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Paramedic Protocol Update 2009

Westchester Adult Paramedic Protocol Update 5/09. 2. Adult Protocols . Westchester Regional Paramedic Protocol Update 2009. Westchester Adult Paramedic Protocol Update 5/09. 3. Routine Medical Care M1.0. Replaces old protocol (P-1)Consolidated: ABC's, C-spine, vitals and initiation of NYS BLS prot

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Paramedic Protocol Update 2009

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    1. Westchester Adult Paramedic Protocol Update 5/09 1 Paramedic Protocol Update 2009 Westchester Regional Emergency Medical Services Council

    2. Westchester Adult Paramedic Protocol Update 5/09 2 Adult Protocols Westchester Regional Paramedic Protocol Update 2009

    3. Westchester Adult Paramedic Protocol Update 5/09 3 Routine Medical Care M1.0 Replaces old protocol (P-1) Consolidated: ABC's, C-spine, vitals and initiation of NYS BLS protocols to step 1. Added: Pulse Oximetry now a Standing Order Removed: "draw appropriate blood as necessary”

    4. Westchester Adult Paramedic Protocol Update 5/09 4 Airway Management M2.0 Replaces old protocol P-2, P2a, and P-3 Consolidated: Protocols combined to facilitate rapid intervention Added: Now includes Needle Decompression for suspected Tension Pneumothorax. Added: Etomidate now a standing order (see next slide). Removed – Lidocaine from Medical Control Options (Continued on next slide)

    5. Westchester Adult Paramedic Protocol Update 5/09 5 Airway Management M2.0 (Continued from previous slide) Etomidate now a standing order If patient needs facilitated advanced airway management: Consider ETOMIDATE 0.3 mg/kg IV or IO, perform ENDOTRACHEAL INTUBATION, and CONTACT MEDICAL CONTROL

    6. Westchester Adult Paramedic Protocol Update 5/09 6 Bronchospasm/Asthma/COPD M3.0 Replaces old protocol P-4 Changed: in line 3, “repeat Albuterol every 10 minutes” changed to “ treatment continuously up to 3 doses” Added: Methylprednisolone now a Standing Order (see next slide) Added: Magnesium Sulfate now a standing order (see next slide) Changed: Terbutaline now administered IM route (Continued on next slide)

    7. Westchester Adult Paramedic Protocol Update 5/09 7 Bronchospasm/Asthma/COPD M3.0 (Continued from previous slide) Methylprednisolone now a Standing Order For patients with severe Bronchospasm, administer METHYLPREDNISOLNE 125 mg/50 ml 0.9% Normal Saline infused over 2 minutes. Magnesium Sulfate now a Standing Order For patients exhibiting severe Bronchospasm, administer MAGNESIUM SULFATE 2 g IV infused over 10 minutes.

    8. Westchester Adult Paramedic Protocol Update 5/09 8 Cardiac M4.0 New protocol Refers to appropriate sub-protocol Added: 12 lead ECG Added: Note: “Remember to search for and treat (if possible) any likely contributing factors: Hypovolemia, Hypoxia, Hydrogen Ion (Acidosis), Hypo/Hyperkalemia, Hypoglycemia, Hypothermia, Toxins, Tamponade, Tension Pneumothorax, Thrombosis, and Trauma.”

    9. Westchester Adult Paramedic Protocol Update 5/09 9 Acute Coronary Syndrome M4.1 Replaces old protocol P-18 Changed: SBP must remain greater than or equal to 100 mmHg to repeat nitroglycerin. Changed: Aspirin can be administered if the patient has not taken any in the past 24 hours. Changed: Morphine Sulfate in Medical Control Options to be repeated as directed. (Continued on next slide)

    10. Westchester Adult Paramedic Protocol Update 5/09 10 Acute Coronary Syndrome M4.1 (Continued from previous slide) Added: - Note a. NITROGLYCERIN should be given with caution to patients taking erectile dysfunction (ED) medications (i.e., Viagra, Cialis, Levitra), or suspected inferior wall or right ventricle (RV) myocardial infarctions (MI) Removed: - Naloxone from Medical Control Options Removed: Nitro paste Removed: - Footnote a. Stable is defined as normal vital signs without evidence of inadequate perfusion (i.e., pallor, cool damp skin, SBP 100 or less) altered mental status.

    11. Westchester Adult Paramedic Protocol Update 5/09 11 Acute Pulmonary Edema Congestive Heart Failure M4.2 Replaces old protocol P-20 Added: Administer CPAP if available Added: Obtain 12 lead ECG if possible Added: - Note a. NITROGLYCERIN should be given with caution to patients taking erectile dysfunction (ED) medications (i.e., Viagra, Cialis, Levitra), or suspected inferior wall or right ventricle (RV) myocardial infarctions (MI) Changed: Nitroglycerin may be repeated every 5 minutes if SBP remains above 100 mmHg (Continued on next slide)

    12. Westchester Adult Paramedic Protocol Update 5/09 12 Acute Pulmonary Edema Congestive Heart Failure M4.2 (Continued from previous slide) Changed: Medical Control Option for Lasix changed from 40-80 mg to 80-120 mg Changed: Morphine Sulfate in Medical Control Options to be repeated as directed. Removed: Nitro paste Removed: Medical Control Options for Albuterol and Naloxone

    13. Westchester Adult Paramedic Protocol Update 5/09 13 Bradycardia M4.3 Replaces old protocol P-19 Added: Now states “For patients with Symptomatic Bradycardia” Added: Obtain 12 lead ECG Added: Now states “ If signs or symptoms of Poor Perfusion (b) caused by the Bradycardia:” Added: Note b. “Signs of Poor Perfusion includes acute altered mental status, ongoing chest pain, hypotension or other signs of shock.” (Continued on next slide)

    14. Westchester Adult Paramedic Protocol Update 5/09 14 Bradycardia M4.3 (Continued from previous slide) Changed: TCP now before atropine Added: Atropine maximum dose of 3mg Added: Note a. If STEMI, avoid Atropine Added: sedation/analgesia medications under Medical Control Options (see next slide) Changed: Dopamine under Medical Control Options now 2-10 mcg/kg/min Added: Note c. “If beta or calcium channel blocker OD suspected, Contact Medical Control.” (Continued on next slide)

    15. Westchester Adult Paramedic Protocol Update 5/09 15 Bradycardia M4.3 (Continued from previous slide) sedation/analgesia medications under Medical Control Options For sedation/analgesia for TRANSCUTANEOUS PACING; consider: DIAZEPAM 5-10 mg slow IVP; MIDAZOLAM 2-5 mg slow IVP; or MORPHINE SULPHATE 5-10 mg IVP

    16. Westchester Adult Paramedic Protocol Update 5/09 16 Supraventricular Tachycardia Previous protocol P-22 This protocol has been divided into two new protocols: M4.4 Narrow Complex Tachycardia – Unstable M4.5 Narrow Complex Tachycardia – Stable

    17. Westchester Adult Paramedic Protocol Update 5/09 17 Narrow Complex Tachycardia Unstable M4.4 Added: Note a. “UNSTABLE denotes signs or symptoms of POOR PERFUSION, including acute altered mental status, ongoing chest pain, hypotension or other signs of shock.” Added: “Apply cardiac monitor to determine rhythm (b)” Added: Note b. “If at any time the rhythm is determined to be a WIDE COMPLEX TACHYCARDIA, go to Protocol M - 4.6.” Added: Fluid challenge now Standing Order (Continued on next slide)

    18. Westchester Adult Paramedic Protocol Update 5/09 18 Narrow Complex Tachycardia Unstable M4.4 (Continued from previous slide) Changed: Doses of energy for Cardioversion depends on the underlying rhythm: Afib/MonomorphicVT – 100 joules (monophasic) or 100-120 (biphasic). If no change - 200, 300, 360 joules (monophasic) or 120-200 joules (biphasic). Aflutter/SVT – 50, 100, 200, 300, 360 joules (monophasic). Per manufacturer’s recommendation (biphasic). PolymorphicVT (Torsades) – 360 joules (monphasic) or 200 (biphasic) (Continued on next slide)

    19. Westchester Adult Paramedic Protocol Update 5/09 19 Narrow Complex Tachycardia Unstable M4.4 (Continued from previous slide) Medical Control Option for Amiodarone now 150 mg/100ml of D5W over 10 minutes. Medical Control Option for Amiodarone infusion now 1mg/min in D5W. Added: Diltiazem 15-25 mg over 2 min with repeat in 15 minutes as Medical Control Option. Added: sedation/analgesia medications for Cardioversion under Medical Control Options

    20. Westchester Adult Paramedic Protocol Update 5/09 20 Narrow Complex Tachycardia Stable M4.5 Added: Note a. “STABLE denotes no signs or symptoms of POOR PERFUSION, including acute altered mental status, ongoing chest pain, hypotension or other signs of shock.” Added: “Obtain a 12 Lead EKG (b)” Added: Note b. “If at any time the rhythm is determined to be a WIDE COMPLEX TACHYCARDIA, go to Protocol M - 4.7. Added: Fluid challenge now Standing Order for Sinus Tachycardia (Continued on next slide)

    21. Westchester Adult Paramedic Protocol Update 5/09 21 Narrow Complex Tachycardia Stable M4.5 (Continued from previous slide) Changed: Standing Order of Adenosine to include 10ml flush. Changed: Medical Control Option for Amiodarone to 150 mg/100 ml D5W over 10 minutes. Changed: Medical Control Option for Amiodarone 1mg/min in D5W (Continued on next slide)

    22. Westchester Adult Paramedic Protocol Update 5/09 22 Narrow Complex Tachycardia Stable M4.5 (Continued from previous slide) Added: Diltiazem 15-25mg as Standing Order for ATRIAL FLUTTER, ATRIAL FIBRILLATION or MULTIFOCAL ATRIAL TACHYCARDIA unless patient has a known history of Wolff-Parkinson-White Syndrome (WPW) (Continued on next slide)

    23. Westchester Adult Paramedic Protocol Update 5/09 23 Narrow Complex Tachycardia Stable M4.5 (Continued from previous slide) Changed: Doses of energy for Cardioversion depends on the underlying rhythm: Afib/MonomorphicVT – 100 joules (monophasic) or 100-120 (biphasic). If no change - 200, 300, 360 joules (monophasic) or 120-200 joules (biphasic). Aflutter/SVT – 50, 100, 200, 300, 360 joules (monophasic). Per manufacturer’s recommendation (biphasic). PolymorphicVT (Torsades) – 360 joules (monphasic) or 200 (biphasic) Added: sedation/analgesia medications for Cardioversion under Medical Control Options

    24. Westchester Adult Paramedic Protocol Update 5/09 24 Wide Complex Tachycardia Unstable M4.6 Replace old protocol P-17 (Ventricular Tachycardia with a pulse – unstable) Changed: Doses of energy for Cardioversion depends on the underlying rhythm: Afib/MonomorphicVT – 100 joules (monophasic) or 100-120 (biphasic). If no change - 200, 300, 360 joules (monophasic) or 120-200 joules (biphasic). Aflutter/SVT – 50, 100, 200, 300, 360 joules (monophasic). Per manufacturer’s recommendation (biphasic). PolymorphicVT (Torsades) – 360 joules (monphasic) or 200 (biphasic) (Continued on next slide)

    25. Westchester Adult Paramedic Protocol Update 5/09 25 Wide Complex Tachycardia Unstable M4.6 (Continued from previous slide) Added: “Apply cardiac monitor to determine rhythm (b)” Added: Note b. If at any time the rhythm is determined to be a NARROW COMPLEX TACHYCARDIA, go to Protocol M - 4.4. Added: Total maximum dose of Amiodarone in Standing Orders is now 2.2gm/24 hrs. Added: Standing Order for 12 lead ECG. Added: Adenosine to Medical Control Options. Added: sedation/analgesia medications for Cardioversion under Medical Control Options (Continued on next slide)

    26. Westchester Adult Paramedic Protocol Update 5/09 26 Wide Complex Tachycardia Unstable M4.6 (Continued from previous slide) Added: Note a. “UNSTABLE denotes signs or symptoms of POOR PERFUSION, including acute altered mental status, ongoing chest pain, hypotension or other signs of shock.” Removed: “If patient presents with hypotension , unconsciousness, pulmonary edema, or….” To now read “If SYNCHRONOUS CARDIOVERSION cannot be accomplished for technical reasons, use ASYNCHRONOUS CARDIOVERSION.

    27. Westchester Adult Paramedic Protocol Update 5/09 27 Wide Complex Tachycardia Stable M4.7 Replaces old protocol P-16 (Ventricular Tachycardia with a pulse – stable) Added: “Obtain a 12 Lead EKG (b)” Added: Note b. If at any time the rhythm is determined to be a NARROW COMPLEX TACHYCARDIA, go to Protocol M - 4.5. Changed: Standing Order of Amiodarone to 150 mg/100 ml of D5W. Repeat if VT persists. Max 2.2 gm/24 hrs. Changed: Procainamide now Medical Control Option only. Added: Note a. “STABLE denotes no signs or symptoms of POOR PERFUSION, including acute altered mental status, ongoing chest pain, hypotension or other signs of shock.” (Continued on next slide)

    28. Westchester Adult Paramedic Protocol Update 5/09 28 Wide Complex Tachycardia Stable M4.7 (Continued from previous slide) Added: Cardioversion to Medical Control Options with revised energy settings. Added: sedation/analgesia medications for Cardioversion under Medical Control Options Added: Magnesium Sulfate 1-2 grams IV over 5 minutes to Medical Control Options Changed: Medical Control Option for Lidocaine to 1-1.5 mg/kg IVP. Changed: Medical Control Option for Lidocaine to 2-4 mg/min.

    29. Westchester Adult Paramedic Protocol Update 5/09 29 Cardiac (Arrest) Non-Traumatic Cardiopulmonary Arrest M5.0 Replaces old Protocol 11 This protocol directs the EMS provider to two new protocols: M5.1 – Shockable Rhythm M5.2 – Non-Shockable Rhythm Added: Notes for consideration of the following medications for all Cardiac Arrests: SODIUM BICARBONATE 1 mEq/kg IVP or IO with suspected hyperkalemia, profound acidosis, tricyclic antidepressant, cocaine, or diphenhydramine overdoses. Dose may be repeated at 0.5 mEq/kg every 10 minutes. DEXTROSE 50% IVP or IO if clinically indicated; may be repeated once. NALOXONE 2 mg IV or IO if clinically indicated. (Continued on next slide)

    30. Westchester Adult Paramedic Protocol Update 5/09 30 Cardiac (Arrest) Non-Traumatic Cardiopulmonary Arrest M5.0 (Continued from previous slide) Added: The following Medical Control Options for all Cardiac Arrests: Repeat any standing orders DOPAMINE 400 mg in 250 ml 0.9% Normal Saline; initiate drip at 5 - 10 mcg/kg/min. If there is insufficient improvement in status, the infusion may be titrated upward every 5 minutes in increments of 5 mcg/kg/min until desired therapeutic effect (max. 25 mcg/kg/min). CALCIUM CHLORIDE 250 – 500 mg IVP or IO; may be repeated to a maximum of 1 gm. Only indicated with hyperkalemia, hypocalcemia, or calcium channel blocker toxicity.

    31. Westchester Adult Paramedic Protocol Update 5/09 31 Cardiac Arrest Shockable Rhythm (VF or Pulseless VT) M5.1 Replaces old protocol P-12 Changed: First Standing Order is Defibrillate 360 joules (monphasic) or 120-200 joules (Biphasic); Continue CPR (2 minutes) immediately after every defibrillation Removed: Precordial thump Removed: Stacked shocks Added: When possible during CPR initiate airway control, monitor adequate ventilation, and vascular access. (Continued on next slide)

    32. Westchester Adult Paramedic Protocol Update 5/09 32 Cardiac Arrest Shockable Rhythm (VF or Pulseless VT) M5.1 (Continued from previous slide) Changed: After 2 minutes of CPR, check rhythm (no longer than 10 seconds). If non-shockable rhythm go to Protocol 5.2 otherwise, defibrillate and continue CPR. Changed: Epinephrine or Vasopressin (in place of 1st or 2nd dose of Epinephrine) Changed: Epinephrine repeated once during every 2 minutes (5 cycles) of CPR Changed: Antidysrhythmic (Amiodarone or Lidocaine) after 3rd series (6 minutes) of CPR (Continued on next slide)

    33. Westchester Adult Paramedic Protocol Update 5/09 33 Cardiac Arrest Shockable Rhythm (VF or Pulseless VT) M5.1 (Continued from previous slide) Added: Standing Order for Magnesium Sulfate for known Hypomagnesemia or Torsades. Added: Note d. “Adminster drug during CPR as soon as possible after rhythm check confirms SHOCKABLE RHYTHM.” Removed: Medical Control Options

    34. Westchester Adult Paramedic Protocol Update 5/09 34 Cardiac Arrest Non-Shockable Rhythm M5.2 Replaces old protocols P-13 and P-14 Added: Search for and treat for contributing factors; address as appropriate. Added: When possible during CPR initiate airway control, monitor adequate ventilation, and vascular access. Added: Vasopressin now Standing Order (Continued on next slide)

    35. Westchester Adult Paramedic Protocol Update 5/09 35 Cardiac Arrest Non-Shockable Rhythm M5.2 (Continued from previous slide) Changed: Epinephrine or Vasopressin (in place of 1st or 2nd dose of Epinephrine) Changed: After 2 minutes of CPR, check rhythm (no longer than 10 seconds). If shockable rhythm, go to Protocol 5.1 Added: IV drug boluses followed by flush of 20-30 ml. Removed: Medical Control Options

    36. Westchester Adult Paramedic Protocol Update 5/09 36 Field Termination of Resuscitation Efforts M5.3 Replaces old protocol P-15 Removed: Grief counseling.

    37. Westchester Adult Paramedic Protocol Update 5/09 37 Altered Mental Status M6.0 Replaces old protocol P-24 Removed: Thiamine from Standing Orders. Changed: Naloxone dose now 0.4 mg IV, IN, or IM, may be repeated up to 8 mg.

    38. Westchester Adult Paramedic Protocol Update 5/09 38 Anaphylactic Reaction M7.0 Replaces old protocol P-23 Changed: Following Initiating Routine Medical Care, Epinephrine is indicated as follows: Cardiovascular collapse present, 1:10,000 1 mg IVP Mild reaction, 1:1,000 0.3 ml IM If patient is taking beta-blockers, also administer GLUCAGON 1 mg IM or IV. Changed: For a mild reaction, Epinephrine 1:1000 now administered 0.3 ml IM (Continued on next slide)

    39. Westchester Adult Paramedic Protocol Update 5/09 39 Anaphylactic Reaction M7.0 (Continued from previous slide) Added: Standing Order for Methylprednisolone 125 mg / 50 ml 0.9% Normal Saline IV Added: Standing Order for rapid infusion up to 3 liters of 0.9% Normal Saline Added: Standing Order for Albuterol 2.5 mg with 0.3 cc 0.9% Normal Saline via nebulizer Changed: Medical Control Options for Epinephrine now: 1:1000 0.1 – 0.5 ml IM/SC, repeat every 5 minutes 1:10,000 1 mg in 250 ml NS infused IV 1 – 2 ml/min (to effect) 1:10,000 1 – 5 ml IV

    40. Westchester Adult Paramedic Protocol Update 5/09 40 Toxic Exposure / Poisoning M8.0 Replaces old protocol P-25 Added: For suspected ingestion, Contact Medical Control Added: Carbon Monoxide (CO) exposure with history and signs/symptoms - Monitor CO levels (if available) - 100% oxygen therapy Changed: For Cyanide toxicity, use facility provided Cyanide Antidote Kit or Cyanokit (Hydroxycobalamine) Changed: For Organophosphate Exposure, Atropine 2 mg now administered IV, IO or IM.

    41. Westchester Adult Paramedic Protocol Update 5/09 41 Non-Traumatic Shock M9.0 Replaces old protocol P-21 Changed: 0.9% Normal Saline 250 ml now titrated to adequate perfusion. Removed: Dopamine. Added: Dobutamine as a Medical Control Option 400mg/250 ml NS ,initiate drip at 5 – 10 mcg/kg/min. May be titrated in increments of 5 mcg/kg/min until desired therapeutic effect is reached (max dose of 25 mcg/kg/min)

    42. Westchester Adult Paramedic Protocol Update 5/09 42 Post Partum Hemorrhage M10.0 Replaces old protocol P-28 Changed: Oxytocin now a Standing Order “after delivery of placenta”: 20 units in 1000ml Normal Saline IV given rapidly. If IV not available, administer 10 units IM.

    43. Westchester Adult Paramedic Protocol Update 5/09 43 Obstetrical Toxemia of Pregnancy M11.0 Replaces old protocol P-29 Changed: PRE-ECLAMPSIA now defined as – combination of BP 140/90 or greater, peripheral edema, and symptoms: headache, visual disturbances, upper abdominal pain. Added: Magnesium Sulfate 4 gm/250 ml NS over 20 minutes now a Standing Order for Pre-Eclampsia and Eclampsia. Added: For Eclampsia, go to Seizure protocol after Magnesium Sulfate Removed: Lorazepam and Diazepam from Medical Control Options

    44. Westchester Adult Paramedic Protocol Update 5/09 44 Seizures M12.0 Replaces old protocol P-27 Removed: Indication for Status Epilepticus Changed: After initiating Routine Medical Care, “measure serum glucose”, and treat hypoglycemia. Changed: Standing Order for “a Benzodiazepine”: - Diazepam 5 – 10 mg slow IV or rectal. May repeat up to 20 mg. - Lorazepam 2 mg slow IV or IM. May be repeated once in 5 minutes. - Midazolam 2 mg slow IV or IM. May be repeated once in 5 minutes.

    45. Westchester Adult Paramedic Protocol Update 5/09 45 Questions WREMSCO Office 914-231-1616

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