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

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

4. Routine 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”.

5. NEW PROTOCOL Adrenal Insufficiency

6. Adrenal Insufficiency cont.

7.   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

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

9. New New

10. Removed ipratropium Removed methylprednisolone

11. 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: Fastest = Lateral Thigh 8 +/- 2 minutes Fastest = Lateral Thigh 8 +/- 2 minutes Deltoid = 34 +/- 14 minutes Deltoid = 34 +/- 14 minutes  SQ method removed – IM gets absorbed better.

12. What happened to ipratropium?

13. Anaphylaxis - methylprednisolone

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

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

17. Glucagon New for EMT-I

18. Intermediates & Glucagon  after completion of a NH Bureau of EMS approved training module

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

20. 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.

22. AHA Circulation 2010;122;S909-919

26. Newborn Resuscitation con’t.

27. 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 Adult: 25 – 100 mcg slow IV or 50 – 100 mcg IM, every 5 minutes to a total of 300 mcg

28. New

30. 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.

31. Higher dosages Note: Valium is IV only

32. Same changes as Adult Increased maximum dose

33. NEW PROTOCOL

34. Shock – cont.

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

38. Stroke

39. AHA Circulation 2010;122;S818-828

41. AHA Circulation 2010; Part 10: page S790

43. Acute Coronary Syndrome (adult)  Intermediate Added nitroglycerin 0.4 mg sublingual Added 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 Practice  Providers will need to wait until they have had the additional training before utilization.

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

45. 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. 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. If patient is unresponsive, consider transport to facility capable of inducing therapeutic hypothermia.

46. AHA Circulation 2010; 122:S787-S817

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

48. 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.

50. A section of AHA Tachycardia Algorithm

51. Removed bullet “Consider Air Medical Transport directly to burn center Removed bullet “Consider Air Medical Transport directly to burn center”

52.  Rationale: If airway is involved the provider should go to closest facility or be transported by air (this is included in AMT), otherwise burn care not considered emergent and can await transport by ground.  Risk vs. benefit. Discussed by Dr Sutton at the NH Trauma Conference. Removed the last bullet under B/I, “consider air medical transport directly to burn center.

53. Needle Decompression  *Tension pneumothorax is defined as respiratory distress in association with hypotension, with asymmetric or absent unilateral breath sounds, and with POSSIBLE tracheal deviation above the sternal notch.

54. Moved up from Intermediate

55. Simplified New to be consistent with Adult

56. Airway Management Protocols 5.1 – 5.5  updated with “ongoing monitoring of ventilation status with waveform capnography is required for all patients at the paramedic level.

58. NAME Change & Removed FDA reference Broke out

59.  From Dr. McVicar, Chairman of the Medical Control Board  Copies of this Bulletin available on our website at:http://www.nh.gov/safety/divisions/fstems/ems/documents/bulletin11cricot hyrotomy.pdf Cricothyrotomy Eliminated

61. New Combined 2 bullet items Revised for clarity

62. Revised to reflect changes in the protocol

63. New New

64. Overall, improved the layout for easier reading

65. New

66. SPECIAL RESUSCITATION SITUATIONS & EXCEPTIONS 6.4

67. Re- ordered

68. Interfacility Transfer Protocol 7.0

69. Interfacility Transport 7.0  PIFT stands for paramedic interfacility transport  For the State of New Hampshire, PIFT would refer to a paramedic who belonged to an EMS Unit that had met PIFT prerequisites and had the PIFT training.  PIFT training is that which is above and beyond the standard paramedic DOT curriculum, but not so extensive as that of a critical care paramedic.

70. Interfacility Transfer Protocol 7.0

71. Interfacility Transfers 7.0  And the other change to the high risk patients was that the crew be comprised of a Critical Care Transport crew, which had met the critical care prerequisites and training; or a PIFT Paramedic, Basic, and a (sending) hospital-based, qualified Advanced Health Care Provider.

72. In 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

73. Basics   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

74. Basics  Stroke 2.4 Consider transport to facility specializing in stroke care Consider transport to facility specializing in stroke care Time of onset is critical Time of onset is critical  Newborn Baby Routine suctioning is discouraged Routine suctioning is discouraged  Newborn Resuscitation Initiate assisted ventilations on room air Initiate assisted ventilations on room air  Cardiac Protocols Administer oxygen to keep SpO 2 ≥ 94% Administer oxygen to keep SpO 2 ≥ 94%

75. Basics  Acute Coronary Syndrome Transport suspected STEMI patients to closest facility that performs PCI Transport suspected STEMI patients to closest facility that performs PCI  Cardiac Arrest Great emphasis on chest compressions! Great emphasis on chest compressions!

76. Basics   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

77. Basics   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

78. Basics  Special Resuscitation Situations & Exceptions Reordering of When not to stop Reordering of When not to stop Defined maceration and anencephaly Defined maceration and anencephaly Added the statement: “Prolonging resuscitation efforts beyond 15 minutes without a return of spontaneous circulation is usually futile, unless the cardiac arrest is compounded by hypothermia or cold water submersion” Added the statement: “Prolonging resuscitation efforts beyond 15 minutes without a return of spontaneous circulation is usually futile, unless the cardiac arrest is compounded by hypothermia or cold water submersion”

79. Basics  Advanced Spinal Assessment Added new section to define highly risk or questionable mechanism of injury Added new section to define highly risk or questionable mechanism of injury Change age of reliable patient to 9 years of age Change age of reliable patient to 9 years of age Clarified normal neurological function for the extremities Clarified normal neurological function for the extremities

80. In Summary for Intermediates  Adrenal Insufficiency New Protocol requiring additional training on NHOODLE New Protocol requiring additional training on NHOODLE  Allergic Reaction/Anaphylaxis (adult) Lateral thigh is the preferred location for IM injections of epinephrine Lateral thigh is the preferred location for IM injections of epinephrine  Diabetic (adult) Added glucagon Added glucagon  Acute Coronary Syndrome Added nitroglycerin Added nitroglycerin  Cardiac Arrest No more atropine No more atropine  Pain Added nitronox Added nitronox

81. Summary for Intermediates  Use of glucagon, nitroglycerin, and nitronox only after completion of a NH Bureau of EMS approved training module.  These training modules will not be available until the new National Education Standards have been rolled out the NH State instructors.  It is anticipated that Intermediates will receive this training during their refresher after 2011.

82. Summary for Paramedics  Adrenal Insufficiency New protocol requiring additional training on NHOODLE website New protocol requiring additional training on NHOODLE website  Asthma/RAD/Croup (pedi) Added magnesium sulfate infusion Added magnesium sulfate infusion  Diabetic (pedi) Changed pediatric glucagon doses Changed pediatric glucagon doses  Pain (adult) Increase fentanyl dose Increase fentanyl dose  Seizures (adult) Increase benzo dosages Increase benzo dosages  Seizures (pedi) Increased diazepam dose Increased diazepam dose

83. Summary for Paramedics  Bradycardia Moved atropine to unstable Moved atropine to unstable  Tachycardia No more lidocaine for wide complex No more lidocaine for wide complex  Congestive Heart Failure Furosimide dose changed to range IF fluid overload is present Furosimide dose changed to range IF fluid overload is present No more morphine No more morphine

84. Summary Paramedic  Cardiac Arrest Advanced airways: 1 attempt with ETT then move on to supraglottic. OK to start with supragllotic airway. Advanced airways: 1 attempt with ETT then move on to supraglottic. OK to start with supragllotic airway.  Shock New protocol New protocol  Adrenal Insufficiency New protocol New protocol Requires completion of training module available on NHOODLE Requires completion of training module available on NHOODLE

85. Paramedic  Tension PTX – tracheal deviation may be present.  Traumatic Brain Injury (pedi) Added benzos for sedation Added benzos for sedation  Airway Management Updated that patients with ETT or blind airway have ongoing monitoring of ventilation status with waveform capnography. Updated that patients with ETT or blind airway have ongoing monitoring of ventilation status with waveform capnography.  Interfacility Transfers Medium risk = PIFT level care and prerequisite required Medium risk = PIFT level care and prerequisite required High risk = Critical care level and prerequisite required High risk = Critical care level and prerequisite required

86. Vicki Blanchard vicki.blanchard@dos.nh.gov 603-223-4200