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2011 NH Patient Care Protocols

2011 NH Patient Care Protocols. Vicki Blanchard, BS, EMT-P Advanced Life Support Coordinator Tom D’Aprix, MD NH State Medical Director New Hampshire Department of Safety Division of Fire Standards and Training and EMS. Preface. Online Medical Control

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2011 NH Patient Care Protocols

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  1. 2011 NH Patient Care Protocols Vicki Blanchard, BS, EMT-P Advanced Life Support Coordinator Tom D’Aprix, MD NH State Medical Director New Hampshire Department of Safety Division of Fire Standards and Training and EMS

  2. Preface • Online Medical Control • Can not direct you to do something out of your scope of practice. • Examples: • Medication Assisted Intubation • Propofol for non-PIFT paramedics

  3. 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”. Routine Patient Care

  4. NEW PROTOCOL Adrenal Insufficiency

  5. Adrenal Insufficiency cont.

  6. 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

  7. Moved up from Notes AVPU gone. Use GCS instead NEW

  8. New New

  9. Removed ipratropium Removed methylprednisolone

  10. Why the Thigh? • Simons, FER, Gu, X, Simons, KJ. Epinephrine absorption in adults: intramuscular versus subcutaneous injection. J Allergy ClinImmunol 2001; 108:871. • Peak plasma level varies by site: • Fastest = Lateral Thigh 8 +/- 2 minutes • Deltoid = 34 +/- 14 minutes • SQ method removed – IM gets absorbed better.

  11. What happened to ipratropium?

  12. Anaphylaxis - methylprednisolone

  13. 90% - helps reduces the risk of oxygen narcosis Change to be consistent with pediatric Culled to generic names CPAP moved up before methylprednisolone 8 puffs total

  14. Culled to generic names New Racemic & L-epi are biologically equal.

  15. Glucagon New for EMT-I

  16. Intermediates & Glucagon • after completion of a NH Bureau of EMS approved training module

  17. Dose change Previous edition 20 ml/kg & only one fluid bolus

  18. Diabetic – Pediatric reference • References: • Claudius, Ilene, et. al. Emergency Department Approach to Newborn and Childhood Metabolic Crisis. Emergency Medicine Clinics of North America. Vol. 23 (2005), pgs.843-883. • Pediatric Advanced Life Support. American Heart Association. 2006. • The S.T.A.B.L.E. Program: Post-resuscitation / Pre-transport Stabilization Care of Sick Infants. 5th Edition. 2006.

  19. AHA Circulation 2010;122;S909-919

  20. AHA Circulation 2010;122;S909-919

  21. AHA Circulation 2010;122;S909-919

  22. Newborn Resuscitation con’t.

  23. Pain • Intermediate (adult) moved nitronox up from paramedic (after completion of a NH Bureau of EMS approved training module) • Nitronox at the Intermediate level is consistent with the National Scope of Practice • Paramedic (adult) increase fentanyl dose. • Adult: 25 – 100 mcg slow IV or 50 – 100 mcg IM, every 5 minutes to a total of 300 mcg

  24. New

  25. 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.

  26. Note: Valium is IV only Higher dosages

  27. Same changes as Adult Increased maximum dose

  28. NEW PROTOCOL

  29. Shock – cont.

  30. Smoke Inhalation • Changed Cyanide Poisoning to Smoke Inhalation • No more Lily Kit • Units notified about pending change in 2009 • Lily kit is associated with significant toxicity and is harder to administer than Cyanokit. • Downside: Cyanokit is more expensive • Consider getting grant from manufacturer.

  31. Stroke

  32. AHA Circulation 2010;122;S818-828

  33. AHA Circulation 2010;122;S818-828

  34. AHA Circulation 2010; Part 10: page S790

  35. Acute Coronary Syndrome (adult) • Intermediate • Added nitroglycerin 0.4 mg sublingual • (Must have IV access prior to admin) To be consistent with the National Scope of Practice • Providers will need to wait until they have had the additional training before utilization.

  36. Added underlying causes Atropine moved up before pacing Pressors moved up

  37. Cardiac Arrest • New bullet emphasizing chest compression • No more atropine • Airway changes • Placement of an advanced airway during cardiac arrest should not interrupt chest compressions. In this setting, supraglotic airways and ETT can be considered equivalent. ETT placement, if used, should be limited to 1 attempt of 10 seconds or less. • Transport decision under Post Resuscitation Care: • If patient is unresponsive, consider transport to facility capable of inducing therapeutic hypothermia.

  38. AHA Circulation 2010; 122:S787-S817

  39. “…consider transport to facility capable of inducing therapeutic hypothermia.”

  40. Congestive Heart Failure • Change oxygen administration to ≥ 94% • Change furosimide to range of 20 – 40 mg IF previous dx of CHF AND there is evidence of fluid overload • Removed morphine • Frequently CHF is misdiagnosed in the field and furosimide is then given inappropriately, hence the reduction in the dose.

  41. A section of AHA Tachycardia Algorithm

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