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Please check regional policy on Tetracaine and Morgan Lens this may be optional in your region. *Ketamine and Fentanyl must be added to your controlled substance license if required by your region. *Midstate will be requiring both Ketamine and Fentanyl. *North Country and Central New York will have both as an option. 9

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Additional Key Point Considerations added: Do not interrupt compressions for placement of advanced airway or mechanical CPR device References to other special situation protocols o Termination of Resuscitation o 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

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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 o Termination of Resuscitation o 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

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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

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

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Medical Control: EMT consider epi auto-injector or epi kit administration Additional albuterol doses Epinephrine 1:1000 nebulized Key point/considerations: Albuterol/ipratropium bromide 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. There is now a separate STEMI Confirmed Protocol. Additional Key Points/Consideration added. 22

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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 a secondary airway. Digital intubation removed for Paramedics 25

Albuterol removed for wheezing at AEMT level Solumedrol removed 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 verbiage removed Dopamine removed 29

Incorporated information from previous tension pneumothorax protocol 30

Parenteral preparation of dexamethasone can be given orally Medical Control Considerations: o Added magnesium 2 grams IV over 10 minutes in 100 ml NS Solumedrol removed Terbutaline removed 31

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

Additional Medical Control Considerations: Haldol Additional Versed Additional ketamine* 33

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Key Points/Considerations: o If patient regains responsiveness prior to infusion of the complete dose of dextrose, stop the infusion and record the amount infused. o Diabetic patient's may exhibit signs of hypoglycemia with a blood sugar between 60-80 mg/dl. If you suspect the symptoms are hypoglycemia-induced, titrate dextrose 10% using 5 grams(5 ml) aliquots for treatment and diagnosis. Dextrose 50% was removed 37

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

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IM administration of Narcan removed for AEMT level 41

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Key points/considerations: ONE pain medication may be given under standing orders, to exceed standing order dose or to switch to another agent 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 the regional policies 44

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*Ketamine- Paramedic only 47

Nitro Paste was removed 48

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Criteria removed for blood glucose and replaced with refer to the Hypoglycemia or Hyperglycemia Protocols 50

Dopamine was removed 51

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North Country Regional STEMI Protocol time 60 minutes to facility capable of primary angioplasty 53

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 designated 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

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Medical Control Consideration : For additional normal saline - 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

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You should consult with patient s VAD program provider 61

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

Diphenhydramine(Benadryl) PO was removed Fluid bolus was removed for CC 63

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Consideration for Narcan and fluid challenge was removed 68

Medical Control Considerations: Atropine dose was changed to 1 mg every 3-5 minutes for organophosphate poisoning Dystonic reaction - Benadryl 1 mg/kg IV or IM was added Sympathomimetic ingestion (cocaine/amphetamine) - midazolam (Versed) 0.1 mg/kg IV, IM, or IN was added Calcium channel blocker OD - calcium chloride 20 mg/kg IV was added Removed information for beta blocker OD- glucagon 0.1 mg/kg IV or IM up to 2 mg max 69

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Reference to Pediatric Hypoglycemia or Hyperglycemia Protocols was added 72

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Solumedrol was 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 The pediatric stable and unstable tachycardia protocols were combined 75

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