new york state ems collaborative protocols

Hemodialysis access sites may result in life threatening hemorrhage. This update is required to be completed by all New York State certified EMS providers: The 2015 BLS Protocol update on hemorrhage control and spinal injuries is approved for 3 hours of CME (Preparatory, Trauma, or Other). Over the course of the last three years, a group of physicians created a memorandum of understanding between regions and created a set of protocols that have been adopted by every EMS region north of the Bronx. NYSDOH Protocols Listing. If abnormal, refer to the “General: Hypoglycemia - Adult” protocol, as indicated, Midazolam (Versed) 10 mg IM or ketamine* 250 mg IM, May administer ketamine 250 mg IM after 5 minutes (as a single repeat dose or as a single dose after midazolam [Versed]), should the patient remain uncontrolled, Additional Midazolam (Versed) 2.5 to 10 mg IV or IM, Additional ketamine* up to 0.5-2 mg/kg IV or 3-5 mg/kg IM, If the agitated patient goes into cardiac arrest, consider possibility of acidosis in the appropriate cardiac arrest protocol, A team approach should be attempted at all times for the safety of the patient and the providers. These protocols are effective immediately for all Monroe-Livingston Regional EMS providers upon completion of the required training. You may give an additional dose of aspirin (324 mg chewed) if there is any concern about the patient having received an effective dose prior to your arrival, Consider 12-lead ECG for adults, with any one of the following: dyspnea, syncope, dizziness, fatigue, weakness, nausea, or vomiting, **If equipped, trained, and regionally approved, have baseline oxygen saturations between 65 and 85% rather than above 94% (ask care provider about patient’s usual oxygen saturation level), be fed by either a nasogastric tube (tube in nose) or by gastrostomy (tube through abdominal wall), not have a pulse or accurate blood pressure in an extremity after heart surgery, ABCs and vital signs, including blood pressure, Keep patient on continuous pulse oximeter monitoring, if available (will monitor both heart rate and SpO2), Ask parents if the patient has a heart condition and/or has been operated on (look for a scar in the middle or side of chest); ask what type of heart condition it is, Keep the child in a somewhat upright position to enable optimal breathing, or allow child to be in position of comfort, Ask parents what the child’s usual oxygen saturation is and provide only sufficient oxygen to bring the SpO2 to his/her usual baseline, Ask parent if the patient has a pacemaker and/or internal defibrillator, If patient has a fever, minimize the child’s clothing and keep the ambulance at a comfortable temperature, Assess for signs of poor perfusion (such as prolonged capillary refill > 2 seconds, cool and dusky distal extremities, poor radial and dorsalis pedis pulses, and/or hypotension), If patient has a gastrostomy tube, suggest to parent/caregiver to open the tube to air or aspirate stomach contents to improve the child’s ability to breathe, Obtain vital signs including blood pressure every 15 minutes, If patient has altered mental status, obtain fingerstick blood glucose and refer to the “General: Hypoglycemia - Pediatric” and/or “General: Altered Mental Status” protocol, as indicated, Chest pain in children is rarely a sign of a cardiac condition (it is more frequently related to conditions such as costochondritis or pleuritis), Notify the destination hospital ASAP and state that the patient has signs of cardiac failure or decompensation, Infants with congenital heart disease may present with symptoms very similar to septic shock (poor perfusion, poor distal pules, tachypnea, or dusky appearance), Pediatric patients with a congenital heart condition often have oxygen saturations in the 65-85% range. Aggressive nitroglycerin 0.4 mg SL or equivalent, as needed: One dose/tablet every 5 minutes if the patient’s systolic BP 120-160 mmHg, Two doses/tablets every 5 minutes if the patient’s systolic BP 160-200 mmHg, Three doses/tablets every 5 minutes if the patient’s systolic BP > 200 mmHg, Consider albuterol 2.5 mg in 3 mL (unit dose) + ipratropium (Atrovent) 0.5 mg in 2.5 mL (unit dose) mixed together, via nebulizer, only if wheezes are present, All patients with rales do not have pulmonary edema; consider the possibility of pneumonia or chronic obstructive pulmonary disease (COPD) exacerbation, Monitor BP closely, particularly when administering nitroglycerin for pulmonary edema (may not be able to lay patient in a supine position if he or she becomes hypotensive), BiPAP may be used in place of CPAP as training and equipment allow, Patients with increased work of breathing (retractions, grunting, nasal flaring) and prolonged expiration and/or poor air movement, Excludes stridor/croup (see “Difficulty Breathing: Stridor - Pediatric” protocol), Refer immediately to the “Extremis: Foreign Body Obstructed Airway - Pediatric” protocol, if indicated, Refer to the “Extremis: Respiratory Arrest/Failure - Pediatric” protocol, if necessary, Allow patient to determine position of comfort. Special thanks to Robin Snyder-Dailey for the protocol design. These protocols are effective immediately for all Monroe-Livingston Regional EMS providers upon completion of the required training. INITIATING MECHANICAL VOLUME VENTILATION An immediate oral report shall be made to: NYS Child Abuse and Maltreatment Register: This is a hotline number for mandated reporters only, not the public, All oral reports must be followed up with a written report within 48 hours, using form. If the respirations remain absent, gasping, or become depressed (< 30/min) despite stimulation, if the airway is obstructed, or if the heart rate is < 100/min: Clear the infant’s airway by suctioning the mouth and nose gently with a bulb syringe, and then ventilate the infant at a rate of 40-60 breaths/minute with an appropriate BVM as soon as possible, with a volume just enough to see chest rise. ventriculoperitoneal or V-P shunt), Internal tube that drains spinal fluid from the brain into the abdomen, Gastrostomy (PEG tube, MIC-KEY® “button”) or J-tube, Feeding tube that goes through the abdominal wall, Bowel connected through abdominal wall for collection of waste in a bag, Connection of the urinary system through the abdominal wall or through the back for collection of urine in a bag, Catheter in urethra to collect urine from the bladder into a bag, ABCs and vital signs including blood pressure, Basic airway management if needed, give high flow oxygen (non-rebreather) if neede, If on ventilator and there are respiratory concerns, disconnect and attempt to ventilate via tracheostomy adapter using BVM, If tracheostomy tube is fully or partially dislodged, remove it, cover tracheostomy stoma with an occlusive dressing, and ventilate via mouth and nose using BVM, Central venous catheters: if catheter is broken or leaking, clamp (pinch off) catheter between patient and site of breakage or leakage, Gastrostomy tube or button, ureterostomy or nephrostomy tube: if tube or button is fully dislodged, cover the site with an occlusive dressing; if partially dislodged, tape in place, Gastrostomy, colostomy, ileostomy, or nephrostomy: if stoma site is bleeding, apply gentle direct pressure with a saline-moistened gauze sponge, Foley catheter: if catheter is dislodged, tape in place, Notify the destination hospital ASAP and state that the patient has special health care needs that requires technological assistance (be specific), Obtain frequent vital signs, including blood pressure. Select the appropriate mode, if applicable Prepare the BVM device for emergent use in case of a ventilator failure The medical control agreement contained within these protocol document states, “providers are expected to utilize their best clinical judgment and deliver care and procedures according to what is reasonable and prudent for specific situations.” The determination of when to utilize an adult or pediatric protocol shall be no different and subject to the same CQI review that is compulsory with any other aspect of prehospital emergency care. cardiac arrest), follow the orders as written, If advanced directives not mentioned above are present (living will or health care proxy), contact medical control for direction, Direction regarding wishes expressed via other forms of advanced directives including living wills, health care proxies, and in-hospital do not resuscitate orders, Any appropriate directive indicated on the MOLST or eMOLST should be honored, including the directive for the patient not to be transported to the hospital, A MOLST is still valid even if the physician signature has expired, A copy of the original MOLST is a valid document, The eMOLST form may be printed and affixed with electronic signatures. Pre-Conference 2018 Prehospital Ultrasound Guided Resuscitation; About Us! Repeat 150 mg in 5 minutes, If pulses return, refer to the “Extremis: Return of Spontaneous Circulation (ROSC) - Adult” protocol, Consider magnesium 2 grams IV if suspected hypomagnesemia or torsades de pointes, Lidocaine 1.5 mg/kg IV bolus and/or infusion, Amiodarone 150 mg in 100 mL normal saline IV over 10 min, Consult medical control if patient has return of pulses (even transiently), Note that a pneumothorax may also occur spontaneously (without trauma), Refer to the “Extremis: Termination of Resuscitation” protocol as indicated, Pediatric AED pads preferred for children with weight < 25 kg or age < 8 years o CC/Paramedic may substitute manual defibrillation as indicated), Defibrillate at 4 J/kg between doses of medication, Higher doses of energy may be considered for refractory ventricular fibrillation not to exceed the lesser of 10 J/kg or the recommended adult maximum dose, Amiodarone 5 mg/kg bolus IV (up to a maximum of 300 mg/dose), Repeat once in 5 minutes (up to a maximum of 150 mg/dose), Additional amiodarone 5 mg/kg IV (up to 15 mg/kg total), Use the small (pediatric) pads for patients weighing less than 10 kg, Consider toxic ingestions, including tricyclic antidepressants, Patients with a partial or complete foreign body airway obstruction, If the patient is conscious and can breathe, cough, or speak, Transport in a sitting position or other position of comfort, Administer supplemental oxygen; refer to the “Resources: Oxygen Administration and Airway Management” protocol, Perform ongoing assessment and watch for progression to complete obstruction, Facilitate transportation, ongoing assessment, and supportive care, If the patient is conscious and cannot breathe, cough, or speak, Perform airway maneuvers according to current AHA / ARC / NSSC guidelines, Remove any visible airway obstruction by hand, Performlevel-appropriateairwaymaneuvers,asindicated, Perform CPR, refer to “Extremis: Cardiac Arrest: General Approach - Pediatric” protocol, Pediatric patients with a partial or complete foreign body airway obstruction, Consider allowing parent to hold face mask with oxygen 6 - 8 inches from the child’s face as tolerated, Perform airway maneuvers according to current AHA/ARC/NSSC guidelines, In infants (< 1 yr old): perform 5 chest thrusts alternating with 5 back-blows. Acetaminophen contraindications (unless medical control approved): Hx of liver problems / acute liver failure, AcuteliverinflammationduetohepatitisCvirus, In the setting of shock or overdose (especially acetaminophen overdose). If you are here for COVID-19 training assigned by the NYS Department of Health please select "NYS - COVID-19" as your agency. If an eyewash station is not available, use tap water, Decontamination may be limited because of the lack of available resources, Report the exposure to a supervisor, immediately, Seek immediate medical attention and post-exposure evaluation at the hospital the source patient was transported to, if possible. wremac collaborative protocol formulary NYSDOH Protocols Listing. The color-coded format of the protocols allows each EMS professional to easily follow the potential interventions that could be performed by level of certification. If blood pressure <90mmHg, or evidence of distributive shock, blood loss, or dehydration: IV 0.9% NS in 250mL boluses; may be repeated to one liter total if hypotension is persistent. The child and parent/caregiver should each be restrained appropriately, All patients on the stretcher must be secured when the vehicle is in motion or the stretcher is being carried or moved; stretcher harness straps should always be used, A child’s own safety seat - when available and intact - can be used to restrain a child during transport. Immediate intervention for severe bleeding: Apply pressure directly on the wound with a dressing, Hemostatic gauze* may be applied with initial direct pressure, Rolled gauze may be used if hemostatic gauze is not available, If bleeding soaks through the dressing, apply additional dressings, If bleeding is controlled, apply a pressure dressing to the wound, If severe bleeding persists through conventional dressings and hemostatic dressing becomes available, remove all conventional dressings, expose site of bleeding, and apply hemostatic dressing*, Cover the dressed site with a pressure bandage. Assess for hypovolemia. Home » EMS Resources » Protocols » 2019 NYS Collaborative ALS Protocols Version 002 09242019 2019 NYS Collaborative ALS Protocols Version 002 09242019 Published October 31, 2019 Patients may not have a readily measurable blood pressure, In pulsatile flow VAD patients with a HeartMate 3© centrifugal device, patients may have a palpable pulse (pulse is generally set to 30 BPM) in the setting of a normally functioning device, yet may not have a readily measurable blood pressure, Ascertain, and make note of: pump model, installing institution, and institution VAD coordinator phone number from a tag located on the pocket controller. No prophylactic IV lines / access may be established using pre-existing vascular devices. Regions will determine the requisite training that providers must review prior to utilizing these protocols, “*if equipped and trained” is noted to indicate interventions that may be performed if an agency or region chooses to implement these variations. Regional Emergency Medical Services Council. If you suspect the symptoms are hypoglycemia-induced, titrate dextrose 10 % using 5 grams (50 mL) aliquots for treatment and diagnosis, For pediatric patients with known or suspected hypoglycemia, Refer to “Extremis: Respiratory Arrest/Failure - Pediatric,” protocol if necessary, If unable to obtain adequate results with oral glucose consider glucagon 0.5 mg IM if < 20 kg, otherwise, 1 mg IM*, if needed, IV access, and dextrose 10% 5 mL/kg IV via syringe (, If vascular access is limited: glucagon 0.5 mg IM if < 20 kg, otherwise, 1 mg IM*, If the patient’s parent or guardian wishes to refuse medical care for the patient, and you have administered any medications, including oral glucose, regional procedure may require consultation with medical control prior to completing the refusal, *Preschool aged children and infants may have limited response to glucagon, Normal saline 500 mL IV bolus; may repeat once, if lung sounds remain clear, Consider a 12-lead ECG and cardiac monitor, Ondansetron (Zofran) 4 mg ODT/PO, IV, or IM, may repeat x 1 in 10 minutes, Diphenhydramine (Benadryl) 25 mg IV or IM for motion sickness, This protocol is intended for the prevention and treatment of nausea and/or vomiting, Ondansetron (Zofran) 2 mg IM or 4 mg ODT/PO, This protocol does not apply to patients under the age of two years, A single dose of ondansetron (Zofran) may be given to the pediatric patient prior to seeking medical consultation, Refer to the “General: Hypoglycemia - Adult” or “General: Hypoglycemia - Pediatric” protocol, as indicated, Determine what and how much was taken, along with the time, if possible, In the pediatric patient, administer naloxone (Narcan®) 1 mg** intranasal; 1⁄2 mg per nostril, may repeat once in 5 minutes, if no significant improvement occurs, Titrate naloxone (Narcan) to max 2 mg per dose IV, IM, or intranasal, ONLY if hypoventilation or respiratory arrest. Monitor carefully for bradycardia and hypotension, If the patient becomes hypotensive after nitroglycerin administration, place the patient in a supine position, if there is no contraindication to doing so such as severe pulmonary edema, An IV is not required for nitroglycerin administration, particularly in the absence of pulmonary edema because positioning is the primary intervention for nitroglycerin-induced hypotension, Consider a right-sided ECG in the setting of a suspected inferior STEMI, For patients presenting with acute focal neurologic deficits including, but not limited to, slurred speech, facial droop, and/or unilateral (one-sided) weakness or paralysis. Ongoing assessment is required to assess: The need for compressions should the patient lose his or her pulse (refer immediately to the “Extremis: Cardiac Arrest: General Approach” protocol), Adequate ventilation may require disabling the pop-off valve if the bag-valve mask unit is so equipped, Signs of ineffective breathing include cyanosis, visible retractions, severe use of accessory muscles, altered mental status, respiratory rate less than 12 breaths per minute, Provide positive pressure ventilation using an appropriate size bag mask (BVM), If ventilations are not successful, refer immediately to the “Extremis: Foreign Body Obstructed Airway - Pediatric” protocol, Use of level-appropriate airway adjuncts and bag mask device, as indicated, with BLS airway management, including suction (as needed), as available, Bag mask should be connected to supplemental oxygen, if available, Attach pulse oximeter if available and have a goal of oxygen saturation ≥ 94%, See also, “Resources: Oxygen Administration and Airway Management” protocol, Do not delay ventilations to connect to supplemental oxygen but add supplemental oxygen when available, The need for compressions should the patient lose his or her pulse (refer immediately to the “Extremis: Cardiac Arrest: General Approach - Pediatric” protocol), Adequate ventilation may require disabling the pop-off valve, if the bag mask unit is so equipped, Airway management and appropriate oxygen therapy, Vascular access, ideally at 2 sites (no more than one IO), If needed, administer normal saline to a total of 2 L to maintain MAP > 65 mmHg or SBP > 100 mmHg, provided there is no concern of pulmonary edema, Cardiac monitor with 12-lead ECG as soon as possible, Treatment for appropriate presenting rhythm, Discuss antiarrhythmic treatment options with medical control if patient was in a shockable rhythm, If an AED shock was delivered for a rhythm that was not seen on a monitor, treat as ventricular fibrillation / ventricular tachycardia, If needed, administer normal saline to a total of 2 L, provided there is no concern of pulmonary edema, Consider norepinephrine 2 mcg / min, titrated to 20 mcg / min, if needed, after fluid bolus infused, to maintain MAP > 65 mmHg or SBP > 100 mmHg, Antiarrhythmic (additional amiodarone or lidocaine), Amiodarone 150 mg in 100 mL normal saline over 10 min, Lidocaine 1.5 mg / kg bolus and / or infusion. 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