Continuing Medical Education – News & Information
December 2007 – Volume 13, Issue 12
Multi-agency Edition
==========================================================================
*On Dec. 19, REMAC exam-day CME at FDNY BOT will be held 10:30-14:30*
From the Editor: A Holiday Classic, 2007-08
Inside this issue:
FAQ: “Which protocols are on the MAC exam?”
(bold = new content)
From the Editor
1
Every time this question is asked a paramedic gets their wings (ding). At this
Protocol Changes
2
rate, heaven will be full by July….
ePCR Tips
3
The January 2008 REMAC protocol revisions are available for use after
Cert & CME info
3
January 1, 2008 and after providers are updated by their Medical Director. Until
FDNY contacts
4
then, they should use the January 2007 version both in the field and on the
OLMC physicians 4
REMAC exam. After July 1, 2008 everyone must be updated, and only the
CME Article
5
January 2008 protocols will be in effect.
CME Quiz
23
Citywide CME
27
Exam calendar
28
“So which protocols should I study for an exam during the rest of 2007?
(Ding.) Only the January 2007 protocols.
“And what about after January 1 but before July 1?” (Ding.) Whichever
version your ambulance service is using.
-------------------------------Journal CME Newsletter
Published monthly
FDNY – Office of
Medical Affairs
th
9 Metrotech Center 4 fl
Brooklyn, NY 11201
718-999-2671
swansoc@fdny.nyc.gov
“But which protocols will be on the exam?” (Ding!) From January 1 to
July 1, 2008, the REMAC exam will accept answers based on either version of
the protocols. Don’t worry, there will be no conflict.
“What about after July 1?”(Sigh... ding.) After July 1, 2008 the REMAC
exam will refer to only the January 2008 protocols.
“I think I get it now. Are there any other study tips for the exam?”
(…ding.) Over the last 2 years, the REMAC Certification & Credentialing
subcommittee has reported that candidates have difficulty with:
* Epinephrine use for peds patients;
* 12-lead EKG interpretation;
* ventilation rates for peds & neonates.
* compensated vs. decompensated shock;
Good luck with the protocols, and Happy Holidays. It’s a wonderful life.
December 2007 – Journal CME Newsletter
page 1 of 28
Effective January 1, 2008, NYC REMAC has issued protocol revisions that may be implemented after
paramedics are updated by their Medical Director. All EMS personnel must be updated by July 1, 2008.
Per REMAC, ambulance services in NYC are responsible to provide copies of the protocols to their personnel.
REMAC Advisories and Protocols are available to all at www.nycremsco.org
The REMAC exams will not include questions reflecting the protocol changes until after July 1, 2008.
Questions may be referred to the REMAC Liaison at swansoc@fdny.nyc.gov or 718-999-2671.
Outline of January 2008 protocol changes:
 GOP: added Maintenance of IVs by EMT-Bs
 GOP: added IO access via extremity with drug
administration for adult cardiac arrest
 GOP Pharmacology Table: added Amiodarone;
removed Lidocaine infusion
 GOP: removed pediatric age limit for IO
 GOP: added STEMI transportation decision by
OLMC
 GOP: changed blood drawing to discretion of
medical director
 GOP and Protocols 442 & 543: changed the term
Newly Born to Neonate
 400 WMD: removed antidote brand name
 404 Chest Pain: added Nitroglycerine spray
 407 Asthma: removed upper age limit, BORG
scale, and OLMC contact for cardiac history;
increased Albuterol administration to 3 doses
 414 Poisoning/Drug OD: removed reference to
shock
 420 Traumatic Arrest: added AED application
and defibrillation
 430 EDP: added request for ALS for chemical
restraint
 443 Newly Born Resuscitation: updated CPR to
AHA revisions
 500 Cyanide Toxicity/Smoke Inhalation: new
protocol
 503-A V-Fib/Pulseless V-Tach: removed
Amiodarone drip after conversion to
supraventricular rhythm
 504-A Myocardial Ischemia: removed Lidocaine;
removed Narcan for hypotension or stupor from
Morphine; added referral to GOP re: STEMI
patients
December 2007 – Journal CME Newsletter
 506 APE: removed Narcan for hypotension or
stupor from Morphine; changed PPMC Nitro
 507 Asthma: changed to Standing Orders:
Epinephrine, Magnesium Sulfate,
Methylprednisolone, and Dexamethasone
 508 COPD: changed to Standing Orders:
Methylprednisolone and Dexamethasone
 510 Anaphylactic Reaction: removed
Epinephrine via endotracheal tube
 511 Altered Mental Status: changed Glucometer
criteria for withholding Dextrose
 520 Traumatic Arrest: added cardiac monitoring
and defibrillation
 529 Pain Management For Injury: changed to
Standing Orders, and criteria and dose for
Morphine; removed Narcan for hypotension or
stupor from Morphine
 530 Emotionally Disturbed Patient: new
protocol for chemical restraint
 543 Neonate Resuscitation: removed Narcan via
ET tube; added Epinephrine via IO/IV
 551 Peds Obstructed Airway: added Needle
Cricothyroidotomy
 553 Peds Non-Traumatic Arrest: changed to
Standing Orders: Amiodarone; removed
Lidocaine; added Magnesium Sulfate
 554 Peds Asthma/Wheezing: removed
Metaproterenol; added Ipratropium & Terbutaline
 555 Peds Anaphylactic Reaction: added referral
to Broselow tape
 556 Peds Altered Mental Status: added referral
to Broselow tape
 557 Peds Seizures: added Midazolam
 558 Peds Decompensated Shock: clarified
maximum doses for Adenosine
page 2 of 28
ePCR Tips
New: To avoid damaging the LIFEPAK Data Port and Data
Cable when transferring EKG data, please remember:
 Keep the LP12 in an upright position; this also ensures
continuous data flow to the ePCR Computer.
 Disconnect the Data Cable from the back of the LP12 before
walking away from the ePCR Computer.
------------------------------------------------------------------------------Uninsured patients may consider refusing care for fear of
ambulance fees.
Please direct them to the green Patient Copy sheet of the FDNY
ePCR, which advises the availability of free or low-cost health
insurance (see figure at right).
====================================================================
Certification & CME Information

Of the 36 hours of Physician Directed Call Review CME required for REMAC Refresher
recertification, at least 18 hours must be ACR/PCR Review (which may include QA/QI
Review). The remaining 18 hours may include ED Teaching Rounds and OLMC Rotation.

Failure to maintain a valid NYS EMT-P card will invalidate your REMAC certification.

By the day of their refresher exam all candidates must present a letter from their Medical Director
verifying fulfillment of CME requirements. Failure to do so will prevent recertification.

FDNY paramedics, see your ALS coordinator or Division Medical Director for CME letters.

CME letters must indicate the proper number of hours, per REMAC Advisory # 2000-03:

36 hours – Physician Directed Call Review
- ACR Review, QA/I Session (after 6/1/07, minimum 18 hours of ACR/QA review)
- Emergency Department Teaching Rounds, OLMC Rotation

36 hours – Alternative Source CME – Maximum of 12 hours per Venue
- Online CME
- Journal CME
- Lectures/Symposiums / Conferences
- Clinical
- Associated Certifications: BCLS / ACLS / PALS / NALS / PHTLS
------------------------------------------------------------------------------------------------------------------------------REMAC Refresher (written) examinations are held monthly, and may be attended up to 6 months before
your expiration date. See the exam calendar at the end of this Journal. To register, call the Registration
Hotline @ 718-999-7074 by the last day of the month prior to your exam.
REMAC Challenge (written and orals) examinations are held every January, April, July & October.
Registration is limited to the first 50 applicants. See the exam calendar at the end of this journal.
REMAC CME and Protocol information is available, and suggestions or questions about the newsletter
are welcome. Call 718-999-2671 or email swansoc@fdny.nyc.gov
------------------------------------------------------------------------------------------------------------------------------REMSCO: www.NYCREMSCO.org
Online CME: www.EMS-CE.com
www.MedicEd.com
NYS/DOH: www.Health.State.NY.US
www.EMCert.com
www.WebCME.com
www.EMINET.com
December 2007 – Journal CME Newsletter
page 3 of 28
FDNY ALS Division Coordinators
 Citywide ALS:
Lt. Patrick Dillon
718-999-1738
 Division 4:
Paramedic Lisa DeSena
718-281-3392
 Division 1:
212-964-4518
Paramedic Andrea Katsanakos
 Division 5:
718-979-7175
Paramedic Russell Shewchuk
 Division 2:
Paramedic Steve Pilla
 Bureau of Training:
718-281-8325
Paramedic James "Bubba" Fallar
718-829-6069
 Division 3:
718-968-9750
Paramedics Gary Simmonds & Al Navarro
 EMS Pharmacy:
Paramedic Andrew Batho
718-571-7620
----------------------------------------------------------------------------------------------------------------------------------
FDNY Division Medical Directors
 BOT and OLMC:
Dr. John Freese
718-999-2665
 QA, EMD & PASU:
Dr. Bradley Kaufman
 Divisions 1 and 2:
Dr. Dario Gonzalez
718-281-8473
 Divisions 3, 4 and 5:
Dr. Glenn Asaeda
718-999-2666
 EMS Fellows:
Dr. Lincoln Cox
Dr. David Schoenwetter
718-999-1872
718-999-2670
718-999-0749
----------------------------------------------------------------------------------------------------------------------------------
FDNY OLMC Physicians and ID Numbers
Acosta, Juan
Alexandrou, Nikolaos
Asaeda, Glenn
Ben-Eli, David
Cordi, Heidi
Cox, Lincoln
Freese, John
Giordano, Lorraine
Gonzalez, Dario
Hansard, Paul
Hegde, Hradaya
Hew, Phillip
80286
80282
80276
80298
80279
80305
80293
80243
80256
80226
80262
80267
December 2007 – Journal CME Newsletter
Huie, Frederick
Isaacs, Doug
Jacobowitz, Susan
Kaufman, Bradley
Lombardi, Gary
McIntosh, Barbara
Pascual, Jay
Schenker, Josef
Schneitzer, Leila
Schoenwetter, David
Silverman, Lewis
Soloff, Lewis
80300
80299
80297
80289
80225
80246
80287
80296
80241
80304
80249
80302
page 4 of 28
December 2007 Journal CME
Felix sit annus novus
Felix sit annus novus… Happy New Year – in Latin… On December 31st, as the clock moves from
11:59pm into that next minute, many of us will find ourselves wishing our co-workers, our friends, our loved
ones, and our families a Happy New Year.
And as we enter 2008, so too do we enter a time in which prehospital medicine will be practiced as never
before in this City. The year 2008 brings with it the latest set of protocols from the New York City Regional
Emergency Medical Advisory Committee (REMAC), and therein lie some of the most expansive and
empowering protocols ever put forth in this Region, allowing prehospital providers to deliver timely and
appropriate care to a wide variety of patients.
In this month’s CME article, we will review the changes that are included in these protocols – changes
which take the Region from providing the standard of care to defining it. An accompanying PowerPoint
presentation has been distributed by the FDNY and REMAC, and this article has been written to conform to the
structure of that presentation – much as if you were listening to a lecture while watching an accompanying slide
set.
While this article is intended to address all of the changes in these new protocols, it may not address every
question that you may have regarding these protocols. For such questions / concerns / or comments, you should
seek out you agency’s medical director.
Also, some sections (such as STEMI) are written with the intent of educating all EMS providers but with
the caveat that some operational components described herein may be applicable only with the 911 system (such
as the mandate to contact FDNY OLMC). If you come across a section of this article about which you are
uncertain as to its relation to the care that you provide or your agency, you should seek clarification with your
EMS medical director.
We will begin by reviewing the changes to those sections of the General Operating Procedures (GOPs)
that affect all providers, as well as the BLS Protocols. Once that is complete, we will move on to the changes
December 2007 – Journal CME Newsletter
page 5 of 28
within the GOPs and protocols that pertain to the ALS providers. And consistent with our new format, the quiz
that follows this article will begin with a series of questions for all providers and end with a series of further
questions specific to ALS providers.
General Operating Procedures – All Providers
There are five changes of note that have occurred in the GOPs that pertain to all providers. These include
changes in the definitions of shock and acute stroke, revision of the policy related to the transportation of patients
with saline locks by BLS providers, a terminology change within the pediatrics section, and the addition of the
STEMI transport decision.
STEMI STEMIs, or ST-segment elevation myocardial infarctions, are a unique group of patients with
acute coronary syndromes (ACS). While their signs and symptoms may be similar to any other ACS patient, it is
their 12-lead EKG findings which set them apart. And it distinguishes them not only in that they have a different
EKG, but the standard of care in the hospital should be different for these patients – namely, they are best suited
by receiving treatment in a center capable of PCI - percutaneous coronary interventions (i.e. catheterization,
angioplasty, and/or stent placement).
While there is a respectable amount of science to show that these patients have better outcomes when they
are initially brought to and treated in PCI centers, the same cannot be said for all patient with chest pain or other
ACS symptoms. It is the act of identifying these STEMI patients that is so critical and which now requires astute
and expedient care from prehospital providers in this
region.
New York City is redefining the standard of care
for ACS patients in the state by undertaking this pilot
project that allows for the transport of STEMI patients to
911 receiving facilities that have been certified by the New
York State Department of Health to provide PCI services.
But in order for this project to succeed, we must ensure
that the protocol is applied uniformly throughout the 911
system and that compliance with the process is absolute.
Because “time is muscle,” one of the most critical
aspects of the care of the ACS patient is expedience. This
does not imply that the packaging and transport of the
patient is the sole concern, but rather it means that
ensuring that the patient receives an appropriate, expedient
evaluation and transport decision is foremost in their care.
December 2007 – Journal CME Newsletter
Figure 1: Left-sided coronary circulation as seen during
a cardiac catheterization. The ability to visualize the site
of occlusion and open the artery via angioplasty or stent
placement is now considered the standard of care for
acute coronary syndromes.
page 6 of 28
For the BLS provider, this means that a request for ALS assistance should be made as soon as the patient
is found to have signs and symptoms consistent with an ACS – not once the patient is in the ambulance, being
packaged for transport, or after a complete history and physical examination have been performed. Approaching
the patient and the request for ALS in this manner will eliminate or at least minimize the amount of time spent
awaiting the arrival of the ALS providers once the patient is brought to the BLS ambulance. (In the event that the
patient is hemodynamically unstable, the request for ALS is still appropriate, but transport to the closest 911
receiving facility should be initiated immediately upon reaching the BLS ambulance if ALS is not already
present.)
For the ALS provider, this approach to the ACS patient means that the acquisition of the 12-lead EKG
should follow immediately after the initial assessment of the patient (which is being reviewed in this month’s
drill). If the 12-lead EKG demonstrates a STEMI, FDNY OLMC
should be immediately contacted for a transport decision. If no STEMI changes are noted on the 12-lead EKG,
then the patient should be treated per the appropriate protocol and transported to the nearest 911 receiving
facility.
Three final points are important to note for all providers, with the last two pertaining only to those
providers within the 911 system. First (for all providers), patients that do not meet the STEMI criteria (i.e. those
for whom ALS is not available, those without STEMI changes on their EKG) may not be selectively transported
to a PCI-capable facility. To do so would potentially impact upon the patient, the hospitals involved, and the
entire STEMI project. Second, for those patients who do meet the STEMI criteria, transport to a PCI-capable
facility may only be initiated upon the direction of FDNY OLMC. Because these PCI-capable centers are not
designated specialty centers and because of the need for advance notification to be given by the FDNY OLMC
physicians to the PCI center, contacting the FDNY OLMC facility should be done early on in the patient’s care
and prior to transport. Finally (also only for the 911 system), crews must recontact the FDNY OLMC facility at
the conclusion of the call to provide information about the time when care was turned over to the receiving
facility, the location within the facility to which the patient was transported, and clinical information about the
stability or deterioration of the patient while en route.
Shock Redefined The definition of shock has been modified slightly based on recent data that suggest
that capillary refill is not a reliable indicator of a patient’s hemodynamic state. Because the definition of “normal”
capillary refill time varies with age and gender, and because it is affected by other factors such as the
environmental temperature and the patient’s medications, the concept of “delayed capillary refill” has been
deleted from the definitions of shock.
Acute Stroke Redefined Those patients suffering an acute stroke had been previously defined as not
meeting the stroke center criteria if the interval from the onset of symptoms until the anticipated time of the
patient’s arrival at a designated stroke center was greater than two hours. Because this was felt to be too
restrictive, particularly given the effort noted among prehospital providers to minimize the scene time for such
December 2007 – Journal CME Newsletter
page 7 of 28
patients, the language was changed. The patient is now considered to not be a stroke center candidate if the
interval from the onset of symptoms until the time when the patient is assessed by EMS is more than two hours.
This not only expands the number of patients who may quality for Stroke Center referral, but it also reinforces the
need for expedited evaluation and transport of such patients in order to deliver them to and have them receive
definitive care within three hours from the time of symptom onset.
One additional point that has been mentioned before, but which is worth revisiting: When inquiring about
the onset of a patient’s symptoms, you will obtain far more accurate information if you ask now “when did the
weakness (or other symptoms) begin,” but rather “when was the last time that the patient was seen in their normal
state of health?” If that time is less than two hours, the patient should be considered a Stroke Center candidate,
transport should be expedited, and a pre-arrival notification should be given to the Stroke Center so that the
facility can ensure timely delivery of care once the patient arrives.
Maintenance of IVs by the EMT-B The New York State Department of Health has issued a policy
stating that it is acceptable for an EMT-B to transport a patient “with a secured saline lock device in place as long
as no fluids or medication are attached to the port.” This is particularly important for both interfacility transports
and for 911 calls originating from within a medical facility.
If a BLS crew arrives to find a patient with an intravenous infusion of fluid or medication, the crew
should advise the facility that they are not allowed to transport the patient because of that infusion. If the facility
is willing to discontinue the fluids and / or medications, and they are able to convert the IV to a saline lock
device, the patient may then be transported by the BLS crew so long as there is no other reason to need / request
ALS assistance. If there is any question as to the appropriateness of such an action, crews are encouraged to use
their usual OLMC contacts for further advice / guidance.
Pediatrics As with other changes made in the protocols this past year, the pediatrics sections of these
GOPs and protocols are being updated to include the latest recommendations from the American Heart
Association and other international resuscitation guidelines. Among the changes that have been incorporated into
these protocols is a change in terminology.
While the term “newly born” had been used throughout the protocols, the accepted term for this age group
(in the hours following birth) is “neonate.” As such, the term newly born has been changed to neonate throughout
the GOPs and protocols. Unless otherwise indicated, this change is merely a new terminology and does not
otherwise impact upon the protocols themselves. (Of note, in order to demonstrate an understanding of these
protocols and the care described therein, these terms should also be used consistently in all prehospital
documentation.)
Basic Life Support Protocols
400 - Weapons of Mass Destruction As the current stockpiles of Mark I kits (Figure 2) expire, they will
be replaced with the only currently available alternative – the Duodote autoinjector kits (Figure 3). Similar to the
December 2007 – Journal CME Newsletter
page 8 of 28
Mark I kit, the Duodote kit includes both atropine and pralidoxime (2-PAM). The difference is that the Duodote
kit contains both drugs inside of a single autoinjector.
Because each agency will convert their current supplies from the
Mark I kits to the Duodote kits at different times, two changes were
required in the Nerve Agent Exposure protocol. First, the terminology
was changed to allow for the use of either kit without having to have
different protocols for each. Second, the dosing for pralidoxime (2PAM) for yellow tag, adult patients was increased.
Initial patient management will remain the same no matter which
kit is being used, with one exception (yellow tag adult patients). To
avoid confusion, the term “autoinjector kit” will be used to refer to both
Mark I autoinjector kits and Duodote autoinjector kits. If using the Mark
Figure 2: The Mark I autoinjector kit
contains one autoinjector of atropine
and another autoinjector of 2-PAM.
I kits, administer both autoinjectors. If using the Duodote kits,
administer the single autoinjector.
 Red Tag Adults - 3 autoinjector kits
 Yellow Tag Adults - 2 autoinjector kits (note this is an increased 2-PAM dose as compared to earlier protocols)
 Green Tag Adults - no kits should be administered
 Red Tag Pediatrics (<1 year) - 1 pediatric atropine autoinjector (no 2-PAM)
 Red Tag Pediatrics (1-8 years) - 1 autoinjector kit
 Green Tag Pediatrics - no kits should be administered
Figure 3: Duodote autoinjector kit
contains atropine and 2-PAM in a
single autoinjector.
No changes have been made to the continued treatment of either adult or
pediatric patients.
404 – Non-traumatic chest pain Two changes have been made to this protocol. First, because the prior
protocols only described the ability of the EMT-B to assist the patient in the administration of their “nitroglycerin
tablets”, the option of assisting them with their nitroglycerin “spray” has been added. Second, because it is both
inappropriate to give aspirin to young children and because the use of the term is medically inappropriate, the
words “two (2) chewable baby aspirin” have been reworded as “two (2) chewable aspirin.”
407 – Asthma New York City’s EMS system treats one of - if not the - largest asthma populations in the
United States. Given the proven safety of the recent approaches to asthma management in the City, a number of
changes have been made to both the BLS and ALS asthma protocols with the intent of allowing prehospital
providers to more broadly and rapidly provide treatment to this patient population.
The first series of changes in this protocol are designed to increase the number of patients who may be
treated by the EMT-B under standing orders. The age limitations have been reduced by eliminating an upper age
December 2007 – Journal CME Newsletter
page 9 of 28
limit. Where albuterol was only able to be administered to patients age 1-65 under the previous protocol,
albuterol may now be administered to all patients age one (1) and over – no upper age limit. The restricted use
among patients with cardiac histories has also been removed by deleting the “Note” that required OLMC contact
prior to albuterol administration to such patients.
The patient assessment of severity (BORG) has also been removed from the protocol. This is not to say
that an assessment of the severity of the patient’s illness is not important. Providers should always document the
patient’s respiratory rate, as well as the presence of any other physical findings that would help to describe the
severity of the patient’s illness (retractions, tripod position, number of words that the patient is able to speak at a
time, cyanosis, mental status changes, air movement, inspiratory and/or expiratory wheezing).
The final change to this protocol is the expanded number of albuterol nebulizer treatments that may be
provided to a patient. The previous protocol had limited the number of albuterol treatments that could be
administered under standing orders to two (2). This protocol expands that number to three (3), allowing for the
administration of a third treatment while en route to the 911 receiving facility.
Before we move on to the next protocol – a word about discretionary orders for the management of the
critical asthma patient. Although the changes in the 911 dispatching algorithms have resulted in a large number of
asthma patients being properly treated and transported by BLS personnel, there remain a very small number of
patients whose phone description to the call-taker does not demonstrate the severity of their illness. For these
patients, BLS personnel have been appropriately expediting transport and/or requesting ALS assistance.
Among those patients to whom BLS are initially dispatched and for whom ALS is requested, there exist
an even smaller population who present to the BLS crew in impending or actual respiratory arrest. For such
patients, a life-saving treatment may be the administration of intramuscular epinephrine.
In the event that BLS providers find themselves treating such a patient, and when an epinephrine
autoinjector is available, BLS providers should consider contacting their OLMC facility to request the
administration of this medication to the patient. (NOTE: Any such use within the 911 system must be reported to
the FDNY Office of Medical Affairs within 48 hours.) While this treatment option is only allowable as a
discretionary order and is likely to never be used by the majority of providers, it should be remembered as a
potentially life-saving technique for the most critical of asthma patients.
414 – Poisoning or Drug Overdose Only once change to this protocol, and is it more a matter of wording
than any change in care. The previous protocols had included a step where the provider was advised to “assess for
shock and treat, if appropriate.” Because there are already other protocols for shock, and because shock would be
treated according those protocols independent of whether a poisoning or overdose had occurred, this step has
been removed from Protocol 414.
420 – Traumatic Cardiac Arrest The problem with traumatic cardiac arrest is that is isn’t always
traumatic. This is no law of nature or physics that would keep a patient from suffering a nontraumatic cardiac
December 2007 – Journal CME Newsletter
page 10 of 28
arrest and then sustaining trauma as a result (i.e. the patient who arrests at the top of a flight of stairs, while
driving, or while standing close to a ledge). In fact, this might happen more often than we think.
The problem with these patients is that, when they are treated as traumatic arrests, we miss the window of
opportunity during which we might be able to save them from their medical arrest. If a patient were in a
shockable rhythm, ventricular fibrillation or ventricular tachycardia, and the patient was only given CPR and an
expedited trip to the nearest 911 receiving facility, the time during which defibrillation may restore circulation
will be lost. At the same time, patients who are found by prehospital providers to be in arrest because of trauma
have a nearly non-existent rate of survival. As such, the way we have been treating arrests thought to be due to
trauma presented the potential to benefit few while potentially depriving others of benefit.
To remedy this problem, we need a change in protocol. Because we know that these shockable rhythms
are seen among patients who might be thought to be in arrest because of trauma, and because defibrillation can
truly be a life-saving treatment for those patients, the new protocols call for the application of an AED for all
arrests, except those with penetrating chest trauma.
Once the AED is applied, it should be allowed to analyze the heart rhythm. If a shock is advised (or for
FDNY providers, if the AED says anything other than “No Shock Advised”), the patient should be treated as a
medical arrest according to Protocol 403. If the AED states “No Shock Advised”, continue with spinal injury
precautions, a request for ALS assistance, and rapid transport as indicated in the remainder of Protocol 420.
430 – Emotionally Disturbed Patients In an effort to allow for both the safe management of violent or
severely agitated, emotionally disturbed patients (EDPs), a new ALS protocol has been developed that allows for
the chemical restraint / sedation of such patients. For this reason a reference to this protocol has been added to
Protocol 430.
It is important to keep in mind that the use of this option (requesting ALS for sedation) is an option that
should not be necessary for most patients. That said, in recognizing that there are those occasional situations in
which either the patient or the providers are subject to potential harm because of the patient’s emotional and/or
physical state, this option was developed to allow for the more adequate and appropriate treatment and transport
of such patients.
441 – Emergency Childbirth Although there thirteen changes were made to this protocol, they are all
merely the change in wording (“newly born”  “neonate”) that was described in the GOP section.
442 – Care of the Newly Born Neonate In addition to the wording change, two other changes have been
made to Protocol 442. First, the previous recommendation that the neonate be wrapped “in a clean, dry towel”
has now been changed to “in a silver swaddler”, the more appropriate choice given its ability to more completely
retain the neonate’s body heat. Second, the administration of oxygen to all neonates has been withdrawn and
replaced by the administration to all neonates “unless the neonate remains completely pink.” This latter change is
because oxygen is not completely harmless, and it is considered unnecessary for the neonate who is pink over the
entirety of its body, suggesting adequate oxygenation.
December 2007 – Journal CME Newsletter
page 11 of 28
443 – Newly Born Neonatal Resuscitation Again, there is that change in terminology, and as with
Protocol 442, there are also two other changes to note. First, for the neonate for whom artificial ventilation was
begun (because of central cyanosis, respirations < 30 per minute, or a heart rate between 60 and 100), ventilation
should be discontinued and replaced with a high-flow oxygen if the respiratory rate increases to >30 or if the
heart rate increases to >100. This is a change from the previous protocol where the heart rate needed to exceed
120 before artificial ventilation was discontinued.
For neonates for whom chest compressions were initiated because of a heart rate <60 or full
cardiopulmonary arrest, chest compressions should be discontinued if the heart rate reaches 60 and is rapidly
increasing, not only once it reaches 100 as previously stated.
450 – Pediatric Respiratory Distress / Failure Just to show how thoroughly these protocols were
reviewed, this protocol was also changed – numbers were added to each of the steps.
453 – Pediatric Non-Traumatic Cardiac Arrest and Severe Bradycardia The use of AED is no longer
limited to patients age one (1) and older. Instead, when
available, pediatric pads may be used in all patients “under
nine years of age.” When pediatric pads are not available,
adult pads may be used in the same age group. In either case,
it is important to note that the use of AED pads in patients
Figure 4: In patients less than one year of age, AED
pads should always be placed in the anteriorposterior configuration. Here, the placement of the
posterior pad is shown.
under one (1) year of age may result in pad overlap and, for
this reason, pads should always be placed in the anteriorposterior configuration in this age group (Figure 4).
The other change to this protocol is the rate of chest compressions. While the ratio of compressions to
ventilations remains 15:2, the rate of chest compressions should be increased so that a total of seven cycles (105
compressions, 14 ventilations) is provided every minute.
455 – Pediatric Anaphylactic Reaction The only change to this protocol was meant to emphasize the
priorities in treating such patients. The “note” which stated that the BLS provider should “Request ALS
assistance, if available” has been removed. This is to emphasize the fact that immediate transport is a priority for
these patients. Though ALS should still be requested, if the ALS unit has not arrived during the time necessary to
package the patient and move to the BLS ambulance, transport should occur immediately.
458 – Pediatric Shock Similar to protocol 455, the emphasis here is on rapid transport. While ALS may
be requested, if the ALS unit has not arrived during the time necessary to package the patient and move to the
BLS ambulance, transport should occur immediately.
Summary This concludes the changes to the BLS protocols and the GOPs that are relevant to all
providers. As you can see, there have been broad and comprehensive changes in the prehospital care directed
within these protocols, each meant to maximize the benefit to patients that comes with receiving prehospital
medical treatment and transport. At this point, though encouraged to read through the changes in ALS care for
December 2007 – Journal CME Newsletter
page 12 of 28
their own enhancement, BLS providers may move onto the quiz included at the end of this article. For ALS
providers, let us now move onto the ALS-specific changes…
General Operating Procedures – ALS Providers
Pharmacology Table for Small Adults Consistent with the changes that have occurred throughout the
protocols in this and previous revisions, the lidocaine infusion has been removed (no longer used in any protocol)
and amiodarone has been added (with a dose that is specific to sustained ventricular fibrillation and pulseless
tachycardia as described in Protocol 503-A).
Blood Drawing In a prior revision of these protocols, the ability of ALS providers to draw blood samples
(tubes) that were then turned over to the 911 receiving facility was removed with the intent of minimizing
“needlestick” injuries among providers. Because of both the new Cyanide Toxicity protocol (see below) and the
desire of some agencies to reinstitute this practice, and because of the advances in needleless systems that have
further reduced the risk to providers, this section has been modified to allow the acquisition of blood samples by
ALS providers at the discretion of each agency’s medical director.
Intraosseous Access – Pediatrics As described below, the ability of the ALS provider to obtain
intraosseous access has now been extended to the adult cardiac arrest population. For this reason, the wording
with this section that limited to the use of IO access to patients less than age 7 has been removed.
Controlled Substances Perhaps one of the most striking changes in this latest version of the REMAC
protocols is the ability of the ALS provider to now administer narcotic analgesia in the prehospital setting under
standing orders. Because of this change, and in anticipation of future protocol changes that may further expand
the use of controlled substances under standing orders, this section of the GOPs has been rewritten in more
general terms, limiting the use of controlled substances by the AEMT to Medical Control Options “unless
specifically described in the Standing Orders section of a particular protocol.”
STEMI To again emphasize the points mentioned above, it is critical that each ALS provider appreciate
the more prominent role of the 12-lead EKG in the management of ACS patients. The 12-lead is no longer an
evaluation that should be performed prior to transport, rather it should be the first act performed following the
initial evaluation of the patient. And for those patients whose 12-lead EKG demonstrates a STEMI, the very next
act should be to have one of the paramedics contact OLMC (for all providers in the 911 system, it is the FDNY
OLMC facility that must be used) to begin to process of selective transport and advanced notification to the
nearest PCI-capable facility. And, for providers in the 911 system, it is essential to remember the mandatory
contact with FDNY OLMC both prior to initiating transport (to allow for proper advanced notification) and at the
conclusion of patient care (to provide necessary quality assurance information).
Intraosseous Access – Adult The administration of medications via the endotracheal route to patients in
cardiac arrest is falling out of favor, both because of data showing a lack of survivors among such patients and
pharmacokinetic / pharmacodynamic data suggesting a lack of efficacy. For this reason, and in accordance with
December 2007 – Journal CME Newsletter
page 13 of 28
the latest international resuscitation guidelines, the use of intraosseous access in all cardiac arrest patients,
including adults, is now allowed within the New York City Region.
When intravenous access cannot be established, intraosseous access may be obtained via an extremity
approach. Because of the potential for interrupting chest compressions, which are far more important to a
patient’s chances of survival, the sternal approach is not permitted in the New York City Region. While each
agency’s medical director is responsible for deciding which sites and equipment are to be used to obtain
intraosseous access, two possible methods have been described in the accompanying PowerPoint presentation and
will be described in an FDNY Office of Medical Affairs Directive (MAD) due to be released at nearly the same
time as this article.
Intranasal (IN) Drug Administration In light of the addition of intranasal naloxone (Narcan) in the
2007 REMAC protocols, and in light of the possible addition of other medications to be administered via the
intranasal route in future protocols, a section describing the use of this medication administration route has been
added to the GOPs.
Advance Life Support Protocols
The 2008 REMAC protocols include a number of improvements to the ALS protocols, as well as the
addition of two entirely new protocols. Following the format of the accompanying PowerPoint presentation, we
will begin by reviewing the changes to the existing protocols.
501 – Respiratory Arrest Because the management of suspected poisoning and / or drug overdoses is
described in other protocols, the empiric use of naloxone has been removed from this protocol. Instead, a note has
been added referring providers to the Altered Mental Status protocol for patients in whom a poisoning / overdose
is suspected as the cause of the patient’s respiratory depression / arrest.
503-A – Ventricular Fibrillation / Pulseless Ventricular Tachycardia Because there does not appear,
based on data that is currently available, that recurrent ventricular fibrillation / ventricular tachycardia (VF/VT)
are frequent complications of resuscitative efforts, the administration of the 150mg dose of amiodarone to
patients in whom a supraventricular rhythm has been restored with just defibrillation (with or without
epinephrine) has been removed. Should VF/VT recur after such a conversion, the resuscitation continues as
described under Standing Orders in the protocol, meaning that the patient would receive a full 300mg dose of
amiodarone. After the initial amiodarone, Medical Control Options provide for additional 150mg in the event of
still another recurrence.
504-A – Drug Therapy of Myocardial Ischemia As with the BLS protocol, the word “baby” has been
removed from the description of aspirin. But this is not the only change to this protocol.
Each protocol that includes the administration of morphine has included a “note” that called for the
administration of naloxone / reversal of the morphine in the event that the patient developed stupor, hypotension,
or hypoventilation. While well-intended, the problem with such a requirement is that a slight depression of
December 2007 – Journal CME Newsletter
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mental status is not an unexpected result of morphine administration, and it is also not of concern so long as it is
not accompanied by hypoventilation or loss of protective airway reflexes. Similarly, though hypotension may
result from morphine administration, this is a result of morphine-induced release of histamine, not a direct result
of the mechanism of action of morphine itself. For these reasons, naloxone (Narcan) administration is only
indicated for hypoventilation that results from morphine administration. This change was made to this protocol,
as well as all others in which morphine administration was allowed.
As to the treatment of “hemodynamically compromising PVCs”, the only true indication for such
treatment is the presence of a “run of three” (which qualifies as ventricular tachycardia) or an R-on-T
phenomenon resulting in VT or VF. In either case, a protocol already exists for the treatment of VF and VT, so
the use of antidysrhythmics in this protocol was felt to be both unnecessary and inappropriate. Any PVCs not
meeting these criteria should have their underlying cause (myocardial ischemia, hypoperfusion, shock) treated,
but not the PVCs themselves. For this reason, the recommended administration of lidocaine has been removed.
Finally, a reference to the STEMI transport decision has been added. This is particularly worth
mentioning because any patient treated under this protocol should have a 12-lead EKG performed and may,
therefore, quality for the STEMI transport decision.
506 – Acute Pulmonary Edema There are three items worth mentioning within this protocol. First, the
“note” related to morphine administration has been modified as in
all other protocols (see the section on Protocol 504 for more
information). Second, the Medical Control Options have been
modified to allow for continued nitrate administration for all
patients, not just those for whom “transportation is delayed or
extended.” The final item relates to the administration of morphine
to acute pulmonary edema (APE) patients.
While the REMAC continues to review the literature related
Figure 5: Frank-Starling curve showing
the increase in stroke volume as preload
increases.
to morphine administration in APE patients, it seems appropriate to
mention this issue here, as providers should expect to find differing
opinions among OLMC physicians until such time as the REMAC
reaches a decision on the inclusion of morphine within this protocol.
Initially, it was thought that morphine’s role in the management of acute pulmonary edema was to aid in
vasodilation and preload reduction, but the data suggested that the doses necessary to accomplish that physiologic
response were large enough to also cause respiratory depression and worsened outcomes. Then the role of
morphine changed to smaller doses intended to provide anxiolysis, the thought being that reduced anxiety would
result in reduced sympathetic tone, reduced levels of circulating catecholamines, reductions in heart rate (via
reduced chronotropic stimulation), and subsequently increased ventricular filling times – all of that shifting the
cardiac output to the right on Starling’s curve, resulting in improved cardiac output.
December 2007 – Journal CME Newsletter
page 15 of 28
The problem, even with this latter and seemingly logical use of morphine, is that it neglects to account for
the fact that morphine is, itself, a direct myocardial depressant. The most recent literature suggests that the use of
morphine, in any amount, results in an increase in the rate of endotracheal intubation among APE patients, an
increased rate of ICU admissions, and worsened outcomes.
For this reason, alternative medications that can provide the same physiologic benefits without the
myocardial depression may have advantages in the APE patient. This is why some OLMC physicians, using the
same rationale as some of the REMAC physicians who are reviewing the literature, prefer to use benzodiazepines
instead of morphine for APE patients. Though it is premature to recommend that ALS providers request a
benzodiazepine instead of morphine for this patient population, it is also important to understand the differences
of opinion (and orders) that may arise from different OLMC physicians.
507 – Asthma Much like the BLS protocols, the management of asthma and COPD exacerbations
represent one area where the latest REMAC protocols seek to define the standard of care, rather than meeting it.
In short, the treatments previously reserved for Medical Control Options have been moved to Standing Orders.
The result, shown in Figure 6, is a novel, appropriately aggressive, and cutting edge approach to the prehospital
management of asthma exacerbations. Note the use of IM epinephrine, IV magnesium sulfate, and IV
corticosteroids under standing order for the most severe of patients.
A New Approach to ALS Asthma Management
Begin treatment with nebulized
albuterol / metaproterenol.
Is the patient in impending
respiratory failure?
Yes
No
For continued symptoms, repeat
albuterol / metaproterenol to a
total of three doses.
Administer Epinephrine 1:1,000
0.3mg IM
Administer Magnesium Sulfate 2gm IV
Administer Methylprednisolone 125mg
or Dexamethasone 12mg IV
Contact OLMC for further
treatment options.
December 2007 – Journal CME Newsletter
Yes
Does the patient show signs of
continued severe respiratory distress?
No
Begin / continue transport to the
nearest appropriate 911 receiving facility.
page 16 of 28
508 – Chronic Obstructive Pulmonary Disease Similar to what was done in the Asthma protocol, the
use of corticosteroids has been moved to the standing orders section for patients with continued signs of “severe
respiratory distress” despite the administration of inhaled beta-agonists (albuterol or methylprednisolone).
510 – Anaphylactic Reaction As in the management of cardiac arrest, the use of endotracheal
medications has fallen out of favor. For this reason, the use of endotracheal epinephrine has been removed from
this protocol. Instead, the initial focus of this protocol lies in airway management – with the use of endotracheal
intubation for obvious respiratory compromise. Once the airway is evaluated, and possibly managed, the
administration of epinephrine should occur via the intramuscular route (0.3mg of a 1:1,000 solution, IM).
For both this protocol and the revised asthma management protocol described above, it would not be
unexpected or inappropriate to find some providers questioning the safety of this more aggressive use of
epinephrine. Therefore, it is important to mention that this change was instituted based on data from hundreds of
cases of critical asthma exacerbations and anaphylaxis cases to whom epinephrine administration was provided
under the “old” protocols. What we found was that, despite the concern for hypertension / tachycardia /
myocardial ischemia, the average patient to whom this medication was provided showed a reduction in blood
pressure and heart rate. When you consider that these patients suddenly, because of the epinephrine, found
themselves able to breathe once again, these findings are not unexpected
511 – Altered Mental Status A brief mention of the one change to this protocol… Using common sense,
a patient for whom “the glucometer reading is above 120mg/dl, and the patient has no symptoms or signs of
hypoglycemia…” Wait, by virtue of the fact that we would be using the protocol in the first place, the patient has
potential signs of hypoglycemia. Hats off to Dr. Brad Kaufman for pointing out this error. So now, even if the
patient has signs or symptoms of hypoglycemia, dextrose may be withheld “if the glucometer reading is above
120 mg/dl.”
520 – Traumatic Cardiac Arrest For reasons
described above under the changes to Protocol 420, the
use of cardiac monitor for traumatic cardiac arrest patients
has been added. If the patient is found to be in VF/VT, the
patient should be treated according to Protocol 503-A, and
not per this protocol. If the patient is found to be in any
other rhythm, care should continue as per this protocol.
529 – Pain Management for Isolated Extremity
Injury Without question, the most common chief
complaint / presenting problem that results in a 911 call,
an EMS transport, or a visit to the emergency department
is pain. And without question, one of the most frequently
Figure 6: Morphine, named after Morpheus - Greek god
of dreams (not the Matrix character!) may now allow
New York City paramedics to address the most common
of chief complaints based on standing orders, rather than
requiring OLMC contact / permission.
cited issues with prehospital and emergency department
December 2007 – Journal CME Newsletter
page 17 of 28
care is the failure to address a patient’s pain. Keeping that in mind, we come to what is potentially one of the most
progressive changes (equaled only by the improvements in asthma management and traumatic cardiac arrest – in
the author’s opinion) in this newest set of protocols.
Under standing orders, ALS providers may now provide narcotic analgesia to the hemodynamically stable
patient (SBP >110 mmHg) with an isolated extremity injury. While this does not restrict its use to this population
(OLMC may still be contacted to request morphine administration for other painful conditions such as burns), it
will hopefully allow for the more prompt and appropriate management of the one patient population for whom
most analgesia is requested under the current protocols.
One concern that should be addressed here is the potential requests for ALS assistance solely for the
purpose of pain management. While there is no question that the majority of “pain” seen in the prehospital setting
does not require narcotic administration prior to transport, there are those conditions for which its appropriateness
is equally without question (e.g., the hip fracture with excruciating pain that prevents proper movement /
immobilization, the femur fracture in need of traction splinting that is unable to be accomplished because of
pain). In such situations, requests for ALS assistance are both medically appropriate and ethically defensible – no
different than the critical asthmatic in need of ALS intervention, the ACS patient for whom PCI may be needed,
or the acute pulmonary edema patient in need of advanced hemodynamic management.
The other change to this protocol, described in more detail above, is the change in the note regarding
adverse effects to morphine administration (see the section on Protocol 504 for more information).
543 – Newly Born Neonatal Resuscitation As first described in the section specific to GOP changes
relative to all providers, the words “newly born” have been replaced with the word “neonate” or “neonatal.” In
addition, there is a typographical error among the initially distributed REMAC changes that is important to note.
For this population, the dosing of epinephrine under Standing Order #4 and Medical Control Option A should
read “Epinephrine 0.01mg/kg (0.1ml/kg of a 1:10,000 solution).” Other changes, all of which occur in the
Medical Control Options, include the removal of endotracheal naloxone administration and the use of IV/IO
epinephrine.
551- Pediatric Obstructed Airway It is now permissible, if all other methods of airway management
fail, to use a needle cricothyroidotomy in the pediatric patient with an obstructed airway.
553 – Pediatric Non-Traumatic Cardiac Arrest The most recent international guidelines for
resuscitation management were included in the 2007 REMAC Protocols, and this year’s revisions include the
most recent international recommendations for pediatric resuscitation. Specific to this protocol, there are five
items worth reviewing.
First, atropine is no longer recommended as a standard part of pediatric resuscitation. Because
hemodynamically compromising bradycardias in this population are almost exclusively the result of airway
compromise / hypoxia, drug overdoses, and electrolyte disturbances, atropine plays no role in the resuscitation of
the pediatric patient.
December 2007 – Journal CME Newsletter
page 18 of 28
Second, unlike adults, initial defibrillation attempts in pediatrics are not delayed in order to provide a
period of chest compressions and ventilations. This recommendation is a result of the physiologic differences
between adults and pediatric patients, the etiology of VF/VT in pediatrics, and the lack of available data
regarding delayed defibrillation in this population. For these reasons, pediatric patients found in VF/VT should be
immediately defibrillated.
Third, nasogastric (NG) or orogastric (OG) tube placement remains a part of the resuscitation of the
pediatric patient. The negative impact of gastric distension upon blood return via the inferior vena cava,
impacting on the Frank-Starling curve mentioned above and diminishing the blood available for sustaining
cardiac output during chest compressions, mandates the decompression of the stomach in order to augment this
route of blood return to the heart during CPR.
Fourth, as with adults, amiodarone has replaced lidocaine as the preferred drug for the management of
sustained VF/VT in pediatric patients.
Finally, because of the possibility of torsades de pointes in the pediatric as well as the adult population,
the administration of magnesium sulfate for the specific management of this dysrhythmia has been added to the
medical control options.
554 – Pediatric Asthma / Wheezing Three changes have been made to the pediatric asthma / wheezing
protocol. First, the option of using metaproterenol has been eliminated from the protocol, making albuterol the
only beta agonist approved for use in the New York City Region. Second, “if available” options for the use of
ipratroprium bromide and terbutaline have been added. While these latter options are only applicable if the drugs
are available within a particular agency, to omit a brief discussion of these medications from this article would be
inappropriate.
Ipratroprium bromide (Atrovent) is an anticholinergic agent that appears, based on animal models, to
inhibit the release of acetylcholine from the vagus nerve, thereby inhibiting vagal-mediated bronchoconstriction.
And although it is an anticholinergic medication, it does not appear to alter the volume or viscosity (thickness) of
respiratory secretions. The most common side effects of ipratroprium include dry mouth and bitter taste, though
adverse effects may also include cardiac symptoms (i.e. bradycardia), ocular symptoms (e.g, pain or other
symptoms related to glaucoma) and allergic reactions.
Terbutaline is an injectable beta agonist that demonstrates preferential effects on beta2-adrenergic
receptors, resulting in less cardiovascular side effects than may be seen with less selective medications such as
epinephrine. The administration of terbutaline produces clinically significant changes in bronchospasm within 15
minutes, with a peak in 30-60 minutes and a duration of effect of 90 minutes to four hours. Adverse effects of
terbutaline most commonly include nervousness, drowsiness, palpitations, and dizziness.
555 – Pediatric Anaphylactic Reaction and 556 – Pediatric Altered Mental Status The only change to
this protocol was the emphasized use of the Broselow Tape – something that should be used in the management
December 2007 – Journal CME Newsletter
page 19 of 28
of every pediatric patient to help minimize errors in weight-based dosing, equipment choices (e.g. endotracheal
tube size), and other patient-specific decisions.
557 – Pediatric Seizures Under Medical Control Options, ALS providers now have the option, when IV /
IO access is not available, of utilizing either rectal diazepam (Valium) or the newly added intramuscular (IM)
administration of midazolam (Versed). The recommended dose of IM midazolam is 0.1mg/kg, not to exceed a
total dose of 5mg.
558 – Pediatric Decompensated Shock Under the Medical Control Options, simple clarification was
provided regarding adenosine (Adenocard) administration for the patients with narrow complex supraventricular
dysrhythmias, with the initial dose to not exceed 6mg and subsequent doses to not exceed 12mg. This is
consistent with the maximum doses utilized for adult patients.
New ALS Protocols
500 – Suspected Cyanide Toxicity / Smoke Inhalation In order to deal with both the potential for acts
of terrorism and the more likely incident in which a patient is exposed to a significant amount of cyanide, a new
protocol was developed for the management of such patients irrespective of the circumstances of the exposure.
This protocol incorporates both the previously described use of sodium thiosulfate (see prior FDNY Medical
Affairs Directive 2003-05a) and the newly added use of hydroxocobalamin.
Cyanide exposure may occur via a variety of routes including inhalation, ingestion, dermal absorption,
and/or parenteral administration. In addition to the potential use of this agent as a chemical warfare agent / act of
terrorism, cyanide exposure may also be found among patients involved in fires / smoke inhalation (as a result of
burning plastics), at the site of industrial accidents (where is it commonly used in the production of a variety of
products – see the accompanying PowerPoint for a more detailed listing), following accidental ingestions (certain
beans, nuts, and seeds), and in cases in which patients intentionally expose themselves to cyanide-containing
compounds.
Regardless of the route of or reason for exposure, the end result of cyanide toxicity is that the body reacts
as though it is deprived of oxygen (hypoxia, shock). Cyanide binds to a specific site (cytochrome oxidase) within
the midochondria that is known as the electron transport chain. This series of chemical processes is normally
responsible for the oxygen-dependent processes that generate energy (ATP) within the cell. Despite having
adequate oxygen, the binding of cyanide within this “chain” results in the inability of the cell to maintain its
energy (ATP) stores – no different than if the cell were deprived of oxygen.
Clinical signs of cyanide toxicity include the entire spectrum of symptoms that may be seen in a hypoxic
patient. However, for the purposes of this protocol, and in the hopes of maximizing the benefit of the drugs used
in this protocol while minimizing their potential adverse effects, the use of this protocol is limited to those
patients who are suspected of cyanide toxicity and who exhibit both hypotension and altered mental status.
December 2007 – Journal CME Newsletter
page 20 of 28
Although other treatment options exist for the management of cyanide toxicity (i.e. ETDA, DMAP, the full
Cyanide Antidote Kit – formerly known as the Lily Kit), these treatment alternatives carry with them a significant
risk of hypotension. Because any treatment initiated in the prehospital setting would be anecdotal (based on
suspicion rather than proof) and limited to patients who were already hypotensive, this protocol includes only the
use of sodium thiosulfate and hydroxocobalamin.
Sodium thiosulfate, when administered to a patient
with cyanide toxicity, helps to more rapidly eliminate
cyanide from the body. An enzyme within the body,
rhodenase, uses the sodium thiosulfate to form thiocyanate
which is more easily eliminated from the body via the
kidneys. This reaction is shown in Figure 7.
New ALS Protocols - 500
Sodium
Thiosulfate
Sodium thiosulfate, when
administered to a patient
with cyanide toxicity, helps
to more rapidly eliminate
cyanide from the body. An
enzyme within the body,
rhodenase, uses the sodium
thiosulfate to form
thiocyanate which is more
easily eliminted from the
body via the kidneys.
Hydroxocobalamin, when administered to the same
Cyanide
Rhodenase (enzyme)
Thiocyanate
Excreted in the urine
patient, preferentially binds to the cyanide molecule,
removing it from the electron transport chain (specifically,
the cytochrome oxidase molecule), forming a product called
Figure 7: Administration of sodium thiosulfate
helps to expedite the removal of cyanide from
the body.
cyanocobalamin that reduces the toxicity of the cyanide
within the body. This reaction is shown in Figure 8.
Under the new protocol, cyanide toxicity kits are
being
developed
that
include
sodium
thiosulfate,
hydroxocobalamin, the fluid necessary to administer the
hydroxocobalamin, and three blood tubes that (time
permitting) should be obtained prior to the administration of
hydroxocobalamin and that should be turned over to the 911
receiving facility to which the patient is transported.
This new protocol may be carried out only via
Medical Control Options or a part of a Class Order issued by
an FDNY OMA Medical Director. In the even that either
Figure 8: The addition of hydroxocobalamin
results in cyanide's removal from cytochrome
oxidase and the formation of cyanocobalamin.
such order is received, patients treated under this protocol
should have two large-bore IVs established. As noted above, if time and the number of patients permit, the three
blood samples included in the Cyanide Toxicity Kit should be obtained. Hydroxocobalamin and sodium
thiosulfate, in order of preference, should then be administered via separate IV lines, with only hydroxocobalamin
being administered if only one IV is able to be established. Because of the hemodynamic compromise implicit in
these patients, additional cardiovascular support using dopamine may be required.
530 – Emotionally Disturbed Patients As described in the BLS Protocols section of this article, the
recognition that there are not an insignificant number of cases involving emotionally disturbed patients (EDPs)
December 2007 – Journal CME Newsletter
page 21 of 28
among whom there is a risk of injury to the patient or the providers prompted the creation of a new protocol to
address this issue. As a result there now exists, under Medical Control Options, Protocol 530 which allows for the
administration of benzodiazepines to the severely agitated / violent EDP. Although the number of patients treated
under this protocol should be few in number, it was felt that the lack of such a protocol would allow for an
unacceptable risk to providers, as well as patients.
In the event that ALS providers finds themselves caring for or called to assist in the care of a violent or
severely agitated EDP, efforts should be made to ensure that an alternative reason for the agitation cannot be
found (i.e. head injury, hypoglycemia, hypoxia). If no such cause can be identified and treated, OLMC should be
contacted for orders for IM administration of a benzodiazepine (midazolam or lorazepam). Once those
medications have been administered and have taken effect, IV access should be obtained and orders for additional
IV benzodiazepines requested from OLMC as needed.
Because of the risk of hypoxia and/or hypoventilation, any patient to whom benzodiazepines are
administered for the purposes of EDP sedation require high-flow oxygen therapy, as well as both frequent
ventilatory assessments continuous pulse oximetry monitoring.
Summary As with the changes in the BLS protocols, the changes in the GOPs specific to ALS providers
and the ALS protocols themselves are meant to allow for the most appropriate, timely, safe, and evidence-based
care that is both possible and appropriate in the prehospital setting. As mentioned in the opening, any questions /
comments / concerns related to these changes should be directed to your agency’s medical director, though the
author of this article always welcomes direct comments as well. These changes would not be possible were it not
for the demonstrated ability of you - the providers within this system - to deliver such care on a regular basis,
your willingness to accept changes and in particular those that allow for an expanded scope of practice in the
prehospital setting, and your attention to detail in the documentation of the care that you provide (which allows
for the very quality assurance activities that allow us to pursue changes such as these).
And now, on to the quiz….
Written by:
John Freese, MD
FDNY EMSC Medical Director
Bureau of Training & OLMC
December 2007 – Journal CME Newsletter
page 22 of 28
DECEMBER 2007 JOURNAL CME QUIZ – “Felix sit annus novus”
1. According to NYS DOH and the NYC REMAC’s 2008 Protocols, BLS personnel may transport:
A. a hemodynamically stable patient with only normal saline infusing through an IV line
B. any patient with a saline lock or equivalent device in place
C. any patient with a saline lock or simple IV in place
D. a patient with an IV in place, so long as only fluids and/or vitamins are infused
E. none of the above
2. Which of the following is correct regarding changes to the BLS WMD / Nerve Agent Exposure protocol (400)?
A. no changes were made regarding this protocol
B.
C.
the amount of 2-PAM (pralidoxime) administered to the yellow tag adult patient was increased
the type of autoinjector kits used in the protocol may vary
D. more than one of the above is correct
E. none of the above is correct
3. Under the 2008 REMAC Protocols, which of the following is correct regarding the use of AEDs in pediatric patients?
A. adult AED pads should be used in all patients
B.
C.
only pediatric pads may be used in patients age 1-8
peds pads (or if unavailable, adult pads) should be used in patients until age eight (8)
D. peds pads (or if unavailable, adult pads) should be used in patients age 1-8
E. only pediatric pads are able to be used in patients less than one year of age
4. For the hemodynamically unstable patient with signs and symptoms consistent with an acute coronary syndrome,
which of the following is the correct treatment to be provided by BLS providers?
A. Immediately request ALS assistance and, if available, await their arrival.
B. Immediately request ALS assistance and, if they have not arrived by the time the patient is in the BLS
ambulance, transport to the nearest 911 facility.
C.
Immediately request ALS assistance and, if they have not arrived by the time the patient is in the BLS
ambulance, begin transport if the ETA of the ALS unit exceeds the transport time to the closest facility.
D. Immediately initiate transport to the nearest 911 facility.
E. Do not move the patient, rather request ALS assistance and await their arrival on scene.
5. Which is the recommended treatment under the 2008 REMAC BLS Protocol 420 - Traumatic Cardiac Arrest?
A. An AED should be applied and, only if the patient is found to be in a shockable rhythm, treatment should
proceed according to Protocol 403.
B.
An AED should be applied and, if the AED recommends anything other than “No Shock Advised”, treatment
should proceed according to Protocol 403.
C.
An AED should be applied and, if the patient is found to be in a shockable rhythm, treatment should proceed
according the Traumatic Cardiac Arrest Protocol 420.
D. An AED should be applied and, regardless of the AEDs recommendation, treatment should proceed according
to Protocol 403.
E.
An AED should not be applied as rapid transport to a 911 receiving facility is the only factor likely to benefit
the patient.
** QUIZ CONTINUES ON THE NEXT PAGE **
December 2007 – Journal CME Newsletter
page 23 of 28
** CME QUIZ CONTINUED FROM PREVIOUS PAGE **
6. Which of the following is incorrect regarding the use of amiodarone in the management of ventricular fibrillation /
pulseless ventricular tachycardia under the 2008 REMAC Protocols?
A. if a supraventricular rhythm is restored following the administration of 300mg amiodarone,
administer 150mg amiodarone slowly over 10 minutes
B.
if a supraventricular rhythm is restored following the administration of 300mg amiodarone,
administer 150mg amiodarone over 1-2 minutes
C.
if a supraventricular rhythm is restored prior to the administration of 300mg amiodarone,
administer 150mg amiodarone slowly over 10 minutes
D. if a supraventricular rhythm is restored following the administration of 300mg amiodarone,
administer 150mg amiodarone over 1-2 minutes
E.
all of the above are incorrect
7. Which of the following is most correct regarding the role of OLMC contact in STEMI transport decisions?
A. for providers in the 911 system, contact with the FDNY OLMC facility is mandatory
OLMC contact is required for STEMI patients prior to initiating transport to a PCI-capable facility
B.
for providers in the 911 system, QA data must be reported to the FDNY OLMC facility
at the completion of the assignment
C. BLS providers should request ALS assistance and ALS providers should perform a 12-lead EKG as soon
D. as the initial assessment of an ACS patient is complete
E. all of the above are correct
8. Which of the following describes a preferred treatment option, under Medical Control Options,
for the management of the severely agitated or violent EDP?
A. IM diazepam
C. IM midazolam
E.
a. IV lorazepam
B. IV diazepam
D. IV midazolam
9. When a Class Order is issued by an FDNY OMA Medical Director, which of the following is one
of the possible treatments of cyanide toxicity as described in the 2008 REMAC Protocols?
A. sodium thiosulfate
C. IM hydroxocobalamin
E. all of the above are correct
B. dopamine
D. acquiring blood samples
10. For neonatal resuscitation, which of the following is the correct dosing for intravenous / intraosseous epinephrine?
0.01mg/kg (0.1ml/kg of a 1:1,000 solution)
A. 0.1mg/kg (0.1ml/kg of a 1:1,000 solution)
D.
B. 0.1mg/kg (1ml/kg of a 1:1,000 solution)
E. 0.01mg/kg (0.1ml/kg of a 1:10,000 solution)
C. 0.1mg/kg (0.1ml/kg of a 1:10,000 solution)
** SEND ANSWER SHEET (next page) BY LAST DAY OF DECEMBER 2007**
December 2007 – Journal CME Newsletter
page 24 of 28
After reading the article, place your answers to the following quiz on this answer sheet
Paramedics receiving a minimum grade of 80% will receive 1 hour of Online/Journal CME
------------------------------------------------------------------------------------------------------------------------------
Please submit this page only once, by one of the following methods:

FAX to 718-999-0119

U.S. MAIL to FDNY OMA, 9 MetroTech Center 4th flr, Brooklyn, NY 11201
Direct inquiries to Paramedic Allison Fry at 718-999-2790
You are strongly advised to keep a copy for your records
------------------------------------------------------------------------------------------------------------------------------------------------------------------------
All respondents: * Info required to receive your CME
December 2007 CME
“Felix sit Annus Novus”
Quiz Answers
*Name
NY State / REMAC #
*Work Location
*Email address
1.
2.
Required for
3.
BLS & ALS
4.
Providers
5.
6.
Please submit answer sheet by
the last day of December 2007
7.
Required for
8.
ALS Providers
9.
Only
10.
December 2007 – Journal CME Newsletter
page 25 of 28
This page intentionally left blank.
December 2007 – Journal CME Newsletter
page 26 of 28
Citywide CME – December 2007
*On Dec. 19, REMAC exam-day CME at FDNY BOT will be held 10:30-14:30*
During the holiday season, it is recommended to confirm CME offerings with the provider.
BK
BK
BK
BK
BK
BK
BK
Facility
Brookdale
Brookdale
Flatlands VAC
Lutheran RSVP-->
Lutheran
Lutheran
Lutheran
Date
12/3/07
1/7/08
1/7/08
12/5/07
12/12/07
12/26/07
1/9/08
Time
1300-1400
1300-1400
1930-2200
1730-21:30
1700-1900
-->
1700-1900
Topic
Call Review [ next: Jan 7 ]
Call Review [ next: Feb 4 ]
Protocol Update RSVP-->
Symposium: CVA/Trauma/MI
Call Review [ next: Jan 9 ]
cancelled
Call Review [ next: Jan 23 ]
Location
EMS Crew Room
EMS Crew Room
Kings Plaza Mall
Medical Staff Auditorium
ER Conference Room
--ER Conference Room
Host
Dr Cherson
Dr Cherson
Dr Leak
--Dr Chitnis
--Dr Chitnis
Contact
Mordechai Lax 718-240-5570
Mordechai Lax 718-240-5570
Arthur Berkovitz 718-904-3472
718-630-6107
Dale Garcia 718-630-7230
Dale Garcia 718-630-7230
Dale Garcia 718-630-7230
BX
BX
BX
Montefiore
Montefiore
Montefiore
12/4/07
1930-2230
-->
1930-2230
Call Review [ next: Feb 5 ]
cancelled
Call Review [ next: Mar 4 ]
Cherkasky Auditorium
Cherkasky Auditorium
Cherkasky Auditorium
Dr Wollowitz
Dr Wollowitz
Dr Wollowitz
Don Cardone 718-763-8888x506
Don Cardone 718-763-8888x506
Don Cardone 718-763-8888x506
QN
QN
QN
QN
QN
QN
QN
QN
QN
QN
QN
FDNY-BOT
Flushing Hosp
Flushing Hosp
Jamaica Hosp
Jamaica Hosp
NY Hosp Queens
Parkway Hosp
Parkway Hosp
Queens Hosp
Queens Hosp
SJU-EMSI RSVP-->
12/19/07
12/20/07
1/17/08
12/12/07
1/9/08
Call Review or Lecture
Call Review [ next: Jan 17 ]
Call Review [ next: Feb 21 ]
Call Review [ next: Jan 9 ]
Call Review [ next: Feb 13 ]
Trauma Rounds
Call Review [ next: Jan 16 ]
Call Review [ next: Feb 20 ]
Call Review
Call Review [ next: Jan 10+24 ]
Protocol Update and STEMI
Fort Totten Building 325
Board Room
Board Room
ED Admin Conf Rm
ED Admin Conf Rm
East bldg, courtyard level
Board Room, 1st flr
Board Room, 1st flr
Emergency Dept
Emergency Dept
175-05 Horace Harding
Dr Schoenwetter
Dr Crupi
Dr Crupi
Dr Silberman
Dr Silberman
REMAC Liaison 718-999-2671
Mordechai Lax 718-240-5570
Mordechai Lax 718-240-5570
Mordechai Lax 718-240-5570
Mordechai Lax 718-240-5570
George Benedetto 718-670-2929
12/19/07
1/16/08
12/13/07
12/27/07
12/5/07
1030-1400
1400-1500
1400-1500
1500-1600
1500-1600
1600-1800
1830-2130
1830-2130
1615-1815
1615-1815
1700-?
Dr Politi
718-883-3070
718-883-3070
Frank Riboni 718-990-8416
SI
Richmond County Amb
12/5/07
1700-?
Call Review
1355 Castleton Ave
Dr. Hashmi
Kevin Mullaney 718-273-3555
Boro
January
2/5/08
Mondays
December 2007 – Journal CME Newsletter
pabruzzino@capitolhealthmgmt.com
pabruzzino@capitolhealthmgmt.com
page 27 of 28
`2007- 2008 NYC REMAC Examination Schedule
Month
REMAC Refresher Exam
REMAC Challenge Exam
(written only - CME letter required)
(written & 3 oral scenarios)
Part A – Written
@18:00
Part B – Orals
@09:00
Registration
Deadline
Exam Date
(on Wednesdays)
December ‘07
11/30/07
12/19/07
January ‘08
12/31/07
1/16/08
1/31/08
2/20/08
2/29/08
3/19/08
3/31/08
4/16/08
May
4/30/08
5/14/08
5/15/08
June
5/31/08
6/18/08
6/19/08
July
6/30/08
7/16/08
August
7/31/08
8/13/08
September
8/31/08
9/17/08
October
9/30/08
10/22/08
November
10/31/08
11/19/08
Figure 9:
Anterior MI Note ST February
segment
elevation in March
V2, V3, and
V4, as well as
April
the PVCs.
Registration
Deadline
NYS/DOH
Written
Exam
12/13/07
Thursday
Thursday
Thursday
1/17/08
1/24/08
1/31/08
1/17/08
3/13/08
Tuesday
Tuesday
Tuesday
4/15/08
4/22/08
4/29/08
Wednesday
Wednesday
Wednesday
7/16/08
7/23/08
7/30/08
8/21/08
Thursday
Thursday
Thursday
10/16/08
10/23/08
10/30/08
11/20/08
The REMAC Refresher examination (written only) is offered monthly for paramedics who meet CME requirements, and whose REMAC certifications are either
current or have expired less than 30 days. They may attend an exam no more than 6 months prior to expiration. Call 718-999-7074 before the registration
deadline. Refresher exams are held at 07:00 or 18:00 hours at FDNY-EMS Bureau of Training, Fort Totten, Queens.
The REMAC Challenge examination (written and orals) is offered quarterly, for initial certification, or for paramedics with either inadequate CME or whose
certifications have expired more than 30 days. Write to swansoc@fdny.nyc.gov before the registration deadline. You are encouraged to register at least 30
days prior to the exam as seating is limited. Part A (written) is held at 18:00 and Part B (orals) at 09:00 at FDNY-EMS Bureau of Training, Fort Totten, Queens.
Send correspondence to: FDNY Office of Medical Affairs, Attn: REMAC Liaison, 9 MetroTech Center - 4th Floor, Brooklyn, New York 11201-3857
December 2007 – Journal CME Newsletter
page 28 of 28