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ICP Guidelines > ICP Guidelines > Flashcards

ICP Guidelines Flashcards

1
Q

What factors precipitate acute adrenal insufficiency?

A

Withdrawal from steroid medication, recent increase in physical or psychological stress and acute illness.

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2
Q

Signs and symptoms of adrenal insufficiency?

A

Altered GCS, dehydration - hypovolaemia, hyper K, hypoglycaemia, nausea, vomiting and abdo pain

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3
Q

Management of acute adrenal insufficiency?

A
  • Check for management plan
  • Basic care, 12 lead, BGL
  • Treat dehydration and hypoglycaemia symptomatically
  • Hydrocortisone
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4
Q

Dose of hydrocortisone for AAI?

A

Adults: 100mg single dose IV, IM, IO
Paediatrics: 4mg/kg up to a single dose of 100mg

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5
Q

CPAP contraindications

A
  • Hypotension
  • pneumothorax
  • GCS < 12
  • facial trauma
  • Epistaxis
  • Nausea and vomiting
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6
Q

CPAP considerations in ACPO

A
  • Should be applied early
  • BP > 120
  • 5cm (8L) or 10cm (12L)
  • Nasal specs under if SpO2 low as FiO2 reduced
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7
Q

IV GTN in ACPO considerations

A
  • 15mg GTN in 50mLs
  • initial bolus to prime cannula
  • systolic BP > 120
  • Consider PDE5 inhibitors - (fils)
  • BP every 3 mins
  • Stop infusion if BP <100 or GCS < 12
  • recommence at 50% if ceased
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8
Q

Treatment of symptomatic bradycardia

A
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9
Q

Advanced airway analgesia and sedation doses

A

Adults: Fentanyl up to 50 microg IV/IO every 5 mins up to a max of 300microg
Midazolam: (after two doses of fentanyl) 1mg IV/IO repeat as required every 5 mins.

Paediatrics: Fentanyl 0.5 microg/kg up to 25 microg
Midazolam: 50 microg/kg up to 1 mg

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10
Q

Anaphylaxis fluid and adrenaline doses? (Adult/Paed)

A

Fluid: Saline 0.9% in 250ml aliquots up to a total of 30mg/kg

Adrenaline (Adult): if at least 2 IM doses - 5-20microg/min titrated to effect (syringe driver)
1000microg into saline bag (2 microg/ml) 0.1/microg/min
Blouses of 25 microg PRN

Adrenaline (Paed):
Consult for IV/IO - typically 0.5microg/kg/min (syringe driver)
Saline bag 2microg/ml - same as adult

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11
Q

Differences in ICP adult Asthma guideline?

A 
Mild to Mod the same.
Severe additions:
Administer steroids (if no previous therapeutic doses administered within the past 24 hours):
-IV hydrocortisone 250 mg; OR
-Oral prednisolone 50 mg

If no improvement, commence IV/IO magnesium infusion:
-Magnesium 2.47 g (10 mmol), prepared as 2.47 g (10 mmol) made to 50 mL with sodium
chloride 0.9%, via syringe driver over 20 min, OR
-Magnesium 2.47 g (10 mmol), prepared as 2.47 g (10 mmol) in 100 mL bag sodium
chloride 0.9% over 20 min

Life threatening (additions):
- As above and…
o IV/IO adrenaline infusion titrated to effect:
Adrenaline (prepared as 3 mg made to 50 mL with sodium chloride 0.9%) via
syringe driver starting at 3 microg/min, consult if > 50 micorg/min required

Adrenaline 2 microg/1 mL sodium chloride 0.9% (prepared as adrenaline 1000
microg in sodium chloride 0.9% 500 mL)

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12
Q

Additions to ICP Paed Asthma CPG?

A

Mild - Severe the same.

Life threatening additions:
IV/IO magnesium infusion:
- Magnesium 25 mg/kg (0.1 mmol/kg), to a maximum 2.47g (10 mmol) prepared as calculated weight-based dose, made to 50 mL with sodium chloride 0.9%,via syringe driver over 20 min
- Magnesium 25 mg/kg (0.1 mmol/kg), to a maximum 2.47g (10 mmol) prepared as weight-based dose in 100 mL bag sodium chloride 0.9%, over 20 min

-IV/IO hydrocortisone 4 mg/kg, to a maximum of 250 mg

-If no response to magnesium or adrenaline (after 5 mins) Consult SAAS Medical Practitioner for adrenaline infusion rate, and titrate to
effect, using either IV/IO adrenaline (prepared as 3 mg made to 50 mL with sodium
chloride 0.9%) via syringe driver, OR IV/IO adrenaline 2 microg/1 mL sodium chloride 0.9%

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13
Q

Adult Bradycardia management

A

Consider a combination of therapies below

  • IV/IO saline 250 mL aliquots up to 20 mL/kg
  • IV/IO atropine 600 microg, repeat prn total max dose 3 mg
  • IV/IO adrenaline titrated to effect via: syringe driver infusion: start at 5 microg/min. Consult if > 50 microg/min required
  • manual infusion: start at 0.1 microg/kg/min (1 drop per sec ≈ 6 microg/min)
  • bolus 25 - 50 microg if required
  • Transcutaneous pacing (fixed mode) rate - balance cardiac workload and oxygen demand and electrical setting – minimum for ventricular capture and palpable pulse
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14
Q

Paediatric bradycardia management

A
  • Optimise oxygenation and perfusion
  • IV/IO saline 10 mL/kg aliquots (max 250 mL) up to 20 mL/kg IF hypovolaemic
  • if vagal stimulation or cholinergic drug toxicity is a factor IV/IO atropine 20 microg/kg
    • single max dose 600 microg
    • repeat once after 5 mins
  • Consider IV/IO adrenaline (via CMO) titrated to effect via:
    syringe driver infusion - start at 0.5 microg/kg/min
    consult to discuss ongoing rates and adjust by 0.1 microg/kg/min to a max 2 microg/kg/min
  • manual infusion: start at 0.5 microg/kg/min (1 drop per sec ≈ 6 microg/min)
    -If refractory bradycardia consider transcutaneous cardiac pacing
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15
Q

Challenging behaviour ICP differences (Adult)?

A

In patients ≥ 16 and < 60 years of age exhibiting challenging behaviour WITH a SAT score of
+2 or above with a likely or apparent non-medical cause, select from:
• IM droperidol 5 mg to 10 mg:
o For a patient of average weight, 5 mg should be a sufficient initial dose

If patient is not adequately sedated after 15 min, repeat IM droperidol
OR
• IV droperidol 2.5 mg (slow push): If the patient is not adequately sedated, repeat IV droperidol 2.5 mg (slow push) at 5 to 15 min intervals as required (total cumulative dose must not exceed 20 mg within a 24 hour period).

If the patient is not adequately sedated 15 min after the maximal cumulative dose of droperidol
(20 mg) has been administered, OR the patient is ≥ 60 years of age with a SAT score of +2 or
above, OR a medical cause is likely or apparent OR droperidol is contraindicated select from:
- IM midazolam 50 microg/kg to a maximum single dose of 5 mg. Repeat after 5 min
if required to a maximum total accumulated dose of 10 mg
- IV midazolam up to 3 mg: Initial 3 mg dose to be administered in 1 mg increments (slow push), and the
patient must be reassessed after each dose.
- Additional doses up to 3 mg (slow push) can be repeated every 5 min, to a maximum total accumulated dose of 10 mg.

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16
Q

Challenging behaviour ICP differences (Paediatric)?

A

In paediatric patients ≥ 8 years of age exhibiting challenging behaviour who require sedation,
and are able to cooperate in taking oral medications, administer:
- Oral lorazepam 0.5 mg to 1 mg

In paediatric patients ≥ 8 years of age exhibiting challenging behaviour, with a SAT score of
+2 or above, select from:
- IM midazolam 50 microg/kg. Repeat after 5 min if required to a maximum total accumulated dose of 0.2 mg/kg up to 10 mg
- IV midazolam up to 1 mg - Initial 1 mg dose to be administered in 0.5 mg increments (slow push), and the patient must be reassessed after each dose.
- Additional doses up to 1 mg (slow push) can be repeated every 5 min, to a maximum total accumulated dose of 0.2 mg/kg up to 10 mg.

  • If patient ≥ 14 to < 16 years of age, consider consult to EOC clinician for possible IM Droperidol: 0.1 – 0.2 mg/kg up to single max 10 mg, one repeat after 15 mins, total max dose 20 mg
17
Q

ICP Chest pain differences?

A

Treat cardiogenic shock as below if following signs present: cardiac chest pain, ischaemic ECG changes and SBP < 90 mmHg

If associated arrythmia treat as per relevant CPG

If no associated dysrhythmia:
- IV/IO saline up to 250 mL (given slowly)
monitor closely for signs of heart failure

  • If responsive to saline but SBP still < 90 mmHg:
    repeat IV/IO saline 250 mL prn. Consult if 10 mL/kg reached.

If unresponsive to saline:
IV/IO adrenaline via either:
syringe driver infusion (start at 5 microg/min)
or
manual infusion (start at 0.1 microg/kg/min)
or
bolus 25 microg prn

18
Q

ICP COPD Differences

A

If bronchodilator therapy is non-therapeutic and adequate oxygenation of 88-92% cannot be
achieved or the patient is physically exhausted:
- Provide CPAP at 5 cm H2O.
- A potential pneumothorax must be carefully considered where CPAP is utilised. Any sign
of pneumothorax is a contraindication of CPAP use.

  • Salbutamol 15 mg and ipratropium 500 microg via inline nebulisation with concomitant CPAP
  • IV hydrocortisone 250 mg (if no previous therapeutic doses of steroids administered in past 24 hours)
19
Q

Dose of Atropine in organophosphate poisoning?

A

1.2 mg IV or IO 5 mins IV /IO PRN

20
Q

ICP OD CPG:

A

Opioid - same as Paramedic

Beta/calcium channel blocker:
- IV atropine 600 microg, and repeat up to a maximum of 3 mg
- IV access and sodium chloride 0.9% with IV adrenaline (epinephrine) infusion (as per Bradycardia CPG)
- Transcutaneous cardiac pacing:
- IV glucagon 0.05 mg/kg, repeat as required for reversal of hypotension and
bradycardia, noting high doses may be required and may exceed ambulance stock.

Tricyclic ADs:
Consider intubation and hyperventilation if obtunded
- Monitor EtCO2 in the intubated patient and aim for EtCO2 levels of 25- 30mmHg

21
Q

ICP Pain Management additions:

A
  • Second line / adjunctive agents (indicated when first line agents are not clinically suitable for use or are ineffective in adequately controlling pain):

KETAMINE
- IV ketamine 0.1 mg/kg; injected slowly over 3 – 4 minutes to a maximum of 10 mg. Repeated
at 5 min intervals until pain is controlled.
- The total cumulative dose of ketamine must not exceed 1 mg/kg
- ketamine should not be used in patients ≥ 65 years of age unless IV fentanyl is not clinically appropriate

MIDAZOLAM
- If anxiety remains a significant factor, consider a single dose of IV midazolam 0.5 mg – 1
mg (administered over a minimum of 30 sec) as an adjunct.
- The combination therapy of opiate plus ketamine plus benzodiazepine should
be avoided.

22
Q

ICP Post-ROSC Management (ABCDE)

A

Airway and Breathing
• Reassess and optimise airway.
• Avoid hyperventilation. Start at 10-12 breaths/min and consider ventilation strategy.
o For paediatric patients, ventilate at an age-appropriate rate, refer to SAAS paediatric RDR
chart.
• Continue high-flow oxygen therapy.
o For patients requiring assisted ventilations, continue oxygen ≥ 15L/min.
o For patients not requiring assisted ventilations, re-assess and apply optimal oxygen to
maintain SpO2 94-98%. If SpO2 is unreliable, maintain high-flow oxygen
• Continue waveform capnography monitoring.
o In patients with a prolonged time to hospital with persisting or increasing hypercapnia
(EtCO2 >45 mmHg), cautiously increase ventilation rate to slowly decrease EtCO2 (as a
guide, aim to decrease EtCO2 by 1 mmHg/min if safe to do so).

Circulation
Blood Pressure Management
• Treat hypotension. For adults, maintain SBP>100 mmHg
o Judicious fluid administration of sodium chloride 0.9% IV/IO in 250 ml aliquots,
reassessing after each aliquot.
o Adrenaline (epinephrine) up to 50 microgram IV/IO bolus increments titrated to effect, OR
Adrenaline (epinephrine) 5-20 microgram/min IV/IO via syringe driver titrated to effect, OR
Adrenaline (epinephrine) 1 microgram/1ml saline 0.9% IV/IO infusion titrated to effect.
• For paediatrics, maintain a SBP within the predictive normal range for their age (refer to SAAS
paediatric RDR chart). If hypotensive:
o Initiate fluid administration of sodium chloride 0.9% IV/IO up to 10 ml/kg. Reassess and
repeat once if required.
o Consult with a SAAS Medical Practitioner via the EOC Clinician for further treatment.

Anti-arrhythmic Considerations
• Treat arrhythmias, following relevant CPGs
o For adults with recurrent episodes of VF/VT, or non-sustained episodes of VT, administer
300 mg amiodarone infusion over 20 minutes, OR 150 mg over 10 minutes (if 300 mg
already administered during arrest). NB do not exceed a total of 450 mg of amiodarone
 In 250 ml 10% glucose IV/IO
 In 50 ml with 10% glucose via syringe driver
o For paediatrics with recurrent episodes of VF/VT, or non-sustained episodes of VT,
consult with a SAAS Medical Practitioner via the EOC Clinician.
Coronary Reperfusion Considerations
• If ST elevation diagnostic of STEMI persists on the 12 lead ECG, activate the receiving hospital
PCI team using the Code STEMI line (refer to Coronary Care (Acute) CPG) and notify the
receiving hospital early.

23
Q

ICP Seizure Differences (Adult)

A

IV/IO midazolam
- Up to 3 mg (adults)

  • IV/IO levetiracetam 20 mg/kg to a maximum of 2000 mg (administered over 15 min). If no response post second dose of midazolam
  • If no IV/IO access, then repeat IM midazolam 0.1 mg/kg (100 microg/kg) to a total cumulative dose of 0.3 mg/kg.

Post - ictal agitation
< 60 years of age: Up to 1 mg, to a total maximum cumulative dose of 5 mg
≥ 60 years of age: Up to 0.5 mg, to a total maximum cumulative dose of 5 mg

24
Q

Seizure differences ICP (Paed)

A

IV/IO midazolam
0.1 mg/kg (100 microg/kg) up to 3 mg (patients < 16 years)

Levetiracetam
o IV/IO levetiracetam 40 mg/kg to a maximum of 2000 mg (administered over 15 min)
o If no IV/IO access, then repeat IM midazolam 0.1 mg/kg (100 microg/kg) to a total cumulative dose of 0.3 mg/kg.

Post-ictal agitation
o ≥ 8 to < 16 years of age: Up to 0.5 mg IV, to a total maximum cumulative dose of 0.1 mg/kg (2 DOSES)
o < 8 years of age: Consult SAAS Medical Practitioner via EOC Clinician

25
Q

Sepsis ICP differences:

A

Adrenaline: If unable to achieve a SBP of > 100 mmHg or MAP > 65 mmHg following administration
of IV sodium chloride 0.9% up to 20 mL/kg, commence adrenaline infusion and titrate to
effect whilst cautiously continuing fluids.

o IV/IO adrenaline (3 mg made to 50 mL with sodium chloride 0.9%) administered via syringe driver starting at 5 microg/min
Or, if syringe driver unavailable: IV adrenaline 2 microg/mL in sodium chloride 0.9% (as adrenaline 1000 microg in sodium chloride 0.9% 500 mL) starting at 0.5 microg/kg/min

26
Q

SVT - ICP

A

In adults who are haemodynamically stable:

  • Record a 12 lead ECG
  • Perform a Valsalva manoeuvre
  • Establish a large bore, proximal IV when adenosine is being considered
  • Adenosine 6mg IV as a rapid push, followed by saline flush
  • if required, repeat with second dose adenosine 12mg IV
  • If required, repeat with final dose adenosine of 12mg IV

In adults who are inadequately perfused:
- Consider midazolam up to 5mg IV (in 1mg increments) to achieve amnesia. The aim is drowsiness with the ability to respond to verbal
stimuli
- Synchronised cardioversion at 100 joules. Repeat synchronised cardioversion at 150 joules if required

In paediatrics with stable symptomatic SVT:

  • Valsalva manoeuvre
  • Consider adenosine 100 microgram/Kg IV as a rapid push
  • If required, repeat with second dose adenosine 200 microgram/Kg
  • If required, repeat with final dose adenosine 300 microgram/Kg

In paediatrics who are inadequately perfused with a deteriorating conscious state:
- Synchronised cardioversion at 1 joules/Kg and repeat synchronised cardioversion at 2 joules/Kg if required

27
Q

Traumatic or Hypoxic Brain Injury - ICP

A

Basic care, including monitoring of:
o GCS
o ECG
o BGL
o Pulse oximetry; administer oxygen to achieve SpO2 of ≥ 95%.
o Capnography and ETCO2 (aim for a good volume curve and adequate rate):
- In an intubated patient, aim for an ETCO2 of 30-35 mmHg.
- Note that ETCO2 numbers are often not reliable in a spontaneously breathing patient.

  • Establish IV/IO access and administer 0.9% saline:
    o ≥ 14 years of age, attempt to maintain a systolic BP ≥ 110 mmHg.
    o < 14 years of age, attempt to maintain a systolic BP within the predictive normal range for their age (refer to SAAS paediatric RDR chart).
  • Exclude or treat other causes for altered behaviour e.g. hypovolaemia, hypoglycaemia,
    alcohol/psychostimulant overdose, psychosis, etc.

Posture 30 degrees head up if patient condition permits. Consider neck position, constrictive clothing, tight collars, tight tube ties.

In patients ≥ 14 years of age with systolic BP ≥ 110 mmHg requiring sedation to enable safe assessment and management:
- If < 60 years of age: Midazolam: Increments of up to 1 mg IV as a slow push, repeated after 5 mins up to a maximum total cumulative dose of 5 mg if required.
- If unable to gain IV access due to agitation, a single dose of midazolam 25 micrograms/kg IM to a maximum of 2.5 mg.
- If ≥ 60 years of age: Midazolam increments of up to 0.5 mg IV as a slow push, repeated after 5 mins up
to a maximum cumulative total dose of 5 mg if required.

28
Q

VT ICP (Adult)

A

Haemodynamically stable adults
- IV amiodarone 300 mg over 20 mins via:
o 100 mL saline bag (≈ 2 drops/sec)
o syringe driver made to 50 mL with saline

Poorly perfused adults
• IV/IO midazolam 1 mg increments total max dose 5 mg
• Synchronised cardioversion:
o 1st dose 100 J
o 2nd dose 150 J (if required)
29
Q

VT ICP (Paed)

A
  • Synchronised cardioversion:
    o 1st dose 1 J/kg
    o 2nd dose 2 J/kg (if required)
  • IV amiodarone 5 mg/kg over 20 mins via:
    o 100 mL saline bag (≈ 2 drops/sec)
    or
    o syringe driver made to 50 mL with saline
30
Q

ICP Spinal injury (Adult)

A

For isolated traumatic spinal cord injury with signs and symptoms of neurogenic shock:
- Aim to maintain normal temperature
- If the patient has symptomatic bradycardia refer to Clinical Practice Guideline
- For Hypotension resuscitation should be targeted to achieve a MAP of 80mm/Hg
- Administer IV/IO sodium chloride 0.9% up to 20 mLl/kg
- IV/IO Adrenaline (epinephrine) up to 50 microgram bolus increments titrated to
effect, OR
o IV/IO Adrenaline (epinephrine) 5-20 microgram/min via syringe driver titrated to
effect, OR
o IV/IO Adrenaline (epinephrine) 1 microgram/1 mL sodium chloride 0.9% infusion titrated to effect.

31
Q

Spinal Injury ICP (Paed)

A

• Aim to maintain normal temperature
• If the patient has symptomatic bradycardia refer to Clinical Practice Guideline
• Administer IV/IO sodium chloride 0.9% up to 20 mL/kg. Target a low range of normal BP as per RDR chart.
• Administer IV/IO adrenaline (epinephrine) starting at 0.5 microg/kg/min and consult
SAAS Medical Practitioner to discuss infusion rates via:
o syringe driver – 3mg made to 50 mL with saline
o manual infusion – 1mg into 500 mL saline bag
 2 microg / mL where 1 drop/sec

• Consider clinical support if the patient is experiencing significant cardiovascular or ventilatory instability
ventilatory instability

ICP Guidelines (1 decks)

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