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B. Mine-Boss, M.S., Ph.D.
Clinical Director, Texas Tech University Health Sciences Center School of Medicine
Routine, scheduled transport; Patient clearly stable for transport with no requirement for airway management and no device in place that is actively running or requires any maintenance or monitoring. Patient may have a device in place, but device must be locked and clamped, not require any maintenance and not be actively running. Instrumentation or medication running must be consistent with the Interfacility Transfer Guidelines. Patient with an acute problem with high potential to become unstable; Critical care patient with any other instrumentation or medication running that is not included in the Interfacility Transfer Guidelines. Brief history of present illness and any intervention(s) which has occurred to date;. Presence of or need for additional medical personnel; Protocol Continues Massachusetts Department of Public Health Office of Emergency Medical Services Statewide Treatment Protocols version 2018. If the transferring physician is unavailable, or the patient is unstable, the Medical Control Physician may recommend to the transferring facility additional therapies prior to the transfer of the patient in the interest of patient safety and quality care. If the transferring facility cannot provide appropriate medical care or appropriately trained and experienced personnel to accompany the patient, alternative means of transfer, including Critical Care Transport, must be utilized. The use of a local Emergency Ambulance Service is strongly discouraged in such a situation. It is primarily the responsibility of the referring physician and Medical Control Physician to determine the appropriate method of transferring an unstable patient. Such sending facility additional health care professional would be responsible for primary patient care of that patient during transport, and would receive any additional orders from the sending physician, since the care of the patient exceeded what the ambulance and its crew could provide. If the accompanying staff includes a physician from the transferring facility, that physician shall be in charge of patient care. Clear lines of command and responsibility shall be established prior to transport. Paramedics must obtain Medical Control through normal channels, through the Affiliation Agreement for Medical Control of the ambulance service for whom they are working. Appropriate provisions for re-contacting the Medical Control physician en route, if necessary, should be made prior to departure from the transferring facility. Any pathology associated with the potential for imminent upper airway collapse and / or obstruction (including but not limited to airway burns, toxic inhalation, epiglottitis, retropharyngeal abscess, etc. All artificially ventilated patients (and all other patients where it is clinically indicated) will have continuous monitoring of waveform capnography. Medications may also be administered through any central venous catheter Paramedics may administer medication boluses, infusions and fluids through administration sets connected by the sending facility to subcutaneous devices. All monitoring and therapy will be continued until care is transferred to the receiving medical staff. Paramedics may not accept any medications from the sending facility for the purposes of bolus administration during transport. If there is identification of a clinical concern of thoracic or lumbosacral spine injury, the patient should be immobilized with a long board and log roll precautions used at all times. Paramedics must be familiar with the treatments and interventions instituted at sending facility. Any significant patient care related questions or issues prior to transfer or en route. On occasion good medical practice and the needs of patient care may require deviations from these protocols, as no protocol can anticipate every clinical situation. A3 q In high-risk situations, a physician / registered nurse will accompany the patient for transport. Any patient-specific information Any adverse effects of the medication being administered. The seven rights of medication administration should always be considered, even when transporting patients between facilities. Right patient, drug, dose, route, time, outcome, documentation q Paramedics may not accept any medications from the sending facility for the purposes of bolus administration during transport. Deliver all empty transfusion bags and tubing to the receiving facility with the patient.
Theophylline to be used with caution as impaired hepatic oxidation/hydroxylation can increase plasma level of the drug to toxic levels. Prolonged administration of steroids to be avoided as it may result in exacerbation of pre-existing osteoporosis and electrolyte imbalance (hypokalaemia). Diarrhoea Fluid and electrolyte loss should be carefully monitored and their replacement must be meticulous. Hypovolaemia and haemoconcentration can result in stroke, peripheral vascular occlusion and gangrene. Hyperthyroidism/senile tremors Initiate propranolol therapy with caution as its serum level may be increased due to decreased first pass metabolism through the liver. Psychiatric disorders Antipsychotic drugs must be used with caution as they may cause falls and confusional states. Drug therapy in the elderly should be employed only after nonpharmacologic means have been considered and tried. Once pharmacotherapy has been decided upon, the drug should be started with the minimal optimal dose and thereafter the dose may be increased gradually as required. The dosage schedule of the drugs administered should be such that maximal patient compliance is attained as decreased compliance due to memory deficit is common in geriatric patients. It must always be kept in mind, while prescribing drugs to geriatric patients that older people are more likely to have adverse drug reactions due to the following factors: a. Volume of distribution of drug is affected due to decrease in total body water and increase in body fat (water soluble drugs become more concentrated and fat soluble drugs have longer half-lives). Serum albumin levels decline with ageing and so there is decrease in protein binding of some drugs. Antibiotics Chapter 13 Substance Abuse 770 Manual of Practical Medicine Alcohol Alcoholic Equivalents Whisky 30 ml 1 Unit Wine 100 ml 1 Unit Beer 250 ml 1 Unit Safe weekly limits of alcohol For males 21 units/week For females 14 units/week 1 unit = 10 gm Metabolism of Alcohol Alcohol is metabolised by a. Consumption of alcohol results in gain of empty calories (nutritionally valueless). Alcohol is excreted through the lungs and also by body secretions (urine and sweat). Drinking Pattern the average intake of alcohol of male cirrhotics was 160 gm/day/8 years. Sex Women develop higher blood ethanol values following a standard dose intake and it progresses from alcoholic hepatitis to cirrhosis even if they stop drinking. It is because the alcohol dehydrogenase, from the gastric mucosa contributes to alcohol metabolism. Gastric First-pass Metabolism the majority of oral ethanol is rapidly absorbed by passive diffusion from the stomach and the duodenum. Acetaldehyde binds with phospholipids, amino acid residues, and sulphydryl groups and thus becomes reactive and toxic. It affects the plasma membranes by depolymerising proteins and altering surface antigens. Fatty liver: Fatty liver is defined as the presence of more than 5 gm of fat/100 gm of liver tissue. In the more severely affected conditions, fatty change is diffuse (usually fat accumulates in zones 3 and 2). The formation of the nodules is often slow, because of a presumed inhibitory effect of alcohol on hepatic regeneration. Transaminases are increased Hypoalbuminaemia Prothrombin time is prolonged the other features are leukopenia, thrombocytopenia and anaemia. The patients are usually asymptomatic, the diagnosis being made when an enlarged, smooth, firm liver is present. Nausea and vomiting with periumbilical, epigastric or right upper quadrant pain with jaundice are present in severe fatty liver.
Metabolic disorders of the foetus or infant like galactosaemia, galactokinase deficiency iii. If the opacity is large and central in position, there is marked visual impairment. The opacity is sharply demarked and the area of the lens within and around the opacity is clear. There are multiple club-shaped opacities near the periphery of the lens usually hidden by the iris. Anterior capsular cataract It is due to the delayed formation of Coronary cataract the anterior chamber. It may occur following perforation of a corneal ulcer in ophthalmia neonatorum cases. It may project forwards into the anterior chamber like a pyramid (anterior pyramidal cataract). The underlying cortex may become opaque (anterior cortical cataract) occasionally. Posterior capsular cataract It is often due to persistence of posterior part of vascular sheath. Mydriasis with atropine-It is advocated atleast until puberty if the cataract is small, central and the vision is good. Optical iridectomy-It may be done if the opacity is small, central and stationary. Lens aspiration-Aspiration of lens matter can be done as the lens material is soft in children. Lensectomy-In this operation, the lens including anterior and posterior capsule along with anterior vitreous are removed. Lens Aspiration the child should be operated earlier as the fixation reflex develops between 2-4 months of age. Technique Aspiration of lens matter can be done by limbal route, (either single incision or two-port bimanual technique) or corneo scleral tunnel technique. A subconjunctival injection of gentamicin and dexamethasone is given postoperatively. Posterior capsular opacification-This is almost universal if the posterior capsule is retained. The incidence is reduced when posterior capsulorhexis is combined with vitrectomy. Proliferation of lens epithelium is common but may not be visually significant if visual axis is not involved. Lensectomy In this operation, the lens including anterior and posterior capsule along with anterior vitreous are removed with the help of vitreous cutter, infusion and suction device. A well constructed sclera tunnel may not require suturing, but placement of one horizontal suture (with 10-0 nylon) ensures wound stability and reduces postoperative astigmatism. Spectales-They are useful for older children with bilateral aphakia but not for unilateral aphakia. Contact lenses-These are superior optical solution for both bilateral and unilateral aphakia iii.
