REMSCO General Operating Procedures
REMSCO Appendices
Northwell Interfacility
SIUH Guidelines
Protocol Other InformationGOP
Protocol Other InformationGOP
1 Conscious patients requiring Synchronized Cardioversion or Transcutaneous Pacing 1
Diazepam 5-10 mg IV bolus with repeat doses of diazepam 5-10 mg IV bolus as necessary, max dose of 20 mg
Indications for IO Access Standing Orders IO ContraindicationsGOP
1 Unconscious patients2 Conscious patients in decompensated shock
Maximum of 2 attempts for both IV or IOSites: "an approved EXTREMITY approach"; humeral
is ok.
Intraosseus Access
Midazolam 1-2 mg IV/IN bolus, repeat doses of midazolam 1 mg IV/IN bolus as necessary, max dose of 5 mg
or
Cardioversion ONLY: Etomidate 0.15 mg/kg IV bolus over 30-60 seconds, max dose of 20 mg
or
For use after two failed peripheral IV attempts in the following patient subsets:
May infuse 0.5 mg/kg of 2% preservative-free lidocaine via IO port prior to infusion, up to a maximum of 50 mg.
1
Dosing of medications is identical to IV doses in the REMAC protocols
Conscious patients requiring endotracheal intubation1Diazepam 5-10 mg IV bolus with repeat doses of diazepam 5-10 mg IV bolus as necessary, max dose of 20 mg
1 Patient weight >200 lbs is poorly predictive for
ETI success
Sternal site is contraindicated.
Midazolam 1-2 mg IV/IN bolus, repeat doses of midazolam 1 mg IV/IN bolus as necessary, max dose of 5 mg
or
Etomidate 0.3 mg/kg IV bolus over 30-60 seconds, max dose of 40 mg followed by diazepam 5 mg IV bolus or lorazepam 2 mg IV/M for continued sedation
or
Medical Control Options
Indications for Prehospital Sedation
Apneic oxygenation: administer oxygen by
nasal cannula at maximum flow rate
during laryngoscopy and intubation.
Medical Control Options
Indications for Prehospital Sedation
An additional infusion of 0.25 mg/kg of 2% preservative-free lidocaine may be given for continued pain, up to a maximum of 25 mg.
2
Prehospital Sedation for Intubation
Prehospital Sedation for
Cardioversion or Pacing
Indications for Pre-Existing CVC Access Contraindications for CVC Access Other InformationGOP
1 Chest or neck lines
2 If non-PICC, must contact OLMC prior to use
Other InformationAppendix T
1
2
3
4
5
Contraindications to Starting Resuscitation Indications to Halt CPR Other InformationNYC REMAC
1 Extreme dependent lividity2 Rigor mortis3 Tissue decomposition 2 ROSC achieved4 Obvious mortal injury
4 Crew exhaustion
Any port requiring troubleshooting, unclogging3
Usage has been expanded for use in the Soft Tissue Injury Protocols (CFR and BLS).
Treat Cardiac Arrests due to HANGING,
DROWNING, ELECTROCUTION,
SMOKE INH/CYANIDE as MEDICAL [vs.
Traumatic].
Healthcare proxy, Living Will, In-hospital DNR
are not valid
A qualified, licensed physician assumes responsibility for the patient (SNF physician)
Valid Out-of-Hospital DNR or MOLST form presented1
3
Application
To reduce of stop severe extremity hemorrhage that cannot be controlled by direct pressure by appliying
mechanical circumferential pressure to an open wound.
For use as a Constriction Band in venomous bites [loose application of tourniquet proximal to extremity
bite] in conjunction with limb immobilization.
1
If these measures fail to control the bleeding, appy a tourniquet 2-3 inches proximal to the bleeding siteTighten the tourniquet until the bleeding stops and distal pulses are lost. Apply a 2nd tourniquet parallel and proximal to the first as needed until the bleeding stops.
Indications for Tourniquet Usage
6
Use of Tourniquets
Any port requiring a needle to break the skin (port-a-cath)2Use of Pre-
Existing Central Venous Catheter
In cardiac arrest / unstable pt with no peripheral access, paramedic may consider using a PICC line in the upper extremity
1
Leave the tourniquets exposed so that they can be easily seen and monitored.Document time of tourniquet application on prehospital report as well as by placing tape on the patient.
Apply direct pressure & pressure dressings
All patients with tourniquet usage should be transported to the nearest Trauma Center.
CPR General Operating
Procedures
Indications for CPAP Contraindications for CPAP Other InformationAppendix P
1 Patient is alert 1 Need for immediate Adv Airway Mgmt2 Patient can maintain an open airway on their own 2 AMS/Unresponsive or uncooperative patients3 Patient has systolic BP >100 mmHg 3 Patients unable to control their own airway
5 Known active unstable angina or AMI
7 Gastric distention
NYC REMAC Current REMAC IN Formulary Contraindications Other InformationFentanyl EpistaxisGlucagonLorazepamMidazolamNaloxone
Contraindications to Terminating Resuscitation Considerations for Terminating Resusc. Other InformationSIUH Guideline
1 Patient is in a moving ambulance. 1 Unwitnessed arrest2 Pediatric (<18) or pregnant patient 2 No bystander CPR3 Patient is at the scene of a crime/public view 3 No shockable ryhtym during resuscitation
4 No ALS crew onscene 4 End-Tidal CO2 < 20 mmHg after 20 minutes of ACLS care
5 Hypothermic patients
6 No contact with Online Medical Control Physician
4
Support system is in place for patient's family (NYPD will guard the body until OCME arrives)
CPAP is to be immediately d/c'd if:
1) an immediate need for advanced airway
control arises
2) the patient becomes hemodynamically
unstable3) the patient cannot
tolerate the mask due to pain or discomfort
4
Pregnancy NOT a CONTRAINDICATION 6 Known PNA, PTX, anaphylaxis, pulmonary embolism, aspiration
Patient has significant respiratory distress, indicated by cyanosis, accessory muscle use, or other signs/symptoms
Use of the CPAP Device
Intranasal (IN) Drug
Administration
5
Approved for use in the absence of intravenous
access, as stated in individual protocols.
Trauma, facial burns, impending respiratory or cardiac arrest
Paramedics trained and authorized by the service medical director may utilize CPAP if available and appropriate.
Termination of Prehospital
Resuscitation Criteria
Guidelines
Interfacility Internal Process Discretionary Decisions Other Information
1 Must be transported by an Advanced Life Support ambulance crew (aka "Paramedics")
Allergic Reaction: discontinue blood transfusion.
a) Diphenhydramine 25-50 mg IV pushb) Epinephrine 0.3 mg (0.3 mL
of 1,1:000 solution) IM3 ED staff are not required to "ride along" C) Methylprednisolone 125 mg IV push
c) NS bolus 500 mL IV Dyspnea: consider TRALI or fluid overload. Discontinue blood transfusion.
a) Give CPAP if available. b) Furosemide & nitroglycerin not
recommended without CXR
3Direct crew to the nearest ED for emergent patient stabilization & management - can return to sending facility.
Interfacility Standing Orders Medical Control Options Other Information1 Apply monitoring devices (EKG, SpO2, BP, EtCO2) 1 Primary Medical Control: SIUH South.2 Administer O2 to keep SpO2 >95%3 Obtain hospital records if readily available (CD, chart)4 Maintain HOB at 15 degrees
5Measure vitals & Neuro checks (LOC, motor changes, sudden headache, N/V, sudden HTN) q15mins. Call OLMC for any changes.
6 Record tPA metrics: Dose, Start Time, End Time
7 Administer labetalol 10 mg over 2 mins for HTN (SBP>180mmHg or DBP > 105 mmHg)
8Re-eval BP in 10 minutes. If HTN persists, re-administer labetalol 10 mg. Contact OLMC if HTN persists after TWO doses.
9 Hypotension: place patient in supine position, administer 0.9%NS 500 mL bolus. Contact OLMC.
10 Limit sedation of any kind to ensure accurate Neurologic checks.
11 Anaphylaxis/Airway Edema: discontinue t-PA and utilize REMAC Protocol 510. 5 Neurologic deterioration: discontinue t-PA
infusion, reassess patient
Febrile reactions: stop transfusion
Do not delay txp for paperwork!
Dopamine 5 mcg/kg/min IV drip titrate up to max 20 mcg/kg/min
2
Hypertension: administer labetalol 10 mg over 2 minutes. Evaluate pt response in 10 minutes. May repeat one additional time for a total of FOUR doses.
4
Hypotension: consider discontinuing t-PA and other infusions. Repeat 0.9% NS 500 mL bolus.
2
Acute hemolytic reactions from ABO
incompatibiltiy should occur soon after
intiiation (10 mins)Blood
Transfusion Reaction 2
1
Stroke Rescue Protocol
3
Must have transfusion initiated and flowing for 10 minutes prior to crew leaving the ED
Adult & Adult/Peds Protocols
NYC REMSCO
Protocol Other Information500 A
0-2 years: 1/4 bottle1 BLS procedures Cyanide Toxicity Kit (if available) 3-5 years: 1/4 bottle2 Adv Airway Mgmt if necessary (Prehosp Sed in GOP) 6-14 years: 1/2 bottle3 Cardiac monitor & pulse oximetry Adult: 5 gm
4 SpCO (carbon monoxide cooximetry) if available Two (2) 100 ml bag 0/9% NS, D5W, LR
5 NS IV KVO x 2 One (1) 100 ml bag D5W
Refer to Protocol 528 for pts with burns One (1) 2 mL fluoride oxalate whole blood tube
One (1) 2 mL K2 EDTA tube
One (1) 2 mL lithium heparin tube
Protocol Other Information500 B
0-2 years: 1/4 bottle3-5 years: 1/4 bottle6-14 years: 1/2 bottle
1 Advanced Airway Mgmt (ETI) if necessary Cyanide Toxicity Kit (if available) Adult: 5 gm2 Cardiac monitor & pulse oximetry3 NS IV KVO x 2
Two (2) 100 ml bag 0/9% NS, D5W, LR One (1) 100 ml bag D5W One (1) 2 mL fluoride oxalate whole blood tubeOne (1) 2 mL K2 EDTA tube One (1) 2 mL lithium heparin tube
One (1) 5.0 g bottle of crystalline powder hydroxocobalamin
Medical Control Options
One (1) 5.0 g bottle of crystalline powder hydroxocobalamin
Pediatric Sodium Thiosulfate dose: (250mg/kg or 3 mL/kg prepared soln)
If BP remains <90 mmHg, dopamine 5 mcg/kg/min IV drip titrate up to max 20 mcg/kg/min7
If cardiac/respiratory arrest, seizures, coma, AMS, unexplained hypotension, hydroxycobalamin 250 mg/kg over 10 minutes (age-based dose) + sodium thiosulfate 12.5 g (150 mL of prepared solution) over 10 minutes IV
Medic should draw the 3 provided tubes of blood prior to admin HCB. Follow HCB with 20mL NS flush.
Dopamine 5 mcg/kg/min IV drip titrate up to max 20 mcg/kg/min5
4
Pediatric Sodium Thiosulfate dose:
(250mg/kg or 3 mL/kg prepared soln)
A
A
6 Medic should draw the 3 provided tubes of
blood prior to admin of HCB. Follow HCB with
20mL NS flush.
Standing Orders
Standing Orders
If cardiac/respiratory arrest, seizures, coma, AMS, unexplained hypotension, hydroxycobalamin 250 mg/kg over 10 minutes (age-based dose) + sodium thiosulfate 12.5 g (150 mL of prepared solution) over 10 minutes IV
Medical Control Options
Smoke Inhalation
Only for symptomatic patients after exposure to smoke in an enclosed space
Only for critically ill patients with suspected exposure to cyanide, not with > 5 patients exposed (>5 requires FDNY OMA Class Order)
Cyanide Exposure
Ensure pt has been decontaminated prior to treatment!
Protocol Other Information502
1 BLS Obstructed Airway procedures
2 Direct Laryngoscopy & attempt to remove foreign body with Magill forceps
3 Perform Advanced Airway Mgmt
4 If able to confirm ETI with direct visualization but unable to ventilate:a) note ETT depth. b) deflate ETT cuff. c) advance ETT to deepest depth.d) return ETT to original depth. e) reinflate ETT cuff. f) if still unable to ventilate, initiate immediate transport.
Protocol Other Information503
1 BLS Non-Traumatic Cardiac Arrest procedures2 Cardiac monitoring & EKG
3Transition from BLS AED to ALS monitor can only be done after completion of the next analysis/shock decision.
Protocol Other Information503 A
1 CPR + Defibrillate at maximum joule setting (3 rounds) A If VF/PVT returns, Amiodarone 150 mg IV/IO bolus
2 Advanced Airway Mgmt + IV/IO NS/LR KVO B Sodium Bicarbonate 44-88 mEq IV/IO bolus, repeat 1 amp q 10 mins
3 Vasopressin 40 units IV/IO bolus IF AVAILABLE. C Magnesium 2 gm IV/IO bolus (in 10 mL NS)4 Amiodarone 300 mg IV/IO bolus5 Epinephrine 1 mg (1:10,000) IV/IO q 5 mins D
If hyper-kalemia/suspected CaCB overdose, Calcium Chloride 1 gm IV/IO slow bolus + NS flush
If patient has a pacemaker, place the defibrillator pads at
least one inch from the pacemaker device.
Medical Control Options
Standing Orders Medical Control Options
Obstructed Airway
Continue CPR with minimal interruption
Medical Control Options
Standing Orders
Standing Orders
(CPR before AED in unwitnessed arrests, CPR for 2 minutes in EMS-unwitnessed arrest)
Non-Traumatic Cardiac Arrest
VF / Pulseless VT
Protocol Other Information503 B
1
2 Needle decompress if suspected tension PTX A Sodium Bicarbonate 44-88 mEq IV/IO bolus, repeat 1 amp q 10 mins
3 Advanced Airway Management4 IV/IO NS KVO5 Vasopressin 40 units IV/IO bolus IF AVAILABLE.6 Dextrose 25 gm IV/IO bolus7 Epinephrine 1 mg (1:10,000) IV/IO q 5m
Protocol Other Information504 A
1 Aspirin 162 mg PO. 2 NTG 0.4 mg q 5 mins x 3 doses
Hold NTG if SBP<100 mmHg unless OLMC advises
Hold NTG if Erectile Dysfunction Rx have been used within 72 hours unless OLMC advises
LBBB no longer STEMI criteria (old or new)
Protocol Other Information504 B
1 NS bolus IV 250 mL, repeat x 1 (total 500 mL NS)
2 Dopamine 5 mcg/kg/min IV drip titrate up to max 20 mcg/kg/min
Protocol Other Information505 A
1 If unstable, synchronized cardioversion with 100 joules
B If narrow complex & low BP, synchronized cardioversion with 100 joules
2 If stable, adenosine 6-12-12 mg IV rapid bolus + NS flush (max 30 mg)
Prehospital sedation (etomidate 0.15 mg/kg up to 20 mg) prior to cardioversion recommended
Observe EKG for 1-2 mins between doses C Amiodarone 150 mg in 100 mL D5W over 10 minutes
Cardiogenic Shock
STEMI patients must be transported to a STEMI
CenterMyocardial Ischemia
Medical Control Options
Standing Orders Medical Control Options
C
Medical Control Options
Medical Control Options
If defib max joule setting <360 j, use
equivalent cardioversion energies Repeated synchronized cardioversion attempts with defib's max setting.
NS bolus IV/IO up to 3 liters
Consider treatable conditions masquerading as PEA/Asysole
If narrow complex & normal BP, diltiazem 0.25 mg/kg IV bolus over 2 minutesA
Standing Orders
If hyper-kalemia/suspected CaCB overdose, Calcium Chloride 1 gm IV/IO slow bolus + NS flush
BPEA / Asystole
Standing Orders
Standing Orders
Continue synchronized cardioversion with 200, 300, 360 joules
SVT
Protocol Other Information505 B
1 If unstable, synchronized cardioversion with 100 joules
2 Continue synchronized cardioversion with 200, 300, 360 joules
B Amiodarone 150 mg in 100 mL D5W over 10 minutes
Protocol Other Information
505 C1 If unstable, synchronized cardioversion with 100 joules
Continue synchronized cardioversion with 200, 300, 360 joules A Synchronized cardioversion with 100 joules,
followed by 200, 300, 360 joules2 Amiodarone 150 mg in 100 mL D5W over 10 minutes B Magnesium 2 gm IV/IO bolus (in 10 mL NS)
CIf hyperkalemia/suspected CaCB overdose, Calcium Chloride 1 gm IV/IO slow bolus + NS flush
D Sodium Bicarbonate 44-88 mEq IV/IO bolus, repeat 1 amp q 10 mins
Protocol Other Information505 D
1 Atropine 0.5 mg IV bolus
2 Begin Transcutaneous Pacing B Dopamine 2 mcg/kg/min IV drip titrate up to max 10 mcg/kg/min
CIf hyperkalemia/suspected CaCB overdose, Calcium Chloride 1 gm IV/IO slow bolus + NS flush
D Sodium Bicarbonate 44-88 mEq IV/IO bolus, repeat 1 amp q 10 mins
A Fib / A Flutter
Standing Orders
If ventricular rate < 60 bpm & in shock
Medical Control Options
If amiodarone does not convert or patient is in shock
If defib max joule setting <360 j, use
equivalent cardioversion energies Repeated synchronized cardioversion attempts with defib's max setting.
A
A
Medical Control Options
If defib max joule setting <360 j, use
equivalent cardioversion energies Repeated synchronized cardioversion attempts with defib's max setting.
Repeat atropine 0.5 mg IV bolus q 3-5min, max up to 3 mg
Standing Orders
If stable AF with HR>150 bpm, diltiazem 0.25 mg/kg IV bolus over 2 minutes
Standing Orders Medical Control Options
Brady-dysrhythmias & Complete Heart
Block
VT with Pulse / WCT of Uncertain
Etiology
Protocol Other Information506 1 Cardiac monitoring
2 NTG 0.4 mg q 5 mins x 3 dosesHold NTG if SBP < 100 mmHg Hold NTG if Erectile Dysfunction Rx have been used within 72 hours unless OLMC advises B Furosemide 20-80 mg IV bolus (max
combined total dose 80 mg)3 CPAP (if available)
Protocol Other Information507
1 Albuterol 0.083%& Ipratropium 0.02% by neb x 3If signs of impending respiratory failure
2 Epinephrine 0.3 mg (0.3 mL of 1:1,000) IM
3 Cardiac monitoring if respiratory distress or hx of dysrhythmia/cardiac disease
3 NS KVO if severe respiratory distress4 Magnesium 2 gm in 50-100 mL NS over 10-20 mins
5 Methylprednisolone 125 mg IV/IM or Dexamethasone 12 mg IV/IM
Protocol Other Information508 ˙
1 Cardiac monitoring with EKG/monitoring
2 Albuterol 0.083% & Ipratropium 0.02% by neb x 3 doses
3 NS KVO
4 Methylprednisolone 125 mg IV/IM or Dexamethasone 12 mg IV/IM
COPD
Morphine 0.1 mg/kg up to 5 mg IV/IO/IM bolus, repeat up to 10 mg total
Lorazepam 1-2 mg IV/IN bolus or Midazolam 1-2 mg IV/IN bolusA
Standing Orders Medical Control Options
Standing Orders Medical Control Options
Medical Control Options
Administer or repeat epinephrine 0.3 mg (0.3 mL of 1:1,000) IM1
Standing Orders
Acute Pulmonary Edema
Asthma
Protocol Other Information510
1 BLS Anaphylactic Reaction Procedures A Repeat any of the Standing Orders
2 Early Advanced Airway Mgmt if airway compromise SIMULTANEOUS WITH #3a. B Dopamine 5 mcg/kg/min IV drip titrate up to
max 20 mcg/kg/min
3 If the patient has signs of shock or a past history of anaphylaxis:
a Administer Epinephrine 0.3 mg (0.3 mL of 1:1,000 solution), IM
b NS or LR large bore bolus up to three liters via macro-drip
c Methylprednisolone 125 mg IV/IM or Dexamethasone 12 mg IV/IM
d Diphenhydramine 50 mg IV (or IM if no IV access)
4 If the patient does not have signs of shock and does not have a history of anaphylaxis:
a NS or RL large bore KVO
b Methylprednisolone 125 mg IV/IM or Dexamethasone 12 mg IV/IM
c Diphenhydramine 50 mg IV (or IM if no IV access)
5
If the patient has signs of bronchospasm, administer Albuterol sulfate 0.085% (one unit dose bottle of 3mL), by nebulizer, at a flow rate that will deliver the solution over 5-15 minutes
6 Monitor vital signs every 5 minutes
7 Begin cardiac monitoring, record and evaluate EKG rhythym
Protocol Other Information511
1 BLS AMS procedures2 IV NS KVO
Use glucometer to document blood glucose levelWithold dextrose & glucagon if FSBG > 120 mg/dL
3 Dextrose 25 gm (50 mL of 50% soln) IV 4 If pt is diabetic without IV access, glucagon 1 mg IM/IN
5 If AMS persists, naloxone 0.5 mg titrate to response up to 2 mg IV.If IV unavailable, naloxone 0.5 mg titrate to response up to 4 mg IM/IN
6 If AMS persists, repeat dextrose 25 gm (50mL of 50% soln) IV
A Repeat any of the Standing Orders
Patients with an allergic reaction and signs of bronchospasm may require treatment for
anaphylaxis
Alert patients requiring Advanced Airway Mgmt
should undergo Prehospital Sedation
(GOP) via OLMC.
Consider Discretionary Order for Glucagon 1
mg IV bolus with repeats q 5min in
patient on beta-blocker & refractory to epinephrine
Medical Control Options
Medical Control Options
Standing Orders
Allergic Reaction / Anaphylactic
Reaction
Altered Mental Status
Standing Orders
Protocol Other Information513
1 BLS Seizure procedures A Repeat lorazepam 2 mg IV/IM/IN2 Cardiac monitor and EKG, IV KVO or Repeat diazepam 5 mg IV
3 IV NS KVO, use glucometer to document FSBG or Repeat midazolam 10 mg IM/IN
Withold dextrose & glucagon if FSBG > 120 mg/dL
4 Dextrose 25 gm (50 mL of 50% solution) bolus IV
5 If pt is diabetic without IV access, glucagon 1 mg IM/IN
6 Lorazepam 2 mg IV bolus (IM/IN if no access) + 1 repeat @ 5 mins if persistent generalized seizures
or Diazepam 5 mg IV bolus + 1 repeat @ 5 mins if persistent generalized seizures
or Midazolam 10 mg IM/IN if no access
Protocol Other Information515
1 Needle decompress if suspected tension PTX2 NS bolus up to 3 liters3 Cardiac monitor and EKG
Protocol Other Information515-B
1 BLS Shock measures2 If inadequate ventilation, perform Adv. Airway Mgmt
3 IV NS/RL up to 2 liters macro-drip via 1-2 large bore gauge catheters
Consider IO access after 2 failed peripheral attemptsa Document IVF amount accurately
4 Cardiac monitoring, record EKG rhythym5 Measure and record lactate level (if available)
6 Measure and record oral temp (if available) or last temp at patients' facility
Consider intraosseuous route if peripheral
attempts have failed
Severe Sepsis & Septic Shock
Additional NS/RL 1 liter macro-drip via 1-2 large bore gauge catheterA
Medical Control Options
Standing Orders Medical Control Options
Standing Orders Medical Control Options
Standing Orders
Alert patients requiring Advanced Airway Mgmt
should undergo Prehospital Sedation
(GOP) via OLMC.
"Seizure" wording changed to
"generalized seizures"; paramedics may only give Rx if tonic-clonic activity is witnessed.
Noncardiogenic Shock
Seizures
Protocol Other Information5__
1 BLS Shock measures2 If inadequate ventilation, perform Adv. Airway Mgmt 3 Use a glucometer to measure a blood glucose level.4 For pts with blood glucose levels above:
300 mg/dL w/ AMS, Tachypnea, Dehydration signs500 mg/dL or "high"
a Adults: rapid IV infusion of NS/RL up to 1 liter
b Peds: rapid IV infusion of NS/RL up to 20 ml/kg (max 1 L)
5 Cardiac monitoring, record EKG rhythym6 Transport decision7 OLMC for MCO
Protocol Other Information520
1 BLS Traumatic Cardiac Arrest procedures2 Decompress suspected tension PTX
5 IV NS/RL up to 2 liters macro-drip via 1-2 large bore gauge catheters
4 Cardiac monitor and EKG if no penetrating chest trauma. Treat under 503A as needed.
Advanced Airway Mgmt if airway is not controlled by other means3
Standing Orders Medical Control Options
Hyperglycemia (Adult & Peds)
A
A
Adults: additional rapid IV infusion of NS/RL up to 1 literPeds: rapid IV infusion of NS/RL up to 10 ml/kg (max 1 L)
Dehydration signs not absolutely clarified: can
use shock signs as surrogate
Medical Control OptionsRapid transport is highest priority.
Standing Orders
Traumatic Cardiac Arrest
Protocol Other Information521
1 BLS Head & Spine Injuries procedures
or Repeat diazepam 5 mg IV3 Cardiac monitor and EKG4 NS KVO5 If seizure witnessed:
a Lorazepam 2 mg IV bolus (IM/IN if no access) + 1 repeat @ 5 mins if persistent generalized seizures
b Diazepam 5 mg IV bolus + 1 repeat @ 5 mins if persistent generalized seizures
c Midazolam 10 mg IM/IN if no access
5Hyperventilate via ETCO2 to 30-35 mmHg if GCS < 8 or fixed pupils/anisocoria, posturing, Cushing's reflex, periodic breathing, decreasing GCS by 2 points
Protocol Other Information527
1 BLS Eye injury procedures
2 Assist with removal of contact lens if present
Protocol Other Information528
1 BLS Burn procedures2 Adv Airway Mgmt if upper airway burn or compromise
suspected3 Cardiac monitor and EKG for electrical burns
4 Pulse oximetry monitoring
5 NS/LR bolus up to 2 liters if txp is delayed/extended6 If severe pain due to injury:
a If SBP > 110 mmHg, morphine 0.1 mg/kg up to 5 mg IV/IO/IM bolus, repeat up to 10 mg total
b Fentanyl 1 mcg/kg (max 100 mcg) IV/IO/IN/IM
Admin of narcotic analgesics is
contraindicated in patients with burns involving the face
and/or airway.
Standing Orders
2
OR
Medical Control Options
Medical Control Options
Head Injuries
Repeat midazolam 10 mg IN/IM if no accessor
OR
Standing Orders Medical Control Options
Standing Orders
Repeat lorazepam 2 mg IV (IN/IM if no access)
Burns (Adult & Peds)
Chemical Eye Injuries (Adult &
Peds)
A
3
(Naloxone up to 2 mg IV if hypoventilation
occurs)
Advanced Airway Mgmt if GCS < 8 AND airway is not controlled by other means
If agitated or unable to hold eyelid open, proparacaine HCl 0.5% soln (or tetracaine HCl 0.5% soln) 1-2 gtts into affected eye, + 1 repeat of initial dose
Protocol Other Information529
1 BLS procedures2 Cardiac monitor and EKG3 Pulse oximetry monitoring4 IV NS KVO5 Vitals q5 mins6 If severe pain due to injury:
a If SBP > 110 mmHg, morphine 0.1 mg/kg up to 5 mg IV/IO/IM bolus, repeat up to 10 mg total
b Fentanyl 1 mcg/kg (max 100 mcg) IV/IO/IN/IM
Protocol Other Information530
1 BLS procedures DISSOCIATIVE AGENTSA Ketamine 2-4 mg/kg IM or 1-2 mg IN
IM BENZODIAZEPINESa Midazolam 10 mg IM or IN B Midazolam 10 mg IM
3 IV NS/RL 1 liter via macro-drip after patient is sedated or Lorazepam 4 mg IM4 Cardiac monitor and EKG
5 Pulse oximetry monitoring IV or IN BENZODIAZEPINES
C Diazepam 5-10 mg IVor Midazolam 5 mg INor Lorazepam 2 mg IN or IV
Protocol Other Information531
1 IV NS KVO2 Treat underlying cause of N/V (AMI, Poisoning)
Ondansetron 0.1 mg/kg (not >4mg) IV over 1-2 mins. May repeat x 1 for total up to 8 mg.3
Standing Orders
Pain Mgmt of Isolated Extremity
Injury (Adult & Peds)
A
Standing Orders Medical Control Options
Severe Nausea/Vomiting
Standing Orders Medical Control Options
If pt is at risk for respiratory or cardiac arrest while being physically restrained by the police, contact OLMC for MCO
6
Prehospital Chemical Restraint Procedure: if the patient continues to struggle while being physically restrained:
2
Hypotensive patients: Fentanyl 1 mcg/kg (max 100 mcg) IV/IN if available
(Naloxone up to 2 mg IV if hypoventilation
occurs)
If the patient is agitated, the preferred intiial
route of choice is IM.
Mandatory QA for every Midazolam 10 mg IM/IN
given under Standing Orders: ACR review by
agency Medical Director + forward to REMAC
Ondansetron has been assoc. w/ prolongation of QT interval, possibly causing Torsades de
Pointes. Caution advised for use in pts w/ cardiac disease, use of other QT prolonging-Rx,
or familial QT prolongation.
Medical Control Options
If MOI suggests other injuries, begin txp & Rx given en route after d/w OLMC
Excited Delirium
Protocol Other Information540
1 BLS Obstetric Emergencies procedures2 NS KVO3 OLMC for MCO
Obstetric Complications
For severe pre-eclampsia, eclampsia or post-partum hemorrhage (BP > 160 mmHg + severe headaches, visual disturbances, acute pulmonary edema or upper abdominal tenderness)
Magnesium 2 gm in 50-100 mL NS over 10-20 mins. If seizures, repeat magnesium 2 gm in 50-100 mL NS over 10-20 mins
A
Standing Orders Medical Control Options
NYC REMSCO
Pediatric Protocols
Protocol Other Information543
1 BLS Neonatal Resuscitation procedures2 If CPR and HR <60 after 30 sec, perform ETI
During txp, or if txp delayed:3 Pass NGT/OGT for abdominal distention
4 If ETI+ and HR <60 bpm, epi 0.1 mg/kg (1 mL/kg of 1:10,000 soln) via ETI
6 IV NS KVO
7 Epi 0.01 mg/kg (0.1 mL/kg of 1:10,000 soln) IV/IO q3-5 mins
Protocol Other Information550
A NS IV/IO KVO, no more than 2 attempts
1 BLS Pediatric Respiratlry Distress procedures. Do not hyperextend the neck; use #551 if obstructed airway is suspected.
2 Perform Advanced Airway Mgmt if less methods are not effective
3 Decompress (with 18-20 g angio) if suspected tension PTX
4 During txp: naloxone 0.5 mg IM, titrate up to 2 mg (>2y/o) or up to 1 mg (<2 y/o)
5 Pass NGT/OGT for abdominal distention6 OLMC for MCO
Actual or impending respiratory arrest, unconscious and cannot be ventilated
Peds: 14 years old or younger
Consider Protocol 551 if obstructed airway is
suspected
Consider Protocol 556 if overdose suspected
Medical Control Options
Medical Control OptionsStanding Orders
Neonatal Resuscitation
Pediatric Respiratory Arrest
Standing Orders
If txp delayed, obtain IV/IO access (no more than 2 attempts) & NS 10 mL/kg5
Protocol Other Information551
1 Begin BLS Pediatric Obstructed Airway procedures
If epiglottis is enlarged, treat under Protocol 552.
a) note ETT depth. b) deflate ETT cuff. c) advance ETT to deepest depth.
d) return ETT to original depth. e) reinflate ETT cuff. f) if still unable to ventilate, initiate immediate transport.
Protocol Other Information552
1 Begin BLS Pediatric Croup/Epiglottitis procedures
During txp or if txp delayed:2 Pass NGT/OGT for abdominal distention
Perform Adv Airway Mgmt if less invasive measures of airway mgmt are not effectiveIf able to confirm ETI with direct visualization but unable to ventilate:
3
4
Perform Direct Laryngoscopy. Attempt removal of FB with appropriate-sized Magill forceps.2
Goal of Standing Order #5 is to force the FB
into the patient's main stem bronchus and
allow for ventilation in the contralateral lung.
Pediatric Obstructed
Airway
Standing Orders
Medical Control OptionsStanding Orders
Do not attempt Advanced Airway Mgmt - use high pressure BVM or mouth-mask ventilation.
Medical Control Options
Pediatric Croup-Epiglottitis Do not try NGT/OGT in
conscious pt
Do not attempt Advanced Airway
Mgmt.
Protocol Other Information553
1 Begin BLS Pediatric nontraumatic arrest procedures A Repeat any of the Standing Orders2 Cardiac monitor and EKG3 If VF or pulselessVT:
a Defibrillate at 4 joules/kg using appropriate padsb CPR x 5 cycles immediately after defibrillation
4 If VF or pulseless VT persists: D Sodium bicarbonate 1 mEq/kg IV/IO bolusa Defibrillate at 10 joules/kg using appropriate pads
5 CPR x 5 cycles immediately after defibrillation
6 Perform Adv Airway Mgmt if other methods of airway management are not effective F NS IV/IO 20 mL/kg bolus
7 During txp: epinephrine 0.1 mg/kg (0.1 mL/kg of 1:1,000) via ETT if pt intubated
8 Pass NGT/OGT for abdominal distention9 NS IV/IO KVO, no more than 2 attempts10 If VF or pulseless VT persists:
a Defibrillate at 10 joules/kg using appropriate pads
b CPR x 5 cycles immediately after defibrillation
c Amiodarone 5 mg/kg IV
11 Repeat Epinephrine 0.01 mg/kg (0.1 mL/kg of 1:10,000) IV/IO q 5 minsor Repeat Epinephrine 0.1 mg/kg (0.1 mL/kg of 1:1,000) ETT q5 mins if no access
12 OLMC for MCO
Protocol Other Information554
1 Begin BLS Respiratory Distress procedures A Repeat albuterol 0.083% by neb Pediatric: 14 years old or younger
2 Albuterol 0.083% (1 unit dose of 3 mL) by neb up to 3 doses
3 Ipratropium 0.02% (1 unit dose of 2.5 mL if > 6 yrs, 1/2 unit dose of 2.5 mL if < 6 yrs) by neb up to 3 doses
4If > 1 year with respiratory distress/failure, epinephrine 0.01 mg/kg (0.01 mL/kg of 1:1,000) IM, max dose 0.3 mg
C NS IV/IO KVO, no more than 2 attempts
5 OLMC for MCO
Standing Orders
Severe resp distress: agitation, dyspnea,
tripod positions, retractions.
If defibrillator is unable to deliver the
recommended dose, use lowest available
setting.
C
Repeat epinephrine 0.01 mg/kg (0.01 mL/kg of 1:1,000) IM 20 minutes after 1st doseB
Pediatric: 14 years old or younger
Pediatric Asthma or Wheezing
B
Dextrose 0.5 gm/kg, IV/IO. Use D10% if < 1 month, D25% if > 1 month but < 14 years
Naloxone 2 mg IV/IO/ETT/IM if > 2 years, 1 mg if < 2 years
Medical Control OptionsStanding Orders
If torsades de pointes, magnesium 25-50 mg/kg IV/IO bolusE
Medical Control Options
Pediatric Non Traumatic Cardiac
Arrest
Protocol Other Information
5551 Begin BLS Anaphylactic procedures A Repeat any of the Standing Orders
B NS IV/IO KVO, no more than 2 attemptsC NS IV/IO 20 mL/kg bolus, repeat as
necessary
During txp or if txp delayed:4 Pass NGT/OGT for abdominal distention5 OLMC for MCO
Protocol Other Information556
1 BLS AMS Procedures2 During txp or if txp delayed:
a Glucagon 1 mg IM/IN3 IV / IO NS KVO. 2 attempts max.
4 Dextrose 0.5 gm/kg, IV/IO. Use D10% if < 1 month, D25% if > 1 month but < 15 years
5 If no change in mental status; naloxone 0.5 mg increments up to 2 mg IV/IO/IM/IN
6 OLMC for MCO
Protocol Other Information557
1 BLS Seizure procedures; document glucose level2 Glucagon 1 mg IM/IN (hold if glucose > 120 mg/dL)
or Diazepam 0.1 mg/kg IV/IO over 2 minutes with repeat same doses if seizures persist
4 During transport, IV / IO NS KVO. 2 attempts max.
6 If seizures persistt, OLMC for MCO.
Standing Orders
Diazepam 0.5 mg/kg PR if no access or other options have been exhaustedC
Midazolam 0.2 mg/kg (maximum dose 5 mg), IN/IM if no accessB
Do not administer lorazepam, diazepam,
or midazolam if seizures have stopped.
Pediatric Seizures
Pediatric Altered Mental Status
2Pediatric
Anaphylactic Reaction
Medical Control OptionsStanding Orders
If respiratory failure, airway obstruction, or decompensated shock: ETI and give Epinephrine 0.01 mg/kg (0.1 mL/kg of 1:10,000 soln) via ETT.
Pediatric: 14 years old or younger
If seizures persist, midazolam 0.2 mg/kg IM/IN. (IN preferred, max dose 5 mg)3
Dextrose 0.5 gm/kg, IV/IO. Use D10% if < 1 month, D25% if > 1 month but < 15 years5
If no ETI, epinephrine 0.01 mg/kg (0.1 mL/kg of 1:10,000) IM. Maximum dose is 0.3 mg (0.3 mL of 1:1,1000 soln)
3
Standing Orders Medical Control Options
Pediatric: 14 years old or younger
Pediatric: 14 years old or younger
Repeat any of the Standing OrdersA
A
Medical Control Options
For persistent seizures, lorazepam 0.05 mg/kg, IV/IN/IO over 2 minutes with repeat same doses if seizures persist
1st priority is maintenace of cardiorespiratory function: treat under other protocols if AMS due to shock, trauma,
respiratory failure, drowning, anoxic injury.
Protocol Other Information558
1 Begin BLS Pediatric Shock procedures
5 If still in shock, go to MCO
Protocol Other Information559
A NS/LR IV/IO 20 mL/kg (total 60 mL/kg)1 Begin txp & BLS Traumatic Cardiac Arrest procedures
During txp, or if txp delayed
3 Decompress suspected tension PTX4 NS/LR IV/IO 20 mL/kg bolus, no more than 2 attempts
6 If patient still in arrest; NS/LR IV/IO 20 mL/kg via second IV (total 40 mL/kg), no more than 2 attempts
7 MCO
Pass NGT/OGT for abdominal distention (no NGT in craniofacial trauma)
Perform Adv Airway Mgmt if airway is not controlled by other means2
5
3
If no signs of hemorrhage present, cardiac monitor and EKG2
Pediatric: 14 years old or younger
Rapid transport is the highest priorityStanding Orders Medical Control Options
If monitor cannot deliver calculated dose and in unstable SVT, adenosine 0.1 mg/kg IV/IO rapid bolus + flush (with 2 repeats of 0.2 mg/kg IV/IO rapid bolus). Maximum doses are 6-12-12 mg.
a
b
If signs of hemorrhage/dehydration & still in shock, NS/LR IV/IO 20 mL/kg via second IV (total 40 mL/kg), no more than 2 attempts
4
During txp: NS/LR IV/IO 20 mL/kg bolus, no more than 2 attempts
Pediatric Traumatic Cardiac
Arrest
Medical Control OptionsStanding Orders
If signs of shock still present, NS/LR IV/IO 20 mL/kg (total 60 mL/kg)A
Pediatric: 14 years old or younger
Do not perform cardioversion in
pediatric patients with SVT/VT with a pulse
unless the defibrillator can deliver a calculated
dose
Pediatric Decompensated
Shock
If unstable SVT or VT, go to Medical Control OptionsB
If rhythm fails to convert, synchronized cardioversion at 1-2 joules/kg
If in unstable SVT/VT with pulse & monitor can deliver a calculated dose, synchronized cardioversion at 0.5-1 joule/kg using appropriate sized paddles