Bullets are used throughout this document. Contact medical control for additional fluids beyond one liter, TAH patients have had their heart removed and replaced with a rigid device which pneumatically pumps blood throughout the body, As these patients do not have a heart, there is no indication for an ECG or cardiac monitoring. The 2017 New York State EMS Collaborative Protocols are posted on the www.midstateems.org web site. * D5W 100 mL bags may be substituted for normal saline 100 mL, if there is a persistent shortage and normal saline is not available. 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. Links to the protocol training modalities for currently credentialed TEKs are also available there, as are links to Paramedic, Critical Care and AEMT level credentialing exams for new … All Midstate Providers should review both the protocols and the reference material prior to attending a REMAC Update. The patient may be covered and, if allowed by law enforcement, may be moved to an adjacent private location. Search for and treat possible contributing factors that EMS can manage according to your level of certification: For cardiac arrest associated with fire, see also “General: Cyanide Poisoning / Smoke Inhalation - Symptomatic” protocol. Vitals should be frequently assessed during transport to avoid unnecessary prehospital overhydration, Consider potential causes of hypoperfusion: anaphylaxis, toxic ingestions, cardiac rhythm disturbances, myocardial infarction, sepsis, ectopic pregnancy, ruptured abdominal aortic aneurysm, adrenal crisis, or others, Temperature > 100.4° F (38° C), if available, White blood count > 12,000 cells/mm3or < 4,000 cells/mm3 or > 10% bands, if available, Airway management and high flow oxygen (non-rebreather as tolerated), If the patient has altered mental status, refer to the “General: Altered Mental Status” protocol, Attempt to maintain normal body temperature, Advise the destination hospital that the patient has signs of sepsis/septic shock, Obtain vital signs, including blood pressure, frequently, Notify the destination hospital of potential septic shock patient with a verbal report prior to your arrival, Cardiac monitor and continuous pulse oximetry, Patients in septic shock may require boluses of up to 3-4 L (or 30cc/kg) prior to initiating vasopressors, provided there are no contraindications to doing so, such as renal failure or pulmonary edema, Consider norepinephrine 2 mcg/min, titrated to 20 mcg/min, if needed, after the fluid bolus is completed to maintain MAP > 65 mmHg or SBP >100 mmHg, Focus on rapid identification, IV hydration, and early notification of concern for potential septic shock patient to destination facility, Concern for any new or worsening infection includes reported fever, shaking chills, diaphoresis, new cough, difficult or less than usual urination, unexplained or newly altered mental status, flushed skin, pallor, new rash, or mottling, Vitals should be frequently assessed during transport to avoid prehospital over- hydration, For patients with hypoperfusion because of trauma, bleeding, vomiting, diarrhea, or sepsis. This resource is for those adult patients who are suspected of being exposed to an organophosphate or a chemical nerve agent, and are experiencing some or all of following signs/symptoms: MODERATE: SLUDGEM = Salivation-Lacrimation-Urination-Diarrhea-GI Distress-Emesis-Muscle Twitching-Miosis, SEVERE: SLUDGEM + Agitation/Confusion/Seizures/Coma + Respiratory Distress, This is a reference to assist with the implementation of BEMS policy statement 03-05 (“Mark I Kits”) or the updated version in a WMD incident, Contact dispatch to declare an incident; request an appropriate response, Request ALS, if not already present or en route, Contact medical control to request CHEMPACK Program Antidote Kits, Consider requesting an EMS physician to scene, Airway management with high concentration oxygen, If SEVERE signs and symptoms are present, administer three (3) atropine 2 mg auto-injectors and three (3) pralidoxime (2-PAM) auto-injectors in rapid succession (stacked). We have also posted the roll out 2017 reference materials and schedule of Midstate REMAC Protocol Roll Out dates and locations. to the hospital with the patient, if possible. Monitor surroundings and utilize the assistance of law enforcement for crowd control, Ketamine and haloperidol may not be available in all regions, If the patient is in police custody and/or has handcuffs on, a police officer should accompany the patient in the ambulance to the hospital; the provider must have the ability to immediately remove any mechanical restraints that hinder patient care at all times, Excited delirium is frequently associated with drug abuse, Excited delirium does not frequently occur in the elderly, All uses of this protocol may require Agency Medical Director review or regional QA, depending on regional procedure, For patients with smoke inhalation, patients for whom a CO alarm has gone off in the residence, or any other potential exposure to CO, See also “General: Smoke Inhalation/Cyanide Poisoning - Symptomatic” protocol, as indicated, Any patient with suspected carbon monoxide poisoning should receive high flow oxygen via non-rebreather mask (NRB), An objective carbon-monoxide evaluation tool may be used to guide therapy, if available, Any pregnant (or potentially pregnant) woman should receive high flow oxygen and be transported to the hospital, An asymptomatic patient with a known CO level >25% should receive high flow oxygen and be transported to the hospital, An asymptomatic patient with a CO level 12-25% should receive high flow oxygen for 30 minutes and then should be reassessed, unless the patient requests transport to the hospital, Strongly encourage transport if CO levels are not decreasing, Carbon monoxide poisoning does not have specific, clear cut symptoms; other medical conditions may present with dizziness, nausea, and/or confusion, All symptomatic patients should be transported, regardless of CO level, If there is no soot in the airway, consider CPAP* 5-10 cm H2O (if the device delivers 100% oxygen), For older pediatric patients consider CPAP, as equipment size allows if available and trained, Consult medical control for guidance regarding transport location decisions and on- scene treatment and release when multiple patients are involved, If there is potential for greater than 5 patients, consider requesting an EMS physician to the scene, if available, The Masimo RAD 57® is an example of an objective carbon-monoxide evaluation tool. Set PEEP to 5 cmH2O The collaborative protocols have been developed to serve all the levels of certification within New York State. Working to establish Pediatric Emergency Care Coordinators at EMS agencies across New York State. 2017 NYS Collaborative Protocols. See “General Approach: to Transportation” protocol, Vital Signs (repeated frequently if abnormal or critical patient), Blood glucose determination, if approved, equipped and appropriate, If a patient chooses to refuse care or transportation, please refer to “Refusal of Medical Attention” protocol and regional policy, Develop a prehospital patient impression by combining all information available in the history of present illness, past medical history, and physical exam, Submit a verbal report to the responsible medical personnel upon arrival at the emergency department, Label any items that were transported with the patient such as ECGs, paperwork from facilities, medications, or belongings, Complete a patient care report in compliance with state, regional and agency policy, It is not permissible or safe to have a parent or caregiver hold a child in his/her arms or lap. Titrate to appropriate EtCO2 Children with special health care needs requiring technological assistance for life support: Central venous catheters (tunneled catheter, Broviac catheter, Mediport, PICC), Catheters that enter a large (central) vein, CSF shunt (e.g. Place the second clamp 3 inches from the first clamp toward the mother, Cover the infant’s scalp with an appropriate warm covering, Wrap the infant in a dry, warm blanket or towels and a layer of foil or plastic wrap over the layer of blankets or towels or use a commercial-type infant swaddler, if one is provided with the OB kit. Avoid tap water storage, if possible, but do not allow the permanent tooth to dry, This protocol authorizes the use of hemostatic dressings, compressive devices, and commercially manufactured tourniquets, These devices are not mandatory for any agency to stock or carry, Junctional tourniquets, wound closure devices, and other hemostatic devices may be used in accordance with manufacturer instructions, if regionally approved, Tactical application of these devices beyond this protocol may be regionally approved. NYS Collaborative Protocol; Prehospital Ultrasound. EpiPen®), as available and as trained, Adult autoinjector 0.3 mg IM (e.g. Establish or participate in unified command or ICS structure, as appropriate. Each region will determine which levels will be credentialed to practice within their jurisdiction. Typical situations include: Pulmonary hypertension - epoprostenol (Flolan) infusion when PICC line breaks, Congenital adrenal hyperplasia - assisting IM hydrocortisone (Solu-Cortef), If a patient is on a continuous drip medication and they lose their access, it is potentially fatal. For cardiac arrest associated with hypothermia: If defibrillation is required, provide no more than three shocks, Limit administration of medication in cardiac arrest associated with hypothermia to one round, Rhythm changes may be treated with a single round of the appropriate drug See also “General: Environmental - Cold Emergencies” protocol, Termination of resuscitation in instances that are not covered by standing order criteria may be authorized by medical control, Do not interrupt compressions for placement of an advanced airway, Minimize interruption in compressions for placement of a mechanical CPR device, Do not delay beginning compressions to begin ventilations, Do not delay ventilations to connect supplemental oxygen, Adequate ventilation may require disabling the pop-off valve is the bag-valve mask unit is so equipped, AED should be placed as soon as possible without interrupting compressions to do so, If a patient has a medication patch, it may be removed (use appropriate PPE), Artifact from vibrations in a moving ambulance may compromise the effectiveness of the AED, Compressions in moving ambulances pose a significant danger to providers, are less effective, and should be avoided, Consider mechanical CPR devices when available for provider safety if there is a need to do compressions in moving ambulances (e.g. Look for MedicAlert® jewelry, Emergency Information Form (EIF), or Patient Care Plan (PCP), or other health care forms, if usual caregiver is not available, Take Emergency Information Form (EIF), Patient Care Plan, or other health care forms to the hospital with the patient, Assess and communicate with the child based on developmental, not chronological, age, Take necessary specialized equipment (e.g. Assess airway and breathing. Provide or direct care for amputated part: Moisten sterile dressing with sterile saline solution and wrap amputated part, Place the severed part in a water-tight container, such as a sealed plastic bag, Place this container on ice or cold packs, using caution to avoid freezing the limb, Distal amputations (those distal to wrist or ankle) do not typically require a trauma center, Transport the amputated part with the patient, if possible, but do not delay transport to search for amputated part, Consider medical control consultation if there is uncertainty regarding appropriate destination facility, Hold the tooth by the crown (not the root), Quickly rinse the tooth with saline before reimplantation, but do not brush off or clean the tooth of tissue, Remove the clot from the socket; suction the clot, if needed, Reimplant the tooth firmly into its socket with digital pressure, Have the patient hold the tooth in place using gauze and bite pressure, Report to hospital staff that a tooth has been reimplanted, The best chance for success is when reimplantation occurs within five minutes of the injury, Do not reimplant if the patient is immunosuppressed, or reports having cardiac issues that require antibiotics prior to procedures, If the patient is not a candidate for reimplantation and avulsed a permanent tooth, place the avulsed tooth in interim storage media (commercial tooth preservation media, lowfat milk, patient’s saliva, or saline) and keep cool. Acetaminophen contraindications (unless medical control approved): Hx of liver problems / acute liver failure, AcuteliverinflammationduetohepatitisCvirus, In the setting of shock or overdose (especially acetaminophen overdose). Continuously monitor the infant’s respirations. new york state bls protocols. Please refer to the manufacturer’s ventilator operation manual for specific directions on how to operate your ventilator. 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. warfarin/Coumadin), Fentanyl should be used if there is concern for potential hemodynamic instability, For ease of administration, if clinically appropriate: consider approximating the dose of fentanyl and administer either 25 or 50 mcg; consider approximating the dose of morphine and administer either 2.5 or 5 mg, Refer to the “General: Nausea and/or Vomiting (>2 y/o) - Pediatric” protocol, if needed, This protocol is intended for the undifferentiated toxic exposure, For a suspected carbon monoxide exposure, see the “General: Carbon Monoxide Exposure - Suspected” protocol, For an opioid overdose, see the “General: Opioid (Narcotic) Overdose” protocol, For an organophosphate exposure, see “General: Organophosphate Exposure” protocol, For smoke inhalation, see “General: Smoke Inhalation/Cyanide Poisoning - Symptomatic” protocol, For altered mental status, see “General: Altered Mental Status” protocol, If suspected WMD nerve agent, refer to the “Resource: Nerve Agent-Suspected” protocol, Refer to the “General: Hypoglycemia - Adult” protocol, as indicated, For contamination of the skin or eyes, refer to the “Trauma: Burns” protocol, Consider a 12-lead ECG, especially if the patient is bradycardic or tachycardic. These protocols are intended to guide and direct patient care by EMS providers across New York State. This protocol is intended to be used for the prevention of potentially fatal cardiac rhythm abnormalities in patients with known or suspected hyperkalemia including: Patients with known elevated laboratory values, Patients with renal failure who should be receiving dialysis, Patients with suspected renal failure who are not yet receiving dialysis, For patients with crush injury refer to the “Trauma: Crush Injuries” protocol, There are no standing orders for hyperkalemia. warfarin / Coumadin), Administer oxygen therapy utilizing the appropriate delivery device and titration to maintain SpO, If fever is due to suspected viral or bacterial infection, refer to protocol “General: Severe Sepsis / Septic Shock” protocol and treat as indicated, If fever is due to suspected reaction to blood / blood product transfusion, immediately stop the transfusion, replace all tubing (save for receiving hospital blood bank) and maintain IV access with new bag of 0.9% NaCl, contact medical control, and treat per appropriate protocol, Temperature monitoring, take initial and every 10 minutes, Recipient of a blood/blood product transfusion, Patient has not had a dose of acetaminophen (either acetaminophen or an acetaminophen containing product) or ibuprofen within the last 4 hours, Check blood glucose level, if equipped. Advisory 2020-08 Flu Prevention; Advisory 2020-07 Suspension of … Low flow alarms are frequently due to MAP >90 mmHg. Many processes are not sequential and tasks should be performed as most appropriate for patient care. This general approach guidance document is intended to provide a standardized framework for patient transport. Use EtCO2 detection and pulse oximetry to evaluate the effectiveness of the ventilation technique and to verify artificial airway patency and position As a general guideline for use with these protocols, the following definition has been established: In protocols requiring weight-based dosing guidelines, pediatric dosing should be calculated on a per-kilogram (kg) basis using the adult dose as the pediatric dose maximum. 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. patient trach/ventilator pack, G-tube connectors, etc.) Statewide Pre-Hospital Treatment Protocols Version 16.04 (PDF) We have also posted the roll out 2017 reference materials and schedule of Midstate REMAC Protocol Roll Out dates and locations. Assure a secondary oxygen source with a minimum of 1000psi in a D tank Titrate to appropriate EtCO, Select the appropriate tidal volume (Vt) of 6-8 mL/kg ideal body weight, Select the appropriate inspiratory time (It), if applicable, Verify a high pressure alarm no higher than 40 cm H, Evaluate the patient for adequate chest rise, EtCO, Adjust the ventilator settings, as necessary, to improve clinical parameters, Record all set parameters on the patient transport record, If at any time the ventilator should fail, or an alarm is received that cannot be corrected, the patient should be immediately ventilated with a BVM device attached to a 100% oxygen source, Emergency Medical Technicians (all levels) are, Document observations, thoroughly and objectively on the patient care report (PCR), Notify the emergency department staff of concerns and your intent to report. 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