2006 Protocol Update2006 Protocol Update

Central New York EMS50 Presidential Plaza

Jefferson Tower, Suite LL1Syracuse, New York 13202

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OverviewOverview

• Format Readjustments• Adult Protocol Changes• Pediatric Protocol Changes• Special Protocols and Charts• Review

Format ChangesFormat Changes

• Index– Easier to read and quickly locate protocols

• Pages – Laminated for durability and longevity

• Section tabs– Indicate the protocol section on the side of

the page– Sections are no longer designated at the top

of the page

Format ChangesFormat Changes

• Fonts– Though it may still seem small, font

size has been maximized without compromising the size of the book

• Clinical judgment boxes– Protocol sections that require clinical

judgment are:

black with white letters

Format ChangesFormat Changes

• Cardiac Protocol Titles– Titles are based on subject and the word

“cardiac” has been removed from the titles

– Asystole– Bradycardia, Symptomatic– Cardiogenic Shock– Chest Pain– PEA– Tachycardia, Unstable– Tachycardia, Stable– V-Fib / Pulseless V-Tach

Adult Protocol ChangesAdult Protocol Changes

• Pain – Non-Cardiac (page 29)Routine Medical or Trauma Care

Nubain 10 mg IVOR

Morphine up to 5 mg IV

May repeat every 5 min.

up to 20 mg

Major Pain

Acetaminophen PO 15 mg/kg (maximum dose 1000mg) if patient can tolerate oral

medication

Assess with Visual Analog Pain Scale (page 71) or

equivalent

Minor Pain

EMT-CC/EMT-P

* For pain of 6 and below via the Visual Analog Pain Scale (page 71) consider treatment via the Minor Pain pathway only, and care may be transferred to BLS.

Adult Protocol ChangesAdult Protocol Changes

• Pain – Non-Cardiac– Agencies will carry 325 mg and/or 500 mg

tablets of acetaminophen and potable water. – While available under standing order and not

technically a controlled substance, the storage, use, distribution and record-keeping shall be the same for nalbuphine (Nubain) as is currently utilized for ALL controlled substances.

Adult Protocol ChangesAdult Protocol Changes

• Facilitated Intubation (page 5)– Etomidate 0.3 mg/kg

Etomidate 20 mg IV over 30 to 60 seconds

Repeat Etomidate dose after 1-2 minutes if desired effect is not achieved

After successful intubationConsider Diazepam 5.0 mg or Versed 2.0 mg for continued

sedation*

To reverse effects of diazepam (Valium ) or midazolam (Versed ) due to complications arising from unsuccessful intubation (for

example: hypotension or inability to maintain an airway) flumazenil (Romazicon ) 0.2 mg IV may be given.

Adult Protocol ChangesAdult Protocol Changes• Allergic Reaction/Anaphylaxis (page 10)

Systolic BP <90 mmHg or severe respiratory

compromise

Epi 1:1000 0.3 mg SC

Benadryl 50 mg slow IV/IM

If patient does not improve

Fluid Challenge (page 7)

Transport

If patient does not improve

Epi 1:1000 0.3 mg SC

Epi 1:10,000 0.5 –1.0 mg IV or 2 mg ET

Epi 1:10,000 0.3mg IV slow over 5 minutes or 2 mg ET

Adult Protocol ChangesAdult Protocol Changes

• Pulmonary Edema (page 13)

Furosemide 80 mg IV over 1 min.

May repeat or increase initial dose

Nitroglycerin 0.4 mg SLMay repeat every 5 min. x

2

Morphine 2 mg IVMay repeat every 5 min. up to 10

mg

Nitroglycerin 0.4 mg SLMay repeat every 5 min. x

2

Furosemide 40 mg IV over 1 min.

Morphine up to 5 mg IV for adults

May repeat every 5 min. up to 10 mg

Furosemide 80 mg IV over 1 min.

If patient does not improve

Adult Protocol ChangesAdult Protocol Changes

• Morphine initial dose change to range, still requires orders for all providers– “Up to 5 mg” for adults

• Pulmonary Edema (page 13)• Chest Pain (page 17)

Pediatric Protocol Pediatric Protocol ChangesChanges

• All pediatric protocols:– Use of Broselow Tape for adjunct

sizes and drug dosages is required.

Pediatric Protocol Pediatric Protocol ChangesChanges

• Acute Respiratory Distress– Atrovent 500 mcg in 2.5 milliliters

normal saline

Albuterol (2.5 mg in 3 ml NS) andAtrovent (500 micrograms in 2.5ml

NS)Administer via nebulizer*

Wheezing or history ofAsthma or Bronchiolitis

Albuterol 2.5 mg in 3 ml via nebulizer

orEpi 1:1000 0.01 mg/kg SC

to a total of 0.3 mgMay repeat in 20 min.

Pediatric Protocol Pediatric Protocol ChangesChanges

• Seizures (page 52)– Added “Maximum Total Doses” of

Diazepam and Versed

Diazepam 0.1 mg/kg IVMay repeat X 1

Maximum total Dose5 mg

ORDiazepam 0.5 mg/kg PR*

May repeat X 1Maximum total Dose

10 mg

ORVersed 0.07 mg/kg IM

May repeat X 1Maximum total Dose 5

mg

Special ProtocolsSpecial Protocols

• Trauma Triage Criteria added (page 64)

Major trauma is present if the mechanism of injury or patient’s physical findings meet any one of the following criteria:

Mechanism of Injury 

- Death in the same passenger compartment- Fall >20 feet- Vehicle-pedestrian collision- Patient ejected from the vehicle- Vehicle collision >20 mph resulting in 12 inches of deformity to the vehicle- Vehicle rollover- Motorcycle crash- Vehicle vs. bicycle collision >5 mph

 

Physical Findings 

- Pulse <50/min or >120/min- Systolic blood pressure of 90 mmHg or less- Respiratory rate <10/min or >28/min- Glasgow Coma Scale <14- Penetrating injuries of the trunk, head, neck, chest, abdomen or groin- Two or more proximal long bone fractures- Flail chest- Burns that involve 15% or more of the body surface or facial/airway burns- Combined system trauma that involves two or more body systems- Spinal cord injury or limb paralysis- Amputation (except digits)

Special ProtocolsSpecial Protocols

• 12 Lead EKG (page 65)

– Criteria– Frequency– Considerations for suspected MI– Reminders

ILateral

aVR V1Septal

V4Anterio

rIIInferior

AVLLateral

V2Septal

V5Lateral

IIIInferior

AVFInferior

V3Anterio

r

V6Lateral

V1 4th intercostal space @ R sternum edge

V2 4th intercostal space @ L sternum edge

V3 Between V2 & V4

V4 5th intercostal space, midclavicular line

V5 Level with V4, L anterior axillary line

V6 Level with V5, L mid axillary line

ChartsCharts

• Visual Analog Pain Scale (page 71)• This scale is designed to be used as a tool to

subjectively determine pain level. • Refer to the Pain — Non-Cardiac protocol (page

29)

ReviewReview

• Provider-friendlier format• Adult protocol changes to:

– Pain – Non-Cardiac – Facilitated Intubation– Allergic Reaction/Anaphylaxis– Pulmonary Edema– Chest Pain

ReviewReview

• Pediatric Protocol changes to:– Acute Respiratory Distress

• Special Protocol Additions:– Trauma Triage Criteria– 12 Lead EKG

• Charts Additions:– Visual Analog Pain Scale

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