Embed Size (px)
Citation preview
2011 NH Patient Care 2011 NH Patient Care ProtocolsProtocols
Vicki Blanchard, BS, EMT-PVicki Blanchard, BS, EMT-PAdvanced Life Support CoordinatorAdvanced Life Support Coordinator
Tom D’Aprix, MDTom D’Aprix, MDNH State Medical DirectorNH State Medical Director
New Hampshire Department of SafetyNew Hampshire Department of SafetyDivision of Fire Standards and Training and EMSDivision of Fire Standards and Training and EMS
PrefacePreface
Online Medical ControlOnline Medical Control Can not direct you to do something out of Can not direct you to do something out of
your scope of practice.your scope of practice. Examples:Examples:
• Medication Assisted IntubationMedication Assisted Intubation• Propofol for non-PIFT paramedicsPropofol for non-PIFT paramedics
Routine Patient CareRoutine Patient Care
Assessing level on consciousness now uses the Glasgow Coma Scale
Fluid administration to pediatrics: “to maintain central capillary refill, pulse rates
at age specific range per “Pediatric vital sign chart”.
NEW PROTOCOL
Adrenal Insufficiency
Adrenal Insufficiency cont.
Adrenal Insufficiency cont.
Intermediates and paramedic will be required to complete the NH Bureau of EMS Adrenal Insufficiency training module before practicing this protocol.
The training module is available at:www.nhoodle.com
Moved Moved up from up from NotesNotes
AVPU AVPU gone. gone. Use GCS Use GCS insteadinstead
NEWNEW
NewNew
NewNew
Removed ipratropiumRemoved ipratropium
Removed methylprednisoloneRemoved methylprednisolone
Why the Thigh?Why the Thigh? Simons, FER, Gu, X, Simons, KJ. Epinephrine absorption in adults: intramuscular
versus subcutaneous injection. J Allergy Clin Immunol 2001; 108:871.
Peak plasma level varies by site:Peak plasma level varies by site: Fastest = Lateral Thigh 8 +/- 2 minutesFastest = Lateral Thigh 8 +/- 2 minutes
Deltoid = 34 +/- 14 minutesDeltoid = 34 +/- 14 minutes
SQ method removed – IM gets absorbed SQ method removed – IM gets absorbed better.better.
What happened to ipratropium?What happened to ipratropium?
Anaphylaxis - methylprednisoloneAnaphylaxis - methylprednisolone
Change to Change to be be consistent consistent with with pediatricpediatric
Culled to Culled to generic generic namesnames
CPAP moved up CPAP moved up before before methylprednisolonemethylprednisolone
90% - helps 90% - helps reduces the risk of reduces the risk of oxygen narcosisoxygen narcosis
8 puffs total
Culled to Culled to generic namesgeneric names
NewNew
Racemic & Racemic & L-epi are L-epi are biologically biologically equal.equal.
Glucagon Glucagon New for New for EMT-IEMT-I
Intermediates & GlucagonIntermediates & Glucagon
after completion of a NH Bureau of EMS after completion of a NH Bureau of EMS approved training module approved training module
Dose Dose changechange
Previous edition Previous edition
20 ml/kg & only one fluid 20 ml/kg & only one fluid bolusbolus
Diabetic – Pediatric referenceDiabetic – Pediatric reference
References: References: Claudius, Ilene, et. al. Claudius, Ilene, et. al. Emergency Department Emergency Department
Approach to Newborn and Childhood Metabolic Approach to Newborn and Childhood Metabolic Crisis.Crisis. Emergency Medicine Clinics of North Emergency Medicine Clinics of North America. Vol. 23 (2005), pgs.843-883.America. Vol. 23 (2005), pgs.843-883.
Pediatric Advanced Life Support. American Pediatric Advanced Life Support. American Heart Association. 2006.Heart Association. 2006.
The S.T.A.B.L.E. Program: Post-resuscitation / The S.T.A.B.L.E. Program: Post-resuscitation / Pre-transport Stabilization Care of Sick Infants. Pre-transport Stabilization Care of Sick Infants. 5th Edition. 2006.5th Edition. 2006.
AHA Circulation 2010;122;S909-919AHA Circulation 2010;122;S909-919
AHA Circulation 2010;122;S909-919AHA Circulation 2010;122;S909-919
AHA Circulation 2010;122;S909-919AHA Circulation 2010;122;S909-919
Newborn Resuscitation con’t.Newborn Resuscitation con’t.
PainPain
Intermediate (adult) moved nitronox up from Intermediate (adult) moved nitronox up from paramedic (paramedic (after completion of a NH Bureau after completion of a NH Bureau of EMS approved training moduleof EMS approved training module ) )
Nitronox at the Intermediate level is consistent Nitronox at the Intermediate level is consistent with the National Scope of Practicewith the National Scope of Practice
Paramedic (adult) increase fentanyl dose. Paramedic (adult) increase fentanyl dose. Adult: 25 – 100 mcg slow IV or 50 – 100 mcg IM, Adult: 25 – 100 mcg slow IV or 50 – 100 mcg IM,
every 5 minutes to a total of 300 mcgevery 5 minutes to a total of 300 mcg
NewNew
Harrison D, Stevens B, Bueno M, et al. Efficacy of sweet solutions for analgesia in infants between 1 and 12 months of age: a systematic review.
Arch Dis Child. 2010 Jun;95(6):406-13. Epub 2010 May 12.
CONCLUSION: Infants aged 1-12 months administered sucrose or glucose before immunization had moderately reduced incidence and duration of crying. Healthcare professionals should consider using sucrose or glucose before and during immunization.
Higher Higher dosagesdosages
Note: Note: Valium is Valium is
IV onlyIV only
Same Same changes changes as Adultas Adult
Increased Increased maximum maximum
dosedose
NEW PROTOCOLNEW PROTOCOL
Shock – cont.
Smoke InhalationSmoke Inhalation
Changed Cyanide Poisoning to Smoke Changed Cyanide Poisoning to Smoke InhalationInhalation
No more Lily KitNo more Lily Kit Units notified about pending change in 2009Units notified about pending change in 2009 Lily kit is associated with significant toxicity Lily kit is associated with significant toxicity
and is harder to administer than Cyanokit.and is harder to administer than Cyanokit. Downside: Cyanokit is more expensiveDownside: Cyanokit is more expensive Consider getting grant from manufacturer.Consider getting grant from manufacturer.
StrokeStroke
AHA Circulation 2010;122;S818-828AHA Circulation 2010;122;S818-828
AHA Circulation 2010;122;S818-828AHA Circulation 2010;122;S818-828
AHA Circulation 2010; Part 10: page S790AHA Circulation 2010; Part 10: page S790
Acute Coronary Syndrome (adult)Acute Coronary Syndrome (adult)
IntermediateIntermediate Added nitroglycerin 0.4 mg sublingualAdded nitroglycerin 0.4 mg sublingual (Must have IV access prior to admin)(Must have IV access prior to admin)
To be consistent with the National Scope of To be consistent with the National Scope of PracticePractice
Providers will need to wait until they have Providers will need to wait until they have had the additional training before utilization.had the additional training before utilization.
Added Added underlying underlying causescauses
Atropine Atropine moved up moved up before before pacingpacing
Pressors Pressors moved upmoved up
Cardiac ArrestCardiac Arrest New bullet emphasizing chest compressionNew bullet emphasizing chest compression No more atropineNo more atropine Airway changesAirway changes
Placement of an advanced airway during cardiac Placement of an advanced airway during cardiac arrest should not interrupt chest compressions. In this arrest should not interrupt chest compressions. In this setting, supraglotic airways and ETT can be setting, supraglotic airways and ETT can be considered equivalent. ETT placement, if used, considered equivalent. ETT placement, if used, should be limited to 1 attempt of 10 seconds or less. should be limited to 1 attempt of 10 seconds or less.
Transport decision under Post Resuscitation Transport decision under Post Resuscitation Care:Care: If patient is unresponsive, consider transport to facility If patient is unresponsive, consider transport to facility
capable of inducing therapeutic hypothermia.capable of inducing therapeutic hypothermia.
AHA Circulation 2010; 122:S787-S817AHA Circulation 2010; 122:S787-S817
“…“…consider transport to facility capable of consider transport to facility capable of inducing therapeutic hypothermia.”inducing therapeutic hypothermia.”
Congestive Heart FailureCongestive Heart Failure
Change oxygen administration to Change oxygen administration to ≥ 94%≥ 94% Change furosimide to range of 20 – 40 mg Change furosimide to range of 20 – 40 mg
IF previous dx of CHF AND there is IF previous dx of CHF AND there is evidence of fluid overloadevidence of fluid overload
Removed morphineRemoved morphine
Frequently CHF is misdiagnosed in the field and Frequently CHF is misdiagnosed in the field and furosimide is then given inappropriately, hence furosimide is then given inappropriately, hence the reduction in the dose.the reduction in the dose.
A section of AHA Tachycardia AlgorithmA section of AHA Tachycardia Algorithm
Removed bullet “Consider Air Removed bullet “Consider Air Medical Transport directly to Medical Transport directly to burn centerburn center”
Rationale: If airway is involved the Rationale: If airway is involved the provider should go to closest facility or be provider should go to closest facility or be transported by air (this is included in transported by air (this is included in AMT), otherwise burn care not considered AMT), otherwise burn care not considered emergent and can await transport by emergent and can await transport by ground. ground.
Risk vs. benefit. Discussed by Dr Sutton Risk vs. benefit. Discussed by Dr Sutton at the NH Trauma Conference.at the NH Trauma Conference.
Removed the last bullet under B/I, Removed the last bullet under B/I, “consider air medical transport directly “consider air medical transport directly
to burn center.to burn center.
Needle DecompressionNeedle Decompression
*Tension pneumothorax is defined as *Tension pneumothorax is defined as respiratory distress in association with respiratory distress in association with hypotension, with asymmetric or absent hypotension, with asymmetric or absent unilateral breath sounds, and with unilateral breath sounds, and with POSSIBLEPOSSIBLE tracheal deviation above the tracheal deviation above the sternal notch.sternal notch.
Moved up Moved up from from
IntermediateIntermediate
SimplifiedSimplified
New to be New to be consistent consistent with Adultwith Adult
Airway Management Airway Management Protocols 5.1 – 5.5Protocols 5.1 – 5.5
updated with “ongoing monitoring of updated with “ongoing monitoring of ventilation status with ventilation status with waveform waveform capnography is required for all patients at capnography is required for all patients at the paramedic level.the paramedic level.
NAME NAME Change & Change & Removed Removed
FDA FDA referencereference
Broke Broke out out
From Dr. McVicar, Chairman of the Medical Control BoardFrom Dr. McVicar, Chairman of the Medical Control Board
Copies of this Bulletin available on our website Copies of this Bulletin available on our website at:http://www.nh.gov/safety/divisions/fstems/ems/documents/bulletin11cricotat:http://www.nh.gov/safety/divisions/fstems/ems/documents/bulletin11cricothyrotomy.pdfhyrotomy.pdf
Cricothyrotomy EliminatedCricothyrotomy Eliminated
NewNew
Combined 2 bullet Combined 2 bullet itemsitems
Revised for Revised for clarityclarity
Revised to Revised to reflect reflect
changes in changes in the the
protocolprotocol
NewNew
NewNew
Overall, Overall, improved the improved the
layout for layout for easier readingeasier reading
NewNew
SPECIAL RESUSCITATION SPECIAL RESUSCITATION SITUATIONS & EXCEPTIONSSITUATIONS & EXCEPTIONS 6.4 6.4
Re-Re-orderedordered
Interfacility Transfer Protocol 7.0Interfacility Transfer Protocol 7.0
Interfacility Transport 7.0Interfacility Transport 7.0
PIFT stands for paramedic interfacility transportPIFT stands for paramedic interfacility transport For the State of New Hampshire, PIFT would For the State of New Hampshire, PIFT would
refer to a paramedic who belonged to an EMS refer to a paramedic who belonged to an EMS Unit that had met PIFT prerequisites and had the Unit that had met PIFT prerequisites and had the PIFT training.PIFT training.
PIFT training is that which is above and beyond PIFT training is that which is above and beyond the standard paramedic DOT curriculum, but not the standard paramedic DOT curriculum, but not so extensive as that of a critical care paramedic. so extensive as that of a critical care paramedic.
Interfacility Transfer Protocol 7.0Interfacility Transfer Protocol 7.0
Interfacility Transfers 7.0Interfacility Transfers 7.0
And the other change to the high risk And the other change to the high risk patients was that the crew be comprised of patients was that the crew be comprised of a Critical Care Transport crew, which had a Critical Care Transport crew, which had met the critical care prerequisites and met the critical care prerequisites and training; or a PIFT Paramedic, Basic, and training; or a PIFT Paramedic, Basic, and a (sending) hospital-based, qualified a (sending) hospital-based, qualified Advanced Health Care Provider. Advanced Health Care Provider.
In Summary for BasicsIn Summary for Basics
Air Medical Transport 2.1 Updated Physiologic Criteria Added to the Anatomic Criteria:
• Spinal injury with obvious paralysis• Electrocution injuries with loss of consciousness, arrhythmia
or any respiratory abnormality• Multiple long bone fracture
Additional Notes: Added patients with an uncontrolled airway or uncontrollable hemorrhage should be brought to the nearest hospital unless ALS can intercept in a more timely fashion
BasicsBasics Diabetic 2.3 Basic (adult & pedi)
Hyperglycemia: if patient is not vomiting and can maintain their own airway, proved oral hydration with water.
Pain 2.10 Basic (Pedi) Added Sucrose for pediatric use.
Seizure 2. 13 (adult & pedi) Assist with Diastat Suggest family use magnet for patient’s with VNS
Cyanide Protocol changed to Smoke Inhalation Protocol
BasicsBasics Stroke 2.4Stroke 2.4
Consider transport to facility specializing in Consider transport to facility specializing in stroke carestroke care
Time of onset is criticalTime of onset is critical Newborn Baby Newborn Baby
Routine suctioning is discouragedRoutine suctioning is discouraged Newborn ResuscitationNewborn Resuscitation
Initiate assisted ventilations on room airInitiate assisted ventilations on room air Cardiac ProtocolsCardiac Protocols
Administer oxygen to keep SpOAdminister oxygen to keep SpO22≥ 94%≥ 94%
BasicsBasics
Acute Coronary SyndromeAcute Coronary Syndrome Transport suspected STEMI patients to Transport suspected STEMI patients to
closest facility that performs PCIclosest facility that performs PCI Cardiac ArrestCardiac Arrest
Great emphasis on chest compressions!Great emphasis on chest compressions!
BasicsBasics
Burn 4.2 Removed bullet, “Consider Air Medical
Transport directly to burn center” Traumatic Brain Injury 4.3
Move ventilation parameters up from Intermediate
Moved blood glucose check up from Intermediate
Simplified Blood Pressure parameters for pediatrics
BasicsBasics
6.4 DNR/Advanced Directives Grammar improved Clarification of what NOT TO do in actual or
imminent cardiac arrest Clarification of what TO do if the person is not
in cardiac or respiratory arrest
BasicsBasics
Special Resuscitation Situations & Special Resuscitation Situations & ExceptionsExceptions Reordering of When not to stopReordering of When not to stop Defined maceration and anencephalyDefined maceration and anencephaly Added the statement: “Prolonging Added the statement: “Prolonging
resuscitation efforts beyond 15 minutes resuscitation efforts beyond 15 minutes without a return of spontaneous circulation is without a return of spontaneous circulation is usually futile, unless the cardiac arrest is usually futile, unless the cardiac arrest is compounded by hypothermia or cold water compounded by hypothermia or cold water submersion”submersion”
BasicsBasics
Advanced Spinal AssessmentAdvanced Spinal Assessment Added new section to define highly risk or Added new section to define highly risk or
questionable mechanism of injuryquestionable mechanism of injury Change age of reliable patient to 9 years of Change age of reliable patient to 9 years of
ageage Clarified normal neurological function for the Clarified normal neurological function for the
extremitiesextremities
In Summary for IntermediatesIn Summary for Intermediates Adrenal InsufficiencyAdrenal Insufficiency
New Protocol requiring additional training on NHOODLENew Protocol requiring additional training on NHOODLE Allergic Reaction/Anaphylaxis (adult)Allergic Reaction/Anaphylaxis (adult)
Lateral thigh is the preferred location for IM injections of Lateral thigh is the preferred location for IM injections of epinephrineepinephrine
Diabetic (adult)Diabetic (adult) Added glucagonAdded glucagon
Acute Coronary SyndromeAcute Coronary Syndrome Added nitroglycerinAdded nitroglycerin
Cardiac ArrestCardiac Arrest No more atropineNo more atropine
PainPain Added nitronoxAdded nitronox
Summary for IntermediatesSummary for Intermediates
Use of glucagon, nitroglycerin, and nitronox only Use of glucagon, nitroglycerin, and nitronox only after completion of a NH Bureau of EMS after completion of a NH Bureau of EMS approved training module.approved training module.
These training modules will not be available until These training modules will not be available until the new National Education Standards have the new National Education Standards have been rolled out the NH State instructors.been rolled out the NH State instructors.
It is anticipated that Intermediates will receive It is anticipated that Intermediates will receive this training during their refresher after 2011.this training during their refresher after 2011.
Summary for ParamedicsSummary for Paramedics Adrenal InsufficiencyAdrenal Insufficiency
New protocol requiring additional training on NHOODLE websiteNew protocol requiring additional training on NHOODLE website Asthma/RAD/Croup (pedi)Asthma/RAD/Croup (pedi)
Added magnesium sulfate infusionAdded magnesium sulfate infusion Diabetic (pedi)Diabetic (pedi)
Changed pediatric glucagon dosesChanged pediatric glucagon doses Pain (adult)Pain (adult)
Increase fentanyl doseIncrease fentanyl dose Seizures (adult)Seizures (adult)
Increase benzo dosagesIncrease benzo dosages Seizures (pedi)Seizures (pedi)
Increased diazepam doseIncreased diazepam dose
Summary for ParamedicsSummary for Paramedics
BradycardiaBradycardia Moved atropine to unstableMoved atropine to unstable
TachycardiaTachycardia No more lidocaine for wide complex No more lidocaine for wide complex
Congestive Heart FailureCongestive Heart Failure Furosimide dose changed to range Furosimide dose changed to range IF fluid IF fluid
overload is presentoverload is present No more morphineNo more morphine
Summary ParamedicSummary Paramedic
Cardiac ArrestCardiac Arrest Advanced airways: 1 attempt with ETT then Advanced airways: 1 attempt with ETT then
move on to supraglottic. OK to start with move on to supraglottic. OK to start with supragllotic airway.supragllotic airway.
Shock Shock New protocolNew protocol
Adrenal InsufficiencyAdrenal Insufficiency New protocolNew protocol Requires completion of training module Requires completion of training module
available on NHOODLEavailable on NHOODLE
ParamedicParamedic
Tension PTX – tracheal deviation may be present.Tension PTX – tracheal deviation may be present. Traumatic Brain Injury (pedi)Traumatic Brain Injury (pedi)
Added benzos for sedationAdded benzos for sedation Airway ManagementAirway Management
Updated that patients with ETT or blind airway have Updated that patients with ETT or blind airway have ongoing monitoring of ventilation status with waveform ongoing monitoring of ventilation status with waveform capnography.capnography.
Interfacility TransfersInterfacility Transfers Medium risk = PIFT level care and prerequisite requiredMedium risk = PIFT level care and prerequisite required High risk = Critical care level and prerequisite requiredHigh risk = Critical care level and prerequisite required
