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<!doctype html>
<html lang="en">
<head>
<!-- Required meta tags -->
<meta charset="utf-8">
<meta name="viewport" content="width=device-width, initial-scale=1">
<!-- Bootstrap CSS -->
<link href="https://cdn.jsdelivr.net/npm/bootstrap@5.1.0/dist/css/bootstrap.min.css" rel="stylesheet" integrity="sha384-KyZXEAg3QhqLMpG8r+8fhAXLRk2vvoC2f3B09zVXn8CA5QIVfZOJ3BCsw2P0p/We" crossorigin="anonymous">
<title>NYS EMS Protocols</title>
</head>
<body>
<main class="container">
<div class="px-4 py-5 my-5 text-center">
<h1 class="display-5 fw-bold">Disclaimer</h1>
<div class="col-lg-12 mx-auto">
<p class="lead mb-4" style="text-align: justify;">This website is not affiliated with New York State in any way. Information here is meant to be helpful but not authoriative. Protocols here should always be checked against <a href="//www.health.ny.gov/professionals/ems/protocol.htm">the current protocol set on the New York State</a> website to ensure consistency as well against the <a href="//www.health.ny.gov/professionals/ems/semac_advisories.htm">current advisories</a>.</p>
<p class="lead mb-4" style="text-align: justify;">Local policies, procedures, and protocols may vary based on REMSCO and REMAC. Please check your local authority to ensure consistency as it is your responsibility as a provider to ensure compliance.</p>
<div class="d-grid gap-2">
<a target="_blank" class="btn btn-primary btn-lg px-4 gap-3" href="https://www.health.ny.gov/professionals/ems/protocols_advisories.htm">New York State DOH EMS</a>
<a target="_blank" class="btn btn-dark btn-lg px-4" href="https://www.murumed.com">Muru: The Offical EMS App of New York</a>
<a target="_blank" class="btn btn-info btn-lg px-4" href="https://github.com/MimoCAD/protocols">Pull Requests Welcome on Github</a>
</div>
</div>
</div>
<div class="p-5 mb-4 bg-light rounded-3">
<div class="container-fluid py-5 text-center">
<h1>New York State</h1>
<h2>Department of Health</h2>
<h3>Bureau of Emergency Medical Service and Trauma Systems</h3>
<h4>Collaborative Advanced Life Support Adult and Pediatric Treatment Protocols</h4>
<h5>2019 Version 1.0 [April 12, 2019]</h5>
<h6>Effective August 1, 2019</h6>
<h6><a href="//health.ny.gov/ems" class="text-warning">health.ny.gov/ems</a></h6>
<h6><a href="//www.health.ny.gov/professionals/ems/docs/collaborative_protocols.pdf" target="_blank" class="text-warning">Version 011619A</a></h6>
</div>
</div>
<style>
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font-size: 1.6em;
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<div class="page toc">
<h1>Index</h1>
<ol aria-role="directory">
<lh><a href="#Background">Background</a></lh><br />
<lh><a href="#Introduction">Introduction</a></lh><br />
<ol>
<lh><a href="#Pediatric Definition and Discussion">Pediatric Definition and Discussion</a></lh><br />
<lh><a href="#Acknowledgements">Acknowledgements</a></lh><br />
</ol>
<li><a href="#General Approach to Prehospital Care">General Approach to Prehospital Care</a></li>
<ol>
<li><a href="#General Approach to the EMS Call">General Approach to the EMS Call</a></li>
<li><a href="#General Approach to the Patient">General Approach to the Patient</a></li>
<li><a href="#General Approach to Safety Restraining Devices">General Approach to Safety Restraining Devices</a></li>
<li><a href="#General Approach to Transportation">General Approach to Transportation</a></li>
</ol>
<li><a href="#Extremis/Cardiac Arrest Protocols">Extremis / Cardiac Arrest Protocols</a></li>
<ol>
<li>Cardiac Arrest</li>
<ol>
<li>General Approach</li>
<ol type="A">
<li><a href="#Cardiac Arrest: General Approach - Adult">Adult</a></li>
<li value="16"><a href="#Cardiac Arrest: General Approach - Pediatric">Pediatric</a></li>
</ol>
<li>Asystole / Pulseless Electrical Activity (PEA)</li>
<ol type="A">
<li><a href="#Cardiac Arrest: Asystole / Pulseless Electrical Activity (PEA) - Adult">Adult</a></li>
<li value="16"><a href="#Cardiac Arrest: Asystole / Pulseless Electrical Activity (PEA) - Pediatric">Pediatric</a></li>
</ol>
<li>Ventricular Fibrillation or Pulseless V Tachycardia</li>
<ol type="A">
<li><a href="#Cardiac Arrest: Ventricular Fibrillation or Pulseless V Tachycardia - Adult">Adult</a></li>
<li value="16"><a href="#Cardiac Arrest: Ventricular Fibrillation or Pulseless V Tachycardia - Pediatric">Pediatric</a></li>
</ol>
</ol>
<li>Foreign Body Obstructed Airway</li>
<ol type="A">
<li><a href="#Foreign Body Obstructed Airway - Adult">Adult</a></li>
<li value="16"><a href="#Foreign Body Obstructed Airway - Pediatric">Pediatric</a></li>
</ol>
<li><a href="#Obvious Death">Obvious Death</a></li>
<li>Respiratory Arrest / Failure</li>
<ol type="A">
<li><a href="#Respiratory Arrest/Failure - Adult">Adult</a></li>
<li><a href="#Respiratory Arrest/Failure - Pediatric">Pediatric</a></li>
</ol>
<li>Return of Spontaneous Circulation</li>
<ol type="A">
<li><a href="#Return of Spontaneous Circulation - Adult">Adult</a></li>
</ol>
<li><a href="#Termination of Resuscitation">Termination of Resuscitation</a></li>
</ol>
<li><a href="#General Adult and Pediatric Medical Protocols">General Adult And Pediatric Medical Protocols</a></li>
<ol>
<li>ALTE / BRUE</li>
<ol type="A">
<li value="16"><a href="#ALTE/BRUE - Pediatric">Pediatric</a></li>
</ol>
<li><a href="#Altered Mental Status">Altered Mental Status</a></li>
<li>Anaphylaxis</li>
<ol type="A">
<li><a href="#Anaphylaxis - Adult">Adult</a></li>
<li><a href="#Anaphylaxis - Pediatric">Pediatric</a></li>
</ol>
<li>Behavioral Emergencies</li>
<ol>
<li>Agitated Patient</li>
<ol type="A">
<li><a href="#Behavioral Emergencies: Agitated Patient - Adult">Adult</a></li>
<li value="16"><a href="#Behavioral Emergencies: Agitated Patient - Pediatric">Pediatric</a></li>
</ol>
<li>Excited Delirium</li>
<ol type="A">
<li value="16"><a href="#Behavioral Emergencies: Excited Delirium - Adult">Adult</a></li>
</ol>
</ol>
<li><a href="#Carbon Monoxide Exposure - Suspected">Carbon Monoxide Exposure - Suspected</a></li>
<li>Cardiac Arrhythmia</li>
<ol>
<li>Bradycardia</li>
<ol type="A">
<li><a href="#Cardiac Arrhythmia: Bradycardia/Heart Blocks - Symptomatic - Adult">Heart Blocks - Symptomatic - Adult</a></li>
<li><a href="#Cardiac Arrhythmia: Bradycardia - Pediatric">Pediatric</a></li>
</ol>
<li>Tachycardia</li>
<ol type="A">
<li value="16"><a href="#Cardiac Arrhythmia: Tachycardia - Pediatric">Pediatric</a></li>
</ol>
<ol>
<li></li>
<ol>
<li>Narrow Complex</li>
<ol type="A">
<li><a href="#Cardiac Arrhythmia: Tachycardia - Narrow Complex - Adult">Adult</a></li>
</ol>
<li>Wide Complex with a Pulse</li>
<ol type="A">
<li><a href="#Cardiac Arrhythmia: Tachycardia - Wide Complex with a Pulse - Adult">Adult</a></li>
</ol>
</ol>
</ol>
</ol>
<li>Cardiac Related Problem</li>
<ol type="A">
<li><a href="#Cardiac Related Problem/Chest Pain - Adult">Chest Pain - Adult</a></li>
<li value="16"><a href="#Cardiac Related Problem - Pediatric">Pediatric</a></li>
</ol>
<li>Cardiogenic Shock</li>
<ol type="A">
<li><a href="#Cardiogenic Shock - Adult">Adult</a></li>
</ol>
<li>Childbirth</li>
<ol>
<li><a href="#Childbirth: Obstetrics">Obstetrics</a></li>
<li><a href="#Childbirth: Preterm Labor (24 - 37 weeks)">Preterm Labor (24 - 37 weeks)</a></li>
<li><a href="#Childbirth: Newborn/Neonatal Care">Newborn / Neonatal Care</a></li>
</ol>
<li>Difficulty Breathing</li>
<ol>
<li><a href="#Difficulty Breathing: Asthma/COPD/Wheezing - Adult">Asthma / COPD / Wheezing - Adult</a></li>
<li><a href="#Difficulty Breathing: Pulmonary Edema - Adult">Pulmonary Edema - Adult</a></li>
<li><a href="#Difficulty Breathing: Asthma/Wheezing - Pediatric">Asthma / Wheezing - Pediatric</a></li>
<li><a href="#Difficulty Breathing: Stridor - Pediatric">Stridor - Pediatric</a></li>
</ol>
<li>Environmental</li>
<ol>
<li><a href="#Environmental - Cold Emergencies">Cold Emergencies</a></li>
<li><a href="#Environmental - Heat Emergencies">Heat Emergencies</a></li>
</ol>
<li>Fever</li>
<ol type="A">
<li><a href="#Fever - Adult">Adult</a></li>
<li value="16"><a href="#Fever - Pediatric">Pediatric</a></li>
</ol>
<li>Hyperkalemia</li>
<ol type="A">
<li><a href="#Hyperkalemia - Adult">Adult</a></li>
</ol>
<li>Hyperglycemia</li>
<ol type="A">
<li><a href="#Hyperglycemia - Adult">Adult</a></li>
<li value="16"><a href="#Hyperglycemia - Pediatric">Pediatric</a></li>
</ol>
<li>Hypoglycemia</li>
<ol type="A">
<li><a href="#Hypoglycemia - Adult">Adult</a></li>
<li value="16"><a href="#Hypoglycemia - Pediatric">Pediatric</a></li>
</ol>
<li>Nausea and / or Vomiting</li>
<ol type="A">
<li><a href="#Nausea and/or Vomiting - Adult">Adult</a></li>
<li value="16"><a href="#Nausea and/or Vomiting (> 2 Y/O) - Pediatric">(> 2 Y/O) - Pediatric</a></li>
</ol>
<li><a href="#Opioid (Narcotic) Overdose">Opioid (Narcotic) Overdose</a></li>
<li><a href="#Organophosphate Exposure">Organophosphate Exposure</a></li>
<li>Pain Management</li>
<ol type="A">
<li><a href="#Pain Management - Adult">Adult</a></li>
<li value="16"><a href="#Pain Management - Pediatric">Pediatric</a></li>
</ol>
<li>Poisoning / Overdose: Undifferentiated</li>
<ol type="A">
<li><a href="#Poisoning/Overdose: Undifferentiated">Adult</a></li>
<li value="16"><a href="#Poisoning/Overdose: Undifferentiated - Pediatric">Pediatric</a></li>
</ol>
<li>Post Intubation Management</li>
<ol type="A">
<li><a href="#Post Intubation Management - Adult">Adult</a></li>
</ol>
<li>Procedural Sedation</li>
<ol type="A">
<li><a href="#Procedural Sedation - Adult">Adult</a></li>
<li value="16"><a href="#Procedural Sedation - Pediatric">Pediatric</a></li>
</ol>
<li>Rapid Sequence Intubation (RSI)</li>
<ol type="A">
<li><a href="#Rapid Sequence Intubation (RSI) - Adult">Adult</a></li>
</ol>
<li>Seizures</li>
<ol type="A">
<li><a href="#Seizures">Adult</a></li>
<li value="16"><a href="#Seizures - Pediatric">Pediatric</a></li>
</ol>
<li>Shock</li>
<ol>
<li>Shock / Hypoperfusion</li>
<ol type="A">
<li><a href="#Shock: Shock/Hypoperfusion - Adult">Adult</a></li>
</ol>
<li>Severe Sepsis / Septic Shock</li>
<ol type="A">
<li><a href="#Shock: Severe Sepsis/Septic Shock">Adult</a></li>
</ol>
<li>Sepsis / Shock / Hypoperfusion</li>
<ol type="A">
<li value="16"><a href="#Shock: Sepsis/Shock/Hypoperfusion - Pediatric">Pediatric</a></li>
</ol>
</ol>
<li><a href="#Smoke Inhalation/Cyanide Poisoning - Symptomatic">Smoke Inhalation / Cyanide Poisoning - Symptomatic</a></li>
<li>ST Elevation MI (STEMI) - Confirmed</li>
<ol type="A">
<li><a href="#ST Elevation MI (STEMI) - Confirmed - Adult">Adult</a></li>
</ol>
<li><a href="#Stroke">Stroke</a></li>
<li></li>
<ol type="A">
<li value="16"><a href="#Technology Assisted Children">Technology Assisted Children</a></li>
</ol>
<li><a href="#Total Artificial Heart (TAH)">Total Artificial Heart (TAH)</a></li>
<li><a href="#Ventricular Assist Device (VAD)">Ventricular Assist Device (VAD)</a></li>
</ol>
<li><a href="#Trauma Protocols">Trauma Protocols</a></li>
<ol>
<li><a href="#Amputation">Amputation</a></li>
<li><a href="#Avulsed Tooth">Avulsed Tooth</a></li>
<li><a href="#Bleeding/Hemorrhage Control">Bleeding / Hemorrhage Control</a></li>
<li><a href="#Burns">Burns</a></li>
<li><a href="#Chest Trauma">Chest Trauma</a></li>
<li>Crush Injuries</li>
<ol type="A">
<li><a href="#Crush Injuries - Adult">Adult</a></li>
</ol>
<li><a href="#Eye Injuries">Eye Injuries</a></li>
<li><a href="#Musculoskeletal Trauma">Musculoskeletal Trauma</a></li>
<li><a href="#Patella Dislocation">Patella Dislocation</a></li>
<li><a href="#Suspected Spinal Injuries">Suspected Spinal Injuries</a></li>
<li>Trauma Associated Shock</li>
<ol type="A">
<li><a href="#Trauma Associated Shock - Adult">Adult</a></li>
</ol>
<li><a href="#Trauma Patient Destination">Trauma Patient Destination</a></li>
</ol>
<li><a href="#Resources">Resources</a></li>
<ol>
<li><a href="#Advance Directives/DNR/MOLST">Advance Directives / DNR / MOLST</a></li>
<li></li>
<ol type="A">
<li value="16"><a href="#APGAR">APGAR</a></li>
</ol>
<li><a href="#Automatic Transport Ventilator">Automatic Transport Ventilator</a></li>
<li></li>
<ol type="A">
<li value="16"><a href="#Child Abuse Reporting">Child Abuse Reporting</a></li>
</ol>
<li><a href="#Glasgow Coma Score (GCS)">Glasgow Coma Score (GCS)</a></li>
<li><a href="#Incident Command">Incident Command</a></li>
<li><a href="#Interfacility Transport">Interfacility Transport</a></li>
<li><a href="#Medication Formulary">Medication Formulary</a></li>
<li><a href="#Medication Infusion">Medication Infusion</a></li>
<li><a href="#Needlestick/Infectious Exposure">Needlestick / Infectious Exposure</a></li>
<li><a href="#Nerve Agent - Suspected">Nerve Agent - Suspected</a></li>
<li></li>
<ol type="A">
<li value="16"><a href="#Normal Vital Signs for Infants/Children">Normal Vital Signs for Infants / Children</a></li>
</ol>
<li><a href="#Oxygen Administration and Airway Management">Oxygen Administration and Airway Management</a></li>
<li></li>
<ol type="A">
<li value="16"><a href="#Pediatric Assessment Triangle">Pediatric Assessment Triangle</a></li>
</ol>
<li><a href="#Prescribed Medication Assistance">Prescribed Medication Assistance</a></li>
<li><a href="#Refusal of Medical Attention">Refusal of Medical Attention</a></li>
<li><a href="#Responsibilities of Patient Care">Responsibilities of Patient Care</a></li>
<li><a href="#Transfer of Patient">Transfer of Patient</a></li>
<li><a href="#Vascular Access">Vascular Access</a></li>
<li><a href="#Vascular Devices - Pre-Existing">Vascular Devices - Pre-Existing</a></li>
</ol>
</ol>
</div>
<div class="page">
<a name="Background"></a>
<h1>Background</h1>
<p>These protocols are intended to guide and direct patient care by EMS. They reflect the current evidence-based practice and consensus of content experts. These protocols are not intended to be absolute treatment documents, rather, as principles and directives which are sufficiently flexible to accommodate the complexity of patient management.</p>
<p>No protocol can be written to cover every situation that a provider may encounter, nor are protocols a substitute for good judgment and experience. Providers are expected to utilize their best clinical judgment and deliver care and procedures according to what is reasonable and prudent for specific situations. However, it will be expected that any deviations from protocol shall be documented and reviewed, according to regional procedure.</p>
<center class="font-weight-bold">THESE PROTOCOLS ARE NOT A SUBSTITUTE FOR GOOD CLINICAL JUDGEMENT</center>
</div>
<div class="page">
<a name="Introduction"></a>
<h1>Introduction</h1>
<p>Pursuant to Article 3004-A, the Regional Emergency Medical Advisory Committee (REMAC) shall develop policies, procedures and protocols for triage, treatment, and transport. On behalf of the REMACs of the participating regions, the Collaborative Protocols Committee members are proud to put forth these collaborative protocols.</p>
<p>These protocols have been updated to be consistent with the Statewide BLS Protocols. Advanced providers are also responsible for, and may implement, the standing orders indicated for BLS care. Protocols are listed for each provider level and STOP lines indicate the end of standing orders. Generally, BLS interventions should be completed before ALS interventions.</p>
<p>Bullets are used throughout this document. Many processes are not sequential and tasks should be performed as most appropriate for patient care.</p>
<p>Regional protocols and policies may accompany these protocols.</p>
<p>The color-coded format of the protocols allows each EMS professional to easily follow the potential interventions that could be performed by level of certification.</p>
<p>The collaborative protocols have been developed to serve all the levels of certification within New York State. Each region will determine which levels will be credentialed to practice within their jurisdiction.</p>
<h2 class="CRITERIA">CRITERIA</h2>
<ul>
<li>Any specific information regarding the protocol in general</li>
</ul>
<h2 class="CFR">CFR AND ALL PROVIDER LEVELS</h2>
<ul>
<li>CFR standing orders</li>
<li>These are also standing orders for all levels of credential above CFR</li>
</ul>
<span class="STOP"><i class="fas fa-fw fa-octagon"></i> CFR STOP</span>
<h2 class="EMT">EMT</h2>
<ul>
<li>EMT standing orders</li>
<li>These are also standing orders for all levels of credential above EMT</li>
</ul>
<span class="STOP"><i class="fas fa-fw fa-octagon"></i> EMT STOP</span>
<h2 class="ADVANCED">ADVANCED</h2>
<ul>
<li>AEMT standing orders</li>
<li>These are also standing orders for all levels of credential above AEMT</li>
</ul>
<span class="STOP"><i class="fas fa-fw fa-octagon"></i> ADVANCED STOP</span>
<h2 class="CC">CC</h2>
<ul>
<li>EMT-CC and paramedic standing orders</li>
</ul>
<span class="STOP"><i class="fas fa-fw fa-octagon"></i> CC STOP</span>
<h2 class="PARAMEDIC">PARAMEDIC</h2>
<ul>
<li>Paramedic standing orders</li>
<li>EMT-CC medical control (non-standing order) options</li>
</ul>
<span class="STOP"><i class="fas fa-fw fa-octagon"></i> PARAMEDIC STOP</span>
<h2 class="PHYSICIAN">MEDICAL CONTROL CONSIDERATIONS</h2>
<ul>
<li>Medical control may give any order within the scope of practice of the provider</li>
<li>Options listed in this section are common considerations that medical control may choose to order as the situation warrants</li>
</ul>
<h2 class="KEYPOINTS">KEY POINTS/CONSIDERATIONS</h2>
<ul>
<li>Additional points specific to patients that fall within the protocol</li>
<li>These protocols do not supplant regionally required equipment specifications or the items required under Public Health Law and Regulations</li>
<li>These protocols should not serve as a demonstration of required equipment or training, as regional and agency variations will exist</li>
<ul>
<li>The collaborative protocol formulary exists as a minimum guide line for all agencies operating within these protocols. REMACs may entertain substitutions, as needed, for drug shortages or local variations, but must share these with the group</li>
</ul>
<li>The Regions will continue to perform QI audits of patient care to develop training programs that will improve proficiency and the REMACs will continue to evaluate literature to update these protocols to optimize the outcomes of patients. Regions will determine the requisite training that providers must review prior to utilizing these protocols</li>
<li>“*if equipped and trained” is noted to indicate interventions that may be performed if an agency or region chooses to implement these variations. These are not required</li>
</ul>
</div>
<div class="page">
<a name="Pediatric Definition and Discussion"></a>
<h1>Pediatric Definition and Discussion</h1>
<p>The period of human development from childhood to adulthood is a continuum with the transition occurring during puberty. Since the completion of this transition is not sharply demarcated and varies among individuals, it is difficult to set a precise age when childhood ends and adulthood begins. It follows that use of such a definition to determine when a pediatric or an adult protocol is to be used is also problematic.</p>
<p>The medical control agreement contained within these protocol document states, “providers are expected to utilize their best clinical judgment and deliver care and procedures according to what is reasonable and prudent for specific situations.” The determination of when to utilize an adult or pediatric protocol shall be no different and subject to the same CQI review that is compulsory with any other aspect of prehospital emergency care.</p>
<p>As a <i>general guideline</i> for use with these protocols, the following definition has been established:</p>
<ul>
<li class="font-weight-bold">Pediatric protocols should be considered for patients who have not yet reached their 15th birthday</li>
</ul>
<p>In protocols requiring weight-based dosing guidelines, pediatric dosing should be calculated on a per-kilogram (kg) basis using the adult dose as the pediatric dose maximum. It is strongly recommended that length-based resuscitation tapes or similar weight calculation devices be used for all pediatric medication doses or treatments to confirm a patient’s weight.</p>
</div>
<div class="page">
<a name="Acknowledgements"></a>
<h1>Acknowledgements</h1>
<p>The State and Regional Emergency Medical Services Councils, State and Regional Emergency Medical Advisory Committees, State Emergency Medical Services for Children Advisory Committee, and Regional Program Agency staff of all that contributed to this and previous versions of these protocols.</p>
<p>The BLS Protocols Advisory and Writing Group</p>
<p>NYS DOH Bureau of EMS staff</p>
<p>Special thanks to Robin Snyder-Dailey for the protocol design.</p>
</div>
<div class="page">
<a name="General Approach to Prehospital Care"></a>
<h1>(1.0) General Approach to Prehospital Care</h1>
</div>
<div class="page">
<a name="General Approach to the EMS Call"></a>
<h1>(1.1) General Approach to the EMS Call</h1>
<h2>Applies to adult and pediatric patients</h2>
<h2 class="CRITERIA">CRITERIA</h2>
<p>This general approach guidance document is intended to provide a standardized framework for approaching the scene. Follow common sense, apply good clinical judgment, and follow regionally approved polices and protocols.</p>
<h2 class="CFR">CFR AND ALL PROVIDER LEVELS</h2>
<h2 class="EMT">EMT</h2>
<h2 class="ADVANCED">ADVANCED</h2>
<h2 class="CC">CC</h2>
<h2 class="PARAMEDIC">PARAMEDIC</h2>
<ul>
<lh>Consider dispatch information while responding:</lh>
<li>Type of response (emergency/non)</li>
<li>Prevailing weather</li>
<li>Road conditions</li>
<li>Time of day</li>
<li>Location of call</li>
<li>EMD determinant/mechanism of illness/injury</li>
<li>Number of anticipated patients</li>
<li>Need for additional resources</li>
</ul>
<ul>
<lh>Survey the scene - do not approach the scene unless acceptably safe to do so. Stage proximate to the scene until scene is rendered acceptably safe:</lh>
<li>Environmental hazards</li>
<li>CBRNE hazards</li>
<li>Evidence of unknown powders / other unknown substances / sharps</li>
<li>Indicators of a chemical suicide</li>
<li>Mechanical hazards</li>
<li>Violence/threat of violence</li>
<li>Traffic hazards</li>
<li>Number of actual patients</li>
<li>Activate local MCI plan as necessary</li>
</ul>
<ul>
<lh>Consider shelter-in-place or evacuation based on hazards; consider additional support resources:</lh>
<li>ALS intercept</li>
<li>Additional ambulance</li>
<li>Air medical services</li>
<li>EMS physician</li>
<li>Fire department/heavy rescue</li>
<li>Law enforcement</li>
<li>Utilities</li>
</ul>
<p>Ensure universal precautions/personal protective equipment appropriate to the task.</p>
<p class="ml-5">For situations in which EMS PPE would not sufficiently protect the provider, the provider should assist the other emergency responders in determining response objectives based on life safety, property preservation, and environmental protection.</blockquote>
<p>Establish or participate in unified command or ICS structure, as appropriate.</p>
<p class="ml-5">For MCIs, establish a command structure as soon as possible.</p>
</div>
<div class="page">
<a name="General Approach to the Patient"></a>
<h1>(1.2) General Approach to the Patient</h1>
<h2>Applies to adult and pediatric patients</h2>
<h2 class="CRITERIA">CRITERIA</h2>
<p>This general approach guidance document is intended to provide a standardized framework for approaching the patient. Always follow common sense, apply good clinical judgment, and follow regionally approved polices and protocols.</p>
<h2 class="CFR">CFR AND ALL PROVIDER LEVELS</h2>
<h2 class="EMT">EMT</h2>
<h2 class="ADVANCED">ADVANCED</h2>
<h2 class="CC">CC</h2>
<h2 class="PARAMEDIC">PARAMEDIC</h2>
<ul>
<lh class="font-weight-bold">History of present illness</lh>
<li>What events led up to the EMS contact?</li>
<li>Use SAMPLE, OPQRST or similar to guide approach to events/illness/complaint</li>
<li>Pertinent past medical history/medications/allergies</li>
<li>Obtain additional pertinent medical information from the family and bystanders</li>
</ul>
<ul>
<lh class="font-weight-bold">Physical Exam</lh>
<li>Focused or complete exam directed by patient presentation, chief complaint, and mechanism of injury or illness</li>
<li>Check for medical alert tags</li>
</ul>
<ul>
<lh class="font-weight-bold">Patient examination - Primary</lh>
<lh>Airway</lh>
<li>Identify and correct any existing or potential airway obstruction while protecting the cervical spine if appropriate</li>
<ul>
<li>Is the airway patent?</li>
<li>Will it stay open on its own?</li>
<li>Is intervention necessary (OPA, NPA, Suction)</li>
</ul>
<lh>Breathing</lh>
<li>Apply oxygen and/or positive pressure ventilations, as indicated</li>
<li>See “Oxygen Administration” protocol</li>
<ul>
<li>Is breathing present?</li>
<li>Is breathing too fast or too slow to sustain life?</li>
<li>Is the patient speaking effectively?</li>
</ul>
<lh>Circulation</lh>
<li>Control serious life-threatening hemorrhage</li>
<li>Refer to the “<a href="#Trauma: Bleeding/Hemorrhage Control">Trauma: Bleeding/Hemorrhage Control</a>” protocol</li>
<ul>
<li>Is a pulse present?</li>
<li>Is the pulse too fast or too slow to sustain life?</li>
<li>Is the pulse regular or irregular?</li>
<li>What is the skin color, condition, and temperature?</li>
<li>Is there serious external hemorrhage?</li>
<li>Is there evidence of internal hemorrhage or signs of shock?</li>
</ul>
</ul>
<p>Continually reassess and correct any existing or potentially compromising threats to the ABCs</p>
<ul>
<lh>Disability</lh>
<li>Determine level of consciousness</li>
<ul>
<li>Alert, Voice, Pain, Unresponsive (AVPU)</li>
<li>GCS</li>
<li>Pupils</li>
<li>Cincinnati Pre-Hospital Stroke Screen (or other regionally approved stroke scale)</li>
</ul>
<lh>Expose</lh>
<li>Appropriately expose patient as needed to perform complete physical exam and perform necessary interventions</li>
<ul>
<li>Are exposed patients sufficiently protected from public view?</li>
</ul>
<lh>Transport Decision</lh>
<li>See “General Approach: to Transportation” protocol</li>
</ul>
<ul>
<lh class="font-weight-bold">Secondary Patient Assessment</lh>
<li>Vital Signs (repeated frequently if abnormal or critical patient)</li>
<ul>
<li>Pulse rate and quality</li>
<li>Respirations rate and quality</li>
<li>Blood pressure</li>
<ul>
<li>Obtain BP by palpation only if necessary</li>
</ul>
<li>Skin color, condition, and temperature</li>
</ul>
<li>Blood glucose determination, if approved, equipped and appropriate</li>
</ul>
<p>Locate records including: MOLST, eMOLST, or DNR as appropriate</p>
<h2 class="PHYSICIAN">MEDICAL CONTROL CONSIDERATIONS</h2>
<ul>
<li>Medical control may give any order within the scope of practice of the provider</li>
<li>Options listed in this section are common considerations that medical control may choose to order as the situation warrants</li>
</ul>
<h2 class="KEYPOINTS">KEY POINTS/CONSIDERATIONS</h2>
<ul>
<li>If a patient chooses to refuse care or transportation, please refer to “Refusal of Medical Attention” protocol and regional policy</li>
<li>Develop a prehospital patient impression by combining all information available in the history of present illness, past medical history, and physical exam</li>
<li>Submit a verbal report to the responsible medical personnel upon arrival at the emergency department</li>
<li>Label any items that were transported with the patient such as ECGs, paperwork from facilities, medications, or belongings</li>
<li>Complete a patient care report in compliance with state, regional and agency policy</li>
</ul>
</div>
<div class="page">
<a name="General Approach to Safety Restraining Devices"></a>
<h1>(1.3) General Approach to Safety Restraining Devices</h1>
<h2>Applies to adult and pediatric patients</h2>
<h2 class="CRITERIA">CRITERIA</h2>
<p>This general approach guidance document is intended to provide a standardized framework for patient transport. Follow common sense, apply good clinical judgment, and follow regionally approved policies and procedures</p>
<h2 class="CFR">CFR AND ALL PROVIDER LEVELS</h2>
<h2 class="EMT">EMT</h2>
<h2 class="ADVANCED">ADVANCED</h2>
<h2 class="CC">CC</h2>
<h2 class="PARAMEDIC">PARAMEDIC</h2>
<p>All passengers including patients and EMS personnel should be restrained</p>
<ul>
<li>It is not permissible or safe to have a parent or caregiver hold a child in his/her arms or lap. The child and parent/caregiver should each be restrained appropriately</li>
<li>All patients on the stretcher must be secured when the vehicle is in motion or the stretcher is being carried or moved; stretcher harness straps should always be used</li>
<li>A child’s own safety seat - when available and intact - can be used to restrain a child during transport. He/she should be placed in the device and the device should be belted to an ambulance seat. If the child is the patient, the seat should be secured onto the stretcher and the child belted in the child safety seat</li>
<li>If the ambulance service does not have an ambulance equipped with child safety seats or restraint, it is recommended that the agency purchase approved child safety seat(s) or restraint(s) for each ambulance. More than one size seat/restraint may be needed as location of the restraint (i.e., stretcher, or captain’s chair) may not accommodate all size children</li>
<li>Agencies should routinely train EMS personnel in the use of various child safety seats/restraints available and have a policy for how injured or uninjured children will be transported</li>
<li>As an agency considers the purchase of new vehicles, or is retrofitting current vehicles, design considerations, such as integrated child restraints, should be considered</li>
<li>All safety seats/restraints should be used according to manufacturer’s recommendations</li>
</ul>
<h2 class="KEYPOINTS">KEY POINTS/CONSIDERATIONS</h2>
<ul>
<li>If a patient chooses to refuse safety restraints, please refer to “Refusal of Medical Attention” protocol, as well as agency and regional policy</li>
</ul>
</div>
<div class="page">
<a name="General Approach to Transportation"></a>
<h1>(1.4) General Approach to Transportation</h1>
<h2>Applies to adult and pediatric patients</h2>
<h2 class="CRITERIA">CRITERIA</h2>
<p>This general approach guidance document is intended to provide a standardized framework for patient transport. Follow common sense, apply good clinical judgment, and follow regionally approved policies and procedures.</p>
<h2 class="CFR">CFR AND ALL PROVIDER LEVELS</h2>
<h2 class="EMT">EMT</h2>
<h2 class="ADVANCED">ADVANCED</h2>
<h2 class="CC">CC</h2>
<h2 class="PARAMEDIC">PARAMEDIC</h2>
<ul>
<lh>Ongoing scene and patient assessment</lh>
<li>Scene safety is not just a yes/no question; it is continual situational awareness</li>
<li>Take note of the effect of patients and bystanders</li>
<li>Don’t get pinned into area</li>
<li>Be aware of your egress routes</li>
</ul>
<p>Consideration for ALS intercept and air medical services should be made based on agency and regional protocol, policy, patient needs, regional capabilities, and travel times. Do not delay transport waiting for ALS to arrive. The closest ALS may be at a hospital</p>
<p>Transport to the closest appropriate receiving hospital in accordance with regional hospital destination policies for travel time, hospital capabilities and NY State designation</p>
<ul>
<li>The closest appropriate hospital may not be the nearest hospital, even for patients in extremis such as those in cardiac or respiratory arrest</li>
</ul>
<p>Ensure ongoing patient assessment, check for improving / deteriorating patient condition, and respond accordingly. Check to ensure that previously initiated therapies remain functional</p>
<p>Carefully consider use of appropriate emergency warning devices for transport: Lights and siren use is a medical intervention - does the patient condition warrant the use?</p>
<p>Provide a brief pre-arrival report to receiving hospital in accordance with regional policy. Ensure early notification for serious trauma, STEMI, stroke, and sepsis</p>
<h2 class="PHYSICIAN">MEDICAL CONTROL CONSIDERATIONS</h2>
<ul>
<li>Medical control may assist with questions of care or there are complex medical conditions</li>
<li>Medical control may assist with the determining the most appropriate receiving facility</li>
</ul>
<h2 class="KEYPOINTS">KEY POINTS/CONSIDERATIONS</h2>
<ul>
<li>If a patient chooses to refuse care or transportation, please refer to “Refusal of Medical Attention” protocol, as well as agency and regional policy</li>
</ul>
</div>
<div class="page">
<a name="Extremis/Cardiac Arrest Protocols"></a>
<h1>(2.0) Extremis/Cardiac Arrest Protocols</h1>
</div>
<div class="page">
<a name="Cardiac Arrest: General Approach - Adult"></a>
<h1>(A2.1.0) Cardiac Arrest: General Approach</h1>
<h2>For pediatric, see “Cardiac Arrest - General Approach - Pediatric”</h2>
<h2 class="CRITERIA">CRITERIA</h2>
<ul>
<li>For patients who are unresponsive without signs of life</li>
<li>For patients that do not meet the criteria of the “Extremis: Obvious Death” protocol or otherwise excluded by a DNR/MOLST order, see also “Resources: Advance Directives/MOLST/DNR” protocol</li>
</ul>
<h2 class="CFR">CFR AND ALL PROVIDER LEVELS</h2>
<ul>
<li>CPR should be initiated prior to defibrillation unless the cardiac arrest is witnessed by the responding EMS provider</li>
<ul>
<li>Perform compressions while awaiting the application of defibrillation pads</li>
</ul>
<li>Push hard and fast (100-120 compressions/min)</li>
<ul>
<li>Metronome or feedback devices may be used</li>
</ul>
<li>Ensure full chest recoil</li>
<li>Minimize interruptions in chest compressions</li>
<li>Cycle of CPR = 30 compressions then 2 breaths</li>
<ul>
<li>5 cycles = 2 minutes</li>
<li>Rotate compressors every two minutes with pulse checks, as resources allow</li>
<li>Minimize interruptions in chest compressions</li>
</ul>
<li>Continuous compressions with asynchronous ventilation (not stopping compressions while ventilating) is permitted to substitute for cycles of CPR that have pauses for ventilation even in non-intubated patients</li>
<li>Avoid hyperventilation (breathing too quickly or deeply for the patient)</li>
<li>Use of airway adjuncts and bag-valve mask device, as indicated, with BLS airway management, including suction (as needed), as available</li>
<ol>
<li>Bag-valve mask should be connected to supplemental oxygen, if available</li>
</ol>
<li>Rhythm check or AED “check patient” every 5 cycles or two minutes of CPR</li>
<li>Defibrillate as appropriate</li>
<ol>
<li>Resume CPR immediately after defibrillation (do not check a pulse at this time)</li>
<li>Continue CPR for approximately 2 minutes cycles before doing a pulse check, or until the patient no longer appears to be in cardiac arrest</li>
</ol>
</ul>
<span class="STOP"><i class="fas fa-fw fa-octagon"></i> CFR STOP</span>
<h2 class="EMT">EMT</h2>
<ul>
<li>After 20 minutes consider calling medical control for: termination of resuscitation, continuing efforts, or transportation in extenuating circumstances</li>
</ul>
<span class="STOP"><i class="fas fa-fw fa-octagon"></i> EMT STOP</span>
<h2 class="ADVANCED">ADVANCED</h2>
<h2 class="CC">CC</h2>
<h2 class="PARAMEDIC">PARAMEDIC</h2>
<ul>
<li>Manage the airway and confirm placement of any advanced airway device utilized with waveform capnography</li>
<ul>
<li>Waveform capnography may be used on any ventilated patient, regardless of the use of an airway adjunct</li>
</ul>
<li>Check heart rhythm every two minutes</li>
<li>See also rhythm-specific protocols</li>
<li>Refer to “Resources: Vascular Devices - Pre-existing” protocol as needed</li>
<li>After an advanced airway is placed, no longer deliver “cycles” of CPR</li>
<ul>
<li>Give continuous chest compressions without pauses for breaths</li>
</ul>
<li>Give 8-10 breaths/minute</li>
<li>Search for and treat possible contributing factors that EMS can manage according to your level of certification:</li>
<ul>
<li><b>H</b>ypoglycemia, <b>H</b>ypovolemia, <b>H</b>ypoxia, <b>H</b>ydrogen ion (acidosis), <b>H</b>yperkalemia, <b>T</b>oxins, <b>T</b>ension pneumothorax, <b>T</b>rauma</li>
</ul>
<li>For cardiac arrest associated with fire, see also “General: Cyanide Poisoning / Smoke Inhalation - Symptomatic” protocol</li>
<li>For cardiac arrest associated with hypothermia:</li>
<ul>
<li>If defibrillation is required, provide no more than three shocks</li>
<li>Limit administration of medication in cardiac arrest associated with hypothermia to one round</li>
<li>Rhythm changes may be treated with a single round of the appropriate drug See also “General: Environmental - Cold Emergencies” protocol</li>
</ul>
</ul>
<span class="STOP"><i class="fas fa-fw fa-octagon"></i> ADVANCED, CC, AND PARAMEDIC STOP</span>
<h2 class="PHYSICIAN">MEDICAL CONTROL CONSIDERATIONS</h2>
<ul>
<li>Termination of resuscitation in instances that are not covered by standing order criteria may be authorized by medical control</li>
</ul>
<h2 class="KEYPOINTS">KEY POINTS/CONSIDERATIONS</h2>
<ul>
<li>Do not interrupt compressions for placement of an advanced airway</li>
<li>Minimize interruption in compressions for placement of a mechanical CPR device</li>
<li>Do not delay beginning compressions to begin ventilations</li>
<li>Do not delay ventilations to connect supplemental oxygen</li>
<li>Adequate ventilation may require disabling the pop-off valve is the bag-valve mask unit is so equipped</li>
<li>AED should be placed as soon as possible without interrupting compressions to do so</li>
<li>If a patient has a medication patch, it may be removed (use appropriate PPE)</li>
<li>Artifact from vibrations in a moving ambulance may compromise the effectiveness of the AED</li>
<li>Compressions in moving ambulances pose a significant danger to providers, are less effective, and should be avoided</li>
<ul>
<li>Consider mechanical CPR devices when available for provider safety if there is a need to do compressions in moving ambulances (e.g. AutoPulse®, LUCAS®, LifeStat®, or other FDA approved device)</li>
</ul>
</ul>
</div>
<div class="page">
<a name="Cardiac Arrest: General Approach - Pediatric"></a>
<h1>(P2.1.0) Cardiac Arrest: General Approach - Pediatric</h1>
<h2 class="CRITERIA">CRITERIA</h2>
<ul>
<li>For patients who are unresponsive without signs of life</li>
<li>For patients that do not meet the criteria of the “Extremis: Obvious Death” protocol or otherwise excluded by a DNR/MOLST order, see also “Resources: Advance Directives/MOLST/DNR” protocol</li>
</ul>
<h2 class="CFR">CFR AND ALL PROVIDER LEVELS</h2>
<h2 class="EMT">EMT</h2>
<ul>
<li>CPR should be initiated prior to defibrillation unless the cardiac arrest is witnessed by the responding EMS provider</li>
<ul>
<li>Perform compressions while awaiting the application of defibrillation pads</li>
</ul>
<li>Push hard and fast (100-120 compressions/min)</li>
<ul>
<li>Metronome or feedback devices may be used</li>
</ul>
<li>Ensure full chest recoil</li>
<li>Minimize interruptions in chest compressions</li>
<li>Cycle of CPR = 30 compressions then 2 breaths (single rescuer) 15 compressions then 2 breaths (if two rescuers available)</li>
<ul>
<li>5 cycles = 2 minutes (10 cycles = 2 minutes for 2-rescuers)</li>
<li>Rotate compressors every two minutes with rhythm checks, as resources allow</li>
<li>Minimize interruptions in chest compressions</li>
</ul>
<li>Avoid hyperventilation</li>
<li>Use of level-appropriate airway adjuncts and bag-mask device (BVM), as indicated, with BLS airway management, including suction (as needed), as available</li>
<ul>
<li>Bag-mask should be connected to supplemental oxygen, if available</li>
</ul>
<li>Rhythm check or AED “check patient” every two minutes of CPR</li>
<li>Defibrillate as appropriate (Pediatric AED pads preferred for children with weight < 25 kg or age < 8 years, if available.) (CC/Paramedic may substitute manual defibrillation, as indicated)</li>
<ul>
<li>Resume CPR immediately after defibrillation (do not check a pulse at this time)</li>
<li>Continue CPR for approximately 2 minutes cycles before doing a pulsecheck, or until the patient no longer appears to be in cardiac arrest</li>
</ul>
</ul>
<span class="STOP"><i class="fas fa-fw fa-octagon"></i> CFR AND EMT STOP</span>
<h2 class="ADVANCED">ADVANCED</h2>
<h2 class="CC">CC</h2>
<ul>
<li>See also rhythm-specific protocols</li>
</ul>
<span class="STOP"><i class="fas fa-fw fa-octagon"></i> ADVANCED and CC STOP</span>
<h2 class="PARAMEDIC">PARAMEDIC</h2>
<ul>
<li>Consider intubation only if unable to effectively ventilate with BVM and basic airway adjuncts</li>
</ul>
<span class="STOP"><i class="fas fa-fw fa-octagon"></i> PARAMEDIC STOP</span>
<h2 class="PHYSICIAN">MEDICAL CONTROL CONSIDERATIONS</h2>
<ul>
<li>Termination of resuscitation in instances that are not covered by standing order criteria may be authorized by medical control</li>
</ul>
<h2 class="KEYPOINTS">KEY POINTS/CONSIDERATIONS</h2>
<ul>
<li>Intubation is not necessary if oxygenating and ventilating patient well with BLS airway management</li>
<li>Do not interrupt compressions for placement of an advanced airway</li>
<li>Minimize interruption in compressions for placement of a mechanical CPR device</li>
<li>Do not delay beginning compressions to begin ventilations</li>
<li>Do not delay ventilations to connect supplemental oxygen</li>
<li>Adequate ventilation may require disabling the pop-off valve if the bag mask unit is so equipped</li>
<li>AED should be placed as soon as possible without interrupting compressions to do so</li>
<li>If a patient has a medication patch, it may be removed (use appropriate PPE)</li>
<li>Artifact from vibrations in a moving ambulance may compromise the effectiveness of the AED</li>
<li>Consider calling medical control for termination of resuscitation or initiation of transport after 20 minutes of CPR</li>
<li>Compressions in moving ambulances pose a significant danger to providers, are less effective, and should be avoided</li>
<ul>
<li>If appropriate for the patient’s size, consider mechanical CPR devices when available for provider safety if there is a need to do compressions in moving ambulances (e.g. AutoPulse®, LUCAS®, LifeStat®, or other FDA approved device)</li>
<li>Note: The use of a particular mechanical CPR device may be contraindicated in the pediatric patient; refer to manufacturer’s recommendation</li>
</ul>
</ul>
</div>
<div class="page">
<a name="Cardiac Arrest: Asystole or Pulseless Electrical Activity (PEA) - Adult"></a>
<h1>(A2.1.1) Cardiac Arrest: Asystole or Pulseless Electrical Activity (PEA) - Adult</h1>
<h2>For pediatric, see “Asystole or Pulseless Electrical Activity (PEA) - Pediatric”</h2>
<h2 class="CFR">CFR AND ALL PROVIDER LEVELS</h2>
<h2 class="EMT">EMT</h2>
<ul>
<li>General cardiac arrest care, “Extremis: Cardiac Arrest: General Approach” protocol</li>
</ul>
<span class="STOP"><i class="fas fa-fw fa-octagon"></i> CFR AND EMT STOP</span>
<h2 class="ADVANCED">ADVANCED</h2>
<ul>
<li>Manage airway: Use of naso- and/or oropharyngeal airway and bag-valve mask device is acceptable while deferring advanced airway until more urgent care is completed</li>
<li>Vascular access; check glucose level</li>
<li>Normal saline 500 mL bolus</li>
<li>Epinephrine (1:10,000 / 0.1 mg/mL) 1 mg IV; repeat every 3-5 minutes</li>
</ul>
<span class="STOP"><i class="fas fa-fw fa-octagon"></i> ADVANCED STOP</span>
<h2 class="CC">CC</h2>
<ul>
<li>Cardiac monitor</li>
</ul>
<span class="STOP"><i class="fas fa-fw fa-octagon"></i> CC STOP</span>
<h2 class="PARAMEDIC">PARAMEDIC</h2>
<ul>
<li>For suspected hyperkalemia or acidosis:</li>
<ul>
<li>Sodium bicarbonate 50 mEq IV</li>
<li>Calciumchloride 1 gram IV</li>
</ul>
</ul>
<span class="STOP"><i class="fas fa-fw fa-octagon"></i> PARAMEDIC STOP</span>
<h2 class="PHYSICIAN">MEDICAL CONTROL CONSIDERATIONS</h2>
<ul>
<li>Termination of resuscitation in instances that are not covered by standing order criteria may be authorized by medical control</li>
</ul>
<h2 class="KEYPOINTS">KEY POINTS/CONSIDERATIONS</h2>
<ul>
<li>Do not interrupt compressions for placement of an advanced airway</li>
<li>Minimize interruption in compressions for placement of a mechanical CPR device</li>
<li>If the cardiac monitor shows asystole, confirm in more than one lead</li>
<li>A minimum of 50 mL of normal saline should be given between the bolus of calcium chloride and the bolus of sodium bicarbonate</li>
<li>Refer to the “<a href="#Extremis: Termination of Resuscitation">Extremis: Termination of Resuscitation</a>” protocol, as indicated</li>
<li>Search for and treat possible contributing factors that EMS can manage according to your level of certification:</li>
<ul>
<li><b>H</b>ypoglycemia, <b>H</b>ypovolemia, <b>H</b>ypoxia, <b>H</b>ydrogen ion (acidosis), <b>H</b>yperkalemia, <b>T</b>oxins, <b>T</b>ension pneumothorax, <b>T</b>rauma</li>
</ul>
<li>Advanced and above: consider bilateral chest decompression in patients with an organized cardiac rhythm presenting in cardiac arrest thought to be secondary to trauma</li>
<ul>
<li>Note thata pneumothorax may also occur spontaneously (without trauma)</li>
</ul>
<li>For cardiac arrest associated with fire, see also “General: Cyanide Poisoning/Smoke Inhalation - Symptomatic” protocol</li>
</ul>
</div>
<div class="page">
<a name="Cardiac Arrest: Asystole/Pulseless Electrical Activity (PEA) - Pediatric"></a>
<h1>(P2.1.1) Cardiac Arrest: Asystole/Pulseless Electrical Activity (PEA) - Pediatric</h1>
<h2 class="CFR">CFR AND ALL PROVIDER LEVELS</h2>
<h2 class="EMT">EMT</h2>
<ul>
<li>General pediatric cardiac arrest care, “Extremis: Cardiac Arrest: General Approach - Pediatric” protocol</li>
</ul>
<span class="STOP"><i class="fas fa-fw fa-octagon"></i> CFR AND EMT STOP</span>
<h2 class="ADVANCED">ADVANCED</h2>
<ul>
<li>Vascular access</li>
</ul>
<span class="STOP"><i class="fas fa-fw fa-octagon"></i> ADVANCED STOP</span>
<h2 class="CC">CC</h2>
<ul>
<li>Cardiac monitor</li>
<li>Normal saline 20 mL/kg bolus (up to 500 mL bolus) rapid IV</li>
<li>Epinephrine (1:10,000 / 0.1 mg/mL) 0.01 mg/kg IV</li>
<ul>
<li>Repeat epinephrine every 3 - 5 minutes</li>
</ul>
</ul>
<span class="STOP"><i class="fas fa-fw fa-octagon"></i> CC STOP</span>
<h2 class="PARAMEDIC">PARAMEDIC</h2>
<ul>
<li>Consider intubation only if unable to effectively ventilate with BVM and basic airway adjuncts</li>
</ul>
<span class="STOP"><i class="fas fa-fw fa-octagon"></i> PARAMEDIC STOP</span>
<h2 class="PHYSICIAN">MEDICAL CONTROL CONSIDERATIONS</h2>
<ul>
<li>Sodium bicarbonate 1 mEq/kg IV</li>
</ul>
<h2 class="KEYPOINTS">KEY POINTS/CONSIDERATIONS</h2>
<ul>
<li>Intubation is not necessary if oxygenating and ventilating patient well with BLS airway management</li>
<li>Do not interrupt compressions for placement of an advanced airway</li>
<li>Confirm asystole in more than 1 lead</li>
<li>Perform CPR for at least 3 minutes between medication doses</li>
<li>Consider airway obstruction</li>
<li>Search for and treat possible contributing factors that EMS can manage according to your level of certification:</li>
<ul>
<li><b>H</b>ypoglycemia, <b>H</b>ypovolemia, <b>H</b>ypoxia, <b>H</b>ydrogen ion (acidosis), <b>H</b>yperkalemia, <b>T</b>oxins, <b>T</b>ension pneumothorax, <b>T</b>rauma</li>
</ul>
<li>For cardiac arrest associated with fire, see also “General: Cyanide Poisoning / Smoke Inhalation - Symptomatic”</li>
</ul>
</div>
<div class="page">
<a name="Cardiac Arrest: Asystole/Pulseless Electrical Activity (PEA) - Pediatric"></a>
<h1>(P2.1.1) Cardiac Arrest: Asystole/Pulseless Electrical Activity (PEA) - Pediatric</h1>
<h2 class="CFR">CFR AND ALL PROVIDER LEVELS</h2>
<h2 class="EMT">EMT</h2>
<ul>
<li>General pediatric cardiac arrest care, “Extremis: Cardiac Arrest: General Approach - Pediatric” protocol</li>
</ul>
<span class="STOP"><i class="fas fa-fw fa-octagon"></i> CFR AND EMT STOP</span>
<h2 class="ADVANCED">ADVANCED</h2>
<ul>
<li>Vascular access</li>
</ul>
<span class="STOP"><i class="fas fa-fw fa-octagon"></i> ADVANCED STOP</span>
<h2 class="CC">CC</h2>
<ul>
<li>Cardiac monitor</li>
<li>Normal saline 20 mL/kg bolus (up to 500 mL bolus) rapid IV</li>
<li>Epinephrine (1:10,000 / 0.1 mg/mL) 0.01 mg/kg IV</li>
<ul>
<li>Repeat epinephrine every 3 - 5 minutes</li>
</ul>
</ul>
<span class="STOP"><i class="fas fa-fw fa-octagon"></i> CC STOP</span>
<h2 class="PARAMEDIC">PARAMEDIC</h2>
<ul>
<li>Consider intubation only if unable to effectively ventilate with BVM and basic airway adjuncts</li>
</ul>
<span class="STOP"><i class="fas fa-fw fa-octagon"></i> PARAMEDIC STOP</span>
<h2 class="PHYSICIAN">MEDICAL CONTROL CONSIDERATIONS</h2>
<ul>
<li>Sodium bicarbonate 1 mEq/kg IV</li>