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EXHIBIT A –
REVISED AND
REDACTED
EXECUTION
MANUAL PORTION
110
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NEVADA DEPARTMENT OF CORRECTIONS

EXECUTION MANUAL
EM 110
EXECUTION PROCEDURE
(REDACTED)
Effective Date: June 21, 2021 (Replaces June 9, 2021 Version Due to a Typographical
Error in EM 110.01 (Heading – “Comdenmed” as opposed to
Condemned), EM 110.02(D)(3)(d), 110.02(D)(3)(d)(i) and
110.02(D)(3)(d)(ii) as well as a Separate Typographical Error (12,500
mg as opposed to 25,000 mg) in EM 110.02(D)(3)(c)– No other changes
made

CONFIDENTIAL IN UN-REDACTED FORMAT: YES

AUTHORITY AND RESPONSIBILITY

The Director and designated Deputy Director will ensure that this manual is accurately revised
and published upon order of the Governor prior to a scheduled execution.

110.01 FINAL PREPARATION OF CONDEMNED INMATE

A.

1. The Warden will ensure that the Execution Area Viewing Room blinds are closed and
that the Viewing Room lights are at full illumination.

2. The Team

a.

officers will then move

3. The condemned inmate is placed

B.
will inform the Warden that the condemned inmate is ready to enter the Execution
Area Chamber Room.

C. with permission of the

Warden, the inmate is escorted to the Execution

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Chamber Room , placed on the table and secured using soft restraints.
The restraints that were used during escort will then be removed. A head support will be
placed under the inmate’s head and the table will be placed at a reverse Trendelenburg
position. The Team will ensure the inmate is properly secured to the table
and announce “inmate secured.”

D. officers
will post themselves in the Execution Chamber Room while the Team
escorts the EMT's into the Execution Chamber Room to set the IV lines and cardiac
monitor leads.

1. The EMT will perform a venipuncture of both arms or alternate sites derived from the
advice of the Attending Physician such as (in the order of preference) the condemned
inmate’s ankle, lower leg or neck.

a. Using the appropriate gauge needle/catheter set (18 or 20 depending upon the size
and condition of the vein at the intended venipuncture site) the EMT will perform a
venipuncture of the condemned inmate’s right arm (or alternate site derived from the
advice of the Attending Physician). The venipuncture site should be selected as distal
on the extremity as possible which will also accommodate at least a 20 gauge
needle/catheter set. Should that site prove unsuccessful, a site proximal on the arm
can then be selected and a second venipuncture re-attempted. When the venipuncture
of the right arm is successful, the EMT will withdraw and appropriately discard the
needle, connect the catheter tubing to the IV line, remove the tourniquet on the
condemned inmate’s upper arm and then check the patency of the venipuncture.

i. The EMT will open the IV line flow-valve and observe for a free flow of saline
inside the IV drip chamber.

ii. The EMT will also observe the IV site for any unwanted swelling, discoloration
or fluid seeping at the venipuncture site. If any of these problems are observed,
the EMT will discontinue the IV at that site. If no problems are observed, the
catheter/IV line will be secured with sufficient tape and set the IV flow at a rate
sufficient to keep the vein open.

b. The process set forth above in Section 110.01(D)(1)(a) will be repeated for the
contralateral side or at another location on the same side to establish another adequate
intravenous line.

2. If the EMT is unable to find an adequate vein in an arm, the venipuncture will occur into
a vein of an ankle, lower leg or neck as advised by the Attending Physician. Once
established and secure, a normal saline solution will then be infused at a slow rate in
order to keep the vein open.

3. Once both venipunctures are successfully completed, cardiac leads will be attached to the
condemned inmate by the EMT. The EMT will check
to ensure that the cardiac monitor is functioning properly. The cardiac monitor will then
be turned off until the end of the process; there will be no dynamic cardiopulmonary
electronic monitoring of the condemned inmate during the process.
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E. once these tasks have

been accomplished successfully, the Team and the EMT will then
exit the Execution Area Chamber Room The only person
remaining with the condemned inmate will be the Warden.

F. the Warden will direct

the Team posted in the Execution Area Viewing Rooms to dim the
lights. The Warden will then open the Execution Area Viewing Room blinds and advise the
condemned inmate that those witnessing the execution may now hear his last words. A
digital audio recorder will also record them.

110.02 EXECUTION OF CONDEMNED INMATE

A. the Director will positively contact the Attorney General/designee and the
Governor/designee in person or on their direct lines in order to confirm
a possible stay of execution, order, pardon or commutation of sentence. If none exists, the
Director will inform the Warden to proceed with the execution.

B. Prior to the execution, the Warden will receive practical training in:

1. Measuring and reporting the condemned inmate’s level of consciousness.

2. Monitoring the IV sites for signs of compromise.

C. Prior to the administration of lethal drugs, an Attending Physician or properly trained and
qualified medical professional will enter the Execution Chamber Room behind a screen in
order to monitor the condemned inmate’s level of consciousness during the procedure.

D. The Warden will instruct the Drug Administrators to begin injecting the lethal drugs into the
condemned inmate as specified below.

1. It must be understood that after the infusion of the lethal drugs has begun the execution
may still be stopped, but the inmate’s respiratory and cardiovascular systems will be
progressively more compromised.

a. If the execution is ordered to be stopped at any point after the infusion of the lethal
drugs has begun, all reasonable attempts to save the inmate’s life will be made by the
Attending Physician and medical personnel present using equipment that will be
made available for that possible contingency as noted in EM 104.01 – List of Needed
Equipment, Materials and External/Internal Contacts.

b. If necessary, the inmate will be transported to the nearest emergency

room for further stabilization and medical care.

2. If at any point, the Attending Physician determines that the condemned inmate’s
responses to the lethal drugs deviates from as expected, the Drug Administrators, Warden
and Director will pause the procedure, close the Viewing Room window blinds and

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consult with the Attending Physician. Following the consultation with the Attending
Physician, the Director will then decide how to proceed from that point. If the execution
is to continue, the Viewing Room blinds will be reopened before proceeding.

3. in the following order and manner, a Drug Administrator will

administer the lethal drugs while the Attending Physician and other medical personnel,
assisted by the Warden in the Chamber Room, closely observes and measures the level of
consciousness of the condemned inmate.

a. Throughout the procedure the Warden, Attending Physician, and other medical
personnel will evaluate the patency of the IV sites by ensuring that the IV drip
chambers show continuous steady drips and that the IV sites show no signs of
compromise. If the patency of one of the IV’s is believed to be compromised, the
medical professionals will inform the Drug Administrators to use the other, patent IV
site. If both IV’s appear to be compromised, the Warden will then consult with the
Attending Physician before allowing the EMT to proceed with steps to re-establish
patent IV access.

b. After the contents of each syringe has been administered, the syringe will be removed
from the injection port and the syringe/needle unit will be placed in a new, small
sharps container labeled and provided for that purpose.

c. From Tray-1, a Drug Administrator will obtain either the Fentanyl or Alfentanil
syringes #1-1 through #1-2 containing either 2,500 micrograms of Fentanyl or 25,000
micrograms of Alfentanil. The contents of the syringes will then be administered
consecutively at the rate of one minute each.

i. Two minutes after injecting the last syringe of either Fentanyl or Alfentanil, the
Attending Physician or other medical personnel will attempt to elicit an
interpretable physical response to a verbal stimulus (i.e. move fingers, open eyes)
and to a physical stimulus in the form of a medical grade pinch. If the condemned
inmate does not respond to both attempts, the Attending Physician or other
medical personnel will inform the Drug Administrator. The Drug Administrator
will then begin injection of Ketamine.

ii. If, after the injection of the last syringe of Fentanyl or Alfentanil, the inmate
shows a response to either stimulus, the Drug Administrator shall not proceed.
The Director will consult with the Attending Physician. The Director will then
decide the next course of action, which may include:

1. Waiting and observing for an additional short period of time

2. Initiating another IV
3. Administering additional Fentanyl or Alfentanil to titrate to effect
4. Halting the execution
5. Begin with the injection of Ketamine if the IV is patent

iii. If the Director chooses actions 1, 2, and/or 3 above, after their completion the
Attending Physician or other medical personnel will attempt to elicit an

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interpretable physical response to a verbal stimulus (i.e. move fingers, open eyes)
and to a physical stimulus in the form of a medical grade pinch. If the condemned
inmate does not respond to both attempts, the Attending Physician or other
medical personnel will inform the Drug Administrator. The Drug Administrator
will then begin injection of Ketamine.

d. From Tray-2, a Drug Administrator will obtain Ketamine syringes #2-1 containing
1,000 milligrams of Ketamine. The contents of the syringe will then be administered
within two minutes.
i. One minute after the injection of 1,000 milligrams of Ketamine, the Attending
Physician or other medical personnel will attempt to elicit a response to physical
stimuli (in the form of a medical grade pinch) from the condemned inmate. If the
condemned inmate does not respond to the physical stimulus, the injection of
Ketamine will stop and, if the four-drug protocol is being used, the injection of
Cis-atracurium will begin.

ii. If, after the injection of the 1,000 milligrams of Ketamine, the inmate shows a
response to physical stimuli, the Drug Administrator shall not proceed. The
Director will consult with the Attending Physician. The Director will then decide
the next course of action, which may include:

1. Waiting and observing for an additional short period of time

2. Initiating another IV
3. Administering additional Ketamine to titrate to effect.
4. Halting the execution

v. If the Director chooses actions 1, 2, and/or 3 above, after their completion the
Attending Physician or other medical personnel will attempt to elicit an
interpretable physical response to a physical stimulus in the form of a medical
grade pinch. If the condemned inmate does not respond, the Attending Physician
or other medical personnel will inform the Drug Administrator. The Drug
Administrator will then begin either injection of Cis-atracurium (if a four-drug
protocol is being used) or Potassium (either Potassium Chloride or Potassium
Acetate) (if the three-drug protocol is being used).

e. From Tray-3, if utilizing the four-drug protocol, a Drug Administrator will obtain
Cis-atracurium syringes #3-1 through #3-4 containing 200 milligrams of Cis-
atracurium. The contents of all syringes will then be administered within one minute.

i. Two minutes after injecting the last syringe of Cis-atracurium, the Attending
Physician or other medical personnel will attempt to elicit an interpretable
physical response to a verbal stimulus (i.e. move fingers, thumbs up, open eyes)
and to a physical stimulus in the form of a medical grade pinch. If the condemned
inmate does not respond to both attempts, the Attending Physician or other
medical personnel will inform the Drug Administrator. The Drug Administrator
will then begin injection of either Potassium Chloride or Potassium Acetate.

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ii. If, after the injection of the last syringe of Cis-atracurium, the inmate shows a
response to either stimulus, the Drug Administrator shall not proceed. The
Director will consult with the Attending Physician. The Director will then decide
the next course of action, which may include:
1. Waiting and observing for an additional short period of time
2. Initiating another IV
3. Administering additional Cis-atracurium to titrate to effect.
4. Halting the execution
5. Begin with the injection of Potassium Chloride or Potassium
Acetate if the IV is patent.

iii. If the Director chooses actions 1, 2, and/or 3 above, after their completion the
Attending Physician or other medical personnel will attempt to elicit an
interpretable physical response to a verbal stimulus (i.e. move fingers, thumbs up,
open eyes) and to a physical stimulus in the form of a medical grade pinch. If the
condemned inmate does not respond to both attempts, the Attending Physician or
other medical personnel will inform the Drug Administrator. The Drug
Administrator will then begin injection of Potassium Chloride or Potassium
Acetate.

f. From Tray-4, a Drug Administrator will obtain the syringes of Potassium Chloride or
Potassium Acetate syringes #4-1 through #4-4 containing 240mEq Potassium
Chloride or Potassium Acetate. The contents of all syringes will then be administered
within two minutes. If a three-drug protocol has been used, then the Potassium
Chloride or Potassium Acetate will be obtained from Tray-3 as opposed to Tray-4, as
there will be no Tray-4. If the three-drug protocol is being utilized, the Potassium
Chloride or Potassium Acetate will be labeled syringes #3-1 through #3-4 as opposed
to #4-1 through #4-4. Under either the three-drug or four-drug protocol, the following
steps are to be followed:

i. Five minutes after injecting the last syringe of Potassium Chloride or Potassium
Acetate, the Attending Physician or other medical personnel will attempt to elicit
an interpretable physical response to a verbal stimulus (i.e. move fingers, open
eyes) and to a physical stimulus in the form of a medical grade pinch. If the
condemned inmate does not respond to both attempts, the Attending Physician or
other medical personnel in Workroom # 1 will then turn on the cardiac monitor.
The Attending Physician or other medical personnel will observe it until all signs
of electrical activity of the heart have ceased.

ii. If, at anytime after the final the injection of the last syringe of Potassium Chloride
or Potassium Acetate, but before the cardiac monitor is turned on, the inmate
shows any response to the stimulus referenced in the preceding paragraph, the
Drug Administrator shall not proceed. The Director will consult with the
Attending Physician. The Director will then decide the next course of action,
which may include:

1. Waiting and observing for an additional short period of time

2. Initiating another IV

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