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Mass Protocols > Medical Protocols > Flashcards

Medical Protocols Flashcards

1
Q

Adrenal Insufficiency Adult/Pedi: Indications

A

Stress Dose Indications if known/suspected adrenal insufficiency:

  • Shock (any cause)
  • Fever >100.4 F and ill-appearing
  • Multi-system trauma
  • Drowning
  • Environmental hyper/hypothermia
  • Multiple long-bone fx
  • V/D w/ dehydration
  • Resp Distress
  • 2nd/3rd degree burns >5% BSA
  • RSI (Etomidate may precipitate adrenal crisis)
  • Hypoglycemia
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2
Q

Adrenal Insufficiency Adult/Pedi

A

Adult:

  • Hydrocortisone: 100 mg IV/IO/IM OR
  • Methylprednisone: 125 mg IV/IO/IM

Pedi:

  • Hydrocortisone: 2 mg/kg, max of 100 mg IV/IO/IM OR
  • Methylprednisone: 2 mg/kg max of 125 mg IV/IO/IM
MEDCONTROL:
- Additional Doses esp if demonstrating S/S as listed
 > N/V
 > abd pain
 > weakness
 > dizz
 > muscle pain
 > dehydration
 > tachycardia
 > fever
 > AMS
- Additional consideration:
 > Aggressive vol replacement
 > Treat other conditions
 > Normalize body temp
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3
Q

Allergic Reaction/Anaphylaxis Adult

A

MILD DISTRESS:
- Diphenhydramine: 25-50 mg IV/IO/IM

SEVERE DISTRESS:

  • Epi: 0.3 mg (1:1,000) auto-injector may repeat once in 5 min
  • Diphenhydramine: 25-50 mg IV/IO/IM
  • Hydrocortisone: 100 mg IV/IO/IM OR
  • Methylprednisone: 125 mg IV/IO/IM

MEDCONTROL

  • Additional doses
  • Epi: 0.1-0.5 mg (1:10,000) IV/IO
  • Epi Infusion: 1-10 mcg/min IV/IO (1mg 1:1,000/250 mL)
  • Dopamine: 2-20 mcg/kg/min (Rate determined by physician)
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4
Q

Allergic Reaction/Anaphylaxis Adult: Mild vs Severe

A 
Mild:
- Itching
- Urticaria
- Nausea
- No Resp Distress
Severe:
- Stridor
- Bronchospasm
- Severe Abd Pain
- Resp Distress
- Tachycardia
- Shock
- Edema of lips, tongue and/or face
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5
Q

Allergic Reaction/Anaphylaxis Pedi: Clinical Criteria for Anaphylaxis

A

Treat for Anaphylaxis if one the the following is fulfilled:

1.) Acute on set of skin/mucosal involvement w/ one of the following:
A.) Resp Compromise
B.) Decreased BP or evidence of end-organ hypoperfusion

2.) >/= 2 of the following occur rapidly after exposure to likely antigen:
A.) Skin/mucosal involvement
B.) Resp Compromise
C.) Decreased BP or evidence of end-organ hypoperfusion
D.) Persistent GI symptoms

3.) Decreased BP after exposure to a known allergen for that pt.

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6
Q

Allergic Reaction/Anaphylaxis Pedi

A
  • Epi Autoinjector:
    a. ) >/=25 kg: 0.3 mg (Adult auto injector)
    b. ) Contact Med Control for additional Epi after 5 min
  • Diphenhydramine: 1 mg/kg max single dose of 50 mg IV/IO/IM
  • Hydrocortisone: 2 mg/kg max single of 100 mg IV/IO/IM or
  • Methylprednisone: 2 mg/kg max single of 125 mg IV/IO/IM

MEDCONTROL

  • Additional doses
  • Epi Infusion: 0.1-1 mcg/kg/min IV/IO
  • Albuterol:
    a. ) >/=2 y.o.: 2.5-3 mg neb
    b. ) <2 y.o.: 1.5 mg neb
  • Epi: 1:10,000 0.01 mg/kg IV/IO max single of 0.3 mg
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7
Q

AMS/Neurological Status/DM Emergencies Adult

A
  • Unconscious/seizing pt: place in LLR if not contraindicated
  • DM Hypoglycemia BGL Able to Swallow and Speak:
    a. ) Oral Glucose: One tube, can sub other sugar source. Repeat in 10 min if still symptomatic.

> Unable to Swallow and Speak:

a. ) Dextrose: Up to 25 mg IV/IO, recheck BGL in 5 min. May repeat dose if BGL still 300:
a. ) 500 mL fluid bolus, then 250 mL/hr

  • Consider Thiamine: 100 mg IV/IO/IM

MEDCONTROL
- Additional doses

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8
Q

Dextrose Note

A

May be administered in D50/D25/D10, as long as dosage is correct. Dosage adjustments as listed

  • D50: 0.5 mg/mL = 25g/50mL
  • D25: 0.25 mg/mL = 25g/100mL
  • D10: 0.1 mg/mL = 25g/250mL
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9
Q

AMS/Neurological Status/DM Emergencies Pedi

A
  • Unconscious/seizing, place in LLR position if not contraindicated
  • DM Hypoglycemia BGL Dextrose 10%: 0.5 g/kg IV/IO
    > Glucagon (Unable to est IV) 0.1 mg/kg IV/IO/IM/IN/SC max single of 1 mg
  • DM Hyperglycemia BGL >300 and symptomatic:
    a. ) 20 mL/kg fluid bolus
  • Consider confirming adrenal insufficiency

MEDCONTROL
- Additional doses

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10
Q

Behavioral Emergencies Adult/Pedi

A

After or Before:

  • Est IV w/ NS KVO
  • Monitor and 12 lead if feasible
  • Position as to not impair breathing
Adult:
- Haloperidol: 5 mg IM, and/or
- Lorazepam: 2 mg IV/IO/IM or
- Midazolam: 2.5-5 mg IV/IO/IM/IN
Note: Pts > 70 y.o., limit dose to half

Pedi:
- Midazolam: 0.1 mg/kg IV/IO/IM/IN

MEDCONTROL
- Additional doses

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11
Q

Behavioral Emergencies Notes

A
  • Haldol: Preferred for psychotic and head trauma pts. Contraindicated for hx of seizures and prolonged QT intervals
  • Lorazepam: Preferred for pts w/ alcohol w/drawl or sympathomimetic toxicity (cocaine or PCP)
  • Diazepam: Should NOT be used with pt experiencing behavioral emergencies.
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12
Q

Bronchospasm/Resp Distress Adult

A
  • O2
  • Albuterol: 2-3 mg neb, additional treatments as necessary.
  • Ipratropium Bromide: 500 mcg via neb, maybe combine with Albuterol. May or may not be administered with additional Albuterol treatments.
  • Pts with dx asthma/COPD w/o hx or S/S of CHF consider
    a. ) Hydrocortisone: 100 mg IV/IO/IM or
    b. ) Methylprednisone: 125 mg IV/IO/IM
  • Pts </= 40 y.o. Consider: Epi 0.15-0.3 mg via auto-injector only as one time dose only.
  • CPAP: Consider in not contraindicated
  • Asthma Consider Mag: 2-4 g IV/IO over 5 min

MEDCONTROL

  • Additional doses
  • Epi: 1:10,000 0.1-0.5 mg IV/IO very slowly
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13
Q

Bronchospasm/Resp Distress Pedi

A
  • O2
  • Albuterol
    a. ) >/=2 y.o.: 2.5-3 mg neb
    b. ) < 2 y.o.: 1.5 mg via neb
    c. ) May provide one additional dose w/ or w/o atrovent
  • Ipratropium:
    a. ) >/=2 y.o.: 500 mcg neb
    b. ) < 2 y.o.: 250 mcg neb
  • Pt >/=2 y.o. with dx of asthma consider
    a.) Hydrocortisone: 2 mg/kg, max single of 100 mg IV/IO/IM or
    b.) Methylprednisone: 2 mg/kg, max single of 125 mg
    IV/IO/IM
  • Severe distress, pt > 5 y.o.: Epi auto injector based on wt. May repeat once in 5 min if needed.
  • Mag: 25 mg/kg IV/IO over 10 min, max single dose of 2g

MEDCONTROL
- Additional doses

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14
Q

Bronchospasm/Resp Distress Criteria

A

Mild Distress: Children with minor wheezing and good air entry.

Severe Distress: Poor air entry, accessory muscle use (extreme), nasal flaring, grunting, cyanosis and/or AMS

Resp Distress: Inadequate breathing in terms of rate, rhythm, quality and/or depth. Causes inadequate O2 SpO2 of hgb and may increase PaCO2.

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15
Q

Hyperthermia (Environmental) Adult/Pedi

A
  • Remove from environment
  • Position supine
  • Loosen/remove all unneeded clothing
  • Cool packs in armpits, neck, and groin
  • Fan
  • Keep skin wet
  • Heat Cramps and/or Heat Exhaustion: Consider 500 mL bolus even w/ normal vitals or sports drink if able to swallow and speak.
    a. ) Pedi: 20 mL/kg if indicated
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16
Q

Hypothermia (Environmental) Adult/Pedi

A
  • Avoid rough handling
  • Remove from environment
  • Remove any wet clothing
  • Insulate and blankets
  • Cover head
  • Assess hemodynamics and ABC, check for at least 60 seconds
  • Provide humidified O2 (104-107 F, 40-42 C) if resus needed
  • Warm Fluids
  • DO NOT: Massage extremities
17
Q

Obstetrical Emergencies

A
  • Expose as needed to assess for bleeding, breech birth, crowning, prolapsed cord, limb presentation.
  • Exceptions for digital insertion:
    a.) Management of baby’s airway in breech presentation
    b.) Prolapsed cord
    > knee to chest or t-berg
    > Assess for blood flow and maintain with gentle pressure if needed
  • Remember regular travel position is LLR
  • Eclamptic Seizures
    a. ) Lorazepam: 2-4 mg slow IV/IO/IM or
    b. ) Diazepam: 5-10 mg slow IV/IO/IN or
    c. ) Midazolam: 2.5-5 mg IV/IO/IM/IN

MEDCONTROL

  • Additional IV fluids
  • Mag: 1-4 g IV/IO over 10 min (eclapmsia)
  • Ca++Chl-: 10% 2-4 mg/kg slow IV/IO over 5 min (Mag OD)
  • Further anticonvulsant Therapy
18
Q

Newly Born Care

A
  • Dry, Warm, position, and stimulate
  • Clear secretion only if needed:
    a. ) Position supine or on side, head in neural position or slightly extended.
    b. ) Suction with resp distress, oropharynx first . Meconium suctioning only if thick/present, resp depression and/or obstruction.
  • Clamp/cut cord:
    a. ) After initial assessment and it has stopped pulsating
    b. ) Leave minimum of 6 in
  • Prevent heat loss, swaddler tech preferred, esp head.
  • Place skin-to-skin on mother abd/brest
  • Assess Resp:
    a. ) Flick soles of feet, rub back.
  • Assess Circ:
    a. ) Auscultate apical pulse or
    b. ) palp umbilical pulse at base
  • Assign APGAR 1 and 5 min
19
Q

Resuscitation of New Born

A
  • Resp inadequate or chest fails to rise: Vent at room air 40-60 bpm (full term and pre term)
  • HR < 60: Initiate CPR and vent w/ high flow O2. Vent for one minute and reassess pulse.
    a. ) HR 60-80: If responds and rapidly rises with vent, continue vent, and apply monitor
    b. ) HR < 60: Continue CPR with Vent. Consider advanced airway with ETCO2.
  • Defib indicated:
    a. ) Initial: 2 j/kg. Followed by: 4 j/kg
  • Synchro Cardio indicated: 0.5 -1 j/kg
  • Est IV/IO: treat for shock, 10cc/kg of NS over 5-10 min

MEDCONTROL

  • Epi: 1:10,000 (0.01-0.03 mg/kg IV/IO
  • Epi Infusion: Administer 0.1-1 mcg/kg/min
20
Q

Pain/Nausea Management Adult/Pedi

A

Pain:
- Adult:
a.) Morphine: 2 mg IV/IO/IM/SC q 5 min, max of 10 mg
OR
b.) Fentanyl: 1 mcg/kg slow IV/IO/IM/IN, max of 150 mcg

  • Pedi:
    a.) Morphine: 0.1 mg/kg IV/IO/IM/SC, max single of 5mg
    OR
    b.) Fentanyl: 1 mcg/kg slow IV/IO/IM/IN, max of 150 mcg

Nausea:

  • Adult: Zofran 4 mg IV/IO/IM or disintegrating tablet
  • Pedi:
    a. ) >/= 25 kg: 4 mg IV/IM or ODT
    b. ) <25 kg: 2 mg IV/IM or ODT

MEDCONTROL
- Additional doases

21
Q

Seizures Adult

A
  • If pt is Rx rectal gel diazepam: Assist caregiver in administration
  • Vagus Nerve Stimulator: Suggest family pass magnet over q 3-5 min, total of 3x; assist if needed.
    a. ) Note: do not delay med admin
  • Cardiac Monitor and 12 if feasible
  • Status Epilepticus: Seizure lasting >5 min. Use one of the following.
    a. ) Midazolam: 2.5-5 mg slow IV/IO/IM/IN
    b. ) Lorazepam: 2-4 mg slow IV/IO/IM
    c. ) Diazepam: 5-10 mg slow IV/IO/IM/PR

MEDCONTROL

  • Additional doses
  • Mag: 1-4 g IV/IO over 10 min if suspected eclampsia.
    a. ) Note: Eclampica seizures can occur up to several weeks s/p birth

Note: Beznos contraindicated with head injury or hypotension Consult with MC.

22
Q

Seizures Pedi

A
  • If Rx diazepam rectal gel, assist care giver in administration
  • Vagus Nerve Stimulator: Have Family and/or assist pass magnet over q 3-5 min, total of 3x.
    a. )Note: do not delay med administration
  • Status Epilepticus: Choose one of the following.
    a. ) Midazolam: 0.05 mg/kg IV/IO/IM/IN, max single dose of 4 mg OR
    b. ) Lorazepam: 0.05-0.1 mg/kg IV/IO/IM slow (dilute 1:1 NS), max single of 2 mg OR
    c. ) Diazepam: 0.25 mg/kg IV/IO/IM, max single 5-10 mg of rectal dose of 0.5 mg/kg unless contraindicated.

MEDCONTROL
- Additional doses

23
Q

Shock - Adult

A
  • Determine and treat underlying causes
  • Physiological Signs:
    a. ) AMS
    b. ) Rapid pulse cannot be detected
    c. ) SBP <100
  • Cardiogenic:
    a. ) Assess and treat for Pulmonary Edema and/or CHF
    b. ) No Fluid Bolus
  • Distributive Shock:
    a. ) Fluid vol administered based on hemodynamic stability
  • Hypovolemic Shock:
    a. ) Control bleeding as needed
    b. ) Fluid vol administered based on hemodynamic stability
  • Obstructive Shock:
    a. ) Fluid vol administered based on hemodynamic stability

MEDCONTROL

  • Cardio/Hypovolemic/Obstructive: Dopamine 2-20 mcg/kg/min IV/IO
  • Obstructive Shock: Needle decompression with tension pneumothorax.

Note: S/S of persistent Hypoperfusion or S/S worsen, consider dopamine via med control regardless of etiology in the absence of hemorrhagic shock.

24
Q

Pts w/ uncontrolled hemorrhagic or penetrating injuries

A
  • Restrict IV fluids. Delay aggressive fluid resuscitation until operative intervention may improve then outcome.
  • Pt should be reassessed frequently, w/ special attention given to the lungs to ensure vol overload does not occur.
  • Several Mech that can worsen pt outcome w/ IV fluids:
    a. ) Dislodgement of clots
    b. ) Dilution of clotting factors
    c. ) Acceleration of hemorrhage by elevating BP
25
Q

Shock - Pedi

A
  • Keep pt supine
  • Prevent heat loss if not febrile
  • Determine and treat underlying causes
  • Distributive Shock:
    a. ) Fluid Resuscitation: Therapeutic End-point to fluid resuscitation in order of importance
    1. ) Cap refill
    2. ) Normal Pulse
    3. ) No difference btw peripheral and central pulse
    4. ) Warm extremities, normal mental status
    5. ) Noramal BP
  • Hypovolemic Shock:
    a. ) Control Bleeding as indicated
    b. ) Fluid Resuscitation: As with distributive shock

MEDCONTROL:
- Regardless of etiology, and in the absents of hemorrhagic shock, if S/S of hypoperfusion persist or S/S worsen consider dopamine with length based tape via medcontrol

  • Needle Decompression for tension pneumothorax
26
Q

Stroke

A
  • Preform Mass Stroke Scale of equivalent
  • Clearly determine time of onset
  • First symptoms onset 4.5 hrs tx to appropriate facility according to local guidelines/agreements
  • Elevate stretcher to 30 degrees
  • Consider taking family member of bystander to cooberate onset time
27
Q

Mass Stroke Scale

A
  1. ) One or more of the following
    - Facial Droop (Show teeth or smile)
    a. ) Normal: Both sides of face move equally
    b. ) Abnormal: One side of face does not move as well
  • Arm Drift: (Close eyes and extend arms for 10 seconds)
    a. ) Normal: No drift or both arms drift equally
    b. ) Abnormal: One arm drifts/moves down compared to other or one more noticeably weaker than other
  • Speech: (Score first attempt: The sky is always blue in Boston)
    a. ) Normal: Correct words and no slurring on first attempt
    b. ) Abnormal: Incorrect/unable to speak words, and/or slurring
  1. ) One or more Sudden Acute Stroke Symptoms:
    - Sudden numbness, weakness/paralysis, especially if unilaterally
    - Sudden confusion, trouble speaking or understanding words
    - Sudden trouble seeing in one/both eyes
    - Sudden trouble walking, loss of balance or coordination
    - Sudden severe h/a w/ no known cause
28
Q

Nerve Agents Organophosphate Poisoning: Adult/Pedi

A 
- Assess for SLUDGEM:
 S- Salivation
 L- Lacrimation
 U- Urination
 D- Defecation 
 G- Gastric distress
 E- Emesis 
 M- Muscle twitching/ miosis (pupil constriction) 
- Assess for Killer Bs: Bradycardia, Bronchorrhea, Bronchospasm
  • Administer 3 DuoDote kits
  • If S/S persist administer:
    a.) Atropine: 2 mg IV/IO; q 5 min until secretions clear
    b.) Pralidoxime: 1-2 G IV/IO over 30-60 min
    c.) Diazepam: 5 mg IV/IO q 5 or 10 mg Auto-injector q 10 min, prn. Diazepam not available may consider one of the following.
    >Lorazepam: 1 mg IV/IO may repeat once in 5 min, or 2 mg IM may repeat once in 10. OR
    > Midazolam: 2.5 mg IV/IO/IN q 5 min, or 5 mg IM q 10 min, prn.

MEDCONTROL

  • Additional doses
  • Pralidoxime Maint Infusion: up to 500 mg/hr (max od 12 g/24hrs)
29
Q

Poisoning/Substance Abuse/OD/Toxicology: Adult/Pedi

A
  • OD: Naloxone 0.4-2mg IV/IO/IM/IN repeat as indicated
  • Alcoholism: Consider Thiamine 100 mg IV/IO/IM

MEDCONTROL
- CBB OD/hypermag: Ca+Chl- 10% 2-4 mg IV/IO slow over 5 min
- Na+HCO3: 0.5-1mEq/kg IV/IO (eg: TCA, ASA, Acidosis, Barbiturate OD)
- Atropine: 2-5 mg IV/IO (eg: Organophosphate OD)
- Albuterol: 2.5-3 mg neb (eg: Bronchospasm)
- Furosemide: 40 mg IV/IO (eg: Pulm Edema/CHF)
- Diazepam: 5-10 mg slow IV/IO/IM/PR; or
- Lorazepam: 2-4 mg slow IV/IO/IM (seizures); or
- Midazolam: 2.5-5 mg IV/IO/IM/IN
- Amyl Nitrate: Crush, administer under nose with high flow O2 for 15/30 sec.
- Cyanide Antidote Kit: If available
a.) 2 Amyl Nitrate inhalants
b.) 3% Na+ Nitrate: (stop amyl nitrate)
> Adult: 10 mL slow IV/IO over 2-4 minutes
> Pedi: 0.2 mL/kg (up to 10 mL) slow IV/IO over 5 min
c.) Na+ Thiosulfate 25%:
> Adult: 50 mL IV/IO
> Pedi: 5 mL of Na+ thiosulfate per 1 mL of Na+ Nitrate.
> Note: if hypotension develops, STOP all nitrates, treat for shock, and consider dopamine
- Hydroxocobalamin: 5 gm IV/IO for cyanide toxicity
- Glucagon: 1-5 mg IV/IO/IM for BB/CBB OD

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