EMS Protocol of the Week - Altered Mental Status (Adult and Pediatric)

At some point in the next year or so, the NYC REMAC protocols will introduce a dedicated section for suspected opioid/drug overdoses. For the time being, naloxone administration patterns can be found here, in the prehospital AMS protocol.

Note that instructions for naloxone doses permeate all three levels of training in this protocol – 1-2mg IN at the CFR level, 1-2mg IN at the BLS level, and up to 4mg IV (in 0.5mg increments) at the ALS level, all by Standing Order. Remembering that this new protocol format is meant to be followed from top to bottom, note that a patient with an opioid overdose has the potential to receive a large cumulative dose of naloxone across all three sections – one administration from a CFR unit, one from a BLS unit, and one from an ALS unit. However, as the Key Points/Considerations section highlights, each level of provider is only permitted to administer naloxone per their specific section; this means that if ALS arrives first on scene, they will only give their IV doses, not the IN doses described in the CFR and BLS portions above.

Starting at the BLS level, EMTs will also assess for hypoglycemia as a cause for AMS and manage if able. This means offering some formulation of oral glucose to patient that can tolerate PO. ALS has a larger toolbox, able to provide parenteral solutions in the forms of IV dextrose or IM/IN glucagon. 

Opioid overdose and hypoglycemia are really the only two etiologies addressed in this protocol, with the expectation that if the crew on scene suspects a different etiology, they will refer to the respective protocol for it. That does make this protocol somewhat of a miscellany section, and as the protocols evolve to become more focused, we may very well lose it in favor of separate overdose and hypoglycemia protocols. When that happens, you can bet I’ll be there with an email and a smile!

See you all next week! www.nycremsco.org and the protocol binder til then!

Dave