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Pinellas County Protocol 2023 > ALS Skills > Flashcards

ALS Skills Flashcards

1
Q

OG tube indications and contraindications

A

indications: gastric decompress in ped & adult pts getting assisted ventilations

Contraindications: alert, gag reflex, esophagus issues (varices, disease, structures), no advanced airway, Caustic ingestions

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2
Q

What size OG tube to use for infants, pediatrics, and adults?

A

infants (3-15kg) = 6FR

Peds (16-25kg) = 12 FR

Adults (>25kg) = 18 FR

3-15-25… 6-12-18

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3
Q

Your pt is about 10kg. What size OG tube to use and why?

A

All pts 3 to 15kg get a 6FR.

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4
Q

Your pt is about 20kg. What size OG tube to use and why?

A

All pts 16-25kg get a 12 FR

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5
Q

Your pt is about 30kg. What size OG tube to use and why?

A

all pts >25kg get an 18 FR

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6
Q

how to measure an OG tube?

A

Corner of mouth > behind earlobe > midpoint between sternum tip and navel

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7
Q

how would you insert an OG tube differently between a king airway and an ETT

A

King airway = insert into the OG slot/hole

ETT = insert NEXT TO the ET tube

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8
Q

what position do you want the pt’s head when inserting an OG tube?

A

neutral

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9
Q

how do you confirm placement of an OG tube?

A

inject 5-20 ml bolus of air (depending on pt size) into OG tube via 60cc catheter tip syringe, while listening w/ stethoscope. Listen for gurgling sounds

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10
Q

what sounds should you hear with a stethoscope when confirming OG tube placement? where should you hear it?

A

gurgling in the stomach

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11
Q

what suction setting to use on an OG tube? when to stop suctioning an OG tube?

A

low non-continuous suction. Stop the suction when there is no more stomach gunk coming out

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12
Q

how to secure an OG tube?

A

tape lightly to exterior cheek

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13
Q

What are the basic overview steps of inserting an OG tube?

A
  1. I-MACC
  2. Choose appropriate tube size & measure length
  3. Place the tube (w/ lube)
  4. Confirm placement
  5. Suction
  6. Secure tube
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14
Q

Indications and contraindications of a King Airway

A

Indications: cardiac arrest, resp insufficiency/failure/arrest

contra = known esophageal disease, caustic substance, height < 4ft

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15
Q

what sizes do the king airways come in?

A

3 tube = 4-5ft

#4 tube = 5-6ft
#5 tube = 6-7ft

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16
Q

What technique to insert (just the insertion part) a king tube in the mouth?

A
  1. grab jaw & tongue > lift anteriorly
  2. tube in corner of mouth, rotated 45-90 deg to the side
  3. advance down posterior tongue and rotate back to midline
  4. stop when hub at lip/gum line
  5. inflate balloon up to 60cc air for seal
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17
Q

how much air to inflate a king airway

A

Up to 60cc, but varies based on packaging

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18
Q

how far down to push a king airway

A

until the hub is at lip/gum line

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19
Q

once you initially insert a king airway, what should happen as you start bagging?

A

gently retract the tube as you bag until it “seats”. the ventilations will be easy after

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20
Q

what to do if you fully inflate a king tube and air is still leaking?

A

add additional 20cc air

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21
Q

5 confirmation methods of a king tube placement

A
  1. good bag compliance
  2. good Etco2 waveform
  3. chest rise
  4. lung sounds
  5. no epigastric sounds

*bag to butt

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22
Q

What ventilation rate and ETCO2 to maintain with a king tube?

A

12-16 breaths/min

EtCO2 35-45 mmH20

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23
Q

What are the general steps to inserting a king tube?

A
  1. I-MACC
  2. choose appropriate device size
  3. lube & insert tube
  4. inflate
  5. attach EtCO2 & ventilate/seat the tube
  6. confirm placement
  7. secure
  8. maintain ventilations/spo2/etco2
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24
Q

Adult Endotracheal Intubation indications and contraindications

A

Indication: Resp insufficiency/failure/arrest

Contraindications: none

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25
Q

How long to pre-oxygenate the pt and what does pre-oxygenating actually mean?

A

Oxygenating the pt for 30 seconds prior to intubation. NOT hyperventilating.

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26
Q

How many seconds per adult intubation attempt? What is the total number of attempts per pt?

A

Max 15s per attempt, max 2 attempts per pt

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27
Q

What are the 5 confirmation methods for adult intubation?

A
  1. Good bag compliance.
  2. Good waveform capno
  3. Chest rise
  4. Lung sounds
  5. No epigastric sounds
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28
Q

What would you do if you suspected your intubation tube when into the R bronchus only>

A

Retract 1-2cm & reassess

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29
Q

What are the general steps for adult endotracheal intubation?

A
  1. I-MACC
  2. Assemble equipment
  3. Pre-oxygenation
  4. Insert tube
  5. Confirm (EtCO2)
  6. Secure
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30
Q

Medication Facilitation Intubation indications and contraindications

A

Indications = resp insufficiency/failure/arrest, need airway mgmt but is still conscious, gag reflex, or jaw clenching

Contra = medication allergy

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31
Q

Can you facilitate intubate kids?

A

Only in extreme cases w/ OLMC consult

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32
Q

What’s the “SAFETY ALERT” for medication facilitation intubation?

A

Be extremely cautious with difficult airways

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33
Q

What medications and dosages for facilitated intubation?

A

Fentanyl 2 mcg/kg IVP

Etomidate 0.3 mg/kg SIVP (over 20s)

After success = Versed 2.5mg repeat x1 PRN

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34
Q

How much fentanyl to give for a facilitated intubation

A

2 mcg/kg IVP

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35
Q

How much Etomidate to give during an adult facilitated intubation? How fast to push it?

A

0.3mg/kg SIVP (over 20s)

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36
Q

How much Midazolam to give to an adult during a facilitated intubation?

A

2.5mg, repeat x1 PRN

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37
Q

What to do if you are unsuccessful at a facilitated intubation?

A

Call OLMC asap

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38
Q

General steps for medication facilitation intubation

A
  1. I-MACC
  2. Prep equipment
  3. IV or IO access
  4. Administer meds (fentanyl then etomidate)
  5. Intubate, confirm, and secure
  6. Versed (2.5mg, repeat x1 PRN)
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39
Q

IO Access indications and contraindications

A

Indication: cardiac arrest, or can’t get a critical IV on a red pt

Contraindication (FLIIP) - fracture, no landmarks/excessive tissue, infection, prosthetics

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40
Q

What landmarks for an IO

A

Proximal tibial plateau

Proximal humeral head

Distal tibia (proximal to medial malleolus)

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41
Q

Which pts get a hand bore IO instead of the power drill?

A

Pt < 1 years old

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42
Q

When performing an IO, what drug and dose to give for the pain?

A

Lidocaine 2%

Adult = 20 mg SIVP

Peds = 0.5mg/kg (max 20mg) SIVP

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43
Q

How do you know if an IO site has infiltrated?

A

Swelling at site

Fluids not running

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44
Q

General steps for IO access

A
  1. I-MACC
  2. Prep & drill w/ proper needle length
  3. Confirm (aspiration) & flush
  4. Lidocaine 2$ (if pt conscious)
  5. Note time & operator name on limb
  6. Secure
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45
Q

How do you confirm proper placement of an IO?

A

Aspirate the line before flushing.

Assess for swelling or fluids running

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46
Q

Needle Thoracostomy indications and contraindications

A

Indications = suspected pneumothorax w/ severe resp distress, hypotension or cardiovascular collapse (shock), traumatic cardiac arrest w/ chest/abdominal injury

Contraindications = simple pneumothorax

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47
Q

Primary vs secondary site to needle decompress an adult vs ped?

A

Adult:
Primary = Lateral 5th intercostal, anterior axillary
2nd = anterior 2nd intercostal, mid-clavicular (10g 3.25in)

Ped:
1st = lateral 4th intercostal, anterior axillary
2nd = anterior 2nd intercostal, mid clavicular (16g, 1.16in)

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48
Q

What needle decompression size for adults vs peds

A

Adult = 10g - 3.25in

ped = 16g, 1.16in

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49
Q

How do you know your needle decompress is in the correct spot?

A

Rush of air from catheter

Ventilation improvements

Equal chest rise returns

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50
Q

Needle thoracostomy general steps

A
  1. I-MACC
  2. Prep equip
  3. Expose/prep site & identify landmarks
  4. Insert needle
  5. Confirm placement
  6. Secure and reassess (lungs/vitals) per 5min
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51
Q

Defibrillation indications and contraindications

A

Indications: V-fib, pVtach, polymorphic Vtach

Contraindications: hazardous environment, DNR

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52
Q

2 ways to dump a charge

A
  1. Switch down to “on” position then back
  2. Press the soft key
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53
Q

how to manually change the MRX pacer from fixed back to demand mode

A

Check mark (menu) > pacer mode > demand

54
Q

MRX fixed vs demand pacing?

A

Demand = MRX analyzes and paces as needed

Fixed = MRX paces regardless of underlying rhythm

55
Q

When pacing someone, which setting (fixed or demand) does the MRX automatically start on? When does it transition?

A

It starts on demand, but will transition to fixed if the limb leads are pulled off

56
Q

What two pieces of equipment do you need attached, in order to pace a pt?

A

Limb leads

Defib pads

57
Q

Fast way to calculate fentanyl single dose (in mL for pain management)

A

Pt weight (in pounds) move decimal 2 to the left:

80kg = 160lb = 1.6mL (single dose)

58
Q

What’s the dose of fentanyl for adult facilitated intubation? Max dose? Repetitions?

A

2mcg/kg

Only ONE single dose (no repetitions) with max 400mcg

59
Q

Fast way to calculate fentanyl dose (in mL) for adult facilitated intubation? (Ex. Pt weights 80kg)

A

Pt weight (in kg) x 4 / 100

80kg x 4 = 320 / 100 = 3.2mL

60
Q

Can you facilitate intubation for peds?

A

Only in extreme circumstances after OLMC consult

61
Q

How does our fentanyl come packaged (dose per volume)

A

100mcg/2mL

62
Q

How does our etomidate come packaged? (Dose/volume)

A

40mg/20ml vial

63
Q

What is the dose of etomidate for facilitated intubation? how should you push it?

A

0.3mg/kg SIVP (over 20seconds)

64
Q

What is the fast way to calculate dosage of etomidate for facilitated intubation (ex 100kg pt)

A

Pt weight (in kg) times 3 / 10 / 2

100 x 3 = 300 /10 = 30 / 2 = 15mL

65
Q

What meds to give to a pt gnawing on their tube in a facilitated intubation vs all other cases where pt is intubated

A

All non-facilitated cases = 50mcg fentanyl + 2.5mg versed (repeat doses x1 in 5 min)

Facilitated = ONLY 2.5mg versed (repeat x1)

66
Q

During facilitated intubation, how long after pushing fentanyl do you give the etomidate?

A

1-2min after

67
Q

Why SHOULDNT you push air into an amio vial prior to drawing it up?

A

You will cause foaming

68
Q

What packaging do we carry Amio?

A

150mg/3mL vial

69
Q

Amio drip rate, time, and volume?

A

150mg mixed 100mL bag over 10min (Just remember 50 drops per 15s)

70
Q

Why site would you confirm a mechanical pulse when pacing a pt?

A

Radial or femoral

71
Q

Transcutaneous Pacing indications and contraindications

A

Indications = unstable bradycardia

Contraindications = hazardous environment

72
Q

When pacing, whats the initial rate and amps to start? Which would you adjust upwards until you get mechanical capture? By how much each increment?

A

60 BPM & 60 milliamps

Increase MILLIAMPS by 10 until pulses felt

73
Q

What to do if you begin pacing a pt and they end up hypotensive? Normotensive?

A

Hypotensive = increase rate by 10 > 70bpm up to 90bpm. Epi drip if still hypo

Normotensive = monitor pt condition

74
Q

What are the general steps to transcutaneous pacing

A
  1. I-MACC
  2. Limb leads (press “lead select” > pick best R wave
  3. Attach & connect pads
    /
  4. Switch knob > pacer & verify R wave markers
  5. “Pacer rate” = 60bpm, “Pacer output” = 60milliamps > “start pacing”
  6. Confirm mechanical capture (radial or femoral) & adjust output PRN
  7. Reassess & maintain BP
75
Q

Synchronized Cardioversion indications and contraindications

A

Indications = unstable tachydysrhythmia

Contraindications = hazardous environment

76
Q

When doing a synchronized cardiovert, how do you know the monitor is synced?

A

A sync marker will appear with each R-wave

77
Q

What joules to start & progress for regular (narrow or wide) unstable tachycardia?

A

100J - 120 - 150 - 170

78
Q

What joules to start and progress for an irregular - narrow tachycardia?

A

120J - 150J - 170J

79
Q

What to say every time you want to clear the pt before a cardiovert or defib

A

“I’m clear”, “you’re clear”, “Oxygen clear”

80
Q

What general steps for synchronized cardioversion

A
  1. I-MACC
  2. Knob to “Monitor”
  3. Sync button
  4. Confirm sync marker
  5. Charge & clear
  6. HOLD shock button
81
Q

When defibrillating, what position to place the pads on an Adult vs Ped?

A

Adult = anterior / anterior

Ped = Anterior / Posterior

82
Q

Vector change indications

A

Adult refractory V-fib w/ x3 shocks & antiarrhythmics onboard

83
Q

what general steps to perform defibrillation?

A
  1. I-MACC
  2. Expose & prep skin (watch for devices)
  3. Pads (place & connect)
  4. Turn dial knob > “Manual Defib”
  5. Charge & CLEAR
  6. Shock
84
Q

Surgical Cricothyrotomy indications and contraindications

A

indications = >10years w/ resp insufficiency/failure/arrest and inability to ventilation/oxygenate by ETT, BVM, or extraglottic

Contra = <10 years, can’t locate landmarks

85
Q

what equipment do you need to do a surgical cric?

A

alcohol prep or betadine

scalpel

6.0 ETT

Curved Kelly Clamp

ETCO2, 10ml syringe, BVM

86
Q

What are the general steps to performing a surgical cric?

A
  1. I-MACC
  2. Gather equipment & prep pt
  3. non-dominant hand stabilize thyroid cartilage
  4. 3cm vertical cut on cricothyroid membrane
  5. transverse cut & insert scalpel
  6. Insert Kelly clamps & pry open
  7. guide down ETT, Confirm placement, secure
  8. Ventilate & monitor ETCO2 / SPO2
87
Q

how to confirm tube placement on a surgical cric?

A

*Bag to Butt:

Bag compliance
Etco2
Bilat chest rise
Equal lung sounds
no epigastric sounds

88
Q

Pediatric Endotracheal Intubation indications & contraindications

A

indications = resp. insufficiency/failure/arrest

Contraindications = BVM is effective enough

89
Q

what equipment do you want to have ready when intubating a kid?

A

ETT
blades & laryngoscope
ETCO2
Tube securing device
suction
rescue airway

90
Q

max time and number of attempts to intubate a kid?

A

<15 seconds

total of 2 times

91
Q

should you inflate the ETT cuff on a kid?

A

Yes but NOT if < 30 days

92
Q

how long to pre-oxygenate a kid? what does pre-oxygenate mean?

A

30s of Oxygen prior to ETT. NOT hyperventilating

93
Q

General steps to intubating a pediatric?

A
  1. I-MACC
  2. Assemble gear (tell partner to continue bagging during)
  3. pre-oxygenate
  4. Insert
  5. Confirm placement
  6. secure & ventilate
  7. OG TUBE
94
Q

when should you confirm placement of an ETT on a pt?

A

VERY often during pt contact and on arrival at ED

95
Q

is ventilation rate and ETCO2 goal different on a pediatric vs an adult? what about for trauma’s?

A

NO. they are identical

96
Q

Needle Cricothryotomy indications and contraindications

A

indications: peds <10years, can’t ventilate by other means due to facial trauma or obstructed airway

Contra = can’t find landmarks. Neck tumor obstructs landmarks

97
Q

what equipment do you need to needle cric a kid?

A

alcohol prep or betadine

14g IV

10cc syringe

3.0mm ETT

Pedi BVM

98
Q

how to position a kid prior to needle cric

A

Supine w/ neck slightly hyperextended (rule out C-spine first)

99
Q

where should the clinician stand during a needle cric?

A

Right handed = L side of pt
Left handed = R side of pt

100
Q

What are the general steps to needle cric

A
  1. I-MACC
  2. assemble gear
  3. position pt and self
  4. grab the larynx & cricothyroid membrane
  5. insert @ 45 degree w/ syringe (drawback as you go)
  6. advance catheter & remove needle
  7. attach 15mm adapter and ventilate
  8. secure best you can
101
Q

How to mix an Epi drip? What dose and frequency to titration? Max dose?

A

1mg (either 10,000 or 1000) mix in 1000cc bag - 60gtt set

Start at 60gtt per min > increase by 60 each mcg (1mcg = 60 drops) until 5mcg/min max

102
Q

How to mix norepi (dose, drip set)

What starting and max dose?

A

4mg in 1000cc bag in 60gtt set

Start at 1 mcg/min (15drops) to max 10 mcg

Each mcg is 15drop increments

103
Q

How to mix push dose Epi

What dose to give

A

Squirt out 1cc from a 10cc flush

Add 1cc 1:10,000

Give 1ml (10mcg) until max of 5

104
Q

What Epi drip range for bradycardia? Allergic?

A

Brady = 2-5mcg/min

Allergic = 1-4 mcg/min

105
Q

Minimum IV size for norepi

A

18g

106
Q

Cyanokit dose? Mix? Time of administration

A

5g in 200ml over 15min

107
Q

Pt bucks the tube. What drugs to give this pt if you facilitated intubated vs normal arrest intubated him?

A

Facilitated intubation = just 2.5mg versed, repeat x1

Normal arrest intubation = 2.5versed, 50mcg fentanyl, repeat x1

108
Q

Indications and dosage of cardizem?

A

Stable narrow irregular tachycardia (or regular w/ hx a-fib)

.25mg/kg SIVP (max single dose 20mg)

109
Q

Indications and dose/mix of an amio infusion?

A

Stable wide tachyarrhythmia (regular or irregular)

150mg in a 100bag over 10min

110
Q

Versed dose for a psych?

A

2.5mg IV/IM or 5mg IN, repeat x1

Severe = double dose, repeat normal dose x1

111
Q

Versed dose for a seizure

A

2.5mg IV/IM or 5mg IN

Repeat per 5min until max of 10mg total

112
Q

Dose mag sulfate for ecclampsia? severe asthma? Torsades?

A

Ecclampsia = 4g over 10min

Asthma = 2g over 10min

Torsades = 2g over 10min

113
Q

Atropine dose?

A

0.5mg repeat until max 3mg

114
Q

Adenosine adult dose?

A

6mg then 12mg then OLMC

115
Q

How to do modified valsalva

A

Semifowlers > vagal 15s > supine w/ legs raised 45 degrees > semifowlers again

116
Q

What is SVT for a ped vs infant?

A

> 220 infant

> 180 ped

117
Q

Ped stable tachy Rx

A

Fluid
Vagal
Adenosine x2
Amio drip x20min

118
Q

Ped brady Rx

A

Rule out reversible (hypoxia, OD, seizure, BGL)’
Epi 1:10,000 per 3-5min
Atropine if block/vagal/organo
3rd degree = pace
Bolus x2

119
Q

Ped ROSC Rx

A

Fluid bolus x1
Epi drip > titrate to SBP 90
OLMC for norepi

120
Q

ped w/ RONF bucks the tube. What Rx

A

Versed and fentanyl

121
Q

Ped arrest has suspected hyper K . What Rx?

A

Sodium bicarb (4.2% - diluted 1:1 w/ NS) & calcium chloride

122
Q

Sodium bicarb dose

A

100mEq

123
Q

Calcium chloride dose

A

1g

124
Q

Narcan dose on an arrest? (max dose?)

A

2mg IV/IO (max 6mg)

125
Q

D10 dose on an arrest?

A

25g (250ml) repeat x1

126
Q

Nitro dose for a CHF pt

A

90 - 120 - 160

0.4 - 0.8 - 1.2

127
Q

What sex drugs are contraindicated for nitro? What times

A

Gotta be SLiC for the Chicks*

Stendra (<12hr)

Levitra viagra (<24)

Cialis (<48)

128
Q

What needle decompress size for an adult? A kid?

A

Adult = 10g - 3.25in

Kid = 16g - 1.16in

129
Q

What size ETT requires the yellow inline capno

A

4.5 and below

130
Q

What size ETT needed for a surgical cric?

A

6.0mm

131
Q

What size ETT needed for a needle CRIC? What needle size?

A

3.0 ETT

14g

Pinellas County Protocol 2023 (9 decks)

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