1. Respiratory & Medical Critical Care and Paramedic Levels

2. Airway Management Changes: – CPAP for EMT-I – Must be credentialed – Earlier use of supraglottic airways Waveform required for intubated patients

3. Airway Management (cont) Second page – Very few protocols go to second page

4. Airway Management Comparison

5. Medication Facilitated Intubation Changes – Age now 14* – Lidocaine removed – Only Etomidate for induction – Weight based dosing – Only 2 total attempts

6. Continuous Positive Airway Pressure Changes – EMT-I allowed* *If credentialed Remember indications and contraindications

7. Asthma/COPD Replaces “Respiratory Signs and Symptoms” – Clinical judgment Includes CPAP – EMT-I (if credentialed) Changes: – No albuterol alone – Magnesium in standing orders

8. Asthma Comparison

9. Acute Pulmonary Edema Replaces “Respiratory Signs and Symptoms” – Clinical judgment Includes CPAP – EMT-I (if credentialed) Changes: – NTG SL based on BP – Lasix removed from standing orders

10. Suspected Smoke Inhalation Changes: – Cyanokit may be used in place of Sodium Thiosulfate if approved by Medical Director Will affect labs for 48 hours – Attempt to draw blood samples prior to administration

11. Suspected Smoke Inhalation Comparison

12. Allergic Reaction/Anaphylaxis Changes: – Essentially none Caution administering Epinephrine if patient is over 55 years old

13. Allergic Reaction Comparison

14. Altered Mental Status Changes: – Separate from “Stroke” protocol – Meant as reminder follow other protocols that cause altered mental status

15. Diabetic Emergencies NEW PROTOCOL Addresses low and high blood sugar Thiamine only if KNOWN chronic ETOH – Other Hypoglycemic treatments unchanged

16. Diabetic Emergencies Comparison

17. Seizures Changes: – Magnesium now standing order if known pregnant or within 6 weeks post-partum without seizure history – Thiamine removed

18. Seizure Comparison

19. Stroke Changes: – No longer combined with “Altered Mental Status” protocol Key point: – Confirm time last known “NORMAL”

20. Overdose or Toxic Exposure NEW PROTOCOL Exposure specific treatments – Opiate – Organophosphate – Dystonic reaction Physician Options for – Calcium channel and beta blockers – Tricyclic, sympathomimetic

21. Overdose

22. Shock/Hypoperfusion Changes: – More aggressive fluid resuscitation with sepsis – 12 lead EKG for possible STEMI Remember: – Shock and hypoperfusion are signs of another disease process

23. Shock/Hypoperfusion Comparison

24. Adrenal Crisis NEW PROTOCOL Fairly rare diagnosis If CONFIRMED diagnosis by patient or family, steroids can be lifesaving in presence of shock

25. Adrenal Crisis Comparison

26. Pain / Nausea /Sedation A fluid bolus makes almost anyone feel better Morphine standing orders are under utilized in WNY Sedation standing orders are not intended for chemical restrains

27. Pain / Nausea / Sedation Comparison