Adult Treatment Protocols Flashcards
Cardiocerebral Resuscitation (CCR): Contraindications ATP-01
Contraindication to CCR:
•Children
Cardiocerebral Resuscitation (CCR): Algorithm ATP-01
*Inadequate/no bystander CPR/CCR prior to arrival: •200 Chest Compressions •IV/IO •NRB with 100% O2 •Epinephrine 1mg IV/IO
**Adequate CPR/CCR prior to arrival
•Rhythm analysis
•Single shock @ ____J without pulse √
[200 Compressions/ Epi 1mg IV/IO]
[Rhythm analysis/Single Shock @ ____J without pulse √]
[200 Compressions/ Epi 1mg IV/IO]
[Rhythm analysis/Single Shock @ ____J without pulse √]
[200 Compressions/ Epi 1mg IV/IO]
[ET Intubation/Resume Standard ACLS]
Cardiocerebral Resuscitation (CCR): Documentation ATP-01
CCR Documentation: •Was bystandard CPR/CCR in progress? •If so, who was preforming i.e. family, friends, law •Est. time of collapse •Was AED used PTA? •Was Pt gasping PTA? •Specify whether CCR was utilized. •Time and dose of all defibrillation and Rx •All monitored cardiac rhythms
ACLS: VF/VT Algorithm
ATP-02.01/02.02
ACLS: VF/VT Algorithm:
*use when CCR CI/Post-CCR
{1}-[Start CPR/Give O2/Attach Monitor]
Shockable?
No–» Go to Asystole/PEA Algorithm
{2}-Yes–»VF/VT
{3}-Shock @ ___J
{4}[CPR-2min, IV/IO]
Shockable?
No–» Go to Asystole/PEA Algorithm
{5}Yes–»VF/VT –»Shock @ ___J
{6}[CPR-2min/Epi 1mg q3-5 or 40U Vasopressin, consider Advanced Airway/Capnography]
Shockable?
No–» Go to Asystole/PEA Algorithm
{7}Yes–»VF/VT –»Shock @ ___J
{8}[CPR-2min
Amiodarone 300/150mg bolus (1st/2nd dose)
treat reversible causes]
Shockable?
No–» Go to Asystole/PEA Algorithm
{7}Yes–»VF/VT –»Shock @ ___J
Repeat until rhythm changes or ROSC
ACLS: Asystole/PEA Algorithm
ATP-02.01/02.02
ACLS: Asystole/PEA Algorithm
*use when CCR CI/Post-CCR
{1}-[Start CPR/Give O2/Attach Monitor]
Shockable?
Yes–» Go to VF/VT Algorithm
{9}No–» Asystole/PEA
{10}[CPR-2min
Epi 1mg q3-5 or 40U Vasopressin
consider Advanced Airway/Capnography]
Shockable?
Yes–» Go to VF/VT Algorithm step 5 or 7
No–» Asystole/PEA
{11}[CPR-2min/Tx reversible causes]
Shockable?
Yes–» Go to VF/VT Algorithm step 5 or 7
No–» Asystole/PEA go to step 10 repeat until rhythm
changes or ROSC
ACLS: Reversible Causes
ATP-02.01/02.02
ACLS: Reversible Causes: •Hypovolemia - Fluid bolus •Hypoxia - Airway/Oxygen •H+ (acidosis) •Hypokalemia •Hyperkalemia •Hypothermia - Warmth/handle gently •Tension Pneumothoax •Tamponade - Cardiac •Toxins - OD •Thrombosis - PE •Thrombosis - coronary
Bradycardia
ATP-03
Assess clinical condition: HR.20), if stable, observe and transport;
if too slow: Atropine IV: 0.5mg q3-5 to max of 3mg
•2º Type1 - Widening PRI until Dropping QRS
If too slow: Atropine IV: 0.5mg q3-5 to max of 3mg
•2º Type2 - Fixed PRI, more P’s than QRS
If too slow and P’s>QRS —»Atropine
If too slow and P’s
Tachycardia (w/ pulse)
ATP-04
Assess clinical condition: HR>150/min •Secure airway–»Assist Ventilations as necessary •O2 (if hypoxic) •Monitor-Rhythm/12-Lead/BP/SpO2 •IV/IO
Persistent Tachyarrythmia causing: •Hypotension? •AMS? •Shock? •Ischemic Chest Discomfort? •Acute Heart Failure?
Yes? —» Synchronized Cardioversion •Narrow regular = 50-100J •Narrow irregular = 120-200J •Wide regular = 100J •Wide irregular = defibrillation dose not synched
No— Is QRS wider than ≥0.12 seconds? No: •IV access/12-Lead/Vagal Maneuvers •Refer to Stable SVT (ATP-06) •Refer to A-Fib/A-Flutter (ATP-07)
Yes:
IV access/12-Lead/Vagal Maneuvers
•If regular and monomorphic - Adenosine
1st - 6mg rapid IV push with 20cc NS flush
2nd - 12mg rapid IV push with 20 cc NS flush
•If polymorphic VTach (Torsades) - Mag Sulfate
1-2G in 10ml D5W IV/IO over 10 minutes
•Consider Amiodarone IV for VT
150mg over 10min PRN if VT recurs
OMD for maintenance infusion @ 1mg/min.
•May use Lidocaine if Amiodarone is not available
Unstable Supraventricular Tachycardia
ATP-05
Assess clinical condition: HR>150/min, Narrow QRS
•Secure airway–»Assist Ventilations as necessary
•O2 (if hypoxic)
•Monitor-Rhythm/12-Lead/BP/SpO2
•IV/IO - Lock/Bolus as appropriate
Borderline - Angina, mild SOB, Borderline Low BP,
Decreased LOC
Rx: Adenosine
1st - 6mg rapid IV push with 20cc NS flush
-if does not convert ≤2min
2nd - 12mg rapid IV push with 20 cc NS flush
-if does not convert, contact Med Control for 3rd dose-
Unstable - Unconscious, Pulmonary Edema, Shock
Tx: Synchronized Cardioversion
@ 50J/100J/200J/300J/360J
If conscious, consider sedation:
•Midazolam—2.5-5mg slow IV
•Lorazepam—1-2mg slow IV
•Diazepam—2.0-10mg slow IV
-if rhythm does not convert contact OMD-
Stable Supraventricular Tachycardia
ATP-06
Assess clinical condition: HR>150/min, Narrow QRS
•Secure airway–»Assist Ventilations as necessary
•O2 (if hypoxic)
•Monitor-Rhythm/12-Lead/BP/SpO2
•IV/IO - Lock/Bolus as appropriate
Stable: Compensating BP, AOx4, øCP, øSOB
Tx: Vagal Manuvers (bearing down)
-¿conversion?-
No—»
Rx: Adenosine
1st - 6mg rapid IV push with 20cc NS flush
-if does not convert ≤2min
2nd - 12mg rapid IV push with 20 cc NS flush
-if does not convert, contact Med Control for 3rd dose-
*Consider age/PMHx/Transport time prior to Adenosine
-Online Medical Control for further orders
Narrow QRS Atrial Fibrillation/Atrial Flutter: Stable
ATP-07
Assess clinical condition: HR>150/min, Narrow QRS
•Secure airway–»Assist Ventilations as necessary
•O2 (if hypoxic)
•Monitor-Rhythm/12-Lead/BP/SpO2
•IV/IO - NS bolus of 500ml
-contact Med Control if suspected WPW
Unstable: Rate >150 and/or Hx of WPW
Stable: (Consider transport time, Length of Time in rhythm
due to potential for clot to form in Atria
•Vagal maneuvers
•With rate >120/ SPB >100/ no Hx of WPW and
not on oral ß-Blockers (if so contact Med Control)
•Rx: Diltiazem 10-20mg slow IV
-Consider 10mg for age >60 and/or 100
Narrow QRS Atrial Fibrillation/Atrial Flutter: Unstable
ATP-07
Assess clinical condition: HR>150/min, Narrow QRS
•Secure airway–»Assist Ventilations as necessary
•O2 (if hypoxic)
•Monitor-Rhythm/12-Lead/BP/SpO2
* IV/IO - NS bolus of 500ml * Contact Med Control if suspected WPW
Unstable: Rate >150 and/or Hx of WPW
•AMS
•Hypotensive
•SOB
•CP
Consider length of Time in rhythm due to
potential for clot to form in Atria≈PE
Tx: Synchronized Cardioversion
•A-Flutter @ 50J/100J/200J/300J/360J
•A-Fib @ 120J/200J/300J/360J
If conscious, consider sedation:
•Midazolam—2.5-5mg slow IV
•Lorazepam—1-2mg slow IV
•Diazepam—2.0-10mg slow IV -if rhythm does not convert contact Medical Control-
Acute Coronary Syndrome or Anginal Equivalent:
Algorithm
TCP-08
Assess clinical condition:
•Secure airway–»Assist Ventilations as necessary
•O2 (if hypoxic)
•Monitor-Rhythm/BP/SpO2
•12-Lead within 5min on any Pt w/ Classical, Atypical,
or anginal equivalent symptoms of ACS
•if STEMI - Transmit to appropriate facility,
•Note presence of ST elevation in I/S/A/L
•document transmission
•Rx: Aspirin - Ax?
•If no, 325mg or 4x81mg - Chewable
•IV/IO - Lock or fluids as indicated
NTG may be given prior to IV if SBP>120
•Monitor V/S, if SBP >90 Tx:—»NTG if:
•not Inferior MI - Hypotension may be due to
RVMI—» fluid bolus / TCP
•ØED Rx (Cialas, Viagra, Levitra) w/in 48hours
Online medical direction with Med Control
•Rx:
•NTG: 0.4mg q5 min x2 if BP>90
•Consider Morphine: 2-4mg if not hypotensive and
ø relief from NTG
-or-
•Fentanyl IV: 50-100µg PRN to max of 200µg total
•Fentanyl IM/IN: 2µg/kg to max of 200µg total
Is there significant improvement? (i.e. ≤3/10 pain) w/out S&S of cardiopulmonary compromise?
Yes? —»Courtesy Notification
No?—»Medical Control
Acute Coronary Syndrome or Anginal Equivalent:
Symptoms suggestive of possible MI
TCP-08
- CP -crushing/squeezing/pressure/radiation/burning/tight
- Angina
- Dyspnea
- Diaphoresis
- Dizziness
- Palpitations
- Isolated Arm or Jaw pain
- Dysrhythmias
- Syncope/Near-Syncope
- Unexplained N/V
- Epigastric pain or dyspepsia
- Weakness or fatigue
- Apprehension
Acute Coronary Syndrome or Anginal Equivalent:
Pt’s who present atypically
TCP-08
Patients who are most likely to present atypically:
•Elderly
•Diabetics
•Women
Acute Coronary Syndrome or Anginal Equivalent:
Appropriate STEMI receiving locations
TCP-08
EVEN if the hospital is on diversion
•AH - Arrowhead Hospital
•BEMC - Banner Estrella Medical Center
•BBWMC - Banner Boswell Medical Center
•BTMC - Banner Thunderbird Medical Center
•BDWMC - Banner Del Webb Medical Center
•JCL-NM - John C. Lincoln - North Mountain
•JCL-DV - John C. Lincoln - Deer Valley
•WV - West Valley Hospital
Respiratory Arrest/Insufficiency - Bronchospasm
ATP-09
Assess clinical condition:
•Secure airway–»Assist Ventilations as necessary
•O2 (if hypoxic)
•Monitor
•IV/IO - Lock/Bolus as appropriate—» Don’t delay Tx
Rx:
•Albuterol: 2.5mg in 3ml NS - Neb/In-line
•Atrovent: 500µg should be given together for x3
•Methylprednisolone: 125mg IV/IM
for severe respiratory distress
•Consider: Epinephrine: 0.3mg 1:1000 IM
if: SBP
Respiratory Arrest/Insufficiency:
Indications of Severe Respiratory Distress
ATP-09
Indications of Severe Respiratory Distress include:
•Apprehension
•Anxiety
•Combativeness
•Inspiratory and/or expiratory wheezes
•Little or no air mvmt. on auscultation
•Too tight to wheeze
•Use of accessory muscles
•Worsening dyspnea; One or two word dyspnea
•Cough
•Skin color changes
•Diaphoresis
•Tachycardia
•Tripod body positioning
Respiratory Arrest/Insufficiency - Pulmonary Edema/CHF
ATP-10
Assess clinical condition:
•Secure airway–»Assist Ventilations as necessary
•O2 (if hypoxic)
•Monitor
* Consider Pt's PMHx * Tx dysrhythmias appropriately. •IV/IO - Lock/Bolus as appropriate—» Don't delay Tx
Rx:
•NTG 0.4mg q5 min x2 if SBP>90
ØED Rx (Cialas, Viagra, Levitra) w/in 48hours
-Online medical direction-
Tx:
•Consider CPAP (CPAP Protocol ATP-13)
Symptoms resolved?
Yes? Courtesy Notification
No—»Medical Direction
Rx:
•Morphine Sulfate IV: 2-4mg if not hypotensive and no
relief from NTG
-or-
•Fentanyl IV: 50-100µg PRN up to max of 200µg
•Fentanyl IM/IN: 2µg/kg to a max of 200µg
•Consider: Furosemide 0.5-1mg/kg slow IV if BP >90,
up to a max of 80mg
*Furosemide CI w/ Pneumonia: presenting with fever/productive cough/dyspnea/or CP that + on inspiration
-contact Med Control prior-
Respiratory Arrest/Insufficiency - Narcotic Overdose
ATP-11
Assess clinical condition:
•Secure airway–»Assist Ventilations as necessary
•O2 (if hypoxic)
•Monitor
•IV/IO - Lock/Bolus as appropriate—» Don’t delay Tx
Rx: -may induce nausea, have suction ready-
•Naloxone IV: 0.4mg PRN to a max of 4mg
•Naloxone IM: (if no IV access) 2mg, may repeat 1x,
max of 4mg
•Naloxone IN: 2mg into each nostril (4mg) via atomizer
*If adequate respiratory status—»Altered LOC (ATP-14)
Symptoms resolving?
Yes? If Pt wants refusal—» Med Control Narcotic vs Narcan
No? Med Control
Respiratory Arrest/Insufficiency: Anaphylaxis
ATP-12
Assess clinical condition: Mild vs Severe
•Hypotension SBP
Respiratory Arrest/Insufficiency: Acute allergic reaction
ATP-12
Assess clinical condition: Mild vs Severe
•Itching
•Localized Urticaria
•Nausea
•ø respiratory distress
* Secure airway–»Assist Ventilations as necessary * O2 (if hypoxic) * Monitor * IV/IO - Lock/Bolus as appropriate—» Don't delay Tx
Rx:
•Diphenhydramine: 50mg slow IV or IM
•Methylprednisolone: 125mg IV or IM
•If severe respiratory distress and
Respiratory Arrest/Insufficiency:
Anaphylaxis vs.Acute allergic reaction
ATP-12
Anaphylaxis
•Hypotension SBP
Respiratory Arrest/Insufficiency:
Epinephrine Infusion
ATP-12
Epinephrine Infusion
Add 2.0mg Epi 1:1000 to 250ml NS = 8.0 µg/cc
Infusion rate: 2-10µg/min = 15gtts-75gtts/min; Titrate
Continuous Positive Airway Pressure
ATP-13
Assess clinical condition:
•Secure airway–»Assist Ventilations as necessary
•O2 (if hypoxic)
•Monitor - SpO2/ETCO2
•IV/IO - Lock/Bolus as appropriate—» Don’t delay Tx
- Minimize Pt effort —» Carry
- Place in seated position with head at 45º
Tx: if Pt is in respiratory distress despite Hi-flow O2 via NRB
a-Connect CPAP to O2
b-attach CPAP to breathing circuit and test function
c-Apply/secure breathing circuit mask to Pt
d-Titrate increases in pressure to SpO2,
*do not exceed 10 cm H2O
* Continually reassess Pt/Monitor for pneumothorax * Transport emergently and notify receiving hospital
Rx: To decrease anxiety if Pt is benefiting from CPAP
consider.
•Morphine Sulfate IV: 2-4mg if not hypotensive and no
relief from NTG
-or-
•Fentanyl IV: 50-100µg PRN up to max of 200µg
•Fentanyl IM/IN: 2µg/kg to a max of 200µg
-or-
•Diazepam—2.0-5mg slow IV
•Lorazepam—1-2mg slow IV
**Consider lower doses when Pt>60 or
Continuous Positive Airway Pressure:
Indications
ATP-13
Indications:
Conscious Pt in severe respiratory distress due to suspected:
•Pulmonary edema
•Pneumonia
•COPD exacerbation (asthma/bronchitis/emphysema)
Continuous Positive Airway Pressure:
Contraindications
ATP-13
Contraindications:
•Upper airway/facial trauma or abnormalities that
prevent mask from sealing
•Open stoma or tracheotomy
•Severe cardio-respiratory instability (respiratory or
cardiac arrest, penetrating chest trauma, suspected
pneumothorax, arrhythmias)
•Persistent nausea/vomiting
•Active upper GI bleeding or Hx of recent gastric Sx
•Age
Continuous Positive Airway Pressure:
Relative-Contraindications
ATP-13
Relative-Contraindications:
•SBP
Altered Level of Consciousness - Non-Traumatic:
Conscious or Unconscious No BGL available or BGL
Conscious or Unconscious No BGL available or BGL
Altered Level of Consciousness - Non-Traumatic
Conscious or Unconscious BGL>60
ATP-14
Conscious or Unconscious BGL>60
* Secure airway–»Assist Ventilations as necessary * O2 (if hypoxic) * Test BGL = BGL >60
Establish IV lock or fluids as indicated
-if Pt is unconscious-
Rx: -may induce nausea, have suction ready-
•Naloxone IV: 0.4mg PRN to a max of 4mg
•Naloxone IM: (if no IV access) 2mg, may repeat 1x,
max of 4mg
•Naloxone IN: 2mg into each nostril (4mg) via atomizer
Tx: If you suspect:
1-Hypoglycemia - Thiamine 100mg, Dextrose 25G IV
2-Hyperglycemia/ETOH/infection/dehydration/metabolic
acidosis—»Administer 300-500ml NS bolus
3-Stroke - proceed to stroke protocol (ATP-14)
Suspected Stroke
ATP-15
- Secure airway–»Assist Ventilations as necessary
- O2 (if hypoxic)
- Monitor
- IV/IO - Lock/Bolus as appropriate
- √BGL
- Conduct “FAST” assessment
- Obtain MHx
- Rx history
- Document Findings
-Did the Pt’s symptoms start w/in the last 4 hours?-
Yes-»Transport Pt w/ positive prehospital stroke assessment to Primary Stroke Center for possible thrombolysis w/in 4 hours of onset.
No—»Early Online Medical Direction (prior to transport) for medical direction to nearest Primary Stroke Center or closest appropriate facility
Suspected Stroke: Stroke Symptoms
ATP-15
Stroke Symptoms
•Sudden numbness/weakness of face/arm/leg especially
on one side of the body.
•Sudden confusion, trouble speaking or understanding.
•Sudden trouble seeing in one or both eyes.
•Sudden trouble walking, dizziness, loss of balance or
coordination.
•Sudden severe headache with no known cause.
Suspected Stroke: FAST Assessment
ATP-15
FAST Assessment
•FACE: Ask Pt to show teeth—»Facial Droop?
•ARMS: Raise both arms w/ eyes closed—»Arm Drift?
•SPEECH: Repeat sentence—»Words slurred? Correct?
•TIME: What time was onset of S/S? Last seen well time?
Suspected Stroke: West Valley Stoke Centers
ATP-15
EVEN if the hospital is on diversion
•AH - Arrowhead Hospital
•BEMC - Banner Estrella Medical Center
•BBWMC - Banner Boswell Medical Center
•BTMC - Banner Thunderbird Medical Center
•BDWMC - Banner Del Webb Medical Center
•JCL-NM - John C. Lincoln - North Mountain
•JCL-DV - John C. Lincoln - Deer Valley
•WV - West Valley Hospital
•PB - Phoenix Baptist
•MH - Maryvale Hospital
Seizures: Lasting > 5min: Vascular access
ATP-16
*if in 3rd Trimester refer to ATP-21
* Secure airway–»Assist Ventilations as necessary * O2 (if hypoxic) * √BGL * Establish IV access
Rx:
•If BGL is 60: reduce dose by half
-or-
Diazepam IV
•5-10mg IV in 2mg increments, no faster than 2mg/min
•Age>60: reduce dose by half.
Symptoms resolve?
Yes—»Courtesy Notification
No—»Med Control
Seizures: Lasting > 5min: No vascular access
ATP-16
*if in 3rd Trimester refer to ATP-21
* Secure airway–»Assist Ventilations as necessary * O2 (if hypoxic) * √BGL
Rx:
•If BGL is 60: Reduce dose by half
*For IM administration, inject deep into large muscle mass
Establish vascular access
Yes—»Courtesy Notification
No—»Med Control
Ingestions - Conscious Patient
ATP-17
- Secure airway–»Assist Ventilations as necessary
- O2 (if hypoxic)
- Monitor - Tx dysrhythmias as appropriate
- Inspect the scene:
- Bring Rx containers if possible
- Consider effects of substance
- Consider consulting Poison Control 602-253-3334
Symptoms resolving?
Yes—»Courtesy Notification
No—»Med Control
Hypotension - Non-Traumatic
ATP-18
- Secure airway–»Assist Ventilations as necessary
- O2 (if hypoxic)
- Consider PMHx
- Consider PRx
- Establish IV/IO of NS (Consider 2 large bore IV’s)
- Administer fluid challenge of 200-300cc ASAP
•Yes-»Continue Fluid Therapy-»Courtesy Notification
•No—» Dopamine IV infusion: 2-20µg/kg/min(60gtts)
Online Med Control
Behavioral Emergencies/Excited Delirium:
Patient Assessment
(To be used for ≥15 y/o)
ATP-19
Patient Assessment
•ALS provider must assess Pt that has been restrained
•Pt must be under direct Supervision at all times
•Pt: Airway, breathing, VS, SpO2
•Circulation to extremities must be evaluated every 10
minutes when restraints are applied
Behavioral Emergencies/Excited Delirium:
Types of Restraint:
(To be used for ≥15 y/o)
ATP-19
Type of Restraint:
•Only leather or other agency approved “soft” restraints
•If locking restraints used, key must be transported in
the ambulance.
•Handcuffs may only be used wen law enforcement
officer accompanies Pt to Hospital.
•Paramedic must have immediate access to keys
needed to release handcuffs or devices.
•The use of linens as a restrain device is acceptable,
providing secured in a manner allowing rapid access in
emergency.
Behavioral Emergencies/Excited Delirium:
(To be used for ≥15 y/o)
ATP-19
Secure airway–»Assist Ventilations as necessary
O2 (if hypoxic)
Consider all possible medical & trauma causes for behavior
•Hypoxia
•Alcohol
•Medication effect/overdose
•Withdrawal syndromes
•Hypoglycemia
•Head Injuries
•Mental illness
*Tx appropriately
-Is Pt an immediate threat to him/herself or others?-
No—» Proceed with appropriate algorithm
Yes—» Apply restraints as necessary, Paramedic must
accompany Pt to receiving facility.
* Monitor - Tx dysrhythmias as appropriate * Establish Lock/IV as indicated * √BGL, if 60 or
Behavioral Emergencies/Excited Delirium:
Restraint Documentation
(To be used for ≥15 y/o)
ATP-19
Restraint Documentation:
•Reason restraint was required
•Type of restraint used
•Position of Pt during Tx and transport
•Data indicating constant supervision of ABC, V/S, SpO2
•Status of circulation distal to restraints
•Total time Pt was restrained while in care of EMS
•Pt status at the time of transfer of care.
Behavioral Emergencies/Excited Delirium:
Patient Positioning
(To be used for ≥15 y/o)
ATP-19
Pt positioning:
•Positioned not to compromise airway
•Access to airway maintained for adv. airway mgmt.
•Access to chest for CPR/defibrilation
•Access to extremities for IV/IO
•ø prone position/hogtied
•ø placed between backboards/stretchers
•restrained to backboard for Pt transfer/vomiting
•restraints placed to facilitate assessment/prevent injury
