HVREMS ALS Prot Hudson Valley Regional EMS

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					   Hudson Valley
   Regional EMS




      DRAFT
Advanced Life Support
  Protocol Manual
                    Hudson Valley Regional Emergency Medical Services Council, INC.
                        DRAFT Advanced Life Support Protocol Manual DRAFT

                                          Table of Contents

Operations                                                                            Page
Introduction                                                                          GOP-1
EMT-Intermediate/Critical Care Program                                                GOP-1
Clinical Judgment                                                                     GOP-1
Interpretation of Protocols                                                           GOP-2
Medical Control                                                                       GOP-3
Medical Authority at the Scene                                                        GOP-3
Communications                                                                        GOP-4
Communications Failure                                                                GOP-4
Transfer of Care                                                                      GOP-5
Patients Who Refuse Care                                                              GOP-5
Initiation and Termination of CPR Including DNR                                       GOP-5
Pediatric Definitions                                                                 GOP-6
Procedures                                                                            GOP-7
Medications                                                                           GOP-10
Equipment                                                                             GOP-10
Destination Decision                                                                  GOP-10
Ambulance Diversion                                                                   GOP-10
Inter-Facility Transfers                                                              GOP-10
Protocol Exceptions                                                                   GOP-11
Record Keeping                                                                        GOP-11
EMS Complaint/Concern Procedures                                                      GOP-12
EMS Disciplinary Procedures                                                           GOP-14
Protocol Changes                                                                      GOP-14
Initial ALS Care
ALS Care Protocol                                                                     ACP-1

Adult Medical Protocols
Respiratory Arrest/Imminent Respiratory Arrest/Intubation                             AMP-1
Obstructed Airway, Unconscious                                                        AMP-2
Respiratory Distress                                                                  AMP-3
Cardiopulmonary Arrest (Non-Traumatic)                                                AMP-5
Ventricular Fibrillation or Pulseless Ventricular Tachycardia                         AMP-6
Asystole/Pulseless Electrical Activity                                                AMP-9
Sustained Ventricular Tachycardia with a Pulse, Stable                                AMP-11
Sustained Ventricular Tachycardia with a Pulse, Unstable                              AMP-12
Suspected Myocardial Infarction                                                       AMP-14
Bradyrhythmia Including 3rd Degree Heart Block                                        AMP-17
Acute Pulmonary Edema/Congestive Heart Failure (SBP>100)                              AMP-18
Non-Traumatic Shock (Cardiogenic/Septic)                                              AMP-19
Supraventricular Tachycardia                                                          AMP-20




Table of Contents                                                                             TOC-   1
                    Hudson Valley Regional Emergency Medical Services Council, INC.
                        DRAFT Advanced Life Support Protocol Manual DRAFT

                                          Table of Contents

Adult Medical Protocols                                                               Page
Abdominal Pain                                                                        AMP-21
Systemic Allergic Reactions/Anaphylaxis                                               AMP-22
Altered Mental Status                                                                 AMP-23
Overdose                                                                              AMP-24
Toxic Exposure                                                                        AMP-25
Hypertensive Crisis                                                                   AMP-26
Status Epilepticus                                                                    AMP-27
Suspected Stroke                                                                      AMP-28
Adult Medical Protocol Supplement                                                     AMP-30

Adult Trauma Protocols
Major Trauma                                                                          ATP-1
High Risk Patients                                                                    ATP-2
Traumatic/Hypovolemic Shock                                                           ATP-3
Traumatic/Hypovolemic Cardiopulmonary Arrest                                          ATP-4
Tension Pneumothorax                                                                  ATP-5
Head Trauma                                                                           ATP-6
Burns                                                                                 ATP-7
Isolated Extremity Trauma                                                             ATP-9
Major Trauma Transport                                                                ATP-10
Adult Trauma Protocol Supplement                                                      ATP-11

Special Considerations Protocols
Pain Management/Analgesia                                                             SCP-1
Medication Facilitated/Rapid Sequence Intubation                                      SCP-2
Mark I Kit Use                                                                        SCP-4
Emergency Incident REHAB                                                              SCP-8
Toxemia of Pregnancy                                                                  SCP-9
Childbirth/Precipitous Delivery                                                       SCP-10
Neonatal Resuscitation                                                                SCP-11

Pediatric Medical Protocols
Respiratory Arrest/Imminent Respiratory Arrest/Intubation                             PMP-1
Obstructed Airway, Unconscious                                                        PMP-2
Respiratory Distress                                                                  PMP-3
Cardiopulmonary Arrest (Non-Traumatic)                                                PMP-4
Ventricular Fibrillation/Pulseless Ventricular Tachycardia                            PMP-5
Asystole/Pulseless Electrical Activity                                                PMP-8
Bradyrhythmia including 3rd Degree Heart Block                                        PMP-9
Non-Traumatic Shock (Cardiogenic/Septic)                                              PMP-10
Supraventricular Tachycardia                                                          PMP-11
Abdominal Pain                                                                        PMP-12
Systemic Allergic Reactions/Anaphylaxis                                               PMP-13

Table of Contents                                                                          TOC-   2
                    Hudson Valley Regional Emergency Medical Services Council, INC.
                        DRAFT Advanced Life Support Protocol Manual DRAFT

                                          Table of Contents

Pediatric Medical Protocols                                                           Page
Altered Mental Status                                                                 PMP-14
Overdose                                                                              PMP-15
Toxic Exposure                                                                        PMP-16
Status Epilepticus                                                                    PMP-17
Pediatric Medical Protocol Supplement                                                 PMP-18

Pediatric Trauma Protocols
Major Trauma                                                                          PTP-1
High Risk Patients                                                                    PTP-2
Traumatic/Hypovolemic Shock                                                           PTP-3
Traumatic/Hypovolemic Cardiopulmonary Arrest                                          PTP-4
Tension Pneumothorax                                                                  PTP-5
Head Trauma                                                                           PTP-6
Burns                                                                                 PTP-7
Isolated Extremity Trauma                                                             PTP-9
Major Trauma Transport                                                                PTP-10
Pediatric Trauma Protocol Supplement                                                  PTP-11

Appendix A
Regional Helicopter Utilization Guidelines                                            A-1

Appendix B
Regional Hospital Information                                                         B-1
Medical Control Hospital Information                                                  B-2
Additional Hospital Disposition Codes                                                 B-4
Location Codes                                                                        B-5

Appendix C
Physician Release Form                                                                C-1

Appendix D
Equipment List                                                                        D-1

Appendix E
Medication List                                                                       E-1
Drug Formulary                                                                        E-3




Table of Contents                                                                           TOC-   3
Advanced Life Support Protocols
  General Operating Procedures
                Hudson Valley Regional Emergency Medical Services Council, INC.
                    DRAFT Advanced Life Support Protocol Manual DRAFT


Introduction
This manual was developed with guidance provided by emergency physicians, physician’s
assistants, nurses, EMS personnel, and administrative support personnel affiliated with the
Hudson Valley Regional Emergency Medical Services Council (HVREMSCO) and representing
the counties of Dutchess, Orange, Putnam, Rockland, Sullivan, and Ulster. The intent of the
effort was to establish a field and medical control reference that would be standardized
throughout the six county Region. This Manual represents the standard of care for provision of
pre-hospital advanced levels of care in the Hudson Valley Region.

The HVREMSCO recognizes Certified First Responder (CFR), Emergency Medical Technician-
Basic (EMT-B), Emergency Medical Technician-Intermediate (EMT-I), Emergency Medical
Technician-Critical Care (EMT-CC) and Paramedic (EMT-P) levels of New York State certified
EMS providers. The Regional Advanced Life Support (ALS) system incorporates three different
tiers of ALS care which includes EMT-I, EMT-CC, and EMT-P levels of personnel and services.
EMS personnel certified by the New York State Department of Health (NYS DOH) as EMT-I,
EMT-CC, or EMT-P must be credentialed by the Hudson Valley REMAC prior to practicing ALS
skills in the Region. Each level of certification follows a specific standard of care which has been
developed and approved by the NYS DOH and HVREMSCO.

EMT-I/CC Program
Within the Hudson Valley Region, there is a diversity of geography, economy, population and
infrastructure which affects the development and implementation of the Regional ALS system.
Inclusion of the EMT-I and EMT-CC levels of care is specifically intended to further enhance the
Regional ALS system in areas where Paramedic resources may be limited, making it possible
for ALS intervention to begin while Paramedic units are responding. The EMT-
Intermediate/EMT-Critical Care (EMT-I/EMT-CC) program is designed for use only as an
adjunct within an established EMT-P (Paramedic) system. Since the EMT-I/EMT-CC
program is specifically designed to enhance an EMS system, but is focused in ALS capability,
any EMS agency employing the EMT-I/EMT-CC program agrees to utilize an EMT-P
(Paramedic) two-tiered priority response with simultaneous dispatch according to the criteria
established by the REMAC and in accordance with the criteria published in the NYS DOH
Statewide Basic Life Support (BLS) Adult and Pediatric Treatment Protocols.
Services providing EMT-Intermediate/Critical Care level services must agree, in writing between
the EMT-I/CC service and the HVREMSCO, to provide care within an established EMT-P
(Paramedic) system and must demonstrate such participation by providing written service
procedures (EMT-I/CC within existing EMT-P service) or mutual aid agreements between the
EMT-I/CC service and the EMT-P service (independent EMT-I/CC services).

Clinical Judgment:
The Hudson Valley Regional EMS ALS Protocols are guidelines which should be used in
conjunction with good clinical judgment. Since patients do not always fit into a rigid formula
approach, situations may occur which are not included in these protocols. In situations where
there is no existing protocol and a clear need for ALS exists, the ALS provider shall initiate Initial
Advanced Life Support Care, Protocol ACP-1, and contact Medical Control who shall order the
most appropriate treatment within the provider’s scope of practice as defined by level of training,
certification, and protocols.
General Operating Procedures                                    Revised: September 13, 2010   GOP-   1
                Hudson Valley Regional Emergency Medical Services Council, INC.
                    DRAFT Advanced Life Support Protocol Manual DRAFT


Interpretation of Protocols
It is understood that the New York State ―Basic Life Support Protocols‖ as issued by the New
York State Department of Health are always to be initiated, in conjunction with the HVREMSCO
Advanced Life Support Protocols. All ALS care begins with the implementation of Initial
Advanced Life Support Care, Protocol ACP-1. EMT-Is, EMT-CCs, and EMT-Ps will initiate Initial
Advanced Life Support Care, Protocol ACP-1, for every ALS patient regardless of whether or
not standing orders for their level of care exist.
In each protocol, for every standing order and medical control option, there is indication as to
which level of provider may initiate that order.
Example:

   1. Airway control procedures
   2. If patient is intubated, secondary confirmation must be performed, at a minimum,
      with End-tidal CO2 monitoring and Pulse Oximetry. Continuous CO2 monitoring is
      recommended.
   3. Refer to appropriate protocol for further assessment and treatment.



Some protocols are designed to have numbered standing orders only; other protocols have
numbered standing orders and medical control options. Standing orders may be initiated prior to
contacting medical control, and MUST be performed in numerical sequence. If there is clinical
improvement, further standing orders may be withheld based upon the ALS Provider’s clinical
judgment.
Example:

   4. Airway control procedures
   5. If patient is intubated, secondary confirmation must be performed, at a minimum,
      with End-tidal CO2 monitoring and Pulse Oximetry. Continuous CO2 monitoring is
      recommended.
   6. Refer to appropriate protocol for further assessment and treatment.



                          EMT-I’s Stop Here. EMT-CC/P’s Contact Medical Control.

                                       Medical Control options
      Diazepam                5-10mg IVP
      Morphine Sulfate        2-10mg IVP
      Midazolam               0.5-2mg Slow IVP
      Lidocaine               1.0-1.5mg/kg slow IVP (as appropriate for increased intracranial
                               pressure)


Medical Control options may not be initiated until ordered by Medical Control. Medical Control
will sequence Medical Control options.

General Operating Procedures                                     Revised: September 13, 2010   GOP-   2
                Hudson Valley Regional Emergency Medical Services Council, INC.
                    DRAFT Advanced Life Support Protocol Manual DRAFT


Additional information pertinent to the protocol has been included in separate sections entitled
―Considerations‖.
Example:                            Considerations
    Prior to nasotracheal intubation, consider the administration of Phenylephrine HCl 1%
       Nasal Spray. If utilized, administer 2 sprays in the selected nostril.
    RSI Credentialed Paramedics may refer to Medication Facilitated/Rapid Sequence
       Intubation Protocol SCP-5 as appropriate.


It is understood that a patient’s clinical presentation may require care involving more than one
protocol. In addition, it may be necessary to move from one protocol to another as the patient’s
condition changes. In such cases, the patient’s most emergent clinical problem should be
treated as a priority. In the event that a patient’s condition changes, requiring a change in
protocol, implement the standing orders in the new protocol without exceeding the maximum
recommended medication dosages and contact Medical Control as indicated.

Medical Control
―Medical Control‖ means on-line advice and direction provided by a physician or under the
direction of a physician to CFRs, EMT-Bs, EMT-Is, EMT-CCs, or EMT-Ps who are providing
medical care at a scene of an emergency or en route to a health care facility (Medical Control
Options) or off-line medical direction including the written policies, procedures, and protocols
for pre-hospital emergency medical care and transportation developed by the State Emergency
Medical Advisory Committee (SEMAC), approved by the State Council (SEMSCO) and the
Commissioner and implemented by the Regional Emergency Medical Advisory Committee
(REMAC) (Standing Orders).
Medical Control may be used as a resource at any time prior to the implementation or
completion of Standing Orders. Once contact has been made, the Medical Control
Practitioner is responsible for all subsequent treatment options, including transportation
decision.
―Medical Control Practitioner‖ means a HVREMAC credentialed Physician or Physician’s
Assistant.
―Medical Control Facility‖ means a hospital which has been approved by the HVREMAC as
having met the policies and procedures to provide on-line medical control.
Since ALS activity is always under medical control, whether on-line or off-line, ALS credentials
are required of all pre-hospital ALS personnel and Medical Control Practitioners in order to
practice ALS care in the Hudson Valley Region. The HVREMAC authorizes ALS credentials.

Medical Authority at a Scene
Advanced Life support personnel may not relinquish medical control to any person at the scene.
Only a Medical Control Practitioner may relinquish medical control, and only to an identified
physician at a scene.

The Medical Control Practitioner may allow ALS providers to follow orders from the physician at
a scene, provided such orders are included within the established Hudson Valley Regional ALS
Protocols.

General Operating Procedures                                  Revised: September 13, 2010   GOP-   3
                Hudson Valley Regional Emergency Medical Services Council, INC.
                    DRAFT Advanced Life Support Protocol Manual DRAFT


Orders given by an on scene physician that are not within established HVREMSCO protocols
require:
       1.     That the on scene physician implements the order.
       2.     That the on scene physician utilizes his/her own drugs and equipment.
       3.     That the on scene physician accompanies the patient to hospital.
The on scene physician who accepts medical control will complete and sign the "Physician
Release Form" (see appendix C). If the physician at a scene who accepts medical control
wishes to relinquish medical control, the ALS Provider will communicate with the Hudson Valley
Regional EMS Medical Control Practitioner who will resume medical control. HVREMSCO
Medical Control Practitioners may re-establish medical control at any time.

Communications
ALS Providers may contact Medical Control at any time. The ALS Provider must contact the
Medical Control Facility upon completion of standing orders, and whenever there is a patient
who requires ALS services, but refuses treatment or transport. When requesting Medical Control
orders, ALS Providers should identify themselves by level of certification, name and agency,
and clearly state ―medical control orders requested.‖ When not requesting Medical Control
orders, ALS providers’ should state ―notification only.‖ ALS Providers should attempt to
communicate with the receiving hospital as soon as possible when transporting ALS patients.
When patients are transported to a hospital not providing the Medical Control for the transport,
the Medical Control Practitioner providing the order will notify the clinical practitioner (Physician,
Physician’s Assistant, Nurse Practitioner as appropriate) designated as in charge of the
Receiving Hospital Emergency Department (ED) of the transport and will include all medical
control orders authorized as well as the patient’s medical status. In all such cases, the ALS
provider will document on a Patient Care Report (PCR) addendum the name of the Medical
Control Practitioner and Medical Control Facility as well as the time of communication and all
Medical Control orders received or denied. The ALS Provider will have the PCR addendum
signed by the authorized clinical practitioner designated as in charge of the Receiving Hospital
ED.
In the event that an ALS Provider must unavoidably operate on the scene of a call in excess of
20 minutes and is unable to establish communications with Medical Control, the ALS Provider
will document the incident in detail and notify the Chief Operations Officer of the agency, or
designee in writing. The Chief Operations Officer of the agency will submit monthly summaries
of all ALS calls with extended on-scene times to their respective quality improvement committee
and Medical Director for evaluation.

Communication Failure
In the situation where voice contact with medical control cannot be established by
radio/telephone/cellular apparatus/telemetry, the ALS Provider will complete appropriate
standing orders and initiate transport. Continued attempts should be made to establish voice
contact. Attempts should be made to establish voice contact with any available Regional
Medical Control Facility. Upon completion of a call in which there has been a communication
failure, medical control must be contacted and advised of the situation. PCR documentation
must include attempts to contact medical control, and reasons for communication failure.

General Operating Procedures                                     Revised: September 13, 2010   GOP-   4
                        Hudson Valley Regional Emergency Medical Services Council, INC.
                            DRAFT Advanced Life Support Protocol Manual DRAFT

Transfer of Care
The ALS provider may release patients not having received, or not requiring ALS care, to Basic
Life Support personnel for care and transportation to an appropriate receiving facility provided
the presumptive diagnosis does not anticipate the need for ALS care.
ALS Providers may transfer care of a patient to another provider within the following provisions:
            1. To an equal or higher level of care provider:
                a. When transport is by helicopter critical care team.
                b. When transport is by another provider/service with the same level of training.
                c. When patient is turned over to an appropriate receiving facility.
            2. To an equal or lower level of care provider:
                a. When the ALS Provider at the scene recognizes that there is no indication for ALS
                   intervention.
                b. When ALS capabilities are exceeded (ex. MCI) and patient is triaged to other ALS
                   or BLS services.
                c. When a coroner or other appropriate agency takes custody.
In each situation indicated in item 2 (above), the ALS Provider will document the type of incident
on the PCR. The Chief Operations Officer of the agency will submit monthly summaries of all
ALS patient care transfers to lower level care providers to their respective quality improvement
committee and Medical Director for evaluation.
When an ALS provider encounters a patient requiring ALS treatment and transportation requires
the use of a Basic Life Support ambulance, any ALS protocol initiated by the ALS provider
should continue en route by an equal or higher level of ALS provider.
The ALS Provider must contact medical control whenever there is a patient who requires ALS
services, but refuses treatment or transport.

Patients Who Refuse Care
All competent adults have the right to refuse medical treatment and/or transport. It is the
responsibility of the pre-hospital care provider to be sure that the patient is fully informed about
their situation and the possible implications of refusing treatment or transport.1
When a patient or legal guardian/proxy refuses treatment or transport:
  1. Refer to New York State Department of Health, Bureau of EMS Basic Life Support
     Protocol SC-5 ―Refusing Medical Aid (RMA)‖;
  2. Communicate with Medical Control if ALS is indicated.

Initiation and Termination of CPR including Do Not Resuscitate (DNR)
A DNR order is only an order to not perform resuscitation in the event of cardiac or respiratory
arrest. It does not infer that any other treatment is to be withheld. All decisions concerning DNR,
initiation and termination of CPR shall be consistent with current New York State Department of
Health memorandums.




1
    New York State Department of Health, Bureau of EMS Statewide Basic Life Support Adult and Pediatric Treatment Protocols, 2003.
General Operating Procedures                                                              Revised: September 13, 2010            GOP-   5
                Hudson Valley Regional Emergency Medical Services Council, INC.
                    DRAFT Advanced Life Support Protocol Manual DRAFT

The only exceptions to initiating CPR are:
   1. For any patient originating from an Article 28 facility (hospital or nursing facility) when
      written DNR orders signed by a physician are presented;
   2. For any patient NOT originating from an Article 28 Facility (hospital or nursing facility)
      when a non-hospital DNR order is presented on the standard Department of Health form
      (DOH-3474) or when the standard Department of Health DNR bracelet is found on the
      patient’s body;
   3. In cases of obvious death such as rigor mortis, decomposition, extreme dependant
      lividity, or mortal injuries such as decapitation.
Once CPR is initiated by a CFR, EMT or AEMT it must be continued until one of the following
occurs:
   1. Effective spontaneous circulation has been restored;
   2. Resuscitative efforts have been transferred to another appropriately trained individual
        who continues CPR and other basic life support measures;
   3. A Medical Control Practitioner agrees to relinquish Medical Control to an on-scene
        physician who assumes responsibility for the care of the patient;
   4. A Medical Control Practitioner orders termination of CPR (by radio, telephone, or other
        communication means);
   5. Care of the patient is transferred to hospital staff assigned responsibilities for emergency
        care;
   6. A valid DNR is presented;
   7. The CFR, EMT or AEMT is exhausted and physically unable to continue resuscitation.
If the decision is made to terminate CPR, the patient must still be transported if;
            Arrest is in a public place
            An environmental situation not conducive to termination exists
            No police agency or coroner is present
            Communication failure occurred
            Asystole developed after the arrival of EMS
            Inadequate IV access or airway control was obtained.
If decision is made not to transport, the ALS provider will leave all tubes and lines in place.

Pediatric Definitions
Patients who fit the following criteria will be treated under pediatric protocols:
    A pediatric patient is any patient who is less than eighteen (18) years old.
    The term ―infant‖ refers to pediatric patients less than 1 year old.
    The term ―neonate‖ refers to pediatric patients in the first minutes to hours immediately
       after birth.
    For the purposes of CPR and AED a child will be considered eight (8) years of age or
       less.
Transportation of the pediatric patient should be considered earlier than in the care of the adult
patient, and should be initiated prior to the institution of ALS procedures whenever possible.




General Operating Procedures                                    Revised: September 13, 2010   GOP-   6
                Hudson Valley Regional Emergency Medical Services Council, INC.
                    DRAFT Advanced Life Support Protocol Manual DRAFT

Procedures
Any references to airway control will include the use of supplemental oxygen, oropharyngeal
airways, nasopharyngeal airways, bag-valve-masks with supplemental oxygen, flow restricted
oxygen powered ventilation devices, foreign body removal, tracheal suctioning, gastric
decompression, endotracheal intubation, nasotracheal intubation, combitube (or similar device),
laryngeal mask airway, pleural decompression, and/or cricothyrotomy. Procedures may only be
performed consistent with the providers’ level of training and certification.

Endotracheal Intubation Confirmation must include clinical signs for primary confirmation
including:

   1.   Direct visualization of the ETT passing through the vocal cords;
   2.   Visual inspection of the chest for the presence of symmetrical chest rise;
   3.   Auscultation at the epigastrum for absence of gurgling sounds;
   4.   Auscultation at the anterior and lateral chest walls for the presence of bilateral breath
        sounds;

Continuous waveform capnography monitoring is required for all out of hospital adult and
pediatric patients who require endotracheal intubation. The capnography device must have the
ability to print and/or store the data for continuous waveform monitoring documentation as well
as QA/QI purposes. The ability to print the data should be accomplished at the hospital
whenever possible.

Cricothyrotomy is an invasive surgical procedure that is intended to be used only by
Paramedics who demonstrate expertise performing the procedure at a minimum of once every
year in a clinical lab setting. Cricothyrotomy is to be performed only in circumstances where the
Paramedic is unable to ventilate a patient by any other method as a result of a complete airway
obstruction (i.e., severe facial trauma, angio edema, irremovable foreign body). Cricothyrotomy
may be performed with a large bore over-the-needle catheter or with a REMAC approved device
such as the ―Quick Trach‖ or ―Nu-Trake‖ devices.

Pleural Decompression is an invasive surgical procedure that is intended to be used only by
EMT-CC’s and Paramedics who demonstrate expertise performing the procedure at a minimum
of once every year in a clinical lab setting. Pleural decompression is to be performed only for the
treatment of a tension pneumothorax when the patient presents with evidence of the following
signs resulting from suspected trauma:
       a. Respiratory distress with absent lung sounds; AND
       b. Cardiovascular compromise;
              i.     Hypotension
              ii.    Cardiopulmonary arrest


Medication Facilitated / Rapid Sequence Intubation (RSI) may only be performed by
Paramedics who are affiliated with an ALS agency approved by the HVREMAC to participate in
the RSI Program, and who have satisfied all of the RSI Program credentialing requirements.



General Operating Procedures                                     Revised: September 13, 2010   GOP-   7
                Hudson Valley Regional Emergency Medical Services Council, INC.
                    DRAFT Advanced Life Support Protocol Manual DRAFT


Intravenous Access (with or without Saline Lock) refers to surgical cannulation of a peripheral
vein including external jugular cannulation with an over-the-needle-catheter to deliver
medication and/or fluids or withdraw blood specimens for laboratory analysis.
Intravenous Infusion refers to administration of normal saline with a Micro-Drip or Macro-Drip
administration device through an intravenous access site. To administer medications or maintain
venous access, the ALS provider should use a catheter of sufficient size to keep the vein open
(KVO) and deliver medication as needed along with Micro-Drip administration tubing and run
according to the recommended infusion rate. To replace fluid volume, or replace body
electrolytes, the ALS provider should use the largest catheter that can be introduced into the
patient's vein along with Macro-Drip administration tubing and run according to the
recommended infusion rate.
Intraosseous Access is primarily for critical medical and trauma patients for whom peripheral
IV access is not available, and it is recognized that IV access is needed urgently for delivery of
fluids and/or medications. This procedure may be performed as a standing order only in cardiac
arrest, respiratory arrest, and in cases with unstable patients where the provider is unable to
obtain peripheral IV access following two attempts. In other cases, Medical Control must be
consulted. Peripheral IV sites must be considered prior to intraosseous access.
Intraosseous Infusion refers to administration of normal saline with a Micro-Drip or Macro-Drip
administration device through an intraosseous access site run according to the recommended
infusion rate. To administer medications the ALS provider should use Micro-Drip administration
tubing. To replace fluid volume the ALS provider should use Macro-Drip administration tubing,
or in the case of a pediatric patient, Micro-Drip administration tubing, or preferably Macro-Drip
administration tubing along with a pediatric burette or soluset.
KVO (Keep Vein Open) Rate refers to administration of normal saline at an approximate rate of
1 drip every 2 seconds when using Micro-Drip administration tubing and one drip every 10 to 15
seconds when using Macro-Drip administration tubing.
Electrical defibrillation is currently the most effective method for converting ventricular
fibrillation (VF) or pulseless ventricular tachycardia (VT) to a more life sustaining rhythm.
AEMT’s may use defibrillation on standing orders. Success of defibrillation depends largely on
the amount of time the patient has been in VF or VT. For this reason, in the cardiac arrest
situation, it is essential to check the rhythm and defibrillate as early as possible. In the pediatric
patient, defibrillation is weight related (2 Joules/kg initially). Specific pediatric sized defibrillation
paddles/pads must be used to prevent damage to the chest and to facilitate proper defibrillation.
Biphasic defibrillation is an acceptable option if used according to the specific manufacturer’s
instructions.
Synchronized cardioversion is the treatment of choice for supraventricular and ventricular
tachydysrhythmias when the patient is unstable or the dysrhythmia is refractory to drug therapy
when the patient is stable. The synchronizer circuit must be turned on and there must be capture
marks on the QRS complexes or the defibrillator will not synchronize correctly. If there are no
marks, adjust the EKG size accordingly. Biphasic cardioversion is an acceptable option if used
according to the specific manufacturer’s instructions.




General Operating Procedures                                       Revised: September 13, 2010   GOP-   8
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                    DRAFT Advanced Life Support Protocol Manual DRAFT


External pacing is the treatment of choice in profound bradydysrhythmias. The pacing circuit
monitors the QRS complexes similar to the synchronizing circuit in cardioversion, but it
determines the rate and provides pacing if it is slower than the specified rate (usually 60 BPM).
For this reason, the patient cables must be in place and good QRS complexes must be sensed.
During pacing, the patient should be visually monitored at all times and should be assessed for
both electrical and mechanical capture. Skeletal muscle twitching should be expected, but it is
not an indication of pacing capture.
12 Lead ECG implementation is strongly recommended by the American Heart Association in
its ACLS Guidelines 2000 and this recommendation is strongly supported by the HVREMAC.
Therefore, EMT-CC and EMT-P services are urged to upgrade all EMS units with 12 lead ECG
capabilities when considering replacement of cardiac equipment.
Cardiac Monitoring shall be performed on all patients where indicated by the patient’s clinical
condition. EMT-I services are required to utilize Automated External Defibrillators. EMT-CC and
EMT-P services are required to utilize defibrillators, which are capable of continuous EKG
monitoring. EMT-CC and EMT-P services are recommended to utilize defibrillators capable of
continuous EKG monitoring, 12-Lead EKG acquisition, and computer recognition of EKG
changes associated with Acute Myocardial Infarction.
Continuous Positive Air Pressure (CPAP), if available, shall be applied on all patients where
indicated by the patient’s clinical condition. This skill is limited for implementation by EMT-P
personnel only.
Medications
  Administration procedures
   1. Medications may be given only:
           a. On the order of a Medical Control Practitioner, either verbally or by specific written
              standing orders.
           b. By a HVREMAC credentialed ALS Provider, as appropriate
           c. When selected from the medication schedule in this manual
           d. When administered according to HVREMAC approved operating procedures
   2. The ALS Provider is responsible for patient presentation, confirming orders and control of
      all medications designated to their possession.
   3. If, at any time, an order is unclear, the ALS Provider will ask the Medical Control
      Practitioner to repeat the order or clarify it.
   4. When any medications are administered, they must be documented on a PCR or ALS
      addendum.
   Supply and Inventory Procedures
       1. Each ALS Unit is responsible for a daily inventory of all medications and must keep a
          record of said inventory.
       2. Agencies will be required to stock each ALS unit and maintain stock levels according
          to the minimum guidelines as set forth in the medication lists in the appendix.
       3. All Controlled Substances must be stored in compliance with the agency’s controlled
          substances (Part 80) plan.




General Operating Procedures                                   Revised: September 13, 2010   GOP-   9
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Equipment
  Supply and Inventory Procedures
       1. Each ALS Unit is responsible for a daily inventory of all equipment and must keep a
          record of said inventory.
       2. Agencies will be required to stock each ALS unit and maintain stock levels according
          to the minimum guidelines as set forth in the equipment list in the appendix.

Destination Decision
Patients shall be transported to the nearest appropriate hospital, as defined by patient choice,
medical condition, and state/regional protocols. Medical Control must approve any anticipated
deviation from this standard. When patients are transported to a hospital not providing the
Medical Control for the transport, the Medical Control Practitioner will notify the clinical
practitioner (Physician, Physician’s Assistant, or Nurse Practitioner as appropriate) designated
as in charge of the Receiving Hospital ED of the transport and the patient treatment/status.

Ambulance Diversion
Ambulance diversion is a hospital based decision and is not binding upon the ALS service;
compliance is a voluntary act that will be jointly decided by Medical Control and the senior ALS
Provider involved with the patient transport. Diversion may not be appropriate if the hospital "on
diversion" is the nearest appropriate hospital and the patient's well being may be compromised
by a longer transport time.

Inter-Facility Transfers
Patient care is the direct responsibility of the referring hospital and physician for all inter-facility
transfer of patients. Pre-hospital emergency personnel must insure that prior to initiating the
patient transfer, they:
       1. Are supplied with written documentation of at least the following information:
             a. Patients name;
             b. Diagnosed condition of the patient;
             c. Any treatment and any medication administered to the patient;
             d. Name of physician ordering transfer;
             e. Name of hospital from which the patient is being transferred;
             f. Name of the physician(s) who is or are willing and authorized to receive the
                  patient at the new location;
             g. Name of hospital or other facility that is to receive the patient;
             h. Date and time of transfer
             i. Signature of the physician ordering the transfer.
       2. Obtain written medical orders that do not exceed their level of medical training;
       3. Confirm that the receiving facility has agreed to accept the patient in transfer;
       4. Are supplied with appropriate copies of the patient’s medical records, including
          radiographs;
       5. Are utilizing the appropriate equipment needed to transfer the patient;
       6. Verify that the patient has been stabilized to the fullest extent capable by the referring
          hospital prior to transfer.


General Operating Procedures                                       Revised: September 13, 2010   GOP- 10
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The Hudson Valley Regional Emergency Medical Services Council will not assume
responsibility for providing Medical Control (on-line or off-line) for inter-facility transfers.
If a patient’s condition becomes critical (i.e., respiratory/cardiac arrest, unmanageable airway, or
uncontrollable hemorrhage) during an inter-facility transport and/or requires immediate medical
intervention not provided for by the referring physician’s written medical orders, HVREMAC
credentialed pre-hospital emergency medical personnel may initiate patient care by utilizing the

HVREMAC approved ALS protocols in conjunction with the New York State approved BLS
protocols provided medical control is contacted as soon as possible.

Protocol Exceptions
Should a situation arise which fails to conform to the Regional ALS Protocols, the ALS Provider
and on-line Medical Control Practitioner may agree upon an altered course of action.
The Medical Control Practitioner should generate and document the order on the PCR/ALS
Addendum. The ALS Provider should clarify the on-line Medical Control Practitioner’s order and
patient’s condition if the ALS Provider does not understand what actions are requested or if the
ALS Provider feels those actions would be contrary to the patient's well being.
While acting in a setting which falls beyond the scope of the Regional ALS Protocols, no ALS
Provider shall be faulted or suffer punitive action for:
    following on-line Medical Control orders, provided the orders are within the ALS
      Provider’s standard of care and scope of training;
    for refusing to follow an order which the provider believes to increase risk to the patient;
    for refusing to perform a procedure which is beyond the ALS Provider’s scope of training
      or expertise.

Whenever an action occurs outside of the Regional ALS Protocols, the Medical Control
Practitioner and the ALS Provider shall each generate and forward a report of the action to the
HVREMAC within 3 days of the deviation.

Record Keeping
The documentation included on the Patient Care Report (PCR) provides vital information, which
may be necessary for continued care at the hospital.
       ALS providers must document all ALS procedures performed on an appropriate PCR
        addendum (ex. PCR Continuation Form or other form approved by the HVREMSCO to
        be used in place of a PCR Continuation Form).
       ALS Providers must complete a PCR (and when appropriate, a PCR addendum)
        immediately following a call, and an authorized clinical practitioner (Physician,
        Physician’s Assistant, or Nurse Practitioner as appropriate) from the Receiving Hospital
        Emergency Department (ED) must also sign the ALS PCR or PCR addendum.




General Operating Procedures                                   Revised: September 13, 2010   GOP- 11
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                           DRAFT Advanced Life Support Protocol Manual DRAFT


           In cases where patients are transported to a hospital not providing the Medical Control
            for the transport, the ALS provider will document on a PCR addendum the name of the
            Medical Control Practitioner and Medical Control Facility as well as the time of
            communication and all Medical Control orders received or denied. The ALS Provider will
            have the PCR addendum signed by the clinical practitioner designated as in charge of
            the Receiving Hospital ED.
           All online medical control orders must be documented on a PCR addendum and must be
            authorized by a Medical Control Practitioner either by verbal authorization to the clinical
            practitioner designated as in charge of the Receiving Hospital ED (when the patient is
            transported to a hospital not providing medical control) or by written authorization (when
            the patient is transported to the hospital providing medical control).
           As part of transferring the patient to the Emergency Department Staff, the agency
            should not leave the hospital until a completed PCR is provided to the appropriate
            hospital staff2. The ALS Provider will distribute copies of all pertinent records to the
            receiving facility and will retain the Agency and Research copies of the PCR. Copies of
            the PCR will be distributed as follows:
             Agency Copy                                    - Agency completing report
             Research Copy                                  - Hudson Valley Regional EMS Office
             Hospital Patient Record Copy                   - Receiving facility

EMS Complaint / Concern Procedures
Note: The NYS DOH, Bureau of EMS mandates specific incident reporting responsibilities and
requirements for all EMS services. Mandatory reporting of incidents must be performed as
indicated in NY State EMS Code, Part 800, Section 21(q) 1-5 and Section 21(r), Part 80, 80.136
(k), NYS DOH, Bureau of EMS Policy Statement 98-11, and any other NYS DOH Policies and
Procedures.
Regional complaints or concerns can be made by a patient, the public, participating
organizations or individual participants, including HVREMSCO staff members. All such
complaints or concerns should be brought to the attention of the HVREMSCO Executive
Director.
In order to handle complaints or concerns regarding participating organizations, or individual
participants such as BLS or ALS Providers, Nurses and Physicians involved in pre-hospital ALS,
the following procedure has been established:
            Appropriate grounds for complaints or concerns include:
              1. Practicing without proper NYS or HVREMSCO certification
              2. Deviation from HVREMSCO ALS Protocols, including interim updates from
                  Regional MAC. (HVREMSCO protocols, procedures, medications schedule,
                  policies)
              3. Unprofessional conduct (Including but not limited to: disrespect towards patients,
                  families, fellow providers, intoxication while on duty, breaking patient
                  confidentiality, etc.)
              4. Immoral or indecent behavior

2
    New York State Department of Health, Bureau of EMS Policy Statement 02-05, ―Pre-Hospital Care Reports‖, October 29, 2002.
General Operating Procedures                                                             Revised: September 13, 2010            GOP- 12
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                    DRAFT Advanced Life Support Protocol Manual DRAFT


           5. Fraud, falsification of records, unauthorized possession or misappropriation of
              property
           6. Insubordination


       Complaints or concerns will be handled by the following process:
     1. Complaint or concern is brought to the attention of the HVREMSCO Executive Director,
        who may request written documentation of the complaint or concern.
     2. HVREMSCO Executive Director confers with the named party privately, if possible, and
        notifies the named organization, ALS Provider, Nurse or Physician of the complaint by
        certified mail.
     3. The HVREMSCO Executive Director sends written notification of the alleged infraction
        to the Regional Medical Director and the party's supervisor at his/her field agency or
        institution.
     4. HVREMSCO Executive Director in conjunction with the Regional Medical Director may
        choose any of the following options:
          a. Decide the complaint or concern is unwarranted, and report to the Evaluation
              Committee.
          b. Decide the complaint or concern is warranted, refer to the Evaluation Committee
          c. Decide the complaint or concern is warranted, resolved by discussion amongst,
              Executive Director, Regional Medical Director, Evaluation Committee Chairperson,
              party making complaint, and involved individual / agency.
          d. If there is a serious infraction, the Executive Director may confer immediately with
              the Regional Medical Director and Evaluation Committee Chairperson, then hold a
              meeting of same with the named party and one representative of his/her
              institution. The Regional Medical Director, in conjunction with the Executive
          e. Director and Chairman of the Evaluation Committee, may suspend the named
              party. The Evaluation Committee will meet within fourteen (14) days.
     5. All Medical Control Hospitals will be notified in writing of the party's suspension and
        only the HVREMSCO Executive Director will notify the Hospital in writing when the
        party has been reinstated.
     6. The HVREMSCO Evaluation Committee will review, at their next scheduled meeting,
        complaints processed through steps 4 A-C above.
     7. In cases where it is the consensus of opinion of the HVREMSCO Evaluation Committee
        that no follow-up action is warranted, the Chairman of the Evaluation Committee, or the
        Regional Medical Director, shall communicate that opinion in writing, to the
        complainant, the named party, and the named party's supervisor at his/her field agency
        or institution.




General Operating Procedures                                  Revised: September 13, 2010   GOP- 13
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                    DRAFT Advanced Life Support Protocol Manual DRAFT

EMS Disciplinary Procedures
The Evaluation Committee is a sub-committee of the Regional Medical Advisory Committee
(REMAC). The Evaluation Committee consists of seven (7) members as follows:
       Chairman of the Evaluation Committee             Chairman of the HVREMAC
       Regional Medical Director                        Regional Executive Director
       Regional Quality Improvement Coordinator         Two EMS Providers
No member of the field unit or institution involved in the complaint shall be appointed to the
Evaluation Committee.
The Evaluation Committee's report shall become the basis for a consensus recommendation to
the REMAC. The REMAC may conduct any subsequent investigations and/or hearings deemed
warranted and shall issue a decision in the matter within 30 days of receipt of the consensus
recommendation of the Evaluation Committee. The decision shall then be transmitted by
certified mail to the named party, and the employer/supervisor. The decision of the REMAC
shall be considered binding and final.
Disciplinary options include, but are not limited to: probation, probation with supervision,
suspension for a specified time period, or revocation of privileges to participate in the Hudson
Valley Regional EMS System. A record of each complaint or concern and the completion of the
appropriate disciplinary steps shall be kept by the HVREMSCO staff.
Appeals by the complainant or the named party should be directed at the New York State EMS
Council Medical Advisory Committee, with notification to be sent to the Hudson Valley REMAC.

Protocol Changes
Any recommendations or request for changes in the Regional ALS Protocols should be referred
in writing to the Hudson valley Regional Medical Advisory Committee for review by the Protocol
Committee. There will be periodic updates of the Regional ALS Protocols that will be instituted
with SEMAC oversight/approval.




General Operating Procedures                                   Revised: September 13, 2010   GOP- 14
Advanced Life Support Protocols
       Initial ALS Care
                Hudson Valley Regional Emergency Medical Services Council, INC.
                    DRAFT Advanced Life Support Protocol Manual DRAFT
                                      ALS Care Protocol-1
                                             (ACP-1)
                                        Initial ALS Care

                                        Considerations
This protocol is to be implemented in conjunction with the New York State Basic Life Support
Adult and Pediatric Treatment Protocols for every patient that the ALS provider determines to
require pre-hospital ALS care. In an uncooperative patient, the requirement to initiate full ALS
assessment and care may be waived in favor of assuring the patient is transported to an
appropriate facility.


   1. Scene Size-Up:
       Assess scene for safety/hazards;
       Employ standard precautions and transmission based precautions;
       Note number of patients/mechanism(s) of injury and request additional
          personnel/equipment/resources as necessary;
       Consider C-spine stabilization.
   2. Initial Assessment/General Impression/Identify Priority Patients:
       Assess for immediate life threatening conditions
       Determine patient’s level of consciousness and orientation;
       Assess ABC’s, perform appropriate airway control, and begin Oxygen therapy
          per New York State Department of Health standards;
       If the patient’s condition is determined to meet New York State Department of
          Health High Priority criteria, consider immediate transport (vital signs, rapid
          assessment, detailed physical exam, on-going assessment, and treatment
          should be completed en route to the nearest appropriate hospital).
   3. Obtain and record initial vital signs and repeat as often as the situation indicates;
   4. Obtain SAMPLE/Perform Focused History and Physical Exam;
   5. EMT-CC and EMT-P apply EKG monitor and evaluate cardiac rhythm;
   6. Initiate IV access (IO access if appropriate), with Normal Saline or Saline Lock as
      appropriate to protocol;
   7. Administer appropriate treatment according to specific protocol and contact
      medical control as indicated in the operations section of the protocols;
   8. Make transport decision based on New York State Department of Health standards.




ALS Care Protocol                                                                          ACP-    1
Advanced Life Support Protocols
        Adult-Medical
                 Hudson Valley Regional Emergency Medical Services Council, INC.
                     DRAFT Advanced Life Support Protocol Manual DRAFT
                                   Adult Medical Protocol-1
                                           (AMP-1)
                Respiratory Arrest/Imminent Respiratory Arrest/Airway Control

                                          Considerations
      Prior to nasotracheal intubation, ALS providers may consider the administration of
       Phenylephrine HCl 1% Nasal Spray. If utilized, administer 2 sprays in the selected nostril.
      RSI Credentialed Paramedics may refer to Medication Facilitated/Rapid Sequence
       Intubation Protocol SCP-2 as appropriate.




   7. Airway control procedures
   8. If patient is intubated, secondary confirmation must be performed, at a minimum, with
      End-tidal CO2 monitoring and Pulse Oximetry.
   9. Refer to appropriate protocol for further assessment and treatment.


                                        EMT-I/CC’s Stop Here.


   4. If the patient requires sedation, contact Medical Control



                                 EMT-CC/P’s Contact Medical Control.


                                    Medical Control Options
      Diazepam             5-10mg IVP
      Morphine Sulfate     2-10mg IVP
      Midazolam            0.5-2mg Slow IVP
      Lidocaine            1.0-1.5mg/kg slow IVP (as appropriate for increased intracranial
                            pressure)
    Naloxone               2mg IVP, may be repeated up to 8 mg.




Adult Medical Protocol                                                                    AMP-   1
                 Hudson Valley Regional Emergency Medical Services Council, INC.
                     DRAFT Advanced Life Support Protocol Manual DRAFT
                                  Adult Medical Protocol-2
                                           (AMP-2)
                               Obstructed Airway, Unconscious


   1.   BLS procedure.
   2.   Direct laryngoscopy and remove foreign body using Magill Forceps
   3.   Airway control procedures.
   4.   Refer to appropriate protocol, or contact medical control.


                                        EMT-I/CC’s Stop Here.



   5. If unable to ventilate because of obstruction, perform cricothyrotomy with approved
      device.




Adult Medical Protocol                                                                  AMP-   2
                 Hudson Valley Regional Emergency Medical Services Council, INC.
                     DRAFT Advanced Life Support Protocol Manual DRAFT
                                   Adult Medical Protocol-3
                                           (AMP-3)
                                     Respiratory Distress
                                 Asthma/Bronchospasm/COPD


   1. Airway control procedures
   2. Pulse Oximetry.



   3. Albuterol 2.5mg/3cc normal saline or Levalbuterol 1.25mg/3cc normal saline, may repeat
      Albuterol or Levalbuterol once after 10 minutes.



                                         Considerations
      Administration of bronchodilators may begin prior to IV initiation.

                                         EMT-I’s Stop Here.


   4. Albuterol 2.5mg and Ipratropium 0.5mg/3cc normal saline or Levalbuterol 1.25mg/3cc
      normal saline.
   5. Additional treatments of Albuterol 2.5mg/3cc normal saline or Levalbuterol 1.25mg/3cc
      normal saline ONLY, may be administered every 10 minutes.


                             EMT-CC’s Stop Here. Contact Medical Control.




   4. Albuterol 2.5mg and Ipratropium 0.5mg/3cc normal saline or Levalbuterol 1.25mg/3cc
      normal saline.
   5. If CPAP is available, the patient’s condition does not improve, and the patient meets the
      criteria for CPAP, apply CPAP at 5 cm H2O. If the patient’s status does not improve
      within 5 minutes, increase CPAP to a maximum of 10 cm H2O. Maintain SaO2>91%. If
      CPAP is not available, proceed to step 6.
   6. Additional treatments of Albuterol 2.5mg/3cc normal saline or Levalbuterol 1.25mg/3cc
      normal saline ONLY, may be administered every 10 minutes.




                                     - Continued on next page -




Adult Medical Protocol                                              Revised: March 3, 2008   AMP-   3
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                                Adult Medical Protocol-3 (Cont.)
                                            (AMP-3)
                                      Respiratory Distress
                                 Asthma/Bronchospasm/COPD

                                     Medical Control Options

      Albuterol            2.5mg/3cc normal saline via nebulizer, repeat as directed
      Levalbuterol         1.25mg/3cc normal saline via nebulizer, repeat as directed
      Ipratropium          0.5mg/3cc normal saline via nebulizer, repeat as directed
      Terbutaline          0.25mg subcutaneous, repeat as directed
      Epinephrine          1:1,000 0.3mg subcutaneous, repeat as directed
      Magnesium Sulfate    1-2gm IV over 5 minutes
      Methylprednisolone   125mg/50cc normal saline over 3-5 minutes


                                        Considerations
      Use Epinephrine with caution in patients with history of or presence of hypertension,
       heart disease, current pregnancy, and/or beta-blockers.


                                    Medical Control Options
    CPAP                   At 5 cm H2O. If the patient’s status does not improve within 5
                            minutes, increase CPAP to a maximum of 10 cm H2O




Adult Medical Protocol                                             Revised: March 3, 2008    AMP-   4
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                                  Adult Medical Protocol-4
                                         (AMP-4)
                           Cardiopulmonary Arrest (Non-traumatic)


   1. Initiate basic cardiac life support (BCLS).
   2. Follow appropriate sub-protocol:
           a. Ventricular fibrillation or pulseless ventricular tachycardia
           b. Asystole and Electromechanical dissociation/Pulseless electrical activity


                                           Considerations
      Biphasic defibrillation is an acceptable option if used according to the specific
       manufacturer’s instructions.

                                           EMT-I’s Stop Here.

                                            Considerations
      In the adult patient ET dosing of medications is twice the amount of the usual IV dose
       followed by 10-20cc of normal saline flush.
      IV medications by bolus are followed by a 20-30cc bolus of normal saline. When
       practical, elevation of the arm is recommended.




Adult Medical Protocol                                                                     AMP-   5
                 Hudson Valley Regional Emergency Medical Services Council, INC.
                     DRAFT Advanced Life Support Protocol Manual DRAFT
                                     Adult Medical Protocol-5
                                              (AMP-5)
                  Ventricular Fibrillation or Pulseless Ventricular Tachycardia


   1. Cardiac arrest standing orders.
   2. If arrest is witnessed, administer precordial thump.
      a. Immediately Defibrillate (at device specific energy (120-200joules) if biphasic or 360
            joules if monophasic) if defibrillator is not immediately available, perform CPR until
            defibrillator is available to shock.
      b. After one shock, resume CPR. After 5 cycles of CPR, recheck pulse and rhythm. If
            rhythm has not converted, continue CPR. Prepare to shock, establish airway
            control, and establish IV access with normal saline.

   3. If arrest is unwitnessed, or downtime is over 5minutes, perform at least 5 cycles of CPR.
      a. When monitor/defibrillator is available, analyze and deliver ONE shock, if indicated.
      b. Immediately resume CPR. After 5 cycles of CPR, recheck pulse and rhythm. If
            rhythm has not converted, continue CPR. Prepare to shock, establish airway
            control, and establish IV access with normal saline.




   4. Defibrillate at (biphasic device specific energy; monophasic at 360J) making certain to
      continue CPR while defibrillator charges.
   5. Resume CPR immediately. Continue CPR stopping every 5 cycles to check pulse and
      rhythm. Shock ONE TIME when indicated and immediately resume CPR.



                                EMT-I’s Stop Here. Contact Medical Control.




                                  - Continued on Next Page -




Adult Medical Protocol                                          Revised: September 13, 2010   AMP-   6
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                     DRAFT Advanced Life Support Protocol Manual DRAFT
                             Adult Medical Protocol-5 (Continued)
                                              (AMP-5)
                  Ventricular Fibrillation or Pulseless Ventricular Tachycardia


     6. Prepare to administer medications.
     7. Defibrillate at (biphasic device specific energy; monophasic at 360J )making certain to
         continue CPR while defibrillator charges.
     8. Resume CPR immediately.
     9. Epinephrine 1:10,000 1mg IV, may be repeated every 3 minutes.
     10. If at any point, the rhythm converts to a supraventricular rhythm, and the patient has
         not received an anti-arrhythmic, administer Lidocaine 1mg/kg -1.5mg/kg IVP, and then
         administer a drip of Lidocaine at 2mg/min.
     11. After 5 cycles of CPR, recheck pulse and rhythm. If indicated, defibrillate at (biphasic
         device specific energy; monophasic at 360J ), making certain to continue CPR while
         defibrillator charges.
     12. Resume CPR immediately
     13. Lidocaine 1mg/kg-1.5mg/kg IVP, may be repeated at 1mg/kg every 3 minutes to a total
         dose of 3mg/kg
     14. After 5 cycles of CPR, recheck pulse and rhythm. If indicated, defibrillate at (biphasic
         device specific energy; monophasic at 360J), making certain to continue CPR while
         defibrillator charges.
     15. Resume CPR immediately. Continue CPR stopping every 5 cycles to check pulse and
         rhythm. Shock ONE TIME when indicated and immediately resume CPR.
     16. If at any point after the administration of Lidocaine, the rhythm converts to a
         supraventricular rhythm, administer a Lidocaine infusion at:
              Lidocaine 2mg/min           if 1-2mg/kg of Lidocaine was used
              Lidocaine 4mg/min           if 2-3mg/kg of Lidocaine was used

                                         Considerations

      If at any point, the rhythm converts to supraventricular, and the patient has not received
       an anti-arrhythmic, administer Lidocaine 1mg/kg IVP, and then administer an infusion of
       Lidocaine at 2mg/min.

      If at any point after receiving Lidocaine, the rhythm converts to a supraventricular rhythm,
       administer an infusion of Lidocaine:
    Lidocaine 2mg/min           if 1-2mg/kg of Lidocaine was used
    Lidocaine 4mg/min           if 2-3 mg/kg of Lidocaine was used



                                EMT-CC’s Stop Here. Contact Medical Control.




Adult Medical Protocol                                         Revised: September 13, 2010   AMP-   7
                 Hudson Valley Regional Emergency Medical Services Council, INC.
                     DRAFT Advanced Life Support Protocol Manual DRAFT
                             Adult Medical Protocol-5 (Continued)
                                              (AMP-5)
                  Ventricular Fibrillation or Pulseless Ventricular Tachycardia
                                           Considerations
      Paramedics may consider Vasopressin 40U IVP in place of Epinephrine; if no acceptable
       response after 5-10 minutes, you may resume Epinephrine 1:10,000 1.0mg IVP every 3
       minutes.
      Paramedics may consider Amiodarone 300mg/20cc normal saline or 5mg/kg, IVP in
       place of Lidocaine; if necessary repeat Amiodarone 150mg/20cc normal saline IVP or
       2.5mg/kg
      If at any point after receiving Amiodarone, the rhythm converts to a supraventricular
       rhythm, administer an infusion of Amiodarone at 1mg/min


                               EMT-P’s Stop Here. Contact Medical Control.


                                    Medical Control Options
    Defibrillate                 360 joules(biphasic device specific energy; monophasic at
                                  360J )



                                     Medical Control Options

      Naloxone                   2mg IV or ET; may be repeated to a total dose of 8mg
      Sodium Bicarbonate         1mEq/kg IVP; may repeat ½ original dose every 10 minutes
      Dextrose 50%               25 grams IVP (50cc)
      Magnesium Sulfate          1-2 grams IV over 5 minutes
      Epinephrine 1:10,000       1mg IVP (10cc)



                                     Medical Control Options

    Amiodarone                   150-300mg/20cc normal saline IVP
    Amiodarone                   Infusion at 1mg/min
    Vasopressin                  40U IVP




Adult Medical Protocol                                          Revised: September 13, 2010   AMP-   8
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                     DRAFT Advanced Life Support Protocol Manual DRAFT
                                   Adult Medical Protocol-6
                                           (AMP-6)
                                     Asystole and PEA


   1. Cardiac arrest standing orders.
   2. The rhythm is checked in more than one lead before the interpretation of asystole is
      made. If the rhythm is unclear and possibly low amplitude ventricular fibrillation, consider
      CPR for 5 cycles and then defibrillation.
   3. Airway control procedures, ventilation, and IV access: normal saline at KVO with a large
      bore catheter.



                                EMT-I’s Stop Here. Contact Medical Control.


   4. Epinephrine 1:10,000 1mg IVP, dose may be repeated every 3 minutes.
   5. If no response to initial dose of Epinephrine, IV infusion of normal saline wide open.
   6. If absolute bradycardia (<60bpm), Atropine 1mg; may be repeated every 3 minutes to a
      total dose of 0.04mg/kg.



                                           Considerations
      Dextrose 50% 25 grams (50cc) IVP if clinically indicated. May be repeated once.
      Naloxone 2mg IVP if clinically indicated, may be repeated up to 8mg.
      Consider underlying causes of hypovolemia, hypoxia, hydrogen ion (acidosis), hypo or
       hyperkalemia, hypoglycemia, hypothermia, toxins, tamponade, tension pneumothorax,
       thrombosis, and trauma.
      If patient is found upon arrival by EMS in non-traumatic asystole, appears normothermic,
       has satisfactory IV access and airway control performed, and does not respond to all
       above standing orders, the EMT-CC/EMT-P will contact Medical Control to discuss
       termination of resuscitative efforts, if indicated.

                               EMT-CC’s Stop Here. Contact Medical Control.




                                      Considerations
      Consider using Vasopressin 40U IVP in place of first or second dose of Epinephrine
       1:10,000 IVP

                                EMT-P’s Stop Here. Contact Medical Control.




                                  - Continued on Next Page -
Adult Medical Protocol                                                                    AMP-   9
                 Hudson Valley Regional Emergency Medical Services Council, INC.
                     DRAFT Advanced Life Support Protocol Manual DRAFT
                             Adult Medical Protocol-6 (Continued)
                                           (AMP-6)
                                      Asystole and PEA

                                     Medical Control Options

    Defibrillation               at device specific energy if biphasic or 360 if monophasic.




                                   Medical Control Options
    Sodium Bicarbonate          1mEq/kg IVP, repeat at 0.5mEq/kg as directed.
    Epinephrine 1:10,000        1mg IVP (10cc)
    Termination of resuscitative efforts


                                     Medical Control Options
    Calcium Chloride             250-500mg IVP, may be repeated to maximum of 1gram. Only
                                  indicated if there is likelihood of acute hyperkalemia,
                                  hypocalcemia, or calcium channel blocker toxicity.
    Glucagon                     1mg IV or IM, may be repeated. Only indicated if there is
                                  likelihood of beta-blocker toxicity.




Adult Medical Protocol                                                                   AMP- 10
                 Hudson Valley Regional Emergency Medical Services Council, INC.
                     DRAFT Advanced Life Support Protocol Manual DRAFT
                                       Adult Medical Protocol-7
                                                (AMP-7)
                         Sustained Ventricular Tachycardia with a Pulse, Stable

                                         Considerations
      Stable indicates the absence of chest pain, dyspnea, CHF, ischemia, infarction,
       hypotension (SBP<90), or altered consciousness.
      Any sustained wide complex tachycardia should be treated as ventricular tachycardia.


   1. In the event of communication failure, administer one of the following anti-arrhythmics:
    Lidocaine 1.5mg/kg IVP, may be repeated in 5-10 minutes 1 time; Or
    Amiodarone 150mg/20cc normal saline IV bolus over 10 minutes, may repeat every 10
      minutes if VT persists up to a maximum dose of 450mg

                                EMT-P’s Stop Here. EMT-CC/P’s Contact Medical Control.

                                          Medical Control Options
    Lidocaine                         0.5-1mg/kg IVP
    Lidocaine                         infusion at 3-4mg/min



                                          Medical Control Options
    Amiodarone                        150mg/20cc normal saline IV bolus over 10 minutes
    Amiodarone                        infusion at 1mg/min




Adult Medical Protocol                                              Revised: September 13, 2010   AMP- 11
                 Hudson Valley Regional Emergency Medical Services Council, INC.
                     DRAFT Advanced Life Support Protocol Manual DRAFT
                                   Adult Medical Protocol-8
                                            (AMP-8)
                    Sustained Ventricular Tachycardia with a Pulse, Unstable

                                       Considerations
      Unstable denotes sustained Ventricular Tachycardia combined with any of the following;
       chest pain, dyspnea, CHF, ischemia, infarction, altered mental status or hypotension
       (SBP<90).
      Any sustained wide complex tachycardia should be treated as ventricular tachycardia.
      Biphasic defibrillation/cardioversion is an acceptable option if used according to the
       specific manufacturer’s instructions.


   1. If the patient presents with hypotension, unconsciousness, pulmonary edema, or if
       synchronous cardioversion cannot be accomplished for technical reasons, use
       asynchronous cardioversion.
   2. Cardiovert at 100 joules.
   3. If not successful, cardiovert at 200 joules.
   4. If not successful, cardiovert at 300 joules.
   5. If not successful, cardiovert at 360 joules.
   6. If rhythm fails to convert to a supraventricular rhythm AND the patient remains in an
       unstable ventricular tachycardia, administer Lidocaine 1.5mg/kg IVP, may be repeated in
       5-10 minutes 1 time
   7. If patient converts to a supraventricular rhythm, prior to antiarrhythmic drug
       administration, administer Lidocaine 1mg/kg, then begin an infusion of Lidocaine
       2mg/min.
   If at any point after receiving an anti-arrhythmic drug, the rhythm converts to a
   supraventricular rhythm, administer an infusion of the effective anti-arrhythmic:
    Lidocaine                      2mg/min if 1-2mg/kg of Lidocaine was used
    Lidocaine                      4mg/min if 2-3 mg/kg of Lidocaine was used

                                EMT-CC’s Stop Here. Contact Medical Control.

                                              Considerations
          If conscious, may pre-medicate with Midazolam 2mg slow IVP; may repeat in 2
           minutes if needed.
          If rhythm fails to convert to a supraventricular rhythm AND the patient remains in an
           unstable ventricular tachycardia, consider Amiodarone 150mg/20cc normal saline
           over 10 minutes in place of Lidocaine; Amiodarone may be repeated every 10
           minutes up to 450mg
          If patient converts to a supraventricular rhythm, prior to antiarrhythmic drug
           administration, consider Amiodarone 150mg/20cc normal saline over 10 minutes in
           place of Lidocaine followed by an infusion of Amiodarone at 0.5mg/min
          If at any point after receiving Amiodarone, the rhythm converts to a supraventricular
           rhythm, administer an infusion of Amiodarone at 0.5mg/min


                                   - Continued on next page -
Adult Medical Protocol                                         Revised: September 13, 2010   AMP- 12
                 Hudson Valley Regional Emergency Medical Services Council, INC.
                     DRAFT Advanced Life Support Protocol Manual DRAFT
                             Adult Medical Protocol-8 (Continued)
                                            (AMP-8)
                    Sustained Ventricular Tachycardia with a Pulse, Unstable

                                      Medical Control Options
      Cardiovert                  200/300/360 joules
      Lidocaine                   0.5mg/kg-1.5mg/kg IVP
      Lidocaine                   infusion at 2-4mg/min
      Magnesium Sulfate           1-2gm IV over 5 minutes
      Morphine Sulfate            2-5mg IV bolus, up to a total dose of 15mg
      Diazepam                    5mg-10mg IV
      Midazolam                   0.5-4mg slow IV push
      Naloxone                    2mg IVP, may be repeated up to 8mg


                                      Medical Control Options
    Amiodarone                    150mg IV bolus over 10 minutes
    Amiodarone                    infusion at 0.5mg/min




Adult Medical Protocol                                       Revised: September 13, 2010   AMP- 13
                 Hudson Valley Regional Emergency Medical Services Council, INC.
                     DRAFT Advanced Life Support Protocol Manual DRAFT
                                   Adult Medical Protocol-9
                                           (AMP-9)
                                Suspected Myocardial Infarction

     1. If chest pain is present and the patient is otherwise stable (SBP >120)
            a. Nitroglycerin 0.4mg SL or spray
            b. May be repeated every 5 minutes if symptoms are unrelieved and the vital
               signs remain stable.
     2. Aspirin (2) 81mg tablets chewed (total dose of 162mg)
     3. Obtain12-lead EKG.
     4. When 12-lead EKG indicates a ST-segment elevation myocardial infarction (STEMI):
             a. Transport the patient directly to a PCI capable Receiving Facility if the transport
                can be accomplished within 30 minutes, by either ground or air medical
                transport.
             b. Contact Medical Control at the PCI capable Receiving Facility to advise of a
                STEMI alert.
             c. Transmit 12-Lead EKG to the PCI capable Receiving Facility, if transmission
                capability exists.
             d. If transport to a PCI capable receiving facility cannot be accomplished within 30
                minutes, contact Medical Control to discuss whether or not the patient should
                be brought to the closest emergency department or if the patient should still be
                transported directly to the PCI capable Receiving Facility, by either ground or
                air medical transport.


                              EMT-CC/P’s Stop Here. Contact Medical Control.

                                   Medical Control Options
        Nitroglycerin                  0.4mg SL every 5 minutes if vital signs remain stable
        Nitroglycerin Ointment 2%      ½‖-2‖ to chest wall
        Morphine Sulfate               2-5mg IV slow push. Can be repeated up to a
                                        maximum of 15mg
        Lidocaine                      1mg/kg slow IVP
        Lidocaine                       0.5mg/kg IV bolus may be repeated in 2-5 minutes
                                         after the initial bolus
        Lidocaine                      infusion at 2-4mg/min
        Aspirin                        1-4 81mg tablets chewed
        Naloxone                       0.4mg-2mg IVP

                                 Medical Control Options
      Metoprolol                     5mg IV every 5 minutes to a maximum of 3 doses
                                      (15mg) provided heart rate remains greater than
                                      60bpm and systolic BP remains greater than 100
                                      mmHg
      Promethazine Hydrochloride     12.5mg-25mg IV
      Ondansetron HCl                4mg IV/IM

Adult Medical Protocol                                          Revised: September 13, 2010   AMP- 14
                 Hudson Valley Regional Emergency Medical Services Council, INC.
                     DRAFT Advanced Life Support Protocol Manual DRAFT
                                  - Continued on Next Page –
                                    Adult Medical Protocol-9
                                            (AMP-9)
                                Suspected Myocardial Infarction

 PCI capable Receiving facilities are those with 24/7 emergency interventional cardiac
 catheterization capabilities and include:

     Good Samaritan Hospital - Suffern
     Orange Regional Medical Center - Middletown
     St. Luke’s Cornwall Hospital - Newburgh
     Vassar Brothers Medical Center - Poughkeepsie
     Westchester Medical Center - Valhalla

     Danbury Hospital – Danbury, CT
     Greenwich Hospital – Greenwich, CT
     Norwalk Hospital – Norwalk, CT
     Stamford Hospital – Stamford, CT

     Albany Medical Center - Albany
     St. Peter’s Hospital - Albany




                                  - Continued on Next Page –




Adult Medical Protocol                                       Revised: September 13, 2010   AMP- 15
                 Hudson Valley Regional Emergency Medical Services Council, INC.
                     DRAFT Advanced Life Support Protocol Manual DRAFT
                            Adult Medical Protocol-9 (Continued)
                                           (AMP-9)
                 Thrombolytic Checklist for ST-Elevation Myocardial Infarction

Inclusion Criteria:
  Patient 18 years of age or older
  Patient presents with chest pain or anginal equivalent
  EKG confirmation of Acute Myocardial Infarction (ST-elevation of 1mm or more in two or more leads)
  Duration of symptoms is less than 6 hours
Absolute Contraindications:
  Previous hemorrhagic stroke at any time
  Other stroke or cerebrovascular events within past year
  Known intracranial neoplasm, arteriovenous malformation, or aneurysm
  Active internal bleeding (menses is NOT a contraindication)
  Suspected aortic dissection
  Severe uncontrolled hypertension (Systolic BP greater than 200, diastolic greater
   than 120 mmHg)
  Intracranial or intraspinal surgery or trauma within previous 2 months
Relative Contraindications:
   Hypertension: systolic BP greater than 180 mmHg and/or diastolic BP greater than 110mmHg
   History of cerebrovascular accident or other intra-cerebral pathology
   Current use of anticoagulants (e.g. Coumadin)
   Known bleeding disorders
   Recent trauma in past 2-4 weeks, including head trauma
   Recent major surgery or puncture or non-compressible vascular site
   Recent internal bleeding in past 2-4 weeks
   Active peptic ulcer
   History of chronic hypertension
   High likelihood of left heart thrombus (e.g. mitral stenosis with atrial fibrillation)
   Acute pericarditis
   Subacute bacterial endocarditis
   Hemostatic dysfunction
   Diabetic hemorrhagic retinopathy or other hemorrhagic ophthalmic conditions
   Septic thrombophlebitis or occluded AV cannula at seriously infected site
   Recent administration of GP 2b/3a inhibitors
   Very elderly, e.g. age greater than 75 years, at increased risk of intracranial hemorrhage
High Risk Patients:
  Patient presents with Tachycardia (≥100bpm)
  Patient presents with Hypotension (Systolic BP ≤100mmHg)
  Patient presents with signs of Shock
  Patient presents with signs of Pulmonary Edema




Adult Medical Protocol                                            Revised: September 13, 2010   AMP- 16
                 Hudson Valley Regional Emergency Medical Services Council, INC.
                     DRAFT Advanced Life Support Protocol Manual DRAFT
                                   Adult Medical Protocol-10
                                            (AMP-10)
                         Bradysrhythmia Including 3rd Degree Heart Block

                                           Considerations
      This protocol is indicated for any patient with any bradysrhythmia with a ventricular rate
       less than 60bpm and is hemodynamically unstable.
      Unstable denotes bradycardia combined with any of the following; chest pain, dyspnea,
       CHF, ischemia, infarction, altered mental status or hypotension (SBP<90).
      For any patient in a Second Degree Mobitz II or Third Degree Heart Block, omit step 1,
       and proceed directly to transcutaneous pacing.
      Consider Suspected Myocardial Infarction Protocol (AMP-9)



   1. Atropine 0.5mg IVP. If inadequate response within 3 minutes, administer Atropine 0.5mg
      IVP.
   2. If inadequate response to Atropine, consider initiating transcutaneous pacing.


                              EMT-CC/P’s Stop Here. Contact Medical Control.

                                       Medical Control Options
    Atropine                      0.5mg-1mg IVP every 3 minutes as above to a maximum of
                                   0.04mg/kg
      Transcutaneous pacing       consider sedation
      Diazepam                    5-10mg IV
      Morphine                    2-10mg IV
      Naloxone                    0.4-2mg IVP
      Midazolam                   0.5-4mg slow IVP
      IV Infusion                 normal saline (250-500cc rapid infusion), repeat as directed
      Dopamine HCL                400mg/250cc normal saline, initial rate 5-10mcg/kg/min
                                   titrated upwards every 5minutes in increments of 5mcg/kg/min
                                   until desired therapeutic effect is achieved to a maximum of
                                   25mcg/kg/min.
    Epinephrine 1:10,000          1mg/250cc normal saline (4mcg/ml) administer at
                                   2-10mcg/min titrated to SBP of 100




                                        Medical Control Options
    Calcium Chloride              250-500mg IVP, may be repeated to maximum of 1gram. Only
                                   indicated if there is likelihood of acute hyperkalemia,
                                   hypocalcemia, or calcium channel blocker toxicity.
    Glucagon                      1mg IV or IM, may be repeated. Only indicated if there is
                                   likelihood of beta-blocker toxicity.
Adult Medical Protocol                                                                     AMP- 17
                 Hudson Valley Regional Emergency Medical Services Council, INC.
                     DRAFT Advanced Life Support Protocol Manual DRAFT
                                 Adult Medical Protocol-11
                                          (AMP-11)
                    Acute Pulmonary Edema/Congestive Heart Failure
                                       Considerations
      CPAP is indicated for patients in Respiratory Distress associated with pulmonary
       edema/congestive heart failure and exhibiting one or more of the following:
           o   Retractions
           o   Cyanosis
           o   Respiratory rate > 28 bpm
           o   Pulse Oximetry <92%
      Consider Suspected Myocardial Infarction Protocol (AMP-9)



   1. Nitroglycerin 0.4mg SL or spray. If CPAP is available and indicated, proceed to step 2,
      otherwise nitroglycerine may be repeated every 5 minutes if the patient’s systolic BP is
      above 100
   2. If CPAP is available, the patient’s condition does not improve, and the patient meets the
      criteria for CPAP, apply CPAP at 5 cm H2O. If the patient’s status does not improve
      within 5 minutes, increase CPAP to a maximum of 10 cm H2O. Maintain SaO2>91%.
   3. Nitroglycerin 0.4mg SL or spray may be repeated every 5 minutes if the patient’s systolic
      BP is above 100
   4. Furosemide 40mg slow IVP



                               EMT-P’s Stop Here. Contact Medical Control.


                                     Medical Control Options
    Nitroglycerin                      0.4mg SL or spray
    Furosemide                         40-100mg IV bolus
    Morphine Sulfate                   2-5mg IV bolus; may be repeated up to a maximum
                                        dose of 15mg
      Nitroglycerin Ointment 2%        ½-2‖ to chest wall
      Naloxone                         0.4-2mg IVP
      Midazolam                        0.5-4mg slow IVP
      Lorazepam                        0.5-2mg IVP


                                     Medical Control Options
    CPAP                                5 cm H2O to a maximum of 10 cm H2O to maintain
                                         SaO2>91%




Adult Medical Protocol                                               Revised: March 3, 2008   AMP- 18
                 Hudson Valley Regional Emergency Medical Services Council, INC.
                     DRAFT Advanced Life Support Protocol Manual DRAFT
                                 Adult Medical Protocol-12
                                         (AMP-12)
                          Non-Traumatic Shock (Cardiogenic/Septic)


   1. IV infusion of 250cc normal saline; may be repeated as needed if SBP <100. Avoid in the
      presence of pulmonary edema


                              EMT-I/CC’s Stop Here. Contact Medical Control.

    In the event of communication failure, administer Dopamine 400mg/250cc normal saline,
     initiate drip at 5-10mcg/kg/min.If there is insufficient improvement in status, the infusion
     rate may be titrated upward every 5 minutes in increments of 5mcg/kg/min until desired
     therapeutic effect to a maximum of 25mcg/kg/min.



                               EMT-P’s Stop Here. Contact Medical Control.


                                      Medical Control Options
    Dopamine                      400mg/250cc normal saline, initiate drip at 5-10mcg/kg/min.
                                   If there is insufficient improvement in status, the infusion rate
                                   may be titrated upward every 5 minutes in increments of
                                   5mcg/kg/min until desired therapeutic effect to a maximum of
                                   25mcg/kg/min.
    IV infusion                   normal saline (250-500cc rapid infusion), repeat as directed.
                                   Avoid in the presence of pulmonary edema




Adult Medical Protocol                                                                       AMP- 19
                 Hudson Valley Regional Emergency Medical Services Council, INC.
                     DRAFT Advanced Life Support Protocol Manual DRAFT
                                  Adult Medical Protocol-13
                                          (AMP-13)
                                 Supraventricular Tachycardia
                                      Considerations
      Any wide complex tachycardia should be treated as ventricular tachycardia.
      Unstable denotes Supraventicular Tachycardia combined with any of the following; chest
       pain, dyspnea, CHF, ischemia, infarction, altered mental status, or hypotension
       (SBP<90).
      This protocol is indicated for patients with Supraventricular Tachycardia (ventricular rate
       150-250) with narrow (QRS < .10) complexes who are hemodynamically unstable.


   1. If unconscious, synchronized cardioversion at 100, 200, 300, 360 joules.
   2. If possible, ask the patient to perform a Valsalva maneuver (if necessary, this may be
      repeated).
                               EMT-CC’s Stop Here. Contact Medical Control.


   3. If rhythm regular, Adenosine 6mg IVP; if ineffective after 2 minutes, Adenosine 12mg
      IVP; repeat in two (2) minutes if needed one (1) time. Follow each dose of Adenosine
      with 20cc saline bolus.
   4. If Adenosine following full dosing is unsuccessful initiate synchronized cardioversion at
      100, 200, 300, 360 joules or equivalent biphasic energy.
   5. If conscious, may pre-medicate with Midazolam 2mg slow IVP; may repeat in 2 minutes if
      needed.

                               EMT-P’s Stop Here. Contact Medical Control.

                                  Medical Control Options
      Adenosine                     6mg or 12mg rapid IVP; if ineffective, may immediately
                                      repeat at 12mg bolus up to a total dose of 30mg; follow
                                      doses with 20cc saline bolus.
      Synchronized Cardioversion    100, 200, 300 or 360 joules or equivalent biphasic
                                     energy, consider sedation.
      Morphine Sulfate              2mg-5mg IV bolus (may be repeated up to maximum
                                      dose 15mg).
      Diazepam                      5-10mg IV bolus (not to exceed 5mg/min.).
      Vagal Maneuvers
      Midazolam                     0.5-2mg slow IVP.
      Naloxone                      0.4-2.0mg IVP

                                     Medical Control Options
    Amiodarone                         150mg/20cc normal saline IV bolus over 10 minutes.
    Amiodarone                         Infusion at 1mg/min
    Diltiazem                          15-25mg over 2 minutes, may be repeated after 15
                                         minutes.

Adult Medical Protocol                                                                     AMP- 20
                 Hudson Valley Regional Emergency Medical Services Council, INC.
                     DRAFT Advanced Life Support Protocol Manual DRAFT
                                   Adult Medical Protocol-14
                                           (AMP-14)
                                        Abdominal Pain

                                            Considerations
      The ALS provider must consider all abdominal pain to be acute.
      If the patient is a female of any age, the potential for an OB-GYN emergency must be
       considered; the ALS provider should then refer to Special Considerations Protocol-5
       (SCP-5) Toxemia of Pregnancy or Special Considerations-6 (SCP-6)
       Childbirth/Precipitous Delivery, if appropriate.
      Transport samples of products of conception, if applicable



   1. Keep patient NPO
   2. If patient has evidence of blood loss or signs of shock, refer to Traumatic/Non-traumatic
      Shock protocol, as appropriate.
   3. Prepare for transport.


                         EMT-I/CC/P’s Stop Here. EMT-P’s Contact Medical Control.


                                 Medical Control Options
    Consider Special Considerations Protocol-1 (SCP-1) Pain Management/Analgesia
    Promethazine Hydrochloride      12.5mg-25mg IV
    Ondansetron Hydrochloride       4mg IV




Adult Medical Protocol                                          Revised: September 13, 2010   AMP- 21
                 Hudson Valley Regional Emergency Medical Services Council, INC.
                     DRAFT Advanced Life Support Protocol Manual DRAFT
                                  Adult Medical Protocol-15
                                           (AMP-15)
                            Systemic Allergic Reactions/Anaphylaxis

                                       Considerations
      Epinephrine should be used with caution in patients with beta-blockers, cardiac disease,
       hypertension, or pregnancy.



   1. If signs of shock or imminent airway obstruction, administer Epinephrine 1:1,000 0.3mg
      SQ; may be repeated once after 5 minutes
   2. Administer Diphenhydramine 50mg IM or IV.
   3. If signs of shock, IV infusion of normal saline run wide open.


                         EMT-CC/P’s Stop Here. EMT-I/CC/P’s Contact Medical Control.


                                       Medical Control Options
    IV Infusion                          normal saline (250-500cc rapid infusion), repeat as
                                          directed


                                       Medical Control Options
    Epinephrine 1:10,000                 1mg/250cc normal saline, 1-2cc/min IV infusion, titrated
                                          to effect
    Epinephrine 1:1,000                  0.1-0.5mg is given subcutaneously. May be repeated
                                          every 5 minutes per Medical Control orders.
    Diphenhydramine                      25-50mg IM or IV.
    Albuterol                            2.5mg/3cc normal saline via nebulizer, repeat as
                                          directed
    Ipratropium                          0.5mg/3cc normal saline via nebulizer, repeat as
                                          directed
    Levalbuterol                         1.25mg/3cc normal saline via nebulizer, repeat as
                                          directed
    Dopamine Infusion                    400mg/250cc normal saline and started at
                                          5-10mcg/kg/min. then titrated to desired BP
                                          (maximum of 25mcg/kg/min.).
    Glucagon                             1mg IV or IM.
    Methylprednisolone                   125mg/50cc normal saline over 3-5 minutes.




Adult Medical Protocol                                                                    AMP- 22
                 Hudson Valley Regional Emergency Medical Services Council, INC.
                     DRAFT Advanced Life Support Protocol Manual DRAFT
                                   Adult Medical Protocol-16
                                           (AMP-16)
                                     Altered Mental Status

                                         Considerations
      Consider neurological, toxicological, or traumatic etiology
      For suspected Stroke, refer to AMP-21 Suspected Stroke



   1. Obtain a field glucometer reading.
   2. If unable to obtain a field glucometer reading, draw a blood sample for the hospital lab
      and contact medical control.
   3. For documented hypoglycemia:
          a. Administer Dextrose 50% 25 grams (50cc) IVP; if no response in 5 minutes, repeat
             Dextrose 50% 25 grams (50cc) IVP.
          b. When an IV route is unobtainable, administer Glucagon 1mg IM.
          c. If Dextrose 50% or Glucagon administered, administer Thiamine 100mg IM or slow
             IVP.
   4. For suspected narcotic overdose, administer Naloxone ET/IV/IM, to be administered in
      increments of 0.8mg doses until appropriate patient response (if suspected chronic
      narcotic user, initiate Naloxone at 0.4mg). Naloxone may be repeated up to 8mg.
   5. Airway control should be reconsidered if no response to medical interventions above.



                             EMT-CC/P’s Stop Here. Contact Medical Control.
                                    Medical Control Options
      Dextrose 50%         25 grams (50cc) IVP
      Glucagon             1mg IV or IM
      Thiamine             100mg IM or slow IVP
      Naloxone             0.4-2mg ET/IV/IM up to 8mg




Adult Medical Protocol                                                                AMP- 23
                 Hudson Valley Regional Emergency Medical Services Council, INC.
                     DRAFT Advanced Life Support Protocol Manual DRAFT
                                   Adult Medical Protocol-17
                                           (AMP-17)
                                          Overdose


   1. Treat dysrhythmias, hypotension, seizures, or altered mental state according to
      appropriate protocol.
   2. If known or suspected medication overdose, attempt to identify source and bring to
      hospital.


                             EMT-CC/P’s Stop Here. Contact Medical Control.


                                     Medical Control Options
      Naloxone                         0.4-2mg IV/IM/ET; up to 8mg.
      Dextrose 50%                     25 grams (50cc) IVP.
      Thiamine                         100mg slow IVP or IM.
      Activated Charcoal               1gm/kg PO.
      Sodium Bicarbonate               1-2mEq/kg slow IVP.
      Sodium Bicarbonate               44-132mEq in 250cc normal saline, run at 1cc/min.
      Glucagon                         1.0mg IV or IM, repeat as indicated.


                                     Medical Control Options
    Calcium Chloride                   250-1000mg slow IVP.




Adult Medical Protocol                                                                 AMP- 24
                 Hudson Valley Regional Emergency Medical Services Council, INC.
                     DRAFT Advanced Life Support Protocol Manual DRAFT
                                      Adult Medical Protocol-18
                                              (AMP-18)
                                           Toxic Exposure

If there is an exposure to or release of hazardous materials, prior to initiating patient care,
complete the following:
    1. Avoid entrance to and/or contact with contaminated environment.
    2. Call for rescue assistance from Fire/ Rescue/ HAZMAT
    3. In the event of or if there is likelihood for a Mass Casualty Incident (MCI), notify the appropriate
       local competent authority as per the specific county MCI plan and contact medical control.
    4. In a disaster situation where there is a KNOWN exposure to the release of nerve and/or
       organophosphate agents confirmed by a local competent authority (i.e., HAZMAT Team, County
       or State DOH, On-line Medical Control, Regional Poison Control Center), refer to Special
       Considerations Protocol 3 (SCP-3) ―Mark I Kit Administration‖.

                                       Patient Decontamination:
  Scenes containing hazardous materials (HAZMAT), or contaminated patients, should be separated
   into three zones; ―HOT‖, ―WARM‖, and ―COLD‖. The ―HOT‖ and ―WARM‖ zones require the highest
   level of Personal Protective Equipment (PPE) specified for the toxic agent identified. Gross
   decontamination of patients may begin, when indicated, in the ―HOT‖ zone by appropriately trained
   and equipped HAZMAT personnel with more complete decontamination achieved in the ―WARM‖
   zone. EMS lacking HAZMAT training and equipment will make contact with the patients in
   the “COLD” zone. At this point the usual dermal, respiratory, and optical PPE required for EMS
   operations should be sufficient to safely provide patient care.
  Patient triage will be initiated in the ―HOT‖ zone and continued in the ―WARM‖ zone by HAZMAT or
   other appropriately trained responders wearing the required PPE, as determined by the incident
   commander. Patient treatment should be conducted by EMS personnel in the ―COLD‖ zone.
  Personnel operating in the ―COLD‖ zone should be aware of the potential for ―Off-Gassing‖ of
   vapors from chemically contaminated clothing. Emergency Responders assisting evacuated victims
   of nerve agent and/or organophosphate agent exposure should avoid exposing themselves to
   cross-contamination by ensuring that they do not come into direct contact with the patient’s
   clothing.
                           EMT-I’s Stop Here. EMT-CC/P’s Contact Medical Control.

                                              Medical Control Options
      If there is a history of potential Organophosphate and/or Carbamate Insecticide exposure AND
       findings are consistent with parasympatholytic toxicity, administer Atropine 1mg IV or ET; may be
       repeated until signs of atropinization.
      If there is a history of potential Chlorine gas exposure AND findings are consistent with Chlorine
       gas toxicity (coughing, choking, or wheezing), combine 2ml Sodium Bicarbonate with 2ml of
       normal saline and administer via nebulizer; may repeat every 20 minutes.
      If there is a history of potential cyanide exposure AND findings are consistent with cyanide
       toxicity AND the facility provides the ―Cyanide Antidote Kit‖;
             o Administer Amyl Nitrite perls for 15 seconds, every 30 seconds until Sodium Nitrite is
                available.
             o Administer Sodium Nitrite 3%, 10ml IV over 4 minutes.
             o Administer Sodium Thiosulfate 25%, 50ml over 10 minutes.
      If findings are consistent with ocular irritant exposure;
             o Attempt to positively identify the involved substance;
             o Administer Tetracaine 2 drops in affected eye followed by irrigation of 1000cc Normal
                Saline (may use the Morgan Therapeutic Lens).

Adult Medical Protocol                                                                             AMP- 25
                 Hudson Valley Regional Emergency Medical Services Council, INC.
                     DRAFT Advanced Life Support Protocol Manual DRAFT
                                   Adult Medical Protocol-19
                                           (AMP-19)
                                     Hypertensive Crisis

                                            Considerations
      This protocol is only indicated if the patient presents with a diastolic BP of 130 or greater
       in both arms associated with symptoms such as nausea, vomiting, headache, and visual
       disturbances.


                             EMT-CC/P’s Stop Here. Contact Medical Control.



                                     Medical Control Options
    Furosemide             40mg-100mg IV
    Nitroglycerin          0.4mg SL or spray
    Nitroglycerin 2%       ½‖-2‖ to chest wall


                                    Medical Control Options
    Labetalol              10mg IV over 2 minutes; may repeat at 10-20mg after 10 minutes




Adult Medical Protocol                                                                       AMP- 26
                 Hudson Valley Regional Emergency Medical Services Council, INC.
                     DRAFT Advanced Life Support Protocol Manual DRAFT
                                   Adult Medical Protocol-20
                                           (AMP-20)
                                      Status Epilepticus

                                           Considerations
      This protocol is indicated for patients in Status Epilepticus (Two or more seizures without
       a lucid interval or a continuous seizure lasting more than 5 minutes).
      The administration of Diazepam or Lorazepam will be discontinued as soon as the
       seizure stops, whether or not the entire ordered dosage has been administered.
      In pregnant patient, consider Special Considerations Protocol-5 (SCP-5) Toxemia of
       Pregnancy.




   1. If the patient is having sustained seizures, administer Diazepam 10mg IV over 1-2
      minutes. If IV route not available, give rectally, via syringe without needle up to 10mg.
      Either route may be repeated once after 10 minutes.
                                                 Or
      Administer Lorazepam 2mg IV over 1-2 minutes. If IV route not available, administer
      Lorazepam 0.5mg/kg IM (to a maximum of 4mg). Either route may be repeated once after
      10 minutes.
   2. Obtain a field glucometer reading.
   3. If unable to obtain a field glucometer reading, draw blood sample for the hospital lab and
      contact medical control.
   4. For documented hypoglycemia:
           a. Dextrose 50% 25 grams (50cc) IVP or Glucagon 1mg IM, if IV not accessible.
           b. If Dextrose 50% or Glucagon administered, administer Thiamine 100mg slow IVP
              or IM.
   5. If above actions do not terminate seizure, or respirations are depressed, reconsider
      airway control.



                             EMT-CC/P’s Stop Here. Contact Medical Control.


                                     Medical Control Options
    Diazepam               5-10mg IV injection; may be repeated up to 20mg or rectally via
                            syringe without needle, up to 20mg.
    Lorazepam              2mg IV injection; may be repeated up to 4mg or IM injection at
                            0.5mg/kg up to 4mg.
    Dextrose 50%           25 grams (50cc) IVP
    Glucagon               1mg IV or IM
    Thiamine               100mg IM or slow IVP




Adult Medical Protocol                                                                     AMP- 27
                 Hudson Valley Regional Emergency Medical Services Council, INC.
                     DRAFT Advanced Life Support Protocol Manual DRAFT
                                    Adult Medical Protocol-21
                                            (AMP-21)
                                       Suspected Stroke

                                           Considerations
      This protocol is indicated for patients experiencing an acute episode of neurological
       deficit without any evidence of trauma.
      Refer to NYS DOH BLS Protocol M-17 Suspected Stroke.
      Do not delay transport to perform ALS procedures.
      Determine time of symptom onset.
      Contact receiving facility as soon as possible.

   1. Airway control procedures.
   2. Place patient on cardiac monitor.
   3. Neurological Assessment with the use of the Cincinnati Prehospital Stroke Scale (see
      below).
   4. Establish an IV of Normal Saline.
   5. Transport patient to a NYS DOH designated Stroke Center. Suspected stroke patients
      MUST be transported to closest appropriate hospital emergency department if any of the
      following apply:

               A. Patient is in cardiac arrest;
               B. Patient has an unmanageable airway;
               C. Patient has (an)other medical condition(s) that warrant(s) transport to the
                  closest appropriate hospital emergency department (ED) as per NYS and/or
                  Regional protocol;
               D. Total prehospital time (time from onset of patient’s signs and symptoms to
                  anticipated time of arrival at the Stroke Center) would exceed 2 hours;
               E. On-line Medical Control so directs.




                                EMT-I’s Stop Here. Contact Medical Control.




                                    - Continued on Next Page –




Adult Medical Protocol                                                                    AMP- 28
                 Hudson Valley Regional Emergency Medical Services Council, INC.
                     DRAFT Advanced Life Support Protocol Manual DRAFT
                            Adult Medical Protocol-21 (Continued)
                                          (AMP-21)
                                     Suspected Stroke

       6. Obtain a field glucometer reading. For documented hypoglycemia, refer to AMP-17
          Altered Mental Status.
       7. Obtain a 12-Lead ECG if possible.

                               EMT-CC/P’s Stop Here. Contact Medical Control.

                                   Medical Control Options
    For systolic blood pressure greater than 220mm Hg or diastolic blood pressure greater
     than 120mm Hg (in both arms) administer:

           1.) Labetalol                   5mg IV over 2 minutes; may repeat at 5-20mg after
                                           10 minutes.

                                                                -OR-

               Metoprolol                  5mg IV every 5 minutes to a maximum of 3 doses
                                           (15mg) provided heart rate remains greater than
                                           60bpm and systolic BP remains greater than 100
                                           mmHg.

           2.) Nitroglycerin Ointment 2%   1 inch transdermal




                             Cincinnati Pre-Hospital Stroke Scale
       1. Assess for facial droop: have the patient show their teeth or ask the patient to
          smile.
       2. Assess for arm drift: have the patient close their eyes and hold both arms
          straight out for 10 seconds.
       3. Assess for abnormal speech: have the patient say, “you can’t teach an old dog
          new tricks.”




Adult Medical Protocol                                                                 AMP- 29
                 Hudson Valley Regional Emergency Medical Services Council, INC.
                     DRAFT Advanced Life Support Protocol Manual DRAFT
                               Adult Medical Protocol-Supplement

                                      Assorted Infusion Charts
                     Drug                    Preparation                  Rate
              Amiodarone (3mg/cc)         150mg in 50cc NS        0.5mg/min=10gtts/min
              Dopamine (800μg/cc)         200mg in 250cc NS      200mcg/min=15gtts/min
                                                                 400mcg/min=30gtts/min
                                                                 600mcg/min=45gtts/min
                                                                 800mcg/min=60gtts/min
              Dopamine (1600μg/cc)        400mg in 250cc NS      400mcg/min=15gtts/min
                                                                 800mcg/min=30gtts/min
                                                                 1200mcg/min=45gtts/min
                                                                 1600mcg/min=60gtts/min
              Epinephrine (4mcg/cc)        1mg in 250cc NS         2mcg/min=30gtts/min
               Lidocaine (4mg/cc)           1G in 250cc NS         1mg/min=15gtts/min
                                                                   2mg/min=30gtts/min
                                                                   3mg/min=45gtts/min
                                                                   4mg/min=60gtts/min




                                 Glasgow Coma Scale             Adult
                                             Eye Opening
                                      Spontaneously               4
                                      To Command                  3
                                         To Pain                  2
                                      No Response                 1
                                         Best Verbal Response
                                        Orientated                5
                                        Confused                  4
                                  Inappropriate Words             3
                                    Incomprehensible              2
                                      No Response                 1
                                         Best Motor Response
                                   Obeys Commands                 6
                                      Localized pain              5
                                  Withdraws from Pain             4
                                  Flexion (decorticate)           3
                                Extension (decerebrate)           2
                                      No Response                 1
                            Is the GCS less than 8? Consider Intubation




Adult Medical Protocol                                        Revised: September 13, 2010   AMP- 30
Advanced Life Support Protocols
        Adult-Trauma
                Hudson Valley Regional Emergency Medical Services Council, INC.
                    DRAFT Advanced Life Support Protocol Manual DRAFT
                                     Adult Trauma Protocol-1
                                             (ATP-1)
                                          Major Trauma

                                            Indications
For patients presenting with any of the following physical findings which are directly attributed
to a traumatic event:
   1. Glasgow Coma Scale is less than or equal to 13
   2. Respiratory rate is less than 10 or more than 29 breaths per minute
   3. Pulse rate is less than 50 or more than 120 beats per minute
   4. Systolic blood pressure is less than 90mmHg
   5. Penetrating injury to the head, neck, torso or proximal extremities
   6. Two or more suspected proximal long bone fractures
   7. Suspected flail chest
   8. Suspected spinal cord injury or limb paralysis
   9. Amputation (except digits)
   10. Suspected pelvic fracture
   11. Open or depressed skull fracture
   12. Facial / Airway Burns, Electrical Burns, or Burns >15% BSA
                   Or, if there is evidence of the following mechanism of injury:
   A.   Ejection or partial ejection from an automobile
   B.   Death in the same passenger compartment
   C.   Extrication time in excess of 20 minutes
   D.   Vehicle collision resulting in 12 inches of intrusion in to the passenger compartment
   E.   Motorcycle crash >20 MPH or with separation of rider from motorcycle
   F.   Falls from greater than 20 feet (or 3 times the patients height)
   G.   Vehicle rollover (90 degree vehicle rotation or more) with unrestrained passenger
   H.   Vehicle vs. pedestrian or bicycle collision above 5 MPH


Initiate New York State Basic Life Support Adult Treatment Protocol for “Adult Major
Trauma” and;
    1. Initiate transportation as soon as possible according to Adult Trauma Protocol 9
        (ATP-9) “Trauma Transport Protocol”; Consider Air Medical Transport;
    2. Establish IV access and initiate infusion of Normal Saline according to the
        appropriate protocol;
    3. Refer to appropriate protocol for further treatment as necessary;
    4. Contact medical control as soon as practical.

                                          Considerations
       Initiating IV therapy should not delay transport. If transportation is unavoidably delayed,
        IV therapy may be started prior to transport.
       A high index of suspicion must exist for hidden injuries even if the patient is initially
        hemodynamically stable.



Adult Trauma Protocol                                                                        ATP-     1
                Hudson Valley Regional Emergency Medical Services Council, INC.
                    DRAFT Advanced Life Support Protocol Manual DRAFT
                                     Adult Trauma Protocol-2
                                             (ATP-2)
                                       High Risk Patients

If a patient does not meet Major Trauma criteria but has sustained an injury and has one
           or more of the following “High Risk” criteria, contact medical control:
    Bleeding disorders or patients who are on anticoagulant medications
    Cardiac disease and/or respiratory disease
    Insulin dependant diabetes, cirrhosis, or morbid obesity
    Immunosuppressed patients (HIV disease, transplant patients, and patients on
       chemotherapy treatment)
    Age >55

                                          Considerations
      A high index of suspicion must exist for hidden injuries even if the patient is initially
       hemodynamically stable.

                               EMT-I/CC/P’s Stop Here. Contact Medical Control


                                  Medical Control Options
    Initiate transport to a Trauma Center
    IV access




Adult Trauma Protocol                                                                          ATP-   2
                Hudson Valley Regional Emergency Medical Services Council, INC.
                    DRAFT Advanced Life Support Protocol Manual DRAFT
                                    Adult Trauma Protocol-3
                                            (ATP-3)
                                 Traumatic/Hypovolemic Shock

                                          Considerations
      For the purpose of this protocol, shock is defined as:
   1. Systolic BP of 90mmHg or less; Or
   2. Systolic BP above 90mmHg and any of the following;
           a. Altered mental state (restlessness, inattention, confusion, agitation)
           b. Tachycardia (pulse greater than 100)
           c. Pallor
           d. Cold, clammy skin
      Do not allow procedures to delay transport. If transport is unavoidably delayed, IV’s may
       be started prior to transport.




   1. If there is evidence of significant mechanism of injury and/or physical findings
      meeting Major Trauma criteria but the patient does not present with signs of
      shock, establish IV access with one (1) large bore IV and run at KVO rate.
   2. If the patient presents with signs of shock, establish IV access with two (2) large
      bore IV’s and initiate infusion of Normal Saline. Infuse at a rate appropriate to keep
      BP above 90mmHg.




Adult Trauma Protocol                                                                    ATP-   3
                Hudson Valley Regional Emergency Medical Services Council, INC.
                    DRAFT Advanced Life Support Protocol Manual DRAFT
                                   Adult Trauma Protocol-4
                                           (ATP-4)
                        Traumatic/Hypovolemic Cardiopulmonary Arrest


   1. Basic Life Support is initiated
   2. Airway control
   3. Transportation is initiated. If the patient is accessible, time on scene should not
      exceed 10 minutes.
   4. Begin rapid infusion of Normal Saline via large bore catheter. Begin second
      infusion if possible. IV attempts should not delay transport from the scene.
   5. Initiate the appropriate cardiac arrest protocol.


                                         Considerations
      Document total fluid infused on the pre-hospital care report.




Adult Trauma Protocol                                                                ATP-   4
                Hudson Valley Regional Emergency Medical Services Council, INC.
                    DRAFT Advanced Life Support Protocol Manual DRAFT
                                  Adult Trauma Protocol-5
                                          (ATP-5)
                                  Tension Pneumothorax


   1. Airway control procedures


                                        EMT-I’s Stop Here.


   2. Perform pleural decompression using large bore over-the-needle catheter if there
      is evidence of the following signs resulting from suspected trauma:

           a. Respiratory distress with absent lung sounds;
                                 AND
           b. Cardiovascular compromise;
                 i. Cardiopulmonary arrest
                ii. Hypotension




Adult Trauma Protocol                                                             ATP-   5
                Hudson Valley Regional Emergency Medical Services Council, INC.
                    DRAFT Advanced Life Support Protocol Manual DRAFT
                                    Adult Trauma Protocol-6
                                            (ATP-6)
                                          Head Trauma

                                         Considerations
      Consider neurological, toxicological, or medical etiology.



 1. If unconscious, airway control and ventilate at 12-16 respirations/minute. If signs of
    cerebral herniation develop, increase ventilation rate to 20 respirations/minute.
 2. If signs of shock, refer to Shock Protocol. (Traumatic or Non-traumatic, as
    appropriate.)

                                           EMT-I’s Stop Here.



 3. If there is clinical documentation of hypoglycemia associated with
    unconsciousness, administer Dextrose 50% 50cc IV.
 4. If there is clinical indication of narcotic use associated with unconsciousness,
    administer Naloxone ET/IV/IM, to be administered in increments of 0.8mg doses until
    appropriate patient response (if suspected chronic narcotic user, initiate Naloxone
    at 0.4mg). Naloxone may be repeated up to 8mg.


                            EMT-CC’s Stop Here. Contact Medical Control.

                                       Considerations
      RSI credentialed paramedics may refer to Special Considerations Protocol 2 (SCP-2)
       ―Medication Facilitated/Rapid Sequence Intubation‖ as necessary


                             EMT-P’s Stop Here. Contact Medical Control.

                                    Medical Control Options
    Naloxone               0.4-2mg IV, ET, or IM; may be repeated to a total of 8mg.
    Dextrose 50%           50cc IV.
    Thiamine               100mg IM or IV.




Adult Trauma Protocol                                                                   ATP-   6
                Hudson Valley Regional Emergency Medical Services Council, INC.
                    DRAFT Advanced Life Support Protocol Manual DRAFT
                                   Adult Trauma Protocol-7
                                           (ATP-7)
                                            Burns


   1. Determine the type of burn and percentage of body surface area (BSA) as soon as
      possible;
   2. For thermal burns, stop the burning process and proceed to step 5.
   3. For electrical burns, ensure that the patient is not in contact with the source of
      current and proceed to step 5.
   4. For chemical burns, consider Adult Medical Protocol 19 (AMP-19) “Toxic
      Exposure” and proceed to step 5.
   5. If there is evidence of smoke inhalation, carbon monoxide poisoning, or airway
      burns, refer to Adult Medical Protocol-3 (AMP-3) “Respiratory Distress” or Adult
      Medical Protocol-1 (AMP-1) “Imminent Respiratory Arrest” as necessary.
   6. Transport. Consider transportation to the Regional Trauma Center as indicated by
      Adult Trauma Protocol 9 (ATP-9) “Trauma Transport Protocol”. Consider Air
      Medical Transport;
   7. Initiate IV access with large bore IV (avoid burn tissue if possible) and Normal
      Saline at KVO; If >15% BSA burn estimate, initiate infusion at 100cc/hr. If transport
      is delayed, IV access may be obtained prior to transport.


                            EMT-I/CC/P’s Stop Here. Contact Medical Control.


                                   Medical Control Options
    Adjust IV Rate




                                Medical Control Options
    Special Considerations Protocol-1 (SCP-1) ―Pain Management / Analgesia‖




                                 - Continued on Next Page -

Adult Trauma Protocol                                                               ATP-      7
                Hudson Valley Regional Emergency Medical Services Council, INC.
                    DRAFT Advanced Life Support Protocol Manual DRAFT
                            Adult Trauma Protocol-7 (Continued)
                                          (ATP-7)
                                           Burns
                        Estimation of Body Surface Area Involvement




Adult Trauma Protocol                                                             ATP-   8
                Hudson Valley Regional Emergency Medical Services Council, INC.
                    DRAFT Advanced Life Support Protocol Manual DRAFT
                                   Adult Trauma Protocol-8
                                            (ATP-8)
                                  Isolated Extremity Trauma

                                        Considerations
   o For presenting Crush Injuries:
       Medical Control contact should be made as soon as practical;
       If prolonged extrication is anticipated, consider initiating two large bore IV’s
       Consider 12-Lead EKG


                            EMT-CC/P’s Stop Here. Contact Medical Control.



                                Medical Control Options
    Special Considerations Protocol-1 (SCP-1) ―Pain Management / Analgesia‖
    Sodium Bicarbonate               50 mEq IV
    Sodium Bicarbonate               50 mEq in 1 liter of normal saline, infused at 1.5L/hr




Adult Trauma Protocol                                                                      ATP-   9
                   Hudson Valley Regional Emergency Medical Services Council, INC.
                       DRAFT Advanced Life Support Protocol Manual DRAFT
                                           Adult Trauma Protocol-9
                                                   (ATP-9)
                                       Major Trauma Transport Protocol
                                                        Considerations
       Patients meeting Major Trauma criteria should be transported to the nearest designated Regional or Area Trauma
        Center if the time elapsed between the estimated time of injury and the estimated time of arrival at the Trauma Center
        is less than one hour.
       If the transport time from the scene to the trauma center is more than 30 minutes, CONTACT MEDICAL CONTROL.
       Transport the patient to the nearest hospital emergency department if the patient is in cardiac arrest, has an
        unmanageable airway, or if an on-line medical control physician so directs.

                              PHYSICAL FINDINGS Suspected to be Caused by Trauma
                         Glasgow Coma Scale is less than or equal to 13
                         Respiratory rate is less than 10 or more than 29 breaths per minute
                         Pulse rate is less than 50 or more than 120 beats per minute
                         Systolic blood pressure is less than 90mmHg

                                                   PHYSICAL FINDINGS
                         Penetrating injury to the head, neck, torso or proximal extremities
                         Two or more suspected proximal long bone fractures
                         Suspected flail chest
                         Suspected spinal cord injury or limb paralysis
                         Amputation (except digits)
                         Suspected pelvic fracture
                         Open or depressed skull fracture
                         Suspected head injury resulting in neurological compromise
                         Facial / Airway Burns, Electrical Burns, or Burns >15% BSA
                         YES                                                            NO
                                                                                        
  Transport To Nearest Regional Or Area Trauma Center                                 Evaluate Mechanism Of Injury

                                                   MECHANISM OF INJURY
                 Ejection or partial ejection from an automobile
                 Death in the same passenger compartment
                 Extrication time in excess of 20 minutes
                 Vehicle collision resulting in (12 inches of intrusion in to the passenger compartment, steering
                  wheel displacement, and/or starred windshield
                 Motorcycle/ATV/Bicycle crash >20 MPH or with separation of rider
                 Falls from greater than 20 feet (or 3 times the patients height)
                 Vehicle rollover (90 degree vehicle rotation or more) with unrestrained passenger
                 Vehicle vs. pedestrian or bicycle collision above 5 MPH
                              YES                                                       NO
                                                                                       

         Transport To Nearest Regional Or Area Trauma Center              Transport To Nearest Hospital Emergency Department

The following should be transported directly to the Regional Trauma Center provided the time elapsed between the
estimated time of injury and the estimated time of arrival at the Regional Trauma Center is less than one hour.
     Pediatric Trauma Patients < 12 Y/O
     Thoracic Trauma with Respiratory Distress or Signs of Shock
     Limb Amputation / Severe Crushing Injury Requiring Reimplantation or Reconstruction
     Unstable Multi Systems Trauma with Associated Open Pelvic Fracture
     Facial / Airway Burns, Electrical Burns, or Burns >15% BSA

If a patient does not meet Major Trauma criteria but has sustained an injury and has one or more of the following “High
Risk” criteria, CONTACT MEDICAL CONTROL:
      Patients with Bleeding Disorder (Hemophilia, Anticoagulants)
      Cardiac and/or Respiratory Disease
      Insulin Dependant Diabetes, Cirrhosis or Morbid Obesity
      Immunosuppressed Patient (HIV Disease, Transplant Patients and Patients on Chemotherapy Treatment)
      Age >55 Y/O
      Pregnancy


Adult Trauma Protocol                                                                                                ATP- 10
                Hudson Valley Regional Emergency Medical Services Council, INC.
                    DRAFT Advanced Life Support Protocol Manual DRAFT
                             Adult Trauma Protocol-Supplement

                               Glasgow Coma Scale             Adult
                                           Eye Opening
                                    Spontaneously               4
                                    To Command                  3
                                       To Pain                  2
                                    No Response                 1
                                       Best Verbal Response
                                      Orientated                5
                                      Confused                  4
                                Inappropriate Words             3
                                  Incomprehensible              2
                                    No Response                 1
                                       Best Motor Response
                                 Obeys Commands                 6
                                    Localized pain              5
                                Withdraws from Pain             4
                                Flexion (decorticate)           3
                              Extension (decerebrate)           2
                                    No Response                 1
                          Is the GCS less than 8? Consider Intubation




Adult Trauma Protocol                                                             ATP- 11
Advanced Life Support Protocols
     Special Considerations
                 Hudson Valley Regional Emergency Medical Services Council, INC.
                     DRAFT Advanced Life Support Protocol Manual DRAFT
                                   Special Considerations Protocol-1
                                               (SCP-1)
                                     Pain Management / Analgesia

                                           Considerations
      This protocol is indicated if the patient is experiencing pain due to fractures/dislocations,
      burns (without airway involvement), significant crushing injuries to limbs, abdominal pain
                    (without suspected obstruction), renal colic, and cancer pain.


                                  Pain Management Using Nitrous Oxide

   Following implementation of the appropriate ALS protocol, this protocol may be
   considered for pain management by those paramedic services that choose to carry
   nitrous oxide.

   Contraindications: altered mental status, head trauma (with or without mental status
   change), inebriation, overdose, hypotension, neurological deficit, COPD, dyspnea,
   baro-trauma, abdominal distention, decompression sickness, airway burns, use of
   Viagra within past 24 hours.

       1. Administer Nitrous Oxide 50/50 using self-administration technique (have
          patient hold the mask and self administer the gas). Patient should continue to
          inhale gas until relief is felt.


                             EMT-P’s Stop Here. Contact Medical Control.

                                        Medical Control Options
       Adult Administration:
        Morphine Sulfate              2-10mg IVP
        Naloxone                      0.4-2mg IVP



                                        Medical Control Options
     Pediatric Administration:
       Morphine Sulfate       0.05mg/kg IVP, to a maximum single dose of 2.5mg
       Naloxone               0.1mg/kg ET/IVP/IM to a maximum dose of 2mg




Special Considerations Protocol                                                              SCP-     1
                 Hudson Valley Regional Emergency Medical Services Council, INC.
                     DRAFT Advanced Life Support Protocol Manual DRAFT
                               Special Considerations Protocol-2
                                             (SCP-2)
                        Medication Facilitated/Rapid Sequence Intubation

                                          Considerations
                                             Indications
   Any patient who requires emergency airway control as indicated by:
    1. Inability of the conscious patient in respiratory compromise to oxygenate/ventilate
        adequately
    2. Inability of the patient to protect the airway (i.e., GCS 3-8)
    3. Inability of the paramedic to oxygenate/ventilate the unresponsive patient with
        noninvasive techniques
    4. Objective evidence of imminent airway compromise (i.e., intra-oral burns, laryngeal
        stridor, progressive upper airway obstruction)
   AND
   Who may be difficult to intubate by conventional methods because of:
    1. Trismus
    2. Status Epilepticus
    3. Agitation/Combativeness
   AND
   For whom transport to the nearest hospital is likely to be greater than 10 minutes.
                                        Contraindications
   Paramedic concern that both intubation and mask ventilation may not be successful due to
   major laryngeal trauma, upper airway obstruction, and/or distorted facial or airway anatomy.

   Patients who present with the following should be discussed with Medical Control for
   substitution of Vecuronium for Succinylcholine:
     Penetrating eye injuries
     Hyperkalemia or renal failure
     Neuromuscular disorders (paraplegia, M.D., etc.)
     Pseudocholinesterase deficiency
     4 days or more since crush injury or burn


                                    Administration
   Preparation
    1. Assemble all equipment and medications
   Pre-oxygenation (T-5 minutes)
    1. Pulse oximetry is applied
   Pre-medication I (T-3 minutes)
    1. Lidocaine 1.0mg/kg slow IVP if head injury or suspected elevated ICP
    2. Atropine 0.5mg IVP if pulse <60bpm
   Pre-medication II (T-1 minutes)
    1. Etomidate 0.3mg/kg IVP
    2. Apply Sellick maneuver
   Paralytic (T-0 minutes)
    1. Succinylcholine 1.5mg/kg IVP
                                    - Continued on next page -
Special Considerations Protocol                                                           SCP-    2
                 Hudson Valley Regional Emergency Medical Services Council, INC.
                     DRAFT Advanced Life Support Protocol Manual DRAFT
                         Special Considerations Protocol-2 (Continued)
                                             (SCP-2)
                        Medication Facilitated/Rapid Sequence Intubation

   Once jaw laxity is demonstrated
    1. Intubate, BVM with 100% O2
    2. May use Atropine as per Bradycardia Protocol if pulse <60bpm
    3. May repeat Succinylcholine 1.5mg/kg IVP if paralysis is not adequate
   If unable to intubate after two (2) attempts
      1. Maintain airway control.
   Post-Intubation
      1. Confirm tube placement with:
          a. Direct visualization
          b. End-tidal CO2 monitoring. Continuous CO2 monitoring is recommended.
          c. Pulse oximetry
          d. Auscultation
   If tube placement is confirmed and patient shows signs of increasing levels of
   consciousness, administer Midazolam 2.0mg IV increments to sedation, then
   Vecuronium 0.1mg/kg IVP.
   Transport


                           RSI Credentialed EMT-P’s Stop Here. Contact Medical
                       Control.
                               Medical Control Options
      Vecuronium 0.1-0.3mg/kg IVP
      Midazolam 2.0mg IV increments to sedation




Special Considerations Protocol                                                    SCP-   3
                 Hudson Valley Regional Emergency Medical Services Council, INC.
                     DRAFT Advanced Life Support Protocol Manual DRAFT
                                  Special Considerations Protocol-3
                                              (SCP-3)
                                            Mark I Kit Use

                                           Considerations
Purpose:
To provide guidelines to Emergency Medical Services (EMS) personnel for the use of antidotes
in instances of exposure to nerve agents or organophosphate agents.

Mark I Kit Contents:
   1. Atropine Auto-Injector (2mg total dose per injection).
   2. Pralidoxime Chloride (2-PAM CL) Auto-Injector (600mg total dose per injection).

Use:
   1. Mark I Kits are to be used only in a disaster situation where there is a KNOWN exposure
      to the release of nerve and/or organophosphate agents confirmed by a local competent
      authority (i.e., HAZMAT Team, County or State DOH, On-line Medical Control, Regional
      Poison Control Center).
   2. Patients exposed to other parasympatholytic agents may be treated in compliance with
      HVREMS ALS Adult Medical Protocol-19 (AMP-19) or Pediatric Medical Protocol-13
      (PMP-13), Toxic Exposure as appropriate.
   3. Mark I Kits may only be administered by qualified EMS personnel who have had the
      minimum required WMD awareness training in on-site recognition and treatment of nerve
      and/or organophosphate agent intoxication (i.e., Department of Defense, Department of
      Justice, or Federal Emergency Management Agency Training).
   4. Mark I Kits are to be used only by EMS agencies that are part of the MMRS and/or a
      Municipal Response Plan.
   5. Mark I Kits are to be used only under the authority of Direct (On-line) Medical Control.
   6. ALS agencies may carry additional doses of Atropine during periods of heightened
      Federal Terrorism Threat Levels.
Note: Mark I auto injectors are not to be used as a prophylactic modality. There is to be
no self-administration of the antidote. In the event that EMS personnel become exposed
to nerve and/or organophosphate agents, they must leave the contaminated area and
seek immediate medical attention.




                                     - Continued on next page -
Special Considerations Protocol                                                         SCP-   4
                 Hudson Valley Regional Emergency Medical Services Council, INC.
                     DRAFT Advanced Life Support Protocol Manual DRAFT
                          Special Considerations Protocol-3 (Continued)
                                             (SCP-3)
                                         Mark I Kit Use

                                         Considerations
Patient Decontamination:
Scenes containing hazardous materials (HAZMAT), or contaminated patients, should be
separated into three zones; ―HOT‖, ―WARM‖, and ―COLD‖. The ―HOT‖ and ―WARM‖ zones
require the highest level of Personal Protective Equipment (PPE) specified for the toxic agent
identified. Gross decontamination of patients may begin, when indicated, in the ―HOT‖ zone by
appropriately trained and equipped HAZMAT personnel with more complete decontamination
achieved in the ―WARM‖ zone. EMS lacking HAZMAT training and equipment will make
contact with the patients in the “COLD” zone. At this point the usual dermal, respiratory, and
optical PPE required for EMS operations should be sufficient to safely provide patient care.
Patient triage will be initiated in the ―HOT‖ zone and continued in the ―WARM‖ zone by HAZMAT
or other appropriately trained responders wearing the required PPE, as determined by the
incident commander. Patient treatment should be conducted by EMS personnel in the ―COLD‖
zone, but Mark I Kits may be administered simultaneous with and/or prior to decontamination by
properly trained and PPE equipped personnel in the ―WARM‖ zone if exposure symptoms are
present. Children should be decontaminated and have expedited transport off scene especially
if they are demonstrating ANY signs and symptoms of exposure.
Note: Personnel operating in the “COLD” zone should be aware of the potential for “Off-
Gassing” of vapors from chemically contaminated clothing. Emergency Responders
assisting evacuated victims of nerve agent and/or organophosphate agent exposure
should avoid exposing themselves to cross-contamination by ensuring that they do not
come into direct contact with the patient’s clothing.

Indications:
Mark I auto-injectors are to be used only if the patient presents with SLUDGEM +
RESPIRATIONS + AGITATION.
S – Salivation (excessive drooling)            + RESPIRATION
L - Lacrimation (tearing)                      (Difficulty Breathing/Respiratory Distress)
U – Urination
D – Defecation/diarrhea
G – Gastrointestinal aggravation (cramps)      + AGITATION
E – Emesis (vomiting)                          (CNS Signs – Agitation, Confusion,
M – Muscle twitching                           Seizures, Coma.)




                                   - Continued on next page –

Special Considerations Protocol                                                          SCP-   5
                 Hudson Valley Regional Emergency Medical Services Council, INC.
                     DRAFT Advanced Life Support Protocol Manual DRAFT
                          Special Considerations Protocol-3 (Continued)
                                             (SCP-3)
                                         Mark I Kit Use

Adult Administration:
   1. Initiate Initial ALS Care (ACP-1);
   2. If BLS airway management is inadequate, 100% Oxygen with BVM and initiate ALS
      airway management (if available);
   3. If the patient has had a KNOWN exposure to the release of a nerve agent and/or
      organophosphate agent, depending on the level of exposure symptoms,
      administer:
              Exposure         Signs and         Atropine Dose      2 Pam Cl
                               Symptoms                               Dose
                           SLUDGEM,         3 Stacked Doses =6mg 3 Stacked
                           Severe           Repeat 2mg q3-5 min  Doses=1.8G
                           Respiratory      PRN
               Severe      Distress,
                           Unconsciousness,
                           Seizures,
                           Confusion
                           SLUDGEM,         2 Stacked Doses=4mg 2 Stacked
                           Respiratory      Repeat 2mg q5-10 min Doses=1.2G
              Moderate Distress, Agitation PRN


                              SLUDGEM,       1 Dose=2mg           1
                  Mild        Agitation      Repeat 2mg q5-15 min Dose=600mg
                                             PRN
Note: Always Administer Atropine BEFORE Pralidoxime Chloride (2-PAM CL)
   4. If an exposure is suspected, but the patient is asymptomatic, DO NOT administer
      Mark I auto injectors, but monitor the patient for any changes;
   5. ALS Personnel should refer to HVREMS ALS Adult Medical Protocol-21 (AMP-21)
      Status Epilepticus for the treatment of patients presenting with continuous
      seizures;
   6. Monitor the patient for adverse reaction/deterioration and transport to the
      appropriate hospital for definitive care.




                                   - Continued on next page -
Special Considerations Protocol                                                    SCP-   6
                 Hudson Valley Regional Emergency Medical Services Council, INC.
                     DRAFT Advanced Life Support Protocol Manual DRAFT
                     Special Considerations Protocol-3 (Continued)
                                         (SCP-3)
                                     Mark I Kit Use
Pediatric Administration (Age < 15 Year of Age):
   1. Initiate Initial ALS Care (ACP-1);
   2. If BLS airway management is inadequate, 100% Oxygen with BVM and initiate ALS
      airway management (if available);
   3. If the patient has had a KNOWN exposure to the release of a nerve agent and/or
      organophosphate agent, depending on the level of exposure symptoms,
      administer:
              Exposure         Signs and          Atropine Dose    2 Pam Cl
            Age 0-10YRS        Symptoms                              Dose
                           SLUDGEM,          1 Dose =2mg        1 Dose=600
                           Severe                               mg
                           Respiratory
               Severe      Distress,
                           Unconsciousness,
                           Seizures,
                           Confusion
                           SLUDGEM,          Medical Control    Medical
                           Respiratory       Option Only        Control
           Moderate/Mild Distress, Agitation 0.5mg – 1.0mg IM   Option Only
                                                                15mg/kg IM


              Exposure        Signs and           Atropine Dose         2 Pam Cl
            Age 11-14YRS      Symptoms                                    Dose
                          SLUDGEM,            2 Doses =4mg           2 Doses=1.2G
                          Severe
                          Respiratory
              Severe      Distress,
                          Unconsciousness,
                          Seizures,
                          Confusion
                          SLUDGEM,            1 Dose =2mg            1 Dose
                          Respiratory                                =600mg
            Moderate/Mild Distress, Agitation


        Note: Always Administer Atropine BEFORE Pralidoxime Chloride (2-PAM CL)
   4. If an exposure is suspected, but the patient is asymptomatic, DO NOT administer
      Mark I auto injectors, but monitor the patient for any changes;
   5. ALS Personnel should refer to HVREMS ALS Pediatric Medical Protocol-16 (PMP-
      16) Status Epilepticus for the treatment of patients presenting with continuous
      seizures;
   6. Monitor the patient for adverse reaction/deterioration and transport to the
      appropriate hospital for definitive care.

Special Considerations Protocol                                                     SCP-   7
                  Hudson Valley Regional Emergency Medical Services Council, INC.
                      DRAFT Advanced Life Support Protocol Manual DRAFT
                                     Special Considerations Protocol-4
                                                 (SCP-4)
                                       Emergency Incident REHAB
                                                     Indications
This protocol is to be implemented in conjunction with pre-established standard operating procedures that address
REHAB implementation, coordination, location, staffing, and accountability. This protocol is intended to provide ALS
personnel guidelines to evaluate the physical and mental status of rescue personnel who have been working during
an emergency incident or training exercise and to determine what medical treatment, if any, may be necessary.

                                                  Considerations
           Rescue personnel should have their baseline vital signs obtained prior to involvement in an incident.
           Rescue personnel should be kept well hydrated and rested to minimize heat exhaustion and/or fatigue.
           Upon arriving at the REHAB medical evaluation/treatment area, all SCBA and turnout gear should be
            removed from rescue personnel prior to exam.
           Continuous medical evaluation should be provided to identify early signs of heat or stress related
            illnesses.
           Documentation (including name, time, vitals, and triage disposition) should be completed for all
            personnel entering the REHAB medical evaluation/treatment area. A PCR should be completed for all
            patients meeting triage disposition #3 whether or not they are transported to the hospital.

Any of the following findings indicate mandatory triage to the REHAB medical evaluation/treatment area:
         Heart Rate >120
         Blood Pressure >200 systolic; <90 systolic; >110 diastolic
         Body temperature >100.6F
         Injury of any type
Personnel with any of the above findings should be treated as follows:
        1. Provide a minimum of 20 minutes cool down/rest time;
        2. Provide oral rehydration and nourishment as necessary;
        3. Treat minor injuries as necessary, take vital signs every 5 minutes and document accordingly;
        4. Reevaluate status after minimum cool down/rest time and triage accordingly.

                                                  Triage Dispositions:
        1. Adequately rehabbed/medically sound/vitals within criteria limits – Return to duty
        2. Vitals remain outside of criteria limits after initial REHAB treatment – Repeat REHAB treatment one
           time
        3. Identified or potential for serious illness or injury/vitals remain outside of criteria limits – Remove from
           duty
    Personnel with any identified potentially serious medical complaints or conditions should be treated
    immediately according to the appropriate protocol and transported to the hospital. Signs and
    symptoms include but are not limited to:
        Chest Pain and/or Dyspnea
        Altered Mental Status
        Irregular pulse
        Pulse >150 or >140 after cool down/rest time
        Systolic BP >200mmHg after cool down/rest time or Diastolic >130mmHg
        Body temperature >101F or hot and flushed skin that is either moist or dry

                                    EMT-I/CC/P’s Stop Here. Contact Medical Control.


                                              Medical Control Options
         IV infusion             normal saline (250-500cc rapid infusion), repeat as directed.



Special Considerations Protocol                                                                                 SCP-      8
                 Hudson Valley Regional Emergency Medical Services Council, INC.
                     DRAFT Advanced Life Support Protocol Manual DRAFT
                                  Special Considerations Protocol-5
                                              (SCP-5)
                                       Toxemia of Pregnancy

   1.   Position patient in left lateral decubitus if tolerated.



                           EMT-I/CC/P’s Stop Here. EMT-CC/P’s Contact Medical Control.


                                       Medical Control Options
    Diazepam                         5-10mg IV over 1-2 minutes; may be repeated once.
                                      ALS provider to withhold further Diazepam once the
                                      seizures have been controlled.

    Lorazepam                        2mg IV injection; may be repeated up to 4mg or IM
                                      injection at 0.5mg/kg up to 4mg.

    Magnesium Sulfate                4gm/250cc normal saline and run at 250cc/hr. If patient
                                      becomes lethargic or hypotonic, discontinue Magnesium
                                      Sulfate infusion.

    Adjust IV rate



                                       Medical Control Options
    Calcium Chloride                 250-1000mg IV




Special Considerations Protocol                                                            SCP-   9
                 Hudson Valley Regional Emergency Medical Services Council, INC.
                     DRAFT Advanced Life Support Protocol Manual DRAFT
                                  Special Considerations Protocol-6
                                               (SCP-6)
                                   Childbirth/Precipitous Delivery

   1. If SBP <100, infusion of normal saline to maintain a SBP of 100.



                           EMT-I/CC/P’s Stop Here. EMT-CC/P’s Contact Medical Control.



                                       Medical Control Options
    Adjust IV rate




Special Considerations Protocol                                                          SCP- 10
                 Hudson Valley Regional Emergency Medical Services Council, INC.
                     DRAFT Advanced Life Support Protocol Manual DRAFT
                                  Special Considerations Protocol-7
                                              (SCP-7)
                                       Neonatal Resuscitation

   1. For newborns requiring resuscitation whose amniotic fluid does not contain thick
      meconium, proceed to step 3.
   2. For newborns requiring resuscitation whose amniotic fluid does contain thick
      meconium and who are limp, apneic, or pulseless:
         a. Clear the airway using endotracheal intubation and directly suction the
             endotracheal tube.
         b. Repeat procedure until the endotracheal tube is clear of thick meconium up
             to a maximum of three (3) times.
         NOTE: Do NOT replace the endotracheal tube once the airway has been cleared
         of thick meconium unless the newborn remains limp, apneic, or pulseless.
   3. Suction airway, followed by drying the baby and maintaining warmth.

           a. If color is normal or only peripheral cyanosis, no resuscitation indicated;
              If central cyanosis, provide 100% O2 and assist ventilation as indicated.

           b. If respiratory rate >30, no resuscitation indicated.
              If respiratory rate <30, tactile stimulation and assist ventilation as indicated
              with BVM at 40-60/min. and 100% O2.

           c. If pulse >100, no resuscitation indicated.
              If pulse 60-100, ventilate with BVM at 40-60/min. and 100% O2.
              If after 1 minute, the pulse remains less than 80, begin chest compressions.
              If pulse <60, ventilate with BVM at 40-60/min. and 100% O2, and begin chest
              compressions.
              If BVM not effective, establish airway control.

                                             EMT-I’s Stop Here.

           d. If pulse remains <60 despite ventilation and chest compressions for 1
              minute, obtain vascular access and give Epinephrine 1:10,000 0.01mg/kg
              (0.01cc/kg) IV, ET or IO; may be repeated every 3 minutes if pulse <60.


                                EMT-CC/P’s Stop Here. Contact Medical
                             Control.
                                       Medical Control Options
    Naloxone                              0.1mg/kg IV, ET or IO to maximum dose 2mg; may
                                           repeat.
    Normal Saline                         10cc/kg IV or IO.
    Epinephrine 1:10,000                  0.01mg/kg - 0.03mg/kg (0.01cc - 0.03cc/kg) IV, ET or
                                           IO; may be repeated every 5 minutes.
    Dextrose 25%                          2cc/kg IV.
    Vascular Access                       via IV or IO.


Special Considerations Protocol                                                           SCP- 11
Advanced Life Support Protocols
      Pediatric-Medical
                  Hudson Valley Regional Emergency Medical Services Council, INC.
                      DRAFT Advanced Life Support Protocol Manual DRAFT
                                      Pediatric Medical Protocol-1
                                                 (PMP-1)
                             Respiratory Arrest/Imminent Respiratory Arrest


    1. Airway control procedures
    2. If patient is intubated, secondary confirmation must be performed, at a minimum with
       End-tidal CO2 monitoring and Pulse Oximetry. Continuous CO2 monitoring is
       recommended.
    3. Refer to appropriate protocol for further assessment and treatment.




Pediatric Medical Protocol                                                              PMP-   1
                  Hudson Valley Regional Emergency Medical Services Council, INC.
                      DRAFT Advanced Life Support Protocol Manual DRAFT
                                  Pediatric Medical Protocol-2
                                            (PMP-2)
                                Obstructed Airway, Unconscious


    1.   BLS procedure.
    2.   Direct laryngoscopy and remove foreign body using Magill Forceps
    3.   Airway control procedures.
    4.   Refer to appropriate protocol, or contact medical control.



                                         EMT-I/CC’s Stop Here.



    5. If unable to ventilate because of obstruction, perform cricothyrotomy with appropriately
       sized approved device.




Pediatric Medical Protocol                                                                PMP-    2
                  Hudson Valley Regional Emergency Medical Services Council, INC.
                      DRAFT Advanced Life Support Protocol Manual DRAFT
                                  Pediatric Medical Protocol-3
                                            (PMP-3)
                                      Respiratory Distress
                             Asthma/Bronchospasm/Croup/Epiglottitis

                                             Considerations
       If patient has stridor or drooling, do not initiate IV access without medical control.
       Administration of bronchodilators may begin prior to IV initiation.


    1. Airway control.
    2. Pulse Oximetry.
    3. IV of normal saline at KVO if clinically indicated.


    4. Albuterol 2.5mg/3cc normal saline or Levalbuterol 0.63mg/3cc normal saline if less than 6
       months of age or Levalbuterol 1.25mg/3cc normal saline if 6 months of age or greater via
       nebulizer, may repeat once after 10 minutes.


                                 EMT-I’s Stop Here. Contact Medical Control.


    5. Albuterol 2.5mg/3cc normal saline or Levalbuterol 0.63mg/3cc normal saline if less than 6
       months of age or Levalbuterol 1.25mg/3cc normal saline if 6 months of age or greater via
       nebulizer, repeated every 10 minutes, as necessary.


                               EMT-CC/P’s Stop Here. Contact Medical Control.

                                      Medical Control Options
     Albuterol                     2.5mg/3cc normal saline via nebulizer; repeat as directed
     Levalbuterol                  0.63mg/3cc normal saline if less than 6 months of age,
                                    1.25mg/3cc normal saline if 6 months of age or greater via
                                    nebulizer; repeat as directed


                                       Medical Control Options
     Epinephrine 1:1,000           0.01mg/kg subcutaneous; maximum dose of 0.3mg; repeat
                                    as directed
     Ipratropium                   0.25-0.5mg/3cc normal saline via nebulizer; repeat as
                                    directed
     Magnesium Sulfate             20-40mg/kg IV over 5 minutes
     Methylprednisolone            2mg/kg IV




Pediatric Medical Protocol                                                                       PMP-   3
                  Hudson Valley Regional Emergency Medical Services Council, INC.
                      DRAFT Advanced Life Support Protocol Manual DRAFT
                                   Pediatric Medical Protocol-4
                                             (PMP-4)
                             Cardiopulmonary Arrest (Non-Traumatic)


    1. Initiate basic cardiac life support (BLS).
    2. Follow appropriate sub-protocol:
            a. Ventricular fibrillation or pulseless ventricular tachycardia
            b. Asystole/Electromechanical dissociation/Pulseless electrical activity


                                            Considerations
       Biphasic defibrillation is an acceptable option if used according to the specific
        manufacturer’s instructions.

                                            EMT-I’s Stop Here.



       IV medications by bolus are followed by a 5-10cc bolus of normal saline. When practical,
        elevation of the arm is recommended.




Pediatric Medical Protocol                                                                  PMP-   4
                  Hudson Valley Regional Emergency Medical Services Council, INC.
                      DRAFT Advanced Life Support Protocol Manual DRAFT
                                   Pediatric Medical Protocol-5
                                              (PMP-5)
                    Ventricular Fibrillation/Pulseless Ventricular Tachycardia


    1. Cardiac arrest standing orders.
    2. If arrest is witnessed:
       a. Immediately defibrillate ONE TIME at 2 joules/kg. If the defibrillator is not immediately
           available, do CPR until the defibrillator is available to shock.
       b. After ONE shock, resume CPR. After 5 cycles of CPR, recheck pulse and rhythm. If
           rhythm has not converted, continue CPR. Prepare to shock, establish airway control,
           and establish IV or IO access with normal saline.
    3. If arrest is unwitnessed or down time is greater than five minutes, perform at least 5
       cycles of CPR.
       c. When defibrillator is available, check pulse, check rhythm, and, if indicated, defibrillate
           ONE TIME at 2 joules/kg making certain to continue CPR while defibrillator charges.
       d. Immediately resume CPR. After 5 cycles of CPR, recheck pulse and rhythm. If rhythm
           has not converted, continue CPR. Prepare to shock, establish airway control, and
           establish IV or IO access with normal saline.




    4. Defibrillate at 4 joules/kg making certain to continue CPR while defibrillator charges.
    5. Resume CPR immediately. Continue CPR stopping every 5 cycles to check pulse and
       rhythm. Shock ONE TIME when indicated and immediately resume CPR.


                               EMT-I’s Stop Here. Contact Medical Control.




                                    - Continued on next page -




Pediatric Medical Protocol                                                                   PMP-   5
                  Hudson Valley Regional Emergency Medical Services Council, INC.
                      DRAFT Advanced Life Support Protocol Manual DRAFT
                                   Pediatric Medical Protocol-5
                                               (PMP-5)
                      Ventricular Fibrillation/Pulseless Ventricular Tachycardia

    6.  Prepare to administer medications.
    7.  Defibrillate at 4 joules/kg making certain to continue CPR while defibrillator charges.
    8.  Resume CPR immediately.
    9.  Epinephrine 1:10,000 0.01mg/kg IVP or IO, may be repeated every 3 minutes; ET dose is
        Epinephrine 1:1,000 0.1mg/kg
    10. If at any point, the rhythm converts to a supraventricular rhythm, and the patient has not
        received an anti-arrhythmic, administer Lidocaine 1mg/kg IVP, and then administer a drip
        of Lidocaine at 20mcg/kg/min.
    11. After 5 cycles of CPR, recheck pulse and rhythm. If indicated, defibrillate at 4 joules/kg,
        making certain to continue CPR while defibrillator charges.
    12. Resume CPR immediately
    13. Lidocaine 1mg/kg IVP or IO, may be repeated at 1mg/kg every 3 minutes to a total dose
        of 3mg/kg
    14. After 5 cycles of CPR, recheck pulse and rhythm. If indicated, defibrillate at 4 joules/kg,
        making certain to continue CPR while defibrillator charges.
    15. Resume CPR immediately. Continue CPR stopping every 5 cycles to check pulse and
        rhythm. Shock ONE TIME when indicated and immediately resume CPR.
    16. If at any point after the administration of Lidocaine, the rhythm converts to a
        supraventricular rhythm, administer a Lidocaine infusion at:
             20mcg/kg/min.           if 1mg/kg of Lidocaine was used
             40mcg/kg/min            if 2mg/kg-3mg/kg of Lidocaine was used



                                   EMT-CC’s Stop Here. Contact Medical Control.

                                       Considerations
        Paramedics may consider Amiodarone 5mg/kg/20cc normal saline, IVP or IO in place of
         Lidocaine.

                               EMT- P’s Stop Here. Contact Medical Control.


                                      Medical Control Options
          Defibrillate                  4 joules/kg




                                    - Continued on next page -




Pediatric Medical Protocol                                                                 PMP-   6
                  Hudson Valley Regional Emergency Medical Services Council, INC.
                      DRAFT Advanced Life Support Protocol Manual DRAFT
                            Pediatric Medical Protocol-5 (Continued)
                                              (PMP-5)
                    Ventricular Fibrillation/Pulseless Ventricular Tachycardia

                                      Medical Control Options
         Sodium Bicarbonate             1mEq/kg IVP; may repeat ½ original dose every 10
                                         minutes
         Dextrose 25%                   2cc/kg IVP
         Magnesium Sulfate              25-50mg/kg IV or IO (200mg-1gm IV over 5 minutes)
                                          If suspect Torsades de Pointes or hypomagnesaemia
         Lidocaine Infusion              20-50mcg/kg/min



                                      Medical Control Options
         Amiodarone                     5mg/kg/20cc normal saline IV bolus or IO




Pediatric Medical Protocol                                                           PMP-     7
                  Hudson Valley Regional Emergency Medical Services Council, INC.
                      DRAFT Advanced Life Support Protocol Manual DRAFT
                                    Pediatric Medical Protocol-6
                                              (PMP-6)
                             Asystole/Pulseless Electrical Activity (PEA)


    1. Cardiac arrest standing orders.
    2. Rhythm is checked in more than one lead before the interpretation of asystole is made. If
       the rhythm is unclear and possibly low amplitude ventricular fibrillation, perform 5 cycles
       of CPR then consider defibrillation at 2 joules/kg making certain to continue CPR while
       defibrillator charges.
    3. Airway control, ventilation, and IV/IO access with normal saline.
    4. Resume CPR immediately. Continue CPR stopping every 5 cycles to check pulse and
       rhythm.


                                   EMT-I’s Stop Here. Contact Medical Control.


    5. Epinephrine 1:10,000 0.01mg/kg IVP/IO; dose may be repeated every 3 minutes until
       there is a rhythm with a pulse. ET dose is Epinephrine 1:1,000 0.1mg/kg


                                EMT-CC/P’s Stop Here. Contact Medical Control.


                                       Medical Control Options
     Defibrillate                   2-4 joules/kg, repeat as indicated.




                                      Medical Control Options
     Sodium Bicarbonate             1mEq/kg IVP/IO; repeat as directed at 0.5mEq/kg



                                           Considerations
       25% Dextrose 2cc/kg, if clinically indicated.
       Naloxone 0.1MG/KG IV/IO/ET if clinically indicated. May be repeated up to 2mg.
       Consider underlying causes of hypovolemia, hypoxia, hydrogen ion (acidosis), hypo or
        hyperkalemia, hypoglycemia, hypothermia, toxins, tamponade, tension pneumothorax,
        thrombosis, and trauma.




Pediatric Medical Protocol                                                                PMP-   8
                  Hudson Valley Regional Emergency Medical Services Council, INC.
                      DRAFT Advanced Life Support Protocol Manual DRAFT
                                   Pediatric Medical Protocol-7
                                             (PMP-7)
                         Bradyrhythmia’s Including 3rd Degree Heart Block

                                          Considerations
       Unstable denotes bradycardia combined with any of the following; chest pain, dyspnea,
        CHF, ischemia, infarction, age dependant hypotension, or signs of inadequate perfusion,
        such as; altered mental status (restlessness, inattention, confusion, agitation), weak or
        absent distal pulses, delayed capillary refill (greater than 2 seconds), pallor, or cold,
        clammy or mottled skin.
       Consider neurological, toxicological, or traumatic etiology.



    1. Ventilate with 100% O2 and BVM.
    2. Perform chest compressions on infant or child if despite oxygenation and ventilation,
       heart rate remains less than 60 beats/min and there are signs of poor systemic perfusion.

                               EMT-I/CC’s Stop Here. Contact Medical Control.


    For patients with any bradycardia (including 3rd degree heart block) with a ventricular rate
    less than 60 beats/min and unstable;
    3. Epinephrine 1:10,000 0.01mg/kg IV; may repeat same dose if inadequate response
       within 3 minutes.


                                 EMT-P’s Stop Here. Contact Medical Control.

                                      Medical Control Options
     IV/IO infusion                normal saline 10-20cc/kg



                                      Medical Control Options
     Atropine                      0.02mg/kg IV, may repeat. Minimum dose of 0.1mg and
                                    maximum total dose 1mg
     Epinephrine 1:10,000          0.01mg/kg IV
     Transcutaneous pacing
     Morphine Sulfate              0.05mg/kg slow IV push




Pediatric Medical Protocol                                                                  PMP-   9
                  Hudson Valley Regional Emergency Medical Services Council, INC.
                      DRAFT Advanced Life Support Protocol Manual DRAFT
                                   Pediatric Medical Protocol-8
                                             (PMP-8)
                             Non-Traumatic Shock (Cardiogenic/Septic)

                                          Considerations
For the purpose of this protocol, shock is defined as signs of inadequate perfusion, such as:
    1. Altered mental state (restlessness, inattention, confusion, agitation)
    2. Tachycardia (see pediatric vital signs supplement)
    3. Weak or absent distal pulses
    4. Delayed capillary refill (greater than 2 seconds)
    5. Pallor
    6. Cold, clammy skin, or mottled skin

   Consider appropriate sub-protocol
    1. Tachycardia (PMP-9)
    2. Altered Mental Status (PMP12)

                               EMT-I/CC/P’s Stop Here. Contact Medical Control.


                                       Medical Control Options
     IV/IO infusion                 10-20cc/kg of normal saline in absence of pulmonary edema;
                                     repeat as directed




Pediatric Medical Protocol                                                               PMP- 10
                  Hudson Valley Regional Emergency Medical Services Council, INC.
                      DRAFT Advanced Life Support Protocol Manual DRAFT
                                  Pediatric Medical Protocol-9
                                            (PMP-9)
                                  Supraventricular Tachycardia

                                          Considerations
       The standing orders in this protocol are intended for patients with narrow (QRS less than
        or equal to 0.08 seconds) complexes in supraventricular tachycardia (ventricular rate
        greater than 180bpm; greater than 220bpm in infants) who are hemodynamically
        unstable. If the patient is hemodynamically stable or presents with a wide-QRS
        tachycardia, contact medical control immediately.
       Unstable denotes supraventricular tachycardia (ventricular rate greater than 180bpm;
        greater than 220bpm in infants) combined with any of the following, chest pain, dyspnea,
        CHF, ischemia, infarction, age dependant hypotension, or signs of inadequate perfusion,
        such as; altered mental status (restlessness, inattention, confusion, agitation), weak or
        absent distal pulses, delayed capillary refill (greater than 2 seconds), pallor, or cold,
        clammy or mottled skin.



In patients with hemodynamically unstable-SVT:
    1. If possible, attempt Vagal Maneuvers
    2. If vascular access is immediately available (<30seconds), administer Adenosine
       0.1mg/kg rapid bolus (maximum single dose is 6mg); if tachydysrhythmia persists,
       0.2mg/kg rapid bolus (maximum single dose is 12mg).
    3. If vascular access is not immediately available (>30seconds) or if tachydysrhythmia
       persists following maximum Adenosine dosage, perform synchronized cardioversion at
       0.5 joules/kg; if tachydysrhythmia persists, 1.0 joules/kg once.


                              EMT-P’s Stop Here. EMT-CC/P’s Contact Medical
                                              Control.
                                      Medical Control Options
       Vagal Maneuvers
       Adenosine                  0.1-0.2mg/kg
       Cardioversion              0.5 joules/kg – 1.0 joules/kg, repeat as directed
       Lidocaine                  1mg/kg slow IVP over 2-4 minutes
       Magnesium Sulfate          25mg/kg slow IVP over 10-20 minutes


                                     Medical Control Options
     Amiodarone                   5mg/kg IV over 20-60 minutes, may repeat to a maximum
                                   dose of 15mg/kg.




Pediatric Medical Protocol                                                                PMP- 11
                  Hudson Valley Regional Emergency Medical Services Council, INC.
                      DRAFT Advanced Life Support Protocol Manual DRAFT
                                     Pediatric Medical Protocol-10
                                               (PMP-10)
                                            Abdominal Pain

                                             Considerations
       The ALS provider must consider all abdominal pain to be acute.
       If the patient is a female of any age, the potential for an OB-GYN emergency must be
        considered; the ALS provider should then refer to Special Considerations Protocol-5
        (SCP-5) Toxemia of Pregnancy or Special Considerations-6 (SCP-6)
        Childbirth/Precipitous Delivery, if appropriate.
       Transport samples of products of conception, if applicable



    4. Keep patient NPO
    5. If patient has evidence of blood loss or signs of shock, refer to Traumatic/Non-traumatic
       Shock Protocol, as appropriate.
    6. Prepare for transport.


                             EMT-I/CC/P’s Stop Here. EMT P’s Contact Medical Control.

                                  Medical Control Options
     Consider Special Considerations Protocol-1 (SCP-1) Pain Management/Analgesia




Pediatric Medical Protocol                                                                PMP- 12
                  Hudson Valley Regional Emergency Medical Services Council, INC.
                      DRAFT Advanced Life Support Protocol Manual DRAFT
                                  Pediatric Medical Protocol-11
                                              (PMP-11)
                              Systemic Allergic Reactions/Anaphylaxis


      1. Fluid bolus of normal saline 20cc/kg IV bolus or IO if signs of shock


                                EMT-I’s Stop Here. Contact Medical Control.



      2. If signs of shock or imminent airway obstruction, administer Epinephrine 1:1,000
         0.01mg/kg SQ to a maximum dose of 0.3mg
      3. Diphenhydramine 1mg/kg slow IVP or IM (Maximum dose is 50mg)


                              EMT-CC/P’s Stop Here. Contact Medical Control.


                                        Medical Control Options
     IV/IO Infusion                      10-20cc/kg normal saline



                                      Medical Control Options
     Epinephrine 1:10,000               0.01mg/kg ET/IVP/IO, may be repeated every 5
                                         minutes
       Epinephrine 1:1,000              0.01mg/kg SQ up to a maximum dose of 0.3mg
       Diphenhydramine                  1mg/kg slow IVP or IM
       Albuterol                        2.5mg/3cc normal saline via nebulizer
       Ipratropium                      0.25-0.5mg/3cc normal saline; repeat as
                                         directed
     Levalbuterol                       0.63mg/3cc normal saline if less than 6 months of age,
                                         1.25mg/3cc normal saline if 6 months of age or greater
                                         via nebulizer; repeat as directed
     Dopamine Infusion                  400mg/250cc normal saline and started at
                                         5-10mcg/kg/min., titrated to desired BP
                                         (maximum of 20mcg/kg/min.).
     Methylprednisolone                 2mg/kg/50cc normal saline over 3-5 minutes
     Glucagon                           0.1mg/kg up to 1mg IM




Pediatric Medical Protocol                                                                  PMP- 13
                  Hudson Valley Regional Emergency Medical Services Council, INC.
                      DRAFT Advanced Life Support Protocol Manual DRAFT
                                  Pediatric Medical Protocol-12
                                            (PMP-12)
                                     Altered Mental Status

                                           Considerations
           Consider neurological, toxicological, or traumatic etiology



        1. Obtain a field glucometer reading.
        2. If unable to obtain a field glucometer reading, draw a blood sample for the hospital
           and contact medical control.
        3. For documented hypoglycemia:
               a. Administer Dextrose 25% 2cc/kg IVP, if no response in 5 minutes; repeat
                  Dextrose 25% 2cc/kg IVP.
               b. When an IV route is unobtainable, administer Glucagon 0.1mg/kg IM to a
                  maximum dose of 1mg.
        4. For suspected opioid overdose, administer Naloxone 0.1mg/kg ET, IVP, or IM to a
           maximum dose of 2mg; may be repeated up to 3 times.
        5. Airway control should be considered if no response to medical interventions above.


                                         EMT-CC/P’s Stop Here.

                                      Medical Control Options
     Dextrose                           25% 2cc/kg IVP, repeat as directed
     Glucagon                           0.1mg/kg up to 1mg IM to a maximum dose of 1mg
     Naloxone                           0.1mg/kg ET, IVP, or IM to a maximum dose of 2mg




Pediatric Medical Protocol                                                                PMP- 14
                  Hudson Valley Regional Emergency Medical Services Council, INC.
                      DRAFT Advanced Life Support Protocol Manual DRAFT
                                       Pediatric Medical Protocol-13
                                                 (PMP-13)
                                                 Overdose


    1. Treat dysrhythmias, hypotension, seizures, or altered mental status according to
       appropriate protocol.
    2. If known or suspected overdose, attempt to identify source and bring to hospital




                             EMT-I/CC/P’s Stop Here. EMT-CC/P’s Contact Medical Control.

                                           Medical Control Options
     Naloxone                           0.1mg/kg ET, IVP, or IO; to a maximum dose of 2mg; may
                                         repeat 4 times
       Dextrose 25%                     2cc/kg IV or IO
       Activated Charcoal               1gm/kg PO
       Sodium Bicarbonate               1mEq/kg IVP
       Sodium Bicarbonate               1-2mEq/kg in 250cc Normal Saline, run at 1cc/min
       Glucagon                         0.1mg/kg IV or IM, up to 1mg; repeat as directed


                                           Medical Control Options
     Calcium Chloride                   20mg/kg slow IVP




Pediatric Medical Protocol                                                                 PMP- 15
                  Hudson Valley Regional Emergency Medical Services Council, INC.
                      DRAFT Advanced Life Support Protocol Manual DRAFT
                                     Pediatric Medical Protocol-14
                                               (PMP-14)
                                            Toxic Exposure

If there is an exposure to or release of hazardous materials, prior to initiating patient care,
complete the following:
    5. Avoid entrance to and/or contact with contaminated environment.
    6. Call for rescue assistance from Fire/ Rescue/HAZMAT
    7. In the event of or if there is likelihood for a Mass Casualty Incident (MCI), notify the appropriate
       local competent authority as per the specific county MCI plan and contact medical control.
    8. In a disaster situation where there is a KNOWN exposure to the release of nerve and/or
       organophosphate agents confirmed by a local competent authority (i.e., HAZMAT Team, County
       or State DOH, On-line Medical Control, Regional Poison Control Center), refer to Special
       Considerations Protocol 3 (SCP-3) ―Mark I Kit Administration‖.


Patient Decontamination:
   Scenes containing hazardous materials (HAZMAT), or contaminated patients, should be separated
    into three zones; ―HOT‖, ―WARM‖, and ―COLD‖. The ―HOT‖ and ―WARM‖ zones require the highest
    level of Personal Protective Equipment (PPE) specified for the toxic agent identified. Gross
    decontamination of patients begins in the ―HOT‖ zone with more complete decontamination
    achieved in the ―WARM‖ zone. EMS lacking HAZMAT training and equipment will make contact
    with the patients in the ―COLD‖ zone. At this point the usual dermal, respiratory, and optical PPE
    required for EMS operations should be sufficient to safely provide patient care.
   Patient triage will be initiated in the ―HOT‖ zone and continued in the ―WARM‖ zone by HAZMAT or
    other appropriately trained responders wearing the required PPE, as determined by the incident
    commander. Patient treatment should be conducted by EMS personnel in the ―COLD‖ zone.
   Personnel operating in the ―COLD‖ zone should be aware of the potential for ―Off-Gassing‖ of
    vapors from chemically contaminated clothing. Emergency Responders assisting evacuated victims
    of nerve agent and/or organophosphate agent exposure should avoid exposing themselves to
    cross-contamination by ensuring that they do not come into direct contact with the patient’s
    clothing.
                             EMT-I/CC/P’s Stop Here. EMT-CC/P’s Contact Medical Control.

                                         Medical Control Options
     If there is a history of potential Organophosphate and Carbamate Insecticide exposure
      AND findings are consistent with parasympatholytic toxicity, administer Atropine
      0.02mg/kg ET, IVP, or IO (minimum dose 0.1mg); may be repeated until signs of
      atropinization.
     If there is a history of potential Chlorine gas exposure AND findings are consistent with
      Chlorine gas toxicity (coughing, choking, or wheezing), combine 2ml Sodium Bicarbonate
      with 2ml of normal saline and administer via nebulizer; may repeat every 20 minutes.
     If findings are consistent with ocular irritant exposure;
           o Attempt to positively identify the involved substance;
           o Administer Tetracaine 2 drops in affected eye followed by irrigation of 1000cc
               Normal Saline (may use the Morgan Therapeutic Lens).




Pediatric Medical Protocol                                                                         PMP- 16
                  Hudson Valley Regional Emergency Medical Services Council, INC.
                      DRAFT Advanced Life Support Protocol Manual DRAFT
                                  Pediatric Medical Protocol-15
                                            (PMP-15)
                                       Status Epilepticus

                                             Considerations
           This protocol is indicated for patients in Status Epilepticus (Two or more seizures
            without a lucid interval or a continuous seizure lasting more than 5 minutes)
           The ALS provider will discontinue the administration of Diazepam or Lorazepam as
            soon as the seizure stops, whether or not the entire ordered dosage has been
            administered.


    If known history of seizure disorder, proceed to step 1. If hypoglycemia is suspected or
    history is unknown, proceed to step 2.

    1. If known seizure disorder, administer Diazepam 0.1mg/kg slow IV over 1 minute to a
       maximum dose of 10mg; may be repeated after 5 minutes. If IV route not available, give
       rectally via syringe without needle at dose 0.5mg/kg, up to 10mg; may be repeated after
       10 minutes.
                                                 Or
       Administer Lorazepam IV 0.1 mg/kg over 2-5 minutes to a maximum dose of
       4mg. If IV route not available, administer Lorazepam IM 0.05mg/kg to a maximum dose
       of 4mg
                                  If seizure continues, proceed to step 2.
    2. Obtain a field glucometer reading.
    3. If unable to obtain a field glucometer reading, draw blood sample for the hospital and
       contact medical control.
    4. For documented hypoglycemia:
           a. Dextrose 25% 2cc/kg IVP or if IV is unobtainable, administer Glucagon 0.1mg/kg
              IM up to a maximum dose of 1mg. If seizure continues, proceed to step 1.
    5. If above actions do not terminate seizure, or respirations are depressed, reconsider
       airway control.



                              EMT-CC/P’s Stop Here. Contact Medical Control.

                                       Medical Control Options
     Diazepam               0.1-0.2mg/kg slow IV; may be repeated. May give rectally
                             via syringe without needle at 0.5mg/kg, up to 10mg; may be
                             repeated
     Lorazepam              0.05 – 0.1mg/kg IV injection over 2-5 minutes or IM injection at
                             0.05mg/kg to a maximum dose of 4mg
     Dextrose 25%           2cc/kg IVP
     Glucagon               0.1mg IM




Pediatric Medical Protocol                                                                 PMP- 17
                  Hudson Valley Regional Emergency Medical Services Council, INC.
                      DRAFT Advanced Life Support Protocol Manual DRAFT
                                 Pediatric Medical Protocol-Supplement

                                                 Glasgow Coma Scale
    Infant                                           Eye Opening                                 Child
       4                       Spontaneously                            Spontaneously             4
       3                        To Speech                               To Command                3
       2                          To Pain                                  To Pain                2
       1                       No Response                              No Response               1
                                                 Best Verbal Response
      5                        Coos, Babbles                              Orientated              5
      4                        Irritable Cries                            Confused                4
      3                         Cries to Pain                       Inappropriate Words           3
      2                        Moans, Grunts                          Incomprehensible            2
      1                        No Response                              No Response               1
                                             Best Motor Response
      6                      Spontaneous                          Obeys Commands                  6
      5                     Localized pain                           Localized pain               5
      4                  Withdraws from Pain                     Withdraws from Pain              4
      3                  Flexion (decorticate)                   Flexion (decorticate)            3
      2                 Extension (decerebrate)                Extension (decerebrate)            2
      1                      No Response                             No Response                  1
                                 Is the GCS less than 8? Consider Intubation.
                                          Abnormal Pediatric Vital Signs
                             Age Group        Criteria for    Criteria for       Criteria for
                                              Tachypnea      Tachycardia        Hypotension
                         Infant (<1yr)         >60/min         >160/min          <60mmHg
                        Toddler (1-3yr)            >40/min       >150/min        <70mmHg
                     Preschooler (3-5yr)           >35/min       >140/min        <75mmHg
                     School Age (6-12yr)           >30/min       >120/min        <80mmHg
                      Adolescent (13-18)           >30/min       >100/min        <90mmHg

                                     Pediatric Age and Weight Estimation:
                                            Age        Pounds     Kilograms
                                        Premature        4.4           2
                                         Newborn         6.6           3
                                        6 months        15.4           7
                                          1 year         22           10
                                          2 years       26.4          12
                                          3 years       30.8          14
                                          4 years       35.2          16
                                          5 years       39.6          18
                                          6 years        44           20
                                          7 years        53           24
                                          8 years       57.2          26
                                       9 – 10 years      66           30
                                      11 – 12 years     74.8          34

                                          Lidocaine Drip Formula
             60 X body weight in kilograms = number of mg to be diluted in 100ml normal saline

                                           1ml/hr delivers 10mcg/kg/min
Pediatric Medical Protocol                                                                        PMP- 18
Advanced Life Support Protocols
       Pediatric-Trauma
                 Hudson Valley Regional Emergency Medical Services Council, INC.
                     DRAFT Advanced Life Support Protocol Manual DRAFT
                                     Pediatric Trauma Protocol-1
                                                (PTP-1)
                                            Major Trauma
                                            Indications
For patients presenting with any of the following physical findings which are directly attributed
to a traumatic event:
     1. Pulse greater than normal range for patient’s age (see pediatric vital signs supplement)
     2. Systolic blood pressure below normal range (see pediatric vital signs supplement)
     3. Respiratory status inadequate (central cyanosis, respiratory rate low for child’s age,
         capillary refill time greater than two seconds)
     4. Glasgow Coma Scale is less than or equal to 13
     5. Penetrating injury to the head, neck, torso or proximal extremities
     6. Two or more suspected proximal long bone fractures
     7. Suspected flail chest
     8. Suspected spinal cord injury or limb paralysis
     9. Amputation (except digits)
     10. Suspected pelvic fracture
     11. Open or depressed skull fracture
     12. Suspected head injury resulting in neurological compromise
     13. Burns that involve 15% or more of the body surface (10% if associated with other injuries
         or the child is less than five years old) or facial/airway burns or, if there is evidence of the
         following mechanism of injury:
                A.   Ejection or partial ejection from an automobile
                B.   Death in the same passenger compartment
                C.   Extrication time in excess of 20 minutes
                D.   Vehicle collision resulting in 12 inches of intrusion in to the passenger
                     compartment, steering wheel displacement, and/or starred windshield
                E.   Motorcycle/ATV/Bicycle crash >20 MPH or with separation of rider
                F.   Falls from greater than 10 feet
                G.   Vehicle rollover (90 degree vehicle rotation or more) with unrestrained
                     passenger
                H.   Vehicle vs. pedestrian or bicycle collision above 5 MPH
Initiate New York State Basic Life Support Pediatric Treatment Protocol for “Pediatric
Major Trauma” and;
    1. Initiate transportation as soon as possible according to Pediatric Trauma Protocol
        9 (PTP-9) “Major Trauma Transport Protocol”; Consider Air Medical Transport;
    2. Establish vascular access and initiate infusion of Normal Saline according to the
        appropriate protocol;
    3. Refer to appropriate protocol for further treatment as necessary;
    4. Contact medical control as soon as practical.
                                            Considerations
     Initiating IV therapy should not delay transport. If transportation is unavoidably delayed, IV
      therapy may be started prior to transport.
     A high index of suspicion must exist for hidden injuries even if the patient is initially
      hemodynamically stable.
Pediatric Trauma Protocol                                                                        PTP-   1
                 Hudson Valley Regional Emergency Medical Services Council, INC.
                     DRAFT Advanced Life Support Protocol Manual DRAFT
                                   Pediatric Trauma Protocol-2
                                              (PTP-2)
                                       High Risk Patients

If a patient does not meet Major Trauma criteria but has sustained an injury and has one
           or more of the following “High Risk” criteria, contact medical control:
    Bleeding disorders or patients who are on anticoagulant medications
    Cardiac disease and/or respiratory disease
    Insulin dependant diabetes, cirrhosis, or morbid obesity
    Immunosuppressed patients (HIV disease, transplant patients, and patients on
       chemotherapy treatment)


                                          Considerations
      A high index of suspicion must exist for hidden injuries even if the patient is initially
       hemodynamically stable.

                                 EMT-I/CC/P’s Stop Here. Contact Medical Control


                                  Medical Control Options
    Initiate transport to a Trauma Center
    IV access




Pediatric Trauma Protocol                                                                      PTP-   2
                 Hudson Valley Regional Emergency Medical Services Council, INC.
                     DRAFT Advanced Life Support Protocol Manual DRAFT
                                   Pediatric Trauma Protocol-3
                                              (PTP-3)
                                  Traumatic/Hypovolemic Shock

                                          Considerations
      For the purpose of this protocol, shock is defined as signs of inadequate perfusion, such
       as:
           1.   Altered mental state (restlessness, inattention, confusion, agitation)
           2.   Tachycardia (see pediatric vital signs supplement)
           3.   Weak or absent distal pulses
           4.   Delayed capillary refill (greater than 2 seconds)
           5.   Pallor
           6.   Cold, clammy skin, or mottled skin
      Do not allow procedures to delay transport. If transport is unavoidable delayed, IV’s may
       be started prior to transport.




   1. If there is evidence of significant mechanism of injury and/or physical findings
      meeting Major Trauma criteria but the patient does not present with signs of
      shock, establish IV access with one (1) IV and run at KVO rate.
   2. If the patient presents with signs of shock, establish IV access, IO access if
      peripheral access not available and administer fluid bolus of 20cc/kg (10cc/kg for
      neonates) normal saline; repeat bolus as needed if shock persists.




Pediatric Trauma Protocol                                                                 PTP-     3
                 Hudson Valley Regional Emergency Medical Services Council, INC.
                     DRAFT Advanced Life Support Protocol Manual DRAFT
                                     Pediatric Trauma Protocol-4
                                                (PTP-4)
                            Traumatic/Hypovolemic Cardiopulmonary Arrest


   1. Basic Life Support is initiated
   2. Airway control procedures
   3. Transportation is initiated. If the patient is accessible, time on scene should not
      exceed 10 minutes.
   4. Normal Saline at 20cc/kg (10cc/kg for neonates) IV or IO bolus. IV/IO attempts
      should not delay transport from the scene.
   5. Initiate the appropriate cardiac arrest protocol.


                                         Considerations
      Document total fluid infused on the pre-hospital care report.




Pediatric Trauma Protocol                                                            PTP-   4
                 Hudson Valley Regional Emergency Medical Services Council, INC.
                     DRAFT Advanced Life Support Protocol Manual DRAFT
                                  Pediatric Trauma Protocol-5
                                             (PTP-5)
                                    Tension Pneumothorax


   1. Airway control


                                        EMT-I’s Stop Here.



   2. Perform pleural decompression using appropriately sized over-the-needle catheter
      if there is evidence of the following signs resulting from suspected trauma:

           c. Respiratory distress with absent lung sounds;

                                  AND

           d. Cardiovascular compromise;
                 i. Signs of inadequate perfusion, such as;
                       1. Altered mental state (restlessness, inattention, confusion,
                          agitation)
                       2. Tachycardia (see pediatric vital signs supplement)
                       3. Weak or absent distal pulses
                       4. Delayed capillary refill (greater than 2 seconds)
                       5. Pallor
                       6. Cold, clammy, or mottled skin
                ii. Cardiopulmonary arrest




Pediatric Trauma Protocol                                                           PTP-   5
                 Hudson Valley Regional Emergency Medical Services Council, INC.
                     DRAFT Advanced Life Support Protocol Manual DRAFT
                                  Pediatric Trauma Protocol-6
                                             (PTP-6)
                                          Head Trauma

                                         Considerations
      Consider neurological, toxicological, or medical etiology.



   1. If unconscious, airway control and ventilate at 20-24 respirations/minute. If signs
      of cerebral herniation develop, increase ventilation rate to 30 respirations/minute.

   2. If signs of shock, refer to Shock Protocol. (Traumatic or Non-traumatic, as
      appropriate.)


                                          EMT-I’s Stop Here.


   3. If there is clinical documentation of hypoglycemia associated with
      unconsciousness, administer Dextrose 25% 2cc/kg IV.

   4. If there is clinical indication of narcotic use associated with unconsciousness,
      administer Naloxone 0.1mg/kg IV up to 2mg


                             EMT-CC/P’s Stop Here. Contact Medical Control.


                                    Medical Control Options
    Naloxone               0.1mg/kg IV up to 2mg.
    Dextrose 25%           2cc/kg IV.




Pediatric Trauma Protocol                                                           PTP-     6
                 Hudson Valley Regional Emergency Medical Services Council, INC.
                     DRAFT Advanced Life Support Protocol Manual DRAFT
                                  Pediatric Trauma Protocol-7
                                             (PTP-7)
                                              Burns


   1. Determine the type of burn and percentage of body surface area (BSA) as soon as
      possible;
   2. For thermal burns, stop the burning process and proceed to step 5.
   3. For electrical burns, ensure that the patient is not in contact with the source of
      current and proceed to step 5.
   4. For chemical burns, consider Pediatric Medical Protocol 15 (PMP-15) “Toxic
      Exposure” and proceed to step 5.
   5. If there is evidence of smoke inhalation, carbon monoxide poisoning, or airway
      burns, refer to Pediatric Medical Protocol-3 (PMP-3) “Respiratory Distress” or
      Pediatric Medical Protocol-1 (PMP-1) “Imminent Respiratory Arrest” as necessary.
   6. Transport. Consider transportation to the Regional Trauma Center as indicated by
      Pediatric Major Trauma Protocol 9 (PTP-9) “Trauma Transport Protocol”. Consider
      Air Medical Transport;
   7. If >15% BSA burn estimate (10% if associated with other injuries or the child is less
      than five years old), then initiate IV access, or IO access if peripheral access not
      available (avoid burn tissue if possible) and administer Normal Saline at KVO. If
      transport is delayed, IV access may be obtained prior to transport.
   8. Contact medical control for infusion rate


                             EMT-I/CC/P’s Stop Here. Contact Medical Control.

                                    Medical Control Options
    Adjust IV Rate




                                Medical Control Options
    Special Considerations Protocol-1 (SCP-1) ―Pain Management / Analgesia‖




                                   - Continued on Next Page -

Pediatric Trauma Protocol                                                           PTP-   7
                 Hudson Valley Regional Emergency Medical Services Council, INC.
                     DRAFT Advanced Life Support Protocol Manual DRAFT
                              Pediatric Trauma Protocol-7 (Continued)
                                              (PTP-7)
                                               Burns
                            Estimation of Body Surface Area Involvement




Pediatric Trauma Protocol                                                          PTP-   8
                 Hudson Valley Regional Emergency Medical Services Council, INC.
                     DRAFT Advanced Life Support Protocol Manual DRAFT
                                  Pediatric Trauma Protocol-8
                                             (PTP-8)
                                   Isolated Extremity Trauma


                             EMT-CC/P’s Stop Here. Contact Medical Control.



                                Medical Control Options
    Special Considerations Protocol-1 (SCP-1) ―Pain Management / Analgesia‖




Pediatric Trauma Protocol                                                          PTP-   9
                   Hudson Valley Regional Emergency Medical Services Council, INC.
                       DRAFT Advanced Life Support Protocol Manual DRAFT
                                          Pediatric Trauma Protocol-9
                                                     (PTP-9)
                                        Major Trauma Transport Protocol
                                                          Considerations
        Pediatric patients meeting Major Trauma criteria should be transported to the nearest designated Regional or Area
         Trauma Center capable of receiving pediatric patients if the time elapsed between the estimated time of injury and
         the estimated time of arrival at the Trauma Center is less than one hour.
        If the transport time from the scene to the trauma center is more than 30 minutes, CONTACT MEDICAL CONTROL.
        Transport the patient to the nearest hospital emergency department if the patient is in cardiac arrest, has an
         unmanageable airway, or if an on-line medical control physician so directs.

                                  PHYSICAL FINDINGS Suspected to be Caused by Trauma
                         Pulse greater than normal range for patient’s age (see pediatric appendix)
                         Systolic blood pressure below normal range (see pediatric appendix)
                         Respiratory status inadequate (central cyanosis, rate low for child’s age, capillary refill
                          time > 2 seconds)
                         Glasgow Coma Scale is less than or equal to 13
                                                        PHYSICAL FINDINGS
                         Penetrating injury to the head, neck, torso or proximal extremities
                         Two or more suspected proximal long bone fractures
                         Suspected flail chest
                         Suspected spinal cord injury or limb paralysis
                         Amputation (except digits)
                         Suspected pelvic fracture
                         Open or depressed skull fracture
                         Suspected head injury resulting in neurological compromise
                         Burns that involve 15% or more of the BSA (10% is associated with other injuries or
                          the child is < 5 yrs. Old) or facial/airway burns
                                YES                                                                NO
                                                                                                   
        Transport To Nearest Regional Or Area Trauma Center                                       Evaluate Mechanism Of Injury

                                                      MECHANISM OF INJURY
                  Ejection or partial ejection from an automobile
                  Death in the same passenger compartment
                  Extrication time in excess of 20 minutes
                  Vehicle collision resulting in 12 inches of intrusion in to the passenger compartment
                  Motorcycle crash >20 MPH or with separation of rider from motorcycle
                  Falls from greater than 10 feet
                  Vehicle rollover (90 degree vehicle rotation or more) with unrestrained passenger
                  Vehicle vs. pedestrian or bicycle collision above 5 MPH
                                  YES                                                        NO
                                                                                            

 Transport To Nearest Regional Or Area Trauma Center                   Transport To Nearest Hospital Emergency Department

  The following should be transported directly to the Regional Trauma Center provided the time elapsed between the
    estimated time of injury and the estimated time of arrival at the Regional Trauma Center is less than one hour.
     Pediatric Trauma Patients < 12 Y/O
     Thoracic Trauma with Respiratory Distress or Signs of Shock
     Limb Amputation / Severe Crushing Injury Requiring Reimplantation or Reconstruction
     Unstable Multi Systems Trauma with Associated Open Pelvic Fracture
     Facial / Airway Burns or Burns >15% BSA or Electrical Burns

If a patient does not meet Major Trauma criteria but has sustained an injury and has one or more of the following “High
Risk” criteria, CONTACT MEDICAL CONTROL:
        Patients With Bleeding Disorder (Hemophilia, Anticoagulants)
        Cardiac and/or Respiratory Disease
        Insulin Dependant Diabetes, Cirrhosis Or Morbid Obesity
        Immunosuppressed Patient (HIV Disease, Transplant Patients And Patients On Chemotherapy Treatment)
        Pregnancy


Pediatric Trauma Protocol                                                                                                 PTP- 10
                 Hudson Valley Regional Emergency Medical Services Council, INC.
                     DRAFT Advanced Life Support Protocol Manual DRAFT
                               Pediatric Trauma Protocol-Supplement

                                              Glasgow Coma Scale
    Infant                                        Eye Opening                                Child
       4                    Spontaneously                            Spontaneously            4
       3                     To Speech                               To Command               3
       2                       To Pain                                  To Pain               2
       1                    No Response                              No Response              1
                                              Best Verbal Response
      5                     Coos, Babbles                              Orientated             5
      4                     Irritable Cries                            Confused               4
      3                      Cries to Pain                       Inappropriate Words          3
      2                     Moans, Grunts                          Incomprehensible           2
      1                     No Response                              No Response              1
                                            Best Motor Response
      6                     Spontaneous                          Obeys Commands               6
      5                    Localized pain                           Localized pain            5
      4                 Withdraws from Pain                     Withdraws from Pain           4
      3                 Flexion (decorticate)                   Flexion (decorticate)         3
      2                Extension (decerebrate)                Extension (decerebrate)         2
      1                     No Response                             No Response               1
                                Is the GCS less than 8? Consider Intubation.


                                  Pediatric Age and Weight Estimation:
                                         Age        Pounds     Kilograms
                                     Premature        4.4           2
                                      Newborn         6.6           3
                                     6 months        15.4           7
                                       1 year         22           10
                                       2 years       26.4          12
                                       3 years       30.8          14
                                       4 years       35.2          16
                                       5 years       39.6          18
                                       6 years        44           20
                                       7 years        53           24
                                       8 years       57.2          26
                                    9 – 10 years      66           30
                                   11 – 12 years     74.8          34


                                      Abnormal Pediatric Vital Signs
                        Age Group         Criteria for    Criteria for        Criteria for
                                          Tachypnea      Tachycardia         Hypotension
                       Infant (<1yr)       >60/min         >160/min           <60mmHg
                      Toddler (1-3yr)      >40/min         >150/min           <70mmHg
                   Preschooler (3-5yr)     >35/min         >140/min           <75mmHg
                   School Age (6-12yr)     >30/min         >120/min           <80mmHg
                    Adolescent (13-18)     >30/min         >100/min           <90mmHg




Pediatric Trauma Protocol                                                                     PTP- 11
Advanced Life Support Protocols
          Appendix A
                       Hudson Valley Regional Emergency Medical Services Council, INC.
                           DRAFT Advanced Life Support Protocol Manual DRAFT
                                    Regional Helicopter Utilization Guidelines

                                                    T AB LE O F CO NT E NT S

 S ECT IO N                                                                                    P AG E

 In tro d uc t i o n                                                                               3

 Cri t er ia f or R eq u es t i n g D ir ec t P ic k - Up b y H e lic o pt er                      3

 Es t im at e d T im e of Ar r i v a l ( E T A) vs . Ac t u al T i m e of Arr i va l ( AT A)       4

 O p era t io n a l Cr i t er ia F or He l ic o pt er T ra ns por t:                               4

 Me d ic a l Cri t er ia A lg or i thm For H e l ic op ter T ra ns p or t                          5

 W eather C o nd i t io ns                                                                         6

 Loc a l D is p a tc h C e nt er S t an d - B y R eq u es t Cr i ter i a                           6

 He l ic op te r A ut o - La u nc h Pr o gr am                                                     6

 La n d in g Zo n es ( LZ)                                                                         7

 Ra d io C o nt ac t                                                                               7

 P os t - L an d in g O p er at i o ns & Pa t ie nt Lo a di n g                                    8

 Re p ort i ng I nc i de nts                                                                       9



 SU P P LEM E NT S

 Fi gu re A - Em er g enc y Com m unic at i on C e nt er s B y C o un t y                         11

 Fi gu re C – B as e O per at i ons B y S er v ic e                                               12

 Fi gu re D – H e l ic o p ter Inc i de n t Re p or t F orm                                       13

 Fi gu re E – R eg i on a l E M S O f f ic e C on tac t I nf o rm ati on                          14




Appendix A                                                                                              A-   1
                    Hudson Valley Regional Emergency Medical Services Council, INC.
                        DRAFT Advanced Life Support Protocol Manual DRAFT



INT RO D UCT IO N
This document was created by the Hudson Valley – Westchester Helicopter Committee, an inter-regional advisory
group established by the Hudson Valley and Westchester Regional EMS Councils and the local air-medical
services. Its purpose is to serve as a guide for all emergency service agencies – law enforcement, fire departments
and EMS – in the lower seven counties of the Hudson River Valley (geographically north to south, west to east) –
Sullivan, Ulster, Dutchess, Orange, Putnam, Rockland, and Westchester. In today’s environment of increasingly
scarce EMS resources, appropriate use of air-medical services is of the utmost importance. Adherence to the
practices included in this handbook will help to ensure that the proper resources are provided to the right patients at
the right time while maintaining safe and efficient EMS operations.




CR IT ER I A FO R R EQ U E ST ING D IR E CT P IC K UP O F P AT I ENT S BY HE LI C O PT ER
Helicopter Transport is an air ambulance and an extension of EMS. It should be considered in situations wherein
the transport of critically ill or injured patient(s) to an appropriate facility will be faster by helicopter than by ground
ambulance if time is determined to be a factor in patient care.
Police, Fire, or EMS will evaluate the situation or condition and if necessary, request that air medical services be
dispatched. This is done anywhere in the region by radio with the appropriate County Communication Center
       3
(ECC).
The helicopter can be requested to respond to the scene when:


             a. ALS personnel request air medical transport.
             OR
             b. BLS personnel request air medical transport when ALS is delayed or unavailable.
             OR
             c.    In the absence of an EMS provider, any emergency agency may request air medical services.



                                                  I M P O R T A N T

          WHEN EMS ARRIVES, THEY SHOULD ASSESS THE SCENE. IF IT IS LATER DETERMINED BY THE HIGHEST
          TRAINED EMS PROVIDER ON THE SCENE THAT THE HELICOPTER IS NOT NEEDED, IT MUST BE CANCELLED AS
          SOON AS POSSIBLE.

          IF A HELICOPTER IS ALREADY ON THE SCENE, THE ONLY AGENCY THAT MAY CANCEL AN ADDITIONAL
          HELICOPTER IS THE HELICOPTER AGENCY ON THE SCENE.




3
    See FIGURE A
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                    Hudson Valley Regional Emergency Medical Services Council, INC.
                        DRAFT Advanced Life Support Protocol Manual DRAFT


ESTIMATED TIME OF ARRIVAL (ETA) vs ACTUAL TIME OF ARRIVAL (ATA)
Upon request for air medical transport, the dispatch center will issue an Estimated Time of Arrival (ETA) based
upon operational startup of the aircraft and travel time from point of origin to the call scene. If the ETA provided by
the dispatch center is greater than the time needed to secure and transport the patient to the nearest appropriate
         4
hospital by ground ambulance, TRANSPORT SHOULD BE COMPLETED BY GROUND AMBULANCE.
Once a helicopter is airborne, the pilot will use the aircraft’s onboard computer to calculate a more accurate ETA
based upon a global positioning system (GPS) coordinates and wind conditions. The crew will attempt to
communicate this updated ETA to the scene personnel. In the event that contact cannot be made, the dispatch
center will be requested to regain radio communications with the ground units and provide them the updated ETA.
If the updated ETA provided by the helicopter crew or dispatch center is greater than the time needed to secure
                                                                  5
and transport the patient to the nearest appropriate hospital by ground ambulance, TRANSPORT SHOULD BE
COMPLETED BY GROUND AMBULANCE.
The Actual Time of Arrival (ATA) is when the helicopter has reached the location of the scene (at high orbit.) All
communications and times should be recorded by scene personnel for their records, especially when care of the
patient was transferred to the air medical personnel.


O P E R AT IO N AL C RIT E RI A FO R H EL ICO PT E R T R AN S P O RT
The following operational criteria MUST be met prior to requesting a helicopter for direct pickup of patients:
1. Ground transportation to the appropriate critical care facility will exceed thirty (30) minutes.
                                                                            6
2. The helicopter can be airborne and return to the nearest appropriate hospital faster than an ambulance can
   transport the patient(s) to the nearest appropriate hospital.
                                                     7
3. A proper helicopter-landing site is available.
Appropriate utilization of helicopter resources at an emergency scene includes, but is not limited to:
1. A patient’s condition warrants transportation to a specialty care facility as indicated by specific State or
   Regional Protocols and the helicopter can complete such transportation faster than ground transportation.
2. A Multiple Casualty Incident (MCI) threatens to overload local capabilities.
3. Ground transportation is compromised.
4. Difficult access situations such as wilderness rescue, ambulance access or egress impeded at the scene by
   road conditions, weather or traffic, or other situations cleared by the flight team.
Ground providers should notify dispatch if more than one patient requires air transport. If available, one helicopter
will be dispatched per critical patient requiring air transport.
Note: Patients in cardiac arrest Will Not be transported by helicopter - unless a situation exists where air transport
would be faster than ground transport to the Nearest hospital.


M ED IC A L CR IT E RI A A LG O RIT H M FO R H E LI CO PT ER T RA N S PO RT
The following medical criteria MUST be met prior to requesting a helicopter for direct pickup at a scene of patients.
(See next page)




4
  See Medical Criteria Algorithm for appropriate facility type.
5
  See Medical Criteria Algorithm for appropriate facility type.
6
  See Medical Criteria Algorithm for appropriate facility type.
7
  See Landing Zone Criteria
Appendix A                                                                                                        A-     3
                  Hudson Valley Regional Emergency Medical Services Council, INC.
                      DRAFT Advanced Life Support Protocol Manual DRAFT

              M EDIC AL CR IT E RI A AL G O RIT HM FO R H E LICO PT E R T R AN S P O RT (co nt’d):

                                 MEASURE VITAL SIGNS AND LEVEL OF CONSCIOUSNESS
                              GLASGOW COMA SCALE                      < 13
                              SYSTOLIC BLOOD PRESSURE                 < 90
                              RESPIRATORY RATE                    < 10 OR > 29
                              PULSE RATE                       < 50 OR > 120 BPM

                     YES                                                    NO
                                                                            
TRANSPORT TO AREA/ REGIONAL TRAUMA CENTER                                 ASSESS ANATOMY OF INJURY
                                                                                                 

   PENETRATING INJURIES TO HEAD, NECK, TORSO AND EXTREMITIES PROXIMAL TO ELBOW AND KNEE
   TWO OR MORE SUSPECTED PROXIMAL LONG BONE FRACTURES
   SUSPECTED FLAIL OR UNSTABLE CHEST
   SUSPECTED SPINAL CORD INJURY OR LIMB PARALYSIS
   AMPUTATION (EXCEPT DIGITS)
   SUSPECTED PELVIC FRACTURE
   OPEN OR DEPRESSED SKULL FRACTURE
   SUSPECTED HEAD INJURY RESULTING IN NEUROLOGICAL COMPROMISE
   FACIAL / AIRWAY BURNS, ELECTRICAL BURNS, OR BURNS >15% BSA

                     YES                                                   NO
                                                                           
TRANSPORT TO AREA/ REGIONAL TRAUMA CENTER                         EVALUATE FOR MECHANISM OF INJURY
                                                                                                 

        EJECTION OR PARTIAL EJECTION FROM AUTOMOBILE
        DEATH IN SAME PASSENGER COMPARTMENT
        EXTRICATION TIME > 20 MINUTES
        VEHICLE COLLISION RESULTING IN (12 INCHES OF INTRUSION INTO PASSENGER COMPARTMENT, STEERING WHEEL
         DISPLACEMENT, AND / OR STARRED WINDSHIELD)
        MOTORCYCLE / ATV / BICYCLE CRASH >20 MPH OR WITH SEPARATION OF RIDER FROM BIKE OR VEHICLE
        FALLS > 20 FEET OR > 3 TIMES PATIENT’S HEIGHT
        ROLLOVER (90 DEGREE VEHICLE ROTATION OR MORE) WITH UNRESTRAINED OCCUPANT
        VEHICLE VS. PEDESTRIAN OR BICYCLE COLLISION ABOVE 5MPH

                        YES                                                          NO
                                                                                     

TRANSPORT TO AREA/ REGIONAL TRAUMA CENTER                TRANSPORT TO REGIONALLY APPROVED HOSPITAL


                                   AUTOMATIC REGIONAL TRAUMA CENTER CRITERIA

        PEDIATRIC TRAUMA PATIENTS < 12 Y/O
        THORACIC TRAUMA WITH RESPIRATORY DISTRESS OR SIGNS OF SHOCK
        LIMB AMPUTATION / SEVERE CRUSHING INJURY REQUIRING REIMPLANTATION OR RECONSTRUCTION
        UNSTABLE MULTI SYSTEMS TRAUMA WITH ASSOCIATED OPEN PELVIC FRACTURE
        FACIAL / AIRWAY BURNS, ELECTRICAL BURNS, OR BURNS >15% BSA


                   SPECIAL CONSIDERATIONS FOR TRANSPORT TO REGIONAL OR AREA TRAUMA CENTER

        AGE <5 OR >55 Y/O
        CARDIAC AND/OR RESPIRATORY DISTRESS DISEASE
        INSULIN DEPENDANT DIABETIC, CIRRHOSIS OR MORBID OBESITY
        PREGNANCY
        IMMUNOSUPRESSED PATIENT
         (HIV DISEASE, TRANSPLANT PATIENTS AND PATIENTS ON CHEMOTHERAPY TREATMENT)
        PATIENTS WITH BLEEDING DISORDER (HEMOPHILIA, ANTICOAGULANTS)
    CARDIAC ARREST AND PATIENTS WITH AN UNMANAGEABLE AIRWAY WILL BE TRANSPORTED TO THE CLOSEST
                                        APPROPRIATE HOSPITAL.




Appendix A                                                                                              A-   4
                    Hudson Valley Regional Emergency Medical Services Council, INC.
                        DRAFT Advanced Life Support Protocol Manual DRAFT


W EA TH E R CO N DI TIO NS
Air-medical agencies abide by strict weather minimums to ensure the safety of their flight team and the patient.
However, ground emergency service personnel generally underestimate the aircraft's flight abilities during
inclement weather. The helicopter is capable of safe flight through mild to moderate rain, snow and winds.
Weather requirements are primarily based upon the following indicators:
         CEILING: Height of the clouds above the ground.
         VISIBILITY: Distance visible in front of the aircraft.
Also, the "LOCAL" flying area encompasses the lower seven counties of the Hudson River Valley (geographically
north to south, west to east) – Sullivan, Ulster, Dutchess, Orange, Putnam, Rockland, and Westchester. (Anything
outside of this area would be considered "CROSS-COUNTRY"). Atmospheric conditions on scene may be quite
different than those at the dispatch point of the aircraft.
For all of these reasons, emergency service personnel at the scene are encouraged NOT to make weather
decisions on their own.
If the air transport of a patient is being considered, ground emergency services should contact the appropriate
                                                                                               8
County ECC who will advise whether or not the air medical transportation service is available.
DI S P AT C H C ENT E R S T AN D - BY C RIT ER A
                                                                                                             9
A ―STAND-BY‖ procedure may be requested by any local dispatch center to the appropriate County ECC based
upon the report of the following:
         Gas or other type explosion
         Severe burn injury
         Head on collision of motor vehicles
         Motor vehicle crash involving an all terrain vehicle (ATV) or motorcycle
         Any incident with the potential of producing mass casualties
Under these circumstances:
1. The appropriate County ECC will contact the AIR MEDICAL dispatch center to have the air medical crew
   ―STAND-BY‖.
2. Responding EMS crews will be advised that a ―STAND-BY‖ has been requested by the ECC.
3. Once EMS have arrived and assessed the need for air medical services, a determination to launch or cancel
   the assigned helicopter will be made by the highest trained EMS provider on the scene.
4. As soon as it is determined from the scene that the helicopter is or is not needed, the requesting County ECC
   shall notify the AIR MEDICAL dispatch center.
HE LI CO PT ER AUT O - L AU N C H P RO G R AM
Due to the size of the area covered in the lower Hudson River Valley by the air-medical services, and the increased
flight times needed to reach locations at its farthest boarders, an ―Auto-Launch‖ procedure will be used based upon
the following:
1. Upon request to place a helicopter on ―STAND-BY‖, the AIR MEDICAL dispatch center will determine the
   estimated distance (in miles) from the assigned helicopter unit to the incident scene;
2. If it is determined that the incident scene is greater than 25 miles away from the assigned helicopter unit, the
   AIR MEDICAL dispatch center will automatically dispatch the unit to the scene;
3. The AIR MEDICAL dispatch center will then notify the requesting County ECC of the Auto-Launch status;


8
    See FIGURE B
9
    See FIGURE A
Appendix A                                                                                                       A-   5
                   Hudson Valley Regional Emergency Medical Services Council, INC.
                       DRAFT Advanced Life Support Protocol Manual DRAFT

4. As soon as it is determined from the scene that the helicopter is or is not needed, the requesting County ECC
   shall notify the AIR MEDICAL dispatch center;
5. If for any reason the helicopter unit arrives prior to this decision being made by the requesting agency, the
   helicopter will remain in the vicinity of the scene until the request to have the unit land is confirmed either with
   the AIR MEDICAL dispatch center or directly with the requesting agency or upon notification that the unit has
   been cancelled;
6. As soon as it is determined from the scene that the helicopter unit will be utilized, the requesting County ECC
   shall notify the AIR MEDICAL dispatch center of the utilization request and the unit will be advised to proceed
   to the landing zone under standard helicopter request procedures.


L AN DI NG ZO N E S
The landing zone (LZ) is an area intended for the purpose of landing and taking off in the helicopter. The
preparation of an LZ is one of the primary functions of the ground personnel. Proper preparation is essential to the
safe operation of an air-medical mission.
The LZ should be adjacent to the scene to avoid the need for intermediate transport that could prolong a patient's
prehospital time. A helicopter should be as close to the scene as possible and practical.
When a hospital’s helipad is determined to be the most appropriate landing zone to effectuate field transfer of a
patient from EMS to air medical services, notification shall be made from the County ECC to the hospital as soon
as possible.




LZ Criteria
The minimum area of the LZ should not change:



                                          MINIMUM LANDING ZONE AREA

                                        Length                      100 feet

                                         Width                      100 feet



Although past local practice has been to allow for a smaller LZ during the day, due to the possibility of requesting
air medical services from other neighboring areas with larger airships, having one uniform size is preferable.
An LZ must also be:
       Free of overhanging obstructions.
       Generally level. (Slope should not be greater than 5 degrees)
       On a firm surface. (If unpaved, shrubs, brush, grass or weeds should be less than 24 inches in height.)


Marking the LZ
Mark the four corners of the LZ. The use of flares for marking the LZ is discouraged because of the inherent fire
risk. The preferred means of LZ marking is by placement of orange traffic cones at each corner. For night
operations, a flashlight can be placed in each cone for illumination. The cones will likely blow over as the aircraft
makes its final approach into the LZ. This occurrence should not concern the ground providers, as the cones are
not light enough to be blown airborne into the rotor system.


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                  Hudson Valley Regional Emergency Medical Services Council, INC.
                      DRAFT Advanced Life Support Protocol Manual DRAFT



R AD IO CO NT ACT
As the flight team approaches the LZ, they will contact you on your own radio frequency. When radio contact is
made, it is imperative that the flight crew communicates with the Landing Zone Officer, the one person assigned to
establish and secure the landing zone. The LZ Officer should describe the LZ, any hazards in the area, wind
direction, condition of the touchdown surface, and security information (i.e. crowd is secured and traffic is stopped).
NOTE: Pay special attention to looking for overhead wires and reporting their location to the pilot when the
helicopter arrives overhead.


PO ST - L AN D ING O P E R AT IO N S & P AT I ENT LO AD IN G
Once a helicopter has landed, the following should be observed:
   Assure that no one approaches the helicopter or enters the LZ unless directed to do so by the flight team.
   Never allow a vehicle to drive up to the helicopter.
   If you are directed to approach the helicopter by the flight team, NEVER approach the rear of the helicopter,
    only approach from the front. The tail rotors are invisible when spinning. (See diagrams)




Assisting In Loading The Patient
The flight team will ask for four (4) responders to assist in carrying and loading the stretcher into the aircraft after
the patient has been prepared. Follow the flight team’s direction when carrying the patient toward the aircraft.
Please do not allow more than four (4) responders to assist in the carry unless directed to by the flight team. Once
the patient has been loaded into the rear of the helicopter, exit the LZ by the same direction that you used to enter.
Never attempt to operate any of the aircraft doors or the stretcher-securing device.


P ati ent “ HO T” O f f - Lo adi ng
When a patient is off loaded from the aircraft while the rotors are turning and engines remain running, it is classified
as a ―HOT‖ off-load and requires the following:
    1. Aircraft medical crew determine that a ―HOT‖ off-load will be necessary;
    2. Notification is made to the AIR MEDICAL dispatch center from the medical crew that a ―HOT‖ off load will
       be necessary;
    3. AIR MEDICAL dispatch center will alert the receiving hospital Emergency Department of the aircraft’s
       ―HOT‖ off load status;
    4. A member of the aircraft crew or medical team must be in position at the tail rotor prior to hospital
       personnel approaching the aircraft.

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                     Hudson Valley Regional Emergency Medical Services Council, INC.
                         DRAFT Advanced Life Support Protocol Manual DRAFT



A patient may be “HOT” off-loaded for the following reasons:
    1. Patient with failed airway
    2. Patient in extremis
    3. Adverse weather consideration
    4. Pending mission.
    5. All scene calls arriving at Westchester Medical Center’s Emergency Department Heli-stop


RE P O RT ING I NC ID E N T S
Note: The New York State Department of Health Bureau of EMS (NYSDOH BEMS) mandates specific incident
reporting responsibilities and requirements for all EMS services. Incidents identified must be reported as indicated
in NYCRR, Part 800, Section 21(q) 1-5 and Section 21(r), Part 80, 80.136 (k), NYSDOH BEMS Policy Statement
98-11, as well as other applicable state and regional policies and procedures.
Regional complaints or concerns involving air medical services may be made by a patient, the public, participating
organizations or individual providers. All such complaints or concerns should be brought to the attention of the
Executive Director of the appropriate Regional EMS Council.
           Appropriate grounds for Regional air medical services complaints or concerns include:
              7. Deviation from accepted standards. (e.g. protocols, advisories, policies, procedures, equipment
                  and medication schedules).
                  Note: Especially those practices specifically related to air medical operations such as the provision
                  of accurate ETA information so that appropriate patient transportation decisions may be made by
                  ground crews.
              8. Unprofessional conduct (Including but not limited to: disrespect towards patients, families, fellow
                  providers, intoxication while on duty, breaking patient confidentiality, etc.)
              9. Practicing without proper NYS or Regional certification
              10. Immoral or indecent behavior
              11. Fraud, falsification of records, unauthorized possession or misappropriation of property
              12. Insubordination (The scope of which rose to a level that threatened patient care and/or patient or
                  provider safety.)
In order to handle complaints or concerns regarding the delivery of emergency air-medical services, the following
procedure has been established. Additionally, all deviations from or complications to effective transfer of care from
ground Emergency Services to Air Medical Services will be reported to the Regional Helicopter Committee for
evaluation:
           Complaints or concerns will be handled by the following process:
         8. Complaint or concern is brought to the attention of the Executive Director of the appropriate Regional
                                                                                                  10
             EMS Council, who may request written documentation of the complaint or concern.
         9. Executive Director confers with the appropriate authorized representative of the involved organization(s)
             and, if applicable, the EMS Provider(s), Nurse(s) or Physician(s) identified in the complaint.
         10. The Executive Director sends written notification of the alleged infraction to the Regional Medical
             Director, the Regional Helicopter Committee, and the appropriate authorized representative of the
             involved organization(s).




    10
         See FIGURE C

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                Hudson Valley Regional Emergency Medical Services Council, INC.
                    DRAFT Advanced Life Support Protocol Manual DRAFT

     11. The alleged infraction will be brought before the Regional Helicopter Committee for investigation and
         discussion. The Regional Helicopter Committee will report back to the appropriate Regional Executive
         Director its findings and suggested corrections.
     12. Based upon the complaint and the report from the Regional Helicopter Committee, the Executive Director
         in conjunction with the Regional Medical Director may choose any of the following options:
           a. Decide the complaint or concern is unwarranted, and report the matter concluded to the Regional
               Emergency Medical Advisory Committee (REMAC).
           b. Decide the complaint or concern is warranted, and refers the matter to the Evaluation Committee of
               the REMAC.
           c. Decide the complaint or concern is warranted, resolved by discussion amongst, Executive Director,
               Regional Medical Director, Evaluation Committee Chairperson, party making complaint, and
               involved individual / agency.
           d. If there is a serious infraction, the Executive Director may confer immediately with the Regional
               Medical Director, and Evaluation Sub-Committee Chairperson, then hold a meeting of same with
               the named party and one representative of his/her organization. The Regional Medical Director, in
               conjunction with the Executive Director and Chairman of the Evaluation Sub-Committee, may
               suspend the named party’s Regional credentials, if applicable. The Evaluation Sub-Committee will
               meet within fourteen (14) days to issue a formal finding.
     13. If the credentials of any agency have been suspended, all Medical Control Hospitals, EMS agencies, and
         Emergency Communication Centers (ECC) will be notified in writing of the party's suspension. Only the
         Executive Director will notify the same in writing when the party has been reinstated.
     14. If the credentials of an individual have been suspended, all Medical Control Hospital and EMS agencies
         will be notified in writing of the party’s suspension. Only the Executive Director will notify the same in
         writing when the party has been reinstated.
     15. The Evaluation Sub-Committee will review, at their next scheduled meeting, complaints processed
         through steps 5 A-C above.
     16. In cases where it is the consensus of opinion of the Evaluation Sub-Committee that no follow-up action is
         warranted, the Chairman of the Evaluation Sub-Committee, or the Regional Medical Director, shall
         communicate that opinion in writing, to the complainant, the named party, and the named party's
         supervisor at his/her field agency or organization.




Appendix A                                                                                                   A-   9
                   Hudson Valley Regional Emergency Medical Services Council, INC.
                       DRAFT Advanced Life Support Protocol Manual DRAFT


FIG U R E A – Co unt y E me rg en c y C om mun ic ati on Ce nte r s ( E CC )

NO T E: R eq u es ts f or a ir m ed ic a l tr ans p ort s ho u l d b e m ad e t hr o ug h t h e a ppr o pr ia te Co u nty
EC C. T h is a l l ows f or c oor d i na t ed us e of r es ourc es , prev e nts d up l i c at e r e qu es ts f or t h e s am e
s c en e , an d pr ov i des f o r b et t er ov er a l l m a na g em e nt o f l oc a l em er g e nc y as s e ts .



                   ECC                                                                             Emergency
County                                 Radio Frequency
                   Designation                                                                     Phone

                                       465.450 - F-15 Field Ops; repeater (PL 114.8)
Dutchess           Dutchess 911                                                                    (845) 486-6560
                                       460.450 - F-16 Field Ops; non-repeater (PL 114.8)

                                       46.160 - F1 36 Control-to-units (123.0)
Orange             36 Control                                                                      (845) 469-4911
                                       46.220 - F1 Units-to-36 Control (123.0)

                                       46.38 - County Fire Communications - F-1
                                       (Dispatch)(PL 123.0)
                                       46.44 - County Fire Communications - F-5
Putnam             40 Control                                                                      (845) 225-4300
                                       (Control-to-mobile)(PL 127.3)
                                       46.54 - County Fire Communications - F-5
                                       (Mobile to control)(PL 127.3)

Rockland           44 Control          46.18 - F-1 - Dispatch/Operations (131.8)                   (845) 354-9000

                                       46.10 - Countywide Fire Communications -
Sullivan           53 Control                                                                      (845) 583-7100
                                       Dispatch (CSQ)

                                       46.46 - Countywide Fire Communications - F-1
                                       (Countywide dispatch) (114.8)
Ulster             56 Control                                                                      (845) 338-1440
                                       46.34 - Countywide Fire Communications - F-2
                                       (Unit to Control/Unit-to-unit) (114.8)

                                       46.26 - Dispatch/Operations (CSQ)
Westchester        60 Control          46.14 - Fireground/Command (CSQ)                            (914) 231-1900
                                       (commonly assigned for Air Medical usage)




Appendix A                                                                                                             A- 10
                    Hudson Valley Regional Emergency Medical Services Council, INC.
                        DRAFT Advanced Life Support Protocol Manual DRAFT


FIG U R E B – AI R M ED IC AL B AS E O P ER AT I O N S BY S ER V IC E

NO T E: T he l oc at i on of eac h bas e op er at i on i s be i n g pr ov id e d t o o f fer a n u n ders ta n d in g of th e
d is t anc es c ov er ed by eac h a ge nc y . W h en a ir m ed ic a l s erv ic e s ar e r eq u es t e d, e ac h EC C w i l l
at te m pt to ob t ai n t h e CLO S E ST a ir s h i p av a i l ab l e f or res p ons e t o t he e mer g enc y . D ep e nd i n g
on f ac t ors s uc h as w ea t her c o n d it i ons a t th e b as e l oc at i ons o r a c o mm i t me nt t o a n ot h er
m is s i o n, “ l oc a l ” s er v ic es m ay b e u n av a i l a bl e a nd a n a ir m e d ic a l s erv ic e fro m o u ts id e of t h e
l ow er H uds o n V a ll ey R iv er V a ll ey , or ev en ou t of s t at e, may ne e d to b e r e qu es te d .


                                                                                                         Air Medical
    Airship Unit                    Service                    Base Location
                                                                                                         Dispatch Entity

                                                               Westchester Medical Center
    STAT Flight Air 1               STAT Flight
                                                               Valhalla, NY                              LIFECOMM
    LN 7-3                          (LIFE NET)
                                                               (Westchester County)

                                                               Kobelt Airport
    STAT Flight Air 2               STAT Flight
                                                               Wallkill, NY                              LIFECOMM
    LN 7-4                          (LIFE NET)
                                                               (Ulster County)

                                                               Catskill Regional Medical Center
    Catskill Regional
                                    LIFE NET                   Harris, NY                                LIFECOMM
    LN 7-5
                                                               (Sullivan County)

                                    Mobile Life                Stewart Air National Guard Base
                                                                                                         Mobile Life Support
    LIFEGUARD                       Support Services           Newburgh, NY
                                                                                                         Services (MLSS)
                                    / NYS Police               (Orange County)

                                                               Albany County Airport
    LIFEGUARD                       Colonie EMS                                                          LIFECOMM
                                                               Albany, NY

                                                               Albany Medical Center
    Albany Med FLIGHT
                                    LIFE NET                   Albany, NY                                LIFECOMM
    LN 7-1
                                                               (Albany County)

    LIFE NET North                                             Glenn, NY
                                    LIFE NET                                                             LIFECOMM
    LN 7-2                                                     (Montgomery County)

                                                                                                         Regional
                                    UMDNJ / NJS                University Hospital                       Emergency Medical
    NORTH STAR
                                    Police                     Newark, NJ                                Communication
                                                                                                         System (REMCS)

                                                               Hartford Hospital                         Hartford Hospital
    LIFE STAR                       LifeStar
                                                               Hartford, CT                              ECC

                                    University of              Lehigh Valley International
    PENNSTAR 3                      Pennsylvania /             Airport                                   PENNCOMM
                                    PENNSTAR Flight            Allentown, PA




Appendix A                                                                                                                    A- 11
                    Hudson Valley Regional Emergency Medical Services Council, INC.
                        DRAFT Advanced Life Support Protocol Manual DRAFT
                            FIG U R E C - H EL ICO PT ER I NC ID E NT R E PO R T FO RM
            This form is to be filled out and forwarded to the appropriate Regional EMS Council in the event that
there is a deviation or complication to effective transfer of care from ground Emergency Services to Air Medical Services.
                                              Contact Information


Name                                                               Title

Contact #                                                          Email

Signature                                                          Date

                                              Incident Information

Date of Incident:                                  NYS PCR #:


Helicopter Service Involved:

Other Agencies / Parties Involved:

Requested By (i.e. EMT, Fire Chief etc.)

Requesting Dispatch Entity

Location of Incident:

Destination (If known):

Describe Incident : (Attach additional information if necessary)




                  Call Times
                                                                   For Regional EMS Office Use Only
Time of Incident:
                                                        Date Received:
Helicopter Requested:

Helicopter Enroute:

Helicopter Orbiting Scene:

Flight Crew Began Care:
                                                        Reviewed By:
Patient Loaded on Helicopter:

Helicopter Enroute to Hospital:

ETA of Helicopter Given:          (    ) Minutes
ETA to Hospital by Ground:        (    ) Minutes



Appendix A                                                                                                                   A- 12
               Hudson Valley Regional Emergency Medical Services Council, INC.
                   DRAFT Advanced Life Support Protocol Manual DRAFT

RE G IO N AL EM S O FFI CE C O NT ACT INF O R M AT IO N

Hudson Valley Regional EMS Council
45 Academy Avenue
Cornwall on Hudson, NY 12520
845-534-2430


Westchester Regional EMS Council
c/o Westchester County Department of Emergency Services
4 Dana Rd.
Valhalla, NY 10595
914-231-1616




Appendix A                                                                       A- 13
Advanced Life Support Protocols
          Appendix B
                       Hudson Valley Regional Emergency Medical Services Council, INC.
                           DRAFT Advanced Life Support Protocol Manual DRAFT

                                            91 1 R ec e iv ing H osp it al s B y Count y

   Legend:
                 H yp er bar ic Me d ic in e                                                       HM
                 B urn C e nt er                                                                   BR N
                 He l i pa d                                                                       HP
                 Le v e l 1 ( R e gi o na l) T r a um a C en t er                                  RT C
                 Le v e l 2 ( Ar e a) T r aum a C en t er                                          AT C
                 O bs t e tr ic S er vic es                                                        OB
                 Ne o na ta l I nt e ns i ve C a r e                                               NI C
                 P ed i atr ic I nt e ns i ve C a r e                                              P ED
                 Ps yc hi a tr ic S er v ic es                                                     PSY
                 Str ok e C en te r                                                                ST
                 T her a p eu t ic Ca r d i ac C at h eri za t i o n C en te r                     TC

   NO T E:    Th e fac i l it i es n ot e d i n th e c h art b e l ow ar e ac c ura t e as of J an u ary 2 6, 2 0 06 . Pr ior t o
              tra ns por t, hos p it a l c a p ab i l it i es s h ou l d b e v er i fi e d by o n - s c en e E MS pers o n ne l d ir ec t ly
              wi t h on- l i n e Me d ic a l C on tr ol or thr o u gh t h e l oc a l EC C. Pl e as e v is it t he H u ds o n V a l l ey
              Re g io n a l E MS Co u nc il ’s w eb s it e at w ww . hv r ems c o .or g f or c h art u p da t es .


Dutchess                               Location             Trauma BRN           PED     NIC     OB       TC     HM      HP      ST      PSY


Northern Dutchess Hospital             Rhinebeck                                                 ●                               ●
St. Francis Hospital                   Poughkeepsie           ATC                                                        ●       ●         ●
Vassar Brothers Medical Center         Poughkeepsie                                      ●       ●        ●              ●       ●
Orange                                 Location             Trauma BRN           PED     NIC     OB       TC     HM      HP      ST      PSY


Bon Secours Community Hospital Port Jervis                                                       ●                                         ●
Keller Army Community Hospital         West Point                                                                        ●
Orange Regional M.C. Arden Hill        Goshen                                                    ●                       ●       ●         ●
Orange Regional M.C. Horton            Middletown                                                ●                               ●
St. Anthony Community Hospital         Warwick                                                   ●
St. Luke's Cornwall Hospital
Cornwall Campus
                                       Cornwall                                                                                  ●
St. Luke’s Cornwall Hospital
Newburgh Campus
                                       Newburgh                                                  ●                               ●

                           91 1 R ec e iv ing H osp it al s B y Count y - Continued on next page



   Appendix B                                                                                                                         B-       1
                       Hudson Valley Regional Emergency Medical Services Council, INC.
                           DRAFT Advanced Life Support Protocol Manual DRAFT
                                   91 1 R ec e iv ing H osp it al s B y Count y - Co nt’ d

Putnam                              Location          Trauma BRN     PED    NIC    OB        TC   HM   HP   ST    PSY


Putnam Hospital Center              Carmel                                         ●                        ●         ●
Rockland                            Location          Trauma BRN     PED    NIC    OB        TC   HM   HP   ST    PSY


Good Samaritan Hospital             Suffern            ATC                         ●         ●         ●    ●         ●
Nyack Hospital                      Nyack              ATC                                                  ●
Sullivan                            Location          Trauma BRN     PED    NIC    OB        TC   HM   HP   ST    PSY


Catskill Regional Medical Center    Catskill                                       ●                   ●              ●
Catskill Regional Medical Center    Callicoon


Ulster                              Location          Trauma BRN     PED    NIC    OB        TC   HM   HP   ST    PSY


Benedictine Hospital                Kingston                                       ●                   ●    ●         ●
Ellenville Community Hospital       Ellenville


Kingston Hospital                   Kingston                                       ●
Westchester                         Location          Trauma BRN     PED    NIC    OB        TC   HM   HP   ST    PSY


Dobbs Ferry Community Hospital      Dobbs Ferry


Hudson Valley Hospital Center       Cortlandt Manor                          ●     ●                   ●    ●
Lawrence Hospital                   Bronxville                               ●     ●                        ●
Northern Westchester
Hospital Center
                                    Mt. Kisco                                ●     ●                        ●         ●
Phelps Memorial Hospital            Sleepy Hollow                                  ●         ●              ●         ●
Sound Shore Medical Center          New Rochelle       ATC                   ●     ●                        ●
St. Johns Riverside Hospital        Yonkers (North)                                ●                        ●
St. Joseph's Medical Center         Yonkers (South)                                                         ●
The Mt. Vernon Hospital             Mt. Vernon                                                    ●         ●         ●
Westchester Medical Center          Valhalla           RTC      ●     ●      ●     ●         ●    ●    ●    ●         ●
White Plains Hospital Center        White Plains                             ●     ●                        ●
   Appendix B                                                                                                    B-   2
                 Hudson Valley Regional Emergency Medical Services Council, INC.
                     DRAFT Advanced Life Support Protocol Manual DRAFT

                                Medical Control Hospital Information
                          Hospital                Disp Code Medical Control Phone
                                             Dutchess
                           Vassar                    134           845-454-7872
                        Saint Francis                136           845-431-8220
                     Northern Dutchess               132           845-876-7411
                                              Orange
             Saint Luke’s/Cornwall-Newburgh          357           845-562-1177
                      ORMC-Arden Hill                351           845-294-4886
                       ORMC-Horton                   354           845-342-7107
              Bon Secours Community Hospital         353           845-858-8611
              St. Anthony Community Hospital         363           845-987-5125
                                               Ulster
                      Kingston Hospital              553           845-334-2885
                                              Putnam
                      Putnam Hospital                392           845-279-4179
                                             Rockland
                      Good Samaritan                 431           845-368-5313
                       Nyack Hospital                436           845-358-0401
                                             Sullivan
                      Catskill Regional              796           845-794-2116
                                               Other
                Westchester Medical Center           803           914-493-7311
                Hudson Valley (Westchester)          825           914-734-3397
                    Sharon (Connecticut)             998           860-364-4111

                            Hudson Valley Regional Trauma Centers

                       Hospital                              Address
             Westchester Medical Center    Office of Emergency Medical Services and Trauma
               Level I Trauma Center       Macy Pavilion, Room 1423
                                           Valhalla, New York 10595
               Good Samaritan Hospital     255 Lafayette Avenue
                Level 2 Trauma Center      Suffern New York 10901-4869

                   Nyack Hospital          160 North Midland Avenue
                Level 2 Trauma Center      Nyack, New York 10960

                Saint Francis Hospital     241 North Road
                Level 2 Trauma Center      Poughkeepsie, New York 12601




Appendix B                                                                                   B-   3
             Hudson Valley Regional Emergency Medical Services Council, INC.
                 DRAFT Advanced Life Support Protocol Manual DRAFT

                          Additional Hospital Disposition Codes
             Albany                     Westchester                  New York City
Albany Medical Center    018 Blythesdale Children’s 821                  Bronx
  St. Peter’s Hospital   015     Community Hospital     804       Montefiore MC         639
       Albany VA         016     Lawrence Hospital      806    Our Lady of Mercy        627
            Columbia           Mount Vernon Hospital 808         Saint Barnabas         629
  Columbia-Greene        101      New Rochelle MC       809         Bronx VA            634
            Delaware            Northern Westchester    810              Kings
   Bassett Hospital      125 Hudson Valley Hospital 825             Brookdale           902
   Delaware Valley       122      Phelps Memorial       812  Kings County Hospital      672
Margaretville Memorial   123     St. Agnes Hospital     813      Wyckoff Heights        935
            Dutchess             St. John’s Hospital    814            New York
    Castle Point VA      135    St. Joseph’s Hospital   815     Bellevue Hospital       712
             Orange             United Medical Center 816          Cabrini MC           715
  Arden Hill Hospital    351         Montrose VA        805    Lenox Hill Hospital      728
   Cornwall Hospital     352      Westchester MC        803   Mount Sinai Hospital      734
St. Anthony’s Hospital   363    White Plains Hospital   817   NYU Medical Center        719
 Keller Army Hospital    359      Yonkers General       818   Presbyterian Hospital     742
            Rockland                    Out of State          St. Luke’s-Roosevelt      745
Helen Hayes Hospital     437         Connecticut        830   St. Vincent’s Hospital    748
          Schenectady              Massachusetts        840       Manhattan VA          724
      Ellis Hospital     462         New Jersey         850             Queens
  St. Clares Hospital    464        Pennsylvania        860 Long Island Jewish MC       763
             Ulster                    Vermont          870      Astoria General        761
  Ellenville Hospital    552                                    Jamaica Hospital        768




Appendix B                                                                             B-   4
                Hudson Valley Regional Emergency Medical Services Council, INC.
                    DRAFT Advanced Life Support Protocol Manual DRAFT

                                       Location Codes
             Rockland                      Orange                           Ulster
         Airmont          4338        Blooming Grove     3550           Denning        5550
     Chestnut Ridge       4335            Chester        3551           Ellenville     5526
       Clarkstown         4350      Cornwall-on-Hudson   3522           Esopus         5552
  Grandview-on-Hudson     4323            Cornwall       3552           Gardiner       5552
       Haverstraw         4351            Crawford       3553         Hardenburgh      5553
         Hillburn         4327           Deer Park       3554            Hurley        5554
          Kaser           4337             Florida       3534        Kingston (City)   5501
       Montebello         4336            Goshen         3555       Kingston (Town)    5555
      New Square          4331           Greenville      3556             Lloyd        5556
    New Hempstead         4334       Greenwood Lake      3533         Marbletown       5557
          Nyack           4324         Hamptonburg       3557         Marlborough      5558
      Orangetown          4352           Harriman        3530          New Paltz       5559
        Piermont          4325         Highland Falls    3524             Olive        5560
        Pomona            4332           Highlands       3558           Pine Hill      5525
        Ramapo            4353          Kiryas Joel      3537           Plattekill     5561
       Sloatsburg         4330           Maybrook        3532          Rochester       5562
      South Nyack         4326          Middletown       3501          Rosendale       5563
      Spring Valley       4328            Minisink       3559          Saugerties      5564
       Stony Point        4354            Monroe         3560          Shandaken       5565
         Suffern          4329          Montgomery       3561         Shawangunk       5566
      Upper Nyack         4320          Mount Hope       3562            Ulster        5567
      Wesley Hills        4333         New Windsor       3564          Wawarsing       5568
    West Haverstraw       4322        Newburgh (City)    3502          Woodstock       5569
                                     Newburgh (Town)     3563
             Dutchess                     Otisville      3531              Sullivan
          Amenia          1350           Port Jervis     3535            Bethel        5250
          Beacon          1301             Tuxedo        3565        Bloomingburg      5224
         Beekman          1351         Tuxedo Park       3536          Callicoon       5251
          Clinton         1352           Unionville      3525          Cochecton       5252
           Dover          1352            Walden         3528          Delaware        5253
       East Fishkill      1354             Wallkill      3566          Fallsburg       5254
          Fishkill        1320            Warwick        3567         Forestburgh      5255
        Hyde Park         1356        Washingtonville    3520           Fremont        5256
         Lagrange         1357          Wawayanda        3568           Highland       5257
           Milan          1358           Woodbury        3569        Jeffersonville    5225
         Millbrook        1328                                           Liberty       5258
         Millerton        1321              Putnam                    Lumberland       5259
         Northeast        1359          Brewster         3922         Mamakating       5260
          Pawling         1360           Carmel          3950          Monticello      5222
        Pine Plains       1361         Cold Spring       3920          Neversink       5261
      Pleasant Valley     1362             Kent          3951          Rockland        5262
    Poughkeepsie (City)   1302         Nelsonville       3921          Thompson        5263
   Poughkeepsie (Town)    1363          Patterson        3952            Tusten        5264
         Red Hook         1364         Phillipstown      3953         Woodridge        5223
        Rhinebeck         1365        Putnam Valley      3954          Wurtsboro       5221
         Stanford         1366          Southeast        3955
           Tivoli         1326
        Union Vale        1367
        Wappinger         1368
     Wappingers Falls     1324
        Washington        1369




Appendix B                                                                             B-   5
Advanced Life Support Protocols
         Appendix C
               Hudson Valley Regional Emergency Medical Services Council, INC.
                   DRAFT Advanced Life Support Protocol Manual DRAFT

                                 PHYSICIAN RELEASE FORM

AGENCY NAME_________________________________                  RUN #___________________
WARNING THE SIGNING OF THIS DOCUMENT CONSTITUTES THE ASSUMPTION OF
LEGAL LIABILITY BY THE SIGNER FOR THE CARE AND TREATMENT OF THE PATIENT
NAMED BELOW.
The physician whose signature appears below, by subscribing this instrument acknowledges
that:
   1. He/she is aware that the ambulance or rescue squad, named above, called to attend the
      below named patient, is operating under the coordination of the Hudson Valley Regional
      Emergency Medical Services. (Hereinafter referred to as HVREMS).
   2. That the HVREMS supplies coordination for Basic and Advanced Life Support Systems in
      this geographical area.
   3. That there is available to the ambulance or rescue squad, named above, a
      communications system capable of eliciting advice and instruction for the care and
      treatment of this patient by trained emergency physicians under a system of protocols and
      procedures subscribed to by physicians in the geographical area served by HVREMS.
   4. That the undersigned physician assumes full responsibility for the care and treatment of the
      patient named below and by his/her signature agrees to hereby forever release and
      discharge HVREMS, its agents, servants or employees and the attending ambulance or
      rescue unit and its/their agents, servants or employees from any cause of action
      whatsoever, including but not limited to, any action ever as a defendant in a lawsuit
      brought by the patient or his/hers heirs, executors, administrators or assigns against said
      HVREMS and/or the ambulance or rescue squad named above, by reason of the care and
      treatment tendered to said patient under the orders and control of said undersigned
      physician.

WARNING THIS IS AN ASSUMPTION OF LEGAL RESPONSIBILITY FOR CARE OF THIS
PATIENT AND AN INDEMNIFICATION TO AND RELEASE OF HVREMS AND THE
ATTENDING AGENCY.

IN WITNESS WHEREOF, I have hereunto set my hand and seal this ____day of _________,
20_____.

__________________________________
PHYSICIAN SIGNATURE

Physician:   Name     ___________________________________________
             Address ___________________________________________
             City     _______________________ State_____________ Zip _____________


Patient:     Name     ___________________________________________
             Address ___________________________________________
               City   _______________________ State_____________ Zip _____________
Appendix C                                                                                  C-   1
Advanced Life Support Protocols
         Appendix D
                 Hudson Valley Regional Emergency Medical Services Council, INC.
                     DRAFT Advanced Life Support Protocol Manual DRAFT
                                             Equipment List
                                                                    Quantity
                                  Item                                             I   CC        P
                                                                    Required
                                                   Required
12-14G 2‖ Over-the-needle Catheter for Pleural Decompression           2               X         X
14G IV Catheter                                                        3           X   X         X
16G IV Catheter                                                        3           X   X         X
18G IV Catheter                                                        3           X   X         X
20G IV Catheter                                                        3           X   X         X
22G IV Catheter                                                        3           X   X         X
24G IV Catheter                                                        3           X   X         X
1cc Syringes                                                           3               X         X
3cc Syringes                                                           3               X         X
5cc Syringes                                                           3               X         X
10cc Syringes for ET Sets                                              2           X   X         X
10cc Syringes for Medication Administration                            3               X         X
20cc Syringes                                                          2               X         X
18G Needles                                                            3               X         X
23G IM Needles                                                         3               X         X
27G SQ Needles                                                         3               X         X
2.5 Uncuffed Endotracheal Tube                                         2           X   X         X
3.0 Uncuffed Endotracheal Tube                                         2           X   X         X
3.5 Uncuffed Endotracheal Tube                                         2           X   X         X
4.0 Uncuffed Endotracheal Tube                                         2           X   X         X
4.5 Uncuffed Endotracheal Tube                                         2           X   X         X
5.0 Endotracheal Tube                                                  2           X   X         X
6.0 Endotracheal Tube                                                  2           X   X         X
7.0 Endotracheal Tube                                                  2           X   X         X
8.0 Endotracheal Tube                                                  2           X   X         X
Adult End-Tidal Monitor (Colorimetric or Capnography)                  1           X   X         X
Adult Laryngoscope Handles                                             2           X   X         X
Adult Magill Forceps                                                   1           X   X         X
Adult Stylet                                                           2           X   X         X
Blood Tube Sets (Amount and Type Determined by Agency)                 2           X   X         X
Automated External Defibrillator (AED)                                 1           X
EKG Monitor/Defibrillator with Pacing Capabilities                     1               X         X
    o Adult Pacing Pads                                                1               X         X
    o Defibrillation Gel/Defibrillation Pads                           1           X   X         X
    o Electrodes                                                      10           X   X         X
    o Monitor Cables                                                   1           X   X         X
    o Pacing Cables                                                    1               X         X
    o Pediatric Pacing Pads                                            1               X         X
    o Pediatric Defib. Paddles or Pads                               1 pair        X   X         X
    o Spare EKG Battery                                                1           X   X         X
    o Spare EKG Paper                                                  1           X   X         X
Glucometer                                                             1               X         X
Glucometer Strips                                                      5               X         X




Appendix D                                                                                  D-   1
                 Hudson Valley Regional Emergency Medical Services Council, INC.
                     DRAFT Advanced Life Support Protocol Manual DRAFT
                                       Equipment List(Continued)
                                                                       Quantity
                                   Item                                                I   CC        P
                                                                      Required
Hand-Held Nebulizers                                                      3            X   X         X
Adult and Pediatric Intraosseous Needles                                  2            X   X         X
Macintosh Laryngoscope Blades                                        4 Asst Sizes      X   X         X
Macrodrip Administration Sets                                             4            X   X         X
Meconium Aspirator                                                        1            X   X         X
Microdrip Administration Sets                                             6            X   X         X
Miller/Wisconsin Laryngoscope Blades                                 4 Asst Sizes      X   X         X
Needle Cricothyrotomy Kit or approved device                              1                          X
Pediatric End-Tidal Monitor (Colorimetric or Capnography)                 1            X   X         X
Pediatric Magill Forceps                                                  1            X   X         X
Pediatric Stylet                                                          2            X   X         X
Pulse Oximeter with Adult and Pediatric Sensors                           1            X   X         X
Spare Batteries for Laryngoscope Handle                                 1 set          X   X         X
Tourniquets                                                               2            X   X         X
Vacutainer ™ (or equivalent) Blood Tube Holder                            2            X   X         X
Water Soluble Lubricant                                               6 packets        X   X         X

                                              Recommended
12-Lead EKG Capability with Associated Equipment                          1                X         X
Broselow Tape                                                             1            X   X         X
Combitube or Laryngeal Mask Airway                                        1            X   X         X
Waveform Capnometry                                                       1            X   X         X
Large Spare Laryngoscope Bulbs                                            2            X   X         X
Pediatric Burette or Soluset                                              1            X   X         X
Small Spare Laryngoscope Bulbs                                            2            X   X         X
CPAP Device                                                               1                          X




Appendix D                                                                                      D-   2
                                                                   Revised March 3, 2008
Advanced Life Support Protocols
          Appendix E
                Hudson Valley Regional Emergency Medical Services Council, INC.
                    DRAFT Advanced Life Support Protocol Manual DRAFT
                                             Medication List
                                                  Required
                            Item                             Quantity Required         I     CC        P
    Activated Charcoal (with Sorbitol)                             100Gm                      X        X
    Adenosine                                                       30mg                      X        X
    Albuterol                                                       10mg               X      X        X
    Amiodarone                                                     600mg                               X
    Aspirin (81mg tablets)                                   972mg (12 tablets)              X         X
    Atropine Sulfate                                                 4mg                     X         X
    Calcium Chloride 10%                                            1Gm                                X
    Dextrose 25%                                                   500mg                     X         X
    Dextrose 50%                                                    50Gm                     X         X
    Diazepam                                                        30mg                     X         X
    (Lorazepam may be utilized in place of Diazepam)
    Diltiazem                                                       50mg                               X
    Diphenhydramine                                                100mg                     X         X
    Dopamine                                                       800mg                     X         X
    Epinephrine (1:1000) 1mg ampule                                  2mg                     X         X
    Epinephrine (1:1000) 30mg vials                                 30mg                     X         X
    Epinephrine (1:10,000) 1mg bristojet                             6mg                     X         X
    Furosemide                                                     200mg                     X         X
    Glucagon                                                         2mg                     X         X
    Ipratropium Bromide                                              2mg                     X         X
    Labetalol                                                      100mg                               X
    Lidocaine 2%                                                   400mg                     X         X
    Lidocaine 20%                                                   2Gm                      X         X
    Magnesium Sulfate                                               10Gm                     X         X
    Methylprednisolone                                             250mg                     X         X
    Metoprolol                                                      15mg                               X
    Midazolam                                                        4mg                     X         X
    Morphine Sulfate                                                20mg                     X         X
    Naloxone                                                         8mg                     X         X
    Phenylephrine HCl 1% Nasal spray                        (1) 15cc spray bottle      X     X         X
    Nitroglycerine 0.4mg (tablets or spray)                       25 doses                   X         X
    Nitroglycerine Ointment                                    (1) 30Gm tube                 X         X
    Promethazine Hydrochloride                                      25mg                               X
    Sodium Bicarbonate                                            100mEq                     X         X
    Terbutaline                                                      2mg                     X         X
    Tetracaine HCl ½% Ophthalmic drops                       (1) 1ml droperette              X         X
    Thiamine                                                       200mg                     X         X
    Vasopressin                                                    40 units                            X
    0.9% Normal Saline 50cc bag                                    2 bags                    X         X
    0.9% Normal Saline 250cc bag                                   4 bags              X     X         X
    0.9% Normal Saline 1000cc bag                                  6 bags              X     X         X
                              RSI Medications for Approved Paramedic Services
                            Item                             Quantity Required         I     CC        P
    Etomidate                                                       60mg                               X
    Succinylcholine                                                500mg                               X
    Vecuronium                                                      20mg                               X

Appendix E                                                               Revised: September 13, 2010       E-   1
                Hudson Valley Regional Emergency Medical Services Council, INC.
                    DRAFT Advanced Life Support Protocol Manual DRAFT
                                 Medication List-(Continued)
                                         Optional
                        Item                          Quantity Required       I    CC    P
Levalbuterol                                                 5mg              X     X    X
Lorazepam                                                    10mg                   X    X
Nitrous Oxide 50% N2O / 50% O2                          1- ―A‖ cylinder                  X
                                                    (30 minutes minimum)
Ondansetron Hydrochloride                                    8mg                         X




Appendix E                                                     Revised: September 13, 2010   E-   2
             Hudson Valley Regional Emergency Medical Services Council, INC.
                 DRAFT Advanced Life Support Protocol Manual DRAFT

                           Drug Formulary Table of Contents

             0.9% Normal Saline                                                E-4
             Activated Charcoal (with Sorbitol)                                E-5
             Adenosine                                                         E-6
             Albuterol                                                         E-7
             Amiodarone                                                        E-8
             Aspirin                                                           E-9
             Atropine Sulfate                                                  E-10
             Calcium Chloride 10%                                              E-11
             Dextrose                                                          E-12
             Diazepam                                                          E-13
             Diltiazem                                                         E-14
             Diphenhydramine                                                   E-15
             Dopamine                                                          E-16
             Epinephrine                                                       E-17
             Etomidate                                                         E-18
             Furosemide                                                        E-19
             Glucagon                                                          E-20
             Ipratropium Bromide                                               E-21
             Labetalol                                                         E-22
             Levalbuterol                                                      E-23
             Lidocaine                                                         E-24
             Lorazepam                                                         E-25
             Magnesium Sulfate                                                 E-26
             Methylprednisolone                                                E-27
             Metoprolol                                                        E-28
             Midazolam                                                         E-29
             Morphine Sulfate                                                  E-30
             Naloxone                                                          E-31
             Nitroglycerine                                                    E-32
             Nitrous Oxide                                                     E-33
             Ondansetron HCl                                                   E-34
             Phenylephrine 1% Nasal spray                                      E-35
             Promethazine Hydrochloride                                        E-36
             Sodium Bicarbonate                                                E-37
             Succinylcholine                                                   E-38
             Terbutaline                                                       E-39
             Tetracaine HCl ½% Ophthalmic drops                                E-40
             Thiamine                                                          E-41
             Vasopressin                                                       E-42
             Vecuronium                                                        E-43




Appendix E                                                 Revised: September 13, 2010   E-   3
               Hudson Valley Regional Emergency Medical Services Council, INC.
                   DRAFT Advanced Life Support Protocol Manual DRAFT
                                  0.9% Normal Saline

Class:
Isotonic Crystalloid Solution

Description:
Normal Saline contains 154mEq/L of sodium ions and approximately 154mEq/L of chloride ions.
Because the concentration of sodium is near that of the blood, the solution is considered
isotonic.

Mechanism of Action:
Normal Saline replaces water and electrolytes.

Indications:
Heat related problems (heat exhaustion, heat stroke).

Contraindications:
The use of 0.9%NaCl should not be considered in patients with congestive heart failure because
circulatory overload can easily be induced.

Precautions:
When large amounts of Normal Saline are administered, it is quite possible for other
physiological electrolytes to become depleted.

Side Effects:
Rare in therapeutic doses.

Interactions:
Few in the emergency setting.




Appendix E                                                                               E-   4
               Hudson Valley Regional Emergency Medical Services Council, INC.
                   DRAFT Advanced Life Support Protocol Manual DRAFT
                         Activated Charcoal with Sorbitol

Class:
Adsorbent

Description:
Activated charcoal is used to adsorb ingested toxins that cannot be removed through emesis, or
after emesis has been induced, to adsorb remaining toxins.

Mechanism of Action:
Adsorbs toxins by chemical binding and prevents gastrointestinal adsorption.

Indications:
Poisoning following emesis, or when emesis is contraindicated.

Contraindications:
None in severe poisoning.

Precautions:
Use with caution in patients with altered mental status. May adsorb ipecac before emesis; if
ipecac is administered, wait at least 10 minutes to administer Activated Charcoal.

Side Effects:
Nausea and vomiting, constipation.

Interactions:
None reported in the emergency setting.




Appendix E                                                                                     E-   5
                 Hudson Valley Regional Emergency Medical Services Council, INC.
                     DRAFT Advanced Life Support Protocol Manual DRAFT
                                         Adenosine

Class:
Antiarrhythmic

Description:
Adenosine is a naturally occurring nucleoside that slows AV conduction through the AV node. It
has an exceptionally short half-life and a relatively good safety profile.

Mechanism of Action:
Adenosine decreases conduction of the electrical impulse through the AV node and interrupts
AV re-entry pathways in PSVT. The half-life of Adenosine is about 5 seconds. Because of its
rapid onset of action and very short half-life, the administration of Adenosine is sometimes
referred to as chemical cardioversion.

Indications:
Adenosine is used in PSVT refractory to common vagal maneuvers.

Contraindications:
Adenosine is contraindicated in patients with second or third degree heart block, sick sinus
syndrome, or those with known hypersensitivity to the drug.

Precautions:
Adenosine typically causes arrhythmias at the time of cardioversion; in extreme cases transient
asystole may occur. Adenosine should be used cautiously in patients with asthma.

Side Effects:
Facial flushing, headache, shortness of breath, dizziness and nausea.

Interactions:
Methylxanthines (Aminophylline and Theophylline) may decrease the effectiveness of
Adenosine, requiring larger doses. Dipyridamole (Persantine) can potentiate the effects of
Adenosine.




Appendix E                                                                                     E-   6
               Hudson Valley Regional Emergency Medical Services Council, INC.
                   DRAFT Advanced Life Support Protocol Manual DRAFT
                                          Albuterol

Class:
Sympathetic Agonist

Description:
Albuterol is a sympathomimetic that is selective for Beta-2 adrenergic receptors.

Mechanism of Action:
Albuterol is a selective Beta-2 agonist with a minimal number of side effects. It causes prompt
bronchodilation and has a duration of action of approximately 5 hours.

Indications:
Bronchial asthma, reversible bronchospasm associated with COPD and emphysema.

Contraindications:
Known hypersensitivity to the drug.

Precautions:
Use caution when administering this drug to elderly patients and those with cardiovascular
disease or hypertension. If possible, peak flow rate should be measured before and after
administration.

Side Effects:
Palpitations, anxiety, dizziness, headache, nervousness, tremor, hypertension, arrhythmias,
chest pain, nausea, vomiting.

Interactions:
The possibility of developing unpleasant side effects increases when administered with other
sympathetic agonists. Beta blockers may blunt the effects of Albuterol.




Appendix E                                                                                   E-   7
                Hudson Valley Regional Emergency Medical Services Council, INC.
                    DRAFT Advanced Life Support Protocol Manual DRAFT
                                           Amiodarone

Class:
Antiarrhythmic Agent

Description:
Amiodarone is a Class III Antiarrhythmic agent used to treat ventricular arrhythmias
unresponsive to other antiarrhythmics.

Mechanism of Action:
Amiodarone prolongs the action potential duration in all cardiac tissues.

Indications:
Ventricular fibrillation, ventricular tachycardia.

Contraindications:
Breast-feeding patients in cardiogenic shock, severe sinus node dysfunction resulting in marked
bradycardia, second or third degree AV block, symptomatic bradycardia, or known
hypersensitivity.

Precautions:
Amiodarone should be used with caution in patients with latent or manifest heart failure because
failure may be worsened by its administration.

Side Effects:
Hypotension, bradycardia, increased ventricular beats, prolonged P-R interval, prolonged QRS
complex, prolonged Q-T interval. The patient should also be monitored for signs of pulmonary
toxicity such as dyspnea and cough.

Interactions:
Amiodarone may react with Warfarin, Digoxin, Procainamide, Quinidine, and Phenytoin.




Appendix E                                                                                 E-   8
               Hudson Valley Regional Emergency Medical Services Council, INC.
                   DRAFT Advanced Life Support Protocol Manual DRAFT
                                             Aspirin

Class:
Platelet Aggregator Inhibitor

Description:
Aspirin is an anti-inflammatory agent and an inhibitor of platelet function.

Mechanism of Action:
Aspirin blocks the formation of the substance thromboxane A 2, which causes platelets to
aggregate and arteries to constrict.

Indications:
Aspirin is used for new chest pain suggestive of acute myocardial infarction.

Contraindications:
Known hypersensitivity. Aspirin is relatively contraindicated in patients with active ulcer disease
and asthma.

Precautions:
Aspirin can cause GI upset and bleeding. Aspirin should be used with caution in patients who
report allergies to NSAIDS.

Side Effects:
Heartburn, GI bleeding, nausea, vomiting, wheezing, and prolonged bleeding.

Interactions:
When administered together, aspirin and other anti-inflammatory agents may cause an
increased incidence of side effects. Administration of aspirin with antacids may reduce blood
levels by reducing absorption.




Appendix E                                                                                     E-     9
                  Hudson Valley Regional Emergency Medical Services Council, INC.
                      DRAFT Advanced Life Support Protocol Manual DRAFT
                                      Atropine Sulfate

Class:
Anticholinergic

Description:
Atropine is a parasympatholytic that is derived from parts of the Atropa Belladonna plant.

Mechanism of Action:
Atropine is a potent parasympatholytic and is used to increase the heart rate in
hemodynamically significant bradycardias. Atropine acts by blocking acetylcholine receptors,
thus inhibiting parasympathetic stimulation. Atropine has positive chronotropic properties, and
little or no inotropic effect. It plays an important role as an antidote in organophosphate
poisonings. Atropine is also used in the treatment of respiratory emergencies due to its
bronchodilation and drying of respiratory tract secretions.

Indications:
Hemodynamically significant bradycardia, and asystole.
Bronchial asthma, reversible bronchospasm associated with chronic bronchitis and emphysema.
Organophosphate overdose.

Contraindications:
Known hypersensitivity.

Precautions:
Atropine may worsen the bradycardia associated with second-degree type II and third-degree
AV blocks. In these instances, pacing should be attempted prior to administration of Atropine
For respiratory use: Use caution when administering this drug to elderly patients and those with
cardiovascular disease or hypertension. If possible, peak flow rate should be measured before
and after administration.

Side Effects:
Blurred vision, dilated pupils, dry mouth, tachycardia, drowsiness, confusion, palpitations,
anxiety, dizziness, headache, nervousness, rash, nausea, and vomiting.

Interactions:
There are few interactions in the pre-hospital setting.




Appendix E                                                                                     E- 10
               Hudson Valley Regional Emergency Medical Services Council, INC.
                   DRAFT Advanced Life Support Protocol Manual DRAFT
                                 Calcium Chloride 10%

Class:
Calcium supplement

Description:
Calcium Chloride provides elemental calcium in the form of the cation. Calcium is required for
many physiological activities.

Mechanism of Action:
Calcium Chloride replaces calcium in cases of hypocalcemia. It causes a significant increase in
myocardial contractile force, and increases ventricular automaticity. Calcium Chloride is an
antidote for Magnesium Sulfate, and can minimize the some of the side effects of calcium
channel blocker usage.

Indications:
Acute hyperkalemia, acute hypocalcemia, calcium channel blocker toxicity.

Contraindications:
Calcium may precipitate Digitalis toxicity in patients taking Digoxin.

Precautions:
Flush IV line between administrations of Calcium Chloride and Sodium Bicarbonate to avoid
precipitation.

Side Effects:
Bradycardia, arrhythmias, syncope, nausea, vomiting, cardiac arrest.

Interactions:
Flush IV line between administrations of Calcium Chloride and Sodium Bicarbonate to avoid
precipitation. Calcium Chloride can cause elevated Digoxin levels, and Digitalis toxicity in those
patients receiving Digitalis preparations.




Appendix E                                                                                    E- 11
                Hudson Valley Regional Emergency Medical Services Council, INC.
                    DRAFT Advanced Life Support Protocol Manual DRAFT
                                         Dextrose 50%

Class:
Carbohydrate

Description:
Dextrose is used to describe the 6-carbon sugar D-glucose, which is the principal form of
carbohydrate used by the body.

Mechanism of Action:
Dextrose supplies supplemental glucose in cases of hypoglycemia.

Indications:
Hypoglycemia, coma of unknown origin.

Contraindications:
There are no major contraindications to the administration of Dextrose for suspected
hypoglycemia.

Precautions:
It is important to obtain a Glucometer reading and obtain a blood sample prior to administration
of Dextrose. Infiltration can cause local tissue necrosis. Dextrose should be used with caution in
patients with increased intracranial pressure, because the Dextrose load may worsen cerebral
edema.

Side Effects:
Tissue necrosis, phlebitis at the injection site.

Interactions:
There are no interactions in the emergency setting.




Appendix E                                                                                   E- 12
               Hudson Valley Regional Emergency Medical Services Council, INC.
                   DRAFT Advanced Life Support Protocol Manual DRAFT
                                          Diazepam

Class:
Anticonvulsant and Sedative

Description:
Diazepam is a benzodiazepine that is frequently used as an anticonvulsant, sedative, and
hypnotic.

Mechanism of Action:
Diazepam is used primarily for its anticonvulsant properties. It suppresses the spread of seizure
activity through the motor cortex of the brain, but appears not to abolish the abnormal discharge
focus. It is used in the management of anxiety and stress. It is effective in treating the tremors
and anxiety associated with alcohol withdrawal. It is an effective skeletal muscle relaxant, and
induces amnesia.

Indications:
Diazepam is used in major motor seizures, status epilepticus, pre-medication prior to
cardioversion, skeletal muscle relaxant, and acute anxiety states.

Contraindications:
Known hypersensitivity

Precautions:
Because Diazepam is a relatively short-acting drug, seizure activity may recur. Injectable
Diazepam can cause local venous irritation.

Side Effects:
Hypotension, drowsiness, headache, amnesia, respiratory depression, blurred vision, nausea,
vomiting.

Interactions:
Diazepam is incompatible with many medications. Whenever Diazepam is given intravenously in
conjunction with other drugs, the IV line should be adequately flushed. The effects of Diazepam
can be additive when used in conjunction with other CNS depressants and alcohol.




Appendix E                                                                                   E- 13
                Hudson Valley Regional Emergency Medical Services Council, INC.
                    DRAFT Advanced Life Support Protocol Manual DRAFT
                                              Diltiazem

Class:
Calcium Channel Blocker

Description:
Diltiazem is a calcium ion antagonist, causing a relaxation of vascular smooth muscle, and
slowed conduction through the AV node. Diltiazem has a nearly equal effect on vascular smooth
muscle and AV conduction.

Mechanism of Action:
Diltiazem causes relaxation of vascular dilation and slows conduction through the AV node. It
slows the rapid ventricular rate associated with atrial fibrillation and atrial flutter. It is also used in
the treatment of angina because of its negative inotropic effect and because it dilates the
coronary arteries.

Indications:
Rapid ventricular rates associated with atrial fibrillation and atrial flutter, angina pectoris, PSVT
refractory to Adenosine.

Contraindications:
Severe hypotension, cardiogenic shock, ventricular tachycardia, Wolff-Parkinson-White
syndrome.

Precautions:
Diltiazem can cause systemic hypotension. Calcium chloride can be used to prevent the
hypotensive effects of calcium channel blockers and in the management of calcium channel
blocker overdose.

Side Effects:
Diltiazem can cause nausea, vomiting, dizziness, headache, bradycardia, heart block,
hypotension, and asystole.

Interactions:
Diltiazem should not be administered to patients receiving intravenous beta-blockers because of
an increased risk of congestive heart failure, bradycardia, and asystole.




Appendix E                                                                                           E- 14
                Hudson Valley Regional Emergency Medical Services Council, INC.
                    DRAFT Advanced Life Support Protocol Manual DRAFT
                                    Diphenhydramine

Class:
Antihistamine

Description:
Diphenhydramine is a potent antihistamine that blocks H1 and H2 histamine receptors.

Mechanism of Action:
Diphenhydramine blocks the effects of H1 receptor stimulation (bronchoconstriction, visceral
contractions) and that of H2 receptor stimulation (peripheral vasodilation and secretion of gastric
acids). Diphenhydramine is also useful in the treatment of dystonic reactions accompanying
phenothiazine use.

Indications:
Anaphylaxis, Allergic reactions, Dystonic (extrapyramidal) reactions due to phenothiazines

Contraindications:
Asthma, nursing mothers

Precautions:
The primary drug for treatment of severe allergic reactions is epinephrine, as it reverses the
effects of histamines. Diphenhydramine will block histamine receptors, preventing subsequent
stimulation.

Side Effects:
Sedation, dries bronchial secretions, blurred vision, headache, palpitations, tachycardia

Interactions:
Potentiation can occur by the administration of CNS depressants, other antihistamines,
narcotics, and alcohol.




Appendix E                                                                                    E- 15
              Hudson Valley Regional Emergency Medical Services Council, INC.
                  DRAFT Advanced Life Support Protocol Manual DRAFT
                                        Dopamine

Class:
Sympathetic Agonist

Description:
Dopamine is a naturally occurring catecholamine. It acts on alpha, beta-1, and Dopaminergic
adrenergic receptors. Its effect on alpha-receptors is dose dependent.

Mechanism of Action:
Dopamine’s effect on beta-1 receptors causes a positive inotropic effect on the heart. Dopamine
also acts on alpha-adrenergic receptors causing peripheral vasoconstriction. Dopamine
maintains renal and mesenteric blood flow because of its effect on the Dopaminergic receptors.
Dopamine increases both systolic and pulse pressure. There is usually less effect on the
diastolic pressure.

Indications:
Hemodynamically significant hypotension not resulting from hypovolemia, and cardiogenic
shock.

Contraindications:
Dopamine should not be used as the sole agent in the management of hypovolemic shock
unless fluid resuscitation is well under way. Pheochromocytoma.

Precautions:
Dopamine can induce or worsen SVT and ventricular arrhythmias. Dopamine should not be
administered in the presence of tachyarrhythmias or ventricular fibrillation.

Side Effects:
Nervousness, headache, dysrhythmias, palpitations, chest pain, dyspnea, nausea, vomiting.

Interactions:
Dopamine can be deactivated by alkaline solutions. If a patient is taking a monoamine oxidase
inhibitor, the dose should be reduced. Dopamine can cause hypotension when used
concomitantly with Phenytoin.




Appendix E                                                                                E- 16
               Hudson Valley Regional Emergency Medical Services Council, INC.
                   DRAFT Advanced Life Support Protocol Manual DRAFT
                                        Epinephrine

Class:
Sympathetic Agonist

Description:
Epinephrine is a naturally occurring catecholamine. It is a potent alpha- and beta-adrenergic
stimulant with more profound beta effects.

Mechanism of Action:
Epinephrine works directly on alpha- and beta-adrenergic receptors with effects of increased
heart rate, cardiac contractile force, increased electrical activity in the myocardium, systemic
vascular resistance, increased blood pressure, and increased automaticity. It also causes
bronchodilation. Effects usually appear within 90 seconds of administration, and last only a short
duration.

Indications:
Bronchial asthma, exacerbation of COPD, anaphylaxis.

Contraindications:
Underlying cardiovascular disease, hypertension.

Precautions:
Epinephrine should be protected from light. It also tends to be deactivated by alkaline solutions.

Side Effects:
Palpitations, anxiety, tremulousness, headache, dizziness, nausea, vomiting, myocardial oxygen
demand.

Interactions:
Effects can be intensified in patients taking antidepressants




Appendix E                                                                                    E- 17
               Hudson Valley Regional Emergency Medical Services Council, INC.
                   DRAFT Advanced Life Support Protocol Manual DRAFT
                                         Etomidate

Class:
General anesthetic and adjunct to general anesthesia

Description:
Etomidate is a short-acting, intravenously administered sedative hypnotic. Etomidate has a rapid
onset of action and recovery. It has minimal cardiac and respiratory-depressive effects and
causes no histamine release, so it is useful in patients with compromised cardiopulmonary
function.

Mechanism of Action:
Etomidate appears to facilitate GABAminergic neurotransmission by increasing the number of
available GABA receptors, possibly by displacing endogenous inhibitors of GABA binding.
Etomidate produces clinical responses such as hypnosis, elevations in arterial carbon dioxide
tension, reduced cortisol plasma levels, and a transient 20—30% decrease in cerebral blood
flow. Its effects are at least partially due to depression of the brainstem reticular formation.

Indications:
Induction of general anesthesia.

Contraindications:
Use with caution in the elderly and in patients with hepatic disease because they are more likely
to develop etomidate-related adverse reactions.

Precautions:
Use with caution during lactation.

Side Effects:
Skeletal muscle: Myoclonic skeletal muscle movements, tonic movements. Respiratory: Apnea
of short duration, hyperventilation or hypoventilation, laryngospasm. CV: Either hypertension or
hypotension; tachycardia or bradycardia; arrhythmias. GI: Postoperative N&V. Miscellaneous:
Eye movements, averting movements, hiccoughs, snoring.

Interactions:
Etomidate potentiates the effects of CNS depressants such as ethanol, general anesthetics,
local anesthetics, antidepressants, H1-blockers, opiate agonists, skeletal muscle relaxants,
phenothiazines, barbiturates, and benzodiazepines. Concurrent use of antihypertensive agents
and etomidate can result in hypotension. This is particularly true if any of the following agents
are used with etomidate: calcium-channel blockers, diazoxide, mecamylamine.




Appendix E                                                                                   E- 18
               Hudson Valley Regional Emergency Medical Services Council, INC.
                   DRAFT Advanced Life Support Protocol Manual DRAFT
                                        Furosemide

Class:
Diuretic

Description:
Furosemide is a potent diuretic that inhibits sodium and chloride reabsorption in the kidneys and
causes venous dilation.

Mechanism of Action:
Furosemide is a loop diuretic that inhibits sodium and chloride reabsorption in the kidneys.
Furosemide first causes venous dilation within 5 minutes of administration, reducing preload and
decreasing cardiac work. Diuretic effects begin 5-15 minutes after administration.

Indications:
Congestive Heart Failure, Pulmonary Edema.

Contraindications:
Use in pregnancy should be limited to life threatening situations in which the benefits of
administration outweigh the risks. It should not be administered to patients who are allergic to
the sulfa class of medications.

Precautions:
Dehydration, electrolyte depletion, and hypotension can result from excessive doses. Blood
pressure should be frequently monitored. Furosemide should be protected from light.

Side Effects:
Headache, dizziness, hypotension, volume depletion, potassium depletion, arrhythmias,
diarrhea, nausea, vomiting.

Interactions:
Furosemide should not be administered in the same line as Amrinone, as a precipitate will form.
Administration with other diuretics can lead to severe volume depletion and electrolyte
imbalance.




Appendix E                                                                                    E- 19
               Hudson Valley Regional Emergency Medical Services Council, INC.
                   DRAFT Advanced Life Support Protocol Manual DRAFT
                                          Glucagon

Class:
Hormone and Anti-hypoglycemic

Description:
Glucagon is a hormone secreted by the alpha cells of the pancreas. It is used to increase the
blood glucose level in cases of hypoglycemia in which an IV cannot immediately be placed.

Mechanism of Action:
Glucagon causes a breakdown of stored glycogen to glucose, and inhibits the synthesis of
glycogen from glucose. A return to consciousness following the administration of Glucagon
usually takes from 5-20 minutes. Glucagon is only effective if there are sufficient stores of
glycogen in the liver. Glucagon exerts a positive inotropic action on the heart and decreases
renal vascular resistance.

Indications:
Hypoglycemia, Beta-Blocker overdoses.

Contraindications:
Known hypersensitivity.

Precautions:
Glucagon is only effective if there are sufficient stores of glycogen in the liver. Glucagon should
be administered with caution to patients with a history of cardiovascular or renal disease.

Side Effects:
Hypotension, dizziness, headache, nausea, vomiting.

Interactions:
There are few interactions reported in the emergency setting.




Appendix E                                                                                     E- 20
                  Hudson Valley Regional Emergency Medical Services Council, INC.
                      DRAFT Advanced Life Support Protocol Manual DRAFT
                                   Ipratropium Bromide

Class:
Anticholinergic

Description:
Ipratropium is an anticholinergic that is chemically related to atropine.

Mechanism of Action:
Ipratropium is a parasympatholytic used in the treatment of respiratory emergencies. It causes
bronchodilation and dries respiratory tract secretions. Ipratropium acts by blocking acetylcholine
receptors, thus inhibiting parasympathetic stimulation.

Indications:
Bronchial asthma, reversible bronchospasm associated with chronic bronchitis and emphysema.

Contraindications:
Known hypersensitivity.

Precautions:
Use caution when administering this drug to elderly patients and those with cardiovascular
disease or hypertension. If possible, peak flow rate should be measured before and after
administration.

Side Effects:
Palpitations, anxiety, dizziness, headache, nervousness, tremor, hypertension, arrhythmias,
chest pain, nausea, vomiting.

Interactions:
There are few interactions in the prehospital setting.




Appendix E                                                                                   E- 21
               Hudson Valley Regional Emergency Medical Services Council, INC.
                   DRAFT Advanced Life Support Protocol Manual DRAFT
                                          Labetalol

Class:
Non-Selective Beta Blocker

Description:
Labetalol is a non-selective beta-blocker and a selective alpha-1 blocker.

Mechanism of Action:
Labetalol is a nonselective beta-adrenergic antagonist. It also blocks alpha-1 adrenergic
receptors, inhibiting peripheral vasoconstriction. It lowers blood pressure by decreasing cardiac
output, and by causing peripheral vasodilation.

Indications:
Acute management of hypertensive crisis.

Contraindications:
Bronchial asthma, CHF, heart block, bradycardia, cardiogenic shock.

Precautions:
Prehospital personnel should be alert for signs of CHF, bradycardia, shock, heart block, or
bronchospasm. Postural hypotension might occur and should be expected.

Side Effects:
Bradycardia, hypotension, lethargy, CHF, dyspnea, wheezing, weakness.

Interactions:
Labetalol should not be administered to patients who have received intravenous verapamil. It
should be administered with caution to patients taking antihypertensive agents.




Appendix E                                                                                    E- 22
               Hudson Valley Regional Emergency Medical Services Council, INC.
                   DRAFT Advanced Life Support Protocol Manual DRAFT
                                       Levalbuterol

Class:
Sympathetic Agonist

Description:
Levalbuterol is the (R)-isomer of the drug substance Racemic Albuterol and is a
sympathomimetic that is selective for Beta-2 adrenergic receptors.

Mechanism of Action:
Levalbuterol is a selective Beta-2 agonist with a minimal number of side effects. It relaxes the
smooth muscle of all airways, from the trachea to the terminal bronchioles and has a mean
duration of effect of approximately 5 hours (Pediatric Dose), approximately 6 hours (Adult Dose)
but may last up to 8 hours.

Indications:
Bronchial asthma, reversible bronchospasm associated with COPD and emphysema.

Contraindications:
Known hypersensitivity to the drug.

Precautions:
Use caution when administering this medication to patients with cardiovascular disease, cardiac
arrhythmias, hypertension, convulsive disorders, hyperthyroidism, or diabetes mellitus and who
may be unusually responsive to sympathomimetic amines. If possible, peak flow rate should be
measured before and after administration.

Side Effects:
Palpitations, anxiety, dizziness, headache, nervousness, tremor, hypertension, arrhythmias,
chest pain, nausea, vomiting, diarrhea.

Interactions:
The possibility of developing unpleasant side effects increases when administered with other
sympathetic agonists. Beta blockers may blunt or block the effects of Levalbuterol. Levalbuterol
should be used with caution in the presence of Diuretics, Digoxin, Monoamine Oxidase
Inhibitors or Tricyclic Antidepressants.




Appendix E                                                                                  E- 23
                 Hudson Valley Regional Emergency Medical Services Council, INC.
                     DRAFT Advanced Life Support Protocol Manual DRAFT
                                           Lidocaine

Class:
Antiarrhythmic

Description:
Lidocaine is an amide-type local anesthetic. It is frequently used to treat life-threatening
dysrhythmias.

Mechanism of Action:
Lidocaine depresses depolarization and automaticity in the ventricles, and increases the
ventricular fibrillation threshold by increasing phase IV repolarization.

Indications:
Ventricular tachycardia, ventricular fibrillation, malignant premature ventricular contractions.

Contraindications:
Second and third degree heart blocks, ventricular escape beats.

Precautions:
CNS depression may occur when the drug exceeds 300mg/hr. Exceedingly high doses can
result in coma and death.

Side Effects:
Drowsiness, seizures, confusion, hypotension, bradycardia, heart blocks, nausea, vomiting, and
respiratory and cardiac arrest.

Interactions:
Lidocaine should be used with caution when administered concomitantly with Procainamide,
Phenytoin, Quinidine, and beta-blockers as drug toxicity may result.




Appendix E                                                                                         E- 24
               Hudson Valley Regional Emergency Medical Services Council, INC.
                   DRAFT Advanced Life Support Protocol Manual DRAFT
                                         Lorazepam
Class:
Anticonvulsant, antianxiety, analgesic agent

Description:
Lorazepam is a benzodiazepine used in the management of status epilepticus, as an adjunct in
the management of anxiety or insomnia, and for preoperative sedation.

Mechanism of Action:
Lorazepam depresses the CNS by potentiating GABA, an inhibitory neurotransmitter.
Therapeutic effects include sedation, decreased anxiety, and decreased seizure activity.
Lorazepam is absorbed and eliminated faster than other benzodiazepines.

Indications:
Lorazepam is used in the management of status epilepticus and as an adjunct in the
management of anxiety or insomnia. Lorazepam is also used for preoperative sedation and as
an antiemetic prior to chemotherapy. Lorazepam decreases preoperative anxiety and provides
amnesia.

Contraindications:
Hypersensitivity, CNS depression, comatose, uncontrolled severe pain, narrow-angle glaucoma,
pregnancy, and lactation.

Precautions:
Lorazepam should be used with caution in patients with severe hepatic/renal/pulmonary
impairment, myasthenia gravis, history of suicide or drug abuse, geriatric or debilitated patients.

Side Effects:
CNS: Dizziness, drowsiness, lethargy, hangover, headache, mental depression, paradoxical
excitation. EENT: Blurred vision. RESP: Respiratory depression. CV: Rapid IV use may cause
apnea, cardiac arrest, bradycardia, and hypotension. GI: Constipation, diarrhea, nausea,
vomiting. Derm: Rash. Misc: Physical/psychological dependence, tolerance.

Interactions:
Additive CNS depression with other CNS depressants including alcohol, antihistamines, opioid
analgesics, and other sedative/hypnotics including other benzodiazepines. Lorazepam may
decrease the efficacy of levodopa. Probenecid may decrease metabolism or Lorazepam,
enhancing its actions. Smoking may increase metabolism and decrease effectiveness.




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                   DRAFT Advanced Life Support Protocol Manual DRAFT
                                   Magnesium Sulfate

Class:
Antiarrhythmic, Mineral, Electrolyte

Description:
Magnesium Sulfate is a salt that dissociates into the Magnesium cation and the sulfate anion
when administered. Magnesium is an essential element in numerous biochemical reactions that
occur within the body.

Mechanism of Action:
Magnesium Sulfate acts as a physiological calcium channel blocker and blocks neuromuscular
transmission. A decreased magnesium level is associated with cardiac arrhythmias, symptoms
of cardiac insufficiency, and sudden death. Hypomagnesemia can cause refractory ventricular
fibrillation. Magnesium Sulfate is also a central nervous system depressant effective in the
management of seizures associated with eclampsia.

Indications:
Magnesium Sulfate is used in refractory ventricular fibrillation, pulseless ventricular tachycardia,
post-myocardial infarction for prophylaxis of arrhythmias, and torsade de pointes or multiaxial
ventricular tachycardia. It is also used in severe bronchospasm, and in eclampsia.

Contraindications:
Shock, persistent severe hypertension, third degree AV block, routine dialysis patients, known
hypocalcemia.

Precautions:
Magnesium Sulfate should be administered slowly to minimize side effects. Use with caution in
patients with known renal insufficiency. Hypermagnesemia can occur, Calcium Chloride should
be available as an antidote if serious side effects occur.

Side Effects:
Flushing, sweating, bradycardia, decreased deep tendon reflexes, drowsiness, respiratory
depression, arrhythmia, hypotension, hypothermia, itching, and rash.

Interactions:
Magnesium Sulfate can cause cardiac conduction abnormalities if administered in conjunction
with digitalis.




Appendix E                                                                                     E- 26
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                   DRAFT Advanced Life Support Protocol Manual DRAFT
                                   Methylprednisolone

Class:
Corticosteroid and Anti-inflammatory

Description:
Methylprednisolone is a synthetic steroid with potent anti-inflammatory properties. It is related to
the natural hormones secreted in the adrenal cortex.

Mechanism of Action:
The pharmacological effects of steroids are vast and complex. Effective as anti-inflammatory
agents, they are used in the management of allergic reactions, asthma, and anaphylaxis.
Methylprednisolone is considered an intermediate-acting steroid with a plasma half-life of 3 to 4
hours.

Indications:
Severe anaphylaxis, asthma, or COPD, urticaria, and spinal cord injury.

Contraindications:
There are no major contraindications in the use of Methylprednisolone in the emergency setting.

Precautions:
A single dose is all that should be given in the prehospital setting. Long-term steroid therapy can
cause gastrointestinal bleeding, prolonged wound healing, and suppression of adrenocortical
steroids.

Side Effects:
Fluid retention, congestive heart failure, hypertension, abdominal distention, vertigo, headache,
nausea, malaise, and hiccups.

Interactions:
There are few interactions in the prehospital setting.




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                   DRAFT Advanced Life Support Protocol Manual DRAFT
                                          Metoprolol

Class:
Selective Beta-Blocker

Description:
Metoprolol is a selective beta1-adrenoreceptor blocking agent. It is a white, practically odorless,
crystalline powder made available in ampules mixed with sodium chloride and water for
injection.

Mechanism of Action:
Metoprolol affects beta1 adrenoreceptors, chiefly located in cardiac muscle. However at higher
doses also inhibits beta2-adrenoreceptors, chiefly located in the bronchial and vascular
musculature. Effects of Metoprolol include slowing of the sinus rate and decreasing AV nodal
conduction resulting in reduction of heart rate and cardiac output, reduction of systolic blood
pressure, reduction of reflex orthostatic tachycardia, and inhibition of catecholamine-induced
tachycardia.

Indications:
Acute Myocardial Infarction, Angina Pectoris, and Hypertension.

Contraindications:
Metoprolol is contraindicated in sinus bradycardia, heart block, cardiogenic shock, systolic blood
pressure <100mmHg, or moderate-to-severe cardiac failure.

Precautions:
Patients with Bronchospastic Diseases, Diabetes and Hypoglycemia, or Thyrotoxicosis should in
general not receive beta blockers.

Side Effects:
Tiredness and dizziness, depression, confusion, short-term memory loss, headache, insomnia,
diarrhea, nausea, gastric pain, shortness of breath, wheezing, bradycardia, congestive heart
failure, hypotension, rash, tinnitus.

Interactions:
In hypertension and angina patients with congestive heart failure controlled by digitalis and
diuretics, Metoprolol should be administered with extreme caution since beta blockade caries
the potential of further decreasing myocardial contractility and precipitating more sever failure.




Appendix E                                                                                     E- 28
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                   DRAFT Advanced Life Support Protocol Manual DRAFT
                                        Midazolam

Class:
Sedative and Hypnotic

Description:
Midazolam is a benzodiazepine with strong hypnotic and amnestic properties.

Mechanism of Action:
Midazolam is a potent but short-acting benzodiazepine used as a sedative and hypnotic. It is
three to four times more potent than Diazepam. Its onset of action is approximately 1.5 minutes
when administered IV. Midazolam has impressive amnestic properties, and like other
benzodiazepines, it has no effect on pain.

Indications:
Midazolam is used as a premedication before cardioversion and other painful procedures.

Contraindications:
Known hypersensitivity, narrow angle glaucoma, shock, depressed vital signs, and alcoholic
coma.

Precautions:
Emergency resuscitative equipment must be available prior to the administration of Midazolam.
Midazolam has more potential than the other benzodiazepines to cause respiratory depression
and respiratory arrest.

Side Effects:
Laryngospasm, bronchospasm, dyspnea, respiratory depression and arrest, drowsiness, altered
mental status, amnesia, bradycardia, tachycardia, premature ventricular contractions, and
retching.

Interactions:
The effects of Midazolam can be accentuated by CNS depressants such as narcotics and
alcohol.




Appendix E                                                                                 E- 29
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                   DRAFT Advanced Life Support Protocol Manual DRAFT
                                    Morphine Sulfate

Class:
Narcotic Analgesic

Description:
Morphine is a potent CNS depressant and analgesic.

Mechanism of Action:
Morphine acts on opiate receptors in the brain, providing analgesia and sedation. It increases
peripheral venous capacitance and decreases venous return. Morphine also decreases
myocardial oxygen demand.

Indications:
Severe pain associated with myocardial infarction, kidney stones, etc., and pulmonary edema.

Contraindications:
Volume depletion, severe hypotension, hypersensitivity, undiagnosed head injury or abdominal
pain.

Precautions:
Morphine has a high tendency for addiction and abuse. Morphine can cause severe respiratory
depression in high doses, especially in patients with respiratory impairment. Narcan should be
available as an antagonist.

Side Effects:
Nausea, vomiting, abdominal cramps, blurred vision, constricted pupils, altered mental status,
headache, respiratory depression.

Interactions:
CNS depression can be enhanced when administered with antihistamines, antiemetics,
sedatives, hypnotics, barbiturates, and alcohol.




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                   DRAFT Advanced Life Support Protocol Manual DRAFT
                                          Naloxone

Class:
Narcotic Antagonist

Description:
Naloxone is an effective narcotic antagonist.

Mechanism of Action:
Naloxone is chemically similar to narcotics, however it has only antagonistic properties.
Naloxone competes for opiate receptors in the brain, and displaces narcotic molecules from
opiate receptors. It can reverse respiratory depression from narcotic overdose.

Indications:
Complete or partial reversal of depression caused by narcotics. Naloxone can also be used in
the treatment of coma of unknown origin.

Contraindications:
Known hypersensitivity.

Precautions:
Naloxone should be administered cautiously to patients who are known or are suspected to be
physically dependent on narcotics. Abrupt and complete reversal by Naloxone can cause
withdrawal type effects.

Side Effects:
Hypotension, hypertension, ventricular arrhythmias, nausea, vomiting.

Interactions:
Naloxone may cause narcotic withdrawal in the narcotic dependent patient. Only enough of the
drug should be given to reverse respiratory depression.




Appendix E                                                                               E- 31
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                   DRAFT Advanced Life Support Protocol Manual DRAFT
                                      Nitroglycerine

Class:
Nitrate

Description:
Nitroglycerine is a potent smooth muscle relaxant used in the treatment of angina pectoris.

Mechanism of Action:
Nitroglycerine is a rapid smooth muscle relaxant that reduces cardiac work and to a lesser
degree dilates the coronary arteries. This results in increased coronary blood flow and improved
perfusion of the myocardium. Pain relief following Nitroglycerine administration usually occurs
within 1 to 2 minutes, with therapeutic effects up to 30 minutes later.

Indications:
Chest pain associated with angina pectoris, acute myocardial infarction, and acute pulmonary
edema.

Contraindications:
Hypotension, increased intracranial pressure.

Precautions:
Patients taking Nitroglycerine may develop a tolerance to the drug necessitating a higher dose.
Headache from vasodilation of the cerebral vessels is common. Nitroglycerine deteriorates
rapidly once opened. Nitroglycerine should be protected from light.

Side Effects:
Headache, dizziness, weakness, tachycardia, hypotension, orthostasis, skin rash, dry mouth,
nausea, vomiting.

Interactions:
Nitroglycerine can cause hypotension in patients who have recently ingested alcohol. It can
cause orthostatic hypotension when used in conjunction with beta-blockers.




Appendix E                                                                                    E- 32
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                   DRAFT Advanced Life Support Protocol Manual DRAFT
                                       Nitrous Oxide

Class:
Analgesic and Anesthetic Gas

Description:
Nitronox is a blended mixture of 50 % Nitrous Oxide and 50% Oxygen that has potent analgesic
effects.

Mechanism of Action:
Nitrous Oxide is a CNS depressant with analgesic properties. The effects dissipate within 2-5
minutes after cessation of administration. Nitronox must be self administered through a modified
demand valve. It is effective in treating many varieties of pain, including those from trauma. The
high concentration of oxygen delivered with nitrous oxide will increase the oxygen amount in the
blood, thus reducing hypoxia.

Indications:
Pain of musculoskeletal origin, burns, suspected ischemic chest pain, states of severe anxiety
including hyperventilation.

Contraindications:
Nitronox should not be used with any patient who cannot understand verbal instructions or who
is intoxicated with alcohol or other drugs. It should not be administered to any patient with a
head injury who exhibits altered mental status. Nitronox should not be administered to COPD
patients, as it tends to diffuse into closed spaces more readily than carbon dioxide or oxygen,
thereby causing blebs to swell, and possibly rupture. Nitronox should also not be administered
to patients with pneumothorax or tension pneumothorax, as the gas will accumulate and
increase the size of the injury.

Precautions:
Nitronox should be used only in well-ventilated areas. Nitrous oxide exists in a liquid state inside
the gas cylinder. Heat will cause the gas to vaporize, making the cylinder and lines cool to the
touch. In very cold environments (less than 21 degrees F) the liquid may be slow to vaporize,
and administration impossible.

Side Effects:
Dizziness, lightheadedness, altered mental state, hallucinations, nausea, and vomiting.

Interactions:
Nitronox can potentiate the effects of other CNS depressants such as narcotics, sedatives,
hypnotics, and alcohol.




Appendix E                                                                                     E- 33
               Hudson Valley Regional Emergency Medical Services Council, INC.
                   DRAFT Advanced Life Support Protocol Manual DRAFT
                            Ondansetron Hydrochloride

Class
Selective 5-HT3 receptor antagonist.

Description
Ondansetron hydrochloride (HCl) is the racemic form of ondansetron and a selective blocking
agent of the serotonin 5-HT3 receptor type.

Mechanism of Action
Ondansetron's mechanism of action has not been fully characterized. The released serotonin
may stimulate the vagal afferents through the 5-HT3 receptors and initiate the vomiting reflex.
Ondansetron selectively antagonizes 5-HT3 receptors.

Indications
Nausea and vomiting prevention.

Contraindications
History of Long QT syndrome, hypersensitivity to drug/class.

Precautions:
Category B in pregnancy- animal studies showed no harm. Human studies – not done, but
unlikely to harm fetus. Caution in liver failure patients.

Side Effects:
Headache, dizziness, diarrhea, agitation, and prolonged QT interval.

Interactions:
Apomormphine, methadone, fluconazole, phenytoin, carbamazepine, rifampicin, and tramadol.




Appendix E                                                                                E- 34
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                   DRAFT Advanced Life Support Protocol Manual DRAFT
                           Phenylephrine 1% Nasal Spray

Class:
Alpha-adrenergic agent (sympathomimetic)

Description:
Phenylephrine is commonly used orally in combination with other drugs and intranasally to treat
nasal congestion.

Mechanism of Action:
After intranasal administration, Phenylephrine stimulates alpha-adrenergic receptors on the
nasal mucosa (direct effect) causing vasoconstriction of local vessels. The vasoconstrictive
action decreases mucosal edema, thereby leading to a decongestant effect.

Indications:
Vasoconstriction of local vessels to facilitate nasotracheal intubation

Contraindications:
Severe hypertension, VT.

Precautions:
Use with extreme caution in geriatric clients, severe arteriosclerosis, bradycardia, partial heart
block, myocardial disease, hyperthyroidism, and during pregnancy and lactation. Systemic
absorption with nasal or ophthalmic use.

Side Effects:
CV: Reflex bradycardia, arrhythmias (rare). CNS: Headache, excitability, restlessness.
Ophthalmologic: Rebound miosis and decreased mydriatic response in geriatric clients, blurred
vision.

Interactions:
Atropine blocks the vagal reflex bradycardia caused by Phenylephrine and increases its pressor
effect. The concomitant use of Phenylephrine with diuretics can cause decreased arterial
responsiveness to vasopressor agents. Phenylephrine can cause severe persistent
hypertension if administered concurrently with Oxytocin.




Appendix E                                                                                     E- 35
                Hudson Valley Regional Emergency Medical Services Council, INC.
                    DRAFT Advanced Life Support Protocol Manual DRAFT
                             Promethazine Hydrochloride

Class:
Antihistamine, phenothiazine-type

Description:
Promethazine hydrochloride is commonly used as an antiemetic for treatment and prophylaxis
of nausea and vomiting and is also used for the hypersensitivity reactions and sedation.

Mechanism of Action:
Promethazine hydrochloride is an H1 receptor blocking agent. In addition to its antihistaminic
action, it provides clinically useful sedative and antiemetic effects. In therapeutic dosage,
promethazine produces no significant effects on the cardiovascular system. Promethazine
hydrochloride’s antiemetic effects are due to inhibition of the CTZ. By its central anticholinergic
effect, it inhibits the vestibular apparatus and the integrative vomiting center. Clinical effects are
apparent within 3-5 minutes after intravenous administration and generally last four to six hours,
although they may persist as long as 12 hours.

Indications:
Prevention and control of severe nausea and/or vomiting, active and prophylactic treatment of
motion sickness, perennial and seasonal allergic rhinitis, uncomplicated allergic skin
manifestations of urticaria and angioedema, amelioration of allergic reactions to blood or
plasma, anaphylactic reactions, and preoperative, postoperative, or obstetric sedation.

Contraindications:
Pediatric patients < 2yrs of age, CNS depression due to drugs, comatose patients, lactation,
previous phenothiazine idiosyncrasy.

Precautions:
Subcutaneous or intra-arterial use may result in tissue necrosis and gangrene.
May cause severe drowsiness. Use in children may cause respiratory depression, or
paradoxical hyperexcitability. Safe use in pregnancy has not been established. Geriatric patients
are more likely to experience confusion, dizziness, hypotension, and sedation.

Side Effects:
CNS: Sedation, sleepiness, occasional blurred vision, dryness of mouth, dizziness,
disorientation, and extrapyramidal symptoms such as oculogyric crisis, torticollis, and tongue
protrusion. CV: Increased or decreased blood pressure. Derm: Rash, photosensitivity. GI:
Nausea and vomiting. Hem: Leukopenia and agranulocytosis.

Interactions:
The sedative action of promethazine hydrochloride is additive to the sedative effects of other
central nervous system depressants, including alcohol, narcotic analgesics, sedatives,
hypnotics, tricyclic antidepressants, and tranquilizers; therefore, these agents should be avoided
or administered in reduced dosage to patients receiving promethazine hydrochloride.



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                                 Sodium Bicarbonate

Class:
Alkalinizing Agent

Description:
Sodium Bicarbonate is a salt that provides bicarbonate to buffer metabolic acidosis.

Mechanism of Action:
Sodium Bicarbonate increases pH by providing the bicarbonate buffer (a weak base). Making
the urine more alkaline enhances Tricyclic Antidepressant excretion. Sodium Bicarbonate is
used to increase the pH of the urine and thereby speed excretion from the body.

Indications:
Tricyclic antidepressant overdose, Phenobarbital overdose, severe acidosis refractory to
hyperventilation, and known hyperkalemia.

Contraindications:
There are no absolute contraindications.

Precautions:
Sodium Bicarbonate can cause metabolic alkalosis when administered in large quantities. It is
important to calculate the dosage based on weight and size.

Side Effects:
There are few side effects when used in the emergency setting.

Interactions:
Most catecholamines and vasopressors (e.g., Epinephrine and Dopamine) can be deactivated
by alkaline solutions such as Sodium Bicarbonate. Calcium Chloride should not be administered
in conjunction with Sodium Bicarbonate, as a precipitate will form.




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                                      Succinylcholine

Class:
Depolarizing Neuromuscular Blocker

Description:
Succinylcholine is a short acting, depolarizing skeletal muscle relaxant used to facilitate
endotracheal intubation.

Mechanism of Action:
Like acetylcholine, Succinylcholine combines with cholinergic receptors in the motor nerves to
cause depolarization. Neuromuscular transmission is thus inhibited, which renders the muscles
unable to be stimulated by acetylcholine. Complete paralysis is obtained within 60 to 90
seconds, and persists for approximately 4 to 5 minutes. Effects then begin to fade, and a return
to normal is seen within 6 minutes. Muscle relaxation begins in the eyelids and the jaw, and then
progresses to the limbs, abdomen, diaphragm, and intercostals. Succinylcholine has no effect
on consciousness.

Indications:
Succinylcholine is used to achieve temporary paralysis when endotracheal intubation is
indicated, and muscle tone or seizure activity prevents it.

Contraindications:
Known hypersensitivity, penetrating eye injuries, and narrow-angle-glaucoma.

Precautions:
Succinylcholine should not be administered unless personnel skilled in endotracheal intubation
are present and ready to perform the procedure. Oxygen and emergency resuscitative drugs
should be readily available. Cardiac arrest and ventricular arrhythmias have been reported when
Succinylcholine was administered to patients with severe burns and severe crush injuries.

Side Effects:
Succinylcholine can cause wheezing, respiratory depression, apnea, aspiration, arrhythmias,
bradycardia, sinus arrest, hypertension, hypotension, increased intraocular pressure, increased
intracranial pressure.

Interactions:
Lidocaine, Procainamide, beta-blockers, magnesium sulfate, and other neuromuscular blockers
enhance the effects of Succinylcholine.




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                   DRAFT Advanced Life Support Protocol Manual DRAFT
                                        Terbutaline

Class:
Sympathetic Agonist and Tocolytic

Description:
Terbutaline is a synthetic sympathomimetic that is selective for Beta-2 adrenergic receptors.

Mechanism of Action:
Terbutaline causes immediate bronchodilation with minimal cardiac effects. Its onset of action is
similar to that of Epinephrine. Terbutaline is also used to suppress pre-term labor.

Indications:
Bronchial asthma, reversible bronchospasm associated with chronic bronchitis and emphysema,
preterm labor.

Contraindications:
Known hypersensitivity.

Precautions:
Use caution when administering this drug to elderly patients and those with cardiovascular
disease or hypertension. If possible, peak flow rate should be measured before and after
administration.

Side Effects:
Palpitations, anxiety, dizziness, headache, nervousness, tremor, hypertension, arrhythmias,
chest pain, nausea, vomiting.

Interactions:
The possibility of developing unpleasant side effects increases when administered with other
sympathetic agonists. Beta-blockers may blunt the effects of Terbutaline.




Appendix E                                                                                   E- 39
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                   DRAFT Advanced Life Support Protocol Manual DRAFT
                        Tetracaine ½% Ophthalmic Drops

Class:
Ophthalmic Anesthetic

Description:
Tetracaine is an ester-type local anesthetic with an intermediate to long duration of action.

Mechanism of Action:
Tetracaine, like all local anesthetics, causes a reversible blockade of nerve conduction by
decreasing nerve membrane permeability to sodium. This decreases the rate of membrane
depolarization thereby increasing the threshold for electrical excitability.

Indications:
Ophthalmic anesthesia

Contraindications:
Use Tetracaine with caution in patients with known ester type anesthetic hypersensitivity.

Precautions:
After Tetracaine is applied to the eye, do not rub or wipe the eye until the anesthetic has worn
off and feeling in the eye returns. To do so may cause injury or damage to the eye.

Side Effects:
Dizziness or drowsiness; increased sweating; irregular heartbeat; muscle twitching or trembling;
nausea or vomiting; shortness of breath or troubled breathing; unusual excitement,
nervousness, or restlessness; unusual tiredness or weakness, Burning, stinging, redness, or
other irritation of eye.

Interactions:
The vagal effects and respiratory depression induced by opiate agonists may be increased by
local anesthetics. Use of local anesthetics with rapid onset vasodilators, such as nitrates, may
result in hypotension. Local anesthetics may enhance the effect of CNS depressive agents.




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                   DRAFT Advanced Life Support Protocol Manual DRAFT
                                          Thiamine

Class:
Vitamin

Description:
Thiamine is an important vitamin commonly referred to as vitamin B1. It is required for the
conversion of pyruvic acid to acetyl coenzyme A.

Mechanism of Action:
Thiamine is required for the conversion of pyruvic acid to acetyl coenzyme A. Without this step,
a significant amount of the energy available in glucose cannot be obtained. Chronic alcohol
intake interferes with the intake, absorption, and use of Thiamine. During extended periods of
fasting, neurological symptoms owing to Thiamine deficiency may occur. These symptoms
include Wernicke’s encephalopathy and Korsakoff’s psychosis.

Indications:
Thiamine is used for coma of unknown origin, especially if alcohol may be involved, and delirium
tremens.

Contraindications:
There are no contraindications to the administration of Thiamine in the emergency setting.

Precautions:
A few cases of hypersensitivity have been reported.

Side Effects:
Hypotension, dyspnea, and respiratory failure have been reported with its use.

Interactions:
There are no interactions in the emergency setting.




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                   DRAFT Advanced Life Support Protocol Manual DRAFT
                                        Vasopressin

Class:
Pituitary (antidiuretic) hormone

Description:
Causes vasoconstriction (pressor effect) of the splanchnic and portal vessels (and to a lesser
extent of peripheral, cerebral, pulmonary, and coronary vessels).

Mechanism of Action:
Depending on the concentration, the hormone acts on both V 1 and V2 receptors.
IV use of Vasopressin may result in severe vasoconstriction.

Indications:
Alternative pressor to epinephrine in the treatment of adult shock refractory VF, useful for
hemodynamic support in vasodilatory shock.

Contraindications:
Vascular disease, especially when involving coronary arteries; angina pectoris.

Precautions:
Increased peripheral vascular resistance may provoke cardiac ischemia and angina, not
recommended for responsive patients with coronary artery disease.

Side Effects:
GI: N&V, increased intestinal activity (e.g., belching, cramps, urge to defecate), abdominal
cramps, flatus. Miscellaneous: Facial pallor, tremor, sweating, allergic reactions vertigo, skin
blanching, bronchoconstriction, anaphylaxis, ―pounding‖ in head, water intoxication
(drowsiness, headache, coma, convulsions).

Interactions:
High doses of epinephrine, heparin, or ethanol can also decrease the response to Vasopressin.




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                   DRAFT Advanced Life Support Protocol Manual DRAFT
                                        Vecuronium

Class:
Non-depolarizing Neuromuscular Blocker

Description:
Vecuronium is a derivative of Pancuronium and is used to provide muscle relaxation to facilitate
endotracheal intubation.

Mechanism of Action:
Vecuronium is one-third more potent that Pancuronium with a shorter duration of effect.
Vecuronium competes with acetylcholine for cholinergic receptor sites on the post junctional
membrane. This competition results in paralysis of muscle fibers served by the occupied
neuromuscular junction. It does not cause an initial depolarization wave, as does
Succinylcholine. The onset is about 1 minute, with good to excellent intubation conditions within
2-3 minutes.

Indications:
Vecuronium is used to achieve temporary paralysis when endotracheal intubation is indicated,
and muscle tone or seizure activity prevents it.

Contraindications:
Known hypersensitivity.

Precautions:
Vecuronium should not be administered unless personnel skilled in endotracheal intubation are
present and ready to perform the procedure. Oxygen and emergency resuscitative drugs should
be readily available.

Side Effects:
Vecuronium can cause wheezing, respiratory depression, apnea, aspiration, arrhythmias,
bradycardia, sinus arrest, hypertension, hypotension, increased intraocular pressure, increased
intracranial pressure.

Interactions:
Lidocaine, Procainamide, beta-blockers, magnesium sulfate, and other neuromuscular blockers
enhance the effects of Vecuronium.




Appendix E                                                                                   E- 43