REMAC Protocol Update 2002 Prepared for Chevra Hatzalah

REMAC Protocol Update 2002 Prepared for Chevra Hatzalah VAC By Jerry Rozenberg, PA-C, EMT-P (F 98) & Yosef Simha, EMT-P (F 80) 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, Ph. D EMT-P Winston Lee, EMT-P John Mc. Farland, EMT-P Daniel Meisels, EMT-P James Mejias, EMT-P 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 Regional EMS Council of NYC 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 ò Physicians may not give EMS providers orders that exceed the provider’s training or scope of practice ò EMS Providers should not follow orders of a physician that exceed their level of training or scope of practice. ò 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: ò Breathing less than 8 times per minute ò Breathing more than 24 times per minute ò 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 -800 -635 -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 • Accessory muscle use • Inability to speak…. . in complete… sentences. • Anxiety (hypoxia) • Prolonged expiratory phase • Tripod positioning • Nasal Flaring (infants) Regional EMS Council of NYC 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 • Palpitations • Drowsiness • Chest discomfort • Muscle cramps • Insomnia • Weakness Regional EMS Council of NYC 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 2 nd 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: Pens Criteria for administration of Epi- 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 w. Medication name: ØGeneric – Epinephrine ØTrade – Adrenalin w. Properties ØBronchodilation ØVasoconstriction Regional EMS Council of NYC BLS Protocol Slide 76

Indications • Must meet the following three criteria ØPatient must exhibit findings of severe allergic reaction (anaphylaxis) ØMedication 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: diet Ensure that patients are able to swallow, prior to administration of orange juice, nonsoda, 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 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: by Utilization of Poison Control Centers 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.

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 newly the 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: 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