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Please check regional policy on this Tetracaine and Morgan lens may be optional in region *Ketamine and Fentanyl must be added to your CS license if required by your region *Midstate will be requiring both Ketamine and Fentanyl *North Country and Central New York they will both remain an option 9

(The safety aspect is not the primary reason in this care for not doing manual compressions in a moving ambulance [although an important one]. Moving a patient interrupts good quality compressions. In addition, it is almost impossible to provide optimal compression quality in a moving ambulance. In an ideal world most patients would be worked on the scene until ROSC or termination) 10

Additional Key Point Considerations added Do not interrupt compressions for placement of advanced airway or mechanical CPR device References to other special situation protocols Termination of Resuscitation Smoke Inhalation-Symptomatic Consider bilateral Chest Decompression in patients with organized cardiac rhythm presenting in cardiac arrest thought to be secondary to trauma (pneumothorax can occur spontaneously note) 11

Key Point/Consideration added Do not interrupt compressions for placement of advanced airway or mechanical CPR device A minimum of 50 ml of normal saline should be given between the bolus of calcium chloride and the bolus of sodium bicarbonate Amiodarone Bolus doses should be diluted in a minimum of 20 ml NS to minimize post ROSC Hypotension and phlebitis Consult medical control for ROSC References to other special situation protocols Termination of Resuscitation Smoke Inhalation-Symptomatic Consider bilateral Chest Decompression in patients with organized cardiac rhythm presenting in cardiac arrest thought to be secondary to trauma (pneumothorax can occur spontaneously note) 13

Key Point Considerations 12 lead and neurologic exam should be done before transport All patients with STEMI and ROSC should be transported to hospital capable of primary angioplasty, if feasible, within transport time recommended per regional procedure Patients with recurrent cardiac arrest should be transported to the closest hospital unless authorized by Medical Control Documentation must include accurate pupil exam, and initial GCS recorded by element (Eyes/4, Verbal/5, Motor/6), not as a total Call hospital ASAP 15

Intercept with ALS or transport to the hospital removed- This is now assumed that it would be the appropriate action 19

Medical Control EMT consider epi auto-injector or epi kit administration Additional albuterol doses Epinephrine 1:1000 nebulized Key point/considerations Albuterol/Ipratropium limited to 3 doses, contact medical control for additional BIPAP can be used if trained instead of CPAP IM administration of Epinephrine 1:000 should only be used if severe distress and tidal volume is so small that nebulized medications will not work Other educational points Previously combined protocol with COPD under Acute Respiratory Distress 21

Nitroglycerin paste removed from protocols Separate Confirmed STEMI protocol Additional Key Points/Consideration added AEMT's in the North Country may give Nitorglyccerin 0.4 mg SL tablet or spray if BP is >120 mmhg. A policy statement will be developed to allow this regionally. 22

Diphenhydramine 50 mg for dystonic reaction removed 24

Key Note /Considerations AEMT may utilize a supraglottic airway instead of intubation If intubation is attempted, only 2 attempts at intubation by AEMT before going to a secondary airway, if another AEMT is available they may attempt once before going to secondary airway. Digital intubation removed for Paramedics 25

Albuterol removed for wheezing at AEMT level Solumedrol removed AEMT's in the the North Country will be allowed to give epinephrine 1:1000 (0.3 mg IM) as previously allowed for Adult Allergic Reaction, a policy statement will be developed to allow this regionally. 26

Consider fluid challenge removed Dopamine removed 27

Additional Key points/considerations added (notable ones below) When considering the total of a burn, DO NOT count first degree burns Burns with trauma should go to the closest appropriate trauma center Contact medical control about destination if you are unsure 28

Fluid challenge wording removed Dopamine removed 29

Incorporated information from old tension pneumothorax 30

Medical Control Considerations Added Magnesium 2 grams IV over 10 minutes in 100 ml NS Solumedrol removed Terbutaline removed the parenteral preparation of dexamethasone can be given orally 31

Please check regional policy on this, Tetracaine and Morgan Lens may be optional in region 32

Additional Medical Control Considerations More versed Haldol More ketamine* 33

If patient regains responsiveness prior to infusion of the complete dose of dextrose, stop the infusion and record the amount infused. Diabetic patient's may exhibit signs of hypoglycemia with a blood sugar between 60-80 mg/dl. If you suspect he symptoms are hypoglycemia-induced, titrate dextrose 10% using 5 grams(5 ml) aliquots for treatment and diagnosis D50 removed 37

Change repeat of Zofran if needed from 5 minutes to 10 minutes CC, P 39

IM administration of Narcan removed for AEMT 41

Key points/considerations ONE pain medication may be given under standing orders, to exceed standing order dose or to switch to another agency you must consult medical control If clinically appropriate you can round dose to nearest 50 mcg for Fentanyl and 5 mg for Morphine Nitrous oxide, ketamine, and ketorolac are not required formulary items. Check regional policies 44

*Ketamine- Paramedic only 47

Nitro Paste removed Nitrogycerin Paste will remain an option in the North Country, regional policy statement being developed. Nitroglycerin paste 1 inch if systolic BP is greater than 120 mmhg. Aggressive nitroglycerin administration of tablets or spray is preferred, but paste may be used if clinically indicated. 48

Removed criteria for Blood Glucose and replaced with refer to hypo or hyperglycemia protocol 50

Dopamine removed 51

Medical Control Considerations Metoprolol 5 mg slow IV push CC, P North Country should contact medical control if transport is outside of 2 hours due to the distance of stroke centers and 5 hours will take them out of the timeframe to receive TPA 54

Key Point Consideration- Combined use of IV metoprolol and diltiazem may precipitate hypotension and may not be done on standing order 55

Medical Control Consideration For additional NS AEMT, CC, P Norepinephrine 2mcg/min, titrated to 20 mcg/min, if needed after fluid bolus is completed, to maintain a MAP>65 mmhg or SBP >100 mmhg CC, P 57

You should consult with VAD program Coordinator for patient 61

Medical Control Considerations Magnesium 50 mg/kg over 10 minutes IV, max 2 grams Repeat dose of Epinephrine 1:1000 CC,P Solumedrol removed 62

Diphenhydramine(Benadryl) PO removed Fluid bolus removed for CC- medical control option for vascular access 63

Consideration for Narcan and fluid challenge removed 68

Medical Control Considerations Atropine dose change to 1 mg every 3-5 minutes for organophosphate Poisoning Dystonic Reaction Benadryl 1 mg/kg IV or IM added Sympathomimetic ingestion (cocaine/amphetamine Midazolam (Versed) 0.1 mg/kg IV, IM, or IN added Calcium channel blocker OD Calcium chloride 20 mg/kg IVadded Removed information for beta blocker OD- Glucagon 0.1 mg/kg IV or IM up to 2 mg max 69

Reference to pediatric hypoglycemia or hyperglycemia instead of being outlined 72

Solumedrol removed 74

Key point/consideration Newborn/infant SVT if pulse >220 bpm, Child> 1 year SVT if pulse > 180 bpm and has no discernable p-waves and regular R-R interval on PRINTED ECG strip Stable and unstable combined 75