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ER ‘Guidelines’
Shane Barclay MD and Ian Gummeson MD, Revised July 2018
Page
Medications in the ER 2 -5
Acute Chest pain (ACS), STEMI, NSTEMI (TNK) 6 - 7
ACS Admission orders – post ER 8 – 9
ACS – Inferior MI 10
Acute Pulmonary Edema (CHF) 11
Airway Management (Rapid Sequence Induction) 12
Analgesia – Procedural Sedation - Adult 13-14
Analgesia – Procedural Sedation – Pediatrics 15
Anaphylaxis 16
Asthma 17
Atrial Fibrillation – decompensated 18
Bites – Human and Animal 19
Bronchiolitis 20
Burns, Chemical Eye burns 21 – 23
Coma 24 - 25
Croup 26
Diabetic Ketoacidosis and Hyperosmolar Hyper glycemia 27-29
Electrolytes – treating critical values 30
Frostbite 31
Gout 32
Head Injury/Concussion 33-34
Hypertensive Emergencies/Urgencies 35-36
Hypoglycemia 37
Hypothermia 38
Intravenous Lipid Emulsion therapy (ILT) 39
Migraine Headaches 40
Overdose – Benzodiazepine 41
- Misc. (other alcohols, cocaine, opioid, TCA, PCP) 42-44
- Acetaminophen 45
Post Cardiac Arrest Care 46
Sedation for Severe Agitation/Alcohol Withdrawal 47
Seizures – Adult 48
Seizures – Pediatric 49
Shock / Hypotension 50-52
Spinal Cord Injury 53
Trauma Resuscitation - ATLS Protocol 54-55
Glasgow Coma Scales (Adult and Pediatric), FOUR scale 56
Ventilator Support (settings) 57-59
Procedures: Chest tube, Tick removal, Zipper injury, ABI 60-70
Subungual hematoma, Fishhook removal, Priapism,
Shoulder Dislocation
Medications in the Emergency Department
Drug 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, then 0.5 mg/min x 18 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 Hypocalcemia .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 Hypocalcemia 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 Start 2 mcg/kg/min. Maint. 2-20 mc/kg/min
Dopamine Cardiac decom/Shock Start 2-5 mcg/kg/min. Maint 1-20 mcg/kg/min
Epinephrine ACLS-VT/VFib/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 50-100 mcg IV (1-1.5 mcg/kg)
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
CCB/BBlocker OD 0.04 mg IV then 2-10 mcg/min
Torsade’s to shorten QT 0.04 mg IV then 2-10 mcg/min
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
Drug Indication Dosage
Ketofol 1:1 Ketamine/Propofol. Proc Sed: 0.3 – 0.5 mg/kg
Labetalol 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. Hypo Mg 1-4 gm IV
Seizure/Eclampsia 8-10 gm IM or 6 gm IV then 1-2 gm/hr IV
Vent. Arrhyth/Torsade’s 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 2-10 mg IV/IM, (0.05-0.1 mg/kg)
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 200-400 mcg/min
Norepinephrine Hypotension/Sepsis Start 0.1 mcg/kg/min. Titrate. Max 2 mcg/kg/min
Phenobarbital Seizure 10-20 mg.kg IV x1 May repeat 10mg/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
Post intubation sedation start 5 mcg/kg/min. Titrate 5-50 mcg/kg/min
Procainamide Wide complex tachy/SVT 100 mg IV q 5-10 min. Max 1.5 gm
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 pre-medicate with atropine
Sotalol VT/VF 75- 100 mg IV q 12 h
TNKase STEMI 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, theb 1-4 mg/min
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),
dromotropic (‘conduction’)
Beta 2 – Lung effects: agonists cause bronchodilation, antagonists cause bronchoconstriction
β1 β 1 β1
Drug α1&2 Inotr Chron Dromo β2 V/C V/D
|Phenylephrine |+++ | |
|41-50 kg |2700 units |550 units/hr. = 11ml/hr. |
|51-60 kg |3300 units |650 units/hr. = 13ml/hr. |
|61-70 kg |3900 units |750 units/hr. = 15ml/hr. |
| 71-80 kg |4000 units |900 units/hr. = 18ml/hr. |
|>80 kg |4000 units |1000unit/hr. = 20ml/hr. |
If NSTEMI or Unstable angina
Do 1 – 13 above. then
1. Clopidogrel 600 mg Stat
2. If GFR > 30 Fondaparinux 2.5 mg SC (and then daily x 2 days)
If GFR < 30 Unfractionated Heparin – bolus then infusion.
|Patient Weight | Heparin I.V. Bolus |Initial Heparin Infusion |
|41-50 kg |2700 units |550 units/hr. = 11ml/hr. |
|51-60 kg |3300 units |650 units/hr. = 13ml/hr. |
|61-70 kg |3900 units |750 units/hr. = 15ml/hr. |
| 71-80 kg |4000 units |900 units/hr. = 18ml/hr. |
|>80 kg |4000 units |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 ___ ___
Admission orders: ACS – post ER
MRP Name: _______________________________________
Patient: AGE __ WT kg GFR ________
Code Status ______________________________
Diet: Healthy heart Diabetes NPO Other _______________________.
Activity: Bed rest Commode Activity as tolerated Advance activity prn
ASA 325 mg po daily
Oxygen @ ___ Liters/min, or to maintain Oxygen Sats > 90%
ECG Daily x _____ days
Urinary catheter - In and Out catheterization for retention PRN
Lab: Fasting lipid profile x 1, Fasting glucose x 1
Daily: CBC, GFR, Na, Cl, K, CO2.
Repeat troponin at _____________ hrs, date _________________.
IV normal saline lock or ________________ ___________________________
Nitroglycerin 0.4 mg sublingual q 5 min PRN for chest pain if systolic BP > 90
Nitroglycerin patch _____mg/hr. at ____h and off at ___ h. Keep on overnight first night.
Acetaminophen 500-1000 mg q 6 h PRN for mild pain or fever.
Clopidogrel 75 mg po daily
Morphine ________ mg IV q 5 min PRN if systolic BP > 90.
Metoprolol 25 mg po BID or Metoprolol ______ mg po BID
Atorvostatin 80 mg po daily or _______________________________
Ramipril 5 mg po daily or _______________________________
Dimenhydrinate 12.5 – 25 mg IV q 4 h PRN
Pantoprazole 40 mg PO daily or Ranitidine 150 mg PO BID
Lorazepam 1 mg hs PRN or _______________________________
Zoplicone 7.5 mg hs PRN
Laxatives as indicated by RN, PRN
STEMI patients – post thrombolysis in ER.
Age < 75 years
Enoxaparin: GFR > 30: 1 mg/Kg S.C. q 12 h for 48 hours.
GFR < 30: 1 mg/Kg S.C. q 24 h for 48 hours.
Age > 75 years
Enoxaparin: GFR > 30: 1 mg/Kg S.C. q 12 h for 48 hours.
GFR < 30: 1 mg/Kg S.C. q 24 h for 48 hours.
Unfractionated Heparin x 48 hours
| Patient Weight | Heparin I.V. Bolus |Initial Heparin Infusion |
|41-50 kg |2700 units |550 units/hr. = 11ml/hr. |
|51-60 kg |3300 units |650 units/hr. = 13ml/hr. |
|61-70 kg |3900 units |750 units/hr. = 15ml/hr. |
| 71-80 kg |4000 units |900 units/hr. = 18ml/hr. |
|>80 kg |4000 units |1000unit/hr. = 20ml/hr. |
NSTEMI patients/Unstable Angina – no thrombolysis.
GFR > 30: Fondaparinux 2.5 mg S.C. daily.
GFR < 30 unfractionated heparin x 48 hrs.
|Patient Weight | Heparin I.V. Bolus |Initial Heparin Infusion |
|41-50 kg |2700 units |550 units/hr. = 11ml/hr. |
|51-60 kg |3300 units |650 units/hr. = 13ml/hr. |
|61-70 kg |3900 units |750 units/hr. = 15ml/hr. |
| 71-80 kg |4000 units |900 units/hr. = 18ml/hr. |
|>80 kg |4000 units |1000unit/hr. = 20ml/hr. |
____________________ _______________ ______________ ______________
Signature, Designation College License# 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, labs, ECG, CXR,
3. Oxygen if Sats less than 93%
4. Have patient on Lifepak with defib pads and have amp of Atropine handy
5. 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.
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
10. Fentanyl for pain – 25 mcg aliquots and consider infusion.
Acute Pulmonary Edema
IF Adequate Perfusion or Hypertensive (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’. NB: morphine has not shown to be effective in CHF
9. CXR, ultrasound for B lines, ECG, troponin, CBC, lactic acid, lytes, BNP
IF Hypotensive (decompensated CHF) (MAP < 65 and cold extremities)
1. Oxygen if Sats 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
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 (NOT nebulized hypertonic saline)
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!)
High flow nasal oxygen/CPAP
Wait 1 hour – if improved (Sa02 > 92%) discharge
- if not improved, try one dose of Epinephrine 0.05 ml/Kg; administer with jet nebulizer over ~15 minutes. or
- 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 with congenital cardiopulmonary disease
Corticosteroids: been shown to decrease recurrence of bronchiolitis in recurrent cases
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.
Burns – Thermal
1st Degree Burn - Superficial
Minor epithelial damage, no blistering.
2nd 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.
3rd Degree Burn
Full thickness, white leathery appearance, no pain sensation.
If > 1 cm in diameter, usually need skin grafting.
4th 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.
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 burns with clean linen. DO NOT APPLY ICE.
15. Do NOT give prophylactic antibiotics.
Chemical Eye Burns
Alkaline substances are more damaging than acids.
Most commonly seen in small children.
1. Immediate and continuous water irrigation via Morgan lens is ideal. Use Ringers lactate for irrigation as it is the closest to normal eye pH.
[pic]
2. May need repeated topical ocular analgesics.
3. If small children may need analgesia and sedation.
4. Alkaline burns should be irrigated for at least 2 hours, regardless of surface pH.
5. Apply topical erythromycin ung.
6. Refer to ophthalmology.
7. Chemicals that should NOT be treated with immediate irrigation include Dry Lime, phenol and elemental metals (sodium, potassium, magnesium, lithium)
8. Dry lime should be brushed off the skin prior to any water irrigation.
9. Elemental metals should be removed and the eye covered in mineral oil or other nonaqueous solution.
10. Phenol should be wiped off using 50% polyethylene glycol (PEG). Water irrigation can be used until PEG is available.
Coma Management
1. ABC’s with C-Spine control if indicated.
2. Complete exam, neuro exam (especially before intubation)
3. Glasgow coma scale or FOUR score (next page)
4. IV’s and Oxygen
5. ECG, Temp
6. Start looking for the cause while doing management.
7. Bedside glucose. If blood glucose < 3, give 50 mls 50% glucose (25 gms)
over 3 – 4 minutes IV. Give concurrent Thiamine.
8. Thiamine 100 mg IV.
9. Draw blood for CBC, LFT, lactate, lytes, Ca, CK, Mg, INR,blood cultures
10. Urine for drug screen
11. Narcan 0.1 mg IV bolus or 0.4 mg IM
12. 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)
13. Consider IV Lipid Emulsion therapy for suspected drug overdose of:
Tricyclic antidepressants, Wellbutrin, Calcium channel, beta blocker,
Antipsychotic (Haldol)
Dosage:
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.
14. If suspected or known increased ICP, Mannitol 1 gm.kg IV
[pic] [pic]
Decorticate: damage to cortex, brainstem/thalamus Decerebrate: damage upper brain stem
(more serious)
The FOUR Score for Coma Assessment
(Full Outline for UnResponsiveness)
Score of 0 – 16 with lower score associated with worse outcome.
Can be used with or without the patient intubated.
Has better sensitivity, specificity, accuracy and positive predictive value than the Glasgow Coma scale.
[pic]
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: (NB: up to 15 percent of children require admission)
1. Moderate symptoms (stridor at rest, retractions, poor color, not tolerating po fluids, abnormal SpO2) persisting after more than 4 hours from corticosteroid dose.
2. Moderate symptoms (above) persist after more than 2 hours from epinephrine dose
3. Recurrent ER admissions within past 24 hours.
4. Less than 6 months of age.
Note: if intubating, use an ETT 0.5 – 1 mm smaller that you would normally use.
Diabetic Ketoacidosis (DKA) and
Hyperosmolar Hyperglycemic state HHS
For Pediatric Diabetic Ketoacidosis – call Pediatrician!
Differentiate DKA vs HHS
[pic]
DKA develops over hours to 1-2 days. HHS develops over days to weeks.
Diabetic Ketoacidosis - DKA:
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
[pic]
Treatment of DKA
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.
Hyperosmolar Hyperglycemic state - HHS
1. Usually precipitated by infection, meds (BB, diuretics), GI bleed, pancreatitis, ACS, stroke, noncompliance with meds
2. Clinically dehydrated, hypotensive, altered mental status, lethargy, seizures
Treatment of HHS:
1. Look for precipitating causes.
2. IV fluids – N/S (average 8-12 liter deficit). Replace 50% in first 12 hours or 20 ml/kg/hr
Once fluid restored change to 1/2 N/S (0.45% NS at 5 ml/kg/hr if Na normal. Otherwise N/S if Na is low)
3. K+ If < 3.3 mEq/L give 40 mEq until K > 3.3
K+ > 3.3 but < 5.0 give 20-30 mEq K+ in each liter of fluid.
Keep K between 4-5 mEq/L
If > 5.0 give do not give any K+, but check q 2 hrs.
4. Once K stable (4-5 mEq/L) give Insulin 0.1 unit/kg/hr bolus then IV infusion 0.1 unit/kg/hr.
5. Check glucose hourly. If not falling, increase insulin infusion (double)
6. Once glucose normal, change IV fluids to D5/1/2NS and decrease insulin infusion to 0.02-0.05 units/kg/hour.
7. If pH < 6.9 give 100 mEq NaHC0 with 20 mEq KCL in 500 ml sterile water over 2 hours.
Electrolyte Disorders
Hypo Hyper
| |K < 3.5 mmol/L Critical = K < 2.5 mmol/L | K > 5 mmol/L (Normal 3.5-5 mmol/L) |
|K | | |
| |Causes: GI loss, renal loss, malnutrition |Causes: CRF, DKA, hemolysis, rhabdo |
| |S/S: weakness, paralysis, leg cramps, resp. distress, |S/S: weakness, resp. failure, ECG peaked T, wide QRS |
| |ECG flat T waves, Vent arrhythmia, PEA |K 6-7 mmol/L: 10 u reg insulin in 25 g glucose |
| |K < 2.5 mmol/L: K 10-20 mEq/hr |(50 ml D50) IV over 20 minutes |
| |Cardiac arrest due to hypoK: K 10 mEq IV over 5 min. |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 |Na > 145-150 mmol/L (Normal 135-145 mmol/L) |
|Na |Causes: reduced excretion water by kidneys, diuretics, renal failure, |Causes: Increase Na, Cushing’s, Free water loss (GI, renal) |
| |vomiting, SIADH, CHR, cirrhosis |S/S: altered mentation, weakness, neuro deficits, seizure |
| |S/S nausea, irritable, lethargy, seizures, coma |Trt: reduce ongoing water loss, N/S or D5 ½ NS |
| |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 | |
| | Mg < 0.65 mmol/L |Mg > 1.05 mmol/L (Normal 0.7-1 mmol/L) |
| |Causes: decreased absorption, loss via GI and renal. Meds – diuretics, |Causes: renal failure |
|Mg |Alcohol |S/S muscle weakness, paralysis, ataxia, lowered LOC, hypoventilation, |
| |S/S: tremors, nystagmus, tetany, altered mentation, ataxia, seizures, |cardiorespiratory arrest. |
| |torsade de pointes. |Mg > 1.1mmol/L: CaGluconate 1500-3000mg IV |
| |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 |Ca > 3 mmol/L (Normal 2.1-2.6 mmol/L) |
| |Causes: toxic shock, Mg abnormalities, tumor lysis |Causes: primary hyperparathyroidism, malignancy |
|Ca |S/S: paresthesia, cramps, stridor, seizures, hyperreflexia, heart |S/S: depression, weakness, confusion, hallucinations, seizures, coma, |
| |failure |constipation, |
| |Ca < 2.1 mmol/L with symptoms: Ca gluconate 10 – 20 mls of 10% sol’n IV |ECG QT shortening, PR & QRS prolonged, AV block, cardiac arrest |
| |over 10 minutes |Ca > 3 mmol/L: N/S 300-500 mg/h to replace fluid deficit |
| |Then infuse 60 ml of 10% Ca gluconate in 500-1000 ml of D5W at 1 mg/kg |Monitor Mg and K |
| |per hour | |
| |Monitor Mg, K and pH. | |
Frostbite
Prethaw
1. Protect part
2. Stabilize core temperature
3. IV rehydration (R/L, N/S)
4. Avoid friction massage
Thaw
1. Re-warm part in circulating water (or large tub) at 37 – 39 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. If available and < 24 hrs, intra-arterial directed TNK or tPA. (or IV TNK)
2. Plus: LMWH 500 units/hr infusion or Enoxaparin 1 mg/kg/dose S.C. q 12 hours
(no evidence heparin on its own is of any value)
3. Debride clear vesicles (see below)
4. Drain Hemorrhagic vesicles by aspiration but do no debride.
5. If available, apply topical Aloe Vera q 6 h.
6. Give Ibuprofen (Motrin) 400 -600 mg q 12 h.
7. Tetanus if indicated.
8. Analgesics as needed.
9. Elevate involved parts
10. Place cotton pledges/balls between frozen toes
11. Cover with loose clean sheets. No compressive dressings. No topical antibiotics
12. If any sign of infection, give Cefazolin 1 gm IV q8h.
13. 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.
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
Involvement of 1st 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
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. Avoid Hyperventilation if intubated. Keep PaCO2 35-38 mmHg range (> 30 mmHg)
5. Consult Neurosurgeon
6. ? Mannitol 1 g/Kg IV for worsening neurological condition (consult Neurosurgeon)
7. Or Hypertonic Saline 3% 100 ml aliquots to reach Na+ 155 mmol/L (145-155) (not well studied. Use if mannitol unavailable)
8. Steroids NOT recommended
9. Barbiturates NOT recommended (unless ordered by neurosurgeon)
10. If sedation necessary, use a Propofol 5 mcg/kg/min then titrate (usual dose 5-50 mcg/k/min).
11. Watch for cardiac dysrhythmias (especially PSVT)
12. Control seizures with Ativan 2 – 4 mg IV or Midazolam 2 – 4 mg IV
13. 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.
14. Maintain normal glucose levels.
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.
There are multiple scoring systems – SCAT5, SAC, Maddocks, etc
‘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.
Hypertensive Urgencies and Emergencies
Definitions:
Hypertensive Urgencies: >180/>120 mmHg without evidence of end organ damage.
Hypertensive Crisis/Emergency: >180/>120 mmHg 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: (treat over hours to days)
Goal: 220/120 mmHg treat.
2. Acute aortic dissection – lower to 100-120 mmHg systolic. (IV labetalol)
3. Acute intracerebral bleed –
Rx: Nitroprusside 0.3 – 0.5 mcg/kg/min titrate by 0.5 mcg/kg/min.
Max 10mcg/kg/min
Labetalol 20 mg IV push over 2 minutes. Max 40-80 mg.
Infusion 1-2 mg/min titrate.
Hydralazine 10 – 20 mg IV (not as reliable)
2. Hypertension with Pulmonary Edema
Rx: Nitroglycerin - treat for CHF as per guideline page 7.
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. MgS04
Rx: discuss with Obstetrician – usually use hydralazine or labetalol.
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.
Hypothermia
Measure CORE (Rectal) temperature using rectal hypothermia thermometer.
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. EXCEPT no compressions if rhythm on monitor or contractions on ultrasound, but no palpable pulse (PEA)
4. Try to re-warm to 35 degrees before pronouncing dead.
5. Give empiric 250 – 500 ml HEATED (40-42 deg. C) NS or D5W (NOT R/L)
6. Consider dopamine infusion to maintain perfusion.
7. Oropharyngeal intubation is not harmful, nor rhythmogenic
8. Place NG tube
9. ECG monitor
10. Do active external re-warming of THORAX only. Heated pads, bear hugger, blankets etc.
11. Use heated, humidified Oxygen (42 – 45 degrees)
Signs of possible futile resuscitation: severe hyperK+ > 12,
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
3. Wellbutrin overdose
4. SSRI overdose
5. Calcium channel
6. Beta blocker overdose
7. Antipsychotic overdose (Haldol)
Dosage:
1.6 ml/kg (ideal body wt.) bolus over 1-3 minutes, then
0.25 ml/kg/min for 30-60 minutes
Bolus can be repeated 1-2 times for persistent asystole.
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, IV
3. Metoclopramide (Maxeran) 10 mg IV (combine with DHE)
4. Toradol 30 mg IV/IM and Maxeran 10 mg IV and 1 liter fluids IV
5. IV fluids
6. ? +/- Dexamethasone 4 – 8 mg IV – may help reduce early recurrence
Overdose – Benzodiazepine
(Ativan, Valium, Propofol, Versed, Serax)
1. ABCD – maintain oxygenation
2. IV access
3. Activated charcoal NOT of benefit.
4. Preferably do NOT use Flumazenil as this may precipitate a seizure. If you HAVE to use it then:
5. 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 Flumazenil around 45 minutes) may start infusion at 0.1 – 0.4 mg/hr.
- Titrate to response.
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.
Call Poison BC Poison Control for all overdoses. BC 1-800-567-8911
Isopropyl Alcohol (in rubbing alcohol, antifreeze)
Lethal dose is 150 – 250 ml or 2 – 4 ml/Kg. Fatality is rare.
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: raised ketonemia, raised osmolar gap (occurs with isopropyl, ethylene and methanol OD), falsely high Creat.
Treatment – mainly symptomatic - ABCs
- 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 uneventfully)
- Correct hypoglycemia
Ethylene Glycol (motor coolant, detergents, antifreeze)(toxic metabolite – glycolate – renal injury)
Lethal dose 1 gm/Kg
Signs and Symptoms
- ‘drunk’ appearing, elevated BP, CHF, flank pain, oliguria, acute respiratory distress syndrome (respiratory failure)
Lab: high anion gap, high osmolal gap, check for hypoglycemia, ECG r/o conduction issues/QT interval. Lytes,
Treatment: ABCs
- +/- Lavage stomach if less than 1 hour post ingestion
- NO activated charcoal (absorption too fast)
- NaHCO3 IV 1-2 mEq/k if pH below 7.3. Infusion 133mEq in 1 L D5W run at 200 ml/hr.
- Thiamine 100 mg IV, folic acid 50 mg IV q 6 hr
- Fomepizole 15 mg/Kg IV then 10 mg/Kg q 12 hours.
- Treat CHF with standard therapy
- +/- Hemodialysis – consider need for medivac
Methanol (antifreeze, window washing fluid)(toxic metabolite is formate – renal and optic injury, brainstem stroke
Lethal dose ~ 30 mls (1 gm/kgKg of 40% methanol)(even 1 tsp can have serous toxicity)
As little as 4 ml can cause blindness
Labs: as for ethylene glycol.
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
- 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 etc)
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)
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 Guidelines for “Sedation for Severe
Agitation” page 46.
Anticholinergics (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
- 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
- Lipid emulsion therapy
SSRI Antidepressants (Prozac, Zoloft, Paxil etc)
Signs and Symptoms
- drowsy, increase heart rate, ECG changes, nausea, vomiting, tremor
Treatment:
- treat symptoms
- Lipid emulsion
Opioids (Morphine, Codeine, Demerol, Fentanyl, Heroine, Lomotil)
Signs and Symptoms:
- Note: if addict, tolerance built up except for miosis (small pupils) so the following 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.
Overdose - Acetaminophen
Toxic Dose > 150 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. Activated charcoal 1g/Kg orally if within 4 hrs post ingestion.
3. Do baseline AST, SGOT, LDH, PT, PTT, CBC, Lytes, BUN, Creat.
4. Acetyl cysteine – Mucomyst
Give within 12 – 16 hours, preferably < 8 hours ingestion.
Oral: (preferred route) (72-hour protocol)
- 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) (20-hour protocol)
- Loading dose of 150 mg/Kg in 200 ml D5W over 1 hour.
- Then 50 mg/Kg in 500 ml D5W over 4 hours
- Then 100 mg/Kg in 1000 ml D5W over 16 hours.
Anaphylactoid/Anaphylaxis to Acetyl cysteine – 10-20 pecent
- Treat with Epi, Benadryl and steroids
[pic]
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.
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
Ketamine 3 – 5 mg/Kg IM
or if IV established:
Time of dosages Haldol IV + Ativan IV
0 min 3 mg 0.5 – 1 mg
20 min 5 mg 0.5 – 2 mg
40 min 10 mg 0.5 – 10 mg
Every hour 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.
Seizures – Adult
1. ABCDE’s
2. IV lines
3. Do finger prick glucose and take Temperature.
4. Draw blood for CBC, LFT, Calcium, Magnesium
5. If glucose < 3, give Glucose 50 ml of 50% (25 gms) over 5 minutes IV
6. Thiamine 100 mg IV, IM
7. 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
(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
Onset Peak Action Half life
Ativan: 2 – 3 min. 45 – 60 min 6 – 8 hrs.
Valium: 1 – 3 min. 15 – 30 min 3 – 4 hrs.
Midazolam: 1 –5 min. 4 hrs.
Seizures – Pediatric
1. ABCDE’s: oxygen, suction secretions, recovery position
2. IV line/intraosseous access.
3. glucose, CBC, lytes
4. If glucose < 3, give 25% glucose 2 – 4 ml/Kg IV.
5. Lorazepam 0.1 mg/kg (max 4 mg/dose) IV/IO/IN
6. 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)
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)
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.
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%.
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
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. Neurogenic shock is hypotension and bradycardia caused by transient autonomic cord injury. Maintain MAP of 85-90 using fluids or vasopressors. Atropine may be needed for profound bradycardia.
5. Be careful to not over resuscitate with IV fluids, as this can increase cord swelling.
6. Remember – lying on a backboard more than 45 minutes leads to high risk of decubitus ulcers.
7. Urinary catheter.
8. Maintain normothermia.
9. 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 non-penetrating spinal cord injury, it should be started within 8 hours of injury.
NOTE: Some Neurosurgeons do not advocate corticosteroid use so check with them before administering.
Trauma Resuscitation - ATLS Protocol
Are you protected?? Gloves, gown and goggles?
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.
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.
Glasgow Coma Scale
ADULT
Eye Response Score Motor Response
Spontaneous 4 Obey command 6
To Voice 3 Localizes pain 5
To Pain 2 Withdraws from pain 4
None 1 Flexes to pain 3
Verbal Response Extension to pain 2
Oriented 5 None 1
Confused 4
Inappropriate 3 SCORE /15
Incomprehensible 2
None 1
PEDIATRIC
Best Eye Response
Eyes open spontaneously 4
Eye opening to speech 3
Eye opening to pain 2
No eye opening or response 1
Best Verbal Response
Smiles, oriented to sounds, follows objects, interacts 5
Cries but consolable, inappropriate interactions 4
Inconsistently inconsolable, moaning 3
Inconsolable, agitated 2
No verbal response 1
Best Motor Response
Infant moves spontaneously or purposefully 6
Infant withdraws from touch 5
Infant withdraws from pain 4
Abnormal flexion to pain for an infant (decorticate) 3
Extension to pain (decerebrate) 2
No motor response 1
SCORE /15
See also Four score (section on Coma, page 24)
Ventilator Support
Ventilator Settings for Philips Trilogy 202
Ideal Body Weight
Height 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”
Male-kg 52 53 55 57 59 61 63 65 66 68 70 72 74 76 78 79 81 83 85 87
Female-kg 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.
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.
Settings for LTV 1000 Ventilator
Ideal Body Weight
Height 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”
Male-kg 52 53 55 57 59 61 63 65 66 68 70 72 74 76 78 79 81 83 85 87
Female-kg 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
(*) 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)
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
Pleurovac (has plastic connecting tubing)
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:
1. 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 below
2. Prep skin with betadine or antiseptic. Note this is a sterile procedure, so wear sterile gloves and mask.
3. Infiltrate skin with 2% lidocaine along site of incision, subcutaneous tissue and along
anterior rib margin.
4. Make a linear incision along the rib, one interspace below the site of insertion.
5. 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
6. 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
7. 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
8. 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
9. Secure the tube to the skin with 0 – silk as in diagram. Close remaining incision site opening with sutures. Fig 4.31, 4.32
10. 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
Figures 4.25 – 4.32
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. If it is a child you may need to use oral sedation.
2. Can also infiltrate skin with local Xylocaine
3. Paint the area with povidone-iodine.
4. 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.
5. If mineral oil doesn’t work, there are two techniques to try.
6. 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
7. 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.
8. Assess need for tetanus vaccination
9. Clean the skin and if necessary suture or steristip any laceration.
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
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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
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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 18-gauge) 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.
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Shoulder Dislocation
Before attempting a reduction.
1. Check for axillary nerve compromise and artery damage – (ie check for intact sensation over the deltoid muscle area)(check for radial pulse or pulsatile mass in axilla)
2. Obtain xrays to ensure no fracture.
90% of shoulder reductions do not require procedural sedation.
Oral or IV analgesia is often adequate.
The following are not in order of preference or efficecy.
Anterior Dislocations (95-97% Dislocations)
There are at least 10 maneuvers for reducing an anterior shoulder dislocation. They all work!
Best if know more than one, as one technique may not work on all patients.
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Cunningham Technique
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External Rotation Technique
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Fares Technique
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Modified Kocher Technique or Hennipen Technique
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Stimson Technique
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Milch-Cooper Technique
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Scapular Manipulation Technique
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Posterior Dislocation (2-4% dislocations)
- X-rays miss 50% of posterior dislocations. Clinically posterior shoulder will be prominent with flattening of the anterior shoulder. Pt will hold arm usually in adduction and internal rotation.
- Have higher incidence of surgical neck fractures, Hill-Sachs and damage to labrum.
- may require OR reduction.
[pic]
Inferior Shoulder Dislocations (less than 1% dislocations)
- Pts will hold arm above the head and are unable to adduct the arm.
- usually occur with the arm fully abducted and the axial loading or via forceful hyperabduction of the am.
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Sternoclavicular Dislocation
- SC joint can sublux or dislocate either anteriorly (more common) or posteriorly.
- Posterior dislocations can be associated with subclavian laceration, pneumothorax,
mediastinal compression, esophageal rupture, tracheal tear and other severe complications.
- Posterior dislocation need orthopedic referral.
- Pt can usually not abduct the shoulder anteriorly. Passive movement will cause pain.
- Need specialized xrays (SC joint cone down – serendipity view) and even CT to distinguish.
- Usually do to blunt force blow to the medial clavicle or medial compression of the shoulder
girdle.
Management:
- Anterior dislocations are usually managed nonoperatively.
- Sling for pain. Usually settles in 2-3 weeks with residual ventral protrusion.
- Closed reduction rarely indicated and often unsuccessful.
- If reduction is attemped:
- Classical: Patient positioned supine with a towel/sandbag between scapulae. Sedation is administered
and traction is applied to the abducted arm with simultaneous extension. This has an 80% success rate.
- Buckerfield and Castle: While shoulders are pushed posteriorly by an assistant, the ipsilateral arm is
adducted against the torso and caudal traction is applied.
- Towel Clip: Anterior traction force can be applied to clavicle by percutaneously applied towel clip,
often used with one of the above methods.
- A figure of eight sling is applied after the reduction for 4-6 weeks to allow for ligamentous healing
-----------------------
Beta-blocker – if systolic BP > 100, (caution with COPD, ASTHMA, CHF)
Beta-blocker – if systolic BP > 100, (caution with COPD, ASTHMA, CHF)
Beta-blocker – if systolic BP > 100, (caution with COPD, ASTHMA, CHF)
Beta-blocker – if systolic BP > 100, (caution with COPD, ASTHMA, CHF)
Beta-blocker – if systolic BP > 100, (caution with COPD, ASTHMA, CHF)
Beta-blocker – if systolic BP > 100, (caution with COPD, ASTHMA, CHF)
Beta-blocker – if systolic BP > 100, (caution with COPD, ASTHMA, CHF)
Beta-blocker – if systolic BP > 100, (caution with COPD, ASTHMA, CHF)
Beta-blocker – if systolic BP > 100, (caution with COPD, ASTHMA, CHF)
Beta-blocker – if systolic BP > 100, (caution with COPD, ASTHMA, CHF)
Beta-blocker – if systolic BP > 100, (caution with COPD, ASTHMA, CHF)
Beta-blocker – if systolic BP > 100, (caution with COPD, ASTHMA, CHF)
Beta-blocker – if systolic BP > 100, (caution with COPD, ASTHMA, CHF)
Beta-blocker – if systolic BP > 100, (caution with COPD, ASTHMA, CHF)
Pupil Size in Different Overdoses
Miosis (Pinpoint) Mydriasis (Dilated) Nystagmus
Heroin Cocaine, caffeine, amphetamines Barbiturates
Morphine (opioids) Anticholinergic (Benadryl, older antihistamines) Carbamazepine
Ethylene glycol LSD, Mescaline PCP
Benzo Sedative hypnotics Alcohols – all
Antipsychotics Ketamine
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)
A
B
C
D
E
Mode: A/C Volume
Tidal Volume (Vt): 6-8 cc/kg IBW
Resp. Rate: 18 bpm
PEEP: 5 cm H2O
FiO2: 100% initially
After 5 min, do ABG, follow ARDSnet chart
Goal: PaO2 55-85 mmHg or SaO2 90%
Pulm Edema, Pneumonia, OD…
Everything except Asthma/COPD
Type 1
O2 +/- CO2
Asthma/COPD
Type 2
CO2 +/ - O2
NIV/BPAP
Mechanical
Ventilation
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: 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: A/C Volume
Tidal Volume (Vt): 8 cc/kg
Resp. Rate: 10 bpm
PEEP: O-4 cm H2O
FiO2: 40 %
Goal: Keep pH above 7.1
Asthma/COPD
Type 2
[pic] CO2 +/ - [pic]O2
Pulm Edema, Pneumonia, OD….
Everything except Asthma/COPD
Type 1
[pic] O2 +/- [pic] CO2
Mechanical
Ventilation
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
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
Mode: SIMV/CPAP
PEEP: O – 5 cm H20
PSV (IPAP): 10-15 cm H2O (max 20)
FiO2: 100% initially
Mode: SIMV/CPAP
Set Breath rate to - - (or will be in SIMV)
PEEP: 5 cm H20 (max 15) (*)
PSV (IPAP): 10 cm H20 (max 20)
Fi02: 100% initial
NIV/BPAP
Pleurovac
[pic]
< 0.8 and lower should NOT have compression stockings applied.
0.8-0.9 should only use compression stockings with caution.
>1.4 can be seen in diabetics and elderly patients.
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.
Anterior Shoulder Dislocation: appearance and anatomy.
Pt usually holds arm adducted, internally rotated. Prominent acromion and ‘flattening’ over the humeral head.
Cunningham
- Have Pt adduct the arm against the chest and to pull
their shoulders together and straighten back.
- MD sits in front of Pt on a chair.
- Pt places hand atop the MD’s shoulder or upper arm
- MD rests one arm on elbow crease with other hand
gently massaging the biceps, deltoid and trapezius.
External Rotation
- rarely requires sedation and often not even analgesia.
- Pt supine with elbow flexed 90 degrees.
- Hold the elbow to ensure adduction
- With other hand, grasp Pt’s wrist and slowly externally rotate.
- If pain, stop and wait. Then proceed.
- Reduction can be subtle, with no clunk.
Fares (or Hand Shake)
- Pt supine. MD grasps Pt’s wrist, extends the arm straight and gently pulls the arm to provide traction.
- No counter traction is needed.
- arm is gradually abducted while the MD
continuously moves the arm up and down in an arc
~ 10 cm. (‘hand shake’)
- the up and down motion relaxes the shoulder.
- if not reduced by 90 degrees then externally rotation
is added.
Modified Kocher
- Pt can be seated upright, 45 degrees or supine. MD stabilizes the elbow and wrist.
- Slowly externally rotate the Pt’s elbow
until 90 degrees. It may have to be in
steps to let muscle spasm and pain
subside.
- Usually reduction occurs by 90 degrees,
but if not, then slowly elevate the arm.
(modified Kocher)
Stimson
- Pt is placed in prone position on a stretcher.
- A rolled up towel is then placed under the
coracoid process.
- A weight is affixed to the wrist (wts or a
bucket of water). Use gauze roll not tape.
- If necessary the MD can facilitate by gently
internally/externally rotating the arm.
Milch-Cooper
- Pt is supine. Needs heavy sedation!
- With arm slightly abducted and forward traction, start to bring the arm up until it is directly overhead.
- Often reduction will occur at this point. If
not, one can slowly internally/externally
rotate the arm.
- If last step is ineffective, using outward
traction and abduction, bring the arm
slowly through a full lateral downward arc.
- 46>HIJ•¤¨¬ÌÏÐàæï÷þ [pic] ðáðáðÝÙÕÝÑÍÑɾ³«œ?‡~riciZiTNh¸baJh•9ÖaJh•9ÖhÓB”aJScapular Manipulation
- lease traumatic technique
- Pt sits upright and leans unaffected shoulder against the stretcher.
- MD stands behind Pt and palpates tip of scapula with thumbs and
directs a force medially.
- Assistant stands in front of P and provides gentle downward
traction on the humerus.
Posterior Dislocation
- usually require conscious sedation.
- gentle traction on the arm with an additional anterior and laterally directed force applied to the posterior aspect of the humeral head.
Inferior Dislocation
- Usually require sedation.
- Apply traction-countertraction in line with the abducted humerus.
- Gentle, gradual adduction of the arm reduces dislocation.
- Closed reduction is may not work if there is a ‘buttonhole’ deformity (humeral head is trapped in a tear of the inferior capsule) exists, in which case open reduction is required.
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