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Proposed WREMAC Protocol Changes

posted Feb 13, 2015, 7:25 AM by Andrew Steel

To:          All WREMAC hospitals, REMSCO’s, County EMS Coordinators, EMS Agencies & Providers

From:     Brian M. Walters, DO, FACEP, FAAEM

WREMAC Chairman

Date:      February 12, 2015

RE:          Proposed Protocol Changes


At the last WREMAC meeting several proposed protocol changes were approved by the voting membership. In accordance with NYS Bureau of EMS policies, these proposed changes are now posted for comment for 30 days. Any comments on the proposed changes are welcome, but must be received in writing to the WREMAC by 5 pm on Tuesday March 17, 2015. Any comments will be shared and reviewed by the WREMAC the following day, at which time the protocols and any suggested feedback or revisions will be voted on for final approval. 

A summary of the proposed updates is included below. The accompanying “2015 DRAFT WREMAC Protocol Updates” has the proposed revisions highlighted in red for your convenience. This summary and the proposed protocol changes will also be posted on our website. 

1. CPAP Changes - In anticipation of final approval of a statewide BLS CPAP protocol, the WREMAC CPAP protocol and other protocols that include CPAP have been amended to be more consistent with the proposed statewide protocol. Even when these changes are approved by the WREMAC, CPAP will only be approved for use at the BLS level when the Bureau of EMS officially approves and implements these changes, and when an agency is credentialed to do so by their medical director. The following protocols have been revised: Procedure: AIRWAY MANAGEMENT, Procedure: CONTINUOUS POSITIVE AIRWAY PRESSURE, Respiratory: ASTHMA / COPD, Respiratory: ACUTE PULMONARY EDEMA, Procedure: PEDIATRIC AIRWAY MANAGEMENT, Pediatric: ACUTE ASTHMA. 

2. Procedure: AIRWAY MANAGEMENT Protocol - Adds surgical airways for paramedics credentialed by their medical director, this is currently allowed in several protocols across NYS including the Collaborative Protocols. 

3. Medical: ALLERGIC REACTION / ANAPHYLAXIS Protocol - This would allow AEMT’s to administer epinephrine to adult patients by drawing up the medication and administering it IM, rather than just allowing auto-injector use. This skill was moved from the CC to the AEMT level in the proposed changes and is consistent with AEMT protocols currently in use in the Central New York EMS Protocols. 

4. Medical: SEIZURES Protocol - The wording of midazolam dose was reworded to be more consistent with other protocols, however, the dose remains the same. 

5. ADULT PAIN / NAUSEA / SEDATION Protocol - The morphine dose and interval for repeat dosing remains the same, but the maximum dose has been clarified. Fentanyl has been moved to standing order, where it was previously a medical control option. Fentanyl is becoming a more commonly utilized analgesic in EMS throughout the country and in other regions of NYS. With all ALS agencies now being required to carry narcotics, many agencies in the region have been approved to carry fentanyl in their controlled substance plans. The fentanyl dosing was taken from that currently utilized in the Collaborative Protocols. The midazolam dose in this protocol was revised to be consistent with the dose in the Medical: SEIZURES Protocol. Previously the doses were slightly different, and this was thought to be confusing to providers and a potential for medication errors. 

6. Pediatric: DIABETIC EMERGENCIES Protocol - The intranasal route of administration for glucagon was added. Intranasal glucagon was already in the adult protocol, but has been specifically added to the pediatric protocols.

 7. Pediatric: SEIZURES & Pediatric: PAIN / NAUSEA / SEDATION Protocols - Under the current protocols there was no differentiation in midazolam dosing based on route of administration. In certain instances, the IV dose could have exceeded our adult midazolam dose. These discrepancies were clarified to differentiate dosing based on route of administration as well as maximum doses to not exceed current adult protocols. The midazolam doses are also standardized between both pediatric protocols for consistency.

 8. Intranasal Administration - As intranasal atomizers have become a routinely stocked item on many ambulances due to the NYS BLS intranasal naloxone policy, this route of medication administration is a viable option for many agencies. The accompanying protocol revisions now specifically mention the intranasal route for all adult and pediatric protocols that include fentanyl, midazolam, and glucagon. Under the current protocols IN was listed for these medications in some, but not all the protocols. These three medications along with naloxone are the most commonly administered medications given intranasally with good data supporting their absorption, clinical efficacy, and safety. This will specifically allow for more rapid medication administration when an IV is not immediately available.

Andrew Steel,
Feb 13, 2015, 7:25 AM
Andrew Steel,
Feb 13, 2015, 7:25 AM