2011 MLREMS Protocols

Regional

2011

Standards of Care

Updated June 30, 2011

Monroe-Livingston Regional EMS Protocols Updated June 30, 2011

TABLE OF CONTENTS

Authorization / Verification Protocol Development and Update Procedure Preface and Statement of Philosophy Definitions Levels of Care ALS Agency Definition ALS Criteria Medical Control and Hospital Communication Requirements SECTION 1 Routine Medical Care ................................................................................................................................... 1.0 Radio / Phone Failure ................................................................................................................................... 1.1 On-Scene Medical Personnel ...................................................................................................................... 1.2 Do Not Resuscitate Orders .......................................................................................................................... 1.3 Termination of Resuscitation ........................................................................................................................ 1.4 Obvious Death .............................................................................................................................................. 1.5

SECTION 2 Airway Management - ADULT ...................................................................................................................... 2.0 Airway Management - PEDIATRIC ............................................................................................................... 2.1 Airway Obstruction - ADULT ......................................................................................................................... 2.2 Airway Obstruction - PEDIATRIC ................................................................................................................. 2.3 Altered Mental Status ................................................................................................................................... 2.4 Anaphylaxis / Allergic Reaction ................................................................................................................... 2.5 Apparent Life Threatening Event (ALTE) ...................................................................................................... 2.6 Avulsed Tooth Reimplantation ...................................................................................................................... 2.7 Behavioral Emergencies ............................................................................................................................... 2.8 Burns ............................................................................................................................................................ 2.9 Chest Pain / Threatened Myocardial Infarction ........................................................................................... 2.10 Chest Trauma ............................................................................................................................................ 2.11 Conducted Energy Weapons ...................................................................................................................... 2.12 Croup .......................................................................................................................................................... 2.13 Diabetic Emergencies ................................................................................................................................ 2.14 Fluid Challenge / Replacement .................................................................................................................. 2.15 Head Trauma ............................................................................................................................................. 2.16 Hyperthermia / Heat Exhaustion / Heat Stroke ........................................................................................... 2.17 Hypotension / Shock .................................................................................................................................. 2.18 Hypothermia ............................................................................................................................................ 2.19A Hypothermic Cardiac Arrest ...................................................................................................................... 2.19B Nausea / Vomiting ...................................................................................................................................... 2.20 Near Drowning ........................................................................................................................................... 2.21 Neonatal Resuscitation ............................................................................................................................... 2.22 Obstetric Emergencies .............................................................................................................................. 2.23 Pain Management ....................................................................................................................................... 2.24 Poisoning / Overdose ................................................................................................................................ 2.25 Pulmonary Edema / CHF ........................................................................................................................... 2.26 Rapid Sequence Intubation (RSI) ............................................................................................................... 2.27 Re-establishing Patient Medication IV ........................................................................................................ 2.28 Respiratory Distress / Bronchospasm ....................................................................................................... 2.29 Sedation ...................................................................................................................................................... 2.30 Seizures ..................................................................................................................................................... 2.31 Stroke ......................................................................................................................................................... 2.32 Suspected Spinal Injuries ........................................................................................................................... 2.33 Vascular Access ......................................................................................................................................... 2.34 Ventilator Management – Emergent Prehospital ........................................................................................ 2.35 Ventilator Management – Stable Outpatient ............................................................................................... 2.36


SECTION 3 – ADULT CARDIAC LIFE SUPPORT Cardiac Arrest – General Procedures .......................................................................................................... 3.0 Ventricular Fibrillation / Pulseless Ventricular Tachycardia .......................................................................... 3.1 Post-Conversion of VF / VT ......................................................................................................................... 3.2 Asystole / Pulseless Electrical Activity .......................................................................................................... 3.3 Bradycardia .................................................................................................................................................. 3.4 Unstable Tachycardia ................................................................................................................................... 3.5 Stable Narrow Complex Tachycardia .......................................................................................................... 3.6 Stable Wide Complex Tachycardia ............................................................................................................... 3.7 SECTION 4 - PEDIATRIC CARDIAC LIFE SUPPORT Cardiac Arrest – General Procedures……………….…………………………………………………………….. 4.0 Ventricular Fibrillation / Pulseless Ventricular Tachycardia…………..………………………………………… 4.1 Post-Conversion of VF / VT…………………………………….……………………………………………………4.2 Asystole / Pulseless Electrical Activity………………..…………………………………………………………… 4.3 Bradycardia ……………………..………………………………………………………………………………….. 4.4 Unstable Tachycardia……..……………………………………………………………………………………….. 4.5 Stable Narrow Complex Tachycardia……………………………………………………………………………… 4.6 Stable Wide Complex Tachycardia………..……………………………………………………………………… 4.7 SECTION 5 – BLS PHARMACOLOGY Activated Charcoal ...................................................................................... ................................................. 5.1 Albuterol ...................................................................................................... ................................................. 5.2 Aspirin ......................................................................................................... ................................................. 5.3 Epinephrine ................................................................................................. ................................................. 5.4 Nitroglycerin ................................................................................................ ................................................. 5.5 Oral Glucose ............................................................................................... ................................................. 5.6 Oxygen ....................................................................................................... ................................................. 5.7 SECTION 6 – ALS PHARMACOLOGY Activated Charcoal ...................................................................................... ................................................. 6.1 Adenosine (Adenocard) .............................................................................. ................................................. 6.2 Albuterol ...................................................................................................... ................................................. 6.3 Amiodarone (Cordarone) ............................................................................ ................................................. 6.4 Aspirin ......................................................................................................... ................................................. 6.5 Atropine Sulfate .......................................................................................... ................................................. 6.6 Calcium Chloride ........................................................................................ ................................................. 6.7 Dextrose ..................................................................................................... ................................................. 6.8 Diphenhydramine (Benadryl) ...................................................................... ................................................. 6.9 Dopamine Hydrochloride ............................................................................ ............................................... 6.10 Epinephrine ................................................................................................. ............................................... 6.11 Etomidate (Amidate) RSI ONLY ................................................................. ............................................... 6.12 Glucagon .................................................................................................... ............................................... 6.13 Ipratropium (Atrovent) ................................................................................. ............................................... 6.14 Lidocaine (Xylocaine) ................................................................................. ............................................... 6.15 Magnesium Sulfate ..................................................................................... ............................................... 6.16 Metoprolol ................................................................................................... ............................................... 6.17 Midazolam (Versed) .................................................................................... ............................................... 6.18 Morphine Sulfate ......................................................................................... ............................................... 6.19 Naloxone (Narcan) ...................................................................................... ............................................... 6.20 Nitroglycerin ................................................................................................ ............................................... 6.21


SECTION 6, continued Oxygen ....................................................................................................... ............................................... 6.22 Promethazine (Phenergan) ......................................................................... ............................................... 6.23 Sodium Bicarbonate ................................................................................... ............................................... 6.24 Succinylcholine (Anectine) RSI ONLY ........................................................ ............................................... 6.25 Vecuronium (Norcuron) RSI ONLY ............................................................. ............................................... 6.26 Diltiazem (Cardizem) - Optional .................................................................. ............................................... 6.27 Procainamide - Optional ............................................................................. ............................................... 6.28 APPENDIX Glasgow Coma Scale – ADULT Glasgow Coma Scale – PEDIATRIC Trauma Triage Criteria – ADULT Trauma Triage Criteria – PEDIATRIC Normal Weights, Vitals – PEDIATRIC Airway Equipment Sizes – PEDIATRIC APGAR Chart Rule of 9’s Area Hospital Information Dopamine Infusion Chart Medication and Dosage Sheet


AUTHORIZATION / VERIFICATION The Regional Emergency Medical Advisory Committee (REMAC) of the Monroe-Livingston Regional Emergency Medical Services Council (MLREMSC) and the Monroe-Livingston Regional EMS Medical Director attest that these Prehospital Emergency Medical Care Standards are reasonable and consistent with standard medical practices in Livingston and Monroe Counties in the State of New York. These protocols constitute standards for physician supervision for the Advanced Life Support Systems in the Counties of Monroe and Livingston in the State of New York, as required by Article 30, subsection 31 of the State of New York Public Health Law, as well as the requirements for medical direction specified in Part 800 of the Codes and Regulations of the State of New York. The Monroe-Livingston Regional Emergency Medical Advisory Committee further attests that these protocols constitute the standard of care to be observed by all EMS providers when practicing within the Monroe-Livingston Regional Emergency Medical Services System. The protocols contained herein are effective as of June 30, 2011.

Jeremy T. Cushman, MD, MS, EMT-P, FACEP System Medical Director, Monroe-Livingston Region

Rollin J. “Terry” Fairbanks, MD, MS, EMT-P, FACEP Chair, Monroe-Livingston REMAC


PROTOCOL DEVELOPMENT

These protocols have been developed by the Protocol Sub-Committee and presented for a period of public comment before being approved collectively by the Monroe-Livingston Regional Emergency Medical Advisory Committee (REMAC).

Protocol Sub-Committee Members

Nicole Acquisto, Pharm. D Sheri Adam, EMT-P Robert Breese, EMT-P Kevin Clarke, EMT Jeremy Cushman, MD (Chair) Elizabeth Darrow, EMT-P Rollin J. (Terry) Fairbanks, MD Chris Forsyth, EMT-P

Dick Garrett, EMT-P A. Zachary Hettinger, MD Marc Lampell, MD Bryan McKinley, EMT-P Richard Race, EMT-P Manish Shah, MD Terry Taylor, EMT-P Bruce Thompson, MD

REMAC Members Sheri Adam, EMT-P Robert Breese, EMT-P Charles Cavallaro, MD Jeremy Cushman, MD Tim Czapranski, EMT-P Liz Darrow, EMT-P Eric Davis, MD (Honorary) Stephanie Elsen, MD Rollin J. (Terry) Fairbanks, MD (Chair) Tim Frost, EMT-P A. Zachary Hettinger, MD John Hilmi, MD Julie Jordan, EMT-P Bill Joyce, EMT

David Kluge, MD (Honorary) Michael Kuder, EMT-P Marc Lampell, MD Jan Lloyd, EMT Joe Meath, EMT-P George Nasra, MD Kevin O’Gara, MD Amy Pollard Erik Rueckmann, MD Manish Shah, MD Bill Sheahan, EMT-P Bruce Thompson, MD Mark Tornstrom, EMT-P Steven Wolfe, MD

PROTOCOL UPDATE PROCEDURE

These protocols will be reviewed and updated as necessary. New procedures or updates to old procedures will be distributed throughout the system through provider agencies and to individual ALS providers when feasible. Pages should be replaced or added as future modifications occur. All updates/changes must first be approved by the Monroe-Livingston Regional Medical Advisory Committee (REMAC). Suggestions for changes or additions to the protocols may be made by contacting:

Monroe-Livingston Regional Program Agency

601 Elmwood Avenue, Box 655 Rochester, NY 14642

(585) 463-2900 [email protected]


PREFACE This document represents the Standards of Prehospital Care of the Monroe-Livingston Emergency Medical Services System. This document has been approved by the Monroe-Livingston Regional Emergency Medical Advisory Committee (REMAC) as the standard of care and is to be followed at all times by all EMS providers practicing in Monroe and Livingston Counties. Furthermore, they are designed to act as standing orders within the guidelines under radio and phone failure.

Protocols are listed in an algorithm format, and lengthy discussion of signs/symptoms, pathophysiology, and technique have been purposely excluded to allow for efficient use. The protocols assume the provider is already familiar with emergency medical care up to the level of their certification, and the emergency situations contained in the document. Many of the Adult and Pediatric Protocols are contained in the same Patient Care Section; however pediatric-specific medication dosages are denoted by the teddy bear icon: . If a medication dosage does not have the teddy bear icon next to it, it is not to be given to a pediatric patient and is meant for adult patients only.

A section on Monroe Livingston Regional policies and procedures relating to the provision of medical care has been included in this document. This allows for a common location of all documents that reflect patient care in the region.

An additional section to this document is the Specialty Care Transport Protocols which are to be used only by those providers credentialed as Specialty Care Transport Paramedics within the Monroe-Livingston EMS System. While published as a separate document due to its specialized nature, it is an integral part of the protocols that are used in this system.

An additional section to this document is the HAZMAT Protocols which are to be used only by those providers credentialed as Tox Medics within the Monroe-Livingston EMS System. While published as a separate document due to its specialized nature, it is an integral part of the protocols that are used in this system.

Additional appendices are included for reference purposes.

STATEMENT OF PHILOSOPHY No protocol can be written to cover every situation that a provider may encounter while practicing prehospital medicine, nor are protocols a substitute for the judgment and experience of the provider. Providers are expected to utilize their best clinical judgment and deliver care and procedures according to what is reasonable and prudent for specific situations, however, it will be expected that any deviations from protocol be documented.

Advanced providers should be prepared to administer additional treatments beyond what is called for in these protocols when directed to do so by a duly designated Medical Control Physician, and such additional treatment/procedures do not conflict with or exceed the scope of the advanced provider’s training.

Any order given to an advanced provider by any Physician (Medical Control Physician or otherwise), which directly contradicts or lies outside the advanced provider’s scope of training must be respectfully declined.


DEFINITIONS The following definitions are used throughout this document: Adult Person at least 12 yrs old or of such physical development and/or size to dictate treatment as an adult AED Automatic External Defibrillator ALS Advanced Life Support AMI Acute Myocardial Infarction BG Blood Glucose BLS Basic Life Support CFR Certified First Responder CPAP Continuous Positive Airway Pressure CPR Cardiopulmonary Resuscitation CVA Cerebrovascular Accident DNR Do Not Resuscitate ECG Electrocardiogram EMS Emergency Medical Services EMT Emergency Medical Technician – Basic EMT-CC Emergency Medical Technician – Critical Care EMT-I Emergency Medical Technician – Intermediate EMT-P Emergency Medical Technician – Paramedic ET Endotracheal ETT Endotracheal Tube GCS Glasgow Coma Scale ILS Intermediate Life Support IM Intramuscular IO Intraosseous IV Intravenous mL Milliliter MOLST Medical Orders for Life Sustaining Treatment MVC Motor Vehicle Collision Neonate Same as a Newborn Newborn A patient prior to their first hospital discharge NYS New York State PCR Prehospital Care Report Pediatric Person who does not qualify as an adult REMAC Regional Emergency Medical Advisory Committee RSI Rapid Sequence Intubation SCT Specialty Care Transport


LEVELS OF CARE

This document is designed for use by Emergency Medical Personnel certified at varying levels of care. The levels are as follows:

CFR: A first responder certified by New York State. Follows specific NYS Certified First Responder

protocols and may provide ONLY the following additional skills in the Monroe-Livingston Region as indicated in the following protocols under ALL LEVELS, if agency is authorized to perform and if previously trained by a NYS certified instructor:

• Blood pressure • Spinal immobilization • Administration of oral glucose

EMT-B: A technician certified by New York State as an Emergency Medical Technician trained in the use of a

semi-automatic defibrillator and other assessment and treatment skills per the NYS EMT curriculum. If trained, may include skills such as Epi-Pen, Albuterol, or blood glucose level determination.

EMT-I: A technician certified by New York State as an Emergency Medical Technician - Intermediate. Includes

skills in airway management, and IV fluid administration in addition to the skills of an EMT-B. EMT-I’s may NOT intubate patients, but may place an alternative airway device.

EMT-CC: A technician certified by New York State as an Emergency Medical Technician - Critical Care.

Includes skills in advanced airway management, IV fluid administration, cardiac monitoring/defibrillation, and medication usage/administration. EMT-CCs may NOT intubate pediatric patients.

EMT-P: A technician certified by New York State as an Emergency Medical Technician - Paramedic. Includes

skills in advanced airway management, IV fluid administration, cardiac monitoring/defibrillation, and medication usage/administration and additional training in physiology and pathophysiology.

Although providers are certified at one of the above levels, the standard of care to which they practice on a call is related to the level of care provided by the agency for which they are responding and are not responsible for interventions or assessments higher than the agency’s level.

ALS AGENCY DEFINITION

An ALS agency in the Monroe-Livingston Region is one that can fulfill all levels of care specified within these Standards of Care with the exception of Rapid Sequence Induction which is an optional regional program. All ALS agencies must be able to provide narcotic pain relief and benzodiazepines for sedation or seizure control in order to be considered an ALS agency in the Monroe-Livingston Region after April 30, 2010. Failure to do so will prevent the agency from practicing above the ILS level.

ALS CRITERIA

Dispatch centers should utilize nationally recognized Emergency Medical Dispatch protocols that have been reviewed with their Medical Director to recommend Advanced Life Support (ALS) on any potentially serious illness or injury. First Responders or BLS/ILS crews should request ALS, or begin transport to the nearest hospital (if hospital closer than ALS or if ALS can meet en route) should they identify the need for such a resource.


MEDICAL CONTROL AND HOSPITAL COMMUNICATIONS REQUIREMENTS Medical Control may be contacted at any time by any level if there is a question or concern, or if the provider would like additional guidance. Follow the hospital’s local policy for pre-arrival notification for circumstances not described herein. Providers may not practice beyond the “STOP” line for their level of certification, even with Medical Control Authorization Medical Control is indicated prior to the medication/procedure anytime the telephone logo appears next to the procedure or medication: All levels must consult Medical Control BLS providers must consult Medical Control; EMT-CC, EMT-P Standing Order EMT-CC must consult Medical Control; EMT-P Standing Order EMT-P must consult Medical Control

ABSOLUTE ONLINE Protocols below the “ABSOLUTE ONLINE” line require On-line physician direction for any level, no exception for radio/phone failure


Monroe-Livingston Regional EMS

Protocols

Section 1


1.0 ROUTINE MEDICAL CARE 1. Determine if patient has capacity to make decisions. For patients without capacity, EMS providers should perform

care under the concept of implied consent. Patients without capacity cannot refuse medical treatment.

Capacity Assessment Criteria: a. Ability to clearly demonstrate awareness of person, place, period of time and problem b. Ability to clearly demonstrate ”decisional capacity“ by expressing understanding of the situation, being

able to explain their decision to consent or refuse in rational terms, and demonstrating an understanding of the risks and benefits of a decision or action

c. Not suicidal and not a threat of harm to others 2. Appropriate equipment to provide oxygenation, ventilation and patient assessment should be brought to the patient,

along with an AED or cardiac monitor and the means (stairchair, backboard, or stretcher) to appropriately move the patient from the scene to the ambulance. Equipment should be specific for the size and age of the patient. ALS should also bring medications and advanced airway equipment as appropriate.

3. At least one full set of vital signs should be taken on all patients. If the patient refuses, document at least the patient’s respiratory rate and quality, and any other assessment parameters such as skin color, neurologic assessment and GCS.

4. Serial vital signs including pulse oximetry and pain scale should be completed every 15 minutes for non-critical

patients and every 5 minutes for critical patients whenever possible. Document vital signs and patient response after any medication administration. If patient care or other extenuating circumstances do not allow for this frequency, the reason should be documented on the PCR.

5. Oxygen therapy, suction, and ventilatory assistance as needed per protocol and to the provider’s training level.

Apply appropriate oxygen delivery device (nasal cannula or non-rebreather mask) and flow rate to maintain SpO2 ≥ 96%. If unable to obtain accurate pulse oximeter reading, apply non-rebreather mask with appropriate flow rate. If patient has history of COPD or is on home oxygen, continue home oxygen flow rate and delivery device unless contraindicated by patient’s presentation.

6. Trauma patients meeting New York State Major Trauma Criteria (see Appendix) should be transported to the

nearest regional trauma center unless the patient has an unmanageable airway or is in cardiac arrest, in which case the patient should be transported to the nearest emergency department.

7. Contact with the receiving hospital should be made per receiving hospital guidelines and as soon as possible in the following circumstances: a. Patients meeting trauma triage criteria b. Patients with evidence of an acute stroke or myocardial infarction c. Patients in cardiopulmonary or respiratory arrest d. Any unstable patient

8. Should the ALS provider not have the ability to call Medical Control, another provider or dispatcher should contact

the receiving hospital to notify the physician/staff of a patient’s unstable condition.

9. Timely transport to the receiving hospital should occur in all cases. Use of lights and sirens on such calls should be at the discretion of the provider in charge, and should be based on the stability of the patient, the need for stabilizing procedures such as airway management or drug administration at the scene, the need for procedures/medications available only at the hospital, etc. The provider in charge should also consider the possibility of increased risk to patient and crew in deciding on use of lights and sirens.

Protocol continued on next page


1.0 ROUTINE MEDICAL CARE (continued) 10. Crew safety during transport is a high priority. All crew and patients should be secured by a seat belt while the

vehicle is in motion. Patient care providers should only move freely to provide critical patient care interventions such as CPR, airway management, and medication administration. All patient care equipment should be secured by a strap, clip, or mount or placed within a cabinet.

11. When possible, transport pediatric patients in car seats appropriate for age. 12. Provide patient care consistent with NYS BLS Protocols and for the patient’s specific complaint using the

appropriate protocol included herein. 13. The patient care interaction and all procedures performed and medications given must be documented in the PCR. 14. Blood glucose determination is mandatory for patients with diabetes, seizure disorder, syncope, and any patient

with altered mental status when cared for by an ALS provider. It is recommended for all other patient presentations as time and patient condition allows. Blood Glucose monitoring can only be done using a Blood Glucometer. Chemstrips are not allowed.

EMT STOP 15. Establish vascular access as appropriate.

16. Establish an alternate advanced airway as appropriate. EMT-I STOP 17. Establish an advanced airway as appropriate. 18. Monitor ECG on appropriate patients including all patients with potential cardiac problems. A 12 lead ECG is

required for patients with potential myocardial infarction, angina, syncope, or other appropriate problems as specified in protocol. A copy of the ECG strip(s) must be attached to the PCR. An AED may not be used as an ECG monitor.


1.1 RADIO / PHONE FAILURE Situations may occur where communications with Medical Control cannot be established due to one or more of the

following: 1. The crew does not have cellular service and no telephones or radios are available at the scene 2. No physician is available at the Medical Control base station 3. EMS providers are operating as part of a mutual aid disaster response outside of the Monroe-Livingston region In the event of the above, all protocols listed in this document become standing orders for use by the EMT-I, EMT-CC or EMT-P with the exception of those orders so identified as “Absolute Online”. Absolute Online orders may only be performed by a direct verbal order from a physician and may not be performed on standing orders under any circumstances. Any instance of radio/phone failure must be documented. Further, the event must be reported to the Agency Director of Operations, the Agency Medical Director, and the Monroe-Livingston Program Agency by the next business day.


1.2 ON SCENE MEDICAL PERSONNEL PATIENT'S PERSONAL PHYSICIAN

If the patient's personal physician is on the scene, they may assume responsibility for the patient. The physician wishing

to assume responsibility for the patient must:

1. Write all orders for the EMS provider on the PCR. 2. Sign for their orders on the PCR. 3. If the physician refuses to sign, Medical Control is to be contacted. Unless the physician accompanies the patient to the hospital, standard operating procedures and standing orders will

prevail if the patient’s condition deteriorates and/or other procedures are required. If the patient's personal physician accompanies the patient to the hospital, he/she continues to assume full responsibility for all orders and patient care decisions. The EMS provider will decline any orders that are contrary to, or exceed the level of their training.

BYSTANDER PHYSICIAN

A bystander physician wishing to assume responsibility for a patient may do so only after approval from the Medical

Control Physician. If a bystander physician wishes to assume responsibility for the patient, they must:

1. Write all orders for the EMS provider on the PCR. 2. Sign for their orders on the PCR. 3. Accompany the patient to the hospital. If the physician does not agree to accompany the patient to the hospital, standard operating procedures and standing

orders will prevail both on scene and during transport. If the physician accompanies the patient to the hospital, he/she continues to assume full responsibility for all patient care decisions. The EMS provider will decline any orders that are contrary to or exceed the level of their training. The EMS provider should make reasonable effort to verify the credentials and qualifications of the bystander physician prior to involving them in patient care. If doubt exists, Medical Control should be contacted and system protocols shall dictate patient care.

If approval from Medical Control cannot be obtained, the bystander physician may not assume responsibility for the

patient, and the EMS provider will follow system protocols. REGISTERED NURSE, PHYSICIANS ASSISTANT, LICENSED PRACTICAL NURSE, ETC.

Non-physician medical personnel may assist with patient care under direction of the EMS provider, but may not be in

charge of, or assume responsibility for patient care.

OTHER PRE-HOSPITAL CARE PROVIDERS Off-Duty EMS personnel and On-Duty personnel from a lower scope of practice agency may assist with patient care

under the direction of the EMS providers on scene but may not be in charge of, or assume responsibility for patient care.


1.3 DO NOT RESUSCITATE ORDERS The following procedure is to be used in determining course of action for all patients. For conscious, alert patients, their

wishes are to be followed according to standard consent procedures. For unconscious patients, the following steps should be followed:

1. Determine presence of valid DNR at the scene:

a. Signed New York State approved document, bracelet, or necklace; b. Properly documented nursing home or hospital DNR form; c. Properly completed Medical Orders for Life Sustaining Treatment (MOLST) form.

2. If DNR document, bracelet or necklace is not present - begin standard treatment per protocol 3. If DNR document, bracelet or necklace is present, and is valid for the patient’s condition, check presence of pulse:

If pulse is present: Provide comfort measures such as oxygen, airway suctioning, and transport as requested by patient, family, or patient’s private physician. If additional care is specified on a properly completed MOLST form, follow those instructions.

If pulse not present: Contact local police, who will contact the Medical Examiner/Coroner


1.4 TERMINATION OF RESUSCITATION CRITERIA

• For patient’s meeting Do Not Resuscitate criteria, refer to Do Not Resuscitate Protocol (1.3). • For patients with obvious death, refer to Obvious Death Protocol (1.5). • Patient’s must meet all of the following requirements for termination of resuscitative efforts to occur:

• Age 18 or older • Non-traumatic, non-hypothermic • ECG is asystole confirmed in three leads, ventricular standstill, or pulseless idioventricular rhythm with a

rate < 10 beats per minute • Cardiac arrest protocols have been followed for at least 25 minutes, including successful intubation or

advanced alternate airway, IV/IO access, adequate CPR, and appropriate pharmacologic therapy • There has been no return of a perfusing cardiac rhythm at any time during at least 25 minutes of

resuscitative measures • Patient is not in a public place • Appropriate emotional support by family, neighbors, clergy, police, or EMS crewmembers is available at

the scene if the family is present

ABSOLUTE ONLINE 1. Follow cardiac arrest protocols for at least 25 minutes.

2. Assure all of the above criteria have been met. 3. Obtain authorization from Medical Control to terminate resuscitative efforts. 4. Terminate resuscitative efforts. 5. Contact Medical Examiner /Coroner through police officer, telephone, or other appropriate means. Do not remove

endotracheal tubes, king airways or IV/IO tubing. The patient may be covered, and may be moved back onto a bed or sofa if appropriate.

TRANSPORT TO THE HOSPITAL SHOULD BE INITIATED IF ANY OF THE ABOVE CRITERIA ARE NOT MET, OR

IF THE FAMILY OR THE PATIENT’S PRIVATE PHYSICIAN (if contacted) DISAGREE WITH TERMINATION OF EFFORTS AT THE SCENE.

PATIENTS ALREADY MOVED TO AN AMBULANCE ARE NOT ELIGIBLE FOR TERMINATION OF

RESUSCITATION IN THE FIELD, AND MUST BE TRANSPORTED TO THE HOSPITAL.


1.5 OBVIOUS DEATH CRITERIA

• CPR and ALS treatment are to be withheld only if the patient is obviously dead or has a valid Do Not Resuscitate order, refer to Do Not Resuscitate Protocol (1.3).

• If the patient has no pulse and meets one or more of the following criteria for obvious death, CPR and ALS

therapy need not be instituted: • Body decomposition • Rigor mortis with warm air temperature • Dependent lividity • Injury not compatible with life (i.e. decapitation, burned beyond recognition, massive open or penetrating

trauma to the head or chest with obvious organ destruction)

• All cases of hypothermia should receive full resuscitative efforts, refer to Hypothermia Protocol (2.19A or B).

1. Verify apnea and pulselessness 2. Verify that the patient meets obvious death criteria as defined above

If doubt exists, start resuscitation immediately. Once initiated continue resuscitation efforts until one of the following occurs: • Resuscitation efforts meet criteria for Field Termination Protocol (1.4). • Patient care responsibilities are transferred to the transporting provider or the destination hospital staff. • Return of spontaneous pulse.

Medical Control must be contacted in the following circumstances before following the Obvious Death Protocol:

• If a bystander or first responder has initiated CPR or Automatic External Defibrillation prior to EMS arrival and

any of the obvious death criteria are present. • If the patient was submerged for greater than one hour in any water temperature


Monroe-Livingston Regional EMS Protocols

Section 2

Patient Care


2.0 AIRWAY MANAGEMENT - ADULT 1. Establish a patent BLS airway.

• Manually open airway as needed • Head tilt / chin lift (non-trauma) • Modified jaw thrust (trauma)

2. Suction as needed. 3. Oropharyngeal or nasopharyngeal airway as needed unless contraindicated. 4. If ventilation status is inadequate, use positive pressure ventilation utilizing BVM with high concentration oxygen to

ventilate at a rate of 10-12 breaths per minute. Support spontaneous ventilations at an appropriate rate. EMT STOP 5. If in respiratory/cardiac arrest, establish an advanced airway utilizing an alternative airway device. Verify placement

and continuously monitor with waveform capnography. 6. Ventilate to maintain EtCO2 38-42 mmHg. EMT-I STOP 7. If necessary, establish an advanced airway:

• Orotracheal intubation (using manual in-line neck stabilization for trauma) may be attempted twice with an attempt being defined as placing a laryngoscope blade in the oropharynx. The patient must be ventilated between attempts.

• If unable to intubate, continue use of BLS airway adjuncts or use alternate airway device. • Early use of an alternative airway device is encouraged.

8. Following intubation, ventilate patient with bag valve device and 100% oxygen. Auscultate for bilateral breath

sounds and absence of epigastric sounds. Verify placement and continuously monitor with waveform capnography. 9. Secure endotracheal tube and ventilate to maintain EtCO2 38-42 mmHg. EMT-CC STOP 10. If unable to establish patent airway and unable to ventilate using BLS techniques or alternate airway device,

perform needle or surgical cricothyrotomy. Verify and manage as indicated above. Medical Control must be advised after performing procedure.


2.1 AIRWAY MANAGEMENT - PEDIATRIC 1. Establish a patent airway.

• Manually open airway as needed • Head tilt / chin lift (non-trauma) • Modified jaw thrust (trauma)

2. Suction as needed. 3. Oropharyngeal or nasopharyngeal airway as needed unless contraindicated. 4. If ventilation status is inadequate, use positive pressure ventilations utilizing BVM with high concentration oxygen to

ventilate at a rate of 12-20 breaths per minute. Support spontaneous ventilations as necessary. EMT STOP EMT-I STOP EMT-CC STOP 5. If necessary, establish an advanced airway:

• Orotracheal intubation (using manual in-line neck stabilization for trauma) may be attempted twice with an attempt being defined as placing a laryngoscope blade in the oropharynx. The patient must be ventilated between attempts.

• If unable to intubate, continue use of BLS airway adjuncts or use alternate airway device. • Early use of an alternative airway device is encouraged.

6. Following intubation, ventilate patient with bag valve device and 100% oxygen. Auscultate for bilateral breath

sounds and absence of epigastric sounds. Verify placement and continuously monitor with waveform capnography. 7. Secure endotracheal tube and ventilate to maintain EtCO2 38-42 mmHg. 8. If unable to establish patent airway and unable to ventilate using BLS techniques, perform needle cricothyrotomy.

Verify and manage as indicated above. Medical Control must be advised after performing procedure.


2.2 AIRWAY OBSTRUCTION - ADULT

Conscious patient Adequate air exchange (able to cough, speak, or breathe) 1. Reassure patient and place in position of comfort. 2. Encourage coughing. Clear oropharynx as needed. 3. Administer high flow oxygen. Inadequate air exchange (cannot cough, speak, or breathe) 4. Administer continuous abdominal thrusts (Heimlich Maneuver; chest thrusts on pregnant patient) until adequate air

exchange is restored or the patient loses consciousness.

Unconscious patient 5. Manually open airway, attempt to ventilate with 2 breaths. If unable to ventilate, reposition and reattempt to

ventilate. 6. Administer CPR. 7. Suction and finger sweep only if object visible. 8. Repeat this sequence from #5 as needed and begin timely transport. EMT STOP EMT-I STOP 9. Attempt direct laryngoscopy and removal of foreign object with Magill forceps. EMT-CC STOP 10. If unable to oxygenate and ventilate by any other means, perform needle or surgical cricothyroidotomy. Verify and

manage per Adult Airway Management Protocol (2.0). Contact Medical Control following all cricothyroidotomy attempts.


2.3 AIRWAY OBSTRUCTION - PEDIATRIC

Conscious patient: Airway should not be unnecessarily stimulated or examined in the situation of possible epiglottis or croup. Adequate air exchange (able to cough, speak, breathe, or cry) 1. Reassure patient and place in position of comfort. 2. Encourage coughing. Clear oropharynx as needed. DO NOT PERFORM BLIND FINGER SWEEPS. 3. Administer high flow oxygen. Inadequate air exchange (cannot cough, speak, breathe, or cry) 4. Age <1 yr: Administer 5 back slaps with head lower than body Administer 5 chest thrusts Repeat as necessary

Age >1 yr: Administer continuous abdominal thrusts (Heimlich maneuver) until adequate air exchange is restored, or patient

loses consciousness.

Unconscious patient: 5. Manually open airway, attempt to ventilate with 2 breaths. If unable to ventilate, reposition and reattempt to

ventilate. 6. Administer CPR. 7. Suction and finger sweep only if object visible. 8. Repeat this sequence from #5 as needed and begin timely transport. EMT STOP EMT-I STOP 9. Attempt direct laryngoscopy and removal of foreign object with Magill forceps. 10. If initial efforts to dislodge object are unsuccessful, begin timely transport and continue efforts enroute. EMT-CC STOP 11. If not seen supraglottically, attempt to push the object with right mainstem intubation. 12. If object seen supraglottically, and if unable to oxygenate and ventilate by any other means, perform needle

cricothyroidotomy. Verify and manage per Pediatric Airway Management Protocol (2.1). Contact Medical Control following all cricothyroidotomy attempts.


2.4 ALTERED MENTAL STATUS CRITERIA

• Decreased level of consciousness from all causes should be treated using protocol below. • An ALS evaluation (including BG, SPO2, and ECG) should be performed on all patients whose mental status is

decreased and on all patients over the age of 35 who have had a syncopal episode. 1. Routine medical care. 2. Assure airway patency and administer oxygen per protocol. 3. Assess signs, symptoms, hemodynamic status, medical history, possibility of poisoning, etc. 4. Consider need for spinal immobilization as appropriate. 5. Assess Blood Glucose (BLS if available) and refer to Diabetic Emergencies Protocol (2.14) if BG < 80 mg/dl. 6. All patients with an altered mental status should have timely transport to the hospital. 7. Consider other possible causes of decreased level of consciousness and refer to the appropriate protocol:

• head trauma - refer to Head Trauma Protocol (2.16) • postictal - refer to Seizure Protocol (2.31) • meningitis or other infectious processes – refer to agency infectious disease plan • hypoxia – refer to Airway Management Protocols (2.0-2.3) • stroke – refer to Stroke / CVA Protocol (2.32) • overdose – refer to Poisoning / Overdose Protocol (2.25)


2.5 ANAPHYLAXIS / ALLERGIC REACTION CRITERIA

• Respiratory distress (wheezing, stridor, or use of respiratory accessory muscles) • Tongue, oropharynx, or uvular swelling • Hives, itching, or flushing • Signs of shock • Auscultation of unusual/abnormal breath sounds (wheezing, stridor), or markedly decreased movement of air

1. Routine medical care including oxygen saturation if available. 2. Assure airway patency and administer oxygen per protocol. 3. Assess signs, symptoms, and hemodynamic status. 4. If symptoms of shock, airway swelling or respiratory distress are present and:

• The patient has their own anaphylactic emergency kit, the provider may assist the patient in administering the kit’s contents or

• If the BLS agency has completed registration as an EpiPen agency, the provider has been trained in its use and an auto injector Epinephrine device (0.3 mg IM) is available, the provider may administer the device’s contents.

• If the patient has not had an epinephrine autoinjector previously prescribed, Medical Control must be contacted before BLS may administer.

Use EpiPen Jr./Pediatric auto-injector (0.15 mg IM) for children under 30 kg (66 lbs).

5. Begin timely transport. If Epinephrine has been given, ALS must transport with the patient, but do not delay

transporting the patient while waiting for ALS. EMT STOP 6. If evidence of shock, establish vascular access and administer fluid challenge per protocol (2.34, 2.15). EMT-I STOP



2.5 ANAPHYLAXIS / ALLERGIC REACTION, continued Allergic Reaction without Signs of Anaphylaxis (Localized symptoms or hives with no respiratory distress or signs of

shock)

7. Diphenhydramine (Benadryl) 50 mg IV/IO (May be given IM if IV/IO not available)

Diphenhydramine 2 mg/kg IV/IO (Max 25 mg) (May be given IM if IV/IO not available) Anaphylaxis (Respiratory distress or signs of shock)

8. Epinephrine 1:1000 0.3 mg IM, repeat every 5 minutes as needed Epinephrine 1:1000 0.01 mg/kg IM (Max 0.3 mg), repeat every 5 minutes as needed NOTE: Never administer Epinephrine 1:1000 via IV/IO route. 9. Diphenhydramine (Benadryl) 50 mg IV/IO (if not already given, may be given IM if IV/IO not available)

Diphenhydramine 2 mg/kg IV/IO (Max 25 mg) (if not already given, may be given IM if IV/IO not available)

10. If wheezing present:

Albuterol 5 mg and Ipratroprium Bromide (Atrovent) 0.5 mg by nebulizer. May be mixed and given simultaneously and may be given via bag-valve mask if necessary

Albuterol 2.5 mg and Ipratroprium Bromide (Atrovent) 0.5 mg by nebulizer. May be diluted with NS to 5 mL. May be given via bag-valve mask if necessary

11. If patient with profound shock and poor perfusion:

Epinephrine 1:10,000 0.5 mg slow IV/IO

Epinephrine 1:10,000 0.01 mg/kg (Max 0.3 mg) slow IV/IO EMT-CC STOP 12. If Epinephrine not effective, or if patient on beta-blocker:

Glucagon 1 mg IV/IO, may repeat once (Adult only) 13. If hypotension persists, consider vasopressor therapy per Hypotension / Shock Protocol (2.18)


2.6 APPARENT LIFE THREATENING EVENT (ALTE) CRITERIA

• An episode in an infant or child less than 2 years old which is frightening to the observer and is characterized by one or more of the following: • Apnea (central or obstructive) • Skin color change: cyanosis, erythema (redness), pallor, plethora (fluid overload) • Marked change in muscle tone • Choking or gagging not associated with feeding or a witnessed foreign body aspiration • Seizure-like activity

1. Routine medical care. 2. Assure airway patency and administer oxygen per protocol. 3. Timely transport to the emergency department. If the parent or guardian refuses medical care or transport, the

provider must contact Pediatric Medical Control. BLS cannot cancel ALS for ALTE. EMT STOP EMT-I STOP 4. Place patient on cardiac monitor. 5. Consider initiating IV access per protocol (2.34). NOTE

Most patients will appear stable and exhibit a normal physical exam. However, this episode may be a sign of underlying serious illness or injury and further evaluation by medical staff is strongly recommended. The provider must explain the potential risks of refusal to the caretaker on scene. In the event that the legal guardian is not with the patient and transport is being refused, it is recommended that the legal guardian be contacted.


2.7 AVULSED TOOTH REIMPLANTATION CRITERIA

• Only reimplant permanent teeth • Best chance for success is when reimplantation occurs less than 5 minutes from injury • Do not reimplant if the alveolar bone / gingiva are missing or if the root is fractured • Do not reimplant if the patient is immunosuppressed or reports having cardiac issues that require antibiotics

prior to procedures • Do not reimplant if the patient requires spinal immobilization • If not candidate for reimplantation, place tooth in interim storage media (low fat milk, patients’ saliva, or saline)

and keep cool. Avoid tap water storage but do not allow the permanent tooth to dry.

1. Routine medical care 2. Assure airway patency and administer oxygen per protocol 3. Assess signs, symptoms, hemodynamic status, and medical history 4. Consider need for spinal immobilization as appropriate (if spinal immobilization needed, do not reimplant) 5 Patients with an altered mental status should not be considered candidates for dental reimplantation 6. Hold the tooth by the crown 7. Quickly rinse the tooth with saline before reimplantation but do not brush off or clean tooth of tissue

8. Rinse and suction the clot from the socket

9. Reimplant tooth firmly into socket with digital pressure

10. Have the patient hold tooth in place using gauze and bite pressure

11. Report to hospital staff the efforts made to reimplant tooth


2.8 BEHAVIORAL EMERGENCIES CRITERIA

Any patient who demonstrates potentially violent behavior regardless of underlying diagnosis, who continues to resist against appropriately applied restraints, and needs facilitation of physical restraint.

CAUTION

Agitation may signal a physiologic deterioration of the patient and accompany hypoxia, hypoglycemia, cerebral edema, or other medical problems. Treatment of medical disorders should always be done prior to any chemical restraint.

1. Assess mental, emotional, and physical status thoroughly including all other potential causes of aggressive

behavior. Other causes should be treated first, which may be sufficient to resolve the aggressive behavior. 2. Attend to medical or trauma needs as per protocol.

No patient will be transported without law enforcement presence if his or her emotional or mental status poses a threat

to patient or crew safety.

Follow ‘Management of Violent and Potentially Violent Behavior’ procedures (Policy 9.3). If unable to manage with physical restraints, consider chemical restraints below.

EMT STOP EMT-I STOP

3. If patient is at immediate risk of harming themselves or others:

Midazolam (Versed) up to 2.5 mg IV/IM. Contact Medical Control following administration.

ABSOLUTE ONLINE 4. If patient remains immediate risk of harming themselves or others after first dose: Midazolam (Versed) 2.5 mg IV/IM (repeat doses per Medical Control)


2.9 BURNS 1. Remove patient from source of burn – heat source, chemicals, electricity source etc. Precautions should be taken

to prevent injury to the rescuers. Only trained personnel should perform high-risk rescue procedures as appropriate. Decontamination measures should be taken as appropriate.

2. Assure airway patency and administer high flow oxygen. 3. Stop burning process by application of water, except in case of elemental metal burn. Dry chemicals should be

brushed away as much as possible before water is applied. In most cases 5-10 minutes is sufficient, although longer periods may be needed for hot grease, asphalt or chemicals. Burns from sodium metal, potassium metal, phosphorus, etc. should not be flushed with water, but instead should be covered with dry sterile dressings to prevent both air and water from making contact with the area. Remove jewelry and clothing as appropriate.

4. Apply dry sterile dressings. Take other measures to keep the patient warm as needed. 5. Timely transport with early notification to emergency department if patient unstable, possibility of airway obstruction

exists, or extensive burns. Transport to burn center for: • Burns compromising patient’s airway • Burns of face, hands, feet, joints, perineum or genitalia • Circumferential burns • 20% total of 2nd / 3rd degree burns • 5% 3rd degree burns • Significant chemical burns

EMT STOP 6. Establish IV Access (Vascular Access Protocol 2.34). Two large bore IVs or an IO are preferable, but time should

not be wasted at the scene to obtain IV access. Consider fluid bolus per Fluid Challenge / Replacement Protocol (2.15), if extensive burns and/or if blood pressure is unstable.

EMT-I STOP 7. Treat pain; see Pain Management Protocol (2.24)


2.10 CHEST PAIN / THREATENED MYOCARDIAL INFARCTION CRITERIA

Patient with non-traumatic chest pain or other indications of possible Myocardial Infarction (shortness of breath, nausea, diaphoresis, etc)

1. Routine medical care. 2. If systolic BP > 120 mmHg, may assist patient with taking own nitroglycerin tablets.

If systolic BP remains > 120 mmHg, one tablet may be taken sublingually every 3-5 minutes up to total of 3 doses. CAUTION

Avoid Nitroglycerin in patients who have taken erectile dysfunction medication (Viagra™, Levitra™, or Cialis™) in the past 72 hours

3. Aspirin (if not contraindicated by allergy or active bleeding): 4 tablets 81 mg each should be chewed and swallowed for total dose of 324 mg. EMT STOP 4. Establish IV according to Vascular Access Protocol (2.34). EMT-I STOP 5. When possible, perform 12-lead ECG prior to administration of nitroglycerin. 6. Evaluate 12-lead ECG for evidence of ST Elevation Myocardial Infarction (STEMI). This requires:

1. ECG has good baseline with minimal artifact AND 2. Computer interpretation of a “suspected acute myocardial infarction”

If 12-lead ECG reveals evidence of STEMI as defined above, contact Medical Control of a STEMI Center* and advise of a “STEMI Alert.” Provide appropriate clinical information and review the ECG findings with the Medical Control Physician.

7. If systolic BP > 90 mmHg, HR > 50 and <130 bpm and there are no signs of right ventricular involvement:

Nitroglycerin 0.4 mg SL every 3-5 minutes as long as pain continues and systolic BP remains > 90 mmHg

8. If systolic BP < 90 mmHg, HR < 50 or >130, contact Medical Control before giving nitroglycerin.

9. If signs of right ventricular involvement:

1. Avoid Nitroglycerin 2. If systolic BP < 90 mmHg and lung sounds are clear - Fluid Challenge / Replacement Protocol (2.15)

EMT-CC STOP 10. If systolic BP remains < 90 mmHg after fluid challenge AND patient is symptomatic for shock

Dopamine HCl 5 mcg/kg/min to Maximum 10 mcg/kg/min IV/IO titrated to maintain systolic BP > 90 mmHg using a rate-limiting device. Use Y-site secondary tubing for dopamine running into free-flowing normal saline primary tubing. Do not use a primary line for dopamine to prevent extravasation.

11. If BP > 90 mmHg systolic and inadequate response to above:

Morphine 5 mg slow IV



2.10 CHEST PAIN / THREATENED MYOCARDIAL INFARCTION, continued *NOTE STEMI Centers are facilities with 24-hour cardiac catheterization capabilities and include:

1. Rochester General Hospital 2. Unity Hospital – Park Ridge 3. University of Rochester Medical Center – Strong Memorial Hospital IMPORTANT CONSIDERATIONS FOR TRANSPORT TO A STEMI CENTER:

1. A patient in cardiac arrest should be taken to the nearest emergency department regardless of ECG findings.

2. Patients may be brought to a code red STEMI center if 12-lead ECG indicates a STEMI.

3. Patients with unstable vital signs and evidence of STEMI should still be diverted to the cardiac

catheterization capable facility. If this results in a significant delay in reaching definitive care, this should be related to Medical Control to determine the best receiving facility for the patient.

4. If no STEMI, routine care and transport to the nearest appropriate Emergency Department.


2.11 CHEST TRAUMA 1. Routine medical care. 2. Assure airway patency and administer high flow oxygen. 3. Stabilize but do not remove penetrating objects. Use occlusive dressing to seal sucking wounds on 3 sides only –

leave open on 4th side. Stabilize flail segments. 4. If signs/symptoms of tension pneumothorax present:

Remove occlusive dressing from sucking wound (if present). 5. Timely transport with early notification to hospital EMT STOP 6. Notify Medical Control as soon as possible (at least 5-10 min prior to arrival).

7. If symptoms of cardiac tamponade present:

Give continuous wide-open Normal Saline IV/IO. EMT-I STOP 8. Monitor pulse oximeter and ECG. 9. If signs/symptoms of tension pneumothorax present:

Perform needle decompression thoracostomy


2.12 CONDUCTED ENERGY WEAPONS CRITERIA Conducted Energy Weapons (also referred to as Electronic Control Devices, Conducted Energy Devices, etc) are used by law enforcement as an alternative to ballistic devices and other physical force in order to gain compliance with a non-cooperative person. These devices send an electrical charge of up to 50,000 volts per pulse with 12 to 20 pulses per second up to five seconds per cycle. The electrical current is about 2.1-3.5 milliamps. The delivered energy is between 0.7 to 1.76 joules. The number of discharges and the duration of discharges can be controlled by the operator. The discharge can either be through probes fired from the device with a range of up to 35 feet or with a contact discharge where the device is held against the subject. Either method will work through clothing. Either method uses electricity to cause the skeletal muscles between the probes to contract and release rapidly preventing voluntary control of the affected muscles. The device may cause a brief altered mental status, but subjects regain normal mentation and muscle control almost immediately, although some subjects may take up to a minute to recover. 1. Assure patient is appropriately restrained and not a danger to care providers. 2. Assess patient for problems and treat as per appropriate protocol. The device does not cause an altered mental

status. Any altered level of consciousness must be assessed and treated in accordance with the Altered Mental Status Protocol (2.4).

3. Assess patient for high-risk criteria. Most patients who have been exposed to a CED will be in police custody and

treatment decisions should be a cooperative venture. Presence of one or more of the following risk factors indicates need for an ALS response and transport to an Emergency Department is encouraged: • Known cardiac history including pacemaker/implantable defibrillator • Known seizure disorder • Pregnancy • Altered mental status • Extended physical struggle including multiple discharges or cycles

4. The barbs that contact the patient have an end that is similar to a fishhook and may imbed as much as 1.5 cm. To

remove the probe, stabilize the soft tissue around area with a gloved hand and remove the probe by pulling outward. If there is resistance when removing the probe, leave the probe in place and transport to the Emergency Department. Clean the area and dress appropriately.


2.13 CROUP

CRITERIA • History consistent with upper respiratory infection • Difficulty / inability to speak or presence of stridor

1. Routine medical care. 2. Assure airway patency and administer humidified high flow oxygen. CAUTION

If possibility of epiglottitis, airway should not be stimulated or examined and Medical Control should be contacted before other treatment is undertaken.

3. Timely transport. EMT STOP EMT-I STOP EMT-CC STOP 4. If patient exhibits stridor at rest:

Epinephrine 1:1000 nebulized:

Age Dose Maximum Note <1 0.5 mL/kg 2.5 mL Mix with 3mL Normal Saline 1-4 2.5 mL Mix with 3mL Normal Saline ≥5 5 mL Mix with 3mL Normal Saline

5. If patient is unable to ventilate adequately, refer to Airway Obstruction Protocol (2.3).


2.14 DIABETIC EMERGENCIES 1. Routine medical care. 2. Assure airway patency and administer oxygen per protocol. 3. Assess signs, symptoms, medical history, and blood glucose (BG), if available.

4. If patient has BG < 80 mg/dL, appears hypoglycemic, or if you are unsure if patient is hypoglycemic:

If patient is able to speak coherently, offer any form of available sugar (non-diet soda, candy, orange juice, granular sugar, or glucose gel).

5. All patients on oral hypoglycemic medications or long-acting insulin, who have been treated for potential

hypoglycemia, should be transported. 6. Treatment should not be withheld from patients with a stroke-like presentation, as this is likely due to hypoglycemia. EMT STOP 7. Establish intravenous access per Vascular Access Protocol (2.34) 8. Assess blood glucose (BG) 9. If BG > 300 mg/dL and patient with symptoms

Consider fluid bolus per Fluid Challenge / Replacement Protocol (2.15) EMT-I STOP 10. If BG < 80 mg/dL and patient symptomatic:

D50W 12.5-25 gm IV/IO D25W 0.5-1 gm/kg IV/IO for patients <5 kg D50W 0.5-1 gm/kg IV/IO for patients ≥5 kg 11. Reassess BG and repeat D50W as needed. 12. If unable to establish IV access:

Glucagon 1 mg IM (once) Glucagon 0.1 mg/kg IM (Max 1 mg) (once) 13. If level of consciousness does not improve, consider Altered Mental Status Protocol (2.4)


2.15 FLUID CHALLENGE / REPLACEMENT

CRITERIA • Medical hypovolemia due to dehydration:

• history consistent with decreased fluid intake and/or increased fluid loss • decreased skin turgor or sunken eyeballs • sinus tachycardia not clearly explained by other causes • orthostatic changes: either patient becomes dizzy when standing, or pulse increases by >20 bpm

• Shock due to trauma or other causes (see appropriate protocol) EMT STOP 1. Start IV/IO of 0.9% Normal Saline (NS) per Vascular Access Protocol (2.34) 2. If lung sounds are clear, infuse 500 mL NS Infuse 20 mL/kg NS (Max 500 mL) 3. Reassess patient (including vital signs and lung sounds) 4. Repeat procedure once to maintain appropriate systolic blood pressure for age, unless pulmonary edema develops. 5. If patient undergoes renal dialysis, Medical Control authorization prior to additional fluid challenge is required.


2.16 HEAD TRAUMA 1. Routine medical care. 2. Spinal immobilization. Patient’s head should not be lower than the body. 3. Assure airway patency and administer oxygen per protocol. 4. If BVM ventilation needed, ventilations should be slow and steady at a constant rate of 10 breaths per minute. 5. Timely transport with early notification to emergency department. EMT STOP 6. Establish vascular access; see Vascular Access Protocol (2.34). Adjust rate as follows:

If isolated head trauma – IV/IO at KVO

If multiple trauma – follow Fluid Challenge / Replacement Protocol (2.15)


2.17 HYPERTHERMIA / HEAT EXHAUSTION / HEAT STROKE CRITERIA

• Body temperature > 40.6 °C (105 ° F). Do not use tympanic thermometers. • Infants and children, and frail, elderly, or chronically ill adults may show symptoms of hyperthermia at lower

temperatures than listed above. Patients on anticholinergic medications (Benadryl, Ditropan, Detrol, haloperidol, amitriptyline, nortriptyline, etc) are prone to hyperthermia due to an inability to perspire.

• May be accompanied by CNS dysfunction (delirium, psychoses, coma, seizures), absence of sweating, pallor, tachycardia, hypotension, cramping or tingling, nausea /vomiting, headache, dizziness.

1. Routine medical care. 2. Assure airway patency and administer oxygen per protocol. 3. Assess signs, symptoms. 4. Remove patient from hot environment. Remove clothing. 5. Cool patient using whatever means immediately available:

• sprinkle or spray with fine water mist • air conditioned ambulance, or fanning

CAUTION

Rapid cooling may cause shivering and vomiting Wet sheets without air circulation will retain heat rather than dissipate it Do not use alcohol to lower temperature Do not delay transport to the hospital

6. Continue to monitor body temperature. EMT STOP 7. If hypotensive or dehydrated, proceed with Fluid Challenge / Replacement Protocol (2.15) 8. If decreased level of consciousness, proceed with Altered Mental Status Protocol (2.4) 9. If patient has seized, or is seizing, proceed with Seizure Protocol (2.31)


2.18 HYPOTENSION / SHOCK CRITERIA

• Inadequate tissue perfusion as evidenced by one or more of the following: • poor peripheral pulses, or capillary refill > 2 sec • altered mental status • cyanosis, pallor, diaphoresis, cool skin • dizziness, light-headedness, nausea or vomiting • tachycardia (in conjunction with one or more other symptoms and suggestive history)

SHOCK MAY BE PRESENT EVEN IN THE PRESENCE OF A NORMAL BLOOD PRESSURE, PARTICULARLY IN CHILDREN AND YOUNG ADULTS 1. Routine medical care. 2. Assure airway patency and administer oxygen per protocol. 3. Assess signs, symptoms, and medical history. 4. Consider treatable causes:

• Anaphylaxis - see Anaphylaxis Protocol (2.5) • Dysrhythmia - see appropriate Protocol (Section 3 or 4) • Hypoglycemia - see Diabetic Emergency Protocol (2.14) • Hypovolemia - see #5-6 below • Hypoxia - see Airway Management Protocol (2.0, 2.1) • Neurogenic or septic shock - see # 5-7 below • Trauma - see appropriate Trauma Protocol (Chest – 2.11, Head – 2.16)

5. Timely transport in supine position, or shock position if appropriate. Keep the patient warm by passive measures

including warm ambulance compartment temperature, but avoid hyperthermia. EMT STOP 6. Establish vascular access and administer fluid challenge per protocol if lung sounds are clear (Protocols 2.34 and

2.15). EMT-I STOP EMT-CC STOP 7. If no improvement, and no history suggestive of hypovolemia:



2.19A HYPOTHERMIA CRITERIA

• Body temperature < 35 °C (95 ° F) • Do not use tympanic thermometers.

1. Routine medical care. 2. Move out of cold environment. Gently remove wet clothing, cover with blankets and otherwise protect from further

heat loss. 3. Assure airway patency and administer oxygen per protocol (with warm moist air if possible). 4. Maintain horizontal position. 5. Avoid rough handling during patient movement. 6. Timely transport (goal of <15 minute scene time).

7. Monitor temperature; assess cardiopulmonary status, and presence of other factors such as trauma, drug usage,

etc. Heart rates should be assessed for at least 1 full minute.

8. If temp is 30-35°C (86 - 95°F), gentle re-warming measures may be instituted (heated ambulance). 9. Assess BG (BLS if available). If hypoglycemic, see Diabetic Emergencies Protocol (2.14). EMT STOP 10. Establish vascular access with warmed Normal Saline; see Vascular Access Protocol (2.34).

2.19B HYPOTHERMIC CARDIAC ARREST

1. Institute CPR. NOTE

Pharmacological and electrical interventions are often ineffective in severe hypothermia, and should be used only with extreme caution.

2. Defibrillate once if shock advised. EMT STOP 3. Establish vascular access refer to Vascular Access Protocol (2.34). EMT-I STOP 4. Intubation should be performed with minimal manipulation. 5. First round medication (vasoconstrictor and antiarrhythmic) administration as per usual arrest protocols for temps >

30°C (86oF). No medications are to be given if patient’s temperature is below 30°C (86oF). 6. Contact Medical Control for all additional medication and defibrillation orders based on body temperature.


2.20 NAUSEA / VOMITING CRITERIA

Patient with uncontrolled nausea/vomiting and no evidence of head injury: 1. Attempt to treat cause of the nausea. EMT STOP EMT-I STOP 2. If nausea unrelieved by other interventions: Promethazine (Phenergan) 6.25-12.5 mg diluted in 50 mL NS and given over 10 minutes. 3. If dystonic reaction (torticollis/stiff neck, back spasm, agitation) occurs, give: Diphenhydramine (Benadryl) 25 mg IM/IV (May repeat once).


2.21 NEAR-DROWNING 1. Routine medical care. 2. Assure airway patency, and administer oxygen per protocol. NOTE

Heimlich maneuver is contraindicated for the removal of water from the lungs. 3. If patient is pulseless and apneic, refer to Cardiac Arrest Protocols (3.0, 3.1, 4.0 and 4.1). 4. Initiate spinal immobilization precautions and trauma care as appropriate; see Spinal Immobilization Protocol (2.33). 5. Treat hypothermia (even in warm water drowning or warm environmental conditions) - see Hypothermia Protocol

(2.19A). 6. All patients should be transported for evaluation. 7. Unless contraindicated, transport patient in lateral recumbent position.


2.22 NEONATAL RESUSCITATION CRITERIA

• The primary concerns of newborn resuscitation are adequate oxygenation, airway patency, and warmth.

• Signs of inadequate oxygenation include:

• Quiet, not crying • No response to tactile stimulation • Diffuse, dark cyanosis over entire body (Initial cyanosis should "pink up" rapidly) • Respiratory rate < 20 rpm • Pulse rate < 100 bpm • Flaccid, non-moving extremities

• Supplemental oxygenation (when needed) may be provided by holding mask near or on face: 1. Suction mouth then nose as soon as head is visible. Do not bulb syringe back of throat. If meconium is present,

suction with bulb syringe or catheter as soon as head is delivered, if possible. 2. Keep baby at level of vagina until umbilical cord is cut. Cord should be clamped and cut 30-45 seconds after birth. 3. Dry baby, warm with blankets, provide tactile stimulation. Environment should be warm. 4. If respirations < 30 rpm or heart rate < 100 bpm

Ventilate with 100% oxygen using neonatal or small child bag-valve mask at a rate of 40-60 breaths per minute. 5. If heart rate < 60 bpm

Begin chest compressions at rate of 120 per minute utilizing a compression/ventilation ratio of 3:1. Begin timely transport.

EMT STOP EMT-I STOP EMT-CC STOP 6. If thick meconium is present and respiratory distress, HR<100 bpm, or poor muscle tone is present, or if unable to

maintain airway, consider endotracheal intubation for suctioning. The trachea should be suctioned before any bag valve ventilation attempts.

May need to re-intubate with clean tube after suctioning

7. Establish intravenous access if no clinical improvement. Intraosseous or peripheral IV is preferred.

Medical Control must authorize cannulation of the infant’s umbilical vein with an intracath, Insert only 1-2 cm.

8. If continued heart rate < 60 bpm and adequacy of ventilation and oxygenation is assured:

Epinephrine 1:10,000 0.01 mg/kg (0.1 mL/kg) IV/IO (Max 1 mg per dose) 9. Consider Naloxone (Narcan) 0.1 mg/kg IV/IO (Max 2 mg)

10. Consider fluid bolus 20 mL/kg normal saline IV/IO, see Fluid Challenge / Replacement Protocol (2.15) 11. Consider repeat doses of Epinephrine at above dose every 5 min


2.23 OBSTETRIC EMERGENCIES 1. Routine medical care. Administer oxygen per protocol. 2. Assess signs, symptoms, and obstetric history. 3. If delivery imminent:

• Allow baby to deliver spontaneously. • Support infant, but do not attempt to retard or hasten delivery. • Begin timely transport with ALS transport/intercept if possible, but do not delay transport to wait for ALS. • Contact Medical Control as necessary for instructions and destination. • For routine deliveries, preference hospital affiliated with maternal Ob/Gyn physician

4. Suction mouth and nares of infant upon delivery of the head. Check for nuchal cord. 5. Clamp cord in two places 8-12" from infant; cut cord between clamps. 6. Assess infant and proceed with neonatal resuscitation - see Neonatal Resuscitation Protocol (2.22) 7. Do not wait for delivery of placenta to begin transport. If the placenta delivers spontaneously, bring to hospital in

plastic bag. Do not pull on cord under any circumstances. 8. After delivery of placenta, massage uterus as needed for control of maternal hemorrhage. 9. If mother is hypotensive, refer to Hypotension/Shock Protocol (2.18) as needed.


2.24 PAIN MANAGEMENT CRITERIA

• Pain (>4 out of 10) due to burns, amputation, or isolated extremity (including hip/shoulder) fracture / dislocation without evidence of head or spinal injury.

• May also be used for other pain management, if ordered by Medical Control and if other pain management techniques are insufficient.

1. Routine medical care. If pain is secondary to a burn, refer to Burn Protocol (2.9). 2. Assure airway patency. Administer oxygen per protocol. 3. Apply pain relief measures such as splinting, positioning, ice packs, etc. as appropriate. EMT STOP EMT-I STOP 4. Morphine 5 mg IM or slow IV/IO (if SBP >100 mmHg). Medical control authorization is required for any other

indication, or any repeat doses.

Morphine 0.1 mg/kg (Max 5 mg) IM or slow IV/IO if SBP normal for age. Medical control authorization is required for any other indication, or any repeat doses.

ABSOLUTE ONLINE

5. If pain persists and if BP > 100 mmHg systolic and RR > 8 rpm:

Morphine 0.1 mg/kg every 10 minutes IM or slow IV/IO

Morphine 0.1 mg/kg (Max 5 mg per dose) every 10 minutes IM or slow IV/IO NOTE: IV is preferred route for burn patients due to inconsistent absorption associated with IM route.


2.25 POISONING / OVERDOSE CRITERIA

• Suspected or actual overdose of patient’s prescribed medications - accidental or intentional. • Suspected or actual ingestion/injection of non-prescribed medications - accidental or intentional. • Exposure to potentially toxic substance - ingestion, inhalation, dermal contact, etc.

1. Routine medical care with transport in left lateral recumbent position if oral ingestion. 2. Assure airway patency and administer oxygen per protocol. CAUTION

If carbon monoxide inhalation or inhalation injury, patient must be on 100% oxygen 3. Assess signs, symptoms, hemodynamic status, type, time and amount of poisoning. If possible, bring poison

container to hospital. 4. Poison control may be contacted for management advice, however all treatment orders must come from on-line

Medical Control. 5. If orally ingested poison less than one hour old in an alert patient who is able to protect their airway AND if directed by Medical Control:

Sorbitol-free Activated Charcoal 50 gm PO Sorbitol-free Activated Charcoal 2 gm/kg PO (Max 50 gm) EMT STOP EMT-I STOP 6. If potential opiate overdose with respiratory depression: Naloxone (Narcan) 0.4 mg IV/IO/IM. May repeat to support respiratory efforts OR Naloxone (Narcan) 0.8 mg via Mucosal Atomization Device, may repeat to support respiratory efforts Naloxone 0.1 mg/kg IV/IO/IM titrated to support respiratory efforts (Max 0.4 mg). May repeat to support respiratory efforts. NOTE

Remove any transdermal narcotic delivery device from patients receiving Naloxone and bring to the Emergency Department for proper disposal.

EMT-CC STOP



2.25 POISONING / OVERDOSE, continued

7. If potential calcium channel blocker overdose with hypotension (SBP < 90 mmHg) or symptomatic bradycardia (HR < 60 bpm) then: 10% Calcium Chloride 1000 mg slow IV/IO

Contact Medical Control 8. If potential Tricyclic antidepressant or aspirin overdose with QRS > 0.10 seconds or SBP <90 mmHg then:

Sodium Bicarbonate 100 mEq slow IV/IO Contact Medical Control 9. If potential beta-blocker overdose with hypotension (SBP < 90 mmHg) or symptomatic bradycardia (HR < 60 bpm)

then:

Glucagon 2 mg IV/IO/IM

Glucagon 0.1 mg/kg IV/IO/IM (Max 2 mg)


2.26 PULMONARY EDEMA / CHF CRITERIA

• Dyspnea/Tachypnea • Rales/wheezing • Pink, frothy sputum may be present or absent

1. Routine medical care. 2. Assess signs, symptoms and hemodynamic status. 3. Position patient with head elevated (High Fowlers). 4. Initiate oxygen therapy. 5. If inadequate respirations or decreased level of consciousness, consider use of BVM. 6. Begin timely transport. EMT STOP EMT-I STOP 7. If systolic BP > 90 mmHg: Nitroglycerin 0.4 mg SL every 3-5 minutes as long as systolic BP > 90 mmHg 8. Consider CPAP EMT-CC STOP 9. If patient has respiratory failure, altered mental status, or inadequate ventilations consider intubation. 10. If systolic BP < 90 mmHg:



2.27 RAPID SEQUENCE INTUBATION

RSI PARAMEDIC ONLY This procedure requires two advanced providers (EMT-P or EMT-CC) authorized to perform endotracheal intubation and administer medications. One provider must be a paramedic who has been credentialed to perform this procedure by the System Medical Director.

The following indication for Rapid Sequence Intubation is standing order for the RSI Credentialed Paramedic. Absolute On-Line Medical Direction is required for performance of this procedure outside of this indication (eg: potential airway compromise, smoke inhalation, combativeness that threatens airway or spinal cord stability, etc). STANDING ORDER INDICATION Inability to tolerate laryngoscopy and ALL of the following:

1. GCS ≤8 2. Oxygen saturation less than 90% with 100% supplemental oxygen (via non-rebreather, CPAP, or BVM) 3. Transport time to the nearest appropriate Emergency Department >10 minutes

CONTRAINDICATIONS 1. Patient <40 kg (88 lbs) 2. Obvious facial, neck, and/or spinal deformity that would prevent establishing an airway 3. Full or significant partial thickness burns greater than 48 hours old 4. Paralysis from spine injury greater than 48 hours old 5. Degenerative neurological diseases (ALS, muscular dystrophy, myasthenia gravis, etc.) 6. End-stage renal disease requiring dialysis PROCEDURE 1. Prepare equipment 2. Pre-oxygenate with 100% oxygen 3. Pre-treat

a. Atropine 0.5 mg IV/IO push for signs or symptoms of symptomatic bradycardia b. Lidocaine (Xylocaine) 1.5 mg/kg IV/IO for suspected elevated intracranial pressure

4. Sedate a. Etomidate (Amidate) 0.3 mg/kg IV/IO push

5. Paralyze a. Succinylcholine (Anectine) 1.5 mg/kg IV/IO push b. A second dose of Succinylcholine (Anectine) 0.5 mg/kg IV/IO push may be given if initial dose ineffective

6. Intubate a. Orotracheal intubation (using manual in-line neck stabilization for trauma) may be attempted up to two

times with an attempt being defined as placing a laryngoscope blade in the oropharynx. The patient must be ventilated between attempts. The patient’s SpO2 must be continuously monitored during each attempt.

b. If unable to intubate after two attempts, place an alternative airway device.

7. Confirm Placement a. Following intubation or placement of an alternative airway device, ventilate patient with bag valve device

and 100% oxygen. b. Auscultate for bilateral breath sounds, absence of epigastric sounds, confirm placement with waveform

capnography.

8. Monitor a. Continuously monitor placement with continuous waveform capnography. b. Ventilate to achieve EtCO2 38-42 mmHg. c. Treat and manage other conditions per appropriate protocol.


2.27 RAPID SEQUENCE INTUBATION, continued

POST INTUBATION MANAGEMENT

The following post-intubation sedation and analgesia protocols are standing order for the RSI Credentialed Paramedic. They may be used for patients having just undergone RSI, or for patients who were successfully orotracheally intubated without paralytics and now require sedation.

Sedation

Midazolam (Versed) 2.5 mg IV/IO (Use with caution if systolic blood pressure < 90 mmHg)

Repeat dose(s) with Medical Control authorization

Analgesia

Morphine 5 mg slow IV/IO (Use with caution if systolic blood pressure < 90 mmHg)

Repeat dose(s) with Medical Control authorization

ABSOLUTE ONLINE

Paralysis

Indicated only to facilitate ventilation, must use in conjunction with sedation and analgesia:

Vecuronium (Norcuron) 0.1 mg/kg IV


2.28 RE-ESTABLISHING PATIENT MEDICATION IV CRITERIA

• Adult or Pediatric patient with life-sustaining IV treatment which cannot be discontinued for a brief time without major consequences (See list of allowed drugs below)

• IV/Central line infiltrated or pulled out with no other means of rapid IV access

1. Routine medical care as appropriate and transport to appropriate hospital. Bring bag of patient medication to hospital if available and alert Medical Control that patient is en route.

EMT STOP EMT-I STOP EMT-CC STOP 2. If drug is on list of allowable drugs, re-establish peripheral IV and hook directly to patient’s existing IV medication

line. Do not use extension tubing or saline lock. 3. If drug not on list of allowable drugs, determine compatibility with saline (if available) and contact Medical

Control for authorization CAUTION

Avoid use of line established for patient medication for administering EMS medications to avoid compatibility issues.

List of allowed drugs include

Allowed Med Type & Use Urgency Compatibility Flolan (epoprostenol) Potent vasodilator in pulmonary

hypertension Emergent (2-5 min half life) Incompatible with saline

Remodulin (treprostinil) Potent vasodilator in pulmonary hypertension

Urgent (2-4 hour half life) Compatible with saline


2.29 RESPIRATORY DISTRESS / BRONCHOSPASM CRITERIA

• Oxygen saturation < 92% • Cyanosis • Respiratory rate < 8 rpm or > twice normal for age • Use of accessory muscles for respiration • Auscultation of adventitious breath sounds (wheezing, stridor), or markedly decreased air movement

1. Routine medical care including ensuring airway patency and administering high flow oxygen. 2. Assess signs, symptoms and hemodynamic status including vital signs, ability to speak in sentences, presence of

accessory muscle use or wheezing. 3. If patient has own inhaler / nebulizer, may assist patient to use the device. 4. If patient is between 1 and 65 years of age and

• has physician diagnosed asthma with previously prescribed use of Albuterol, and • agency approved for Albuterol use with a provider trained in Albuterol administration:

Albuterol 5 mg by nebulizer, if available, may repeat x1 if ALS still en route or not available

Albuterol 2.5 mg by nebulizer, if available, may repeat x1 if ALS still en route or not available

CAUTION

Medical Control should be contacted first (BLS Only) if patient has cardiac history (CHF, angina, arrhythmias, previous AMI, etc)

5. Timely transport with ALS if available. (ALS can not release to BLS for transport after medication administration.) EMT STOP EMT-I STOP 6 Albuterol 5 mg by nebulizer, may give via bag-valve mask if necessary.

Albuterol 2.5 mg diluted with NS to 5 mL by nebulizer, may give via bag-valve mask if necessary.

7. Ipratroprium Bromide (Atrovent) 0.5 mg once by nebulizer. (May mix with Albuterol to give simultaneously)

Ipratroprium Bromide 0.5 mg by oxygen powered nebulizer. (May mix with Albuterol to give simultaneously)

8. Repeat Albuterol 2.5 mg – 5 mg PRN up to total 30 mg/hr.

Repeat Albuterol 2.5 mg – 5 mg PRN up to total 30 mg/hr. 9. Consider CPAP (Adult Only). EMT-CC STOP



2.29 RESPIRATORY DISTRESS / BRONCHOSPASM, continued 10. For severe respiratory distress, not responding to other therapy:

Epinephrine: 1:1000 0.3 mg IM

Epinephrine 1:1000 0.01 mg/kg IM (Max 0.3 mg) 11. Consider Magnesium Sulfate 2 gm IV in 100 mL NS over 10 minutes. Do not administer if the patient is

suspected to have renal failure. Magnesium Sulfate 50 mg/kg IV (Max 2 gm) in 100 mL NS over 10 minutes 12. If a patient is not responding to therapy (if change in mental status, SpO2 still < 90% on oxygen, or with persistent

cyanosis) consider intubation. Intubation should be a last resort in severe asthma patients.

13. Repeat Epinephrine 1:1000 0.3 mg IM repeated up to 2 times at 15 minute intervals

Repeat Epinephrine 1:1000 0.01 mg/kg IM (Max 0.3 mg) repeated up to 2 times at 15 minute intervals


2.30 SEDATION CRITERIA

Any adult or pediatric patient who requires a painful therapeutic procedure or whose condition is interfering with their clinical management including:

• Synchronized cardioversion • Transcutaneous pacing • Post-intubation sedation

CONTRAINDICATIONS

• Known history of hypersensitivity or other adverse reactions to the required medications • Clinical condition or vital signs contraindicate the use of sedative medications

NOTE For extremely agitated or combative patients, refer to Behavioral Emergencies Protocol (2.8)

EMT STOP EMT-I STOP 1. Routine Medical Care 2. Assess ECG rhythm, hemodynamic status, and stability of patient. 3. SpO2 and end-tidal waveform capnography must be in place. Closely monitor respiratory/ ventilatory status and

treat per Airway Management Protocol (2.0, 2.1). 4. Synchronized Cardioversion Morphine 5 mg slow IV/IO once (Additional doses per Medical Control, must contact Medical Control after use) Morphine 0.1 mg/kg slow IV/IO (Max 5 mg) (Additional doses per Medical Control, must contact Medical Control after use) AND Midazolam (Versed) 2.5 mg IV/IO (Additional doses per Medical Control, must contact Medical Control after use) Midazolam 0.05 mg/kg (Max 2.5 mg) (Additional doses per Medical Control, must contact Medical Control after use) OR Etomidate (Amidate) 0.1 mg/kg IV/IO (Adults only by RSI Paramedic if available, must contact Medical Control after use) 5. Transcutaneous Pacing (Adult Only)

Morphine 5 mg slow IV/IO once (Additional doses per Medical Control, must contact Medical Control after use) AND

Midazolam (Versed) 2.5 mg IV/IO once (Additional doses per Medical Control, must contact Medical Control after use)

6. Post Intubation Sedation (Adult patients only, RSI Providers must use Rapid Sequence Intubation Protocol (2.27)

Use with caution in patients with systolic blood pressure < 90 mmHg:

Morphine 5 mg slow IV/IO once, (Additional doses per Medical Control, must contact Medical Control after use)

AND Midazolam (Versed) 2.5 mg IV/IO once

(Additional doses per Medical Control, must contact Medical Control after use)


2.31 SEIZURES 1. Routine medical care.

2. Assure airway patency and administer oxygen per protocol.

3. Assess signs, symptoms, and medical history.

4. Consider possible causes: • Existing seizure disorder • Toxic ingestion - see Poisoning / Overdose Protocol (2.25) • Head Injury - see Head Trauma Protocol (2.16) • Hypoglycemia - see Diabetic Emergencies Protocol (2.14) • Eclampsia (if maternity patient beyond 20 weeks or up to 6 weeks after delivery)

5. If seizing, begin timely transport. 6. Assess BG (BLS, if available; mandatory for ALS) - If hypoglycemic, see Diabetic Emergencies Protocol (2.14). EMT STOP 7. Establish IV Access; see Vascular Access Protocol (2.34) EMT-I STOP 8. If active tonic-clonic seizure ongoing:

Midazolam (Versed) 2.5 mg IV/IO/IM once (Must contact Medical Control after use)

Midazolam 0.05 mg/kg IV/IO/IM (Max 2.5 mg, must contact Medical Control after use) All levels must call Medical Control prior to administration if Diastat was given prior to arrival.

EMT-CC STOP

9. If maternity patient over 20 weeks gestation OR up to 6 weeks post partum AND no history of seizures:

Magnesium Sulfate 5 gm in 100mL NS over 5 minutes IV/IO May follow with Midazolam (as above) if seizure refractory

ABSOLUTE ONLINE 10. If additional seizure control needed, contact Medical Control for repeat dose.

11. For eclamptic patient 2 gm additional Magnesium Sulfate (for a total of 7 gm) may be requested from Medical

Control.


2.32 STROKE

1. Routine medical care with evaluation of the Cincinnati Stroke Scale

, which includes:

• Facial droop during smile Normal = equal smile Abnormal = one side moves less

• Arm drift (arms held straight for 10 seconds with eyes closed)

Normal = no movement or equal movement Abnormal = 1 arm drifts or cannot lift arm against gravity

• Speech (“You can’t teach an old dog new tricks”)

Normal = correct words/ no slurring Abnormal = slurred words / wrong words / no speech

Determine the time at which the patient’s symptoms began (abnormal speech, extremity weakness, numbness, paralysis, facial droop, etc.)

2. Assure airway patency and administer oxygen per protocol. 3. Consider other causes for altered mental status – refer to Altered Mental Status Protocol (2.4). 4. Assess blood glucose (BLS if available). If hypoglycemic, refer to Diabetic Emergencies Protocol (2.14). Do not withhold treatment for hypoglycemic patients who present with stroke-like symptoms 5. Timely transport. If patient fulfills following criteria, contact Medical Control of a Stroke Center* and advise of a

“Stroke Alert” by providing appropriate clinical information to the Medical Control Physician:

• One or more abnormal findings on Cincinnati Stroke Scale (see above) AND • Symptoms for < 2 hours AND • Blood Glucose >80 mg/dl

EMT STOP EMT-I STOP 6. Initiate vascular access, refer to Vascular Access Protocol (2.34), ECG, and SpO2 monitoring. NOTE: A Stroke Center is a NYS Department of Health designated Stroke Center and includes:

1. Lakeside Memorial Hospital 2. Rochester General Hospital

3. Unity Hospital – Park Ridge 4. University of Rochester Medical Center – Highland Hospital

5. University of Rochester Medical Center – Strong Memorial Hospital IMPORTANT CONSIDERATIONS FOR TRANSPORT TO A STROKE CENTER:

1. Patients may be brought to a code red facility if they meet Stroke Alert criteria.

2. Patients with unstable vital signs should still be diverted to a Stroke Center. If this results in a significant delay in reaching definitive care, this should be related to Medical Control to determine the best receiving facility for the patient.

3. If no Stroke Alert, routine care and transport to the nearest appropriate Emergency Department.


2.33 SUSPECTED SPINAL INJURIES

1. Patients with mechanism capable of producing spinal injuries meeting any of the following criteria must immediately receive spinal immobilization:

Age Patients < 8 or > 65 years old

Medical History

Patient’s with Down Syndrome History of spinal tumors History of degenerative bone disorders History of spina bifida

Mechanism of Injury

Death of passenger in same compartment Motorcycle crash Falls greater than standing height Vehicle versus bicycle >5 mph

Vehicle-pedestrian collision Axial load (diving injury, spearing tackle) Patient ejection Vehicle rollover Collision >20 mph with 12 inches deformity to vehicle

Physical Findings

HR < 50 or > 120 bpm SBP < 90 mmHg RR < 10 or > 28 bpm GCS < 15 Penetrating injuries to trunk, head, neck, Two or more proximal long bone fractures chest, abdomen or groin Flail Chest Burns >15% BSA or facial/airway burns Trauma of two or more body systems Amputation (except digits)

2. Patients not meeting any of the above criteria should be assessed for the following. If any are present, the patient must receive spinal immobilization.

• Altered Mental Status for any reason, including possible intoxication from alcohol or drugs (signs of poor judgment, GCS <15 or AVPU other than A).

• Complaint of neck and/or spine pain or tenderness.

• Weakness, tingling, or numbness of the trunk or extremities at any time since the injury.

• Deformity of the spine not present prior to this incident.

• Distracting injury or circumstances (i.e. anything producing an unreliable physical exam or history).

3. Provide routine care per relevant protocol. NOTE:

Once spinal immobilization has been initiated (i.e. extrication collar placed on patient) spinal immobilization MUST be completed and may not be removed in the prehospital setting.


2.34 VASCULAR ACCESS EMT STOP 1. Locate appropriate peripheral intravenous insertion site. Whenever possible, do not place IV on side of injured arm

or chest, side of mastectomy, or side of stroke or paralysis unless no other site is available. 2. Start IV as appropriate. Limit attempts at the scene.

• Trauma patients should have at least one 14g or 16g IV catheter. • Medical patients should have at least one 18g or 20g IV catheter. • Any patient with signs of shock should have two large bore (14g or 16g) catheters placed.

For pediatric patients, the largest appropriate size catheter should be used based on the patient’s clinical

presentation as suggested above. 3. Consider intraosseous access if IV not readily attainable in unstable patients. If adult patient is conscious, consider Lidocaine 2% 30mg (1.5 mL) slow IO push after placement and before fluid

administration.

For pediatric patients requiring immediate intravenous access (cardiac arrest), consider immediate IO placement.

4. If patient does not require fluid therapy, consider placement of a saline lock. 5. If patient requires fluid therapy, refer to Fluid Challenge / Replacement Protocol (2.15). EMT-I STOP EMT-CC STOP External jugular IV access permitted in cases of actual or imminent cardiopulmonary arrest when no other suitable peripheral IV site is immediately available. Hickman catheters or other indwelling IV access ports (not renal shunts) should be used in cases of actual or imminent cardiopulmonary arrest when no other access is available.

ABSOLUTE ONLINE Use of renal shunt for IV access must receive Medical Control approval.


2.35 VENTILATOR MANAGEMENT – EMERGENT PREHOSPITAL

PARAMEDIC ONLY CRITERIA A patient who requires manual ventilation in the prehospital environment who has received emergent endotracheal intubation or who has a pre-existing tracheostomy tube and meets the following criteria:

• At least 10 minutes of patient contact expected • Weight ≥ 40 kg • Systolic blood pressure ≥ 90 • Able to ventilate without difficulty

1. Provide routine medical care. ECG monitoring, continuous SpO2, and continuous waveform capnography are

required throughout all transports. 2. Confirm patient’s ventilatory and hemodynamic stability with BVM ventilations with FiO2 @ 1.0 (100%) for at least

two minutes prior to being placed on the ventilator. 3. If the patient is not spontaneously breathing, set the device for Assist/Control (A/C), Rate 10-12, FiO2 1.0 (100%),

with a tidal volume of 5-6 mL/kg. (Lean body mass should be utilized for this calculation). 4. Adjust the ventilator settings to achieve an SpO2 ≥ 96% and EtCO2 38-42. Set PEEP at 5 cmH2O and may adjust

up to 10 cmH2O. 5. If the patient is spontaneously breathing and the device is capable, consider Pressure Support with a rate of 0 and

initial PEEP of 5 cm H2O. 6. If patient becomes hypoxic, hypercarbic, or has increased work of breathing, discontinue the ventilator and perform

BVM ventilations per Airway Management Protocol (2.0 or 2.1). Evaluate the patient for the following:

• Dislodged airway or circuit • Obstruction in airway, kink in circuit or requires suctioning • Pneumothorax • Equipment failure due to loss of power, circuit failure, or loss of oxygen

7. Sedation as per the Sedation Protocol (2.30) 8. Adjustment of PEEP > 10 cm H2O or use of ventilator modes other than those listed, (e.g., A/C pressure, SIMV volume/pressure, etc.) requires Medical Control.


2.36 VENTILATOR MANAGEMENT – STABLE OUTPATIENT

PARAMEDIC ONLY CRITERIA

A patient on a ventilator in an outpatient setting with no acute cardiac or respiratory complaints who is requesting ambulance transport:

1. Provide routine medical care. ECG monitoring, continuous SpO2, and continuous waveform capnography are required throughout all transports.

2. If a Respiratory Therapist (RT) is accompanying the patient, that provider will manage the ventilator. 3. If no RT is accompanying the patient, the paramedic will manage the ventilator utilizing the patient’s existing

settings and circuit unless patient has separate transport ventilator or circuit. 4. The paramedic may increase the ventilator’s FiO2, if required by the patient and allowed by the device. 5. If patient becomes hypoxic, hypercarbic, or has increased work of breathing, and the ventilator is NOT managed by

an RT, discontinue the ventilator and perform BVM ventilations per Airway Management Protocol (2.0 or 2.1). Evaluate patient for the following:

• Dislodged airway or circuit • Obstruction in airway, kink in circuit, or requires suctioning • Pneumothorax • Equipment failure due to loss of power, circuit failure, or loss of oxygen

If any of these are found and are able to be corrected easily without significant delay, patient may be reconnected to ventilator after problem is resolved.



Section 3

Adult Cardiac Life Support


3.0 CARDIAC ARREST – GENERAL PROCEDURES 1. Verify patient is pulseless and apneic. 2. Initiate or continue CPR. CPR is to be continued at all times as is practical. 3. Assure airway patency and begin use of BVM. Provide initial BLS airway management, including Oropharyngeal or

Nasopharyngeal Airway. 4. Apply AED or SAED if available. If switching to a different AED/monitor you may use previously applied patches if

compatible with new unit. 5. Follow prompts provided by AED/SAED device. 6. Utilize ALS, or initiate timely transport toward ALS (ALS intercept or hospital if closer). If ALS not available, no

more than 3 shocks should be delivered at the scene. Defibrillation should not be performed in a moving ambulance.

7. Advise receiving hospital ASAP. EMT STOP 8. If AED not already applied, defibrillate PRN after CPR of at least 5 cycles (about 2 minutes). 9. Obtain vascular access; refer to Vascular Access Protocol (2.3). 10. Secure definitive airway, refer to Airway Management Protocol (2.0). If BLS airway is sufficient to maintain chest

rise, continue until additional time or resources are available. Do not interrupt compressions for placement of an advanced airway.

Remove Bag Valve device whenever transferring patient, moving patient in and out of ambulance, or other times when Bag Valve device may dislodge the device. Reassess airway patency after any movement of patient.

EMT-I STOP 11. Give medications as listed in the following specific arrhythmia / dysrhythmia protocols. NOTE:

Should IV/IO access not be available, Epinephrine may be administered via ETT under direct, on-line Medical Control.

NOTE: AED’s and manual defibrillators may use the manufacturer’s default setting for defibrillation/cardioversion. Should there not be a manufacturer recommended setting the energy setting referenced in the Standards of Care shall prevail.


3.1 VENTRICULAR FIBRILLATION & PULSELESS V-TACH 1. Follow Adult Cardiac Arrest - General Procedures Protocol (3.0) EMT STOP EMT-I STOP 2. Defibrillate once at the manufacturers recommended energy dose If converts to another rhythm - see appropriate protocol for that rhythm If converts to adequate pulse - see Post Conversion Protocol (3.2)

3. Establish IV/IO access and attempt to secure airway (per protocols 2.34 and 2.0) 4. Epinephrine 1:10,000 1 mg (10mL) IV/IO 5. Defibrillate once at the manufacturers recommended energy dose 6. If no conversion:

Amiodarone (Cordarone) 300 mg diluted in a minimum of 20mL of normal saline IV/IO 7. Defibrillate once at the manufacturers recommended energy dose

8. If no conversion:

Continue defibrillations at the manufacturers recommended energy dose as long as VF or pulseless VT continues, alternating shocks with medication doses:

Repeat Epinephrine every 3-5 minutes between shocks

Repeat Amiodarone once at 150 mg diluted in a minimum of 20mL of normal saline IV/IO

If Amiodarone unavailable, may administer Lidocaine (Xylocaine) 1.5 mg/kg IV/IO push. May repeat

Once.

Administer each medication during a period of 2 minutes of CPR and follow with a defibrillation attempt

9. If Torsades de Pointes or hypomagnesemic state suspected,

Magnesium Sulfate 2 gm diluted in 10mL of normal saline IV/IO push


3.2 RETURN OF SPONTANEOUS CIRCULATION CRITERIA

• The following is for a patient with Return of Spontaneous Circulation (ROSC) as evidenced by a palpable pulse following CPR, electrical, or drug therapy for a patient previously pulseless.

• Post-conversion treatment of VF or VT should only be started if the patient has regained a pulse of adequate rate (>60). If not, refer to other cardiac protocols as appropriate.

1. Routine medical care. EMT STOP EMT-I STOP 2. Following ROSC, the patient should be reassessed and a complete neurologic exam, including GCS, pupillary

response, and core temperature (if available) is performed.

3. Determine blood glucose and perform 12-lead EKG. EMT-CC STOP

4. Maintain MAP >65 mmHg

Dopamine 5 mcg/kg/min to maximum 10 mcg/kg/min IV/IO titrated to maintain MAP > 65 mmHg using a rate-limiting device. Use Y-site secondary tubing for dopamine running into free-flowing normal saline primary tubing. Do not use a primary line for dopamine to prevent extravasation.

5. Determine inclusion and exclusion criteria for therapeutic hypothermia:

Inclusion: GCS ≤ 8

Exclusion: Pregnancy, arrest as a result of trauma, suspected sepsis, drug intoxication, continued seizure activity, major surgery within 14 days, or temperature < 34°C (if known)

If patient meets inclusion and exclusion criteria:

Establish second, large bore, vascular access site and infuse 4°C normal saline to a total of 30 mL/kg or 2 L max (if available) Apply ice packs to axilla, groin, and neck; change every 10-15 minutes

6. Do not delay transport to initiate therapeutic hypothermia. Transport to a facility capable of maintaining therapeutic

hypothermia (Rochester General, Unity and URMC-Strong), and contact Medical Control while enroute if hypothermia begun. If recurrent cardiac arrest, transfer to closest Emergency Department.

7. Prevent shivering

Midazolam (Versed) 2.5 mg IV/IO once if Systolic BP > 100 mmHg (Additional doses per Medical Control, must contact Medical Control after use) RSI Providers may contact Medical Control for authorization of Vecuronium 0.1 mg/kg to max of 10mg if shivering or ventilatory problems. Paralytic agents are NOT indicated unless sedation can safely be administered AND the patient has an advanced airway.


3.3 ASYSTOLE / PULSELESS ELECTRICAL ACTIVITY (PEA) 1. Follow Cardiac Arrest - General Procedures Protocol (3.0) EMT STOP EMT-I STOP 2. Confirm asystole in 2 leads:

If possibility of fine VF exists, treat patient as for VF, refer to VF / Pulseless VT Protocol (3.1)

3. Establish IV/IO access and attempt to secure airway (per protocols 2.34, 2.0). Do not interrupt compressions for placement of an IV/IO or an advanced airway.

4. Epinephrine 1:10,000 1 mg (10mL) IV/IO 5. Repeat Epinephrine 1:10,000 1 mg IV/IO every 3-5 minutes throughout arrest. 6. Consider and treat possible causes:

• Hypoxia – Airway Management Protocol (2.0) • Hypovolemia – Fluid Challenge / Replacement Protocol (2.15) • Hypothermia – Hypothermia Protocol (2.19B) • Hyperkalemia – Consider Sodium Bicarbonate 1 mEq/kg IV once and Calcium Chloride 1 gm IV once (requires

normal saline flush between medications)

• Hydrogen ion problem (metabolic acidosis) – Consider Sodium Bicarbonate 1 mEq/kg IV once

• Hypoglycemia – Diabetic Emergencies Protocol (2.14) • Tension Pneumothorax – Chest Trauma Protocol (2.11) • Cardiac Tamponade – Chest Trauma Protocol (2.11) • ‘Tablets’ or other poisoning / overdose – Poisoning / Overdose Protocol (2.25) • Thrombosis – coronary or pulmonary embolism – Timely transport

7. If no change in patient status - consider Termination of Resuscitation Protocol (1.4)


3.4 BRADYCARDIA CRITERIA

• Bradycardia may be absolute (HR <60 bpm) or relative, which is a rate slower than expected for the patient’s condition. Bradycardia may be normal status for patient on beta blockers or with an athletic life style.

• Treatment listed to be used only if one or more of these conditions exist: • altered mental status • severe chest pain • lightheadedness, dizziness, nausea • systolic BP <90 mmHg, or relative hypotension for patient • frequent PVCs

1. Routine medical care EMT STOP 2. If patient is hypotensive and the lungs are clear, see Fluid Challenge / Replacement Protocol (2.15) EMT-I STOP If patient is in 2nd degree type II or 3rd degree AV heart block, or if patient is unstable, go to step 4.

3. Atropine 0.5 mg (5 mL) IV/IO

If Atropine is ineffective, repeat every 3 - 5 min up to 0.04 mg / kg Maximum

4. If Atropine is not effective, if patient is unstable, if patient has heart transplant or denervated heart, or if patient is in

2nd degree type II or 3rd degree AV heart block:

Transcutaneous external pacemaker, begin at 60 bpm and 60 mA and adjust to capture

If pacemaker captures, consider sedation and pain control; refer to Sedation Protocol (2.30)

EMT-CC STOP 5. If pacemaker fails to capture and Atropine is not effective, or if symptomatic hypotension continues with pacing:



3.5 UNSTABLE TACHYCARDIA (WIDE OR NARROW COMPLEX)

CRITERIA

• Stable Tachycardia - Asymptomatic or minor symptoms (palpitations, heart racing, etc.) • Unstable Tachycardia - HR > 150 bpm with mental status change or evidence of shock (hypotension, poor

peripheral pulses, cool distal extremities)

1. Routine medical care. EMT STOP EMT-I STOP 2. Assess ECG rhythm, hemodynamic status, and stability of patient. If patient is in Polymorphic VT and is unstable,

treat as in Pulseless Ventricular Tachycardia, refer to VF / Pulseless VT Protocol (3.1). 3. Consider sedation before cardioversion; refer to Sedation Protocol (2.30) 4. Synchronized cardioversion: 50-100 joules biphasic energy dose (100-200 joules monophasic) 5. If inadequate response from 1st cardioversion:

Synchronized cardioversion: 150 joules biphasic energy dose (300 joules monophasic) 6. If inadequate response from 2nd cardioversion:

Synchronized cardioversion: 200 joules biphasic energy dose (360 joules monophasic) 7. If inadequate response from 3rd cardioversion: Contact Medical Control.


3.6 STABLE NARROW COMPLEX TACHYCARDIA CRITERIA

• Supraventricular is defined as non-sinus, narrow complex tachycardia with HR usually > 150 bpm. • If ECG complex > 0.12 seconds,

• Stable Narrow Complex Tachycardia protocol - asymptomatic or minor symptoms (palpitations, heart racing, etc.)

refer to Wide Complex Tachycardia Protocol (3.7), especially if patient > 50 years of age, or has a history of previous MI, coronary artery disease, or CHF.

• Unstable Narrow Complex Tachycardia protocol - HR >150 bpm

with mental status change or evidence of shock (hypotension, poor peripheral pulses, cool distal extremities)

1. Routine medical care. EMT STOP EMT-I STOP 2. Assess ECG rhythm, hemodynamic status, and stability of patient. Unless emergent cardioversion is indicated,

obtain 12 lead ECG prior to any rhythm management: • If unstable, refer to UNSTABLE TACHYCARDIA Protocol (3.5) • If supraventricular tachycardia, go to Step 3 • If atrial flutter or atrial fibrillation, go to Step 6

3. Valsalva or other vagal maneuver. (No eyeball pressure/massage). 4. If inadequate response from vagal maneuver:

Adenosine (Adenocard) 6 mg rapid IV push with 10mL rapid saline flush 5. If inadequate response from 1st dose within 2 minutes:

Adenosine 12 mg rapid IV push with 10mL rapid saline flush, May repeat x1 (If inadequate response from Adenosine in narrow complex tachycardia with signs of CHF, go to step 7.) EMT-CC STOP 6. If atrial flutter / atrial fibrillation OR if inadequate response from Adenosine in narrow complex tachycardia with no

signs of CHF: Metoprolol 5 mg slow IV push, may repeat every 5 minutes to Max 15 mg or HR < 120 bpm OR Diltiazem (if available) 0.25 mg/kg (max 15 mg per dose) slow IV, May repeat once at 0.35 mg/kg (max 15 mg per

dose). 7. If patient unresponsive to previous interventions or if patient has signs of CHF: Procainamide (if available) 20 mg/min until: Maximum dose of 17mg/kg or 1 gram is reached Hypotension occurs QRS widens by 50% of original width Rhythm converts To administer: Dilute 1000mg/2mL vial in 100mL (concentration 10 mg/mL); Administer 2 mL/min OR Amiodarone (Cordarone) 150 mg diluted in a minimum of 50mL of NS given IV over 10 minutes NOTE

If patient becomes UNSTABLE (See criterion above), refer to Unstable Tachycardia Protocol (3.5). If patient has a recent history of cocaine use, do not use Metoprolol.


3.7 STABLE WIDE COMPLEX TACHYCARDIA CRITERIA

• If patient has wide complex tachycardia and is pulseless, refer to VF/ Pulseless VT Protocol (3.1) • Stable VT protocol - Asymptomatic or minor symptoms (palpitations, heart racing, etc.) • Unstable VT protocol – HR >150 bpm with altered mental status changes or evidence of shock (hypotension,

poor peripheral pulses, cool distal extremities).

1. Routine medical care. EMT STOP EMT-I STOP EMT-CC STOP 2. Assess hemodynamic status & stability of patient - If unstable; refer to UNSTABLE TACHYCARDIA Protocol

(3.5). Unless emergent cardioversion, obtain 12 lead ECG prior to any rhythm management. 3. Establish Vascular Access per Vascular Access Protocol (2.34).

3. If monomorphic VT or non-Torsades polymorphic VT (normal baseline QT interval), or Wolff-Parkinson-White with aberrancy:

Procainamide (if available) 20 mg/min until: Maximum dose of 17mg/kg or 1 gram is reached Hypotension occurs QRS widens by 50% of original width Rhythm converts To administer: Dilute 1000mg/2mL vial in 100mL (concentration 10 mg/mL); Administer 2 mL/min OR

Amiodarone (Cordarone) 150 mg diluted in a minimum of 50mL NS and given IV over 10 minutes 4. If polymorphic VT (long baseline QT interval): Magnesium Sulfate 2gm in 100 mL NS given over 10 min – contraindicated if the patient has suspected renal

failure 5. If undifferentiated wide complex tachycardia:

Adenosine (Adenocard) 6 mg rapid IV push with 10mL rapid saline flush If inadequate response from 1st dose within 2 minutes: Adenosine 12 mg rapid IV push with 10mL rapid saline flush, May repeat x1

NOTE: If patient becomes UNSTABLE (See criterion above), refer to Unstable Tachycardia Protocol (3.5).



Section 4

Pediatric Cardiac Life Support


4.0 PEDIATRIC CARDIAC ARREST – GENERAL PROCEDURES 1. Verify patient is pulseless and apneic. 2. Initiate or continue CPR. CPR is to be continued at all times as is practical. 3. Assure airway patency and begin use of BVM. Provide initial BLS airway management, including Oropharyngeal or

Nasopharyngeal Airway. 4. Apply AED or SAED if available. If switching to a different AED/monitor you may use previously applied patches if

compatible with new unit.

If patient ≥ age 8 - automatic external defibrillator may be used as appropriate.

If patient < age 8 - Use pediatric cables if available. 5. Follow prompts provided by AED/SAED device. 6. Utilize ALS, or initiate timely transport toward ALS (ALS intercept or hospital if closer). If ALS not available, no

more than 3 shocks should be delivered at the scene. Defibrillation should not be performed in a moving ambulance.

EMT STOP 7. Obtain Vascular access, refer to Vascular Access Protocol (2.34) EMT-I STOP 8. If AED /SAED not already applied quick look using manual monitor and defibrillate PRN after CPR of at least 10

cycles (about 2 minutes). Apply limb leads and pads in between shock sequences as appropriate. 9. Secure definitive airway (per protocol 2.1). If BLS airway is sufficient to maintain chest rise, continue until

additional time or resources are available. Do not interrupt compressions for placement of an advanced airway.

Remove Bag Valve device whenever transferring patient, moving patient in and out of ambulance or other times when Bag Valve device may dislodge the device. Reassess airway patency after any movement of patient.

10. Give medications as listed in the following specific arrhythmia / dysrhythmia protocols. NOTE:

Should IV/IO access not be available, Epinephrine may be administered via ETT with direct on-line medical control.


4.1 VENTRICULAR FIBRILLATION / PULSELESS V-TACH 1. Follow Pediatric Cardiac Arrest, see General Procedures Protocol (4.0) EMT STOP EMT-I STOP 2. Defibrillate once at 2 J/kg energy dose (Max 100 joules biphasic, 200 joules monophasic) If converts to another rhythm – refer to appropriate protocol for that rhythm If converts to adequate pulse – refer to Post Conversion Protocol (4.2). 3. Defibrillate once at 4 J/kg dose (Max 200 joules biphasic, 360 joules monophasic)

4. Establish IV/IO access and attempt to secure airway (per protocols 2.34 and 2.1). 5. Epinephrine 1:10,000 0.01 mg/kg (0.1mL/kg, Max 1mg) IV/IO 6. Defibrillate once at 4 J/kg (Max 200 joules biphasic, 360 joules monophasic) 7. If no conversion:

Amiodarone (Cordarone) 5 mg/kg diluted in a minimum of 20mL NS and given IV/IO push (Max 300mg)

8. Defibrillate once at 4 J/kg (Max 200 joules biphasic, 360 joules monophasic)

9. If no conversion:

Continue defibrillations at 4 J/kg (Max 200 joules biphasic, 360 joules monophasic)) as long as VF or pulseless VT continues, alternating shocks with medication doses:

Repeat Epinephrine every 3-5 minutes between shocks

Repeat Amiodarone (Cordarone) 5 mg/kg diluted in a minimum of 20mL NS and given IV/IO push, once (Max 150 mg)

If Amiodarone unavailable, may administer Lidocaine (Xylocaine) 1.5 mg/kg IV/IO push. May repeat

Once

Deliver each medication administration during a period of 2 minutes of CPR and coordinate with a defibrillation attempt

EMT-CC STOP 10. If Torsades de Pointes or hypomagnesemic state suspected consider

Magnesium Sulfate 50 mg/kg diluted in a minimum of 10mL NS and given IV/IO push (Max 2 gm)

NOTE: If using the maximal weight-based energy setting it is appropriate to use the manufacturers recommended energy dose for an adult.


4.2 RETURN OF SPONTANEOUS CIRCULATION CRITERIA

The following is for a patient with Return of Spontaneous Circulation (ROSC) as evidenced by a palpable pulse following CPR, electrical, or drug therapy for a patient previously pulseless. • Post-conversion treatment of VF or VT should only be started if the patient has regained a pulse of adequate

rate (>60). If not, refer to other cardiac protocols as appropriate.

1. Routine medical care. EMT STOP EMT-I STOP 2. Following ROSC, the patient should be reassessed and a 12 lead ECG and blood glucose should be performed.

3. Perform complete neurologic exam, including GCS and pupillary response.

EMT-CC STOP

4. Maintain MAP >65 mmHg

Dopamine 5 mcg/kg/min to maximum 10 mcg/kg/min IV/IO titrated to maintain MAP > 65 mmHg using a rate-limiting device. Use Y-site secondary tubing for dopamine running into free-flowing normal saline primary tubing. Do not use a primary line for dopamine to prevent extravasation.


4.3 ASYSTOLE / PULSELESS ELECTRICAL ACTIVITY (PEA) 1. Follow General Procedures Protocol (4.0) EMT STOP EMT-I STOP 2. Confirm asystole in 2 leads:

If possibility of fine VF exists, treat patient as for VF, refer to VF / Pulseless VT Protocol (4.1) 3. Establish IV/IO access and attempt to secure airway (per protocols 2.34 and 2.1). Do not interrupt compressions for

placement of an IV/IO or an advanced airway. 4. Epinephrine: 1:10,000 0.01 mg/kg (0.1 mL/kg) (Max dose 1mg) IV/IO 5. Repeat Epinephrine every 3-5 minutes throughout arrest using above dose 6. Consider and treat cause

• Hypoxia – Airway Management Protocol (2.1) • Hypovolemia – Fluid Challenge / Replacement Protocol (2.15) • Hypothermia – Hypothermia Protocol (2.19B) • Hyperkalemia – Consider Sodium Bicarbonate 1 mEq/kg IV once and Calcium Chloride 5 mg/kg (Max dose

1gm) IV once (requires normal saline flush between medications)

• Hydrogen ion problem (metabolic acidosis) – Consider Sodium Bicarbonate 1 mEq/kg IV once

• Hypoglycemia – Diabetic Emergencies Protocol (2.14) • Tension pneumothorax – Chest Trauma Protocol (2.11) • Cardiac Tamponade – Chest Trauma Protocol (2.11) • ‘Tablets’ or other poisoning / overdose – Poisoning / Overdose Protocol (2.25) • Thrombosis – coronary or pulmonary embolism – Timely transport


4.4 BRADYCARDIA

CRITERIA • Bradycardia may be absolute or relative, which is a rate slower than expected for the

patient’s condition and is almost always the result of hypoxia in children.

• Treatment listed to be used only if one or more of these conditions exist: • altered mental status • severe chest pain • lightheadedness, dizziness, nausea • systolic BP <80 mmHg, or relative hypotension for patient’s expected normal • frequent PVCs

1. Routine medical care and begin timely transport. For newborns, refer ro Neonatal Resuscitation Protocol (2.22). 2. Assure airway patency and administer high flow oxygen. Bag-valve mask assisted ventilation should always be

done for children < 8 yrs of age with bradycardia with poor perfusion. 3. Administer chest compressions if, despite ventilation and oxygenation, pulse remains < 60 bpm with poor perfusion. EMT STOP EMT-I STOP 4. If evidence of poor perfusion potentially due to hypovolemia with no signs or history of heart disease, see Fluid

Challenge / Replacement Protocol (2.15) 5. If continued pulse < 60 bpm and evidence of poor perfusion despite assurance of adequate ventilation / oxygenation:

Epinephrine: 1:10,000 0.01 mg/kg (0.1 mL/kg), (Max dose 1mg) IV/IO

EMT-CC STOP 6. If continued pulse < 60 bpm and evidence of poor perfusion after Epinephrine despite assurance of adequate ventilation / oxygenation:

Atropine 0.02 mg/kg IV/IO (Min 0.1 mg, Max 1mg) 7. If inadequate response:

Epinephrine at above doses IV/IO every 3-5 minutes 8. If inadequate response:

Atropine once 5 minutes after initial dose: 0.02 mg/kg IV/IO (Min 0.1 mg, Max 1mg) Maximum total Atropine dose – 0.04 mg/kg

9. If inadequate response, consider Pacing.


4.5 UNSTABLE TACHYCARDIA (WIDE OR NARROW COMPLEX) CRITERIA

• Stable Tachycardia - Asymptomatic or minor symptoms (palpitations, heart racing, etc.) • Unstable Tachycardia - HR > 150 bpm with mental status change,or evidence of shock (hypotension, poor

peripheral pulses, cool distal extremities) 1. Routine medical care. 2. Assure airway patency and administer high flow oxygen. 3. Timely transport. EMT STOP EMT-I STOP EMT-CC STOP 4. Consider sedation; refer to Sedation Protocol (2.30) 5. Synchronized cardioversion 0.5 j/kg biphasic energy dose (Max 50j; 1 j/kg monophasic, Max 200j)

Consider the use of pediatric paddles if patient ≤ 10kg, or use anterior-posterior placement of paddles if body area is small (or when pediatric paddles are not available).

6. If inadequate response from 1st cardioversion:

Synchronized cardioversion: 1 j/kg biphasic energy dose (Max 100j; 2 j/kg monophasic, Max 300j)

7. If inadequate response from 2nd cardioversion:

Synchronized cardioversion: 2 j/kg biphasic energy dose (Max 200j; 4 j/kg monophasic, Max 360j)

8. If inadequate response from 3rd cardioversion:

Contact Medical Control


4.6 STABLE NARROW COMPLEX TACHYCARDIA

CRITERIA

• Supraventricular is defined as non-sinus, narrow complex tachycardia with HR usually > 160 bpm. If ECG complex > 0.12 seconds,

• Stable Narrow Complex Tachycardia protocol - Asymptomatic or minor symptoms (palpitations, heart racing, etc.) refer to Wide Complex Tachycardia Protocol (4.7)

• Unstable Narrow Complex Tachycardia protocol - HR >150 bpm

with mental status change, or shock symptoms (hypotension, poor peripheral pulses, cool distal extremities)

1. Routine medical care.

2. Assure airway patency and administer high flow oxygen.

3. Timely transport. EMT STOP EMT-I STOP 4. Assess hemodynamic status & stability of patient - If unstable; refer to UNSTABLE TACHYCARDIA Protocol

(4.5). 5. Valsalva maneuver (application of ice water bag over the face (do not block the airway), ‘blowing on thumb’ or into

straw may work on child) 6. Establish vascular access, refer to Vascular Access Protocol (2.34) EMT-CC STOP 7. If inadequate response from Valsalva:

Adenosine (Adenocard) 0.1 mg/kg rapid IV push (Max 6 mg) with 5mL rapid saline flush

8. If inadequate response from Adenosine:

Repeat Adenosine 0.2 mg/kg rapid IV push (Max 12 mg) with 5mL rapid saline flush, may repeat once

9. If inadequate response from 3rd dose of Adenosine:

Refer to Stable Wide Complex Tachycardia Protocol (4.7).

NOTE:

If no response to above and patient becomes UNSTABLE, refer to Unstable Tachycardia Protocol (4.5).


4.7 STABLE WIDE COMPLEX TACHYCARDIA CRITERIA

• If patient has wide complex tachycardia and is pulseless, refer to VF / Pulseless VT Protocol (4.1) • Stable VT protocol - Asymptomatic or minor symptoms (palpitations, heart racing, etc.) • Unstable VT protocol – HR >150 bpm with altered mental status change or shock symptoms (hypotension,

poor peripheral pulses, cool distal extremities). 1. Routine medical care. 2. Assure airway patency and administer high flow oxygen. EMT STOP EMT-I STOP EMT-CC STOP 3. Assess hemodynamic status & stability of patient - If unstable; refer to UNSTABLE TACHYCARDIA Protocol

(4.5) 4. Establish vascular access; refer to Vascular Access Protocol (2.34).

Procainamide (if available) 20 mg/min until: Maximum dose of 17mg/kg or 1 gram is reached Hypotension occurs QRS widens by 50% of original width Rhythm converts To administer: Dilute 1000mg/2mL vial in 100mL (concentration 10 mg/mL); Administer 2 mL/min OR

5. Amiodarone (Cordarone) 5mg/kg diluted in a minimum of 50 mL NS IV/IO given over 20 min, (Max 150 mg)

If undifferentiated wide complex tachycardia: Adenosine (Adenocard) 0.1 mg/kg rapid IV push (Max 6 mg) rapid IV push with 5 mL rapid saline flush. If inadequate response from 1st dose within 2 minutes: Adenosine 0.2 mg/kg rapid IV push (Max 12 mg) with 5mL rapid saline flush, May repeat x1

NOTE:

If no response to above or if patient becomes UNSTABLE, refer to Unstable Tachycardia Protocol (4.5)



Section 5

BLS Pharmacology


5.1 ACTIVATED CHARCOAL (WITHOUT SORBITOL) a) Indications Poisoning by mouth b) Adverse Effects May indirectly induce vomiting and cause nausea c) Precautions Does not absorb all drugs and toxic substances

d) Contraindications (1) Altered mental status (2) Patients who have received an emetic

e) Preparations

(1) 25 grams/125 mL bottle (2) 50 grams/250 mL bottle

f) Dosage (1) Adult: Administer 50 grams (2) Pediatric: Administer 2 grams/kg (Max 50gm)


5.2 ALBUTEROL (PROVENTIL, VENTOLIN)

a) Indications (1) Signs and symptoms of respiratory distress (2) Bronchospasm/wheezing associated with Asthma

b) Adverse Effects

(1) Tachycardia/ Palpitations (2) Hypertension (3) Angina (4) Nervousness/ Anxiety (5) Tremors (6) Dizziness (7) Headache (8) Sweating (9) Nausea/ Vomiting (10) Sore throat

c) Precautions

(1) May cause severe bronchospasm from repeated excessive use. (2) Patient must have his/her own physician-prescribed hand-held aerosol inhaler.

d) Contraindications

(1) Known hypersensitivity (2) Albuterol not prescribed for the patient

e) Preparations 2.5mg/3mL (0.083%) solution f) Dosage

(1) Adult: 5 mg via nebulizer may repeat once

(2) Pediatric: 2.5 mg via nebulizer may repeat once


5.3 ASPIRIN a) Indications Non-traumatic chest pain

b) Adverse Effects

(1) Heartburn (2) Nausea and vomiting (3) Wheezing

c) Precautions GI bleeding and upset


Known hypersensitivity

e) Preparations 81 mg tablets f) Dosage

(1) Adult: 324 mg chewed (4 tablets) (2) Pediatric: Not Indicated


5.4 EPINEPHRINE AUTO-INJECTOR

a) Indications Moderate to severe allergic reaction with respiratory distress, shock or airway swelling b) Adverse Effects

(1) Tachycardia / Palpitations (2) Angina (3) Headache (4) Nausea / vomiting (5) Dizziness (6) Hypertension (7) Nervousness / Anxiety (8) Tremors

c) Precautions Unless in severe allergic reaction or severe asthma, medical consultation should be obtained before

administering to pregnant or cardiac patients d) Contraindications

None in the presence of anaphylaxis e) Preparations

Epinephrine Auto-injector only (Patient prescribed or EMS service authorized) (1) Adult: 0.3 mg (EpiPen) (2) Pediatric: 0.15 mg (EpiPen Jr.)

f) Dosage

(1) Patients greater than 30 kg (66lbs): Adult Auto-injector: 0.3 mg IM (2) Patients less than 30 kg (66lbs): Pediatric Auto-injector: 0.15 mg IM


5.5 NITROGLYCERIN a) Indications

(1) Patient must have own prescribed sublingual nitroglycerin. (2) Chest pain

b) Adverse Effects

(1) Hypotension (2) Headache (3) Dizziness (4) Tachycardia

c) Precautions

(1) Reassess blood pressure before and after administration. (2) If systolic blood pressure drops more than 20 mmHg, obtain medical consultation before further

administration. d) Contraindications

(1) Blood pressure below 120 mmHg systolic (2) Heart rate less than 60 bpm (3) Medication not prescribed for the patient (4) Pediatric patient (5) Any patient having taken medication for erectile dysfunction (e.g., Viagra™, Levitra™, or Cialis™) within the

past 72 hours. Medical consultation is required to override this contraindication. e) Preparations

0.4 mg sublingual tablet f) Dosage

(1) Adult: One tablet sublingually (a) Repeat in 3 to 5 minutes if chest pain persists (b) Maximum of three doses (a combination of patient-administered and EMT-B-administered) (2) Pediatric:

Not Indicated


5.6 ORAL GLUCOSE a) Indications

(1) Altered mental status with patent airway and known diabetic history b) Adverse Effects

Not clinically significant c) Precautions

Patient without gag reflex may aspirate. d) Contraindications Inability to speak e) Preparations

10-15 grams of glucose (contained in 24, 30, or 37.5 gram tube) f) Dosage (1) Adult: Administer 10-15 grams of glucose paste between the gum and cheek.

(2) Pediatric: Administer 10-15 grams of glucose paste between the gum and cheek; this may be accomplished through

several small administrations.


5.7 OXYGEN

a) Indications All medical and trauma patients

b) Adverse Effects

High concentrations of oxygen will reduce the respiratory drive in some COPD patients; these patients should be carefully monitored.

c) Precautions

(1) Never withhold oxygen from those who need it. (2) Oxygen should be given with caution to patients with COPD. (3) Nasal cannula should not be used with more than 6 lpm. (4) Non-rebreather face masks must be supplied with a minimum 12 lpm.


None e) Dosage (1) Adult: Administer per protocol (2) Pediatric: Administer per protocol



Section 6

ALS Pharmacology


ALS Medication Requirements

The drugs listed below are items identified in the Monroe/Livingston Standards of Care for the treatment of Adult and Pediatric Patients. These items are provided for replacement by participating Hospitals in the Region.

Generic Name Trade Name Desired Unit Box Total

Adenosine Adenocard 6 mg Preloaded Syringe 5 Albuterol Sulfate 0.083% Albuterol 2.5 mg/3 ml Solution for Inhalation 9 Amiodarone HCl Cordarone 150 mg Vial 3 Aspirin Aspirin 81 mg Tablet 8 Atropine Sulfate Atropine Sulfate 1 mg Preloaded Syringe 2 Calcium Chloride 10% Calcium Chloride 10% 1 gm Preloaded Syringe 1 Dextrose 25% Dextrose 25% 2.5 gm Preloaded Syringe 1 Dextrose 50% Dextrose 50% 25 gm Preloaded Syringe 2 Diphenhydramine Benadryl 50 mg Vial 1 Dopamine Hydrochloride Intropin 1,600 mcg/mL Solution 1 Epinephrine 1:1000 Epinephrine 1:1000 30 mg Multidose Vial 1 Epinephrine 1:10,000 Epinephrine 1:10,000 1 mg Preloaded Syringe 8 Glucagon Glucagon 1 mg Kit 2 Ipratropium Bromide 0.02% Atrovent 0.5 mg/2.5 mI Solution for Inhalation 2 Lidocaine Lidocaine 100 mg Preloaded Syringe 2 Magnesium Sulfate 50% Magnesium Sulfate 50% 5 gm Vial 2 Metoprolol Tartrate Metoprolol 5 mg Vial 3 Naloxone Hydrochloride Narcan 2 mg Preloaded Syringe 2 Nitroglycerin Nitroglycerin 0.4 mg Tablet Multidose Bottle (25) 1 Promethazine HCI Phenergan 25 mg Vial 1 Sodium Bicarbonate 8.4% Sodium Bicarbonate 8.4% 50 mEq Preloaded Syringe 2

Optional ALS Medications

This list indicates medications that may be obtained by agencies wishing to carry them and in the case of RSI medications, are credentialed/authorized to do so. This list does not address medications included in the Specialty Care Transport Unit or HazMat / ToxMedic Standards of Care which are obtained by agencies using those specific protocols.

Generic Name Trade Name Desired Unit Box Total

Diltiazem Cardizem 25 mg / 5ml Vial 2 Procainamide Procainamide 1000 mg / 2 ml Vial 1 Etomidate Etomidate 40 mg / 20 ml Vial/Preloaded Syringe 2 Succinylcholine Succinylcholine 200 mg / 10 ml Vial 2 Vecuronium Vecuronium 10 mg / 10 ml Vial 1

Controlled Substances

Controlled substances, which are also included in the Standards and required of ALS agencies, are obtained by individual agencies and at stock and substock consistent with internal agency policy, under agreement with a provider Hospital.


6.1 ACTIVATED CHARCOAL (WITHOUT SORBITOL) a) Pharmacology

Variable drug or toxin absorption when ingested

b) Pharmacokinetics Absorbs poisons and prevents toxins from entering body systems

c) Indications

Poisoning by mouth

d) Contraindications (1) Altered mental status (2) Patients who have received an emetic

e) Adverse Effects

Not clinically significant

f) Precautions Does not adsorb all drugs and/or toxic substances

g) Dose (1) Adult: Administer 50 grams (2) Pediatric:

Administer 2 grams/kg (Max 50gm)


6.2 ADENOSINE (ADENOCARD) a) Pharmacology

(1) Naturally occurring purine nucleoside (2) Used to treat narrow complex tachycardia, PSVT (3) Slows conduction through the AV node (4) No effect on ventricular contractility (5) Causes peripheral vasodilatation (often dramatic)

b) Pharmacokinetics

Onset of action within 5 to 20 seconds following an IV dose; half-life is 10 seconds.

c) Indications (1) To slow the rate of narrow complex tachycardia (2) Is effective on SVT/PSVT (3) No effect on atrial fibrillation, or flutter (4) May be useful for differentiating wide complex tachycardia


Known hypersensitivity e) Adverse Effects

Flushing, dyspnea, chest pressure, nausea, headache, dizziness, and hypotension f) Precautions

(1) Effects antagonized by theophylline (2) Effects enhanced by dipyridomole (persantine), digitalis, calcium channel blockers, and benzodiazepines

such that the dose of adenosine should be reduced for patients on these medications (3) Be prepared for up to 40 seconds of asystole

g) Dosage

(1) Adult: 6 mg rapid IV bolus followed by a rapid flush Give 12 mg if no response within 2 minutes Give an additional 12 mg if no response within another 1 to 2 minutes (2) Pediatric:

0.1 mg/kg rapid IV bolus followed by a rapid flush (Max 6 mg) Give 0.2 mg/kg if no response within 2 minutes (Max 12 mg) Give an additional 0.2 mg/kg if no response within another 2 minutes (Max 12 mg)


6.3 ALBUTEROL SULFATE (PROVENTIL, VENTOLIN)

a) Pharmacology (1) Synthetic sympathomimetic amine (a type of stimulant) (2) Stimulates beta-2 adrenergic receptors of the bronchioles (3) Little effect on blood pressure (4) Main effect is bronchodilation. (5) It may cause some vasodilation as evidenced by headache or flushing

b) Pharmacokinetics

(1) Bronchodilation begins within 5 to 15 minutes after inhalation. (2) Peak effect occurs in 30-120 minutes. (3) Duration of action is usually 3-4 hours.

c) Indications

To reverse bronchospasm (wheezing) d) Contraindications

Known hypersensitivity e) Adverse Effects

(1) Tachycardia (2) Palpitations (3) Peripheral vasodilatation (4) Tremors and nervousness (5) Headache (6) Sore throat (7) PVCs (8) Nausea and vomiting

f) Precautions

(1) Bronchospasm may worsen in rare situations due to patient tolerance or hypersensitivity. (2) If respirations worsen, consider discontinuing use. (3) Should be used with caution in patients with hyperthyroidism or coronary artery disease.

(4) Use with caution when administering to patients taking MAO inhibitors or tricyclic antidepressants which may be potentiated by albuterol.

(5) Medical direction required before administering to pregnant patient or patient having a cardiac history. g) Dosage (1) Adult: 5 mg by nebulizer may repeat up to 30 mg/hr (2) Pediatric: 2.5 mg by nebulizer may repeat up to 30 mg/hr


6.4 AMIODARONE (CORDARONE) a) Pharmacology

Class III antiarrhythmic prolongs action potential and refractory period with some Class Ia, II, and IV effects b) Pharmacokinetics

Onset within 30-180 minutes, half life of 58 days

c) Indications (1) Ventricular Fibrillation/Pulseless Ventricular Tachycardia (2) Post Conversion of Ventricular Fibrillation/Pulseless Ventricular Tachycardia (3) Stable Ventricular Tachycardia (4) Stable Supraventricular Tachycardia refractory to Adenosine, Diltiazem and Metoprolol

d) Contraindications (1) Iodine hypersensitivity (2) Cardiogenic shock (3) Bradycardia

(4) Hypotension (5) 2nd or 3rd Degree AV Block (6) Pregnancy (relative contraindication)

e) Adverse Effects (1) AV conduction abnormalities (2) Hepatoxicity (3) Prolonged QT interval (4) VFib / V-Tach (5) Dizziness

f) Precautions

(1) Requires dilution and slow administration

g) Dosage (1) Cardiac Arrest

(a) Adult: 300 mg diluted in a minimum of 20mL NS and given slow IV/IO, may repeat at 150 mg once

(b) Pediatric: 5 mg/kg diluted in a minimum of 20mL NS and given slow IV/IO (Max 300 mg), may repeat at 5 mg/kg

IV/IO once (Max 150 mg) (2) Post conversion of VF-VT

(a) Adult 150 mg diluted in a minimum of 50mL NS and given IV/IO over 10 minutes

(b) Pediatrics 5 mg/kg diluted in a minimum of 50mL NS and given IV/IO, Maximum 150 mg, over 10 minutes (Max

150mg) (3) Stable refractory narrow complex tachycardia

(a) Adult: 150 mg diluted in a minimum of 50mL NS and given IV/IO over 10 minutes

(b) Pediatric: Not indicated

(4) Stable Wide Complex Tachycardia (a) Adult

150 mg diluted in a minimum of 50mL NS and given IV/IO over 10 minutes (b) Pediatric

5 mg/kg diluted in a minimum of 50 mL NS and given over 20 minutes (Max 150mg)


6.5 ASPIRIN a) Pharmacology

(1) Platelet inhibitor (2) Anti-inflammatory

b) Pharmacokinetics

Blocks platelet aggregation

c) Indications Chest pain when acute myocardial infarction is suspected.

d) Contraindications (1) Known hypersensitivity (2) Active bleeding

e) Adverse Effects (1) Heartburn (2) Nausea and vomiting (3) Wheezing

f) Precautions

GI bleeding and upset

g) Dosage (1) Adult:

324 mg chewed (2) Pediatric:

Not Indicated


6.6 ATROPINE SULFATE a) Pharmacology

(1) Parasympatholytic (vagolytic action) (2) Anticholinergic (accelerates the heart rate) (3) May restore cardiac rhythm in asystole

b) Pharmacokinetics

(1) Accelerated heart rate within minutes of IV injection (2) Peak effect is seen within the first 15 minutes. (3) Atropine disappears rapidly from the blood. (4) Excreted in the urine within the first 12 hours

c) Indications

(1) Symptomatic bradycardia (2) Organophosphate poisoning (3) Nerve agents


(1) Known hypersensitivity (2) Dysrhythmias in which enhancement of conduction may accelerate the ventricular rate and cause

decreased cardiac output (e.g. atrial fibrillation, atrial flutter, or PAT with block) (3) Relative Contraindications (Weigh risk/benefits.):

(a) AV block at His-Purkinje level (second-degree Type II AV Block and third-degree AV Block) (b) Suspected acute myocardial infarction or ischemia (c) Glaucoma

e) Adverse Effects

(1) Excessive doses of atropine can cause delirium, restlessness, disorientation, tachycardia, coma, flushed and hot skin, ataxia, blurred vision, dry mucous membranes.

(2) Ventricular fibrillation and tachycardia have occurred following IV administration of atropine.

f) Precautions Not clinically significant

g) Dosage

(1) Adult: Bradycardia: Administer 0.5 mg IV/IO repeated every 3-5 minutes to a total dose of 0.04 mg/kg

(2) Pediatric Cardiac Arrest: Administer 0.02 mg/kg IV/IO repeated every 3-5 minutes (minimum dose 0.1 mg; Maximum single dose

1 mg; Maximum total dose 0.04mg/kg)


6.7 CALCIUM CHLORIDE (10% Solution) a) Pharmacology

(1) Increase cardiac contractile state, and ventricular automaticity (2) Is useful in reversing cardiac arrhythmias due to hyperkalemia (often seen in renal dialysis patients)

b) Pharmacokinetics

Rapid onset of action with IV administration

c) Indications (1) Hyperkalemia (2) Hypocalcemia (3) To treat adverse effects caused by calcium channel blocker overdose (4) Hypotension secondary to Diltiazem administration.


(1) Patient currently taking Digoxin with suspected calcium channel overdose (2) Not indicated in cardiac arrest except when hyperkalemia, hypocalcemia, or calcium channel toxicity is

highly suspected

e) Adverse Effects (1) Bradycardia may occur with rapid injection. (2) Syncope, cardiac arrest, arrhythmia, bradycardia

f) Precautions

(1) Use with caution on patients taking digitalis, as calcium may increase ventricular irritability and precipitate digitalis toxicity.

(2) If given with sodium bicarbonate, calcium will precipitate. (3) Calcium salts may produce coronary and cerebral artery spasm.

g) Dosage

(1) Adult: (a) Cardiac Arrest with suspected hyperkalemia – 1 gram IV (b) Calcium Channel Blocker Overdose – 1 gram slow IV, reassess with Medical Control for additional

doses (2) Pediatric:

Administer 20 mg/kg (0.2 mL/kg) slow IV/IO, Maximum dose 1 gram or 10 mL.


6.8 DEXTROSE a) Pharmacology

Dextrose is a water-soluble monosaccharide found in corn syrup and honey

b) Pharmacokinetics (1) Dextrose restores circulating blood sugar and is rapidly utilized following IV injection (2) Excess dextrose is rapidly excreted unchanged in the urine

c) Indications Correction of altered mental status due to low blood sugar (hypoglycemia) seizures and cardiac arrest

d) Contraindications Known hyperglycemia

e) Adverse Effects May worsen hyperglycemia (high blood sugar)

f) Precautions (1) May worsen pre-existing hyperglycemia (2) Tissue necrosis if extravasation occurs

g) Dosage

(1) Adult: Administer D50W 25 grams/50 mL IV/IO

(2) Pediatric: (a) For patients < 5 kg - D25W 0.5-1 gm/kg IV/IO (b) For patients > 5 kg - D50W 0.5-1 gm/kg IV/IO


6.9 DIPHENHYDRAMINE HYDROCHLORIDE (BENADRYL) a) Pharmacology

Antihistamine

b) Pharmacokinetics (1) Effect begins within 15 minutes of IV dose. (2) Peak effect 1 to 4 hours (3) Metabolized by the liver (4) The half-life ranges from 2 to 10 hours.

c) Indications

(1) Allergic reaction (2) Anaphylaxis (3) Dystonic reactions



e) Adverse Effects (1) Drowsiness (2) Loss of coordination (3) Blurred vision (4) Headache (5) Hypotension (6) Tachycardia (7) Palpitations (8) Thickening of bronchial secretions leading to chest tightness (9) Wheezing

f) Precautions

Should be used with caution in patients with: (1) Severe vomiting (2) Alcohol intoxication (3) Medical consultation required for:

(a) Asthma (b) Nursing mothers


Administer 50 mg slow IV or IM (2) Pediatric:

Administer 1 mg/kg slow IV/IO or IM, Maximum single dose 25 mg


6.10 DOPAMINE HYDROCHLORIDE (INTROPIN) a) Pharmacology

(1) Alpha and beta adrenergic receptor stimulator (2) Dopaminergic receptor stimulator (3) Precursor of norepinephrine (4) At low doses, less than 2 mcg/kg/min

(a) Dilates renal and mesenteric blood vessels (b) Venoconstricts (c) Arterial resistance varies

(5) At moderate doses, 2-6 mcg/kg/min Beta1 stimulating effect on heart, results in increased cardiac output

(6) High dose, 6-10 mcg/kg/min Exhibits alpha1 effects; peripheral vasoconstriction including renal and mesenteric vessels, increases left and right ventricular preload

(7) Doses greater than or equal to 10 mcg/kg/min Alpha1 stimulating effects may reverse mesenteric and renal artery dilatation resulting in decreased blood flow, causing increased preload due to effects on venous system

b) Pharmacokinetics

(1) Extremely rapid onset of action (2) Extremely brief duration of action (3) The rate of administration may be used to control the effect of dopamine

c) Indications

(1) Cardiogenic shock (2) Septic shock (3) Anaphylactic shock


(1) Pheochromocytoma (adrenal tumor which causes excessive release of epinephrine and norepinephrine) (2) Pre-existing tachydysrhythmias (3) Uncorrected hypovolemia

e) Adverse Effects

(1) Anginal pain (2) Tachydysrhythmias (3) Nausea and vomiting (4) Hypertension (5) Undesirable degree of vasoconstriction

f) Precautions

(1) Extravasation should be reported to the hospital staff on arrival. (2) Patients receiving monoamine oxidase (MAO) inhibitors are extremely sensitive to the effects of dopamine

and should receive a much lower dosage than is usually given. (3) Patients with pheochromocytoma are extremely sensitive to dopamine and may develop profound

hypertension in response to minimal doses. (4) To be infused with rate limiting device only.

g) Dosage

(1) For IV infusion use only (2) In general, the infusion rate is adjusted to blood pressure and clinical response. (3) Adult:

Administer 5-10 mcg/kg/min IV drip titrated to BP > 90 systolic or Medical Control selected BP, a rate-limiting device must be used when administering this medication. Use Y-site secondary tubing for dopamine running into free-flowing normal saline primary tubing. Do not use a primary line for dopamine to prevent extravasation.

(4) Pediatric Not indicated


6.11 EPINEPHRINE 1:10,000 / 1:1,000 a) Pharmacology

(1) The administration of epinephrine causes increases in: (a) Systemic vascular resistance (b) Systemic arterial pressure (c) Heart rate (positive chronotropic effect) (d) Contractile state (positive inotropic effect) (e) Myocardial oxygen requirement (f) Cardiac automaticity (g) AV conduction (positive dromotropic effect)

(2) Causes a reduction with bronchodilation by relaxing smooth muscles in the bronchial tree (bronchial dilation)

b) Pharmacokinetics

(1) IV administered epinephrine has an extremely rapid onset of action. (2) Is rapidly inactivated by the liver (3) Subcutaneous administration of epinephrine results in slower absorption due to local vasoconstriction. (4) Local massage will hasten absorption. (5) Topically applied nebulizer within the respiratory tract, epinephrine has vasoconstrictor properties which

result in reduction of mucosal and submucosal edema. It also has bronchodilator properties which reduce airway smooth muscle spasms.

c) Indications

(1) Cardiac arrest (2) Moderate to severe allergic reaction/anaphylaxis (3) IV epinephrine should be reserved for cardiac arrest patients and for impending cardiac arrest due to

anaphylactic shock. (4) Bronchial asthma (5) Respiratory Stridor (Suspected Croup)


(1) Hypertension (2) Pre-existing tachydysrhythmias with a pulse (ventricular and supraventricular) (3) Use with pregnant women should be avoided whenever possible.

e) Adverse Effects

(1) Tachydysrhythmias (supraventricular and ventricular) (2) Hypertension (3) May induce early labor in pregnant women (4) Headache (5) Nervousness (6) Decreased level of consciousness (7) Rebound edema may occur 20-30 minutes after administration to croup patients

f) Precautions

(1) Do not mix with sodium bicarbonate (unstable) (2) Epinephrine causes a dramatic increase in myocardial oxygen consumption. (3) Its use in the setting of an acute MI should be restricted to cardiac arrest. (4) IV epinephrine (1:1,000) should not be administered to any patient with a pulse.

Medication Information, continued on next page


6.11 EPINEPHRINE 1:10,000/1:1,000, continued

g) Dosage (1) Cardiac Arrest

(a) Adult: Administer 1 mg (1:10,000) IV every 3-5 minutes

(b) Pediatric: Administer 0.01 mg/kg (1:10,000) IV/IO, Max 1mg/dose; repeat every 3-5 minutes

(c) Neonate: Administer 0.01 mg/kg (1:10,000) IV/IO, Max 1mg/dose; repeat every 5 minutes

(2) Bradycardia (a) Adult:

Not indicated. (b) Pediatric:

Administer 0.01 mg/kg (1:10,000) IV/IO, Max 1mg/dose; repeat every 3-5 minutes as needed (c) Neonate:

Administer 0.01 mg/kg (1:10,000) IV/IO, Max 1mg/dose; repeat every 3-5 minutes as needed (3) Anaphylactic Shock/Asthma

(a) Adult: Administer 0.3 mg (1:1,000) IM, repeat every 15 minutes as needed

(b) Pediatric: Administer 0.01 mg/kg (1:1,000) IM, repeat every 5 minutes as needed (Max 0.3 mg)

(c) FOR ANAPHYLACTIC SHOCK ONLY Consider Epinephrine (1:10,000) 0.01 mg/kg slow IV/IO with Medical Control (Max 0.5mg)

(4) Croup (a) Adult:

Not indicated (b) Pediatric:

Age Dose Maximum Note <1 0.5 mL/kg 2.5 mL Mix with 3mL Normal Saline 1-4 2.5 mL Mix with 3mL Normal Saline ≥5 5 mL Mix with 3mL Normal Saline


6.12 ETOMIDATE (AMIDATE) - RSI ONLY a) Pharmacology

Hypnotic

b) Pharmacokinetics A short-acting nonbarbiturate hypnotic agent without analgesic properties

c) Indications (1) Pre-sedation of responsive patients prior to administration of neuromuscular blocking agents (2) Pre-sedation of responsive patients prior to cardioversion

d) Contraindications Known hypersensitivity to Etomidate

e) Adverse Effects (1) Respiratory depression or apnea (2) Hypotension (infrequent) (3) Involuntary myoclonus (4) Adrenal suppression

f) Precautions

(1) The effects of Etomidate can be accentuated by CNS depressants, such as narcotics and alcohol. (2) Myoclonic movements are common and should not be confused with fasciculations due to a depolarizing

neuromuscular blocking agent or seizure activity.


Administer 0.3 mg/kg IV over 30 seconds for induction. Administer 0.1 mg/kg IV over 30 seconds for cardioversion.

(2) Pediatric Not indicated


6.13 GLUCAGON a) Pharmacology

(1) Hormone synthesized by the pancreas (2) Increases blood glucose concentration (3) Inhibits gastric and pancreatic secretions (4) May increase heart rate and cardiac output (5) May decrease blood pressure (6) Increases metabolic rate

b) Pharmacokinetics

(1) Destroyed by the GI tract and is not effective orally (2) Maximum hyperglycemic activity occurs within 30 minutes and disappears after 1-2 hours. (3) Relaxation of smooth muscle occurs within 8-10 minutes and persists for 12-27 minutes. (4) The half-life is 3-10 minutes. (5) Degraded in liver and kidneys

c) Indications

(1) Unconscious patients who are highly suspected of being hypoglycemic where IV access is unobtainable (2) Unconscious combative patients where IV access is unobtainable due to venous collapse or altered mental

status (3) Beta Blocker Overdose (4) Allergic Reaction with patient on Beta Blocker medications and inadequate response to routine treatment



e) Adverse Effects Nausea and vomiting

f) Precautions

Glucagon only works if liver has significant glycogen stores.

g) Dosage (1) For suspected hypoglycemia without IV access:

(a) Adult: 1mg IM

(b): Pediatric 0.1mg/kg IM (Max 2 mg)

(2) For suspected beta-blocker overdose (a) Adult:

2 mg IV or IO/IM (b) Pediatric:

0.1 mg/kg IV or IO/IM


6.14 IPRATROPIUM (ATROVENT) a. Pharmacology

(1) Anticholinergic (parasympatholytic) brochodilator (2) Brochodilator is site-specific, not systemic (3) Dries respiratory tract secretions (4) Most effective in combination with a beta-adrenergic brochodilator

b. Pharmacokinetics

(1) Improved pulmonary function in 15 - 30 minutes (2) Peak effects occur in 1 - 2 hours (3) Duration of action is usually 4 - 5 hours

c. Indications

(1) Allergic reactions/ anaphylaxis (2) Bronchial asthma (3) Reversible bronchospasms associated with chronic bronchitis and emphysema

d. Contraindications

(1) Hypersensitivity to Ipratroprium (2) Hypersensitivity to atropine (3) Less than one year of age

e. Adverse Effects

(1) More common: dry mouth, cough, or unpleasant taste (2) Less common: vision changes, eye burning or pain, dizziness, headache, nervousness, palpitations,

sweating, trembling, chest tightness, rash, hives, or facial sweating

f. Precautions (1) Use with caution inpatients with congestive heart failure, heart disease, hypertension, glaucoma and elderly

patients. (2) May worsen the condition of glaucoma if it gets into the eyes. Having the patient close his/her eyes during

nebulization may prevent this. (3) Not to be used as a single agent — must be used in combination with albuterol.

g) Dosage

(1) Adult: Single administration ONLY, 0.5 mg by nebulizer in combination with Albuterol 5 mg

(2) Pediatric: Single administration ONLY, 0.5 mg by nebulizer in combination with Albuterol 2.5 mg


6.15 LIDOCAINE (XYLOCAINE)

a) Pharmacology (1) Suppresses ventricular ectopy (2) Elevates VT and VF threshold b) Pharmacokinetics

Extremely rapid (within minutes) onset following IV administration and lasts approximately 10-20 minutes c) Indications

(1) Prevent recurrence of ventricular fibrillation/tachycardia after defibrillation and conversion to supraventricular rhythm

(2) Ventricular tachycardia (VT) (3) Ventricular fibrillation (VF) (4) Reduce or eradicate ventricular ectopy, especially closely coupled, multifocal, or short bursts of five or more PVCs in succession (5) Decrease intracranial pressure with Rapid Sequence Intubation d) Contraindications (1) AV blocks (2) Known hypersensitivity (3) Idioventricular escape rhythms (4) Accelerated idioventricular rhythm (5) Sinus bradycardia or arrest or block (6) Hypotension (7) Shock (8) Ventricular conduction defects e) Adverse Effects (1) Lidocaine may cause clinical evidence of toxicity usually related to the central nervous system. (2) Toxicity:

(a) Early: muscle twitching, slurred speech, altered mental status, decreased hearing, paresthesia (pins and needles), anxiety, apprehension, visual disturbances, nausea, numbness, difficulty breathing or swallowing, decreased heart rate

(b) Late: convulsions, hypotension, coma, widening of QRS complex, prolongation of the P-R interval, hearing loss, hallucinations

f) Precautions

(1) Reduce the dosage in patients with decreased cardiac output, liver dysfunction, and the elderly (age over 70)

(2) Bolus doses should be administered over a 1-minute period, except in ventricular fibrillation/ventricular tachycardia, when they are administered IV.

g) Dosage (1) Adult Cardiac Arrest: Administer 1.5 mg/kg IV/IO followed by 0.75 mg/kg every 8-10 minutes as needed, up to 3 mg/kg. (2) Pediatric Cardiac Arrest Administer 1 mg/kg IV/IO followed by 1 mg/kg every 8-10 minutes to a Maximum of 3 mg/kg. (3) Rapid Sequence Intubation

Administer 1.5 mg/kg IV/IO for pretreatment in patients with suspected elevated intracranial pressure


6.16 MAGNESIUM SULFATE

a) Pharmacology (1) Anti-inflammatory (2) Electrolyte b) Pharmacokinetics Immediate onset c) Indications (1) Torsades de Pointes (2) Eclamptic seizures (3) Acute respiratory distress d) Contraindications (1) AV Heart block (2) Hypotension e) Adverse Effects (1) Hypotension (2) CNS depression (3) Flushing (4) Sweating (5) AV Heart block f) Precautions Use with caution in patients with impaired renal function g) Dosage (1) Torsades de Pointes (a) Adult Administer 2 grams diluted in 10mL NS slow IV/IO (b) Pediatric 50 mg/kg diluted in 10mL NS (Max 2 grams) slow IV/IO (2) Polymorphic Stable Wide Complex Tachycardia (a) Adult 2 gm IV/IO diluted in 50mL of NS and given over 10 min (b) Pediatric Not indicated (3) Eclampsia (a) Adult Magnesium Sulfate 4 gm in 100mL NS over 5 minutes IV/IO (b) Pediatric Not indicated (4) Asthma (a) Adult

Administer 2 grams diluted in 100 mL NS over 10 minutes IV/IO (b) Pediatric

Administer 50 mg/kg (Max 2 grams) diluted in 100 mL NS over 10 minutes IV/IO


6.17 METOPROLOL

a) Pharmacology (1) Antagonizes beta-1 adrenergic receptors b) Pharmacokinetics (1) Intravenously administered (2) Effects within 3-5 minutes after administration (3) Duration of action is 30-60 minutes. c) Indications (1) For rate control of atrial flutter or atrial fibrillation d) Contraindications (1) Known hypersensitivity (2) Uncompensated congestive heart failure (3) 2nd or 3rd degree heart block (4) Cardiogenic shock (5) Blood pressure below 100 mmHg systolic (6) Heart rate less than 60 bpm (7) Recent/suspected cocaine use e) Adverse Effects Hypotension, bradycardia, bronchospasm, nausea, vomiting, and dizziness f) Precautions May cause hypotension g) Dosage (1) Adult: 5 mg slow IV push every 5 minutes to Maximum dose of 15 mg or HR <120 bpm (2) Pediatric: Not indicated


6.18 MIDAZOLAM (VERSED)

a) Pharmacology (1) Sedative (2) Hypnotic

b) Pharmacokinetics A short-acting benzodiazepine with strong hypnotic and amnesiac properties

c) Indications (1) Sedation of responsive patients prior to cardioversion or transcutaneous pacing (2) Sedation of combative patients who threaten both their and providers’ safety (3) Sedation of intubated patients with ventilatory difficulty secondary to bucking or combativeness (4) Active seizures

d) Contraindications (1) Hypotension (2) Acute narrow-angle glaucoma (3) Known hypersensitivity to Midazolam

e) Adverse Effects (1) Respiratory depression or apnea (2) Hypotension (3) Amnesia

f) Precautions The effects of Midazolam can be accentuated by CNS depressants, such as narcotics and alcohol

g) Dosage (1) Adult: Administer 2.5-5 mg slow IV/IO/IM (2) Pediatric: Administer 0.05 mg/kg slow IV/IO/IM (2.5 mg Max)


6.19 MORPHINE SULFATE a) Pharmacology (1) Decreases pain perception and anxiety (2) Relaxes respiratory effort (3) Causes peripheral dilation which decreases preload (4) Decreases left ventricular afterload b) Pharmacokinetics (1) Binds with opiate receptors in the CNS, altering both perception and emotional response to pain (2) Onset of action is in less than 5 minutes after IV dose and effects last 4-5 hours. (3) Causes peripheral arterial and venous vasodilation c) Indications (1) Acute myocardial infarction (2) Acute pulmonary edema (3) Burns (4) Isolated injuries requiring pain relief (5) Sedative for transcutaneous pacing d) Contraindications (1) Head injury (2) Undiagnosed abdominal pain (3) Multiple trauma (4) COPD with compromised respiratory effort (5) Hypotension (6) Known hypersensitivity morphine, codeine, oxycodone or hydromorphone e) Adverse Effects (1) Respiratory depression/arrest (2) Altered mental status (decreased level of consciousness) (3) Increased vagal tone due to suppression of sympathetic pathways (slowed heart rate) (4) Nausea and vomiting (5) Constricted pupils (pin-point) (6) Increased cerebral blood flow f) Precautions (1) Naloxone reverses all effects. (2) Administration masks pain, making hospital diagnosis difficult. (3) Should be administered slowly and titrated to effect. (4) Vital signs should be monitored frequently. (5) Hypotension is a greater possibility in volume-depleted and elderly patients. g) Dosage (1) Adult: Administer 5 mg slow IV, repeat doses with medical control authorization (2) Pediatric: Administer 0.1 mg/kg slow IV/IO (Max 5 mg), repeat doses with medical control authorization


6.20 NALOXONE (NARCAN) a) Pharmacology

Reverses all effects due to opioid (morphine-like) agents. This drug will reverse the respiratory depression and all central and peripheral nervous system effects.

b) Pharmacokinetics (1) Onset of action is within a few minutes if administered IVP. (2) Intramuscular and endotracheal administration results in a slower onset of action.

(3) Patients responding to Naloxone may require additional doses and transportation to the hospital since most opioids last longer than Naloxone.

(4) Has no effect in the absence of narcotics c) Indications To reverse respiratory and central nervous system depression induced by opiates d) Contraindications Not clinically significant e) Adverse Effects Not clinically significant f) Precautions (1) Naloxone may induce opiate withdrawal in patients who are physically dependent. (2) Certain drugs may require much higher doses of Naloxone for reversal than are currently used.

(3) Should be administered and titrated so respiratory efforts return but not intended to restore full consciousness

g) Dosage (1) Adult: Administer 0.4 mg IV/IM; repeat as necessary to maintain respiratory activity (Max 2mg) (2) Pediatric: Administer 0.1 mg/kg IV/IM; repeat as necessary to maintain respiratory activity (Max 2mg)


6.21 NITROGLYCERIN a) Pharmacology

(1) Vasodilator-effect on veins more than arteries (2) Decreases right heart return (preload) by venous pooling, thereby decreasing myocardial workload and

oxygen consumption

b) Pharmacokinetics (1) Absorbed through oral mucosa (2) Anti-anginal and vasodilation effects within 1-2 minutes after administration. Half-life is 1-4 minutes. (3) Duration of action is less than 5 minutes.

c) Indications

(1) For treatment of angina (2) Congestive heart failure, acute pulmonary edema


(1) Known hypersensitivity (2) Pediatric patient under the age of 12 (3) Any patient having taken medication for erectile dysfunction (e.g., Viagra™, Levitra™, or Cialis™) within the

past72 hours. Medical Control is required to override this contraindication. (4) Asymptomatic hypertension (5) Blood pressure below 90 mmHg systolic (6) Heart rate less than 60 bpm

e) Adverse Effects

Headache, hypotension, nausea, vomiting, and dizziness, decreased level of consciousness

f) Precautions May cause hypotension

g) Dosage (1) Adult

(a) If patient has a prescription or previous history of nitroglycerin use, administer nitroglycerin: 0.4 mg SL (may repeat dose 3 times at 3-5 minute intervals). May be repeated if symptoms persist, and BP is greater than 90 mm Hg

(b) If patient does not have a prescription or previous history of nitroglycerin use, establish IV prior to the administration of nitroglycerin, then administer nitroglycerin as above.

(c) Additional doses may be administered with medical consultation (2) Pediatric:

Not indicated


6.22 OXYGEN a) Pharmacology

(1) Increases oxygen content of the blood (2) Improves tissue oxygenation

b) Pharmacokinetics

Changing the percentage of inspired oxygen results in an increased blood and tissue level equilibration within minutes

c) Indications

(1) Acute chest pain (2) Suspected hypoxemia of any etiology (3) Cardiopulmonary arrest (4) Trauma (5) Dyspnea


Not clinically significant

e) Adverse Effects High concentrations of oxygen will reduce the respiratory drive in some COPD patients; these patients should

be carefully monitored.

f) Precautions (1) Never withhold oxygen from those who need it. (2) Oxygen should be given with caution to patients with COPD. (3) Nasal cannula should be supplied with no more than 6 lpm. (4) Non-breather face masks must be supplied with a minimum 12 lpm.

g) Dosage

(1) Adult: Administer per protocol

(2) Pediatric: Administer per protocol


6.23 PROMETHAZINE (PHENERGAN) a) Pharmacology

First generation H1 antagonist with antiemetic, sedative and antipsychotic properties

b) Pharmacokinetics Onset within 5-15 minutes, duration 3-6 hours

c) Indications

(1) Nausea (2) Vomiting


(1) Nursing mothers (2) Pediatric patients (3) Suspected head injury

e) Adverse Effects

(1) Extrapyramidal symptoms (Dystonic reaction) - Administer Diphenhydramine 25 mg IV/IM (2) Coma (3) Convulsions (4) Cardio-respiratory impairment (5) Dizziness

f) Precautions

Use with caution in patients with (1) Impaired hepatic function (2) Cardiovascular disease (3) Asthma (4) COPD (5) Glaucoma (6) Leukopenia (7) Seizures (8) Sulfa allergy

g) Dosage

(1) Adult: Administer 6.25 - 12.5 mg diluted in 50 mL NS given IV over 10 minutes, may repeat with Medical

Control (2) Pediatric:

Not indicated


6.24 SODIUM BICARBONATE a) Pharmacology

Alkaline solution used to correct acidosis b) Pharmacokinetics

(1) Rapid onset of action in the blood (2) Delayed onset of action in the tissues

c) Indications

(1) Used in cardiac arrest only after adequate ventilation assured (2) Hyperkalemia (3) Tricyclic and Phenobarbital overdose


Pre-existing alkalosis e) Adverse Effects

(1) Worsened intracellular acidosis due to carbon dioxide formation (2) Hyperosmolality (3) May precipitate congestive heart failure. (4) Metabolic alkalosis (5) Acute hypokalemia (6) Exacerbation of central venous acidosis (7) Shifting the oxyhemoglobin dissociation curve, inhibiting the release of oxygen to the tissues

f) Precautions

(1) Incompatible with epinephrine (2) Priorities before use:

(a) Intubation (b) Hyperventilation (c) Defibrillation (d) Epinephrine (e) Antiarrhythmics

g) Dosage

(1) Should only be given after airway has been secured and ventilations achieved (2) Adult:

Administer 1-2 mEq/kg (50-100mEq) IV/IO (3) Pediatric:

Administer 1 mEq/kg IV/IO


6.25 SUCCINYLCHOLINE (ANECTINE) – RSI ONLY

a) Pharmacology Depolarizing neuromuscular blocking agent

b) Pharmacokinetics Onset of action within 30-60 seconds, duration 5-7 minutes

c) Indications To achieve paralysis to facilitate endotracheal intubation in patients as per RSI Protocol


(1) Conditions that may cause hyperkalemia: (a) Burns greater than 24 hours old (b) Spinal cord injury greater than 24 hours old (c) Known neuromuscular disease (Guillain-Barré Syndrome, myasthenia gravis, amyotrophic lateral

sclerosis, muscular dystrophy) (d) Chronic renal failure on hemodialysis or presence of hemodialysis access

(2) History of malignant hyperthermia (3) Patients with known hypersensitivity to the drug

e) Adverse Effects

(1) Apnea (2) Bradycardia (2) Prolonged paralysis

f) Dosage/Route

(1) Adult: Administer 1.5 mg/kg rapid IV, if relaxation is inadequate after 2-3 minutes, a repeat dose of 0.5 mg/kg

rapid IV may be given (2) Pediatric:

Not indicated


6.26 VECURONIUM (NORCURON) – RSI ONLY a) Pharmacology

Non-depolarizing neuromuscular blocking agent

b) Pharmacokinetics Onset 2-3 minutes with duration of 30-60 minutes

c) Indications

For paralysis in cases of ventilatory difficulty secondary to bucking or combativeness in intubated patients d) Contraindications

(1) Non-intubated patients (2) Known hypersensitivity

e) Adverse Effects

(1) Bradycardia (2) Prolonged paralysis

f) Precautions

(1) Pre-sedation must be provided when Vecuronium is administered to a patient who is either responsive to stimulus or who may become responsive to stimulus during neuromuscular blockade.

g) Dosage

(1) Adult: Administer 0.1 mg/kg IV

(2) Pediatric: Not indicated


6.27 DILTIAZEM (CARDIZEM) - Optional a) Class

Calcium channel blocker (Class IV) b) Actions

(1) Inhibits the movement of calcium ions across cardiac muscle cells (2) Decreases conduction velocity and ventricular rate

c) Indications

Symptomatic atrial fibrillation and atrial flutter d) Contraindications

(1) Hypotension below 90 mm Hg (2) Second or third degree heart block (3) Known hypersensitivity (2) Patients less than 12 years of age

e) Precautions

Use cautiously in patients with renal failure or congestive heart failure f ) Side effects

(1) Headache (2) Nausea (3) Vomiting (4) Bradycardia (5) Hypotension

g) Significant interactions

Congestive heart failure may result if used along with beta blockers h) Dosage (1) Adult: (a) 0.25 mg/kg (maximum dose 15 mg) slow IV, if response is not adequate, repeat with a dosage of 0.35 mg/kg (maximum dose 15 mg) (b) For patients older than 50 years of age or borderline blood pressure, consider initial dose of 5-10 mg administered IV over 2 minutes, repeating subsequent doses as needed (2) Pediatric: Not indicated i) Overdose or Toxicity Presentation Generally consists of exaggeration of side effects, including severe hypotension and symptomatic bradycardia j) Treatment of Overdose or Other Adverse Reactions (1) Give general supportive measures, monitor vitals, administer oxygen. (2) Hypotension: Consider calcium chloride 500 mg SLOW IVP with Medical Control and IV fluid challenge (3) Bradycardia: Consider atropine (0.5 to 1 mg); if necessary, consider pacing.


6.28 PROCAINAMIDE (PROCAN, PRONESTYL, PROCANBID) - Optional a) Class

Sodium Channel Blocker (Class IA) b) Actions

(1) Inhibits the movement of sodium ions across cardiac muscle cells (2) Decreases conduction velocity and ventricular rate

c) Indications

Wide complex tachycardias Narrow complex tachycardia’s resistant to metoprolol and/or diltiazem or in patients with CHF


(1) Hypotension below 90 mm Hg (2) Second or third degree heart block (3) Prolonged QT or Torsades de Pointes (4) Myasthenia gravis (5) Systemic Lupus Erythematosus

e) Precautions

Use cautiously in patients with renal failure, those with a bundle branch block, suspected digitalis toxicity f ) Side effects

(1) Hypotension (2) Nausea/vomiting (3) Widening QRS, prolonged QT, junctional tachycardia, PVC’s, worsening heart block (4) Hypersensitivity reactions/allergies (5) Lupus-like hypersensitivity rash (6) Lethargy, mental confusion, visual hallucinations (7) Diaphragmatic paralysis

g) Significant interactions

None h) Dosage

(1) Adult and Pediatric: 20 mg/min until:

Maximum dose of 17mg/kg or 1 gram is reached Hypotension occurs QRS widens by 50% of original width Rhythm converts (2) To administer: Dilute 1000mg/2mL vial in 100mL (concentration 10 mg/mL) Administer 2 mL/min

DO NOT BOLUS PROCAINAMIDE i) Overdose or Toxicity Presentation

Generally consists of exaggeration of side effects, including severe hypotension j) Treatment of Overdose or Other Adverse Reactions

(1) Give general supportive measures, monitor vitals, administer oxygen. (2) Hypotension: Stop infusion, administer fluid challenge



Appendix


Adult GCS Score

Eye Opening Response

Spontaneous-open with blinking at baseline 4 points

Opens to verbal command, speech, or shout 3 points

Opens to pain, not applied to face 2 points

None 1 point

Verbal Response

Oriented 5 points

Confused conversation, but able to answer questions 4 points

Inappropriate responses, words discernible 3 points

Incomprehensible speech 2 points

None 1 point

Motor Response

Obeys commands for movement 6 points

Purposeful movement to painful stimulus 5 points

Withdraws from pain 4 points

Abnormal flexion, decorticate posture 3 points

Extensor response, decerebrate posture 2 points

None 1 point

Pediatric GCS Score

Eye Opening Response

Spontaneous-open with blinking at baseline 4 points

Opens to verbal command, speech, or shout 3 points

Opens to pain, not applied to face 2 points

None 1 point

Verbal Response

Smiles or coos appropriately 5 points

Crying and irritable 4 points

Cries to pain 3 points

Moans or grunts to pain 2 points

No response 1 point

Motor Response

Moves spontaneously or purposefully 6 points

Withdraws from touch 5 points

Withdraws from pain 4 points

Abnormal flexion, decorticate posture 3 points

Extensor response, decerebrate posture 2 points

None 1 point


Adult Trauma Triage Criteria

The patient should be taken to a trauma center should they meet any one of the following criteria. Medical Control consultation is required to transport to a non-trauma center.

PHYSICAL FINDINGS

1. Glasgow Coma Scale is less than 14 2. Respiratory rate is less than 10 or more than 29 breaths per minute 3. Pulse rate is less than 50 or more than 120 beats per minute 4. Systolic blood pressure is less than 90 mmHg 5. Penetrating injuries to head, neck, torso or proximal extremities 6. Two or more suspected proximal long bone fractures 7. Flail chest 8. Spinal cord injury or limb paralysis 9. Amputation (except digits) 10. Suspected pelvic fracture 11. Open or depressed skull fracture MECHANISM OF INJURY 1. Ejection or partial ejection from an automobile 2. Death in the same passenger compartment 3. Extrication time in excess of 20 minutes 4. Vehicle collision resulting in 12 inches of intrusion in to the passenger compartment 5. Motorcycle crash >20 MPH or with separation of rider from motorcycle 6. Falls from greater than 20 feet 7. Vehicle rollover (90 degree vehicle rotation or more) with unrestrained passenger 8. Vehicle vs. pedestrian or bicycle collision above 5 MPH HIGH RISK PATIENTS

If a patient does not meet the above criteria for Major Trauma, but has sustained an injury and has one or more of the following criteria, they are considered a “High Risk Patient”. Consider contacting medical control and transporting to a Trauma Center:

1. Bleeding disorders or patients who are on anticoagulant medications 2. Cardiac disease and/or respiratory disease 3. Insulin dependent diabetes, cirrhosis, or morbid obesity 4. Immunosuppressed patients (HIV disease, transplant patients and patients on chemotherapy treatment) 5. Age >55

Source: NYS EMT-B Protocols (2004) T-6 p1


Pediatric Trauma Triage Criteria

The patient should be taken to a trauma center should they meet any one of the following criteria. Medical Control consultation is required to transport to a non-trauma center.

PHYSICAL FINDINGS 1. Pulse greater than normal range for patient’s age (see pediatric appendix) 2. Systolic blood pressure below normal range (see pediatric appendix) 3. Respiratory status inadequate (central cyanosis, respiratory rate low for the child’s age, capillary refill time greater than two seconds) 4. Glasgow coma scale less than 14 5. Penetrating injuries of the trunk, head, neck, chest, abdomen or groin 6. Two or more proximal long bone fractures 7. Flail chest 8. Burns that involve 15% or more of the body surface (10% if associated with other injuries or the child is less than five years old) or facial/airway burns 9. Combined system trauma that involves two or more body systems, injuries or major blunt trauma to the chest or abdomen 10. Spinal cord injury or limb paralysis 11. Amputation (except digits) MECHANISM OF INJURY 1. Death in the same passenger compartment 2. Fall more than 10 feet 3. Vehicle-pedestrian collision 4. Patient ejected from the vehicle 5. Vehicle collision >20 MPH resulting in 12 inches of deformity to the vehicle 6. Vehicle rollover 7. Motorcycle crash 8. Vehicle vs. bicycle collision >5 MPH Source: NYS EMT-B Protocols (2004) T-7 p1


Normal Pediatric Weights and Vital Signs

AGE WEIGHT (lbs) WEIGHT (kg) SYSTOLIC BP HEART RATE RESP. RATE Birth 6mo. 1 yr. 2 yr. 3 yr. 4 yr. 5 yr. 6 yr. 7 yr. 8 yr. 9-10 11-12

8 15 22 29 33 37 42 48 55 62 66 81

3.5 7 10 13 15 17 19 22 25 28 30 37

60-80 70-100 80-115 80-115 80-115 80-115 80-115 80-115 80-115 85-115 90-130 95-135

110-160 100-140 100-140 90-110 90-110 80-100 80-100 80-100 70-90 70-90 70-90 70-90

30-60 30-50 25-35 20-30 20-30 20-30 20-30 20-30 15-25 15-25 10-20 10-20

Pediatric Airway Equipment Sizes

AGE LARYNGOSCOPE ETT (mm) SUCTION CATH.

Preemie Miller 0 2.5-3.0 uncuffed 6 French Term infant Miller 0-1 3.0-3.5 uncuffed 6 French 6 months Miller 0-1 3.5-4.0 uncuffed 8 French

1 year Miller 1 4.0-4.5 uncuffed 8 French 2 years Miller 2 4.5 uncuffed 8 French 4 years Miller 2 5.0 uncuffed 10 French 6 years Miller 2 5.5 uncuffed 10 French 8 years Miller 2, Mac 2 6.0 cuffed 10 French

10 years Miller 2, Mac 2 6.5 cuffed 12 French 12 years Mac 3 7.0 cuffed 12 French

Adolescent Mac 3, Miller 3 7.0-8.0 cuffed 12 French


Rule of Nines


Area Hospital Information

Regional Medical Control Hospitals - BOLD

Hospital Disposition Code Phone Number Frequency

Clifton Springs 341 315-462-7816 155.340

F.F. Thompson 342 585-396-6820 155.175

Lakeside 273 585-395-6095 x 4282 155.340

Newark-Wayne 584 585-359-2120 155.340

Noyes Memorial 251 585-335-4240 155.340

Rochester General 276 585-338-3367 155.340

Soldiers and Sailors 612 315-531-2500 155.340

Unity (Park Ridge) 275 585-723-7070 155.340

URMC/Highland 272 585-341-6444 155.340

URMC/Strong Memorial Adult 278 585-271-2769 155.340

URMC/Strong Memorial Pediatrics 278 585-756-3430 155.340

Dopamine Infusion Chart

Mix 400 mg Dopamine HCl in 250 mL Normal Saline or D5W to achieve base concentration of 1,600 mcg/mL

Use 60 gtt/ml administration set. A rate-limiting device must be used when administering this medication. Use Y-site secondary tubing for dopamine running into free-flowing normal saline primary tubing. Do not use a primary line for dopamine to prevent extravasation.

Choose desired infusion concentration and follow row to the column indicating patients weight, the number is the gtt/min

Weight Kilograms 40 kg 50 kg 60 kg 70 kg 80 kg 90 kg 100 kg 110 kg 120 kg 130 kg 140 kg 150 kg

Pounds 88 lbs 110 lbs 132 lbs 154 lbs 176 lbs 198 lbs 220 lbs 242 lbs 264 lbs 286 lbs 308 lbs 330 lbs

Desired Infusion

5 mcg/kg/min 8 9 11 13 15 17 19 21 23 25 27 29

10 mcg/kg/min 15 19 23 26 30 34 38 42 46 50 54 58

Monroe-Livingston Regional EMS Protocols Effective Jan 1 2010


Section 7

Specialty Care Transport


7.0 Scope of Practice The MLREMS Specialty Care Transport Paramedic provides a level of care above that of the EMT-P in order to safely provide interfacility transport of critically ill patients. These Specialty Care Transport Protocols are to be used only by credentialed MLREMS SCT Paramedics and are to be used in concert with the EMT-P scope of practice outlined in the MLREMS Standards of Care when performing an interfacility transport. These Protocols do not limit the ability of a provider to transport a patient with the physiology (pericardial effusion for example) stated in these protocols, but rather are only to be used during interfacility transports of patients with additional medications or devices not allowed under MLREMS EMT-P Standards of care including, but not limited to:

Patients that have more than one vasoactive medication. Patients that are orotracheally or nasotracheally intubated, or have a tracheostomy tube and are unstable, who require

mechanical ventilation based on their condition, thus requiring staff with advanced knowledge of ventilator management.

Patients that are being hemodynamically monitored with invasive monitoring devices, including arterial, Swan Ganz, or similar central access devices.

The following protocols are considered standing order except if notation is made to contact medical control, which is considered Absolute On-Line with no exception for radio or phone failure. All MLREMS EMT-P Standards of Care are standing order for the Specialty Care Transport Paramedic when executing an interfacility transport except in cases identified as Absolute On-Line with no exception for radio or phone failure.


7.1 Care Expectations The specialty care transport team will work collaboratively to achieve the following objectives:

1. Introduce yourself and the team members to the patient, family, and hospital staff. 2. Utilize full universal precautions.

3. Provide a primary and secondary assessment prior to transport on every patient transported including a history and

review of interventions by the sending facility and x-ray results/lab information when applicable.

4. Treatment for life-threatening problems detected during the primary and secondary assessment must be initiated before transport unless the patient is being transported for management of that problem.

5. Establish and maintain a patent airway. If the patient is on a ventilator, maintain the ventilator settings as per the

sending facility unless otherwise indicated by the clinical condition of the patient.

6. Contact the SCT Medical Control unless all the following criteria are met.

a. The patient’s condition is stable and an accurate report of the patient’s condition has been given to the Specialty Care Transport Paramedic.

b. The written protocols and any written orders currently address the immediate and foreseeable needs of the patient.

c. There is clear evidence of discussion between the sending and receiving facilities and the receiving facility has accepted care of the patient.

d. There is a completed hospital transfer form with the name of the accepting physician.

7. Before leaving the hospital, have the patient and family visit and, if possible, explain the patient’s condition and probable course.

8. A phone report should be given to the receiving facility should any significant changes occur enroute. Before leaving

the sending facility, try to obtain a contact person responsible for patient care at the receiving facility.

9. In the event of cardiac arrest of the patient during transport the Specialty Care Transport Unit will proceed to the nearest appropriate emergency department. The transporting paramedic should notify the SCT Medical Control as soon as practical. The Emergency Department should also be notified by the most appropriate means.

10. Patients carrying a “Do Not Resuscitate” order will not be transported until limitations of treatment in the form of a

written order from the sending physician have been secured. This should be discussed with the SCT Medical Control before transport.

11. The Specialty Care Paramedic will give a complete report to the staff on arrival at the receiving facility.

12. ALL PROCEDURES MUST BE DOCUMENTED.


7.2 Routine Standard of Care These “Specialty Care Transport Protocols” are only to be used by personnel assigned to units that have been designated as a “Specialty Care Transport Unit” by the MLREMS Medical Director. The protocols are NOT to be used for routine Advanced Life Support care. Routine advanced life support care is directed by the “Monroe-Livingston REMAC EMS Protocols”. They are meant to act as general guidelines for rendering medical care and/or treatments and may not be inclusive for every situation. The protocols should be regarded as the prevailing norms of treatment and should be considered prudent in the delivery of medical care. Deviation from these protocols may be necessary based on patient need and must be documented. All patients being transported by the Specialty Care Transport Team should have the following in place prior to leaving the referring facility:

Stable airway.

Cardiac monitor – 3-lead with 12-lead capability immediately available.

Minimum of two intravenous lines (peripheral or central), large bore if clinically indicated.

Continuous pulse oximetry, cardiopulmonary monitoring including: blood pressure (invasive or noninvasive), and capnography (when clinically indicated; required for any patient on a ventilator)

Vital signs taken a minimum of every 15 minutes unless a change occurs which requires immediate repetition of them.

Confirmation that any medications being infused in the same IV line are compatible.

Any continuous infusion requires the use of a continuous electronic infusion device.

All patients should be maximally stabilized prior to transport, including intubation and peripheral or central venous access if necessary. It is the responsibility of the sending hospital to ensure that stabilization is complete. In the event the Specialty Care Transport Team does not feel the patient is stable for transport, they must communicate with both the sending hospital and the SCT Medical Control before transport is initiated.


7.3 Medical Control Specialty Care Transport Medical Control is provided by the SCT Agency performing the transport. The SCT Technician must have a means of direct communication to SCT Medical Control at any time during their care of the patient. SCT Medical Control Physicians must be approved by the Agency Medical Director prior to performing any direct on-line medical control for SCT interfacility transports.

The presence of a phone icon next to a medication or procedure requires SCT Medical Control prior to initiating the order. Specialty Care Transport Medical Control/Communication Failure: Contact with medical control will be dictated by protocol and should be available at all times. For the Specialty Care Transport unit the preferred medical control is the designated SCT Medical Control. In the event of being unable to contact the SCT Medical Control the following mechanism will be instituted.

1. Direct contact with a designated back-up MLREMS approved SCT Medical Control (if available). 2. Direct contact with standard medical control. 3. In the event of failure of all the above, treatment protocols will be regarded as standing order, however procedures

requiring absolute on-line medical command should not be undertaken unless in a life threatening emergency situation. 4. In the event of a procedure requiring absolute on-line direction being undertaken without medical control, the procedure

and events surrounding it will be reviewed within 24 hours by the agency Specialty Care Medical Director to determine if retroactive approval is warranted.

Orders from transferring/ receiving physicians: During inter-hospital transport, medical crews will be asked to continue treatment initiated at the transferring hospital. These orders must be written and signed by the referring physician. If, at any time the Specialty Care Transport Crew questions orders from a referring or receiving physician, Specialty Care Medical Control MUST be contacted. Likewise, anytime a transferring or receiving physician asks the Specialty Care Transport crew to carry out medical treatment for which they have not been trained, or which appears to be in conflict with established treatment protocols, Specialty Care Medical Control MUST be contacted before initiating care. Potentially Unstable Transports: It is the requirement of the transferring hospital to provide sufficient interventions to stabilize the patient prior to transport. If, in the opinion of the Specialty Care Paramedic, the patient is not stable for transport, discussions with the transferring hospital and possibly Specialty Care Transport Medical Control should occur to determine how best to stabilize the patient for transport. Potential solutions include further interventions (such as intubation) at the transferring hospital or use of another Specialty Care Transport unit or agency with additional capabilities. Intubation before transport is the responsibility of the sending facility and should be done by them. SCT Paramedics will not begin a transport until the sending facility has successfully managed to create a stable airway. In the event that they refuse, contact Specialty Care Transport Medical Control.


7.10 Aortic Emergencies

INDICATIONS

Known or suspected aortic dissection or aneurysm. MANAGEMENT GOALS

Reduce afterload Reduce HR and stroke volume to the lowest levels that allow for adequate systemic perfusion. Systolic blood pressures

< 90 mmHg may be required to maintain MAP greater than 65 mmHg. Reduce anxiety and pain

CARE GUIDELINES 1. Routine medical care 2. Ensure two patent large bore IVs 3. Consider pain management if SBP > 100 mmHg and RR > 8 rpm :

Administer Morphine 0.1mg/kg, may repeat to a max 10 mg 4. Consider nausea/vomiting management:

Promethazine (Phenergan) 6.25 – 12.5 mg diluted in 50 mL NS and given over 10 minutes, may repeat to max 25 mg OR

Ondansetron (Zofran) 4 mg IV, may repeat once

5. Consider mild sedation if patient is still anxious after adequate analgesia:

Midazolam 0.05 mg/kg IV, may repeat to max 5 mg 6. If SBP remains over 120 mm Hg, consider:

Sodium Nitroprusside at 0.3 mcg/kg/min (increase by 0.5 mcg/kg/min every 5 minutes) OR

Nitroglycerin at 10 mcg/min (increase by 5mcg/min every 5 minutes)

Titrate either agent to a systolic blood pressure of approximately 90 mm Hg

If Sodium Nitroprusside or Nitroglycerin is initiated, the patient must receive beta blockade to reduce the potential for reflex tachycardia and additional strain. Maximum nitroprusside dosing of 10mcg/kg/min may only be infused continuously for up to ten minutes, usual dose from 0.5mcg/kg/min to 3mcg/kg/min.

7. If HR is over 100, consider:

Esmolol (Brevibloc): Bolus 500 mcg/kg over 1 minute, then start infusion at 50mcg/kg/min. May increase by 50 mcg/kg/min every 5-10 minutes up to a max of 200 mcg/kg/min

OR Labetalol Hydrochloride 10-20mg slow IVP; repeat q10 min prn (hold for HR less than 80)

OR Metoprolol (Lopressor) 5mg q 10 minutes X 3 doses up to max 15mg

TREATMENT CONSIDERATIONS

Medications should be titrated by MAP and patient consciousness. Any evidence of EKG changes necessitates a higher MAP.


7.11 Cardiogenic Shock

INDICATIONS

Hypoperfusion with systolic blood pressure < 90 mmHg and: PAOP >15 mmHg (if available)

OR Overt signs of left ventricular failure

o Acute pulmonary edema o Altered mentation o Cool, mottled extremities o Low urine output

MANAGEMENT GOALS

Maintenance of adequate tissue perfusion, as evidenced by clinical signs & symptoms Improvement in cardiac output and coronary perfusion Target MAP of 65 mmHg or greater, target systolic pressure greater than 80 mmHg Maintain urine output of at least 0.5 mL/kg/hour

CARE GUIDELINES 1. Routine medical care 2. Ensure two patent large bore IVs 3. In patients experiencing cardiogenic shock without pulmonary congestion, administer 100 – 250 mL crystalloid fluid boluses

PRN to obtain and maintain management goals. Observe patient carefully for development of pulmonary congestion. 4. If tissue perfusion is inadequate, circulating volume is adequate and the patient presents with or develops pulmonary

congestion, consider initiating medical therapy:

Systolic BP > 80 mmHg with signs of inadequate tissue perfusion: Dobutamine, at 5 mcg/kg/min titrate to effect, max dose of 20 mcg/kg/min

If response to Dobutamine is inadequate, add Dopamine; begin at 5 mcg/kg/min and titrate to effect, max dose

20 mcg/kg/min

If inadequate perfusion persists, add Milrinone. Begin at 0.375 mcg/kg/min and titrate to effect, max dose 0.75 mcg/kg/min

Systolic BP < 80 mmHg with signs of inadequate tissue perfusion:

Dopamine 5 mcg/kg/min, titrate to effect. Max dose 20 mcg/kg/min.

Consider adding Dobutamine to increase cardiac output. Start at 5 mcg/kg/min and titrate to effect. Hold if

HR>120 BPM


7.11 Cardiogenic Shock (Continued) TREATMENT CONSIDERATIONS

The patient in cardiogenic shock must be treated aggressively. Obtaining PAOP or PCWP is not indicated during transport. If available, review chest x-ray for presence of pulmonary edema and/or infiltrates. If available, review all labs and/or diagnostic material; i.e. echocardiogram, BNP, etc. Central venous access is desirable if possible. If central access is present, consider transducing the line for central

venous pressure (CVP). Continuous arterial pressure monitoring is desired if possible. If the patient is experiencing cardiogenic shock as the result of an MI, ASA and anti-thrombin therapy should be initiated

unless otherwise contraindicated. If Dopamine infusion is resulting in tachycardia and tachydysrhythmias, especially if cause of cardiogenic shock is the

result of AMI, attempt to wean Dopamine and begin a peripherally-acting agent, such as Norepinephrine or Phenylephrine.

Vasodilators should be used with caution. Beta Blockers should be avoided. Be extremely cautious with afterload and/or preload reducing agents if instituted to increase cardiac output. Be cautious with Dobutamine and Milrinone. Although Dobutamine and Milrinone increase contractility, they also

decrease systemic vascular resistance (SVR) which may lead to hypotension.


7.12 Elevated Intracranial Pressure INDICATIONS

History of brain injury (traumatic, intracranial hemorrhage, or mass) with GCS ≤ 8 MANAGEMENT GOALS

Prevention of secondary brain injury due to hypoxia or hypotension Reduction of cerebral oxygen demand Reduction of intracranial pressure while maintaining cerebral perfusion pressure MAP 80 – 100 mmHg (Should the MAP be markedly elevated, consider Hypertensive Emergencies Protocol (7.13)) EtCO2 35 - 45 mmHg

CARE GUIDELINES 1. Routine medical care 2. Consider early intubation. Maintain SpO2 >95% and EtCO2 35 - 45mm Hg. Avoid allowing EtCO2 to fall below 30 mmHg. 3. Consider sedation. Level of sedation should be maintained to a Ramsay Scale score of 4-6:

Midazolam - titrate to continued sedation with 1-5 mg IV every 10-15 minutes to a maxi of 20 mg or hemodynamic instability OR Propofol – initiate at 10 mcg/kg/min, titrate to continued sedation or hemodynamic instability, by increasing rate 5 mcg/kg/min every 5 minutes to a total of six (6) times (30 mcg/kg/min max total increase); 0.5-1 mg/kg bolus may be administered once while increasing rate

4. Consider analgesia:

Morphine - 0.025-0.1 mg/kg IV, titrate to continued pain control every 5-10 minutes to a max of 50 mg or hemodynamic instability OR Fentanyl – titrate to continued sedation with 25-100 mcg IV every 15-20 minutes to a max of 300 mcg or hemodynamic instability

5. Consider paralysis per Intubated and Chemically Paralyzed Patient Protocol (7.14) 6. Consider seizure prophylaxis:

Phenytoin 20mg/kg IV, no faster than 50mg/min via filtered tubing. Typical adult dose 1000 mg/250cc NaCl. Watch for hypotension with infusion. OR

Fosphenytoin 20 mg (PE) /kg at a max rate of 150 mg/min

7. For cerebral edema and global swelling consider:

Mannitol 1gm/kg IV. Hypotension is an absolute contraindication in osmotic diuresis. 8. If an open skull fracture is suspected consider:

Ceftriaxone (Rocephin) 2g IV, if not contraindicated. TREATMENT CONSIDERATIONS

Minimize external stimuli and maintain normothermia. Hyperventilate patient to a respiratory rate of NO MORE than 20 breaths/minute if signs & symptoms of brainstem

herniation are present. Hyperventilation should be avoided in the first 24 hours of a severe brain injury. Hypertonic saline, if initiated at the sending facility, should be limited to 1.5-3.0 mL/kg with a target serum sodium of 155

mEq/L.. This should be infused through a central line.


7.13 Hypertensive Emergencies

INDICATIONS

Blood pressure > 200/130 mmHg without symptoms or > 180/110 mmHg with: Acute change in mental status New focal neurological deficit Acute ischemic ECG changes Acute LV dysfunction Renal failure (increased serum creatinine) Hematuria

MANAGEMENT GOALS

Prevention of serious cardiac or neurologic complications Initiation of gradual therapy to lower blood pressure to the point that immediate life-threatening complications (acute

CHF, CVA) are avoided CARE GUIDELINES 1. Routine Medical Care 2. Attempt to identify and correct the cause of the BP elevation (pain, pre-eclampsia,

overdose, etc.); consult the appropriate standard of care or medical control. 3. If blood pressure greater than 200/130 mmHg and asymptomatic; or blood pressure

greater than 180/110 mmHg and accompanied by symptoms such as tachycardia, headache, nausea/vomiting, or confusion:

Consider Labetalol: 10-20 mg IV over 2 minutes, May double the previous dose and repeat PRN for desired effect (max total dose 300 mg)

Consider Nicardepine (Cardene): Initiate infusion at 5mg/hr, increase by 2.5 mg/hr every 15 minutes to a max of 15 mg/hr

Consider Esmolol (Brevibloc): Bolus 500 mcg/kg over 1 minute, then start infusion at 50mcg/kg/min. May increase by

50 mcg/kg/min every 5-10 minutes up to a max of 200 mcg/kg/min

Consider Nitroglycerin infusion: Initiate infusion at 10 mcg/min, may increase by 5 mcg/min up to a max of 20 mcg/min

Consider Nitroprusside (Nipride) infusion: Initiate infusion at 0.3 mcg/kg/min, may increase by 0.5 mcg/kg/min every 5 minutes to a max of 3 mcg/kg/min. May increase up to 10 mcg/kg/min but for no longer than 10 minutes total.

TREATMENT CONSIDERATIONS

Rapid reduction in BP is indicated in the setting of AMI, hypertensive encephalopathy, and subarachnoid hemorrhage. In all other cases, BP should be lowered no more rapidly than about 10% per hour until a baseline BP is reached.

Consider adequate pain management as an initial step in patients with cephalalgia Consider Morphine 0.1 mg/kg, up to a max of 10 mg

If an aortic emergency is known or suspected, see Aortic Emergencies Protocol (7.10) If response to hypotension, discontinue antihypertensive infusions, elevate patients’ feet and administer 250 ml

crystalloid fluid bolus as needed. Repeat as needed to maintain MAP of at least 65 mm Hg


7.14 Intubated and Chemically Paralyzed Patients INDICATIONS

Patients who are intubated and mechanically ventilated MANAGEMENT GOALS

Provide for patient comfort and safety Optimize ventilatory parameters

CARE GUIDELINES

1. ALL PATIENTS WHO ARE CHEMICALLY PARALYZED MUST HAVE ALSO RECEIVED A SEDATIVE AND AN ANALGESIC BY THE SCT PARAMEDIC UNLESS SPECIFICALLY CONTRAINDICATED.

More than two doses or incremental increases of the following medications necessitate Specialty Care Transport Medical Control.

Sedation: Midazolam - titrate to continued sedation with 1-5 mg IV every 10-15 minutes to a max of 20 mg or

hemodynamic instability Propofol – Initiate infusion at 10 mcg/kg/min and titrate to continued sedation or hemodynamic

instability, by increasing rate 5 mcg/kg/min every 5 minutes to a total of six (6) times or 30 mcg/kg/min max total increase; 0.5-1 mg/kg bolus may be administered once while increasing rate

Analgesia: Morphine - 0.025-0.1 mg/kg IV titrate to continued pain control every 5-10 minutes to a max of 50 mg

or hemodynamic instability Fentanyl – titrate to continued sedation with 25-100mcg IV every 15-20 minutes to a max of 300mcg or

hemodynamic instability

2. Soft restraints should be used for patient safety.

3. All intubated patients may be re-dosed with Vecuronium 0.1mg/kg IV if needed to maintain paralysis. Vecuronium may be given as needed every 40 minutes. ALL patients MUST be given a repeat dose of a SEDATIVE agent PRIOR to Vecuronium.

4. If unable to sedate/paralyze, ensure IV lines are in place and patent. In the event of continued failure to paralyze,

Specialty Care Transport Medical Control should be contacted.


7.15 Pericardial Effusion and Cardiac Tamponade INDICATIONS

Patients with asymptomatic pericardial effusion or evidence of Cardiac Tamponade MANAGEMENT GOALS

Render optimal care to improve outcome CARE GUIDELINES If evidence of symptomatic pericardial effusion:

1. Treat hypotension with repeated fluid boluses 2. Confirm equal bilateral breath sounds and chest rise with breaths

If evidence of cardiac tamponade:

1. The patient must be taken to the nearest Emergency Department and Specialty Care Transport Medical Control contacted as able.


7.16 Thoracostomy (Chest) Tubes INDICATIONS

Patients being transported with Thoracostomy Tubes in place MANAGEMENT GOALS

Render optimal care to minimize discomfort and monitor for changes in patient condition during transport CARE GUIDELINES

All thoracostomy tubes must be securely attached to patient before transport. This should include: confirmation of suturing to the skin, occlusive dressing to thoracostomy site, and secure taping of the thoracostomy tube to the patient.

All thoracostomy tubes should be connected to a commercially available Pleur-Evac or a Heimlich valve.

If suction was being applied to the Pleur-Evac at the sending facility, it will be maintained during the transport at the

same setting.

In the event of a sudden deterioration in the patient’s status, all thoracostomy tubes will be placed to suction.

Thoracostomy tubes should be re-examined every 15 minutes during transport to ensure proper function.

In the event that a thoracostomy tube becomes dislodged, no attempt will be made to reposition. The thoracostomy tube should be put to suction and the patient observed for signs of tension pneumothorax.

If tension pneumothorax should develop, initiate appropriate care with needle decompression and contact Specialty

Care Transport Medical Control.

Provide appropriate analgesia to all patients, per MRLEMS Pain Management Protocol (2.23).


7.17 Titration of Vasoactive Medications INDICATIONS

Patients being transported with intravenous vasoactive medications MANAGEMENT GOALS

Provide for safe titration and use of intravenous vasoactive medication during transport CARE GUIDELINES

1. All vasoactive medications must be controlled utilizing a Continuous Electronic Infusion Device (commonly referred to as a medication pump).

2. Whenever possible, vasoactive medications should be given through a central access device (central line, PICC line,

etc). If this is not possible, the vasoactive medication should be infused through the Y-site of free flowing NS.

3. Whenever possible, initial administration of vasoactive substances should begin in the sending facility. Addition of vasoactive medications during transport should be made after SCT Medical Control consultation.

4. Unless otherwise specified by the sending facility or SCT Medical Control, vasoactive medications should generally be

titrated to achieve a Mean Arterial Pressure of 65 mmHg or greater.

5. Titration of vasoactive substance should be performed utilizing an understanding of the medication’s pharmacokinetics, with typical half-life determining the period of observation to determine medication effect.

6. Titration of any vasoactive medication more than twice requires SCT Medical Control Consultation, unless specifically

authorized by written order from the sending facility.


7.18 Transvenous (Temporary) Pacemaker INDICATIONS

Patients being transported with a transvenous (temporary) pacemaker MANAGEMENT GOALS

Provide for safe transfer of patients with a transvenous (temporary) pacemaker CARE GUIDELINES

Check to assure the insertion site dressing is clean and dry and the pacing electrode position is anchored securely with tape.

Secure the pacing generator and place the plastic cover over the pacemaker controls. Manage complications, should they develop, according to the following: 1. Failure to capture –due to electrode displacement or a high stimulation threshold

Check and tighten all connections Increase the pacemaker output/mA. Turn the patient to a left lateral recumbent position Call Specialty Care Transport Medical Control immediately and report if effective capture is not regained after the

above interventions. Place the external pacer on the patient and pace if needed for symptomatic bradycardia following the MLREMS

Bradycardia Protocol. Turn off any internal pacer if one is present.

2. Failure to pace with no spike present –caused by a broken or loose connection, electrode fracture, inhibition of

pacemaker output, battery or circuit failure. Check and tighten all connections. Check for any equipment that might cause electrical interference and remove if possible. Replace the battery and/or pacing generator. Call Specialty Care Transport Medical Control immediately and report if effective pacing is not regained after the


Bradycardia Protocol (3.4; 4.4). Turn off any internal pacer if one is present.

3. Failure to sense – occurs when the pacemaker does not sense an intrinsic beat.

Check and tighten all connections. Increase the sensitivity of the pacing unit. Place the patient in a position where adequate sensing was last observed. A left lateral recumbent position is

usually best. Increase the pacing rate to override the intrinsic rhythm if possible Turn the pacemaker off if it is not needed, but do not disconnect from the electrode wires. Call Specialty Care Transport Medical Control immediately and report if effective pacing is not regained after the



4. Over-sensing –occurs when the pacemaker sensitivity is set too high. (It should be suspected when pauses are seen intermittently on the ECG or when the paced rate falls below that set on the pacemaker generator. The pacemaker-induced problem may be mistaken for electrode fracture or impending generator failure. Over-sensing leads to under-pacing.)

Decrease the sensitivity on the pacemaker. Replace the pacemaker generator if the problem continues. Call Specialty Care Transport Medical Control immediately and report if effective pacing is not regained after the




7.19 Sepsis INDICATIONS

Suspected or documented infection and at least two of the following:

Temperature > 101°F (38.3°C) or < 96.8°F (36°C) Tachycardia HR >90 bpm Tachypnea RR > 20 rpm or PaCO2 < 32 mmHg Increased WBC count >12,000 c/mm3, < 4,000 c/mm3 or >10% bands

MANAGEMENT GOALS

Maintain airway patency and oxygenation / ventilation status to goal of SpO2 92% or greater Maintain intravascular fluid volume status to goal of MAP of 65 mmHg or higher

CARE GUIDELINES 1. Routine medical care 2. Aggressive fluid maintenance, even if patient is normotensive (at least 100ml/hr crystalloids) to a target CVP goal of 8-12

mmHg If target CVP has been reached and patient is still hypotensive, consider adding the following:

Norepinephrine 2-20 mcg/min or higher or Dopamine 5-20 mcg/kg/min (primary agents, with target goal of MAP >65 mmHg)

Dobutamine 2-40 mcg/kg/min if cardiac output remains poor (secondary agent for CI <3.0L/min/m2 and ScvO2 >70%

with Hct >30)

Phenylephrine 20-200 mcg/min (secondary agent, if HR > 140)

Vasopressin 0.01 – 0.04 units/min (adjunct therapy in addition to another vasopressor) TREATMENT CONSIDERATIONS

Maintain urine output of 0.5mL/kg/hour Maintain anti-infective therapy as begun at referring facility; consider a broad spectrum and gram-negative antibiotic

infusion if specific causative agent is not known


7.20 STEMI / Acute MI Management INDICATIONS

Patients presenting to outlying Hospital Emergency Departments lacking interventional cardiac capabilities, with ST elevation > 1mm in 2 contiguous leads or new LBBB with symptoms less than 12 hours in duration.

MANAGEMENT GOALS

Provide for patient comfort and safety Optimize transport times to meet AHA guidelines for “door to balloon” time of 90 minutes or less.

CARE GUIDELINES 1. Routine medical care. 2. 12 lead EKG; Do not delay transport to obtain. 3. Ensure two patent IVs.

4. If not already administered or started by sending facility: Aspirin, 324 mg chewed PO x 1 and

Clopidogrel (Plavix), 300 mg PO x 1

5. Consider anticoagulation/antiplatelet administration:

Eptifibatide (Integrilin), 180 mcg/kg IV bolus x 2 10 minutes apart then 2 mcg/kg/hr infusion, (If GFR or CrCL < 50 ml/min then reduce infusion to 1 mcg/kg/hr; if GFR or CrCl < 30 ml/min do not administer).

Heparin 60 units/kg IV bolus x 1, (Maximum of 4,000 units), followed by 12 units/kg/hr infusion, (Maximum of 1,000 units/hr)

6. Consider Nitrates:

Nitroglycerine 0.4mg SL q 5 minutes prn pain if SBP > 110mmHg OR

Consider Nitroglycerin infusion: Initiate infusion at 10 mcg/min, may increase by 5 mcg/min up to a max of 20 mcg/min 7. Consider beta blockade if HR >80 and SBP >110 mmHg:

Metoprolol (Lopressor) 5mg q 10 minutes X 3 doses up to max 15mg 8. Consider pain management if SBP > 110 mmHg and RR > 8:

Administer Morphine 0.1 mg/kg up to 5 mg single dose; may repeat to a maximum of 10 mg.

9. Consider nausea/vomiting management:

Promethazine 6.25 mg – 12.5 mg diluted in 100 ml normal saline, given over 10 minutes.

10. Should patients’ condition deteriorate to the point of cardiogenic shock, treat per section 7-11. Contact the receiving facility to advise them on the patients change in condition.


7.21 Ventilator Management INDICATIONS Patients who are mechanically ventilated MANAGEMENT GOALS

Provide for patient comfort and safety Optimize ventilatory parameters

CARE GUIDELINES 1. Connect ventilator hose to the gas supply. 2. Turn on gas supply and check cylinder contents. 3. Set ventilation parameters to suit the patient. Refer to referring or receiving physician orders. 4. The following Specialty Care Transport unit standard (adult) ventilator settings will be initiated unless other physician

orders/patient condition dictate: a. FIO2=100% b. Respiratory rate=10-12 c. Tidal Volume=5-10 mL/kg d. PEEP=5 e. Mode = A/C [Volume Control]

5. Briefly occlude the patient connection port of the patient-valve with thumb and check that the peak inflation-pressure reading on the manometer is appropriate for the patient.

6. Connect the patient valve to the endotracheal tube. 7. Monitor the inflation pressure manometer to ensure correct ventilation 8. Make appropriate adjustments per patient’s clinical condition. 9. ETCO2 should be maintained at 38-42 mmHg. ETCO2 must be monitored by waveform capnography at all times. 10. Adjustments beyond the following parameters require Specialty Care Transport Medical Control or physician order.

a. Respiratory rate <8 or >16 b. PEEP >10


Specialty Care Transport

Medication Data Sheets


7.30 Dobutamine This medication is to be started by the sending facility. SCT Teams can continue this medication by direct written order and with provision of the medication by the sending facility. a) Pharmacology

(1) Pure synthetic beta adrenergic agonist, potent inotrope, mild chronotrope, increases cardiac output

b) Pharmacokinetics (1) Fast onset: Almost immediate (2) Half life: 1-2 minutes

c) Indications (1) Acute decompensated heart failure (2) Decreased cardiac output (3) Cardiogenic shock

d) Contraindications (1) Tachydysrhythmias (2) Hypertrophic subaortic stenosis (left ventricular outflow obstruction)

e) Adverse Effects (1) Cardiac dysrhythmias (2) Coronary arteriosclerosis, worsening (3) Dyspnea (4) Nausea (5) Syncope (6) Hypokalemia (7) Infusion site reaction

f) Precautions

(1) Can lead to ventricular tachycardia or ventricular fibrillation (2) Can precipitate ACS or AMI (3) Hypovolemia

g) Dosage (1) Maintenance infusion: 2-20 mcg/kg/min (2) In the event of tachydysrhythmias, reduce dose by 5mcg/kg/min (or to a minimum of 2mcg/kg/min)


7.31 Esmolol (Brevibloc) This medication is to be started by the sending facility. SCT Teams can continue this medication by direct written order and with provision of the medication by the sending facility.

a) Pharmacology

(1) Esmolol is a short acting beta-adrenergic antagonist with Beta-1cardioselectivity

b) Pharmacokinetics (1) Fast onset: 2-10 minutes (2) Duration of effect: 10-30 minutes, prolonged following high cumulative doses and/or extended duration of use (3) Metabolism: In blood via red blood cell esterases

c) Indications

(1) Tachycardia and/or hypertension (2) Reduction of heart rate and sheering forces associated with aortic aneurysm (3) Rapid atrial fibrillation/flutter


(1) Sinus bradycardia, heart block greater than 1st degree, uncompensated congestive heart failure, cardiogenic shock, or allergy to beta-blockers, hypertension/tachycardia induced by cocaine

e) Adverse effects (1) Hypotension (2) Bradycardia (3) Heart block (4) Exacerbated heart failure (5) Peripheral ischemia (6) Dizziness (7) Agitation (8) Nausea/vomiting

f) Precautions

(1) Use of beta adrenergic antagonists must be weighed against potential adverse effects, especially in patients with reactive airway disease, diabetes mellitus, hypoglycemia or renal failure

g) Dosing (1) Loading dose of 500 mcg/kg over 1 minute, followed by 50 mcg/kg/min. Can increase infusion by 50 mcg/kg/min

every 5 minutes up to a maximum of 200 mcg/kg/min.

f) Special Notes (1) Esmolol is incompatible with furosemide, amphotericin B, and procainamide. Esmolol may cause increased serum

digoxin levels and enhanced AV node block. (2) It may be mixed in D5W or NS to a concentration of 10 mg/ml (2.5 grams in 250 ml).

Esmolol (Brevibloc) 2.5 gram/250 ml (10mg/mL) D5W or NS only

Patient Weight Drip Rate Lb kg 50 mcg/kg 100mcg/kg 150 mcg/kg 200 mcg/kg 110 50 15mL/hr 30mL/hr 45mL/hr 60mL/hr 132 60 18mL/hr 36mL/hr 54mL/hr 72mL/hr 154 70 21mL/hr 42mL/hr 63mL/hr 84mL/hr 176 80 24mL/hr 48mL/hr 72mL/hr 96mL/hr 198 90 27mL/hr 54mL/hr 81mL/hr 108mL/hr 220 100 30mL/hr 60mL/hr 90mL/hr 120mL/hr


7.32 Fibrinolytic Agents This medication is to be started by the sending facility. SCT Teams can continue this medication by direct written order and with provision of the medication by the sending facility. a) Pharmacology

(1) To promote lysis of the clot allowing return of blood flow to the infarct related vessel

b) Pharmacokinetics (1) Dose varies (depends on specific agent and indication) (2) Half-life: 10-130 minutes (depends on specific agent used)

c) Indications (1) Acute myocardial infarction (2) Acute stroke (within 3 hours of onset) (3) Pulmonary embolus (4) Intraarterial thrombosis (usually low continuous dose, no titration)


(1) Active internal bleeding (i.e. GI Bleed) or acute trauma (2) Previous or current hemorrhagic stroke on pretreatment head CT (3) Known intracranial neoplasm, AV malformation, or aneurysm (4) Uncontrolled hypertension; blood pressure >185/110 mmHg (5) Intracranial or intraspinous surgery, serious head trauma, or previous stroke (< 3 months) (6) Suspected aortic dissection (7) Pregnancy (8) Anticoagulant use that has produced any of the following: INR > 1.7; prothrombin time (PT) > 15 seconds; activated

partial thromboplastin time (aPTT) > than the upper limit of normal (9) Platelet count <100,000/mm3 (10) History of ischemic stroke or TIA in past 6 months (for acute MI indication)

e) Adverse Effects

(1) Bleeding (2) Hypersensitivity reactions (3) Angioedema ***If bleeding or severe angioedema – stop infusion after contact Specialty Care Transport Medical Control***

f) Precautions

(1) Stroke within the previous 6 months (2) Myocardial infarction within the previous 3 months (3) Serious trauma or major surgery within the last 14 days (4) Recent gastrointestinal or urinary tract hemorrhage within the previous 21 days (5) Postmyocardial infarction pericarditis (6) Recent pregnancy (up to 10 days postpartum) (7) Active peptic ulcer disease (8) Subclavian line (non-compressible site) or recent arterial puncture at a non-compressible site within the past 7 days (9) CPR within the last 10 days (10) Abnormal blood glucose level (<50 or >400 mg/dL)

g) Dosage

(1) The dose varies based upon the type of agent used and specific indication. If a patient is receiving thrombolytics during transport, ensure that proper physician orders have been written detailing dosing and timing of doses.


7.33 Milrinone (Primacor) This medication is to be started by the sending facility. SCT Teams can continue this medication by direct written order and with provision of the medication by the sending facility. a) Pharmacology

(1) Milrinone is a phosphodiesterase III enzyme inhibitor which enhances the contractility of the ventricles by inhibiting the breakdown of cAMP, thereby increasing the levels of available Ca++ in cardiac sarcomeres.

(2) Milrinone also has shown diastolic relaxation properties (positive lucitropy) which may aid in ventricular filling

b) Pharmacokinetics (1) Highly bound to plasma (2) Elimination half-life of approximately 2.5 hours (3) ~85% excreted unchanged in the urine, hepatic metabolism

c) Indications

(1) Acute decompensated heart failure (2) Decreased cardiac output (3) Cardiogenic shock


(1) Hypotensive (2) Known hypersensitivity

e) Adverse Effects

(1) Hypotension (2) Ventricular arrhythmias (3) Headache (4) Myocardial infarction (5) Anaphylaxis, bronchospasm

f) Precautions

(1) May aggravate symptoms of idiopathic hypertrophic subaortic stenosis (IHSS) (2) SVT and VT have been observed, as well as increased ectopy and non-sustained VT (3) Shortening of AV node conduction time, may increase ventricular response in a-fib/a-flutter (4) If prior vigorous diuretic therapy was used, caution should be observed due to potential for significant decreases

in ventricular filling pressures. HR, BP and clinical symptomatology should be closely monitored. (5) Not recommended in acute myocardial infarction (6) Dosage reduction in patient’s with renal impairment (7) Milrinone-induced improvement in cardiac-output with resultant diuresis may necessitate a reduction in the

dose of diuretics (8) Potassium loss from excessive diuresis may predispose digitalized patients to arrhythmia. Hypokalemia

should be corrected prior to, or during the use of Milrinone g) Dosing

(1) Milrinone may be mixed with D5W or NS. Add 1 vial (20mg/20mL) to 80 ml of D5W or NS for a final concentration of 20mg/100mL (200mcg/mL)

(2) Maintenance infusion between 0.375 and 0.75 mcg/kg/min, do not bolus, causes hypotension. (3) See Dosing Table Next Page h) Special Notes

(1) Milrinone is not compatible with furosemide or procainamide


7.33 Milrinone (Primacor) (Continued)

Milrinone 20 mg in 100 mL (200mcg/mL) Pt weight (kg) Pt weight (lb) 0.375 mcg/kg/min

(ml/hr) 0.5 mcg/kg/min

(mL/hr) 0.75 mcg/kg/min

(mL/hr) 40 88 4.5 6 9 45 99 5.1 6.8 10.1 50 110 5.6 7.5 11.3 55 121 6.2 8.2 12.4 60 132 6.8 9 13.5 65 143 7.3 9.8 14.6 70 154 7.9 10.5 15.8 75 165 8.4 11.2 16.9 80 176 9 12 18 85 187 9.6 12.7 19.1 90 198 10.1 13.5 20.3 95 209 10.7 14.2 21.4

100 220 11.3 15 22.5 105 231 11.8 15.7 23.6 110 242 12.4 16.5 24.8 115 253 12.9 17.2 25.9 120 264 13.5 18 27 125 275 14 18.7 28.1 130 286 14.6 19.5 29.2 135 297 15.2 20.2 30.4


7.34 Norepinephrine (Levophed) This medication is to be started by the sending facility. SCT Teams can continue this medication by direct written order and with provision of the medication by the sending facility. a) Pharmacology

(1) Alpha adrenergic and to a lesser effect Beta adrenergic agonist, used to increase peripheral resistance, blood pressure, and to a lesser effect heart rate

b) Pharmacokinetics

(1) Rapid onset (2) Half life: 2-5 minutes

c) Indications

(1) Hypotension due to sepsis/hypovolemia (often in conjunction with intravenous fluid therapy)

d) Contraindications (1) Mesenteric or peripheral vascular disease (ischemia)

e) Adverse Effects

(1) Bradyarrhythmias (2) Peripheral ischemia (3) Headache (4) Extravasation causing skin necrosis

f) Precautions

(1) Avoid hypertension (2) Central lines should be used for infusions due to risk of extravasation

g) Dosage

(1) Maintenance infusion: 4-80mcg/min

Norepinephrine 4mg in 250 mL (16mcg/mL) 2 mcg/min 8 mL/hr 3 mcg/min 11 mL/hr 4 mcg/min 15 mL/hr 5 mcg/min 19 mL/hr 6 mcg/min 22 mL/hr 7 mcg/min 26 mL/hr 8 mcg/min 30 mL/hr 9 mcg/min 34 mL/hr

10 mcg/min 38 mL/hr 11 mcg/min 41 mL/hr 12 mcg/min 45 mL/hr 13 mcg/min 49 mL/hr 14 mcg/min 53 mL/hr 15 mcg/min 56 mL/hr 16 mcg/min 60 mL/hr 17 mcg/min 64 mL/hr 18 mcg/min 68 mL/hr 19 mcg/min 71 mL/hr 20 mcg/min 75 mL/hr


7.35 Octreotide (Sandostatin)

This medication is to be started by the sending facility. SCT Teams can continue this medication by direct written order and with provision of the medication by the sending facility.

a) Pharmacology

(1) Octreotide is a longer acting, synthetic form of the hormone somatostatin. (2) For its use in variceal bleeding, octreotide constricts splanchnic blood vessels and inhibits the release of GI

hormones, including serotonin, vasoactive intestinal peptide (VIP), gastrin, secretin and pancreatic polypeptide.

b) Pharmacokinetics (1) Onset of action: ~10 minutes (2) Duration of action: 1.5-2 hours (3) Metabolized by the liver and excreted by the kidneys. Liver disease reduces metabolism and kidney failure reduces

elimination to 3-4 hours.

c) Indications (1) Octreotide is indicated as an adjunct in the treatment of upper GI bleed, especially those associated with

esophageal varices. (2) Octreotide is indicated in patients who have undergone pancreatic surgery, have pancreatic sepsis, acute

pancreatitis or pancreatic fistula

d) Contraindications (1) Relatively contraindicated in bradycardia (2) Known allergy or sensitivity

e) Adverse effects

(1) Octreotide may cause depression of gall bladder function (2) Octreotide may cause hypoglycemia or hyperglycemia (3) Octreotide may precipitate acute pancreatitis (4) Redness, flushing, abdominal pain, nausea/vomiting headache, fever, fatigue have been associated with octreotide

f) Precautions

(1) Concomitant use with beta blockers due to bradydysrhythmia risk. (2) Blood glucose monitoring should be undertaken on any patient taking diabetic medications, including sulfonylureas

or insulin

g) Dosing (1) Initial bolus of 25-50 mcg, followed by continuous infusion of 25-50 mcg/hr.

h) Special Notes (1) Octreotide is compatible with both D5W and Normal Saline.

Mix 1200 mcg Octreotide in 250 mL (concentration 4.8 mcg/mL) Dose Infusion Rate

50 mcg/hr 10 mL/hr 100 mcg/hr 20 mL/hr 150 mcg/hr 30 mL/hr 200 mcg/hr 40 mL/hr 250 mcg/hr 50 mL/hr


7.36 Phenylephrine (Neosynephrine) This medication is to be started by the sending facility. SCT Teams can continue this medication by direct written order and with provision of the medication by the sending facility. a) Pharmacology

(1) Pure alpha adrenergic agonist used to increase peripheral resistance and blood pressure

b) Pharmacokinetics (1) Onset of action: immediate (2) Half life approximately 2-3 hours; duration 15-30 minutes

c) Indications

(1) Hypotension due to sepsis/hypovolemia (often in conjunction with intravenous fluid therapy)

d) Contraindications (1) Mesenteric or peripheral vascular disease (ischemia) (2) Ventricular tachycardia

e) Adverse Effects (1) Reflex bradycardia (2) Severe peripheral and visceral vasoconstriction (3) Extravasation leading to skin necrosis

f) Precautions

(1) Avoid hypertension (2) Use with caution in patients with heart block, hyperthyroidism, bradycardia, myocardial disease, severe CAD (3) Central lines should be used for infusions due to risk of extravasation

g) Dosage

(1) Maintenance infusion: 40 - 100 mcg/min


7.37 Propofol (Diprivan) a) Pharmacology

(1) Propofol is an anesthetic/sedative/hypnotic that is neither a barbiturate nor a benzodiazepine. (2) It produces anesthesia through a number of interrelated mechanisms, including enhancement of GABA-A,

sodium channel blockade and through activation of the endocannabinoid system (a retrograde neuronal signaling system to maintain higher levels of GABA)

b) Pharmacokinetics

(1) Onset of Action: 30-40 sec; rapid distribution due to high lipophilicity (2) Duration of action: 2-4 minutes (3) Elimination half-life is 30-60 minutes (4) Propofol is metabolized in the liver by glucuronide conjugation and is excreted via the kidneys

c) Indications (1) Sedation of ventilated patient in a critical care/ICU setting (2) Induction and maintenance of anesthesia (3) Procedural sedation


(1) Allergy to eggs or egg products, soy or soy products. (2) Hypotensive, especially those who are volume depleted.

e) Adverse effects

(1) Hypotension, bradycardia, arrhythmias, hyperlipidemia, bronchospasm, laryngospasm , anaphylaxis, green urine, injection site burning

f) Precautions (1) Maintenance of sedation with propofol decreases systemic vascular resistance and decreases cardiac output (2) Propofol should be used with extreme caution in patients with known ventricular failure or extremes of HR (3) Hypocapnia (from hyperventilation) while using propofol for maintenance of sedation is associated with an

increased risk of hypoperfusion to the brain (4) Rapid oxygen desaturation may occur following a bolus of propofol (5) Bolus injections of propofol are associated with an increase in undesirable cardiorespiratory effects in older

patients. Consider ½ dose until pt stability and response established (6) Discard infusion bottle after 12 hours or 6 hours if mixed as an admixture in D5W due to poor sterility of the

lipid emulsion past these time points

g) Dosing (1) Initial dose is 10-20 mcg/kg/min as a slow infusion. Rapid bolus injections should be avoided due to the

increased incidence of hypotension (2) Maintenance infusion 10-80 mcg/kg/min

h) Special Notes

(1) Propofol is incompatible with many antibiotics and vasoactive agents. It should be infused via its own IV line. (2) Propofol is compatible with fentanyl. These 2 agents can be given together through the Y-site.

Propofol (Diprivan) Infusion Chart Propofol concentration 10mg/mL Pt weight (kg) 10 mcg/kg/min 20 mcg/kg/min 30 mcg/kg/min 40 mcg/kg/min 50mcg/kg/min

50 3 mL/hr 6 mL/hr 9 mL/hr 12 mL/hr 15 mL/hr 60 3.6 mL/hr 7.2 mL/hr 10.8 mL/hr 14.4 mL/hr 18 mL/hr 70 4.2 mL/hr 8.4 mL/hr 12.6 mL/hr 16.8 mL/hr 21 mL/hr 80 4.8 mL/hr 9.6 mL/hr 14.4 mL/hr 19.2 mL/hr 24 mL/hr 90 5.4 mL/hr 10.8 mL/hr 16.2 mL/hr 21.6 mL/hr 27 mL/hr

100 6 mL/hr 12 mL/hr 18 mL/hr 24 mL/hr 30 mL/hr


Ideal Body Weight Table for Ventilator Tidal Volume Calculation

Male Female

Height (in)

IBW (Kg)

4mL/kg

5mL/kg

6mL/kg

7mL/kg

8mL/kg

46 26 103 129 155 180 206 47 28 110 138 166 193 221 48 29 118 147 177 206 236 49 31 125 157 188 219 250 50 33 133 166 199 232 265 51 35 140 175 210 245 280 52 37 147 184 221 258 295 53 39 155 194 232 271 310 54 41 162 203 243 284 324 55 42 170 212 254 297 339 56 44 177 221 266 310 354 57 46 184 231 277 323 369 58 48 192 240 288 336 384 59 50 199 249 299 349 398 60 52 207 258 310 362 413 61 54 214 268 321 375 428 62 55 221 277 332 387 443 63 57 229 286 343 400 458 64 59 236 295 354 413 472 65 61 244 305 365 426 487 66 63 251 314 377 439 502 67 65 258 323 388 452 517 68 66 266 332 399 465 532 69 68 273 342 410 478 546 70 70 281 351 421 491 561 71 72 288 360 432 504 576 72 74 295 369 443 517 591 73 76 303 379 454 530 606 74 78 310 388 465 543 620 75 79 318 397 476 556 635 76 81 325 406 488 569 650 77 83 332 416 499 582 665 78 85 340 425 510 595 680 79 87 347 434 521 608 694 80 89 355 443 532 621 709

Height (in)

IBW (Kg)

4mL/kg

5mL/kg

6mL/kg

7mL/kg

8mL/kg

46 26 102 128 153 179 205 47 27 109 136 163 191 218 48 29 115 144 173 202 231 49 31 122 153 183 214 244 50 32 129 161 193 225 257 51 34 135 169 203 237 271 52 35 142 177 213 248 284 53 37 148 186 223 260 297 54 39 155 194 233 271 310

55 40 162 202 243 283 323

56 42 168 210 252 294 337 57 44 175 219 262 306 350 58 45 181 227 272 318 363 59 47 188 235 282 329 376 60 49 195 243 292 341 389 61 50 201 252 302 352 403 62 52 208 260 312 364 416 63 54 214 268 322 375 429 64 55 221 276 332 387 442 65 57 228 285 342 398 455 66 59 234 293 351 410 469 67 60 241 301 361 422 482 68 62 247 309 371 433 495 69 64 254 318 381 445 508 70 65 261 326 391 456 521 71 67 267 334 401 468 535 72 68 274 342 411 479 548 73 70 280 351 421 491 561 74 72 287 359 431 502 574 75 73 294 367 441 514 587 76 75 300 375 450 525 601 77 77 307 384 460 537 614 78 78 313 392 470 549 627 79 80 320 400 480 560 640 80 82 327 408 490 572 653

Updated Dec 2009

Monroe-Livingston Regional EMS

Protocols

Section 8

Tox-Medic Hazardous Materials Protocols

Updated Dec 2009

8.0 SPECIAL LEVEL OF CARE EXPLANATION OVERVIEW There are certain situations where additional treatments beyond the scope of the standard MLREMS protocols are beneficial for the patient. Hazardous materials exposures require additional training for patients to be recognized and treated appropriately. This training includes the specific toxidromes most commonly associated with the exposure, antidotes, pharmaceutical interventions, and familiarity with operating in the vicinity of an ongoing hazard. These protocols are to be used by regionally-credentialed specially trained paramedics under strict physician oversight. It is recognized that these Tox-Medics have primary responsibility to the Hazardous Materials Team operating at an incident, and it is more likely that these Tox-Medics will be required to constantly monitor the occupational hazards incurred by a Hazardous Materials Technician rather than civilians affected by such an exposure. The Tox-Medic must have a close working relationship with responding hazardous materials team in order to be an effective advocate for their health and safety. CREDENTIALING The following is required to operate at the MLREMS Tox-Medic level and utilize the protocols contained herein:

1. Certified and cleared at the paramedic level in the Monroe-Livingston Region. 2. Certified in ACLS, PALS/PEPP and ITLS/PHTLS. 3. Successfully completed an approved Hazmat Operations and Advanced HazMat Life Support

course. 4. Member of a Hazardous Materials Medical Response Team. 5. Attend a minimum 8 hours per year of Hazmat /Tox-Medic specific training. 6. Participate in a minimum of 50% of Hazardous Materials Response Team training drills and one live

drill per year. 7. Receive approval from the System Medical Director or his/her designee to participate at such a

level. STANDARD OF CARE These “Hazardous Materials Protocols” are only to be used by personnel regionally credentialed as Tox-Medics. These protocols are to be used in concert with the EMT-P scope of practice outlined in the MLREMS Standards of Care and are NOT to be used for routine Advanced Life Support care. These protocols are meant to act as general guidelines for rendering medical care and/or treatments and may not be inclusive for every situation. The protocols should be regarded as the prevailing norms of treatment and should be considered prudent in the delivery of medical care. Deviation from these protocols may be necessary based on patient need and must be documented. MEDICAL CONTROL The following protocols are considered standing order for credentialed Tox-Medics when operating at the scene of a hazardous materials incident. In these circumstances, all MLREMS EMT-P Standards of Care are also standing order for the Tox-Medic except in cases identified as Absolute On-Line with no exception for radio or phone failure. Any deviation from the Hazardous Material Protocols requires Absolute On-Line Medical Control. Medical Control for Tox-Medics is provided by the Regional Medical Director On-Call, the Hazmat Team Toxicologist, or Poison Control Center Physician. The Tox-Medic must have a means of direct communication to Medical Control at any time during their care of the patient. In the event of being unable to contact Tox-Medic Medical Control, the Tox-Medic should institute direct contact with standard medical control. In the event of failure of all the above, treatment protocols will be regarded as standing order, however procedures requiring Absolute On-Line medical command should not be undertaken unless a life threatening emergency.

Updated Dec 2009

8.1 CHOLINESTERASE INHIBITORS CRITERIA

Exposure to cholinesterase inhibitors including nerve agents may result in the following:

Mild Symptoms Moderate Symptoms Severe Symptoms Salivation Mild symptoms plus: Moderate symptoms plus: Lacrimation Fasciculations Vomiting Pinpoint Pupils Diarrhea Confusion Wheezing/Coughing Difficulty breathing Unresponsiveness Seizures

TOX-MEDIC

1. Routine Standing Orders. 2. Rapid transport once necessary decontamination completed.

3. Establish intravenous access and cardiac monitoring.

4. Exposures with none of the above symptoms should be given oxygen and observed for signs and

symptoms. No antidotes should be administered for asymptomatic patients.

5. Do not administer Furosemide or Morphine.

6. If exposure and symptoms, administer the following:

Mild Symptoms Adult 1 Mark I Kit/ or Atropine 2 mg IV/IM/IO every 5 minutes until secretions resolve

1 Duodote Kit Pralidoxime 1 g IV/IM/IO over 10 minutes Pediatric 1 Mark I Kit/ or Atropine 0.02 mg/kg IV/IM/IO every 5 minutes until secretions resolve 1 Duodote Kit Pralidoxime 40 mg/kg IV/IM/IO over 10 minutes

Moderate Symptoms

Adult 2 Mark I Kits/ or Atropine 4 mg IV/IM/IO every 5 minutes until secretions resolve 2 Duodote Kits Pralidoxime 2 g IV/IM/IO over 10 minutes Pediatric

2 Mark I Kits/ or Atropine 0.02 mg/kg IV/IM/IO every 5 minutes until secretions resolve 2 Duodote Kits Pralidoxime 40 mg/kg IV/IM/IO over 10 minutes

Severe Symptoms Adult 3 Mark I Kits/ or Atropine 6 mg IV/IM/IO every 5 minutes until secretions resolve 3 Duodote Kits Pralidoxime 2 g IV/IM/IO over 10 minutes 1 CANA Diazepam 10 mg IV/IM/IO Pediatric 3 Mark I Kits/ or Atropine 0.04 mg IV/IM/IO every 5 minutes until secretions resolve 3 Duodote Kits Pralidoxime 40 mg/kg IV/IM/IO over 10 minutes 1 CANA Diazepam 0.2 mg/kg IV/IM/IO

Updated Dec 2009

8.2 CORROSIVES

CRITERIA

1. Inhalation of a corrosive may result in the following signs or symptoms: a. Coughing, burning, or difficulty breathing b. Laryngospasm, bronchospasm, and/or edema of the upper/lower airway c. Dysphonia, throat tightness, hoarseness, stridor, and aphonia

2. Dermal exposure to a corrosive may result in the following signs or symptoms:

a. Burn(s)/pain at area of contamination b. Hypovolemia c. Prolonged QT interval, dysrhythmias d. Anxiety, confusion, agitation, seizures, possible decreased level of consciousness e. Liquefactive necrosis of tissue (Alkali burns) f. Coagulative necrosis of tissue (Acid burns)

TOX-MEDIC

1. Routine Standing Orders.

2. Minimize recumbent position to avoid aspiration risks.

3. Flush all affected skin surfaces with normal saline for at least 15 minutes even after complete

decontamination.


5. Provide care directed to the patients symptoms:

a. Altered Mental Status – Refer to Altered Mental Status Protocol

b. Dysrhythmias – Refer to relevant Dysrhythmia protocol

c. Hypotension – Refer to Hypotension/Shock Protocol

d. Nausea/Vomiting i. Avoid Promethazine

e. Pulmonary Edema

i. Provide adequate oxygenation and ventilation with bag valve mask or CPAP ii. Do not administer Furosemide or nitroglycerin

f. Respiratory Distress/Bronchospasm

i. Provide adequate oxygenation and ventilation with bag valve mask or CPAP ii. Albuterol 5.0 mg by nebulizer. May give via bag-valve mask or CPAP if necessary. May

repeat up to 30 mg/hr. iii. Ipratroprium Bromide (Atrovent) 0.5 mg by nebulizer. May mix with Albuterol to give

simultaneously, may not repeat.

g. Seizures i. Administer 5 mg diazepam IV/IO, may repeat as needed.

6. If ocular irritation present refer to Ocular Contamination Protocol.

8.3 CYANIDE CRITERIA 1. Known or suspected exposure to cyanogenic compound. 2. Signs and symptoms including any of the following:

a. Tachypnea b. Tachycardia c. Central and peripheral cyanosis d. Throbbing headache e. Hypotension f. Syncope g. Weakness h. Agitation i. Seizures

TOX-MEDIC


2. Rapid transport once necessary decontamination completed. Transport patients who

have ingested cyanide salts in vehicles with windows open and/or good ventilation.

3. Establish intravenous access and cardiac monitoring. Determine and treat blood glucose as appropriate.

4. Mild exposures with conscious and alert patients should be given oxygen and observed for signs and

symptoms. No antidotes should be administered for mild exposure.

5. If patient is exhibiting life-threatening symptoms (severe respiratory compromise or arrest, shock, seizures, coma) and there is no concomitant CO exposure administer EITHER Sodium Nitrate/Sodium Thiosulfate OR hydroxycobalamin:

a. Sodium Nitrate/Sodium Thiosulfate

i. 300 mg of 3% Sodium Nitrite diluted in 100 mL of Normal Saline and given IV/IO over 5 minutes. Decrease infusion rate if hypotension develops.

ii. 12.5 gm Sodium Thiosulfate IV/IO over 10 minutes.

iii. One half the dose of Sodium Nitrite and Sodium Thiosulfate may be repeated if

adequate clinical response has not occurred in 30 minutes.

b. Hydroxycobalamin (CyanoKit) i. 5 gm hydroxycobalamin IV/IO over 15 minutes.

NOTE: Each 2.5 gm vial must be reconstituted with 100 mL of normal saline using the supplied sterile transfer spike. The line on each vial represents 100 mL volume. Following reconstitution the vial should be repeatedly inverted or rocked for at least 30 seconds prior to infusion. DO NOT SHAKE. If the reconstituted solution is not dark red or if particular matter is seen after the solution has been appropriately mixed, the solution should be discarded.

6. If adequate ventilation has been established, administer Sodium Bicarbonate 1 mEq/kg IV/IO. 7. Provide supportive care directed to the patients symptoms:

a. Hypotension – Refer to Hypotension/Shock Protocol b. Seizures – Administer 5 mg diazepam IV/IO, may repeat as needed


8.4 HYDRAZINES CRITERIA

1. Respiratory signs and symptoms secondary to known or suspected hydrazine exposure: a. Burning sensation b. Upper airway edema, coughing, dysphonia, stridor, laryngospasm c. Wheezing/rales d. Tachypnea

2. Presentation can also include:

a. Tachydysrhythmias b. Chest pain c. Ischemic changes (inverted T waves and/or ST segment depression/elevation) d. Seizures e. Coma f. Hematemesis g. Abdominal pain, nausea, and vomiting

TOX-MEDIC





a. Altered Mental Status – Refer to Altered Mental Status Protocol b. Chest Pain – Refer to Chest Pain Protocol

c. Dysrhythmias – Refer to relevant Dysrhythmia protocol

d. Hypotension – Refer to Hypotension/Shock Protocol e. Pulmonary Edema

i. Provide adequate oxygenation and ventilation with bag valve mask or CPAP.

ii. Do not administer Furosemide or Nitroglycerin.


i. Provide adequate oxygenation and ventilation with bag valve mask or CPAP ii. Albuterol 5.0 mg by oxygen powered nebulizer. May give via bag-valve mask or CPAP

if necessary. May repeat up to 30 mg/hr. iii. Ipratroprium Bromide (Atrovent) 0.5 mg by nebulizer. May mix with Albuterol to give


g. Seizures

i. Administer 5 mg diazepam IV/IO, may repeat as needed.


8.5 HYDROCARBONS CRITERIA

1. Known exposure to hydrocarbons.

2. Signs and symptoms including any of the following: a. CNS – Confusion, combativeness, decreased level of consciousness, seizures b. G.I. – Nausea, vomiting c. Cardiac – Dysrhythmias d. Pulmonary – Pulmonary edema, wheezing, rhonchi e. Dermatologic – Dermatitis and burns

TOX-MEDIC





a. Altered Mental Status – Refer to Altered Mental Status Protocol b. Dysrhythmias

i. Avoid epinephrine ii. Refer to relevant Dysrhythmia protocol

c. Hypotension – Refer to Hypotension/Shock Protocol d. Nausea/Vomiting

i. Avoid Promethazine

e. Pulmonary Edema

i. Provide adequate oxygenation and ventilation with bag valve mask or CPAP

ii. Do not administer Furosemide, albuterol, or nitroglycerin


i. Provide adequate oxygenation and ventilation with bag valve mask or CPAP ii. Do not administer albuterol or epinephrine

g. Seizures – Refer to Seizures Protocol

i. Administer 5 mg diazepam IV/IO, may repeat as needed.


8.6 HYDROFLUORIC ACID AND FLUORIDES CRITERIA

Exposure to hydrofluoric acid or fluorides may result in any of the following: a. Coughing b. Burning c. Dyspnea d. Bronchospasm e. Laryngospasm f. Edema of upper and lower airway

g. Wheezes/rales h. Hypovolemia i. Tachydysrhythmias j. Ischemic changes k. Pain at burn site

TOX-MEDIC

1. Routine Standing Orders. 2. Flush all affected skin surfaces with large quantities of water and a mild liquid detergent for at least 15

minutes even after complete decontamination.

3. Rapid transport once necessary decontamination completed.


5. If hypotensive, refer to Hypotension/Shock protocol.

6. Place patient on cardiac monitor and monitor for dysrhythmias, if they occur treat per protocol.

7. If Hydrofluoric Acid burns to skin:

Apply Calcium Gluconate 2.5% gel liberally to affected skin surfaces and cover with occlusive dressing. Do not place in eyes. 8. If Hydrofluoric Acid to eye:

Follow Ocular Contamination Protocol, however instead of Normal Saline, irrigate with 1% Calcium Gluconate Solution (50 mL 10% Calcium Gluconate in 500 mL NS). Repeat indefinitely.

9. If Hydrofluoric Acid inhalation: Nebulize 1 mL 10% Calcium Gluconate mixed with 3 mL NS. Repeat indefinitely. 10. Administer Morphine Sulfate 5 mg IV/IO every 10 minutes as needed for pain >4/10.

8.7 IRRITANT GASES CRITERIA

Respiratory signs and symptoms secondary to known or suspected irritant gas exposure:

1. Burning sensation 2. Upper airway edema, coughing, stridor, laryngospasm, dysphonia or aphonia 3. Wheezing/rales 4. Tachypnea

TOX-MEDIC

1. Routine Standing Orders. 2. Establish intravenous access and cardiac monitoring. 3. Provide care directed to the patients symptoms:

a. Pulmonary Edema/CHF

i. Provide adequate oxygenation and ventilation with bag valve mask or CPAP ii. Do not administer Furosemide or Nitroglycerin.

b. Respiratory Distress/Bronchospasm

i. Provide adequate oxygenation and ventilation with bag valve mask or CPAP ii. Albuterol 5.0 mg by oxygen powered nebulizer. May give via bag-valve mask or CPAP

if necessary. May repeat up to 30 mg/hr. iii. Ipratroprium Bromide (Atrovent) 0.5 mg by nebulizer. May mix with Albuterol to give


c. Seizures

ii. Administer 5 mg diazepam IV/IO, may repeat as needed

4. If chlorine or hydrochloric acid inhalation and significant respiratory distress, administer Sodium Bicarbonate via nebulizer (3 ml of 8.4% NaHCO3 and 3 ml of normal saline). May repeat indefinitely.


8.8 METHEMOGLOBINEMIA CRITERIA The Methemoglobinemia treatment protocol should be instituted when all of the four criteria are met:

1. Known or suspected exposure to oxidizing agents (nitrates, nitrites, chlorates, etc) including: a. Amyl Nitrate b. Aniline Dye Derivatives (Shoe Dyes,

Marking Inks) c. Butyl Nitrite d. Chlorobenzene

e. Isobutyl Nitrite f. Naphthaline g. Notrophenol h. Nitrous Gases i. Sodium Nitrite

2. Central or peripheral cyanosis. 3. Signs and symptoms of significant (>20%) methemeglobinemia:

a. Dyspnea b. Chest Pain c. Agitation

d. Confusion e. Seizures f. Coma

4. Chocolate-brown-colored blood viewed in flash chamber when starting IV.

A history of Glucose-6-Phosphate Dehydrogenase Deficiency (G6PD) is an absolute contraindication to Methylene Blue Administration.

TOX-MEDIC

1. Routine Standing Orders. 2. Rapid transport once necessary decontamination completed.


4. Administer 2 mg/kg 1% Methylene Blue slow IV/IO over 5 minutes followed by a minimum 50 mL normal

saline. May repeat once in 30 minutes if no response and symptoms persist.


a. Altered Mental Status – Refer to Altered Mental Status Protocol b. Dysrhythmias – Refer to relevant Dysrhythmia protocol

c. Hypotension – Refer to Hypotension/Shock Protocol

d. Seizures

i. Administer 5 mg diazepam IV/IO, may repeat as needed


8.9 OCULAR CONTAMINATION SCOPE OF PRACTICE Placement of a Morgan Lens may be performed by any Tox-Medic and any level provider who has been trained and approved by the agency medical director on the indications, insertion, and use of the device. A recurrent training program is required for all providers eligible to insert the Morgan Lens in order to maintain skills competency. Once placed, the Morgan Lens may be maintained by any EMT-P level provider, with preference to a Tox-Medic. CRITERIA

Indication Chemical exposure to the eye Contraindications Ocular foreign body Penetrating eye injury Unable to remove contact lens Allergy to “caine” anesthetics

PROCEDURE

1. Ensure contact lenses are removed prior to treatment. 2. Instill 2 drops of Tetracaine Ophthalmic solution to the affected eye(s). 3. Insert Morgan Lens in affected eye(s) with Normal Saline flowing (Do NOT insert a dry Morgan

Lens)

4. Continuously flush eye(s) with Normal Saline for at least 20 minutes.

5. Tetracaine may be repeated once for patient comfort.

6. The Morgan Lens may only be removed with a Medical Control order.

7. A 1% solution of Calcium Gluconate may be used in lieu of Normal Saline for ocular Hydrofluoric Acid burns.

8.10 TOX-MEDIC FORMULARY I. Atropine Sulfate

a. Indications i. Organophosphate or carbamate exposure with the following symptoms :

Mild Symptoms Moderate Symptoms Severe Symptoms Salivation Mild symptoms plus: Moderate symptoms plus: Lacrimation Fasciculations Vomiting Pinpoint Pupils Diarrhea Confusion Wheezing/Coughing Difficulty breathing Unresponsiveness Seizures

b. Contraindications i. Absolute

1. None ii. Relative

1. Third degree heart block

c. Complications and Adverse Effects i. Dry mouth ii. Tachycardia

d. Dosage and Route

i. Administer repeated doses (no maximum) until secretions resolve : 1. Adult

a. 2-6 mg IV/IO (initial and subsequent doses) 2. Pediatric

a. 0.04 mg/kg, minimum of 0.1 mg, IV/IO (initial and subsequent doses)

e. How Supplied i. 1 mg prefilled syringe ii. 2 mg prefilled autoinjector iii. 8 mg/20 mL multidose vial

II. Calcium Gluconate

a. Indications i. Ocular, dermal, or airway burns due to Hydrofluoric Acid


1. Digoxin Toxicity (only when given IV, no contraindication when topical) ii. Relative

1. Hypercalcemia

c. Complications and Adverse Effects i. Hypercalcemia ii. Irritation and pain at burn sites

d. Dosage and Route

i. Adult and Pediatric 1. Topical

a. Apply Calcium Gluconate 2.5% gel liberally to affected skin surfaces but NOT in eyes.

i. May mix 10 mL 10% Calcium Gluconate with 2 oz of KY jelly to make 2.5% gel.

ii. May place 10 mL 10% Calcium Gluconate inside surgical glove and apply for hand/finger burns.

2. Ocular a. Irrigate with 1% Calcium Gluconate Solution

i. Mix 50 mL 10% Calcium Gluconate in 500 mL NS. ii. Repeat indefinitely.

3. Inhalational a. Nebulize 1 mL 10% Calcium Gluconate mixed with 3 mL NS. b. Repeat indefinitely.

e. How Supplied

i. 1 gram 10% Calcium Gluconate 10 mL vial

III. Methylene Blue

a. Indications i. Severe methemeglobinemia


1. Glucose-6-Phosphate Dehydrogenase Deficiency (G6PD) 2. Allergy

ii. Relative 1. Known methemoglobin reductase deficiency 2. Severe renal failure 3. Cyanide poisoning 4. Cardiac arrest

c. Complications and Adverse Effects i. Nausea ii. Vomiting iii. Headache iv. Blue-green urine v. Hemolysis

d. Dosage and Route

i. Adult and Pediatric 1. 2 mg/kg IV/IO over 5 minutes followed by a minimum of 50 mL normal saline 2. May repeat once in 30 minutes if no improvement.

e. How Supplied i. 10 mg/1mL (1%) solution in 10 mL ampoule

IV. Pralidoxime

a. Indications i. Organophosphate pesticide or unknown cholinesterase inhibitor poisoning with symptoms.



1. Inability to establish airway 2. Myasthenia Gravis 3. Renal Failure

c. Complications and Adverse Effects i. Neuromuscular blockade resulting in laryngospasm, muscular rigidity and tachycardia ii. Nausea iii. Blurred vision iv. Headache

d. Dosage and Route

i. Adult 1. 1-2 grams IV/IO over 10 minutes

ii. Pediatric 1. 40 mg/kg IV/IO over 10 minutes

e. How Supplied i. 1 gm / 20 mL ampoule ii. 600 mg pre-filled autoinjector

V. Sodium Nitrite

a. Indications i. Severe respiratory compromise, shock, seizures, coma or arrest after exposure to

cyanogenic compound.


1. Allergy ii. Relative

1. Significant hypotension 2. Methemoglobinemia > 40% 3. Carbon Monoxide poisoning

c. Complications and Adverse Effects i. Hypotension ii. Headache

d. Dosage and Route

i. Adult 1. 300 mg of 3% Sodium Nitrite (10 mL) diluted in 100 mL of Normal Saline and given

IV/IO over 5 minutes. 2. May repeat once in 20 minutes if no improvement with 150 mg of 3% Sodium Nitrite

diluted in 100 mL of Normal Saline and given IV/IO over 5 minutes. 3. Must be given in conjunction with Sodium Thiosulfate.

ii. Pediatric 1. 0.33 mL/kg of 3% Sodium Nitrite (max 10 mL) diluted in 100 mL of Normal Saline

and given IV/IO over 5 minutes. 2. May repeat once in 20 minutes if no improvement with 0.16 mg of 3% Sodium

Nitrite (max 10 mL) diluted in 100 mL of Normal Saline and given IV/IO over 5 minutes.

3. Must be given in conjunction with Sodium Thiosulfate.

e. How Supplied i. 300 mg in 10 mL (3%) ampoule

VI. Sodium Thiosulfate

a. Indications i. Severe respiratory compromise, shock, seizures, coma or arrest after exposure to

cyanogenic compound.



1. None

c. Complications and Adverse Effects i. Nausea ii. Vomiting iii. Pain at injection site

d. Dosage and Route

i. Adult 1. 12.5 grams IV/IO over 10 minutes 2. May repeat once in 20 minutes if no improvement with 6.25 gm over 10 minutes. 3. Must be given after sodium nitrite.

ii. Pediatric 1. 1.6 mL/kg IV/IO over 10 minutes 2. May repeat once in 20 minutes if no improvement with 0.8 mL/kg over 10 minutes. 3. Must be given after sodium nitrite.

e. How Supplied i. 12.5 gm in 50 mL ampoule

VII. Tetracaine

a. Indications i. Temporary topical anesthesia prior to Morgan Lens insertion.


1. Allergy ii. Relative

1. None

c. Complications and Adverse Effects i. Burning sensation

d. Dosage and Route i. Adult or Pediatric

1. 2 drops to the affected eye(s). May repeat once.

e. How Supplied i. 0.5% solution in 2 mL dropper bottle

Monroe Livingston Regional EMS Policies and Procedures Last Updated December 28, 2009


Section 9

Policies and Procedures

9.0 BASIC PROVIDERS ASSISTING ON ADVANCED PROCEDURES PURPOSE To outline duties that an ALS provider may delegate to a BLS provider during patient care. POLICY 1) A BLS provider may set up the following equipment after successful completion of a training

program as approved by the Agency Medical Director: a) Assembly of IV/IO fluid administration sets to include:

Saline lock Fluids and drip sets

b) Assembly of medication administration devices to include:

Nebulizer devices

c) Application of ALS monitoring equipment to include: Monitoring leads 12-Lead Electrocardiogram Noninvasive automatic blood pressure devices Continuous pulse oximetry devices Continuous waveform capnography devices

2) A BLS provider may use an ALS provider’s blood glucose monitor to determine a patient’s

blood glucose if so trained. BLS providers may independently determine blood glucose only if so trained and the agency for which they are practicing under has approval to carry and use point-of-care blood glucose testing equipment.

3) Under no circumstances shall a BLS provider perform IV cannulation or diagnose electrocardiograms.

4) Even after the completion of any “ALS assistant” program (also known as Assist-A-Tech), the

BLS EMT is not certified to practice beyond the scope of the NYS BLS curriculum. 5) BLS providers shall have the responsibility to decline requests for assistance if they have not

been trained or are not comfortable in providing the assistance. Original December 15, 1997 Revised April 21, 2008


9.1 CANCELLATION OF ALS BY BLS PURPOSE To outline the procedure by which Advanced Life Support (ALS) providers are cancelled appropriately. POLICY 1. Any individual certified at the First Responder or higher level shall have the authority to

request the response of an ALS unit if it has not been dispatched. 2. A responding Advanced Life Support unit may be canceled by an Emergency Medical

Technician - Basic or higher trained pre-hospital provider on scene under the following circumstances:

a. The provider has personally assessed the patient, and; b. The patient does not require evaluation or management by an ALS provider based on

potential injury, medical condition, or complaint, and; c. The ALS unit is not the only responding transporting unit if the patient will need to be

transported. 3. The provider canceling the ALS unit will be responsible for completing appropriate prehospital

documentation, including documenting the cancellation of the ALS unit. 4. Paramedics providing service with a non-transport/non-ALS service shall have the authority

to supersede the BLS provider’s decision to cancel a responding ALS unit. 5. Once the ALS provider has made visual contact with a patient, he/she shall follow the “ALS

Release to BLS” policy. 6. The transporting EMT is ultimately responsible for patient care and may call back a cancelled

ALS unit if they are uncomfortable caring for the patient, regardless of who cancelled the ALS unit.

Original September 1, 2000 Revised March 1, 2003 Revised April 21, 2008


9.2 ALS RELEASE TO BLS PURPOSE On occasion, an ALS provider is dispatched to a call that does not require ALS. Although these instances may be infrequent, the patient should receive an assessment by the ALS provider and the release to BLS must be properly documented and mutually agreed upon by both the ALS and BLS provider. This policy applies to all patients where patient contact has been made and the ALS provider desires to release the patient to a BLS provider or the BLS provider feels ALS is not indicated. Patient contact is defined by the provider’s visual contact with the patient. POLICY An ALS unit (i.e. an ambulance or first response unit staffed by an EMT-CC or EMT-P technician and certified to operate at the ALS level) who makes patient contact may transfer care of a patient to a BLS unit according to the following procedure: 1. The ALS technician will complete a focused assessment on the patient. This will include:

a. Focused subjective assessment including history of the problem. b. Complete medical history including current medications, allergies, and recent hospitalizations. c. Assessment of all pertinent systems. d. A complete set of vital signs including blood pressure, pulse, respirations, level of consciousness, and

skin color/temperature.

2. The ALS technician will assure that the patient’s condition does not currently, and will likely not in the reasonably near future, warrant pre-hospital ALS-level care (to include pain control).

3. The ALS technician will assure through verbal conference with the BLS crew that they are comfortable

assuming care of the patient. 4. The ALS technician will complete a PCR which includes full documentation of the assessment performed,

physical findings, pertinent negatives, and vital signs. In cases where both the BLS unit and the ALS provider are from the same agency, it is acceptable for the ALS assessment to be completed as an addendum on the transporting provider’s PCR.

Considerations 1. The ALS technician must accompany the patient to the hospital if the BLS crew expresses any discomfort with assuming care for the patient. This is regardless of whether or not the ALS technician believes any ALS procedures are warranted. However, it is the obligation of the BLS crew to state if they are not comfortable with managing the patient. 2. The ALS provider may not use tests to rule out pathology. For example, a normal 3 or 12 lead EKG does not

rule out the presence of myocardial infarction or other cardiac emergency. Acquisition of an EKG should not be used as a determining factor for whether a patient may be released to BLS care. Similarly, normal SpO2 or EtCO2 do not rule out respiratory disorders.

3. It is the responsibility of the ALS technician on scene to contact Medical Control if there is any debate as to

the appropriateness of the release to BLS. Original December 15, 1997 Revised April 21, 2008


9.3 MANAGEMENT OF VIOLENT AND POTENTIALLY VIOLENT BEHAVIOR PURPOSE To define the techniques that may be used for the management of violent and potentially violent patients. Underlying this policy is the expectation that the safety of pre-hospital personnel is paramount and at no time should the provider put their safety in jeopardy. POLICY 1. Responders should apply the following techniques on every call to promote their safety and the safety of

those around them: Use an established panic code with a communications center and other responders when in a life-

threatening circumstance to summon rapid law enforcement response. Have two means of communication with a communications center at all times Ensure that location changes are reported to a communications center Be aware of an exit route from the scene Have a plan for an alternate source of cover or concealment Have dogs and other potentially hostile animals secured Scan the scene for improvised weapons Be alert to the body language of all persons on the scene Treat the patient in an alert posture to be able to defend or escape

2. Law Enforcement should be requested for situations where EMS providers have a high index of suspicion that

violence may occur. 3. Patient contact may be delayed if the responders believe the scene may be unsafe based on either dispatch

information or a scene size up. EMS units should stage out of sight from any potential hostile incident and notify the communications center of their staging location.

4. If patient contact is delayed due to a potentially dangerous environment, it should be reported to the

communications center and documented on the PCR with both the reason and the time. 5. If an EMS provider is already on the scene and the situation becomes hostile, the providers should exit the

situation to a safe area until law enforcement can establish order on the scene. 6. EMS personnel should consider potential medical causes for the hostile reaction including hypoxia,

hypoglycemia, and postictal state. The causes, once identified, should be treated according to the Standards of Care.

7. If exit is not practicable, the providers should verbally direct the hostile party(ies) to stop their actions. These

directions should be specific, direct, and respectful. Responders should be prepared to seek exit or refuge, and should request expedited assistance from law enforcement.

8. Physical confrontations between EMS providers and the public should be avoided. EMS providers should exit

the situation expeditiously should the situation escalate to violence. It is acceptable to leave behind equipment and the patient if necessary to ensure scene safety. The EMS providers should reengage in patient care as soon as the scene is safe.

Continued on Next Page


9.3 MGMT OF VIOLENT & POTENTIALLY VIOLENT BEHAVIOR, CONTINUED 9. If a physical confrontation can not be avoided, EMS providers may defend themselves, the other responders,

and the patient. The confrontational physical contact must be limited to the amount of force reasonably expected to ensure the safety of everyone on scene and the physical contact should be defensive in nature. The use of improvised weapons (such as large metal objects including flashlights and oxygen cylinders) must only be in defense of responders or civilians on scene, when one reasonably believes there is an imminent danger of death or serious physical injury. On duty possession or use of traditional weapons (pepper spray or similar, TASER, firearm, bludgeons, or edged weapons) are strongly discouraged and must be conducted only within a specific written policy approved by the agency operations staff and medical director. If there is any physical contact resulting from a confrontation with a violent person, the EMS responders must document the situation thoroughly and report it as per the agency’s policies. Incidents resulting in physical injury to the patient must be reported to the New York State Bureau of EMS consistent with the policies outlined in Part 800.21.

10. Patient restraint may be performed with law enforcement personnel or under the order of a Medical Control

Physician. Assess the patient’s need for restraint in collaboration with the on-scene police agency. Prior to restraining a patient, explain to the patient and patient’s significant other(s) the reason for restraint use. Select the least restrictive device possible, but one that will ensure the patient cannot harm themselves or others. Maintain constant, direct supervision of the restrained patient

11. Patients must be restrained in a supine or lateral recumbent position. Patients must be restrained using a soft

restraint (such as a cravat or spiral gauze) or handcuffs provided by law enforcement. Handcuffs or plastic bands should be replaced with cloth or leather restraints if feasible. A means for removing the handcuff (keys) or plastic band (removal device) must be present at all times to allow removal. The restraints should be secured to a non-moving portion of the patient carrying device. All limbs should be restrained. It may be appropriate to place a belt around the patient’s thighs, pelvis, and chest however these belts must not restrict chest expansion.

12. Once restraints are applied, the EMS providers must regularly reassess vital signs, and circulatory, motor,

and sensory status distal to the restraints. Restrained extremities must be monitored for constriction, ischemia, or other signs of injury. The patient’s medical status must be continuously monitored. The patient must never be left alone.

13. If the patient is spitting, it is appropriate to apply a “Spit Sock” or non-rebreather mask with flaps and reservoir

removed. The EMS provider must constantly monitor the patient’s airway, respiratory status, and level of consciousness.

14. Depending on the situation, law enforcement may follow the ambulance to the hospital. If at any time the

provider in charge of patient care is not comfortable in transporting a patient alone in the back of the ambulance, law enforcement should be requested to ride along.

15. Advanced Life Support and pharmacological intervention may be indicated. Refer to the MLREMS Standards

of Care for indications and dosage.




9.3 MGMT OF VIOLENT & POTENTIALLY VIOLENT BEHAVIOR, CONTINUED 16. Documentation is expected to include the following:

Steps taken to control patient prior to use of physical restraints, including the reasons restraints were needed and why less restrictive measures were unable to be utilized.

Baseline skin color and integrity prior to application of restraints. The time restraints were applied. Pertinent observations including vital signs and any changes in behavior. Name of police agency, and if possible, name of police officer. Vital signs and patient evaluation must be documented every 5 minutes for restrained patients, or every

15 minutes for stable, non-restrained patients.

9.4 RAPID SEQUENCE INDUCTION PROGRAM PURPOSE The Monroe-Livingston Region’s Rapid Sequence Induction Program (RSI Program) provides advanced airway capabilities, specifically rapid sequence induction and intubation, to properly identified patients potentially requiring such definitive airway management. POLICY I. Overview Rapid Sequence Induction has been used in the hospital setting for years to help provide the highest possible intubation success rate for patients undergoing emergent intubation. Its use in the pre-hospital setting has been the subject of significant research and this program is established after a review of the medical literature and best practices existing in other parts of the country. The Rapid Sequence Induction Program (RSI Program) exists to provide RSI services to Monroe and Livingston Counties in a careful, safe, and controlled fashion. It is important to recognize that the successful performance of a RSI procedure does not imply appropriateness of the procedure. II. Authorization The program is authorized by the Monroe-Livingston REMAC and overseen by the Regional EMS Medical Director and the REMAC QA Sub-Committee. As such, the RSI Program is a regional program, not one implemented at the agency level. The Regional EMS Medical Director may designate additional physicians to supervise the implementation, quality assurance, and continuing education requirements of the RSI program. Individuals and agencies provide RSI as an added service under the oversight of the REMAC QA Committee and the Regional EMS Medical Director. Failure to follow these regulations will lead to the penalties described in this policy, including revocation of RSI credentials for the paramedic and/or the agency. III. Medical Care This policy does not define the manner in which the RSI procedure is performed. The “RSI Protocol”, as defined in the most recent edition of the Monroe/Livingston Regional EMS System Standards of Care, shall be the sole authority on how such a procedure is performed in the pre-hospital setting. Both the RSI Protocol and RSI Policy and Procedure here are to be used ONLY by individuals currently credentialed as an RSI-Paramedic while working for an RSI authorized agency. They are not to be used for routine Advanced Life Support care. IV. Credentialing Requirements A. RSI Agency

A RSI Agency is one that maintains the following criteria: 1. Has unrestricted authorization from the NY State Department of Health and the Monroe-Livingston

County REMAC to provide Advanced Life Support care. 2. Has unrestricted authorization from the NY State Department of Health to carry and administer controlled

substances to patients. 3. Has agreed to abide by the RSI Protocol and the RSI Policies and Procedures approved by the Monroe-

Livingston REMAC, including agreeing to provide the RSI Paramedic the proper medications and equipment as detailed in the Protocol and following all QA requirements as detailed in this Policy.

4. Has agreed to make RSI Paramedics available to all EMS agencies in the region when RSI skills may be required.

5. Has been approved by the Monroe-Livingston County REMAC to provide RSI.

Participating in the RSI Program is equivalent to agreeing to these criteria.


9.4 RAPID SEQUENCE INDUCTION PROGRAM, continued B. RSI Paramedic

An RSI Paramedic is an individual who is credentialed to provide RSI services to patients in the Monroe-Livingston EMS Region. The following credentialing process occurs at the level of the Monroe-Livingston Region. RSI Agencies can and are encouraged to create their own clearance process for RSI Paramedics. However, no paramedics can provide RSI services at any agency if they are not credentialed at the regional level. To act as an RSI Paramedic, the individual must practice with an agency authorized to provide RSI care. Thus, an RSI Paramedic practicing with an agency that does not provide RSI services cannot perform RSI on a patient.

The RSI Paramedic or RSI Agency is responsible for any costs required for maintaining their credentialing.

C. Credentialing Process

1. Initial Credentialing The following are required to be considered for practice as an RSI Paramedic:

1. Active practice as a paramedic for a minimum of four years and two years in the Monroe

Livingston System; 2. Be in good standing with REMAC QA Committee; 3. Have a letter of recommendation from the Agency ALS Chief; 4. Have a letter of support from the Agency Medical Director; 5. Have a current NY State Paramedic certification; 6. Have a current ACLS certification; 7. Have a current PALS/PEPP certification; 8. Provide RSI service availability with an RSI Agency in the Monroe-Livingston Region on average

a minimum of 20 hours a week per 12 month rolling average.

A formal application for entry into the RSI Program will be available through the Division of Prehospital Medicine at the University of Rochester and must be completed prior to consideration. All RSI applicants will be reviewed by the Regional EMS Medical Director. Providers will be considered for enrollment in the program based upon their quality of clinical care, the thoroughness and accuracy of their documentation, and their procedural and clinical competency. The Regional EMS Medical Director may request documentation from the sponsoring agency to substantiate the provider’s documentation and clinical skills. Providers meeting the clinical and documentation expectations of the Regional EMS Medical Director may be invited to a Paramedic RSI Class and Procedural Skills lab which must be successfully completed to enter in the program. RSI providers will be added to the system in a quantity and at a time dictated by the Regional EMS Medical Director to ensure the most appropriate distribution of providers within the Monroe-Livingston Region.

2. Transfer of Credentials

Experienced RSI Providers requesting transfer of RSI credentials from another agency must meet the qualifications of 9.4 C 1, 1-8 and submit a formal application as outlined. Providers who, upon review and recommendation of the Regional EMS Medical Director, have the experience and who exhibit the desired clinical judgment necessary may be granted standing as an RSI provider in the Monroe-Livingston EMS Region after having demonstrated competency in their knowledge of MLREMS RSI protocols/policies, as judged by the Regional EMS Medical Director. The Regional EMS Medical Director has complete discretion on who may be considered and approved, without appeal. Providers who have been credentialed after the beginning of the training year must complete a pro-rated number of hours, as determined appropriate by the Regional EMS Medical Director for the first year of


9.4 RAPID SEQUENCE INDUCTION PROGRAM, continued

2. Transfer of Credentials (Continued) their participation in the MLREMS RSI program. All requirements for maintaining credentialing as an RSI provider must be met for subsequent calendar years. 3. Maintenance of Credentials RSI Paramedics must meet all initial credentialing requirements at all times. It is the responsibility of the RSI Paramedic and the RSI Agency for whom they operate to report noncompliance with these criteria. Failure to meet any of these criteria at any time immediately revokes the RSI Paramedic’s credentials to provide RSI services to the community. This change must immediately (within one business day) be reported in writing to the RSI Agency ALS Chief, the Agency Medical Director, and the Regional EMS Medical Director. If in the case that a RSI provider does not meet the requirements as stipulated and the Agency and its Medical Director feel that a variance is recommended to maintain the RSI Provider status, this should be forwarded in writing to the Regional EMS Medical Director. All RSI Paramedics must fulfill all requirements of initial credentialing and successfully complete a minimum of 12 hours of RSI continuing education per calendar year that is approved by the Regional EMS Medical Director. RSI Paramedics will be continuously reviewed and may be suspended from the program at any time for not meeting the continuing education requirements, or the documentation, clinical, or procedural expectations of the Regional EMS Medical Director. Suspension of RSI privileges can be appealed to the System Medical Director but he/she is under no obligation to change the recommendation and approve any RSI Paramedic. Reinstatement to the program will be considered on a case-by-case basis.

4. Considerations Criteria for maintaining credentials may be altered based on the latest research on RSI proficiency. Any changes to the program will result in e-mail notification of credentialed RSI providers by the Regional EMS Medical Director. All RSI Paramedics are encouraged to track their own intubations of all kinds (RSI and non-RSI). Paramedics who are regional preceptors may track non-RSI intubations during which they precept other ALS technicians, but must note that it was a precepted intubation.

V. Continuing Education

Continuing education is a key component to the maintenance of RSI proficiency. It must include both practical and didactic education. It is the responsibility of the RSI Paramedic to ensure that he/she meets the continuing education requirements described within this policy.

The Division of Prehospital Medicine at the University of Rochester will provide RSI continuing education programs that meet the demands of the current research on the subject of RSI and the needs of the REMAC. The Regional EMS Medical Director may designate one or more individuals to serve as “RSI Preceptors” to facilitate both the initial training and clearance of providers as well as assist with the provision of continuing education.

An RSI provider must successfully complete 12 (twelve) hours of RSI-Specific CME per Calendar Year. This includes a minimum of 2 (two) hours of cadaver lab and 4 (four) hours of skills review under the supervision of a physician. No more than 4 hours of annual CME may be self-directed. All CME not sponsored by the Division of Prehospital Medicine must be approved by the Regional EMS Medical Director prior to the start of the class.

Agencies that provide RSI services must sponsor a minimum of 2 hours of RSI-specific continuing education per calendar year that is open to all RSI providers in the region and approved in advance by the Regional EMS Medical Director. Failure to do so will result in the agency losing RSI status.


9.4 RAPID SEQUENCE INDUCTION PROGRAM, continued VI. Operations A. Requesting RSI Paramedic Assistance

Any level provider can request assistance from an RSI Paramedic via their agency dispatch or via the Monroe or Livingston County 911 Center. All dispatch centers should establish a protocol to identify and send the nearest RSI Paramedic in a safe and efficient manner.

B. Actions on Arrival All RSI Paramedics should thoroughly evaluate the setting and patient upon arrival at the patient’s side. He / she must consider all issues as detailed in the RSI Protocol.

Considerations of note include:

1. Consideration of BLS and ALS airway options—The RSI Paramedic must evaluate and ensure that all BLS airway options and ALS airway options have been considered. These considerations must be documented on the PCR.

2. Proximity to hospital ED—Transport to the ED should not be significantly delayed to RSI the patient.

3. Indications have been met and contraindications have been excluded. 4. Anticipated difficulty of RSI—the need for RSI in patients expected to be very difficult intubations

should receive particular consideration. 5. Medical control authorization—Medical Control exists to discuss the case and determine the best

options for the patient.

If the patient is felt to need RSI, Medical Control authorization must be obtained (absolute on line, no exception for radio communications failure), and then the protocol should be followed. If the patient is not felt to need RSI, the RSI Paramedic must transport with the patient to monitor for further deterioration of the patient’s respiratory status.

C. After-Call Actions

After-call actions include a combination of detailed documentation and verbal debriefing with a designated physician. The intent of this process is to ensure that quality patient care is delivered, any RSI Paramedic issues are immediately noted, and detailed clinical information is obtained. As detailed below, some debriefing will occur immediately after care is provided, while other debriefing will occur when possible after care is provided.

1. Patients Receiving RSI

After completing the RSI, whether the procedure is successful or not, and transferring care to the ED, the RSI Paramedic is responsible for the following:

a. PCR—A thorough and complete PCR must be completed immediately. The PCR must include

the reasoning behind performing the RSI, response to the BLS and ALS airway options, and medical control authorization.

b. RSI Quality Assurance Form—The Monroe Livingston Region RSI QA Data Form must be completed and submitted with a copy of the PCR to the Regional EMS Medical Director within two business days for RSI Agencies not using emsCharts. For agencies using emsCharts, agencies shall participate in the QA process by utilizing a quality assurance research module designed specifically for the RSI program. For agencies using emsCharts, completion of a separate Quality Assurance form will not be required.


9.4 RAPID SEQUENCE INDUCTION PROGRAM, continued

c. Debriefing – After transfer of care, the On-Call EMS Medical Director must be paged via either the agency dispatcher or the 911 Dispatch Center. A debriefing will be immediately performed. If the On-Call EMS Medical Director is not immediately available, then the Regional EMS Medical Director should be paged.

2. Patient for Whom RSI Was Not Needed

In some cases, either the RSI Paramedic or Medical Control will decide that RSI was not indicated. In the event that this occurs, the RSI Paramedic is responsible for the following:

a. PCR—A thorough and complete PCR must be completed immediately. The PCR must include

the reasoning behind not performing the RSI, response to the BLS and ALS airway options, and medical control discussion (if applicable).

b. RSI Quality Assurance Form—The Monroe Livingston Region RSI QA Data Form must be

completed and submitted with a copy of the PCR to the Regional EMS Medical Director within two business days for RSI Agencies not using emsCharts. For agencies using emsCharts, agencies shall participate in the QA process by utilizing a quality assurance research module designed specifically for the RSI program. For agencies using emsCharts, completion of a separate Quality Assurance form will not be required.

c. Should the RSI Paramedic wish to discuss the call, they are to contact the On-Call EMS Medical Director or the Regional EMS Medical Director.

VII. Quality Assurance The Monroe Livingston Regional RSI Quality Assurance Program includes immediate debriefing of the RSI Paramedic with a physician after successful or unsuccessful RSI. It further includes reporting and debriefing of requests for RSI in which an RSI was not performed. A detailed Quality Improvement Tool (the Monroe Livingston Region RSI QA Data Form or emsCharts Research Module) is to be completed by an RSI Paramedic immediately after the transfer of patient care, and is to be included with a copy of the PCR to the Regional EMS Medical Director. The Regional EMS Medical Director will review all calls in which both successful and unsuccessful RSI’s were performed, as well as all calls where a RSI Paramedic was requested but the patient did not meet RSI criteria. The Regional EMS Medical Director will advise the REMAC QA Committee and System Medical Director of any patient care concerns or trends observed system-wide that may benefit by additional training or modification to existing medical care protocol. The Regional EMS Medical Director has the responsibility and authority to advise the REMAC QA Committee of any RSI Paramedic that should be restricted from providing the RSI procedure. Furthermore, the On-Call Medical Director that debriefs the RSI Paramedic at the time of the procedure has the authority to immediately suspend an individual’s RSI privileges should it be required. Doing so requires immediate notification of the System Medical Director, Agency Medical Director, and Agency Operations Director, as well as written documentation submitted to the Division of Prehospital Medicine for distribution to the above parties within three business days. Changes to this policy and the RSI Protocol will be done in accordance with the available literature, best standards, and intensive continuing review of all RSI procedures performed in the Monroe-Livingston region. Original September 18, 2006 Revised April 21, 2008 Revised October 20, 2008 Revised February 21, 2011

9.5 REFUSAL OF TREATMENT/TRANSPORT POLICY PURPOSE This policy outlines the evaluation of a patient refusing treatment or transport and the documentation expected when obtaining such a refusal. POLICY I. Overview A patient is defined as a person encountered by EMS personnel with an actual or potential injury or medical problem. “Encountered” refers to visual contact with the patient. These persons may have requested an EMS response or may have had an EMS response requested for them. Due to the hidden nature of some illnesses or injuries, an assessment should be performed on all patients. For patients initially refusing care, an attempt to evaluate the individual, even if only by visual assessment, is expected and must be documented. II. Evaluation The evaluation of any patient refusing medical treatment or transport should include the following:

1. Visual Assessment – To include responsiveness, level of consciousness, orientation, obvious injuries, respiratory distress, and gait.

2. Initial Assessment – Airway, breathing, circulation, and disability. 3. Vital Signs – Pulse, blood pressure, respiratory rate and effort. Pulse oximetry and/or blood glucose when

clinically indicated. 4. Focused Exam – As dictated by the patient’s complaint (if any). 5. Medical Decision Making Capacity Determination – As defined below.

Patients at the scene of an emergency who demonstrate capacity for medical decision making shall be allowed to make decisions regarding their medical care, including refusal of evaluation, treatment, or transport. In order to ensure that a patient exhibits the capacity for medical decision making, the patient must have the ability to understand the nature and consequences of their medical care decision. A patient, who is evaluated and found to have any one of the following conditions, shall be considered incapable of making medical decisions regarding care and/or transport and should be transported to the closest appropriate medical facility under implied consent:

1. Altered mental status from any cause including altered vital signs, intoxication from drugs and/or alcohol, presumed metabolic causes (ingestion, hypoglycemia, stroke, etc), head trauma, or dementia.

2. Age less than 18 unless an emancipated minor or with legal guardian consent. 3. Attempted suicide, danger to self or others, or verbalizing suicidal intent. 4. Acting in an irrational manner, to the extent that a reasonable person would believe that the capacity to make

medical decisions is impaired. 5. Severe illness or injury to the extent that a reasonable and medically capable person (or, for a pediatric patient,

the parent/guardian) would seek further medical care. 6. When appropriate documents are signed and patient is placed under involuntary commitment pursuant to Article 9

of the New York State Mental Hygiene Law. Patient consent in these circumstances is implied, meaning that a reasonable and medically capable adult would allow appropriate medical treatment and transport under similar conditions. Providers who identify a patient requiring transport under implied consent and are refusing to do so may require Medical Control consultation and Law Enforcement involvement to ensure the patient is transported to an appropriate emergency facility for evaluation. Medical care should be provided according to the most recent edition of the Monroe-Livingston Regional EMS Standards of Care.



9.5 REFUSAL OF TREATMENT/TRANSPORT POLICY, CONTINUED Once a patient assessed to lack decisional capacity is transported under implied consent to the appropriate emergency facility, another determination of decisional capacity may be required for continued involuntary care and treatment. Patients exhibiting the following at risk criteria should receive particular attention to an appropriate evaluation and risk/benefit discussion prior to not transporting and the EMS provider should consider medical control consultation prior to obtaining a refusal:

1. Age greater than 65 years or less than 2 months. 2. Pulse > 120 or <50. 3. Systolic blood pressure >200 or <90. 4. Respirations >29 or <10. 5. Serious chief complaint (chest pain, SOB, syncope). 6. Significant mechanism of injury or high suspicion of injury.

Patients exhibiting medical decision making capacity and wishing to refuse care/transport may do so after the provider has assured the following have been completed:

1. Determined the patient exhibits decisional capacity to refuse care/transport. 2. Offered transport to a hospital. 3. Explained the risks of refusing care/transport. 4. Explained that by refusing care/transport, the possibility of serious illness of death may increase. 5. Advised the patient to seek medical attention and gave instructions for follow-up care. 6. Confirmed that the patient understands these directions. 7. Ensured that the patient signed the Refusal of Treatment/ Transport Form or documented why it was not signed. 8. Left the patient in the care of a responsible adult when possible. 9. Advised the patient to call 911 with any return of symptoms or if they wish to be re-evaluated and transported to

the hospital. III. Medical Control The EMS provider should consider consulting Medical Control if the patient does not wish transport. The purpose of the consultation is to obtain a “second opinion” with the goal of helping the patient realize the seriousness of their condition and accept transportation. Medical consultation is highly recommended for the following:

1. The provider is unsure if the patient is medically capable to refuse treatment and/or transport. 2. The provider disagrees with the patient’s decision to transport due to unstable vital signs, clinical factors

uncovered by the assessment, or the provider’s judgment that the patient is likely to have a poor outcome if not transported (See at risk criteria, above).

Medical Control consultation is required for the parent or legal guardian refusing transport of a child being evaluated for an Acute Life Threatening Event (ALTE). IV. Documentation Patient refusals are the highest risk encounters in clinical EMS. Careful assessment, patient counseling, and appropriate Medical Control consultation can decrease non-transport of high-risk refusals. Paramount to the decision-making involved in a patient refusal of treatment and/or transport is the documentation of that refusal.



9.5 REFUSAL OF TREATMENT/TRANSPORT POLICY, CONTINUED Documentation is expected to include:

1. Documentation of the provider’s assessment, the treatment provided, reasons for refusal, and Medical Control consultation as appropriate on the Prehospital Care Report.

2. Completion of the Monroe-Livingston EMS Region Refusal of Treatment/Transport Form: a. Identify the agency name. b. Identify the date of the incident. c. Identify the PCR associated with the refusal. d. Appropriately mark the boxes indicating Medical Decision Making Capacity Determination. Any boxes

checked “yes” indicate that the patient cannot refuse treatment and/or transport as they lack decision making capacity.

e. Identify any Absolute On-Line Medical Control criteria and any high risk criteria that may benefit by Medical Control Consultation.

f. Identify the reason for refusal of care and/or transport and directions for follow-up care in the PCR. g. Print, sign, and indicate the provider’s EMT number after completing the items on the Patient Refusal

Checklist. h. Have the patient print, sign, date, and time the release form. Should the patient refuse to sign, check the

“Patient refused to sign” box. A witness should still sign. i. Have a witness sign the release form.

3. Provide the patient with a Patient Refusal Information Card (If available)

4. Attach the refusal form to the PCR (electronically or paper)

For agencies using an electronic medical record and a device capable of capturing patient and provider signatures electronically in the field, the agency may use a modified Monroe-Livingston EMS Region Refusal of Treatment/Transport Form for use on such an electronic device as approved by the Regional Medical Director or his/her designee. Associated Documents:

1. MLREMS Refusal of Treatment/Transport Form 2. MLREMS Refusal of Treatment/Transport Information Card

Policy Approved October 15, 2007 Policy Effective January 1, 2008 Policy Reaffirmed April 21, 2008


9.6 AGENCY POLICY EXPECTATIONS PURPOSE To identify the written policies expected of EMS agencies that serve the Monroe-Livingston Region. POLICY All agencies should have internal policies that address the following (NYS DOH BEMS Policy numbers are listed if available): 1. Vehicle Safety (07-07, 00-13)

a. Requirements and eligibility for driving an emergency vehicle b. Initial and recurrent training c. Use of safety restraints by crew, patients, passengers, and equipment d. Expected speeds and use of emergency response mode e. Idling of ambulances (05-01) f. Vehicle preventive maintenance (02-11)

2. Infectious Disease (02-09, 99-06, SARS 05-01, 03-11) (OSHA 1910.1030 Blood borne pathogens standard). a. Prevention and use of universal precautions b. Disposal of contaminated supplies c. Cleaning of contaminated durable equipment d. Disinfection of contaminated vehicles including the process and schedule for monthly deep-cleaning e. Exposure reporting f. Initial and recurrent training requirements

3. Mandatory Reporting a. Child Abuse (02-01) b. AED use (PAD Agencies only)

4. Sexual Harassment (00-11) 5. Smoking (00-07) 6. Hazardous Materials Response Plan (OSHA 1910.120, 1910.1200) 7. Quality Assurance (QA) (NYS Workbook and Guidance Document Version 1, 2007)

a. Composition of QA Committee b. Procedure for referral and evaluation of care provided c. Procedure for corrective action/remediation d. Procedure for complaint tracking and resolution e. Procedure for vehicle and equipment failure reporting

8. Medical Equipment a. Durable medical equipment preventive maintenance (02-11) b. Training and quality assurance for BLS determination of BG (05-04) c. Process for vehicle equipment checking d. Storage of medications (00-15, 00-14, 00-06)

i. Maximum/minimum temperature ranges and policy for their documentation and replacement. ii. For controlled substances, the means of accountability and secure storage as well as compliance with all

parts of NYS Part 80. Original April 21, 2008


9.7 CARBON MONOXIDE EVALUATION USING HANDHELD CO-OXIMETRY

PURPOSE The mere presence of carbon monoxide (CO) detected in a building or confined space cannot accurately predict the amount of CO in an individual. Previously, the only means to determine the level of carbon monoxide in the bloodstream was to obtain a blood sample and use an arterial blood gas analyzer with co-oximetry capabilities. As a result, many patients that were exposed to CO in the field were transported to the hospital for measuring a CO level when in fact their levels may be negligible. This policy is created to instruct the EMS provider on the use of the Masimo Rainbow SET Rad-57 Pulse CO-Oximeter. The CO-Oximeter is an optional device for prehospital use in the Monroe-Livingston Region and its use and interpretation is defined by this policy. This policy is not for use by personnel undergoing emergency incident rehabilitation. POLICY I. Indications The Co-Oximeter may be used on any patient greater than 30 kg where there is a concern for carbon monoxide exposure. II. Contraindications Weight <30 kg III. Instructions for use The Rad-57 Rainbow SET Pulse CO-Oximiter is a non-invasive, arterial oxygen saturation and pulse rate monitor. It features a multicolored LED display that continuously displays numeric values for SpO2 and pulse rate, a Low Signal IQ Indicator (Low SIQ), LED indicator bars for Perfusion Index (PI), Carboxyhemoglobin saturation (%SpCO), alarm status, alarm silence, battery life, and SpCO sensor connected indicators.

1. Connect the sensor cable to the Patient Cable Connector of the oximeter. Make sure the connection is secure and the cable is not twisted, sliced, or frayed.

2. Remove any substances (nail polish, paint, etc) on the patient’s second, third, or fourth digit that may interfere with the transmission of light between the sensor’s light source and photo detector.

3. Attach the sensor to the patient, applying it to the index (second), middle (third), or ring (fourth) digits. Only these digits can be accurately used by the CO-Oximiter.

4. Press the Power button ON. The machine will go through a self-test procedure that will last approximately 10 seconds.

5. The device will default to displaying the pulse rate and SpO2 when it is turned on. Verify that these are accurate readings by checking the patients pulse and clinical picture before continuing. The SpO2 low alarm limit defaults to 90%.

6. Pressing the SpCO button will display the numeric SpCO value for 10 seconds in place of the SpO2 numeric value.

7. Once monitoring is complete, remove the sensor from the patient and turn the device off. Wipe the sensor and device with a soft cloth dampened with mild soap and water. Never submerge the sensor or the monitoring device.

8. When examining multiple patients, turn the device OFF then ON to recalibrate between patients.



9.7 CARBON MONOXIDE EVAL, HANDHELD CO-OXIMETRY, CONTINUED The front panel controls are identified and described in the following diagram:



9.7 CARBON MONOXIDE EVAL, HANDHELD CO-OXIMETRY, CONTINUED IV. Considerations 1. Cyanide toxicity and methemeglobinemia cannot be readily determined by this handheld device. The CO-Oximeter should be used in addition to clinical judgment and a normal reading in the setting of a patient with

severe respiratory distress or cyanosis should not rule out a significant oxygen-transfer deficit (cyanide, methemeglobinemia, sulfhemoglobinemia, or profound anemia) requiring aggressive airway management and high-flow oxygen. Always treat the patient first and not the reading on the CO-Oximeter.

2. The device is not intrinsically safe and should not be used in the presence of flammable substances. 1. If the device indicates a “Low SIQ,” this refers to a low signal IQ and flashes when the SpO2 and SpCO

measurements may be compromised. If this occurs:

a. Reassess the patient. b. Check the sensor to ensure it is properly applied to the patient and inserted into the RAD- 57 device. c. Determine if an extreme change in the patient’s physiology and blood flow at the monitoring site has occurred

(e.g. an inflated blood pressure cuff, tourniquet, severe hypotension, hypothermia, or cardiac arrest). d. After completing this check, if the “Low SIQ” indication occurs frequently or continuously, you cannot rely on

the device for either SpO2 or SpCO levels. 4. The Perfusion Index (PI) is a relative assessment of perfusion at the monitoring site. PI is displayed on a 10 segment

LED bar on the right of the display ranging from <0.1% (very weak perfusion) to >5% (strong perfusion). The PI is shown as a “bouncing bar” indicator, where the peak of the bar coincides with the peak of an arterial pulsation. The highest LED will remain lit continuously to allow a PI level to be viewed. If evidence of low perfusion (<1%) is frequently displayed, find a better perfusion monitoring site and be sure the sensor is placed properly and there are no substances on the finger that could impede the emitter and photo detector. Very high ambient light situations can also produce falsely low PI. Should a low PI be persistent after these measures, review the procedure for “Low SIQ” above. If a low PI still persists you cannot rely on the device for either SpO2 or SpCO levels.

V. Interpreting CO Values 1. The SpCO reading is to be used as a screening measure. Definitive carboxyhemoglobin determinations are

performed via blood draw in the hospital setting. Any patient with suspected carbon monoxide poisoning should receive oxygen by a non-rebreather mask until their CO level can be determined.

2. Any patient with airway compromise, respiratory distress, or symptoms of significant carbon monoxide poisoning (nausea, vomiting, loss of judgment, chest pain, dizziness, muscle weakness, or a change in mental status) should be treated according to the MLREMS Standards of Care and transported with high-flow oxygen to an emergency department regardless of the SpCO reading.

3. Pregnant women are at high risk in carbon monoxide exposure. The fetus is highly susceptible and the SpCO may be 10-15% higher than maternal readings. All pregnant women with possible CO exposure should be transported to the emergency department for evaluation.

4. Any patient with a SpCO reading >12%, even if without symptoms, should be transported with high-flow oxygen to an emergency department.

5. Any patient with a SpCO reading >25%, even if without symptoms, MUST be transported with high-flow oxygen to an emergency department.



9.7 CARBON MONOXIDE EVAL, HANDHELD CO-OXIMETRY, CONTINUED 6. Patients with carbon monoxide exposure and SpCO <25% may be treated and released provided the following

conditions are met: a. The patient is asymptomatic. b. The patient exhibits no signs of respiratory distress, and pulse oximeter reading is above 92%. c. The SpCO must be below 5% in non-smokers, and 10% in smokers. d. The lungs are clear on auscultation. e. There are no other significant burn or traumatic injuries. f. Both the pulse oximetry and the CO levels must be documented. g. The patient has medical decision making capacity per the MLREMS Refusal of Care Policy.

VI. Documentation Use of the Rad-57 and serially recorded SpCO levels should be documented accordingly in the Prehospital Care report. It cannot be emphasized enough that the patient’s clinical presentation is what should drive routine medical care and not the SpCO level observed. If there is ever doubt regarding the patient’s disposition, provide high flow oxygen and transport to the hospital for evaluation. Original April 21, 2008


9.8 USE OF EMERGENCY MEDICAL DISPATCH PURPOSE To establish the recommended standard with which emergency requests for emergency medical service are processed. POLICY 1. All telephone requests for emergency medical care received in Monroe or Livingston Counties should be processed

using an Emergency Medical Dispatch (EMD) program. Such a program should assure the following:

a. EMD is used as an integral part of every EMS call receipt and dispatch process. b. Emergency Medical Dispatchers handle all calls and are trained in the principles and procedures of EMD

following the standards of a recognized curriculum. c. A nationally recognized EMD reference system is used which includes standardized caller interrogation and

pre-arrival instructions. d. There are written policies and procedures for call receipt, call processing, and dispatch of resources based on

the identified patient need. This should include the time frames for call processing, a priority assignment of resources based on need and availability, simultaneous dispatch of resources, ALS intercept, mutual aid, Mass Casualty Incidents, etc.

e. There are written policies for maintaining documentation including voice and text records compliant with state requirements.

f. There are written policies and procedures for variance investigation and an EMD quality improvement program.

g. There is an identified physician Medical Director who is an active participant in the regional EMS system and is familiar with EMD dispatch principles and the local EMS system. This physician shall also be responsible for the medical component and quality improvement of the EMD program.

h. Emergency Medical Dispatch should be used to determine the level of response and that level should balance the need of the patient and risk to the community.

2. Any public safety agency (law enforcement, fire, and emergency medical service) that does not refer calls for

emergency medical care to an EMD-enabled Public Safety Answering Point should have in place a written policy outlining the process used to handle telephone requests for emergency medical care and providing pre-arrival instructions. This policy should be written with and approved by the agency Medical Director.

Original April 21, 2008


9.9 PUBLIC ACCESS DEFIBRILLATION PURPOSE To outline the responsibilities of Public Access Defibrillation (PAD) agencies and NYS certified agencies that own or operate an AED. POLICY 1. Definition

a. Certified Agency – Any transporting agency or any agency that is an ILS/ALS first response agency. b. PAD Agencies – All others, including BLS first-response agencies, physicians’ offices, health clubs, public

meeting places, etc. 2. Event Reporting

a. PAD Agencies are required to fill out an event form and forward it to the MLREMS Program Agency along with a copy of the AED report within 48 hours of its use.

b. Certified Agencies are not required to fill out an event form but must complete requisite prehospital documentation (eg a PCR).

3. Regulations

a. PAD Agencies are required to post a sign at their front entrance that states they have an AED and where it is located inside the building.

b. PAD Agencies are required to fill out a new Notice of Intent when significant changes are made to the original application.

c. PAD Agencies and Certified Agencies are required to have written policy for the use of AEDs to include: i. Training requirements ii. Routine inspection of the AED iii. Regular maintenance of the AED

d. PAD Agencies must participate in a regionally approved QA/QI program. e. PAD Agencies must have a collaborative agreement with a physician.



Monroe-Livingston Region Public Access Defibrillation Event Form

Organization Name _________________________________________________________ Contact Person _______________________________ Phone # ______________________ Patient Name ______________________________________________________________ Date of Birth ________________________________ Age _______ Sex: Male Female Was patient’s collapse witnessed? YES NO Was CPR started prior to AED? YES NO Was AED applied to patient? YES NO Was there an attempt to breathe for the patient? YES NO Did AED allow shocks? YES NO Were there any problems with the AED? YES NO If yes, please describe: Time of collapse ____:____ AM PM Time from collapse until CPR started _____ minutes Time from collapse until AED applied _____ minutes Time from collapse until 911 called _____ minutes If any, how many shocks delivered _____ Did patient regain a pulse? YES NO Did patient begin breathing on own? YES NO Did patient regain consciousness? YES NO Was AED downloaded and sent to Medical Director? YES NO Transporting ambulance __________________________________________________________ Comments _____________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 2007-11


9.10 CARE AND TRANSPORT OF MINORS PURPOSE EMS providers are occasionally called to treat and transport minors. New York State does not allow a person under age 18, unless emancipated, to assume responsibility for their medical care. This policy defines an emancipated minor and outlines the treatment expectations of minors and emancipated minors. POLICY 1. Definition of emancipation shall be a person between the ages of 16 and 18 who:

a. Live separate and apart from their parents b. Do not receive any financial support from them c. Live beyond the parent’s custody and control d. Are not in foster care

2. An emancipating event includes:

a. Marriage b. Pregnancy (only for prenatal care) c. Parenthood d. Degree/Diploma e. Military service

3. If a minor is ill or injured in any way, they should be transported to a medical facility. 4. If a minor is between the ages of 16 and 18 and relates an emancipating event, they may make their own decisions

regarding treatment and transport to include refusing such care. 5. If a minor is not injured use the following guidelines:

a. A law enforcement officer has the legal authority to assume responsibility for a minor who is not injured until a parent/guardian can be located. If willing, the officer must sign the refusal form in the area for guardian.

b. Make reasonable efforts to contact parent/guardian. Document who you spoke with and their treatment decision for the minor. Care and treatment should never be delayed to accomplish this.

c. If contact with a parent/guardian cannot be made, contact Medical Control. Original April 21, 2008


9.11 USE OF INTRAOSSEOUS INSERTION DEVICES PURPOSE This policy outlines the use of Intraosseous Insertion Devices in the Prehospital Environment. POLICY Intraosseous access devices will be maintained by all ALS agencies in the Monroe Livingston Region and will be used according to the following procedure. I. Indications

Any patient in extremis/cardiac arrest when IV attempts have been unsuccessful - all approved ALS intravenous medications may be administered intraosseously

II. Contraindications

ABSOLUTE 1. Suspected or known fractures of the extremity targeted for placement. 2. Sites below the waist when there has been vascular disruption of extremity or pelvis.

RELATIVE 1. Infection, burn or cellulitis overlying the site. 2. Congenital deformities of the bone. 3. Metabolic bone disease.

III. Procedure

1. No more than 2 attempts, each attempt should be limited to 90 seconds 2. Sterile technique must be followed at all times. 3. Position appropriately and stabilize extremity. 4. Identify infusion site 5. Primary

1 cm medial to the tibial tuberosity, 2 cm distal to the tibial plateau 6. Alternate

Distal tibia, anteromedial flat bony surface, 1-3 cm proximal to medial malleolus Humeral head

7. Clean site 8. Insert IO Needle

a. Insert needle through skin at 90 degree angle (if using a powered device, use according to manufacturer’s directions)

b. Penetrate to periosteal surface (bone contact) c. Rotate and apply firm pressure on needle d. Stop when "pop" felt e. Remove obturator

9. Confirm Placement a. Attach syringe to needle or extension set b. Aspirate to confirm position, if no aspirate, continue to next step c. Flush rapidly with 20 mL saline d. If needle flushes without resistance, proceed e. If resistance is met, remove needle, apply pressure, and attempt alternate access f. Disconnect syringe

10. Attach pre-flooded IV tubing 11. Stabilize needle with gauze pads, secure with tape and immobilize 12. Fluid administration may require hand or pressure pump

NOTE: If patient is conscious, consider Lidocaine 2% 30mg slow IO push after placement and before fluid administration per MLREMS Standards of Care.


9.12 USE OF CONTINUOUS POSITIVE AIRWAY PRESSURE DEVICES PURPOSE This policy outlines the use of Continuous Positive Airway Pressure Devices in the Prehospital Environment. POLICY Continuous Positive Airway Pressure Devices may be used when available by EMT-CC or EMT-P Providers trained in its use according to the following procedure and as approved by the Agency Medical Director. I. Indications

1. Acute respiratory distress, due to cardiogenic pulmonary edema or COPD/Asthma in which the patient demonstrates spontaneous respirations and a patent, self-maintained airway.

2. Patient is 16 years of age or greater. II. Contraindications

1. Respiratory or cardiac arrest 2. Inability to maintain airway patency 3. Altered level of consciousness / lethargy 4. Head injury with increased ICP 5. Significant chest trauma 6. Vomiting or upper GI bleeding 7. Signs and symptoms of pneumothorax

III. Procedure

1. Assure patent airway. 2. Administer 100% Oxygen. 3. Perform patient assessment, including obtaining vital signs, pulse oximeter (SpO2) reading, and cardiac

rhythm. 4. Apply CPAP device per manufacturer’s instructions. 5. Continuously reassess the patient. 6. Monitor continuous pulse oximetry. 7. Monitor continuous ETCO2 (if available). 8. Follow the appropriate MLREMS Standards of Care for continued treatment of underlying condition

(Pulmonary Edema, Asthma/COPD). 9. Contact the Medical Control to allow for prompt availability of hospital CPAP equipment and respiratory

personnel. NOTE: If the patient does not improve or deteriorates despite CPAP and/or medical therapy, terminate CPAP administration and perform BVM ventilation and endotracheal intubation if necessary. Original May 1, 2004 Revised April 21, 2008


9.13 12 LEAD ECG ACQUISITION PURPOSE This policy outlines the use of 12-Lead ECG’s in the Prehospital Environment. POLICY 12 Lead Electrocardiogram devices will be maintained by all ALS agencies in the Monroe-Livingston Region and will be used according to the following procedure. I. Indications

1. Patients 18 years of age or over who are complaining of non-traumatic chest pain. 2. Any patient with syncope. 3. Any patient with a dysrhythmia noted on standard electrocardiographic monitoring. 4. Any patient in whom the provider has concern for cardiac cause of their symptoms.


1. None III. Procedure

1. Provide routine medical care and oxygen. 2. Apply chest and limb leads in accordance with manufacturer’s instructions. 3. Obtain an initial 12-Lead ECG as soon as practicable, preferably BEFORE nitroglycerin administration. 4. Obtain additional 12-Lead ECGs at any time during if the patient’s pain status changes, if ECG changes

are noted on the rhythm strip, and every 15 minutes if transport times are long. 5. If there is any evidence of ST-Segment Myocardial Infarction (>1mm ST segment elevation in at least two

anatomically contiguous limb leads or >2mm ST segment elevation in at least two anatomically contiguous precordial leads) contact Medical Control and consider transporting to a cardiac catheterization capable facility.

Original September 1, 2000 Revised April 21, 2008


9.14 EMERGENCY INCIDENT REHABILITATION PURPOSE To ensure the physical and mental condition of responders operating at the scene of an emergency or training exercise does not deteriorate to a point that affects the safety and health of the responder, fellow responders, or the safety and integrity of the operation. Agency leadership are strongly encouraged to review the United States Fire Administration guide to Emergency Incident Rehabilitation (February 2008 revision) and the National Fire Protection Association Standard 1584 to assist in placing this policy into context. Regardless of how rehabilitation is implemented, it is absolutely crucial that all responders follow this policy. No one, including officers, should be allowed to skip the rehabilitation process as enforcement of this policy will have a measurable affect on the long-term well-being of all responders. POLICY The following policy is strongly recommended for events, including training, fireground operations, hazardous materials incidents, prolonged extrication, and any other event where emergency response personnel are engaged in activities that pose a risk of exceeding a safe level of physical or mental endurance. This policy defines the minimum expectations of Emergency Incident Rehabilitation in the Monroe/Livingston Region, however agencies may, upon approval of their Medical Director, choose to implement additional criteria for rest, re-hydration, or physiologic measures provided they are not less than the minimum expectations set forth herein. Expectations 1. It is the responsibility of all responders at the scene to monitor themselves and their personnel to ensure the safety,

health, and welfare of all responders by ensuring adequate rest and hydration following the recommendations as set forth in this policy.

2. All providers are encouraged to participate in self-rehabilitation. This should ideally include 10 minutes between

work periods and/or SCBA exchanges whereby the provider is allowed to rest and consume appropriate fluids while awaiting reassignment.

3. The Incident Commander shall consider the circumstances of each incident or training exercise early in the

evolution of the incident or exercise, and make adequate provisions for the rest and rehabilitation for all personnel operating at the scene.

4. For any event where the above criteria are met, it is recommended that the Incident Commander or their designee

(Incident Safety Officer or Logistics Section Chief) establish the following minimum: a. Rehabilitation Area Ample space with preference to seating for responders Protection from the elements, fumes, or hazards Accessible by EMS Clearly identified Temperature control including active cooling and re-warming of responders as indicated by

environmental conditions Re-hydration to include water and electrolyte replacement Nutrition (as appropriate for the duration of the incident) Staffing should include at least one Rehabilitation Officer/Manager with training of at least the NYS EMT-B

and BLS equipment to include oxygen, blood pressure cuff and pulse oximeter. Availability of an AED in proximity to the Rehabilitation Area is strongly encouraged. Pulse co-oximetry is optional, but encouraged.

Continued on Next Pag

9.14 EMERGENCY INCIDENT REHABILITATION, CONTINUED


b. Treatment Area Separate from the rehabilitation area In close proximity to a transporting ALS ambulance and the rehabilitation area Staffing should include a fully-staffed ALS transporting ambulance

5. There should be at least one rehabilitation staff member trained to at least the EMT-B level for every 5 responders

in the Rehabilitation Area. 6. For large incidents, it may be advisable to have more than one Rehabilitation and/or Treatment Area established.

This decision should be made by the Incident Commander or their designee. 7. For incidents greater than a single alarm, it is recommended that a minimum of one fully staffed ALS transporting

ambulance is available per alarm assignment. Additional transporting ambulances may be required depending on the type of operation, environmental conditions, and number of responders involved.

8. No personnel should enter the warm or hot zone of a declared Hazardous Materials Incident unless the

Rehabilitation and Treatment areas have been established and staffed according to the policies and procedures of the respective Hazardous Materials Team. This must include an ALS transporting ambulance and a regionally credentialed Tox-Medic.

9. It is advised that pre-hydration, when possible, occurs to include a minimum of 16 ounces of non-caffeinated fluids

over the two hours prior to scheduled events, such as training exercises. Protocol 1. Responders should be detailed to the Rehabilitation Area by the Incident Commander or their designee after every

45 minutes of continuous hard labor, one 45 minute or 60 minute rated SCBA cylinder, two, thirty-minute rated SCBA cylinders, or after being decontaminated. The Incident Commander or Incident Safety Officer may direct personnel to the Rehabilitation Area at any time for reasons not mentioned above.

2. All responders must be decontaminated (if necessary) and remove personal protective equipment prior to entering

the Rehabilitation Area. 3. All responders must follow their agencies accountability system when entering/departing the Rehabilitation and/or

Treatment Areas. 4. Upon entering the Rehabilitation Area, the responder is expected to do the following:

a. Drink at least 16 ounces of fluid (water first, then half-strength electrolyte solution). b. No tobacco use in the Rehabilitation or Treatment Areas. c. Heed the directives of the Rehabilitation Officer/Manager with regards to their disposition to the

manpower/staging or the treatment areas. 5. The responder will be assessed by the Rehabilitation Officer/Manager or other qualified medically trained

personnel. 6. Any responder entering the rehabilitation area with complaints of chest pain, shortness of breath (beyond normal

exertion), or altered mental status will be immediately moved to the Treatment Area and may not return to duty for the duration of the incident. This shall be immediately reported to the individual(s) responsible for scene safety, accountability and/or command.

7. Every responder will be assessed for presence of other symptoms to include dizziness, weakness, nausea,

headache, cramps, aches or pain, changes in gait, speech or behavior, mental/physical stress, exhaustion, and symptoms of heat or cold-related stress. These symptoms do not require immediate removal to the Treatment Area, but must resolve prior to returning to manpower/staging.



9.14 EMERGENCY INCIDENT REHABILITATION, CONTINUED 8. Every responder will have vital signs assessed to include Pulse, Respiratory Rate, Blood Pressure, and Pulse-

Oximetry over a thirty-second period and recorded on the Incident Rehabilitation Log. Use of pulse co-oximetry is optional, but encouraged.

9. Abnormal Vital Signs are considered any one of the following:

a. Pulse >110 per minute b. Respirations >20 per minute c. Systolic Blood Pressure >160 d. Diastolic Blood Pressure >100 e. Pulse oximetry <96% in ambient air f. Pulse co-oximetry >5% (if measured)

10. If on any vital sign exam an irregular pulse is identified that is not previously known to the responder, the responder

should be moved to the Treatment Area for further evaluation. This shall be immediately reported to the individual(s) responsible for scene safety, accountability and/or command.

11. If vital signs are within normal limits (as defined above) the responder is encouraged to drink at least 16 ounces of

fluid and may return to manpower/staging after a minimum of 10 minutes rest. 12. If vital signs are abnormal (as defined above), the responder will be monitored for 10 minutes and encouraged to

rest and consume appropriate fluids. 13. After 10 minutes from time of entry to the Rehabilitation Area, the responder will be re-assessed and all vital signs

retaken. a. If vital signs are within normal limits, the responder may return to manpower/staging. b. If vital signs continue to remain abnormal (as defined above), the responder will be observed for another 10

minutes and encouraged to rest and consume appropriate fluids. 14. After 20 minutes from time of entry to the Rehabilitation Area, the responder will be re-assessed and all vital signs

retaken. a. If vital signs are within normal limits, the responder may return to manpower/staging. b. If vital signs continue to remain abnormal (as defined above), the responder will be referred to the

Treatment Area. This shall be immediately reported to the individual(s) responsible for scene safety, accountability and/or command.

15. If the responder exhibits any symptoms of chest pain, shortness of breath, or altered mental status during their time

in the Rehabilitation Area, they should be moved to the Treatment Area immediately and may not return to duty. This shall be immediately reported to the individual(s) responsible for scene safety, accountability and/or command.

16. No responder may return to manpower/staging unless they fulfill the following:

a. No symptoms of dizziness, weakness, nausea, headache, cramps, aches or pain, changes in gait, speech or behavior, and symptoms of heat or cold-related stress.

b. Pulse ≤110 per minute c. Respirations ≤20 per minute d. Systolic Blood Pressure ≤160 e. Diastolic Blood Pressure ≤100 f. Pulse oximetry ≥96% in ambient air g. Pulse co-oximetry ≤5% (if measured)

17. Any responder moved to the Treatment Area should have care provided according to the most recent edition of the

MLREMS Standards of Care.



9.14 EMERGENCY INCIDENT REHABILITATION, CONTINUED

18. All personnel should be encouraged to hydrate with at least 36 ounces of appropriate fluids over two hours after the conclusion of the incident.

Interpreting CO Values During Incident Rehabilitation 1. The use of hand-held pulse co-oximetry devices is optional, and not required for Incident Rehabilitation. 2. The SpCO reading is to be used as a screening measure. Definitive carboxyhemoglobin determinations are

performed via blood draw in the hospital setting. Any patient with complaints of chest pain, shortness of breath, or altered mental status should receive oxygen by a non-rebreather mask and moved to the Treatment Area, regardless of SpCO reading.

3. The following CO treatment guidelines will pertain to the asymptomatic emergency responder on entry to the

Rehabilitation Area. a. If SpCO <5% and vital signs are within normal limits, the provider is encouraged to drink at least 16 ounces

of fluid and may return to manpower/staging after a minimum of 10 minutes rest. b. If SpCO ≥5% and <12%, the responder may breathe ambient air and may not leave the rehabilitation area

until their CO level is below 5%. c. If SpCO ≥12% the responder should be moved to the Treatment Area and receive high-flow oxygen until the

SpCO is <5%. d. If SpCO ≥25%, the responder will be moved to the Treatment Area and transported with high-flow oxygen to

an emergency department. Documentation 1. All responders entering the Rehabilitation Area should have their name, vital signs, and disposition recorded on the

Rehabilitation Log (Attached). This Log should be attached and stored with the stand-by PCR associated with the incident and a copy given to the Incident Commander or Incident Safety Officer.

2. A separate PCR must be completed for any responder referred to the Treatment Area, regardless of whether the responder was transported by EMS. Should the responder not wish transport, a MLREMS Refusal Form must be completed and the individual(s) responsible for scene safety, accountability and/or command shall be notified.



9.15 ACCESS TO EMERGENCY PSYCHIATRIC SERVICES PURPOSE To define a decision tree for accessing hospital based emergency psychiatric services. NOTE: This policy applies to patients not presenting with a primary medical or traumatic condition.

If the patient has a presenting medical or traumatic condition requiring immediate treatment, follow the appropriate MLREMS Standard of Care.

In all cases clinical continuity and safety for patients and providers should be considered. POLICY For patients requiring emergency department based psychiatric services, the following guidelines should be

followed:

Transport the person to the destination noted on the transport papers, regardless of both Code Red status and the patient’s preference.

In the absence of written transport papers, transport the person to the Article 9.39 hospital where current

psychiatric treatment is being provided. If the intended destination is Code Red, the patient should be taken to the nearest non-Code Red Article 9.39 hospital

If the person is not in a current treatment program (at a 9.39 facility), they should be taken to the nearest

Article 9.39 hospital that is not Code Red. NOTE: Article 9.39 Hospitals in the Monroe-Livingston area include: Monroe County Rochester General Hospital University of Rochester Medical Center – Strong Memorial Hospital

St. Mary’s (Unity) Surrounding Counties

Clifton Springs Hospital (Clifton Springs) Newark-Wayne Community Hospital (Newark)

St. James Mercy Hospital (Hornell) Wyoming County Community Hospital (Warsaw)


9.16 FIRE DEPARTMENT BLS FIRST RESPONSE DOCUMENTATION REQUIREMENTS

PURPOSE To define the minimum documentation expectations of Fire Department Basic Life Support First Response agencies who respond to requests for emergency medical services. This policy does not apply to transporting agencies or non-transporting ALS agencies that must complete a Prehospital Care Report for every incident to which they are dispatched per NYS DOH BEMS Policy and regulation. POLICY Fire Department Basic Life Support First Response (BLSFR) agencies must record all requests for emergency medical services using either a PCR or a written or electronic fire service log, hereafter referred to as a Fire Record Management System (FireRMS). For every request for emergency medical services, the following must be included in the FireRMS:

1. Date and time of incident 2. Incident location 3. EMD Code associated with the incident 4. The disposition of the incident

A Prehospital Care Report (PCR) must be completed any time patient care is provided independently by a member of the BLSFR agency at any point during the response. “Independent patient care” refers to a member of the BLSFR agency who is in charge of patient care to their level of certification prior to the arrival of a transport unit or an advanced provider who assumes responsibility for that patient's care. Should the BLSFR agency not provide independent patient care during that incident, then a PCR is not required and the FireRMS may be used to document the service type provided. The FireRMS incident dispositions and documentation requirements are: 1. Cancelled

The BLSFR agency is cancelled en-route or on-scene by a law enforcement, fire, or EMS agency and makes no patient contact. Patient contact is defined as visual contact with the patient. No PCR is required and the disposition is recorded in FireRMS. NFIRS Equivalent:

611 - Dispatched and canceled en route. Incident cleared or canceled prior to arrival of the responding unit.

2. No Patient Found

The BLSFR agency arrives on scene and finds no patient. A patient is defined as a person encountered by EMS personnel with an actual or potential injury or medical problem. No PCR is required and the disposition is recorded in FireRMS. NFIRS Equivalents:

324 - Motor vehicle accident with no injuries. 621 - Wrong location. Excludes malicious false alarms (710 series). 622 - No incident found on arrival at dispatch address. 661 - EMS call where injured party has been transported by a non-fire service agency or left the scene prior to arrival. 600 - Good intent call, other.



9.16 FIRE DEPARTMENT BLS FIRST RESPONSE DOCUMENTATION REQUIREMENTS, CONTINUED

3. Assist Ambulance

The BLSFR agency assists the transporting ambulance or a higher level of care (in the case of a non-transporting ALS unit) with patient care (lifting, packaging, obtaining vital signs, riding with the transporting crew, etc) at the direction of the provider in charge. No PCR is required and the disposition is recorded in FireRMS. NFIRS Equivalent:

311- Medical assist. Includes incidents where medical assistance is provided to another group/agency that has primary EMS responsibility.

4. Patient Care Provided

The BLSFR agency is in charge of providing independent patient care to the level of their certification at any time during the incident. A PCR is required and the disposition is recorded in FireRMS. This includes:

A. An agency provider administers the agency’s aspirin, albuterol, or epi-pen. B. An agency provider utilizes the agency’s AED or blood glucometer. C. An agency provider performs cervical spine immobilization using a cervical

immobilization device and/or backboard. D. An agency provider performs immobilization of a suspected fracture using a splint or

other immobilization device.

Generally, anytime the BLSFR agency is at the patient’s side before the transporting provider, a PCR is expected as an evaluation and “independent patient care” has been performed. Other instances such as mandated reporter conditions (abuse, neglect) should result in the generation of a PCR. When in doubt, complete a PCR. NFIRS Equivalents:

321 - EMS call. Includes calls when the patient refuses treatment. Excludes vehicle accident with injury (322) and pedestrian struck (323).

322 - Motor vehicle accident with injuries. Includes collision with other vehicle, fixed objects, or loss of control resulting in leaving the roadway.

323 - Motor vehicle/pedestrian accident (MV Ped). Includes any motor vehicle accident involving a pedestrian injury.

5. Standby

The BLSFR agency provides EMS standby services for hazardous conditions with the intent to provide emergency medical aid or assessment should it be required. This includes emergency incident rehabilitation. No PCR is required and the disposition is recorded in FireRMS. If a patient is assessed or treated beyond that which is specified in emergency incident rehabilitation policy, a PCR is required. NFIRS Equivalent:

381 - Rescue or EMS standby for hazardous conditions. Excludes aircraft standby (462). It is expected that the BLSFR agency monitor compliance with these documentation expectations. PCRs must be submitted to the Office of Prehospital Care via fax or electronically, monthly by the 10th of the month following the date of the incident.


9.17 ON-LINE MEDICAL CONTROL REQUIREMENTS PURPOSE To define the requirements of facilities and physicians providing on-line medical control to EMS providers in the Monroe-Livingston Region. DEFINITION On-Line Medical Control (OLMC) is the advice and direction through a direct, live communication link (two-way radio or telephone) from a physician to certified first responders, emergency medical technicians or advanced emergency medical technicians who are providing medical care at the scene of an emergency. POLICY Facility Requirements To be a considered an OLMC facility in the Monroe-Livingston Region, the facility must:

1. Have an emergency department meeting all standards for emergency department/service as defined in Section 405 of the NYS Hospital Code.

2. Have a physician staff member physically present in the emergency department and immediately available 24 hours a day that is credentialed by the Monroe-Livingston REMAC to provide OLMC.

3. Provide on-line medical direction for BLS and ALS agencies that transport patients to their facility and to facilities not able to provide OLMC.

4. Accept patients requiring BLS and or ALS services who may have received EMS care under physician direction originating from another medical control hospital.

5. Maintain direct two-way radio and/or compatible telephones connected to regional communications systems to communicate with BLS and ALS units and medical control hospitals.

6. Use only Monroe-Livingston REMAC approved medical control logs and maintain them for a minimum of 7 years.

7. Record all audio from direct two-way radio and/or compatible telephones providing OLMC and maintain them for a minimum of 7 years.

8. Assume the responsibility for the care and maintenance of necessary communications equipment within the institution.

9. Familiarize staff members with approved regional and state protocols. 10. Participate in local and or regional EMS planning activities as appropriate. 11. Participate in quality improvement activities as defined in Part 405.19 item (f) of the NYS Hospital Code. 12. Participate in quality improvement activities as requested by the Monroe-Livingston REMAC or System

Medical Director as they relate to the provision of OLMC. 13. Designate a Hospital Medical Control Director to be in charge of overall coordination of medical control in

that facility. Physician Requirements To be credentialed as an On-Line Medical Control Physician in the Monroe-Livingston Region, the physician must:

1. Be licensed to practice medicine or osteopathy in New York 2. Be Board Certified/Board Eligible by the American Board of Emergency Medicine or the American

Osteopathic Board of Emergency Medicine or be credentialed in basic and advanced cardiac life support, and Advanced Trauma Life Support, or equivalent.

3. Physicians-in-training must be credentialed in basic and advanced cardiac life support and Advanced Trauma Life Support, or equivalent, and be at the PGY2 or higher training level.

4. Be trained in and thoroughly familiar with the following: Continued on Next Page


9.17 ON-LINE MEDICAL CONTROL REQUIREMENTS, continued

a. Regional and state BLS and ALS protocols b. Communication systems c. EMS levels of training and responsibilities d. Medical control system and responsibilities of a medical control physician

5. Successfully complete (80% or better) an open book, written OLMC Test administered by the Monroe-Livingston REMAC.

6. Review, and as directed, complete re-training regarding the provision of OLMC as regional protocols and policies are updated.

Hospital Medical Control Director Requirements Each OLMC hospital is to identify one physician as the Hospital Medical Control Director whose duty is the overall coordination and medical accountability of the medical control system in his/her facility. The Hospital Medical Control Director is responsible to the Regional Medical Director for all functions of the medical control system in that hospital. The Hospital Medical Control Director must meet all requirements of an OLMC Physician. Additionally, the Hospital Medical Control should be familiar with the Monroe-Livingston BLS and ALS protocols, system configuration, and communication, and have a thorough knowledge of and strong dedication to the support and improvement of emergency medical services. The Hospital Medical Control Director will:

1. Maintain knowledge levels appropriate for an EMS medical director through continued education. 2. Sit as a member of the Monroe-Livingston REMAC and participate regularly in its functions, or appoint a

suitable physician alternate. 3. Ensure adequate training and familiarity of all emergency department physician and nursing staff with:

a. Pre-hospital medical control system and issues b. Training and responsibilities of all levels of pre hospital EMS providers c. Quality improvement concerns d. Monroe-Livingston REMAC protocols e. Pre-hospital/hospital interface and cooperation

4. Develop and implement an effective quality improvement program for continuous system and patient care improvement.

a. EMS call audits shall be conducted at a minimum of twelve (12) hours per year. 5. Direct and facilitate an on-going review of the medical control system and quality improvement program.

Mediate pre-hospital issues and problems concerning medical control, as appropriate. 6. Report any EMS personnel or ALS Agency complaint, protocol violation, or lack of cooperation with other

aspects of medical control and or quality improvement activities, to the Monroe-Livingston REMAC. 7. Maintain Monroe-Livingston REMAC protocols and appropriate policies immediately available at the

medical control telephone/radio base station. Note: Medical Control facilities will have until September 1, 2009 to meet physician credentialing requirements and will have until January 1, 2009 to meet audio recording requirements. Original June 15, 2000


9.18 CONTINUOUS INFUSIONS PURPOSE This policy outlines the use of continuous infusions in the prehospital and interfacility environment. POLICY Certain continuous infusions may be maintained by an EMT-P provider during prehospital or interfacility transport and do not require the use of a Specialty Care Transport provider. Specific medications may require the use of a Continuous Electronic Infusion Device (commonly referred to as a medication pump). Paramedics using a Continuous Electronic Infusion Device must be trained in its use according to manufacturer’s guidelines and as approved by the Agency Medical Director. The agency using such a device must have a written policy outlining the training requirements, eligibility, quality assurance program, and parameters for use of the specific device being used by the agency. Medical Control is not required for use of the device, but is required for any deviation from agency policy on its use. INDICATIONS

The following continuous infusions may be maintained by an EMT-P provider. Medications that require use of a Continuous Electronic Infusion Device are indicated by an asterisk (*):

Abciximab* Any Antibiotic Amiodarone* Dextrose 5% in Water (D5W) Diltiazem* Eptifibatide* Fentanyl* Insulin* Heparin* Hydromorphone*

Lactated Ringer’s Lidocaine* Magnesium* Methylprednisolone Morphine* Nitroglycerin* Normal Saline Pantoprazole* Sodium Bicarbonate Total Parenteral Nutrition ± Lipids

CONTRAINDICATIONS

1. The EMT-P Provider may transport no more than three continuous medication infusions; no more than one of which may be vasoactive.

2. Contraindications related to the specific medication or solution being infused.

PROCEDURE

1. The patient requires continuous infusion of an indicated medication or crystalloid. 2. A reliable source of intravenous access (large bore peripheral IV or central venous

catheter) exists.

3. If required, adjust infusion device to appropriate administration rate per manufacturers instructions.

4. The patient must be constantly monitored throughout the transport including:

a. Continuous pulse oximetry. b. Continuous ECG monitoring.

c. Frequent blood pressure monitoring. d. Frequent examination of the infusion site.

5. During interfacility transports, an order for the infusion rate must be given by the sending

physician and this rate entered and double-checked prior to departing the sending facility. The compatibility of more than one infusion must be verified with the sending facility prior to departure.

6. Any adjustment to the infusion rate during transport may only be done with Absolute On-

Line Medical Control. The only exceptions are for medications (antibiotics, etc) that are completed during the transport or for medications that have infiltrated their access site. Specialty Care Transport Paramedics should follow their specific protocols.

7. A EMT-P provider with access to a Continuous Electronic Infusion Device may use such

device for administering any medication included in the MLREMS Standards of Care. TRAINING CONSIDERATIONS Implementation of a Continuous Electronic Infusion Device Program requires additional training and review above and beyond the standard New York State Paramedic Curriculum. The training for the use of any Continuous Electronic Infusion Device should include a didactic module presented by the Agency Medical Director or their designee. This didactic module should, at a minimum, include: an overview of the pharmacology, indications, contraindications, and side effects of common medications to be used under this protocol; familiarization with central access devices and proper technique to access and maintain them; and a detailed understanding of the infusion device being used. To supplement the didactic information, a practical application module utilizing scenario-based training is expected to ensure device familiarity and clinical decision-making. The purchase, training, continuing education, authorization, and use of a Continuous Electronic Infusion Device must be approved by the Agency Medical Director. Original October 19, 2009

9.19 USE OF TRANSPORT VENTILATORS PURPOSE This policy outlines the minimum equipment, training, and quality assurance requirements for the use of transport ventilators in the prehospital environment. POLICY This policy does not define the circumstances of transport ventilator use. The “Ventilator Management” protocol, as defined in the most recent edition of the Monroe/Livingston Regional EMS System Standards of Care, shall be the sole authority on how such a device is utilized in the prehospital setting. Both Policies and Protocols define who are credentialed by their agency and authorized by their Agency Medical Director to use such equipment Transport Ventilators may be used as indicated in MLREMS Standards of Care when available by EMT-P providers trained in its use according to manufacturer’s guidelines and as approved by the Agency Medical Director. The agency using such a device must have a written policy outlining how they will implement the prescribed MLREMS training requirements, eligibility, quality assurance program, and parameters for use of the specific device being used by the agency. DEVICE REQUIREMENTS Devices must be FDA approved. Additionally, the Transport Ventilator must, at a minimum, possess:

Adjustable ventilatory rates between 8 and 20 breaths per minute Adjustable tidal volumes between 200 and 1000 ml High pressure alarm

TRAINING CONSIDERATIONS Implementation of a Transport Ventilator Program requires additional training and review above and beyond the standard New York State Paramedic Curriculum. The training for the use of any Transport Ventilator Program should include a didactic/competency module presented by the Agency Medical Director or their designee. This didactic/competency module should, at a minimum, include:

An overview of the use of positive pressure ventilation Control of ventilation using a mechanical ventilator, including modes of cycling, pressure

limits, alarm meanings and standard settings Pulmonary/ventilator mechanics Assessment of ventilatory status, including respiratory and ventilatory failure Hemodynamic effects of positive pressure ventilation and PEEP Barotrauma Monitoring of patient ventilatory status while on a ventilator Troubleshooting ventilator failure and alarms Competency-based evaluation of proper set-up, use and troubleshooting of the

equipment, including scenario-based problems CONTINUING EDUCATION Any Paramedic who maintains credentials at the SCT level has met the above criteria for continuing education in ventilator use. Paramedics who are not credentialed as SCT providers

must successfully complete 6 hours of didactic continuing education and pass a competency based evaluation for proper set-up, use and troubleshooting of their ventilator on an annual basis. The agency is responsible for maintaining records regarding currency of credentials. QUALITY ASSURANCE A written Quality Assurance plan approved by the Agency Medical Director must exist for monitoring the appropriate use of transport ventilators. It is expected that any use of the transport ventilator will be reviewed by the Agency Medical Director. Original October 19, 2009

9.20 USE OF INVASIVE TEMPERATURE PROBES PURPOSE This policy outlines the indications for use of invasive temperature probes in the Prehospital Environment. POLICY Invasive temperature probes (defined herein as thermometers placed in the esophageal and rectal space) may be used when available by EMT-P providers trained in its use according to manufacturer’s guidelines, the following procedure, and as approved by the Agency Medical Director. I. Indications

1. Accurate core temperature measurements are necessary to optimize patient care in the following circumstances:

a. Management of therapeutic hypothermia b. Concern for significant hyperthermia c. Concern for significant hypothermia

2. Patient is 16 years of age or greater 3. Patient is unconscious


1. Caustic ingestion for esophageal placement 2. Active upper GI hemorrhage for esophageal and rectal placement 3. Active lower GI hemorrhage for rectal placement 4. Known esophageal disease (varices, esophageal cancer, etc) for esophageal placement

III. Procedure

1. In intubated non-trauma patients, preference is given to insertion of the esophageal probe. 2. In intubated trauma patients, preference is given to insertion of the rectal probe. 3. In unconscious but non-intubated patients, preference is given to insertion of the rectal probe. 4. Insert device according to manufacturers instructions. Attempts should be limited to three. 5. Follow the appropriate MLREMS Standards of Care for continued treatment of underlying condition

(Hyperthermia or Hypothermia). Original Approved 12-21-09


9.21 Specialty Care Transport Paramedic PURPOSE This policy outlines the initial training, credentialing, and continuing education requirements of the Specialty Care Transport Paramedic. POLICY Glossary of Terms

CCEMT-P: Critical Care Emergency Medical Technician. Paramedic as certified through the University of Maryland-Baltimore Critical Care Transport curriculum.

CICP: Certified Intensive Care Paramedic. Paramedic as certified through the Cleveland Clinic Certified Intensive Care Paramedic curriculum.

FP-C: Flight Paramedic - Certified Medical Director: The Physician at the Agency or System level authorizing practice at the SCT level. MICP: Mobile Intensive Care Paramedic certification as issued by Monroe Community College. Specialty Care Medical Control: On-line medical control provided specifically for the Specialty Care

Transport team by the Agency Medical Director. Specialty Care Transport Intern: SCT certified (CCEMT-P, CICP, MICP, FP-C) individual undergoing

internship and not credentialed to practice at the SCT level without peer supervision. Specialty Care Transport Internship: Process used to evaluate an SCT candidate’s performance in

transfer situations under the guidance of a preceptor. Specialty Care Transport Paramedic: Has completed the SCT internship program, and is credentialed by

the System Medical Director to provide Specialty Care Transports in the Monroe-Livingston EMS Region. This individual has the ultimate responsibility for the care of the patient and the well being of the transport crew. He/She must maintain contact with the patient from the hand over of care at the sending facility to the hand over of care at the receiving facility. He/She is responsible for communication with medical control, transport reports and documentation.

Specialty Care Transport Preceptor: Individual credentialed to evaluate and document the performance of an SCT Intern.

Specialty Care Transport Chief Paramedic: Individual designated by an agency to represent that organization’s Specialty Care Transport program to the Medical Director and to the REMAC.

Standard Medical Control: On-line medical control provided for all field providers by designated hospitals. Change of Status/Role

Achieving Active Status/Clearance as an SCT Paramedic: Requirements – Current EMT-P, ACLS, PALS (or PEPP), completed an appropriate internship, and completed and maintained current certification in CCEMT-P, CICP, MICP, or FP-C. Maintenance of Active Status A Specialty Care Transport Paramedic must complete a minimum of 3 Specialty Care Transports in any 12-month period. In the event that this quota is not reached, the Specialty Care Transport Paramedic must complete a Specialty Care Transport under the supervision of a Specialty Care Transport Preceptor and must re-credential with the Specialty Care Transport agency medical director. All Specialty Care Transport Paramedics must be reviewed and re-credentialed yearly by the Agency Medical Director. This review must at least take the form of QA and medical record review. Specialty Care Transport Paramedics will be regionally credentialed Paramedics in accordance with REMAC ALS Credentialing Requirements. All Specialty Care Transport Paramedics must complete annual continuing education requirements as detailed later in this policy.


9.21 Specialty Care Transport Paramedic, continued Suspension The Specialty Care Transport Paramedic will be suspended from his/her role in the event any of the above listed requirements are not met. Immediate reinstatement to his/her role will occur if the specialist re-credentials within three months from the suspension date. If the specialist fails to re- credential within the given time period, he/she will be required to repeat the internship period. Notification of Status The System Medical Director must be notified immediately in the event that the status of a Specialty Care Transport Paramedic changes. Leave of Absence An SCT Paramedic may request a leave of absence of up to 1 year from SCT transports. The request must be done in writing and sent to the Agency Medical Director. The Medical Director may reinstate the paramedic without any formal retraining or reclearing, if in the opinion of the Medical Director, the paramedic provided appropriate care before requesting a leave. If concerns exist regarding the paramedic’s skills due to the leave of absence, the Medical Director can require any of the following – specific remediation, demonstration of skill proficiencies, performance of transport(s) with an SCT Paramedic Preceptor, or full reclearing. Leave of Absence Greater than One Year For a leave of absence greater than 1 year, the SCT Paramedic will be required to complete a full internship. If the leave of absence includes a leave from all ALS activities entirely, the Specialty Care Transport Paramedic will also be required to fully reclear at the ALS level prior to reclearing at the SCT level. Exceptions may be presented by the Agency and System Medical Director for consideration.

SCT Paramedic Internship

The SCT Paramedic Internship is a structured program used to evaluate and document the performance of an individual who has completed required didactic coursework to operate as a Specialty Care Transport Paramedic. Internship is required for newly certified Specialty Care Transport Paramedics and for those who have been absent from the specialty care setting for an extended period of time.

The internship period should be used for familiarization with equipment, procedures, and documentation requirements. Orientation to an individual organization’s policies, procedures, and equipment shall be done according to that organization’s procedures and will not be included in the scope of this document.

The following are the minimum expectations for authorization to provide Specialty Care Transport in the Monroe-Livingston Regional EMS System, and may be exceeded by individual organizations. Internship Period Entry to a SCT Paramedic Internship is open to all currently certified NYS EMT-Paramedics who hold a current CCEMT-P, CICP, MICP, or FP-C certification, and can produce verification of all other requirements. The SCT Chief Paramedic or his/her designee shall complete the SCT Internship Registry Form and present it to the System Medical Director. The intern has 6 months to complete the internship. If after 6 months, the Intern has not successfully completed the program, the SCT Chief Paramedic may request a 3-month extension from the Agency Medical Director. Approval will be based on the SCT Chief Paramedic’s recommendation.


9.21 Specialty Care Transport Paramedic, continued Failure to Complete Internship If the Internship is not completed after the 3-month extension, the Intern and his/her SCT Chief Paramedic shall communicate with the Agency Medical Director to review progress, discuss alternatives, and determine the viability of the SCT Paramedic Intern as an SCT provider. With agreement of the System Medical Director, an additional 3-month extension may be granted. If the Intern violates the terms of the agreement or fails to complete the requirements of the Internship, the agency can terminate the internship. The Intern and System Medical Director shall be notified of the termination. If an Intern fails to complete his/her internship at one agency, then he/she can attempt internship at another agency with the agreement of the new agency’s SCT Chief Paramedic and Medical Director. Internship Requirements:

1. Demonstration of knowledge and skills competency 2. Demonstrated knowledge of the Monroe-Livingston Regional SCT Protocols 3. Completion of at least 16 hours in various ICU or SCT Clinical settings as approved by the Agency

Medical Director 4. A minimum of nine (9) transports including at least three (3) successful transports which include the

use of mechanical ventilation. The SCT Chief Paramedic should assure that the transports reflect a varied set of patients

5. Clearance recommendations from two (2) SCT Paramedic Preceptors (based on observed patient transports) to practice as an SCT Paramedic

6. Agency SCT Chief Paramedic and Agency Medical Director approval 7. System Medical Director approval

Documentation All SCT training shifts will be documented on the Specialty Care Transport Evaluation Form or an acceptable equivalent. All positive and constructive commentary shall be discussed, documented and the appropriate forms should be signed by both Preceptor and Intern. These sheets will be retained by the organization for use in the clearance decision and as part of the Specialty Care Transport Paramedic’s permanent record. All documentation regarding the SCT Paramedic’s training and internship will be retained by the Agency as specified in the approved SCT QA/QI plan. Internship Content An Intern may practice only under the direct supervision of a credentialed Monroe-Livingston Regional EMS System SCT Preceptor that is approved to precept for that agency. The Intern must be able to competently demonstrate:

1. Knowledge of MLREMS ALS and SCT Protocols 2. Knowledge and proper use of SCT specific equipment 3. Proper and aseptic technique for all parenteral skills 4. Proper patient assessment, diagnosis, and appropriate treatment decisions 5. Skill in interpretation of patient ECG’s and lab values 6. Proper airway management skills including suctioning of the patient with airway adjuncts 7. Knowledge and proper use of mechanical ventilation and troubleshooting ventilators 8. Knowledge and proper use of pharmacological interventions 9. Documentation skills


9.21 Specialty Care Transport Paramedic, continued Clearance Only calls taken during the official internship period may be counted toward clearance of the Intern. Once the internship requirements have been completed, the SCT Chief Paramedic and the Agency Medical Director should review all documentation and determine if the Intern is ready to be cleared. Clinical training requirements may be completed prior to the start of the official internship. The Intern must express agreement to be cleared before the SCT Chief Paramedic can proceed. If after review, the SCT Chief Paramedic and Agency Medical Director are not completely satisfied with the performance of the Intern, he/she may recommend continued training with periodic reviews. The SCT Chief Paramedic should document said reasons and discuss them with the Intern. This documentation should include any recommendations for remediation.

Internship Completion

Upon successful completion of the prescribed internship program, the SCT Chief Paramedic shall do the following:

1. Complete the SCT Registry Form. The Registry Form shall be forwarded to the Monroe-Livingston Regional Program Agency for addition of the new provider to the SCT Registry.

2. Complete and sign the SCT Internship Completion Form and forward to the Monroe-Livingston Regional Program Agency for inclusion in the regional provider database.

Appeals Appeals to this procedure shall be directed to the System Medical Director. Agency Requirements Quality Assurance/Quality Improvement Due to the critical nature of the patients transported by the Specialty Care Transport teams, each agency must devise and implement a 100% QA/QI program and upon request submit the program to the REMAC for review. Each agency providing SCT Level transports within the MLREMS region shall submit, yearly, a summary of their QA/QI program to the REMAC for review. This review is due by July 30th of each year.

Long Distance Transport

Each agency must have in place written policy that defines a long distance transport: the staffing required for a long distance transport, the minimum equipment required for a long distance transport, actions for crew rest, vehicle/equipment failure, and patient deterioration during long distance transport. Continuing Education Continuing education requirements for Specialty Care Transport Paramedics include: didactic, interactive skills labs and independent, self-study totaling a minimum of 24 hours per year. This shall include the following:

1. SCT Paramedics must obtain at least 4 hours of clinical CME with up to (no more than) 12 hours counting toward the 24 hour goal with at least 4 hours of respiratory clinical CME

2. SCT Paramedics must obtain at least 12 hours of didactic CME with up to (no more than) 20 hours counting toward the 24 hour goal

a. Up to 6 hours of Self Study b. No more than 8 hours of MLREMS Program Agency sponsored/approved lectures c. No more than 8 hours of Agency Sponsored Lectures d. No more than 6 hours of Hospital sponsored events/vendor events/conferences.

The training year for SCT Paramedic Continuing Education is July 1 through June 30. The Agency SCT Medical Director must sign off on each SCT Paramedic’s Continuing Medical Education requirements at the end of each year.


9.21 Specialty Care Transport Paramedic, continued SCT Paramedic Preceptor

An SCT Preceptor is a knowledgeable person, credentialed to practice as an SCT Paramedic in the MLREMS region, who meets the qualifications listed below. The Preceptor serves as an evaluator who identifies areas of excellence and areas of required improvement on the performance of an SCT Intern. The Preceptor should “refrain from acting” unless patient care may be compromised. The Preceptor is a teacher to the student / Intern. For consideration, a candidate must inform the SCT Chief Paramedic of his/her intent to become a preceptor. The preceptor candidate may then be recommended by the SCT Chief Paramedic and Agency Medical Director, and appointed by the System Medical Director in accordance with the following guidelines: Preceptor Qualifications The Preceptor Candidate must have served as a Specialty Care Transport Paramedic for a minimum of 1 year. The following qualifications are subjective in nature and are to be assessed by the SCT Chief Paramedic and Agency Medical Director:

Demonstrates ability for instruction and guidance of those persons training under them Demonstrates exceptional initiative and competency in knowledge and skills Excellent communication skills Excellent documentation skills

Preceptor Approval The SCT Chief Paramedic must submit a completed preceptor recommendation form to the System Medical Director for final approval. The SCT Paramedic’s status as a Preceptor will be updated in the regional provider database. Maintenance of Preceptor Status Preceptor status for all SCT Preceptors will be reviewed annually by the SCT Chief Paramedic. Review criteria will consist of:

Preceptor is actively participating as an SCT provider Compliance with established Continuing Medical Education (CME) requirements Record in good standing as a preceptor Teaching Continuing Education courses each year

Original 2001 Revised 12-21-09


9.22 ALS PRECEPTOR POLICY PURPOSE To outline the requirements for designation as an ALS Preceptor. POLICY

1. Although a preceptor must be recognized by the region in order to meet the requirements of

credentialing as outlined in this policy, an agency is not obligated to use that provider as a preceptor. However, agencies must only use MLREMS preceptors to provide ALS skills field education to students and interns.

2. The Monroe-Livingston Region desires to develop and foster a cadre of experienced ALS providers to

precept new ALS providers in the MLREMS region. As such, desired qualities of a regional preceptor include:

a. An understanding of the educational process for the various levels of care. b. Excellent interpersonal skills with a specific emphasis on coaching and mentoring. c. The ability to apply an evaluation rubric in an objective manner to assist in learning. d. Demonstrated professionalism including high ethical standards, appropriate administrative

ability, continuous development, consistent adherence to standards of care, and knowledge of quality assurance.

3. Preceptor Eligibility

a. Certified ALS provider actively practicing at the preceptor level being desired (EMT-I, EMT-CC, EMT-P) for a minimum of 3 years prior to the date of application.

i. Agencies may submit for consideration preceptor candidates whom do not meet the 3 year active practice certification requirement with support of the Agency Medical Director.

b. System-cleared as an ALS provider actively practicing in the Monroe-Livingston system for one year prior to the date of application.

c. Score of 85% or greater on the MLREMS protocol exam within 6 months of the application. d. Completion of any required regional training as outlined by MLREMS or REMAC. e. Recommendation from agency ALS supervisor and Agency Medical Director.

4. Preceptor Selection

a. Preceptor applications will be reviewed by the REMAC QA Committee. b. An interview with the preceptor candidate may be required by a member of the QA

Committee. c. Preceptors will be appointed by the Regional Medical Director following the recommendation

of the REMAC QA Committee. d. Preceptor candidates who do not receive appointment as a preceptor may appeal to the

REMAC for review of their application.

5. Preceptor Training a. Preceptor candidates will receive the following minimum initial training to obtain System

Preceptor status (may be waived with prior QA Committee Approval): i. Skill development and evaluation of adult learners ii. Coaching and providing appropriate feedback iii. Interpersonal communication skills iv. Curriculum familiarity and stages of development v. Administration of the learning process vi. Use of evaluation forms vii. Confidential feedback to educational institute or employee viii. Professional behavior discussion

b. Once designated as a preceptor, preceptors must meet the following: i. Meet all required regional training as outlined by MLREMS or REMAC. ii. Have no outstanding agency, or regional quality assurance concerns. iii. Complete any preceptor continuing education made available by the Region that may

include highlights and updates of the preceptor program, common concerns, and case studies.

6. It is strongly encouraged that agencies do not overburden their preceptors by limiting their preceptor

time to a maximum of 2/3 of their scheduled road time. 7. A preceptor may have their system preceptor status suspended or revoked by the Regional Medical

Director independent of their ability to practice. Appeals of this decision can be made to the Regional QA committee.

8. A preceptor may request a Leave of Absence and voluntarily suspend their privileges for personal

reasons (e.g. maternity leave, military deployment, temporary disability, etc) by providing such a request in writing to the Regional Program Agency. The Regional Medical Director will confidentially review this request and determine an appropriate plan to allow the preceptor to be reinstated once the preceptor elects to return to active practice.

Original June 21, 2010 Revised February 21, 2011

9.23 LIFE THREATENING HEMORRHAGE PURPOSE Controlling life threatening hemorrhage is a primary goal of emergency medical care. This policy authorizes the use of either a tourniquet or hemostatic gauze to gain rapid hemorrhage control and minimize blood loss from external life threatening hemorrhage. POLICY This procedure may be used by any level provider who is trained on and authorized to use a tourniquet and/or hemostatic gauze by their Agency Medical Director. INDICATIONS

1. Life threatening hemorrhage is indicated by arterial hemorrhage or massive venous hemorrhage as a result of blunt or penetrating trauma.

CONTRAINDICATIONS

1. Tourniquets should not be used on limbs with a dialysis fistula, except in cases of traumatic penetration, amputation, or crush injury without response to a pressure dressing.

2. Never apply tourniquet over a joint. PROCEDURE Hemorrhage from an extremity:

1. In cases where life threatening hemorrhage to a limb cannot be controlled with a pressure dressing, apply tourniquet 2 inches above wound.

2. Tighten tourniquet until bleeding has stopped. 3. Record time that tourniquet was applied. 4. Tourniquet shall remain on until hospital arrival. 5. Inform all subsequent care providers of the location of the tourniquet, its effectiveness,

and time of application. Hemorrhage from axilla, groin, neck, or large scalp wounds:

1. Clear pooled blood from the wound. 2. Pack with hemostatic gauze and maintain direct pressure for at least 3 minutes.

CONSIDERATIONS:

• A tourniquet may be placed over clothing however it does not work well over leather coats or bulky clothing.

• When a tourniquet is placed over clothing, it should be placed as close to the torso as possible.

• If tourniquet placement exceeds 2 hours, contact medical control. • The tourniquet and hemostatic gauze should be re-evaluated every time there is a

change in the patient’s status, or the patient is moved. Original February 21, 2011

9.24 LONG DISTANCE TRANSPORT POLICY

PURPOSE

This policy outlines polices required by agencies that engage in long distance transport (LDT) and shares best practices when considering staffing models for long distance transport of patients out of and into the Monroe-Livingston EMS Region, by Monroe-Livingston Regional EMS provider services.

DEFINITIONS

Ambulance – Any vehicle which meets the motor vehicle, airplane or boat outlined in Chapter VI Title 10 of the New York State Emergency Medical Services Code Part §800.3.e or §800.3.i Crew Configuration – Any combination of emergency medical technician, EMT-Critical Care, EMT-Paramedic, Specialty Care Transport Paramedic (CCEMTP, CCP-C, FP-C, MICP, etc…), or Hospital Specialty provider (Physician, Registered Nurse, Respiratory Therapist, Perfusionist, etc…) Driver – Any person who operates an ambulance. This includes, but is not limited to full time, part time, per-diem or contracted operators. Long Distance Transport – Any transport that involves driving, one way over three hours with a patient onboard.

POLICY

Long distance transport of patients places a demonstrated strain on the crew members tasked with the transport. Crew fatigue and potential adverse weather are likely to promote potentially unsafe conditions for proper vehicle operation and patient care. Agencies are encouraged to develop internal policies governing long distance transport. While no specific Department of Transportation (DOT) or NYS Department of Health (DOH) regulation(s) define or regulate long distance EMS transport, DOT Motor Carrier Rules do place limitations on length of time while driving. Each agency which provides long distance transport shall establish policies that deal with long distance transport. Such policies should include, but not be limited to: Such policies should include, but not be limited to:

1. Limitations of distance/time in which personnel may operate ambulances or act as the medical provider during a long distance transport.

2. Standard Operating Guidelines which outlines standardized checklist or other device to

ensure that sufficient planning and resources are available to ensure the safety of transport of the patient and the crew.

3. Actions when vehicle/equipment failure delay or endanger patient transport

a. Vehicle failure b. Medical equipment failure c. Communications failure d. Diversion to appropriate facilities e. Emergency resupply during transport

The following matrix should be considered when staffing for long distance transports:

Parameter Crew Configuration Comments BLS < 3 hours EMT, EMT BLS > 3 hours EMT, EMT Driver change every 3 hours ALS < 3 hours EMT, ALS ALS > 3 hours EMT, EMT, ALS Driver change every 3 hours SCT, no vent < 3 hours EMT, SCT Add crew as needs/complexity dictate SCT, Vent > 3 hours EMT, EMT, SCT, SCT Driver change every 3 hours, 2nd SCT for pt care Any transport > 10 hours As above Mandated crew rest (overnight) or sufficient crew

replacement (complete) Approved 9-20-2010

9.25 AGENCY MEDICAL DIRECTOR CREDENTIALING

PURPOSE

The primary role of the medical director is to ensure quality patient care. Responsibilities include involvement with the ongoing design, operation, evaluation and revision of the agency’s care for patients from initial patient access to definitive patient care and from basic first response through advanced level care (as indicated by the service type). Each EMS agency should ensure that the medical director has ultimate authority over patient care, including authority to limit the patient care activities of those who deviate from established standards or do not meet training standards, and the responsibility and authority to develop and implement medical policies and procedures. The EMS medical director's qualifications, responsibilities, and authority must be delineated in writing within each EMS agency. The EMS agency has an obligation to provide the EMS medical director with the resources, authority, indemnification, and compensation commensurate with these responsibilities. The following outlines the essential and desired qualifications of a physician providing EMS Medical Direction for an Agency in the Monroe-Livingston Region along with the credentialing requirements and expected responsibilities of the agency EMS Medical Director. POLICY Essential Qualifications:

1. Current and unrestricted New York State license to practice medicine. 2. Current and unrestricted DEA registration. 3. Current and active practice of emergency or acute care medicine in Monroe or Livingston County. 4. Experience or training in the out-of-hospital emergency care of the acutely ill or injured adult or

pediatric patient. 5. Experience or training in on-line and off-line medical direction of out-of-hospital emergency

personnel. 6. Familiarity with the design and operation of out-of-hospital EMS systems. 7. Experience or training in the instruction of out-of-hospital personnel. 8. Experience or training in the EMS quality improvement process. 9. Knowledge of regional protocols, New York State EMS statutes and regulations, New York State

Bureau of EMS Policies, and Federal EMS laws and regulations. 10. Participation in committees or subcommittees of the Regional Medical Advisory Committee.

Desirable Qualifications:

1. Board Certification in Emergency Medicine by the American Board of Emergency Medicine or the American Board of Osteopathic Emergency Medicine.

2. EMS Fellowship training or 2 years of equivalent experience providing medical direction of an EMS agency or system.

3. Completion of an EMS Medical Directors training course. 4. Involvement in state or national EMS organizations.

Credentialing Requirements:

In order to assure agencies in the Monroe-Livingston Region are receiving appropriate physician oversight, the individual physician wishing to serve as an Agency Medical Director must submit the following to the Regional Program Agency for review by the Monroe-Livingston REMAC:

1. Copy of NYS License and DEA. 2. Copy of current curriculum vitae indicating residency training and experience/training in the above

essential expectations. 3. Satisfactory completion of the MLREMS Base Station Course. 4. Satisfactory completion of a REMAC ALS Protocol Test. 5. Completed Medical Direction Authorization Form (DOH 4362).

Physicians wishing to provide Medical Direction for more than 10 transport or ALS-First Response Agencies, or more than 100 ALS providers or 500 BLS providers in one or more regions must receive REMAC Approval before doing so. With the approval of the REMAC Chair in writing, a physician may exceed the maximum thresholds described herein until the next available REMAC meeting in which a quorum is present, at which time the

REMAC Chair’s approval will expire. Final Agency Medical Director Credentialing is subject to REMAC Approval. Agency Medical Director Expectations:

Unless otherwise provided for in statute, rule or policy the responsibilities of an agency EMS Medical Director shall include at a minimum, but not be limited to:

1. Assure that service certified EMS personnel are oriented to the protocols promulgated by the

SEMAC and the REMAC(s) for the area(s) of operation of the service. 2. Interact with REMAC in the development of protocols, the regional Quality Improvement (QI)

process and in disciplinary issues. 3. Active development, review and participation in the Quality Improvement program developed by

the service as part of the Regional Council’s Quality Improvement program, as required in PHL §3006, or §3004-a.

4. Working with the service’s providers on issues and questions regarding all ages of patient care. 5. Participate/interact in other activities that relate to the provision of medical care or affect the

patient care provided by the EMS service. 6. Participate, as necessary, with the service’s certified EMS personnel in Continuing Education

Programs and the re-certification process. 7. Verify, by affirmation provided by the department (DOH-4362 Medical Director Verification form),

that he/she serves as the medical director for the EMS service, providing medical oversight inclusive of the levels of care and/or BLS adjunct treatment protocols specified on the form.

8. In accordance with NYS law, regulation or department policy submit any documentation required for additional level of care approvals obtained by the EMS agency represented.

Original June 20, 2011

9.26 Management of Pelvic Fractures PURPOSE To outline the indications and applications for use of a pelvic immobilization device (Traumatic Pelvic Orthotic Device [T-POD]®, SAM Sling®

, sheet, or similar). POLICY This procedure may be used by any level provider (EMT-B and up) who is trained on and authorized to use a pelvic immobilization device by their Agency Medical Director. INDICATIONS The pelvic immobilization device should be applied to those patients that clinically present with one of the following:

1. Suspected pelvic fracture with hypotension 2. Suspected pelvic fracture with severe pain and high energy mechanism (fall from

significant height or high speed MVC/MCC) 3. Known “open book” fracture

CONTRAINDICATIONS

1. Evisceration of abdominal contents in the area of pelvic immobilization device placement. PROCEDURE

1. Routine medical care. 2. Apply device according to manufacturer instructions being sure to place at the level of the

greater trochanters. 3. Note time of placement and contact receiving facility with relevant patient information and

to advise of pelvic immobilizer placement. Approved 2/21/2011

9.27 USE OF OROGASTRIC TUBES PURPOSE This policy outlines the indications for placement of orogastric tubes. POLICY Orogastric tubes may be placed when available by EMT-P providers trained in its use according to manufacturer’s guidelines, the following procedure, and as approved by the Agency Medical Director. The Agency choosing to carry orogastric tubes must assure providers are trained and that the training is approved by the Agency Medical Director. I. Indications

1. Patient is 12 years of age or greater 2. Patient is orotracheally intubated or a King LTS-D is in place


1. Caustic ingestion 2. Known esophageal disease (varices, esophageal cancer, etc)

III. Procedure

1. Size and measure patient for desired orogastric tube. 2. Adequately lubricate with water-based lubricant. 3. Insert into oropharynx and advance to appropriate measured depth. 4. If a King LTS-D is in place, the appropriately sized orogastric tube may be advanced to

appropriate measured depth through the decompression port of the King LTS-D. Under no circumstances may the tube be placed around any King airway device.

5. Confirm placement by auscultation following expulsion of a large volume syringe filled with air attached to the orogastric tube.

6. Secure the orogastric tube. 7. Manually provide intermittent suction. Under no circumstances should the orogastric tube be left

on continuous suction. 8. Insertion of an orogastric tube should not delay transport. 9. No medications or fluids may be administered via the OG tube without direct, on-line medical

control. 10. Once placed, the tube should remain until removed by hospital personnel unless the patient self-

extubates prior to hospital arrival. Approved 2/21/2011

2011 MLREMS Protocols

Documents

Transcript of 2011 MLREMS Protocols