Transcript Slide 1

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 vfib 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
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
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
443 Neonate Resuscitation
• 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
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 autoinjector, 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 autoinjector, 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
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
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.
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
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
Symptoms
Seizures, AMS, COMA
Headache
Mydriasis
Confusion
Tachypnea/Hyperpnia
Dyspnea
Bradypnea/Apnea (late)
Nausea
Hypertension (early)/Hypotension (late)
Chest Tightness
Cardiovascular Collapse
Vomiting
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 VTach 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
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 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.
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
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 > 6 years
– one half unit dose vial of 0.5 ml in children < 6 years
• Can be used in conjunction (mixed with)
Albuterol.
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
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*