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NYC REMSCO Protocols Jan. 2008 updates

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EMT-Paramedic. Protocol. 543 Neonate Resuscitation. Newly Born changed back ... EMT-Paramedic. Protocol. 529 Pain Management For Isolated Extremity Injury ... – PowerPoint PPT presentation

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Title: NYC REMSCO Protocols Jan. 2008 updates


1
NYC REMSCO ProtocolsJan. 2008 updates
  • Dr. Victor Politi

2
Where to begin?
  • All protocols have been approved by the New York
    State Emergency Medical Advisory Committee
    (SEMAC) for use in the NYC region (REMAC)
  • Some changes are effective immediately
  • Changes are reflected in
  • GOP
  • BLS
  • ALS

3
The GOP Changes
  • Maintenance of IVs by EMT-Bs
  • Excerpt from DOH policy 04-02 added.
  • IO Access and Drug Administration
  • IO access via an extremity added.
  • Pharmacology Table
  • Amiodarone dose added.
  • Subcutaneous Epinephrine deleted, now IM.
  • Lidocaine Infusion deleted
  • Pediatric Protocols
  • Age limitation for use of IO deleted.

4
The GOP Changes
  • Compensated Shock (adult)
  • Use of Delayed capillary refill as a sign of
    adult shock deleted.
  • Blood Drawing
  • Blood drawing is no longer limited for glucose
    level determination now at discretion of service
    medical director.
  • Stroke
  • Stroke Criteria for transport to Stroke Center
    clarified.
  • Newly Born
  • Term changed back to Neonate

5
EMT-Basic Protocol
  • 400 WMD
  • Reference to brand name (MARK I) removed.
  • Atropine dosages for extended treatment
    clarified.
  • 404 Non-Traumatic Chest Pain
  • Nitro in spray form added (assist the patient).

6
EMT-Basic Protocol
  • 407 Asthma
  • Age restriction deleted.
  • BORG deleted
  • Requirement to contact medical control prior to
    administering Albuterol to cardiac patients
    deleted.
  • Albuterol may be administered a total of 3 times
    (originally 2).

7
EMT-Basic Protocol
  • 414 Poisoning or Drug Overdose
  • Reference to shock deleted.
  • 420 Traumatic Cardiac Arrest
  • AED application and defibrillation added.
  • 430 Emotionally Disturbed Patient
  • Add direction to contact ALS for chemical
    restraint if needed.
  • 442 Care of the Newly Born
  • Newly Born changed back to Neonate
  • Minor language changes
  • 443 Newly Born Resuscitation
  • AHA revisions

8
EMT-Basic Protocol
  • 450 Pediatric Respiratory Distress/Failure
  • Minor language change
  • 453 Pediatric Non-Traumatic Cardiac Arrest and
    Severe Bradycardia
  • Minor language change
  • 455 Pediatric Anaphylactic Reaction
  • Minor language change
  • 458 Pediatric Shock
  • Minor language change

9
EMT-Paramedic Protocol
  • 501 Respiratory Distress
  • Narcan is eliminated Protocol now stresses
    suspected OD be treated under AMS Protocol.
  • In Prehospital Sedation, Midazolam is replaced by
    Lorazepam.
  • 503-A V-Fib / Pulseless V-Tach
  • Amiodarone mandatory is no longer an option.
  • 504-A Drug Therapy of Myocardial Ischemia
  • Lidocaine eliminated.
  • Narcan no longer administered for hypotension or
    stupor.
  • Reference to GOP for Patients with STEMI

10
EMT-Paramedic Protocol
  • 506 Acute Pulmonary Edema
  • Narcan no longer administered for hypotension or
    stupor.
  • 507 Asthma
  • Epinephrine, Magnesium Sulfate,
    Methylprednisolone, and Dexamethasone no longer
    Medical Control Options, may be administered
    under Standing orders.
  • 508 COPD
  • Methylprednisolone, and Dexamethasone no longer
    Medical Control Options, may be administered
    under Standing orders.

11
EMT-Paramedic Protocol
  • 510 Anaphylactic Reaction
  • Epinephrine no longer administered via
    endotracheal tube.
  • 511 Altered Mental Status
  • Glucometer parameters for with-holding dextrose
    limited to reading greater than 120 mg/dl.
  • Narcan may be administered Intranasally (IN).
  • 520 Traumatic Cardiac Arrest
  • Cardiac monitoring and defibrillation for v-fib
    or pulseless v-tach added.

12
EMT-Paramedic Protocol
  • 543 Neonate Resuscitation
  • Newly Born changed back to Neonate.
  • Delete Narcan via ET tube.
  • Add Epinephrine via IO/IV.
  • 551 Pediatric Obstructed Airway
  • Add Needle Cricothyroidotomy.
  • 553 Pediatric Non-Traumatic Cardiac Arrest
  • Amiodarone added as Standing Order.
  • Delete lidocaine.
  • Add Magnesium Sulfate for Torsades de pointes.

13
EMT-Paramedic Protocol
  • 529 Pain Management For Isolated Extremity
    Injury
  • Morphine Sulfate no longer Medical Control
    option, may be administered under Standing orders
    new dosage.
  • Narcan no longer administered for hypotension or
    stupor.
  • 530 Emotionally Disturbed Patient
  • Add medical control option for chemical
    restraint.

14
EMT-Paramedic Protocol
  • 554 Pediatric Asthma/Wheezing
  • Delete Metaproterenol.
  • Add Ipratropium Bromide (atrovent) and
    Terbutaline.
  • 555 Pediatric Anaphylactic Reaction
  • Add Broselow tape.
  • 556 Pediatric Altered Mental Status
  • Add Broselow tape.
  • 557 Pediatric Seizures
  • Add midazolam and IO.
  • 558 Pediatric Decompensated Shock
  • Clarify dose for adenosine.

15
GOP
  • In cases of adult cardiopulmonary arrest in which
    IV access is unable to be obtained, IO access
    should be attempted via an approved extremity
    approach.
  • Drug administration via this route will utilize
    doses identical to those used for IV
    administration.
  • IO access via the sternum is considered to be
    unacceptable in the NYC region.

16
GOP
  • According to NYS Department of Health EMS Policy
    04-02 (issued 02/26/04)
  • It is allowable for an EMT-B to transport a
    patient with a secured saline lock device in
    place as long as no fluids or medication are
    attached to the port. However, the EMT-B must
    ensure the venous access site is secured and
    dressed prior to leaving the health care
    facility.

17
GOP
  • In the absence of intravenous access, Naloxone
    (Narcan) may be administered via the intranasal
    (IN) route when an appropriate atomizer device is
    available. The route of administration is
    contraindicated in patients with epistaxis
  • Available on all TransCare ALS levelambulances
    and can be ordered through logistics

18
PHARM TABLE REVISEDgt14 yrs of age under 40 kg in
weight
Atropine Sulfate 0.02 mg/kg (min 0.1 mg)
Epinephrine 0.01 mg/kg/dose
Furosemide (Lasix) 1 mg/kg/dose
Lidocaine (bolus) 1.5 mg/kg/dose
Lidocaine (infusion) 1-2 mg/min REMOVED
Sodium Bicarbonate 1 mEq/kg/dose
Amiodarone (new) 5 mg/kg ADDED
19
STEMI (ST Elevation) / Myocardial Infarction
  • For all adults, historical / physical findings
    indicate an AMI, and they have
  • ST segment elevation on 12 lead EKG in 2
    contiguous leads
  • 1 mm in the limb leads,
  • 2 mm in the chest leads
  • or new left bundle branch block
  • Transport to the nearest 24 Hour NYS certified
    interventional cardiac catheterization facility,
    as per OLMC

20
STEMI (ST Elevation) / Myocardial Infarction
  • STEMI Center transport unless
  • The patient is in extremis
  • The patient has an unmanageable airway
  • The patient has other medical conditions (Trauma,
    Burn, CVA) that warrant transport to the closest
    appropriate hospital emergency department as per
    protocol.

21
400 Weapons of Mass Destruction
Adult Dosing
22
400 Weapons of Mass Destruction
Pediatric Dosing
23
407- Asthma
  • Age criteria removed (no longer 1 to 65)
  • BORG Scale removed (patients self assessment of
    excertion)
  • Cardiac precautions removed, OLMC is no longer
    required for,
  • Angina History
  • MI History
  • CHF History

24
407- Asthma
  • Albuterol Sulfate 0.083 may be repeated twice
    for a total of three (3) doses with the third
    occurring during transport
  • (old protocol was 2 maximum on standing orders)

25
420 TRAUMATIC CARDIAC ARREST
  • Begin BCLS procedures
  • Excluding patients with penetrating chest trauma,
    apply AED as described in Protocol 403.
  • If the Shock indicated message is received,
    continue with treatment as described in Protocol
    403.
  • If the No shock indicated message is received,
    begin transport immediately.

26
AHA Circulation 2005112IV-146-IV-149
  • Traumatic Cardiac Arrest
  • BLS ALS support of ABCs
  • Deterioration associated with trauma
  • Hypoxia secondary to respiratory arrest,
  • airway obstruction,
  • large open pneumothorax, tracheobronchial or
    thoracoabdominal injury
  • Injury to vital structures, such as the heart,
    aorta, or pulmonary arteries
  • Severe head injury with secondary cardiovascular
    collapse
  • Underlying medical problems or other conditions
    that led to the injury, such as sudden cardiac
    arrest (eg, VF or VT) in the driver of a motor
    vehicle or in the victim of an electric shock)
  • Diminished cardiac output or pulseless arrest
    (PEA) from tension pneumothorax or pericardial
    tamponade
  • Extreme blood loss leading to hypovolemia and
    diminished delivery of oxygen

27
AHA continued
  • The most common terminal cardiac rhythms observed
    in victims of trauma are
  • PEA (pulseless electrical activity)
  • Brady/Asystolic rhythms
  • occasionally V-Fib/V-Tach
  • VF and pulseless VT are treated with CPR and
    attempted defibrillation
  • Cardiac contusions causing significant
    arrhythmias or impaired cardiac function are
    present in approximately 10 to 20 of victims of
    severe blunt chest trauma

28
443 Neonate Resuscitation
  • AHA 2006 revisions implemented
  • For neonates with
  • Persistent central cyanosis (longer than 15 to 30
    seconds)
  • Respiratory rate less than 30 breaths per minute
    (hypoventilation)
  • Heart rate less than 100 beats per minute
    (bradycardia) OR
  • Cardiac arrest (absence of breathing and pulse)
  • Initiate Neonatal Resuscitation procedures.
  • Request ALS

29
443 Neonate Resuscitation
  • CPR in a Neonate is performed utilizing
    compression to ventilation ratio of 31
  • 120 events per minute (90 Comp30 Vent)
  • If the neonate has
  • Persistent Central Cyanosis OR
  • A Respiratory Rate Less Than 30 Breaths Per
    Minute OR
  • A Heart Rate Between 60 And 100 Beats Per Minute
  • Assist ventilation at a rate of 30 to 60 breaths
    per minute
  • Switch to blow by if RR gt30 HR gt 100 cyanosis
    disappears

30
443 Neonate Resuscitation
  • If the neonate has
  • A Heart Rate Less Than 60 Beats Per Minute OR
  • Cardiac Arrest
  • Start CPR immediately.
  • Stop CPR and begin assisted ventilation at a rate
    of 30 to 60 per minute once the heart rate is gt60
    beats per minute and rapidly increasing.
  • Switch to blow by if RR gt30 HR gt 120 cyanosis
    disappears

31
453 Pediatric Non Traumatic Cardiac Arrest
  • For infants and children with non-traumatic
    cardiac arrest, or infants and children lt9 years
    of age with a HR lt60 bpm (severe bradycardia) and
    signs of inadequate central perfusion
    (decompensated shock)
  • Pediatric AED-capable pads and cables should be
    used for all pediatric patients aged 1 to 8 (lt9
    years of age)
  • Do Not delay or withhold AED for any reason who
    present in Non Traumatic Cardiac Arrest
  • CPR in an Infant/Child is performed utilizing
    compression to ventilation ratio of 152
  • 120 events per minute (105 Comp15 Vent)

32
453 Pediatric Non Traumatic Cardiac Arrest
  • If The Infant has a HR lt60 bpm
  • ventilate at a rate of 20 breath per minute.
  • Start CPR if the heart rate is not rapidly
    increasing following 30 seconds of assisted
    ventilation.
  • Stop CPR and resume assisted ventilation at a
    rate of 20 breaths per minute once the heart rate
    is gt 60 bpm and rapidly increasing.
  • Switch to blow by if RR gt20 HR gt 100 cyanosis
    disappears

33
Mandatory QA Component
  • Every application of an AED on a Pediatric
    patient (even if no shocks were delivered) the
    ACR will be reviewed by the Agencys Medical
    Director and they are required to forward all
    documentation to REMAC for system wide QA
    purposes continuing until further notice

34
455 Pediatric Anaphylactic Reaction
  • Minor language changes (in red)
  • Assess the cardiac and respiratory status of the
    patient.
  • If both the cardiac and respiratory status of the
    patient are normal, initiate transport.
  • If either the cardiac or respiratory status of
    the patient is abnormal, proceed as follows
  • If the patient is having severe respiratory
    distress or shock and has been prescribed a
    pediatric(0.15 mg) Epinephrine auto-injector,
    assist the patient in administering the
    Epinephrine.
  • If the patients auto-injector is not available
    or expired, and the EMS agency carries a
    pediatric (0.15mg) Epinephrine auto-injector,
    administer the Epinephrine as authorized by the
    agencys Medical Director.

35
500 Suspected Cyanide Toxicity Or Smoke
Inhalation
  • This protocol should be utilized ONLY for the
    management of hypotensive patients with suspected
    cyanide toxicity when
  • OLMC has been provided for the management of less
    than five patients.
  • At the scene of a mass casualty incident for
    which a class order issued by a FDNY-OMA Medical
    Director who is on-scene
  • or as relayed by an FDNY-OMA Medical Director
    through OLMC (Telemetry)
  • or through FDNY Emergency Medical Dispatch

36
500 Suspected Cyanide Toxicity Or Smoke
Inhalation
EFFECTIVE IMMEDIATELY IF AVAILABLE
  • NOTE The issuance of a Class Order shall be
    conveyed to all regional medical control
    facilities for relay to units in the field.
  • Treatment within the Hot and Warm Zones may
    be performed only by appropriately trained
    personnel wearing chemical protective clothing
    (CPC) as determined by the FDNY Incident
    Commander
  • If providers encounter a patient who has not been
    appropriately decontaminated, the providers
    should leave the area immediately until such time
    as appropriate decontamination has been preformed

37
500 Suspected Cyanide Toxicity Or Smoke
Inhalation
  • Begin BLS Procedures.
  • If necessary, perform Endotracheal Intubation
  • Begin two IV infusions of Normal Saline (0.9 NS)
    to KVO.
  • PRIOR TO ADMINISTRATION OF HYDROXOCOBALAMIN, IF
    POSSIBLE, OBTAIN THREE BLOOD SAMPLES USING THE
    TUBES PROVIDED IN THE CYANIDE TOXICITY KIT.

38
500 Suspected Cyanide Toxicity Or Smoke
Inhalation
  • Administer, via separate IV lines, the following
    medications

NOTE SODIUM THIOSULFATE, DOPAMINE, and DIAZEPAM
MAY NOT BE administered via the same IV line as
HYDROXOCOBALAMIN. MCO Dopamine 5 ug/kg/min,
IV/Saline Lock drip. If there is insufficient
improvement in hemodynamic status, the infusion
rate may be increased until the desired
therapeutic effects are achieved or adverse
effects appear. (Maximum dosage is 20 ug/kg/min,
IV/Saline Lock drip
39
Signs and Symptoms of Cyanide Poisoning
  • Cyanide is an extremely toxic poison. In the
    absence of rapid and adequate treatment, exposure
    to a high dose of cyanide can result in death
    within minutes due to the inhibition of
    cytochrome oxidase resulting in arrest of
    cellular respiration

Signs
Seizures, AMS, COMA
Mydriasis
Tachypnea/Hyperpnia
Bradypnea/Apnea (late)
Hypertension (early)/Hypotension (late)
Cardiovascular Collapse
Vomiting
Symptoms
Headache
Confusion
Dyspnea
Nausea
Chest Tightness
40
501 Respiratory Arrest
  • If OD is suspected utilize the AMS protocol
  • MCO use of Naloxone is removed
  • MCO Sedation procedure change
  • Administer Etomidate 0.3 mg/kg, IV/Saline Lock
    bolus, over 30-60 seconds. (Maximum total dose is
    20 mg.) After successful intubation, consider
    Diazepam 5 mg IV/Saline Lock bolus or Lorazepam 2
    mg, IV/Saline Lock or IM, for continued sedation
  • Midazolam is removed p Etomidate and ? to
    Lorazepam

41
503-A V-Fib/Pulseless V-Tach
  • Language change and Amiodarone is now Mandatory

42
504 Drug Therapy for Myocardial Ischemia
  • Language changes
  • Chewable Baby term removed from text when
    referring to aspirin
  • HYPOTENSION, HYPOVENTILATION, or STUPOR removed
    from text p morphine use
  • Lidocaine bolus maintenance drip removed from
    protocol.
  • GOP reference for STEMI center considerations

43
506 Acute Pulmonary Edema
  • Language changes
  • HYPOTENSION, HYPOVENTILATION, or STUPOR removed
    from text p morphine use

Mandatory QA Component For every application of
CPAP on a patient the ACR will be reviewed by the
Agencys Medical Director and they are required
to forward all documentation to REMAC for system
wide QA purposes
44
507 Asthma
  • Standing Orders now versus MCO
  • Epinephrine 0.3 mg (0.3 ml 11,000)
  • Magnesium Sulfate, 2 gm, IV/Saline lock, in
    50-100 ml 0.9 NS over 10-20 minutes.
  • Methylprednisolone 125 mg, IV bolus, or IM,
  • Or
  • Dexamethasone, 12 mg, IV bolus, or IM.

45
508 - COPD
  • Standing Orders now versus MCO
  • Methylprednisolone 125 mg, IV bolus, or IM,
  • Or
  • Dexamethasone, 12 mg, IV bolus, or IM.

46
510 Anaphylactic Reaction
  • Endotracheal Administration of Epinephrine
    completely removed.
  • AHA ACLS Studies (Circulations Dec. 2005)
  • some resuscitation drugs may be administered by
    the endotracheal route, multiple animal studies
    showed that epinephrine (among other meds)
    administered into the trachea results in lower
    blood concentrations than the same dose given
    intravascularly
  • Furthermore studies suggest that the lower
    epinephrine concentrations achieved when the drug
    is delivered by the endotracheal route may
    produce transient ß-adrenergic effects. These
    effects can be detrimental, causing hypotension,
    lower coronary artery perfusion pressure and
    flow, and reduced potential for return of
    spontaneous circulation (ROSC)

47
511 - AMS
  • Language change
  • IF THE GLUCOMETER READING IS ABOVE 120 mg/dl, AND
    THE PATIENT HAS NO SYMPTOMS OR SIGNS OF
    HYPOGLYCEMIA, DEXTROSE MAY BE WITHHELD.
  • Intranasal Narcan has been added.

48
520 Traumatic Cardiac Arrest
  • Begin cardiac monitoring, record and evaluate ECG
    rhythm. If the ECG demonstrates ventricular
    fibrillation or pulseless ventricular
    tachycardia, while in route, treat as per
    protocol 503A.
  • Yes you will be cardiac monitoring and Yes you
    will be shocking V-Fib pulseless V-Tach in
    Traumatic Cardiac Arrest !!!

49
To reiterate the AHA
  • Traumatic Cardiac Arrest
  • BLS ALS support of ABCs
  • Deterioration associated with trauma
  • Hypoxia secondary to respiratory arrest,
  • airway obstruction,
  • large open pneumothorax, tracheobronchial or
    thoracoabdominal injury
  • Injury to vital structures, such as the heart,
    aorta, or pulmonary arteries
  • Severe head injury with secondary cardiovascular
    collapse
  • Underlying medical problems or other conditions
    that led to the injury, such as sudden cardiac
    arrest (eg, VF or VT) in the driver of a motor
    vehicle or in the victim of an electric shock)
  • Diminished cardiac output or pulseless arrest
    (PEA) from tension pneumothorax or pericardial
    tamponade
  • Extreme blood loss leading to hypovolemia and
    diminished delivery of oxygen
  • Think reversable causes 5 Hs 5 Ts

50
529 Pain Management Isolated Extremity
  • Morphine is a Standing Order now with a dosage
    change (weight based now)
  • For patients with a systolic blood pressure
    greater than 110 mmHg, administer Morphine
    Sulfate 0.1 mg/kg (not to exceed 5 mg), IV/Saline
    lock bolus. For continued pain, repeat dose of
    0.1 mg/kg (not to exceed 5 mg) may be
    administered.
  • Maximum total dose is 10 mg.

51
530 - EDP
  • BLS before ALS
  • EDPs PRESUMED to have an underlying Medical or
    Trauma causing AMS
  • Contact medical control if patient agitation
    inhibits treatment.
  • POST SEDATION Begin an IV infusion of 0.9 NS
    KVO or Lock
  • Begin cardiac monitoring, record and evaluate
    rhythm strip.
  • Apply pulse-oximeter, if available.
  • Left Lateral (NEVER PRONE Position)

52
530 - EDP
  • If patient is at risk for respiratory or cardiac
    arrest by continuing to struggle while being
    physically restrained by the police, contact OLMC
  • IF PATIENT IS AGITATED, INITIAL ROUTE OF CHOICE
    IS IM.
  • Once sedated IV access should be established
  • Diazepam, 510 mg, IVB.
  • OR
  • Midazolam, 1 2 mg, IVB or if IV access is
    unavailable, administer Midazolam, 10 mg IM.
  • OR
  • Lorazepam, 24 mg, IVB or if IV access is
    unavailable, administer Lorazepam, 4 mg IM.

53
543 Neonatal Resusitation
  • Language change back to Neonate
  • Narcan has been removed via ET Tube
  • DO NOT INTUBATE unless other methods of airway
    management are not effective, i.e., failure to
    increase the heart rate
  • IV or IO medication administration is the
    preferred method. Reminder attempt vascular
    access no more than twice.

54
551 Pediatric Obstructed Airway
  • Needle Cricothyroidotomy added
  • Consider Needle Cricothyroidotomy only if all
    less invasive methods of airway management are
    not effective.

55
553 Pediatric Non Traumatic Cardiac Arrest
  • Changes reflect the AHA guidelines for Pediatric
    resuscitation.
  • In V-Fib/V-Tach immediately defibrillate at 2
    joules/kg using paddles (pads) of the appropriate
    size.
  • Immediately resume CPR for 5 cycles while
    defibrillator is recharging
  • If still in V-Fib/V-Tach immediately defibrillate
    at 4 joules/kg
  • Immediately resume CPR for 5 cycles while
    defibrillator is recharging

56
553 Pediatric Non Traumatic Cardiac Arrest
  • Atropine Sulfate 0.02 mg/kg is removed from
    standing orders
  • Continue with
  • If still in V-Fib/V-Tach immediately defibrillate
    at 4 joules/kg
  • Immediately resume CPR for 5 cycles while
    defibrillator is recharging
  • Administer Amiodarone, 5 mg/kg, IV or IO.
    (Broselow Tape or Appendix J.)
  • Repeat Epinephrine 0.01 mg/kg (0.1 ml/kg of a
    110,000 sol) IV/ or IO bolus q 3-5 minutes

57
553 Pediatric Non Traumatic Cardiac Arrest
  • repeat epinephrine 0.1 mg/kg (0.1 ml/kg of a
    11,000 sol) via the ETT q 3-5 min if no IV or IO
    has been established.
  • THE IV/SALINE LOCK OR IO DOSE OF EPINEPHRINE FOR
    PEDIATRIC PATIENTS IS 0.01 MG/KG (0.1 ML/KG OF A
    110,000 SOL). THE ENDOTRACHEAL TUBE DOSE OF
    EPINEPHRINE FOR PEDIATRIC PATIENTS IS 0.1 MG/KG
    (0.1 ML/KG OF A 11,000 SOL).

58
553 Pediatric Non Traumatic Cardiac Arrest
  • MCO removals
  • Epinephrine 0.1 mg/kg (now q 3-5 on standing
    orders)
  • Lidocaine 1 mg/kg, IV/Saline Lock or IO bolus, or
    via the Endotracheal Tube REMOVED
  • Amiodarone 5 mg/kg, IV/Saline Lock or IO bolus.
    REMOVED
  • Added
  • If torsades de pointes is present, administer
    Magnesium Sulfate, 25-50 mg/kg, IV or IO.

59
554 Pediatric Asthma Wheezing
  • Metaproterenol 5 has been removed
  • Medications in MCO options have been added
  • Ipratropium Bromide 0.02 (one unit dose vial of
    0.5 ml in children 6 years of age or older, one
    half unit dose vial of 0.5 ml in children under 6
    years of age), by nebulizer, may be mixed (if
    available) with Albuterol Sulfate. (See broselow
    Tape or Appendix J)
  • Terbutaline Added
  • Repeat Epinephrine 0.01 mg/kg (0.01 ml/kg of a
    11,000 solution), IM, or Terbutaline 0.01 mg/kg,
    SC, 20 minutes after the initial dose.

60
557 Pediatric Seizures
  • IO added as part of standing orders, attempt
    vascular access no more than twice!
  • If IV/Saline Lock or IO access has not been
    established, administer Midazolam (Versed) 0.1
    mg.kg, IM.
  • DO NOT ADMINISTER LORAZEPAM, DIAZEPAM, OR
    MIDAZOLAM IF THE SEIZURES HAVE STOPPED.

61
558 Pediatric Decompensated Shock
  • Clarification on the dose of Adenosine
  • Adenosine 0.1 mg/kg, IV or IO bolus, rapidly,
    followed by 2 - 3 ml of 0.9 NS flush.
  • Maximum initial dose is 6 mg.
  • If this fails to convert the dysrhythmia,
    Adenosine may be repeated twice at 0.2 mg/kg, IV
    or IO bolus, rapidly, followed by 2 - 3 ml of
    0.9 NS flush
  • Maximum subsequent doses are 12 mg.

62
Amiodarone
  • Amiodarone is a Class III antiarrhythmic drug
    whose properties include
  • sodium channel blockade
  • antisympathetic action
  • calcium channel blockade
  • potassium channel blockade
  • Becoming more favorable than Lidocaine as an
    antiarrhythmic drug.
  • Onset and duration of Amiodarones action is
    variable, though the half-life of the drug
  • has been reported to be as long as 40 days

63
Aminodarone
  • Amiodarone is approved for use in the treatment
    of
  • Atrial fibrillation,
  • Ventricular arryhthmias (ventricular
    fibrillation, ventricular tachycardia)
  • Wide complex tachycardias of unknown etiology
    (Torsades De Pointes)

64
Contraindications Reactions
  • Contraindicated in
  • bradycardia,
  • second or third degree heart block,
  • cardiogenic shock
  • pulmonary congestion
  • Reactions
  • long-term (i.e. pulmonary and hepatic toxicity),
    some immediate side effects may be seen in
    patients.
  • Nausea, vomiting, hypotension
  • Nearly 5 of patients (IV amiodarone) will
    develop bradycardia or heart block

65
Drug Interactions
  • Amiodarone precipitates when given at the same
    time as sodium bicarbonate.
  • Other cardiac medications (beta blockers, calcium
    channel blockers, other antiarrhythmics)
    Amiodarone causes a prolongation of the QT
    interval

66
Doses
  • V-Fibrillation / Pulseless V-Tach
  • 300mg, diluted up to a total of 20ml of D5W,
    given IV or IO.
  • converts to a supraventricular (NOT SVT but supra
    above the ventricle) rhythm 150mg, diluted in
    100ml D5W, over ten minutes

67
Doses
  • V-Tach With A Pulse / Wide Complex Tachycardia
    Of Uncertain Type
  • 150mg, diluted in 100 ml D5W, over ten minutes
  • Supraventricular Tachycardia (SVT)
  • OLMC option 150mg, diluted in 100 ml D5W, over 10
    minutes
  • Atrial Fibrillation / Atrial Flutter
  • OLMC option 150mg, diluted in 100 ml D5W, over 10
    minutes

68
The Cyanide Kit
  • 2 2.5g vials of crystalline powder
    hydroxocobalamin
  • 1 12.5g vial of sodium thiosulfate (50cc of 25
    solution)
  • 1 250cc bag 0.9 NS
  • 1 2 ml fluoride oxalate whole blood tube
  • 1 2ml K2 EDTA tube
  • 1 2ml lithium heparin tube

69
Hydroxocobalamin
  • Hydroxocobalamin, a precursor of vitamin B12
    neutralizes cyanide by fixing it to form
    cyanocobalamin (vitamin B12), a nontoxic compound
    that is eliminated in the urine
  • Each hydroxocobalamin molecule can bind one
    cyanide ion by substituting it for the hydroxo
    ligand linked to the trivalent cobalt ion, to
    form cyanocobalamin

70
Preparation
  • Each 2.5 g vial of hydroxocobalamin for injection
    is to be reconstituted with 100 mL of diluent
    using the supplied sterile transfer spike
  • The recommended diluent is 0.9 Sodium Chloride
    injection (0.9 NaCl).
  • Lactated Ringers injection and D5W injection have
    also been found to be compatible with
    hydroxocobalamin and may be used if 0.9 NaCl is
    not readily available.
  • Following the addition of diluent to the
    lyophilized powder, each vial should be
    repeatedly inverted or rocked, not shaken, for at
    least 30 seconds prior to infusion

71
Sodium Thiosulfate
  • Classified as an Antidote.
  • Mechanism of Action
  • Used for cyanide detoxification because it can
    convert cyanide to the relatively nontoxic
    thiocyanate ion
  • Indications
  • Cyanide poisoning
  • The rationale for using methemoglobin-inducers in
    cyanide poisoning is based on methemoglobin's
    ferric iron ability to bind cyanide, thus freeing
    the cytochrome and allowing aerobic cellular
    respiration to continue.
  • the IV sodium thiosulfate converts
    cyanmethemoglobin (converted by the
    Hydroxocobalamin) to thiocyanate sulfite and
    hemoglobin. Thiocyanate is then excreted.
  • So, administration of sodium thiosulfate improves
    the ability of the hydroxycobalamin to detoxify
    cyanide poisoning

72
Ipratropium Bromide
  • Class
  • Parasympatholitic Bronchodilator
  • Actions
  • It is an anticholinergic agent chemically related
    to Atropine, nebulized it acts directly on smooth
    muscle of the brochial tree by inhibiting
    acetycholine receptor sites
  • Contraindications
  • sensitivity or allergy to Atropine derivatives

73
Ipratropium Bromide
  • Effects
  • peak effect is 1.5 to 2 hours duration is 4-6
    hours
  • Packaged in a bullet or Unit Dose Vial like
    albuterol.
  • Dose
  • 0.02 solution
  • one unit dose vial of 0.5 ml in children gt 6
    years
  • one half unit dose vial of 0.5 ml in children lt 6
    years
  • Can be used in conjunction (mixed with)
    Albuterol.

74
Terbutaline
  • Class
  • beta-adrenergic agonist bronchodilator
  • Actions
  • stimulation through beta-adrenergic receptors of
    intracellular adenyl cyclase, the enzyme which
    catalyzes the conversion of adenosine
    triphosphate (ATP) to cyclic 3',5'-adenosine
    monophosphate (cAMP).
  • Increased cAMPlevels are associated with
    relaxation of bronchial smooth muscle and
    inhibition of release of mediators of immediate
    hypersensitivity from cells, especially from mast
    cells.
  • Contraindications
  • hypersensitive to allergic to sympathomimetics

75
Terbutaline
  • Effects
  • After SQ administration of 0.25 mg of
    Terbutaline, a measurable change in expiratory
    flow rate usually occurs within 5 minutes
  • Side effects
  • Tremor, nervousness, dizziness, drowsiness,
    weakness, headache, upset stomach, flushing,
    sweating, dry mouth, throat irritation
  • Dose
  • 0.01 mg/kg, SC, 20 minutes after the initial
    dose
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