Download Current ALS Protocols with AEMT changes

CENTRAL NEW YORK EMS
MIDSTATE EMS
NORTH COUNTRY EMS
Serving Cayuga, Cortland, Herkimer, Jefferson, Lewis, Madison,
Oneida, Onondaga, Oswego, St. Lawrence & Tompkins Counties
Collaborative Protocol Handbook
2013
CENTRAL NEW YORK EMS
PROGRAM AGENCY STAFF
Regional Medical Director
Daniel J. Olsson, DO
FACOEP-D
MIDSTATE EMS
PROGRAM AGENCY STAFF
Regional Medical Director
John J. DeTraglia, MD
Executive Director
Susie Surprenant,
NREMT-P
EMS Program Director
Daniel Broedel,
NREMT-P
Clinical Consultant
Kevin Carver, EMT-P
EMS Clinical Coordinator
Vinny Faraone, EMT-P
Clinical Consultant
William McGarrity,
EMT-P
Administrative Assistant
Christina Buda
Clinical Consultant
Colleen Price,
RN, EMT-P
Administrative Assistant
Tamara Eckstadt
NORTH COUNTRY EMS
PROGRAM AGENCY STAFF
Regional Medical Director
Sarah DelaneyRowland, MD
Director
James Stockman, EMT-P
Secretary
Mysti Putnam
REGIONAL EMERGENCY MEDICAL ADVISORY COMMITTEES
CENTRAL NEW YORY EMS REMAC PHYSICIANS
Daniel J. Olsson, DO, FACOEP-D
Chairman and Regional Medical Director
Tom-meka Archinard, MD Michael Jorolemon,DO
James Ciaccio, MD
Jeremy Joslin, MD
Derek Cooney, MD
Drew Koch, DO
Norma Cooney, MD
David Landsberg, MD
Mary DiRubbo, MD
Joseph Markham, MD
Jerry Emmons, MD
Daniel Olsson, DO
Christopher Fullagar, MD
Cupid Gascon, MD
Patsy Iannolo, MD
Naveen Seth, MD
David Thomson, MD
David Wirtz, MD
Central New York EMS
50 Presidential Plaza
Jefferson Tower, Suite LL1
Syracuse, New York 13202
(315) 701-5707
(315) 701-5709 Fax
http://www.cnyems.org
MIDSTATE EMS
NORTH COUNTRY EMS
REMAC PHYSICIANS
REMAC PHYSICIANS
John J. DeTraglia,
Sarah DelaneyMD-FACS
Rowland, MD
Chairman and
Chairman and
Regional Medical
Regional Medical
Director
Director
Lingappa Amernath, MD
Harriet Burris, MD
Andrew Bushnell, MD
Troy Johnson, MD
Dan Horth, MD Maja Lundborg-Gray,MD
John Rubin, DO
Rosemarie Heisse, MD
Naveen Seth, MD
Todd Howland, MD
Michael Thomas, MD
Matt Maynard, DO
George Snicer, MD
Midstate EMS
North Country EMS
1705 Burrstone Road
34 Cornell Drive WH 027
New Hartford, New York 13413
Canton, NY 13617
(315) 738-8351
(315) 379-3977
(315) 738-8981 Fax
(315) 379-3979 Fax
http://midstateems.org
http://www.canton.edu/ncems/
Content Copyright © 2013 by Central New York EMS, Midstate EMS and North Country EMS.
2
INDEX
INTRODUCTION
PEDIATRIC PROTOCOLS (continued…)
4 Medical Control Agreement
43 Altered Mental Status
5 Responsibilities of Providers
44 Asystole / PEA
ADULT PROTOCOLS
45 Facilitated Intubation
6 Routine Medical Care
46 Fluid Challenge
7 Routine Trauma Care
47 IV / IO Therapy
8 Acute Coronary Syndrome
48 Neonatal Resuscitation
9 12 Lead ECG
49 Neonatal Resuscitation - continued
10 Acute Resp. Distress Asthma/COPD 50 Pain Management
11 Airway Management
51 Percutaneous Airway
12 Airway Obstruction
52 Poisoning / Overdose
13 Allergic Reaction / Anaphylaxis
53 Seizures
14 Altered Mental Status
54 Symptomatic Bradycardia
15 Antiemesis
55 Tachycardia - Stable
16 Asystole / PEA
56 Tachycardia - Unstable
17 Burns
57 Tension Pneumothorax
18 Facilitated Intubation
58 V. Fib and Pulseless V. Tach
19 Fluid Challenge
SPECIAL PROTOCOLS
20 Hypoperfusion / Cardiogenic Shock
59 Air Medical Protocol
21 IV / IO Therapy
60 Continuous Positive Airway Pressure
22 OB Complications / Emer. Childbirth 61 Do Not Resuscitate / MOLST
23 Pain Management
62 Interfacility Transfers
24 Patient Restraint
63 Left Ventricular Assist Device (LVAD)
25 Percutaneous Airway
64 Left Ventricular Assist Device -continued
26 Poisoning / Overdose
65 Physician On Scene
27 Post Cardiac Arrest Hypothermia
66 Physician On Scene Card
28 Pulmonary Edema
67 Radio Failure
29 Rapid Sequence Intubation (RSI)
68 Patient Refusals Against Medical Advice
30 Seizures
69 Termination of Resuscitation
31 Stroke
70 Transfer of Care
32 Symptomatic Bradycardia
71 Trauma Triage Criteria
33 Tachycardia - Stable
CHARTS
34 Tachycardia - Unstable
72 Adult Protocol Drug Chart
35 Tension Pneumothorax
73 Adult Protocol Drug Chart - continued
36 V. Fib and Pulseless V. Tach
74 Adult IV Drip & Pediatric Drug Charts
PEDIATRIC PROTOCOLS
75 APGAR & Abnormal Pediatric Vital Signs
37 Routine Medical Care
76 Glasgow Coma & Cincinnati Stroke
38 Routine Trauma Care
77 Cranial Nerve Exam & Visual Pain Scale
39 Acute Resp. Distress
78 Rule of Nines Chart
40 Airway Management
79 Hospital Telephone & Fax Numbers
41 Airway Obstruction
80 Hospital Telephone & Fax Numbers
42 Allergic Reaction / Anaphylaxis
81 Notes
3 All
MEDICAL CONTROL AGREEMENT
These protocols are intended to result in improved patient care by
pre-hospital Providers. They reflect the American Heart Association,
Basic, Advanced and Pediatric Care standards. These protocols are
not intended to be absolute treatment documents, rather as principals
and directives which are sufficiently flexible to accommodate the
complexity of patient management.
THESE PROTOCOLS ARE NOT A SUBSTITUTE
FOR GOOD CLINCAL JUDGEMENT
The goal of pre-hospital care is to provide the best definitive care in a timely
and safe manner.
As an Advanced Provider in the Central New York, Midstate and North
Country Regional EMS Systems you agree to:
 Membership in a regionally approved Advanced Life Support Agency.
 Maintain registration in the Regional EMS Program including all REMAC
approved required documents.
 Successful completion of the appropriate level Protocol Exam.
 Participation in the Regional Continuing Medical Education and skills
maintenance programs.
 Participation in the Regional Quality Assurance Program.
In turn, the Central New York, Midstate and North Country REMACs agree to
authorize you to practice in their respective system of medical control at the
level at which you are currently certified.
If you deviate from the protocols in such a manner as to endanger, potentially
endanger a patient or employ a skill improperly, you may be subject to
suspension of privileges by the respective Regional Medical Director. If your
privileges are suspended (or practice limited), you will be given the opportunity
for a REMAC hearing. If you have any questions or concerns please contact
your Program Agency for assistance.
4
RESPONSIBILITIES OF PREHOSPITAL PATIENT
CARE PROVIDERS AND
COORDINATION OF SERVICES
The provision of patient care is a responsibility given to certified and licensed
individuals who have completed a medical training and evaluation program
specified by the NYS Public Health or Education Laws and related to regulations
or policy. Pre-hospital Providers are required to practice the standards of the
certifying agency (DOH) and the medical protocols authorized by the local
REMAC.
Patient care takes place in many settings, some of which are hazardous or
dangerous. The equipment and techniques used in these situations are the
responsibility of the locally designated, specially trained and qualified personnel.
Emergency incident scenes may be under the control of designated incident
commanders who are not emergency care providers. These individuals are
generally responsible for scene administration, safe entry to a scene or
decontamination of patients or responders.
Pursuant to the provisions of Public Health Law, the individual having the
highest level of pre-hospital certification, and who is responding with authority
(duty to act) is responsible for providing and or directing the emergency medical
care and the transportation of a patient. Such care and direction shall be in
accordance with all NYS standards of training, applicable State and Regional
protocols and may be provided under medical control.
The Governor’s Executive order No. 26 of March 5, 1996, establishes the
National Incident Management System (NIMS) as the standard of command
and control system for emergency operations in New York’s State. The Incident
Command System (ICS) does not define who is in charge, but rather defines an
operational framework to manage many types of emergency situations. One
essential component of ICS is Unified Command. Unified Command is used to
manage situations involving multiple jurisdictions, multiple agencies or multiple
situations involving multiple jurisdictions, multiple agencies or technical needs.
The specific issues of direction, provision of patient care, and the associated
communications among responders must be integrated into each single or
unified command structure and assigned to the appropriately trained personnel
to carry out.
5
ROUTINE MEDICAL CARE
INTERMEDIATE
The following procedures will be performed on medical emergencies
requiring Advanced Life Support:
 Assure scene safety
 Bring ALS equipment to the patient and utilize as indicated:
o AED, Pulse oximetry, Oxygen, Suction
o Advanced airway equipment, Continuous waveform capnography
o IV access, Glucometer (Agencies with Regional approval)
o Capability for field to hospital communications
 Initial patient assessment and vital signs; blood pressure, pulse,
and respirations every 5- 15 minutes and after every treatment
(first BP manually)
 Reassurance and proper positioning
 Medical Control notification as soon as reasonable
INTERMEDIATE STOP
CRITICAL CARE
 Bring ALS equipment to the patient and utilize as indicated:
o Monitor/defibrillator
o Medications
o Obtain 12 Lead ECG if appropriate
CRITICAL CARE STOP
PARAMEDIC
PARAMEDIC STOP
MEDICAL CONTROL ORDER
Key Points/Considerations
 Multiple Patient Procedures:
If a potential MCI exists, contact 911 center and medical control
ASAP. The medical control physician may authorize standing
orders during the MCI. Document incident commander’s name
and affiliated agency.
 Upon completion of patient assessment and identification of need for
ALS, ILS transporting units need to request and then rendezvous
with ALS units or transport to hospital, whichever is closer.
6
ROUTINE TRAUMA CARE
INTERMEDIATE


Establish large bore Normal Saline IV or IO
Intercept with ALS
INTERMEDIATE STOP
CRITICAL CARE
 Apply & Monitor ECG
 If indicated consider Fluid Challenge
 If in traumatic cardiac arrest consider bilateral chest decompression
CRITICAL CARE STOP
PARAMEDIC
PARAMEDIC STOP
MEDICAL CONTROL ORDER
Key Points/Considerations
 Patients meeting Trauma Triage Criteria will be transported to a
designated Trauma Center, unless one of the following conditions
exists transport to nearest hospital:
o Patient in Cardiac Arrest
o Unmanageable Airway
o Directed by Medical Control
7
ACUTE CORONARY SYNDROME
INTERMEDIATE
 Routine Medical Care
 Aspirin 325 mg PO
INTERMEDIATE STOP
ADVANCED EMT
 Nitroglycerin 0.4 mg SL tablet or 1 spray. May repeat every 5 min.
maintaining systolic BP > 100 mmHg.
OR
 Nitroglycerin Paste 1 inch (if systolic BP is > 100 mmHg)
ADVANCED EMT STOP
CRITICAL CARE
 Obtain 12 Lead ECG
For confirmed STEMI:
 Strongly recommend transport to facility capable of primary
angioplasty if transport time is less than one hour
 Notify receiving hospital as soon as possible to discuss transport
options if patient requests facility not capable of primary
angioplasty
 Consider use of air-medical if transport time is greater than one hour
CRITICAL CARE STOP
PARAMEDIC
PARAMEDIC STOP
MEDICAL CONTROL ORDER
 Morphine Sulfate up to 4 mg IV. May repeat every 5 min. up to 10 mg
OR
 Fentanyl 50 mcg slow IV or IM
Key Points/Considerations
 Nitroglycerin, in any form, is not to be administered to patients that
have taken erectile dysfunction medications within the last
72 hours
 4 Baby Aspirin (324 mg total) PO is an acceptable substitute for
Aspirin 325 mg PO
Revised
Revised
2014
2014
8
12 LEAD ECG
Criteria:
 Classic Angina Chest Pain
 Atypical Chest Pain
 Chest Pressure
 Chest Palpitations
 Consider 12 Lead ECG, for patients >55 years old with hypertension
( >140 systolic) or hypertension history or vascular history that
present with one of the following criteria:
o Dyspnea
o Syncope or Dizziness
o Fatigue or Weakness
o Nausea/Vomiting
Frequency:
 Initially with vital signs, where patient is found
 In ambulance, before leaving scene-if not done initially where patient
was found OR if abnormalities found on initial 12 Lead
 If abnormalities noted, repeat with vital signs (every 5-10 minutes)
Considerations For Suspected Acute Myocardial Infarction:
 Consider Second IV access enroute - same arm
 Consider continued Nitroglycerin as per protocol every 5 minutes
even without pain; If systolic BP > 100
V1
V2
V3
V4
V5
V6
4th intercostal space @ R sternum edge
4th intercostal space @ L sternum edge
Between V2 & V4
5th intercostal space, midclavicular line
Level with V4, L anterior axillary line
Level with V5, L mid axillary line
I
aVR
II
AVL
Lateral
Inferior
Lateral
III
AVF
Inferior
Inferior
V1
V4
Septal
Anterior
V2
Septal
V3
V5
Anterior
Lateral
V6
Lateral
Key Points/Considerations
 Radio report (and FAX, if capable) on ALL suspected AMIs
 Document note on PCR if patient was NOT lying flat
 Copies of 12 Leads to hospital AND Agency
 Consider silent MI
9
ACUTE RESPIRATORY DISTRESS
ASTHMA OR COPD
INTERMEDIATE
 Routine Medical Care
 Asthma Patients Only:
o Albuterol Sulfate 2.5 mg in 3ml NS via nebulizer
Repeat x 2 (total of 3 unit doses can be given);
If agency approved. (Critical Care and Paramedic
medication administration begins at the Critical Care line.)
INTERMEDIATE STOP
ADVANCED EMT
 Albuterol Sulfate 2.5 mg in 3ml NS via nebulizer
rate of 6 lpm O2
 Consider CPAP if:
o Patient is and remains alert; No active vomiting
o Is able to follow commands
o No history of pneumothorax
ADVANCED EMT STOP
CRITICAL CARE
 Albuterol Sulfate 2.5 mg in 3ml NS mixed with
Ipratropium Bromide 0.5 mg (one unit dose) via nebulizer at flow
rate of 6 lpm O2
 If no relief: Methylprednisolone 125 mg IV
 Albuterol Sulfate 2.5 mg in 3ml NS via nebulizer; Repeat x 2
 Consider 12 Lead ECG
CRITICAL CARE STOP
PARAMEDIC

Epinephrine 1:1000 (0.3 mg IM)
PARAMEDIC STOP
MEDICAL CONTROL ORDER
Advanced EMT and Critical Care Technician:
 Epinephrine 1:1000 (0.3 mg IM)
Critical Care Technician and Paramedic:
 Albuterol Sulfate 2.5mg in 3ml NS (4th dose and higher) via nebulizer
 Terbutaline 0.25 mg IM should be administered prior to Epinephrine
for patients 51 years and older
Key Points/Considerations
Revised 2014
10
AIRWAY MANAGEMENT
INTERMEDIATE





Manually open the airway
Suction as needed
Insert oropharyngeal or nasopharyngeal airway
Ventilate patient with Bag-Valve Mask and 100% oxygen
May place appropriate alternative rescue airway device for patients
in respiratory or cardiac arrest.
INTERMEDIATE STOP
ADVANCED EMT
ADVANCED EMT STOP
CRITICAL CARE
 May perform endotracheal intubation up to a total of 3 attempts on
patients in respiratory or cardiac arrest. Consider using
GumBougie. (If unsuccessful place appropriate alternative rescue
airway device)
 May attempt endotracheal intubation if patient has an altered mental
status, respiratory rate < 10, and tolerates an oropharyngeal airway.
CRITICAL CARE STOP
PARAMEDIC
 May attempt endotracheal intubation on patients requiring definitive
airway management.
 If direct laryngoscopy is impossible, digital intubation may be
attempted.
 If abdominal distention occurs, pass an Orogastric Tube.
PARAMEDIC STOP
MEDICAL CONTROL ORDER
Key Points/Considerations
 In trauma, manual stabilization is required.
 Confirm and monitor airway device with continuous End-Tidal CO2
waveform capnography. If capnography unsuccessful, confirm
position with EDD or End-Tidal CO2 Detector.
Revised 2014
11
AIRWAY OBSTRUCTION
INTERMEDIATE
 Follow NYS BLS Protocols
 Routine Medical or Trauma Care
INTERMEDIATE STOP
CRITICAL CARE
If BLS maneuvers are unsuccessful:
 Use direct laryngoscopy and Magill forceps
 If unsuccessful, insert an ET tube in attempt to push through the
obstruction or push it into the lower airway
 If unsuccessful, continue efforts and transport
CRITICAL CARE STOP
PARAMEDIC
 If unable to adequately ventilate with BLS/ALS techniques,
perform Needle Cricothyroidotomy. Refer to Percutaneous
Airway Protocol.
PARAMEDIC STOP
MEDICAL CONTROL ORDER
Key Points/Considerations
 Upon completion of patient assessment and identification of need for
ALS, BLS and ILS transporting units need to request and then
rendezvous with ALS units or transport to hospital, whichever
is closer.
12
ALLERGIC REACTION / ANAPHYLAXIS
INTERMEDIATE
 Routine Medical Care
Epi-Pen Autoinjector per NYS BLS Protocols. (AEMT, Critical Care and
Paramedic medication administration begins at the AEMT line.)
 If systolic BP < 90 mmHg with no signs and symptoms of pulmonary
edema, perform Fluid Challenge
INTERMEDIATE STOP
ADVANCED EMT
Inadequate perfusion with respiratory distress, stridor, wheezing,
hypotension, altered level of consciousness, throat tightness, or shock:
 Epinephrine 1:1000 (0.3 mg IM)
 Albuterol Sulfate 2.5 mg in 3 ml NS via nebulizer may repeat
as needed
ADVANCED EMT STOP
CRITICAL CARE
Adequate Perfusion with hives and no respiratory compromise:
 Diphenhydramine 50 mg slow IV; IM
Inadequate perfusion with respiratory distress, stridor, wheezing, hypotension,
altered level of consciousness, throat tightness, or shock:
 Diphenhydramine 50 mg slow IV; IM
 Methylprednisolone 125 mg slow IV; IM
CRITICAL CARE STOP
PARAMEDIC
 Repeat Epinephrine 1:1000 (0.3 mg IM) if no improvement
PARAMEDIC STOP
MEDICAL CONTROL ORDER
 Advanced EMT and Critical Care Technician:
o Epinephrine 1:1000 (0.3mg IM) for repeat dose
 Critical Care Technician and Paramedic:
o Diphenhydramine 50 mg IV or IM for repeat dose
o Glucagon 1mg IM for patients on beta-blockers
o Consider Epinephrine 1:10,000 (0.5 mg IV)
 Paramedic:
o Dopamine Drip 5 -10 mcg/kg/min; Titrate to BP > 100mmHg
systolic
Key Points/Considerations
Revised 2014
13
ALTERED MENTAL STATUS
INTERMEDIATE
 Routine Medical Care
 Assess Blood Glucose
INTERMEDIATE STOP
ADVANCED EMT
 Hypoglycemia:
 If Blood Glucose < 60 mg/dL:
Dextrose 50% 50 ml IV
 If repeat Blood Glucose < 60 mg/dL:
Consider 2nd Dose of Dextrose 50% 50ml IV
 If no IV access: Glucagon 1mg IM
 Signs and symptoms of opiate overdose with respiratory distress
or apnea:
o Naloxone 0.4 mg IV; IM or IN; May repeat every 5 minutes until
respiratory effort improves.
ADVANCED EMT STOP
CRITICAL CARE
o Hyperglycemia:
 If Blood Glucose > 300 mg/dL and patient is without signs
and symptoms of pulmonary edema, consider Fluid
Challenge
CRITICAL CARE STOP
PARAMEDIC
PARAMEDIC STOP
MEDICAL CONTROL ORDER
 Suspected Sympathomimetic OD - (Cocaine or Amphetamines)
o Benzodiazepines
 Suspected Tricyclic OD
o Sodium Bicarbonate
 Suspected Beta Blocker OD
 Glucagon
** Doses to be determined by Medical Control**
Key Points/Considerations
 Consider other etiologies if no response:
o Poisoning
o Head Injury
o Stroke
Revised 2014
14
ANTIEMESIS
INTERMEDIATE
 Routine Medical Care
INTERMEDIATE STOP
CRITICAL CARE
 Obtain 12 Lead ECG
 Ondansetron 4 mg IV or IM or PO or ODT
 Repeat once after 5 minutes as needed
CRITICAL CARE STOP
PARAMEDIC
PARAMEDIC STOP
MEDICAL CONTROL ORDER
 Contact Medical Control for additional doses
Key Points/Considerations
 Prevention and treatment of severe nausea and vomiting
15
ASYSTOLE and
PULSELESS ELECTRICAL ACTIVITY (PEA)
INTERMEDIATE
 CPR
 AED
 Routine Medical Care
 Consider Advanced Airway
INTERMEDIATE STOP
ADVANCED EMT
 Epinephrine 1:10,000 (1 mg IV or IO) Repeat every 3-5 min. during
arrest.
ADVANCED EMT STOP
CRITICAL CARE
 Confirm Asystole in 2 Leads
 Epinephrine 1:10,000 (1 mg IV or IO) Repeat every 3-5 min. during
arrest.
OR
 Vasopressin 40 units IV or IO (as replacement for first or second
dose of Epinephrine).
CRITICAL CARE STOP
PARAMEDIC
PARAMEDIC STOP
MEDICAL CONTROL ORDER
 Sodium Bicarbonate 1 meq/kg IV or IO
Key Points/Considerations
 If witnessed Asystole, immediate Transcutaneous Pacing (TCP)
if available.
 Consider ET medication administration.
 Search for and treat contributing factors:
o Hypovolemia, Hypoxia, Hydrogen Ion (Acidosis),
Hypo/Hyperkalemia, Hypoglycemia, Hypothermia
o Toxins, Tamponade, Tension Pneumothorax, Thrombosis,
Trauma
Revised 2014
16
BURNS
INTERMEDIATE
 Routine Trauma Care
INTERMEDIATE STOP
CRITICAL CARE
 Consider Airway Management
 Consider Fluid Challenge for partial/full thickness burns > 15% BSA
 Consider Pain Management Protocol
CRITICAL CARE STOP
PARAMEDIC
PARAMEDIC STOP
MEDICAL CONTROL ORDER
Key Points/Considerations
 Contact Medical Control as soon as possible for possible referral to
burn center.
 If airway compromise, transport immediately to nearest facility.
 Phosphorous burns should not be irrigated with water. Brush
chemical off thoroughly.
 Hydrofluoric Acid burns be aware of cardiac implications.
17
FACILITATED INTUBATION
PARAMEDIC




Spray hypopharynx with topical anesthetic spray (optional)
Etomidate 20 mg IV over 30 to 60 seconds
If needed, repeat Etomidate 20mg IV over 30 to 60 seconds
After successful intubation, consider medical control option for
continued sedation
 If unsuccessful place appropriate secondary advanced airway device
PARAMEDIC STOP
MEDICAL CONTROL ORDER
 For continued sedation, Midazolam 5 mg IV
 Midazolam 5 mg IV in place of Etomidate
o If Intubation unsuccessful, may repeat Midazolam 5 mg IV
Key Points/Considerations
 Indicated for airway control in combative patients or patients who have
a gag reflex.
 SPO2 monitoring is required during intubation attempts.
 Continuous End-Tidal CO2 waveform capnography is required.
 Confirm and document proper ETT placement .
 Confirm and monitor airway device with continuous End-Tidal CO2
waveform capnography. If capnography unsuccessful, confirm
position with EDD or End-Tidal CO2 Detector.
18
FLUID CHALLENGE
INTERMEDIATE




Routine Medical / Trauma Care
Infuse 500 ml Normal Saline rapidly
Reassess and reconfirm indications
Infuse 500 ml Normal Saline rapidly
INTERMEDIATE STOP
CRITICAL CARE
CRITICAL CARE STOP
PARAMEDIC
PARAMEDIC STOP
MEDICAL CONTROL ORDER
 Paramedic:
o Consider additional fluid
o Dopamine Drip 5 -10 mcg/kg/min;
Titrate to BP > 100mmHg systolic
Key Points/Considerations
 Indicated for patients in cardiac arrest or profound hypovolemia with
alteration in mental status
 Reassess lung sounds
 Up to 1000 ml Normal Saline may be administered
19
HYPOPERFUSION / CARDIOGENIC SHOCK
INTERMEDIATE
 Routine Medical Care
 Systolic BP less than 100 mmHg (if no pulmonary edema)
o Normal Saline bolus 250 ml - 500 ml
o Repeat bolus if lung sounds are clear
 Serial lung sounds assessment
INTERMEDIATE STOP
CRITICAL CARE
 Obtain 12 Lead ECG
 Waveform Capnography
 Advanced airway if indicated
CRITICAL CARE STOP
PARAMEDIC
 For systolic BP less than 100 mmHg:
o Dopamine Drip 5 -10 mcg/kg/min; Titrate to BP > 100 mmHg
systolic
PARAMEDIC STOP
MEDICAL CONTROL ORDER
Key Points/Considerations
 Search for and treat contributing factors:
o Hypovolemia, Hypoxia, Hydrogen Ion (Acidosis),
Hypo/Hyperkalemia, Hypoglycemia, Hypothermia
o Toxins, Tamponade, Tension Pneumothorax, Thrombosis,
Trauma
 Contact Medical Control early if patient remains hypotensive
20
IV / IO THERAPY
INTERMEDIATE
 Patients 16 years and older: May establish Normal Saline IV
 IO access for patients in cardiac arrest or profound hypovolemia with
alteration in mental status
INTERMEDIATE STOP
CRITICAL CARE
 External jugular access for critical patients when no other access is
available
CRITICAL CARE STOP
PARAMEDIC
 Patients any age: IV access
PARAMEDIC STOP
MEDICAL CONTROL ORDER
Key Points/Considerations
 Normal Saline Lock or Normal Saline IV with macro drip
 Critical Patients no more than 90 seconds to obtain IV if available
consider IO
 Critical Care Technician and Paramedic:
o Consider use of EJV in unresponsive patients
o Any vascular access device with an external hub (example:
PICC or Central Line) for patients in cardiac arrest or
profound hypoperfusion with alteration in mental status.
21
OBSTETRICAL COMPLICATIONS and
EMERGENCY CHILDBIRTH
INTERMEDIATE
 Routine Medical Care
 APGAR score at 1 and 5 minutes
 Support fetus
 Gentle delivery
 Provide airway to fetus
 Normal Delivery:
o Follow NYS BLS Protocol
 Umbilical Cord Prolapse:
o DO NOT GRAB CORD
o Place mother face up with hips elevated
o Gently displace fetus off cord
 Breach Presentation:
o DO NOT TUG OR PULL ON FETUS
INTERMEDIATE STOP
CRITICAL CARE
 Postpartum hemorrhage - Follow Hypoperfusion Protocol
 Eclampsia: Magnesium Sulfate 4gm in 50 ml NS IV over 15min.
CRITICAL CARE STOP
PARAMEDIC
PARAMEDIC STOP
MEDICAL CONTROL ORDER
 Pre-eclampsia
o Magnesium Sulfate 4gm in 50 ml NS IV over 15 min OR
o If unable to establish an IV, administer Magnesium Sulfate in
2 doses of 1 gram each in 2ml NS in the buttocks. Administer
1 dose IM in each buttock.
Key Points/Considerations
22
PAIN MANAGEMENT
INTERMEDIATE
 Routine Medical Care
INTERMEDIATE STOP
CRITICAL CARE
Standing Order Indications:
 Patients with pain secondary to:
o Severe burns without hemodynamic compromise
o Suspected extremity fractures or dislocations with severe pain
o Amputations
Medications:
 Morphine Sulfate 4 - 5 mg IV; Dose may be repeated once in
5 minutes as needed
OR
 Fentanyl 50 mcg slow IV or IM
OR
 Nitrous Oxide if available
CRITICAL CARE STOP
PARAMEDIC
PARAMEDIC STOP
MEDICAL CONTROL ORDER
 Presence of any Contraindication (for standing order) or the need
for additional pain control requires a medical control order.
 Painful conditions not listed under “Standing Order Indications”.
 Ketorolac 30 mg IV or 60 mg IM
 66 years and older Ketorolac 15 mg IV or 30 mg IM
Key Points/Considerations
23
PATIENT RESTRAINT
INTERMEDIATE



Routine Medical Care
Assess Blood Glucose
Physical Restraint:
o Appropriate physical restraints can be used but must be
capable of IMMEDIATE RELEASE
o Patient restraint must be in a manner to continuously monitor
airway and vital signs
o Restrain in supine position
o Medical Control MUST be contacted and advised of patient
condition
INTERMEDIATE STOP
CRITICAL CARE

Chemical Restraint:
o Haloperidol 5mg slow IV or IM
o Medical Control MUST be contacted to advise of patient
condition
o Diphenhydramine 50mg IV or IM if dystonic reactions occur
CRITICAL CARE STOP
PARAMEDIC
PARAMEDIC STOP
MEDICAL CONTROL ORDER
Critical Care Technician and Paramedic:
 Midazolam 5 mg IV or IM
Key Points/Considerations
 Emergency personnel should involve law enforcement as early as
possible.
 The above may be used for hemodynamically stable patients
with a psychosocial condition exhibiting extreme anxiety and/or
combative/ violent behavior, if the patient presents a substantial
risk of bodily harm or injury to themselves.
24
PERCUTANEOUS AIRWAY
PARAMEDIC
 Routine Trauma Care
 Confirm indications for Percutaneous Airway
 Percutaneous airway device or surgical airway if trained and
equipped
PARAMEDIC STOP
MEDICAL CONTROL ORDER
Key Points/Considerations
 This procedure applies to situations in which standard endotracheal
intubations cannot be performed.
 This procedure is to be used as a last resort and may not provide
adequate oxygenation for long periods of time. Rapid transport to
the closet hospital is required for definitive airway management.
 Use slow ventilations with extended exhalation periods.
25
POISONING / OVERDOSE
INTERMEDIATE
 Routine Medical Care
 Assess Blood Glucose
INTERMEDIATE STOP
ADVANCED EMT
 If appropriate, Naloxone 0.4 mg IV or IM or IN for respiratory
depressions or apnea; May repeat every 5 minutes until
respiratory effort improves.
ADVANCED EMT STOP
CRITICAL CARE
CRITICAL CARE STOP
PARAMEDIC
PARAMEDIC STOP
MEDICAL CONTROL ORDER
 Tricyclic Antidepressants:
o Sodium Bicarbonate 1 mEq/kg IV
 Beta Blockers:
o Glucagon 0.1 mg/kg IV or IM, up to 2 mg maximum
 Organophosphate insecticides/cholinesterase inhibitors (ingested,
absorbed, or inhaled):
o Atropine 0.02 – 0.05 mg/kg IV or IN
Key Points/Considerations
 Consider scene safety first
 Field decontaminate as indicated
 Identify substance and quantity
Revised 2014
26
POST CARDIAC ARREST
INDUCED HYPOTHERMIA
INTERMEDIATE
 Routine Medical Care
INTERMEDIATE STOP
CRITICAL CARE
 Obtain 12 Lead ECG
 Infuse NS @ 4 degrees Celsius. Maximum 30 ml/kg not to
exceed 2 liters
 Apply ice packs
CRITICAL CARE STOP
PARAMEDIC
PARAMEDIC STOP
MEDICAL CONTROL ORDER
Key Points/Considerations
 Consider potential causes:
o Hypovolemia
o Hypoxia
o Hydrogen Ion (acidosis)
o Hypo / Hyperkalemia
o Hypoglycemia
o Hypothermia
o Toxins
o Tamponade, cardiac
o Tension Pneumothorax
o Thrombosis
o Trauma
27
PULMONARY EDEMA
INTERMEDIATE
 Routine Medical Care
INTERMEDIATE STOP
ADVANCED EMT
 Nitroglycerin 0.4 mg SL tablet or 1 spray. May repeat every 5 min.
maintaining systolic BP > 100 mmHg.
OR
 Nitroglycerin Paste 1 inch (if systolic BP is > 100 mmHg)
 Consider CPAP if:
o Patient is and remains alert; No active vomiting
o Is able to follow commands
o No history of pneumothorax
ADVANCED EMT STOP
CRITICAL CARE
 Consider Acute Respiratory Distress - Asthma or COPD Protocol
 Obtain 12 Lead ECG if appropriate
CRITICAL CARE STOP
PARAMEDIC
PARAMEDIC STOP
MEDICAL CONTROL ORDER
Critical Care Technician and Paramedic:
 Furosemide 40 – 80 mg IV or IM
Key Points/Considerations
 Nitroglycerin, in any form, is not to be administered to patients that
have taken erectile dysfunction medications within the last
72 hours
 Remove Nitro Paste if systolic BP falls below 100 mmHg
Revised 2014
28
RAPID SEQUENCE INTUBATION (RSI)
PARAMEDIC
 Prepare Equipment:
o
o
o
o
o
o
o
o
Suction and BVM with reservoir connected to 100% oxygen
Endotracheal Tube with Stylet and Commercial tube holder device
Laryngoscope with blade and functioning light
Venous Access and Required medications prepared
Cardiac monitor with continuous waveform capnography & SPO2
Secondary confirmation device
Secondary advanced airway
Surgical airway kit
 Routine Medical Care and Preoxygenate patient
 Presedate:
o Lidocaine 100mg IV and
o For Suspected Head Injury or Stroke:
 Vecuronium 1 mg IV OR Lidocaine 1.0 – 1.5mg/kg IV
o For Bradycardia:
 Atropine 0.5 mg IV
 Sedate:
o Etomidate 0.2 – 0.4 mg/kg IV (20-40mg IV)
 Paralysis:
o Succinylcholine 1- 2 mg/kg IV (100 – 200 mg IV) OR
o For severe burns, major crush injury or pre-existing spinal cord injury
 Rocuronium 0.6 mg/kg IV (up to 60 mg IV)
o Intubation: 3 attempts with GumBougie
o Confirm tube placement using primary & secondary methods
 Successful Intubation:
o Monitor heart rate, continuous waveform capnography & SPO2
o Midazolam 2 - 4 mg IV every 5 minutes as needed
o Vecuronium 0.1 mg/kg IV (up to 10 mg)
 Unsuccessful Intubation:
o Utilize secondary advanced airway OR
o BLS airway & ventilations OR Surgical cricothyroidotomy
PARAMEDIC STOP
MEDICAL CONTROL ORDER
Key Points/Considerations

This procedure requires two paramedics to be present. For ground, both paramedics
must be credentialed for this procedure by the REMAC & Regional Medical Director.
 Patient requires sedation and/or paralysis to secure airway. Includes combative patient
that threatens airway, spinal cord stability or safety of crew and/or patient.
 Contraindications: Patients unable to be effectively ventilated using BVM should not
receive paralytics prior to establishment of a definitive airway.
29
SEIZURES
INTERMEDIATE
 Routine Medical Care
 Protect patient from harm
 Assess Blood Glucose
INTERMEDIATE STOP
ADVANCED EMT
 If Blood Glucose < 60 mg/dL:
o Dextrose 50% 50 ml IV
o If unable to start IV:
 Glucagon 1mg IM
ADVANCED EMT STOP
CRITICAL CARE
 If continued seizure activity, administer:
o Midazolam 5 mg IV or IM or IN (Active Seizures Only)

After seizures are controlled, consider 12 Lead ECG
CRITICAL CARE STOP
PARAMEDIC
PARAMEDIC STOP
MEDICAL CONTROL ORDER
 May repeat Midazolam 5 mg IV or IM or IN, if seizures continue
Key Points/Considerations
 Consider other etiologies:
o Hypoglycemia
o Cardiac
o Overdose
o Obstetric Complications
 Midazolam: Maximum volume 1 ml per nostril
Revised 2014
30
STROKE
INTERMEDIATE





Routine Medical Care
Time of onset - last seen “normal”
Obtain Blood Glucose
NYS DOH BLS Protocol
Stroke Assessment
o Cincinnati Prehospital Stroke Scale
INTERMEDIATE STOP
CRITICAL CARE
CRITICAL CARE STOP
PARAMEDIC
PARAMEDIC STOP
MEDICAL CONTROL ORDER
Key Points/Considerations
 Contact Medical Control (REQUIRED)
 Transport the patient to the closest NYS DOH Designated Stroke
Center if the total prehospital time (time from when the patient’s
symptoms and/or began to when the patient is expected to arrive
at the Stroke Center) is less than two (2) hours.
31
SYMPTOMATIC BRADYCARDIA
INTERMEDIATE
 Routine Medical Care
INTERMEDIATE STOP
CRITICAL CARE
 Atropine 0.5 mg IV; May repeat every 3-5 min. up to 3 mg
 Transcutaneous Pacing (TCP)
o Consider Sedation: Etomidate 10 mg IV or IO; May repeat x 1
as needed
 Obtain 12 Lead ECG
 Consider Fluid Challenge
CRITICAL CARE STOP
PARAMEDIC
 Dopamine Drip 5 -10 mcg/kg/min; Titrate to BP > 100 mmHg systolic
PARAMEDIC STOP
MEDICAL CONTROL ORDER
 Consider Sedation for Transcutaneous Pacing (TCP):
o Midazolam
 Consider Pain Management for Transcutaneous Pacing (TCP)
Key Points/Considerations
 Symptomatic Bradycardia is defined by a pulse rate < 50 bpm with a
systolic BP < 90 mmHg AND one or more of the following:
o Chest Pain
o Dyspnea
o Altered Mental Status
o Pulmonary Edema
o Other Signs of Hypoperfusion
32
TACHYCARDIA - STABLE
INTERMEDIATE
 Routine Medical Care
INTERMEDIATE STOP
CRITICAL CARE
 If Stable and Narrow:
o Vagal Maneuvers OR
o Adenosine 6 mg IV rapid push. Adenosine 12 mg IV rapid
push. May repeat once in 1-2 min.
OR
o Cardizem 0.25 mg/kg slow IV push over 10 min. Maximum
single dose 25 mg
 If Stable and Wide:
o Amiodarone 150 mg in 50 ml NS over 10 min.
 Obtain 12 Lead ECG
CRITICAL CARE STOP
PARAMEDIC
PARAMEDIC STOP
MEDICAL CONTROL ORDER
 Lopressor 5 mg in 50 ml NS over 5–10 min.
Key Points/Considerations
 HR > 150 bpm
 Stable Tachycardia is defined as tachycardia with a pulse and
adequate perfusion.
33
TACHYCARDIA - UNSTABLE
INTERMEDIATE
 Routine Medical Care
INTERMEDIATE STOP
CRITICAL CARE
 If Unstable and Wide:
o Consider Sedation:
 Etomidate 10 mg IV
o Cardiovert : 100 joules, 200 joules, 300 joules, 360 joules
 If Unstable and Narrow:
o Consider Sedation:
 Etomidate 10 mg IV
o Cardiovert: 50 joules, 100 joules, 200 joules, 300 joules,
360 joules
o Consider Adenosine:
 Adenosine 6 mg IV rapid push.
 Adenosine 12 mg IV rapid push.
May repeat once in 1-2 min.
CRITICAL CARE STOP
PARAMEDIC
PARAMEDIC STOP
MEDICAL CONTROL ORDER
Critical Care Technician and Paramedic:
 Consider Sedation for Cardioversion:
o Midazolam 5 mg IV
Key Points/Considerations
 HR > 150 bpm
 Unstable Tachycardia is defined as tachycardia with a pulse and
inadequate perfusion.
34
TENSION PNEUMOTHORAX
CRITICAL CARE
 Routine Medical or Trauma Care
 Confirm indications for emergency Needle Chest Decompression
 If patient is in cardiac arrest, proceed with Needle Chest
Decompression
 Needle Chest Decompression - Use second intercostal space,
midclavicular line for landmark. Once catheter is in place, it
should be left open.
CRITICAL CARE STOP
PARAMEDIC

For any patient in need of proceed with Needle Chest Decompression
PARAMEDIC STOP
MEDICAL CONTROL ORDER
Critical Care Technician:
 If patient is not in cardiac arrest, contact Medical Control for
consideration of Needle Chest Decompression
Key Points/Considerations
 Signs of tension pneumothorax include:
o severe respiratory distress
o absent lung sounds on the affected side
o diminished lung sounds on the opposite side
o hypotension
o tachycardia
o distended neck veins
o tracheal deviation away from the affected side
35
V-FIB / PULSELESS V-TACH
INTERMEDIATE
 CPR
 Defibrillation – AED
 Resume CPR immediately for 2 minutes
 Routine Medical Care and Consider Advanced Airway
INTERMEDIATE STOP
ADVANCED EMT
 Epinephrine 1:10,000 (1 mg IV or IO). Repeat every
3-5 min. during arrest.
ADVANCED EMT STOP
CRITICAL CARE
 Defibrillation – deliver 1 shock
o Manual biphasic – device specific (typically 120 to 200 joules) OR
o Monophasic – 360 joules
o Repeat 1 shock every 2 minutes
 Shocks are not stacked; Second and subsequent
doses should be equivalent, and higher doses may
be considered.
 Resume CPR immediately for 2 minutes
 Epinephrine 1:10,000 (1 mg IV or IO or 2 mg ET). Repeat every
3-5 min. during arrest. OR
 Vasopressin 40 units IV or IO (as replacement for first or second
dose of Epinephrine)
 Amiodarone 300 mg IV or IO; Repeat 150 mg in 5 minutes OR
Lidocaine 1-1.5 mg/kg IV or IO or ET. Repeat 0.5 – 0.75 mg/kg IV or
IO or ET every 5 minutes up to total of 3 mg/kg
 In Torsades de Pointes, administer Magnesium Sulfate 1- 2 grams
in 50 ml NS over 5 minutes as the first line antiarrhythmic drug
CRITICAL CARE STOP
PARAMEDIC
PARAMEDIC STOP
MEDICAL CONTROL ORDER
 Sodium Bicarbonate 1 mEq/kg IV or IO
Key Points/Considerations
 CPR for 2 minutes prior to defibrillation; If witnessed arrest,
defibrillate immediately.
 Use same antiarrhythmic drug for duration of protocol.
 Consider ET medication administration.
Revised 2014
36
ROUTINE MEDICAL CARE - Pediatric
INTERMEDIATE
The following procedures will be performed on medical emergencies
requiring Advanced Life Support:
 Assure scene safety
 Patients 16 years and older
 Bring ALS equipment to the patient and utilize as indicated:
o AED, Pulse oximetry, Suction, Oxygen
o Glucometer (Agencies with Regional approval)
o Capability for field to hospital communications
 Initial patient assessment and vital signs; blood pressure, pulse,
and respirations every 5- 15 minutes and after every treatment
(first BP manually)
 Reassurance and proper positioning
 Medical Control notification as soon as reasonable
INTERMEDIATE STOP
CRITICAL CARE
o Bring ALS equipment to the patient and utilize as indicated:
o Advanced airway equipment (refer to Airway Management
Pediatric Protocol), Continuous waveform capnography
o IV access:
 Patients 6 years and older : IV or IO access
 Patients < 6 years in cardiac arrest: IV or IO access
o Monitor/defibrillator; Obtain 12 Lead ECG if appropriate
o Medications
CRITICAL CARE STOP
PARAMEDIC
PARAMEDIC STOP
MEDICAL CONTROL ORDER
Key Points/Considerations
 Multiple Patient Procedures:
If a potential MCI exists, contact 911 center and medical control
ASAP. The medical control physician may authorize standing
orders during the MCI. Document incident commander’s name
and affiliated agency.
 Pediatric protocols apply to patients from birth to onset of puberty.
Onset of puberty is usually 12 -14 years of age with the
development of axillary hair on males and breast buds on females.
37
ROUTINE TRAUMA CARE – Pediatric
INTERMEDIATE


Intercept with ALS
Patients 16 years and older
INTERMEDIATE STOP
CRITICAL CARE
 Advanced airway equipment (refer to Airway Management
Pediatric Protocol)
 Establish large bore Normal Saline IV or IO
(refer to IV or IO Pediatric Protocol)
 Apply & Monitor ECG
 If indicated consider Fluid Challenge
CRITICAL CARE STOP
PARAMEDIC
PARAMEDIC STOP
MEDICAL CONTROL ORDER
Key Points/Considerations
 Patients meeting Trauma Triage Criteria will be transported to a
designated Trauma Center, unless one of the following conditions
exists transport to nearest hospital:
o Patient in Cardiac Arrest
o Unmanageable Airway
o Directed by Medical Control
 Pediatric protocols apply to patients from birth to onset of puberty.
Onset of puberty is usually 12 -14 years of age with the
development of axillary hair on males and breast buds on females.
38
ACUTE RESPIRATORY DISTRESS - Pediatric
INTERMEDIATE
INTERMEDIATE STOP
CRITICAL CARE
 Routine Medical Care
 Wheezing or History of Asthma/ Bronchiolitis:
o Albuterol Sulfate (2.5 mg in 3 ml NS) and Ipratropium Bromide
(0.5 mg in 2.5 ml NS) via nebulizer
o Repeat Albuterol Sulfate (2.5 mg in 3 ml NS) via nebulizer
o Epinephrine 1:1000 (0.01 mg/kg IM) (Maximum single
dose 0.3 mg); May repeat in 20 min.
 Stridor or Drooling:
o Administer 100% oxygen
o Allow position of comfort, do not agitate patient
o Transport without delay
CRITICAL CARE STOP
PARAMEDIC
 Wheezing or History of Asthma/ Bronchiolitis:
o Epinephrine 1:1000 (0.01 mg/kg IM)
(Maximum single dose 0.3 mg); May repeat in 20 min.
OR
o Epinephrine 1:1000 (5 mg combined with 3 ml NS via nebulizer)
 Stridor or Drooling:
o Epinephrine 1:1000 (5 mg combined with 3 ml NS via nebulizer)
PARAMEDIC STOP
MEDICAL CONTROL ORDER
 Critical Care Technician and Paramedic:
o Methylprednisolone 2mg/kg slow IV push (Maximum dose
single 125 mg)
Key Points/Considerations
 You may begin nebulizer therapy prior to establishing IV access.
 Consider respiratory protection for all non-patients in the immediate
area of patient receiving a nebulized epinephrine treatment.
39
AIRWAY MANAGEMENT – Pediatric
INTERMEDIATE






Patients 16 years and older
Manually open the airway
Suction as needed
Insert oropharyngeal or nasopharyngeal airway
Ventilate patient with Bag-Valve Mask and 100% oxygen
May place appropriate alternative rescue airway device for patients
in respiratory or cardiac arrest.
INTERMEDIATE STOP
ADVANCED EMT
ADVANCED EMT STOP
CRITICAL CARE
 May perform endotracheal intubation up to a total of 3 attempts on
patients in respiratory or cardiac arrest. Consider using
GumBougie. (If unsuccessful place appropriate alternative rescue
airway device)
 May attempt endotracheal intubation if patient has an altered mental
status, respiratory rate < 10, and tolerates an oropharyngeal airway.
CRITICAL CARE STOP
PARAMEDIC
 May attempt endotracheal intubation on patients requiring definitive
airway management.
 If direct laryngoscopy is impossible, digital intubation may be
attempted.
 If abdominal distention occurs, pass an Orogastric Tube.
PARAMEDIC STOP
MEDICAL CONTROL ORDER
Key Points/Considerations
 In trauma, manual stabilization is required.
 Confirm and monitor airway device with continuous End-Tidal CO2
waveform capnography. If capnography unsuccessful, confirm
position with EDD or End-Tidal CO2 Detector.
Revised 2014
40
AIRWAY OBSTRUCTION - Pediatric
INTERMEDIATE
 Follow NYS BLS Protocols
 Routine Medical Care or Trauma Care
INTERMEDIATE STOP
CRITICAL CARE
If BLS maneuvers are unsuccessful:
 Use direct laryngoscopy and Magill forceps
 If unsuccessful, insert an ET tube and attempt to push through the
obstruction or push it into the lower airway
 If unsuccessful, continue BLS efforts and transport
CRITICAL CARE STOP
PARAMEDIC
 If unable to adequately ventilate with BLS/ALS techniques, perform
Needle Cricothyroidotomy. Refer to Percutaneous Airway
Protocol.
PARAMEDIC STOP
MEDICAL CONTROL ORDER
Key Points/Considerations
41
ALLERGIC REACTION / ANAPHYLAXIS - Pediatric
INTERMEDIATE
 Routine Medical Care
 Assess BP and respiratory status
 If hemodynamically unstable, consider Epinephrine Autoinjector
INTERMEDIATE STOP
CRITICAL CARE
 Adequate Perfusion with hives and no respiratory distress:
o Diphenhydramine – PO:
 2 - 6 years old: 6.25 mg
 7 - 12 years old: 12.5 mg
 >12 years old: 25 mg
OR
o Diphenhydramine 1mg/kg up to 50 mg slow IV or IM
 Inadequate Perfusion with respiratory distress, stridor, wheezing,
hypotension, altered mental status, throat tightness, or shock:
o Epinephrine 1:1000 (0.01 mg/kg IM up to dose 0.3 mg)
o Diphenhydramine 1mg/kg up to 50 mg slow IV or IM
o Albuterol (2.5 mg in 3 ml NS) and Ipratropium Bromide
o
(0.5 mg in 2.5 ml NS) via nebulizer
o Fluid Challenge
CRITICAL CARE STOP
PARAMEDIC
 Repeat Epinephrine 1:1000 (0.01 mg/kg IM up to 0.3 mg)
PARAMEDIC STOP
MEDICAL CONTROL ORDER
 Critical Care Technician:
o Repeat Epinephrine 1:1000 (0.01 mg/kg IM up to 0.3 mg)
 Critical Care Technician and Paramedic:
o Methylprednisolone 2mg/kg slow IV or IM up to 125 mg
 Paramedic:
o Dopamine Drip 5-10 mcg/kg/min; Titrate to BP > 100mmHg
systolic
Key Points/Considerations
 Consider immediate drug therapy prior to IV access in critical
patients.
42
ALTERED MENTAL STATUS - Pediatric
INTERMEDIATE
 Routine Medical Care
 Assess Blood Glucose for patients 16 years and old
INTERMEDIATE STOP
CRITICAL CARE
 Assess Blood Glucose:
o Hypoglycemia:
 If Blood Glucose < 60 mg/dL:
Dextrose 25% 2ml/kg IV (Maximum single dose
100 ml)
 If unable to start IV, Glucagon 0.1 mg/kg IM (Maximum
single dose 1 mg)
 If no response, consider
Naloxone 0.1 mg/kg IV or IM or IN
(Maximum single dose 2 mg)
o If Blood Glucose > 60 mg/dL:
 Consider Naloxone 0.1 mg/kg IV or IM or IN
(Maximum single dose 2 mg)
CRITICAL CARE STOP
PARAMEDIC
PARAMEDIC STOP
MEDICAL CONTROL ORDER
 Suspected Sympathomimetic OD - (Cocaine or Amphetamines)
o Benzodiazepines
 Suspected Tricyclic OD
o Sodium Bicarbonate
 Suspected Beta Blocker OD
o Glucagon
**Doses to be determined by Medical Control**
Key Points/Considerations
 To make D25: Add 50 ml D50 into 50 ml NS
43
ASYSTOLE and PULSELESS ELECTRICAL
ACTIVITY (PEA) – Pediatric
INTERMEDIATE
 Rendezvous with ALS Intercept or transport to hospital, whichever
is closer
 CPR
 AED
INTERMEDIATE STOP
CRITICAL CARE




Routine Medical Care
Confirm Asystole in 2 leads
Epinephrine 1:10,000 (0.01 mg/kg IV or IO repeat every 3-5 min.)
Consider Advanced Airway
CRITICAL CARE STOP
PARAMEDIC
PARAMEDIC STOP
MEDICAL CONTROL ORDER
 Consider Epinephrine 1:1,000 (0.1 mg/kg ET if no IV or IO
every 3-5 min.)
Key Points/Considerations
 Use adult paddles/electrodes for children weighing > 10 kg
 Consider Underlying Causes:
o Hypovolemia
o Hypoxia
o Hydrogen Ion (acidosis)
o Hypo / Hyperkalemia
o Hypothermia
o Toxins
o Tamponade, cardiac
o Tension Pneumothorax
o Thrombosis
o Trauma
44
FACILITATED INTUBATION -Pediatric
PARAMEDIC
 Spray hypopharynx with topical anesthetic spray (optional)
 >10 years: Etomidate 0.3 mg/kg IV over 30 to 60 seconds ;
(Maximum single dose 20 mg)
 After successful intubation, consider medical control option for
continued sedation
PARAMEDIC STOP
MEDICAL CONTROL ORDER

For intubation in place of Etomidate:
o Midazolam > 6 months 0.025 – 0.05 mg/kg IV (Maximum
single dose 5mg)
 If Intubation unsuccessful:
o May repeat Midazolam 0.025 – 0.05 mg/kg IV (Maximum
single dose 5mg)
 Continued Sedation:
o Midazolam 0.025 – 0.05 mg/kg IV (Maximum
single dose 5mg)
Key Points/Considerations




SPO2 monitoring is required during intubation attempts.
Continuous End-Tidal CO2 waveform capnography is required.
Confirm and document proper ETT placement.
Confirm and monitor airway device with continuous End-Tidal CO2
waveform capnography. If capnography unsuccessful, confirm
position with EDD or End-Tidal CO2 Detector.
 Consult Pediatric Measuring Device for adjunct sizes and drug
dosages; contact Medical Control for any discrepancies.
45
FLUID CHALLENGE - Pediatric
INTERMEDIATE
INTERMEDIATE STOP
ADVANCED EMT





Routine Medical Care/Trauma Care
Confirm indications for fluid challenge
Administer 20 ml/kg NS IV or IO bolus
Repeat bolus of 20 ml/kg if indicated x 2 unless contraindicated.
If potential cardiogenic shock or other significant cardiac disease,
limit fluid administration to 5-10 ml/kg IV or IO unless directed
otherwise by medical control.
ADVANCED EMT STOP
CRITICAL CARE
CRITICAL CARE STOP
PARAMEDIC
 Patients in cardiac arrest or profound hypovolemia with alteration in
mental status: IO access any age
PARAMEDIC STOP
MEDICAL CONTROL ORDER
 Advanced EMT and Critical Care Technician:
o Patients under 6 years: IV or IO access
Key Points/Considerations
 Use large syringe to administer NS bolus.
Revised 2014
46
IV / IO THERAPY - Pediatric
INTERMEDIATE

Patients 16 years and older: May establish Normal Saline IV or IO
INTERMEDIATE STOP
ADVANCED EMT
 Patients 6 years and older : IV or IO access
 Patients < 6 years in cardiac arrest: IV or IO access
ADVANCED EMT STOP
CRITICAL CARE
CRITICAL CARE STOP
PARAMEDIC
 Patients any age: IV access
 Patients in cardiac arrest or profound hypovolemia with alteration in
mental status: IV or IO access any age
 Critical patients 6 years and older when no other access is
available: External Jugular access
PARAMEDIC STOP
MEDICAL CONTROL ORDER
Advanced EMT and Critical Care Technician:
 Patients < 6 years: IV or IO access
Key Points/Considerations
 Do not delay transport for IV or IO access
Revised 2014
47
NEONATAL RESUSCITATION - Pediatric
INTERMEDIATE
 Perform an initial assessment of the infant. Quickly assess the infant’s
respiratory status, pulse and general condition.
o If the infant is breathing spontaneously and crying
vigorously and has a pulse greater than 100/min:
 Ongoing assessment. Obtain and record vital signs,
as often as the situation indicates.

If the infant is not breathing spontaneously and crying vigorously:
o If the infant’s respirations are absent or depressed (less
than 30/minute in a newborn):
 Gently stimulate
o If the respirations remain absent or become depressed (less
than 30/minute in a newborn) despite stimulation, or if
cyanosis is present:
 Clear the infant’s airway by suctioning the mouth and nose
gently with a bulb syringe.

Monitor the infant’s pulse rate continuously.
o If the pulse rate drops below 100 beats per minute at any time,
assist ventilations at a rate of 40 – 60/minute with
supplemental oxygen.
o If the pulse rate drops below 60 beats per minute at any time, or
does not increase above 60 beats per minute after 30
seconds of assisted ventilations, add chest compressions to
assisted ventilations following AHA/ARC/NSC guidelines.
o If respirations remain absent or depressed (less than 30/minute
in a newborn) despite stimulation and oxygen:
 Insert the proper size oral airway gently.
 Ventilate the infant without supplemental oxygen at a rate
of 40 – 60 /minute with an appropriately sized pocket
mask or bag-valve-mask as soon as possible. Each
ventilation given over one second assuring that the
chest rises with each ventilation. If patient does not
respond within 30 seconds add supplemental oxygen.
INTERMEDIATE STOP
continued on next page……
48
NEONATAL RESUSCITATION - Pediatric
continued……
CRITICAL CARE
CRITICAL CARE STOP
PARAMEDIC
 Establish ET and IV or IO access
 Assess blood glucose. If less than 40 mg/dL, treat with
Dextrose 10% 2-4 ml/kg
 Treat dysrhythmias;
 If heart rate less than 60 bpm after adequate ventilation;
o Epinephrine 1:10,000 (0.01 mg/kg IV or IO)
Repeat every 3-5 min.
 Fluid Challenge @ 10 ml/kg
 Consider Naloxone 0.1 mg/kg IV or IO; Maximum single dose is 2mg
PARAMEDIC STOP
MEDICAL CONTROL ORDER
Key Points/Considerations
 To Make Dextrose 10%: Add 12 ml D50 into 50 ml NS bag
 Naloxone can be administered in the case of respiratory depression
and history of narcotic administered to mother within 4 hours
before delivery, unless mother has a history of narcotic addiction
(may precipitate withdrawal in infant with severe seizures).
49
PAIN MANAGEMENT - Pediatric
INTERMEDIATE
 Routine Medical Care or Trauma Care
INTERMEDIATE STOP
CRITICAL CARE
CRITICAL CARE STOP
PARAMEDIC
PARAMEDIC STOP
MEDICAL CONTROL ORDER
Critical Care Technician and Paramedic:
 Morphine Sulfate 0.1 mg/kg IV; Maximum single dose 5mg
o May repeat every 5 minutes
 Fentanyl 1 mcg/kg IV
Key Points/Considerations
 Indicated for patients experiencing pain due to
musculoskeletal injuries, burns (without airway involvement)
abdominal pain (without suspected obstruction) and
cancer pain
50
PERCUTANEOUS AIRWAY - Pediatric
PARAMEDIC
 Routine Trauma Care
 Confirm indications for percutaneous airway
 Percutaneous airway device or equivalent
PARAMEDIC STOP
MEDICAL CONTROL ORDER
Key Points/Considerations
 Situations in which standard endotracheal intubations cannot be
performed.
 This procedure is to be used as a last resort and may not provide
adequate oxygenation for long periods of time. Rapid transport to
the closet hospital is required for definitive airway management.
 Use slow ventilations with extended exhalation periods.
 Medical control must be notified following performance of the
procedure.
 For patients 3 years and younger utilize needle cricothyrotomy.
51
POISONING / OVERDOSE - Pediatric
INTERMEDIATE
 Routine Medical Care
INTERMEDIATE STOP
CRITICAL CARE
 Evaluate potential substance involved and utilize specific treatments
as listed below.
CRITICAL CARE STOP
PARAMEDIC
PARAMEDIC STOP
MEDICAL CONTROL ORDER
 Tricyclic Antidepressants:
o Sodium Bicarbonate 1 mEq/kg IV
 Beta Blockers:
o Glucagon 0.1 mg/kg IV or IM, up to 2 mg maximum
 Organophosphate insecticides/cholinesterase inhibitors (ingested,
absorbed, or inhaled):
o Atropine 0.02 – 0.05 mg/kg IV or IN
Key Points/Considerations




Give nothing by mouth unless directed by medical control
Initiate transport with attention to protection of airway
Determine substance, quantity and route of exposure
Transport substance container to hospital
52
SEIZURES - Pediatric
INTERMEDIATE
 Routine Medical Care
 Protect patient from harm
 Assess Blood Glucose for patients 16 years and older
INTERMEDIATE STOP
CRITICAL CARE
 If Blood Glucose < 60 mg/dL:
o Administer Dextrose according to following dosing schedule:
 < 6 years old: Administer Dextrose 25% 2 ml/kg IV
(Maximum single dose 100 ml)
 > 6 years old: Administer Dextrose 50% 2 ml/kg IV
(Maximum single dose 50 ml)
o If unable to start IV:
 Glucagon 0.1 mg/kg IM (Maximum single dose is 1 mg)
o If continued seizure activity, administer:
 Midazolam 0.1 mg/kg IV or IM or IN (Maximum single
dose is 2 mg)
 Dextrose or Glucagon may be repeated in 10 minutes if repeat Blood
Glucose is < 60mg/dL
CRITICAL CARE STOP
PARAMEDIC
PARAMEDIC STOP
MEDICAL CONTROL ORDER
 May order additional doses of Midazolam
Key Points/Considerations
 If status epilepticus, begin rapid transport
 Treat Underlying Causes
 To make D25: Add 50 ml D50 into 50 ml NS
53
SYMPTOMATIC BRADYCARDIA - Pediatric
INTERMEDIATE
 Rendezvous with ALS unit or transport to hospital, whichever is
closer
INTERMEDIATE STOP
CRITICAL CARE




Routine Medical Care
CPR if heart rate < 60 bpm with poor perfusion
Epinephrine 1:10,000 (0.01 mg/kg IV or IO every 3-5 min.)
Atropine 0.02 mg/kg IV or IO; May repeat once
o (Minimum single dose 0.1 mg)
o (Maximum single dose 0.5 mg)
o (Maximum total dose 1 mg)
 Obtain 12-Lead ECG
CRITICAL CARE STOP
PARAMEDIC
PARAMEDIC STOP
MEDICAL CONTROL ORDER
 Consider Epinephrine 1:1,000 (0.1 mg/kg ET if no IV or IO every
3-5 min.)
 Consider Atropine 0.04 mg/kg ET if no IV or IO; May repeat once
o (Minimum single dose 0.1 mg)
o (Maximum single dose 1 mg)
 Consider Transcutaneous Pacing
Key Points/Considerations
 Treat Underlying Causes
54
TACHYCARDIA – STABLE - Pediatric
INTERMEDIATE
 Rendezvous with ALS Intercept or transport to hospital, whichever
is closer
INTERMEDIATE STOP
CRITICAL CARE
 Routine Medical Care
 Obtain 12 Lead ECG
 Treat Underlying Causes
CRITICAL CARE STOP
PARAMEDIC
PARAMEDIC STOP
MEDICAL CONTROL ORDER
Key Points/Considerations
 HR > 150 bpm
 Stable Tachycardia is defined as tachycardia with a pulse and
adequate perfusion.
55
TACHYCARDIA – UNSTABLE - Pediatric
INTERMEDIATE
 Rendezvous with ALS Intercept or transport to hospital, whichever
is closer
INTERMEDIATE STOP
CRITICAL CARE




Routine Medical Care
Obtain 12 Lead ECG
Treat Underlying Causes
Consider Paramedic Intercept or transport to hospital, whichever
is closer
CRITICAL CARE STOP
PARAMEDIC
EVALUATE QRS:
QRS Normal <0.09 (SVT)
QRS Wide >0.09 (VT)
 Vagal Maneuver
 *Synchronized Cardioversion
0.5 – 1 joules/kg
May repeat at 2 joules/kg
 Adenosine 0.1 mg/kg rapid IV
 Amiodarone 5mg/kg in 50 ml NS
(Maximum single dose 6mg)
over 20-60 min.
(Maximum single dose 300 mg)
*Consider sedation prior to cardioversion
PARAMEDIC STOP
MEDICAL CONTROL ORDER
 Paramedic:
Consider Midazolam 0.1 mg/kg IV for sedation
Key Points/Considerations
 HR > 150 bpm
 Unstable Tachycardia is defined as tachycardia with a pulse and
inadequate perfusion.
56
TENSION PNEUMOTHORAX – Pediatric
PARAMEDIC
 Routine Medical or Trauma Care
 Confirm indications for emergency needle chest decompression
 Needle Decompression - Use second intercostal space, midclavicular
line for landmark. Once catheter is secured in place secure to the
chest wall.
PARAMEDIC STOP
MEDICAL CONTROL ORDER
Key Points/Considerations
 Signs of tension pneumothorax include:
o severe respiratory distress
o absent lung sounds on the affected side
o diminished lung sounds on the unaffected side
o hypotension
o tachycardia
o distended neck veins
o tracheal deviation away from the affected side
57
V-FIB / PULSELESS V-TACH - Pediatric
INTERMEDIATE
 Rendezvous with ALS Intercept or transport to hospital, whichever
is closer
 CPR
 Defibrillation – AED
o Resume CPR immediately for 2 minutes
INTERMEDIATE STOP
CRITICAL CARE
 CPR for 2 minutes prior to defibrillation; If witnessed arrest,
defibrillate immediately.
 Defibrillate at 2 joules/kg – deliver 1 shock
 Resume CPR immediately for 2 minutes
 Routine Medical Care
 Consider Advanced Airway
 Defibrillate at 4 joules/kg – deliver 1 shock
 Epinephrine 1:10,000 (0.01 mg/kg IV or IO every 3-5 min.)
 Resume CPR immediately for 2 minutes
 Defibrillate at 4 joules/kg – deliver 1 shock
 Amiodarone 5mg/kg IV or IO (Maximum single dose 300 mg)
o Repeat once in 3-5 min. (Maximum single dose 150 mg)
 Resume CPR immediately for 2 minutes
CRITICAL CARE STOP
PARAMEDIC
PARAMEDIC STOP
MEDICAL CONTROL ORDER
 Consider Epinephrine 1:1,000 (0.1 mg/kg ET if no IV or IO
every 3-5 min.)
Key Points/Considerations
 Use adult paddles/electrodes for children weighing > 10 kg
58
AIR MEDICAL
SPECIAL PROTOCOL
Air Medical transport should be considered for the following:
 Anytime a patient outcome could be improved by shortened
transport time such as:
o Ground transport greater than 30 minutes
o Prolonged extrication
o A remote or wilderness area, difficult terrain, or any other time
when ground ambulance access is prevented or delayed.
o Multiple critical / unstable patients / multiple casualty incident
o To bring special medical personnel and equipment to the
scene, such as a physician or surgeon,
o Paramedic level care is otherwise unavailable
Request for Air Medical Service should be made immediately when
one of the above criteria is met.
Patient transport should not be delayed awaiting a helicopter. Begin
transport to the hospital and rendezvous with the helicopter, if
possible and at a predetermined safe landing site, enroute to the
hospital.
Requests from the scene should be made by the highest trained EMS
provider (through the incident commander, as appropriate) to the
County Dispatch (Fire control or 911 centers). Requests will be made
through the Central NY Air Medical Clearing House.
The pilot will determine if the mission will be flown. Once at the
scene the flight medical crew may elect to fly the patient, accompany
the patient by ground, or have the patient transported by ground with
the on-scene crew.
59
CONTINUOUS POSITIVE AIRWAY PRESSURE
(CPAP)
SPECIAL PROTOCOL
CRITICAL CARE







Routine Medical Care
Confirm indications for CPAP
Assemble equipment per manufacturer’s directions
Explain procedure to the patient
Start CPAP at 5 cm H2O pressure
Evaluate respiratory status in 3 - 5 minutes
If patient does not improvement, then increase CPAP to 10 cm
CRITICAL CARE STOP
PARAMEDIC
PARAMEDIC STOP
MEDICAL CONTROL ORDER
 Critical Care Technician and Paramedic:
o Consider Midazolam 2.5 mg IV for sedation
Key Points/Considerations
Contraindications:
 Respiratory arrest (or obvious need for intubation)
 Systolic BP < 90 mmHg
 Pneumothorax
 Decreased level of consciousness (must be coachable)
 Severe facial injuries / deformity
 Active vomiting
Warning:
If patient fails to improve with treatment, begin positive ventilation
with BVM or intubation.
60
DO NOT RESUSCITATE / MOLST
SPECIAL PROTOCOL
If a valid DNR/MOLST exists, and a patient becomes pulseless and or
apneic DO NOT ATTEMPT RESUSCITATION:
DNR/MOLST forms should be honored:
 Transferring a patient from a health care facility with a valid
DNR/MOLST order, or an order signed by a physician to accompany
the patient in the ambulance.
 When the patient has a valid DNR/MOLST form.
DNR/MOLST should be disregarded:
 The provider in good faith believes the order has been revoked.
 A physical confrontation with a family member, who disagrees with
the order, appears likely.
Living Will and Health Care Proxies:
 Living Wills have no validity in the pre-hospital setting and should be
disregarded if necessary contact Medical Control for assistance.
 When a health care proxy is present (both the document and the
designated individual) and there is a disagreement as to the validity,
and whether resuscitation attempts should be initiated/continued,
contact Medical Control.
In the event a patient expires during transport between medical facilities
that patient should be returned to the sending facility. Contact Medical
Control for additional assistance.
61
INTERFACILITY TRANSFERS
SPECIAL PROTOCOL
 Field providers may transport patients with the following IV equipment and
IV drips without facility staff:
EMT
EMT-I
Saline lock
Stable patient with no anticipation of further interventions enroute
Peripheral IV lines with no additives
Stable, non-intubated patients with no further interventions needed enroute
EMT-CC
Peripheral IV lines
Cardiac monitor/defibrillator
Intubated patients > 5 years old
Antibiotic (may not be 1st dose ) drip
Amiodarone drip [1, 2]
Chest Tubes [1, 2]
Diltiazem drip [1, 2]
Glycoprotein (GPIIb/IIIa) Inhibitor drip [1, 2]
Insulin drip [1, 2]
Lidocaine drip
Bretylium drip [1, 2]
Heparin drip [1, 2]
Methylprednisolone drip [1, 2]
IV drips:
All electrolyte and lipid solutions
Dobutamine
Procainamide
Aminophylline
EMT-CC protocol drugs
EMT-CC protocol drugs (MS, NTG. Etc.)
EMT-P
In addition to above:
Benzodiazepine drip or bolus [1, 2]
Levophed drip [1, 2]
Propofol drip [1, 2]
Intubated patients any age
Central venous lines/PICC Lines [3]
Hickman catheters [3]
Subclavian IV [3]
Internal jugular IV [3]
Port-a-Cath [3]
Arterial lines-May not be used for IV access or any medications
Paramedic protocol drugs
Key Points/Considerations
1. The transferring facility must supply the IV pump and training for the above drips.
Unless the agency has their own equipment.
2. Contingent on approval of the Agency Medical Director. In addition, a provider
must have received chest tube training as prescribed by the Agency Medical Director.
3. Not to be accessed by EMT-P during transport. If the line is to be used for medication
infusion, facility personnel must access it prior to leaving the hospital.
62
LEFT VENTRICULAR ASSIST DEVICE (LVAD)
SPECIAL PROTOCOL
INTERMEDIATE
Criteria:
Any request for service that requires evaluation and transport of a patient with a
Left Ventricular Assist Device (LVAD).
 Assess airway and breathing. Treat airway obstruction or respiratory
distress per protocol. Treat medical or traumatic condition per protocol.
 Assess pump function and circulation:
o Listen to motor of pump over heart and observe green light on
system control device.
 Assess perfusion based on mental status, capillary refill, and skin color. The
absence of a palpable pulse is normal for patients with a functioning
LVAD. They may not have a blood pressure.
o DO NOT PERFORM CPR.
 Perform secondary assessment, treat per protocol.
 Notify Heart Failure Coordinator ASAP, regardless of the patient's
complaint. Patient will have contact numbers.
 Contact Medical Control. Bring patient's power unit and batteries to the
Emergency Department.
 Trained support member must remain with patient.
 Do not delay transport to hospital.
INTERMEDIATE STOP
CRITICAL CARE
 If hypotensive (defined as poor perfusion based on mental status,
capillary refill, or skin color):
o Establish IV or IO access and administer 500 ml NS bolus.
o Reassess and repeat up to 1000 ml total. Contact Medical Control for
additional fluid boluses.
 If patient does not have evidence of adequate perfusion and
oxygenation with treatment, despite the device being on, treat with
standard ACLS measures.
CRITICAL CARE STOP
continued on next page……
63
LEFT VENTRICULAR ASSIST DEVICE (LVAD)
continued……
PARAMEDIC
PARAMEDIC STOP
MEDICAL CONTROL ORDER
Key Points/Considerations
 Community patients are entirely mobile and independent.
 Keep device and components dry.
 Batteries and the emergency power pack can provide 24-36 hours
of power.
 Trained support members include family and caregivers who have
extensive knowledge of the device. Its function, and its battery
units and are a resource to the EMS provider when caring for a
LVAD patient.
 Patients are frequently on three different anticoagulants and are
prone to bleeding complications.
 Patient may have VF/VT and be asymptomatic. Contact Medical
Control for treatment instructions.
64
PHYSICIAN ON SCENE
SPECIAL PROTOCOL
 A patient's personal physician may assume medical control
responsibility for his/her patient if he/she desires. In such
circumstances, do the following:
o Give the physician the card describing the function of the
Regional Medical Control System.
o If the physician still desires that the patient be transported
without ALS, he should order "NO ALS, TRANSPORT ONLY"
on the Patient Care Report and sign this order.
o Notify the destination hospital of the case after you are enroute
o If the patient's condition deteriorates enroute, contact the
Emergency Department physician who will decide if ALS
protocols should be started.
o If the patient's physician accompanied the patient in the
ambulance, he/she will be responsible for this decision.
o Bystander physicians may not circumvent standard operating
procedures or assume Medical Control without approval from
the Resource Hospital physician.
Key Points/Considerations
 Physicians Only: Physician Assistants, Nurse Practitioners, etc. are
excluded.
65
PHYSICIAN ON SCENE CARD
SPECIAL PROTOCOL
CENTRAL NEW YORK EMS, MIDSTATE EMS and
NORTH COUNTRY EMS PROGRAM AGENCIES
Thank you for your offer of assistance. Please be advised that we are
working under Medical Control from physicians at a hospital. We are not
permitted to relinquish Medical Control to a physician on the scene without
approval from the physician at the Resource Hospital.
Should you wish to assume Medical Control, you may request to speak with
the Resource Hospital Physician. If you are authorized to provide Medical
Control, you must sign the patient's Prehospital Care Report and
accompany the patient to the hospital.
If you have any questions regarding this Physician-On-Scene Policy, please
contact the Central New York Emergency Medical Services Program Agency
at: (315) 701-5707 or Midstate EMS Program Agency at: (315) 738-8351
or North Country EMS Program Agency at: (315) 379-3977.
Daniel J. Olsson, DO
Regional Medical Director, Central New York EMS Program Agency
John J. DeTraglia, MD
Regional Medical Director, Midstate EMS Program Agency
Sarah Delaney-Rowland, MD
Regional Medical Director, North Country EMS Program Agency
66
RADIO FAILURE
SPECIAL PROTOCOL
 In the event that direct communications with any hospital cannot be
established because the crew is not in UHF/VHF radio range due to
either distance from the radio tower, or radio dead spots, or the
UHF/VHF radio is malfunctioning, making voice communications
impossible, and no telephones are available at the scene, and no
other means of direct communications are available, the following
policy will be in effect:
Given the above circumstances, to allow for the immediate
treatment of any emergency deemed appropriate in the
judgment of the EMT-CC or EMT-P in charge, all treatments in
the Regional ALS Protocol Handbook, except for controlled
substances (excluding seizures), which would ordinarily require
a physician's order may be carried out by any individual
appropriately certified to use the protocols within the Region.
All time sequences, as specified in the protocols will be
followed. All indications for the treatment, the time treatments
were performed, and patient responses to the treatment MUST
be thoroughly documented on the PCR or other appropriate run
record.
Key Points/Considerations
 Use of this protocol assumes that attempts have been made via all
available means to make contact with Medical Control.
 Thorough documentation is MANDATORY with regard to description
of the communications problems encountered including location,
number of attempts at communications which were made, and the
description of the patient's condition which warranted immediate
treatment. In addition, attempts to contact Medical Control will be
repeated at 5-minute intervals.
 All documentation regarding each case utilizing the Radio
Failure protocol will be submitted to the Program Agency
within one week from the date of occurrence for review
by the Executive CQI Committee.
YOU MAY NOT USE THE RADIO FAILURE PROTOCOL TO
TERMINATE RESUSCITATION EFFORTS IN THE FIELD
67
PATIENT REFUSALS AGAINST
MEDICAL ADVICE
SPECIAL PROTOCOL
 Talk with patient, family and friends and attempt to convince of the
need for treatment/transport. Offer to call Medical Control and have
patient speak with a physician.ie still refuses treatment/transport and
 If patient still refuses treatment/transport and > 18 years old
Assess Level of Consciousness:
Alert and oriented x 3 / GCS x 15
Altered Mental Status
 Assess for the following:
 Attempted/threatened suicide,
 minor (<18) refusing care,
 parent refusing and the
potential for a serious
illness/child abuse exists
Criteria Absent: Criteria Present:
 Patient cannot refuse.
Contact Medical Control.
Elicit assistance from
law enforcement
Patient can
Patient cannot
refuse.
refuse.
Educate patient
Contact Medical
and family.
Control.
Patient signs
Elicit assistance from
AMA on
law enforcement.
Regional
Refusal Form.
Key Points/Considerations
 Contact On-Line Medical Control for ALS Refusals.
 Under no circumstances should field personnel allow themselves
to be placed in danger. If this potential exists, go to a safe area
and call for assistance.
68
TERMINATION OF RESUSCITATION
SPECIAL PROTOCOL
CRITICAL CARE






Document Asystole in 2 leads
Contact Medical Control for order to discontinue
Contact local law enforcement and medical examiner/coroner
Leave invasive therapies in place
Provide support to family members
Bring or fax Prehospital Care Report to hospital for signature
immediately upon completion of call
CRITICAL CARE STOP
PARAMEDIC
PARAMEDIC STOP
MEDICAL CONTROL ORDER
Key Points/Considerations
 THIS PROTOCOL CANNOT BE USED DURING RADIO FAILURE
 Once begun, you may terminate resuscitation efforts if a DNR or
MOLST form with a valid DNR order is found to exist or if you have
completed the Adult Asystole Protocol with no success.

Do not delay transport in traumatic cardiac arrest.
69
TRANSFER OF CARE
SPECIAL PROTOCOL
 ALS assessment complete
 Mechanism of injury, chief compliant or assessment warrants ALS
intervention and/or ALS transport
o ALS shall care for and transport patient
OR
 Mechanism of injury, chief compliant or assessment does not
warrant ALS intervention and/or ALS transport
o ALS provider may transfer care or contact Medical Control to
affirm decision to transfer patient to EMT-Basic or EMT-I.
Document decision on Patient Care Report.e
Key Points/Considerations
 ALS providers are authorized to transfer care of a patient to an EMT
Basic or EMT–I after patient assessment indicates no need or
anticipated need for ALS.
 EMT-P providers are authorized to transfer ALS care to EMT-CC
providers if no Paramedic interventions have been initiated or are
anticipated or after contacting Medical Control to affirm decision to
transfer patient care. Document this decision on the PCR.
 Transfer of care may not be made by any level to a CFR.
70
TRAUMA TRIAGE CRITERIA
SPECIAL PROTOCOL
Adult and Pediatric:
Major trauma is present if the patient’s physical findings or the mechanism of
injury meets any one of the following criteria:
 Glasgow Coma Scale < 13 or deterioration of Glasgow Coma Scale –
trauma related
 Trauma with hypotension (systolic BP 90 mmHg or less), tachycardia
(pulse 120 or greater)
 Multiple system trauma
 Penetrating head, neck, chest or abdominal injuries
 Major chest wall injury/flail chest
 Two or more proximal long bone fractures
 Patients requiring assisted ventilation – trauma related
 Head injury with changing neurological status
 Suspected spinal cord injury or limb paralysis
 Comatose, trauma related
 Crushed chest or pelvis/major amputations
 Falls 20 feet or greater in an adult / 10 feet or greater in a child
 Patient ejected from closed vehicle
 Burns > 20% of body surface area or 20% with airway or facial burns
 Severe facial, airway, or neck injuries
 Pediatric trauma that meets any of above criteria
 All near-drowning victims with hypothermia or respiratory distress
 Hanging victims with respiratory distress
 Trauma transfer patients from other hospitals receiving blood to maintain
vital signs
 Emergency physician discretion
Source: 2012 American College of Surgeons Standards
71
ADULT - PROTOCOL DRUG CHART
DRUG
DOSE
INDICATIONS
Adenosine (Adenocard)
6 mg IV, 12 mg IV
Anti-Arrhythmic
Albuterol Sulfate
2.5 mg in 3 ml NS via Nebulizer
Amiodarone
300 mg IV/IO
150 mg IV/IO
150 mg in 50 ml NS over 10 min
1 spray
Respiratory Distress
Allergic Reaction
V. Fibrillation/Pulseless V. Tach
V. Fibrillation/Pulseless V. Tach
Tachycardia-Stable
Facilitated Intubation
Anesthetic Spray (Cetacaine)
Aspirin
Acute Coronary Syndrome
Cardizem
325 mg PO
324 mg PO (Baby Aspirin)
0.5 mg IV
0.02-0.05 mg/kg IV/IN
0.5 mg IV
0.25 mg/kg IV over 10 min
50% Dextrose
50 ml IV
Diphenhydramine (Benadryl)
50 mg IV/IM
50 mg IV/IM
5-10 mcg/kg/min drip
Hypoglycemia
Seizures
Allergic Reaction/Anaphylaxis
Sedation
Allergic Reaction/Anaphylaxis
Hypoperfusion
Symptomatic Bradycardia
Cardiac Arrest
Anaphylaxis
Allergic Reaction/Anaphylaxis
Respiratory Distress
Facilitated Intubation
Sedation
Rapid Sequence Intubation
Pain Management
Acute Coronary Syndrome
Pulmonary Edema
Atropine
Dopamine
Epinephrine 1:10,000
Epinephrine 1:1,000
Etomidate
1 mg IV/IO, 2 mg ET
0.5 IV
0.3 mg IM
Fentanyl
20mg IV
10 mg IV/IO
0.2-0.4 mg/kg IV
50 mcg IV/IM
Furosemide (Lasix)
40 – 80 mg IV/IM
Glucagon
1 mg IM
0.1mg/kg IV/IM
Haloperidol (Haldol)
5 mg IV/IM
Ipratropium Bromide (Atrovent)
0.5 mg in 2.5 ml NS via
Nebulizer
30 mg IV or 60 mg IM
66 years and older 15 mg IV or
30 mg IM
Ketorolac (Toradol)
Symptomatic Bradycardia
Poisoning / Overdose
Rapid Sequence Intubation
Anti-Arrhythmic
Hypoglycemia without IV
Poisoning/Overdose
Allergic Reaction/Anaphylaxis
Alerted Mental Status, Seizures
Sedation
Bronchospasm,
Respiratory distress
Pain Management
72
ADULT- PROTOCOL DRUG CHART
DRUG
Lidocaine
Magnesium Sulfate
Methylprednisolone
(Solu-Medrol)
Metoprolol (Lopressor)
Midazolam (Versed)
Morphine Sulfate
continued……
DOSE
1 – 1.5 mg/kg IV/IO/ET
0.5 – 0.75 mg/kg IV/IO/ET
100 mg IV
1-2 GM in 50 ml NS over 5 min
4 GM in 50 ml NS over 15 min
2 grams IM
125 mg IV/IM
5 mg IV
5 mg in 50 ml NS over 5-10 min
5 mg IV/IM/IN
2 -4 mg IV
INDICATIONS
V. Fibrillation/Pulseless V. Tach
V. Fibrillation/Pulseless V. Tach
Rapid Sequence Intubation
V. Fibrillation/Pulseless V. Tach
Pre-Eclampsia/Eclampsia
Pre-Eclampsia/Eclampsia
Respiratory Distress
Allergic Reaction/Anaphylaxis
Acute Coronary Syndrome
Tachycardia-Stable
Sedation, Seizures
Rapid Sequence Intubation
Naloxone (Narcan)
4-5mg IV
4 mg IV
2 mg IV/IM/IN
Nitroglycerin
Nitroglycerin Paste
Nitrous Oxide
0.4 mg SL or 1 spray
1 inch
Pt. demand, inhaled gas
Pain Management
Acute Coronary Syndrome
Poisoning Overdose
Altered Mental Status
ACS, Pulmonary Edema
ACS, Pulmonary Edema
Pain Management
Ondansetron (Zofran)
4mg IV/IM/PO/ODT
Antiemesis
Rocuronium
0.6mg/kg IV
Rapid Sequence Intubation
Sodium Bicarbonate
1 mEq/kg IV/IO
Succinylcholine
1-2 mg/kg IV
Asystole,
V. Fibrillation/Pulseless V. Tach
Poisoning Overdose,
Altered Mental Status
Rapid Sequence Intubation
Terbutaline
0.25mg IM
Respiratory Distress
Vasopressin
40 units IV/IO
Cardiac Arrest
Vecuronium
1mg IV
0.1mg/kg IV
Rapid Sequence Intubation
1 mEq/kg IV
73
DRUG
ADULT - IV DRIP CHART
CONCENTRATION DRIP RATE (MICRODRIP)
Dopamine
5-10 mcg/kg/min
200 mg in 250 ml NS
400 mg in 500 ml NS
(800 mcg/ml)
Magnesium Sulfate
(PreEclampsia/Eclampsia)
4 grams in 50 ml NS over 15 min
200 mcg/min. 15 drops/min.
400 mcg/min. 30 drops/min.
600 mcg/min. 45 drops/min.
800 mcg/min. 60 drops/min.
4 grams in 50 ml NS (run wide open)
PEDIATRIC - PROTOCOL DRUG CHART
DRUG
DOSE
INDICATIONS
Adenosine
Albuterol Sulfate
0.1 mg/kg
2.5 mg in 3 ml NS via Nebulizer
Atropine
0.02 mg/kg IV/IO; 0.04 mg/kg ET
0.02-0.05 mg/kg IV/IN
5 mg/kg in 50ml NS over 20-60 min
5mg/kg (max. dose 300 mg);
5mg/kg (max. dose150 mg)
1 spray
Amiodarone
Anesthetic Spray
50% Dextrose
25% Dextrose
10% Dextrose
Diphenhydramine
Tachycardia-Unstable
Respiratory Distress
Allergic Reaction/Anaphylaxis
Symptomatic Bradycardia
Poisoning/Overdose
Tachycardia-Unstable
V. Fib./Pulseless V. Tach
Facilitated Intubation
Seizures
Hypoglycemia; Seizures
Hypoglycemia (Neonate)
Allergic Reaction/Anaphylaxis
Dopamine
2 ml/kg IV > 6 yrs old (max. 50ml)
2 ml/kg IV < 6 yrs old (max. 100 ml)
2-4 ml/kg
1 mg/kg IV/IM (max. dose 50 mg)
PO / Elixir: 2-6 yrs. 6.25 mg;
7-12 yrs. 12.5 mg;
>12 yrs. 25 mg
5-10 mcg/kg/min drip
Epinephrine 1:10,000
0.01mg/kg/IV/IO
Epinephrine 1:1,000
Epinephrine 1:1,000
Epinephrine 1:1,000
Etomidate
Fentanyl
Ipratropium Bromide
Glucagon
Methylprednisolone
Midazolam
Morphine Sulfate
Naloxone
0.1 mg/kg ET
5 mg in 3 ml NS via Nebulizer
0.01 mg/kg IM (max. dose 0.3 mg)
0.3 mg/kg IV (max. dose 20 mg)
1mcg/kg IV
0.5 mg in 2.5 ml via Nebulizer
0.1mg/kg IM (max dose 1mg)
2 mg/kg IV (max. dose 125 mg)
>6 mos. 0.025 – 0.05 mg/kg IV
(max. 5 mg)
0.1 mg/kg IV/IM/IN
0.1 mg/kg IV
0.1 mg/kg IV (max. 5 mg)
0.1 mg IV/IM/IN (max. 2 mg)
Cardiac Arrest
Symptomatic Bradycardia
Cardiac Arrest, Bradycardia
Croup, Epiglottitis
Anaphylaxis, Resp. Distress
Facilitated Intubation > 10 yrs
Pain Management
Anaphylaxis, Resp. Distress
Hypoglycemia, AMS,Overdose
Anaphylaxis, Resp. Distress
Facilitated Intubation
Sodium Bicarbonate
1 mEq/kg IV
Midazolam
Allergic Reaction/Anaphylaxis
Seizures
Sedation
Pain Management
Alerted Mental Status,
Neonatal Resuscitation
Poisoning/Overdose
74
APGAR CHART
SIGN
0
1
2
Heart Rate
Absent
Below 100
Over 100
Respiration
Absent
Slow and irregular
Normal crying
Limp
Some flexion-
Active; good motion
in extremities
(effort)
Muscle Tone
extremities
Irritability
No Response
Crying; some motion
Crying; vigorous
Skin Color
Bluish or paleness
Pink or typical
newborn color; hands
and feet are blue
Pink or typical
newborn color; entire
body
ABNORMAL PEDIATRIC VITAL SIGNS CHART
AGE
RR
PULSE
(YEARS)
B/P
(SYSTOLIC)
< 1 month
<40 or > 60
<80 or > 160
< 60
1 month - 1 year
<15 or > 30
<80 or > 140
< 70
1 year - 10 years
<12 or > 25
<60 or > 120
<(70 + 2 x age)
> 10 years
<10 or > 20
<50 or > 110
< 90
75
GLASGOW COMA SCALE
Physical Signs
Infants
Children
Adult
Points
Eye Opening
Spontaneous
To Voice
To Pain
None
Coos and Babbles
Irritable Cry
Cries to Pain
Moans to Pain
None
Spontaneous
Withdraws to
Touch
Withdraws to Pain
Flexion
Extension
None
Spontaneous
To Voice
To Pain
None
Smiles
Cries
Consolable
Inconsolable
None
Spontaneous
Localizes Pain
Withdraws to Pain
Flexion
Extension
None
Spontaneous
To Voice
To Pain
None
Oriented
Confused
Inappropriate Words
Incomprehensible Sounds
None
Obeys Commands
Localizes Pain
Withdraw (pain)
Flexion (pain)
Extension (pain)
None
4
3
2
1
5
4
3
2
1
6
5
4
3
2
1
Verbal Response
Motor Response
CINCINNATI PREHOSPITAL STROKE SCALE
FACIAL DROOP: Have the patient show their teeth or smile
 Normal – Both sides of face move equally well
 Abnormal – One side of face does not move as well as
the other side
ARM DRIFT : Have the patient close their eyes and hold both arms out


Normal – Both arms move the same or both arms do not move
at all (other findings, such as pronator grip, may be helpful)
Abnormal – One arm does not move or one arm drifts down
compared with the other
SPEECH : Have the patient say, “you can’t teach an old dog new tricks”


Normal – Patient uses correct words with no slurring
Abnormal – Patient slurs words, uses inappropriate words, or is
unable to speak
76
ONE-MINUTE CRANIAL NERVE EXAM CHART
Cranial Nerve
I
II, III
III, IV & VI
V
VII
IX, X
XII
VIII
XI
The Test
Normally not done in the field
Direct response to light
“H” test for extraocular movement
Clench teeth, test sensory
Show teeth
Say “ahh”, test gag reflex
Stick tongue out and move around
Test balance and hearing
Shrug shoulders, turn head against resistance
VISUAL ANALOG PAIN SCALE
If you are having pain,
Point to the number that describes your pain.
Sin Dolor
Duele un
Poquito
Duele un
Duele todavia
Poquito mas
mas
Duele mucho
El peor dolor
Infant Pain Scale
0
1-2
3-4
5-6
7-8
9-10
Restful Sleep
Quiet, awake, calm face
Restless, occasional grimace or whimper
Irritable with intermittent crying and occasional grimace (easily consolable)
Frequent crying, constant grimace, tense muscles (difficult to console)
Constant high-pitched cry, thrashing of limbs, constant grimace (unable to console)
77
RULE OF NINES CHART
78
CODE HOSPITAL EMERGENCY DEPT.
053
053
446
446
221
221
541
541
441
441
442
442
331
331
261
261
114
114
332
332
448
448
241
241
212
212
445
445
n/a
n/a
n/a
262
262
372
372
Auburn Community Hospital
Auburn Community Hospital
Canton-Potsdam Hospital
Canton-Potsdam Hospital
Carthage Area Hospital
Carthage Area Hospital
Cayuga Medical Center
Cayuga Medical Center
Claxton-Hepburn Medical Center
Claxton-Hepburn Medical Center
Clifton-Fine Hospital
Clifton-Fine Hospital
Upstate University Hospital at Community
Upstate University Hospital at Community
Community Memorial Hospital - Hamilton
Community Memorial Hospital - Hamilton
Cortland Regional Medical Center
Cortland Regional Medical Center
Crouse Hospital
Crouse Hospital
E. J. Noble Hospital
E. J. Noble Hospital
Lewis County General Hospital
Lewis County General Hospital
Little Falls Hospital
Little Falls Hospital
Massena Memorial Hospital
Massena Memorial Hospital
Midstate Resource
Midstate Resource
Midstate Resource
Oneida Healthcare
Oneida Healthcare
Oswego Hospital
Oswego Hospital
continued on next page ….
TELEPHONE #
315-253-1700
315-255-7189 (fax)
315-265-3300 ext. 1000
315-261-6410 (fax)
315-493-1000 ext. 2499
315-493-6360
607-274-4514
607-274-4132 (fax)
315-393-3600
315-393-8995 (fax)
315-848-3351 ext. 262
315-848-3692
315-492-5684
315-492-5222 (fax)
315-824-6094
315-824-1956 (fax)
607-756-3740
607-756-3515 (fax)
315-470-7411
315-470-2682 (fax)
315-287-1000
315-535-9226 (fax)
315-376-5071
315-376-6775 (fax)
315-823-3189
315-823-5335 (fax)
315-769-4263
315-769-4278 (fax)
315-724-4979 (line #1)
315-724-0704 (line #2)
315-624-6623 (fax)
315-361-2327
315-361-2305 (fax)
315-349-5522
315-349-5714 (fax)
79
CODE HOSPITAL EMERGENCY DEPT. TELEPHONE #
227
227
324
324
223
223
326
326
334
334
327
327
336
336
336
336
n/a
338
338
River Hospital
River Hospital
Rome Memorial Hospital
Rome Memorial Hospital
Samaritan Medical Center
Samaritan Medical Center
St. Elizabeth Hospital
St. Elizabeth Hospital
St. Joseph's Hospital
St. Joseph's Hospital
St. Luke’s Hospital
St. Luke’s Hospital
Upstate University Hospital - Adult ED
Upstate University Hospital - Adult ED
Upstate University Hospital - Peds ED
Upstate University Hospital - Peds ED
Upstate New York Poison Center
VA Medical Center
VA Medical Center
315-482-1212
315-482-7153 (fax)
315-338-7230
315-338-7293 (fax)
315-785-4504
315-779-5227 (fax)
315-798-8174
315-734-3158 (fax)
315-448-5101
315-448-5732 (fax)
315-624-6068
315-624-6308 (fax)
315-464-5612
315-464-6520 (fax)
315-464-5613
315-464-6521 (fax)
800-222-1222
315-425-4400 ext. 54100
315-425-4623 (fax)
NOTES
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80
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