Clinical Operating Guidelines

Transcription

1 upplemental Oxygen RN Adequate Assess AC's Rate, Efft, Adequacy & ulse Oximetry nadequate ystem ET - ET- ET- edical Control asic aneuvers First -High flow Oxygen -Open Airway/uction -Nasal Oral Airway -ag Valve ask (V) Obstruction? Unsuccessful/nadequate ecomes nadequate Continue V uccessful Obstructed Airway rocedure Direct Laryngoscopy King Airway Cardiac Arrest only AD (King Airway) Oral-Tracheal ntubation Nasal-Tracheal ntubation (2) Unsuccessful Attempts Failed Airway rotocol uccessful Consider: Gastric Tube rocedure tify Destination Contact C as needed earls: This protocol is only f use in the patients with an Age Kg patients longer than the roselow-luten Tape. Capnometry (EtCO2) and pulse oximetry is mandaty with all methods of intubations. Colimetric(EZ Cap) may be used f initial CO2 detection when continuous capnometry is not immediately available. Document Results. f an airway is being maintained by V with ulse Oximetry 90% advanced airway is not required. f difficult intubation is anticipated consider early use of AD, assisted intubation with ougie, ellicks/ur maneuver. f intubation attempt fails CHANGE something: different blade, smaller tube size, use adjunctive maneuver. An intubation attempt is when the laryngoscope blade passes the plane of the teeth the tube is inserted into the nares. Ventilaty rate should be per minute OR to maintain ETCO (when appropriate). aintain R in those patients with suspected spinal injury. Hyperventilation in head trauma patients should only be done to maintain ETCO2 of F advanced airways secure airway with tube holder, c-collar, R. R - 01

2 Two (2) failed intubation attempts Anatomy inconsistent with intubation attempts. Continue V Ventilation with OA/NA f O2 drops < 90% it becomes difficult to ventilate with V Good air movement and/ O2 >90% With V Ventilation? One additional intubation attempt ystem ET - ET- ET- Facial Trauma/welling that prevents use of V and/ adjunct airway? edical Control AD (King Airway) O2 90% Continue to ventilate Via AD urgical Airway rocedure edical Control Ventilate at 12 aintain ETCO2 between and O2 >90% earls: Capnometry/Capnography (EtCO2 Col etric) is mandaty with all AD, Endotracheal intubations & urgical airways. Continuous ETCO2 when available should be used on all Advanced Airways. Document results and attach wave fm strips once placed on stretcher and just pri to hand off at Hospital. f an airway is being maintained by V with ulse Oximetry >90%, it is acceptable to maintain basic airway measures instead of using a AD ET. A secure airway is when the patient is now appropriately oxygenated and ventilated. f a AD is providing good ventilaty exchange and is functioning appropriately: DO NOT REOVE EXCHANGE. aintain R in those patients with suspected spinal injury. ellick s and UR methods should be used to assist with difficult endotracheal intubations. f first intubation attempt fails, make an adjustment and try again: - Different laryngoscope blade - Change head positioning -Different ETT size -Continuous pulse oximetry should be utilized in all patients. -Change cricoid pressure -Consider applying UR maneuver Continuous pulse oximetry should be used and documented. tify edical Control AA regarding patient s difficult failed airway.

3 Histy: Congestive heart failure ast medical histy edications (digoxin, lasix) Viagra, Levitra, Cialis Cardiac histy --past myocardial infarction igns & ymptoms: distress, bilateral rales Apprehension, thopnea Jugular vein distention ink, frothy sputum eripheral edema, diaphesis Hypotension, shock Chest pain Differential: yocardial infarction Congestive heart failure Asthma Anaphylaxis Aspiration COD leural effusion neumonia ulmonary embolus ericardial tamponade Toxic Exposure Universal atient Care rotocol (U-01) Consider CA up to 10 cm H 2 O EE atient Assist NTG 0.4 mg L q 5min if 100 Albuterol 2.5mg via Nebulizer F atients with significant ronchospasm ystem ET - ET- ET- edical Control 12-Lead ECG Acquisition V Access UT be established pri to second dose of NTG. Consider Hypotension rotocol (-11) if < 90 mmhg NTG 0.4 mg L q 5min if 100 mmhg Acquire 12-lead ECG pri to NTG Administration nterpret 12 Lead ECG phine ulfate 5-20 mg V/O 5mg ax ncrements Hold if < 100 mmhg f acute schemic Changes with T Elevation: declare a TE Alert and expedite transpt to appropriate TE Center. Furosemide 40 mg V/O (2) Times atient s Oral Daily Dose Up to a ax of 120mg Hold if < 100 mmhg edical Control earls: Avoid Nitroglycerin in any patient who has used Viagra Levitra in the past 24 hours Cialis in the past 48 hours due to possible severe hypotension. Careful moniting of level of consciousness,, and respiraty status with above interventions is essential. Consider myocardial infarction in all these patients. f suspected give AA. Allow the patient to be in their position of comft to maximize their breathing efft. R-03

4 Histy: Asthma; COD chronic bronchitis, emphysema, congestive heart failure Home treatment (oxygen, nebulizer) edications (theophylline, steroids, inhalers) Toxic exposure, smoke inhalation. igns & ymptoms: htness of breath ursed lip breathing Decreased ability to speak ncreased respiraty rate and efft Wheezing, rhonchi, rales, strid Use of accessy muscles Fever, cough Tachycardia Differential: Asthma/COD (Emphysema, ronchitis) Anaphylaxis Aspiration leural effusion neumonia ulmonary embolus neumothax Cardiac ( CHF) ericardial tamponade Hyperventilation nhaled toxin (Carbon monoxide, etc.) Airway rotocol R-01 ulmonary Edema rotocol R-03 Universal atient Care rotocol (U-01) /Ventilaty nsufficiency? ETCO2 and ulse Oximetry if available Rales signs of CHF? ystem ET - ET- ET- edical Control Wheezing osition of comft trid Assist with patient D -- Albuterol 2.5mg Neb Continuous Neb as needed Consider CA 5 cmh2o EE (if refracty to NE) Albuterol 2.5 mg with Atrovent 0.5 mg Neb x1 Consider Epi 1:1, mg ay repeat q20 min x 3 Consider 12 lead ECG ethylprednisolone 125 mg V/O Nebulized rmal aline 3mL Consider Epi 1:1, mg Epi Neb (2mg 1:1000 mixed 1 ml N) Consider 12 lead ECG ethylprednisolone 125 mg V/O agnesium ulfate 2 grams V/O over 20 min edical Control earls: ETCO2 & ulse Oximetry must be monited continuously if initial saturation is less than 95%, there is a decline in patient s status despite nmal pulse oximetry readings. Epinephrine may precipitate cardiac ischemia. A 12-lead ECG must be perfmed on these patients. Consider contacting edical Control if patient is refracty to therapy. A silent chest in respiraty distress is a pre-respiraty arrest sign. R-04

5 Universal atient Care rotocol repare Equipment, uction, AD re-oxygenate atient with 100% O2 ystem ET - ET- ET- Consider re-edications Lidocaine 2% 1.5mg/kg V/O f uspected C Atropine 0.5mg V/O f radycardia edical Control Etomidate 0.4 mg/kg V/O Ketamine 3 mg/kg V/O Rocuronium 1 mg/kg V/O Vecuronium 0.1 mg/kg V/O ntubation per Adult Airway rotocol ntubation uccessful? Failed Airway rotocol idazolam 2-5 mg V/O RN To aintain edation Continuous oniting of Tube lacement edical Control earls: Continuous ulse Oximetry, ETCO2 and ECG oniting are required f sedated patients. Careful moniting of level of consciousness, blood pressure, and respiraty status with above interventions is essential. aralyzed patients in this protocol UT be sedated. onit pulse, and respiraty effts f indications of sedation. There have been limited repts of laryngospasms caused by Ketamine. R-05