INTERFACILITY PROTOCOLS

7) ASTHMA

1) GENERAL

8) CHRONIC OBSTRUCTIVE PULMONARY DISEASE

2) VENTILATOR

9) ALLERGIC AND ANAPHYLACTIC REACTION

3) BALLOON PUMP

10) ALTERED MENTAL STATUS

4) CONTINUOUS MEDICATION ADMINISTRATION

11) SEIZURES

5) CHEST TUBE

12) NON CARDIOGENIC SHOCK

6) HIGH RISK NEONATAL

13) NAUSEA/VOMITING

7) HIGH RISK PEDIATRIC 8) INTRAVENOUS CONTROLLED SUBSTANCES

PEDIATRIC PROTOCOLS 14) PEDIATRIC RESPIRATORY ARREST

ADULT ACUTE CARE PROTOCOLS

15) PEDIATRIC NON TRAUMATIC CARDIAC ARREST

1) RESPIRATORY ARREST

16) PEDIATRIC ASTHMA/WHEEZING

2) OBSTRUCTED AIRWAY

17) PEDIATRIC ANAPHYLACTIC REACTION

3) NON TRAUMATIC CARDIAC ARREST

18) PEDIATRIC SEIZURES

A. VENTRICULAR TACHYCARDIA/ VENTRICULAR FIBRILLATION

19) PEDIATRIC DECOMPENSATED SHOCK 20) PEDIATRIC BRADYCARDIA

B. PEA-PULSELESS ELECTRICAL ACTIVITY 4) MYOCARDIAL ISCHEMIA A. SUPECTED MYOCARDIAL INFARCTION B. CARDIOGENIC SHOCK 5) CARDIAC DYSRYTHMIAS A. NARROW COMPLEX TACHYCARDIA B. VENTRICULAR TACHYCARDIA WITH PULSE/WIDE COMPLEX TACHYCARDIA OF UNCERTAIN TYPE C. BRADYDYSRYTHMIAS/COMPLETE HEART BLOCK 6) PULMONARY EDEMA

21) STANDING ORDERS FOR NEONATAL RESUSCITATION

FOUR WAYS TO CONTACT MEDICAL CONTROL APPROVED PROCEDURE: 12-LEAD ECG COMMUNICATION FAILURE PROTOCOL APPROVED PROCEDURE: CAPNOGRAPHY GENERAL OPERATING PROCEDURE POLICY: ESTIMATED TIME OF ARRIVAL REPORTING APPROVED PROCEDURE: EMERGENCY USE OF CENTRAL VENOUS ACCESS DEVICES

POLICY: TRIP CANCELLATION DOCUMENTATION

APPROVED PROCEDURE: NEEDLE CHEST DECOMPRESSION

POLICY: RN TRAINING REQUIREMENTS/JOB DESCRIPTION

APPROVED PROCEDURE: SPINAL IMMOBILIZATION

POLICY: LATEX ALLERGIX PATIENTS

APPROVED PROCEDURE: DEFIBRILLATION

POLICY: NARCOTICS/ACCOUNTABILITY

APPROVED PROCEDURE: ENDOTRACHEAL INTUBATION

POLICY: MEDICATION BAG/ACCOUNTABILITY

APPROVED PROCEDURE: KING TUBE INSERTION

POLICY: PRE-TRANSPORT VEHICLE CHECK

APPROVED PROCEDURE: SUBCUTANEOUS INJECTION

POLICY: TRANSPORT CANCEL

APPROVED PROCEDURE: INTRAMUSCULAR INJECTION

POLICY: INCIDENT REPORTS

APPROVED PROCEDURE: INTRAVENOUS CANNULATION (IV INSERTION)

POLICY: QUALITY ASSURANCE (QA) POLICY: PREVENTATIVE EQUIPMENT MAINTAINENCE

APPROVED PROCEDURE: EXTERNAL PACING POLICY: SCTU DOCUMENTATION APPROVED PROCEDURE: NEBULIZER TREATMENT POLICY: ENDOTRACHEAL INTUBATION KIT APPROVED PROCEDURE: INTRAVENOUS MEDICATION ADMINISTRATION APPROVED PROCEDURE: ENDOTRACHEAL MEDICATION ADMINISTRATION

POLICY: ISOLETTE (NICU) TRANSPORTS POLICY: TIMESHEETS POLICY: CALL FOR REPORT

APPROVED PROCEDURE: SYNCHRONIZED CARDIOVERSION APPROVED PROCEDURE: INTRAOSSEOUS INFUSION APPROVED PROCEDURE: PULSE OXYMETRY APPROVED PROCEDURE: FINGERSTICK GLUCOSE

POLICY: OB CRITICAL CARE TRANSPORT POLICY: PHYSICIAN’S ORDER FOR TRANSPORT DOCUMENTATION

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LIFELINE MEDICAL SERVICES CRITICAL CARE TRANSPORT UNIT POLICY AND PROCEDURE MANUAL Updated: MAY 2014

Philosophy Statement

LifeLine Medical Services of New Jersey proudly presents this Critical Care Transport Policy and Procedure Manual. LifeLine Nurses, EMTs, administrators, operations, dispatchers, call-intake and billing personnel have all been instrumental in the development of this document. These health care professionals and contributors are committed to a dynamic, coordinated, and medically appropriate EMS transport system that provides the best possible care for patients who require the services of our Critical Care Transport Division.

Disclaimer

The policies, procedures, and treatment protocols contained herein are to be utilized only while providing Critical Care Transport services for LifeLine Medical Services of New Jersey. Any and all previous existing policies, procedures, and protocols are not authorized and shall not be followed.

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FOUR WAYS TO CONTACT MEDICAL CONTROL: 1) USE THE VHF H.E.A.R. RADIO LOCATED IN EACH AMBULANCE 2) CONTACT THE SENDING OR RECEIVING PHYSICIAN USING THE APPROPRIATE PHONE NUMBERS 3) SUMMON ASSISTANCE FROM THE MICU OF SURROUNDING HOSPITALS 4) CALL MEDICAL DIRECTOR - BY CELLULAR TELEPHONE USING NUMBERS ON CLIPBOARD

COMMUNICATION FAILURE PROTOCOL: In the event that communication failure exists due to: 1) Standard biotelemetry communication equipment fails 2) Backup biotelemetry fails (cell phone) 3) The crewmembers can not access any medical command physician via the H.E.A.R. radio system 4) The crewmembers can not access any medical command by any other means The nurse will then follow the following protocol set forth by the medical director: 1) The nurse will follow standing orders approved and signed by the medical director, including medical control options in life-threatening situations 2) Attempts will be made to correct the communication problem 3) Once communication is corrected, the nurse will contact the medical director and advise of all events that occurred In the event that communications failure protocols are utilized, the nurse who utilized the protocols shall prepare a report indicating the call on which the protocols were utilized, treatment rendered, a description of communication problem, a list of alternate means attempted, problems encountered, and attempts to remedy the problem. This report will be forwarded to the medical director within 24 hours of the incident.

APPROVED BY:

(on file) ______________________________________ Dr. Jack Chambers, DO Medical Director

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INDEX INTERFACILITY PROTOCOLS 1) GENERAL 2) VENTILATOR 3) BALLOON PUMP 4) CONTINUOUS MEDICATION ADMINISTRATION 5) CHEST TUBE 6) HIGH RISK NEONATAL 7) HIGH RISK PEDIATRIC 8) INTRAVENOUS CONTROLLED SUBSTANCES

ACUTE CARE PROTOCOLS ADULT PROTOCOLS 1) RESPIRATORY ARREST 2) OBSTRUCTED AIRWAY 3) NON TRAUMATIC CARDIAC ARREST A. VENTRICULAR TACHYCARDIA/ VENTRICULAR FIBRILLATION B. PEA-PULSELESS ELECTRICAL ACTIVITY 4) MYOCARDIAL ISCHEMIA A. SUPECTED MYOCARDIAL INFARCTION B. CARDIOGENIC SHOCK 5) CARDIAC DYSRYTHMIAS A. NARROW COMPLEX TACHYCARDIA B. VENTRICULAR TACHYCARDIA WITH PULSE/WIDE COMPLEX TACHYCARDIA OF UNCERTAIN TYPE C. BRADYDYSRYTHMIAS/COMPLETE HEART BLOCK 6) PULMONARY EDEMA 7) ASTHMA 8) CHRONIC OBSTRUCTIVE PULMONARY DISEASE 9) ALLERGIC AND ANAPHYLACTIC REACTION 10) ALTERED MENTAL STATUS 11) SEIZURES 12) NON CARDIOGENIC SHOCK 13) NAUSEA/VOMITING PEDIATRIC PROTOCOLS 14) PEDIATRIC RESPIRATORY ARREST 15) PEDIATRIC NON TRAUMATIC CARDIAC ARREST 16) PEDIATRIC ASTHMA/WHEEZING 17) PEDIATRIC ANAPHYLACTIC REACTION 18) PEDIATRIC SEIZURES 19) PEDIATRIC DECOMPENSATED SHOCK 20) PEDIATRIC BRADYCARDIA 21) STANDING ORDERS FOR NEONATAL RESUSCITATION

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GENERAL OPERATING PROCEDURES These protocols apply to patient transports that originate from a location where a licensed physician has already assumed patient care responsibility. That physician is usually ultimately responsible for patient care and assuring that an adequate level of care is provided during the transport. Unless an alternate arrangement has been made with the receiving facility prior to the transport, the sending physician maintains responsibility for the patient until the patient has arrived at the receiving hospital. An example of this would be a receiving tertiary care facility sending a physician or other health care team member under a physician's order to assume care of the patient upon their arrival at the sending facility. A LifeLine SCTU team shall provide a minimum of an RN and 2 EMTs. When the LifeLine SCTU team is not accompanied by health care representatives of the sending or accepting attending physician, the LifeLine RN shall assume patient care responsibility in accordance with the interfacility transfer protocol. When health care members accompany the patient from the sending facility, orders from the sending physician already delineating the responsibility of each member of the health care team should be written so that no confusion exists between patient care providers as to their function if the patient becomes unstable. Likewise, if the receiving facility accepts care of a patient during transport, orders from the accepting physician should be provided. The LifeLine SCTU team shall always be under the authority of off-line and on-line medical direction. The patient and members of the health care team from the sending facility remain under the authority of the sending or accepting physician. The LifeLine SCTU Team may follow written orders from a responsible physician for drug administration or assist in procedures provided they are within the RNs or EMTs scope of care. When no order exists specific to a patient problem that develops enroute, the transport nurse shall revert to the protocol specific to the problem for standing orders and contact Medical Control for further instructions and orders as necessary; Interfacility PROTOCOL #1 applies to all transports. The remainder will be used where applicable. Acute Care Protocols are to be utilized when a change in patient condition occurs during a Transport which falls within the scope of the appropriate protocol. Sending Physicians Orders shall supersede both Acute Care and Interfacility Transport Protocols.

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SCTU INTERFACILITY PROTOCOL 1 SCTU PATIENT TRANSPORT

A. BEFORE TRANSPORT 1. Written Consent to Transfer must be obtained from either the patient or a responsible party such as a relative/POA or appropriate facility staff. 2. Physician Transfer Orders form must be completed and signed 3. A signature from sending facility must be obtained 4. Any property which will accompany patient in ambulance must be documented 5. Verify patent airway. a. To be witnessed by the physician, nursing staff, or respiratory therapist b. Ensure that any endotracheal/tracheostomy tube is patent, intact, properly positioned, and secured – document size and position 6. Place patient on Cardiac Monitor, Pulse Oximeter, NIBP (Non-Invasive Blood Pressure Monitor) unless contraindicated, and Capnography as clinically indicated and record vital signs 7. A monitor cardiac rhythm strip with vital signs must be printed and attached to the LifeLine PCR (Patient Care Report) at the beginning of every transport. If a strip is not printed, an explanation must be noted in the chart ie. “NICU- Isolette unable to generate rhythm strip” The following assessment is to be performed and information is to be obtained on all patients: 1. Always assure scene safety for yourself, SCTU team members, and your patient. 2. Primary survey: A = Airway with cervical spine control B = Breathing C = Circulation with control of bleeding (these three are referred to as the "ABCs".) D = Disability Determination A = alert and conscious V = responsive to verbal stimuli P = responsive to painful stimuli U = unresponsive (these four are referred to by the acronym "AVPU".) E = Exposure 3. Secondary survey:

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A. Obtain vital signs and perform objective head-to-toe assessment B. Obtain and document history      

4. 5. 6. 7.

Sex, age, and approximate weight Chief complaint Precipitating factors Significant past medical history Allergies Current medications Apply appropriate protocol and standing order based on assessment. Contact medical control (Sending Physician or other per document “Four ways to contact medical control”) if needed or for any problems or questions. Position patient comfortably as indicated by condition or situation. Transport as soon as feasible.

B. DURING TRANSPORT 1. BLS-Continuously monitor airway, breath sounds, adequate chest rise, and vital signs 2. In event of clinical emergency, assist as necessary upon request. 3. If patient becomes unstable and ancillary assistance not available: a. Follow Standing Orders b. Contact Medical Control as soon as possible. C. AFTER TRANSPORT 1. A signature must be obtained from the receiving facility indicating acceptance of patient’s property and care 2. A monitor rhythm strip with vital signs must be printed and attached to PCR. 3. Patient condition upon arrival at receiving facility must be documented along with the name of the responsible/capable individual who will assume patient care 4. Document position and patency of endotracheal tube, tracheostomy

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SCTU INTERFACILITY PROTOCOL 2 VENTILATOR MANAGEMENT A. BEFORE TRANSPORT 1. Verify patent airway. a. To be witnessed by the physician, nursing staff, or respiratory therapist, b. Ensure that the endotracheal/tracheostomy** tube is patent, Intact, properly positioned, and secured. c. Place patient on Pulse Oximeter, Capnography as clinically indicated and record vital signs. 2. Obtain written order for ventilator settings to be used enroute. 3. If you are unfamiliar/uncomfortable with the ventilator or settings being used. a. Contact the responsible physician for further orders and/or ancillary assistance. b. If not satisfied, contact Medical Control for further assistance 4. Prepare the LifeLine Pulmonetic Systems LTV ventilator a. Prepare device with settings and check function prior to application. b. Assist staff with detaching endotracheal/ tracheostomy tube** from facility's ventilator. c. Verify patent airway with breath sounds and vital signs. B. DURING TRANSPORT 1. Continuously monitor airway, breath sounds, adequate chest rise, and vital signs 2. If ventilator failure occurs and unable to troubleshoot a. Detach ventilator b. Ventilate with BVM using 10-15 LPM oxygen @12 B.P.M. 3. In event of clinical emergency, assist as necessary upon request. 4. If patient becomes unstable and ancillary assistance not available: a. Follow step B-2 b. Contact Medical Control as soon as possible. C. AFTER TRANSPORT 1. Verify with physician, nurse, or respiratory therapy staff that facility ventilator is functioning properly. Verify settings and that it is ready to be attached to patient. 2. Assist staff with detaching endotracheal/tracheostomy tube from transport ventilator. 3. Hyperventilate if necessary prior to applying facility's ventilator 4. Verify patent airway with breath sounds and vital signs. 5. Complete PCR, recording all vital signs, assessment, and any changes in detail. Record type, model and settings of ventilator used in transport. *NOTE: Pediatric patients requiring Pressure-Cycled vent MUST NOT be put on VolumeCycled vent. **In a patient with a tracheostomy tube, take care when changing ventilator circuits to avoid displacing the cannula. Thick secretions could necessitate the use of saline solution along with proper suctioning techniques.

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SCTU INTERFACILITY PROTOCOL 3 INTRA-AORTIC BALLOON PUMP MANAGEMENT PLEASE NOTE: ONLY NURSES WHO HAVE COMPLETED AND PASSED AN IABP COMPETENCY/TEST MAY PERFORM THESE TRANSPORTS ALONE. ALL OTHER NURSES MAY ONLY PERFORM AN IABP TRANSFER IF ANOTHER NURSE/PHYSICIAN (WHO IS DEEMED COMPETENT) ACCOMPANIES THE PATIENT. A. BEFORE TRANSPORT: 1. Perform patient assessment. Obtain vital signs. 2. To be witnessed by the physician, nursing staff, or cardiovascular staff: a. Ensure intra-aortic balloon catheter properly secured and site is clear (no bleeding/drainage). b. Confirm adequacy of distal pulses and perfusion, record pre-transport balloon pump settings. Note: May need Doppler stethoscope to confirm pulses in cardiogenic shock. c. Document that balloon tubing is clear without presence of internal blood d. Measure and record augmented systolic, mean and diastolic blood pressures. 3. Obtain written order for intra-aortic balloon pump settings to be used enroute. 4. If you are unfamiliar/uncomfortable with the balloon pump or settings being used: a. Contact the responsible physician for further orders and/or ancillary assistance. b. If concerns still exist, contact Medical Control for further assistance. 5. Prepare Datascope 97T OR 98 Intra-Aortic Balloon Pump: a. Apply settings; verify that acceptable ECG trigger is present. Check function and place on standby. b. Assist staff with transfer to transport pump. 1. Place hospital pump on standby. 2. Detach intra-aortic catheter from hospital pump and attach to transport pump. 3. Fill chamber, remove transport pump from "standby" and begin pumping. 4. Detach transducer set from hospital pump and attach to transport pump. 5. Zero and check blood pressure measurements. B. DURING TRANSPORT: 1. In addition to standard vitals, monitor augmented systolic, mean and diastolic blood pressure. 2. In the event of Mechanical failure: a. If patient stable, attempt troubleshooting no longer than 10 minutes. b. If unable to correct, detach catheter from pump and pump manually with a 60 cc syringe and 3 way Stopcock to prevent thrombus formation. 3. In event of clinical emergency assist staff upon request. 4. In event of clinical emergency and staff is not present, contact Medical Control as soon as possible! * Note: CPR and defibrillation may be performed while the intra-aortic balloon pump is functioning.

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C. AFTER TRANSPORT: TRANSFER TO HOSPITAL'S BALLOON PUMP: 1. Verify correct setting, presence of acceptable ECG trigger, proper function and place on standby. 2. Assist staff with transfer to hospital pump: a. Place hospital pump on standby. b. Detach intra-aortic catheter from transport pump and attach to hospital pump. c. Fill chamber, remove hospital pump from "standby" and begin pumping. d. Detach transducer set from transport pump and attach to hospital pump. e. Zero and check blood pressure measurements. 3. Record on PCR: a. Type, model and settings of balloon pump used in transport. b. Vitals, augmented diastolic, mean and systolic blood pressures. c. Any changes in patient condition or modification in Balloon Pump settings

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SCTU INTERFACILITY PROTOCOL 4 CONTINUOUS MEDICATION ADMINISTRATION A. BEFORE TRANSPORT: With appropriate facility staff: 1. Obtain written orders for all dosages, volumes, concentrations, and infusion rates of medications 2. Verify actual rate of infusions with desired dose (physician's orders.) 3. Request parameters to titrate medications as necessary. 4. Ensure IV/IO lines are patent (infusing, not infiltrating) and secured. 5. Assure tubing is compatible with medication, and medications in the same line are compatible. 6. If you are unfamiliar/ uncomfortable with the rates being used: a. Contact the responsible physician/ agent for further orders and/ or ancillary assistance. b. If not satisfied, contact Medical Control for further assistance. 8. Transfer all medications on hospital pump to transport pump. a. Set pump with flow rate from your calculations based on sending physician's orders. b. Close all stopcocks and be sure all lines are clear of air pockets. c. Switch each infusion from hospital pump to transport pump maintaining sterile procedures. d. Dial-A-Flow and similar tubing is acceptable only for maintenance infusion of crystalloid solution which does not contain medication 9. In the event that physician's written orders are not present, drip rates should remain unchanged. B. DURING TRANSPORT: 1. Monitor vital signs, tissue perfusion, IV/ IO access sites and infusion device function. 2. Adjust medications according to parameters provided. 3. In the event of mechanical failure which cannot be corrected, detach medication from pump and continue infusion with dial-a-f1ow, monitoring infusion with direct eye contact. 4. In case of a clinical emergency, assist responsible medical care provider within scope of protocol. 5. In case of clinical emergency and additional health care provider not present contact Medical Control as soon as possible. 6. If a medication is to be discontinued, begin an infusion of 0.9% NS @ KVO 7. Medications must not be titrated without sending physician's orders unless medical control is contacted. C. AFTER TRANSPORT: 1. Record type and model of infusion device, dosages, volume and concentration of medication, and fluid administered, along with any changes in patient condition and modifications in settings.

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SCTU INTERFACILITY PROTOCOL 5 CHEST TUBE MANAGEMENT A. Prior to transport: 1. With staff, ensure chest tube is patent and secured, connections have tight seal, and collection device is properly functioning. 2. Obtain written order to leave chest tube to water seal or amount of suction to maintain enroute. B. During Transport: 1. Maintain collection device in upright position. 2. If unclamped, provide sufficient suction to maintain prescribed negative pressure. 3. If collection device falls and water seal is lost, clamp chest tube temporarily and reestablish collection device competency. 4. If chest tube becomes dislodged while enroute, seal wound with occlusive dressing and tape all four sides. If tension pneumothorax develops unseal one side of dressing, have patient exhale, and reseal - contact Medical Control. 5. Monitor continuously, observing for signs and symptoms of tension pneumothorax. If present, contact Medical Control immediately. 6. If uncomfortable/ unfamiliar with device or settings being used, contact Medical Control C. After Transport: Record on PCR: 1. Vital signs including SpO2 2. Patient condition including lung sounds. 3. Pressure Maintained, volume and character of drainage.

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SCTU INTERFACILITY PROTOCOL 6 HIGH RISK NEONATAL TRANSPORT This protocol refers to, but is not limited to patients less than one month old born prematurely, low birth weight, or life-threatening respiratory/circulatory illness, infections, congenital anomalies, or metabolic disorders. A nurse or doctor trained and credentialed in highrisk neonatal transport by their respective hospital is the minimum mandatory requirement for these transports. They shall render interfacility treatment in accordance with accepted standards of medical and nursing practice to the extent permitted by their professional licenses, and shall be chiefly responsible for patient care. Assist with the following tasks: 1. Airway maintenance/ suctioning. 2. Oxygen administration. 3. Airway adjuncts (OPA) 4. Assisted ventilations (BVM) 5. Endotracheal intubation (OT/NT) 6. Gastric intubation (NG/OG) 7. Vascular access (IV/IO) 8. Fluid/medication administration (IVIIO/ET device) 9. Ventilator management 10. Chest tube management 11. Vital sign monitoring (EKG/Sp02) Direct medical control during transport shall be provided by the Medical Director of the highrisk neonatal unit or properly credentialed designee. Indirect Medical Control shall be provided by the Medical Directors of both the high-risk neonatal transport team and the ambulance service.

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SCTU INTERFACILITY PROTOCOL 7 HIGH-RISK PEDIATRIC TRANSPORT High risk pediatric patients include (but are not limited to) infants and children with life threatening respiratory, circulatory, neurologic, metabolic, infectious or traumatic illness. A nurse or doctor trained and credentialed in high-risk pediatric transport by their respective hospital/transport agency is the minimum mandatory requirement for these transports. They shall render interfacility treatment in accordance with accepted standards of medical and nursing practice to the extent permitted by their professional licenses, and shall be chiefly responsible for patient care. Assist with the following tasks: 1. Airway maintenance/ suctioning. 2. Oxygen administration. 3. Airway adjuncts (OPA) 4. Assisted ventilations (BVM) 5. Endotracheal intubation (OT/NT) 6. Gastric intubation (NG/OG) 7. Vascular access (IV/IO) 8. Fluid/medication administration (IV/IO/ET device) 9. Ventilator management 10.Chest tube management 11.Vital sign monitoring (EKG/Sa02) Direct medical control during transport shall be provided by the Medical Director of the highrisk neonatal transport unit or properly credentialed designee. Indirect Medical Control shall be provided by the Medical Directors of both the high-risk neonatal transport team and the ambulance service.

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SCTU INTERFACILITY PROTOCOL 8 INTRAVENOUS ADMINISTRATION OF CONTROLLED SUBSTANCES AND ANALGESICS This protocol refers to the benzodiazepines and narcotics class of medications approved for nursing administration that may cause hypotension and respiratory depression. This includes, but is not limited to: Benzodiazepines: diazepam (Valium) Narcotics: morphine sulfate A. Before Transport: 1. Obtain written orders clearly stating dosage, rate of administration, and clinical situation under which the medication should be administered 2. Obtain medication from sending facility if not carried on transport unit. 3. Perform patient assessment. Be sure to have respiratory support equipment available. 4. Apply high concentration oxygen unless medically contraindicated. 5. Place patient on pulse oximeter and cardiac monitor. 6. Ensure and secure IV access. B. During Transport: 1. Obtain vital signs prior to administration. 2. Administer medication via IV route slowly! Maximum rates: Midazolam @ 1.0 mg/minute Lorazepam @ 1.0 mg/ minute Diazepam @5.0 mg/minute Morphine @ 4.0 mg/minute Toradol @ 30 mg/minute 3. After administration, monitor closely and obtain frequent vital signs. 4. If hypotension or respiratory depression occurs, perform BLS. a. Naloxone If patient was given a narcotic, administer 0.8 mg IV push. b. Flumazenil If patient was given a benzodiazepine, contact Medical Control. Please take care when considering flumazenil to avoid status-seizure, especially for patients who receive chronic doses of benzodiazepine-based medication. C. After Transport 1. Unused controlled substances supplied by the sending facility shall be returned to the sending facility. 2. Wasted CDS are to be documented utilizing established LifeLine Medical Services forms. MEDICAL CONTROL OPTIONS: 1. Flumazenil a. If patient received a benzodiazepine and is respiratory depressed, consider 0.2 mg IV push.

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LIFELINE NJ SCTU ACUTE CARE PROTOCOL 1 RESPIRATORY ARREST For patients in actual or imminent respiratory arrest: NOTE: IF OVERDOSE IS SUSPECTED, REFER TO PROTOCOL 10 (Altered Mental Status) 1. Begin Basic Life Support Respiratory Distress procedures. 2. If a tension pneumothorax is suspected, perform Needle Decompression. 3. Secure airway, consider Endotracheal Intubation*. 4. Begin Cardiac Monitoring, record and evaluate EKG rhythm. 5. Begin an IV infusion of Normal Saline (0.9% NS) to keep vein open, or a Saline Lock. 6. If the patient requires sedation, contact Medical Control for implementation of one or more of the following MEDICAL CONTROL OPTIONS:

MEDICAL CONTROL OPTIONS: 1. PREHOSPITAL SEDATION PROCEDURE: Prior Permission from Medical Control Is Required If the patient is alert prior to performing Endotracheal Intubation, consider prehospital sedation as follows: a. Administer Diazepam 5 - 10 mg, IV/Saline Lock bolus. Repeat doses of Diazepam 5 -10 mg, IV/Saline Lock bolus, may be given as necessary. (Maximum total dosage is 20 mg.) OR b. Administer Midazolam 1 - 2 mg, IV/Saline Lock bolus. Repeat doses of Midazolam 1 mg, IV/Saline Lock bolus, may be given as necessary. (Maximum total dosage is 5 mg.) OR c. Administer Etomidate 0.3 mg/kg, IV/Saline Lock bolus, over 30-60 seconds. (Maximum total dose is 20 mg.) After successful intubation, consider Diazepam 5 mg IV/Saline Lock bolus or Lorazepam 2 mg, IV/Saline Lock or IM, for continued sedation.

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LIFELINE NJ SCTU ACUTE CARE PROTOCOL 2 OBSTRUCTED AIRWAY 1. Begin Basic Life Support Obstructed Airway procedures. 2. Perform Direct Laryngoscopy. Attempt to remove the foreign body with Magill Forceps. 3. Secure Airway, consider Endotracheal Intubation.

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NJ SCTUACUTECARE PROTOCOL 3 NON-TRAUMATIC CARDIAC ARREST 1. Begin Basic Life Support Non-Traumatic Cardiac Arrest procedures. 2. Begin Cardiac Monitoring, record and evaluate EKG rhythm, preferably using quick-look Paddles/pads. Follow Sub-Protocols: 3-A Ventricular Fibrillation/Pulseless Ventricular Tachycardia 3-B Pulseless Electrical Activity (PEA)/Asystole In the event that initial EKG rhythm changes, refer to the appropriate cardiac arrest subprotocol. Complete Standing Orders without repetition of previously administered drugs and contact Medical Control for further orders

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LIFELINE NJ SCTU ACUTE CARE PROTOCOL 3-A VENTRICULAR FIBRILLATION/PULSELESS VENTRICULAR TACHYCARDIA 1. Continue CPR with minimal interruption. NOTE:IN ARRESTS WITNESSED BY EMS, PERFORM CPR UNTIL DEFIBRILLATOR IS ATTACHED IN ARRESTS NOT WITNESSED BY EMS, PERFORM TWO (2) MINUTES OF CPR PRIOR TO DEFIBRILLATOR USE 2. Defibrillate* using 360 joules, or equivalent biphasic. NOTE: IF PATIENT HAS A PERMANENT PACEMAKER IN PLACE, POSITION THE PADDLES OR AUTOMATED DEFIBRILLATOR PADS AT LEAST ONE (1) INCH AWAY FROM THE PACEMAKER DEVICE. 3. Continue CPR. If after two minutes of additional CPR if there is no change in the rhythm, Defibrillate* a 2nd time as previously stated. 4. Continue CPR. If after two minutes of additional CPR if there is no change in the rhythm, Defibrillate* a 3rd time as previously stated. 5. Consider Endotracheal Intubation. 6. If, after every two minute interval of additional CPR, there is no change in the rhythm, Defibrillate* as previously stated. 7. Begin an IV infusion of Normal Saline (0.9% NS), administer a 500 mL IV bolus. 8. Administer Vasopressin 40 unit IV/Saline Lock Bolus, single dose. OR Administer Epinephrine 1 mg (10 ml of a 1:10,000 solution), IV/Saline Lock bolus. 9. If there is no change in the rhythm within 3 - 5 minutes, administer Epinephrine 1 mg (10 ml of a 1:10,000 solution), IV/Saline Lock bolus, every 3 - 5 minutes. 10. Administer Amiodarone 300 mg, diluted up to a total of 20 ml of DsW, IV/Saline Lock Bolus 11. If there is insufficient improvement in hemodynamic status, contact Medical Control for implementation of one or more of the following MEDICAL CONTROL OPTIONS: MEDICAL CONTROL OPTIONS: OPTION A: If Ventricular Fibrillation or Pulseless Ventricular Tachycardia recurs, a repeat dose of 150 mg Amiodarone diluted up to a total of 10 ml D5W, IV/Saline Lock Bolus may

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be given. OPTION B: Administer Sodium Bicarbonate 44-88 mEq IV/Saline Lock bolus. Repeat doses of Sodium Bicarbonate 44 mEq, IV/Saline Lock bolus, may be given every 10 minutes. OPTION C: Administer Magnesium Sulfate 2 gm, IV/Saline Lock bolus, diluted in 10 ml of Normal Saline (0.9% NS), over 2 minutes. OPTION D: In cases of hyperkalemia or Calcium Channel Blocker overdose administer Calcium Chloride (CaCI2) 1 gm, SLOWLY, IV/Saline Lock bolus. Follow with a Normal Saline (0.9% NS) flush. OPTION E: If at any point the patient has return of spontaneous circulation and has not been given any anti-dysrhythmic medication, then administer Amiodarone 150 mg over 10 minutes via vascular access. OPTION F: Transportation Decision.

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LIFELINE NJ SCTU ACUTE CARE PROTOCOL 3-B PULSELESS ELECTRICAL ACTIVITY (PEA) / ASYSTOLE NOTE: CONSIDER THE POSSIBILITY OF CONDITIONS CAUSING PEA/ASYSOLE WHICH REQUIRE IMMEDIATE IN-HOSPITAL TREATMENT SUCH AS SEVERE SHOCK, TRAUMATIC CARDIAC ARREST, PERICARDIAL TAMPONADE, HYPOVOLEMIA, TENSION PNEUMOTHORAX, ETC. 1. Continue CPR with minimal interruption. If asystole, confirm in a second lead. 2. If a tension pneumothorax is suspected, perform Needle Decompression. (See Appendix) 3. Consider Endotracheal Intubation. Once an advanced airway has been established, perform CPR as indicated with continuous compressions at a rate of at least 100 per minute, while giving ventilations at a rate of 8 to 10 times per minute, for 2-minute cycles. 4. Begin an IV infusion of Normal Saline (0.9% NS), administer a 500 mL IV bolus. 5. Administer Vasopressin 40 unit IV/Saline Lock Bolus, single dose. OR: Administer Epinephrine 1 mg (10 ml of a 1:10,000 solution), IV/Saline Lock bolus. 6. If there is no change in the rhythm within 3 - 5 minutes, administer Epinephrine 1 mg (10 ml of a 1:10,000 solution) IV/Saline Lock bolus, every 3 - 5 minutes. 7. If blood glucose test indicated a level less than 60 mg/dl, administer 25 g of 50 percent Dextrose in water intravenously. 8. If the patient has a heart rate (based on rhythm strip) less than 60 beats/min, administer Atropine Sulfate 1 mg, IV/Saline Lock bolus. If there is no change in the heart rate within 3 - 5 minutes, repeat Atropine Sulfate 1 mg, IV/Saline Lock bolus, every 3 - 5 minutes. (Maximum total dosage is 3 mg.) 9. If there is insufficient improvement in hemodynamic status, contact Medical Control for implementation of one or more of the following MEDICAL CONTROL OPTIONS: OPTION A: Administer Sodium Bicarbonate 44-88 mEq IV/Saline Lock bolus. Repeat doses of Sodium Bicarbonate 44 mEq, IV/Saline Lock bolus, may be given every 10 minutes. OPTION B: In cases of hyperkalemia or Calcium Channel Blocker overdose administer Calcium Chloride (CaCI2) 1 gm, SLOWLY, IV/Saline Lock bolus. Follow with a Normal Saline (0.9% NS) flush. OPTION C: Begin rapid IV/Saline Lock infusion of Normal Saline (0.9% NS), up to 3 liters. OPTION D: Transportation Decision.

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LIFELINE NJ SCTU ACUTE CARE PROTOCOL 4 SUSPECTED MYOCARDIAL INFARCTION/CHEST PAIN 1. Begin Basic Life Support Chest Pain procedures. 2. Begin Cardiac Monitoring, record and evaluate EKG rhythm. 3. Perform, record, and evaluate a 12 Lead EKG (if available) on any patient hemodynamically stable (i.e., systolic blood pressure greater than 90 mmHg). NOTE: AN UNSTABLE DYSRHYTHMIA MUST BE TREATED PRIOR TO INITIATION OF A 12 LEAD EKG. 5. Monitor vital signs every 2 - 3 minutes. Sub-Protocols: 4-A Drug Therapy of Myocardial Ischemia/Chest Pain 4-B Cardiogenic Shock

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LIFELINE NJ SCTU ACUTE CARE PROTOCOL 4-A DRUG THERAPY OF MYOCARDIAL ISCHEMIA AND CHEST PAIN 1. If chest pain persists, administer a Nitroglycerin Tablet 1/150 gr. or Spray 0.4 mg, sublingually, every 5 minutes, for a total of 3 doses if pain persists and only if systolic blood pressure remains greater than or equal to 100 mmHg. Before each administration, check the patient's pulse and blood pressure to ensure the patient is hemodynamically stable. 2. If chest pain still persists, apply Nitropaste 1% inches (if available). NOTE: NITROGLYCERIN AND/OR NITROPASTE MAY NOT BE ADMINISTERED TO PATIENTS WITH A SYSTOLIC BLOOD PRESSURE OF LESS THAN 100 mmHg, UNLESS AN IV/SALINE LOCK IS IN PLACE. 3. Administer four (4) chewable Aspirin Tablets, 324 mg. If patient has taken Aspirin prior to ALS encounter, reduce this dose by that amount. 4. Begin an IV infusion of Normal Saline (0.9% NS) to keep vein open, or a Saline Lock. 5. If chest pain or other evidence of myocardial ischemia still persists, contact Medical Control for implementation of one or more of the following MEDICAL CONTROL· OPTIONS: MEDICAL CONTROL OPTIONS: OPTION A: Administer Morphine Sulfate 2 - 5 mg, IV/Saline Lock bolus. Repeat doses of Morphine Sulfate 2 - 5 mg IV/Saline Lock bolus, may be given as necessary. (Maximum total dosage is 15 mg.) NOTE: IF HYPOVENTILATION DEVELOPS, ADMINISTER NALOXONE UP TO 2 MG, IV/SALINE LOCK BOLUS. OPTION B: Repeat Nitroglycerin Tablet 1/150 gr. or Spray 0.4 mg, sublingually, every 5 minutes (if transport is delayed or extended). OPTION C: Transportation Decision. NOTE: FOR PATIENTS EXHIBITING ST ELEVATION, REFER TO GENERAL OPERATING PROCEDURES - TRANSPORTATION DECISIONS AND PROCEDURES: STEMI PATIENTS.

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LIFELINE NJ SCTU ACUTE CARE PROTOCOL 4-8 CARDIOGENIC SHOCK 1. Begin an IV infusion of Normal Saline (0.9% NS) to keep vein open, or a Saline Lock. 2. Contact Medical Control for implementation of one or more of the following MEDICAL CONTROL OPTIONS: MEDICAL CONTROL OPTIONS: OPTION A: Administer a 250 ml IV bolus of Normal Saline (0.9% NS). Repeat once for a maximum total dose of 500 ml. OPTION B: Administer Dopamine 5 ug/kg/min, IV/Saline Lock drip. If there is insufficient improvement in hemodynamic status, the infusion rate may be increased until the desired therapeutic effects are achieved or adverse effects appear. (Maximum dosage is 20 ug/kg/min, IV/Saline Lock drip.) OPTION C: Transportation Decision.

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LIFELINE NJ SCTU ACUTE CARE PROTOCOL 5 CARDIAC DYSRHYTHMIAS 1. Begin appropriate Basic Life Support Procedures. 2. Begin Cardiac Monitoring, record and evaluate EKG rhythm. 3. Begin an IV infusion of Normal Saline (0.9% NS) to keep vein open, or a Saline lock. 4. Monitor blood pressure every 2-3 minutes. Sub-Protocols 5-A: Narrow Complex Tachycardia 5-B: Ventricular Tachycardia with a PulselWide Complex Tachycardia of Uncertain Type 5-C: Bradydysrhythmias/Complete Heart Block

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LIFELINE NJ SCTU ACUTE CARE PROTOCOL 5-A NARROW COMPLEX TACHYCARDIA 1. In patients with unstable narrow complex tachycardia, perform Synchronized Cardioversion* using 100 joules, or equivalent biphasic. If this fails to convert the dysrhythmia and the patient still has a pulse, Synchronized Cardioversion may be repeated as necessary, using, 200, 300 and 360 joules, or equivalent biphasic. 2. In patients with stable narrow complex tachycardia, administer Adenosine as follows: a. Perform 12-Lead electrocardiogram if technology is available. If Wolff-ParkinsonWhite is identified, stop and contact medical control. b. If atrial fibrillation or atrial flutter is identified at any time, and no Wolff-ParkinsonWhite is known or suspected, administer Diltiazem 0.25mg/kg IV over 2 minutes. c. If atrial fibrillation or atrial flutter is not identified, and no Wolff-Parkinson-White is known or suspected, proceed as follows: 1. Administer Adenosine 6 mg, IV/Saline Lock bolus, rapidly (over 1-3 seconds), followed by a Normal Saline (0.9% NS) 20cc flush. 2. Observe EKG monitor for 1 - 2 minutes for evidence of cardioversion. 3. If there is no evidence of cardioversion, administer Adenosine 12 mg, IV/Saline Lock bolus, rapidly, followed by a Normal Saline (0.9% NS) flush. 4. If there is still no evidence of cardioversion, repeat Adenosine 12 mg IV/Saline Lock bolus, rapidly, followed by a Normal Saline (0.9% NS) flush. d. If there is no conversion with the third dose of Adeonsine and no Wolff-ParkinsonWhite is known or suspected, then administer Diltiazem 0.25 mg/kg over 2 minutes via vascular access and contact medical control e. If adenosine/diltiazem fails to convert/slow the dysrhythmia or the patient has evidence of low cardiac output, contact Medical Control and prepare for implementation of one or more of the following MEDICAL CONTROL OPTIONS: MEDICAL CONTROL OPTIONS: OPTION A: If complex width is narrow and blood pressure is normal or elevated, administer Diltiazem 0.25 mg/kg, IV/Saline Lock bolus, slowly, over 2 minutes, monitoring blood pressure continuously. OPTION B: If complex width is narrow and blood pressure is low, perform Synchronized Cardioversion* using 100 joules, or equivalent biphasic. If this fails to convert the dysrhythmia and the patient still has a pulse, Synchronized Cardioversion* may be repeated as necessary using, 200, 300, and 360 joules, or equivalent biphasic. OPTION C: Administer Amiodarone 150 mg, diluted in 100 ml DsW over 10 minutes. OPTION D: Transportation Decision. * PREHOSPITAL SEDATION PROCEDURE: Prior Permission from Medical Control Is Required If the patient is alert prior to performing Synchronized Cardioversion, consider prehospital

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sedation as follows: a) Administer Diazepam 5 - 10 mg, IV/Saline Lock bolus. Repeat doses of Diazepam 5 - 10 mg, IV/Saline Lock bolus, may be given as necessary. (Maximum total dosage is 20 mg.) OR b) Administer Midazolam 1 - 2 mg, IV/Saline Lock bolus. Repeat doses of Midazolam 1 mg, IV/Saline Lock bolus, may be given as necessary. (Maximum total dosage is 5 mg.)

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LIFELINE NJ SCTU ACUTE CARE PROTOCOL 5-B VENTRICULAR TACHYCARDIA WITH A PULSE/ WIDE COMPLEX TACHYCARDIA OF UNCERTAIN TYPE NOTE: IN PATIENTS WITH PULSELESS VENTRICULAR TACHYCARDIA, SEE APPROPRIATE SUBPROTOCOL 1. If patient is unstable, perform Synchronized Cardioversion* using 100 joules, or equivalent biphasic. If this fails to convert the dysrhythmia and the patient still has a pulse, Synchronized Cardioversion* may be repeated as necessary using 200, 300 and 360 joules, or equivalent biphasic. If rhythm is converted at any point (and Amiodarone has not already been given), administer Amiodarone 150 mg via vascular access over 10 minutes. 2. If patient is stable, administer Amiodarone 150 mg, diluted in 100 ml DsW over 10 minutes. 3. If Amiodarone fails to convert the dysrhythmia or the patient has evidence of low cardiac output, contact Medical Control for implementation of one or more of the following MEDICAL CONTROL OPTIONS: MEDICAL CONTROL OPTIONS OPTION A: Perform Synchronized Cardioversion* using 100 joules, or equivalent biphasic. If this fails to convert the dysrhythmia and the patient still has a pulse, Synchronized Cardioversion may be repeated as necessary using 200,300, and 360 joules, or equivalent biphasic. OPTION B: Administer Magnesium Sulfate 2 gm, IV/Saline Lock bolus, diluted in 10 ml of Normal Saline (0.9% NS), over 2 minutes. OPTION C: In cases of hyperkalemia or Calcium Channel Blocker overdose administer Calcium Chloride (CaCI2) 1 gm, SLOWLY, IV/Saline Lock bolus. Follow with a Normal Saline (0.9% NS) flush. OPTION D: Administer Sodium Bicarbonate 44 - 88 mEq, IV/Saline Lock bolus, for preexisting acidosis. Repeat doses of Sodium Bicarbonate 44 mEq, IV/Saline Lock bolus, may be given every 10 minutes. OPTION E: Transportation Decision. * PREHOSPITAL SEDATION PROCEDURE: Prior Permission from Medical Control Is Required If the patient is alert prior to performing Synchronized Cardioversion, consider prehospital sedation as follows: a) Administer Diazepam 5 -10 mg, IV/Saline Lock bolus. Repeat doses of Diazepam 5 - 10 mg, IV/Saline Lock bolus, may be given as necessary.

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(Maximum total dosage is 20 mg.) OR b) Administer Midazolam 1 - 2 mg, IV/Saline Lock bolus. Repeat doses of Midazolam 1 mg, IV/Saline Lock bolus, may be given as necessary. (Maximum total dosage is 5 mg.)

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LIFELINE NJ SCTU ACUTE CARE PROTOCOL 5-C BRADY DYSRHYTHMIAS AND COMPLETE HEART BLOCK If the patient has a ventricular rate of less than 60 beats/min and signs of decompensated shock such as chest pain, shortness of breath, hypotension, or altered mental status: 1. Obtain 12 lead electrocardiogram if technology is available. 2. Administer Atropine Sulfate 0.5 mg, IV/Saline Lock bolus if patient does not have the signs or symptoms of an acute myocardial infarction. If IV access is unavailable, proceed directly to Transcutaneous Pacing. 2a. Note: Denervated hearts (ie. heart transplants) and patients with high degree heart blocks will not response to Atropine Sulfate. In such cases, initiate external cardiac pacing. Atropine sulfate 0.5 mg IV/Saline Lock may be repeated every 3-5 minutes to a maximum of 3 mg total. 3. Begin Transcutaneous Pacing* if bradycardia is refractory to atropine sulfate IV therapy. 4. If there is insufficient improvement in cardiac status, contact Medical Control for implementation of one or more of the following MEDICAL CONTROL OPTIONS: MEDICAL CONTROL OPTIONS: OPTION A: Administer Dopamine 2 ug/kg/min, IV/Saline Lock drip. If there is insufficient improvement in hemodynamic status, the infusion may be increased until the desired therapeutic effects are achieved or adverse affects appear. (Maximum dosage is 10 ug/kg/min, IV/Saline Lock drip.) OPTION B: Administer Epinephrine 2 ug/min, IV/Saline Lock drip. Prepare infusion by adding 1 mg of Epinephrine (1 ml of a 1:1,000 solution) to 250 ml of Normal Saline (0.9% NS) (1 ug/min = 15 ml/hr = 15 gtts/min). If there is insufficient improvement in hemodynamic status, the infusion may be increased until the desired therapeutic effects are achieved or adverse affects appear. (Maximum dosage is 10 ug/min, IV/Saline Lock drip.) OPTION C: In cases of hyperkalemia or Calcium Channel Blocker overdose administer Calcium Chloride 1 gm, SLOWLY, IV/Saline Lock bolus. Follow with a Normal Saline (0.9% NS) flush. OPTION D: Administer Sodium Bicarbonate 44 - 88 mEq, IV/Saline Lock bolus, for preexisting acidosis. Repeat doses of Sodium Bicarbonate 44 mEq, IV/Saline Lock bolus, may be given every 10 minutes. OPTION E: Transportation Decision. * PREHOSPITAL SEDATION PROCEDURE: Prior Permission from Medical Control Is

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Required If the patient is alert prior to performing Transcutaneous Pacing, consider prehospital sedation as follows: a) Administer Diazepam 5 - 10 mg, IV/Saline Lock bolus. Repeat doses of Diazepam 5 - 10 mg, IV/Saline Lock bolus, may be given as necessary. (Maximum total dosage is 20 mg.) OR b) Administer Midazolam 1 - 2 mg, IV/Saline Lock bolus. Repeat doses of Midazolam 1 mg, IV/Saline Lock bolus, may be given as necessary. (Maximum total dosage is 5 mg.)

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LIFELINE NJ SCTU ACUTE CARE PROTOCOL 6 ACUTE PULMONARY EDEMA 1. Begin Basic Life Support Respiratory Distress procedures. 2. Begin Cardiac Monitoring, record and evaluate EKG rhythm. 3. Begin an IV infusion of Normal Saline (0.9% NS) to keep vein open, or a Saline Lock. 4. Monitor vital signs every 2-3 minutes. 5. Administer Nitroglycerin Tablet 1/150 gr or Spray 0.4 mg, sublingually, every 5 minutes, for a total of 3 doses. Before each administration, check the patient's pulse and blood pressure to ensure the patient is hemodynamically stable (SBP remains greater than or equal to 100mmHg). 6. Administer Nitropaste 1% inches (if available). NOTE: NITROGLYCERIN AND/OR NITROPASTE MAY NOT BE ADMINISTERED TO PATIENTS WITH A SYSTOLIC BLOOD PRESSURE OF LESS THAN 100 mm Hg, UNLESS AN IV/SALINE LOCK IS IN PLACE. 7. Administer Furosemide 20mg, IV/Saline Lock bolus. 8. Initiate CPAP Therapy, if available. 9. Contact Medical Control for implementation of one or more of the following MEDICAL CONTROL OPTIONS: MEDICAL CONTROL OPTIONS: OPTION A: Administer Morphine Sulfate 2 - 5 mg, IV/Saline Lock bolus. Repeat doses of Morphine Sulfate 2 - 5 mg, IV/Saline Lock bolus, may be given as necessary. (Maximum total dosage is 15 mg.) NOTE: IF HYPOVENTILATION DEVELOPS, ADMINISTER NALOXONE UP TO 2 MG, IV/SALINE LOCK BOLUS OPTION B: Repeat Nitroglycerin Tablet 1/150 gr. or Spray 0.4 mg, sublingually.

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LIFELINE NJ SCTU ACUTE CARE PROTOCOL 7 ASTHMA In patients with acute asthma and/or active wheezing: 1. Begin Basic Life Support Respiratory Distress procedures. 2. Administer Albuterol Sulfate 0.083% (one unit dose bottle of 3 ml), by nebulizer, at a flow rate that will deliver the solution over 5 to 15 minutes. May be repeated twice (total of 3 doses). OR Administer Xopenex 1.25 mgt 3 mL at a flow rate that will deliver the solution over 5 - 15 minutes. May be repeated twice (total of 3 doses). NOTE: DO NOT DELAY TRANSPORT TO ADMINISTER ADDITIONAL NEBULIZER TREATMENTS. 3. In patients with signs of impending respiratory failure, administer Epinephrine 0.3 mg (0.3 ml of a 1:1,000 solution), IM. 4. Begin Cardiac Monitoring, record and evaluate EKG rhythm, in patients in severe respiratory distress with history of dysrhythmia or cardiac disease. 5. In patients in severe respiratory distress, begin an IV/Saline Lock infusion of Normal Saline (0.9% NS) to keep vein open, or a Saline Lock. 6. In patients with persistent severe respiratory distress, administer Magnesium Sulfate, 2 gm, IV/Saline lock, diluted in 50-100 ml Normal Saline (0.9% NS) over 10-20 minutes. 7. In patients with persistent severe respiratory distress, administer Methylprednisolone 125 mg, IV/Saline lock bolus, or IM, OR Administer Dexamethasone, 12 mg, IV/Saline Lock bolus, or IM. 8. If the patient develops or remains in severe respiratory distress, contact Medical Control for implementation of one or more of the following MEDICAL CONTROL OPTIONS: MEDICAL CONTROL OPTIONS: OPTION A: Repeat Albuterol Sulfate 0.083% (one unit dose bottle of 3 ml), by nebulizer, at a flow rate that will deliver the solution over 5 to 15 minutes. OR

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Repeat Xopenex 1.25 mgt/3mL, by nebulizer, at a flow rate that will deliver the solution over 5 - 15 minutes. OPTION B: Administer Epinephrine 0.3 mg (0.3 ml of a1:1,000 solution), IM.

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NJ SCTU ACUTE CARE PROTOCOL 8 CHRONIC OBSTRUCTIVE PULMONARY DISEASE In patients in severe respiratory distress due to chronic obstructive pulmonary disease: 1. Begin Basic Life Support Respiratory Distress procedures. 2. Begin Cardiac Monitoring, record and evaluate EKG rhythm. 3. Administer Albuterol Sulfate 2.5mg 0.083% (one unit dose bottle of 3 ml), by nebulizer, at a flow rate that will deliver the solution over 5 - 15 minutes. May be repeated twice (total of 3 doses). OR Administer Xopenex 1.25 mgt 3 mL at a flow rate that will deliver the solution over 5 - 15 minutes. May be repeated twice (total of 3 doses). NOTE: DO NOT DELAY TRANSPORT TO ADMINISTER ADDITIONAL NEBULIZER TREATMENTS. 2. Begin an IV infusion of Normal Saline (0.9% NS) to keep vein open, or Saline Lock. 3. In patients with persistent severe respiratory distress, administer Methylprednisolone 125 mg, IV/Saline lock bolus, or IM, OR Administer Dexamethasone, 12 mg, IV/Saline Lock bolus, or IM. 4. If the patient remains in severe respiratory distress, contact Medical Control for implementation of one or more of the following MEDICAL CONTROL OPTIONS: MEDICAL CONTROL OPTIONS: OPTION A: Repeat Albuterol Sulfate 0.083% (one unit dose bottle of 3 ml), by nebulizer, at a flow rate that will deliver the solution over 5 - 15 minutes. OR Repeat Xopenex 1.25 mg/3mL, by nebulizer, at a flow rate that will deliver the solution over 5 - 15 minutes.

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LIFELINE NJ SCTU ACUTE CARE PROTOCOL 9 ALLERGIC/ANAPHYLACTIC REACTION The following standing orders are authorized in the event that an adult patient presents with signs of generalized allergic findings such as urticaria without signs of acute significant respiratory distress and/or profound hypotension (systolic blood pressure less than or equal to 90 mmHg): 1) Assess and secure airway. 2) Administer oxygen therapy as patient condition indicates. 3) Establish vascular access 4) Administer 50 mg Diphenhydramine HCL via vascular access 5) Contact medical control as needed The following standing orders are authorized in the event that an adult patient presents with signs of generalized allergic findings such as urticaria with signs of acute significant respiratory distress and/or profound hypotension (systolic blood pressure less than or equal to 90mmHg) with clinical evidence of shock (altered mental status, cool clammy or mottled skin, and/or delayed capillary refill): 1) Begin Basic Life Support Anaphylactic Reaction procedures. 2) If the patient is exhibiting obvious airway compromise, perform Endotracheal Intubation*. 3) Administer Epinephrine 0.3 mg (0.3 ml of a 1:1,000 solution), IM. 4) If the patient has signs of bronchospasm, administer Albuterol Sulfate 0.083% (one unit dose bottle of 3 ml), by nebulizer, at a flow rate that will deliver the solution over 5 - 15 minutes. 5) Monitor vital signs every 5 minutes. 6) Begin Cardiac Monitoring, record and evaluate EKG rhythm. 7) Begin an IV infusion of Normal Saline (0.9% NS) via a large bore (14 - 16 gauge) catheter. Administer 500 mL fluid bolus. The fluid bolus should be repeated up to one liter if systolic blood pressure remains less than 100 mmHg and the patient is not exhibiting new signs of pulmonary edema. 8) Administer diphenhydramine HCL 50mg via vascular access. 9) Contact Medical Control for implementation of one or more of the following MEDICAL CONTROL OPTIONS:

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MEDICAL CONTROL OPTIONS: OPTION A: Repeat any of the above Standing Orders. OPTION B: Administer Epinephrine 1 ug/min, IV/Saline Lock drip. Prepare infusion by adding 1 mg of Epinephrine (1 ml of a 1:1,000 solution) to 250 ml of Normal Saline (0.9% NS) (1 ug/min =15 m/hr =15 gtts/min). If there is insufficient improvement in hemodynamic status, the infusion may be increased until the desired therapeutic effects are achieved or adverse affects appear. (Maximum dosage is 4 ug/min, IV/Saline Lock drip.) OPTION C: Administer Dopamine 5 ug/kg/min, IV/Saline Lock drip. If there is insufficient improvement in hemodynamic status, the infusion rate may be increased until desired therapeutic effects are achieved or adverse effects appear. (Maximum dosage is 20 ug/kg/min, IV/Saline Lock drip.) OPTION D: Administer Methylprednisolone 125 mg, IV/Saline Lock bolus, slowly, over 2 minutes. OR Administer Dexamethasone 12 mg, IV/Saline Lock Bolus, slowly over 2 minutes.

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LIFELINE NJ SCTU ACUTE CARE PROTOCOL 10 ALTERED MENTAL STATUS 1. Begin Basic Life Support Altered Mental Status procedures. 2. Begin an IV infusion of Normal Saline (0.9% NS) to keep vein open, or Saline Lock. 3. Administer Dextrose 25 gm (50 ml of a 50% solution), IV/Saline Lock bolus. NOTE: A GLUCOMETER (IF AVAILABLE) MAY BE USED TO DOCUMENT BLOOD GLUCOSE LEVEL PRIOR TO DEXTROSE ADMINISTRATION. IF THE GLUCOMETER READING IS ABOVE 120 mg/dl, DEXTROSE MAY BE WITHHELD. 4. Administer Thiamine 100 mg, IV/Saline Lock bolus. 5. In patients with diabetic histories where an IV/Saline Lock route is unavailable, administer Glucagon 1 mg, IM. (Thiamine need not be administered to these patients). 6. If there is no change in mental status, administer Naloxone up to 2 mg, IV/Saline Lock bolus. If IV/Saline Lock access has not been established, administer Naloxone up to 2 mg, IM or IV. (Start with 0.4 mg and titrate the dose to reversal of any respiratory depression) NOTE: IF AN OVERDOSE IS STRONGLY SUSPECTED, ADMINISTER NALOXONE PRIOR TO DEXTROSE AND THIAMINE. 7. If there still is no change in mental status or it fails to improve significantly, repeat Dextrose 25 gm (50 ml of a 50% solution), IV/Saline Lock bolus. 8. If there still is no change in the patient's mental status or it fails to improve significantly, repeat Naloxone up to 2 mg, IV/Saline Lock bolus. If IV/Saline Lock access has not been established, administer Naloxone up to 2 mg, IM or IN. 9. If there is still no change in mental status, contact Medical Control for implementation of one or more of the following MEDICAL CONTROL OPTIONS: MEDICAL CONTROL OPTIONS: OPTION A: Repeat Naloxone, up to 2 mg, IV/Saline Lock bolus (IM or IN if IV/Saline Lock access has not been established), up to 3 additional doses. (Maximum total dosage is 10 mg.) OPTION B: Transportation Decision.

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LIFELINE NJ SCTU ACUTE CARE PROTOCOL 11 SEIZURES For patients experiencing seizures that are ongoing or recurring (a generalized seizure for 2 minutes or greater or having repetitive seizures): 1. Begin Basic Life Support Seizures procedure. 2. Begin Cardiac Monitoring, record and evaluate EKG rhythm. 3. Begin an IV/Saline Lock infusion of Normal Saline (0.9% NS) to keep vein open, or a Saline Lock. 4. If blood glucose is less than 50mg/dl, Administer Dextrose 25 gm (50 ml of a 50% solution), IV/Saline Lock bolus. 5. Administer Lorazepam 2 mg, IV/Saline Lock bolus, or, if IV access is unavailable, IM. A single repeat dose of Lorazepam 2 mg, IV/Saline Lock bolus, or, if IV access is unavailable, IM, may be given after 5 minutes if seizure activity persists or recurs. OR Administer Diazepam 5 mg, IV/Saline Lock bolus. A single repeat dose of Diazepam 5 mg, IV/Saline Lock bolus, may be given if seizure activity persists or recurs. (Rate of administration may not exceed 5 mg/min.) OR Administer Midazolam 10 mg, IM, if IV access is unavailable. 6. Administer Thiamine 100 mg, IV/Saline Lock bolus. 7. If seizure activity persists, contact Medical Control for implementation of one or more of the following MEDICAL CONTROL OPTIONS: MEDICAL CONTROL OPTIONS: OPTION A: Repeat Lorazepam 2 mg, IV/Saline Lock bolus, or, if IV access is unavailable, IM. OR Repeat Diazepam 5 mg, IV/Saline Lock bolus. (Rate of administration may not exceed 5 mg/min.) OR

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Repeat Midazolam 10 mg, IM, if IV access is unavailable.

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LIFELINE NJ SCTU ACUTE CARE PROTOCOL 12 NON-CARDIOGENIC SHOCK 1. Begin Basic Life Support Shock procedures. 2. If a tension pneumothorax is suspected, perform Needle Decompression. (See Appendix) 3. Begin rapid IV/Saline Lock infusion of Normal Saline (0.9% NS) or Ringer's Lactate (RL) via one to two large bore (14 - 16) gauge catheters, up to 3 liters, via a macro-drip. 4. Begin Cardiac Monitoring, record and evaluate EKG rhythm. 5. If transportation of the patient is delayed or extended and/or the above measures fail to maintain or improve hemodynamic status, contact Medical Control for implementation of one or more of the following MEDICAL CONTROL OPTIONS: MEDICAL CONTROL OPTIONS: OPTION A: Continue rapid IV/Saline Lock infusion of Normal Saline (0.9% NS) or Ringer's Lactate (RL), up to an additional 3 liters (total of 6 liters), via a macro-drip.

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LIFELINE NJ ACUTE CARE PROTOCOL 13 ADULT NAUSEA/VOMITING DURING TRANSPORT For adult patients with persistent nausea and/or vomiting: NOTE: PATIENTS WITH SYSTOLIC BLOOD PRESSURE