Section 2: Medical Protocols Flashcards

Question

2.08 Adult Respiratory Distress (Asthma/COPD/RAD) Recognition/BLS

Answer 1

* Shortness of breath, pursed lip breathing, wheezing/rhonchi, prolonged expiratory phase, use of accessory muscles, increased respiratory rate and effort, fever, cough. E * Routine patient care. * For patients with wheezing and history of asthma, assist the patient with one dose of the patient’s own rescue inhaler (use a spacer if available) or administer ALBUTEROL 2.5 mg (+/- IPRATROPIUM BROMIDE 500 mcg) via SVN. Contact MEDICAL CONTROL for authorization to administer additional doses. * For patient not responding to initial therapy, consider continuous positive airway pressure (CPAP) at 5-10 cmH2O. * Transport the patient to the nearest appropriate Hospital Emergency Facility.

Answer 2

* ALBUTEROL 2.5-5 mg (initial dose should include IPRATROPIUM BROMIDE 500 mcg, subsequent doses may be +/- IPRATROPIUM) via SVN (may repeat PRN to a maximum of 4 doses). * METHYLPREDNISOLONE 125 mg IV or PREDNISONE 60 mg PO or DEXAMETHASONE 10-20 mg IV/IM. * Consider LEVALBUTEROL 1.25 mg via SVN or MDI (may repeat every 20 minutes as needed x4). * For patients with asthma, consider MAGNESIUM SULFATE 2 gm IV over 10 minutes. * For the patient with a diagnosis of asthma who is in extremis, EPINEPHRINE (1:1000) 0.3 mg IM, may repeat every 15 minutes x2. * Consider MIDAZOLAM 1-2 mg IV if needed to enhance CPAP compliance. * For patient not responding to initial therapy, consider bilevel positive airway pressure (BiPAP) at an initial rate of 12 breaths per minute and pressure of 15/5 or as directed by Medical Control if available.

Answer 3

* Recommended exam: mental status, HEENT, skin, neck, cardiac, abdomen, pulmonary, extremities, neurologic. * Differential diagnosis should include asthma, COPD, anaphylaxis, aspiration, pleural effusion, pneumonia, pulmonary embolus, CHF, hyperventilation, inhaled toxin, exit appropriate protocol based on index of suspicion. * SpO2 and EtCO2 should be monitored continuously in patients with persistent distress. * A “silent chest” in the asthmatic patient is a pre-respiratory arrest indicator. * When considering endotracheal intubation in the asthmatic patient, if possible administer a rapid IV bolus of 1L NS or LR prior to intubation. * Asthmatics are prone to hypotension following conversion to positive pressure ventilation (endotracheal intubation) due to decreased cardiac return (preload). Address volume status prior to intubation, following intubation ventilate the patient at a lower rate and utilize lower tidal volumes. Hypercapnia, as evidenced by increased EtCO2 levels is acceptable and attempts to correct with hyperventilation should be avoided.

Answer 4

* Respiratory distress with tachypnea, nasal flaring, retractions. * Bronchiolitis: < 2 y.o. (peak 3-6 mo), +/- history of poor feeding/fussiness, increasing coryza and congestion, +/- low-grade fever, cough, fine crackles, fine/diffuse wheezing. * Croup: 6 mo. - 6 y.o. (peak <4 yo), upper respiratory tract infection, low grade fever, coryza, “barking” cough, varying degrees of respiratory distress. * Asthma/RAD: > 2 y.o., wheezing, cough, chest tightness, prolonged expiratory phase, +/- fever. * Epiglottitis: > 2 y.o., fever, toxic/ill appearing, favors upright position, drooling, stridor. * Routine patient care. * Allow patient to assume position of comfort. * OXYGEN if the SpO2 is ≤ 92%. * For patients with wheezing and history of asthma, assist the patient with one dose of the patient’s own rescue inhaler (use a spacer if available) or administer ALBUTEROL 2.5 mg (+/- IPRATROPIUM BROMIDE 500mcg) via SVN. Contact MEDICAL CONTROL for authorization to administer additional doses. * For patients with suspected epiglottitis: * Allow patient to assume position of comfort. * Allow secretions to drain passively (i.e., avoid suctioning). * Minimize airway manipulation, provide airway management per age appropriate Airway Management Protocols only in the event of complete airway obstruction (most patients with epiglottis related airway obstruction can be effectively bag-mask ventilated). * Transport the patient to the nearest appropriate Hospital Emergency Facility.

Answer 5

* For patients < 2 y.o. with respiratory distress and suspected bronchiolitis: * Perform gentle nasopharyngeal suctioning for copious secretions. * Supplemental oxygen if the SpO2 is ≤ 92%. * If the patient appears to be dehydrated, consider a 20 ml/kg NORMAL SALINE IV bolus. For patients < 6 y.o. with respiratory distress and suspected croup: * Supplemental oxygen if the SpO2 is ≤ 92%. * If the patient appears to be dehydrated, consider a 20 ml/kg NORMAL SALINE IV bolus. * DEXAMETHASONE 0.6 mg/kg PO/IM/IV (PO preferred, maximum 10 mg). * For patients with significant respiratory distress or stridor at rest, consider EPINEPHRINE (2.25% solution) 0.5ml/3ml NS or EPINEPHRINE 5 mg (1mg/1ml concentration) via SVN, may repeat x1. * For patients ≥ 2 y.o .with reactive airway disease (RAD)/asthma: * ALBUTEROL 2.5-5mg (initial dose should include IPRATROPIUM 500 mcg, subsequent doses may be +/- IPRATROPIUM) via SVN for continued wheezing (may repeat x3). * Consider IV access if the SpO2 is ≤ 92% following the first dose of inhaled beta agonist. * Consider continuous positive airway pressure (CPAP) @ 5-10 cmH20 if tolerated. * METHYLPREDNISOLONE 2 mg/kg IV (maximum 60 mg ) or HYDROCORTISONE 2 mg/kg IV (100 mg maximum) or PREDNISONE/PREDNISOLONE (Orapred) 2 mg/kg PO (60 mg maximum) or DEXAMETHASONE 0.6 mg/kg PO/IM/IV [PO preferred] (maximum 10 mg). * Consider MAGNESUM SULFATE 40 mg/kg IV over 10 minutes (2 gm maximum). * For continued respiratory distress, EPINEPHRINE (1:1:000) 0.15-0.3 mg IM (lateral thigh).

Answer 6

* Differential diagnosis should include asthma/reactive airway disease, anaphylaxis, aspiration, foreign body airway obstruction, upper or lower airway infection (pneumonia), congenital heart disease, CHF, toxic ingestion. * SpO2 should be monitored continuously in patients with persistent distress. * Bronchiolitis is a viral infection usually affecting infants and that results in wheezing and typically does not respond to inhaled beta agonist. The management of bronchiolitis is largely supportive. * Nebulized epinephrine is typically not recommended in bronchiolitis unless the patient is in extremis. Use of nebulized epinephrine prolongs ED stays as it requires a 3 to 4 hour observation time after administration . * Croup typically affects children from 6 mo to 6 yo with a peak around 2 yo of age at year < 4 y.o. and is characterized by a barking like cough resulting from upper airway edema. It is viral, may be associated with fever, is typically of gradual onset, and drooling is not typically noted. * Use of nebulized epinephrine for croup should be limited to those patients with significant respiratory distress or stridor at rest. * Epiglottitis is a bacterial infection typically affecting children > 2 yo. It is usually of rapid onset, associated with fever and drooling. Stridor may be present and the patient may assume the tripod position. Airway manipulation may worsen the condition and should be avoided. The incidence of epiglottis has decreased over the last couple of decades due to routine immunization against Haemophilus influenzae. * A “silent chest” in the asthmatic patient is a pre-respiratory arrest indicator. * When considering endotracheal intubation in the asthmatic patient, if possible, administer a rapid 20 ml/kg IV bolus of NS or LR prior to intubation. * Asthmatics are prone to hypotension following conversion to positive pressure ventilation (endotracheal intubation) due to decreased cardiac return (preload). Address volume status prior to intubation, following intubation ventilate the patient at a lower rate and utilize lower tidal volumes. Hypercapnia, as evidenced by increased EtCO2 levels is acceptable and attempts to correct with hyperventilation should be avoided.

Answer 7

* Patient exhibiting any one or a combination of the following: anxiety, agitation, affect change including withdrawn/depressed affect, hallucinations, delusional thoughts, bizarre behavior, combative or violent behavior, expression of suicidal/homicidal thoughts. * Consider safety of EMS healthcare professionals first. If law enforcement is not present at the scene, consider staging in a safe area until the arrival of law enforcement. * Routine patient care. * Consider possible medical etiologies, managing per the following age appropriate protocols as indicated: * Altered Mental Status * Diabetic Emergencies * Delirium with Agitation * Head Trauma - Traumatic Brain Injury * Toxicological Emergencies * Patient in Police Custody E * Remove patient from stressful environment, if present. * Use the SAFER model: * Stabilize the situation by lowering stimuli, including voice. * Assess and acknowledge crisis by validating the patient’s feelings and not minimizing them. * Facilitate identification and activation of resources (clergy, family, friends, mental health professionals and police, as indicated). * Encourage the patient to use resources and take action in their own best interest. * Recovery/referral – transport the patient to a Hospital Emergency Facility or approved alternative destination (see below). If the patient is not transported, be sure the patient is in the care of a responsible individual or Healthcare Professional. * Consider Patient Restraint Protocol if indicated (aggressive, agitated, psychosis, possible danger to self or others). Restraint should be performed/assisted by law enforcement when available. * Transport the patient to the nearest appropriate Hospital Emergency Facility. * If there are no medical or substance use disorder etiologies, transport patient to a mental health preferred facility if the transport time is less than 20 minutes (see Table 2 Point of Entry – Specialized Hospital Emergency Facilities in Routine Patient Care). * For patients with known or suspected opioid overdose who are stable, with adequate ventilation (before or after NALOXONE administration), transport the patient to an opioid use disorder preferred facility, if the transport time is less than 20 minutes (see Table 2 Point of Entry – Specialized Hospital Emergency Facilities in Routine Patient Care). * For patients with known or suspected alcohol or opioid use disorder, that are stable with adequate ventilation and mental status, consider transport a mental health and opioid use disorder facility (see Table 2 Point of Entry – Specialized Hospital Emergency Facilities in Routine Patient Care) by following the Alternative Transportation Algorithm. * For patients with known mental health history who are presenting with an acute exacerbation of their condition and not exhibiting danger to self or others, consider transport a mental health and opioid use disorder facility (see Table 2 Point of Entry – Specialized Hospital Emergency Facilities in Routine Patient Care) by following the Alternative Transportation Algorithm.

Answer 8

* For patients ≥16 y.o. with aggressive or agitated behavior who are not responsive to the above interventions, consider chemical restraint: * HALOPERIDOL 5 mg IV/IM or DROPERIDOL 5 mg IV/IM (2.5 mg if age ≥ 65), may repeat either in 10 minutes to a cumulative dose of 10 mg or * MIDAZOLAM 2.5-5 mg IV or 5 mg IM/IN, may repeat every 10 minutes PRN if SBP >100 to a cumulative dose of 10 mg (5 mg if age ≥ 65, avoid if suspected alcohol intoxication or sedative use) or * KETAMINE 2 mg/kg IM (maximum 200 mg) or 1 mg/kg IV (maximum 100mg). * For hypersalivation following KETAMINE administration, consider ATROPINE SULFATE 0.5 mg IV/IM. Contact Medical Control if repeat or different doses are indicated. * For patients <16 y.o., contact Medical Control to discuss treatment options.

Answer 9

* Be sure to consider all possible medical/trauma etiologies for behavior (hypoglycemia, toxicological, hypoxic, head injury). * Do not position or transport any restrained patient in such a way (e.g., prone) that could negatively affect the patient’s respiratory or circulatory status. * Any patient who is handcuffed or restrained by law enforcement and transported by EMS must be accompanied by a law enforcement officer. * Continuous monitoring of EtCO2 (waveform) and SpO2 are mandatory in patients who receive physical or chemical restraint. When clinically feasible, ECG monitoring is required for patients that have received haloperidol and strongly recommended for all patients who receive chemical restraint. * It may be necessary/appropriate to administer IM injections through clothing in extremely agitated patients. * Extrapyramidal reactions associated with haloperidol or droperidol should be managed per the age appropriate Toxicological Emergencies Protocol. * BH Link - 401-414-5465 (LINK)

Answer 10

* Hypoglycemia: anxiety, altered mental status, diaphoresis, seizures, tachycardia. * Diabetic ketoacidosis: warm dry skin, tachycardia, rapid shallow breathing, hypotension/ shock, acetone odor on breath, EtCO2 ≤29 mmHg. * Routine patient care. * Perform blood glucose (bG) analysis and determine bG level if not previously determined. * Treat as below (in the absence of the ability to determine bG, patients with signs or symptoms of hypoglycemia should be treated as below as appropriate for their mental status and their ability to receive ORAL GLUCOSE SOLUTION).

Answer 11

≤ 60 mg/dl Patient is Awake and Alert 1. ORAL GLUCOSE SOLUTION* (15 gm glucose) PO 2. Recheck bG in 15 minutes 3. Repeat dose of ORAL GLUCOSE SOLUTION if bG ≤ 60 mg/dl ≤ 60 mg/dl Patient is Not Alert to Verbal Stimuli or is Nauseated/Vomiting 1. Thiamine 100 mg IV/IM 2. D10W 250 ml (25g) IV over 5 minutes, may repeat in 5 minutes if bG <60 mg/d 3. If unable to establish IV access, GLUCAGON 1mg (1U) IM or GLUCAGON (Baqsimi) 3mg IN. ≥ 250 mg/dl 1. If patient is dehydrated without evidence of CHF/fluid overload, administer NORMAL SALINE 500 ml IV bolus. Repeat as needed 2. Infuse NORMAL SALINE at 150 ml/hr * Thiamine should be reserved for patients who have a history of alcohol abuse or who appear malnourished. * If the patient is hypotensive, manage per age appropriate General Shock and Hypotension Protocol. * Encourage patients who refuse transport after improvement in GCS and are back to baseline to consume complex carbohydrates (15 grams) and protein (12-15 grams) such as peanut butter toast, mixed nuts, milk or cheese to stabilize blood sugar. * Transport the patient to the nearest appropriate Hospital Emergency Facility.

Answer 12

* Patients who present with a bG≤ 60 mg/dl and are taking oral hypoglycemic agents should be strongly encouraged to agree to transport due to long half life of most oral hypoglycemics.

Answer 13

* Hypoglycemia: anxiety, altered mental status, diaphoresis, seizures, tachycardia. * Diabetic ketoacidosis: warm dry skin, tachycardia, rapid shallow breathing, hypotension/ shock, acetone odor on breath, EtCO2 ≤29 mmHg. * Routine patient care. * Perform blood glucose (bG) analysis and determine bG level if not previously determined. * Treat as below (in the absence of the ability to determine bG, patients with signs or symptoms of hypoglycemia should be treated as below as appropriate for their mental status and their ability to receive ORAL GLUCOSE SOLUTION).

Answer 14

≤ 60 mg/dl Patient is Awake and Alert 1. ORAL GLUCOSE SOLUTION* (15 gm glucose) PO 2. Recheck bG in 15 minutes 3. Repeat dose of ORAL GLUCOSE SOLUTION if bG ≤ 60 mg/dl ≤ 60 mg/dl Patient is Not Alert to Verbal Stimuli or is Nauseated/Vomiting 1. D10W 5 ml/kg over 5 minutes, may repeat in 5 minutes if bG <60 mg/dl 2. If unable to establish IV access, GLUCAGON 0.1 mg/kg IM [1 mg maximum ≥ 250 mg/dl 1. If patient is dehydrated without evidence of CHF/fluid overload, administer NORMAL SALINE 20 ml/kg IV bolus. Repeat as needed 2. Infuse NORMAL SALINE at 20 ml/hr * If the patient is hypotensive, manage per age appropriate General Shock and Hypotension Protocol. * Encourage patients who refuse transport after improvement in GCS and are back to baseline to consume complex carbohydrates (15 grams) and protein (12-15 grams) such as peanut butter toast, mixed nuts, milk or cheese to stabilize blood sugar. * Transport the patient to the nearest appropriate Hospital Emergency Facility.

Section 2: Medical Protocols Flashcards

(38 cards)