Regional Emergency Medical Advisory Committee of New York City Prehospital Basic Life Support Protocols Copyright January 1996 (12/96)

• PURPOSE
• SCOPE
• RESPONSIBILITIES
• MEDICAL CONTROL AT THE SCENE
• SCENE SAFETY
• CARDIOPULMONARY RESUSCITATION
• AIRWAY MANAGEMENT
• OXYGEN ADMINISTRATION
• DEFINITION OF COMPENSATED SHOCK
• DEFINITION OF DECOMPENSATED SHOCK
• CONTROL OF EXTERNAL BLEEDING
• MEDICATIONADMINISTRATION
• REQUESTING ADVANCED LIFE SUPPORT ASSISTANCE
• INTIATING TRANSPORT
• SUSPECTED CHILD/SPOUSE/ELDER ABUSE
• PEDIATRIC PATIENTS
• MINORS

PURPOSE

The Regional Emergency Medical Advisory Committee (REMAC) of New York City Basic Life Support Protocols define the minimum standard of care provided to patients by Emergency Medical Technicians (EMTs) and Advanced Emergency Medical Technicians (A EMTs) in New York City. These protocols reflect both the curriculum and Emergency Medical Technician (EMT) and Advanced Emergency Medical Technician-Paramedic (AEMT-P) certification requirements of the New York State Department of Health Bureau of Emergency Medical Services and the Regional Emergency Medical Advisory Committee (REMAC) of New York City. They have been approved by the Regional Emergency Medical Services Council of New York City and the Medical Standards Committee of the New York State Emergency Medical Council

These protocols are guidelines which should be used in conjunction with good clinical judgment.

SCOPE

These protocols apply to all New York State-Certified Emergency Medical Technicians (EMTs) and Advanced Emergency Medical Technicians (AEMTs) including supervisory and administrative personnel, operating within the New York City region.

RESPONSIBILITIES

EMTs and AEMTs shall provide appropriate care in accordance with these Basic Life Support Protocols as indicated by the patient's complaint and/or condition without exceeding the limit of their training.

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MEDICAL CONTROL AT THE SCENE

In accordance with Article 30 of the New York State Public Health Law, the Regional Emergency Medical Services Council is responsible for the coordination of emergency medical services within the region. In accordance with Article 30 of the New York State Public Health Law, the Regional Emergency Medical Advisory Committee is responsible for the medical oversight of the emergency medical service system within the region. In accordance with the Regional Protocol on Coordination of Prehospital Resources, the agency which first arrives at the scene of a prehospital medical emergency is responsible for coordination of patient care resources at the scene. In accordance with the Regional Protocol on Coordination of Prehospital Resources, the New York City Emergency Medical Service will act as an operational resource for information regarding hospital diversions/availability, incident scene safety, and is responsible for coordination of patient care resources at the scene of multiple casualty incidents (MCIs) and similar public health/safety emergencies. (See Protocol #400-B.)

In all cases where EMTs are present at the scene of a medical emergency and AEMTs are not present, EMTs are responsible for medical control at the scene. EMTs shall also assume medical control at the scene if EMTs and Certified First Responders (CFRs) are present; CFRs shall assume medical control at the scene until the arrival of EMTs. AEMTs shall assume medical control at the scene if AEMTs and EMTs (and/or CFRs) are present. Under no circumstances shall an AEMT or EMT transfer responsibility for patient care to a CFR once patient care has been initiated by an AEMT or EMT. This does not relieve CFRs of their patient care responsibilities.

AEMT/EMT/CFR medical control includes, but is not limited to, decisions involving patient care, movement, and transportation, in accordance with scope of practice, these protocols, and agency policy.

If a prehospital care provider receives an order from a public safety official that is detrimental to the patient's condition, contrary to good patient care, or in violation of these protocols or agency policy, the crew shall inform the official of such and continue providing appropriate care.

If the official persists, the crew shall request a prehospital care supervisor from the appropriate agency to respond to the scene.

Upon completion of the assignment, the crew shall prepare a written statement and forward it to the Regional Emergency Medical Advisory Committee via appropriate supervisory personnel.

In the event that a physician who appropriately identifies himself/herself appears at the scene and wishes to intervene in patient care, the physician will be presented with a document outlining the agency's policy regarding "Non-Solicited Medical Intervention". The physician's requests concerning emergency care and movement of the patient should be followed provided they do not conflict with standard policies and procedures. The physician's name and address shall be noted in the comment section of the Prehospital Care Report (PCR). If any conflicts arise, the EMTs/AEMTs shall contact Medical Control and proceed as directed.

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SCENE SAFETY

It is the responsibility of the EMTs/AEMTs to evaluate and judge the scene with regard to safety. Safety factors include, but are not limited to, environmental conditions, the emotional state of a patient or family members, and the contact with potentially hazardous materials and/or spreading of contaminants or disease. Such conditions may be a threat to the health or safety of EMTs/AEMTs, patients, and other persons at the scene. EMTs/AEMTs must also use caution in situations that they are not trained or equipped to handle.

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CARDIOPULMONARY RESUSCITATION

Basic Cardiac Life Support in adults, children, infants, and newborns should conform to the current guidelines set by the American Heart Association and the American Red Cross. The following guidelines apply to the initiation and termination of CPR:
CPR should be initiated on all patients who are apneic and pulseless unless one of the following conditions exist:

• Extreme dependent lividity;
• Rigor mortis;
• Tissue decomposition;
• Obvious mortal injury; or
• A valid Do Not Resuscitate (DNR) order is present. (See Appendix C.)

CPR should also be initiated in newborns, infants, and children under 9 years of age with heart rates less than 60 (severe bradycardia) and signs of inadequate central (proximal) perfusion (decompensated shock).

CPR should be continued until one of the following occurs:

• Spontaneous circulation has been restored;
• Resuscitative efforts have been transferred to providers of equal or higher level of training;
• A qualified, licensed physician assumes responsibility for the outcome of the patient;
• The crew is exhausted to the point of not being able to continue resuscitative efforts

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AIRWAY MANAGEMENT

All patients require continuous monitoring of their airways to ensure airway patency. Wherever the term "Monitor airway" is used throughout these protocols, the following elements must be considered:

• Position of the patient's head;
• Need for airway adjuncts;
• Need for oropharyngeal suctioning; and
• Need for Advanced Life Support airway management techniques.

OXYGEN ADMINISTRATION

Adult patients who require supplemental oxygen should receive high concentration oxygen via a non-rebreathing mask set at 10 to 15 liters per minute. The reservoir bag must remain at least one-third full following inspiration. If a mask is not tolerated by the patient, a nasal cannula set at 6 liters per minute should be used and such use properly documented.

Patients who are chronically maintained on oxygen and do not require high concentration oxygen shall be administered oxygen at their prescribed rate of flow.

• Pocket mask with supplemental oxygen set at 10-15 liters/minute;
• Bag-Valve-Mask and reservoir with flow set at 10-15 liters/minute;
• Mouth-to-mouth or mouth-to-mouth and nose (at provider option, only when adjuncts are not available).

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DEFINITION OF COMPENSATED SHOCK

Any adult patient having a systolic blood pressure ABOVE 90 mm Hg AND exhibiting signs of inadequate perfusion, which may include:

• Altered mental status (e.g. agitation, confusion);
• Tachycardia;
• Pallor;
• Diaphoresis;
• Pale conjunctiva;
• Delayed capillary refill;
• Orthostatic vital sign changes.

• Altered mental status (e.g. agitation, confusion);
• Tachycardia;
• Pallor;
• Cool, cyanotic lower extremities;
• Mottling;
• Delayed capillary refill;
• Weak or absent peripheral (distal) pulses (radial, tibial, pedal).

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DEFINITION OF DECOMPENSATED SHOCK

Any adult patient having a systolic blood pressure BELOW 90 mm Hg AND exhibiting signs of inadequate perfusion, which may include:

• Altered mental status (e.g. lethargy, coma);
• Tachycardia;
• Pallor;
• Diaphoresis;
• Pale conjunctiva;
• Delayed capillary refill;
• Orthostatic vital sign changes.

• Altered mental status (e.g. lethargy, coma);
• Extensive cyanosis of all extremities;
• Weak or impalpable central (proximal) pulses (femoral, brachial, carotid).

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CONTROL OF EXTERNAL BLEEDING

Whenever the term "Control external bleeding" is used throughout these protocols, the following elements must be considered:

• Application of direct pressure with a sterile dressing.
• Elevation of the injured part above the level of the heart.
• Application of a pressure dressing.

• Application of pressure to proper arterial pressure point.
• Application and inflation of MAST (lower extremity only).
• Application of a tourniquet (only as a last resort).

• Pulmonary edema
• Cardiogenic shock
• Penetrating chest injury
• Appropriate size not available

• Evisceration
• Impaled object
• If the patient is known to be pregnant
• Pediatric Patient Under 9 Years Of Age

• Impaled object (other compartments may be inflated)

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MEDICATION ADMINISTRATION

EMTs/AEMTs may assist a patient in self-administration of the patient's own medication as prescribed by the patient's physician.

SUSPECTED CHILD/SPOUSE/ELDER ABUSE

Whenever child, spouse, or elder abuse is suspected, visually assess the scene for evidence of possible abuse, and record all appropriate information on the Prehospital Care Report (PCR). Make a verbal report summarizing the above to the responsible medical personnel upon arrival at the Emergency Department. Complete any appropriate paperwork in compliance with organizational and administrative procedures, e.g., Report of Suspected Child Abuse or Maltreatment (NYS-DSS-2221-A).

• Premature - birth prior to the eighth month of gestation;
• Newborn - immediately following birth;
• Infant - from birth to 1 year;
• Child - from 1 year to under 14 years of age.

• Is a mother;
• Is married;
• Has left home and is self-supporting;
• Is enlisted in the Armed Forces;
• Is requesting treatment for a sexually transmitted disease, drug abuse, or child abuse.

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