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Flashcards in Neurological Protocols Deck (33):
1

Agitated pt, 17-60 years old, <50kg
What are the criteria for medication admin and what are the medication dosages?

BGL > 4mmol, BP > 110 systolic (or good pulse pressure), SaO2 > 95% (or no signs of cyanosis or resp distress), RR > 12, GCS >=14

Haloperidol 5mg / Midazolam 1mg IM
repeat Midazolam in 5 minutes (once) if persistent agitation.

GCS <14?, Haloperidol 5mg IM/IV

2

Agitated pt, 17-60 years old, >50kg
What are the criteria for medication admin and what are the medication dosages?

BGL > 4mmol, BP > 110 systolic (or good pulse pressure), SaO2 > 95% (or no signs of cyanosis or resp distress), RR > 12, GCS >= 14

Haloperidol 5mg / Midazolam 2mg IM
repeat Midazolam in 5 minutes (once) if persistent agitation.

GCS <14?, Haloperidol 5mg IM/IV

3

Agitated pt, >60 years old
What are the criteria for medication admin and what are the medication dosages?

BGL > 4mmol, BP > 110 systolic (or good pulse pressure), SaO2 > 95% (or no signs of cyanosis or resp distress), RR > 12, GCS >= 14

Haloperidol 2.5mg / Midazolam 0.5mg IM
repeat Midazolam in 5 minutes (once) if persistent agitation.

GCS <14?, Haloperidol 2.5mg IM/IV

4

Agitated pt, 14-16 years old
What are the criteria for medication admin and what are the medication dosages?

BGL > 4mmol, BP > 110 systolic (or good pulse pressure), SaO2 > 95% (or no signs of cyanosis or resp distress), RR > 12, GCS >= 14

Med: Midazolam 0.05mg/kg (max 2.5mg) IM/IV; one dose.

5

Possible organic causes of agitation

Acute intoxication states
Acute drug or alcohol withdrawal
Acute metabolic disorders (hypoglycemia, hypoxia, sepsis)
Head injury
Seizure disorder
Psychiatric illness

6

Restraint procedure

Minimum of 6 people.
Highest rank medical personnel take control of head and assume role of incident commander.
One person per limb.
Never restrain in prone position.

7

Symptoms of excited delirium

S - Super human strength
T - Though disorder
R - Resist violently
O - Overheating
N - No pain
G - Gasping

8

IPDA exclusion criteria (7)

¤ Signs/history of significant recent trauma/injury
¤ New/acute inability to ambulate
¤ New/acute inability to verbalize
¤ Focal neurological deficit
¤ Indication of acute overdose
¤ Poor general Impression
¤ Vital signs not within reasonable limits for patient’s condition

9

Signs & symptoms of ethanol intoxication (4)

slurred speech
disinhibited behaviour
central nervous system depression
altered coordination

10

Examples of sources of ingested ethanol acceptable in IPDA

Hairspray
Mouthwash
Hand sanitizer

11

Examples of inhaled intoxicants acceptable in IPDA

Gasoline
Paint
Lacquer thinner

12

Examples of toxic alcohols which must be transported to hospital

Methanol (windshield washer fluid)
Ethylene Glycol (antifreeze)

13

Clinically important features of the mental status and neurologic assessment

Pupils for size, reactivity and aniscoria
Cranial nerve function
Motor, sensory and brainstem functions
Deep tendon reflexes
Note any decorticate or decerebrate posturing
Able to maintain same level of alertness throughout assessment

14

Dosing for D50W in hypoglycemic adult or adolescent patient

50cc (1 amp); repeat if patient remains symptomatic after 10 minutes and blood sugar remains less than 4 mmol/L

15

Treatment for unconscious hypoglycemic adult or adolescent patient if IV unsuccessful

1mg glucagon IM

16

Dosing for D50W in hypoglycemic 1-9 year old patient

1ml/kg D50W

17

Dosing for Dextrose in hypoglycemic 1 month to 1 year old patient

2ml/kg D25W

18

Glucagon dose in hypoglycemic pediatric patient if no patent IV

.02mg/kg (max dose 1mg) IM/SC

19

Pre-intubation of any patient with signs of increased ICP

1mg/kg (max 100mg) IV LIDOCAINE to blunt the rise in ICP associated with laryngoscopy.

20

Signs of increased ICP

Cushings Triad:
Irregular respirations
Bradycardia
Systolic hypertension (widening pulse pressure)

21

Patient positioning consideration for ICP

Head of bed elevated 30 degrees.

22

Indications to consider administration of naloxone

* Suspected opioid or unknown substance overdose
* RR < 8 or altered LOC
* BGL > 4

23

Dosing of naloxone in suspected opioid overdose of an adult or adolescent patient.

0.4 - 2mg IM/IV PRN as required.
Clinical improvement will generally occur within 60 seconds after IV administration.

24

Opioid withdrawal symptoms

Lacrimation
Rhinorrhea
Sweating
Yawning
Chills
Goose pimples

25

Dosing of naloxone in suspected opioid overdose of pediatric patient.

0.1mg/kg IV/IM (max single dose 2mg)
Repeat PRN only if clinical improvement after first dose. Otherwise intubate (if BVM ventilations inadequate) and transport.

26

Treatment of Tricyclic overdose (adults)

If a widened QRS complex
¤ SODIUM BICARBONATE 100 mEq (2 ampoules) IV, or 2 mEq/kg (max. 100 mEq) in pediatric/adolescent patients.

If seizures develop treat as per Seizure Protocol

If wide complex tachycardia persists treat as per
Dysrhythmia: Wide Complex Tachycardia Protocol

27

Signs and symptoms of TCA overdose

Signs and symptoms of overdose include:
CNS - Altered level of consciousness progressing to seizures and coma
CVS - Widened QRS duration (greater than 0.12 sec or 0.08 sec in pediatric patient), dysrhythmias - PVC’s, VT, VF, Hypotension
Autonomic - Dry mouth, dilated pupils, ileus, decreased or absent bowel sounds, urinary retention

28

TCA overdose, cardiac arrest

In the event of cardiac arrest from tricyclic overdose, the appropriate ALS/PALS protocol should be followed
and, in addition, SODIUM BICARBONATE 100 mEq (2 ampoules), or 2 mEq/kg (max. 100 mEq) in pediatric/adolescent patients, should be administered intravenously.

29

Management of adult seizing patient.

Confirm patient is not hypoglycemic (<4)

¤ MIDAZOLAM 2.5 mg IV q5 min. for ongoing seizure activity
¤ Max. total dose of 10 mg

30

Management of adolescent seizing patient.

Confirm patient is not hypoglycemic (<3)

¤ MIDAZOLAM 0.15 mg/kg (max 2.5mg) IV q5 min. for ongoing seizure activity
¤ Max. total dose of 10 mg

31

Management of pediatric seizing patient.

Confirm patient is not hypoglycemic (neonate/<72 hours age BGL <2.6; infant BGL <3)

¤ MIDAZOLAM 0.15 mg/kg (max 2.5mg) IV q5 min. for ongoing seizure activity OR 0.3 mg/kg IN (max 5mg)
¤ Max 4 doses

32

Differential diagnosis for seizure

epilepsy or underlying seizure disorder
hypoglycemia
toxic ingestion / overdose
increased ICP / intracranial event (hemorrhage, infection, tumour, stroke)
eclampsia
heat stroke

33

What are the 12 cranial nerves?

the olfactory nerve (I),
the optic nerve (II),
oculomotor nerve (III),
trochlear nerve (IV),
trigeminal nerve (V),
abducens nerve (VI),
facial nerve (VII),
vestibulocochlear nerve (VIII),
glossopharyngeal nerve (IX),
vagus nerve (X),
accessory nerve (XI), and
hypoglossal nerve (XII)