NYC REMSCO Protocols Jan. 2008 updates Dr. Victor Politi.

NYC REMSCO Protocols

Jan. 2008 updates

Dr. Victor Politi

Where to begin?

• All protocols have been approved by the New York State Emergency Medical Advisory Committee (SEMAC) for use in the NYC region (REMAC)

• Some changes are effective immediately• Changes are reflected in

– GOP– BLS – ALS

The GOP Changes

• Maintenance of IVs by EMT-Bs – Excerpt from DOH policy 04-02 added.

• IO Access and Drug Administration – IO access via an extremity added.

• Pharmacology Table – Amiodarone dose added.– Subcutaneous Epinephrine deleted, now IM.– Lidocaine Infusion deleted

• Pediatric Protocols – Age limitation for use of IO deleted.

The GOP Changes

• Compensated Shock (adult) – Use of ‘Delayed capillary refill’ as a sign of adult shock

deleted.

• Blood Drawing – Blood drawing is no longer limited for glucose level

determination; now at discretion of service medical director.

• Stroke – Stroke Criteria for transport to Stroke Center clarified.

• Newly Born – Term changed back to Neonate

EMT-Basic Protocol

• 400 – WMD – Reference to brand name (MARK I) removed.– Atropine dosages for extended treatment clarified.

• 404 – Non-Traumatic Chest Pain – Nitro in spray form added (assist the patient).

EMT-Basic Protocol

• 407 – Asthma – Age restriction deleted.– BORG deleted– Requirement to contact medical control prior to

administering Albuterol to cardiac patients deleted.– Albuterol may be administered a total of 3 times

(originally 2).

EMT-Basic Protocol

• 414 – Poisoning or Drug Overdose– Reference to shock deleted.

• 420 – Traumatic Cardiac Arrest – AED application and defibrillation added.

• 430 – Emotionally Disturbed Patient – Add direction to contact ALS for chemical restraint if

needed.

• 442 – Care of the Newly Born – Newly Born changed back to Neonate– Minor language changes

• 443 – Newly Born Resuscitation – AHA revisions

EMT-Basic Protocol

• 450 – Pediatric Respiratory Distress/Failure – Minor language change

• 453 – Pediatric Non-Traumatic Cardiac Arrest and Severe Bradycardia– Minor language change

• 455 – Pediatric Anaphylactic Reaction – Minor language change

• 458 – Pediatric Shock – Minor language change

EMT-Paramedic Protocol

• 501 – Respiratory Distress – Narcan is eliminated Protocol now stresses suspected OD be

treated under AMS Protocol.– In Prehospital Sedation, Midazolam is replaced by Lorazepam.

• 503-A – V-Fib / Pulseless V-Tach– Amiodarone mandatory – is no longer an option.

• 504-A – Drug Therapy of Myocardial Ischemia – Lidocaine eliminated.– Narcan no longer administered for hypotension or stupor.

• Reference to GOP for Patients with STEMI


• 506 – Acute Pulmonary Edema – Narcan no longer administered for hypotension or

stupor.

• 507 – Asthma – Epinephrine, Magnesium Sulfate, Methylprednisolone,

and Dexamethasone no longer Medical Control Options, may be administered under Standing orders.

• 508 – COPD– Methylprednisolone, and Dexamethasone no longer

Medical Control Options, may be administered under Standing orders.


• 510 – Anaphylactic Reaction – Epinephrine no longer administered via endotracheal

tube.

• 511 – Altered Mental Status – Glucometer parameters for with-holding dextrose

limited to reading greater than 120 mg/dl.– Narcan may be administered Intranasally (IN).

• 520 – Traumatic Cardiac Arrest – Cardiac monitoring and defibrillation for v-

fib or pulseless v-tach added.


• 543 – Neonate Resuscitation – Newly Born changed back to Neonate.– Delete Narcan via ET tube.– Add Epinephrine via IO/IV.

• 551 – Pediatric Obstructed Airway – Add Needle Cricothyroidotomy.

• 553 – Pediatric Non-Traumatic Cardiac Arrest– Amiodarone added as Standing Order.– Delete lidocaine.– Add Magnesium Sulfate for Torsades de pointes.


• 529 – Pain Management For Isolated Extremity Injury– Morphine Sulfate no longer Medical Control option,

may be administered under Standing orders – new dosage.

– Narcan no longer administered for hypotension or stupor.

• 530 – Emotionally Disturbed Patient – Add medical control option for chemical restraint.


• 554 – Pediatric Asthma/Wheezing – Delete Metaproterenol.– Add Ipratropium Bromide (atrovent) and Terbutaline.

• 555 – Pediatric Anaphylactic Reaction – Add Broselow tape.

• 556 – Pediatric Altered Mental Status – Add Broselow tape.

• 557 – Pediatric Seizures – Add midazolam and IO.

• 558 – Pediatric Decompensated Shock – Clarify dose for adenosine.

GOP

• In cases of adult cardiopulmonary arrest in which IV access is unable to be obtained, IO access should be attempted via an approved extremity approach.

• Drug administration via this route will utilize doses identical to those used for IV administration.

• IO access via the sternum is considered to be unacceptable in the NYC region.

GOP

• According to NYS Department of Health EMS Policy # 04-02 (issued 02/26/04):

• It is allowable for an EMT-B to transport a patient with a secured saline lock device in place as long as no fluids or medication are attached to the port. However, the EMT-B must ensure the venous access site is secured and dressed prior to leaving the health care facility.

GOP

• In the absence of intravenous access, Naloxone (Narcan) may be administered via the intranasal (IN) route when an appropriate atomizer device is available. The route of administration is contraindicated in patients with epistaxis

• Available on all TransCare ALS levelambulances and can be ordered through logistics

PHARM TABLE REVISED>14 yrs of age under 40 kg in weight

Atropine Sulfate 0.02 mg/kg (min 0.1 mg)

Epinephrine 0.01 mg/kg/dose

Furosemide (Lasix) 1 mg/kg/dose

Lidocaine (bolus) 1.5 mg/kg/dose

Lidocaine (infusion) 1-2 mg/min REMOVED

Sodium Bicarbonate 1 mEq/kg/dose

Amiodarone (new) 5 mg/kg ADDED

STEMI (ST Elevation) / Myocardial Infarction

• For all adults, historical / physical findings indicate an AMI, and they have

• ST segment elevation on 12 lead EKG in 2 contiguous leads – 1 mm in the limb leads, – 2 mm in the chest leads– or new left bundle branch block

• Transport to the nearest 24 Hour NYS certified interventional cardiac catheterization facility, as per OLMC

STEMI (ST Elevation) / Myocardial Infarction

• STEMI Center transport unless– The patient is in extremis;– The patient has an unmanageable airway;– The patient has other medical conditions

(Trauma, Burn, CVA) that warrant transport to the closest appropriate hospital emergency department as per protocol.

400 – Weapons of Mass Destruction

Adult Dosing

400 – Weapons of Mass Destruction

Pediatric Dosing

407- Asthma

• Age criteria removed (no longer 1 to 65)

• BORG Scale removed (patients self assessment of excertion)

• Cardiac precautions removed, OLMC is no longer required for, – Angina History– MI History– CHF History

407- Asthma

• Albuterol Sulfate 0.083% may be repeated twice for a total of three (3) doses with the third occurring during transport(old protocol was 2 maximum on standing

orders)

420 TRAUMATIC CARDIAC ARREST

• Begin BCLS procedures

• Excluding patients with penetrating chest trauma, apply AED as described in Protocol 403.– If the “Shock indicated” message is

received, continue with treatment as described in Protocol 403.

– If the “No shock indicated” message is received, begin transport immediately.

AHA Circulation 2005112:IV-146-IV-149

• Traumatic Cardiac Arrest• BLS & ALS support of ABCs• Deterioration associated with trauma

– Hypoxia secondary to respiratory arrest, – airway obstruction, – large open pneumothorax, tracheobronchial or thoracoabdominal

injury – Injury to vital structures, such as the heart, aorta, or pulmonary

arteries – Severe head injury with secondary cardiovascular collapse – Underlying medical problems or other conditions that led to the

injury, such as sudden cardiac arrest (eg, [VF or VT) in the driver of a motor vehicle or in the victim of an electric shock)

– Diminished cardiac output or pulseless arrest (PEA) from tension pneumothorax or pericardial tamponade

– Extreme blood loss leading to hypovolemia and diminished delivery of oxygen

AHA continued

• The most common terminal cardiac rhythms observed in victims of trauma are – PEA (pulseless electrical activity) – Brady/Asystolic rhythms– occasionally V-Fib/V-Tach

• VF and pulseless VT are treated with CPR and attempted defibrillation

• Cardiac contusions causing significant arrhythmias or impaired cardiac function are present in approximately 10% to 20% of victims of severe blunt chest trauma

443 Neonate Resuscitation

• AHA 2006 revisions implemented • For neonates with:

– Persistent central cyanosis (longer than 15 to 30 seconds);

– Respiratory rate less than 30 breaths per minute (hypoventilation);

– Heart rate less than 100 beats per minute (bradycardia); OR

– Cardiac arrest (absence of breathing and pulse)

• Initiate Neonatal Resuscitation procedures.• Request ALS

• CPR in a Neonate is performed utilizing compression to ventilation ratio of 3:1

• 120 events per minute (90 Comp:30 Vent)• If the neonate has:

– Persistent Central Cyanosis; OR– A Respiratory Rate Less Than 30 Breaths Per

Minute; OR– A Heart Rate Between 60 And 100 Beats Per

Minute:• Assist ventilation at a rate of 30 to 60 breaths

per minute• Switch to blow by if RR >30 & HR > 100

cyanosis disappears


• If the neonate has:– A Heart Rate Less Than 60 Beats Per Minute; OR– Cardiac Arrest:

• Start CPR immediately.• Stop CPR and begin assisted ventilation at a

rate of 30 to 60 per minute once the heart rate is >60 beats per minute and rapidly increasing.

• Switch to blow by if RR >30 & HR > 120 cyanosis disappears


453 Pediatric Non Traumatic Cardiac Arrest

• For infants and children with non-traumatic cardiac arrest, or infants and children <9 years of age with a HR <60 bpm (severe bradycardia) and signs of inadequate central perfusion (decompensated shock)

• Pediatric AED-capable pads and cables should be used for all pediatric patients aged 1 to 8 (<9 years of age)

• Do Not delay or withhold AED for any reason who present in Non Traumatic Cardiac Arrest

• CPR in an Infant/Child is performed utilizing compression to ventilation ratio of 15:2

• 120 events per minute (105 Comp:15 Vent)


• If The Infant has a HR <60 bpm:– ventilate at a rate of 20 breath per minute.– Start CPR if the heart rate is not rapidly

increasing following 30 seconds of assisted ventilation.

– Stop CPR and resume assisted ventilation at a rate of 20 breaths per minute once the heart rate is > 60 bpm and rapidly increasing.

– Switch to blow by if RR >20 & HR > 100 cyanosis disappears

Mandatory QA Component

Every application of an AED on a Pediatric patient (even if no shocks

were delivered) the ACR will be reviewed by the Agency’s Medical Director and they are required to

forward all documentation to REMAC for system wide QA purposes continuing until further notice

455 Pediatric Anaphylactic Reaction

• Minor language changes (in red) • Assess the cardiac and respiratory status of the patient.• If both the cardiac and respiratory status of the patient

are normal, initiate transport.• If either the cardiac or respiratory status of the patient is

abnormal, proceed as follows:– If the patient is having severe respiratory distress or shock and

has been prescribed a pediatric(0.15 mg) Epinephrine auto-injector, assist the patient in administering the Epinephrine.

– If the patient’s auto-injector is not available or expired, and the EMS agency carries a pediatric (0.15mg) Epinephrine auto-injector, administer the Epinephrine as authorized by the agency’s Medical Director.

500 – Suspected Cyanide Toxicity Or Smoke Inhalation

• This protocol should be utilized ONLY for the management of hypotensive patients with suspected cyanide toxicity when:– OLMC has been provided for the management of less

than five patients.– At the scene of a mass casualty incident for which a

class order issued by a FDNY-OMA Medical Director who is on-scene

– or as relayed by an FDNY-OMA Medical Director through OLMC (Telemetry)

– or through FDNY Emergency Medical Dispatch

• NOTE: The issuance of a Class Order shall be conveyed to all regional medical control facilities for relay to units in the field.

• Treatment within the “Hot” and “Warm” Zones may be performed only by appropriately trained personnel wearing chemical protective clothing (CPC) as determined by the FDNY Incident Commander

• If providers encounter a patient who has not been appropriately decontaminated, the providers should leave the area immediately until such time as appropriate decontamination has been preformed


EFFECTIVE IMMEDIATELY IF AVAILABLE

• Begin BLS Procedures.• If necessary, perform Endotracheal Intubation*• Begin two IV infusions of Normal Saline (0.9% NS) to

KVO.

• PRIOR TO ADMINISTRATION OF HYDROXOCOBALAMIN, IF POSSIBLE, OBTAIN THREE BLOOD SAMPLES USING THE TUBES PROVIDED IN THE CYANIDE TOXICITY KIT.


• Administer, via separate IV lines, the following medications


NOTE: SODIUM THIOSULFATE, DOPAMINE, and DIAZEPAM MAY NOT BE

administered via the same IV line as HYDROXOCOBALAMIN.

MCO:Dopamine 5 ug/kg/min, IV/Saline Lock drip. If there is insufficient improvement

in hemodynamic status, the infusion rate may be increased until the desired therapeutic effects are achieved or adverse effects appear.

(Maximum dosage is 20 ug/kg/min, IV/Saline Lock drip

Signs and Symptoms of Cyanide Poisoning

• Cyanide is an extremely toxic poison. In the absence of rapid and adequate treatment, exposure to a high dose of cyanide can result in death within minutes due to the inhibition of cytochrome oxidase resulting in arrest of cellular respiration

Signs

Seizures, AMS, COMA

Mydriasis

Tachypnea/Hyperpnia

Bradypnea/Apnea (late)

Hypertension (early)/Hypotension (late)

Cardiovascular Collapse

Vomiting

Symptoms

Headache

Confusion

Dyspnea

Nausea

Chest Tightness

501 Respiratory Arrest

• If OD is suspected utilize the AMS protocol• MCO use of Naloxone is removed• MCO Sedation procedure change

– Administer Etomidate 0.3 mg/kg, IV/Saline Lock bolus, over 30-60 seconds. (Maximum total dose is 20 mg.) After successful intubation, consider Diazepam 5 mg IV/Saline Lock bolus or Lorazepam 2 mg, IV/Saline Lock or IM, for continued sedation

– Midazolam is removed p Etomidate and ∆ to Lorazepam

503-A V-Fib/Pulseless V-Tach

• Language change and Amiodarone is now Mandatory

504 Drug Therapy for Myocardial Ischemia

• Language changes – “Chewable Baby” term removed from text

when referring to aspirin – HYPOTENSION, HYPOVENTILATION, or

STUPOR removed from text p morphine use

• Lidocaine bolus & maintenance drip removed from protocol.

• GOP reference for STEMI center considerations

506 Acute Pulmonary Edema

• Language changes – HYPOTENSION, HYPOVENTILATION, or

STUPOR removed from text p morphine use

Mandatory QA ComponentFor every application of CPAP on a patient the ACR will

be reviewed by the Agency’s Medical Director and they are required to forward all documentation to

REMAC for system wide QA purposes

507 Asthma

• Standing Orders now versus MCO– Epinephrine 0.3 mg (0.3 ml 1:1,000)– Magnesium Sulfate, 2 gm, IV/Saline lock, in

50-100 ml 0.9% NS over 10-20 minutes.– Methylprednisolone 125 mg, IV bolus, or IM,

Or – Dexamethasone, 12 mg, IV bolus, or IM.

508 - COPD

• Standing Orders now versus MCO– Methylprednisolone 125 mg, IV bolus, or IM,

Or – Dexamethasone, 12 mg, IV bolus, or IM.

510 Anaphylactic Reaction

• Endotracheal Administration of Epinephrine completely removed.

• AHA ACLS Studies (Circulations Dec. 2005) – some resuscitation drugs may be administered by the

endotracheal route, multiple animal studies showed that epinephrine (among other meds) administered into the trachea results in lower blood concentrations than the same dose given intravascularly

– Furthermore studies suggest that the lower epinephrine concentrations achieved when the drug is delivered by the endotracheal route may produce transient ß-adrenergic effects. These effects can be detrimental, causing hypotension, lower coronary artery perfusion pressure and flow, and reduced potential for return of spontaneous circulation (ROSC)

511 - AMS

• Language change • IF THE GLUCOMETER READING IS ABOVE 120 mg/dl,

AND THE PATIENT HAS NO SYMPTOMS OR SIGNS OF HYPOGLYCEMIA, DEXTROSE MAY BE WITHHELD.

• Intranasal Narcan has been added.

520 Traumatic Cardiac Arrest

• Begin cardiac monitoring, record and evaluate ECG rhythm. If the ECG demonstrates ventricular fibrillation or pulseless ventricular tachycardia, while in route, treat as per protocol 503A.

• Yes you will be cardiac monitoring and Yes you will be shocking V-Fib & pulseless V-Tach in Traumatic Cardiac Arrest !!!

To reiterate the AHA

• Traumatic Cardiac Arrest• BLS & ALS support of ABCs• Deterioration associated with trauma

– Hypoxia secondary to respiratory arrest, – airway obstruction, – large open pneumothorax, tracheobronchial or thoracoabdominal

injury – Injury to vital structures, such as the heart, aorta, or pulmonary

arteries – Severe head injury with secondary cardiovascular collapse – Underlying medical problems or other conditions that led to the

injury, such as sudden cardiac arrest (eg, [VF or VT) in the driver of a motor vehicle or in the victim of an electric shock)

– Diminished cardiac output or pulseless arrest (PEA) from tension pneumothorax or pericardial tamponade

– Extreme blood loss leading to hypovolemia and diminished delivery of oxygen

– Think reversable causes 5 H’s & 5 T’s

529 Pain Management Isolated Extremity

• Morphine is a Standing Order now with a dosage change (weight based now)

• For patients with a systolic blood pressure greater than 110 mmHg, administer Morphine Sulfate 0.1 mg/kg (not to exceed 5 mg), IV/Saline lock bolus. For continued pain, repeat dose of 0.1 mg/kg (not to exceed 5 mg) may be administered.

• Maximum total dose is 10 mg.

530 - EDP

• BLS before ALS• EDPs PRESUMED to have an underlying

Medical or Trauma causing AMS• Contact medical control if patient agitation

inhibits treatment.• POST SEDATION: Begin an IV infusion of 0.9%

NS KVO or Lock• Begin cardiac monitoring, record and evaluate

rhythm strip.• Apply pulse-oximeter, if available.• Left Lateral (NEVER PRONE Position)

530 - EDP

• If patient is at risk for respiratory or cardiac arrest by continuing to struggle while being physically restrained by the police, contact OLMC

• IF PATIENT IS AGITATED, INITIAL ROUTE OF CHOICE IS IM. – Once sedated IV access should be established

• Diazepam, 5–10 mg, IVB.OR

• Midazolam, 1 – 2 mg, IVB or if IV access is unavailable, administer Midazolam, 10 mg IM.

OR• Lorazepam, 2–4 mg, IVB or if IV access is

unavailable, administer Lorazepam, 4 mg IM.

543 Neonatal Resusitation

• Language change back to Neonate

• Narcan has been removed via ET Tube• DO NOT INTUBATE unless other methods of

airway management are not effective, i.e., failure to increase the heart rate

• IV or IO medication administration is the preferred method. Reminder attempt vascular access no more than twice.

551 Pediatric Obstructed Airway

• Needle Cricothyroidotomy added

• Consider Needle Cricothyroidotomy only if all less invasive methods of airway management are not effective.


• Changes reflect the AHA guidelines for Pediatric resuscitation.

• In V-Fib/V-Tach immediately defibrillate at 2 joules/kg using paddles (pads) of the appropriate size.

• Immediately resume CPR for 5 cycles while defibrillator is recharging

• If still in V-Fib/V-Tach immediately defibrillate at 4 joules/kg


• Atropine Sulfate 0.02 mg/kg is removed from standing orders– Continue with

• If still in V-Fib/V-Tach immediately defibrillate at 4 joules/kg


• Administer Amiodarone, 5 mg/kg, IV or IO. (Broselow Tape or Appendix J.)

• Repeat Epinephrine 0.01 mg/kg (0.1 ml/kg of a 1:10,000 sol) IV/ or IO bolus q 3-5 minutes


• repeat epinephrine 0.1 mg/kg (0.1 ml/kg of a 1:1,000 sol) via the ETT q 3-5 min if no IV or IO has been established.

• THE IV/SALINE LOCK OR IO DOSE OF EPINEPHRINE FOR PEDIATRIC PATIENTS IS 0.01 MG/KG (0.1 ML/KG OF A 1:10,000 SOL). THE ENDOTRACHEAL TUBE DOSE OF EPINEPHRINE FOR PEDIATRIC PATIENTS IS 0.1 MG/KG (0.1 ML/KG OF A 1:1,000 SOL).


• MCO removals • Epinephrine 0.1 mg/kg (now q 3-5 on standing orders) • Lidocaine 1 mg/kg, IV/Saline Lock or IO bolus, or via the

Endotracheal Tube REMOVED• Amiodarone 5 mg/kg, IV/Saline Lock or IO bolus.

REMOVED• Added• If torsades de pointes is present, administer

Magnesium Sulfate, 25-50 mg/kg, IV or IO.


554 Pediatric Asthma Wheezing

• Metaproterenol 5% has been removed• Medications in MCO options have been added • Ipratropium Bromide 0.02% (one unit dose vial of 0.5 ml

in children 6 years of age or older, one half unit dose vial of 0.5 ml in children under 6 years of age), by nebulizer, may be mixed (if available) with Albuterol Sulfate. (See broselow Tape or Appendix J)

• Terbutaline Added• Repeat Epinephrine 0.01 mg/kg (0.01 ml/kg of a 1:1,000

solution), IM, or Terbutaline 0.01 mg/kg, SC, 20 minutes after the initial dose.

557 Pediatric Seizures

• IO added as part of standing orders, attempt vascular access no more than twice!

• If IV/Saline Lock or IO access has not been established, administer Midazolam (Versed) 0.1 mg.kg, IM.

• DO NOT ADMINISTER LORAZEPAM, DIAZEPAM, OR MIDAZOLAM IF THE SEIZURES HAVE STOPPED.

558 Pediatric Decompensated Shock

• Clarification on the dose of Adenosine• Adenosine 0.1 mg/kg, IV or IO bolus, rapidly,

followed by 2 - 3 ml of 0.9% NS flush. • Maximum initial dose is 6 mg.• If this fails to convert the dysrhythmia,

Adenosine may be repeated twice at 0.2 mg/kg, IV or IO bolus, rapidly, followed by 2 - 3 ml of 0.9% NS flush

• Maximum subsequent doses are 12 mg.

Amiodarone

• Amiodarone is a Class III antiarrhythmic drug whose properties include – sodium channel blockade– antisympathetic action– calcium channel blockade – potassium channel blockade

• Becoming more favorable than Lidocaine as an antiarrhythmic drug.

• Onset and duration of Amiodarone’s action is variable, though the half-life of the drug

has been reported to be as long as 40 days

Aminodarone

• Amiodarone is approved for use in the treatment of – Atrial fibrillation, – Ventricular arryhthmias (ventricular fibrillation,

ventricular tachycardia) – Wide complex tachycardias of unknown

etiology (Torsades De Pointes)

Contraindications & Reactions

• Contraindicated in – bradycardia, – second or third degree heart block, – cardiogenic shock– pulmonary congestion

• Reactions– long-term (i.e. pulmonary and hepatic toxicity), some

immediate side effects may be seen in patients.– Nausea, vomiting, hypotension– Nearly 5% of patients (IV amiodarone) will develop

bradycardia or heart block

Drug Interactions

• Amiodarone precipitates when given at the same time as sodium bicarbonate.

• Other cardiac medications (beta blockers, calcium channel blockers, other antiarrhythmics) Amiodarone causes a prolongation of the QT interval

Doses

• V-Fibrillation / Pulseless V-Tach– 300mg, diluted up to a total of 20ml of D5W,

given IV or IO.– converts to a supraventricular (NOT SVT but

supra above the ventricle) rhythm 150mg, diluted in 100ml D5W, over ten minutes

Doses

V-Tach With A Pulse / Wide Complex Tachycardia Of Uncertain Type– 150mg, diluted in 100 ml D5W, over ten minutes

Supraventricular Tachycardia (SVT)– OLMC option 150mg, diluted in 100 ml D5W, over 10

minutes

Atrial Fibrillation / Atrial Flutter– OLMC option 150mg, diluted in 100 ml D5W, over 10

minutes

The Cyanide Kit

2 – 2.5g vials of crystalline powder hydroxocobalamin

1 – 12.5g vial of sodium thiosulfate (50cc of 25% solution)

1 – 250cc bag 0.9% NS

1 – 2 ml fluoride oxalate whole blood tube

1 – 2ml K2 EDTA tube

1 – 2ml lithium heparin tube

Hydroxocobalamin

• Hydroxocobalamin, a precursor of vitamin B12 neutralizes cyanide by fixing it to form cyanocobalamin (vitamin B12), a nontoxic compound that is eliminated in the urine

• Each hydroxocobalamin molecule can bind one cyanide ion by substituting it for the hydroxo ligand linked to the trivalent cobalt ion, to form cyanocobalamin

Preparation

• Each 2.5 g vial of hydroxocobalamin for injection is to be reconstituted with 100 mL of diluent using the supplied sterile transfer spike

• The recommended diluent is 0.9% Sodium Chloride injection (0.9% NaCl).

• Lactated Ringers injection and D5W injection have also been found to be compatible with hydroxocobalamin and may be used if 0.9% NaCl is not readily available.

• Following the addition of diluent to the lyophilized powder, each vial should be repeatedly inverted or rocked, not shaken, for at least 30 seconds prior to infusion

Sodium Thiosulfate

• Classified as an Antidote. • Mechanism of Action:

– Used for cyanide detoxification because it can convert cyanide to the relatively nontoxic thiocyanate ion

• Indications– Cyanide poisoning

• The rationale for using methemoglobin-inducers in cyanide poisoning is based on methemoglobin's ferric iron ability to bind cyanide, thus freeing the cytochrome and allowing aerobic cellular respiration to continue.

• the IV sodium thiosulfate converts cyanmethemoglobin (converted by the Hydroxocobalamin) to thiocyanate sulfite and hemoglobin. Thiocyanate is then excreted.

• So, administration of sodium thiosulfate improves the ability of the hydroxycobalamin to detoxify cyanide poisoning

Ipratropium Bromide

• Class: – Parasympatholitic Bronchodilator

• Actions: – It is an anticholinergic agent chemically

related to Atropine, nebulized it acts directly on smooth muscle of the brochial tree by inhibiting acetycholine receptor sites

• Contraindications: – sensitivity or allergy to Atropine derivatives

• Effects: – peak effect is 1.5 to 2 hours duration is 4-6 hours

• Packaged in a “bullet” or Unit Dose Vial like albuterol.

• Dose– 0.02% solution– one unit dose vial of 0.5 ml in children > 6 years– one half unit dose vial of 0.5 ml in children < 6 years

• Can be used in conjunction (mixed with) Albuterol.

Ipratropium Bromide

• Class– beta-adrenergic agonist bronchodilator

• Actions– stimulation through beta-adrenergic receptors of intracellular

adenyl cyclase, the enzyme which catalyzes the conversion of adenosine triphosphate (ATP) to cyclic 3',5'-adenosine monophosphate (cAMP).

– Increased cAMPlevels are associated with relaxation of bronchial smooth muscle and inhibition of release of mediators of immediate hypersensitivity from cells, especially from mast cells.

• Contraindications– hypersensitive to allergic to sympathomimetics

Terbutaline

• Effects – After SQ administration of 0.25 mg of Terbutaline, a

measurable change in expiratory flow rate usually occurs within 5 minutes

• Side effects – Tremor, nervousness, dizziness, drowsiness,

weakness, headache, upset stomach, flushing, sweating, dry mouth, throat irritation

• Dose– 0.01 mg/kg, SC, 20 minutes after the initial dose*

Terbutaline

NYC REMSCO Protocols Jan. 2008 updates Dr. Victor Politi.

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Transcript of NYC REMSCO Protocols Jan. 2008 updates Dr. Victor Politi.