Medical Care |

Medical Care

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The new State approved Prehospital and Interfacility drug protocols have been developed by the
Division of EMS in conjunction with the Medical Control Committee using the most current drug
standards available.
New drug standards were developed specifically to assist the Paramedic in carrying out his / her daily
function as it relates to drug therapy and the standard by which Paramedics are trained and tested.
There are specific drugs contained in this document which require on-line medical control. These
drugs are denoted by the statement: "ONLY WITH ON-LINE MEDICAL CONTROL ORDER." There
can be no standing order for Morphine (CII) and Nubain as these are controlled drugs. Scheduled
Drugs are indicated by the symbol: "C" in the upper right hand corner of the page.
Due to the potential for abuse, the Medical Control Committee has added Nubain to the "Controlled
Substances List" for EMS. This change requires that Nubain be inventoried, stored, and protected as
would any other narcotic (e.g. Morphine).
On-Line directions to Paramedics should be rendered by the physician - either in person,
by telephone, or over the radio. If a physician is unable to speak directly to the
Paramedic, medical control should not be abandoned. It is then permissible for a
physician's designee to relay his/her (the physician's) direct orders by telephone or radio. It is,
however, never acceptable for orders to originate from a nurse, physician's assistant, or
anyone other than the on-line Medical Control Physician
(ATTACHMENT A - DHEC-DEMS
Memo: 11 October 1994).
The EMS Advisory Council specifically clarified that "only drugs listed in this drug
document are to be used in the field."
Also, only the approved indications, dosages,
and routes of administration in this document are to be used in the field and in all
Paramedic training programs. Any other use of these drugs is not the approved
standard and will be considered non-compliance. This document is designed to
educate the Paramedic and the Medical Control Physician (on-line and off-line) on the
drugs Paramedics are prepared to utilize in the field. It is not meant to interfere in the
practice of medicine - and if better methods are devised, we request the medical
director to submit a pilot project for test and evaluation (SEE ATTACHMENT G - Pilot
Projects; ATTACHMENT H - Request for Addition or Deletion of Drug from State
Approved Drug List and ATTACHMENT I - How to Request Formulary Changes. )
Medication pumps used by home-bound patients are considered patient administered
medication and all EMTs may transport such patients as long as the EMT does not have
to do anything to the pump and the route of administration is a venous line.
Patients who have certain intravenous access devices such as Percutaneously Placed
Central Venous Catheters
(e.g. CVP line; Triple Lumen Catheter; Subclavian, Internal
Jugular, or Femoral Line - but NOT including Swan Ganz catheters) or Implantable
Central Venous Catheters
(e.g. Hickman or Broviac Catheter) may have medications

administered through these catheters - by Paramedics ONLY - when no other option is
available for intravenous access. Such medication administration may be guided either
by Standing Order or direct On-Line Medical Control order. Intermediate and Basic
EMTs may transport patients with these catheters provided that the catheter is either
not in use or has plain (non-medicated) IV Fluids in place. These privileges are
delineated in the Invasive / Implanted Device List
Patients who have certain implanted access devices such as the Completely
Implantable Venous Access Port
(i.e. Porta-Cath) may be transported by Paramedics
with previously placed medication infusions. Since these devices require special
needles for access
, a Paramedic may administer medications through this device
ONLY by way of previously placed lines when NO OTHER OPTION is available. This
action may be authorized either by Standing Order or direct On-Line Medical Control
Order - PROVIDED that the device has already been accessed with the appropriate
needle set PRIOR to transport. These privileges are delineated in the Invasive /
Implanted Device List
.
Other devices - e.g. Epidural Catheters - are approved for TRANSPORT ONLY. The
Paramedic MAY NOT utilize this catheter to administer ANY medication during transport
and the device MAY NOT BE MANIPULATED by EMS personnel.
Effective in 1997, Paramedics may utilize the Per Rectal route of drug administration in
certain patients - provided the Paramedic has received In-Service Training on the
method and technique of rectal administration, and provided that the route is approved
by the local Medical Control Physician for that service. The utilization of the Per Rectal
route of administration for Diazepam in adult patients was approved in 1999.
For endotracheal drug administration, medications should be administered at 2.0 to 2.5 times the recommended IV dose and should be diluted in 10 ml of Normal Saline. A catheter should be used for administration to hasten absorption. However, intravenous drug administration is still the preferred route. In the cardiac arrest situation, normal saline (or Lactated Ringer's) is the preferred infusion solution, although D5W remains acceptable. In 1999, the Medical Control Committee approved the use of Rapid Sequence Induction (Conscious Sedation) prior to Endotracheal Intubation as an additional skill for the Paramedic who has been properly trained. Training for this procedure may be obtained through local In-Service courses directed by the Service's Medical Control Physician based upon the training module provided by DHEC-EMS, or through the Regional EMS Offices. Initiation of the Rapid Sequence Induction (RSI) Protocol no longer requires Direct On-Line Medical Control Authorization. However, Direct On-Line Medical Control should be established as soon as feasible without interfering with the care of the patient. The drugs contained within the approved RSI Protocol are indicated by the symbol: "Rs" in the upper right hand corner of the page. There is now a requirement for services who wish to utilize the Rapid Sequence Induction Protocol that a functioning program for Laryngeal Mask Airways (LMA) be in place. All EMS units that
will function to provide RSI must have the appropriate LMA equipment on board and those
paramedics who will participate in RSI must have appropriate training in the use of Laryngeal Mask
Airways. (See Attachment "J")
In addition to changes in the Rapid Sequence Induction protocols, the Medical Control Committee, in conjunction with the Bureau of Drug Control - DHEC, has relaxed the requirement for Direct On-Line Medical Control authorization prior to the administration of several Scheduled Drugs - e.g. Ativan and Valium. These may be initiated under Standing Order or Protocol - but still must be approved by the Medical Control Physician for the Service. The Paramedic should make every reasonable effort to contact Medical Control prior to utilizing these agents - or immediately after utilizing these agents - provided that this does not interfere with the appropriate delivery of care to the patient. Also, during 2000, the Department has also approved the transport of patients on various "interfacility drugs" and in so doing has eliminated the previous "Interfacility Drug List." These drugs
were approved because the Department agreed that they may be necessary for continued patient
care during transport - rather than for the sake of convenience. The interfacility transport drugs must
be initiated at the sending facility and the patient must be stabilized on the medication prior to
transport. The Paramedic in charge of the call is responsible for accepting the patient and for
ensuring that the appropriate documentation (Interfacility Drug Transport Form) has been completed.
The Paramedic in charge of the call must also ensure that he/she has received adequate education
and information on the Interfacility Drugs to be transported with the patient (i.e. side effects, adverse
reactions, etc.) prior to accepting the patient for transfer. This information is to be documented on
the Interfacility Drug Transport Form.
Interfacility drugs must be supplied and initiated by the sending facility. An interfacility transport form
(ATTACHMENT B) must accompany the patient when the patient is to be administered an interfacility
transport drug enroute between facilities. It is necessary that all the information requested on the
form be completed if the Paramedic is to accept the patient and act within the required protocols for
appropriate interfacility transport and treatment. (ATTACHMENT C: DHEC-DEMS Memo: 16 August
2000)
Paramedics are not authorized to mix interhospital transport drugs. If it is anticipated intravenous
therapy will run out during transport, an additional bag of fluid should be supplied - pre-mixed - and
piggybacked into the existing IV infusion before or during transport. Paramedics are not authorized to
initiate any additional units of Whole Blood or Packed Cells during transport.
When sodium nitroprusside, magnesium sulfate, and/or nitroglycerine are being administered, a
volumetric infusion pump and a noninvasive electronic blood pressure monitor are required during
transport. Patients being transported on mannitol require an indwelling urinary catheter to be in place
prior to transport. Drugs will be monitored in transit by the Paramedic based upon signed, written
orders of the sending physician. ONLY Paramedics are authorized to maintain these drugs.
During transfer of the patient on an Interfacility Transport Drug, the Paramedic may reduce or
discontinue the drug in the event of adverse reaction or complication or upon the direction of on-line
medical control. The paramedic, however, is not authorized to increase the rate of administration of
any drug listed as an Interfacility Transport Drug once the transport has begun - even upon on-line
physician direction.
Authority for Paramedics to possess and utilize certain drugs and medications on an Ambulance; as
defined in this document is found in State Law 44-61-130 (Authority of Emergency Medical
Technicians [ATTACHMENT D]); and Sections 602 and 1105 of South Carolina Act 1118 of 1974 as
amended [ATTACHMENTS D2 and D3].
It is the responsibility of the Local Medical Control Physician to insure that the appropriate State and
Federal Registrations are in place for each EMS Service he/she oversees. The Local Medical Control
Physician must have separate and individual State and Federal Controlled Substance Registrations
for each and every Service that he/she oversees and authorizes to utilize controlled substances (i.e.
Diazepam, Lorazepam, and Morphine) (State Law 44-53-290 § e)(ATTACHMENT E). Other
responsibilities incumbent upon the Service's Local Medical Control Physician are outlined in the
DHEC-DEMS Memo of 16 October 1996 (ATTACHMENT F).
It is the responsibility of the EMS Service to ascertain that it (the Service) is in compliance with the
State Board of Pharmacy Licensing requirements and has the appropriate Pharmaceutical
Dispensing Permit(s) for the Service. Applications for these permits (ATTACHMENT "K") may be
obtained by writing the State Board of Pharmacy at:
LLR-Board of Pharmacy 110 Centerview Drive - Suite 306 (29210) Post Office Box 11927 Columbia, SC 29211-1927 Telephone: (803) 896-4700 The form may also be downloaded in Acrobat PDF Format from: http://www.llr.state.sc.us/pol/pharmacy/pforms/ems.pdf Questions regarding this Formulary or Division Policy concerning these agents may be directed to: Mr. Jim Catoe, Deputy Director Division of EMS - SC DHEC 2600 Bull Street Columbia, SC 29201-1708 Telephone: (803) 545-4204 Fax: (803) 545-4212 E-mail: catoejc@dhec.state.sc.us

Other resources concerning this Formulary, Pilot Projects, and Procedures for Application for Pilot
Project or Addition and Deletion of Drugs include the Division's Medical Control Committee
(ATTACHMENT M) or the Regional EMS Offices (ATTACHMENT M2 )
Alonzo W. Smith, Director
Edgar G. DesChamps, III, M.D.
Division
Director
Division
PRE-HOSPITAL EMS FORMULARY


Tylenol, Feverall, Panadol Oral Liquid, Rectal Suppository 10 – 15 mg/kg PO / PR THERAPEUTIC EFFECTS:
Relief of mild to moderate pain and fever reduction RELATIVE
Should be used with caution in patients with liver and renal disease SIDE EFFECTS:
None when administered in the therapeutic dosage range SPECIAL NOTES /
RESTRICTIONS:

Initially Issued: Revision Date: Current Printing: 5.16.2008 Edgar G. DesChamps, III, M.D. State Medical Director


ACTIVATED CHARCOAL USP
Actidose, CharcoAid Particularly effective in binding: ADMINISTRATION:



1 gm/kg mixed with water
1 gm/kg mixed with water ONLY WITH DIRECT MEDICAL ORDER
It binds & absorbs ingested toxins still present in the gastro- THERAPEUTIC EFFECTS:
intestinal tract following emesis. Once bound, the combined complex is excreted Should not be given before or together with ipecac, as it will absorb the ipecac & render it ineffective. RELATIVE
not be given in cyanide poisoning.
no value in poisoning due to:
_ Caustic alkalis/acids None, unless the airway cannot be adequately controlled. SIDE EFFECTS:

Should only be given PO or NG in a slurry solution mixed with water / SPECIAL NOTES /
RESTRICTIONS:

Initially Issued: 06/30/93 Revision Date: 11/03/96 Current Printing: 5.16.2008 Edgar G. DesChamps, III, M.D. State Medical Director


ADENOSINE

Initial dose up to 12 mg rapid IV bolus
12 mg within 1-2 minutes of continuing SVT – given rapid IV bolus 12 mg dosage may be repeated once in 1-2 minutes to maximum dose of 36 mg 0.1 mg/kg (over 1 to 2 sec) IV followed by rapid saline flush. Max initial dose 6 mg. 0.2 mg/kg within 1-2 minutes of continuing SVT – given rapid IV bolus. Max single dose 12 mg. Slows conduction time through the A-V node THERAPEUTIC EFFECTS:
Interruption of reentry pathways through the A-V node Restoration of NSR in patients with PSVT RELATIVE
Second or third degree A-V block CONTRAINDICATIONS:

Short-lasting first, second or third degree AV block SIDE EFFECTS:
Transient Asystole Various arrhythmias lasting only a few seconds SPECIAL NOTES /
The onset of the effect is generally within less than one minute Reported adverse experiences are predictable, short lived and easily Initially Issued: 06/30/93 Revision Date:: 06/30/93 Current Printing: 5.16.2008 Edgar G. DesChamps, III, M.D. State Medical Director


ALBUTEROL SULFATE
Ventolin / Proventil Acute bronchospasm INDICATIONS:

Cardiac arrest associated with asthma Handheld nebulizer OR Nebulizer Mask Or via ET Tube Connection Per Medical Order or Standing Order / Protocol. All patients regardless of age: May receive a dosage of up to a
maximum of 1cc (5mg) of aerosolized Albuterol with no on-line medical
control.
Δ Repeat treatments of aerosolized Albuterol per Local protocol.
Decreases bronchospasm; Improves pulmonary function THERAPEUTIC EFFECTS:

Hypersensitivity to any of the contents of the inhalation solution RELATIVE
CONTRAINDICATIONS:

Tremor; Dizziness; Nervousness; Headache; Nausea; Tachycardia; SIDE EFFECTS:
Repeat treatments of aerosolized Albuterol per Local protocol.
SPECIAL NOTES /
RESTRICTIONS:

When administering via endotracheal tube, the maximum dosage
may be doubled to 2 cc. For Bronchospasm associated with
COPD refractory to Albuterol, DUONEB may be administered via
nebulizer. DUONEB is a premixed solution of 0.5 mg Ipratropium
Bromide/3 mg Albuterol Sulfate. ONE DOSE MAY BE
ADMINISTERED PER STANDING ORDERS. REPEAT DOSES
REQUIRE DIRECT MEDICAL CONTROL ORDER.

Initially Issued: 06/30/93 Revision Date: 02/14/05 Current Printing: 5.16.2008 Edgar G. DesChamps, III, M.D. State Medical Director AMIODARONE
Shock resistant Ventricular Fibrillation or pulseless Ventricular Unstable Ventricular Tachycardia Rapid atrial arrhythmias with impaired LV function IV Push and by Continuous Infusion Pulseless VT / VF Rapid 300 mg IV diluted 20 – 30 cc of D5W or NS 150 – 300 mg IV followed by IV infusion @ 1 mg / min Rapid atrial arrhythmias with impaired LV function 150 mg over 10 minutes Pulseless VT / VF 5mg/kg IV/IO Rapid IV bolus 5mg/kg IV/IO over 20 to 60 minutes Repeat does of 5mg/kg up to maximum dose of 15 mg/kg per day Class IIb agent for treatment of cardiac arrest due to shock-resistant VF or pulseless VT. THERAPEUTIC EFFECTS:
Increases Action Potential and Refractory Period Reduces Ventricular Dysrhythmias Hypersensitivity to any of the contents RELATIVE
Cardiogenic Shock Marked Sinus Bradycardia Second or Third Degree AV Block (unless pacemaker is available) Do not routinely administer Amiodarone and Procainamide together Hypotension Bradycardia SIDE EFFECTS:
PEA Hepatoxicity


See Attachment on Use of Guidelines and Amiodarone at end of Formulary. SPECIAL NOTES /
Serial use of calcium channel blockers, B-blockers, and primary antiarrhythmic agents should be discouraged because of the potential additive hypotensive, bradycardic, and proarrhythmic effects of these drugs in combination. This may be amended / altered / overridden by Local Medical Control based on individual situations. Initially Issued: 05/2000 Revision Date: 05/2000 Current Printing: 5.16.2008 Edgar G. DesChamps, III, M.D. State Medical Director


AMYL NITRITE
(Special Purpose: Toxicology) Cyanide Poisoning INDICATIONS:

Inhalation only ADMINISTRATION:



One or two inhalants of amyl nitrite should be crushed and inhaled for
15 to 30 seconds.
One inhalant should be crushed and inhaled for 15 to 30 seconds.
(Smallest effective dosage should be used.) It is effective in the emergency management of cyanide poisoning. THERAPEUTIC EFFECTS:
Amyl nitrite causes the oxidation of hemoglobin to a compound called methemoglobin. Methemoglobin reacts with the toxic cyanide ion to form cyanomethemoglobin, which can be enzymatically degraded. No contraindications for amyl nitrite in the management of cyanide RELATIVE
CONTRAINDICATIONS:

Headache and hypotension have been known to occur following SIDE EFFECTS:
Special Purpose Drug for TOXICOLOGY SPECIAL NOTES /
RESTRICTIONS:

Initially Issued: 05/14/98 Revision Date: 05/14/98 Current Printing: 5.16.2008 Edgar G. DesChamps, III, M.D. State Medical Director


(Children's chewable aspirin) Myocardial Infarction Chest pain suspicious of cardiac origin ADMINISTRATION:


162mg to 324mg

Give two (2) to four (4) "children's" chewable Aspirin (81mg x 4 = NOT APPROVED
Given as an early potent anticoagulant. Blocks formation of THERAPEUTIC EFFECTS:
thromboxane A2. Thromboxane A2 causes platelets to aggregate and arteries to constrict. Reduce overall mortality of acute MI Reduce nonfatal re-infarction. RELATIVE
Hypersensitivity to aspirin CONTRAINDICATIONS:

Allergic reaction; Nausea/Vomiting; Indigestion; Heartburn; Tinnitus SIDE EFFECTS:

A cost effective medication that can be given within minutes of arrival SPECIAL NOTES /
to the acute MI patient that may reduce overall mortality to almost the same degree as thrombolytic agents. Initially Issued: 01/90 Revision Date: 09/02/96 Current Printing: 5.16.2008 Edgar G. DesChamps, III, M.D. State Medical Director ATROPINE SULFATE
Sinus bradycardia when accompanied by PVCs or hypotension 2nd or 3rd degree block Asystole Organophosphate poisoning Pulseless Electrical Activity (PEA) Pediatric: Symptomatic bradycardia secondary to AV block or vagal activity 2nd line after epinephrine for bradycardia due to poor perfusion or hypotension IV, IO, ET IM (May double IV dosage with ET administration.) ADMINISTRATION:



1. Bradycardia

0.5 - 1.0 mg IV administration; repeat Q 3-5 minutes to
a total of 0.04 mg/kg
2. Asystole & Slow Pulseless Electrical Activity (PEA)
1 mg IV administration Q 3-5 minutes to 0.04 mg/kg 3. Organophosphate Poisoning:
To block parasympathetic response: 1 - 2 mg; IV dose repeated Q 5 minutes until a decrease in secretions are observed or to total dose of 6 mg. May be administered per standing orders
1. Bradycardia

0.02 mg/kg (0.2 ml/kg) IV administration Maximum single dose 0.5 mg child; 1.0 mg adolescent. May be repeated once 2. Organophosphate Poisoning:
PEDIATRIC:
To block parasympathetic response: Children: 0.05 to 0.1 mg/kg Loading dose. Adolescents: 2 mg Repeat every 10 – 15 minutes until rales and bronchial secretions resolved. May be administered per standing orders Blocks acetylcholine receptor sites THERAPEUTIC EFFECTS:
Increase SA & AV node conduction May suppress PVCs secondary to bradycardia RELATIVE
Atrial fibrillation/atrial flutter with rapid ventricular response



-Tachycardia
-Dry mouth
-Thirst
-Flushing of skin SIDE EFFECTS:
-Headache -Pupillary dilatation -Urine retention SPECIAL NOTES /
RESTRICTIONS:

Initially Issued: 06/30/93 Revision Date: 09/08/94 Current Printing: 5.16.2008 Edgar G. DesChamps, III, M.D. State Medical Director ATROVENT
IPRATROPIUM BROMIDE
Bronchospasm, COPD INDICATIONS:

ADMINISTRATION:

Inhibits ACTH receptor sites on bronchial smooth muscle THERAPEUTIC EFFECTS:

Hypersensitivity to Atrovent and/or Atropine and its derivatives CONTRAINDICATIONS:

Tachycardia, palpitations, eye pain, urinary retention, UTI, Uticaria, SIDE EFFECTS:
Can be mixed with Xopenex and Albuterol. ONE DOSE PER
SPECIAL NOTES /
STANDING ORDERS. REPEAT DOSES REQUIRE DIRECT
MEDICAL ORDER.
Initially Issued 06/30/93 Revision Date: 08/14/03 Current Printing: 5.16.2008 Edgar G. DesChamps, III, M.D. State Medical Director CALCIUM GLUCONATE (Tox)
(Special Purpose: Toxicology) Hydrofluoric acid burns and exposure INDICATIONS:

Topical application, IV, or by nebulizer; rarely by direct injection ADMINISTRATION:

10ml mixed with one ounce of water soluble lubricant for topical application, IV as ordered, or 2.5% solution nebulized with oxygen for inhalation exposure; 0.3-0.5 ml of 5% solution/cm2 burn area injected directly for deep or subungual burns.
Same as adult
Binds with fluoride ion, prevents or reverses hypocalcemia. THERAPEUTIC EFFECTS:

Not to be injected for GENERAL SKIN BURNS from THERMAL RELATIVE
CONTRAINDICATIONS:

Hypercalcemia, local tissue damage, pressure necrosis if injected SIDE EFFECTS:
under nail beds. Special Purpose Utilization: TOXICOLOGY SPECIAL NOTES /
Infiltration of wound with local anesthetic should not be used, regional blocks may be necessary to provide adequate treatment of large or deeply penetrated burns. Ocular exposure should be treated with 1% aqueous irrigation following proparacaine anesthetic. Initially Issued: 05/28/99 Revision Date: 05/28/99 Current Printing: 5.16.2008 Edgar G. DesChamps, III, M.D. State Medical Director CALCIUM GLUCONATE
Overdose (calcium channel blocker) Magnesium Sulfate drip toxicity Certain types of arrest, i.e. dialysis patients Known Hypocalcemia ADMINISTRATION:

5-20 ml slow administration
ONLY WITH DIRECT MEDICAL ORDER
50 - 100 MG/KG slow administration
ONLY WITH DIRECT MEDICAL ORDER
Reverses overdose with Magnesium Sulfate or calcium channel THERAPEUTIC EFFECTS:
Relieves some types of muscle spasm Replaces electrolytes necessary for the contractile function of Use with extreme caution in patients taking digitalis
RELATIVE
CONTRAINDICATIONS:


- Hypotension
SIDE EFFECTS:
Chalky or metallic taste Feeling that a "wave of heat" is passing through the body Adult Dosage: 5-20 ml slow IV administration SPECIAL NOTES /
Pediatric Dosage: 50 - 100 mg/kg ONLY WITH DIRECT MEDICAL ORDER
Do not administer with Sodium Bicarbonate Use smaller doses for patients on Digoxin Initially Issued: 06/30/93 Revision Date: 11/03/96 Current Printing: 5.16.2008 Edgar G. DesChamps, III, M.D. State Medical Director COMBINATION DEXTROSE/SODIUM CHLORIDE
5% dextrose in 0.45% Sodium chloride (D51/2NS) Impaired Renal Function (TKO) Cardiovascular function (TKO) ADMINISTRATION:

Dependent upon patient condition and situation being treated Used for Maintenance Only.
Dependent upon patient size and condition Provides electrolyte and sugar replacement THERAPEUTIC EFFECTS:

Need for Rapid fluid replacement indicated RELATIVE
CONTRAINDICATIONS:

SIDE EFFECTS:


CLASSIFICATION:
Slightly hypertonic sugar and electrolyte solution
Normal saline or lactated ringers is the preferred infusion
solution during cardiac arrest, although D5W remains acceptable

SPECIAL NOTES /
Any combination of Dextrose and Sodium Chloride is
approved. Some other combinations include:
- 5% Dextrose in 0.9% Sodium Chloride (D5NS) - 5% Dextrose in 0.2% Sodium Chloride (D5 0.2NS) - 3.3% Dextrose in 0.3% Sodium Chloride Initially Issued: 06/30/93 Revision Date: 11/03/96 Current Printing: 5.16.2008 Edgar G. DesChamps, III, M.D. State Medical Director DEXTROSE 5% IN WATER
IV access for emergency drugs (cardiac) For dilution of concentrated drugs for IV infusion Patients with actual or potential for volume overload Patients requiring sodium restriction ADMINISTRATION:

Generally administered to keep open (TKO) Generally administered to keep open (TKO) vein for medications.
ONLY WITH DIRECT MEDICAL ORDER
Glucose nutrient solution THERAPEUTIC EFFECTS:

As a main line for blood transfusion RELATIVE
For fluid replacement in hypovolemic states CONTRAINDICATIONS:

SIDE EFFECTS:


CLASSIFICATION:
Hypotonic Sugar Solution
Normal saline or lactated ringers is the preferred infusion
solution during cardiac arrest, although D5W remains
SPECIAL NOTES /
In Pediatric Patients:
ONLY WITH DIRECT MEDICAL ORDER

Initially Issued: 06/30/93 Revision Date: 03/97 Current Printing: 5.16.2008 Edgar G. DesChamps, III, M.D. State Medical Director DEXTROSE 50 %
D50W, 50% Dextrose Suspected hypoglycemia Coma/Seizure of unknown etiology IO, IV through a free flowing line; Per Rectum in Pediatrics ADMINISTRATION:

25.0 grams slow administration - initial dose May repeat doses based upon Medical Control Order or Protocols/Standing Orders for persistent hypoglycemia. 0.5 - 1.0 grams/kg, slow administration Dilute D50W 1:1 with sterile water, Ringer's Lactate, or
Saline (2-4 ml/kg of D25 mixture)

Immediate source of glucose and water THERAPEUTIC EFFECTS:

RELATIVE
CONTRAINDICATIONS:

SIDE EFFECTS:
May precipitate severe neurologic symptoms in alcoholics Draw blood sample OR do a D-stix prior to administration SPECIAL NOTES /
Causes local tissue necrosis if IV infiltrates RESTRICTIONS:

Initially Issued: 06/30/93 Revision Date: 11/03/96 Current Printing: 5.16.2008 Edgar G. DesChamps, III, M.D. State Medical Director DIAZEPAM
Major motor seizures Pre-medication prior to cardioversion, transcutaneous Skeletal muscle relaxant Acute anxiety states Medication for combative patients and difficult intubations Per Rectum in Pediatrics and Adults Slow IV administration; titrated to effect up to 15 mg (by Standing Order/Protocol) IV Doses GREATER THAN 15 mg require Direct Medical
Rectal 10 mg maximum on initial dosage. May be repeated two times - not to exceed 30 mg Maximum Dose. - IV 0.2 mg/kg titrate to effect, max dose 10mg or 0.75 mg/kg which ever is less - PR 0.5 mg/kg, may repeat 0.25 mg/kg in 10 minutes if Suppresses the spread of seizure activity through the THERAPEUTIC EFFECTS:
motor cortex of the brain Effective skeletal-muscle relaxant
- Respiratory
RELATIVE
ETOH or other sedative drugs CONTRAINDICATIONS:

Hypersensitivity to drug - Respiratory/Cardiac SIDE EFFECTS:
This is a Schedule CIV Drug.
Relatively short-acting when given IV; seizure activity may reoccur; additional doses may be required No mixing with other drugs because of precipitation After administration patient must be closely monitored with vital signs taken and recorded Q 5-10 minutes if possible • IV Doses GREATER THAN 15 mg require Direct
Medical Order
SPECIAL NOTES /
Iatrogenic dose related complications may be
improved with reversal using Flumazenil.
• CANA Autoinjector may be used one time only without Medical Control Authorization in bioterrorism incidents With suspected nerve agent present. • Paramedic members of the state's COBRA teams and State certified paramedics are authorized to use the Autoinjector in those instances when a nerve agent is suspected. • The CANA Autoinjector delivers a 10MG dose via IM Initially Issued: 06/30/93 Revision Date: 05/28/99 Current Printing: 5.16.2008 Edgar G. DesChamps, III, M.D. State Medical Director DILTIAZEM
Rate Control in Refractory Atrial Fibrillation and SVT INDICATIONS:

IV Bolus and Drip, IO ADMINISTRATION:

20 - 25 mg Bolus Dose 10 mg/Hr infusion - titrated to effect NOT APPROVED

The therapeutic effects of Diltiazem appear related to its ability to
inhibit the influx of calcium ions during membrane depolarization of THERAPEUTIC EFFECTS:
cardiac and vascular smooth muscle. These effects may be seen as slowing of conduction times at the SA or Concurrent or Recent use of Beta Blockers RELATIVE
CONTRAINDICATIONS:

Hypotension; Heart Block SIDE EFFECTS:

SPECIAL NOTES /
RESTRICTIONS:

Initially Issued: 10/10/96 Revision Date: 10/10/96 Current Printing: 5.16.2008 Edgar G. DesChamps, III, M.D. State Medical Director Allergic reactions Urticaria Extrapyramidal reaction IV, deep IM, IO ADMINISTRATION:

Up to 50 mg slow administration - initial dose Up to 100 mg total dose ONLY WITH DIRECT MEDICAL ORDER
Up to 1 mg/kg slow administration - initial dose Up to 2 mg/kg total dose ONLY WITH DIRECT MEDICAL ORDER
-Inhibits histamine release and effects THERAPEUTIC EFFECTS:
-Inhibits motion sickness RELATIVE
-Nursing mothers -Acute glaucoma

-Sedation
-Dries bronchial secretions SIDE EFFECTS:
Up to 100 mg total dose - ADULTS
SPECIAL NOTES /
Up to 2 mg/kg total dose - PEDIATRICS
**DIRECT MEDICAL ORDER REQUIRED**
Initially Issued: 06/30/93 Revision Date: 09/08/94 Current Printing: 5.16.2008 Edgar G. DesChamps, III, M.D. State Medical Director DOBUTAMINE
Cardiogenic shock Short term management of CHF IV infusion, IO ADMINISTRATION:

2.0 to 20 mcg/kg/min 2.0 to 20 mcg/kg/min Improves cardiac output & renal blood flow with little systemic arterial constriction THERAPEUTIC EFFECTS:
Increases cardiac contractility Increases conduction velocity Relatively little effect on heart rate Hypovolemia (Uncorrected) RELATIVE
CONTRAINDICATIONS:

SIDE EFFECTS:
Generally used secondary to Dopamine SPECIAL NOTES /
Monitor BP closely RESTRICTIONS:

Initially Issued: 06/30/93 Revision Date: 06/30/93 Current Printing: 5.16.2008 Edgar G. DesChamps, III, M.D. State Medical Director DOPAMINE
Cardiogenic shock associated with hypotension INDICATIONS:

IV infusion, IO ADMINISTRATION:

2-5 mcg/kg/min initially, up to 20 mcg/kg/min titrated to B/P 2-5 mcg/kg/min initially, up to 20 mcg/kg/min titrated to B/P Increases perfusion & BP by increasing cardiac output & systemic arterial pressure while dilating vessels to the heart, THERAPEUTIC EFFECTS:
Depending on dose; stimulates alpha, beta, & dopamine Hypovolemic shock where complete fluid resuscitation has not RELATIVE
Uncorrected tachydysrhythmias or VF
- Tachydysrhythmias
SIDE EFFECTS:
- Nausea/Vomiting Titrate according to blood pressure SPECIAL NOTES /
Range is 2-20 mcg/kg/min RESTRICTIONS:

Initially Issued: 06/30/93 Revision Date: 06/30/93 Current Printing: 5.16.2008 Edgar G. DesChamps, III, M.D. State Medical Director EPINEPHRINE
Ventricular Fibrillation/Pulseless Ventricular Tachycardia Pulseless Electrical Activity (PEA) Bronchospasm Croup
ADMINISTRATION:

MAY GIVE CONTINUOUS IV INFUSION ONLY WITH DIRECT
MEDICAL ORDER
1. Bronchospasm
Up to 0.5 mg SQ (1:1000) Q 15-30 min. x 3 total doses
2. Generalized Urticaria
1:1000
solution, SQ 0.3 - 0.5 ml
3. Anaphylaxis (In association with hypotension)
Up to 0.5 mg of a 1:10,000 solution IV only if medical
control contact is not possible or feasible in the situation.
In anaphylaxis the reason for not contacting medical
control must be documented.
Any dose above 0.5 mg. ONLY WITH DIRECT MEDICAL
ORDER

4. Asystole or Pulseless Electrical Activity (PEA)
Standard adult protocol (1:10,000) 1 mg IV Q 3-5 minutes
ET dose 2.0 - 2.5 mg, Q 3-5 minutes V Fib/Pulseless V Tach 1 mg IV push, repeat every 3 to 1. Bronchospasm
0.01 mg/kg SQ up to 0.3 mg Q 15-30 minutes to 3 total
doses (1:1,000)
2. Bradycardia
0.01 mg/kg IV or IO Q 3-5 min. (1:10,000) (0.1 ml/kg) ET dose 0.1 - 0.2 mg/kg, (0.1 - 0.2 ml/kg, 1:1,000) Q 3-5
3. Asystole or Pulseless Electrical Activity (PEA)
0.01 mg/kg IV or IO initially (0.1 ml/kg, 1:10,000) Subsequent doses 0.1 - 0.2 mg/kg IV or IO (1:1,000)
ET dose 0.1 - 0.2 mg/kg, (0.1 - 0.2 ml/kg, 1:1,000) Q 3-5

Continued on Next Page
4. Anaphylaxis (In association with hypotension)
Up to 0.01 mg/kg IV (1:10,000)
ONLY WITH DIRECT MEDICAL ORDER
Maximum dose is 0.5 mg IV ONLY WITH DIRECT MEDICAL ORDER
The dosing for 1:1000 nebulized epinephrine is 0.5 ml/kg. (2.5 ml maximum dose of epinephrine if less that 4 years old and 5.0 ml maximum dose if greater than 5 years old. Then add this to 3cc of normal saline. Give every 1-2 hours. Increased systemic vascular resistance Increased arterial B/P Increased heart rate Increased coronary and cerebral blood flow THERAPEUTIC EFFECTS:
Increased myocardial contraction Increased myocardial O2 demand no contraindications to the use of epinephrine
RELATIVE
in the situation of cardiac arrest CONTRAINDICATIONS:


- Palpitations
SIDE EFFECTS:
Can be inactivated by alkaline solutions Will increase myocardial oxygen demand; provide patient with high-flow oxygen SPECIAL NOTES /
MAY GIVE CONTINUOUS IV INFUSION ONLY WITH
DIRECT MEDICAL ORDER
In anaphylaxis the reason for not contacting medical
control must be documented.

Any dose above 0.5 mg. may be administered ONLY
WITH DIRECT MEDICAL ORDER

Edgar G. DesChamps, III, M.D. Initially Issued: 06/30/93 State Medical Director Revision Date: 09/25/2006 Current Printing: 5.16.2008 ETOMIDATE

INDICATIONS:

For use in RSI protocol – for anesthesia induction.
ADMINISTRATION:


THERAPEUTIC EFFECTS:

Hypnotic drug (no analgesic activity)
RELATIVE

Known sensitivity to drug CONTRAINDICATIONS:
SIDE EFFECTS:

Transient venous pain, skeletal muscle movement SPECIAL NOTES /
RESTRICTIONS:

Initially Issued: 08/2002 Revision Date: Current Printing: May 16, 2008 Edgar G. DesChamps, III, M.D. State Medical Director FLUMAZENIL
Reversal of acute side effects of Benzodiazepines (Valium /
Ativan / Versed) limited to iatrogenic causes only with on-line
medical control. (Iatrogenic - Resulting from, or in the course of,
treatment or diagnostic procedures. Condition caused by medical
personnel or procedures or through exposure to the environment of
a health care facility.)
ADMINISTRATION:

IVP over 15 seconds for conscious sedation reversal; 0.2 mg initially then wait 45 sec. Δ If desired level of consciousness not attained, repeat 0.2 mg over 15 seconds IVP wait 45 seconds--may repeat this cycle to total of 1 mg (5 cycles). If successful, then re-sedation OCCURS, may repeat
above cycle again at 20 minute intervals not to exceed
total 3 mg in one hour.
Benzodiazepine overdose reversal: Δ 0.2 mg over 30 seconds, wait as above 30 seconds. 0.3 mg over 30 seconds, wait as above 30 seconds 0.5 mg over 30 seconds, wait 30 seconds Total cumulative - 3 mg.
Do not rush administration.
Secure
NOT APPROVED
Benzodiazepine Antagonist THERAPEUTIC EFFECTS:

hypersensitivity. Patients given Benzodiazepine for the control of life threatening conditions. (E.g. control ICP, status epilepticus.) Δ Risk of seizure greatest if Benzodiazepine used is long RELATIVE
Risk of seizure if undergoing concurrent major sedative- hypnotic drug withdrawal; recent therapy with parenteral Benzodiazepine concurrent TCA overdose, those exhibiting seizure activity prior to attempt of reversal. Caution in patients with known raised ICP due to risk of seizure and withdrawal reaction (vomiting). SIDE EFFECTS:
Return of Sedation
This agent is approved ONLY for use in treatment of iatrogenic
sedation secondary to benzodiazepine therapy.
SPECIAL NOTES /
This agent is specifically NOT approved for use in treatment
of self-administered (or "street level") Valium or benzodiazepine overdose. Initially Issued: 10/10/96 Revision Date: 10/10/96 Current Printing: 5.16.2008 Edgar G. DesChamps, III, M.D. State Medical Director FUROSEMIDE
Pulmonary edema ADMINISTRATION:

40 mg slow administration (Higher dose per local protocol) Up to 300 mg total dose **DIRECT MEDICAL ORDER REQUIRED for Maximum Dose
Administration**
Up to 2 mg/kg slow administration **DIRECT MEDICAL ORDER REQUIRED**
THERAPEUTIC EFFECTS:
Inhibits sodium & chloride reabsorption in the kidneys RELATIVE
SIDE EFFECTS:
- Nausea/Vomiting ⌦Maximum Doses may be given ONLY WITH DIRECT MEDICAL
SPECIAL NOTES /
RESTRICTIONS:

Initially Issued: 06/30/93 Revision Date: 09/08/94 Current Printing: 5.16.2008 Edgar G. DesChamps, III, M.D. State Medical Director GLUCAGON USP
Beta blocker overdose Calcium channel overdose ADMINISTRATION:

Maximum dosage = 1.0 mg Causes breakdown of glycogen to glucose; inhibits glycogen THERAPEUTIC EFFECTS:
synthesis; elevates blood glucose level - Hypersensitivity RELATIVE
- Pheochromocytoma Relatively free of adverse reactions except for occasional nausea and vomiting SIDE EFFECTS:
Urticaria, respiratory distress and hypotension have been May be repeated 1-2 times if no response in 15-20 minutes SPECIAL NOTES /
RESTRICTIONS:

Initially Issued: 06/30/93 Revision Date: 06/30/93 Current Printing: 5.16.2008 Edgar G. DesChamps, III, M.D. State Medical Director HEPARIN LOCK FLUSH
Alternate method for keeping the vein open in the acutely ill patient To be used as a flush, not as a drug ADMINISTRATION:

10 units initially Less than 100 units total dose NOT APPROVED
Clears intermittent infusion set to keep vein open THERAPEUTIC EFFECTS:

Not given to flush out or to irrigate clotted IV lines
RELATIVE
CONTRAINDICATIONS:

SIDE EFFECTS:

Use only when the set is placed or after drug infusion.
SPECIAL NOTES /
This agent is not given to flush out or to irrigate clotted IV lines
RESTRICTIONS:

Initially Issued: 06/30/93 Revision Date: 06/30/93 Current Printing: 5.16.2008 Edgar G. DesChamps, III, M.D. State Medical Director HIGH DOSE HEPARIN
Patients with 12 lead EKG proven STEMI who: o are expected to undergo PTCA or surgical revascularization INDICATIONS:

o are expected to receive TPA or Retavase (Class IIa) To be administered ONLY by direct order of medical control
physician.
ADMINISTRATION:

Up to Maximum of 5,000 IU for 12 lead EKG proven STEMI Patients that meet criteria listed under Indications. NOT APPROVED
Heparin is an anticoagulant that directly inhibits thrombin. THERAPEUTIC EFFECTS:

Same as those on checklist for fibrinolytic therapy. RELATIVE
CONTRAINDICATIONS:

No immediate side effects except hypersensitivity reaction. SIDE EFFECTS:
Late side effects include minor or major hemorrhage, including intracerebral hemorrhage. High dose Heparin to be administered ONLY after 12 lead
SPECIAL NOTES /
EKG and ONLY with DIRECT medical control order.
RESTRICTIONS:

Initially Issued: 07/20/05 Revision Date: Current Printing: 5.16.2008 Edgar G. DesChamps, III, M.D. State Medical Director IBUPROFEN
Motrin, Advil, Pedia-Profen Pain, Fever, Inflammation INDICATIONS:

ADMINISTRATION:

NOT APPROVED (IN PATIENTS > 12 YEARS OF AGE)
Analgesia, Antipyretic, Anti-inflammatory THERAPEUTIC EFFECTS:

Active ulcer; < 2 months of age; RELATIVE
Dose Within Previous 6 hours; Known Bleeding Disorders CONTRAINDICATIONS:

Allergic reaction; Nausea/Vomiting; Indigestion; Heartburn; SIDE EFFECTS:

Not Approved for use in patients > 12 years of age SPECIAL NOTES /
Not Approved for Pediatrics younger than 2 months of age RESTRICTIONS:

Initially Issued: 05/08/97 Revision Date: 05/08/97 Current Printing: 5.16.2008 Edgar G. DesChamps, III, M.D. State Medical Director IPECAC SYRUP
Certain poisons and overdoses INDICATIONS:

ADMINISTRATION:

15 to 30 ml followed by several glasses of warm water or **DIRECT MEDICAL ORDER REQUIRED**
− Less than 6 months old - NOT APPROVED
− 1 – 12 years 15 ml − 12 years 30 ml **DIRECT MEDICAL ORDER REQUIRED**
Induces vomiting and thereby empties the stomach of ingested THERAPEUTIC EFFECTS:
Impaired LOC: Stupor; Coma RELATIVE
Ingestion of strong acids/alkalis or petroleum products Strychnine or iodides Children under one year Possibility of aspiration SIDE EFFECTS:

ONLY WITH DIRECT MEDICAL ORDER
SPECIAL NOTES /
Constantly monitor the patient's airway during and following Walking should be encouraged Initially Issued: 06/30/93 Revision Date: 09/08/94 Current Printing: 5.16.2008 Edgar G. DesChamps, III, M.D. State Medical Director LABETALOL
Normodyne, Trandate Control of Blood Pressure in Severe Hypertension INDICATIONS:

IV Push (Slow); IV Infusion; IO ADMINISTRATION:

10 - 20 mg (0.25 mg/kg) IV Slow (over at least 2 minutes) Δ Repeat: May administer additional IV Slow boluses at 10 minute intervals - to a Maximum of 300 mg IV
MAY GIVE IV BOLUS ONLY WITH DIRECT MEDICAL
Δ 2 - 8 mg/min maintenance MAY GIVE CONTINUOUS IV INFUSION ONLY WITH DIRECT
MEDICAL ORDER
Δ 0.2 - 0.5 mg/kg/dose to a MAXIMUM of 20 mg/dose as intermittent bolus (slow). MAY GIVE PEDIATRIC IV BOLUS ONLY WITH DIRECT
MEDICAL ORDER
Δ 0.2 - 1.0 mg/kg/hr MAY GIVE CONTINUOUS IV INFUSION ONLY WITH DIRECT
MEDICAL ORDER
Dose related decrease in Blood Pressure without reflex tachycardia THERAPEUTIC EFFECTS:
and without significant decrease in Heart Rate. Also has less decrease in cerebral perfusion pressure than with nitroprusside. Asthma; Cardiogenic Shock; Cocaine Induced Hypertension; RELATIVE
Severe Bradycardia; Hypotension; Heart Block - Greater than 1st Degree; Mild & Transient Hypotension; SIDE EFFECTS:
Postural Hypotension if patient allowed upright within first 3 hours.
∇ IV Push dosage MUST be administered slowly (over at least 2
minutes) with frequent (Q 5 minute) Blood Pressure monitoring. SPECIAL NOTES /
Maximum of 300 mg may be given as IV Bolus Administration
in adults.
MAY GIVE IV BOLUS or CONTINUOUS IV INFUSION
ONLY WITH DIRECT MEDICAL ORDER
Initially Issued: 05/08/97 Revision Date: 05/08/97 Current Printing: 5.16.2008 Edgar G. DesChamps, III, M.D. State Medical Director LACTATED RINGERS
Hypovolemic shock IV infusion, IO ADMINISTRATION:



As indicated by the patient condition and situation being treated

As indicated by the patient condition and situation being treated
- Source of electrolytes THERAPEUTIC EFFECTS:
- Increase circulating volume - Congestive heart failure RELATIVE
CONTRAINDICATIONS:

SIDE EFFECTS:


CLASSIFICATION: Isotonic crystalloid

SPECIAL NOTES /
RESTRICTIONS:

Normal saline or lactated ringers is the preferred infusion
solution during cardiac arrest, although D5W remains
acceptable

Initially Issued: 06/30/93 Revision Date: 06/30/93 Current Printing: 5.16.2008 Edgar G. DesChamps, III, M.D. State Medical Director LIDOCAINE
Ventricular tachycardia Ventricular fibrillation Combative Head Injuries (before Intubation) IV, IV infusion, ET, IO, Jelly ADMINISTRATION:


1. VF & pulseless VT
∇ 1.5 mg/kg rapid IV bolus, repeated Q 3 to 5 minutes;
Maximum loading dose of 3 mg/kg;
∇ Loading dose followed by maintenance infusion of 2 to 4
2. VT with pulse, PVCs
∇ 1 - 1.5 mg/kg rapid IV bolus; ∇ Followed by 0.5 - 0.75 mg/kg IV Q 5-10 minutes to maximum dose of 3 mg/kg;
∇ Followed by 2-4 mg/min maintenance infusion 1.0 mg/kg loading dose 20 - 50 mcg/kg/min maintenance dose - Suppresses ventricular ectopic activity THERAPEUTIC EFFECTS:
- Elevates the threshold for ventricular fibrillation - Suppresses re-entry dysrhythmias - PVCs in conjunction with bradycardia RELATIVE
- High degree AV blocks - Ventricular escape rhythms -caine drugs

- Hypotension
SIDE EFFECTS:

Maintenance infusion should be decreased by 50% for
patients in CHF, shock, or over 70 years of age

_ Xylocaine 2% jelly may be used as a lubricant for the NG or
ET tube for intubation of the conscious patient. It is not intended for repeated use or for use on areas of denuded tissue. Possible side effect is a localized allergic reaction. SPECIAL NOTES /
Serial use of calcium channel blockers, B-blockers, and primary antiarrhythmic agents should be discouraged because of the potential additive hypotensive, bradycardic, and proarrhythmic effects of these drugs in combination. This may be amended / altered / overridden by Local Medical Control based on individual situations. Initially Issued: 06/30/93 Revision Date: 09/11/96 Current Printing: 5.16.2008 Edgar G. DesChamps, III, M.D. State Medical Director LOPRESSOR
Ventricular rate control in patients with rapid atrial fibrillation/flutter ST segment elevation indicative of myocardial infarction (STEMI) when heart rate is greater than 70 IV, inject slowly over 1 minute Ventricular rate control in atrial fib/flutter: 1.25-5 mg, may repeat every 5 minutes for effect, up to a maximum dose of 15 mg. STEMI process: 5 mg IV, may repeat up to 3 times for a maximum THERAPEUTIC EFFECTS:
Selective Beta Blocker Hypersensitivity to the drug Sinus Bradycardia Heart block greater than first degree (except in patient with functioning pacemaker) RELATIVE
CONTRAINDICATIONS:

SIDE EFFECTS:
Bronchospasm Congestive heart failure Drowsiness SPECIAL NOTES /
RESTRICTIONS:

Initially Issued: 06/30/93 Revision Date:: 02/07/08 Current Printing: 5.16.2008 Edgar G. DesChamps, III, M.D. State Medical Director LORAZEPAM
Major Motor Seizures Status epilepticus Pre-Medication prior to cardioversion or Transcutaneous Pacing Skeletal muscle relaxant Acute Anxiety States Medication for combative patients and difficult intubations ADMINISTRATION:



∇ Up to total of 4.0 mg slow administration (Over 2 - 5 minutes)
Doses GREATER THAN 4 mg require Direct Medical Order


∇ Up to total of 0.1 mg/kg slow administration (Over 2 - 5 minutes)
Contact medical control for additional doses!
Doses GREATER THAN 4 mg require Direct Medical
- Suppresses the spread of seizure activity through the motor cortex THERAPEUTIC EFFECTS:
- Effective skeletal muscle relaxant Respiratory depression RELATIVE
ETOH or other sedative drugs Hypersensitivity to the drug

Δ Respiratory / Cardiac Arrest
Δ Decreased LOC SIDE EFFECTS:
This is a Schedule CIV Drug.
Repeat doses may be given: ONLY WITH DIRECT MEDICAL ORDER

Lorazepam MAY BE initiated by Standing Order or Protocol.
It is RECOMMENDED – where feasible – that On-Line
Medical Control be obtained prior to initiation – but this
should not supercede the appropriate care of the patient

SPECIAL NOTES /
Doses GREATER THAN 4 mg require Direct Medical
- Relatively short-acting when given IV; seizure activity may reoccur; additional doses may be required. - No mixing with other drugs because of precipitation. - After administration, patient must be closely monitored with vital signs taken and recorded Q 5 - 10 minutes if possible. ∇ iatrogenic dose related complications may be improved
with reversal using Flumazenil.
Initially Issued: 10/10/96 Revision Date: 10/10/96 Current Printing: 5.16.2008 Edgar G. DesChamps, III, M.D. State Medical Director MAGNESIUM SULFATE
Refractory VT/VF unresponsive to lidocaine, Torsades de Pointes, especially in the setting of tricyclic antidepressant overdose not resolved by sodium bicarbonate and lidocaine. Digitalis induced ventricular arrhythmias. As an anticonvulsant in eclampsia. Suspected hypomagnesemia IV Push in cardiac arrest. IO Over 1-2 minutes when patient is not in arrest. − 1-2 Grams IV up to 15 Grams − 25 – 50 mg/kg to max 2 gm over several minutes for arrhythmias 15 – 20 minutes for hypomagnesemia Essential for the activity of many enzymes. Plays an important role in THERAPEUTIC EFFECTS:
neurotransmission and muscular excitability. Overall is a CNS and muscular depressant. Hypermagnesemia, hypocalcemia, anuria, heart block, active labor RELATIVE
CONTRAINDICATIONS:

Bradycardia, hypotension, hyporeflexia, diaphoresis and drowsiness, SIDE EFFECTS:
decreased respiratory rate, flaccid paralysis. Magnesium insufficiency should be suspected in patients who use SPECIAL NOTES /
diuretics and in patients with poor dietary habits, poor nutrition, or poor dietary intake (such as may be seen in chronic alcohol abuse). Initially Issued: 07/13/2000 Revision Date: 07/13/2000 Current Printing: 5.16.2008 Edgar G. DesChamps, III, M.D. State Medical Director METHYLENE BLUE
Treatment of cyanide poisoning and symptomatic methemoglobinemia (iatrogenic or accidental exposure to oxidizing DIRECT MEDICAL ORDER REQUIRED
1 mg/kg IV SLOWLY (over 10-15 minutes) Same as adult dose, but must be used with extreme caution due to potential for producing methemoglobinemia. Reduces methemoglobin (ferric [Fe+3] iron in methemoglobin to THERAPEUTIC EFFECTS:
ferrous [Fe+2] iron in normal hemoglobin. Excessive methemoglobinemia in the treatment of cyanide or RELATIVE
sulfide poisoning due to possible release of cyanide or sulfide back into cellular sites with subsequent toxicity. Patients with renal insufficiency or known allergy to methylene blue Excessive methemoglobinemia, as characterized by progressive and persistent cyanosis unresponsive to oxygen therapy and the appearance of chocolate brown color of the blood. Use of oxidizing agents may produce an acute hemolytic SIDE EFFECTS:
reaction in patients with glucose-6-phosphodehydrogenase (G6PD) deficiency. Blue-green urine May cause bladder irritation, nausea, vomiting, and diarrhea. Large doses may produce abdominal and precordial pain, dizziness, profuse sweating, fever, and/or mental confusion. Rapid administration may produce increased methemoglobin SPECIAL NOTES /
formation, especially in the presence of other oxidizing agents. **DIRECT MEDICAL ORDER REQUIRED**
Initially Issued: 05/28/99 Revision Date: 05/28/99 Current Printing: 5.16.2008 Edgar G. DesChamps, III, M.D. State Medical Director MIDAZOLAM
Major Motor Seizures Status epilepticus Pre-Medication prior to cardioversion or Transcutaneous Pacing Skeletal muscle relaxant Acute Anxiety States Medication for combative patients and difficult intubations Slow IV, IM, IO ADMINISTRATION:

NON-RSI Indications:
0.5 mg – 2.5 initial dose. RSI Indications:
.02 mg/kg - .05 mg/kg initial dose For initial administration dose of Versed, consider decreased dose if systolic BP is 80 – 100 mm REPEAT DOSES OF VERSED MAY BE ADMINISTERED
ONLY WITH DIRECT ONLINE MEDICAL ORDER.
- After successful intubation, airway control and additional IV,
Versed may be administered based on patient effect up to a
total of 10 MG IV.
- Not Indicated Short-acting benzodiazepine CNS depressant Short-term sedation THERAPEUTIC EFFECTS:
Postoperative amnesia Hypersensitivity to versed RELATIVE
Cardiac arrhythmias SIDE EFFECTS:
- Impairs memory in 90% of patients. - Flumazenil will reverse sedative effects.
SPECIAL NOTES /
RSI MAY BE initiated by Standing Order or Protocol. It is
RECOMMENDED – where feasible – that On-Line Medical
Control be obtained prior to initiation – but this should not
supercede the appropriate care of the patient

100% QI / PI is required for ALL RSI runs. Initially Issued: 05/13/99 Revision Date: 05/13/99 Current Printing: 5.16.2008 Edgar G. DesChamps, III, M.D. State Medical Director MORPHINE SULFATE C
Acute pulmonary edema Combative Head Injuries (Before Intubation) Severe pain in selected situations Premedication for cardioversion, transcutaneous pacing ADMINISTRATION:

Initial dose 2 mg to 5 mg Dosing based upon Direct Medical Order **DIRECT MEDICAL ORDER REQUIRED**
0.05 - 0.2 mg/kg Dosing based upon Direct Medical Order **DIRECT MEDICAL ORDER REQUIRED**
THERAPEUTIC EFFECTS:
- Peripheral vasodilation / venous pooling - Decreases sensitivity to pain

- Head
RELATIVE
CONTRAINDICATIONS:

not caused by pulmonary edema
- Undiagnosed abdominal pain
- Hypersensitivity to the drug

- Respiratory
SIDE EFFECTS:
- Nausea/Vomiting
This Schedule CII Controlled Substance may be
administered:

ONLY WITH ON-LINE MEDICAL CONTROL ORDER
IN THE PRE-HOSPITAL SETTING!

INTERFACILITY SETTING, MORPHINE
SPECIAL NOTES /
ADMINISTRATION IS APPROVED BY DIRECT
MEDICAL ORDER (Written Orders) FOR THE
SPECIFIC PATIENT!
- Have Atropine/Narcan and respiratory assistance available - Monitor VS closely before & after administration - After administration patient must be closely monitored with vital signs taken and recorded Q 5-10 minutes if possible Initially Issued: 06/30/93 Revision Date: 09/08/94 Current Printing: 5.16.2008 Edgar G. DesChamps, III, M.D. State Medical Director NALBUPHINE
Moderate to severe pain INDICATIONS:

ADMINISTRATION:

5 to 10 mg slow administration (10 mg/70 kg) **DIRECT MEDICAL ORDER REQUIRED**
0.1 - 0.2 mg/kg IV (slow) or IM **DIRECT MEDICAL ORDER REQUIRED**
THERAPEUTIC EFFECTS:
- Decreases sensitivity to pain
- Undiagnosed abdominal pain
RELATIVE
- Hypersensitivity to the drug

- Respiratory
SIDE EFFECTS:
- Altered level of consciousness - Nausea - Common May precipitate withdrawal syndrome in narcotic dependent SPECIAL NOTES /
persons due to antagonist properties ONLY WITH DIRECT MEDICAL ORDER
Initially Issued: 06/30/93 Revision Date: 11/03/96 Current Printing: 5.16.2008 Edgar G. DesChamps, III, M.D. State Medical Director NALOXONE
Narcotic overdoses; i.e.: Synthetic analgesic overdose; i.e.: Darvon/Darvocet ADMINISTRATION:

− 1-2 mg slow administration titrated to respirations − 0.1 mg/kg for children up to 5 years old or 20 kg − 2.0 mg for children over 5 years or > 20 kg − may repeat every 2 – 3 minutes as needed Reverses most effects of nearly all narcotic and/or synthetic narcotic THERAPEUTIC EFFECTS:
- Hypersensitivity to the drug RELATIVE
CONTRAINDICATIONS:


- Vomiting with rapid administration
SIDE EFFECTS:
- Precipitate acute narcotic withdrawal syndrome - Seizures - Hypertension - May reverse ETOH induced coma SPECIAL NOTES /
- Rapid onset, short acting - possible re-sedation RESTRICTIONS:

Initially Issued: 06/30/93 Revision Date: 09/08/94 Current Printing: 5.16.2008 Edgar G. DesChamps, III, M.D. State Medical Director Nitro-Bid, Nitrostat, Nitro Chest pain consistent with acute coronary symptoms. Pulmonary edema Sprayed under tongue on mucous membrane or given sublingual Ointment paste applied to truncal skin 0.4 mg/metered dose. No more than 3 metered doses should be administrated in
a 15 minute period. A 4th, and subsequent doses, may be
administered PER STANDING ORDERS if chest pain
persists and as long as systolic BP remains at 100 or
greater.

2. Sublingual
1 tablet 0.3 - 0.4 mg sublingual No more than 3 tablets should be administrated within a 15
minute period. A 4th, and subsequent tablets, may be
administered PER STANDING ORDERS if chest pain
persists and as long as systolic BP remains at 100 or
greater.

3. Ointment Paste
Apply in ½" to 1" thin layer to patient's skin by means of the dose measured applicator supplied with the tube DO NOT RUB THE PASTE INTO THE SKIN
NOT APPROVED
THERAPEUTIC EFFECTS:
Dilates coronary and systemic arteries - Increased Intracranial Pressure (ICP) RELATIVE
- Hypotension/Shock - Use of VIAGRA within previous 24 Hours SIDE EFFECTS:
SPECIAL NOTES /
Monitor BP closely before & after administration Should not be administered if erectile dysfunction drugs
have been used in the previous 24 hours.
Initially Issued: 06/30/93 Revision Date: 06/23/05 Current Printing: 5.16.2008 Edgar G. DesChamps, III, M.D. State Medical Director Division of EMS NITROUS OXIDE (50%) & OXYGEN (50%)
Moderate to severe pain Severe anxiety states ADMINISTRATION:



Self-administered by mask

Self-administered by mask.
Must be old enough to self-administer.
Decreases sensitivity to pain THERAPEUTIC EFFECTS:

RELATIVE
- ETOH or drug intoxication SIDE EFFECTS:
- Nausea/Vomiting Effects diminish within 2 to 5 minutes after removal of source. SPECIAL NOTES /
RESTRICTIONS:

Initially Issued: 06/30/93 Revision Date: 09/11/96 Current Printing: 5.16.2008 Edgar G. DesChamps, III, M.D. State Medical Director OXYTOCIN
Postpartum hemorrhage INDICATIONS:

ADMINISTRATION:



- 10 to 20 units in 500 or 1000 ml of NS/RL; slow administration
titrated according to severity of bleeding & uterine response, in postpartum females only
NOT APPROVED (UNLESS PATIENT IS POST PARTUM)
- Stimulates uterine smooth muscle to contract THERAPEUTIC EFFECTS:
vasoconstriction - Presence of a second fetus RELATIVE
- Previous cesarean section CONTRAINDICATIONS:


- Uterine
SIDE EFFECTS:
- Nausea/Vomiting - Hypertension
_ For use ONLY in FEMALE patients.

only after baby & placenta are delivered
SPECIAL NOTES /
- Overdose can cause uterine rupture RESTRICTIONS:

- Vital signs & uterine tone should be monitored constantly - Do not give to patients taking vasopressors
Initially Issued: 06/30/93 Revision Date: 11/03/96 Current Printing: 5.16.2008 Edgar G. DesChamps, III, M.D. State Medical Director PRALIDOXIME
2-Pam, Protopam Chloride (Special Purpose: Toxicology) Cholinergic crisis due to acetylcholinesterase inhibition caused by organophosphate toxicity (e.g. dichlorvos, dioxanthion, echothiophate iodide, endothion, fenthion, formothion, isoflurophate, malathion, methyl parathion, parathion, TEPP, diazinon). Poisoning by nerve agents having anticholinesterase activity. IV, IM (if IV access not feasible) ADMINISTRATION:

1 - 2 Gram, over 10-15 minutes in 100 cc NS. If not practicable or in the event of pulmonary edema, administer slowly as 5% solution in water over not less than 5 minutes.
20-40 mg/kg/dose over 10-15 minutes Reactivation of phosphorylated acetylcholinesterase. Reversal of nicotinic effects of acetylcholinesterase inhibition, THERAPEUTIC EFFECTS:
particularly on skeletal muscle. Reversal of muscarinic effects of cholinesterase inhibition, usually additive with atropine. Cholinergic crisis due to acetylcholinesterase inhibition by RELATIVE
carbamate insecticides or other short acting cholinesterase CONTRAINDICATIONS:

inhibitors (physostigmine, neostigmine, etc.). Occasional Sinus Tachycardia, laryngospasm, and muscle rigidity seen with too rapid injection. Occasional dizziness, SIDE EFFECTS:
headache, blurred vision, nausea, or diplopia (all of which may be related to the underlying poison as well). Special Purpose Drug for TOXICOLOGY
SPECIAL NOTES /
RESTRICTIONS:

May be administered per standing order. Initially Issued: 05/26/99 Revision Date: 05/26/99 Current Printing: 5.16.2008 Edgar G. DesChamps, III, M.D. State Medical Director Procan, Pronestyl PVCs refractory to lidocaine Ventricular tachycardia refractory to lidocaine INDICATIONS:

Pediatric: symptomatic tachyarrhythmias not responsive to primary IV, IV infusion, IO ADMINISTRATION:



- 20 mg/min slow IV push administration
- Up to a total of 17 mg/kg - 1-4 mg/min IV infusion **DIRECT MEDICAL ORDER REQUIRED**
− 15 mg / kg over 30 – 60 minutes - Elevates ventricular fibrillation threshold THERAPEUTIC EFFECTS:
- Suppresses ventricular ectopic activity - High degree heart blocks (Mobitz II Second Degree; Third Degree) RELATIVE
- PVCs in conjunction with profound bradycardia CONTRAINDICATIONS:

SIDE EFFECTS:
- Widening of QRS Constant monitoring of BP essential Should be withheld until 3 mg/kg of lidocaine has been given & has demonstrated no clinical response Should be given until:
a.
Dysrhythmia is suppressed SPECIAL NOTES /
QRS widens by 50% Total of 17 mg/kg given In urgent situations (such as refractory VF) may administer up to 30 DIRECT MEDICAL ORDER REQUIRED
Initially Issued: 06/30/93 Revision Date: 11/03/96 Current Printing: 5.16.2008 Edgar G. DesChamps, III, M.D. State Medical Director May be administered by paramedics for emesis. INDICATIONS:

ADMINISTRATION:

12.5mg to 25mg IV Push Not Approved

THERAPEUTIC EFFECTS:


- Comatose
- Those with CNS depressants already received or RELATIVE
administered (ETOH, etc.) hypersensitivity - Never give intra-arterial SIDE EFFECTS:
- Rare changes in Heart Rate/Blood Pressure In the case of a reaction treat with benadryl SPECIAL NOTES /
RESTRICTIONS:

Initially Issued: 01/90 Revision Date: 05/28/99 Current Printing: 5.16.2008 Edgar G. DesChamps, III, M.D. State Medical Director Ocu-Caine (Alcaine)
To ease discomfort associated with the following:
Ocular foreign bodies Corneal abrasions Ocular burns Prolonged eye irrigation ADMINISTRATION:

1 to 2 drops in the affected eye Q 5-10 minutes 1 to 2 drops in the affected eye Q 5-10 minutes Topical ophthalmic analgesia THERAPEUTIC EFFECTS:

Known hypersensitivity RELATIVE
CONTRAINDICATIONS:


- Occasional
SIDE EFFECTS:
- Severe hyperallergenic corneal reaction Δ Can NOT be stored at room temperature
SPECIAL NOTES /
Must be Refrigerated at 2 - 8o C.
- Throw away after one use - Very few side effects Initially Issued: 06/30/93 Revision Date: 09/08/94 Current Printing: 5.16.2008 Edgar G. DesChamps, III, M.D. State Medical Director PROPRANOLOL
Hemodynamically significant tachydysrhythmias or ventricular irritability unresponsive to, or when standard antidysrhythmics may be contraindicated. (e.g. Myocardial and neural hypersensitivity due to chlorinated hydrocarbon toxicity.) IV SLOWLY (over not less than 1 minute) ADMINISTRATION:

DIRECT MEDICAL ORDER REQUIRED
0.5 - 1.0mg may be repeated up to a total of 3mg upon further order if desired effect does not occur within 5 minutes of Competitive inhibition of beta THERAPEUTIC EFFECTS:
1 and beta2 adrenergic receptor Bradydysrhythmias and/or conduction disturbances. RELATIVE
CONTRAINDICATIONS:

Asthma or underlying chronic pulmonary disease (relative) 1. Bradydysrhythmias or conduction disturbances SIDE EFFECTS:
2. Bronchoconstriction Reduced effect of catecholamines SPECIAL NOTES /
Increased effect of standard antidysrhythmics **DIRECT MEDICAL ORDER REQUIRED**
Initially Issued: 11/03/96 Revision Date: 05/28/99 Current Printing: 5.16.2008 Edgar G. DesChamps, III, M.D. State Medical Director VITAMIN B6

INDICATIONS:

Hydrazine poisoning.
ADMINISTRATION:

25 mg/kg over five (5) minutes 25 mg/kg over five (5) minutes Provides a required synthetic cofactor that enables the brain to THERAPEUTIC EFFECTS:
regenerate GABA and stop seizures
RELATIVE

CONTRAINDICATIONS:

None acutely; peripheral neuropathy with chronic, excessive dosing; SIDE EFFECTS:
Pyridoxine withdrawal seizures in neonates of mothers who took chronic, excessive doses of pyridoxine during pregnancy
SPECIAL NOTES /

Initially Issued: 08/2002 Revision Date: Current Printing: May 16, 2008 Edgar G. DesChamps, III, M.D. State Medical Director RACEMIC EPINEPHRINE
MicroNEFRIN, Vaponephrine Croup (Laryngotracheobronchitis) INDICATIONS:

Inhalation only ADMINISTRATION:

0.05 mg/kg/dose (diluted to 3.0 cc with NS) to a maximum dose of 0.5 mg. Only used initially and not repeated. 0.05 mg/kg/dose (diluted to 3.0 cc with NS) to a maximum dose of 0.5 mg. Only used initially and not repeated Bronchodilation from B2 receptor stimulation THERAPEUTIC EFFECTS:

Should not be used in the management of epiglottitis. RELATIVE
CONTRAINDICATIONS:

Can result in tachycardia and possible arrhythmias. SIDE EFFECTS:

Usually supplied in vials of 7.5 cc. Note that medication is diluted up to SPECIAL NOTES /
3.0 cc with Normal Saline. Physician in receiving ED should be notified that treatment has been Initially Issued: 05/14/98 Revision Date: 05/14/98 Current Printing: 5.16.2008 Edgar G. DesChamps, III, M.D. State Medical Director SODIUM BICARBONATE
Severe metabolic acidosis Cardiac arrest (after ventilation problems are corrected) Certain medication overdoses IV, IV infusion, IO - Repeat 0.5 mEq/kg Q 10 minutes ∇ Age < 2 years: Must be diluted 1:1 with D5W or NS prior
to administration
- Provides bicarbonate ion to buffer strong acids THERAPEUTIC EFFECTS:
RELATIVE
CONTRAINDICATIONS:


- Metabolic
- Increased vascular volume SIDE EFFECTS:
- Dysrhythmias through serum potassium depletion - Transiently raises the arterial PCO2
May add up to 50 mEq to 500-1000 ml of D5W, Saline (Normal
or ½ Normal) or Ringer's Lactate, infuse at rate determined by
medical control
ONLY WITH DIRECT MEDICAL ORDER
Age < 2 years: Must be diluted 1:1 with D5W or NS prior
SPECIAL NOTES /
RESTRICTIONS:

to administration
- Administration & dosage best determined by ABG's in cardiac arrest situations - Administration must be accompanied by controlled
hyperventilation to blow-off excess CO2 produced by NaHCO3 administration Initially Issued: 06/30/93 Edgar G. DesChamps, III, M.D. Revision Date: 09/08/94 State Medical Director Current Printing: 5.16.2008 SODIUM CHLORIDE 0.9%
Heat exhaustion and related heat problems Diabetic disorders Freshwater Drowning Head injury (depending upon Medical Control Physician) Hypovolemia IV infusion, IO ADMINISTRATION:

Dependent upon patient condition and situation being treated Dependent upon patient size and condition Provides fluid and sodium replacement THERAPEUTIC EFFECTS:
Congestive Heart Failure RELATIVE
CONTRAINDICATIONS:

Volume Overload Congestive Heart Failure SIDE EFFECTS:

Normal saline or lactated ringers is the preferred infusion
solution during cardiac arrest, although D5W remains
acceptable

SPECIAL NOTES /
RESTRICTIONS:

Any combination of Dextrose and Sodium Chloride is
approved. Some other combinations include:
- 5% Dextrose in 0.9% Sodium Chloride (D5NS) - 5% Dextrose in 0.2% Sodium Chloride (D5 0.2NS) - 3.3% Dextrose in 0.3% Sodium Chloride Initially Issued: 06/30/93 Revision Date: 06/30/93 Current Printing: 5.16.2008 Edgar G. DesChamps, III, M.D. State Medical Director SODIUM NITRITE
(Special Purpose for Toxicology) Acute cyanide poisoning Acute sulfide poisoning ADMINISTRATION:

300mg (10 ml) over 3-5 minutes 4- 6 mg/kg to a maximum of 300mg (10ml) over 3-5 minutes Produces methemoglobin (oxidizes ferrous [Fe+2] iron in THERAPEUTIC EFFECTS:
normal hemoglobin to ferric [Fe+3] iron or methemoglobin. RELATIVE
CONTRAINDICATIONS:


1. Excessive methemoglobinemia, as characterized by
progressive and persistent cyanosis unresponsive to oxygen therapy and the appearance of chocolate brown SIDE EFFECTS:
color of the blood. 2. Use of oxidizing agents may produce an acute hemolytic reaction in patients with glucose-6-phosphodehydrogenase (G6PD) deficiency. Methylene blue, a reducing agent, may be used to reverse SPECIAL NOTES /
excessive methemoglobinemia. Special Purpose Drug for TOXICOLOGY
May be administered per standing order Initially Issued: 05/28/99 Revision Date: 05/28/99 Current Printing: 5.16.2008 Edgar G. DesChamps, III, M.D. State Medical Director SODIUM THIOSULFATE
(Special Purpose for Toxicology) Acute cyanide poisoning following administration of nitrates. INDICATIONS:

ADMINISTRATION:

12.5 grams (50 ml) over 1-2 minutes 250 mg/kg (1 ml/kg) to a maximum of 12.5 G over 3-5 Removes cyanide ion from ferrocyanate complex formed THERAPEUTIC EFFECTS:
with methemoglobin, producing thiocyanate; excreted by the RELATIVE
CONTRAINDICATIONS:

No significant side effects in setting of cyanide poisoning SIDE EFFECTS:
following administration of nitrates. May rarely be ordered without previous administration of SPECIAL NOTES /
nitrate if history is unclear. Special Purpose Drug for TOXICOLOGY
May be administered per standing order Initially Issued: 05/28/99 Revision Date: 05/28/99 Current Printing: 5.16.2008 Edgar G. DesChamps, III, M.D. State Medical Director SOLUMEDROL
Methylprednisolone Bronchodilator for Asthma refractory to Albuterol. ADMINISTRATION:

40 – 125 MG IV 1 – 2 mg/kg IV Potentiates vascular smooth muscle relaxation by beta THERAPEUTIC EFFECTS:
adrenergic agonists. Use with caution in patients with: RELATIVE
• Diabetes Mellitus • Severe Infection Headache, Hypertension, Sodium and water retention, SIDE EFFECTS:
Hypokalemia, Alkalosis Hypoglycemic responses to insulin and oral Hypoglycemic SPECIAL NOTES /
agents may be blunted; Potassium depleting agents may potentiate Hypokalemia induced by corticosteroids. Initially Issued: 05/24/04 Revision Date: Current Printing: 5.16.2008 Edgar G. DesChamps, III, M.D. State Medical Director Skeletal muscle relaxation during operative and manipulative Facilitate management of patients undergoing mechanical Adjunct to general anesthesia ADMINISTRATION:

-1.5mg/kg over 30 seconds; not to exceed 150mg total dose - NOT INDICATED. -Prevents neuromuscular transmission by blocking the effect THERAPEUTIC EFFECTS:
of acetylcholine at the myoneural junction -Hypersensitivity to succinylcholine -History of malignant hyperthermia RELATIVE
-Skeletal muscle myopathies -Penetrating eye injury -Cardiac arrhythmias SIDE EFFECTS:
-Increased intraocular pressure -Muscle fasciculations -Succinylcholine has no effect on consciousness, pain threshold, or cerebration. Must be used only with adequate - In elderly time of onset may be delayed due to slower circulation time in cardiovascular disease. -Use with extreme caution in patients with severe burns, electrolyte imbalance, hyperkalemia, and those receiving quinidine or digitalis. -The potential for releasing histamine is present following succinylcholine use. Serious histamine-mediated flushing, hypotension, and bronchoconstriction are, however, SPECIAL NOTES /
uncommon in clinical usage. -Incidence of side effects increase with second or subsequent
- STORAGE: Refrigerate at 35 O - 46 O F. Multi-dose vials are
stable for up to 14 days at room temperature.
RSI MAY BE initiated by Standing Order or Protocol. It is
RECOMMENDED – where feasible – that On-Line Medical
Control be obtained prior to initiation– but this should not
supercede the appropriate care of the patient.

100% QI / PI is required for ALL RSI runs. Initially Issued: 05/13/99 Revision Date: 05/13/99 Current Printing: 5.16.2008 Edgar G. DesChamps, III, M.D. State Medical Director TERBUTALINE SULFATE
Moderate to severe bronchial asthma INDICATIONS:

Reversible bronchospasm in COPD ADMINISTRATION:

0.25 mg (0.25 ml) ∇Maximum Dose = 0.25 mg
- Bronchodilator through selective beta 2 stimulation THERAPEUTIC EFFECTS:
- Relatively little effect on heart rate - Relaxes bronchial smooth muscle RELATIVE
- Hypersensitivity to the drug
- Palpitations
- Tremor
SIDE EFFECTS:
- Sweating - Nausea - Muscle cramping - May repeat dosage in 15-30 minutes SPECIAL NOTES /
not give with other sympathomimetic drugs
Initially Issued: 06/30/93 Revision Date: 11/03/96 Current Printing: 5.16.2008 Edgar G. DesChamps, III, M.D. State Medical Director TETRACAINE OPTHALMIC DROPS
Scleral/corneal abrasions Blunt/non-penetrating eye trauma Burns to the eye Aid in irrigation of the eye 1 to 2 drops to affected eye 1 to 2 drops in affected eye every 5-10 minutes as needed for pain Same dosage as adult THERAPEUTIC EFFECTS:
Known hypersensitivity to the drug Penetrating eye trauma Use with caution with patients that are pregnant or nursing. RELATIVE
CONTRAINDICATIONS:

SIDE EFFECTS:
Occasional stinging sensation or conjunctival redness Burning sensation Sensitivity to light Rare pupillary dilation and/or blurred vision SPECIAL NOTES /
Does not require refrigeration Initially Issued: 06/30/93 Revision Date:: 02/07/08 Current Printing: 5.16.2008 Edgar G. DesChamps, III, M.D. State Medical Director Division of EMS THIAMINE
Coma and seizures of unknown origin, especially if alcohol use Delirium Tremens ADMINISTRATION:

10-25 mg (rarely used) Provides the appropriate thiamine levels to allow glucose to be THERAPEUTIC EFFECTS:
utilized in sufficient amounts, thus reversing cellular hypoglycemia secondary to thiamine deficiency Known hypersensitivity to Thiamine RELATIVE
CONTRAINDICATIONS:

Be alert for sensitivity (allergic) reactions in patients SIDE EFFECTS:


- A few cases of hypersensitivity have been reported but these
SPECIAL NOTES /
- Deaths, while rare, have resulted from IV administration. However the possibility of Wernicke's Syndrome following glucose administration presents substantially greater risk than the possibility of significant hypersensitive reaction. Initially Issued: 10/10/96 Revision Date: 10/10/96 Current Printing: 5.16.2008 Edgar G. DesChamps, III, M.D. State Medical Director VASOPRESSIN
VF / pulseless VT, asystole 40 U IV, single dose, 1 time only Not recommended in pediatrics Vasopressin produces the same positive effects as epinephrine in terms of vasoconstriction and increasing the blood flow to the brain THERAPEUTIC EFFECTS:
and heart during CPR. Moreover, vasopressin does not have the negative, adverse effects of epinephrine on the heart, such as increased ischemia and irritability and, paradoxically, the propensity for VF. RELATIVE
None when administered for indications CONTRAINDICATIONS:

SIDE EFFECTS:
None when administered for indications SPECIAL NOTES /
RESTRICTIONS:

Initially Issued: Revision Date: 6-16-2005 Current Printing: 5.16.2008 Edgar G. DesChamps, III, M.D. State Medical Director VECURONIUM BROMIDE
Facilitates endotracheal intubation by paralysis of skeletal To increase pulmonary compliance during mechanical ADMINISTRATION:

0.1mg/kg over 30-60 seconds Onset of 2-3 min., duration of 25-30 min. -Prevents neuromuscular transmission by blocking the effect THERAPEUTIC EFFECTS:
of acetylcholine at the myoneural junction -Skeletal muscle paralysis - Hypersensitivity to vecuronium RELATIVE
CONTRAINDICATIONS:

- No side effects have occurred except with overdoses SIDE EFFECTS:

- Paralysis may be prolonged by succinylcholine, quinidine, and beta blockers RSI MAY BE initiated by Standing Order or Protocol. It is
SPECIAL NOTES /
RECOMMENDED – where feasible – that On-Line Medical
Control be obtained prior to initiation – but this should not
supercede the appropriate care of the patient.
100% QI / PI is required for ALL RSI runs. Initially Issued: 05/13/99 Revision Date: 05/13/99 Current Printing: 5.16.2008 Edgar G. DesChamps, III, M.D. State Medical Director Levalbuterol HCI
Adults and adolescents 12 years of age and older with reversible obstructive airway disease. Nebulized Inhalation ADMINISTRATION:


.63 or 1.25 mg

For ages 12 and over, same as adult dosage; not indicated for ages
less than 12 years. THERAPEUTIC EFFECTS:

History of sensitivity to levalbuterol or Racemic albuterol CONTRAINDICATIONS:

Tachycardia, Leg Cramps, Nervousness, Tremor SIDE EFFECTS:

SPECIAL NOTES /
RESTRICTIONS:

Initially Issued: 06/30/93 Revision Date: 08/14/03 Current Printing: 5.16.2008 Edgar G. DesChamps, III, M.D. State Medical Director Nausea / Vomiting 0.15 mg/kg IV or IM Same dosage as adult THERAPEUTIC EFFECTS:
Prevents nausea and vomiting Hypersensitivity to the drug
RELATIVE

CONTRAINDICATIONS:

SIDE EFFECTS:
Extra-pyramidal reaction (rare) SPECIAL NOTES /
RESTRICTIONS:

Initially Issued: 06/30/93 Revision Date: 02/07/08 Current Printing: 5.16.2008 Edgar G. DesChamps, III, M.D. State Medical Director Division of EMS RAPID SEQUENCE INDUCTION
ETOMIDATE

INDICATIONS:

For use in RSI protocol – for anesthesia induction.
ADMINISTRATION:


THERAPEUTIC EFFECTS:

Hypnotic drug (no analgesic activity)
RELATIVE

Known sensitivity to drug CONTRAINDICATIONS:
SIDE EFFECTS:

Transient venous pain, skeletal muscle movement SPECIAL NOTES /
RESTRICTIONS:

Initially Issued: 08/2002 Revision Date: Current Printing: May 16, 2008 Edgar G. DesChamps, III, M.D. State Medical Director MIDAZOLAM
Major Motor Seizures Status epilepticus Pre-Medication prior to cardioversion or Transcutaneous Pacing Skeletal muscle relaxant Acute Anxiety States Medication for combative patients and difficult intubations Slow IV, IM, IO ADMINISTRATION:

NON-RSI Indications:
0.5 mg – 2.5 initial dose. RSI Indications:
.02 - .05 mg/kg not to exceed 5 mg For administration of initial dose of Versed consider decreased dose if systolic BP is 80 – 100 mm hg After successful intubation / airway control, additional IV Versed may be administered based on patient effect up to a total of 10 mg IV. Repeat doses may be administered with Direct Medical Order. - Not Indicated Short-acting benzodiazepine CNS depressant Short-term sedation THERAPEUTIC EFFECTS:
Postoperative amnesia - Hypersensitivity to versed RELATIVE
- Pregnancy - Renal Failure Cardiac arrhythmias SIDE EFFECTS:
- Impairs memory in 90% of patients. - Flumazenil will reverse sedative effects.
SPECIAL NOTES /
RSI MAY BE initiated by Standing Order or Protocol. It is
RECOMMENDED – where feasible – that On-Line Medical
Control be obtained prior to initiation – but this should not
supercede the appropriate care of the patient

100% QI / PI is required for ALL RSI runs. Initially Issued: 05/13/99 Revision Date: 05/13/99 Current Printing: 5.16.2008 Edgar G. DesChamps, III, M.D. State Medical Director Skeletal muscle relaxation during operative and manipulative Facilitate management of patients undergoing mechanical Adjunct to general anesthesia ADMINISTRATION:

-1.5mg/kg over 30 seconds; not to exceed 150mg total dose - NOT INDICATED. -Prevents neuromuscular transmission by blocking the effect THERAPEUTIC EFFECTS:
of acetylcholine at the myoneural junction -Hypersensitivity to succinylcholine -History of malignant hyperthermia RELATIVE
-Skeletal muscle myopathies -Penetrating eye injury -Cardiac arrhythmias -Increased intraocular pressure SIDE EFFECTS:
-Muscle fasciculations -Bradycardia in children -Succinylcholine has no effect on consciousness, pain threshold, or cerebration. Must be used only with adequate - In elderly time of onset may be delayed due to slower circulation time in cardiovascular disease. -Use with extreme caution in patients with severe burns, electrolyte imbalance, hyperkalemia, and those receiving quinidine or digitalis. -The potential for releasing histamine is present following succinylcholine use. Serious histamine-mediated flushing, hypotension, and bronchoconstriction are, however, SPECIAL NOTES /
uncommon in clinical usage. -Incidence of side effects increase with second or subsequent
- STORAGE: Refrigerate at 35 O - 46 O F. Multi-dose vials are
stable for up to 14 days at room temperature.
RSI MAY BE initiated by Standing Order or Protocol. It is
RECOMMENDED – where feasible – that On-Line Medical
Control be obtained prior to initiation– but this should not
supercede the appropriate care of the patient.

100% QI / PI is required for ALL RSI runs. Initially Issued: 05/13/99 Revision Date: 05/13/99 Current Printing: 5.16.2008 Edgar G. DesChamps, III, M.D. State Medical Director VECURONIUM BROMIDE
Facilitates endotracheal intubation by paralysis of skeletal To increase pulmonary compliance during mechanical ADMINISTRATION:

0.1mg/kg over 30-60 seconds Onset of 2-3 min., duration of 25-30 min. -Prevents neuromuscular transmission by blocking the effect THERAPEUTIC EFFECTS:
of acetylcholine at the myoneural junction -Skeletal muscle paralysis - Hypersensitivity to vecuronium RELATIVE
CONTRAINDICATIONS:

- No side effects have occurred except with overdoses SIDE EFFECTS:

- Paralysis may be prolonged by succinylcholine, quinidine, and beta blockers RSI MAY BE initiated by Standing Order or Protocol. It is
SPECIAL NOTES /
RECOMMENDED – where feasible – that On-Line Medical
Control be obtained prior to initiation – but this should not
supercede the appropriate care of the patient.
100% QI / PI is required for ALL RSI runs. Initially Issued: 05/13/99 Revision Date: 05/13/99 Current Printing: 5.16.2008 Edgar G. DesChamps, III, M.D. State Medical Director TOXICOLOGIC EMERGENCIES FORMULARY
ACTIVATED CHARCOAL USP
Actidose, CharcoAid Particularly effective in binding: ADMINISTRATION:



1 gm/kg mixed with water
1 gm/kg mixed with water ONLY WITH DIRECT MEDICAL ORDER
It binds & absorbs ingested toxins still present in the gastro- THERAPEUTIC EFFECTS:
intestinal tract following emesis. Once bound, the combined complex is excreted Should not be given before or together with ipecac, as it will absorb the ipecac & render it ineffective. RELATIVE
not be given in cyanide poisoning.
no value in poisoning due to:
_ Caustic alkalis/acids None, unless the airway cannot be adequately controlled. SIDE EFFECTS:

Should only be given PO or NG in a slurry solution mixed with water / SPECIAL NOTES /
RESTRICTIONS:

Initially Issued: 06/30/93 Revision Date: 11/03/96 Current Printing: 5.16.2008 Edgar G. DesChamps, III, M.D. State Medical Director AMYL NITRITE
(Special Purpose: Toxicology) Cyanide Poisoning INDICATIONS:

Inhalation only ADMINISTRATION:



One or two inhalants of amyl nitrite should be crushed and inhaled for
15 to 30 seconds.
One inhalant should be crushed and inhaled for 15 to 30 seconds.
(Smallest effective dosage should be used.) It is effective in the emergency management of cyanide poisoning. THERAPEUTIC EFFECTS:
Amyl nitrite causes the oxidation of hemoglobin to a compound called methemoglobin. Methemoglobin reacts with the toxic cyanide ion to form cyanomethemoglobin, which can be enzymatically degraded. No contraindications for amyl nitrite in the management of cyanide RELATIVE
CONTRAINDICATIONS:

Headache and hypotension have been known to occur following SIDE EFFECTS:
Special Purpose Drug for TOXICOLOGY SPECIAL NOTES /
RESTRICTIONS:

Initially Issued: 05/14/98 Revision Date: 05/14/98 Current Printing: 5.16.2008 Edgar G. DesChamps, III, M.D. State Medical Director ATROPINE AND PRALIDOXIME
CHLORIDE INJECTION
DUODOTE AUTO INJECTOR Poisoning by nerve agents having anticholinesterase activity. INDICATIONS:

2.1 mg atropine, 600 mg pralidoxime chloride via auto injector. May be repeated to a total of 3 doses. Competitively blocks the effects of acetylcholine, including excess acetylcholine due to organophosphorous poisoning at muscarinic cholinergic receptors and in peripheral autonomic ganglia and the central nervous system. Reactivation of phosphorylated THERAPEUTIC EFFECTS:
acetylcholinesterase. Reversal of nicotinic effects of acetylcholinesterase inhibition, particularly on skeletal muscle. Reversal of muscarinic effects of cholinesterase inhibition, usually additive with atropine. In the presence of life-threatening poisoning by organophosphorous nerve agents or insecticides, there are no absolute contraindications. When symptoms of poisoning are not severe, DuoDote Auto-Injector should be used with extreme caution in people with heart disease, arrhythmias, recent myocardial infarction, severe narrow angle glaucoma, pyloric stenosis, prostatic hypertrophy, significant renal insufficiency, chronic pulmonary disease, or hypersensitivity to any component of the product. Blurred vision, dry mouth, flushing of skin, pupillary dilatation, urine SIDE EFFECTS:
retention, dizziness, headache, drowsiness, nausea, tachycardia, hypertension, hyperventilation, and muscular weakness. SPECIAL NOTES /
MAY ADMINISTER PER STANDING ORDER
Initially Issued: 05/13/08 Revision Date: 05/13/08 Current Printing: 5.16.2008 Edgar G. DesChamps, III, M.D. State Medical Director CALCIUM GLUCONATE (Tox)
(Special Purpose: Toxicology) Hydrofluoric acid burns and exposure INDICATIONS:

Topical application, IV, or by nebulizer; rarely by direct injection ADMINISTRATION:

10ml mixed with one ounce of water soluble lubricant for topical application, IV as ordered, or 2.5% solution nebulized with oxygen for inhalation exposure; 0.3-0.5 ml of 5% solution/cm2 burn area injected directly for deep or subungual burns.
Same as adult
Binds with fluoride ion, prevents or reverses hypocalcemia. THERAPEUTIC EFFECTS:

Not to be injected for GENERAL SKIN BURNS from THERMAL RELATIVE
CONTRAINDICATIONS:

Hypercalcemia, local tissue damage, pressure necrosis if injected SIDE EFFECTS:
under nail beds. Special Purpose Utilization: TOXICOLOGY SPECIAL NOTES /
Infiltration of wound with local anesthetic should not be used, regional blocks may be necessary to provide adequate treatment of large or deeply penetrated burns. Ocular exposure should be treated with 1% aqueous irrigation following proparacaine anesthetic. Initially Issued: 05/28/99 Revision Date: 05/28/99 Current Printing: 5.16.2008 Edgar G. DesChamps, III, M.D. State Medical Director HYDROXOCOBALAMIN INJECTION
Known or suspected cyanide poisoning. INDICATIONS:

5g in 200 ml of 0.9% NaCL over 15 min. 5 mg may be repeated for total dose of 10 mg. Binds cyanide ions for excretion. THERAPEUTIC EFFECTS:

RELATIVE
CONTRAINDICATIONS:

Hypertension, chromaturia, anaphylaxis, chest tightness, SIDE EFFECTS:
edema, urticaria, pruritis, dyspnea, and rash. MAY ADMINISTER PER STANDING ORDER
SPECIAL NOTES /
RESTRICTIONS:

Initially Issued: 05/26/99 Revision Date: 05/02/08 Current Printing: 5.16.2008 Edgar G. DesChamps, III, M.D. State Medical Director IPECAC SYRUP
Certain poisons and overdoses INDICATIONS:

ADMINISTRATION:

15 to 30 ml followed by several glasses of warm water or **DIRECT MEDICAL ORDER REQUIRED**
− Less than 6 months old - NOT APPROVED
− 1 – 12 years 15 ml − 12 years 30 ml **DIRECT MEDICAL ORDER REQUIRED**
Induces vomiting and thereby empties the stomach of ingested THERAPEUTIC EFFECTS:
Impaired LOC: Stupor; Coma RELATIVE
Ingestion of strong acids/alkalis or petroleum products Strychnine or iodides Children under one year Possibility of aspiration SIDE EFFECTS:

ONLY WITH DIRECT MEDICAL ORDER
SPECIAL NOTES /
Constantly monitor the patient's airway during and following Walking should be encouraged Initially Issued: 06/30/93 Revision Date: 09/08/94 Current Printing: 5.16.2008 Edgar G. DesChamps, III, M.D. State Medical Director METHYLENE BLUE
Treatment of cyanide poisoning and symptomatic methemoglobinemia (iatrogenic or accidental exposure to oxidizing ADMINISTRATION:

DIRECT MEDICAL ORDER REQUIRED
1 mg/kg IV SLOWLY (over 10-15 minutes) Same as adult dose, but must be used with extreme caution due to potential for producing methemoglobinemia. Reduces methemoglobin (ferric [Fe+3] iron in methemoglobin to THERAPEUTIC EFFECTS:
ferrous [Fe+2] iron in normal hemoglobin. Excessive methemoglobinemia in the treatment of cyanide or RELATIVE
sulfide poisoning due to possible release of cyanide or sulfide back into cellular sites with subsequent toxicity. Patients with renal insufficiency or known allergy to methylene blue Excessive methemoglobinemia, as characterized by progressive and persistent cyanosis unresponsive to oxygen therapy and the appearance of chocolate brown color of the blood. Use of oxidizing agents may produce an acute hemolytic SIDE EFFECTS:
reaction in patients with glucose-6-phosphodehydrogenase (G6PD) deficiency. Blue-green urine May cause bladder irritation, nausea, vomiting, and diarrhea. Large doses may produce abdominal and precordial pain, dizziness, profuse sweating, fever, and/or mental confusion. Rapid administration may produce increased methemoglobin SPECIAL NOTES /
formation, especially in the presence of other oxidizing agents. **DIRECT MEDICAL ORDER REQUIRED**
Initially Issued: 05/28/99 Revision Date: 05/28/99 Current Printing: 5.16.2008 Edgar G. DesChamps, III, M.D. State Medical Director PRALIDOXIME
2-Pam, Protopam Chloride (Special Purpose: Toxicology) Cholinergic crisis due to acetylcholinesterase inhibition caused by organophosphate toxicity (e.g. dichlorvos, dioxanthion, echothiophate iodide, endothion, fenthion, formothion, isoflurophate, malathion, methyl parathion, parathion, TEPP, diazinon). Poisoning by nerve agents having anticholinesterase activity. IV, IM (if IV access not feasible) 1 - 2 Gram, over 10-15 minutes in 100 cc NS. If not practicable or in the event of pulmonary edema, administer slowly as 5% solution in water over not less than 5 minutes.
20-40 mg/kg/dose over 10-15 minutes Reactivation of phosphorylated acetylcholinesterase. Reversal of nicotinic effects of acetylcholinesterase inhibition, THERAPEUTIC EFFECTS:
particularly on skeletal muscle. Reversal of muscarinic effects of cholinesterase inhibition, usually additive with atropine. Cholinergic crisis due to acetylcholinesterase inhibition by RELATIVE
carbamate insecticides or other short acting cholinesterase CONTRAINDICATIONS:

inhibitors (physostigmine, neostigmine, etc.). Occasional Sinus Tachycardia, laryngospasm, and muscle rigidity seen with too rapid injection. Occasional dizziness, SIDE EFFECTS:
headache, blurred vision, nausea, or diplopia (all of which may be related to the underlying poison as well). MAY ADMINISTER PER STANDING ORDER
SPECIAL NOTES /
RESTRICTIONS:

Initially Issued: 05/26/99 Revision Date: 05/26/99 Current Printing: 5.16.2008 Edgar G. DesChamps, III, M.D. State Medical Director VITAMIN B6

INDICATIONS:

Hydrazine poisoning.
ADMINISTRATION:

25 mg/kg over five (5) minutes 25 mg/kg over five (5) minutes Provides a required synthetic cofactor that enables the brain to THERAPEUTIC EFFECTS:
regenerate GABA and stop seizures
RELATIVE

CONTRAINDICATIONS:

None acutely; peripheral neuropathy with chronic, excessive dosing; SIDE EFFECTS:
Pyridoxine withdrawal seizures in neonates of mothers who took chronic, excessive doses of pyridoxine during pregnancy
SPECIAL NOTES /

Initially Issued: 08/2002 Revision Date: Current Printing: May 16, 2008 Edgar G. DesChamps, III, M.D. State Medical Director SODIUM NITRITE
(Special Purpose for Toxicology) Acute cyanide poisoning Acute sulfide poisoning ADMINISTRATION:

300mg (10 ml) over 3-5 minutes 4- 6 mg/kg to a maximum of 300mg (10ml) over 3-5 minutes Produces methemoglobin (oxidizes ferrous [Fe+2] iron in THERAPEUTIC EFFECTS:
normal hemoglobin to ferric [Fe+3] iron or methemoglobin. RELATIVE
CONTRAINDICATIONS:


1. Excessive methemoglobinemia, as characterized by
progressive and persistent cyanosis unresponsive to oxygen therapy and the appearance of chocolate brown SIDE EFFECTS:
color of the blood. 2. Use of oxidizing agents may produce an acute hemolytic reaction in patients with glucose-6-phosphodehydrogenase (G6PD) deficiency. Methylene blue, a reducing agent, may be used to reverse SPECIAL NOTES /
excessive methemoglobinemia. May Administer Per Standing Order
Initially Issued: 05/28/99 Revision Date: 05/28/99 Current Printing: 5.16.2008 Edgar G. DesChamps, III, M.D. State Medical Director SODIUM THIOSULFATE
(Special Purpose for Toxicology) Acute cyanide poisoning following administration of nitrates. INDICATIONS:

ADMINISTRATION:

12.5 grams (50 ml) over 1-2 minutes 250 mg/kg (1 ml/kg) to a maximum of 12.5 G over 3-5 Removes cyanide ion from ferrocyanate complex formed THERAPEUTIC EFFECTS:
with methemoglobin, producing thiocyanate; excreted by the RELATIVE
CONTRAINDICATIONS:

No significant side effects in setting of cyanide poisoning SIDE EFFECTS:
following administration of nitrates. May rarely be ordered without previous administration of SPECIAL NOTES /
nitrate if history is unclear. May Administer Per Standing Order
Initially Issued: 05/28/99 Revision Date: 05/28/99 Current Printing: 5.16.2008 Edgar G. DesChamps, III, M.D. State Medical Director IV INFUSION FLUIDS
٭COMBINATION DEXTROSE/SODIUM CHLORIDE
5% dextrose in 0.45% Sodium chloride (D51/2NS) Impaired Renal Function (TKO) Cardiovascular function (TKO) ADMINISTRATION:

Dependent upon patient condition and situation being treated ∇Used for Maintenance Only.
Dependent upon patient size and condition Provides electrolyte and sugar replacement THERAPEUTIC EFFECTS:

Need for Rapid fluid replacement indicated RELATIVE
CONTRAINDICATIONS:

SIDE EFFECTS:


CLASSIFICATION:
Slightly hypertonic sugar and electrolyte solution
Normal saline or lactated ringers is the preferred infusion
solution during cardiac arrest, although D5W remains acceptable

SPECIAL NOTES /
Any combination of Dextrose and Sodium Chloride is
approved. Some other combinations include:
- 5% Dextrose in 0.9% Sodium Chloride (D5NS) - 5% Dextrose in 0.2% Sodium Chloride (D5 0.2NS) - 3.3% Dextrose in 0.3% Sodium Chloride Initially Issued: 06/30/93 Revision Date: 11/03/96 Current Printing: 5.16.2008 Edgar G. DesChamps, III, M.D. State Medical Director DEXTROSE 5% IN WATER
IV access for emergency drugs (cardiac) For dilution of concentrated drugs for IV infusion Patients with actual or potential for volume overload Patients requiring sodium restriction ADMINISTRATION:

Generally administered to keep open (TKO) Generally administered to keep open (TKO) vein for ONLY WITH DIRECT MEDICAL ORDER
Glucose nutrient solution THERAPEUTIC EFFECTS:

As a main line for blood transfusion RELATIVE
For fluid replacement in hypovolemic states CONTRAINDICATIONS:

SIDE EFFECTS:


CLASSIFICATION:
Hypotonic Sugar Solution
Normal saline or lactated ringers is the preferred infusion
solution during cardiac arrest, although D5W remains
SPECIAL NOTES /
In Pediatric Patients:
ONLY WITH DIRECT MEDICAL ORDER

Initially Issued: 06/30/93 Revision Date: 03/97 Current Printing: 5.16.2008 Edgar G. DesChamps, III, M.D. State Medical Director LACTATED RINGERS
Hypovolemic shock ADMINISTRATION:



As indicated by the patient condition and situation being treated

As indicated by the patient condition and situation being treated
- Source of electrolytes THERAPEUTIC EFFECTS:
- Increase circulating volume - Congestive heart failure RELATIVE
CONTRAINDICATIONS:

SIDE EFFECTS:


CLASSIFICATION: Isotonic crystalloid

SPECIAL NOTES /
RESTRICTIONS:

Normal saline or lactated ringers is the preferred infusion
solution during cardiac arrest, although D5W remains
acceptable

Initially Issued: 06/30/93 Revision Date: 06/30/93 Current Printing: 5.16.2008 Edgar G. DesChamps, III, M.D. State Medical Director SODIUM CHLORIDE 0.9%
Heat exhaustion and related heat problems Diabetic disorders Freshwater Drowning Head injury (depending upon Medical Control Physician) Hypovolemia ADMINISTRATION:

Dependent upon patient condition and situation being treated Dependent upon patient size and condition Provides fluid and sodium replacement THERAPEUTIC EFFECTS:
Congestive Heart Failure RELATIVE
CONTRAINDICATIONS:

Volume Overload Congestive Heart Failure SIDE EFFECTS:

Normal saline or lactated ringers is the preferred infusion
solution during cardiac arrest, although D5W remains
acceptable

SPECIAL NOTES /
RESTRICTIONS:

Any combination of Dextrose and Sodium Chloride is
approved. Some other combinations include:
- 5% Dextrose in 0.9% Sodium Chloride (D5NS) - 5% Dextrose in 0.2% Sodium Chloride (D5 0.2NS) - 3.3% Dextrose in 0.3% Sodium Chloride Initially Issued: 06/30/93 Revision Date: 06/30/93 Current Printing: 5.16.2008 Edgar G. DesChamps, III, M.D. State Medical Director END OF FORMULARY
Attachment A

Attachment B
SCDHEC - EMS DIVISION
INTERFACILITY TRANSPORT FORM
PART A - DRUG REPORT
Patient Care Form #: Transferring Facility: Receiving Facility: ************************************************************************************
Instructions: Part A (Drug Report) and Part B (Device Report) must be completed by and signed by the
sending physician or nurse.
************************************************************************************
DIAGNOSIS: (1)
LAST VITAL SIGNS:
Rate/Concentration: Comments/Additional Rate/Concentration: Comments/Additional Rate/Concentration: Comments/Additional PLEASE CHECK THE INTERFACILITY DEVICES BEING USED IN THIS TRANSPORT ON
THE BACK PAGE OF THIS FORM.
This report was given by (physician/nurse signature):
(None of the drugs being sent with this patient are part of an experimental program.)
This report was accepted by (EMT-P signature):
EMS Service must retain a copy of this form for their records.
If any problems are experienced en route, the EMT-P must contact on-line medical control. Version # 1-06/00 SCDHEC - EMS DIVISION
INTERFACILITY TRANSPORT FORM
PART B - DEVICE REPORT
Patient Care Form #: Transferring Facility: Receiving Facility: ***************************************************************************************
Instructions: Part A (Drug Report) and Part B (Device Report) must be completed by and signed by the
sending physician or nurse.
************************************************************************************
INTERFACILITY INVASIVE/IMPLANTED DEVICES USED IN THIS TRANSPORT

Check all devices being used:
_
Automatic Internal Cardiac Defibrillator (AICD) Arterial Lines, Arterial Sheathes Tube Thoracostomy/Chest Tube Percutaneously Placed Central Venous Catheters (does not include Swan-Ganz catheters) Peritoneal Dialysis Catheters _ Urethral/Suprapubic Implantable Central Venous Catheters _ Nasogastric/Orogastric Surgically Placed Gastrointestinal Tubes Percutaneous Drainage Tubes Completely Implantable Venous Access Port Comments/Additional Version # 1-06/00
Attachment C

Attachment D

Attachment E

Attachment F

Attachment G

Attachment H

Attachment I
MEMORANDUM

TO:
Emergency Service Provider Directors Medical Control Physicians Alonzo W. Smith, Director Ed DesChamps, MD, State Medical Director EMS Division November 8, 2001 Revision of the state approved drug list
The state's Medical Control Committee will be reviewing requests for the addition of drugs to the list at
their February or March meeting. If there are drugs you wish to add to this list, you should complete the
attached form and give it to your regional EMS Medical Director no later than February 15 The form
MUST be typed and completely filled out. Remember: there is no longer a separate interfacility drug list,
so we will not be taking requests to add interfacility drugs. The interfacility drug form allows EMT-P's to
transport any drug requested by the sending physician.

The regional EMS medical directors are:
Region 1: Upstate
Carol Burger, MD William C. Gerard, MD Region 3: Pee Dee Richard Rogers, MD John F. Sorrell, MD 4009 Southborough Rd. 951 Scottland Dr. Florence, SC 29501 Mt. Pleasant, SC 29464
Review of this list occurs only on an annual basis.
enclosure
DRUG APPROVAL PROCESS

1. The approval process is initiated by a service request or directly from the Medical Control Committee; 2. New Drugs must be approved by the Medical Control Committee; 3. After approval from the Medical Control Committee, they must then go to, and be approved by, the EMS Advisory Council; 4. After approval from the EMS Advisory Council the drugs must go to, and be approved by, the DHEC Board of Commissioners; 5. After approval by the DHEC Board an official letter shall to be sent to EMS providers from the Division of EMS and Trauma; 6. ONLY following the date on the official letter from the DIVISION are the drugs approved for use in EMS services and only then based on the attached formulary pages that will accompany the letter; 7. DHEC Board approval alone DOES NOT constitute approval for stocking or using the drugs by EMS providers. That must wait until after receipt of the official letter. 8. Failure to adhere to this policy may result in penalties to the service (for stocking the drug) and to the medic (if the drug is used).
Attachment J

ATTACHMENT J
ATTACHMENT J
ATTACHMENT J
Attachment K
ATTACHMENT K
Attachment L
WHO SHOULD I TALK TO AT THE SC STATE EMS OFFICE?
(803) 545-4204
Administrative Support. L. Woods Ambulance Licensure: Manager: Compliance. T. Horton Inspection Schedule. T. Horton EMS Inspectors/Investigators.D. Spigner Ambulance Run Reports .T. Hooks Budgets .A. Smith/S. Wright Certification . J. Paddock/C. Smith Communication. A. Smith Compliance Monitoring Enforcement . A. Smith Computer Resources . V. Grimes Contract Management. S. Wright Director, Division of EMS. Al Smith Disaster Emergency Preparedness . J. Catoe DNR.J. Paddock EMS Advisory Council & Subcommittees . L. Woods EMS Clearinghouse . L. Woods EMS FAX NUMBER .(803) 545-4989 EMS Library . D. Whiteley EMS Arm Patches. L. Woods EMS State Plan .G. Kitchens EMT Examinations State Certification Examination. D. Whiteley State Examination Schedule . Y. Martin National Registry Examination SC State Representative .D. Whiteley/T. Horton EMT First Responder Agencies. T. Horton EMT Records.C. Smith EMT Training Programs: Deputy Director: Training and Compliance . J.Catoe Manager: Training and Certification . D. Whiteley EMT-Basic . J. Catoe EMT-Intermediate . D. Whiteley/J. Catoe EMT-Paramedic. D. Whiteley In Service Program . D. Whiteley Pilot Programs .J. Catoe/G. Kitchens Specialty Programs . J. Catoe EMS for Children .J. Paddock Grant-In-Aid . S. Wright Compliance. T. Horton Training Programs . D. Whiteley Issue Development/Technical Assistance/Pilot Projects. A. Smith Location of Staff . L. Woods Medical Control Committee .J. Catoe/G. Kitchens Medical Control Physicians . T. Horton Prevention Injury (Seat Belt, Alcohol, Fire, Drowning) .J. Paddock Protocols .J. Catoe/G. Kitchens Program Development & Evaluation.A. Smith/V. Grimes Quality Assurance. A. Smith Recertification.D. Whiteley/J. Paddock/C. Smith Reciprocity. D. Whiteley/J. Paddock Trauma System/Centers/Committee .G. Kitchens Trauma Registry/Data. V. Grimes Attachment M
MEDICAL CONTROL COMMITTEE
Edgar G. DesChamps, M. D., Chairman Raymond Bynoe, M.D., FACS
Member Since: 1985

Member Since: 2003
STATE MEDICAL DIRECTOR
ACS - COMMITTEE ON TRAUMA
Apt 924, Vista Commons Two Richland Medical Park, Suite 402 1100 Pulaski St. Columbia, SC 20203 Columbia, SC 29201 Phone: (803) 254-3501(ofc) Phone: (803) 256-2657 (ofc) beeper: (800) 502-8002 email: bynoe@medpark.sc.edu e-mail: Edeschamps@ftc-i.net E. Douglas Norcross, M. D.
Carol T. Burger, M. D.
Member Since: 1989
Member Since 1990
DIRECTOR OF TRAUMA SERVICES - MUSC
UPSTATE REGIONAL MEDICAL DIRECTOR
171 Ashley Avenue 101 Willow Point Way Charleston, SC 29425 Easley, SC 29642 Phone: (843) 792-9737 (ofc) Phone: (864) 455-7157 (ofc) (864) 455-5474 - (864) 220-1924 email: Norcroed@MUSC.edu email: andkris@worldnet.att.net John F. Sorrell, M. D.
William C. Gerard, MD, FACEP
Member Since: 1989
Member Since: 2001
LOWCOUNTRY REGIONAL MEDICAL DIRECTOR
MIDLANDS REGIONAL MEDICAL DIRECTOR
951 Scottland Drive Mt. Pleasant, SC 29464 Chapin, SC 29036 Phone: (843) 881-0100 (ofc) Phone: (803) 434-7088 (ofc) (843) 881-6349 - (843) 881-4357 email: jsorrellmd@aol.com email: Wcgresq911@mindspring.com James Mock, M. D.
Ron Fuerst, M. D.
Member Since: 2001
Member Since: 1997
SC MEDICAL ASSOCIATION
USC SCHOOL OF MED - DEPT. OF PEDIATRICS
112 Turtle Cove Ct. North Myrtle Beach, SC 29582 Lexington, SC 29072 Phone: (843) 692-1759(ofc) Phone: (803) 359-0323 (ofc) or 954-3867 Phone: (843) 457-4747(ofc) email: fuerstr@pol.com email: catgutjim@aol.com Richard Rogers, M. D.
Mac Nowell, M.D.
Member Since: 1996
Member Since: 2002
PEE DEE REGIONAL MEDICAL DIRECTOR
SCCEP - EMS COMMITTEE
4009 Southborough Rd. 346 Whiteford Way Florence, SC 29501-8814 Phone: (843) 777-2027 (ofc) Phone: (803) 951-2151 (home) Home: (843) 464-8844 email: macnowell@hotmail.com
Attachment M2
Attachment N
SC EMS Training Committee Members Updated on November 29, 2001 Paul Lucas
Robert Johnson
Debbie Hession
Lowcountry Regional EMS Council Kershaw County EMS Upstate EMS Council, Inc. 6435-A Fain Street Suite A Haile & Roberts Street 121 Interstate Drive Suite 5 B North Charleston, SC 29406 Camden, SC 29020 Greenville, SC 29615 Regional Director
SC Assoc. Of Rescue Squads
Regional Director
Phone: 843-569-2220
Phone: 803-432-4311 ex: 169 Phone: 864-289-0112
Email: paul@lowcountryems.com
Email: kcmcems@yahoo.com
Email: uemsc@cris.com
Fax: 843-569-2226
Fax: 864-289-0114
Chris Cothran
Lanny Bernard
Mike Fisher
Midlands EMS Management Assoc. Lancaster County EMS Greenville Technical College 3201 Leaphart Road West Columbia, SC 29169 Lancaster, SC 29721 Greenville, SC 29606 Regional Director
Phone: 803-283-4134
State Board of Tech. & Comp. Edu.
Phone: 803-794-3940
Email: lcems@infoave.net
Phone: 864-250-8490
Email: scmidlans@aol.com
Fax: 803-283-2092
Email: fishermaf@gvltec.edu
Fax: 803-794-3941
Pager #: 803-872-3601
Don Lundy
Charles Stewart
3870 Leeds Avenue Pee Dee Regional EMS 1314 West Darlington Street Charleston, SC 29405 Florence, SC 29501 EMS Association
Regional Director
Phone: 843-740-3253
Phone: 843-662-5771
Email: pdrems@bellsouth.net
Fax: 843-662-9444
Fax: 803-740-3255
John Dobson
Teddy Griffith
Myrtle Beach Fire Dept. Myrtle Beach, SC 29578 Conway, SC 29527 Phone: 843-918-2245
EMS Educators Association
Fax: 843-918-2244
Phone: 843-545-7911

Attachment O

POSITION STATEMENT ON THE USE AND IMPLEMENTATION OF GUIDELINES
EMS systems frequently encounter new guidelines and standards established by a variety of organizations,
including professional societies (such as NAEMSP), clinical specialty societies (such as AHA, the American
Heart Association), government agencies (such as OSHA, the Occupational Safety and Health Administration),
industry associations (such as NFPA, the National Fire Protection Association), and other nonprofit groups
(such as ASTM, the American Society for Testing and Materials). In some cases, particularly those involving
government agencies, true standards are being set forth, with regulatory backing and mandatory compliance.
Frequently, however, voluntary guidelines are being set forth as the best opinion of the promulgating agency,
group, or society. In the vast majority of cases, these guidelines are developed through a rigorous process
involving a detailed review of available information on the topic, and often involving a consensus process
between members of many organizations with interest in the topic.
While such guidelines may be accompanied by advice regarding implementation, this is not always the case.
EMS systems face myriad standards and guidelines that potentially affect the patient care practices of the
system. The systems frequently turn to medical oversight, regional or state EMS offices, or other sources of
leadership for assistance in evaluating these standards and guidelines for possible implementation.
DEFINITION: For the purpose of this position statement, only "voluntary guidelines" will be considered.
This position statement is not meant to address regulatory standards and other guidelines that are mandated by
legal authority, through statute or formal regulation.
POSITION: The Medical Control Committee believes that:
1. The approach that a given EMS agency, system, region, or state office takes in implementing voluntary
guidelines must be driven by both local needs and local resources. It must be recognized that logistical,
financial, and public health needs, and regulatory realities may influence how, when, or even whether a given
EMS agency, system, or region considers or adopts new guidelines. Incorporation of new guidelines into any
existing EMS system must be considered in the context of the public's health as a whole, rather than a single
illness or injury.
A. Logistical/Operational: Given the tremendous variability in EMS system size, design,
capabilities, and resources, it is obvious that EMS systems must have different approaches to
evaluating and implementing new guidelines. The manner in which any given system goes about
evaluating and implementing guidelines will necessarily be affected by these factors as well as
local EMS and public health needs. Additionally, the effect of incorporating new guidelines into
pre-existing, day-to-day operations must be considered. From an operational standpoint, systems
should not sacrifice baseline performance to institute new guidelines, unless the new guidelines
have a higher public health priority.
B. Financial: It must be recognized that implementation and adherence to a new set of
guidelines may have significant associated costs, such as training of personnel, purchase and
maintenance of new equipment, and medical oversight expenses. The costs of attaining
compliance with such guidelines must be recognized: resources expended on compliance with
one set of guidelines will not be available for compliance with other guidelines, or for routine
functions. From a financial standpoint, as well as an operational standpoint as outlined in A,
above, it is rarely reasonable to sacrifice baseline capabilities in favor of compliance with new
guidelines.
While in optimal circumstances new guidelines could be viewed as tools which EMS systems could use as leverage for additional resources, this is not always possible. In particular, EMS systems that rely principally on billing for services rendered (as opposed to local tax revenue support or other subsidization) will likely not be able to utilize this strategy. Similarly, many EMS services with public funding or subsidies are constrained by statutory or contractual limitations on the amount funds available. Accordingly, it may be necessary to evaluate guidelines in terms of the opportunity costs of compliance, cost-benefit (comparing economic costs with economic benefits), and cost-effectiveness (evaluating cost per degree of effect, either marginal or incremental). C. Regulatory: Each EMS agency and its medical director must be aware of the degree of
latitude granted by state legislation and regulations in modifying patient care activities and
crafting protocols, policies, and other documents that involve areas for which guidelines have
been promulgated. (For example: Those working in states where strict adherence to state-wide
standards is required may have to consider new guidelines in a different way than those working
in states that allow local variation. The former will need to work with or through the appropriate
state-level authorities and agencies, while the latter will need to take on the responsibility
locally.)

2. When considering the implementation of guidelines, EMS systems should consider both the strength of the
science supporting the guidelines as well as its applicability to the local EMS and public health environment.
A. Strength of science: EMS systems evaluating a set of guidelines must consider the
strength of the science supporting the guidelines to determine if the evidence is significant
enough to warrant EMS system implementation, especially when its implementation may
compromise other infrastructure needs of the EMS system.
applicability: Guidelines should also be considered in the context of a local EMS
system's characteristics, operations, and environment. A given set of guidelines may not be applicable to all given EMS systems. For instance, some guidelines while appropriate for urban EMS systems may not be appropriate for EMS systems operating in rural or remote areas. Additionally, guidelines based on scientific studies of effectiveness in one community may not be applicable to all communities because of differences in the characteristics of the community and/or EMS/public safety systems.
3. Summary: EMS systems must provide the highest quality of service and patient care based on current
resources and public health needs. Voluntary guidelines should be used to supplement and enhance the overall
local system structure and function, and should be implemented in a systematic process encompassing all facets
of an EMS system. Voluntary guidelines should not be considered required standards of care.
Attachment P

POSITION STATEMENT ON THE USE AND IMPLEMENTATION
OF AMIODARONE and VASOPRESSIN
IN ACLS PROTOCOLS

The following summarizes the Position of the Medical Control Committee on the utilization of AMIODARONE and
VASOPRESSIN in the Advanced Cardiac Life Support Protocols authored by the American Heart Association
(Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care – International
Consensus on Science
. American Heart Association, Supplement to Circulation – Volume 102, Number 8 –
August 22, 2000.). This position is in concert with national organizations – e.g. the American College of Emergency
Physicians – and is excerpted in large part from the Position Statement developed by the American Academy of
Emergency Medicine to address this issue.
THE USE OF AMIODARONE AND/OR VASOPRESSIN:
It is the position of the Medical Control Committee that the use of Vasopressin and/or Amiodarone in
refractory pulseless ventricular tachycardia or ventricular fibrillation (VT/VF) should NOT be
considered the current "Standard of Care" for this condition.
It is the position of the Medical Control Committee that while these agents MAY be appropriate for
treatment of the conditions described; the strength of the science at this point is NOT CONCLUSIVE
enough to consider their use mandatory or that their use represents a "Standard of Care".
Until ongoing or future research clarifies this issue, the Medical Control Committee has approved these agents for use in the Pre-Hospital setting. The Local Medical Control Physician should use his/her discretion and expertise in developing protocols for antiarrhythmic therapy in patients with cardiac arrest for their Local EMS Services IMPLANTED / INVASIVE DEVICE LIST
Invasive / Implanted Device List

The purpose of this manual is to denote medical devices not specifically covered in EMS
training which may be transported by EMS personnel and are in place at the time of arrival of
the EMTs.
Any invasive or implanted device not described within this manual should NOT be
transported by EMS personnel without an accompanying nurse or physician capable of
caring for the device.
Additions to this manual will be considered yearly after requests for
inclusion of a new device are received by DHEC's EMS Division. A request must be signed by
the requesting service's medical director and regional medical director. The appropriate
request form accompanies this manual.
This list should be treated in a manner similar to the state-approved drug list. EMS services
and their medical control physicians may choose not to transport patients - interhospital - with
any of the included devices. However, given the likelihood that an EMT may be called upon to
transport a patient with one of these devices in an emergency situation, all services MUST
provide inservice training on these devices to their personnel.
AUTOMATIC INTERNAL CARDIAC DEFIBRILLATOR

Various names
TRADE NAMES:
Device implanted under skin which detects dangerous ventricular arrhythmias and automatically delivers a countershock directly to the heart to defibrillate the heart if such an arrhythmia develops. TRAINING LEVEL:
ALL Levels
Approved for transport only. May not be manipulated by EMS personnel. SPECIAL NOTES /
Presence of device has only a minimal potential IMPORTANT
for minor shock to EMTs and no effect on cardiac resuscitation protocols. Initially Issued: 11/95 Revision Date: November 1996 Current Printing: May 16, 2008 Edgar G. DesChamps, III, M.D. State Medical Director INVASIVE / IMPLANTED DEVICE
ARTERIAL LINES, ARTERIAL SHEATHS
TRADE NAMES:

Catheter placed into an artery for monitoring of blood
pressure, for easy sampling of blood or for
radiographic or invasive procedures. TRAINING LEVEL:
PARAMEDICS
Approved for transport only. May not be inserted or manipulated by EMS CAN NOT BE USED FOR MEDICATION
INFUSION!
May not be used to monitor blood pressure unless set up to do so at referring facility. Generally requires ongoing infusion of heparinized saline solutions under pressure at low rates to maintain patency and to prevent backup of blood into tubing. This must be prepared and set up at referring institution. If dislodged - Apply pressure to site for a minimum of 15 minutes, and contact medical SPECIAL NOTES /
IMPORTANT
Monitor site routinely for signs of hematoma or Initially Issued:11/95 Revision Date: November 1996 Current Printing: May 16, 2008 Edgar G. DesChamps, III, M.D. State Medical Director INVASIVE / IMPLANTED DEVICE
TUBE THORACOSTOMY / CHEST TUBE
TRADE NAMES:
Placed into pleural cavity to drain fluid, evacuate blood or remove air for treatment of pneumothorax. Tube usually attached to a device which establishes and maintains a vacuum in the pleural space, or a one- way valve (e.g. Heimlich valve). TRAINING LEVEL:
ALL Levels
Approved for transport only. Can not be manipulated or inserted by EMS May place attached vacuum control device to suction if instructed to do so by referring physician or medical control. Keep suction device upright at all times. If tube is accidentally dislodged, cover wound with SPECIAL NOTES /
occlusive dressing taped on three sides, monitor for IMPORTANT
development of pneumothorax and contact medical Initially Issued: 11/95 Revision Date: November 1996 Current Printing: May 16, 2008 Edgar G. DesChamps, III, M.D. State Medical Director INVASIVE / IMPLANTED DEVICE
PERCUTANEOUSLY PLACED CENTRAL VENOUS CATHETERS
(Not to include Swan-Ganz catheters) CVP Line, Triple Lumen Catheter, Subclavian Line, TRADE NAMES:
Internal Jugular Line, Femoral Line

Large IV placed into one of several large central veins.
Used for infusion of fluids or withdrawal of blood. Also used to monitor pressures inside right side of heart. TRAINING LEVEL:
ALL Levels
Δ
PARAMEDICS (only) may administer medications
through previously placed percutaneous central
venous lines when no other option is available,
under direct on-line medical control or standing
protocols.
Intermediates and Basic EMTs may transport
IV fluids in place only (no medications). If line becomes dislodged, apply pressure to control bleeding and contact medical control. Prevent air embolus. (PARAMEDICS ONLY) If used for
monitoring, may require infusion of heparin solution under pressure. 4) For medication administration: prevent air embolus; maintain stringent sterile technique; flush bolus medication with double the usual amount of fluid IMPORTANT POINTS: (compared to peripheral flush). Initially Issued: 11/95 Revision Date: November 1996 Current Printing: May 16, 2008 Edgar G. DesChamps, III, M.D. State Medical Director INVASIVE / IMPLANTED DEVICE
PERITONEAL DIALYSIS CATHETERS
TRADE NAMES:
Tenckhoff Catheter Fluid infused into abdomen through catheter. Peritoneal lining acts as a dialysis filter. TRAINING LEVEL:
ALL Levels
Approved for transport only. If catheter actively in use at time of transport a physician, nurse or individual actively involved in patient dialysis regimen must accompany patient in ambulance. (Awake, alert patient may fill this role.) SPECIAL NOTES /
If catheter accidentally dislodges, apply sterile IMPORTANT
pressure dressing and contact medical control. Edgar G. DesChamps, III, M.D. State Medical Director Initially Issued: 11/95 Revision Date: November 1996 Current Printing: May 16, 2008 INVASIVE / IMPLANTED DEVICE
EPIDURAL CATHETERS
TRADE NAMES:
Catheter placed in epidural space around spinal cord for administration of analgesic medications. TRAINING LEVEL:
ALL Levels
Approved for transport only. May NOT be used for administration of any medication during transport. May NOT be manipulated by EMS personnel. SPECIAL NOTES /
If catheter accidentally dislodges, apply sterile IMPORTANT
pressure dressing and contact medical control. Edgar G. DesChamps, III, M.D. State Medical Director Initially Issued: 11/95 Revision Date: November 1996 Current Printing: May 16, 2008 INVASIVE / IMPLANTED DEVICE
URETHRAL/SUPRAPUBIC CATHETER
TRADE NAMES:
Foley Catheter, others Placed into bladder to drain urine and monitor urine TRAINING LEVEL:
ALL Levels
Approved for transport only. Can not be manipulated or inserted by EMS personnel. SPECIAL NOTES /
If accidentally dislodged, contact medical control. IMPORTANT
Edgar G. DesChamps, III, M.D. State Medical Director Initially Issued: 11/95 Revision Date: November 1996 Current Printing: May 16, 2008 INVASIVE / IMPLANTED DEVICE
IMPLANTABLE CENTRAL VENOUS CATHETERS
TRADE NAMES:
Hickman Catheter, Broviac Catheter Surgically implanted venous access device for patients requiring long term venous access for medications or dialysis. May have more than one lumen. TRAINING LEVEL:
ALL Levels
PARAMEDICS (only) may administer medications
through previously placed percutaneous central venous line when no other option is available, under direct on-line medical control or standing Intermediates and Basic EMTs may transport
IV fluids in place only (no medications). Maintenance of sterility of significant importance. Maintain dressing and, if new
SPECIAL NOTES /
medications being initiated through line, sterile IMPORTANT
technique must be maintained when accessing Initially Issued: 11/95 Revision Date: November 1996 Current Printing: May 16, 2008 Edgar G. DesChamps, III, M.D. State Medical Director INVASIVE / IMPLANTED DEVICE
NASOGASTRIC / OROGASTRIC TUBES
TRADE NAMES:
Salem Sump, Dobhoff, others To evacuate stomach contents. Usually placed through nose but can be placed through mouth. Also used to feed patients into stomach or proximal small TRAINING LEVEL:
ALL Levels
transportation only by basic and
intermediate EMTs.
Paramedics may transport and may manipulate/replace. May be connected to suction if instructed to do so by referring institution. If dislodged, contact medical control, watch for vomiting and/or aspiration and have suction available SPECIAL NOTES /
to clear oropharynx if needed. IMPORTANT
If being used for feedings, discontinue feeds prior to transport and flush tube with saline. Edgar G. DesChamps, III, M.D. State Medical Director Initially Issued: 11/95 Revision Date: November 1996 Current Printing: May 16, 2008 INVASIVE / IMPLANTED DEVICE
SURGICALLY PLACED
GASTROINTESTINAL
Gastrostomy Tube, Jejunostomy Tube, Baker Tube, TRADE NAMES:
Peg Tube, others Tubes placed into GI tract directly through the skin. Used for drainage or feeding. TRAINING LEVEL:
ALL Levels
SPECIAL NOTES /
If accidentally dislodged, place dressing over site and IMPORTANT
contact medical control. If used for feedings, can be a continuous feed. Edgar G. DesChamps, III, M.D. State Medical Director Initially Issued: 11/95 Revision Date: November 1996 Current Printing: May 16, 2008 INVASIVE / IMPLANTED DEVICE
PERCUTANEOUS DRAINAGE TUBES
TRADE NAMES:
Percutaneous Nephrostomy, Pigtail catheter, others Used to drain fluid or pus from interior of body. TRAINING LEVEL:
ALL Levels
Approved for transport only. Can not be manipulated or inserted by EMS personnel. SPECIAL NOTES /
If accidentally dislodged, place dressing over site and IMPORTANT
contact medical control. Edgar G. DesChamps, III, M.D. State Medical Director Initially Issued: 11/95 Revision Date: November 1996 Current Printing: May 16, 2008 INVASIVE / IMPLANTED DEVICE
COMPLETELY IMPLANTABLE
VENOUS ACCESS PORT
TRADE NAMES:
Porta-cath, others Used for infusion of fluids or long-term medication (antibiotic, chemotherapy, etc.) therapy. TRAINING LEVEL:
ALL Levels
Δ MAY NOT BE ACCESSED BY EMS
PERSONNEL.
May continue infusions initiated prior to PARAMEDICS
may administer medications through previously placed lines when no other option is available under direct on-line medical control or standing protocol and when device is already accessed prior to transport. Requires special needle to access. Any other needle will destroy device. SPECIAL NOTES /
If needle in accessing port should IMPORTANT
become dislodged, discontinue infusions and contact medical control. Edgar G. DesChamps, III, M.D. Initially Issued: 11/95 Revision Date: November 1996 State Medical Director Current Printing: May 16, 2008 INVASIVE / IMPLANTED DEVICE
SURGICAL DRAINS
TRADE NAMES:
Sump drain, Jackson Pratt drain, Penrose drain, others Placed to evacuate fluid or debris from surgical fields. Some are placed to continuous suction. Others have attached devices to apply suction and collect fluid. TRAINING LEVEL:

Approved for transport only. Can not be manipulated

RESTRICTIONS:

or inserted by EMS personnel. SPECIAL NOTES /
If drain becomes dislodged, place dressing over wound IMPORTANT
and contact medical control. Edgar G. DesChamps, III, M.D. State Medical Director Initially Issued: 11/95 Revision Date: November 1996 Current Printing: May 16, 2008 INVASIVE / IMPLANTED DEVICE
END OF DEVICE LIST

Source: http://www.bcgov.net/departments/public-safety/emergency-medical-services/documents/2008emsformulary.pdf

Ag-323

A Production Guidefor North Carolina North Carolina Cooperative Extension ServiceNorth Carolina State University North Carolina State University Description and Stages of Growth . 3 General Culture . 4 Site Selection . 4 Shade Requirements . 5 Site Preparation . 5 Transplanting Roots . 7 Shade Management . 8 Fertilization . 8 Pest Management. 8 Seed Production, Harvesting, and Handling. 9

rph.wa.gov.au

Malaria resources Division of Laboratory Medicine Royal Perth Hospital Contents History Malaria is a protozoal disease transmitted by the Anopheles mosquito, caused by minute parasitic protozoa of the genus Plasmodium, which infect human and insect hosts alternatively. It is a very old disease and prehistoric man is thought to have suffered from malaria. It probably originated in Africa and accompanied human migration to the Mediterranean shores, India and South East Asia. In the past it used to be common in the marshy areas around Rome and the name is derived from the Italian, (mal-aria) or "bad air"; it was also known as Roman fever. Today some 500 hundred million people in Africa, India, South East Asia and South America are exposed to endemic malaria and it is estimated to cause two and a half million deaths annually, one million of which are children. Fishermen and traders, long before British colonisation, probably introduced the disease into northern Australia and in the past malaria was not uncommon in the northern parts of the country. In Western Australia an explosive outbreak of falciparum malaria occurred at Fitzroy Crossing in 1934 which at first was mistaken for influenza and resulted in 165 deaths. WHO declared Australia free of malaria in 1981, however since that time 9 patients have contracted locally acquired malaria. The so called "airport malaria" has become a problem in recent years. A publican working in an establishment close to London's Heathrow Airport became acutely ill and was found to be suffering from falciparum malaria; he had never been out of the country. A lady driving her car past the same airport became ill with malaria although she too had never been out of the country. Four workers unloading a cargo plane at Amsterdam airport became infected with malaria. It is assumed that infected mosquitoes were carried on planes from Africa and released at the destination airport.