REMSCO General Operating Procedures REMSCO Appendices …static1.squarespace.com/static/53317aa0e4b047ff30f4b064/t/578f5c94... · REMSCO General Operating Procedures REMSCO Appendices

REMSCO General Operating Procedures

REMSCO Appendices

Northwell Interfacility

SIUH Guidelines

Protocol Other InformationGOP

Protocol Other InformationGOP

1 Conscious patients requiring Synchronized Cardioversion or Transcutaneous Pacing 1

Diazepam 5-10 mg IV bolus with repeat doses of diazepam 5-10 mg IV bolus as necessary, max dose of 20 mg

Indications for IO Access Standing Orders IO ContraindicationsGOP

1 Unconscious patients2 Conscious patients in decompensated shock

Maximum of 2 attempts for both IV or IOSites: "an approved EXTREMITY approach"; humeral

is ok.

Intraosseus Access

Midazolam 1-2 mg IV/IN bolus, repeat doses of midazolam 1 mg IV/IN bolus as necessary, max dose of 5 mg

or

Cardioversion ONLY: Etomidate 0.15 mg/kg IV bolus over 30-60 seconds, max dose of 20 mg

or

For use after two failed peripheral IV attempts in the following patient subsets:

May infuse 0.5 mg/kg of 2% preservative-free lidocaine via IO port prior to infusion, up to a maximum of 50 mg.

1

Dosing of medications is identical to IV doses in the REMAC protocols

Conscious patients requiring endotracheal intubation1Diazepam 5-10 mg IV bolus with repeat doses of diazepam 5-10 mg IV bolus as necessary, max dose of 20 mg

1 Patient weight >200 lbs is poorly predictive for

ETI success

Sternal site is contraindicated.

Midazolam 1-2 mg IV/IN bolus, repeat doses of midazolam 1 mg IV/IN bolus as necessary, max dose of 5 mg

or

Etomidate 0.3 mg/kg IV bolus over 30-60 seconds, max dose of 40 mg followed by diazepam 5 mg IV bolus or lorazepam 2 mg IV/M for continued sedation

or

Medical Control Options

Indications for Prehospital Sedation

Apneic oxygenation: administer oxygen by

nasal cannula at maximum flow rate

during laryngoscopy and intubation.


Indications for Prehospital Sedation

An additional infusion of 0.25 mg/kg of 2% preservative-free lidocaine may be given for continued pain, up to a maximum of 25 mg.

2

Prehospital Sedation for Intubation

Prehospital Sedation for

Cardioversion or Pacing

Indications for Pre-Existing CVC Access Contraindications for CVC Access Other InformationGOP

1 Chest or neck lines

2 If non-PICC, must contact OLMC prior to use

Other InformationAppendix T

1

2

3

4

5

Contraindications to Starting Resuscitation Indications to Halt CPR Other InformationNYC REMAC

1 Extreme dependent lividity2 Rigor mortis3 Tissue decomposition 2 ROSC achieved4 Obvious mortal injury

4 Crew exhaustion

Any port requiring troubleshooting, unclogging3

Usage has been expanded for use in the Soft Tissue Injury Protocols (CFR and BLS).

Treat Cardiac Arrests due to HANGING,

DROWNING, ELECTROCUTION,

SMOKE INH/CYANIDE as MEDICAL [vs.

Traumatic].

Healthcare proxy, Living Will, In-hospital DNR

are not valid

A qualified, licensed physician assumes responsibility for the patient (SNF physician)

Valid Out-of-Hospital DNR or MOLST form presented1

3

Application

To reduce of stop severe extremity hemorrhage that cannot be controlled by direct pressure by appliying

mechanical circumferential pressure to an open wound.

For use as a Constriction Band in venomous bites [loose application of tourniquet proximal to extremity

bite] in conjunction with limb immobilization.

1

If these measures fail to control the bleeding, appy a tourniquet 2-3 inches proximal to the bleeding siteTighten the tourniquet until the bleeding stops and distal pulses are lost. Apply a 2nd tourniquet parallel and proximal to the first as needed until the bleeding stops.

Indications for Tourniquet Usage

6

Use of Tourniquets

Any port requiring a needle to break the skin (port-a-cath)2Use of Pre-

Existing Central Venous Catheter

In cardiac arrest / unstable pt with no peripheral access, paramedic may consider using a PICC line in the upper extremity

1

Leave the tourniquets exposed so that they can be easily seen and monitored.Document time of tourniquet application on prehospital report as well as by placing tape on the patient.

Apply direct pressure & pressure dressings

All patients with tourniquet usage should be transported to the nearest Trauma Center.

CPR General Operating

Procedures

Indications for CPAP Contraindications for CPAP Other InformationAppendix P

1 Patient is alert 1 Need for immediate Adv Airway Mgmt2 Patient can maintain an open airway on their own 2 AMS/Unresponsive or uncooperative patients3 Patient has systolic BP >100 mmHg 3 Patients unable to control their own airway

5 Known active unstable angina or AMI

7 Gastric distention

NYC REMAC Current REMAC IN Formulary Contraindications Other InformationFentanyl EpistaxisGlucagonLorazepamMidazolamNaloxone

Contraindications to Terminating Resuscitation Considerations for Terminating Resusc. Other InformationSIUH Guideline

1 Patient is in a moving ambulance. 1 Unwitnessed arrest2 Pediatric (<18) or pregnant patient 2 No bystander CPR3 Patient is at the scene of a crime/public view 3 No shockable ryhtym during resuscitation

4 No ALS crew onscene 4 End-Tidal CO2 < 20 mmHg after 20 minutes of ACLS care

5 Hypothermic patients

6 No contact with Online Medical Control Physician

4

Support system is in place for patient's family (NYPD will guard the body until OCME arrives)

CPAP is to be immediately d/c'd if:

1) an immediate need for advanced airway

control arises

2) the patient becomes hemodynamically

unstable3) the patient cannot

tolerate the mask due to pain or discomfort

4

Pregnancy NOT a CONTRAINDICATION 6 Known PNA, PTX, anaphylaxis, pulmonary embolism, aspiration

Patient has significant respiratory distress, indicated by cyanosis, accessory muscle use, or other signs/symptoms

Use of the CPAP Device

Intranasal (IN) Drug

Administration

5

Approved for use in the absence of intravenous

access, as stated in individual protocols.

Trauma, facial burns, impending respiratory or cardiac arrest

Paramedics trained and authorized by the service medical director may utilize CPAP if available and appropriate.

Termination of Prehospital

Resuscitation Criteria

Guidelines

Interfacility Internal Process Discretionary Decisions Other Information

1 Must be transported by an Advanced Life Support ambulance crew (aka "Paramedics")

Allergic Reaction: discontinue blood transfusion.

a) Diphenhydramine 25-50 mg IV pushb) Epinephrine 0.3 mg (0.3 mL

of 1,1:000 solution) IM3 ED staff are not required to "ride along" C) Methylprednisolone 125 mg IV push

c) NS bolus 500 mL IV Dyspnea: consider TRALI or fluid overload. Discontinue blood transfusion.

a) Give CPAP if available. b) Furosemide & nitroglycerin not

recommended without CXR

3Direct crew to the nearest ED for emergent patient stabilization & management - can return to sending facility.

Interfacility Standing Orders Medical Control Options Other Information1 Apply monitoring devices (EKG, SpO2, BP, EtCO2) 1 Primary Medical Control: SIUH South.2 Administer O2 to keep SpO2 >95%3 Obtain hospital records if readily available (CD, chart)4 Maintain HOB at 15 degrees

5Measure vitals & Neuro checks (LOC, motor changes, sudden headache, N/V, sudden HTN) q15mins. Call OLMC for any changes.

6 Record tPA metrics: Dose, Start Time, End Time

7 Administer labetalol 10 mg over 2 mins for HTN (SBP>180mmHg or DBP > 105 mmHg)

8Re-eval BP in 10 minutes. If HTN persists, re-administer labetalol 10 mg. Contact OLMC if HTN persists after TWO doses.

9 Hypotension: place patient in supine position, administer 0.9%NS 500 mL bolus. Contact OLMC.

10 Limit sedation of any kind to ensure accurate Neurologic checks.

11 Anaphylaxis/Airway Edema: discontinue t-PA and utilize REMAC Protocol 510. 5 Neurologic deterioration: discontinue t-PA

infusion, reassess patient

Febrile reactions: stop transfusion

Do not delay txp for paperwork!

Dopamine 5 mcg/kg/min IV drip titrate up to max 20 mcg/kg/min

2

Hypertension: administer labetalol 10 mg over 2 minutes. Evaluate pt response in 10 minutes. May repeat one additional time for a total of FOUR doses.

4

Hypotension: consider discontinuing t-PA and other infusions. Repeat 0.9% NS 500 mL bolus.

2

Acute hemolytic reactions from ABO

incompatibiltiy should occur soon after

intiiation (10 mins)Blood

Transfusion Reaction 2

1

Stroke Rescue Protocol

3

Must have transfusion initiated and flowing for 10 minutes prior to crew leaving the ED

Adult & Adult/Peds Protocols

NYC REMSCO

Protocol Other Information500 A

0-2 years: 1/4 bottle1 BLS procedures Cyanide Toxicity Kit (if available) 3-5 years: 1/4 bottle2 Adv Airway Mgmt if necessary (Prehosp Sed in GOP) 6-14 years: 1/2 bottle3 Cardiac monitor & pulse oximetry Adult: 5 gm

4 SpCO (carbon monoxide cooximetry) if available Two (2) 100 ml bag 0/9% NS, D5W, LR

5 NS IV KVO x 2 One (1) 100 ml bag D5W

Refer to Protocol 528 for pts with burns One (1) 2 mL fluoride oxalate whole blood tube

One (1) 2 mL K2 EDTA tube

One (1) 2 mL lithium heparin tube

Protocol Other Information500 B

0-2 years: 1/4 bottle3-5 years: 1/4 bottle6-14 years: 1/2 bottle

1 Advanced Airway Mgmt (ETI) if necessary Cyanide Toxicity Kit (if available) Adult: 5 gm2 Cardiac monitor & pulse oximetry3 NS IV KVO x 2

Two (2) 100 ml bag 0/9% NS, D5W, LR One (1) 100 ml bag D5W One (1) 2 mL fluoride oxalate whole blood tubeOne (1) 2 mL K2 EDTA tube One (1) 2 mL lithium heparin tube

One (1) 5.0 g bottle of crystalline powder hydroxocobalamin


One (1) 5.0 g bottle of crystalline powder hydroxocobalamin

Pediatric Sodium Thiosulfate dose: (250mg/kg or 3 mL/kg prepared soln)

If BP remains <90 mmHg, dopamine 5 mcg/kg/min IV drip titrate up to max 20 mcg/kg/min7

If cardiac/respiratory arrest, seizures, coma, AMS, unexplained hypotension, hydroxycobalamin 250 mg/kg over 10 minutes (age-based dose) + sodium thiosulfate 12.5 g (150 mL of prepared solution) over 10 minutes IV

Medic should draw the 3 provided tubes of blood prior to admin HCB. Follow HCB with 20mL NS flush.

Dopamine 5 mcg/kg/min IV drip titrate up to max 20 mcg/kg/min5

4

Pediatric Sodium Thiosulfate dose:

(250mg/kg or 3 mL/kg prepared soln)

A

A

6 Medic should draw the 3 provided tubes of

blood prior to admin of HCB. Follow HCB with

20mL NS flush.

Standing Orders

Standing Orders

If cardiac/respiratory arrest, seizures, coma, AMS, unexplained hypotension, hydroxycobalamin 250 mg/kg over 10 minutes (age-based dose) + sodium thiosulfate 12.5 g (150 mL of prepared solution) over 10 minutes IV


Smoke Inhalation

Only for symptomatic patients after exposure to smoke in an enclosed space

Only for critically ill patients with suspected exposure to cyanide, not with > 5 patients exposed (>5 requires FDNY OMA Class Order)

Cyanide Exposure

Ensure pt has been decontaminated prior to treatment!

Protocol Other Information502

1 BLS Obstructed Airway procedures

2 Direct Laryngoscopy & attempt to remove foreign body with Magill forceps

3 Perform Advanced Airway Mgmt

4 If able to confirm ETI with direct visualization but unable to ventilate:a) note ETT depth. b) deflate ETT cuff. c) advance ETT to deepest depth.d) return ETT to original depth. e) reinflate ETT cuff. f) if still unable to ventilate, initiate immediate transport.


1 BLS Non-Traumatic Cardiac Arrest procedures2 Cardiac monitoring & EKG

3Transition from BLS AED to ALS monitor can only be done after completion of the next analysis/shock decision.


1 CPR + Defibrillate at maximum joule setting (3 rounds) A If VF/PVT returns, Amiodarone 150 mg IV/IO bolus

2 Advanced Airway Mgmt + IV/IO NS/LR KVO B Sodium Bicarbonate 44-88 mEq IV/IO bolus, repeat 1 amp q 10 mins

3 Vasopressin 40 units IV/IO bolus IF AVAILABLE. C Magnesium 2 gm IV/IO bolus (in 10 mL NS)4 Amiodarone 300 mg IV/IO bolus5 Epinephrine 1 mg (1:10,000) IV/IO q 5 mins D

If hyper-kalemia/suspected CaCB overdose, Calcium Chloride 1 gm IV/IO slow bolus + NS flush

If patient has a pacemaker, place the defibrillator pads at

least one inch from the pacemaker device.


Standing Orders Medical Control Options

Obstructed Airway

Continue CPR with minimal interruption


Standing Orders

Standing Orders

(CPR before AED in unwitnessed arrests, CPR for 2 minutes in EMS-unwitnessed arrest)

Non-Traumatic Cardiac Arrest

VF / Pulseless VT


1

2 Needle decompress if suspected tension PTX A Sodium Bicarbonate 44-88 mEq IV/IO bolus, repeat 1 amp q 10 mins

3 Advanced Airway Management4 IV/IO NS KVO5 Vasopressin 40 units IV/IO bolus IF AVAILABLE.6 Dextrose 25 gm IV/IO bolus7 Epinephrine 1 mg (1:10,000) IV/IO q 5m


1 Aspirin 162 mg PO. 2 NTG 0.4 mg q 5 mins x 3 doses

Hold NTG if SBP<100 mmHg unless OLMC advises

Hold NTG if Erectile Dysfunction Rx have been used within 72 hours unless OLMC advises

LBBB no longer STEMI criteria (old or new)


1 NS bolus IV 250 mL, repeat x 1 (total 500 mL NS)

2 Dopamine 5 mcg/kg/min IV drip titrate up to max 20 mcg/kg/min


1 If unstable, synchronized cardioversion with 100 joules

B If narrow complex & low BP, synchronized cardioversion with 100 joules

2 If stable, adenosine 6-12-12 mg IV rapid bolus + NS flush (max 30 mg)

Prehospital sedation (etomidate 0.15 mg/kg up to 20 mg) prior to cardioversion recommended

Observe EKG for 1-2 mins between doses C Amiodarone 150 mg in 100 mL D5W over 10 minutes

Cardiogenic Shock

STEMI patients must be transported to a STEMI

CenterMyocardial Ischemia



C



If defib max joule setting <360 j, use

equivalent cardioversion energies Repeated synchronized cardioversion attempts with defib's max setting.

NS bolus IV/IO up to 3 liters

Consider treatable conditions masquerading as PEA/Asysole

If narrow complex & normal BP, diltiazem 0.25 mg/kg IV bolus over 2 minutesA

Standing Orders

If hyper-kalemia/suspected CaCB overdose, Calcium Chloride 1 gm IV/IO slow bolus + NS flush

BPEA / Asystole

Standing Orders

Standing Orders

Continue synchronized cardioversion with 200, 300, 360 joules

SVT


1 If unstable, synchronized cardioversion with 100 joules

2 Continue synchronized cardioversion with 200, 300, 360 joules

B Amiodarone 150 mg in 100 mL D5W over 10 minutes

Protocol Other Information

505 C1 If unstable, synchronized cardioversion with 100 joules

Continue synchronized cardioversion with 200, 300, 360 joules A Synchronized cardioversion with 100 joules,

followed by 200, 300, 360 joules2 Amiodarone 150 mg in 100 mL D5W over 10 minutes B Magnesium 2 gm IV/IO bolus (in 10 mL NS)

CIf hyperkalemia/suspected CaCB overdose, Calcium Chloride 1 gm IV/IO slow bolus + NS flush

D Sodium Bicarbonate 44-88 mEq IV/IO bolus, repeat 1 amp q 10 mins

Protocol Other Information505 D

1 Atropine 0.5 mg IV bolus

2 Begin Transcutaneous Pacing B Dopamine 2 mcg/kg/min IV drip titrate up to max 10 mcg/kg/min

CIf hyperkalemia/suspected CaCB overdose, Calcium Chloride 1 gm IV/IO slow bolus + NS flush

D Sodium Bicarbonate 44-88 mEq IV/IO bolus, repeat 1 amp q 10 mins

A Fib / A Flutter

Standing Orders

If ventricular rate < 60 bpm & in shock


If amiodarone does not convert or patient is in shock



A

A




Repeat atropine 0.5 mg IV bolus q 3-5min, max up to 3 mg

Standing Orders

If stable AF with HR>150 bpm, diltiazem 0.25 mg/kg IV bolus over 2 minutes


Brady-dysrhythmias & Complete Heart

Block

VT with Pulse / WCT of Uncertain

Etiology

Protocol Other Information506 1 Cardiac monitoring

2 NTG 0.4 mg q 5 mins x 3 dosesHold NTG if SBP < 100 mmHg Hold NTG if Erectile Dysfunction Rx have been used within 72 hours unless OLMC advises B Furosemide 20-80 mg IV bolus (max

combined total dose 80 mg)3 CPAP (if available)


1 Albuterol 0.083%& Ipratropium 0.02% by neb x 3If signs of impending respiratory failure

2 Epinephrine 0.3 mg (0.3 mL of 1:1,000) IM

3 Cardiac monitoring if respiratory distress or hx of dysrhythmia/cardiac disease

3 NS KVO if severe respiratory distress4 Magnesium 2 gm in 50-100 mL NS over 10-20 mins

5 Methylprednisolone 125 mg IV/IM or Dexamethasone 12 mg IV/IM

Protocol Other Information508 ˙

1 Cardiac monitoring with EKG/monitoring

2 Albuterol 0.083% & Ipratropium 0.02% by neb x 3 doses

3 NS KVO

4 Methylprednisolone 125 mg IV/IM or Dexamethasone 12 mg IV/IM

COPD

Morphine 0.1 mg/kg up to 5 mg IV/IO/IM bolus, repeat up to 10 mg total

Lorazepam 1-2 mg IV/IN bolus or Midazolam 1-2 mg IV/IN bolusA




Administer or repeat epinephrine 0.3 mg (0.3 mL of 1:1,000) IM1

Standing Orders

Acute Pulmonary Edema

Asthma


1 BLS Anaphylactic Reaction Procedures A Repeat any of the Standing Orders

2 Early Advanced Airway Mgmt if airway compromise SIMULTANEOUS WITH #3a. B Dopamine 5 mcg/kg/min IV drip titrate up to

max 20 mcg/kg/min

3 If the patient has signs of shock or a past history of anaphylaxis:

a Administer Epinephrine 0.3 mg (0.3 mL of 1:1,000 solution), IM

b NS or LR large bore bolus up to three liters via macro-drip

c Methylprednisolone 125 mg IV/IM or Dexamethasone 12 mg IV/IM

d Diphenhydramine 50 mg IV (or IM if no IV access)

4 If the patient does not have signs of shock and does not have a history of anaphylaxis:

a NS or RL large bore KVO

b Methylprednisolone 125 mg IV/IM or Dexamethasone 12 mg IV/IM

c Diphenhydramine 50 mg IV (or IM if no IV access)

5

If the patient has signs of bronchospasm, administer Albuterol sulfate 0.085% (one unit dose bottle of 3mL), by nebulizer, at a flow rate that will deliver the solution over 5-15 minutes

6 Monitor vital signs every 5 minutes

7 Begin cardiac monitoring, record and evaluate EKG rhythym


1 BLS AMS procedures2 IV NS KVO

Use glucometer to document blood glucose levelWithold dextrose & glucagon if FSBG > 120 mg/dL

3 Dextrose 25 gm (50 mL of 50% soln) IV 4 If pt is diabetic without IV access, glucagon 1 mg IM/IN

5 If AMS persists, naloxone 0.5 mg titrate to response up to 2 mg IV.If IV unavailable, naloxone 0.5 mg titrate to response up to 4 mg IM/IN

6 If AMS persists, repeat dextrose 25 gm (50mL of 50% soln) IV

A Repeat any of the Standing Orders

Patients with an allergic reaction and signs of bronchospasm may require treatment for

anaphylaxis

Alert patients requiring Advanced Airway Mgmt

should undergo Prehospital Sedation

(GOP) via OLMC.

Consider Discretionary Order for Glucagon 1

mg IV bolus with repeats q 5min in

patient on beta-blocker & refractory to epinephrine



Standing Orders

Allergic Reaction / Anaphylactic

Reaction

Altered Mental Status

Standing Orders


1 BLS Seizure procedures A Repeat lorazepam 2 mg IV/IM/IN2 Cardiac monitor and EKG, IV KVO or Repeat diazepam 5 mg IV

3 IV NS KVO, use glucometer to document FSBG or Repeat midazolam 10 mg IM/IN

Withold dextrose & glucagon if FSBG > 120 mg/dL

4 Dextrose 25 gm (50 mL of 50% solution) bolus IV

5 If pt is diabetic without IV access, glucagon 1 mg IM/IN

6 Lorazepam 2 mg IV bolus (IM/IN if no access) + 1 repeat @ 5 mins if persistent generalized seizures

or Diazepam 5 mg IV bolus + 1 repeat @ 5 mins if persistent generalized seizures

or Midazolam 10 mg IM/IN if no access


1 Needle decompress if suspected tension PTX2 NS bolus up to 3 liters3 Cardiac monitor and EKG

Protocol Other Information515-B

1 BLS Shock measures2 If inadequate ventilation, perform Adv. Airway Mgmt

3 IV NS/RL up to 2 liters macro-drip via 1-2 large bore gauge catheters

Consider IO access after 2 failed peripheral attemptsa Document IVF amount accurately

4 Cardiac monitoring, record EKG rhythym5 Measure and record lactate level (if available)

6 Measure and record oral temp (if available) or last temp at patients' facility

Consider intraosseuous route if peripheral

attempts have failed

Severe Sepsis & Septic Shock

Additional NS/RL 1 liter macro-drip via 1-2 large bore gauge catheterA




Standing Orders

Alert patients requiring Advanced Airway Mgmt

should undergo Prehospital Sedation

(GOP) via OLMC.

"Seizure" wording changed to

"generalized seizures"; paramedics may only give Rx if tonic-clonic activity is witnessed.

Noncardiogenic Shock

Seizures

Protocol Other Information5__

1 BLS Shock measures2 If inadequate ventilation, perform Adv. Airway Mgmt 3 Use a glucometer to measure a blood glucose level.4 For pts with blood glucose levels above:

300 mg/dL w/ AMS, Tachypnea, Dehydration signs500 mg/dL or "high"

a Adults: rapid IV infusion of NS/RL up to 1 liter

b Peds: rapid IV infusion of NS/RL up to 20 ml/kg (max 1 L)

5 Cardiac monitoring, record EKG rhythym6 Transport decision7 OLMC for MCO


1 BLS Traumatic Cardiac Arrest procedures2 Decompress suspected tension PTX

5 IV NS/RL up to 2 liters macro-drip via 1-2 large bore gauge catheters

4 Cardiac monitor and EKG if no penetrating chest trauma. Treat under 503A as needed.

Advanced Airway Mgmt if airway is not controlled by other means3


Hyperglycemia (Adult & Peds)

A

A

Adults: additional rapid IV infusion of NS/RL up to 1 literPeds: rapid IV infusion of NS/RL up to 10 ml/kg (max 1 L)

Dehydration signs not absolutely clarified: can

use shock signs as surrogate

Medical Control OptionsRapid transport is highest priority.

Standing Orders

Traumatic Cardiac Arrest


1 BLS Head & Spine Injuries procedures

or Repeat diazepam 5 mg IV3 Cardiac monitor and EKG4 NS KVO5 If seizure witnessed:

a Lorazepam 2 mg IV bolus (IM/IN if no access) + 1 repeat @ 5 mins if persistent generalized seizures

b Diazepam 5 mg IV bolus + 1 repeat @ 5 mins if persistent generalized seizures

c Midazolam 10 mg IM/IN if no access

5Hyperventilate via ETCO2 to 30-35 mmHg if GCS < 8 or fixed pupils/anisocoria, posturing, Cushing's reflex, periodic breathing, decreasing GCS by 2 points


1 BLS Eye injury procedures

2 Assist with removal of contact lens if present


1 BLS Burn procedures2 Adv Airway Mgmt if upper airway burn or compromise

suspected3 Cardiac monitor and EKG for electrical burns

4 Pulse oximetry monitoring

5 NS/LR bolus up to 2 liters if txp is delayed/extended6 If severe pain due to injury:

a If SBP > 110 mmHg, morphine 0.1 mg/kg up to 5 mg IV/IO/IM bolus, repeat up to 10 mg total

b Fentanyl 1 mcg/kg (max 100 mcg) IV/IO/IN/IM

Admin of narcotic analgesics is

contraindicated in patients with burns involving the face

and/or airway.

Standing Orders

2

OR



Head Injuries

Repeat midazolam 10 mg IN/IM if no accessor

OR


Standing Orders

Repeat lorazepam 2 mg IV (IN/IM if no access)

Burns (Adult & Peds)

Chemical Eye Injuries (Adult &

Peds)

A

3

(Naloxone up to 2 mg IV if hypoventilation

occurs)

Advanced Airway Mgmt if GCS < 8 AND airway is not controlled by other means

If agitated or unable to hold eyelid open, proparacaine HCl 0.5% soln (or tetracaine HCl 0.5% soln) 1-2 gtts into affected eye, + 1 repeat of initial dose


1 BLS procedures2 Cardiac monitor and EKG3 Pulse oximetry monitoring4 IV NS KVO5 Vitals q5 mins6 If severe pain due to injury:

a If SBP > 110 mmHg, morphine 0.1 mg/kg up to 5 mg IV/IO/IM bolus, repeat up to 10 mg total

b Fentanyl 1 mcg/kg (max 100 mcg) IV/IO/IN/IM


1 BLS procedures DISSOCIATIVE AGENTSA Ketamine 2-4 mg/kg IM or 1-2 mg IN

IM BENZODIAZEPINESa Midazolam 10 mg IM or IN B Midazolam 10 mg IM

3 IV NS/RL 1 liter via macro-drip after patient is sedated or Lorazepam 4 mg IM4 Cardiac monitor and EKG

5 Pulse oximetry monitoring IV or IN BENZODIAZEPINES

C Diazepam 5-10 mg IVor Midazolam 5 mg INor Lorazepam 2 mg IN or IV


1 IV NS KVO2 Treat underlying cause of N/V (AMI, Poisoning)

Ondansetron 0.1 mg/kg (not >4mg) IV over 1-2 mins. May repeat x 1 for total up to 8 mg.3

Standing Orders

Pain Mgmt of Isolated Extremity

Injury (Adult & Peds)

A


Severe Nausea/Vomiting


If pt is at risk for respiratory or cardiac arrest while being physically restrained by the police, contact OLMC for MCO

6

Prehospital Chemical Restraint Procedure: if the patient continues to struggle while being physically restrained:

2

Hypotensive patients: Fentanyl 1 mcg/kg (max 100 mcg) IV/IN if available

(Naloxone up to 2 mg IV if hypoventilation

occurs)

If the patient is agitated, the preferred intiial

route of choice is IM.

Mandatory QA for every Midazolam 10 mg IM/IN

given under Standing Orders: ACR review by

agency Medical Director + forward to REMAC

Ondansetron has been assoc. w/ prolongation of QT interval, possibly causing Torsades de

Pointes. Caution advised for use in pts w/ cardiac disease, use of other QT prolonging-Rx,

or familial QT prolongation.


If MOI suggests other injuries, begin txp & Rx given en route after d/w OLMC

Excited Delirium


1 BLS Obstetric Emergencies procedures2 NS KVO3 OLMC for MCO

Obstetric Complications

For severe pre-eclampsia, eclampsia or post-partum hemorrhage (BP > 160 mmHg + severe headaches, visual disturbances, acute pulmonary edema or upper abdominal tenderness)

Magnesium 2 gm in 50-100 mL NS over 10-20 mins. If seizures, repeat magnesium 2 gm in 50-100 mL NS over 10-20 mins

A


NYC REMSCO

Pediatric Protocols


1 BLS Neonatal Resuscitation procedures2 If CPR and HR <60 after 30 sec, perform ETI

During txp, or if txp delayed:3 Pass NGT/OGT for abdominal distention

4 If ETI+ and HR <60 bpm, epi 0.1 mg/kg (1 mL/kg of 1:10,000 soln) via ETI

6 IV NS KVO

7 Epi 0.01 mg/kg (0.1 mL/kg of 1:10,000 soln) IV/IO q3-5 mins


A NS IV/IO KVO, no more than 2 attempts

1 BLS Pediatric Respiratlry Distress procedures. Do not hyperextend the neck; use #551 if obstructed airway is suspected.

2 Perform Advanced Airway Mgmt if less methods are not effective

3 Decompress (with 18-20 g angio) if suspected tension PTX

4 During txp: naloxone 0.5 mg IM, titrate up to 2 mg (>2y/o) or up to 1 mg (<2 y/o)

5 Pass NGT/OGT for abdominal distention6 OLMC for MCO

Actual or impending respiratory arrest, unconscious and cannot be ventilated

Peds: 14 years old or younger

Consider Protocol 551 if obstructed airway is

suspected

Consider Protocol 556 if overdose suspected


Medical Control OptionsStanding Orders

Neonatal Resuscitation

Pediatric Respiratory Arrest

Standing Orders

If txp delayed, obtain IV/IO access (no more than 2 attempts) & NS 10 mL/kg5


1 Begin BLS Pediatric Obstructed Airway procedures

If epiglottis is enlarged, treat under Protocol 552.

a) note ETT depth. b) deflate ETT cuff. c) advance ETT to deepest depth.

d) return ETT to original depth. e) reinflate ETT cuff. f) if still unable to ventilate, initiate immediate transport.


1 Begin BLS Pediatric Croup/Epiglottitis procedures

During txp or if txp delayed:2 Pass NGT/OGT for abdominal distention

Perform Adv Airway Mgmt if less invasive measures of airway mgmt are not effectiveIf able to confirm ETI with direct visualization but unable to ventilate:

3

4

Perform Direct Laryngoscopy. Attempt removal of FB with appropriate-sized Magill forceps.2

Goal of Standing Order #5 is to force the FB

into the patient's main stem bronchus and

allow for ventilation in the contralateral lung.

Pediatric Obstructed

Airway

Standing Orders


Do not attempt Advanced Airway Mgmt - use high pressure BVM or mouth-mask ventilation.


Pediatric Croup-Epiglottitis Do not try NGT/OGT in

conscious pt

Do not attempt Advanced Airway

Mgmt.


1 Begin BLS Pediatric nontraumatic arrest procedures A Repeat any of the Standing Orders2 Cardiac monitor and EKG3 If VF or pulselessVT:

a Defibrillate at 4 joules/kg using appropriate padsb CPR x 5 cycles immediately after defibrillation

4 If VF or pulseless VT persists: D Sodium bicarbonate 1 mEq/kg IV/IO bolusa Defibrillate at 10 joules/kg using appropriate pads

5 CPR x 5 cycles immediately after defibrillation

6 Perform Adv Airway Mgmt if other methods of airway management are not effective F NS IV/IO 20 mL/kg bolus

7 During txp: epinephrine 0.1 mg/kg (0.1 mL/kg of 1:1,000) via ETT if pt intubated

8 Pass NGT/OGT for abdominal distention9 NS IV/IO KVO, no more than 2 attempts10 If VF or pulseless VT persists:

a Defibrillate at 10 joules/kg using appropriate pads

b CPR x 5 cycles immediately after defibrillation

c Amiodarone 5 mg/kg IV

11 Repeat Epinephrine 0.01 mg/kg (0.1 mL/kg of 1:10,000) IV/IO q 5 minsor Repeat Epinephrine 0.1 mg/kg (0.1 mL/kg of 1:1,000) ETT q5 mins if no access

12 OLMC for MCO


1 Begin BLS Respiratory Distress procedures A Repeat albuterol 0.083% by neb Pediatric: 14 years old or younger

2 Albuterol 0.083% (1 unit dose of 3 mL) by neb up to 3 doses

3 Ipratropium 0.02% (1 unit dose of 2.5 mL if > 6 yrs, 1/2 unit dose of 2.5 mL if < 6 yrs) by neb up to 3 doses

4If > 1 year with respiratory distress/failure, epinephrine 0.01 mg/kg (0.01 mL/kg of 1:1,000) IM, max dose 0.3 mg

C NS IV/IO KVO, no more than 2 attempts

5 OLMC for MCO

Standing Orders

Severe resp distress: agitation, dyspnea,

tripod positions, retractions.

If defibrillator is unable to deliver the

recommended dose, use lowest available

setting.

C

Repeat epinephrine 0.01 mg/kg (0.01 mL/kg of 1:1,000) IM 20 minutes after 1st doseB

Pediatric: 14 years old or younger

Pediatric Asthma or Wheezing

B

Dextrose 0.5 gm/kg, IV/IO. Use D10% if < 1 month, D25% if > 1 month but < 14 years

Naloxone 2 mg IV/IO/ETT/IM if > 2 years, 1 mg if < 2 years


If torsades de pointes, magnesium 25-50 mg/kg IV/IO bolusE


Pediatric Non Traumatic Cardiac

Arrest

Protocol Other Information

5551 Begin BLS Anaphylactic procedures A Repeat any of the Standing Orders

B NS IV/IO KVO, no more than 2 attemptsC NS IV/IO 20 mL/kg bolus, repeat as

necessary

During txp or if txp delayed:4 Pass NGT/OGT for abdominal distention5 OLMC for MCO


1 BLS AMS Procedures2 During txp or if txp delayed:

a Glucagon 1 mg IM/IN3 IV / IO NS KVO. 2 attempts max.

4 Dextrose 0.5 gm/kg, IV/IO. Use D10% if < 1 month, D25% if > 1 month but < 15 years

5 If no change in mental status; naloxone 0.5 mg increments up to 2 mg IV/IO/IM/IN

6 OLMC for MCO


1 BLS Seizure procedures; document glucose level2 Glucagon 1 mg IM/IN (hold if glucose > 120 mg/dL)

or Diazepam 0.1 mg/kg IV/IO over 2 minutes with repeat same doses if seizures persist

4 During transport, IV / IO NS KVO. 2 attempts max.

6 If seizures persistt, OLMC for MCO.

Standing Orders

Diazepam 0.5 mg/kg PR if no access or other options have been exhaustedC

Midazolam 0.2 mg/kg (maximum dose 5 mg), IN/IM if no accessB

Do not administer lorazepam, diazepam,

or midazolam if seizures have stopped.

Pediatric Seizures

Pediatric Altered Mental Status

2Pediatric

Anaphylactic Reaction


If respiratory failure, airway obstruction, or decompensated shock: ETI and give Epinephrine 0.01 mg/kg (0.1 mL/kg of 1:10,000 soln) via ETT.


If seizures persist, midazolam 0.2 mg/kg IM/IN. (IN preferred, max dose 5 mg)3

Dextrose 0.5 gm/kg, IV/IO. Use D10% if < 1 month, D25% if > 1 month but < 15 years5

If no ETI, epinephrine 0.01 mg/kg (0.1 mL/kg of 1:10,000) IM. Maximum dose is 0.3 mg (0.3 mL of 1:1,1000 soln)

3




Repeat any of the Standing OrdersA

A


For persistent seizures, lorazepam 0.05 mg/kg, IV/IN/IO over 2 minutes with repeat same doses if seizures persist

1st priority is maintenace of cardiorespiratory function: treat under other protocols if AMS due to shock, trauma,

respiratory failure, drowning, anoxic injury.


1 Begin BLS Pediatric Shock procedures

5 If still in shock, go to MCO


A NS/LR IV/IO 20 mL/kg (total 60 mL/kg)1 Begin txp & BLS Traumatic Cardiac Arrest procedures

During txp, or if txp delayed

3 Decompress suspected tension PTX4 NS/LR IV/IO 20 mL/kg bolus, no more than 2 attempts

6 If patient still in arrest; NS/LR IV/IO 20 mL/kg via second IV (total 40 mL/kg), no more than 2 attempts

7 MCO

Pass NGT/OGT for abdominal distention (no NGT in craniofacial trauma)

Perform Adv Airway Mgmt if airway is not controlled by other means2

5

3

If no signs of hemorrhage present, cardiac monitor and EKG2


Rapid transport is the highest priorityStanding Orders Medical Control Options

If monitor cannot deliver calculated dose and in unstable SVT, adenosine 0.1 mg/kg IV/IO rapid bolus + flush (with 2 repeats of 0.2 mg/kg IV/IO rapid bolus). Maximum doses are 6-12-12 mg.

a

b

If signs of hemorrhage/dehydration & still in shock, NS/LR IV/IO 20 mL/kg via second IV (total 40 mL/kg), no more than 2 attempts

4

During txp: NS/LR IV/IO 20 mL/kg bolus, no more than 2 attempts

Pediatric Traumatic Cardiac

Arrest


If signs of shock still present, NS/LR IV/IO 20 mL/kg (total 60 mL/kg)A


Do not perform cardioversion in

pediatric patients with SVT/VT with a pulse

unless the defibrillator can deliver a calculated

dose

Pediatric Decompensated

Shock

If unstable SVT or VT, go to Medical Control OptionsB

If rhythm fails to convert, synchronized cardioversion at 1-2 joules/kg

If in unstable SVT/VT with pulse & monitor can deliver a calculated dose, synchronized cardioversion at 0.5-1 joule/kg using appropriate sized paddles

REMSCO General Operating Procedures REMSCO Appendices …static1.squarespace.com/static/53317aa0e4b047ff30f4b064/t/578f5c94... · REMSCO General Operating Procedures REMSCO Appendices

Documents