adult protocol

Question 1

abdominal pain

Answer 1

if pain above umbilicus, 12-lead ekg. IV established. If evidence of dehydration: poor skin turgor, tachycardic, dry mucous membranes. NS bolus of 250 mL and hold at 500 mL if not hypotensive. use zofran for severe nausea and vomiting (4mg). for severe pain use pain protocol.

Question 2

Airway emergency

Answer 2

assess for respiratory distress (pulse ox 94% or less) with tachypnea, excessive muscle movement, etc.
Look for signs of respiratory failure: Hypoxia - O2 sat less than 90% with no improvement. Increasing C02 with no improvement; altered mental status; Inability to maintain airway…Begin CPAP if signs are severe.
Acute bronchospasm with Asthma or COPD: give duonebulizer with 2.5 mg albuterol and 0.5 mg atrovent (REPEAT TWICE IF NEEDED).
Solumedrol 125 mg IV push if wheezing persists after nebulizer treatment.
MagSulfate 2G in 100 ML 5% dextrose over 10-15 min DO NOT USE if hx of renal failure OR CHF suspected.
If wheezing persists use EPI 1:1000 IM 0.3 mg/mL. CAUTION if patient 55 yo or on Beta blockers (blocks effects of epinephrine) call medical control.
Refusal of transport: mild asthma, never signs of severe dyspnea, never shows hypoxia, significant improvement with single nebulizer treatment.
Acute PULMONARY EDEMA: pedal edema, hx of CHF or elevated SBpressure. Consider CPAP with significant SOB or hypoxia (ALSO CONSIDER DUONEB): administer Nitro 0.4 mg SL /5 min unless 90 SBP…except if used viagara 24 hrs; cialis 48
HYPOTENSION <90 consider noreip drip 2 - 12 mcg a minute

Question 3

Respiratory Failure

Answer 3

If trauma: C spine precautions. suction all debris from airway. supplemental O2 with BVM is sufficient if O2 sat and capnography are acceptable limits along with proper seal and good bag compliance.
Continue with advanced airway if needed:
PRIORITIZE high quality CPR! LMA acceptable
Sedative twilight drugs ETOMIDATE 0.3 MG/KG or KETAMINE 2 MG/KG. Administer paralytic after sedation if needed. SUCCINYLCHOLINE 1.5 MG/KG unless suspected crush injuries (hyperkalemia), glaucoma or penetrating eye injury, malignant hyperthermia, BURNS or PARALYSIS
ROCURONIUM 1 MG/KG
APNEIC OXYGENATION
SEDATIVE MAINTENANCE USE MIDAZOLAM 2-4 MG OR FENTANYL 100-250 MCG

Question 4

Albuterol - what you know

Answer 4

selective beta 2 bronchodilator to relax smooth muscle tissue in bronchi. Use for bronchospasm secondary to Asthma or COPD exacberation. CONTRA: HTN, tachycardia secondary to digitalis toxicity or hypersenisitve. Caution in patients with cardiovascular disease and/or CHF. (check lung sounds). SIDE EFFECTS: headache, tachycardia, possible PVC’s, palpitations. 2.5 mg in 3 mL of saline for nebulizer.

Question 5

DuoNeb

Answer 5

0.5 mg of atrovent with the 2.5 of albuterol for greater bronchoDILATION effects! use for Asthma COPD, drowning, respiratory distress. allergic reaction, toxic inhalation. SIDE effects: headache, palpitations, tachycardia.

Question 6

Epinephrine

Answer 6

vasoconstrictor and bronchodilator with increased perfusion to coronary and cerebral tissues. Increases myocardial oxygen demand. USED FOR cardiac arrest, bronchospasm due to asthma or COPD and allergic reaction. SIDE EFFECTS: head ache, palpitations, dizziness, tachycardia and N&V.

Question 7

Etomidate (Amidate)

Answer 7

Hypnotic, twilight sedative…Does not have analgesic effect or muscle relaxing properties. May cause myoclonus and is given at same time as paralytic medications. CONTRA: hypersensitivity or Pregnant mother, lactating or child under 3 months. ONSET usually within 1 minute and duration 5 minutes. Pt. fully awake in 7-14 minutes. SIDE EFFECTS: transient pain at injection site/myoclonus reactions

Question 8

Fentanyl (sublimaze)

Answer 8

Opioid analgesic. Alters response and perception to pain. May produce respiratory/CNS depression in higher doses. USE for pain control and sedation of intubated patient. CONTRA: MAO inhibitors (anti-depressant drugs), HYPOTENSION, any indication of inferior wall myocardial infarct V4R. SIDE EFFECTS: apnea, hypotension..50-100 mcg for pain control SLOW push IV or IM injection. up to 250 mcg. monitor pain scale and VS.

Question 9

Ketamine

Answer 9

analgesic and sedative, creates a dissociative state with cardiovascular and respiratory stimulation and sometimes a transient and MINIMAL respiratory depression. USED for RSI in children or adults and Agitated Delirium. Can create HTN, tachycardia, respiratory depression, N&V. CONTRA: patient with significant HTN BP 240/120…Hemorrhagic stroke or children Less than 3 months. DOSE at 2mg/kg but use caution with Agitated delirium as 30-40% will require intubation after use.

Question 10

Magnesium Sulfate

Answer 10

Depresses the CNS and myocardial nerves/tissues which will limit seizure activity, relax Broncho spasms and control dysrhythmias such as polymorphic V-tach. USE in cardiac arrest if torsades or hypomagnesemia is present. USE in Seizures due to eclampsia, and Bronchospasm secondary to COPD or Asthma asthmaticus. CONTRA: do not use with a symptomatic heart block, Caution with pt. renal impairment. CAN cause bradycardia, paralysis, widened QRS complexes, diaphoresis. INCOMPATIBLE with bicarbonates. MIX 2 grams in 100 mL bag over 10-20 minutes for Respiratory Distress and 4 grams over 15 minutes for eclampsia.

Question 11

Methylprednisolone SoluMedrol

Answer 11

Anti-inflammatory glucocorticoid. Can control severe inflammation such as anaphylaxis and severe allergic reactions as well as exacerbations of COPD and asthma. ONSET within an hour of administration and last for 12 hours. CONTRA: systemic fungal infections or hypersensitivity. Caution for patient who received steroids’ in past 12 hours. May cause Nervousness, dizziness, headache and raise glucose (hyperglycemia). 125 mg IV or IM vial for adults and 2mg/kg for children with MAX 125mg. AVOID IM for pediatrics.

Question 12

Midazolam Versed

Answer 12

Benzodiazepine for CNS depression USED for sedative for agitation, intubation maintenance or Seizure activity. CONTRA: hypersensitive, hypotensive/shock, respiratory distress…Caution with pulmonary disease, CHF, renal or liver impairment and geriatric patients. CAN CAUSE N&V, agitation, drowsiness, bronchospasm, coughing…DOSE for cardioversion or post-intubation 2-4 mg IV/IO, Agitated Delirium: 5-10mg IV/IO or 10 mg with MAD device. In patient fewer than 50 KG use 5 mg IV/IO for seizure activity otherwise 10 mg MAD.
pediatric RSI or cardioversion use 0.1 mg/kg max of 2 mg…OR for Seizure 0.2 mg/kg or max of 10mg MAD. ONEST after IV administration 1.5 to 5 minutes. MONITOR vital signs.

Question 13

Nitroglycerin

Answer 13

peripheral vasodilator to decrease preload and therefore minimize oxygen demand on heart. USE for Ischemic chest pain, HTN, Acute pulmonary edema possibly secondary to CHF. CONTRA: hypotension, Head injury or concern for intracranial hemorrhage, use of viagra or levitra within 24 to 48 hours, DO NOT use if signs of right ventricular infarction. MAY increase intraocular pressure. CAN cause headache, hypotension, diaphoresis, syncope and N&V. DOSE 0.4 mg SL/3-5 minutes up to 1.2 mg total.

Question 14

Norepinephrine

Answer 14

peripheral vasoconstrictor and coronary artery vasodilator with a rapid onset that lasts 1-2 minutes and needs to be given as a continuous infusion. USED for bradycardia with a pulse, treatment of hypotension with cardiogenic shock or any state where patient is suspected to have fluid overload (needing to maintain at least 90 systolic). Treatment of hypotension refractory to fluid challenge. CONTRA: do not use with dehydrated patients or patients in shock who would benefit more from a fluid bolus. Do not use on patient who is severely tachycardic or for bradycardia if patient is maintaining good perfusion. DO NOT administer in catheter less than 18 gauge or more distal than the AC vein (IO is acceptable). extravasation can cause devastating tissue lossSIDE EFFECTS may be HTN or tachycardia. 250 bag makes 16 mcg/mL..Recheck VS every two minutes while adjusting drip rate then every 5 minutes afterwards. Monitor for infiltration or HTN…

Question 15

Zofran (ondansetron)

Answer 15

Anti-emetic blocks serotonin effects in vagal nerve. Prevents and treats N&V. CONTRA: hypersensitive. Children less than 3 years old should not receive. Caution with pregnant or lactating females. Liver impairment DO NOT exceed 8 mg. MAY cause headache, dizziness, dry mouth, fatigue, constipation…DOSE 4mg IV/IM given over 30 seconds slow push preferably 2-5 minutes. Pediatric give 0.1mg/kg if under 40KG

Question 16

Rocuronium (Zemuron)

Answer 16

Non-depolarizing neuromuscular blocking agent causes skeletal muscle paralysis. May also facilitate chest wall compliance for mechanical ventilation. Causes transient HTN. CONTRA: known hypersensitivity to bromides. Patients with liver disease will have 1.5 times longer effect than usual. DOSE: 1mg/kg IV. Rocuronium is a LONG acting paralytic and requires post-induction sedation with versed and/or fentanyl. ONSET is about 45-60 seconds and duration is from 25-70 minutes.

Question 17

Succinylcholine (Anectine)

Answer 17

motor nerve depolarizer, skeletal muscle relaxant. Will cause fasciculations (spontaneous muscle contraction) followed by paralysis. USE after induction of anesthesia for skeletal muscle paralysis. For intubation if seizure activity or muscle tone prevents it. For any patient that exhibits high airway compromise during transport. CONTRA: known hypersensitivity, crush injuries, burns, penetrating eye injuries, hx of glaucoma or malignant hyperthermia. SIDE EFFECTS: hypotension, hypertension, Cardiac arrest, ventricular dysrhythmias. In children under 5 increased chance of intracranial pressure. DOSE: 1.5 mg/kg IV/IO or in extreme circumstances deep IM max of 150 mg (3-4 mg/kg). **Complete paralysis with IV injection is obtained within 1 minute and persists for approximately 2 to 4 minutes. The effects will fade within 4 to 10 minutes. IM injection starts in 3 minutes and can last up to 30 minutes.

Question 18

Allergic Reaction

Answer 18

If patient has auto-injector assist them with it - self administration. For a mild allergic reaction Diphenhydramine 1mg/kg max 50 mg. (itching or hives). Benadryl may be administered IM if no IV access. For a moderate allergic reaction with wheezes, chest tightness or dyspnea use Albuterol/ipratropium…repeat 2x if wheezing persists. SoluMedrol 125 mg. For a severe allergic reaction with BP less than 90 Epinephrine 1:1000 IM 0.3 mg. REPEAT epi if signs of severe allergic reaction continue. Then give duoneb treatment, then diphenhydramine then solumedrol. If cardiac arrest from allergic reaction do all steps above except with 1:10000 epi as in a code scenario.

Question 19

Altered Mental Status

Answer 19

Glucose less than 60, If patient can self administer glucose gel or orange juice without choking..otherwise 25 grams 10% IV. Recheck with different glucometer if necessary after 10 minutes of administration. If no IV access administer glucagon 1 mg IM deltoid. If glucose elevated above 200 with signs of hyperglycemia then give 500 mL bolus. If opioid OD suspected give 0.5 mg of naloxone; repeat every 3 minutes with a maximum of 8 mg. If stroke suspected:protocol.

Question 20

Behavioral/Agitated delirium

Answer 20

Remove patient from stressful environment if possible. Calm and reassure patient if able. If refuses care, determine patient mental acuity (sharpness, able to think responsibly) Utilize TPD and restraints if needed whether medical or mechanical. Detail rationale in report for restraints and check PMS in limbs after securing straps. Evaluate BlGl if less than 70 give D10. Obtain 12 lead. Midazolam 5-10mg IV is Preferred for patient who is suspected of recent drug abuse. Can do 10 mg MAD 5mg ea. nostril for more RAPID effect.
Haldol 5 mg IV/IM may repeat once in 10 minutes if needed. May be better for patients with hx. of psychosis. use with caution in pt. older than 50 and do NOT use in patient with wide Q-T interval.
Ketamine 2 mg/kg IM/IV Utilize in EXTREME cases of excited delirium and if respiratory depression occurs treat accordingly.
For a dystonic reaction give Benadryl/diphenhydramine at 50mg IV/IM slow. May repeat once in 10 minutes if needed.

Question 21

Bradycardia with a pulse

Answer 21

Check patient condition and general appearance as some may normally have a resting HR below 50 BPM. It may or may not be acute symptomatic bradycardia. Identify and treat the underlying cause. Bradycardia can be from medications, heart blocks, toxins, respiratory disorders, head injuries/trauma, etc. Provide O2 if indicated and ensure patent airway. Apply cardiac monitor and identify 4 lead rhythm, BP and Pulse Oximetry. Obtain IV access at least 18 gauge AC or higher and perform 12 lead. Examine for signs of hypoperfusion namely altered mental status, chest pain, symptoms of heart failure - cardiogenic shock.
Give Atropine if not ventricular wide QRS rhythm 0.5 mg/3-5 minutes up to 3 mg max. Otherwise, PACE or Norepinephrine drip 2-12 mcg/min. CONSIDER online Medical Control.

Question 22

H’s and T’s

Answer 22

Hypovolemia, hypoxia, hydrogen ion acidosis, hyperkalemia, hypokalemia, Hypothermia…cardiac tamponade, tension pneumothorax, toxicity OD, thrombosis cardiac or thrombosis pulmonary.

Question 23

Chest Pain

Answer 23

Perform 12 lead: If If ST elevation greater than 1 mm (one small box in height) in II, III, aVF then obtain a V4R and assess for symptoms of RV infarct, including hypotension, JVD and dry lung sounds. STEMI alert for patients with 1 mm or greater elevation in 2 or more contiguous leads. New LBBB with signs of MI qualifies as a STEMI alert. If STEMI present transmit EKG to receiving facility. Get serial EKG’s and print for physician at facility. Give Aspirin 324 mg PO, Nitroglycerine 0.4 mg/5 minutes up to 1.2 mg if BP is 100 systolic or greater, they DO NOT have RV4 infarct and have not taken Levitra/viagra in last 24-48 hours. Consider fentanyl for pain 50 mcg every 5 minutes up to 150 mcg if no signs of RV4 infarct and BP at least 100 if pain continues despite nitro. Treat hypotension with 500 mL NS bolus. Can treat tachycardia with 5 mg labetalol up to 20 mg if BP is 100 or above and no signs of hypoperfusion.

Question 24

Cerebral Vascular Accident

Answer 24

Check BlGl if less than 60 give 25 grams D10% IV if no access Glucagon 1 mg IM. Establish when first signs occurred up to 24 hours is allowed to call a stroke alert. Use family or bystanders to know when last seen normal and record on stroke Checklist. Do not delay transport and access two 18G AC IV lines in route. Perform FAST-ED protocol and document. Keep stretcher head at 30 to 45 degree elevation. Do not treat HTN in case of stroke unless above 220 systolic then contact medical control. If seizure activity is present then use seizure protocol.

Question 25

Obstetric Emergencies

Answer 25

Suspect preeclampsia if Gestational age is less than 20 weeks, BP above 160/110, edema is present or epigastric pain, headache. Severe preeclampsia can present with AMS, pulmonary edema, and/or cyanosis. Actual Eclampsia is all signs above plus seizure activity. IF ONLY PREECLAMPSIA treat with Labetalol 10 mg every 10 minutes up to 20 mg until BP is 130/100 or less. DO NOT use Labetalol is HR is below 60 bpm. If seizure activity is present us Magnesium Sulfate 4 grams over 15 minutes IV. MONITOR for signs of Magnesium toxicity such as respiratory depression or hypotension. If Seizure activity is still present then administer Benzodiazepine per TFR protocol. CONSIDER other underlying causes of seizure such as hypoglycemia, head injury, drug OD or fever/infection. If patient is less than 20 weeks gestation and Magnesium is being considered CONSULT medical control. IF Vaginal bleeding and patient is greater than 20 weeks gestational bring to closest OB receiving facility. If less than 20 weeks than put in position of comfort of left lateral recumbent position. Transport any bodily pieces such as placenta with you to facility.

Question 26

Seizure Protocol

Answer 26

If any possibility of trauma consider C-spine. Check Glucose level early and treat less than 60 accordingly. If patient is actively seizing with airway compromise apply airway procedures. DO NOT use invasive (advanced) airway procedure UNLESS status epilepticus 5 min or greater seizure or multiple seizures in a 5 minute period. Put patient in “lateral decubitus” position and ensure tongue is not blocking airway. If O2 sats are 90% or less use supplemental O2. NPA may be preferred to avoid placing fingers in mouth of patient. Treat activity of seizure with benzodiazepine. If IV access not obtained USE Midazolam 10 mg MAD. IV placement then use Lorazepam 2 to 4 mg IV/IO SLOW PUSH. If the patient is UNDER 50 kg (100 pounds) then use only 5 mg of Versed total. OR use Valium, Diazepam 5 mg IV slow push or MAD. Use benzo every 5 minutes until 8 mg Lorazepam and 10 mg diazepam. DO NOT REPEAT MAD for Versed (only once).

Question 27

SEPSIS

Answer 27

Must be identified early: Temperature over 38 degrees Celsius or or 100.4, Respiratory rate greater than 20 breaths/min, or CO2 less than 32 (respiratory alkalosis due to metabolic acidosis), HR greater than 90 bpm. Call Sepsis Alert to notify ER for rapid assessment and treatment of patient when two or more of the following apply:

1) Temp greater than 100.4 or less than 96.8
2) Respiratory rate greater than 20
3) HR greater than 90 bpm
4) ETCO2 equal to or less than 25

Administer NS bolus 250 mL until BP over 90 syst.
DO NOT exceed 2000 mL of fluid
Boluses MAY be given in rapid succession if BP remains less than 90.
IF after 1000 mL of fluids the BP is still less than 90 run a NorEpi drip to maintain a 90 or greater systolic.
Report fluid amount given to hospital.

Question 28

Syncope

Answer 28

Consider C-spine. Check blood glucose. Place patient on cardiac monitor 12-lead EKG. Consider potential causes such as Bradycardia, tachycardia, hypotension, hypoperfusion, stroke, pregnancy, seizure, AMS. REMEMBER 25% of geriatric syncope is cardiac based. APPROXIMATELY 15% of syncope is caused by brain bleed, ectopic pregnancy, aortic dissection, leaking aortic aneurysm.

Question 29

Tachycardia with a pulse

Answer 29

May in fact be atrial fibrillation, supraventricular tachycardia, or ventricular tachycardia with a pulse. Tachycardic rhythms may result from dehydration, hemorrhage, medication use, drugs or withdrawal, anxiety or even pain. MUST IDENTIFY whether patient is STABLE or UNSTABLE to treat appropriately.
Pay special attention to BP and PulseOx.
Identify rhythm and treat patient if necessary. If possible obtain a 12 lead EKG.
If patient is showing signs of AMS, ischemic chest pain, /acute heart failure or just plain looks like SHIT, then cardioversion is your game!
Initial dose depends on rhythm present.
Narrow, regular (flutter) 50-100 jewels
Narrow, irregular (fib) 120-200 jewels
Wide, regular ventricular with a pulse (100J)
Wide, irregular Defibrillate without synchronization (200J)
May administer midazolam pre cardioversion if time permits at 1-2 mg IV/IN
Cardizem/Diltiazem SLOW PUSH @ 0.25mg/kg for irregular tachydysrhythmias such as Atrial fibrillation
DO NOT administer Cardizem if pt. has hx of WPW syndrome
For regular, narrow complex tachycardia (SVT)(>160 bpm) consider vagal maneuvers and Adenosine 6 mg then 12 mg rapid push with rapid flush 20 mL.
Cardizem may be used (max of 20 mg) if adenosine fails.
Wide complex tachycardias such as V-tach with a pulse use Amiodarone 150 mg in a 100 mL bag over 10 minutes.
Torsades with Mag at 2 grams for slow infusion 15 minutes
If hyperkalemia suspected use Calcium chloride 1 G IV/IO for renal insufficiency patients

Question 30

Headaches caused by

Answer 30

Dilated blood vessels in head

Question 31

Mean Arterial Pressure (MAP)

Answer 31

SBP + 2 (DBP) then divide by 3

if SBP 220 and DBP 120 you multiply 120 x 2= 240 + 220 = 460 then divide by 3 = 153

• *Important with Sepsis, head injury or stroke patients.
• **Should be maintained at 65mmHg or greater

Question 32

Cushing’s Triad

Answer 32

Cushing’s triad of signs includes hypertension, bradycardia and apnea. As intracranial pressure continues to increase, the patient’s heart rate will increase, breathing will became shallow, periods of apnea will occur, and blood pressure will begin to fall. Eventually an agonal rhythm will develop as herniation begins, followed soon by cessation of brain stem activity, respiratory arrest and cardiac arrest.

Question 33

Dextrose

Answer 33

carbohydrate in a hypertonic solution to increase blood glucose levels. Used for hypoglycemia, altered level of consciousness and coma or seizure of unknown etiology. NO CONTRA. Use caution with CVA or possible cerebral hemorrhage. Thrombophlebitis or sclerosis at vein site may occur. 25 grams 250 mL solution D10%. May discontinue if patient becomes alert before full administration and can take PO foods. May REPEAT dose in 10 minutes if glucose still not above 60. FOR PEDIATRIC 5mL/kg max of 10 Grams.

Question 34

Toxins/Overdose

Answer 34

Contact poison control center for any possible toxic ingestion. Determine agent involved, when it was ingested and how much approximately. Bring any container or pill bottle to ED. If respiratory depression present with suspected OD use Naloxone 0.5 mg increments every 5 minutes or 4 mg IN MAD device. Repeat as needed until symptoms subside up to 8 mg. If there are no SIGNIFICANT SYMPTOMS monitor closely and transport.
Organophosphate poisoning: Dyspnea, bronchorrhea (watery mucous 100 mL or more), lacrimation, vomiting and diarrhea, paralysis, seizures. Use Atropine 2 mg every 5 minutes until respiratory secretions subside.
Trycyclic Antidepressant OD: Hypotension, arrythmias, wide QRS complexes (> 0.09 sec.). USE sodium bicarb IV and DO NOT MIX with Calcium Chloride. 50 mEq IV. May repeat in 10 minutes.
Calcium channel blocker or beta blocker OD: symptoms and signs of bradycardia, hypotension, heart blocks, hypoglycemia, AMS.
If poisoning due to Calcium channel blocker use Calcium chloride 1G slow push IV.
Uncontrollable muscle contractions: Diphenhydramine 25 - 50mg.
Insulin Overdose: Use hypoglycemia protocol

Question 35

Vomiting and Diarrhea

Answer 35

Obtain IV access, check for signs of dehydration/hypovolemia. Give a 500mL bolus of NS. Check blood glucose level according to protocol. Symptomatic N&V give zofran 4 mg but not to pregnant or lactating females. give SLOW PUSH OVER 2-5 MINUTES.

Question 36

Becks Triad - Cardiac tamponade (pericardium)

Answer 36

Distended jugular/neck veins, Muffled Heart sounds, Hypotension. An accumulation of fluid in the pericardial sac impairs diastolic filling and REDUCES cardiac output.

Question 37

Pain control

Answer 37

Patient pain severity is a 6 or greater out of 10 AND patient condition warrants an IV (ALS). Fentanyl 50-100 mcg IV SLOW PUSH. May repeat every FIVE minutes up to 250 mcg MAX. If more is needed contact MEDICAL control. DO NOT give is BP <100. Use caution in patient with head injury, respiratory distress/COPD. DOCUMENT patient PAIN score pre and post medication administration. Recheck and document vitals after administration.

Question 38

Palliative Care

Answer 38

IMPORTANT to obtain original DNR or HIGH quality photo copy SIGNED by the patient AND physician. DNR form original and/or copy MUST be on Yellow paper to be valid. If any doubt exists contact MEDICAL CONTROL. In cardiac arrest: do not perform any life saving measures. In Respiratory Distress: support Airway but DO NOT intubate or use any advanced airway. Any manageable condition such as hypovolemia or pain control may be treated. A living will will be of assistance in guiding treatment. CONTACT medical control and communicate with family and patient.

Question 39

Seizure Protocol

Answer 39

Spinal precautions, Check blood glucose early. <60 dextrose 25 grams 10% (250mL) IV SLOW. IF patient actively seizing with airway compromise USE airway protocol. Consider Apneic NC with EtCO2 15 LPM. If patient is in a continuous state of seizing without a return to baseline or post-dictal state, then use Advanced measures to protect airway. Keep Oxygen levels above 90% to avoid hypoxia. LAY patient in lateral recovery position, suction and place OPA or NPA if necessary to prevent airway obstruction. Try to avoid RSI as the medications will prevent ability to monitor seizure activity. Treat seizure ACTIVITY with Benzo IF no IV access use MAD device Midazolam. IF IV already established preferred method is Lorazepam 2-4 mg IV/IO SLOW PUSH. Midazolam 5 mg MAD <50kg OR 10 mg MAD >50kg IN. If not available USE Diazepam 5 mg IV/IO SLOW PUSH or 5mg MAD IN. Benzo may be repeated every 5 minutes but DO NOT repeat MAD dosing. Max 8 mg Lorazepam and 10 mg Midazolam. One dose of Diazepam 5 mg IV/IO or 5 mg MAD IN. Contact Medical control for further advice. IF patient NO LONGER seizing obtain medical hx and focused exam. FOR pregnant female in 3rd trimester or <4 weeks postpartum with active seizing USE Magnesium sulfate 4 Grams over 15 minutes for eclampsia. HTN may be 160/110 or greater. Use labetalol 10 mg/10 min slow IV. MONITOR for Respiratory Depression when administering magnesium.

Question 40

Sepsis

Answer 40

Systemic Inflammatory Response Syndrome S&S will indicate Sepsis is present: 1. Temperature >100.4 (38 C) or <96.8 (36 C). 2. Respiratory rate >20 breaths or EtCO2 <32 3. Heart Rate >90 beats.

SEVERE SEPSIS requires a SEPSIS ALERT: If two or more of the following apply:

• Temp less than 96.8 or > 100.4
• EtCO2 equal to or <25
• RR >20
• HR >90

Notify ED prior to arrival.
IV with 250 mL bolus until BP >90 mmHg syst.
Total amount of fluids should not exceed 2 L
Boluses may be given RAPIDLY in succession if <90 sys
If AFTER 1L of fluid BP is still <90 administer NorEpi 4mg/4mL. 16 mcg/min from 2-12 mcg/min range.
Report amount of total fluids given.

Question 41

signs of respiratory failure:

Answer 41

Hypoxia - O2 sat less than 90% with no improvement. Increasing C02 with no improvement; altered mental status; Inability to maintain airway