Summary of Changes


1. The word “solely” was added for emphasis in Section II, pg II, ¶ c.

2. Substitute medications may be used if a drug is unavailable. (Section II, pg II, ¶ 2).

3. Similarly, lorazepam may be substituted for diazepam depending upon the Medical Director’s preference (this choice will be influenced by availability and cost).

4. The boxes for cardiac monitors were removed from most protocols. Cardiac monitors are expected to be applied as soon as feasible (Section III. This is a brand new section). This is also addressed in the Initial Patient Care protocols.

5. An IO needle is now approved for adults (pg III, Section IV, ¶ 1). Providers must be credentialed and the Medical Director must approve. IO option appears in the protocols as IV/IO.

6. The age limits for child was revised to be consistent with the American Heart Association (AHA) guidelines. “Obvious signs of puberty” are defined and utilized. The overlap for children/adults is 10 – 14 y.o. The term ‘adolescent’ is no longer used (pg III, Section V, ¶ 1).

7. Pediatric dosages and equipment sizes may be calculated using charts, tapes, books, etc (pg III, Section V, ¶ 2).

8. Pg V, Section VIII, ¶ 1 is new. This clarifies when it is OK to call back-up MC.

9. Pg V, Section IX, ¶ 1 adopts the NYS BLS protocol regarding transport to nearest facility.

10. Driving with lights and sirens is further restricted to only critical/unstable patients (Section IX, ¶ 3). ADULT (where noted, some of these changes also appear in pediatrics)

INITIAL PATIENT CARE (adult and peds) 11. “Cardiac monitor as soon as feasible” box is new. This replaces each of the “Cardiac monitor” boxes that were in each protocol.

ADVANCED AIRWAY PROCEDURE (adult & peds) 12. Credentialed AEMT-I may now perform needle thoracostomy. In addition to LMA/ILMA, other FDA-approved, Medical Director-approved devices may be used (Footnote 1), (also in RSI).

13. An additional intubation attempt allowed after the first three attempts if another more experienced AEMT arrives on the scene to assist (Footnote 3 adult; Footnote 2 peds), (also in RSI).

RSI 14. ‘Special note’ at bottom of page was changed from 2 credentialed providers to one credentialed provider and another “experienced” Paramedic, CC, or I.

15. Pg 6, Footnote 4 added to define confirmatory requirements.

SUSPECTED SMOKE INHALATION (adults and peds) 16. ‘Signs of cyanide toxicity?’ diamond is new as are Footnotes 1 & 2.

17. The hyperbaric chamber MC TO was eliminated and a burn specialty center option was added.

RESPIRATORY SIGNS/SYMPTOMS 18. Adult & peds: A ‘Consider Allergic Reaction protocol’ box was added. Note regarding resuscitation protocols below: This revision adheres closely with the AHA, 2005 ACLS guidelines. There is no deviation from these new AHA guidelines.

19. Pg 9: A new pathway differentiating mild from moderate or severe bronchospasm was created. Page 2 October 23, 2006

20. Adult & peds: Ipratropium now mandatory for bronchospasm (for moderate/severe symptoms/signs in adults and all cases in peds). Because ipratropium is now mandatory, atropine is no longer necessary and was eliminated. Steroids are now a standing order in adults (also in Suspected Allergic Reaction) and oral steroids are added as an option because they are as effective as IV steroids. The infant dose of albuterol was eliminated. One standard dose will be used in adults and peds.

ASYSTOLE & PEA 21. Possible contributing factors expanded and directs EMTs to treat them.

22. Greater emphasis on the consideration of field termination of resuscitation (‘Special note’ at bottom left of Asystole page).

23. New emphasis on quality CPR consistent with the 2005 AHA BLS guidelines (Footnote 1).

24. Asystole only: Vasopressin may be substituted for 1st or 2nd doses of Epinephrine (Footnote 3).

25. TCP box eliminated.

BRADYCARDIA 26. TCP no longer optional (the words “if available” were eliminated). TCP is now administered concurrent with atropine if there are severe signs and/or symptoms.

27. Glucagon dose increased to 3 mg in B-blocker or Ca+ channel overdose (MC TO E).

TACHYCARDIA 28. Completely revised to conform to ACLS.

29. Amiodarone is the new DoC for wide complex tachycardia and, if adenosine fails, narrow complex.

30. Unstable A-fib may now be treated with Amiodarone without first calling MC. Formerly, MC had to be contacted to obtain an order to treat this dysrhythmia.

31. Adenosine and overdrive TCP eliminated as MC TOs.

VF 32. The boxes and diamonds were lettered for reference (following the same convention used in ACLS by the AHA).

33. The 2005 AHA guidelines were adopted: CPR is emphasized; the new shock standard (single shock after CPR, biphasic device is emphasized) is adopted; pulse checks before every shock; AAP is moved down (because there is no evidence that intubation improves outcome in the pre-hospital setting) unless IV/IO not successful; amiodarone is the drug of choice over lidocaine (which is used only if there is no IV/IO – then give down the ETT); magnesium sulfate is now a standing order for suspected torsades de pointes. Page 3 October 23, 2006

34. A Medical Director may substitute vasopressin for the 1st or 2nd doses of Epinephrine (Footnote 6).

35. The ½ loading dose boluses of lidocaine, as a substitute for continuous infusion, was eliminated. Post-resuscitation lidocaine infusion was moved to MC TO A because, according to the AHA, there is “insufficient evidence to recommend for or against prophylactic administration of antiarrhythmic drugs to patients who have survived cardiac arrest from any cause.”

SUSPECTED ALLERGIC REACTION 36. Extensively revised. IV epinephrine eliminated. Epinephrine should be given IM if there are severe signs. Diphenhydramine dose is adjusted if the patient self-administered some prior to EMS arrival. Methylpednisolone moved from MC TO to standing order. H2 blockers (cimetadine, famotidine, renitadine) were added as optional meds.

SEIZURES 37. An adult patient who had seized but is no longer seizing, and is alert and stable, may, after approval by MC, be transferred to and transported by BLS.

38. Thiamine is indicated only if alcohol abuse is suspected. (Also in Altered Mental or Neurologic Status and/or Suspected Stroke).

39. Lorazepam added as optional standing order with added reference to Benzodiazapine policy (Footnote 2).

ALTERED MENTAL STATUS 40. Expanded to include “and/or Suspected Stroke.” If stroke is suspected, the BLS Suspected Stroke protocol will be followed. This BLS protocol contains the Cincinnati Stroke Scale. Diversion to a Stroke Center was added as a MC TO E.

CHEST PAIN 41. New “STEMI?” diamonds were added off the “12-lead EKG” boxes.

42. The AEMT is allowed to interpret ST elevation in the EKG, contact MC regarding this finding and complete Chest Pain Checklist.

43. References to Viagra were changed to “drug for erectile dysfunction” to accommodate other drugs in this class that are now on the market.

OVERDOSE/TOXIC EXPOSURE (adult and peds) 44. Ipecac was eliminated.

45. Transport to hyperbaric chamber is eliminated.

SHOCK 46. Adult & peds: The fluid boluses were changed to conform with BTLS.

47. Footnote 1 is new.

MAJOR TRAUMA/BURNS 48. ‘2 large-bore IVs, wide open,’ was deleted and changed to 200 ml fluid bolus which should be repeated until BP > 90 mm Hg. This conforms with BTLS.

PAIN/VOMITING CONTROL (formerly Pain Control) 49. Three anti-emetics were added as Medical Director optional meds for adults only.

50. Adults & peds: Diphenhydramine was added for morphine-induced itching or nausea.

PEDIATRICS ADVANCED AIRWAY PROCEDURE 51. McGill forceps emphasized in suspected FB at top of algorhythm.

52. The esophageal detector device was added for children > 20 kg (Footnote 3).

RESPIRATORY SIGNS/SYMPTOMS 53. Do not intubate if epiglottitis is suspected (Footnote 1).

ASYSTOLE & PEA 54. Possible contributing factors expanded and directs EMTs to treat them.

55. New emphasis on quality CPR consistent with the 2005 AHA BLS guidelines (Footnote 1).

56. Maximum doses of epinephrine added.

BRADYCARDIA 57. First diamond changed from "Serious signs and/or symptoms" to "Signs of shock." New emphasis on quality CPR consistent with the 2005 AHA BLS guidelines (Footnote 2).

58. Dopamine was eliminated.

TACHYCARDIA with pulse 59. First diamond changed from, ”Severely depressed LOC” to “Signs of Shock.”

60. Amiodarone replaces lidocaine and procainamide.

VF 61. The boxes and diamonds were lettered for reference (following the same convention in by the AHA).

62. The 2005 AHA guidelines were adopted: CPR is emphasized (Footnote 1); the new shock standard (single shock after CPR) is adopted; pulse checks before every shock; AAP is moved down; amiodarone is the drug of choice over lidocaine (which is used only if substituted by the Medical Director or if there is no IV/IO – then give down the ETT); magnesium sulfate is now a standing order for suspected torsades de pointes.

SUSPECTED ALLERGIC REACTION 63. Epinephrine (1:1000) either ETT or IM for severe signs.

64. Diphenhydramine dose is adjusted if the patient had received some prior to EMS arrival.

SEIZURES 65. Rectal diazepam added as a standing order.

66. Lorazepam added as optional standing order with added reference to Benzodiazapine policy (Footnote 2).

ALTERED MENTAL OR NEUROLOGIC STATUS 67. Initial naloxone dose decreased to 0.4 mg.

SHOCK 68. Volume of fluid for patient without clear lungs increased from 5 ml/kg to 10 ml/kg.

NEONATAL RESUSCITATION AND STABILIZATION (formerly Emergency Childbirth) 69. Entire algorhythm was extensively revised to conform to PALS. Laryngoscopic suctioning is indicated only if there is thick meconium and if there is weak or absent cry.

MAJOR TRAUMA/BURNS 70. Transport box was revised to include NYS BLS protocol.

PAIN CONTROL 71. Diphenhydramine added as MC TO for itching or nausea.

MCI 72. Both MCI protocols were extensively revised.

73. DUMBELS acronym added to both adult & peds.

ADULT 74. NAAK incorporated. (Footnote 1)

PEDIATRIC 75. Three pathways reduced to 2.

76. Lorazepam added as an option for seizures.

77. Atropen autoinjector added.

78. Dosing chart added (MCI 3).

POLICIES BENZODIAZEPINE (formerly Diazepam policy) 79. Lorazepam now included.

80. New ¶ 4 regarding intercept.

RESTRAINT 81. The following sentence was added to ¶ 4, “Do not place restrained patient in a prone position during transport.”

TRAUMA TRANSPORT 82. Now incorporates the NYS BLS Trauma Transport protocols.

83. Covers pediatrics and adults.

84. The age cut-off for peds remains < 16 y.o.

85. New paragraph on high risk patients added.

DOSAGE TABLES 86. No changes.

MEDICATION LIST 87. Amiodarone and ipatroprium are the 2 new mandatory drugs. Formerly, both were optional.

88. New optional meds: Anesthetic spray, lidocaine jelly, ceftriaxone (Rocephin), cimetadine (Tagamet), famotadine (Pepcid), metoclopromide (Reglan), prednisone tablets and liquid, prochlorperazine (Compazine), promethazine (Phenergan), ranidatine (Zantac).
89. Medication Formulary has been added.