New Hampshire EMS Quick Reference Guide for Hospital Staff Provided by: NH Department of Safety Div. of Fire Standards and Training & EMS NH EMS for Children Program at Dartmouth Copies of this guide, with or without modification, can only be made with the expressed consent of the NH EMSC Program and NH Division of Fire Standards and Training and EMS. 2011 EMT-Basic (EMT) Medications Assists with self-administration of patient’s medications: ■ Diazepam rectal gel ■ Epinephrine by auto-injector ♦ Albuterol metered dose inhalers ■ Nitroglycerin-oral May administer: ■ Activated Charcoal - oral ♦ Aspirin - oral ■ Nerve antidote kits ( Mark 1, Atropine, Pralidoximine, or Duodote) ■ Glucose - oral ■Adult and child ♦Adult only Skills Airway Procedures Immobilization ■ Pulse oximetry ■ Advanced spinal assessment ■ Cervical and spinal ■ Bag valve mask ventilation immobilization ■ Nasopharyngeal airway ■ Stabilize and immobilize fractures ■ Oropharyngeal airway Other Skills ♠ Supraglottic airway ■ Vital signs ■ Oral suctioning ■ Emergency childbirth ■ Oxygen administration via nasal cannula and mask ■ Stroke scale assessment ■ Tracheostomy ventilation ■ Body temperature and maintenance assessment Vascular Access ■ Vagal nerve stimulator activation ■ Blood glucose analysis ■ Wound management / Cardiac Management burn care ■ CPR ■ Automatic External Defibrillator ( AED) ■ Application of 3- or 4-Lead ECG ■ Application of 12-Lead ECG ■Adult and child Adult cardiac arrest only ♠ EMT BASIC EMT-Intermediate (Advanced) Medications Can provide all Medication Administration medications that an Routes: EMT–Basic can provide ♦ Inhalation plus: ♦ Intramuscular ♦ Epinephrine ● Intraosseous needle ♦ Glucagon ♦ Intravenous ■ Hydrocortisone (Solu-Cortef) ▲ Intravenous pump ♦ Hydroxocobalamin (Cyanokit) ♦ Intranasal ♦ Ipratropium bromide (Atrovent) ♦ Subcutaneous ♦ Naloxone (Narcan) ■ Sublingual ♦ Nitroglycerin (Tridil, Nitrobid, Nnitrostat) ♦ Nitrous oxide premixed with oxygen (Nitronox) ♦ Crystalloid infusion ■Adult and child ♦Adult only ■ Dextrose ●Adult cardiac arrest and shock only ▲During interfacility adult transfers only Skills Can provide all skills that Cardiac Management an EMT-Basic can provide ♦ Manual defibrillation plus: ♦ Interpretation of 3- or 4-lead ECG (V-Fib/V-Tach, Asystole, PEA) Airway Procedures ■ Capnography ♦ CPAP ● Laryngeal mask airway ♦ Nebulizer Treatment Vascular Access ♦ Blood draw ● Commercial intraosseous needle ♦ Peripheral venous access - extremities ■Adult and child ♦Adult only Adult cardiac and shock only ● EMT-I (ADVANCED) (ADVANCED) EMT-I Paramedic Medications Can provide all medications ♦ Haloperidol (Haldol) ♦ Prochlorperazine that an EMT–Basic and EMT–I ♦ Heparin (Compazine) (Advanced) can provide plus: ■ Ibuprofen (Motrin) ■ Proparacaine (Alcaine) ∇ Rocuronium (Zemuron) ■ Acetaminophen (Tylenol) ♦ Ketorolac (Toradol) ■ Sodium bicarbonate ■ Adenosine (Adenocard) ■ Levalbuterol (Xopenex) ∇ ■ Amiodarone (Cordarone) ■ Lidocaine Succinylcholine (Anectine) ■ Atropine ■ Lorazepam (Ativan) ■ Tetracaine ♦ Bumetanide (Bumex) ■ Magnesium sulfate ♦ Vasopressin ∇ ■ Calcium Chloride ♦ Methylprednisolone Vecuronium (Norcuron) (Solumedrol) ■ Diazepam (Valium) ♦ Verapamil (Calan) ♦ Metoclopramide (Reglan) ♦ Diltiazem (Cardizem, Medication ♦ Metoprolol (Lopressor) Administration Routes: Dilacor, Tiazac) ■ Diphenhydramine (Benadryl) ■ Midazolam (Versed) ■ Endotracheal ♦ Dolasetron (Anzemet) ■ Morphine ■ Intraosseous ■ Dopamine ■ Norepinephrine (Levophed) ■ Intravenous pump ∇ Etomidate (Amidate) ■ Ondansetron (Zofran) ■ Rectal ■ Fentanyl (Sublimaze) ♦ Oxytocin (Pitocin) ■ Transdermal ♦ Phenylephrine ■ Flumazenil (Romazicon) (Neo-Synephrine) ■Adult and child ♦ Furosemide (Lasix) ■ Pralidoxime (2-Pam, ♦Adult only ∇Additional training required; ■ Granisetron (Kytril) Protopam Chloride) Skill may vary by EMS agency Skills Can provide all skills that an Vascular Access EMT-Basic and EMT-I ♥ Central line access (Advanced) can provide plus: ■ Peripheral venous access - external jugular Airway Procedures ■ Intraosseous ■ Capnography ■ Umbilical vein ■ Foreign body removal in obstructed airway ■ Blood draw ■ Endotracheal intubation and Cardiac Management Suctioning ■ Interpretation of 12-lead ECG ■ Nasotracheal intubation ■ Interpretation of 3- or 4-lead ECG ■ Nasogastric tube ■ Synchronized cardioversion ■ Tracheal tube replacement through stomas ■ Transcutaneous pacing ♦ Resuscitation ventilator operation Other Skills ■ Needle decompression ■ Eye irrigation ■ Laryngeal mask airway ■ Immunization ■ Supraglottic airway ■ Restraint – pharmacological ■ Nebulizer Treatment ■Adult and child ♦Adult only ∇ ∇Additional training required; Rapid sequence intubation Skill may vary by EMS agency ♥Emergent care only PARAMEDIC PARAMEDIC Paramedic: Inter-facility Transfers Paramedic for Inter-facility Transfers (PIFT) Paramedic for Critical Care Transport (CCT) PIFT Paramedics and CCT Paramedics have skills and may provide medications over and above all other levels of providers, particularly during inter-facility transport of critically injured and ill persons. Any medication or blood product ordered and NOTE: A neonatal or pediatric patient may require expertise and initiated in a health care facility or home health care setting equipment provided by a dedicated may be continued during transport staffed by a PIFT or CCT pediatric transport service. Paramedic. Advanced skills of PIFT Paramedics and CCT Paramedics are listed in Transfer Patient Acuity Levels and Minimum Staffing Requirements. All paramedics staffing the transfer of a critically ill patient must be credentialed at a minimum of PIFT level. A small number of patients will have a level of acuity and/or complexity requiring the higher CCT level. If a credentialed CCT Crew is not available, it is acceptable to supplement the PIFT crew with hospital staff qualified to provide the level of care required by the patient. These include critical care or emergency registered nurse, physician assistant, nurse practitioner, physician, or a CCT Paramedic. Two advanced care providers must be in the patient compartment during transport. Transfer Patient Acuity Levels and Minimum Staffing Requirements Stable patient with virtually NO risk of ■ Medical monitoring, procedures, and medication administration consistent with skill set, approved deterioration medications, protocols, and licensure 1 EMT-Basic and 1 First Responder (driver) ■ Advanced airway management ■ No IV infusions ■ Chest tube Oxygen for stable patient permitted ■ ■ Infusion of previously initiated blood products ■ Previously inserted Foley catheter, suprapubic tube, Maintenance of previously initiated medications feeding tube (NG, PEG, J-tube not connected to ■ infusion or suction) ■ Epidural catheter if secured, capped and labeled ■ Saline lock permitted Stable patient with LOW risk of UNSTABLE patient or stable with HIGH risk deterioration of deterioration 1 EMT-Intermediate and 1 First Responder (driver) CCT Crew or 1 PIFT Paramedic, 1 advanced care provider (hospital-based) and 1 EMT (driver) ■ IV crystalloids ■ Multiple vasoactive medication drips ■ No ongoing meds administered or anticipated ■ Uncorrected shock ■ PCA pump ■ Invasive monitoring ■ IV pump for non-pharmacological agents ■ Balloon pump ■ Established feeding tube ■ Transvenous pacing Stable patient with MEDIUM risk of ■ Intubated/ventilated patients with advanced or complex vent settings (such as pressure support deterioration PEEP >10, etc.)♦ 1 PIFT Paramedic and 1 EMT (driver) ■ Procedures consistent with provider licensure, scope ■ Transcutaneous pacing of practice, and training ■ Stable patient on ventilator discharged to long term care facility ■ Intubated/ventilated patient with non-complex settings (i.e. no pressure support, PEEP ≤10)* ♦Non CCT Crews MUST ALSO have respiratory care practitioner in patient compartment. This is in addition to PIFT *MUST have a second provider in the patient compartment Paramedic and hospital-based advanced health care provider. INTER-FACILITY TRANSFERS INTER-FACILITY Is PaƟent Unstable or Transfer Staffing Stable With High Risk For DeteroraƟon? Requirements YES NO Is PaƟent Stable CCT with Medium Risk CREW For DeterioraƟon ? YES NO Is PaƟent Stable PIFT with Low Risk PARAMEDIC For DeterioraƟon ? YES NO EMT-INTERMEDIATE Is PaƟent Stable With or Virtually No Risk PARAMEDIC For DeterioraƟon ? YES EMT-BASIC With gratitude, we acknowledge the Utah Department of Health and EMSC program for creating the original concept and for granting permission to New Hampshire to modify Utah’s Quick Reference Guide. This publication was made possible though a grant from the EMS Program, US Department of Health and Human Services, Health Resources and Services Administration, Maternal and Health Bureau. (Project no. H33MC06727 ) .