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From: Timothy Chizmar, MD, FACEP
State EMS Medical Director

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Date: July 8, 2021

RE: Maryland Medical Protocols for Emergency Medical Services – 2021 Clarifications
Please note the following clarifications for the 2021 release of the Maryland Medical Protocols for Emergency Medical Services:

• Pain Management (4.10-A and 4.10-P): The following text was unintentionally
  omitted:
  • Chest pain due to suspected acute coronary syndrome should be managed with nitroglycerin, absent any contraindications. Pain that persists despite nitroglycerin may be treated with opioid analgesia.
  • Opioid analgesia should be used with caution in the management of multiple trauma patients due to the risk of hypotension.
  • Opioid analgesia should be used with caution in patients with altered mental status due to the risk of respiratory depression.
  • Patients who have received a parenteral (IV/IO/IM/IN) dose of opioid, benzodiazepine, or ketamine from a sending facility or ALS clinician must be transported by ALS:
    • If any of the above medications were given within the past 1 hour, or
    • If the patient has an altered mental status without return to their
      baseline after receiving any of the above medications, or
    • If the patient has potential for respiratory compromise (RR<14,
      oxygen saturation less than 94%, clinician judgment after receiving
      any of the above medications.
• Asthma/COPD (6.1-A and 6.1-P): As noted in the medical consultation section, BLS
  clinicians must continue to obtain medical consultation for IM epinephrine for asthma
  patients with known history of cardiac disease.
• Chlorine/Phosgene Exposure (6.2): The BLS treatment section should not reference dexamethasone or CPAP. These are in the ALS scope of practice. Additionally, albuterol is the only approved bronchodilator for BLS.
• Procedures, Medical Devices, and Medications for EMS (9.2): Nebulized route is now a standing order (SO) for EMT, CRT, PM levels.