emergency medical care committee meeting agendanext meeting: thursday, may 16th, 2019 at 8:30am....

EMERGENCY MEDICAL CARE COMMITTEE MEETING AGENDA

Thursday, April 18th at 8:30 A.M. Health Campus Second Floor Large Conference Room 2180 Johnson Avenue, San Luis Obispo MEMBERS CHAIR Dr. Tom Hale, Physicians, 2018-22 VICE CHAIR Dr. Rachel May, Emergency Physicians, 2018-22 Bob Neumann, Consumers, 2018-22 Tom Frutchey , City Government, 2016-20 Alexandra Kohler, Consumers, 2016-20 Chris Javine, Pre-hospital Transport Providers, 2018-22 Michael Talmadge, EMS Field Personnel, 2016-20 Jonathan Stornetta, Public Providers, 2016-20 Stuart MacDonald, Sheriff’s Department, 2016-20 Mark Lisa, Hospitals, 2017-20 Jennifer Sandoval, MICNs, 2018-22

EX OFFICIO Vince Pierucci, EMS Division Director Dr. Tom Ronay, EMS Medical Director STAFF Douglas Brim, EMS Coordinator Kyle Parker, EMS Coordinator Michael Groves, EMS Coordinator Michelle Pinney, Administrative Assistant Elizabeth Merson, PHEP Program Manager

AGENDA ITEM LEAD

Call To Order Introductions

T.Hale Public Comment

Action/Discussion

Approval of minutes: March Minutes (attached) T. Hale

• Field Treatment Protocol and Policy Revisions (Recommend Approve) o Protocol #601 Universal o Protocol #602 Airway Management o Protocol #611 Allergic Reaction/Anaphylaxis o Protocol #612 Altered Mental Status o Protocol #618 Respiratory Distress – Opiate Overdose o Protocol #620 Seizure (Active) o Protocol #621 Suspected CVA/TIA o Procedure #703 CPAP o Protocol #619 Medical Shock o Protocol #641 Pulseless Cardiac Arrest o Protocol #644 Bradycardia o Protocol #660 General Trauma

• Policies # 205: ALS and BLS Equipment Supplies & Policy #205 Attachment A- Equipment & Supply List (Recommend Approve)

• Policy #215 EMT Elective Skills (addendum to previously approved policy)

V. Pierucci

M. Groves/D. Brim

Staff Reports • Health Officer • EMS Agency Staff Report • EMS Medical Director Report • PHEP Staff Report

P. Borenstein V. Pierucci T. Ronay E. Merson

Committee Members Announcements or

Reports

Opportunity for Board members to make announcements, provide brief reports on their EMS-related activities, ask questions for clarification on items not on the agenda, or request consideration of an item for a future agenda (Gov. Code Sec. 54954.2[a][2])

Committee Members

Adjourn Next Meeting: Thursday, May 16th, 2019 at 8:30am

EMCC - Page 1 of 2

Draft Emergency Medical Care Committee Meeting Minutes Thursday, March 21, 2019 Health Agency Second Floor Large Conference Room 2180 Johnson Avenue San Luis Obispo

Members Ex Officio CHAIR Dr. Tom Hale, Physicians Vince Pierucci, EMS Division Director VICE CHAIR Dr. Rachel May, Emergency Medicine

Physicians Dr. Thomas Ronay, LEMSA Medical Director

Bob Neumann, Consumers Tom Frutchey, City Government Staff Alexandra Kohler, Consumers Douglas Brim, EMS Coordinator Michael Talmadge, EMS Field Personnel Mike Groves, EMS Coordinator Michael Stornetta, Public Providers Kyle Parker, EMS Coordinator Stuart MacDonald, Sheriff’s Department Elizabeth Merson, PHEP Mark Lisa, Hospitals Michelle Pinney, Administrative Assistant Jennifer Sandoval, MICNs Guests – Rob Jenkins - Cal Fire

Ron Taggart – REACH AIR AGENDA ITEM / DISCUSSION ACTION

CALL TO ORDER Introductions – Roundtable Meeting called to order at 0834 Public Comment – No comment Approval of May Meeting minutes Neuman/Talmadge REPORTS & DISCUSSION/ACTION ITEMS ● TXA – Presentation of Staff Report D. Brim: Joint Application with SB & Ventura Cos LSOP Report State approval Nov. ‘18 Policy #714 & Formulary – Approved as part of State LSOP CAC – Review – Tri-Tac – Medical Director – Staff – FTO Santa Barbara & Ventura counties currently in use Dr. Ronay : TXA hx in Surgical Centers, used in conjunction w/ hospitals, good use in CA Dr. Ronay: As part of LSOP Application, LEMSA will be collecting data Dr. Ronay: Anticipate transition to paramedic basic scope from LSOP in years to come • # 660 & # 661 – Presentation and highlight changes (Request and Approval) Implementation date tentative late Spring/Summer M. Talmage: Suggestion on #660 General Trauma reemphasize age differential Dr. May: Agrees with suggestion J. Stornetta: Use a 100ml bag? Same as D10% in 250ml bags D. Brim: System wide move to 100ml Dr.. Ronay: 100ml wide-open gives correct Dose R. Jenkins: CAL FIRE moving forward with 100ml NS

J. Stornetta: Policy TXA Formulary Contraindications has “Non-blood loss conditions;” Policy #714 does not have same/similar language D. Brim: Oversight on development of #714; will be added for consistency

J. Stornetta: Quantity on Units? D. Brim: Operations discussion probably 1 dose per Unit

Motion Approved – Talmage/Newman

EMCC - Page 2 of 2

Health Agency Officer • No Report

EMS Agency Director Report • Introduced new CCHD Healthcare Administrator Maureen Robles-Wilson • Met with SB & Ventura LEMSAs to begin to build tri-county mutual aid system for

LEMSA staff to support on-going operations during DOC/EOC operations EMS Medical Director

• Have noticed an increase of cases involving SMR policy applications; working with QIC & stakeholders to address

PHEP Staff Report • No Report

Next Regular Meeting Next meeting will be held April 18th, 2019

Meeting adjourned 0907

COUNTY OF SAN LUIS OBISPO HEALTH AGENCY PUBLIC HEALTH DEPARTMENT Michael Hill Health Agency Director Penny Borenstein, MD, MPH Health Officer/Public Health Director

Emergency Medical Services 2180 Johnson Avenue | San Luis Obispo, CA 93401 | (P) 805-781-2511 | (F) 805-788-2517

www.slopublichealth.org

MEETING DATE April 18th, 2019 STAFF CONTACT Mike Groves

805.788.2514 [email protected] SUBJECT Field Treatment Protocol and Policy Revisions; EMT Elective Skills

SUMMARY In January 2019, the EMCC approved Policies #215 EMT Basic Scope of Practice Approved Elective Skills Requirements for EMS Provider Agencies (EMT Elective Skills), and #216 EMT Accreditation. In order to fully implement the EMT Elective Skills, a number of treatment protocols were revised and updated to reflect the new EMT skills. The treatment protocols specific to EMT Elective Skills that were revised are:

• Protocol #601 Universal • Protocol #602 Airway Management • Protocol #611 Allergic Reaction/Anaphylaxis • Protocol #612 Altered Mental Status • Protocol #618 Respiratory Distress – Opiate Overdose • Protocol #620 Seizure (Active) • Protocol #621 Suspected CVA/TIA • Procedure #703 CPAP

All treatment protocols were revised by deleting the header “BLS Optional” and replacing the title with “BLS Elective Skills” The items previously under “BLS Optional” (pulse oximetry and O2 administration) were moved to the “BLS” section. The new EMT Elective Skills were placed in the “BLS Elective Skills” section in the appropriate treatment protocol. If no BLS Elective Skills are applicable, that section of the protocol was removed. We have included the proposed revised protocols with the revisions and updates highlighted in yellow.

In Policy #215, EMT Elective Skills, we added a section (IV-Policy-I, highlighted in yellow) allowing trained and accredited EMT’s on duty with an approved provider to perform a finger stick blood glucose measurement on any patient at the request and under direction of a SLO County paramedic on scene.

The removal of dopamine has necessitated changes in the following treatment protocols, these protocols were also amended to account for changes associated with EMT Elective Skills (changes are noted in yellow):

• Protocol #619 Shock (medical) – Hypotension/Sepsis • Protocol #641 Pulseless Arrest (Atraumatic) • Protocol #644 Bradycardia • Protocol #660 General Trauma

Policy #205, ALS and BLS Equipment and Supplies, and Policy #205 Attachment A -Equipment and Supply List, also required revision and update to reflect the addition of

of 2

EMT Elective Skills, as well as other changes in equipment and supplies resulting from protocol changes.

Attachment A is the equipment and supply list for ALS and BLS units. We have added a descriptor in the column ‘BLS First Responder Minimum’ that reads ‘† Elective skills as required’. The minimum required stocking is for each EMT Elective Skill is listed in that column and notated with the † symbol.

We have added TXA, Fentanyl, and saline delivery equipment to the list. Changes have been made to Morphine and 0.9% Normal Saline. Dopamine and colorimetry blood glucose analyzer have been removed.

For purposes of review, all changes and additions have been highlighted in yellow and removals highlighted in orange..

REVIEWED BY Clinical Advisory Committee (Treatment Protocol Changes) FTO group (Treatment Protocol Changes) Operations Subcommittee (Policy #205 and Attachment A) EMS Agency Staff EMS Medical Director

RECOMMENDED ACTION(S)

Recommend EMCC Approval

ATTACHMENT(S) Field Treatment Protocols 601,602,611,612,618,619,620,621,641,644,660 Procedure 703 Policy #205 ALS and BLS Equipment and Supplies Policy #205 Attachment A (Equipment and Supply List) Policy #215 EMT Approved Elective Skills Requirements

County of San Luis Obispo Public Health Department Protocol #601

Division: Emergency Medical Services Agency Effective Date: --/--/2019

UNIVERSAL

MEDICAL TRAUMA BLS Procedures

• Evaluate Scene Safety/Personal Protective Equipment

• Assess, establish and maintain airway o Suction as needed

• Pulse Oximetry o O2 administration per Airway

Management Protocol #602 • Evaluate breathing and circulation • Assess chief complaint • Focused physical exam and vital signs:

o Pulse o Blood pressure o Respiratory rate o Lung sounds o Skin signs

• BLS treatment protocols

• Evaluate Scene Safety/Personal Protective Equipment

• Assess, establish and maintain airway o Suction as needed

• Pulse Oximetry o O2 administration per Airway

Management Protocol #602 • Evaluate breathing and circulation • Control life-threatening bleeding • Remove patient’s clothing to expose and

identify injuries • Ensure patient warmth – cover patient after

clothing removal to maintain core body temperature

• Spinal motion restriction (SMR) if indicated per Spinal Motion Restriction Procedure # 702

• BLS treatment protocols BLS Elective Skills

Obtain Blood Glucose Level if indicated by: • Policy #612 ALOC • Policy #620 Seizures • Policy #621 CVA/TIA • As directed by ALS provider

ALS Procedures • Vascular access – Procedure #710 • Consider 12-lead ECG early • Capnography (if available/applicable) • Blood Glucose Measurement • Transport Determination • ALS Treatment Protocols

• Trauma Triage and Destination • ALS Treatment Protocols

Base Hospital Orders Only • Determined on patient needs • Determined on patient needs

Notes • Use Pediatric Policies for patients ≤34 kg and consider use of Broselow tape or equivalent

County of San Luis Obispo Public Health Department Protocol #602 Division: Emergency Medical Services Agency Effective Date: xx/xx/2019

AIRWAY MANAGEMENT

ADULT PEDIATRIC (<34 kg) BLS

• Universal Protocol #601 • Administer O2 as clinical symptoms indicate

(see notes below) • Pulse oximetry • Patients who have oxygen saturations ≥ 94%

without signs or symptoms of hypoxia or impending respiratory compromise should not receive O2

• When applying O2 use the simplest method to maintain O2 Sat ≥ 94%

• Do not withhold O2 if patient is in respiratory distress

• Foreign Body/Airway Obstruction o Use current BLS choking procedures o Basic airway adjuncts and suctioning as

indicated and tolerated

Same as Adult (except for newborns) • Newborn (< 1 day) follow AHA guidelines –

Newborn Protocol #651

BLS Elective Skills • Moderate to Severe Respiratory Distress

o CPAP as needed – CPAP procedure #703 CPAP not used for patients ≤34 kg

ALS Standing Orders • Foreign Body/Airway Obstruction

If obstruction not relieved with BLS maneuvers o Visualize and remove obstruction with

Magill forceps o If obstruction persists consider – Needle

Cricothyrotomy Procedure #704 o Upon securing airway monitor O2 Sat

and ETCO2 – Capnography Procedure #701

• Endotracheal intubation – as needed to control airway

• Needle thoracostomy with symptoms of tension pneumothorax – Needle Thoracostomy Procedure #705

• Foreign Body/Airway Obstruction If obstruction not relieved with BLS maneuvers

o Visualize and remove obstruction with Magill forceps

o If obstruction persists consider – Needle Cricothyrotomy Procedure #704

o Upon securing airway monitor O2 Sat and ETCO2 – Capnography Procedure #701

• Needle thoracostomy with symptoms of tension pneumothorax – Needle Thoracostomy Procedure #705

Base Hospital Orders Only • Symptomatic Esophageal Obstruction

o Glucagon 1mg IV followed by rapid flush. Give oral fluid challenge 60 sec after admin - check a blood sugar prior

• As needed

• Symptomatic Esophageal Obstruction o Glucagon 0.1mg/kg IV not to exceed

1mg followed by rapid flush. Give oral fluid challenge 60 sec after admin - check a blood sugar prior

• As needed

Notes • Oxygen Delivery

County of San Luis Obispo Public Health Department Protocol #602 Division: Emergency Medical Services Agency Effective Date: xx/xx/2019

o Mild distress – 0.5-6 L/min nasal cannula o Severe respiratory distress – 15 L/min via non-rebreather mask o Moderate to severe distress – CPAP 3-15 cm H2O o Assisted respirations with BVM – 15 L/min

• Pediatric intubation is no longer an approved ALS skill – maintain with BLS options


Division: Emergency Medical Services Agency Effective Date: xx/xx/2019

ALLERGIC REACTION/ANAPHYLAXIS

ADULT PEDIATRIC (≤34 KG) BLS

• Universal Protocol #601 • Pulse Oximetry

o O2 administration per Airway Management Protocol #602

• May assist with the administration of patient’s prescribed medication (i.e. Epi Auto-injector, inhaler, etc.)

Same as Adult

BLS Elective Skill Unstable

(Dyspnea/Wheezing/Shock) • Adult 0.3 mg Epinephrine Auto-Injector

administered in anterio-lateral thigh o May repeat, if indicated, every 5 min,

max 3 doses

Unstable (Dyspnea/Wheezing/Shock)

• Pediatric 0.15 mg Epinephrine Auto-Injector administered in anterio-lateral thigh o May repeat, if indicated, every 5 min,

max 3 doses ALS Standing Orders

Stable (Itching/rash)

• Diphenhydramine 50 mg IV/IM


• Albuterol 2.5-5 mg via HHN/Mask/BVM with adjunct, over 5-10 min

o repeat as needed • Epinephrine 1:1,000 0.01 mg/kg IM – not to

exceed 0.5 mg o may repeat every 5 min, max 3 doses

• Diphenhydramine 50 mg IV/IM

Extremis • Epinephrine 1:1,000 0.01 mg/kg SL – not to


Stable (Itching/rash)

• Diphenhydramine 2 mg/kg IV/IM – not to exceed 50 mg


• Albuterol 2.5-5 mg via HHN/Mask/BVM with adjunct, over 5-10 min

o repeat as needed • Epinephrine 1:1,000 0.01 mg/kg IM – not to


• Diphenhydramine 2 mg/kg IV/IM – not to exceed 50 mg

Extremis • Epinephrine 1:1,000 0.01 mg/kg SL – not to


Base Hospital Orders Only Unresponsive to previous therapy • Epinephrine 1:10,000 0.01 mg/kg slow IV

titrated – not to exceed 0.5 mg

• As needed

Unresponsive to previous therapy • Epinephrine 1:10,000 0.01 mg/kg slow IV

titrated – not to exceed 0.3 mg

• As needed Notes

Follow manufacture’s instructions when using Epinephrine auto-injector



ALTERED MENTAL STATUS

ADULT PEDIATRIC (≤34KG) BLS



• Evaluate and treat for possible cause, see notes

Suspected, or confirmed (BG <60 mg/dL) Diabetic Emergency: • Oral Glucose 15 Gm assist with self-

administration in patient meeting criteria below, repeat as needed o Awake patient able to follow commands

• Able to swallow without difficulty, and able to control secretions

Same as Adult

BLS Elective Skills All patients with Altered Mental Status

Obtain Blood Sugar Level ALS Standing Orders

With Blood Glucose (BG) <60 mg/dL Stable • Oral Glucose 15 Gm assist with self-

administration, repeat as needed

Unstable • Dextrose 10% (250mL bag) 150 mL IV

o Recheck BG level after 5 min o If BG < 60mg/dL – repeat 100 mL IV bolus

Or • Dextrose 50% 25 Gm (50 mL) slow IV

Or • Glucagon 1 mg IM if unable to establish IV

after 2 attempts

With Blood Glucose (BG) <60 mg/dL (Newborn <40 mg/dL)

Stable – Same as adult

Unstable • Dextrose 10% (250 mL bag) 0.5 Gm/kg

(5 mL/kg) IV not to exceed 150 mL o A syringe may be utilized for administering

small volumes < 50 mL o Recheck BG level after 5 min o If BG < 60mg/dL – repeat 0.5 Gm/kg (5

mL/kg) IV, not to exceed 100 mL Or

• Dextrose 25% 0.5 Gm/kg (2 mL/kg) slow IV (see dilution preparation below)

Or • Glucagon 0.1 mg/kg IM not to exceed 1 mg if

unable to establish IV after 2 attempts Base Hospital Orders Only

• As needed • As needed

Notes



• Assisting a patient with Oral Glucose requires they be awake, able to swallow, and follow commands • Dextrose 10% may be administered via IV drip tubing at an open (rapid) rate • Pediatric dilution of Dextrose 50% when 25% pre-package is unavailable

o Use a 250 mL bag NS and remove/discard 200 mL of NS o Add 50 mL of Dextrose 50% o Verify total bag volume = 100 mL o This concentration is now approximately 0.25 Gm/mL or 25% Dextrose

• Evaluate for possible causes and refer to appropriate treatment protocol: ○ A – alcohol ○ E – epilepsy ○ I – insulin ○ O – overdose/low oxygen (hypoxia) ○ U – uremia ○ T – trauma ○ I – infection ○ P – psychiatric ○ S - stroke



RESPIRATORY DISTRESS – OPIATE OVERDOSE ADULT PEDIATRIC (≤34 KG)

BLS • Universal Protocol #601 • Pulse Oximetry


• May assist with administration of patient’s prescribed medication

Same as Adult

BLS Elective Skills Suspected Opiate Overdose with inadequate respirations

(O2 Sat < 94%, rate ≤ 8 bpm) • Narcan 1 mg IN in one nare – assess for adequate respirations

o may repeat in alternate nare if no improvement after 2 min, max total of 4 doses ALS Standing Orders

Suspected Opiate Overdose with inadequate respirations

(O2 Sat < 94% or ETCO2 > 45 mmHg)

• Narcan up to 1 mg IV/IM/IN (split between nares) – assess for adequate respirations

o repeat as needed

Extremis • Narcan 0.5 mg SL – assess for adequate

respirations o repeat as needed

Suspected Opiate Overdose with inadequate respirations

(O2 Sat < 94% or ETCO2 > 45 mmHg)

• Narcan 0.1 mg/kg IV/IM/IN (split between nares) up to 1 mg – assess for adequate respirations

o repeat as needed

Extremis • Narcan 0.5 mg SL – assess for adequate

respirations o repeat as needed

Base Hospital Orders Only • As needed • As needed

Notes • IV is preferred route for Narcan administration • Inadequate airway, and respirations should be supported with BLS adjuncts and ventilations prior

to Narcan administration • Poly-mixed drugs may require additional doses of Narcan titrated to maintain respirations



SHOCK (MEDICAL) - HYPOTENSION/SEPSIS




• Place in supine position if tolerated

Same as Adult

BLS Optional Scope Pulse Oximetry - O2 administration per Airway Management Protocol #602

ALS Standing Orders SBP < 100 mmHg or other signs of hypotension

• Normal Saline up to 500 mL IV o repeat x1 if hypotension persists

• Consider establishing secondary IV access • Consider 12-lead ECG • If shock is due to trauma refer to General

Trauma Protocol #660

Signs of hypotension specific to age

• Normal Saline 20 mL/kg IV/IO o repeat x1 if hypotension persists

• Consider establishing secondary IV access • If shock is due to trauma refer to General

Trauma Protocol #660

Base Hospital Orders Only Non-Hypovolemic Shock

• Dopamine 5-20 mcg/kg/min infusion OR

• Push-Dose Epinephrine 10 mcg/mL 1 mL IV/IO every 1-3 min o repeat as needed titrated to SBP

>90mmHg o See notes for mixing instructions

• As needed

• As needed

Notes • Mixing Push-Dose Epinephrine 10 mcg/mL (1:100,000): Mix 9 mL of Normal Saline with 1 mL of

Epinephrine 1:10,000, mix well • Consider underlying causes of shock • Use caution with fluid challenges if signs of CHF or history of liver or renal failure • Keep patient warm • Treatable/Reversible considerations:

o Hypoxemia o Tachycardia o Bradycardia o Hyper/Hypothermia o Hypovolemia o Altered mental status o Fractures/Bleeding/Tension pneumothorax o Anaphylaxis o Chest pain o Overdose



SEIZURE (ACTIVE)




• Prevent patient from injuring themselves – Do not restrain

Same as Adults

BLS Elective Skills Obtain Blood Sugar Level – if <60 mg/dL see Altered Mental Status Protocol #612

ALS Standing Orders • Midazolam

o Up to 2 mg slow IV or o 5 mg IM/IN (2.5 mg each nostril) o May repeat once after 10 min

• Obtain blood sugar level

• Midazolam o 0.1 mg/kg slow IV not to exceed 2mg o 0.1 mg/kg IM/IN (max 0.3 mL each

nostril) • Obtain blood sugar level

Base Hospital Orders Only • As needed • Repeat doses of Midazolam

• As needed Notes

County of San Luis Obispo Public Health Department Protocol # 621 Division: Emergency Medical Services Agency Effective Date: xx/xx/2019

SUSPECTED CVA/TIA




• Place patient in position of comfort with head elevated

• Complete B-E-F-A-S-T exam, see Notes

Same as Adult

BLS Elective Skills Obtain Blood Sugar Level – if <60 mg/dL see Altered Mental Status Protocol #612

ALS Standing Orders • Initiate STROKE ALERT base report and EARLY

transport if ANY of B-E-F-A-S-T present and last seen normal is < 6 hours

Same as Adult

Base Hospital Orders Only • As needed • As needed

Notes • Contact receiving hospital early if patient meets STROKE ALERT criteria • Do not delay transport to hospital for on scene treatment • B-E-F-A-S-T ( new onset or change from previous “normal”)(*)

o B – Balance – changes or problems o E – Eyes – sudden change in vision or double vision o F – Facial droop o A – Arm drift o S – Speech abnormalities o T – Time last seen normal < 6 hrs. (record the time)

• “Time last seen normal” – do not confuse with time symptoms noticed – “time last seen normal” starts the clock

• Evaluate and correct for other potential causes i.e. o Hypoxia o Hypoglycemia o Overdose o Seizure

• If time is available and the patient or family can provide the information, gather the criteria listed in the Fibrinolytic Evaluation listed below (Fibrinolytic Evaluation – ASA/NSA Standards)

o Use of anticoagulants o History of stroke/TIA/brain tumor o Mental Status - orientation o Known bleeding disorder o Age > 18 yrs. o Active bleeding, surgery, or trauma < 3 weeks o Jaundice, hepatitis, kidney failure o Terminal illness

(*) BEFAST – was developed by Intermountain Healthcare, as an adaptation of the FAST model implemented by the American Stroke Assoc. Reproduction with the permission from Intermountain Healthcare, Copyright 2011, Intermountain Health Care.

County of San Luis Obispo Public Health Department Protocol #641 Division: Emergency Medical Services Agency Effective Date: --/--/2019

PULSELESS CARDIAC ARREST (ATRAUMATIC)

ADULT PEDIATRIC (≤34 kg) BLS

• Universal Protocol #601 • High Performance CPR (HPCPR) (10:1)

per Procedure #712 o Continuous compressions with 1

short breath every 10 • AED application (if shock advised, administer

30 compressions prior to shocking) • Pulse Oximetry


• Same as Adult (except for neonate) • Neonate (< 1 month) follow AHA guidelines • CPR compression to ventilation ratio

o Newborn – CPR 3:1 o 1 day to 1 month – CPR 15:2 o > 1 month – HPCPR 10:1

• AED – pediatric patient > 1 year • Use Broselow tape or equivalent if available

BLS Optional Pulse Oximetry – O2 administration per Airway Management Protocol #602

ALS Standing Orders • Rhythm analysis and shocks – At 200

compressions begin charging the monitor – continue CPR while monitor is charging. Once fully charged, stop CPR for rhythm analysis:

o V-fib/Pulseless V-tach – shock at 120J o Subsequent shock at 150J then 200J o Recurrent V-fib/Pulseless V-tach use

last successful shock level o No shock indicated – dump the

charge • V-fib/Pulseless V-tach – medications

o Epinephrine 1:10,000 1 mg IV/IO repeat every 3-5 min

o Lidocaine 1.5 mg/kg IV/IO repeat once in 3-5 min (max total dose 3 mg/kg)

• Non-shockable rhythm – medications o Epinephrine 1:10,000 1 mg IV/IO

repeat every 3-5 min

• Rhythm analysis and shocks – At 200 compressions begin charging the monitor – continue CPR while monitor is charging. Once fully charged, stop CPR for rhythm analysis:

o V-fib/Pulseless V-tach - shock at 2J/kg o Subsequent shock at 4J/kg o Recurrent V-fib/Pulseless V-tach use

last successful shock level o No shock indicated – dump the charge

• V-fib/Pulseless V-tach – medications o Epinephrine 1:10,000 0.01 mg/kg

(0.1 ml/kg) IV/IO, not to exceed 0.3mg, repeat every 3-5 min

o Lidocaine 1 mg/kg IV/IO repeat every 5 min (max total dose 3 mg/kg)

• Non-shockable rhythm – medications o Epinephrine 1:10,000 0.01 mg/kg (0.1

ml/kg) IV/IO, not to exceed 0.3mg, repeat every 3-5 min

Base Hospital Orders Only Contact STEMI Receiving Center (French Hospital)

ROSC with Persistent Hypotension

• Dopamine 5-20 mcg/kg/min IV/IO infusion OR

• Push-Dose Epinephrine 0.01 mg(10 mcg)/mL 1 mL IV/IO every 1-3 min

o repeat as needed titrated to SBP >90mmHg

o See notes for mixing instructions

Contact closest Base Hospital for additional orders

ROSC with Persistent Hypotension for Age • Dopamine 5-20 mcg/kg/min IV/IO infusion

OR • Push-Dose Epinephrine 10 mcg/mL

Up to 1 mL IV/IO every 1-3 min o repeat as needed titrated to age

appropriate SBP o See notes for mixing instructions

County of San Luis Obispo Public Health Department Protocol #641 Division: Emergency Medical Services Agency Effective Date: --/--/2019

• Refractory V-Fib or V-Tach not responsive to

treatment • Request for a change in destination if patient

rearrests en route • Termination orders when unresponsive to

resuscitative measures • As needed Contact appropriate Base Station per Base Station Report Policy #121 - Atraumatic cardiac arrests due to non-cardiac origin (OD, drowning, etc.)

• As needed


Epinephrine 1:10,000, mix well • Use manufacturer recommended energy settings if different from listed • Assess for reversible causes

o Tension PTX, hypoxia, hypovolemia, hypothermia, hyperkalemia, hypoglycemia, overdose • Vascular access – IV preferred over IO – continue vascular access attempts even if IO access

established • Oral Intubation (Adults) – Consider only if airway is not compliant or with maintained ROSC • Adult ROSC that is maintained:

o Obtain 12-lead ECG and vital signs o Transport to the nearest STEMI Receiving Center regardless of 12-lead ECG reading o Maintain O2 Sat > 94% o Monitor ETCO2 o Consider oral intubation o With BP < 100 mmHg, contact SRC (French Hospital) for fluid, Dopamine, or Push-Dose

Epinephrine orders • Termination for patients > 34 Kg - Contact SRC (French Hospital) for termination orders

o If the patient remains pulseless and apneic following 20 minutes of resuscitative measures

o Persistent ETCO2 values < 10mmHg, consider termination of resuscitation o Documentation shall include the patient’s failure to respond to treatment and of a non-

viable cardiac rhythm (copy of rhythm strip) • Pediatric patients ≤ 34 kg

o Stay on scene to establish vascular access, provide for airway management, and administer the first dose of epinephrine followed by 2 min of HPCPR.

o Emphasize quality CPR rather than immediate transport o Evaluate and treat for respiratory causes o Use Broselow tape if available o Contact and transport to the nearest Base Hospital o Receiving Hospital shall provide medical direction/termination for pediatric patients



BRADYCARDIA




• Same as Adult


ALS Standing Orders • Obtain 12-lead ECG • With STEMI contact STEMI base prior to

administration of Atropine unless in extremis

Unstable • Atropine 0.5 mg IV

o May repeat every 3-5 min (not to exceed 3 mg total)

• Obtain 12-lead ECG

Unstable • Epinephrine 1:10,000 0.01 mg/kg (0.1 ml/kg)

slow IV not to exceed 0.3 mg per dose o May repeat every 3-5 min

Base Hospital Orders Only • Normal Saline fluid bolus 500 mL • Atropine 0.5 mg IV for stable patient or

STEMI patient not in extremis • Dopamine 5-20 mcg/kg/min IV/IO infusion

OR • Push-Dose Epinephrine 10 mcg/mL

1 mL IV/IO every 1-3 min o repeat as needed titrated to SBP

>90mmHg o See notes for mixing instructions

Beta Blocker Overdose

• Glucagon 3-10 mg slow IV (when cache available)

Calcium Channel Blocker Overdose

• Calcium Chloride 1 Gm slow IV/IO

Organophosphate Overdose • Atropine 2 mg IV/IO/IM repeat as needed Tricyclic Overdose – with wide QRS (>0.1 seconds) • Sodium Bicarbonate 1 mEq/kg IV/IO, may

repeat every 10 minutes at ½ the initial dose with persistent QRS widening

Hyperkalemia

• Calcium Chloride 1 Gm slow IV/IO

• Atropine 0.02 mg/kg IV (minimum dose of 0.1 mg and maximum dose of 0.5 mg)

o May repeat every 3-5 min (not to exceed 1 mg total)

• Normal Saline fluid bolus 20 mL/kg

Beta Blocker Overdose • Glucagon 0.1 mg/kg IV/IM

Calcium Channel Blocker Overdose • Calcium Chloride 20mg/kg slow IV/IO

(maximum single dose of 500 mg)

Organophosphate Overdose • Atropine 0.05-0.1 mg/kg IV/IO/IM Tricyclic Overdose – with signs of QRS widening • Sodium Bicarbonate 1 mEq/kg IV/IO, may

repeat every 10 minutes at ½ the initial dose with persistent QRS widening

• As needed



• Sodium Bicarbonate 1 mEq/kg IV/IO • As needed


Epinephrine 1:10,000, mix well • Atropine in pediatric patients may cause paradoxical bradycardia • High degree heart blocks (Second degree type II, and Third degree) may respond poorly to

Atropine o If unstable consider obtaining Base Hospital Orders for Dopamine or Push-Dose

Epinephrine instead of Atropine • Ensure all Calcium Chloride is thoroughly flushed from IV tubing prior to administration of Sodium

Bicarbonate • Higher doses of Atropine may be needed for organophosphate OD



GENERAL TRAUMA

ADULT PEDIATRIC (≤34 KG) BLS



• Assess for injuries meeting Trauma Triage Guidelines Policy #153

• Possible Spinal Injury - Spinal Motion Restriction (SMR) Procedure #702

• Uncontrolled Hemorrhage - Tourniquet/ Hemorrhage Control Procedure #706

Unstable • Communicate if SBP ≤90mmHg at ANY time • Pelvic injury – Pelvic Binder Procedure #713

o Place pelvic binder if: High-risk mechanism Pelvic, low back, or groin pain SBP ≤90 mmHg

Same as Adult • Communicate ANY age specific hypotension

see Universal Protocol #601 Attachment A


ALS Standing Orders Stable

• Monitor patient

Unstable • Hypotension – SBP of ≤90mmHg or if unable to

palpate peripheral pulses o Normal Saline up to 500 mL IV, may repeat X

1 for ongoing hypotension o TXA if indicated and ≥15 y/o - TXA

Administration Procedure #714

TXA 1 gm in 100 mL IV infusion over 10 min, no repeat

• Tension pneumothorax - Needle Thoracostomy Procedure #705

Stable • Monitor patient

Unstable

• Hypotension – as identified for age group o Normal Saline IV/IO 20 mL/kg – may

repeat x1 if no change in SBP o If <15 y/o no TXA administration

• Tension pneumothorax - Needle

Thoracostomy Procedure #705

Base Hospital Orders Only • Additional Normal Saline

• Neurogenic Shock Refractory to Fluids • Dopamine 5-20 mcg/kg/min IV/IO infusion

OR o Push-Dose Epinephrine 10 mcg/mL

1 mL IV/IO every 1-3 min

• Additional Normal Saline

• Neurogenic Shock Refractory to Fluids • Dopamine 5-20 mcg/kg/min IV/IO infusion

OR o Push-Dose Epinephrine 10 mcg/mL up

to 1 mL IV/IO every 1-3 min



o repeat as needed titrated to SBP >90mmHg

o See notes for mixing instructions

• As needed

o repeat as needed titrated to age appropriate SBP

o See notes for mixing instructions • As needed

Notes

• Mixing Push-Dose Epinephrine 10 mcg/mL (1:100,000): Mix 9 mL of Normal Saline with 1 mL of Epinephrine 1:10,000, mix well

• Maintain body temperature/warm as indicated • Destination and documentation per Trauma Triage and Destination Policy #153 • Early transport with treatment en route for high risk or unstable patients • A manual blood pressure is preferred for all unstable trauma patients • BLS responders – when in doubt regarding pelvic injury – avoid unnecessary movement, consider

preparation for placement of pelvic binder until ALS evaluation • Pain Control – Pain Management Protocol #603 • Include Step Criteria with MIVT Base Hospital report – update 5 min out or with changes • IV access large bore (>18G) with a saline lock to facilitate tubing changes at the Trauma Center • Treatable considerations for critical trauma patients: Hypoxia, Hypovolemia, Tension Pneumothorax

County of San Luis Obispo Public Health Department Procedure #703


CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)

FOR USE IN PATIENTS >34 KG BLS

Universal Protocol #601 Pulse Oximetry – O2 administration per Airway Management Protocol #602

BLS Elective Skills For Moderate to Severe Respiratory Distress

Application • Monitor pulse oximetry throughout use • Place patient in sitting position • Set up CPAP per manufacturer recommendations • Confirm air flow prior to applying mask to patient • Instruct patient to inhale through nose and exhale through mouth • Adjust settings, beginning low and titrate in 3cm/H2O increments – monitoring patient’s

tolerance and improved VS • Consider BVM if patient fails to show improvement • Document patient response before and after application – see notes Discontinue (support respirations with BVM) if: • Hypotension – SBP < 90 mmHg (remove topical Nitroglycerin products if used) • Increasing respiratory distress or decrease in respiratory drive • Decreasing LOC • Evidence of barotrauma (subcutaneous air or pneumothorax)

Other signs or symptoms of decompensation (ALOC, sustained decrease in O2 Sat, etc.) ALS Standing Orders

• Monitor End-tidal Capnography throughout use • Medication(s) per appropriate treatment protocol (some patients may not tolerate application

until medications take effect) • Consider BVM or endotracheal intubation (adults only) if patient fails to show improvement

Base Hospital Orders Only As needed Notes

• Notify Base Hospital when used

Clinical Condition Therapeutic Range Maximum Settings Asthma/Anaphylaxis 3.0-5.0 cm H2O 15 cm H2O COPD/Pneumonia 5.0-7.5 cm H2O 15 cm H2O Pulmonary Edema/Drowning 7.5-10.0 cm H2O 15 cm H2O

• Indications – Moderate or Severe Respiratory Distress associated with: o Acute pulmonary edema o COPD o Asthma/Anaphylaxis o Drowning o Pneumonia

County of San Luis Obispo Public Health Department Procedure #703


• Contraindications

o Unconscious or decreased level of consciousness with inability to adequately ventilate o Respiratory failure/arrest or cardiac arrest o Tracheostomy o Sign and symptoms of a pneumothorax o Major facial, head or chest trauma o Vomiting or upper GI bleed o Epistaxis – moderate to severe o Unable to control secretions o Uncooperative patient after coaching o Hypotension (SBP < 90 mmHg)

• Documentation o Pressure settings and any adjustments o Pulse oximetry readings o ETCO2 and ECG (ALS Providers) o Vital Signs o Response to treatments

County of San Luis Obispo Public Health Department Page 1 of 1 Division: Emergency Medical Services Agency Effective Date: --/--/2019

POLICY #: 205 ADVANCED LIFE SUPPORT AND BASIC LIFE SUPPORT EQUIPMENT AND SUPPLY

PURPOSE

A. To establish the minimum requirement of equipment and supplies to be available on ALS ambulances, BLS and ALS First Responder units and for ALS Special Use Medic in the County of San Luis Obispo.

POLICY

A. Ambulances, ALS and BLS First Responder Units and ALS Special Use Medic personnel authorized to operate in the County of San Luis Obispo must, at a minimum, have the equipment and supplies available in the unit/at the event as referenced in Attachment A of this document.

B. Ambulance, ALS and BLS First Responder Units and ALS Special Use Medic may carry equipment and supplies appropriate to their specific level of service in excess of minimum levels defined in Attachment A of this document.

AUTHORITY California Health and Safety Code, Division 2.5, Sections 1797.204, 1797.206 and

1797.220 California Code of Regulations, Title 22, Section 100167 (a) 3

ATTACHMENTS

A. EMS Equipment and Suppy List

Description Strength/SizeALS

Transport Minimum

ALS First Responder Minimum

ALS Special Use

Medic Minimum

BLS First Responder Minimum

† Elective skills as required

MEDICATIONSActivated charcoal 50 gm bottle (aqueous solution) 1 1 0 0

Adenosine 6.0 mg/2 mL 5 3 3 0Albuterol unit dose 2.5 mg/3 mL solution 4 2 2 0

Aspirin 81 mg nonenteric coated chewable 1 bottle 1 bottle 4 tablets 1 bottleAtropine 1 mg/10 mL 2 2 2 0Atropine 8 mg multi-dose vial 1 1 0 0

Calcium Chloride 10% 1 gm/10 mL 1 1 0 0Dextrose 10% 25 gm/250 mL bag 2 2 1 0*Dextrose 50% 25 gm/50 mL 2 2 1 0

Diphenhydramine 50 mg/1 mL or 50 mg/10mL 2 2 2 0Dopamine 400 mg in 250 mL normal saline or D5W OR 1 1 0 0

400 mg vials (400mg/10mL)Epinephrine 1:1,000 1 mg/1 mL (1mL preload) 4 2 2 0

†Epinephrine Auto-Injector Pediatric and Adult 0 0 0 †2 eachEpinephrine 1:10,000 1 mg/10 mL (10 mL preload) 8 6 3 0

Fentanyl 100 mcg/2 mL 2 2 2 0Glucagon 1 mg/1 mL 1 1 0 0

Glucose gel 15 gm 2 tubes 2 tubes 2 tubes 2 tubesLidocaine 2% 100 mg/ 5 mL 6 4 3 0‡ Mark I Kits 6 6 0 9Midazolam 5 mg/1 mL 2 1 1 0Naloxone 2 mg (vial or pre-load) 2 2 2 0

†Naloxone IN Kit §2 mg pre-load and Atomizer 0 0 0 †2Nitroglycerine SL tablets or spray 2 1 1 0

Nitro Paste 2% 1 gm single dose packet 3 3 0 0Ondansetron 4 mg /2 mL injectable 3 3 0 0

4 mg dissolvable tablets 3 3 1 0Sodium Bicarbonate 50 mEq/50 mL 2 2 0 0

Tranexamic Acid (TXA) 100 mg/1 mL 10 mL vial 2 1 0 0Because variations in medication supply occur, equivalent total dosage quantities may be substituted. *Dextrose D50 is being phased out in favor of Dextrose D10†Elective skills equipment required for participating agencies‡Optional Emergency Medical Services Agency suggested equipment

Alternate Medications to be Stocked ONLY with Medical Director Approval§Other pre-packaged single dose intranasal

with Medical Director Approvalnaloxone delivery devices may be used 0 0 0 †2

Diazepam (disaster cache/by order of Med Dir ONLY) 10 mg 2 1 1 0Morphine (alternate/by order of Med Dir ONLY) 10 mg 3 2 2 0

COUNTY OF SAN LUIS OBISPO EMS EQUIPMENT AND SUPPLY LIST Policy 205 Attachment A - DRAFT --/--/2019

1


Transport Minimum


ALS Special Use

Medic Minimum



IV SOLUTIONS/EQUIPMENT0.9% Normal Saline 250 mL bag 1 1 0 00.9% Normal Saline 1,000 mL bag (or equivalent total volume) 6 4 2 0

100 mL Saline Delivery Equipment 0.9% NS 100 mL bag OR Burette 2 1 0 00.9% Normal Saline 10 mL Vials/Flush 5 5 2 0

IV SOLUTIONS/EQUIPMENT CONT.IV Tubing 60gtt/mL 4 2 0 0IV Tubing 10-20gtt/mL 6 3 2 0

IV Catheters Sizes 14, 16, 18, 20, 22, 24 gauge 2 each 2 each 2 each 0Syringes Assorted - 1mL, 3mL, 6mL-20mL 2 each 2 each 1 each 0

Needles Assorted - ½”, 1”, 1 ½” - 18-30 gauge 2 each 2 each 2 each 0Intraosseous (IO) single needle device (FDA approved) adult and pediatric 1 each 1 each 1 each 0

Tourniquets (for IV start) 2 2 2 0Saline locks 4 2 2 0

Luer-Lock adaptors (Not required but recommended for use with STEMI patients) 2 2 0 0

Alcohol and betadine swabs 10 each 10 each 10 each †10 each Visual or electronic colorimetry blood glucose with appropriate supplies 1 1 1 0

TRAUMABandages and bandaging supplies:

Bandaids Assorted 10 10 5 10Sterile bandage compresses or equivalent 4"x4" 12 10 10 10

Trauma dressing 10"x30" or larger universal dressing 2 2 2 2Roller gauze 3" or 4” 12 rolls 8 rolls 2 rolls 8 rolls

Cloth adhesive tape 1, 2, or 3" 1 roll 1 roll 1 roll 1 rollTriangular bandages with safety pins 4 2 1 2

Tourniquet See approved list for commercial devices 2 2 1 2Vaseline gauze 3"x8", or 5"x9" 2 2 1 2

Tongue blade or bite stick 2 2 2 2Burn Sheets (sterile or clean) – may be disposable or linen (with date of

sterilization indicated) 2 2 0 2

Cervical collars Stiff: Sizes to fit all patients over one year old 1each 1 each 1 each 1 each

Cold packs 2 2 2 2Irrigation equipment and supplies:

Saline, sterile 250mL 4 2 1 2Long spine board and light weight head

immobilizer blocks (or equivalent immobilization device) 2 1 0 1

Straps to secure patient to boards 2 sets 1 set 0 1 setSplints, traction Adult and pediatric (or a single device

suitable for both) 1 each 1 each 0 1 each

2


Transport Minimum


ALS Special Use

Medic Minimum



TRAUMA CONT.Splints, cardboard or equivalent arm and leg splint 2 each 2 each 1 each 2 each

K.E.D. or equivalent 1 1 0 0Pediatric spinal immobilization board (or equivalent immobilization device) 1 1 0 0

Sheet or commercial pelvic binder 1 1 0 1

Infection ControlMeet the minimum requirement per crew member as stated in the California Code of Regulations Title 8 (All Providers)

Transportation EquipmentCollapsible gurney cot with adjustable contour 1 0 0 0

Stair chair or equivalent device 1 0 0 0Sheets, pillow, pillow case, towels, blankets (cloth

or disposable) 2 0 0 0

Scoop stretcher with straps 1 0 0 0Flat vinyl/canvas stretchers with straps 1 0 0 0

MISCELLANEOUSBlood pressure cuffs (portable): Adult 1 1 1 1

Large adult or thigh 1 1 0 1Pediatric 1 1 0 1

Obstetrical kit - sterile, prepackaged 1 1 0 1

Restraints - non-constricting wrist and ankle 1 set each 1 set each 0 1 set each

Stethoscope 1 1 1 1Trash bags/receptacles 2 2 1 2

Blanket Disposable 1 each 1 each 1 each 1 eachBandage scissors (heavy duty) 1 1 1 1

Emesis basins or emesis bags with containers 2 2 1 2Water, potable 1 liter 1 liter 0 1 liter

Maps, entire county 1 1 0 1Penlight 1 1 1 1

Triage tags 20 20 0 20Bed pan 1 0 0 0Urinal 1 0 0 0

†Glucometer disposable sensors with ≥10 test strips, lancets, and other

appropriate supplies 1 1 1 †1MISCELLANEOUS CONT.

Puncture proof sharps container small 2 2 1 †1Thermometer 1 1 0 0

Automatic External Defibrillator With AED pads * For EMT-D Provider Agencies (1)

3


Transport Minimum


ALS Special Use

Medic Minimum



AIRWAYEndotracheal tubes: sizes 3.0, 5.0, 5.5, 6.0, 6.5, 7.0, 7.5, 8.0, 8.5,

9.0 1 each 1 each 1 each 0

Laryngoscope handles, with extra batteries 2 2 1 0Laryngoscope blades: Miller # 0, 1, 2, 3, 4 Macintosh # 1, 2, 3, 4 1 each 1 each 1 each 0

Magill forceps (pediatric and adult) 1 each 1 each 1 each 0Adult stylets 2 each 1 each 1 each 0

10-20 mL syringe, sterile lubricant 2 each 1 each 1 each 0Needle Cricothyrotomy kit with: 10 or 12 ga needle, 10-20 mL syringe,

alcohol and betadine wipes 1 1 1 0

and oxygen supply adapterCapnography Device Qualitative or Quantitative 1 1 1 0

Hand held nebulizer for inhalation therapy 2 2 1 0Medrafter or equivalent 1 1 0 0

Portable, battery powered, cardiac monitor-defibrillator with 12-lead ECG capability with the

ability to perform computerized 1 1 1 0

ECG readings and provide hard copy ECG tracings with: **Optional EMSA suggested equipment

Patient ECG cable 1 1 1 0ECG recording chart paper 1 1 1 0

Adult ECG electrodes 4 sets 4 sets 2 sets 0Defibrillation pads or equivalent - Adult and

Pediatric 1 set each 1 set each 1 set each 0

Conductive defibrillation pads, 4 4 2 0or tubes of conductive gel 2 2 1 0

IV catheter for pleural decompression 10 gauge/3 inch 2 2 1 0Asherman chest seal or equivalent open wound

dressing 1 1 1 1

Pulse oximeter 1 1 1 1

†Continuous Positive Airway Pressure (CPAP) Ventilator

portable/adjustable pressure settings, FDA Approved with an oxygen supply 1 1 0 †1

Nasopharyngeal airways (soft rubber) Medium and Large adult sizes 2 each 2 each 1 each 2 eachLubricant, water-soluble jelly (K-Y) 2 2 2 2

Oropharyngeal airways (sizes 5.5 – 12 or equivalent) 2 each 1 each 1 each 1 eachAdult non-rebreather masks 2 2 1 2

Pediatric/infant non-rebreather mask 2 2 1 2Adult nasal cannula 4 2 1 2Oxygen Cylinders D or E size cylinder with regulator capable of

delivering 2-15 LPM 1 1 1 1M, H, or K cylinder with wall outlet(s) and

constant flow regulator(s) 1 0 0 0

4


Transport Minimum


ALS Special Use

Medic Minimum



Oxygen reserve:D or E cylinders 1 1 0 1

Face masks for resuscitation (clear) 2 1 1 1Bag-valve mask with O2 reservoir and supply

Adult 1 1 1 1Pediatric 1 1 1 1

Infant 1 1 1 1Suction equipment and supplies:

Rigid pharyngeal tonsil tip 2 2 0 2Spare suction tubing 1 1 0 1

Suction apparatus (portable) 1 1 1 1Suction catheters at least 2 sizes suitable for adult and 2 each 1 each 1 each 1 each

pediatric endotracheal suctioning

5

COUNTY OF SAN LUIS OBISPO EMS EQUIPMENT AND SUPPLY LIST

Policy 205 Attachment A - DRAFT


Transport Minimum


ALS Special Use

Medic Minimum



MEDICATIONS

Activated charcoal 50 gm bottle (aqueous solution) 1 1 0 0

Adenosine 6.0 mg/2 mL 5 3 3 0

Albuterol unit dose 2.5 mg/3 mL solution 4 2 2 0

Aspirin 81 mg nonenteric coated chewable 1 bottle 1 bottle 4 tablets 1 bottleAtropine 1 mg/10 mL 2 2 2 0

Atropine 8 mg multi-dose vial 1 1 0 0

Calcium Chloride 10% 1 gm/10 mL 1 1 0 0

Dextrose 10% 25 gm/250 mL bag 2 2 1 0

*Dextrose 50% 25 gm/50 mL 2 2 1 0

Diphenhydramine 50 mg/1 mL or 50 mg/10mL 2 2 2 0

NTY OF SAN LUIS OBISPO EMS EQUIPMENT AND SUPPLY


Dopamine 400 mg in 250 mL normal saline or D5W OR 1 1 0 0

400 mg vials (400mg/10mL)Epinephrine 1:1,000 1 mg/1 mL (1mL preload) 4 2 2 0

†Epinephrine Auto-Injector Pediatric and Adult 0 0 0 †2 eachEpinephrine 1:10,000 1 mg/10 mL (10 mL preload) 8 6 3 0

Fentanyl 100 mcg/2 mL 2 2 2 0Glucagon 1 mg/1 mL 1 1 0 0

Glucose gel 15 gm 2 tubes 2 tubes 2 tubes 2 tubesLidocaine 2% 100 mg/ 5 mL 6 4 3 0‡ Mark I Kits 6 6 0 9Midazolam 5 mg/1 mL 2 1 1 0Naloxone 2 mg (vial or pre-load) 2 2 2 0

†Naloxone IN Kit §2 mg pre-load and Atomizer 0 0 0 †2Nitroglycerine SL tablets or spray 2 1 1 0

Nitro Paste 2% 1 gm single dose packet 3 3 0 0Ondansetron 4 mg /2 mL injectable 3 3 0 0

4 mg dissolvable tablets 3 3 1 0Sodium Bicarbonate 50 mEq/50 mL 2 2 0 0

Tranexamic Acid (TXA) 100 mg/1 mL 10 mL vial 2 1 0 0Because variations in medication supply occur, equivalent total dosage quantities may be substituted. *Dextrose D50 is being phased out in favor of Dextrose D10†Elective skills equipment required for participating agencies‡Optional Emergency Medical Services Agency suggested equipment§Other pre-packaged single dose intranasal naloxone delivery devices may be used with Med Dir approvalAlternate Medications That May Be Stocked with Medical Director Approval

pam (disaster cache/by order of Med D 10 mg 2 1 1 0rphine (alternate/by order of Med Dir O 10 mg 3 2 2 0V SOLUTIONS/EQUIPMENT

0.9% Normal Saline 250 mL bag 1 1 0 0


0.9% Normal Saline 1,000 mL bag (or equivalent total volume) 6 4 2 000 mL Saline Delivery Equipme 0.9% NS 100 mL bag OR Burette 2 1 0 0

0.9% Normal Saline 10 mL Vials/Flush 5 5 2 0 OLUTIONS/EQUIPMENT CONT.

IV Tubing 60gtt/mL 4 2 0 0IV Tubing 10-20gtt/mL 6 3 2 0

IV Catheters Sizes 14, 16, 18, 20, 22, 24 gauge 2 each 2 each 2 each 0Syringes Assorted - 1mL, 3mL, 6mL-20mL 2 each 2 each 1 each 0

Needles Assorted - ½”, 1”, 1 ½” - 18-30 gauge 2 each 2 each 2 each 0Intraosseous (IO) single

needle device (FDA approved) adult and pediatric 1 each 1 each 1 each 0Tourniquets (for IV start) 2 2 2 0

Saline locks 4 2 2 0Luer-Lock adaptors (Not required but recommended for use with

STEMI patients) 2 2 0 0

Alcohol and betadine swabs 10 each 10 each 10 each †10 each Visual or electronic

colorimetry blood glucose analyzer

with appropriate supplies 1 1 1 0

TRAUMABandages and bandaging

supplies: Bandaids Assorted 10 10 5 10

Sterile bandage compresses or equivalent 4"x4" 12 10 10 10

Trauma dressing 10"x30" or larger universal dressing 2 2 2 2Roller gauze 3" or 4” 12 rolls 8 rolls 2 rolls 8 rolls

Cloth adhesive tape 1, 2, or 3" 1 roll 1 roll 1 roll 1 rollTriangular bandages with

safety pins 4 2 1 2Tourniquet See approved list for commercial devices 2 2 1 2

Vaseline gauze 3"x8", or 5"x9" 2 2 1 2Tongue blade or bite stick 2 2 2 2

Burn Sheets (sterile or clean) –

may be disposable or linen (with date of sterilization indicated) 2 2 0 2

Cervical collars Stiff: Sizes to fit all patients over one year old 1each 1 each 1 each 1 each


Cold packs 2 2 2 2Irrigation equipment and

supplies:Saline, sterile 250mL 4 2 1 2

Long spine board and light weight head

immobilizer blocks(or equivalent immobilization device) 2 1 0 1

Straps to secure patient to boards 2 sets 1 set 0 1 set

Splints, traction Adult and pediatric (or a single device suitable for both) 1 each 1 each 0 1 each

TRAUMA CONT.Splints, cardboard or

equivalent arm and leg splint 2 each 2 each 1 each 2 each K.E.D. or equivalent 1 1 0 0

Pediatric spinal immobilization board (or equivalent immobilization device) 1 1 0 0Sheet or commercial

pelvic binder 1 1 0 1

Infection ControlMeet the minimum requirement per crew member as stated in the California Code of Regulations Title 8 (All Providers)

Transportation EquipmentCollapsible gurney cot with adjustable contour 1 0 0 0Stair chair or equivalent

device 1 0 0 0Sheets, pillow, pillow

case, towels, blankets (cloth or disposable)

2 0 0 0

Scoop stretcher with 1 0 0 0Flat vinyl/canvas

stretchers with straps 1 0 0 0

MISCELLANEOUS


Blood pressure cuffs (portable): Adult 1 1 1 1

Large adult or thigh 1 1 0 1Pediatric 1 1 0 1

Obstetrical kit - sterile, prepackaged 1 1 0 1

Restraints - non-constricting wrist and 1 set each 1 set each 0 1 set each

Stethoscope 1 1 1 1Trash bags/receptacles 2 2 1 2

Blanket Disposable 1 each 1 each 1 each 1 eachBandage scissors (heavy

duty) 1 1 1 1Emesis basins or emesis

bags with containers 2 2 1 2Water, potable 1 liter 1 liter 0 1 liter

Maps, entire county 1 1 0 1Penlight 1 1 1 1

Triage tags 20 20 0 20Bed pan 1 0 0 0

Urinal 1 0 0 0†Glucometer disposable

sensors with ≥10 test strips, lancets, and other

appropriate supplies 1 1 1 †1

MISCELLANEOUS Puncture proof sharps

container small 2 2 1 †1Thermometer 1 1 0 0

Automatic External Defibrillator With AED pads * For EMT-D Provider Agencies (1)

AIRWAYEndotracheal tubes: sizes 3.0, 5.0, 5.5, 6.0, 6.5, 7.0, 7.5, 8.0, 8.5, 1 each 1 each 1 each 0

Laryngoscope handles, with extra batteries 2 2 1 0

Laryngoscope blades: Miller # 0, 1, 2, 3, 4 Macintosh # 1, 2, 3, 4 1 each 1 each 1 each 0


Magill forceps (pediatric and adult) 1 each 1 each 1 each 0

Adult stylets 2 each 1 each 1 each 010-20 mL syringe, sterile

lubricant 2 each 1 each 1 each 0Needle Cricothyrotomy kit

with:10 or 12 ga needle, 10-20 mL syringe,

alcohol and betadine wipes 1 1 1 0and oxygen supply adapter

Capnography Device Qualitative or Quantitative 1 1 1 0Hand held nebulizer for

inhalation therapy 2 2 1 0Medrafter or equivalent 1 1 0 0

Portable, battery powered, cardiac monitor-

defibrillator with 12-lead ECG capability with the

ability to perform

1 1 1 0

ECG readings and provide hard copy ECG

tracings with:**Optional EMSA suggested equipment

Patient ECG cable 1 1 1 0ECG recording chart paper 1 1 1 0

Adult ECG electrodes 4 sets 4 sets 2 sets 0Defibrillation pads or equivalent - Adult and

Pediatric 1 set each 1 set each 1 set each 0Conductive defibrillation pads, 4 4 2 0

or tubes of conductive gel 2 2 1 0 IV catheter for pleural

decompression 10 gauge/3 inch 2 2 1 0Asherman chest seal or equivalent open wound

dressing1 1 1 1

Pulse oximeter 1 1 1 1

†Continuous Positive Airway Pressure (CPAP)

portable/adjustable pressure settings, FDA Approved with an oxygen supply 1 1 0 †1


Nasopharyngeal airways (soft rubber) Medium and Large adult sizes 2 each 2 each 1 each 2 each

bricant, water-soluble jelly (K-Y) 2 2 2 2Oropharyngeal airways (sizes 5.5 – 12 or equivalent) 2 each 1 each 1 each 1 each

Adult non-rebreather masks 2 2 1 2atric/infant non-rebreather mask 2 2 1 2

Adult nasal cannula 4 2 1 2Oxygen Cylinders D or E size cylinder with regulator capable of

delivering 2-15 LPM 1 1 1 1M, H, or K cylinder with wall outlet(s) and

constant flow regulator(s) 1 0 0 0Oxygen reserve:

D or E cylinders 1 1 0 1Face masks for

resuscitation (clear) 2 1 1 1Bag-valve mask with O2

reservoir and supply Adult 1 1 1 1

Pediatric 1 1 1 1Infant 1 1 1 1

ction equipment and supplies:Rigid pharyngeal tonsil tip 2 2 0 2

Spare suction tubing 1 1 0 1Suction apparatus (portable) 1 1 1 1

Suction catheters at least 2 sizes suitable for adult and 2 each 1 each 1 each 1 eachpediatric endotracheal suctioning

County of San Luis Obispo Public Health Department Page 1 of 5 Division: Emergency Medical Services Agency Effective Date: 02/01/19

POLICY #215: EMT Basic Scope of Practice Approved Elective Skills Requirements for EMS Provider Agencies

PURPOSE

A. To establish criteria as defined by Title 22, Division 9, Chapter 2 of the California code of Regulations (CCR), for approval, including requirements and responsibilities, of Emergency Medical Service (EMS) provider agencies to adopt all or part(s) of the following Emergency Medical Technician (EMT) Basic Scope of Practice Approved Elective Skills (Elective Skills).

1. CPAP use

2. Epinephrine auto injector use

3. Finger stick blood glucose testing

4. Intranasal (IN) naloxone administration

SCOPE

A. This policy applies to County of San Luis Obispo EMS provider agencies, fire departments and ambulance providers, that employ individuals as EMTs who provide first responder emergency medical care in the County of San Luis Obispo.

DEFINITIONS

A. Emergency Medical Technician (EMT): A person who has successfully completed an EMT course, passed all required tests, and has been certified by a California EMT certifying entity. CCR Title 22, Division 9, Chapter 2, §100060

B. EMT Basic Scope of Practice Approved Elective Skills (Elective Skills): Refers to skills listed in the EMT basic scope of practice that require EMS Agency Medical Director approval described in CCR Title 22, Division 9, Chapter 2, §100063.

C. EMT Accreditation: EMTs working for any County of San Luis Obispo (SLO) provider agency approved to use any EMT Basic Scope of Practice Approved Elective Skills (Elective Skills) and who have been trained and completed competency-based evaluations on each Elective Skill approved for their agency. Refer to Policy #216 for complete EMT Accreditation guidelines.

D. EMS Provider Agency: An agency or organization in the County of San Luis Obispo that is responsible for and approved to provide emergency medical care using licensed/accredited EMTs and/or paramedics

E. Emergency Medical Services Agency (EMS Agency): The agency having primary responsibility for administration of emergency medical services in San Luis Obispo County. (§1797.94)

POLICY #215: EMT Basic Scope of Practice Approved Elective Skills Requirements for EMS Provider Agencies Page 2 of 5

IV. POLICY

A. An EMS Provider Agency requesting to carry and deploy one or more of the Elective Skills will submit an application packet to the County of San Luis Obispo Emergency Medical Services Agency (EMS Agency) for approval.

B. The EMS Agency will notify the applicant within twenty-one (21) business days of receiving the application of its decision to approve or deny the program.

C. The applying agency will have a training program approved by the EMS Agency prior to implementation of an Elective Skills program.

D. The EMS Agency may revoke or suspend the EMS provider agency’s Elective Skills program authorization for failure to meet and maintain the requirements of this policy or applicable state regulations.

E. EMTs trained in any Elective Skill must be accredited by the EMS Agency as outlined in Policy # 216 Emergency Medical Technician Accreditation.

F. Authorized personnel who fail to meet and maintain training and accreditation requirements may not utilize the Elective Skill(s).

G. Ongoing training, continued competency, and accreditation for personnel must be completed and documented every two (2) years.

H. When a trained and accredited EMT has started an Elective Skill and an ALS unit arrives on scene prior to completing that skill, the EMT may continue the skill with the approval and under the direction of the arriving San Luis Obispo County (SLO County) accredited paramedic if the continuation of the skill expedites necessary patient care.

I. A trained and accredited EMT, while on duty with an approved provider, may perform finger stick blood glucose measurements for any patient at the request and under the direction of an on scene SLO County paramedic.

J. Any costs incurred creating, implementing and maintaining for the use of CPAP equipment, epinephrine auto-injectors, blood glucose test equipment, and IN naloxone will be the sole responsibility of the EMS provider agency.

K. CPAP devices and parts, epinephrine auto-injectors, blood glucose test strips, and naloxone will be maintained in accordance with drug manufacturer recommendations including, but not limited to: expiration dates, storage, use, disposal, and temperature.

L. The approval of an EMS Provider Agency’s Elective Skills program authorization will be valid for four (4) years from authorization date. To continue authorization, the EMS Agency may audit all documentation and training records pertaining to the use of CPAP, epinephrine auto-injector, blood glucose monitoring, and IN naloxone.

M. These policies and procedures may be revised, modified or deleted at any time by the EMS Agency.


N. The EMS Agency Medical Director must approve any exceptions to the requirements of

this policy and procedures.

V. PROCEDURE

A. The EMS provider agency requesting to implement an Elective Skills program must apply to the EMS Agency for approval. A complete application will include the following:

1. A letter of intent to provide one or more of the Elective Skills signed by a Chief Officer or Operations Director agreeing to abide by County of San Luis Obispo EMS Agency policies, procedures and program requirements.

2. A description of need for use of Elective Skill(s).

3. An outline of the process for documenting Elective Skills use in respective e-PCR systems.

4. Identify a Program Coordinator who will be responsible for program oversight and coordination of quality improvement.

5. A written procedure for ongoing Quality Improvement activities specific to the use of Elective Skills. Include the names of individuals assigned to complete this responsibility.

6. A description of the plans for initial training and ongoing competency verification for authorized EMTs using the guidelines listed in the following section.

VI. GUIDELINES FOR TRAINING: ALL SKILLS

A. Primary instructor(s) must be a physician, registered nurse, physician assistant, or paramedic licensed in California.

B. Primary instructor(s) must be approved by the EMS Agency.

C. An EMT approved by a provider agency’s Primary Instructor and trained and authorized to use the Elective Skill(s) may, in the absence of the Primary Instructor, lead the training, administer the written exam, and demonstrate and evaluate skill(s) competencies.

D. All EMTs trained and authorized to use Elective Skills must have and maintain a current State of California EMT certificate

E. Training will include a written examination, instructor demonstration, and student demonstration of Elective Skill(s). Training programs, written examinations, and skills competencies will be coordinated between the EMS Agency and EMS Provider Agencies using Elective Skill(s).

F. Skills review, written test, demonstration of competency on Elective Skill(s), and reaccreditation for authorized EMTs must be completed and documented every two (2)


years. Refer to Policy #216 for complete EMT accreditation and reaccreditation guidelines.

G. IN Naloxone

1. Training should be a minimum of one-(1.0) hour and will cover:

i. Background information on opioid use and abuse

ii. Definition of opioids

iii. Signs and symptoms of an opioid overdose

iv. Reversal of opioids using IN naloxone

v. Emergency field treatment of the opioid overdose patient including confirmation of ALS dispatch and the use of AED if indicated

vi. Mechanism of drug action of naloxone, dosing, and administration of IN naloxone

vii. Documentation in e-PCR, including signs and symptoms of opioid overdose, respiratory rate and effort, and effect of naloxone

H. Continuous Positive Airway Pressure (CPAP)

1. Training should be minimum of one (1.0) hour and will cover:

i. Signs and symptoms of respiratory emergencies including: acute pulmonary edema, COPD, asthma, near-drowning, pneumonia

ii. Introduction to CPAP

iii. Indications for CPAP use

iv. Contraindications of CPAP use

v. Procedure for CPAP use including starting pressures, constant monitoring, and indications for discontinuing CPAP use

vi. Documentation of CPAP use in an e-PCR, including pressure setting and adjustments made, patient response to treatment, need to discontinue, and continuous vital sign recording

I. Epinephrine Auto-Injector

1. Training should be a minimum of one and one half (1.5) hours and will cover:

i. Signs and Symptoms of anaphylaxis


ii. Action and effects of epinephrine

iii. Indications for using epinephrine auto-injector

iv. Contraindications for using epinephrine auto injector

v. Demonstration of epinephrine auto injector use

vi. Practice and evaluation of epinephrine auto injector use

vii. Documentation in an e-PCR, including signs and symptoms of anaphylaxis, time epinephrine was administered, and effect of epinephrine administration

J. Finger Stick Blood Glucose Measurement

1. Training should be a minimum of one half (0.5) hour and will cover:

i. Signs and symptoms of diabetes and diabetic emergencies

ii. Define finger stick blood glucose testing indications

iii. Describe and demonstrate finger stick blood glucose test procedure

iv. Results of testing and what those results indicate

v. Appropriate treatment

vi. Documentation in an e-PCR, including blood glucose reading and any appropriate treatment as a result

VII. AUTHORITY

A. Title 22, California Code of Regulations, Division 9, Chapter 2, §100063

emergency medical care committee meeting agendanext meeting: thursday, may 16th, 2019 at 8:30am....

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