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REMAC Protocol Update 2002
Prepared for Chevra Hatzalah VAC
By
Jerry Rozenberg, PA-C, EMT-P (F98)
&
Yosef Simha, EMT-P (F80)
Regional EMS Council of NYC
BLS Protocol Slide 1
Regional Emergency Medical Advisory Committee of New York City
Acknowledgements:
Contributing Authors:
Lewis W. Marshall, Jr., MD
Peter Andryuk, EMT-P
Yedidyah Langsam, PhD EMT-P
Winston Lee, EMT-P
John McFarland, EMT-P
Daniel Meisels, EMT-P
James Mejias, EMT-P
Regional EMS Council of NYC
Manuel Delgado, EMT-P
Frank Mineo, EMT-P
Greg Santa-Maria, EMT-P
Wil Silvestry, EMT-P
Chris Stewart, EMT-P
John Violante, EMT-P
Willard Wright, EMT
BLS Protocol Slide 2
Regional Emergency Medical Advisory Committee of New York City
Training program developed and edited by:
Marie Diglio
Executive Director, Operations
Regional EMS Council
of New York City
Todd E. R. Strom, BS, EMT-P, CIC
Training Center Coordinator
Wyckoff Heights Medical Center
Liz Donnelly, EMT-P
Quality Assurance/REMAC
Coordinator
Regional EMS Council
of New York City
Manuel Delgado, EMT-P
REMAC Liaison
FDNY-EMS
Office of Medical Affairs
Regional EMS Council of NYC
BLS Protocol Slide 3
Revisions in
General Operating
Procedures (GOP)
Regional EMS Council of NYC
BLS Protocol Slide 4
Protocol Update Training Curriculum Objectives
General Operating Procedures
To familiarize all emergency medical service
providers in the NYC region with the changes and
additions to the general operating procedures
Regional EMS Council of NYC
BLS Protocol Slide 5
REMAC
The Regional Emergency Medical Advisory
Committee (REMAC) of New York City is
designated by Article 30 of the New York
State Public Health Law to develop triage,
treatment, and transportation protocols for
the NYC region.
Regional EMS Council of NYC
BLS Protocol Slide 6
Reasons for Changes
•
Changes in AHA Guidelines
•
Need for changes to GOP identified through practice and
quality improvement.
•
Changes in New York State EMT Curriculum
•
Questions and comments from EMS Providers
Regional EMS Council of NYC
BLS Protocol Slide 7
Direct Medical Control at the Scene
Physicians who are credentialed by:
• Their EMS system/agency
• REMAC as an On-Line Medical Control Physician
May provide direct medical control:
• Only within the scope of practice for the EMS Provider
• Only to EMS Providers on Scene who operate within the
system/agency that credentialed the physician.
Regional EMS Council of NYC
BLS Protocol Slide 8
Direct Medical Control at the Scene

Physicians may not give EMS providers orders that
exceed the provider’s training or scope of practice

EMS Providers should not follow orders of a physician
that exceed their level of training or scope of practice.

Physicians may not provide direct medical control to
providers outside their EMS system/agency.
Regional EMS Council of NYC
BLS Protocol Slide 9
Direct Medical Control at the Scene

Physicians may perform procedures that are
beyond the EMS provider’s scope of practice.
 The physician’s name, NYS License #, and
REMAC On-Line Medical Control Physician
# must be documented on the PCR or ACR.
Regional EMS Council of NYC
BLS Protocol Slide 10
Oxygen Administration
Criteria for Assisted Ventilations
Any ONE of the following:
 Breathing less than 8 times per minute
 Breathing more than 24 times per minute
 Exhibiting signs of inadequate ventilations
Regional EMS Council of NYC
BLS Protocol Slide 11
Oxygen Administration
Assisted Ventilations
The presence of a DNR order does not alter this
requirement for a patient who in not in respiratory or
cardiac arrest.
Regional EMS Council of NYC
BLS Protocol Slide 12
Suspected Child/Spouse/Elder Abuse
• New York State Social Services Law considers EMTs and AEMTs,
but not CFRs, to be mandatory child abuse reporters.
• Failure to report suspected cases of child abuse to the New York
State Child Abuse and Maltreatment Register (“State Central
Register”) may subject the EMT or AEMT to liability for criminal
and civil prosecution and penalties.
• Notification of suspected child abuse is to be accomplished in
accordance with agency policy. The State Central Register may
be contacted by telephone at 1-800-635-1522.
Regional EMS Council of NYC
BLS Protocol Slide 13
Abandoned Infant Protection Act
• New York State Social Services Law states that infants five days of
age or younger may be abandoned by their parents or caretakers in
a suitable safe location, such as a hospital, ambulance, police
station, or fire house, or with an appropriate person.
• Some of these parents or caretakers may wish to remain
anonymous, but if they offer their name and address, they should
be recorded in the comment section of the Prehospital Care Report.
Regional EMS Council of NYC
BLS Protocol Slide 14
Abandoned Infant Protection Act
• THE ABANDONED INFANT PROTECTION ACT DOES NOT
RELIEVE THE EMT OR AEMT OF THE RESPONSIBILITY TO
REPORT SUCH ABANDONMENT TO THE NEW YORK
STATE CHILD ABUSE AND MALTREATMENT REGISTER
(“STATE CENTRAL REGISTER”). THE STATE CENTRAL
REGISTER MAY BE CONTACTED BY TELEPHONE AT 1-800635-1522
Regional EMS Council of NYC
BLS Protocol Slide 15
Mandated Reporting
Contact your area Coordinator, who will then
contact the appropriate EMHT
Follow-up with your Coordinator
Regional EMS Council of NYC
BLS Protocol Slide 16
MAST Trousers
MAST trousers have been removed from the NYC REMAC
protocols.
Regional EMS Council of NYC
BLS Protocol Slide 17
Regional Emergency Medical Advisory Committee of New York City
BLS
PROTOCOLS
Regional EMS Council of NYC
BLS Protocol Slide 18
Protocol Update Training Curriculum Objectives
Basic Life Support Protocols
To familiarize all emergency medical service
providers in the NYC region with the additions and
revisions to the basic life support protocols
Regional EMS Council of NYC
BLS Protocol Slide 19
400: WEAPONS OF MASS DESTRUCTION
NERVE AGENT EXPOSURE PROTOCOL
NEW PROTOCOL: To ensure safe operations at incidents
involving weapons of mass destruction
Authorization for the use of the MARK I Antidote kits
comes ONLY from the FDNY Office of Medical Affairs
(OMA) through a class order* issued by a FDNY-OMA
Medical Director who is on-scene or as relayed by an
FDNY-OMA Medical Director through On-Line Medical
Control (Telemetry) or through FDNY Emergency Medical
Dispatch.
Regional EMS Council of NYC
BLS Protocol Slide 20
400: WEAPONS OF MASS DESTRUCTION
NERVE AGENT EXPOSURE PROTOCOL
• The issuance of any class order shall be conveyed
to all regional medical control facilities for relay to
units in the field.
• Treatment within the “hot” and “warm” zones
maybe performed only by appropriately trained
personnel wearing appropriate chemical protective
clothing (CPC) as determined by the FDNY
Incident Commander.
Regional EMS Council of NYC
BLS Protocol Slide 21
401: Respiratory Distress/Failure
Clarification:DNR Orders
 Only NYS Prehospital DNR Orders are to be honored.
 Only valid for patients in respiratory or cardiac arrest.
 Patients with valid DNRs NOT in arrest must be treated like
any other patient!
 THIS INCLUDES PROVIDING ASSISTED
VENTILATIONS for patients with signs of inadequate
respirations or having respiration rates of less than 8 or more
than 24 times a minute.
Regional EMS Council of NYC
BLS Protocol Slide 22
401: Respiratory Distress/Failure
Change: Criteria for assisted ventilations
Any ONE of the following:
 Breathing less than 8 times per minute.
 Breathing more than 24 times per minute.
 Exhibiting signs of inadequate ventilations.
Regional EMS Council of NYC
BLS Protocol Slide 23
401: Respiratory Distress/Failure
Added Option:
Transport Position
In addition to the previously allowed transport positions for
patients in respiratory distress (Fowler’s or semi-Fowler’s),
“position of comfort.”
This option added to reflect current practice by EMTs and
AEMTs, as well as the fact that patients find their position
of comfort.
Regional EMS Council of NYC
BLS Protocol Slide 24
401: Respiratory Distress/Failure
Added Reference: Asthma Patients
For patients between 1 and 65 years of age who experiencing
exacerbation of their previously diagnosed asthma, refer to
protocol # 407 (Asthma) [including Albuterol treatment]
Regional EMS Council of NYC
BLS Protocol Slide 25
403: Non-Traumatic Cardiac Arrest
Added Reference: Pediatric AED
The term Semi-Automated External Defibrillator has been
replaced with the term Automated External Defibrillator (AED).
Do not use the AED for pediatric patients less than 8 years old
unless the pediatric modified pad and cable system is available.
Do not defibrillate patients less than one year of age.
Regional EMS Council of NYC
BLS Protocol Slide 26
404: Non-Traumatic Chest Pain
ALS Assistance Requests:
ALS assistance should be requested, if available.
Do NOT delay transport.
Regional EMS Council of NYC
BLS Protocol Slide 27
404: Non-Traumatic Chest Pain
Added: Aspirin Administration
Administer 2 chewable Baby-Aspirin tablets (162 mg total)
to patients experiencing non-traumatic chest pain and that
fall into either of the following categories:
 35 years of age or older
 Patients of any age with a cardiac history
Regional EMS Council of NYC
BLS Protocol Slide 28
404: Non-Traumatic Chest Pain
Aspirin Administration
Contraindications:
 Known Aspirin allergy or hypersensitivity
 Recent GI bleeding (bloody stool or vomitus)
 Bleeding disorder (e.g. hemophilia, clotting disorder...)
 Taking Warfarin (Coumadin) “blood thinners”
Regional EMS Council of NYC
BLS Protocol Slide 29
407: Asthma
Regional EMS Council of NYC
BLS Protocol Slide 30
Inclusion Criteria
• Patients between the ages of 1 and 65
years old (with no ALS immediately
available).
• Patients complaining of difficulty breathing
secondary to an exacerbation of their
previously diagnosed asthma.
Regional EMS Council of NYC
BLS Protocol Slide 31
Exclusion Criteria
• Patients with a history of hypersensitivity to
albuterol sulfate.
• Patients exhibiting signs of respiratory failure (a
patient requiring ventilations)
–
–
–
–
Decreased level of consciousness
Too dyspneic to speak
Cyanosis (despite oxygen therapy)
Diminished breath sounds
Regional EMS Council of NYC
BLS Protocol Slide 32
Pediatric Respiratory
Failure
Sign of ineffective respiratory effort:
–
–
–
–
–
central cyanosis
agitation or lethargy
severe dyspnea or labored breathing
bobbing or grunting
marked intercostal or parasternal retractions.
Regional EMS Council of NYC
BLS Protocol Slide 33
Differential Diagnosis of
Bronchospasm
•
•
•
•
•
•
COPD
Foreign body obstruction
Pulmonary Embolus
Anaphylactic reaction
Pulmonary Edema
Asthma
Regional EMS Council of NYC
BLS Protocol Slide 34
Pathology of Asthma
• Reversible smooth muscle spasm of the airway
associated with hypersensitivity of the airway to
different stimuli. Primarily an inflammatory
process.
• Smooth muscle contractions
• Mucosal edema
• Mucous plugging
Regional EMS Council of NYC
BLS Protocol Slide 35
Triggers of Asthma Attacks
•
•
•
•
•
Allergies
Infection
Stress
Temperature changes
Seasonal changes
Regional EMS Council of NYC
BLS Protocol Slide 36
Signs and Symptoms
•
•
•
•
•
•
Dyspnea
Wheezing
Tachypnea
Tachycardia
Cyanosis
Cough
Regional EMS Council of NYC
• Accessory muscle use
• Inability to speak…..
in complete… sentences.
• Anxiety (hypoxia)
• Prolonged expiratory phase
• Tripod positioning
• Nasal Flaring (infants)
BLS Protocol Slide 37
Assessment of the Asthmatic
• Chief complaint
• History of present illness
• Past medical history
Regional EMS Council of NYC
BLS Protocol Slide 38
History of Present Illness
•
•
•
•
•
•
•
How long
Events leading up to…
How severe (Borg Scale)
Aggravating / Alleviating factors
Other complaints
Steroid use in last 24 hours (p.o. / inhaled)
Other medications
Regional EMS Council of NYC
BLS Protocol Slide 39
Past Medical History
•
•
•
•
Confirm asthma history
Other medical conditions (cardiac)
E.D. visits for asthma in the last 12 months
Hospital admissions for asthma in last 12
months
• Previously intubated due to asthma?
• Allergies to medications, etc.
Regional EMS Council of NYC
BLS Protocol Slide 40
Physical Examination
•
•
•
•
•
•
•
•
Respiratory distress vs. Respiratory failure
Posturing (tripod positioning)
Pursed lip breathing
Vital signs
Skin color, temperature and moisture
Ability to speak... in complete... sentences
Accessory muscle use
BORG Scale
Regional EMS Council of NYC
BLS Protocol Slide 41
Regional EMS Council of NYC
BLS Protocol Slide 42
Physical Examination (cont.)
• Assessing lung sounds
•
•
•
•
Rales
Rhonchi
Stridor
Wheezing
Regional EMS Council of NYC
BLS Protocol Slide 43
Wheezes
• High pitched, continuous sounds
• Occur on inspiration or expiration
• Result of narrowed bronchioles
Regional EMS Council of NYC
BLS Protocol Slide 44
Absent or Diminished Sounds
•
•
•
•
•
•
Pneumothorax
Hemothorax
Obesity
Hypoventilation
Fluid or pus in pleura or lung
COPD or Asthma with poor airflow
Regional EMS Council of NYC
BLS Protocol Slide 45
Stethoscope Placement
Regional EMS Council of NYC
BLS Protocol Slide 46
Albuterol Sulfate Ampules
Regional EMS Council of NYC
BLS Protocol Slide 47
Pharmacology: Albuterol Sulfate
• Actions
– Bronchodilator
• Minimal side effects
•
•
•
•
•
•
Nervousness
Dizziness
Flushing
Tachycardia
Dry mouth
Tremors
Regional EMS Council of NYC
• Palpitations
• Drowsiness
• Chest discomfort
• Muscle cramps
• Insomnia
• Weakness
BLS Protocol Slide 48
Dosage
• One unit dose, 3.0 cc or 0.083%
Via nebulizer at 6 liters per minute or
at a flow rate that will deliver the
medication over 5 to 15 minutes.
• Dose may be repeated if the symptoms
persist for a total of 2 doses.
Regional EMS Council of NYC
BLS Protocol Slide 49
Administration (cont.)
•
•
•
•
•
Assemble nebulizer
Add medication
Attach to oxygen regulator
Set flow meter to 6 lpm
Instruct patient on use
– inform adult patient
– modify delivery for very young patients
Regional EMS Council of NYC
BLS Protocol Slide 50
Nebulizer
Regional EMS Council of NYC
BLS Protocol Slide 51
Assembled Nebulizer
Regional EMS Council of NYC
BLS Protocol Slide 52
Assembled Nebulizer and Oxygen
Tubing
Regional EMS Council of NYC
BLS Protocol Slide 53
Treatment of Asthma Patient
• Assess breathing
• Administer oxygen via non - rebreather
or assist ventilations
• Monitor Breathing
• Do not permit physical activity
• Place patient in position of comfort
Regional EMS Council of NYC
BLS Protocol Slide 54
Assess and Document prior to
administration of albuterol
• Patient is between 1 and 65 years of age
• Dyspnea is secondary to previously diagnosed
asthma
• Vital signs
• Ability to speak… in complete... sentences
• Accessory muscle use
• Wheezing assessment
Regional EMS Council of NYC
BLS Protocol Slide 55
Treatment (cont.)
• Administer albuterol sulfate (one unit dose) via
nebulizer (6 lpm)
• Begin transport
– Do not delay transport to administer medication
• If symptoms persist, give 2nd dose
• Upon transfer of patient, reassess and document
as before.
Regional EMS Council of NYC
BLS Protocol Slide 56
Treatment (cont.)
• Medical control MUST be contacted for
any patient who refuses medical assistance
or transport.
• Request ALS if the patient is in respiratory
failure
Regional EMS Council of NYC
BLS Protocol Slide 57
Documentation
• ACR : All pertinent data should be
recorded in the “Comments” and
“Treatment / Response” sections
Regional EMS Council of NYC
BLS Protocol Slide 58
410: Anaphylactic Reaction
•
•
•
•
Many studies have shown that
the use of an EPI- PEN can be safely
administered by an EMT
Goals
Early recognition of anaphylaxis
Early BLS intervention
Early ALS intervention
Administration of Epinephrine using the Epi-Pen
Auto injector
Regional EMS Council of NYC
BLS Protocol Slide 59
410: Anaphylactic Reaction
Clarification:Criteria for administration of Epi-Pens
Epinephrine Auto-Injectors
(Epi-Pen) should only be used for
patients presenting with true
anaphylactic reactions.
Regional EMS Council of NYC
BLS Protocol Slide 60
410: Anaphylactic Reactions
Symptoms of anaphylactic reactions:
 Respiratory Distress
 Upper Airway Obstruction (Stridor)
 Lower Airway Disease/Severe Bronchospasm(Wheezing)
 Cardiovascular Collapse/Hypotensive Shock
Regional EMS Council of NYC
BLS Protocol Slide 61
Anaphylaxis
• Allergic reaction – immune response to any
substance.
• Reaction can be localized or severe and life
threatening (anaphylaxis)
• Allergen – substance that causes the
immune response
Regional EMS Council of NYC
BLS Protocol Slide 62
Common allergens
•
•
•
•
•
•
Insects – bees, wasps
Food – nuts, fish, milk, chocolate
Plants – poison ivy, oak
Medications – antibiotics
Other – outdoor allergens, fragrances
Latex
Regional EMS Council of NYC
BLS Protocol Slide 63
Patient Assessment
Regional EMS Council of NYC
BLS Protocol Slide 64
Skin
• Swelling to face, neck, hands, feet, tongue and
periorbitally
• Urticaria – hives
• Itching
• Erythema – redness
• Flushed skin
• Warm tingling feeling to face, mouth, chest, feet
and hands
Regional EMS Council of NYC
BLS Protocol Slide 65
Respiratory system
•
•
•
•
•
•
•
Tightness to throat and chest
Cough
Tachypnea
Labored breathing
Hoarseness
Noisy breathing – stridor or wheezing
bronchoconstriction
Regional EMS Council of NYC
BLS Protocol Slide 66
Cardiovascular system
• Tachycardia
• Vasodilation
• Hypotension
Regional EMS Council of NYC
BLS Protocol Slide 67
Other systems
•
•
•
•
•
Itchy, watery eyes
Headache
Sense of impending doom
Runny nose, nasal congestion
Decreased mental status
Regional EMS Council of NYC
BLS Protocol Slide 68
Reminder
• Findings that reveal hypoperfusion (shock),
or respiratory distress (upper airway
obstruction, lower airway disease, severe
bronchospasm ) may indicate the presence
of a severe allergic reaction (anaphylactic
shock).
Regional EMS Council of NYC
BLS Protocol Slide 69
Treatment Protocol
Patients Over Age 9 or Weighing Over 30 Kilos
• Determine that patients history includes past
history of anaphylaxis, severe allergic reactions,
and/or recent exposure to an allergen
• Administer high concentration oxygen
• Request ALS assistance
• Assess the cardiac and respiratory status of the
patient
Regional EMS Council of NYC
BLS Protocol Slide 70
Continued
• If both the cardiac & respiratory status of
the patient are normal, initiate transport
• If either the cardiac or respiratory status of
the patient is abnormal, proceed as
follows:
Regional EMS Council of NYC
BLS Protocol Slide 71
Continued
• If the patient has severe respiratory distress or
shock and has a prescribed Epi-Pen assist the
patient in administration. If the auto injector is
not available or expired and the EMS agency
carries one, administer (0.3 mg.) as authorized by
the agency medical directors.
• If the patient does not have a prescribed Epi-Pen,
begin transport and contact medical control for
authorization to administer 0.3 mg via auto
injector
Regional EMS Council of NYC
BLS Protocol Slide 72
Note
• If unable to make contact with on-line medical
control and the patient is under 35 years old,
you may administer 0.3 mg epinephrine via an
auto-injector if indicated.
• The incident should be reported to medical
control or your medical director as soon as
possible
Regional EMS Council of NYC
BLS Protocol Slide 73
Protocol cont.
• Contact medical control for authorization
to administer a second dose if needed
• Refer to other protocols as needed (resp
distress/failure, obstructed airway, shock)
• If patient arrests treat as per the nontraumatic cardiac arrest protocol
Regional EMS Council of NYC
BLS Protocol Slide 74
Pediatric differences
• The age for pediatrics in this protocol is
patients under 9 years old or weighing less
than 30 kg (66 lbs)
• The dose of epinephrine is 0.15 mg
Regional EMS Council of NYC
BLS Protocol Slide 75
Pharmacology - Epinephrine
Medication name:
Generic
– Epinephrine
– Adrenalin
Properties
Bronchodilation
Vasoconstriction
Trade
Regional EMS Council of NYC
BLS Protocol Slide 76
Indications
• Must meet the following three criteria
Patient must exhibit findings of severe allergic
reaction (anaphylaxis)
Medication is prescribed for this patient by
their physician, direction by medical control,
or inability to contact medical control and
epinephrine is indicated
Regional EMS Council of NYC
BLS Protocol Slide 77
Contraindications
• None when used to treat anaphylaxis
Regional EMS Council of NYC
BLS Protocol Slide 78
Dosage
• Adult- one adult auto injector (0.3 mg)
• Infant and Child- one auto injector
(infant/child) 0.15 mg
Regional EMS Council of NYC
BLS Protocol Slide 79
Administration
• Obtain order from medical control either
on line or as per protocol
• Obtain patients prescribed unit if available
• Ensure prescription is written for patient
• Ensure medication is not discolored
• Remove safety cap from device
Regional EMS Council of NYC
BLS Protocol Slide 80
Administration cont.
• Place tip of device against the patients thigh:
• Use lateral portion of thigh midway between the
waist and knee
• Push firmly until the injector activates
• Record activity and time
• Dispose of injector in appropriate container
• Can be administered through patients clothes
Regional EMS Council of NYC
BLS Protocol Slide 81
Reassessment
• Continually assess ABC’S for signs of
worsening patient condition such as:
• Mental status change
• Increased respiratory rate
• Decreasing B/P
Regional EMS Council of NYC
BLS Protocol Slide 82
Reassessment
• Be prepared to initiate BCLS measures if
indicated including: CPR, AED, ALS
intercept
• Treat for shock
• As the drug lasts in the system 10-20
minutes, be prepared for a potential return
of the anaphylactic reaction
Regional EMS Council of NYC
BLS Protocol Slide 83
Transportation Decision
•Any patient who received Epinephrine
should be transported to an Emergency Room
for evaluation
•On-Line Medical Control must be contacted
for any patient refusing treatment or
transportation after treatment with Epi.
Regional EMS Council of NYC
BLS Protocol Slide 84
410: Anaphylactic Reactions
Symptoms of Allergic Reactions:
Skin Rashes
Hives
Itching
These are symptoms of allergic, NOT anaphylactic,
reactions unless accompanied by severe respiratory
distress or cardiovascular collapse. Such allergic
reactions do NOT warrant treatment with Epi-Pens.
Regional EMS Council of NYC
BLS Protocol Slide 85
411: Altered Mental Status and
414: Poisoning or Drug Overdose
Clarification:Gag-Reflex vs. Ability to Swallow
Ensuring that patients have a gag-reflex is replaced by:
Ensure that patients are able to swallow,
prior to administration of orange juice, non-diet
soda, glucose, syrup of ipecac, or activated charcoal.
Regional EMS Council of NYC
BLS Protocol Slide 86
412: Stroke
NO CHANGES
Regional EMS Council of NYC
BLS Protocol Slide 87
413: Seizures
Priority Change: Transportation and
Information Gathering
Gathering of information regarding the seizure should:
NOT DELAY TRANSPORTATION.
Added: Information Gathering
Without delaying transportation, ascertain if the patient has
a history of seizures along with the other information
gathering previously required by the protocol
Regional EMS Council of NYC
BLS Protocol Slide 88
413: Seizures
Deleted:
Term “Status Epilepticus”
The term “status epilepticus” has been deleted from the
protocol since it is not a part of the revised NYS EMT
curriculum.
Regional EMS Council of NYC
BLS Protocol Slide 89
414: Poisoning or Drug OD
Deletion:
Utilization of Poison Control Centers by
EMS Providers
The option to contact poison control centers for direction of
treatment of patients has been deleted in accordance with
SEMAC policy. All direction should come from NYC
REMAC authorized On-Line Medical Control Facilities.
Regional EMS Council of NYC
BLS Protocol Slide 90
414: Poisoning / Drug OD
Deletion: Hot Water Soaking of Marine Envenomations
Patients with marine envenomations should be transported,
but the direction to soak the area in hot water for 30 minutes
has been deleted.
Regional EMS Council of NYC
BLS Protocol Slide 91
415: Shock
420: Traumatic Cardiac Arrest
Deletion:
Option to Use MAST Pants
The application of MAST has been deleted from the all
NYC REMAC protocols.
Regional EMS Council of NYC
BLS Protocol Slide 92
No Changes To:
416: Abdominal Pain
421: Head and Spine Injuries
422: Neck Injuries
Regional EMS Council of NYC
BLS Protocol Slide 93
423: Chest Injuries
OPEN CHEST WOUND:
• Place an occlusive dressing over the wound and
tape on three sides.
• If the patient’s condition worsens, remove the
occlusive dressing and have the patient fully
exhale. Replace and retape the occlusive
dressing on three sides after exhalation, and
request Advanced Life Support assistance.
Regional EMS Council of NYC
BLS Protocol Slide 94
No Changes To:
424: Abdominal Injuries
425: Bone and Joint Injuries
426: Soft Tissue Injuries
427: Eye Injuries
428: Burns
430: Emotionally Disturbed Patient
431: Heat Related Emergencies
Regional EMS Council of NYC
BLS Protocol Slide 95
432: Cold Related Emergencies
Clarification:Gag-Reflex vs. Ability to Swallow
Ensuring that patients have a gag-reflex is replaced by:
Ensure that patients are able to swallow,
prior to administration of orange juice, non-diet soda,
glucose, syrup of ipecac, or activated charcoal.
Regional EMS Council of NYC
BLS Protocol Slide 96
No Changes To:
433: Drowning or Near Drowning
434: Decompression Sickness
Regional EMS Council of NYC
BLS Protocol Slide 97
440: Obstetric Emergencies
Change:
ALS Assistance
ALS assistance should be requested for the following
special situations:
 Hypertension
 Seizures
 Imminent delivery (if delivery has begun)
Regional EMS Council of NYC
BLS Protocol Slide 98
440: Obstetric Emergencies
Change:
Terminology
The term “pre-eclampsia” has been replaced by
hypertension.
The term “eclampsia” has been replaced by seizures.
Regional EMS Council of NYC
BLS Protocol Slide 99
441: Emergency Childbirth
Change:
ALS Assistance Requests
ALS Assistance must be requested if delivery has begun.
Regional EMS Council of NYC
BLS Protocol Slide 100
441: Emergency Childbirth
Change:
Special Conditions Listing
A listing of special conditions that have special
instructions has been added to the beginning of the
protocol.
 Prolapsed Umbilical Cord
 Umbilical Cord Wrapped Around the Newly born’s
neck
 Breech (Buttocks) Presentation
 Breech (Extremity) Presentation
Regional EMS Council of NYC
BLS Protocol Slide 101
441: Emergency Childbirth
Special Conditions Listing (continued)




Multiple Births
Premature Births
Amniotic Sac Not Ruptured
Amniotic Fluid That is Meconium Stained
Regional EMS Council of NYC
BLS Protocol Slide 102
441: Emergency Childbirth
Change:
Airway suctioning
The direction to clear the airway by suctioning the mouth
and nose utilizing a bulb syringe is no longer “if time
permits.”
Regional EMS Council of NYC
BLS Protocol Slide 103
441: Emergency Childbirth
Change:
Placement of Umbilical Cord Clamps
First Clamp:
8” to 10” from the newly born.
Second Clamp: Approximately 4 finger widths from the
newly born.
Regional EMS Council of NYC
BLS Protocol Slide 104
441: Emergency Childbirth
442: Care of the Newly Born
443: Care of the Newly Born
Change:
Terminology: Newly Born
Newly Born: Someone minutes to hours old
Replaces “Newborn”
Regional EMS Council of NYC
BLS Protocol Slide 105
442: Care of the Newly Born
Change: Ventilation (Indications and Rates)
Indications:
If the Newly Born has ONE of the following:
 Persistent central cyanosis
 Respiratory rate <30 breaths/min
 Heart rate less than 100 BPM
Rates:
Initiate assisted ventilations at a rate of 30 to 60
ventilations per minute. (Previously 40 to 60).
Regional EMS Council of NYC
BLS Protocol Slide 106
443: Newly Born Resuscitation
Ventilation Indications and Rates:
Initiate “blow-by” high concentration oxygen therapy when
the newly born has ALL of the following:
 Respiratory rate >30 breaths/min
 Heart rate >100/min
 Free of central cyanosis
Regional EMS Council of NYC
BLS Protocol Slide 107
443: Newly Born Resuscitation
CPR Indications and Rates
Indications:
If the Newly Born has EITHER of the following:
 A heart rate <60 BPM
OR
 Cardiac Arrest
Regional EMS Council of NYC
BLS Protocol Slide 108
443: Newly Born Resuscitation
CPR Indications and Rates (cont)
Initiate the following resuscitation measures:
 Begin CPR Immediately
 Stop CPR when the newly born’s HR >100 and provide
assisted ventilations at 30 – 60 ventilations per minute.
Regional EMS Council of NYC
BLS Protocol Slide 109
443: Newly Born Resuscitation
CPR Indications and Rates (cont)
Initiate “blow-by” high concentration oxygen therapy when the
newly born has ALL of the following:
 Respiratory rate >30 breaths/min
 Heart rate >120/min and central cyanosis disappears
Regional EMS Council of NYC
BLS Protocol Slide 110
No Changes
450: Pediatric Respiratory Distress / Failure
451: Pediatric Obstructed Airway
452: Pediatric Croup/Epiglottitis
Regional EMS Council of NYC
BLS Protocol Slide 111
453: Pediatric Non-Traumatic Cardiac
Arrest and Severe Bradycardia
Added Reference: Pediatric AED
The term Semi-Automated External Defibrillator has
been replaced with the term Automated External
Defibrillator (AED).
Do not use the AED for pediatric patients less than 8
years old unless the pediatric modified pad and cable
system is available.
Do not defibrillate patients less than one year of age.
Regional EMS Council of NYC
BLS Protocol Slide 112
455: Pediatric Anaphylactic Reaction
Clarification:Criteria for administration of Epi-Pens
Epinephrine Auto-Injectors
(Epi-Pen) should only be used for
patients presenting with true
anaphylactic reactions.
Regional EMS Council of NYC
BLS Protocol Slide 113
455: Pediatric Anaphylactic Reaction
Symptoms of anaphylactic reactions:
 Respiratory Distress
 Upper Airway Obstruction (Stridor)
 Lower Airway Disease/Severe Bronchospasm (Wheezing)
 Cardiovascular Collapse/Hypotensive Shock
Regional EMS Council of NYC
BLS Protocol Slide 114
455: Pediatric Anaphylactic Reaction
Symptoms of Allergic Reactions:
Skin Rashes
Hives
Itching
These are symptoms of allergic, NOT anaphylactic,
reactions unless accompanied by severe respiratory
distress or cardiovascular collapse. Such allergic
reactions do NOT warrant treatment with Epi-Pens.
Regional EMS Council of NYC
BLS Protocol Slide 115
458: Pediatric Shock
NO CHANGES
Regional EMS Council of NYC
BLS Protocol Slide 116
Questions
Regional EMS Council of NYC
BLS Protocol Slide 117