EMT Medical SOP Flashcards
What are the standing orders for allergic reaction involving localized urticaria and mild bronchospasm?
(4)
- Oxygen via nonrebreather mask at 15L
- Start IV of NSS
- Benadryl 50mg IV
- Monitor vital signs, cardiac rhythm and clinical status for any changes
How does the EMT SOP define anaphylactic reactions in the SOP?
(6)
Allergic reaction accompanied by hypotension (BP<90mmHg) with generalized urticaria, bronchospasms, laryngeal edema, respiratory failure, and evidence of shock (altered mental status, cool clammy or mottled skin with delayed cap refill)
What are the standing interventions for anaphylactic reaction that involve airway?
(2)
- Airway - O2 100% NRB, intubate or King tube if necessary
2. If wheezing is present, administer albuterol 3mg/Atrovent 0.5mg via neb
What are the standing interventions for anaphylactic reaction that involve hypotension (BP<90mmHg)?
(4)
- Place pt in supine position
- If hypotensive administer 0.5-1.0mg of epinephrine 1:10,000 IV over 1 minute. If no IV, administer 0.3mg Epinephrine 1:1000 IM in lateral thigh. May repeat after 5 min
- If hypotension continues to be a problem (SBP<100) administer push dose epi 1-2 ml every 3 minutes until desired effect or total max dose of 100 mcg of 100mcg (10ml)
- 500cc bolus of NS to maintain SBP > 100, may repeat if no sign of pulmonary edema
How do you mix push dose Epinephrine?
When mixed correctly, how many mcg are in each ml of the solution?
Can be made by drawing 1ml of 1:10,000 cardiac epi (100 mcg) in a 10 ml syringe and then drawing 9 ml of NSS. The syringe should be mixed by vigorously rolling it between the palms and is then ready to be infused by slow push. Every ml of the now 1:100,000 epinephrine contains 10 mcg of Epinephrine
What are the standing orders for anaphylactic reaction that involve medications?
(this is the hard one, name the doses)
- If hypotensive administer 0.5-1.0mg of epinephrine 1:10,000 IV over 1 minute. If no IV, administer 0.3mg Epinephrine 1:1000 IM in lateral thigh. May repeat after 5 min
- If wheezing is present, administer albuterol 3mg/Atrovent 0.5mg via neb
- If hypotension continues to be a problem (SBP<100) administer push dose epi 1-2 ml every 3 minutes until desired effect or total max dose of 100 mcg of 100mcg (10ml)
- 50 mg of Benadryl IV, if no IV then IM
- Solu Medrol 125mg IV
- 500cc bolus of NS to maintain SBP > 100, may repeat if no sign of pulmonary edema
What are the standing orders for anaphylactic reaction that involve medications?
(this is the easy one, just name the meds)
(7, 3 are epi)
- Epinephrine 0.5-1.0mg 1:10,000 IV over 1 minute
- If no IV, administer 0.3mg Epinephrine 1:1000 IM in lateral thigh. May repeat after 5 min
- Push dose Epi
- albuterol 3mg/Atrovent 0.5mg via neb
- 50 mg of Benadryl IV, if no IV then IM
- Solu Medrol 125mg IV
- 500cc bolus of NS
How many mcg in a mg?
1000
What are the EMT SOP orders for Altered Mental Status?
6
- R/O hypotension or hypoxia
- q 15 minute neuro checks
If unconscious without a gag reflex, intubate or insert a King tube - O2 for >95%
- IV access
- Check blood glucose, if less than 60mg/dl administer 25g of 50% Dextrose in water IV push, or 100 ml of 10% Dextrose in 250ml, or if no IV Glucagon 1 mg IM
- If suspected narcotics and blood glucose is > 60, Narcan 1mg IV push may repeat x1, or 2mg nasal starting with 0.4 in each nare. May also give Narcan 2 mg IM if no IV access.
EMT SOP orders for Altered Mental Status, what are the options for narcan?
(3) IV, nasal, and IM
What should you monitor for afterwards?
If suspected narcotics and blood glucose is > 60, Narcan 1mg IV push may repeat x1, or 2mg nasal starting with 0.4 in each nare. May also give Narcan 2 mg IM if no IV access.
Monitor for pulmonary edema after administration.
What are the EMT SOP orders for Adult Agitation?
3
- Assess for underlying cause and attempt verbal calming.
- Administer 1-2 mg IV/IM, or intranasally.
- Use lower doses in the elderly
What are the EMT SOP orders for Adult Excited Delirium Syndrome?
- Ketamine 4mg/kg for a dissociative state for 15-20 min. Monitor for histamine like side affects such as tachycardia and hypertension
- 500 cc bolus NSS
What should you do if you use Ketamine?
Notify medical control and chief transport nurse in the event of Ketamine usage for Excited delirium.
What are the EMT SOP orders for medication interventions involving COPD?
(6)
- Supplemental O2 for SpO2<95%.
- Administer Albuterol 2.5mg/3cc by aerosol nebulizer, may give up to three times if needed
- NSS 100cc/hr
- Solu Medrol 125mg IV over 1 minute
- If respiratory failure intubate or establish King tube
- If patient does not respond contact Medical control for further treatment
What are the EMT SOP orders for medication interventions involving Asthma/Bronchoconstriction?
- Supplemental O2 for SpO2<95%. If COPD patient, 88% or better.
- Administer Albuterol 2.5mg/3cc together with Atrovent 0.5mg by aerosol nebulizer
- NSS 100cc/hr unless rales are present
- Administer 125mg Solu-Medrol IV over 1 minute
- May repeat Albuterol Q 20 min up to 3 treatment of needed.
- Contact Medical control if patient does not respond to treatment
What are the EMT SOP orders for interventions involving Congestive Heart Failure/ Pulmonary Edema?
(7)
- Initiate CPCP therapy (consider inclusion/exclusion criteria)
- Intubation or King tube
- IV KVO
Administer NTG 0.4 tab or SL spray if SBP>100mHg, may repeat q5min for total of 3 doses. - If hemodynamically stable may apply 1inch nitro paste to anterior wall after 3 doses NTG SL if SBP remains >100.
- Administer Lasix 40mg IV if BP is greater than 110mmHg systolic
- If no improvement in 10 min. and BP remains stable, administer Morphine Sulfate 2mg IV
- If pt SBP<100mmHg contact medical control for possible initiation of vasopressors.
What are the EMT SOP medications involved for cardiac distress secondary to left sided HF/Congestive Heart Failure causing Pulmonary Edema?
Nitro SL tab
Nitro paste
Lasix 40mg
Morphine 2 mg
What are the EMT SOP orders for CPAP interventions involving vent settings for the treatment of Congestive Heart Failure/ Pulmonary Edema?
- Initial pressure settings are usually around 5-10cm H20 and then adjust based on comfort or clinical response.
- FiO2 initially set for 100% and then titrated down once stabilized
What are the EMT SOP orders for CPAP inclusion criteria involving Congestive Heart Failure/ Pulmonary Edema?
(8)
- Respiratory failure and Muscular fatigue
- Poor response to medical treatment
- Decreased SpO2
- Use of accessory respiratory muscles
- Ability to wear face mask
- not in obvious need of intubation
- not actively vomiting
- not having seizures
What are the EMT SOP orders for CPAP exclusion criteria involving Congestive Heart Failure/ Pulmonary Edema?
- Obvious need for intubation
- decreased LOC who cannot cooperate with mask
- Cardiovascular instability (SBP less than 90 or on vasopressors; relative)
- Acute abdominal processes, recent gastro-esophageal sx, recent facial or ENT Sx, facial deformities or facial trauma
What are the EMT SOP orders for CPAP discontinuation criteria involving Congestive Heart Failure/ Pulmonary Edema?
(5)
- Deteriorating mental status/ lethargy
- Inability to tolerate mask due to pain or discomfort
- Inability to improve respiratory function
- Hemodynamic instability
- Suspicion of pneumothorax
What are the EMT SOP medications involved for chest pain?
5
- NTG tab x3 q5min as long as SBP>100 and pt does not already have a nitro drip
- if SBP falls >100 p NTG than give 250 ml NSS bolus
- Fentanyl 1.0mcg/kg slow IV push q 15min to a max dose of 200 mcg
- Zofran 4mg for nausea, may repeat p 15 min to max dose of 8mg
- If continued pain and/or hypotension contact medical control
What are the EMT SOP medication orders for Fentanyl involving chest pain?
Fentanyl 1.0mcg/kg slow IV push q 15min to a max dose of 200 mg
What are the EMT SOP medication orders for Zofran involving chest pain?
Zofran 4mg for nausea, may repeat p 15 min to max dose of 8mg
What are the EMT SOP medication orders for NTG involving chest pain?
And what do you do if the blood pressure tanks?
- NTG tab x3 q5min as long as SBP>100 and pt does not already have a nitro drip
- if SBP falls >100 p NTG than give 250 ml NSS bolus
What are the EMT SOP medications involved for nausea/vomiting?
Zofran IV 4mg over 2 minutes. May repeat after 15 minutes if N/V continues
what are the goals of treating cardiac chest pain?
- decrease myocardial oxygen consumption, pain, and anxiety
When treating the chest pain pt, administer O2 to maintain saturation > __%, or __% if Hx of COPD or as indicated by medical director.
95%
88%
If patient continues to have chest pain, you should monitor vital signs Q __ minutes
5
If chest pain pt is already on Tridil gtt increase incriments of __mcg/min every __ minutes until chest pain is resolved or SBP < __mmHg. If chest pain not resolved or SBP
10
5
100
100
what is another name for Tridil?
nitro
If pt does not have a nitro drip and SBP>100, what can you do?
How many times?
How often?
What do you do in between?
Nitro 0.4 tabs SL
3
q 5 minutes
take vital signs
If SBP falls below 100mmHg after administration of NTG and there are no ___ present, what can you do?
rales
give a 250 cc bolus of NSS
If chest pain is severe and/or unrelieved by NTG, what can you give?
1.0mcg/ Fentanyl 1.0 mcg/kg slow push IV q15 min to a max dose of 200mcg. Titrate to relief with stable BP and adequate oxygenation.
When treating severe chest pain that is unrelieved by NTG, you may give __mcg/ Fentanyl __ mcg/kg slow push IV every __ min to a max dose of __mcg. Titrate to relief with stable BP and adequate oxygenation.
10
1.0
q 15
200
Nausea associated with chest pain may be treated with what? How many times and how often?
zofran 4 mg
can be repeated one more time after 15 minutes for a maximum dose of 8 mg
You should provide medical intervention for a patient with a SBP > 180 and/ or Diastolic > 100 exhibiting one or more of these 4 symptoms
severe headache
change in mental status
epistaxis
visual disturbances
Primary assessment and treatment of uncontrolled hypertension includes what 4 things?
administer oxygen at 15 L NRB mask
Establish IV of NSS
Administer Labetolol (dose on other card)
If BP not controlled after 30 minutes contact medical control
When treating uncontrolled HTN, what are the dosing parameters for Labetolol?
How much?
How much repeat? How many repeats?
When should you NOT give it?
20mg IV push
may repeat q 10 min for a total of 3 doses as needed to control BP.
Do NOT administer Labetolol for a SBP < 130 or HR <80
SOP for Hypotension can be applied to what other conditions? (4)
What actually defines Hypotension?
shock due to dehydration
sepsis
non-traumatic hemorrhage unaccompanied by bradycardia or trauma
Symptomatic hypotension SBP<100
When treating the patient with hypotension, what is the first thing you can do?
place patient in Trendelenburg position
When treating a patient with Hypotension what can you do as long as there is no sign of CHF or pulmonary edema present?
administer fluid bolus of 500cc NSS rapidly
When treating a patient with hypotension, after giving a initial bolus of 500cc NSS rapidly, of no symptoms of CHF and hypotension persists, what can you do?
repeat fluid bolus of 250 cc, may repeat up to a total of 1 liter
When treating a patient with hypotension, determine hemodynamical instability by assessing what?
(3)
- Shock index (HR/SBP) greater than or equal to 0.80 with SBP < 110mmHg
- MAP less than or equal to 65mmHg
- SBP less than or equal to 90mmHg
When treating a patient with Hypotension, you have already tried repositioning, have already given a total of 1 L NSS and pt is still hemodynamically unstable, what can you do?
Administer push dose epinephrine 1-2ml every 3 minutes until desired effect or total max dose of 100 mcg (10ml)
How do you prepare push dose epinephrine?
draw 1 ml of 1:10,000 cardiac epinephrine (100mcg) in a 10 ml syringe and then drawing 9ml in NSS and mix by vigorously rolling it between the palms
When treating a patient with CVA what is the first thing you do do?
What are the 4 steps in which you should go about it?
Make sure the patient is able to maintain their own airway.
- supplemental O2 of at least 2L O2
- Maintain SpO2 of at least 95% in a healthy adult and 90% in a patient with significant airway disease such as COPD
- Intubate or establish King tube for GCS of less than 8. If definitive airway is necessary, obtain ventilator settings from medical control and monitor continuous O2 and EtCO2 with optimal range 35 - 40 throughout transport with good waveform and suction ready
- Maintain HOB at 15 degrees with head in neutral position unless risk for ICP keep 30 degrees
When treating a patient with CVA, GCS less than 8, ___
intubate
True or false
You are treating a patient with CVA and have intubated. It’s ok to have one IV
False
you need to have at least 2 patent IV’s
When treating a patient with CVA, complete and document an initial neurological exam including what
(6)
- GCS
- Pupil size
- Document Cincinnati Stroke scale
- If possible - obtain exact time of symptoms
- Repeat and document neuro exam q15 minutes during transport
- Document sending facility findings from CT scan
When treating a CVA patient, what should you do along with any other patient who has a change in mental status?
get a blood glucose
You have a patient who has found to have a blood glucose of less than 60mg/dl, what do you do?
administer 50% Dextrose 25gm IV and repeat measurement in 15 minutes
when treating a patient with CVA you should maintain a MAP of between what parameters?
90 - 110
When treating a CVA patient, if MAP <90, what should you do? Can you repeat?
administer 250cc NS bolus and reassess. May repeat x1 if needed.
When treating a CVA patient, if MAP <90 and you have already given a total of 500cc bolus, what should you do?
contact medical control for further orders
When treating a CVA patient and MAP is > 110 and HR is lower than 60, what can you give?
Hydralazine 10mg slow push IV
When treating a CVA patient and MAP is > 110 and heart rate is greater that 60, what can you give?
Can you repeat?
Labetolol 20 mg IV push over 1 - 2 minutes. Repeat up to a total of 100 mg IV
If MAP continues to run high, call medical control for further orders
When assessing a seizure patient, what are three things you want first?
Hx of seizures
Timeline of events and coresponding symptoms
Blood glucose
What are some possible causes for seizures?
Trauma Stroke Brain tumor anoxic event hypoxia sepsis hypoglycemia meningitis withdrawal from alcohol or drugs
When should you prepare to intubate the seizure patient?
in the absence of spontaneous respirationsand GCS <8
When treating a seizure pt, what can you give to help control seizure activity? If no IV How often can you repeat? What should you be cautious of? What is the max total dose?
Ativan 1 -2 mg IV push slowly
May repeat q 5 minutes if seizures persist
If no IV can give same dose IM or intranasal.
Do not exceed 8mg in a 12 hour period.
Be prepared to intubate as Ativan can be a strong respiratory depressant.
When treating a seizure pt, what is the first thing you should check, and what do you do if it is lower than 60?
Administer 25mg 50% dextrose and continue to monitor glucose q 15 min
When treating a pt with nausea/vomiting, what are the two things you should do first?
Maintain airway
Establish IV access
When treating a pt with nausea/vomiting, once you have IV access, how can you treat the patient?
Can you repeat and what is the total max dose?
And if that doesn’t work?
Zofran 4 mg IV over 2 minutes for nausea and/or vomiting. May repeat after 15 minutes for a total of 8 mg
If N/V persists contact medical control for further orders.
when treating a trauma patient, what would be considered a hemodynamically unstable patient?
And if that were the case, what would you do about it?
A patient with a SBP>100 and or a heart rate of >120.
Give 500cc bolus of NSS or LR
If hemodynamically stable keep fluids at KVO
if no response to fluids than contact medical control for additional orders
What trauma patients would you NOT give fluids to?
Patients with isolated head trauma or penetrating thoracic/abdominal trauma
if you are unable to establish two large bore IV’s due to extent of burns, what should you do?
Establish IO access
What are the standing orders for pain control while transporting a burn victim?
If you are unable to maintain orders from sending physician.
Fentanyl 0.5mcg/kg IV
may repeat after 15 minutes x1
For the burn victim, infuse fluid bolus of lactated ringers or NSS as per the ___ formula.
What is it?
Parkland formula
4ml x pt wt (kg) x %body surface area
administer 50% of the total fluid in the first 8 hours
administer 50% of the total amount in the next 16 hours
Name 8 obsterical emergencies
Preterm labor pre/eclampsia Placenta previa breech presentation Premature rupture of membranes HELPP Syndrome Abrupto Placentae Prolapsed umbilical cord
When treating the Obsterical patient, what medical hx should you be concerned with?
(7)
hx of present illness estimated due date date of last menstrual period last ultrasound prenatal care complications to date previous pregnancies (para, gravida)
When treating the obsterical patient, what should your assessment include?
frequency, duration, location, and intensity
Assess fetal heart tones q__ minutes if not on fetal monitor. What is the normal range for fetal heart tones?
15 minutes
Normal FHT 120-160 bpm)
In the case of trauma in the Obsterical patient, if patient is on a long board and past __ weeks gestation, what do you need to do and why?
20 weeks gestation, tilt the board 15 degrees to the left in order to prevent compression of the vena cava
In the Obsterical patient, what are loss of deep tendon reflexes, respiratory depression, hypotension, and weakness a sign of?
magnesium toxicity
If noted fetal distress what should you try first?
If that doesn’t work call medical director for orders for what?
maternal repositioning (left side lying, trendelenburg), 300-500 ml bolus of NSS or LR Obtain orders for tocolytes, (magnesium sulfate or Terbutaline)
When treating the Obsterical patient, when should you prepare for delivery?
if cervix is 4-5 cm dilated and/ or membranes are bulging or ruptured
consult with both sending and receiving doctors to determine imminent delivery
What are 7 symptoms of Preeclampsia/ Eclampsia?
Hypertension, proteinuria, edema, headache, visual disturbances, seizures, coma
What does HELPP syndrome stand for?
Hemolytic anemia, anemia, elevated liver enzymes, low platelets, abdominal pain
When treating the obsterical patient, what should you do to treat hypertension?
call medical control for orders
When treating the obsterical patient with altered level of consciousness, headache, blurred vision, sleepiness, nausea/vomiting, and seizure activity, what should you do?
Administer anticonvulsant and antiemetic as per policies
When transporting a patient with S/S of preeclampsia / eclampsia or HELPP syndrome, what should you give?
Magnesium sulfate 2-4 gm IV bolus over 15 - 20 min, then 1 - 2 gm / hr maintenance infusion
What are the S/S of placenta previa?
painless bright red vaginal bleeding, abdoman is soft
What are the S/S of placenta abrupto?
dark red bleeding with or without clots, irritable cramping, abdominal pain
What is the rule about transporting imminent birth?
Delivery should be avoided in a transport vehicle. Transport should be delayed and delivery should occur at sending facility if imminent birth is decided
If you should encounter a breech birth during transport, what should you do?
Do not touch mother, neonate, or unbillical cord, and allow the neonate to spontaneously emerge.
Due to cord compression, if the neonate has emerged breech to the level of the umbillicus, the head should be delivered in what time frame?
If the head is delayed, what should you do?
3 - 5 minutes
if head is delayed, insert two fingers to the neonates face on either side of the maxilla and exert pressure to help the head flex downward
You may also apply suprapubic pressure to help disimpact the neonates head from the maternal pubis
Umbillical cord prolapse occurs most often when what happens?
premature rupture of the membranes
If you should encounter a cord prolapse, what is the first thing you should do?
Place mother in the trendelenburg position, side lying or knee to chest so gravity can assist moving the fetus up and out of the pelvis
When encountering a prolapsed cord, what should you encourage the other to do?
encourage the mother to “pant” and not push during contractions
In the case of a cord prolapse, what do you need to do to prevent cord compression?
What if it is around the neonates neck?
Reach into the vagina and apply pressure to the presenting part to shift it higher than the pelvis and maintain this position until you reach the recieving hospital. If cord is around the neck place two fingers between the cord and the neck.
What should you do with any part of the umbillical cord that is visible outside of the vagina?
apply saline soaked dressing
In the case of a prolapsed cord, what are two things you shouldn’t do?
Don’t pull it out and don’t push it back in.
Also do not attempt to deliver. Ok, three things. My bad.
What are the 4 stages of Labor?
Stage 1 - cervical dilation
Stage 2 - starts with full dilation and ends with birth of neonate
Stage 3 - Starts with delivery of neonate and ends with delivery of placenta
Stage 4 - 1 to 4 hours after the delivery of placenta
what are the orders for treatment of altered mental status that involve a blood sugar of less than __mg/dl?
What are the 2 options if you have IV access?
what do you do if no IV?
60
Check blood glucose, if less than 60mg/dl administer 25g of 50% Dextrose in water IV push, or 100 ml of 10% Dextrose in 250ml, or if no IV Glucagon 1 mg IM
what are the orders for treatment of altered mental status that involve suspicion of narcotics overdose?
- If suspected narcotics and blood glucose is > 60, Narcan 1mg IV push may repeat x1, or 2mg nasal starting with 0.4 in each nare. May also give Narcan 2 mg IM if no IV access.
what are the EMT SOP for chest pain that involve Fentanyl?
Fentanyl 1.0 mcg/kg slow IV push q 15 min to a max dose of 200mcg
shock index is ___ divided by ___ greater than or equal to __ with a SBP lower than __ mmHg
HR
SBP
0.80
110
