŚŝĂǌŝŶĞƐ;ĂŶƚŝƉƐǇĐŚŽƚŝĐŵĞĚŝĐĂƚŝŽŶƐͿ͘ /ŶĚŝĐĂƚŝŽŶƐ x ŶĂƉŚǇůĂĐƚŝĐƐŚŽĐŬĂŶĚƐĞǀĞƌĞĂůůĞƌŐŝĐƌĞĂĐƚŝŽŶ x KĐƵůŽŐǇƌŝĐĐƌŝƐŝƐĚƵĞƚŽĞǆƚƌĂƉǇƌĂŵŝĚĂůƐǇŵƉƚŽŵƐ;W^͕WĂƌŬŝŶƐŽŶͲůŝŬĞŵŽǀĞŵĞŶƚĚŝƐŽƌĚĞƌƐͲ ĚǇƐƚŽŶŝĂͿĐĂƵƐĞĚďǇƚŚĞƵƐĞŽĨƉŚĞŶŽƚŚŝĂǌŝŶĞƐ ŽŶƚƌĂŝŶĚŝĐĂƚŝŽŶƐ x WƌĞŐŶĂŶĐǇ x ĐƚŝǀĞĂƐƚŚŵĂĞǆĂĐĞƌďĂƚŝŽŶ x 'ůĂƵĐŽŵĂŽƌƉƌŽƐƚĂƚĞƉƌŽďůĞŵƐ x <ŶŽǁŶĂůĐŽŚŽůŽƌĚĞƉƌĞƐƐĂŶƚĂďƵƐĞ ^ŝĚĞĨĨĞĐƚƐ x ƌŽǁƐŝŶĞƐƐ͕ĐŽŶĨƵƐŝŽŶ x ůƵƌƌĞĚǀŝƐŝŽŶ x ƌǇŵŽƵƚŚ x ǇƐƵƌŝĂ x tŚĞĞǌŝŶŐĚƵĞƚŽƚŚŝĐŬĞŶŝŶŐŽĨďƌŽŶĐŚŝĂůƐĞĐƌĞƚŝŽŶƐ x ǆĐŝƚĂďŝůŝƚǇŝŶƉĞĚŝĂƚƌŝĐƉĂƚŝĞŶƚƐ ŽƐĂŐĞĂŶĚĚŵŝŶŝƐƚƌĂƚŝŽŶ x Adults:ϱϬŵŐ/sŽƌĚĞĞƉ/DŽƌϮϱŵŐ/sͬϮϱŵŐĚĞĞƉ/D x Pediatric:ϭͲϮŵŐͬŬŐ͕ŶŽƚƚŽĞǆĐĞĞĚϱϬŵŐŝŶĂƐŝŶŐůĞĚŽƐĞ/sŽƌĚĞĞƉ/D ^ƉĞĐŝĂůŽŶƐŝĚĞƌĂƚŝŽŶƐ x ^ŚŽƵůĚďĞƵƐĞĚĂƐĂŶĂĚũƵŶĐƚƚŽĞƉŝŶĞƉŚƌŝŶĞĂŶĚŽƚŚĞƌƐƚĂŶĚĂƌĚŵĞĂƐƵƌĞƐĂĨƚĞƌƚŚĞĂĐƵƚĞ ƐǇŵƉƚŽŵƐŽĨĂŶĂƉŚǇůĂǆŝƐŚĂǀĞďĞĞŶĐŽŶƚƌŽůůĞĚ͘ x ŶƚŝŚŝƐƚĂŵŝŶĞŽǀĞƌĚŽƐĞƌĞĂĐƚŝŽŶƐŵĂǇǀĂƌǇĨƌŽŵĐĞŶƚƌĂůŶĞƌǀŽƵƐƐǇƐƚĞŵĚĞƉƌĞƐƐŝŽŶƚŽƐƚŝŵƵůĂƚŝŽŶ͘

Cypress Creek EMS System Policies and Treatment Guidelines

341 MEDICATIONS Revised 8/2016 Approved: Levon Vartanian, MD

ŽƉĂŵŝŶĞ DĞĚŝĐĂƚŝŽŶ ŽƉĂŵŝŶĞŝƐĂŶĂĚƌĞŶĞƌŐŝĐĂŐŽŶŝƐƚǁŝƚŚǀĂƐŽĐŽŶƐƚƌŝĐƚŝǀĞ͕ŝŶŽƚƌŽƉŝĐ͕ĐŚƌŽŶŽƚƌŽƉŝĐ͕ĂŶĚĚƌŽŵŽƚƌŽƉŝĐ ĞĨĨĞĐƚƐ͘ DĞĐŚĂŶŝƐŵŽĨĐƚŝŽŶ ŽƉĂŵŝŶĞŝƐĚŽƐĞĚĞƉĞŶĚĞŶƚ͘ƚůŽǁĚŽƐĞƐ;ϮʹϱŵĐŐͬŬŐͬŵŝŶͿ͕ŽƉĂŵŝŶĞĐĂƵƐĞƐƌĞŶĂůǀĂƐŽĚŝůĂƚŝŽŶ͘ƚ ŵŽĚĞƌĂƚĞĚŽƐĂŐĞƐ;ϱʹϭϬŵĐŐͬŬŐͬŵŝŶͿ͕ŽƉĂŵŝŶĞŚĂƐƉƌŝŵĂƌŝůǇɴͲĂĚƌĞŶĞƌŐŝĐĞĨĨĞĐƚƐ͕ƉĂƌƚŝĐƵůĂƌůǇĂŶ ŝŶĐƌĞĂƐĞŝŶĐĂƌĚŝĂĐŽƵƚƉƵƚĂŶĚĐĂƌĚŝĂĐĐŽŶƚƌĂĐƚŝůŝƚǇ͘ƚŚŝŐŚĞƌĚŽƐĂŐĞƐ;ϭϬʹϮϬŵĐŐͬŬŐͬŵŝŶͿ͕ŽƉĂŵŝŶĞ ŚĂƐƐŝŐŶŝĨŝĐĂŶƚůǇŵŽƌĞɲĞĨĨĞĐƚƐĐĂƵƐŝŶŐƉĞƌŝƉŚĞƌĂůǀĂƐŽĐŽŶƐƚƌŝĐƚŝŽŶ͘ /ŶĚŝĐĂƚŝŽŶƐ x DĂŝŶƚĂŝŶŝŶŐďůŽŽĚƉƌĞƐƐƵƌĞŝŶƐŚŽĐŬŽƌƐŚŽĐŬͲůŝŬĞƐƚĂƚĞƐŶŽƚƌĞůĂƚĞĚƚŽƉƌŝŵĂƌǇŚǇƉŽǀŽůĞŵŝĂ x /ŶĐŽŶũƵŶĐƚŝŽŶǁŝƚŚŽƚŚĞƌĂŐĞŶƚƐĨŽƌƚŚĞƚƌĞĂƚŵĞŶƚŽĨĐŚƌŽŶŝĐƌĞĨƌĂĐƚŽƌǇůĞĨƚŚĞĂƌƚĨĂŝůƵƌĞ ŽŶƚƌĂŝŶĚŝĐĂƚŝŽŶƐ x ŽŶŽƚŵŝǆǁŝƚŚƐŽĚŝƵŵďŝĐĂƌďŽŶĂƚĞ x hŶĐŽƌƌĞĐƚĞĚƚĂĐŚǇĂƌƌŚǇƚŚŵŝĂŽƌǀĞŶƚƌŝĐƵůĂƌĨŝďƌŝůůĂƚŝŽŶ x ^ĞƌŝŽƵƐĂĐƵƚĞŚǇƉĞƌƚĞŶƐŝŽŶŵĂǇĚĞǀĞůŽƉŝŶƉĂƚŝĞŶƚƐǁŝƚŚƉŚĞŽĐŚƌŽŵŽĐǇƚŽŵĂ x hƐĞǁŝƚŚĞǆƚƌĞŵĞĐĂƵƚŝŽŶŝŶƉĂƚŝĞŶƚƐǁŝƚŚƐŝŐŶŝĨŝĐĂŶƚŚĞŵŽƌƌŚĂŐŝŶŐ ^ŝĚĞĨĨĞĐƚƐ x ĐƚŽƉŝĐďĞĂƚƐ͕ƉĂůƉŝƚĂƚŝŽŶƐ͕ĂŶĚƚĂĐŚǇĐĂƌĚŝĂ͘ x EĂƵƐĞĂĂŶĚǀŽŵŝƚŝŶŐ͘ x ǇƐƉŶĞĂ x ŶŐŝŶĂ x ,ĞĂĚĂĐŚĞ ŽƐĂŐĞΘĚŵŝŶŝƐƚƌĂƚŝŽŶ DĂǇďĞĂĚŵŝŶŝƐƚĞƌĞĚŝŶĂƚŝƚƌĂƚĞĚ/sŝŶĨƵƐŝŽŶƵƐŝŶŐĂŵŝĐƌŽĚƌŝƉƐĞƚ͘

ŽƐŝŶŐƌĂŶŐĞŝƐďĂƐĞĚŽŶĚĞƐŝƌĞĚĞĨĨĞĐƚƐďƵƚƐŚŽƵůĚŶŽƚĞǆĐĞĞĚϮʹϮϬŵĐŐͬŬŐͬŵŝŶ͘

Dose Range Therapeutic Effects Conditions Treated ϮʹϱŵĐŐͬŬŐͬŵŝŶ ŝůĂƚĞƐƌĞŶĂůĐŝƌĐƵůĂƚŝŽŶ ϱʹϭϬŵĐŐͬŬŐͬŵŝŶ WƌŝŵĂƌŝůǇďĞƚĂͲĂĚƌĞŶĞƌŐŝĐ͗ŝŶĐƌĞĂƐĞƐ ƌĂĚǇĐĂƌĚŝĂ͕ĐĂƌĚŝŽŐĞŶŝĐƐŚŽĐŬ͘ ŚĞĂƌƚƌĂƚĞĂŶĚĐŽŶƚƌĂĐƚŝůŝƚǇ͘ ϭϬʹϮϬŵĐŐͬŬŐͬŵŝŶ WƌŝŵĂƌŝůǇĂůƉŚĂͲĂĚƌĞŶĞƌŐŝĐ͗ŝŶĐƌĞĂƐĞƐ ŝƐƚƌŝďƵƚŝǀĞƐŚŽĐŬƐƚĂƚĞƐ ^sZƚŚƌŽƵŐŚƉĞƌŝƉŚĞƌĂů ŝŶĐůƵĚŝŶŐƐĞƉƐŝƐĂŶĚŶĞƵƌŽŐĞŶŝĐ ǀĂƐŽĐŽŶƐƚƌŝĐƚŝŽŶ͘ ƐŚŽĐŬ͘

Cypress Creek EMS System Policies and Treatment Guidelines

342 MEDICATIONS Revised 8/2016 Approved: Levon Vartanian, MD

ŽƉĂŵŝŶĞĚŽƐĞƌĂŶŐĞƐĚŽŽǀĞƌůĂƉĂŶĚƚŚĞƌĞŝƐĂůǁĂǇƐĂĐŽŵďŝŶĂƚŝŽŶŽĨĞĨĨĞĐƚƐ͘dŚĞƌĂŶŐĞƐŽĨĨĞƌĂ ƐƚĂƌƚŝŶŐƉŽŝŶƚĨŽƌƚŝƚƌĂƚŝŽŶďĂƐĞĚŽŶĐŽƌƌĞĐƚŝŶŐƚŚĞƵŶĚĞƌůǇŝŶŐƉƌŽďůĞŵ͕ǁŚĞƚŚĞƌŝƚŝƐŝŶĂĚĞƋƵĂƚĞĐĂƌĚŝĂĐ ĐŽŶƚƌĂĐƚŝůŝƚǇ͕ďƌĂĚǇĐĂƌĚŝĂ͕ŽƌŝŶĂĚĞƋƵĂƚĞƐǇƐƚĞŵŝĐǀĂƐĐƵůĂƌƌĞƐŝƐƚĂŶĐĞ͘ ^ƉĞĐŝĂůŽŶƐŝĚĞƌĂƚŝŽŶƐ x /ŶĐƌĞĂƐĞƐŵǇŽĐĂƌĚŝĂůŽǆǇŐĞŶĚĞŵĂŶĚĂŶĚŵĂǇďĞĚĞƚƌŝŵĞŶƚĂůŝŶƉĂƚŝĞŶƚƐĞǆƉĞƌŝĞŶĐŝŶŐŵǇŽĐĂƌĚŝĂů ŝƐĐŚĞŵŝĂ͘ x dƌĞĂƚƵŶĚĞƌůǇŝŶŐŚǇƉŽǀŽůĞŵŝĂŝƐƐƵĞƐǁŝƚŚ/sĨůƵŝĚƐƉƌŝŽƌƚŽŝŶŝƚŝĂƚŝŶŐĚŽƉĂŵŝŶĞ;ƵŶůĞƐƐ ĐŽŶƚƌĂŝŶĚŝĐĂƚĞĚͿ͘

Cypress Creek EMS System Policies and Treatment Guidelines

343 MEDICATIONS Revised 8/2016 Approved: Levon Vartanian, MD

ƉŝŶĞƉŚƌŝŶĞ,>;ĚƌĞŶĂůŝŶĞͿ DĞĚŝĐĂƚŝŽŶ

ŶĞŶĚŽŐĞŶŽƵƐĐĂƚĞĐŚŽůĂŵŝŶĞǁŝƚŚŶŽŶƐĞůĞĐƚŝǀĞEϭ͕EϮ͕ĂŶĚDƉƌŽƉĞƌƚŝĞƐ͘/ƚŝƐĂŶĂĚƌĞŶĞƌŐŝĐĂŐĞŶƚĂŶĚ ĐĂƌĚŝĂĐƐƚŝŵƵůĂŶƚ͘ DĞĐŚĂŶŝƐŵŽĨĐƚŝŽŶ x ZĂƉŝĚŝŶƚƌĂǀĞŶŽƵƐŝŶũĞĐƚŝŽŶƉƌŽĚƵĐĞƐĂƌĂƉŝĚƌŝƐĞŝŶďůŽŽĚƉƌĞƐƐƵƌĞ;ŵĂŝŶůǇƐǇƐƚŽůŝĐďůŽŽĚƉƌĞƐƐƵƌĞͿ x 'ŝǀĞŶƐůŽǁůǇ/s͕ƵƐƵĂůůǇƉƌŽĚƵĐĞƐĂŵŽĚĞƌĂƚĞƌŝƐĞŝŶƐǇƐƚŽůŝĐĂŶĚĂĨĂůůŝŶĚŝĂƐƚŽůŝĐƉƌĞƐƐƵƌĞƐ͘ ůƚŚŽƵŐŚƐŽŵĞŝŶĐƌĞĂƐĞŝŶƉƵůƐĞƉƌĞƐƐƵƌĞŽĐĐƵƌƐ͕ƚŚĞƌĞŝƐƵƐƵĂůůǇŶŽŐƌĞĂƚĞůĞǀĂƚŝŽŶŝŶŵĞĂŶďůŽŽĚ ƉƌĞƐƐƵƌĞ͘ x dŚĞEĞĨĨĞĐƚ͗ŝŶĐƌĞĂƐĞĚŵǇŽĐĂƌĚŝĂůĐŽŶƚƌĂĐƚŝůŝƚǇ͕ĚĞĐƌĞĂƐĞĚƚŚƌĞƐŚŽůĚĨŽƌĚĞĨŝďƌŝůůĂƚŝŽŶ͕ ďƌŽŶĐŚŽĚŝůĂƚŝŽŶ͘ x dŚĞDĞĨĨĞĐƚƐ͗ĐĂƵƐĞƐǀĂƐŽĐŽŶƐƚƌŝĐƚŝŽŶ͕ƚŚƵƐŝŶĐƌĞĂƐŝŶŐƚŚĞƉĞƌĨƵƐŝŽŶƉƌĞƐƐƵƌĞ /ŶĚŝĐĂƚŝŽŶƐ x ŶĂƉŚǇůĂǆŝƐͬƐĞǀĞƌĞĂůůĞƌŐŝĐƌĞĂĐƚŝŽŶ x ĂƌĚŝĂĐƌƌĞƐƚ x ,ǇƉŽƚĞŶƐŝŽŶ;ƉŽƐƚͲĐĂƌĚŝĂĐĂƌƌĞƐƚͿ ŽŶƚƌĂŝŶĚŝĐĂƚŝŽŶƐ dŚĞƌĞĂƌĞŶŽĐŽŶƚƌĂŝŶĚŝĐĂƚŝŽŶƐĨŽƌƚŚĞƵƐĞŽĨĞƉŝŶĞƉŚƌŝŶĞŝŶĐĂƌĚŝĂĐĂƌƌĞƐƚŽƌĂŶĂƉŚǇůĂĐƚŝĐƐŚŽĐŬ͘dŚĞ ŵĞĚŝĐĂƚŝŽŶƐŚŽƵůĚďĞƵƐĞĚǁŝƚŚĐĂƵƚŝŽŶǁŚĞŶƚŚĞƉĂƚŝĞŶƚƉƌĞƐĞŶƚƐǁŝƚŚ͗ x ,ǇƉĞƌƚĞŶƐŝŽŶ͕ĂŶŐŝŶĂ͕ĂŶĚͬŽƌŚǇƉĞƌƚŚǇƌŽŝĚŝƐŵ x /ŵŵĞĚŝĂƚĞůǇĨŽůůŽǁŝŶŐĂĚŵŝŶŝƐƚƌĂƚŝŽŶŽĨƐŽĚŝƵŵďŝĐĂƌďŽŶĂƚĞ͕ǁŚŝĐŚŵĂǇŝŶĂĐƚŝǀĂƚĞĞƉŝŶĞƉŚƌŝŶĞ x WĂƚŝĞŶƚƐƌĞĐĞŝǀŝŶŐŽƚŚĞƌŵĞĚŝĐĂƚŝŽŶƐƚŚĂƚƐĞŶƐŝƚŝǌĞƚŚĞŵǇŽĐĂƌĚŝƵŵƚŽƚŚĞĂĐƚŝŽŶƐŽĨ ƐǇŵƉĂƚŚŽŵŝŵĞƚŝĐĚƌƵŐƐ ^ŝĚĞĨĨĞĐƚƐ x WĂůƉŝƚĂƚŝŽŶƐ x ŶŐŝŶĂůƉĂŝŶ x dĂĐŚǇĐĂƌĚŝĂ x ŶǆŝĞƚǇͬƌĞƐƚůĞƐƐŶĞƐƐ x ĐƚŽƉǇ x dŚƌŽďďŝŶŐŚĞĂĚĂĐŚĞ x ,ǇƉĞƌƚĞŶƐŝŽŶ x dƌĞŵŽƌ x ǇƐƌŚǇƚŚŵŝĂƐ x tĞĂŬŶĞƐƐ x ĞƌĞďƌĂůŚĞŵŽƌƌŚĂŐĞ x sĞƌƚŝŐŽ x ,ĞŵŝƉůĞŐŝĂ x WĂůůŽƌ x ^ƵďĂƌĂĐŚŶŽŝĚŚĞŵŽƌƌŚĂŐĞ x ZĞƐƉŝƌĂƚŽƌǇĚŝƐƚƌĞƐƐ

Cypress Creek EMS System Policies and Treatment Guidelines

344 MEDICATIONS Revised 8/2016 Approved: Levon Vartanian, MD

ŽƐĂŐĞĂŶĚĚŵŝŶŝƐƚƌĂƚŝŽŶ Cardiac Arrest: ĚƵůƚ: 1 mg ŽĨϭ͗ϭϬ͕ϬϬϬ/sͬ/KĞǀĞƌǇϱŵŝŶƵƚĞƐĂƐŶĞĞĚĞĚ͘ WĞĚŝĂƚƌŝĐ͗0.01–0.03 mgŽĨϭ͗ϭϬ͕ϬϬϬ/sͬ/KĞǀĞƌǇϱŵŝŶƵƚĞƐĂƐŶĞĞĚĞĚ͘

Asthma/COPD ĚƵůƚ͗0.3 mgϭ͗ϭϬϬϬ/DĂŶĚͬŽƌϬ͘ϯϭ͗ϭϬ͕ϬϬϬ/sͬ/K͘ and Anaphylaxis: WĞĚŝĂƚƌŝĐ͗0.01 mg/kgϭ͗ϭϬϬϬ/DĂŶĚͬŽƌϬ͘ϬϭŵŐͬŬŐϭ͗ϭϬ͕ϬϬϬ/sͬ/K͘ KŶůǇĂĚŵŝŶŝƐƚĞƌ/sĨŽƌƐĞǀĞƌĞĂŶĂƉŚǇůĂǆŝƐ͘ Bradycardia and ĚƵůƚ͗2–10 mcg/minƚŝƚƌĂƚĞĚƚŽĞĨĨĞĐƚ͘ Shock: WĞĚŝĂƚƌŝĐ͗0.05–0.1 mcg/kg/minƚŝƚƌĂƚĞĚƚŽĞĨĨĞĐƚ͘ DŝǆϭŵŐŽĨϭ͗ϭϬϬϬĞƉŝŶĞƉŚƌŝŶĞŝŶϭϬϬŵ>ŽĨŶŽƌŵĂůƐĂůŝŶĞĨŽƌĂ ĐŽŶĐĞŶƚƌĂƚŝŽŶŽĨϭϬŵĐŐͬŵ>͘ĚŵŝŶŝƐƚĞƌǁŝƚŚĂŵŝĐƌŽĚƌŝƉƐĞƚ͘ /ŶĨƵƐŝŽŶŽƐŝŶŐ͗ Rate Dosage ϲϬŐƚƚͬŵŝŶ ϭϬŵĐŐͬŵŝŶ ϰϱŐƚƚͬŵŝŶ ϳ͘ϱŵĐŐͬŵŝŶ ϯϬŐƚƚͬŵŝŶ ϱŵĐŐͬŵŝŶ ϭϱŐƚƚͬŵŝŶ Ϯ͘ϱŵĐŐͬŵŝŶ ϭϮŐƚƚͬŵŝŶ ϮŵĐŐͬŵŝŶ ^ƉĞĐŝĂůŽŶƐŝĚĞƌĂƚŝŽŶƐ x /ŶƚƌĂǀĞŶŽƵƐŝŶũĞĐƚŝŽŶƉƌŽĚƵĐĞƐĂŶŝŵŵĞĚŝĂƚĞĂŶĚŝŶƚĞŶƐŝĨŝĞĚƌĞƐƉŽŶƐĞ͘&ŽůůŽǁŝŶŐ/sŝŶũĞĐƚŝŽŶ͕ ĞƉŝŶĞƉŚƌŝŶĞĚŝƐĂƉƉĞĂƌƐƌĂƉŝĚůǇĨƌŽŵƚŚĞďůŽŽĚƐƚƌĞĂŵ͘ x /ŶĐĂƐĞƐŽĨĂŶĂƉŚǇůĂǆŝƐĂŶĚĂƐƚŚŵĂ͕ŝĨƚŚĞƉĂƚŝĞŶƚƉƌĞƐĞŶƚƐǁŝƚŚƉĂůĞ͕ĐŽŽů͕ĂŶĚĚŝĂƉŚŽƌĞƚŝĐƐŬŝŶ ;ƐŚŽĐŬͿ͕ĞƉŝŶĞƉŚƌŝŶĞƐŚŽƵůĚďĞĂĚŵŝŶŝƐƚĞƌĞĚǀŝĂƚŚĞŝŶƚƌĂǀĞŶŽƵƐƌŽƵƚĞƌĂƚŚĞƌƚŚĂŶƚŚĞ ƐƵďĐƵƚĂŶĞŽƵƐƌŽƵƚĞ͘

Cypress Creek EMS System Policies and Treatment Guidelines

345 MEDICATIONS Revised 8/2016 Approved: Levon Vartanian, MD

ƚŽŵŝĚĂƚĞ;ŵŝĚĂƚĞͿ DĞĚŝĐĂƚŝŽŶ ^ĞĚĂƚŝǀĞŚǇƉŶŽƚŝĐ͘

ŶŽŶͲďĂƌďŝƚƵƌĂƚĞŚǇƉŶŽƚŝĐǁŝƚŚŽƵƚĂŶĂůŐĞƐŝĐƉƌŽƉĞƌƚŝĞƐ͘/ŶƚŚĞƌĂƉĞƵƚŝĐĚŽƐĞƐŝƚŚĂƐŵŝŶŝŵĂůĞĨĨĞĐƚŽŶ ŵǇŽĐĂƌĚŝĂůŵĞƚĂďŽůŝƐŵ͕ĐĂƌĚŝĂĐŽƵƚƉƵƚ͕ĂŶĚƉĞƌŝƉŚĞƌĂůŽƌƉƵůŵŽŶĂƌǇĐŝƌĐƵůĂƚŝŽŶ͘/ƚŵĂǇĂůƐŽƌĞĚƵĐĞ ŝŶƚƌĂĐƌĂŶŝĂůƉƌĞƐƐƵƌĞ͘ DĞĐŚĂŶŝƐŵŽĨĐƚŝŽŶ ƚŽŵŝĚĂƚĞŝƐĂŶŽŶͲďĂƌďŝƚƵƌĂƚĞŚǇƉŶŽƚŝĐǁŝƚŚŽƵƚĂŶǇĂŶĂůŐĞƐŝĐƉƌŽƉĞƌƚŝĞƐ͘/ƚŚĂƐĞĨĨĞĐƚƐƚŚĂƚĂƉƉĞĂƌƚŽ ďĞƐŝŵŝůĂƌƚŽ'ͲĂĨĨĞĐƚŝŶŐĚƌƵŐƐƐƵĐŚĂƐďĞŶǌŽĚŝĂǌĞƉŝŶĞƐǁŝƚŚŽƵƚƚŚĞƐĂŵĞĚĞŐƌĞĞŽĨĞĨĨĞĐƚƐŽŶ ĐĂƌĚŝŽǀĂƐĐƵůĂƌŚĞŵŽĚǇŶĂŵŝĐƐ͘/ƚŝŶĚƵĐĞƐƐůĞĞƉ͕ƉŽƐƐŝďůǇďǇĚĞƉƌĞƐƐŝŶŐƉĂƌƚƐŽĨƚŚĞƌĞƚŝĐƵůĂƌĨŽƌŵĂƚŝŽŶŝŶ ƚŚĞďƌĂŝŶƐƚĞŵ;ƚŚĞƉĂƌƚŽĨƚŚĞďƌĂŝŶƚŚĂƚŝƐƌĞƐƉŽŶƐŝďůĞĨŽƌďĞŝŶŐĂǁĂŬĞĂŶĚĂǁĂƌĞͿ͘ƚŽŵŝĚĂƚĞŚĂƐĂ ƌĂƉŝĚŽŶƐĞƚ;ϯϬʹϲϬƐĞĐŽŶĚƐͿĂŶĚƐŚŽƌƚĚƵƌĂƚŝŽŶ;ϯʹϱŵŝŶƵƚĞƐͿ͘ /ŶĚŝĐĂƚŝŽŶƐ /ŶĚƵĐƚŝŽŶŽĨĂŶĞƐƚŚĞƐŝĂƉƌŝŽƌƚŽĂĚŵŝŶŝƐƚƌĂƚŝŽŶŽĨĂŶĞƵƌŽŵƵƐĐƵůĂƌďůŽĐŬĂĚĞ ŽŶƚƌĂŝŶĚŝĐĂƚŝŽŶƐ EŽŶĞǁŚĞŶƵƐĞĚĂƐŝŶĚŝĐĂƚĞĚ ĂƵƚŝŽŶƐ x WĂƚŝĞŶƚƐǁŝƚŚĨŽĐĂůĞƉŝůĞƉƐǇ x ƚŽŵŝĚĂƚĞƐƵƉƉƌĞƐƐĞƐĐŽƌƚŝĐŽƐƚĞƌŽŝĚƉƌŽĚƵĐƚŝŽŶĂŶĚƐŚŽƵůĚďĞƵƐĞĚǁŝƚŚĐĂƵƚŝŽŶŝŶƚƌĂƵŵĂĂŶĚ ƐĞƉƐŝƐƉĂƚŝĞŶƚƐ͘ x hƐĞǁŝƚŚĐĂƵƚŝŽŶŝŶƉĂƚŝĞŶƚƐǁŝƚŚŚǇƉŽƚĞŶƐŝŽŶ͘ ^ŝĚĞĨĨĞĐƚƐ x ĂƌĚŝŽǀĂƐĐƵůĂƌ͗ŚǇƉŽƚĞŶƐŝŽŶ͕ĂƌƌŚǇƚŚŵŝĂƐ͕ŚǇƉĞƌƚĞŶƐŝŽŶ x WƵůŵŽŶĂƌǇ͗ŚǇƉĞƌǀĞŶƚŝůĂƚŝŽŶ͕ŚǇƉŽǀĞŶƚŝůĂƚŝŽŶ͕ůĂƌǇŶŐŽƐƉĂƐŵ x E^͗ŵǇŽĐůŽŶƵƐ͕ƚŽŶŝĐŵŽǀĞŵĞŶƚ͕ĞǇĞŵŽǀĞŵĞŶƚƐ x '/͗EĂƵƐĞĂĂŶĚǀŽŵŝƚŝŶŐ ŽƐĂŐĞΘĚŵŝŶŝƐƚƌĂƚŝŽŶ x 0.3 mg/kg/sͬ/K ^ƉĞĐŝĂůŽŶƐŝĚĞƌĂƚŝŽŶƐ x /ŶũĞĐƚŝŽŶŝŶƚŽƐŵĂůůǀĞŝŶƐǁŝůůůŝŬĞůǇĐĂƵƐĞƉĂŝŶ͘

Cypress Creek EMS System Policies and Treatment Guidelines

346 MEDICATIONS Revised 8/2016 Approved: Levon Vartanian, MD

&ĞŶƚĂŶǇů;^ƵďůŝŵĂǌĞͿ DĞĚŝĐĂƚŝŽŶ EĂƌĐŽƚŝĐĂŶĂůŐĞƐŝĐǁŝƚŚƌĂƉŝĚŽŶƐĞƚĂŶĚƐŚŽƌƚĚƵƌĂƚŝŽŶ;ĂďŽƵƚϯϬŵŝŶƵƚĞƐͿ͘ DĞĐŚĂŶŝƐŵŽĨĐƚŝŽŶ &ĞŶƚĂŶǇůŝƐĂƐǇŶƚŚĞƚŝĐŽƉŝŽŝĚĂŐŽŶŝƐƚƚŚĂƚŝƐƐŝŐŶŝĨŝĐĂŶƚůǇŵŽƌĞƉŽƚĞŶƚƚŚĂŶŵŽƌƉŚŝŶĞ͘&ĞŶƚĂŶǇůĂĐƚƐŽŶ ŽƉŝŽŝĚƌĞĐĞƉƚŽƌƐŝŶƚŚĞďƌĂŝŶĂŶĚďƌĂŝŶƐƚĞŵƚŽƌĞĚƵĐĞƉĂŝŶĂŶĚŵĂǇĂůƐŽĐĂƵƐĞƌĞƐƉŝƌĂƚŽƌǇĚĞƉƌĞƐƐŝŽŶ͘ /ŶĚŝĐĂƚŝŽŶƐ WĂŝŶĂƐƐŽĐŝĂƚĞĚǁŝƚŚŽƌƚŚŽƉĞĚŝĐŝŶũƵƌŝĞƐ͕ƌĞŶĂůĐŽůŝĐ͕ĂĐƵƚĞĐŽƌŽŶĂƌǇƐǇŶĚƌŽŵĞƐ͕ĂŶĚďƵƌŶƐ ŽŶƚƌĂŝŶĚŝĐĂƚŝŽŶƐ x ,ǇƉŽƚĞŶƐŝŽŶ x <ŶŽǁŶŚǇƉĞƌƐĞŶƐŝƚŝǀŝƚǇ x ^ǇŵƉƚŽŵĂƚŝĐďƌĂĚǇĐĂƌĚŝĂ x ůŽƐĞĚŚĞĂĚŝŶũƵƌǇǁŝƚŚƐŝŐŶƐͬƐǇŵƉƚŽŵƐŽĨE^ŝŶǀŽůǀĞŵĞŶƚ ^ŝĚĞĨĨĞĐƚƐ x ZĞƐƉŝƌĂƚŽƌǇĚĞƉƌĞƐƐŝŽŶ x ůƚĞƌĞĚŵĞŶƚĂůƐƚĂƚƵƐ x ŝǌǌŝŶĞƐƐ ŽƐĂŐĞΘĚŵŝŶŝƐƚƌĂƚŝŽŶ x AdultͲϬ͘ϱʹϭŵĐŐͬŬŐƐůŽǁ/sͬ/EƌĞƉĞĂƚĂƐŶĞĞĚĞĚƵƉƚŽĂŵĂǆŝŵƵŵƚŽƚĂůĚŽƐĞŽĨϯŵĐŐͬŬŐ x PediatricͲϬ͘ϱŵĐŐͬŬŐƐůŽǁ/sͬ/EƌĞƉĞĂƚĂƐŶĞĞĚĞĚĂƚϬ͘ϮϱŵĐŐͬŬŐƵƉƚŽĂŵĂǆŝŵƵŵƚŽƚĂůĚŽƐĞŽĨϮ ŵĐŐͬŬŐŽƌϮϬϬŵĐŐ ^ƉĞĐŝĂůŽŶƐŝĚĞƌĂƚŝŽŶƐ x ůƚĞƌĂƚŝŽŶƐŝŶƌĞƐƉŝƌĂƚŽƌǇƌĂƚĞĂŶĚĂůǀĞŽůĂƌǀĞŶƚŝůĂƚŝŽŶŵĂǇůĂƐƚůŽŶŐĞƌƚŚĂŶƚŚĞĂŶĂůŐĞƐŝĐĞĨĨĞĐƚ͘ x DĂǇƉƌŽĚƵĐĞůĞƐƐŶĂƵƐĞĂͬĞŵĞƚŝĐĂĐƚŝǀŝƚǇƚŚĂŶŽƚŚĞƌŶĂƌĐŽƚŝĐƐ͘

Cypress Creek EMS System Policies and Treatment Guidelines

347 MEDICATIONS Revised 8/2016 Approved: Levon Vartanian, MD

&ƵƌŽƐĞŵŝĚĞ;>ĂƐŝǆͿ DĞĚŝĐĂƚŝŽŶ ƉŽƚĞŶƚůŽŽƉĚŝƵƌĞƚŝĐ DĞĐŚĂŶŝƐŵŽĨĐƚŝŽŶ x ƐĂůŽŽƉĚŝƵƌĞƚŝĐ͕ĨƵƌŽƐĞŵŝĚĞǁŽƌŬƐŝŶƚŚĞĂƐĐĞŶĚŝŶŐůŽŽƉŽĨ,ĞŶůĞŝŶƚŚĞŬŝĚŶĞǇƐƚŽŝŶŚŝďŝƚƐŽĚŝƵŵ͕ ƉŽƚĂƐƐŝƵŵ͕ĂŶĚĐŚůŽƌŝĚĞƌĞĂďƐŽƌƉƚŝŽŶ͕ǁŚŝĐŚůŝŵŝƚƐǁĂƚĞƌƌĞĂďƐŽƌƉƚŝŽŶĂŶĚŝŶĐƌĞĂƐĞƐƵƌŝŶĞŽƵƚƉƵƚ͕ ƚŚƵƐĚĞĐƌĞĂƐĞĚďůŽŽĚǀŽůƵŵĞ͘/ƚĂůƐŽŝŶĐƌĞĂƐĞƐƉƌŽƐƚĂŐůĂŶĚŝŶƉƌŽĚƵĐƚŝŽŶ͕ĐĂƵƐŝŶŐǀĂƐŽĚŝůĂƚŝŽŶ͘ E^/ƐƐƵĐŚĂƐŝďƵƉƌŽĨĞŶŽƌŬĞƚŽƌŽůĂĐďůŽĐŬƚŚŝƐĂĐƚŝŽŶĂŶĚĐĂŶƌĞĚƵĐĞĞĨĨĞĐƚŝǀĞŶĞƐƐŽĨĨƵƌŽƐĞŵŝĚĞ͘ ĞĐĂƵƐĞŽĨƚŚĞŝƌŵĞĐŚĂŶŝƐŵŽĨĂĐƚŝŽŶ͕ĨƵƌŽƐĞŵŝĚĞĂŶĚŽƚŚĞƌůŽŽƉĚŝƵƌĞƚŝĐƐƌĞƐƵůƚƐŝŶĂůŽƐƐŽĨ ƉŽƚĂƐƐŝƵŵŝŽŶƐǁŚŝĐŚĐĂŶůĞĂĚƚŽŚǇƉŽŬĂůĞŵŝĂ͘ǇƌĞĚƵĐŝŶŐďůŽŽĚǀŽůƵŵĞĂŶĚƐŽĚŝƵŵ ĐŽŶĐĞŶƚƌĂƚŝŽŶƐ͕ĨƵƌŽƐĞŵŝĚĞƌĞĚƵĐĞƐĐĂƌĚŝĂĐǁŽƌŬůŽĂĚĂŶĚƉƵůŵŽŶĂƌǇĞĚĞŵĂ͘&ƵƌŽƐĞŵŝĚĞŝƐƌĂƉŝĚ ǁŝƚŚƉĞĂŬĞĨĨĞĐƚƐǁŝƚŚŝŶϯϬͲϲϬŵŝŶƵƚĞƐŽĨĂĚŵŝŶŝƐƚƌĂƚŝŽŶ͘ /ŶĚŝĐĂƚŝŽŶƐ x WƵůŵŽŶĂƌǇĞĚĞŵĂĂƐƐŽĐŝĂƚĞĚǁŝƚŚĐŽŶŐĞƐƚŝǀĞŚĞĂƌƚĨĂŝůƵƌĞ x ,ǇƉĞƌƚĞŶƐŝŽŶĂƐƐŽĐŝĂƚĞĚǁŝƚŚƉƵůŵŽŶĂƌǇĞĚĞŵĂǁŝƚŚ^K ŽŶƚƌĂŝŶĚŝĐĂƚŝŽŶƐ x ůŽŽĚƉƌĞƐƐƵƌĞŵƵƐƚďĞŵŽŶŝƚŽƌĞĚĐĂƌĞĨƵůůǇĚƵƌŝŶŐĂĚŵŝŶŝƐƚƌĂƚŝŽŶĚƵĞƚŽƉŽƚĞŶĐǇŽĨŵĞĚŝĐĂƚŝŽŶ͘ ^ŚŽƵůĚŶŽƚďĞŐŝǀĞŶƚŽ͗

x WƌĞŐŶĂŶƚƉĂƚŝĞŶƚƐ x WĂƚŝĞŶƚƐǁŝƚŚŬŶŽǁŶŽƌƐƵƐƉĞĐƚĞĚŚǇƉŽŬĂůĞŵŝĂ x WĂƚŝĞŶƚƐǁŝƚŚŚǇƉŽǀŽůĞŵŝĂĂŶĚͬŽƌĚĞŚǇĚƌĂƚŝŽŶ ^ŝĚĞĨĨĞĐƚƐ x EĂƵƐĞĂĂŶĚǀŽŵŝƚŝŶŐ x WŽƚĂƐƐŝƵŵĚĞƉůĞƚŝŽŶ x ĞŚǇĚƌĂƚŝŽŶ x hƌŝŶĞŽƵƚƉƵƚ ŽƐĂŐĞĂŶĚĚŵŝŶŝƐƚƌĂƚŝŽŶ Adults:Ϭ͘ϱͲϭŵŐͬŬŐ/sŽǀĞƌϮŵŝŶƵƚĞƐʹŵĂǆŝŵƵŵϭϮϬŵŐ/s Pediatric:Ϭ͘ϱͲϭŵŐͬŬŐ/sŽǀĞƌϮŵŝŶƵƚĞƐ ^ƉĞĐŝĂůŽŶƐŝĚĞƌĂƚŝŽŶƐ /ĨƚŚĞƉĂƚŝĞŶƚŝƐĐƵƌƌĞŶƚůǇƚĂŬŝŶŐWK&ƵƌŽƐĞŵŝĚĞ͕ĐŽŶƐŝĚĞƌŐŝǀŝŶŐ/s&ƵƌŽƐĞŵŝĚĞĂƚĚŽƵďůĞƚŚĞƉĂƚŝĞŶƚ͛Ɛ ƚŽƚĂůĚĂŝůǇĚŽƐĞƵƉƚŽĂŵĂǆŝŵƵŵĚŽƐĞŽĨϭϮϬŵŐ/s͘

dŚĞƌĞŶĂůƉĂƚŝĞŶƚǁŝƚŚƉƵůŵŽŶĂƌǇĞĚĞŵĂůŝŬĞůǇǁŝůůŶŽƚďĞŶĞĨŝƚĨƌŽŵ>ĂƐŝǆĂĚŵŝŶŝƐƚƌĂƚŝŽŶĂƐĂĚĞƋƵĂƚĞ ŬŝĚŶĞǇĨƵŶĐƚŝŽŶŝƐŶĞĐĞƐƐĂƌǇĨŽƌƚŚŝƐŵĞĚŝĐĂƚŝŽŶƚŽďĞĞĨĨĞĐƚŝǀĞĂŶĚƵƌŝŶĞƉƌŽĚƵĐƚŝŽŶͬĚŝƵƌĞƐŝƐƚŽŽĐĐƵƌ͘

Cypress Creek EMS System Policies and Treatment Guidelines

348 MEDICATIONS Revised 6/2019 Approved: Levon Vartanian, MD

'ůƵĐĂŐŽŶ;'ůƵĐĂ'ĞŶͿ DĞĚŝĐĂƚŝŽŶ ŚŽƌŵŽŶĞƐǇŶƚŚĞƐŝǌĞĚĂŶĚƐĞĐƌĞƚĞĚŝŶƚŚĞƉĂŶĐƌĞĂƐƚŚĂƚŚĂƐĞĨĨĞĐƚƐŽƉƉŽƐŝƚĞŽĨŝŶƐƵůŝŶ͘ DĞĐŚĂŶŝƐŵŽĨĐƚŝŽŶ x ĂƵƐĞƐŐůǇĐŽŐĞŶƚŽďƌĞĂŬĚŽǁŶŝŶƚŽŐůƵĐŽƐĞ x /ŶŚŝďŝƚƐŐůǇĐŽŐĞŶƐǇŶƚŚĞƐŝƐ x ůĞǀĂƚĞƐďůŽŽĚŐůƵĐŽƐĞůĞǀĞů x /ŶĐƌĞĂƐĞƐĐĂƌĚŝĂĐĐŽŶƚƌĂĐƚŝůĞĨŽƌĐĞĂŶĚŚĞĂƌƚƌĂƚĞďǇƐƚŝŵƵůĂƚŝŶŐƉƌŽĚƵĐƚŝŽŶŽĨĐǇĐůŝĐDW /ŶĚŝĐĂƚŝŽŶƐ x ,ǇƉŽŐůǇĐĞŵŝĂʹŽŶůǇǁŚĞŶ/sĂĐĐĞƐƐǁŝƚŚĚĞǆƚƌŽƐĞĂĚŵŝŶŝƐƚƌĂƚŝŽŶĂƌĞŶŽƚƉŽƐƐŝďůĞ x ^ǇŵƉƚŽŵĂƚŝĐďĞƚĂͲďůŽĐŬĞƌŽǀĞƌĚŽƐĞǁŝƚŚďƌĂĚǇĐĂƌĚŝĂĂŶĚͬŽƌŚǇƉŽƚĞŶƐŝŽŶ ŽŶƚƌĂŝŶĚŝĐĂƚŝŽŶƐ x <ŶŽǁŶŚǇƉĞƌƐĞŶƐŝƚŝǀŝƚǇ x hƐĞǁŝƚŚĐĂƵƚŝŽŶŝŶƉĂƚŝĞŶƚƐǁŝƚŚŽƵƚŐůǇĐŽŐĞŶƐƚŽƌĞƐ;ĂůĐŽŚŽůŝĐͬŵĂůŶŽƵƌŝƐŚĞĚƉĂƚŝĞŶƚƐͿ ^ŝĚĞĨĨĞĐƚƐ x ZĞƐƉŝƌĂƚŽƌǇĚĞƉƌĞƐƐŝŽŶ x ůƚĞƌĞĚŵĞŶƚĂůƐƚĂƚƵƐ x ŝǌǌŝŶĞƐƐ x EĂƵƐĞĂͬǀŽŵŝƚŝŶŐ ŽƐĂŐĞΘĚŵŝŶŝƐƚƌĂƚŝŽŶ Hypoglycemia: Adult:ϭʹϮŵŐ/D Pediatric:Ϭ͘ϬϯŵŐͬŬŐ/D

Beta-Blocker Overdose: Adult:ϮŵŐ/s Pediatric: Ϭ͘ϬϯŵŐͬŬŐ/s͕ϮŵŐŵĂǆŝŵƵŵ ^ƉĞĐŝĂůŽŶƐŝĚĞƌĂƚŝŽŶƐ x WƌĞŐŶĂŶĐǇ͗dŚŝƐĚƌƵŐŚĂƐďĞĞŶƵƐĞĚǁŝƚŚŽƵƚĂƉƉĂƌĞŶƚŚĂƌŵĨƵůĞĨĨĞĐƚƐ͘'ůƵĐĂŐŽŶĚŽĞƐŶŽƚĐƌŽƐƐƚŚĞ ŚƵŵĂŶƉůĂĐĞŶƚĂďĂƌƌŝĞƌ͘ x KŶůǇĞĨĨĞĐƚŝǀĞǁŚĞŶƚŚĞƌĞĂƌĞƐƵĨĨŝĐŝĞŶƚƐƚŽƌĞƐŽĨŐůǇĐŽŐĞŶŝŶƚŚĞůŝǀĞƌ͘hƐĞǁŝƚŚĐĂƵƚŝŽŶŝŶƉĂƚŝĞŶƚƐ ǁŝƚŚĐĂƌĚŝŽǀĂƐĐƵůĂƌŽƌƌĞŶĂůĚŝƐĞĂƐĞ͘ x It is imperative to allow enough time for Glucagon to affect the patient. This is typically 15-20 minutes following an IM injection.

Cypress Creek EMS System Policies and Treatment Guidelines

349 MEDICATIONS Revised 8/2016 Approved: Levon Vartanian, MD

,ĞƉĂƌŝŶ DĞĚŝĐĂƚŝŽŶ ,ĞƉĂƌŝŶƐŽĚŝƵŵŝƐĂŶĂŶƚŝĐŽĂŐƵůĂŶƚĂŐĞŶƚƵƐĞĚŝŶƚŚĞ^dͲůĞǀĂƚŝŽŶD/;^dD/ͿĂƐĂϱϬϬϬƵŶŝƚͬŵů ƐŽůƵƚŝŽŶ͘,ĞƉĂƌŝŶƐŽĚŝƵŵĨůƵƐŚŝƐĂŶĂŶƚŝĐŽĂŐƵůĂŶƚĂŐĞŶƚƵƐĞĚŝŶĨůƵƐŚŝŶŐŝŵƉůĂŶƚĞĚĐĞŶƚƌĂůĐĂƚŚĞƚĞƌƐĂƐ ĂϭϬϬƵŶŝƚͬŵůƐŽůƵƚŝŽŶ͘ DĞĐŚĂŶŝƐŵŽĨĐƚŝŽŶ ,ĞƉĂƌŝŶƐŽĚŝƵŵŝƐĂŐůǇĐŽƐĂŵŝŶŽŐůǇĐĂŶĂŶƚŝĐŽĂŐƵůĂŶƚŶŽƌŵĂůůǇŽĐĐƵƌƌŝŶŐŝŶŵĂƐƚĐĞůůƐ͘/ƚĂĐƚƐĂƐĂ ĐĂƚĂůǇƐƚďǇŝŶĐƌĞĂƐŝŶŐƚŚĞƌĂƚĞĂƚǁŚŝĐŚĂŶƚŝƚŚƌŽŵďŝŶ///ŶĞƵƚƌĂůŝǌĞƐĂŶƚŝƚŚƌŽŵďŝŶĂŶĚĂĐƚŝǀĂƚĞĚ ĐŽĂŐƵůĂƚŝŽŶĨĂĐƚŽƌy͘ /ŶĚŝĐĂƚŝŽŶƐ ^dͲůĞǀĂƚŝŽŶD/ ŽŶƚƌĂŝŶĚŝĐĂƚŝŽŶƐ x ,ǇƉĞƌƐĞŶƐŝƚŝǀŝƚǇ x ZĞĐĞŶƚŽƌŬŶŽǁŶĂĐƚŝǀĞďůĞĞĚŝŶŐ x <ŶŽǁŶďůĞĞĚŝŶŐĚŝƐŽƌĚĞƌƐ x <ŶŽǁŶƚŚƌŽŵďŽĐǇƚŽƉĞŶŝĂ;ůŽǁƉůĂƚĞůĞƚĐŽƵŶƚͿ ^ŝĚĞĨĨĞĐƚƐ x WƌŽůŽŶŐĞĚďůĞĞĚŝŶŐƚŝŵĞ x /ŶĐƌĞĂƐĞĚďůĞĞĚŝŶŐ x ZĂƌĞůǇ͕ĂůůĞƌŐŝĐƌĞĂĐƚŝŽŶ ŽƐĂŐĞΘĚŵŝŶŝƐƚƌĂƚŝŽŶ ^dD/͗5000 units IV

Cypress Creek EMS System Policies and Treatment Guidelines

350 MEDICATIONS Revised 8/2016 Approved: Levon Vartanian, MD

,ǇĚƌŽǆŽĐŽďĂůĂŵŝŶ;ǇĂŶŽŬŝƚͿ DĞĚŝĐĂƚŝŽŶ ŶƚŝĚŽƚĞĨŽƌ,ǇĚƌŽŐĞŶǇĂŶŝĚĞƉŽŝƐŽŶŝŶŐͬ/ŶŚĂůĂƚŝŽŶ DĞĐŚĂŶŝƐŵŽĨĐƚŝŽŶ ,ǇĚƌŽǆŽĐŽďĂůĂŵŝŶďŝŶĚƐƚŽĐǇĂŶŝĚĞŝŶƚŚĞďůŽŽĚƐƚƌĞĂŵĨŽƌŵŝŶŐĐǇĂŶŽĐŽďĂůĂŵŝŶ͕ǁŚŝĐŚŝƐƚŚĞŶ ĞǆĐƌĞƚĞĚŝŶƚŚĞƵƌŝŶĞ͘ /ŶĚŝĐĂƚŝŽŶƐ x ^ŵŽŬĞŝŶŚĂůĂƚŝŽŶǀŝĐƚŝŵƐ x ǆƉŽƐƵƌĞƚŽĨŝƌĞŽƌƐŵŽŬĞŝŶĂŶĞŶĐůŽƐĞĚĂƌĞĂ x WƌĞƐĞŶĐĞŽĨƐŽŽƚĂƌŽƵŶĚƚŚĞŵŽƵƚŚ͕ŶŽƐĞ͕ŽƌŽƌŽƉŚĂƌǇŶǆ x ůƚĞƌĞĚŵĞŶƚĂůƐƚĂƚƵƐ;ĐŽŶĨƵƐŝŽŶ͕ĚŝƐŽƌŝĞŶƚĂƚŝŽŶ͕ƐĞŝǌƵƌĞƐͿ ŽŶƚƌĂŝŶĚŝĐĂƚŝŽŶƐ x ŝƐĐŽŶƚŝŶƵĞŝŶĨƵƐŝŽŶŝĨƉĂƚŝĞŶƚďĞŐŝŶƐƚŽƉƌĞƐĞŶƚǁŝƚŚƐŝŐŶƐŽĨĂůůĞƌŐŝĐƌĞĂĐƚŝŽŶƐ͘ ^ŝĚĞĨĨĞĐƚƐ x ŚƌŽŵĂƚƵƌŝĂ;ƌĞĚͲĐŽůŽƌĞĚƵƌŝŶĞͿ x ƌǇƚŚĞŵĂ;ƌĞĚͲĐŽůŽƌĞĚƐŬŝŶͿ x ,ǇƉĞƌƚĞŶƐŝŽŶ ŽƐĂŐĞΘĚŵŝŶŝƐƚƌĂƚŝŽŶ x /ŶƐƚŝůůϮϬϬŵůŽĨEĂůŝŶƚŽƚŚĞŚǇĚƌŽǆŽĐŽďĂůĂŵŝŶǀŝĂů͘ x DŝǆƚŚĞƐŽůƵƚŝŽŶďǇƌŽůůŝŶŐƚŚĞǀŝĂůďĂĐŬĂŶĚĨŽƌƚŚďĞƚǁĞĞŶǇŽƵƌŚĂŶĚƐ͘ x ^ƉŝŬĞƚŚĞƉƌĞƉĂƌĞĚǀŝĂůǁŝƚŚƚŚĞŝŶĐůƵĚĞĚǀĞŶƚĞĚĚƌŝƉƐĞƚ͘;ŽŶŽƚƵƐĞƐƚĂŶĚĂƌĚĚƌŝƉƐĞƚƐͿ x /ŶĨƵƐĞϱŐƌĂŵƐŽǀĞƌϭϱŵŝŶƵƚĞƐǀŝĂ/sͬ/K x DĂǇƌĞƉĞĂƚŽŶĐĞĂƐŶĞĞĚĞĚ ^ƉĞĐŝĂůŽŶƐŝĚĞƌĂƚŝŽŶƐ x KEKdƐŚĂŬĞŽƌĂŐŝƚĂƚĞƚŚĞǀŝĂů x /ĨŽƚŚĞƌŵĞĚŝĐĂƚŝŽŶƐŶĞĞĚƚŽďĞĂĚŵŝŶŝƐƚĞƌĞĚ͕ƐƚĂƌƚĂƐĞĐŽŶĚ/sĨŽƌ,ǇĚƌŽǆŽĐŽďĂůĂŵŝŶ ĂĚŵŝŶŝƐƚƌĂƚŝŽŶ͘

Cypress Creek EMS System Policies and Treatment Guidelines

351 MEDICATIONS Revised 8/2016 Approved: Levon Vartanian, MD

/ďƵƉƌŽĨĞŶ;DŽƚƌŝŶͿ DĞĚŝĐĂƚŝŽŶ ŶŽŶͲƐƚĞƌŽŝĚĂůĂŶƚŝͲŝŶĨůĂŵŵĂƚŽƌǇ;E^/ͿĂŐĞŶƚƚŚĂƚŚĂƐĂŶƚŝƉǇƌĞƚŝĐƉƌŽƉĞƌƚŝĞƐ DĞĐŚĂŶŝƐŵŽĨĐƚŝŽŶ ZĞĚƵĐĞƐĨĞǀĞƌďǇŝŶŚŝďŝƚŝŽŶŽĨƉƌŽƐƚĂŐůĂŶĚŝŶƐ /ŶĚŝĐĂƚŝŽŶƐ x &ĞǀĞƌĂďŽǀĞϭϬϬ͘ϰ϶& ŽŶƚƌĂŝŶĚŝĐĂƚŝŽŶƐ x ^ĞǀĞƌĞĂƐƉŝƌŝŶĂůůĞƌŐǇ x ^ĞǀĞƌĞƌĞĂĐƚŝǀĞĂŝƌǁĂǇĚŝƐĞĂƐĞ x <ŶŽǁŶŚǇƉĞƌƐĞŶƐŝƚŝǀŝƚǇ ^ŝĚĞĨĨĞĐƚƐ x 'ĂƐƚƌŝĐŝƌƌŝƚĂƚŝŽŶ ŽƐĂŐĞΘĚŵŝŶŝƐƚƌĂƚŝŽŶ x 10 mg/kgďǇŵŽƵƚŚŽĨĂĐŽŶĐĞŶƚƌĂƚŝŽŶŽĨϭϬϬŵŐͬϱŵů͕ĞǀĞƌǇϲͲϴŚŽƵƌƐ ^ƉĞĐŝĂůŽŶƐŝĚĞƌĂƚŝŽŶƐ x ŽŶŽƚĂĚŵŝŶŝƐƚĞƌŝĨůĂƐƚĂĚŵŝŶŝƐƚƌĂƚŝŽŶǁĂƐфϲŚŽƵƌƐĂŐŽ x ^ŚŽƵůĚŶŽƚďĞĂĚŵŝŶŝƐƚĞƌĞĚƚŽĂĐŚŝůĚůĞƐƐƚŚĂŶϲŵŽŶƚŚƐŽůĚ x ŽŶŽƚĂĚŵŝŶŝƐƚĞƌŽƌĂůŵĞĚŝĐĂƚŝŽŶƐƚŽƉŽƐƚŝĐƚĂůƉĂƚŝĞŶƚƐŽƌƚŚŽƐĞĂƚƌŝƐŬĨŽƌĂƐƉŝƌĂƚŝŽŶ͖ƵƐĞŽƚŚĞƌ ĐŽŽůŝŶŐŵĞĂƐƵƌĞƐŝĨŶĞĞĚĞĚ;ƵŶĚƌĞƐƐ͕ĐŽůĚƉĂĐŬƐ͕/sĨůƵŝĚƐ͕ĞƚĐ͘ͿĨŽƌĨĞǀĞƌ

Cypress Creek EMS System Policies and Treatment Guidelines

352 MEDICATIONS Revised 8/2016 Approved: Levon Vartanian, MD

/ƉƌĂƚƌŽƉŝƵŵƌŽŵŝĚĞ;ƚƌŽǀĞŶƚͿ DĞĚŝĐĂƚŝŽŶ ŶƚŝĐŚŽůŝŶĞƌŐŝĐĂŐĞŶƚƵƐĞĚƚŽƚƌĞĂƚKWĂŶĚĂĐƵƚĞĂƐƚŚŵĂ DĞĐŚĂŶŝƐŵŽĨĐƚŝŽŶ ^ƚŽƉƐƌĞƐƉŝƌĂƚŽƌǇƚƌĂĐƚƐĞĐƌĞƚŝŽŶƐĂŶĚŝŵƉƌŽǀĞƐďƌŽŶĐŚŽĚŝůĂƚŝŽŶĨƌŽŵĂůďƵƚĞƌŽů͘ /ŶĚŝĐĂƚŝŽŶƐ x ĐƵƚĞďƌŽŶĐŚŽƐƉĂƐŵƌĞĨƌĂĐƚŽƌǇƚŽĂůďƵƚĞƌŽůƐƵůĨĂƚĞ͖ƉĂƌƚŝĐƵůĂƌůǇǁŚĞŶĂ ƉĂƌĂƐǇŵƉĂƚŚĞƚŝĐͬĐŚŽůŝŶĞƌŐŝĐƌĞƐƉŽŶƐĞŝƐƉƌĞƐĞŶƚĂƐŝŶĚŝĐĂƚĞĚďǇĚŝĨĨƵƐĞƌŚŽŶĐŚŝ͕ĐŽĂƌƐĞĐƌĂĐŬůĞƐ͕ ŚŝƐƚŽƌǇŽĨĐŚƌŽŶŝĐďƌŽŶĐŚŝƚŝƐ͕ŵƵĐŽƵƐƉƌŽĚƵĐƚŝŽŶŽŶĐŽƵŐŚ͕Z^s͕ŽƌďƌŽŶĐŚŝŽůŝƚŝƐ͘ ŽŶƚƌĂŝŶĚŝĐĂƚŝŽŶƐ x <ŶŽǁŶ,ǇƉĞƌƐĞŶƐŝƚŝǀŝƚǇ ^ŝĚĞĨĨĞĐƚƐ x WĂůƉŝƚĂƚŝŽŶƐ x ŝǌǌŝŶĞƐƐ x ŶǆŝĞƚǇ x ,ĞĂĚĂĐŚĞ x EĞƌǀŽƵƐŶĞƐƐ ŽƐĂŐĞΘĚŵŝŶŝƐƚƌĂƚŝŽŶ x 500 Pg / 3 ml ĂĚŵŝŶŝƐƚĞƌĞĚĐŽŶĐƵƌƌĞŶƚůǇǁŝƚŚĂůďƵƚĞƌŽůƐƵůĨĂƚĞĂƐĂΗĐŽŵďŝŶĂƚŝŽŶΗƚƌĞĂƚŵĞŶƚ ^ƉĞĐŝĂůŽŶƐŝĚĞƌĂƚŝŽŶƐ x EŽŶĞ

Cypress Creek EMS System Policies and Treatment Guidelines

353 MEDICATIONS Revised 8/2016 Approved: Levon Vartanian, MD

<ĞƚĂŵŝŶĞ;<ĞƚĂůĂƌͿ DĞĚŝĐĂƚŝŽŶ ŝƐƐŽĐŝĂƚŝǀĞĂŶĞƐƚŚĞƚŝĐ͘ DĞĐŚĂŶŝƐŵŽĨĐƚŝŽŶ EDƌĞĐĞƉƚŽƌĂŶƚĂŐŽŶŝƐƚĐŽŵŵŽŶůǇƵƐĞĚƚŽŝŶĚƵĐĞĂƐƚĂƚĞŽĨĂŶĞƐƚŚĞƐŝĂƌĞĨĞƌƌĞĚƚŽĂƐĚŝƐƐŽĐŝĂƚŝǀĞ ĂŶĞƐƚŚĞƐŝĂƌĞƐƵůƚŝŶŐŝŶĂŶĂůŐĞƐŝĂ͕ĂŶǆŝŽůǇƐŝƐ͕ĂŶĚĂŵŶĞƐŝĂ͘^ĞƉĂƌĂƚĞƐƚŚĞŵŝĚͲďƌĂŝŶĨƌŽŵƚŚĞĐŽƌƚĞǆ ĚŝƐŽƌŐĂŶŝǌŝŶŐŝŶƉƵƚ͘KĐĐƵƉŝĞƐŽƉŝĂƚĞƌĞĐĞƉƚŽƌƐ͕ǁŚŝůĞĂůƐŽĞǆĐŝƚŝŶŐůŽǁĞƌďƌĂŝŶĐŽŶƚƌŽůƐ͘ /ŶĚŝĐĂƚŝŽŶƐ x ^ĞĚĂƚŝŽŶ x ĚũƵŶĐƚƚŽŶĂƌĐŽƚŝĐƐĨŽƌƉĂŝŶŵĂŶĂŐĞŵĞŶƚ ŽŶƚƌĂŝŶĚŝĐĂƚŝŽŶƐ x WĂƚŝĞŶƚƐǁŝƚŚĂƉƌĞĚŝƐƉŽƐŝƚŝŽŶĨŽƌůĂƌǇŶŐŽƐƉĂƐŵ x ,ŝƐƚŽƌǇŽĨŐůĂƵĐŽŵĂ͕ŽƌĂĐƵƚĞŐůŽďĞŝŶũƵƌǇ x ^ĞǀĞƌĞĐĂƌĚŝŽǀĂƐĐƵůĂƌĚŝƐĞĂƐĞ;ĂŶŐŝŶĂ͕ŚĞĂƌƚĨĂŝůƵƌĞ͕ƵŶĐŽŶƚƌŽůůĞĚŚǇƉĞƌƚĞŶƐŝŽŶ^WхϮϮϬͿ ^ŝĚĞĨĨĞĐƚƐ x ^ŵŽŽƚŚŵƵƐĐůĞƌĞůĂǆĂŶƚͬďƌŽŶĐŚŽĚŝůĂƚŽƌ x dƌĂŶƐŝĞŶƚƚĂĐŚǇĐĂƌĚŝĂ͕ŝŶĐƌĞĂƐĞŝŶďůŽŽĚƉƌĞƐƐƵƌĞ͕ĂŶĚŝŶĐƌĞĂƐĞŝŶĐĂƌĚŝĂĐŽƵƚƉƵƚ͕ƉĂƌƚŝĐƵůĂƌůǇǁŚĞŶ ĂĚŵŝŶŝƐƚĞƌĞĚƌĂƉŝĚůǇ͘ x ,ĂůůƵĐŝŶĂƚŝŽŶƐĂŶĚƉƐǇĐŚŽƚŝĐĞƉŝƐŽĚĞƐ x >ĂƌǇŶŐŽƐƉĂƐŵ;ƌĂƌĞͿ x ƉŶĞĂĂƚŚŝŐŚĚŽƐĞƐ ŽƐĂŐĞΘĚŵŝŶŝƐƚƌĂƚŝŽŶ x ŝƐĂƐƐŽĐŝĂƚŝŽŶͬƐĞĚĂƚŝŽŶ͗5 mg/kg/DŽƌϭͲϭ͘ϱŵŐͬŬŐ/sͬ/K x ŶĂůŐĞƐŝĂ͗0.2–0.5 mg/kg/sͬ/E ^ƉĞĐŝĂůŽŶƐŝĚĞƌĂƚŝŽŶƐ x ĂƵƚŝŽŶǁŚĞŶŐŝǀŝŶŐ/sƉƵƐŚ͘ZĂƉŝĚ/sƉƵƐŚĐĂŶƌĞƐƵůƚŝŶƌĞƐƉŝƌĂƚŽƌǇĚĞƉƌĞƐƐŝŽŶͬĂƉŶĞĂĂŶĚ ŚǇƉĞƌƐĂůŝǀĂƚŝŽŶ͘ x ŶĂůŐĞƐŝĂŝƐĚŽƵďůĞƚŚĂƚƉƌŽǀŝĚĞĚďǇŵŽƌƉŚŝŶĞ͕ĂŵŶĞƐŝĂŝƐƐŝŵŝůĂƌƚŽƚŚĂƚŝŶĚƵĐĞĚďǇŵŝĚĂǌŽůĂŵ x ^ŽŵĞƉĂƚŝĞŶƚƐŵĂǇĞǆƉĞƌŝĞŶĐĞƵŶƉůĞĂƐĂŶƚĞŵĞƌŐĞŶĐĞƌĞĂĐƚŝŽŶƐ͕ǁŚŝĐŚŚĂǀĞďĞĞŶƐŚŽǁŶƚŽďĞ ĞĂƐŝůǇĐŽŶƚƌŽůůĞĚǁŝƚŚƌĞĂƐƐƵƌĂŶĐĞĂŶĚĂĚŵŝŶŝƐƚƌĂƚŝŽŶŽĨďĞŶǌŽĚŝĂǌĞƉŝŶĞƐ x ŵĞƌŐĞŶĐĞƌĞĂĐƚŝŽŶƐ;ŚĂůůƵĐŝŶĂƚŝŽŶƐĂŶĚƉƐǇĐŚŽƚŝĐĞƉŝƐŽĚĞƐͿĂƌĞĐŽŵŵŽŶůǇƚƌĞĂƚĞĚǁŝƚŚ ďĞŶǌŽĚŝĂǌĞƉŝŶĞƐ x KŶƐĞƚŽĨĂĐƚŝŽŶ͗/sͲϯϬƐĞĐŽŶĚƐĂŶĚ/DͲϯƚŽϱŵŝŶƵƚĞƐ x ƵƌĂƚŝŽŶŽĨĂĐƚŝŽŶ͗/sͲϱƚŽϭϱŵŝŶƵƚĞƐĂŶĚ/DͲϭϬƚŽϯϬŵŝŶƵƚĞƐ

Cypress Creek EMS System Policies and Treatment Guidelines

354 MEDICATIONS Revised 8/2016 Approved: Levon Vartanian, MD

<ĞƚŽƌŽůĂĐ;dŽƌĂĚŽůͿ DĞĚŝĐĂƚŝŽŶ EŽŶͲƐƚĞƌŽŝĚĂůĂŶƚŝͲŝŶĨůĂŵŵĂƚŽƌǇĚƌƵŐ;E^/Ϳ DĞĐŚĂŶŝƐŵŽĨĐƚŝŽŶ x ŶĂůŐĞƐŝĂ x ŶƚŝͲŝŶĨůĂŵŵĂƚŽƌǇ /ŶĚŝĐĂƚŝŽŶƐ x DŝůĚƚŽŵŽĚĞƌĂƚĞŵƵƐĐƵůŽƐŬĞůĞƚĂůƉĂŝŶ ŽŶƚƌĂŝŶĚŝĐĂƚŝŽŶƐ x ,ǇƉĞƌƐĞŶƐŝƚŝǀŝƚǇƚŽƚŚĞĚƌƵŐŽƌĂƐƉŝƌŝŶ x ĐƚŝǀĞďůĞĞĚŝŶŐ x ,ŝƐƚŽƌǇŽĨƉĞƉƚŝĐƵůĐĞƌĚŝƐĞĂƐĞ x &ƌĂĐƚƵƌĞƐǁŚĞƌĞƚŚĞƉŽƚĞŶƚŝĂůĨŽƌĞǆĐĞƐƐŝǀĞďůĞĞĚŝŶŐĞǆŝƐƚƐ x Renal Insufficiency or failure ^ŝĚĞĨĨĞĐƚƐ x ĚĞŵĂ x ZĂƐŚ x ,ĞĂƌƚďƵƌŶ ŽƐĂŐĞΘĚŵŝŶŝƐƚƌĂƚŝŽŶ Adult: x ϭϱͲϯϬŵŐ/s x ϯϬͲϲϬŵŐĚĞĞƉ/D;ŐůƵƚĞĂůͿ Pediatric (use only in children > 10 y/o): x ϭϬͲϭϱŵŐ/sŽƌ/D ^ƉĞĐŝĂůŽŶƐŝĚĞƌĂƚŝŽŶƐ x '/ŝƌƌŝƚĂƚŝŽŶĐĂŶŽĐĐƵƌ x WŽƐƐŝďůĞŝŶŚŝďŝƚŝŽŶŽĨƉůĂƚĞůĞƚĨƵŶĐƚŝŽŶ;ĂŐŐƌĞŐĂƚŝŽŶͿƐŝŵŝůĂƌƚŽĂƐƉŝƌŝŶ

Cypress Creek EMS System Policies and Treatment Guidelines

355 MEDICATIONS Revised 8/2016 Approved: Levon Vartanian, MD

>ŝĚŽĐĂŝŶĞ,>;yǇůŽĐĂŝŶĞ͕>ŝĚŽĐĂŝŶĞ:ĞůůǇͿ DĞĚŝĐĂƚŝŽŶ ŶĂŶƚŝĂƌƌŚǇƚŚŵŝĐĚƌƵŐǁŚĞŶƵƐĞĚŝŶƚƌĂǀĞŶŽƵƐůǇ͖ĂĐŽŵŵŽŶůŽĐĂůĂŶĞƐƚŚĞƚŝĐĚƌƵŐǁŚĞŶƵƐĞĚ ƚŽƉŝĐĂůůǇͬŝŶũĞĐƚĞĚ͘ DĞĐŚĂŶŝƐŵŽĨĐƚŝŽŶ >ŝĚŽĐĂŝŶĞďůŽĐŬƐĨĂƐƚƐŽĚŝƵŵĐŚĂŶŶĞůƐ͕ŝŶĐƌĞĂƐŝŶŐƚŚĞĚĞƉŽůĂƌŝǌĂƚŝŽŶƚŚƌĞƐŚŽůĚŝŶŵǇŽĐǇƚĞƐ;ĐĂƌĚŝĂĐ ŵƵƐĐůĞĐĞůůƐͿĂŶĚŶĞƵƌŽŶƐ͘/ŶƚŚĞŚĞĂƌƚ͕ƚŚŝƐŚĂƐƚŚĞĞĨĨĞĐƚŽĨĚĞĐƌĞĂƐŝŶŐĂƵƚŽŵĂƚŝĐŝƚǇĂŶĚĞǆĐŝƚĂďŝůŝƚǇ͕ ƚŚƵƐƐƵƉƉƌĞƐƐŝŶŐĞĐƚŽƉǇĂŶĚǀĞŶƚƌŝĐƵůĂƌĂƌƌŚǇƚŚŵŝĂƐ͘/ƚŚĂƐŵŝŶŝŵĂůĞĨĨĞĐƚƐŝŶƚŚĞĂƚƌŝĂĂŶĚĚŽĞƐŶŽƚ ƐŝŐŶŝĨŝĐĂŶƚůǇĂůƚĞƌĐŽŶĚƵĐƚŝŽŶŽƌĐŽŶƚƌĂĐƚŝůŝƚǇŝŶŚĞĂůƚŚǇŚĞĂƌƚƚŝƐƐƵĞ͘/ŶƚŚĞŶĞƌǀŽƵƐƐǇƐƚĞŵ͕ůŝĚŽĐĂŝŶĞ ĚĞĐƌĞĂƐĞƐŶĞƵƌŽŶĞǆĐŝƚĂďŝůŝƚǇĂŶĚƐůŽǁƐĐŽŶĚƵĐƚŝŽŶŽĨƐŝŐŶĂůƐ͕ǁŚŝĐŚƉƌŝŵĂƌŝůǇƌĞƐƵůƚƐŝŶĂĚĞĐƌĞĂƐĞŝŶ ƐĞŶƐĂƚŝŽŶĂŶĚƉĂŝŶǁŚĞŶĂĚŵŝŶŝƐƚĞƌĞĚŽƌĂƉƉůŝĞĚƉĞƌŝƉŚĞƌĂůůǇ͘ /ŶĚŝĐĂƚŝŽŶƐ x sĞŶƚƌŝĐƵůĂƌĨŝďƌŝůůĂƚŝŽŶŽƌǀĞŶƚƌŝĐƵůĂƌƚĂĐŚǇĐĂƌĚŝĂ x dŽƉƌĞǀĞŶƚƚŚĞƌĞĐƵƌƌĞŶĐĞŽĨǀĞŶƚƌŝĐƵůĂƌĨŝďƌŝůůĂƚŝŽŶŽƌǀĞŶƚƌŝĐƵůĂƌƚĂĐŚǇĐĂƌĚŝĂĂĨƚĞƌĐŽŶǀĞƌƐŝŽŶ͘ x dŽŵŝŶŝŵŝǌĞƉĂŝŶĂŶĚĚŝƐĐŽŵĨŽƌƚǁŚĞŶŝŶƐĞƌƚŝŶŐŶĂƐŽƉŚĂƌǇŶŐĞĂůĂŝƌǁĂǇ͕ŶĂƐŽŐĂƐƚƌŝĐƚƵďĞ͕ŽƌŶĂƐĂů ŝŶƚƵďĂƚŝŽŶ͘ ŽŶƚƌĂŝŶĚŝĐĂƚŝŽŶƐ x <ŶŽǁŶŚǇƉĞƌƐĞŶƐŝƚŝǀŝƚǇ x ϮqŽƌϯqs x ^ŝŶƵƐďƌĂĚǇĐĂƌĚŝĂŽƌƐŝŶƵƐĂƌƌĞƐƚ x /ĚŝŽǀĞŶƚƌŝĐƵůĂƌƌŚǇƚŚŵ ^ŝĚĞĨĨĞĐƚƐ x ƵĞƚŽŝƚƐŵĞĐŚĂŶŝƐŵŽĨĂĐƚŝŽŶ͕ůŝĚŽĐĂŝŶĞŵĂǇĐĂƵƐĞĂĨĂůůŝŶĐĂƌĚŝĂĐŽƵƚƉƵƚĂŶĚďͬƉĂŶĚǁŚĞŶŐŝǀĞŶ ŝŶŚŝŐŚĚŽƐĞƐ͕ĞƐƉĞĐŝĂůůǇƚŽƚŚĞĞůĚĞƌůǇŽƌƉĂƚŝĞŶƚƐŝŶŚĞĂƌƚĨĂŝůƵƌĞ͕ŵĂǇĐĂƵƐĞƐĞŝǌƵƌĞͲůŝŬĞĂĐƚŝǀŝƚǇ ŽƐĂŐĞΘĚŵŝŶŝƐƚƌĂƚŝŽŶ x Initial Bolus͗ϭ͘ϬͲϭ͘ϱŵŐͬŬŐ/sͬ/K x Subsequent Bolus͗Ϭ͘ϱͲϬ͘ϳϱŵŐͬŬŐ/sͬ/K͕Dy͗ϯŵŐͬŬŐ x Adult Infusion͗Ϯ͘ϬͲϰ͘ϬŵŐͬŵŝŶ x Pediatric Infusion͗ϮϬͲϱϬŵĐŐͬŬŐͬŵŝŶ/sŝŶĨƵƐŝŽŶƵƉŽŶƚĞƌŵŝŶĂƚŝŽŶŽĨĚǇƐƌŚǇƚŚŵŝĂ x Topical: Ϯй:ĞůůǇŝŶϱŵůƉůĂƐƚŝĐƚƵďĞƐ͕ŵĂǆŽĨϮĨŽƌĂĚƵůƚƵƐĂŐĞ͕ϭĨŽƌƉĞĚŝĂƚƌŝĐƵƐĂŐĞ ^ƉĞĐŝĂůŽŶƐŝĚĞƌĂƚŝŽŶƐ x ZĞĚƵĐƚŝŽŶŽĨĚŽƐĂŐĞƐŚŽƵůĚďĞĐŽŶƐŝĚĞƌĞĚŝŶƉĂƚŝĞŶƚƐхϳϬǇͬŽ͕ƉĂƚŝĞŶƚƐƉƌĞƐĞŶƚŝŶŐǁŝƚŚpĐĂƌĚŝĂĐ ŽƵƚƉƵƚ;,&͕ƐŚŽĐŬͿ͕ŽƌƚŚŽƐĞǁŝƚŚůŝǀĞƌĚŝƐĞĂƐĞ͘

Cypress Creek EMS System Policies and Treatment Guidelines

356 MEDICATIONS Revised 8/2016 Approved: Levon Vartanian, MD

DĂŐŶĞƐŝƵŵ^ƵůĨĂƚĞ DĞĚŝĐĂƚŝŽŶ x ŶĞůĞĐƚƌŽůǇƚĞƐĂůƚƐŽůƵƚŝŽŶ DĞĐŚĂŶŝƐŵŽĨĐƚŝŽŶ x ĐŽĨĂĐƚŽƌŝŶŶƵŵĞƌŽƵƐĞŶǌǇŵĂƚŝĐƌĞĂĐƚŝŽŶƐĂŶĚŝƐĞƐƐĞŶƚŝĂůĨŽƌƚŚĞĨƵŶĐƚŝŽŶŽĨƚŚĞƐŽĚŝƵŵͲ ƉŽƚĂƐƐŝƵŵdWĂƐĞƉƵŵƉ͕ŝƚĂĐƚƐĂƐĂƉŚǇƐŝŽůŽŐŝĐĂůĐĂůĐŝƵŵĐŚĂŶŶĞůďůŽĐŬĞƌĂŶĚďůŽĐŬƐ ŶĞƵƌŽŵƵƐĐƵůĂƌƚƌĂŶƐŵŝƐƐŝŽŶ͘DĂŐŶĞƐŝƵŵƐƵůĨĂƚĞŝƐĂůƐŽĂƉŽƚĞŶƚƉĞƌŝƉŚĞƌĂůǀĂƐŽĚŝůĂƚŽƌ͘ /ŶĚŝĐĂƚŝŽŶƐ x ZĞĨƌĂĐƚŽƌǇs&/Žƌsd, x dŽƌƐĂĚĞƐͲĚĞͲWŽŝŶƚĞƐ x dŽǆĞŵŝĂŽĨƉƌĞŐŶĂŶĐǇ;ĞĐůĂŵƉƐŝĂͿ ŽŶƚƌĂŝŶĚŝĐĂƚŝŽŶƐ x EŽŶĞǁŚĞŶƵƐĞĚĂƐŝŶĚŝĐĂƚĞĚ ^ŝĚĞĨĨĞĐƚƐ x ĂƌĚŝŽǀĂƐĐƵůĂƌ͗ŚǇƉŽƚĞŶƐŝŽŶ͕ĐŝƌĐƵůĂƚŽƌǇĐŽůůĂƉƐĞ͕ŚĞĂƌƚďůŽĐŬ x WƵůŵŽŶĂƌǇ͗ƌĞƐƉŝƌĂƚŽƌǇƉĂƌĂůǇƐŝƐ x E^͗ĨůĂĐĐŝĚƉĂƌĂůǇƐŝƐ͕ĚĞƉƌĞƐƐĞĚƌĞĨůĞǆĞƐ x DĞƚĂďŽůŝĐ͗ŚǇƉŽĐĂůĐĞŵŝĂ x &ůƵƐŚŝŶŐ͕ƐǁĞĂƚŝŶŐ͕ŚǇƉŽƚŚĞƌŵŝĂ ŽƐĂŐĞΘĚŵŝŶŝƐƚƌĂƚŝŽŶ x ĂƌĚŝĂĐ͗1-2 grams/sͬ/K x KďƐƚĞƚƌŝĐ͗4 grams^>Kt/sͬ/K͕ŵĂǇƌĞƉĞĂƚŽŶĐĞ x WĞĚŝĂƚƌŝĐ͗25-50 mg/kg/sͬ/K͗ŵĂǆϮŐĨŽƌƌĞĨƌĂĐƚŽƌǇƐƚĂƚĞĂŶĚͬŽƌĨŽƌƚŽƌƐĂĚĞƐͲĚĞͲƉŽŝŶƚĞƐ͕ŵĂǇ ƌĞƉĞĂƚŽŶĐĞ ^ƉĞĐŝĂůŽŶƐŝĚĞƌĂƚŝŽŶƐ x ^ŝĚĞĞĨĨĞĐƚƐĂƌĞƵƐƵĂůůǇĨƌŽŵĂĚŵŝŶŝƐƚĞƌŝŶŐƚŽŽƌĂƉŝĚůǇ

Cypress Creek EMS System Policies and Treatment Guidelines

357 MEDICATIONS Revised 4/2018 Approved: Levon Vartanian, MD

DĞƉĞƌŝĚŝŶĞ,ů;ĞŵĞƌŽůͿ DĞĐŚĂŶŝƐŵŽĨĐƚŝŽŶ ZĞĚƵĐĞƐƉĂŝŶďǇĂĐƚŝŶŐŽŶʅͲŽƉŝŽŝĚƌĞĐĞƉƚŽƌƐ͘DĞƉĞƌŝĚŝŶĞŝƐĂƐǇŶƚŚĞƚŝĐŽƉŝŽŝĚĂŶĂůŐĞƐŝĐ͕ƐŝŵŝůĂƌƚŽ ŵŽƌƉŚŝŶĞďƵƚŽŶůǇĂďŽƵƚĂƚĞŶƚŚĂƐƉŽƚĞŶƚ͘ůƐŽŚĂƐůŝŵŝƚĞĚĂŶƚŝĐŚŽůŝŶĞƌŐŝĐĂŶĚůŽĐĂůĂŶĞƐƚŚĞƚŝĐĞĨĨĞĐƚƐ͘ KŶƐĞƚŽĨĂĐƚŝŽŶŝƐĂďŽƵƚĨŝǀĞŵŝŶƵƚĞƐ͘ƵƌĂƚŝŽŶŝƐĂďŽƵƚϮŚŽƵƌƐ͘ /ŶĚŝĐĂƚŝŽŶ x ^ĞǀĞƌĞƉĂŝŶĂƐƐŽĐŝĂƚĞĚǁŝƚŚĂĐƵƚĞƚƌĂƵŵĂ͕ƌĞŶĂůŽƌďŝůŝĂƌǇĐŽůŝĐ͕ĂŶĚĐĂŶĐĞƌ͘ ŽŶƚƌĂŝŶĚŝĐĂƚŝŽŶƐ x ,ǇƉĞƌƐĞŶƐŝƚŝǀŝƚǇƚŽŵĞƉĞƌŝĚŝŶĞ x WĂƚŝĞŶƚƐƚĂŬŝŶŐDKŝŶŚŝďŝƚŽƌƐ;ĂĐůĂƐƐŽĨĂŶƚŝĚĞƉƌĞƐƐĂŶƚƐͿǁŝƚŚŝŶƚŚĞƉĂƐƚϭϰĚĂǇƐ͕ŝŶĐůƵĚŝŶŐ ƉŚĞŶĞůǌŝŶĞ͕ƐĞůĞŐŝůŝŶĞ͕/ƐŽĐĂƌďŽǆĂǌŝĚ͕ĂŶĚƚƌĂŶǇůĐǇƉƌŽŵŝŶĞ x hƐĞǁŝƚŚĐĂƵƚŝŽŶŝŶƉĂƚŝĞŶƚƐǁŝƚŚĂƚƌŝĂůĨůƵƚƚĞƌŽƌƐƵƉƌĂǀĞŶƚƌŝĐƵůĂƌƚĂĐŚǇĐĂƌĚŝĂ ^ŝĚĞĨĨĞĐƚƐ x ZĞƐƉŝƌĂƚŽƌǇĚĞƉƌĞƐƐŝŽŶ x EĂƵƐĞĂ͕ǀŽŵŝƚŝŶŐ͕ĚŝǌǌŝŶĞƐƐ͕ƐĞĚĂƚŝŽŶ͕ĚŝĂƉŚŽƌĞƐŝƐ͕ƵƌŝŶĂƌǇƌĞƚĞŶƚŝŽŶ͕ĂŶĚĐŽŶƐƚŝƉĂƚŝŽŶ͘ x ,ǇƉŽƚĞŶƐŝŽŶ͕ƉĂƌƚŝĐƵůĂƌůǇŝŶƉĂƚŝĞŶƚƐǁŝƚŚƌĞĚƵĐĞďůŽŽĚǀŽůƵŵĞ ŽƐĂŐĞΘĚŵŝŶŝƐƚƌĂƚŝŽŶ x Adult͗ϮϱʹϱϬŵŐǀĞƌǇƐůŽǁ/sͬ/Kͬ/D͕ŵĂǇƌĞƉĞĂƚŽŶĐĞĂĨƚĞƌϭϱŵŝŶƵƚĞƐ͘ EŽƚƚŽĞǆĐĞĞĚϭϱϬŵŐĐƵŵƵůĂƚŝǀĞĚŽƐĞ͘ x Pediatric͗ϭŵŐͬŬŐǀĞƌǇƐůŽǁ/sͬ/Kͬ/D͕ŵĂǇƌĞƉĞĂƚŽŶĐĞĂĨƚĞƌϭϱŵŝŶƵƚĞƐ͘ EŽƚƚŽĞǆĐĞĞĚϮϱŵŐƐŝŶŐůĞĚŽƐĞ͘ ^ƉĞĐŝĂůŽŶƐŝĚĞƌĂƚŝŽŶƐ x hƐĞĂŚĂůĨĚŽƐĞ;ϭϮ͘ϱʹϮϱŵŐͿŝŶĞůĚĞƌůǇƉĂƚŝĞŶƚƐĂŶĚĂĚƵůƚƉĂƚŝĞŶƚƐǁŝƚŚƌĞŶĂůĨĂŝůƵƌĞ͘ x &Žƌ/sĂŶĚ/KĂĚŵŝŶŝƐƚƌĂƚŝŽŶ͕ĚŝůƵƚĞĚŽƐĂŐĞŝŶĂƚůĞĂƐƚϭϬŵ>ŽĨŶŽƌŵĂůƐĂůŝŶĞĂŶĚĂĚŵŝŶŝƐƚĞƌƐůŽǁůǇ͘ x ^ŝŐŶŝĨŝĐĂŶƚƌĞƐƉŝƌĂƚŽƌǇĚĞƉƌĞƐƐŝŽŶĐĂŶŽĐĐƵƌĂƚůŽǁƚŽŶŽƌŵĂůĚŽƐĞƐ͖ƉĂƚŝĞŶƚƐŵƵƐƚŚĂǀĞdKϮ͕ ^ƉKϮ͕ĂŶĚ'ŵŽŶŝƚŽƌĞĚĐŽŶƚŝŶƵŽƵƐůǇĂŶĚƚŚĞĂďŝůŝƚǇƚŽĚĞůŝǀĞƌƐƵƉƉůĞŵĞŶƚĂůŽǆǇŐĞŶ͕ĂƐƐŝƐƚĞĚ ǀĞŶƚŝůĂƚŝŽŶƐ͕ĂŶĚŶĂůŽǆŽŶĞŵƵƐƚďĞĂǀĂŝůĂďůĞ͘ x ^ĞƌŽƚŽŶŝŶƐǇŶĚƌŽŵĞŵĂǇŽĐĐƵƌŝĨƉĂƚŝĞŶƚƐĂƌĞĂůƐŽƚĂŬŝŶŐĚƌƵŐƐƚŚĂƚĂĨĨĞĐƚƐĞƌŽƚŽŶŝŶŵĞƚĂďŽůŝƐŵ͘ ^ĞƌŽƚŽŶŝŶƐǇŶĚƌŽŵĞŽĐĐƵƌƐǁŚĞŶŵƵůƚŝƉůĞƐĞƌŽƚŽŶŝŶͲƉƌŽĚƵĐŝŶŐŵĞĚŝĐĂƚŝŽŶƐŝŶƚĞƌĂĐƚƚŽŝŶĐƌĞĂƐĞ ĐŝƌĐƵůĂƚŝŶŐƐĞƌŽƚŽŶŝŶƚŽƚŽǆŝĐůĞǀĞůƐ͘dŚŝƐƚǇƉŝĐĂůůǇƉƌĞƐĞŶƚƐǁŝƚŚƐǇŵƉƚŽŵƐƐƵĐŚĂƐ͗ o Cognitive changesƐƵĐŚĂƐĂŐŝƚĂƚŝŽŶŽƌŵĞŶƚĂůƐƚĂƚƵƐĐŚĂŶŐĞƐ͘ o Neuromuscular symptoms ƐƵĐŚĂƐŵƵƐĐůĞƐƉĂƐŵƐ͕ƚƌĞŵŽƌƐ͕ƌŝŐŝĚŝƚǇ͕ŽƌĂƚĂǆŝĂ͘ o Autonomic nervous symptomsƐƵĐŚĂƐĨĞǀĞƌ͕ƚĂĐŚǇĐĂƌĚŝĂ͕ďůŽŽĚƉƌĞƐƐƵƌĞĐŚĂŶŐĞƐ͕ ŚǇƉĞƌƚŚĞƌŵŝĂ͕ŽƌĚŝůĂƚĞĚƉƵƉŝůƐ͘ o WƌĞŚŽƐƉŝƚĂůƚƌĞĂƚŵĞŶƚĨŽƌƐĞƌŽƚŽŶŝŶƐǇŶĚƌŽŵĞĐŽŶƐŝƐƚƐŽĨƐƵƉƉŽƌƚŝǀĞĐĂƌĞĂŶĚƚƌĂŶƐƉŽƌƚƚŽ ŚŽƐƉŝƚĂů͖ĞŶƐƵƌĞƐǇŵƉƚŽŵƐĂŶĚŵĞĚŝĐĂƚŝŽŶƐĂƌĞĂĐĐƵƌĂƚĞůǇƌĞƉŽƌƚĞĚƚŽŚŽƐƉŝƚĂůƐƚĂĨĨ͘

Cypress Creek EMS System Policies and Treatment Guidelines

358 MEDICATIONS Revised 8/2016 Approved: Levon Vartanian, MD

DĞƚŚǇůƉƌĞĚŶŝƐŽůŽŶĞ;^ŽůƵͲDĞĚƌŽůͿ DĞĚŝĐĂƚŝŽŶ ŐůƵĐŽĐŽƌƚŝĐŽŝĚŵĞĚŝĐĂƚŝŽŶ͕ƵƐĞĚƉƌŝŵĂƌŝůǇƚŽƚƌĞĂƚƐĞǀĞƌĞĂůůĞƌŐŝĐƌĞĂĐƚŝŽŶŽƌƌĞƐƉŝƌĂƚŽƌǇĚŝƐƚƌĞƐƐ͘ DĞĐŚĂŶŝƐŵŽĨĐƚŝŽŶ /ŶŚŝďŝƚƐŝŶĨůĂŵŵĂƚŽƌǇƌĞƐƉŽŶƐĞŽĨƚŝƐƐƵĞƐĚƵĞƚŽŵĞĐŚĂŶŝĐĂů͕ĐŚĞŵŝĐĂů͕ŝŶĨĞĐƚŝŽƵƐ͕ŝŶĨůĂŵŵĂƚŽƌǇ͕Žƌ ŽƚŚĞƌĐĂƵƐĞƐ͕ƉƌĞƐĞƌǀĞƐƚŚĞŝŶƚĞŐƌŝƚǇŽĨƐŵĂůůďůŽŽĚǀĞƐƐĞůƐŝŶƐŚŽĐŬƐƚĂƚĞƐ͕ŝŶĐƌĞĂƐĞĐĂƌĚŝĂĐŽƵƚƉƵƚ͕ĂŶĚ ƐƚĂďŝůŝǌĞƐĐĞůůƵůĂƌŵĞŵďƌĂŶĞƐ͘ǇƌĞĚƵĐŝŶŐŝŶĨůĂŵŵĂƚŝŽŶĂŶĚƚŚĞƌĞůĞĂƐĞŽĨŚŝƐƚĂŵŝŶĞƐĂŶĚĐǇƚŽŬŝŶĞƐ͕ ŵĞƚŚǇůƉƌĞĚŶŝƐŽůŽŶĞƌĞĚƵĐĞƐƌĞďŽƵŶĚŽƌƌĞĐƵƌƌŝŶŐĞǆĂĐĞƌďĂƚŝŽŶŽĨďƌŽŶĐŚŽĐŽŶƐƚƌŝĐƚŝǀĞĐŽŶĚŝƚŝŽŶƐ͘ /ŶĚŝĐĂƚŝŽŶƐ x ŶĂƉŚǇůĂĐƚŝĐƐŚŽĐŬͬĂůůĞƌŐŝĐƌĞĂĐƚŝŽŶ x ƐƚŚŵĂ x KW ŽŶƚƌĂŝŶĚŝĐĂƚŝŽŶƐ x <ŶŽǁŶŚǇƉĞƌƐĞŶƐŝƚŝǀŝƚǇ x ůŽƐĞĚŚĞĂĚŝŶũƵƌǇŽƌĐĞƌĞďƌŽǀĂƐĐƵůĂƌĂĐĐŝĚĞŶƚ ^ŝĚĞĨĨĞĐƚƐ x EĞƵƌŽůŽŐŝĐĂůĨŝŶĚŝŶŐƐŵĂǇďĞĂĨĨĞĐƚĞĚďǇƚŚĞĂĚŵŝŶŝƐƚƌĂƚŝŽŶŽĨ^ŽůƵͲDĞĚƌŽů ŽƐĂŐĞΘĚŵŝŶŝƐƚƌĂƚŝŽŶ x Adult͗ϭϮϱŵŐ^>Kt/sŽƌ/D x Pediatric͗Ϯ͘ϬŵŐͬŬŐ^>Kt/sŽƌ/D ^ƉĞĐŝĂůŽŶƐŝĚĞƌĂƚŝŽŶƐ x ŽĐƵŵĞŶƚĂƚŝŽŶŽĨŶĞƵƌŽůŽŐŝĐĂůƐƚĂƚƵƐŝƐĞƐƐĞŶƚŝĂůƉƌŝŽƌƚŽĂĚŵŝŶŝƐƚƌĂƚŝŽŶ͘ x ĐƚͲKͲsŝĂůƵƐĞ͗ o WƌĞƐƐĚŽǁŶƚŚĞƉůĂƐƚŝĐĂĐƚŝǀĂƚŽƌƚŽĨŽƌĐĞĚŝůƵĞŶƚŝŶƚŽƚŚĞůŽǁĞƌĐŽŵƉĂƌƚŵĞŶƚ͘ o 'ĞŶƚůǇĂŐŝƚĂƚĞƚŽĞĨĨĞĐƚƐŽůƵƚŝŽŶ͘ o ZĞŵŽǀĞƉůĂƐƚŝĐƚĂďĐŽǀĞƌŝŶŐĐĞŶƚĞƌŽĨƐƚŽƉƉĞƌ͘ o ^ƚĞƌŝůŝǌĞƚŽƉŽĨƐƚŽƉƉĞƌǁŝƚŚĂƐƵŝƚĂďůĞŐĞƌŵŝĐŝĚĞ͘ o /ŶƐĞƌƚŶĞĞĚůĞƐƋƵĂƌĞůǇƚŚƌŽƵŐŚƚŚĞĐĞŶƚĞƌŽĨƐƚŽƉƉĞƌƵŶƚŝůƚŝƉŝƐũƵƐƚǀŝƐŝďůĞ͘ o /ŶǀĞƌƚǀŝĂůĂŶĚǁŝƚŚĚƌĂǁĚŽƐĞ͘

Cypress Creek EMS System Policies and Treatment Guidelines

359 MEDICATIONS Revised 2/2017 Approved: Levon Vartanian, MD

DĞƚŽĐůŽƉƌĂŵŝĚĞ;ZĞŐůĂŶͿ DĞĚŝĐĂƚŝŽŶ ŶƚŝĞŵĞƚŝĐ͗ůŽĐŬƐĚŽƉĂŵŝŶĞƌĞĐĞƉƚŽƌƐŝŶƚŚĞE^ǀŽŵŝƚŝŶŐĐŚĞŵŽƌĞĐĞƉƚŽƌƚƌŝŐŐĞƌƐǇƐƚĞŵ͘ DĞĐŚĂŶŝƐŵŽĨĐƚŝŽŶ

DĞƚŽĐůŽƉƌĂŵŝĚĞďůŽĐŬƐĚŽƉĂŵŝŶĞϮƌĞĐĞƉƚŽƌƐĂƐǁĞůůĂƐůŝŵŝƚĞĚďůŽĐŬŝŶŐŽĨƐĞƌŽƚŽŶŝŶƌĞĐĞƉƚŽƌƐŝŶƚŚĞ ĐŚĞŵŽƌĞĐĞƉƚŽƌƚƌŝŐŐĞƌƐǇƐƚĞŵ͕ƚŚƵƐƉƌĞǀĞŶƚŝŶŐŶĂƵƐĞĂĂŶĚǀŽŵŝƚŝŶŐĨƌŽŵďĞŝŶŐƚƌŝŐŐĞƌĞĚďǇŵŽƐƚ ƐƚŝŵƵůŝ͘DĞƚŽĐůŽƉƌĂŵŝĚĞĂůƐŽŝŶĐƌĞĂƐĞƐŶŽƌŵĂů'/ŵŽǀĞŵĞŶƚ͘

KŶƐĞƚŽĨĂĐƚŝŽŶŝƐϭƚŽϯŵŝŶƵƚĞƐ͘DĞĚŝĐĂƚŝŽŶŚĂůĨͲůŝĨĞŝƐϱʹϲŚŽƵƌƐ͘ /ŶĚŝĐĂƚŝŽŶƐ x sŽŵŝƚŝŶŐ ŽŶƚƌĂŝŶĚŝĐĂƚŝŽŶƐ x <ŶŽǁŶŚǇƉĞƌƐĞŶƐŝƚŝǀŝƚǇ x '/ŚĞŵŽƌƌŚĂŐĞ͕'/ŽďƐƚƌƵĐƚŝŽŶ͕'/ƉĞƌĨŽƌĂƚŝŽŶ;ŝŶĐƌĞĂƐĞƐŐĂƐƚƌŝĐŵŽǀĞŵĞŶƚͿ x WŚĞŽĐŚƌŽŵĂĐǇƚŽŵĂ;ŵĂǇĐĂƵƐĞŚǇƉĞƌƚĞŶƐŝǀĞĐƌŝƐŝƐͿ x WĞĚŝĂƚƌŝĐƉĂƚŝĞŶƚƐůĞƐƐƚŚĂŶϱǇĞĂƌƐŽůĚ ^ŝĚĞĨĨĞĐƚƐ x ŽŵŵŽŶƐŝĚĞĞĨĨĞĐƚƐŝŶĐůƵĚĞƌĞƐƚůĞƐƐŶĞƐƐ͕ĨĂƚŝŐƵĞ͕ĚŝǌǌŝŶĞƐƐ͕ŽƌĞǆŚĂƵƐƚŝŽŶ x ZĂƌĞƐŝĚĞĞĨĨĞĐƚƐŝŶĐůƵĚĞŚĞĂĚĂĐŚĞ͕ĐŽŶĨƵƐŝŽŶ͕ĂďŶŽƌŵĂůŵƵƐĐůĞŵŽǀĞŵĞŶƚƐ͕ĂŶĚĚĞƉƌĞƐƐŝŽŶ x ǆƚƌĂƉǇƌĂŵŝĚĂůƐǇŵƉƚŽŵƐĂŶĚĚǇƐƚŽŶŝĐƌĞĂĐƚŝŽŶƐŚĂǀĞďĞĞŶŶŽƚĞĚŚŽƵƌƐƚŽĚĂǇƐĂĨƚĞƌƚƌĞĂƚŵĞŶƚ͕ ĞƐƉĞĐŝĂůůǇŝŶƉĂƚŝĞŶƚƐǁŝƚŚĂŚŝƐƚŽƌǇŽĨĞƉŝůĞƉƐǇŽƌƌĞĐĞŝǀŝŶŐŵĞĚŝĐĂƚŝŽŶƐƚŚĂƚĐĂƵƐĞĞǆƚƌĂƉǇƌĂŵŝĚĂů ƐǇŵƉƚŽŵƐ͕ƐƵĐŚĂƐƉŚĞŶŽƚŚŝĂǌŝŶĞƐ͕ŚĂůŽƉĞƌŝĚŽů͕ƐĞƌƚƌĂůŝŶĞ;ŽůŽĨƚͿ͕ĂŶĚ^^Z/Ɛ͘ ŽƐĂŐĞΘĚŵŝŶŝƐƚƌĂƚŝŽŶ Adults:ϭϬŵŐƐůŽǁ/sƉƵƐŚŽŶĞƚŝŵĞ

Pediatric: Ϯ͘ϱʹϱŵŐƐůŽǁ/sƉƵƐŚŽŶĞƚŝŵĞ͘ŽŶŽƚĂĚŵŝŶŝƐƚĞƌƚŽĐŚŝůĚƌĞŶůĞƐƐƚŚĂŶϱǇĞĂƌƐŽůĚ͘ ^ƉĞĐŝĂůŽŶƐŝĚĞƌĂƚŝŽŶƐ x ĚŵŝŶŝƐƚĞƌŝŶŐŵĞƚŽĐůŽƉƌĂŵŝĚĞƚŽŽƋƵŝĐŬůǇŝŶĐƌĞĂƐĞƐƚŚĞƐŝĚĞĞĨĨĞĐƚƐŽĨĂŶǆŝĞƚǇ͕ƌĞƐƚůĞƐƐŶĞƐƐ͕ĂŶĚ ĚƌŽǁƐŝŶĞƐƐ͘ x &ƌĞƋƵĞŶƚ͕ůŽŶŐͲƚĞƌŵƵƐĞ;ŐƌĞĂƚĞƌƚŚĂŶƚŚƌĞĞŵŽŶƚŚƐͿŽĨŵĞƚŽĐůŽƉƌĂŵŝĚĞĐĂŶĐĂƵƐĞƚĂƌĚŝǀĞ ĚǇƐŬŝŶĞƐŝĂ͘dŚŝƐŝƐŶŽƚĂƐŝŐŶŝĨŝĐĂŶƚƌŝƐŬŝŶƚŚĞƉƌĞŚŽƐƉŝƚĂůĐĂƌĞƐĞƚƚŝŶŐďƵƚƉƌŽǀŝĚĞƌƐƐŚŽƵůĚďĞĂǁĂƌĞ͘ x hƐĞŚĂůĨͲĚŽƐĞƐŝŶŐĞƌŝĂƚƌŝĐĂŶĚƉĞĚŝĂƚƌŝĐƉĂƚŝĞŶƚƐ͘ x dƌĞĂƚĚǇƐƚŽŶŝĐƌĞĂĐƚŝŽŶƐƵƐŝŶŐDiphenhydramine 50 mg IV/IM x dŚĞƌĞĂƌĞƌĂƌĞŽĐĐƵƌƌĞŶĐĞƐŽĨneuroleptic malignant syndromeǁŝƚŚƐǇŵƉƚŽŵƐŽĨŚǇƉĞƌƚŚĞƌŵŝĂ͕ ĂůƚĞƌĞĚŵĞŶƚĂůƐƚĂƚƵƐ͕ĂŶĚŵƵƐĐůĞƌŝŐŝĚŝƚǇ͘/ĨƚŚŝƐŽĐĐƵƌƐ͕ƉƌŽǀŝĚĞƐƵƉƉŽƌƚŝǀĞĐĂƌĞ͕ŶŽƚŝĨǇƚŚĞ ŚŽƐƉŝƚĂů͕ĂŶĚƉƌŽǀŝĚĞƌĂƉŝĚƚƌĂŶƐƉŽƌƚ͘

Cypress Creek EMS System Policies and Treatment Guidelines

360 MEDICATIONS Revised 8/2016 Approved: Levon Vartanian, MD

DĞƚŽƉƌŽůŽů;>ŽƉƌĞƐƐŽƌͿ DĞĚŝĐĂƚŝŽŶ ĞƚĂďůŽĐŬĞƌ DĞĐŚĂŶŝƐŵŽĨĐƚŝŽŶ DĞƚŽƉƌŽůŽůǁŽƌŬƐďǇďůŽĐŬŝŶŐƚŚĞďĞƚĂĂĚƌĞŶĞƌŐŝĐƌĞĐĞƉƚŽƌƐƚŚĞƌĞďǇĚĞƉƌĞƐƐŝŶŐƚŚĞƉƵŵƉŝŶŐĨƵŶĐƚŝŽŶ ŽĨƚŚĞŚĞĂƌƚǁŚŝĐŚƌĞƐƵůƚƐŝŶĂĚĞĐƌĞĂƐĞĚďůŽŽĚƉƌĞƐƐƵƌĞĂŶĚŚĞĂƌƚƌĂƚĞ͘ /ŶĚŝĐĂƚŝŽŶƐ x &ŝƌƐƚůŝŶĞŵĞĚŝĐĂƚŝŽŶĨŽƌŚǇƉĞƌƚĞŶƐŝŽŶƌĞůĂƚĞĚƚŽs͕ĂůƚĞƌŶĂƚŝǀĞŵĞĚŝĐĂƚŝŽŶĨŽƌŚǇƉĞƌƚĞŶƐŝǀĞĐƌŝƐŝƐ͕ ǁŚĞŶŶŝƚƌĂƚĞƐĂƌĞĐŽŶƚƌĂŝŶĚŝĐĂƚĞĚ x ^dD/ƉĂƚŝĞŶƚƐŐŽŝŶŐƚŽƚŚĞĂƚŚ>ĂďƚŚĂƚĂƌĞŚǇƉĞƌƚĞŶƐŝǀĞ;ŝĨĐŽŶƚŝŶƵĞĚŚǇƉĞƌƚĞŶƐŝŽŶĂĨƚĞƌEd' ĂĚŵŝŶŝƐƚƌĂƚŝŽŶͿ ŽŶƚƌĂŝŶĚŝĐĂƚŝŽŶƐ

x ,ĞĂƌƚƌĂƚĞůĞƐƐƚŚĂŶϳϬ x ^ǇƐƚŽůŝĐďůŽŽĚƉƌĞƐƐƵƌĞůĞƐƐƚŚĂŶϭϬϬŵŵ,Ő x WƌĞƐĞŶĐĞŽĨsŚĞĂƌƚďůŽĐŬ x WƵůŵŽŶĂƌǇĞĚĞŵĂĂƐĞǀŝĚĞŶĐĞĚďǇĐƌĂĐŬůĞƐ ^ŝĚĞĨĨĞĐƚƐ x ƌĂĚǇĐĂƌĚŝĂ x ,ǇƉŽƚĞŶƐŝŽŶ ŽƐĂŐĞΘĚŵŝŶŝƐƚƌĂƚŝŽŶ Hypertensive Crisis

x 5 mgƐůŽǁ/s͕ŽǀĞƌϭƚŽϮŵŝŶƵƚĞƐ;ŵĂǇƌĞƉĞĂƚŽŶĐĞŝŶϭϬƚŽϭϱŵŝŶƵƚĞƐŝĨWƌĞŵĂŝŶƐхϭϴϬŵŵͬ,Ő ƐǇƐƚŽůŝĐĂŶĚͬŽƌϭϭϬŵŵͬ,ŐĚŝĂƐƚŽůŝĐͿ Cath Alert (hypertensive patients only)

x 5 mgƐůŽǁ/s͕ŵĂǇƌĞƉĞĂƚǆϭŝŶϭϬŵŝŶƵƚĞƐ͕ŝĨŶŽƚĐŽŶƚƌĂŝŶĚŝĐĂƚĞĚ

Cypress Creek EMS System Policies and Treatment Guidelines

361 MEDICATIONS Revised 8/2018 Approved: Levon Vartanian, MD

DŝĚĂǌŽůĂŵ;sĞƌƐĞĚͿ DĞĚŝĐĂƚŝŽŶ WŽƚĞŶƚďĞŶǌŽĚŝĂǌĞƉŝŶĞƐĞĚĂƚŝǀĞͬŚǇƉŶŽƚŝĐ͕ǁŝƚŚƐŝŐŶŝĨŝĐĂŶƚE^ĚĞƉƌĞƐƐĂŶƚ͕ƌĞƐƉŝƌĂƚŽƌǇĚĞƉƌĞƐƐĂŶƚ͕ĂŶĚ ĂŵŶĞƐƚŝĐƉƌŽƉĞƌƚŝĞƐ͘ DĞĐŚĂŶŝƐŵŽĨĐƚŝŽŶ DŝĚĂǌŽůĂŵĞŶŚĂŶĐĞƐƚŚĞĂĐƚŝŽŶŽĨƚŚĞŝŶŚŝďŝƚŽƌǇŶĞƵƌŽƚƌĂŶƐŵŝƚƚĞƌ'ďǇĂĐƚŝŶŐĂƚƚŚĞ' ƌĞĐĞƉƚŽƌ͘ /ŶĚŝĐĂƚŝŽŶƐ x ^ĞŝǌƵƌĞƐ x ^ĞĚĂƚŝŽŶĨŽƌĞůĞĐƚƌŝĐĂůƚŚĞƌĂƉǇ͕ƌĞƐƚƌĂŝŶƚ͕ŽƌĂŝƌǁĂǇŵĂŶĂŐĞŵĞŶƚ͘ ŽŶƚƌĂŝŶĚŝĐĂƚŝŽŶƐ x <ŶŽǁŶŚǇƉĞƌƐĞŶƐŝƚŝǀŝƚǇ x ,ǇƉŽƚĞŶƐŝŽŶ;^WфϭϬϬŵŵ,ŐŝŶĂĚƵůƚƐ͕фϵϬŝŶƉĞĚŝĂƚƌŝĐƐͿ ^ŝĚĞĨĨĞĐƚƐ x ƌŽǁƐŝŶĞƐƐͬƐĞĚĂƚŝŽŶͬŚǇƉŶŽƐŝƐ x ,ǇƉŽƚĞŶƐŝŽŶ x ZĞƐƉŝƌĂƚŽƌǇĚĞƉƌĞƐƐŝŽŶ ŽƐĂŐĞĂŶĚĚŵŝŶŝƐƚƌĂƚŝŽŶ Seizures: ĚƵůƚ͗1–2 mg/sͬ/EŽƌϱŵŐ/D͘ZĞƉĞĂƚĞǀĞƌǇϱŵŝŶƵƚĞƐĂƐŶĞĞĚĞĚ͘ WĞĚŝĂƚƌŝĐ͗0.05–0.1 mg/kg/sͬ/Dͬ/Eͬ/K͘ZĞƉĞĂƚĞǀĞƌǇϱŵŝŶƵƚĞƐĂƐŶĞĞĚĞĚ͘ Excited ĚƵůƚ͗ 5 mg/Dͬ/E͕ŵĂǇƌĞƉĞĂƚŽŶĐĞ͘ Delirium: /ĨŶŽƚƌĂƉŝĚůǇĞĨĨĞĐƚŝǀĞĂƚƐĞĚĂƚŝŶŐƉĂƚŝĞŶƚ͕ĐŽŶƐŝĚĞƌKetamine͘ Sedation: ĚƵůƚ͗1–2 mgŝŶĐƌĞŵĞŶƚƐ/sͬ/Dͬ/EƚŝƚƌĂƚĞĚƚŽĚĞƐŝƌĞĚƐĞĚĂƚŝŽŶ͘ WĞĚŝĂƚƌŝĐ͗0.05–0.1 mg/kg/sͬ/Dͬ/Eͬ/KƚŝƚƌĂƚĞĚƚŽĚĞƐŝƌĞĚƐĞĚĂƚŝŽŶ͘ ŽŶŽƚĞǆĐĞĞĚϬ͘ϭŵŐͬŬŐƉĞƌĚŽƐĞŽƌĐŽŶƚŝŶƵĞĂĚŵŝŶŝƐƚƌĂƚŝŽŶŝĨ^WфϵϬŵŵ,Ő͘ ^ƉĞĐŝĂůŽŶƐŝĚĞƌĂƚŝŽŶƐ x DŽŶŝƚŽƌǀŝƚĂůƐŝŐŶƐĐůŽƐĞůǇĂŶĚǁĂƚĐŚĨŽƌĐůŝŶŝĐĂůůǇƐŝŐŶŝĨŝĐĂŶƚŚǇƉŽƚĞŶƐŝŽŶ;ŝ͘Ğ͘^WфϭϬϬŵŵ,ŐĨŽƌƉͿ͘ x ĚŵŝŶŝƐƚĞƌŝŶŐĂďĞŶǌŽĚŝĂǌĞƉŝŶĞŝŶĐŽŶũƵŶĐƚŝŽŶǁŝƚŚĂŶĂƌĐŽƚŝĐƉĂŝŶƌĞůŝĞǀĞƌĚƵƌŝŶŐƉĂƚŝĞŶƚĐĂƌĞ ƐŚŽƵůĚďĞĂǀŽŝĚĞĚ͕ŝĨƉŽƐƐŝďůĞ͕ĂƐƚŚĞŝŶĐŝĚĞŶĐĞĨŽƌƌĞƐƉŝƌĂƚŽƌǇĚĞƉƌĞƐƐŝŽŶĂŶĚͬŽƌŵĞŶƚĂůƐƚĂƚƵƐ ĚĞƚĞƌŝŽƌĂƚŝŽŶŝƐůŝŬĞůǇ͕ĚƵĞƚŽƚŚĞƉŽƚĞŶƚŝĂƚŝŶŐĞĨĨĞĐƚƐŽĨƚŚĞƐĞŵĞĚŝĐĂƚŝŽŶƐ͘ x ĞŶǌŽĚŝĂǌĞƉŝŶĞƐŵĂǇĐĂƵƐĞƌĞƐƉŝƌĂƚŽƌǇĚĞƉƌĞƐƐŝŽŶĂŶĚͬŽƌĂŝƌǁĂǇĐŽŵƉƌŽŵŝƐĞ͘ŝƌǁĂǇŵĂŶĂŐĞŵĞŶƚ ĞƋƵŝƉŵĞŶƚŵƵƐƚďĞƌĞĂĚŝůǇĂǀĂŝůĂďůĞ͘

Cypress Creek EMS System Policies and Treatment Guidelines

362 MEDICATIONS Revised 8/2016 Approved: Levon Vartanian, MD

DŽƌƉŚŝŶĞ^ƵůĨĂƚĞ DĞĚŝĐĂƚŝŽŶ ƉŽƚĞŶƚŶĂƌĐŽƚŝĐ͕ĂŶĂůŐĞƐŝĐĚƌƵŐƚŚĂƚŝƐĚĞƌŝǀĞĚĨƌŽŵŽƉŝƵŵ;ƉŽƉƉǇͿ͘ DĞĐŚĂŶŝƐŵŽĨĐƚŝŽŶ dŚĞƌĂƉĞƵƚŝĐĂĐƚŝŽŶƐĂƌĞĂŶĂůŐĞƐŝĂĂŶĚƐĞĚĂƚŝŽŶ͘DŽƌƉŚŝŶĞŝƐĂŶŽƉŝŽŝĚĂŐŽŶŝƐƚ͘ /ŶĚŝĐĂƚŝŽŶƐ x /ƐĐŚĞŵŝĐĐŚĞƐƚƉĂŝŶͬĂŶǆŝĞƚǇ x WĂŝŶ ŽŶƚƌĂŝŶĚŝĐĂƚŝŽŶƐ x <ŶŽǁŶŚǇƉĞƌƐĞŶƐŝƚŝǀŝƚǇ x ,ǇƉŽƚĞŶƐŝŽŶ ĂƵƚŝŽŶƐ x ,ĞĂĚŝŶũƵƌǇ͕ĞůĞǀĂƚĞĚ/W͕ŽƌƐƵƐƉĞĐƚĞĚE^ƉĂƚŚŽůŽŐǇ͘ x ZĞƐƉŝƌĂƚŽƌǇĚĞƉƌĞƐƐŝŽŶ͕ŚǇƉŽǆŝĂ͕ĂŶĚͬŽƌďƌŽŶĐŚŽĐŽŶƐƚƌŝĐƚŝŽŶ͘ x hƐĞǁŝƚŚĐĂƵƚŝŽŶĂŶĚŝŶƌĞĚƵĐĞĚĚŽƐĂŐĞƐŝŶƚŚĞƉƌĞƐĞŶĐĞŽĨŽƚŚĞƌE^ĚĞƉƌĞƐƐĂŶƚƐŝŶĐůƵĚŝŶŐ͕ďƵƚ ŶŽƚůŝŵŝƚĞĚƚŽƚƌŝĐǇĐůŝĐĂŶƚŝĚĞƉƌĞƐƐĂŶƚƐ͕ƚƌĂŶƋƵŝůŝǌĞƌƐ͕ďĂƌďŝƚƵƌĂƚĞƐ͕ĂŶĚĂůĐŽŚŽů͘ ^ŝĚĞĨĨĞĐƚƐ x DĂǇƉƌŽĚƵĐĞƐĞǀĞƌĞŚǇƉŽƚĞŶƐŝŽŶďǇĐĂƵƐŝŶŐƉĞƌŝƉŚĞƌĂůǀĂƐŽĚŝůĂƚŝŽŶĂŶĚĂĚƌŽƉŝŶƉƌĞůŽĂĚ͘ x ĚŵŝŶŝƐƚƌĂƚŝŽŶŵĂǇƉƌŽĚƵĐĞŽƌƚŚŽƐƚĂƚŝĐŚǇƉŽƚĞŶƐŝŽŶŝŶĂŵďƵůĂƚŽƌǇƉĂƚŝĞŶƚƐ x ĞĐƌĞĂƐĞƐƚŚĞĐŽƵŐŚƌĞĨůĞǆĂŶĚ x ŽŶƐƚƌŝĐƚƐƉƵƉŝůƐ x DĂǇƉƌĞĐŝƉŝƚĂƚĞůŝŐŚƚŚĞĂĚĞĚŶĞƐƐ͕ǀĞƌƚŝŐŽ͕ŶĂƵƐĞĂ͕ǀŽŵŝƚŝŶŐ͕ĂŶĚƐǁĞĂƚŝŶŐ x ĂƌĚŝŽǀĂƐĐƵůĂƌƌĞĂĐƚŝŽŶƐŵĂǇŝŶĐůƵĚĞƚĂĐŚǇĐĂƌĚŝĂ͕ďƌĂĚǇĐĂƌĚŝĂ͕ƉĂůƉŝƚĂƚŝŽŶƐ͕ĨĂŝŶƚŶĞƐƐ͕ƐǇŶĐŽƉĞ͕ĂŶĚ ŽƌƚŚŽƐƚĂƚŝĐŚǇƉŽƚĞŶƐŝŽŶ͘ ŽƐĂŐĞΘĚŵŝŶŝƐƚƌĂƚŝŽŶ x Adult:Ϯ͘ϬͲϱ͘ϬŵŐ^ůŽǁ/sŽƌ/DĂƐŶĞĞĚĞĚ͕ĚŽŶŽƚĞǆĐĞĞĚϭϱŵŐƚŽƚĂů x Pediatric͗Ϭ͘ϬϱͲϬ͘ϭŵŐͬŬŐ^ůŽǁ/sŽƌ/D͕ŵĂǇƌĞƉĞĂƚĂƐŶĞĞĚĞĚĂƚŚĂůĨƚŚĞŝŶŝƚŝĂůĚŽƐĞ ^ƉĞĐŝĂůŽŶƐŝĚĞƌĂƚŝŽŶƐ x ZĂƉŝĚŝŶĨƵƐŝŽŶŝŶĐƌĞĂƐĞƐƚŚĞŝŶĐŝĚĞŶĐĞŽĨĂĚǀĞƌƐĞƌĞĂĐƚŝŽŶƐ͘^ŚŽƵůĚŶŽƚďĞĂĚŵŝŶŝƐƚĞƌĞĚƵŶůĞƐƐĂ ŶĂƌĐŽƚŝĐĂŶƚĂŐŽŶŝƐƚĂŶĚƚŚĞĨĂĐŝůŝƚŝĞƐĨŽƌƌĞƐƵƐĐŝƚĂƚŝŽŶĂŶĚĐŽŶƚƌŽůůĞĚƌĞƐƉŝƌĂƚŝŽŶƐĂƌĞĂǀĂŝůĂďůĞ͘ WĂƚŝĞŶƚƐƐŚŽƵůĚďĞůǇŝŶŐĚŽǁŶ͘ŽŶĐƵƌƌĞŶƚĂĚŵŝŶŝƐƚƌĂƚŝŽŶǁŝƚŚWƌŽŵĞƚŚĂǌŝŶĞĐŽƵůĚƉƌŽĚƵĐĞ ƌĞƐƉŝƌĂƚŽƌǇĚĞƉƌĞƐƐŝŽŶŽƌĂƌƌĞƐƚ͘ĂƌĞĨƵůŵŽŶŝƚŽƌŝŶŐŽĨƚŚĞƉĂƚŝĞŶƚΖƐƌĞƐƉŝƌĂƚŽƌǇƐƚĂƚƵƐŝƐĞƐƐĞŶƚŝĂů͘ /ĨMorphineŝƐŶŽƚĂǀĂŝůĂďůĞʹƵƐĞFentanylʹƐĞĞŝŶĚŝǀŝĚƵĂůƉƌŽƚŽĐŽůƐĨŽƌĚŽƐŝŶŐ

Cypress Creek EMS System Policies and Treatment Guidelines

363 MEDICATIONS Revised 8/2016 Approved: Levon Vartanian, MD

EĂůŽǆŽŶĞ;EĂƌĐĂŶͿ DĞĚŝĐĂƚŝŽŶ KƉŝĂƚĞĂŶƚĂŐŽŶŝƐƚ͖ƌĞǀĞƌƐĞƐĂĐƚŝŽŶƐŽĨŽƉŝŽŝĚƐŝŶĐůƵĚŝŶŐƉƌĞƐĐƌŝƉƚŝŽŶŶĂƌĐŽƚŝĐƉĂŝŶŬŝůůĞƌƐ;ŵŽƌƉŚŝŶĞ͕ ĨĞŶƚĂŶǇů͕ĞƚĐ͘ͿĂŶĚƌĞĐƌĞĂƚŝŽŶĂůŶĂƌĐŽƚŝĐĚƌƵŐƐ;ŚĞƌŽŝŶͿ͘ DĞĐŚĂŶŝƐŵŽĨĐƚŝŽŶ EĂůŽǆŽŶĞĂŶƚĂŐŽŶŝǌĞƐƚŚĞŽƉŝŽŝĚĞĨĨĞĐƚƐďǇĐŽŵƉĞƚŝŶŐĨŽƌƚŚĞƐĂŵĞƌĞĐĞƉƚŽƌƐŝƚĞƐ͘EĂůŽǆŽŶĞǁŝůů ƌĞǀĞƌƐĞƐƚƵƉŽƌ͕ĐŽŵĂ͕ĂŶĚƌĞƐƉŝƌĂƚŽƌǇĚĞƉƌĞƐƐŝŽŶǁŚĞŶĂĚŵŝŶŝƐƚĞƌĞĚƚŽƉĂƚŝĞŶƚƐƚŚĂƚŚĂǀĞƚĂŬĞŶ ŶĂƌĐŽƚŝĐƐ͘ /ŶĚŝĐĂƚŝŽŶƐ x <ŶŽǁŶŽƌƐƵƐƉĞĐƚĞĚŶĂƌĐŽƚŝĐŽǀĞƌĚŽƐĞ ŽŶƚƌĂŝŶĚŝĐĂƚŝŽŶƐ x EŽŶĞ ^ŝĚĞĨĨĞĐƚƐ x ZĂƉŝĚĂĚŵŝŶŝƐƚƌĂƚŝŽŶŵĂǇƉƌĞĐŝƉŝƚĂƚĞƉƌŽũĞĐƚŝůĞǀŽŵŝƚŝŶŐĂŶĚǀĞŶƚƌŝĐƵůĂƌĚǇƐƌŚǇƚŚŵŝĂƐ͖ŝŶƌĂƌĞĐĂƐĞƐ ŝƚŚĂƐďĞĞŶƌĞƉŽƌƚĞĚƚŽĐĂƵƐĞƉƵůŵŽŶĂƌǇĞĚĞŵĂĂŶĚƐƵĚĚĞŶĚĞĂƚŚ͘ĚŵŝŶŝƐƚĞƌŝŶĐŽŶƚƌŽůůĞĚ͕ƐŵĂůů ĚŽƐĂŐĞƐƵŶƚŝůƌĞƐƉŝƌĂƚŽƌǇƐƚĂƚƵƐŝŵƉƌŽǀĞƐ͘ ŽƐĂŐĞΘĚŵŝŶŝƐƚƌĂƚŝŽŶ x Adult͗Ϭ͘ϰͲϮŵŐ/sͬ/Dͬ/Eͬ^Y͕ĂƐŶĞĞĚĞĚƚŝƚƌĂƚĞĚƚŽĂŶŝŵƉƌŽǀĞŵĞŶƚŝŶƌĞƐƉŝƌĂƚŽƌǇƐƚĂƚƵƐ x Pediatric͗Ϭ͘ϭŵŐͬŬŐ/sͬ/Dͬ/Eͬ^Y͕ĂƐŶĞĞĚĞĚƚŝƚƌĂƚĞĚƚŽĂŶŝŵƉƌŽǀĞŵĞŶƚŝŶƌĞƐƉŝƌĂƚŽƌǇƐƚĂƚƵƐ ^ƉĞĐŝĂůŽŶƐŝĚĞƌĂƚŝŽŶƐ x dŚĞƉĂƚŝĞŶƚǁŚŽŚĂƐƐĂƚŝƐĨĂĐƚŽƌŝůǇƌĞƐƉŽŶĚĞĚƚŽŶĂůŽǆŽŶĞƐŚŽƵůĚďĞŬĞƉƚƵŶĚĞƌĐŽŶƚŝŶƵĞĚ ƐƵƌǀĞŝůůĂŶĐĞ͖ƌĞƉĞĂƚĞĚĚŽƐĞƐƐŚŽƵůĚďĞĂĚŵŝŶŝƐƚĞƌĞĚĂƐŶĞĐĞƐƐĂƌǇ͕ƐŝŶĐĞƚŚĞĚƵƌĂƚŝŽŶŽĨĂĐƚŝŽŶŽĨ ƐŽŵĞŶĂƌĐŽƚŝĐƐŵĂǇĞǆĐĞĞĚƚŚŽƐĞŽĨŶĂůŽǆŽŶĞ͘

Cypress Creek EMS System Policies and Treatment Guidelines

364 MEDICATIONS Revised 8/2016 Approved: Levon Vartanian, MD

EŝƚƌŽŐůǇĐĞƌŝŶ;EŝƚƌŽƐƚĂƚ͕EŝƚƌŽůŝŶŐƵĂů^ƉƌĂǇͿ DĞĚŝĐĂƚŝŽŶ ŶŽƌŐĂŶŝĐŶŝƚƌĂƚĞ͖ĂǀĂƐŽĚŝůĂƚŝŶŐĂŐĞŶƚ͘ DĞĐŚĂŶŝƐŵŽĨĐƚŝŽŶ x ŝůĂƚŝŽŶŽĨƚŚĞƉŽƐƚĐĂƉŝůůĂƌǇǀĞƐƐĞůƐ͕ŝŶĐůƵĚŝŶŐůĂƌŐĞǀĞŝŶƐ͕ƉƌŽŵŽƚĞƐƉĞƌŝƉŚĞƌĂůƉŽŽůŝŶŐŽĨďůŽŽĚĂŶĚ ĚĞĐƌĞĂƐĞƐǀĞŶŽƵƐƌĞƚƵƌŶƚŽƚŚĞŚĞĂƌƚ͕ĚĞĐƌĞĂƐĞƐůĞĨƚǀĞŶƚƌŝĐƵůĂƌĞŶĚͲĚŝĂƐƚŽůŝĐƉƌĞƐƐƵƌĞ;ƉƌĞůŽĂĚͿ͘ x ƌƚĞƌŝŽůĂƌƌĞůĂǆĂƚŝŽŶƌĞĚƵĐĞƐƐǇƐƚĞŵŝĐǀĂƐĐƵůĂƌƌĞƐŝƐƚĂŶĐĞĂŶĚĂƌƚĞƌŝĂůƉƌĞƐƐƵƌĞ;ĂĨƚĞƌůŽĂĚͿ͘ x DǇŽĐĂƌĚŝĂůŽǆǇŐĞŶĐŽŶƐƵŵƉƚŝŽŶŽƌĚĞŵĂŶĚŝƐĚĞĐƌĞĂƐŝŶŐďǇďŽƚŚƚŚĞĂƌƚĞƌŝĂůĂŶĚǀĞŶŽƵƐĞĨĨĞĐƚƐ͕ ĐƌĞĂƚŝŶŐĂŵŽƌĞĨĂǀŽƌĂďůĞƐƵƉƉůǇͲĚĞŵĂŶĚƌĂƚŝŽ͘ /ŶĚŝĐĂƚŝŽŶƐ x /ƐĐŚĞŵŝĐĐŚĞƐƚƉĂŝŶ x ,ǇƉĞƌƚĞŶƐŝǀĞĐƌŝƐŝƐ x WƵůŵŽŶĂƌǇĞĚĞŵĂ ŽŶƚƌĂŝŶĚŝĐĂƚŝŽŶƐ x WĂƚŝĞŶƚƐƚĂŬŝŶŐsŝĂŐƌĂ;ŽƌŽƚŚĞƌĞƌĞĐƚŝůĞĚǇƐĨƵŶĐƚŝŽŶŵĞĚŝĐĂƚŝŽŶͿ x ^ŚŽƵůĚďĞƵƐĞĚǁŝƚŚĞǆƚƌĞŵĞĐĂƵƚŝŽŶ;ŽƌŶŽƚĂƚĂůůͿŝŶƉĂƚŝĞŶƚƐƉƌĞƐĞŶƚŝŶŐǁŝƚŚ͗ o /ŶĐƌĞĂƐĞĚ/W o 'ůĂƵĐŽŵĂ o ,ǇƉŽƚĞŶƐŝŽŶ o ^ĞǀĞƌĞĂŶĞŵŝĂ o Stroke / intracerebral hemorrhage x EŝƚƌŽŐůǇĐĞƌŝŶĐĂƵƐĞƐĐĞƌĞďƌĂůǀĂƐŽĚŝůĂƚŝŽŶ͕ŝŶĐƌĞĂƐŝŶŐ/W͘ ^ŝĚĞĨĨĞĐƚƐ x dƌĂŶƐŝĞŶƚ͕ƚŚƌŽďďŝŶŐŚĞĂĚĂĐŚĞ x sĞƌƚŝŐŽ x ,ǇƉŽƚĞŶƐŝŽŶͬƉŽƐƚƵƌĂůŚǇƉŽƚĞŶƐŝŽŶ x WĂůƉŝƚĂƚŝŽŶƐ x tĞĂŬŶĞƐƐ ŽƐĂŐĞΘĚŵŝŶŝƐƚƌĂƚŝŽŶ x 0.4 mg ^>ŵĞƚĞƌĞĚͲĚŽƐĞƐƉƌĂǇƌĞƉĞĂƚĞĚĞǀĞƌǇϱŵŝŶƵƚĞƐ͘ ^ƉĞĐŝĂůŽŶƐŝĚĞƌĂƚŝŽŶƐ x ^ŚŽƵůĚďĞĂĚŵŝŶŝƐƚĞƌĞĚƚŽƉĂƚŝĞŶƚƐƐŝƚƚŝŶŐŽƌƐĞŵŝͲƌĞĐůŝŶĞĚ x ZĞĂƐƐĞƐƐďůŽŽĚƉƌĞƐƐƵƌĞ͕ĐŚĞƐƚƉĂŝŶ͕ĂŶĚͬŽƌŽƚŚĞƌƐŝŐŶƐͬƐǇŵƉƚŽŵƐďĞƚǁĞĞŶƌĞͲĚŽƐŝŶŐ͖ĚŽĐƵŵĞŶƚĂůů ĨŝŶĚŝŶŐƐŝŶƚŚĞWZ

Cypress Creek EMS System Policies and Treatment Guidelines

365 MEDICATIONS Revised 8/2016 Approved: Levon Vartanian, MD

EŽƌŵĂů^ĂůŝŶĞ DĞĚŝĐĂƚŝŽŶ /ƐŽƚŽŶŝĐĐƌǇƐƚĂůůŽŝĚĨŽƌ/sƵƐĞ DĞĐŚĂŶŝƐŵŽĨĐƚŝŽŶ EŽƌŵĂů^ĂůŝŶĞŝƐĂŶŝƐŽƚŽŶŝĐĐƌǇƐƚĂůůŽŝĚǁŝƚŚϭϱϰŵƋͬ>ŽĨƐŽĚŝƵŵĂŶĚϭϱϰŵƋͬ>ŽĨĐŚůŽƌŝĚĞ͘WŚŝƐϱ͘ϱ͘ /ŶĚŝĐĂƚŝŽŶƐ x &ůƵŝĚƌĞƐƵƐĐŝƚĂƚŝŽŶ x DĞĚŝĐĂƚŝŽŶĚŝůƵƚŝŽŶΘĂĚŵŝŶŝƐƚƌĂƚŝŽŶ x &ůƵƐŚŝŶŐƉŽƌƚƐĂŶĚůŝŶĞƐ x /ƌƌŝŐĂƚŝŽŶŽĨǁŽƵŶĚƐ x /ƌƌŝŐĂƚŝŽŶŽĨĞǇĞƐ ŽŶƚƌĂŝŶĚŝĐĂƚŝŽŶƐ x EŽŶĞ ŽƐĂŐĞĂŶĚĚŵŝŶŝƐƚƌĂƚŝŽŶ x ϮϬŵůͬŬŐ/sŝŶĨƵƐŝŽŶ x ϭϬŵ>ͬŬŐ/sŝŶĨƵƐŝŽŶŝŶƉĂƚŝĞŶƚƐфϯϬǁĞĞŬƐ x ϯϬŵ>ͬŬŐ/sŝŶĨƵƐŝŽŶŝŶĂĚƵůƚƐĞƉƐŝƐƉĂƚŝĞŶƚƐ ^ƉĞĐŝĂůŽŶƐŝĚĞƌĂƚŝŽŶ x dŽĂǀŽŝĚĐĂƵƐŝŶŐĨůƵŝĚŽǀĞƌůŽĂĚ͕ƵƐĞ/sĨůƵŝĚƐǁŝƚŚĐĂƵƚŝŽŶŝŶƉĂƚŝĞŶƚƐǁŚŽŚĂǀĞĚŝŵŝŶŝƐŚĞĚƌĞŶĂů ĨƵŶĐƚŝŽŶ͕,&͕ŽƌŚĂǀĞƐŝŐŶŝĨŝĐĂŶƚĞĚĞŵĂ͘ x dŽĂǀŽŝĚĂĐĐŝĚĞŶƚĂůĨůƵŝĚŽǀĞƌůŽĂĚ͕ƵƐĞĂƵƌĞƚƌŽůĂŶĚĐĂƌĞĨƵůůǇŵŽŶŝƚŽƌĨůƵŝĚĂĚŵŝŶŝƐƚƌĂƚŝŽŶŝŶ ƉĞĚŝĂƚƌŝĐƉĂƚŝĞŶƚƐ͘ x ǀŽŝĚƵŶƌĞƐƚƌŝĐƚĞĚĨůƵŝĚƌĞƐƵƐĐŝƚĂƚŝŽŶŝŶƉĂƚŝĞŶƚƐǁŝƚŚƵŶĐŽŶƚƌŽůůĞĚŚĞŵŽƌƌŚĂŐĞ͖ƉƌĂĐƚŝĐĞƉĞƌŵŝƐƐŝǀĞ ŚǇƉŽƚĞŶƐŝŽŶ͘ x ĞĐĂƵƐĞŽĨŝƚƐůŽǁƉ,ĂŶĚŚŝŐŚĐŚůŽƌŝĚĞůĞǀĞůƐ͕ŶŽƌŵĂůƐĂůŝŶĞĐĂŶĐĂƵƐĞŚǇƉĞƌĐŚůŽƌĞŵŝĂĂŶĚǁŽƌƐĞŶ ĂĐŝĚŽƐŝƐŝŶƉĂƚŝĞŶƚƐǁŚŽĂƌĞĂůƌĞĂĚǇŝŶĂŶĂĐŝĚŽƚŝĐƐƚĂƚĞ͕ƐƵĐŚĂƐƐŚŽĐŬ͕ƐĞƉƐŝƐ͕ĞǆĐŝƚĞĚĚĞůŝƌŝƵŵ͕ ƚƌĂƵŵĂ͕ĐĂƌĚŝĂĐĂƌƌĞƐƚ͕ŽƌŵĂũŽƌďƵƌŶƐ͘dŚĞƐĞƉĂƚŝĞŶƚƐǁŝůůďĞŶĞĨŝƚŵŽƌĞĨƌŽŵĂŶĂůƚĞƌŶĂƚŝǀĞĨůƵŝĚ ƐƵĐŚĂƐWůĂƐŵĂůǇƚĞ͘ x ŽŶŽƚǁŝƚŚŚŽůĚĨůƵŝĚƐŝĨƉĂƚŝĞŶƚĚŽĞƐŶŽƚŚĂǀĞŽŶĞŽĨƚŚĞĂďŽǀĞĐĂƵƚŝŽŶƐ͘DŽƐƚƉĂƚŝĞŶƚƐǁŝůůďĞŶĞĨŝƚ ĨƌŽŵĨůƵŝĚƌĞƐƵƐĐŝƚĂƚŝŽŶ͘

Cypress Creek EMS System Policies and Treatment Guidelines

366 MEDICATIONS Revised 6/2019 Approved: Levon Vartanian, MD

KŶĚĂŶƐĞƚƌŽŶ,>;ŽĨƌĂŶͿ DĞĚŝĐĂƚŝŽŶ ŶƚŝĞŵĞƚŝĐ;ƐĞůĞĐƚŝǀĞůǇĂŶƚĂŐŽŶŝǌĞƐƐĞƌŽƚŽŶŝŶϱͲ,dϯƌĞĐĞƉƚŽƌƐͿ DĞĐŚĂŶŝƐŵŽĨĐƚŝŽŶ x ZĞĚƵĐĞƐĂĐƚŝǀŝƚǇŽĨƚŚĞǀĂŐƵƐŶĞƌǀĞǁŚŝĐŚƚŚĞŶĚĞĂĐƚŝǀĂƚĞƐƚŚĞǀŽŵŝƚŝŶŐĐĞŶƚĞƌŝŶƚŚĞŵĞĚƵůůĂ ŽďůŽŶŐĂƚĂ x ůŽĐŬƐƐĞƌŽƚŽŶŝŶƌĞĐĞƉƚŽƌƐŝŶƚŚĞĐŚĞŵŽƌĞĐĞƉƚŽƌƚƌŝŐŐĞƌǌŽŶĞ /ŶĚŝĐĂƚŝŽŶƐ WƌŽĨŽƵŶĚŶĂƵƐĞĂĂŶĚͬŽƌǀŽŵŝƚŝŶŐ ŽŶƚƌĂŝŶĚŝĐĂƚŝŽŶƐ x <ŶŽǁŶŚǇƉĞƌƐĞŶƐŝƚŝǀŝƚǇ x ŚŝůĚƌĞŶůĞƐƐƚŚĂŶϰǇĞĂƌƐŽĨĂŐĞ ^ŝĚĞĨĨĞĐƚƐ x ŽŶƐƚŝƉĂƚŝŽŶ x ŝǌǌŝŶĞƐƐ x ,ĞĂĚĂĐŚĞ ŽƐĂŐĞΘĚŵŝŶŝƐƚƌĂƚŝŽŶ x Adults: ϰŵŐƚŽϴŵŐKd͕ŵĂǇƌĞƉĞĂƚyϭ;ŵĂǆƚŽƚĂůĚŽƐĞϭϲŵŐͿ x Pediatric: Ϭ͘ϭϱŵŐͬŬŐ;ƐƚĂƌƚǁŝƚŚϮŵŐͿŵĂǇƌĞƉĞĂƚĂƐŶĞĞĚĞĚ;ŵĂǆƚŽƚĂůĚŽƐĞϴŵŐͿ x ŽŶŽƚŐŝǀĞƚŽĐŚŝůĚƌĞŶůĞƐƐƚŚĂŶϰǇĞĂƌƐŽĨĂŐĞ͘ ^ƉĞĐŝĂůŽŶƐŝĚĞƌĂƚŝŽŶƐ x WƌĞŐŶĂŶĐǇ͗EŽƉƌŽǀĞŶƌŝƐŬŝŶŚƵŵĂŶƐ

Cypress Creek EMS System Policies and Treatment Guidelines

367 MEDICATIONS Revised 10/2018 Approved: Levon Vartanian, MD

KƌĂů'ůƵĐŽƐĞ DĞĐŚĂŶŝƐŵŽĨĐƚŝŽŶ /ŶĐƌĞĂƐĞďůŽŽĚŐůƵĐŽƐĞ͘ /ŶĚŝĐĂƚŝŽŶ x ,ǇƉŽŐůǇĐĞŵŝĂ;ďůŽŽĚŐůƵĐŽƐĞфϲϬŵŐͬĚ>Ϳ ŽŶƚƌĂŝŶĚŝĐĂƚŝŽŶƐ x WĂƚŝĞŶƚƵŶĂďůĞƚŽƐǁĂůůŽǁ͘ ^ŝĚĞĨĨĞĐƚƐ x EŽŶĞƐŝŐŶŝĨŝĐĂŶƚ ŽƐĂŐĞΘĚŵŝŶŝƐƚƌĂƚŝŽŶ Adult and pediatric: ϭ͘ ŽŶĨŝƌŵƉĂƚŝĞŶƚŝƐĂďůĞƚŽƐǁĂůůŽǁĂŶĚŚĂƐĂŶŝŶƚĂĐƚŐĂŐƌĞĨůĞǆ͘ Ϯ͘ ĚŵŝŶŝƐƚĞƌŽŶĞƚƵďĞŽĨŽƌĂůŐůƵĐŽƐĞ͕ƉůĂĐŝŶŐŐĞůďĞƚǁĞĞŶĐŚĞĞŬĂŶĚŐƵŵƐ͘ ϯ͘ ZĞĂƐƐĞƐƐƉĂƚŝĞŶƚĂŶĚƌĞƉĞĂƚĂĚŵŝŶŝƐƚƌĂƚŝŽŶŝĨŶĞĐĞƐƐĂƌǇ͘ ^ƉĞĐŝĂůŽŶƐŝĚĞƌĂƚŝŽŶƐ x KƌĂůŐůƵĐŽƐĞĐŽŵĞƐƉĂĐŬĂŐĞĚƵŶĚĞƌĂǀĂƌŝĞƚǇŽĨďƌĂŶĚŶĂŵĞƐ͕ŝŶĐůƵĚŝŶŐ͞ŐůƵƚŽƐĞϭϱ͟ĂŶĚ͞/ŶƐƚĂͲ 'ůƵĐŽƐĞ͕͟ĂŶĚĚĞůŝǀĞƌƐďĞƚǁĞĞŶϭϱĂŶĚϯϬŐƌĂŵƐŽĨŐůƵĐŽƐĞƉĞƌƚƵďĞ͘ x ZĞƐƉŽŶƐĞƚŽŽƌĂůŐůƵĐŽƐĞŵĂǇƚĂŬĞĂƐůŽŶŐĂƐϭϬŵŝŶƵƚĞƐ͘,ŽǁĞǀĞƌ͕ƌĞĂƐƐĞƐƐƚŚĞƉĂƚŝĞŶƚŵŽƌĞ ĨƌĞƋƵĞŶƚůǇĂŶĚƌĞĐŚĞĐŬďůŽŽĚŐůƵĐŽƐĞĂƚůĞĂƐƚĞǀĞƌǇϱŵŝŶƵƚĞƐƵŶƚŝůŚǇƉŽŐůǇĐĞŵŝĂŝƐƌĞǀĞƌƐĞĚ͘

Cypress Creek EMS System Policies and Treatment Guidelines

368 MEDICATIONS Revised 8/2016 Approved: Levon Vartanian, MD

KǆǇŐĞŶ DĞĚŝĐĂƚŝŽŶ EĂƚƵƌĂůŐĂƐĞŽƵƐĞůĞŵĞŶƚ;ϮϭйŽĨƌŽŽŵĂŝƌͿ DĞĐŚĂŶŝƐŵŽĨĐƚŝŽŶ KǆǇŐĞŶŝƐĂŶĞƐƐĞŶƚŝĂůĞůĞŵĞŶƚƌĞƋƵŝƌĞĚĨŽƌĂůůďŽĚǇĨƵŶĐƚŝŽŶƐ͘ /ŶĚŝĐĂƚŝŽŶƐ x ,ǇƉŽǆŝĂ x ZĞƐƉŝƌĂƚŽƌǇŝŶƐƵĨĨŝĐŝĞŶĐǇ x ĂƌĚŝĂĐͬƌĞƐƉŝƌĂƚŽƌǇƌƌĞƐƚ x /ŶĐƌĞĂƐĞĚŽǆǇŐĞŶĚĞŵĂŶĚ x hƐĞƚŽƐĞƌǀĞĂƐĂĚĞůŝǀĞƌǇŵĞĚŝƵŵĨŽƌĂĚŵŝŶŝƐƚƌĂƚŝŽŶŽĨŶĞďƵůŝǌĞĚŵĞĚŝĐĂƚŝŽŶƐ ŽŶƚƌĂŝŶĚŝĐĂƚŝŽŶƐ x EŽŶĞŝŶƚŚĞĞŵĞƌŐĞŶĐǇƐĞƚƚŝŶŐ ^ŝĚĞĨĨĞĐƚƐ x EŽŶĞ ŽƐĂŐĞĂŶĚĚŵŝŶŝƐƚƌĂƚŝŽŶ x KǆǇŐĞŶŵĂǇďĞĂĚŵŝŶŝƐƚĞƌĞĚĂƐŶĞĞĚĞĚďĞƚǁĞĞŶϮͲϮϱ>WDǀŝĂƚŚĞĨŽůůŽǁŝŶŐĚĞǀŝĐĞƐ͗ o EĂƐĂůĐĂŶŶƵůĂ o EŽŶͲƌĞďƌĞĂƚŚĞƌŵĂƐŬ o ĂƉŶŽŐƌĂƉŚǇŵŽŶŝƚŽƌŝŶŐŶĂƐĂůĐĂŶŶƵůĂ o ĂŐͲǀĂůǀĞŵĂƐŬ o ůŽǁͲďǇĂĚŵŝŶŝƐƚƌĂƚŝŽŶ o EĞďƵůŝǌĞƌŚĂŶĚͲŚĞůĚĚĞǀŝĐĞͬŵĂƐŬ o ŽŶƚŝŶƵŽƵƐƉŽƐŝƚŝǀĞĂŝƌǁĂǇƉƌĞƐƐƵƌĞŵĂƐŬ o ZĞƐY'ĂƌĚ o sĞŶƚŝůĂƚŽƌ x dŝƚƌĂƚĞƚŽ^ƉKϮŽĨϵϰʹϵϵй x ŽŶŽƚǁŝƚŚŚŽůĚŽǆǇŐĞŶĨƌŽŵƚƌĂƵŵĂƉĂƚŝĞŶƚƐ ^ƉĞĐŝĂůŽŶƐŝĚĞƌĂƚŝŽŶƐ

x ĚŵŝŶŝƐƚƌĂƚŝŽŶŽĨŽǆǇŐĞŶƚŽƉĂƚŝĞŶƚƐƌĞƚĂŝŶŝŶŐKϮͬKWƉĂƚŝĞŶƚƐŵĂǇĚĞĐƌĞĂƐĞƚŚĞŝƌƌĞƐƉŝƌĂƚŽƌǇ ĚƌŝǀĞ͘ĞƉƌĞƉĂƌĞĚƚŽĂƐƐŝƐƚǀĞŶƚŝůĂƚŝŽŶƐĂƐŶĞĐĞƐƐĂƌǇ͘ x ƉƉůŝĐĂƚŝŽŶŽĨŚƵŵŝĚŝĨŝĞƌƐŚŽƵůĚďĞĚŽŶĞŽŶƉĂƚŝĞŶƚƐǁŝƚŚĚƌǇŵƵĐƵƐŵĞŵďƌĂŶĞƐ͘ x ǆĐĞƐƐŝǀĞŽǆǇŐĞŶŝƐŚĂƌŵĨƵůĨŽƌƉĂƚŝĞŶƚƐĞǆƉĞƌŝĞŶĐŝŶŐĂĐƵƚĞĐŽƌŽŶĂƌǇƐǇŶĚƌŽŵĞŽƌĐĂƌĚŝĂĐŝƐĐŚĞŵŝĂ͘ KǆǇŐĞŶƐĂƚƵƌĂƚŝŽŶхϵϵйŵĂǇŝŶĚŝĐĂƚĞƚŽŽŵƵĐŚŽǆǇŐĞŶ

Cypress Creek EMS 2016 Policies and Treatment Guidelines

369 MEDICATIONS Revised 8/2015 Approved: Levon Vartanian, MD

KǆǇƚŽĐŝŶ;WŝƚŽĐŝŶͿ DĞĚŝĐĂƚŝŽŶ KǆǇƚŽĐŝŶ͕ĂŶĂƚƵƌĂůůǇŽĐĐƵƌƌŝŶŐŚŽƌŵŽŶĞƉƌŽĚƵĐĞĚďǇƚŚĞƉŝƚƵŝƚĂƌǇŐůĂŶĚ͕ŝƐŵĂŶƵĨĂĐƚƵƌĞĚƐǇŶƚŚĞƚŝĐĂůůǇ͘ DĞĐŚĂŶŝƐŵŽĨĐƚŝŽŶ ^ǇŶƚŚĞƚŝĐŽǆǇƚŽĐŝŶĂĐƚƐŽŶƚŚĞƐŵŽŽƚŚŵƵƐĐůĞŽĨƚŚĞƵƚĞƌƵƐƚŽƐƚŝŵƵůĂƚĞĐŽŶƚƌĂĐƚŝŽŶƐ͘/ƚĞǆĞƌƚƐĂ ƐĞůĞĐƚŝǀĞĂĐƚŝŽŶŽŶƚŚĞƐŵŽŽƚŚŵƵƐĐƵůĂƚƵƌĞŽĨƚŚĞƵƚĞƌƵƐ͘dŚĞĐŽŶƚƌĂĐƚŝŶŐƵƚĞƌƵƐƐƋƵĞĞǌĞƐĚŽǁŶŽŶ ƵƚĞƌŝŶĞďůŽŽĚǀĞƐƐĞůƐĂŶĚƚŚĞƌĞďǇƌĞĚƵĐĞƐƉŽƐƚƉĂƌƚƵŵďůĞĞĚŝŶŐ͘ /ŶĚŝĐĂƚŝŽŶƐ x WŽƐƚƉĂƌƚƵŵŚĞŵŽƌƌŚĂŐĞ;ŽŶůǇĂĚŵŝŶŝƐƚĞƌĞĚĂĨƚĞƌƚŚĞƉůĂĐĞŶƚĂŚĂƐďĞĞŶĚĞůŝǀĞƌĞĚͿ x hŶĐŽŶƚƌŽůůĞĚŚĞŵŽƌƌŚĂŐĞĨŽůůŽǁŝŶŐĂƐƉŽŶƚĂŶĞŽƵƐŽƌĞůĞĐƚŝǀĞĂďŽƌƚŝŽŶ ŽŶƚƌĂŝŶĚŝĐĂƚŝŽŶƐ x KďƐƚĞƚƌŝĐĂůĞŵĞƌŐĞŶĐŝĞƐǁŚĞƌĞƚŚĞďĞŶĞĨŝƚͲƚŽͲƌŝƐŬƌĂƚŝŽĨŽƌĞŝƚŚĞƌƚŚĞĨĞƚƵƐŽƌƚŚĞŵŽƚŚĞƌĨĂǀŽƌƐ ƐƵƌŐŝĐĂůŝŶƚĞƌǀĞŶƚŝŽŶ x &ĞƚĂůĚŝƐƚƌĞƐƐǁŚĞƌĞĚĞůŝǀĞƌǇŝƐŶŽƚŝŵŵŝŶĞŶƚ x tŚĞƌĞƚŚĞƵƚĞƌƵƐŝƐĂůƌĞĂĚǇŚǇƉĞƌĂĐƚŝǀĞŽƌŚǇƉĞƌƚŽŶŝĐ x WĂƚŝĞŶƚƐǁŚŽĂƌĞŚǇƉĞƌƐĞŶƐŝƚŝǀĞƚŽƚŚĞŵĞĚŝĐĂƚŝŽŶ x ^ŝƚƵĂƚŝŽŶƐǁŚĞƌĞǀĂŐŝŶĂůĚĞůŝǀĞƌǇŝƐĐŽŶƚƌĂŝŶĚŝĐĂƚĞĚ͕ƐƵĐŚĂƐĐŽƌĚƉƌĞƐĞŶƚĂƚŝŽŶ͕ƉƌŽůĂƉƐĞĚĐŽƌĚ͕Žƌ ƉůĂĐĞŶƚĂƉƌĞǀŝĂ ^ŝĚĞĨĨĞĐƚƐ x ŶĂƉŚǇůĂĐƚŝĐƌĞĂĐƚŝŽŶ x WŽƐƚƉĂƌƚƵŵŚĞŵŽƌƌŚĂŐĞ x ĂƌĚŝĂĐĂƌƌŚǇƚŚŵŝĂ x &ĂƚĂůĂĨŝďƌŝŶŽŐĞŶĞŵŝĂ x EĂƵƐĞĂĂŶĚǀŽŵŝƚŝŶŐ x WsƐ x WĞůǀŝĐŚĞŵĂƚŽŵĂ ŽƐĂŐĞĂŶĚĚŵŝŶŝƐƚƌĂƚŝŽŶ 20 unitsŝŶϭ͕ϬϬϬŵ>ŽĨŶŽƌŵĂůƐĂůŝŶĞŽƌWůĂƐŵĂůǇƚĞ͕ƌƵŶǁŝĚĞŽƉĞŶ͘ ^ƉĞĐŝĂůŽŶƐŝĚĞƌĂƚŝŽŶƐ x WƌŝŽƌƚŽŝŶŝƚŝĂƚŝŽŶŽĨŽǆǇƚŽĐŝŶ͕ƚŚĞWƌĞͲ,ŽƐƉŝƚĂůWƌŽǀŝĚĞƌƐŚŽƵůĚƉƌŽǀŝĚĞĂŐŐƌĞƐƐŝǀĞĨƵŶĚĂůŵĂƐƐĂŐĞƚŽ ƉƌŽŵŽƚĞƵƚĞƌŝŶĞĐŽŶƚƌĂĐƚŝŽŶƐĂĨƚĞƌǀĂŐŝŶĂůĚĞůŝǀĞƌǇŝŶŽƌĚĞƌƚŽƐůŽǁƉŽƐƚƉĂƌƚƵŵŚĞŵŽƌƌŚĂŐĞ͘ x ZĂƉŝĚƚƌĂŶƐƉŽƌƚƚŽĂŶĂƉƉƌŽƉƌŝĂƚĞĨĂĐŝůŝƚǇƐŚŽƵůĚŶŽƚďĞĚĞůĂǇĞĚ͘ x ĂƌĞĨƵůŵŽŶŝƚŽƌŝŶŐŽĨƚŚĞƉĂƚŝĞŶƚĚƵƌŝŶŐĂĚŵŝŶŝƐƚƌĂƚŝŽŶŝƐĞƐƐĞŶƚŝĂů͘

Cypress Creek EMS System Policies and Treatment Guidelines

370 MEDICATIONS Revised 5/2017 Approved: Levon Vartanian, MD

WĂŶĐƵƌŽŶŝƵŵ;WĂǀƵůŽŶͿ DĞĚŝĐĂƚŝŽŶ ŶŽŶͲĚĞƉŽůĂƌŝǌŝŶŐ;ĐŽŵƉĞƚŝƚŝǀĞͿ͕ĂŵŝŶŽƐƚĞƌŽŝĚ͕ŶĞƵƌŽŵƵƐĐƵůĂƌďůŽĐŬŝŶŐĂŐĞŶƚ DĞĐŚĂŶŝƐŵŽĨĐƚŝŽŶ dŚƌŽƵŐŚĐŽŵƉĞƚŝƚŝǀĞŝŶŚŝďŝƚŝŽŶ͕ďůŽĐŬƐĐŚŽůŝŶĞƌŐŝĐƌĞĐĞƉƚŽƌƐĂƚƚŚĞŵŽƚŽƌĞŶĚƉůĂƚĞŝŶŝƚŝĂƚŝŶŐĂ ŶĞƵƌŽŵƵƐĐƵůĂƌƉĂƌĂůǇƐŝƐǁŝƚŚŝŶĂďŽƵƚϰŵŝŶƵƚĞƐǁŝƚŚƌĞĐŽǀĞƌǇĂƚĂƉƉƌŽǆŝŵĂƚĞůǇϭϬϬŵŝŶƵƚĞƐ͘ /ŶĚŝĐĂƚŝŽŶƐ x dŽƐƵƐƚĂŝŶŶĞƵƌŽŵƵƐĐƵůĂƌƉĂƌĂůǇƐŝƐĂĨƚĞƌƚŚĞƉĂƚŝĞŶƚŚĂƐďĞĞŶŝŶƚƵďĂƚĞĚ ǁŝƚŚĂŶĞŶĚŽƚƌĂĐŚĞĂůƚƵďĞ͘ x DĂǇďĞƵƐĞĚĂƐƉƌŝŵĂƌǇĂŐĞŶƚĨŽƌZĂƉŝĚ^ĞƋƵĞŶĐĞ/ŶĚƵĐƚŝŽŶŝĨ^ƵĐĐŝŶǇůĐŚŽůŝŶĞŝƐĐŽŶƚƌĂŝŶĚŝĐĂƚĞĚ͘ ŽŶƚƌĂŝŶĚŝĐĂƚŝŽŶƐ x ,ǇƉĞƌƐĞŶƐŝƚŝǀŝƚǇ x ŽŶŽƚƵƐĞŝŶŶĞŽŶĂƚĞƐŽƌƉƌĞŵĂƚƵƌĞŝŶĨĂŶƚƐ ^ŝĚĞĨĨĞĐƚƐ x WƵůŵŽŶĂƌǇ͗ŚǇƉŽǀĞŶƚŝůĂƚŝŽŶ͕ĂƉŶĞĂ x ĂƌĚŝŽǀĂƐĐƵůĂƌ͗DŽĚĞƌĂƚĞŝŶĐƌĞĂƐĞŝŶŚĞĂƌƚƌĂƚĞ͕DW͕ĂŶĚĐĂƌĚŝĂĐŽƵƚƉƵƚ x ^ŬŝŶ͗KĐĐĂƐŝŽŶĂůƚƌĂŶƐŝĞŶƚƌĂƐŚ;ƌĂƌĞĂŶĚƚǇƉŝĐĂůůǇŶŽƚƐĞƌŝŽƵƐͿ ŽƐĂŐĞΘĚŵŝŶŝƐƚƌĂƚŝŽŶ x 0.1 mg/kg /s ^ƉĞĐŝĂůŽŶƐŝĚĞƌĂƚŝŽŶƐ x ŶƐƵƌĞĂĚĞƋƵĂƚĞƐĞĚĂƚŝŽŶƉƌŝŽƌƚŽĂŶĚƚŚƌŽƵŐŚŽƵƚĂĚŵŝŶŝƐƚƌĂƚŝŽŶ͘ƵƌĂƚŝŽŶŽĨĂĐƚŝŽŶƐŝŐŶŝĨŝĐĂŶƚůǇ ĞǆĐĞĞĚƐƚŚĞĚƵƌĂƚŝŽŶŽĨƐĞĚĂƚŝǀĞĂŐĞŶƚƐĐĂƌƌŝĞĚďǇǇƉƌĞƐƐƌĞĞŬD^͘ x ,ĂůĨͲůŝĨĞŝƐĚŽƵďůĞĚŝŶƉĂƚŝĞŶƚƐǁŝƚŚƌĞŶĂůĨĂŝůƵƌĞĂŶĚĚƵƌĂƚŝŽŶŽĨĂĐƚŝŽŶĞǆƚĞŶĚĞĚ͘

Cypress Creek EMS System Policies and Treatment Guidelines

371 MEDICATIONS Revised 8/2016 Approved: Levon Vartanian, MD

WůĂƐŵĂ>ǇƚĞͲ;WůĂƐŵĂůǇƚĞͿ

DĞĚŝĐĂƚŝŽŶ Chemical Properties: /ƐŽƚŽŶŝĐĐƌǇƐƚĂůůŽŝĚĨŽƌ/sƵƐĞ ^ŽĚŝƵŵ͗ ϭϰϬŵƋ ŚůŽƌŝĚĞ͗ ϵϴŵƋ DĞĐŚĂŶŝƐŵŽĨĐƚŝŽŶ ĐĞƚĂƚĞ͗ ϮϳŵƋ WůĂƐŵĂůǇƚĞͲŝƐĂŶŝƐŽƚŽŶŝĐĐƌǇƐƚĂůůŽŝĚƐŽůƵƚŝŽŶǁŝƚŚƐŝŵŝůĂƌĞůĞĐƚƌŽůǇƚĞ 'ůƵĐŽŶĂƚĞ͗ ϮϯŵƋ ĐŽŶĐĞŶƚƌĂƚŝŽŶĂŶĚƉ,ƚŽďůŽŽĚƉůĂƐŵĂ͘ WŽƚĂƐƐŝƵŵ͗ϱŵƋ DĂŐŶĞƐŝƵŵ͗ ϯŵƋ /ŶĚŝĐĂƚŝŽŶƐ Ɖ,͗ ϳ͘ϰ x &ůƵŝĚƌĞƐƵƐĐŝƚĂƚŝŽŶĨŽƌǀŽůƵŵĞͲĚĞƉůĞƚĞĚƉĂƚŝĞŶƚƐ͕ƉĂƚŝĞŶƚƐŝŶƐŚŽĐŬ͕ ďƵƌŶƉĂƚŝĞŶƚƐ͕ƚƌĂƵŵĂƉĂƚŝĞŶƚƐ͕ĚĞŚǇĚƌĂƚĞĚƉĂƚŝĞŶƚƐ͕ĞǆĐŝƚĞĚĚĞůŝƌŝƵŵ͕ĂŶĚŽƚŚĞƌĐŽŶĚŝƚŝŽŶƐ ƌĞƋƵŝƌŝŶŐĨůƵŝĚƌĞƐƵƐĐŝƚĂƚŝŽŶ͘ ŽŶƚƌĂŝŶĚŝĐĂƚŝŽŶƐ x EŽŶĞ ŽƐĂŐĞĂŶĚĚŵŝŶŝƐƚƌĂƚŝŽŶ x 20 ml/kg/sŝŶĨƵƐŝŽŶ x 10 mL/kg/sŝŶĨƵƐŝŽŶŝŶƉĂƚŝĞŶƚƐфϯϬǁĞĞŬƐ x 30 mL/kg/sŝŶĨƵƐŝŽŶŝŶĂĚƵůƚƐĞƉƐŝƐƉĂƚŝĞŶƚƐ ^ƉĞĐŝĂůŽŶƐŝĚĞƌĂƚŝŽŶƐ x EŽƌŵĂůƐĂůŝŶĞŝƐĂĐŝĚŽƚŝĐĂŶĚŚǇƉĞƌĐŚůŽƌĞŵŝĐ͕ǁŚŝůĞWůĂƐŵĂůǇƚĞŝƐŶĞĂƌůǇŝĚĞŶƚŝĐĂůƚŽďůŽŽĚƉůĂƐŵĂŝŶ ĞůĞĐƚƌŽůǇƚĞĐŽŶĐĞŶƚƌĂƚŝŽŶĂŶĚƉ,͘dŚŝƐŵĂŬĞƐWůĂƐŵĂůǇƚĞĂďĞƚƚĞƌĐŚŽŝĐĞĨŽƌƉĂƚŝĞŶƚƐǁŚŽĂƌĞŝŶĂŶ ĂĐŝĚŽƚŝĐƐƚĂƚĞ͕ĞƐƉĞĐŝĂůůǇƐŚŽĐŬ͕ƚƌĂƵŵĂ͕ƐĞƉƐŝƐ͕ĂŶĚďƵƌŶƉĂƚŝĞŶƚƐ͘ x dŽĂǀŽŝĚĐĂƵƐŝŶŐĨůƵŝĚŽǀĞƌůŽĂĚ͕ƵƐĞ/sĨůƵŝĚƐǁŝƚŚĐĂƵƚŝŽŶŝŶƉĂƚŝĞŶƚƐǁŚŽŚĂǀĞĚŝŵŝŶŝƐŚĞĚƌĞŶĂů ĨƵŶĐƚŝŽŶ͕,&͕ŽƌŚĂǀĞƐŝŐŶŝĨŝĐĂŶƚĞĚĞŵĂ͘ x dŽĂǀŽŝĚĂĐĐŝĚĞŶƚĂůĨůƵŝĚŽǀĞƌůŽĂĚ͕ƵƐĞĂƵƌĞƚƌŽůĂŶĚĐĂƌĞĨƵůůǇŵŽŶŝƚŽƌĨůƵŝĚĂĚŵŝŶŝƐƚƌĂƚŝŽŶŝŶ ƉĞĚŝĂƚƌŝĐƉĂƚŝĞŶƚƐ͘ x ǀŽŝĚƵŶƌĞƐƚƌŝĐƚĞĚĨůƵŝĚƌĞƐƵƐĐŝƚĂƚŝŽŶŝŶƉĂƚŝĞŶƚƐǁŝƚŚƵŶĐŽŶƚƌŽůůĞĚŚĞŵŽƌƌŚĂŐĞ͖ƉƌĂĐƚŝĐĞƉĞƌŵŝƐƐŝǀĞ ŚǇƉŽƚĞŶƐŝŽŶ͘

Cypress Creek EMS System Policies and Treatment Guidelines

372 MEDICATIONS Revised 8/2016 Approved: Levon Vartanian, MD

WƌŽŵĞƚŚĂǌŝŶĞ;WŚĞŶĞƌŐĂŶͿ DĞĚŝĐĂƚŝŽŶ

ŶƚŝŚŝƐƚĂŵŝŶĞ;,ϭĂŶƚĂŐŽŶŝƐƚͿ DĞĐŚĂŶŝƐŵŽĨĐƚŝŽŶ x DŝůĚĂŶƚŝĐŚŽůŝŶĞƌŐŝĐĂĐƚŝǀŝƚǇ x ŶƚŝĞŵĞƚŝĐ x WŽƚĞŶƚŝĂƚĞƐĂĐƚŝŽŶŽĨĂŶĂůŐĞƐŝĐƐ /ŶĚŝĐĂƚŝŽŶƐ x WƌŽĨŽƵŶĚŶĂƵƐĞĂĂŶĚͬŽƌǀŽŵŝƚŝŶŐ ŽŶƚƌĂŝŶĚŝĐĂƚŝŽŶƐ x <ŶŽǁŶŚǇƉĞƌƐĞŶƐŝƚŝǀŝƚǇ ^ŝĚĞĨĨĞĐƚƐ x ůƚĞƌĞĚŵĞŶƚĂůƐƚĂƚƵƐ;ĚƌŽǁƐŝŶĞƐƐͿ x >ŽĐĂůǀĞŶŽƵƐŝƌƌŝƚĂƚŝŽŶŽƌƉŚůĞďŝƚŝƐ ŽƐĂŐĞΘĚŵŝŶŝƐƚƌĂƚŝŽŶ x Adult: ϭϮ͘ϱŵŐ^>Kt/sͬ/K͕ŵĂǇƌĞƉĞĂƚKEŝĨŶĞĞĚĞĚ͕ŽƌϮϱŵŐĚĞĞƉ/D͕ĚŽŶŽƚƌĞƉĞĂƚ͘ x Pediatric: Ϭ͘ϮϱŵŐͬŬŐ/sͬ/KŽƌϬ͘ϱŵŐͬŬŐĚĞĞƉ/D͘ŽŶŽƚƌĞƉĞĂƚ͘ ^ƉĞĐŝĂůŽŶƐŝĚĞƌĂƚŝŽŶƐ x ŽŶĐƵƌƌĞŶƚĂĚŵŝŶŝƐƚƌĂƚŝŽŶǁŝƚŚDŽƌƉŚŝŶĞ^ƵůĨĂƚĞĐŽƵůĚƉƌŽĚƵĐĞƌĞƐƉŝƌĂƚŽƌǇĚĞƉƌĞƐƐŝŽŶŽƌĂƌƌĞƐƚ͘ ĂƌĞĨƵůŵŽŶŝƚŽƌŝŶŐŽĨƚŚĞƉĂƚŝĞŶƚΖƐƌĞƐƉŝƌĂƚŽƌǇƐƚĂƚƵƐŝƐĞƐƐĞŶƚŝĂů͘ x ^ŚŽƵůĚďĞĚŝůƵƚĞĚŝŶĂƚůĞĂƐƚϭϬŵůEĂůďĞĨŽƌĞ/sĂĚŵŝŶŝƐƚƌĂƚŝŽŶ͖ƉƵƐŚ^>Kt>zŽǀĞƌĂŵŝŶƵƚĞ ĞŶƐƵƌŝŶŐƉĂƚĞŶĐǇŽĨ/sůŝŶĞƚŚƌŽƵŐŚŽƵƚĂĚŵŝŶŝƐƚƌĂƚŝŽŶ͘ x ŽŶƐŝĚĞƌĚŝůƵƚŝŶŐŝŶϭϬϬŵ>EĂ>ĂŶĚĂĚŵŝŶŝƐƚĞƌŝŶŐĂƐŝŶĨƵƐŝŽŶŽǀĞƌϭϬŵŝŶƵƚĞƐ͘ x EŽƚƌĞĐŽŵŵĞŶĚĞĚŝŶĐŚŝůĚƌĞŶƵŶĚĞƌϮǇĞĂƌƐŽĨĂŐĞ

Cypress Creek EMS System Policies and Treatment Guidelines

373 MEDICATIONS Revised 8/2016 Approved: Levon Vartanian, MD

ZŽĐƵƌŽŶŝƵŵ;ĞŵƵƌŽŶͿ DĞĚŝĐĂƚŝŽŶ ŶŽŶͲĚĞƉŽůĂƌŝǌŝŶŐ;ĐŽŵƉĞƚŝƚŝǀĞͿ͕ĂŵŝŶŽƐƚĞƌŽŝĚ͕ŶĞƵƌŽŵƵƐĐƵůĂƌďůŽĐŬŝŶŐĂŐĞŶƚ DĞĐŚĂŶŝƐŵŽĨĐƚŝŽŶ dŚƌŽƵŐŚĐŽŵƉĞƚŝƚŝǀĞŝŶŚŝďŝƚŝŽŶ͕ďůŽĐŬƐĐŚŽůŝŶĞƌŐŝĐƌĞĐĞƉƚŽƌƐĂƚƚŚĞŵŽƚŽƌĞŶĚƉůĂƚĞŝŶŝƚŝĂƚŝŶŐĂ ŶĞƵƌŽŵƵƐĐƵůĂƌƉĂƌĂůǇƐŝƐǁŝƚŚŝŶ|ϭͲϮŵŝŶƵƚĞƐĂŶĚůĂƐƚŝŶŐ|ϰϱƚŽϲϬŵŝŶƵƚĞƐ /ŶĚŝĐĂƚŝŽŶƐ x dŽƐƵƐƚĂŝŶŶĞƵƌŽŵƵƐĐƵůĂƌƉĂƌĂůǇƐŝƐĂĨƚĞƌƚŚĞƉĂƚŝĞŶƚŚĂƐďĞĞŶŝŶƚƵďĂƚĞĚ ǁŝƚŚĂŶĞŶĚŽƚƌĂĐŚĞĂůƚƵďĞ͘ x DĂǇďĞƵƐĞĚĂƐƉƌŝŵĂƌǇĂŐĞŶƚĨŽƌZĂƉŝĚ^ĞƋƵĞŶĐĞ/ŶĚƵĐƚŝŽŶŝĨ^ƵĐĐŝŶǇůĐŚŽůŝŶĞŝƐĐŽŶƚƌĂŝŶĚŝĐĂƚĞĚ͘ ŽŶƚƌĂŝŶĚŝĐĂƚŝŽŶƐ x EŽŶĞ ^ŝĚĞĨĨĞĐƚƐ x WƵůŵŽŶĂƌǇ͗ŚǇƉŽǀĞŶƚŝůĂƚŝŽŶ͕ĂƉŶĞĂ x ĂƌĚŝŽǀĂƐĐƵůĂƌ͗ƐůŝŐŚƚďƌĂĚǇĐĂƌĚŝĂ͕ƚƌĂŶƐŝĞŶƚŚǇƉĞƌͬŚǇƉŽƚĞŶƐŝŽŶ ŽƐĂŐĞΘĚŵŝŶŝƐƚƌĂƚŝŽŶ x 1 mg/kg /s͕ŵĂǇƌĞƉĞĂƚĂƐŶĞĞĚĞĚǁŝƚŚŝŶϮϬͲϰϬŵŝŶƵƚĞƐĂƚϭŵŐͬŬŐ ^ƉĞĐŝĂůŽŶƐŝĚĞƌĂƚŝŽŶƐ x ŶƐƵƌĞĂĚĞƋƵĂƚĞƐĞĚĂƚŝŽŶƉƌŝŽƌƚŽĂĚŵŝŶŝƐƚƌĂƚŝŽŶ͘ x ,ĂƐďĞĞŶŬŶŽǁŶƚŽƉƌŽůŽŶŐƚŚĞYdŝŶƚĞƌǀĂůŝŶƉĞĚŝĂƚƌŝĐƉĂƚŝĞŶƚƐ x WŚǇƐŝĐĂůůǇŝŶĐŽŵƉĂƚŝďůĞǁŝƚŚ͗ĚŝĂǌĞƉĂŵ͕ĨƵƌŽƐĞŵŝĚĞ͕ŬĞƚŽƌŽůĂĐ͕ĂŶĚŵĞƚŚǇůƉƌĞĚŶŝƐŽůŽŶĞ

Cypress Creek EMS System Policies and Treatment Guidelines

374 MEDICATIONS Revised 8/2016 Approved: Levon Vartanian, MD

^ŽĚŝƵŵŝĐĂƌďŽŶĂƚĞ DĞĚŝĐĂƚŝŽŶ ŚǇƉĞƌƚŽŶŝĐƐŽůƵƚŝŽŶƵƐĞĚƚŽƌĞƉůĂĐĞƐŽĚŝƵŵĂŶĚďŝĐĂƌďŽŶĂƚĞŝŽŶƐ DĞĐŚĂŶŝƐŵŽĨĐƚŝŽŶ ŽƌƌĞĐƚƐŵĞƚĂďŽůŝĐĂĐŝĚŽƐŝƐďǇŶĞƵƚƌĂůŝǌŝŶŐĞǆĐĞƐƐĂĐŝĚ͕ŚĞůƉŝŶŐƌĞƚƵƌŶƚŚĞďůŽŽĚƚŽǁĂƌĚƐĂƉŚǇƐŝŽůŽŐŝĐ Ɖ,͕ŝŶǁŚŝĐŚŶŽƌŵĂůŵĞƚĂďŽůŝĐƉƌŽĐĞƐƐĞƐĂŶĚƐǇŵƉĂƚŚŽŵŝŵĞƚŝĐĂŐĞŶƚƐǁŽƌŬŵŽƌĞĞĨĨŝĐŝĞŶƚůǇ͘/Ŷ ƚƌŝĐǇĐůŝĐĂŶƚŝĚĞƉƌĞƐƐĂŶƚŽǀĞƌĚŽƐĞ͕ĂůŬĂůŝŶŝǌĂƚŝŽŶŽĨƐĞƌƵŵƉ,ŝŶĐƌĞĂƐĞƐƉƌŽƚĞŝŶďŝŶĚŝŶŐŽĨdƐ͕ǁŚŝĐŚ ƐŝŐŶŝĨŝĐĂŶƚůǇůĞƐƐĞŶƐƚŚĞƉŽƚĞŶƚŝĂůĨŽƌĚƌƵŐƚŽǆŝĐŝƚǇďĞĐĂƵƐĞŝƚƌĞĚƵĐĞƐƚŚĞĂŵŽƵŶƚŽĨĂǀĂŝůĂďůĞĨƌĞĞĚƌƵŐ͘ /ŶĚŝĐĂƚŝŽŶƐ x /ŶĐĂƌĚŝĂĐĂƌƌĞƐƚƐŝƚƵĂƚŝŽŶƐǁŚĞƌĞƚŚĞƌĞƐƵƐĐŝƚĂƚŝŽŶƚŝŵĞŝƐƉƌŽůŽŶŐĞĚ;хϭϬŵŝŶͿĂŶĚƚŚĞƉĂƚŝĞŶƚŝƐ ŝŶƚƵďĂƚĞĚ x dƌŝĐǇĐůŝĐĂŶƚŝĚĞƉƌĞƐƐĂŶƚŽǀĞƌĚŽƐĞǁŚĞƌĞƚŚĞƉĂƚŝĞŶƚŝƐƵŶĐŽŶƐĐŝŽƵƐĂŶĚƚŚĞ<'ƐŚŽǁƐYZ^ĐŽŵƉůĞǆ ǁŝĚĞŶŝŶŐ x ǆĐŝƚĞĚĚĞůŝƌŝƵŵǁŝƚŚĂƚĞŵƉĞƌĂƚƵƌĞхϭϬϮΣ& x ^ƵƐƉĞĐƚĞĚŚǇƉĞƌŬĂůĞŵŝĂǁŝƚŚƐĞǀĞƌĞƐŝŐŶƐĂŶĚƐǇŵƉƚŽŵƐ͘ ŽŶƚƌĂŝŶĚŝĐĂƚŝŽŶƐ x ,ǇƉŽŬĂůĞŵŝĂ x WĂƚŝĞŶƚƐǁŚŽĐĂŶŶŽƚƚŽůĞƌĂƚĞĂƐĂůƚůŽĂĚ;Ğ͘Ő͘,&Ϳ ^ŝĚĞĨĨĞĐƚƐ x &ĞǁǁŚĞŶƵƐĞĚŝŶƚŚĞĞŵĞƌŐĞŶĐǇƐĞƚƚŝŶŐ ŽƐĂŐĞĂŶĚĚŵŝŶŝƐƚƌĂƚŝŽŶ Cardiac Arrest: Adult and Pediatric: ϭŵƋͬŬŐ/sͬ/KŽĨĂŶϴ͘ϰйƐŽůƵƚŝŽŶ͘ ZĞƉĞĂƚĂƚϬ͘ϱŵƋͬŬŐ͘ Infant (< 1 y/o): ^ĂŵĞĚŽƐĂŐĞďƵƚƵƐĞϰ͘ϮйƐŽůƵƚŝŽŶ͘ Tricyclic Antidepressant Loading:ϭʹϮŵƋͬŬŐƐůŽǁ/sͬ/K Overdose: Infusion:ϱϬŵƋŝŶϭ͕ϬϬϬŵ>ŽĨŶŽƌŵĂůƐĂůŝŶĞ͕ƌƵŶǁŝĚĞ ŽƉĞŶ͘ Excited Delirium: ϱϬŵƋŝŶϭ͕ϬϬϬŵ>ŽĨĐŽŽůͲĐŽůĚ;ϲϬ϶&ͿŶŽƌŵĂůƐĂůŝŶĞ͕ƌƵŶ ǁŝĚĞŽƉĞŶ͘ Suspected Hyperkalemia: ϭŵƋͬŬŐƐůŽǁ/sͬ/K

Cypress Creek EMS System Policies and Treatment Guidelines

375 MEDICATIONS Revised 8/2016 Approved: Levon Vartanian, MD

^ƵĐĐŝŶǇůĐŚŽůŝŶĞŚůŽƌŝĚĞ;ŶĞĐƚŝŶĞͿ DĞĚŝĐĂƚŝŽŶ ĚĞƉŽůĂƌŝǌŝŶŐŶĞƵƌŽŵƵƐĐƵůĂƌďůŽĐŬŝŶŐĂŐĞŶƚƵƚŝůŝǌĞĚƐƉĞĐŝĨŝĐĂůůǇƚŽĨĂĐŝůŝƚĂƚĞĞŶĚŽƚƌĂĐŚĞĂůŝŶƚƵďĂƚŝŽŶďǇ ĐŽŵƉůĞƚĞƉĂƌĂůǇƐŝƐŽĨŵƵƐĐƵůĂƌƚŽŶĞ DĞĐŚĂŶŝƐŵŽĨĐƚŝŽŶ WƌŽĚƵĐĞƐĐŽŵƉůĞƚĞŶĞƵƌŽŵƵƐĐƵůĂƌƉĂƌĂůǇƐŝƐďǇĚĞƉŽůĂƌŝǌŝŶŐƚŚĞŶĞƵƌŽŵƵƐĐƵůĂƌĞŶĚƉůĂƚĞĂŶĚ ƉƌĞǀĞŶƚŝŶŐƌĞƉŽůĂƌŝǌĂƚŝŽŶ͘/ŶĚŽŝŶŐƐŽ͕ŝƚƉƌŽĚƵĐĞƐŵŝŶƵƚĞ͕ďƵƚǀŝƐŝďůĞŵƵƐĐůĞŵŽǀĞŵĞŶƚƐĐĂůůĞĚ ĨĂƐĐŝĐƵůĂƚŝŽŶƐ͘dŚĞůĞŶŐƚŚŽĨĞĨĨĞĐƚĚĞƉĞŶĚƐŽŶƚŚĞĚŽƐĞĂŶĚƚŚĞƉĂƚŝĞŶƚ͛ƐĂďŝůŝƚǇƚŽŵĞƚĂďŽůŝǌĞƚŚĞĚƌƵŐ͘ /ŶŐĞŶĞƌĂůĨŽƌƚŚĞƌĂƉĞƵƚŝĐĚŽƐĂŐĞƐ͕ƚŚĞŽŶƐĞƚƚŝŵĞŝƐ|ϰϱƐĞĐŽŶĚƐĂŶĚƚŚĞĞĨĨĞĐƚƐůĂƐƚ|ϱŵŝŶƵƚĞƐ͘ /ŶĚŝĐĂƚŝŽŶƐ x dŽŝŶĚƵĐĞŶĞƵƌŽŵƵƐĐƵůĂƌƉĂƌĂůǇƐŝƐŝŶŽƌĚĞƌƚŽĨĂĐŝůŝƚĂƚĞĞŶĚŽƚƌĂĐŚĞĂůŝŶƚƵďĂƚŝŽŶ͘ ŽŶƚƌĂŝŶĚŝĐĂƚŝŽŶƐ x WĂƚŝĞŶƚƐŝŶǁŚŽŵĂƐƵƌŐŝĐĂůĂŝƌǁĂǇǁŽƵůĚďĞĚŝĨĨŝĐƵůƚŽƌŝŵƉŽƐƐŝďůĞ;ŝ͘Ğ͘ŵĂƐƐŝǀĞƐǁĞůůŝŶŐŽƌ ƐŝŐŶŝĨŝĐĂŶƚŶĞĐŬŝŶũƵƌǇͿ x WĂƚŝĞŶƚƐƚŚĂƚǁŽƵůĚďĞĚŝĨĨŝĐƵůƚ͕ŽƌŝŵƉŽƐƐŝďůĞƚŽŝŶƚƵďĂƚĞŽƌǀĞŶƚŝůĂƚĞĂĨƚĞƌƉĂƌĂůǇƐŝƐ;ŝ͘Ğ͘ƵŶƌĞƐŽůǀĞĚ ƵƉƉĞƌĂŝƌǁĂǇŽďƐƚƌƵĐƚŝŽŶŽƌĂĐƵƚĞĞƉŝŐůŽƚƚŝƚŝƐͿ ZĞůĂƚŝǀĞŽŶƚƌĂŝŶĚŝĐĂƚŝŽŶƐ /ĨŽŶĞŽĨƚŚĞĨŽůůŽǁŝŶŐŝƐƉƌĞƐĞŶƚ͕ƉĂƌĂůǇƐŝƐŵƵƐƚďĞƌĞĞǀĂůƵĂƚĞĚŽŶĂƌŝƐŬǀĞƌƐƵƐďĞŶĞĨŝƚƐďĂƐŝƐ͗

x WƌĞͲĞǆŝƐƚŝŶŐŚǇƉĞƌŬĂůĞŵŝĂŽƌƌŝƐŬĨŽƌŚǇƉĞƌŬĂůĞŵŝĂƐƵĐŚĂƐ͗ x ZĞŶĂůĨĂŝůƵƌĞƉĂƚŝĞŶƚƐ x ƌƵƐŚŝŶũƵƌǇхϭǁĞĞŬĂŐŽ x DĂũŽƌďƵƌŶƐхϮϰŚŽƵƌƐĂŐŽ x ^ƉŝŶĂůĐŽƌĚŝŶũƵƌǇďĞƚǁĞĞŶϭǁĞĞŬƚŽϲŵŽŶƚŚƐĂŐŽ x EĞƵƌŽŵƵƐĐƵůĂƌĚŝƐŽƌĚĞƌƐƐƵĐŚĂƐDƵůƚŝƉůĞ^ĐůĞƌŽƐŝƐ͕DƵƐĐƵůĂƌǇƐƚƌŽƉŚǇ͕ĂŵǇŽƚƌŽƉŚŝĐůĂƚĞƌĂů ƐĐůĞƌŽƐŝƐ;Ă͘Ŭ͘Ă͘>^Žƌ>ŽƵ'ĞŚƌŝŐ͛ƐŝƐĞĂƐĞͿ x ,ŝƐƚŽƌǇŽĨŵĂůŝŐŶĂŶƚŚǇƉĞƌƚŚĞƌŵŝĂ ^ŝĚĞĨĨĞĐƚƐ x ĂƌĚŝŽǀĂƐĐƵůĂƌ͗ŚǇƉŽƚĞŶƐŝŽŶ͕ďƌĂĚǇĐĂƌĚŝĂ͕ĂƌƌŚǇƚŚŵŝĂƐ͕ƚĂĐŚǇĐĂƌĚŝĂ͕ŚǇƉĞƌƚĞŶƐŝŽŶ x WƵůŵŽŶĂƌǇ͗ŚǇƉŽǀĞŶƚŝůĂƚŝŽŶ͕ĂƉŶĞĂ͕ďƌŽŶĐŚŽƐƉĂƐŵ x '/͗nƐĂůŝǀĂƚŝŽŶ͕nŝŶƚƌĂŐĂƐƚƌŝĐΘůŽǁĞƌĞƐŽƉŚĂŐĞĂůƉƌĞƐƐƵƌĞ xnŝŶƚƌĂŽĐƵůĂƌƉƌĞƐƐƵƌĞ͕ŚǇƉĞƌŬĂůĞŵŝĂ͕ŵĂůŝŐŶĂŶƚŚǇƉĞƌƚŚĞƌŵŝĂ͕ŵǇŽŐůŽďŝŶĞŵŝĂ ŽƐĂŐĞĂŶĚĚŵŝŶŝƐƚƌĂƚŝŽŶ x Adult͗ ϭ͘ϬͲϭ͘ϱŵŐͬŬŐ/sͬ/KŽƌϭ͘ϱʹϮ͘ϬŵŐͬŬŐ/D x Pediatric͗ Ϯ͘ϬŵŐͬŬŐ/sͬ/Dͬ/K

Cypress Creek EMS System Policies and Treatment Guidelines

376 MEDICATIONS Revised 8/2016 Approved: Levon Vartanian, MD

^ƉĞĐŝĂůŽŶƐŝĚĞƌĂƚŝŽŶƐ x ůůŵŽŶŝƚŽƌƐ;'͕ďͬƉ͕ƉƵůƐĞŽǆŝŵĞƚĞƌ͕ĐĂƉŶŽŐƌĂƉŚǇͿĂŶĚŝŶƚƵďĂƚŝŶŐĞƋƵŝƉŵĞŶƚƐŚĂůůďĞŝŶƉůĂĐĞ ƉƌŝŽƌƚŽƐĞĚĂƚŝŶŐĂŶĚƉĂƌĂůǇǌŝŶŐƚŚĞƉĂƚŝĞŶƚ x ƌŝĐŽŝĚƉƌĞƐƐƵƌĞƐŚĂůůďĞŵĂŝŶƚĂŝŶĞĚƵŶƚŝůƚŚĞĐƵĨĨŽŶƚŚĞdƚƵďĞŝƐŝŶĨůĂƚĞĚ x ^ŚŽƵůĚƚŚĞŝŶƚƵďĂƚŝŽŶďĞƵŶƐƵĐĐĞƐƐĨƵů͕ƚŚĞƉĂƚŝĞŶƚƐŚŽƵůĚďĞŽǆǇŐĞŶĂƚĞĚĂŶĚǀĞŶƚŝůĂƚĞĚƉƌŝŽƌƚŽĂŶǇ ĨƵƌƚŚĞƌĂƚƚĞŵƉƚƐ͘ x ƋƵŝƉŵĞŶƚƚŽƉĞƌĨŽƌŵĂŶĞŵĞƌŐĞŶĐǇŶĞĞĚůĞŽƌƐƵƌŐŝĐĂůĐƌŝĐŽƚŚǇƌŽƚŽŵǇƐŚŽƵůĚďĞƌĞĂĚŝůǇĂĐĐĞƐƐŝďůĞ x ĞĨŽƌĞƵƐŝŶŐ^ƵĐĐŝŶǇůĐŚŽůŝŶĞ͕ƚŚĞ/WƐŚŽƵůĚĂƐƐĞƐƐŝĨĂƉĂƚŝĞŶƚŵĂǇďĞĚŝĨĨŝĐƵůƚƚŽǀĞŶƚŝůĂƚĞ͕ŝŶƚƵďĂƚĞ͕ ŽƌƉůĂĐĞĂŶĞŵĞƌŐĞŶĐǇƐƵƌŐŝĐĂůĂŝƌǁĂǇ͘

Cypress Creek EMS System Policies and Treatment Guidelines

377 MEDICATIONS Revised 8/2016 Approved: Levon Vartanian, MD

dĞƚƌĂĐĂŝŶĞKƉŚƚŚĂůŵŝĐ^ŽůƵƚŝŽŶ DĞĚŝĐĂƚŝŽŶ ůŽĐĂůĂŶĞƐƚŚĞƚŝĐĂŐĞŶƚŽĨƚŚĞĞƐƚĞƌůŝŶŬĂŐĞƚǇƉĞ͕ƌĞůĂƚĞĚƚŽƉƌŽĐĂŝŶĞ͕ƵƐĞĚƚŽƉŝĐĂůůǇĂŶĚďǇŝŶĨŝůƚƌĂƚŝŽŶ͘ DĞĐŚĂŶŝƐŵŽĨĐƚŝŽŶ WƌĞǀĞŶƚƐŝŶŝƚŝĂƚŝŽŶĂŶĚƚƌĂŶƐŵŝƐƐŝŽŶŽĨŶĞƌǀĞŝŵƉƵůƐĞƐƚŚĞƌĞďǇĞĨĨĞĐƚŝŶŐůŽĐĂůĂŶĞƐƚŚĞƐŝĂ͘KŶƐĞƚŽĨ ĂŶĞƐƚŚĞƐŝĂƵƐƵĂůůǇďĞŐŝŶƐǁŝƚŚŝŶϯϬƐĞĐŽŶĚƐĂŶĚůĂƐƚƐĂƌĞůĂƚŝǀĞůǇƐŚŽƌƚƉĞƌŝŽĚ͘ /ŶĚŝĐĂƚŝŽŶƐ x &ŽƌƐŝƚƵĂƚŝŽŶƐŝŶǁŚŝĐŚĂƌĂƉŝĚĂŶĚƐŚŽƌƚĂĐƚŝŶŐƚŽƉŝĐĂůŽƉŚƚŚĂůŵŝĐĂŶĞƐƚŚĞƚŝĐŝƐŝŶĚŝĐĂƚĞĚ͘ x /ƚŝƐŵŽƐƚŽĨƚĞŶƵƐĞĚŝŶƚŚĞĨŝĞůĚƚƌĞĂƚŵĞŶƚŽĨďƵƌŶƐƚŽƚŚĞĞǇĞƐ͘ ŽŶƚƌĂŝŶĚŝĐĂƚŝŽŶƐ x <ŶŽǁŶŚǇƉĞƌƐĞŶƐŝƚŝǀŝƚǇ ^ŝĚĞĨĨĞĐƚƐ x dƌĂŶƐŝĞŶƚƌĞĂĐƚŝŽŶƐŵĂǇŽĐĐƵƌĂŶĚŝŶĐůƵĚĞƐƚŝŶŐŝŶŐ͕ďƵƌŶŝŶŐ͕ĂŶĚĐŽŶũƵŶĐƚŝǀĂůƌĞĚŶĞƐƐ͘KŶǀĞƌǇƌĂƌĞ ŽĐĐĂƐŝŽŶƐĂƐĞǀĞƌĞ͕ŝŵŵĞĚŝĂƚĞ͕ĂůůĞƌŐŝĐĐŽƌŶĞĂůƌĞĂĐƚŝŽŶŵĂǇŽĐĐƵƌ͘ ŽƐĂŐĞĂŶĚĚŵŝŶŝƐƚƌĂƚŝŽŶ 1-2 drops ĂƐŶĞĞĚĞĚŝŶŝŶũƵƌĞĚĞǇĞ;ƐͿ ^ƉĞĐŝĂůŽŶƐŝĚĞƌĂƚŝŽŶƐ x WƌŽůŽŶŐĞĚƵƐĞƌĞƐƵůƚƐŝŶĚŝŵŝŶŝƐŚĞĚĚƵƌĂƚŝŽŶŽĨĂŶĞƐƚŚĞƐŝĂĂŶĚƌĞƚĂƌĚĞĚŚĞĂůŝŶŐ͘ x WĂƚŝĞŶƚƐƐŚŽƵůĚďĞĂĚǀŝƐĞĚŶŽƚƚŽƚŽƵĐŚŽƌƌƵďƚŚĞĞǇĞ;ƐͿƵŶƚŝůƚŚĞĞĨĨĞĐƚŽĨƚŚĞĂŶĞƐƚŚĞƚŝĐŚĂƐǁŽƌŶ ŽĨĨ͘ x ŶǇƵŶƵƐĞĚƉŽƌƚŝŽŶƐƐŚŽƵůĚďĞĚŝƐĐĂƌĚĞĚ͘ŽŶŽƚŐŝǀĞďŽƚƚůĞƚŽƚŚĞƉĂƚŝĞŶƚ͘

Cypress Creek EMS System Policies and Treatment Guidelines

378 MEDICATIONS Revised 8/2016 Approved: Levon Vartanian, MD

dŚŝĂŵŝŶĞ DĞĚŝĐĂƚŝŽŶ ǀŝƚĂŵŝŶŽĨƚŚĞĐŽŵƉůĞǆƚŚĂƚŽĐĐƵƌƐŶĂƚƵƌĂůůǇĂŶĚŝƐƉƌŽĚƵĐĞĚƐǇŶƚŚĞƚŝĐĂůůǇ͘tŝĚĞůǇĚŝƐƚƌŝďƵƚĞĚŝŶ ǀĂƌŝŽƵƐĂŶŝŵĂůĂŶĚƉůĂŶƚĨŽŽĚƐ͕ĞƐƉĞĐŝĂůůǇǁŚĞĂƚŐĞƌŵ͕ĚƌǇǇĞĂƐƚ͕ŶƵƚƐ͕ůĞŐƵŵĞƐ͕ŵŽƐƚǀĞŐĞƚĂďůĞƐ͕ĂŶĚ ƐŽŵĞŵĞĂƚƐ͘ DĞĐŚĂŶŝƐŵŽĨĐƚŝŽŶ ƐƐĞŶƚŝĂůĨŽƌƚŚĞŶŽƌŵĂůŵĞƚĂďŽůŝƐŵŽĨĐĂƌďŽŚǇĚƌĂƚĞƐĂŶĚĨĂƚƐ /ŶĚŝĐĂƚŝŽŶƐ x ĞŶĞĨŝĐŝĂůĨŽƌƉĂƚŝĞŶƚƐƉƌĞƐĞŶƚŝŶŐǁŝƚŚƐŝŐŶƐĂŶĚƐǇŵƉƚŽŵƐŽĨĂůĐŽŚŽůƚŽǆŝĐŝƚǇ͕tĞƌŶŝĐŬĞ͛ƐƐǇŶĚƌŽŵĞ Žƌ<ŽƌƐĂŬŽĨĨ͛ƐƉƐǇĐŚŽƐŝƐ͘ ŽŶƚƌĂŝŶĚŝĐĂƚŝŽŶƐ x <ŶŽǁŶŚǇƉĞƌƐĞŶƐŝƚŝǀŝƚǇ ^ŝĚĞĨĨĞĐƚƐ x EŽŶĞ ŽƐĂŐĞĂŶĚĚŵŝŶŝƐƚƌĂƚŝŽŶ x 100 mg /sͬ/Dͬ/KĂŶĚƉƌŝŽƌƚŽĂĚŵŝŶŝƐƚĞƌŝŶŐϱϬ͘ ^ƉĞĐŝĂůŽŶƐŝĚĞƌĂƚŝŽŶƐ x /ŶĂůĐŽŚŽůŝĐƐ͕ƚŚŝĂŵŝŶĞĚĞĨŝĐŝĞŶĐǇĐĂƵƐĞƐtĞƌŶŝĐŬĞ͛ƐƐǇŶĚƌŽŵĞ͕ĂŶĂĐƵƚĞĂŶĚƌĞǀĞƌƐŝďůĞ ĞŶĐĞƉŚĂůŽƉĂƚŚǇĐŚĂƌĂĐƚĞƌŝǌĞĚďǇĂƚĂǆŝĂ͕ĞǇĞŵƵƐĐůĞǁĞĂŬŶĞƐƐ͕ĂŶĚŵĞŶƚĂůĚĞƌĂŶŐĞŵĞŶƚƐ͘ x ŵŽƌĞƐĞƌŝŽƵƐĐŽŵƉůŝĐĂƚŝŽŶŽĨƚŚŝĂŵŝŶĞĚĞĨŝĐŝĞŶĐǇŝƐŬŶŽǁŶĂƐ<ŽƌƐĂŬŽĨĨ͛ƐƉƐǇĐŚŽƐŝƐ͕ĂŵĞŵŽƌǇ ĚŝƐŽƌĚĞƌƚŚĂƚŵĂǇďĞŝƌƌĞǀĞƌƐŝďůĞŽŶĐĞŝƚďĞĐŽŵĞƐĞƐƚĂďůŝƐŚĞĚ͘^ŝŶĐĞƚŚŝĂŵŝŶĞŝƐƵƚŝůŝǌĞĚŝŶ ĐĂƌďŽŚǇĚƌĂƚĞŵĞƚĂďŽůŝƐŵ͕ƚŚĞƐĞƐǇŶĚƌŽŵĞƐŵĂǇďĞƉƌĞĐŝƉŝƚĂƚĞĚďǇƚŚĞĂĚŵŝŶŝƐƚƌĂƚŝŽŶŽĨĚĞǆƚƌŽƐĞ ƚŽƚŚĞĂůĐŽŚŽůŝĐǁŝƚŚƉƌĞĞǆŝƐƚŝŶŐƚŚŝĂŵŝŶĞĚĞĨŝĐŝĞŶĐǇ͘

Cypress Creek EMS System Policies and Treatment Guidelines

379 MEDICATIONS Revised 6/2019 Approved: Levon Vartanian, MD

sĞĐƵƌŽŶŝƵŵ;EŽƌĐƵƌŽŶͿ DĞĚŝĐĂƚŝŽŶ ŶŽŶͲĚĞƉŽůĂƌŝǌŝŶŐ;ĐŽŵƉĞƚŝƚŝǀĞͿ͕ĂŵŝŶŽƐƚĞƌŽŝĚ͕ŶĞƵƌŽŵƵƐĐƵůĂƌďůŽĐŬŝŶŐĂŐĞŶƚ DĞĐŚĂŶŝƐŵŽĨĐƚŝŽŶ dŚƌŽƵŐŚĐŽŵƉĞƚŝƚŝǀĞŝŶŚŝďŝƚŝŽŶďůŽĐŬƐĐŚŽůŝŶĞƌŐŝĐƌĞĐĞƉƚŽƌƐĂƚƚŚĞŵŽƚŽƌĞŶĚƉůĂƚĞŝŶŝƚŝĂƚŝŶŐĂ ŶĞƵƌŽŵƵƐĐƵůĂƌƉĂƌĂůǇƐŝƐǁŝƚŚŝŶ|ϯŵŝŶƵƚĞƐĂŶĚůĂƐƚŝŶŐ|ϮϱʹϯϬŵŝŶƵƚĞƐ /ŶĚŝĐĂƚŝŽŶƐ x dŽƐƵƐƚĂŝŶŶĞƵƌŽŵƵƐĐƵůĂƌƉĂƌĂůǇƐŝƐĂĨƚĞƌƚŚĞƉĂƚŝĞŶƚŚĂƐďĞĞŶŝŶƚƵďĂƚĞĚ ǁŝƚŚĂŶĞŶĚŽƚƌĂĐŚĞĂůƚƵďĞ͘ ŽŶƚƌĂŝŶĚŝĐĂƚŝŽŶƐ x EŽŶĞ ^ŝĚĞĨĨĞĐƚƐ x WƵůŵŽŶĂƌǇ͗ŚǇƉŽǀĞŶƚŝůĂƚŝŽŶ͕ĂƉŶĞĂ x ĂƌĚŝŽǀĂƐĐƵůĂƌ͗ƐůŝŐŚƚďƌĂĚǇĐĂƌĚŝĂ ŽƐĂŐĞΘĚŵŝŶŝƐƚƌĂƚŝŽŶ x 0.05–0.1 mg/kg /sͬ/K͕ŵĂǇƌĞƉĞĂƚĂƐŶĞĞĚĞĚǁŝƚŚŝŶϮϱͲϰϬŵŝŶƵƚĞƐ ^ƉĞĐŝĂůŽŶƐŝĚĞƌĂƚŝŽŶƐ x WƌĞŐŶĂŶĐǇ͗ŽŶƐŝĚĞƌƌŝƐŬǀĞƌƐƵƐďĞŶĞĨŝƚ͘ x ŶƐƵƌĞĂĚĞƋƵĂƚĞƐĞĚĂƚŝŽŶƉƌŝŽƌƚŽĂĚŵŝŶŝƐƚƌĂƚŝŽŶ͘ x /ĨƐƵĐĐŝŶǇůĐŚŽůŝŶĞŝƐƵƐĞĚĂƐŝŶŝƚŝĂůĂŐĞŶƚ͕ĚĞůĂǇĂĚŵŝŶŝƐƚƌĂƚŝŽŶŽĨǀĞĐƵƌŽŶŝƵŵƵŶƚŝůƐƵĐĐŝŶǇůĐŚŽůŝŶĞ ŚĂƐǁŽƌŶŽĨĨ͘ x WĞĚŝĂƚƌŝĐƉĂƚŝĞŶƚƐůĞƐƐƚŚĂŶϭϬǇĞĂƌƐŽůĚŵĂǇƌĞƋƵŝƌĞĂŚŝŐŚĞƌŝŶŝƚŝĂůĚŽƐĞĂŶĚŵŽƌĞĨƌĞƋƵĞŶƚ ƌĞĚŽƐŝŶŐ͘

Cypress Creek EMS System Policies and Treatment Guidelines

380 MEDICATIONS Revised 10/2018 Approved: Levon Vartanian, MD tŚŽůĞůŽŽĚΘůŽŽĚWƌŽĚƵĐƚƐ DĞĚŝĐĂƚŝŽŶ x >ŽǁdŝƚĞƌƚǇƉĞKͲƉŽƐŝƚŝǀĞĂŶĚƚǇƉĞKͲŶĞŐĂƚŝǀĞǁŚŽůĞďůŽŽĚ x WĂĐŬĞĚZĞĚůŽŽĚĞůůƐ x &ƌĞƐŚ>ŝƋƵŝĚWůĂƐŵĂ DĞĐŚĂŶŝƐŵŽĨĐƚŝŽŶ

x WĂĐŬĞĚZĞĚůŽŽĚĞůůƐĂŶĚtŚŽůĞůŽŽĚƌĞƉůĂĐĞŚĞŵŽŐůŽďŝŶ͕ǁŚŝĐŚĚĞůŝǀĞƌƐŽǆǇŐĞŶĂŶĚƌĞŵŽǀĞƐKϮ͕ ŝŵƉƌŽǀŝŶŐƉĞƌĨƵƐŝŽŶ͘ x &ƌĞƐŚ>ŝƋƵŝĚWůĂƐŵĂĂŶĚtŚŽůĞůŽŽĚƌĞƉůĂĐĞůŽƐƚĨůƵŝĚǀŽůƵŵĞ͕ĞůĞĐƚƌŽůǇƚĞƐ͕ĂŶĚƉůĂƐŵĂƉƌŽƚĞŝŶƐ͘sŽůƵŵĞ ƌĞƉůĂĐĞĚǁŝƚŚƉůĂƐŵĂŽƌǁŚŽůĞďůŽŽĚƌĞŵĂŝŶƐŝŶƚŚĞǀĂƐĐƵůĂƌƐƉĂĐĞ͕ƵŶůŝŬĞĐƌǇƐƚĂůůŽŝĚƐǁŚŝĐŚƐŚŝĨƚƚŽ ŝŶƚĞƌƐƚŝƚŝĂůƐƉĂĐĞƌĂƉŝĚůǇ͘ x tŚŽůĞďůŽŽĚĂůƐŽƌĞƉůĂĐĞƐƉůĂƚĞůĞƚƐĂŶĚĐůŽƚƚŝŶŐĨĂĐƚŽƌƐ͕ĂŝĚŝŶŐŝŶŚĞŵŽƐƚĂƐŝƐĂŶĚƌĞĚƵĐŝŶŐŽŶŐŽŝŶŐ ŚĞŵŽƌƌŚĂŐĞ͘ /ŶĚŝĐĂƚŝŽŶƐ x ,ĞŵŽƌƌŚĂŐŝĐƐŚŽĐŬĐĂƵƐĞĚďǇďůŽŽĚůŽƐƐ͘ZĞĨĞƌƚŽWhole Blood & Blood Product TransfusionĨŽƌƐƉĞĐŝĨŝĐ ƚƌĂŶƐĨƵƐŝŽŶŝŶĚŝĐĂƚŝŽŶĐƌŝƚĞƌŝĂ͘ ŽŶƚƌĂŝŶĚŝĐĂƚŝŽŶƐ x <ŶŽǁŶƚƌĂŶƐĨƵƐŝŽŶƌĞĂĐƚŝŽŶ x ŽĞƐŶŽƚŵĞĞƚŝŶĨƵƐŝŽŶĐƌŝƚĞƌŝĂ x WĂƚŝĞŶƚƌĞĨƵƐĂůĚƵĞƚŽƌĞůŝŐŝŽƵƐŽƌŽƚŚĞƌƌĞĂƐŽŶƐ ŽƐĂŐĞĂŶĚĚŵŝŶŝƐƚƌĂƚŝŽŶ Adult (age > 12 years): x >ŽǁƚŝƚĞƌƚǇƉĞͲKǁŚŽůĞďůŽŽĚ͗KŶĞƵŶŝƚ͘DĂǇƚƌĂŶƐĨƵƐĞƐĞĐŽŶĚƵŶŝƚŝĨƉĂƚŝĞŶƚĐŽŶƚŝŶƵĞƐƚŽŵĞĞƚƚƌĂŶƐĨƵƐŝŽŶ ŝŶĚŝĐĂƚŝŽŶĐƌŝƚĞƌŝĂ͘ x ůŽŽĚƉƌŽĚƵĐƚƐ͗ϭhŽĨĨƌĞƐŚůŝƋƵŝĚƉůĂƐŵĂ͕ϭhŽĨƉĂĐŬĞĚƌĞĚďůŽŽĚĐĞůůƐ͘DĂǇƌĞƉĞĂƚŝŶƉĂŝƌƐŝĨƉĂƚŝĞŶƚ ĐŽŶƚŝŶƵĞƐƚŽŵĞĞƚƚƌĂŶƐĨƵƐŝŽŶŝŶĚŝĐĂƚŝŽŶĐƌŝƚĞƌŝĂ͘ Pediatric (age 1–12 years): x >ŽǁƚŝƚĞƌƚǇƉĞͲKǁŚŽůĞďůŽŽĚ͗ϱϬŵ>ďŽůƵƐĞƐƵƉƚŽϭϬŵ>ͬŬŐ͘DĂǇƌĞƉĞĂƚŽŶĐĞŝĨƉĂƚŝĞŶƚĐŽŶƚŝŶƵĞƐƚŽŵĞĞƚ ƚƌĂŶƐĨƵƐŝŽŶŝŶĚŝĐĂƚŝŽŶĐƌŝƚĞƌŝĂ͘ x ůŽŽĚƉƌŽĚƵĐƚƐ͗ϱϬŵ>ďŽůƵƐĞƐŽĨĨƌĞƐŚůŝƋƵŝĚƉůĂƐŵĂĂŶĚƉĂĐŬĞĚƌĞĚďůŽŽĚĐĞůůƐ͕ƵƉƚŽϭϬŵ>ͬŬŐŽĨĞĂĐŚ͘DĂǇ ƌĞƉĞĂƚŽŶĐĞŝĨƉĂƚŝĞŶƚĐŽŶƚŝŶƵĞƐƚŽŵĞĞƚƚƌĂŶƐĨƵƐŝŽŶŝŶĚŝĐĂƚŝŽŶĐƌŝƚĞƌŝĂ ^ƉĞĐŝĂůŽŶƐŝĚĞƌĂƚŝŽŶƐ x ůǁĂǇƐƵƐĞĂŶĂƉƉƌŽǀĞĚĨůƵŝĚǁĂƌŵĞƌĚĞǀŝĐĞĨŽƌďůŽŽĚĂŶĚďůŽŽĚƉƌŽĚƵĐƚƚƌĂŶƐĨƵƐŝŽŶ͘DO NOT TRANSFUSE COLD BLOOD. x ZĞĨĞƌƚŽtŚŽůĞůŽŽĚΘůŽŽĚWƌŽĚƵĐƚƐdƌĂŶƐĨƵƐŝŽŶƉƌŽĐĞĚƵƌĞƉƌŽƚŽĐŽůĨŽƌƐƉĞĐŝĨŝĐƐŽĨƚƌĂŶƐĨƵƐŝŽŶ͘ x &ŽůůŽǁƌĞĐŽŵŵĞŶĚĞĚŐƵŝĚĞůŝŶĞƐĨŽƌƐƚŽƌŝŶŐ͕ƚƌĂŶƐƉŽƌƚŝŶŐ͕ĂŶĚŚĂŶĚůŝŶŐďůŽŽĚĂŶĚďůŽŽĚƉƌŽĚƵĐƚƐ͘ x ŵĞƌŐĞŶĐǇŵĂƐƐƚƌĂŶƐĨƵƐŝŽŶŽĨƵŶͲĐƌŽƐƐͲŵĂƚĐŚĞĚďůŽŽĚŽƌďůŽŽĚƉƌŽĚƵĐƚƐŚĂƐĂƌŝƐŬŽĨŵŝŶŽƌƚƌĂŶƐĨƵƐŝŽŶ ƌĞĂĐƚŝŽŶƐ͖ůŽǁͲƚŝƚĞƌǁŚŽůĞďůŽŽĚŚĂƐƚŚĞůŽǁĞƐƚƌŝƐŬĂŶĚƚǇƉĞKŚĂƐƵŶŝǀĞƌƐĂůƚǇƉĞĐŽŵƉĂƚŝďŝůŝƚǇ͘ x dŚĞZŚͲĨĂĐƚŽƌ;ŶĞŐĂƚŝǀĞŽƌƉŽƐŝƚŝǀĞͿĚŽĞƐŶŽƚŚĂǀĞƚŽďĞĂĚŝƌĞĐƚŵĂƚĐŚĨŽƌĞŵĞƌŐĞŶĐǇƚƌĂŶƐĨƵƐŝŽŶƐ͕ŚŽǁĞǀĞƌ͕ ŝĨĂŶZŚͲŶĞŐĂƚŝǀĞĨĞŵĂůĞƉĂƚŝĞŶƚƌĞĐĞŝǀĞƐZŚͲƉŽƐŝƚŝǀĞďůŽŽĚ͕ƚŚĞǇĐĂŶĚĞǀĞůŽƉĂŶƚŝďŽĚŝĞƐůĞĂĚŝŶŐƚŽƉŽƚĞŶƚŝĂů ĐŽŵƉůŝĐĂƚŝŽŶƐĚƵƌŝŶŐƉƌĞŐŶĂŶĐǇ͘dŚĞƐĞƉĂƚŝĞŶƚƐŵĂǇƌĞĐĞŝǀĞĂŵĞĚŝĐĂƚŝŽŶƚŽƚƌĞĂƚƚŚŝƐĂƚƚŚĞŚŽƐƉŝƚĂů͘

Cypress Creek EMS System Policies and Treatment Guidelines

381 APPENDICES Revised 8/2016 Approved: Levon Vartanian, MD

ƉƉĞŶĚŝĐĞƐ

BVM Nebulizer Setup ...... 383 Capnography ...... 384 Chain of Command and PhoneDirectory ...... 386 Medication Calculation/ Drips ...... 387 Operative IQ Check Sheet User Guide ...... 388 Station Map ...... 397 Truck Swap Checklist ...... 398 Underhood Inspection ...... 399

Cypress Creek EMS System Policies and Treatment Guidelines

382 APPENDICES Revised 9/2016 Approved: Levon Vartanian, MD

sDEĞďƵůŝǌĞƌ^ĞƚƵƉ

Cypress Creek EMS System Policies and Treatment Guidelines

383 APPENDICES Revised 8/2016 Approved: Levon Vartanian, MD

ĂƉŶŽŐƌĂƉŚǇ dKϮ͕ĐŝĚͲĂƐĞ͕ĂŶĚWĞƌĨƵƐŝŽŶ Respiratory Acidosis Respiratory Alkalosis Metabolic Acidosis Metabolic Alkalosis ĂƵƐĞ͗Hypoventilation ĂƵƐĞ͗Hyperventilation dKϮ͗>Žǁ dKϮ͗,ŝŐŚ ;ĚĞĐƌsŽƌŽďƐƚƌƵĐƚŝŽŶͿ WĂKϮ͗>Žǁ s͗,ŝŐŚ;ĐŽŵƉĞŶƐĂƚŝŶŐͿ s͗>Žǁ;ĐŽŵƉĞŶƐĂƚŝŶŐͿ WĂKϮ͗,ŝŐŚ dKϮ͗>Žǁ dKϮ͗,ŝŐŚ;ŝĨĂĚĞƋƵĂƚĞ ĚŝĨĨƵƐŝŽŶͬƉĞƌĨƵƐŝŽŶͿ *VE = Minute Ventilation (Tidal Volume x Respiratory Rate)

x dKϮůĞǀĞůƐĐŽƌƌĞůĂƚĞǁŝƚŚWĂKϮ;ĂƌƚĞƌŝĂůĐĂƌďŽŶĚŝŽǆŝĚĞͿůĞǀĞůƐ͘dKϮŝƐĂůǁĂǇƐůŽǁĞƌƚŚĂŶ WĂKϮ͕ĂŶĚŝŶŶŽƌŵĂůƉĂƚŝĞŶƚƐŝƐǁŝƚŚŝŶϱŵŵ,ŐŽĨWĂKϮ͘EŽƌŵĂůWĂKϮǀĂůƵĞƐĂƌĞϯϱʹϰϱŵŵ,Ő͕ ĂŶĚƚŚƵƐĂŶŽƌŵĂůdKϮǀĂůƵĞŝƐŝŶƚŚĞƌĂŶŐĞŽĨϯϬʹϰϱŵŵ,Ő͘ x PerfusionĂŶĚDiffusion ĐŚĂŶŐĞƐĂĨĨĞĐƚƚŚĞŐĂƉďĞƚǁĞĞŶdKϮĂŶĚWĂKϮ͘ŚŝŐŚWĂKϮŵĂǇďĞ ŵĂƐŬĞĚďǇƉŽŽƌƉĞƌĨƵƐŝŽŶŽƌƉŽŽƌĚŝĨĨƵƐŝŽŶ͕ĐĂƵƐŝŶŐƚŚĞdKϮƚŽƌĞĂĚůŽǁ͘ x /ŶĂƉĂƚŝĞŶƚǁŝƚŚŶŽƌŵĂůͲƚŽͲĞůĞǀĂƚĞĚŵŝŶƵƚĞǀĞŶƚŝůĂƚŝŽŶ͕ĂůŽǁdKϮ;ůŽǁWĂŽϮͿŝƐĂƐŝŐŶŽĨ ŵĞƚĂďŽůŝĐĂĐŝĚŽƐŝƐ͘ŽŵŵŽŶĐĂƵƐĞƐŽĨŵĞƚĂďŽůŝĐĂĐŝĚŽƐŝƐŝŶĐůƵĚĞ͗ x >ĂĐƚŝĐĂĐŝĚŽƐŝƐĨƌŽŵƐŚŽĐŬ x ŝĂďĞƚŝĐŬĞƚŽĂĐŝĚŽƐŝƐ x dŽǆŝĐŝŶŐĞƐƚŝŽŶͬĞǆƉŽƐƵƌĞ͕ŝŶĐůƵĚŝŶŐĂƐƉŝƌŝŶ͕ĂĐĞƚĂŵŝŶŽƉŚĞŶ͕ĂůĐŽŚŽů͕ŵĞƚŚĂŶŽů͕ŵĞƚĨŽƌŵŝŶ͕ ŐůǇĐŽůƐ͕ĂŶĚŝŶŚĂůĞĚƐŽůǀĞŶƚƐ͘ x ZĞŶĂůĨĂŝůƵƌĞ x ŝĂƌƌŚĞĂ x WĂƚŝĞŶƚƐĞǆƉĞƌŝĞŶĐŝŶŐŵĞƚĂďŽůŝĐĂĐŝĚŽƐŝƐĐŽŵƉĞŶƐĂƚĞďǇŝŶĐƌĞĂƐŝŶŐŵŝŶƵƚĞǀĞŶƚŝůĂƚŝŽŶ;ƌĞƐƉŝƌĂƚŽƌǇ ƌĂƚĞǆƚŝĚĂůǀŽůƵŵĞͿ͘ŚŝŐŚĞƌƚŚĂŶƵƐƵĂůǀĞŶƚŝůĂƚŽƌǇƌĂƚĞŵĂǇďĞƌĞƋƵŝƌĞĚŝĨŵĂŶƵĂůůǇǀĞŶƚŝůĂƚŝŶŐ ƉĂƚŝĞŶƚ͘ x DĞƚĂďŽůŝĐĂůŬĂůŽƐŝƐŝƐĐŽŵƉĂƌĂƚŝǀĞůǇƌĂƌĞ͕ďƵƚǁŽƵůĚƉƌĞƐĞŶƚǁŝƚŚĂŚŝŐŚWĂKϮĂŶĚŚŝŐŚdKϮ͕ĂŶĚ ĚĞĐƌĞĂƐĞĚŵŝŶƵƚĞǀĞŶƚŝůĂƚŝŽŶ;ƚŽĐŽŵƉĞŶƐĂƚĞͿ͘ŽŵŵŽŶĐĂƵƐĞƐŝŶĐůƵĚĞ͗ x sŽŵŝƚŝŶŐ x ŝƵƌĞƚŝĐƚŚĞƌĂƉǇ x ǇƐƚŝĐĨŝďƌŽƐŝƐ x ůŬĂůŝŶĞŝŶŐĞƐƚŝŽŶ x ZĞƐƉŝƌĂƚŽƌǇĂĐŝĚŽƐŝƐŽĐĐƵƌƐǁŝƚŚŚǇƉŽǀĞŶƚŝůĂƚŝŽŶĂŶĚƉƌĞƐĞŶƚƐǁŝƚŚŚŝŐŚWĂKϮĂŶĚŚŝŐŚdKϮ;ŝĨ ĚŝĨĨƵƐŝŽŶͬƉĞƌĨƵƐŝŽŶŝƐƐƵĨĨŝĐŝĞŶƚͿ͘ŚƌŽŶŝĐƌĞƐƉŝƌĂƚŽƌǇĂĐŝĚŽƐŝƐĐŽŵƉĞŶƐĂƚĞƐŽǀĞƌƚŝŵĞĂŶĚƚŚĞ ƉĂƚŝĞŶƚǁŝůůŚĂǀĞĂŶŽƌŵĂůƉ,ǁŝƚŚĂŚŝŐŚWĂKϮ͘ŽŵŵŽŶĐĂƵƐĞƐŝŶĐůƵĚĞ͗ x KďƐƚƌƵĐƚŝǀĞĚŝƐĞĂƐĞƐ;ĂƐƚŚŵĂ͕KWͿ x EĞƵƌŽŵƵƐĐƵůĂƌĚŝƐĞĂƐĞ;ŵǇĂƐƚŚĞŶŝĂŐƌĂǀŝƐ͕>^͕'ƵŝůůĂŝŶͲĂƌƌĠ͕ŵƵƐĐƵůĂƌĚǇƐƚƌŽƉŚǇͿ x KďĞƐŝƚǇ x ZĞƐƉŝƌĂƚŽƌǇĚĞƉƌĞƐƐŝŽŶĐĂƵƐĞĚďǇĚƌƵŐƐ͕ŵĞĚŝĐĂƚŝŽŶ͕ŽƌE^ĚŝƐŽƌĚĞƌƐ͘ x ZĞƐƉŝƌĂƚŽƌǇĂůŬĂůŽƐŝƐŽĐĐƵƌƐǁŝƚŚŚǇƉĞƌǀĞŶƚŝůĂƚŝŽŶĂŶĚƉƌĞƐĞŶƚƐǁŝƚŚůŽǁWĂKϮĂŶĚůŽǁdKϮ͘ ^ǇŵƉƚŽŵƐŵĂǇŝŶĐůƵĚĞƉĂƌĞƐƚŚĞƐŝĂ͕ƚĞƚĂŶǇ͕ĨĂŝŶƚŝŶŐ͕ĂŶĚĐƌĂŵƉŝŶŐ͘ŽŵŵŽŶĐĂƵƐĞƐŝŶĐůƵĚĞ͗ x E^ĚŝƐŽƌĚĞƌƐ;ƐƚƌŽŬĞ͕ŵĞŶŝŶŐŝƚŝƐ͕ƐƵďĂƌĂĐŚŶŽŝĚŚĞŵŽƌƌŚĂŐĞͿ x &ĞǀĞƌ

Cypress Creek EMS System Policies and Treatment Guidelines

384 APPENDICES Revised 8/2016 Approved: Levon Vartanian, MD

x dŽǆŝĐŝŶŐĞƐƚŝŽŶ;ŵĂǇŝŶĐůƵĚĞĂƐƉŝƌŝŶĂŶĚĐĂĨĨĞŝŶĞĂďƵƐĞͿ x WŶĞƵŵŽŶŝĂ x WƐǇĐŚŝĂƚƌŝĐĐĂƵƐĞƐ;ĂŶǆŝĞƚǇ͕ĂŐŝƚĂƚŝŽŶ͕ƐƚƌĞƐƐͿ x ǆĐŝƚĞĚĞůŝƌŝƵŵ ^ĂŵƉůĞdKϮtĂǀĞĨŽƌŵƐ Normal Tracing: x ƚŽŝƐďĂƐĞůŝŶĞ x ƚŽŝƐĞǆƉŝƌĂƚŽƌǇƵƉƐƚƌŽŬĞ x ƚŽŝƐĞǆƉŝƌĂƚŽƌǇƉůĂƚĞĂƵ x ŝƐĞŶĚͲƚŝĚĂůKϮǀĂůƵĞ x ƚŽŝŶƐƉŝƌĂƚŝŽŶďĞŐŝŶƐ

Esophageal Intubation: x DŝƐƐĞĚŽƌĚŝƐůŽĚŐĞĚŝŶƚƵďĂƚŝŽŶ x EŽƌŵĂůdKϮǁĂǀĞĨŽƌŵŝƐďĞƐƚĞǀŝĚĞŶĐĞŽĨ ƉƌŽƉĞƌƉůĂĐĞŵĞŶƚ

x >ŝƚƚůĞŽƌŶŽKϮŝƐƉƌĞƐĞŶƚŝĨƚƵďĞŝƐŝŶĞƐŽƉŚĂŐƵƐ

Inadequate Seal: x >ĞĂŬǇŽƌĚĞĨůĂƚĞĚĞŶĚŽƚƌĂĐŚĞĂůƚƵďĞĐƵĨĨ x ŶĚŽƚƌĂĐŚĞĂůƚƵďĞŝƐƚŽŽƐŵĂůůĨŽƌƉĂƚŝĞŶƚ

Bronchospasm: x WĂƌƚŝĂůůǇŬŝŶŬĞĚŽƌŽĐĐůƵĚĞĚĞŶĚŽƚƌĂĐŚĞĂůƚƵďĞ x WƌĞƐĞŶĐĞŽĨĨŽƌĞŝŐŶďŽĚǇŝŶĂŝƌǁĂǇ x ƌŽŶĐŚŽƐƉĂƐŵͬďƌŽŶĐŚŽĐŽŶƐƚƌŝĐƚŝŽŶ

Rebreathing: x /ŶĂĚĞƋƵĂƚĞŝŶƐƉŝƌĂƚŽƌǇĨůŽǁ x /ŶƐƵĨĨŝĐŝĞŶƚĞǆƉŝƌĂƚŽƌǇƚŝŵĞ x &ĂƵůƚǇĞǆƉŝƌĂƚŽƌǇǀĂůǀĞ Muscle Relaxants (curare cleft): x ƉƉĞĂƌǁŚĞŶŵƵƐĐůĞƌĞůĂǆĂŶƚƐ;ƉĂƌĂůǇƚŝĐƐͿ ďĞŐŝŶƚŽƐƵďƐŝĚĞ x ĞƉƚŚŽĨĐůĞĨƚŝƐŝŶǀĞƌƐĞůǇƉƌŽƉŽƌƚŝŽŶĂůƚŽ ĚĞŐƌĞĞŽĨĚƌƵŐĂĐƚŝǀŝƚǇ

Cypress Creek EMS System Policies and Treatment Guidelines

385 APPENDICES Revised 8/2016 Approved: Levon Vartanian, MD

ŚĂŝŶŽĨŽŵŵĂŶĚĂŶĚWŚŽŶĞŝƌĞĐƚŽƌǇ ZĞĨĞƌƚŽ^ƉĂŶŽĨŽŶƚƌŽůŽƉĞƌĂƚŝŽŶĂůƉŽůŝĐǇĨŽƌĚĞƚĂŝůƐŽŶĐŚĂŝŶŽĨĐŽŵŵĂŶĚ͘ Field/Operations ŵďƵůĂŶĐĞƐ͗ŵďƵůĂŶĐĞƚƌƵĐŬƉŚŽŶĞŶƵŵďĞƌƐĐŚĂŶŐĞƉĞƌŝŽĚŝĐĂůůǇ͘ZĞĨĞƌƚŽǇŽƵƌƚƌƵĐŬƉŚŽŶĞ͘

ϱϭ&ŝĞůĚ^ƵƉĞƌǀŝƐŽƌ͗;ϮϴϭͿϲϯϵͲϳϯϰϳ

ϱϮ&ŝĞůĚ^ƵƉĞƌǀŝƐŽƌ͗;ϳϭϯͿϮϱϵͲϱϭϰϬ

D^/d^ƵƉƉŽƌƚ͗;ϮϴϭͿϲϲϳͲϳϭϬϴ

D^DĂŝŶƚĞŶĂŶĐĞ͗;ϮϴϭͿϯϱϯͲϱϳϬϵ

D^ĚŵŝŶŝƐƚƌĂƚŝŽŶ͗;ϮϴϭͿϯϳϴͲϬϴϬϬ

D^^ĐŚĞĚƵůŝŶŐ͗;ϮϴϭͿϯϳϴͲϬϴϯϰ

Clinical/Administration /ĨĂĨŝĞůĚƐƵƉĞƌǀŝƐŽƌŝƐŶŽƚĂǀĂŝůĂďůĞŽƌŝƐƵŶĂďůĞƚŽŚĂŶĚůĞŝƚ͕ƚŚĞĨŝƌƐƚůŝŶĞĨŽƌƉƌŽďůĞŵƐŽƌŶŽƚŝĨŝĐĂƚŝŽŶŝƐ ƚŚĞĂĚŵŝŶŝƐƚƌĂƚŽƌŽŶĐĂůů͗;ϮϴϭͿϯϳϴͲϬϴϴϳ͘dŚŝƐŶƵŵďĞƌƌŽƚĂƚĞƐďĞŚŝŶĚĐůŝŶŝĐĂůĂĚŵŝŶŝƐƚƌĂƚŝŽŶƐƚĂĨĨ͘

&ŽƌƌŽƵƚŝŶĞĐůŝŶŝĐĂůƋƵĞƐƚŝŽŶƐŽƌĐŽŶĐĞƌŶƐ͕ĐĂůůƚŚĞD^ĚŵŝŶŝƐƚƌĂƚŝŽŶŶƵŵďĞƌĂďŽǀĞĚƵƌŝŶŐŶŽƌŵĂů ďƵƐŝŶĞƐƐŚŽƵƌƐĂŶĚƌĞƋƵĞƐƚƚŚĞĐůŝŶŝĐĂůĚĞƉĂƌƚŵĞŶƚ

Cypress Creek EMS System Policies and Treatment Guidelines

386 APPENDICES Revised 8/2016 Approved: Levon Vartanian, MD

DĞĚŝĐĂƚŝŽŶĂůĐƵůĂƚŝŽŶͬƌŝƉƐ

Volume on handŝƐŵ>ĂŵŽƵŶƚŝŶĐŽŶƚĂŝŶĞƌ͘ Drip factorŝƐĞŝƚŚĞƌϭϬŽƌϲϬŐƚƚͬŵ>͕ďĂƐĞĚŽŶĚƌŝƉƐĞƚ͘ Dosage on hand ŝƐŵŐͬŵĐŐĂŵŽƵŶƚŝŶĐŽŶƚĂŝŶĞƌ͘ Desired doseŝƐĞŝƚŚĞƌĂƐŝŶŐůĞĚŽƐĞŽƌƚŚĞĚŽƐĞƉĞƌŵŝŶƵƚĞ͘ Medication Infusion Drip Rate ݁ݏ݋݀݀݁ݎ݅ݏ݁݀ ൈ ݎ݌݂ܽܿݐ݋݅ݎ݀ ݋݈ݑ݉݁݋݄݊ܽ݊݀ ൈܸ ݐݐȀ ൌ݃ ܦ݋ݏܽ݃݁݋݄݊ܽ݊݀ Medication Administration Volume ݁ݏ݋݀݀݁ݎ݅ݏ݁݀ ݋݈ݑ݉݁݋݄݊ܽ݊݀ ൈܸ ൌ ݋݄݊ܽ݊݀ሺ݅݊ݒ݈݅ܽሻ݁݃ܽݏ݋ܦ Fluid Volume Over Time ݎ݌݂ܽܿݐ݋݅ݎ݀ ൈ ݀݁ݎݐ݁ݏ݋݈ݑ݉݁ݐ݋ܾܸ݁ܽ݀݉݅݊݅ ݐݐȀ ൌ݃ ݏݑݐ݁݊݅݉݊݅݁݉݅ܶ Dopamine Infusion* ݁ݏ݋݌ܽ݉݅݊݁݀݋ܦ ݐ݅݊݇݃ ൈ݄ܹ݃݅݁ ݐݐȀ ൌ݃ ʹ͸Ǥ͸ ΎďĂƐĞĚŽŶĂƐƚĂŶĚĂƌĚϴϬϬŵŐͬϱϬϬŵ>ĐŽŶĐĞŶƚƌĂƚŝŽŶ͕ǁŚŝĐŚǇŝĞůĚƐϮϲ͘ϲŵĐŐͬŐƚƚ͘Dopamine doseŝƐƚŚĞ ĚĞƐŝƌĞĚŶƵŵďĞƌĨƌŽŵϮʹϮϬŵĐŐͬŬŐͬŵŝŶ͘ Epinephrine Infusion* Rate Dosage ϲϬŐƚƚͬŵŝŶ ϭϬŵĐŐͬŵŝŶ ϰϱŐƚƚͬŵŝŶ ϳ͘ϱŵĐŐͬŵŝŶ ϯϬŐƚƚͬŵŝŶ ϱŵĐŐͬŵŝŶ ϭϱŐƚƚͬŵŝŶ Ϯ͘ϱŵĐŐͬŵŝŶ ϭϮŐƚƚͬŵŝŶ ϮŵĐŐͬŵŝŶ ΎĂƐĞĚŽŶĂϭŵŐͬϭϬϬŵ>ĐŽŶĐĞŶƚƌĂƚŝŽŶǁŝƚŚĂϲϬŐƚƚƐĞƚ

Cypress Creek EMS System Policies and Treatment Guidelines

387 APPENDICES Revised 8/2016 Approved: Levon Vartanian, MD

ŚĞĐŬ^ŚĞĞƚhƐĞƌ'ƵŝĚĞ Purpose dŚĞKƉĞƌĂƚŝǀĞ/YŚĞĐŬ^ŚĞĞƚŝƐƵƐĞĚĨŽƌƚŚĞĨŽůůŽǁŝŶŐ͗ x /ŶƐƉĞĐƚ/ŶǀĞŶƚŽƌǇ;/ŶǀĞŶƚŽƌǇͿ x ZĞĐŽƌĚ^ƵƉƉůŝĞƐhƐĞĚĨŽƌWĂƚŝĞŶƚĂƌĞ;>ŽŐWZͿ x ZĞƋƵĞƐƚ^ƵƉƉůŝĞƐ;ZĞƋƵĞƐƚ^ƵƉƉůŝĞƐͿ x WĞƌĨŽƌŵsĞŚŝĐůĞĂŶĚ^ƚĂƚŝŽŶ/ŶƐƉĞĐƚŝŽŶƐ;/ŶƐƉĞĐƚŝŽŶƐͿ Log In dŽŐĞƚƐƚĂƌƚĞĚĞŶƚĞƌĂhƐĞƌͬWĂƐƐǁŽƌĚĂŶĚĐůŝĐŬ>ŽŐŝŶ͘ Customer: cypresscreek(All one word, lower case. Usually already on screen) Login: &ŝƌƐƚŝŶŝƚŝĂůĂŶĚůĂƐƚŶĂŵĞ;ǆ͗:^ŵŝƚŚͿ Default Password: ϭϮϯϰ

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Shift Options dŚĞĨŽůůŽǁŝŶŐŽƉƚŝŽŶƐŵĂǇďĞĂǀĂŝůĂďůĞƚŽďĞŐŝŶĂƐŚŝĨƚ͗ x New Shift ʹ^ĞůĞĐƚƚŽƐƚĂƌƚĂŶĞǁƐŚŝĨƚĂŶĚĐůŽƐĞĂŶǇƐŚŝĨƚƐĐƵƌƌĞŶƚůǇŽƉĞŶ͘ x ;dŚŝƐĂƵƚŽŵĂƚŝĐĂůůǇůŽŐƐŽĨĨĂŶǇŽƚŚĞƌƵƐĞƌƐ͘Ϳ x Join Shift ʹ^ĞůĞĐƚƚŽũŽŝŶĂƐŚŝĨƚƚŚĂƚŝƐĐƵƌƌĞŶƚůǇĂĐƚŝǀĞ͘ x Continue Shift ʹ^ĞůĞĐƚƚŽĐŽŶƚŝŶƵĞĂƉƌĞǀŝŽƵƐƐŚŝĨƚŝĨƚĞŵƉŽƌĂƌŝůǇůŽŐŐĞĚŽĨĨ͘

Cypress Creek EMS System Policies and Treatment Guidelines

388 APPENDICES Revised 8/2016 Approved: Levon Vartanian, MD

KŶĐĞĂƵŶŝƚŝƐƐĞůĞĐƚĞĚ͕ƚŚĞŵĞŶƵďĂƌǁŝůůĂƉƉĞĂƌƚŽƚŚĞůĞĨƚŽĨƚŚĞƉĂŐĞ͘dŚŝƐĐĂŶďĞŚŝĚĚĞŶďǇĐůŝĐŬŝŶŐ ƚŚĞDĞŶƵďƵƚƚŽŶŽŶƚŚĞƚŽƉďĂƌ͘ Menu Applications WĞƌĨŽƌŵ/ŶƐƉĞĐƚŝŽŶƐ ^ĞůĞĐƚInspections ŝŶƚŚĞŵĞŶƵďĂƌƚŽƚŚĞůĞĨƚĂŶĚƚŚĞŶƚŚĞ/ŶƐƉĞĐƚŝŽŶYƵĞƐƚŝŽŶŶĂŝƌĞ ǇŽƵǁŝƐŚƚŽ ĂŶƐǁĞƌ͘ dŚĞYƵĞƐƚŝŽŶŶĂŝƌĞƐĂƌĞĐŽůŽƌĐŽĚĞĚƚŽƋƵŝĐŬůǇƐĞĞǁŚĂƚǁŽƌŬŚĂƐďĞĞŶĐŽŵƉůĞƚĞĚ͘ Red ʹEŽƚŚĞĐŬĞĚ

Green ʹŚĞĐŬĞĚŽŵƉůĞƚĞ ŶƐǁĞƌƚŚĞƋƵĞƐƚŝŽŶƐŽŶƚŚĞĨŽƌŵ͘YƵĞƐƚŝŽŶƐǁŝƚŚĂƌĞĚΎĂƌĞƌĞƋƵŝƌĞĚ͘ĚĚŽŵŵĞŶƚƐƚŽĂŶǇŽĨƚŚĞ ƌĞƐƉŽŶƐĞƐ͘tŚĞŶĐŽŵƉůĞƚĞĐůŝĐŬ^Ƶďŵŝƚ͘/ĨƚŚĞ/ŶƐƉĞĐƚŝŽŶYƵĞƐƚŝŽŶŶĂŝƌĞǁĂƐĐŽŵƉůĞƚĞĚŝƚǁŝůůƚƵƌŶƚŚĞ ^ƚĂƚƵƐƚŽ'ƌĞĞŶʹŚĞĐŬĞĚŽŵƉůĞƚĞ͘

Cypress Creek EMS System Policies and Treatment Guidelines

389 APPENDICES Revised 8/2016 Approved: Levon Vartanian, MD

Perform Inventory ^ĞůĞĐƚƚŚĞInventory ďƵƚƚŽŶŽŶƚŚĞůĞĨƚŵĞŶƵďĂƌĂŶĚƚŚĞŶƐĞůĞĐƚƚŚĞŝŶǀĞŶƚŽƌǇŐƌŽƵƉ ;ĐĂďŝŶĞƚƚǇƉĞͿƚŽ ďĞĐŚĞĐŬĞĚ͘dŚĞŝŶǀĞŶƚŽƌǇŐƌŽƵƉƐĂƌĞĐŽůŽƌĐŽĚĞĚƚŽƋƵŝĐŬůǇƐĞĞǁŚĂƚǁŽƌŬŚĂƐďĞĞŶ ĐŽŵƉůĞƚĞĚ͘ Red ʹEŽƚŚĞĐŬĞĚ Yellow ʹŚĞĐŬĞĚǁŝƚŚǆĐĞƉƚŝŽŶƐ Green ʹŚĞĐŬĞĚŽŵƉůĞƚĞ EĞǆƚƐĞůĞĐƚƚŚĞCabinet ƚŽďĞŝŶǀĞŶƚŽƌŝĞĚ͘

sĞƌŝĨǇƚŚĞĐĂďŝŶĞƚŝŶǀĞŶƚŽƌǇĂŐĂŝŶƐƚƚŚĞƌĞƋƵŝƌĞĚWZůĞǀĞů͘hƐĞƚŚĞSet to Par ďƵƚƚŽŶĂŶĚͬŽƌƚŚĞнͬͲ ďƵƚƚŽŶƐƚŽĂĚũƵƐƚƚŚĞƋƵĂŶƚŝƚŝĞƐ͘ ŶƚĞƌĞǆƉŝƌĂƚŝŽŶĚĂƚĞƐǁŚĞƌĞƌĞƋƵŝƌĞĚ͘/ĨƚŚĞƌĞŝƐŵŽƌĞƚŚĂŶŽŶĞĞǆƉŝƌĂƚŝŽŶĚĂƚĞĨŽƌĂŶŝƚĞŵ͕ĞŶƚĞƌƚŚĞ ŶĞǆƚŽĐĐƵƌƌŝŶŐĚĂƚĞ͘

tŚĞŶĐŽŵƉůĞƚĞĐůŝĐŬ^ĂǀĞ͘ ^ƵƉƉůŝĞƐƚŚĂƚĂƌĞŶĞĞĚĞĚƚŽƌĞƚƵƌŶƚŚĞĐĂďŝŶĞƚƚŽWZǁŝůůďĞĂĚĚĞĚƚŽƚŚĞƐƵƉƉůǇƌĞƋƵĞƐƚ͘ůŝĐŬ^Ƶďŵŝƚ ƚŽƐĞŶĚƚŚĞƐƵƉƉůǇƌĞƋƵĞƐƚƚŽƚŚĞ^ƚĂƚŝŽŶ^ƵƉƉůǇZŽŽŵ͘ ĂďŝŶĞƚƐƚĂƚƵƐǁŝůůďĞƵƉĚĂƚĞĚĂĐĐŽƌĚŝŶŐůǇ͘ ^ĞĂůĞĚĂďŝŶĞƚƐ ^ŽŵĞĐĂďŝŶĞƚƐĂƌĞƐĞĂůĞĚƚŽĂĚĚĞĨĨŝĐŝĞŶĐǇƚŽƚŚĞŝŶǀĞŶƚŽƌǇƉƌŽĐĞƐƐ͘^ĞĂůĞĚĐĂďŝŶĞƚƐǁŝůůŽŶůǇƌĞƋƵŝƌĞ ǀĞƌŝĨŝĐĂƚŝŽŶŝĨƚŚĞƐĞĂůŶƵŵďĞƌŝƐŵŝƐƐŝŶŐŽƌĚŝĨĨĞƌĞŶƚĨƌŽŵƚŚĞŶƵŵďĞƌůŝƐƚĞĚ͘

Cypress Creek EMS System Policies and Treatment Guidelines

390 APPENDICES Revised 8/2016 Approved: Levon Vartanian, MD

KƉĞƌĂƚŝǀĞ/YǁŝůůŝŶĚŝĐĂƚĞŝĨƚŚĞƐĞĂůŶƵŵďĞƌŝƐŵŝƐƐŝŶŐŽƌŝĨƚŚĞĐĂďŝŶĞƚĐŽŶƚĂŝŶƐĂŶǇĞǆƉŝƌĞĚƉĂƌƚƐ͘ ^ĞĂůĞĚĐĂďŝŶĞƚƐŵĂǇƌĞƋƵŝƌĞϭŽƌϮƐĞĂůŶƵŵďĞƌƐĚĞƉĞŶĚŝŶŐŽŶƚŚĞĐĂďŝŶĞƚƐŝǌĞ͘ dŽǀĞƌŝĨǇĂƐĞĂůŶƵŵďĞƌŝƐĐŽƌƌĞĐƚ͗ ϭ͘'ƌĂǇŚĞĐŬDĂƌŬĐĂŶďĞĐůŝĐŬĞĚŝĨƚŚĞƐĞĂůƐŵĂƚĐŚĂŶĚĂƌĞƵŶďƌŽŬĞŶ Ϯ͘ŶƚĞƌƚŚĞ^ĞĂůEƵŵďĞƌŝŶƚŚĞYƵŝĐŬ^ĞĂůŝŶƉƵƚďŽǆ dŽĞŶƚĞƌĂŶĞǁƐĞĂůŶƵŵďĞƌ͕ŝŶǀĞŶƚŽƌǇƚŚĞĐĂďŝŶĞƚĨŝƌƐƚĂŶĚĐůŝĐŬ^Ƶďŵŝƚ͘/ĨƚŚĞĐĂďŝŶĞƚŝƐĂƚĨƵůůWZƚŚĞŶ ĂƉƌŽŵƉƚǁŝůůĂƉƉĞĂƌƚŽĞŶƚĞƌĂƐĞĂůŶƵŵďĞƌ͘

Log Patient Usage dŚŝƐĨƵŶĐƚŝŽŶƚƌĂĐŬƐƐƵƉƉůǇƵƐĂŐĞďǇŝŶĐŝĚĞŶƚŶƵŵďĞƌ͘

^ƚĂƌƚďǇĞŶƚĞƌŝŶŐƚŚĞWĂƚŝĞŶƚĂƌĞZĞĐŽƌĚCall Number͘ dŚĞŶĐůŝĐŬAdd Supplies͘ ůůƐƵƉƉůŝĞƐŽŶƚŚĞƵŶŝƚĂƌĞĚŝƐƉůĂǇĞĚĂŶĚĂƌĞŽƌŐĂŶŝǌĞĚĂůƉŚĂďĞƚŝĐĂůůǇ͘dŽŶĂƌƌŽǁĚŽǁŶƐƉĞĐŝĨŝĐŝƚĞŵƐ͕ ƵƐĞƚŚĞĨŽůůŽǁŝŶŐŽƉƚŝŽŶƐ͗ ^ĞĂƌĐŚďŽǆƚŽĞŶƚĞƌƚŚĞŶĂŵĞŽĨĂƐƉĞĐŝĨŝĐƉĂƌƚ hƐĞƚŚĞĂůƉŚĂďĞƚďƵƚƚŽŶƐƚŽŶĂƌƌŽǁĚŽǁŶďǇĨŝƌƐƚůĞƚƚĞƌ &ŝůƚĞƌĨŽƌƉĂƌƚƐŝŶĂƐƉĞĐŝĨŝĐĐĂďŝŶĞƚ

Cypress Creek EMS System Policies and Treatment Guidelines

391 APPENDICES Revised 8/2016 Approved: Levon Vartanian, MD

^ĞůĞĐƚƚŚĞƐƵƉƉůŝĞƐƵƐĞĚŽŶƚŚĞĐĂůůĂŶĚƚŚĞĐĂďŝŶĞƚƚŚĞǇǁĞƌĞƵƐĞĚĨƌŽŵŝĨƐƚŽĐŬĞĚŝŶŵƵůƚŝƉůĞ ĐĂďŝŶĞƚƐ͘tŚĞŶĐŽŵƉůĞƚĞĐůŝĐŬAdd to Call͘ ĨƚĞƌƐĞůĞĐƚŝŶŐƚŚĞŝƚĞŵƐ͕ƌĞǀŝĞǁƚŚĞĐĂůů͛ƐƐƵƉƉůǇůŝƐƚ͘ĚĚŵŽƌĞƐƵƉƉůŝĞƐŝĨŶĞĞĚĞĚŽƌŵŽĚŝĨǇƚŚĞĐĂůů ŶƵŵďĞƌďĞĨŽƌĞƐƵďŵŝƚƚŝŶŐ͘tŚĞŶĐŽŵƉůĞƚĞĐůŝĐŬSubmit Call͘

^ƵƉƉůŝĞƐƵƐĞĚŽŶƚŚĞĐĂůůǁŝůůďĞĂĚĚĞĚƚŽǇŽƵƌSupply Request͘ĂďŝŶĞƚƐƚĂƚƵƐĞƐǁŝůůďĞƵƉĚĂƚĞĚ ĂĐĐŽƌĚŝŶŐůǇ͘^ƵƉƉůŝĞƐŵƵƐƚƐƚŝůůďĞƐĞŶƚďĞĨŽƌĞƚŚĞƌĞƋƵĞƐƚŐŽĞƐƚŽƚŚĞ^ƚĂƚŝŽŶ^ƵƉƉůǇZŽŽŵ͘

Cypress Creek EMS System Policies and Treatment Guidelines

392 APPENDICES Revised 8/2016 Approved: Levon Vartanian, MD

Request Supplies KŶĐĞĂƐƵƉƉůǇůŝƐƚŚĂƐďĞĞŶƐƵďŵŝƚƚĞĚ͕ĂŐƌĞĞŶĞǆĐůĂŵĂƚŝŽŶƉŽŝŶƚǁŝůůĂƉƉĞĂƌŶĞǆƚ ƚŽďŽƚŚƚŚĞRequest SuppliesďƵƚƚŽŶŽŶƚŚĞůĞĨƚŵĞŶƵďĂƌĂŶĚƚŚĞDĞŶƵďƵƚƚŽŶŽŶ ƚŚĞƚŽƉďĂƌ͘^ĞůĞĐƚƚŚĞRequest SuppliesďƵƚƚŽŶŽŶƚŚĞůĞĨƚŵĞŶƵďĂƌƚŽƚŚĞƐĞĞ ƚŚĞƐƵƉƉůǇůŝƐƚ͘

x ZĞǀŝĞǁƚŚĞƉĂƌƚƐůŝƐƚĞĚŽŶƚŚĞ^ƵƉƉůǇZĞƋƵĞƐƚ͘ x ^ƵƉƉůŝĞƐĐĂŶŶŽǁďĞƌĞƋƵĞƐƚĞĚIf truck is connected to the internet͘ x tŚĞŶĐŽŵƉůĞƚĞĐůŝĐŬ^Ƶďŵŝƚ͘ x DŽŶŝƚŽƌƚŚĞƐƚĂƚƵƐŽĨǇŽƵƌƌĞƋƵĞƐƚĨƌŽŵƚŚĞZĞƋƵĞƐƚ^ƵƉƉůŝĞƐƉĂŐĞ͘ x KŶĐĞĂĐĐĞƉƚĞĚƚŚĞƋƵĂŶƚŝƚǇĨŝůůĞĚǁŝůůďĞĂĚĚĞĚƚŽƚŚĞĂƉƉƌŽƉƌŝĂƚĞĐĂďŝŶĞƚ͕ďƵƚƚŚĞĐĂďŝŶĞƚ ŝŶǀĞŶƚŽƌǇǁŝůůƐƚŝůůŶĞĞĚƚŽďĞǀĞƌŝĨŝĞĚďĞĨŽƌĞŝƚǁŝůůďĞŵĂƌŬĞĚ'ƌĞĞŶʹŚĞĐŬĞĚŽŵƉůĞƚĞ͘

Cypress Creek EMS System Policies and Treatment Guidelines

393 APPENDICES Revised 8/2016 Approved: Levon Vartanian, MD

Unit Menu ŚĂŶŐĞhŶŝƚƐ dŽĐŚĂŶŐĞhŶŝƚƐǁŝƚŚŽƵƚůŽŐŐŝŶŐŽƵƚͬŝŶŐŽƚŽƚŚĞůĞĨƚDĞŶƵďĂƌĂŶĚƐĞůĞĐƚChange Unit͘ ^ĞůĞĐƚǁŚĞƚŚĞƌƚŽůŽƐĞǇŽƵƌƐŚŝĨƚŽƌdĞŵƉŽƌĂƌŝůǇ>ŽŐŽƵƚďĞĨŽƌĞƐĞůĞĐƚŝŶŐƚŚĞŶĞǆƚhŶŝƚ͘ Close ʹdŚŝƐǁŝůůĐůŽƐĞƚŚĞƐŚŝĨƚĂŶĚǁŝůůŶŽƚĂĨĨĞĐƚŽƚŚĞƌƵƐĞƌƐůŽŐŐĞĚŽŶƚŽƚŚĞƐĂŵĞƐŚŝĨƚ Temp. Logout ʹůůŽǁƐůŽŐŐŝŶŐŽĨĨǁŝƚŚŽƵƚĐůŽƐŝŶŐƚŚĞƐŚŝĨƚ

ĨƚĞƌůŽŐŐŝŶŐŽƵƚƐĞůĞĐƚǇŽƵƌƵŶŝƚƚŽĐŽŶƚŝŶƵĞĂƐƵƐƵĂů͘

Change Unit Status ŚĂŶŐŝŶŐĂƵŶŝƚ͛ƐƐƚĂƚƵƐŝƐŶĞĐĞƐƐĂƌǇĨŽůůŽǁĂƵŶŝƚĞǆĐŚĂŶŐĞƚŽƐŚŽǁǁŚĞƚŚĞƌĂƚƌƵĐŬŝƐ /ŶͲ^ĞƌǀŝĐĞ͕KƵƚŽĨ^ĞƌǀŝĐĞŽƌĂǀĂŝůĂďůĞĂƐĂƌĞƐĞƌǀĞ͘ dŽĐŚĂŶŐĞĂhŶŝƚ͛ƐƐƚĂƚƵƐǁŝƚŚŽƵƚŐŽŝŶŐƚŽƚŚĞďĂĐŬŽĨĨŝĐĞ͕ƐĞůĞĐƚƚŚĞChange Unit Status ŽŶƚŚĞůĞĨƚDĞŶƵďĂƌ͘^ĞůĞĐƚƚŚĞƐƚĂƚƵƐĨƌŽŵƚŚĞƉŽƉͲƵƉǁŝŶĚŽǁ͘

View Activity Log dŚŝƐĚŝƐƉůĂǇƐĂůůĂĐƚŝǀŝƚǇĨŽƌĂŐŝǀĞŶƵŶŝƚďǇĚĂƚĞ͕ƚŝŵĞ͕ĂĐƚŝŽŶƚĂŬĞŶĂŶĚĐƌĞǁŵĞŵďĞƌ͘

Cypress Creek EMS System Policies and Treatment Guidelines

394 APPENDICES Revised 8/2016 Approved: Levon Vartanian, MD

View Unit Details dŚŝƐĚŝƐƉůĂǇƐĂůůŝŶĨŽƌŵĂƚŝŽŶĂďŽƵƚĐĂďŝŶĞƚƐŽŶĂŐŝǀĞŶƵŶŝƚŝŶĐůƵĚŝŶŐĂůůŝƚĞŵƐ͕ǁŚŝĐŚĐĂďŝŶĞƚƚŚĞǇƐŚŽƵůĚ ďĞůŽĐĂƚĞĚŝŶ͕ƋƵĂŶƚŝƚǇĂŶĚǁŚĞƚŚĞƌŽƌŶŽƚƚŚĞĐĂďŝŶĞƚƐŚĂǀĞďĞĞŶĐŚĞĐŬĞĚ͘

System Menu ZĞǦƐǇŶĐĂƚĂ;&ƵůůĂƚĂZĞůŽĂĚͿ /ĨƚŚĞĚĂƚĂĚŽĞƐŶŽƚĂƉƉĞĂƌƚŽďĞĐƵƌƌĞŶƚ͕ĂFull Data Reload ĐĂŶďĞŝŶŝƚŝĂƚĞĚ͘dŚŝƐǁŝůů ĚĞůĞƚĞƚŚĞůŽĐĂů ƐƚŽƌĂŐĞĂŶĚƐǇŶĐŚƌŽŶŝǌĞƚŚĞĚĂƚĂǁŝƚŚƚŚĞƐĞƌǀĞƌ͘ /ŶŝƚŝĂƚĞƚŚĞƌĞůŽĂĚďǇŐŽŝŶŐƚŽƚŚĞůĞĨƚDĞŶƵďĂƌĂŶĚĐůŝĐŬŝŶŐRe-sync Data͘ƉƌŽŵƉƚǁŝůů ĂƉƉĞĂƌƚŽĐŽŶĨŝƌŵƚŚĞƐǇƐƚĞŵƐŚŽƵůĚŵĂŬĞĂĨŽƌĐĞĚĚĂƚĂƐǇŶĐ͘hƉŽŶĐŽŵƉůĞƚŝŽŶƚŚĞ ůŽŐŝŶƉĂŐĞǁŝůůĂƉƉĞĂƌ͘ Note: A Re-sync Data (Full Data Reload) can only be performed while connected to the Internet.

Cypress Creek EMS System Policies and Treatment Guidelines

395 APPENDICES Revised 8/2016 Approved: Levon Vartanian, MD

Refresh Page Refresh Page ĨŽƌĐĞƐƚŚĞƐǇƐƚĞŵƚŽƌĞĨƌĞƐŚƚŚĞĐƵƌƌĞŶƚƉĂŐĞŝĨƚŚĞƌĞŝƐĂŶĞĞĚƚŽƋƵŝĐŬůǇƐĞĞƵƉĚĂƚĞƐ ŵĂĚĞĨƌŽŵƚŚĞďĂĐŬŽĨĨŝĐĞ͘ ^ĞůĞĐƚƚŚĞZĞĨƌĞƐŚWĂŐĞďƵƚƚŽŶŝŶƚŚĞůĞĨƚDĞŶƵďĂƌĂŶĚƚŚĞƌĞĨƌĞƐŚǁŝůůŽĐĐƵƌ͘

Cypress Creek EMS System Policies and Treatment Guidelines

396 APPENDICES Revised 8/2016 Approved: Levon Vartanian, MD

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Station 50:ϱϭͬDĂŝŶ^ƵƉƉůǇ Station 23: ϱϮ;ǇƉƌĞƐƐƌĞĞŬ&Ϳ ϭϲϲϱϬ^ƵŐĂƌWŝŶĞ>Ŷ͕,ŽƵƐƚŽŶ͕dyϳϳϬϵϬ ϵϴϲϬǇƉƌĞƐƐǁŽŽĚƌ͕,ŽƵƐƚŽŶ͕dyϳϳϬϳϬ Station 51: DϱϭͬDϱϬϭͬDϱϮϭ Station 57: Dϱϳ ϭϲϬϯƐŚDĞĂĚŽǁƌ͕,ŽƵƐƚŽŶ͕dyϳϳϬϵϬ ϭϰϱϬϯĂŵŵĞůE,ŽƵƐƚŽŶZĚ͕^ƵŝƚĞϰϬϭ͕ ,ŽƵƐƚŽŶ͕dyϳϳϬϭϰ Station 52:DϱϮ ϯϯϬϴdƌĞĂƐĐŚǁŝŐZĚ͕,ƵŵďůĞ͕dyϳϳϯϯϴ Station 58: DϱϴͬDϱϮϴ ϭϮϮϭϰ'ƌĂŶƚZĚ͕ǇƉƌĞƐƐ͕dyϳϳϰϮϵ Station 53: Dϱϯ;&ƵĞůͿ ϭϯϲϬϯWĞƌƌǇZĚ͕,ŽƵƐƚŽŶ͕dyϳϳϬϳϬ Station 59: Dϱϵͬ^ƉĞĐKƉƐͬĚŵŝŶ;&ƵĞůͿ ϳϭϭϭ&ŝǀĞ&ŽƌŬƐƌ͕^ƉƌŝŶŐ͕dyϳϳϯϳϵ Station 54: Dϱϰ ϮϬϮϮϱ^ƚƵĞďŶĞƌŝƌůŝŶĞZĚ͕^ƉƌŝŶŐ͕dyϳϳϯϳϵ Station 510:DϱϭϬ ϮϬϴϭϬ>ĞĞZĚ͕,ƵŵďůĞ͕dyϳϳϯϯϴ Station 55:Dϱϱ;ŚĂŵƉŝŽŶƐ&Ϳ ϭϮϳϮϲŚĂŵƉŝŽŶ&ŽƌĞƐƚƌ͕,ŽƵƐƚŽŶ͕dyϳϳϬϲϲ Station 511:Dϱϭϭ ϮϴϴϮϲEůĚƌŝĚŐĞWŬǁǇ͕dŽŵďĂůů͕dyϳϳϯϳϳ Station 56:DϱϲͬDĂŝŶƚĞŶĂŶĐĞ;&ƵĞůͿ ϮϬϵϮϯ,ŽůǌǁĂƌƚŚZĚ͕^ƉƌŝŶŐ͕dyϳϳϯϴϴ Station 512:DϱϭϮ;tŽŽĚůĂŶĚƐ&^ƚĂƚŝŽŶϭϬϴͿ ϮϲϳϮϮ<ƵǇŬĞŶĚĂŚůZĚ͕^ƉƌŝŶŐ͕dyϳϳϯϴϵ Station 513: DϱϭϯͬDϱϲϯ;^ƉƌŝŶŐ&^ƚĂƚŝŽŶϳϬͿ ϮϮϯϭϬ^ƉƌŝŶŐǁŽŽĚƐsŝůůĂŐĞWŬǁǇ͘ ^ƉƌŝŶŐ͕dyϳϳϯϴϵ

Cypress Creek EMS System Policies and Treatment Guidelines

397 APPENDICES Revised 8/2016 Approved: Levon Vartanian, MD

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Cypress Creek EMS System Policies and Treatment Guidelines

398 APPENDICES Revised 8/2016 Approved: Levon Vartanian, MD hŶĚĞƌŚŽŽĚ/ŶƐƉĞĐƚŝŽŶ

Braun 6.0L Diesel Engine Diagram

Frazer 6.7L Diesel Engine Diagram &ůƵŝĚůĞǀĞůƐƚŽďĞŝŶƐƉĞĐƚĞĚ;ƐĞĞĨŽůůŽǁŝŶŐƉĂŐĞƐĨŽƌƉƌŽĐĞĚƵƌĞƐͿ͗ tŝŶĚƐŚŝĞůĚǁĂƐŚƚĂŶŬ dƌĂŶƐŵŝƐƐŝŽŶĨůƵŝĚůĞǀĞů KŝůůĞǀĞů WŽǁĞƌƐƚĞĞƌŝŶŐ ƌĂŬĞĨůƵŝĚ ŽŽůĂŶƚ

Cypress Creek EMS System Policies and Treatment Guidelines

399 APPENDICES Revised 8/2016 Approved: Levon Vartanian, MD 1. Windshield wash tank x sŝƐƵĂůŝŶƐƉĞĐƚŝŽŶŽŶůǇ x /ĨƚŚĞůĞǀĞůŝƐůŽǁĨŝůůĂƐĨŽůůŽǁƐ͗ &ŝůůŝŶŐƉƌŽĐĞĚƵƌĞ 1. >ŝĨƚƚŚĞĐŽǀĞƌŽĨĨƚŚĞĨŝůůĐŽŶŶĞĐƚŝŽŶŽĨƚŚĞǁĂƐŚƚĂŶŬ͘ 2. ĚĚǁĂƐŚĞƌĨůƵŝĚƵŶƚŝůůĞǀĞůŝƐƐĞĞŶŝŶĨŝůůƚƵďĞ͘ ͻ Be careful not to overfill, asit will spill onto the apparatus bay floor. 3. ZĞĂƚƚĂĐŚƚŚĞĐŽǀĞƌƐĞĐƵƌĞůǇ͘ 2. Transmission fluid level x dŽŽďƚĂŝŶĂŶĂĐĐƵƌĂƚĞĨůƵŝĚĐŚĞĐŬ͕ƚŚĞĂŵďƵůĂŶĐĞŶĞĞĚƐƚŽďĞĂƚŶŽƌŵĂůŽƉĞƌĂƚŝŶŐƚĞŵƉĞƌĂƚƵƌĞ͘ x WĂƌŬƚŚĞǀĞŚŝĐůĞŽŶĂůĞǀĞůƐƵƌĨĂĐĞ͘ x tŝƚŚǇŽƵƌĨŽŽƚŽŶƚŚĞďƌĂŬĞƉĞĚĂů͕ƐƚĂƌƚƚŚĞĞŶŐŝŶĞĂŶĚŵŽǀĞƚŚĞŐĞĂƌƐŚŝĨƚůĞǀĞƌƚŚƌŽƵŐŚĂůůŽĨƚŚĞ ŐĞĂƌƌĂŶŐĞƐ͘ůůŽǁƐƵĨĨŝĐŝĞŶƚƚŝŵĞĨŽƌĞĂĐŚŐĞĂƌƚŽĞŶŐĂŐĞ͘ x ZĞƚƵƌŶƚŚĞƐŚŝĨƚůĞǀĞƌƚŽƉĂƌŬĂŶĚůĞĂǀĞƚŚĞĞŶŐŝŶĞƌƵŶŶŝŶŐ͘ x ZĞŵŽǀĞƚŚĞĚŝƉƐƚŝĐŬ͕ǁŝƉŝŶŐŝƚĐůĞĂŶǁŝƚŚĂĐůĞĂŶ͕ĚƌǇ͕ůŝŶƚĨƌĞĞĐůŽƚŚ͘ x /ŶƐƚĂůůƚŚĞĚŝƉƐƚŝĐŬŵĂŬŝŶŐƐƵƌĞŝƚŝƐĨƵůůǇƐĞĂƚĞĚŝŶƚŚĞĨŝůůĞƌƚƵďĞ͘ x ZĞŵŽǀĞƚŚĞĚŝƉƐƚŝĐŬĂŶĚŝŶƐƉĞĐƚƚŚĞĨůƵŝĚůĞǀĞů͘dŚĞĨůƵŝĚůĞǀĞůƐŚŽƵůĚďĞŝŶƚŚĞĚĞƐŝŐŶĂƚĞĚĂƌĞĂĨŽƌ ŶŽƌŵĂůŽƉĞƌĂƚŝŶŐƚĞŵƉĞƌĂƚƵƌĞ͘ x /ĨƚŚĞĨůƵŝĚŝƐŶŽƚŝƐƚŚŝƐĂƌĞĂʹƐƵďŵŝƚĂŚĞůƉĚĞƐŬƚŝĐŬĞƚĂŶĚĐĂůůŵĂŝŶƚĞŶĂŶĐĞĨŽƌĚŝƐƉŽƐŝƚŝŽŶ͘

3. Oil level x DĂŬĞƐƵƌĞƚŚĞĂŵďƵůĂŶĐĞŝƐƉĂƌŬĞĚŽŶůĞǀĞůŐƌŽƵŶĚĂŶĚƚŚĞĞŶŐŝŶĞŝƐĐŽůĚ͕ƐŽǇŽƵĚŽŶ͛ƚďƵƌŶ ǇŽƵƌƐĞůĨŽŶĂŚŽƚĞŶŐŝŶĞƉĂƌƚ͘ x tŝƚŚƚŚĞĞŶŐŝŶĞŽĨĨ͕ŽƉĞŶƚŚĞŚŽŽĚĂŶĚĨŝŶĚƚŚĞĚŝƉƐƚŝĐŬ͘ x WƵůůƚŚĞĚŝƉƐƚŝĐŬŽƵƚĨƌŽŵƚŚĞĞŶŐŝŶĞĂŶĚǁŝƉŝŶŐŝƚĐůĞĂŶǁŝƚŚĂĐůĞĂŶ͕ĚƌǇ͕ůŝŶƚĨƌĞĞĐůŽƚŚ͘ x dŚĞŶŝŶƐĞƌƚƚŚĞĚŝƉƐƚŝĐŬďĂĐŬŝŶƚŽŝƚƐƚƵďĞĂŶĚƉƵƐŚŝƚĂůůƚŚĞǁĂǇďĂĐŬŝŶ͘

Cypress Creek EMS System Policies and Treatment Guidelines

400 APPENDICES Revised 8/2016 Approved: Levon Vartanian, MD x WƵůůŝƚďĂĐŬŽƵƚ͕ĂŶĚ ƚŚŝƐƚŝŵĞůŽŽŬĂƚďŽƚŚ ƐŝĚĞƐŽĨƚŚĞĚŝƉƐƚŝĐŬ ƚŽƐĞĞǁŚĞƌĞƚŚĞŽŝů ŝƐŽŶƚŚĞĞŶĚ͘ x ǀĞƌǇĚŝƉƐƚŝĐŬŚĂƐ ƐŽŵĞǁĂǇŽĨ ŝŶĚŝĐĂƚŝŶŐƚŚĞƉƌŽƉĞƌ ŽŝůůĞǀĞů͕ǁŚĞƚŚĞƌŝƚ ďĞƚǁŽƉŝŶŚŽůĞƐ͕ƚŚĞůĞƚƚĞƌƐůĂŶĚŚ;ůŽǁĂŶĚŚŝŐŚͿ͕ƚŚĞǁŽƌĚƐŵŝŶĂŶĚŵĂǆ͕ŽƌƐŝŵƉůǇĂŶĂƌĞĂŽĨ ĐƌŽƐƐŚĂƚĐŚŝŶŐ͘ x /ĨƚŚĞƚŽƉŽĨƚŚĞŽŝů͞ƐƚƌĞĂŬ͟ŝƐďĞƚǁĞĞŶƚŚĞƚǁŽŵĂƌŬƐŽƌǁŝƚŚŝŶƚŚĞĐƌŽƐƐŚĂƚĐŚĞĚĂƌĞĂ͕ƚŚĞůĞǀĞůŝƐ ĨŝŶĞ͘ x ƵƚŝĨƚŚĞŽŝůŝƐďĞůŽǁƚŚĞŵŝŶŝŵƵŵŵĂƌŬ͕ǇŽƵŶĞĞĚƚŽĂĚĚŽŝů͘ x ĚĚŽŝůƵŶƚŝůƚŚĞ͞ŽŝůƐƚƌĞĂŬ͟ŝƐǁŝƚŚŝŶƚŚĞĐƌŽƐƐŚĂƚĐŚĞĚĂƌĞĂ͘ x /ĨŵŽƌĞƚŚĂŶƚǁŽƋƵĂƌƚƐŝƐŶĞĞĚĞĚʹƐƵďŵŝƚĂŚĞůƉĚĞƐŬƚŝĐŬĞƚĂŶĚĐŽŶƚĂĐƚŵĂŝŶƚĞŶĂŶĐĞĨŽƌĨƵƌƚŚĞƌ ĚŝƐƉŽƐŝƚŝŽŶ͘ 4. Power steering x DĂŬĞƐƵƌĞƚŚĞĂŵďƵůĂŶĐĞŝƐƉĂƌŬĞĚŽŶůĞǀĞůŐƌŽƵŶĚĂŶĚƚŚĞĞŶŐŝŶĞŝƐĐŽůĚ͕ƐŽǇŽƵĚŽŶ͛ƚďƵƌŶ ǇŽƵƌƐĞůĨŽŶĂŚŽƚĞŶŐŝŶĞƉĂƌƚ͘ x tŝƚŚƚŚĞĞŶŐŝŶĞŽĨĨ͕ŽƉĞŶƚŚĞŚŽŽĚĂŶĚĨŝŶĚƚŚĞƉŽǁĞƌƐƚĞĞƌŝŶŐĐĂƉ͘ x dǁŝƐƚƚŽƚŚĞůĞĨƚƚŽƵŶƐĐƌĞǁƚŚĞĐĂƉ͘ x dŚĞĚŝƉƐƚŝĐŬŝƐĂƚƚĂĐŚĞĚƚŽƚŚĞĐĂƉ͘ x tŝƉĞƚŚĞĚŝƉƐƚŝĐŬĐůĞĂŶǁŝƚŚĂĐůĞĂŶ͕ĚƌǇ͕ůŝŶƚĨƌĞĞĐůŽƚŚ͘ x dŚĞŶŝŶƐĞƌƚƚŚĞĚŝƉƐƚŝĐŬďĂĐŬŝŶƚŽŝƚƐƚĂŶŬĂŶĚƚǁŝƐƚƚŽƚŚĞƌŝŐŚƚ͘ x dǁŝƐƚƚŽƚŚĞůĞĨƚĂŐĂŝŶĂŶĚƌĞŵŽǀĞĨƌŽŵƚŚĞƚĂŶŬ͘ x /ĨƚŚĞƚŽƉŽĨƚŚĞŽŝů͞ƐƚƌĞĂŬ͟ŝƐďĞƚǁĞĞŶƚŚĞƚǁŽŵĂƌŬƐŽƌǁŝƚŚŝŶƚŚĞĐƌŽƐƐŚĂƚĐŚĞĚĂƌĞĂ͕ƚŚĞůĞǀĞůŝƐ ĨŝŶĞ͘ x ZĞͲŝŶƐĞƌƚĚŝƉƐƚŝĐŬďĂĐŬŝŶƚŽƚĂŶŬĂŶĚƚǁŝƐƚƚŽƚŚĞƌŝŐŚƚ x /ĨƚŚĞůĞǀĞůŝƐŶŽƚďĞƚǁĞĞŶƚŚĞƚǁŽŵĂƌŬƐŽƌǁŝƚŚŝŶƚŚĞĐƌŽƐƐŚĂƚĐŚĞĚĂƌĞĂʹƐƵďŵŝƚĂŚĞůƉĚĞƐŬƚŝĐŬĞƚ ĂŶĚĐŽŶƚĂĐƚŵĂŝŶƚĞŶĂŶĐĞĨŽƌĨƵƌƚŚĞƌĚŝƐƉŽƐŝƚŝŽŶ͘

Cypress Creek EMS System Policies and Treatment Guidelines

401 APPENDICES Revised 8/2016 Approved: Levon Vartanian, MD 5. Brake fluid—Visual Inspection Only x dŚĞĨůƵŝĚůĞǀĞůƐŚŽƵůĚďĞĂƌŽƵŶĚƚŚĞƚŽƉĐƌŽǁŶŝŶŐŽĨƚŚĞƌĞƐĞƌǀŽŝƌƚĂŶŬ x /ĨƚŚĞůĞǀĞůŝƐŶŽƚĂƌŽƵŶĚƚŚĞƚŽƉĐƌŽǁŶŝŶŐŽĨƚŚĞƌĞƐĞƌǀŽŝƌƚĂŶŬʹƐƵďŵŝƚĂŚĞůƉĚĞƐŬƚŝĐŬĞƚĂŶĚ ĐŽŶƚĂĐƚŵĂŝŶƚĞŶĂŶĐĞĨŽƌĨƵƌƚŚĞƌĚŝƐƉŽƐŝƚŝŽŶ͘

6. Coolant—Visual Inspection Only x CAUTIONĚŽŶŽƚŽƉĞŶƚŚĞĐĂƉƚŽƚŚĞĐŽŽůĂŶƚďŽƚƚůĞ x dŚĞĐŽŽůĂŶƚŝƐƵŶĚĞƌƉƌĞƐƐƵƌĞĂŶĚĐĂŶƉŽƚĞŶƚŝĂůůǇďƵƌŶǇŽƵ x /ĨƚŚĞůĞǀĞůŝƐŶŽƚĂƌŽƵŶĚƚŚĞƚŽƉĐƌŽǁŶŝŶŐŽĨƚŚĞƌĞƐĞƌǀŽŝƌƚĂŶŬʹƐƵďŵŝƚĂŚĞůƉĚĞƐŬƚŝĐŬĞƚĂŶĚ ĐŽŶƚĂĐƚŵĂŝŶƚĞŶĂŶĐĞĨŽƌĨƵƌƚŚĞƌĚŝƐƉŽƐŝƚŝŽŶ

Cypress Creek EMS System Policies and Treatment Guidelines

402

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