NYC REMSCO Protocols Jan. 2008 updates
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NYC REMSCO Protocols Jan. 2008 updates NYC REMSCO Protocols Jan. 2008 updates Presentation Transcript

  • NYC REMSCO Protocols Jan. 2008 updates Dr. Victor Politi
  • 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
  • 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.
  • 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
  • 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).
  • 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).
  • 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
  • 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
  • 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
  • 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.
  • 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 .
  • 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.
  • 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.
  • 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.
  • 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.
  • 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.
  • 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
  • PHARM TABLE REVISED >14 yrs of age under 40 kg in weight 5 mg/kg ADDED Amiodarone (new) 1 mEq/kg/dose Sodium Bicarbonate 1-2 mg/min REMOVED Lidocaine (infusion) 1.5 mg/kg/dose Lidocaine (bolus) 1 mg/kg/dose Furosemide (Lasix) 0.01 mg/kg/dose Epinephrine 0.02 mg/kg (min 0.1 mg) Atropine Sulfate
  • 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
  • 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.
  • 400 – Weapons of Mass Destruction Adult Dosing
  • 400 – Weapons of Mass Destruction Pediatric Dosing
  • 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
  • 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)
  • 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.
  • AHA Circulation 2005 112:IV-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
  • 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
  • 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
    • CPR in a Neonate is performed utilizing compression to ventilation ratio of 3:1
    • 120 events per minute (90 Comp:30 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 >30 & HR > 100 cyanosis disappears
    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 > 60 beats per minute and rapidly increasing .
    • Switch to blow by if RR >30 & HR > 120 cyanosis disappears
    443 Neonate Resuscitation
  • 453 Pediatric Non Traumatic Cardiac Arrest
    • For infants and children with non-traumatic cardiac arrest, or infants and children <9 years of age with a HR <60 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 (<9 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 15:2
    • 120 events per minute (105 Comp:15 Vent)
  • 453 Pediatric Non Traumatic Cardiac Arrest
    • If The Infant has a HR <60 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 > 60 bpm and rapidly increasing.
      • Switch to blow by if RR >20 & HR > 100 cyanosis disappears
  • 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 Agency’s Medical Director and they are required to forward all documentation to REMAC for system wide QA purposes continuing until further notice
  • 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 patient’s 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 agency’s Medical Director.
  • 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
    • 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
    500 – Suspected Cyanide Toxicity Or Smoke Inhalation EFFECTIVE IMMEDIATELY IF AVAILABLE
    • 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.
    500 – Suspected Cyanide Toxicity Or Smoke Inhalation
    • Administer, via separate IV lines , the following medications
    500 – Suspected Cyanide Toxicity Or Smoke Inhalation 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
  • 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
    Vomiting Cardiovascular Collapse Hypertension (early)/Hypotension (late) Bradypnea/Apnea (late) Tachypnea/Hyperpnia Mydriasis Seizures, AMS, COMA Signs Chest Tightness Nausea Dyspnea Confusion Headache Symptoms
  • 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
  • 503-A V-Fib/Pulseless V-Tach
    • Language change and Amiodarone is now Mandatory
  • 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
  • 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 Agency’s Medical Director and they are required to forward all documentation to REMAC for system wide QA purposes
  • 507 Asthma
    • Standing Orders now versus MCO
      • Epinephrine 0.3 mg (0.3 ml 1:1,000)
      • 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.
  • 508 - COPD
    • Standing Orders now versus MCO
      • Methylprednisolone 125 mg, IV bolus, or IM,
      • Or
      • Dexamethasone, 12 mg, IV bolus, or IM.
  • 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)
  • 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.
  • 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 !!!
  • 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 H’s & 5 T’s
  • 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.
  • 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)
  • 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 , 5–10 mg, IVB.
    • OR
    • Midazolam , 1 – 2 mg, IVB or if IV access is unavailable, administer Midazolam, 10 mg IM.
    • OR
    • Lorazepam , 2–4 mg, IVB or if IV access is unavailable, administer Lorazepam, 4 mg IM.
  • 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.
  • 551 Pediatric Obstructed Airway
    • Needle Cricothyroidotomy added
    • Consider Needle Cricothyroidotomy only if all less invasive methods of airway management are not effective.
  • 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
    • 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 1:10,000 sol) IV/ or IO bolus q 3-5 minutes
    553 Pediatric Non Traumatic Cardiac Arrest
    • repeat epinephrine 0.1 mg/kg (0.1 ml/kg of a 1:1,000 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 1:10,000 SOL). THE ENDOTRACHEAL TUBE DOSE OF EPINEPHRINE FOR PEDIATRIC PATIENTS IS 0.1 MG/KG (0.1 ML/KG OF A 1:1,000 SOL).
    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.
    553 Pediatric Non Traumatic Cardiac Arrest
  • 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 1:1,000 solution), IM, or Terbutaline 0.01 mg/kg, SC, 20 minutes after the initial dose.
  • 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.
  • 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.
  • 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 Amiodarone’s action is variable, though the half-life of the drug
    • has been reported to be as long as 40 days
  • 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)
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
    • 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 > 6 years
      • one half unit dose vial of 0.5 ml in children < 6 years
    • Can be used in conjunction (mixed with) Albuterol.
    Ipratropium Bromide
    • 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
    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*
    Terbutaline