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NYC REMSCO Protocols Jan. 2008 updates

NYC REMSCO Protocols Jan. 2008 updates. Dr. Victor Politi. 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 . Where to begin?.

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NYC REMSCO Protocols Jan. 2008 updates

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  1. NYC REMSCO ProtocolsJan. 2008 updates Dr. Victor Politi

  2. 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 Where to begin?

  3. 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

  4. 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 The GOP Changes

  5. 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

  6. 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

  7. 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

  8. 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-Basic Protocol

  9. 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 EMT-Paramedic Protocol

  10. 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. EMT-Paramedic Protocol

  11. 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. EMT-Paramedic Protocol

  12. 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. EMT-Paramedic Protocol

  13. 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. EMT-Paramedic Protocol

  14. 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. EMT-Paramedic Protocol

  15. 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

  16. 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

  17. 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 GOP

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

  19. 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

  20. 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. STEMI (ST Elevation) / Myocardial Infarction

  21. 400 – Weapons of Mass Destruction Adult Dosing

  22. 400 – Weapons of Mass Destruction Pediatric Dosing

  23. 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

  24. 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) 407- Asthma

  25. 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. 420 TRAUMATIC CARDIAC ARREST

  26. 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 Circulation 2005112:IV-146-IV-149

  27. 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 AHA continued

  28. 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 443 Neonate Resuscitation

  29. 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 443 Neonate Resuscitation

  30. 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 443 Neonate Resuscitation

  31. 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 shouldbe 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) 453 Pediatric Non Traumatic Cardiac Arrest

  32. 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 453 Pediatric Non Traumatic Cardiac Arrest

  33. 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 Mandatory QA Component

  34. Minor language changes (in red) Assess the cardiac and respiratory status of the patient. If boththe cardiac and respiratory status of the patient are normal, initiate transport. If eitherthe cardiac or respiratory status of the patient is abnormal, proceed as follows: If the patient is having severe respiratory distress orshock andhas 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. 455Pediatric Anaphylactic Reaction

  35. 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 500 – Suspected Cyanide Toxicity Or Smoke Inhalation

  36. 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 500 – Suspected Cyanide Toxicity Or Smoke Inhalation EFFECTIVE IMMEDIATELY IF AVAILABLE

  37. 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. 500 – Suspected Cyanide Toxicity Or Smoke Inhalation

  38. Administer, via separate IV lines, the following medications 500 – Suspected Cyanide Toxicity Or Smoke Inhalation 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

  39. 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

  40. 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 501 Respiratory Arrest

  41. Language change and Amiodarone is now Mandatory 503-A V-Fib/Pulseless V-Tach

  42. 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 504 Drug Therapy for Myocardial Ischemia

  43. Language changes HYPOTENSION, HYPOVENTILATION, or STUPOR removed from text p morphine use 506 Acute Pulmonary Edema Mandatory QA Component For 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

  44. 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. 507 Asthma

  45. Standing Orders now versus MCO Methylprednisolone 125 mg, IV bolus, or IM, Or Dexamethasone, 12 mg, IV bolus, or IM. 508 - COPD

  46. 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) 510 Anaphylactic Reaction

  47. 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. 511 - AMS

  48. 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 !!! 520 Traumatic Cardiac Arrest

  49. 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 To reiterate the AHA

  50. 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. 529 Pain Management Isolated Extremity

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