Section 2: Medical Protocols Flashcards

Question

2.07 Pediatric Patient Comfort - Treatment

Answer 1

• Assess pain severity utilizing age appropriate pain scale (numeric, Wong-Baker faces or FLACC scale), circumstances, mechanism of injury, and severity of illness or injury. • For mild to moderate pain (scale of 1-6), consider: ⃝ IBUPROFEN 10 mg/kg (800 mg max) PO or ⃝ACETAMINOPHEN 15 mg/kg (1000 mg max) PO. • For minor to moderate pain (scale of 1-6), consider KETOROLAC 0.5 mg/kg IV/IM (max 30 mg) or, as an alternative to ACETAMINOPHEN above, consider ACETAMINOPHEN 15 mg/kg IV (1000 mg max single dose). • For severe pain (scale >6): ⃝ FENTANYL 0.5-1 mcg/kg IV/IM/IN [max 75 mcg] (q 10 min, max 150 mcg). or ⃝ For patients with traumatic pain or burns, KETAMINE 0.1 mg/kg IV or 0.2 mg/kg IM/IN. IV dosing may be repeated every 10 minutes and IM/IN doses may be repeated once in 30 minutes as needed to a max cumulative dose of 10 mg. • For patients with nausea or vomiting, ONDANSETRON 0.2 mg/kg (max dose 4 mg) PO/IV/IM/ODT (may repeat x1 in 15 minutes). Do not use in patients <3 months old. • For patients requiring electrical therapy (cardioversion or pacing) or other procedure requiring sedation, consider MIDAZOLAM 0.1 mg/kg [2.5 mg max] IV/IM/ IN or FENTANYL 2 mcg/kg [75 mcg max] IV/IM/IN or KETAMINE 0.5-1 mg/kg IV or KETAMINE 2 mg/kg IM (must have continuous quantitative waveform capnography in place). • For patients with an advanced airway in place (ETI/BIAD/cricothyrotomy) requiring sedation, consider FENTANYL 1.5-3.0 mcg/kg IV. • Monitor and reassess response to treatment and vital signs prior to and 5 minutes following any dose of narcotic analgesic and before transfer of care (patient hand off). This must be documented in the PCR.

Answer 2

• Use extreme caution in administering opioids to patients < 10 kg. • DO NOT administer Ibuprofen and ketorolac (Toradol) to patients that are pregnant, have a history of renal failure or transplant, are allergic to non-steroidal anti-inflammatory agents (NSAIDs), have active bleeding (including GI bleeding), have suspected intracranial hemorrhage, or in patients that may require surgical intervention such as those with open fractures/fractures with deformity. • DO NOT administer aspirin to patients that have active bleeding, including GI bleeding, have suspected intracranial hemorrhage, or in patients that may require surgical intervention such as those with open fractures / fractures with deformity. • DO NOT administer PO medications to patients that may require surgical intervention. • PO analgesics are not indicated for abdominal pain. • Individual patients may respond differently to opioid analgesics. The patient’s age, weight, clinical condition, co-administered/ingested drugs (alcohol, benzodiazepines) and prior exposure to opiates should all be considered when determining the dose to be administered. Weight based dosing provides a standard means for dose calculation, but does not predict patient response. Example: minimal doses of opioids may cause respiratory depression in elderly, opiate naïve or alcohol intoxicated patients. • Avoid co-administering multiple sedating agents in non-intubated patients due to the risk for respiratory depression. • Consider the use of waveform capnography in all patients receiving narcotic analgesics or ketamine. • Patients with alcohol intoxication or those that have received benzodiazepines are at increased risk for respiratory depression following the administration of narcotic analgesics. • For pediatric administration, the 10 mg/ml concentration of ketamine is to be used. • Sub-anesthetic (low) dose ketamine has demonstrated significant analgesic efficacy without the adverse effects associated with higher doses. While uncommon, ketamine administration may result in laryngeal spasm and/or increased salivation. Laryngeal spasm is transient and can be managed with positive pressure ventilation if need be. • As the dose related effect of ketamine transitions from analgesia to anesthesia, nystagmus emerges and as such, ketamine administration should be discontinued when nystagmus occurs. • Ketamine should not be used in patients with penetrating ocular injuries or known coronary artery disease. • Vomiting without diarrhea in pediatric patients may be related to pyloric stenosis, bowel obstruction or a CNS process (bleed, tumor, increased ICP). • Utilize age appropriate pain scoring systems (see next page). For most patients > 9 yo, the numeric (1-10) scale is appropriate. For patients 2 months-7 years, the FLACC scale may be used. The Wong-Baker-Faces scale may be used for patients > 3 yo. • Advanced airway placement MUST be confirmed by the presence of a waveform capnography (> 6 breaths) prior to the administration of rocuronium or vecuronium. continuous airway monitoring with side stream capnography is required.

Answer 3

• Shortness of breath, pursed lip breathing, wheezing/rhonchi, prolonged expiratory phase, use of accessory muscles, increased respiratory rate and effort, fever, cough.

Answer 4

* Routine patient care. * For patient not responding to initial therapy, consider continuous positive airway pressure (CPAP) at 5-10 cm H2O. * ALBUTEROL 2.5-5 mg (initial dose should include IPRATROPIUM BROMIDE 500 mcg, subsequent doses may be +/- IPRATROPIUM) via SVN (may repeat PRN to a max of 4 doses). * METHYLPREDNISOLONE 125 mg IV or PREDNISONE 60 mg PO or DEXAMETHASONE 10-20 mg IV/IM. * Consider LEVALBUTEROL 1.25 mg via SVN or MDI (may repeat every 20 minutes as needed x4). * For patients with asthma, consider MAGNESIUM SULFATE 2 gm IV over 10 minutes. * For the patient with a diagnosis of asthma who is in extremis, EPINEPHRINE (1:1000) 0.3 mg IM, may repeat every 15 minutes x2. * Consider MIDAZOLAM 1-2 mg IV if needed to enhance CPAP compliance.

Answer 5

* Recommended exam: mental status, HEENT, skin, neck, cardiac, abdomen, pulmonary, extremities, neurologic. * Differential diagnosis should include asthma, COPD, anaphylaxis, aspiration, pleural effusion, pneumonia, pulmonary embolus, CHF, hyperventilation, inhaled toxin, exit appropriate protocol based on index of suspicion. * SpO2 and EtCO2 should be monitored continuously in patients with persistent distress. * A “silent chest” in the asthmatic patient is a pre-respiratory arrest indicator. * When considering endotracheal intubation in the asthmatic patient, if possible administer a rapid IV bolus of 1L NS or LR prior to intubation. * Asthmatics are prone to hypotension following conversion to positive pressure ventilation (endotracheal intubation) due to decreased cardiac return (preload). Address volume status prior to intubation, following intubation ventilate the patient at a lower rate and utilize lower tidal volumes. Hypercapnia, as evidenced by increased EtCO2 levels is acceptable and attempts to correct with hyperventilation should be avoided.

Answer 6

* Respiratory distress with tachypnea, nasal flaring, retractions. * Bronchiolitis: < 2 yo (peak 3-6 mo), +/- history of poor feeding/fussiness, increasing coryza and congestion, +/- low-grade fever, cough, fine crackles, fine/diffuse wheezing. * Croup: 6 mo - 6 yo (peak <4 yo), upper respiratory tract infection, low grade fever, coryza, “barking” cough, varying degrees of respiratory distress. * Asthma/RAD: > 2 yo, wheezing, cough, chest tightness, prolonged expiratory phase, +/- fever. * Epiglottitis: > 2 yo, fever, toxic/ill appearing, favors upright position, drooling, stridor.

Answer 7

• Routine patient care. • Allow patient to assume position of comfort. • OXYGEN if the SpO2 is ≤ 92%. • For patients with wheezing and history of asthma, assist the patient with one dose of the patient’s own rescue inhaler (use a spacer if available) or administer ALBUTEROL 2.5 mg (+/- IPRATROPIUM BROMIDE 500 mcg) via SVN. Contact MEDICAL CONTROL for authorization to administer additional doses. • For patients with suspected epiglottitis: ⃝ Allow patient to assume position of comfort. ⃝ Allow secretions to drain passively (i.e. avoid suctioning). ⃝ Minimize airway manipulation, provide airway management only in the event of complete airway obstruction (most patients with epiglottis related airway obstruction can be effectively bag-mask ventilated). • For patients < 2 yo with respiratory distress and suspected bronchiolitis: ⃝ Perform gentle nasopharyngeal suctioning for copious secretions. ⃝Supplemental oxygen if the SpO2 is ≤ 92%. ⃝If the patient appears to be dehydrated, consider a 20 ml/kg NORMAL SALINE IV bolus. • For patients < 6 yo with respiratory distress and suspected croup: ⃝Supplemental oxygen if the SpO2 is ≤ 92%. ⃝ If the patient appears to be dehydrated, consider a 20 ml/kg NORMAL SALINE IV bolus. ⃝ DEXAMETHASONE 0.6 mg/kg PO/IM/IV (PO preferred, max 10 mg). ⃝ For patients with significant respiratory distress or stridor at rest, consider EPINEPHRINE (2.25% solution) 0.5ml/3ml NS or EPINEPHRINE 5 mg (1mg/1ml concentration) via SVN, may repeat x1. • For patients ≥ 2 yo with reactive airway disease (RAD)/asthma: ⃝ ALBUTEROL 2.5-5mg (initial dose should include IPRATROPIUM 500 mcg, subsequent doses may be +/- IPRATROPIUM) via SVN for continued wheezing (may repeat x3). ⃝Consider IV access if the SpO2 is ≤ 92% following the first dose of inhaled beta agonist. ⃝Consider continuous positive airway pressure (CPAP) @ 5-10 cmH20 if tolerated. ⃝METHYLPREDNISOLONE 2 mg/kg IV (max 60 mg ) or HYDROCORTISONE 2 mg/kg IV (100 mg max) or PREDNISONE/PREDNISOLONE (Orapred) 2 mg/kg PO (60 mg max) or DEXAMETHASONE 0.6 mg/kg PO/IM/IV [PO preferred] (max 10 mg). ⃝ Consider MAGNESUM SULFATE 40 mg/kg IV over 10 minutes (2 gm max). ⃝ For continued respiratory distress, EPINEPHRINE (1:1:000) 0.15-0.3 mg IM (lateral thigh).

Answer 8

* Differential diagnosis should include asthma/reactive airway disease, anaphylaxis, aspiration, foreign body airway obstruction, upper or lower airway infection (pneumonia), congenital heart disease, CHF, toxic ingestion. * SpO2 should be monitored continuously in patients with persistent distress. * Bronchiolitis is a viral infection usually affecting infants and results in wheezing and typically does not respond to inhaled beta agonist. The management of bronchiolitis is largely supportive. * Nebulized epinephrine is typically not recommended in bronchiolitis unless the patient is in extremis. Use of nebulized epinephrine prolongs EDs stays as it requires a 3 to 4 hour observation time after administration . * Croup typically affects children from 6 mo to 6 yo with a peak at year < 4 yo and is characterized by a barking like cough resulting from upper airway edema. It is viral, may be associated with fever, is typically of gradual onset, and drooling is not typically noted. * Use of nebulized epinephrine for croup should be limited to those patients with significant respiratory distress or stridor at rest. * Epiglottitis is a bacterial infection typically affecting children > 2 yo. It is usually of rapid onset, associated with fever and drooling. Stridor may be present and the patient may assume the tripod position. Airway manipulation may worsen the condition and should be avoided. The incidence of epiglottis has decreased over the last couple of decades due to routine immunization against H. influenza. * A “silent chest” in the asthmatic patient is a pre-respiratory arrest indicator. * When considering endotracheal intubation in the asthmatic patient, if possible administer a rapid 20 ml/kg IV bolus of NS or LR prior to intubation. * Asthmatics are prone to hypotension following conversion to positive pressure ventilation (endotracheal intubation) due to decreased cardiac return (preload). Address volume status prior to intubation, following intubation ventilate the patient at a lower rate and utilize lower tidal volumes. Hypercapnia, as evidenced by increased EtCO2 levels is acceptable and attempts to correct with hyperventilation should be avoided.

Answer 9

• Patient exhibiting any one or a combination of the following: anxiety, agitation, affect change, hallucinations, delusional thoughts, bizarre behavior, combative or violent behavior, expression of suicidal/homicidal thoughts.

Answer 10

• Consider possible medical etiologies, managing per the following age appropriate protocols as indicated: ⃝ Altered Mental Status ⃝ Diabetic Emergencies ⃝ Excited Delirium ⃝ Head Trauma - Traumatic Brain Injury ⃝ Toxicological Emergencies ⃝ Patient in Police Custody • Remove patient from stressful environment. • Utilize the SAFER model: • Stabilize the situation by lowering stimuli, including voice. • Assess and acknowledge crisis by validating the patient’s feelings and not minimizing them. • Facilitate identification and activation of resources (clergy, family, friends, and police). • Encourage patient to use resources and take action in the patient’s best interest. • Recovery/referral – transport patient to a Hospital Emergency Facility. If the patient is not transported, be sure the patient is in the care of a responsible individual or professional. • Consider Patient Restraint Procedure if indicated (aggressive, agitated, psychosis, possible danger to self or others). Restraint should be performed/assisted by law enforcement when available. • If there are no medical or substance use disorder etiologies, transport patient to a mental health preferred facility if the transport time is less than 20 minutes (see Table 2 Point of Entry – Specialized Hospital Emergency Facilities in Routine Patient Care). • For patients with known or suspected opioid overdose, that are stable with adequate ventilation (before or after NALOXONE administration), transport patient to an opioid use disorder preferred facility, if the transport time is less than 20 minutes (see Table 2 Point of Entry – Specialized Hospital Emergency Facilities in Routine Patient Care). • For patients with known or suspected alcohol or opioid use disorder, that are stable with adequate ventilation, consider transport to the recovery navigation program or mental health and opioid use disorder facility (see Table 2 Point of Entry – Specialized Hospital Emergency Facilities in Routine Patient Care) by following the Alternative Transportation Algorithm. • For patients with known mental health history and presenting with an acute exacerbation of their condition, without danger to self or others, consider transport to the recovery navigation program or mental health and opioid use disorder facility (see Table 2 Point of Entry – Specialized Hospital Emergency Facilities in Routine Patient Care) by following the Alternative Transportation Algorithm. • For patients ≥16 yo with aggressive or agitated behavior who are not responsive to the above interventions, consider chemical restraint with: ⃝ HALOPERIDOL 5 mg IV/IM or DROPERIDOL 5 mg IV/IM (2.5 mg if age ≥ 65), may repeat either to a cumulative dose of 10 mg or ⃝ MIDAZOLAM 2.5-5 mg IV or 5 mg IM/IN, may repeat PRN if SBP >100 to a cumulative dose of 10 mg (5 mg if age ≥ 65, avoid if suspected alcohol intoxication) or ⃝ KETAMINE 4 mg/kg IM (max 400 mg) or 2 mg/kg IV (max 200 mg), for hypersalivation following KETAMINE administration, consider ATROPINE SULFATE 0.5 mg IV/IM.

Answer 11

* Be sure to consider all possible medical/trauma etiologies for behavior (hypoglycemia, toxicological, hypoxic, head injury). * Do not position or transport any restrained patient in such a way (e.g. prone) that could negatively affect the patient’s respiratory or circulatory status. * Any patient who is handcuffed or restrained by law enforcement and transported by EMS must be accompanied by a law enforcement officer. * Continuous monitoring of EtCO2 (waveform) and SpO2 are mandatory in patients who receive physical or chemical restraint. When clinically feasible, ECG monitoring is required for patients that have received haloperidol. * It may be necessary/appropriate to administer IM injections through clothing in extremely agitated patients. * Extrapyramidal reactions associated with haloperidol or droperidol should be managed per the Toxicological Emergencies Protocol. * BH Link - 401-414-5465 (LINK)

Answer 12

* Hypoglycemia: anxiety, altered mental status, diaphoresis, seizures, tachycardia. * Diabetic ketoacidosis: warm dry skin, tachycardia, rapid shallow breathing, hypotension/ shock, acetone odor on breath, EtCO2 ≤29 mmHg.

Answer 13

• Perform blood glucose (bG) analysis and determine bG level if not previously determined. Treat as below (in the absence of the ability to determine bG, patients with signs or symptoms of hypoglycemia should be treated as below as appropriate for their mental status and their ability to receive ORAL GLUCOSE SOLUTION). ≤ 60 mg/dl Patient is Awake and Alert 1. ORAL GLUCOSE SOLUTION* (15 gm glucose) PO. 2. Recheck bG in 15 minutes. 3. Repeat dose of ORAL GLUCOSE SOLUTION if bG ≤ 60 mg/dl. ≤ 60 mg/dl Patient is Not Alert to Verbal Stimuli or is Nauseated/ Vomiting 1. Thiamine 100 mg IV/IM. 2. D10W 250 ml (25g) IV over 5 minutes, may repeat in 5 minutes if bG <60 mg/dl. 3. If unable to establish IV access, GLUCAGON 1mg (1U) IM. ≥ 250 mg/dl 1. If patient is dehydrated without evidence of CHF/fluid overload, administer NORMAL SALINE 500 ml IV bolus. Repeat as needed. 2. Infuse NORMAL SALINE at 150 ml/hr. *Alternate glucose sources may be administered. Oral glucose equivalents include 3-4 glucose tablets, 4 oz. fruit juice (e.g. orange juice), non-diet soda, 1 tablespoon of pure RI maple syrup, sugar, or honey. * Thiamine should be reserved for patients that have a history of alcohol abuse or who appear malnourished. * If the patient is hypotensive, manage per age appropriate General Shock and Hypotension Protocol. * Encourage patients who refuse transport after improvement in GCS and are back to baseline to consume complex carbohydrates (15 grams) and protein (12-15 grams) such as peanut butter toast, mixed nuts, milk or cheese to stabilize blood sugar.

Answer 14

• Patients who presented with a bG≤ 60 mg/dl and are taking oral hypoglycemic agents should be strongly encouraged to agree to transport.

Answer 15

* Hypoglycemia: anxiety, altered mental status, diaphoresis, seizures, tachycardia. * Diabetic ketoacidosis: warm dry skin, tachycardia, rapid shallow breathing, hypotension/shock, acetone odor on breath, EtCO2 ≤29 mmHg.

Answer 16

* Perform blood glucose (bG) analysis and determine bG level if not previously determined. * Treat as below (in the absence of the ability to determine bG, patients with signs or symptoms of hypoglycemia should be treated as below as appropriate for their mental status and their ability to receive ORAL GLUCOSE SOLUTION). ≤ 60 mg/dl Patient is Awake and Alert 1. ORAL GLUCOSE SOLUTION* (15 gm glucose) PO. 2. Recheck bG in 15 minutes. 3. Repeat dose of ORAL GLUCOSE SOLUTION if bG≤ 60 mg/dl. ≤ 60 mg/dl Patient is Not Alert to Verbal Stimuli or is Nauseated/ Vomiting 1. D10W 5 ml/kg over 5 minutes, may repeat in 5 minutes if bG <60 mg/dl. 2. If unable to establish IV access, GLUCAGON 0.1 mg/kg IM [1 mg max]. ≥ 250 mg/dl 1. If patient is dehydrated without evidence of CHF/fluid overload, administer NORMAL SALINE 20 ml/kg IV bolus. 2. Infuse NORMAL SALINE at 20 ml/hr. *Alternate glucose sources may be administered. Oral glucose equivalents include 3-4 glucose tablets, 4 oz. fruit juice (e.g. orange juice), non-diet soda, 1 tablespoon of pure RI maple syrup, sugar, or honey. * If the patient is hypotensive, manage. * Encourage patients who refuse transport after improvement in GCS and are back to baseline to consume complex carbohydrates (15 grams) and protein (12-15 grams) such as peanut butter toast, mixed nuts, milk or cheese to stabilize blood sugar.

Answer 17

* Volume overload: shortness of breath, dyspnea on exertion, crackles, JVD, peripheral edema. * Hyperkalemia: muscle weakness, cardiac arrhythmias, peaked T waves, wide QRS complex/sine wave ECG.

Answer 18

* For patients with hemorrhage from a shunt/fistula, manage. * For patients with pulmonary edema, manage. * For patients that have had hemodialysis within the past 4 hours with a SBP < 90, and clear lung sounds, NORMAL SALINE 250ml IV BOLUS (repeat as needed if the lungs remain clear [max 1 L]). * For patients in cardiac arrest or with suspected hyperkalemia, manage per the age appropriate Cardiac Arrest Protocol (if applicable) and consider CALCIUM CHLORIDE 1 gm IV or CALCIUM GLUCONATE 3 gm IV and SODIUM BICARBONATE 50 mEq IV.

Answer 19

* Do not take a blood pressure or establish IV access in an extremity with a shunt/fistula in place. * Access of a shunt or dialysis catheter in indicated only in the peri-arrest/cardiac arrest patient only when no other access is available. IO access should be attempted/utilized if available. * Consider hyperkalemia in all dialysis or renal failure patients. * Renal failure patients typically have multiple coexisting medical problems. Cardiac disease and hypertension are most prevalent in this population. * Sodium bicarbonate and calcium preparations are not compatible and should be given through separate IV lines if possible. If they must be administered via the same IV line, the line should be flushed in between the administration of each. * If locally applied pressure does not control hemorrhage from a dialysis fistula, a tourniquet should be utilized. The tourniquet should be applied as far away from the fistula as possible.

Answer 20

``` • New onset (<24 hours) ⃝ Unilateral motor weakness or paralysis (including facial droop) ⃝ Unilateral numbness ⃝ Speech/language disturbance ⃝ Visual disturbance ⃝ Abrupt gait disturbance ```

Answer 21

* Routine patient care. * Determine blood glucose level (bG) level, manage.. * Determine the time of symptom onset (the last time the patient was seen normal). Every effort should be made to be precise in this determination. If the patient awoke with neurologic symptoms and was normal when they went to sleep, the last time seen normal should be documented as the time they went to sleep. * Perform neurologic assessment and calculate the patient’s Los Angeles Motor Scale (LAMS) score [applies to new (<24 hours) neurologic deficits only]: Facial Droop Absent-0 Present-1 Arm Drift Absent-0 Drifts Down-1 Fall Rapidly-2 Grip Strength Normal-0 Weak grip-1 No Grip-2 * For patients with a LAMS score of ≥ 4 transport the patient to the nearest Comprehensive Stroke Center (CSC). * For patients with a LAMS score of 0-3, transport the patient to the nearest Primary Stroke Center (PSC) or Acute Stroke Ready Hospital (ASRH). * Provide early notification to the stroke center and include the LAMS score for all suspected ischemic stroke patients. A LAMS score of ≥ 4 is suggestive of an Emergent Large Vessel Occlusion (ELVO). Patients with ELVO are best managed by a combination of thrombolysis and emergent embolectomy. These are time sensitive interventions. Embolectomy is only available at CSCs. * On scene time should be limited to ≤ 10 minutes. * Provide the receiving facility with an early CODE STROKE alert. * If able, obtain the name of the patient’s next of kin/healthcare proxy and their contact information (cell phone, etc.). This information may be required to obtain consent for treatment at the receiving facility. * Attempt to determine if the patient is taking oral anticoagulants [warfarin (Coumadin), apixaban (Eliquis), dabigatran (Pradaxa), rivaroxaban (Xarelto), edoxaban (Savaysa)] and any recent history of surgery, trauma or seizures. * If established, IV access should be placed above the wrist (establishing IV access should not delay transport). * Paramedics may transport patients receiving fibrinolytic agents (tPA), NICARDAPINE and LABETALOL via IV infusion. Infusions of NICARDIPINE and LABETALOL may be titrated as per protocol 2.13 or following parameters set by the sending physician.

Answer 22

* Stroke requires time sensitive interventions. Each minute that passes during an acute stroke, approximately 2 million neurons are lost! * Establishing IV access in the field or during transport may expedite the time to intervention at the receiving center, however this should not delay transport. * The following conditions may mimic ischemic stroke: alcohol intoxication, cerebral infectious process, toxic ingestions, hypoglycemia, metabolic disorders, migraines, neuropathies (Bell’s palsy), seizures, post-seizure persistent neurological deficits (Todd’s paralysis), neoplasms, and hypertensive encephalopathy. * Right hemispheric strokes may present with dysarthria (slurred speech), left sided hemiparesis /paralysis, left sided neglect, right sided gaze preference. * Left hemispheric stroke may present with aphasia, impaired comprehension, right sided hemiparesis/paralysis, left gaze preference. * Brainstem strokes may present with nausea, vomiting, vertigo, impaired speech, dysphasia, abnormal eye movements, and decreased level of consciousness, crossed findings.

Answer 23

Transfer Only

Answer 24

• Anterior epistaxis is identified by blood draining primarily from one or both nares. • Posterior epistaxis is identified by the observation of blood draining into the posterior pharynx.

Answer 25

* For patients with significant or multisystem trauma, manage.. * Compress nostrils with direct pressure, tilt head forward, place patient in position of comfort. * If bleeding is not controlled, have patient blow their nose, suction active bleeding as required, insufflate OXYMETAZOLINE 2 sprays to the affected nostril, and follow by direct pressure. * Consider the need for airway management. * If the patient is hypotensive, also manage. * For uncontrolled bleeding, consider placement of nasal packing following the Nasal Packing Procedure Protocol. * All patients with nasal packing placed in the field will likely require prophylactic antibiotics and therefore require transport.

Answer 26

* It may be difficult to quantify the amount of blood loss with epistaxis. * 90% of nosebleeds are anterior in etiology, however posterior bleeding may be present. Evaluate for posterior by examining the posterior pharynx. * Obtain medication history in all patients with epistaxis. * Anticoagulants including warfarin (Coumadin), heparin, enoxaparin (Lovenox), dabigatran (Pradaxa), rivaroxaban (Xarelto), and many over the counter headache relief powders may contribute to bleeding. * Antiplatelet agents including ASA, clopidogrel (Plavix), ASA/dipyridamole (Aggrenox), and ticlopidine (Ticlid) may contribute to bleeding. * Oxymetazoline is contraindicated in patients with known coronary artery disease or those with a diastolic blood pressure > 110 . * Prolonged nasal packing has been associated with toxic shock syndrome.

Answer 27

• Body temperature ≥ 100.4°F / 38°C.

Answer 28

* Institute passive cooling (remove excessive clothing/bundling). * If no acetaminophen has been taken/administered in the last 4 hours, administer ACETAMINOPHEN 500-1000 mg PO. * If acetaminophen has been taken/administered in the last 4 hours and the body temperature is ≥ 100.4°F / 38°C, administer IBUPROFEN 400-800 mg PO. * If only IBUPROFEN has been administered in the last 6 hours and the body temperature is ≥ 100.4°F / 38°C, administer ACETAMINOPHEN 500-1000 mg PO. • As an alternative to ACETAMINOPHEN above, consider ACETAMINOPHEN 500-1000 mg IV.

Answer 29

* Ascertain medication allergies prior to administering any medications. An allergy to non- steroidal anti-inflammatory medications (NSAIDs) is a contraindication to the administration of ibuprofen. * Ibuprofen should not be administered to patients with preexisting renal disease/ insufficiency or that are pregnant. Administer Ibuprofen with caution in patients with dehydration. * Acetaminophen should not be administered to patients with liver disease. * Consider whether elevated temperature is due to “fever” (suspected infection) vs. an environmental heat emergency. * NSAIDs should not be administered in the setting of environmental heat emergencies. * Rehydration with fluids will increase the patient’s ability to sweat and may improve temperature control. * The primary goal of treating fever is increasing patient comfort vs. normalization of body temperature. Absent neurologic injury/insult (traumatic brain injury, CVA, post cardiac arrest states) there is no evidence that fever worsens illness.

Answer 30

• Body temperature ≥ 100.4°F / 38°C.

Answer 31

• Institute passive cooling (remove excessive clothing/bundling). • If no acetaminophen has been taken/administered in the last 4 hours, administer ACETAMINOPHEN 15 mg/kg PO/PR (1000 mg max) • If acetaminophen has been taken/administered in the last 4 hours and the body temperature is ≥ 100.4°F / 38°C, administer IBUPROPHEN 10 mg/kg PO (800 mg max) if patient is ≥6 months of age. • If only ibuprofen has been administered in the last 6 hours and the body temperature is ≥ 100.4°F / 38°C, administer ACETAMINOPHEN 15 mg/kg mg PO/ PR (max 1000 mg). • As an alternative to ACETAMINOPHEN above, consider ACETAMINOPHEN 15 mg/kg IV (1000 mg max single dose.

Answer 32

* All patients < 2 months of age with fever require a complete workup and should be transported to the hospital. * Ascertain medication allergies prior to administering any medications. Allergy to NSAIDs is a contraindication to the administration of ibuprofen. * Ibuprofen should not be administered to patients with preexisting renal disease/ insufficiency. Administer Ibuprofen with caution in patients with dehydration. * Acetaminophen should not be given to patients with liver disease. * Consider whether elevated temperature is due to “fever” (suspected infection) vs. an environmental heat emergency. * NSAIDs should not be administered in the setting of environmental heat emergencies. * Rehydration with fluids will increase the patient’s ability to sweat and may improve temperature control. * The primary goal of treating fever is increasing patient comfort vs. normalization of body temperature. Absent neurologic injury/insult (traumatic brain injury, CVA, post cardiac arrest states) there is no evidence that fever worsens illness.

Answer 33

• Newly born infant meeting any of the following criteria: ⃝ Less than term gestation (<37 weeks) ⃝ Not crying/breathing or has a HR <100 ⃝ Poor muscle tone ⃝ Labored breathing/gasping, or persistent (>5-10 min) central cyanosis

Answer 34

• Perform the following within the first 60 seconds of delivery: ⃝ Warm the infant and maintain normothermia. ⃝ Position the infant to establish and maintain a patent airway. ⃝ Clear airway secretions by suctioning with a bulb syringe or suction catheter only if secretions are copious and/or obstructing the airway or positive pressure ventilation is required. ⃝ Stimulate the infant. ⃝ Assess breathing and heart rate (HR) [HR should be assessed by the use of 3 lead ECG monitoring, alternative methods is by auscultation of the apical pulse or by palpating the base of the umbilical cord]. • If the infant’s HR is >100 bpm, but breathing is labored or there is persistent central cyanosis: ⃝ Reposition and clear the airway as indicated. ⃝Utilize pulse oximetry to assess oxygenation (SpO2 should be measured utilizing the right hand [pre-ductal]). ⃝ Provide supplemental oxygen if needed to achieve targeted preductal oxygen saturations as outlined in Table 1 below. ⃝ Monitor and reassess. If the infant becomes apneic, begins gasping or the HR decreases to <100, manage as below. • If the infant is apneic or gasping, or the HR is <100 bpm: ⃝ Provide positive pressure ventilation (PPV) at a rate of 40-60 bpm. ⃝ In term infants (>37 weeks), initial PPV may be provided with room air. ⃝ In infants of <35 weeks gestation, initial PPV should be provided with low concentration OXYGEN (<30%). Titrate supplemental oxygen to achieve targeted preductal oxygen saturations in Table 1 below. ⃝ Continue to monitor HR and provide PPV until the HR >100 bpm. ⃝ Supplemental oxygen should be titrated down as soon as possible. • If the HR is <60 bpm: ⃝ Provide PPV with supplemental OXYGEN at a rate of 40-60 bpm for a period of 30 seconds. If the HR increases to >60 bpm, but is <100 bpm, monitor HR and continue provide PPV until the HR is >100 bpm. ⃝ If the HR remains < 60 bpm after 30 seconds of PPV, provide external chest compressions following current AHA Guidelines for CPR and ECC (two thumb technique preferred, 3:1 ratio of compressions to ventilations with 90 compressions and 30 breaths to achieve approximately 120 events/minute). Infants requiring continued chest compressions should receive PPV with high concentration (FiO2 1.0) OXYGEN. ⃝ Reassess the HR every 60 seconds. If the heart rate fails to increase, check for adequate chest rise and take corrective actions as indicated. ⃝ Supplemental oxygen should be titrated down as soon as possible. • Calculate and document 1 and 5 minute APGAR Scores * Provide advanced airway management (ETI/BIAD) * Consider IV/UVC access as indicated by the clinical situation and response to therapy. * For patients requiring continued chest compressions, EPINEPHRINE (1:10,000) 0.01-0.03 mg/kg IV, repeat every 3-5 min. In the event IV access is not yet established, consider EPINEPHRINE (1:10,000) 0.05-0.10/kg via ETT (IV administration if preferred). * If hypovolemia is suspected (pale skin, poor perfusion, weak pulse, HR unresponsive to resuscitative measures), consider NS 10 ml/kg over 5-10 minutes (may repeat x1). * All critically ill neonates should have their bG determined. If hypoglycemia is present (bG <50 mg/dl), administer DEXTROSE 10% 2-4 ml/kg IV at 1 ml/min and recheck the bG. * Perform needle thoracostomy for suspected tension pneumothorax. ``` Table 1: Targeted Preductal SpO2 1 minute 60%-65% 2 minute 65%-70% 3 minute 70%-75% 4 minute 75%-80% 5 minute 80%-85% 10 minute 85%-95% ```

Answer 35

• Patients not meeting the above criteria should remain with the mother and be provided routine post-partum newborn infant care as outlined in the Obstetrical Delivery-Labor Protocol. • Pulse oximetry is inaccurate in determining heart rate during the first few minutes of life and should not be used for this purpose. • In uncompromised neonates, blood oxygen levels may not reach extra uterine levels until approximately 10 minutes after birth. • Attaching the SpO2 probe to the neonate before connecting the probe to the monitor may facilitate more rapid signal acquisition. • Preductal oxygen saturations are more representative of brain oxygenation. • Peripheral cyanosis affects the hands and feet and is caused by peripheral vasoconstriction. It is a common benign condition in the newborn. • Central cyanosis affects the mucous membranes, lips, skin, and nailbeds, should be considered pathological until proven otherwise. • Initiating resuscitation with high oxygen concentrations (≥65%) is not recommended and to reduce the risks associated with hyperoxia, supplemental oxygen concentrations should be weaned as soon as possible. • Infants born through meconium stained amniotic fluid who are vigorous with good respiratory effort and muscle tone may stay with the mother to receive the initial steps of newborn care. • Routine intubation for tracheal suctioning in the presence of meconium staining is not recommended. • When providing PPV, a manometer should be used to monitor the positive inspiratory pressure (PIP) delivered. An initial inflation pressure of 20 cmH20 may be effective, but ≥30-40 cmH20 may be required in some term infants without spontaneous breathing. • Risk for hypoglycemia include prematurity, small for gestational age, infant of a diabetic mother, stress or sickness. • A general rule of thumb for normal neonatal blood pressure is that the MAP should equal the gestational age in weeks. • Rapid administration of large volumes of resuscitation fluids neonates has been associated with intraventricular hemorrhage. Resuscitation fluids should be administered over 5-10 minutes. • Needle thoracostomy should be performed utilizing an 18, 20, or 22 gauge IV catheter (preferred) or a 23 or 25 gauge scalp vein (butterfly) needle.

Answer 36

• Obtain history: ⃝ Length of gestation and due date ⃝ Time of onset of contractions, intensity, duration and interval ⃝ +/- rupture of membranes ⃝ Gravida/para status ⃝ Presence of vaginal bleeding ⃝ High risk factors ⃝ Past medical history/medications ⃝ Use of narcotics within last 4 hours ⃝ +/- Prenatal care • Identify imminent delivery (+ rupture of membranes, contractions ≤ 2 minutes apart, crowning, urge to push or move bowels). • If imminent delivery is not identified or there is evidence of complications (breech, prolapsed umbilical cord), initiate transport, manage.. • If an uncomplicated imminent delivery is identified, stay on scene and immediately prepare to assist with delivery. ⃝ Position mother supine on flat surface, if possible. ⃝ Administer high flow oxygen. ⃝ Do not attempt to impair or delay delivery. ⃝ Support and control delivery of the head as it emerges. ⃝ Protect the perineum with gentle hand pressure. ⃝ After partial delivery of the head and prior to delivery of other fetal parts, suction the nasopharynx and oropharynx and perform a finger sweep of the fetal neck to check for the presence of a nuchal cord. ⃝ If a nuchal cord is identified, the cord should be disentangled by slipping the cord over the baby’s head. If disentanglement of the cord is not possible, the cord should be double-clamped and cut prior to further delivery efforts. ⃝ As the shoulders emerge, gently guide the head and neck downward to deliver the anterior shoulder. ⃝ Support and gently lift the head and neck to deliver the posterior shoulder. ⃝ If delivery is not progressing due to suspected shoulder dystocia, manage. ⃝ After delivery of the shoulders, the remainder of the fetus should deliver passively and with minimum difficulty. • Provide routine post-partum infant care as follows: ⃝ Wrap in infant in blanket, maintain normal temperature. ⃝ Suction the mouth and nose only if signs of obstruction are present. ⃝ If the infant is not vigorous, stimulate by flicking the soles of the feet and/or rubbing the infant’s back. ⃝ If the infant is not of term gestation, has poor tone, is not crying or breathing, is cyanotic or has a HR <100, double clamp and cut umbilical cord and manage. ⃝ For infants not requiring resuscitation, delay clamping and cutting the umbilical for 30 sec following delivery. Clamp the cord 6” from the infant’s abdominal wall. The infant should be maintained at the level of the uterus until the cord is clamped. ⃝ Allow infant to nurse. ⃝ Document 1 and 5 minute APGAR scores (see Table 1). ⃝ Transport newborn infant in appropriately sized child safety seat. • Provide maternal postpartum care: ⃝ Encourage the mother to deliver the placenta (placenta should deliver within 20-30 minutes). Do not pull on the umbilical cord to hasten delivery of the placenta. Once the placenta is delivered, note if it is intact and place in a plastic bag and transport it with the mother. ⃝ Inspect the perineum for tearing or bleeding; apply direct pressure with sanitary pads if indicated. ⃝ Manage postpartum hemorrhage (>500 ml estimated blood loss or blood loss with hemodynamic instability)

Answer 37

* Normal pregnancy is accompanied by higher heart rates and lower blood pressures. Shock will be manifested by signs of poor perfusion. * Labor can take 8-12 hours, but as little as 5 minutes if high PARA (the higher the PARA, the shorter the labor is likely to be). * High risk factors include: no prenatal care, drug use, teenage pregnancy, DM, HTN, cardiac disease, prior breech or C-section, preeclampsia, twins. * Newborns are prone to hypothermia which may lead to hypoglycemia, hypoxia, and lethargy. Aggressive warming techniques should be initiated including drying, swaddling, and warm blankets.

Answer 38

* Prolapsed umbilical cord: umbilical cord precedes the fetus. * Shoulder dystocia: failure of the fetal shoulder to deliver shortly after delivery of the head. * Malpresentation (breech): presentation of the fetal buttocks or legs. * 3rd trimester bleeding: vaginal bleeding occurring ≥ 28 weeks of gestation. * Postpartum hemorrhage: >500 ml estimated blood loss or blood loss with hemodynamic instability. * Preterm labor: onset of labor/contractions prior to the 37th week of gestation.

Answer 39

• Do not delay transport for patients with obstetrical complications. Provide early notification to the receiving facility. The following actions may not be feasible in every case, nor may every obstetrical complication be anticipated or effectively managed in the field. These should be considered “best advice” for rare, difficult scenarios. • Administer high-flow oxygen. • For prolapsed umbilical cord: ⃝ Discourage pushing by the mother. ⃝ Place the patient in the knee chest or Trendelenburg position. ⃝ Place a gloved hand in the mother’s vagina and decompress the umbilical cord by elevating the presenting fetal part off of the cord. ⃝ Feel for cord pulsation and monitor for fetal bradycardia (HR <120). ⃝ Keep the exposed cord moist and warm. Do not replace it. • For shoulder dystocia: ⃝ Discourage pushing by the mother. ⃝ Support the baby’s head, do not pull on it. Suction the nasopharynx and oropharynx as needed. ⃝ Place the patient in an extreme the knee chest position (McRoberts maneuver) and apply gentle suprapubic pressure with an open hand. ⃝ If the above method is unsuccessful, consider rolling the patient from her existing position to the all-fours position. Often, the shoulder will dislodge during the act of turning, so that this movement alone may be sufficient to dislodge the impaction. In addition, once the position change is completed, gravitational forces may aid in the disimpaction of the fetal shoulders. • For malpresentation (breech) delivery: ⃝ Transport unless delivery is imminent. ⃝ Support presenting parts (never attempt to pull the presenting parts). ⃝ If the legs have delivered, gently elevate the trunk and legs to aid delivery of the head. ⃝ If the head is not delivered within 30 seconds of the legs, place two fingers into the vagina to locate the infant’s mouth. Press the vaginal wall away from the infant’s mouth to maintain the fetal airway. ⃝ Apply gentle pressure to the uterine fundus. • For 3rd trimester bleeding: ⃝ Suspect placenta previa (placenta is implanted in the lower uterine segment) or placental abruption (placenta is separated from the uterine wall before delivery). ⃝ Do not perform a digital examination. ⃝ Place the patient in the left lateral recumbent position. ⃝ Manage hypotension or shock • If the infant is delivered, provide postpartum care. • For postpartum hemorrhage: ⃝ Provide vigorous fundal massage until the uterus is firm. ⃝ If possible, initiate infant nursing. ⃝ Treat hypotension or shock. • For seizures, manage. • For cardiac arrest in the pregnant patient (regardless of etiology): ⃝ Follow appropriate medical Cardiac Arrest Protocol(s) or Traumatic Cardiac Arrest Protocol. ⃝ For patients ≥ 20 weeks gestation or if the fundus is palpable at or above the level of the umbilicus, apply left lateral uterine displacement (LUD) with the patient in the supine position to decrease aortocaval compression. LUD should be maintained during CPR. If ROSC is achieved, the patient should be placed in the left lateral decubitus position or, if the patient is on a long spine board, the board can be wedged 15 degrees to the left. ⃝ IV access should be obtained above the diaphragm. ⃝ Consider rapid transport to the nearest Hospital Emergency Facility for possible peri-mortem cesarean delivery (PMCD). • Transport patient to the nearest appropriate Hospital Emergency Facility. • For preterm labor, consider: ⃝ NORMAL SALINE 20 ml/kg IV (may repeat x1). ⃝ MAGNESIUM SULFATE 4 gm IV over 20 min. ⃝ ALBUTEROL 2.5-5 mg via SVN. • For postpartum hemorrhage, after delivery of the placenta, PITOCIN 10 -20U IM (if not previously administered) followed by PITOCIN 20 units/1 L NS/LR at 40 mU/min. • For seizures in the pregnant patient (>20 weeks gestation), MAGNESIUM SULFATE 4 gm/IV over 10 min (may repeat 2 gm in 5 min).

Answer 40

* Shoulder dystocia usually occurs when the fetal anterior shoulder impacts against the maternal symphysis following delivery of the vertex. Less commonly, shoulder dystocia results from impaction of the posterior shoulder on the sacral promontory. * Placental abruption may present with mild, dark vaginal bleeding with abdominal pain/ uterine tenderness to massive hemorrhage and fetal demise. Because hemorrhage may occur into the abdominal/pelvic cavity, shock can develop despite relatively little visible (vaginal) bleeding. * Placenta previa is usually associated with painless, bright red vaginal bleeding and a non- tender, soft uterus. Unlike the case with abruption, placenta previa related hemorrhage passes through the vaginal outlet and is not occult. * Maternal hypotension is defined as a SBP < 100 or < 80% of baseline. * Maternal hypotension can result in decreased placental perfusion. * In the setting of pregnancy, HTN is defined as a SBP > 140 or a DBP > 90, or a relative increase of 30 systolic and 20 diastolic from the patient’s normal (pre-pregnancy) BP. * Severe headache, visual changes, edema, or RUQ pain may indicate preeclampsia. * Eclamptic seizures may occur up to two months post-partum. * For the pregnant patient in cardiopulmonary arrest, best outcomes for the mother and the fetus are achieved by aggressive maternal resuscitation. * Perform high quality CPR and follow appropriate Cardiac Arrest Protocols. * The most common causes of maternal cardiopulmonary arrest are hemorrhage, cardiovascular disease (MI, Aortic dissection, myocarditis), pulmonary embolism, amniotic fluid embolism, eclampsia and sepsis. * Aortocaval compression can occur at 20 weeks gestation. * At 20 weeks gestation the fundus is palpable at or above the umbilicus.

Answer 41

* Generalized or grand mal: loss of consciousness accompanied by bilateral tonic-clonic activity. * Petit mal: “absence” period in which patients are not fluently conversant and have diminished neurological status. * Focal or partial: seizure activity that is localized to one part of the body.

Answer 42

• Perform blood glucose (bG) analysis, manage. • Loosen any constrictive clothing, protect patient and providers. • If the patient has been prescribed DIAZEPAM rectal gel or MIDAZOLAM (IN or via auto-injector) assist the family or caregiver with administration following the prescribed instructions. • If the patient has a vagal nerve stimulator (VNS) device, assist family members or caregiver with use if needed. The VNS is activated by passing a magnet closely over the device. This may be repeated every 3-5 minutes for a total of 3 times. • For active generalized or focal seizures in the patient without IV access: MIDAZOLAM 10 mg IM or 2 mg IN. • For active generalized or focal seizures in the patient with IV access or the patient with seizure activity refractory to MIDAZOLAM as above: ⃝ LORAZEPAM 4 mg IV (repeat 2 mg every 3-5 minutes to a max of 10 mg) or ⃝ MIDAZOLAM 2.5 mg IV [5 mg IM or 2 mg IN] (repeat 2 mg every 3-5 minutes to a max of 20mg) or ⃝ DIAZEPAM 5 mg IV (repeat every 3-5 minutes to a max of 20 mg). • For seizures refractory to benzodiazepines, consider LEVETIRACETAM 20 mg/kg IV over 15 minutes (may repeat once). • For seizures in a known or suspected pregnant patient (> 20 weeks gestation), manage.

Answer 43

• Recommended exam: mental status, HEENT, cardiac, pulmonary, extremities, neurologic. • Do not delay medication administration to obtain vascular access. The IM/IN routes are preferred if there is no immediate IV access at the time of EMS contact. • Lorazepam is the first-line antiepileptic of choice if IV/IO access is available. • Diazepam has the longest half-life and the least desirable choice when other benzodiazepines are available. Diazepam may be administered rectally. • Respiratory depression may occur after the administration of benzodiazepines, monitor the patient closely and utilize waveform capnography if available. • Phenobarbital has additive respiratory depressant effects. • Status epilepticus (SE) is defined as two or more successive seizures without a period of consciousness or recovery, or one prolonged seizure lasting > 5 minutes. SE is a true emergency requiring rapid airway control and treatment. • For seizures in the pregnant patient, magnesium is the first line medication.

Answer 44

* Generalized or grand mal: loss of consciousness accompanied by bilateral tonic-clonic activity. * Petit mal: “absence” period in which patients are not fluently conversant and have diminished neurological status. * Focal or partial: seizure activity that is localized to one part of the body.

Answer 45

• Perform blood glucose (bG) analysis, manage. • Loosen any constrictive clothing, protect patient and providers. • For the patient with active generalized or focal seizures with a prescription for DIAZEPAM rectal gel or MIDAZOLAM (IN or via Auto-injector) assist the family or caregiver with administration following the prescribed instructions. • If the patient has a vagal nerve stimulator (VNS) device, assist family members or caregiver with use if needed. The VNS is activated by passing a magnet closely over the device. This may be repeated every 3-5 minutes x3. • For suspected febrile seizures (generalized seizures with no seizure history [except previous febrile seizures] in the setting of any grade fever, with an otherwise normal neurologic examination): ⃝ Obtain body temperature. ⃝ Passive cooling measures (undress patient). ⃝ ACETAMINOPHEN 15 mg/kg suppository PR if the temperature is ≥ 100.4. • For active generalized or focal seizures: ⃝ MIDAZOLAM 0.2 mg/kg IM/IN or 0.1 mg/kg IV [4 mg max single dose via any route)] (may repeat every 5 min to a max of 1 mg/kg) or ⃝ LORAZEPAM 0.1 mg/kg IV [4 mg max single dose] (may repeat every 5 minutes to a max of 0.5 mg/kg) or ⃝ DIAZEPAM 0.1 mg/kg IV [5 mg max single dose] or 0.5 mg/kg PR [20 mg max single dose] (may repeat every five minutes to a max of 1 mg/kg). • For persistent seizures, consider, if available, PHENOBARBITAL 20 mg/kg IV at rate of < 50 mg/min (may repeat 5 mg/kg IV every 5 minutes until seizure activity is terminated) or LEVETIRACETAM 20 mg/kg IV over 15 min (may repeat once).

Answer 46

* Recommended exam: mental status, HEENT, cardiac, pulmonary, extremities, neurologic. * Do not delay medication administration to obtain vascular access. The IM/IN route is preferred if no immediate IV access at the time of EMS contact. * Lorazepam is the first-line antiepileptic of choice if IV/IO access is available. * Diazepam has the longest half-life and the least desirable choice when other benzodiazepines are available. Diazepam may be administered rectally. * Respiratory depression may occur after the administration of benzodiazepines, monitor the patient closely and utilize waveform capnography if available. * Phenobarbital has additive respiratory depressant effects. * Status epilepticus (SE) is defined as two or more successive seizures without a period of consciousness or recovery, or one prolonged seizure lasting > 5 minutes. SE is a true emergency requiring rapid airway control and treatment. * A focal to generalized seizure starts in one area and generalizes to the whole body. * The area where the seizure starts is typically the last to resolve. Knowing this focality is helpful.

Answer 47

* This protocol applies to undifferentiated, hypovolemic, obstructive, cardiogenic, and neurogenic shock. * Restlessness, confusion, pale and cool clammy skin. * Weak, rapid pulse, hypotension (SBP <90 or MAP <65) or shock index (HR/SBP) ≥0.6. * Hypovolemic: history of volume loss (vomiting, diarrhea). * Obstructive: history of chest trauma, JVD, absent breath sounds, narrow pulse pressure, history of DVT, risk factors for pulmonary embolus. * Cardiogenic: STEMI, heart failure, dysrhythmias, bradycardia or tachycardia. * Neurogenic: spinal cord injury with hypotension, warm & dry skin with a normal or bradycardic heart rate.

Answer 48

* Manage suspected obstructive shock per protocols specific to etiology (e.g. Multiple Trauma Protocol for suspected tension pneumothorax). * If tolerated, maintain patient in a supine position. * Maintain and promote normothermia by use of and increasing the ambient temperature if possible. • For undifferentiated and hypovolemic shock: ⃝ LACTATED RINGER’S 500 ml IV, repeat to achieve a SBP of ≥100 or MAP of ≥65 (max 2L). ⃝ For persistent hypotension following 2L of IVF, push dose EPINEPHRINE 10-20 mcg IV every 3-5 minutes or push dose PHENYLEPHRINE 100 mcg every 10 min [max dose 500 mcg] or NOREPINEPHRINE 2-20 mcg/minute or DOPAMINE HCL 2 -20 mcg/kg/min or PHENYLEPHRINE 10-180 mcg/min or EPINEPHRINE 0.1-0.5 mcg/kg/min. Titrate vasopressors to achieve a SBP of ≥100 or MAP ≥65. • For post arrest hypotension: ⃝ LACTATED RINGER’S 250-500 ml IV, repeat to achieve a SBP of ≥100 or MAP of ≥65 (max 2L). ⃝ Push dose EPINEPHRINE 10-20 mcg IV every 3-5 minutes or push dose PHENYLEPHRINE 100 mcg every 10 min [max dose 500 mcg] or NOREPINEPHRINE 2-20 mcg/minute or DOPAMINE HCL 2-20 mcg/kg/min or PHENYLEPHRINE 10-180 mcg/min or EPINEPHRINE 0.1-0.5 mcg/kg/min. Titrate vasopressors to achieve a SBP of ≥100 or MAP ≥65. • For cardiogenic shock: ⃝ LACTATED RINGER’S 250 ml IV, (do not administer IVF if there is shortness of breath or evidence of pulmonary edema/CHF), repeat x1 if needed to achieve SBP ≥100 or MAP ≥65. ⃝ NOREPINEPHRINE 2-20 mcg/min (preferred) or DOPAMINE HCL 2-20 mcg/kg/ min. Titrate vasopressors to achieve a SBP ≥100 or MAP ≥65. • For neurogenic shock: ⃝ LACTATED RINGER’S 500 ml IV, repeat to achieve a SBP of ≥100 or MAP of ≥65. ⃝ For persistent hypotension following the administration of 2L of IVF, PHENYLEPHRINE 10-180 mcg/min or NOREPINEPHRINE 2-20 mcg/min or DOPAMINE HCL 2-20 mcg/kg/min. Titrate vasopressors to achieve a SBP ≥100 or MAP ≥65 • If adrenal insufficiency is suspected, also manage per the Adrenal Insufficiency Protocol.

Answer 49

• Shock is a state in which inadequate tissue perfusion impairs cellular metabolism. • Shock may be present with a normal blood pressure. • Blood pressure and heart rate individually are unreliable determinants of hypovolemic shock. • The systolic blood pressure must be evaluated in the context of the patient’s normal blood pressure. Patients with a history of long standing hypertension often require a higher MAP to maintain perfusion pressures. • Consider all possible etiologies of undifferentiated hypotension/shock and treat accordingly per appropriate protocols. • Patients at increased risk for adrenal insufficiency (AI) include those with HIV/AIDS, a history of chronic steroid use (current, recently discontinued or remote), Addison’s disease, or dehydration. • The use of the Trendelenburg position (head down, feet elevated) should be avoided. • The use of push-dose phenylephrine allows for the rapid correction of acute hypotension and as bridge to the administration of a vasopressor via IV infusion.

Answer 50

* This protocol applies to undifferentiated, hypovolemic, obstructive, cardiogenic, and neurogenic shock. * Restlessness, confusion, pale and cool clammy skin, prolonged capillary refill (CRT) * Weak, rapid pulse, hypotension (SBP <70 + [age in years x2] mmHg) [Neonates SBP <60 mmHg, 1 m.o. to 1 yr. SBP <70 mmHg]. * Hypovolemic: history of volume loss (vomiting, diarrhea). * Obstructive: history of chest trauma, JVD, absent breath sounds, narrow pulse pressure, history of DVT, risk factors for pulmonary embolus. * Cardiogenic: STEMI, heart failure, dysrhythmias. * Neurogenic: spinal cord injury with hypotension, warm and dry skin with a normal or bradycardic heart rate.

Answer 51

* Treat suspected obstructive shock per age appropriate protocol specific to etiology (e.g. Multiple Trauma Protocol for suspected tension pneumothorax). * If tolerated, maintain patient in a supine position. * Maintain and promote normothermia by use of blankets and increasing the ambient temperature if possible. • For undifferentiated and hypovolemic shock: • LACTATED RINGER’S 20 ml/kg IV (10 ml/kg if < 3 months old), repeat to achieve age appropriate BP (max 60 ml/kg). Do not administer IV fluids if signs of fluid overload (crackles) develop. ⃝ For persistent hypotension following the administration of 60 ml/kg of IVF, consider push dose EPINEPHRINE 1 mcg/kg IV (0.1 ml/kg EPINEPHRINE 10 mcg/ml) every 3-5 minutes or push dose PHENYLEPHRINE 5 mcg/kg [max single dose 100 mcg] every 10 min [max total dose 500 mcg] or NOREPINEPHRINE 0.1-2 mcg/kg/ min or EPINEPHRINE by IV infusion at 0.01-1 mcg/kg/min. Titrate vasopressors to achieve age appropriate BP. • For cardiogenic shock, consider DOPAMINE 2-20 mcg/kg/min titrated to achieve age appropriate BP. • For neurogenic shock: • LACTATED RINGER’S 20 ml/kg IV (10 ml/kg if < 3 months old), repeat to achieve age appropriate BP [max 60 ml/kg]. Do not administer IV fluids if signs of fluid overload (crackles) develop. ⃝ For persistent hypotension following the administration of 60 ml/kg of IVF, consider NOREPINEPHRINE 0.1-2 mcg/kg/min or EPINEPHRINE 0.01-1 mcg/kg/min. Titrate vasopressors to achieve age appropriate BP. • If adrenal insufficiency is suspected, also manage per the Adrenal Insufficiency Protocol.

Answer 52

• Shock is a state in which inadequate tissue perfusion impairs cellular metabolism. • Shock may be present with a normal blood pressure. • Blood pressure and heart rate individually are unreliable determinants of hypovolemic shock. • The systolic blood pressure must be evaluated in the context of the patient’s normal blood pressure. Patients with a history of long standing hypertension often require a higher MAP to maintain perfusion pressures. • Consider all possible etiologies of undifferentiated hypotension/shock and treat accordingly per appropriate protocol. • Patients at increased risk for adrenal insufficiency (AI) include those with HIV/AIDS, a history of chronic steroid use (current, recently discontinued or remote), Addison’s Disease, or dehydration. • The use of the Trendelenburg position (head down, feet elevated) should be avoided.

Answer 53

* Restlessness, confusion, pale and cool clammy skin. * Weak, rapid pulse, hypotension (SBP <90 mmHg or MAP <65 mmHg) or shock index (HR/SBP) ≥0.6. * External hemorrhage or overt or suspected occult internal hemorrhage (blunt trauma, GI bleeding, vaginal bleeding, suspected ruptured ectopic pregnancy, ruptured AAA).

Answer 54

* Control external hemorrhage. * If tolerated, maintain patient in a supine position. * Maintain and promote normothermia by use of blankets, heat reflective shield, and increasing the ambient temperature if possible. • For hemorrhagic shock related to external hemorrhage: ⃝ Once hemorrhage control is achieved, LACTATED RINGER’S 500 ml IV, repeat as needed to achieve a SBP ≥90 or MAP ≥65 (max 2L). ⃝ For patients with penetrating torso trauma and NO evidence of traumatic brain injury, LACTATED RINGER’S 250 ml IV, repeat to achieve a palpable radial pulse or a SBP ~80 or MAP ≥65 or normal mental status (max 2L). ⃝ For patients with penetrating torso trauma with evidence of traumatic brain injury, LACTATED RINGER’S 250-500 ml IV, repeat to achieve a SBP ≥90 or MAP ≥65 (max 2L). ⃝ For persistent hypotension following the administration of 2L of IVF, consider push dose EPINEPHRINE 10-20 mcg (1-2 ml Epinephrine 10 mcg/ml) IV every 3-5 min or push dose PHENYLEPHRINE 100 mcg IV every 10 min [max dose 500 mcg] or NOREPINEPHRINE 2-20 mcg/min or EPINEPHRINE at 0.1-0.5 mcg/ kg/min. Titrate vasopressors to achieve a SBP of ≥90 or MAP ≥65. Vasopressors should only be considered AFTER the administration of 2L IVF and in the peri-arrest patient. • For patients with blunt or penetrating trauma (including extremity trauma) with signs of significant hemorrhage (SBP < 90 mm Hg, HR > 110 BPM); or any patient who considered in paramedic judgment to be at high risk of significant hemorrhage (external or internal), administer TRANEXAMIC ACID 1gm/100 ml NS IV as soon as possible, but not >3 hours after injury. • For hemorrhagic shock related to internal hemorrhage: ⃝ LACTATED RINGER’S 500 ml IV, repeat to achieve a SBP ≥90 or MAP ≥65 (max 2L). ⃝ For hypotension refractory to 2L IVF, consider push dose EPINEPHRINE 10-20 mcg IV every 3-5 min or push dose PHENYLEPHRINE 100 mcg every 10 min [max dose 500 mcg] or NOREPINEPHRINE 2-20 mcg/min or PHENYLEPHRINE 10-180 mcg/min or EPINEPHRINE 0.1-0.5 mcg/kg/min. Titrate vasopressors to achieve a SBP of ≥90 or MAP ≥65. Vasopressors should only be considered AFTER the administration of 2L IVF. • If adrenal insufficiency is suspected, also manage.

Answer 55

• Shock is a state in which inadequate tissue perfusion impairs cellular metabolism. • Shock may be present with a normal blood pressure. • Blood pressure and heart rate individually are unreliable determinants of hypovolemic shock. • The systolic blood pressure must be evaluated in the context of the patient’s normal blood pressure. Patients with a history of long standing hypertension often require a higher MAP to maintain perfusion pressures. • Permissive hypotension (hypotensive resuscitation) is indicated in patients with penetrating torso trauma. • Consider all possible etiologies of hypotension/shock and treat accordingly. • Etiologies of internal hemorrhage include GI or vaginal bleeding, suspected ruptured ectopic pregnancy or AAA and blunt trauma. • Vasopressors are indicated as a bridge to surgical intervention in hemorrhagic shock only after adequate volume resuscitation and in the peri-arrest patient. • Patients at increased risk for adrenal insufficiency (AI) include those with HIV/AIDS, a history of chronic steroid use (current, recently discontinued or remote), Addison’s disease, congenital adrenal hyperplasia (CAH) or dehydration. • The use of the Trendelenburg position (head down, feet elevated) should be avoided. • If tranexamic acid is administered, it is imperative that the receiving facility acknowledges the time of administration (there is a time window for the administration of a 2nd dose).

Answer 56

* Compensated: normal blood pressure, decreased distal pulses, delayed CRT, tachycardia, cool extremities, tachypnea, restlessness, +/- altered mental status. * Uncompensated: Hypotension (SBP < 70 + [age in years x2] mmHg. * External hemorrhage or overt or suspected occult internal hemorrhage (blunt trauma, GI bleeding). * For newborns the lower limit for SBP is <60, for children 1 mo to 1 yr. the lower limit for SBP is <70.

Answer 57

* Control external hemorrhage following the External Hemorrhage Control Protocol. * If tolerated, maintain patient in a supine position. * Maintain and promote normothermia by use of blankets and increasing the ambient temperature if possible. * LACTATED RINGER’S 20 ml/kg, repeat to achieve age appropriate BP (max 60 ml/ kg). * For patients with blunt or penetrating trauma (including extremity trauma) with signs of significant hemorrhage (age specific hypotension, tachycardia); or who are considered in paramedic judgment to be at high risk of significant hemorrhage (external or internal), administer TRANEXAMIC ACID as soon as possible, but not >3 hours after injury as follows: for patients < 12 yo, administer 15 mg/kg (max 1 gm) in 100 ml NS IV and for patients >12 yo, administer 1 gm/100 ml NS. * For persistent hypotension following the administration of 60 ml/kg of IV fluids, consider push dose EPINEPHRINE 1 mcg/kg IV (0.1 ml/kg Epinephrine 10 mcg/ml) every 3-5 min or push dose PHENYLEPHRINE 5 mcg/kg [max single dose 100 mcg] every 10 min [max total dose 500 mcg] or EPINEPHRINE by IV infusion at 0.01-1 mcg/kg/min or NOREPINEPHRINE 0.1-2 mcg/kg/min IV. Titrate vasopressors to achieve age appropriate BP. * If adrenal insufficiency is suspected, manage.

Answer 58

* Shock is a state in which inadequate tissue perfusion impairs cellular metabolism. * Shock may be present with a normal blood pressure. * Children maintain BP and cardiac output by increasing HR and vasoconstriction, even with the loss of significant volume. * A child can lose up to 1/3 of his/her blood volume before a significant drop in BP occurs. * Pediatric hypotension should be viewed as a “pre-arrest state”. * Use of an appropriate size BP cuff is crucial as use of an incorrectly sized cuff will lead to inaccurate measurement of the BP (i.e. too small = falsely ↑BP, too large = falsely ↓ BP). * Possible etiologies of internal hemorrhage include GI or vaginal bleeding, suspected rupture ectopic pregnancy or AAA and blunt trauma. * Consider all possible etiologies of undifferentiated hypotension/shock and treat. * Vasopressors are indicated as a bridge to surgical intervention in hemorrhagic shock only after adequate volume resuscitation and in the peri-arrest patient. * The use of the Trendelenburg position (head down, feet elevated) should be avoided. * Patients at increased risk for adrenal insufficiency (AI) include those with HIV/AIDS, a history of chronic steroid use (current, recently discontinued or remote), Addison’s Disease, congenital adrenal hyperplasia (CAH) or dehydration.

Answer 59

• Sepsis is defined as life threatening organ dysfunction caused by a dysregulated host response to infection (the body’s response to an infection injures its own tissues and organs). It is identified when a patient with a known infection (pneumonia, urinary tract, intra-abdominal, biliary, skin/soft tissue, etc.) or with findings suggestive of infection (fever [T≥100.4°F/38°C], cough, presence of a wound with signs of infection, etc.) has ≥2 of the following: 1. Respiratory rate ≥22/min 2. AMS or increasing mental status change with previously AMS 3. Systolic BP ≤100 • Septic shock is identified when a patient with sepsis, despite adequate fluid resuscitation requires vasopressors to maintain a SBP ≥100 or a MAP ≥65 and has a serum (fingertip) lactate >2 mmol/L or an EtCO2 ≤25 mmHg.

Answer 60

* If tolerated, maintain patient in a supine position. * Provide early notification to destination facility and declare a SEPSIS ALERT. * LACTATED RINGER’S 500 ml IV bolus, repeat to achieve a SBP ≥100 or MAP of ≥65 (max 3L) * For hypotension refractory to IVF, push dose EPINEPHRINE 10-20 mcg (1-2 ml EPINEPHRINE 10 mcg/ml) IV every 3-5 min or push dose PHENYLEPHRINE 100 mcg IV every 10 minutes [max dose 500 mcg] or NOREPINEPHRINE 2-20 mcg/min (preferred) or DOPAMINE HCL 2-20 mcg/kg/min or PHENYLEPHRINE 10-180 mcg/min or EPINEPHRINE 0.1-0.5 mcg/kg/min. Titrate vasopressors to achieve a SBP of ≥100 or MAP ≥65.

Answer 61

* Shock may be present with a normal blood pressure. * The qSOFA (quick sequential organ failure score) [MS, RR, SBP] is an abbreviated version of a larger scoring system (SOFA) used to identify organ failure. * Assess for signs of pulmonary edema, especially patients with a known history of CHF, or ESRD on dialysis, stop fluid administration if pulmonary edema develops. * The systolic blood pressure must be evaluated in the context of the patient’s normal blood pressure. Patients with a history of long standing hypertension often require a higher MAP to maintain perfusion pressures. * EtCO2 correlates to serum lactate levels. An EtCO2 of ≤25 mmHg is strongly correlated to a serum lactate of 4.0 mm/L. * Septic shock has a 50% mortality rate and must be treated aggressively. Early goal directed therapy consisting of IV fluid administration and early antibiotics reduces mortality in septic patients. * Common sites/sources for infection include the urinary tract, lungs, skin, GI tract and indwelling catheters and devices. * Patients with sepsis are at an increased risk for acute lung injury (ALI) related to positive pressure ventilation. If positive pressure ventilation is required, avoid excessive tidal volumes. * Patients at increased risk for adrenal insufficiency (AI) include those with HIV/AIDS, a history of chronic steroid use (current, recently discontinued or remote), Addison’s Disease, congenital adrenal hyperplasia or dehydration.

Answer 62

• Suspected or known infectious process and temperature abnormality (>38.5°C or <36.0°C ) and a heart rate greater than normal for age (see Table 1 below) and one of the following: 1. Mental status abnormality (includes anxiety, restlessness, agitation, irritability, inappropriate crying, drowsiness, confusion, lethargy, obtundation). 2. Perfusion abnormality (mottled or cool extremities, capillary refill time (CRT) <1 sec (flash) or > 3 sec, warm extremities, bounding pulse, SBP < 70 + 2x age in years)*. 3. High risk condition (<56 days of life, BMT or solid organ x-plant, immune compromise, asplenia, sickle cell disease, malignancy). 4. EtCO2 <25 mmHg. 5. Finger stick lactate level >4 mmol/L. • For newborns the lower limit for SBP is <60, for children 1 mo to 1 yr. the lower limit for SBP is <70. ``` Age Tachycardia 1 mo - 1 yr > 180 2 - 5 yr > 140 6 - 12 yr > 130 13-18 yr > 120 ```

Answer 63

* If tolerated, maintain patient in a supine position. * Perform blood glucose analysis, manage. * Provide early notification to destination facility and declare a SEPSIS ALERT. * LACTATED RINGER’S 20 ml/kg IV (10 ml/kg if < 3 months old), repeat to achieve age appropriate BP (max 60ml/kg). Do not administer IV fluids if signs of fluid overload (crackles) develop. * For patients with cold shock and continued hypotension or other evidence of hypoperfusion, consider push dose EPINEPHRINE 1 mcg/kg IV (0.1 ml/kg EPINEPHRINE 10 mcg/ml) every 3-5 minutes or EPINEPHRINE 0.1-1.0 mcg/kg/min titrated to achieve age appropriate BP. * For patients with warm shock and continued hypotension or other evidence of hypoperfusion, consider NOREPINEPHRINE 0.1-2 mcg/kg/min titrated to achieve age appropriate BP. * If adrenal insufficiency is suspected, manage per the Adrenal Insufficiency Protocol.

Answer 64

• Shock is state in which inadequate tissue perfusion impairs cellular metabolism. • Shock may be present with a normal blood pressure. • Tachycardia and tachypnea are early signs of shock in children. • Children maintain BP and cardiac output by increasing HR and vasoconstriction, even with the loss of significant volume. • Heart rate is affected by pain, anxiety, medications, and hydration status. • Heart rate may not be elevated in septic hypothermic patients. • Septic shock has a 50% mortality rate and must be treated aggressively. Early goal directed therapy consisting of IV fluid administration and early antibiotics reduces mortality in septic patients. • Common sites/sources for infection include the urinary tract, lungs, skin, GI tract and indwelling catheters and devices. • Systemic inflammatory response syndrome (SIRS) is a clinical syndrome that results from a deregulated inflammatory response or to a noninfectious insult. • EtCO2 correlates to serum lactate levels. An EtCO2 of ≤25 mmHg is strongly correlated to a serum lactate of 4.0 mm/L. • Common sites/sources for infection include the urinary tract, lungs, skin, GI tract and indwelling catheters and devices. • Cold shock = CRT >3 sec, diminished peripheral pulses, mottled or cool extremities. • Warm shock = CRT <1 sec, bounding peripheral pulses, wide pulse pressure, warm/flushed extremities. • Patients with sepsis are at an increased risk for acute lung injury (ALI) related to positive pressure ventilation. If positive pressure ventilation is required, avoid excessive tidal volumes. • Patients at increased risk for adrenal insufficiency (AI) include those with HIV/AIDS, a history of chronic steroid use (current, recently discontinued or remote), Addison’s disease, or dehydration. • In smaller patients (<10-20 kg) rapid boluses may be most easily administer in a 60 ml syringe utilizing the push/pull method.

Answer 65

* Sickle cell crisis occurs in patients with sickle cell disease (a family of diseases including a hemolytic anemia known as sickle cell anemia). * Acute pain (often described as sharp, intense, stabbing, or throbbing) in any part of the body, but most commonly in the joints, lower back, legs, arms, abdomen, or chest. * Patients may also present with stroke, priapism, acute chest syndrome (fever, chest pain, hypoxemia, respiratory symptoms) skin ulcerations, or ocular manifestations. * In young children, additional presentations include dactylitis (swollen digits), splenic sequestration (enlarged spleen, pallor, hypotension) and aplastic crisis (bone marrow shutdown, noted by pallor)

Answer 66

* Consider the administration of supplemental OXYGEN. * Treat patients with suspected stroke per Ischemic Stroke Protocol. * Consider analgesia. * NORMAL SALINE 20 ml/kg IV if the patient appears dehydrated.

Answer 67

* Most of the manifestations of sickle cell crisis are secondary to vascular occlusion and inflammation. * Sickle cell crisis may be precipitated by a number of physical and environmental factors. Treat any identified possible precipitating factors. * Pulse oximetry may be unreliable in patients with sickle cell crisis. * Patients with sickle cell disease are at high risk for life threatening disorders at a very young age.

Answer 68

• Transient, self-limited loss of consciousness with an inability to maintain postural tone that is followed by spontaneous recovery.

Answer 69

* Consider Spinal Motion Restriction Precautions. * Perform blood glucose (bG) analysis, treat. * Assess for traumatic injuries if associated with a fall. * If patient is hypotensive, manage. * Acquire a multi-lead ECG, manage. * Institute continuous ECG monitoring.

Answer 70

* History and physical examination are the most specific and sensitive ways of evaluating syncope. * Patients with any of the following require a thorough in hospital work-up: exertional onset, chest pain, dyspnea, back pain, palpitations, severe headache, focal neurologic deficits, diplopia, ataxia, or dysarthria. * Consider all syncope to be of cardiac origin until proven otherwise. * While often thought as benign, syncope can be the sign of more serious medical emergency. * Syncope that occurs during exercise often indicates an ominous cardiac cause. Patients should be evaluated at the ED. Syncope that occurs following exercise is almost always vasovagal and benign. * Prolonged QTc (generally >500ms) and Brugada Syndrome (incomplete RBBB pattern in V1/V2 with ST segment elevation) should be considered in all patients. Consider vasovagal response, GI bleed, dysrhythmia, ectopic pregnancy and aortic aneurysm or dissection as possible causes of syncope. * Greater than 25% of geriatric syncope is cardiac dysrhythmia related.

Answer 71

• Individual ≥16 yo exhibiting bizarre and aggressive behavior including agitation and ≥6 of the following; increased tolerance to pain, tachypnea, diaphoresis, agitation, warm/hot skin to touch, non-compliance to police presence/commands, absence of fatigue, unusual strength, naked or dressed inappropriately for conditions, unusual attraction to glass or mirrors, or keening (unintelligible animal like noises). ExDS is often associated with the chronic use of sympathomimetic drugs (cocaine, methamphetamine, PCP).

Answer 72

* Control and/or restrain patient as soon as possible to reduce the risks of prolonged struggle. Physical restraint should be performed/assisted by law enforcement when available. If restraints are applied by EMS practitioners, follow the Patient Restraint Procedure Protocol. * Remove/limit unnecessary stimuli where possible, including warning lights/sirens. * Manage per appropriate protocols as indicated (Altered Mental Status, Patient in Police Custody). * KETAMINE (preferred) 4 mg/kg IM (max 400 mg) or 2 mg/kg IV (max 200 mg) or HALOPERIDOL 5-10 mg IM/IV (may repeat x1) or MIDAZOLAM 2.5-5 mg IV [5 mg IM/IN] (may repeat if SBP >100 to max of 10 mg). * Initiate continuous monitoring of EtCO2, SpO2 and ECG. * If sedation is required subsequent to KETAMINE administration, MIDAZOLAM 2.5 mg IV. * For hypersalivation following KETAMINE administration, ATROPINE SULFATE 0.5 mg IV//IM. * NORMAL SALINE 1000 ml IV (may repeat x1). * Initiate cooling measures if temperature >101°F. * In the event of cardiac arrest, SODIUM BICARBONATE 50 mEq IV and manage..

Answer 73

• Be sure to consider all possible medical/trauma etiologies for behavior (hypoglycemia, toxicological, hypoxic, head injury). • Risk factors associated with excited delirium syndrome include male gender (average age 36), stimulant drug abuse (cocaine and to a lesser extent methamphetamine, PCP, and LSD), history of chronic stimulant drug abuse with recent acute bridge, and preexisting psychiatric disorder (schizophrenia, bipolar disorder). • Do not position or transport any restrained patient in such a way (e.g. prone) that could negatively affect the patient’s respiratory or circulatory status. • Any patient who is handcuffed or restrained by law enforcement and transported by EMS must be accompanied by a law enforcement officer. • For IM administration, a 100 mg/ml concentration of Ketamine is preferred. • Ketamine in a concentration of 100 mg/ml must be diluted 1:1 with 0.9% saline, D5W or sterile water creating a 50 mg/ml concentration prior to IV use. • When administered IV, Ketamine should be administered slowly (over a period of 60 seconds). More rapid administration may result in respiratory depression and enhanced pressor response. • While uncommon with doses ≤4 mg/kg, laryngospasm may occur following the administration of ketamine, it is usually easily managed with positive pressure ventilation. • Continuous monitoring of waveform EtCO2 and SpO2 are mandatory in patients who have received midazolam or ketamine for sedation. When clinically feasible, ECG monitoring is required for patients that have received droperidol or haloperidol. • It may be necessary/appropriate to administer IM injections through clothing in extremely agitated patients. • Patients with ExDS are at risk for acidosis, rhabdomyolysis and hyperkalemia.