MD Protocols Flashcards
Agitation - Moderate - Adult - Medical Delirium (e.g. Infection)
Droperidol 2.5mg IM. (1.25mg IM over 69)
Contraindication- pregnant Pt or QT interval longer than 440ms
Agitation - Moderate - Adult - Psych Emergency (e.g. schitz, off meds)
Droperidol 2.5mg IM. (1.25mg IM over 69)
Contraindication- pregnant Pt or QT interval longer than 440ms
Agitation - Moderate - Adult - Drugs or ETOH
Versed 5mg IV/IM (2.5mg over 69)
Agitation - Moderate - Adult - Head Injury
Versed 5mg IV/IM (2.5mg over 69)
Agitation - Moderate - Adult - Unknown
Versed 5mg IV/IM (2.5mg over 69)
Agitation - Severe - Adult
Versed 5mg IV/IO (2.5mg over 69)
Or
Ketamine 1mg/kg IM/IO (max 100mg) or 4mg/kg IM (max 400mg) - only if immediate and danger to Pt or EMS
Agitation - Moderate - Pedi < 5yo
No meds
Agitation - Moderate - Pedi 5-12
Med Control for versed
Agitation - Moderate - Pedi 12-18
Doperdol - 2.5 IM or
Med Control for Versed
0.1mg/kg max 5mg IV/IO
0.2mg/kg max 5mg IM/IN (IM Preferred)
Agitation - Severe - Pedi < 13
Med Control for ketamine or versed
Agitation - Severe - Pedi 13-18
Ketamine 1mg/kg IV/IO (max 100mg) or 4mg/kg IM (max 400mg) - only if immediate and danger to Pt or EMS (If not…Med Control)
Versed
Allergic Reaction - Mild - Adult
Benadryl 25mg Slow IV/IM
or
Epi 0.5mg IM
Allergic Reaction - Moderate - Adult
Epi 0.5mg IM (3x every 5 min)
Establish IV
Benadryl 50mg IV/IM
DuoNeb 2.5mg albuterol 0.5 mg Atrovent - 2nd dose Albuterol 2.5 mg only
Allergic Reactions - Mild - Pedi
Benadryl 1mg/kg Slow IV/IM (max 25mg)
or
Epi
<5 yo 0.15 mg
5yo+ 0.5mg
Allergic Reactions - Moderate - Pedi
Epi - <5 yo 0.15 mg or 5yo+ 0.5mg
Establish IV
If hypotensive 20ml/kg LR (2x)
Benadryl 1mg/kg - slow IV/IM (max 50 mg)
DuoNeb
< 1 yo only 1.25 mg Albuterol
1-2 yo 1.25 mg Albuterol and 0.25mg Atrovent
>2 yo 2.5 mg Albuterol and 0.5 mg Atrovent
May repeat Albuterol 1x
Altered Mental Status - Ck
Tox/Environment
Hyper/Hypoglycemia
Seizures
Sepsis
Stroke
Anaphylaxis - Adult
Epi 0.5mg IM (3x every 5 min)
Establish IV
DuoNeb 2.5mg albuterol 0.5 mg Atrovent - 2nd dose Albuterol 2.5 mg only
Benadryl 50mg IV/IM
If hypotensive 20ml/kg LR (2x)
Dex 10mg IV/IO
Epi Drip after 3 doses of Epi IM - 1mL/min titrate to 2mL/min (1mg in 100mL = 10mcg/mL)
Anaphylaxis - Pedi
Epi - <5 yo 0.15 mg or 5yo+ 0.5mg Q5 3x
Establish IV
DuoNeb
< 1 yo only 1.25 mg Albuterol
1-2 yo 1.25 mg Albuterol and 0.25mg Atrovent
>2 yo 2.5 mg Albuterol and 0.5 mg Atrovent
May repeat Albuterol 1x
Benadryl 1mg/kg - slow IV/IM (max 50 mg)
If hypotensive 20ml/kg LR (2x) till 70 +2x age to 10 (90)
Dex 0.5mg/kg IV/IO (max 10mg)
ALTE/BRUE
Place on cardiac monitor
Establish IV access on if required by Pt condition
Hypoglycemia - Adult
If BG is below 70mg/dL
50mL of D10 every minute to max of 250mL (25g) until:
normal mental status and
BG above 90
If still altered and BG below 90 repeat dosing
If no IV access 1mg Glucagon IM/IN
If still altered TX to hospital
Hyperglycemia - Adult
If BG is greater than 300mg/dL
10mL/kg bolus of LR unless, rales, wheezing, pedal edema or Hx of renal failure or CHF
Hypoglycemia - Pedi
If less than 28 days BG below 40mg/dL
If greater than 28 days BG below 70mg/dL
Hyperkalemia - Adult
LR 20mg/kg (per hypoperfusion protocol)
If Brady follow brady protocol
Calcium Chloride 0.5g-1g SLOW IVP 3-5 min
Sodium Chloride 50mEq IVP over 5 min
If crush syndrome or good kidneys
after Sodium Bicarb push add Sodium Bicarb drip of 100mEq in 1 L over 30-60 min
Albuterol 20mg neb - Med Control
Make sure to FLUSH w 5ml of LR b/t calcium and sodium.
Hyperkalemia - Pedi
LR 20mg/kg (per hypoperfusion protocol)
If Brady follow brady protocol
Calcium Chloride 20mg/kg SLOW IVP 3-5 min (max 1g)
MC
Albuterol
<2 yo 1.25mg neb
>=2 yo 2.5mg neb
If crush syndrome or good kidneys
Sodium Bicarb 1mEq/kg IV over 5min (50mEq max)
if <1yo dilute 1:1 w LR
Make sure to FLUSH w 5ml of LR b/t calcium and sodium.
N/V - Adult
LR 20mL/kg to systolic of 90mmHg
Zofran 8mg IV over 2-5 min or 4-8mg IM or 8mg PO dissolved (2x)
MC 3rd dose of Zofran
Watch QT Interval
Contra pregnant
N/V - Peds
LR 20mL/kg to systolic of 70+2x age to 10yo (90mmHg)
Zofran
28 days to 12 yo - 0.1 mg/kg IV over 2-5 min
13-18 8mg IV over 2-5 min or 8mg PO dissolved or 0.1 mg/kg IM (max 8mg) (2x)
MC 3rd dose of Zofran
Watch QT Interval
Pain - Adult
Fent - 1mcg/kg IV/IO/IM/IN (200mcg max) (2x)
Ketamine 0.2mg/kg IV/IO over 1-2 min (20mg max) (2x)
0.5mg/kg IM/IN (50mg max) (2x)
Toradol - 15mg IV or 30mg IM (1x)
Pain - Pedi
Fent - 1mcg/kg IV/IM/IO (200mcg max) (2x)
Ketamine 0.2mg/kg IV/IO over 1-2 min (20mg max) (2x)
0.5mg/kg IM/IN (50mg max) (2x)
Toradol < 2 nothing
2+ 0.5mg/kg to 15mg max IV
1mg/kg to 30mg max IM
Seizures - Adult
Blood sugar
IM/IN - 5mg Versed
IV/IO - 0.1 mg/kg, 2mg at a time to 5mg - SLOW
For Pts 69 and over cut dose by 50%
Seizures - Pregnant
Check blood sugar
IM/IN - 5mg Versed
IV/IO - 0.1 mg/kg - 2mg at a time up to 5mg - SLOW
IV/IO - 4g of Mag in 50-100mL over 10 min
Seizures - Pedi
Check BG
IM/IN - 0.2mg/kg - 5mg max
IV/IO - 0.1 mg/kg - 2mg at a time, 5mg max SLOW
Sepsis - Adult (not fluid sensitive)
NS via pump
If still hypotensive - levophed 0.1 mcg/kg/min to 2mcg/kg/min
Till MAP < 65 or systolic < 90
Sepsis - Adult (fluid sensitive)
If PMHx of CHF or end stage renal failure
250mL NS
If still hypotensive - levophed 0.1 mcg/kg/min to 2mcg/kg/min
Till MAP < 65 or systolic < 90
Consult after that
Sepsis Definition
Source of infection plus 2 of the following
Sys BP < 90
HR > 100
RR > 25 or ETCO2 <=32
Temp > 100.4 or < 95.9
Sepsis Definition - Peds < 28 days
Known Infection Plus 3 others
HR > 205
RR > 60
Temp 100.4
Cap Refil > 3 sec
Sys BP < 60
Mental - Unresponsive, confused, inappropriate or lethargic
High risk condition - Cancer, transplants, indwelling catheters, immunodeficiency, immunosuppression
Sepsis Definition - Peds 1-12 Mos
Known Infection Plus 3 others
HR > 205
RR > 60
Temp 100.4
Cap Refil > 3 sec
Sys BP < 70
Mental - Unresponsive, confused, inappropriate or lethargic
High risk condition - Cancer, transplants, indwelling catheters, immunodeficiency, immunosuppression
Sepsis Definition - Peds 1-<2
Known Infection Plus 3 others
HR > 190
RR > 40
Temp 100.4
Cap Refil > 3 sec
Sys BP < 70+2 x age
Mental - Unresponsive, confused, inappropriate or lethargic
High risk condition - Cancer, transplants, indwelling catheters, immunodeficiency, immunosuppression
Sepsis Definition - Peds 2-4
Known Infection Plus 3 others
HR > 140
RR > 40
Temp 100.4
Cap Refil > 3 sec
Sys BP < 70 + 2 x age
Mental - Unresponsive, confused, inappropriate or lethargic
High risk condition - Cancer, transplants, indwelling catheters, immunodeficiency, immunosuppression
Sepsis Definition - Peds 5-12
Known Infection Plus 3 others
HR > 140
RR > 35
Temp 100.4
Cap Refil > 3 sec
Sys BP < 70 + 2 x age
Mental - Unresponsive, confused, inappropriate or lethargic
High risk condition - Cancer, transplants, indwelling catheters, immunodeficiency, immunosuppression
Sepsis Definition - Peds 13-17
Known Infection Plus 3 others
HR > 100
RR > 25
Temp 100.4
Cap Refil > 3 sec
Sys BP < 90
Mental - Unresponsive, confused, inappropriate or lethargic
High risk condition - Cancer, transplants, indwelling catheters, immunodeficiency, immunosuppression
Sepsis TX - Peds
20mL/kg LR over 5-20 min
If no improvement additional 20mL/kg LR to 60ml/kg total
Sepsis Peds - fluid sensitive
10ml/kg to 250mL
fluid sensitive includes neonates (,28 days), congenital heart disease, chronic lung disease or chronic renal failure
Cardiogenic shock
NS on pump
If still hypotensive - levophed 0.1 mcg/kg/min to 2mcg/kg/min
Till MAP < 65 or systolic < 90
Hemorrhagic Shock
LR bolus up to 250 at a time.
If still hypotensive - levophed 0.1 mcg/kg/min to 2mcg/kg/min
Till MAP < 65 or systolic < 90
If head injury Sys BP >110
COPD - Adult
DuoNeb 2.5mg albuterol 0.5 mg Atrovent - 2nd dose Albuterol 2.5 mg only
Dexamethasone 10mg IV
CPAP
Mag 2g in 100ml over 10min (MED CONTROL)
Asthma - Peds
DuoNeb
< 1 yo only 1.25 mg Albuterol
1-2 yo 1.25 mg Albuterol and 0.25mg Atrovent
>2 yo 2.5 mg Albuterol and 0.5 mg Atrovent
May repeat Albuterol 1x
Epi - <5 yo 0.15 mg or 5yo+ 0.5mg 5q 3x
Establish IV
Dex 0.5mg/kg IV/IO (max 10mg)
Mag 50mg/kg - 2g max IV/IO in 100mL over 10 min (med control)
Chlorine/Phosgene Exposure
For wheezing and bronchospasm
2.5mg Albuterol
Dex - 0.5mg/kg 10mg max IV/IO
For rales or suspected pulmonary edema
O2 and CPAP per CHF protocol
CHF/Pulmonary Edema - Adult - Mild
SPO2 < 94 O2
Nitro 0.4mg q5 3x
CHF/Pulmonary Edema - Adult - Moderate to Severe
CPAP
Assess BP bf each Nitro
If SBP>150
Nitro 0.4 and 1” nitro paste
Nitro 0.8mg 5q until 20% drop in SBP
If SBP drops < 90 250ml of LR 2x
CHF/Pulmonary Edema - Adult - Hypotensive
250 mL LR (MED Control for more)
Epi drip 1mg in 100ml LR 10mcg/min max of 20mcg/min
Titrate to 90SBP or MAP of 65 (MED Control for more)
CHF/Pulmonary Edema - Peds
NRB/CPAP
MED Control
Albuterol
<2 1.25mg
>2 2.5mg
Epi Drip
Croup - Mild
Dex 0.5mg/kg PO - max 10mg
Croup - Moderate
Dex 0.5mg/kg PO - max 10mg
Epi neb - 2.5mg
Croup - Severe
Epi 0.01mg/kg IM 0.5mg max
Dex 0.5mg/kg IV/IM - max 10mg
Epi neb - 2.5mg
Carbon Monoxide/Smoke Inhalation
Consider hyperbaric if
carboxyhemoglobin > 25%
or any of the following
carboxyhemoglobin > 15%
EMS/Fire Carbon Monoxide
alarm goes off
AND
LOC at any point
GCS<14
Rapid decline of neuro
Pregnancy (fetus has high affinity for CO so mom can b OK)
Chest Pain
Very young or old
OD/Poison - Adult - Opioids
Narcan - 2mg IVP/IO/IM/IN 1mg each nare
Narcan - 4mg/0.1mL in one nare
OD/Poison - Adult -CCB
Calcium Chloride 0.5-1g IVP over 10 min (UNLESS Pt in on Digoxin)
OD/Poison - Adult - Dystonic reaction
Benadryl - 25mg IV or IM
OD/Poison - Adult - General Ingestion
Charcoal - 1g/kg charcoal
OD/Poison - Adult - BB
Glucagon - 1mg q5 IVP
OD/Poison - Adult - Organophosphate
Atropine 2-4mg q5 until Pt has dry secretions/adequate O2
OD/Poison - Adult - Tricyclics
Sodium Bicarb - 1mEq/kg IVP up to 50mEq. q10 2nd dose 0.5mEq/kg
OD/Poison - Peds - Opioids
Narcan - 2mg IVP/IO/IM/IN 1mg each nare
Narcan - 4mg/0.1mL in one nare
OD/Poison - Peds -CCB
Calcium Chloride 20mg/kg - 1g max IVP over 10 min (UNLESS Pt in on Digoxin)
OD/Poison - Peds - Dystonic reaction
Benadryl - 1mg/kg, 25 mg max IVP/IM
OD/Poison - Peds - General Ingestion
1g/kg charcoal
OD/Poison - Peds - BB - 5yo+
Glucagon - 1mg IVP q5
OD/Poison - Peds - BB - 28 days to 5yo
Glucagon - 0.5mg IVP q5
OD/Poison - Peds - Organophosphate
Atropine - 0.02 mg/kg - max 2mg q5-10min until dry secretions and adequate breathing
OD/Poison - Peds - Tricyclics - 1yo+
Sodium Bicarb - 1mEq/kg
OD/Poison - Peds - Tyicyclics - <1 yo
Sodium Bicarb - 1mEq/kg diluted 1:1 with LR
Snakebites
Immobilize extremity
Take a pic if possible
20mL/kg LR titrate SBP to appropriate levels (e.g. 70+2x age or 90 - whichever is less)
OD/Poison - Adult - Stimulant
Versed 0.1 mg/kg 2 mg dose 5mg max slow IVP
half dose for over 69
or IM/IN 5mg
OD/Poison - Peds - Stimulant
Versed 0.1 mg/kg 2 mg dose 5mg max slow IVP
or 0.2 mg/kg IM/IN 5mg max
Burns - Burn Center Criteria
All full thickness
Partial thickness > 10% BSA
Burns to hands, face, feet, major joints, genitalia or perineum
Electrical burns from greater than 120V.
Suspected smoke inhalation
Circumfrencial burns involving extremities or torso
Burns - Peds - Destination
Younger than 15yo - peds burn center
Burns - TX - < 20% BSA or superficial
manage airway
no need for fluids
Burns - TX - 20%+ BSA - 15yo+
No shock
Airway
500mL/hr LR up to 2L. (MED Consult for more)
If in shock
250mL LR. SBP ck after each bolus to maintain 90SBP or 65MAP.
If head injury target 110 SBP
Burns - TX - 20%+ - <15yo
No shock
Airway
No fluids unless in shock
If in shock
250mL LR. SBP check after each bolus to maintain (70+2x age)
GCS - Eye
4 - Spntanious
3 - Voice
2 - Pain
1 - No response
GCS - Motor
6 - Verbal
5 - Localizes pain
4 - Withdrawal from pain
3 - Abnormal flexion - decorticate
2 - Extended/rigid - decerebrate
1 - No response
GCS - Verbal
5 - Appropriate
4 - Confused but able to answer
3 - Inappropriate words
2 - Gibberish
1 - No response
Spinal Motion Restrictions
MOI and
Midline Pt tenderness
New paraplegia/quadriplegia
Focal neuro deficit
Altered Mental/Disoriented
Distracting Injury
Neck pain or torticollis
High Impact crash
Death in same crash
Substantial torso injury
Spinal Motion Restrictions - C-collar only
Pt found to be standing or ambulatory
GCS of 15
No neuro
No gross deformities
No distracting injuries
STEMI w hypotension
If clear lungs 250mL of LR
STEMI
ASA
Nitro
Pain mgmt
Cardiac center if within 45 min
ACS
12 lead w/in 10 min
IV access
ASA 324
Nitro 0.4 SL q5 3x if
SBP>90
SBP does not drop 20mmHg after 1st dose
HR b/t 60-150
ED w/in 48hrs
If Pt does not have nitro script you need to have IV access before nitro
Stroke
Last know well 22 hrs
Blood thinners
BG
LAMS 0-3 closest acute/primary stroke ctr or comprehensive stroke center
LAMS 4 or greater - comprehensive stroke center or thrombectomy capable primary stroke center
Face droop
No
Yes
Arm drift
Absent
Drifts slow
Drifts fast
Grip strength
Normal
Weak
No grip
Category Alpha
Motor<6
SBP<90 (10yo+)
RR <10 or > 29
RR < 20 if less than 1YO
Category Bravo
2 or more proximal long bones
Amputation proximal to wrist of ankle
Chest wall instability
Crushed, degloved, mangled or pulseless extremity
Open or depressed skull fracture
Penetrating injuries to anything other than distal to elbow or knees
Pelvic fracture
Paralysis
Category Charlie
High risk auto crash greater than 12” on occupant side or 20” anywhere
Ejection including partial
Death in same compartment
Vehicle telemetry data consistent with high risk of injury
Rollover without restraint
Auto v ped/cyclist thrown, run over or over 20mph impact
Falls - 20’ for adult - 10’ or 3x of child’s height
Exposure to blast or explosion
Category Delta
> 55YO
SBP < 110 if Pt older then 65
Peds
Burns wo trauma - burn ctr
Burns w trauma - trauma ctr
Pregnancy > 20 weeks
Blood thinners/bleeding disorder
EMS judgement
Asthma - Adult
DuoNeb 2.5mg albuterol 0.5 mg Atrovent - 2nd dose Albuterol 2.5 mg only
Epi 0.5mg IM 5q 3x
Dexamethasone 10mg
CPAP
Mag 2g in 100ml over 10min (MED CONTROL)
TOR - Adult Exclusions
Pregnant
Hypothermic
Submersion
TOR - Adult
15 2-min cycles of CPR
Asystole
Vtach, Vfib or PEA and ETCO2 < 15
1 Epi on board
TOR - Peds (< 18yo)
15 2-min cycles of CPR
1 dose of Epi
Asystole AND
ETCO2 < 15 AND
PD & EMS believe the scene can handle leaving child
If VT, VF or PEA transport after 3 epi
Pronouncement of Death in the Field
Decapitation
Rigor Mortis
Decomposition
Dependent Lividity
Injury nor comparable with life
At MCI - pulseless and apneic pt my be left
Pronouncement of death in the field exception
Pregnancy
MOLST A-1 prior to arrest
Everything
MOLST A-2 prior to arrest
Same as A-1 except no intubation
MOLST B prior to arrest
Palliative care.
Passive O2. no BVM
You can suction
No IVs
You may admin pain meds
Penetrating Trauma Arrest
15 YO+
Asystole - u can stop immediately
PEA, VF or VT
20ml/kg LR
Bilateral needle decompression if penetrating neck, chest or abdominal trauma
12-lead and ID and treat rhythm
Usually do not use Epi!
Treat reversible causes and transport to trauma center is within 15 min otherwise closest ED
Blunt Trauma Arrest
15 yo+
Asystole - u can stop immediately
PEA, VT or VF
20ml/kg LR
Bilateral needle decompression if multi-system blunt trauma
12-lead and ID and treat rhythm
Usually do not use Epi!
If all reversible causes have been treated and still in arrest after 5 2min cycles of CPR consider TOR.
ROSC - Adult
ID rhythm and treat
If VF or VT were present during arrest and currently a sinus rhythm consider amiodarone if not previously given. 150 in 100ml over 10
Target 90 SBP w LR or epi drip 1mg in 100ml
Begin transport to cardiac center unless further than 45 min
Synchronized Cardioversion (adult)
SVT, A Flutter Vtach w pulse
100, 200, 300 and 360
Synchronized Cardioversion (adult)
Afib
200, 300 and 360
Synchronized Cardioversion (peds)
SVT, A Flutter, Vtach
0.5, 1, 2 Joules/kg
If they go to VFib DEFIB @ 2 to 4 joules/kg
Pacing
13+ - 80
1-12 - 100
< 1yo 120
