Protocol Test from Sim Lab

Clinical Considerations for Asthma/COPD

• Advanced airway management may be necessary based on clinical assessment.
• Positive Airway Pressure (PAP) should be considered, following protocol T709.

Nitroglycerin Contraindications

• Contraindications include:
  • Systolic Blood Pressure (BP) below 100 mmHg.
  • Recent use of sildenafil (Viagra) or avanafil (Stendra) within the last 24 hours.
  • Recent use of vardenafil (Levitra, Staxyn) within the last 48 hours.
  • Recent use of tadalafil (Cialis) within the last 72 hours.
  • Current medications for pulmonary hypertension, such as:
    • Sildenafil (Revatio)
    • Macitentan or tadalafil (Opsynvi)
    • Tadalafil (Adcirca)
    • Vardenafil (Levitra, Staxyn)
    • Riociguat (Adempas)
    • Vericiguat (Verquvo)

Initial Management Steps

• Establish intravenous (IV) access as part of initial treatment.
• Obtain a 12-lead electrocardiogram (EKG) for further assessment.
• Administration of nitroglycerin should be considered for symptom relief.

Nitroglycerin Administration Guidelines

• For patients with mild symptoms (e.g., heart rate < 100 bpm, systolic BP 100-150 mmHg, respiratory rate 94%):
  • Administer low-dose nitroglycerin 0.4 mg sublingual every 3-5 minutes, up to a maximum of 3 doses.
• For patients exhibiting moderate to severe symptoms (e.g., heart rate > 100 bpm, systolic BP > 150 mmHg, respiratory rate > 25, use of accessory muscles, retractions, fatigue, low oxygen saturation):
  • Monitor closely and adjust treatment based on symptom severity.

Asthma/COPD Management Protocol

• Clinical impression aligns with asthma or COPD, refer to protocol M403.III.PROTOCOL for detailed guidance.
• Evaluate need for advanced airway management based on patient condition.
• Consider Positive Airway Pressure (PAP) as per protocol T709.

Nitroglycerin Contraindications

• Contraindicated if systolic blood pressure (BP) is less than 100 mmHg.
• Avoid in patients who took sildenafil (Viagra) or avanafil (Stendra) within 24 hours.
• Wait 48 hours post-vardenafil (Levitra, Staxyn) usage before administering nitroglycerin.
• Observe a 72-hour interval after tadalafil (Cialis) intake.
• Not allowed in patients on Pulmonary Hypertension medications, examples include:
  • Sildenafil (Revatio)
  • Macitentan/Tadalafil (Opsynvi)
  • Tadalafil (Adcirca)
  • Vardenafil (Levitra, Staxyn)
  • Riociguat (Adempas)
  • Vericiguat (Verquvo)

Initial Medical Actions

• Establish intravenous (IV) access for medication administration.
• Obtain a 12 Lead Electrocardiogram (EKG) for cardiac assessment.

Nitroglycerin Administration Guidelines

• For patients exhibiting mild symptoms:

  • Heart Rate (HR) under 100, Systolic BP between 100-150, Respiratory Rate (RR) at 94%.
  • Administer low-dose nitroglycerin: 0.4 mg sublingually every 3-5 minutes, maximum of 3 doses.

• For patients with moderate to severe symptoms:

  • Symptoms include HR over 100, Systolic BP exceeding 150 mmHg, RR over 25, and signs of respiratory distress such as accessory muscle use, retractions, and fatigue.
  • Monitor oxygen saturation levels closely for deteriorating conditions.

Clinical Management of Asthma/COPD

• Advanced airway management should be considered if required for patients.
• Positive Airway Pressure (PAP) may be necessary; refer to protocol T709 for guidance.

Nitroglycerin Contraindications

• Systolic Blood Pressure: Do not administer if BP is below 100 mmHg.
• Recent Medication Use:
  • No nitroglycerin if sildenafil (Viagra) or avanafil (Stendra) taken within the last 24 hours.
  • No nitroglycerin if vardenafil (Levitra, Staxyn) taken within the last 48 hours.
  • No nitroglycerin if tadalafil (Cialis) taken within the last 72 hours.
• Pulmonary Hypertension Medications:
  • Avoid nitroglycerin if the patient is on medications such as sildenafil (Revatio), macitentan/tadalafil (Opsynvi), tadalafil (Adcirca), vardenafil (Levitra, Staxyn), riociguat (Adempas), or vericiguat (Verquvo).

Immediate Actions

• Establish intravenous (IV) access for patient care.
• Obtain a 12 Lead Electrocardiogram (EKG) for assessment.
• Consider nitroglycerin based on symptom severity.

Nitroglycerin Administration Guidelines

• Mild Symptoms: For heart rate (HR) < 100, systolic blood pressure (SBP) between 100-150, and respiratory rate (RR) ≥ 94%:

  • Administer LOW DOSE nitroglycerin 0.4 mg sublingually every 3-5 minutes, maximum of 3 doses.

• Moderate to Severe Symptoms: For HR > 100, SBP > 150 mmHg, RR > 25, and signs like accessory muscle use, retractions, fatigue, or low oxygen saturation:

  • Closely monitor and escalate treatment as needed based on patient condition.

Emergency Cardiac Care Protocol

• Apply quick look paddles to monitor the patient's cardiac status.
• Utilize a cardiac monitor and obtain a 12-lead EKG to assess for Acute Myocardial Infarction (AMI).
• If AMI is confirmed on EKG, consult medical control prior to medication administration or pacing interventions.
• Establish IV or IO access for medication delivery.
• Administer atropine at a dosage of 1 mg via IV or IO push.

Atropine Administration

• If there is no response to the initial dose, repeat atropine at 1 mg every 3-5 minutes, up to a maximum of 3 mg.
• Perform a repeat 12-lead EKG following any notable rhythm changes in the patient.

External Pacing Considerations

• Consider external pacing when the patient is unstable during the initial assessment or remains symptomatic with conditions like hypotension, altered mental status, syncope, or shock after atropine administration.
• Contraindications for pacing include:
  • Patients younger than 16 years old.
  • Patients experiencing cardiac arrest.

Pacing Procedure

• Attach pacing electrodes and cables carefully.
• Avoid placing electrodes over existing implanted devices, such as pacemakers or defibrillators.
• Ensure that limb leads are connected for demand-mode pacing on cardiac monitor/pacer/defibrillator devices.

Pacing Mode and Settings

• Asynchronous pacing (non-demand) is usually not preferred; use demand-mode pacing.
• Begin pacing at a rate of 60-80 beats per minute with an initial output of 20 mA.
• Incrementally increase the output every 10 seconds until either electrical and mechanical capture is achieved or the maximum output limit is reached.
• Maintain pacer operation even if the patient reports significant discomfort, as stability is crucial.

Immediate Response Protocol

• Do not postpone the treatment of unstable patients for IV/IO access or drug administration.
• If sedation is necessary, consider administering midazolam at a dosage of 2-5 mg via IV, IM, IN, or IO, contingent on the patient's blood pressure.
• Upon achieving capture, reassess the patient's peripheral pulses and vital signs.

Management of Bradycardia and Hypotension

• If bradycardia and hypotension persist, contemplate administering a push dose of epinephrine, following the SB205 guideline for Hypotension/Shock management.

Defibrillation Protocol for Adult Patients

• Recommended energy levels for defibrillation are 200-300-360 Joules, applied in increasing increments.
• Immediate defibrillation at 360 Joules is essential if the rhythm is ventricular fibrillation (VF) or ventricular tachycardia (VT).
• After defibrillation, resume cardiopulmonary resuscitation (CPR) without delay.

CPR and Medication Administration

• Perform CPR for 2 minutes before reassessing pulse or rhythm.
• Evaluate and search for possible reversible causes per established protocols.
• Administer Epinephrine 1 mg (10 ml of 0.1 mg/mL) as an IV/IO push, repeating every 3 to 5 minutes as long as cardiac arrest persists.
• Administer Amiodarone 300 mg IV/IO push; if still in VF/VT, repeat with 150 mg IV/IO push in 3 to 5 minutes.
• Lidocaine can be used as an alternative: start with 1.5 mg/kg IV/IO push; if necessary, repeat with 0.5 to 0.75 mg/kg IV/IO every 3 to 5 minutes.

Rhythm Monitoring and Post-Event Care

• Recheck the cardiac rhythm after each 2-minute CPR cycle; if VF/VT persists, defibrillate again at 360 Joules.
• Notify the receiving hospital if transport of the patient is required.
• If spontaneous circulation returns, continue care according to Protocol C307 for post-circulation care.
• Transition to appropriate protocols if the rhythm changes to a different type.

Clinical Management of Asthma/COPD

• Consider advanced airway management if needed.
• Evaluate use of Positive Airway Pressure (PAP), referencing protocol T709.

Nitroglycerin Contraindications

• Do not administer if systolic BP is below 100 mmHg.
• Avoid in patients who have taken sildenafil or avanafil within 24 hours.
• Avoid vardenafil use within 48 hours prior to administration.
• Do not give if tadalafil has been taken in the last 72 hours.
• Contraindicated in patients receiving medications for Pulmonary Hypertension.

Initial Assessment and Interventions

• Establish IV access for medication administration.
• Obtain a 12 Lead EKG for cardiac monitoring.
• Administer nitroglycerin in specific scenarios based on symptom severity:
  • For mild symptoms (HR < 100, SBP 100-150, RR 94%), give low dose (0.4 mg sublingual) every 3-5 minutes, up to 3 doses.
  • For moderate to severe symptoms (HR > 100, SBP > 150, RR > 25), further assessment and monitoring required.

Acute Myocardial Infarction (MI) Protocol

• Apply quick look paddles if not already monitored and place on cardiac monitor.
• If MI is shown on EKG, consult medical control before any medication or pacing.
• Initiate IV/IO access and administer atropine 1 mg IV/IO push:
  • Can repeat every 3-5 minutes up to 3 mg if no response.

Pacing Protocol

• Consider external pacing if the patient remains unstable post-atropine.
• Contraindications include patients younger than 16 years and those in cardiac arrest.
• Connect pacing electrodes avoiding areas over existing pacemakers.
• Start pacing at a rate of 60–80 with output starting at 20 mA, increasing every 10 seconds until capture occurs or maximum output is reached.
• Do not delay treatment for access; administer midazolam (2-5 mg IV/IM/IN/IO) for sedation as needed, with caution based on BP.

Cardiac Arrest Response

• Use 200-300-360 Joules for defibrillation based on Physio-Stryker recommendations.
• Immediate defibrillation at 360 Joules if ventricular fibrillation or tachycardia is present.
• Perform CPR for 2 minutes prior to pulse/rhythm checks.
• Search for potential causes of cardiac arrest as outlined in protocol SB204.
• Administer Epinephrine (1 mg IV/IO) every 3-5 minutes throughout the arrest.
• For continued ventricular fibrillation or tachycardia, administer Amiodarone (300 mg IV/IO) followed by a 150 mg dose if necessary.
• Lidocaine can be an alternative, with doses of 1.5 mg/kg IV/IO and subsequent 0.5-0.75 mg/kg if required.
• Monitor rhythm every 2 minutes post-CPR, applying defibrillation if indicated.

Post-Resuscitation Care

• Notify receiving hospital if transporting the patient.
• Continue care per Protocol C307 if return of spontaneous circulation occurs.
• Adjust protocols for changes in rhythm as appropriate.

Rapid Transport and Cardiac Monitoring

• Initiate rapid transport to the nearest suitable medical facility with prior notification.
• Ensure continuous cardiac monitoring throughout the process.

Intravenous Access and Medication Administration

• Establish IV/IO access for medication delivery.
• For Torsades de Pointes, administer magnesium sulfate 2 g IV/IO, diluted in at least 10 mL normal saline, over 10-15 minutes.

Cardioversion Protocol

• If the patient is to be cardioverted and is conscious, administer Midazolam (Versed) 2-4 mg IV/IO/IM until slurred speech occurs, with a maximum dose of 8 mg.
• Begin synchronized cardioversion at 100 joules (or biphasic equivalent) if ventricular tachycardia (VT) persists.
• If VT continues, escalate cardioversion to 200 joules, then to 300 joules, and finally to 360 joules, using biphasic equivalents as necessary.

Management of Recurring Ventricular Tachycardia

• If ventricular tachycardia recurs, utilize previously successful energy levels for synchronized cardioversion.
• If cardioversion fails, increase the energy level to the next higher setting and adhere to the established protocol.

Post-Cardioversion Procedure

• Obtain a 12-lead EKG following successful cardioversion to assess heart rhythm and overall cardiac function.

Protocol for Cardiac Arrest Management

• Follow protocols addressing suspected underlying causes of arrest to guide treatment.
• Ensure patent airway and administer oxygen to correct hypoxia, targeting appropriate oxygen saturation levels for different age groups.

Vital Signs and Age-Related Norms

• Toddler (1-2 years): Heart rate 80-140 bpm, respiratory rate 22-37 breaths/min, systolic BP >70 mmHg.
• Preschool (3-5 years): Heart rate 60-120 bpm, respiratory rate 20-28 breaths/min, systolic BP >80 mmHg.
• School age (6-12 years): Heart rate 58-118 bpm, respiratory rate 18-25 breaths/min, systolic BP >85 mmHg.
• Adolescent (12+ years): Heart rate 50-100 bpm, respiratory rate 12-20 breaths/min, systolic BP >90 mmHg.

Defibrillation and Transport Procedures

• Keep defibrillator pads attached to the patient throughout treatment.
• Monitor vital signs frequently, as rearrest can occur after initial return of spontaneous circulation.
• Notify receiving hospital and prepare for patient transport, considering Advanced Life Support (ALS) back-up if available.
• Implement rapid transport to the nearest facility if ALS is not accessible.

Transport Destination Protocols

• Consult the AOM ED capabilities survey to determine appropriate hospital facilities.
• Follow Trauma Triage Guidelines when indicated.
• For presumed cardiac arrest, transport to facilities with 24-hour cardiac catheterization capabilities.
• For unresponsive patients not following commands, direct to hospitals capable of therapeutic hypothermia or targeted temperature management.

IV/IO Access and Hypotension Management

• Establish IV or IO access if not yet completed; having a secondary access point is recommended.
• For patients aged 16 and older, treat hypotension (systolic BP <90 mmHg) with a fluid bolus and push dose epinephrine per protocol SB205.

Cardiac Monitoring and ECG Acquisition

• Maintain continuous cardiac monitoring and capnography throughout treatment.
• Obtain a 12-lead ECG promptly after return of spontaneous circulation; if STEMI is observed, ensure transport to a facility with 24-hour cardiac catheter lab.

Additional Notes on Ventilation and Coronary Conditions

• Avoid over-ventilation, which can reduce cerebral perfusion and worsen neurological outcomes post-arrest; aim for normal ventilation rates and use capnography for assessment.
• Be aware that Acute Coronary Syndromes, including ST-elevation myocardial infarction, are frequent causes of sudden cardiac arrest.
• Consider coronary thrombosis among the treatable factors when managing the patient.

Epinephrine Administration

• Administer 1 mg of epinephrine (10 ml of 0.1 mg/mL) via IV/IO push during cardiac arrest.
• Repeat dose every 3 to 5 minutes for ongoing cardiac arrest situations.

Management Considerations

• Consider potential causes of Asystole/PEA (Pulseless Electrical Activity) as listed in protocol SB204.
• In renal failure or end-stage renal disease (ESRD), manage hyperkalemia early during resuscitation (protocol M418).
• For patients with metabolic acidosis or tricyclic antidepressant overdose, administer sodium bicarbonate at a dose of 1 mEq/kg IV/IO.
• For hypovolemic arrests, provide a 1-liter normal saline bolus; chilled saline is preferable if available.
• Perform needle thoracostomy if pneumothorax is suspected.

Resuscitation Guidelines

• After 30 minutes of resuscitation efforts, consider termination based on the Determination of Death / Termination of ACLS protocol (A105).
• If transporting the patient, notify the receiving hospital.

Post-Return of Spontaneous Circulation (ROSC)

• If return of spontaneous circulation occurs, continue care according to Protocol Post-Return of Spontaneous Circulation Care (C307).
• If rhythm changes, follow the appropriate protocol for the new rhythm.

High-Quality CPR

• High-quality cardiopulmonary resuscitation (CPR) is essential and is considered the cornerstone of treatment for cardiac arrest.

Additional Considerations

• Hypoxia is a leading cause of PEA; continuous evaluation of ventilation effectiveness is crucial during resuscitation.
• Use the H’s and T’s mnemonic to assess potential reversible causes (refer to SB204).
• Endotracheal (ET) administration of medications is allowed but not preferred; use double the standard dose with a 10 ml normal saline flush afterwards.
• Medications given through peripheral veins or intraosseous (IO) routes should be followed by a 10 mL fluid bolus.
• Utilize waveform end-tidal CO2 monitoring if available; an abrupt and sustained increase in ETCO2 may suggest return of spontaneous circulation.

Explore the essential protocols for managing asthma and COPD, including advanced airway management and considerations for nitroglycerin usage. This quiz covers critical contraindications and the importance of patient history in treatment decisions.