Paramedic Certificate

Transcription

1 Paramedic Certificate Treatment Parameters Polk State EMS Program Clinical Education Office Revised: February 7 th, 2013

2 Cardiac 1. Angina / Myocardial Infarction 2. Supraventricular Bradycardia and A.V. Blocks 3. A - Fib / Flutter 4. Supraventricular Tachycardia 5. Ventricular Tachycardia with a Palpable Pulse 6. Torsades de Pointes 7. Asystole 8. PEA 9. V-Fib / Pulseless V-Tachycardia Cardiac Arrest Medical Emergencies 10. Abdominal Pain 11. Allergic Reaction / Anaphylactic Shock 12. Altered Mental Status 13. Asthma / COPD 14. Behavioral Emergency 15. Rapid Sequence Intubation (RSI) - Adult 16. Pulmonary Edema 17. Seizure 18. Overdose and Poisonings 19. Overdose Tricyclic and Tetracyclic Antidepressant Anticholergenic Poisoning/Organophosphates Overdose 20. Overdose Antipsychotic / Acute Dystonic Reaction, Carbon Monoxide, Cocaine & Sympathomimetic Overdose 21. Overdose Beta Blocker Toxicity 22. Overdose Calcium Channel Blocker Overdose 23. Adult Trauma Transport 24. Adult Pain Management Trauma Emergencies Pediatric Emergencies

3 25. Rapid Sequence Intubation (RSI) 26. Allergic Reaction / Anaphylactic Shock 27. Altered Mental Status 28. Bronchospasm 29. Supraventricular Bradycardia 30. Supraventricular Tachycardia (SVT) 31. Ventricular Tachycardia with a Palpable Pulse 32. Overdose, Poisoning or Ingestion 33. Seizure Pediatric Cardiac Arrest 34. Asystole 35. Pulseless Electrical Activity (PEA) 36. Ventricular Fibrillation / Pulseless Ventricular Tachycardia 37. Pain Management 38. Trauma Transport Pediatric Trauma Emergencies

4 Angina / Myocardial Infarction Initial Medical Care (Oxygen, IV, Monitor) Record and monitor vital signs Initiate cardiac monitoring, record and evaluate EKG strip. AMI (STEMI) is indicated if 12 Lead indicates > 1mm ST elevation in: Lead II, III, AVF (Inferior Wall MI) (Check V4R) V1, V2 (Septal Wall MI) V3, V4 (Anterior Wall MI) V5, V6, Lead I, AVL, or (Lateral Wall MI) Any 2 contiguous leads Do not interpret ST elevation in ECGs presenting with right or left BBB. Baby ASA (4) 324 mg, chewed. (81 mg each) Nitroglycerin (Nitrostat) 0.4 mg SL spray, at 5 minute intervals until Nitroglycerin Drip established. Contraindicated in patients: Systolic BP < 90 mm Hg / Viagra use in past 24 hrs Use with caution in acute Inferior Wall MI, (Assess V4R to rule out RVI) NOTE: Ensure IV line started, SBP < 110 mm Hg and be prepared to administer IV NS boluses at ml if hypotension develops) Nitroglycerin Drip at 10 mcg / minute via infusion regulator. Titrate and increase at 5 mcg / minute increments every 3-5 minutes until relief of discomfort or systolic B/P <100 mm Hg. If pain unrelieved by Nitro Drip, Morphine Sulfate 2 mg slow IVP every 5 minutes (Maximum 10 mg) Contraindicated in patients: Systolic BP < 90 mm Hg / Use with caution in acute Inferior Wall MI, (Assess V4R to rule out RVI) Promethazine (Phenergan) 12.5 mg diluted with 9 ml of NS or RL slow IVP for severe vomiting. If BP < 90 mm Hg systolic, administer 0.9% NaCl at ml until systolic BP > 90 mm Hg 1

5 Bradycardia / A.V. Blocks Secure airway and administer supplemental oxygen Record and monitor vital signs Advanced airway/ventilatory management as needed Initiate cardiac monitoring, record and evaluate EKG strip Record and evaluate 12-lead EKG Do not delay treatment by obtaining EKG unless diagnosis is in question Record & monitor oxygen saturation IV 0.9% NaCl KVO or IV lock If systolic BP < 90 mm/ Hg, administer boluses of 0.9% NaCl at ml until systolic BP > 90 mm Hg Symptomatic (B/P <90 AND altered mental status AND signs of shock) Atropine 0.5 B 1.0 mg fast IVP repeat every 3 minutes as needed (Maximum 3mg) (Consider TCP before Atropine if 2nd II or 3 AV Blocks) Administer sedation if needed Midazolam (Versed) 2.5mg slow IVP Initiate transcutaneous pacing using Demand Mode Start at lowest MA=s until electrical capture with pulses achieved. Verify mechanical capture, if not, continue increase in MA until mechanical capture Start rate at 70 or default and increase rate to achieve systolic BP > 90mm Hg (Maximum 100 beats/minute) If above unsuccessful Dopamine (Intropin) infusion at 5-20 mcg/kg/minute IV titrated to maintain systolic BP > 90 mm/hg If drug induced, treat as per specific drug overdose Calcium Chloride 1 gram IV for calcium channel blocker OD Avoid if patient on digoxin/lanoxin Asymptomatic Place Transcutaneous Pacing on standby and use in demand mode if needed Medical Control Contact medical control for Epinephrine (Adrenalin) infusion at 2-10 mcg/minute IV. NOTE: Epinephrine (Adrenalin) 2mg in a 250 ml bag equates to 15 gtts / 2 mcg 2

6 Atrial Fibrillation / Atrial Flutter Secure airway - Administer supplemental oxygen Record and monitor vital signs Advanced airway/ventilatory management as needed Initiate cardiac monitoring, record and evaluate EKG strip and record and evaluate 12-lead EKG Heart Rate > 150 beats/minute Do not delay treatment if patient is unstable by obtaining EKG unless diagnosis is in question Record & monitor oxygen saturation IV 0.9% NaCl KVO or IV lock Stable (BP > 90 mm Hg) Rate > 150 beats/minute B and wide complex or WPW history Advise ED physician if patient has had rhythm > 48 hours Unstable (BP < 90 mm Hg AND altered consciousness AND Heart Rate > 150 beats/minute. Sedation if needed Midazolam (Versed) 2.5mg slow IVP Synchronized Cardioversion 1st energy level 100 J Biphasic If no response 150 J Biphasic If no response 200 J Biphasic Additional Drugs to consider: Diltiazem (cardizem) 0.25 mg/kg slow IVP Verapamil (Calan, Isoptin) 2.5 mg slow IVP 3

7 Supraventricular Tachycardia SVT Secure airway and administer supplemental oxygen Record and monitor vital signs Advanced airway/ventilatory management as needed Initiate cardiac monitoring, record and evaluate EKG strip Record and evaluate 12-lead EKG Do not delay treatment by obtaining EKG unless diagnosis is in question Record & monitor oxygen saturation IV 0.9% NaCl KVO or IV lock - Initiate in Antecubital fossa if possible (E/Z IO if 2 unsuccessful attempts at IV and patient is symptomatic) NOTE: Assess etiology Only treat if cardiac related Stable or borderline (Rate >150): Vagal maneuvers (Valsalva or cough) Adenosine phosphate (Adenocard) 6 mg rapid IVP over 1-3 seconds with 10cc flush If no response in 2 minutes, 12 mg rapid IVP over 1-3 seconds with 10cc flush Additional Drugs to consider: If no response in 2 minutes, repeat 12 mg IVP over 1-3 seconds with 10cc flush (Total of 30 mg) Unstable with serious signs and symptoms ((B/P <90 AND altered mental status AND signs of shock) (Ventricular rate > 150): May give brief trial of Adenosine (Adenocard) 6mg rapid IVP over 1-3 seconds with 10 cc flush Sedation if needed Midazolam (Versed) 2.5mg slow IVP Synchronized Cardioversion First energy level If no response If no response If no response If no response 50 J Biphasic 100 J Biphasic 150 J Biphasic 150 J Biphasic 150 J Biphasic 4

8 Ventricular Tachycardia with Pulse Secure airway - Administer supplemental oxygen Record and monitor vital signs Advanced airway/ventilatory management as needed Initiate cardiac monitoring, record and evaluate EKG strip Record and evaluate 12-lead EKG Do not delay treatment by obtaining EKG unless diagnosis is in question In general, assume wide complex tachycardia is ventricular tachycardia as EKG and clinical criteria are unreliable in excluding VT as cause of wide complex tachycardia Record & monitor oxygen saturation IV 0.9% NaCl (E/Z IO if 2 unsuccessful attempts at IV and patient is symptomatic) Stable Amiodarone (Cordarone) 150 mg IV over 10 minutes every minutes (Maximum of 450 mg total.) Additional Medication to consider: Procainamide (Pronestyl) 20 mg / min until: 1) A maximum of 1 gram or 17mg/kg 2) Rhythm subsides 3) QRS widens by greater than 50% 4) Hypotension ensues Unstable wide complex tachycardia (B/P <90 AND altered mental status AND signs of shock) Sedation if needed: Midazolam (Versed) 2.5mg slow IVP Synchronized Cardioversion o 1st energy level 100 J Biphasic o If no response, 150 J Biphasic o If no response 150 J Biphasic o If no response 150 J Biphasic o If delays in synchronization occur and clinical condition is critical, go immediately to unsynchronized shocks. Following electrical Cardioversion o If no antiarrythmic agent was given: Amiodarone (Cordarone) 150 mg IV over 10 minutes o If Amiodarone (Cordarone) was given: VT Reoccurs repeat at 150 mg IV over 10 minutes every minutes (Maximum 450 mg cumulative total dose) 5

9 Torsades de Pointes Secure airway - Administer supplemental oxygen Record and monitor vital signs Advanced airway/ventilatory management as needed Initiate cardiac monitoring, record and evaluate EKG strip Record and evaluate 12-lead EKG Do not delay treatment by obtaining EKG unless diagnosis is in question In general, assume wide complex tachycardia is ventricular tachycardia as EKG and clinical criteria are unreliable in excluding VT as cause of wide complex tachycardia Record & monitor oxygen saturation IV 0.9% NaCl (E/Z IO if 2 unsuccessful attempts at IV and patient is symptomatic) Magnesium Sulfate 2 g slow IV in 10 ml NS over 1-2 minutes If no response, perform Cardioversion - if clinical condition permits sedate before Cardioversion Sedation if needed Midazolam (Versed) 2.5mg slow IVP Synchronized Cardioversion o 1st energy level 100 J Biphasic o If no response, 150 J Biphasic o If no response 150 J Biphasic o If no response 150 J Biphasic If delays in synchronization occur and clinical condition is critical, go immediately to unsynchronized shocks Synchronized Cardioversion o 1st energy level 100 J Biphasic o If no response, 150 J Biphasic o If no response 150 J Biphasic o If no response 150 J Biphasic 6

10 Asystole Begin immediate CPR 1. 30:2 at 100 compressions / minute with minimal pauses NOTE: If estimated down-time is 5 minutes or longer without adequate CPR prior to Fire/EMS arrival, provide effective CPR for 2 minutes while preparing to evaluate for defibrillation. (200 high quality compressions/rate of 100 /min with Interposed ventilation at a rate of 10 bpm) Continue high quality CPR with minimal interruptions and rescue breathing with BVM (100% oxygen) as indicated Advanced airway/ventilatory management as needed Endotracheal Intubation (Max 2 attempts) Combitube if unable to intubate in appropriate patients Confirm airway device placement with assessment and detection device (ETCO2) and capnography. Continue CPR with no pause for ventilation. IV 0.9% NaCl wide open (E/Z IO if 2 unsuccessful attempts at IV) Epinephrine (Adrenalin) 1:10,000 1 mg IVP or IO (2 mg ETT) repeated every 3-5 minutes Consider and treat possible causes 1. Hypoxia / Acidosis - (Hyperventilate) 2. Hypothermia Warm Patient 3. Hypovolemia Fluid bolus ( cc up to 1-2 liters) 4. Hyperkalemia 5. Tablet (Drug) overdoses (see specific drug OD/toxicology section) a. Beta blocker OD - Glucagon 2 mg IVP b. Calcium channel blocker OD - Calcium Chloride 1 gram IV i. Avoid if patient on Digoxin / Lanoxin c. Narcotic OD - Naloxone (Narcan) 2 mg slow IVP 7

11 Pulseless Electrical Activity (PEA) Begin immediate CPR 1. 30:2 at 100 compressions / minute with minimal pauses NOTE: If estimated down-time is 5 minutes or longer without adequate CPR prior to Fire/EMS arrival, provide effective CPR for 2 minutes. (200 high quality compressions/rate of 100 /min with interposed ventilation at a rate of 10 bpm) Continue high quality CPR with minimal interruptions and rescue breathing with BVM (100% oxygen) as indicated Advanced airway/ventilatory management as needed Endotracheal Intubation (Max 2 attempts) Combitube if unable to intubate in appropriate patients Confirm airway device placement with assessment and detection device (ETCO2) and capnography. Continue CPR with no pause for ventilation. IV 0.9% NaCl wide open (E/Z IO if 2 unsuccessful attempts at IV Epinephrine (Adrenalin) 1:10,000 1 mg fast IVP or IO (2 mg ETT) repeated every 3-5 minutes Potential PEA cause Hypovolemia (most common cause) Hypoxia / Hydrogen ion acidosis Hyperkalemia Hypothermia Treatment Normal Saline cc Bolus up to 1-2 Liters IV Open/secure airway and ventilate Call for orders Active core rewarming Tablets (drugs) Tamponade, cardiac Tension pneumothorax Thrombosis (Coronary / Pulmonary) Beta blocker OD - Glucagon 2 mg IVP Calcium channel blocker OD - Calcium Chloride 1 gram IV Avoid if patient on Digoxin / Lanoxin Narcotic OD - Naloxone (Narcan) 2 mg IVP Normal Saline 1-2 Liters IV (In hospital pericardiocentesis) Plural Decompression (In hospital thrombolytics, cardiac cath.) 8

12 V-Fib / Pulseless V-Tach Begin immediate CPR 1. 30:2 at 100 compressions / minute with minimal pauses NOTE: If estimated down-time is 5 minutes or longer without adequate CPR prior to Fire/EMS arrival, provide effective CPR for 2 minutes while preparing to evaluate for defibrillation. (200 high quality compressions/rate of 100 /min with Interposed ventilation at a rate of 10 bpm Apply monitor/defibrillator If V-Fib / Pulseless V-Tachycardia identified: Defibrillate at 150J biphasic (360 J monophasic) followed by immediate CPR beginning with compressions. Perform 200 high quality compressions/rate of 100 p/m with ventilations at a rate of 10 bpm (2) minute cycles Repeat defibrillation x1 at 150 J biphasic (360j mono-phasic) as indicated at end of each CPR cycle Continue rescue breathing with BVM (100% oxygen) without CPR if pulse present Advanced airway/ventilatory management as needed - King Airway (If available) - Endotracheal Intubation (Max 2 Attempts) - Combitube if unable to intubate in appropriate patients Confirm airway device placement with exam and detection device (EtCO2 and Capnography) IV 0.9% NaCl wide open (E/Z IO if 2 unsuccessful attempts at IV) Epinephrine 1mg (Adrenalin) fast IVP/IO every 3-5 minutes (2 mg ETT if no IV or IO access.) Defibrillate 150 J Biphasic (or 360 J Monophasic) Bfollowed by immediate CPR for two minutes. This step may be repeated as indicated at end of two minute CPR cycles. Antiarrythmic/additional medications B administer sequentially (in the order listed) and defibrillate as indicated at end of 2 minute CPR cycles-followed with immediate CPR. Amiodarone (Cordarone) 300 mg IVP/IO may repeat 1 time at 150mg after 10 minutes, Reassess patient for conversion between each intervention above. 9

13 Abdominal Pain / GI Bleeding Secure airway and administer supplemental oxygen Record and monitor vital signs Nothing by mouth (NPO) Advanced airway/ventilatory management as needed Initiate cardiac monitoring, record and evaluate EKG strip Record and evaluate 12-lead EKG Record & monitor oxygen saturation IV 0.9% NaCl KVO (if condition warrants) If BP < 90 mm / Hg systolic, administer boluses of 0.9% NaCl at ml until systolic BP > 90 mm Hg Record and evaluate 12-lead EKG For patients with severe vomiting: Promethazine (Phenergan), 12.5 mg slow IVP 10

14 Allergic Reaction / Anaphylactic Shock Secure airway and administer supplemental oxygen (100%) Record and monitor vital signs Nothing by mouth (NPO) Advanced airway/ventilatory management as needed Initiate cardiac monitoring, record and evaluate EKG strip Record & monitor oxygen saturation IV 0.9% NaCl KVO or IV lock Mild Reaction (Itching/Hives) Diphenhydramine (Benadryl) 1 mg/kg IV (Maximum 50 mg) May be administered IM if no IV access Additional Drugs to consider: Cimetidine (Tagamet) 300 mg in 100cc over 5-10 minutes Moderate Reaction (Dyspnea, Wheezing, Chest tightness) Albuterol 2.5 mg (Proventil) and Ipratropium Bromide.02% (Atrovent) 0.5 mg/2.5 ml via updraft May repeat once in 20 minutes Diphenhydramine (Benadryl) 1 mg/kg IV (Maximum 50 mg) May be administered IM if no IV access available Additional Drugs to consider: Cimetidine (Tagamet) 300 mg in 100cc over 5-10 minutes Severe systemic reaction (BP < 90 mm Hg, stridor, severe respiratory distress) Administer boluses of 0.9% NaCl at ml until systolic BP > 90 mm Hg Epinephrine (Adrenalin) 1:1, mg SQ Albuterol 2.5 mg (Proventil) and Ipratropium Bromide.02% (Atrovent) 0.5 mg/2.5 ml via updraft May repeat once in 20 minutes Diphenhydramine (Benadryl) 1 mg/kg IV (Maximum 50 mg) May be administered IM if no IV access available Additional Drugs to consider: Cimetidine (Tagamet) 300 mg in 100cc over 5-10 minutes Methylprednisolone (Solu-Medrol) 125 mg slow IVP Imminent Cardiac Arrest or Cardiopulmonary Arrest: Epinephrine (Adrenalin) 1:10, mg IVP (instead of 1:1,000 SQ) Albuterol 2.5 mg (Proventil) and Ipratropium Bromide.02% (Atrovent) 0.5 mg/2.5 ml via updraft Diphenhydramine (Benadryl) 1 mg/kg IV (Maximum 50 mg) 11

15 Altered Mental Status Secure airway and administer supplemental oxygen Record / monitor vital signs and Blood Glucose level Nothing by mouth, unless patient is a known diabetic and is able to self-administer Glucose paste, orange or apple juice Assess for etiology Advanced airway/ventilatory management as needed Initiate cardiac monitoring, record and evaluate EKG strip and record and evaluate 12-lead EKG Record & monitor oxygen saturation & end-tidal C02 (if available) IV 0.9% NaCl KVO or IV lock If Hypoglycemic (Blood glucose < 60 mg/dl) with IV access Additional Drugs to consider: If malnourished or Alcohol history Thiamine 100 mg IV with initial Dextrose Dextrose 50% 25 gm Slow IVP May repeat as needed every 5 or 10 minutes to Blood Glucose > 100 mg/dl If Hypoglycemic (Blood glucose < 60 mg/dl) without IV access Glucose paste (Glutose) or other oral glucose agent (e.g. orange juice) if patient alert enough to self-administer oral agent or Glucagon 1 mg IM If Drug (narcotic) overdose suspected Naloxone (Narcan) 2 mg slow IVP If no IV access has been established, administer Naloxone (Narcan) 2.0mg IM. 12

16 Asthma / COPD Secure airway and administer supplemental oxygen Record and monitor vital signs Advanced airway/ventilatory management as needed Initiate cardiac monitoring, record and evaluate EKG strip Record and evaluate 12-lead EKG Record & monitor oxygen saturation IV 0.9% NaCl KVO or IV lock If Acute Bronchospasm (wheezing) Note: Patient may present with CLEAR diminished lung sounds due to the inability to move air because they are so constricted. If Asthma History - Albuterol (Proventil) 2.5 mg via updraft. Additional Drugs to consider: Repeat Albuterol (Proventil) 2.5 mg via updraft x2 as needed Ipratropium Bromide 0.02% (Atrovent) 0.5 mg/ 2.5 ml via updraft Methylprednisolone (Solu-Medrol) 125 mg slow IVP If COPD History - Albuterol (Proventil) 2.5 mg AND Ipratropium Bromide 0.02% (Atrovent) 0.5 mg/2.5 ml via updraft o May repeat in 20 minutes x2 o If patient condition deteriorates, Utilize CPAP at 5.0 cmh20 Additional Drugs to consider: Methylprednisolone (Solu-Medrol) 125 mg slow IVP If patient experiences decreased level of consciousness with respiratory failure OR poor ventilatory effort (with hypoxia unresponsive to supplemental 100% oxygen) OR unable to maintain patent airway, intubation is indicated. If conscious sedation needed proceed with RSI protocol 13

17 Behavioral Emergencies Secure airway and administer supplemental oxygen Record / monitor vital signs and Blood Glucose level Restrain as needed for patient/crew safety Advanced airway/ventilatory management as needed Begin cardiac monitoring, record and evaluate EKG strip and evaluate 12-lead EKG Record & monitor oxygen saturation IV 0.9% NaCl KVO (if condition warrants) o If BP < 90 mm Hg systolic, administer boluses of 0.9% NaCl at ml until systolic BP > 90 mm Hg For patients with extreme agitation resulting in interference with patient care or patient/crew safety o Midazolam (Versed) < 70 kg 5 mg IM > 70 kg 10 mg IM Select MAO inhibitors Nardil (Phenelzine) Parnate (Tranylcypromine) Additional Drugs to consider: Haloperidol (Haldol) < 60 kg 5 mg IM > 60 kg 10 mg IM. Medical Control Call Medical Control if further sedation needed Repeat Haloperidol (Haldol) 5 mg IV or IM 14

18 Rapid Sequence Induction (RSI) Adult REMEMBER ESTABLISHMENT OF A PATENT AIRWAY IS FIRST PRIORITY AND TAKES PRECEDENT OVER TRAUMA SCENE TIME!!! This protocol is only to be utilized under the following circumstances: TRAUMA BMR <= 4 (UNCONSCIOUS withdraws to painful stimulus) Head Injury with BMR <=5 with clenched teeth (UNCONSCIOUS localizes painful stimulus) Unstable traumatic airway condition as assessed by the Paramedic MEDICAL - As specified in specific protocols Secure airway - Administer supplemental oxygen 100% via BVM device Record and monitor vital signs Evaluate RSI criteria for inclusion - Rule out seizure related to acute Head Injury (not epileptic history) Evaluate and grade airway (1, 2, 3, 4). If grade 3 or 4 airway, intubation attempts limited to one (1) before utilizing King Airway Begin cardiac monitoring, record and evaluate EKG strip Visually evaluate oropharynx for indications of difficult intubation situation. If no visual indications present, then proceed with RSI. IV 0.9% NaCl wide open, (E/Z IO if 2 unsuccessful attempts at IV) If no seizure: o Etomidate (Amidate) 0.3 mg/kg IV; attempt intubation (if still clenched) o If clenched induce paralysis with Succinylcholine 1.5 mg/kg IV o Confirm tube placement with CO 2 detector color change o Provide oxygenation between intubation attempts (Maximum of 2 attempts, then SALT or Combitube) o Midazolam (Versed) 5 mg IV if Succinylcholine is given or needed for continued sedation. May repeat for a Midazolam (Versed) 5 mg IV for sedation If seizure: o Lidocaine (Xylocaine) 1mg/kg IV if Head Injury o Etomidate (Amidate) 0.3 mg/kg IV; attempt intubation o Midazolam (Versed) 5 mg IV for sedation if needed. o Intubate gently using cricoid pressure, visualizing landmarks and confirming tube placement with CO 2 detector color change o If two (2) endotrachael attempts fail, begin BCLS procedures, control airway and ventilate with BVM and airway adjunct 15

19 Pulmonary Edema Secure airway and administer supplemental oxygen Record and monitor vital signs Advanced airway/ventilatory management as needed Initiate cardiac monitoring, record and evaluate EKG strip Record and evaluate 12-lead EKG Record & monitor oxygen saturation IV 0.9% NaCl KVO or IV lock Only if Wheezing is present: Albuterol (Proventil) 2.5 mg AND Ipratropium Bromide.02% (Atrovent) 0.5 mg/2.5 ml via updraft May repeat once in 20 minutes Contraindicated if: HR > 150 or systolic BP > 180 mm Hg Nitroglycerin (Nitrostat) 0.4 mg spray SL every 5 minutes, until Nitroglycerin drip established at 10mcg/min via infusion regulator. Contraindicated if: Systolic BP < 90 mm Hg Viagra taken within 24 hrs Additional Drugs to consider: Furosemide (Lasix) 1 mg / kg to a maximum of 100mg Utilize CPAP at 10.0 cm H2O. Evaluate effectiveness and need for intubation If patient experiences decreased level of consciousness with respiratory failure OR poor ventilatory effort (with hypoxia unresponsive to supplemental 100% oxygen) OR unable to maintain patent airway, intubation is indicated. If conscious sedation needed to effect intubation proceed with RSI protocol Dopamine (Intropin) infusion at 5-20 mcg/kg/min titrated as needed if systolic BP < 90 mm Hg 16

20 Seizure Secure airway and administer supplemental oxygen Record / monitor vital signs and Blood Glucose level Protect patient from injury Advanced airway/ventilatory management as needed Begin cardiac monitoring, record and evaluate EKG strip Record and evaluate 12-lead EKG if seizure has stopped Record & monitor oxygen saturation Blood Glucose measurement IV 0.9% NaCl KVO or IV lock (medications only for active seizures) If Hypoglycemic (Blood glucose < 60 mg/dl) with IV access Additional Drugs: If malnourished or Alcohol history Thiamine 100 mg IV with initial Dextrose NOTE: Must be given PRIOR to or in conjunction with Dextrose. Dextrose 50% 25 gm Slow IVP May repeat as needed every 5 or 10 minutes to Blood Glucose > 100 mg/dl If Hypoglycemic (Blood glucose < 60 mg/dl) without IV access Glucose paste (Glutose) or other oral glucose agent (e.g. orange juice) if patient alert enough to self administer oral agent or Glucagon 1 mg IM Midazolam (Versed) 2.5 mg slow IVP repeat once for a maximum of 5 mg If NO IV access: Midazolam (Versed) 5 mg slow IVP repeat once for a maximum of 10 mg 17

21 Overdose and Poisonings NOTE: General considerations for any overdose or poisoning include determining the particular agent(s) involved, the time of the ingestion/exposure, and the amount ingested. Bring empty pill bottles, etc., to the receiving facility. See HAZMAT protocol for exposure to hazardous materials. Secure airway and administer supplemental oxygen (100%) Record / monitor vital signs and Blood Glucose level Nothing by mouth (depending on agent, patient may be at risk for seizure or rapid loss of consciousness with subsequent aspiration) Advanced airway/ventilatory management as needed Initiate cardiac monitoring, record and evaluate EKG strip Record & monitor 0 2 saturation IV 0.9% NaCl KVO o If BP < 90 mm Hg systolic, administer boluses of 0.9% NaCl at ml until systolic BP > 90 mm Hg Tricyclic antidepressants Antidepressants Category Drugs Overdose Effects Amitriptyline (Elavil, Endep, Etrafon, Vanatrip, Levate) Other Cyclic Antidepressants Selective Serotonin Reuptake Inhibitors (SSRI s) Clomipramine (Anafranil) Doxepin (Sinequan, Zonalon, Triadapin) Imipramine (Tofranil, Impril) Nortriptyline (Aventyl; Pamelor, Norventyl) Desipramine (Norpramin) Protriptyline (Vivactil) Hypotension Anti-cholinergic effects (tachycardia, seizures, altered mental status, mydriasis) AV conduction blocks, prolonged QT interval, wide QRS, VT and VF Trimipramine (Surmontil) (Limbitrol) Amitriptyline + chlordiazepoxide Maprotiline (Ludiomil) Ludiomil is similar to tricyclics, Amoxapine (Asendin) Asendin produces mostly seizures Bupropion (Wellbutrin) Minimal-moderate seizures Trazodone (Desyrel, Trazorel) Less seizures and cardiac effects than tricyclics Citalopram (Celexa) Hypertension, tachycardia, agitation, Fluoexitine (Prozac) diaphoresis, shivering, tremor, muscle rigidity Fluvoxamine (Luvox) Malignant Hyperthermia Paroxetine (Paxil) Sertraline (Zoloft) 18

22 Overdose Tricyclic and Tetracyclic Antidepressant Secure airway and administer supplemental oxygen 100% Record and monitor vital signs Advanced airway/ventilatory management as needed Begin cardiac monitoring, record and evaluate EKG strip and 12-lead EKG Record & monitor oxygen saturation IV 0.9% NaCl KVO If wide QRS, hypotension, or arrhythmias present: Consider: Sodium Bicarbonate 1mEq / kg IVP Anticholinergic Poisoning/Organophosphates Wear protective clothing including masks, gloves, and eye protection. Toxicity to ambulance crew may result from inhalation or topical exposure. Any traces of contamination must be removed from the vehicle prior to the next transport. Secure airway and administer supplemental oxygen Record and monitor vital signs Decontaminate patient o Remove clothing o Irrigate with normal saline may also use soap and water o Contain run-off of toxic chemicals when flushing Advanced airway/ventilatory management as needed Begin cardiac monitoring, record and evaluate EKG strip and 12-lead EKG Record & monitor oxygen saturation IV 0.9% NaCl KVO o Remember SLUDGE: Salivation, Lactation, Urination, Defecation, GI, Emesis o If signs of severe toxicity, (severe respiratory distress, bradycardia, heavy respiratory secretions do not rely on pupil constriction to diagnose or to titrate medications) o Atropine 2.0 mg fast IVP every 5 min titrate until respiratory secretions/distress begins to decrease 19

23 Antipsychotic/Acute Dystonic Reaction Commonly used Antipsychotic and Antipsychotic related medicines (e.g. antiemetics) in medical practice include, but are not limited to the following: Prochlorperazine (Compazine) Promethazine (Phenergan) Thorazine Prolixin Haloperidol Secure airway and administer supplemental oxygen 100% Record and monitor vital signs Advanced airway/ventilatory management as needed Begin cardiac monitoring, record and evaluate EKG strip and 12-lead EKG Record & monitor oxygen saturation IV 0.9% NaCl KVO For Dystonic reactions, administer Diphenhydramine (Benadryl) 25 mg IVP. Repeat Diphenhydramine (Benadryl) 25 mg IVP if inadequate response, in 10 minutes Carbon Monoxide Secure airway and administer supplemental oxygen 100% Record and monitor vital signs Advanced airway/ventilatory management as needed Begin cardiac monitoring, record and evaluate EKG strip and 12-lead EKG Record & monitor oxygen saturation IV 0.9% NaCl KVO Draw blood and place with cold pack Consider transport to hyperbaric chamber Cocaine and Sympathomimetic Overdose Secure airway and administer supplemental oxygen 100% Record and monitor vital signs Advanced airway/ventilatory management as needed Begin cardiac monitoring, record and evaluate EKG strip and 12-lead EKG Record & monitor oxygen saturation IV 0.9% NaCl KVO For patients with Sympathomimetic toxidrome (hypertension, tachycardia, agitation): o Midazolam (Versed) < 70 kg mg slow IVP > 70 kg - 5 mg slow IVP 20

24 Beta Blocker Toxicity Commonly used Beta Blockers(lol) in medical practice include but are not limited to the following: Propranolol (Inderal) Atenolol (Tenormin) Metroprolol (Lopressor) Nadolol (Corgard) Timolol (Blocadren) Labetolol (Trandate) Esmolol (Brevibloc) Acebatolol (Sectral) In addition beta-blockers are contained in many combination drugs. It is the beta-blocker component that leads to specific toxicity. Combination beta-blocker drugs include, but are not limited to the following: Corzide (Nadolol/bendroflumethlazide) Inderide LA (Propranolol/HCTZ) Tenoretic (Atenolol/Chlorthalidone) Ziac (Bisoprolol/HCTZ) Inderide (Propranolol/HCTZ) Lopressor HCT (Metoprolol/HCTZ) Timolide (Timolol/HCTZ) Secure airway and administer supplemental oxygen 100% Record and monitor vital signs Advanced airway/ventilatory management as needed Begin cardiac monitoring, record and evaluate EKG strip and 12-lead EKG Record & monitor oxygen saturation IV 0.9% NaCl KVO If BP < 90 mm Hg systolic administer boluses of 0.9% NaCl at ml until systolic BP > 90 mm Hg For patients with cardiovascular toxicity (chest pain, syncope, SBP < 90 mm Hg, altered mental mentation) with (1) bradycardia with rate < 60 or (2) Heart block, including third degree heart block and high grade second degree heart blocks i.e. Mobitz Type II second degree Administer the following agents Atropine 0.5 mg IV, may repeat X 2 If no response, begin Transcutaneous Pacing Medical Control Dopamine (Intropin) infusion, or additional orders if cardiovascular toxicity persists 21

25 Calcium Channel Blockers include: Polk State College Calcium Channel Blockers Amlodipine (Norvasc) Felodipine (Plendil, Renedil) Isradipine (DynaCirc) Nicardipine (Cardene) Verapamil (Calan) Nifedipine (Procardia, Adalat) Diltiazem (Cardizem) Secure airway and administer supplemental oxygen 100% Record and monitor vital signs Advanced airway/ventilatory management as needed Begin cardiac monitoring, record and evaluate EKG strip and 12-lead EKG Record & monitor oxygen saturation IV 0.9% NaCl KVO o If BP < 90 mm Hg systolic administer boluses of 0.9% NaCl at ml until systolic BP > 90 mm Hg For patients with cardiovascular toxicity (chest pain, syncope, SBP < 90 mm Hg, altered mental mentation) (1) bradycardia with rate < 60 or (2) Heart block, including third degree heart block and high grade second degree heart blocks i.e. - Mobitz Type II second degree Administer the following agents o Atropine 0.5 mg fast IV, may repeat X 2 o If no response, Calcium Chloride 1 gram IV Avoid if patient taking digoxin (Lanoxin) o If no response, may repeat Calcium Chloride 1 gram IV o If no response, begin transcutaneous pacing Medical Control Dopamine (Intropin) or epinephrine infusion, or additional orders if cardiovascular toxicity persists 22

26 Adult Trauma Triage Criteria COMPONENT BLUE RED AIRWAY RESPIRATORY RATE > = 30 / MINUTE Active Airway Assistance Beyond Administration of Oxygen CIRCULATION Sustained Heart Rate > 120 (1) Lack of Radial Pulse With Sustained H/R > 120 OR (2) B/P < 90 mm / hg BEST MOTOR RESPONSE (Pinch of the inner thigh) BMR = 5 (1) BMR < = 4 OR (2) EXHIBITS PRESENCE OF PARALYSIS OR (3) Suspicion of Spinal Cord Injury OR Loss of Sensation CUTANEOUS LONG BONE FRACTURE (1) Soft Tissue Loss via Degloving Injuries OR (2) Major Flap Avulsions > 5 Inches OR (3) GSW To Extremities of The Body S/S of Single Long Bone FX Site Resulting From a MVC OR Fall > 10 Feet (1) Amputation Proximal To Wrist / or Ankle OR (2) 2nd / 3rd Degree Burns To > 15 % TBSA OR (3) Penetrating Injury To Head, Neck, Torso ( Excluding superficial wounds where the depth of the wound can be determined) S/S of 2 OR more Long Bone FX Sites (SEE LONG BONE DEFINITION BELOW) AGE > 55 MECHANISM OF INJURY (1) Ejection From Vehicle (EXCEPT: ATVS, Motorcycles, Bicycles, Open Body of Pick-ups, Mopeds OR (2) Driver Impact of Steering Wheel Causing Deformity LONG BONES ARE DEFINED AS 1. Radius AND Ulna, 2. Humerus 3. Femur 4. Tibia AND Fibula Adult Pain Management 23

27 Establish patient responsiveness If trauma suspected, stabilize spine Assess Airway/Breathing/Oxygenation Assess perfusion and circulation, obtaining a baseline blood pressure Assess mental status Assess baseline pain level (0-10 scale), (0 = no pain, 10 = worst pain) Administer nothing by mouth (NPO) Assess airway/breathing and ensure no airway intervention or ventilation needed Begin cardiac monitoring Record and monitor oxygen saturation IV 0.9% NaCl KVO Perform a focused history and detailed physical examination en route to the hospital if patient status and management of resources permit. Analgesic agents may be administered if patient has severe pain and one of following o Extremity injury including long bone fracture in the presence of multi-system trauma. (Pt must be alert, normotensive) o Burn without airway, breathing, or circulatory compromise o Medical Control Contact required for Sickle crisis with pain that is typical for that patient s sickle cell disease o Acute chest pain see chest pain protocol for management Agents for pain control Phenergan (Promethazine) 6.25 mg diluted in 5ml 0.9% NaCl slow IVP Morphine Sulfate 2 mg slow IVP every 5 minutes until pain relief achieved (Maximum 10 mg) (Maximum 20 mg for burns) Reassess the patient frequently 24

28 Rapid Sequence Induction (RSI) Pediatric REMEMBER ESTABLISHMENT OF A PATENT AIRWAY IS FIRST PRIORITY AND TAKES PRECEDENT OVER TRAUMA SCENE TIME!!! This protocol is only to be utilized under the following circumstances: TRAUMA BMR <= 4 (UNCONSCIOUS withdraws to painful stimulus) Head Injury with BMR <=5 with clenched teeth (UNCONSCIOUS localizes painful stimulus) Unstable traumatic airway condition as assessed by the Paramedic MEDICAL - As specified in specific protocols Secure airway - Administer supplemental oxygen 100% via BVM device Record and monitor vital signs Evaluate RSI criteria for inclusion - Rule out seizure related to acute Head Injury (not epileptic history) Evaluate and grade airway (1, 2, 3, 4). If grade 3 or 4 airway, intubation attempts limited to one (1) before utilizing King Airway Begin cardiac monitoring, record and evaluate EKG strip IV 0.9% NaCl wide open, (E/Z IO if 2 unsuccessful attempts at IV) If no seizure: Atropine 0.02 mg/kg fast IVP Information: Atropine Minimum of 0.1 mg or 1cc / fast IVP Etomidate (Amidate) 0.3 mg/kg IV; attempt intubation (if still clenched) Induce paralysis with Succinylcholine 2.0 mg/kg slow IVP over seconds Confirm tube placement with CO 2 detector color change Provide oxygenation between intubation attempts (Maximum of 2 attempts, then OPA/NPA) Midazolam (Versed) 0.1 mg/kg slow IVP if Succinylcholine has been given or for continued sedation. May repeat once to a maximum of 5 mg. If seizure: Atropine 0.02 mg/kg IV Information: Atropine Minimum of 0.1 mg or 1cc / fast IVP Etomidate (Amidate) 0.3 mg/kg IV; attempt intubation (if still clenched) Fentanyl (Sublimaze) 6 mcg/kg IV for sedation if needed Intubate gently using cricoid pressure, visualizing landmarks and confirming tube placement with CO 2 detector color change Provide oxygenation between intubation attempts (Maximum of 2 attempts, then BVM and airway adjunct Midazolam (Versed) 0.1 mg/kg slow IVP for continued sedation. May repeat once to a maximum of 5 mg.. Medical Control Contact medical control for continued sedation or higher dosage of medication to facilitate intubation 25

29 Allergic Reaction / Anaphylactic Shock (Pediatric) Establish responsiveness If trauma suspected, stabilize spine Airway/Breathing/Oxygenation - Assist breathing/ventilation if needed Assess perfusion and circulation Advanced airway/ventilatory management as needed Initiate cardiac monitoring, record and evaluate EKG strip IV 0.9% NaCl KVO or IV lock If patient meets criteria for anaphylactic shock Epinephrine (Adrenalin) 1:1,000 solution of 0.01 mg/kg SQ (max individual dose 0.3 mg) o Massage the injection site vigorously for seconds Epinephrine (Adrenalin) 1:1,000 solution of 0.01 mg/kg is equal to 0.01cc/kg SQ If bronchospasm is present in a patient with adequate ventilation, o Albuterol (Proventil) 2.5 mg via nebulizer over a minute period If bronchospasm persists, o Repeat Albuterol (Proventil) 2.5 mg via nebulizer once in 20-minutes Reassess patient for signs of anaphylactic shock. If criteria are still present repeat o Epinephrine (Adrenalin) 1:1,000 solution at 0.01 mg/kg (0.01cc/kg) (Maximum individual dose 0.3 mg) via SQ injection. Additional Drugs to consider: Ipratropium Bromide (Atrovent) 0.02% 0.5 mg/2.5 ml Methylprednisolone (Solu-Medrol) 2 mg / kg to a maximum of 125 mg slow IVP IV 0.9% NaCl KVO or IV lock If evidence of shock, If IV access cannot be obtained, place intraosseous needle (IO). Administer fluid bolus of 0.9% NaCl at 20 ml/kg set to maximum flow rate IV or IO After reassessment, if shock persists, repeat bolus X 2 to a maximum total of 60 ml/kg. Diphenhydramine (Benadryl) 1.0 mg/kg IV or deep IM (maximum individual dose 50 mg) Expose the child only as necessary to perform further assessments. Maintain the child s body temperature throughout the examination 26

30 Altered Mental Status Pediatric This protocol is intended for pediatric patients with an altered mental status of unknown etiology. Establish responsiveness If trauma suspected, stabilize spine Airway/Breathing/Oxygenation - Assist breathing/ventilation if needed Assess perfusion and circulation Advanced airway/ventilatory management as needed If signs or respiratory distress, failure or arrest are present refer to the appropriate protocol If breathing adequate, place child in a position of comfort and administer high-flow oxygen 100% as necessary. Use a non rebreather mask or blow-by as tolerated Initiate cardiac monitoring and determine rhythm IV 0.9% NaCl KVO, if IV access cannot be obtained after 2 attempts proceed with E/Z IO Determine blood glucose and treat glucose < 60 mg/dl (0.5 1 g/kg) (NOTE: The following dosages are equivalent to 0.5g/kg) D10W 5 ml/kg for neonates D25W 2 ml/kg for children 2 years D50W 1 ml/kg for children > 2 years IF IV or IO access is unavailable: < 20 kg, Glucagon 0.5 mg IM > 20 kg, Glucagon 1.0 mg IM Repeat Dextrose once if Blood glucose remains < 60 mg/dl after treatment OR cannot determine blood glucose and no change in mental status If patient has continued altered mental status Naloxone (Narcan) 0.1 mg/kg (Maximum individual dose 2.0 mg) via IV or IO route If IV or IO unavailable administer same dose endotracheally or IM If evidence of shock If IV access cannot be obtained, and 5 years place intraosseous needle (IO) Fluid bolus 0.9% NaCl at 20 ml/kg If shock persists, repeat bolus X 2 to a maximum total of 60 ml/kg. Expose the child only as necessary to perform further assessments. Maintain the child s body temperature throughout the examination 27

31 Bronchospasm Pediatric Assess airway and breathing and administer oxygen If breathing adequate, place child in a position of comfort and administer high-flow oxygen 100% with non-rebreather mask or blow-by as tolerated Assess circulation and perfusion Obtain and record pulse oximetry reading Assist breathing/ventilation if needed If bronchospasm Albuterol (Proventil) 2.5 mg via nebulizer over minutes If bronchospasm persists, repeat Albuterol (Proventil) 2.5 mg via nebulizer once in 20-minutes If patient shows signs of respiratory distress or failure with clinical evidence of bronchospasm or a history of asthma and inadequate ventilation Epinephrine (Adrenalin) 1:1,000 at 0.01 mg/kg (max 0.3 mg) subcutaneously Repeat Albuterol (Proventil) 2.5 mg via nebulizer once in 20 minutes AND Epinephrine every 15 minutes as needed x 2. NOTE: May administer at same time nebulizer is being administered Additional Drugs to consider: Ipratropium Bromide (Atrovent) 0.02% 0.5 mg/2.5 ml Methylprednisolone (Solu-Medrol) 2 mg / kg to a maximum of 125 mg slow IVP Magnesium Sulfate 50mg/kg IV over 5-10 minutes Initiate transport and perform focused history and detailed physical examination en route to the hospital if patient status and management of resources permit. Reassess the patient frequently 28

32 Bradycardia Pediatric Advanced airway/ventilatory management as needed / Obtain and record pulse oximetry reading Initiate cardiac monitoring and determine rhythm Initiate chest compressions if signs of severe cardiopulmonary compromise are present in an infant (< 1 year) or neonate and the heart rate remains slower than 60 beats per minute despite oxygenation and ventilation Identify and treat possible causes of bradycardia If hypoxia open airway - assist breathing If hypothermic rewarm If signs of severe cardiopulmonary compromise IV 0.9% NaCl KVO NOTE: If IV cannot be obtained after 2 attempts, AND the patient shows signs of severe cardiopulmonary compromise, proceed with E/Z IO access. Do not delay transport to establish access *Check blood glucose and treat glucose < 60 mg/dl (0.5 1 g/kg) (NOTE: The following dosages are equivalent to 0.5g/kg) D10W 5 ml/kg for neonates D25W 2 ml/kg for children 2 years D50W 1 ml/kg for children > 2 years If signs of severe cardiopulmonary compromise persist: Use 1 st route available Epinephrine (Adrenalin) 1:10,000 at 0.01 mg/kg (Max 1 mg) via IV/IO Repeat dose every 3-5 minutes until either the bradycardia or severe cardiopulmonary compromise resolves If signs of severe cardiopulmonary compromise persist despite epinephrine and above measures Atropine at 0.02 mg/kg via IV, IO, (0.2cc/kg) Minimum dose is 0.1 mg and Maximum individual dose is 0.5 mg / child and 1.0 mg / adolescent May repeat once after 3-5 minutes until maximum dose reached. If severe cardiopulmonary compromise persists despite epinephrine/atropine If weight is < 15 kg apply pediatric external pads, 15 kg apply adult external pacer pads use lowest energy that causes every pacer impulse to result in ventricular capture (pulse) If severe cardiopulmonary compromise persists despite pacing Dopamine (Intropin)infusion at 5-20 mcg/kg/minute IV Medical Control Repeated administration of Epinephrine (Adrenalin) and Atropine 29

33 Supraventricular Tachycardia Pediatric Establish responsiveness If trauma suspected, stabilize spine Airway/Breathing/Oxygenation Assess perfusion and circulation Assess patient to ensure etiology and this is cardiac in nature! Assist airway, ventilation if needed If breathing adequate, place child in a position of comfort and administer high-flow oxygen 100% with non-rebreather mask or blow-by as tolerated Initiate cardiac monitoring and determine rhythm IV 0.9% NaCl KVO If IV cannot be obtained after 2 attempts, AND the patient shows signs of severe cardiopulmonary compromise, proceed with E/Z IO access. Do not delay transport to obtain vascular access *Check blood glucose and treat glucose < 60 mg/dl (0.5 1 g/kg) (NOTE: The following dosages are equivalent to 0.5g/kg) D10W 5 ml/kg for neonates D25W 2 ml/kg for children 2 years D50W 1 ml/kg for children > 2 years Supraventricular tachycardia (HR > 220 Infants, >190 Child) with severe cardiopulmonary compromise Adenosine (Adenocard) 0.1 mg/kg (0.1cc/3kg) Max individual dose 6.0 mg via rapid IV/IO bolus at the port closest to the IV hub. Repeat Adenosine (Adenocard) twice at 0.2 mg/kg if needed (Maximum individual dose 12 mg) If Adenosine is unsuccessful and patient still has severe cardiopulmonary compromise See Medical Control box for possible sedation orders Medical Control Sedate the patient before Cardioversion as permitted by Medical Direction Midazolam (Versed) 0.1 mg/kg IV (Maximum individual dose 5.0mg) Synchronized Cardioversion at joules/kg May repeat at 2 joules/kg to maximum of 4 joules/kg (max individual dose 360 joules) 30

34 Establish responsiveness If trauma suspected, stabilize spine Airway/Breathing/Oxygenation Assess perfusion and circulation Polk State College Ventriclular Tachycardia (With Pulse) Pediatric Assist airway, ventilation if needed If breathing adequate, place child in a position of comfort and administer high-flow oxygen 100% with non-rebreather mask or blow-by as tolerated Initiate cardiac monitoring and determine rhythm IV 0.9% NaCl KVO If IV cannot be obtained after 2 attempts, AND the patient shows signs of severe cardiopulmonary compromise, proceed with E/Z IO access. Do not delay transport to obtain vascular access *Check blood glucose and treat glucose < 60 mg/dl (0.5 1 g/kg) (NOTE: The following dosages are equivalent to 0.5g/kg) D10W 5 ml/kg for neonates D25W 2 ml/kg for children 2 years D50W 1 ml/kg for children > 2 years Amiodarone (Cordarone) 5mg/kg IV over 10 minutes (Mix in a 100cc bag 1ml/kg) If vascular access is not readily available AND the patient is poorly perfused See Medical Control box for possible sedation orders Medical Control Sedate the patient before Cardioversion as permitted by Medical Direction Midazolam (Versed) 0.1 mg/kg IV (Maximum individual dose 5.0mg) Synchronized Cardioversion at joules/kg May repeat at 2 joules/kg to maximum of 4 joules/kg (max individual dose 360 joules) 31

35 Establish responsiveness If trauma suspected, stabilize spine Airway/Breathing/Oxygenation Assess perfusion and circulation Polk State College Overdose / Poisoning or Ingestion Pediatric Assist airway, ventilation if needed If breathing adequate, place child in a position of comfort and administer high-flow oxygen 100% with non-rebreather mask or blow-by as tolerated Initiate cardiac monitoring and determine rhythm IV 0.9% NaCl KVO If respiratory depression is present and a narcotic overdose is suspected, Administer Naloxone (Narcan) at 0.1 mg/kg (Maximum dose 2.0 mg) via IV, IO, or IM route Treatment for specific toxic exposures: Organophosphates Atropine 0.02 mg/kg fast IVP or IO (minimum dose 0.1 mg) Calcium channel and B-blocker overdose Glucagon 0.5 mg if less than 20 kg; or 1.0 mg if greater than 20 kg if inadequate response Atropine 0.02 mg/kg fast IVP or IO (minimum dose 0.1 mg) for symptomatic bradycardia, if inadequate response Calcium Chloride 0.3 ml/kg slow IV over 2 minutes for calcium channel blocker overdose Dystonic reactions acute uncontrollable muscle contractions Diphenhydramine (Benadryl) 1 mg/kg IV or deep IM (Maximum dose 50 mg) Medical Control Contact Medical Control for questions concerning individual toxic exposures and treatments. 32

36 Seizure Pediatric Establish responsiveness If trauma suspected, stabilize spine Airway/Breathing/Oxygenation Assess perfusion and circulation Assist airway, ventilation if needed If breathing adequate, place child in a position of comfort and administer high-flow oxygen 100% with non-rebreather mask or blow-by as tolerated Initiate cardiac monitoring and determine rhythm IV 0.9% NaCl KVO If IV access cannot be obtained AND patient in shock, proceed with E/Z IO access *Check blood glucose and treat glucose < 60 mg/dl (0.5 1 g/kg) (NOTE: The following dosages are equivalent to 0.5g/kg) o D10W 5 ml/kg for neonates o D25W 2 ml/kg for children 2 years o D50W 1 ml/kg for children > 2 years o Glucagon 0.5 mg if less than 20 kg; or 1.0 mg if greater than 20 kg Repeat dextrose once if Blood glucose remains < 60 mg/dl after treatment OR cannot determine blood glucose and no change in mental status. Administer anticonvulsants IV slowly over 1-2 minutes if patient in status epilepticus (More than 10 minute seizure, or more than 1 seizure without awakening) Midazolam (Versed) 0.1 mg/kg IV (Max. individual dose 5 mg) OR if no IV Midazolam (Versed) 0.2 mg/kg IM (Max. individual dose 10 mg) Medical Control Contact Medical Control for any further orders, questions, or assistance. 33

37 Asystole Pediatric Establish patient responsiveness - If spine trauma suspected, stabilize spine Confirm Cardiac Arrest: Begin CPR (Two minute cycles of 30:2 or 15:2 with two rescuers) NOTE: If estimated down-time is 5 minutes or longer without adequate CPR prior to Fire/EMS arrival, provide effective CPR for 2 minutes while preparing to evaluate rhythm. (200 high quality compressions/rate of 100 per minute with Interposed ventilation) Apply heart monitor as soon as available. Follow Non-traumatic Cardiac Arrest Protocol Confirm the presence of Asystole in two leads Maintain adequate ventilation via BVM with 100% oxygen o Endotracheal Intubation (Max 2 attempts) o Assess effective ventilations with exam, and ETCO2/capnography o If unable to intubate, maintain adequate ventilations via BVM with airway adjunct and 100% oxygen. IV 0.9% NaCl KVO, if signs of severe cardiopulmonary compromise; proceed with E/Z IO access. Using the most readily available route, administer Epinephrine (Adrenalin) 1:10,000 of 0.01 mg/kg IV or IO, repeat every 3-5 min. Potential Asystole cause Treatment Hypovolemia (most common cause) Normal Saline 20 cc / kg may repeat times 2 (to a maximum total of 60ml/kg) Hypoxia / Hydrogen ion acidosis Open/secure airway and ventilate Hypothermia Active core rewarming Hypoglycemia (Blood glucose < 60 mg/dl) - Dextrose 50% 25 gm Slow IVP Tablets (drugs) Calcium channel blocker OD - Glucagon 0.5 mg < 20 kg or 1 mg > 20 kg If no response: Atropine 0.02 mg/kg If no response: Calcium Chloride 30 mg/kg Narcotic OD - Naloxone (Narcan) 0.1 mg/kg Tamponade, cardiac Normal Saline 20 m1/ kg (In hospital pericardiocentesis) Tension pneumothorax Plural Decompression (20 gauge needle) Trauma (In hospital surgery) Maintain the child s body temperature throughout the examination Medical Control Contact Medical Control for any further orders, questions, or assistance. 34