Adult Protocols Flashcards
Adult Pit Crew CPR Positions
- Patient’s right hand side - check pulses. Initiate first 2 minutes of CPR. When not performing compressions, assist position #3 with BVM.
- Patient’s left hand side - Attache AED and follow prompts. Alternate compressions with positions #1 on 2 minute intervals. When not performing compressions, assist position #3 with BVM.
- Patient’s head - Initiate airway management as per protocol. Alternate with positions #1/#2 for compressions.
- First arrive EMT-P after positions 1-3 are filled. Obtain IV/IO access and administer ACLS medications. Temporarily slide to position #3 if advanced airway is required. Directs ACLS interventions based on rhythm, EtCO2, pulse
- Quality assurance – Utilized check list. Records rhythms and pulse checks ever 2 minutes. Records times of ACLS administration of drugs.
- Liaison with family.
Adult VFib/VTach Arrest
CPR w/ compression at rate of 100-120/minute
For witnessed arrest apply pads and defibrillate at manufacturer recommended setting (150 J for our monitors). Immediately resume CPR for 2 minutes. Place OP or NP airway and provide O2 via 100% NRB. Establish IV/IO. [For arrests suspected to be of respiratory cause, initiate BVM ventilations.]
Administer 1 mg epi 1:10,000 IVP/IOP every 3-5 minutes.
Check for organized rhythm at 2 minute intervals; shock when indicated.
If still in VF/VT after 3rd cycle of CPR and shock, consider advanced airway techniques or BVM at rate of 8-10/min.
Administer 300 mg amiodarone IV/IO. Can repeat with half in 3-5 minutes.
If no response to amiodarone, consider 2g magnesium sulfate IV/IO. May repeat one time in 3-5 minutes.
If after 3 defibrillations VF/VT has not resolved, consider double sequential.
Adult Resolved VFib/VTach
Administer amiodarone (150 mg over 10 minute drip) if the 300 mg bolus had not been administered during the arrest.
If magnesium was administered during the arrest, begin a magnesium IV infusion at 33 mg/min (2g/hour). Infuse at 50 gtt/min using microdrip.
Double Sequential Defibrillation Requirements
Refractory to 3 or more standard shocks AND has received 300 mg Amiodarone AND VFib/VTach never converted.
Adult PEA Cardiac Arrest Protocol
CPR 100-120 per minute
BVM Ventilations with 15LPM O2
- If rhythm is unclear and possibly VFib, defibrillate as for VF.
- Immediately resume CPR for 2 minutes. Apply 100% NRB with NP or OP if no gag reflex. Establish IV/IO.
- ASAP Administration 1 mg epinephrine 1:10,000 IVP or IOP every 3-5 minutes.
- Check for an organized rhythm at 2-minute intervals. Shock if indicated. Immediately resume CPR.
Indications for Chemical Restraint
Chemical restraint is reserved for patients who cannot otherwise be restrained or restrained only at the risk of significant harm to the patient, law enforcement, or ems providers or if provider has concern for excited delirium.
Indications for chemical restraint include:
- Evidence of excited delirium such as drug usage, severe agitation, violent behavior, aggressiveness, hyperthermia, surprising physical strength, lack of response to pain such as Tasers.
- Violent, agitated patients who cannot be otherwise restrained or restrained only at the risk of significant harm to the patient, law enforcement, or EMS provider.
Chemical Restraint Drugs
Midazolam IV, IM, or IN –> 5 mg (if over 50 kg); 2.5 mg (if under 50 kg)
Ketamine IM for patients 12 years of age or older. Ketamine is the preferred drug for patients with suspected excited delirium. 300 mg IM if > 50 kg; 150 mg if <50 kg
**if adequate sedation is not achieved with one of the above options, contact medical control for requests for additional medication or other orders.
Ketamine Restraint Special Consideration
Use Ketamine with caution in patients with history of coronary artery disease. If there is concern for an acute ischemic event such as a stroke or MI, do NOT administer ketamine.
Ketamine Adverse Effect
Laryngospasm is a rare, but serious adverse effect of ketamine administration. Management of laryngospasm:
- Apply airway maneuvers, such as a jaw thrust or chin lift. Consider OPA/NPA.
- Assist with BVM at 100% O2 to apply positive pressure.
- If these methods prove to be inadequate and patient is not being ventilated, follow advanced airway protocols with the modification that only a single attempt attempt to visualize the vocal cords should be made with direct laryngoscopty. Do NOT attempt to pass anything through vocal cords if they are closed/spasming and proceed to cric.
- Do not administer any more ketamine.
What must all sedated patients be placed on?
Capnography.
All patients that receive midazolam or ketamine are required to be placed on nasal waveform capnography. Monitor for signs of hypoventilation such as decreased respiratory rate or increase in EtCO2.
Excited Delirium Cardiac Arrest
If patient subsequently has a cardiac arrest, follow ALS protocol for cardiac arrest, but consider early administration of sodium bicarbonate 100 mEq IVP if patient initially presented with severe agitation or concerns for excited delirium.
Dialysis Considerations
If the patient on the hemodialysis machine, have the dialysis technician disconnect the patient from the machine. If the technician is not present, turn off the machine, clamp off the access device and disconnect the patient from the machine OR remove the needles, apply pressure as the needle is removed so as to avoid cutting the access device.
Do not place a tourniquet device on a limb with dialysis access.
ALS:
- Initiate an IV in an extremity containing a shunt or fistula ONLY if an immediate life-threatening situation exists and there is NO other IV site. DO NOT START AN IV IN A SHUNT OR FISTULA.
If you have a dialysis patient that you suspect to have a venous or arterial air embolus, what do you do?
Immediately place the patient in Trendelenburg position on the Left side.
Hyperkalemic/Dialysis Protocol
For patients who may be hyperkalemic (with or without missed dialysis) that exhibit a wide QRS (>0.12 sec) and hypotension or refractory VFIB, give the following medications in this order:
- Calcium chloride 1 g SLOW IVP
- Albuterol 5 mg nebs back-to-back/continuously for the spontaneously breathing patient.
- If no change in patient condition, consider Sodium Bicarbonate, 100 mEq IVP
Injected Poisons
Bites, stings, or open wounds caused by an object contaminated with a poisonous substance.
Apply a venous constricting band above the site of injection on an extremity.
Immobilize the extremity.
Keep it below the level of the heart.
For stings, scrape the stinger away (do not squeeze it)
