adult protocol Flashcards
(41 cards)
abdominal pain
if pain above umbilicus, 12-lead ekg. IV established. If evidence of dehydration: poor skin turgor, tachycardic, dry mucous membranes. NS bolus of 250 mL and hold at 500 mL if not hypotensive. use zofran for severe nausea and vomiting (4mg). for severe pain use pain protocol.
Airway emergency
assess for respiratory distress (pulse ox 94% or less) with tachypnea, excessive muscle movement, etc.
Look for signs of respiratory failure: Hypoxia - O2 sat less than 90% with no improvement. Increasing C02 with no improvement; altered mental status; Inability to maintain airway…Begin CPAP if signs are severe.
Acute bronchospasm with Asthma or COPD: give duonebulizer with 2.5 mg albuterol and 0.5 mg atrovent (REPEAT TWICE IF NEEDED).
Solumedrol 125 mg IV push if wheezing persists after nebulizer treatment.
MagSulfate 2G in 100 ML 5% dextrose over 10-15 min DO NOT USE if hx of renal failure OR CHF suspected.
If wheezing persists use EPI 1:1000 IM 0.3 mg/mL. CAUTION if patient 55 yo or on Beta blockers (blocks effects of epinephrine) call medical control.
Refusal of transport: mild asthma, never signs of severe dyspnea, never shows hypoxia, significant improvement with single nebulizer treatment.
Acute PULMONARY EDEMA: pedal edema, hx of CHF or elevated SBpressure. Consider CPAP with significant SOB or hypoxia (ALSO CONSIDER DUONEB): administer Nitro 0.4 mg SL /5 min unless 90 SBP…except if used viagara 24 hrs; cialis 48
HYPOTENSION <90 consider noreip drip 2 - 12 mcg a minute
Respiratory Failure
If trauma: C spine precautions. suction all debris from airway. supplemental O2 with BVM is sufficient if O2 sat and capnography are acceptable limits along with proper seal and good bag compliance.
Continue with advanced airway if needed:
PRIORITIZE high quality CPR! LMA acceptable
Sedative twilight drugs ETOMIDATE 0.3 MG/KG or KETAMINE 2 MG/KG. Administer paralytic after sedation if needed. SUCCINYLCHOLINE 1.5 MG/KG unless suspected crush injuries (hyperkalemia), glaucoma or penetrating eye injury, malignant hyperthermia, BURNS or PARALYSIS
ROCURONIUM 1 MG/KG
APNEIC OXYGENATION
SEDATIVE MAINTENANCE USE MIDAZOLAM 2-4 MG OR FENTANYL 100-250 MCG
Albuterol - what you know
selective beta 2 bronchodilator to relax smooth muscle tissue in bronchi. Use for bronchospasm secondary to Asthma or COPD exacberation. CONTRA: HTN, tachycardia secondary to digitalis toxicity or hypersenisitve. Caution in patients with cardiovascular disease and/or CHF. (check lung sounds). SIDE EFFECTS: headache, tachycardia, possible PVC’s, palpitations. 2.5 mg in 3 mL of saline for nebulizer.
DuoNeb
0.5 mg of atrovent with the 2.5 of albuterol for greater bronchoDILATION effects! use for Asthma COPD, drowning, respiratory distress. allergic reaction, toxic inhalation. SIDE effects: headache, palpitations, tachycardia.
Epinephrine
vasoconstrictor and bronchodilator with increased perfusion to coronary and cerebral tissues. Increases myocardial oxygen demand. USED FOR cardiac arrest, bronchospasm due to asthma or COPD and allergic reaction. SIDE EFFECTS: head ache, palpitations, dizziness, tachycardia and N&V.
Etomidate (Amidate)
Hypnotic, twilight sedative…Does not have analgesic effect or muscle relaxing properties. May cause myoclonus and is given at same time as paralytic medications. CONTRA: hypersensitivity or Pregnant mother, lactating or child under 3 months. ONSET usually within 1 minute and duration 5 minutes. Pt. fully awake in 7-14 minutes. SIDE EFFECTS: transient pain at injection site/myoclonus reactions
Fentanyl (sublimaze)
Opioid analgesic. Alters response and perception to pain. May produce respiratory/CNS depression in higher doses. USE for pain control and sedation of intubated patient. CONTRA: MAO inhibitors (anti-depressant drugs), HYPOTENSION, any indication of inferior wall myocardial infarct V4R. SIDE EFFECTS: apnea, hypotension..50-100 mcg for pain control SLOW push IV or IM injection. up to 250 mcg. monitor pain scale and VS.
Ketamine
analgesic and sedative, creates a dissociative state with cardiovascular and respiratory stimulation and sometimes a transient and MINIMAL respiratory depression. USED for RSI in children or adults and Agitated Delirium. Can create HTN, tachycardia, respiratory depression, N&V. CONTRA: patient with significant HTN BP 240/120…Hemorrhagic stroke or children Less than 3 months. DOSE at 2mg/kg but use caution with Agitated delirium as 30-40% will require intubation after use.
Magnesium Sulfate
Depresses the CNS and myocardial nerves/tissues which will limit seizure activity, relax Broncho spasms and control dysrhythmias such as polymorphic V-tach. USE in cardiac arrest if torsades or hypomagnesemia is present. USE in Seizures due to eclampsia, and Bronchospasm secondary to COPD or Asthma asthmaticus. CONTRA: do not use with a symptomatic heart block, Caution with pt. renal impairment. CAN cause bradycardia, paralysis, widened QRS complexes, diaphoresis. INCOMPATIBLE with bicarbonates. MIX 2 grams in 100 mL bag over 10-20 minutes for Respiratory Distress and 4 grams over 15 minutes for eclampsia.
Methylprednisolone SoluMedrol
Anti-inflammatory glucocorticoid. Can control severe inflammation such as anaphylaxis and severe allergic reactions as well as exacerbations of COPD and asthma. ONSET within an hour of administration and last for 12 hours. CONTRA: systemic fungal infections or hypersensitivity. Caution for patient who received steroids’ in past 12 hours. May cause Nervousness, dizziness, headache and raise glucose (hyperglycemia). 125 mg IV or IM vial for adults and 2mg/kg for children with MAX 125mg. AVOID IM for pediatrics.
Midazolam Versed
Benzodiazepine for CNS depression USED for sedative for agitation, intubation maintenance or Seizure activity. CONTRA: hypersensitive, hypotensive/shock, respiratory distress…Caution with pulmonary disease, CHF, renal or liver impairment and geriatric patients. CAN CAUSE N&V, agitation, drowsiness, bronchospasm, coughing…DOSE for cardioversion or post-intubation 2-4 mg IV/IO, Agitated Delirium: 5-10mg IV/IO or 10 mg with MAD device. In patient fewer than 50 KG use 5 mg IV/IO for seizure activity otherwise 10 mg MAD.
pediatric RSI or cardioversion use 0.1 mg/kg max of 2 mg…OR for Seizure 0.2 mg/kg or max of 10mg MAD. ONEST after IV administration 1.5 to 5 minutes. MONITOR vital signs.
Nitroglycerin
peripheral vasodilator to decrease preload and therefore minimize oxygen demand on heart. USE for Ischemic chest pain, HTN, Acute pulmonary edema possibly secondary to CHF. CONTRA: hypotension, Head injury or concern for intracranial hemorrhage, use of viagra or levitra within 24 to 48 hours, DO NOT use if signs of right ventricular infarction. MAY increase intraocular pressure. CAN cause headache, hypotension, diaphoresis, syncope and N&V. DOSE 0.4 mg SL/3-5 minutes up to 1.2 mg total.
Norepinephrine
peripheral vasoconstrictor and coronary artery vasodilator with a rapid onset that lasts 1-2 minutes and needs to be given as a continuous infusion. USED for bradycardia with a pulse, treatment of hypotension with cardiogenic shock or any state where patient is suspected to have fluid overload (needing to maintain at least 90 systolic). Treatment of hypotension refractory to fluid challenge. CONTRA: do not use with dehydrated patients or patients in shock who would benefit more from a fluid bolus. Do not use on patient who is severely tachycardic or for bradycardia if patient is maintaining good perfusion. DO NOT administer in catheter less than 18 gauge or more distal than the AC vein (IO is acceptable). extravasation can cause devastating tissue lossSIDE EFFECTS may be HTN or tachycardia. 250 bag makes 16 mcg/mL..Recheck VS every two minutes while adjusting drip rate then every 5 minutes afterwards. Monitor for infiltration or HTN…
Zofran (ondansetron)
Anti-emetic blocks serotonin effects in vagal nerve. Prevents and treats N&V. CONTRA: hypersensitive. Children less than 3 years old should not receive. Caution with pregnant or lactating females. Liver impairment DO NOT exceed 8 mg. MAY cause headache, dizziness, dry mouth, fatigue, constipation…DOSE 4mg IV/IM given over 30 seconds slow push preferably 2-5 minutes. Pediatric give 0.1mg/kg if under 40KG
Rocuronium (Zemuron)
Non-depolarizing neuromuscular blocking agent causes skeletal muscle paralysis. May also facilitate chest wall compliance for mechanical ventilation. Causes transient HTN. CONTRA: known hypersensitivity to bromides. Patients with liver disease will have 1.5 times longer effect than usual. DOSE: 1mg/kg IV. Rocuronium is a LONG acting paralytic and requires post-induction sedation with versed and/or fentanyl. ONSET is about 45-60 seconds and duration is from 25-70 minutes.
Succinylcholine (Anectine)
motor nerve depolarizer, skeletal muscle relaxant. Will cause fasciculations (spontaneous muscle contraction) followed by paralysis. USE after induction of anesthesia for skeletal muscle paralysis. For intubation if seizure activity or muscle tone prevents it. For any patient that exhibits high airway compromise during transport. CONTRA: known hypersensitivity, crush injuries, burns, penetrating eye injuries, hx of glaucoma or malignant hyperthermia. SIDE EFFECTS: hypotension, hypertension, Cardiac arrest, ventricular dysrhythmias. In children under 5 increased chance of intracranial pressure. DOSE: 1.5 mg/kg IV/IO or in extreme circumstances deep IM max of 150 mg (3-4 mg/kg). **Complete paralysis with IV injection is obtained within 1 minute and persists for approximately 2 to 4 minutes. The effects will fade within 4 to 10 minutes. IM injection starts in 3 minutes and can last up to 30 minutes.
Allergic Reaction
If patient has auto-injector assist them with it - self administration. For a mild allergic reaction Diphenhydramine 1mg/kg max 50 mg. (itching or hives). Benadryl may be administered IM if no IV access. For a moderate allergic reaction with wheezes, chest tightness or dyspnea use Albuterol/ipratropium…repeat 2x if wheezing persists. SoluMedrol 125 mg. For a severe allergic reaction with BP less than 90 Epinephrine 1:1000 IM 0.3 mg. REPEAT epi if signs of severe allergic reaction continue. Then give duoneb treatment, then diphenhydramine then solumedrol. If cardiac arrest from allergic reaction do all steps above except with 1:10000 epi as in a code scenario.
Altered Mental Status
Glucose less than 60, If patient can self administer glucose gel or orange juice without choking..otherwise 25 grams 10% IV. Recheck with different glucometer if necessary after 10 minutes of administration. If no IV access administer glucagon 1 mg IM deltoid. If glucose elevated above 200 with signs of hyperglycemia then give 500 mL bolus. If opioid OD suspected give 0.5 mg of naloxone; repeat every 3 minutes with a maximum of 8 mg. If stroke suspected:protocol.
Behavioral/Agitated delirium
Remove patient from stressful environment if possible. Calm and reassure patient if able. If refuses care, determine patient mental acuity (sharpness, able to think responsibly) Utilize TPD and restraints if needed whether medical or mechanical. Detail rationale in report for restraints and check PMS in limbs after securing straps. Evaluate BlGl if less than 70 give D10. Obtain 12 lead. Midazolam 5-10mg IV is Preferred for patient who is suspected of recent drug abuse. Can do 10 mg MAD 5mg ea. nostril for more RAPID effect.
Haldol 5 mg IV/IM may repeat once in 10 minutes if needed. May be better for patients with hx. of psychosis. use with caution in pt. older than 50 and do NOT use in patient with wide Q-T interval.
Ketamine 2 mg/kg IM/IV Utilize in EXTREME cases of excited delirium and if respiratory depression occurs treat accordingly.
For a dystonic reaction give Benadryl/diphenhydramine at 50mg IV/IM slow. May repeat once in 10 minutes if needed.
Bradycardia with a pulse
Check patient condition and general appearance as some may normally have a resting HR below 50 BPM. It may or may not be acute symptomatic bradycardia. Identify and treat the underlying cause. Bradycardia can be from medications, heart blocks, toxins, respiratory disorders, head injuries/trauma, etc. Provide O2 if indicated and ensure patent airway. Apply cardiac monitor and identify 4 lead rhythm, BP and Pulse Oximetry. Obtain IV access at least 18 gauge AC or higher and perform 12 lead. Examine for signs of hypoperfusion namely altered mental status, chest pain, symptoms of heart failure - cardiogenic shock.
Give Atropine if not ventricular wide QRS rhythm 0.5 mg/3-5 minutes up to 3 mg max. Otherwise, PACE or Norepinephrine drip 2-12 mcg/min. CONSIDER online Medical Control.
H’s and T’s
Hypovolemia, hypoxia, hydrogen ion acidosis, hyperkalemia, hypokalemia, Hypothermia…cardiac tamponade, tension pneumothorax, toxicity OD, thrombosis cardiac or thrombosis pulmonary.
Chest Pain
Perform 12 lead: If If ST elevation greater than 1 mm (one small box in height) in II, III, aVF then obtain a V4R and assess for symptoms of RV infarct, including hypotension, JVD and dry lung sounds. STEMI alert for patients with 1 mm or greater elevation in 2 or more contiguous leads. New LBBB with signs of MI qualifies as a STEMI alert. If STEMI present transmit EKG to receiving facility. Get serial EKG’s and print for physician at facility. Give Aspirin 324 mg PO, Nitroglycerine 0.4 mg/5 minutes up to 1.2 mg if BP is 100 systolic or greater, they DO NOT have RV4 infarct and have not taken Levitra/viagra in last 24-48 hours. Consider fentanyl for pain 50 mcg every 5 minutes up to 150 mcg if no signs of RV4 infarct and BP at least 100 if pain continues despite nitro. Treat hypotension with 500 mL NS bolus. Can treat tachycardia with 5 mg labetalol up to 20 mg if BP is 100 or above and no signs of hypoperfusion.
Cerebral Vascular Accident
Check BlGl if less than 60 give 25 grams D10% IV if no access Glucagon 1 mg IM. Establish when first signs occurred up to 24 hours is allowed to call a stroke alert. Use family or bystanders to know when last seen normal and record on stroke Checklist. Do not delay transport and access two 18G AC IV lines in route. Perform FAST-ED protocol and document. Keep stretcher head at 30 to 45 degree elevation. Do not treat HTN in case of stroke unless above 220 systolic then contact medical control. If seizure activity is present then use seizure protocol.
