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Paramedic Protocol Update 2009 Westchester Regional Emergency Medical Services Council Introduction Each agency will be provided with CD containing the protocol roll-out training materials.

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Paramedic Protocol Update2009

Westchester Regional Emergency Medical Services Council

Westchester Paramedic Protocol Update 5/09 - Overview


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Introduction

  • Each agency will be provided with CD containing the protocol roll-out training materials.

  • Protocol roll-out presentations cover all changes by section (Adult Medical, Pediatric Medical, Trauma, etc.).

  • Agencies are expected to deliver content to affiliated paramedics. Agency Medical Director should approve delivery mechanism (i.e., classroom session, computer delivery, follow-up quiz ??)

Westchester Paramedic Protocol Update 5/09 - Overview


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Introduction

  • Protocols also included on CD in PDF format. Will also be posted on WREMSCO website. *No field guides initially as additional changes are expected.

  • Protocol implementation date – July 1, 2009

  • Agency Medical Director must affirm that affiliated paramedics have received training (affirmation form included on CD).

Westchester Paramedic Protocol Update 5/09 - Overview


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Overview

  • New Format indicating STANDING ORDERS, MEDICAL CONTROL OPTIONS, and NOTATIONS.

  • Each protocol initiates with M1.0-Routine Medical Care or T1.0-Routine Trauma Care.

  • To be carried out in conjunction with appropriate policies, procedures, and advisories.

  • Separate Interfacility Transport Protocols under development

Westchester Paramedic Protocol Update 5/09 - Overview


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New Format

Westchester Paramedic Protocol Update 5/09 - Overview


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Trauma Protocols

Westchester Regional Paramedic Protocol Update 2009

Westchester Paramedic Protocol Update 5/09 - Overview


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Routine Trauma Care T1.0

Replaces old trauma protocols

Consolidated: Routine Medical Care, airway, transport consideration, fluid resuscitation for shock, analgesics for pain management, and CPR/rapid transport for Traumatic arrest.

Added: Directs provider to Airway Management Protocols, Trauma Transport Algorithm, and Pain Management Protocol.

Westchester Paramedic Protocol Update 5/09 - Overview


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Trauma Report Appendix 2.3

Westchester Paramedic Protocol Update 5/09 - Overview


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Adult Medical Protocols

Westchester Regional Paramedic Protocol Update 2009

Westchester Paramedic Protocol Update 5/09 - Overview


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Adult Medical Protocols

  • New Standard Operating Procedures for Advanced Airway Management, Tension Pneumothorax, and Intravenous Access (separate document)

  • Endotracheal drug administration has been removed from all protocols

  • Pediatric protocols now in separate pediatric section

Westchester Paramedic Protocol Update 5/09 - Overview


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Adult Medical Protocols

  • Routine Medical Care M1.0 - Pulse Oximetry now a Standing Order

  • Airway Management M2.0 - Etomidate now a standing order.

    • If patient needs facilitated advanced airway management:

    • Consider ETOMIDATE 0.3 mg/kg IV or IO, perform ENDOTRACHEAL INTUBATION, and

    • CONTACT MEDICAL CONTROL

  • Bronchospasm/Asthma/COPD M3.0 - Methylprednisolone and Magnesium Sulfate now Standing Orders. Terbutaline now administered IM route.

Westchester Paramedic Protocol Update 5/09 - Overview


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Adult Medical Protocols

  • Cardiac M4.0 - Refers to appropriate sub-protocol. 12 lead ECG added.

  • Acute Coronary Syndrome M4.1 -NITROGLYCERIN should be given with caution to patients taking erectile dysfunction (ED) medications (i.e., Viagra, Cialis, Levitra), or suspected inferior wall or right ventricle (RV) myocardial infarctions (MI)

  • Acute Pulmonary Edema Congestive Heart Failure M4.2 -Administer CPAP if available. Medical Control Option for Lasix changed from 40-80 mg to 80-120 mg

Westchester Paramedic Protocol Update 5/09 - Overview


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Adult Medical Protocols

  • Bradycardia M4.3 - TCP now before atropine. Dopamine under Medical Control Options now 2-10 mcg/kg/min

  • Supraventricular Tachycardia– Divided into two new protocols

  • Narrow Complex Tachycardia Unstable M4.4 - Fluid challenge now Standing Order. Doses of energy for Cardioversion depend on the underlying rhythm. Diltiazem added as Medical Control Option

  • Narrow Complex Tachycardia Stable M4.5 -Diltiazem 15-25mg as Standing Order for ATRIAL FLUTTER, ATRIAL FIBRILLATION or MULTIFOCAL ATRIAL TACHYCARDIA unless patient has a known history of Wolff-Parkinson-White Syndrome (WPW)

Westchester Paramedic Protocol Update 5/09 - Overview


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Adult Medical Protocols

  • Wide Complex Tachycardia Unstable M4.6 - Doses of energy for Cardioversion depend on the underlying rhythm. Total maximum dose of Amiodarone in Standing Orders is now 2.2gm/24 hrs.

  • Wide Complex TachycardiaStable M4.7 - Standing Order of Amiodarone to 150 mg/100 ml of D5W. Repeat if VT persists. Max 2.2 gm/24 hrs.Procainamide now Medical Control Option only.

Westchester Paramedic Protocol Update 5/09 - Overview


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Adult Medical Protocols

  • Cardiac (Arrest) Non-Traumatic Cardiopulmonary Arrest M5.0 - This protocol directs the EMS provider to two new protocols:

    M5.1 – Shockable Rhythm

    M5.2 – Non-Shockable Rhythm

  • Notes for consideration of the following medications for all Cardiac Arrests have been added:

    • SODIUM BICARBONATE 1 mEq/kg IVP or IO with suspected hyperkalemia, profound acidosis, tricyclic antidepressant, cocaine, or diphenhydramine overdoses. Dose may be repeated at 0.5 mEq/kg every 10 minutes.

    • DEXTROSE 50% IVP or IO if clinically indicated; may be repeated once.

    • NALOXONE 2 mg IV or IO if clinically indicated.

    • DOPAMINE 400 mg in 250 ml 0.9% Normal Saline; initiate drip at 5 - 10 mcg/kg/min.

    • CALCIUM CHLORIDE 250 – 500 mg IVP or IO; may be repeated to a maximum of 1 gm. Only indicated with hyperkalemia, hypocalcemia, or calcium channel blocker toxicity.

Westchester Paramedic Protocol Update 5/09 - Overview


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Adult Medical Protocols

  • Cardiac Arrest Shockable Rhythm (VF or Pulseless VT) M5.1 – Follows latest CPR guidelines; single shocks, CPR @ 2 min. intervals. Precordial thump removed. Standing Order added for Magnesium Sulfate for known Hypomagnesemia or Torsades.

  • Cardiac Arrest Non-Shockable Rhythm M5.2 – Prompt to Search for and treat for contributing factors; address as appropriate. Vasopressin now a Standing Order but under review.

Westchester Paramedic Protocol Update 5/09 - Overview


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Adult Medical Protocols

  • Field Termination of Resuscitation Efforts M5.3– Grief counseling removed.

  • Altered Mental Status M6.0– Naloxone dose now 0.4 mg IV, IN, or IM, may be repeated up to 8 mg.

  • Anaphylactic Reaction M7.0 - Standing Orders now for Methylprednisolone, rapid fluid infusion, and Albuterol. Epinephrine is indicated as follows:

    • Cardiovascular collapse present, 1:10,000 1 mg IVP

    • Mild reaction, 1:1,000 0.3 ml IM

    • If patient is taking beta-blockers, also administer GLUCAGON 1 mg IM or IV.

Westchester Paramedic Protocol Update 5/09 - Overview


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Adult Medical Protocols

  • Toxic Exposure / Poisoning M8.0– For Carbon Monoxide (CO) exposure with history and signs/symptoms - Monitor CO levels (if available) - 100% oxygen therapy

  • Non-Traumatic Shock M9.0 – Dobutamine added as a Medical Control Option

    • 400mg/250 ml NS ,initiate drip at 5 – 10 mcg/kg/min.

    • May be titrated in increments of 5 mcg/kg/min until desired therapeutic effect is reached (max dose of 25 mcg/kg/min)

  • Post Partum Hemorrhage M10.0 - Oxytocin now a Standing Order “after delivery of placenta”

  • Westchester Paramedic Protocol Update 5/09 - Overview


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    Adult Medical Protocols

    • Obstetrical Toxemia of Pregnancy M11.0– PRE-ECLAMPSIA now defined as – combination of BP 140/90 or greater, peripheral edema, and symptoms: headache, visual disturbances, upper abdominal pain. Magnesium Sulfate 4 gm/250 ml NS over 20 minutes now a Standing Order for Pre-Eclampsia and Eclampsia.

    • Seizures M12.0– “measure serum glucose”, and treat hypoglycemia after initiating Routine Medical Care. Standing Order now for “a Benzodiazepine”(Diazepam, Lorezapam, or Midazolam).

    Westchester Paramedic Protocol Update 5/09 - Overview


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    Pediatric Medical Protocols

    Westchester Regional Paramedic Protocol Update 2009

    Westchester Paramedic Protocol Update 5/09 - Overview


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    Pediatric Medical Protocols

    • Endotracheal drug administration has been removed from all protocols

    • 14 years or youngerfor pediatric patient

    Westchester Paramedic Protocol Update 5/09 - Overview


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    Pediatric Medical Protocols

    • Pediatric Airway Management P1.0– Etomidate dose 0.3 mg/kg IV or IO now a Medical Control Option for all Paramedics. Continuous EKG, pulse oximetry and wave-form capnography added.

    • Bronchospasm / Asthma P2.0 –Separated from Croup/Epiglottitis in old protocol. Albuterol 2.5 mg plus one unit dose of Ipratropium 0.5 mg via nebulizer may be repeatedonce if needed under standing orders. Dexamethasone 0.6 mg/kg IM added as a Medical Control Option.

    Westchester Paramedic Protocol Update 5/09 - Overview


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    Pediatric Medical Protocols

    • Croup/Epiglottitis P3.0– Nebulized Epinephrine or Racemic Epinephrine now a Standing Order. Dexamethasone 0.6 mg/kg IM added as a Medical Control Option

    • Cardiac P4.0 – Refers to appropriate sub-protocol. 12 lead ECG added.

    • Bradycardia P4.1 - Now states “ If increased vagal tone, or primary AV Block, administer Atropine 0.02 mg/kg IV or IO – minimum dose 0.1mg; maximum single dose:

      • 0.5 mg for children

      • 1 mg for adolescents.

      • If inadequate response, may repeat once”

    Westchester Paramedic Protocol Update 5/09 - Overview


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    Pediatric Medical Protocols

    • Narrow Complex Tachycardia P4.2– If Sinus Rhythm, consider Fluid Challenge of 0.9% Normal Saline (10-20 ml/kg rapid infusion) if indicated; search for and treat any causes found as appropriate

    • Wide Complex Tachycardia P4.3 –New protocol. Apply cardiac monitor to determine rhythm.

    • If patient is Unstable:

      • If it does not delay CARDIOVERSION, administer ADENOSINE 0.1 mg/kg IV or IO first to determine if the rhythm is SVT with aberrant conduction.

      • SYNCHRONOUS CARDIOVERSION 0.5 J/kg – 1 J/kg; if no change, repeat at 2 J/kg (c);consider sedation / analgesia, CONTACT MEDICAL CONTROL.

      • If rhythm FAILS TO COVERT after 2nd CARDIOVERSION to a supraventricular rhythm, CONTACT MEDICAL CONTROL

    Westchester Paramedic Protocol Update 5/09 - Overview


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    Pediatric Medical Protocols

    • Cardiac (Arrest) Non-Traumatic Cardiopulmonary Arrest P5.0–This protocol directs the EMS provider to two new protocols:

      P5.1 – Shockable Rhythm

      P5.2 – Non-Shockable Rhythm

    • Cardiac Arrest Shockable Rhythm (VF or Pulseless VT) P5.1 – Follows latest CPR guidelines; single shocks, CPR @ 2 min. intervals. Precordial thump removed. “In the event of return of spontaneous circulation (ROSC), CONTACT MEDICAL CONTROL for post-resuscitation care.”

    Westchester Paramedic Protocol Update 5/09 - Overview


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    Pediatric Medical Protocols

    • Cardiac Arrest Non-Shockable Rhythm P5.2– Search for and treat for contributing factors; address as appropriate.

    • Altered Mental Status P6.0 – For documented or suspected hypoglycemia:

      • Administer DEXTROSE 1g/kg IV or IO:

        • For patients 40 kg or less, DEXTROSE 25% 4 ml/kg

        • For patients 40 kg or more, DEXTROSE 50% 2 ml/kg

      • if no response in 5 minutes, repeat the same dose.

    Westchester Paramedic Protocol Update 5/09 - Overview


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    Pediatric Medical Protocols

    • Anaphylactic Reaction P7.0– Standing Orders for Methylprednisolone, Albuterol, and rapid fluid infusion added. Prior to initiating Routine Medical Care, Epinephrine is indicated as follows:

      • Cardiovascular collapse present, 1:1,000 0.01 mg/kg (max dose 0.3mg) IM

      • Post RMC, if patient still manifests Cardiovascular collapse, administer Epinephrine 1:10,000 0.01 mg/kg IV or IO

    • Toxic Exposure / Poisoning P8.0 – For Carbon Monoxide (CO) exposure with history and signs/symptoms - Monitor CO levels (if available) - 100% oxygen therapy

    Westchester Paramedic Protocol Update 5/09 - Overview


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    Pediatric Medical Protocols

    • Non-Traumatic Shock P9.0– Fluid Challenge 0.9% Normal Saline IV or IO 5-10 ml/kg, rapid infusion; may be repeated as needed. Avoid in the presence of pulmonary edema

    • Note: PALS recommends giving smaller volumes if myocardial dysfunction or distributive shock is present of suspected but more rapid infusion boluses may be needed to correct hypotensive or septic shock.

    • REMAC contends that infusion volumes of 20 ml/kg may be necessary. Plans to appeal to SEMAC.

    Westchester Paramedic Protocol Update 5/09 - Overview


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    Pediatric Medical Protocols

    • Neonatal Resuscitation P10.0– Now states: If thick meconium is observed in amniotic fluid AND the newborn demonstrates absent or depressed respirations, heart rate under 100 per minute, or poor muscle tone:

      • Clear the airway using endotracheal intubation and directly suction the endotracheal tube.

      • Repeat the procedure until the endotracheal tube is clear of thick meconium up to a maximum of three (3) times.

      • DO NOT re-intubate once the airway has been cleared of thick meconium unless the newborn still meets the criteria in STEP 2.

    Westchester Paramedic Protocol Update 5/09 - Overview


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    Pediatric Medical Protocols

    • Seizures P11.0– After initiating Routine Medical Care, “measure serum glucose”, for hypoglycemia administer:

      • DEXTROSE 1g/kg IV or IO:

        • For patients 40 kg or less, DEXTROSE 25% 4 ml/kg

        • For patients 40 kg or more, DEXTROSE 50% 2 ml/kg

          • If no response in 5 minutes, repeat the same dose.

      • GLUCAGON 0.1 mg/kg IM if IV or IO route is not available, up to a maximum dose of 1 mg.

  • Standing Order now for “a Benzodiazepine”(Diazepam, Lorezapam, or Midazolam).

  • Westchester Paramedic Protocol Update 5/09 - Overview


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    Special Protocols

    Westchester Regional Paramedic Protocol Update 2009

    Westchester Paramedic Protocol Update 5/09 - Overview


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    Pain Management S1.0

    Replaces old protocols 31 and 31a

    Changed: For patients presenting with need for pain management (a) with a SBP greater than 110 mmHg:

    MORPHINE 0.1 mg/kg IV or IO (maximum 5 mg) (b); For continued pain, repeat once (maximum total dose 10 mg)

    Contact Medical Control

    Westchester Paramedic Protocol Update 5/09 - Overview


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    Pain Management S1.0

    Replaces old protocols 31 and 31a

    Added: Notes a & b.

    a. Pain management is CONTRAINDICATED for patients presenting with (including but not limited to):

    Altered Mental Status, Moderate or Severe Head Trauma, Overdoses, or Hypotension

    b. If HYPOVENTILATION develops:

    in the ADULT PATIENT, administer NALOXONE up to 2 mg IV, IO or IN.

    in the PEDIATRIC PATIENT, administer NALOXONE 0.1 mg/kg IV, IM, IO or IN

    Westchester Paramedic Protocol Update 5/09 - Overview


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    Rapid Sequence Intubation S2.0

    Replaces old protocol S-1

    Added: Note b. Once medication is used to facilitate intubation, whether or not it is successful, the patient’s respiratory effort MUST be monitored with CONTINUOUS WAVEFORM CAPNOGRAPHY.

    Westchester Paramedic Protocol Update 5/09 - Overview


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    Nerve Agent Antidotes S3.0

    Replaces old protocol S-2

    Added: Commercially available DuoDoteTM auto-injectors, or the previously manufactured Mark I kits, may be possessed / used by a paramedic only under the following conditions…

    Changed: Directs provider to Adult Administration Protocol (S3.1) and Pediatric Administration Protocol (S3.2)

    (Continued on Next Slide)

    Westchester Paramedic Protocol Update 5/09 - Overview


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    Nerve Agent Antidote-Adult S3.1

    Changed: Standing Orders now:

    MILD - 1 MARK I KIT /1 DUODOTETM KIT or ATROPINE 2 mg IV, IM or IO every 5 minutes until secretions resolve / PRALIDOXIME 1 g IV, IM or IO over 10 minutes

    MODERATE - 2 MARK I KITS / 2 DUODOTETM KITS or ATROPINE 4 mg IV, IM or IO every 5 minutes until secretions resolve / PRALIDOXIME 2 g IV, IM or IO over 10 minutes

    SEVERE - 3 MARK I KITS /3 DUODOTETM KITS or ATROPINE 6 mg IV, IM or IO every 5 minutes until secretions resolve / PRALIDOXIME 2 g IV, IM or IO over 10 minutes

    (Continued on Next Slide)

    Westchester Paramedic Protocol Update 5/09 - Overview


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    Nerve Agent Antidote-Pediatric S3.2

    Changed: Standing Orders now:

    MODERATE - 2 MARK I KITS / 2 DUODOTE KITS or ATROPINE 0.02 mg/kg IV, IM or IO every 5 minutes until secretions resolve / PRALIDOXIME 40 mg/kg IV, IM or IO over 10 minutes

    SEVERE- 3 MARK I KITS /3 DUODOTE KITS or ATROPINE 0.04 mg IV, IM or IO every 5 minutes until secretions resolve / PRALIDOXIME 40 mg/kg IV, IM or IO over 10 minutes

    If the patient is presenting with MILD exposure symptoms, CONTACT MEDICAL CONTROL.

    1 MARK I KIT /1 DUODOTE KIT or ATROPINE 0.02 mg/kg IV, IM or IO every 5 minutes until secretions resolve / PRALIDOXIME 40 mg/kg IV, IM or IO over 10 minutes

    Westchester Paramedic Protocol Update 5/09 - Overview


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    Standard Operating Procedures

    Westchester Regional Paramedic Protocol Update 2009

    Westchester Paramedic Protocol Update 5/09 - Overview


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    Standard Operating Procedures

    • Three new procedures:

      • Advanced Airway Management

      • Tension Pneumothorax

      • Intravenous Access

    Westchester Paramedic Protocol Update 5/09 - Overview


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    Advanced Airway Management

    Includes:

    • Endotracheal Intubation (ETT)

    • Laryngeal Mask Airway (LMA)

    • Multi-lumen Airway (i.e. Combitube)

    • Foreign Body Airway Removal via direct Laryngoscopy

    • Needle Cricothyrotomy

    • Tracheal Suctioning (including meconium aspiration)

    • Gastric Decompression

    • Needle Decompression

    • Rapid Sequence Intubation (RSI)*

      *May only be performed by with approval of WREMAC

    Westchester Paramedic Protocol Update 5/09 - Overview


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    Advanced Airway Management

    Must document PRIMARY confirmation of ETT placement using:

    • Qualitative Methods

      • Colormetric end-tidal CO2 detectors

    • Quantitative Methods

      • Digital end-tidal CO2 detectors

      • Wave form capnography

    Westchester Paramedic Protocol Update 5/09 - Overview


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    Advanced Airway Management

    • Document secondary confirmation using accepted clinical parameters per ACLS guidelines.

    • Continuous Waveform Capnography must be monitored if medication is used to facilitate intubation.

    Westchester Paramedic Protocol Update 5/09 - Overview


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    Tension Pneumothorax

    Evidence of respiratory/cardiovascular compromise and two of the following:

    - Absent/decreased breath sounds on affected side- Tracheal deviation- Subcutaneous emphysema

    Pleural decompression is indicated using a large bore over the needle catheter or other REMAC approved device.

    Procedure may be repeated if signs and symptoms recur.

    Westchester Paramedic Protocol Update 5/09 - Overview


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    Intravenous Access

    IV KVO of NS or IV lock unless fluid challenge is required.

    • IV NS with large bore (18ga or larger) catheter for patients requiring rapid volume replacement.

    • Peripheral veins (not external jugular) should be used as primary access site.

    • IO may be used only if other sites are not accessible.

    • IO med administration is preferred over ETT if no IV.

    • Blood drawing as indicated. Before med administration.

    Westchester Paramedic Protocol Update 5/09 - Overview


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    Future SOPs

    Additional SOPs will be added as needed

    Westchester Paramedic Protocol Update 5/09 - Overview


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    Questions

    • WREMSCO Office

      • 914-231-1616

    Westchester Paramedic Protocol Update 5/09 - Overview


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