ALS Flashcards
When are you able to call for a medical TOR? When is it contraindicated?
- you can call when they are 18 years or older, when the arrest was not witnessed by EMS (or fire), and NO shocks given
- you can not call when death thought to be of non-cardiac origin
In terms of shocks during CPR, what is the dosing/interval?
If a person is 8 or older, they get 120, 150, 200, 200
- 4 times max, 2 minutes apart
If a person is under 8 years old, they get 2J/kg for the first shock, than after that can be given 3 more shocks at 4J/kg
In what cases is epi used in CPR?
Only when anaphylaxis is suspected cause of arrest
- 1 dose (0.01mg/kg up to a max of 0.5mg)
What situations would a “one and go” in terms of cardiac arrest be appropriate?
- pregnancy over 20 weeks
- hypothermia
- airway obstruction
- PE
- toxicology/overdose
- trauma
When must you patch to base hospital in a medical cardiac arrest?
- after 3rd analysis (for TOR or for transport)
What are the most amount of shocks you can give a patient and how does that occur?
6
- FBAO gets relieved after 1 shock, if still pulseless - 4 shocks for medical directive, if pt ROSCs and re-arrests - 1 more shock
What are the conditions for manual defibrillation?
Age: >=30 days
LOA: altered
Other: VF or pulseless VT
What should be considered for tx in the medical cardiac arrest directive?
- CPR
- Supraglottic airway = where more than an OPA/NPA and BVM are required without interrupting CPR
- Manual Defib
- Epi = if anaphylaxis is suspected as causative event of cardiac arrest
When can you call for a trauma TOR? When can you not?
- you can when they are 16 or older, NO shocks given, in asystole or if in PEA and closest hospital is 30 minutes or greater away
What are the steps for neonatal resuscitation?
Under 30 days of age
1. Term gestation AND good muscle tone AND breathing or crying (YES OR NO)
- if no provide warmth, position/clear airway and dry/stimulate for 30 seconds
- if yes provide warmth and clear airway as necessary (and then begin supportive care)
2. If you said NO to Step 1 - evaluate respirations and heart rate
3. Breathing and HR>=100?
- if yes provide supportive care
- if no continue neonatal resuscitation - for 30 seconds provide positive pressure ventilation (BVM) using room air
4. Reassess - is patients HR >= 60bpm
- if no begin CPR 3:1 ration making sure to plug oxygen to BVM
- continue CPR until HR above 60
- if HR is above 60 but less than 100 (or not breathing) then continue ventilations on room air until you reach 100 and can start supportive care
What 2 things should be placed on a neonate during resuscitation?
- pulse oximetry
- cardiac monitor
Normal SPO2 for neonate?
after 1 minute normal = 60-65%
by 5 minutes normal is 80-85%
by 10 minutes normal is 85-95%
What to do upon a ROSC?
- get base vitals - restart primary
- If >= 2 years, Hypotensive, and Chest auscultation is clear then provide fluid at a rate of 10ml/kg up to 1L. Reassessing every 100ml for someone someone less than 12, and every 250ml for someone >= 12
What is ROSC oxygen standard?
- SpO2 = 94-98%
- ETCO2 = 30-40mmHg
What are the conditions for insertion of a supraglottic airway?
Other: patient must be in cardiac arrest
What are the contraindications for insertion of a supraglottic airway?
- active vomiting
- inability to clear airway
- airway edema
- stridor
- caustic ingestion
What are the indications for insertions of a supraglottic airway?
Need for ventilatory assistance/airway control
AND
other airway management is ineffective
ASA conditions:
Age: >=18 years
LOA: unaltered
Other: able to chew and swallow
ASA Contraindications:
- allergy or sensitivity
- CVA or TBI in the previous 24 hours
- active bleed
- asthmatic with no use of ASA before
ASA dosage/route:
160-162mg by mouth (1 dose)
- can give even if they have already taken
Nitro conditions (cardiac ischemia)
Age: >= 18 years
SBP: normotensive
HR: 60-159bpm
Other: need hx of nitro use or IV obtained
Nitro Contraindications (cardiac ischemia)
- allergy or sensitivity
- phosphodiesterase use within 48 hours
- SBP drops by 1/3 or more from its initial value after nitro is administered
- 12 lead compatible with RVI
What is the dosage for nitro in cardiac ischemia with NO STEMI?
SL
Dose: 0.3 or 0.4mg
Dosing interval: 5 mins
Max # of doses: 6
What is the dosage for nitro in cardiac ischemia with STEMI?
SL
Dose: 0.3 or 0.4mg
Dosing interval: 5 mins
Max # of doses: 3
What is the treatment for a patient with pulmonary edema
- Nitro
- CPAP
What are the indications for acute cardiogenic pulmonary edema?
- moderate to severe respiratory distress
AND - suspected acute cardiogenic pulmonary edema
Nitro Conditions (ACPE):
Age: >=18 years
HR: 60-159bpm
SBP: normotension
Nitro Contraindications (ACPE):
- allergy or sensitivity to nitrates
- phosphodiesterase use within previous 48 hours
- SBP drops by 1/3 or more of its initial value after nitro is administered
What is the dosage for nitro in ACPE when SBP is >=100 and <140 with IV or a history of nitro use?
SL
Dose: 0.3 or 0.4mg
Dosing interval: 5 mins
Max # of doses: 6
What is the dosage for nitro in ACPE when SBP is >=140 with IV or hx of nitro use?
SL
Dose: 0.6 or 0.8mg
Interval: 5 mins
Max # of doses: 6
What is the dosage for nitro in ACPE when SBP is >=140 with no IV or no hx of nitro use?
SL
Dose: 0.3 or 0.4mg
Interval: 5mins
Max # of doses: 6
Dextrose conditions/contraindications:
Conditions - hypoglycemic, >=2 years, altered
Contraindications - allergy
Dextrose dosing/route:
IV - 2 doses, 10 minutes apart
If D10 - 0.2g/kg (2ml/kg) up to a max of 10g (100ml)
If D50 - 0.5g/kg (1ml/kg) up to a max of 25g (50ml)
Glucagon conditions:
LOA: altered
Other: hypoglycemic
Glucagon Contraindications:
- allergy or sensitivity
- pheochromocytoma
What are the indications for hypoglycemia?
- agitation
- altered LOA
- seizure
- symptoms of stroke
what is the treatment for hypoglycemia with glucagon when a pt is <25kg?
IM
Dose: 0.5mg
Interval: 20 mins
Max # of doses: 2
What is the treatment for hypoglycemia with glucagon when a pt is >=25kg?
IM
Dose: 1mg
Interval: 20 mins
Max # of doses: 2
What are the indications for Bronchoconstriction Directive?
- respiratory distress
AND - suspected bronchoconstriction
What conditions need to be met in order to give Salbutamol in bronchoconstriction?
NONE
What conditions need to be met in order to give Epinephrine in bronchoconstriction?
RR: BVM ventilations required
Other: hx of asthma
What are the contraindications of Salbutamol?
- allergy or sensitivity to salbutamol
What are the contraindications of Epi for bronchoconstriction?
- allergy or sensitivity to epi
What is the dosage of Salbutamol for a pt <25kg?
MDI:
- rate - 1 puff every 4 breaths
- dose - 600mcg (6 puffs)
- interval - 5 mins
- max # of doses - 3
NEB:
- dose - 2.5mg
- interval - 5 mins
- max # of doses - 3
What is the dosage of Salbutamol for a pt >=25kg?
MDI:
- rate - 1 puff every 4 breaths
- dose - 800mcg (8 puffs)
- interval - 5 mins
- max # of doses - 3
NEB:
- dose - 5mg
- interval - 5 mins
- max # of doses - 3
What is the proper dosage equation of Epinephrine?
IM
Concentration: 1mg/ml (1:1000)
Dose: 0.01mg/kg (rounded to nearest 0.05mg, to a max of 0.5mg)
Max # of doses: 1 for bronchoconstriction, 2 for anaphylaxis
What is a contraindication for the nebulizer?
- fever
- declared febrile respiratory illness outbreak
What are the conditions that need to be met in order to give Epi in moderate to severe allergic reactions?
Other: for anaphylaxis only (2 body systems)
What are the indications for moderate to severe allergic reactions?
- exposure to a probable allergen
AND - s&s of a moderate to severe allergic reaction
What conditions need to be met in order to give Diphenhydramine (Benadryl) in moderate to severe allergic reactions?
Weight: >=25kg
What are the contraindications for Diphenhydramine (Benadryl)?
- allergy or sensitivity to diphenhydramine
What is the dosage of Diphenhydramine (Benadryl) for a pt >=25kg and <50kg?
IV&IM
Dose - 25mg
Max # of doses - 1
What is the dosage of Diphenhydramine (Benadryl) for a patient >=50kg
IV & IM
Dose - 50mg
Max # of doses - 1
Epi Dosage in Anaphylaxis:
0.01mg/kg up to 0.5 (rounded to the nearest 0.05) x2 doses - at least 5 minutes apart
What are the indications for Croup?
severe respiratory distress
AND
stridor at rest
AND
current hx of URTI
AND
barking cough or recent hx of barking cough
What are the conditions for Epinephrine in Croup?
Age: >= 8 years
HR: <200bpm
What are the contraindications for Epinephrine in Croup?
allergy or sensitivity
What is the treatment for a patient with croup who is <1 year and <5kg via NEB?
Dose: 0.5mg
Max # of doses: 1
- add 2ml of saline (minimum NEB volume must be 2.5ml)
What is the treatment for a patient with croup who is <1 year and >=5kg via NEB?
Dose:2.5mg
Max # of doses: 1
What is the treatment for a patient with croup who is >=1 year and <8 years old via NEB?
Dose:5mg
Max # of doses: 1
What are the indications for Acetaminophen and Ibuprofen/Ketorolac?
Pain
What are the conditions for Acetaminophen?
Age: >=12 years
LOA: unaltered
What are the contraindications for acetaminophen?
- use within the previous 4 hours
- allergy or sensitivity
- hx of liver disease
- active vomiting
- unable to tolerate oral meds
- suspected ischemic chest pain
What is the treatment for pain with acetaminophen for a pt >=12 years and <18 years?
PO
Dose: 500-600mg
Max # of doses: 1
What is the treatment for pain with acetaminophen for a pt >=18 years?
PO
Dose: 960-1000mg
Max # of doses: 1
What are the conditions for Ibuprofen?
Age: >=12 years
LOA: unaltered
What are the contraindications for Ibuprofen?
- NSAID use within the previous 6 hours
- allergy or sensitivity to NSAIDs
- pt on anticoagulation therapy
- current active bleed
- hx of peptic ulcer disease or GI bleed
- Pregnant
- if asthmatic, no prior use of ASA or NSAIDs
- CVA or TBI in the previous 24 hours
- known renal impairment
- active vomiting
- unable to tolerate oral meds
- suspected ischemic chest pain
What is the treatment for pain with Ibuprofen for a pt >=12 years?
PO
Dose: 400mg
Max # of doses: 1
What are the conditions for Ketorolac?
Age: >=12 years
LOA: unaltered
SBP: normotension
What are the contraindications for Ketorolac?
- NSAID use within previous 6 hours
- allergy or sensitivity to NSAIDs
- pt on anticoagulation therapy
- current active bleed
- hx of peptic ulcer disease or GI bleed
- pregnant
- if asthmatic, no prior use of ASA or NSAIDs
- CVA or TBI in the previous 24 hours
- known renal impairment
- suspected ischemic chest pain
What is the treatment for pain with Ketorolac?
IM/IV
Dose: 10-15mg
Max # of doses: 1
What is the preferred method of pain control?
Co-administration of Tylenol/Ibuprofen if possible
- in cases of renal colic, Ketorolac is preferred
What are the indications for Opioid Toxicity Medical Directive?
altered LOA
AND
respiratory depression
AND
inability to adequately ventilate
AND
suspected opioid overdose
What are the conditions for Naloxone for opioid toxicity?
Age: >=24 hours
LOA: altered
RR: <10 breaths/min
What are the contraindications for naloxone?
allergy or sensitivity to naloxone
What is the treatment for Naloxone in opioid toxicity?
IV
Dose: up to 0.4mg (titrate)
Interval: 5 min
Max # of doses: 3
IM
Dose: 0.4mg
Interval: 5 min
Max # of doses: 3
IN
Dose: 2-4mg
Interval: 5 min
Max # of doses: 3
SC
Dose: 0.8mg
Interval: 5 min
Max # of doses: 3
When would you disconnect a home dialysis machine?
Patient needs to be transported and they can not disconnect it AND no family/caretaker there to disconnect
- follow directions that come with machine
- make sure patient and machine side of connection are clamped before disconnecting anything
Indications for suspected adrenal crisis medical directive?
A patient with primary adrenal failure who is experiencing clinical signs of an adrenal crisis
Conditions for adrenal crisis directive?
- Paramedics are presented with a vial of hydrocortisone for the identified pt AND
- Age-related hypoglycemia OR
- GI symptoms (vomiting, diarrhea, abdo pain) OR
- Syncope OR
- Temp >= 38C or suspected/hx of fever OR
- Altered LOA OR
- Age-related tachycardia OR
- Age-related hypotension
Contraindications for adrenal crises directive?
allergy or sensitivity to hydrocortisone
Tx with hydrocortisone for adrenal crisis directive?
IM/IV
Dose: 2mg/kg (rounded to nearest 10mg)
Max Dose: 100mg
Max # of doses: 1
Indications for Endotracheal and Tracheostomy Suctioning & Reinsertion Directive:
- patient with endotracheal and tracheostomy tube
AND - airway obstruction or increased secretions
Conditions for tracheostomy suctioning:
NONE
Conditions for emergency tracheostomy reinsertion:
- pt with an existing trach where the inner and/or outer cannula(s) have been removed from the airway
AND - respiratory distress
AND - inability to adequately ventilate
AND - paramedics are presented with a trach cannula for the identified pt
Contraindications for Trach Reinsertion:
inability to landmark or visualize
treatment guidelines for trach suctioning:
<1 year
Dose: 60-100mmHg
Max single dose: 10sec
> =1 year to <12 years
Dose: 100-120mmHg
Max single dose: 10sec
> =12 years
Dose: 100-150mmHg
Max single dose: 10sec
Steps for suctioning a trach?
- pre-oxygenate with 100% O2
- only suction for 10 seconds at a time and on the way out only
- oxygenate between suction attempts
How many attempts can be made to reinsert a trach?
2
Indications for IV and Fluid Therapy Medical Directive
- actual or potential need for intravenous medication OR fluid therapy
Conditions for IV fluid therapy:
Age: >=2 years
SBP: hypotensive
(if only cannulating than they don’t need to be hypotensive)
Contraindications for IV fluid therapy:
- suspected fracture proximal to the access site
- fluid overload symptoms (or BP >= 90mmHg)
What is the rate of fluid in an IV for TKVO?
- For pts >=2 years to <12 years = 15ml/hr
- For pts >=12 years = 30-60ml/hr
Rate of fluid for IV therapy for pts >=2 years and <12 years
20ml/kg
reassess every 100ml to a max of 2000ml
Rate of fluid for IV therapy for pts >=12 years
20ml/kg
reassess every 250ml to a max of 2000ml
When must you patch before giving fluids?
If the patient >=2 years and <12 years with suspected DKA
Indications for Cardiogenic shock medical directive:
- STEMI positive 12-lead ECG
AND - cardiogenic shock
Conditions for fluid therapy in cardiogenic shock?
Age: >=18 years
SBP: hypotension
Other: chest auscultation clear
Contraindications for fluid therapy in cardiogenic shock?
- fluid overload
- SBP >=90mmHg
What is the fluid rate for someone in cardiogenic shock?
10ml/kg
reassess every 250ml to a max of 1000ml
Indications for CPAP directive?
- severe respiratory distress
AND - signs and/or symptoms of ACPE or COPD
What are the conditions for CPAP?
Age: >=18 years
RR: tachypnea
SBP: normotension
Other: SPO2 <90% or accessory muscle use
What are the contraindications for CPAP?
- asthma exacerbation
- suspected pneumo
- unprotected or unstable airway
- tracheostomy
- inability to sit upright
- unable to cooperate
What is the initial setting when treating a pt with CPAP?
5cm H2O
What is the titration increment when treating a pt with CPAP?
2.5cm H2O
What is the titration interval when treating a pt with CPAP?
5 min
What is the max setting when treating a pt with CPAP?
15cm H2O
When would you increase FIO2 when treating a pt with CPAP?
If SPO2 <92% despite treatment and/or 10cm H2O pressure
What are the indications for nausea/vomiting?
nausea
OR
vomiting
What conditions need to be met in order to give Dimenhydrinate (Gravol) for nausea/vomiting?
Weight: >=25kg
What are the contraindications for Dimenhydrinate (Gravol)?
- allergy or sensitivity to dimenhydrinate or other antihistamines
- overdose on antihistamines, anticholinergics or tricyclic antidepressants
What is the dosage of dimenhydrinate (gravol) for a pt >=25kg and <50kg?
IV & IM
Dose: 25mg
Max # of doses: 1
What is the dosage of dimenhydrinate (gravol) for a pt >=50kg?
IV & IM
Dose: 50mg
Max # of doses: 1
In order to administer dimenhydrinate (gravol) through IV what must you do first?
dilute the dimenhydrinate with normal saline or sterile water with a ratio of 1:9
Probe Removal Directive Indications:
Age: >=18 years
LOA: unaltered
Probe removal contraindications:
probe embedded above the clavicles, in the nipple(s), or in the genital area
