CPR, ALS treatment, and transport to an emergency department may be withheld in an apneic and pulseless patient that meets ANY one of the following: Presence of a valid MOLST, eMOLST, or DNR indicating that no resuscitative efforts are desired by the patient. This Pediatric Emergency Care Coordinator and EMS Pediatric Prepared project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) as part of an award totaling $100,000 with 0% percent financed with nongovernmental … When transferring patients, both the receiving and transferring providers should: All personnel and agencies must comply with NYSDOH BEMS policy statement 12-02 (or updated version) regarding documentation: Does the patient meet Adult/Pediatric Major Trauma Criteria with a BLUNT mechanism of injury? This general approach guidance document is intended to provide a standardized framework for patient transport. Each region will determine which levels will be credentialed to practice within their jurisdiction. May be repeated every 5 minutes, as needed, if SBP > 100 mmHg or MAP > 65 mmHg. Allow them to assist with care. The WREMAC will issue new guidance on cardiac arrest management in the near future. anything producing an unreliable physical exam). For MCIs, establish a command structure as soon as possible. They reflect the current evidence-based practice and consensus of content experts. ), Patient who is pulseless and apneic with no organized cardiac activity on ECG (performed by an ALS provider) following significant blunt or penetrating traumatic injury*, Cardiopulmonary arrest patients in whom the mechanism of injury does not correlate with clinical condition, suggesting a nontraumatic cause of the arrest, are excluded from this criterion, Patient who has been submerged for greater than one hour in any water temperature, If a patient meets any of the aforementioned criteria, resuscitation efforts may be withheld, even if they have already been initiated. On this episode, we start right where we left off discussing part two of the historic New York State Collaborative Protocols.The nuances, the evidence, the rational for implementing it and instituting this new set of protocols across 13 out of the 16 regions in New York State. * Does not include atropine included in DOH field deployment stock, ** Etomidate (Amidate), ketorolac (Toradol), nitrous oxide, haloperidol (Haldol), and ondansetron ODT may not be required by every region, *** Tetracaine is required only if Morgan Lenses are utilized, The minimum number of medications will be determined by regional procedure, †A combination unit dose (such as a DuoNeb®) may carried in place of ipratropium (Atrovent). BLS Protocol Update Dr Dailey, Donovan. See also the following collaborative protocols, as indicated: General: Behavioral Emergencies: Agitated Patient, General: Behavioral Emergencies: Excited Delirium, General: Poisoning / Overdose: Undifferentiated - Adult, General: Poisoning / Overdose: Undifferentiated - Pediatric, Check blood glucose level, if equipped and safe to do so. Patients may also have a medical bracelet, necklace, or wallet card with this information, Perform a secondary assessment and treat per appropriate protocol, Assure that patient has the power unit, extra batteries, and backup controller for transport, A trained support member should remain with patient, Unless otherwise directed by medical control, transport patient to a facility capable of managing VAD patients, Apply cardiac monitor and obtain 12-lead ECG. Please refer to the manufacturer’s ventilator operation manual for specific directions on how to operate your ventilator. Bullets are used throughout this document. New York State Department of Health Bureau of Emergency Medical Service and Trauma Systems Collaborative Advanced Life Support Adult and Pediatric Treatment Protocols 2019 Version 1.0 [April 12, 2019] Effective August 1, 2019 health.ny.gov/ems Version 011619A Patients who do not meet the “Extremis: Obvious Death” protocol, but are in cardiopulmonary arrest, must meet ALL of the following requirements for termination of resuscitative efforts to be considered without a medical control order: Arrest not witnessed by a bystander or by EMS, No automated external defibrillator or manual shock delivered, No return of spontaneous circulation up to the time termination is considered o At least 20 minutes of resuscitation has been provided, See also “Resources: Advance Directives/MOLST/DNR” protocol, as indicated, Patients that do not meet the above standing order termination of resuscitation may be considered for termination of resuscitation with medical control, if the family is amenable to this decision, Consider the EtCO2 when discussing termination with medical control, If resuscitative efforts are terminated, contact law enforcement per regional or jurisdictional procedure. If patient has a history of anaphylaxis and has an exposure to an allergen developing respiratory distress and/or hypoperfusion and/or rash: If the patient does not improve within 5 minutes, you may repeat epinephrine once, The Syringe Epinephrine for EMT may be substituted for an autoinjector, If the patient is wheezing, albuterol 2.5 mg in 3 mL (unit dose), via nebulizer; may repeat to a total of three doses, Epinephrine (1:1,000 / 1mg/mL) 0.3 mg IM, ONLY if patient is hypotensive and/or is developing respiratory distress w/airway swelling, hoarseness, stridor, or wheezing. Each region will determine which levels will be credentialed to practice within their jurisdiction. As a result, there should be no significant changes to patient care performed within the MLREMS region related to the release of the 2019 NYS EMS Collaborative Protocols. New York State Collaborative EMS Protocols 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. 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. Rocuronium is to be used for paralysis only when succinylcholine is contraindicated. These protocols are effective immediately for all Monroe-Livingston Regional EMS providers upon completion of the required training. wremac collaborative protocol formulary This protocol is designed to assure that the EMS provider and medical control provider are best prepared to assist patients with ongoing disease processes that are not covered by these protocols, and who have already been given therapy by their prescribers. Check a blood glucose level, if equipped. 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. Regional protocols and policies may accompany these protocols. Assure a secondary oxygen source with a minimum of 1000psi in a D tank Designed by a medical team with years of pre-hospital experience, NYS EMS Collaborative protocol app allows users to … new york state bls protocols. Maximum dose 5 mg, Additional Midazolam (Versed) 0.1-0.2 mg/kg IV, IM, or intranasal, Consult medical control, if seizures persist, as soon as possible, Any EMS provider may assist the patient’s family or caregivers with the administration of rectal diazepam (Valium/Diastat), if available (see “Resources: Prescribed Medication Assistance” protocol), This protocol excludes traumatic hypovolemia, cardiogenic, and septic shock, For cardiogenic shock, “General: Cardiogenic Shock - Adult”, For septic shock, “General: Severe Sepsis/Septic Shock”, For trauma, “Trauma: Trauma Associated Shock - Adult”, Administer supplemental oxygen; refer to the “Resource: Oxygen Administration and Airway Management” protocol, Normal saline, to a total of 2 L, if there is no concern for pulmonary edema, Consider norepinephrine 2 mcg/min, titrated to 20 mcg/min, if needed, after the fluid bolus is completed, Consider dexamethasone (Decadron) 10 mg PO, IM, or IV. The NYS EMS Collaborative protocol app allows users to make clinical decisions with ease. If no response after 30-60 seconds of effective ventilation add oxygen, Each ventilation should be given gently, over one second per respiratory cycle, assuring that the chest rises with each ventilation, Monitor the infant’s pulse rate (by palpation at the base of the umbilical cord or by auscultation over the heart), and apply continuous pulse oximetry using (ideally the right) wrist or palm, *if available and trained. AutoPulse®, LUCAS®, LifeStat®, or other FDA approved device), Cycle of CPR = 30 compressions then 2 breaths (single rescuer) 15 compressions then 2 breaths (if two rescuers available), 5 cycles = 2 minutes (10 cycles = 2 minutes for 2-rescuers), Rotate compressors every two minutes with rhythm checks, as resources allow, Use of level-appropriate airway adjuncts and bag-mask device (BVM), as indicated, with BLS airway management, including suction (as needed), as available, Bag-mask should be connected to supplemental oxygen, if available, Rhythm check or AED “check patient” every two minutes of CPR, Defibrillate as appropriate (Pediatric AED pads preferred for children with weight < 25 kg or age < 8 years, if available.) 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. Michael Dailey, Heidi Cordi. When extremity bleeding sites cannot be rapidly determined, tourniquets may be placed high and tight in accordance with training, Conventional and pressure splints may also be used to control bleeding, Hemostatic dressings* should be used according to manufacturer’s instructions and training and may require removal of coagulated blood to directly access the source of bleeding, Remove smoldering clothing that is not adhering to the patient’s skin, Remove rings, bracelets, and constricting objects at or distal to burned area, if possible, Cover the burn with dry sterile dressings, Burns to the eye require copious irrigation with normal saline - do not delay irrigation, Other neutral fluid may be used, if needed, such as tap water, Consider the potential for carbon monoxide poisoning and refer to the “General: Carbon Monoxide Exposure - Suspected” protocol, as indicated, Burns should be covered with dry, sterile dressings, Vascular access at 2 sites, if possible (no more than one IO), for severe burns, Refer to the “General: Pain Management - Adult” or “General: Pain Management - Pediatric” protocol, Be prepared to intubate, if the patient has signs of airway involvement, Tetracaine (0.5%) 2 drops in the affected eye for pain every 3 minutes, as needed, For chemical exposure to the eye, you may use a Morgan Lens® for irrigation, Additional fluid to maintain perfusion while exercising caution against administering excessive volume, Assure scene safety and patient decontamination for chemical burns/HAZMAT exposure, For liquid chemical burns, flush with copious amount of water or saline, ideally for a minimum of 20 minutes, For dry powder burns, brush powder off before flushing, Use caution to avoid the spread of the contaminant to unaffected areas, Consider other injuries, including cardiac dysrhythmias, Consider smoke inhalation and airway burns, Oxygen saturation readings may be falsely elevated, If hazardous material involvement is suspected, immediately notify the destination hospital to allow for decontamination, The whole area of the patient’s hand is ~1% BSA (body surface area), When considering the total area of a burn, DO NOT count first degree burns, Hypothermia is a significant concern in these patients, Burns associated with trauma should go to the closest appropriate trauma center, Consider direct transport to a burn center in discussion with medical control, If there is a sucking chest wound, cover with occlusive dressing; if dyspnea increases, release the dressing, momentarily, during exhalation, A sucking chest wound occurs when air passes through a wound in the chest wall when the patient breathes in, Contact the receiving hospital as soon as possible, Vascular access; use the side opposite of the injury if possible, Normal saline administration, per the “Trauma: Trauma Associated Hypoperfusion/Hypovolemia” protocol, If the patient is in cardiac arrest, proceed with bilateral needle chest decompression and refer to appropriate arrest protocol*, If the patient is not in cardiac arrest, contact medical control for consideration of needle chest decompression if there is concern for a tension pneumothorax, Needle decompression if signs and symptoms of tension pneumothorax, including hemodynamic compromise, If patient has signs and symptoms consistent with tension pneumothorax AND hemodynamic compromise, consider needle chest decompression for Advanced, Signs and symptoms of a tension pneumothorax include absent lung sounds on one side, extreme dyspnea, AND hemodynamic compromise (may also include jugular vein distention, cyanosis, and tracheal deviation), May repeat chest decompression if tension pneumothorax recurs, If resuscitating a patient in traumatic arrest, consider bilateral chest decompression, Hemodynamic compromise: hypotension, narrowed pulse pressure, and tachycardia, Thoracic decompression is a serious medical intervention that requires a chest tube in the hospital, CQI review may be required by regional procedure, Thoracic decompression should only be performed with a ≥ 3.25”, ≥ 14G IV catheter (size for adults), *Advanced EMTs in tactical EMS may be trained and equipped for decompression, but the agency must be approved by the REMAC, ABCs and vital signs every 5 minutes, if practical, Consider EMS physician response, if available, or early physician consultation for prolonged entrapment, Cardiac monitor, if possible, with 12-lead ECG repeated at 30 minute intervals. This general approach guidance document is intended to provide a standardized framework for approaching the patient. Select the appropriate inspiratory time (It), if applicable Start with room air. The patient may be covered and may be moved back onto a bed or sofa, if appropriate and approved by law enforcement, Whenever possible, termination of resuscitation should be done when the patient is not in a public place, If the family is present, appropriate emotional support by other family, neighbors, clergy, or police should be available when considering termination of resuscitation, Skin color change: cyanosis, erythema (redness), pallor, plethora (fluid overload), Choking or gagging not associated with feeding or a witnessed foreign body aspiration, Check pupils and, if constricted, consider “General: Opioid (Narcotic) Overdose” protocol, Refer to “General: Altered Mental Status” protocol, if necessary, Ongoing assessment of the effectiveness of breathing, Refer to “Extremis: Respiratory Arrest / Failure - Pediatric” protocol, if necessary, For the undifferentiated patient with altered mental status, Including, but not limited to, BLS management of hypoglycemia. wremac collaborative protocol formulary These protocols are intended to guide and direct patient care by EMS. If the patient is unable to swallow on command, or mental status remains altered following administration of oral glucose: Refer to “Extremis: Respiratory Arrest/Failure” or “Extremis: Pediatric Respiratory Arrest/Failure,” protocol, if necessary, See etiology-specific protocols cross referenced in the “CRITERIA” section above, Assess the scene for safety and, if it is not, retreat to a safe location and obtain police assistance, Consider closed head injury and non-accidental trauma, especially in children, Consider drug ingestion, meningitis/encephalitis, Allow the patient to maintain position of comfort, Refer to the “Extremis: Respiratory Arrest/Failure - Adult” protocol, if necessary. For example: Known or suspected hyperkalemia (e.g. Auscultate (listen with a stethoscope) over the precordial/epigastric (heart/upper stomach) area for a motorized “hum” and simultaneously visualize the controller for a green light or lit screen, Assess perfusion based on mental status, capillary refill, and skin color, Incontinuous flow VAD patients (Heart Mate II©, Heartware©, or axial flow device), the absence of a palpable pulse is normal even in the setting of a normally functioning device. AutoPulse®, LUCAS®, LifeStat®, or other FDA approved device), Note: The use of a particular mechanical CPR device may be contraindicated in the pediatric patient; refer to manufacturer’s recommendation, General cardiac arrest care, “Extremis: Cardiac Arrest: General Approach” protocol, Manage airway: Use of naso- and/or oropharyngeal airway and bag-valve mask device is acceptable while deferring advanced airway until more urgent care is completed, Epinephrine (1:10,000 / 0.1 mg/mL) 1 mg IV; repeat every 3-5 minutes, If the cardiac monitor shows asystole, confirm in more than one lead, A minimum of 50 mL of normal saline should be given between the bolus of calcium chloride and the bolus of sodium bicarbonate, Refer to the “Extremis: Termination of Resuscitation” protocol, as indicated, Advanced and above: consider bilateral chest decompression in patients with an organized cardiac rhythm presenting in cardiac arrest thought to be secondary to trauma, Note thata pneumothorax may also occur spontaneously (without trauma), For cardiac arrest associated with fire, see also “General: Cyanide Poisoning/Smoke Inhalation - Symptomatic” protocol, General pediatric cardiac arrest care, “Extremis: Cardiac Arrest: General Approach - Pediatric” protocol, Normal saline 20 mL/kg bolus (up to 500 mL bolus) rapid IV, Epinephrine (1:10,000 / 0.1 mg/mL) 0.01 mg/kg IV, Perform CPR for at least 3 minutes between medication doses, For cardiac arrest associated with fire, see also “General: Cyanide Poisoning / Smoke Inhalation - Symptomatic”, AED defibrillation, as indicated (CC/Paramedic may substitute manual defibrillation as indicated below), Manage airway: Initial use of naso- and/or oropharyngeal airway and bag-valve mask device is acceptable while deferring advanced airway until initial care is complete, Amiodarone 300 mg IV. 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