CONTRA COSTA HEALTH SERVICES October 1, 2005December 1, 2006 EMERGENCY MEDICAL SERVICES

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2 First Responder Paramedic Equipment List 1. Vehicles CONTRA COSTA HEALTH SERVICES October 1, 2005December 1, 2006 EMERGENCY MEDICAL SERVICES a) Vehicles shall be equipped with appropriate mobile and/or portable radios for communications with: 1) provider agency dispatch center 2) Contra Costa County Sheriff s dispatch center 3) Base hospitals on the County-designated radio system b) Vehicles shall be maintained, clean and in sound mechanical and body condition at all times. 2. General Emergency Care Equipment and Supplies Paramedic First Responder units shall meet requirements for emergency care equipment and supplies specified by Contra Costa EMS. All equipment and supplies carried for use in providing emergency medical care shall be maintained in clean condition and good working order and shall include, but not be limited to: ITEMS Oropharyngeal airways: 00, 0, 1, 2, 3, 4, 5, 6 Nasopharyngeal airways: 28, 30, 32, 34 Oxygen mask adult/pediatric (non-rebreather) Oxygen mask infant/pediatric Nasal cannula pediatric/adult Portable O 2 tank with regulator (sufficient to provide patient with not less than 10 lpm for 20 minutes) Resuscitation Bag-Valve, with clear mask capable of use with O 2 : Infant, Pediatric, Adult Minimum Inservice Requirement 2/adult 2/ped Portable Suction mechanical/hand powered 1 Pharyngeal tonsil tip (rigid) for suctioning 2 Suction catheters: 8FR, 10FR, 18FR 1 Band-Aids 12 4 Sterile bandage compresses or equivalent 12 3x3 or 4x4 sterile gauze pads 4 2 or 3 rolled bandages 6

3 40 triangular bandages 4 10x30 or larger universal dressing 2 1, 2 or 3 adhesive tape 2 rolls Bandage shears 1 Vaseline gauze 2 Arm splints with soft or cushioned surface or equivalent padded board, wrap around, wire ladder, inflatable or cardboard Leg splints with soft or cushioned surface or equivalent padded board, wrap around, wire ladder, inflatable or cardboard Traction splints with lower extremity limb support slings, padded ankle hitch traction strap and heel rest or equivalent (reel, sager or equivalent): Adult, Pediatric (required on designated apparatus) Spineboard long with 4 straps (or equivalent) 1 Head immobilzer disposable or impervious to bodily fluids sand bags are not acceptable Cervical collars Hard: sizes to fit all patients over one (1) year of age Optional: adjustable cervical collar (hard only sizes to fit all patients over one (1) year of age) Blood pressure cuffs with manometers (portable): Adult, Large arm (obese), Pediatric, Infant Stethoscope: Adult/Pediatric combination 1 Burn sheets (sterile) may be disposable or linen (with date of sterilization and expiration indicated) Irrigation tubing 1 Saline for irrigation, sterile: set 2000cc Cold packs 2 Obstetrical Kit (sterile, to include minimum of umbilical cord tape or clamps (2), 1 scissors or scalpel, 1 aspirating bulb syringe, 1 pair gloves, 2 drapes, dressings & towels, clean plastic bag Newborn stocking cap 1 Emergency thermal blanket (reflective foil) or equivalent 2 Triage tags 20 Current Contra Costa EMS Field Treatment Guidelines and policies 1 Battery operated flashlight 1 Glucose paste 2 Lifepak500 (required on designated apparatus) 1 1

4 First Responder Paramedic Equipment and Supplies: In addition to the BLS supply/equipment requirements, advanced life support units shall include, but not be limited to, the following: Minimum ITEMS Inservice Requirement Cellular telephone 1 Monitor/defibrillator (portable) must have strip chart recorder and 1 synchronized cardioversion capabilities Extra charged batteries for monitor/defibrillator 1 Defibrillator paddles/patches: Adult, Pediatric 1 set each Laryngoscope handle 1 Laryngoscope blades: #0, 1, 2, 3, 4 Miller Laryngoscope blades: #2, 3, 4 Macintosh Endotracheal tubes: 6.0, 7.0, 8.0, 9.0 cuffed Endotracheal tubes: 2.5, 3.0, 3.5, 4.0 uncuffed Endotracheal tubes: 4.5, 5.0, 5.5, 6.0 uncuffed 4 each Water soluble lubricant individual packets 3 Magill forceps: Adult, Pediatric Batteries (extra) for laryngoscope 1 set Bulbs (extra) for laryngoscope 1 ETT securing device: Adult, Pediatric Stylet: Adult, Pediatric Pen light 1 End-Tidal CO 2 (ETCO 2 ) detector 2 ETT placement assessment device (bulb) 1 Meconium aspirator 2 Esophageal Tracheal Double Lumen Airway (ETDLA) 1 Hand-held nebulizer for inhalation 2 ETT Nebulizer Adapater 1 Nebulizer mask 2 Pleural Decompression/Needle Thoracostomy kit: (or equivalent) Angiocatheter 12-14ga Syringe 30cc One-way valve Rubber connecting tube Betadine swabs (4) Alcohol swabs (4) Vaseline gauze (2) 2 sets

5 Sterile gauze pads (2) Tape Needle cricothyrotomy kit (or equivalent): Angiocatheter ga Syringe 30cc Scalpel with #11 blade Betadine swabs (4) Alcohol swabs (4) Vaseline gauze (2) Sterile gauze pads (2) Tape Oxygen tubing Y connector IV extension tubing Intraosseous IV kit (or equivalent): Sterile gloves (2 pair) Intraosseous needle (2) Betadine swabs (3) Syringe 3cc Syringes: 1cc, 30cc 2 Syringes: 3cc, 5cc, 10/12cc Needles: 18ga 1, 20ga 1, 22ga 1, 25ga (or equivalent) Medication-added labels 2 IV catheters: 14ga, 16ga, 18ga, 20ga, 22ga, 24ga Alcohol swabs 5 Tourniquet 2 Razor 1 Armboard: child, adult Normal Saline solution 1000cc bag 2 Normal Saline solution 250ml or 500ml bag for pediatric patients 2 Saline lock with extension tubing 2 IV tubing: mini drip (60gtt), macro drip (10/15gtt), extension tubing (or equivalent) Secured drug box 1 Braslow tape (or length-based equivalent) 1 Glucometer (with lancets and test strips) 1 Activated Charcoal (25gm) 2 Adenosine (6mg) 5 Albuterol (2.5mg/3ml unit dose ampule) 4 1 set 2 sets 4 each

6 Atropine (1mg preload) 4 Aspirin (81mg tablets) 1 bottle Diphenhydramine (Benadryl) (50mg/1cc) 2 Calcium Chloride (1 gm) 1 Dextrose 25% 2 Dextrose 50% (25gm/50cc) 2 Dopamine (400mg/250cc premixed bag) (or equivalent) 1 Epinephrine 1:10,000 (1mg/10cc) 4 Epinephrine 1:1,000 (1mg/1cc) 2 Glucagon (1mg/1cc) 1 Furosemide (Lasix) 100mg Lidocaine 2% 300 mg Midazolam (Versed) (5mg/ml ampule/vial) mg Morphine Sulfate (10mg/1cc ampule/vial) 2 Naloxone (Narcan) 6 mg Nitroglycerin (0.4 mg/tab or multidose spray) 1 bottle Sodium Bicarbonate (50mEq/50cc) 1

7 CONTRA COSTA HEALTH SERVICES March 1, 2006December 1, 2006 EMERGENCY MEDICAL SERVICES AMBULANCE EQUIPMENT AND SUPPLY REQUIREMENTS 1. Vehicles a. Ambulance vehicles shall meet standards specified in Title 13, California Code of Regulations, and each shall possess a valid emergency vehicle permit issued by the California Highway Patrol. b. Vehicles shall be maintained, clean and in sound mechanical and body condition at all times. c. All ambulances shall have adequate space in the patient care compartment to accommodate at least one stretcher patient and two providers. There shall be sufficient space to allow for patient care activities during transport. d. Vehicles shall be equipped with appropriate mobile and/or portable radios for communications with: 1) provider agency dispatch center 2) Contra Costa County Sheriff s dispatch center 3) Base hospitals on the County-designated radio system 2. General Emergency Care Equipment and Supplies Ambulances shall meet the State requirements for emergency care equipment and supplies. All equipment and supplies carried for use in providing emergency medical care shall be maintained in clean condition and good working order and shall include, but not be limited to: ITEMS Minimum Inservice Requirement Oropharyngeal airways: 00, 0, 1, 2, 3, 4, 5, 6 Nasopharyngeal airways: 28, 30, 32, 34 Padded bite sticks (commercial or homemade) 2 Oxygen mask adult/pediatric (non-rebreather) Oxygen mask infant/pediatric Nasal cannula pediatric/adult 2/adult 2/ped O 2 tank fixed in vehicle with regulator (M-tank or equivalent) 1 Portable O 2 tank with regulator (sufficient to provide patient with not less than 10 lpm for 20 minutes) Resuscitation Bag-Valve, with clear mask, capable of use with O 2 : Infant, Pediatric, Adult Portable Suction mechanical/hand powered 1 Pharyngeal tonsil tip (rigid) for suctioning 2 1

8 Suction catheters: 8FR, 10FR, 18FR Band-Aids 12 4 Sterile bandage compresses or equivalent 12 3x3 or 4x4 sterile gauze pads 4 2 or 3 rolled bandages 6 40 triangular bandages 4 10x30 or larger universal dressing 2 1, 2 or 3 adhesive tape 2 rolls Bandage shears 1 Vaseline gauze 2 Arm splints with soft or cushioned surface or equivalent padded board, wrap around, wire ladder, inflatable or cardboard 2 Leg splints with soft or cushioned surface or equivalent padded board, wrap around, wire ladder, inflatable or cardboard 2 Traction splints with lower extremity limb support slings, padded ankle hitch traction strap and heel rest or equivalent (reel, sager or equivalent): Adult/Pediatric Spineboard long with 4 straps (or equivalent) 2 Spineboard short with 2 straps or equivalent (Kendrick Extrication Device) 1 Head immobilzer disposable or impervious to bodily fluids sand bags are not acceptable Cervical collars Hard: sizes to fit all patients over one (1) year of age Optional: adjustable cervical collar (hard only): sizes to fit all patients over one (1) year of age Scoop stretcher with straps (or equivalent) 1 Blood pressure cuffs with manometers (portable): Adult, Large arm (obese), Pediatric, Infant Stethoscope: Adult/Pediatric (or combination) 1 Burn sheets (sterile) may be disposable or linen (with date of sterilization and expiration indicated) Irrigation tubing 1 Saline for irrigation, sterile: Cold packs 2 Obstetrical Kit (sterile, to include minimum of umbilical cord tape or clamps (2), 1 scissors or scalpel, 1 aspirating bulb syringe, 1 pair gloves, 2 drapes, dressings & towels, clean plastic bag Newborn Stocking Cap 1 Emergency thermal blanket (reflective foil) or equivalent 2 Ambulance gurney capability for elevating the head and be adjustable, straps for securing patient to gurney, wheels, non-permeable covering material, means of securing gurney in vehicle set 2000cc 1 1

9 Triage tags 20 Current map of entire county (within 2 years) or ambulance zone maps 1 Current Contra Costa EMS Field Treatment Guidelines and policies 1 Restraints leather ankle and wrist or other soft restraints (4 per set) 1 set Battery operated flashlight 1 Emesis basin or disposable emesis bags and covered waste container 1 Linen towels, sheets, pillow cases, blankets, pillows Glucose Paste 1 tube

10 ALS Ambulance Emergency Care Equipment and Supplies: In addition to the BLS ambulance supply/equipment requirements, advanced life support units shall include, but not be limited to, the following: ITEMS Minimum Inservice Requirement Cellular telephone 1 Monitor/defibrillator (portable) must have strip chart recorder and synchronized cardioversion capabilities 1 Extra charged batteries for monitor/defibrillator 1 Defibrillator paddles/patches: Adult, Pediatric 1 set each Laryngoscope handle 1 Laryngoscope blades: #0, 1, 2, 3, 4 Miller Laryngoscope blades: #2, 3, 4 Macintosh Endotracheal tubes: 6.0, 7.0, 8.0, 9.0 cuffed Endotracheal tubes: 2.5, 3.0, 3.5, 4.0 uncuffed Endotracheal tubes: 4.5, 5.0, 5.5, 6.0 uncuffed Water soluble lubricant individual packets 3 Magill forceps: Adult, Pediatric Batteries (extra) for laryngoscope Bulbs (extra) for laryngoscope 1 ETT securing device: Adult, Pediatric Stylet: Adult, Pediatric Pen light 1 End-Tidal CO 2 (ETCO 2 ) detector 2 ETT placement assessment device (bulb) 1 ETT Nebulizer Adapter 2 Meconium aspirator 2 Esophageal Tracheal Double Lumen Airway (ETDLA) 1 Hand-held nebulizer for inhalation 2 1each 4 each 1 set Nebulizer mask 2 Pleural Decompression/Needle Thoracostomy kit: (or equivalent) Angiocatheter 12-14ga Syringe 30cc One-way valve 2 sets Rubber connecting tube Betadine swabs (4) Alcohol swabs (4)

11 Vaseline gauze (2) Sterile gauze pads (2) Tape Needle cricothyrotomy kit (or equivalent): Angiocatheter ga Syringe 30cc Scalpel with #11 blade Betadine swabs (4) Alcohol swabs (4) Vaseline gauze (2) Sterile gauze pads (2) Tape Oxygen tubing Y connector IV extension tubing Intraosseous IV kit (or equivalent): Sterile gloves (2 pair) Intraosseous needle (2) Betadine swabs (3) Syringe 3cc Syringes: 1cc, 30cc 2 Syringes: 3cc, 5cc, 10/12cc Needles: 18ga 1, 20ga 1, 22ga 1, 25ga (or equivalent) Medication-added labels 2 IV catheters: 14ga, 16ga, 18ga, 20ga, 22ga Alcohol swabs 5 Tourniquet 2 Razor 1 Armboard: child, adult Normal Saline solution 1000cc bag 4 Normal Saline solution 250ml or 500ml for pediatric patients 2 Saline lock with extension tubing 2 IV tubing: mini drip (60gtt), macro drip (10/15gtt), extension tubing (or equivalent) Glucometer (with lancets and test strips) 1 Secured drug box 1 Broselow tape (or length-based equivalent) 1 Activated Charcoal (25gm) 2 Adenosine (6mg) 5 Albuterol (2.5mg/3ml unit dose ampule) 4 1 set 2 sets 2each 2each 4 each 4 each

12 Atropine (1mg preload) 4 Aspirin (81mg tablets) 1 bottle Diphenhydramine (Benadryl) (50mg/1cc) 2 Calcium Chloride (1 gm) 2 Dextrose 25% 2 Dextrose 50% (25gm/50cc) 2 Dopamine (400mg/250cc premixed bag) (or equivalent) 1 Epinephrine 1:10,000 (1mg/10cc) 4 Epinephrine 1:1,000 (1mg/1cc) 2 Glucagon (1mg/1cc) 1 Furosemide (Lasix) 100 mg Lidocaine 2% 300 mg Midazolam (Versed) (5mg/ml ampule/vial) 20 mg Morphine Sulfate (10mg/1cc ampule/vial) 2 Naloxone (Narcan) 6 mg Nitroglycerin (0.4 mg/tab or multidose spray) 1 bottle Sodium Bicarbonate (50mEq/50cc) 1

13 RESPIRATORY EMERGENCIES Acute Pulmonary Edema R4 ACUTE PULMONARY EDEMA Acute onset of respiratory difficulty, may have history of cardiac disease, rales, occasional wheezes. 1. Ensure a patent airway OXYGEN high flow. Be prepared to support ventilations as needed 2. Position of comfort - if decreased level of consciousness, place patient in left lateral decubitus position 3. Consider: CPAP if available and patient meets requirements Limit any physical exertion or movement by the patient Calm and reassure the patient 4. Cardiac monitor. Consider 12-lead ECG if patient not in extremis 5. IV ACCESS TKO 6. Consider: NITROGLYCERIN 0.4 mg (1/150 gr.) SL if systolic BP greater than 90 and less than 150 systolic OR NITROGLYCERIN 0.8 mg if systolic BP greater than 150. If blood pressure decreases below 150 systolic after treatment, use lower dose for subsequent treatment(s). May repeat every five minutes to a total dose of 4.8 mg (12 sprays or tablets), until condition improves or BP less than 90 systolic. and ppatient hasmust not have not taken Viagra or Levitra with the previous twenty four hours, or Cialis within the previous thirty six hours., Levitra or similar drugs within the previous 24 hours - may repeat every 5 minutes until maximum of 6 doses administered, or: condition improves severe headache BP less than 90 systolic FUROSEMIDE 40 mg IV if moderate to severe dyspnea and hypoxia despite supplemental oxygen (pulse oximetry less than 93%)obvious signs and symptoms of pulmonary edema MORPHINE SULFATE 2-5 mg IV in 1-2 mg increments if BP greater than 90. Titrate to reduction in symptoms. Do not use in patients with altered mental status or decreased respiratory effort. DOPAMINE infusion beginning at 5 mcg/kg/min (see Table 1) if BP is less than 90 systolic 7. Contact Base Hospital if any questions or if additional therapy is required Contra Costa County Prehospital Care Manual Page 105

14 Tracheostomy Tube Replacement This may only be performed when patient has a new replacement tracheostomy tube available.establishing a patent airway in a patient with a tracheostomy may be accomplished by suctioning or by replacement of an old tracheostomy tube when suctioning is not successful. Tracheostomy tube replacement may only be preformed when patient has a new replacement tracheostomy tube available. If tracheostomy tube is not available, or placement of a new tube is unsuccessful, use of an endotracheal tube is appropriate (stomal intubation). Indications: Dislodged tracheostomy tube (decannulation) Tracheostomy tube obstruction not resolved by suction Contraindications: Recent tracheostomy surgery (less than 1 month) Inadequately sized tract or stoma for insertion of new tube (use endotracheal tube instead) Procedure: 1. Remove old tracheostomy tube if obstructed a. Hyperextend head to extent possible to expose tracheostomy site b. Apply oxygen over mouth and nose and occlude stoma or tracheostomy tube c. If existing tube has a cuff, deflate with 5-10 ml syringe (do not cut balloon) d. Cut or untie cloth ties holding tube in place e. Withdraw tube using a slow and steady outward and downward motion f. Assess airway for patency and adequate ventilation g. Provide oxygen through stoma as needed 2. Replace tracheostomy tube a. If tube has obturator, place in tube. If tube has outer and inner cannula, use the outer cannula and obturator for placement. b. Moisten or lubricate tip of tube and obturator with water, saline, or a water-soluble lubricant c. Hold device by flange (wings) or actual tube like a pencil d. Gently insert tube with arching motion (follow curvature of tube) posteriorly and then downward. Slight traction on skin above and below stoma may help. e. Once tube is in place, remove obturator, attach BVM and attempt to ventilate. If tube uses inner cannula, insert to allow ventilation with BVM. f. Check for proper placement by observing bilateral chest rise, listening for equal breath sounds, and general patient assessment. Signs of improper placement include lack of chest rise, unusual resistance to assisted ventilation, air in surrounding tissues, or lack of patient improvement. g. If tube cannot be inserted, withdraw, administer oxygen, and ventilate as needed. h. If insertion not successful, consider use of smaller tracheostomy tube (if available) or endotracheal tube placement. i. An additional aid in placement may be use of a suction catheter as a guide (without applying suction) for tube placement. Remove obturator and slide tube along suction catheter into stoma. Remove suction catheter after placement and assess. j. If still unsuccessful and patient requires ventilation, consider endotracheal intubation or BVM ventilation through newborn mask or via nose and mouth with stoma occluded. k.3.after proper placement, place tracheostomy ties through openings on flanges and tie around neck, allowing room for a little finger to pass between ties and neck. Page 32 Contra Costa County Prehospital Care Manual

15 Possible Complications Creation of false lumen Subcutaneous air Pneumothorax or pneumomediastinum Bleeding at insertion site or through tube Contra Costa County Prehospital Care Manual Page 33

16 12-Lead Electrocardiography Indications Chest pain/acute Coronary Syndrome o Includes patients with atypical symptoms or anginal equivalents such as dyspnea, syncope, dizziness, weakness, diaphoresis, nausea/vomiting, or altered level of consciousness Consider in arrhythmias if patient stable or not in extremis Consider in pulmonary edema if patient not in extremis Consider in cardiogenic shock or post-cardioversion patients en route (do not delay on scene) Contraindications (relative) Uncooperative patient Presence of ventricular tachycardia, ventricular fibrillation, or 3 rd degree block Life-threatening conditions Any condition in which delay to obtain ECG would compromise care of the patient Equipment Monitor-defibrillator with 12-lead ECG capability Electrode pads for limb leads and chest leads Clippers, scissors, or razor for chest hair removal Gauze or commercially available skin prep for electrode placement Sheet or blanket to cover patient as necessary while obtaining ECG Procedure 1. Expose Chest. Remove excess hair, prep skin. 1.2.Place electrodes on chest and limbs. See section below (12-lead placement). 2.3.Acquire ECG tracing as per manufacturer s directions. ECG can be done prior to medication administration if it can be done in timely fashion. May acquire ECG at incident location or in vehicle prior to beginning transport. 3.4.Make patient report to receiving hospital as soon as possible if machine notes ***Acute MI*** or ***Suspected Acute MI Suspected***. 4.5.Leave electrodes in place unless defibrillation, cardioversion, or pacing is required 5.6.Deliver copy of ECG to hospital registered nurse or physician upon arrival. Documentation 1. PCR documentation should reflect findings of 12-lead ECG. Electronic attachment of 12-lead ECG data to PCR should be done if available. Page 48 Contra Costa County Prehospital Care Manual

17 2. A copy of 12-lead ECG shall be forwarded with the PCR to the appropriate identified personnel at the provider agency. Hospital Report 1. Receiving hospitals will receive report as soon as possible in the instances in which the 12-lead ECG indicates ***Suspected Acute MI*** or ***Acute MI Suspected***. 2. Report will include: a. ETA to facility a.b. patient age and gender; b.c. chief complaint, including duration of complaint (PQRST) c.d. Vital signs d.e. Significant physical findings e.f. ECG interpretation (***message***) f.g. Paramedic treatments and response to treatments g.h.eta to facility 12-Lead Placement 1.Excess hair should be removed 2.1.Limb leads should be placed on distal extremities if possible. May be moved to proximal if needed. 3.2.Chest leads should be placed: V1 4 th intercostal space at the right sternal border V2 4 th intercostal space at the left sternal border V3 Directly between V2 and V4 V4 5 th intercostal space at left midclavicular line V5 Level of V4 at left anterior axillary line V6 Level of V4 at left mid-axillary line Contra Costa County Prehospital Care Manual Page 49

18 DRAFT Prehospital Care Manual Update Process Jan (MAC) First suggested changes discussed. Change requests accepted from anyone until April 2. Mar (MAC) Catalogued list of received requests distributed. Apr Deadline for change requests May Formatted Draft of changes available for internal review May Formulated treatment guideline/procedure/notes changes ready for public comment/distributed with MAC Agenda May Internal EMS Review May (MAC) Discussion of changes May EMS Physicians Meeting reviews formulated changes June Public Comment period ends July Revised proposals distributed with MAC Agenda July (MAC) Final discussion of proposed changes August 2007 Possible meeting for any reformulated changes September New PCM version finished, training materials available (Have dedicated part of meeting to dedicate to PCM Update)