Sim prep Flashcards
Interventions for someone with abdominal pain
- Administer prophylactic antiemetics
- Maintain NPO status
- Place NG tube prior to flight for patient with suspected or diagnosed bowel obstruction for changes in altitude
When should a FAST exam be considered on a patient with abdominal pain
- patients with abdominal trauma
- pregnant patients who present with lower abdominal pain with or without vaginal bleeding
What should be anticipated with potential for solid organ injury
hypovolemia
What should be considered for patients with hollow organ rupture
low altitude flight path
What can abdominal pain indicate in pediatric patients
pneumonia
STEMI criteria
ST segment elevation in two or more continuous leads:
- 2 mm or more in V2/V3
- 1 mm or more in all other leads
when to perform serial 12 lead EKGs on patients
continued complaint of ACS or prolonged transport time to evaluate potential evolving cardiac events
Nitro administration with a suspected inferior MI
administer 250 ml LR bolus prior to administering NTG unless SBP above 150. repeated boluses may be indicated to maintain SBP over 100. Ongoing pulmonary assessment for development of pulmonary edema
nitro administration if not evidence of an inferior MI
if SBP above 100 give NNTG as needed or initiate NTG infusion
NTG SL dose
0.4 mg Q5 min
NTG infusion range
5-200 mcg/min
What is the NTG drip titrated to?
chest pain relief while maintaining SBP above 100
ASA administration in ACS
administer 324 mg. withhold ASA if taken within the last 4 hours. Administer supplemental dose if full 324 not taken within 4 hours
Pain medications and doses if not relieved with NTG
Fentanyl: 1-2 mcg/kg IVP q 5min
Morphine: 2-5 mg Q5 min
Max single dose for ACS fentanyl
100 mcg
Interventions for ACS if SBP above 140 and HR above 100
Metoprolol 5 mg IVP Q15 x3
parameters for ongoing metoprolol administration with ACS
maintain SBP above 90 and HR above 60
What to consider for symptomatic sinus bradycardia associated with inferior wall MI
Epi infusion
Epi infusion dose
0-0.5 mcg/kg/min (IBW)
Epi infusion concentration
1 mg/100 ml
Heparin administration dose bolus and gtt
Bolus: 60 u/kg max dose 5000 units
infusion: 12 u/kg/hr rounded to nearest 50 units, max 1000 units/hr
Heparin gtt concentration
5000 units/250 NS
Contraindications to administer Heparin
- Patient received low molecular weight heparin
- INR over 2.5
- Evidence of bleeding, such as extensive bruising, hematemesis, melon, history of intracranial bleed or evidence of hepatic failure
What to do if patient is taking or has received an anticoagulant other than heparin with ACS
consult medical control
heparin orders with TNK administration
obtain orders for heparin prior to administration if patient received TNK
when to consider performing a right sided 12 lead EKG
for all patient who present with inferior elevation to assess right sided ventricular involvement (V4R)
Transient vs permanent heart blocks for ACS patients
Mobitz 1 associated with inferior wall MI and typically transient
Mobitz 2 or type 3 associated with anterior wall MI and is typically permanent
what intervention should be considered for patients in heart blocks
pacer pads
vent modes used for ARDS
either volume or pressure control modes
goal parameter for vents
PPlat below 30
PEEP parameters without an order for adult and peds
adult up to 14
pediatric up to 10
what to do if PEEP above 14
if from sending facility may continue per sending MD
goal SpO2 for ARDS
above 88%
Parameters to consider paralyzing
PEEP above 12 and FiO2 above 100%
Roc bolus dose and frequence
1 mg/kg Q30 minutes
requirements for ARDS diagnosis
bilateral diffuse infiltrates on imaging, PaO2:FiO2 ratio less than 300, acute onset (< 1 week), cause felt not to be fluid overload related
ARDS CVP goals
4-8
Inhaled medications that should not be abruptly stopped
Flolan or Nitric Oxide
what should be done after 2 failed intubation attempts
an alternate airway
Goal sat during intubation attempts
90 or above
what VS must be documented during an intubation
the lowest sat reading
steps to confirm ETT placement (5 parameters)
- visualization of ETT going through cords
- Appropriate capnography waveform within 30 seconds of airway placement, ETCO2 greater than 10
- visible chest rise
- bilateral breath sounds
- absent epigastric sounds
If unable to insert ETT/LMA but able to maintain sats with BVM how should the patient be transported
set PEEP valve between 3-8, and ventilate with BVM
If unable to ventilate a patient with BVM and failed airway attempts, what intervention is done
surgical cricothyrotomy is considered in adult patients
what airway intervention is performed after failed intubations and unable to ventilate with BVM for pediatric patients
needle cricothyrotomy for patients less than 12 years old
Interventions to have in place for intubated patients
ETCO2
Consider NG/OG
elevate HOB
what clinical findings are necessary to require RSI
intact gag reflex
trismus
GCS 8 or less
OBLEAK SCENE
oxygen/opa/npa
bougie
LMA
ETT
Ambu bag
Cmac
Suction
Commercial securing device
End tidal
paralytic
sedative
What interventions to utilize prior to intubation if shock index is >1
ensure patient is adequately resuscitated with IV fluids
utilize push dose epi as needed
consider using hemodynamically stable induction agents like Etomidate or Ketamine at reduced dose
push dose epi range (adult and peds)
5-20 mcg Q1-5 minutes
1 mcg/kg (max 20 mcg)
how to pre-oxygenate for RSI
for 2-5 minutes using high flow oxygen via NC, assisting ventilation only if apneic
medication doses for sedation and induction
Ketamine: 1-2 mg/kg
Midazolam: 0.2 mg/kg
Etomidate: 0.3 mg/kg
Paralytic dose
Roc 1 mg/kg
interventions if patient becomes bradycardic during an intubation attempt
Ventilate using BVM with PEEP at 8, if no improvement, give Atropine 0.02 mg/kg
pediatric sedation and induction medications and doses
Ketamine 1-2 mg/kg
Midazolam: 0.1 mg/kg
Patient positioning to help with a successful intubation
elevate patients shoulders and allow the neck to extent in patients whom a cervical collar is not indicated.
LMA usage in burn patients
LMA may be an adequate airway inn patients with airway burns since majority of airway burns do not descend below the vocal cords
why should BVM not be used after the paralytic has been administered
once paralyzed, air can be easily introduced into the stomach with BVM ventilation
treatment for extrapyramidal reactionn
Benadryl 25 mg IV/IM
symptoms that determine a mild allergic reaction
swelling, itching, redness, hives
treatment for mild allergic reaction
-Benadryl 25-50 mg IV/IM
- Famotidine 20mg IVP
symptoms that determine a moderate allergic reaction
-mild symptoms
-wheezing
-difficulty swallowing
-mild hypotension
treatment for a moderate allergic reaction
-benadryl 25-50 mg
-Famotidine 20 mg
-Solumedrol 125 mg
-Albuterol up to 3 doses
-Consider Epi 0.5 mg IM, with progression of symptoms or history of severe reaction, may repeat x1
sedation agent to be considered for an allergic reaction
Ketamine 0.5-1 mg/kg
symptoms for a severe allergic reaction
impending respiratory failure, severe hypotension
interventions for severe allergic reaction
-Epi 0.5 mg IM
- Epi 0.1 mg Q3 min IV only if impending or actual cardiac arrest.
-Benadryl
-Famotidine
-Solumedrol
-LR 20 ml/kg
- Ketamine if sedation is required
Consider epi drip for continued hypotension
Peds doses for mild allergic reaction
-Benadryl 1 mg/kg I or IM (max 25)
-Famotidine 1 mg/kg (max 20 mg)
peds doses for moderate allergic reaction
-Benadryl 1 mg/kg
-Famotidine 1 mg/kg
-Solumedrol 0.5-1 mg/kg
-Albuterol 2.5 mg up to 3 treatments
-Consider epi 0.01 mg/kg IM max 0.3 mg, repeat x1 if needed
-Ketamine 0.5-1 mg/kg if sedation is required
Consider starting LR bolus here instead of waiting for more profound hypotension
PEDS doses for severe allergic reaction
-Epi 0.01 mg/kg IM (max 0.3), may repeat x1
-Epi 0.01 mg/kg IV (max single dose 0.1 mg), max total dose 0.3 mg
-Benadryl 1mg/kg
-Famotidine 1 mg/kg
-Solumedrol 0.5-1 mg/kg
-Utilize Ketamine if sedation is required 0.5-1 mg/kg
-NS or LR bolus 20 ml/kg, repeat as necessary
-Consider Epi infusion for continued hypotension
PEDS epi drip dose range
0-1 mcg/kg/min
When should epi be used with caution
patients over 50 yo, have a history of cardiac disease or if the HR is above 150
when and how to treat hypoglycemia Adult
treat if less than 60
give 100-200 ml D10
when to treat and with what for hypoglycemia PEDS
less than 1 month: treat when less than 40 with 2 ml/kg of D10
Older than 1 month: treat when less than 60 with 2 ml/kg of D10
treatment to maintain euglycemia in peds patients after correcting hypoglycemia
initiate dextrose infusion to prevent recurrent hypoglycemia
<1 month: d10 at 5 ml/kg/hr
>1 month: D10 at 2 ml/kg/hr
Increase rate by 1 ml/kg/hr every 15 minutes to maintain euglycemia
Medication to consider if hypoglycemia due to chronic alcoholism or severe malnutrition
Thiamine 100 mg IVP
Narcan dose adults
0.4 mg IV/IO/ETT/IM
Doubling the dose every 5 min to max of 2 mg
OR
2 mg IN
Narcan dose PEDS
0.1 mg/kg every 5 minutes (max single dose 0.4 mg)
reasons to obtain an EKG for AMS
if suspected cardiac cause, cardiotoxic ingestion, or electrolyte imbalance
why not to give too much narcan
only give enough narcan to achieve adequate ventilation, but not to wake the patient completely. Prepare for possibility of vomiting/withdrawal
Versed dosing adults for anxiety/agitation
1-5 mg q 5 min, max dose 10 mg. (reduce by 50 percent in chronically ill or geriatric patients)
post intubation Versed continuous infusion dose and concentration
1-10 mg/hr
10 mg/100 ml NS
Ketamine anxiety/agitation Ketamine dose
IV/IO: 0.5-1 mg/kg
IM: 0.5-2 mg/kg
IN: 0.5-3 mg/kg
Ketamine excited delirium dose
0.5-2 mg/kg IM followed by 1-2 mg/kg IV if needed
Post intubation continuous infusion Ketamine and concentration
0.1-2 mg/kg/hr of 500mg/100ml
Extreme agitation or excited delirium Haldol dose
5 mg IV/IM 5-10 min, titrate to a max of 15 mg
Versed dose for anxiety/agitation PEDS
IV/IO
0-5 yo: 0.05-0.1 mg/kg
6-12 yo (less than 50 kg): 0.025-0.05 mg/kg
>12 yo: adult dosing
IM
0.05-0.1 mg/kg max total dose 10 mg
IN:
0.2 mg/kg single dose
post intubation versed drip dose and concentration PEDS
0.05-0.12 mg/kg/hr
10 mg/100 mls
Ketamine dose for anxiety/agitation PEDS
IV/IO: 0.5-1 mg/kg
IM: 0.5-2 mg/kg, may repeat x1 at 0.5-1
IN: 0.5-3 mg/kg, may repeat x1 at 0.5-1
Ketamine post intubation drip dose PEDS
0.1-2 mg/kg/hr
Aortic emergency VS goals
HR<60 and SBP 100-120
what medication should not be used to treat pain in a patient with an aortic emergency
Ketamine due to the potential to worsen the patients status
If patient is bradycardia or Labetalol is maxed out, what medications can be requested from the sending facility
Nipride, Nicardipine or Cleviprex
What patient population should not have an aortic emergency/hypertensive emergency treated with a beta blocker
patients with methanphetamiens or cocaine use within 72 hours
beta blocker use may cause unopposed alpha stimulation resulting in increased blood pressure
When do we treat hypertension
Only if the patient is symptomatic AND after two confirmed blood pressure readings 5 minutes apart
what is the limit for how much we try to drop the blood pressure of a patient in hypertensive emergency
BP should not be decreased by more than 25% of initial reading
Labetalol dose for hypertension
10-20 mg IVP over 1-2 minutes, repeat x1 in 10 minutes
Labetalol infusion dose and concentration
1-10 mg/min
Mix 20 ml into 100 ml NS
100 mg/100ml
Nicardipine infusion dose and concentration
5-15 mg/hr (titrate by 2.5)
mix 10 ml into 100 ml NS
25mg/100ml
Hydralazine dose for hypertension
10-20 mg Q15 minutes. max dose 60 mg
Nitro dose range for treating aortic emergencies
5-200 mcg/min
Hypertensive crisis vs hypertensive emergency
Hypertensive emergency is required to have evidence of end organ dysfunction
Blood pressure parameters that indicate hypertensive crisis
SBP >210 or DBP> 110
parameters to give push dose epi
patients with 2 consecutive SBP <60 docummented 2 minutes apart or significant hypotension with other indication of hypo perfusion (low ETCO2, AMS)
how to mix push dose epi
1 ml of cardiac epi in 9 ml of saline
Epi dose for imminent threat of cardiac arrest with a pulse
250-500 mcg
onset and duration of push dose epi
onset is less than 1 minute and while duration of a single dose may last 10 minutes, in most cases the effects are gone within 5 minutes
Prehospital emergent blood administration criteria
Must have: penetrating injury, significant blunt traumatic injury, or significant visible hemorrhage (GI bleed, pelvic fracture, amputation, postpartum hemorrhage)
and 2 of the following:
- SBP <90 and HR >120
- Or SBP <70
-Peds SBP <70, HR>150
-Hemoglobin less than 7
- Hypovolemia confirmed by POCUS
PEDS blood transfusion dose
max 20 ml/kg
rate to run blood for non emergent transfusions PEDS
start at 2.5 ml/kg/hr to avoid circulatory overload. decrease to 1 ml/kg/hr for patients at risk for volume overload or call PICU for rate orders and volume to be infused
rate to run blood for non emergent transfusions
Start at 60-120 ml/hr for first 15 minutes then as rapidly as tolerated to complete within 4 hours from unit removal from blood bank
“damage control” massive transfusion recommendations
1:1:1 ratio of PRBCs/FFP/PLT
When to consider giving Calcium replacement in regards to blood transfusions
If a patient has received greater than 4 units of PRBCs
stored blood products contain citrate, and anticoagulant/preservative that functions by binding ionized calcium
blood products to be used for uncrossed blood transfusions
for men and women whom childbearing is not a consideration: O neg or O pos
for girls, pregnant women, and women of childbearing age: O neg if possible
what should be removed from a patient with burns
all clothing that does not adhere to the patient along with jewelry and other constricting objects
what treatment should be initiated if carbon monoxide poisoning is possible
oxygen via non-rebreather
what type of dressing should be applied to burns
clean, dry dressing or sheet
interventions to maintain body temperature
cover with blankets or chemical blanket
provide continuous temperature monitoring
administer heated IV fluids
increase temperature of transport vehicle
initial fluids and rate to be started for burn patients
administer warmed fluids at 500 ml/hr LR
when should the burn formulas be initiated
for partial thickness and full thickness burns greater than 20% BSA
fluid resuscitation formula for flame, scald, and chemical burns
2ml x weight in kg x % TBSA
give half of the volume over the first 8 hours then the second half over the subsequent 16 hours
starting fluid rate for PEDS burns patients
0-5 yo: 125 ml/hr
6-13 yo: 250 ml/hr
>13 yo: 500 ml/hr
PEDS burn formula
3 ml x weight in kg x % TBSA
Additional fluids and rate for PEDS burn patient
If younger than 14 add D5W at maintenance rate
4 ml/kg for first 10 KG plus
2 ml/kg for the next 10 kg plus
1 ml/kg for every kg after that
formula for fluid resuscitation for electrical burns
4 ml x weight in KG x % TBSA
Burn center criteria
-partial thickness burns of greater than 10% of the TBSA
- Significant turns that involve the face, hands, feet, genetalia, perineum, or major joints
- 3rd degree burns in any age group
- electrical burns, including lightning injury
- Chemical burns
- inhalation injury
- burn injury I patients with preexisting medical disorders that could complicate management, prolong recovery or affect mortality
- burn injury in inpatients who will require special social, emotional, or rehabilitative interventions
effects of flame inhalation burns on airway
flame inhalation burns rely affect the area below the vocal cords. A LMA is a reasonable alternative to endotracheal intubation if attempts at ETT have failed
effects of liquid and aerosolized chemicals on airway
more likely to affect the supraglottic area while subglottic injury occurs with smoke inhalation. ETT is considered to be the definitive airway
expected hemodynamics associated with burns
Expect tachycardia, normal adult HR should be 100-120.
Hypotension is not expected in patients suffering burns. assess for other causes, such as trauma
diagram for rule of nines for adult, peds and infacts
Adult:
- head 9
- torso 36
- arm 9 each
- leg 18 each
Peds:
- head 14
- torso 36
- arm 9 each
- leg 16 each
Infant:
- head 18
- chest 18
- back 13
- butt 5
- leg 14 each
- arm 9 each
ETT epi dose ECLS
2.5 mg
When must medical control be contacted during a cardiac arrest
for possible administration of sodium bicarbonate
termination of efforts
permission to transport
What must be done during a cardiac arrest prior to termination of efforts
a minimum of 3 rounds of epi
cardiac ultrasound must be done to confirm cardiac standstill/fibrilation
classifications for severity of fib RVR
stable: asymptomatic and normotensive
unstable: SBP <80 or MAP < 60 (shock)
symptomatic: lightheadedness, SOB, hypoxic, chest pain, syncope but adequate BP
treatment for stable a fib RVR with transport less than 20 minutes
monitor without therapy
treatment for stable Afib RVR with transport time >20 minutes
- SBP >100 give Metoprolol 5 mg. If no response to HR and SBP remains >100 may repeat x1
- if no response after second dose, call medical control for additional orders
treatment for unstable AFIB RVR regardless of acute or chronic
- synchronized cardioversion (100/150/200(
- address hypotension with fluids and/or pressors concurrent with Amiodarone 150 mg over 10 minutes
- begin amio infusion at 1 mg/min (40 ml/hr)
concentration of amio gtt
150 mg/100 ml
treatment for acute symptomatic AFIB RVR
- Amio 150 mg over 10 minutes
- strat amio infusion if transport time greater than. 20 minutes
treatment for chronic symptomatic AFIB RVR
- Metoprolol 5 mg x1
- if HR remains >110, metoprolol 5 mg IV every 5 minutes to a total of 15 mg
- to maintain HR <110 start Labetalol drip
treatment for 2nd degree type 2 or 3rd degree heart block with poor signs of perfusion
immediate TCP
treatment for symptomatic bradycardia that isn’t an advanced heart block
- Atropine 1 mg IV every 3-5 minutes. Max 3 mg
- TCP if unresponsive to atropine or unable to obtain IV/IO access
- if refractory to interventions consider Epi drip
interventions for non symptomatic bradycardia
transport
what population should atropine be used with caution
in the presence of acute coronary ischemia or MI
interventions for patients with narrow complex tachycardia with signs of poor perfusion and not verbally responsive
consider cardio version first
interventions for patients with SVT and signs of poor perfusion
- Valsalva maneuver, if no response
- Adenosine 6 mg, if no response
- Adenosine 12 mg, if no response
- Synchronized cardio version (100/150/200J)
interventions for AFIB/Flutter with signs of poor perfusion
synchronized cardio version
interventions for narrow complex tachycardia without signs of poor perfusion
contact medical control for Adenosine orders
medication treatment for PVCs
Lidocaine 1.5 mg/kg push followed by gtt 2-4 mg/min
ETT Epi dose ACLS
2.5 mg
mag dose for Torsades
2 gm magnesium wide open
interventions for wide complex tachycardia with a pulse and signs of poor perfusion
synchronized cardiovert x4, amio bolus, shock again. call medical control if no changes
interventions for wide complex tachycardia with no signs of poor perfusion
Amio bolus and drip if transport time greater than 30 minutes
signs of tension pneumothorax
absent breath sounds, tracheal deviation, hypotension
when to perform a needle thoracotomy on a patient with chest trauma
with evidence of tension pneumothorax especially for patients on positive pressure ventilation
how many needle thoracotomy attempts before moving to a simple thoracostomy
2 unsuccessful attempts
signs of pericardial tamponade
Becks triad: muffled heart tones, JVD and hypotension
interventions with evidence of large flail segment with decreased gas exchange
intubation and positive pressure ventilation
interventions performed with impaled objects
stabilize, do not remove
Things to consider for patients with suspected pulmonary contusions
use judicious fluid administration.
If intubated, assess plateau pressure and implement PRVC mode on the ventilator for lung protective strategy
when to consider a chest tube based on Xray results
if imaging shows pneumothorax greater than 25% (or 2 cm), consider CT prior to transport.
fluid bolus parameters for DKA
20 ml/kg of LR over 1 hour
insulin drip starting dose
0.1 unit/kg/hr
what does the potassium level need to be above before starting the insulin gtt
3.3
intervention performed when Bg goes below 300
decrease insulin gtt to 0.05 u/kg/hr
intervention if BG drops below 250 on insulin gtt
start D10 gtt at 150 ml/hr
intervention if BG drops below 100 on insulin gtt
stop insulin infusion and recheck BGL every 15 minutes. Continue D10 infusion
Interventions for patients in DKA that BG drops below 80
give D10 bolus 50-100 ml in addition to D10 drip
What should be requested from sending facility if K less than 5.3 and patient being started on insulin gtt
request potassium m replacement
Peds DKA fluid bolus dose
10 ml/kg of NS
additional bolus of 20 ml/kg may be administered if patients remains hemodynamically unsteady or with signs of poor perfusion
initial insulin infusion rate PEDS
0.05-0.1 unit/kg/hr
maintenance fluids for PEDS DKA patient
1.5x the normal maintenance rate
how to immobilize fractures
try to immobilize the joint above and below the injury
medication to give if open fracture or any break in skin over obvious fracture
2 grams ceftriaxone (50 mg/kg for PEDS)
interventions for amputations
apply a tourniquet proximal to the amputation
rinse wound with sterile saline and place moist dressing over stump
rinse amputated part with sterile saline and place in dry container on ice
consider administration of ASA if bleeding controlled and possibility of preimplantation
fluid administration for hypovolemic shock
administer 500 ml fluid boluses up to 2L to maintain MAP over 65 prior to starting pressors. watch for signs of fluid overload
fluid administration with cardiogenic shock
caution with aggressive IVF resuscitation in cardiac patients. monitor for pulmonary edema frequently.
interventions with obstructive shock
consider potential causes including tension pneumothorax, pericardial tamponade or pulmonary embolism. Adminster 500 fluid boluses, max 1L while initiating vasopressor support.
interventions to reduce ICP
- Elevate HOB 30 degrees
- ensure that head is midline
- Avoid flexion of limbs
- Limit airway suctioning
- Control pain and anxiety
- Control nausea and vomiting
- Consider paralytics to minimize high airway pressures and minimize vent dyssynchrony
target MAP for head and facial trauma with suspected head injury
MAP above 80-90
Target CO2 initially with head trauma
35-40
Target CO2 with signs of herniation
28-32
signs of cerebral herniation
bradycardia, hypertension, unilateral blown pupil, extensor motor posturing, deterioration of GCS by more than 2 points when initial GCS was less than 9
what interventions are performed for hypertension with suspected head trauma
do not treat hypertension with a head trauma unless ordered by physician
What medication can we consider asking for from a sending facility for a patient with a traumatic brain injury
hypertonic saline
what type of head trauma is less likely to cause a brain injury
blunt trauma to the face without a blow to another part of the head rarely leads to brain injury
blood pressure goal for penetrating trauma and hypovolemia
permissive hypotension goal SBP 70-90 MAP 60-65
Blood pressure goal for blunt trauma and traumatic brain injury
SBP 100-120 MAP greater than 80
steps to control life threatening external hemorrhage
- apply direct pressure to the wound
- apply an approved tourniquet for life threatening hemorrhage
- pack wound with hemostatic dressing followed by 3 minutes of direct pressure
- consider pelvic binder in the presence of high energy trauma with lower abdominal pain
TXA administration criteria
- Traumatic injury with suspected or observed ed internal and/or external hemorrhage requiring large volume fluid resuscitation or predited blood administration
- Moderate traumatic brain injury (GCS >8 but less than 13) presenting within three hours of injury
- Post party hemorrhage with suspected or observed internal and/or external hemorrhage requiring large volume resuscitation or blood administration
TXA exclusion criteria
- Time out from injury greater than 3 hours
- Concomitant administration with other approved procoagulant agent
PEDS TXA dose
15 mg/kg max dose 1 gram
PEDS fluid administration for hemorrhage
20 ml/kg
may repeat x2 if no improvement
how to apply a tourniquet
high and tight, not over bulky clothing or equipment that would decrease their effectiveness.
initial settings for HHFNC
60 l/min 100%
how to determine size of HHFNC cannula
should fill approximately 3/4 of the patient’s nostril
Initial PEDS HHFNC setting
2L/Kg/min up to 60 L and 100%
signs of respiratory failure and intolerance of HFNC
- decreasing level of consciousness
- Inability to maintain respiratory effort
- Cyanosis
PEEP provided by HHFNC
1 cmH2O of PEEP for every 10 L/min if mouth is closed
medications and doses for hyperkalemia
Calcium chloride 1 gm SIVP
Albuterol 10 mg continuous neb
Lasix 20 mg IVP if acute/chronic kidney disease or overdose patient (not DKA, burn, crush or rhabdo patient)
Peds doses for hyperkalemia medicationns
Albuterol 5 mg continuous neb
20 mg/kg calcium IVP
additional medications available for nausea besides zofran and doses
phenergan (6.25-25) and Benadryl (12.5-25)
PEDS zofran dose
0.15 mg/kg max 4 mg
PEDS phenergan dose
0.25 mg/kg max dose 12.5 mg
dangers of giving phenergan to a dehydrated patient
may cause severe hypotension. give LR bolus before administration if patient is hypotensive
prebirth questions
-expected gestational age
- amniotic fluid color
- additional risk factors (drug use, prenatal complications, etc.)
- Umbilical cord management
Interventions for newborn with HR>100 and pink
-delay cord clamping 30-60 seconds
- Warm: continous temperature monitoring device
- Dry: only if it is a term baby, will damage premie skin
- Stimulate: run 2 fingers on either side of the spine
- position and suction airway if needed
- place on monitor
- place in a plastic bag to preserve warmth
Interventions for newborn with HR>100 and central cyanosis
- place pulse oximeter on right hand
- Give oxygen if Sat <90 after 10 minutes
- for preterm <35 weeks, start oxygen at 21%
interventions for newborn HR>100 with labored breathing or low sats despite free flow oxygen
- CPAP- make a tight seal around Tpiece resuscitator on infants face
- Do not apply to crying baby- may result in pneumo
interventions for newborn with HR<100 or apneic, persistent cyanosis
- Positive pressure ventilation within 10 seconds
- if meconium staining noted, provide PPV and only intubate/suction if complete airway obstruction found
- PPV breath cadence “breath, 2,3, breath, 2,3” at approximately 40-60 breaths per minute
MRSOPA
Mask adjustment- lift jaw, two hand hold
Reposition neck- neutral alignment, extended
Suction- mouth before nose
Open mouth- ift jaw forward
Pressure increase- increase PIP 5-10
Alternate Airway- laryngeal mask or ETT
Max PIP for full term and premature babies
full term max of 40 and preterm max of 30
interventions for newborn with HR<60
- Positive pressure ventilation at least 30 seconds with chest rise, consider intubation
- increase FiO2 to 100% once chest compressions start
- 3:1 chest compressions to ventilation ratio
- Epi 0.02 mg/kg IV IO or 0.1 mg/kg via ETT
- fluid bolus 10 ml/kg call for orders to repeat fluid boluses
- HR assessed at 60 second intervals following chest compressions
PIP settings for newborn
Set PIP to 30-40 for first few breaths ,then decrease to 20-25. PEEP at 5
minimum BP for newborns
MAP equal to gestational age
cath size for neonatal chest decompression and technique for neo
20 gauge, do not leave catheter in, once decompressed, remove catheter adn seal with a tegaderm
length to measure for UVC
<38 weeks measure length of cord plus 1 cm. 38 weeks+ measure length of cord plus 2 cm
APGAR scoring
Activity
Pulse
Grimace
Appearance
Respiration
signs to stay at sending facility for delivery of baby
if crowning present, contractions less than 20 minutes apart, the mother is feeling the urge to push or bearing down
interventions for delivery of baby on sight
- place mom in lithotomy position
- drape mother, place absorbent pads under pelvis, don PPE
- prepare for NRP
- guide and control to prevent precipitous delivery, do not pull on the head of the baby but allow for the baby to come naturally
- document time of birth
- wait 30-60 seconds after delivery to clamp the umbilical cord in two places, 8-10 inches from infant and cut the cord between clamps
- do not wait for delivery of placenta. if it is delivered, bring to hospital
interventions for excessive vaginal bleeding and/or signs of shock
- massage fundus
- increase IV flow rate to wide open
- maintain sats at 100%
- initiate breastfeeding if possible
- initiate Oxytocin infusion
- Administer TA if previous interventions are unsuccessful
Oxytocin administration
mix 20 units into 250 ml. Administer 125 ml over 10-20 minutes then infuse at 31.2 ml/hr
interventions for patient with a prolapsed cord
-Place mother on back with hips elevated or place her in knee/chest position
- place gloved index and middle fingers into the vagina and gently push the baby up to relieve pressure on the cord
- check cord for pulse. if cord is outside the canal, wrap in sterile wet dressing
- treansport and notify receiving facility of impending arrival. do not remove hand until adequate assistance is available
interventions for abnormal fetal presentation or decreased fetal heart tones
- place mom in left lateral position
- transport and notify receiving hospital of impending arrival
interventions for rupture of membranes with decreased fetal heart rate
- place mother on back with hips elevated or place her in knee/chest position if no improvement
- perform vaginal exam to insure that cord is not compressed between cervix and baby’s head
- sweep finger between cervix and babies head in attempt to remove pressure from cord
- frequently monitor fetal heart rate with mother maintaining in kneel to chest position to ensure that the cord does not become compressed again
If baby is breech and hips are delivered without head, how long do we wait before inserting hand to create airway for newborn
4-6 minutes
interventions if cord is wrapped around the neck
slip it over the head off the neck. it may be necessary to clamp and cut the cord if it is tightly wrapped
sizing of ETT for pregnant women
an ETT 0.5-1 size smaller
initial interventions to slow preterm labor
-position mom on left side
- NRB oxygen
- administer 500 ml bolus up to 2L
- place foley catheter
medications that can be given to slow contractions
- terbutaline 0.25 mg SQ x3 doses Q 20 minutes
- phenergan 12-25 mg Q3-5 minutes
- magnesium 4 gm bolus over 20 minutes then continuous infusion 2 gm/hr
treatment for mag toxicity
stop magnesium infusion
give 1 gm calcium chloride
signs of mag toxicity
decrease in DTRs or respiratory rate less than 12
PIH fluid administration
limit to 100 ml/hr
BP parameters for PIH
SBP<160 and/or DBP<110
Labetalol administration for PIH
10 mg every 10 minutes increasing dose by 10 mg each time. Max single dose 80 mg or total 360
Hydralazine dose PIH
2-5 mg followed by 10 mg (max total dose 40 mg)
intervention for seizure lasting longer than one minute for pregnant woman
10 mg versed IM, may repeat x1 or 5 mg IV
4 gms Magnesium over 20 minutes (4 gms in 100 ml NS) followed by 2-4 gms/hr continuous infusion
HELLP syndrome
Hemolysis, elevated liver enzymes, and low platelets
s/s headache, vomiting, visual disturbances, HTN, peripheral and central edema and DIC like bleeding
Fentanyl pain dose
IV/IO 1-3 mcg/kg max single dose 200 mcg
IN: 1-3 mcg/kg
IM: 100 mcg
Fentanyl infusion dose and concentration for pain
25-300 mcg/hr
300 mcg in 100 ml NS
Morphine pain dose
IV/IO: 2-5 mg
IM 2-10 mg
Ketamine pain dose
IV/IO/IM/IN 0.15-0.3 mg/kg
continuous infusion: 0.1-0.2 mg/kg/hr (500 mg in 100 ml)
PEDS fentanyl pain dose
IV/IO/IN 0.1-1 mcg/kg
PEDS morphine pain dose
IV/IO 0.1 mg/kg
PEDS ketamine pain dose
0.15-0.3 mg/kg
PEDS tylenol dose
15 mg/kg
Recommended pain medication for burns
morphine
PALS epi dose
0.01 mg/kg IV/IO
PEDS narcan dose
0.1 mg/kg (max single dose 0.4 mg up to 2 mg)
Atropine PEDS dose
0.02 mg/kg (minimum dose 0.1 mg)
PALS adenosine doses
0.1 mg/kg followed by
0.2 mg/kg
PALS synchronized cardioversion dose
0.5-2 J/kg
what intervention must be done when administering adenosine
continuous EKG
PEDS BVM ventilation rate
20-30 bpm
PALS defibrilation dose
2-10 J/kg
PALS amio dose
5 mg/kg
Lidocaine PALS dose
1 mg/kg IV/IO
PEDS dehydration fluid dose
20 ml/kg over 5-15 minutes
Asthma/reactive airway medications
- Albuterol 2.5-5 mg
- consider duoneb for subsequent doses
- Solu-Medrol 125 mg
- Consider Mag 2 gms IV over 20 minutes
- for imminent respiratory failure, administer Epi 0.3 mgIM then 0.3 mg IV
- Start BIPAP as early as possible to stent open the obstructed airways, reduce fatigue, and improve gas exchange
PEDS Asthma medications and doses
- Albuterol 0.15 mg/kg for 3 doses followed by .5 mg/kg/hr mixed with 3 ml saline for continuous neb
- Epi 0.01 mg/kg up to 0.3 mg IM
- impending respiratory failure Epi 0.01 mg/kg IV max dose 0.3 mg
- Solumedrol 0.5-1 mg/kg
- Consider Magnesium 50 mg/kg up to 2 gms over 20 minutes
- if these medications do not help, call medical control for terbutaline orders (0.01 mg/kg max 0.4 mg)
Interventions for stridor or hypoxia related to croup/epiglottitis
- allow patient to remain sitting up
- Racemic Epi
- assure adequate hydration with maintenance IV fluids
Interventions for chronic lung disease with deterioration
- Administer albuterol unit dose until symptoms improve
- Consider duoneb for second and third nebulizer
- Solumedrol 125 mg
- for impending respiratory failure, give continuous albuterol nebulizer diluted with 3 mll saline
- consider placing patient on BIPAP
interventions for pulmonary edema
- position patient sitting up as blood pressure tolerates
- administer NTG SL or IVP if SBP >100 then prepare a nitro gtt range 50-200 mcg/min to keep SBP >90
- Furosemide 40 mg IV if not currently taking at home or the equivalent of one dose of their home oral regimen IV
- consider assisting breathing with BVM and use of PEEP valve to provide noninvasive positive pressure ventilation. begin with PEEP of 8 and max of 10
- consider starting BIPAP
initial bipap settings
IPAP: 7-15 (adjust to target TV of 6-8 ml/kg)
PEEP: 5-10
High inspiratory flow rate
prolonged I:E ratio
signs of auto PEEP
Increasing peak airway pressures
Treatment for Auto PEEP
Select lower respiratory rate and consider paralysis
Increase the set PEEP
switch to pressure control ventilation if necessary
four signs that suggest imminent respiratory arrest in a patient with acute respiratory distress
- decreasing level of consciousness
- Rising ETCO2
- Inability to maintain respiratory effort
- Cyanosis
Interventions for Seizures
- protect patient from injury and aspiration
- consider sidestream ETCO2
- Chec the pulse immediately after seizure stops
- Check blood glucose and treat per protocol
Versed dose for seizures Adult and Peds
- Adult: 10 mg IM may repeat x1 or 5 mg IV may repeat x1
- 13-40 kg: 5 mg IM may repeat x1 or 2.5 mg may repeat x1
- less than 13 kg: 0.2 mg/kg IV/IO/IM/IN
interventions if patient is still seizing after 2 doses of versed
call for further orders from medical control
Keppra loading dose
30 mg/kg max dose 1500 mg
PEDS keppra loading dose
30 mg/kg
what allergy contraindicates Ceftriaxone
Allergy to Cephalosporin
fluid resuscitation for sepsis
if hypotensive give 30 ml/kg LF wide open. If MAP remains <65 give additional 500-100 ml bolus
CVP goal for Sepsis patients
8-10 if not intubated, 10-12 if intubated
4 questions used to determine if patient should be placed in C collar
- are there any distracting injuries
- is there motor or sensory deficits
- is there focal midline tenderness or deformity
- is there limited range of motion
if any of these are yes then they are placed in C collar
Blood pressure parameter for possible spinal injury
MAP>80
Fluid resusciation for possible spinal injury
up to 1L LR
FAST ED assessment components
Facial palsy
Arm weakness
Speech changes
Eye deviation
Denial/neglect
inclusion criteria for stroke prealert
- positive FAST ED exam
- over the age of 18
- within 4.5 hours of symptom onset or LTKW
stroke pre-alert exclusion criteria
- stroke or head trauma in the past 3 months
- previous intracranial hemorrhage
- major surgery in the past 2 weeks
- active bleeding
BP to treat for an ischemic stroke
SBP >220 or DBP>120
when to treat a patient with an ischemic stroke that received TPA
Keep SBP <180 and DBP<105
BP parameters for spontaneous brain bleed
SBP<140
BP goal for subarachnoid bleed
SBP<160
treat initially with pain meds. More likely to have labile BP
exclusion criteria for BIPAP
inability for patient to safely and quickly remove mask due to obtundation or weakness unless patient is a DNR/DNI and BIPAP is the only viable option
Absolute contraindications for BIPAP
- inability to achieve a good seal
- suspected pneumothorax/barotrauma
- inability to maintain airway patency
- major trauma, especially head injury with increased ICP
- Vomiting
Relative contraindications to BIPAP
- inability to cooperate, tolerate, or understand the use of the device
- clausterphobia
- RR>30
BIPAP settings
our BIPAP is additive, PEEP plus P support equals IPAP.
Pramp 50-100
ETS to 40%
Maximum pressure for BIPAP
Maximum additive pressure of 20
When to put a Neonatal curcuit on the vent
pt <10 kg
Plimit vs High pressure alarm
Plimit is 10 below high pressure limit alarm setting.
Initial venilator settings
APVCMV
TV: 6-8 ml/kg
Rate: 16-25 Adult, 18-30 PEDS, 30-40 Neo
I-time: 1:2 (unless obstructive disease then 1:3/1:4
PEEP: 5-8
FiO2: 100%
PIP alarm: 40 ADULT, 20 PEDS and NEO
Max PEEP before calling medical control
14
When to consider changing to pressure control ventilation
to prevent barotrauma in adult/peds patient with severe airway disease (asthma/ARDS) with high PIP/Pplat on volume ventilation and whose clinical status does not improve with volume ventilation. Additionally for patients with significant vent dyssynchrony
Initial PCV settings (ADULT)
RR: ADULT 16-25, PEDS 18-30
I:E 1:2
PEEP: same as APVCMV (5-8 adult)
Pcontrol: titrate pcontrol to achieve approximate tidal volume of 6-9 ml/kg
max P control without physician orders
40
Settings for ASV
set a minute ventilation: start at 120% and titrate from 90-180 to maintain EtCO2 between 35-45
PEEP 5-8
Contraindications for ASV
Morbidly obese patient
Peds patient less than 12 yo
PCV settings for Peds <10 kg
RR: Peds: 18-30, Neo 30-40
Pcontrol: 15 max of 25
I:E- 1:3
PEEP 3-8
Max pPeak PEDS
30 (addititve of Pcontrol and PEEP)
max PEEP for PEDS
10
Pplat equation
(VTE/Cstat) + PEEEP
interventions if Pplat is >30
provide interventions that decrease pressures and continue to monitor. Decrease VT by 1 ml/kg as low as 4 ml/kg. switch to pressure targeted mode.
