Emergency Standing Orders (ESO) Procedure

Emergency Standing Orders (ESO) Standardized Procedure

• ESOs expedite treatment for patients in urgent conditions when a physician isn't immediately available.
• A physician must be notified when ESOs are initiated.
• Documentation is required.

Documentation Requirements

• Document events including life-threatening condition(s), precipitating factors, specific ESOs implemented—medication(s) and/or treatment(s), and patient status after interventions.
• Note when and which physician was notified.
• Electronic medical records should contain specific treatments administered.
• No co-sign is required.
• ESO implementation as a code blue is documented.
• Both a code blue record and a Rapid Response Team record will be completed.

Resuscitation

• Critical steps for pulseless patient include adequate chest compressions.
• Push hard at a rate of 100-120/min, ensure full chest recoil, and minimize interruptions.
• One cycle of CPR is 30 compressions alternating with 2 ventilations (02 delivered at 10 breaths/min).
• Avoid hyperventilation, secure the airway, confirm placement, and use end-tidal carbon dioxide to assess the ETCO2 quantity.
• Monitor for ROSC (Return of Spontaneous Circulation).
• Respiratory therapy can assist with endotracheal tube connection.
• Give continuous chest compressions with a breath every 6 seconds, after inserting the advanced airway.
• Check rhythm and pulse every 2 minutes, rotate compressors, and benchmark the arrest data.

Cardiac Arrest Data

• Time metrics for data include recognizing the event and first chest compressions.
• Note time events, that include first defibrillation, pulse-lessness, subsequent shocks, and assisted ventilation.
• Initiate targeted temperature management is implemented for patients not following commands or not shivering.

General Interventions

• These interventions are for all emergency situations and require obtaining intravenous (IV) or intraosseous (IO) access.
• Central line should be first target for IV access.
• Infuse normal saline (NS) to keep intravascular volume.
• Epinephrine may be administered through the ET tube if peripheral IV access fails, with a 20 u1t/e2 at1medso stehse olfV dose, and dilute normal saline.
• Continuously ventilate, but do not interrupt the transmission.
• Flush IV line with 20 mL of NS to enhance mediaiton delivery.
• Note applicable situations depend on obtaining oxygen saturation through oximetry.
• ETCO2 is monitored and documented for code blue events.
• Titrate oxygen to patients response, apply appropriate oxygen, then adjust to provide stability.
• Treatments are administered concurrently.

Specific/Threatening Conditions

• Signs of Tachypnea, apnea, respiratory depression, decreased 02 saturation, dyspnea, change in mental status, increased Intracranial Pressure (ICP), and status epilepticus may include the unstable definitions.
• Symptoms include dizziness, lightheadedness, chest pain, cold, diaphoresis, heart palpitations, and anxiousness.

Managing Asystole

• Verify pulse and ensure asystole does not reflect fine ventricular fibrillation.
• Shocking is potentially harmful treat asystole with CPR 2 minutes, followed by O2 at 15L/min with ambu bag at 10 breaths/min.
• Epinephrine 1mg IVP/IO (or I mg in 10 mL) should be administered along with considering possible causes.
• Transcutaneous pacing for asystole is not supported.

Changes to the Asystole Algorithm

• CPR cycles and epinephrine doses should have their separation.

Bradycardia

• Bradycardia is defined as heart rate under 50, may require treatment to maintain adequate blood pressure.
• An unstable patient will exhibit either slow or difficult breathing.
• Types range from sinus bradycardia to complete heart block. The following blocks are outlined, 1st degree AV block, 2nd degree AV block, and 3rd degree AV block.
• Treat unstable bradycardia (HR under 50) with 02 at minimum 10 L/min if patient responds; if not commence transvenous or epicommdical tøaai pal wier genp pacing(not performed bye Patchdem nfuor Isleoswi.ng:1 f 1.Atropine 1 mg | V-B/mOnutepeap eveaymaxi mur
• Changes to the Algorithm : the separation of CPR cycles and epinephrine doses. Clrifcation of the ephinehrine drip could be started.

Pulseless Electrical Activity (PEA)

• PEA reveals electrical activity in the heart without a pulse.
• This is often tied to states that may be treated Hypovolemia and hypoxia are common.
• Initiate CPR (2 min) and consider possible causes; Hs and Ts should be evaluated..
• H’s include hypovolemia, hypoxia, hydrogen ion (acidosis), hypokalemia or hyperkalemia, hypoglycemia and hypothermia.
• T's include toxins, tamponade, thrombosis (coronary or pulmonary), trauma and tension pneumothorax.
• 02 at 15L/min with ambu bag (10 breaths/min) while continuing CPR for 2 cycles.
• If signs of ROSC persist then check for pulse after 5 min, otherwise improve/treat indications along with Stat- CXR.
• With no sign of ROSC, start Epinephrine.

Changes to PEA Algorithm

• The changes noted for PEA algorithm involved a separation of CPR cycles and epinephrine doses.

Ventricular Tachycardia (VT)

• Occurs if the Ventricular Rate is 100 beats per minute.
• In order to correct, call physician for orders, and obtain ECG readings to treat stable VT.
• Provide O2 at minimum, note if the patent is conscious

Treatment for Unstable VT

• Requires oxygen at the minimum 10 L/minute.
• Use synchronized cajrdú loevær si on at 200 if the patent is awake and responsive.
• if no changes, repeat and verify.
• Draw serum K +,Mg ++ , Note,
• Flumazenil can cause severe issues with altered Benzodiazepines and has to be followed by 11 Lead EKG.
• In some cases Flumazenil (Romazicon) at 0.2 mg

Changes to vT Algorthms

• After defibrillations, always wait for the first reading to happen before deciding if the treatment is effective, then add 12 lead.

Cardiopulmonary Arrest Data

• Ventricular fibrillations, along with defribillation may enable the amplitude.
• Coarse usually indicates the need for defribillation, indicates Væ hædrá sp raplpomaching and makes the process difficult for diagnosis.

Treat Pulselessless VT

• Provide continuous CPR unless defibrillatng, or for 2 minutes and or until defibrillator arrives plus follow with IV and or medication support like Epinephrine and Bipapeat:q20mi
• Ensure Resumption, and every procedure is repeated.

Changes to VT Algorithms

• To include "per approved energy dose" and separate CPR cycles and Amiodarone to reduce tachycardia..

Refractory Tachycardia Treatments

Treatment for chest pain may consist of a Q-wave.

• Chest pain from ischemia is discomfort, pressure, fullness, or squeezing in the chest for more than 15 minutes.
• The pain could spread to the shoulder between the shoulder blades and is described as discomfort, even a global feeling of distress/anxiety.
• Be sure top priority is pain relief.
• First, the patient's 02 must be at a minimum, and the body maintain greater stability.
• Use nitroglycerin, morphine sulfate (2 mg), aspirin to treat pain or pressure.
• If hypotension is present, then use N/S as required.
• Finally, utilize all findings and make a diagnosis after a. 12Lead reading.
• After treatments and readings, document CBC, BMPH and other treatment information.

Hypo-tension

• Can be due to lack of perfusion and is defined as a reading with a SBP less.
• There may be several signs indicating a cause depending on the data.
• If patient is symptomatic, exhibit signs of hypotension

Algorithm to follow

• Address whether the patient's O2 can be set up to help follow a given range, if hypotensive and needs support of N/S.
• Then, address hypotension issues regarding causes, boluses and other methods.
• For Immadiate, use the step and administer (S1, S2) and Ephedrine/N-C if the above fail..

Changes for Hypotenstion

• NOR/Epi is an administered for cases of bolus.

Glucose

• Glucose can be addressed by following proper steps and procedures as a P&P

Pressure Concerns

• Include hemiporesis and fixed pupils may be due to trauma on the cranium, so check the patient and begin steps with physicians orders..
• Treat increased symptoms.
• If pressure rises, use BMO serums to counter-acct.

Changes To Intracellular Pressure

• Additional steps can be addressed, such as BMP reading and increased lab numbers, etc.

Anaphylaxis

• This may occur when other treatments fail and should be considered if all the right measures have been taken
• If O2 is increased to a patient, it may resolve all issues..

###Respiratory function and changes

• Monitor the levels and set the Narcarat to check, plus direct to treat per symptoms, if needed.

Respiratory Distresses

• May require specific actions in order to determine if the patient requires what's needed.

Seizures

• These require a time assessment and other details depending on if and when they begin
• It's important patients continue being monitored for potential triggers such as a seizure as well..