Protocols Flashcards
(1002 cards)
1
Q
Abdominal pain/trauma assessment considerations- history
A
-History of traumatic event- mechanism/time
-Vomiting- timing, color, amount
-Stool- timing, color, amount, consistence
-Abdominal surgeries or chronic GI disease
-Previous similar episodes
-Last menstrual period, birth control
-Pregnancy related causes
2
Q
Interventions for patients with suspected or diagnosed bowel obstruction for changes in altitude
A
Place gastric tube prior to flight
3
Q
What exam should be performed for all patients with abdominal trauma
A
eFAST
must document in ePCR: ultrasound completed/indication/impression/image number/ultrasound device number
4
Q
when should an ultrasound be performed on a pregnant patient
A
when they present with lower abdominal pain with or without vaginal bleeding
5
Q
What complication do you prepare for with potential solid organ injury
A
hypovolemia
6
Q
What abdominal injury do you consider a low altitude flight path?
A
If potential for hollow organ rupture
7
Q
when can ischemic cardiac pain present as abdominal pain
A
in elderly patient and/or anterior wall AMI
8
Q
What pediatric diagnosis may present with a chief complaint of abdominal pain
A
pneumonia
9
Q
atraumatic abdominal pain in pediatric patients should warrant what assessment
A
thorough pulmonary assessment
10
Q
ACS assessment considerations- history
A
-Presenting symptoms- chest pain
- Associated symptoms- nausea, diaphoresis, shortness of breath, dizziness, lightheaded, back pain
- Risk factors- familial, smoking, obesity, HTN, DM
-Previous episodes- course, treatment, diagnosis
-Hx of cardiac surgery, pacer/AICD, prescriptions
-Recent illicit drug use
- treatment prior to arrival
-Activity prior to onset
11
Q
Minimum O2 sat goal with ACS
A
at or above 90%
12
Q
timeframe to obtain 12 lead
A
10 minutes
13
Q
STEMI criteria
A
ST segment elevation in two or more contiguous leads
-2mm elevation in leads V2, V3
-1 mm elevation in all other leads
14
Q
Actions for notification after meeting STEMI criteria
A
call STEMI alert to receiving hospital as soon as evident along with the name of cardiologist if known
15
Q
When to perform serial 12 lead ECGs
A
if patient continues to complain of ACS or prolonged transport time to evaluate potential evolving cardiac events
16
Q
Treatment for patients with evidence of inferior wall MI
A
administer 250 mls LR bolus prior to administering NTG unless SBP>150. Repeat boluses to maintain SBP>100.
Monitor pulmonary assessment for development of pulmonary edema
17
Q
nitro administration
A
if SBP greater than 100, give NTG 0.4 SL Q5min x3 or initiate NTG gtt titrated to chest pain relief while maintaining SBP greater than 100
18
Q
A
19
Q
nitro gtt dose
A
5-200 mcg/min
20
Q
nitro gtt concentration
A
50 mg in 250mls D5W (200 mcg/ml)
21
Q
Aspirin administration with ACS
A
give 324 mg chewable ASA. withhold ASA if taken within the last four hours.
22
Q
treatment if no relief of chest pain from NTG or SBP <100
A
-Fentanyl 1-2 mcg/kg (to max single dose 100 mcg) Q5 min
- morphine 2-5mg increments Q5min
23
Q
Interventions if STEMI and SBP >140 and HR >100
A
-metoprolol 5 mg IV Q115min x3 doses as long as SBP >90 and HR >60
-may be given in conjunction with NTG
24
Q
ACS with symptomatic sinus brady associated with inferior MI
A
Consider Epi injusion
25
Epi concentration
1 mg of Epi (1mg/1ml) in 100 mls NS
26
Epi gtt dose
0-0.5 mcg/kg/min (IBW)
27
ACS Heparin orders with confirmed STEMI in the field
if STEMI is called in the field, call the receiving facility for heparin orders to administer prior to or during transport
28
Interfacility transfer with confirmed STEMI heparin administration
If patient has not received Heparin or low molecular weight heparin, administer heparin as follows:
- Heparin bolus: 60 units/kg to max 5000 units
-heparin infusion: 12 units/kg/hr, rounded to the hearest 50 units, max 1000 units/hour
29
heparin gtt concentration
mix 5000 units Heparin in 250 ml NS
30
Contraindications for administering heparin with ACS
-patient received low molecular weight heparin
-INR over 2.5
-Evidence of bleeding, such as extensive bruising, hematemesis, melena, history of intracranial bleed, or evidence of hepatic failure
- antiplatelet medications are not considered a contraindication to heparin
31
Types of low molecular weight Heparins
Enoxaprin (Lovenox), Dlteparin (fragmin), and Tinzaparin (Innohep)
32
ACS what to do if patient is taking or has received na anticoagulant other than a low molecular weight heparin
consult medical control for orders
33
If patient received TNK, what do you do in regards to anticoagulation
must obtain orders for Heparin prior to administration
34
goal temp for interfacility TTM transfer
34-36 degrees celsius
35
treatment for shivering in TTM patient
no not paralyze if possible, choose analgesia and /or sedation first
36
additional consideration for interventions with an inferior MI
consider performing a right sided 12 lead EKG (V4R) to assess right sided ventricular involvement
37
Treatment of heart block associated with ACS
-Wenchebach associated with inferior MI is commonly transient and should be treated conservatively
- Mobitz 2 or 3rd degree associated with anterior MI is commonly permanent. Strongly consider placing pacer pads for transportation
38
antiplatelet medications
ASA, Plavix, Integrilin, Abciximab (Reopro), Tirofiban (Aggrastat), Brilinta, Effient
39
Anticoagulants
Angiomax, Argatroban, Warfarin, Eliquis, Pradaxa, Xarelto
40
Ventilator modes okay to utilize for ARDS
either volume or pressure control
41
goal vent settings with ARDS
Plateau pressures <30 with tidal volumes of 6-8 ml/kg/IBW
42
PEEP parameters for adults and peds for ARDS
May use higher PEEP (up to 14/ up to 10 for pediatrics) without calling medical director. if PEEP >14 at the sending facility, may continue PEEP per sending MD
43
SAT goal with ARDS
88%
44
for ARDS if PEEP >12 and FIO2 100% what other interventions can we do
paralyze with Rocuronium 1 mg/kg IV prior to and/or during transport and bolus every 30 minutes to maintain paralysis.
45
Requirements for ARDS diagnosis
Bilateral diffuse infiltrates on imaging, PAO2:FIO2 ratio <300, acute onset (<1 week), cause felt to not be from fluid overload
46
Classifications of ARDS
-Mild (P:F 200-300)
-Moderate (P:F 100-200)
-Severe (P:F <100)
47
Five P's of supportive therapy
Perfusion, positioning, protective lung ventilation, protocol weaning, preventing complications
48
Action to consider when switching an ARDS patient to the transport vent
Consider clamping the ETT prior to switching to transport vent to retain recruitment of the alveoli
49
ARDS and fluid status goals
ARDS patients do better with lower volume status (goal CVP 4-8) and may benefit from diuresis
50
Inhaled Flolan or Nitric Oxide
may be used by sending facility and may be continued during transport with sending physician orders. Do not suddenly discontinue these as it may cause rebound and fatal hypoxemia
51
Number of intubation attempts for careflight
limit two endotracheal intubation attempts before an alternate airway is used
52
SAT goals during intubation
goal is to assure no SpO2 <90 during intubation attempts.
53
What is required to chart during an intubation
lowest SPO2
54
When should an LMA be used?
An LMA can be used at any point for adult or pediatric patients, at medical crew discretion
55
How to confirm ETT/LMA placement
-Visualization of ETT going through vocal cords
- Appropriate capnography waveform within 30 seconds of airway placement, ETCO2 greater than 10
-Visible chest rise
- Bilateral breath sounds
- Absent epigastric sounds
56
When is it appropriate to transport a patient without an advanced airway?
if unable to insert ETT/LMA but adequate oxygen saturation can be maintained with BVM with PEEP valve set from 3-8.
57
If unable to establish advanced airway or adequately ventilate with BVM, what interventions are done for adult and pediatric patients
Adult: surgical cricothyrotomy
Pediatrics: Needle cricothyrotomy for patients less than 12 y/o
58
When should you confirm placement of an artificial airway?
After every patient move (down a flight of stairs) and after all transfers of care between providers
59
What monitoring is required for all intubated patients
Continuous cardiac and ETCO2 is required, including those receiving CPR
60
What do you monitor continuously on all intubated and perfusing patients
SpO2
61
What position is used on intubated patients to minimize risk of ventilatory associated pneumonia
Elevate head of bed/apply 30 degree reverse trendelenburg unless contraindicated
62
Criteria for using RSI for intubation
-intact gag reflex
-Trismus
- GCS 8 or less
63
prepare equipment and medications using O-BLEAK SCENE checklist
-Oxygen/OPA/NPA
-Bougie
-ET tube
-Ambu bag
-King vision or laryngoscope
-Suction
-Commercial suctioning device
-End tidal setup
- Neuromuscular blockade
-Effective, appropriate induction agent
64
factors to take into account prior to intubating a high shock index patient
for high shock index >1 ensure patient is adequately resuscitated via IV fluids and administer push dose Epi as needed. consider hemodynamically stable induction agents at a reduced dose to prevent further shock
65
Hemodynamically stable induction agents
Etomidate or Ketamine
66
protocol for preoxygenation prior to intubation
pre-oxygenate for 2-5 minutes using high flow oxygen via nasal cannula, assisting ventilation only if apneic
67
goal SAT for pre-oxygenation
100% SPO2
68
oxygenation provided during intubation
passive apneic oxygenation via nasal cannula 15 lpm throughout procedure
69
when to discontinue intubation attempt based on SPO2
if SPO2 drops below 90% in a patient that achieved SPO2 over 95% with passive oxygenation.
70
intervention after terminating intubation attempt
Ventilate with BVM with PEEP valve set from 3-8 to increase SPO2 goal
71
analgesia and/or attenuation to be used in patient with increased ICP
consider Fentanyl 2-3 mcg/kg prior to induction (max single dose 200 mcg)
72
Sedation and intubation drugs and doses
-Ketamine: 1-2 mg/kg
-Midazolam 0.2 mg/kg (may repeat x1 up to 10 mg)
-Etomidate: 0.3 mg/kg
73
paralytic for intubation
- Rocuronium: 1 mg/kg (IBW)
- Vecuronium: 0.1 mg/kg (IBW)
74
IBW algorithm for male and female
Male: 52 kg + 1.9 kg/inch over 5 feet
Female: 49 kg + 1.7 kg?inch over 5 feet
75
if utilizing cricoid pressure, when should you release the pressure
if the patient vomits, release the pressure and suction as needed
76
After induction and paralysis, what criteria must be met prior to intubation
when jaw flaccid and gag is no longer present
77
Interventions if bradycardia occurs during intubation
Ventilate using BVM with PEEP valve, set PEEP to 8 and high flow oxygen, if no response, give Atropine 0.02 mg/kg (max dose 0.5-1 mg)
78
sedation protocol post intubation
continue sedation/analgesia per Pain and Anxiety protocol immediately after medication assisted intubation
79
Continued paralysis- Rocuronium/Vecuronium
Roc: 1 mg/kg every 30 minutes
Vec: 0.1 mg/kg every 30 minutes
Both must be accompanied by Versed/Propofol/ketamine for sedation and/or Fentanyl/Ketamine for analgesia if CPOT >2
80
PEDS analgesia and/or attenuation of increased ICP
consider Fentanyl 2-3 mcg/kg prior to inducation
81
PEDS sedation and induction medications and doses
-Ketamine 1-2 mg/kg
-Midazolam 0.1 mg/kg
82
PEDS paralysis medications and doses
-Roc: 1 mg/kg
-Vec: 0.1 mg/kg
83
Cricoid pressure protocol for pediatric patients
Cricoid pressure is contraindicated in PEDS
84
Continued paralysis for PEDS
-Roc: 1 mg/kg IV every 30 minutes
-Vec: 0.1 mg/kg IV every 30 minutes
85
Different duration in time for PEDs and paralysis
Duration is shortest in children 2-11 yo and longest in neonates and infants
86
Sedation to accompany paralysis in PEDS
Must be accompanied by Versed or Ketamine for sedation and/or Fentanyl or Ketamine for analgesia if FLACC>2
87
Protocols if unable to establish advanced airway for PEDS but can oxygenate with BVM
If oxygen saturation can be maintained by BVM with PEEP set from 3-8, the patient may be transported without an advanced airway.
88
Protocol if unable to establish advanced airway and unable to oxygenate with BVM- PEDS
needle cricothyrotomy is considered for patients <12
89
When to consider antiemetics for intubated patients
for supine patients who have a contraindication to elevated HOB
90
potential complications from Fentanyl in PEDS patients
Rigid chest may occur with rapid administration of
Fentanyl in peds patients and infants and can be treated with Narcan
91
patient positioning that can help improve intubation success rate
consider elevating patient's shoulders and allowing the neck to extend in patients in whom cervical motion restriction is not indicated, especially pediatric patients
92
special considerations for sedation medications for patients in shock
it is recommended to stay on the low end of dosing when using Ketamine or Etomidate
93
Shock index relevance for PEDs patients
shock index is not a reliable factor for mortality in children
94
What can be used on intubated patients to help prevent accidental extubation
cervical collar
95
advanced airways and burn patients
LMA may be an adequate airway management tool in patients with airway burns, the majority of airway burns do not descend below the vocal cords
96
Initial things to check when a patient starts to deteriorate
immediately recheck ETT/LMA position if patient condition starts to deteriorate
97
BVM ventilation between administration of paralytic and intubation
once paralyzed, air can b easily introduced into the stomach with BVM ventilation. Avoid BVM ventilation between administration of paralytic and intubation
98
Treatment of airway obstruction in awake adult
Abdominal thrusts until the obstruction is alleviated or patient is unconscious
99
Treatment of airway obstruction in unconscious patient
-position head, finger sweep, attempt ventilation
-if unable to ventilate, attempt visualization with laryngoscope. If visible, attempt removal with McGill forceps, taking care not to cause further obstruction
- if still unable to ventilate, attempt intubation. If unable, move to surgical cricothyrotomy
100
Treatment of airway obstruction in awake PEDS patient- younger than 1 year old
chest thrusts and back blows
101
Treatment of airway obstruction in awake PEDS patient- over 1 yo
abdominal thrusts
102
Treatment of airway obstruction in unconscious PEDS patient
-position to open airway, attempt assisted ventilation
-if unable to ventilate, attempt visualization with laryngoscope. if visible, attempt removal with McGill forceps, taking care not to cause further obstruction.
-If still unable to ventilate, attempt intubation. if unable, move to needle cricothyrotomy
103
Allergy/Anaphylaxis/Extrapyramidal reaction/Angioedema History questions
-time of onset of symptoms
-progression of symptoms
-trigger, if known
-prior episodes
-known allergies, history of angioedema in first degree relatives
-treatment by patient, bystanders, or first responders
-new medications
104
Allergy/Anaphylaxis/Extrapyramidal reaction/Angioedema physical questions
-flushing, presence of rash, evidence of scratching
-edema- location, extent
-ability to talk, muffled/stridor, ability to handle secretions
-dysphagia/pain with swallowing
-breath sounds- wheezes, stridor, absent
105
Extrapyramidal reaction
-Diphenhydramine 25 mg IV/IM
106
Mild-swelling, itching, redness, hives
-Diphenhydramine 25-50 mg IM or slow IVP
- Famotidine 20 mg IVP
107
Moderate- mild symptoms and wheezing, difficulty swallowing, mild HOTN
-Diphenhydramine
-Famotidine
-Methylprednisolone 125 mg IVP
-Albuterol HHN up to 3 doses
- consider Epinephrine 0.5 (1mg/ml) IM, with progression of symptoms or history of severe reaction. may repeat x1 dose
-If sedation is required, consider Ketamine 0.5-1 mg/kg IV/IO if wheezing or bronchorrhea
108
Severe- impending respiratory failure, severe HOTN
-Epi 0.5 mg IM
-Epi 0.1 mg Q3 min, up to a max of 0.3 IV/ETT (1mg/10ml
) only if impending or actual cardiac arrest. IV Epi should be reserved for symptoms refractory to IM Epi or impending cardiovascular collapse.
-Diphenhydramine
-Famotidine
-Methylprednisolone
-LR 20 ml/kg (IBW) bolus. repeat as necessary
Ketamine 0.5-1 mg/kg if wheezing or bronchorrhea
-consider Epi infusion for continued HOTN at 0-0.5 mcg/kg/min (IBW)
109
PEDS Mild allergic reaction- swelling, itching, redness, hives
-Diphenhydramine 1mg/kg IV or IM, max 25 mg
-Famotidine 1 mg/kg, max 20 mg
110
PEDS Moderate- mild symptoms with wheezing, difficulty swallowing, mild HOTN
-Diphenhydramine 1mg/kg, max 25 mg
-Famotidine 1 mg/kg, max 20 mg
-Methylprednisolone 0.5-1 mg/kg IVP
-Albuterol HHN up to 3 treatments
-Consider Epi 0.01 mg/kg IM (1mg/ml) max 0.3 mg with progression of symptoms or history of severe reaction. repeat x1 if needed
-If sedation is required, consider Ketamine 0.5-1 mg/kg if wheezing
-Consider starting IV LR here instead of waiting for more profound HOTN
111
PEDS- severe allergic reaction- impending respiratory failure, severe HOTN
- Epi 0.01 mg/kg IM, max 0.3 mg. repeat x1 if needed
-Epi 0.01 mg/kg IV q3 min, max single dose of 0.1 mg. Max total dose of 0.3 mg and use as a bridge to Epi drip when symptoms are refractory to IM Epi
-Diphenhydramine
-Famotidine
-Methylprednisolone
-Ketamine if sedation is required
- NS or LR IV bolus 20 ml/kg, repeat as necessary
- consider Epi drip 0.1-1 mcg/kg/min for continued HOTN
112
Allergic reaction association between severity and time to onset of symptoms
the shorter the time from contact to onset of symptoms, the greater the potential for severe reaction.
113
most common causes of anaphylaxis
-foods, particularly nuts and shellfish
-insect stings
-drugs, particularly antibiotics
-latex
-iodine contrast dyes
114
Angioedema treatment
It is not an allergic reaction but we treat it as such. prepare for intubation if symptoms are progressing because diphenhydramine and Epi have little effect. consider discussions with sending facility of plasma (FFP) transfusion for prolonged transfers in patients with hereditary angioedema
115
Epi for anaphylaxis precautions
use cautiously in patients who are >50 years of age, have a history of cardiac disease or if the patient's HR is >150. Epi may lead to cardiac ischemia
116
possible complications from Epi
Associated with high incidence of ventricular dysrhythmias, hypertensive crisis, and pulmonary edema
117
Medications that can lead to extrapyramidal side effects
Antipsychotic medications such as Haldol, or phenothiazine derivatives such as promethazine or compazine
118
extrapyramidal side effects
dystonia, akathisia, and or agitation
119
treatment for extrapyramidal side effects
diphenhydramine (this is not an allergic reaction)
120
initial intervention with any altered mental status
measure blood glucose
121
Treatment for hypoglycemia, Adult
<60 give 100-200 ml of D10
122
Treatment for hypoglycemia, PEDS
<1 month of age: BGL <40, give 2ml/kg of D10
>1 month of age: BGL<60, give 2ml/kg D10
123
For PEDS patients, dextrose infusion should be initiated to prevent recurrently hypoglycemia once they are euglycemic
<1 month of age: D10 at 5ml/kg/hr
>1 month of age: D10 at 2ml/kg/hr
increase rate by 1ml/kg/hr every 15 minutes to maintain blood sugar above 40 for infants and above 60 for children
124
How often do you repeat a blood glucose after interventions
Repeat assessment every 10 minutes, repeat dextrose as needed until patient alert and oriented or normal glycemia is achieved
125
When can oral glucose be utilized
if the patient is alert with a glucose <60 (only on CCT)
126
What else can be given if the hypoglycemia is suspected to be due to chronic alcoholism or severe malnutrition
Thiamine 100 mg slow IV push
127
Adult dose for Narcan
0.4 mg IV/IO/ET/IM or 2 mg IN. titrate by doubling the dose each time Q5 min to max of 2 mg if cause of decreased LOC is not immediately apparent
128
PEDS dose for Narcan
0.1 mg/kg every 5 min (max single dose 0.4) up to 2 mg IV/IO/IM/ET/IN
129
potential next step if AMS and no response to dextrose or Narcan and unable to protect airway
Advanced airway management if patient unable to protect airway or maintain adequate oxygenation/ventilation
130
AMS- when to obtain 12 lead EKG
If suspected cardiac cause, cardiotoxic ingestion or electrolyte imbalance
131
What needs to be ruled out with AMS prior to intubation
Rule out reversible causes such as hypoglycemia, drug or narcotic toxicity
132
Considerations when dosing Narcan
only give enough Narcan to achieve adequate ventilation, but not to "wake" the patient completely. prepare for possibility of vomiting/withdrawal
133
Acute confusion and signs of sepsis
sepsis is common cause of AMS in elderly, typically females is UTI and men is PNA
134
signs of opioid overdose post Narcan administration
a rapid, pronounced increase in LOC, dilation of pupils, piloerection, rhinorrhea and return or respiratory function
135
AEIOU-TIPS mnemonic for causes of AMS
A- Alcohol, Apnea, Arrhythmia, Anaphylaxis
E- Epilepsy, Environmental (heat, cold)
I- Insulin
O- overdose
U- uremia
T- trauma
I- infection
P- Psychiatric, poisoning
S- Stroke, shock, sepsis
136
Common causes of coma for PEDS
poisoning, diabetes, child abuse or neurologic disorders
137
Thermalregulation and PEDS with AMS
AMS in PEDS who is exposed can become quickly hypothermic, assure application of continuous temp monitoring
138
continuous monitoring for patients receiving medications for anxiety/agitation
SPO2 and side stream ETCO2 is recommended when not intubated
139
Versed- Adult dosing for push and gtt
IV/IO/IM: 1-5 mg Q5 min, max dose 10 mg. may give alone or in combination with an antipsychotic (reduce by 50% in chronically ill or geriatric patients)
Drip: 1-10 mg/hr continuous infusion (10 mg/100mls)
140
Ketamine- Adult dosing push and drip
IV/IO: 0.5-1 mg/kg Q10 minutes
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
Post intubation: 1-2 mg/kg Q10 minutes
Excited delirium: 0.5-2 mg/kg IM initially, continue with 1-2 mg/kg IV
Drip: 0.1-2 mg/kg/hr (500 mg in 100mls)
141
Extreme agitation or excited delirium Haldol dose
5 mg IM/IV Q5-10 minutes, titrate to max 15mg
142
PEDS Versed IV/IO dose
0-5 yo: 0.05-0.1 mg/kg Q10-15 minutes
6-12 yo (less than 50kg): 0.025-0.05 mg/kg
>12 yo: adult dosing
143
PEDS versed IM, IN, post intubation
IM: 0.05-0.1 mg/kg, max total dose 10 mg
IN: 0.2 mg/kg single dose, may repeat in 15 in, max dose 10mg/dose
Post intubation: 0.05-0.12 mg/kg/hr
144
PEDS Ketamine dosing
IV/IO: 0.5-1 mg/kg Q10 minutes
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
Post intubation: 1-2 mg/kg Q10 minutes
Drip: 0.1-2 mg/kg/hr (500 mg in 100mls)
145
IN administration practices
50% in each nostril
146
Contraindications for Ketamine infusion
Globe injury, liver disease, uncontrolled HTN, history of psychosis.
Avoid in older patients, schizophrenics and patients with heart disease
147
settings where ketamine is useful
-when initial treatment such as benzos or antipsychotics have failed
- In patients with excited delirium (agitated delirium)
-adrenergic excess often related to acute-on-chronic drug abuse in patients who may have mental illness
148
during of action for ketamine
10-20 minutes
149
side effects of Ketamine
HTN, tachycardia, laryngospasm, emergence reactions, and vomiting (more common after a rapid IV administration)
150
When to consider other sedation medications aside from Ketamine
in patients with significant HTN
151
What medication can be considered to attenuate psychotropic effects and recovery agitation when giving Ketamine
Versed
152
Aortic Emergencies VS goals
Goal HR <60 and SBP 100-120
153
If an aortic emergency, what intervention should be performed
12 lead EKG
154
What medication should not be used that is within the Pain/Anxiety protocol
Ketamine due to its mechanism of action and potential to worsen the patients' overall outcome
155
What is given to avoid HTN and tachycardia
beta blocker
156
Medications given for suspected aortic dissections
Start with Labetalol 10-20 mg IVP. may repeat x1 in 10 minutes. If target VS is not achieved, begin Labetalol gtt.
157
Medications for confirmed dissection
-Labetalol gtt 1-10 mg/min to goal HR/BP (100mg/100mls)
-Nipride, Nicardipine or Clevidipine may be requested from the sending facility if Labetalol is max and HR <50, SBP >120. Dose to be ordered by sending provider
-If above are not available, Nitro infusion may in initiated. 5-200 mcg/min to achieve target SBP (premix 50 mg/250D5W)
158
What is the goal bedside time for Aortic Dissection patients
15 minutes
159
Typical location of dissection based on symptoms
Ascending (type A) may present with anterior chest pain
Descending (Type B) pain will often be experienced posteriorly
160
Special considerations when calling report for dissection
Be sure to clearly state that the patient is an "aortic emergency"
161
What to do in aortic emergency patients with available lab values
If labs show a decrease in HGB or additional evidence of bleeding, consider requesting the sending facility send blood, either O negative or type specific.
162
What to do if drop in HGB or evidence of bleeding but no type and cross
Do not delay transport for type and cross to be done
163
In what scenario should you consult a physician prior to starting Beta blocker for an aortic emergency patient
if the patient has used meth or cocaine within the past 72 hours, consult physician. isolated Beta blocker use can cause unopposed alpha stimulation resulting in increased blood pressure. need alpha antagonist if going to give beta blocker in this patient population.
164
first line treatment for meth/cocaine users with aortic emergency and HTN/tachycardia control
Benzos
165
typical symptoms to raise suspicion of an aortic emergency
chest pain tearing to back is a typical presenting symptom but higher suspicion if associated with neurological changes or new onset heart murmur
166
Symptoms of involvment of the ascending aorta
back pain, anterior chest pain, hemodynamic instability, diastolic cardiac murmur, tamponade, syncope or stroke, weak or absent carotid or subclavian pulse, upper extremity pain/parasthesia/motor deficit
167
symptoms of a descending aorta
back pain, chest pain, abdominal pain, weak or absent femoral pulses, lower extremity pain/paresthesia/motor deficit, acute paraplegia
168
possible EKG findings iwth aortic emergency
right coronary artery involvement and signs of ACS
169
trauma and aortic emergencies
trauma will rarely cause classic dissection, however, it may induce a tear at the aortic isthmus. hive a high index of suspicion for possible aortic rupture or transection in patients suffering from blunt chest trauma secondary to acute decelerations (MVAs)
170
classification for HTN crisis
SBP>210 or SBP>110
171
what additional parameters are necessary to initiate treatment for HTN crisis
if the patient is symptomatic and after two confirmed blood pressure readings five minutes apart
172
besides antihypertensives, what other meds can be given for HTN
relief of pain/anxiety may lower blood pressure to acceptable levels
173
Additional test to get with HTN
12 lead ECG
174
What percentage do we not want to surpass for how quickly you decrease the BP
BP should not decrease by more than 25% of initial reading
175
Labetalol administration for HTN
10-20 mg SIVP over 1-2 minutes, repeat x1 in 10 minutes (if HR >60)
Labetalol infusion: initiate infusion at 1-10 mg/min (100mg/100mls remove 20 mls from bag)
176
Nicardipine infusion for HTN
initiate at 5mg/hr, titrate by 2.5 mg/hr Q10 minutes. max dose 15 mg/hr (25mg/100mls, remove 10 mls from bag)
177
Hydralazine dose for HTN
10-20 mg SIVP Q15 min, max dose 60 mg
178
Patient population to use hydralazine with caution
in patients with suspected cardiac morbidities due to possibility of reflex tachycardia with resultant increased oxygen demand and ischemia
179
non anti-htn medication treatment for patients with HTN emergency due to illicit drug use
sedation with benzos
180
Medication to avoid in HTN patients with illicit drug use
Avoid use of Beta blocking agents alone as this may easily result in HTN emergency and end organ failure
181
Definition of HTN emergency
diagnosed by evidence of end organ dysfunction or failure such as elevated BUN and Creatinine or oliguria
182
Interventions for asymptomatic and otherwise healthy patients with severe essential HTN
these patients should not be treated due to possible relative HOTN and subsequent end organ damage
183
Goal in treating most HTN emergencies
reduce BP by 25% in the first 24 hours
184
patient population that is an exception and requires a more rapid reduction in blood pressure
patients with aortic dissection are treated more aggressively. Must call for a much more rapid blood pressure reduction
185
Epi push for HOTN
5-20 mcg (0.5-2mls) IVP Q1-5 minutes (Mix 1 ml of Epi in 9 ml saline, 10 mcg/ml)
186
Criteria for HOTN
2 consecutive SBP <60 documented 2 minutes apart (to avoid treating a false reading of HOTN) or significant HOTN with other indications of hypoperfusion
187
PEDS push Epi dose
1 mcg/kg max dose 20 mcg
188
Epi dose for imminent threat of cardiac arrest with a pulse
250-500 mcg of 0.1 mg/ml
189
pharmacology for Epi
Epi has Alpha 1 and 2, Beta 1 an d2 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 5 minutes
190
Interfacility transfer administration of blood products
Verify patient name and DOB with the patient, with order, and that patient is wearing ID band with correct information. Verify with two clinicians prior to initiating the infusion and document names in PCR.
Confirm donor number, blood product type, expiration date, and patient ID all match blood product paperwork.
191
Indications for prehospital emergent blood administration
patient must have: penetrating injury, significant blunt traumatic injury or significant visible hemorrhage
And 2 of the following:
-SBP <90 and HR>120
-or SBP <70
- HGB <7 if lab work is available
- hypovolemia confirmed by POCUS
192
PEDS vitals criteria for emergent blood transfusion
-SBP <70
-HR >150
193
Documentation for emergent blood administration
Verify blood product type, expiration date, blood product paperwork, and donor number with
both crew members prior to initiating infusion. Visually confirm that the blood product appears to
have no foreign objects, discoloration, clots, sediment, or cracks in the container leading to
leaking. Document verification in PCR including name of hospital sending the product, MD
releasing the blood, and number and type of product released to provider.
194
Informed consent for emergent blood transfusion
Informed consent to be obtained as soon as possible with patients who are responsive. In
patients who are non-responsive, emergent administration should be initiated without consent.
Documentation of patient's mental status and emergent reason for administration should be
done in the PCR.
195
PEDS infusion for blood products
max dose of 20 ml/kg of blood. infuse at a wide open rate with pressure bag
196
Adult-Rate to administer blood products for emergent transfusion
infuse at a wide open rate with a pressure bag. monitor closely for s/s of transfusion reaction and /or volume overload
197
vital signs during blood transfusion
document VS Q10 minutes with both pre and post transfusion VS including temp
198
Fluids compatible with blood products
NS, ABO compatible plasma or albumin
199
Rate for administering non emergent blood products
start at 60-120 ml/hr for 15 minutes then as rapidly as tolerated to complete within 4 hours from removal from blood bank
200
Complications to monitor for from blood transfusion
fluid overload, pulmonary edema, poor cardiac or renal function
201
What can be given with some complications from a blood transfusion
consider giving lasix if the patient develops signs of fluid overload or TRALI
202
What do you do with the blood products once you arrive at the facility
leave all blood products used and unused, tubing and documentation with the receiving facility and document name of the person who received it
203
S/s transfusion reaction
pain at infusion site, back and substernal pain, dyspnea, HOTN, bleeding due to DIC, mental status changes, hives, itching, fever, wheezing, HA, nausea
204
some blood transfusion reactions present as mild allergic reactions to anaphylaxis, now are they treated
treat as appropriately according to the allergic reaction protocol when necessary
205
interventions for a blood transfusion reaction
stop transfusion, get immediate vital signs, notify receiving MD, note what time unit was stopped and how much was infused
206
PEDS non emergent transfusion administration rate
Start at 2.5 ml/kg/hr to avoid circulatory overload.
207
PEDS non emergent transfusion administration rate for patients at risk for volume overload
Decrease to 1 ml/kg/hr or call PICU MD for verbal order on rate, product type and volume to be infused
208
Special consideration for vital signs for pediatric patients and blood administration
keep patient warm, monitor temperature using continuous temp probe
209
Transfusion parameters based on hgb
in patients with a documented hgb >7, limit further transfusions unless actively bleeding or hemodynamically unstable
210
Fluids to avoid giving with blood products
no LR, dextrose or calcium containing solutions or medications in the same line at the same time as blood. Can be given through a different lumen of a central line
211
Expected change in labs from one unit of RBC
one unit of PRBC contains approximately 200 ml of red cells and in an adult will increase hgb by 1 point and the hct by 3-4% unless patient is continuing to bleed
212
Current recommendations for "damage control" massive transfusion
Massive transfusions are 1:1:1 ratio of PRBC/FFP/Plt to ensure hemostasis
213
Temperature monitoring and blood transfusions
it is essential to maintain normal body temperature to prevent further coagulopathies
214
Blood warmer temperature parameters
if using a blood warmer, do not heat blood product above 40 C
215
oxygen release in transfused RBC vs normal RBC
oxygen release by transfused RBC is diminished in comparison to normal RBC
216
stored RBC and 2, 3 diphosphoglycerate (DPG) levels
Blood storage decreases 2, 3 diphosphoglycerate (DPG) levels, leading to a left shift in the
carboxyhemoglobin dissociation curve. Therefore, there may be immediate problems with
oxygen unloading post transfusion. However, RBC's regenerate 2, 3 DPG to normal levels
within 6-24 hours after transfusion.
217
Consideration for calcium replacement with blood transfusions
If a patient has received greater than 4 units of PRB's, consider the necessity for calcium
replacement. Stored blood products contain citrate, an anticoagulant / preservative that
functions by binding ionized calcium.
218
hypocalcimia and the clotting cascade
significant calcium depletion may interfere with the function of several key clotting factors in the coagulation cascade
219
potential electrolyte issues in infants and patients with impaired renal function
patients with impaired renal status may develop hyperkalemia due to intracellular shifts during blood storage or irradiation
220
blood product type to consider for men and women in an emergent blood transfusion
consider O neg or O pos for men and women whom child bearing is not a consideration
for girls, pregnant women and women of childbearing age, consider O neg if possible
221
History questions for flame injury
-Fire occurred in enclosed space or outside?
-Patient location when found (inside or outside)?
-How did the patient escape the fire?
-Did the clothes catch on fire?
-How long did it take to extinguish the flames and how were the flames extinguished?
-Was there an explosion and did the patient get thrown?
-Was the patient unconscious at the scene?
-Evidence of fuel or chemical spill that could result in a chemical burn as
well as thermal injury?
-ETOH/drug use?
-Are the purported circumstances of the injury consistent with the burn characteristics
(i.e., is abuse a possibility)?
222
History questions for scald injuries
-What was the temperature of the liquid (from faucet, cooking)?
-How much and what was the liquid?
-Was the burned area cooled and with what?
-How long was it cooled for?
-Who was with the patient when the burn took place?
-How quickly was care sought?
-Where did the burn occur (e.g., bathtub, kitchen)?
-Are the purported circumstances of the injury consistent with the burn characteristics (i.e., is
abuse a possibility)?
223
history questions with chemical injury
-What was the agent(s)?
-How did the exposure occur?
-What was the duration of contact?
-What decontamination occurred?
-How long was the patient decontaminated for?
-Is there a Material Safety Data Sheet (MSDS) available? -Is there any evidence of ocular
involvement ?
-Is there any evidence of illegal activity?
224
History questions with electrical burns
-What kind of electricity was involved: high (>1000volts) or low voltage, AC or DC?
-What was the duration of contact?
-Was the patient thrown or did they fall?
-Was there loss of consciousness?
-Was CPR administered at the scene?
225
assessment with flame and chemical injury
Assess for inhalation injury:
-facial burns
-singed nasal hair
-carbonaceous sputum
-hoarseness and/or stridor (soot on the face is not an inhalation burn unless accompanied by any of the above findings)
Circumferential burn and area
226
Assessment with scald injuries
-Percentage of burns
-Evidence of abuse- even lines vs spatter pattern
227
Assessment for chemical injuries
location and extent of burns
228
Assessment for electrical injuries
Describe wounds and locations, do not attempt to identify entrance and exit wounds
229
Measuring percentage body surface area burned
Estimate percentage of partial and full thickness burns using Rule of Nines or patients full palm, including fingers, as an estimate of 1% of BSA
230
When to intubate a patient with burns
intubate early if sings of inhalation injury and airway compromise
231
Burn patients and removal of clothing
remove clothing that does not adhere to the patient along with jewelry and other constricting objects
232
oxygenation interventions if carbon monoxide poisoning is possible
administer oxygen via non-rebreather mask
233
Ideal positioning of burned limbs
elevate burned limbs if possible
234
body temp management with burn patients
cover with blankets or chemical blanket and provide continuous temperature monitoring. Administer heated IV fluids. Increase temperature of transport vehicle
Consider plastic sheeting such as Chux with plastic to patient's skin or silver emergency blanket, to preserve heat and prevent evaporative fluid loss
235
Fluid resuscitation for flame, scald and chemical burns
For partial thickness and full thickness burns greater than 20% BSA, initially administer warmed
IV fluids at 500 ml/hr while calculating fluid administration formula: 2mL x weight in Kg x %
TBSA burned over 24 hours. Flow rate to give 50% of total fluid over the first 8 hours from time
of injury. LR is preferred for burn care. Interfacility transfer: ask sending facility for enough LR to
complete the trip.
236
Intervention for PEDS burns to figure out fluid recommendations
If possible call UC Davis for fluid recommendations. Call UMC or Sunrise Hospital and Medical Center for burns originating out of central/south Nevada where Las Vegas is the closest burn center
237
PEDS- initial warmed fluid rate while calculating burn formula
0-5yo: 125 ml/hr
6-13yo: 250 ml/hr
>13 yo: 500 ml/hr
238
PEDS burn fluid resuscitation equation
3ml x weight in Kg x % TBSA over 24 hours, flow rate to give 50% of total fluid over first 8 hours from time of injury
239
Additional fluids given for PEDS burn patients <14 yo
add D5W at maintenance rate in addition to fluid resuscitation
Maintenance rate:
- 4ml/kg for first 10 kg plus
-2 ml/kg for next 10 kg plus
-1 ml/kg for every kg after that
240
For chemical injuries, what must be done prior to loading patient into the aircraft
Ensure patient has been decontaminated per HAZMAT protocol
241
intervention for small chemical injuries
for small, isolated chemical burns, decontaminate patient using running water for 15 minutes
242
Initial action when arriving to a scene with an electrical injury
stop and confirm that the scene is safe. do not approach the victim until the scene has been cleared of active wires
243
CPR and lethal rhythms after electrical injuries
initiate CPR as needed, treat dysrhythmias per cardiac Dysrhythmia protocol
244
Fluid resuscitation for Electrical injuries- all ages
4ml x weight in KG x %TBSA burned over 24 hours. Give 50% total fluid over first 8 hours from the time of injury
245
Burn injuries that may be transported directly to a burn center include the following
- partial thickness burns of greater than 10% of the TBSA
-Significant burns that involve the face, hands, feet, genitalia, perineum or major joints
-third degree burns in any age group
- electrical burns, including lightning injury
-chemical burns
-inhalation injury
- burn injury in patients with preexisting medical disorders that could complicate management, prolong recovery or affect mortality
- burn injury in patients who will require special social, emotional or rehabilitative intervention
246
Exclusion criteria to patient not going to a burn center but meets the burn center criteria
the burns are complicated by major trauma
247
Protocol to bring patient to burn center and patient originates in the state of nevada
The Care Flight staff member will contact an ED physician at RRMC via phone or radio to inform the trauma center that the patient meets burn center referral criteria
and can be transported to the burn center without unreasonable delay. The physician can then
elect to have the patient bypass the ED and continue to UC Davis Medical Center.
248
If the ED physician agrees to have the patient continue transport by air directly to UCD, the medical crew member will contact the ACS. what information is relayed to the ACS by satellite phone:
- Type of burn injury (thermal, chemical, electrical)
-TBSA %
- location of burns
- airway status
-age and sex of patient
-Name and DOB - satellite phone only since this is protected health information
249
Next step after information is relayed to ACS
ACS will contact UCS and request admission of the patient to the burn unit. If the ICU is able to accept the patient, then the aircraft will continue
ACS will then call the burn unit to relay the provided information to the unit. the aircraft will call a radio report as usual to the UCD ED
250
Steps if UCD is unable to accept the patient
the patient will go to RRMC.
251
Steps if UCD is unable to accept a burn patient and the patient originates from Cali
Follow California LEMSA policy for transfer to the most appropriate facility
252
If you are transporting a patient that has a dressing on the burn what should you do
remove dressings and examine burn to re-estimate depth of bun and BSA
253
Airway management for flame inhalation burns
flame inhalation rarely affect the area below the vocal cords. A LMA is a reasonable alternative to ETT intubation if attempts at intubation have failed
254
Airway management for liquid and aerosolized chemicals
liquid and aerosolized chemicals are more likely to affect the supraglottic areas
255
burns that affect subglottic area
subglottic injury occurs from smoke inhalation (may be toxic from burning chemicals) and presents with primarily wheezing and bronchorrhea. Endotracheal intubation is considered to be the definitive airway
256
What other intervention should be requested from the sending facility
Foley placement
257
What can you expect with the BSA over time
expect the BSA and depth of burn to extend. Reassess and adjust fluid calculations.
258
Way to decrease extension of burn
maintaining normothermia
259
special considerations for elderly and very young patients in regards to burns
these populations have thin skin. burns in these age groups may be deeper or more severe than they initially appear
260
Heart rate expectations with burns
normal adult HR should be 100-120 with burns. if HR is less than 100, investigate reasons such as medications, cardiac abnormalities
261
Blood pressure expectations with burns
HOTN is not expected in burn patients. assess for other causes, such as trauma
262
possible complication from full thickness chest burns
may restrict chest expansion
263
interventions with full thickness chest burns and high peak pressures
Remove form the vent and check compliance with BVM with PEEP valve set at 8, check for airway obstruction
264
Circumferential burns and time frame to cause restriction
It typically takes hours for circumferential burns to cause restriction, so that is not usually a problem with scene flights. If interfacility transfer and patient is already some time into the burn, consider Escharotomy by the transferring physician prior to flight.
265
Treatment for escharotomy on areas other than the chest
it is not recommended to complete until the patient reaches the burn center
266
interventions for patients with facial burns
inspect eyes, if suspected burn to eyes, instill ophthalmic anesthetic and irrigate with sterile NS if time allows
267
Considerations for PEDS with scald burns
scald burns are frequently associated with abuse. abuse is much more likely if the burn is symmetrical. Burn from spilled liquids or when a child steps into hot water tend to be unilateral
268
Rule of 9's adult measurements
Head- 9%
Chest- 18%
Back- 18%
Front arm (each)- 4.5%
Back arm (each)- 4.5%
Front leg (each)- 9%
Back leg (each)- 9%
Genital- 1%
269
Rule of 9's PEDS measurements
Head- 14%
Chest- 18%
Back- 18%
Front arm (each)- 4.5%
Back arm (each)- 4.5%
Front leg (each)- 8%
Back leg (each)- 8%
270
Rule of 9s INFANT measurements
Head- 18%
Chest- 18%
Back- 18%
Front arm (each)- 4.5%
Back arm (each)- 4.5%
Front leg (each)- 7%
Back leg (each)- 7%
271
Supportive measures initiated for PEA/asystole
-CAB (compressions, airway, breathing)
- CPR, rhythm checks no more than every 2 minutes and for no longer than 10 seconds. Pulse check only if organized rhythm is present
-cardiac monitor
-ETT/LMA placement
-Obtain IV access. IO access after 2 failed IV attempts or if IV is not feasible
-confirm in at least two leads
272
Consider possible causes for PEA/asystole
-hypovolemia
-tension pneumothorax
-hypoxia
-acidosis
-cardiac tamponade
-hypothermia
-pulmonary embolism
-myocardial infarction
-drug overdose
273
treatment for PEA/asystole causes
-NS fluid bolus
-chest decompression
-check tube placement
-ventilate
-pericardiocentesis
-remove from
-environment/actively rewarm
-Narcan
274
Epi administration IV or ETT
1mg IV/IO every 3-5 minutes or 2.5 mg ETT
275
how to obtain additional orders or orders to terminate treatment
consult medical control for possible administration of sodium bicarb, termination of efforts, or permission to transport
276
What must be completed prior to termination of efforts
a minimum of 3 rounds of epi must be given and cardiac US must be done to confirm cardiac standstill/fibrillation
277
What does a large increase in ETCO2 usually indicate
a return in spontaneous circulation, stop CPR and check for pulses
278
supportive measurements to initiate for Afib RVR (>120)
-Chest compressions, airway, breathing
-administer oxygen to assure adequate oxygenation
-cardiac monitor
-obtain IV access
279
Classifications of Afib with RVR
-Stable- asymptomatic and normotensive
-unstable- shock: SBP<80, or MAP <60
-Symptomatic- Lightheadedness, SOB, hypoxic (requiring more than 10 liters), chest pain, syncope but adequate BP
280
Interventions for stable Afib with less than 20 minutes transport time
monitor without therapy
281
Interventions for stable Afib with more than 20 minutes transport time
-SBP >100 give metoprolol 5 mg IV, if no response to HR and SBP >100, may repeat x1
- if no response after second dose, call medical control for additional orders
282
Treatment for unstable AFib
-Synchronized cardioversion with sedation (100/150/200J)
-Address hotn with fluids and/or pressors consurrent with amio 150 mg IV over 10 minutes
-begin amio infusion IV at 1 mg/min (40 ml/hr) (mix 150 mg amio in 100 mls)
283
treatment for acute symptomatic AFib
-Amio 150 mg x1 over 10 minutes
-if greater than 20 minutes transport, may start amio infusion at 1 mg/min
284
treatment for symptomatic chronic afib
-Metoprolol 5 mg IV x1
-If HR remains >110, Metoprolol 5 mg every 5 minutes to a total of 15 mg
-to maintain HR <110 start IV Labetalol drip at 0.5-10 mg/min (hold for SBP <80) (Mix 100mg of Labetalol in 80 ml NS) (1mg/ml)
285
If patient has pre-exising bundle branch block Afib with RVR may appear as a wide complex tachycardia
if unsure of pre-existing BBB, assume to be ventricular in nature and treat accordingly
286
treatment of afib >48 hours and risk of CVA if converted back to SR
Avoid cardioversion in these patients unless unstable, otherwise make all attempts at rate control only.
287
Association between rate of patients with AFib in the ICU
up to 30% of chritically ill patients will convert into afib during icu stay due to cardiac irritation from primary illness and/or electrolyte abnormalities
288
information needed for chronic Afib patients
be sure to acquire anticoagulation history
289
Supportive measures initiated for patients with bradycardia (HR<60 with signs snd symptoms of poor perfusion)
-Maintain patient airway, assist breathing as needed
-Administer oxygen to assure adequate oxygenation
-Monitor EKG, blood pressure, oximetry
-Obtain and interpret 12 lead EKG
-Obtain IV access
290
Treatment for 2nd degree type 2 or 3rd degree heart block with s/s of poor perfusion
Immediate TCP
291
Treatment not 2nd degree type 2 or 3rd degree with s/s poor perfusion
-Atropine 1 mg !V every 3-5 minutes. Max 3 mg
-TCP if unresponsive to Atropine or unable to obtain IV access. If conscious, consider pain/sedation management
-If refractory to interventions, consider Epi infusion at 0-0.5 mcg/kg/min (IBW)
292
treatment for any bradycardia with no s/s of poor perfusion
transport
293
Atropine should not be given for a high degree AV block with poor perfusion if it delays what intervention
TCP
294
Atropine should be used cautiously in the presence of what acute/chronic medical health issue
acute coronary ischemia or MI
295
supportive measures initiated with narrow complex tachycardia
- Chest compressions, airway, breathing
-Administer oxygen to assure adequate oxygenation
-cardiac monitor
-Obtain IV access
296
possible alternate causes of narrow complex tachycardia
Sepsis, PE, hypovolemia, excessive energy drink consumption, drug use
297
Intervention for narrow complex tachycardia with s/s poor perfusion and patient is not verbally responsive
Cardioversion
298
Steps for interventions for SVT with s/s poor perfusion
-valsalva maneuver
-Adenosine 6 mg
-Adenosine 12 mg
-Sychronized cardioversion (100/150/200J)
299
Interventions for Afib/AfL with s/s of poor perfusion
synchronized cardioversion
300
Interventions for narrow complex tachycardia with no s/s of poor perfusion
contact medical control for Adenosine orders
301
Intervention that must be done when given Adenosine
perform continuous EKG strip during administration
302
Supportive measures initiated for Vfib or pulseless VT
-Chest compressions, breathing, airway
-CPR, rhythm checks no more than every 2 minutes and for no longer than 10 seconds. pulse check only if an organized rhythm is present
-Use cardiac US during one of the pulse checks, it it can be done in less than 10 seconds, to evaluate for tamponade and cardiac activity
303
protocol for unwitnessed arrest
after 2 minutes of CPR, defibrillate at 120J
304
protocol for witnessed arrest
Defibrillate at 120J, give 2 minutes of cpr then check rhythm
305
Pulseless VT/VF treatment
-Defib 150J, CPR 2 minutes, ETT/LMA placement, IV/IO placement
-Epi 1 mg IV/IO or 2.5 mg ETT every 3-5 minutes
-Defib 200J. CPR 2 minutes
-Amio 300 mg IV/IO or
-Lidocaine 1-1.5 mg/kg
-Defibrillate 200J, CPR 2 minutes
-Amio 150 mg IV/IO or lidocaine 0.5-0.75 mg/kg
-Defib 200J. CPR 2 minutes
306
Medication that can be started if transport time is over 20 minutes.
Amio gtt at 1 mg/min (150 mg in 100 mls)
307
If IV/IO access is not possible, what medications besides Epi can be given through the ETT
Lidocaine may be administered via ETT at 3mg/kg and repeated once. If this converts the patient to a perfusing rhythm, begin a Lidocaine gtt at 2-4 mg/min (2 mg in 500mls)
308
Medication given for Torsades de Pointes
2mg IV magnesium wide open (2mg in 100 mls)
309
Intervention to be performed after 3 unsuccessful standard defibrillation attempts for refractory VF
place a new set of pads A/P and continue energy delivery at 200J
310
Intervention completed if patient is in refractory VF and another cardiac monitor is available
move to Double Sequential External Defibrillation (DSED) after 3 unsuccessful standard defibrillation attempts. Place a second set of pads A/P, charge both monitors to 200J and deliver shocks. Verify that pads are not touching to reduce risk of damage to the defibrillators. Ensure the same provider is administering the defibrillation to prevent simultaneous discharge and to allow for a 1sec delay in between defibrillation shocks
311
Wide complex tachycardia with a pulse initial interventions
-if HR<150, obtain a 12 lead EKG to confirm rhythm
-if HR >150, use the algorithm
312
interventions for patient that is alert, conscious and without signs of poor perfusion
-amio 150 mg IV over 10 minutes
-transport and consider amio gtt at 1mg/min if over 30 minutes
313
Wide complex tachycardia and the patient is not conscious, alert and shows signs of poor perfusion
-if conscious, sedate per Anxiety/Agitation protocol
-Synch cardioversion 100J, if no response
-Synch cardioversion 150J, if no reponse
-Synch cardioversion 200J, if no response
-Synch cardioversion 200J, if no response
-Amio 150 over 10 minutes, if no response
-synch cardioversion 200J then contact medical control for further orders
314
What intervention is performed on all patients with chest trauma
eFAST examination
315
signs of tension pneumothorax
absent breath sounds, tracheal deviation, HOTN
316
what intervention is performed when there is evidence of tension pneumothorax
needle thoracostomy
317
what is performed if needle thoracostomy is unsuccessful x2
simple thoracostomy
318
Becks triad
-jugular venous distention
-muffled heart sounds
-narrow pulse pressure
319
when to perform pericardialcentesis
with evidence of potential for pericardial tamponade
320
Interventions for evidence of large flail segment with decreased gas exchange
intubation and positive pressure ventilation
321
what to do for a sucking chest wound
apply occlusive dressing
322
intervention for impaled objects
stabilize the object
323
Treatment for patients suspected to have pulmonary contusions
use judicious fluid administration. If intubated, assess plateau pressure and implement PRVC mode on the ventilator for lung protection strategy
324
Interventions for a pneumothorax greater than 25%
consider placing chest tube prior to transport. if possible, confirm chest tube placement prior to transport
325
PEDS and chest trauma
Pediatric chest walls are thinner and more pliant. the lungs are more easily injured. Bony injury is rare and should lead to suspicion of abuse
326
initial interventions to rewarm patient
remove wet and constrictive clothing, remove rings from fingers and constrictive jewelry. only remove wet clothing if possibility of cold exposure is decreased.
327
positioning of cold trauma patient
maintain supine position, avoid rough movement and excess activity
328
warming blankets and heat pack placement
cover with chemical warming blanket focusing on the truncal areas. Apply chemical hot packs to axilla/groin, chest, and back (in that order). Heat should never be applied directly to the skin to prevent burning. Utilized a barrier between chemical blankets and/or hot packs
329
IV fluids with cold trauma
IVF should be warmed. Rapid rewarming to temp slightly above body temperature is the single most effectvie treatment. Re-warm until the skin is pliable.
330
monitoring core temp
monitor core temp using rectal or esophageal probe. rectal temp should be placed in a warm environment to limit exposure of patient
331
methods to not use to rewarm patient
do not re-warm with exercise or rubbing. do not break blisters
332
Circumstance/area to not re-warm patient
do not re-warm in the field if there is a risk of refreezing
333
how to protect areas of involvement
protect areas from further injury with padding and bandages
334
positioning of affected limbs
elevate and immobilize affected areas
335
medication to be given with signs of frostbite
give 324 ASA if patient is able to safely swallow
336
when to not perform CPR for cold trauma patients with absent pulse or breathing
patients with lethal injuries, avalanche burial >35 minutes with complete airway obstruction by snow and asystole, or chest is too stiff for CPR, do not resuscitate.
337
assessing for signs of life
assess for signs of life for up to 1 minute by palpating central artery and assessing cardiac rhythm. may use ultrasound to assist with assessing.
338
Defibrillation if core body temp is <30 degree C
deliver one attempt at defibrillation at the usual dose
339
Defibrillation if core body temp >30 degrees C
may repeat defibrillation attempts per ACLS protocols
340
Medication dose and frequency with ACLS and cold trauma
give usual dose for medications being administered, but dosing intervals should be twice as long as usual
341
transportation of hypothermic patients
transport all severely hypothermic patients regardless of response to ALS procedures
342
Mild hypothermia (32-35 degree C)
-patient may be shivering, with clear consciousness or slightly altered level of consciousness.
-Tachypnea, tachycardia, and hyperventilation. ataxia, dysarthria, and impaired judgment may be noted
-Prevent heat loss and insulate. remove wet clothing and insulate with blankets
-Encourage shivering and calorie intake. passive external rewarming
343
Moderate Hypothermia (28-32 degree C)
-patient is not shivering with impaired/altered LOC
-Bradycardia with CNS depression, lethargy, Osborne wave on ecg, hypoventilation, muscle rigidity
-Prevent heat loss, insulate, active external and internal warming. Hot packs to truncal areas, chemical blanket to truncal areas.warmed IVFs
344
Severe hypothermia (below 28 degree C)
-patient is comatose, unconscious or may appear to be dead
-Arflexia, organized rhythm on EKG, cold and inflamed skin, fixed pupils, apnea
-ABCs, intubate and continue CPR
345
Profound hypothermia (<13.7 degree C)
- Death as a result of irreversible hypothermia or apparent death
-CPR may be delayed after evacuation if it is not possible or safe to perform CPR
346
Core temperature afterdrop
caused by conductive heat loss after removal from cold exposure. Stems from the warmer core heat loss to the cooler peripheral tissue as blood flow increases. This has a potential to cool the heart causing VF
347
Circumrescue collapse
related to patients of cold water immersion just before, during, or after
removal from water. This may be caused by threatening hypotension or sudden onset VF.
Removing the patient from water decreases hydrostatic pressure allowing blood to pool in
dependent areas causing syncope, collapse, and core temperature afterdrop. Keeping a patient
horizontal and being gentle allows mitigation of decreased hydrostatic pressure to avoid
afterdrop and hypotension.
348
fluid resuscitation for moderate to severely hypothermic patients
saline lock IVFs after boluses will help prevent further cooling from the cooling IVFs. continuous IVFs are not recommended
349
fluid bolus type
LR is contraindicated in hypothermia patients due to the cold liver's inability to metabolize lactate
350
Intubation in cold trauma patients
RSI with paralysis may not be effective in overcoming trisus produced by profound hypothermia. Cricothroidotomy may be required for cold induced trismus
351
rectal and esophageal temperature monitoring
rectal temp may lag behind core temp by as much as an hour versus esophageal temp monitoring
352
additional route to provide rewarming
consider HHFNC for rewarming
353
benefits of intermittent CPR for patients in severe to profound hypothermia
patients with core temp <28 degree C should receive 5 minutes of CPR with alternating periods of <5 min without CPR
354
Frostnip
Partial freezing of tissue, superficial
- redness
-mild swelling
-pallor
-edema
355
Frostbite
True freezing injury of tissue. made evident by sudden blanching of skin, followed by tingling. Intense numbness, followed by cold. Officially considered frostbite when the area becomes painless. partial thickness involves skin and subcutaneous tissue.
-clear blisters
-numbness or burning
-redness and/or graying of skin
356
Deep frostbite
involves bode, muscles, tendons
- bluish, gray skin with bleeding blisters and severe swelling
-loss of function and tissue destruction
357
fluid bolus for DKA patient
bolus 20 ml/kg of LR over one hour if not initially given. If hemodynamically unstable, rapidly infuse bolus and treat with additional fluid bolus
358
if insulin gtt was not started by the sending facility,
initiate infusion at 0.1 unit/kg/hr to a target BG <300
359
K level that you should not start the insulin gtt
less than 3.3
360
change to insulin gtt after BG drops below 300
decrease insulin gtt to 0.05 units/kg/hr
361
BG level to no let the BG level drop below
250
362
intervention if BG drops below 250
begin D10 maintenance gtt
363
intervention if BG drops below 100
stop insulin gtt and recheck BG in 15 minutes, continue D10 gtt
364
intervention if BG less than 80 despite D10 gtt
give 50-100 D10 bolus and recheck BG in 15 minutes
365
Interventions if K at sending facility is less than 5.3
request than potassium be added to maintenance bag
366
how frequently do you check the BG
every 30 minutes
367
DKA vs HHS
DKA in adults often have a glucose level of 350-500 mg/dL compared to HHS where there is
little or no keto acid accumulation, with a glucose level often >1000 mg/dL
368
risk for cerebral edema in DKA patients
Cerebral Edema is more common in patients younger than 20yo and occurs from too rapid correction of osmolarity (too quick of a drop in glucose or changes in sodium). Symptoms
emerge 12-24 hours after initiation of treatment of DKA.
369
S/s of cerebral edema
Headache is the earliest clinical manifestation, but may include vomiting, altered and/or fluctuating mental status, focal neurologic deficits, and lethargy.
370
bicarb administration in DKA
Bicarbonate therapy is controversial in DKA/HHS use as it may cause a decreased rate of recovery of ketosis, neurological deterioration, and post-treatment metabolic alkalosis. It is not
recommended in our protocol unless ordered by sending provider.
371
treatment for euglycemic DKA
This DKA management is the same as above, but being cautious to start dextrose fluids early to prevent hypoglycemia
372
PEDS DKA fluid bolus
Fluid bolus 10ml/kg of NS. An additional bolus of 20 ml/kg may be administered if patient remains hemodynamically unstable or exhibits signs of poor perfusion. max dose is 30 ml/kg total
373
Insulin gtt protocol for PEDS
Insulin gtt should be started at a rate of 0.05-0.1 units/kg/hr. insulin gtt should never be discontinued unless severe hypoglycemia occurs.
374
target BG for PEDS
<250
375
BG level that is classified as severe hypoglycemia in PEDS and calls for discontinuing insulin gtt
<100
376
Insulin gtt rate for PEDS <5 yo or with insulin sensitivity
gtt may begin at 0.025 units/kg/hr
377
PEDS and insulin bolus
Insulin bolus should be avoided in PEDS patients
378
maintenance rate of NS for PEDS DKA patients
initiate maintenance rate of NS at 1.5x the normal calculated rate
Maintenance rate
-4ml/kg for first 10kg plus
-2 ml/kg for the next 10kg plus
-1ml/kg for every kg after that
379
Adjustment to insulin/fluids after BG reaches 250- PEDS
D10 should be initiated at rate of 1.5x the normal calculated rate and insulin infusion should be continued at the same rate.
380
Goal to maintain BG above a certain level for PEDS DKA
BG should be kept above 150 during transport
381
interventions if BG drops below 100- PEDS DKA
stop insulin infusion and continue D10 at 1.5x the normal rate and consult medical direction
382
Potassium parameters for replacement DKA for PEDs
If serum K from sending facility is less than 5.0 request potassium to be added to maintenance bag. Over 5.5, no Potassium replacement is to be used
383
frequency of BG check for PEDS DKA
every 30 minutes or more frequent monitoring is needed
384
Special considerations for who initiates insulin gtt for PEDS pt
If the patient originates from a hospital and an insulin gtt has be initated, ask if the insulin was ordered by the receiving Peds intensivist. If the insulin order did not come from a peds intensivist and you are unable to contact the peds intensivist, discontinue the insulin gtt
385
DKA criteria
-hyperglycemia: usually BG >200
-Metabolic acidosis: Venous pH <7.3 or plasma bicarb <18
-Ketosis: presence of ketones in the blood or urine, elevated serum beta hydroxybutyric acid
-Be aware that there are rare cases of normoglycemic DKA
386
DKA criteria for PEDS patients, different from adult
Expect the PEDS DKA patient to present with a total potassium deficit, despite a possible elevated serum potassium level from lab data. This occurs due to intracellular exchange of hydrogen ions for potassium, leading to urinary potassium loss.
387
Criteria for HHS
-Hyperglycemia usually >600
-Minimal acidosis
-Absent to mild ketosis
-Marked elevation in serum osmolality
388
Insulin administration with HHS in PEDS patients
Delayed insulin administration is recommended in PEDS for HHS. Contact Peds intensivist for further orders with HHS in PEDS
389
Treatment for DKA that can increase risk of cerebral edema
-No insulin bolus should be administered prior to starting insulin gtt
-Bicarbonate therapy has been associated with development of cerebral injury. Rapid correction of acidosis with bicarb may result in hypokalemia
-Failure for sodium levels to rise as the glucose level decreases is associated with cerebral injury
390
danger of hypoglycemia
hypoglycemia is much more dangerous in any patient than hyperglycemia.
391
Positioning intervention for extremity trauma/amputation
Immobilize injured extremity and reassess pulses, motor function and sensation.
392
Dressing for open fractures
Apply sterile dressing to open fractures. carefully note wounds that appear to communicate with bone
393
Care for open fractures that are grossly contaminated
have dirt/debris removed by saline irrigation or wiping followed by sterile dressing application. Vaseline dressings may be utilized as an initial layer over an open fracture.
394
areas to splint from extremity trauma
areas of tenderness or deformity
395
how to splint a deformity
try to immobilize the joint above and below the injury
396
realigning fractures/dislocations by applying gentle axial traction only if indicated
-restore distal circulation and only if >15 minutes ETA
-Immobilize adequately
-for extricate or to position in aircraft
397
Treatment of simple extremity injuries
elevate extremity and apply cold packs
398
Medication given with an open fracture or any break in skin over obvious fracture
Administer Ceftriaxone 2 gm SIVP (Mix 2gm in 20 ml NS)
399
PEDS dose of medication given with an open fracture or any break in skin over obvious fracture
PEDS over 7 days old: 50 mg/kg SIVP (up to 2gm). mix in 10 ml NS
400
Treatment of amputaions
-apply a tourniquet just proximal to the level of amputation
-Rinse wound with sterile saline, place moist sterile dressing over stump and pressure wrap
-Rinse amputated part in sterile saline, wrap in dry pads and place in dry container on ice. Avoid cold injury to part. Transport part with patient whenever possible
-Do not remove foreign bodies, stabilize securely
-Consider administration of ASA in interfacility setting if bleeding is controlled and there is a possibility of reimplantation. ASA sending facility to administer an ASA suppository per rectum if available.
401
Treatment for partial amputation
-Place in anatomical position and splint
-Wrap in bulky sterile saline moistened dressing and keep moist
-Save any avulsed tissue
402
when to consider tourniquet conversion
Convert extremity tourniquet to hemostatic packing and/or pressure bandage as soon as practical to help salvage tissue and prevent TQ related injury
403
criteria to perform tourniquet conversion
-If the patient is not in shock
-If the wound can be closely monitored
-If TQ is not providing bleeding control for an amputation
-If TQ has been in place for <6 hours
404
hemorrhage with amputations
most amputations do not create uncontrolled hemorrhage, arteries frequently contract into the stump
405
If MAP <65 consider causes of hotn and hemodynamic instability. Initiate vasopressors while addressing volume status
-Levo infusion at 0-1 mcg/kg/min (IBW) (mix 4mg in 250 D5W)
-For continued hotn with max dose levo, may start Epi 0-0.5 mcg/kg/min (IBW)
- Consider push dose Epi as a bridge until the vasopressors are infusing. Epi 5-20 mcg
406
Push dose PEDS dose
1 mcg/kg, max dose of 20 mcg
407
Special consideration for hypovolemic shock
Administer 500ml fluid boluses, max of 2L, to maintain MAP >65 prior to or concurrently with starting vasopressors. Reassess frequetly for s/s of fluid overload. Consider inferior vena cava US to further assess hypovolemic state.
408
Special considerations for cardiogenic shock
Caution with aggressive IVF resuscitation in the cardiac patient and monitor for pulmonary edema frequently. Initiate Levo early to maintain MAP >65. Use Epi as a second line agent. May require additional inotropic support including Dobutamine (5-20 mcg/kg/min), Dopamine (2-20 mcg/kg/min), Milrinone (0.375-0.75 mcg/kg/min) or mechanical circulatory support (IABP, Impella) as well which will require an order from the sending facility or call for medical direction.
409
Special consideration for Obstructive shock
Consider potential causes including tension pneumothorax, pericardial tamponade (use bedside US to assess), or pulmonary embolism. Administer 500 ml fluid boluses, max of 1L to maintain MAP >65 while initiating vaopressor support. If known massive PE, consider discussing thrombolytic therapy with the sending provider prior to transfer
410
PEDS BP goals (SBP at least 5th percentile for age)
-<1 month: at least 60
-1 month-10 years: 70 + (2x year in age)
-10 years or older: at least 90
411
PEDS treatment for hotn
- 20 ml/kg bolus of LR up to 3 doses for continued hotn without signs of fluid overload
-Epi 1mcg/kg, max dose of 20 mcg
- continued hotn initiate vasopressors
-Levo 0.1-2 mcg/kg/min
- if from sending, normal dosing for Milrinone: 0.25-0.75 mcg/kg/min or Dobutamine: 2-20 mcg/kg/min
412
Special considerations for PEDS cardiogenic shock
5-10 ml/kg bolus x1 over 15-30. call for additional boluses
413
PEDS physiologic indicators of perfusion to assess after fluid boluses
-Mental status
-Quality of central and peripheral pulses (strong, distal pulses equal to central pulses)
-Skin perfusion (warm, with cap refill <2 seconds)
-Urine output >1 ml/kg/hr once effective circulating volume is restored
414
Signs and exams used to confirm patient volume status peri fluid boluses
Utilized POCUS to perform eFAST exam along with other clinical signs confirming patient's volume status. Consider a small fluid challenge before large boluses if volume depleted
415
Vasopressor to consider asking for if R sided heart failure is considered
Consider obtaining Vasopressin (0.03-0.04 units/min) fromt he sending facility if R sided heart failure is suspected. Vasopressin will increase preload without increasing myocardial oxygen demand.
416
Additional situations where Vasopressin may be beneficial
Great adjunct to Levo in septic shock and in shock from gastrointestinal hemorrhage in a cirrhotic patient (clamps down on splachnic perfusion)
417
Why is milrinone not ideal for the transport environment for heart failure
Milrinone has a long onset time (hours) and needs to be renally adjusted
418
special considerations for administration of Dobutamine
dobutamine shoudl typically be administered wiht LEvo after patient stabilization has occurred. The simultaneous use of these medications is typical as the Dobutamine can induce hotn secondary to its beta 2 adrenergic stimulation
419
efficiency of Levo in various forms of shock
Levo has some inotropic effects (beta stimulation) in addition to its strong vasopressor (alpha) component. in studies of patients in shock (including cardiogenic) it outperform sother typical inotropes including Epi ad Dobutamine
420
Additional treatments for septic shock
consider stress dose steroids (hydrocortisone 50 mg IV q 6hrs) as an adjunct for BP stabilization if the patient remains hotn despite adequate fluid resuscitation and on 2+ pressors
421
Spinal assessment with blunt head injury victims
Assess the need for spinal immobilization in blunt head injury victims. Assure that the cervical collar does not restrict venous return from the head
422
Interventions to reduce ICP
- elevate head at least 30 degrees, even if patient is hypotensive
-ensure that head is stabilized in midline
-avoid flexion of limbs
-limit airway suctioning, if possible
-control pain and anxiety
- control nausea and vomiting
- consider chemical paralysis to minimize high airway pressures and abolish physical resistance and ventilator dyssynchrony, adjust venilator to minimize peak pressures
423
BP parameters for head/facial trauma
Maintain MAP >80-90 in order to optimize CPP with the use of IV fluids, then pressors.
424
Calculation for CPP
CPP= MAP - ICP
425
ETCO2 parameters with head/facial trauma
Maintain normal ETCO2 35-45. If signs of cerebral herniation, target ETCO2 should be 28-32.
426
Signs of cerebral herniation
Bradycardia, HTN, unilaterial blown pupil, asymmetrical pupillary reactivity, extensor motor posturing, or deterioration of GCS by more than 2 points when intial GCS was less than 9
427
management of free drainage from nose or ears
Do not attempt to stop free drainage
428
Treatment of elevated BP in patients wth facial/head trauma
Treatment of elevated BP should be with a physician order only. Obtain parameters for treatment, in addition to when medication should be used. In general, treatment goals are aimed at keeping SBP >90, but not treating high SBP.
429
Airway and facial trauma patients
airway is the primary concern in facial and anterior neck trauma and may supersede the need for complete spinal immobilization or spinal motion restriction. Consider early intubation if potential for swelling that may occlude airway
430
impact of hypoxia or hotn with facial/head trauma
Even a short episode of hypoxia or hypotension significantly increase mortality. incidence of both worsens outcome
431
significance of I/O prior to arrival
Consider I/O prior to our arrival. If possible negative fluid balance, replace fluid before administering pressors
432
extra precaution for head injury patients
Consider hearing protection
433
TBI and hypertonic saline
In traumatic brain injury patients, consider requesting a physician's order for hypertonic saline
434
Dont forget to rule out other causes of altered level of consciousness in patients with head trauma
consider metabolic conditions including hypoglycemia that may manifest unilateral signs
435
Facial injury and altered LOC
the sinuses and bony structures of the face are protective. Blunt trauma to the face without a blow to another part of the head rarely leads to brain injury
436
Consideration for clear drainage from nose
spinal fluid contains glucose, mucus does not. If unsure about clear drainage, test with glucometer
437
Head trauma incidence with PEDS patients
Non-accidental injury accounts for 95% of severe neurologic injuries in children. Be alert for evidence of physical abuse.
438
PEDS and hypoxia with TBI
Children are particularly susceptible to secondary brain injury related to hypoxia. Hypoxia happens more quickly in children.
439
physical examination for patients with heat illness/malignant hyperthermia
Physical examination should include thorough and focused assessments to identify evolving end-organ dysfunction (neuro, pulmonary, CV, renal, GI)
440
Interventions in setting of suspected or identified mils-moderate heat illness
-Do not allow the patient to return to the previous activity
-Prompt extrication from the environment should be performed
-Remove clothing if appropriate and/or feasible
- If no contraindications exist and the patient remains able to tolerate and consume fluids by mouth, the administration of cool/cold water (preferably supplemented with oral rehydration solutions) should be attempted
- Initiate both passive and active cooling measures immediately. These can include shade, fans, air conditioning within a structure or transport vehicle, as well as the peripheral and central application of "cold packs" (core placement is preferred- axilla, groin and abdomen), and the administration of cool/cold isotonic crystalloid solutions can be considered.
- Initiate continuous core temp measurement. Rectal, foley, or esophageal monitoring is preferred method for accurate temp measurement
441
Antipyretic agents and heat illness
administration of antipyretic agents is not recommended in the setting of mild-moderate heat illness as they are ineffective in managing the pathology
442
s/s consistent with heat stroke
end organ dysfunction in the setting of an associated core body temp of greater than 104 degrees F or 40 degrees C
443
Interventions for patients with s/s consistent with heat stroke
- Initiate previous interventions for heat exhaustion with an increased focus placed on resuscitation and stabilization of the respective end organ systems involved (i.e. neurologic, pulmonary, CV, etc.)
- Rapidly cool the patient with continuous temp monitoring to 38 C/100.4F to 39C/102.2F or until the patient regains the ability to exhibit shivering.
- Adequately rehydration through fluid resuscitation is essential without over-correcting the sodium if derangements exist. All fluid resuscitation should be cooled maximally prior to administration
444
Fever vs clinical hyperthermia
Distinguishing between fever and clinical hyperthermia is vitally important as a fever of unknown origin can be subsequently misinterpreted as a hyperthermic emergency
445
definition of fever
Core body temp elevation due to an internal response
446
Definition of clinical hyperthermia
Core body temp elevation due to uncontrolled heat generation. Temps are often higher than in the setting of fever. Unlike fever, hyperthermia involves complete loss of thermal control
447
Definition and s/s of heat exhaustion
State of dehydration and weakness following environmental exposure to extreme heat. usually <104F
-Polydipsia
-N/V
-Cool, clammy skin
-Weakness
-Muscle aches
-Diaphoresis
-Tachycardia, tachypnea
-dizziness and/or lightheadedness
-Lethargy
-HA
448
Definition and s/s of heatstroke
Severe hyperthermia with a loss of adequate compensatory mechanisms and end organ dysfunction. Threshold temp is usually >104F
- No sweating
- Hot and dry skin
- N/V
- HOTN
- Altered LOC
- Tachycardia
- SOB
- Decreased UO
449
Frequency of heatstroke in NV
Heatstroke is rare in NV due to low ambient humidity
450
Definition of malignant hyperthermia
Related to an autosomal dominant mutation of a gene and causes an uncontrolled release of calcium during muscle contraction resulting in increased metabolism. Usually observed following initial administration of Succinylcholine, as well as volatile halogenated anesthetics except nitrous oxide
451
Clinical manifestations of malignant hyperthermia
- High fever (rate of 1 degree every 10 minutes)
- Muscle rigidity (esp. masseter muscle)
- Tachycardia, tachypnea, HOTN
- Prolonged coagulation
- Hyperkalemia
- Increased ET capnography, increased O2 consumption
452
Complications of Malignant hyperthermia
- Disseminated Intravascular Coagulopathy (DIC)
- Rhabdomyolysis
- Lactic and respiratory acidosis
453
Clinical management and treatment for malignant hyperthermia
- increase FiO2 to 100% and optimize oxygenation
- Rapid administration of isotonic fluids
- Initiate passive and active cooling measures
- Immediate administration of Dantrolene: 2.5 mg/kg IV initial dose with repeated doses of 1 mg/kg every 5 min to a total dose 10 mg/kg
- Block of the neuromuscular junction with the administration of a non-depolarizing neuromuscular blocking agent
454
Dantrolene
Unlike the classic paralytic medications that function by blocking postsynaptic acetylcholine receptors, dantrolene acts intracellularly in skeletal muscle to lessen the excitation-contraction coupling interaction between actin and myosin within the individual sarcomere. This function occurs by antagonizing receptors which inhibits the release of calcium ions vital to the contraction process
455
Two main goals of Hemorrhage control
- BP control
- Control of life threatening external hemorrhage
456
BP management for penetrating trauma and hypovolemia
Permissive hotn goal SBP 70-90, MAP 60-65
457
BP management for blunt trauma and TBI
Goal SBP 100-120 with a MAP >85
458
Fluid administration for goal BP
crystalloids only indicated if above BP goals are not met and blood transfusions not immediately available. If crystalloids indicated, give LR in increments of 250 ml to max 1L until BP goals accomplishes
459
Methods to control life-threatening external hemorrhage
- Apply direct pressure to the wound
- Apply an approved tourniquet (CAT or SWAT-T) for life threatening hemorrhage that is anatomically amenable to tourniquet application
- Pack wounds with an approved hemostatic dressing (combat gauze) for life threatening hemorrhage observed from a readily compressible site that is not amenable to tourniquet application. Wound packing with hemostatic gauze should be followed by at least 3 minutes of direct pressure.
- Consider pelvic binder or pelvic sheeting in the presence of high energy trauma with lower abdominal pain, flank/perineal/scrotal ecchymosis, bleeding at the penile meatus/vagina, or unstable pelvis
460
TXA
administration should be optimized through early administration if it is clinically indicated
461
TXA inclusion criteria
- Traumatic injury with suspected or observed internal and/or external hemorrhage requiring large volume crystalloid resuscitation or predicted blood product administration
- Moderate traumatic brain injury (GCS greater than 8 and less than 13) presenting within three hours of injury
- Postpartum hemorrhage with suspected or observed internal and/or external hemorrhage requiring large volume crystalloid resuscitation or predicted blood product administration
462
Exclusion criteria for TXA
- time out from injury greater than 3 hours
- Concomitant administration with other approved procoagulant agents (factor 7, protamine, APCC)
463
Administration of TXA
Bolus: administer 1gm of TXA SIVP over 5-10 minutes (mix 1gm TXA in 10 mls)
464
TXA dose for PEDS 30 days to 14yo
- TXA 15 mg/kg, max dose 1gm
- NS 20 ml/kg bolus
- Repeat after 5 min if no improvement
- Repeat again after 5 min if no improvement
465
treatment for hemorrhage for PEDS <30 days old
- 10 ml/kg NS bolus
- Repeat once after 5 min if no improvement
466
Best method to prevent death d/t hemorrhage
Prevent blood loss
467
Early identification and subsequent treatment of both external and internal hemorrhage remains contingent upon the transport team's ability to complete the following:
- Accurately determine the mechanism of injury and/or nature of the underlying illness
- Thoroughly conduct a focused physical assessment
- Collect any relevant and pertinent underlying medical history
- Initiate appropriate and targeted treatment modalities early in the patient's clinical course
468
Utilizing the US for hemorrhage patients
The utilization of point of care US can substantially increase your team's assessment capabilities. US should be utilized and an eFAST exam conducted for any patients with suspected injuries to the thoracic, abdominal, and retroperitoneal regions
469
Appropriate tourniquet applicatoin
Tourniquets should be applied "high and tight" on the affected extremity and not over bulky clothing or equipment that would decrease their operational effectiveness. Once applied, a tourniquet should not be loosened or removed unless the projected time to definitive care will be unreasonably delayed. Tourniquets applied by laypersons or other on scene medical personnel should be thoroughly evaluated for their effectiveness and may be adjusted, adjuncted, converted, or removed at the transport teams discretion.
470
Intervention for lower extremity injuries with identified external hemorrhage that remain amenable to tourniquet application
Frequently require a second tourniquet to adequately control hemorrhage
471
Suspected pelvic fractures carry with them the potential for profound blood loss and as such the following interventions should be initiated
Application of a commercially developed and approved pelvic sling/binder should be completed early during the patient's clinical course if signs of pelvic instability are observed, or if a significant mechanism of injury is associated with the patient's injury pattern (i.e. significant blunt force trauma or blast injury patterns). Assessment of pelvic instability should be conducted in a thorough and stepwise manner to minimize the likelihood of producing additional injuries.
472
TXA and blood product administration
TXA should not be administered through the same IV/IO line as blood or blood products or in a line utilized for administration of rFVIIa or penicillin
473
Contraindications to HHFNC
- Ventilatory failure- where BIPAP or intubation is more appropriate
- Abnormalities of the face/airway/nose
- Insufficient O2 to complete transfer
- Severe facial trauma or Basilar skull fracture
- Respiratory/cardiac arrest
- Inability to protect airway or GCS <8
474
special considerations for transferring a patient with HHFNC
- Ensure enough sterile water is available for the duration of transport
- Ensure an adequate amount of oxygen is in oxygen tanks for the duration of transport
475
Initiating HHFNC
Ensure appropriate nasal cannula size, approximately 3/4 of the patient's nostril. Initiate high flow at 60 L/min, FiO2 at 100% and wean down rapidly to maintain O2 Sats>90%
476
special considerations for HHFNC interfacility transfers
- Obtain hospital settings and mimic settings
- Flow rate can range from 2-60L
- if oxygen saturation remains low and work of breathing remains high, increase liter flow in 5L increments up to 60 LPM. Additional NRB at 15 LPM can be added over the HHFNC if unable to maintain O2 sats
- Weaning of high flow will begin with FiO2 per saturation while keeping the flow at current LPM
- If sats continue to remain low, consider other means of oxygenation and ventilation such as BIPAP or intubation per Ventilatory Management protocol
- Treat underlying respiratory condition per Respiratory distress protocol
- Continuous O2 sats and cardiac monitoring
477
Initial settings for HHFNC for PEDS
Initiate HHFNC at 2L/kg/min up to 60 L/min. Start at 100% FiO2 and wean down to maintain oxygen sats between 92-99%
478
PEDS considerations for HHFNC
- Flow rate ranges from 2-60 L/min
- Ensure proper fitting cannula with application of wigglepads
- Continuous SpO2 and cardiac monitoring
- Treat underlying condition per respiratory distress protocol
479
PEDS flow rate range for <1 month and <4 kg
- 5-8 L/min
480
PEDS flow rate range 1 month - 1 year and 4-10 kg
8-20 L/min
481
PEDS flow rate range 1-6 years and 10-20 kg
12-25 L/min
482
PEDS flow rate range 6-12 yrs and 20-40 kg
20-30 L/min
483
Signs of respiratory failure and intolerance of HHFNC
- decreasing level of consciousness
- inability to maintain respiratory effort
- Cyanosis
484
PEEP administered with HHFNC
HHFNC administers approximately 1cmH20 of PEEP for every 10L/min, if the patient's mouth is
closed. If open, it gives approximately 0.3cmH20 of PEEP for every 10L/min
485
Interventions if a patients requires increased amounts of PEEP
transitioning to BIPAP may be beneficial
486
is HHFNC compatible with a trach
HHFNC may be utilized via trach tube with a proper attachment piece
487
Interventions if sedation is required
consider using Ketamine per anxiety/agitation protocol as Ketamine has bronchodilatory properties which may help optimize both oxygenation and ventilation
488
Possible complications from HHFNC
abdominal distention, aspiration and barotrauma (rarely)
489
History that can lead to suspected hyperkalemia
- Kidney disease (acute or chronic)
- DKA
- Crush injury or rhabdomyolysis
- Dialysis
- Burns
- Overdose: digitalis drugs, potassium supplements, Potassium sparing diuretics
490
Criteria to treat a patient for hyperkalemia in a prehospital patient
All patients must have a suspected risk for hyperkalemia and a 12 lead indicating cardiac abnormality (peaked T wave)
491
ADULT medications for hyperkalemia in prehospital setting
- Calcium chloride 1gm (10 ml) slow IVP over 3-5 min
- Albuterol 10 mg continuous neb treatment
- Lasix 20 mg IVP if acute/chronic kidney disease or overdose patient (do not give diuretic in DKA, burn, crush or rhabdo patients
492
PEDS medications for hyperkalemia
- Calcium chloride 20 mg/kg slow IVP
- Albuterol 5 mg neb treatment
493
Additional medications for known hyperkalemia for an IFT
ask for orders from sending provider for additional possible therapies (insulin and glucose, K binder like Veltessa/Lokelma) if appropriate
494
Interventions for suspected hyperkalema and crush injury
If suspected crush injury with entrapment/compression for greater than 4 hours, administer 20 ml/kg NS, in addition to above treatment
495
Impact of Calcium in hyperkalemia treatment
Calcium has an immediate onset of action from 1-3 min. It stabilizes the myocardium membrane and does not promote the intracellular shift of elimination of potassium
496
Impact of albuterol in hyperkalemia treatment
Albuterol inhalation stimulates Na/K/ATPase, which causes an intracellular shift of potassium.
Albuterol can decrease serum potassium levels by 0.3-0.6 mEq within 30 minutes.
497
side effects of this dose of albuterol
This dose will cause tachycardia in most patients
498
sodium bicarb and treating hyperkalemia
Bicarb is not indicated unless in a severely acidotic patient as it does not decrease serum potassium significantly or rapidly
499
Major changes in EKG for K levels 5.5-6.5
Tall peaked T waves
500
Major changes in EKG for K levels 6.5-7.5
Loss of P waves
501
Major changes in EKG for K levels 7.0-8.0
Widening of QRS
502
Major changes in EKG for K levels 8.0-10.0
Sine wave, ventricular arrhythmia, asystole
503
History requested when transporting a patient with an impella
- circumstances leading to impella placement
- Type of impella in place (CP, 5.5, RP)
- lab results: LA trends, CBC, CMP, MG, Phos, ACT trends
- imaging: Echo confirming placement, Xray
- Hemodynamics: PA catheter trends, CPO and PAPI scores
- EKGs
504
how to monitor BP for an impella CP or 5.5
do not use the impella CP or 5.5 aortic pressure as a real time BP, utilize our monitor or arterial pressures
505
What screen should the impella always be on when not making adjustments
Console should always be kept on placement signal screen to be able to rapidly assess location via placement signals and motor current waveforms
506
positioning of patients with impella in place
for femoral insertion (CP and RP) reverse trandelenburg patient only, do not elevate HOB. Impella 5.5 or RP flex IJ okay to elevate HOB >30
507
angle of insertion of Impella catheter
Catheter insertion site shold be kept at a 45 degree angle to avoid kinking and hematoma
508
Preparing purge system for IFT of impella
Prior to transfer, ensure spare purge cassette and purge fluid available. typically this is D5W with 25U/ml of Heparin. In patients with HIT or increased risk of bleeding a sodium bicarb purge fluid may be used (D5W with 25 mEq of sodium bicarb)
509
Goal ACT for impella patient with heparin
160-180
510
What fluid should not be used in the purge system
Saline
511
Normal purge pressures on impella
300-1100 mmHG
512
checklist prior to transporting a patient with an impella
-Verify current impella settings and type of impella
- Secure and stabilize all wires and cables
- use a knee immobilizer to assist with securing
- ensure all connnections tight
- do not stress the connections or wires from the impella to the patient, as this may dislodge the system
513
Impella and battery time
Keep the impella connected to AC throughout the transport. Battery life of the impella pump without being plugged in is 60 minutes. When disconnected form AC power, the impella device will been once every 5 min while disconnected
514
ACLS interventions with impella
Decrease to P2 prior to initiating CPR.
If cardioversion or defibrillation indicated, do not touch wires, controller or catheter. You may defibrillate or cardiovert without changing the P level
515
Interpreting perfusing during arrhythmias
Patients may have flat arterial line, lack of palpable pulse, and may still perfuse during arrhythmias.Assess for need for CPR based on perfusion and lack of pulsatile motor current despite proper placement
516
PA catheter monitoring during transport of a patient with an Impella
Monitor PA waveform continuously through transport, checking the CVP every hour or as needed with suction alarms or hemodynamic changes
517
How to address Impella alarms
- Turn down to P2 if position alarm, or noted dysthythmia requiring CPR
- Check AC power
- Ensure connections and tubing are connected and not kinked
- Change purge cassette-follow instructions on Impella console
- Reposition the patient, we are not allowed to reposition the catheter itself
- Maintain MAP >65 and CVP >10
- Call ahead to the receiving facility to notify of possible device malfuntions or migration
518
How to address suction alarms
- Decrease P level by one to two levels to break suction
- Assess cm markings and placement waveforms to ensure catheter did not migrate
- Assess CVP. If catheter has not migrated and CVP <10 administer 250 ml bolus every 15 minutes up to 3 times to achieve adequate preload. Assess hbg, if ,7 and at sending facility discuss blood product administration.
- If still alarm suction despite adequate preload reposition patient laterally slowly to try and break suction.
- Once alarm is resolved slowly increase back to prior P level to ensure suction does not recur.
519
Engaging "flight mode" on the console
Engage "flight mode" on console by pressing and holding airplane button on rear of console for 3 seconds followed by selecting menu > enable flight mode. This will disable Wi-Fi and trigger console to give transport specific troubleshooting prompts if required. Disable flight mode in reverse order on arrival to receiving facility.
520
What to do if troubleshooting fails
treat the patient
521
Uses of the left sided Impella
Used as a short term, temporary ventricular support devices indicated for the treatment of acute cardiogenic shock secondary to myocardial infarction, open heart surgery, myocarditis, acute decompensated heart failure, and cardiomyopathy.
522
Uses of right sided impella
RV failure related to MI or secondary to LV failure. Used in tandem with medical management and can be a bridge to additional therapies (ECMO)
523
pathophysiology for ventricular assist devices
Mechanical circulatory support devices allow for decompression of the left ventricle, reducing myocardial wall stress, improving perfusion of coronary arterial circulation, and assisting with formation of coronary collateralization
524
Risks of an Impella
TIA, Cardiac Tamponade, Perforation, Limb ischemia, bleeding form site, Vfib/Vtach, MI, sepsis, and hemolysis
525
When in flight should you monitor purge pressures
during altitude changes
526
FAA approved altitude for Impella
8000 feet
527
Weight of Impella device
about 35 pounds
528
Impella CP
- Left sided support device directly offloading the left ventricle
- Inserted femorally in cath lab under fluoroscopy, can achieve flow rates up to 4.3 L/min
- Placement signal consist of aortic and left ventricular waveform
529
Impella 5.5
- Left sided support device directly offloading the left ventricle
- Inserted in the OR by CT surgeon via axillary cutdown or direct aortic insertion via sternotomy and delivers peak flow rates up to 6 L/min
- Placement signals consist of aortic and LV waveform
- Ensure catheter is externally secured at 3 points due to high risk for massive blood loss with accidental dislodgement
530
Impella RP
- Right sided support device directly offloading the RV
- Often femorally placed but can be placed via IJ (Impella RP Flex).
- Delivers flow rates of greater than 4 L/min
- Placement signal is PA waveform
- Should always be at level P6 or higher with flow rate greater than 1.5 L/min to prevent clotting due to being in the venous system
- RP patients should still have a PA catheter in place for placement confirmation and monitoring of CVP, PA pressures, and SVR. However, Fick calculations are performed to assess CO/CI instead of thermodilution
531
CPO (cardiac power output)
CPO = (CO + MAP)/451
- predictor of survivability in cardiogenic shock patients, indicator of end organ perfusion
- Measured in watts, like a lightbulb, the brighter the better, indicating a stronger heart
- Normal = >1-1.5 watts, <0.6 is critical and indicative of increased mortality
532
PAPI (Pulmonary artery pulsatility index)
PAPI = (PA systolic/PA diastolic)/CVP
- Hemodynamic index indicative of RV failure in the setting of acute inferior wall MI
- Normal is >2.0, <1.0 indicative of severe RV failure and need for Impella RP
533
Physical assessment of patient with an LVAD
Patient may not have a palpable pulse- perfusion is assessed by skin signs patient's mental function, EtCO2 and urine output.
534
O2 Sat for LVAD patients
pulse oximetry measurement may be inaccurate and should be considered with other clinical indicators to determine hypoxia
535
Blood pressure and LVAD patients
Blood pressure measurement is done by manual cuff and palpation or doppler: BP may not be obtainable. The pressure at which arterial flow becomes audible is the MAP
536
Does Care Flight transport patients with LVADs?
Care Flight provides transport for any patient with an LVAD. If the transport is due to a malfunctioning LVAD, Care Flight medical staff members will contact the receiving facility's accepting physician and the LVAD troubleshooting center to ascertain safe transport of the patient, Care Flight RN will consider obtaining orders from the receiving physician in case the patient's condition deteriorates in flight
537
Special precautions to have in place before transporting a patient with an LVAD
Prior to transport, review with the patient, caregiver, or sending care provider alarms associated with the LVAD, procedure for changing the battery, and assessing connections, should the patient become unable to do so. Ensure continued availability of power source prior to transport. Extra batteries and battery charger should be transported with the patient. The patient's back-up battery should be available in the aircraft at all times
538
Being that SpO2 can be difficult to monitor in a patient with an LVAD, what other form of monitoring should be utilized
EtCO2 is highly recommended for monitoring perfusion status
539
Treatment of ECG findings in patients with LVAD
Do not treat ECG findings unless the patient is symptomatic- AMS, poor skin signs, chest pain, etc.
540
LVAD and defib/cardioversion
patients can be defibrillated and/or cardioverted. If cardiac monitor is not able to synchronize the ECG, perform unsynchronized Cardioversion
541
Treatment of shock in a patient with an LVAD
Shock may be treated according to specific protocols, with the understanding that treatment according to specific vital signs is not appropriate; patient care decisions are based upon signs of decreased perfusion such as change in level of consciousness, poor skin signs, chest pain.
542
Blood pressure guidelines for LVAD
Hypertension: >90
Hypotension: <60
543
Common complications with LVAD
Right heart failure, infection and bleeding
544
Pacer pad placement for LVAD patient
Pacer pads should be placed anterior/posterior for best conduction. Avoid placing pads over the apex of the heart, where the device is located
545
Displacement of LVAD with CPR
Limited data shows a lower incidence of pump displacement when CPR is performed
546
Renown stocked devices for LVAD
Renown ER stocks two Heartmate 3 batteries
547
Care Flight flight crew and patients with obvious LVAD pump issues
When a flight crew encounters a patient with obvious LVAD pump issues, the flight team needs to contact the patient's LVAD center for medical direction. If the patient is not in extremis, the flight team should make every effort to transport the patient directly to the closest appropriate LVAD center rather than a local hospital for definitive care
548
LVAD patients and AICD/pacemaker
LVAD patients commonly have an AICD/pacemaker placed as they have cardiomegaly
549
LVAD and blood thiners
Patients with LVADs must be on anticoagulants/antiplatelet drug. Monitor for bleeding
550
LVAD and fluid challenge
Passive leg lifts are effective in determining patient's responsiveness to fluid challenges prior to administration of fluids. US of IVC is an objective measurement of fluid status
551
Right heart failure and LVADs
Right heart failure is common in patients with LVADs. Consultation with the LVAD center should be made to determine plan of care while in flight. (I.E. administration of Lasix, Epinephrine infusion, BiPap...) If BiPap is used, consider using a lower PEEP setting if possible
552
TXA and LVAD patients
TXA is appropriate to administer to trauma patients when the benefit of decreased internal bleeding is greater than the possible risk of future emboli formation
553
Non-functional LVAD patient with MAP >60
If an LVAD has been non-functional and the patient has a MAP >60, contact with the LVAD center should be made prior to attempting to restart the LVAD due to the increased risk of thrombus formation
554
ADULT Zofran dose
4 mg IV/IO/IM/PO q 15 minutes for unrelieved nausea and/or vomiting, maximum total dose 12 mg
555
Interventions if patient is unresponsive to Zofran
Consider Promethazine (Phenergan) 6.25-35 mg IV/IM
556
NG/OG placement
Consider NG/OG tube placement if not contraindicated
557
Medications if Zofran and Phenergan do not work
Consider Diphenhydramine 12.5-25 IV/IM for vomiting unresponsive to the other medications or if there is a contraindication to the other drugs
558
PEDS dose of Zofran
0.15 mg/kg (max 4 mg) IV/IO/PO q 15 minutes for unrelieved nausea and/or vomiting, max 3 doses
559
PEDS dose and considerations for Phenergan
Over 2 yo: con\sider Phenergan 0.25 mg/kg IV/IM for vomiting unresponsive to Zofran. Maximum single dose 12.5 mg
560
Special considerations and mechanism of action for Zofran
Zofran selectively antagonizes serotonin 5-HT3 receptors; 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
561
Special considerations and mechanism of action for Phenergan
Promethazine is in the phenothiazine class of meds, and possesses anticholinergic properties (antiemetic and sedative effects). May cause severe hotn if patient is dehydrated- deliver LR fluid bolus before administration of drug. May cause extrapyramidal reactions; treat per protocol with Diphenhydramine. Infusion may cause tissue necrosis if administered through an infiltrated IV. Monitor closely and assure IV line is patent prior to administration. It is associated with severe respiratory depression in children and is not recommended for children younger than 2 years of age
562
Correlation between blood sugar and N/V
Alterations in blood glucose may cause N/V
563
Infants vomiting vs spit up
In infants, there is a difference between vomiting and "spitting up, although parents and caregivers may use the term interchangeably. "Spitting up" is more of a symptom of GERD and occurs immediately after burping.
564
Evaluation for patients with continuous vomiting and associated fever
Assess for signs of AMS relative to age, dehydration, dry membranes, delayed cap refill, and decreased urine output
565
Male newborns and forceful vomiting
Forceful vomiting and newborns, especially male newborns may be related to pyloric stenosis
566
NEO history questions
Numbers of babies in this gestation
Pre birth questions:
- Expected gestational age
- Amniotic fluid color- is it clear?
- Additional risk factors (drug use, illness, prenatal complications, etc)
- Umbilical cord management
567
NEO physical assessment
- Breathing or crying
- Muscle tone
- Skin color
- Blood sugar
- APGAR score at 1 min, 5 min, and 10 min
568
NEO interventions HR >100 and pink
- delay cord clamp 30-60 seconds
- Warm- continuous temperature monitoring device (skin or rectal)
- Dry- only if it is a term baby, as this will damage the preterm infant's skin
- Stimulate- run 2 fingers on either side of the spine
- Position and suction airway if needed (mouth before nose)
- Place on monitor
- For all babies, place in a plastic bag to preserve warmth
569
NEO interventions HR >100 but central cyanosis
- Place pulse oximeter on right hand (preductal)
- Give supplementary oxygen if SpO2 <90 after 10 minutes
- Preterm (<35 weeks) gestation should have oxygen started at 21% and titrated to achieve preductal O2 saturations as for healthy term neonates
- Always start at 21% FiO2, if possible, place on a blender with a flow meter at 10 LPM
570
NEO interventions HR >100 with labored breathing or low O2 sat despite free flow oxygen
- CPAP- Make a tight seal around T-Piece resuscitator on infants' face
- Do NOT apply to crying baby- may result in pneumothorax
571
NEO interventions for HR<100 or apneic, persistent cyanosis
- Positive pressure ventilation within 10 seconds
- If Meconium staining noted, provide PPV and only intubate/suction if complete airway obstruction found
- PPV breath cadence: "Breath, 2, 3, Breath, 2, 3" approximately 40-60 BPM
572
Once PPV has been initiated, how often to assessments occur
in 15 second intervals
573
1st assessment/HR after 15 seconds PPV- HR increasing
- Continue PPV
- 2nd HR assessment in 15 seconds
574
1st assessment/HR after 15 seconds PPV- HR not increasing but chest moving
- Continue PPV
- 2nd HR assessment after 15 seconds of PPV that moves chest
575
1st assessment/HR after 15 seconds PPV- HR not increasing and chest NOT moving
- Ventilation correction steps until chest movement with PPV
- Continue PPV that moves chest
- 2nd HR assessment after 30 seconds of PPV that moves chest
576
Ventilation Corrective Measures- MR SOPA
- Mask adjustment- lift jaw, 2 hand hold
- Reposition neck- neutral alignment, extended
Deliver 5 breaths- No chest Movement, proceed to SO
- Suction- mouth before nose (bulb or catheter)
- Open mouth, lift jaw forward
Deliver 5 breaths- no chest movement, proceed to P
- Pressure increase- increase PIP in 5-10 increments (full term max 40, preterm max 30)
Deliver 5 breaths- no chest movement, proceed to A
- Alternate airway- laryngeal mask or ETT
577
2nd Assessment/HR after 30 seconds of PPV that moves chest- HR >100
- Continue PPV 40-60 BPM until spontaneous effort
578
2nd Assessment/HR after 30 seconds of PPV that moves chest- HR 60-99
- Reassess ventilation
- Ventilation corrective steps PRN
579
2nd Assessment/HR after 30 seconds of PPV that moves chest- HR <60
- Reassess ventilation
- Ventilation corrective steps PRN
- Alternate airway
- If no improvement, start 100% oxygen and chest compressions
580
What respiratory criteria must be met prior to starting compressions on a NEO
Newborns must receive 30 seconds PPV WITH chest rise before compressions/meds
581
NEO interventions HR <60
- PPV at least 30 seconds with chest rise, consider intubation
- Chest compressions- increase FiO2 to 100% once chest compressions start
- 3:1 compressions to ventilation ratio cadence: "1 and 2 and 3 and breath" (90:30)
- Epinephrine 0.02mg/kg = 0.2 ml/kg (0.1 mg/ml) UVC/IV/IO OR Epi 0.1 mg/kg= 1 ml/kg ETT if no UVC/IV/IO access. Once access is established, may immediately give IV dose
- Fluid bolus NS 10 ml/kg X1 over 5-10 minutes. Call for orders for repeated fluid boluses
- Flush with 3ml NS following medications
- HR assessed at 60 second intervals following chest compressions
582
If interventions for NEO with Hr <60 fail
Re-check effectiveness of ventilation, chest compressions, endotracheal intubation, and Epi delivery
583
interventions for NEO if HR remains absent for >20 minutes despite resuscitation
Consider calling for termination of efforts
584
If mother and baby are to be transported
Transport neonate with mother
585
NEO interventions for BG<40
Administer D10 at 2ml/kg
586
how to deliver PPV to a NEO
PPV with the T-Piece resuscitator. Set PIP to 20-25 (full term set PIP 30-40 first few breaths, then decrease to 20-25) Set PEEP to 5
587
NEO BP parameters
Minimum MAP should be equivalent to gestational age for NEO. Ex: 39 weeks= MAP of 39, 28 weeks= MAP of 28
588
What to do for an unstable neonate being delivered in health care facility
Call dispatch for activation of neonate team. At least one CF crew member to stay with neonate until neonate team arrives. Both should stay if mother's condition allows it. NICU team will not respond unless the baby is born. It takes approximately 45min-1hr from dispatch to in transit
589
Preferred advanced airway for NEO
Attempt ETT intubation for medication administration. Epi cannot be given via LMA
590
When should a LMA be utilized first for a NEO
For abnormalities of the mouth/tongue/cleft palate, utilize LMA first
591
When is an LMA not indicated for NEO
LMA is not indicated for <28 weeks preemie
592
When to place an OG for NEO
Place OG for prolonged BVM to decompress the stomach. Attach syringe to remove air/contents and then leave the valve open to vent
593
How to provide cricoid pressure for NEO
Provide cricoid pressure by pressing down and to the baby's right ear if needed
594
Treatment for pneumothorax for NEO
Decompress with up to a 20G angiocath. Do not leave the catheter in, instead, once decompressed, remove catheter and seal with a tegaderm
595
Interventions if unable to place UVC or PIV for NEO
pediatric IO may be used without the drill and placed manually. The umbilicus may also be cannulated on the outside towards the abdomen, similar to an IV
596
UVC placement
Usually there are two smaller arteries and one large/collapsible vein. Artery "winks" with cleaning. <38 weeks measure length of cord plus 1cm. 38+ weeks measure length of cord plus 2 cm
597
Type of fluids used for NEO
NS is the preferred IV fluid for the NEO. LR is hypotonic and can decrease serum Na
598
Temp management for NEO
Temp monitoring is essential. NEO must not be allowed to be hypothermic or hyperthermic (keep temp between 36.5-37.5C)
599
How long can a NEO have cyanosis
Central cyanosis may remain up to 10 min, color is not a reliable indicator of O2 sat. Acrocyanosis may last 24 hours
600
Benefit of delayed cord clamping in NEO
Delayed cord clamping 30-60 seconds benefits neurodevelopmental outcomes in term babies and decreased the need for BP support/transfusion and increases survival in preterm babies
601
Quick sizing chart for NEO
If you can hold the baby in:
- one hand: 1 kg (approximately 28 weeks)
- 2 hands: 2 kg (approximately 28-34 weeks)
- hold them in the crook of your arm like a normal baby: 3kg or greater (approximately >35 weeks)
602
APGAR categories
- Activity (muscle tone)
- Pulse
- Grimace (reflex irritability)
- Appearance (skin color)
- Respiration
603
APGAR activity scoring
- Absent (0 pt)
- Arms and legs flexed (1 pt)
- Active movement (2pt)
604
APGAR Pulse scoring
- Absent (0 pt)
- below 100 bpm (1 pt)
- over 100 bpm (2 pt)
605
APGAR Grimace scoring
- Flaccid (0 pt)
- Some flexion of extremities (1 pt)
- Active motion (sneeze, cough, pull away) (2 pt)
606
APGAR Appearance scoring
- Blue, pale (0 pt)
- Body pink, extremities blue (1 pt)
- Completely pink (2 pt)
607
APGAR scoring Respiration
- Absent (0 pt)
- Slow, irregular (1 pt)
- Vigorous cry (2 pt)
608
APGAR score ranges
- 0-3 severely depressed
- 4-6 moderately depressed
- 7-10 excellent condition
609
Targeted pre-ductal SpO2 after birth
- 1 min 60-65%
- 2 min 65-70%
- 3 min 70-75%
- 4 min 75-80%
- 5 min 80-85%
- 10 min 85-95%
610
History questions for OB/childbirth
- prenatal care
- complications during pregnancy
- last normal menstrual period
- gravidity and parity
- previous pregnancies- duration of labor, C-section or vaginal, complications
- single vs multiple fetus (es)
- presence of vaginal bleeding/discharge
- Presence of abdominal/back pain
- presence or absence of contractions
- presence of meconium
- urge to push
611
physical questions for OB/childbirth
- external vaginal exam
- crowning or fetal parts
- bleeding/discharge- amniotic fluid, meconium stain
- FHR by doppler before transport and at least every 15 minutes during transport
- FHR upon transfer of care
- During and between contractions- rate, variability, early or late decelerations
- Pedal and/or facial edema
- Lab work for evidence of HELLP
- Fetal monitor strip from sending facility- evaluate for rate, variability, early or late decelerations
612
positioning of OB patient
Position patient on her left side, or elevate right side of body on a pillow. Right lateral recumbent is also acceptable if left lateral recumbent is not possible
613
IFT of OB patient
The sending physician or OB RN should be asked to perform a vaginal exam prior to transport to ensure stability, including cervical dilation/effacement, for transport. If, in the opinion of the medical crew, the patient is not obstetrically or otherwise stable enough for transport, the medical crew member will call the perinatologist on call and remain at the sending facility until contact with the perinatologist is made.
614
IFT to Reno hospital with OB patient
All maternal IFT to Reno hospitals must be arranges through Perinatology Associates. If this contact has not been made by the sending physician, the clinician will call the perinatologist on call prior to departure
615
Interventions for childbirth
If crowning present, contractions are less than 2 min apart, the mother is bearing down/pushing, or states she "can feel the baby coming" stay and assist delivery
- Place mother in lithotomy position
- Drape mother, place absorbent pads under pelvis, don PPE
- Prepare for neonatal resuscitation
- Assist delivery- guide and control to prevent precipitous delivery, do not pull on the head of the baby, but allow for the baby to come naturally
- Document time of birth
- See Neonatal Resuscitation protocol for care of the newborn
- Wait 30-60 seconds after delivery to clamp the umbilical cord in two places approximately 8-10" from the infant- in both term and preterm infants not requiring immediate resuscitation. Cut the cord between the clamps
- Transport- Do not wait for or attempt delivery of the placenta. If placenta delivers spontaneously, bring to the hospital.
- Once the placenta is delivered, bleeding can be controlled by massaging the uterine fundus
616
Excessive vaginal bleeding and/or signs of shock
- Massage fundus ( regardless of placenta delivery) and increase IV/IO flow rate to wide open
- Administer O2 to maintain SpO2 of 100%
- Initiate breastfeeding if feasible
- Initiate Oxytocin infusion by mixing 20 units in 250ml of NS. Administer 125 ml of this solution IV/IO over 10-20 minutes, then infuse at 31.2 ml/hr
- Administer TXA if previous interventions are unsuccessful. Bolus: Administer 1 gm of TXA SIVP. Mix 1 gm TXA in 10 ml NS
617
Prolapsed cord
- Place mother on back with hips elevated or place her in knee/chest position
- Place gloved index and middle fingers into the vagina and gently push the neonate up to relieve pressure on the cord
- Check cord for pulse. If cord is outside the canal, and if feasible, wrap in sterile wet dressing
- Transport and notify receiving hospital of impending arrival. Do not remove hand until adequate assistance is available (typically all the way into the OR)
618
Abnormal fetal presentation or decreased FHT
- Placed mother in left lateral recumbent position
- Transport and notify receiving hospital of impending arrival
619
Rupture of membranes with decreased FHT
- Place mother on back with hips elevated or place her in knee/chest position if no improvement
- Perform vaginal exam to insure that cord is not compressed between cervix and the baby's head
- Sweep finger between cervix and babies head in attempt to remove pressure from cord
- Frequently monitor FHR with mother maintained in knee to chest position to ensure that the cord does not become compressed again
620
Delivery completed before arrival
- Protect infant from temperature loss- place on wrapped chemical blanket
- Check infant's VS (perform NRP as necessary)
- Clamp the umbilical cord in two places (8-10" from the infant) and cut the cord between clamps
- Suction, warm, dry, and stimulate infant
- Do not pull on cord or attempt to deliver placenta
- Massage uterus firmly to control bleeding
621
Breech presentation
- Allow infant to deliver to the waist with support only, no active assistance. Once the legs and buttocks are delivered, the head can be assisted out. If the head does not deliver within 4-6 minutes, insert a gloved hand into the vagina to create an airway for the infant.
- A position change for the mother may assist in birthing the breech baby.
- If there is a limb presentation (incomplete breech), the success of delivery is small
- If breech delivery is in progress with a transport time >20 min, contact perinatologist for possible delivery assistance
622
Cord wrapped around the neck
- Slit it over the head off the neck. It may be necessary to clamp and cut the cord if it is tightly wrapped
623
Shoulder dystocia
- Signs of shoulder dystocia: infant presentation after head delivery retracts tightly against the perineum or normal downward traction does not deliver the shoulders
- Perform McRoberts maneuver and suprapubic pressure: have the mother flex her legs int a knee-chest position. If not successful, apply pressure to just above the pubic symphysis. Do not apply pressure to the fundus but help to displace the infant posteriorly
- If both maneuvers fail to deliver the baby, rapid transport should be initiated
624
Interventions if not a positive response to drying and stimulation
Avoid unnecessary delays in initiating ventilation if there is not a positive response to drying and stimulation
625
Interventions if meconium is present
It is no longer necessary to intubate and suction using a meconium aspirator for meconium staining. new recommendations are to quickly initiate BVM with 21% oxygen and PEEP valve set to 8 and titrate to achieve SpO2 as noted in NRP chart
626
What to look for in postpartum hemorrhage
look for the 4 T's: Tone, Trauma, Tissue, and Thrombin for reasons for hemorrhage
627
Special considerations for ETT size for pregnant women
An ETT 0.5-1 mm smaller than that used for non-pregnant women should be used
628
CPR special considerations for pregnant women in 3rd trimester
CPR should be performed higher on the sternum
629
VEAL CHOP for determining fetal heart tone variability
FHTs:
- Variable
- Early decelerations
- Accelerations
- Late decelerations
Underlying reason:
- Cord compression
- Head compression
- Okay
- Placental insufficiency
630
History questions for OB preterm labor different from term labor
- Estimated date of confinement
- Blood type/Rh
631
Preterm labor physical examination different than term delivery
- Lab work for evidence of HELLP/UTI/Infection
632
Positioning of preterm labor mom
Position the patient on her side, or elevate the side of the body on a pillow to maximize maternal venous return. Left side if preferable, but the right side is acceptable
633
SpO2 goal for preterm labor patient
SpO2 goal of 98% with supplemental oxygen PRN if suspected fetal distress; i.e. fetal HR>160 or <110, place mother on NRB mask at >12 LPM
634
Fluid given to preterm labor patient
Administer 500 ml bolus of IV LR, up to 2000 ml if no evidence of heart failure
635
Interventions if IV fluids do not slow contractions
Initiate tocolytics:
- Terbutaline 0.25mg SQx 3 doses Q 20 min (hold for previous sensitive to medication or HR >120)
- Phenergan 12-25mg IV over 3-5 minutes (for N/V and mitigate side effects of Terbutaline administration)
Magnesium loading dose:
- Mag 4 mg over 20 minutes on the pump (300 ml/hr). Mix 4gm in 100ml NS
- Mag continuous infusion: 2gm/hr (50 ml/hr) Mix 4gm in 100 NS
636
What to assess when giving Mag infusion
Assess DTRs at least once every 15 minutes to assess for impending cardiovascular collapse
637
Urine production and interventions for preterm labor patient
Foley catheter should be placed to monitor adequate hydration secondary to fluid boluses. The patient should produce approximately 0.5ml/kg/hr of urine. Titrate fluid boluses and maintenance fluids accordingly
638
Signs of mag toxicity
Decrease in DTRs or respiratory rate less than 12 BPM
639
Interventions with suspected mag toxicity
Immediately stop infusion, give Calcium Chloride 1 gm/10ml IV over 3 minutes
640
Interventions for late decelerations or sustained bradycardia (FHR <110)
- Reposition patient (if no change in FHR within 60 seconds continue to attempt improvement in HR with additional repositioning)
- Administer oxygen to achieve SpO2 >98%
- Administer LR bolus 500 ml
- Increase/administer tocolytics per MD order in attempt to decrease contractions
- If detected prior to departure discuss transport with the sending facility and perinatologist
- If detected while in flight notify receiving perinatologist of suspected fetal compromise as soon as possible
641
IFT of preterm labor patient, what must be completed prior to transport
The sending facility must be asked to examine the patient prior to transport to ensure stability, including cervical dilation/effacement, for transport
642
Excluding criteria for sending physician performing a vaginal examination
Vaginal exam should not be performed prior to departure if no premature rupture of membranes due to increased risk of further rupture of membranes, placenta previa, and infection. The patient should have a vaginal exam if she feels the urge to push or have a bowel movement
643
Intervention if the medical crew does not view the patient stable enough for transport obstetrically or otherwise
The medical crew member will call the perinatologist on call and remain at the sending facility until contact with the perinatologist is made
644
Risks associated with rupture of membranes in a preterm labor patient
Rupture of membranes is associated with increased risk of cord compression ergo the FHR should be monitored for 2-3 minutes after rupture of membranes occurs to assess for fetal compromise
645
Side effects of magnesium
bradycardia, hotn, hypothermia, decreased DTR, drowsiness, respiratory depression, dysrhythmias, flushing, nausea, vomiting, sweating, drowsiness, weakness
646
Terbutaline side effects
Jitteriness, N/V, flushed feeling, tachycardia, palpitations, and restlessness
647
Phenergan side effects
Prolonged QT, CNS depression, lowered convulsive threshold, sedation, somnolence, respiratory depression
648
Special considerations if sending facility administers steroids prior to transport
monitor neonate for hypoglycemia closely if born during transport
649
Additional precautions for patients with Pregnancy induced hypertension to reduce stimulation
Protect patient from unnecessary stimuli such as direct sunlight noise and flicker due to increased risk of seizure activity
650
IVF rate for patients with pregnancy induced hypertension
When possible, limit total IVF to 100 ml/hr to minimize risk of possibly exacerbation of hypertension
651
Goal BP for pregnancy induced hypertension
SBP<160, DBP<110
652
How frequently to assess BP in PIH
every 10 minutes
653
Labetalol for BP control
- Administer Labetalol 10 mg IV/IO over 2 minutes
- Continued BP elevation: continue Labetalol 10 mg IV/IO every 10 minutes, increasing dose by 10 mg each time to a single maximum dose of 80 mg, or a total of 360 mg, including doses given PTA.
- Hold Labetalol if HR <60
654
Interventions if Labetalol contraindicated or not effective in lowering BP
- Hydralazine 2-5mg IV/IO followed by 10 mg Q15-20 min (max dose 40 mg)
- May request Nicardipine gtt from sending facility if Labetalol is ineffective
655
Interventions for active seizure lasting more than 1 minute
Midazolam 10 mg IM, may repeat X1 (preferred), alternatively 5 mg IV, may repeat X1
If patient continues to seize, initiate magnesium
656
Magnesium dosing
- Loading dose: 4 gm over 20 minutes on the pump (300 ml/hr)
- start mag continuous infusion: 2-4 gm/hr (50 ml/hr)
657
If magnesium drip started, how frequently do you assess DTR
at least once every 15 minutes
658
Interventions if seizure activities continue
- repeat Midazolam dosage and prepare to manage airway/ventilation per airway protocol
- Contact Perinatologist for additional antiepileptic options
659
HELLP Syndrome
Manifested by Hemolysis, Elevated Liver enzymes, and Low Platelet count. S/s include headache, vomiting, visual disturbances, HTN, peripheral and central edema, and DIC like bleeding
660
Treatment for HELLP
Treatment en route is the same as for PIH
661
Timeframe where Eclampsia can occur
up to 6 weeks postpardum
662
treatment for direct trauma (blunt or sharp) to the eye
- DO NOT attempt to remove any foreign bodies from the eye itself
- Immobilize impaled object
- If not contraindicated, place the patient in a semi-fowler or sitting position to reduce intraocular pressure
- Remove superficial foreign bodies from the skin surface of the eyelids
- If the patient has complaints of eye discomfort or foreign body sensation, instill topical eye anesthetic. This is CONTRAINDICATED with any penetrating trauma injury to the eye
- Cover BOTH eyes to prevent eye movement while making certain that the protection does not place pressure on the eyes
- For eye(s) that are dislodged from the orbit: cover the eye and orbit with saline soaked gauze and then cover both eyes to prevent eye movement. Ensure the gauze remains wet during transport
663
Treatment for ocular chemical burns
- Instill several drops of topical eye anesthetic to the involved eye(s)
- While gently holding the lids open, using gauze if necessary to maintain traction on the skin, irrigate the eye with high volumes of normal saline solution. Continue eye irrigation throughout the course of transport until arrival at the end destination hospital
- Consider contacts and remove immediately
664
Treatment for thermal ocular burns
- Thermal burns to the eye are relatively uncommon and are usually associated with severe facial burns. Treatment should be directed to the more emergent lifesaving procedures as necessary
- If the patient has complaints of eye discomfort, instill several drops of topical eye anesthetic to the involved eye(s)
665
Considerations for flight altitude and intra ocular injury
Consider altitude restriction for patients with possible increased ocular pressure or penetrating trauma to the eye
666
Blunt ocular trauma and bleeding
Blunt trauma to the eye can result in hyphema; a collection of blood in the anterior chamber of the eye. If the patient is upright, a layer of blood may accumulate at the bottom of the cornea. If the patient is flat blood may accumulate in a ring around the cornea. Occasionally, the blood may appear as wisps across the cornea. This is much easier to see in a patient with light colored eyes. Vision will become red or brown if there is enough blood to cover the pupil
667
Retinal detachment in ocular trauma
Blunt trauma to the eye or head can cause retinal detachment. The patient may complain of "flashers" or "floaters" or that a curtain obscures part of the vision
668
ocular trauma with small projectiles
Small projectiles may penetrate the globe. If the object is entirely within the globe, only a small accumulation of vitreous humor may be present on the sclera over the puncture wound. Commonly, the pupil will become misshapen and will "point" toward the area of penetration
669
Ocular trauma and possible impact of ocular muscles
Orbital fractures may trap ocular muscles, preventing normal eye movement. If awake, the patient may complain of diplopia when looking through both eyes, but not when looking through one. The eye may not move through normally when examining extraocular muscle movement. Gently palpate orbit for indication of possible step-off injury
670
Ideal pain scales used for assessing pain level
A pain scoring tool such as the 0-10 pain scale or Wong-Baker pain scale for children is used, if possible, to assess comfort
671
Pain scales used if patient is incapable of self-reporting pain intensity
Either the Critical care Pain Observation Tool (CPOT) or the FLACC score.
672
Pain score treated for pain scales used for a patient incapable of self reporting pain intensity
Pain scores of greater than 2 should be addressed and documented in the medical record
673
Adult Fentanyl pain dosing
- IV/IO: 1-3 mcg/kg (max single dose 200 mcg) q 5-10 minutes, titrate to effect
- IN: 1-3 mcg/kg q5-10 min, titrate to effect
- IM: 100 mcg Q 1 hr PRN
- Continuous infusion: 25-300 mcg/hr, titrate to effect. Mix 300 mcg in 100 ml of NS
674
Adult morphine pain dosing
- IV/IO: 2-5 mg IV/IO q 15-20 min, titrate to effect
- IM 2-10 mg once for pain
675
Adult Ketamine pain dosing
- IV/IO/IM/IN: 0.15-0.3 mg/kg q 5-10 min, titrate to effect
- Continuous: 0.1-0.2 mg/kg/hr (mix 500 mg in 100 ml NS
676
Indications to be able to start continuous Ketamine drip
Transports greater than 30 minutes, after initial bolus, with no contraindications
677
What medication can be given to help with some side effects of Ketamine
Consider Atropine 0.4 mg IV for hypersecretion related to Ketamine administration
678
Adult Acetaminophen pain dosing
1000 mg IV over 15 minutes once. May use for mild/moderate pain.
679
Contraindication to IV Acetaminophen
Those with known cirrhosis
680
Medication given for pain secondary to IO infusion
IO: Lidocaine 2% (cardiac bristojet) 20-40 mg IO slowly over 2-3 minutes
681
Medication given for pain secondary to IV insertion
Intradermal: 0.2 ml or less of 2% lidocaine
682
PEDS Fentanyl pain dosing
!V/IO/IN: 0.1-1 mcg/kg q 5-10 min, titrate to effect
683
PEDS Morphine pain dosing
IV/IO: 0.1 mg/kg q10 min, titrate to effect
684
PEDS Ketamine pain dosing
IV/IO/IM: 0.15-0.3 mg/kg Q 5-10, titrate to effect
685
PEDS meds for possible side effects with Ketamine
Consider Atropine 0.01 mg/kg IV/IO (minimum 0.1 mg, maximum 0.4) for hypersecretion related to Ketamine administration
686
PEDS Acetaminophen pain dosing
Children >2yo: 15 mg/kg IV over 15 minutes once. May use for mild/moderate pain
687
PEDS pain medication secondary to IO infusion
IO: Lidocaine 2% 0.5-1 mg/kg no to exceed 30 mg
688
PEDS pain medication secondary to pain associated with IV infusion
Intradermal: 0.2 ml or less of 2% Lidocaine
689
Methods to consider for pain management prior to medication administration
Padding, positioning, splinting, warmth and distraction
690
IN administation
should be divided into 50% in each nostril, if possible
691
special considerations for when to choose morphine as the treatment for analgesia
Consider Morphine in patients with longer transport times and before transfer to emergency department where there may be a delay in analgesia
692
When would you consider giving Versed to a patient receiving Ketamine
Consider Versed 1mg IV, if hemodynamically stable, to attenuate psychotropic effects and recovery agitation
693
Ketamine infusion contraindications
Globe injury, liver disease, uncontrolled hypertension or history of psychosis
694
What is the recommended pain control medication for burn patients
Morphine is recommended. Consider higher doses to achieve analgesia, wile maintaining blood pressure and ventilation
695
Benzos with analgesia medications
Benzos do not potentiate the analgesic effect of narcotics, they only sedate the patient. A patient in pain without muscle spasm needs analgesia or a dissociative anesthetic
696
Effects of Ketamine on patient
Ketamine dissociates the patient from the perception of pain
697
Initial supportive measures for PEA/Asystole for PEDS patients
- CABs (chest compressions, airway, breathing)
- CPR, rhythm checks no more than every 2 minutes and for no longer than 10 seconds. Pulse check only if an organized rhythm is present
- cardiac monitor
- ETT or supraglottic airway placement
- Obtain IV access. IO access after 2 failed attempts, or if IV access not feasible
- Confirm in at least 2 leads
698
Possible causes to consider for PEDS Asystole/PEA
- hypovolemia
- Tension Pneumothorax
- Hypoxia
- Acidosis
- Cardiac Tamponade
- Hypothermia
- Pulmonary Embolism
- Myocardial Infarction
- Drug Overdose
699
Treatment for possible causes of PEDS Asystole/PEA
- NS fluid bolus
- Chest decompression
- Check ET tube placement
- Ventilate 20-30 bpm
- Pericardiocentesis
- Remove from environment/active rewarm
- Naloxone
700
Epi PEDS dose for Asystole/PEA
0.01 mg/kg (0.1 mg/ml) IV/IO push OR 0.1 mg/kg (0.1 mg/ml) ET repeat every 3-5 minutes
701
Interventions if PALS is unsuccessful
Consult medical control for possible administration of sodium bicarbonate, or termination of efforts
702
How many round of PALS must be completed and other interventions prior to terminating efforts
Prior to termination of efforts, a minimum of three rounds of Epi must be given and cardiac US must be done to confirm cardiac standstill/fibrillation
703
What change in VS could lead to stopping CPR prior to the pulse check
A sudden, large increase in ETCO2 is usually an indication of return of spontaneous circulation. Stop CPR and check for pulses
704
Initial question to ask for PEDS with bradycardia arrhythmia (<60) that helps determine course of treatment
Is the patient alert, behavior appropriate for age, without signs of poor perfusion?
- Yes, then transport patient
- No, then consider possible causes
705
PEDS dose Narcan
0.1 mg/kg max single dose 0.4 mg Q 5min up to 2 mg IV/IO/IM/ET/IN if clinically necessary, repeat
706
Intervention PEDS bradycardia to assist with oxygenation
If breathing is inadequate, assist ventilations with BVM, PEEP valve at 3-8
707
PEDS interventions with signs of severe cardiopulmonary compromise
If signs of cardiopulmonary compromise and the heart rate remains <60, initiate chest compressions
708
Additional possible cause for Bradycardia
Hypoglycemia- check a blood sugar
709
Parameters and treatment for hypoglycemia
- Alert with BG <60: consider oral glucose
- <1 month of age: blood glucose less than 40: D10- 2 ml/kg IV/IO
- >1 month of age: blood glucose less than 60: D10- 2 ml/kg IV/IO
710
Interventions if cardiopulmonary compromise persists after interventions
Administer Epi 0.01 mg/kg IV/IO of 0.1 mg/ml or 0.1 mg/kg of 1 mg/ml ETT q 3-5 minutes
711
PEDS intervention for bradycardia with increased vagal tone or primary AV block
Administer Atropine 0.02 mg/kg IV/IO/ET (minimum dose is 0.1 mg, maximum dose is 0.5 mg), may repeat once in 3-5 min
712
Criteria for tachycardia in infants and children
Infants greater than or equal to 220
Children greater than or equal to 180
713
Interventions for PEDS narrow complex tachycardia with signs of poor perfusion and not verbally responsive
Consider cardioversion first
714
Interventions for PEDS narrow complex tachycardia with signs of poor perfusion in SVT and verbally responsive
- Valsalve maneuver, if no response
- Adenosine 0.1 mg/kg IV/IO, if no response
- 0.2 mg/kg IV/IO, if no response
- Sychronized Cardioversion 0.5-1 J/kg. If conscious consider sedation and analgesia
715
Interventions for PEDS narrow complex tachycardia with no signs of poor perfusion
contact medical control for Adenosine order
716
What intervention needs to be completed when administering Adenosine
Run a continuous EKG strip during administration
717
Additional supportive measure utilized in PEDS VF/pulseless VT
Use cardiac US during one of the pulse checks if it can be done in less than 10 seconds to evaluate for tamponade and cardiac activity
718
Defib for PEDS VF and pulseless VT
Defibrilate at 2 J/kg (max 150 J)
719
Interventions for Perfusing rhythm after 2 minutes of CPR PEDS
- Reassess
- Support CABs
- Transport and treat per protocol
720
Interventions for Pulseless VF/VT after 2 minutes of CPR following defibrilation PEDS
- Consider possible causes, ETT/LMA placement
- Obtain IV access, IO access after 2 failed attempts, or if IV access not feasible
- Ventilate at a rate of 20-30 bpm
- Epi 0.01 mg/kg (0.1 mg/ml) IV/IO or 0.1 mg/kg (of 1mg/ml) ETT every 3-5 minutes
- Defibrillate 4 J/Kg. CPR (2 min)
- Amiodarone 5 mg/kg IV/IO max dose 300 mg or Lidocaine 1 mg/kg IV/IO
- Defibrillate 4-10 J/kg. CPR 2 min
- Amiodarone 5 mg/kg IV/IO max 150 mg or Lidocaine 1 mg/kg IV/IO
- Find and treat reversible causes
721
Antiarrhythmic that can ge given if IV access can not be established
Lidocaine may be administered via ET at 2.5 mg/kg, this may be repeated once.
722
Subsequent dosing if IV/IO is established after first dose is given
IV dose may be repeated at 1 mg/kg.
723
Interventions if Lidocaine pushes convert patient to a perfusing rhythm PEDS
Premix a Lidocaine drip at 20-50 mcg/kg/min (Lidocaine premix is 2 gm in 500 ml NS)
724
PEDS treatment for Torsades de Pointes
Treat with slow (over several minutes) IV push of Magnesium Sulfate 25-50 mg/kg. Max single dose 2gm
725
Max dose for Pediatric AMio
15 mg/kg in 24 hours
726
Wide complex tachycardia interventions based on heart rate being above or below 150
If HR< 150 BPM, obtain a 12 lead EKG to confirm VT
If HR> 150, use the PEDS algorithm
727
If patient is conscious, alert, without signs of poor perfusion
- Consider Adenosine if rhythm regular QRS monomorphic, if rhythm persists
- Amiodarone 5 mg/kg IV/IO over 20 min, if rhythm persists
- transport
728
If patient is NOT conscious, alter, and without signs of poor perfusion
If conscious, sedate per Anxiety/agitation protocol
- Synchronized Cardioversion 0.5-1 J/KG, if no response
- Synchronized Cardioversion 2 J/kg, if no response
- Amiodarone 5 mg/kg over 10 min, if no response
- Synchoronized Cardioversion 2 J/kg, if no response
- Call Medical control for further orders
729
Interventions for PEDS with moderate to severe dehydration
- Maintain body temperature, actively warm if hypothermic
- 30 days to 12 yo (<50): 20 ml/kg NS bolus over 5-15 min, May repeat x1. Contact medical control for further doses
- Less than 30 days old: Ns 10 ml/kg bolus. Repeat once after u5 min if no improvement
730
Treatment for fever in PEDS patient
If oral, temporal, or rectal temp is > 100.4 and the child has not had Acetaminophen in the last 4 hours, medical crew may give Acetaminophen 15 mg/kg PO or PR. IV dose of 15 mg/kg over 15 minutes may also be administered once.
731
PEDS maintenance fluids
- 4 ml/kg for the first 10 kg plus
- 2 ml/kg for the next 10 kg
- 1 ml/kg for every kg after that
732
Fluid selection for PEDS
NS is preferred over LR in a critically ill PEDS patient
733
pathophysiology for PEDS fever
Fever is a normal immune response to illness. However, for the child in shock or for the child with a pulmonary or cardiac abnormality, the increased metabolic demands can be detrimental and may offset any immunologic benefit from the fever. Reducing fever makes the patient more comfortable. Treating fever does not prevent febrile seizures
734
PEDS with fever and covering the patient with blankets
Bundling does not affect fever. Fever is determined by the hypothalamus. Cover the patient enough to make him/her comfortable
735
History questions for poisoning/overdose
-Suspected substance, amount, time of exposure, route of exposure
- Cause of exposure- recreational, accidental, suicide attempt
736
Interventions and observations on the scene for a poisoning/overdose
Look for evidence on scene, such as pill bottles, recreational drugs and paraphernalia, unusual odors or spills. Bring medication containers to the emergency department with patient. In some cases the patient may no realize they have been exposed, careful history of events leading to the illness may be the biggest clue
737
Immediate interventions for poisoning/overdose patient
If skin was exposed to substance (refer to Hazardous Materials protocol), remove clothing and rinse patient with copious amounts of water (see Chemical Burns section of Burns protocol)
738
Carbon Monoxide symptoms ADULT
HA, malaise, nausea, dizziness, chest apin, dyspnea, syncope, confusion, tachypnea, tachycardia, ALOC
739
Carbon Monoxide poisoning symptoms infant/toddler
Only symptoms may be fussiness or difficulty feeding
740
Treatment for carbon monoxide
Non-rebreather mask 15 lpm O2. Do not rely on pulse oximeter. Supportive care
741
SpCO values: 0-5%
Considered normal for non-smokers. When >3% with symptoms, consider high flow oxygen and recommend transport. If asymptomatic, no further medical evaluation necessary for SpCO. Counsel patients on signs and symptoms to watch for offer transport to ED, if refused complete AMA
742
SpCO value: 5-10%
Considered normal for smokers, abnormal for non-smokers. If symptoms are present, consider high flow oxygen and recommend transport to ED
743
SpCO value: 10-15%
abnormal in any patient. Assess for symptoms, consider high flow oxygen and recommend transport to ED
744
SpCO value: >15%
Significantly abnormal in any patient. Administer high flow oxygen and recommend transport to ED
745
SpCo value: 30%
Consider transport/referral to hyperbaric facility (consider referral to hyperbaric facility if >25% for patients with ALC or pregnant)
746
Symptoms of Tricyclic antidepressant
ALOC, HOTN, dysrhythmias, seizures, cardiac arrest
747
Supportive treatment of Tricyclic Antidepressant overdose
Supportive care, aggressive fluid resuscitation, vasopressors if still hypotensive after fluid resuscitation (Levo or Neo preferred)
748
Tricyclic antidepressant treatment if QRS > 100 ms
a sodium bicarbonate 2-3 mEq/kg IV, max 150 mEq bolus, followed by the initiation of a bicarb infusion (40 mEq in 250 D5W). Infuse at 250 ml/hr for adults or 2x maintenance fluid calculation for pediatrics.
749
Precautions to take when completing an IFT on a patient where they have started a bicarb gtt
Make all attempts to obtain a 1 Liter bag of D5W and 150 mEq sodium bicarbonate form the sending facility and mix 150 mEq in 1L. Initiate infusion at 250 ml/hr for adults and 2x the maintenance fluid calculations for peds
750
Organophosphate (insecticide) poisoning symptoms
Muscle tremors, ALOC, seizures, HOTN (hypovolemia), SLUDGE
751
SLUDGE
Salivation
Lacrimation
Urination
Defecation
GI distress
Emesis
752
Atropine in Organophosphate poisoning
Atropine 4 mg IV, doubled every 3-5 min for bronchorrhea or heart rate less than 50, until improvement in symptoms
753
Interventions with dermal exposure for organophosphate
Patient must be decontaminated prior to transport in helicopter. see Hazmat protocol
754
Seizure treatment for organophosphate poisoning
treat per seizure protocol
755
Treatment for HOTN/hypovolemia associated with organophosphate poisoning
Ensure adequate volume resuscitation 500-1000 ml NS bolus
756
RSI considerations with organophosphate poisoning
Succinylcholine should be avoided. Rocuronium is preferred but higher doses may be needed
757
PEDS dosing for Atropine in organophospate poisoning
Atropine 0.05 mg/kg IV (max 3 mg) every 3-5 minutes for bronchorrhea or heart rate less than 60, until improvement in symptoms
758
Acids/Alkalis poisoning and inducing vomiting
If ingested, do not induce vomiting; prevent vomiting per protocol
759
Patients that ingest more than one toxin
It is very common that a patient ingests more than one toxin. Combinations may create atypical presentations
760
Interventions if patient received oral activated charcoal prior to transport
Take measures to prevent vomiting and protect aircraft interior from contamination with charcoal
761
Ethylene glycol and methanol ingestions treatment
Are treated with an ethanol drip (goal is to maintain blood alcohol at .10) so that the body preferentially metabolizes the ethanol and the other alcohol can be excreted intact. Fomepizole is a drug that blocks alcohol dehydrogenase, the enzyme that the body uses to metabolize alcohol, allowing the alcohol to be excreted intact. This drug is given in an IV bolus, not a drip. The usual dose is 15 mg/kg IV loading dose, followed by 10 mg/kg q 12 hours x4 doses
762
Salicylate (ASA, oil of wintergreen) ingestion treatment
Salicylate over dose results in a metabolic acidosis. Do not deter hyperventilation. Toxic ingestion is greater than 150 mg/kg. Toxic serum level is more than 40 mg/dl. Toxic levels may be treated with activated charcoal if ingestion is recent and with IV sodium bicarb (1-2 mEq/kg, max 100 mEq, IVP over 3-4 min)
Administer glucose if the patient has ALOC even if BGL is normal
763
PEDS dosing of sodium bicarb to treat Salicylate poisoning
1.5-2 times calculated maintenance rate
764
Ibuprofen overdose treatment
Ibuprofen toxicity is not measure with serum tests; serum levels do not accurately reflect amount ingested or metabolized. Ibuprofen toxicity affects renal function. Despite high rates of acute NSAID overdoses, few patients experience poor outcomes, most require no medical interventions. Those that do usually experience GI upset and potentially gastric bleeding or renal dysfunction and receive supportive care only as there is no specific antidote
765
Acetaminophen overdose treatment
Acetaminophen metabolism results in a metabolite that is toxic to the liver. The younger the patient, the less this metabolite is produced; this is why Acetaminophen is so safe for infants. Serum APAP levels, 4 hours after ingestion, of 140 mg/kg or greater are considered toxic. Activated charcoal may be useful if given within 4 hours of ingestion. N-acetylcysteine (NAC, Mucomyst) is the antidote. it replenishes the liver's supply of essential enzymes, allowing removal of toxic metabolites. It requires a physician's order and can be given PO, OG/NG, or IV. The standard initial PO dose is 140 mg/kg, followed by half the calculated amount every 4 hours for 17 doses. IV dose is 150 mg/kg over 60 minutes, then 50 mg/kg over 4 hours, then 100 mg/kg over 16 hours. Dilutions may very.
766
CNS stimulants (cocaine, methanphetamines, PCP, Ecstasy or medications prescribed for narcolepsy, ADHD, and obesity)
Oral ingestions may be treated with activated charcoal. Treat following anxiety/agitation protocol
767
Hydrocarbon toxicity (found in petroleum, natural gas, coal, and bitumen)
The immediate danger is an aspiration; if the hydrocarbon was ingested, prevention of vomiting is paramount. Aspiration can cause pneumonitis, which may take several hours to develop. Treat per nausea/vomiting protocol. Systemic absorption may cause decreased LOC, heart blocks, Vfib, vomiting, and GI bleeding. Provide supportive care, especially for respiratory distress, consider Albuterol, HHFNC, Bipap and/or mechanical ventilation as necessary. if wide complex tachycardias develop, ACLS prn, consider Lidocaine instead of Epi
768
Calcium channel blockers
5-10 times the usual dose results in severe overdose. Overdoses of immediate-release MLBs are characterized by rapid progression to hypotension, bradyarrhythmia, and cardiac arrest, while overdoses of extended-release formulations can result in delayed onset of dysrhythmias, shock, sudden cardiac collapse, and bowel ischemia. Calcium can be administered IV/IO to patients who present with symptomatic HOTN or heart block. Usual dose, with physician order: Calcium 1-4 g in adults
Patients may also receive Glucogen, Dextrose, and Insulin. Ensure fluid resuscitation, Atropine for bradycardia, and Levo/Epi for hypotension
769
Calcium chloride dose for PEDS
20 ml/kg IV over 10-15 min. Call medical control for orders
770
Cyanide (released in smoke when certain substances are burned; it is also used in hard-rock mining) poisoning treatment
Cyanide binds to the ferric ion of cytochrome oxidase, inhibiting this final enzyme in the mitochondrial cytochrome complex. The cell must then switch to anaerobic metabolism of glucose to generate ATP. Despite an ample oxygen supply, cells cannot utilize oxygen because their poisoned electron transport chain. Inhaled Cyanide is lethal within minutes. patients may survive longer if Cyanide is orally ingested. If a patient with suspected cyanide exposure is receiving Hydroxocobalamin (Cyanokit) infusion prior to arrival, continue infusion during transport and monitor patient for adverse reactions (allergic reaction, HTN). Cyanokit is usually given 70 mg/kg; 5 grams is the standard dose, given over 15 minutes IV.
771
Which platforms can transported in a prone position
CCT and fixed wing
772
Who should be updated within the company prior to transporting someone prone
the Chief Nursing Officer or SOC
773
Questions to be addressed prior to transporting a patient in the prone position
- Assess if the patient has demonstrated the ability to maintain SaO2/hemodynamic stability in prone positioning prior to transfer
- Is the patient able to tolerate prone positioning for the duration of the transport?
- Does the sending provider understand the risk of delayed response for CPR and the increased risk of device dislodgement during transport in a prone position?
774
Devices that should be in place prior to performing IFT on prone patient
Request the sending facility place a bite block, NG/OG and pacer pads prior to transferring
775
Placement of lines and critical medications for prone patient
place critical lines/medications on the opposite side as the patient's head is facing. Disconnect IV lines if possible. Verify they are not underneath the patient before, during and after transfer
776
Special intervention with ETT when transferring patient to stretcher and between ventilators
Clamp the ETT to retain alveolar recruitment
777
Positioning on the stretcher for a prone patient
Place pillows under bony prominences. Place patient in a swimmer position or modified swimmers crawl with the face turned away from the aircraft wall, tilted slightly to optimize access to the patient's face and ETT. Consider raising patient's arm opposite from their face to facilitate ease of turning if needed. Patients may be slightly tilted from the swimmer's position to optimize access to the ETT and patient's face
778
Restraints for prone patient
place bilateral soft wrist restraints on the patient, assess CMS before and after placement
779
Sedation and paralysis for prone patient
maintain adequate sedation and paralysis throughout the transport. Consider getting orders from the sending provider for a Vecuronium drip
780
Steps to turning the patient from prone to supine if the patient condition changes, necessitating turning the patient into a supine position
- Ensure one person is at the head of the patient to maintain the ETT throughout the move
- Additional crew members will secure the patient in a sheet/blanket, and secure tubing and ETT for turning the patient. Roll the patient in the direction they are facing while assessing and maintaining ETT and lines
- Clamp the ETT and disconnect ventilator tubing prior to turning. If time allows, consider disconnecting IV drips as well
781
Reassessment of skin for prone patient
Skin should be reassessed at a minimum of every 2 hours to reduce risk of pressure ulcers
782
Intervention to eyes to reduce risk of trauma
Consider taping the eyes closed
783
What alternatives can be done to a full prone position
Awake proning or side lying position if patient is able to tolerate on all transport planforms
784
SpO2 goal for a patient with COPD
90-95%
785
Interventions for asthma/reactive airway disease
- Albuterol 2.5-5 mg until symptoms improve. Use Albuterol in HHNC continuously if necessary
- Consider Albuterol/Ipratropium in nebulizers 2 and 3
- Solu-medrol 125 mgx1 dose
- Consider Magnesium 2 grams IV over 20 minutes if the above conventional therapies remain ineffective
- For imminent respiratory failure, administer Epi 0.3 mg (0.3 ml of 1 mg/ml) IM. If no response to IM, give Epi 0.3 mg IV
- See anxiety/sedation protocol for agitation and continued sedation for intubated patients
786
Asthma/reactive airway treatment for PEDS
Albuterol:
- <12 yo: 0.15 mg/kg (max dose 2.5 mg) q 20 minutes for 3 doses followed by 0.5 mg/kg/hr diluted in 3 ml saline for continuous nebulization
- >12 yo: use the adult dose
- Epinephrine: 0.01 mg/kg of 1 mg/ml up to 0.3 mg IM
- Impending respiratory failure: Epi 0.01 mg/kg IV/IO to max dose of 0.3 mg
- Administer Solu-Medrol 0.5-1 mg/kg x1 dose
- Consider Magnesium Sulfate 50 mg/kg up to 2 gm in Ns 100 ml; administer over 20 minutes
- Call medical control if interventions unsuccessful and terbutaline required. Terbutaline 0.01 mg/kg, max dose of 0.4 mg.
- See anxiety/sedation protocol for agitation
787
Treatment for Stridor or hypoxia related to croup or epiglottitis PEDS
- Allow the patient to remain sitting upright if alert
- Racemic Epinephrine (2.25%):
--- <6 months of age nebulizer 0.25 ml
--- >6 months nebulizer 0.5 ml; may repeat in 20 minutes
- Assure adequate hydration with maintenance IV fluids (Peds dehydration protocol)
788
Chronic lung disease with deterioration
- Adminsiter albuterol unit dose until symptoms improve
- Consider Albuterol-Ipratropium in neb 2 and 3
- Solu-Medrol 125 mg IVP X1
- For impending respiratory failure, give continuous Albuterol nebulizers diluted with 3 ml saline (use Albuterol/Ipratropium only in NNMs 2 and 3)
- Consider placing patient on BIPAP per BIPAP per Ventilatory Management protocol
789
Interventions for Pulmonary Edema
- Position patient sitting up at blood pressure will tolerate
- Administer NTG 0.4 mg SL or NTG o.4 mg (2 ml) IVP, q 5 minutes up to 3 is SBP >100 while preparing to initiate Nitro infusion at 50-200 mcg/min to keep SBP >90 and titrate to effect (Nitro 50 mg in 250 D5W)
- Furosemide 40 mg IV/IO over 5 minutes if not currently taking at home, or the equivalent of one dose of their home oral regiment IV/IO (no order needed)
- Treat pain according to Acute Coronary Syndrome protocol
- Employ anxiolysis using anxiety/agitation protocol
- Consider assisting breathing with BVM and use of PEEP valve to provide noninvasive protective pressure ventilation. Begin with a PEEP setting of 8 cm and adjust as necessary to maximum of 10 cm.
- Consider implementation of BIPAP on Hamilton Ventilator (see ventilator management protocol) start with Pinsp 12/ PEEP 5, Pramp 2, and ETS to 40%
790
Interventions for pneumothorax
- Watch for s/s of tension physiology. If patient deteriorates rapidly, perform a needle thoracostomy on the affected side according to procedure. If needle thoracostomy x2 unsuccessful, proceed to simple thoracostomy
- Consider chest tube insertion upon definitive confirmation of a significant pneumothorax or hemothorax by x-ray or US and with MD order
791
Asthma/reactive airway and utilization of BIPAP
Asthma/reactive airway disease with impending respiratory failure, initiate Bipap as early as possible. BIPAP helps to improve gas exchange; stents open the obstructed airways, and reduces fatigue which may prevent the need for intubation. BIPAP can also be used for pre-oxygenation while preparing RSI
792
Initial BIPAP settings
- Pinsp (IPAP): 7-15, adjust to target Vt of 6-8 ml/kg
- PEEP (EPAP): 5-10
- High inspiratory flow rate
- Prolonged I:E ratio (ex. 1:5)
793
Considerations of Ketamine with airway management
Ketamine has bronchodilatory properties which may help optimize both oxygenation and ventilation
794
RSI for intubation
IF RSI is indicated, consider pre-medicating the patient with Fentanyl as this can aid in blunting the sympathetic response to laryngoscopy. Again, utilize Ketamine if possible and consider paralysis. Select the largest diameter ET tube appropriate for the patient size
795
Monitoring and adjusting vent settings for asthma/reactive airway disease
- Select lower respiratory rates (8-12 bpm) and consider paralysis if the patient begins to experience auto PEEP
- Monitor for increasing peak airway pressures as an indicator of possible auto-PEEP
- Increase the set PEEP to overcome the auto-PEEP phenomenon
- Adjust the I:E ratio by monitoring the patient's ETCO2. Consider prolonged ratios for pediatric patients (1:4 or 1:6)
Use pressure control ventilation (PCV) if necessary
796
COPD patient and oxygen administration
Administer oxygen if the COPD patient is hypoxic (< 92%). Oxygen should not be withheld in the COPD patient who is hypoxic. Closely monitor patient for signs of CO2 narcosis
797
4 signs that suggest imminent respiratory arrest in a patient with acute respiratory distress
- Decreasing level of consciousness
- Rising ETCO2
- Inability to maintain respiratory effort
- Cyanosis
Presence of one or more of these warrants immediate intervention, because untreated respiratory arrest will lead to cardiac arrest in very short order
798
oxygen administration in patients that are not hypoxic
Oxygen administrated to patients who aren't hypoxic can be harmful. Oxygen constricts coronary vessels, lowering myocardial oxygen delivery, and likely increases infarct size in the setting of an acute myocardial infarction. In addition to increasing mortality in trauma patients, stroke victims and neonates, prehospital high flow oxygen increases mortality in patients with acute respiratory distress
799
When to use caution with administering Epi IM/IV for airway management
With patients > 45 years old or with previous cardiac history
800
Caution in children with airway issues and stimulation
As long as the child has adequate ventilation and mentation, avoid stimulation which may cause agitation. Include parents as much as possible
801
Children and rate of CO2 build-up
Children have a higher metabolic rate= greater oxygen demand, and faster CO2 build-up
802
Cause and treatment for epiglotitis
Epiglottitis is a bacterial disease most commonly caused by Haemophilus Influenzae type B. It is associated with a fever over 102 and inability to swallow secretions due to pain. Epiglottitis is most common in young adults due to waning immunity after immunization The incidence of epiglottitis in children is on the rise due to falling immunization rates. Attempt to keep child as calm as possible. Do not look down throat unless intubation is absolutely imperative. In most cases, one can successfully administer ventilations via BVM with PEEP valve set at 8 even if patient is in respiratory arrest
803
pathophysiology of Croup
Croup (laryngotracheobronchitis) is a viral disease, associated with a fever less than 102 degrees and a barking cough. Usually, the patient can swallow secretions without difficulty. The swelling in croup is below the vocal cords
804
Wheezing in bronchoconstriction
Wheezing in bronchoconstriction begins with end-expiratory wheezes, progressing to wheezes throughout exhalation, then during inhalation, then absent breath sounds as ventilation ceases in constricted airways. Initiation of albuterol may, at first, increase wheezes because ventilation will increase in areas that previously had no airflow
805
History assessment for seizure patients
- Time, character, and duration of seizure
- Prior history of seizures, including type of seizures, precipitating factors that may lower seizure threshold or cause new onset of seizures
- Medications taken or prescribed, compliance with meds
- Ingestion or injection of toxins
- Exposure to pathogens
- Recent trauma
- Pregnancy trimester
806
Physical assessment for seizure patient
- current seizure activity, mental status, temperature, evidence of injury
- Subtle movement of face or eyes that may indicate seizure activity
- Evidence of recent seizure activity- incontinence, injury to mouth, tongue
PEDS: presence of fever, including onset and home treatment
807
Adult interventions for seizures
- Protect patient from injury and aspiration
- Consider sidestream ETCO2
- Check for pulse immediately after seizure stops
- Verify blood glucose level, see Altered Mental Status protocol for glucose administration
- Midazolam (Versed): for seizure activity lasting more than 2 minutes:
--- Patients >40 kg 10 mg IM, may repeat X1 (preferred), alternatively 5 mg IV, may repeat x1
--- Patients 13-40kg 5 MG IM, may repeat x1, alternatively 2.5 mg IV, may repeat x1
- Call for further orders if patient still seizing after 2 doses for possible Midazolam gtt
- Keppra 30 mg/kg IVP loading dose up to a maximum dose of 1500 mg
808
PEDS interventions for seizures <13 kg
- follow Altered Mental Status protocol for D10 administration
- For seizure activity administer
---Midazolam 0.2 mg/kg IV/IO/IN/IM and repeat q5 min for prolonged or recurrent seizure activity. Max single dose 5 mg
- Keppra 30 mg/kg IVP loading dose up to a maximum dose of 1500 mg
809
Eclampsia seizure treatment
Eclampsia is a true life-threatening emergency for both mother and fetus. For sustained seizure activity the only treatment is fetal delivery. See OB-pregnancy induced hypertension protcol
810
Precautions for patient with history of Epilepsy
If the patient has a history of Epilepsy, consult with the family or care provider to be sure they want the patient transported
811
Etiology of seizures
Seizure etiology ranges from Epilepsy to complex toxicological emergencies. Be prepared to assess for and treat causes whenever possible
812
complication if Versed is given IN
Midazolam has a pH of <4 and will sting when given intranasally
813
categories of pediatric febrile seizures
Pediatric febrile seizures are self-limiting. Febrile seizures are further divided into two categories, simple and complex, based upon clinical features
814
Febrile status epilepticus (FSE)
Some patients present in FSE, i.e. continuous seizures or intermittent seizures without neurologic recovery, lasting for a period of 30 minutes or longer. In up to 1/3 of cases of FSE, the actual seizure duration is underestimated in the ED. Important clinical clues that a seizure has ended include the presence of closed eyes and a deep breath. Children with persistently open and deviated eyes may still be seizing, even if convulsive motor activity has stopped.
815
possible treatment for pediatric epilepsy
Medical marijuana may be used for treatment of pediatric epilepsy
816
Sepsis possible suspected source of infection
- Pneumonia
- UTI
- Bacteremia
- Abscess/cellulitis
- Abdominal
- Bone/joint
- Endocarditis
- Meningitis
817
2 or more of the following are needed for SIRS criteria
- HR>90
- Temp < 96.9 or >101
- RR>20
- PaCO2 <32
- WBC <4 or >14
- Bands >10%
818
Indicator of acute organ dysfunction (one required for sepsis)
- Acute altered mental status
- SBP<90 or MAP <70
- SBP decrease >40 from baseline
- Acute hypoxia, increase in O2 needs
- Arterial hypoxemia (PaO2<300)
- Acute Oliguria (<0.5 ml/kg/hr for 2 hours)
- Creatinine >2 or increase in 0.5 above baseline
- Coagulopathy (INR>1.5, PTT>60 seconds)
- Thrombocytopenia (PLT<100K)
- Bilirubin >2
- Lactate >2
819
PEDS criteria for Sepsis
at least 2 SIRS criteria from table AND suspected or proven infection
820
PEDS newborn to 1 week Criteria
- Tachycardia: >180
- Bradycardia: <100
- RR: >50
- Leukocyte count: >34
- SBP <59
821
PEDS 1 week to 1 month criteria
- Tachycardia: >180
- Bradycardia: <100
- RR: >40
- Leukocyte count: >19.5 or <5
- SBP: <79
822
PEDS 1 month to 1 yo criteria
- Tachycardia: >180
- Bradycardia: <90
- RR: >34
- Leukocyte count: >17.5 or <5
- SBP: <75
823
PEDS criteria 1-4 yo
- Tachycardia: >140
- Bradycardia: NA
- RR: >22
- Leukocyte count: >15.5 or <6
- SBP: <74
824
PEDS criteria 5-11 yo
- Tachycardia: >130
- Bradycardia: NA
- RR: >18
- Leukocyte count: >13.5 or <4.5
- SBP: <83
825
PEDS criteria 12-17 yo
- Tachycardia: >110
- Bradycardia: NA
- RR: >14
- Leukocyte count: >11 or <4.5
- SBP: <90
826
PEDS definition for severe sepsis is defined as ALL of the following
- greater than 2 age-based SIRS criteria
- Suspected or proven infection
- Cardiovascular dysfunction, acute respiratory distress syndrome (ARDS), or at least one non-cardiovascular organ system dysfunctions
827
828
Information needed about cultures with sepsis
Document if cultures were obtained, date/time, and results if available
829
Sepsis and Lactate results
Document date/time of the most recent lactate results if available
830
Interventions if Antibiotics are ordered or hanging
Set rate in order to complete infusion within one hour
831
Interventions if patient has suspected infection with two or more SIRS criteria and a minimum of one indicator of acute organ dysfunction and patient has not received abx
Administer Ceftriaxone 2 grams SIVP in 20 ml NS
832
Contraindication to Ceftriaxone administration
Allergy to Cephalosporin
833
Interventions for Sepsis with SBP <90 or MAP <65
Give 30 ml/kg IBW LR IV bolus wide open. If MAP remains <65, give an additional 500-1000ml LR fluid bolus concurrently while beginning Levo infusion
834
Levo infusion for sepsis
Levo infusion 0-1.0 mcg/kg/min (IBW) if MAP <65 concurrently with second fluid bolus. Titrate to keep SBP >90 and MAP >65. (Mix 4 mg Levo in 250 D5W)
835
RSI in patients with respiratory failure in septic shock with SBP <90
Consider push dose Epi 5-20 mcg q 2-5 min (mix 1 ml of Epi 0.1 mg/ml in 9 ml saline flush for 10 mcg/ml) dose is 0.5-2 ml q 5 min
836
Interventions for sepsis patient if patient has a central line
Transduce and monitor CVP. Initiate NS fluid boluses to a target of 8-10 if not intubated (10-12 if intubated and n mechanical ventilation).
837
Interventions if unable to maintain SBP/MAP goals with Levophed
If unable to achieve SBP of 90 with Levo at 1 mcg/kg/min (IBW), initiate Epi infusion at 0-0.5 mcg/kg/min (IBW). Titrate to keep SBP >90 and MAP >65 (mix 1 mg of 1 mg/1 ml in 100 mls NS)
OR consult medical control for Vasopressin at a fixed rate of 0.03 u/min (mix 40 units of vasopressin in 100 ml NS)
838
ABX administration for PEDS if patient has not received antibiotics
Administer Ceftriaxone 50 mg/kg (up to 2 grams) SIVP (mix in 10 ml NS)
839
Intervention for PEDS patients with:
- Infant <1 yr: SBP <50
- Child 1-5 yr: SBP <60
- Child >5 yr: SBP <70
- Or child WITH ALL THREE: cold extremities, prolonged capillary refill >3 seconds, weak/fast pulse
Give 10-20 ml/kg fluid bolus over 10-20 min. May repeat x2, monitoring for s/s of fluid overload or myocardial dysfunction.
840
PEDS intervention if shock persists after 3 boluses, or any development of myocardial dysfunction
Initiate Epi 0.1-1 mcg/kg/min. Epi drip may be initiated sooner if signs of fluid overload develop. (mix 1 mg of epi in 100 ml NS)
841
PEDS hypoglycemia in Sepsis
Correct hypoglycemia as needed
842
PEDS correction of hypocalcemia
Consult with receiving provider to correct hypocalcemia as needed
843
What to do if poor perfusion persists after above interventions for PEDS
Rule out and correct pericardial effusion, pneumothorax, and increased intra-abdominal pressure
844
When to consult with receiving provider to consider Prostaglandin E-1
for infants <30 days until ductal-dependent cardiac lesion is ruled out by echocardiogram
845
Significance of early ABX administration
early administration of abx has been prove to decrease morbidity and mortality in sepsis
846
Most common cause of mortality in Septic shock adults
Vascular failure
847
Most common cause of mortality in septic shock PEDS
Cardiac failure
848
History assessment for snake bite and other envenomations
- type of animal and its current location
- Time of initial bite
- How animal was encountered and how injury was sustained
- Previous venomous bite/sting
- Allergy to animal stings (see allergy/anaphylaxis protocol)
849
Physical assessment for snake bite and other envenomations
- Location, number of bites/stings
- Description of injuries and initial symptoms
- Localized and generalized evidence of reaction (see allergy/anaphylaxis protocol)
850
Interventions for All Envenomations
- Treat every bite as an envenomation until proven by lab work. Do not delay transport
- If an exotic animal, contact medical control
- Provide basic wound care
- Remove constrictive clothing and jewelry
- Treat pain/anxiety per pain/agitation/anxiety protocol
- Mark advancing inflammation with a pen, noting start time and assess every 15 min
- Remove and avoid tourniquets, suction, ice, alcohol, shock therapy or folk therapies
- If evidence of anaphylaxis, follow allergy/anaphylaxis protocol
851
Monitoring if antivenin is running for an IFT
Monitor for allergic reaction. if signs of systemic reactions occur, stop the infusion and see allergy protocol
852
Interventions for Rattlesnake bite
- Elevate the extremity to the level of the heart, not above as that may increase systemic absorption
- If there may be a delay of more than 6 hours in reaching reno, consider transporting to smaller hospital. Most hospitals in Nevada carry the first dose of antivenin.
- Contact hospital for acceptance or if antivenom is available at hospital
853
Interventions for insect envenomations
Localized reaction: administer Diphenhydramine per Allergy/anaphylaxis protocol. Treat ABCs, pain, and anxiety. Treat symptoms supportively
854
Treatment for Black Widow bite
Treat muscle spasms with Midazolam and analgesia per pain protocol
855
How to show the receiving facility what animal caused the bite
Do not bring the animal, dead or alive, to the ED. Take a picture of the animal, if safe to do so, to aid in diagnosis
856
Serum sickness
Patients may develop serum sickness from days to weeks after treatment with antivenin. Clinical findings include fever, rash, arthralgia, facial swelling, neuropathy, and renal dysfunction. Treat supportively
857
Possible allergies that may indicate an allergy to anitvenom
Depending on the antivenom used, patients who are allergic to horses or papaya may sustain an anaphylactic reaction. Crofab is contraindicated in patients with hypersensitivity to papaya
858
Possible reactions to Hymenoptera (Bee, wasps, and ants)
Patients may react with a generalized or local allergic reaction, or, if multiple stings are incurred, venom toxicity may develop 7-14 days after stings. Venom toxicity manifests as flu-like symptoms. Most deaths are caused by hypersensitivity reactions and anaphylaxis
859
Rattlesnakes in call area
The only venomous snake indigenous to our call area is a subspecies of the Western Rattlesnake, the Great Basin Rattlesnake.
860
Rattlesnake and degree of envenomation and injuries based on the degree
Rattlesnake bites vary greatly in degree of envenomation; 30% are considered minimal and need no antivenin or "dry bites". If the bite is not directly into a blood vessel, the immediate concern is tissue swelling, which can lead to compartment syndrome and Rhabdomyolysis. Hours later, patients may develop coagulopathy. if venom is injected directly into the vascular system, immediate coagulopathy and systemic symptoms may develop; treat supportively and do not delay transport. Characterization of rattle snake bites is based upon one or two puncture wounds. If the bite is serrated or if the victim had to pull the snake off, it was most likely NOT a rattlesnake. Avoid NSAIDS for pain management
861
Scorpions in our call area
Scorpions in our call are inflict a sting similar to a bee sting. The venom does not contain a neurotoxin. They are typically orange to dark brown and 1 1/2-3 inches long. The Arizona Bark Scorpion, found in A, NM, TX, CA and southern NV can cause severe pain, neurotoxic reactions, and can be fatal, especially for those <6 yo. Be sure to ask if the patient has recently moved from an area where there are toxic scorpions, they travel very well in moving boxes.
862
Black widow in our call area
Are widespread in this area at altitudes lower than 7000 feet. The black widow bite usually causes sharp pain at the site with minimal surrounding erythema. Their venom causes presynaptic discharge of neurons/muscle cells. The victim may develop severe muscle cramps originating in the limb where bitten and extending to the abdomen, but these symptoms frequently do not occur, so prophylactic treatment is not recommended. If cramping develops, Midazolam and analgesia are indicated. These symptoms are usually resolved within 8-12 hours. Antivenin is available at RRMC and St. Mary's. Severity of black widow bites range from mild (local skin reaction), moderate (general spasmodic muscle pain in the bitten extremity which may be accompanied by local diaphoresis), to severe (pain that is severe and difficult to control and may be accompanied by systemic findings such as Tachycardia, HTN, N/V and HA.
863
Brown Recluse in our call area
These spiders are not indigenous to our call are, but may be imported on goods and materials from areas east of the Rocky Mountains. Their bites cause a central hemorrhagic vesicle, which develops into an expanding area of necrosis. The Desert Recluse spider, is indigenous to this area; it can cause necrosis, though not as significant as the brown recluse. Spiders also travel well in moving boxes or vehicles. Yellow sac spiders are common in NeJerusevada and can cause a local reaction, but can be mistaken for a brown recluse
864
Jerusalem Cricket in our call area
(Potato Bug) inflicts a painful bite, but is not venomous
865
Physical assessment for spinal trauma and back pain
- Neurologic or motor deficits, including numbness, tingling, radiation of symptoms
- Spinal midline tenderness or anatomic deformity secondary to injury
- incontinence
- Priapism
- Signs of neurogenic shock
866
Focused spine assessment definition
An exam that utilizes mechanism(s) of injury, external factors, and specific physical exam findings to rule out potential spinal injury
867
Spinal motion restrictions (SMR) definition
Application cervical/thoracic splint-collar and patient placed in a position of comfort on the gurney with normal seat belt straps applied
868
Full-spinal immobilization definition
Application cervical/thoracic splint-collar and patient placed on either a vacuum splint or on a padded backboard or equivalent with head and body securely immobilized with straps and tape
869
Categories within a focused spinal exam
- No distracting injury
- No motor or sensory deficits
- no focal midline tenderness or deformity
- No limited range of motion
870
How to assess for "no distracting injury"
Can the patient focus on your exam or are they in severe distress from other injuries or emotional stressors? Long bone fractures, bleeding, joint deformity may or may not be distracting for an individual patient
871
How to assess for "no motor or sensory deficits"
1. Assess bilateral grips/pedal push/pulls
- in the case of extremity injury they should be able to flex/extend at the ankles and wrists or move fingers and toes. The patient should be able to move all distal extremities
2. Check for sense of touch in all extremities by lightly brushing a gloved hand on each extremity
872
How to assess for "no focal midline tenderness or deformity"
Palpate the entire spine on the boney processes one at a time from C1 to L5.
The patient may complain of general back or spine pain, but should not have any focal MIDLINE tenderness to palpation or obvious deformity. Deformity would include but not limited to an obvious step off from one level to another or bony crepitus.
873
How to assess for "no limited rang of motion"
Ask the patient to rotate their head 45 degrees side to side. Do not assist with this process.
- If the patient has any pain they should be placed in SMR
874
What should happen if any of the four components of the focused spinal exam are positive
the patient should then be placed in SMR
875
What finding on a focused spinal assessment algorithm would require a full spinal immobilization
Penetrating injury WITH gross motor or sensory deficits or unresponsive
876
What findings on a focused spinal assessment algorithm would require an SMR
Blunt injury from "significant mechanism" with:
- Altered level of consciousness
- Age >65 or <5 years old, or language barrier preventing reliable history or exam
- injury detracts from or prevents reliable history or exam
- gross motor or sensory deficits
- midline thoracic/cervical spine pain or tenderness
- spinal deformity
- limited cervical spine active range of motion
877
Definition of "significant mechanism"
high-energy events such as ejection, high falls, axial loading, and abrupt deceleration crashes and may indicate the need for spinal immobilization
878
Criteria for immobilization for high risk populations
High-risk populations (<5 or >65 years old) should be immobilized even in low energy mechanisms
879
what patient populations should you consider modified immobilization
any patient with arthritis, cancer, dialysis or other underlying spinal or bone disease
880
what component of immobilization is based on EMS provider discretion
Any patient may be immobilized based on EMS provider discretion
881
Interventions for neurologic deficits above T4 ADULTS
- maintain body temperature with blankets and warming blanket, if needed.
- initially treat hypotension with an LR bolus up to 1L
- If unable to obtain MAP>80, initiate levo gtt (0-1 mcg/kg/min IBW) to achieve a goal MAP>80
882
Immobilization of PEDS patients with possible spinal injury
Consider the Kendrick Extrication device as an immobilization device for infants and toddlers
Infants and toddlers can be adequately immobilized while in their car seats
883
Interventions for PEDS with neurologic deficit above T4
Maintain body temperature with chem and wool blankets if needed.
Treat hypotension with NS or LR 20 ml/kg bolus first, then levo gtt
884
MAP goals for PEDS with neurologic deficit above T4
- MAP >60 in children 6-12 yo
- MAP >50 in children less than 6 yo
885
airway management with SMR
Airway maintenance supersedes spinal motion restriction; if a cervical collar is in place, the front portion can be removed in order to obtain an airway
886
Penetrating trauma and spinal motion restriction
Generally, patients with penetrating trauma do not need SMR unless the injury involves the spinal cord
887
Ground level falls and a low threshold for SMR
Ground level fall in patients over 60 or who have bone disease may be enough mechanism for cervical spine injury. Have a low threshold for SMR in these patients
888
Spinal cord injuries and poikilothermia and neurogenic shock
Cervical and high thoracic spinal cord injuries may result in loss of sympathetic innervation. The patient may develop poikilothermia and neurogenic shock
889
management of SMR on patients with properly fitted helmets and shoulder pads
Athletes needing spinal precautions that are wearing properly fitted helmet and shoulder pads are to be placed in SMR WITH helmet and shoulder pads left on, removing the face mask for airway control.
890
management of SMR on patients with properly fitted helmets without shoulder pads
Athletes who present helmeted without shoulder pads should have their helmets removed using proper technique minimizing cervical spine manipulation prior to SMR
891
Central cord injuries
May affect only the arms, sparing the legs. Arms may become hypersensitive, requiring blood pressure measurement on a leg due to pain associated with inflation of cuff
892
Anterior cord syndrome
Is often associated with flexion type injuries to the cervical spine, causing damage to the anterior portion of the spinal cord and/or the blood supply from the anterior spinal artery. Below the level of injury motor function, pain sensation, and temperature sensation are lost, while touch, proprioception, and sense of vibration remain intact
893
Brown-Sequard syndrome
usually occurs when the spinal cord is hemisectioned or injured on the lateral side. True hemisections of the spinal cord are rare, but partial lesions due to penetrating wounds are more common. On the ipsilateral side of the injury there is a loss of motor function, proprioception, vibration, and light touch. Contralaterally there is a loss of pain, temperature, and crude touch sensation
894
Considerations for injuries at the C1/C2 levels
require positive pressure ventilation
895
Considerations for injuries at the C3 level and above
typically result in loss of diaphragm function; patient is dependent on intercostal muscles only
896
Considerations for injuries at the C4 level
results in a significant loss of function at the biceps and shoulders
897
Considerations for injuries at the C5 level
results in potential loss of function at the biceps and shoulders, and complete loss of function at the wrist and hands
898
Considerations for injuries at the C6 level
results in limited wrist control and complete loss of hand function
899
considerations for injuries at the C7 and T1 level
results in lack of dexterity in the hands and fingers, but allows for limited use of arms
900
Possible complication of excessive fluid resuscitation with spinal cord injury
has the potential to cause further cord swelling, increased damage, and worse outcomes
901
Urine output and spinal cord injury patient
assess urine output if able
902
considerations with positioning if able to elevate HOB
Elevate HOB with towels or stretcher underneath spinal board if not contraindicated
903
Considerations for interventions if constraindicated to elevate HOB
consider antiemetics in supine patients unable to raise HOB
904
History assessment for stroke patient
- Time that patient was last seen functioning at baseline. If known, document the time of onset of symptoms. If onset of symptoms is unknown, document last known "normal" time
- Baseline level of cognitive function
- Changes in symptoms since onset
- medical history, including use of anticoagulants
- Recent head trauma
- recent surgery
- Drug or ETOH use
905
Physical assessment for stroke patients
- detailed neurologic exam
- progression or regress of symptoms en route
- heart tones (irregularity, murmur)
- bruits in the neck
- Pulses in neck, arms, legs, looking for asymmetry, absence, or irregularity
- Skin signs; including purpura, ecchymosis, recent scarring
906
Categories for FAST ED stroke screen
- Facial palsy
- Arm weakness
- Speech changes
- Eye deviation
- Denial/neglect
907
Facial palsy scoring
0- Normal or minor paralysis
1- Partial or complete paralysis
908
Arm weakness scoring
0- no drift
1- Drift or some effort against gravity
2- No effort against gravity or movement
909
Speech change scoring
0- Absent
1- mild to moderate
2- Severe global aphasia or mute
910
Eye deviation scoring
0- absent
1- partial
2- forced deviation
911
Denial/neglect scoring
0- Absent
1- Extinction or bilateral simultaneous stimulation in 1 sensory modality
2- Does not recognize own hand/orients to only one side of body
912
Interventions if patient meets stroke Pre-alert criteria
Contact receiving facility as quickly as possible and transport without delay
Obtain 2 IV sites, if possible
913
Stroke pre-alert criteria
- Patient is positive for any component of the FAST-ED stroke screen
- Over 18 years of age
- Within 4.5 hours of symptom onset or "last seen normal"
914
Exclusion criteria for stroke pre-alert
-Stroke or head trauma in past 3 months
- Previous intracranial hemorrhage
- Major surgery in past 2 weeks
- Active bleeding
915
Anti-hypertensive therapy options based on two reading taken 5 minutes apart
Labetalol, Nicardipine or Hydralazine (HR<60)
916
Labetalol dosing
- Bolus of 10-20 mg SIVP if BP goal not met. May repeat in 10 minutes x1
- IV infusion- Administer 1-10 mg/min via IV infusion. Titrate to desired response. Mix 100 mg to 80 ml NS
917
Nicardipine dosing
IV infusion: initiate infusion at 5 mg/hr. Titrate every 10 minutes as needed in increments of 2.5 mg/hr to desired SBP. Max dose 15 mg/hr. (Mix 25 mg in 90mls NS)
918
Hydralazine dosing
Bolus of 10-20 mg IV every 15 minutes (max dose 60 mg)
919
BP goals for acute ischemic stroke
BP should only be reduced if the SBP is > 220 or DBP >120. the exception to this is if tPA has been given then the goal is less than 180/105. Do not reduce BP more than 15% from the patients baseline blood pressure
920
BP goals for spontaneous bleeds or other acute space occupying lesions
maintain SBP<140
921
BP goal for subarachnoid bleeds
first treat with pain and/or sedation medications with a goal to maintain SBP<160. Remember that patients with subarachnoid bleeds are likely to have very labile blood pressures. Be sure to determine that SBPs are consistently >160 over 5-10 minutes prior to starting anti-hypertensive therapy. Again, do not reduce SBP more than 15% from baseline.
922
When to intervene with low BP
For all types of stroke patients: if at any time the SBP drops below 90, stop any vasodilators and treat with fluid boluses and then begin Levo if fluids are not successful
923
Stroke patients with a fever
If greater than 38C, administer 1000 mg Iv acetaminophen over 15 minutes once. Contraindicated for cirrhosis patients
924
Treatment for patient with intracranial bleeding who is on anticoagulation
confirm appropriate reversal measures have been take and if not, discuss this with the sending MD
925
Stroke BP management and increased ICP
Be very cautious about lowering the BP in the person who is demonstrating signs of increasing ICP. Lowering the BP could result in decreasing CPP to a degree that will result in secondary brain injury from the decreased brain perfusion. Consult the receiving MD for BP parameters and treatment course
926
What other issues can mimic stroke symptoms
Hypoglycemia and seizures. If unsure, treat as a stroke
927
Aphasic patients commonly still retain what other skill
they can still understand speech and follow commands
928
What should be avoided in neuro critical patients
Avoid fever and persistently elevated glucose (>200)
929
What to be alert for with stroke patients
Changing LOC and airway control, secretions may become a problem
930
Facilities with Neurologists on call in Northern Nevada
- RRMC, St Mary's and Northern
931
History assessment with submersion injury
-Precipitating events: epilepsy, dysrhythmias, alcohol use, etc.
- Length of time submerged (less than or equal to 10 min)
- Fresh vs salt water, relative temperature of water
- Associated trauma or possibility of non-accidental trauma (NAT)
- Time to first arrival of rescuers or ALS care
- Duration of resuscitative efforts prior to contact
- Type of resuscitation delivered PTA (ALS vs BLS)
- Comorbidities
932
Physical assessment with submersion injury
- S/s of shock
- rales, rhonchi, wheezing
- Tachypnea and increased WOB
- Hypercarbia, acidosis, hypoxia
- initial and subsequent VS
- GCS
- Dysrhythmia
933
Interventions for submersion injury if patient is unresponsive
-See Cold Injury protocol, if the patient is hypothermic
- Continuous good quality CPR if hypothermic arrest
- Advanced airway management
934
Interventions for submersion injury if patient is responsive
- Aggressive airway management with BVM, PEEP, BIPAP or intubation if respiratory failure. Consider higher PEEP in the intubated patient
- Monitor ETCO2
- Address bronchospasm with Albuterol
- Dry and warm if hypothermic
- Maintain HOB at 30 degrees
- Treat seizures
- Early glucose monitoring and dextrose admin per protocol
- Possible spinal motion restriction if evidence of head/neck trauma or signs of neurologic deficit
- Facilitate transport to hospital, even if patient looks well
935
PEDS interventions for submersion injury
-Transport to a facility with PEDS critical care
- Interventions remain the same as adults
936
Submersion and body temperature
May be associated with profound hypothermia
937
What is the most significantly relevant factor for survival
Length of submersion (>10 minutes) is more statistically relevant to survival than water temperature
938
Submersion injury and spinal immobilization
Routine spinal immobilization is not required unless signs or history of trauma exist
939
What improves chances of neurological recovery
Immediate bystander CPR
940
History assessment with traumatic cardiac arrest
- Additional scene assessment
- Possible causes of cardiac arrest not related to trauma- if arrest could have been caused by non-traumatic event, proceed to Cardiac Dysrhythmia protocols)
- Possible hypothermia- move to hypothermia protocol
- Exact time of incident: necessary for decision-making. Survival rates decline significantly outside of 15 minutes with loss of VS
- If known, time that patient lost pulses or lethal dysrhythmia first noted
941
Physical assessment for traumatic cardiac arrest
Examine for injuries not compatible with life- if found, follow DNR guidelines. If injuries may be compatible with life, ascertain cardiac rhythm as quickly as possible. US FAST exam to be completed on all traumatic cardiac arrest patients to determine cardiac activity.
942
PEDS considerations for traumatic cardiac arrest
Be especially diligent to observe for and preserve evidence of child abuse in the history, scene assessment and physical assessment
943
Review traumatic cardiac arrest algorithm
asdf
944
What must be done if patient is loaded into aircraft with CPR in progress
Document reasons for transport. Consider transport of a victim of traumatic cardiac arrest in unusual circumstances, at the discretion of the medical crew
945
What additional considerations must be considered with a traumatic cardiac arrest
This type of a call may be a crime scene. First, establish scene safety before entering. Be aware of potential evidence and try not to contaminate the scene while providing patient care
946
Criteria that all patients must meet to be able to qualify for BIPAP
All patients must have the physical and mental ability to remove the mask in the event of mechanical failure of emesis. Use of arm restraints is prohibited
947
Continuous monitoring required for patients on BIPAP
Continuous ETCO2, SpO2, ECG monitoring are required for all non-invasive ventilated patients
948
Groups of patients to consider using BIPAP for
Patients whose acute etiology of respiratory distress is transient
949
Exclusion to BIPAP
Inability of patient to safely and quickly remove mask due to obtundation or weakness unless patient is a DNR/DNI and Bipap is the only viable option
950
Indications for bipap
- Spontaneous breathing, able to protect airway reflexes
- Conscious
- Inadequate response to first line interventions where WOB is unrelieved; fatigue, persistent hypoxia, or hypercarbia
951
Absolute contraindications for Bipap
- Inability to achieve a good seal
- Suspected pneumothorax/barotraumas
- Inability to maintain airway patency: cardiac/respiratory arrest, obtunded
- Major trauma, especially head injury with increased ICP
- Vomiting
952
Relative contraindication for BIPAP
- Inability to cooperate, tolerate, or understand the use of device
- Clausterphobia
- RR >30
953
Fitting of BIPAP mask
Ensure proper mask sizing for success. Select smallest mask size possible for patient's facial contour. Facemasks should cover the nose and mouth, extending from the superior bridge of the nose to beneath the lower lip. Head strap should be snug enough to keep the mask in place without significant leaks
954
What type of Mode is BIPAP setting on the Hamilton
Hamilton NIV is an additive ventilator mode
955
BIPAP settings
- Set patient gender and height and then select "NIV" as the mode
- To calculate IPAP add the P support and the PEEP. (i.e. on IFT to set the ventilator to an IPAP/EPAP you subtract the EPAP from the IPAP to find the Psupport. To provide report to receiving facilities ass the Psupport and PEEP to obtain the IPAP)
- Set Psupport: 6
- Set PEEP (EPAP): 6
- IPAP is the sum of PEEP and Psupport, titrate to a max additive pressure of 20
- If currently on BIPAP: mirror facility's settings
- Press "confirm" and then press "start ventilator"
- Adjust FiO2 to maintain SpO2 >92%
- Adjust Pramp to 50-100 ms
- Adjust ETS to 40%
- Place on standby mode
- Apply mask to patient, using correct size, and close external vent ports
956
Adjustments to Psupport
Psupport may be adjusted based on exhaled TV. Titrate Psupport from 6 in increments of 2 every 2 minutes until the goal TV of 6-8 ml/kg. EtCO2 may be unreliable but may be used for trending. Simply monitor to ensure improving EtCO2, mentation, and WOB
957
Criteria to intubate based on BIPAP settings
Intubate if the sumof the Psupport and PEEP are at a max of 20 and the patient is worsening as this indicates failure of BIPAP
958
PEEP adjustment criteria
PEEP (EPAP) may be adjusted from 5-14 to achieve adequate oxygenation if FiO2 is unable to be weaned less than 60%
959
Treating anxiety with BIPAP patient
Ensure adequate anxiolytics for success with NPPV. The management of patient anxiety is a crucial step for success when using noninvasive ventilation
960
Physical assessment for Invasive ventilation
- Breath sounds present, absent epigastic sounds
- Respiratory effort, sedation level
- ETCO2 waveform and >5
- Secure commercial device and that cuff is functioning and inflated
- Size and depth of ETT/LMA
961
Continuous monitoring required for intubated patients
ETCO2, SpO2, ECG
962
Age groups for utilized Hamilton ventilator
Hamilton ventilator to be used on all adult and pediatric patients requiring mechanical ventilation during transport.
Neonatal circuit tubing to be used for patients <10 kg
963
HOB elevation for intubated patients
All intubated patient to have HOB elevated 30 degrees unless in spinal precautions (reverse Trendelenburg to be used)
964
Psupport
Patient triggered ventilatory supported breaths in NIV and APVsimv modes
965
Pcontrol
Ventilator driven breath in PCV+mode
966
Plimit/high pressure alarm
The maximum allowed pressure applied during ventilation. Plimit is 10 below high pressure limit alarm setting. This can be adjusted by changing the high pressure alarm or the plimit. Adjusting one will adjust the other
967
ETS
The percent of peak inspiration flow at which the ventilator cycles from inspiration to exhalation. (Increasing the ETS results in a shorter inspiratory time, this aids with ventilator synchrony)
968
Pramp
The rate of which pressure rises during ventilator supported or driven breaths. This allows for matching of patient's demand. Lower values provide a quicker rise which may be beneficial for patient's with high respiratory demand
969
flow trigger
patient effort required to trigger a ventilator assisted or driven breath
970
TI max
maximum allowed inspiratory time
971
Initial ventilator settings
VT: 6-8 ml/kg IBW
Mode: APVcmv
Rate:
- Adults: 16-25
- PEDS: 18-30
- NEO: 30-40
I-time: Achieve I:E ration of 1:2 (unless patient exhibits obstructive disease then 1:3 or 1:4 may be appropriate)
PEEP: 5-8, Max PEEP 14 before needing to call for medical direction
FiO2: 100%, titrate to maintain SpO2 >92%
PIP alarm:
- Adults: 40
- PEDS: 20
- NEO:20
972
Pressure control ventilator settings
To prevent barotrauma in adult/PEDS (<10kg) patients with severe airway disease (asthma/ARDS) with high PIP/PPlat on volume ventilation, and those clinical status does not improve with volume ventilation. May also be used in patients with significant ventilator dyssynchrony on volume targeted mode of ventilation
973
Suggested settings for pressure control
Select PCV+
Rate:
- Adult: 16-25
- PEDS: 18-30
I-time: Achieve I:E ratio of 1:2
PEEP: as needed up to max of 14
Titrate pressure control to achieve approximate vT of 6-8 ml/kg IBW. If patient requires pressure control >40, physician contact required
Monitor VT/minute ventilation for changes which may indicate clinical decline
Passive humidification devices will be used on all invasively ventilated adult patients with transport times greater than 10 minutes
Be sure to place the filter on the patient with the arrows pointing in the down direction. Do not remove white cap on the top of the filter. That port is provided for additional humidified air. Place filter on using the elbow provided with your vent tubing
PEDS patients have passive humidification devices, such as HME, used on all with invasive ventilation
974
ASV mode
Adaptive Support Ventilation, adapts ventilation breath by breath. Is considered a "smart mode" where the ventilator adapts to the patients needs and spontaneous efforts while keeping then in a goal range minute ventilation
975
Initiating ASV mode
Select ASV mode
Select "patient" to input patient's gender and height. it is crucial to obtain patient's actual height. Use tape measure if needed
In ASV, we do no set a RR, I time, or TV. We do set a % minute volume
- Start at 120% and titrate from 90-180% to maintain EtCO2 between 35-45 or based on patients baseline EtCO2
--- From a baseline 100% MV, add an additional 1500 ft above sea level
---If temp is >101.3, att 20%
- Set PEEP at 5-8, may titrate up to a max of 14
- FiO2 as needed
Contraindications
- Morbidly obese patients
- Pediatric patients less than 12 yo
976
IFT vent settings
- Mirror sending facility settings
- If unable, see above "initiating ASV mode"
977
Neonatal invasive ventilator setting: PEDS/infants <10 kg
Use neonatal specific tubing along with neonatal/infant exhalation valve
Initiate using PCV+ mode
Select "neonate"
Adjust weight and confirm
Complete preop checks after weight confirmation
Select vent mode
- PCV+
- Rate:
---PEDS/infant: 18-30
--- NEO and small infants: 30-40
- pressure control 15, max 25
- Remember that Pcontrol and PEEP are additive to give you total pressure. Max Ppeak is 30
- I:E time: 1:3
- PEEP: 3-8, max PEEP 10, call medical control for PEEP greater than 10. If IFT, may mirror settings, obtain MD order.
- FiO2: 100%, titrate down quickly to maintain SpO2 >92%
Passive humidification devices, such as HME, will be used on all invasively ventilated infant/neonatal patients
978
EtCO2 for patients with head injry
Target EtCO2 per head and facial trauma protocol
979
Calculate Pplat
Pplateau= (VTE/Cstat) +PEEP
980
Interventions if Pplat is >30
Provide interventions that decrease pressures and continue to monitor. Most common adjustment is to decrease Tv by 1 ml/kg to as low as 4 ml/kg. Switching to pressure targeted mode may also help decrease Pplat. High Pplat etiology may include: decreased pulmonary compliance, pulonary edema, pleural effusion, tension pneumothorax, peritoneal gas insufflation, trandelenberg, ascites, and abdominal packing.
981
Interventions for IFT if patients are on specific settings from sending facility
- PEEP >14: continue PEEP settings, call receiving physician to confirm/discuss transport and to obtain orders for further titration of PEEP if necessary
- PEEP >20: Consider CCT/ground transport
982
What should be done before making any interventions to ventilator settings for isseus
Re-confirm tube placement prior to interventions
983
Interventions for hypoxia <92%
-Assess for pneumothorax
- Increase FiO2
- Suction ETT
- Sedate and paralyze for spontaneous respirations/asynchrony as appropriate
- Albuterol/duoneb unit dose in-line nebulizer treatment prn wheezing/bronchospasm
- Increase PEEP. PEEP >14 requires doctors order. Observe for reduced cardiac output
984
Interventions for hypercapnia: EtCO2>45 assuming not chronic
-Increase RR incrementally by 2 bpm to max of 25. >25 requires MD order
- Increase TV 1ml/kg up to max 8 ml/kg IBW (unless patient has ARDS)
- Suction ETT
- Albuterol/Duoneb unit dose in-line nebulizer treatment prn wheezing/bronchospasm
985
Interventions for Hypocarbia: EtCO2<35
- Assess and treat perfusion status
- Decrease RR
- Decrease TV 1 ml/kg to as low as 4 ml/kg
- ASsess for sedation/analgesia and possible paralysis to control RR
- Consider switching to APVsimv if spontaneously breahing with low PS of 5-8
986
Interventions for rising peak inspiratory pressures
987
Adult HME settings and amount of dead space
Adult HME are good for between 250-1500 of tidal volume and create only 60 ml of dead space in the vent circuit
988
PEDS HME settings and amount of dead space
PEDS HME are good for between 50-250 ml of tidal volume and create only 13 ml of dead space in the vent circuit
989
What to use of T1 ventilator is not available
Use back-up ventilator for invasive/noninvasive ventilation in accordance with manufacturer's instructions
990
Relevance of plateau pressure
a direct measurement of overall alveolar health. Consistently high Pplat will lead to alveolar destruction, vascular shunting, and ventricular induced lung injury
991
relation of PIP to Pplat
POP always has to be higher than Pplat as it is the summation of all pressures (PEEP + Pplat)
992
relationship of PIP and Pplat to patient having decreaased pulmonary compliance and/or increased TV
When patients have decreased pulmonary compliance and/or increased TV, PIP and Pplat will increase proportionately. If PIP increases with no change in Pplat, suspect increased airway resistance or high inspiratory gas flow )obstructive process)
993
Adjusting vent settings to "normalize" EtCO2 when patient is known to be acidotic by pH
It is not necessary to change ventilator settings in an effort to "normalize" EtCO2 when patient is know to be acidotic by pH. Remember a "normal EtCO2" may not be appropriate. For example, the patient with an assumed metabolic acidosis (sepsis, DKA, shock) will likely need minute ventilation management to maintain an EtCO2 between 25-35 to help compensate for their metabolic component. A chronic CO2 retainer will likely need to maintain an EtCO2 >40 to prevent "overcorrection" and resultant alkalosis
994
What setting to consider adjusting to optimize invasive ventilation/oxygenation
Consider making fine-tuned adjustment to I:E ration, rise time, flow termination, time termination, and PC flow termination settings to optimize invasive ventilation/oxygenation and patient comfort
995
Patient with COPD and Asthma and I:E ratio
Patients with COPD and asthma will require I:E ration adjusted to 1:3 or 1:4 to allow for adequate exhalation
996
Changes to ETS and Pramp settings for patients that are in respiratory distress on non-invasive distress
For non-invasive ventilation, the ETS and Pramp settings must be changed for patients that are in respiratory distress. ETS may be set fro 5-80%, default is 35%. By lowering ETS, inspiratory time is longer, and increasing ETS results in shorter inspiratory time. By lowering Pramp, you are making it easier for your patient to inhale. Adjust ETS and Pramp befor changing Pinsp(IPAP) and PEEP(EPAP)
997
Benefits of increasing IPAP (pressure support)
Increasing IPAP in increments of 2 provides a "pressure boost" on inspiration that may provide an increase in alveolar ventilation and/or decrease the work of breathing. The need for IPAP >20 requires an MD order
998
Benefits of increasing EPAP (PEEP)
Increasing EPAP (PEEP) in increments of 2 may increase functional residual capacity and along with manipulation in FiO2, improve oxygenation. The need for EPAP (PEEP) >14 requires an MD order
999
administering breathing treatments
Inline albuterol and Duoneb treatments may be provided while using BIPAP
In-line inhaled pulmonary vasodilators (Flolan or iNO) may be administered via Bipap or the ventilator circuits
1000
EtCO2 target and management with presumed severe metabolic acidosis
If the patient is in presumed severe metabolic acidosis state (i.e. sepsis, burns, trauma, DKA), it is likely appropriate to target a higher MV on the ventilator to keep the EtCO2 <30. This will help compensate for the metabolic acidosis while correcting the underlying condition. For example, in a patient with DKA, their EtCO2 before intubation is likely 10 and if we sedate, paralyze, and intubate them and target an EtCO2 25-45, their overall pH will worsen as we have taken away their respiratory compensatory drive
1001
IFT with patients on alternative modes
For IFT patients which are on either ASV or APRV, mirror settings of the sending facility. If unable to mirror settings or complications arise, revert to traditional vent modes as previously referenced in this protocol
1002
