General/Environmental Key Considerations




General Care: Agitated Patient Restraint/Excited Delirium General Care: Pain Management General: Procedural Sedation Medical: Allergic Reaction and Anaphylaxis
Medical: Diabetic Emergencies Medical: Seizure Medical: Shock/Hypoperfusion Medical: Suspected Sepsis
OB/Gyn: Eclampsia OB/Gyn: Pre-term Labor (24 – 37 weeks) General Practice: Medication and Medical Control General Practice: Vascular Access
General Practice: Vascular Devices, Pre-Existing OB/Gyn: Childbirth General Practice: Airway Management and Oxygen Delivery Neonatal Resuscitation



General Care: Agitated Patient Restraint/Excited Delirium

Key Points/Considerations
• Patient must NOT be transported in a face-down position
• If agitated patient goes into cardiac arrest, consider possibility of acidosis, and
administer Sodium Bicarbonate as part of initial resuscitation
• Verbal de-escalation of situation should be attempted prior to chemical restraint
• A team approach should be attempted at all times for the safety of the patient and
the providers
• If the patient is in police custody and/or has handcuffs on, a police officer should
accompany the patient in the ambulance to the hospital
• EMS personnel may only apply “soft restraints” such as towels, cravats or
commercially available soft medical restraints
• All uses of this protocol must have review by the Regional QI Coordinator and the
Agency Medical Director

General Care: Pain Management

Pain Management Key Points/Considerations
• Contraindications to standing order pain management: altered mental status,
hypoventilation, pregnancy, MAP <65 or SBP < 100
• ONE pain medication may be given under standing orders. For additional dosing,
or switching to another agent, you must consult a physician.
• Nitrous Oxide is not a required formulary item
• Contraindications to nitrous oxide include: suspected bowel obstruction,
pneumothorax, pregnancy, hypoxia or the inability to self-administer
• Ketamine is not required formulary item and may not be administered without
a direct physician order
• Lower dosing should be used patients less than 50 kg or the elderly
• Fentanyl should be considered if there is allergy to morphine, undifferentiated
abdominal pain or potential hemodynamic instability
• Morphine should be considered if there is an isolated extremity injury or a longacting
medication would be more efficacious for the patient
• Opioids and Benzodiazepines may not be used together without consultation
with a physician

General: Procedural Sedation

Procedural Sedation Key Points/Considerations
• This protocol may only be used for intubation upon physician order
• One medication may be given under standing orders. For additional dosing, or
switching to another agent, you must consult a physician.
• Not for disentanglement or management of suspected fractures without physician
• Ketamine is not required formulary item and may not be administered without
a direct physician order
• Opioids and Benzodiazepines may not be used together without consultation
with a physician

Medical: Allergic Reaction and Anaphylaxis

Key Points/Considerations
• NO IV Epinephrine without online medical control!
• If an EMT has administered an EpiPen, or the patient utilized their own epinephrine
autoinjector, consult physician prior to allowing a patient to RMA

Medical: Diabetic Emergencies

Key Points/Considerations
• If the patient wishes to refuse transportation to a hospital and you have
administered any medications including oral glucose you should contact a Physician
prior to completing the RMA and leaving the patient
• If the patient’s blood glucose level is below 60 mg/dl and the patient is able to self
administer and swallow on command, administer oral glucose or equivalent rather
than establishing vascular access, if possible
• If patient regains normal responsiveness prior to infusion of the complete dose,
please stop infusion and record amount infused
• Diabetics may exhibit signs of hypoglycemia with a blood sugar between 60-80
mg/dl. If suspected, titrate dextrose 5 gm (D10 50 ml) for treatment and diagnosis

Medical: Seizure

Key Points/Considerations
• Protect the patient and EMS crew from injury during the seizure
• Standing orders are for tonic/clonic seizures (grand mal seizures) only
• Refer to the Eclampsia protocol if patient is pregnant

Medical: Shock/Hypoperfusion

Key Points/Considerations
• Hypoperfusion is defined as MAP < 65 or SBP < 100, with decreased level of
• Vitals should be monitored frequently during transport to avoid unnecessary
prehospital overhydration
• Consider potential causes of hypoperfusion: anaphylaxis, toxic ingestions, cardiac
rhythm disturbances, myocardial infarction, sepsis, ectopic pregnancy, ruptured
abdominal aortic aneurysm, or others

Medical: Suspected Sepsis

Key Points/Considerations
• Focus on rapid identification, IV hydration, and early notification of concern for
potential sepsis patient to destination facility
• Concern for any new or worsening infection: Including reported fever, shaking
chills, sweatiness, new cough, difficulty or less than usual urination, unexplained or
new altered mental status, flush skin, pallor, new rash or mottling
• Vitals should be monitored frequently during transport to avoid unnecessary
prehospital overhydration


OB/Gyn: Eclampsia

Key Points/Considerations
• Pre-eclampsia is defined as BP > 140/90 in a pregnant patient or one who has recently
given birth, with severe headache, confusion and/or hyper-reflexia
• Eclampsia is the above with seizure activity
• If the patient has a known seizure history, refer to “Seizure Protocol”

OB/Gyn: Pre-term Labor (24 – 37 weeks)

Key Points/Considerations
• Transport to the closest appropriate hospital if delivery is imminent or occurs on scene
• Notify destination hospital ASAP
• If patient unwilling to go to closest appropriate hospital, consult physician for assistance in
determining appropriate destination

OB/Gyn: Childbirth

Key Points
• Determine the estimated date of expected birth, the number of previous pregnancies and
number of live births
• Determine if the amniotic sac (bag of waters) has broken, if there is vaginal bleeding or
mucous discharge, or the urge to bear down
• Determine the duration and frequency of uterine contractions
• Examine the patient for crowning
o If delivery is not imminent, transport as soon as possible
o If delivery is imminent, prepare for an on-scene delivery
• If multiple births are anticipated but the subsequent births do not occur within 10 minutes
of the previous delivery, transport immediately
• After delivery of the placenta massage the lower abdomen
• Take the placenta and any other tissue to the hospital for inspection
• Do not await the delivery of the placenta for transport
• If uterine inversion occurs (uterus turns inside out after delivery and extends through the
cervix), treat for shock and transport immediately. Cover the exposed uterus with
moistened towels

Neonatal Resuscitation

Key Points/Considerations
• Begin transport to the closest appropriate hospital as soon as possible

General Practice: Airway Management and Oxygen Delivery
  • Key Points
    • Providers may only perform endotracheal intubation if they have end-tidal waveform
    • Only paramedics may intubate pediatric patients
    • Medication facilitated intubation is to be performed only by paramedics who have received
    specific training and are approved by the agency medical director, within agencies that
    have been approved by the Medical Advisory Committee
    • Only Aeromedical agencies may perform pediatric medication facilitated intubation on
    standing orders
    • Tidal Volume settings for portable automated transport ventilators: 5 – 7 ml/kg
    • Always have a BVM available when using a portable automated transport ventilator (ATV)
    • Intubation may be attempted on a patient a maximum of 2 times by one AEMT and one
    more time by a second AEMT. If unsuccessful utilize an alternative rescue airway device
    or ventilate with BVM
    • A cervical collar should be placed on all intubated patients to assist maintaining secure
    placement of the airway device
    • Approved list of alternative rescue airway device is available through each Regional
    Program Agency
    • Regionally approved BLS agencies may be enrolled in a BLS CPAP program when
    • Relative contraindications for use of alternative rescue airway device:
    o Patients with esophageal disease, pharyngeal hemorrhage, tracheostomy or laryngectomy
    o Patients who have ingested a caustic substance
    o Patients with known obstruction of larynx and/or trachea
General Practice: Medication and Medical Control

Key Points/Considerations – Medications
• Medications not listed in the formulary may not be carried without clearance from the
Regional Medical Advisory Committee
• Local variations in medications, concentration and volume may exist because of restocking
• Alternative concentrations and volumes of medications must be approved by the MAC,
through the Regional Medical Director, prior to use
• In cases of medication shortages, please see approved substitutions or appropriate emergent
• Medications must be kept locked in a secure environment when not being used
• Medications should be protected from extremes of temperature at all times
• If you have administered any medications and the patient wishes to RMA you must contact
a Physician prior to completing the RMA
• A controlled administration set or pump must be used for all drip medications
• Controlled Substances carried must be in accordance with the Agency’s NYS Approved
Controlled Substance Plan
• Medications are only to be carried in NYS-DOH Approved Vehicles and cannot be carried
in a private/personally owned vehicle at any time
Key Points/Considerations – Medical Consultation
• For the protection of the patient, the provider, and the Medical Control Physician,
communication over recorded lines is suggested
Key Points/Considerations – Communications Failure
• If unable to contact a Medical Control Physician, initiate all Standing Orders, and then
continue care of the patient as medically appropriate
o Describe the situation that prevented you from contacting Medical Control on the PCR
o You must notify your ALS coordinator and the Regional QI Coordinator as soon as
possible after the call
o All cases of Communications Failure that cause a provider to perform
interventions below their stop lines must be reviewed by the Agency Medical
Director and reported to the Regional Medical Advisory Committee
Key Points/Considerations – Medical Consultation
• Optimal Medical Consultation will be from a regionally credentialed Medical Control
• Medical consultation may be obtained from the ED physician who will be receiving the
patient from the EMS crew, but only if a credentialed physician is not available
• Advanced providers may only obtain Medical Consultation from physicians
• Orders may be relayed from a Medical Control Physician by RNs, NPs or PAs if absolutely

General Practice: Vascular Access

Key Points
• Intraosseous infusion may only be used in cases of critical patients where IO access may be
• If IO access is started in a conscious patient, the IO should be flushed with Lidocaine (2%)
40 mg (2 mL) for adults, or 1 mg/kg for pediatric patients
• IV sites include peripheral veins, including upper and lower extremities (below the knees)
the external jugular veins in adults and the scalp in infants
• Pediatric vascular access should only be obtained if there is a critical intervention to
perform, such as a fluid bolus in a decompensated shock patient or glucose administration
in a hypoglycemic diabetic
• There are no “prophylactic” IV lines placed in children
• For pediatric vascular access 100 ml NS for all patients under 50 kg
• If vascular access is attempted by a provider and is unsuccessful, an equal or higher level
of provider must accompany the patient to the hospital or a Medical Control Physician
must be consulted.
• The number of vascular access attempts, the provider making the attempt, the site of the
attempt, the catheter size, the solution, the infusion rate (KVO, 250 mL/hr, open) and total
fluid infused should be noted on the PCR
• Good clinical judgment will dictate the maximum number of vascular access attempts

General Practice: Vascular Devices, Pre-Existing

Key Points
• EXTREMIS includes, but is not limited to: Cardiac arrest, respiratory arrest, status
epilepticus, decompensated shock and life threatening arrhythmias
• Pre-existing vascular devices include Central Venous Catheters (CVC), Peripherally
Inserted Central Catheters (PICC) and Renal Dialysis Lines
• Implanted ports and fistulas are not considered pre-existing vascular devices and cannot be
accessed by the pre-hospital provider
• Percutaneous catheters below the nipple are not for vascular access and should not be used
• Once the device is accessed, continuous flow of Normal Saline must be maintained