2. 2006 Protocol Update Central New York EMS 50 Presidential Plaza Jefferson Tower, Suite LL1 Syracuse, New York 13202 Click mouse anywhere on slide to continue….

3. Overview Format Readjustments Adult Protocol Changes Pediatric Protocol Changes Special Protocols and Charts Review

4. Format 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

5. Format 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

6. Format 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

7. Adult Protocol Changes Pain – Non-Cardiac (page 29) Routine Medical or Trauma Care Nubain 10 mg IV OR 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.

8. Adult 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.

9. Adult 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 intubation Consider 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.

10. Adult 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

11. Adult Protocol Changes Pulmonary Edema (page 13) Furosemide 80 mg IV over 1 min. May repeat or increase initial dose Nitroglycerin 0.4 mg SL May repeat every 5 min. x 2 Morphine 2 mg IV May repeat every 5 min. up to 10 mg Nitroglycerin 0.4 mg SL May 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

12. Adult 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)

13. Pediatric Protocol Changes All pediatric protocols: –Use of Broselow Tape for adjunct sizes and drug dosages is required.

14. Pediatric Protocol Changes Acute Respiratory Distress –Atrovent 500 mcg in 2.5 milliliters normal saline Albuterol (2.5 mg in 3 ml NS) and Atrovent (500 micrograms in 2.5ml NS) Administer via nebulizer* Wheezing or history of Asthma or Bronchiolitis Albuterol 2.5 mg in 3 ml via nebulizer or Epi 1:1000 0.01 mg/kg SC to a total of 0.3 mg May repeat in 20 min.

15. Pediatric Protocol Changes Seizures (page 52) –Added “Maximum Total Doses” of Diazepam and Versed Diazepam 0.1 mg/kg IV May repeat X 1 Maximum total Dose 5 mg OR Diazepam 0.5 mg/kg PR* May repeat X 1 Maximum total Dose 10 mg OR Versed 0.07 mg/kg IM May repeat X 1 Maximum total Dose 5 mg

16. Special 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 120/min - Systolic blood pressure of 90 mmHg or less - Respiratory rate 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)

17. Special Protocols 12 Lead EKG (page 65) –Criteria –Frequency –Considerations for suspected MI –Reminders I Lateral aVRV1 Septal V4 Anterior II Inferior AVL Lateral V2 Septal V5 Lateral III Inferior AVF Inferior V3 Anterior V6 Lateral V14 th intercostal space @ R sternum edge V24 th intercostal space @ L sternum edge V3Between V2 & V4 V45 th intercostal space, midclavicular line V5Level with V4, L anterior axillary line V6Level with V5, L mid axillary line

18. Charts 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)

19. Review Provider-friendlier format Adult protocol changes to: –Pain – Non-Cardiac –Facilitated Intubation –Allergic Reaction/Anaphylaxis –Pulmonary Edema –Chest Pain

20. Review Pediatric Protocol changes to: –Acute Respiratory Distress Special Protocol Additions: –Trauma Triage Criteria –12 Lead EKG Charts Additions: –Visual Analog Pain Scale

21. Evaluation All ALS providers must successfully complete the quiz in order to maintain ALS practicing privileges in Central New York. You will be directed from the next slide to take the test. Please evaluate this update. Login www.cnyems.org, and take the “evaluation questionnaire”. www.cnyems.org

22. Protocol Update Tests Click appropriate link below to take test – you will be directed to login to your cnyems account in an Internet browser. Login and proceed from there with the test. (You may have to close the presentation). Paramedic Protocol Update Test Critical Care Protocol Update Test Intermediate Protocol Update Test