Download ER Guidelines April 2017

ER ‘Guidelines’
Shane Barclay MD, Revised October 2016
Acute Chest pain, STEMI, NSTEMI (TNK)
ACS Admission orders – post ER
Acute Pulmonary Edema (CHF)
Airway Management (Rapid Sequence Induction)
Analgesics/Anesthetic – Conscious Procedural Sedation,
Anaphylaxis
Asthma
Atrial Fibrillation – decompensated
Bites – Human and Animal
Bronchiolitis
Burns
Burn management/dressing using Aquacel Ag
Coma
Croup
Diabetic Ketoacidosis
Electrolytes – treating critical values
Frostbite
Gout
Head Injury/Concussion
Hypertensive Emergencies/Urgencies
Hypoglycemia
Hypothermia
Intravenous Lipid Emulsion therapy (ILT)
Migraine Headaches
Overdose – Benzodiazepine
- Misc. (other alcohols, cocaine, opioid, TCA, PCP)
- Acetaminophen
Pediatric analgesia and conscious sedation
Post Cardiac Arrest Care
Sedation for Severe Agitation/Alcohol Withdrawal
Seizures – Adult
Seizures – Pediatric
Shock / Hypotension
Spinal Cord Injury
Ventilator Support (settings)
ATLS Protocol
Glasgow Coma Scales (Adult and Pediatric)
Procedures: Chest tube, Tick removal, Zipper injury, ABI
Subungual hematoma, Fishhook removal, Priapism,
Shoulder Dislocation
IV drugs in the ER
Page
2-3
4-5
6
7
8
10
11
12
13
14
15 – 16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31-33
34
35
36
37
38
39
40-42
43
44-46
47-48
49
50-57
58-61
Page 2 of 61
Acute Chest Pain – Management
1.
2.
3.
4.
5.
Oxygen to maintain O2sats > 93%
Cardiac Monitor (on LifePac), BP, HR, SaO2. RR.
Aspirin – ASA 160. Have patient chew and swallow.
Nitrospray: 1 spray q 10 minutes x 3, prn (check no recent Viagra, Cialis, etc.)
IV access – 2 or 3 lines preferably, above diaphragm. May start 2 lines in
one arm.
6. ECG should be done ASAP.
7. If pain persists, Morphine 2.5 – 5 mg IV q 5 min. As long as systolic BP >
100. NB Caution with Inferior MI’s.
8. If pain still persists, consider Nitro drip IV. Start at 10 mcq/min.
(if systolic BP > 100) (caution with Inferior MI’s)
9. Draw blood for CBC, CPK, LDH, BUN, Creat, Lytes, PT, PTT, and
Troponin. CK/CK-MB if previous MI within 14 days.
10. Beta-blocker – if systolic BP > 100, HR >50, no Rt. heart failure
(Caution with COPD, ASTHMA)
Metoprolol 50 mg orally
Or if uncontrolled HTN, ongoing angina, use Metoprolol 5 mg IV slowly q 5
min x 3 doses (total 15 mg), then in 1 hour give 50 mg PO
11. Atorvostatin 80 mg po stat
12. Ramipril 1.25 mg PO up to 5 mg PO
13. CXR if possible (supine if necessary)
If STEMI (acute MI)
14. Consider Thrombolytic Therapy (TNKase)
Patient Weight
Kg
< 60
< 60 - < 70
> 60 - < 80
> 80 - < 90
> 90
Pt. Weight
Lbs
< 132
> 132 - < 154
> 155 - < 176
> 177 - < 198
> 199
TNKase Reconstituted
TNKase (ml/cc)
30
6
35
7
40
8
45
9
50
10
15. Age < 75 yrs.: Clopidogrel 300 mg-600 PO stat.
Enoxaparin 30 mg IV after TNK plus 1 mg/Kg s.c. (Max
s.c. dose is 100 mg) Caution in renal insufficiency (see page 4). Continue
with Enoxaparin 1mg/Kg s.c. q 12hrs.
Age > 75 yrs.: Clopidogrel 300 mg stat
Page 3 of 61
Unfractionated Heparin
Patient Weight
41-50 kg
51-60 kg
61-70 kg
71-80 kg
>80 kg
Heparin I.V. Bolus
2700 units
3300 units
3900 units
4000 units
4000 units
Initial Heparin Infusion
550 units/hr. = 11ml/hr.
650 units/hr. = 13ml/hr.
750 units/hr. = 15ml/hr.
900 units/hr. = 18ml/hr.
1000unit/hr. = 20ml/hr.
If NSTEMI or Unstable angina
Do 1 – 13 above
16. Clopidogrel 600 mg Stat
17. If GFR > 30 Fondaparinux 2.5 mg SC (and then daily x 2 days)
If GFR < 30 Unfractionated Heparin – bolus then infusion.
Patient Weight
41-50 kg
51-60 kg
61-70 kg
71-80 kg
>80 kg
Heparin I.V. Bolus
2700 units
3300 units
3900 units
4000 units
4000 units
Initial Heparin Infusion
550 units/hr. = 11ml/hr.
650 units/hr. = 13ml/hr.
750 units/hr. = 15ml/hr.
900 units/hr. = 18ml/hr.
1000unit/hr. = 20ml/hr.
Inclusion/Exclusion Criteria for TNKase
Exclusion Criteria:
Absolute
Yes
No
1. Active internal bleeding (except menses)< 10days
___
___
2. Suspected aortic dissection
___
___
3. Previous hemorrhagic stroke at any time,
Other strokes or CVA within 2 – 6 months.
___
___
4. Known intra-cranial neoplasm, AVM, aneurysm
___
___
5. Intra-spinal surgery or trauma within 2 months
___
___
6. Known bleeding diathesis
___
___
Relative
7. Severe uncontrolled hypertension at
presentation (BP> 200/>120)
___
___
8. Other intracranial pathology
___
___
9.
Current use of warfarin (INR >2-3)
___
___
10. Recent trauma (2-4 wks.), including head trauma
___
___
11. Prolonged (>10 min), potentially traumatic CPR
___
___
12. Major surgery (< 3wks prior)
___
___
13. Non compressible vascular bleeding
___
___
14. Pregnancy, post-partum < 6 weeks
___
___
15. Active peptic ulcer.
___
___
16. Diabetic retinopathy, history of laser Sx.
___
___
17. Allergic reaction to Thrombolytic
___
___
18. Advanced Liver disease, with INR > 2-3
___
___
19. Acute Pericarditis
___
___
Inclusion Criteria: (acute MI
1. Chest pain consistent with MI (onset within
6 hrs. or presented to clinic after 6 hours, with
onset of pain equal to or less than 12 hours)
___
___
2. Evidence of MI
___
___
anterior: > or = to 2 mm ST elevation in 2 contiguous leads (V1-V6)
inferior: > or = to 1 mm ST elevation in 2 inf Leads (II, III, AVF)
lateral: > or = 1 mm ST elevation in 2 lateral leads (V5, V6, I, AVL) or new Left Bundle Branch block.
3. Lack of ST normalization and pain after s.l. nitro
___
___
Page 4 of 61
Admission orders: ACS – post ER
MRP ________________________________________
Patient AGE______, WT ________kg, GFR ________.
Code Status ______________________________
Diet:
Healthy heart,
Diabetes,
NPO,
Other ______________________.
B
BActivity as
B tolerated,
Activity:
Bed rest,
Commode,
Advance activity prn
B
B
B
B
e
e
e
ASA 325 mg po daily
e
t
t eOxygent Sats > 90%
Oxygen @ ___eLiters/min, ore
to maintain
t
t
ECG Daily x _____
days ta
at
a
Urinary catheter
a retention
a
a - In and Outa-catheterization- for
- PRN
Lab: Fasting lipid
profile
x
1,
Fasting
glucose
x
1
-b
bb
Daily: CBC, GFR, Na, Cl, K, CO2.
b
b
b
l
l b
l
Repeat troponin at _____________ hrs.
l
l lock or lo ___________________________
ol
o
IV normal saline
o mg sublingual
co q 5 min PRN
c ofor chest
c pain is systolic BP o> 90
Nitroglycerin 0.4
c at ____h and
c first night.
c _____mg/hr.
Nitroglycerin patch
k
k c off at ___
k h. Keep on overnight
Acetaminophen
500-1000
mg
q
6
h
PRN
for
mild
pain
or
fever.
k
k
ek
ek
e
Clopidogrel 75emg po daily re
e
re
r
Morphine ________ mg IV q 5 min PRN if systolic BP > 90.
r
r
r
r
Metoprolol 25 mg po BID or
Metoprolol ______ mg po BID
–
–
Atorvostatin 80 mg po daily –
or
_______________________________
–or
–
–
Ramipril 5 mg–po daily
_______________________________
Dimenhydrinate 12.5 – 25 mg
i IV q 4 h PRNi
i
Pantoprazole 40
mg
PO
daily
or,
Ranitidine
150
mg
i
i
fi
fi
f PO BID
Lorazepam 1 mg
hs
PRN
or
_______________________________
f
f
f
f
Zoplicone 7.5 mg hs PRN
s PRN
s
s
Laxatives as indicated by RN,
s
s
y
ys
y
y
s in ER. s y
s
STEMI patients – ypost thrombolysis
s
ts
t s
t
Age < 75 years
t S.C. q 12 oh for
t 48 hours.
t > 30: 1 mg/Kg
Enoxaparin: GFR
o
o
GFR
<
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1
mg/Kg
S.C.
q
24
h
for
48
hours.
o
lo
l o
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Age > 75 years
l
il
i l
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Enoxaparin: GFR > 30: 1 mg/Kg S.C. q 12 h for 48 hours.
i
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GFR < 30: 1 cmg/Kg S.C. q 24
c
UnfractionatedcHeparin x 48chours
B
B
B
BI.V. Bolus PInitial
B Heparin
Patient Weight
B
HeparinP
P Infusion
41-50 kgP
2700
550
P units
P units/hr. = 11ml/hr.
51-60 kg
3300
units
650
>
> units/hr.
> = 13ml/hr.
61-70 kg>
3900
750
> units
> units/hr. = 15ml/hr.
71-80 kg
4000 units
900 units/hr. = 18ml/hr.
1 units
11000unit/hr.
1 = 20ml/hr.
>80 kg
4000
1
1
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Page 5 of 61
NSTEMI patients/Unstable Angina – no thrombolysis.
GFR > 30: Fondaparinux 2.5 mg S.C. daily.
GFR < 30 unfractionated heparin x 48 hrs.
Patient Weight
41-50 kg
51-60 kg
61-70 kg
71-80 kg
>80 kg
____________________
Signature, Designation
Heparin I.V. Bolus
2700 units
3300 units
3900 units
4000 units
4000 units
_______________
College License#
Initial Heparin Infusion
550 units/hr. = 11ml/hr.
650 units/hr. = 13ml/hr.
750 units/hr. = 15ml/hr.
900 units/hr. = 18ml/hr.
1000unit/hr. = 20ml/hr.
______________
Date
______________
Time
Inferior MI
1. If suspect inferior MI or if ST depression V1-3, do 15 lead ECG r/o posterior
MI
2. IVs, monitor, labs, ECG
3. 15 lead ECG
4. TNK – if severely hypotensive (MAP < 65), consider pressors (below) before
giving TNK. i.e. there may not be enough perfusion for the TNK to work.
5. Have patient on Lifepak and have amp of Atropine handy
6. If hypotensive, give small fluid boluses to maximum 1 liter
7. If still hypotensive, consider Norepinephrine drip – start 0.05 mcg/kg/min
8. If still hypotensive, consider adding Dobutamine Start 2 mcg/kg/min
9. Fentanyl for pain – 25 mcg aliquots and consider infusion.
Page 6 of 61
Acute Pulmonary Edema
IF Adequate Perfusion (i.e. MAP > 65 and warm extremities)
1. Oxygen only if hypoxic. Position patient upright.
2. Non-invasive ventilation (NIV), PEEP 6-8, titrate up to 10-12 as needed.
3. Search for causes (ACS, HTN, arrhythmia, acute aortic or mitral valve regurgitation, aortic dissection,
sepsis, renal failure or anemia) and treat appropriately. (see Vent support page 42)
4. Intubate ONLY if apneic/agonal respirations.
5. Vasodilators – Nitrogylcerin S/L x 4 puffs, then IV infusion starting at 40
mcg/min, increase by 50 mcg/min q 2-4 min up to 200 mcg/min.
6. If Pt in extremis, bolus Nitro loading dose of 400mcg/min x 2 min, then drop to
100 mcg/min. Titrate up prn (Take 200mcg/ml mixture, set pump rate to 120cc/hr. Set
volume to be infused 4 ml – will give 400 mcg/min x 2 min. Or you can take 4 ml nitro and
6 ml NS and give IV over 2 minutes)
7. +/- ACE Inhibitor – SL Captopril 12.5 – 25 mg
8. Fentanyl 20-25 mcg IV for ‘mask anxiety’
9. Labs, CXR, ECG
IF Hypotensive (decompensated CHF) (Cardiogenic shock MAP < 65)
1. Oxygen, vital signs and monitor. 2 IVs large bore.
2. Order ECG, CXR, Labs Search for causes (ACS, PCE, PE, arrhythmia, acute aortic or mitral
valve regurgitation, aortic dissection or sepsis) and treat appropriately.
3. Most of these Pts are complex, consider call to ICU on call physician.
4. Provide non-invasive ventilation (NIV) unless immediate intubation is needed.
NIV will often increase BP.
5. Consider Fluid challenge, 250 – 500 cc N/S over 5 minutes.(Rt HF)
6. Lasix 40 mg IV
7. If known systolic heart failure - Use Inotrope: Dobutamine 2 mcg/Kg/min and
increase to a maximum 20 mcg/Kg/min.
8. If known diastolic heart failure with signs of hypotension– Use IV Vasopressor
- Phenylephrine 0.5mcg/kg/min and titrate. (NO inotropes)
9. If unknown cardiac status and signs of hypotension/shock –
Use Inotrope – Dobutamine 2 mcg/Kg/min and titrate up.
10. If refractory, can add pressor – Norepinephrine start 2 mcg/kg/min
11. Once BP established start low dose Nitro drip and titrate.
12. Fentanyl 20-25 mcg IV prn for anxiety.
Page 7 of 61
Airway Management – RSI Protocols
1. Oxygen. Pre-oxygenate with NRB/+/- OPA or OPA/BVM or LMA/BVM at 15 lpm x 4 minutes
2. Positioning – sniffing position, ideally head up 30 degrees
3. Decide on RSI meds below (16, 17, 18) – ask RN to draw up.
4. Have RN draw up post intubation vent sedation (Fentanyl or Morphine)
5. Have someone get the ventilator, plug in and attach to wall Oxygen.
6. Designate someone to watch monitor. Announce if Sats < 93% or MAP < 65 mmHg.
7. Have someone (or yourself) draw up Push dose pressor of choice (Epi or Phenylephrine)
8. Check for dentures – in for bag mask, out for intubation.
9. Attach in line EtCO2 monitor to BVM
10. Check neck for potential cricothyrotomy, have cric kit available.
11. Have OPA, NPA and LMA available in proper size if not already in use.
12. Pick ET tube. Check balloon with 10 cc air, leave syringe attached. Place stylet or have bougie handy.
13. +/-‘Lube the tube’ – put small amount of sterile lube jelly on ETT tip
14. Choice of laryngoscope. Blade size. Check bulb working. Have spare laryngoscope handy.
15. Suction – turn on, place handle under right shoulder of patient or under pillow.
Normotensive, neurologically stable patient:
16. Pretreatment agent? – Fentanyl 3 mcg/kg
17. Induction agents – Ketamine 2 mg/kg or Propofol 1.5 – 3 mg/kg (or Midazolam 0.3 mg/kg TBW)
18. Neuromuscular blocking agents – Succinylcholine 2 mg/kg or Rocuronium 1.2 mg/kg
Hypotensive/Shock patient
16. Consider Scopolamine 0.4 mg IV
17. Induction agents – Ketamine 0.25 mg/kg or Propofol 0.1 – 0.15 mg/kg
18. Neuromuscular blocking agents – Succinylcholine 2 – 2.5 mg/kg
Elevated ICP/Traumatic head injury patient
16. Have Labetalol 20-25 mg IV on hand for elevated systolic pressure.
17. Induction agents – Ketamine 2 mg/kg
18. Neuromuscular blocking agents – Succinylcholine 2 mg/kg
Asthmatic patient
16. If time permits can give Lidocaine 1.5 mg/kg 3 minutes prior
17. Induction agents – Ketamine 2 mg/kg
18. Neuromuscular blocking agents – Rocuronium 1.2 mg/kg or Succinylcholine 2 mg/kg
19. Ask the team “anything we have missed, any concerns…?”
20. Give Drugs - announce to team "PARALYTICS IN"
21. Cricoid Pressure if needed – BURP
22. Intubate – place ETT 23 cm to lips for males, 21 cm to lips for females. Inflate balloon. Secure
tube.
23. Confirm – listen to chest, check EtCO2 (or colorimetric after 8 breaths)
24. Order CXR to confirm ETT depth
25. Post intubation medications – Fentanyl or morphine infusion. +/- sedation
26. Place NG tube, in line suction
27. Head of bed up 30-45 degrees.
28. Foley catheter.
29. Ventilator settings.
Mode: AC
FiO2: 100%
RR 10-14 bpm for Normotensive or Hypotensive.
14 - 18 bpm for ICP
6 - 10 bpm for Asthmatic
Tidal Volume 8 cc/kg IBW for all patients (except pneumonia, may be less: 6-8)
PEEP 5 or as needed for all except asthmatics.
0 for asthmatics initially.
Give bronchodilators continuously for asthmatics.
30. ABG within 30 minutes post intubation.
Page 8 of 61
Analgesia/Anesthetic for Minor Procedures
“Conscious Sedation”
Resuscitation Setup
1.
2.
3.
4.
Oxygen (prongs or mask)
Atropine 0.4 –0.6 mg amp
Push dose Epinephrine (see page 60 for mixing instructions)
Narcan 0.4 mg. Can dilute in 5 cc syringe N/S. Give 1 – 2 cc (80-160 mcg or 1-2 mcg/kg) to
reverse respiratory depression.
5. Flumazenil (Anexate)
Monitors: BP, O2 Sats, 3 lead ECG and if available, End Tidal C02 monitor
Suction:
IV: one 22 or larger.
Airway: Working Laryngoscope, Oral airway, ET tube on introducer or LMA with Ambubag.
Drugs for Conscious Sedation:
1. Midazolam: 0.02 mg/kg to maximum 2 mg IV slowly over 5 minutes. A drop of BP is often
best indicator of sedation.
Or 1a Propofol: dose 0.5 – 2 mg/kg. Synergistic effect if used with Midazolam
so may have possible apnea.
+
2. Fentanyl: Initial dose is 0.5 mcg/kg (50-100mcg for average adult). Time of onset is
3–4 minutes and lasts 45 minutes.
If respiratory depression, can reverse with Narcan, but Narcan may wear off before Fentanyl
so may need second dose.
Or 3. Ketamine 1-2 mg/kg over 1-2 minutes. May repeat 0.25-0.5 mg/kg
Ketamine (sub-dissociative dose) 0.3 – 0.5 mg/kg
Have on hand:
4. Succinylcholine: Dose 1 mg/kg (comes in 20 mg/cc (have on hand in case patient becomes apneic and you need
to intubate.)
5. Narcan: have drawn up or ready. Use to reverse narcotics (fentanyl)
6. Flumazenil: have drawn up or ready. Use to reverse benzodiazepines (midazolam)
7. Epinephrine push dose: have on hand for hypotension, highly recommended.
8. Atropine: have on hand for bradycardia, highly recommended.
Oral Sedation for Pediatrics: (setting fractures, LPs, suturing etc)
1. Midazolam 0.25 - 0.5 mg/kg up to maximum 8 mg. (tastes awful)
2. Mix with Tylenol 20 mg/kg.
3. can add artificial food tastes
Onset is about 10 – 15 minutes and lasts ~ 30 minutes.
“Quick” Estimate/Calculation of Pediatric Weight
< 8 yr. old = (age x 2) + 8 ~ ____kg
>9 yr. old = (age x 3)
~ ____kg
Page 9 of 61
Procedural Sedation Checklist
Pre-Procedure Assessment
_____ Past medical history (note history of OSA) ______________________________
_____ Prior problems with sedation/anesthesia _________________________________
_____ Allergies to food or medications ______________________________________
_____ Procedure _______________________________________________________
_____ Dentures none / upper / lower
[should remain in during PSA unless intubation required]
_____ Cardiorespiratory reserve no or mild impairment / moderate impairment / significant impairment
_____ Difficult airway features
none / mild concern / significant concern
_____ Weight (kg) ________
_____ Benefits of proceeding with PSA exceed risks
Difficult Airway Features:
Difficult Laryngoscopy: Look externally, Evaluate 3-3-2 rule, Mallampati score, Obstruction, Neck Mobility
Difficult BVM Ventilation: Beard, Obese, No teeth, Elderly, Sleep Apnea / Snoring
Difficult LMA: Restricted mouth opening, Obstruction, Distorted airway, Stiff lungs or c-spine
Difficult Cricothyroidotomy: Surgery, Hematoma, Obesity, Radiation distortion or other deformity, Tumor*
Is this patient a good candidate for ED procedural sedation and analgesia?
The less cardiorespiratory reserve, the more difficult airway features, and the less procedural urgency, the more
likely the patient should not receive PSA in the emergency department.
If not a good candidate for ED-based PSA, other options include regional or local anesthetic; PSA or GA in the
operating room; or endotracheal intubation in the ED.
Emergency Department Procedural Sedation and Analgesia Physician Checklist
_____ Analgesia - maximal patient comfort prior to PSA
_____ Informed consent for PSA and procedure
_____ Patient on monitor: telemetry, NIBP, SpO2, EtCO2
_____ Oxygenate with Nasal Cannula and high flow face mask O2 or non-rebreather mask 15 lpm
_____ Select and draw up PSA agent(s)
_____ Reversal agents and paralytic vials at bedside
_____ Prepare for endotracheal intubation
Pre-procedure Preparation
Airway Equipment
_____ Ambu bag connected to oxygen
_____ Laryngoscopy handles and blades
_____ Suction
____ Oral & nasal airways
_____ Endotracheal tubes & stylets
_____ LMA with lubricant and syringe
_____ Colorimetric capnometer/EtCO2 monitor
_____ Bougie & difficult airway equipment
Page 10 of 61
Anaphylaxis
Clinical Presentation
1. Respiratory compromise. Wheezing, dyspnea, stridor
2. Hypotension – Systolic < 90 mmHg.
3. Skin/mucosal involvement – hives, itch, flushing, swollen lips /tongue/uvula, pilar
erection
4. Persistent gastrointestinal symptoms – cramps, abdominal pain, vomiting.
5. Anxiety, apprehension, sense of impending doom.
6. Seizures, headache.
7. Uterine cramping and/or bleeding.
NB: often anaphylaxis may present as a mild reaction, but can turn into a severe reaction within
minutes… be prepared!
Beware of biphasic anaphylaxis -25% pts have recurrence of symptoms 8-72 hrs. after initial reaction.
Treatment:
Patient should be placed supine with feet elevated.
1. Epinephrine 0.3 -0.5 mg of 1:1,000 IM q 5 min. (Peds: 0.15 mg of 1:1,000 IM)
(there are NO absolute contraindications to epi)
2. If no response, start epi infusion. Start 1-5 mcg/min then titrate
3. Antihistamines: Benadryl 2 mg/Kg up to 50 mg IM, PO, IM – help with itch
and hives but do not treat bronchospasm.
4. Oxygen, 10 – 15 L/min.
5. IV volume resuscitation as needed.
6. Ranitidine 50 mg IV – helps with itch, but not anaphylaxis
7. Consider Methylprednisolone 125 mg IV or 1-2 mg/kg PO daily – may prevent
biphasic reaction only.
8. Ventolin 5 mg via nebulizer for bronchospasm
9. Consider Glucagon 1-5 mg IV q 5 min if Pt on beta blockers. Then infusion of
5-15 mcg per minute.
NB: most common contributor to anaphylaxis related death is not identifying
anaphylaxis and/or delaying treatment with epinephrine
Page 11 of 61
Asthma
Adult Treatment
1.
2.
3.
4.
5.
Oxygen
Ventolin 2 puffs MDI via aero chamber q 5 min up to 12-15 puffs
Or Ventolin 2.5 – 5 mg in 3 cc N/S via neb, q 5 - 10 min.
Add Atrovent aqueous 250 – 500 ug to Ventolin.
If severe, try Epinephrine 0.3 of 1/1,000 S.C. or 2 – 10 ml of 1:10,000 IV q
20min x 3.
6. Steroids: Prednisone 40 – 60 mg PO daily x 7 – 10 days, or Methyprednisolone
125 mg IV x 1 dose, or Hydrocortisone 200 – 500 mg IV x 1 dose.
7. Mg Sulfate 2 gms IV over 20 mins (if status asthmaticus)
8. Consider IV hydration (Normal saline), as often these patients are dehydrated.
Pediatric Treatment
1. Oxygen
2. Ventolin 2 puffs via aero chamber, q 5 minutes up to 12 puffs.
Or Ventolin 0.1 mg/Kg (ie 2 – 5 mg) in 2 – 3 cc N/S via neb.
3. Atrovent 250 ug via neb (can mix with Ventolin)
4. Epinephrine 0.01 mg/Kg of 1:1,100 (up to 0.3 mg) S.C.
Repeat prn q 5 – 10 minutes x 3 doses.
5. If no response after 1 hour (as per Peek Flow) give:
Prednisone 1- 2 mg/Kg PO daily x 3 – 5 days
or Methylprednisolone 1 – 2 mg/Kg q 6 h x 24 hours, then 1 mg/Kg q 12 hours.
6. Consider IV hydration.
7. MgSo4 30-70 mg/kg (max 2 gms) over 20 min for status.
Page 12 of 61
Atrial Fibrillation – Decompensated
This section deals only with decompensated A Fib. Hypotensive.
1. Cardioversion – 360 J. with sedation (ketamine?). Usually doesn’t work
2. Screen for WPW. If wide QRS and Rate 250-300 – Cardioversion+.
3. Phenylephrine take 1 cc from vial (10 mg/ml) add to 100 ml N/S minibag.
Draw up some in syringe – 100mcg/ml. Give .5 - 1 cc q 1-5 min. until
diastolic above 60.
4. Amiodarone 150 mg bolus and then drip
5. Or Diltiazem 2.5 mg/min until HR <100 or maximum 50 mg.
6. If still tachycardic, consider MgSO4, re-shock and consult cardiology.
Page 13 of 61
Bites – Animal and Human
1. All wounds should have vigorous cleaning. Use lidocaine for freezing, clean
surface with 1% Povidone iodine, then copious saline in the wound. Avoid high
pressure irrigation into the wound.
2. X-ray all ‘closed fist’ hand bite injuries. (i.e. cut over knuckles from hitting other
person’s teeth)
3. Cultures of non-infected wounds are of no value
Wound Infection Risk Factors
“High Risk”
“Low Risk”
Bite from:
Cat, human
dog, rodent
Wound on:
hand, below knee, face, scalp, mucosal
over joint, thru & thru oral
Wound type:
puncture (deep), extensive large, superficial, clean, crush, contaminated,
recent (< 24 hrs)
old (> 24 hrs)
Patient:
elderly, diabetic, alcoholic
Wound Care and Prophylactic Antibiotics
Suture
Dog
Cat
yes
Face only
Proph. Antibiotic?
if high risk
all
Antibiotic.
Clavulin or
Clinda + Cipro
Clavulin
or Doxy + Clinda
Clavulin
Human
No
all
(on hand)
Human
Yes
high risk
Clox, Keflex
(not hand)
Self inflicted
Intraoral
Yes
No
Self inflicted
Thru & thru oral Yes
Yes
Pen V
For all wounds: check for Tetanus immunization status.
PCN allergy
Doxy + Clinda
Doxy + Clinda
Doxy + Clinda
Doxy + Clinda
Clindamycin
Suture only if 1. Uninfected, 2. < 12 hours old (< 24 hrs. on face), 3. NOT on the hands or feet.
Indications for Hospital Admission for Human Bites
1. Wound > 24 hours old
2. Established infection
3. Penetration of joint or tendon sheath
4. Bone involvement
5. Foreign body
6. Diabetic
7. Unreliable patient, poor home situation
Page 14 of 61
Bronchiolitis
Clinical: Usually infants < 2 years old, acute onset cough, fever and runny nose for 1 – 2 days,
followed by expiratory wheezing, tachypnea, and respiratory distress. If severe, may have nasal
flaring, intercostal retractions subcostal in-drawing and cyanosis. Has a variable course and
lasts usually a week but can last 3 – 4 weeks.
Most common cause is Respiratory Syncytial virus (RSV).
Treatments:
Do RSV swabs
Mild: Resp. Rate < 40 breaths/min, Sp02 > 92%
Treatment: hydrate, symptomatic (humidified air)
Moderate: Resp. Rate 40 – 60/min, moderate in-drawing, nasal flaring, wheezes/rales, costal
retractions.
Treatment: Oxygen to maintain SpO2 > 90%. (NB O2 is mainstay of Trt! In fact the only
treatment that has been shown to consistently help!)
Saline via nebulization PRN
Wait 1 hour – if improved (Sa02 > 92%) discharge
- if not improved, try ? Epinephrine 0.05 ml/Kg; administer with jet
nebulizer over ~15 minutes every 3-4 hours
- Try? Ventolin 0.03 ml/Kg (.15 mg/Kg/dose) in 2 cc N/S
Wait one hour as above. If no improvement, consider admission.
Severe: As for Moderate + Resp. Rate > 60/min, cyanosis, apneic spells.
Treatment: as above, transfer.
Note: Transfer any patient < 3 months old or who has congenital cardiopulmonary disease
(of any age).
Corticosteroids have been shown to decrease recurrence of bronchiolitis.
Not recommended in healthy infants or for first episode of bronchiolitis. Inhaled steroids
are ineffective.
When indicated, usual dose is Dexamethasone 1 mg/Kg IM daily x 3 days.
Ribavirin, which inhibits RSV, is for children with proven RSV and who are
at risk for severe infections (ie underlying cardiac or pulmonary disease, < 6 weeks
old, metabolic disease, etc.)
Discharge when:
1. Respiratory rate < 60
2. Caretaker can clear infant’s airway using bulb suctioning
3. Patient is stable without supplemental oxygen.
4. Patient has adequate oral intake to prevent dehydration.
5. Caretakers are confident they can provide care at home.
Page 15 of 61
Burns – Thermal
st
1 Degree Burn - Superficial
Minor epithelial damage, no blistering.
nd
2 Degree Burn – Partial thickness
a) Superficial partial thickness – thin walled, fluid filled blister, tender, heal in 2 – 3
weeks.
b) Deep partial thickness – thick walled, commonly rupture, and heal in 3 – 6 weeks.
rd
3 Degree Burn
Full thickness, white leathery appearance, no pain sensation.
If > 1 cm in diameter, usually need skin grafting.
th
4 Degree Burn
Full thickness with underlying fascia, muscle, bone etc. involved.
Assessment
Patients palm is approximately 0.5% Body Surface Area (BSA), palm and fingers (ie hand) is
1%
Use burn sheets with diagrams.
Minor Burns
- 1st or 2nd Degree Burn
- < 10% BSA child or < 20% BSA adult.
- Not over palms, fingers, feet, joints, genitalia or head.
1. If burn occurred within 30 minutes, immerse in cold water for 30 min.
If burn < 9% BSA, may use local cooling for more than 30 minutes.
2. Remove any local jewelry and burned clothing.
3. Leave blisters on palms and soles intact.
4. Blisters elsewhere, aspirate sterilely or remove surface with scalpel.
5. Tetanus shot if indicated.
6. Topical antibiotics of little or no benefit.
7. Prophylactic antibiotics NOT indicated.
8. After cleaning/debriding, apply strips of sterile, fine mesh gauze soaked in
saline. Cover with Flamazine and Telfa dressings. May need to secure in place
with elastic roller gauze.
9. Elevate injured part if possible.
10. Analgesics as necessary.
11. Mobilize injured part after 24 hours.
12. Follow up in 48 hours. Remove outer gauze, if inner gauze adherent to dry
pink wound, simply cover with new 4x4 gauze.
Page 16 of 61
13. Follow up in 4- 5 days. Follow as in 12 above. Because most superficial
partial thickness burns heal in 10-14 days, spontaneous separation of gauze from
burn will occur.
14. If burn exhibits purulent discharge at any time, remove fine mesh, cleanse
with saline. Apply Flamazine and apply Telfa dressing. Remove cream
completely with saline and reapply BID.
15. Encourage use of sun block when necessary over burn x 6 months.
Major Burns – Need Transfer to Burn Center
Transfer if 1st or 2nd Degree Burn and:
- > 10% BSA if < 10 or > 50 years old
- > 20% BSA adult
- Head, feet, hands, genitalia, major joints.
- Inhalation injury known or suspected.
3rd Degree Burn
- > 5% BSA
- Inhalation injury
1. ABC’s,
2. Humidified oxygen @ 10-12 L/min.
3. Elevate legs if hypotensive.
4. Remove all burned clothing and jewelry.
5. Immerse burn in cool water or gauze (12 degrees) for 15 min if burn is less than
30 minutes old and < 20% BSA. Applying cool water to large BSA can cause
hypothermia. DO NOT APLY ICE. Monitor core temp.
6. If transferring to burn center, do not dress burns, just cover in dry sheets.
7. IV – Ringers lactate at 2 – 4 ml/BSA/24 hrs. Give ½ in first 8 hours.
8. Foley
9. Maintain urine output at 30 – 50 ml/hr adults, 1 ml/Kg/hr children.
10. Blood for CBC, LFT, lytes, GFR, carboxyhemoglobin, ABGs.
11. CXR and ECG.
12. If nausea, vomiting insert NG tube.
13. IV narcotics for pain (morphine 5 – 15 mg prn)
14. Cover burn with clean linen. DO NOT APPLY ICE.
15. Do NOT give prophylactic antibiotics.
Page 17 of 61
Burn Care using Aquacel Ag
Page 18 of 61
Coma Management
ABC’s with C-Spine control if indicated.
Glasgow coma scale.
IV’s and Oxygen
ECG, Temp
Do finger prick glucose
Draw blood for CBC, hepatic panel, lytes, Ca, CK, Mg, blood cultures
Urine for drug screen
If blood glucose < 3, give 50 mls of 50% glucose (25 gms) over 3 – 4 minutes
IV
9. Thiamine 100 mg IV
10. Narcan 2 mg IV bolus
11. If febrile (meningitis?) draw blood for blood cultures, then start empiric
antibiotic. Ceftriaxone 2 gm IV (it crosses the blood brain barrier)
This will NOT affect a lumbar puncture test if done within the next 60 hours.
12. Consider Lorazepam for non-convulsive status
13. Consider IV Lipid Emulsion therapy for suspected drug overdose of:
Tricyclic antidepressants, Wellbutrin, Calcium channel, beta blocker,
Antipsychotic (Haldol)
Dosage:
1.5 ml/Kg (ideal body wt) bolus followed by
0.25 ml/Kg/min for 30-60 minutes
Bolus can be repeated 1-2 times for persistent asystole.
1.
2.
3.
4.
5.
6.
7.
8.
Page 19 of 61
Croup
Clinical: usually 2 – 3 days of URTI, low grade fever, runny nose, then ‘seal bark’
coughs – usually at night. Cough lasts 3 – 4 nights and is usually fine during the
day.
Treatment:
Cool mist – ie advice parents to take child in bathroom and put on cold shower to
fill room with cool mist.
In ER:
Mild/Moderate: Sa02 > 93%, Resp. Rate < 60/min, may have retractions with
crying.
- N/S 3 – 5 cc via nebulizer
- If no change/improvement - Epinephrine 0.5 ml/kg (max 5 ml) of 1:1,000
via nebulizer over 15 minutes. Repeat q 20 min.
- Dexamethasone 0.6mg/kg PO (or IM/IV) x 1 dose
- + Pulmicort 2 mg (2 ml) via nebulizer may help if not improving.
Severe: Sa02 < 93%, R.R. > 60/min, stridor & retractions at rest
- 1/1,000 Epinephrine as above.
- Pulmicort 2 mg via neb x 1 dose.
- Dexamethasone 0.6mg/Kg IM or IV
Or Prednisone 1 mg/Kg PO. Controversy whether steroids actually help.
Consider admission if:
1. Moderate symptoms (stridor at rest, retractions) persisting after more than 4
hours from corticosteroid dose.
2. Moderate symptoms persist after more than 2 hours from epinephrine dose
Note: if intubating, use an ETT 0.5 – 1 mm smaller that you would normally
us.
Page 20 of 61
Adult Diabetic Ketoacidosis
For Pediatric Diabetic Ketoacidosis – call Pediatrician!
Laboratory Signs/Diagnosis:
1. Hyperglycemia (serum glucose > 14 mmol/L)
2. Low bicarbonate (HCO < 18 mmol/L)
3. Low pH ( pH < 7.3)
4. Ketones on dipstick – absence almost excludes Dx DKA
5. Anion gap > 10
DDx: Hyperosmolar Hyperglycemic state: glucose > 30, pH>7.3, small or negative
urine ketones,
Treatment
1. Draw serum glucose, K, Cl, BUN, Creat, CBC. LFT, HgA1c PO4, ABG
Urine, ECG, CXR, blood cultures, serum ketones
2. Do K, CL, CO2, creat q 2 hr until glucose less than 14 mmol/L. Glucose q 1 h.
3. Start IV replacement with N/S at liter over 30 minutes. May repeat over 1 hr.
4. Blood glucose should drop by 2.5 – 3 mmol/L over the first hour and about 3 – 5
mmol/L thereafter.
5. Pt’s corrected Na: initial Na + 0.4 X (initial glucose -5.5) = _____mmol/L
If corrected Na >135 mmol/L use 0.45% at 200 ml/hr
If corrected Na < 135 mmol/L use 0.9% NaCl at 200 ml/hr.
When blood glucose < 14 change to D5W + 0.45% NaCl at 150 ml/hr.
6. Potassium replacement. If K > 6 mmol/L no replacement
If K 3.5 – 6 mmol/L give KCL 20 mmol/L added to maintenance fluids
If K 3.0 – 3.4 give KCL 40 mmol/L added to maintenance fluids
If K < 3 mmol/L give KCL 10 mmol in 100 ml minibag over 30 min x 2.
Reassess.
7. Regular insulin Ensure K over 3 mmol/L before starting insulin.
Mix 50 units regular insulin in 250 ml 0.9% NaCl for 0.2 units/ml.
Run at 0.1 units/kg/hr
8. Once serum glucose falls to 11 mmol/L, reduce infusion to 0.02-0.05 units/kg/hr
and change IV to 5% dextrose with 0.45% NS at 150-250ml/hr
9. Maintain glucose 8-11 until resolution DKA.
Page 21 of 61
Treatment Chart of Electrolyte Disorders
Hypo
K
Na
Mg
Ca
Hyper
K < 3.5 mmo/L Critical = K < 2.5 mmol/L
K > 5 mmol/L (Normal 3.5-5 mmol/L)
Causes: GI loss, renal loss, malnutrition
S/S: weakness, paralysis, leg cramps, resp. distress,
ECG flat T waves, Vent arrhythmia, PEA
K < 2.5 mmol/L: K 10-20 mEq/hr
Cardiac arrest due to hypoK: K 10 mEq IV over 5
min.
Causes: CRF, DKA, hemolysis, rhabdo
S/S: weakness, resp. failure, ECG peaked T, wide QRS
K 6-7 mmol/L: 10 u reg insulin in 25 g glucose
(50 ml D50) IV over 20 minutes
K > 7mmol?l: CaGluconate 1 gm (10 ml 10%
sol’n) IV over 10 min.
NaHCO3 50 mEq IV over 5 min
10 units reg insulin in 25 g glucose (50 ml D50) IV
over 20-30 minutes.
Na < 130 mmol/L, Critical < 120 mmol/L
Causes: reduced excretion water by kidneys,
diuretics, renal failure, vomiting, SIADH, CHR,
cirrhosis
S/S nausea, irritable, lethargy, seizures, coma
Na 120-130 mmol/L: fluid restrict
Na < 120 mmol/L slow infusion 50 ml 3% saline
Na < 120 with seizures 100ml bolus 3% saline, then
as above
Na > 145-150 mmol/L (Normal 135-145 mmol/L)
Causes: Increase Na, Cushing’s, Free water loss (GI,
renal)
S/S: altered mentation, weakness, neuro deficits, seizure
Trt: reduce ongoing water loss, N/S or D5 ½ NS
Mg < 0.65 mmol/L
Causes: decreased absorption, loss via GI and renal.
Meds – diuretics, Alcohol
S/S: tremors, nystagmus, tetany, altered mentation,
ataxia, seizures, torsade de pointes.
Mg < 0.65 MgSO4 1-2 g IV over 20-60 min
Torsade de Pointes: MgSO4 1-2 g IV over 5 min
Seizures: MgSO4 2 g IV over 10 minutes.
May need to also give Calcium.
Ca < 2.1 mmol/L
Causes: toxic shock, Mg abnormalities, tumor lysis
S/S: paresthesia, cramps, stridor, seizures,
hyperreflexia, heart failure
Ca < 2.1 mmol/L with symptoms: Ca gluconate 10
– 20 mls of 10% sol’n IV over 10 minutes
Then infuse 60 ml of 10% Ca gluconate in 500-1000
ml of D5W at 1 mg/kg per hour
Monitor Mg, K and pH.
Mg > 1.05 mmol/L (Normal 0.7-1 mmol/L)
Causes: renal failure
S/S muscle weakness, paralysis, ataxia, lowered LOC,
hypoventilation, cardiorespiratory arrest.
Mg > 1.1mmol/L: CaGluconate 1500-3000mg IV
Ca > 3 mmol/L
(Normal 2.1-2.6 mmol/L)
Causes: primary hyperparathyroidism, malignancy
S/S: depression, weakness, confusion, hallucinations,
seizures, coma, constipation,
ECG QT shortening, PR & QRS prolonged, AV block,
cardiac arrest
Ca > 3 mmol/L: N/S 300-500 mg/h to replace fluid
deficit
Monitor Mg and K
Page 22 of 61
Frostbite
Prethaw
1.
2.
3.
4.
Protect part
Stabilize core temperature
IV rehydration (R/L, N/S)
Avoid friction massage
Thaw
1. Re-warm part in circulating water (or large tub) at 40 – 42 degrees C. (no more,
no less) with active motion, until distal flush in skin occurs (usually 10 – 30
minutes). Use thermometer to monitor water temperature.
2. IV analgesics (morphine) as necessary (5 – 10 mg to start then titrate)
Post-Thaw
1. Debride clear vesicles (see below)
2. Leave hemorrhagic vesicles alone.
3. If available, apply topical Aloe Vera q 6 h.
4. Give Ibuprofen (Motrin) 400 mg q 12 h.
5. Analgesics as needed.
6. Elevate involved parts
7. Place cotton pledges/balls between frozen toes
8. Cover with loose clean sheets. No compressive dressings
9. If sever, give strep. Prophylaxis, Pen G, x 48 hours.
10. Avoid nicotine or other vasoconstrictive medications, x 72 hours.
“Progressive Dermal Ischemia” = In clear vesicles with frostbite, arachidonic acid
breakdown products are released forming prostaglandins and thromboxanes which
cause vasoconstriction and further tissue damage under the blister. Thus debride
clear blisters and apply topical aloe vera (Dermaide) and oral Motrin which both
minimize arachidonic acid production. Leave hemorrhagic blisters to prevent tissue
desiccation.
Page 23 of 61
GOUT
“A red joint is septic or crystals – or both”
“No touch Gout Diagnosis”
Score
Male
2
Previous patient reported gout/arthritis attack 2
Onset within 1 day
0.5
Joint redness
1
st
Involvement of 1 MTP
2.5
Hypertension or CVD
1.5
Serum uric acid > 350
3.5
Score of 4 or less – not gout
Score of 4-8 – possible gout (~30% chance)
Score > 8 probable gout
Note: uric acid levels usually fall into low/normal range during an acute attack and return
to normal or elevated only often 2 weeks after the gouty attack.
Treatment options
1. Ice, rest and elevation
2. NSAIDS high dose or Indomethacin 25-50 tid
3. Colchicine 1.2 mg stat then 0.6 mg daily for 5-7 days +/- NSAIDs
4. Prednisone 50 mg daily for 3-5 days
5. Intra-articular cortisone injection
Page 24 of 61
Head Injury/Concussion
Major Head Trauma
1. ABCDE’s as per ATLS. Elevate head of bed 30 degrees.
2. Consider intubation if GCS < 8. (See page 7 on RSI)
3. IV N/S or R/L, NOT D5W. Avoid excessive hypervolemia. Try to maintain MAP 100-110 mmHg.
4. Mild Hyperventilation or normal rates if intubated. Keep PaCO2 35-38 range.
5. Consult Neurosurgeon
6. ? Mannitol 1 g/Kg IV for worsening neurological condition (ie decreasing GCS) (consult Neurosurgeon)
7. ? Lasix 0.3 – 0.5 mg/Kg IV (i.e. 20 – 40 mg)
8. Steroids NOT recommended
9. Barbiturates NOT recommended (unless ordered by neurosurgeon)
10. Watch for cardiac dysrhythmias (especially PSVT)
11. Control seizures with Ativan 2 – 4 mg IV or Valium 5 – 10 mg IV
12. Seizure prophylaxis if:
- Depressed skull fracture
- Paralyzed and intubated (i.e. unable to assess for seizures)
- GCS < 8
- Penetrating brain injury
Use Dilantin 15 mg/Kg IV over 20 – 30 min. Watch BP.
Concussion
“Mild” if GCS 13-15 at 30 minutes post injury
Hallmark signs are confusion and amnesia with or without preceding loss of consciousness.
Westmead Post-concussion Assessment Tool: (one mistake indicates cognitive impairment)
1. What is your name?
2. What is the name of this place? 3. Why are you here?
4. What month are we in? 5. What year are we in?
6. In what town/city are you in?
7. How old are you?
8. What is your date of birth?
9. What time of the day is it?
10. 3 pictures are presented for subsequent recall.
‘Guidelines’ for Sending Patient for CT scan:
CT is usually only required for patients with a history of mild head injury within the previous 24 hours
and any one of the following high risk factors:
1. GCS < 15 at two hours after injury
2. Suspected open or depressed skull fracture
3. Any sign of basal skull fracture (blood behind ear drum, ‘raccoon eyes’, CSF from nose/ears,
‘Battle’s’ Sign.
4. Vomiting > 2 episodes
5. Age > 65
6. Amnesia before impact of 30 or more minutes.
7. Dangerous mechanism (struck by vehicle, fall > 3 ft. or 5 stairs.
8. Neurological deficit
9. Seizure
10. Presence of bleeding diathesis or oral anticoagulant use.
Page 25 of 61
Hypertensive Urgencies and Emergencies
Definitions:
Hypertensive Urgencies: diastolic > 115 mmHg without evidence of end organ damage.
Hypertensive Crisis/Emergency: diastolic > 115 with evidence of end organ damage.
“End organ damage”: renal (increase creatinine, BUN, hematuria or proteinuria), cardiac
hypertrophy/failure (ECG changes of LVH, CXR changes of CHF) or eye damage (cotton wool spots, retinal
hemorrhages).
There is no solid clinical evidence that rapid reduction of asymptomatic sever hypertension is of clinical
benefit. In fact may increase risk.
Elevated BP without evidence of end organ damage rarely requires urgent antihypertensive therapy. ie
look for end organ damage.
The most common cause of hypertensive emergencies/urgencies is inadequately treated essential
hypertension. Other causes are renal and renovascular.
Hypertensive Urgencies:
Treatment can be: watch and wait or ONE or more of the following:
1. Furosemide 20 mg PO
2. Clonidine 0.2 mg PO
3. Hydralazine 10-20 mg IV
4. Captopril 6.25 or 12.5 mg PO
Hypertensive Crisis/Emergencies:
1. Hypertensive Encephalopathy – extremely rare.
Symptoms are severe headache, vomiting, drowsiness, confusion
Rx: Nitroprusside IV drip – 0.25 – 0.5 mcg/kg per min, titrate to max 10 mcg/kg/min
Malignant Hypertension – diastolic > 130mmHg. Is hypertension with evidence of end organ
damage? (see Urgencies above).
Need one or more of the following for diagnosis:
i.
retinal changes (cotton wool spots, hemorrhages)
ii.
elevated BUN/Creat with Hematuria &/or proteinuria
iii.
Left Ventricular Hypertrophy + strain on ECG
iv.
Congestive Heart Failure on CXR
Rx: Nitroprusside drip
Hydralazine 10 – 20 mg IV
Labetalol 20 mg IV push over 2 minutes. Max 40-80 mg. Infusion 2 mg/min titrate.
2. Hypertension with Pulmonary Edema
Rx: Nitroglycerin or Nitroprusside - treat for CHF as per guideline above
3. Hypertension in Pregnancy = > 30 mm systolic rise or > 15 mm
Diastolic or > 130/90
Pre-eclampsia: systolic > 160, diastolic > 110 with a) 24 hr urine < 400c or b) proteinuria > 5
gm/24 hrs or c) visual disturbances.
Eclampsia = pre-eclampsia as above with seizures.
Rx: discuss with Obstetrician – usually use hydralazine or labetalol.
Page 26 of 61
Hypoglycemia
Definition = Blood sugar < 3.0 and symptomatic
1. Have patient ingest 10 – 20 gms of glucose
10 gm glucose is in:
- ½ cup orange juice, soft drink
- 1/3 cup apple juice
- 2 packets or 2 tsp table sugar
2. Follow by starch and protein if next meal is going to be more than 1 hour away.
- 6 soda crackers and 1 ounce of cheese or
- 1 slice of bread and 1 tbsp peanut butter.
3. If unable to give oral glucose, then use one of the following:
- Glucagon 1 mg S.C. or I.M.
(0.5 mg in children under 5 years old)
- 25 gms glucose (50 ml of D5W) IV
- Glucose gel (Instaglucose) inserted into mouth.
Page 27 of 61
Hypothermia
Measure CORE (Rectal) temperature using rectal hypothermia thermometer (in
hypothermia box in Trauma Room)
Clinical:
Mild: 35 – 33
35 – Maximum shivering
34 – Amnesia, dysarthria, normal BP, increase resp. rate.
33 – Ataxia, apathy
Moderate: 32 – 28
32 – Stupor
31 – No shivering any more
30 – Atrial fibrillation, dysrhythmia, decrease BP
29 – Deep loss of consciousness, pupils dilated
28 – Ventricular fibrillation
Severe: 27 – 10
27 – Lost knee jerk (often first thing to return in re-warming)
26 – No pain response
25 – Pulmonary edema
24 – Significant hypotension
23 - No corneal reflex
19 – Flat ECG
18 – Asystole
Management:
1. Avoid excessive movement of patient (may precipitate V. Fib)
2. Avoid pharmacological manipulations of BP (ie no dopamine etc)
3. Treat arrhythmias as per ACLS protocol.
4. Try to re-warm to 35 degrees before pronouncing dead.
5. Give empiric 250 – 500 ml HEATED (40-42 deg.) D5W (NOT R/L)
Microwave 1 liter on high for 2 minutes, shake bag when done)
6. Oropharyngeal intubation is not harmful, nor rhythmogenic
7. Place NG tube
8. ECG monitor
9. Do active external re-warming of THORAX only. Heated pads, bear hugger,
blankets etc.
10. Use heated, humidified Oxygen (42 – 45 degrees)
Page 28 of 61
Intravenous Lipid Emulsion Therapy (ILT)
- ILE is an oil and water microemulsion, soya bean extract. pH 8.0
- Probably works as a ‘lipid sink’ (sequestration) attracting and binding
lipophilic drugs
Indications:
1. Local anesthetic overdose
2. Tricyclic antidepressants, Wellbutrin overdose
3. Calcium channel, beta blocker overdose
4. Antipsychotic overdose (Haldol)
Dosage:
1.6 ml/Kg (ideal body wt) bolus followed by
0.25 ml/Kg/min for 30-60 minutes
Bolus can be repeated 1-2 times for persistent asystole.
Page 29 of 61
Migraine Headache
Beware of Patient with ‘first migraine headache” ie needs Neuro assessment to R/O
other causes.
1. “Classic” (10% Patients)
- preceded by 1 or more reversible aura symptoms (last < 1 hr)
- unilateral (usually)
- photophobia
- Pt should have at least 2 attacks before Diagnosis.
2. “Common” (80% Patients)
- no aura, ½ are bilateral
- aggravated by physical activity
- pulsating
- photophobia, phonophobia
- Pt should have at least 5 attacks before diagnosis
Treatment Options:
1. DHE (dihydroergotamine) 0.5 – 1 mg IM, IV, SC
2. Prochlorperazine 5 – 10 mg IM
3. Metoclopramide (Maxeran) 10 mg IV
4. Toradol 30 mg IV/IM and Maxeran 10 mg IV and 1 liter fluids IV
Page 30 of 61
Overdose – Benzodiazepine
(Ativan, Valium, Propofol, Versed, Serax)
1. ABCD – maintain oxygenation
2. IV access
3. Flumazenil (Anexate)
- 0.3 mg IV over 30 seconds – wait 1 minute
- Then if no response, repeat 0.3 mg IV over 30 seconds.
- May repeat up to maximum 2 mg.
- If no improvement in respirations or level of consciousness, consider other
causes.
- If response, but patient later becomes drowsy again (i.e. ½ life of Anexate
around 45 minutes) may start infusion at 0.1 – 0.4 mg/hr.
- Titrate to response.
Page 31 of 61
Overdoses – Misc.
(Isopropyl Alcohol, Ethylene, Methanol, Cocaine, PCP. TCA, Opioids)
These are ‘some’ of the overdoses, other than alcohol, that one can see in Emergency settings. Often the patient
will not, or can not, give you the information that they have taken a particular drug or substance. The following are
‘clues’ of various signs/symptoms that might warn you of a particular overdose and some first line treatment.
Isopropyl Alcohol (in rubbing alcohol, antifreeze)
Lethal dose is 150 – 250 ml or 2 – 4 ml/Kg
Signs and symptoms
- Headache, dizzy, ataxia (stumbling gait), confused, nausea, vomiting, abdominal pain, no odor of alcohol on breath,
Miosis (pinpoint pupils), sudden respiratory arrest.
Lab: no ketones in urine
Treatment
-
no lavage or activated charcoal (absorption is too rapid)
monitor breathing, give Oxygen
+/- vasopressors (dopamine) for hypotension
+/- dialysis (consider need to be medevac’d – altho most pure isopropyl overdoses recover uneventufully)
Ethylene Glycol (motor coolant, detergents, antifreeze)
Lethal dose ~ 60 mls
Signs and Symptoms
- ‘drunk’ appearing, elevated BP, congestive heart failure, flank pain, oliguria, acute respiratory distress syndrome (respiratory
failure)
Lab: often elevated WBC
Treatment:
- +/- Lavage stomach if less than 2 hours post ingestion
- NO activated charcoal (absorption too fast)
- +/- Narcan 0.4 – 1.4 mg IV
- Thiamine 100 mg IV
- IV fluids (R/L or N/S)
- Consider IV Lasix if signs of CHF
- +/- IV Bicarb (40 mEq) if you know serum pH < 7.2
- Ethanol – can be given PO or IV, but need to measure Ethanol level first.
- +/- dialysis – consider need for medivac
Methanol (antifreeze, window washing fluid)
Lethal dose ~ 30 mls (0.4 ml/Kg of 40% methanol)
As little as 4 ml can cause blindness
Signs and Symptoms
- “walking in a snowstorm”. Pts will complain that their vision is often blurred and it is like walking in a snowstorm
- “yellow spots” in from of eyes. Decreased light perception, headache, dizzy, malaise, dilated sluggish pupils,
(opposite to Isopropyl alcohol ingestion), abdominal tenderness, abrupt respiratory arrest.
Treatment: same as for Ethylene Glycol
Cocaine, ‘Ecstasy’ (MDMA), Amphetamines (‘speed’, diet pills)
Note: Risk of sudden death increases 25 times if cocaine is used with alcohol.
Intoxication Signs and Symptoms:
- euphoria, stimulated, decrease appetite, mydriasis (large sluggish pupils)
- increase BP, HR, RR, Temp
- Chest Pain, angina, acute MI
Overdose Signs and Symptoms
- as above except more so
Page 32 of 61
Bruxism (grinding teeth – esp. with Ecstasy), picking at face, repetitive movements, toxic psychosis, hallucinations
(paranoid)
- Chest pain, cough, SOB, hemoptysis, wheeze (‘crack lung’)
- Bronchitis, pulmonary embolus
- Headache, TIA, CVA, Subdural hemorrhage, spinal cord infarct
- GI ulcers
- Acute renal failure
- Nose bleeds, septal perforation
Treatment:
Pulmonary – Oxygen, +/- intubate
Atrial Tachycardia – beta blockers unless chest pain
Wide QRS Tachycardia – Na Bicarb 40 mEq IV, NO lidocaine
Chest Pain – rule out MI, treat as for angina, but NO Beta Blockers
Seizures/Agitation – IV Ativan, or Haldol (see page 34)
-
PCP (“Angel Dust”, Hog, PeaCe, WOW…..)
Signs and Symptoms
- bizarre behavior, agitated lethargic, confused, can be extremely violent, marked strength, blank stare, nystagmus,
increase BP/HR/Temp, muscle rigidity
Treatment
- Ativan 2 – 4 mg IV, may repeat q 10 – 15 minutes
- Restraints
- Haldol 5 mg IM q 20 min x 3 or until settled. (if given IV watch for hypotension)
- Watch for acute renal failure
- Try to keep temperature down (can develop dangerous hyperthermia)
Pupil Size in Different Overdoses
Miosis (Pinpoint)
Heroin
Morphine
Ethylene glycol
Mydriasis (Dilated)
Cocaine
Anticholinergic (Benadryl, older antihistamines)
LSD, Mescaline
NOTE: If ordering a toxicology urine screen, if you suspect PCP or Ecstasy, they must be specifically asked for,
as ‘routine toxicology screen’ will not detect these.
There is NO drug screen for LSD.
For Treating Major Drug Withdrawal or Agitation see ER Protocol for “Sedation for Severe
Agitation” page 38.
Anticholinergic (Benadryl, Atropine, Cogentin, Atrovent, most older antihistamines)
Signs and Symptoms
- “hot as a hare, red as a beet, blind as a bat, dry as a bone and mad as a hen”
- Increased temp, flushed skin, mydriasis (dilated pupils – blurred vision), dry mouth, low blood sugar, bladder
distention, silly/agitated, violent behavior, visual hallucinations
Treatment:
- Ativan 2 – 4 mg IV or Valium 5 – 10 mg IV
- No physical restraints if possible, as it may increase temperature
- Stomach lavage if ingestion < 1 – 2 hours
- Activated charcoal 1 mg/Kg
Tri-Cyclic Antidepressants (Elavil, Desyrel, Desipramine etc)
Signs and Symptoms
Page 33 of 61
- 4 C’s – convulsions, coma and cardiovascular collapse
- On ECG, will often see ever widening QRS complex until total CV collapse
Treatment:
- maintain airway
- Activated charcoal 1 mg/Kg
- NO diuresis (i.e. no Lasix) or dialysis
- Bicarb if wide QRS or pH < 7.2
SSRI Antidepressants (Prozac, Zoloft, Paxil etc)
Signs and Symptoms
- drowsy, increase heart rate, ECG changes, nausea, vomiting, tremor
Treatment:
- none really, observe, treat symptoms
Opioids (Morphine, Codeine, Demerol, Fentanyl, Heroine, Lomotil)
Signs and Symptoms:
- Note: if addict, there is tolerance built up to all of the following except miosis (small pupils) so the following really
only applies to acute, non addict ingestions.
- Decrease Respiratory rate
- Pulmonary Edema (can have pink frothy sputum)
- Miosis (small pinpoint pupils)
- Nausea and vomiting
- Seizures, twitchy, increase deep tendon reflexes, rigidity
- Usually little on no effect on BP, HR, or heart rhythm
Treatment:
- oxygen
- if oral ingestion, activated charcoal (1 mg/Kg)
- Narcan – use only if sever OD. If used in codeine OD may need large dose of Narcan. Watch for vomiting if using
Narcan, ie protect airway. May need up to 10 mg Narcan.
- If seizures, use IV Ativan 2 – 4 mg
- If pulmonary edema, use oxygen but no? diuretics as that may bottom out BP.
Note: Lomotil OD in children. If child < 5 yrs old, they ALL need hospital admission regardless of dose. They can
develop sudden respiratory arrest.
Page 34 of 61
Overdose - Acetaminophen
Toxic Dose > 140 mg/Kg
(i.e. average 60 Kg adult that is ~ 25 Plain Tylenol tablets)
If Toxic Dose:
1. Obtain a 4 hour ingestion acetaminophen level. If > 150 micrograms/ml, or
above toxic level on graph initiate N-Acetyl cysteine (Mucomyst) therapy.
2. Do baseline AST, SGOT, LDH, PT, PTT, CBC, Lytes, BUN, Creat.
3. Mucomyst (Acetyl cysteine Therapy)
Give within 12 – 16 hours, preferably < 8 hours ingestion.
Oral: (preferred route)
- 140 mg/Kg orally in 20% solution diluted with 4 parts citric juice
or soda.
- Follow with 70 mg/Kg orally q 4 hours for 17 additional doses, or
serum Acetam. level 0.
- If patient vomits within 1 hour of dose, repeat that dose.
Intravenous (use if unable to give orally)
- Loading dose of 150 mg/Kg in 200 ml D5W over 15 min.
- Then 50 mg/Kg in 500 ml D5W over 4 hours
- Then 100 mg/Kg in 1000 ml D5W over 16 hours.
Page 35 of 61
Pediatric Analgesia and Conscious Sedation
LET (lidocaine-epinephrine-tetracaine). It provides adequate local anesthesia for wound closure
in 75 to 90 percent of scalp and facial lacerations in a manner that is equivalent to tetracaine,
adrenaline, and cocaine (TAC) topical solution. LET is less effective on extremity or truncal
wounds
Acetaminophen: Oral - 10-15 mg/kg q 3-4 h
Ibuprofen: Oral - 10-15 mg/kg q 6 h
Nitrous Oxide: 25-50% concentration with oxygen.
Morphine: Oral - 0.3 mg/kg PO q 3-4 h
0.1 mg/kg IV q 2-4 h
Hydromorphone: 0.04 – 0.08 mg/kg ORALLY q 3-4 h
0.015 mg/kg IV q 2-4 h
Ketamine: Oral: 6-10 mg/kg (mix with cola or sweet beverage) – give 30 min prior to
procedure.
IM: 3-7 mg/kg
IV: 0.5 – 1 mg/kg for sedation
Midazolam: 0.25 -0.5 mg/kg PO/SL Mix with liquid Tylenol, cola etc (has bitter taste)
(note: only 15-35% bioavailable orally. Intranasal, buccal and sublingual
has 70-80 % bioavailability)(onset 20-30 min, duration 30-60 min)
0.2-0.3 mg/kg Intranasal
0.2-0.3 mg/kg Buccal
Midazolam IV is also effective for ketamine ‘withdrawal’ effects.
Children undergoing fracture reduction or other painful procedures have been shown to have
good analgesia with combination of Ketamine and Midazolam, with less side effects with
regard to respiratory depression but had slightly higher vomiting rates than when using
Midazolam and Fentanyl.
Page 36 of 61
Post Cardiac Arrest Care
Objectives
1. Control body temperature to optimize neurological recovery and survival.
2. Identify and treat acute coronary syndromes
3. Optimize ventilation
4. Reduce risk of multi-organ injury and support organ function
5. Objectively assess prognosis for recovery
6. Assist survivors with rehab services when required.
7. Involve family members in prognosis and treatment issues.
Treatment
1. Maintain Oxygen saturations >94% but less than 100%
2. Avoid hyperventilation
3. Continuous ECG monitoring
4. Consider therapeutic hypothermia in any patient unable to follow verbal commands after
return of spontaneous circulation (ROSC)
5. Consider sedation/analgesia and even neuromuscular blockade for agitated patients or
who may need induced hypothermia and to control shivering.
6. Consider Vasoactive drugs for sustained hypotension (epinephrine, norepinephrine,
dopamine, dobutamine – consult cardiology/ICU)
7. 12 Lead ECG – if suggestive of ACS treat as per ACS protocol (note: comatose patients
can receive TNK/PCI safely)
8. Maintain blood glucose between 8 – 10 mmol/L.
9. No literature to support use of steroids.
10.Transfer to Tertiary care facility as soon as possible
Therapeutic Hypothermia
1. Goal core temp is 34-36 degrees Celsius for 12 – 24 hours.
2. Place cool wet sheet over patient
3. Ice bags in axilla groin and neck.
4. Wrap hands and feet in dry towels to prevent shivering.
5. Can give ice cold IV fluids (N/S or R/L) 500 ml IV.
6. Monitor core temperature with esophageal (or bladder- less accurate) probes. Not rectal
temp nor axillary.
7. Watch for complications – coagulopathy, arrhythmias and hyperglycemia.
Page 37 of 61
Sedation for Severe Agitation/Psychosis
Haloperidol 5 mg with Midazolam 5 mg IM.
or
Haloperidol 5 mg with Lorazepam 2 mg IM
Or
Midazolam 10 – 15 mg IM
or if IV established:
Time
0 min
20 min
40
Every hour
Haldol IV +
3 mg
5 mg
10 mg
10 mg
Ativan IV
0.5 – 1 mg
0.5 – 2 mg
0.5 – 10 mg
0.5 – 10 mg
Alcohol Withdrawal
4 Components:
1. Early withdrawal – usually occur 6-8 hrs. after last drink
2. Withdrawal seizures – usu. 6-48 hrs. after last drink, can last 2-3 days.
3. Alcoholic hallucinations – occurs 12-48 hrs. after last drink, last 1-2 days
4. Delirium tremens (DTs) occur in 5%, have 5-15% mortality. Can last up to 5
days, not necessarily preceded by hallucinosis or seizures.
1. Lab: CBC, alcohol level, urine drug screen, u/a, CXR/blood/urine culture if
infection suspected.
2. CT head only if altered mental status or clinical suspicion
3. IV and monitor PRN.
4. Ativan 2 mg PO/IV repeat q 2-4 PRN
5. Or Valium 5-20 mg PO/IV PRN
6. Or Phenobarbital 30-60 mg PO for mild symptoms or 15-20 mg/kg slow IV
for severe symptoms or seizures
7. Or Propofol 25-75 mcg/kg/min then titrate as necessary.
8. Dilantin NOT indicated for alcoholic withdrawal seizures.
Page 38 of 61
Seizures – Adult
ABCDE’s
IV lines
Do finger prick glucose and take Temperature.
Draw blood for CBC, LFT, Calcium, Magnesium
If glucose < 3, give Glucose 50 ml of 50% (25 gms)over 5 minutes IV
Thiamine 100 mg IV, IM
Ativan 2 – 4 mg IV or Valium 2 – 10 mg IV or Midazolam 0.1 – 0.2 mg/kg IV (5
– 10 mg)
8. If unable to establish IV, may use Midazolam 0.05 – 0.2mg/Kg IM
1.
2.
3.
4.
5.
6.
7.
(10 mg IM may be more effective than Ativan)
9. For Status Epilepticus:
A. Phenytoin (Dilantin) 20-30 mg/Kg IV at max. 50 mg/min
Patient should be on cardiac monitor to watch for QRS width. Stop drug is
QRS > 50% baseline width. Watch also for hypotension. May repeat 10
min after loading dose. Not for use in alcohol withdrawal seizures. (see
Alcohol Withdrawal page 36)
B. Valproic Acid 20-60 mg/kg IV bolus at 2 mg/min. May repeat 10
Min. after loading dose
C. Phenobarbital 20-30 mg/Kg IV at no faster than 60 mg/min.
D. Propofol 1-2 mg/kg at 20 mcg/kg/min, followed by infusion at
30-200mcg/kg/min (requires mechanical ventilation)
E. Consider Narcan or IV lipid emulsion therapy for drug overdoses
F. Consider empiric IV antibiotics (Ceftriaxone 2 gm) for suspected infection.
IV Antiepileptic Drugs
Ativan:
Valium:
Midazolam:
Onset
Peak Action
Half life
2 – 3 min.
1 – 3 min.
1 –5 min.
45 – 60 min
15 – 30 min
6 – 8 hrs.
3 – 4 hrs.
4 hrs.
Page 39 of 61
Seizures – Pediatric
ABCDE’s: oxygen, suction secretions, recovery position
IV line/intraosseous access.
glucose, CBC, lytes
If glucose < 3, give 25% glucose 2 – 4 ml/Kg IV.
Lorazepam 0.1 mg/kg (max 4 mg/dose) IV/IO/IN
Or Diazepam 0.2 mg/kg IV/IO/PR (max 10 mg/dose) or
Midazolam 0.1 – 0.2 mg/kg IV/IO/IM/IN
7. Phenytoin (Dilantin) 20 mg/kg IV/IO at 50 mg/min (max 1000mg) Have
patient on cardiac monitor, watch BP.
8. Phenobarbital 20 mg/kg IV/IO/IM (note IM takes 2 hours for onset)
1.
2.
3.
4.
5.
6.
For Refractory Status Epilepticus:
9. For Status Epilepticus:
A. Phenytoin (Dilantin) 20-30 mg/Kg IV at max. 50 mg/min
Patient should be on cardiac monitor to watch for QRS width. Stop drug is
QRS > 50% baseline width. Watch also for hypotension. May repeat 10
min after loading dose. Not for use in alcohol withdrawal seizures.
B. Valproic Acid 20-60 mg/kg IV bolus at 2 mg/min. May repeat 10
Min. after loading dose
C. Phenobarbital 20-30 mg/Kg IV at no faster than 60 mg/min.
D. Propofol 1-2 mg/kg at 20 mcg/kg/min, followed by infusion at
30-200mcg/kg/min (requires mechanical ventilation)
Consider Etiology of Pediatric Seizures:
Infectious (febrile, meningitis, abscess..)
Traumatic (cerebral contusion, epidural/subdural hematoma)
Vascular (AVM, subarachnoid/subdural hematoma, migraine)
Metabolic (hypoglycemia, lytes, hypoxia, hepatic and renal failure)
Neoplastic (primary and metastatic tumors)
Toxic (intoxication, withdrawal)
Page 40 of 61
Shock / Hypotension
Think of the cause of shock: (i.e. treat the cause if possible)
1. Hemorrhage
2. Cardiogenic
3. Distributive/Sepsis
4. Neurogenic
Hemorrhagic Shock Class
- Class I : (blood loss up to 15%, < 750 cc)
Vital Signs: normal
- Class II : (blood loss 15-30%, 750-1500 cc)
HR , BP normal, + RR, urine output normal
- Class III : (blood loss 30-40%, 1500-2000 cc)
HR , BP , RR , urine output
- Class IV : (blood loss > 40%, > 2 liters)
HR , BP
, RR
,
urine output.
Rx: Class I and II: 2 IV (18 gauge or larger) N/S or Ringers lactate 500 cc
bolus, reassess, bolus again prn up to 2 liters.
Class III and IV: as above, N/S or Ringers and packed red cells.
Hemorrhagic Shock
1. Look for cause, CXR, FAST, C-spine and pelvic x-ray.
2. 3 Goals: restore fluid volume, maintain oxygenation, limit ongoing blood loss
3. IV access – 16g x 2 in antecubital fossa or intraosseous.
4. 2 liters N/S. If further fluids needed use Ringer’s lactate. Goal is MAP 65
(Goal in traumatic brain injury or blunt abdominal injury is MAP > 105
5. Blood transfusion: If no change in MAP after 2-3 liters fluid give 2 units PRC.
If uncontrolled bleeding requiring > 4 units PRC over one hour, use PRC, FFP
and platelets in 1:1:1 ration (if in a center with these products)
6. No role for vasopressors.
7. Consider Tranexamic acid if less than 3 hrs post start of hemorrhage. Dose is
1000 mg IV over 10 minutes then 1000 mg over 8 hours.
Page 41 of 61
Cardiogenic Shock
1. IV N/S 500 ml aliquots and monitor MAP (goal is > 65 and warm
extremities).
2. Causes: Arrhythmia, PE, PCE, OD, STEMI (note: if STEMI don’t thrombolyse as there is
not enough perfusion to work)
3. Inotropes:
Dobutamine (use if SBP > 80). May cause Tachyc. Start 2 mcg/kg/min.
or Dopamine (improves myocardial contractility). Start 5-10 mcg/kg/min
If MAP still not up to 65 can then add Norepinephrine 0.5 mcg/kg/min
4. Consider Calcium Chloride 1 gm IV thru central line or good AC line (or Ca
Gluconate 3 gm IV through peripheral line).
5. Lasix 40 mg IV
6. Consider NIPPV if pulmonary edema (see Acute Pulm. Edema pg 6)
7. Often will need intubation.
8. CXR, EXG, CBC, Lactate, BNP, lytes, Creat., Ca, Trop, ABG
9. Fentanyl 20-25 mcg IV for anxiety
Distributive/Septic Shock
1. Diagnosis sepsis: documented or suspected infection, Temp > 38.3 or < 36,
HR > 90, tachypnea >20/min, altered mental status, edema, hyperglycemia
in absence of diabetes, WBC > 12,000, elevated lactate > 1 mmol/L,
mottling or decreased cap refill.
2. Oxygen. May need intubation
3. Labs: Blood cultures, CBC, lactate, Creat, lytes, CRP, MSU, CXR.
4. Antibiotics – based on suspected source or empirical. See below
5. 2 IVs - N/S bolus 2 liters, then give Ringer’s lactate. Goal is MAP > 65,
IVP EDE.
6. If MAP > 65 not achieved, vasopressors – Norepinephrine start 0.5
mcg/kg/min
7. Add Epinephrine drip if low cardiac output. Start 2 mcg/min
8. If refractory shock and decreased cardiac output – Dobutamine start 2
mcg/kg/min
9. If refractory consider IV Hydrocortisone 50 mg q 6 hr (200 mg/day)
10. Insulin infusion for hyperglycemia. Monitor blood glu. q1-2 hrs.
11. Repeat lactate after 6 hours, should be lowered by 10%.
Page 42 of 61
Empiric Antibiotics for Sepsis
Pneumonia – Ceftriaxone 2 g IV and azithromycin 500 mg IV
Skin/soft Tissue – Cefazolin 2 g IV and clindamycin 900 IV
GI – Pip/Taz 4.5 g, +/- Metronidazole 500 mg IV and Gentamicin
GU/Pyelo – Pip/Taz 4.5 g
CNS – Ceftriaxone 2 g IV and Vancomycin 25 mg/k
Unknown Source – Pip/Taz 4.5 g IV and Vancomycin 25mg/k and Gentamicin (as per
GFR. > 60 7 mg/k, GFR < 60 or unknown, 2 mg/k)
Neurogenic/Spinal Shock
Only occurs in cord lesions above T8.
Will have hypotension but also bradycardia or normal HR. Can have warm
extremities and good urine output.
Always look for other causes of hypotension.
1. Management is ABCD of trauma
2. Stabilize spinal injury
3. Fluids, pressors to maintain MAP > 105
4. Insert Foley early as bladder distention may occur
5. Severe bradycardia (lesionsC1-5) may require atropine or external pacing.
6. Watch temperature, may lose temperature regulation.
7. ? Methylprednisolone – ask neurosurgeon
Page 43 of 61
Spinal Cord Injury
1. ABCDE’s
2. A c-spine can be “cleared” if the patient is not drunk, obtunded and able to
cooperate. The 4 criteria for a ‘clear’ c-spine are
1) Patient does not complain of any neck pain
2) No pain on palpation of spinous processes.
3) Normal neurological exam, i.e. no sensory or motor deficits in extremities
4) Take collar off and have patient first rotate neck and then flex and extend
neck. If no pain, neck is cleared. If there is pain on any motion, put back
collar.
If there is any question of c-spine injury, obtain lateral, AP and open-mouth neck
x-rays and more likely CT neck.
If cleared by physician, remove collar.
If you suspect injury, with or without normal x-ray series then:
3. Consult Neurosurgeon
4. Remember – lying on a backboard more than 2 hours leads to high risk of
decubitus ulcers.
5. Neurosurgeon may order Methylprednisolone Sodium Succinate 30 mg/Kg IV
followed by 5.4 mg/Kg per hour over the next 23 hours. If used in nonpenetrating spinal cord injury, it should be stated within 8 hours of injury.
NOTE: Some Neurosurgeons do not advocate corticosteroid use so check with
them before administering.
Page 44 of 61
Ventilator Support
Ventilator Settings for Philips Trilogy 202
Pulm Edema, Pneumonia, OD…
Everything except Asthma/COPD
Type 1
O2
NIV/BPAP
Mechanical
Ventilation
+/-
CO2
Asthma/COPD
Type 2
CO2
+/ -
O2
Mode: S/T
PEEP: 5 cm H20 (max 15)
IPAP: 10 cm H20 (max 20)
Fi02: 100% initial
Rate (Backup): 14
Inspiratory time: 1 sec
Mode: S/T
PEEP: O – 5 cm H20
IPAP: 10-15 cm H2O (max 20)
FiO2: 100% initially, usually 40%
Rate (Backup): 14
Inspiratory time: 1 sec
Mode: A/C Volume
Tidal Volume (Vt): 6-8 cc/kg IBW
Resp. Rate: 18 bpm
PEEP: 5 cm H2O
FiO2: 100% initially
Mode: A/C Volume
Tidal Volume (Vt): 8 cc/kg
Resp. Rate: 10 bpm
PEEP: O-4 cm H2O
FiO2: 40 %
After 5 min, do ABG, follow ARDSnet chart
Goal: PaO2 55-85 mmHg or SaO2 90%
Goal: Keep pH above 7.1
Ideal Body Weight
Height
Male-kg
Female-kg
5’ 5’1” 5’2” 5’3” 5’4” 5’5” 5’6” 5’7” 5’8” 5’9” 5’10” 5’11” 6’ 6’1” 6’2” 6’3” 6’4” 6’5” 6’6” 6’7”
52 53 55 57 59 61 63 65 66 68 70
72
74 76 78 79 81 83 85 87
49 50 52 54 55 57 59 60 62 64 65
67
68 70 72 73 75 77
FiO2/PEEP Chart (ARDSnet Chart)
FiO2 0.3 0.4 0.4 0.5 0.5 0.6 0.7 0.7 0.7 0.8 0.9 0.9 0.9 1.0
PEEP 5 5 8 8 10 10 10 12 14 14 14 16 18 18-24
Points to Remember
Non-Invasive Ventilation (NIV)
1. Never hesitate to call for help from the RT.
2. Be cautious using NIV on patients with pneumonia or excessive secretions
3. Contraindicated with obtunded, respiratory arrest, pH < 7.2, or facial deformity.
4. EtCO2 does NOT equal PaCO2
5. For COPD/Asthma, if following CO2, can use venous blood gases.
6. For COPD/Asthma remember to continue to give nebulizers.
7. Mode can be S/T for all respiratory failure types.
8. Be aware of AutoPEEP in asthmatics/COPD.
9. Pulse Oximetry lags behind present patient condition by at least 30-60 seconds.
10.Never hesitate to call for help from the RT.
Page 45 of 61
Mechanical Ventilation – some hints
1. Never hesitate to call for help from the RT
2. Use Assist/Control mode for all types of respiratory failure.
3. For Pulm Edema and other Type 1 failure, use FiO2 100%, at least initially
4. For Asthma/COPD use FiO2 40%
5. Use ‘Ideal Body Wt” for tidal volume, NOT the patient’s actual weight.
6. Respiratory Rate is what controls CO2 levels
7. FiO2 and PEEP control Oxygenation
8. Don’t change Tidal Volume unless concern about barotrauma. Especially don’t change it
to effect the CO2 levels.
9. In CHF and other Type 1’s, goal is to keep PaO2 ~ 80 mmHg or SpO2 90%
10.In Asthma/COPD, goal is to keep pH > 7.1.
11.In Asthma/COPD remember to continue to give nebulizers.
12.In CHF and other Type 1’s, the worse the CXR, the smaller the tidal volume.
13.If PaO2 is too low – increase PEEP and/or FiO2
14.If PaCO2 is too high – increase the respiratory rate.
15.If PaCO2 is too low – decrease the respiratory rate.
16.If all the alarms are going off, BP dropping etc, disconnect the vent and bag the patient.
Then check for blockage, pneumothorax,…
17.Never hesitate to call for help from the RT.
Page 46 of 61
Settings for LTV 1000 Ventilator
Pulm Edema, Pneumonia, OD….
Everything
except Asthma/COPD
Mode:
SIMV/CPAP
NIV/BPAP
Type
Set Breath rate to - - (or
will1 be in SIMV)
PEEP: 5 cm H20 (max 15) (*)
+/- 20) CO2
PSV (IPAP): 10 cm H20 (max
Fi02: 100% initial
O2
Mechanical
Ventilation
Mode: A/C Volume
Set “Sensitivity” to 3 (**)
Tidal Volume (Vt): 6-8 cc/kg IBW
Resp. Rate: 18 bpm
PEEP: 5 cm H2O
FiO2: 100% initial
IFR: 60-80 lpm
After 5 min, do ABG, follow ARDSnet chart
Goal: PaO2 55-85 mmHg or SaO2 90%
Check Plateau Pressure – push the
‘inspiratory hold’ button.
Keep lowering Vt until Plat pressure < 30
Don’t go below 4 cc/kg IBW
Asthma/COPD
Mode: SIMV/CPAP
Type 2
PEEP: O – 5 cm H20
PSV (IPAP): 10-15 cm H2O (max 20)
FiO2: 100% initially +/ -
CO2
O2
Mode: A/C Volume
Tidal Volume (Vt): 8 cc/kg (***)
Resp. Rate: 10 bpm
PEEP: O-4 cm H2O
FiO2: 40 %
IFR: 80 – 100 lpm
Goal: Keep pH above 7.1
Ideal Body Weight
Height
Male-kg
Female-kg
5’ 5’1” 5’2” 5’3” 5’4” 5’5” 5’6” 5’7” 5’8” 5’9” 5’10” 5’11” 6’ 6’1” 6’2” 6’3” 6’4” 6’5” 6’6” 6’7”
52 53 55
57 59 61 63 65 66 68 70
72
74 76 78 79 81 83 85 87
49 50 52 54 55 57 59 60 62 64 65
67
68 70 72 73 75 7 7
FiO2/PEEP Chart (ARDSnet Chart)
FiO2 0.3 0.4 0.4 0.5 0.5 0.6 0.7 0.7 0.7 0.8 0.9 0.9 0.9 1.0
PEEP 5 5 8 8 10 10 10 12 14 14 14 16 18 18-24
(*) Remember: On the LTV 1000, CPAP is set using the valve located at the terminal end of the
circuit (tubing)
Because the CPAP is not set internally, the LTV is not ‘PEEP compensated’. Thus if you give
‘Pressure Support’ (PSV) of 5 and PEEP of 5, the amount of pressure delivered on inspiration will
be 0. PSV 12 and PEEP 5, pressure delivered will be 7.
(**) in A/C mode, if the sensitivity is set to zero (- -) the mode will be ‘Assist’.
If the sensitivity is anywhere from 1-9, the mode will be A/C.
(***) for COPD/Asthma, use as large an ET as possible (ie 8)
Page 47 of 61
ATLS Protocol
Are you protected?? Gloves, gown and goggles?
A
B
C
D
E
Airway with C-Spine Control
Look, Listen & Feel for breath sounds. Suction if necessary
Chin lift, jaw thrust, oral airway
Problem?
Consider Intubation
Breathing. Listen to chest, look for JVD,
Trachea midline?
Problem?
Consider need for chest tube/pericardiocentesis?
Circulation.
BP, skin color, capillary refill
Look for obvious bleeding, apply pressure
Start 2 IV’s (Ringers), blood for CBC, lytes, Blood type
and x-match
Disability.
AVPU: (Alert, Verbal Response, Pain Response, Unconscious)
Glasgow Coma Scale
Expose and Environment
Remove ALL clothing, cover with warm blanket
Log Roll (protecting spine) and inspect back.
If possible hypothermia, do rectal/core temperature.
eFAST sooner than later if available and competent staff.
Page 48 of 61
Secondary Survey – “Head to Toe”
Light in ears, eyes, mouth
Palpate scalp, facial bones, +/- C-spine and collar bones.
If OK, insert NG tube.
Listen to heart.
Listen to chest; look at neck for JVD and tracheal deviation.
Palpate abdomen.
Palpate pelvic bones (down, out and distract legs).
Rectal exam, any blood at meatus?
If normal, insert Foley – do urine preg test on females.
Palpate arms for pain, have patient move feet, bend knees, assess foot
planar/dorsi flexion, assess sensation and reflexes, plantar responses.
EDE FAST scan
Clear C-Spine?
If patient is alert, sober and cooperative to exam:
1) Patient complains of NO pain in neck
2) No pain on palpation of spinous processes.
3) No abnormality on sensory or motor exam of extremities
NB: If any of the above positive, leave c-spine collar on and neck must
be cleared with C-spine x- rays/CT scan by physician.
4) Remove collar
5) Have patient slowly rotate neck, then flex neck and finally extend neck.
Stop if pain at any point, return collar. If no pain, C-Spine can be
clinically cleared and collar left off.
Radiology “Trauma Series”
1. CXR
2. Pelvis
3. C-Spine
“AMPLE History”
Allergies
Medications, Drugs/Alcohol Ingestion
Past Medical/Surgical history
Last meal, LMP/Pregnant
Events: History of accident and mechanism.
Page 49 of 61
Glasgow Coma Scale
ADULT
Eye Response
Spontaneous
To Voice
To Pain
None
Verbal Response
Oriented
Confused
Inappropriate
Incomprehensible
None
Score
4
3
2
1
5
4
3
2
1
Motor Response
Obey command
Localizes pain
Withdraws from pain
Flexes to pain
Extension to pain
None
SCORE
PEDIATRIC
Best Eye Response
Eyes open spontaneously
Eye opening to speech
Eye opening to pain
No eye opening or response
Best Verbal Response
Smiles, oriented to sounds, follows objects, interacts
Cries but consolable, inappropriate interactions
Inconsistently inconsolable, moaning
Inconsolable, agitated
No verbal response
Best Motor Response
Infant moves spontaneously or purposefully
Infant withdraws from touch
Infant withdraws from pain
Abnormal flexion to pain for an infant (decorticate)
Extension to pain (decerebrate)
No motor response
SCORE
4
3
2
1
5
4
3
2
1
6
5
4
3
2
1
/15
6
5
4
3
2
1
/15
Page 50 of 61
PROCEDURES:
Chest Tube Insertion
Equipment Needed:
Betadine
Sterile field drape
Local anesthetic (1 or 2% lidocaine with epi)
10 ml syringe, 18 gauge needle, 25 gauge needle
#10 scalpel
Chest tube (Adult 28-32 Fr., Child 20-24 Fr., Infant 18 Fr.)
2 Large Curved Kelly clamps
Plastic connecting tubing
Pleurovac
Adequate suction (ideal is wall suction of 60 cm H2O)
Needle holder
Suture scissors
0-silk
Sterile 4x4 sponges
Antibiotic ointment
Orange Elastoplast tape
Procedure:
6. Select site, fourth intercostal space in the mid-axillary line. (this corresponds to a line drawn
from the nipple to underneath the middle of the armpit) Fig 4.25
7. Prep skin with betadine or antiseptic. Note this is a sterile procedure, so wear sterile gloves
and mask.
8. Infiltrate skin with 2% lidocaine along site of incision, subcutaneous tissue and along
anterior rib margin.
9. Make a linear incision along the rib, one interspace below the site of insertion.
10.Insert curved Kelly clamp and tunnel superiorly to the interspace that is to be entered.
Remain on the upper border of the rib to avoid the neurovascular bundle. Fig 4.27
11.Gently but forcibly enter the thoracic cage by advancing the closed curved clamp through
the pleura. A gush of air or blood will usually escape out the hole. Open the curved clamps
to enlarge the opening. Do not advance the tips of the clamps any further than is necessary
to avoid damage to the lungs. Fig 4.28
12.Insert a sterile gloved finger into the pleural space to prevent inadvertent passage of the tube
into the lung should unsuspected pleural adhesions be present. If adhesions are felt, they
should be separated away from the lung with the finger before chest tube insertion. Fig 4.29
13.Cover the pleural opening with the hand before the tube is placed. With a curved clamp,
grasp the tip of the chest tube and advance it through the skin and into the intercostal space.
Fig 4.30
Page 51 of 61
14.Secure the tube to the skin with 0 – silk as in diagram. Close remaining incision site
opening with sutures. Fig 4.31, 4.32
15.Apply antibacterial ointment followed by 4x4 gauze. Secure the dressing with orange
waterproof tape.
Note: A simple underwater seal (3 bottles or Pleurovac) is usually adequate for draining fluid
(blood) from the chest cavity. If air only (ie a pneumothorax) then it is best to add some
suction if possible, if only 20 cm of water.
Pleurovac
Page 52 of 61
Tick Removal
1. Clean around the area with povidone-iodine.
2. With blunt forceps, tweezers or gloved fingers, grasp the tick as close to the skin surface
as possible and pull upward with steady pressure. Do NOT twist or jerk the tick as the
mouthparts may break off.
3. Never squeeze, crush or puncture the body as fluids contain infectious products.
4. Disinfect the bite site.
If the tick is too embedded
1. Disinfect the area as above
2. Apply a punch biopsy so that it encompasses the tick.
3. Advance the punch biopsy down to the dermis.
4. Remove punch, then cut the pedicle with scissors or scalpel.
5. Suture or apply pressure to punch site after disinfecting.
6. Another options is to try ‘drowning’ the tick by covering with a specimen container filled
with water. Tick will sometimes back out on its own.
Zipper Injury
For Penis/scrotum caught in zipper:
1.
2.
3.
4.
5.
6.
7.
8.
9.
If it is a child you may need to use oral sedation.
Can also infiltrate skin with local Xylocaine
Paint the area with povidone-iodine.
Cover the area with liberal amounts of mineral oil. Leave this in place for 15-20
minutes. This lubricates the moving parts and often frees the skin.
If mineral oil doesn’t work, there are two techniques to try.
First method is to grasp the zipper with fingers or Kelly forceps and while gently
pulling apart twist your wrists in opposite directions (supination), which can
sometimes separate the two halves of the zipper
The second method is to cut the metal bar at the bottom of the zipper with wire
cutters, tin snips or a small hack saw. This then releases the zipper.
Assess need for tetanus vaccination
Clean the skin and if necessary suture or steristip any laceration.
Page 53 of 61
Ankle Brachial Index (ABI)
-The Ankle Brachial Index (ABI) is the systolic pressure at the ankle, divided by the systolic pressure at the
arm.
-It has been shown to be a specific and sensitive metric for the diagnosis of Peripheral Arterial Disease. Additionally, the ABI has been shown to predict mortality and adverse cardiovascular events independent of
traditional CV risk factors.
-The major cardiovascular societies advise measuring an ABI in every smoker over 50 years old, every diabetic
over 50, all patients over 70 and ANY patient you are considering using venous compression stockings on.
Method:
-The ABI is performed by measuring the systolic blood pressure from both brachial arteries and from both the
dorsalis pedis and posterior tibial arteries after the patient has been at rest in the supine position for 10 minutes.
-The systolic pressures are recorded with a handheld 5- or 10-mHz Doppler instrument. Usually a standard
blood pressure cuff can be used at the ankle. It is recommended to begin with the right arm, then the right leg,
then the left leg, and finally the left arm, as the blood pressure may drift during the exam, and the two arm
pressures at the beginning and end of the exam provide for some quality control.
-An ABI is calculated for each leg. The ABI value is determined by taking the higher pressure of the 2 arteries
at the ankle, divided by the brachial arterial systolic pressure.
-In calculating the ABI, the higher of the two brachial systolic pressure measurements is used. In normal
individuals, there should be a minimal (less than 10 mm Hg) interarm systolic pressure gradient during a routine
examination. A consistent difference in pressure between the arms greater than 10mmHg is suggestive of (and
greater than 20mmHg is diagnostic of) subclavian or axillary arterial stenosis, which may be observed in
individuals at risk for atherosclerosis.
Eg: Right ABI = Highest pressure in Right foot (post tib or dorsalis)
Highest pressure in Both arms
>1.4 can be seen in diabetics and elderly
patients.
0.8-0.9 should only use compression
stockings with caution.
< 0.8 and lower should NOT have
compression stockings applied.
Page 54 of 61
Subungual Hematoma Evacuation
Indications:
1. Painful Subungual hematoma with nail edges intact. Not necessary if the nail is not
painful.
Contraindications:
1. Crushed or fractured nail bed.
2. Nail edges are disrupted by a deep laceration. However most nail bed lacerations do not
need repair. In the past hematomas over 50% of the nail bed were thought to indicate
laceration of underlying nail bed – which some experts said required removal of the
whole nail and repair of the laceration to avoid post traumatic nail bed deformity – this
has been shown to NOT be the case.
Technique:
1. Consider x-ray for fracture distal phalanx, may need splint for comfort.
2. Clean nail.
3. Heated paper clip (use lamp bulb to heat), or
4. Battery operated Cautery unit (caution with acrylic nails – flammable!), or
5. 18 gauge needle – twirl needle between your fingers to drill hole.
6. Assess for Td vaccination.
7. Keep finger elevated, cool compresses for 12 hours. Avoid soaking and keep dry for 2
days.
8. Advise patient the nail may fall off in the following week but should regrow providing
the nail matrix is intact. Also advise patient this procedure will not hasten healing or
prevent infection.
Fishhook Removal
1. Freeze skin with lidocaine
2. Using an 18 gauge needle, advance down the shaft
to cover the barb.
3. Advance hook slightly to dislodge the barb, then
back the hook and needle out
1. Freeze the skin
2. Advance hook up through skin, and
then clip off with wire cutters.
3. Back out hook.
Page 55 of 61
Priapism
All cases should be discussed with urologist.
Causes: Drugs (anticoagulants, antihypertensives, antidepressants, ED treatments, blockers, cocaine, alcohol,
testosterone, haematological disorders, metabolic disorders, trauma, neurological disorders etc)
Identify if priapism is:
“High flow” – painless and usually caused by blunt tramua to penis or perineum.
Treatment is often just observation, but if unsuccessful, then surgery done by
urology, identifying fistulas etc.
In young children with high flow priapism, perineal compression
with the thumb will cause prompt detumescence, called Piesis sign
“Low Flow”- painful, most commonly seen due to ED medications.
Treatment:
-
-
-
Can try oral pseudoephedrine or oral beta-agonists such as terbutaline.
Intracavernosal phenylephrine (Neo-Synephrine) is the drug of choice and first-line treatment
of low-flow priapism because the drug has almost pure alpha-agonist effects and minimal
beta activity. In short-term priapism (< 6 h), especially for drug-induced priapism,
intracavernosal injection of phenylephrine alone may result in detumescence. Use a mixture
of 1 ampule of phenylephrine (1 mL: 1000 mcg) and dilute it with an additional 9 mL of
normal saline. Using a 29-gauge needle, inject 0.3-0.5 mL into the corpora cavernosa,
waiting 10-15 minutes between injections. Vital signs should be monitored, and compression
should be applied to the area of injection to help prevent hematoma formation. This is found
to be almost 100% effective, if done within 12 hours of onset.
The next step in the treatment of low-flow priapism is aspiration of the corpora cavernosa
followed by saline irrigation and, if necessary, injection of an alpha-adrenergic agonist (eg,
phenylephrine). Placement of a penile nerve block with a long-acting local anesthetic such as
bupivacaine (Sensorcaine) without epinephrine increases patient comfort and improves
patient cooperation with the sometimes-painful penile aspiration procedure.
Aspiration is best performed by placing a large-bore intravenous catheter (ie, 16- to 18gauge) into the lateral aspect of the corpus cavernosum. A unilateral approach is adequate
because of the vascular channels between the 2 corpora cavernosa. Local lidocaine or a
penile ring block may be used for anesthesia. Aspiration may be difficult because of the
sludging of blood within the corpus cavernosum.
Page 56 of 61
Shoulder Dislocation
There are at least 8 maneuvers for reducing a shoulder dislocation. They all work!
Before attempting a reduction.
1. Check for axillary nerve compromise – (ie check for intact sensation over the deltoid
muscle area)
2. Always obtain xrays to ensure no fracture.
If you have no access to IV sedation/analgesia the following can be used.
Hennipen and modified Kocher Technique.
1. Pt is seated upright or at 45 degrees. MD stabilizes the elbow and wrist.
2. Slowly externally rotate the Pt’s elbow until 90 degrees. It may have to be in steps to
let muscle spasm and pain subside.
3. Ususally reduction occurs by 90 degrees, but if not, then slowly elevate the arm.
(modified Kocher)
If you have IV sedation then either of the following can be used
Stimson Technique
1. Pt is placed in prone position on a stretcher.
2. A rolled up towel is then placed under the coracoid process.
3. A weight is affixed to the wrist (wts or a bucket of water). Use gauze roll not tape.
4. If necessary the MD can facilitate by gently internally/externally rotating the arm.
Page 57 of 61
Milch-Cooper Technique
1. Pt is supine on stretcher.
2. With the arm slightly abducted and with forward traction, start to bring the arm up
until it is directly overhead.
3. Often reduction will occur at this point. If not one can slowly internally/externally
rotate the arm.
4. If step 3 is ineffective,using outward traction and abduction bring the arm slowly
through a full lateral downward arc.
Page 58 of 61
Drug
IV Drugs in the Emergency Department
Indication
Dosage
Adenosine
PSVT Conversion
6 mg IV push, may repeat
12 mg IV q 1-2 min x 1-2 doses
Amiodarone
VF/Pulseless VT
300 mg IV/IO
Wide Complex Tach
150 mg IV x 1 over 10 min
Then 1 mg/min x 6 hrs
Atropine
ACLS Brady
0.5 mg IV/IO q 3-5 min, to max 3 mg
ACLS Asystole
1 mg IV/IO q 3-5 min
Cardiogenic shock/brady
0.5 mg IV/IO q 3-5 min
Organophosphate poison
2 mg IV/IO q 5 min
Calcium Chloride Hypocalcaemia
.5- 1gm IV over 10 min
use central line if possible
CCB overdose
1-2 g IV over 10 min, repeat q 20 min x 5 doses
Calcium Gluconate Hypocalcaemia
1.5-3 gm IV over 10 min (may use peripheral IV)
CCB overdose
3-6 g IV over 15-20 min
Dexamethasone Croup
0.6 mg/kg PO x 1
Diazepam
Seizure
5-10 mg IV q 5-10 min, max 30 mg
Diltiazem
AF/Flutter/PSVT
0.25 mg/kg IV, 5-15 mg/hr infusion
Digoxin
CHF/AF/PSVT
4-6mcg/kg IV, then ¼ loading dose q 8 h x 2
Dobutamine
Cardiac decompensation
2-20 mcg/kg/min. Start 2 mcg/kg/min
Epinephrine
ACLS-VT/Vib/PEA
1 mg (1:10,000)IV q 3-5 min
Brady/cardiac output maint. 2-10 mcg/min
Anaphylaxis
0.1-0.5 mg (1:1000) IM/SC, max 1 mg
‘Push Dose’
1 cc 1:10,000 Epi in 9 cc N/S (10mcg/ml).
Use 0.5-1 ml q 3 - 5 min
Fentanyl
Sedation/pain
25-50 mcg IV, infusion 25mcg/hr titrate
RSI
50-100mcg IV
Flumazenil
Benzodiazepine OD
0.2-0.5 mg IV q min x 5 doses max,
Infusion 0.1-0.4 mg/hr
Glucagon
Hypoglycemia
1 mg SC/IM/IV
Beta Blocker OD
3-5 mg IV, 1-5 mg/hr IV infusion
Haloperidol
Acute psychosis
5-10 mg IV
Hydralazine
HTN crisis
10-20 mg IV q 2-4 hr
Hydrocortisone Status asthmaticus
300-400 mg/day IV divided q 6
(Solu-cortef)
Septic Shock
200-300 mg/day IV divided q 6
Isoproterenol
Shock/Hypotension
0.5-30 mcg/min IV
Brady due to
2-10 mcg.min
CCB/BBlocker OD
Ketamine
Anesth induction/Proc Sed 1-4 mg/kg IV over 1 min
Peds Proc. Sedation
0.5- 1.5 mg/kg IV over 1 min
Sub-dissoc dose – analgesia 0.3 – 0.5 mg/kg IV
Pediatric Proc. Sedation
0.5 – 1.5 mg/kg IV over 1 min
Page 59 of 61
Drug
Indication
Dosage
1:1 Ketamine/Propofol. Proc Sed: 0.3 – 0.5 mg/kg
HTN emerg
start 20 mg IV, max 300 mg total
Infusion 2 mg/min IV
Lipid Emulsion Local Anesth/TCA/BBlocker,1.5 ml/kg bolus, then 0.25 ml/kg/min for
1st Gen antipsychotic OD
30-60 min. Repeat bolus for persistent asystole
Lorazepam
Seizure/Status
3-4 mg IV/IO. Repeat x 1 q 10 min
Mannitol
Cerebral Edema
0.25 – 1 gm/kg IV
Magnesium Sulfate Symptom. HypoMg
1-4 gm IV
Seizure/Preeclampsia
1-2 gm/hr IV, start 4 gm IV
Vent. Arrhyth/Torsades
2 gm IV
Methylprednisolone
Anaphylaxis
1 – 2 mg/kg PO daily
Metoprolol
Acute MI
5 mg IV q 2 min x 3 doses
After 15 min give 50 mg po q 6 h
Midazolam
Proc. Sedation
1-2 mg IV q 2-3 min, max 5 mg
RSI
0.1 mg/kg IV
Agitation, violent behavior 5 -10 mg IM
Seizure
10 mg IM
Morphine
Analgesic
2-5 mg IV prn
Naloxone
Opioid OD
0.1 mg IV/IO 0.4 mg IM
0.0025 - 0.16 mg/kg/hr IV
Nitroglycerin
Angina
start 5 mcg/min
Acute Pulm Edema
50 mcg/min to max 200 mcg/min
Norepinephrine Hypotension/Sepsis
start 8-12 mcg/min. Maint 2-4 mcg/min
Phenobarbital
Seizure
10-20 mg.kg IV x1
May repeat 10 mg.kg
Phenylephrine Shock
50-100 mcg/min IV
Mild hypotension
10-150 mcg IV q 10 min. onset 1 min, durat. 15-20 min
“Push Dose”
50 – 100 mcg IV q 5 – 10 min
Propofol
Procedural Sedation
0.5 – 1.5 mg/kg IV
RSI
1.5 – 3 mg/kg IV
Infusion -post intubation
start 5 mcg/kg/min. x 5 min, then titrate (5-50mcg.kg/min)
Ranitidine
Anaphylaxis itch
50 mg IV
Rocuronium
Intubation
0.6 – 1.2 mg/kg IV
Succinylcholine RSI paralysis
1-2 mg/kg IV can premedicate with atropine
Sotalol
VT/VF
75- 100 mg IV q 12 h
TNKase
STEMI
<60 kg = 30 mg IV
60-69=35 mg
70-79=40 mg
80-89=45 mg
>90 kg=50 mg
Vasopressin
VF/VT/Asystole/PEA
40 units IV/IO
Verapamil
PSVT conversion
2.5-10 mg IV
Atr. Fib/Flutter
2.5-10 mg IV
Xylocaine
Status Seizure
1 mg/kg IV bolus
VF/VT
0.5-0.75 mg/kg IV q 5-10 min,
Then 1-4 mg/min
Ketofol
Labetalol
Page 60 of 61
Cardiovascular Effects of IV ER Drugs
Alpha 1 – Agonists cause vasoconstriction. Antagonists cause vasodilation
Alpha 2 – CNS mediated, agonists cause hypotension, sedation.
Beta 1 – heart effects: inotropic (strength of contraction), chronotropic (heart rate),
dromotrophic (‘conduction’)
Beta 2 – Lung effects: agonists cause bronchodilation, antagonists cause bronchoconstriction
 1
1
Inotr Chron Dromo
Drug
&2
Phenylephrine
+++
Epinephrine
+++
+++
++
Norepinephrine
+++
++
Dobutamine
Dopamine
o/+
o
+
++
0.5-2mcg/k/min
5-10
10-20
Digoxin
Amiodarone
Atropine
Ca Chloride/Gluconate
Dihydropyridone –
Amlodipine (Nifedipine)
Non-dihyd - Phenylakytlamine
Verapamil
Non-dihyd. - Benzothiazepine
Diltiazem
Beta Blockers
Nitroglycerine
ACE Inhibitors
Mg Sulfate
Isoproterenol
Ketamine *
++
++
++
++
+++
++
o
+
+
++
++
+
o
o
o
_
Propofol ****
Midazolam #
o
SVR/CO
SVR
+
_
_
_
+
__
_
_
0
_
_
_
Low dose ven V/D
High dose art V/D
__
+
+
-SA/AV
+
+
+ V/D via B2
receptors
+
+
+
_
+
Fentanyl **
Morphine ***
o
+
Arterial V/D
_
V/C V/D
-SA/-AV
+SA/AV
+
Arterial V/D
No venous V/D
Min. Art V/D
2
_
_
+
+
+ SBP
-DBP
+
+
++
++
Page 61 of 61
* Ketamine – negative inotrope but due to secondary CNS simulation causes
increase in pulmonary BP, heart rate, cardiac output and myocardial O2 demand.
Usually there will be no changed in systemic vascular resistance.
** Fentanyl – Usually has minimal or no effect on BP, LV Pressure and cardiac
output. Initial boluses can decrease MAP. May have some negative Chronotropy
(decrease HR) that can be treated with atropine.
*** Morphine – lowers BP via decreasing alpha adrenergic tone mediated through
the CNS.
****Propofol – can cause large reduction in MAP via venous and arterial
vasodilation. It also blocks normal baroreceptor mediated tachycardia which would
normally counteract these changes.
# Midazolam – has minimal CV effects.
Mixing Instruction for Push Dose Pressors and Ketofol
Epinephrine:
Take a 10 cc N/S syringe. Discard 1 cc.
Take a preloaded syringe of Epi 1:10,000 from the cardiac drawer.
Take the bottom stopper off the syringe.
With the 9 cc Saline syringe, draw out 1 cc Epi (1:10,000)
You now have 10 mls of Epinephrine 10 mcg/ml
Dose is 0.5 – 2 ml (5-20 mcg) q 2-5 min
Onset 1 minute, duration 2-5 minutes.
Phenylephrine:
With a 5 ml syringe, draw 1 ml of 10mg/ml (1 vial) Phenylnephrine.
Mix it in 100 cc minibag of normal saline
Draw out 3 – 5 cc of solution.
This is now Phenylephrine of 100 mcg/ml
Put labels on both the minibag and the syringe
Dose is 50 – 100 mcg/min ie give 0.5 – 1 ml q 2-5 minutes.
Action is within 1 minutes and lasts for 10-20 min.
Ketofol
Take 20 cc syringe. Draw up 10 cc of Propofol 10 mg/ml (100 mg Propofol)
Then draw up 2 ml of Ketamine 50 mg/ml (100 mg Ketamine)
Then draw up 8 cc of Normal Saline to fill the 20 cc syringe.
You know have 20 ml of Ketofol at 10 mg/ml
Dosage: Procedural sedation – 0.3 -0.5 mg/kg.