Bernalillo County Fire & Rescue Drug Policy PDF

Bernalillo County Fire & Rescue Policy For the Acquisition, Administration, Destruction, Disposal, Recording and Transfer of Dangerous Drugs and Controlled Substances April, 2023 Version 5.1 Greg Perez -- Fire Chief Robert Gallegos-EMS Division Chief David Lujan-- EMS Captain David Tuto...

Bernalillo County Fire & Rescue Policy For the Acquisition, Administration, Destruction, Disposal, Recording and Transfer of Dangerous Drugs and Controlled Substances April, 2023 Version 5.1 Greg Perez -- Fire Chief Robert Gallegos-EMS Division Chief David Lujan-- EMS Captain David Tuton-EMS- Lieutenant Dorothy Habrat, DO - Medical Director Daniel Castellano - Consultant Pharmacist Bernalillo County Fire & Rescue Department Drug Control Manual and Policy CONTENTS Purpose ======= {#section.ListParagraph} II. Authority ========= A. Chief of Fire and Rescue ------------------------ Medical Director ---------------- Consultant Pharmacist --------------------- Controlled Substances Coordinator --------------------------------- {#section-1.ListParagraph} III. Responsibility and Procedure ============================ A. Controlled Substances --------------------- ### Acquisition ### Transfer ### Inventory ### Possession ### Storage ### Administration ### Replacement ### Disposal #### Expired #### Damaged #### Drugs opened for use #### Lost or Missing Drugs Dangerous Drugs --------------- ### Acquisition ### Transfer ### Inventory ### Possession ### Storage ### Administration ### Replacement ### Disposal #### Expired #### Damaged #### Drugs opened for use #### Lost or Missing Drugs {#section-2.ListParagraph} IV. Records and Forms ================= A. Electronic Controlled Substance Action Form ------------------------------------------- Electronic Controlled Substance Log Form ---------------------------------------- Temperature Logs ---------------- EMS Run Report -------------- V. Inventory Records Required A. Per Truck/Drug Box ------------------ B. Per Drug -------- VI. Definitions =========== A. Chief of Fire and Rescue ------------------------ Consultant Pharmacist --------------------- Department Medical Director --------------------------- Controlled Substances Coordinator --------------------------------- Supervisor ---------- Licensed Provider ----------------- EMT-Paramedic ------------- Employee -------- Administration -------------- Possession ---------- Regional Inventory Station (RIS) -------------------------------- Pharmacy Regulations ==================== {#section-3.ListParagraph} **PURPOSE** =========== This document is intended to provide the information necessary to properly manage and maintain the Controlled Substances and Dangerous Drugs used by the Bernalillo County Fire & Rescue ~~Department ("Department")~~. The Department has established this document to meet or exceed the requirements of Federal, State, and Local government agencies and the New Mexico Board of Pharmacy, in order to remain compliant with law. This document shall serve as the absolute regulation for the acquisition, transfer, inventory, possession, storage, administration, replacement and disposal of Controlled Substances and Dangerous Drugs. **AUTHORITY** ============= A. This document is constructed under the authority of the [Chief of Fire and Rescue], as the appointed manager of the Department through County Ordinance 2000-5. =========================================================================================================================================================================== B. The Contracted [Medical Director], or his designated representative, shall be responsible for reviewing the appropriate administration of drugs, and disposal when the drug container was opened and violated, regardless of whether the drug was administered to a patient. C. The [Consultant Pharmacist], or his designated representative, shall be responsible for: 1. ##### To abide by the code of ethics of the American Society of Consultant Pharmacists. Must be qualified to practice as a consultant pharmacist and is to be aware of all federal and state drug laws, rules and regulations related to pharmacy services, and to provide the facility with current information pertaining to drug service. 2. ##### Ensure that drugs are handled in the facility in which he/she is the consultant pharmacist, in a manner that protect the safety and welfare of the patient. 3. ##### Set the policy and procedures in the facility as related to all facits of drug handling and distribution; these policies and procedures to be reviewed and updated on an annual basis. 4. ##### To visit the facility, commensurate with his duties, as specified by Board regulations relative to the facility or by written contract with the administration of the facility not inconsistent with Board regulations. 5. ##### His/her primary goal and objective shall be the health and safety of the patient, and he/she shall make every effort to assure the maximum level of safety and efficacy in the provision of pharmaceutical services. 6. ##### The consultant pharmacist shall not condone or participate in any transaction with any practitioner of another health profession, or any other persons whosoever under which fees are divided, or rebates or kickbacks paid or caused to be paid, or which may result in financial exploitation of patients or their families in connection with the provision of drugs and medication or supplies or pharmaceutical services. 7. ##### Setting the minimum practices and standards for purchase, receipt, transfer, and storage of drugs, including disposal of drugs that are discovered to be damaged or violated without the intent of administration to a patient. 8. ##### The donation of drugs (not including scheduled drugs) to accredited training institutions using expired medications for classroom purposes will be documented and tracked on the department donation form which is located in binder in the office of the CSC. 9. ##### The consultant pharmacist will: a. ##### Review all instances in which controlled substances were used, and review all or a sample of instances in which other drugs were used, at least every 90 days b. ##### Report in writing any exceptions to the Medical Director and the chief executive within 24 hours upon learning of same c. ##### Otherwise make a written report to the Medical Director and chief executive at least annually on the EMS\'s drug handling practices, including corrective action taken on exception d. ##### Such reports shall be available for review by the Board upon request. e. ##### Develop policies and procedures for EMS regarding the following: 1. ###### functions of consultant pharmacist; 2. ###### formulary; 3. ###### security of drugs; 4. ###### equipment; 5. ###### universal precautions; 6. ###### licensing; 7. ###### drug storage; 8. ###### packaging and repackaging; 9. ###### distribution records; 10. ###### document use of expired drugs for training; 11. ###### administration and/or patient care records; 12. ###### storage of drugs in jump kits; 13. ###### drug destruction and records; 14. ###### drug and device procurement; 15. ###### receipt of drugs and devices; 16. ###### delivery of drugs and devices; 17. ###### designate items to be included in jump kits, define par levels of drugs, storage conditions and locations where the jump kits are in use. D. The [Controlled Substances Coordinator (CSC) (also Division Chief of Emergency Medical Services)], or his designated representative, shall be responsible for the security of the master-controlled substance stock, and is responsible for the replacement of all schedule 2, 2N, 3, 3N, 4, and 5 drugs, and the storage of all associated documentation. **RESPONSIBILITY AND PROCEDURE** ================================ A. **Controlled Substances** are defined as those drugs that require high security and control procedures. Such drugs shall include, but are not limited to, Schedule II Controlled Substances-Morphine Sulfate, Fentanyl Citrate, and Schedule IV Controlled Substances - Diazepam, and Midazolam the Pharmacist may deem any drug that shows potential or history of abuse to be handled according to the following procedures: 1. ### [Acquisition] shall be accomplished by the CSC or their designee. The replacement stock shall be based solely upon the documentation that initial stock values have been accounted for and no conflicts have been found in the reporting system. Controlled Substances will be obtained from the Consultant Pharmacist or an accepted vendor. 2. [Transfer] of drugs is a two-person operation. The employee with current possession (off- going) shall obtain the security container and present it to the employee who will take custody (on-coming). Between the two individuals, the medications shall be inspected, the volume of solution shall be examined, and the expiration dates checked. If no discrepancies are noted, the receiving party shall take possession of the drugs and both members shall sign the Electronic Controlled Substances Log to account for an orderly exchange of responsibility. If a discrepancy is noted, the supervisor and the CSC shall be contacted and a Electronic Controlled Substance Action Form shall be completed. If a determination of a discrepancy is found, an investigation will take place and corrective or disciplinary action may follow. 3. Controlled Substances are not to be shared with any other entities. 4. [Inventory] of controlled substances shall be the responsibility of the employees who are permitted to possess them. Two members shall sign for accuracy any time an inventory is assessed or transferred. Daily inventory of controlled substances shall be taken at any time and date in which a change of possession occurs. Inventory values shall be recorded on the Electronic Controlled Substances Log. 5. [Possession] of Controlled Substances is authorized only by employees who are either licensed at the EMT-Paramedic level or a supervisor (i.e. the on-duty Lieutenant, Captain, Commander or Chief). All employees who take possession of controlled substances must inspect the stock of controlled substances and sign the Electronic Controlled Substances Log associated with the station/unit in which the drug is stored. In the event that an EMT- Paramedic or Lieutenant is not assigned to the station/unit for the next shift, then a supervisor, regardless of his EMT level, must be contacted to take possession of the controlled substances. Controlled substances are to remain on the vehicle assigned, regardless of the employee who is in documented possession. Double lock access will provide the security for controlled substances and the key codes shall be maintained in the immediate control of the employee who signed for the controlled substances. Normally this double-lock access is maintained with the locking doors on the rescue and the MedVault® locker for the controlled substances. 6. [Storage] of controlled substances may be accomplished in one of three methods only: a. Carried by a licensed EMT-Paramedic on their person, in direct control during patient care or during periods when patients are being accessed. b. Stored within a container on the vehicle to which the drugs are assigned. The container must comply with the standards set forth in Section VII. c. Stored within the stock temperature monitored facility located at the EMS Office at the Atrium, subject to the same minimum storage standards as set forth in Section VII. NOTE: Beginning April 2010 the on-board compartments for the storage of controlled substance lock boxes will be transitioned from a keyed locking compartment fixed to the rescue, engine or ladder truck to a fixed Knox® MedVault®. The Knox® MedVault® is a vehicle compartment which has an electronic digital keypad entry mechanism. The controlled substance Lock Box will be secured in the Knox® MedVault® until time for count and inspection of controlled substances or in its instance, administration of controlled substances. The user manual for the Knox® MedVault® system will be available on the ERS website in the EMS section. The administrator's manual and the unique programming cable will be secured in the controlled substance vault at headquarters. Personal access codes of three to six digits can be programmed to open the MedVault® and assigned to employee's names. No number may be assigned twice. The list of employees names authorized to access the Knox® MedVault® (at this time the list consists of Paramedics, Lieutenants, Captains, Commanders and Chiefs) will be randomized. In addition, a series of numbers between 0000 and 999999 will be randomized. Names will be randomly assigned a Personal Access Code. The Controlled Substance Coordinator will keep the database on a portable computer. Audits will be made on occasion to verify that the vault has been opened for inspection and count of controlled substances as required at change of custody and for drug administration. It is very important that personnel do not let anyone else know their personal access code, this includes co-workers. If a code is forgotten, it can be obtained from the CSC. If it is compromised, it must be inactivated and all the MedVault® lockers must be reprogrammed to accept a new personal access code. 7. [Administration]: a. EMS drug administration shall be limited to drugs currently authorized by scopes of practice for EMS personnel. Each licensee shall provide a formulary to the Board on an annual basis or as changes occur. b. EMS shall keep an up-to-date record in readily retrievable format for review by the Board, indicating the following information for the administration of all dangerous drugs; 1. date of administration; 2. name of patient; 3. drug name and dosage administered; 4. name of physician responsible for the order, if by other than the Medical Director's protocols; 5. name of EMS personnel administering the drug or drugs. c. EMS shall keep SCHEDULE II controlled substances administration and receipt records separately from other drug records. d. EMS may keep SCHEDULE III - V controlled substances receipt and administration records in the same record in which dangerous drugs are recorded, provided a mechanism is employed to identify these records (such as a red "C" marked in the margin of these entries). e. All drug receipt and administration records must be readily retrievable and retained for a period of at least three years. 8. [Replacement:] The EMS Division shall be contacted as soon as possible after administration and shall accomplish the replacement of controlled substances. The empty controlled substance container will be disposed of in an appropriate sharps container. The reports shall be submitted to the CSC and reviewed by the Pharmacist and/or Medical Director. 9. [Disposal] [ ] a. b. c. [Controlled drugs opened for use] but not administered to a patient shall also require a controlled substance electronic action form from the employee in current custody of the controlled substance and a copy of the EMS report. If the medication was already drawn into a syringe, the contents shall be wasted into a sharps container in the presence of the providers who were also present when the drug was drawn up and/or any other witnesses who may attest to the disposition of the substance, and documented and initialed by both EMT Providers in the Electronic EMS report. A two-person chain of custody shall be maintained to avoid individual opportunities of misconduct with controlled substances. The empty controlled substance container will be disposed of in an appropriate sharps container. The reports shall be submitted to the CSC and reviewed by the Pharmacist and/or Medical Director. d. [Lost or Missing Drugs] shall be reported immediately to the supervisor and the CSC. An Electronic Controlled Substance Action Form shall be completed by all involved parties including the paramedic responsible or the supervisor in possession of the drug and logged for review by the Pharmacist and/or Medical Director. All lost or missing controlled substances shall be reported to the New Mexico Board of Pharmacy and the Drug Enforcement Agency as per regulations. A DEA 106 Form will also be completed. B. **Dangerous Drugs** are those medications that require a physician's authorization to administer, but are not classified by law, the Medical Director, or the Pharmacist as having potential for abuse. Dangerous drugs shall not include oxygen, but may include such drugs as; Acetylsalicylic Acid, Acetaminophen, Albuterol, Adenosine, Atropine Sulfate, Dextrose, Diphenhydramine, Dopamine HCL, Epinephrine, Lidocaine, Naloxone, Nitroglycerine, Sodium Bicarbonate, Magnesium Sulfate, Atrovent, and Dexamethasone. 1. Acquisition shall be accomplished by the EMS Division or Logistics Division. Such appropriations shall be logged at the site in which the stock is maintained. No other person is to have access to stock quantities of dangerous drugs. 2. [Transfer] is permitted between any authorized members of the department. a. For Controlled Substances the use of the station narcotics Electronic Reporting System and the master narcotics Electronic reporting system will be used to record the transfer. b. For Dangerous Drugs the use of the Electronic Reporting System will be used to record the transfer. 3. [Inventory] of temperature monitored storage rooms shall be the responsibility of the employee charged with controlling medical supply for each region. Inventory shall be performed at a minimum interval of once per month. Kits shall be inventoried earlier if the kit is used and any quantity of drug is replaced or disposed. 4. [Possession] of dangerous drugs is limited to any member of the department who is licensed to administer the medication(s) or a member who is working with such a member. Transport by members is permitted, with the understanding that any person who does not possess adequate licensure and medical control may not dispense or administer such drugs. 5. [Storage] is permitted only within the designated temperature monitored, secured storage stations for which the County has a Clinic License from the New Mexico Board of Pharmacy along with the consultant pharmacist license. Both must be posted on the door of the medication locker at each facility and be current, or upon vehicles owned by the department, unless specialized vehicles are in use, and on the scene of a call. 6. [Replacement] shall be made at a Regional Supply Station. The RSO will submit a Supply Order form to the Logistics Division for submittal to the vendor. 7. [Disposal] a. #### [Expired Dangerous Drugs] shall be turned in to the regional inventory station where they will be logged and returned to the EMS Division for disposal. Alternatively, medication may be used for training in the station providing the drug is properly signed out and accounted for. b. [Damaged Drugs] shall be documented, and if the container is intact, shall be returned to the regional inventory station who will then return the damaged drugs to the EMS division for disposal using the reverse distribution process. c. [Damaged Containers] shall be reported to the supervisor, and disposed of in an appropriate container. A report shall be submitted, documenting the damage of the container and drug and how the damage occurred. d. [Dangerous Drugs opened for use] that are not administered, shall be wasted and the container secured for safety and returned to the regional inventory station for return to the EMS division. An ~~ERS~~ Electronic EMS report shall be generated, referencing the call and accounting for the premature violation of the container\'s integrity and any drug wasted. Two employees must sign as witness to the wasting of drugs. e. [Lost or Missing Drugs] shall be reported to the regional supervisor who will then report the incident to the EMS division. A DEA form 106 will be generated by the EMS Division and the New Mexico Board of Pharmacy will be notified. f. IV. **RECORDS AND FORMS** Unless otherwise stated, each station shall maintain an Electronic Record relevant to the stock carried onsite, in the department\'s vehicles and kits for: - - - - - A. [Electronic Controlled Substance Action Forms] will be kept by the EMS Division and be utilized to document damage, loss, or inappropriate use of a drug. B. [Electronic Controlled Substance Log Forms] shall be maintained for any transaction occurring that involves the receipt, use, damage, exchange, or disposal of a controlled substance. The record shall be maintained both centrally at the EMS Office, with the controlled substance master stock and logged at the station where the specific controlled substance is stored or administered from. C. [Electronic Expired Drug Log Forms] shall be maintained at the Regional Inventory Station to maintain accountability of expired drugs within the Region. The Expired drugs will be collected and returned to the EMS division for proper disposal. D. [Electronic EMS run reports] shall be submitted for any use and or waste of controlled substances, and any use of drugs shall be noted upon it. It is the responsibility of the crew using the drug to make such documentation. **The EMS report will account for all of the medication in the vial either administered or wasted.** Any administration of controlled substances WILL have the EMS report completed by the end of the shift so that medication can be restocked as soon as possible by the EMS Division. This includes late calls. The provider will be required to stay late to finish the report for any controlled substance administration. Eventually all EMS run reports shall be stored at the office of the Chief of Fire and Rescue. A copy shall be filed with the CSC if a controlled substance use occurs. - - V. **INVENTORY RECORDS REQUIRED** The Regional Inventory Station (RIS) shall maintain a record of all drugs within their region. The record shall be maintained in the Electronic Reporting System and shall be accessible by the other members of the inventory committee A. [Per Truck/Drug box]. An Electronic listing shall be maintained for each drug box/kit/container, indicating its contents and the expiration dates for each medication. This log will reflect the on-hand stock that is available for immediate use. This list is the responsibility of the regional inventory representative. B. [Per Drug]. An Electronic listing shall be maintained indicating the quantity of each drug in the region and its location. Be it within expiration date or out of expiration date. This log will reflect the total available quantity for each drug, and serve as a guide for ordering. This list is the responsibility of the regional inventory station for current and expired drugs. C. Annual inventory of controlled substances will be completed by the EMS division within 4 days before or after May 1^st^ of each year. D. All records pertinent to the EMS clinic license must be retained for a minimum of 3 years VI. **DEFINITIONS** Terms contained within the definitions or within this document are intended to be gender neutral. During those occasions where the word he or his is used, it is implied that she or her can be substituted without changing the intent. A. [Chief of Fire and Rescue] refers to the department head appointed by the County Manager or the Board of County Commissioners to be responsible for the administration of the Department, and in his absence, his designated representative. B. [Consultant Pharmacist] refers to the licensed Pharmacist under contract to the Department, who functions as the chief executive regarding drug acquisition, storage, accountability, and disposal. C. Contract [Medical Director] is the licensed Medical Control Emergency Physician (MCEP) who is responsible for issuing the protocol, guidelines, and standing orders for Emergency Medical Technicians operating under the control and/or authority of the Department. The Medical Director is responsible for establishing acceptable practices for the administration of medications. D. [Controlled Substance Coordinator (CSC) (also Division Chief of Emergency Medical Services)] refers to an employee of the Department, who has custody of the master controlled substance master stock, and is responsible for replacement of all schedule 2, 2N, 3, 3N, 4, and 5 drugs, and the storage of all associated documentation. E. [Supervisor] refers to any line supervisor (Lieutenant, Captain or Commander) who is responsible for management of personnel assigned to field positions. This employee is the first point of contact for issues arising from interpretation of this document. The supervisor is to make the decision to pursue matters to higher levels. F. [Licensed Provider] refers to an authorized Emergency Medical Technician who may have cause to administer a dangerous drug or controlled substance consistent with their level of licensure. Physicians and Nurses may be authorized to possess and/or administer medications, as the Medical Director shall direct. G. [ EMT-Paramedic] refers to a licensed technician who is permitted to administer drugs consistent with the Medical Director\'s standing orders, protocols, and guidelines. The Department Paramedic is responsible for the proper management of controlled substances carried by this Department when working with providers of other agencies. H. [Employee] refers to any member of the Department who receives compensation in the form of wages earned, and who is subject to disciplinary actions under the Bernalillo County Personnel Rules and Regulations or the International Association of Fire Fighters Local 244 Collective Bargaining Agreement. I. [Administration] refers to the practice of administering a medication orally, sublingually, subcutaneously, rectally, or parentally to a patient. J. [Possession] refers to the carrying of a medication or the keys by which access to the medication can be obtained. K. [Regional Inventory Station] (RIS) refers to the location that is responsible for maintaining inventory of drugs, consistent with the policies set forth by the Medical Director and Consultant Pharmacist in their respective region and shall also maintain the records of the Department with respect to the content of this document. VII. **PHARMACY REGULATIONS** Controlled substances are to be secure at all times, under double lock and key. The employee who has possession shall maintain the controlled substances in the security container provided, and the container shall be secured in a compartment of the vehicle that the employee is assigned to, providing the compartment is secured and locked. Only employees of the department may sign for controlled substances, and then only while on duty, operating out of the vehicle to which the drugs are assigned. The only exceptions to this rule are when drugs are carried by the employee during delivery of a medication, for replacement or administration on scene, or during an event in which the patient's location must be reached and is not nearby the truck that contains the medication. The only other exception is when no Paramedic is assigned to a unit and the non-Paramedic supervisor is in possession of the controlled substances. Any employee, who takes possession of a controlled substance, shall be responsible for completing any electronic data input associated with receipt, transfer, administration, or disposal of the medications which they received or have replaced. Dangerous drugs are to be secured in drug boxes opened upon the need to administer a drug contained therein. The container shall be secured on the vehicle to which it assigned, until used. All drugs are temperature sensitive and the members of the department shall endeavor to keep the drugs from being exposed to temperatures colder than 68°F, and warmer than 77°F. This is to be accomplished by giving consideration to use of parking features, bay heaters, and air conditioning/heating systems of the vehicle. Use of thermometers that can measure highs and lows will be the responsibility of the EMS Division. All members of the department are compelled to understand their role in regard to pharmaceuticals and are responsible for reporting concerns and violations. Each station shall have internet access to access websites for drug reference i.e. Drug Information Portal: *http://druginfo.nlm.nih.gov/drugportal/drugportal.jsp*. A copy of the Drug Policy Manual shall be maintained in each station under the same conditions as the drug reference materials. List of stations- Station 30 Station 31 Station 32 Station 33 6697 4^th^ st NW 9819 2^nd^ st NW 1701 Arenal SW 3909 Barcelona SW Abq, NM 87107 Abq, NM 87114 Abq, NM 87105 Abq, NM 87121 Station 34 Station 35 Station 36 Station 38 2801 Don Felipe SW 11700 Paeo del Norte 501 Bear Canyon ln.NW 3610 Prince SE Abq, NM 87105 Abq, NM 87122 Abq, NM 87113 Abq, NM 87105 Station 40 Station 41 Station 43 Station 46 48 Public School Rd 10838 Hwy 337 4 Dressage rd 25 Frost rd Tijeras, NM 87059 Tijeras, NM 87059 Tijeras, NM 87059 Sandia Park, NM 87047 The Atrium-Headquarters Logistics Shops (Warehouse) 6840 2^nd^ st NW 1120 Coors SW Abq, NM 87107 Abq, NM 87121 At the time this revision was printed: ---------------------------------- ------------------------- --------------- Phone Medical Director Dorothy Habrat, DO (626)372-7784 Consulting Pharmacist Daniel Castellano, R.Ph 235-2457 Controlled Substance Coordinator Robert Gallegos EMTB 468-1302 ---------------------------------- ------------------------- --------------- This drug manual is adopted as the governing document for the Bernalillo County Fire & Rescue Department on this \_\_\_\_\_\_1\_\_\_ day of \_\_\_\_\_\_April\_\_, 2023. \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Daniel Castellano, R.Ph Consulting Pharmacist \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Dorothy Habrat, DO Medical Director \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ David Lujan, EMS Captain Bernalillo County Fire & Rescue \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Robert Gallegos, EMS Division Chief Bernalillo County Fire & Rescue \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Greg Perez, Fire Chief Bernalillo County Fire & Rescue [ **Appendix**] **Bernalillo County EMS Formulary & Standing Orders** Acetaminophen **(Tylenol): Fever/adult pain management, 1g po, Pain 1g po. Pediatrics: 15mg/kg/24hr fever, 15mg/kg/24hr pain.** Adenosine: Hemodynamically stable SVT with significant symptoms. 6mg\--12mg. Pediatric 0.1mg/kg\--0.2 mg/kg Albuterol: 5 mg nebulized for reactive airway disease (2.5 mg ≤2 y/o) - Amiodarone: Adult Vfib/ Pulseless VTac, Pediatric Cardiac Arrest Adult: 300mg initial bolus IV/IO, after epinephrine, re-bolus 150mg once. Pediatrics: 5mg/kg IV/IO q3-5 minutes, max 15mg/kg. Wide complex tachycardia regular/Irregular: Adult: 150mg over 10 minutes, Repeat 10 minutes 15mg/kg max. Pediatrics: 5mg/kg IV/IO over 20-60 minutes, may repeat twice, max 300mg. Aspirin: 324 mg for chest pain Atropine: 0.5 mg IV/IO/ET max 3 mg for symptomatic bradycardia. Pediatric-0.02 mg/kg IV/IO (0.1 mg minimum dose, 0.5 mg maximum single dose) Calcium Chloride: 1 Gram IV/IO for PEA with suspected hyperkalemia or Ventricular Fibrillation/Pulseless Ventricular Tachycardia Calcium Gluconate Hydrofluoric Acid Exposure/Burns; 2.5% calcium gluconate gel (if available) to burned area of skin every 15 minutes and massage gently until pain resolves. If inhalation injury presents, as soon as possible give calcium gluconate neb, (if available). Mix 1 ml of 10% calcium gluconate with 3 ml of normal saline to give 2.5% solution. For suspected systemic toxicity, IV Calcium gluconate. (If available) For adult patients: administer 10% calcium gluconate: 0.1 ml/kg up to 10ml IV. For pediatric patients: administer calcium gluconate 0.1 ml/kg IV (monitor patient closely) Dexamethasone: Reactive Airway Disease: Adult: 10mg IV/IO slowly over 2 minutes. Pediatrics Dosage; 0.6 mg/kg SIVP to a max of 10mg. Dextrose ~~50%, 25%, 10%, 5% for hypoglycemia~~ D10W (25g/250ml) Medical diabetic [emergencies, seizures, Neonatal resuscitation, pre-eclampsia, eclampsia. Adults: Wide open IV/IO. Pediatrics: 5ml/kg IV/IO up to 25g/250ml.] Diazepam[(Valium):] Airway management, Adult Acute Coronary Syndrome, Adult/ Pediatric Symptomatic Bradycardia, Adult/ Pediatric Narrow Complex Regular Tachycardia, Adult/ Pediatric Narrow Complex Irregular Tachycardia, Adult/ Pediatric Wide Complex Irregular Tachycardia, Adult/ Pediatric Post-Resuscitation Cardiac Arrest Care, Adult Drug Overdose, Bites/Envenomation\'s, Seizures. Adult: 2.5mg IV/IO Repeat once in 5 minutes. Pediatric: 0.05mg/kg IV/IO Repeat once in 5 minutes. Agitated and delirious patient, alcohol/benzodiazepine withdrawal. Based off BSI index and CIWA score. Adult Drug Overdose, Seizures, Status Epilepticus, Pre-Eclampsia/Eclampsia. Adult: 10mg IV/IO Repeat 2.5mg q5 minutes max 20mg. Crush injury: Contact MCEPT. Diphenhydramine: 0.5-1 mg/kg up to 50 mg for anaphylaxis - Droperidol: Chemical Sedation for the agitated and Delirious Patient: Adult: 2.5mg-10mg IM or IV based on the BSI score. Pediatric: Not approved. D5w: 50ml, for use with amiodarone. Epinephrine: Cardiac arrest: 1 mg 1:10,000 IV/IO or 2 mg 1:1,000 ET (pediatric: 0.01 mg/kg 1:10,000 IV/IO or 0.1 mg/kg 1:1,000 ET) Severe croup/epiglottitis and anaphylaxis with airway swelling: 0.05 mg/kg (max 3 mg) 1:1,000 diluted to 3 ml in NS nebulized Anaphylaxis: 0.3 mg 1:1,000 IM (pediatric: 0.01 mg/kg) Reactive airway disease: 0.3 mg 1:1,000 SQ/IM (pediatric 0.01 mg/kg) Bradycardia, Cardiogenic Shock, Anaphylaxis, Drug Overdose, Snakebite & Sepsis: Adult 2-10 mcg/min. Fentanyl: Patients presenting with pain or discomfort. Adult: 1.0-3.0mcg/kg to a maximum of 3.0mcg/kg; MCEP contact required if patient requires more than 3mcg/kg. Administer in 0.5-1.0mcg/kg increments, may repeat every 5 minutes up to a maximum dose. Pediatric: Children 2 years of age and older may receive Fentanyl. The dosing is the same as adults. Glucagon: Diabetic Emergencies. Adult: 0.5-1mg IM, Repeat in 10-20 minutes. Pediatric: 0.1mg/kg IM. Repeat in 10-20 minutes, max 1mg. - Hydroxocobalamin (CyanoKit): Cyanide Poisoning. Adult: 5g IV/IO over 15 minutes. Pediatric: 70mg/kg IV/IO over 15 minutes. - Ibuprofen (Advil, Motrin) Adult pain, Fever: 400-600 mg Po Pediatric Pain/Fever: 10mg/kg PO \>6mos old. Ipatropium Bromide (Atrovent) -- Reactive Airway Disease: Adult & children \> 2 yrs: 0.5mg nebulized - Ketorolac( Toradol) Adult Pain Management: 15mg IV/IO/IM single dose. - Pediatric pain management: 1mg/kg IM max 15mg. 0.5mg/kg IV/IO max of 15mg. Lidocaine: 1.0-1.5 mg/kg (repeat 0.5-0.75 mg/kg PRN, max 3.0 mg/kg) IV/IO (2 mg/kg increments ET) for pulseless VT/VF and unstable VT Page 149 of 15 Magnesium Sulfate: Reactive airway disease refractory to albuterol and epi: 2 gm. IV over 5-10 minutes (pediatric 20-25 mg/kg) Eclampsia: 4 gm. over 10 minutes Pre-eclampsia: 2 gm. over 10 minutes (requires MCEP order) Ventricular Fibrillation/Pulseless Ventricular Tachycardia/Ventricular Tachycardia: 2 gm. over 10 minutes; Pediatric- 25mg/kg IVP over 10 mins for under 50kg Midazolam: Chemical sedation for violently agitated patient: max dose: 1-5 mg IM/IVIN/IO max of 10mg Status epilepticus (consider if IV access not readily available): Adults -- 1-5mg IM/IV/IN/IO, max 10 mg; Infants/Children - 0.1-0.2 mg/kg IN (via MAD nasal atomizer) or 0.05-0.1mg/kg IM/IV/IO/IN, max 5 mg Synchronized cardioversion/Transcutaneous Pacing/Pre-Eclampsia/Eclampsia: 1-5 mg IV/IM/IO/IN, max 10 mg (pediatric: 0.05 -- 0.1 mg/kg IV/IO/IM; 0.1-0.2mg/kg IN) max 5mg Morphine Sulfate: Patients who present with pain or discomfort. Adults age 16 and older: 2-5 mg increments to a total of 20 mg (patients \