Additional Directives Flashcards
(36 cards)
What is ondansetron?
- aka Zofran
- 5-HT3 receptor antagonist (blocks action of serotonin which is a natural substance that may cause nausea/vomiting)
- commonly used in cancer pt receiving chemo, radiation therapy, surgery (post-op) & palliative pt at home
What is apomorphine and why is apomorphine use a contraindication for ondansetron?
What it is: dopamine agonist which stimulates D2 receptors in the part of the brain that affects locomotor control (so commonly used to tx parkinson’s)
Concomitant use of apomorphine & ondansetron can cause profound hypotension & LOC therefore contraindicated
What is dimenhydrinate?
What mechanism of action does this drug have, and what situations would dimenhydrinate work well/not well in?
- aka Gravol
- only functions on certain causes of nausea
- works via H1-antagonism of vestibular center, which reduces input to the vomiting center of the brain (so it is minimally effective when cause of nausea is gastric irritation)
- Works well for vertigo-induced nausea
True or False. Not all nausea requires treatment.
True. Sometimes nausea may be a protective mechanism (such as in toxic ingestion) so you want the body to be nauseous/vomit
Nausea/Vomiting Medical Directive
Indications, Conditions
Indications: Nausea OR vomiting
Conditions:
* Ondansetron: weight ≥25 kg, unaltered LOA (bc may cause further drowsiness)
* Dimenhydrinate: Age <65y.o. (bc may cause ++drowsiness and delirium in elderly population); weight ≥25 kg, unaltered LOA
Nausea/Vomiting Medical Directive
Contraindications
Ondansetron:
* Allergy to ondansetron
* Prolonged QT syndrome (known to pt)
* Apomorphine use
Dimenhydrinate:
* allergy or sensitivity to dimenhydrinate or other antihistamines
* OD on antihistamines or anticholinergics or TCAs (can exacerbate OD states; has anticholinergic and Na+ channel blocking effects
* Co-administration of diphenhydramine
Why is prolonged QT syndrome a contraindication for ondansetron?
May cause additional QT prolongation (>440ms or 0.44sec for men; >460ms for women) because it blocks K+ channels
This increases risk of R-on-T & torsades with QT interval >500ms
Nausea/Vomiting Medical Directive
Treatment & Clinical Considerations
Treatment: Consider ondansetron; Consider dimenhydrinate (seen screenshot)
Clinical Considerations:
1) IV admin of dimenhydrinate for PCP AIV only.
2) Prior to IV administration, dilute dimenhydrinate [50mg/ml] 1:9 with NS or d5W. If administered IM do not dilute.
3) If a patient has received Ondansetron and has no relief of their nausea & vomiting sx after 30 min, dimenhydrinate may be conisdered.
What situations would have preferred uses for ondansetron over dimenhydrinate?
- cause from drug interactions (chemo, alcohol, cannabis, illicit drugs)
- head trauma (less risk of ICP)
- if taking benadryl, anticholinergics, & TCAs
- elderly patients
What situations would dimenhydrinate administration be preferred over ondansetron?
- motion sickness/vertigo
- upset stomach due to food ingestion
- avoid with head injuries (potential to cause increased ICP)
- hyperemesis for preggo patient
- best for people on SSRIs
What is serotonin syndrome?
- Pts who may be on multiple, high doses or have sensitivities to SSRIs or SNRIs may be at higher risk of serotonin syndrome when given ondansetron
S/S:
* nervousness
* NVD
* dilated puils and tremors
* agitation, restlessnes
* muscle twitching, seizures, abnormal side-to-side eye movements
* confusion, disorientation, delirium
* tachycardiac, HTN, high temp, LOS
According to the BLS PCS, what extenuating circumstances would prevent you from complying with the standards? (7)
- Scene conditions
- overwhelmed resources
- equipment failure
- safety concerns
- patient location
- distance from receiving facility
- others not specified (eg. language barrier)
As per Patient Assessment Standard in BLS PCS, what types of calls warrant cardiac monitor?
- All VSA (except those meeting obvi death criteria)
- Unconscious or altered LOC
- collapse/syncope
- OD
- Major or Multi-system trauma
- Moderate to severe SOB
- Suspected cardiac ischemia
- CVA
- Hypothermia, heat exhaustion or heat illness
- Submersion injury
- Electrocution
- Abnormal vital signs as per ALS PCS
- If requested by sending facility staff (for inter-facility transfers)
As per Patient Transport Standard in BLS PCS, what information (if available) would you need when completing inter-facility transfers?
- Name of sending physician
- Name of receiving facility and receiving physician
- Verbal and/or written tx orders from sending physician
- Transfer papers/ personal effects, etc.
- Name(s) of facility staff and list of equipment that is accompanying the pt
As per Patient Refusal/Emergency Treatment Standard, when can you provide emergency tx/transport of an incapable person without consent?
- If Pt does not have capacity
- If Pt is _experiencing severe sufferin_g or at risk of sustaining serious bodily harm if tx is not provided promptly
- If delay in obtaining consent/refusal on pt’s behalf will prolong suffering or put them at risk of sustaining serious bodily harm
and then just document your decision
As per Patient Refusal/Emergency Transport Standard in BLS PCS, when is a paramedic able to initiate emergency tx/transport of a capable person without consent?
- If Pt is _experiencing severe sufferin_g or at risk of sustaining serious bodily harm if tx is not provided promptly
- Communication to get consent/refusal can’t happen (i.e. due to language barrier, disability preventing communication)
- reasonably steps (within the circumstances) have been taken to allow communication to take place but none have been found
- If Pt is _experiencing severe sufferin_g or at risk of sustaining serious bodily harm if tx is not provided promptly
- If there is no reason to believe the pt doesn’t want tx
and document!
Endotracheal and Tracheostomy Suctioning & Reinsertion Medical Directive
Indications
Conditions
Contraindications
Indications: Pt with endotracheal or tracheostomy tube AND airway obstruction or increased secretions
Conditions:
- Suctioning: none
-
Emergency tracheostomy reinsertion: Other
- Patient with an existing tracheostomy where the inner and/or outer cannula(s) have been removed from the airway AND
- Respiratory distress AND
- Inability to adequately ventilate AND
- Paramedics are presented with a tracheostomy cannula for the identified patient
Contraindications:
- Suctioning: none
- Emergency tracheostomy reinsertion: Inability to landmark or visualize
Endotracheal and Tracheostomy Suctioning & Reinsertion Medical Directive
Treatment
Clinical Considerations
Treatment: 1) CONSIDER SUCTIONING
< 1 yr:
- Dose: suction at 60-100mmHg
- Max single dose: 10 seconds
- Dosing interval: 1 min
- Max # of doses: N/A
≥ 1 yr to < 12 yrs:
- Dose: suction at 100-120mmHg
- Max single dose: 10 seconds
- Dosing interval: 1 min
- Max # of doses: N/A
≥ 12 yrs:
- Dose: suction at 100-150mmHg
- Max single dose: 10 seconds
- Dosing interval: 1 min
- Max # of doses: N/A
2) CONSIDER EMERGENCY TRACHEOSTOMY REINSERTION: Max number of attempts is 2
Clinical Considerations:
-
Suctioning:
- Pre-oxygenate with 100% oxygen (to avoid hypoxia)
- In an alert patient, whenever possible, have pt cough to clear airway prior to suctioning (to help loosen mucus)
-
Emergency tracheostomy reinsertion:
- A resinsertion attempt is defined as the insertion of the cannula into the tracheostomy.
- A new replacement inner or outer cannula is preferred over cleaning and reusing an existing one.
- Utilize a family member or caregiver who is available and knowledgeable to replace the tracheostomy cannula
As per companion document, what are advantages and disadvantages of ETT & tracheostomy suctioning?
Advantages: allows suction beyond oropharynx
Disadvantages:
* can cause trauma to surrounding mucosa leading to swelling/obstruction
* aggressive suctioning may also increase likelihood of arrhythmia (start at lower end of pressure suctioning range)
If all attempts to suction/clear the tracheostomy have failed and PCP is unable to oxygenate/ventilate with PPV, what should a PCP’s next steps be?
tracheostomy is now considered FBAO. Remove tracheostomy to gain access to stoma for oxygenation/PPV
If completing tracheostomy/cannula reinsertion, what are a PCPs best practices to follow (i.e. who should be considered to assist and should you use old or new materials)?
1) Utilize family/caregiver first who may be most knowledgeable
2) Use new tracheostomy tube/inner cannula
3) If no new, remove current inner cannula, deflate cuff (if present) and rinse with saline or water rinse for re-use
IV Line Maintenance Standard
What patients with an IV line in can be monitored by paramedics?
- an IV line TKVO
- <12 y.o. - flow rate of 15ml/hr of any isotonic crystalloid soln to maintain IV patency
- ≥12 y.o. - flow rate of 30-60ml/hr of “ ”
- IV line for fluid replacement with:
- max flow rate infused up to 2mL/kg/hr to max of 200ml/hr
- thiamine (vit B1), multivitamin preparations
- drugs within his/her level of certification
- KCl for ≥18 y.o. to max of 10mEq in a 250ml bag
IV Line Maintenance Standard
Which patients require a medically responsible escort when there is a need for IV?
When pt requires an IV:
- for blood (or blood product) administration
- for KCl administration for pt <18 y.o.
- for use of med administration (including pre-packaged medications, except those mentioned earlier) - see prev flashcard
- requires electronic monitoring or uses pressurized IV fluid infuser, pump or central venous line
- neonate or ped pt <2 y.o.
IV Line Maintenance Standard
Prior to transport, what steps shall the paramedic take when monitoring a patient with IV?
- confirm MD’s written IV orders to sending facility staff
- determine:
- IV solution
- IV flow rate
- catheter gauge
- catheter length
- cannulation site
- IV site condition prior to transport
- amount of fluid left in bag
- amount of fluid needed to complete transport time and get more if needed
- document all this in ACR
