500 GENERAL OPERATING PROCEDURES

Purpose
Scope
Interpretation of Protocols
Medical Authority at the Scene
Communications with Medical Control Facilities
Definition of Compensated Shock/Hypovolemia
Definition of Decompensated Shock/Hypovolemia
Endotracheal Drug Administration
Pharmacology Table
Transportation Decision
Pediatric Protocols

The New York City Regional Emergency Medical Advisory Board Advanced Life Support Protocols define the minimum standard of care provided to patients by all pre-hospital advanced life support providers in New York City. These protocols reflect both the curriculum and Advanced Emergency Medical Technician-Paramedic (AEMT-P) certification requirements of the New York State Department of Health Emergency Medical Services Program, and the curriculum of the New York City Emergency Medical Service Division of Training. They have been approved by the Regional Emergency Medical Services Council of New York City.

These protocols apply to all Advanced Emergency Medical Technician-Paramedics (AEMT-P) who are certified by both New York State and the Advanced Life Support committee of the New York City Regional Emergency Medical Advisory Board. Also included are supervisory and administrative personnel operating within the New York City region who are certified Advanced Emergency Medical Technician-Paramedics.

The following Paramedic Treatment Protocols are for the use of the Paramedic in the field and the Medical Control Physician. They have been developed to ensure high quality, standardized pre-hospital emergency medical care. They are predicated on the requirement of two Paramedics staffing the ambulance. The protocols are specific for Advanced Life Support intervention. Patient assessment and Basic Life Support procedures have not been enumerated herein. However, they are the foundation upon which these protocols are based, and are always to be performed as necessary. All references to Basic Life Support procedures refer to the appropriate New York City Regional Emergency Medical Advisory Board Basic Life Support Protocols.

Protocols 501 through 521 apply to patients ten (10) years of age and older who weigh 40 kg or more. For those patients ten (10) years of age and older who weigh less than 40 kg, see the Pharmacology Table below for appropriate drug dosages.

Protocols 527 through 528 apply to all patients.
Protocols 550 through 559 apply to pediatric patients under ten (10) years of age.

These protocols should be considered as the "model" or guideline by which all patients should be treated. Since patients do not always fit into a rigid formula approach, these protocols are not a substitute for good clinical judgment, especially when a situation occurs which does not fit these guidelines. For patients who do not fit into a rigid formula approach, the term "Discretionary Decision" shall be utilized between the Paramedic and the Medical Control physician. At that time, the Medical Control physician shall order the most appropriate treatment within the Paramedic's scope of practice. Paramedics should not exceed their level of training while following these protocols.

Unless specific conditions are outlined in a protocol, Endotracheal Intubation may be performed under Standing Orders whenever it is required for airway management.

In the event that a Paramedic is working on a Basic Life Support unit, i.e., with an EMT-A or EMT-D, the Paramedic may perform the following Advanced Life Support interventions under Standing Orders:

1. Endotracheal Intubation

2. Defibrillation.

Those procedures appearing in italics are Medical Control Options and require contact with Medical Control prior to their implementation. Once Medical Control has been contacted, only those options or procedures listed in the particular protocol(s) being utilized may be considered. Where there is no existing protocol and a clear need for Advanced Life Support exists, the Paramedic may initiate appropriate therapy (oxygen administration, cardiac monitoring, intravenous infusion to keep the vein open, and/or transportation) and should contact Medical Control in order to differentiate the most emergent clinical problem and define the most suitable therapy.

Under no circumstances is a Paramedic to operate at the scene for more than twenty (20) minutes after making patient contact without attempting to contact Medical Control.

Paramedics shall assume Medical Control at a scene when both Advanced and Basic Life Support units are present, regardless of which unit arrives first.

Paramedic Medical Control includes, but is not limited to, decisions involving:

Patient care;

Patient movement; and

Patient transportation.

Paramedics may release patients not having received or not requiring Advanced Life Support care to Basic Life Support personnel for care and transportation to a medical facility.

In the event that any health care professional other than a physician is at the scene, the Paramedic is to maintain responsibility for the care of the patient.

In the event that a physician who appropriately identifies himself/herself appears at the scene and wishes to intervene in patient care, Medical Control is to be contacted to approve the Paramedic taking orders from the physician at the scene. However, the Paramedic must confine his/her procedures to those contained in the appropriate protocol. In this case, on-scene physicians may not order a Discretionary Decision. The physician will be presented with a "Non-Solicited Medical Intervention" card. The physician's request concerning emergency care and movements should be followed provided they do not conflict with standard policies and procedures. The physician's name and address shall be noted in the comments section of the Pre-hospital Care Report (PCR). If any conflicts arise, the Paramedics will contact Medical Control and request a field supervisor to respond.

If the Paramedic is unable to establish contact with Medical Control, the Paramedic, at his/her option, may follow direction from the on-scene physician within the context of the protocols.

Contact with a Medical Control facility should be made within twenty (20) minutes from the time the Paramedics have established contact with the patient.

In the event of failure of voice contact with Medical Control, Paramedics will perform only those procedures which come under Standing Orders and will be required to transport the patient.

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

Altered mental status (e.g. agitation, confusion);

Tachycardia;

Pallor;

Diaphoresis;

Pale conjunctiva;

Delayed capillary refill; and

Orthostatic vital sign changes.

Altered mental status (e.g. agitation, confusion);

Tachycardia;

Pallor;

Cool, cyanotic extremities;

Mottling;

Delayed capillary refill; and

Weak or absent peripheral pulses (radial, tibial, pedal).

• NOTE:
  THE DEFINITION OF SHOCK IN THE PEDIATRIC PATIENT DOES NOT DEPEND UPON BLOOD PRESSURE.

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

Altered mental status (e.g. lethargy, coma);

Tachycardia;

Pallor;

Diaphoresis;

Pale conjunctiva;

Delayed capillary refill; and

Orthostatic vital sign changes.

Altered mental status (e.g. lethargy, coma);

Extensive cyanosis of all extremities;

Weak or impalpable central pulses (femoral, brachial, carotid).

If no IV is in place and the patient is intubated, Lidocaine, Epinephrine, Atropine, and Naloxone may be administered via endotracheal tube at the same dosage as for IV administration.

The following are recommended dosages for patients under 40 kg in weight and over 10 years of age:

Drug	Dosage
Atropine Sulfate	0.01 mg/kg
Epinephrine	0.01 mg/kg
Furosemide	1 mg/kg/dose
Lidocaine (bolus)	1 mg/kg/dose
Lidocaine (infusion)	1-2 mg/min
Sodium Bicarbonate	1-2 mEq/kg/dose

The term "Transportation Decision" appears throughout these protocols. This term encompasses all of the following:

1. Manner of extrication, when required, and preparation of the patient for transport.
2. Safe conveyance of the patient from the scene to the ambulance on appropriate equipment in an appropriate position.
3. Transportation of the patient to the nearest appropriate hospital in accordance with Appendix F, Appendix G, and Appendix H of the New York City Regional Emergency Medical Advisory Board Basic Life Support Protocols.
4. Designation of another unit (e.g., Basic Life Support unit, mortuary unit) to transport the patient.
   

The number of encounters with children are far fewer than with adults. These protocols therefore address situations where Advanced Life Support in the field can directly affect a child's survival.

Control of the airway and rapid transport are the underlying principles of the pediatric protocols and best serve the needs of the pediatric patient. Since intubation and intravenous or intraosseous access are more difficult in small children, these and other Advanced Life Support interventions are carried out enroute, or during a transport delay, except for special circumstances as clearly noted in the protocols.

1. AIRWAY AND VENTILATION

Airway management by mouth-to-mouth-and-nose, mouth-to-mask, or Bag-Valve-Mask should be used in neonates, infants, and children as a first maneuver for providing assisted ventilation. The above will be referred to throughout the pediatric protocols as "Assisted Ventilation." Remember that the correct position to maintain the optimal airway is age-dependent. In pediatric patients with suspected trauma, the airway maneuver of choice is a modified jaw-thrust. Oxygen should always be provided at high concentration in the pediatric patient and should be humidified when feasible. There are NO CONTRAINDICATIONS to high concentration oxygen in the prehospital setting for the pediatric patient.

2. INTUBATION

When other maneuvers used to ventilate the pediatric patient are inadequate, intubation should be attempted. Suspicion of croup/epiglottitis is a contraindication to attempted intubation. The Esophageal Gastric Tube Airway (EGTA) is not to be used in patients less than fifteen (15) years of age.

3. INTRAVENOUS OR INTRAOSSEOUS ACCESS

IV or IO access is to be started only enroute or during transport delay. There should be only one attempt each made at obtaining access in pediatric patients. IV access should always precede IO access. IO access is not to be used in patients greater than three (3) years of age.

4. NASOGASTRIC TUBE

It may be necessary to pass a Nasogastric Tube (NG Tube) in the neonate, infant, or child in order to successfully perform resuscitation.

5. PEDIATRIC DRUG DOSAGE AND FLUID ADMINISTRATION

The Paramedic shall refer to the Pediatric Schedule in the Appendix J. Initial fluid administration should not exceed 20 ml/kg.

6. PEDIATRIC VALUES

The Pediatric Schedule in Appendix J provides average weight, respiratory rate, heart rate, and blood pressure for age as well as drug dosages. Patients who are hypotensive according to blood pressure should be examined for other signs of shock to support the diagnosis. Note that it may be technically difficult for the Paramedic to obtain a blood pressure in a small or agitated child; in this case, clinical judgment should be used in assessing for hypovolemic shock, especially in a trauma patient.

Contents