Protocol test 2 Flashcards
Precautions when administering Versed IN
Midazolam has a pH of < 4 and will sting when given intranasally.
Versed dose for sedation/induction ADULT
0.2mg/kg IV/IO (may repeat x 1 up to 10mg)
Versed dose for anxiety/agitation/sedation ADULT
IV/IO/IM: 1-5 mg q5 min, maximum dose 10 mg.
Monitor respiratory status; may give alone or in combination with an antipsychotic.
What population do you reduce the dose of Versed and by how much
Reduce by 50% in chronically ill or geriatric patients
Post intubation Versed infusion concentration and dose range ADULTS
1-10 mg/hr continuous infusion
Mix 2 ml of Midazolam 10mg/2ml in 100ml NS. (0.1mg/mL)
Time requiring before administering Versed for seizure
more than 2 minutes
Versed dose for seizures
Patients >40 KGs 10mg IM, may repeat x1 (preferred), alternatively 5mg IV, may repeat x1
Patients 13-40 KGs 5 mg IM, may repeat x1, alternatively 2.5 mg IV, may repeat x1
Intervention if seizure does not end after 2 doses
Call for further orders for possible Midazolam gtt
Considerations and dose for Versed for OB seizure
Give after 1 minute of seizure for OB population
Midazolam 10 mg IM, may repeat x1 (preferred), alternatively 5mg IV, may repeat x1 (same as adult population)
For continued seizure activities repeat Midazolam dosage and prepare to manage airway/ventilation per Airway protocol.
Special considerations within pain protocol for Versed
In adults receiving Ketamine, consider Midazolam 1 mg IV/IO, if hemodynamically stable, to attenuate psychotropic effects and recovery agitation.
Used to treat muscle spasms along with analgesics per Pain Protocol
Versed dose for anxiety/agitation/sedation PEDS
IV/IO:
0-5yo: 0.05-0.1 mg/kg Q 10-15 min, titrate to effect
6-12yo (less than 50Kg): 0.025-0.05 mg/kg
>12yo: Adult dosing
IM: 0.05 to 0.1 mg/kg, max total dose 10mg
IN: 0.2mg/kg single dose, may repeat in 15 min, max dose 10mg/dose
Versed dose for induction/sedation PEDS
0.1 mg/kg IV/IO
Versed post intubation continuous infusion PEDS
0.05-0.12 mg/kg/hr, titrate to desired effect
Versed seizure dose PEDS
Midazolam 0.2mg/kg IV/IO/IN/IM and repeat q 5 minutes for prolonged or recurrent seizure activity. Max single dose 5mg
Norepi drip dose range and concentration
0-1 mcg/kg/min (IBW), titrate to effect
Mix 4 mg in 250 mls D5W
Norepi drip dose range and concentration PEDS
0.1-2 mcg/kg/min
Mix 4 mg in 250 D5W
Epi drip dose range and concentration
0-0.5 mcg/kg/min (IBW), titrate to effect
Mix 1 mg (1mg/1ml) in 100 ml NS
Epi drip dose range and concentration PEDS
0.1-1 mcg/kg/min
Mix 1 mg (1mg/1ml) in 100 ml NS
Ketamine infusion contraindications
globe injury, liver disease, uncontrolled hypertension, or history of psychosis. Avoid in older patients, schizophrenics, and patients with heart disease experiencing agitated delirium.
Duration of action and possible side effects of Ketamine
The duration of action of Ketamine is approximately 10 to 20 minutes.
Notable side effects may include hypertension and tachycardia (usually mild and transient), laryngospasm (uncommon), emergence reactions, and vomiting. Side effects may be more common with rapid IV administration. Although respiratory complications are uncommon, clinicians using Ketamine must be prepared to manage airway obstruction.
Population to avoid use of Ketamine for pain/agitation
Aortic Emergency patients due to its mechanism of action and potential to worsen the patients’ overall outcome.
Benefits of Ketamine for the respiratory system
consider the use of Ketamine per anxiety/agitation protocol as Ketamine has bronchodilatory properties which may help optimize both oxygenation and ventilation.
Ketamine sedation and induction dose ADULT and PEDS
1-2 mg/kg IV/IO
Ketamine dose if sedation required for Moderate to Severe allergic reaction ADULT and PEDS:
0.5-1 mg/Kg IV/IO if wheezing or bronchorrhea.
Ketamine dose for Anxiety/agitation/sedation ADULT and PEDS:
IV/IO: 0.5-1 mg/kg q 10 min, titrate to effect
IM: 0.5-2 mg/kg, may repeat x1 at 0.5-1 mg/kg
IN: 0.5-3 mg/kg, may repeat x1 at 0.5-1 mg/kg
Ketamine dose for pain management ADULT and PEDS
IV/IO/IM/IN: 0.15-0.3 mg/kg q 5-10 min
Ketamine infusion dose range and concentration for pain management
Continuous infusion: 0.1-0.2mg/kg/hr (Transports greater than 30 minutes, after initial bolus, with no contraindications)
Mix 500mg of Ketamine in 100ml of NS. (5mg/ml)
Post intubation Ketamine doses ADULT
1-2 mg/kg q 10 minutes as needed for continued sedation
Excited Delirium 0.5-2 mg/kg IM initially. Continue with 1-2 mg/kg IV.
Continuous Infusion: 0.1- 2.0 mg/kg/hr.
Mix 500mg of Ketamine in 100ml of NS. (5mg/ml)
Ketamine dose post intubation PEDS
Post intubation: 1 – 2 mg/kg IV/IO q 10 min, titrate to effect.
Continuous Infusion: 0.1-2.0 mg/kg/hr
Mix 5 ml ketamine (500mg/5ml) in 100ml NS (5mg/mL)
Rocuronium dose for intubation ADULT and PEDS
1mg/kg IV/IO (IBW for adults)
When to start continued paralytics
if requiring PEEP>12 and FiO2 100%
Roc continued paralysis dose ADULT and PEDS
1mg/kg IV/IO every 30 minutes
Special considerations for Roc and PEDS patients
Duration is shortest in children 2-11 years and longest in neonates and infants.
Vecuronium dose for intubation ADULT and PEDS
0.1mg/kg IV/IO (IBW for adults)
Vec dose for continued paralysis ADULT and PEDS
Vecuronium 0.1mg/kg IV every 30 minutes
Special precautions for Zofran
has rarely been associated with QT prolongation and precipitation of Torsades de Pointes. Use cautiously in family history of prolonged QT, ventricular arrhythmias, hepatic insufficiency, and recent myocardial infarction.
Zofran ADULT dose
Ondansetron 4 mg IV/IO/IM/PO q 15 minutes for unrelieved nausea and/or vomiting, maximum total dose 12 mg.
Zofran PEDS dose
Ondansetron 0.15 mg/kg (max 4 mg) IV/IO/PO q 15 minutes for unrelieved nausea and/or vomiting, maximum 3 doses.
Level for hypoglycemia in ADULTS
<60
Intervention for hypoglycemia in ADULTS
Give 100-200 mL of D10.
Level for hypoglycemia in PEDS
PEDS < 1 month of age:
BGL<40
PEDS > 1 month of age:
BGL<60
Intervention for hypoglycemia in PEDS
D10 2ml/kg IV/IO
Intervention to prevent recurrent hypoglycemia PEDS
After euglycemia has been achieved via D10 boluses in the pediatric population, a dextrose infusion should be initiated to prevent recurrent hypoglycemia:
<1 month of age: D10 at 5 mL/kg/hr
>1 month of age: D10 at 2 mL/kg/hr
Increase rate by 1 mL/kg/hr every 15 min to maintain blood sugar above 40 for infants and above 60 for children.
How often do you check blood glucose in a patient with a hypoglycemic episode
every 10 minutes; repeat Dextrose as needed until patient alert and oriented or normal glycemia is achieved.
When can oral glucose be given
the patient is alert with a glucose level <60 mg/dl. (CCT only)
Interventions per DKA protocol if BG <250
begin D10 with maintenance fluids at 150cc/hr
Interventions per DKA protocol if BG <100
stop insulin infusion and recheck BGL in 15 minutes, continue D10 NS.
Interventions per DKA protocol if BG <80 despite D10
give 50-100 mL D10 bolus and recheck the BGL in 15 minutes. Continue running the D10 maintenance infusion after the bolus is completed.
Interventions per DKA protocol if BG <250 PEDS
After BGL reaches 250, D10 should be initiated at a rate of 1.5x the normal calculated rate and insulin infusion should be continued at the same rate.
Goal level to maintain BG above for PEDS in DKA during transport
above 150 mg/dL
Interventions per DKA protocol if BG <100 PEDS
stop insulin infusion and continue D10 at 1.5x the normal rate and consult medical direction
Maintenance rate for fluids for PEDS
4 ml/kg for the first 10kg plus
2 ml/kg for the next 10kg plus
1 ml/kg for every kg after that
Lidocaine dose for R on T PVCs
1.5mg/Kg IV/IO
Lidocaine continuous infusion dose range and concentration
Lidocaine drip at 2-4 mg/min.
Lidocaine premix is 2gm in 500mL NS (4mg/ml)
Lidocaine pulseless VT/VF (1st and 2nd dose)
1-1.5mg/kg THEN
0.5-0.75mg/kg
Lidocaine pulseless VT/VF ETT dose
3mg/kg and repeated once.
if an IV is established after the ETT dose is given Lidocaine may be repeated at 1.5mg/kg IV
Lidocaine dose for pain in IO
IO: Lidocaine 2% (cardiac bristojet) 20 – 40 mg IO Slowly over 2-3 minutes
Lidocaine dose for pain associated with IV insertion ADULT and PEDS
Intradermal: 0.2 ml or less of 2% lidocaine
Lidocaine dose ain secondary to IO infusion PEDS
IO: Lidocaine 2% 0.5-1 mg/kg IO not to exceed 30 mg
Lidocaine Pulseless VT/VF (1st and 2nd dose) PEDS
1mg/kg IV/IO, repeat for all subsequent doses
Lidocaine Pulseless VT/VF ETT dose PEDS
ET at 2.5 mg/kg, this may be repeated once
If IV is established after the ETT dose is given PEDS:
it may be repeated at 1mg/kg IV/IO.
Lidocaine continuous drip dose range and concentration PEDS:
20-50mcg/kg/min
Lidocaine premix is 2gm in 500mL NS (4mg/ml)
When to consider calling medical control for possible administration of sodium bicarbonate
In Asystole/PEA arrest Adult and PEDS
Sodium Bicarbonate dose for Tricyclic Antidepressant overdose
If QRS > 100 ms: a Sodium Bicarbonate 2-3 mEq/kg IV, max 150 mEq bolus
Follow with the initiation of a Sodium Bicarbonate infusion (40 mEq Sodium Bicarbonate in 250 mL D5W). Remove 40 mL from the D5W bag and inject 40 mL of Sodium Bicarbonate (concentration 0.16mEq/1 mL) and infusion at 250 cc/hr for adults
If the call is originating at a sending facility, mix 150 mEq Sodium Bicarbonate in 1 L D5W.
Sodium Bicarbonate dose for Tricyclic Antidepressant overdose PEDS
Same dose concentration as adults, Sodium Bicarbonate infusion (40 mEq Sodium Bicarbonate in 250 mL D5W)
Run at 2 X maintenance fluid calculation for pediatrics.
Sodium Bicarbonate dose for Salicylate (ASA, oil of wintergreen) overdose
1-2 mEq/k, max 100 mEq, IVP over 3-4 min
Sodium Bicarbonate dose for Salicylate (ASA, oil of wintergreen) overdose PEDS
1.5-2 times calculated maintenance rate
what patients should Atropine be used with caution
in the presence of acute coronary ischemia or MI
Atropine dose if patient is bradycardic during intubation, ventilation with a BVM with PEEP valve to 8 and high flow oxygen, if no response
0.02 mg/kg
Atropine dose for bradycardia that is not a 2nd degree type 2 or 3rd degree heart block with signs of poor perfusion:
Atropine 1 mg IV/IO every 3-5 min. Max 3mg
Atropine dose for hypersecretion related to Ketamine administration
Atropine 0.4 mg IV
Atropine dose for Organophosphate overdose
Atropine 4 mg IV, doubled every 3-5 min for bronchorrhea or heart rate less than 50, until improvement in symptoms.
Atropine dose if patient is bradycardic during intubation, ventilation with a BVM with PEEP valve to 3-8 and high flow oxygen, if no response PEDS
Atropine 0.02 mg/kg minimum dose of 0.1mg, maximum dose of 0.5 mg
Atropine dose for hypersecretion related to Ketamine administration PEDS
Atropine 0.01 mg/kg IV/IO (minimum 0.1 mg, maximum 0.4 mg)
Atropine dose for increased vagal tone or primary AV block PEDS
Atropine 0.02mg/kg IV/ IO/ET (Minimum dose is 0.1mg, maximum dose is 0.5mg), may repeat once in 3-5 minutes.
Atropine dose for Organophosphate overdose PEDS
Atropine 0.05mg/kg IV (max 3mg) every 3-5 minutes for bronchorrhea or heart rate less than 60, until improvement in symptoms.
Patients to use caution with for administering Epi
patients who are >50 years of age, have a history of cardiac disease or if the patient’s heart rate is >150. Epinephrine may precipitate cardiac ischemia.
Risks associated with IV epi administration
high incidence of ventricular dysrhythmias, hypertensive crisis, and pulmonary edema.
Mechanism of action, duration and time of onset
Epinephrine has Alpha 1 and 2 and Beta 1 and 2 effects, so it is an inopressor. The onset of effects are seen in <1 min and while the duration of a single dose may last 10 minutes, in almost all cases the effects are gone within five minutes.
Concentration and dose of push dose Epi
5-20mcg as needed Q1-5 minutes
Mix 1 ml of Epinephrine 0.1mg/mL in 9 ml saline flush. (10mcg/mL)
Epi dose for moderate allergic reaction
Consider Epinephrine 0.5mg (1mg/1mL) IM, with progression of symptoms or history of severe reaction. May repeat x1 dose
Epi dose for severe allergic reaction
Epinephrine 0.5mg IM (1mg/1mL)
Epinephrine 0.1mg Q 3 min, up to a max of 0.3 mg IV/ETT (1mg/10mL) only if impending or actual cardiac arrest. IV Epi should be reserved for symptoms refractory to IM injection Epi or impending cardiovascular collapse. Use as a bridge to an Epinephrine infusion.
ACLS Epi dose
1mg (0.1mg/ml) IV/IO
2.5mg ETT
repeat every 3-5 minutes
Epi dose for asthma/reactive airway with imminent respiratory failure:
administer 0.3mg (0.3ml of 1mg/ml) IM.
If no response to IM
give 0.3mg (3 ml of 0.1mg/ml) IV
Push dose Epi PEDS:
Peds 1 mcg/kg, max dose 20mcg
Mix 1 ml of Epinephrine 0.1mg/mL in 9 ml saline flush. (10mcg/mL)
Epi for moderate allergic reaction PEDS
Consider Epinephrine 0.01mg/kg IM (1mg/1mL) max 0.3mg with progression of symptoms or history of severe reaction. Repeat x1 if needed.
Epi for severe allergic reaction PEDS
Epinephrine 0.01 mg/kg IM (1mg/1mL), max 0.3mg. Repeat x1 if needed
Epinephrine 0.01 mg/kg IV (0.1mg/1mL) q 3 min, max single dose of 0.1 mg. Max total dose of 0.3 mg and use as a bridge to Epinephrine Infusion 0.1-1 mcg/kg/min, when symptoms are refractory to IM Epinephrine.
PALS Epi dose
0.01 mg/kg (0.1mg/ml) IV/IO push OR
0.1 mg/kg (0.1mg/ml) ET
Repeat every 3-5 minutes
Epi dose for Asthma PEDS with imminent respiratory failure
Epinephrine 0.01mg/kg of 1 mg/ml up to 0.3mg IM
Epinephrine 0.01mg/kg (0.1mg/ml) IV/IO to max dose of 0.3mg
NRP Epi dose (HR <60)
0.02mg/kg= 0.2 ml/kg (0.1mg/ml) UVC/IV/IO OR
0.1 mg/kg= 1 ml/kg (0.1mg/ml) ETT if no UVC/IV/IO access.
Once IV/IO/UVC established, may immediately give IV dose
Adenosine dose ADULT
Adenosine 6 mg IVP, if no response
Adenosine 12 mg IVP
Adenosine dose PEDS
Adenosine 0.1mg/kg IV/IO, if no response
Adenosine 0.2mg/kg IV/IO
Benadryl dose for extrapyramidal reaction
25 mg IV or IM
Benadryl dose for Mild allergic reaction:
25-50 mg IM or slow IVP
Benadryl dose for Moderate or severe allergic reaction
25-50 mg slow IVP
Benadryl dose for Mild allergic reaction PEDS
1 mg/kg IV or IM, max 25mg
Benadryl dose for Moderate or severe allergic reaction PEDS
1 mg/kg IV, max 25mg
Benadryl dose for vomiting unresponsive to Ondansetron and Promethazine, or if there is a contraindication to these drugs:
12.5 – 25 mg IV/IM/IN
Max PEDS dose for amio
15mg/kg in 24 hours
Amio dose AFRVR
Amiodarone 150 mg IV/IO x1 over 10 min
Amiodarone infusion IV/IO at 1 mg/min (40 ml/hr). Mix 150 mg Amiodarone in 100mL NS (1.5mg/ml)
Amio dose for Pulseless VT/VF (1st and 2nd doses):
Amiodarone 300mg IV/IO
Amiodarone 150mg IV/IO
Wide complex tachycardia with a pulse without signs of poor perfusion:
Amiodarone 150 mg IV/IO over 10 minutes. If rhythm persists,
Amiodarone drip at 1 mg/min (40 ml/hr) if transport time is over 30 minutes.
Amio dose Pulseless VT/VF (1st and 2nd dose) PEDS:
Amiodarone 5mg/kg IV/IO max 300mg
Amiodarone 5mg/kg IV/IO max 150mg
Amio dose Wide complex tachycardia with a pulse PEDS:
Without signs of poor perfusion:
Amiodarone 5 mg/kg IV/IO over 20 min
With signs of poor perfusion:
Amiodarone 5 mg/kg over 10 min
ADULT ETT dose cardiac arrest drugs
Epinephrine 2.5mg ETT
Lidocaine via ETT at 3mg/kg and repeated once.
Naloxone 0.4 mg dose IV/IO/ET/IM
PEDS ETT dose cardiac arrest drugs
Epinephrine 0.1mg/kg of 1 mg/ml ETT
Atropine 0.02mg/kg IV/ IO/ET (Minimum dose is 0.1mg, maximum dose is 0.5mg)
Naloxone 0.1mg/kg max single max dose 0.4 mg q 5 min up to 2mg IV/IO/IM/ET/IN
NRP ETT dose cardiac arrest drugs
Epinephrine 0.1 mg/kg= 1 ml/kg (0.1mg/ml) ETT
IN drugs ADULT
Naloxone 2 mg IN
Ketamine 0.5-3 mg/kg, may repeat x1 at 0.5-1 mg/kg (ANXIETY/AGITATION/SEDATION)
Ketamine 0.15-0.3 mg/kg q 5-10 min (PAIN)
Diphenhydramine 12.5 – 25 mg IV/IM/IN
Fentanyl 1-3 mcg/kg q5-10 min
IN drugs PEDS
Naloxone 0.1mg/kg every 5 min (max single dose of 0.4mg) up to 2 mg IV/IO/IM/ET/IN
Ketamine 0.5-3 mg/kg, may repeat x1 at 0.5-1 mg/kg (ANXIETY/AGITATION/SEDATION)
Versed 0.2mg/kg single dose, may repeat in 15 min, max dose 10mg/dose
Versed 0.2mg/kg IV/IO/IN/IM and repeat q 5 minutes for prolonged or recurrent seizure activity. Max single dose 5mg (SEIZURE)
Fentanyl 0.1-1 mcg/kg q 5-10min,
Fentanyl dose ACS
If no relief with NTG or SBP < 100, Fentanyl 1-2 mcg/kg IVP (to maximum single dose 100mcg), q5min
Fentanyl dose Analgesia and/or attenuation of increased ICP
Consider Fentanyl 2-3 mcg/kg IV/IO prior to induction (Maximum single dose 200 mcg)
Fentanyl dose pain
IV/IO: 1-3 mcg/kg (max single dose 200 mcg) q 5-10min, titrate to effect
IN: 1-3 mcg/kg q5-10 min, titrate to effect
IM: 100 mcg q 1 hr PRN
Fentanyl continuous infusion dose and concentration
Continuous infusion: 25-300 mcg/hr, titrate to effect. Mix 300mcg Fentanyl in 100ml of NS. (3mcg/ml)
Fentanyl dose Analgesia and/or attenuation of increased ICP PEDS
Consider Fentanyl 2-3 mcg/kg IV/IO prior to induction
Fentanyl dose pain PEDS
IV/IO/IN: 0.1-1 mcg/kg q 5-10min, titrated to effect
Heparin dose for ITF with ACS
Heparin bolus: 60 units/kg to max of 5,000 units followed by
Heparin infusion: 12 units/kg/hr, rounded to nearest 50 units, max 1000 units/hr.
Mix 5000 units Heparin in 250 ml NS (20 u/ml)
