Protocol Knowledge

Question 1

ACS Tx (Adult)

Answer 1

ASA 160 mg PO (not req if taken own as per dispatch)
NTG spray 0.4 mg SL (Q 5 min, SBP > 100)
NTG patch 0.2 mg/h (apply w/ 2nd spray, SBP > 100)
Fentanyl 25 mcg IV (Q 5 min, max 200 mcg, SBP > 100 , Sp02 > 95%)

Obtain a 12Lead within 10 min of Pt contact.

Question 2

STEMI (Option 1)

Answer 2

(NOT A CANDIDATE)
Transport to SBGH ED.
Continue ACS Tx.

Question 3

STEMI (Option 2)

Answer 3

(THROMBOLYTICS)
Req DCPO for TNK kit.
Tenecteplase IV (weight-base chart on kit/protocol)
Clopidogrel PO 300 mg (age <75) or 75 mg (age 75+)
Renal Failure - UF Heparin 60 U/kg IV (max 4000 U)
Good Renal - Enoxaparin 30 mg IV + 1 mg/kg SC (max 100 mg) (age <75) or 0.75 mg/kg SC (max 75 mg) (age 75+).

Question 4

STEMI (Option 3)

Answer 4

(DIRECT FOR PCI)
Ticagrelor 180 mg PO.
UF Heparin 70 U/kg IV (max 10 000 U).

Question 5

Analgesic for Transcutaneous Pacing

Answer 5

Tx for discomfort with following.
A: Fentanyl 25 mcg IV (Q 5 min X3, Q 10 min, no max) and/or Midazolam 1-2.5 mg IV (Q 5 min X3, Q 10 min, no max).
T: Fentanyl 0.5 mcg/kg IV (max 25 mcg) (Q 5 min X3, Q 10 min, no max) and/or Midazolam 0.05 mg/kg IV (max 1 mg) (Q 5 min X3, Q 10 min, no max)
P: &laquo_space;Fentanyl 0.5 mcg/kg IV (max 25 mcg) (Q 5 min X3, Q 10 min, no max) and/or Midazolam 0.05 mg/kg IV (max 1 mg) (Q 5 min X3, Q 10 min, no max)&raquo_space;.

Question 6

Synchronized Cardioversion

Answer 6

PreTx for sedation (SBP > 90 and SpO2 > 95%)
A: Midazolam 1-2.5 mg IV.
T: Midazolam 0.05 mg/kg IV (max 2.5 mg).
P: No Tx.

Question 7

Non-traumatic Shock

Answer 7

A: NS 250 mL IV (II/III/IV, PRN to max 2000 mL).
T: NS 10 mL/kg IV (II, over 20 min if DKA, PRN) 20 mL/kg IV (III/IV, PRN).
P: &laquo_space;NS 10 mL/kg IV (II, over 20 min if DKA, PRN) 20 mL/kg IV (III/IV, if class IV can use IO, PRN)&raquo_space;.

Question 8

LVAD

Answer 8

Do not cardiovert or pace.
Troubleshoot LVAD.
Auscultate LUQ for hum of working LVAD.
Do not place V5 and V6 to avoid 60 cycle interference.
Transport to SBGH.

Question 9

Hypoglycemia

Answer 9

A: Glucose paste (no max) || D50W 50 mL IV (Q 10 min, 1X) || Glucagon 1 mg IM/SC.
T: Glucose paste (no max) || D50W 50 mL IV (Q 10 min, 1X) || Glucagon 1 mg IM/SC.
P: Glucose paste (no max) || &laquo_space;1-9 yo - D50W 1 mL/kg IV (1x dose), <1 yo - D25W 2 mL/kg IV (1x dose) || Glucagon 0.02 mg/kg IM/SC (max 1 mg)&raquo_space;
N: &laquo_space;<72h & <2.6 or >72h & <3.3- D10W 10 mL/kg IV || Glucagon 0.02 mg/kg IM/SC (max 1 mg)&raquo_space;

Question 10

Chemical Restraint

Answer 10

Attempt de-escalation, attempt vitals w/ BGL.
If GCS <14, use Haloperidol only.
If Olanzapine given, use Midazolam only.
A: <50 kg - Haloperidol 5 mg IM + Midazolam 1 mg IM (Q 5 min max 1x || no max if narcotics)
>50 kg - Haloperidol 5 mg IM + Midazolam 2 mg IM (Q 5 min max 1x || no max if narcotics)
>60 yo - Haloperidol 2.5 mg IM + Midazolam 0.5 mg IM (Q 5 min max 1x || no max if narcotics)
T: 14-16 yo - Midazolam 0.05 mg/kg IM (max 2.5 mg, 1x dose)

Question 11

Increased ICP

Answer 11

If advanced airway (ETT) is considered …
A: Lidocaine 1 mg/kg IV (max 100 mg) RR 20/min
T: Lidocaine 1 mg/kg IV (max 100 mg) RR 25/min
P: (1-9 yo) RR 25/min, (< 1 yo) RR 30/min
Once ETCO2 available target of 30-35.
Elevate head 30 degrees.

Question 12

Suspected Opiate Overdose

Answer 12

If alt LOC or RR < 8/min or less than age normal …
A: Naloxone 0.4 mg - 2 mg IM/IV PRN
T: Naloxone 0.4 mg - 2 mg IM/IV PRN
P: (<20 kg) Naloxone 1 mg IM PRN, (>=20 kg) Naloxone 2 mg IM PRN.

Question 13

Tricyclic Overdose

Answer 13

If TCA confirmed and QRS >0.12 sec ...
A:  Sodium Bicarb 100 mEq IV
T:  Sodium Bicarb 2 mEq/kg IV
P:  << 2 mEq/kg IV >>
If dysrhythmia continues treat as Wide Complex Tach

Question 14

Amphetamine type Stim Toxicity

Answer 14

Confirm Amphetamine use in last 48 hours, has no acute medical complaint, and showing signs of hallucination or agitation …
A: Olanzapine 10 mg PO

Question 15

Seizure

Answer 15

A: Midazolam 2.5 mg IV (Q 5 min, max 10 mg) || 0.2 mg/kg IM (max 10 mg, max 1x)
T: (>=20 kg) Midazolam 2.5 mg IV (Q 5 min, max 10 mg), (<20 kg) Midazolam 0.15 mg/kg IV (Q 5 min, max 10 mg) || (>40 kg) 0.2 mg/kg IM (max 10 mg, max 1x), (13-40 kg) 0.2 mg/kg IM (max 5 mg, max 1x)
P: &laquo_space;(>=20 kg) Midazolam 2.5 mg IV || 5 mg IN (Q 5 min, max 4X), (<20 kg) Midazolam 0.15 mg/kg IV || 0.3 mg/kg IN (Q 5 min, max 4X)&raquo_space;

A: treat BGL if <4 mmol/L
T: treat BGL if <3 mmol/L
P: (>72 days) treat if BGL <3mmol/L, (<72 days) treat if BGL <2.6 mmol/L

Question 16

Postpartum Hemorrhage

Answer 16

A: Oxytocin 5 mg IM/IV. If significant hemorrhage: Oxytocin 10 mg in 1000 mL NS IV, run wide open
T: Oxytocin 5 mg IM/IV. If significant hemorrhage: Oxytocin 10 mg in 1000 mL NS IV, run wide open

Question 17

Epinephrine for Anaphylaxis

Answer 17

A: 0.3 mg (1:1000) IM (Q 10 min, max 1x)
T: 0.3 mg (1:1000) IM (Q 10 min, max 1x)
P: (5-9 yo) 0.3 mg (1:1000) IM (Q 10 min, max 1x), (1-4 yo) 0.2 mg (1:1000) IM (Q 10 min, max 1x), (0-1 yo) 0.1 mg (1:1000) IM (Q 10 min, max 1x)

If Pt deteriorating 10 min post 2nd dose:
A: 0.1 mg (1:10 000) IV (over 5 min)
T: 0.1 mg (1:10 000) IV (over 5 min)
P: &laquo_space;0.01 mg/kg (1:10 000) IV (over 5 min)&raquo_space;

Question 18

Diphenhydramine

Answer 18

A: 25 mg IV (Q 15 min max 1x).
T: 1 mg/kg IV (max 25 mg, Q 15 min max 1x)
P: &laquo_space;1 mg/kg IV (max 25 mg, Q 15 min max 1x)&raquo_space;

Question 19

Asthma/COPD

Answer 19

A: Salbutamol 2.5 mg NEB or 400 mcg MDI (Q 15 min max 3x, continuous if critical) || Combivent 1 amp NEB (Q 15 min max 3x, continuous if critical)
T: Salbutamol 2.5 mg NEB or 400 mcg MDI (Q 15 min max 3x, continuous if critical) || Combivent 1 amp NEB (Q 15 min max 3x, continuous if critical)
P: Salbutamol 2.5 mg NEB or 400 mcg MDI (Q 15 min max 3x, continuous if critical)

• Combivent 1 amp = 0.5 mg Ipratroprium + 2.5 mg Salbutamol
• Pt <1 yo requires Dx of asthma otherwise consider bronchiolitis
• If critical and no response to prior Tx consider IM Epinepherine Tx as per Anaphylaxis. &laquo_space;MS/ACPP for Peds&raquo_space;

Question 20

Pumonary Edema (Cardiac Origin)

Answer 20

A: NTG spray 0.4 mg SL (Q 5 min if SBP >100). Furosemide 40 mg min IV (or daily dose max 160 mg) (single dose if SBP >100)
T: no protocol
P: no protocol

• Apply NTG patch 0.2 mg/hr after first spray.
• If brochospasm present, consider Salbutamol as per Asthma/COPD.
• Consider CPAP if increased WOB or Sp02 <=92%.

Question 21

Sedation (Post Intubation)

Answer 21

A: Midazolam 2 mg IV (Q 5 min first 3x then Q 10 min, no max)
T: Midazolam 2 mg IV (Q 5 min first 3x then Q 10 min, no max)
P: no protocol

Question 22

Symptomatic Bradycardia

Answer 22

A: Atropine 0.5 mg IV (Q 3 min, max 0.04 mg/kg or 3 mg)