Medical Protocols
General Medical Care Guideline
Patient Refusals
Abdominal Pain
Abuse/Maltreatment and Human Trafficking
Agitated/Behavioral Emergencies
Allergic Reaction/Anaphylaxis
Altered Mental Status/Behavioral
Back Pain
Bronchospasm
Chest Pain/Coronary Syndrome/STEMI
CHF/Pulmonary Edema
End of Life/Hospice
Glucose Emergencies
Hyperkalemia
LVAD – Left Ventricular Assist Device
Nausea-Vomiting
Pain Management
Seizures
Shock/Hypotension (Medical)
Sickle Cell Pain Crisis
Stroke/TIA
Syncope
Resuscitation Protocols
Airway
Cardiac Arrest (Medical)
Cardiac Arrest Algorithm
Pit Crew CPR
ROSC (Return of Spontaneous Circulation)
Termination of Resuscitation
DNR/Advance Directives
Bradycardia with a Pulse
Tachyarrhythmia with a pulse Narrow Complex
Tachyarrhythmia with a Pulse Wide Complex
Tracheostomy care
Withholding Resuscitation
Trauma Protocols
Trauma Management
Trauma Procedure Needle Decompression
Trauma Procedure Finger Thoracostomy
Burns
Crush Injury
Drowning/Submersion
Lift Assist/Fall
High Threat Considerations/Active Shooter Scenario/Care under Fire
Traumatic Arrest
Toxicology Protocols
Poisoning/Overdose
Acetylcholinesterase Inhibitors (Carbamates, Nerve Agents, Organophosphates) Exposure
Airway/Respiratory Irritants
Beta-Blocker Overdose
Calcium Channel Blocker Overdose
Carbon Monoxide/Smoke Inhalation
Cyanide
Opioid Overdose
Radiation Exposure
Riot Control Agents
Stimulant Overdose
TASER Injuries
Topical Chemical Burn
Environmental Protocols
Bites/Envenomation
Electrical Injuries
Diving Injuries
Hyperthermia
Hypothermia
Lightning Injuries
OB Protocols
Labor and Childbirth
Eclampsia/Pre-Eclampsia
OB Emergencies
Pediatric Protocols
Brief Resolved Unexplained Event (BRUE) Bronchiolitis/Croup
Newborn Resuscitation/care Normal Pediatric Vital Signs
Medications
Acetaminophen
Adenosine
Albuterol
Amiodarone
Aspirin
Atropine Sulfate
Calcium Chloride
Dextrose (D10W)
Dexamethasone
Diphenhydramine
Droperidol
Epinephrine
Etomidate
Fentanyl
Haloperidol
Hydroxocobalamin
Ibuprofen
Ipratropium
Isotonic Crystalloid Fluids
Ketamine
Lidocaine
Lorazepam
Magnesium Sulfate
Midazolam
Morphine
Naloxone
Nitroglycerin
Ondansetron
Oral Glucose
Oxygen
Pralidoxime
Sodium Bicarbonate
Medical Protocols
9
General Medical Care Guideline 9
Patient Refusals 10
Abdominal Pain 13
Abuse/Maltreatment and Human Trafficking 15
Agitated/Behavioral Emergencies 16
Allergic Reaction/Anaphylaxis 19
Altered Mental Status (AMS)/Behavioral 23
Back Pain 25
Bronchospasm 26
Chest pain/Coronary Syndrome/STEMI 30
CHF/Pulmonary edema 34
End-of Life/Hospice 35
Glucose Emergencies 36
Hyperkalemia 38
LVAD 40
Nausea-Vomiting 42
Pain Management 43
Seizures 46
Shock/Hypotension (medical) 47
Sickle Cell Pain Crisis 49
Stroke/TIA 50
Syncope 52
Resuscitation Protocols
53
Airway 53
Medical Cardiac Arrest 56
Cardiac Arrest Algorithm 59
Pit Crew CPR 60
ROSC 65
Termination of Resuscitation 66
DNR/Advance Directives 66
Bradycardia with a pulse 67
Tachyarrhythmia Narrow Complex 69
Tachycardia with a pulse wide complex 73
Tracheostomy care 74
Withholding resuscitation 77
Trauma Protocols
78
Trauma Management 78
Trauma Procedure Needle Decompression 82
Trauma Procedure Finger Thoracostomy 83
Burn 84
Crush Injury 88
Drowning/Submersion 89
Lift Assist/Fall 91
High Threat Considerations/Active Shooter Scenario/Care Under Fire 92
Traumatic Arrest 93
Toxicology Protocols
96
Poisoning/Overdose 96
Acetylcholinesterase Inhibitors (Carbamates, Nerve Agents, Organophosphates) Exposure 97
Airway/Respiratory Irritants 98
Beta-Blocker Overdose 99
Calcium Channel Blocker Overdose 100
Carbon Monoxide/Smoke Inhalation 101
Cyanide 102
Opioid Overdose 103
Radiation Exposure 103
Riot Control Agents 104
Stimulant Overdose 105
TASER Injuries 107
Topical Chemical Burn 108
Environmental Protocols
108
Bites/Envenomation 108
Electrical Injuries 110
Diving Injuries 112
Hyperthermia 114
Hypothermia 116
Lightning Injuries 117
OB Protocols
119
Labor and Childbirth 119
Eclampsia/Pre-Eclampsia 124
OB Emergencies 125
Pediatric Protocols
126
Brief Resolved Unexplained Event (BRUE) 126
Bronchiolitis/Croup Pediatric 128
Newborn Resuscitation/Care 130
Normal vital signs pediatric 136
Medications
136
Acetaminophen 136
Adenosine 137
Albuterol 138
Amiodarone 139
Aspirin 140
Atropine 141
Calcium Chloride 142
Dextrose (D10W) 143
Dexamethasone 143
Diphenhydramine 144
Droperidol 145
Epinephrine 146
Etomidate 148
Fentanyl 148
Haloperidol 150
Hydroxycobalamin 151
Ibuprofen 151
Ipratropium 152
Isotonic Crystalloid Fluids 153
Ketamine 154
Lidocaine 155
Lorazepam 156
Magnesium sulfate 157
Midazolam 158
Morphine 159
Naloxone 160
Nitroglycerin 161
Ondansetron 162
Oral glucose 163
Oxygen 164
Pralidoxime 164
Sodium Bicarbonate 165
Medical Protocols
General Medical Care Guideline
Patient Care Goals
Facilitate appropriate initial assessment and management of any EMS patient as required by EMTALA and link to appropriate specific guidelines as dictated by the findings within the Universal Care guideline.
Definition of a patient
A patient is anyone:
-with a complaint which suggests potential for medical, traumatic, or psychiatric illness, who requests or whom another individual in direct contact with them requests evaluation for such a complaint on their behalf,
-with obvious evidence of medical, traumatic, or psychiatric illness, who has experienced an acute event that could reasonably lead to medical, traumatic, or psychiatric illness,
-in a circumstance that could reasonably lead to medical, traumatic, or psychiatric illness.
This definition is to be applied in the broadest sense. If there is any question, the individual should be considered a patient and treated accordingly. Medical assist (i.e. fall out of wheelchair, etc) are considered patients.
Assessment
Pediatric Pearls:
Signs & Symptoms:
Differential:
Use approved reference document for medication dosing, electrical therapy, and equipment sizes.
Always start with
uninjured areas first to build trust
Location
Onset
Precipitating Event(s)
Quality
Radiation
Severity
Time/Duration
Aggravating/Alleviating
Associated Symptoms
Prior history of same/similar
Vascular
Infectious/Inflammatory
Trauma/Toxins
Autoimmune
Metabolic
Idiopathic
Neoplastic
Congenital
Never lie to a child
Clinical Management Options
EMT-B
Demonstrate professionalism and courtesy; Scene/Crew Safety/PPE; with appropriate equipment and medications to the patient side
Use closed looped communication and crew resource management with all on scene providers
Perform an initial assessment and physical exam
Obtain a full set of vital signs: Mental status, BP, pulse rate, respiratory rate, and body temperature
Obtain blood glucose level as appropriate
Orthostatic vital signs if appropriate for patient condition
Oxygen as needed to maintain SpO2 92 – 96% or as indicated by signs of hypoxia
Obtain 12 lead/4 lead as indicated
Perform medication cross check for all medication administrations
Identify need for ALS transportation or rapid transportation for critically ill patients and time critical diagnosis
Paramedic
IV / IO access as appropriate for patient condition
Medication administration as indicated
Advanced airway management as indicated
Place and monitor EtCO2 as indicated
Acquisition and interpretation of 12 lead ECG and/or 4 lead ECG
Consult Online Medical Control as Needed
Rules
Medical Control should be contacted in the following order:
WashU EMS line
Receiving Hospital
Barnes Hospital
Try to state the question first in a med control phone call. It can set up the conversation to be more successful
Ie. I’m calling for a medication request vs. I’m calling for advice
Use feedback communication both in medical control requests and on scene.
Refer to drug formulary charts for all medication dosing for both adults and pediatric patients.
Minimum exam for all patients includes vital signs, mental status including GCS, location of injury or complaint, and pain scale.
Maintain all appropriate medications and procedures that have been initiated at the referral agency or institution.
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Patient Refusals
Patient Care Goals
Ensure that the patient has full understanding of the risks and benefits of refusing transport and to document that the patient’s understanding/capacity. Competency is generally a legal status of a person’s ability to make decisions.
Clinical Management Options
EMT-B
Paramedic
Demonstrate professionalism and courtesy; Scene/Crew Safety/PPE; with appropriate equipment and medications to the patient side
Use closed loop communication and crew resource management with all on scene providers
Perform an initial assessment and physical exam
Obtain vital signs: BP, pulse rate, and respiratory rate
Obtain blood glucose level as appropriate
12 lead/4 lead acquisition as appropriate
Oxygen as needed to maintain SpO2 92 – 96% or as indicated by signs of hypoxia
Perform medication cross check for all medication administrations
Identify need for ALS transportation or rapid transportation for critically ill patients and time critical diagnosis
IV / IO access as appropriate for patient condition
Medication administration as indicated
Advanced airway management as indicated
Place and monitor EtCO2 as indicated
Acquisition and interpretation of 12 lead ECG and/or 4 lead ECG
Complete Refusal and Capacity Checklists
Consult Online Medical Control as Needed
Pearls
BLS can write a refusal after an ALS assessment. Work with your ALS partners to discuss risks and benefits and document these in our chart.
Lift assists require a refusal. Most lift assists are because the patient fell or are now too weak to move. Evaluate and document evidence of injury if patients fell. Evaluate and document patients for causes of weakness if the patient cannot get out of a chair/bed (especially if the patient can typically get up/walk).
AOx4 does not mean the patient has capacity. Many intoxicated patients can state the name and year but do not fully understand the risks of refusals. Documentation of the patient’s reasoning is essential to prove the patient’s capacity.
Pediatric patients cannot consent for transport (or refuse if there is a concern for injury). It is critical that the guardian be contacted. If the guardian cannot be reached, contact medical control to discuss the case.
Document why the patient is refusing transport.
Document if family is present, record their names in the chart as well.
Document the patient’s plan of care (ie. Going to the doctor tomorrow, self-transport, etc.)
If a patient refuses vital signs, medical control should be contacted to discuss the case. It is important to document any vital signs you can observe (respiratory rate, skin signs, mental status).
Medical Translators should be used if the patient does not speak English.
Contact Medical Control for high-risk refusals or if they do not meet the checklist below; it will reduce your own liability and risk
Adult Refusal of Care and/or Treatment Checklist
Patient is not suicidal or homicidal
Patient demonstrates capacity based on capacity checklist
Patient is informed and understands evaluation is incomplete
Solutions to obstacles have been sought
Patient instructed to seek medical attention
Patient instructed to call back at any time
Above documented fully in ePCR
Pediatric Refusal of Care and/or Treatment Checklist
Vital signs are normal for age; must be documented
Patient has normal mental status for age
Patient is not suicidal or homicidal
No obvious injury or distress
Parent/Guardian has capacity, understands the risks of refusal
Parent/Guardian has the ability to care for the patient at home (has meds for child, etc)
No concern for abuse in the home
Patient instructed to call back at any time
Above documented fully in ePCR
Medical control has been contacted
Capacity Checklist
Patient is able to express in their own words:
An understanding of the nature of their illness, and
An understanding of the risks of refusal including death, and
An understanding of alternatives to EMS treatment and/or transport, and
Provide rationale for refusal and debate this rationale.
A patient with any of the following MAY lack decision-making capacity and should be carefully assessed for their ability to perform the above. These are considered high-risk refusals. All high- risk refusals must be discussed with medical control.
If any question exists about their capacity, then contact
Medical Control.
Orientation to person, place, or time that differs from baseline;
History of drug and/or alcohol ingestion with appreciable impairment such as slurred speech or unsteady gait;
Head injury with positive loss of consciousness, amnesia, repetitive questioning;
Medical condition such as hypovolemia, hypoxia, metabolic emergencies (eg. diabetic episode), hypothermia, hyperthermia, etc.;
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Abdominal Pain
Patient Care Goals
Identify life-threatening causes of abdominal pain and improve patient comfort.
Assessment
Pediatric Pearls:
Signs & Symptoms:
Differential:
DKA often presents with abdominal pain, nausea, and vomiting.
Intussusception (episodic pain episodes)
Appendicitis
Consider necrotizing enterocolitis or volvulus in an infant
Bilious vomiting in babies is bad
Pain
Nausea
Vomiting
Diarrhea
Dysuria
Constipation
Vaginal bleeding / discharge
Pregnancy
Fever
Abdominal distension
Pneumonia or P.E.
Cholecystitis
Hepatitis or Pancreatitis
Gastroenteritis
Peptic Ulcer Disease
Myocardial Infarction or CHF
Kidney Stone
Aortic Aneurysms (AAA)
Appendicitis
Bladder/Prostate Disorder/infection
Pelvic – Pregnancy, Ectopic, STI, PID, Ovarian Cyst, Ovarian torsion
Diverticulitis
Bowel Obstruction
Testicular torsion
Clinical Management Options
EMT-B
Paramedic
Place in position of comfort
Keep the patient NPO
Oxygen target SpO2 92% – 96%
Have the patients sniff alcohol swabs as needed for nausea
12 lead/4 lead acquisition as appropriate
Perform medication cross check for all medication administrations
IV / IO access as appropriate for patient condition
IV fluid with Isotonic Crystalloid as needed for dehydration.
Pain Management as needed (Pain Management) with morphine, fentanyl, droperidol, or ketamine
Morphine 0.1 mg/kg IV/IM(2-4 mg max pediatrics, 4-8mg max for adult)
Fentanyl 1mcg/kg max 100mcg IV/IM/IN(round to nearest 12.5mcg-25mcg below 100mcg)
Droperidol 2.5mg IV/IM (adults only)
Ketamine 0.2mg/kg IV (10mg max pediatrics, 25mg max adults)
Antiemetics as needed (Nausea and Vomiting) with ondansetron or droperidol
Ondansetron
Adult 4mg PO/IV/IM
Pediatric: 0.1mg/kg (max 4mg) PO/IV/IM
Droperidol 2.5mg IV/IM adults only
Consider 12 lead ECG and/or 4 lead ECG acquisition and interpretation
Contact Medical Control as needed
Pearls
Using a stethoscope to listen to the abdomen in all quadrants with gentle pressure may allow you to examen the abdomen in patients who are anxious about the exam.
Consider cardiac causes of epigastric abdominal pain in patients older than 40 years old.
Abdominal pain in women of childbearing age should be suspected pregnant until proven otherwise.
Abdominal pain and hypotension in women of childbearing age should suspect ruptured ectopic pregnancy until proven otherwise.
Consider testicular pathology in males as testicular injury can present as abdominal pain.
The diagnosis of abdominal aneurysm should be considered with abdominal pain in patients over 50 Y/O.
Sudden abdominal pain in patients over 50 Y/O and hypotension should suspect ruptured AAA.
Orthostatic vital signs do not need to be assessed on obviously hypotensive patients.
Mesenteric ischemia presents with severe pain with limited exam findings. Risk factors include age > 60, atrial fibrillation, CHF, and atherosclerosis.
For all female patients ask about last menstrual period.
Consider ovarian/testicular torsion in patients with sudden onset of unilateral low abdominal pain.
Intermittent abdominal pain/cramping in young children is classic for intussusception.
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Abuse/Maltreatment and Human Trafficking
Patient Care Goals
Recognize when patients are being mistreated either through coercion, direct harm, or omission of care. Remove the patient from harm while preserving the evidence as much as possible. Document history and exam thoroughly.
Clinical Management Options
EMT-B
Paramedic
Demonstrate professionalism and courtesy
Perform an initial assessment and physical exam- document findings thoroughly
Wound treatment as appropriate
12 lead/4 lead ECG acquisition as appropriate
Perform medication cross check for all medication administrations
12 lead/4 lead ECG acquisition and interpretation as appropriate
Chemical sedation administration as appropriate
Consult Online Medical Control as Needed
Pearls
EMS are mandatory reporters in any case where there is concern for child and elder abuse. Always report your concerns to the hospital and/or law enforcement.
Elder abuse is considered anyone who is 60 years old or older who is dependent on someone for their care
Transport pediatric patients with concern for non-accidental trauma to level 1 pediatric trauma center.
Consider abuse/maltreatment in BRUE cases
You may find patterned bruising, bruising of multiple ages, age-inappropriate behavior, evidence of medical neglect, frequent calls for UTI/genitourinary complaints, evidence of malnourishment
Human trafficking is common in Saint Louis. Signs may include but not limited to: tattoos, padlocks on interior doors, additional security.
Human Trafficking Children’s Division for MO is 800-392-3738;
National Human Trafficking Hotline is 1-888-373-7888
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Agitated/Behavioral Emergencies
Patient Care Goals
Provision of care while maintaining safety for the patient, EMS personnel, and others.
Assessment
Pediatric Pearls:
Signs & Symptoms:
Differential:
agitation, confusion
Use approved reference document
Anxiety,
Refer to Altered Mental Status
for medication dosing, electrical therapy, and equipment sizes.
change, hallucinations
/ overdose
Parents may know what de-escalation techniques have worked in the past
Affect
Delusional thoughts, bizarre behavior
Expression of suicidal homicidal thoughts
Tachycardia, diaphoresis, tachypnea
Struggles violently despite appropriate restraints
Combative / violent
Very “hot” to touch
Hypoglycemia
Hypoxia
Alcohol intoxication
Illicit drug use
Medication effect
Withdrawal syndromes
Bipolar (manic-depressive)
Schizophrenia, anxiety disorders, etc.
Hypertensive emergency
Seizure / Postictal
Domestic Violence or Abuse
Patient Care Goals
EMT-B
Paramedic
Oxygen, target SpO2 92 – 96%
Check a blood glucose
Basic Airway Management as needed
Physical restraint if needed and use Restraint Checklist
Never transport a restrained patient in a prone position on a stretcher
Cooling measures if needed
Perform medication cross check for all medication administrations
Vascular access as appropriate for patient condition
Fluid therapy as needed with Isotonic Crystalloid, preferred cold if excited delirium
Cardiac monitor and 12 ECG
Consider sedation for agitated patients; document a pre-sedation RASS and a RASS after medications have been provided
RASS +3/+4 Ketamine is preferred if available
Adults/peds: 4mg/kg IM (MAX DOSE 400mg, NOTE IM dosing is MUCH different than IV dosing)
Adults/peds: 0.5-1mg/kg IV (MAX DOSE 100mg, NOTE IM dosing is MUCH different than IV dosing)
RASS +2/+3 Droperidol is preferred (droperidol is preferred in anyone has concern for airway compromise)
5-10mg IM (adults only)
5mg IV (adults only)
RASS +1 Midazolam is preferred
Adults: 5-10mg IM
Adults: 5mg IV adults
Pediatric: 0.1mg IV max dose of 5mg
Pediatric: 0.2mg IM/IN max dose of 10mg
Consider lower dosing in patients who are elderly (65yo+) or acutely intoxicated
Alternative agents if none of the above are available
Haloperidol
Adults: 5mg IM/IV
Pediatrics: 2mg IM/IV (not for kids younger than 3 or less than 15kg)
Lorazepam
Adults: 2-4mg IVIM
Pediatric: 0.1 mg/kg IV/IM (max dose 4mg)
If the patient is suspected of excited delirium and suffers cardiac arrest, then consider a fluid bolus and Sodium Bicarbonate early
Consult Medical Control as needed
Richmond Agitation Sedation Score (RASS)
+4
Combative
Overly combative or violent and an immediate danger to provider
+3
Very Agitated
Aggressive, non-combative or pulls on or removes tube(s) or catheter(s)
+2
Agitated
Frequent, non-purposeful movement or patient/ventilation desynchrony
+1
Restless
Anxious or apprehensive, movements not aggressive or vigorous
0
Alert and Calm
Spontaneously pays attention to provider
-1
Drowsy
Not fully alert but sustains more than 10 seconds wake, with eye opening in
response to verbal command
-2
Light Sedation
Awakens briefly for less than 10 seconds with eye contact or verbal command
-3
Moderate Sedation
Any movement, except eye contact, in response to command
-4
Unarousable
No response to voice or physical stimulation
Restraints Checklist
contraindicated.
sensation in all extremities.
sedation, Continuous monitoring, Neurovascular status evaluation
All other calming attempts have failed, which include at minimum verbal de-escalation and/or reduced stimulation.
Adequate personnel to effect restraint, with consideration to include law enforcement.
Place patient in supine position restrained with 1 arm up and 1 arm down, unless clinically
Law enforcement must be immediately available if handcuffed.
EMS personnel in constant attendance.
Chemical sedation administered, if required.
Continuous EtCO2, SpO2, ECG, and vital sign monitoring.
Continuous assessment of neurovascular status every 15 minutes, which includes pulse, motion,
Adequate personnel for transport.
Excited delirium is considered.
Physical and/or chemical restraints reviewed on a periodic basis.
Above documented fully in ePCR, including: Efforts prior to restraint, Time of restraint, Chemical
Pearls
Consider your safety first. Physical restraint should be performed / assisted by Law Enforcement when available.
Be sure to consider all possible medical and/or trauma causes for behavior.
All patients who receive either physical or chemical restraint must be continuously observed by ALS personnel on scene or immediately upon their arrival.
Any transported patient who is handcuffed or restrained by Law Enforcement should be accompanied by an officer whenever possible and if not, then law enforcement must be immediately available.
Restrained patients must never be maintained or transported in a prone position.
SAVE Mnemonic for De-Escalation:
Support – “Let’s work together…”
Acknowledge – “I see this has been hard for you…”
Validate – “I would probably be reacting the same way if I was in your shoes…”
Emotion naming – “You seem upset…”
Excited Delirium (EXD) is interchangeable with Excited Delirium Syndrome (ExDS) and Agitated Delirium (AgDS) and all refer to a condition where the patient continues to struggle violently despite appropriate restraint that results from a combination of delirium, psychomotor agitation, anxiety, hallucinations, speech disturbances, disorientation, violent and bizarre behavior, insensitivity to pain, elevated body temperature, and superhuman strength. Therefore, underlying etiologies of EXD/ExDS/AgDS must be considered:
Metabolic / Endocrine – hypoxia, electrolyte abnormalities, hepatic encephalopathy, hypercarbia, hyper/hypoglycemia, thyrotoxicosis, uremia
Neurologic – dementia, head injury, encephalitis, post-ictal state/seizure
Psychiatric – acute psychosis, mania, medication stoppage, personality disorder, schizophrenia
Infectious/Inflammatory – autoimmune encephalitis, herpes encephalitis, meningitis, sepsis
Toxicologic – alcohol, amphetamines, cocaine, neuroleptic malignant syndrome, PCP, polypharmacy, serotonin syndrome, synthetic cannabinoids, synthetic cathinones
Cold isotonic crystalloid boluses 30 ml/kg with temperature > 104 F up to 2 liters in adults.
Blood samples for performing glucose analysis should be obtained through a finger-stick (heel for infants).
Droperidol can cause dystonic reactions such as akathisia (restlessness and need to move) or torticollis. The treatment for both of these side effects is IV/IM Benadryl.
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Allergic Reaction/Anaphylaxis
Patient Care Goals
Identify anaphylaxis (life-threatening allergic reactions) quickly to prevent cardiorespiratory collapse. Anaphylaxis is defined as two or more of the following symptoms: skin (hives/itching), GI symptoms (nausea/vomiting/diarrhea), respiratory symptoms (chest tightness/wheezing/shortness of breath), swelling (tongue/face/lips), difficulty swallowing, hypotension. Early epinephrine should be considered for anyone with signs of anaphylaxis, or anyone with concern for anaphylaxis with hypotension and/or facial swelling.
Assessment
Pediatric Pearls:
Signs & Symptoms:
Differential:
Obstruction
Fluids and medications titrated to maintain SBP > 70 + (age x 2) mmHg
Do not hesitate to give epinephrine for anaphylaxis
Edema / Voice Changes
Stridor
Itching or Hives
Coughing / Wheezing or Respiratory Distress
Chest or Throat Constriction / Tightness
Difficulty Swallowing
Hypotension or Shock
Vomiting / Diarrhea
Urticaria (rash only)
Anaphylaxis (systemic effect)
Shock (vascular effect)
Angioedema (drug induced)
Aspiration / Airway
Vasovagal event
CHF
Asthma or COPD
Anxiety
Patient Care Goals
EMT-B
Paramedic
Place in position of comfort
Oxygen target SpO2 92% – 96%
Cold pack to inset bite or sting site and remove bee stinger if present.
Basic airway management as needed
Acquisition of 12 lead/4 lead as appropriate
Perform medication cross check for all medication administrations
IV / IO access as appropriate for patient condition
IM Epinephrine, up to 3 additional doses q5 minutes as needed for continued symptoms
Adult: 0.3 mg IM 1;1000 (1mg/mL)
Pediatric: 0.01 mg/kg IM 1;1000 (max 0.3mg)
NOTE: IM vs. IV dosing is VERY different
Consider Albuterol 2.5mg/3mL for wheezing, chest tightness, shortness of breath
Adult: 5mg nebulized
Pediatric: 2.5 mg nebulized
Consider nebulized epinephrine for stridor/other signs of upper airway obstruction
2mg (of 1mg/ml) for a total of 2ml mixed with 1ml normal saline
Consider CPAP, if refractory to Albuterol
Diphenhydramine for Allergic Reaction or Dystonia
Adult: 50mg IV/IM
Pediatric: 1mg/kg IV/IM (max dose 50 mg)
IV fluid therapy with Isotonic Crystalloid, titrated to Adult SBP > 100 mmHg
Consider Dexamethasone
Adult: 10mg PO/IV/IM
Pediatric 0.6 mg/kg PO/IV/IM (max 10mg)
Consider Push dose Epinephrine IV/IO for hypotension
Adult: 20mcg IV (10 mcg/mL 1:100,000)
Pediatric: 10mcg IV (10 mcg/mL 1:100,000)
NOTE: IM vs IV dosing and concentration are VERY different
Monitor ETCO2 in patients with respiratory distress
Consider acquisition/interpretation of 12 lead/4 lead ECG
Consult Medical Control as needed
Pearls
Epinephrine is the single most important intervention in this setting and has small risk for high benefit.
Epinephrine IM vs. IV dosing errors are common, please double/triple check prior to administering.
Hives + vomiting is anaphylaxis and should be treated with epinephrine
Skin symptoms (hives) may be missing in up to 40% of patients
Continuous reassessment for lack of improvement or rebound reaction with need for additional epinephrine.
Lungs should be assessed between each dose of Albuterol prior to additional nebulizers.
Any patient with respiratory symptoms or extensive reaction should receive IV/IO or IM Diphenhydramine.
The shorter the onset from exposure to symptoms, the worse the reaction.
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Altered Mental Status (AMS)/Behavioral
Patient Care Goals
Identify treatable causes of altered mental status.
Assessment
Pediatric Pearls:
Signs & Symptoms:
Differential:
AMS is ominous in peds
Use volume control device for Dextrose infusions
Upper limit BGL is 200
Ask about how formula is being mixed in formula fed babies
Consider head trauma, non-accidental trauma
Decreased mental status
Changes in baseline mental status.
Bizarre behavior
Hypoglycemia (cool, diaphoretic skin)
Hyperglycemia (warm & dry skin, fruity
breath, Kussmaul’s respira tions, signs of dehydration)
Hypo/Hyperglycemia
Post-ictal
Hypoxia
Brain trauma
Meningitis
CNS (Stroke, Tumor, Seizure, Infection)
Cardiac (MI, CHF)
Infection
Thyroid (hyper or hypo)
Shock (septic, metabolic, traumatic)
Toxicological / Carbon Monoxide / Cyanide
Acidosis / Alkalosis
Heat Stroke
or Hypothermia
Electrolyte abnormality
Patient Care Goals
EMT-B
Oxygen, target SpO2 92 – 96%
Blood Glucose Level Assessment
Oral glucose of appropriate
Basic Airway Management as needed
Acquisition of 12 lead/4 lead as appropriate
Perform medication cross check for all medication administrations
Paramedic
Vascular access as appropriate for patient condition
Dextrose if hypoglycemia and not eligible for oral glucose
Adult: 25g (D10W in 250 ml infusion) titrate to effect
Pediatric 30 days or older: 5ml/kg of 25g/250ml
Pediatric 0-29 days: 1ml/kg of 25g/250ml
Stroke Screening
Monitor ETCO2
12 lead/4 lead acquisition and interpretation as appropriate
Consider sedation for agitated patients; document a pre-sedation RASS and a RASS after medications have been provided
RASS +3/+4 Ketamine is preferred if available
Adults/peds: 4mg/kg IM (MAX DOSE 400mg, NOTE IM dosing is MUCH different than IV dosing)
Adults/peds: 0.5-1mg/kg IV (MAX DOSE 100mg, NOTE IM dosing is MUCH different than IV dosing)
RASS +2/+3 Droperidol is preferred (droperidol is preferred in anyone has concern for airway compromise)
5-10mg IM (adults only)
5mg IV (adults only)
RASS +1 Midazolam is preferred
Adults: 5-10mg IM
Adults: 5mg IV adults
Pediatric: 0.1mg IV max dose 5mg
Pediatric:0.2mg IM/IN max dose of 10mg
Consider lower dosing in patients who are elderly (65yo+) or acutely intoxicated
Alternative agents if none of the above are available
Haloperidol
Adults: 5mg IM/IV
Pediatric: 2mg IM/IV (not for kids younger than 3 or less than 15kg)
Lorazepam
Adults: 2-4mg IVIM
Pediatric: 0.1 mg/kg IV/IM (max dose 4mg)
Advance Airway Management as Needed
Consult Online Medical Control as Needed
Restraints Checklist
All other calming attempts have failed, which include at minimum verbal de-escalation and/or reduced stimulation.
Adequate personnel to effect restraint, with consideration to include law enforcement.
Place patient in supine position restrained with 1 arm up and 1 arm down, unless clinically
contraindicated.
Law enforcement must be immediately available if handcuffed.
EMS personnel in constant attendance.
Chemical sedation administered, if required.
Continuous EtCO2, SpO2, ECG, and vital sign monitoring.
Continuous assessment of neurovascular status every 15 minutes, which includes pulse, motion,
sensation in all extremities.
Adequate personnel for transport.
Excited delirium is considered.
Physical and/or chemical restraints reviewed on a periodic basis.
Above documented fully in ePCR, including: Efforts prior to restraint, Time of restraint, Chemical sedation, Continuous monitoring, Neurovascular status evaluation
Pearls
Be aware of AMS as presenting sign of an environmental toxin or Haz-Mat exposure and protect personal safety.
It is safer to assume hypoglycemia than hyperglycemia if doubt exists. Recheck blood glucose after Dextrose or oral glucose.
Do not let alcohol confuse your clinical practice as alcoholics frequently develop hypoglycemia and metabolic illness.
Poor perfusion can cause altered mental status
Blood samples for performing glucose analysis should be obtained through a finger-stick (heel for infants).
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Back Pain
Assessment
Pediatric Pearls:
Signs & Symptoms:
Differential:
Pediatric hypotension is defined as SBP < 70 + (age in years x 2) mmHg Back pain without trauma is concerning in the pediatric patient Weakness Numbness Fever Difficulty urinating/controlling bowel movement Hematuria (renal stone) Herniated disk Cauda equina Muscle strain Renal stone Aortic aneurysm Aortic dissection Osteomyelitis Patient Care Goals EMT-B Paramedic Oxygen, target SpO2 92 – 96% Check movement/sensation in extremities Perform Pain Management procedures Acquisition of 12 lead/4 lead as appropriate Perform medication cross check for all medication administrations Vascular access as appropriate for patient condition Consider acquisition/interpretation of 12 lead/4 lead ECG Consider additional pain management with morphine, fentanyl, or ketamine Morphine 0.1 mg/kg IV/IM(2-4 mg max pediatrics, 4-8mg max for adult) Fentanyl 1mcg/kg max 100mcg IV/IM/IN(round to nearest 12.5mcg-25mcg below 100mcg) Ketamine 0.2mg/kg IV (10mg max pediatrics, 25mg max adults) Consult Online Medical Control as Needed Pearls Tearing back pain that radiates to several locations can be signs of aortic dissection. Consider blood pressures in both arms. Abdominal aneurysms may present as flank/back pain and are a concern in patients over the age of 50. Any new bowel or bladder incontinence is a significant finding and may indicate a spinal cord compression which requires immediate medical evaluation. In patients with history of IV drug abuse or pain management injections, an epidural abscess should be considered. Pulsatile abdominal mass with back pain can be an abdominal aneurysm. Hematuria and back pain can be signs of renal stones page break Bronchospasm Patient Care Goals Alleviate respiratory distress due to bronchospasm. Deliver appropriate therapy by differentiating other causes of respiratory distress. Assessment Pediatric Pearls: Signs & Symptoms: Differential: Pediatric hypotension is defined as SBP < 70 + (age in years x 2) mmHg Wheezing in <2yo is often bronchiolitis and not asthma (unless they have a diagnosis of asthma). Work of breathing is important. Pediatric patients will not start to desaturate until they are in respiratory failure Shortness of breath Pursed lip breathing Decreased ability to speak Increased respiratory rate and effort Wheezing, rhonchi, rales, stridor Use of accessory muscles Fever, cough Tachycardia Anxious appearance Shark-wave appearance on ETCO2 Asthma / COPD (Emphysema, Bronchitis) Anaphylaxis Aspiration Pleural effusion Pneumonia Pulmonary embolus Pneumothorax Cardiac (MI or CHF) Pericardial tamponade Hyperventilation Inhaled toxin (CO, etc.) Croup / Epiglottitis Congenital heart disease Trauma Hydrocarbon ingestion Patient Care Goals EMT-B Paramedic Oxygen, target SpO2 92 – 96% Blood Glucose Level Assessment Basic Airway Management as needed Acquisition of 12 lead/4 lead as appropriate Perform medication cross check for all medication administrations Vascular access as appropriate for patient condition Monitor and interpretation of 12 lead/4 lead ECG & EtCO2 If wheezing (non-cardiac), consider Albuterol with Ipratropium Albuterol Adult: 5mg Pediatrics: 2.5mg Ipratropium 0.5mg (adults and pediatrics) Dexamethasone Adult: 10mg PO/IV/IM Pediatric: 0.6 mg/kg PO/IV/IM (max 10mg) Consider early CPAP with PEEP in distressed patients For severe bronchospasm, consider Magnesium Sulfate and/or IM epinephrine Magnesium Adult: 2g infusion over 10 minutes Pediatric: 50mg/kg, max dose 2g infusion over 10 minutes Epinephrine Adult: 0.3 mg IM 1;1000 (1mg/mL) Use caution in patient’s who are 65yo and older Pediatric: 0.01 mg/kg IM 1;1000 (max 0.3mg) Advance Airway Management as Needed Consult Online Medical Control as Needed Pearls EtCO2 and SpO2 must be monitored continuously if either are abnormal or decline in patient’s mental status/condition. Normalization of ETCO2 can mean improvement of the patient OR failure to compensate with impending death. Monitor the ETCO2 wave and mental status of the patient closely. Consider other reasons for respiratory distress such as pneumothorax or CHF (CHF can also wheeze, consider the entire patient history and exam). A silent chest in respiratory distress is a sign for pre-respiratory arrest. Chronic COPD may have elevated CO2 at baseline. Patient respiratory status must be reassessed after each nebulizer or medication administration to determine need for additional dosing. Chronic COPD may have lower O2 at baseline and have increased mortality with hyper- oxygenation. The O2 goal is above 90% (not 100%). Children less than 2yo are likely bronchiolitis, not asthma. Suctioning and oxygen is the first line treatment for bronchiolitis. A history of intubations and ICU stay can be a poor prognostic sign in some patients. Consider early CPAP in patients with respiratory distress. page break Chest pain/Coronary Syndrome/STEMI Assessment Pediatric Pearls: Signs & Symptoms: Differential: Myocardial infarction Focus on rapid and early BLS airway and ventilation tools. Intubation may not be the best option for these patients. Avoid ASA and nitroglycerin in pediatric patients Pain, discomfort, or pressure between navel and jaw “Heart racing”, “palpitations”, or “heart too slow” CHF signs or symptoms Syncope Severe weakness if > 45 years old
Difficulty breathing
Angina vs
Pericarditis
Pulmonary embolism
Asthma / COPD
Aortic Dissection
Pneumothorax
Aortic dissection
GI reflux / Hiatal hernia / PUD
Esophageal spasm
Chest wall injury or pain
Pleuritic pain
Overdose (sympathomimetic)
Patient Care Goals
EMT-B
Paramedic
100mcg)
Oxygen, target SpO2 92 – 96%
Perform bilateral blood pressures, if difference between R & L arm SBP is > 20mmHg then consider aortic dissection and withhold Aspirin and Nitroglycerin
Acquire a 12-lead EKG
Perform medication cross check for all medication administrations
Aspirin
324 mg PO
Basic Airway Management as needed
Vascular access
Isotonic Crystalloid PRN if hypotensive titrated to SBP > 100 mmHg or MAP > 65
Within 5 minutes of patient contact, 4 lead and 12 lead ECG placement and acquisition
Nitroglycerin if SBP > 100 mmHg
0.4mg (400mcg) SL every 5 minutes PRN up to 3 doses
5-50 mcg/minute infusion
Caution with inferior STEMI
Contraindicated if use of erectile dysfunction drugs within the last 24-48 hours
Monitor and interpretation of ECG & EtCO2
Additional Pain Management if needed with morphine or fentanyl
Morphine 0.1 mg/kg IV/IM(2-4 mg max pediatrics, 4-8mg max for adult)
Fentanyl 1mcg/kg max 100mcg IV/IM/IN(round to nearest 12.5mcg-25mcg below
EKG faxed to destination hospital if STEMI
Consult Online Medical Control as Needed
Pearls
12 lead EKG should be obtained within 5 minutes of first patient contact
Aspirin should be given to ALL patients suspected of having ACS/STEMI and this should be documented. If it was not administered it should be documented why it was not administered (i.e. administered prior to arrival).
The ONLY contraindications to aspirin administration is history of anaphylaxis to aspirin (and not simply mild allergy or intolerance) or active GI bleed.
Diabetics, females, and geriatric patients can have atypical pain, or generalized complaints. Consider cardiac causes for nausea, vomiting, and weakness.
Do not administer Nitroglycerin in any patient who used Viagra (sildenafil) or Levitra (vardenafil) in the past 24 hours or Cialis (tadalafil) in the past 48 hours or other PDE erectile dysfunction medications due to potential severe hypotension.
In patients with suspicious story but unremarkable initial EKG due serial EKG’s every 5 minutes.
Avoid hyperoxemia, as it can lead to increased cardiac damage.
If patient has STEMI, or is going directly to cardiac cath, attempt to establish a second IV but do not delay transport. Transport providers need to minimize scene time to < 15 minutes whenever possible. STEMI Criteria: A STEMI/ACO Alert should be called when a patient is currently symptomatic for an acute coronary syndrome event and has new or presumably new ST segment changes: All Patients: Elevation > 1 mm in two anatomically contiguous leads (Except V2 & V3 in males)
Males: V2 and V3 need 2 mm or more elevation to be concerning for STEMI/ACO
Isolated ST segment depressions in V1-V4 (Posterior Myocardial Infarction)
Any positive findings for Sgarbossa criteria in LBBB or Ventricular Paced patients
ST Segment elevation in aVL and ST segment depression in III (High Lateral MI)
Use modified Sgarbossa criteria for LBBB or Ventricular Paced patients
Concordant ST elevation >1 mm in leads with a positive QRS complex
Concordant ST depression >1 mm in V1-V3
ST Elevation at the J-point, relative to QRS onset, is at least 1 mm AND has an amplitude at least 25% of the preceding S-wave
Lead placement posterior EKG
Lead placement right sided EKG
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CHF/Pulmonary edema
Assessment
Pediatric Pearls:
Signs & Symptoms:
Differential:
Use approved reference document for medication dosing, electrical therapy, and equipment sizes.
Pediatric hypotension is defined as SBP < 70 + (age in years x 2) mmHg Bilateral rales Jugular vein distention Pinky, frothy sputum Peripheral edema Diaphoresis Hypoperfusion Hypotension Chest pain Respiratory distress Apprehension/anxiety Orthopnea Myocardial infarction Congestive heart failure Pulmonary embolus Pericardial tamponade Pleural effusion Pneumonia Asthma Anaphylaxis Aspiration COPD Toxic exposure Patient Care Goals EMT-B Oxygen, target SpO2 92 – 96% Position of comfort Basic airway management Acquire a 12-lead EKG Perform medication cross check for all medication administrations Aspirin if suspected ACS Chest Pain 324mg PO Paramedic Vascular access Consider CPAP with PEEP (5-20 cm H2O) with rales/rhonchi indicating wet lung sounds Nitroglycerin q 5 minutes if SBP > 100 mmHg
SBP 100 – 149 mmHg: 0.4 mg SL
SBP 150 – 199 mmHg: 0.8 mg SL
SBP 200 or greater: 1.2 mg SL
4 lead and 12 lead ECG placement and acquisition
Monitoring and interpretation of ECG, waveform EtCO2
Advanced Airway as needed
Consult Online Medical Control as Needed
Pearls
Avoid Nitroglycerin in any patient who has used Viagra or Levitra in the past 24 hours or Cialis in the past 48 hours or other PDE erectile dysfunction medications due to potential severe hypotension.
Careful monitoring of level of consciousness, BP, and respiratory status with above interventions is essential.
Consider myocardial infarction in all these patients. If suspected give Aspirin.
Allow the patient to be in their position of comfort to maximize their breathing effort.
Patient BP may drop with CPAP, if CPAP is necessary for oxygenation/ventilation, may move to add pressor.
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End-of Life/Hospice
Patient Care Goals
To provide relief from pain and other distressing symptoms. To assist the family and loved ones in understanding the dying process, normalizing the death process, and providing support. To allow patients to remain comfortable in their home when possible.
Assessment
Pediatric Pearls:
Signs & Symptoms:
Differential:
Call medical direction for assistance with pediatric hospice patients
None
None
Patient Care Goals
EMT-B
Paramedic
100mcg)
Offer comfort measures: fan, bedding, food/drink, etc.
Contact hospice or palliative care provider for medical control orders
Perform medication cross check for all medication administrations
Treat pain with hospice plan/home meds or use follow Pain Management COG
Treat nausea and vomiting
Ondansetron
Adult: 4mg PO/IV/IM
Pediatric: 0.1mg/kg (max 4mg) PO/IV/IM
Droperidol 2.5mg IV/IM adults only
Treat agitation/anxiety with hospice plan/home meds or use:
Midazolam
Adults: 5-10mg IM/IN
Adults: 5mg IV adults
Pediatric: 0.2mg IM/IN, max dose of 10mg
Pediatric: 0.1mg IV max dose of 5mg
Lorazepam
Adults: 2-4mg IVIM
Pediatric: 0.1 mg/kg IV/IM (max dose 4mg)
Droperidol
Adults: 2.5mg IV, 5-10mg IM
Opioids can help with respiratory distress
Morphine 0.1 mg/kg IV/IM(2-4 mg max pediatrics, 4-8mg max for adult)
Fentanyl 1mcg/kg max 100mcg IV/IM/IN(round to nearest 12.5mcg-25mcg below
Consult Online Medical Control as Needed
Pearls
Careful and thorough assessments should be performed to identify complaints not related to the illness for which the patient is receiving hospice or palliative care.
Care should be delivered with the utmost patience and compassion.
Families often call because they do not understand the dying process. Normalizing the dying process can be helpful for families.
Patient’s can sometimes appear to be short of breath. Pain medications such as fentanyl can
help reduce this discomfort.
Consider non-medication options as well (ie. A fan blowing on a patient’s face can help reduce
air hunger).
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Glucose Emergencies
Assessment
Pediatric Pearls:
Signs & Symptoms:
Differential:
Use approved reference document for medication dosing, electrical therapy, and equipment sizes.
Newborn hypoglycemia is below 40 mg/dL
Can only use D10 for infants (not D50)
If there is a concern for DKA, consider 20cc/kg fluid bolus
Altered Mental Status
Seizure
Reported low blood sugar prior to arrival
Shakiness
Stroke-like deficits
Sweating
Lethargy
Difficulty Breathing
Kussmaul respirations
Infections / Sepsis
Medication under/overdose
Liver failure
Stroke
Seizure
Cancer
Electrolyte abnormalities
Alcoholism
Care Goals
EMT-B
Paramedic
Oxygen, target SpO2 92 – 96%
BGL Assessment, if BGL < 60 and intact gag reflex then Oral Glucose Consider removing the insulin pump if present. Please bring the insulin pump if present Basic Airway Management as needed Perform medication cross check for all medication administrations Vascular access If BGL < 60 then Dextrose Infusion or oral glucose titrated to patient condition and response Adult: 250ml of D10 IV (25g) Pediatric 30 days or older: 5ml/kg of 25g/250ml Pediatric 0-29 days: 1ml/kg of 25g/250ml If no IV access and unresponsive give IO Dextrose If BGL > 300 (adults)/> 200 (pediatrics) or signs of dehydration, give an IV fluid bolus
ECG Monitoring
Monitor for hyperkalemia changes and treat with Calcium, Albuterol, and Sodium Bicarbonate if present
Calcium Chloride
Adult: 1000mg (1g) IV
Pediatric: 20mg/kg (max 1000mg) IV
Albuterol
Adult: 5mg
Pediatrics: 2.5mg
Sodium Bicarbonate
Adult and Pediatric: 1mEq/kg (max 50 mEq) IVP
Monitor EtCO2 if BGL > 550 mg/dl
If EtCO2 < 21 mmHg, Advise ED of Diabetic Ketoacidosis If using mechanical ventilation, ensure high minute volume Consult Online Medical Control as Needed Pearls Hyperglycemia New onset diabetic ketoacidosis in pediatric patients commonly presents with nausea, vomiting, abdominal pain, and/or urinary frequency Consider causes for hyperglycemia by thinking about the 3 I’s: Insulin – this refers to any medication changes for insulin or oral medications including poor compliance or malfunctioning insulin pump Ischemia – this refers to hyperglycemia sometimes being an indication of physiologic stress in a patient and can be a clue to myocardial ischemia in particular Infection – underlying infection can cause derangements in glucose control Hypoglycemia Consider contribution of oral diabetic medications to hypoglycemia If possible, have family/patient turn off insulin pumps Consider potential for intentional overdose of hypoglycemic agents Avoid overshoot hyperglycemia when correcting hypoglycemia. Administer Dextrose- containing IV fluids in small doses until either mental status improves or a maximum field dose is achieved Hypoglycemia Treatment-In-Place Checklist Has a known history of diabetes Repeat glucose is greater than 80mg/dL Patient takes insulin for glucose control (no oral hypogylcemics as oral hypoglycemics are long acting) There is a clear and reversible cause for the hypoglycemia (ie. Missed a meal) There was no medication error (too much long-acting insulin should be transported) Patient’s mental status has returned to baseline Patient is able to obtain and eat a carbohydrate meal (needs to be immediately available, take at least a few bites) Someone can stay with the patient for the next several hours and monitor the patient Patient is willing and would prefer to stay at home for home treatment page break Hyperkalemia Assessment Pediatric Pearls: Signs & Symptoms: Differential: Use approved reference document for medication dosing, electrical therapy, and equipment sizes. Bradycardia Crush syndrome DKA Cardiac arrest Missed dialysis Decreased PO/urine output Peaked T-waves Widening QRS complexes (later finding) Sine wave (pre-arrest finding on monitor) Arrhythmia Acute kidney injury Fluid overload Care Goals EMT-B Paramedic Oxygen, target SpO2 92 – 96% BGL Assessment Basic Airway Management as needed 4-lead/12-lead acquisition Perform medication cross check for all medication administrations Vascular access ECG Monitoring 4-lead/12-lead acquisition and interpretation Monitor for T-wave changes and treat with Calcium, Albuterol, and Sodium Bicarbonate if present Calcium Chloride Adult: 1000mg (1g) IV Pediatric: 20mg/kg (max 1000mg) IV Albuterol Adult: 5mg Pediatrics: 2.5mg Sodium Bicarbonate Adult and Pediatric: 1mEq/kg (max 50 mEq) IVP Consult Online Medical Control as Needed Pearls Hyperkalemia should be suspected in patients with concern for crush injuries, DKA, or kidney injury. Give calcium first as this helps protect the heart from the impact of hyperkalemia. The albuterol and sodium bicarb are used to reduce the amount of potassium in the blood stream. Consider in patients who have had recent failure to thrive (decreased PO intake can lead to kidney injury and potassium imbalances) Hyperkalemia can have a wide range of EKG changes. The most classic EKG changes are below. LVAD Assessment Pediatric Pearls: Signs & Symptoms: Differential: these patients. Use approved reference document for medication dosing, electrical therapy, and equipment sizes. Focus on rapid and early BLS airway and ventilation tools. Intubation may not be the best option for Cardiovascular compromise Cardiac arrest Medical or injury-related event not involving the cardiovascular system or VAD malfunction Infection Stroke/TIA Bleeding Arrhythmias Cardiac tamponade CHF Aortic insufficiency LV thrombus Care Goals EMT-B Paramedic Oxygen, target SpO2 92 – 96% Basic Airway Management as needed 4-lead/12-lead acquisition Perform medication cross check for all medication administrations Bring batteries/equipment with the patient Assess for Pump Malfunction and contact VAD coordinator BJH LVAD Nurse Coordinator: 314-454-7687 If Pump not working and in cardiac arrest, start CPR Vascular access 12 lead ECG Consider IV Crystalloid Fluid Bolus if the patient appears dehydrated/history consistent with fluid loss May also be indicated by “low flow” alarm Consider push dose Epinephrine for signs of poor perfusion that is not improved with IV fluid boluses Adult: 20mcg IV (1:100,000 which is 10mcg/ml) Pediatric: 10mcg IV (1:100,000 which is 10mcg/ml) IV and IM dosing and concentration are very different! Consult Online Medical Control as Needed Pearls Transport patients to the hospital that placed the LVAD “Flow” on LVAD display is typically 4-6L/min (much like natural cardiac output) Flows less than this (patient usually knows their normal flow rate) indicates hypovolemia so consider IVF “low flow” alarm indicates hypovolemia and should receive IVF bolus Flow around or less than 0.5L/min indicates cardiac arrest Patients with LVADS can have medical issues NOT related to the LVAD (such as the stomach flu). Take a thorough history and physical, treat the cause Low volume should be given volume Avoid volume and move straight to push-dose pressors if the patient has a history and exam related to elevated volume Patients should go to the center that placed the VAD in them whenever possible. You do not need to disconnect the controller or batteries to: Defibrillate or cardiovert Acquire a 12-lead EKG Automatic non-invasive cuff blood pressures may be difficult to obtain due to the narrow pulse pressure created by the continuous flow pump. Flow though many VAD devices is not pulsatile, and patients may not have a palpable pulse or accurate pulse oximetry. The blood pressure, if measurable, may not be an accurate measure of perfusion. Ventricular fibrillation, ventricular tachycardia, or asystole/PEA may be the patient’s “normal” underlying rhythm. Evaluate clinical condition and provide care in consultation with VAD coordinator. Do not shock Vtach/Vfib if the patient appears well-perfused The patient’s travel bag should always accompany them with back-up controller and spare batteries If feasible, bring the patient’s power module, cable, and display module to the hospital. All patients should carry a spare pump controller with them. The most common causes for VAD alarms are “low flow” alarms (secondary to hypovolemia) or low batteries/battery failures. Although automatic non-invasive blood pressure cuffs are often ineffective in measuring systolic and diastolic pressure, if they do obtain a measurement, the MAP is usually accurate. page break Nausea-Vomiting Assessment Pediatric Pearls: Signs & Symptoms: Differential: Pediatric hypotension is defined as SBP < 70 + (age in years x 2) mmHg No Zofran in patients who are less than 1 year old Projective vomiting/green vomiting in less than 2 months old is abnormal Tachycardia is first sign of dehydration Ask about urine output Fever Pain Constipation Diarrhea Anorexia Hematemesis Bilious emesis CNS (Increased ICP, headache, stroke, CNS lesions, Trauma, or hemorrhage) Vestibular AMI Small bowel obstruction Drugs (NSAIDS, antibiotics, narcotics, chemotherapy) GI or GU disorders Uremia Gynecologic disease (Ovarian Cyst / PID) Infections (pneumonia, influenza) Electrolyte abnormalities Food or Toxin induced Pregnancy Care Goals EMT-B Oxygen, target SpO2 92 – 96% Basic Airway Management as needed Orthostatic vital sign assessment if appropriate Allow patient to inhale isopropyl (rubbing) alcohol for aromatherapy to treat nausea 4-lead/12-lead acquisition as appropriate Perform medication cross check for all medication administrations Paramedic Consider vascular access 12 lead ECG acquisition and interpretation adults>50
Consider Ondansetron or Droperidol
Ondansetron
Adult: 4mg PO/IV/IM
Pediatric: 0.1mg/kg (max 4mg) PO/IV/IM
Droperidol 2.5mg IV/IM adults only
Consider IV fluid with Isotonic Crystalloid as needed for dehydration
Reduce the amount of IV fluids if there is a history of CHF
Consult Online Medical Control as Needed
Pearls
Assess number of times of emesis
Appearance of emesis: bloody, coffee ground, bilious – green bile – solids and liquid or just liquid
Heart rate: One of the first clinical signs of dehydration, usually increased heart rate, tachycardia increases as dehydration becomes more severe, very unlikely to be significantly dehydrated if heart rate is close to normal.
Consider small bowel obstructions in patients who have abdominal distension with nausea and vomiting.
Remember to consider exposures and ingestions in some populations
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Pain Management
Assessment
Pediatric Pearls:
Signs & Symptoms:
Differential:
Use approved reference document for medication dosing, electrical therapy, and equipment sizes.
Uses faces scale in younger patients
Consider IN meds for kids without an IV.
Severity (Pain scale)
Quality
Radiation
Relation to movement
Respirations
Reproducible
Increased upon palpation
Per the specific protocol
Musculoskeletal
Visceral (abdominal)
Cardiac
Pleural / Respiratory
Neurogenic
Kidney stone
Care Goals
EMT-B
Bleeding control
Oxygen, target SpO2 to 92-96%
Pain scale assessment 0-10, Wong-Baker faces for pediatrics, FLACC for infants
Splinting/bandaging needed
Ice pack as needed
Perform medication cross check for all medication administrations
Paramedic
Consider vascular access
Isotonic Crystalloid as needed
Consider medications for pain control
Acetaminophen/Ibuprofen for mild to moderate pain
Acetaminophen
Adult: up to 1000mg PO
Pediatric: 15 mg/kg PO (max 1000mg)
Ibuprofen
Adult: 600mg PO
Pediatric: 10mg/kg PO (max 600mg)
Morphine 0.1 mg/kg IV/IM(2-4 mg max pediatrics, 4-8mg max for adult)
Fentanyl 1mcg/kg max 100mcg IV/IM/IN(round to nearest 12.5mcg-25mcg below 100mcg)
Ketamine 0.2mg/kg IV (10mg max pediatrics, 25mg max adults)
Monitor ECG and ETCO2 if fentanyl was provided
Consult Online Medical Control as Needed
Pearls
Pain severity is a vital sign to be recorded pre and post pain intervention, especially medications.
Vital signs should be obtained pre and 5-minutes post all medications.
Monitor patient closely for over sedation, refer to Overdose COG if needed
Be cautious with pain medications in patients with head injury
Do not administer Acetaminophen to patients with history of liver disease or known to have consumed large amounts of ETOH.
Fentanyl should be reserved for acute pain.
Controlled substances are discouraged for non-traumatic back pain.
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Seizures
Assessment
Pediatric Pearls:
Signs & Symptoms:
Differential:
Pediatric hypotension is defined as SBP < 70 + (age in years x 2) mmHg Assess for VP shunt Febrile seizures occur between 6 months and 5 years Consider a broad differential including ingestion non-accidental trauma for seizures Altered mental status Sleepiness Incontinence Observed seizure activity Evidence of trauma Unconscious Fever Seizure activity Tongue trauma Rash Nuchal rigidity CNS/Head trauma Tumor Metabolic, Hepatic, or Renal failure Electrolyte abnormality (Na, Ca, Mg, K) Medication non- compliance Infection / Fever Alcohol withdrawal Eclampsia Stroke Hyperthermia Hypoglycemia Care Goals EMT-B Paramedic Oxygen, Target SPO2 92-96% Blood glucose level BLS airway management For any seizure in a pregnant or recently post-partum patient, consider eclampsia and consult the OB Emergencies guidelines Examine mental status, HEENT, heart, lungs, extremities, and neuro Perform medication cross check for all medication administrations Stroke Assessment Vascular access Consider Isotonic Crystalloid Monitor ECG and ETCO2 Midazolam or Lorazepam if the patient is actively seizing or has a seizure in your presence Preference for IM/IN over IV for first dose if IV not already established Midazolam Adults: 5-10mg IM/IN Adults: 5mg IV adults Pediatric: 0.2mg IM/IN, max dose of 10mg, Pediatric: 0.1mg IV max dose of 5mg Lorazepam Adults: 2-4mg IVIM Pediatrics 0.1 mg/kg IV/IM (max dose 4mg) Consider advanced airway Consult Online Medical Control as Needed Pearls Status epilepticus is defined as two or more successive seizures or a continuous seizure lasting 5 minutes without a period of consciousness or recovery. This is a true emergency requiring rapid airway control, treatment, and transport. Seizures can be grand mal, focal, or staring spell. Grand mal seizure (generalized) is associated with loss of consciousness, incontinence, and tongue trauma. Focal seizures (petit mal) effect only a part of the body and are not usually associated with a loss of consciousness. Jacksonian seizures are seizures which start as focal seizure then become generalized. Avoiding hypoxemia is extremely important. Be prepared to assist ventilations, especially if Midazolam is used. Assess possibility of occult trauma and substance abuse. Addressing the ABCs and verifying blood glucose is more important than stopping the seizure. Hypoglycemia is the 2nd most common cause of seizure. Consider acquiring a 12-lead EKG following cessation of seizure in patients without a history of seizure to determine possible cardiac cause In an infant, a seizure may be the only evidence of a closed head injury. The presence of fever with seizure in children less than 6 months old and greater than 6 yo is not consistent with a simple febrile seizure, and should prompt evaluation for meningitis, encephalitis or other cause Seizure in a patient with a history of VP shunt may be shunt malfunction. Needs to go to the hospital where they are followed for their shunt page break Shock/Hypotension (medical) Assessment Pediatric Pearls: Signs & Symptoms: Differential: Pediatric hypotension is defined as SBP < 70 + (age in years x 2) mmHg Initial NS bolus is 20cc/kg Restlessness, confusion, weakness Syncope Tachycardia Diaphoresis Pale, cool, clammy skin Delayed capillary refill Coffee-ground emesis Tarry stools Infection/Sepsis Dehydration Vomiting Diarrhea Congenital heart disease Medication or Toxin Anaphylaxis Cardiogenic shock Pericardial effusion Hemorrhagic shock Care Goals EMT-B Paramedic Oxygen, target SpO2 to 92-96% Blood glucose assessment Keep the patient warm Acquire 4-lead/12-lead as appropriate Perform medication cross check for all medication administrations Vascular access Monitor ECG and ETCO2 Acquisition and interpretation of 4-lead/12-lead These fluid boluses are for volume depletion – NOT for active bleeding. Pediatric: Isotonic Crystalloid bolus 20 ml/kg may repeat 10 ml/kg bolus x 2 PRN Adult non-cardiac: Isotonic Crystalloid 500-1000 ml bolus, may repeat up to 2 liters Adult Cardiac: Isotonic Crystalloid 250-500 ml bolus, may repeat up to 1 liter Push Dose Epinephrine for hypotension not improved with fluid bolus Adult: 20mcg IV (10 mcg/mL 1:100,000) Pediatric: 10mcg IV (10 mcg/mL 1:100,000) NOTE: IM vs IV dosing and concentration are VERY different Consult Online Medical Control as Needed Pearls Adult hypotension can be defined as a systolic blood pressure of < 90 mmHg or MAP < 60 and signs or symptoms of hypoperfusion – altered mental status, increased respirations, tachycardia, poor pulses, skin changes. ETCO2 is often low in shock. ETCO2 <25mmHg is concerning Consider all possible causes of shock and treat per appropriate protocols Patients should always have adequate intravascular fluid volume prior to the use of vasopressors-> give fluid if you believe they do not have enough intravascular fluid volume.
MAP calculation = [(2 x diastolic) + systolic] divided by 3
Aggressive Isotonic Crystalloid administration should be avoided in patients in whom hemorrhage is suspected.
Note that intubating hypotensive patients can cause them to reduce their blood pressure further and cause sudden cardiac arrest. It is appropriate to resuscitate with fluids prior to obtaining an advanced airway when possible.
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Sickle Cell Pain Crisis
Assessment
Pediatric Pearls:
Signs & Symptoms:
Differential:
Pediatric hypotension is defined as SBP < 70 + (age in years x 2) mmHg Pain Shortness of breath Tachycardia Diaphoresis Hypoxia Fever New stroke-like symptoms Priapism LUQ abdominal pain Shock Infection/Sepsis Dehydration Acute chest Splenic sequestration Osteomyelitis Meningitis Care Goals EMT-B Paramedic Oxygen, target SpO2 to 92-96% Pain scale assessment 0-10, Wong-Baker faces for pediatrics, FLACC for infants Ice pack as needed Perform medication cross check for all medication administrations Consider vascular access Isotonic Crystalloid as needed Consider medications for pain control Acetaminophen/Ibuprofen for mild to moderate pain Acetaminophen Adult: up to 1000mg PO Pediatric: 15 mg/kg PO (max 1000mg) Ibuprofen Adult: 600mg PO Pediatric: 10mg/kg PO (max 600mg) Morphine 0.1 mg/kg IV/IM(2-4 mg max pediatrics, 4-8mg max for adult) Fentanyl 1mcg/kg max 100mcg IV/IM/IN(round to nearest 12.5mcg-25mcg below 100mcg) Ketamine 0.2mg/kg IV (10mg max pediatrics, 25mg max adults) Monitor ECG and ETCO2 if fentanyl, morphine, or ketamine was provided Consult Online Medical Control as Needed Pearls Patients with chest pain, fever, tachycardia, and/or shortness of breath may be suffering from acute chest syndrome. Pediatric patients need to go to a children’s hospital as these patients may need antibiotics and admission. Patients with LUQ abdominal pain, hypotension may be suffering from splenic sequestration. Follow the shock protocols. Patients with sickle cell often have severe pain. It is reasonable to treat this pain en route . page break Stroke/TIA Assessment Pediatric Pearls: Signs & Symptoms: Differential: Pediatric hypotension is defined as SBP < 70 + (age in years x 2) mmHg Altered mental status Weak / Paralysis Blindness or other sensory loss Aphasia / Dysarthria Syncope Vertigo / Dizziness Vomiting Headache Seizures Respiratory pattern change Hyper/hypotension Altered mental status Transient Ischemic Attack (TIA) Seizure Hypoglycemia Hypoxia / Hypercarbia Stroke Thrombotic / Embolic (85%) Hemorrhagic (15%) Tumor Trauma Atypical migraine Care Goals EMT-B Paramedic Oxygen, target SpO2 to 92-96% Blood Glucose Level Basic Airway Management Perform an extended Cincinnati Stroke Scale followed by a LAMS score to look for large vessel occlusion Acquisition of 4-lead/12-lead ECG Perform medication cross check for all medication administrations Vascular access Isotonic Crystalloid if hypotensive Acquisition and interpretation of 4-lead/12-lead Transport immediately to nearest stroke center if stroke suspected and symptoms less than 24 hours old (scene time less than 15 minutes) Consult Online Medical Control as Needed Pearls Stroke patients are transported per Regional TCD Plan. Onset of symptoms or “last known well/normal” is defined as the last time the patient was seen symptom free; example: Awakening with stroke symptoms would be defined as an onset time of the previous night when the patient went to bed symptom free. Whenever possible, a family member should accompany the patient to the hospital to provide a detailed history or provide the hospital with the name and contact information of someone who can. The differential list on the Altered Mental Status guideline should be considered. Be alert for airway problems (swallowing difficulty, vomiting). Hypoglycemia can present as a localized neurological deficit, especially in the elderly. Blood samples for performing glucose analysis should be obtained through a finger-stick (heel for infants). Venous blood samples may produce artificially high glucose values and should be avoided. Expanded Cincinnati Pre-hospital Stroke Screen (eCPSS) Test Finding Balance: Have the patient walk in a line with eyes closed Uncoordinated/ ”Drunk”/ Stumbling gait Eyes: Assess for Partial/Total Vision loss in each eye as well as double vision double vision Facial Droop: Have the patient smile or show their teeth. move as well as the other side. Arm Drift: Patient closes eyes and extends both arms straight out, palms up, and for 10 seconds. both arms and held steady. to lift one arm. Abnormal Speech: Have the patient say: “You cannot teach an old dog new tricks.” no slurring. wrong words, or is unable to speak. Normal – Coordinated walking Abnormal – Abnormal – unable to do a finger-to-nose Normal – No vision loss or double vision. Blurry vision is considered normal Abnormal – Any amount of vision loss or Normal - both sides of face move equally Abnormal - one side of the face does not Normal - both arms move the same or Abnormal - one arm drifts downward or the palm turns towards the ground (pronator drift*) when compared with the other or unable Normal - patient uses correct words with Abnormal - patient slurs words, uses the *Pronator drift is when the forearm will pronate, and arm will drift downwards. Large Vessel Occlusion (LVO) Stroke Screening LA Motor Scale (LAMS) Face 0 Both sides move normally 1 One side is weak or flaccid Arm 0 Both sides move normally 1 One side is weak 2 One side is flaccid/does not move Grip 0 Both hands grip normally 1 One hand is weak 2 One side is flaccid/does not move Total 0 - 5 Score of 4 or 5 = LVO LVO suspected patient must be transported to a MO DHSS Level 1 Stroke Center Transport Group 1: (Thrombectomy Candidates) LAMS ≥4 & Estimated hospital arrival from last known well (LKW) < 24 hours Transport to the closest Level 1 bypassing Level 2 stroke center if difference is less than 20 extra minutes of transportation time. Use of emergency lights and sirens is strongly recommended if safe. If more than 20 extra minutes of transportation time is predicted, transport to closest Level 2 stroke center Notify stroke center that patient is a “Group 1 – Thrombectomy Candidate” LevelIStrokeCenters.pdf (mo.gov) Group 2: (Thrombolysis Candidates) LAMS ≤3 & estimated hospital arrival from last known well (LKW) < 24 hours Transport to the closest Level 1 or Level 2 stroke center. Use of emergency lights and sirens is strongly recommended if safe. Process shall take into consideration time for transport, patient condition, and treatment window, with the goal to secure the appropriate treatment for the patient within the treatment window. LevelIIStrokeCenters.pdf (mo.gov) Group 3: (Out of the therapeutic window) Suspected CVA > 24 hours from LKW
Transport to stroke center (Level 1-4) in a non-emergent manner
LevelIIIStrokeCenters.pdf (mo.gov)
Patients presenting with worst headache of life, loss of consciousness associated with headache or neck stiffness, coma or evidence of very severe stroke (i.e.: mute and unable move arm and leg at all) should be transported to Level 1 stroke center
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Syncope
Assessment
Pediatric Pearls:
Signs & Symptoms:
Differential:
Pediatric hypotension is defined as SBP < 70 + (age in years x 2) mmHg Syncope with activity is concerning Loss of consciousness with recovery Lightheadedness, dizziness Palpitations, slow or rapid pulse Pulse irregularity Decreased blood pressure Vasovagal Hypotension / Hypoperfusion Arrhythmia Pulmonary embolism Micturition / Defecation syncope Stroke Hypoglycemia Seizure Toxicological Medication effect (hypotension) Aoristic Stenosis / Vascular Disease Care Goals EMT-B Paramedic Oxygen titrated and PRN Blood glucose level Basic airway management Assess for injury Orthostatic vital sign assessment if appropriate Acquisition of 4-lead/12-lead ECG Perform medication cross check for all medication administrations Consider vascular access Isotonic Crystalloid as needed for low-volume states, hypotension Acquisition/Interpretation of 4-lead/12-lead ECG Consult Online Medical Control as Needed Pearls . Assess for signs and symptoms of trauma if associated or questionable fall with syncope. Consider dysrhythmias, GI bleed, ectopic pregnancy, and seizure as a possible cause of syncope. More than 25% of geriatric syncope is cardiac dysrhythmia based. Anyone > 65 years old should have continuous cardiac monitoring.
Syncope in the young during activity (passing out while running) is concerning
Syncope without a prodrome (i.e. feeling lightheaded) is also concerning
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Resuscitation Protocols Airway
Assessment
Pediatric Pearls:
Signs & Symptoms:
Differential:
Use approved reference document for medication dosing, electrical therapy, and equipment sizes.
Avoid intubation of the pediatric patient when possible. OPA/NPA is preferred.
Children compensate well initially but decompensate quickly with little warning.
Most pediatric cardiac arrests are due to respiratory compromise.
Percentage of Glottic Opening
Neck mobility
Beard may prevent mask seal.
Facial trauma/instability
Foreign material in airway
Swelling/Edema
Respiratory effort
Thyromental distance
Airway obstruction
Pulmonary edema
COPD/Asthma
Stroke
Drug overdose
Cardiac arrest
Head injury
Anaphylaxis
Clinical Management Options
EMT-B
BLS Foreign Body Airway Obstruction evaluation / removal
Place NPA and/or OPA and ventilate with BVM.
Oxygen, including passive apneic oxygenation 25 LPM with NC
SpO2 monitor
SGA if patient can tolerate an OPA.
Place gastric tube through SGA if possible
Perform medication cross check for all medication administrations
Paramedic
IV / IO access as appropriate for patientcondition
4-lead and 12-lead ECG acquisition and interpretation
Direct laryngoscopy Foreign Body Airway Obstruction evaluation / removal
PEEP Valve: 5 – 20 cm H2O
All advance airway procedures will include passive apneic oxygenation where possible.
Use Airway Management Checklist – Determines PACE (Primary, Alternate, Contingency, Emergency) Plan
Push dose Epinephrine for refractory hypotension prior to sedation
Adult: 20mcg IV (10 mcg/mL 1:100,000)
Pediatric: 10mcg IV (10 mcg/mL 1:100,000)
Sedation before Airway Placement
Ketamine
Adult: 200mg slow IV push
Pediatric: 2mg/kg slow IV push (max dose 200mg)
Etomidate
Adult and pediatric 0.3mg/kg IV
Video laryngoscopy for intubation (Preferred)
Direct laryngoscopy intubation with Gum Bougie
Nasal/Oral Gastric tube when possible
Continuous EtCO2 is mandatory for all intubations.
Post intubation medications for pain/sedation, Goal of RASS -2:
Ketamine
Adult: 100mg slow IV push every 2 minutes PRN
Pediatrics: 1mg/kg (max 100mg per dose) slow IV push every 2 minutes PRN
Fentanyl
Adult and pediatric 1mcg/kg IV (rounded to the nearest 12.5mg)
Nasal/Oral Gastric tube when possible
Consider Tracheostomy Tube change for patients in distress/unable to ventilate
Difficult airway and “Can’t Oxygenate/Can’t Ventilate/No EtCO2”, Cricothyroidotomy as indicated
Surgical – 8 years and above
Needle – Under 8 years
Medical Cardiac Arrest
NOTE: FOR NEONATES PLEASE REFER TO PEDIATRIC PROTOCOL NEONATAL RESUSCITATION
FOR NON-NEONATAL PEDIATRIC ARREST REFER TO THIS PROTOCOL
Assessment
Pediatric Pearls:
Signs & Symptoms:
Differential:
Treating patients on scene for 20 minutes can have improved ROSC rates and survival
Avoid intubation of the
STEMI
Syncope
Seizure
Decreased in ETCO2
Hypovolemia
Hypoxia
Acidosis
Hypoglycemia
Hyperkalemia
Hypothermia
Tension pneumothorax
Tamponade
Toxins
Thrombosis (PE, STEMI)
pediatric patient when
possible. OPA/NPA is
preferred.
Children compensate well
initially but decompensate
quickly with little warning.
Most pediatric cardiac
arrests are due to
respiratory
compromise/hypoxia
Transport pediatric arrests
to a level 1 pediatric center
Clinical Management Options
EMT-B
Assess for unresponsiveness, absence of normal breathing, and pulselessness
Assess for obvious death criteria
Begin Pit Crew CPR procedure with Engine until relieved by CHEMS arrival.
BLS Airway Management and BVM with Oxygen as available
Passive oxygenation with nasal cannula/nonrebreather at 25 LPM
Consider airway management with Igel
Place on monitor
For sustained Vtach/Vfib arrest (after the third shock), add a second set of pads to the patient to change the vector of defibrillation
Do not let the pads touch as it can cause damage to the machines
Perform medication cross check for all medication administrations
Paramedic
Vascular access
Epinephrine for three doses every 5 minutes
Adult: 1mg IV
Pediatrics: 0.01mg/kg (max 1mg) IV
Epinephrine count restarts after a ROSC event
Amiodarone or lidocaine if ventricular fibrillation/tachycardia (VF/VT)
Amiodarone
Adult: 300mg IV 1st dose, 150mg 2nd dose (4 minutes after 1st)
Pediatrics: 5mg/kg IV (max adult doses 300mg 1st dose, 150mg 2nd dose 4 minutes after 1st)
Lidocaine
Adult: 100mg IV every 4 minutes (max total dose 3mg/kg)
Pediatrics: 1mg/kg IV (max dose 100mg) every 4 minutes (max total dose 3mg/kg)
Fluid bolus with Isotonic Crystalloid as needed
Monitor ETCO2 & ECG
Narrow PEA QRS < 0.12 seconds: Consider mechanical causes - Cardiac tamponade, Tension pneumo, Mechanical hyperinflation, PE, Hypovolemia, Acute MI, heart failure Wide PEA QRS > 0.12 seconds or Asystole:
Consider metabolic causes – Tricyclic OD, Severe hyperkalemia, Acidosis, Calcium Channel Blocker OD, Acute MI, heart failure.
If awake/awareness during CPR, treat per RASS score.
Consult Online Medical Control as Needed
Pearls
To be successful in adult or pediatric arrests, a cause must be identified and corrected.
Respiratory arrest is a common cause of pediatric cardiac arrest. Unlike adults, early oxygenation and ventilation is critical.
Assess for airway obstruction if difficult to ventilate
Patients who are greater than 20 weeks pregnant should be transported immediately for consideration of perimortem C-section
In most cases, manage pediatric airways by basic interventions.
Effective CPR is critical: 1) Push hard and fast at appropriate rate 2) Ensure full chest recoil 3) Minimize interruptions in CPR. Pause CPR< 10 seconds only. Effective CPR and prompt Defibrillation are the keys to successful resuscitation. Prolonged cardiac arrests may lead to tired providers and decreased compression quality. Ensure compressor rotation, summon additional resources as needed, and ensure provider “rest and rehab” during and post-event. For pediatrics use volume control device for Dextrose and Fluid infusions Always quickly confirm asystole in more than one lead. Trouble shoot for Equipment settings/ problems Reassess and document airway continuously after every move and at transfer of patient care. Initiate continuous ETCO2 as soon as practicable. Calcium and sodium bicarbonate should be given early if hyperkalemia is suspected (renal failure, dialysis). There is no indication for these medications in most cardiac arrests without suspected hyperkalemia or overdose. Adult treatment priorities: uninterrupted compressions, defibrillation, ventilation, then IV/IO and airway management if needed. Polymorphic VT (Torsades) may benefit from Magnesium Sulfate. Prior to any external shocks, providers should verify that defibrillation pads are well adhered to the patient and that they do not touch. Both lidocaine and amiodarone can be effective for Vtach/Vfib arrests. There is no benefit for amiodarone over lidocaine. Amiodarone can be continued if started by another team. Do not give amiodarone in patients who are pregnant. Cardiac Arrest Algorithm Pit Crew CPR If Engine/Ladder Arrives First Ensure 360o access around patient and consider moving patient before initiating CPR. The crew will always maintain a triangular configuration around the patient and occupy positions 1, 2, and 3. A member of the crew will occupy position number 1. This crewmember will check for a pulse (10 seconds or less) and if the patient is in cardiac arrest, they will immediately begin High Quality chest compressions at a rate of 110 per minute. The goal is 220 compressions in two mins. There will be a 10:1 ratio of compressions to ventilations once the BVM is ready. They will switch off compressions with provider 2. The second crewmember on the pumper will occupy position 2, apply defibrillation pads, and operate the AED/Monitor. Ensure compressions continue during AED charging and immediately resume compressions after shock without pulse check or rhythm analysis. The final provider will move to position three on arrival and place an I-gel airway on all patients. Compressions should not be stopped to secure the airway. The paramedic will then ventilate the patient after every 10th compression in a manner that is asynchronous with chest compressions. Provider 3 can assess for sufficient chest compressions by performing a pulse check (carotid/brachial). The crewmembers in positions 1 and 2 will take turns doing 2 minutes of compressions (110 compressions per minute). During Provider 1’s rest cycle, they can consider IV/IO access and initiate drug therapy. This can be deferred until more help arrives. When the Ambulance Arrives after the Engine/Ladder When the ambulance arrives, one paramedic will assume position 4 and obtain vascular access. An intraosseous line in the proximal humerus is preferred unless there are any contraindications, followed by IV and then tibial IO. This medic will then oversee giving medications. They can also obtain history from the family, contact the hospital, or go for equipment if necessary. The other paramedic on the ambulance will assume position 5 and exchange the AED for the monitor. The goal is to ensure continuous waveform capnography, monitor CPR feedback to correct chest compressions, and defibrillate as needed during pulse checks. Approximately 15 seconds prior to rhythm check, the monitor should be precharged. If a shockable rhythm is noted, an immediate shock should be delivered. After the shock or if no shock is advised and charged is dumped, the provider (1 or 2) coming off a rest cycle will do 2 minutes of chest compressions. A carotid pulse needs to be identified during compressions to assist in pulse checks. Provider 5 will also determine the intubation plan for the patient. If needed, they will convert the I-gel airway to an endotracheal tube. This will be in a controlled fashion with a full intubation setup. Compressions will not be stopped for the intubation attempt. This step can be deferred until after AutoPulse/LUCAS is placed on patient. Adult Cardiac Arrest Algorithm (VF/pVTJAsystoIe/PEA) ›rygen Pusi› Mro ii ust 2 [s cmii.• o ‹.i i oo.•2o/•in xsrstele/PEA plna pt rln ASA.P CPR 2 min EplFgphdne£werj 6necu CPR°2 čfiiri Ho CPR 2”rtiIri ar›eoua C rcuLct Pediatric Cardiac Arrest Algorithm 1 ygg . 2 Shock No Yes Shock ND Epinephrine ASAP No 11 Push hard (z1/3 of anferoposterior diameter of chest) and fast (1D0-120/min) and allow compiete chest recoil Minimize interruptTonb in compressions Change compressor every 2 minutes, or sooner if fatigued If no advanced airway, 15:2 compression-ventilation ratio If advanced aitway, provide continuous compressions and give a breath avery 2-3 seconds First shock 2 J/kg Second shock 4 J/kg Subsequent Ghock6 *4 J/kg, maximum TO J/kg or adult dose Epinephrine N/IO dose: 0.01 mg/kg (0.1 mL/kg Df the mg/mL concentration). Max dosp 1mg. Repeat every 3-5 minutes. If no lv/IO access, may give endotracheal dose: Q.1 mg/kg (0.1 mL/kg of the I mg/mL concentration). Amiodarone IVfiO dose: 5 mg/kg bolus during cardiac arfest. May repeat up to 3 totai doses for refractory VF/pulseless VT Lidocaine IV/IO dose: - • Initial: 1 mg/kg 1oading dose Shock 12 Endotracheal intubation or supraglottic advanced airway Wavefom capnography or NO capnomatry to confim and monitor ET tube placement Hypovolemia Hypoxia Hydrogen ion (acido8is) Hypoglycemia Hypo-/hyperkalemia Hypothermia Tension pneumDthorax Tamponade, cardiac Toxins Thrombosis, pulmonary “ • Thrombosis, coronary ROSC Assessment Pediatric Pearls: Signs & Symptoms: Differential: Stabilize on scene post- ROSC for 10 minutes to optimize the patient Increased in ETCO2 Return of pulses Continue to address specific differentials associated with original dysrhythmia. Clinical Management Options EMT-B Continue Oxygenation, target SpO2 92% - 96% Use Post Resuscitation Checklist below as indicated Wait 10 minutes prior to transport to help optimize the patient prior to transport Acquisition of 4-lead/12-lead EKG Perform medication cross check for all medication administrations Paramedic Vascular access Obtain and monitor 12-lead EKG at 8 minutes Monitor ETCO2, especially during movement Acquisition/interpretation of 4-lead/12-lead EKG Fentanyl as needed for comfort 1mcg/kg max 100mcg IV/IM/IN(round to nearest 12.5mcg-25mcg below 100mcg) Push-dose epinephrine as needed for hypotension Adult: 20mcg IV (10 mcg/mL 1:100,000) Pediatric: 10mcg IV (10 mcg/mL 1:100,000) NOTE: IM vs IV dosing and concentration are VERY different Consult Online Medical Control as Needed Pearls Reassess airway frequently and with every patient move. Take the time to optimize the patient prior to transport: secure all lines, consider IV access, obtain an EKG, prepare push-dose epinephrine, optimize ETCO2. Patients often re-arrest when transporting to the ambulance. Optimizing the patient prior to transport can reduce this risk. It is ideal to wait 8 minutes after ROSC for the EKG. The EKG obtained immediately after the cardiac arrest is abnormal and can hide a STEMI. As many cardiac arrests are from STEMI, it is ideal to get a good EKG to assess for a STEMI. Do not hyperventilate as this is associated with worse outcomes. Post Resuscitation / ROSC Checklist Reassess patient and obtain vital signs Airway confirmed continuously and with each move Oxygen target 92-96%, use mechanical ventilator as soon as possible. Continuous EtCO2 (goal 40-50 mmHg) and ECG monitoring Wait 8 minutes before 12-lead ECG, if STEMI then transmit 12-lead ASAP for early notification Ketamine / Fentanyl if no hypotension (advanced airway only) If saline infused, 30 ml/kg, max 2 L Controlled ventilation < 12 bpm Adequate personnel for transport If loss of ROSC, then go to appropriate guideline Termination of Resuscitation Medical Arrest Termination of Resuscitation Checklist Medical Arrest: Termination of Resuscitation (> 30 minutes of downtime) Checklist:
Adequate CPR has been administered
ETCO2 is less than 20
PEA rate is less than 40
Airway managed with ET, Igel, cric
IV/IO access has been achieved
Rhythm appropriate medications and treatment administered
Identified reversible causes have been addressed
Failure to establish sustained ROSC at any time
Failure to establish recurring/persistent v-fib
Arrest not due to suspected hypothermia
Providers agree with decision to cease efforts
If all present, may terminate without contacting medical control, otherwise discuss case with
medical control
DNR/Advance Directives
Standard:
In the event any provider of the EMS System is presented with a completed Out of Hospital Do Not Resuscitate (OOH-DNR) form and/or OOH-DNR ID device, the provider shall withhold CPR and the listed therapies in the event of cardiac arrest. The form and device may be from any (US) State.
Purpose:
To honor the terminal wishes of the patient and to prevent the initiation of unwanted resuscitation.
If you are unsure whether the patient meets criteria, then resuscitate.
Exceptions:
The provider shall begin resuscitation efforts until such time as a physician or On-Line Medical Control (OLMC) directs otherwise when:
The patient is known to be pregnant.
If there are any indications of unnatural or suspicious circumstances.
If the Provider is unsure of the existence or validity of the DNR.
An advanced directive does not imply that a patient refused supportive or palliative care.
Application:
When confronted with a cardiac arrest patient, one of the following conditions must be present to honor the DNR request and withhold CPR and ALS therapy:
Out-of-Hospital Do Not Resuscitate (OOH-DNR) or OOH-DNR ID device, original or copy.
Valid original or copy of OOH-DNR written order or OOH-DNR ID device from any US state.
A licensed physician on scene or in contact by telephone orders that no resuscitation efforts are to take place.
A DNR request may be overridden by:
The patient or person who executed the order destroying or directing someone in their presence to destroy the form and/or remove the identification device.
The patient or person who executed the order telling EMS providers or attending physician that it is their intent to revoke the order.
The attending physician or physician’s designee if present at the time of
revocation records in the patient’s medical rector the time, date, and place of the revocation and enters “VOID” on each page of the OOH-DNR.
In the event here is a question regarding whether to honor or not honor an OOH-DNR or Advanced Directive, then initiate resuscitation and contact OLMC.
Bradycardia with a pulse
Assessment
Pediatric Pearls:
Signs & Symptoms:
Differential:
Focus on rapid and early BLS airway and ventilation tools. Intubation may not be the best option for these patients.
Pediatric pads should be used in children < 25kg If bradycardia is not corrected rapidly and the patient appears poorly perfused, start CPR. HR < 60 min with hypotension Acute altered LOC CHF Seizure, syncope, or shock secondary to bradycardia. Altered LOC Shock / Hypotension Syncope Sick sinus syndrome Heart block Respiratory distress Hyperkalemia Respiratory obstruction Beta blocker / Digoxin /Calcium Channel Blocker overdose Organophosphate Hypovolemia Hypothermia Hypoxia Infection / Sepsis Medication or Toxin Trauma Acute MI Clinical Management Options EMT-B Oxygen PRN titrated to SpO2 92%-96% Basic airway management If pediatric and HR < 60 with poor perfusion despite oxygenation & ventilation, begin Pit Crew CPR Acquisition of 4-lead/12-lead EKG Perform medication cross check for all medication administrations Paramedic Vascular access Acquistion/interpretation of 4-lead/12-lead EKG Place pads on the patient Monitor ETCO2 Consider fluid bolus Provide atropine or push dose epinephrine for bradycardia with hypotension Atropine Adult: 1mg IV every 3 minutes (max dose 3mg) Pediatric: 0.02mg/kg IV (minimum dose 0.1mg max dose 0.5mg) every 3 minutes (max dose 3mg) Epinephrine Adult: 20mcg IV (10 mcg/mL 1:100,000) Pediatric: 10mcg IV (10 mcg/mL 1:100,000) NOTE: IM vs IV dosing and concentration are VERY different Provide transcutaneous pacing for hypotensive patients who do not improve with atropine or epinephrine Provide sedation if transcutaneous pacing with midazolam, lorazepam, or ketamine Midazolam Adults: 5mg IV adults Pediatric: 0.1mg IV max dose of 5mg Lorazepam Adults: 2-4mg IV Pediatric: 0.1 mg/kg IV (max dose 4mg) Ketamine Adults and Pediatric: 1mg/kg IV (max dose 100mg) Consider hyperkalemia and if suspected treat with calcium, sodium bicarbonate, albuterol Calcium Chloride Adult: 1000mg (1g) IV Pediatric: 20mg/kg (max 1000mg) IV Albuterol Adult: 5mg Pediatrics: 2.5mg Sodium Bicarbonate Adult and Pediatric: 1mEq/kg (max 50 mEq) IVP Consult Online Medical Control as Needed Pearls The use of lidocaine or amiodarone in heart block can worsen bradycardia and lead to asystole and death. Treatment of bradycardia is based on the presence of symptoms. If asymptomatic, monitor only. The use of Atropine for bradycardia in the presence of an MI may worsen ischemia. Consider treatable causes for bradycardia (Beta blocker OD, Calcium channel blocker OD, etc.) – treat appropriately. If wide complex bradycardia, consider hyperkalemia. Tachyarrhythmia Narrow Complex Assessment Pediatric Pearls: Signs & Symptoms: Differential: used in children < 25 Kg. Use approved reference document for medication dosing, electrical therapy, and equipment sizes. Focus on rapid and early BLS airway and ventilation tools. Intubation may not be the best option for these patients. Pediatric pads should be QRS < 0.12 sec Pale or Cyanosis Diaphoresis Tachypnea Vomiting Hypotension Altered Level of Consciousness Pulmonary Congestion Syncope Underlying accessory pathway (WPW, LGL) Tachyarrhythmia SVT AF Myocardial infarction Electrolyte imbalance Exertion, pain, emotional stress Fever Hypoxia or Anemia Hypovolemia Drug effect / Overdose >180 in children
Consider SVT with HR
Consider SVT with HR > 220 in infants
Hyperthyroidism
Pulmonary embolus
Alcohol withdrawal
Clinical Management Options
EMT-B
Paramedic
effective
Oxygen PRN titrated to SpO2 92%-96%
Basic airway management
Acquisition of 4-lead/12-lead EKG
Perform medication cross check for all medication administrations
Vascular access
Acquisition/interpretation of 4-lead/12-lead
Monitor ETCO2
Vascular access
Isotonic Crystalloid PRN titrated to SBP > 100 mmHg or MAP > 65
For stable SVT
Have the patient perform vagal maneuvers
“Modified valsava maneuver” in adults has been shown to be almost 50%
Ice to the face in infants can be effective
Consider adenosine (monitor EKG during adenosine use)
Adult: 6mg rapid IVP, may repeat with 12mg rapid IVP
Pediatric: 0.1mg/kg rapid IVP (max dose of 6 mg), may repeat with 0.2mg/kg rapid IVP (max dose of 12mg)
If the patient becomes unstable, perform a synchronized cardioversion
Adult: 50-100 J
Pediatric Synchronized Cardioversion 0.5-1.0 j/kg, repeat as needed at 2 j/kg
Obtain a new EKG after cardioversion (whether with medication or electricity)
For stable afib/aflutter
Consider Magnesium (may cause hypotension so use with caution)
Adult: 2g slow IVP
Pediatric: 50mg/kg slow IVP (max dose 2g)
If the patient becomes unstable, perform synchronized cardioversion
Adult: maximum joules
Pediatric: 0.5-1.0 j/kg, repeat as needed at 2 j/kg
Consider sedation (if time allows) prior to cardioversion of SVT/afib/aflutter with midazolam, lorazepam, ketamine, or etomidate
Midazolam
Adults: 5mg IV adults
Pediatric: 0.1mg IV max dose of 5mg
Lorazepam
Adults: 2-4mg IV
Pediatric: 0.1 mg/kg IV (max dose 4mg)
Ketamine
Adults and Pediatric: 1mg/kg IV (max dose 100mg)
Etomidate
Adults and pediatric: 0.1 mg/kg (max dose 20mg)
For sinus tachycardia, treat the underlying cause of sinus tachycardia
Consult Online Medical Control as Needed
Pearls
Sinus tachycardia may be misinterpreted as SVT or A-fib. Sinus tach >150 (adult) or >180 (pediatric) may be seen in the septic patient.
Obtaining a full EKG can help determine the underlying rhythm
Use caution in patient currently on antihypertensive medication.
Adenosine may not be effective in identifiable atrial flutter / fibrillation but is not harmful.
Cardioverting afib/aflutter can potentially cause a stroke. Do not attempt to cardiovert stable afib/aflutter.
Document all rhythm changes with monitor strips and obtain monitor strips with each therapeutic intervention.
Continuous pulse oximetry is required for all atrial fibrillation patients.
Narrow complex tachycardia in setting of alcohol withdrawal should be treated aggressively with midazolam. If SVT is “exquisitely regular”, any heart rate variability should lead you to consider sinus tachycardia or atrial fibrillation.
Consider a change of vector of initial cardioversion is unsuccessful to anterior/posterior pad placement.
Tachycardia with a pulse wide complex
Assessment
Pediatric Pearls:
Signs & Symptoms:
Differential:
used in children <25 Kg. Use approved reference document for medication dosing, electrical therapy, and equipment sizes. Focus on rapid and early BLS airway and ventilation tools. Intubation may not be the best option for these patients. Pediatric pads should be QRS > 0.12 sec
Ventricular tachycardia on ECG (runs or sustained)
Conscious, rapid pulse
Chest pain
Shortness of breath
Dizziness
Rate usually 150-180 bpm for sustained V-tach
Artifact / Device failure
Cardiac history
Endocrine / Electrolyte
Hyperkalemia
Drugs / Toxic exposure
Pulmonary disease
Tricyclic OD
EMT-B
Paramedic
Oxygen PRN titrated to SpO2 92%-96%
Basic airway management
Acquisition of 4-lead/12-lead EKG
Perform medication cross check for all medication administrations
Vascular access
Acquisition/interpretation of 4-lead/12-lead
Monitor ETCO2
Vascular access
Isotonic Crystalloid PRN titrated to SBP > 100 mmHg or MAP > 65
If stable, administer amiodarone or lidocaine
Amiodarone
Adult: 150mg IV over 10 minutes
Pediatric: 5mg/kg IV over 10 minutes (max dose 150mg)
Lidocaine
Adult: 100mg IV every 4 minutes (max total dose 3mg/kg)
Pediatrics: 1mg/kg IV (max dose 100mg) every 4 minutes (max total dose 3mg/kg)
Unstable Wide complex tachycardia, cardiovert
Adults: Synchronize cardioversion at 100J
Pediatric Cardioversion: 1J/kg then repeat at 2J/kg as needed
12 lead ECG post conversion
Consider sedation (if time allows) prior to cardioversion of SVT/afib/aflutter with midazolam, lorazepam, ketamine, or etomidate
Midazolam
Adults: 5mg IV adults
Pediatric: 0.1mg IV max dose of 5mg
Lorazepam
Adults: 2-4mg IV
Pediatric: 0.1 mg/kg IV (max dose 4mg)
Ketamine
Adults and Pediatric: 1mg/kg IV (max dose 100mg)
Etomidate
Adults and pediatric: 0.1 mg/kg IV (max dose 20mg)
If Torsades, give Magnesium
If Tricyclic OD, consider Sodium Bicarbonate early
Adult and pediatric: 1mEq/kg IVP (max dose 50 mEq)
If Hyperkalemia, Calcium, Sodium Bicarbonate, and Albuterol
Calcium Chloride
Adult: 1000mg (1g) IV
Pediatric: 20mg/kg (max 1000mg) IV
Albuterol
Adult: 5mg
Pediatrics: 2.5mg
Sodium Bicarbonate
Adult and Pediatric: 1mEq/kg (max 50 mEq) IVP
Consult Online Medical Control as Needed
Pearls
For witnessed / monitor ventricular tachycardia, try having patient cough while preparing other therapies.
Wide complex between 100 – 140 beats/min, consider Hyperkalemia.
Consider a change of vector if initial Cardioversion is unsuccessful to anterior/posterior pad placement.
Tracheostomy care
Patient Care Goals:
The overall goal is to avoid hypoxia. All efforts must be exerted to avoid hypoxia. Any repeated attempts to cannulate the trachea must be accompanied by oxygenation efforts to avoid any hypoxic events. Techniques include high-flow oxygen over the stoma accompanied by BVM with oxygen over mouth/nose or combinations thereof to deliver oxygen throughout the procedure if the changeout attempt is not initially successful
Assessment
Pediatric Pearls:
Signs & Symptoms:
Differential:
All children with tracheostomies should have a “go bag” with emergency equipment to
manage tracheostomy
Respiratory distress
Shortness of breath
Secretions from trach
Tracheostomy dislodgement
Trach obstruction
Pneumonia
Transport patient with “go bag”
Upper respiratory infection
Sepsis
Care Goals
EMT-B
Oxygen titrated and PRN
Suction tracheostomy if c/f obstruction
BVM tracheostomy if indicated
If tracheostomy dislodged BVM over nose and mouth (ineffective if previous laryngectomy) or stoma
Basic airway management
Acquisition of 4-lead/12-lead ECG as indicated
Perform medication cross check for all medication administrations
Paramedic
Suction and BVM tracheostomy if indicated
If unable to relieve tracheostomy obstruction or tracheostomy is dislodged it will need to be emergently replaced (procedure details below)
Consider vascular access
Isotonic Crystalloid as needed for low-volume states, hypotension
Acquisition/Interpretation of 4-lead/12-lead ECG
Consult Online Medical Control as Needed
Procedure:
Have all airway equipment prepared for standard airway management, including equipment for orotracheal intubation and failed airway.
Have airway device (endotracheal tube or tracheostomy tube) of the same size as the tracheostomy tube currently in place as well as 0.5 size smaller available (e.g., if the patient has a #6.0 Shiley, then have a 6.0 and a 5.5 tube).
Lubricate the replacement tube(s) and check the cuff.
Remove the tracheostomy tube from mechanical ventilation devices and use a bag-valve apparatus to preoxygenate the patient as much as possible.
Once all equipment is in place, remove devices securing the tracheostomy tube, including sutures and/or supporting bandages.
If applicable, deflate the cuff on the tube. If unable to aspirate air with a syringe, cut the balloon off to allow the cuff to lose pressure.
Remove the tracheostomy tube.
Insert the replacement tube. Confirm placement via standard measures.
If there is any difficultly placing the tube, re-attempt procedure with the smaller tube size.
If difficulty is still encountered, use standard airway procedures such as oral bag-valve mask or endotracheal intubation. More difficulty with tube changing can be anticipated for tracheostomy sites
that are immature – i.e., less than two weeks old. Great caution should be exercised in attempts to change immature tracheotomy sites.
Document procedure, confirmation, patient response, and any complications in the ePCR
Pearls .
DO NOT replace if it was placed 14 days or less ago (risk of creating a false tract)
Always talk to family and/or caregivers as they have specific knowledge and skill
Important to ask if patient has undergone laryngectomy. This does not allow mouth/nasal ventilation by covering stoma nor will there be ability to orotracheally intubate
Use patient’s equipment if available and functioning properly. Estimate suction catheter size by
doubling the inner tracheostomy tube diameter and rounding down
Suction depth: Ask family / caregiver. No more than 3 to 6 cm typically. Instill 2 – 3 mL of NS before suctioning. Do not suction more than 10 seconds each attempt and pre-oxygenate before and between attempts
DO NOT force suction catheter. If unable to pass, then tracheostomy tube should be changed
Always deflate tracheal tube cuff before removal (if there is a cuff balloon, not all trachs are cuffed). Continual pulse oximetry and EtCO2 monitoring if available
DOPE: Displaced tracheostomy tube / ETT, Obstructed tracheostomy tube / ETT, Pneumothorax and Equipment failure
If trouble is encountered with the trach change, then avoid hypoxia by continuing to deliver oxygen via BVM over mouth/nose or over the stoma while continuing to troubleshoot and attempt smaller trach tube or other techniques to secure the airway
Some trachs have cuffs some don’t
Some trachs have an inner cannula which can be removed and cleaned
To reiterate:The overall goal is to avoid hypoxia. All efforts must be exerted to avoid hypoxia. Any repeated attempts to cannulate the trachea must be accompanied by oxygenation efforts to avoid any hypoxic events. Techniques include high-flow oxygen over the stoma accompanied by BVM with oxygen over mouth/nose or combinations thereof to deliver oxygen throughout the procedure if the changeout attempt is not initially successful
Withholding resuscitation
Signs of obvious death:
Rigor mortis and/or dependent lividity
Decomposition
Decapitation
Incineration
Obviously mortal wounds resulted from severe trauma with obvious signs of organ destruction.
Patient submersion great than 20 minutes from the time the patient was witnessed going underwater or from arrival of first public safety entity until the patient is in a position for effective resuscitative efforts to begin.
Fetal death with a fetus < 20 weeks by best age determination available at scene; consider products of conception and does not require time of death. Fetal death < 20 weeks may be documented on mother’s ePCR. If > 20 weeks, then create a separate ePCR.
Valid DNR
Injuries Incompatible with life
Trauma Protocols Trauma Management
Assessment
Pediatric Pearls:
Signs & Symptoms:
Differential:
Hypotension: (SBP < 70+ 2x Age in years) Massive Hemorrhage Airway Respirations (decompression) Circulation (IV, TXA) Hypothermia / Head injury Pain Wound Care Splinting AMS Respiratory failure Foreign body airway obstruction Hypovolemia Trauma Tension pneumothorax Hypothermia Toxins or Overdose Hypoglycemia Acidosis Acute MI or PE Stroke Clinical Management Options EMT-B Paramedic Control external hemorrhage and apply tourniquet(s) as necessary, including junctional tourniquets if needed and available. Wound packing (junctional/extremity) with pressure dressing as appropriate and apply hemostatic gauze if available BLS airway management Place occlusive dressing/chest seal over penetrating torso trauma between supraclavicular areas to umbilicus Evaluate the need for spinal motion restriction Assess GCS score Keep patient supine and warm Administer Oxygen via NRB to all serious trauma patients. Bandage/splint injuries as appropriate for patient condition Acquisition of 4-lead/12-lead EKG if indicated Perform medication cross check for all medication administrations Needle Decompression of the chest as indicated Avoid hypoxia, hypotension, and hyperventilation with significant head injuries These are the killer H-bombs of head injuries If clear evidence of brain herniation, then MILDLY hyperventilate the patient 20-24 breaths per minute. Then titrate ventilation rate to Adult & Pediatric ETCO2 30-35 mmHg, Otherwise aim for 35-45 mmHg if patient has a traumatic brain injury WITHOUT clear signs of herniation. Vascular access For hemorrhagic shock, Calcium Chloride If Hypotensive, IV Crystalloid in 250 mL increments until MAP > 65 or SBP > 90 or until patient mentation improves
Pain Management Guideline as needed with morphine, fentanyl, or ketamine
Morphine 0.1 mg/kg IV/IM(2-4 mg max pediatrics, 4-8mg max for adult)
Fentanyl 1mcg/kg max 100mcg IV/IM/IN(round to nearest 12.5mcg-25mcg below 100mcg)
Ketamine 0.2mg/kg IV (10mg max pediatrics, 25mg max adults)
12-lead acquisition and interpretation as indicated
ETCO2 assessment
Consider Simple Thoracostomy if concern for chest trauma and patient peri-arrest
Advance airway management as needed
If Adult Neurogenic Shock (as indicated by cervical spine injury, paralysis, hypotension with inappropriately low heart rate/bradycardia) – push-dose epinephrine until MAP > 65
10mcg IV (1:100,000 or 10mcg/ml solution)
Contact Medical Control as needed
Pearls
Consider Chest Decompression with signs of shock and diminished/absent breath sounds. If patient arrests or is peri-arrest, then immediately perform bilateral finger thoracostomies.
See East Central EMS Regional Trauma Guidelines for criteria when declaring trauma alert.
Minimize Scene time. If patient meets Trauma Alert criteria, then interventions should be performed enroute.
Severe bleeding from an extremity not rapidly controlled by direct pressure may necessitate the application of a tourniquet.
Permissive hypotension (target fluid resuscitation to MAP 55-65) should be used in the absence of traumatic brain injury, pregnancy, hypertensive history, and age < 45 years old. If traumatic brain injury is suspected, maintain Adult SBP > 90 mmHg.
Hypotension, hypoxia, and hyperventilation are independent predictors of morbidity and mortality in patients with traumatic brain injuries
These are known as the killer H-bombs
Hypotension is devastating to neurologic injury and should be aggressively treated.
MAP calculation [(2 x diastolic) + systolic] divided by 3
Peripheral neurovascular status should be document on all extremity injuries and before and after splinting procedures. Same for neuro status before and after extrication, and before/after transport.
With traumatic amputations, time is critical. Transport and notify medical control immediately, so that the appropriate destination can be determined.
Hip dislocations and knee and elbow fracture / dislocations have a high incidence of neuro- vascular compromise. Document pulse, motor, and sensation.
Urgently transport any injury with vascular compromise.
Blood loss may be concealed or not apparent with extremity injuries.
If evidence of brain herniation (blown pupil, Cushing’s reflex, rapid decline in GCS, or bradycardia) and in absence of capnometer, MILDLY hyperventilate the patient 20 – 24 breaths per minute. If available titrate to: Adult and Pediatric ETCO2 30 – 35 mmHg. ETCO2 < 30 is associated with poor neurologic outcomes. Increased intracranial pressure (ICP) may cause hypertension and bradycardia with altered breathing (Cushing's Response). Consider Altered Mental Status guideline. The most important item to monitor and document is a change in the level of consciousness and GCS. Avoid nasal airways in patient’s with significant facial trauma Consider Restraints if necessary, for patient’s and/or personnel’s protection per the Restraining Procedure. For dental trauma, collect teeth and place them in a cup of normal saline. Avoid touching the root of the tooth as much as possible. Local Level 1 traumas centers Barnes-Jewish Hospital, St. Louis Children’s Hospital Mercy Hospital SLU Hospital, Cardinal Glennon Children’s Hospital Local Level 2 trauma centers Mercy Hospital, South GCS Score Adult Eyes Open Best Verbal Best Motor 4 – Eyes Open 5 – Oriented 6 – Obeys Commands 3 – To Voice 4 – Confused 5 – Localizes Pain 2 – To Pain 3 – Inappropriate 4 – Withdraws from Pain 1 - None 2 – Incomprehensible 3 – Pain-Flexion 1 - None 2 – Pain-Extended 1 - None GCS Score Pediatric Spinal Motion Restriction Spinal motion restriction can be accomplished by securing the patient to the stretcher. Do not transport patients on rigid long boards unless the clinical situation warrants long board use. C-collars should be placed for the following: Patient complains of midline neck or spine pain Any midline neck or spinal tenderness with palpation Any abnormal mental status (including extreme agitation) Focal or neurologic deficit Any evidence of alcohol or drug intoxication Another severe or painful distracting injury is present A communication barrier that prevents accurate assessment If none of the above apply, patient may be managed without a cervical collar Do not place a C-collar if the patient has a penetrating injury to the neck as it can delay identification of injury and potentially compromise the airway. Trauma Procedure Needle Decompression Clinical Indications: Patients with suspected tension pneumothorax as evidenced by: Hypotension of SBP < 90, clinical signs of hypoperfusion, and at least one of the following: Jugular vein distention Absent or decreased breath sounds on the affect side. Hyper-resonance to percussion on the affected side Increased resistance when ventilating a patient. Tracheal deviation away from the side of injury, which is a late sign. Patient in traumatic arrest with chest or abdominal trauma in whom resuscitation is indicated. These patients may require bilateral chest decompression even in the absence of the signs above. Asthma patient in Cardiac Arrest, perform bilateral decompression. Contraindications: None in the emergency setting. Procedure: Administer high flow oxygen. Prepare equipment and don appropriate PPE. Identify and prep the site: Lateral placement at the fourth or fifth intercostal space in the mid-axillary line. Locate the second intercostal space in the mid-clavicular line. Prepare the site with Alcohol. Insert the appropriate catheter perpendicular to the chest wall over the top of the inferior rib. Advance the needle-catheter assembly through the parietal pleura until a pop is felt and air or blood exists the catheter. Advance only the catheter until the hub is in contact with the chest wall. Remove the needle leaving the plastic catheter in place. Secure the catheter hub to the chest wall. A 60cc syringe may be used to aspirate air to confirm access. Consider placing a one-way valve or creating a flutter valve from the finger of an exam glove. This sho]uld not delay the pleural decompression procedure. Trauma Procedure Finger Thoracostomy Clinical Indications: Traumatic cardiac arrest with known or suspected injury to the chest/abdomen. Hemodynamically unstable patient with clinical presentation of a tension pneumothorax/hemothorax. Contraindications: Definitive loss of pulse for > 10 minutes prior to arrival of first unit.
May consider the procedure if PEA is present at a rate > 60
Any patient that has adequate cardiac output.
Injuries incompatible with life.
Any pediatric patient that appears too small for utilization of simple thoracostomy.
Preparation for Use:
Don appropriate PPE
Ensure all equipment is readily available: Scalpel, Curved Kelly Forceps, Chlorhexidine Sponge, Permanent Marker, Chest Seals
Ventilation, oxygenation, and IV access should be performed by other crew members and not delay thoracostomy.
Procedure (link to video):
Ensure patient is in the supine position and begin on the side most likely to be affected
by a tension pneumothorax. Abduct the patient’s arm on the same side of the procedure.
Identify lateral chest wall site directly over 5th or 6th rib between anterior axillary and midaxillary lines.
Cleanse the site with Alcohol
Using a scalpel, make a 1–2-inch incision directly over the 5th or 6th rib, between the anterior axillary line and midaxillary line.
It is important not to extend or make incisions in or through penetrating wounds when at all possible.
Use scalpel for skin only, there after use blunt dissection to pass through the intercostal muscles.
Utilizing curved forceps, penetrate the thoracic cavity over the rib making sure to control the depth by grasping the forceps near the curved portion while inserting.
Following penetration into the thoracic cavity and with the tips of the forceps, open the forceps maintaining control of the depth and withdraw to create an adequate opening sufficient to place your finger in the chest.
Insert finger into pleural space. Ensure the lung is palpated and, if possible, feel caudally for the diaphragm.
Allow the soft tissues to fall back over the wound to act as a flutter valve.
Repeat the procedure on the opposite side.
Post Procedure:
If ROSC, then place an occlusive dressing over the wound (Pediatric defib pad, vent chest seal, etc).
If no ROSC, then prior to pronouncement circle simple thoracostomy site and/or other incisions made by EMS. Label each with “EMS” to aid in identification for postmortem examination.
If evidence of tension pneumothorax occurs, including cardiac arrest following ROSC, then remove occlusive dressing(s) and re-insert finger to relieve tension.
Burn
Assessment
Pediatric Pearls:
Signs & Symptoms:
Differential:
2) mmHg
for adults and children
thickness (2°) – blistering and painful
thickness (3°) – painless and charred or leathery skin
Pediatric hypotension is defined as SBP < 70 + (age in years x Rule of 9’s is different Rapid heat loss from burns is common Burns, pain, swelling Dizziness Loss of consciousness Hypotension / shock Airway compromise / distress, singed facial or nasal hair, hoarseness / wheezing / stridor Superficial (1°) – red and painful Partial Full Chemical Thermal Electrical Radiation Clinical Management Options EMT-B Paramedic Oxygen, target SpO2 92 – 96% Basic Airway Management as needed Remove rings, bracelets, or other constricting items If thermal burn: < 10% body surface area, then cool down the wound with Isotonic Crystalloid or sterile water If thermal burn: After cooling cover burn with a dry sheet or dressings If chemical burn: Remove clothing or expose area, brush off any dry chemicals or powder, then flush area with large amount of water or Isotonic Crystalloid Establish BSA, location(s), and type of burn Perform medication cross check for all medication administrations Partial/Full Thickness burn area > 10% BSA then:
Isotonic solution infusion
1L NS for adults
20cc/kg for children
Pain Management Guideline with morphine, fentanyl, or ketamine
Morphine 0.1 mg/kg IV/IM(2-4 mg max pediatrics, 4-8mg max for adult)
Fentanyl 1mcg/kg max 100mcg IV/IM/IN(round to nearest 12.5mcg-25mcg below 100mcg)
Ketamine 0.2mg/kg IV (10mg max pediatrics, 25mg max adults)
Continuous ETCO2 and ECG monitoring
If airway burn: Nebulized Epinephrine for Respiratory Distress and prepare to secure the airway with intubation
Adult: 2mg nebulized (1mg/ml) mixed with 1ml normal saline
Pediatric: 1mg nebulized (1mg/ml) mixed with 4ml normal saline
Cricothyrotomy if significant airway edema and unable to intubate
Calcium Chloride for hydrofluoric acid burns with unstable vital signs, such as hypotension, tachy/bradycardia, ectopic beats, and/or ECG changes
Adult: 1000mg IV
Pediatric: 20mg/kg IV (max dose 1000mg)
Consult Online Medical Control as Needed
Pearls
Consider nebulized epinephrine for respiratory distress early in airway burns when horsed/muffled voice, stridor, etc. are presenting. It can cause bronchodilation and reduce the airway edema.
Evaluate BSA: Use chart or use palm side of patient’s hand = 1% BSA
Critical Burns:
>20% body surface area (BSA) age 10-50.
>10% BSA age < 10 or > 50.
3° burns >5% BSA.
2° and 3° burns to face, eyes, hands or feet or genitalia; electrical burns; respiratory burns; deep chemical burns.
Burns with extremes of age or chronic disease; and burns with associated major traumatic injury.
Non-critical burns (< 5% BSA 2nd and 3rd) not complicated by airway compromise or trauma do not require transport to a trauma center. Potential CO exposure should be treated with 100% oxygen. Potential Cyanide (CN) exposure should be treated with hydroxycobalamin (Cyanokit). Circumferential burns to extremities are dangerous due to potential vascular compromise 2° to soft tissue swelling. Burn patients are prone to hypothermia - Never apply ice or cool burns that involve >10% body surface area.
Do not overlook the possibility of multiple system trauma or child abuse with burn injuries.
Hydrofluoric acid burns of 3% BSA may be fatal and may have little to no external signs
Causes massive electrolyte derangements: hypocalcemia, hyperkalemia, and hypomagnesemia resulting in cardiac arrest
Crush Injury
Assessment
Pediatric Pearls:
Signs & Symptoms:
Differential:
2) mmHg
Pediatric hypotension is defined as SBP < 70 + (age in years x Compartment Syndrome Pain on passive stretch Paresthesia Paralysis Pallor Pulselessness Hypoperfusion Hypotension Altered Mental Status Skin irritant exposure Dust concentrations in airway Hypo/Hyperthermia Hyperkalemia Dehydration Additional trauma EMT-B Paramedic Oxygen, target SpO2 92 – 96% Treatment in a confined space should be performed only by appropriately trained personnel. Air quality monitoring should be conducted and documented prior to entry into confined space. Continuous air quality monitoring must be maintained once contact is made with victim and when any rescuer is in a confined space. Document air quality measurement at patient location on PCR. Remove rings, bracelets, and other constricting items N95 mask PRN for dust environment Acquisition of 4-lead/12-lead ECG as appropriate Perform medication cross check for all medication administrations If amputation is being considered, contact WUEMS for physician response. Vascular access x 2 Bolus Isotonic Crystalloid 20cc/kg for max of 1 liter followed by a continuous drip. Continuous ETCO2 and ECG monitoring once practical. If goes into cardiac arrest, then treat for hyperkalemia with both Calcium Chloride and Sodium Bicarbonate in conjunction with cardiac arrest guidelines. Calcium Chloride Adult: 1000mg (1g) IV Pediatric: 20mg/kg (max 1000mg) IV Sodium Bicarbonate Adult and Pediatric: 1mEq/kg (max 50 mEq) IVP Consider a sodium bicarbonate drip if prolonged extrication Add 1 amp bicarb to a 250cc bag of D10. Infuse of 1 hour. Check glucose every 30 minutes if the patient is diabetic or the history is unknown. If MAP > 65 and no respiratory failure, then Morphine, Fentanyl , or Ketamine for refractory pain
Morphine 0.1 mg/kg IV/IM(2-4 mg max pediatrics, 4-8mg max for adult)
Fentanyl 1mcg/kg max 100mcg IV/IM/IN(round to nearest 12.5mcg-25mcg below 100mcg)
Ketamine 0.2mg/kg IV (10mg max pediatrics, 25mg max adults)
If MAP < 65 and/or respiratory failure, then Ketamine for pain Ketamine 0.2mg/kg IV (10mg max pediatrics, 25mg max adults) Push Calcium Chloride and Sodium Bicarbonate immediately prior to released. Start nebulized Albuterol prior to release of the patient. Calcium Chloride Adult: 1000mg (1g) IV Pediatric: 20mg/kg (max 1000mg) IV Albuterol Adult: 5mg Pediatrics: 2.5mg Sodium Bicarbonate Adult and Pediatric: 1mEq/kg (max 50 mEq) IVP Consult Online Medical Control as Needed Pearls Refer to drug formulary charts for all medication dosing for both adults and pediatric patients. Hydration should begin prior to extrication whenever possible. Large volume resuscitation prior to removal of the crush object and extrication is critical to preventing secondary renal failure and death. Crush injury is usually seen with compression of 4-6 hours but may occur in as little as 20 min. If possible, monitor patient for signs of compartment syndrome. Crush injury victims can 3rd space > 12L in the first 48 hours.
Elderly patients should be monitored closely for volume overload but do NOT withhold fluids unless clinical signs/symptoms of volume overload.
The larger the mass crushed (i.e., more limbs) the greater the likelihood of severe rhabdomyolysis and renal failure, which has high risk for hyperkalemia.
Crush injury may cause profound electrolyte disturbances resulting in dysrhythmias. Monitor as soon as practically possible.
Do not overlook treatment of additional injuries, airway compromise, hypothermia/ hyperthermia.
ETCO2 if multiple doses of Narcotic Medication administered or if the patient is altered.
Drowning/Submersion
Assessment
Pediatric Pearls:
Signs & Symptoms:
Differential:
observation
Pediatric hypotension is defined as SBP < 70 + (age in years x 2) mmHg Airway and ventilation is a priority Consider transport to pediatric trauma hospital as these patients may need admission for Unresponsive Mental status changes Decreased or absent vital signs Vomiting Coughing Trauma Pre-existing medical problem Pressure injury (diving) Barotrauma Decompression sickness Duration of immersion Temperature of water Clinical Management Options EMT-B Paramedic Scene safety & decontaminate patient as needed Evaluate for Cardiac Arrest Oxygen, Target SpO2: 92-94% BLS airway management as needed Evaluate for spinal motion restriction if neuro deficits present Keep patient warm Acquisition of 4-lead/12-lead ECG as appropriate Perform medication cross check for all medication administrations If conscious and with wheezing, Albuterol & Ipratropium Bromide nebulizer Albuterol Adult: 5mg Pediatrics: 2.5mg Ipratropium 0.5mg (adults and pediatrics) If conscious and with rales/rhonchi, CPAP Vascular access Evaluate and interpret ECG and EtCO2 Advance airway maneuvers and management as needed Consult Online Medical Control as Needed Pearls Do not attempt a water rescue unless trained. Criteria for resuscitation includes: Suspected arrest from cause other than submersion Patient submersion time less than 20 minutes from witness of person going underwater or from arrival of the first Public Safety entity until the patient is in a position for resuscitative efforts to be initiated. On- scene rescuers should consider conversion from rescue to recovery at 20 minutes unless the patient is a diver with an air source, or a patient trapped with a potential air source. Final decision for transition from rescue to recovery mode rests with on-scene command. Spinal motion restriction should be used when a suspected or known traumatic mechanism preceded the drowning. All victims should be transported for evaluation due to potential for worsening over the next several hours. Drowning is a leading cause of death among would-be rescuers. Allow appropriately trained rescuers to remove victims from areas of danger. With pressure injuries (decompression / barotrauma), if possible, transport dive computer and/or dive logs with patient. Consider CPAP early if respiratory distress for any age if adequate mask seal can be established and patient alert. Assess water temperature (< 10◦ C / < 50◦ F) defines cold water. Lift Assist/Fall Assessment Pediatric Pearls: Signs & Symptoms: Differential: Pediatric hypotension is defined as SBP < 70 + (age in years x 2) mmHg Assess for non-accidental trauma Pain Dizziness Weakness Syncope Difficulty Breathing Altered Mental Status Inability to ambulate Mechanical Fall Stroke Sepsis Electrolyte Abnormality Acute Coronary Syndrome Unmet Healthcare Needs Seizures MI Clinical Management Options EMT-B Paramedic Scene safety & decontaminate patient as needed Oxygen, target SpO2 92 – 96% Complete and document a full set of vitals Basic Airway Management as needed General Trauma Assessment Blood glucose level Acquisition of 4-lead/12-lead ECG as appropriate Perform medication cross check for all medication administrations Consider vascular access Consider evaluating EKG, ETCO2 Consult Online Medical Control as Needed Pearls Patients that refuse transport to the hospital should be able to ambulate/move at the same ability as prior to the fall/lift-assist. This should be documented as a refusal Evaluate and document the reason for the fall. Specifically ask about weakness, lightheadedness, pain prior to falling. Ambulation around the scene for multiple feet can help find signs of a stroke or back/hip/femur fracture. Consider contacting the patient’s primary care doctor to speak with the physician or leave a voicemail stating that the patient is unable to get off the ground on their own. Consider contacting MO Department of Health and Senior Services if there is any amount of concern for elder abuse or the patient is living in a dangerous environment. Attempt to remove any tripping hazards in the living environment and perform a fall-risk assessment. Home Assessment-home checklist High Threat Considerations/Active Shooter Scenario/Care Under Fire Definitions Hot Zone/Direct Threat Zone: an area within the inner perimeter where active threat and active hazards exists. Warm Zone/Indirect Threat Zone: an area within the inner perimeter where security and safety measures are in place. This zone may have potential hazards, but no active danger exists. Cold Zone: Normal EMS Operations Patient Care Goals Assess the scene Mitigating further harm Accomplish goal with minimal additional injuries Assessment, Treatment, and Interventions Hot Zone/Direct Threat care considerations: Look for cover Defer in depth medical interventions if engaged in ongoing direct threat (e.g., active shooter, unstable building collapse, improvised explosive device, hazardous material threat) Threat mitigation techniques will minimize risk to patients and providers Triage should be deferred to a later phase of care Prioritization for extraction is based on resources available and the situation Minimal interventions are warranted Encourage patients to provide self-first aid or instruct aid from uninjured bystanders Consider hemorrhage control: Tourniquet application is the primary “medical” intervention to be considered in Hot Zone/Direct Threat Consider instructing patient to apply direct pressure to the wound if no tourniquet available (or application is not feasible) Consider quickly placing or directing patient to be placed in position to protect airway, if not immediately moving patient Warm Zone/Indirect Threat care considerations: Maintain situational awareness Ensure safety of both responders and patients by rendering equipment and environment safe (firearms, vehicle ignition) Conduct primary survey, per the Trauma Management guideline, and initiate appropriate life-saving interventions: Hemorrhage Control: Tourniquet Wound packing if feasible Needle Decompression Do not delay patient extraction and evacuation for non-life-saving interventions Consider establishing a casualty collection point if multiple patients are encountered Unless in a fixed casualty collection point, triage in this phase of care should be limited to the following categories: Uninjured and/or capable of self-extraction Deceased/expectant All others Traumatic Arrest Assessment Pediatric Pearls: Signs & Symptoms: Differential: tools. Intubation may not be the best option for these patients. be used in children < 25 Kg. cause hypoxia leading to bradycardia Focus on rapid and early BLS airway and ventilation Traumatic Mechanism Apnea Pulseless PEA Medical Cardiac Arrest Exsanguination Tension Pneumothorax Pelvic fracture(s) Hypoventilation Hypovolemia Hemorrhage Toxins Tamponade Pediatric pads should Traumatic airway can Clinical Management Options EMT-B Paramedic Assess for obvious signs of death and withhold resuscitation if present (see pearls) Place tourniquets prior to or concurrent with CPR for major hemorrhagic injuries as indicated. Perform Pit Crew CPR for Trauma with basic airway management until Paramedic arrives, and then pause CPR as necessary for correctable traumatic causes of death. Acquisition of 4-lead/12-lead ECG as appropriate Perform medication cross check for all medication administrations Bilateral finger thoracostomy for any torso trauma Consider non-transport if no ROSC or signs of life Consider advanced airway management 4-lead ECG and EtCO2 placement/interpretation Vascular access with Isotonic Crystalloid bolus until ROSC or up to 1 liter Pull all extremities out to anatomical length/position. Calcium Chloride Adult: 1000mg (1g) IV Pediatric: 20mg/kg (max 1000mg) IV Consider medical etiology if low mechanism Consult Online Medical Control as Needed Pearls Emphasis is to be placed on correcting traumatic causes of death (hemorrhage control, application of pelvic binder/closing open pelvic fractures with a sheet, ventilation, decompression of the chest, reduction of grossly deformed extremities, volume resuscitation, etc.) prior to or concurrent with initiating CPR. LUCAS device is contraindicated in traumatic arrests Chest decompression should not be delayed for any other medical procedure or intervention to be accomplished, including CPR. CPR should be paused during Simple Thoracostomy (Simple Thoracostomy procedure under Trauma Management section) to minimize risk of provider injury. There is no indication for using the Lucas device for chest compressions in a traumatic cardiac arrest. However, if it has already been placed, it can be continued during transportation. Traumatic arrest patients with short downtime and proximity to an appropriate trauma facility can be considered for transport after reasonable lifesaving interventions are first performed. In multi-patient events, traumatic arrests should not receive intervention until there are sufficient responders present to meet the needs of the living patients. Except for lightning strikes, then perform reverse triage by giving higher priority to cardiac/respiratory arrests. Obvious signs of traumatic death include: Rigor mortis or dependent lividity the patient is apneic, pulseless, and without other signs of life upon EMS arrival including, but not limited to spontaneous movement, EKG activity, or pupillary response Injuries incompatible with life (such as massive crush injury, complete exsanguination, severe displacement of brain matter) Decapitation: the complete severing of the head from the remainder of the patient’s body Transection of the torso: the body is completely cut across below the shoulders and above the hips through all major organs and vessels. The spinal column may or may not be severed Incineration: 90% of body surface area with full thickness burns as exhibited by ash rather than clothing and complete absence of body hair with charred skin Finger Thoracostomy Clinical Indications: Traumatic cardiac arrest with known or suspected injury to the chest/abdomen. Hemodynamically unstable patient with clinical presentation of a tension pneumothorax/hemothorax. Contraindications: Definitive loss of pulse for > 10 minutes prior to arrival of first unit.
May consider the procedure if PEA is present at a rate > 60
Any patient that has adequate cardiac output.
Injuries incompatible with life.
Any pediatric patient that appears too small for utilization of simple thoracostomy.
Preparation for Use:
Don appropriate PPE
Ensure all equipment is readily available: Scalpel, Curved Kelly Forceps, Chlorhexidine Sponge, Permanent Marker, Chest Seals
Ventilation, oxygenation, and IV access should be performed by other crew members and not delay thoracostomy.
Procedure (link to video):
Ensure patient is in the supine position and begin on the side most likely to be affected
by a tension pneumothorax. Abduct the patient’s arm on the same side of the procedure.
Identify lateral chest wall site directly over 5th or 6th rib between anterior axillary and midaxillary lines.
Cleanse the site with Alcohol
Using a scalpel, make a 1–2-inch incision directly over the 5th or 6th rib, between the anterior axillary line and midaxillary line.
It is important not to extend or make incisions in or through penetrating wounds when at all possible.
Use scalpel for skin only, there after use blunt dissection to pass through the intercostal muscles.
Utilizing curved forceps, penetrate the thoracic cavity over the rib making sure to control the depth by grasping the forceps near the curved portion while inserting.
Following penetration into the thoracic cavity and with the tips of the forceps, open the forceps maintaining control of the depth and withdraw to create an adequate opening sufficient to place your finger in the chest.
Insert finger into pleural space. Ensure the lung is palpated and, if possible, feel caudally for the diaphragm.
Allow the soft tissues to fall back over the wound to act as a flutter valve.
Repeat the procedure on the opposite side.
Post Procedure:
If ROSC, then place an occlusive dressing over the wound (Pediatric defib pad, vent chest seal, etc).
If no ROSC, then prior to pronouncement circle simple thoracostomy site and/or other incisions made by EMS. Label each with “EMS” to aid in identification for postmortem examination.
If evidence of tension pneumothorax occurs, including cardiac arrest following ROSC, then remove occlusive dressing(s) and re-insert finger to relieve tension.
Toxicology Protocols Poisoning/Overdose
Assessment
Pediatric Pearls:
Signs & Symptoms:
Differential:
Fluids and medications titrated to maintain SBP
> 70 + (age x 2) mmHg
Consider calling poison control early
Altered mental status
Nausea/vomiting/diarrhea
Pupil changes
Tachycardia/bradycardia
Tachypnea/bradypnea/apnea
Seizures
Burns
Hyperthermia
Hypertension/hypotension
Sepsis
Suicidal ideation
Heat illness
Cold illness
DKA
Stroke
Hypoglycemia
Post-ictal
Patient Care Goals
EMT-B
Place in position of comfort
Oxygen target SpO2 92% – 96%
Obtain blood glucose level
Consider contacting poison control at 1-800-222-1222
Obtain 12 lead/4 lead as indicated
Perform medication cross check for all medication administrations
Paramedic
IV / IO access as appropriate for patient condition
IV fluid therapy with Isotonic Crystalloid, titrated to Adult SBP > 100 mmHg
Monitor ETCO2 in patients with respiratory distress/failure
Acquisition and interpretation of 12 lead/4 lead
Provide antidotes when available
Consider Push dose Epinephrine IV/IO for hypotension
Adult: 20mcg IV (10 mcg/mL 1:100,000)
Pediatric: 10mcg IV (10 mcg/mL 1:100,000)
NOTE: IM vs IV dosing and concentration are VERY different
Consult Medical Control as needed
Pearls
Frequent re-evaluations are required as patients can deteriorate rapidly.
Identify amount and timing of any ingestions when possible.
Take pill bottles if available.
Reduce the risk of exposure to you and those around you and perform rapid decontamination on scene if necessary.
Consider contacting poison control early to guide treatment options
Provide antidotes early when possible
Acetylcholinesterase Inhibitors (Carbamates, Nerve Agents, Organophosphates) Exposure
Symptoms-DUMBELS
Diarrhea
Urination
Miosis/Muscle weakness
Bronchospasm/Bronchorrhea/Bradycardia (the killer B’s)
Emesis
Lacrimation
Salivation/Sweating
Patient Care Goals
EMT-B
Paramedic
Place in position of comfort
Oxygen target SpO2 92% – 96%
Remove the patient from exposure, remove clothing if contaminated
Obtain 12 lead/4 lead as indicated
Perform medication cross check for all medication administrations
IV / IO access as appropriate for patient condition
Acquisition and interpretation of 12 lead/4 lead
Atropine and pralidoxime (not available)
May require multiple doses of atropine for respiratory symptoms
Atropine
Adult: 2mg IV/IM every 3 minutes until symptoms resolve (secretions dry out)
Pediatrics: 0.02mg/kg (minimum 0.1mg, maximum 0.5mg per dose) every 3 minutes until symptoms resolve (secretions dry out)
Consult Medical Control as needed
Pearls
Be aware of the environment, particularly closed spaces
Decontaminate the patient prior to transport to avoid contaminating providers
Airway/Respiratory Irritants
Assessment
Pediatric Pearls:
Signs & Symptoms:
Differential:
/dyspnea
laryngospasm and
laryngeal edema
cardiogenic)
Fluids and medications titrated to maintain SBP > 70 + (age x 2) mmHg
Consider early airway management
Unusual odor /smell
Tearing or itchy eyes
Burning sensation and burns to the nose, pharynx and respiratory tract
Sneezing
General excitation
Cough
Chest tightness
Nausea
Shortness of breath
Asthma/COPD
CHF
FB
Tracheitis
Bronchiolitis
Wheezing
Stridor
Dyspnea on exertion
Dizziness Upper
Change in voice
Airway obstruction include
Pulmonary edema (non-
Seizures
Cardiopulmonary arrest
Patient Care Goals
EMT-B
Paramedic
Place in position of comfort
Oxygen target SpO2 92% – 96%
Provide humidified air
10cc normal saline nebulized
Obtain 12 lead/4 lead as indicated
Perform medication cross check for all medication administrations
IV / IO access as appropriate for patient condition
Acquisition and interpretation of 12 lead/4 lead as indicated
Consider albuterol for patients with wheezing
Adult: 5mg nebulized
Pediatric: 2.5 mg nebulized
Consider early advanced airway options in patients with stridor, drooling, etc
Consult Medical Control as needed
Pearls
Inhalation of a variety of gases, mists, fumes, aerosols, or dusts may cause irritation or injury to the airways, pharynx, lung, asphyxiation, or other systemic effects
Inhaled airway/respiratory irritant agents will interact with the mucus membranes, upper and lower airways based on solubility, concentration, particle size, and duration of exposure
The less soluble and smaller the particle size of the agent the deeper it will travel into the airway and respiratory systems the inhaled toxic agent will go before reacting with adjoining tissues thus causing a greater delay in symptom onset
Smell can help identify toxin
Fresh mowed hay= phosgene
Rotten Eggs= Hydrogen Sulfide
Beta-Blocker Overdose
Assessment
Pediatric Pearls:
Signs & Symptoms:
Differential:
Fluids and medications titrated to maintain SBP > 70 + (age x 2) mmHg
Bradycardia
Hypotension
Altered mental status
Weakness
Shortness of breath
Possible seizures
Sepsis
Hypoxia
Hypoglycemia
Hear block
Sick sinus syndrome
Patient Care Goals
EMT-B
Place in position of comfort
Oxygen target SpO2 92% – 96%
Paramedic
Check blood glucose level, especially in the pediatric patient
Obtain 12 lead/4 lead as indicated
Perform medication cross check for all medication administrations
IV / IO access as appropriate for patient condition
Acquisition/interpretation of 12 lead/4 lead ECG
Consider atropine sulfate for symptomatic bradycardia
Adult: Atropine 0.5 mg IV every 5 minutes to maximum of 3 mg
Pediatric: Atropine 0.02 mg/kg (0.1 minimum – 0.5 mg maximum per dose) every 5 minutes, maximum total dose 3 mg
Consider fluid challenge (20 mL/kg) for hypotension with associated bradycardia
For symptomatic patients consider Calcium:
Adult: 1000mg (1g) slow IVP
Pediatric: 20mg/kg (max 1000mg) slow IVP
Consider push dose epinephrine after adequate fluid resuscitation and calcium for the hypotensive patient
Adult: 20mcg IV (10 mcg/mL 1:100,000)
Pediatric: 10mcg IV (10 mcg/mL 1:100,000)
NOTE: IM vs IV dosing and concentration are VERY different
Consider transcutaneous pacing if refractory to initial pharmacologic interventions
Consult Medical Control as needed
Calcium Channel Blocker Overdose
Assessment
Pediatric Pearls:
Signs & Symptoms:
Differential:
Fluids and medications titrated to maintain SBP > 70 + (age x 2) mmHg
Bradycardia
Hypotension
Decreased AV Nodal conduction
Cardiogenic shock
Hyperglycemia
seizures
Sepsis
Hypoxia
Hypoglycemia
Patient Care Goals
EMT-B
Paramedic
Place in position of comfort
Oxygen target SpO2 92% – 96%
Check blood glucose level
Obtain 12 lead/4 lead as indicated
Perform medication cross check for all medication administrations
IV / IO access as appropriate for patient condition
Acquisition/interpretation of 12 lead/4 lead ECG
Consider atropine sulfate for symptomatic bradycardia
Adult: Atropine 0.5 mg IV every 5 minutes to maximum of 3 mg
Pediatric: Atropine 0.02 mg/kg (0.1 minimum – 0.5 mg maximum per dose) every 5 minutes, maximum total dose 3 mg
Consider fluid challenge (20 mL/kg) for hypotension with associated bradycardia
For symptomatic patients consider Calcium:
Adult: 1000mg (1g) slow IVP
Pediatric: 20mg/kg (max 1000mg) slow IVP
Consider push dose epinephrine after adequate fluid resuscitation and calcium for the hypotensive patient
Adult: 20mcg IV (10 mcg/mL 1:100,000)
Pediatric: 10mcg IV (10 mcg/mL 1:100,000)
NOTE: IM vs IV dosing and concentration are VERY different
Consider transcutaneous pacing if refractory to initial pharmacologic interventions
Consult Medical Control as needed
Carbon Monoxide/Smoke Inhalation
Symptoms
Mild intoxication:
Nausea
Fatigue
Headache
Vertigo
Lightheadedness
Moderate to severe:
Altered mental status
Tachypnea
Tachycardia
Convulsion
Cardiopulmonary arrest
Patient Care Goals
EMT-B
Paramedic
Place in position of comfort
100% oxygen via non-rebreather mask or bag valve mask or advanced airway as indicated
Obtain 12 lead/4 lead as indicated
Perform medication cross check for all medication administrations
IV / IO access as appropriate for patient condition
Acquisition and interpretation of 12 lead/4 lead
Consult Medical Control as needed
Pearls
Consider this in homes where everyone is feeling ill at the same time.
Pregnant patients are much more susceptible for carbon monoxide poisoning due to the fetus’
hemoglobin (fetal hemoglobin) binding to carbon monoxide even more tightly.
Cyanide
Symptoms
Anxiety
Vertigo
Weakness
Headache
Tachypnea
Nausea/vomiting
Dyspnea
Tachycardia
Severe poisoning causes altered mental status, arrhythmias, seizures, respiratory arrest
Patient Care Goals
EMT-B
Paramedic
Place in position of comfort
100% oxygen via non-rebreather mask or bag valve mask or advanced airway as indicated
Obtain 12 lead/4 lead as indicated
Perform medication cross check for all medication administrations
IV / IO access as appropriate for patient condition
Consider obtaining EKG
Administer the Hydroxycobalamin (Cyanokit) if immediately available on scene (should be auto-dispatched to scene of fires with suspected entrapped victims)
Adult: Initial dose is 5 g administered over 15 minutes slow IV
Each 5 g vial of hydroxocobalamin for injection is to be reconstituted with 200 mL of LR, NS or D5W (25 mg/mL) and administered at 10-15 mL/minute
Gently mix the cyanokit with 200 mL of LR/NS/D5W by rocking back an forth in vial, DO NOT shake the vial
An additional 5 g dose may be administered with medical consultation.
Pediatric: Administer hydroxocobalamin (Cyanokit) 70 mg/kg (reconstitute concentration is 25 mg/mL)
Each 5 g vial of hydroxocobalamin for injection is to be reconstituted with 200 mL of LR, NS or D5W (25 mg/mL) and administered at 10-15 mL/minute
70 mg/kg = 2.8 mL/kg
Maximum single dose is 5 g
Consult Medical Control as needed
Pearls
Cyanide should be suspected in occupational or other smoke exposures (e.g. firefighting), industrial accidents, natural catastrophes, suicide and murder attempts, chemical warfare and terrorism (whenever there are multiple casualties of an unclear etiology).
Consider early in hypotensive, critically ill patients who are removed from a fire.
Many modern day materials produce cyanide when burned.
Opioid Overdose
Symptoms
exhibiting miosis (pinpoint pupils)
decreased mental status
respiratory depression
Patient Care Goals
EMT-B
Paramedic
Place in position of comfort
Oxygen target SpO2 92% – 96%
Perform medication cross check for all medication administrations
IV / IO access as appropriate for patient condition
Naloxone
Adult: 0.4-0.5mg IV
Adult: 2mg IM/IN
Pediatric: 0.1 mg/kg IV/IM/IN (max dose 2mg)
Consult Medical Control as needed
Pearls
The treatment for opioid overdose is respiratory support; the antidote is naloxone. The BVM is more important/should come before antidote administration
Smaller doses of naloxone can be used to help the patient breathe without putting the patient into acute withdrawal
This can be especially important to consider in patients who have mixed ingestions.
Some patients have pulmonary edema with poor oxygenation after opioid overdose and naloxone administration.
Some patients with pontine strokes present very similar to opioid overdoses (pinpoint pupil, sonorous respirations, unresponsiveness). Consider other causes in patients who are unresponsive to Narcan; consider transport to a stroke center if there is concern for a pontine stroke.
Narcan is not indicated in adult medical cardiac arrests.
Hotline pediatric patients who are in the home of patients requiring Narcan.
Radiation Exposure
Symptoms
Nausea and vomiting
Burns
Altered mental status (severe exposure)
Patient Care Goals
EMT-B
Paramedic
Place in position of comfort
Oxygen target SpO2 92% – 96%
Decontamination by HAZMAT Team/Fire Service
Obtain 12 lead/4 lead EKG as indicated
Perform medication cross check for all medication administrations
IV / IO access as appropriate for patient condition
Acquisition and interpretation of 12 lead/4 lead EKG as indicated
Consider pain management
Acetaminophen/Ibuprofen for mild to moderate pain
Acetaminophen
Adult: up to 1000mg PO
Pediatric: 15 mg/kg PO (max 1000mg)
Ibuprofen
Adult: 600mg PO
Pediatric: 10mg/kg PO (max 600mg)
Morphine 0.1 mg/kg IV/IM(2-4 mg max pediatrics, 4-8mg max for adult)
Fentanyl 1mcg/kg max 100mcg IV/IM/IN(round to nearest 12.5mcg-25mcg below 100mcg)
Ketamine 0.2mg/kg IV (10mg max pediatrics, 25mg max adults)
Consult Medical Control as needed
Pearls
Identification and treatment of life-threatening injuries and medical problems takes priority over decontamination
Don standard PPE capable of preventing skin exposure to liquids and solids (gown and gloves), mucous membrane exposure to liquids and particles (face mask and eye protection), and inhalational exposure to particles (N95 face mask or respirator)
Do not eat or drink any food or beverages while caring for patients with radiation injuries until screening completed for contamination and appropriate decontamination if needed
Use caution to avoid dispersing contaminated materials
Provide appropriate condition-specific care for any immediately life-threatening injuries or medical problems
Riot Control Agents
Symptoms
Eye burning, tearful eyes
Congestion
Coughing
Wheezing
Patient Care Goals
EMT-B
Paramedic
Place in position of comfort
Oxygen target SpO2 92% – 96%
Decontaminate the patient with normal saline, water
Fresh air is often all that is needed
Obtain 12 lead/4 lead EKG as indicated
Perform medication cross check for all medication administrations
Acquisition and interpretation of 12 lead/4 lead EKG as indicated
Albuterol for patients with wheezing and evidence of bronchospasm
Adult: 5mg nebulized
Pediatric: 2.5 mg nebulized
Consult Medical Control as needed
Pearls
Riot Control Agents are not meant to harm, but they can trigger bronchospasm in some patients. These can be treated with albuterol.
Agents can cause corneal abrasions/irritation if in the eye. Please irrigate thoroughly.
Stimulant Overdose
Symptoms
Tachycardia/tachydysrhythmias
Hypertension
Diaphoresis
Delusions/paranoia
Seizures
Hyperthermia
Mydriasis (dilated pupils)
EMT-B
Paramedic
Place in position of comfort
Oxygen target SpO2 92% – 96%
Obtain blood glucose level
Consider external cooling if hyperthermic
Obtain 12 lead/4 lead EKG if possible
Perform medication cross check for all medication administrations
Consider IV/IO as appropriate
Monitor ETCO2
Richmond Agitation Sedation Score (RASS)
+4
Combative
Overly combative or violent and an immediate danger to provider
+3
Very Agitated
Aggressive, non-combative or pulls on or removes tube(s) or catheter(s)
+2
Agitated
Frequent, non-purposeful movement or patient/ventilation desynchrony
+1
Restless
Anxious or apprehensive, movements not aggressive or vigorous
0
Alert and Calm
Spontaneously pays attention to provider
-1
Drowsy
Not fully alert but sustains more than 10 seconds wake, with eye opening in
response to verbal command
-2
Light Sedation
Awakens briefly for less than 10 seconds with eye contact or verbal command
-3
Moderate Sedation
Any movement, except eye contact, in response to command
-4
Unarousable
No response to voice or physical stimulation
Obtain and interpret 12 lead/4 lead EKG if possible
Consider fluid bolus
Restraints as indicated
Consider sedation if severely agitated
RASS +3/+4 Ketamine is preferred if available
Adults/peds: 4mg/kg IM (MAX DOSE 400mg, NOTE IM dosing is MUCH different than IV dosing)
Adults/peds: 0.5-1mg/kg IV (MAX DOSE 100mg, NOTE IM dosing is MUCH different than IV dosing)
RASS +2/+3 Droperidol is preferred (droperidol is preferred in anyone has concern for airway compromise)
5-10mg IM (adults only)
5mg IV (adults only)
RASS +1 Midazolam is preferred
Adults: 5-10mg IM
Adults: 5mg IV adults
Pediatric: 0.1mg IV max dose of 5mg
Pediatric: 0.2mg IM/IN max dose of 10mg
Consider lower dosing in patients who are elderly (65yo+) or acutely intoxicated
Alternative agents if none of the above are available
Haloperidol
Adults: 5mg IM/IV
Pediatrics: 2mg IM/IV (not for kids younger than 3 or less than 15kg)
Lorazepam
Adults: 2-4mg IVIM
Pediatric: 0.1 mg/kg IV/IM (max dose 4mg)
Restraints Checklist
All other calming attempts have failed, which include at minimum verbal de-escalation and/or reduced stimulation.
Adequate personnel to effect restraint, with consideration to include law enforcement.
Place patient in supine position restrained with 1 arm up and 1 arm down, unless clinically
contraindicated.
Law enforcement must be immediately available if handcuffed.
EMS personnel in constant attendance.
Chemical sedation administered, if required.
Continuous EtCO2, SpO2, ECG, and vital sign monitoring.
Continuous assessment of neurovascular status every 15 minutes, which includes pulse, motion,
sensation in all extremities.
Adequate personnel for transport.
Excited delirium is considered.
Physical and/or chemical restraints reviewed on a periodic basis.
Above documented fully in ePCR, including: Efforts prior to restraint, Time of restraint, Chemical
sedation, Continuous monitoring, Neurovascular status evaluation
Consult Medical Control as needed
Pearls
Stimulants can cause significant hyperthermia and lactic acidosis. It is important to reduce the metabolic activity in patients with severe hyperthermia and lactic acidosis as this can cause death.
Consider sedation early in severely agitated patients to help reduce metabolic activity
Cocaine has sodium channel blocking effects and can cause significant cardiac conduction abnormalities with a widened QRS. Treatment is with sodium bicarbonate similar to a tricyclic antidepressant.
Adult and pediatric 1 mEq/kg (max 50 mEq) IVP
Patients with cocaine use and meth use are at higher risk for cardiac disease. Treat chest pain with high degree of suspicion.
TASER Injuries
EMT-B
Paramedic
Place in position of comfort
Oxygen target SpO2 92% – 96%
Remove the barbs
Do not remove barbed dart from sensitive areas (head, neck, hands, feet or genitals)
Obtain 4 lead/12 lead EKG
Obtain and interpret 4 lead /12 lead EKG
Consult Medical Control as needed
Pearls
Patients can fall when being tased- please evaluate for additional injuries
Topical Chemical Burn
EMT-B
Paramedic
Place in position of comfort
Oxygen target SpO2 92% – 96%
Remove as much chemical as possible
If dry chemical, brush as much off as possible
If wet chemical, wash of as much as possible
Perform medication cross check for all medication administrations
Consider placing IV/IO
Consider pain management as indicated
Acetaminophen/Ibuprofen for mild to moderate pain
Acetaminophen
Adult: up to 1000mg PO
Pediatric: 15 mg/kg PO (max 1000mg)
Ibuprofen
Adult: 600mg PO
Pediatric: 10mg/kg PO (max 600mg)
Morphine 0.1 mg/kg IV/IM(2-4 mg max pediatrics, 4-8mg max for adult)
Fentanyl 1mcg/kg max 100mcg IV/IM/IN(round to nearest 12.5mcg-25mcg below 100mcg)
Ketamine 0.2mg/kg IV (10mg max pediatrics, 25mg max adults)
Consult Medical Control as needed
Pearls
Early decontamination is the most important step.
For any ingestions of substances capable of burns (ie, drano), do a brief evaluation of the mouth to assess for irritation. Transport immediately and consider early airway intervention if the patient develops stridor, difficult maintaining secretions.
Environmental
Environmental Protocols Bites/Envenomation
Assessment
Pediatric Pearls:
Signs & Symptoms:
Differential:
Use approved reference document for medication
Rash, skin break, wound
Animal bite
Human bite
dosing, electrical therapy, and equipment sizes.
Pain, soft tissue swelling, redness
Blood oozing from the bite wound
Evidence of infection
Shortness of breath, wheezing
Allergic reaction, hives, itching
Hypotension or shock
Snake bite (poisonous)
Spider bite (poisonous)
Insect sting / bite (bee, wasp, ant, tick)
Infection risk
Rabies risk
Tetanus risk
Abscess
rash
Patient Care Goals
EMT-B
Paramedic
Oxygen, target SpO2 92 – 96%
If Insect Bite:
Remove stinger, if appropriate
Apply ice pack
Minimize movement and remove constricting items
If Snake Bite
Splint limb, bandage, and place at level below heart
Minimize movement and remove constricting items
NO ice pack
12 lead/4 lead acquisition as appropriate
Perform medication cross check for all medication administrations
Vascular access as appropriate for patient condition
Acquisition and interpretation of 12 lead/4 lead as appropriate
Treat for anaphylaxis as indicated
IM Epinephrine, up to 3 additional doses q5 minutes as needed for continued symptoms
Adult: 0.3 mg IM 1;1000 (1mg/mL)
Pediatric: 0.01 mg/kg IM 1;1000 (max 0.3mg)
NOTE: IM vs. IV dosing is VERY different
Consider Albuterol 2.5mg/3mL for wheezing, chest tightness, shortness of breath
Adult: 5mg nebulized
Pediatric: 2.5 mg nebulized
Consider nebulized epinephrine for stridor/other signs of upper airway obstruction
2mg (of 1mg/ml) for a total of 2ml mixed with 1ml normal saline
Consider CPAP, if refractory to Albuterol
Diphenhydramine for Allergic Reaction or Dystonia
Adult: 50mg IV/IM
Pediatric: 1mg/kg IV/IM (max dose 50 mg)
IV fluid therapy with Isotonic Crystalloid, titrated to Adult SBP > 100 mmHg
Consider Dexamethasone
Adult: 10mg PO/IV/IM
Pediatric 0.6 mg/kg PO/IV/IM (max 10mg)
Consider Push dose Epinephrine IV/IO for refractory hypotension
Adult 20mcg IV (10 mcg/mL 1:100,000)
Pediatric 10mcg IV (10 mcg/mL 1:100,000)
NOTE: IM vs IV dosing and concentration are VERY different
Pain management as needed
Acetaminophen/Ibuprofen for mild to moderate pain
Acetaminophen
Adult: up to 1000mg PO
Pediatric: 15 mg/kg PO (max 1000mg)
Ibuprofen
Adult: 600mg PO
Pediatric: 10mg/kg PO (max 600mg)
Morphine 0.1 mg/kg IV/IM(2-4 mg max pediatrics, 4-8mg max for adult)
Fentanyl 1mcg/kg max 100mcg IV/IM/IN(round to nearest 12.5mcg-25mcg below 100mcg)
Ketamine 0.2mg/kg IV (10mg max pediatrics, 25mg max adults)
Consult Medical Control as needed
Pearls
Do not try and catch a live animal (snake, spider, etc) to bring to the Emergency Department.
You may take pictures or bring dead animals in a jar.
Human bites have a very high risk of infection due to oral bacteria.
Dog and Cat bites should be transported/seen that day for antibiotics.
Carnivore bites are much more likely to become infected and all have risk of Rabies exposure.
Cat bites may rapidly progress to infection due to a specific bacterium (Pasteurella).
Venomous snakes in this area are generally of the pit viper family: rattlesnake, copperhead, and water moccasin.
Coral snake bites are rare in our area: Very little pain but very toxic. “Red on yellow – kill a fellow, red on black – venom lack.”
It is NOT necessary to take the snake to the ED with the patient. Take Picture if possible.
Black Widow spider bites have minimal pain initially but may develop muscular pain and severe abdominal pain (spider is black with red hourglass on belly).
Brown Recluse spider bites can be very painful. Little reaction is noted initially but tissue necrosis at the site of the bite develops over the next few days (brown spider with fiddle shape on back). OK to use ice pack for this bite. Most are uncomplicated but in rare cases can progress to a severe systemic reaction that presents similar to sepsis known as “loxoscelism”
Evidence of infection: swelling, redness, drainage, fever, red streaks proximal to wound
Immunocompromised patients are at an increased risk for infection (diabetes, chemotherapy, transplant patients)
May use soap and water to clean wounds if time and patient condition allows.
Consider contacting the Poison Control Center for guidance. 1-800-222-1222
Bats, skunks, foxes, and raccoons are the most common rabies vectors.
Electrical Injuries
Assessment
Pediatric Pearls:
Signs & Symptoms:
Differential:
Can be very painful, treat the pain
Burns
Cardiac Arrest
Arrhythmias
Compartment syndrome
Additional trauma (from patient being thrown)
Medical arrest
Traumatic fall
Patient Care Goals
EMT-B
Paramedic
Oxygen, target SpO2 92 – 96%
Identify arrhythmias
those in cardiac arrest may have excellent outcomes if CPR is started immediately
Remove constricting clothing or jewelry
Dress all open wounds
Assess for additional traumatic injuries
12 lead/4 lead acquisition
Perform medication cross check for all medication administrations
Vascular access as appropriate for patient condition
Acquisition and interpretation of 12 lead/4 lead
Advanced airway management if needed
Pain management as needed
Acetaminophen/Ibuprofen for mild to moderate pain
Acetaminophen
Adult: up to 1000mg PO
Pediatric: 15 mg/kg PO (max 1000mg)
Ibuprofen
Adult: 600mg PO
Pediatric: 10mg/kg PO (max 600mg)
Morphine 0.1 mg/kg IV/IM(2-4 mg max pediatrics, 4-8mg max for adult)
Fentanyl 1mcg/kg max 100mcg IV/IM/IN(round to nearest 12.5mcg-25mcg below 100mcg)
Ketamine 0.2mg/kg IV (10mg max pediatrics, 25mg max adults)
Consult Medical Control as needed
Pearls
Patients may appear dead immediately after electrocution. These patients have excellent survival with CPR.
Internal damage/injury is often more extensive than what appears on the skin. Have a high degree of suspicion for deeper injury.
If the patient became part of the circuit, there will be an additional site near the contact with ground – electrical burns are often full thickness and involve significant deep tissue damage
Assess for potential associated trauma and note if the patient was thrown from contact point –
if patient has altered mental status, assume trauma was involved and treat accordingly
Assess for potential compartment syndrome from significant extremity tissue damage
Assess for additional injuries, as patients can spasm (causing fractures) or be thrown
Determine characteristics of source if possible – AC or DC, voltage, amperage, and also time of injury
Pay special attention to body contact points as these may show burns
Diving Injuries
Assessment
Pediatric Pearls:
Signs & Symptoms:
Differential:
Use approved reference document for medication dosing, electrical therapy, and equipment sizes.
Joint pain
Mental status change
New paralysis
Confusion, appearing intoxicated
Coughing up blood
Hypoxia
Hypothermia
Marine envenomation
Spinal cord injury from diving
Patient Care Goals
EMT-B
Paramedic
known as “the bends”)
Oxygen, high flow 100% if suspect decompression sickness or air embolism
Reduces size of air bubbles in blood stream
Place in left lateral decubitus position and Trendelenberg if air embolism suspected
Traps air in the right ventricle preventing it from traveling to pulmonary arteries and blocking further blood flow from the right ventricle (which would result in cardiac arrest)
12 lead/4 lead acquisition
Perform medication cross check for all medication administrations
Vascular access as appropriate for patient condition
Pain management as indicated (in particular with patients with decompression sickness also
Acetaminophen/Ibuprofen for mild to moderate pain
Acetaminophen
Adult: up to 1000mg PO
Pediatric: 15 mg/kg PO (max 1000mg)
Ibuprofen
Adult: 600mg PO
Pediatric: 10mg/kg PO (max 600mg)
Morphine 0.1 mg/kg IV/IM(2-4 mg max pediatrics, 4-8mg max for adult)
Fentanyl 1mcg/kg max 100mcg IV/IM/IN(round to nearest 12.5mcg-25mcg below 100mcg)
Ketamine 0.2mg/kg IV (10mg max pediatrics, 25mg max adults)
Consult Medical Control as needed
Pearls
Decompression sickness (“the bends”) occurs up to 48 hours after diving (so consider travelers)
Be alert for signs of barotrauma (pulmonary barotrauma, arterial gas embolism, pneumothorax, ear/sinus/dental barotrauma etc.) and/or decompression sickness (joint pain, mental status change, other neurologic symptoms including paralysis) or nitrogen narcosis (confusion, intoxication).
You can consider Trendelenburg and left lateral position as it is sometimes recommended to help trap the air in the dependent right ventricle, but this position may increase cerebral edema (so caution in the confused patient)
Air Embolus when in patient is positioned in Left lateral and Trendelenberg traps the air bubble in the right ventricle preventing it from going into the pulmonary arteries/systemic circulation
Hyperthermia
Assessment
Pediatric Pearls:
Signs & Symptoms:
Differential:
Use approved reference document for medication dosing, electrical therapy, and equipment sizes.
Weakness
Nausea & vomiting
Cramping
Syncope
Diaphoresis & anhidrosis
Altered Mental Status
Bizarre behavior
Hypotension
Tachycardia
CVA
Dehydration
Encephalopathy
Meningitis / Sepsis
Head Trauma
Overdose / Toxin
Hypoglycemia
Excited delirium
Alcohol withdrawal
Patient Care Goals
EMT-B
Paramedic
Age-appropriate core body temperature assessment
Oxygen, target SpO2 92 – 96%
Move to shaded/cool environment, discontinue physical activity, PO fluids if tolerated
If AMS, then BGL assessment
If AMS and/or body temperature > 102.2 F, then active cooling measures per patient condition:
Ice packs to neck, axilla and groin, wet patient, and increased airflow
12 lead/4 lead acquisition
Perform medication cross check for all medication administrations
Vascular access
Consider infusing Isotonic Crystalloid fluids titrated to effect
If AMS, then may infuse cold Isotonic Crystalloid if available up to 30 mL/kg or titrated to effect
If shivering develops, Midazolam or lorazepam for sedation
Midazolam
Adults: 5-10mg IM/IN
Adults: 5mg IV adults
Pediatric: 0.2mg IM/IN, max dose of 10mg,
Pediatric: 0.1mg IV max dose of 5mg
Lorazepam
Adults: 2-4mg IVIM
Pediatrics 0.1 mg/kg IV/IM (max dose 4mg)
Consult Medical Control as needed
Pearls
Signs of improvement to help titrate to effect include improved heart rate, decrease body temperature, resolution of thirst, feeling the need to urinate and/or increased urination, improvement in mental status, improvement in skin conditions, etc.
If increased temperature, utilize passive cooling by removing excessive clothing or covers.
NSAIDS should not be used in the setting of environmental heat emergencies.
Exertional heat stroke should be suspected in anyone with a history of recent exertion and bizarre behavior, seizure, or syncope.
Any AMS should have blood glucose performed. Severe heat emergencies may lead to liver dysfunction and hypoglycemia.
If AMS and cold isotonic crystalloid fluids are not available, then begin isotonic crystalloid boluses.
Damage caused by heat stroke is determined by how high the temperature got and how long it remained elevated.
Cold water immersion is the most effective means of cooling.
Active cooling should be removed when body temperature reaches 102.2 F.
Hypothermia
Assessment
Pediatric Pearls:
Signs & Symptoms:
Differential:
Use approved reference document for medication dosing, electrical therapy, and equipment sizes.
Hypothermia appears quickly in children
Cold, clammy
Shivering
Mental status changes
Extremity pain or sensory abnormality
Bradycardia
Hypotension or shock
Metabolic disorder (hypoglycemia, hypothyroidism)
Toxins
Environmental exposure
Shock
Sepsis
Patient Care Goals
EMT-B
Paramedic
Oxygen, target SpO2 92 – 96%
Temperature less than 95 F (< 35 C): Remove wet clothing, blankets as needed Handle very gently if < 88 F (< 30 C) Can quickly deteriorate to cardiac arrest Blood glucose assessment Use heat packs Increase temperature of transport compartment Vascular access Warm IV Isotonic Crystalloid if available Consult Medical Control as needed Pearls Extremes of age are more susceptible (young and old) < 34 C (93.2 F), shivering may diminish at < 31 C (87.8 F) shivering may stop. With temperature less than 30 C (88 F) ventricular fibrillation is common cause of death. Handle patients gently to reduce the risk. Transport immediately for re-warming. If the temperature is unable to be measured, treat the patient based on the suspected temperature. Hypothermia may produce severe physiologic bradycardia. Do not treat unless profound hypotension unresponsive to fluids. Hypothermia: o Mild: 89.6 – 95 F (32 – 35 C) o Moderate: 82.4 – 89.6 F (28 – 32 C) o Severe: < 82.4 F (< 28 C) During warming, cold blood may re-enter central circulation causing a subsequent decrease in body temperature. Cardiac arrest secondary to hypothermia have high resuscitation potential and should not be terminated on the scene Lightning Injuries Assessment Pediatric Pearls: Signs & Symptoms: Differential: Use approved reference document for medication dosing, electrical therapy, and equipment sizes. Fern-like rash Burns Cardiac Arrest Arrhythmias Compartment syndrome Additional trauma (from patient being thrown) Seizures Confusion Numbness/paralysis Amnesia Fixed pupils (autonomic dysfunction Medical cardiac arrest Traumatic arrest Stroke Herniation hypothermia Patient Care Goals EMT-B Reverse triage-cardiac arrests treated first Oxygen, target SpO2 92 – 96% Paramedic Identify arrhythmias those in cardiac arrest may have excellent outcomes if CPR is started immediately Remove constricting clothing or jewelry Dress all open wounds Assess for additional traumatic injuries Acquisition of 4 lead/12 lead Vascular access as appropriate for patient condition Acquisition and interpretation of 4 lead/12 lead Pain management if indicated Acetaminophen/Ibuprofen for mild to moderate pain Acetaminophen Adult: up to 1000mg PO Pediatric: 15 mg/kg PO (max 1000mg) Ibuprofen Adult: 600mg PO Pediatric: 10mg/kg PO (max 600mg) Morphine 0.1 mg/kg IV/IM(2-4 mg max pediatrics, 4-8mg max for adult) Fentanyl 1mcg/kg max 100mcg IV/IM/IN(round to nearest 12.5mcg-25mcg below 100mcg) Ketamine 0.2mg/kg IV (10mg max pediatrics, 25mg max adults) Consult Medical Control as needed Pearls If multiple victims present, utilize reverse triage and focus initial efforts on those in cardiac arrest first. Patients have excellent survival with CPR Lack of bystanders and patient amnesia can make it difficult to identify lightening scenes. Monitor EKG. Be alert for potential arrhythmias. Consider 12-lead EKG, when available. Risk of arrhythmias can occur up to 24 hours past event. Fixed/dilated pupils may be a sign of neurologic insult, rather than a sign of death/impending death – Should not be used as a solitary, independent sign of death for the purpose of discontinuing resuscitation in this patient population May have stroke-like findings as a result of neurologic insult May have secondary traumatic injury as a result of overpressurization, blast or missile injury Lichtentberg figures is a physical finding that may be seen (pictured below) OB Protocols Labor and Childbirth Assessment History: Signs & Symptoms: Differential: Due date of LMP Time contractions started & how often Rupture membranes Time / amount of any vaginal bleeding Sensation of fetal activity Past medical and pregnancy/delivery history Medications If known high risk pregnancy Episodic pain Vaginal discharge or bleeding Crowning of urge to push Meconium Urge to defecate Abnormal presentation: Buttock Foot Hand Prolapsed cord Placenta previa Abruptio placenta Premature labor Clinical Management Options EMT-B Paramedic High Flow Oxygen to all mothers with imminent childbirth Always check for nuchal cord once the head has been delivered Reference complications of delivery maneuvers Wipe the face and mouth clean with a clean towel If there is evidence of meconium (brown/yellow amniotic fluid) suction the mouth than nostrils. If baby is not in distress, consider delayed cord clamping for up to 60 seconds. Skin to skin contact for mother and baby and encourage infant to breast-feed. Breast feeding helps contract the uterus to prevent post-partum hemorrhage If post-partum hemorrhage fundal massage check perineum for significant lacerations and apply direct pressure if indicated See Clinical Procedures for Birthing and Position Complications Vascular access with Isotonic Crystalloid titrated to SBP 90 mmHg for vaginal hemorrhage Contact Medical Control as needed Pearls Document all times (delivery, contraction frequency, and length) Record APGAR at 1 minute and 5 minutes after birth. If maternal seizures: refer to the Obstetrical Emergencies Guideline. Eclampsia can occur up to 2 months post-partum. After delivery, allowing child to nurse and massaging the uterus (lower abdomen) will promote uterine contraction and help to control postpartum bleeding. Post-partum hemorrhage defined as blood loss > 1000mL or > 500mL with signs/symptoms of hypotension. The perineum should be checked for bleeding from vaginal tears. Bleeding should be controlled by direct pressure over the laceration.
The most common cause of post-partum hemorrhage is uterine atony due to prolonged labor, or multiple gestations.
Complications of Delivery Maneuvers
Most deliveries proceed without complications – If complications of delivery occur, the following are recommended:
Shoulder dystocia – if delivery fails to progress after head delivers, quickly attempt the following
Hyperflex mother’s hips to severe supine knee-chest position
Apply firm suprapubic pressure to attempt to dislodge shoulder
Apply high-flow oxygen to mother
Transport as soon as possible
Contact direct medical oversight and/or closest appropriate receiving facility for direct medical oversight and to prepare team
Prolapsed umbilical cord
Placed gloved hand into vagina and gently lift head/body off cord
Assess for pulsations in cord
Maintain until relieved by hospital staff.
Consider placing mother in prone knee-chest position or extreme Trendelenburg
Apply high-flow oxygen to mother
Transport as soon as possible
Contact/transport to closest appropriate receiving facility for direct medical oversight and to prepare team
Breech birth
Place mother supine, allow the buttocks and trunk to deliver spontaneously, then support the body while the head is delivered
If head fails to deliver, place gloved hand into vagina with fingers between infant’s face
and uterine wall to create an open airway
Apply high-flow oxygen to mother
Transport as soon as possible
Contact direct medical oversight and/or closest appropriate receiving facility for direct medical oversight and to prepare team
The presentation of an arm or leg through the vagina is an indication for immediate transport to hospital
Assess for presence of prolapsed cord and treat as above
Nuchal Cord
Once the baby’s head as been delivered, check an umbilical cord around the neck
If the cord is loose, pull over the head
It is essential not to break the cord, do not pull hard
If the cord is tight, clamp the cord and cut. Then have the mother push to deliver the baby quickly
Anticipate need for oxygen and resuscitation if the cord is cut prior to delivery.
Page Break
Eclampsia/Pre-Eclampsia
Assessment
History:
Signs & Symptoms:
Differential:
Past medical history
Hypertension meds
Prenatal care
Prior pregnancies / births
Gravida / Para
Upper abdominal pain
jaundice
Seizures
Hypertension
Severe headache
Visual changes
Pre-eclampsia / Eclampsia
Chronic hypertension
CHF
Seizure disorder
Edema of the hands and face
Clinical Management Options
EMT-B
Oxygen, target SpO2 to 92-96%
Airway management as indicated
Acquisition of 4 lead/12 lead ECG as appropriate
Paramedic
Vascular access
Give Magnesium Sulfate (give Magnesium sulfate if pregnant and has a seizure)
4g IV slow over 5 minutes
Can consider lorazepam, or midazolam if seizure continue after Magnesium
Midazolam
5-10mg IM/IN
5mg IV
Lorazepam
2-4mg IVIM
Monitoring & Interpretation of 4 lead/12 lead ECG and EtCO2
Pearls
Eclamptic seizures may occur up to 2 months post-partum. Always consider in pregnant/recently pregnant seizing patient.
Magnesium is the first line treatment. Patient’s will continue to seize if not provided magnesium
Some patients have a seizure disorder and pregnancy. You can consider lorazepam or midazolam if seizures continue after magnesium as this may be a sign of a separate seizure disorder.
Severe headache, vision changes, edema, or RUQ pain may indicate preeclampsia.
In the setting of pregnancy, hypertension is defined as a SBP greater than >140 or a DBP > 90, or relative increase of 30 systolic and 20 diastolic from the patient’s normal (pre-pregnancy) blood pressure.
Magnesium may cause hypotension and decreased respiratory drive, monitor closely.
If > 20 weeks consider left lateral position.
OB Emergencies
Assessment
History:
Signs & Symptoms:
Differential:
Past medical history
Hypertension meds
Prenatal care
Prior pregnancies / births
Gravida / Para
Vaginal bleeding
Abdominal pain
Severe headache
Visual changes
Pre-eclampsia / Eclampsia
Placenta previa
Placenta abruptio
Spontaneous abortion
Clinical Management Options
EMT-B
Paramedic
Oxygen, target SpO2 to 92-96%
If post-partum hemorrhage, then fundal massage and encourage infant to breast feed
Vascular access
Isotonic bolus for hypotension
Pearls
Any pregnant patient involved in a MVC should be seen immediately by a physician for evaluation and fetal monitoring in a Trauma Center.
Small trauma can cause placental abruption in patients who are >20 weeks pregnant. Transport to OB capable hospitals if complaining of any abdominal pain after even minor falls/injuries
Post-partum hemorrhage defined as blood loss > 1000mL or greater than 500mL with signs/symptoms of hypotension. 500mL blood loss is commonly seen in uncomplicated vaginal deliveries without signs or symptoms. The perineum should be checked for bleeding from vaginal tears which may be mistaken for uterine bleeding. Bleeding should be controlled by direct pressure over the laceration.
The most common cause of post-partum hemorrhage is uterine atony due to prolonged labor or multiple gestations
If > 20 weeks consider left lateral position.
If >20 weeks pregnant OR the uterus is above the umbilicus in a cardiac arrest patient, consider immediate transport for peri-mortem C-section.
Pediatric Protocols
Brief Resolved Unexplained Event (BRUE)
Patient Care Goals
Recognize patient characteristics and symptoms consistent with a BRUE
Promptly identify and intervene for patients who require escalation of care
Identify high risk patients and choose proper destination for patient transport
Assessment
Pediatric Pearls:
Signs & Symptoms:
Differential:
High Risk if:
Hx of any of the following:
Thorough physical exam and history are critical to exclude other causes
Maintain a high level of suspicion for non- accidental trauma
<60 days old <32 weeks gestation >1 minute (currently or historical)
>1 event
Concerning history or exam
CPR provided
Child < 1yo Well appearing child Cyanosis or pallor Absent, decreased, or irregular breathing Marked change in tone (hyper- or hypotonia) Altered level of responsiveness. No alternative cause Upper or lower respiratory tract infection Trauma/Abuse Toxic Ingestion Sepsis Metabolic disorder GERD (spitting up) Seizures Cardiac disease/arrhythmia Infantile botulism Hypoglycemia Patient Care Goals EMT-B Paramedic Critical Aspects of History-separate into chart under pearls Place in position of comfort Obtain complete set of vitals POC blood glucose Oxygen target SpO2 92% – 96% ETC02 if patient will tolerate Cardiac monitor and continuous pulse oximetry Thorough physical exam of the exposed child Acquisition of EKG if indicated Consider EKG if concern for cardiac etiology or cardiac history IV access not indicated unless signs of shock or dehydration History of circumstances and symptoms before, during, and after the event, including duration, interventions done, and patient color, tone, breathing, feeding, position, location, activity, level of consciousness, bystander CPR or rescue breaths Other concurrent symptoms (fever, congestion, cough, rhinorrhea, vomiting, diarrhea, rash, labored breathing, fussy, less active, poor sleep, poor feeding) Prior history of BRUE Past medical history (prematurity, prenatal/birth complications, gastric reflux, congenital heart disease, developmental delay, airway abnormalities, breathing problems, prior hospitalizations, surgeries, or injuries) Family history of sudden unexplained death or cardiac arrhythmia in other children or young adults Social history: who lives at home, recent household stressors, exposure to toxins/drugs, sick contacts) Considerations for possible child abuse (multiple/changing versions of the story; reported mechanism of injury does not seem plausible, especially for child’s developmental stage) Consult Medical Control as needed Pearls Regardless of patient appearance, all patients with a history of signs or symptoms of BRUE should be transported for further evaluation Consider transport to a facility with pediatric critical care capability for patients with high risk criteria as above Contact direct medical oversight if parent/guardian is refusing medical care and/or transport, especially if any high-risk criteria are present Bronchiolitis/Croup Pediatric Patient Care Goals Promptly identify pediatric respiratory distress, failure, and/or arrest, and intervene for patients who require escalation of therapy. Deliver appropriate therapy by differentiating other causes of pediatric respiratory distress. Patient Safety Considerations Assessment Pediatric Pearls: Signs & Symptoms: Differential: Nasal suctioning can rapidly improve distress Use approved reference document for medication dosing, electrical therapy, and equipment sizes. Focus on rapid and early BLS airway and ventilation tools. Intubation may not be the best option for these patients. Pediatric pads should be used in children < 10 kg. Bronchiolitis occurs in age < 2 years, otherwise consider Rhinorrhea Cough Fever Tachypnea or other signs of respiratory distress Bronchiolitis is a lower airway illness and can cause wheezing and coarse breath sounds Croup is an upper airway illness and can cause Barky cough and/or Inspiratory or Expiratory Stridor Asthma Foreign body aspiration Pneumonia GERD Croup Bronchiolitis Pertussis Epiglottitis Anaphylaxis Submersion/drowning Patient Care Goals EMT-B Paramedic Signs of Respiratory Failure-Separate checklist under pearls please Place in position of comfort Oxygen target SpO2 92% – 96% Suction the nose and/or mouth (via wall mount or portable suction) Basic airway management as needed Perform medication cross check for all medication administrations Monitor ETCO2 if the patient tolerates it Vascular access if critically ill Provide Inhaled Epinephrine for severe respiratory distress suspected secondary to suspected croup or bronchiolitis that is not improved with suctioning and/or oxygen Nebulized: 1mg/ml mixed with 4ml saline Dexamethasone for suspected croup 0.6 mg/kg IV/IM/PO (max dose 10mg) NIPPV for severe respiratory distress Change in mental status such as fatigue and listlessness Pallor Dusky appearance Decreased retractions Decreased or irregular respiratory rate Decreased breath sounds with decreased stridor Consult Medical Control as needed Pearls Bronchiolitis is a common lung infection in children Croup is a common upper airway infection in children Upper airway obstruction can have inspiratory, expiratory, or biphasic stridor Foreign bodies can mimic croup, it is important to ask about a choking event Symptoms worsen over the course of 2-3 days after the onset of a viral syndrome This is a clinical diagnosis and labs or imaging are rarely indicated Suctioning can be a very effective intervention to alleviate distress, since infants are obligate nose breathers Albuterol is not generally indicated or beneficial in the treatment of bronchiolitis but may be trialed if wheezing is present or has been effective in the past Nebulized saline, Ipratropium and other anticholinergic agents should not be given to children with bronchiolitis in the prehospital setting Improvement of oxygenation and/or respiratory distress should be achieved with the least invasive method possible at all times BVM is the preferred airway management option in children. Consider Igel in patients that cannot be ventilated with BVM About 3% of infants will require admission to the hospital, and the mortality rates vary from 0.5% to 7% in high risk patients The management of bronchiolitis is supportive with suctioning, hydration and oxygen. No specific medications treat the infection. Newborn Resuscitation/Care Assessment History: Signs & Symptoms: Differential: Due date and gestational age Multiple gestation (twins, etc.) Meconium Delivery difficulties Congenital disease Maternal medications Maternal risk factors: Substance misuse Smoking Respiratory distress Normal peripheral cyanosis or mottling Abnormal central cyanosis Altered level of responsiveness. Bradycardia Airway failure Secretions Respiratory drive Infection Maternal medication effect Hypovolemia Hypoglycemia Congenital heart disease Hypothermia Narcotic in the system from maternal drug abuse Patient care goals EMT-B “minutes of life” recommendation Paramedic o 0.01 mg/kg (1:10,000) IV/IO Wipe nose and mouth with sterile gauze Suction if meconium or airway obstruction (routine suctioning no longer recommended) Vigorously dry and stimulate infant. Keep warm. If full term, good tone, and breathing/crying: allow to breastfeed & skin to skin contact for mother and baby. SpO2 on right hand (Preductal) - Follow Saturations Chart based on “Minutes of Life.” 1 minute of life 60-65% 2 min 65-70% 3 min 70-75% 4 min 75-80% 5 min 80-85% 10 min 85-95% If just after birth pulse is < 100: BVM on “room air” for 30 seconds @ rate of 30-60 BPM. If, after initial ventilations, pulse continues at: < 60: Begin CPR, 120 compressions with asynchronous ventilations at 30 per minute. 3:1 ratio. Begin with room air and progress to Oxygen 60 - 100: BVM only on “room air” add Oxygen as needed to increase SpO2 if less than ≥ 100: Monitor and Reassess. BGL heel stick if indicated Place on monitor if indicated Intubate if indicated and appropriate equipment available ETT 2.0-2.5 mm I-gel size 1 Continue manual ventilations until spontaneous ventilations Continue chest compressions until HR above 60 Vascular access – IV or IO if cardiac arrest or critical condition (IF appropriate IO size available) Naloxone if mother received narcotics just prior or during childbirth 0.1mg/kg IV/IO Dextrose infusion if BGL < 50 1ml/kg (0.2g/kg) D10W IV/IO infusion Isotonic Crystalloid titrated to perfusion. For refractory bradycardia or cardiac arrest, Epinephrine Do not allow mother to hold newborn in arms during ambulance transport. Advance airway maneuvers and management as needed. Pearls It is very important to keep environment as warm as possible Pulse ox is low in first minutes of life, this is normal keep oxygen levels at goal in fist minutes of life Pulse on right wrist/hand Avoid giving to much oxygen as this can cause brain and lung damage If BVM necessary position child’s head in “sniffing” position If BVM necessary only administer just enough air for chest rise (which is a tiny amount), too much breath can cause pneumothorax BVM rate at about 30-60 breaths per minute To avoid hyperventilation it may be helpful to count “squeeze, two, three, squeeze, two, three” If chest compressions also required count “one and two and three and squeeze” with chest compressions occurring on each number count and then breath administered on “squeeze” Head position Neonatal Resuscitation Algorithm Ter m nes\at•on* Px;ro tres\+sc›latuz•n c •rtt Team all A§x•›oa oco••r• e* HR oelpw t0O/ † ” InLuba'e 17 nDt already -a Cuo-al c ornuress•siw Normal vital signs pediatric Normal Respiratory Rate (breaths/min) Age Infant (< 1 year) Toddler (1 to 3 years) Preschooler ( 4 to 5 years) School – aged child (6 to 12 years) Adolescent (13 to 18 years) Rate 30 to 60 24 to 40 22 to 34 18 to 30 12 to 16 Heart Rate (per minute) Age Awake Rate Mean Sleeping Rate Newborn to 3 months 85 to 205 140 80 to 160 3 months to 2 years 100 to 190 130 75 to 160 2 to 10 years 60 to 140 80 60 to 90 > 10 years
60 to 100
75
50 to 90
Blood Pressure
Typical systolic BP for 1 to 10 years of age: 90 + (age in years x2) mmHg
Lower limits of systolic BP for 1 to 10 years of age: 70 + (age in years x2) mmHg
Lower range of normal systolic BP for > 10 years of age: approximately 90 mmHg
Typical mean arterial pressure: 55 + (age in years x 1.5) mmHg
Medications Acetaminophen
Aliases:
APAP, Tylenol
Indications:
Fever with or without seizures, or pain
Contraindications:
Allergy, hypersensitivity, severe hepatic impairment, or severe active liver disease
Concentrations:
Tablets
325 or 500 mg
Liquid
32 mg/mL
Adult Dosing
Indication
Dose
Route
Note
Pain
Fever
Up to 1000 mg
PO
One time only
Pediatric Dosing
Indication
Dose
Route
Note
Pain
Fever
15 mg/kg (Max: 1000
mg)
PO
One time only
Use Handtevy or Approved Pediatric Reference Guide for Amount to Administer
Precautions:
Pregnancy Category B. Use in caution with known thrombocytopenia and/or Liver Disease. Many medications contain Acetaminophen. Read labels of meds that
patients have taken recently.
Adverse/Side
Effects:
N/V, abdominal pain
Class:
Analgesic, Antipyretic
Mechanism of Action:
Equivalent to Aspirin in both analgesic and antipyretic effects. Unlike Aspirin, Acetaminophen has little effect on platelet function, no effect on homeostasis, and it is not known to produce gastric bleeding. Acetaminophen is not an NSAID, as it has no anti-inflammatory properties. Absorption is rapid. APAP is processed in the
Liver.
Onset of Action
< 1 hour Peak Effect 10 to 60 minutes Duration of Action 4 to 6 hours Page Break Page Break Adenosine Aliases: Adenocard Indications: Supraventricular Tachycardia SVT (including WPW) refractory to vagal maneuvers Contraindications: 2nd or 3rd degree heart block (without a functioning pacemaker); Known Sick sinus syndrome; Known History of Long QT Syndrome; Pregnancy Category C; Irregular Wide-complex tachycardia presumed to be WPW Concentrations Injection 3 mg/mL Adult Dosing Indication Dose Route Note Supraventricular Tachycardia 12 mg Rapid IV Push (mixed in 10 cc flush) May repeat once Pediatric Dosing Indication Dose Route Note Supraventricular Tachycardia 0.2 mg/kg (Max 12 mg) Rapid IV Push (mixed in 10 cc flush) May repeat once Use Handtevy or Approved Pediatric Reference Guide for Amount to Administer Precautions: Advising patient of the side effects of adenosine prior to administering can help minimize patient anxiety. Large bore IV, antecubital access, or IO access & IV wide open during administration; it may help to have your partner administer the fluid bolus. Start your EKG printout before administration and continue printing through bolus and conversion. Administration of adenosine will cause a period of asystole & various conversion dysrhythmias, be patient, most will transiently resolve Adverse/Side Effects: Flushing, Dizziness, Chest Pain, Lightheadedness, Dyspnea, Numbness, Headache, Nausea/Vomiting, Diaphoresis, Palpitations, Metallic Taste Class: Supraventricular Antiarrhythmic, Nucleoside Mechanism of Action: Slows tachycardias associated with the AV node via modulation of the autonomic nervous system without causing negative inotropic effects. It acts directly on sinus pacemaker cells and vagal nerve terminals to decrease chronotropic & dromotropic activity. Slows conduction through the AV node, blocks reentry pathways through the AV node, can transiently slow conduction in the SA node. Onset of Action Rapid Peak Effect Rapid Duration of Action Very Brief Page BreakPage Break Albuterol Aliases: Ventolin, Proventil, Proair Indications: Bronchospasm with or without wheezing, hyperkalemia Contraindications: None in the emergency setting Concentrations Prefilled Unit Doses for Nebulization 2.5 mg/3 mL Adult Dosing Indication Dose Route Note Bronchospasm 5 mg Nebulized May repeat every 5 mins. No limit Hyperkalemia 10 – 20 mg Nebulized Continuous as needed Pediatric Dosing Indication Dose Route Note Bronchospasm 2.5 mg Nebulized May repeat every 5 mins. No limit Hyperkalemia 10 mg Nebulized Continuous as needed Use Handtevy or Approved Pediatric Reference Guide for Amount to Administer Precautions: None Adverse/Side Effects: Palpitations, Tachycardia, Anxiety, Nervousness, Dizziness, HA, Tremor, N/V, Less frequent HTN, Dysrhythmias, Chest Pain Class: Beta2 Agonist, Sympathomimetic Mechanism of Action: Acts selectively on Beta2 receptor sites in the lungs, relaxing bronchial smooth muscle, decreasing airway resistance, relief of bronchospasm, and drives potassium intracellularly. Although Albuterol is beta selective, it will cause some CNS stimulation, cardiac stimulation, increased diuresis, & gastric acid secretion. Onset of Action < 5 minutes Peak Effect 30 minutes Duration of Action 3 to 6 hours Page Break Page Break Amiodarone Aliases: Pacerone, Nextorone, Codarone Indications: V-Fib or Pulseless V-Tach(pVT) Cardiac Arrest, Post Resuscitation Care, Wide Complex Tachycardia with a Pulse, & Symptomatic A-fib. Contraindications: Without a pulse: None; With a pulse: bradycardia, second/third degree AV block Concentrations Injection 50 mg/mL Adult Dosing Indication Dose Route Note Pulseless VT or VF 300 mg (1st dose) 150 mg (2nd dose) IV Push 4 minutes between doses Wide Complex Tachycardia with a Pulse (VT) 150 mg IV infusion over 10 minutes Use a pump when available Pediatric Dosing Indication Dose Route Note Pulseless VT or VF 5 mg/kg (max of adult doses) IV Push 4 minutes between doses Use Handtevy or Approved Pediatric Reference Guide for Amount to Administer Precautions: Use with caution in patients with known thyroid disease. Consider OLMC discussion. Adverse/Side Effects: Vasodilation (usually not associated with decreased cardiac output secondary to the negative inotropic effects), hypotension, bradycardia, AV block, increased QT interval, V-Tach. Class: Antiarrhythmic, Primarily Class III but has properties of all the Vaughan Williams classifications Mechanism of Action: Prolongs the duration of the action potential and refractory period of all Cardiac fibers. Depresses the Phase 0 slope by causing a sodium blockade. Causes a Beta block as well as a weak calcium channel blockade. Primarily a Potassium-channel blocker (Class III antiarrhythmic) blocks the potassium channels that are responsible for phase 3 repolarization. Blocking these channels slows (delays) repolarization, which leads to an increase in action potential duration and an increase in the effective refractory period (ERP). Relaxes vascular smooth muscle, decreases peripheral vascular resistance, and increases coronary contractility. Onset of Action Variable Peak Effect 30 to 45 minutes Duration of Action Variable Page Break Page Break Aspirin Aliases: Bufferin, Zorpin Indications: Chest Pain from suspected Acute Coronary Syndrome/STEMI/ACO Contraindications: Anaphylaxis, known ulcer & active GI bleeding Concentrations Tablet 81 mg Adult Dosing Indication Dose Route Note Suspected ACS or STEMI 324 mg PO May give full amount if already taken earlier in the day Pediatric Dosing Indication Dose Route Note None Use Handtevy or Approved Pediatric Reference Guide for Amount to Administer Precautions: On blood thinners. Pregnancy Category D: There is positive evidence of human fetal risk, but the benefits from use in pregnant women may be acceptable despite the risk (e.g., if the drug is needed in a life-threatening situation or for a serious disease for which safer drugs cannot be used or are ineffective). Adverse/Side Effects: N/V, diarrhea, heartburn, GI bleeding Class: Analgesic, Antipyretic, NSAID, platelet inhibitor Mechanism of Action: Inhibits the formation of prostaglandins associated with pain, fever, and inflammation. Inhibits platelet aggregation by acetylating cyclooxygenase permanently disabling it so that it cannot synthesize prostaglandins and Thromboxanes. Since Thromboxane A2 is important in clotting its absence does not allow blood to clot effectively. Onset of Action < 1 hour Peak Effect 1-2 hours Duration of Action 4-6 hours Page Break Page Break Atropine Aliases: None Indications: Symptomatic Bradycardia (if TCP is not immediately available); Organophosphate poisoning Contraindications: A-Fib or A-Flutter Concentrations Injection 0.1 mg/mL Adult Dosing Indication Dose Route Note Symptomatic Bradycardia 0.5 mg IV Push May repeat every 3 minutes. Max 3 mg. Organophosphate Poisoning 2-6 mg IV Push/IM Repeat every 3 minutes until symptoms resolve. Pediatric Dosing Indication Dose Route Note Symptomatic Bradycardia 0.02 mg/kg (Between 0.1 -0.5 mg) IV Push May repeat every 3 minutes. Max 3 mg. Organophosphate Poisoning IV Push/IM Repeat every 3 minutes until symptoms resolve. Use Handtevy or Approved Pediatric Reference Guide for Amount to Administer Precautions: Slow administration of Atropine can cause paradoxical bradycardia Adverse/Side Effects: Pupil dilation, tachycardia, V-Tach, V-Fib, HA, dry mouth Class: Parasympatholytic & Anticholinergic Mechanism of Action: Competitive antagonist that selectively blocks all muscarinic responses to acetylcholine. Blocks vagal impulses, thereby increasing SA node discharge, thereby enhancing AV conduction and cardiac output. Potent anti-secretory effects caused by the blocking of acetylcholine at the muscarinic site. Atropine is also useful in the treatment of the symptoms associated with nerve agent poisoning. Onset of Action Immediate Peak Effect 0.7-4 minutes Duration of Action Variable Page BreakPage Break Calcium Chloride Aliases: None Indications: Calcium channel- or beta-blocker overdose, hyperkalemia, hypocalcemia, hypermagnesemia, Hydrofluoric acid burn, Blood product transfusion; Cardiac arrest with presumed hyperkalemia or calcium channel-blocker overdose; Pulseless VF/VT. Contraindications: None in the emergency setting Concentrations Injection 100 mg/mL Adult Dosing Indication Dose Route Note Known or suspected hyperkalemia Hemorrhagic Shock Severe Hydrofluoric Acid Burn Calcium channel or Beta blocker overdose 1000 mg (1 g) IV Push Ensure that the IV/IO line is patent before giving the medication Pediatric Dosing Indication Dose Route Note Known or suspected hyperkalemia Hemorrhagic Shock Severe Hydrofluoric Acid Burn Calcium channel or Beta blocker overdose 20 mg/kg (Max 1000 mg) IV Push Ensure that the IV/IO line is patent before giving the medication Use Handtevy or Approved Pediatric Reference Guide for Amount to Administer Precautions: Will cause tissue damage if it extravasates Adverse/Side Effects: Arrhythmias including bradycardia or cardiac arrest, Syncope, N/V, Hypotension, Necrosis with extravasation. Calcium chloride will precipitate when used in conjunction with sodium bicarbonate, Toxicity with digitalis, and may antagonize the effects of calcium channel blockers Class: Inotropic Agent (electrolyte) Mechanism of Action: Replaces elemental calcium, which is essential for regulating excitation threshold of nerves and muscles. Calcium is also essential for blood clotting mechanisms, maintenance of renal function, and bone tissues. Calcium increases myocardial contractile force and ventricular automaticity. Additionally, serves as an antidote for magnesium sulfate and calcium channel blocker toxicity. Onset of Action Immediate Peak Effect Immediate Duration of Action Varies Page Break Dextrose (D10W) Page Break Aliases: Indications: Symptomatic hypoglycemia, altered mentation with glucose < 60, newborn with heart rate < 60 and glucose < 40. Contraindications: Suspected hypoglycemia: None Concentrations Infusion 25 g/250 mL (1 g/10 mL) Adult Dosing Indication Dose Route Note Symptomatic Hypoglycemia 25 g (250mL) IV infusion Titrate to effect. Repeat PRN Pediatric Dosing Indication Dose Route Note Pediatric Hypoglycemia (30 days or older) 1 g/kg (5 mL/kg) IV infusion Titrate to effect. Repeat PRN Newborn Hypoglycemia (0-29 days) 0.2 g/kg (1 ml/Kg) IV infusion Titrate to effect. Repeat PRN Use Handtevy or Approved Pediatric Reference Guide for Amount to Administer Precautions: Use with caution in patients with suspected increased ICP. Adverse/Side Effects: Patients may complain of warmth, pain, or burning at the injection site. Extravasation causes necrosis. Infusing through larger vessels decreases the risk of necrosis Class: Carbohydrate Mechanism of Action: Glucose is readily processed in the blood. Through glycolysis, glucose is turned into pyruvate giving off a small amount of chemical energy (ATP). Pyruvate is further processed through the Citric Acid Cycle yielding even more energy. Glucose is a large molecule and is incapable of being absorbed into a cell without insulin and therefore increases damage to epithelium. It also causes an osmotic pressure as concentrations vary across membranes. Onset of Action Fast Peak Effect Varies Duration of Action Varies Page BreakPage Break Dexamethasone Aliases: Decadron Indications: Inflammation to the respiratory tract. Adrenal insufficiency/crisis Contraindications: None in emergency setting Concentrations Injection 2-10 mg/mL Adult Dosing Indication Dose Route Note Bronchospasm 10 mg PO/IV/IM Use the IV form for any route Airway edema/croup Adrenal Insufficiency/Crisis Pediatric Dosing Indication Dose Route Note Bronchospasm (Age > 2 yo)
0.6 mg/kg (Max: 10 mg)
PO/IV/IM
Use the IV form for any route
Airway edema/croup
Adrenal Insufficiency/Crisis
Use Handtevy or Approved Pediatric Reference Guide for Amount to Administer
Precautions:
Avoid rapid IV push
Adverse/Side
Effects:
Agitation, perineal/body burning sensation, pruritus, nausea/vomiting
Class:
Corticosteroid, anti-inflammatory drugs
Mechanism of Action:
Potent glucocorticoid with minimal to no mineralocorticoid activity. Decreases inflammation by suppressing migration of polymorphonuclear leukocytes (PMNs) and reducing capillary permeability; stabilizes cell and lysosomal membranes, increases surfactant synthesis, increases serum vitamin A concentration, and inhibits prostaglandin and proinflammatory cytokines; suppresses lymphocyte proliferation through direct cytolysis, inhibits mitosis, breaks down granulocyte
aggregates, and improves pulmonary microcirculation
Onset of Action
Few minutes
Peak Effect
60 minutes
Duration of
Action
36 to 54 hours
Page BreakPage Break
Diphenhydramine
Aliases:
Benadryl
Indications:
Allergic Reaction, Anaphylaxis, Adult dystonic reaction, or Persistent
nausea/vomiting
Contraindications:
Known allergy
Concentrations
Injection
50 mg/mL
Tablet
25 mg
Adult Dosing
Indication
Dose
Route
Note
Moderate/Severe Allergic
Reaction – or – Dystonia
50 mg
IV/IM/PO
Slow IV Push
Mild Allergic Reaction with Only Hives/Rash
25 mg
IV/IM/PO
Slow IV Push
Persistent Nausea/Vomiting
IV/IM
Slow IV Push.
May repeat x 1 after 20 minutes
Pediatric Dosing
Indication
Dose
Route
Note
Mild to Severe Allergic
Reaction – or – Dystonia
1 mg/kg Max dose: 50
mg
IV/IM/PO
Do Not Administer if < 5 kg Persistent Nausea/Vomiting 1 mg/kg Max dose: 25 mg IV/IM Use Handtevy or Approved Pediatric Reference Guide for Amount to Administer Precautions: Antihistamine toxicity: Remember: "red as a beet, dry as a bone, hot as a hare, blind as a bat, mad as a hatter, and full as a flask." Brugada-like ECG patterns are seen with anticholinergic toxicity. Elimination mechanism concerns Potent anticholinergic agent Pregnancy Category B Adverse/Side Effects: Mydriasis, photophobia, ataxia, tachycardia, dizziness, drowsiness Class: Antihistamine, Ethanolamine, Anticholinergic Mechanism of Action: Diphenhydramine blocks the effects of Histamine (H1 histamine) on the H1 receptor site through a competitive competition for the peripheral H1 site. When diphenhydramine is bound the H1 site cannot be stimulated preventing the effects of histamines (swelling, etc.). As an antihistamine, diphenhydramine one of the most effective antihistamines. Onset of Action Rapid (Injection) Varies (PO) Peak Effect 1-3 hours Duration of Action 6-12 hours Page Break Droperidol Aliases: Inapsine Indications: Agitation, Atraumatic Headache, Nausea/Vomiting, Vertigo, Acute exacerbation of chronic abdominal pain Contraindications: Hypersensitivity to drug, patients with signs of severe prolonged QTc Concentrations Injection 2.5 mg/mL Adult Dosing Indication Dose Route Note Agitation/Psychosis 10 mg IM 5 mg IV Give once. Trend RASS Score every 5 minutes. Treat accordingly. Atraumatic Headache 2.5 mg IV/IM May repeat once after 10 minutes. Nausea/Vomiting Dizziness/Vertigo Acute exacerbation of chronic abdominal pain Pediatric Dosing Indication Dose Route Note Agitation/Psychosis NOT FOR PEDIATRIC USE AT THIS TIME Atraumatic Headache Nausea/Vomiting Dizziness/Vertigo Acute exacerbation of chronic abdominal pain Use Handtevy or Approved Pediatric Reference Guide for Amount to Administer Precautions: ECG monitor must be applied as soon as possible when medication is given. Adverse/Side Effects: Neuroleptic malignant syndrome, sinus tachycardia, hypotension, akathisia, dystonic reaction, restlessness, drowsiness, anxiety Class: Butyrophenone neuroleptic. Mechanism of Action: Like haloperidol, droperidol antagonizes multiple receptor sites in the CNS including serotonin, GABA, norepinephrine, and especially, dopamine. There is evidence that butyrophenones antagonize dopamine-mediated neurotransmission at the synapse as well as block postsynaptic dopamine receptor sites. The antiemetic activity of droperidol is most likely due to blockade of dopamine receptors in the chemoreceptor trigger zone of the brain. It is associated with prolongation of the QTc interval and serious arrhythmias including torsade de pointes. Droperidol delays the recharging of potassium channels, thereby blocking the rapid component of the delayed rectifier potassium current, within minutes of a dose at the upper limit of the dosage range. Onset of Action 3 to 10 minutes Peak Effect 30 minutes Duration of Action 2-4 hours Page Break Page Break Epinephrine Aliases: Adrenaline Indications: Cardiac arrest, Bradycardia, Allergic reaction or Anaphylaxis, Respiratory distress with presumed bronchospasm, Uncontrollable external hemorrhage, shock, croup/bronchiolitis in kids Contraindications: None in the emergency setting Concentrations Injection 1 mg/10 mL (0.1 mg/mL or 100 mcg/mL) Injection 1 mg/mL (1 mg/mL or 1000 mcg/mL) Infusion 4 mcg/mL Adult Dosing Indication Dose Concentration Route Note Cardiac Arrest 1 mg (0.1 mg/mL) IV Every 5 minutes. Max of 3 doses Push Dose Epinephrine 20 mcg (10 mcg/mL) IV Titrate to MAP > 65 mmHg
Non-hemorrhagic Hypotension
Bradycardia
2-20 mcg/min
Infusion
Anaphylaxis
Respiratory failure from bronchospasm
Angioedema
0.3 mg
(1 mg/mL)
IM
May repeat every 5 minutes up to total 1.2 mg
2 mg
(1 mg/mL)
Nebulizer
2 mg (2 mL) mixed with 1 ml NS
Uncontrollable external hemorrhage
1 mg
(1 mg/mL)
Topical
Topical soaked in gauze or
IN atomizer for epistaxis
Nebulizer
Tonsil, mix 1 mL into 2.5 ml NS
Pediatric Dosing
Indication
Dose
Concentration
Route
Note
Cardiac Arrest
0.01 mg/kg
(Max 1 mg)
(0.1 mg/mL)
IV
Repeat after 4 minutes
Push Dose Epinephrine
10 mcg
(10 mcg/mL)
IV
Repeat every minute PRN
Non-hemorrhagic Hypotension
Bradycardia
0.1 – 1 mcg/kg/min
Infusion
Anaphylaxis
0.01 mg/kg
(Max 0.3
mg)
(1 mg/mL)
IM
0.1 – 1 mcg/kg/min
Infusion
Give for anaphylactic shock
Severe Bronchospasm
Angioedema
0.01 mg/kg
(Max 0.3
mg)
(1 mg/mL)
IM
Stridor/Barking/Croup
Bronchiolitis (< 2 y/o) 1 mg (1 mg/mL) Nebulizer Mix with 4 mL NS Use Handtevy or Approved Pediatric Reference Guide for Amount to Administer Precautions: Harm of epinephrine is small when indicated even with history of CAD Adverse/Side Effects: Palpitations, anxiety, tremulousness, headache, dizziness, nausea, vomiting, increased myocardial oxygen demand Class: Sympathetic Agonist. Epinephrine is a naturally occurring catecholamine. It is a potent alpha- and beta-adrenergic stimulant with more profound beta effects. Mechanism of Action: Epinephrine works directly on alpha- and beta-adrenergic receptors with effects of increased heart rate, cardiac contractile force, increased electrical activity in the myocardium, increased systemic vascular resistance, increased blood pressure, and increased automaticity. It also causes bronchodilation. Onset of Action <1 minute Peak Effect Few minutes Duration of Action Varies Page BreakPage Break Etomidate Aliases: Amidate Indications: Temporary Procedural Sedation , induction prior to intubation Contraindications: Hypersensitivity to Etomidate. Coma Concentrations Injection 2 mg/mL Adult Dosing Indication Dose Route Note Rapid Sequence Induction 0.3 mg/kg IV Give once. Consider half dose in the setting of shock. Brief Procedural Sedation 0.1 mg/kg Pediatric Dosing Indication Dose Route Note Rapid Sequence Induction 0.3 mg/kg (Max: 40 mg) IV Give once. Consider half dose in the setting of shock. Brief Procedural Sedation 0.1 mg/kg (Max: 20 mg) Use Handtevy or Approved Pediatric Reference Guide for Amount to Administer Precautions: Adverse/Side Effects: Apnea/respiratory depression, bradycardia, myoclonus (muscle spasms), hypotension, nausea/vomiting Class: Sedative Mechanism of Action: Etomidate appears to facilitate GABAminergic neurotransmission by increasing the number of available GABA receptors, possibly by displacing endogenous inhibitors of GABA binding. Etomidate also inhibits steroidogenesis, which prevents its long- term use for ICU sedation. Inhibition is probably due to blockage of 11-beta- hydroxylation within the adrenal cortex. Reduced plasma cortisol and aldosterone levels appear to be unresponsive to ACTH stimulation. Onset of Action <1 minute Peak Effect Rapid Duration of Action 3 to 5 minutes Page Break Page Break Fentanyl Aliases: Sublimaze Indications: Pain management, ACS or STEMI, Constant Crush Injury > 4 hours, Procedural
sedation
Contraindications:
Hypotension or Respiratory depression
Concentrations
Injection
50 mcg/mL
Adult Dosing
Indication
Dose
Route
Note
Analgesia (Moderate to Severe)
Procedural Sedation
1 mcg/kg
IV/IM/IN
Round to nearest 25 mcg.
Be sure to give IM/IN if 1st IV attempt fails or delayed.
Repeat every 5 minutes PRN
Avoid in headache
Pediatric Dosing
Indication
Dose
Route
Note
Analgesia (Moderate to Severe)
Procedural Sedation
1 mcg/kg
IV/IM/IN
Round to nearest
12.5 mcg.
Consider diluting in syringe with NS
Be sure to give IM/IN if 1st IV attempt fails or delayed.
Repeat every 5 minutes PRN
Avoid in headache
Use Handtevy or Approved Pediatric Reference Guide for Amount to Administer
Precautions:
Narcan should be available, Lower doses should be considered in elderly and frail
patients.
Adverse/Side Effects:
Fentanyl may cause muscle rigidity, particularly involving the muscles of respiration. As with other narcotic analgesics, the most common serious adverse reactions reported to occur with fentanyl are respiratory depression, apnea, rigidity, and bradycardia. Other adverse reactions that have been reported are hypertension, hypotension, dizziness, blurred vision, nausea, emesis, laryngospasm, and
diaphoresis. May cause Respiratory Depression.
Class:
Opioid, Schedule II controlled substance
Mechanism of
Action:
Competitive agonist that binds to opioid receptors which are found principally in
the central and peripheral nervous system.
Onset of Action
Immediate (IV)
7 – 8 minutes (IN/IM)
Peak Effect
Rapid (IV) 15 to 21 minutes (IM/IN)
Duration of Action
30 to 60 minutes (IV)
1 to 2 hours (IM)
Page BreakPage Break
Haloperidol
Aliases:
Haldol
Indications:
Used to treat certain mental/mood disorders (e.g., schizophrenia, schizoaffective
disorders) & Tourette’s disorder, Severe nausea/vomiting, Acute exacerbation of
chronic abdominal pain , acute agitation
Contraindications:
Severe toxic central nervous system depression, Parkinson’s disease
Concentrations
Injection
5 mg/mL
Adult Dosing
Indication
Dose
Route
Note
Agitation/Psychosis
5 mg
IV/IM
May repeat once after 10 minutes
Severe nausea/vomiting
Atraumatic headache
Acute exacerbation of chronic
abdominal pain
Pediatric Dosing
Indication
Dose
Route
Note
Agitation/Psychosis
2 mg
IV/IM
May repeat once after 10 minutes.
Not for children under
3 y/o or 15 kg.
Severe nausea/vomiting
Atraumatic headache
Acute exacerbation of chronic abdominal pain
Use Handtevy or Approved Pediatric Reference Guide for Amount to Administer
Precautions:
Elderly Patients with Dementia-Related Psychosis Pregnancy Category C
Adverse/Side
Effects:
Tachycardia, hypotension, and hypertension. QT prolongation and/or ventricular
arrhythmias. Dystonia
Class:
Antipsychotic
Mechanism of Action:
Phenylbutylpiperadine; antagonizes dopamine D1 and D2 receptors in brain;
depresses reticular activating system and inhibits release of hypothalamic and hypophyseal hormones
Onset of Action
3
to 20 minutes (IV)
20
to 30 minutes (IM)
Peak Effect
20 – 30
minutes
Duration of Action
3
hours (IV)
2
hours (IM)
Page BreakPage Break
Hydroxycobalamin
Aliases:
Cyanokit
Indications:
Known or suspected cyanide poisoning/smoke inhalation.
Contraindications:
Known anaphylactic reactions to Hydroxocobalamin or cyanocobalamin
Adult Dosing
Indication
Dose
Route
Note
Cyanide Poisoning
5 g
IV infusion over 15 minutes
Mix 5 g vial into 200 ml isotonic crystalloid for concentration of 25
mg/ml.
Pediatric Dosing
Indication
Dose
Route
Note
Cyanide Poisoning
70 mg/kg (Max 5 g)
IV infusion over 15 minutes
Mix 5 g vial into 200 ml isotonic crystalloid for concentration of 25
mg/ml.
Use Handtevy or Approved Pediatric Reference Guide for Amount to Administer
Precautions:
Adverse/Side
Effects:
Anaphylaxis, chest tightness, edema, urticaria, pruritus, dyspnea, rash, and
hypertension. Also, effects skin (turns red), urine and secretions.
Class:
Cobalamin derivative; Vitamin
Mechanism of
Action:
Hydroxocobalamin binds with Cyanide to form nontoxic cyanocobalamin, which is
then excreted in the urine
Onset of Action
Rapid
Peak Effect
Varies
Duration of
Action
Varies
Page Break
Page Break
Ibuprofen
Aliases:
Motrin, Advil
Indications:
Pain, fever, swelling from an acute injury
Contraindications:
Known hypersensitivity. Should not be given to patients who have experienced asthma, urticaria, or allergic-type reactions after taking Aspirin or other NSAIDs.
Known pregnancy. Should be avoided in patient with advanced kidney disease.
Solution
20 mg/mL
Adult Dosing
Indication
Dose
Route
Note
Analgesia (Any level)
600 mg
PO
One dose only.
May combine with Acetaminophen.
Avoid in headache
Fever
Swelling from an acute
injury
Pediatric Dosing
Indication
Dose
Route
Note
Analgesia (Any level)
10 mg/kg (Max 600 mg)
PO
Must be over 6 months old.
One dose only.
May combine with Acetaminophen.
Avoid in headache
Fever
Swelling from an acute injury
Use Handtevy or Approved Pediatric Reference Guide for Amount to Administer
Precautions:
Adverse/Side
Effects:
Aspirin-sensitive asthma, coagulation disorders or patients receiving anticoagulants
should be carefully monitored.
Class:
Non-Steroidal Anti-Inflammatory Drug (NSAID)
Mechanism of Action:
Ibuprofen possesses analgesic and antipyretic activities. Its mode of action, like that of other NSAIDs, is not completely understood, but may be related to prostaglandin synthetized inhibition, by blocking the enzyme in your body that makes prostaglandins. Decreasing prostaglandins helps to reduce pain, swelling, and
fever.
Onset of Action
30 to 60
minutes
Peak Effect
1 to 2 hours
Duration of
Action
6 to 8 hours
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Ipratropium
Aliases:
Atrovent
Indications:
Respiratory Distress (Bronchial asthma, reversible bronchospasm associated with
chronic bronchitis and emphysema), Drowning, Organophosphate exposure.
Contraindications:
Known hypersensitivity
Unit Dose
0.5 mg/Unit
Adult Dosing
Indication
Dose
Route
Note
Respiratory distress
0.5 mg
Nebulizer
Administer with Albuterol
and repeat as needed.
Drowning
Organophosphate exposure
Repeat as needed.
Pediatric Dosing
Indication
Dose
Route
Note
Respiratory distress
0.5 mg
Nebulizer
Administer with Albuterol
and repeat as needed.
Drowning
Organophosphate exposure
Repeat as needed.
Use Handtevy or Approved Pediatric Reference Guide for Amount to Administer
Precautions:
Use caution when administering this drug to elderly patients and those with
cardiovascular disease or hypertension
Adverse/Side
Effects:
Palpitations, anxiety, dizziness, headache, nervousness, tremor, hypertension,
arrhythmias, chest pain, nausea, vomiting
Class:
Anticholinergic
Mechanism of Action:
Ipratropium is a parasympatholytic used in the treatment of respiratory emergencies. It causes bronchodilation and dries respiratory tract secretions.
Ipratropium acts by blocking acetylcholine. 15% of dose reaches lower airway.
Onset of Action
<15 minutes Peak Effect 1 to 2 hours Duration of Action 4 to 5 hours Page Break Page Break Isotonic Crystalloid Fluids Aliases: Normal Saline (0.9%), Lactated Ringer’s, or Plasma-Lyte Indications: Hypovolemia, Sepsis, Dehydration, Establishing vascular access and medication administration Contraindications: Fluid overload resulting in pulmonary edema and/or congestive heart failure Adult Dosing Indication Dose Route Note Hypovolemia 10 to 20 mL/kg (max of 2000 mL) May give in increments of 250 to 1000 mL boluses IV May titrate dose and administration rate based on assessment, MAP > 65 or permissive hypotension when indicated, and most appropriate clinical
operating guideline
Sepsis
Dehydration
Establishing vascular access and medication administration
Pediatric Dosing
Indication
Dose
Route
Note
Hypovolemia
Pediatric: 20 ml/kg boluses
Newborn: 10 ml/kg boluses
IV
May titrate dose and administration rate based on assessment, mental status and vital signs, and most appropriate clinical operating guideline
Sepsis
Dehydration
Establishing vascular access and medication
administration
Use Handtevy or Approved Pediatric Reference Guide for Amount to Administer
Precautions:
Adverse/Side Effects:
Crystalloid fluids are administered for volume expansion as indicated. Crystalloid fluids, such as Lactated Ringers or Normal Saline, do not add oxygen binding capacity. Rapid volume resuscitation of crystalloid fluids, preferably through large- bore line, may be indicated in the acute setting. Always monitor for signs of fluid
overload and titrate to a desired effect. Maintenance infusion is indicated as
needed to maintain patent access or minimum volume to maintain volume
homeostasis.
Class:
Isotonic to human plasma
Mechanism of Action:
Approximate concentrations of various solutes and do not exert as osmotic effect, expand intravascular volume without disturbing ion concentration or significant
fluid shift.
Onset of Action
Immediate
Peak Effect
Varies
Duration of
Action
Varies
Page BreakPage Break
Ketamine
Aliases:
Ketalar
Indications:
Pain, Severe bronchospasm, Procedural sedation, Rapid sequence induction, Severe Agitation, Lifesaving procedure
Contraindications:
Uncontrolled Hypertension, Hypersensitivity. Be cautious administering to older adults and
elderly.
Concentrations
Injection
10 mg/mL
Injection
100 mg/mL
Adult Dosing
Indication
Dose
Route
Note
Pain
Severe bronchospasm
10 mg
IV infusion over 10 minutes
If the patient is hemodynamically unstable defined as MAP < 65 and/or respiratory failure, then ketamine may be used first for pain. If the patient is hemodynamically stable defined as MAP > 65 and no respiratory failure, then the appropriate amount of fentanyl (up to 100 mcg) should be administered first; then ketamine can be administered x 1 10 minutes later if
no relief in pain has occurred.
25 to 50 mg
IM
Procedural Sedation
Alcohol Withdrawal
Refractory Status Epilepticus
100 mg
Slow IV Push
May repeat every 2 minutes PRN
Consider 50 mg increments for hypotensive patients to achieve sedation without CV collapse
Rapid Sequence Induction
200 mg
Severe Agitation/Excited Delirium
Lifesaving Procedure
300 mg
IM
May repeat IM every 5 minutes PRN. Lifesaving procedure when IV/IO access cannot be obtained.
Pediatric Dosing
Indication
Dose
Route
Note
Pain
Severe Bronchospasm
0.2 mg/kg
(Max: 10 mg)
IV/IO infusion over 10
minutes
Must be >3 months old and see pediatric dosing chart for patient weight minimums.
0.4 mg/kg
IM
(Max: 25 mg)
Procedural sedation
Lifesaving procedure
Severe Agitation/Excited
1 mg/kg (Max:
100 mg)
Slow IV Push
4 mg/kg (Max:
IM
Delirium
Refractory Status
300 mg)
Epilepticus
Rapid Sequence Induction
2 mg/kg (Max:
Slow IV Push
200 mg)
Use Handtevy or Approved Pediatric Reference Guide for Amount to Administer
Precautions:
Laryngospasms and other forms of airway obstruction have occurred. Use with caution in patients with history of Schizophrenia. Be aware that in lower dosing some patients may
experience partial disassociation.
Adverse/Side Effects:
Respiratory depression may occur, Laryngospasms, Hypertension, Emergence Reactions (Hallucinations, Delirium), dizziness, nausea, vomiting
Class:
Ketamine hydrochloride is a rapid-acting dissociative anesthetic.
Mechanism of Action:
The anesthetic state produced by ketamine hydrochloride has been termed “dissociative anesthesia” in that it appears to selectively interrupt association pathways of the brain before producing somesthetic sensory blockade. It may selectively depress the thalamoneocortical system before significantly obtunding the more ancient cerebral centers and pathways
(reticular-activating and limbic systems).
Onset of Action
< 30 secs (IV) 3 – 15 mins (IM) Peak Effect Fast (IV) 5 – 30 mins (IM) Duration of Action IV Anesthetic: 5 – 10 mins IM Anesthetic: 12 – 25 mins Analgesia: 15 – 30 mins Page BreakPage Break Lidocaine Aliases: Xylocaine Indications: V-Fib or Pulseless V-Tach (pVT) Cardiac Arrest, Post Resuscitation Care, Wide Complex Tachycardia with a Pulse, Pain Management for IO Flush, Eye Injury, Pain Management for Kidney Stone Contraindications: Second- and third-degree heart blocks, CHF Concentrations Injection 20 mg/mL Adult Dosing Indication Dose Route Note V-fib or pVT Cardiac Arrest 100 mg IV Push May repeat every 4 minutes PRN. Max total dose – 3 mg/kg Wide Complex Tachycardia with a Pulse IO Flush 40 mg Slow IO Push Dilute in 10 mL with IVF Pediatric Dosing Indication Dose Route Note V-fib or pVT Cardiac Arrest IV Push Wide Complex Tachycardia with a Pulse 1 mg/kg (Max: 100 mg) May repeat every 4 minutes PRN. Max total dose – 3 mg/kg IO Flush 0.5 mg/kg (Max: 40 mg) Slow IO Push Dilute in 10 mL with IVF Use Handtevy or Approved Pediatric Reference Guide for Amount to Administer Precautions: CNS depression may occur when the drug exceeds 300mg/hr. Lidocaine should be used with caution when administered concomitantly with Procainamide and beta- blockers as drug toxicity may result. Adverse/Side Effects: Drowsiness, seizures, confusion, hypotension, bradycardia, heart blocks, nausea, vomiting, and respiratory and cardiac arrest Class: Antiarrhythmic (Class 1b), Sodium channel blocker Mechanism of Action: Lidocaine depresses depolarization and automaticity in the ventricles and increases the ventricular fibrillation threshold by increasing phase IV repolarization. Onset of Action 45 to 60 seconds Peak Effect Fast Duration of Action 10 to 20 minutes Page Break Page Break Lorazepam Aliases: Ativan Indications: Procedural/maintenance sedation, Anticonvulsant, Rapid Sequence Induction, Acute behavioral emergencies, EtOH withdrawal, Uncontrolled Anxiety/Panic Attack Contraindications: Allergy, Shock, Coma, Closed Angle Glaucoma Concentrations Injection 2 mg/mL Adult Dosing Indication Dose Route Note Seizure EtOH Withdrawal 2-4 mg IM/IV Repeat every 5 minutes PRN Agitation/Anxiety 2-4mg IM/IV Repeat every 5 minutes PRN Trend RASS Score every 5 minutes Procedural Sedation Pediatric Dosing Indication Dose Route Note Seizure 0.1 mg/kg (Max: 4 mg) IM/IV Repeat every 5 minutes PRN Procedural Sedation Agitation/Anxiety 0.1 mg/kg (Max: 4 mg) IM/IV Repeat every 5 minutes PRN Trend RASS Score every 5 minutes Use Handtevy or Approved Pediatric Reference Guide for Amount to Administer Precautions: Pregnancy Category D. Premedication with an opiate may potentiate lorazepam and lead to apnea. Reducing the dose to 50% is suggested in elderly and patients under the influence of other CNS depressants Adverse/Side Effects: Minor: N/V, Headache, Drowsiness, Lethargy, Cough, Hiccups. Major: Respiratory Depression, Apnea, Hypotension, Cardiac Arrest, Paradoxical CNS stimulation. Class: Short-acting benzodiazepine central nervous system (CNS) depressant. Mechanism of Action: Acts at the level of the limbic, thalamic, and hypothalamic regions of the CNS through potentiation of GABA (inhibitory neurotransmitter). Decreases neural cell activity in all regions of CNS. Anxiety is decreased by inhibiting cortical and limbic arousal. Promotes relaxation through inhibition of spinal motor reflex pathway, also depresses muscle & motor nerve function directly. As an anticonvulsant, augments presynaptic inhibitions of neurons, limiting the spread of electrical activity. However, it does not alter the electrical activity of the seizure’s focus. Much longer acting the midazolam with later peak effect. Onset of Action IV: 3 – 5 mins IM: 15-30 mins Peak Effect IV: 1 hour IM: within 3 hours Duration of Action IV/IM about 6 hours Magnesium sulfate Aliases: Indications: V-Fib or Pulseless V-Tach(pVT) Cardiac Arrest, Wide Complex Tachycardia with a Pulse, All Torsade de Pointes, Respiratory Distress or Failure from asthma/COPD, OB Seizures (eclampsia) Contraindications: Hypotension, third degree AV block, routine dialysis patients, known hypocalcemia. Concentrations Injection 500 mg/mL Adult Dosing Indication Dose Route Note V-fib or pVT Cardiac Arrest 2 g Slow IV Push Refractory VF/pVT only Tachycardia with a Pulse: AFib/AFlutter with RVR Torsades de Pointes IV Infusion over 5 minutes Respiratory Distress/Failure OB Seizures 4 g Pediatric Dosing Indication Dose Route Note V-fib or pVT Cardiac Arrest 50 mg/kg (Max: 2 g) Slow IV Push Refractory VF/pVT only Wide Complex Tachycardia WITH a Pulse (Torsade de Pointes) IV Infusion over 5 minutes Respiratory Distress/Failure Use Handtevy or Approved Pediatric Reference Guide for Amount to Administer Precautions: Magnesium Sulfate should be administered slowly to minimize side effects. Use with caution in patients with known renal insufficiency. In hypermagnesemia Calcium Chloride should be available as an antidote if serious side effects occur Adverse/Side Effects: Hypotension, cardiac arrest, respiratory/CNS depression, flushing, sweating, bradycardia, decreased deep tendon reflexes, drowsiness, respiratory depression, arrhythmia, hypothermia, itching, and rash. Class: Antiarrhythmic (Class V), Electrolyte Mechanism of Action: Magnesium Sulfate is a salt that dissociates into the Magnesium cation and the sulfate anion. Magnesium is an essential element in numerous biochemical reactions that occur within the body. Magnesium Sulfate acts as a calcium channel blocker and blocks neuromuscular transmission. Hypomagnesemia can cause refractory ventricular fibrillation. Magnesium Sulfate is also a central nervous system depressant used for seizures associated with eclampsia and it is also a bronchodilator. Onset of Action Immediate Peak Effect Fast Duration of Action 30 minutes Page Break Page Break Midazolam Aliases: Versed Indications: Procedural/maintenance sedation, Anticonvulsant, Rapid Sequence Induction, Acute behavioral emergencies, EtOH withdrawal, Uncontrolled Anxiety/Panic Attack Contraindications: Allergy, Shock, Coma, Closed Angle Glaucoma Concentrations Injection 5 mg/mL Adult Dosing Indication Dose Route Note Seizure EtOH Withdrawal 10 mg IM/IN Repeat every 5 minutes PRN 5 mg IV Agitation/Anxiety 5 mg IM/IN/IV Repeat every 5 minutes PRN Trend RASS Score every 5 minutes Procedural Sedation Pediatric Dosing Indication Dose Route Note Seizure 0.2 mg/kg (Max: 10 mg) IM/IN Repeat every 5 minutes PRN 0.1 mg/kg (Max: 5 mg) IV Procedural Sedation Agitation/Anxiety IM/IN/IV Repeat every 5 minutes PRN Trend RASS Score every 5 minutes Use Handtevy or Approved Pediatric Reference Guide for Amount to Administer Precautions: Pregnancy Category D. Premedication with an opiate may potentiate midazolam and lead to apnea. Reducing the dose to 50% is suggested in elderly and patients under the influence of other CNS depressants Adverse/Side Effects: Minor: N/V, Headache, Drowsiness, Lethargy, Cough, Hiccups. Major: Respiratory Depression, Apnea, Hypotension, Cardiac Arrest, Paradoxical CNS stimulation. Class: Short-acting benzodiazepine central nervous system (CNS) depressant. Mechanism of Action: Acts at the level of the limbic, thalamic, and hypothalamic regions of the CNS through potentiation of GABA (inhibitory neurotransmitter). Decreases neural cell activity in all regions of CNS. Anxiety is decreased by inhibiting cortical and limbic arousal. Promotes relaxation through inhibition of spinal motor reflex pathway, also depresses muscle & motor nerve function directly. As an anticonvulsant, augments presynaptic inhibitions of neurons, limiting the spread of electrical activity. However, it does not alter the electrical activity of the seizure’s focus. Midazolam has twice the affinity for benzodiazepine receptors than diazepam and has more potent amnesic effects. It is short acting and roughly 3-4 times more powerful than diazepam. Onset of Action IV: 3 – 5 mins IN: ~ 10 mins IM: 5 – 15 mins Peak Effect IV: 3 – 5 mins IN: ~ 15 mins IM: 15 – 30 mins Duration of Action IV: < 2 hours (single dose) IN: ~ 30 mins IM: ~ 2 hours Morphine Aliases: Morphine Indications: Pain management, ACS or STEMI, Constant Crush Injury > 4 hours, Procedural
sedation
Contraindications:
Hypotension or Respiratory depression
Concentrations
Injection 4mg/ml
Adult Dosing
Indication
Dose
Route
Note
Analgesia (Moderate to Severe)
Procedural Sedation
0.1mg/kg max 4-8mg
IV/IM
Repeat every 5 minutes PRN
Avoid in headache
Pediatric Dosing
Indication
Dose
Route
Note
Analgesia (Moderate to Severe)
Procedural Sedation
0.1mg/kg max 2-4mg
IV/IM/IN
Consider diluting in syringe with NS
Repeat every 5 minutes PRN
Avoid in headache
Use Handtevy or Approved Pediatric Reference Guide for Amount to Administer
Precautions:
Narcan should be available, Lower doses should be considered in elderly and frail
patients.
Adverse/Side Effects:
As with other narcotic analgesics, the most common serious adverse reactions reported to occur with morphine are respiratory depression, apnea, rigidity, and bradycardia. Other adverse reactions that have been reported are hypertension, hypotension, dizziness, blurred vision, nausea, emesis, laryngospasm, and
diaphoresis. May cause Respiratory Depression.
Class:
Opioid, Schedule II controlled substance
Mechanism of
Action:
Competitive agonist that binds to opioid receptors which are found principally in
the central and peripheral nervous system.
Onset of Action
Immediate
Peak Effect
5-10 minutes
Duration of
Action
2-4 hours
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Naloxone
Aliases:
Narcan
Indications:
Reversal of respiratory depression caused by opiates or synthetic narcotics
Contraindications:
Known allergy, known hypersensitivity, neonates with narcotic use by mother.
Concentrations
Injection
0.4 mg/mL
Injection
1 mg/mL
Adult Dosing
Indication
Dose
Route
Note
Opioid Overdose
0.4 – 0.5 mg
IV
Repeat PRN until ventilation is sufficient
by patient
2 mg
IM/IN
Pediatric Dosing
Indication
Dose
Route
Note
Opioid Overdose
0.1 mg/kg (Max: 2 mg)
IM/IN/IV
Repeat PRN until ventilation is sufficient
by patient
Use Handtevy or Approved Pediatric Reference Guide for Amount to Administer
Precautions:
The goal is to make the patient breath sufficiently on their own. Alertness is not
required for success.
Adverse/Side Effects:
Tachycardia, hypotension with rapid administration, HTN, dysrhythmias, N/V, and diaphoresis. In neonates, opioid withdrawal may be life-threatening if not
recognized
Class:
Opioid antagonist
Mechanism of Action:
Naloxone hydrochloride is an opioid antagonist that antagonizes opioid effects by competing for the same receptor sites. Naloxone hydrochloride reverses the effects
of opioids, including respiratory depression, sedation, and hypotension.
Onset of Action
IV: ~ 2 minutes IM: 2 – 5
minutes
IN: ~ 5 minutes
Peak Effect
IV: Fast IM/IN: 15 – 30
minutes
Duration of Action
Varies on route & opioid
IV has a shorter duration than IM
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Nitroglycerin
Aliases:
Nitrostat
Indications:
Chest Pain, CHF/Pulmonary Edema
Contraindications:
Hypotension, hypovolemia, severe bradycardia, or tachycardia, use of erectile dysfunction drugs within past 24hrs up to 48 hours depending on use of extended-
release medications.
Concentrations
Sublingual Spray/Tablet
400 mcg (0.4 mg) per dose
Injection/Infusion
100 – 400 mcg/mL
Adult Dosing
Indication
Dose
Route
Note
Chest Pain – ACS suspected
0.4 mg
Sublingual
Repeat every 5 mins PRN. Maintain SBP > 100
mmHg
5-50 mcg/min
Infusion
For refractory chest pain or STEMI/ACO only.
Titrate to pain relief or SBP > 100 mmHg.
Pulmonary Edema from Acute Heart Failure (Hypertensive Crisis)
1st dose: 1000 mcg
Slow IV Push
After NIPPV, consider IV Push before infusion.
Goal SBP 140-160
mmHg. Titrate infusion PRN.
2nd dose: 200 to 400 mcg/min
Infusion
Pediatric Dosing
Indication
Dose
Route
Note
None
Use Handtevy or Approved Pediatric Reference Guide for Amount to Administer
Precautions:
Headache, Tachycardia
Adverse/Side
Effects:
Hypotension, Syncope
Class:
Nitrate
Mechanism of Action:
Potent vasodilator with antianginal, anti-ischemic, and antihypertensive effects. Relaxes vascular smooth muscle by an unknown mechanism. Decreases peripheral
vascular resistance, preload, and afterload.
Onset of Action
SL: 1-3 minutes
IV: Immediate
Peak Effect
5 minutes
Duration of
Action
Less than 10
minutes
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Ondansetron
Page Break Page Break
Aliases:
Zofran
Indications:
Moderate to severe nausea, vomiting
Contraindications:
Known allergy, do not use Zofran concurrently with Procainamide, Haldol, or
amiodarone due to QT prolongation.
Concentrations
Injection
2mg/mL
Tablet
4 mg/dose
Adult Dosing
Indication
Dose
Route
Note
Moderate to Severe
Nausea/Vomiting
4 mg
PO/IV/IM
Repeat every 15 minutes
PRN
Pediatric Dosing
Indication
Dose
Route
Note
Moderate to Severe
Nausea/Vomiting
0.1 mg/kg (Max: 4 mg)
IM/IV/PO
IM preferred over IV
4 mg
PO
For 25 kg and up
Use Handtevy or Approved Pediatric Reference Guide for Amount to Administer
Precautions:
Caution use in patients with long QTc syndrome or on drugs that prolong the QTc.
Adverse/Side Effects:
Arrhythmias (including ventricular and supraventricular tachycardia, premature ventricular contractions, and atrial fibrillation), bradycardia, electrocardiographic
alterations (including second-degree heart block, QT/QTc interval prolongation, and ST segment depression), palpitations, and syncope.
Class:
Anti-emetic, Selective Serotonin (5HT3) Receptor Antagonist
Mechanism of Action:
Ondansetron reduces the activity of the vagus nerve, which activates the vomiting center in the medulla oblongata and blocks serotonin receptors in the chemoreceptor trigger zone. It has little effect on vomiting caused by motion
sickness. Safely tolerated at high dose ranges.
Onset of Action
<30 minutes Peak Effect 30 to 120 minutes Duration of Action Varies Page Break Oral glucose Page Break Aliases: Indications: Hypoglycemia (< 60 mg/dl) with patients who can protect their airway Contraindications: Known allergy, patients who are unable to protect their airway Concentrations Solution 15 g/dose Adult Dosing Indication Dose Route Note Hypoglycemia 15g PO May repeat every 15 minutes PRN. Pediatric Dosing Indication Dose Route Note Hypoglycemia 15g PO May repeat every 15 minutes PRN May substitute with juice with added sugar. Use Handtevy or Approved Pediatric Reference Guide for Amount to Administer Precautions: Ensure adequate airway protection by patient Adverse/Side Effects: Nausea Class: Monosaccharide, Carbohydrate Mechanism of Action: After absorption from GI tract, glucose is distributed in the tissues and provides a prompt increase in circulating blood sugar Onset of Action < 10 minutes Peak Effect Varies Duration of Action Varies Page Break Page Break Oxygen Aliases: O2 Indications: SpO2 < 94%, signs of respiratory distress or failure, signs of hypoxia or hypoxemia, exposure to toxic gases Contraindications: None in the emergency setting Concentrations Adult Dosing Indication Dose Route Note Hypoxia 1-25 lpm Inhaled Titrate to saturation of 92-96% Exposure to toxic gases 15-25 lpm Inhaled Regardless of saturations Pre-airway placement 25 lpm Inhaled Nasal Cannula before and during airway placement Pediatric Dosing Indication Dose Route Note Hypoxia 1-25 lpm Inhaled Titrate to saturation of 92-96% Exposure to toxic gases 15-25 lpm Inhaled Regardless of saturations Pre-airway placement 25 lpm Inhaled Nasal Cannula before and during airway placement Use Handtevy or Approved Pediatric Reference Guide for Amount to Administer Precautions: Adverse/Side Effects: Excessive oxygenation can be harmful, especially with neonates, therefore titrate flow rates and frequently assess oxygen needs. Can dry mucous membranes, prolong high concentration therapy can affect respiratory drive and consciousness of COPD patients. Class: Naturally occurring atmospheric gas Mechanism of Action: Reverses hypoxemia Onset of Action Immediate Peak Effect Rapid Duration of Action < 2 minutes Page Break Page Break Pralidoxime Aliases: 2-PAM, Protopam Indications: Organophosphate Toxidrome Contraindications: Documented hypersensitivity Concentrations Injection 300 mg/mL Adult Dosing Indication Dose Route Note Organophosphate Toxidrome/Nerve Gas Exposure 600 mg IM Use in an autoinjector. Repeat PRN until symptoms resolve. Pediatric Dosing Indication Dose Route Note Organophosphate Toxidrome/Nerve Gas Exposure 600 mg IM Use in an autoinjector. Repeat PRN until symptoms resolve. Use Handtevy or Approved Pediatric Reference Guide for Amount to Administer Precautions: Pregnancy class C. May precipitate myasthenia crisis. Adverse/Side Effects: Laryngospasm, Muscle paralysis, Hypertension, Sinus tachycardia, Mania. Class: Cholinesterase reactivator Mechanism of Action: Pralidoxime is a cholinesterase reactivator that reverses muscle paralysis after organophosphate poisoning. Organophosphate compounds inhibit cholinesterase via phosphorylation of the enzyme. The inhibited cholinesterase is unable to metabolize acetylcholine resulting in an accumulation of the neurotransmitter. Acetylcholine is present in the central nervous system, parts of the autonomic nervous system, and at the skeletal muscle end plates; therefore, accumulation of this neurotransmitter after organophosphate poisoning adversely affects each of these systems. In the somatic nervous system, acetylcholine accumulation leads to paralysis. The clinical effects of pralidoxime are most evident at skeletal neuromuscular junctions. Pralidoxime reverses the paralysis by removing the phosphoryl group from the inhibited cholinesterase molecule, reactivating the enzyme, and restoring the body's ability to metabolize acetylcholine. Onset of Action Few minutes Peak Effect 5 – 15 minutes Duration of Action 75 minutes Page BreakPage Break Page Break Page Break Sodium Bicarbonate Aliases: Baking Soda Indications: Hyperkalemia, Tricyclic or Sodium Channel Blocker Overdose, Crush Syndrome Contraindications: Concentrations Adult Dosing Indication Dose Route Note Hyperkalemia 1 mEq/kg (Max: 50 mEq) IV Push Give once TCA/Sodium Channel Blocker Overdose Repeat every 1-2 minutes PRN until QRS narrows Crush Syndrome Give once prior to releasing body part. Pediatric Dosing Indication Dose Route Note Hyperkalemia 1 mEq/kg (Max: 50 mEq) IV Push Give once TCA/Sodium Channel Blocker Overdose Repeat every 1-2 minutes PRN until QRS narrows Crush Syndrome Give once prior to releasing body part. Use Handtevy or Approved Pediatric Reference Guide for Amount to Administer Precautions: Adverse/Side Effects: Alkalosis, Hyperirritability, Seizures, Tetany (electrolyte imbalance), Cardiac & respiratory arrest. Lowering of serum potassium, Decreased fibrillation threshold. Class: Alkalinizing Agent Mechanism of Action: In the presence of hydrogen ions, sodium bicarbonate dissociates to sodium and carbonic acid, the carbonic acid picks up a hydrogen ion changing to bicarbonate and then dissociates into water and CO2, functioning as an effective buffer and alkalinizing the blood. In summary, increases plasma bicarbonate, which can buffer metabolic acids and move TCAs and phenobarbital off receptor sites and back into circulation. Onset of Action Rapid Peak Effect Fast Duration of Action 8 to 10 minutes Page Break Page Break