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1、AirwayAirway ManagementPt needs airway managementBVM and Adjunct (Oral/Nasal Airway, EOA or King Airway)Adequate Tidal Volume and Airway Control, Pulse Oximetry90%Inadequate Tidal Volume, necessity for Advanced Airway Control, Pulse Oximetry 90%Continue with current adjunct and reassess for Adequate
2、 Tidal Volume, Pulse Oximetry and necessity for Advanced Airway ControlPrepare for IntubationActive Gag ReflexPrepare for (PAI)Pharmacological Assisted IntubationSevere Facial TraumaCrushed Trachea Complete Airway ObstructionSevere Airway CompromiseConsider Needle Cric or Surgical Cric.No Gag Reflex
3、, Intubatereviewed 7/07NasotrachealIntubationSurgical CricothyrotomyEOAHyperextend head and neck and hyperventilate.(Maintain head in neutral position if cervical trauma is suspected.)Place head in neutral position.Maintain cervical support if trauma suspected.Ensure patient qualifies for maneuver.L
4、ocate the hollow opening between the cricoid and thyroid cartilages. Stabilize the cartilage with non-dominant hand. Patient should always be properly ventilated while equipment is prepared for advanced maneuvers.Place head in sniffing position. Lubricate ET tube Using a #11 scalpel make a vertical
5、incision midline between the two cartilages.This incision should go through the skin and subcutaneous tissues. Any deeper may cause damage to the structures. Remove oral airway if present, and slide EOA down posterior oropharyngeal path. Widen the incision with the opposite end of the scalpel. Rotat
6、e mask and seat firmly on face. Attach BVM and ventilate.Pass ET tube through visualized vocal cords.Pass ET tube through the vocal cords. Position the scalpel horizontally, perforate the cricothyroid membrane inserting approximately half of the blade. Auscultate lung fields bi-laterally. If lung so
7、unds present, inflate cuff and continue ventilations.Inflate ET tube and ventilate with BVM. Inflate ET tube and ventilate with BVM. Dress wound accordingly and stabilize. Repeat auscultation to ensure EOA is not displaced during patient movement.Auscultate lung fields bilaterally as well as epigast
8、ric region. Adjust ETT if needed and secure in place.Attach CO2 monitor and SPO2Auscultate lung fields bilaterally as well as epigastric region. Adjust ETT if needed and secure in place. Attach CO2 and SPO2 monitors. Place ETT (6 mm) in the opening no more than 2-3 cm and secure well. Qualifications
9、BVM and intubation unsuccessfulOver 16 years of ageOver 5 and under 6 7 tallOver 100 poundsNo caustic ingestionNo esophageal diseaseNo cervical injuryRepeat ascultation regularly, verify ETCO2 and anytime patient is moved to ensure ET tube remains in place. Ventilate with BVM and auscultate lung fie
10、lds. If ventilations are not equal, then pull tube and reinsert. Auscultate lung sounds again for confirmation of placement and secure in place. Attach ETCO2 and SPO2 monitors. Open airway, insert laryngoscope blade and visualize vocal cords. Sellick maneuver may be used if necessary. (May cause cer
11、vical injury if applied forcefully.)Insert ET tube through Right nare. If resistance is met insert through the Left. Needle CricothyrotomyEndotracheal IntubationExpose the neck andprep if possible.Insert a 14 gauge angiocath (or larger)into trachea. Angle angiocath down towards the feet.Locate the h
12、ollow opening between the cricoid and thyroid cartilages. Stabilize the cartilage with non-dominant hand. In an adult, add 2-3 more angiocaths,and ventilatewith 100% 02Repeat ascultation regularly, verify ETCO2 and any time patient is moved to ensure ET tube remains in place. QualificationsAcute upp
13、er airway obstruction Respiratory Arrest with neck injury who can not be ventilated by EOA, Endotracheal or Nasotracheal intubation Airway CompromiseSevere Facial TraumaNeed for DefinitiveAirwayAdvanced Airway ProtocolReviewed 7/07QualificationsRespiratory Distress, Respiratory Arrest, Airway Compro
14、mise, Severe Trauma with above complications.NOTE: Nasotracheal intubation should be avoided for facial trauma.Advanced Airway ProtocolKing AirwayEnsure patient qualifies for maneuver.Choose correct size based on patients heightWith non-dominant hand, hold mouth open and apply chin liftUsing a later
15、al approach, introduce tip into mouthAdvance the tip behind base of tongue while rotating tube back to midline so blue orientation line faces the chin of patient QualificationsBVM and intubation unsuccessfulIntended for Patients over 4 tall for controlled or spontaneous ventilation.Size 3 yellow (4-
16、5 feet) cuff volume 45-60 mlSize 4 red (5-6 feet) cuff volume 60-80 mlSize 5 purple (greater than 6 feet) cuff volume 70-90 mlTest cuff inflation system for air leakApply water-soluble lubricant to the distal tipHold the KING at the connector with dominant handWithout exerting excessive force, advan
17、ce tube until base of connector is aligned with teeth or gumsAttach the BVM to the KINGWhile bagging the PT gently withdraw the tube until ventilation becomes easy and free flowing (large tidal volume with minimal airway pressure)Adjust cuff inflation if necessary to obtain a seal of the airway at t
18、he peak ventilatory pressure employedInflate the KING with the appropriate volumereviewed 7/07Pharmacological Assisted Intubation PAI:Will obscure the neurologicexamination and physical manifestations of status epilepticus. CompleteNeuro Exam before usingPAIComplete checklistprior to initiatinganest
19、hesiaChecklist1) Complete the baseline Neurologic exam.2) Ensure that the materials for surgical airways are immediately available.3) Make sure suction is working properly and available.4)Preoxygenate the patient.Lidocaine: 1.5 mg/kggiven 1 minute priorto intubation.EtomidateIs patient suspectedof h
20、aving:CVA,Head Injury ,or ICB?YesNoApply Cricoid PressureStop Manual VentilationsPreoxygenate with 100% O2 and assist ventilationsWhen Resp. are 8 and gagReflex is absentintubate the patientimmediately. (Paramedic discretion must be Utilized.)Confirm tube placement.VisualizationAuscultationEnd Tidal
21、 CO2Pt Condition-skin colorVentilate the patientwith 100% O2Inflate ET cuff andrelease cricoid pressureSecure ETTContact Medical ControlTo provide additional sedationBaseline Neuro assesmentGlasgow Coma ScoreAlertVerbalPainUnresponsivenessContact Medical Control8 2000 SSM DePaul Health Centerreviewe
22、d 7/07Cardiac MEDICAL CONTROL OPTIONSSpecial considerations:Hypothermia: Manage per protocolDrug overdoses: Manage per protocolSodium Bicarbonate: 1 mEq/kg IV if;Known pre-existing hyperkalemiaKnown pre-existing bicarbonate-response acidosis orOverdose of tricyclic antidepressant-Initiate transport
23、as soon as possible and notify Medical ControlStanding OrderAdvanced airway managementInitiate IV Normal Saline or LR if not already established Confirm Asystole in 2 leadsStanding OrderEpinephrineIV: 1 mg IV push of 1:10,000 every 3-5 minutesET: 2.0-2.5 mg ETT 1:1000 every 3-5 minutes (dilute with
24、8-10 ml of NS)OrVasopressin40 units IV/IO may be given 1 time to substitute the first or second dose of EpinephrineStanding OrderAtropineIV: 1 mg IV push every 3-5 minutes to a total of 3mg maxET: 2 mg ETT every 3-5 minutes to a total of 6mg max8 2000 SSM DePaul Health CenterRoutine Cardiac Care(Fol
25、low Current AHA Guidelines) Asystole (Cardiac Arrest)Reviewed 7/07During CPRPush hard and fast (100/min) Ensure full chest recoil Minimize interruptions in chest compressions One cycle of CPR: 30 compressions then 2 breaths; 5 cycles = 2 min Avoid hyperventilation Secure airway and confirm placement
26、 After an advanced airway is placed, rescuers no longer deliver “cycles” of CPR. Give continuous chestcompressions without pauses for breaths.Give 8 to 10 breaths/minute. Check rhythm every2 minutes. Rotate compressors every 2 minutes with rhythm checks. Search and treat possible factors (refer to A
27、CLS guide) MEDICAL CONTROL OPTIONSCardizem: 20 mg. Slow IV push (Do not give if B/P 100 sys or S/S of shock).Verapamil:Initial bolus of 2.5-5 mg slow IV pushIf inadequate response after 15-30 minutes, second bolus 5-10 mg slow IV pushContraindications include: Wolff-Parkinson-White Syndrome, 2nd or
28、3rd degree AV block and sick sinus syndrome-Initiate transport as soon as possible and notify Medical ControlStanding OrderVagal maneuvers: Valsalva and/or cough Standing OrderConsider for sedation:Etomidate 0.3mg/kgorValium: Pt weight 70 kg: 5.0 mg slow IV push orVersed: 2.5-5 mg slow IV pushor Mor
29、phine Sulfate:5 mg - 10 mg slow IV push Synchronized Cardioversion:100J, 200J, 300J, 360J (if A-Flutter, start 50j)Recheck rhythm after each cardioversionPatient unstable?NoYesSigns and symptoms of unstable patients may include:Chest painNon-extremis dyspnea ShockPulmonary congestionCongestive heart
30、 failureActue myocardial infarction8 2000 SSM DePaul Health CenterRoutine Cardiac CareAtrial Fibrillation / Atrial Flutterreviewed 7/07Standing OrderCardizem20 mg. Slow IV pushConsider contacting Medical ControlIf non-transporting vehicle:Continue CPR and await transport unit;Upon arrival begin algo
31、rythm againIf transporting vehicle:Continue CPR and transportApply AED pads and cablesDefibrillationindicated?Verify patient is unresponsive, apneic and pulselessInitiate CPR, request ALSNoStop CPR Analyze rhythm status Determine if shock is indicated Continue to AED page twoYesNoAED applicationTurn
32、 on AEDObserve self testBare and wipe off chest to improve conductionConnect cables to AEDApply electrodes and confirm edges are sealedFirmly connect cables to electrodesSelect energy levelYesContinue CPR for 2 minute or 5 cycles Reanalyze cardiac status ( ECG/pulses ) If no shock is indicated, chec
33、k pulse Call CLEAREnsure no contact with the patient When commanded - Press to shock Press Shock button Initial Defibrillation: 1 shock 360J (or equivalent biphasic energy) or manufacturer settingSubsequent defibrillation will be at 360J Allow AED to analyze:Automatically after 2 minute cycle of CPR
34、 Pulse present?Go to appropriate protocolYesNo8 2000 SSM DePaul Health CenterAED available or will beImmediatelyavailableAutomatic / Semi-automatic External DefibrillatorReviewed 4/07Pulse present?YesNoGo to appropriate protocolIf no change after 3 times:Initiate transport, with or without ALS and n
35、otify receiving hospital During transport: Check pulses after every 2 minutes or 5 cycles of CPR or as directed by Medical Control.Avoid: AED analysis and defibrillation while vehicle is in motion.Vibration may interfere with appropriate reading, and may cause accidental electrical discharge. NOTES
36、:1) If a palpable pulse is present, proceed with appropriate, available airway management techniques and continually monitor patients pulse not ECG 2) If at any time the patient becomes pulseless, immediately reanalyze patient to determine if defibrillation is needed 3) If the AED states, during tra
37、nsport, that you should check the patient, stop the vehicle and reanalyze per protocol 4) For patients with known Internal Cardiac Defibrillators (CD), attach the AED and follow standard operating procedures Continued from AED page oneContinue CPR for 2 minute or 5 cycles Repeat algorythm from Stop
38、CPR (Page 1)8 2000 SSM DePaul Health CenterAutomatic / Semi-automatic External Defibrillator ContinuedReviewed 7/07MEDICAL CONTROL OPTIONSConsider for sedation:Etomidate 0.3mg/kgValium: Pt weight 70 kg: 5.0 mg slow IV push Versed: 2.5-5 mg slow IV push Morphine Sulfate:5 mg - 10 mg slow IV pushFluid
39、 bolus of Normal Saline as indicatedDopamine:2 mcg/kg to 10 mcg/kg per minuteEpinephrine Infusion:1 mg in 250cc NS administered at 2-10 mcg/minuteGlucagon:1-5 mg IM, SC or IV for suspected beta blocker toxicityCalcium Chloride 10% solution:2-4 mg/kg slow IV push over 5 minutes for suspected calcium
40、channel blocker toxicity-Initiate transport as soon as possible and notify Medical Control Standing OrderPrepare for Transcutaneous pacing for patients who are in extremis. (Type II second-degree block or third-degree AV Block)(See Med. Cont. Options for sedation)Place patient in supine position and
41、 elevate legsAtropine Sulfate:IV: 0.5 mg IV push every 3-5 minutes, Max dose 3mgET: 1 mg ET followed with 2 ml Normal Saline every 3-5 minutes, Max dose 6 mgPatient Symptomatic?NoYesSigns and symptoms of symptomatic patients may include:Slow heart rates (60) withdecreased LOCWeak, thready pulseDelay
42、ed capillary refillHypotension; systolic BP of 1008 2000 SSM DePaul Health CenterRoutine Cardiac CareCurrent ACLS GuidelinesBradyarrhythmiaReviewed 7/07 MEDICAL CONTROL OPTIONSIV Normal Saline or LR: Titrate IV if systolic BP remains 100-Initiate transport as soon as possible and notify Medical Cont
43、rol Standing Order I.V. NS KVONitroglycerin: (call to administer for 100Absolute contraindication:Nitroglycerin if patient has taken Viagra or Levitra within previous 12 hours. Cialis if taken within 48 hours.Relative contraindication:Nitroglycerin if patient has taken Viagra or Levitra within previ
44、ous 24 hours. Standing OrderNegative BP response:Systolic BP drops below 100, place patient supine, elevate legs, and administer 250cc Normal Saline bolusReassess BPStanding OrderAspirin:324 mg (4 baby aspirin) chewedNOTE: A second IV line may be indicated for high risk patients8 2000 SSM DePaul Hea
45、lth CenterRoutine Cardiac CareChest Pain / Rule Out MIRevised 7/07Is the patient still in pain after nitro and aspirin therapies?YesNoGo to Pain ProtocolCaution:Administer with caution in patients with suspected inferior wall MI with possible right ventricular (RV) involvement. Standing OrderNitrogl
46、ycerin0.4 mg SL tablet/spray q 5 min, up to 3 doses;Reassess after each dose MEDICAL CONTROL OPTIONSMorphine Sulfate2-5 mg IVDopamine infusion2-20 mcg/kg/minutes, rate to determined by Medical Control-Initiate transport as soon as possible and notify Medical ControlStanding OrderFurosemide40 mg IV p
47、ushPatient on diuretics?BP 100 systolic?Standing OrderFurosemide80 mg IV pushYesNoNoYesStanding OrderMorphine Sulfate2 mg IV push if systolic BP1208 2000 SSM DePaul Health CenterRoutine Cardiac CareCongestive Heart Failure / Pulmonary Edemareviewed 7/07No repeat order without direct contact with Med
48、ical ControlIn Extremus Patients O2 saturation is still less than 90% on Non-RebreatherYesUse C-Pap if B/P is stable otherwise Intubate*If B/P falls below 90systolic, remove C-PapNote: Patients on C-Papmust have B/P obtainedevery 2-3 minutesNoAbsolute contraindication:Nitroglycerin if patient has ta
49、ken Viagra or Levitra within previous 12 hours. Cialis if taken within 48 hours.Relative contraindication:Nitroglycerin if patient has taken Viagra or Levitra within previous 24 hours. MEDICAL CONTROL OPTIONSAdditional NS or LR bolus(es) as indicatedSodium Bicarbonate:1 mEq/kg IVPericardiocentesis-I
50、nitiate transport as soon as possible and notify Medical Control YesStanding OrderAdminister 250 cc bolus and titrate accordinglyHypovolemia suspected?NoPneumothoraxStanding OrderEpinephrine 1:10,000: 1 mg IV/IO push every 3-5 minutesorEpinephrine 1:1,000: 2-2.5 mg ETT every 3-5 minutes diluted in 1
51、0cc of NSOrVasopressin40units IV/IO times 1 may replace first or second dose of Epinephrine Standing OrderPerform needle chest decompressionStanding OrderInitiate 2 large bore IVs (warm) Normal SalineGo to specific toxicology protocolStanding OrderAtropine: 1 mg IV/IO push every 3-5 minutes up to 3
52、mg maxorAtropine: 2.0 mg ETT every 3-5 minutes up to 6 mg max8 2000 SSM DePaul Health CenterOverdoseHR60HypothermiaRoutine Cardiac CarePulseless Electrical Activity ( Cardiac Arrest )Reviewed 7/07During CPRPush hard and fast (100/min) Ensure full chest recoil Minimize interruptions in chest compress
53、ions One cycle of CPR: 30 compressions then 2 breaths; 5 cycles = 2 min Avoid hyperventilation Secure airway and confirm placement After an advanced airway is placed, rescuers no longer deliver “cycles” of CPR. Give continuous chestcompressions without pauses for breaths.Give 8 to 10 breaths/minute.
54、 Check rhythm every2 minutes. Rotate compressors every 2 minutes with rhythm checks. Search and treat possible factors (refer to ACLS guide) Complete applicable diagnostics:Physical Exam: Primary and secondaryVital signs: 2 sets; BP (including diastolic), pulse, respirations (document times)Establis
55、h IV : NS or LR TKOOxygen: Initiate at 4lpm NC and titrate to patient condition and medical history. Pulse Oximetry: if availableCardiac Monitor: 3 lead, 12 lead if available and applicableAssess ABCs and life threatening conditionsImmediate action required?YesNoCorrect conditions and reassessPatien
56、t complaining of pain?NoYesAssess with Patient Pain Scale and reassess after each treatmentPlace patient in position of comfortAssess patient for signs and symptomsGo to condition specific protocol Patient Pain Scale AssessmentAssessed by asking the patient to rate the severity of their pain based o
57、n a 1-10 scale; 10 rated as the worst pain they have ever experienced and 1 rated as the least.If cardiac monitor applied:After arrival to the ED, a strip of Lead 2 or a full strip of lead 12 (if Lead 12 capable) should be given to the ED staff when giving patient report for baseline comparison.8 20
58、00 SSM DePaul Health CenterRoutine Cardiac CareRoutine Cardiac CareReviewed 7/07 MEDICAL CONTROL OPTIONSAmiodarone 150mg IV over 10 minutes (Max dose 2.2g over 24 hours)Verapamil:Initial bolus of 2.5-5 mg slow IV pushIf inadequate response after 15-30 minutes, second bolus 5-10 mg slow IV pushCardiz
59、em;20 mg. Slow IV pushContraindications include: Wolff-Parkinson-White Syndrome, 2nd or 3rd degree AV block and sick sinus syndrome-Initiate transport as soon as possible and notify Medical Control YesStanding OrderAdminister 250 cc bolus(es)and titrate accordinglyHypovolemia suspected?NoYesNoStandi
60、ng OrderVagal maneuvers: Valsalva and/or coughBlood pressure 100 and seriousS/S?Standing OrderAdenosine:6 mg rapid IV push over 1-3 secondsIf rhythm not corrected, 12 mg rapid IV push (over 1-3 seconds)If rhythm not corrected, 12 mg rapid IV push (over 1-3 minutes)Follow all Adenosine with 20 cc NS
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