Adult Medical Protocols Flashcards
ANAPHYLACTIC SHOCK / ALLERGIC REACTION
Interventions / Dose
Epi 1:1000
Epi 1:10,000
Pepcid
Methylprednisolone
Albuterol
♦ Diphenhydramine (Benadryl) 25-50 mg
♦ Epinephrine 1:1000 solution 0.3 to 0.5 mg IM. This may be repeated every 20 minutes up to 3 times for a total of 4 doses.
♦ Epinephrine 1:10,000 solution 0.3 mg IO/IV. Slowly titrate to effect. (hemodynamically unstable)
♦ Consider NS bolus and/or vasopressors
♦ Pepcid (Famotidine) 20 mg
♦ Methylprednisolone (Solu-Medrol) 125 mg
♦ Albuterol 2.5 mg (wheezing)
BEHAVIORAL EMERGENCIES / CHEMICAL RESTRAINT
Consider causes first
♦ Midazolam 1-5 mg IV/IO/IN or 5-7.5mg IM/IN
♦ Lorazepam (Ativan) 1-2 mg IM/IN/IV/IO (extremely violent or does not calm within 10 minutes of Versed)
♦ Ketamine 0.1-0.5 mg/kg IV/IO
♦ Haloperidol 5 mg IM with Diphenhydramine 25 mg IM (repeat Haloperidol every 15 minutes up to a max dose of 20 mg)
♦Restraints: may use physical and/or chemical restraints on patients threaten mission safety. Use the minimum amount of restraint necessary
In extreme cases, the Rapid Sequence Intubation protocol may be utilized to ensure patient, crew, and mission safety.
DIABETIC EMERGENCIES
If BGL < 70 Adult
Dextrose 50% (D50) 25 grams IO/IV
Glucagon (GlucaGen) 1 mg IM/IN (unable to get IV)
Thiamine 100 mg IV/IM
If BGL > 250 with signs of poor perfusion and dehydration.
i. Administer Normal Saline bolus.
DYSTONIC REACTION / EXTRAPYRAMIDAL REACTION
involuntary muscle contractions of the face, chest, neck, back, and pelvis along with deviated pupils and a swollen tongue
(Zyprexa, Haldol, Thorazine, and Geodon) and antiemetics (Compazine and Phenergan).
♦ Diphenhydramine (Benadryl) 25-50 mg IM/IO/IV.
HYPERTENSIVE CRISIS
(Treatment Goal)
Goal = lower the mean arterial pressure (MAP) by 20-25% over 30-60 minutes.
Avoid sudden or precipitous changes in MAP (>25% or 50mmHg from known baseline).
Maintain MAP > 90.
The sending physician or OLMD should be consulted for blood pressure parameters in specific cases. Hypertension in suspected stroke patients should rarely be treated. OLMD should be contacted prior to treating BP in suspected stroke patients.
HYPERTENSIVE CRISIS
Interventions
♦ Cardene infusion at 5-15 mg/hr. (25-75 cc/hr) (50mg/250ml ml NS=0.2 mg/ml)
Remember, Cardene is contraindicated in patients who have aortic valve stenosis.
♦ Labetalol 20 mg IV over 2 minutes. Give additional 20-40-80 mg (in that progression) at 10 minute intervals as needed. Maximum cumulative dose of 300 mg.
♦ Hydralazine 5mg IV/IO over 2 minutes. May repeat to a max of 20mg, if necessary.
- *♦ Metoprolol** (Lopressor) 5 mg IO/IV. May be repeated 2 times while monitoring BP, HR, EKG.
- *♦ Nitroprusside** (Nipride) 0.5-10 mcg/kg/min IO/IV titrated to goal BP.
MEDICAL HYPOTENSION
Cardiogenic Shock
(Dopamine)
Rule out acute pulmonary edema (CHF).
Determine cause of hypotension
♦ Dopamine 5-20 mcg/kg/min maintain a SBP > 90
MEDICAL HYPOTENSION
Non-Cardiogenic
Normal Saline bolus IO/IV, may repeat fluid bolus if necessary.
Follow Blood Administration protocol if appropriate.
Consider push dose pressor, as bridge to long term treatments.
PUSH DOSE PRESSORS
Epinephrine
Epinephrine: is an inopressor that has Alpha 1 and 2, and Beta 1 and 2 effects. effects < 1 min duration may last 5-10 min
Take a 10ml syringe with 9ml of normal saline. Draw up 1ml (0.1mg) of 1:10,000 Epinephrine from a pre-mixed vial. The resulting concentration is 10 mcg/ml of Epinephrine (1:100,000) concentration.
Alternatively, take 1ml of 1:1,000 Epinephrine and mix into a 100ml bag of normal saline. The resulting concentration is also 10 mcg/ml of Epinephrine (1:100,000) concentration. Label the syringe as 10 mcg/ml to prevent errors.
Dose: 0.5-2ml (50-200mcg) every 2-5min, with a 5-10 min duration.
PUSH DOSE PRESSORS
Phenylephrine
Phenylephrine is a pure Alpha agent and is the preferred push dose pressor in the presence of tachycardia. The onset < 1 min effects may last 10-20 min.
Mixing: Take a 3ml syringe and draw up 1ml of Phenylephrine with a 10mg/ml concentration. Inject this into a 100ml bag of normal saline. The resulting concentration is 100 mcg/ml of Phenylephrine. Draw up into a syringe and label as 100 mcg/ml to prevent errors.
Dose: 0.5-2ml (50-200mcg) every 2-5min, with a 10-20 min duration.
NAUSEA/VOMITING
♦ Zofran (Ondansetron) 4-8 mg slow IM/IO/IV
♦ Promethazine 12.5-25 mg slow IV/IO (dilute in 50ml prior to administration)
♦ Diphenhydramine 25-50 mg IV/IO/IM
♦ Reglan (Metoclopramide) 10 mg IV/IO/IM over 2 minutes.
♦ Metoclopramide (Reglan) 5-10 mg IO/IV/IM every 6-8 hours
PAIN MANAGEMENT
Morphine
♦ Morphine 0.1 mg/kg (up to 5 mg) IM/IO/IV. May repeat dose once to a max of 10 mg.
If pain not relieved, contact OLMD for further dosing.
♦ Zofran (Ondansetron) 4 mg IM/IO/IV as needed.
POISONING/OVERDOSE
Beta Blockers
Beta Blockers: Administer Glucagon (GlucoGen) 1 mg IM/IO/IV/IN.
S/S - Hypotension/Bradycardia - Prepare for possible cardiac pacing.
MEDICAL HYPOTENSION
Cardiogenic Shock
(Norepinephrine)
♦ Norepinephrine (Levophed) at 2-20 mcg/min(Especially in suspected sepsis)
MEDICAL HYPOTENSION
Cardiogenic Shock
(Epinephrine)
♦ Epinephrine (Adrenalin) at 0.5-10 mcg/min
MEDICAL HYPOTENSION
Cardiogenic Shock
(Dobutamine)
♦ Dobutamine (Dobutrex) 2-20mcg/kg/min
MEDICAL HYPOTENSION
Cardiogenic Shock
(Phenylephrine)
♦ Phenylephrine (Neo-Synephrine) 40-180 mcg/min
PAIN MANAGEMENT
Fentanyl
♦ Fentanyl (Sublimaze) 1 mcg/kg IM/IO/IV/IN. May repeat at 1 mcg/kg. Max single dose 100mcg.
If pain not relieved, contact OLMD for further dosing.
♦ Zofran (Ondansetron) 4 mg IM/IO/IV as needed.
PAIN MANAGEMENT
Ketamine
♦ Ketamine 0.1-0.5 mg/kg IV/IO if opoids are not managing pain, may repeat every 10 minutes.
If pain not relieved, contact OLMD for further dosing.
♦ Zofran (Ondansetron) 4 mg IM/IO/IV as needed.
POISONING/OVERDOSE
Calcium Channel Blockers
♦ Calcium Gluconate (Kalcinate) 1-2 GM SLOW over 1 minute IV/IO OR
♦ Calcium Chloride 1 gram
S/S - Hypotension and Bradycardia - Prepare for possible cardiac pacing.
POISONING/OVERDOSE
Cholinesterase (Organophosphates / Wild Mushrooms)
♦ Atropine 1 -2 mg IO/IV; q 5 minutes to a max dose of 6 mg.
ADULT MEDICAL
HYPOTHERMIA
Assessment:
♦ Determine respiratory rate
♦Determine core temperature <95⁰ F
Interventions:
1. Handle gently and remove wet clothing.
2. Do not allow patient to ambulate and instruct the patient to limit movements.
3. Apply warming blankets.
4. Apply noninvasive monitoring equipment
5. Follow Airway Management Protocols. Avoid intubation if possible.
6. Obtain BGL. If appropriate, follow the Adult: Diabetic Emergencies Protocol.
7. Establish IV of NS and administer bolus – follow Circulation: Intravenous Infusion Procedure. Utilize fluid warmer for administration of ALL IV fluids.
ADULT MEDICAL
REACTIVE AIRWAY DISEASE
Interventions
♦ Combivent (DuoNeb) 3.5 mgOR
♦ Albuterol (Ventolin) 2.5 mg via nebulizer (q PRN)
♦ Consider Methylprednisolone (Solu-Medrol) 125 mg IO/IV if no fever.
♦ Consider Magnesium Sulfate 2 grams IO/IV over 20 minutes
►Magnesium Sulfate toxicity, → Calcium Gluconate (Kalcinate) 1-2 GM SLOW over 1 minute _OR_ Calcium Chloride 1 gram IV/IO.
♦Consider Epinephrine (Adrenalin) 1:1,000 0.3 mg IM.
ADULT MEDICAL
SEIZURES
Obtain BGL→ Diabetic Emergencies Protocol
♦ Lorazepam (Ativan) 1 – 2 mg IM/IN/IO/IVOR
♦ Midazolam (Versed) 2 mg IV/IO/IN
If seizure does not terminate, repeat Midazolam in 1mg increments to a max total dose of 12.5mg.
♦ Alternatively Diazepam (Valium) 5-10 mg IO/IV. q PRN.
♦ If seizure is due to eclampsia, follow Adult: Eclampsia/Preeclampsia Protocol.
ADULT MEDICAL SEPSIS (Assessment)
Temp = SBP = HR = RR = BG =
Lactic Acid = Urine Output = Leukocytes =
SIRS/SEPSIS Criteria: Known* or *suspected* infection *plus two or more of the following:
♦ Temperature > 38.8 (101.0) or < 36 (96.8) degrees
♦ SBP < 90 or > 40 point SBP from baseline
♦ Heart Rate > 90
♦ Respiratory Rate > 20 or PaCO2 < 32 mm Hg
♦ Altered Mental Status
♦ Hyperglycemia with glucose > 149 mg/dL in the absence of diabetes
♦ Lactic Acid > 1.2
♦ Urine Output < 0.5 ml/kg/hr
♦ Leukocytes > 12,000 or < 4,000 or more than 10% bands
ADULT MEDICAL
SEPSIS
Interventions
Normal Saline bolus of 30 ml/kg IO/IV
If appropriate antibiotics have not been administered and cultures have already been drawn on inter-facility transfers
a) Rocephin 1GM IV/IO for suspected pneumonia
b) Zosyn 3.375GM or 4.5GM IV/IO for *other suspected sources*
♦ Hypotension unresponsive to fluid bolus → Norepinephrine (Levophed) at 2-20 mcg/min IO/IV
Alternatively, consider Epinephrine (Adrenalin) at 0.5-10 mcg/min IO/IV
Notes:
♦If cultures have not been (or cannot be) obtained, do not administer antibiotics
♦ For inter-facility transfers, confirm that that patient has been appropriately dosed for fever control.
ADULT MEDICAL
SEPSIS
(Fluid Resuscitation End Points)
Map =
Urine Output =
CVP =
♦ MAP >65
♦Urine Output > 0.5ml/kg/hr
♦ CVP 8-10
ADULT MEDICAL
STROKE / CVA / TIA
Airway → IV → EKG → 12 lead → BG → Cincinnati Stroke Scale → if + notify receiving of Stroke Alert
♦ If symptoms began within 4.5 hours, complete Thrombolytic Check List → if time permits NIH Stroke Scale and RACE score
♦ If significant stroke is suspected and patient meets criteria → consider RSI procedure
♦ Transport supine / or head elevated < 30 degrees if unable to tolerate supine position
♦ Administer 500 mL NS bolus
ADULT MEDICAL
STROKE / CVA / TIA Inter-Facility Transfers
(known intracranial hemorrhage)
B/P goal =
MAP goal =
B/P goal: < 160 systolic
MAP goal: > 90
Individual cases should be discussed with the sending and/or receiving physician or OLMD
ADULT MEDICAL
STROKE / CVA / TIA Inter-Facility Transfers
(TPA Initiated at Sending Facility)
B/P goal:
NIH Stroke Scale performed q___mins?
Maintain B/P of < 180 systolic
♦ Complete the NIH paperwork as indicated
♦ Continue infusion on original pump until medication is complete
♦ Follow with NS to flush remaining medication from line
♦ Ensure a NIH Stroke Scale is performed and documented Q15 minutes.
ADULT MEDICAL
THORACIC AORTIC DISSECTION/AORTIC ANEURYSM
(Assessment)
General Medical Assessment per Protocol.
♦Obtain a history of the event: time of onset, location, description of the pain, any stroke symptoms, and previous aortic pathology.
♦Obtain diagnostic results from the sending facility.
♦Assess for distal pulses and obtain blood pressures from both upper extremities.
♦Assess for neurological deficits
ADULT MEDICAL
THORACIC AORTIC DISSECTION/AORTIC ANEURYSM
(Interventions / Medications)
♦ NIBP q 5 minutes or continuously if an arterial line is available.
♦ Pain Management Protocol for pain/anxiety
(Beta blockers lower blood pressure and also reduce peak left ventricular ejection rate which decreases shear stress and rate of aortic dilatation)
♦ Esmolol
♦ Labetolol
♦ Metoprolol
Notes:
♦In patients with associated MI confirmed by EKG, avoid Heparin, Aspirin, and Thrombolytics.
♦ Treatment should be driven to maintain SBP >90 or <120 (MAP 60-70) and HR 60-70 to the lowest level possible while still maintaining adequate renal, cerebral, and cardiac perfusion.
ADULT MEDICAL
THORACIC AORTIC DISSECTION/AORTIC ANEURYSM
(Esmolol)
♦ Esmolol 500 mcg/kg IV/IO over 1 min, then begin an infusion at 50 mcg/kg/min.
Consider repeating the bolus and increase the infusion by 50 mcg/kg/min increments every 5-15 min up to 300 mcg/kg/min
ADULT MEDICAL
THORACIC AORTIC DISSECTION/AORTIC ANEURYSM
(Labetolol)
♦ Labetolol 10-20mg slow IV/IO push (over 2 min)
→ Can repeat q 10 minutes with additional doses of 40 mg and then 80 mg until a SBP of 100 mmHg OR a maximum of 300 mg is administered.
ADULT MEDICAL
THORACIC AORTIC DISSECTION/AORTIC ANEURYSM
(Metoprolol)
♦ Metoprolol 5 mg IV/IO every 5 min x 3 doses
