Protocols Flashcards
Abdominal pain/trauma assessment considerations- history
-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
Interventions for patients with suspected or diagnosed bowel obstruction for changes in altitude
Place gastric tube prior to flight
What exam should be performed for all patients with abdominal trauma
eFAST
must document in ePCR: ultrasound completed/indication/impression/image number/ultrasound device number
when should an ultrasound be performed on a pregnant patient
when they present with lower abdominal pain with or without vaginal bleeding
What complication do you prepare for with potential solid organ injury
hypovolemia
What abdominal injury do you consider a low altitude flight path?
If potential for hollow organ rupture
when can ischemic cardiac pain present as abdominal pain
in elderly patient and/or anterior wall AMI
What pediatric diagnosis may present with a chief complaint of abdominal pain
pneumonia
atraumatic abdominal pain in pediatric patients should warrant what assessment
thorough pulmonary assessment
ACS assessment considerations- history
-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
Minimum O2 sat goal with ACS
at or above 90%
timeframe to obtain 12 lead
10 minutes
STEMI criteria
ST segment elevation in two or more contiguous leads
-2mm elevation in leads V2, V3
-1 mm elevation in all other leads
Actions for notification after meeting STEMI criteria
call STEMI alert to receiving hospital as soon as evident along with the name of cardiologist if known
When to perform serial 12 lead ECGs
if patient continues to complain of ACS or prolonged transport time to evaluate potential evolving cardiac events
Treatment for patients with evidence of inferior wall MI
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
nitro administration
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
nitro gtt dose
5-200 mcg/min
nitro gtt concentration
50 mg in 250mls D5W (200 mcg/ml)
Aspirin administration with ACS
give 324 mg chewable ASA. withhold ASA if taken within the last four hours.
treatment if no relief of chest pain from NTG or SBP <100
-Fentanyl 1-2 mcg/kg (to max single dose 100 mcg) Q5 min
- morphine 2-5mg increments Q5min
Interventions if STEMI and SBP >140 and HR >100
-metoprolol 5 mg IV Q115min x3 doses as long as SBP >90 and HR >60
-may be given in conjunction with NTG
ACS with symptomatic sinus brady associated with inferior MI
Consider Epi injusion
Epi concentration
1 mg of Epi (1mg/1ml) in 100 mls NS
Epi gtt dose
0-0.5 mcg/kg/min (IBW)
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
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
heparin gtt concentration
mix 5000 units Heparin in 250 ml NS
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
Types of low molecular weight Heparins
Enoxaprin (Lovenox), Dlteparin (fragmin), and Tinzaparin (Innohep)
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
If patient received TNK, what do you do in regards to anticoagulation
must obtain orders for Heparin prior to administration
goal temp for interfacility TTM transfer
34-36 degrees celsius
treatment for shivering in TTM patient
no not paralyze if possible, choose analgesia and /or sedation first
additional consideration for interventions with an inferior MI
consider performing a right sided 12 lead EKG (V4R) to assess right sided ventricular involvement
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
antiplatelet medications
ASA, Plavix, Integrilin, Abciximab (Reopro), Tirofiban (Aggrastat), Brilinta, Effient
Anticoagulants
Angiomax, Argatroban, Warfarin, Eliquis, Pradaxa, Xarelto
Ventilator modes okay to utilize for ARDS
either volume or pressure control
goal vent settings with ARDS
Plateau pressures <30 with tidal volumes of 6-8 ml/kg/IBW
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
SAT goal with ARDS
88%
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.
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
Classifications of ARDS
-Mild (P:F 200-300)
-Moderate (P:F 100-200)
-Severe (P:F <100)
Five P’s of supportive therapy
Perfusion, positioning, protective lung ventilation, protocol weaning, preventing complications
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
ARDS and fluid status goals
ARDS patients do better with lower volume status (goal CVP 4-8) and may benefit from diuresis
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
Number of intubation attempts for careflight
limit two endotracheal intubation attempts before an alternate airway is used
SAT goals during intubation
goal is to assure no SpO2 <90 during intubation attempts.
What is required to chart during an intubation
lowest SPO2
When should an LMA be used?
An LMA can be used at any point for adult or pediatric patients, at medical crew discretion
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
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.
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
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
What monitoring is required for all intubated patients
Continuous cardiac and ETCO2 is required, including those receiving CPR
What do you monitor continuously on all intubated and perfusing patients
SpO2
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
Criteria for using RSI for intubation
-intact gag reflex
-Trismus
- GCS 8 or less
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
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
Hemodynamically stable induction agents
Etomidate or Ketamine
protocol for preoxygenation prior to intubation
pre-oxygenate for 2-5 minutes using high flow oxygen via nasal cannula, assisting ventilation only if apneic
goal SAT for pre-oxygenation
100% SPO2
oxygenation provided during intubation
passive apneic oxygenation via nasal cannula 15 lpm throughout procedure
when to discontinue intubation attempt based on SPO2
if SPO2 drops below 90% in a patient that achieved SPO2 over 95% with passive oxygenation.
intervention after terminating intubation attempt
Ventilate with BVM with PEEP valve set from 3-8 to increase SPO2 goal
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)
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
paralytic for intubation
- Rocuronium: 1 mg/kg (IBW)
- Vecuronium: 0.1 mg/kg (IBW)
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
if utilizing cricoid pressure, when should you release the pressure
if the patient vomits, release the pressure and suction as needed
After induction and paralysis, what criteria must be met prior to intubation
when jaw flaccid and gag is no longer present
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)
sedation protocol post intubation
continue sedation/analgesia per Pain and Anxiety protocol immediately after medication assisted intubation
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
PEDS analgesia and/or attenuation of increased ICP
consider Fentanyl 2-3 mcg/kg prior to inducation
PEDS sedation and induction medications and doses
-Ketamine 1-2 mg/kg
-Midazolam 0.1 mg/kg
PEDS paralysis medications and doses
-Roc: 1 mg/kg
-Vec: 0.1 mg/kg
Cricoid pressure protocol for pediatric patients
Cricoid pressure is contraindicated in PEDS
Continued paralysis for PEDS
-Roc: 1 mg/kg IV every 30 minutes
-Vec: 0.1 mg/kg IV every 30 minutes
Different duration in time for PEDs and paralysis
Duration is shortest in children 2-11 yo and longest in neonates and infants
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
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.
Protocol if unable to establish advanced airway and unable to oxygenate with BVM- PEDS
needle cricothyrotomy is considered for patients <12
When to consider antiemetics for intubated patients
for supine patients who have a contraindication to elevated HOB
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
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
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
Shock index relevance for PEDs patients
shock index is not a reliable factor for mortality in children
What can be used on intubated patients to help prevent accidental extubation
cervical collar
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
Initial things to check when a patient starts to deteriorate
immediately recheck ETT/LMA position if patient condition starts to deteriorate
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
Treatment of airway obstruction in awake adult
Abdominal thrusts until the obstruction is alleviated or patient is unconscious
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
Treatment of airway obstruction in awake PEDS patient- younger than 1 year old
chest thrusts and back blows
Treatment of airway obstruction in awake PEDS patient- over 1 yo
abdominal thrusts
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
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
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
Extrapyramidal reaction
-Diphenhydramine 25 mg IV/IM
Mild-swelling, itching, redness, hives
-Diphenhydramine 25-50 mg IM or slow IVP
- Famotidine 20 mg IVP
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
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)
PEDS Mild allergic reaction- swelling, itching, redness, hives
-Diphenhydramine 1mg/kg IV or IM, max 25 mg
-Famotidine 1 mg/kg, max 20 mg
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
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
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.
most common causes of anaphylaxis
-foods, particularly nuts and shellfish
-insect stings
-drugs, particularly antibiotics
-latex
-iodine contrast dyes
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
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
possible complications from Epi
Associated with high incidence of ventricular dysrhythmias, hypertensive crisis, and pulmonary edema
Medications that can lead to extrapyramidal side effects
Antipsychotic medications such as Haldol, or phenothiazine derivatives such as promethazine or compazine
extrapyramidal side effects
dystonia, akathisia, and or agitation
treatment for extrapyramidal side effects
diphenhydramine (this is not an allergic reaction)
initial intervention with any altered mental status
measure blood glucose
Treatment for hypoglycemia, Adult
<60 give 100-200 ml of D10
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
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
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
When can oral glucose be utilized
if the patient is alert with a glucose <60 (only on CCT)
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
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
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
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
AMS- when to obtain 12 lead EKG
If suspected cardiac cause, cardiotoxic ingestion or electrolyte imbalance
What needs to be ruled out with AMS prior to intubation
Rule out reversible causes such as hypoglycemia, drug or narcotic toxicity
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
Acute confusion and signs of sepsis
sepsis is common cause of AMS in elderly, typically females is UTI and men is PNA
signs of opioid overdose post Narcan administration
a rapid, pronounced increase in LOC, dilation of pupils, piloerection, rhinorrhea and return or respiratory function
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
Common causes of coma for PEDS
poisoning, diabetes, child abuse or neurologic disorders
Thermalregulation and PEDS with AMS
AMS in PEDS who is exposed can become quickly hypothermic, assure application of continuous temp monitoring
continuous monitoring for patients receiving medications for anxiety/agitation
SPO2 and side stream ETCO2 is recommended when not intubated
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)
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)
Extreme agitation or excited delirium Haldol dose
5 mg IM/IV Q5-10 minutes, titrate to max 15mg
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
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
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)
IN administration practices
50% in each nostril
Contraindications for Ketamine infusion
Globe injury, liver disease, uncontrolled HTN, history of psychosis.
Avoid in older patients, schizophrenics and patients with heart disease
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
during of action for ketamine
10-20 minutes
side effects of Ketamine
HTN, tachycardia, laryngospasm, emergence reactions, and vomiting (more common after a rapid IV administration)
When to consider other sedation medications aside from Ketamine
in patients with significant HTN
What medication can be considered to attenuate psychotropic effects and recovery agitation when giving Ketamine
Versed
Aortic Emergencies VS goals
Goal HR <60 and SBP 100-120
If an aortic emergency, what intervention should be performed
12 lead EKG
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
What is given to avoid HTN and tachycardia
beta blocker
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.
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)
What is the goal bedside time for Aortic Dissection patients
15 minutes
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
Special considerations when calling report for dissection
Be sure to clearly state that the patient is an “aortic emergency”
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.
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
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.
first line treatment for meth/cocaine users with aortic emergency and HTN/tachycardia control
Benzos
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
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
symptoms of a descending aorta
back pain, chest pain, abdominal pain, weak or absent femoral pulses, lower extremity pain/paresthesia/motor deficit, acute paraplegia
possible EKG findings iwth aortic emergency
right coronary artery involvement and signs of ACS
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)
classification for HTN crisis
SBP>210 or SBP>110
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
besides antihypertensives, what other meds can be given for HTN
relief of pain/anxiety may lower blood pressure to acceptable levels
Additional test to get with HTN
12 lead ECG
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
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)
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)
Hydralazine dose for HTN
10-20 mg SIVP Q15 min, max dose 60 mg
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
non anti-htn medication treatment for patients with HTN emergency due to illicit drug use
sedation with benzos
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
Definition of HTN emergency
diagnosed by evidence of end organ dysfunction or failure such as elevated BUN and Creatinine or oliguria
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
Goal in treating most HTN emergencies
reduce BP by 25% in the first 24 hours
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
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)
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
PEDS push Epi dose
1 mcg/kg max dose 20 mcg
Epi dose for imminent threat of cardiac arrest with a pulse
250-500 mcg of 0.1 mg/ml
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
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.
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
PEDS vitals criteria for emergent blood transfusion
-SBP <70
-HR >150
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.
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.
PEDS infusion for blood products
max dose of 20 ml/kg of blood. infuse at a wide open rate with pressure bag
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
vital signs during blood transfusion
document VS Q10 minutes with both pre and post transfusion VS including temp
Fluids compatible with blood products
NS, ABO compatible plasma or albumin
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
Complications to monitor for from blood transfusion
fluid overload, pulmonary edema, poor cardiac or renal function
What can be given with some complications from a blood transfusion
consider giving lasix if the patient develops signs of fluid overload or TRALI
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
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
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
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
PEDS non emergent transfusion administration rate
Start at 2.5 ml/kg/hr to avoid circulatory overload.
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
Special consideration for vital signs for pediatric patients and blood administration
keep patient warm, monitor temperature using continuous temp probe
Transfusion parameters based on hgb
in patients with a documented hgb >7, limit further transfusions unless actively bleeding or hemodynamically unstable
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
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
Current recommendations for “damage control” massive transfusion
Massive transfusions are 1:1:1 ratio of PRBC/FFP/Plt to ensure hemostasis
Temperature monitoring and blood transfusions
it is essential to maintain normal body temperature to prevent further coagulopathies
Blood warmer temperature parameters
if using a blood warmer, do not heat blood product above 40 C
oxygen release in transfused RBC vs normal RBC
oxygen release by transfused RBC is diminished in comparison to normal RBC
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.
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.
hypocalcimia and the clotting cascade
significant calcium depletion may interfere with the function of several key clotting factors in the coagulation cascade
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
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
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)?
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)?
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?
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?
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
Assessment with scald injuries
-Percentage of burns
-Evidence of abuse- even lines vs spatter pattern
Assessment for chemical injuries
location and extent of burns
Assessment for electrical injuries
Describe wounds and locations, do not attempt to identify entrance and exit wounds
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
When to intubate a patient with burns
intubate early if sings of inhalation injury and airway compromise
Burn patients and removal of clothing
remove clothing that does not adhere to the patient along with jewelry and other constricting objects
oxygenation interventions if carbon monoxide poisoning is possible
administer oxygen via non-rebreather mask
Ideal positioning of burned limbs
elevate burned limbs if possible
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
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.
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
PEDS- initial warmed fluid rate while calculating burn formula
0-5yo: 125 ml/hr
6-13yo: 250 ml/hr
>13 yo: 500 ml/hr
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
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
For chemical injuries, what must be done prior to loading patient into the aircraft
Ensure patient has been decontaminated per HAZMAT protocol
intervention for small chemical injuries
for small, isolated chemical burns, decontaminate patient using running water for 15 minutes
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
CPR and lethal rhythms after electrical injuries
initiate CPR as needed, treat dysrhythmias per cardiac Dysrhythmia protocol
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
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
Exclusion criteria to patient not going to a burn center but meets the burn center criteria
the burns are complicated by major trauma
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.
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
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
Steps if UCD is unable to accept the patient
the patient will go to RRMC.
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
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
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
Airway management for liquid and aerosolized chemicals
liquid and aerosolized chemicals are more likely to affect the supraglottic areas
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
What other intervention should be requested from the sending facility
Foley placement
What can you expect with the BSA over time
expect the BSA and depth of burn to extend. Reassess and adjust fluid calculations.
Way to decrease extension of burn
maintaining normothermia
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
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
Blood pressure expectations with burns
HOTN is not expected in burn patients. assess for other causes, such as trauma
possible complication from full thickness chest burns
may restrict chest expansion
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
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.
Treatment for escharotomy on areas other than the chest
it is not recommended to complete until the patient reaches the burn center
interventions for patients with facial burns
inspect eyes, if suspected burn to eyes, instill ophthalmic anesthetic and irrigate with sterile NS if time allows
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
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%
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%
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%
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
Consider possible causes for PEA/asystole
-hypovolemia
-tension pneumothorax
-hypoxia
-acidosis
-cardiac tamponade
-hypothermia
-pulmonary embolism
-myocardial infarction
-drug overdose
treatment for PEA/asystole causes
-NS fluid bolus
-chest decompression
-check tube placement
-ventilate
-pericardiocentesis
-remove from
-environment/actively rewarm
-Narcan
Epi administration IV or ETT
1mg IV/IO every 3-5 minutes or 2.5 mg ETT
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
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
What does a large increase in ETCO2 usually indicate
a return in spontaneous circulation, stop CPR and check for pulses
supportive measurements to initiate for Afib RVR (>120)
-Chest compressions, airway, breathing
-administer oxygen to assure adequate oxygenation
-cardiac monitor
-obtain IV access
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
Interventions for stable Afib with less than 20 minutes transport time
monitor without therapy
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
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)
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
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)
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
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.
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
information needed for chronic Afib patients
be sure to acquire anticoagulation history
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
Treatment for 2nd degree type 2 or 3rd degree heart block with s/s of poor perfusion
Immediate TCP
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)
treatment for any bradycardia with no s/s of poor perfusion
transport
Atropine should not be given for a high degree AV block with poor perfusion if it delays what intervention
TCP
Atropine should be used cautiously in the presence of what acute/chronic medical health issue
acute coronary ischemia or MI
supportive measures initiated with narrow complex tachycardia
- Chest compressions, airway, breathing
-Administer oxygen to assure adequate oxygenation
-cardiac monitor
-Obtain IV access
possible alternate causes of narrow complex tachycardia
Sepsis, PE, hypovolemia, excessive energy drink consumption, drug use
Intervention for narrow complex tachycardia with s/s poor perfusion and patient is not verbally responsive
Cardioversion
Steps for interventions for SVT with s/s poor perfusion
-valsalva maneuver
-Adenosine 6 mg
-Adenosine 12 mg
-Sychronized cardioversion (100/150/200J)
Interventions for Afib/AfL with s/s of poor perfusion
synchronized cardioversion
Interventions for narrow complex tachycardia with no s/s of poor perfusion
contact medical control for Adenosine orders
Intervention that must be done when given Adenosine
perform continuous EKG strip during administration
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
protocol for unwitnessed arrest
after 2 minutes of CPR, defibrillate at 120J
protocol for witnessed arrest
Defibrillate at 120J, give 2 minutes of cpr then check rhythm
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
Medication that can be started if transport time is over 20 minutes.
Amio gtt at 1 mg/min (150 mg in 100 mls)
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)
Medication given for Torsades de Pointes
2mg IV magnesium wide open (2mg in 100 mls)
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
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
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
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
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
What intervention is performed on all patients with chest trauma
eFAST examination
signs of tension pneumothorax
absent breath sounds, tracheal deviation, HOTN
what intervention is performed when there is evidence of tension pneumothorax
needle thoracostomy
what is performed if needle thoracostomy is unsuccessful x2
simple thoracostomy
Becks triad
-jugular venous distention
-muffled heart sounds
-narrow pulse pressure
when to perform pericardialcentesis
with evidence of potential for pericardial tamponade
Interventions for evidence of large flail segment with decreased gas exchange
intubation and positive pressure ventilation
what to do for a sucking chest wound
apply occlusive dressing
intervention for impaled objects
stabilize the object
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
Interventions for a pneumothorax greater than 25%
consider placing chest tube prior to transport. if possible, confirm chest tube placement prior to transport
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
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.
positioning of cold trauma patient
maintain supine position, avoid rough movement and excess activity
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
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.
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
methods to not use to rewarm patient
do not re-warm with exercise or rubbing. do not break blisters
Circumstance/area to not re-warm patient
do not re-warm in the field if there is a risk of refreezing
how to protect areas of involvement
protect areas from further injury with padding and bandages
positioning of affected limbs
elevate and immobilize affected areas
medication to be given with signs of frostbite
give 324 ASA if patient is able to safely swallow
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.
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.
Defibrillation if core body temp is <30 degree C
deliver one attempt at defibrillation at the usual dose
Defibrillation if core body temp >30 degrees C
may repeat defibrillation attempts per ACLS protocols
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
transportation of hypothermic patients
transport all severely hypothermic patients regardless of response to ALS procedures
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
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
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
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
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
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.
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
fluid bolus type
LR is contraindicated in hypothermia patients due to the cold liver’s inability to metabolize lactate
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
rectal and esophageal temperature monitoring
rectal temp may lag behind core temp by as much as an hour versus esophageal temp monitoring
additional route to provide rewarming
consider HHFNC for rewarming
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
Frostnip
Partial freezing of tissue, superficial
- redness
-mild swelling
-pallor
-edema
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
Deep frostbite
involves bode, muscles, tendons
- bluish, gray skin with bleeding blisters and severe swelling
-loss of function and tissue destruction
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
if insulin gtt was not started by the sending facility,
initiate infusion at 0.1 unit/kg/hr to a target BG <300
K level that you should not start the insulin gtt
less than 3.3
change to insulin gtt after BG drops below 300
decrease insulin gtt to 0.05 units/kg/hr
BG level to no let the BG level drop below
250
intervention if BG drops below 250
begin D10 maintenance gtt
intervention if BG drops below 100
stop insulin gtt and recheck BG in 15 minutes, continue D10 gtt
intervention if BG less than 80 despite D10 gtt
give 50-100 D10 bolus and recheck BG in 15 minutes
Interventions if K at sending facility is less than 5.3
request than potassium be added to maintenance bag
how frequently do you check the BG
every 30 minutes
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
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.
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.
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.
treatment for euglycemic DKA
This DKA management is the same as above, but being cautious to start dextrose fluids early to prevent hypoglycemia
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
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.
target BG for PEDS
<250
BG level that is classified as severe hypoglycemia in PEDS and calls for discontinuing insulin gtt
<100
Insulin gtt rate for PEDS <5 yo or with insulin sensitivity
gtt may begin at 0.025 units/kg/hr
PEDS and insulin bolus
Insulin bolus should be avoided in PEDS patients
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
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.
Goal to maintain BG above a certain level for PEDS DKA
BG should be kept above 150 during transport
interventions if BG drops below 100- PEDS DKA
stop insulin infusion and continue D10 at 1.5x the normal rate and consult medical direction
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
frequency of BG check for PEDS DKA
every 30 minutes or more frequent monitoring is needed
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
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
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.
Criteria for HHS
-Hyperglycemia usually >600
-Minimal acidosis
-Absent to mild ketosis
-Marked elevation in serum osmolality
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
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
danger of hypoglycemia
hypoglycemia is much more dangerous in any patient than hyperglycemia.
Positioning intervention for extremity trauma/amputation
Immobilize injured extremity and reassess pulses, motor function and sensation.
Dressing for open fractures
Apply sterile dressing to open fractures. carefully note wounds that appear to communicate with bone
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.
areas to splint from extremity trauma
areas of tenderness or deformity
how to splint a deformity
try to immobilize the joint above and below the injury
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
Treatment of simple extremity injuries
elevate extremity and apply cold packs
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)
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
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.
