Medical Protocols Flashcards
(29 cards)
1
Q
Adrenal Insufficiency Adult/Pedi: Indications
A
Stress Dose Indications if known/suspected adrenal insufficiency:
- Shock (any cause)
- Fever >100.4 F and ill-appearing
- Multi-system trauma
- Drowning
- Environmental hyper/hypothermia
- Multiple long-bone fx
- V/D w/ dehydration
- Resp Distress
- 2nd/3rd degree burns >5% BSA
- RSI (Etomidate may precipitate adrenal crisis)
- Hypoglycemia
2
Q
Adrenal Insufficiency Adult/Pedi
A
Adult:
- Hydrocortisone: 100 mg IV/IO/IM OR
- Methylprednisone: 125 mg IV/IO/IM
Pedi:
- Hydrocortisone: 2 mg/kg, max of 100 mg IV/IO/IM OR
- Methylprednisone: 2 mg/kg max of 125 mg IV/IO/IM
MEDCONTROL: - Additional Doses esp if demonstrating S/S as listed > N/V > abd pain > weakness > dizz > muscle pain > dehydration > tachycardia > fever > AMS - Additional consideration: > Aggressive vol replacement > Treat other conditions > Normalize body temp
3
Q
Allergic Reaction/Anaphylaxis Adult
A
MILD DISTRESS:
- Diphenhydramine: 25-50 mg IV/IO/IM
SEVERE DISTRESS:
- Epi: 0.3 mg (1:1,000) auto-injector may repeat once in 5 min
- Diphenhydramine: 25-50 mg IV/IO/IM
- Hydrocortisone: 100 mg IV/IO/IM OR
- Methylprednisone: 125 mg IV/IO/IM
MEDCONTROL
- Additional doses
- Epi: 0.1-0.5 mg (1:10,000) IV/IO
- Epi Infusion: 1-10 mcg/min IV/IO (1mg 1:1,000/250 mL)
- Dopamine: 2-20 mcg/kg/min (Rate determined by physician)
4
Q
Allergic Reaction/Anaphylaxis Adult: Mild vs Severe
A
Mild: - Itching - Urticaria - Nausea - No Resp Distress Severe: - Stridor - Bronchospasm - Severe Abd Pain - Resp Distress - Tachycardia - Shock - Edema of lips, tongue and/or face
5
Q
Allergic Reaction/Anaphylaxis Pedi: Clinical Criteria for Anaphylaxis
A
Treat for Anaphylaxis if one the the following is fulfilled:
1.) Acute on set of skin/mucosal involvement w/ one of the following:
A.) Resp Compromise
B.) Decreased BP or evidence of end-organ hypoperfusion
2.) >/= 2 of the following occur rapidly after exposure to likely antigen:
A.) Skin/mucosal involvement
B.) Resp Compromise
C.) Decreased BP or evidence of end-organ hypoperfusion
D.) Persistent GI symptoms
3.) Decreased BP after exposure to a known allergen for that pt.
6
Q
Allergic Reaction/Anaphylaxis Pedi
A
- Epi Autoinjector:
a. ) >/=25 kg: 0.3 mg (Adult auto injector)
b. ) Contact Med Control for additional Epi after 5 min - Diphenhydramine: 1 mg/kg max single dose of 50 mg IV/IO/IM
- Hydrocortisone: 2 mg/kg max single of 100 mg IV/IO/IM or
- Methylprednisone: 2 mg/kg max single of 125 mg IV/IO/IM
MEDCONTROL
- Additional doses
- Epi Infusion: 0.1-1 mcg/kg/min IV/IO
- Albuterol:
a. ) >/=2 y.o.: 2.5-3 mg neb
b. ) <2 y.o.: 1.5 mg neb - Epi: 1:10,000 0.01 mg/kg IV/IO max single of 0.3 mg
7
Q
AMS/Neurological Status/DM Emergencies Adult
A
- Unconscious/seizing pt: place in LLR if not contraindicated
- DM Hypoglycemia BGL Able to Swallow and Speak:
a. ) Oral Glucose: One tube, can sub other sugar source. Repeat in 10 min if still symptomatic.
> Unable to Swallow and Speak:
a. ) Dextrose: Up to 25 mg IV/IO, recheck BGL in 5 min. May repeat dose if BGL still 300:
a. ) 500 mL fluid bolus, then 250 mL/hr
- Consider Thiamine: 100 mg IV/IO/IM
MEDCONTROL
- Additional doses
8
Q
Dextrose Note
A
May be administered in D50/D25/D10, as long as dosage is correct. Dosage adjustments as listed
- D50: 0.5 mg/mL = 25g/50mL
- D25: 0.25 mg/mL = 25g/100mL
- D10: 0.1 mg/mL = 25g/250mL
9
Q
AMS/Neurological Status/DM Emergencies Pedi
A
- Unconscious/seizing, place in LLR position if not contraindicated
- DM Hypoglycemia BGL Dextrose 10%: 0.5 g/kg IV/IO
> Glucagon (Unable to est IV) 0.1 mg/kg IV/IO/IM/IN/SC max single of 1 mg - DM Hyperglycemia BGL >300 and symptomatic:
a. ) 20 mL/kg fluid bolus - Consider confirming adrenal insufficiency
MEDCONTROL
- Additional doses
10
Q
Behavioral Emergencies Adult/Pedi
A
After or Before:
- Est IV w/ NS KVO
- Monitor and 12 lead if feasible
- Position as to not impair breathing
Adult: - Haloperidol: 5 mg IM, and/or - Lorazepam: 2 mg IV/IO/IM or - Midazolam: 2.5-5 mg IV/IO/IM/IN Note: Pts > 70 y.o., limit dose to half
Pedi:
- Midazolam: 0.1 mg/kg IV/IO/IM/IN
MEDCONTROL
- Additional doses
11
Q
Behavioral Emergencies Notes
A
- Haldol: Preferred for psychotic and head trauma pts. Contraindicated for hx of seizures and prolonged QT intervals
- Lorazepam: Preferred for pts w/ alcohol w/drawl or sympathomimetic toxicity (cocaine or PCP)
- Diazepam: Should NOT be used with pt experiencing behavioral emergencies.
12
Q
Bronchospasm/Resp Distress Adult
A
- O2
- Albuterol: 2-3 mg neb, additional treatments as necessary.
- Ipratropium Bromide: 500 mcg via neb, maybe combine with Albuterol. May or may not be administered with additional Albuterol treatments.
- Pts with dx asthma/COPD w/o hx or S/S of CHF consider
a. ) Hydrocortisone: 100 mg IV/IO/IM or
b. ) Methylprednisone: 125 mg IV/IO/IM - Pts </= 40 y.o. Consider: Epi 0.15-0.3 mg via auto-injector only as one time dose only.
- CPAP: Consider in not contraindicated
- Asthma Consider Mag: 2-4 g IV/IO over 5 min
MEDCONTROL
- Additional doses
- Epi: 1:10,000 0.1-0.5 mg IV/IO very slowly
13
Q
Bronchospasm/Resp Distress Pedi
A
- O2
- Albuterol
a. ) >/=2 y.o.: 2.5-3 mg neb
b. ) < 2 y.o.: 1.5 mg via neb
c. ) May provide one additional dose w/ or w/o atrovent - Ipratropium:
a. ) >/=2 y.o.: 500 mcg neb
b. ) < 2 y.o.: 250 mcg neb - Pt >/=2 y.o. with dx of asthma consider
a.) Hydrocortisone: 2 mg/kg, max single of 100 mg IV/IO/IM or
b.) Methylprednisone: 2 mg/kg, max single of 125 mg
IV/IO/IM - Severe distress, pt > 5 y.o.: Epi auto injector based on wt. May repeat once in 5 min if needed.
- Mag: 25 mg/kg IV/IO over 10 min, max single dose of 2g
MEDCONTROL
- Additional doses
14
Q
Bronchospasm/Resp Distress Criteria
A
Mild Distress: Children with minor wheezing and good air entry.
Severe Distress: Poor air entry, accessory muscle use (extreme), nasal flaring, grunting, cyanosis and/or AMS
Resp Distress: Inadequate breathing in terms of rate, rhythm, quality and/or depth. Causes inadequate O2 SpO2 of hgb and may increase PaCO2.
15
Q
Hyperthermia (Environmental) Adult/Pedi
A
- Remove from environment
- Position supine
- Loosen/remove all unneeded clothing
- Cool packs in armpits, neck, and groin
- Fan
- Keep skin wet
- Heat Cramps and/or Heat Exhaustion: Consider 500 mL bolus even w/ normal vitals or sports drink if able to swallow and speak.
a. ) Pedi: 20 mL/kg if indicated
16
Q
Hypothermia (Environmental) Adult/Pedi
A
- Avoid rough handling
- Remove from environment
- Remove any wet clothing
- Insulate and blankets
- Cover head
- Assess hemodynamics and ABC, check for at least 60 seconds
- Provide humidified O2 (104-107 F, 40-42 C) if resus needed
- Warm Fluids
- DO NOT: Massage extremities
17
Q
Obstetrical Emergencies
A
- Expose as needed to assess for bleeding, breech birth, crowning, prolapsed cord, limb presentation.
- Exceptions for digital insertion:
a.) Management of baby’s airway in breech presentation
b.) Prolapsed cord
> knee to chest or t-berg
> Assess for blood flow and maintain with gentle pressure if needed - Remember regular travel position is LLR
- Eclamptic Seizures
a. ) Lorazepam: 2-4 mg slow IV/IO/IM or
b. ) Diazepam: 5-10 mg slow IV/IO/IN or
c. ) Midazolam: 2.5-5 mg IV/IO/IM/IN
MEDCONTROL
- Additional IV fluids
- Mag: 1-4 g IV/IO over 10 min (eclapmsia)
- Ca++Chl-: 10% 2-4 mg/kg slow IV/IO over 5 min (Mag OD)
- Further anticonvulsant Therapy
18
Q
Newly Born Care
A
- Dry, Warm, position, and stimulate
- Clear secretion only if needed:
a. ) Position supine or on side, head in neural position or slightly extended.
b. ) Suction with resp distress, oropharynx first . Meconium suctioning only if thick/present, resp depression and/or obstruction. - Clamp/cut cord:
a. ) After initial assessment and it has stopped pulsating
b. ) Leave minimum of 6 in - Prevent heat loss, swaddler tech preferred, esp head.
- Place skin-to-skin on mother abd/brest
- Assess Resp:
a. ) Flick soles of feet, rub back. - Assess Circ:
a. ) Auscultate apical pulse or
b. ) palp umbilical pulse at base - Assign APGAR 1 and 5 min
19
Q
Resuscitation of New Born
A
- Resp inadequate or chest fails to rise: Vent at room air 40-60 bpm (full term and pre term)
- HR < 60: Initiate CPR and vent w/ high flow O2. Vent for one minute and reassess pulse.
a. ) HR 60-80: If responds and rapidly rises with vent, continue vent, and apply monitor
b. ) HR < 60: Continue CPR with Vent. Consider advanced airway with ETCO2. - Defib indicated:
a. ) Initial: 2 j/kg. Followed by: 4 j/kg - Synchro Cardio indicated: 0.5 -1 j/kg
- Est IV/IO: treat for shock, 10cc/kg of NS over 5-10 min
MEDCONTROL
- Epi: 1:10,000 (0.01-0.03 mg/kg IV/IO
- Epi Infusion: Administer 0.1-1 mcg/kg/min
20
Q
Pain/Nausea Management Adult/Pedi
A
Pain:
- Adult:
a.) Morphine: 2 mg IV/IO/IM/SC q 5 min, max of 10 mg
OR
b.) Fentanyl: 1 mcg/kg slow IV/IO/IM/IN, max of 150 mcg
- Pedi:
a.) Morphine: 0.1 mg/kg IV/IO/IM/SC, max single of 5mg
OR
b.) Fentanyl: 1 mcg/kg slow IV/IO/IM/IN, max of 150 mcg
Nausea:
- Adult: Zofran 4 mg IV/IO/IM or disintegrating tablet
- Pedi:
a. ) >/= 25 kg: 4 mg IV/IM or ODT
b. ) <25 kg: 2 mg IV/IM or ODT
MEDCONTROL
- Additional doases
21
Q
Seizures Adult
A
- If pt is Rx rectal gel diazepam: Assist caregiver in administration
- Vagus Nerve Stimulator: Suggest family pass magnet over q 3-5 min, total of 3x; assist if needed.
a. ) Note: do not delay med admin - Cardiac Monitor and 12 if feasible
- Status Epilepticus: Seizure lasting >5 min. Use one of the following.
a. ) Midazolam: 2.5-5 mg slow IV/IO/IM/IN
b. ) Lorazepam: 2-4 mg slow IV/IO/IM
c. ) Diazepam: 5-10 mg slow IV/IO/IM/PR
MEDCONTROL
- Additional doses
- Mag: 1-4 g IV/IO over 10 min if suspected eclampsia.
a. ) Note: Eclampica seizures can occur up to several weeks s/p birth
Note: Beznos contraindicated with head injury or hypotension Consult with MC.
22
Q
Seizures Pedi
A
- If Rx diazepam rectal gel, assist care giver in administration
- Vagus Nerve Stimulator: Have Family and/or assist pass magnet over q 3-5 min, total of 3x.
a. )Note: do not delay med administration - Status Epilepticus: Choose one of the following.
a. ) Midazolam: 0.05 mg/kg IV/IO/IM/IN, max single dose of 4 mg OR
b. ) Lorazepam: 0.05-0.1 mg/kg IV/IO/IM slow (dilute 1:1 NS), max single of 2 mg OR
c. ) Diazepam: 0.25 mg/kg IV/IO/IM, max single 5-10 mg of rectal dose of 0.5 mg/kg unless contraindicated.
MEDCONTROL
- Additional doses
23
Q
Shock - Adult
A
- Determine and treat underlying causes
- Physiological Signs:
a. ) AMS
b. ) Rapid pulse cannot be detected
c. ) SBP <100 - Cardiogenic:
a. ) Assess and treat for Pulmonary Edema and/or CHF
b. ) No Fluid Bolus - Distributive Shock:
a. ) Fluid vol administered based on hemodynamic stability - Hypovolemic Shock:
a. ) Control bleeding as needed
b. ) Fluid vol administered based on hemodynamic stability - Obstructive Shock:
a. ) Fluid vol administered based on hemodynamic stability
MEDCONTROL
- Cardio/Hypovolemic/Obstructive: Dopamine 2-20 mcg/kg/min IV/IO
- Obstructive Shock: Needle decompression with tension pneumothorax.
Note: S/S of persistent Hypoperfusion or S/S worsen, consider dopamine via med control regardless of etiology in the absence of hemorrhagic shock.
24
Q
Pts w/ uncontrolled hemorrhagic or penetrating injuries
A
- Restrict IV fluids. Delay aggressive fluid resuscitation until operative intervention may improve then outcome.
- Pt should be reassessed frequently, w/ special attention given to the lungs to ensure vol overload does not occur.
- Several Mech that can worsen pt outcome w/ IV fluids:
a. ) Dislodgement of clots
b. ) Dilution of clotting factors
c. ) Acceleration of hemorrhage by elevating BP
25
Shock - Pedi
- Keep pt supine
- Prevent heat loss if not febrile
- Determine and treat underlying causes
- Distributive Shock:
a. ) Fluid Resuscitation: Therapeutic End-point to fluid resuscitation in order of importance
1. ) Cap refill
2. ) Normal Pulse
3. ) No difference btw peripheral and central pulse
4. ) Warm extremities, normal mental status
5. ) Noramal BP
- Hypovolemic Shock:
a. ) Control Bleeding as indicated
b. ) Fluid Resuscitation: As with distributive shock
MEDCONTROL:
- Regardless of etiology, and in the absents of hemorrhagic shock, if S/S of hypoperfusion persist or S/S worsen consider dopamine with length based tape via medcontrol
- Needle Decompression for tension pneumothorax
26
Stroke
- Preform Mass Stroke Scale of equivalent
- Clearly determine time of onset
- First symptoms onset 4.5 hrs tx to appropriate facility according to local guidelines/agreements
- Elevate stretcher to 30 degrees
- Consider taking family member of bystander to cooberate onset time
27
Mass Stroke Scale
1. ) One or more of the following
- Facial Droop (Show teeth or smile)
a. ) Normal: Both sides of face move equally
b. ) Abnormal: One side of face does not move as well
- Arm Drift: (Close eyes and extend arms for 10 seconds)
a. ) Normal: No drift or both arms drift equally
b. ) Abnormal: One arm drifts/moves down compared to other or one more noticeably weaker than other
- Speech: (Score first attempt: The sky is always blue in Boston)
a. ) Normal: Correct words and no slurring on first attempt
b. ) Abnormal: Incorrect/unable to speak words, and/or slurring
2. ) One or more Sudden Acute Stroke Symptoms:
- Sudden numbness, weakness/paralysis, especially if unilaterally
- Sudden confusion, trouble speaking or understanding words
- Sudden trouble seeing in one/both eyes
- Sudden trouble walking, loss of balance or coordination
- Sudden severe h/a w/ no known cause
28
Nerve Agents Organophosphate Poisoning: Adult/Pedi
```
- Assess for SLUDGEM:
S- Salivation
L- Lacrimation
U- Urination
D- Defecation
G- Gastric distress
E- Emesis
M- Muscle twitching/ miosis (pupil constriction)
- Assess for Killer Bs: Bradycardia, Bronchorrhea, Bronchospasm
```
- Administer 3 DuoDote kits
- If S/S persist administer:
a.) Atropine: 2 mg IV/IO; q 5 min until secretions clear
b.) Pralidoxime: 1-2 G IV/IO over 30-60 min
c.) Diazepam: 5 mg IV/IO q 5 or 10 mg Auto-injector q 10 min, prn. Diazepam not available may consider one of the following.
>Lorazepam: 1 mg IV/IO may repeat once in 5 min, or 2 mg IM may repeat once in 10. OR
> Midazolam: 2.5 mg IV/IO/IN q 5 min, or 5 mg IM q 10 min, prn.
MEDCONTROL
- Additional doses
- Pralidoxime Maint Infusion: up to 500 mg/hr (max od 12 g/24hrs)
29
Poisoning/Substance Abuse/OD/Toxicology: Adult/Pedi
- OD: Naloxone 0.4-2mg IV/IO/IM/IN repeat as indicated
- Alcoholism: Consider Thiamine 100 mg IV/IO/IM
MEDCONTROL
- CBB OD/hypermag: Ca+Chl- 10% 2-4 mg IV/IO slow over 5 min
- Na+HCO3: 0.5-1mEq/kg IV/IO (eg: TCA, ASA, Acidosis, Barbiturate OD)
- Atropine: 2-5 mg IV/IO (eg: Organophosphate OD)
- Albuterol: 2.5-3 mg neb (eg: Bronchospasm)
- Furosemide: 40 mg IV/IO (eg: Pulm Edema/CHF)
- Diazepam: 5-10 mg slow IV/IO/IM/PR; or
- Lorazepam: 2-4 mg slow IV/IO/IM (seizures); or
- Midazolam: 2.5-5 mg IV/IO/IM/IN
- Amyl Nitrate: Crush, administer under nose with high flow O2 for 15/30 sec.
- Cyanide Antidote Kit: If available
a.) 2 Amyl Nitrate inhalants
b.) 3% Na+ Nitrate: (stop amyl nitrate)
> Adult: 10 mL slow IV/IO over 2-4 minutes
> Pedi: 0.2 mL/kg (up to 10 mL) slow IV/IO over 5 min
c.) Na+ Thiosulfate 25%:
> Adult: 50 mL IV/IO
> Pedi: 5 mL of Na+ thiosulfate per 1 mL of Na+ Nitrate.
> Note: if hypotension develops, STOP all nitrates, treat for shock, and consider dopamine
- Hydroxocobalamin: 5 gm IV/IO for cyanide toxicity
- Glucagon: 1-5 mg IV/IO/IM for BB/CBB OD
