Advanced Life

Support Protocol
Update

2006
 Introduction
Developed by the REMAC Protocol
Subcommittee
Derived from the SEMAC ALS Protocol
Template
Distributed to all regional ALS agencies,
Hospitals, County EMS Coordinators for
comment
Approved by the SEMAC/SEMSCO and
REMAC/REMSCO
 Format
Modular Format:
 Operations
Together, the
 Adult Medical seven separate
 Adult Trauma sections make up
 Special Considerations the Regional ALS
 Pediatric Medical Protocol
 Pediatric Trauma
 Appendix
 General Operating Procedures
Table of Contents

 Introduction
 EMT-Intermediate/Critical Care Program
 Clinical Judgment
 Interpretation of Protocols
 Medical Control
 Medical Authority at the Scene
 Communications
 Communications Failure
 Transfer of Care
 Patients Who Refuse Care
 Initiation and Termination of CPR Including DNR
General Operating Procedures
Table of Contents

Pediatric Definitions
Procedures
Medications
Equipment
Destination Decision
Ambulance Diversion
Inter-Facility Transfers
Protocol Exceptions
Record Keeping
EMS Complaint/Concern Procedures
EMS Disciplinary Procedures
Protocol Changes
 Introduction
This manual represents the minimum
standard of care for provision of pre-
hospital advanced levels of care in the
Hudson Valley Region.
The Regional Advanced Life Support
(ALS) system incorporates three different
tiers of ALS care which includes EMT-I,
EMT-CC, and EMT-P levels of personnel
and services.
 EMT-I/CC Program
The EMT-Intermediate/EMT-Critical Care
(EMT-I/EMT-CC) program is designed for
use only as an adjunct within an
established EMT-P (Paramedic) system.
Requires an EMT-P (Paramedic) two-
tiered priority response with simultaneous
dispatch
 Clinical Judgment:
Guidelines which should be used in
conjunction with good clinical judgment.
In situations where there is no existing
protocol and a clear need for ALS exists,
the ALS provider shall initiate Initial
Advanced Life Support Care, Protocol
ACP-1 and contact Medical Control
Interpretation of Protocols
NYS BLS Protocols must be initiated, in
conjunction with the HVREMSCO
Advanced Life Support Protocols.
ALS personnel will initiate Initial Advanced
Life Support Care, Protocol ACP-1, for
every ALS patient
 Interpretation of Protocols
In each protocol, for every standing order and
medical control option, there is indication as to
which level of provider may initiate that order.
EXAMPLE:
1. Airway control procedures
2. If patient is intubated, secondary
confirmation must be performed, at a
minimum, with End-tidal CO2
monitoring and Pulse Oximetry.
Continuous CO2 monitoring is
recommended.
3. Refer to appropriate protocol for further
assessment and treatment.
 Interpretation of Protocols
Some protocols are designed to have numbered
standing orders only; other protocols have
numbered standing orders and medical control
options.
Standing orders may be initiated prior to
contacting Medical Control, and MUST be
performed in numerical sequence.
If there is clinical improvement, further standing
orders may be withheld based upon the ALS
Provider’s clinical judgment.
 Interpretation of Protocols
Medical control options may not be initiated
until ordered by Medical Control. Medical
Control will sequence medical control options.
Example:
EMT-I’s Stop Here. EMT-CC/P’s Contact Medical Control.

Medical Control options

Diazepam 5-10mg IVPMorphine Sulfate 2-10mg IVP
Midazolam 0.5-2mg Slow IVP
Lidocaine 1.0-1.5mg/kg slow IVP (as appropriate for increased
intracranial pressure)
 Interpretation of Protocols
Additional information pertinent to the protocol
has been included in separate sections entitled
“Considerations”.
Example:
Considerations
Prior to nasotracheal intubation, consider the
administration of Phenylephrine HCl 1% Nasal Spray. If
utilized, administer 2 sprays in the selected nostril.
RSI Credentialed Paramedics may refer to Medication
Facilitated/Rapid Sequence Intubation Protocol SCP-5
as appropriate.
 Interpretation of Protocols
It is understood that a patient’s clinical
presentation may require more than one
protocol.
In such cases, the patient’s most emergent
clinical problem should be treated as the priority.
Implement the standing orders in the new
protocol without exceeding the maximum
recommended medication dosages and contact
Medical Control as indicated.
 Medical Control
Standing Orders
Medical Control Options
“Medical Control Practitioner” means a
HVREMAC credentialed Physician or
Physician’s Assistant.
Medical Authority at a Scene
Only a Medical Control Practitioner may
relinquish Medical Control,
 and only to an identified physician at a scene.
 may allow ALS providers to follow orders from
the physician at a scene, provided such
orders are included within the Regional ALS
Protocols.
Medical Authority at a Scene
Orders given by an on scene physician that
are not within established HVREMSCO
protocols require:
 That the on scene physician implements the order.
 That the on scene physician utilizes his/her own
drugs and equipment.
 That the on scene physician accompanies the
patient to hospital.
The on scene physician who accepts Medical
Control will complete and sign the "Physician
Release Form"
 Communications
ALS Providers may contact Medical
Control at any time.
The ALS Provider must contact the
Medical Control Facility upon completion
of standing orders, and whenever there is
a patient who requires ALS services, but
refuses treatment or transport.
 Communications
When patients are transported to a
hospital not providing the Medical Control
 The MC Practitioner providing the order will
notify the clinical practitioner in charge of the
Receiving Emergency Department
If on scene >20 min. document
circumstances
 Communication Failure
Complete appropriate standing orders and
initiate transport.
Attempt voice contact with any available
Regional MC Facility.
After call, advise Medical Control and
document circumstances
 Transfer of Care
ALS Providers may transfer care of a patient to another
provider within the following provisions:
1. To an equal or higher level of care provider:
 When transport is by helicopter critical care team.
 When transport is by another provider/service with the same
level of training.
 When patient is turned over to an appropriate receiving facility.
2. To an equal or lower level of care provider:
 When the ALS Provider at the scene recognizes that there is
no indication for ALS intervention.
 When ALS capabilities are exceeded (ex. MCI) and patient is
triaged to other ALS or BLS services.
 When a coroner or other appropriate agency takes custody.
 Patients Who Refuse Care
When a patient or legal guardian/proxy
refuses treatment or transport:
Refer to New York State Department of
Health, Bureau of EMS Basic Life
Support Protocol SC-5 “Refusing Medical
Aid (RMA)”;
Communicate with Medical Control if
ALS is indicated.
 Initiation and Termination of CPR
including Do Not Resuscitate (DNR)
The only exceptions to initiating CPR are:
For any patient originating from an Article 28 facility
(hospital or nursing facility) when written DNR orders
signed by a physician are presented;
For any patient NOT originating from an Article 28
Facility (hospital or nursing facility) when a non-hospital
DNR order is presented on the standard Department of
Health form (DOH-3474) or when the standard
Department of Health DNR bracelet is found on the
patient’s body;
In cases of obvious death such as rigor mortis,
decomposition, extreme dependant lividity, or mortal
injuries such as decapitation.
 Initiation and Termination of CPR
including Do Not Resuscitate (DNR)
Once CPR is initiated by a CFR, EMT or AEMT it must be continued until
one of the following occurs:

•Effective spontaneous circulation •A Medical Control

has been restored;
•Resuscitative efforts have been
transferred to another
appropriately trained individual
who continues CPR and other
basic life support measures;
•A Medical Control Practitioner
agrees to relinquish Medical
Control to an on-scene physician
who assumes responsibility for
the care of the patient;
Practitioner orders
termination of CPR (by radio,
telephone, or other
communication means);
•Care of the patient is
transferred to hospital staff
assigned responsibilities for
emergency care;
•A valid DNR is presented;
•The CFR, EMT or AEMT is
exhausted and physically
unable to continue
resuscitation.
 Initiation and Termination of CPR
including Do Not Resuscitate (DNR)
If the decision is made to terminate CPR, the
patient must still be transported if;
 Arrest is in a public place
 An environmental situation not conducive to
termination exists
 No police agency or coroner is present
 Communication failure occurred
 Asystole developed after the arrival of EMS
 Inadequate IV access or airway control was obtained.
If decision is made not to transport, the ALS
provider will leave all tubes and lines in
place.
 Pediatric Definitions
A pediatric patient is any patient who is less than
eighteen (18) years old.
The term “infant” refers to pediatric patients less
than 1 year old.
The term “neonate” refers to pediatric patients in
the first minutes to hours immediately after birth.
For the purposes of CPR and AED a child will be
considered eight (8) years of age or less.
 Procedures
New Section (specifies various
procedures)
 Biphasic defibrillation is an acceptable option
if used according to the specific
manufacturer’s instructions.
 12 Lead ECG implementation strongly
supported by the HVREMAC
 EMT-I services are required to utilize
Automated External Defibrillators.
 Medications/Equipment
Agencies will be required to stock each
ALS unit and maintain stock levels
according to the minimum guidelines as
set forth in the medication and
equipment lists in the appendix.
 Inter-Facility Transfers
Patient care is the direct responsibility of
the referring hospital and physician for all
inter-facility transfer of patients.
 Inter-Facility Transfers
Pre-hospital emergency personnel must insure that prior to initiating the
patient transfer, they are supplied with written documentation of at least the
following information:

 Patients name;
 Diagnosed condition of the patient;
 Any treatment and any medication administered to the
patient;
 Name of physician ordering transfer;
 Name of hospital from which the patient is being
transferred;
 Name of the physician(s) who is or are willing and
authorized to receive the patient at the new location;
 Name of hospital or other facility that is to receive the
patient;
 Date and time of transfer
 Signature of the physician ordering the transfer.
 Inter-Facility Transfers
Pre-hospital emergency personnel must insure that prior to
initiating the patient transfer, they are supplied with written
documentation of at least the following information:
Obtain written medical orders that do not exceed
their level of medical training;
Confirm that the receiving facility has agreed to
accept the patient in transfer;
Are supplied with appropriate copies of the patient’s
medical records, including radiographs;
Are utilizing the appropriate equipment needed to
transfer the patient;
Verify that the patient has been stabilized to the
fullest extent capable by the referring hospital prior
to transfer.
 Inter-Facility Transfers
If a patient’s condition becomes critical
during an inter-facility transport
HVREMAC credentialed personnel shall
utilize the ALS protocols in conjunction
with the NYS BLS protocols provided
Medical Control is contacted ASAP
 Protocol Exceptions
While acting in a setting which falls beyond the
scope of the Regional ALS Protocols, no ALS
Provider shall be faulted or suffer punitive action
for:
 following on‑line Medical Control orders, provided the
orders are within the ALS Provider’s standard of care
and scope of training;
 for refusing to follow an order which the provider
believes to increase risk to the patient;
 for refusing to perform a procedure which is beyond
the ALS Provider’s scope of training or expertise.
 Protocol Exceptions
This section is not intended by the
HVREMAC as a means for field providers
and Medical Control representatives to
circumvent procedures or training
requirements specifically addressed by
the protocols.
 Record Keeping
ALS providers must document all ALS
procedures performed on an appropriate
PCR addendum (ex. PCR Continuation
Form or other form approved by the
HVREMSCO to be used in place of a PCR
Continuation Form).
 Record Keeping
ALS Providers must complete a PCR (and
when appropriate, a PCR addendum)
immediately following a call, and a
(Physician, Physician’s Assistant, or Nurse
Practitioner, as appropriate) from the
Receiving Hospital ED must also sign the
ALS PCR or PCR addendum.
 Record Keeping
In cases where patients are transported to a
hospital not providing the Medical Control for the
transport, the ALS provider will
 Document on a PCR addendum the name of the
Medical Control Practitioner and Medical Control
Facility as well as the time of communication and all
Medical Control orders received or denied.
 The ALS Provider will have the PCR addendum
signed by the clinical practitioner designated as in
charge of the Receiving Hospital ED.
 Record Keeping
All online medical control orders must be
documented on a PCR addendum and must be
authorized by a Medical Control Practitioner
either by verbal authorization to the clinical
practitioner designated as in charge of the
Receiving Hospital ED (when the patient is
transported to a hospital not providing Medical
Control) or by written authorization (when the
patient is transported to the hospital providing
Medical Control).
 Record Keeping
The ALS provider MUST NOT leave the
hospital until a completed PCR is
provided to the appropriate hospital
staff 1

1
NYS DOH Policy Statement 02-05
 EMS Complaint / Concern
Procedures

Note: The NYS DOH, Bureau of EMS mandates

specific incident reporting responsibilities and
requirements for all EMS services. Mandatory
reporting of incidents must be performed as
indicated in:
 NY State EMS Code, Part 800, Section 21(q) 1-5 and
Section 21(r), Part 80, 80.136 (k), NYS DOH, Bureau
of EMS Policy Statement 98-11, and any other NYS
DOH Policies and Procedures.
EMS Disciplinary Procedures
The Evaluation Committee is a sub‑committee of the
Regional Medical Advisory Committee (REMAC). The
Evaluation Committee consists of seven (7) members as
follows:
Chairman of the Evaluation Committee
Chairman of the HVREMAC
Regional Medical Director
Regional Executive Director
Regional Quality Improvement Coordinator
Two EMS Providers
No member of the field unit or institution involved in the
complaint shall be appointed to the Evaluation
Committee.
 No Changes

Ambulance Diversion
Destination Decision
Protocol Changes
 Protocol Format Changes
Considerations Boxes
 May preface the clinical steps of the protocol
 May also be found within the protocol’s
clinical steps when the Level of Care changes
(Paramedic considerations maybe different
from those of a Critical Care Technician)
 May also be found at the end of the protocol’s
clinical steps
 Protocol Format Changes
Medical Control Options
 Are found at the end of the clinical steps for a
given level of care.
 May also be found at the end of the protocol’s
clinical steps
 ALS Care Protocol-1
Initial ALS Care
“This protocol is to be implemented in
conjunction with the New York State Basic Life
Support Adult and Pediatric Treatment Protocols
for every patient that the ALS provider
determines to require pre-hospital ALS care.”
Replaces Adult and Pediatric “Routine Medical
Care” Protocol
Incorporates NYS BLS Protocol “General
Approach to Patient Care” as well as ALS
procedures
 L S
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 What’s New?
Adult Medical Protocols
Lorazepam, Metoprolol, and Promethazine
Hydrochloride were added to the formulary
Overdose and Toxic Exposure separated
into two distinct protocols.
Two new protocols added:
 Abdominal Pain
 Suspected Stroke
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 What’s New?
Adult Trauma
New Protocols include:
 Major Trauma
 Major Trauma Transport
 High Risk Patient
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 What’s New
Special Considerations
The following protocols have been moved into
the Special Considerations section:
 Rapid Sequence Intubation
 Child Birth/Precipitous Delivery
 Pain Management/Analgesia
 Toxemia of Pregnancy
 Neonatal Resuscitation
New Protocols in this section include:
 Mark I kit use
 Emergency Incident REHAB
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 What’s New
Pediatric Medical Protocols
Abdominal Pain has been added as a new
protocol to this section
Toxic Exposure and Overdose were
separated into two distinct protocols
 R T
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 What’s New?
Pediatric Trauma Protocols
New Protocols in this section include:
 Major Trauma
 High Risk Patients
 Traumatic/Hypovolemic Shock
 Tension Pneumothorax
 Head Trauma
 Burns
 Major Trauma Transport
 What’s New?

Each of the five clinical sections of the

protocols includes reference charts (such as
GCS and Burn Charts) which may be helpful
to ALS providers in the field.
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 Appendices
Include:
 Regional Helicopter Utilization Guidelines
 Regional Hospital Information
 Location Codes
 Physician Release Form
 Equipment List
 Medication List
 Drug Formulary
 Formulary Changes
Additions to the formulary include:
 Lorazepam
 Metoprolol
 Promethazine HCl
The following have been removed from the
formulary:
 Oxytocin
 Verapamil