THE REGIONAL EMERGENCY MEDICAL SERVICES COUNCIL OF NEW YORK CITY, INC.
NYC REMAC
PUBLIC NOTICE
PROPOSED REVISIONS
PREHOSPITAL TREATMENT
PROTOCOLS
The Regional Emergency Medical Advisory Committee (REMAC) of New York City Prehospital Treatment
Protocols define the minimum standard of care provided to patients by Certified First Responders (CFRs),
Emergency Medical Technicians (EMTs), and Advanced Emergency Medical Technicians-Paramedic (AEMTPs) in New York City. These protocols reflect both the curriculum and certification requirements of the New
York State Department of Health Bureau of Emergency Medical Services and the Regional Emergency
Medical Advisory Committee (REMAC) of New York City.
The REMAC of New York City has proposed revisions to the current regional Prehospital Treatment
Protocols.
Deleted language is BOLD RED AND STRUCK-OUT --- DELETED
New language is BOLD BLUE AND UNDERLINED --- NEW
In order to meet regional needs, the REMAC of New York City is conducting a public notice and is requesting
comments from the Emergency Medical community. Comments must be submitted in writing on the attached
‘Comment Form’ or via email to [email protected] . If available, appropriate supporting documentation
should also be submitted. Comments must be received no later than April 18, 2015.
Draft revised protocols can be reviewed on-line at www.nycremsco.org (under “News and
Announcements”). All NYC REMAC Protocols can be accessed in their entirety at
www.nycremsco.org.
DIRECT ALL INQUIRES AND COMMENTS TO:
Joseph Bove, MD
Chair, Protocol Committee
Regional Emergency Medical Advisory Committee of New York City
c/o
Regional EMS Council of NYC
475 Riverside Drive, Suite 1929
New York, New York 10115
FAX: (212) 870-2302
Email: [email protected]
PLEASE BE ADVISED THAT pursuant to Section 3004-A of Article 30 of the Public Health Law of the State of New York, the Regional
Emergency Medical Advisory Committee (REMAC) of New York City is responsible to develop prehospital triage, treatment, and
transportation protocols that are consistent with the standards of the State Emergency Medical Advisory Committee and that address
specific local conditions with regards to the provision of prehospital medical care rendered by NYS Department of Health certified First
Responders, Emergency Medical Technicians and Advanced Emergency Medical Technicians within the City of New York.
THE REGIONAL EMERGENCY MEDICAL SERVICES COUNCIL OF NEW YORK CITY, INC.
Regional Emergency Medical Advisory Committee (REMAC) of New York City
Protocol Revision Comment Form
Name:
Mailing Address:
Telephone Number:
Fax Number:
e-mail:
Title (e.g., MD, DO, EMT, EMTP, RN, etc.):
Protocol Number:
Protocol Title:
Comments: (Please Type)
(Continue on additional sheet if necessary)
If available, appropriate supporting documentation should be submitted
Comments must be received no later than April 18, 2015to:
Joseph Bove, MD
Chair, Protocol Committee
Regional Emergency Medical Advisory Committee of New York City
c/o Regional EMS Council of NYC
475 Riverside Drive, Suite 1929
New York, New York 10115
Fax: 212-870-2302
Email: [email protected]
Draft revised protocols can be reviewed on-line at www.nycremsco.org (under “News and
Announcements”). All NYC REMAC Protocols can be accessed in their entirety at
www.nycremsco.org.
This form may be duplicated as needed
THE REGIONAL EMERGENCY MEDICAL SERVICES COUNCIL OF NEW YORK CITY, INC.
475 Riverside Drive, Suite 1929
New York, NY 10115
TEL: (212) 870-2118
FAX: (212) 870-2302
Email: [email protected]
March 18, 2015
BOARD OF DIRECTORS
TO:
BLS Ambulance / BLS First Response Services,
ALS Ambulance/ ALS First Response Services,
EMS Agency Medical Directors, REMAC/ Regional Council
Committee Members, Hospital Chief Executive Officers, Hospital
Emergency Department Medical Directors
FROM:
NYC REMAC
RE:
NYC REMAC Public Notice of Protocol Revisions
Officers:
Chair:
Lewis W. Marshall, Jr, MD, JD
Chair, Regional Emergency
Medical Advisory Committee of NYC
Treasurer:
Jeffrey Horwitz, DO
Prohealth Physician
Secretary:
Dorothy Marks
Honorary Commissioner
Fire Department, City of New York
Chair Emeritus:
Walter F. Pizzi, MD, FACS
Members:
Rafael Castellanos, Esq., EMT
Expert Title Insurance Agency, LLC
Arthur Cooper, MD, MS, FACS, FAAP,
FCCM, FAHA
American College of Surgeons
Committee on Trauma
Dennis J. Crowley, MBA
Co-Chair, Development Committee
President, Brand Engineers, LLC
Lorraine M. Giordano, MD, FACEP
Medical Society of the State of NY
Chair, Board of Directors, Queens
County Medical Society
Michael P. Jones, MD
Central Park Medical Unit
Jack S. Kishk, EMT
Co-Chair, Development Committee
Blue Energy, LLC
Yedidyah Langsam, PhD, EMTP
Chair, Computer Science Department
Brooklyn College of CUNY
Marvin Raidman, MBA
Chair, Finance/Personnel Committee
DY Realty Services, LLC
Nancy A. Benedetto, MS, AC
Executive Director Administration
Marie Diglio, EMTP, CLI
Executive Director Operations
TAX EXEMPT
NOT-FOR-PROFIT CORPORATION
Celebrating 40 Years
of Service to the
EMS Community in New York City!
Please find attached the Public Notice for proposed revisions to the NYC REMAC
Protocols.
Attached are a copy of the protocols showing all revisions
Proposed protocol revisions can be reviewed on line at: www.nycremsco.org
(under “News and Announcements”)
All current NYC REMAC Protocols can be accessed in their entirety at
www.nycremsco.org.
Deleted language is BOLD RED AND STRUCK-OUT – DELETED
New language is BOLD BLUE AND UNDERLINED – NEW
All comments must be submitted in writing no later than April 18, 2015 on the
attached ‘Comment Form’. If available, please attach all appropriate supporting
documentation.
Thank you.
THE REGIONAL EMERGENCY MEDICAL SERVICES COUNCIL OF NEW YORK CITY, INC.
Public Notice – Proposed Revisions NYC REMAC Protocols – March 2015
Summary of Proposed Protocol Revisions
GENERAL OPERATING PROCEDURES:
•
New GOP Language: Spinal Precautions & Spinal Injury Protection
CERTIFIED FIRST RESPONDER PROTOCOLS
•
312: Head and Spine Injuries
BASIC LIFE SUPPORT (EMT-B) PROTOCOLS
•
412: Head and Spine Injuries
•
430: Emotionally Disturbed Patient
ADVANCED LIFE SUPPORT (Paramedic EMT-P) PROTOCOLS
•
530: Emotionally Disturbed Patient
Regional Emergency Medical Advisory Committee
New York City
Public Notice
THE REGIONAL EMERGENCY MEDICAL SERVICES COUNCIL OF NEW YORK CITY, INC.
Public Notice – Proposed Revisions NYC REMAC Protocols – March 2015
GENERAL OPERATING PROCEDURES:
New GOP Language: Spinal Precautions & Spinal Injury Protection – approved by REMAC 03/17/2015
All patients should have spinal cord injury precautions taken during their assessment. Transporting a patient
without a rigid longboard will not be considered a deviation from the standard of care. Application of spinal injury
precautions includes the following treatment modalities.
•
•
•
•
•
•
Application of an appropriately-sized rigid cervical collar
Maintenance of patient in a supine position; if the patient is unable to tolerate that, the head of the stretcher
may be raised to position of comfort (maximum 45 degrees)
Adequate security of the patient’s trunk and limbs to a padded stretcher
Minimal movement / transfers
Maintenance of inline stabilization during any movement / transfers
Extrication of and conveyance of patients may be accomplished with a rigid longboard, but should be
removed via logroll maneuver with manual inline stabilization after the patient is moved to the EMS
cot/stretcher. Patients in extremis may remain on the rigid longboard to expedite rapid transport.
The following patients, without evidence of spinal injury, have greater risk of harm than benefit if restrained to a
rigid longboard:
•
Ambulatory patients
•
Patients with extended transport
•
Inter-facility transfer patients
•
Penetrating trauma to the head, neck or torso
•
Patients with significant anatomical derangements (kyphosis, contractures)
NOTE:
SPINAL CORD INJURIES THAT ARE NOT CAUSED BY THE INITIAL FORCE
ARE NOT LIKELY TO BE CAUSED BY THESE MINIMAL PATIENT
MOVEMENTS BY EMS.
DO NOT USE RAPID TAKE-DOWN.
Regional Emergency Medical Advisory Committee
New York City
Public Notice
THE REGIONAL EMERGENCY MEDICAL SERVICES COUNCIL OF NEW YORK CITY, INC.
Public Notice – Proposed Revisions NYC REMAC Protocols – March 2015
CERTIFIED FIRST RESPONDER PROTOCOLS
321
HEAD AND SPINE INJURIES
1. Establish and maintain airway control while stabilizing the cervical spine.
NOTE:
Do not use a nasopharyngeal airway in patients with facial injuries or if severe head
injury has occurred.
2. Utilize the Rapid Takedown Technique if the patient is standing.
3. Monitor breathing for adequacy.
4. Administer oxygen, if needed.
5. Assess for shock and treat, if appropriate (see Protocol #315)
6. Apply a rigid cervical collar. Immobilize the patient's head and spine with a rigid collar and appropriate
immobilization device, if available.
7. Continue to monitor initial assessment.
Regional Emergency Medical Advisory Committee
New York City
Public Notice
THE REGIONAL EMERGENCY MEDICAL SERVICES COUNCIL OF NEW YORK CITY, INC.
Public Notice – Proposed Revisions NYC REMAC Protocols – March 2015
BASIC LIFE SUPPORT (EMT-B) PROTOCOLS
421
HEAD AND SPINE INJURIES
1.
Establish and maintain airway control while stabilizing the cervical spine.
NOTE:
2.
Do not use a nasopharyngeal airway in patients with facial injuries or if severe head
injury has occurred.
Patients meeting one or more of the following criteria, either at the time of evaluation or at any time
following the injury in question, must be immobilized have spinal injury precautions during care and
transport. Do not use Rapid Takedown technique.
a. Altered mental status for any reason, including possible intoxication due to drugs or alcohol.
b. GCS <15
c. Complaint of, or inability of the provider to assess for, neck and/or spine pain or tenderness.
d. Weakness, paralysis, tingling, or numbness of the trunk or extremities at any time since the injury.
e. Deformity of the spine not present prior to the injury.
f. Distracting injury or circumstances, including anything producing an unreliable physical exam or
history.
g. High risk mechanism (axial load such as diving or tackling, high-speed motor vehicle accidents,
rollover accidents, falls greater than standing height).
h. Provider concern for potential spinal injury.
NOTE:
Once spinal immobilization has been initiated, it must be completed.
immobilization may not be removed in the prehospital setting.
Spinal
3.
If necessary, initiate spinal immobilization, utilize the Rapid Takedown technique only if the patient is
standing.
4.
Administer oxygen.
5.
Monitor breathing for adequacy.
NOTE:
Monitor breathing continuously.
respiratory distress.
Be alert for signs of hypoxia and/or increasing
6.
Control external bleeding.
7.
If the patient meets any of the criteria described in #2, is not awake or is unstable, immobilize the patient's
head and spine with a rigid collar and appropriate immobilization device apply a rigid cervical collar.
8.
Assess and Continue to monitor the Glasgow Coma Score. (See Appendix E.)
9.
If the Glasgow Coma Scale (GCS) score is less than 8, ventilate the patient with high concentration oxygen
at a rate of 12 breaths per minute for an adult patient and up to 20 breaths per minute for a pediatric patient.
Regional Emergency Medical Advisory Committee
New York City
Public Notice
THE REGIONAL EMERGENCY MEDICAL SERVICES COUNCIL OF NEW YORK CITY, INC.
Public Notice – Proposed Revisions NYC REMAC Protocols – March 2015
10.
If the Glasgow Coma Scale (GCS) score is less than 8, and active seizures or one or more of the following
signs of brain herniation are present, hyperventilate the patient with high concentration oxygen at a rate of
20 breaths per minute for an adult patient and up to 25 breaths per minute for a pediatric patient.
a. Fixed or asymmetric pupils
b. Abnormal flexion or extension (neurologic posturing)
c. Hypertension and bradycardia (Cushing’s Reflex)
d. Intermittent apnea (periodic breathing)
e. Further decrease in GCS score of 2 or more points (neurologic deterioration)
NOTE:
Do not hyperventilate unless the above criteria are met.
11.
Assess for shock and treat, if appropriate. (See Protocol #415.)
12.
Transport. (See Appendix F.)
Regional Emergency Medical Advisory Committee
New York City
Public Notice
THE REGIONAL EMERGENCY MEDICAL SERVICES COUNCIL OF NEW YORK CITY, INC.
Public Notice – Proposed Revisions NYC REMAC Protocols – March 2015
430
EXCITED DELIRIUM EMOTIONALLY DISTURBED PATIENT
NOTE:
Agitated Emotionally disturbed patients must be presumed to have an underlying medical or
traumatic condition causing an altered mental status.
Assess such patients for an underlying medical or traumatic condition causing an altered
mental status and treat as necessary.
Please refer to General Operating Procedures – Patient Restraints.
1.
Assess the situation for potential or actual danger and establish a safe zone, if necessary.
NOTE:
2.
All suicidal or violent threats or gestures must be taken seriously. These patients should be
in police custody if they pose a danger to themselves and/or others. Law enforcement
presence is strongly recommended.
If the patient is agitated and presents a risk of physical harm to providers, public or self: If an underlying
medical or traumatic condition causing an altered mental status is not apparent; the patient is fully
conscious, alert, and able to communicate; and an emotional disturbance is suspected, proceed as follows:
a. Request police assistance, if appropriate.
NOTE:
If the patient is at risk for respiratory or cardiac arrest by continuing to struggle while being
physically restrained by police, request advanced life support assistance.
b. Open communications with the patient.
c. Attempt to determine the cause of the immediate crisis.
d. Attempt to obtain a past medical history.
e. Document the exact nature of the problem, including the patient's own words.
f. If, in the judgment of the EMT/AEMT, the patient requires and is refusing treatment and the patient's
judgment may be impaired, contact Medical Control.
g. The EMT/AEMT may participate in restraining a patient if a police officer requests assistance or when
it becomes necessary for self-protection.
b. Request law enforcement assistance.
c. If the patient continues to struggle while being physically restrained, request Advanced Life Support
assistance.
d. Attempt to verbally de-escalate the patient’s situation.
e. The EMT/AEMT may participate in restraining a patient if a police officer requests assistance or when it
becomes necessary for self-protection. NOTE:
Only the amount of force required to effectively restrain the patient may be used.
3. If the patient continues to struggle while being physically restrained, request ALS for possible chemical
restraint.
4. Transport.
Regional Emergency Medical Advisory Committee
New York City
Public Notice
THE REGIONAL EMERGENCY MEDICAL SERVICES COUNCIL OF NEW YORK CITY, INC.
Public Notice – Proposed Revisions NYC REMAC Protocols – March 2015
ADVANCED LIFE SUPPORT (Paramedic EMT-P) PROTOCOLS
530
EXCITED DELIRIUM EMOTIONALLY DISTURBED PATIENT
1.
Begin Basic Life Support procedures.
2.
Prehospital Chemical Restraint Procedure: If patient continues to struggle while being physically
restrained:
a. Administer Midazolam, 10 mg, IM or IN.
NOTE:
Assess such patients for an underlying medical or traumatic condition causing an
altered mental status and treat as necessary.
NOTE: If patient is agitated, the PREFERRED route of choice is IM. Once the patient is sedated, IV
access should be established in the event additional sedation is necessary.
3. After adequate sedation, begin IV/Saline Lock infusion of Normal Saline (0.9% NS) or Ringers' Lactate (RL) via a large
bore (14-18) gauge catheter, up to 1 liter, via a macro-drip.
4. Begin Cardiac Monitoring, record and evaluate EKG rhythm.
5. Begin pulse oximetry monitoring.
6. If the patient continues to struggle while being physically restrained after Standing Orders have been administered,
contact medical control for implementation of one of the following MEDICAL CONTROL OPTIONS.
7.
Contact medical control if patient agitation inhibits treatment.
8.
POST IM or IN SEDATION: Begin an IV/Saline Lock infusion of Normal Saline (0.9% NS) to keep vein
open, or a Saline Lock.
9.
Begin Cardiac Monitoring, record and evaluate EKG rhythm.
10.
Begin Pulse Oximetry monitoring.
NOTE:
In order to protect patient’s airway, consider placing patient in a lateral recumbent
position.
Regional Emergency Medical Advisory Committee
New York City
Public Notice
THE REGIONAL EMERGENCY MEDICAL SERVICES COUNCIL OF NEW YORK CITY, INC.
Public Notice – Proposed Revisions NYC REMAC Protocols – March 2015
11.
If patient is at risk for respiratory or cardiac arrest by continuing to struggle while being physically
restrained by the police, contact medical control for implementation of one of the following MEDICAL
CONTROL OPTIONS:
MEDICAL CONTROL OPTIONS:
Prehospital Chemical Restraint Procedure
NOTE:
If patient is agitated, the initial route of choice is IM or IN. Once the patient is sedated,
IV access should be established in the event additional sedation is necessary.
OPTION A:
Administer Diazepam, 5 – 10 mg, IV/Saline Lock bolus.
OR
Administer Midazolam, 1 – 2 mg, IV/Saline Lock bolus or if IV access is unavailable, administer
Midazolam, 10 mg IM or IN.
OR
Administer Lorazepam, 2 – 4 mg, IV/Saline Lock bolus or if IV access is unavailable, administer
Lorazepam, 4 mg IM or IN.
MEDICAL CONTROL OPTIONS:
Option
A
B
C
Class
Medication
Route
Dose
Dissociative
Ketamine
IntraMUSCULAR
2-4 mg/kg
Agents
Ketamine
IntraNASAL
1-2 mg/kg
IM
Midazolam
IntraMUSCULAR
10 mg
Benzodiazepines
Lorazepam
IntraMUSCULAR
4 mg
Diazepam
IV/Saline Lock bolus
5-10 mg
Midazolam
IntraNASAL
5 mg
Lorazepam
IntraNASAL
2 mg
IN or IV
Benzodiazepines
Regional Emergency Medical Advisory Committee
New York City
Public Notice
THE REGIONAL EMERGENCY MEDICAL SERVICES COUNCIL OF NEW YORK CITY, INC.
Public Notice – Proposed Revisions NYC REMAC Protocols – March 2015
OPTION B D: Transportation Decision.
Mandatory Quality Assurance Component
For every administration of Midazolam 10 mg IM or IN under Standing Orders, the ACR/PCR documentation must
be reviewed by the service medical director who is responsible for forwarding a copy of the ACR/PCR to the NY
REMAC for system-wide QA purposes. Patient specific identifiers can be omitted. This QA component is effective
immediately. For the purposes of patient confidentiality, copies of the ACR/PCR can be mailed to: The Regional
EMS Council of NYC, 475 Riverside Drive, Suite 1729, New York, NY 10115. Please label the envelope
“Confidential QA”.
Regional Emergency Medical Advisory Committee
New York City
Public Notice