New Regional EMS Treatment Guidelines

On February 1, 2012, our regional (NorthCentral Connecticut EMS) paramedic treatment guidelines will go into effect. In addition to incorporating many of the latest AHA changes from the 2010 Guidelines, these are some of the highlights of our changes:

Adult Airway Guideline

The Adult Airway Guideline has been revised to emphasize that the airway gold standard is an effectively managed airway, not always an ET tube.  ET, Combi-tube, LMA and King LT are all considered first-line airways. Capnography shall be utilized on all advanced airways (ET, Combi-tube, LMA, King LT).

Acute Coronary Syndromes/Chest Pain

Perform a 12-lead on all possible cardiac patients as soon as possible. If 12-lead shows a STEMI, contact hospital (with medical control) for STEMI alert as soon as possible. Early notification and activation of the cardiac cath lab has been shown to significantly improve patient outcomes.

Paramedics should perform 12-lead prior to administration of NTG. If 12-lead shows inferior STEMI, do not administer NTG prior to performing a right sided ECG. If right side leads reveal possible right ventricular infarct, establish a large bore IV. Giving NTG to patients with right ventricular infarction is contraindicated.

The use of nitrates in patients with hypotension (SBP100 bpm) is also contraindicated. Dropping a patient’s blood pressure may preclude them from receiving proven life-saving drugs in the ED such as beta-blockers and ace inhibitors.

Morphine should be used with caution in patients with unstable angina and NSTEMI.


For unstable atrial fibrillation/aflutter, if patient is on no meds for tachycardia or on Ca+ channel blocker, Diltiazem will be first line. If already on beta blocker then Lopressor will be used.

Lopressor standing order will be 5 mg IV q 5 minutes x 3 doses if needed.

Acute Pulmonary Edema

Lasix/Bumex, Morphine and Nitropaste have been removed. CPAP and NTG SL are now the mainstays of CHF treatment.

Ativan 0.5 mg up to a max of 1 mg may be given on standing order for patient with extreme anxiety if the medic judges that lessening their anxiety will enable them to better tolerate CPAP.

Systolic Blood pressure < 100 mm HG contraindication for CPAP  is removed. Use caution when using CPAP with hypotensive patients.

Pain Management

Standing orders dosing for Fentanyl and Morphine have been increased. Patients may receive up to a total maximum of 3 mcg/kg Fentanyl up to 300 mcg or 0.2 mg/kg Morphine up to a max of 20 mg on standing orders. Maximum single doses are 100 mcg Fentanyl and 10 mg Morphine. Wait ten minutes between full doses. Dosing cycles for patients over 65 should be should be cut in half with the patient receiving a half dose, followed by the second half dose, if necessary five minutes after the first half dose.

Fentanyl maybe given intranasally under the following dosing regime. Administer Fentanyl IN, initial dose 1.5 mcg/kg (100 mcg max single dose), may administer a second dose 1.5mcg/kg (100 mcg max single dose) if needed after 10 minutes, for a total maximum dose of 200 mcg.

**Administer half a single dose in each nare**

Torodol has been removed.

Altered Level of Consciousness

Dextrose can be given in any concentration. D50, D25 or D10. Dextrose should only be given in the amounts necessary to return patient to baseline. Studies have shown a lower concentration and gradual administration may be better for patients than the standard 25 gram D50 IV push.


Phenergan has been removed from protocol. Ondansetron should be used as the front-line anti-emetic agent. Metoclopramide may be preferred in patients that are more calm and relaxed but are allergic to Ondansetron or where gastric emptying is desired.


  • I like the flexibility of the Dextrose policy. I’ve started doing this with good effect. The protocol doesn’t mandate that we give the full dose, but most medics assume it does. I find that giving just enough that the patient becomes alert and oriented works better. Many patients and their families are concerned about the transient hyperglycemia that a full 25Gm dose of D50 cause.

    I’d like to see more medics thinking that way.

  • Bieber says:

    I love your fentanyl dosing! Ours just got reduced from 1 mcg/kg x2 to 50-75 mcg x2… Needless to say, it looks like I’m gonna be giving repeat doses and calling for additional orders a lot more frequently now!

  • jeanine. says:

    @ TOTW- Unless you work in Flagstaff. Never question standing orders, Doctors are always smarter than medics.

  • harrison says:

    Hats off to your progressive medical director

  • @jeanine – Friends of mine in Arizona who are knowledgable about EMS tell me it’s a mess. Statewide protocols without and deviation allowed, even for flight medics. OLD statewide protocols at that.

    My state isn’t perfect, but it’s better than that.

  • SLECK says:

    Florida is bad too unless you are in Miami or the surrounding jurisdictions, its really bad. REALLY bad.

  • Brandon O says:

    You guys were giving field Toradol? How was that working out?

  • medicscribe says:

    Thanks for the comments.

    We could give torodol with on-line medical control. The problem was a few medics were giving it inappropriately without calling for orders and other medics were calling for orders in very appropriate situations — 35 year old healthy patient with history of kidney stones having flank pain, and were being turned down, because some doctors felt giving torodol to anyone prehospitally was not a good idea. There is a huge list of contraindications. Consequantly no one was calling in to use it when they had the opportunity for fear of being turned down. While some of our doctors thought it was still a good drug for us to carry, in the interests of consensus, we got rid of it. And now with out increased standing orders for fentanyl and morphine, it really shouldn’t be an issue.

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