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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 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 • Can not direct you to do something out of your scope of practice. • Examples: • Medication Assisted Intubation • Propofol for non-PIFT paramedics
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
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 up from Notes AVPU gone. Use GCS instead NEW
New New
Removed ipratropium Removed methylprednisolone
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.
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
Culled to generic names New Racemic & L-epi are biologically equal.
Intermediates & Glucagon • after completion of a NH Bureau of EMS approved training module
Dose change Previous edition 20 ml/kg & only one fluid bolus
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.
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
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.
Note: Valium is IV only Higher dosages
Same changes as Adult Increased maximum dose
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.
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.
Added underlying causes Atropine moved up before pacing Pressors moved up
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.
“…consider transport to facility capable of inducing therapeutic hypothermia.”
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.