2024 University Hospitals EMS Training & Disaster Preparedness Institute Critical Care Protocols PDF

2024 R1.4 TABLE OF CONTENTS PREFACE Introduction / Use / Intent........................................................................................................................................... 5-20 Special Requirements................................................................................................................................................... 5-20 Transport Care Guidelines............................................................................................................................................ 6-20 COMMON ADULT AND PEDIATRIC CRITICIAL CARE PROTOCOLS / GUIDELINES Analgesia...................................................................................................................................................................... 7-20 Hypotension / Vasopressors / Shock............................................................................................................................ 9-20 Neuromuscular Blockade............................................................................................................................................ 14-20 Sedation..................................................................................................................................................................... 15-20 Ventilator Management............................................................................................................................................. 16-20 NEONATAL CRITICAL CARE PROTOCOLS / GUIDELINES Neonatal Analgesia / Sedation / Paralysis....................................................................................................................21-20 Neonatal Assessment................................................................................................................................................. 22-20 Neonatal Choanal Atresia........................................................................................................................................... 24-20 Neonatal Diaphragmatic Hernia................................................................................................................................. 25-20 Neonatal Exogenous Surfactant Administration......................................................................................................... 26-20 Neonatal Failed Airway............................................................................................................................................... 28-20 Neonatal Gastroschisis and Omphalocele................................................................................................................... 29-20 Neonatal Glycemic Control......................................................................................................................................... 30-20 Neonatal Hypoplastic Left Heart Syndrome................................................................................................................ 31-20 Neonatal Hypoxic Ischemia Encephalopathy (HIE).......................................................................................................32-20 Neonatal Intubation................................................................................................................................................... 34-20 Neonatal Meconium Aspiration Syndrome................................................................................................................. 36-20 Neonatal Meningomyelocele / Meningocele.............................................................................................................. 37-20 Neonatal Necrotizing Enterocolitis (NEC)....................................................................................................................38-20 Neonatal Oxygen Use................................................................................................................................................. 39-20 Neonatal Persistent Pulmonary HTN (PPHN).............................................................................................................. 40-20 Neonatal Pulmonary Hemorrhage.............................................................................................................................. 41-20 Neonatal Seizure Supplement.................................................................................................................................... 42-20 Neonatal Sepsis / Meningitis...................................................................................................................................... 43-20 Neonatal Shock........................................................................................................................................................... 44-20 Neonatal Tracheal Esophageal Fistula / Esophageal Atresia....................................................................................... 45-20 Neonatal Transient Tachypnea of Newborn (TTN)..................................................................................................... 46-20 Neonatal Therapeutic Hypothermia........................................................................................................................... 47-20 Neonatal Thermoregulation....................................................................................................................................... 49-20 PEDIATRIC CRITICIAL CARE PROTOCOLS / GUIDELINES Pediatric Administration of Blood Products................................................................................................................ 50-20 Pediatric Bradycardia Supplement.............................................................................................................................. 52-20 Pediatric Diabetic Ketoacidosis................................................................................................................................... 53-20 Pediatric Epiglottitis and Croup Supplement.............................................................................................................. 54-20 Pediatric Failed Airway Supplement........................................................................................................................... 55-20 Pediatric Fever............................................................................................................................................................ 56-20 Pediatric Head Injury Supplement.............................................................................................................................. 57-20 Pediatric Maintenance Fluids..................................................................................................................................... 58-20 Pediatric Meningitis and Encephalitis......................................................................................................................... 59-20 Pediatric RSI................................................................................................................................................................ 60-20 Pediatric Seizure Supplement..................................................................................................................................... 61-20 Pediatric Tetralogy of Fallot Spells.............................................................................................................................. 62-20 Pediatric Wheezing - Asthma Supplement.................................................................................................................. 63-20 Pediatric Wheezing - Bronchiolitis Supplement.......................................................................................................... 64-20 U H C r i t i c a l C a r e P r o t o c o l P a g e 2 | 20 ADULT CRITICIAL CARE PROTOCOLS / GUIDELINES ACS Supplement......................................................................................................................................................... 66-20 Acute Ischemic Stroke Supplement............................................................................................................................ 67-20 Blood Products........................................................................................................................................................... 69-20 Burns Supplement...................................................................................................................................................... 72-20 CHF / APE Supplement................................................................................................................................................ 73-20 DSI.............................................................................................................................................................................. 74-20 Envenomation............................................................................................................................................................ 75-20 Eye Injury Supplement................................................................................................................................................ 76-20 Extrapyramidal Symptoms.......................................................................................................................................... 77-20 Failed Airway.............................................................................................................................................................. 78-20 Fever Management.................................................................................................................................................... 79-20 Glycemic Management Supplement........................................................................................................................... 80-20 Head Injury Supplement............................................................................................................................................. 81-20 Intracranial Bleed....................................................................................................................................................... 82-20 Pulmonary Hypertension............................................................................................................................................ 84-20 Hyperkalemia Supplement......................................................................................................................................... 86-20 Hypertensive Emergencies Supplement..................................................................................................................... 87-20 Narcotic Overdose Supplement.................................................................................................................................. 88-20 Narrow Complex Tachycardia Supplement................................................................................................................. 89-20 Post Intubation Management..................................................................................................................................... 90-20 Preoxygenation........................................................................................................................................................... 92-20 Respiratory Distress Supplement................................................................................................................................ 94-20 RSI............................................................................................................................................................................... 95-20 Seizure Supplement.................................................................................................................................................... 97-20 Sepsis.......................................................................................................................................................................... 98-20 Vascular Emergencies............................................................................................................................................... 101-20 Wide Complex Arrest Supplement............................................................................................................................. 103-20 OB / GYN CRITICIAL CARE PROTOCOLS / GUIDELINES Abnormal Delivery Supplement................................................................................................................................. 104-20 Cardiac Arrest in Pregnancy....................................................................................................................................... 105-20 Labor Pain Analgesia.................................................................................................................................................. 106-20 Normal Delivery Supplement..................................................................................................................................... 107-20 OB Hemorrhage / Abruption / Previa........................................................................................................................ 108-20 Premature Labor....................................................................................................................................................... 110-20 Preeclampsia / Eclampsia Supplement...................................................................................................................... 112-20 Premature Rupture of Membranes........................................................................................................................... 126-20 APPENDIX # 2 - CRITICAL CARE MEDICATIONS Alprostadil.................................................................................................................................................................... 2-21 Alteplase...................................................................................................................................................................... 3-21 Amiodarone................................................................................................................................................................. 4-21 Ampicillin..................................................................................................................................................................... 5-21 Beractant..................................................................................................................................................................... 6-21 Cisatracurium............................................................................................................................................................... 7-21 Clevidipine................................................................................................................................................................... 8-21 Crotalidae Polyvalent Immune Fab.............................................................................................................................. 9-21 Diltiazem.................................................................................................................................................................... 10-21 Dobutamine............................................................................................................................................................... 11-21 Dopamine................................................................................................................................................................... 12-21 Epinephrine Infusion.................................................................................................................................................. 13-21 Epoprostenol.............................................................................................................................................................. 14-21 Esmolol....................................................................................................................................................................... 15-21 Etomidate................................................................................................................................................................... 16-21 Fentanyl..................................................................................................................................................................... 17-21 Fosphenytoin............................................................................................................................................................. 18-21 Gentamicin................................................................................................................................................................. 19-21 Hydralazine................................................................................................................................................................ 20-21 Hydrocortisone.......................................................................................................................................................... 21-21 Insulin Regular........................................................................................................................................................... 22-21 U H C r i t i c a l C a r e P r o t o c o l P a g e 3 | 20 Ketamine................................................................................................................................................................... 23-21 Labetalol.................................................................................................................................................................... 24-21 Levetiracetam............................................................................................................................................................ 25-21 Lorazepam................................................................................................................................................................. 26-21 Magnesium................................................................................................................................................................ 27-21 Mannitol..................................................................................................................................................................... 29-21 Midazolam................................................................................................................................................................. 30-21 Milrinone................................................................................................................................................................... 31-21 Morphine................................................................................................................................................................... 32-21 Nicardipine................................................................................................................................................................. 33-21 Nitric Oxide................................................................................................................................................................ 34-21 Nitroglycerine............................................................................................................................................................ 35-21 Nitroprusside............................................................................................................................................................. 36-21 Norepinephrine.......................................................................................................................................................... 37-21 Oxytocin..................................................................................................................................................................... 38-21 Phenobarbital............................................................................................................................................................ 39-21 Phenylephrine............................................................................................................................................................ 40-21 Phenytoin................................................................................................................................................................... 41-21 Poractant Alfa............................................................................................................................................................. 42-21 Procainamide...............................................................................................................................................................43-21 Prochlorperazine........................................................................................................................................................ 44-21 Propofol.......................................................................................................................................................................45-21 Propylthiouracil...........................................................................................................................................................46-21 Rocuronium.................................................................................................................................................................47-21 Sodium Bicarbonate................................................................................................................................................... 48-21 Sodium Chloride 3%................................................................................................................................................... 49-21 Succinylcholine........................................................................................................................................................... 50-21 Terbutaline................................................................................................................................................................. 51-21 Vasopressin................................................................................................................................................................ 52-21 Vecuronium................................................................................................................................................................ 53-21 Vitamin K.................................................................................................................................................................... 54-21 APPENDIX # 2 - CRITICAL CARE PROCEDURES Advanced Airway Securement with Tape..................................................................................................................... 2-22 Airvo 2 Procedure......................................................................................................................................................... 4-22 Bag Mask Oxygenation and Ventilation........................................................................................................................ 6-22 Controlled Substances Infusions Procedure.................................................................................................................. 8-22 ECMO Transport Procedure.......................................................................................................................................... 9-22 Electronic Fetal Heart Monitoring Procedure............................................................................................................. 12-22 Escharotomy Procedure............................................................................................................................................. 15-22 ET Tube Repositioning / Replacement Procedure.......................................................................................................16-22 Inhaled Epoprostenol Therapy Procedure...................................................................................................................20-22 In Line Aerosols Procedure..........................................................................................................................................23-22 Intra-Aortic Balloon Pump Procedure..........................................................................................................................25-22 Intubation Set-Up Procedure.......................................................................................................................................28-22 Impella Device Procedure............................................................................................................................................33-22 Implanted Vascular Access Devices Procedure........................................................................................................... 36-22 Neonatal Vascular Access Procedure.......................................................................................................................... 39-22 Neowrap Procedure....................................................................................................................................................40-22 Non-Invasive Ventilation Procedure............................................................................................................................41-22 Mechanical Ventilation Procedure..............................................................................................................................44-22 Oxygen Calculation Procedure.................................................................................................................................... 46-22 Pediatric High Flow Nasal Cannula Procedure............................................................................................................ 47-22 Pedimate / Neomate Procedure................................................................................................................................. 48-22 Pediatric Tension Pneumothorax Procedure.............................................................................................................. 50-22 Prone Patient Transport Procedure............................................................................................................................ 51-22 Tecotherm Procedure................................................................................................................................................. 53-22 Thoracostomy Procedure........................................................................................................................................... 57-22 Ventilator Management Hamilton Procedure............................................................................................................ 60-22 APPENDIX # 3 - CRITICAL CARE MEDICAL CONTROL Ground Critical Care Providers as Specialty Care – ALS................................................................................................. 2-23 Resuscitation Efforts..................................................................................................................................................... 3-23 UH Prehospital Protocol and Treatment Guidelines U H C r i t i c a l C a r e P r o t o c o l P a g e 4 | 20 INTRODUCTION / USE / INTENT These Critical Care and Interfacility Transport Guidelines / Protocols are designed to be used in situations where patients are being transported from one healthcare facility to another, in field care where Critical Care providers can provide more advanced care, and for continued or upgraded transport care. This document is an adjunct document to the current Prehospital Care Protocol and Treatment Guidelines, and that document outlines core scope of practice as well as current standard of care for out of hospital providers. This document outlines expanded treatment and monitoring for the Critical Care provider and provides Scope of Practice limitations where applicable in this level of care. Where indicated, treatment modalities described in either document may apply to a given patient situation, and knowledge of both documents’ contents is required. Where an amplification of a standard prehospital care technique is written in this document, it is notated as an “supplement”. Standard of field care outlined in the Prehospital Care Protocol and Treatment Guidelines is expected as the beginning of care and the supplemental Critical Care intervention added if warranted. Where a conflict between the two documents may exist for any given treatment, the Critical Care Provider may use their judgement to exercise the most appropriate treatment for the presenting condition. Definitions Prehospital Care Protocols and Treatment Guidelines are referenced as “PCP” (Prehospital Care Protocols) throughout this document. This document will be referenced as “CCTP” (Critical Care Transport Protocols) throughout this document. Hyperlinks This document is hyperlinked as a.PDF file for rapid retrieval of information. The cover is linked to the Table of Contents and each entry is linked to the corresponding page. The header of each page is linked back to the Table of Contents. SPECIAL REQUIREMENTS All therapies and procedures in this document are not automatically authorized for all providers. Many sections require special training and authorization by the Medical Director. This training is to be provided by the participating EMS agency as authorized by the Medical Director or the Medical Director themselves. U H C r i t i c a l C a r e P r o t o c o l P a g e 5 | 20 INTRODUCTION TRANSPORT CARE GENERAL GUIDELINES General 1. Cardiac monitoring, continuous pulse oximetry, and capnography are required on all patients with medications running or attached patient care devices as defined above. 2. 2 sets of vital signs are required as a minimum, and every 10 minutes during transport as a minimum, sooner if unstable or potential for instability. 3. Contact Medical Control as necessary during interfacility transports as defined in this document. 4. Multiple protocols are likely to apply to every patient encounter. 5. Assure double the anticipated amount of medications, including oxygen, are available for expected transport time. 6. Document interventions and medications given before transport by the receiving facility as such on the PCR. 7. Waveform capnography is required on all patients with NPPV or advanced airways in place. 8. Waveform capnography tracings at time of pickup, after patient movement from on bed to another and at departure are to be attached to the PCR. 9. Vital signs at time of pickup and drop off must be recorded and notated as such. Prior to departure 10. A complete assessment shall be conducted of the patient prior to transport. Do not delay transport to obtain already obtained EKG’s. If repeat EKG’s are indicated, obtain during transport. 11. Receive a report on patient condition from their healthcare provider before transporting the patient. Assure patient report if from a direct healthcare provider engaged in the patient’s care. Consult Physician in charge of patient if the patient is critical. a. Ensure appropriate titration orders where applicable. b. Ensure appropriate sedation package and plan response(s) if patient fails the sedation due to out of hospital stimulation. c. Ensure and validate expected NIBP, HR, Spo2 and Co2 targets. 12. Plan for patient decompensation enroute. Put appropriate interventions or monitoring in play before transport. 13. Develop a plan with sending Physician if patient has potential for decompensation enroute before departure of the sending facility. Understand in discussion with the Physician if there is decompensation enroute, whether diversion is appropriate or if specialty care at the destination outweighs any diversion. 14. Assure all pre-established vascular access is functioning prior to departure. 15. Assure knowledge of and function of all patient treatment devices and therapies before transport. 16. Glucose values should be reevaluated prior to or during transport if patients have not eaten, have been made NPO, received large volumes of fluids, has an insulin pump, has received steroids throughout their course of treatment, is post OP, or has had their blood glucose managed as part of their course of treatment. Reassess every 30 minutes at a minimum, or if symptoms develop with patients receiving insulin or glucose products. During Transport 17. If a patient develops complications during transport, treat per appropriate PCP/CCTP. 18. Communicate any changes in patient condition during transport with receiving facility to assure proper patient care is available at the receiving. 19. Reports must be called to the receiving facility if the destination is the ED. 20. EMS is required to leave a PCR at receiving facility during all interfacility transports. U H C r i t i c a l C a r e P r o t o c o l P a g e 6 | 20 COMMON ADULT AND PEDIATRIC CRITICAL CARE PROTOCOL ANALGESIA Patient in pain, and patients undergoing painful or uncomfortable interventions will be adequately addressed Concomitant Adjunctive Sedatives Continue to use fentanyl or ketamine as monotherapy if pain is controlled, and the sedation (RASS) goal is met and sustained. Sedatives may be added as a second adjunctive agent if RASS goals cannot be maintained with fentaNYL or ketamine monotherapy. Treatment: ADULT Bolus Infusion Fentanyl (TBW) 0.5 - 2 mcg / kg IV over 1 min / IM / IN 0.5 - 2 mcg / kg IV over 1 min PRN q 10 mins PRN q 10 mins Fentanyl Drip 25-100 mcg / hr Continuous Morphine 2 - 10 mg IV over 1-2 mins / IM - PRN q 20 mins Hydromorphone 1 mg IV over 2 min / IM - PRN q 15 min Ketamine 0.1 - 0.3 mg / kg IV over 10 min / IM / IN 0.5 - 2 mg IV over 2 mins PRN q 10- PRN q 10 – 20 mins 20 mins Max single dose 30 mg Ketamine Drip 0.5 - 4 mg / kg / hr Continuous Ketorolac 15mg IV, 30mg IM PEDIATRIC Analgesia Maintenance Fentanyl (TBW) 0.5 - 2 mcg / kg IV over 1 min / IM / IN PRN q 10 mins 0.5 - 2 mcg / kg IV over 1 min, IM / IN PRN q 10 mins Fentanyl Drip 1 - 2 mcg / kg / hr Continuous Morphine 0.05 mg / kg IV over 1 - 2 mins / IM PRN q 20 mins Max single dose 2 mg Ketamine 0.1 - 0.3 mg / kg IV over 10 min / IM / IN - 0.5 - 2 mg IV over 2 mins PRN q 10 - 20 mins PRN q 10 - 20 mins Max single dose 30 mg Ketamine Drip 0.5 - 4 mg / kg / hr Continuous Ketorolac 0.5 mg / kg IV over 1 - 2 mins IM Only one dose Max single dose 30 mg Pediatric Mild Pain ACETAMINOPHEN 15 mg / kg PO / PR Maximum 1000 MG per dose, if it has not been given in the previous 4 hours IBUPROFEN 10 mg / kg PO (if available) Maximum 800 MG per dose, if it has not been given in the previous 6 hours a Do not administer to obtunded paƟents a Do NOT give to paƟents with renal disease, acƟve hemorrhage, thrombocytopenia, or platelet dysfuncƟon Key Points: Unable to Assess Level of Pain or Sedation Patients who have received neuromuscular blocking agents or are otherwise unable to be assessed for pain and agitation should be empirically treated using Ketamine monotherapy or an opioid plus sedative dual agent combination. Pain and sedation scales such as CPOT and RASS, measure behaviors that a paralyzed patient cannot display. These scores cannot be used to assess and direct analgesia and anxiolysis in patients that have received NMBs. U H C r i t i c a l C a r e P r o t o c o l P a g e 7 | 20 Multiple or alternating therapeutic approaches may cause adverse events. One pain / sedation approach should be chosen, and then optimized. A Sedative should be added if opioids fully control pain, but sedation goals cannot be met. Choose only 1 sedative to use. For patients under 1 year old, CONTACT MEDICAL COMMAND. Refer to Nausea and Vomiting protocol for any associated nausea or vomiting. Document vital signs after administering medications. If hypotension occurs, administer LACTATED RINGERS (preferred) or NORMAL SALINE at 20 ml / kg IV bolus (maximum 1L). If hypotension persists and / or signs of respiratory depression occur, refer to Opiate Reversal protocol Critical-Care Pain Observation Tool (CPOT) Indicator Description Score Facial Expression No muscular tension observed 0 Frowning, brow lowering, orbit tightening, and levator contraction 1 All facial movements above, plus eyelid tightly closed 2 Body Movements Does not move at all (does not necessarily mean absence of pain) 0 Slow, cautious movements, touching or rubbing pain site, seeking 1 attention through movements Pulling tube, attempting to sit up, moving limbs, thrashing, not following 2 commands, striking at staff, trying to climb out of bed Muscle Tension No resistance to passive movements 0 Resistance to passive movements 1 Strong resistance to passive movements, inability to complete them 2 Only score compliance with ventilator or vocalization depending on patient status Compliance Alarms not activated, easy ventilation 0 (intubated patients) Alarms stop spontaneously 1 Asynchrony: blocking ventilation, alarms frequently activated 2 Vocalization Talking in normal tone or no sound 0 (non-intubated Sighing, moaning 1 patients) Crying out, sobbing 2 RASS (Richmond Agitation Sedation Score) +4 Combative Overtly combative, violent, immediate danger to staff +3 Very Agitated Pulls or removes tube(s) or catheter(s); aggressive +2 Agitated Frequent non-purposeful movement, fights ventilator +1 Restless Anxious but movements not aggressive vigorous 0 Alert and Calm -1 Drowsy Not fully alert, but has sustained awakening (eye-opening/eye contact) to voice (>10 seconds) -2 Light Sedation Briefly awakens with eye contact to voice ( 100 or MAP > 65 adult or age-appropriate systolic blood pressure in pediatrics Adult Drips Starting Dose Titrations Steps Dose Range Max Dose Peripheral IV Max Dose Norepinephrine 0.01 - 0.05 0.01 - 0.05 0.1 – 0.05 Contact Medical 0.2 mcg / kg / min Drip mcg / kg / min mcg / kg / min every mcg / kg / min Command if doses of 8 mg / 250ml 1-5 minutes > 0.5 mcg / kg / min concentration are needed only – higher concentrations require central line Epinephrine Drip 0.01 - 0.05 0.01 - 0.05 0.01 – 1 1 mcg / kg / min 0.2 mcg / kg / min mcg / kg / min mcg / kg / min every mcg / kg / min IV/IO 1 - 5 minutes Phenylephrine Drip 0.5 - 1 0.5 mcg / kg / min 2 mcg / kg / min mcg / kg / min every 1 - 5 minutes for standard IV/IO concentration (10 mg / 250 mL) 9 mcg / kg / min for high concentration (80 mg / 250 mL) Dopamine Drip 5 mcg / kg / min 0.5 – 2.5 0.5 – 20 20 mcg / kg / min IV/IO mcg / kg / min every mcg / kg / min 2 - 5 minutes Dobutamine Drip 2.5 – 5 2.5 mcg / kg / min 0.5 – 20 20 mcg / kg / min mcg / kg / min every 5 - 10 minute mcg / kg / min IV / IO Vasopressin Drip 0.03 units / min None None None 0.03 units / min adjunct to IV / IO infusion IV / IO infusion Norepinephrine Drip after 0.2 in sepsis mcg / kg / min of Norepinephrine Adult Push Dose Per Dose Starting Per Dose Max Repeat Max Pressors Phenylephrine 50 mcg 200 mcg PRN 3 Doses before PUSH DOSE starting infusion Epinephrine 10 mcg 50 mcg PRN 3 Doses before PUSH DOSE starting infusion Pediatric Drips Starting Dose Titrations Steps Dose Range Max Dose Peripheral IV Max Dose Epinephrine Drip 0.01 - 0.05 0.01 - 0.05 0.01 – 1 1 mcg / kg / min 0.2 mcg / kg / min mcg / kg / min every mcg / kg / min mcg / kg / min IV / IO 1 - 5 minutes Norepinephrine 0.01 - 0.05 0.01 - 0.05 0.1 – 3 Contact Medical 0.2 Drip mcg / kg / min mcg / kg / min every mcg / kg / min Command if doses mcg / kg / min 1 - 5 minutes > 0.5 mcg / kg / min are needed Pediatric Push Dose Starting Dose Per Dose Max Repeat Max Pressors Epinephrine 1 mcg / kg max 10 mcg 50 mcg PRN 3 Doses before PUSH DOSE first dose max starting infusion Key Points: It is highly recommended to obtain a second IV line if starting one of the above medications. Ensure adequate IV access as described above before administration of medication to minimize risk of infiltration. U H C r i t i c a l C a r e P r o t o c o l P a g e 10 | 20 Appropriate vasopressor selected based on clinical condition. Hypotension adequately addressed. Do NOT turn a pressor completely off when titrating one down Continuation of Infusions Vasoactive medications in place at the time of patient rendezvous should be continued if they are effective and consistent with the guidelines or standard practice. If therapy at the time of patient rendezvous is ineffective, alternative treatment options consistent with this guideline should be implemented or discussed with the sending provider, receiving physician, and or medical control. If an existing infusion is being administered using a dosing schema inconsistent with guidelines, do one of the following: 1. Continue therapy using the existing dosing schema 2. Recalibrate to the standard dosing schema while leaving the dose delivered unchanged In either case clearly document changes and the dosing schema used in the medication comments section. If an appropriate and effective infusion is in place at the time of rendezvous the delivered dose of medication should be continued. Arbitrarily changing the administration rate and delivered dose to match a dose schema may harm the patient. Push Dose Pressors: IV push EPINEPHrine or phenylephrine may be used to treat transient or profound hemodynamic instability while administering volume or preparing vasoactive infusions. Each drug must be chosen based on its properties and therapeutic goals. Pharmacology: EPINEPHrine is a potent vasoconstrictor, inotrope, and chronotrope suitable for all shock states except for those caused by tachyarrhythmias. Phenylephrine is pure alpha agent and potent vasoconstrictor suitable for hypotension secondary to anesthetic administration and vasodilatory shock. Treatment: IV push pressors must be prepared and administered in the standard dilute push dose concentrations for each pressor Failure to do so may result in medication errors and patient harm Phenylephrine Push Pressor Administration IV push pressor phenylephrine is only indicated in adult patients and should not be used in pediatric patients. IV push pressor phenylephrine should be used as a temporary treatment while preparing an infusion. Administration should be limited to 3 total doses. IV push pressor phenylephrine must be prepared and administered in the standard 100 mcg/mL concentration. Failure to do so may result in medication errors and patient harm. Phenylephrine—Push Pressor 50 – 200 mcg IV push 100 mcg / mL concentration Repeat every 2 – 5 min PRN Administer up to 3 doses total Phenylephrine - Bag Dilution Add 10 mg (1 ml via) phenylephrine to a 100 mL bag of NS—final concentration 100 mcg / mL Label the bag Using an empty syringe, draw the push dose phenylephrine to be administered from the bag Label the syringe The 100 mcg / mL phenylephrine IV bag is also an acceptable infusion mix and may be used for a follow- on infusion U H C r i t i c a l C a r e P r o t o c o l P a g e 11 | 20 Epinephrine Push Pressor Administration IV push pressor EPINEPHrine should be used as a short term or temporary treatment while preparing an infusion. Administration should be limited to 3 total doses. IV Push Pressor EPINEPHrine must be prepared in one of the following ways and administered in the standard 10 mcg / mL concentration. Failure to do so may result in medication errors and patient harm. Epinephrine - Syringe Dilution Transfer 0.1 mg (1 ml) from a 1 mg / 10 mL (0.1 mg / mL) EPINEPHrine prefilled syringe to an empty 10 cc administration syringe Add 9 mL of normal saline to the 10 mL administration syringe Final concentration 10 mcg / mL Label the syringe Segregate the EPINEPHrine prefilled syringe from the push dose syringe by placing it in a pack or other area Epinephrine - Bag Dilution Add 1 mg (1 mL vial or ampule) EPINEPHrine to a 100 mL bag of normal saline Final concentration 10 mcg / mL Label the bag Using an empty syringe, draw the push dose EPINEPHrine to be administered from the bag Label the administration syringe The 10 mcg / mL EPINEPHrine IV bag is also an acceptable infusion mix and may be used for the follow- on infusion Push Dose Syringes Medications diluted by the medical crew for push dose use must be labeled as such on the syringe, following the same guidelines as a bag add-mix. Catecholamine-resistant Shock Stress Dose Steroids Consult Medical control if adrenal crisis is suspected and stress dose steroids are indicated. Adrenal Insufficiency Hydrocortisone 100 mg IV Requires on-line order Shock & Cardiovascular Instability Presentation Anxiousness, confusion, or lethargy Cool, diaphoretic, pale, cyanotic, or mottled skin Delayed capillary refill Absence of distal pulses, unreadable distal SpO2, and poor distal pulse oximetry pleth Abnormal vital signs including tachypnea, tachycardia, hypocarbia, hypotension, and reduced urine output Lactate greater than ≥ 4 mmol/L Metabolic acidosis (pH < 7.35 with a HCO3 < 22) Shock should be the 1st differential diagnosis considered for any patient with metabolic acidosis Key Points: Monitor rhythm, SpO2, EtCO2, and NIBP Assess age-appropriate vital signs for changes consistent with shock and hypoperfusion Assess and document vital signs every 5 minutes Identify and treat the specific underlying condition Ensure or establish an adequate airway, optimize ventilation and oxygenation Improve oxygen delivery to the tissues by transfusion Establish venous access with two large bore IV or IO catheters Obtain a 12 lead ECG, evaluate for STEMI or Non-STEMI, and activate interventional capabilities as indicated Control patient temperature with warm IV fluids, cabin heat, and blankets Decrease analgesic, anesthetic, and anxiolytic medication doses by 1/2 to 1/4 of normal U H C r i t i c a l C a r e P r o t o c o l P a g e 12 | 20 Hemodynamic Targets and Goals Treatment should restore circulation to ensure minimally adequate organ perfusion. It may not be necessary to normalize all vital signs and it could be counterproductive to attain normal systolic blood pressures. Patients with head injuries, indications of increased intracranial pressure, or post cardiac arrest should be resuscitated to maintain a MAP of 80 - 100 mmHg Other patients should be resuscitated to just maintain adequate tissue perfusion as evidenced by skin color, skin temperature, capillary refill, mentation, urine output, presence of radial pulses, or minimally acceptable BP Hemodynamic targets may be further defined for specific conditions in other guidelines Initial Treatment and Stabilization Clinical management and preparation for transport should be efficient and prioritized Preparation time should be minimized if emergent surgical control or a time dependent intervention is necessary to manage the underlying disease such as: Interventional procedures—PCI, embolization, embolectomy Surgical Procedures—CABG, Vascular surgery, surgical hemorrhage control Treatments or devices—Balloon pump, VAD, ECMO Obstructive Shock Causes and Treatment Obstructive Shock Causes and Treatment Early assessment and treatment should systematically identify, rule out, and manage the following causes of obstructive shock and instability: Cause Potential signs / symptoms Treatment Tension Pneumothorax Positive pressure ventilation JVD, Needle decompression and or Tracheal deviation Unilateral Simple thoracostomy decreased or absent breath sounds Auto PEEP Positive pressure ventilation High PIP Disconnect vent circuit + High P Plat + Auto PEEP on Vent Allow pt to fully exhale Shark fin capnogram Slow rate and extend expiratory time Acute Massive Pulmonary Embolism Chest pain, SOB, hypoxia refractory to Thrombolysis (online medical direction) oxygen, unilateral leg swelling, Sinus Embolectomy Tachycardia, Right Bundle Branch Block, S1Q3T3 / RV strain / T-wave inversion in V1-V3 + III on 12 lead ECG, HX of DVT, cancer, surgery, or fracture Cardiac Tamponade JVD, narrowing pulse pressure, Pericardiocentesis muffled heart tones Alternating QRS axis on ECG Ultrasound evidence of pericardial effusion Cardiogenic Shock Rule out or manage myocardial dysfunction by treating the causes: Dysrhythmias —Bradycardia, SVT, VT Electrolyte abnormalities — hypokalemia, hyperkalemia, hypomagnesemia, and hypocalcemia Septic Shock Manage septic shock as per the Sepsis Guideline Hemorrhagic Shock Treat per Prehospital Care Treatment Protocols and Guidelines Control hemorrhage straight away using the techniques described in the trauma guidelines Apply direct pressure, pressure dressings, hemostatic dressings, and tourniquets to amendable wounds Apply pelvic compression devices for pelvic injuries Align and expediently splint long bone fractures U H C r i t i c a l C a r e P r o t o c o l P a g e 13 | 20 COMMON ADULT AND PEDIATRIC CRITICAL CARE PROTOCOL NEUROMUSCULAR BLOCKADE Treatment: ADULT Pre-Intubation Maintenance Rocuronium 1 - 1.2 mg / kg IV over 10 - 15 seconds, 1 - 1.2 mg / kg IV over 10 - 15 seconds, repeat PRN repeat PRN Vecuronium 0.1 mg / kg IV over 10 - 15 seconds, 0.1 mg / kg IV over 10 - 15 seconds, repeat PRN repeat PRN Succinycholine 1 - 2 mg / kg IV, IM May repeat once PRN Cisatracurium 0.1 to 0.2 mg / kg loading dose 1-3 mcg / kg / min infusion PEDIATRIC Pre-Intubation Maintenance Rocuronium 1 - 1.2 mg / kg IV over 10 - 15 seconds, 1 - 1.2 mg / kg IV over 10 - 15 seconds, repeat PRN repeat PRN Vecuronium 0.1 mg / kg IV over 10 - 15 seconds, 0.1 mg / kg IV over 10 - 15 seconds, repeat PRN repeat PRN Succinycholine 1 - 2 mg / kg IV, IM May repeat once PRN Cisatracurium 0.1 to 0.2 mg / kg loading dose 1 - 3 mcg / kg / min infusion Key Points: The sedative and neuromuscular blocker should be prepared in labeled syringes and placed in a secure area. Ketamine and rocuronium should be used unless they are contraindicated or unavailable. Check drug name and concentration by comparing the vial label with the syringe label two times. Once, just before drawing up the medication, and once again after the medication is in the syringe. RSI medications should be administered in the following standard and systematic way: 1. Check the drug name, concentration, dose, and volume to be administered 2. Give the sedative over 30 to 60 seconds 3. Give the full dose of neuromuscular blocker (NMB) right after the sedative 4. Wait 45 seconds to initiate laryngoscopy or place the i-gel 5. A fast flowing IV or IV flush should be used to ensure medications are completely delivered. Patients who have received neuromuscular blocking agents or are otherwise unable to be assessed for pain and agitation should be empirically treated using Ketamine monotherapy or an opioid plus sedative dual agent combination. Pain and sedation scales such as CPOT and RASS measure behaviors that a paralyzed patient cannot display. These scores cannot be used to assess and direct analgesia and anxiolysis in patients that have received NMBs. Multiple or alternating therapeutic approaches may cause adverse events. One pain / sedation approach should be chosen, and then optimized. U H C r i t i c a l C a r e P r o t o c o l P a g e 14 | 20 COMMON ADULT AND PEDIATRIC CRITICAL CARE PROTOCOL SEDATION Anxious, ventilated, and patients undergoing interventions will be adequately sedated Concomitant Adjunctive Sedatives Continue to use fentanyl or ketamine as monotherapy if pain is controlled, and the sedation (RASS) goal is met and sustained. Sedatives may be added as a second adjunctive agent if RASS goals cannot be maintained with fentaNYL or ketamine monotherapy. Treatments: ADULT Anxiolysis Pre-Airway Pre-Airway (DSI) Maintenance Procedural Bolus (RSI) Ketamine 0.5 - 2 mg IV over 4 mg / kg IM or 1 - 0.5 – 2 mg / kg IV 4 mg / kg IM or 1 - 30 - 60 seconds 2 mg / kg IV over 2 over 2 mins PRN q 2 mg/kg IV over 2 mins 10 - 20 mins mins Midazolam 0.5 - 2 mg IV over 1 0.05 - 0.1 mg / kg 0.025 - 0.05 mg / - 2 min, IM / IN IV over 1 - 2 mins kg IV PRN q 20 - 60 PRN q 10 mins mins Lorazepam 0.5 to 2 mg IV over 0.025 - 0.1 mg / kg 1 - 2 min, IM / IN over 1 min max PRN q 10 - 20 mins single dose 2 mg Repeat PRN q 10 - 20 mins Etomidate 0.3 mg / kg IV over 0.1 mg / kg IV over 30 - 60 seconds 30 - 60 seconds PRN repeat dosing 0.05 mg / kg over 3 - 5 mins ADULT Anxiolysis Pre-Airway Pre-Airway (DSI) Maintenance Procedural Infusion (RSI) Ketamine Drip 0.5 - 4 mg / kg / hr IV Con nuous Midazolam Drip 0.05 - 0.2 mg / kg / hr IV Con nuous Propofol Drip 5 - 100 mcg / kg / min Dexmedetomidine 0.2 mcg / kg / hr Drip Max rate 1 - 1.4 mcg / kg / hr Richmond Agitation Sedation Score (RASS) Score Term Description 4 Combative Combative or violent, immediate danger to staff 3 Very agitated Pulls on or removing catheters/tubes or aggressive behavior 2 Agitated Frequent nonpurposeful movement or ventilator desynchrony 1 Restless Anxious but movements not aggressive or vigorous 0 Alert and calm -1 Drowsy Not fully alert, >10 secs awakening, with eye contact, to voice -2 Light sedation Briefly (< 10 secs) awakens with eye contact to voice -3 Moderate sedation Any movement (but no eye contact) to voice -4 Deep sedation No response to voice, any movement to physical stimulation -5 Unarousable No response to voice or physical stimulation U H C r i t i c a l C a r e P r o t o c o l P a g e 15 | 20 PEDIATRIC Anxiolysis Pre-Airway Pre-Airway (DSI) Maintenance Procedural Bolus (RSI) Ketamine 0.5 - 2 mg IV over 4 mg / kg IM or 1- 0.5 – 2 mg / kg IV 4 mg / kg IM or 1 30 - 60 seconds 2 mg / kg IV over over 2 mins PRN q - 2 mg / kg IV over 2 mins 10 - 20 mins 2 mins Midazolam 0.05 - 0.1 mg / kg 0.05 - 0.1 mg/kg 0.025 - 0.05 mg / IV over 1 - 2 min, IV over 1 - 2 mins kg IV PRN q 20 - IM / IN PRN q 10 60 mins mins Max single dose 2 mg Lorazepam 0.05 to 0.1 mg / 0.025 - 0.1 mg / kg IV over 1 - 2 kg over 1 min max min – IM / IN PRN single dose 2 mg q 10 - 20 mins Repeat PRN q 10 - Max single dose 2 20 mins mg Etomidate 0.3 mg / kg IV over 30 - 60 seconds PEDIATRIC Anxiolysis Pre-Airway Pre-Airway (DSI) Maintenance Procedural Infusion (RSI) Ketamine Drip 0.5 - 4 mg / kg / hr IV Con nuous Midazolam Drip 0.05 - 0.2 mg / kg / hr IV Con nuous Propofol Drip 3 – 5 mg / kg / hr Propofol bolus: If inadequate sedation, can bolus 1 - 2 mg / kg at a time every 5 - 10 minutes. If multiple boluses are needed, increase drip by 1mg / kg / hr until adequate sedation. Key Points: A Sedative should be added if opioids fully control pain, but sedation goals cannot be met. Choose only 1 sedative to use Contact medical command if more than 2 push boluses of sedatives are needed Continue infusions in place at patient rendezvous using the existing dose and titrate PRN Propofol lacks analgesic properties. Pain management usually requires concomitant opioid administration. Effective dosages in the hospital unit may provide insufficient sedation during transport due to stimuli and pain. Resuscitative fluids or vasopressors may be required during Propofol administration to prevent hypotension. Patients who have received neuromuscular blocking agents or are otherwise unable to be assessed for pain and agitation should be empirically treated using Ketamine monotherapy or an opioid plus sedative dual agent combination. Pain and sedation scales such as CPOT and RASS, measure behaviors that a paralyzed patient cannot display. These scores cannot be used to assess and direct analgesia and anxiolysis in patients that have received NMBs. Multiple or alternating therapeutic approaches may cause adverse events. One pain/sedation approach should be chosen, and then optimized. U H C r i t i c a l C a r e P r o t o c o l P a g e 16 | 20 COMMON ADULT AND PEDIATRIC CRITICAL CARE PROTOCOL VENTILATOR MANAGEMENT The overarching objectives during mechanical ventilation are adequate oxygenation, effective ventilation, and protecting the lungs from ventilator associated injuries. This guideline uses an adaptable goal directed ventilator management strategy. The goal directed process uses uniform ventilator settings followed by goal directed management based on the patient’s physiologic response. Patients with advanced airways should be mechanically ventilated bedside to beside on Inter- facility transports and aircraft to bedside on scene transports. Airway Placement and Position Confirmation Prior to initiating mechanical ventilation ensure the endotracheal tube is correctly placed and positioned. ETT size—Replace the ETT as necessary. ETT placement and depth—Reposition to the correct depth as needed ETT security—Secure the ETT with a Thomas Tube Holder or approved tape technique ETT cuff pressure—Adjust cuff pressure to 20 - 30 cmH2O. Higher cuff pressures may be necessary with high PIP e.g. Asthma Equipment Preparation and Set Up Select the circuit, EtCO2 sensor, heat and moisture exchanging filter (HMEF), and closed suction catheter based on the patient weight and ventilator DFU. The relative humidity of the inhaled air may be less than optimal (< 60%) when the upper end of the HME volume range is exceeded. Larger HMEF with increased dead space may cause unacceptable elevations in PaCO2. Most infant and some pediatric and adult HMEs do not have an integrated HEPA filter If a HMEF or filter cannot be placed at the ETT, separate inspiratory and expiratory limb filters should be used Initial Ventilator Set Up A high efficiency bacterial/viral HMEF with > 99.97% filtration efficiency should be used. Failing to use a high-quality filter increases the risk of patient, crewmember and equipment exposure to pathogens. Set up the ventilator using the device specific guidelines Settings for established ventilator patients may be different based on physiologic experience with the patient. Ideal body weight must be used to calculate tidal volume and target exhaled tidal volume Vte. See Age, Height, and Body Weight, IBW Chart and Weight Estimation. Settings for established ventilator patients may be different from the initial settings provided in this guideline. Initial settings on the transport ventilator may be adjusted to based on prior settings and physiologic experience with the patient. U H C r i t i c a l C a r e P r o t o c o l P a g e 17 | 20 Goal Directed Ventilator Management Mechanical ventilation goals and measurable physiologic targets should be used to guide ventilator management. Goal Measurable Parameter Avoid Ventilator Associated Lung Injury Plateau pressure < 30 cm / H2O Adequate Oxygenation SpO2 > 93% Adequate Ventilation EtCO2 30 - 50 mm / Hg EtCO2 Lower or higher than the goal range may be acceptable in some clinical scenarios such as Asthma, DKA, severe sepsis, aspirin overdose, and ARDS Correlate EtCO2 with PACO2 when practicable Monitor chest rise, exhaled tidal volume (Vte), and peak inspiratory pressure (PIP). Contact medical control if the patients EtCO2 goals or other ventilation parameters are unclear. If the patient is already on a ventilator at the time of rendezvous, the existing settings should be used to guide the initial set up of the transport ventilator. Monitor the Patient Once the patient is on the ventilator monitor the primary and secondary measurable parameters: Hold Maneuvers Once the patent is on the ventilator, measure plateau pressure, static compliance (volume ventilation) and Auto PEEP Titrate to Goal Use the patient’s physiologic data to make ventilator changes that achieve the goals of adequate oxygenation and ventilation. Respond to EtCO2, Oxygenation, and Pressure abnormalities in a systematic manner. Hypocapnia Management—EtCO2 < 30 mmHg Goal = Normalize MV Adult ~ 100 ml / kg (IBW) Pediatric ~ 150 – 200 ml / kg 1st - Check Tidal Volume 2nd - Check Rate Hypocapnia is usually due to acidosis, poor perfusion, or aggressive and poorly monitored bag ventilation Hypocapnia due to iatrogenic hyperventilation should resolve when a sensible minute volume is established Do not use abnormally low tidal volumes or respiratory rates less than minimum age normal to correct hypocapnia If the patient is acutely ill or known to have a metabolic acidosis higher than normal MV may be necessary, titrate vent settings to match and maintain pre-intubation ETCO2 Change respiratory rate by increments of 2 and do not go below the age normal rate U H C r i t i c a l C a r e P r o t o c o l P a g e 18 | 20 Hypercapnia Management — EtCO2 > 50 mmHg Goal = increase minute ventilation (Ve) Check for and correct ventilator circuit apparatus dead space 1st - Optimize Vt 2nd - Optimize MV 3rd - Manage AutoPEEP In severe cases of AutoPEEP, disconnection from ventilator and manual chest decompression may be needed Hypercapnia may need to be tolerated in ARPV and asthma patients to maxamize oxygenation Decreasing I-time may cause higher PIPs and reduced tidal volume Hypoxia Management — SpO2 < 93 Goal = optimize SpO2 without lung injury Optimize FiO2 Optimize PEEP PEEP Use one of the PEEP and FiO2 escalation ladders below to guide FiO2 and PEEP titration Higher FIO2 / Lower PEEP FIO2 0.3 0.4 0.4 0.5 0.5 0.6 0.7 0.7 0.7 0.8 0.9 0.9 0.9 1.0 PEEP 5 5 8 8 10 10 10 12 14 14 14 16 18 20 Lower FIO2 / Higher PEEP FIO2 0.3 0.3 0.3 0.3 0.3 0.4 0.4 0.5 0.5 0.6 0.7 0.8 0.9 1.0 PEEP 5 8 10 12 14 14 16 16 18 20 22 22 24 24 Optimize PEEP Set PEEP, perform inspiratory hold, and note compliance Repeat process until PEEP increases no longer improve compliance If at any time the compliance decreases, reduce PEEP to the previous level A lower rate and increased inspiratory time combined with a higher PIP may improve oxygenation If FiO2, PEEP, and P Plat / PIP are maximized, and the patient remains hypoxic contact medical control Alarms and Trouble Shooting Alarms should be addressed in a prioritized and systematic way. Abnormal ventilator conditions have specific alarms and a likely set of causes that should prompt a methodical evaluation and corrective maneuvers. If there are multiple alarms, the ventilator may only display the highest priority alarm on the screen. Manually scroll to view other alarms. U H C r i t i c a l C a r e P r o t o c o l P a g e 19 | 20 High Pressure Alarm 1. Temporally set high pressure limit all the way up while trouble shooting 2. Reconfirm airway placement, position, and security 3. Check for tube and circuit for kinks and other obstructions 4. Check for secretions in airway and suction PRN 5. Optimize sedation 6. Check autoPEEP, PIP, and P Plat IF autoPEEP > SET PEEP If PIP high / P Plat OK If PIP high & P Plat high Air trapping Airway problem Lung problem ✔ for exhalation line ✔ Disconnect ✔ Airway obstruction? problems ✔ Adequate tube size? ✔ Tension pneumothorax? ✔ Tube patency ✔ Adequate I time? ✔ Pulmonary edema? ✔ Bronchospasm ✔ Bronchospasm? ✔ Right mainstem? ✔ Abdominal distension? ✔ Low lung compliance? Disconnect—allow exhalation ⬆ E time by ⬇ I time and /or ⬇ rate ⬇ tidal volume Treat bronchospasm with beta agonists Low Lung Compliance (Cstat < 50 ml/cm/H2O) 1. Optimize sedation and use neuromuscular blockers as indicated 2. Decrease PEEP no less than 5 cm / H2O if oxygenation adequate 3. Decrease Vt if EtCO2 is adequate 4. Check for excessive flow and extend i-time too to account for poor lung compliance Change volume control ventilation to pressure control Low Pressure Alarm 1. Check for leak in airway or ventilator circuit 2. Insufficient flow (I-time too long relative to patient compliance.) 3. Too low or too high VE 4. Equipment failure Ventilator Management of the Asthmatic Principles of ventilation of the Asthmatic patient 1. Oxygenation is rarely a problem and a Sp02 of >90% is acceptable 2. Peak inspiratory pressure (PIP) and plateau pressure (P plat) should be kept at safe levels to minimize barotrauma Low tidal volume ventilation is usually necessary to avoid high PIP and P plat 3. Increasing the I:E ratio by using a low initial breath rate (adults 8 - 10, Pediatrics 12 - 16) helps minimize barotrauma 4. The combination of Low VT and low breath rate results in hypercapnia which is usually acceptable in the asthmatic PEEP of 5 - 8 cmH20 may maximize oxygenation and ventilation Sedation and Analgesia RASS and CPOT may not be reliable indicators of the patient’s awareness and pain sensation in certain patient care scenarios. Patients with advanced airways and on mechanical ventilation should always have sedation and analgesia administered and maintained during transport U H C r i t i c a l C a r e P r o t o c o l P a g e 20 | 20 NEONATAL CRITICAL CARE PROTOCOL NEONATAL ANALGESIA / SEDATION / PARALYSIS Patients will remain comfortable during transport Indications: Patients undergoing painful procedures Patients being intubated / mechanically ventilated Consider SWEET-EASE (24% sucrose and purified water solution) 0.1 ml PO for stress or painful procedures a Condi ons concerning for NEC and GI anomalies or compromise I Do NOT use more than 3 doses during a single procedure I Do NOT use for infants requiring ongoing pain relief MORPHINE 0.05 - 0.1 mg / kg IV I Morphine may be repeated once during transport without Medical Command consulta on If further sedation is required MIDAZOLAM at 0.05 - 0.1 mg / kg IV If a SEDATIVE INFUSION is in place by a referring facility, Medical Command must be consulted to discuss settings and titration VECURONIUM 0.1 mg / kg IV for paralysis No paralytic may be used in neonates without Medical Command consultation Key Points: Medical Command must be consulted if the patient is hemodynamically compromised, if repeat doses of sedation are required, or if there is any history of seizure. Pay close attention to hypotension in infants with pulmonary hypertension as this will worsen their hypoxia. Patients can continue to have seizure despite chemical paralysis, look for sudden increases in heart rate and / or blood pressure and consider additional treatment for seizure control after discussion with Medical Command. Only in rare cases should a neonate require paralysis for mechanical ventilation (i.e., post-operative airway surgery). This must always be discussed with medical command. Sedation is given to all neonates in preparation for intubation (as long as the patient is alert and has a gag reflex), and mechanically ventilated patients if not hemodynamically compromised Quality Indicators: Proper dosing of sedatives Medical Command consulted as appropriate U H C r i t i c a l C a r e P r o t o c o l P a g e 21 | 20 NEONATAL CRITICAL CARE PROTOCOL NEONATAL ASSESSMENT Appropriate assessment and care will be provided for neonatal patients Primary Survey: Airway: Ensure airway patency per neonatal airway guidelines. Breathing: Administer oxygen, if needed, per Oxygen guidelines. Assist ventilation as needed. Circulation: Assess rate and quality of pulses and evidence of good perfusion. Establish intravenous access per Vascular Access guidelines Initiate and continue cardiac monitoring. Focused Initial Neonatal Transport History: History of present illness Prenatal care, pertinent past maternal illness, and estimated date of confinement (EDC), results of maternal prenatal labs, maternal medication used during pregnancy Labor history, including pertinent intrapartum factors, such as: o Anesthesia/analgesia o Rupture of membranes, including fluid volume and appearance (? meconium) o Method of delivery o APGAR scores o Any resuscitative procedures performed or required. Secondary Survey: Perform a secondary assessment and physical exam, including: o CV: perfusion, color, rate, rhythm, quality of pulses, liver span, edema o RESP: rate, pulse ox, work of breathing, lung sounds, apneas o CNS: tone, activity, fontanel o GI: distention, concavity, masses Check blood glucose. Treat as per Glycemic Control guidelines. Make note of diagnostic testing performed. Obtain copies for the receiving facility. Make note of medications or blood products given. Note temperature. Also, note ventilator setting or oxygen requirements if applicable. Formulate Transport Plan: After data is gathered, conference call with NICU attending and fellow to discuss plan. Double-check that identification band is in place prior to transport. Begin transport and implement treatment plan. Constantly monitor patient during transport. Keep patient warm. Assess vital signs at least every 5 minutes if patient is unstable or unconscious and every 10 minutes if patient is stable and conscious. Monitor and document response to all interventions. U H C r i t i c a l C a r e P r o t o c o l P a g e 22 | 20 Key Points: The primary survey should be performed simultaneously with initial resuscitative measures. Consider performing blood pressure readings in all four extremities if a cardiac defect is suspected. Do NOT rely solely on automated blood pressure monitors to monitor perfusion. Look at skin color, capillary refill, and other evidence of perfusion at each phase of mission. Consider taking isolation precautions on patients with potential infectious diseases. For infants at or below birth weight, fluid and medication calculations should be based on their birth weight. Quality Indicators: NICU consultation obtained Appropriate frequency of vital signs U H C r i t i c a l C a r e P r o t o c o l P a g e 23 | 20 NEONATAL CRITICAL CARE PROTOCOL NEONATAL CHOANAL ATRESIA Patients with choanal atresia will have an adequate airway established and maintained Indications: Patients with known or suspected choanal atresia Insert an oral airway if infant shows evidence of respiratory distress. If symptoms persist, intubate as per Intubation guidelines. Begin intravenous fluids as per Vascular Access guidelines. The infant should receive nothing by mouth. Check blood glucose (Treat as per Neonatal Glycemic Control guidelines) Key Points: Choanal atresia is a congenital anomaly characterized by a failure of adequate development of the choanal passages with blockage of one or both of the choanae by a membranous or bony closure. Because neonates are preferential nose breathers, this can lead to serious breathing difficulties. Clinical signs vary from infant to infant. Thick, mucoid secretions filling the nostrils are not uncommon. Distress may lessen with crying and get worse when the infant quiets Quality Indicators: Airway management performed as needed Intravenous fluids at correct rate Blood glucose assessed and correctly managed U H C r i t i c a l C a r e P r o t o c o l P a g e 24 | 20 NEONATAL CRITICAL CARE PROTOCOL NEONATAL DIAPHRAMATIC HERNIA Patients with diaphragmatic hernia will have their airway managed aggressively and their stomachs decompressed A diaphragmatic hernia results from the incomplete formation of the diaphragm, which allows the abdominal contents to enter the thoracic cavity, resulting in hypoplasia of the lungs and displacing the mediastinal structures. It is usually left-sided but may be right-sided or bilateral. Indications: Diagnosis of diaphragmatic hernia at referring facility Presentation – Diaphragmatic Hernia The clinical presentation of diaphragmatic hernia may include respiratory distress, absent or diminished breath sounds on the affected side, barrel chest, scaphoid abdomen with bowel sounds audible in the chest, heart sounds audible in one hemithorax, and supraumbilical midline defects. Presentation - Pneumothorax Signs and symptoms of pneumothorax may include absent or diminished breath sounds on the affected side, abrupt worsening of respiratory or circulatory status, pneumothorax by chest x-ray or transillumination, or shift in apical heart impulse. Treatment: Make sure infant’s airway is established. If not already in place, intubate as per intubation guidelines minimizing PPV/BVM during process If not already in place, insert a 10 Fr Replogle tube nasally or orally. Place to gravity and aspirate frequently. Maintain a neutral thermal environment per Thermoregulation guidelines. Establish intravenous access. Check blood glucose and treat as per Neonatal Glycemic Control guidelines. Monitor for signs and symptoms of pneumothorax. Place pulse oximetry probe pre-and post-ductally. Provide up to 100% oxygen as needed to maintain normal saturations Defects detected post-natally without respiratory distress may be transported without intubation but still require repogle. Treatments in Consultation with Medical Command SODIUM BICARBONATE (4.2%) 1 - 2 meq / kg INFUSED IV at a rate of 1 meq / min if pH < 7.20 If a patient is severely hypoxic INHALED NITRIC OXIDE at 20 PPM Key Points: Ensure with medical command that the ECMO attending is contacted and kept updated during transport of these patients. Avoid BMV if possible. Avoid excessive pressure during ventilation. Quality Indicators: Appropriate airway interventions Appropriate oxygen management pressure/volume trauma and pneumothorax U H C r i t i c a l C a r e P r o t o c o l P a g e 25 | 20 NEONATAL CRITICAL CARE PROTOCOL NEONATAL EXOGENOUS SURFACTANT ADMINISTRATION Surfactant replacement goals include improving oxygenation (oxygen index), increased lung compliance and decreased work of breathing by reversing atelectasis due to endogenous surfactant deficiency associated with respiratory distress syndrome Indications: Preterm infants with clinical evidence of endogenous surfactant deficiency: Chest radiograph characteristic of RDS (ground glass appearance) A mean airway pressure >7 cm H2O to maintain an adequate PaO2, SaO2, or SpO2 Requires endotracheal intubation and mechanical ventilation because of increased work of breathing Increasing oxygen requirements as indicated by pulse oximetry. Draw calculated surfactant dose into appropriately sized syringe Verify dose of surfactant to be administered. This will be different depending on kind of surfactant being available and pulse oximetry: PORACTANT ALFA: 2.5 ml / kg BERACTANT: 4 ml / kg CALFACTANT: 3 ml / kg Ensure patient intubated with color change on ETCO2 detector and equal breath sounds and chest rise bilaterally indicating appropriate depth of placement above carina. Verify with chest radiograph if available. Note position of ETT at lip, secure with neobar. Position patient supine with head midline Suction ETT Connect surfactant adaptor to end of ETT Attach T-piece resuscitator or resuscitation bag to the ventilation port on the adaptor. Attach the syringe filled with surfactant to the surfactant port on the adaptor. One care giver will administration of surfactant per patient tolerance, instilling 0.1 ml of surfactant at a time, and stopping between each 0.1 ml aliquot for a second caregiver to provide to provide breaths with T-piece resuscitator or resuscitation bag. During surfactant administration, monitor heart rate, respiratory rate, work of breathing, chest rise, O2 saturation, and reflux of surfactant within the ETT. If signs of intolerance, pause administration and allow for recovery before continuing. Titrate FiO2 to maintain saturation 90 - 95% and peak inspiratory pressure to prevent excessive chest rise as lung compliance increases during surfactant administration. Key Points: Exogenous surfactant is a medication compound composed of phospholipids, neutral lipids and proteins that form a layer between the alveolar surface and the alveolar gas and reduces alveolar collapse by decreasing surface tension within the alveoli. Surfactant may be extracted from animal lung lavage and produced from a naturally occurring material or a synthetic source. Surfactant replacement goals include improving oxygenation, improved pulmonary mechanics, increased lung volumes as seen on chest radiograph, and decreased work of breathing by reversing atelectasis. U H C r i t i c a l C a r e P r o t o c o l P a g e 26 | 20 Complications of surfactant administration include plugging of ETT by surfactant, desaturation and need for increased FiO2, bradycardia due to hypoxia, tachycardia due to agitation, pharyngeal deposition of surfactant or administration of surfactant into one lung due to malpositioned ETT, mucous plugs, pulmonary hemorrhage, barotrauma/volutrauma, pneumothorax Quality Indicators: Correct dose calculated and given based on product available and patient weight Maintenance of ETT placement and patency throughout administration Maintenance of appropriate heart rate and oxygenation throughout and following administration Administration of surfactant into both lungs (ETT in appropriate position above carina) Avoidance of barotrauma and pneumothorax due to rapid increase in lung compliance and failure to decrease PIP accordingly U H C r i t i c a l C a r e P r o t o c o l P a g e 27 | 20 NEONATAL CRITICAL CARE PROTOCOL NEONATAL FAILED AIRWAY Define alternative methods for securing a compromised airway will be used when the crew is unable to intubate Indications: Inability to adequately secure a patient’s airway with an endotracheal tube Bag-mask ventilation is unsuccessful, undesirable (i.e., diaphragmatic hernia), or is needed for a prolonged period Support ventilation with BMV and O2, using oral or nasal airways as needed. Access Neonatologist, Pediatrician, Neonatal APP, Anesthesiologist, or Emergency Physician for assistance if available. Treatment: If unsuccessful obtaining assistance with intubation, insert a size 1 Laryngeal Mask Airway (LMA) if the infant weighs more than 2.0 kg. Confirm placement: Auscultation of breath sounds in axillae and anterior chest. The absence of sounds over epigastrium. in-line end tidal CO2 monitor (preferred) or colorimetric end tidal CO2 detector If there are contraindications to LMA insertion or patient cannot be adequately ventilated with the LMA, continue face mask ventilation, and discuss options with Medical Command. If oxygen saturation cannot be maintained > 90% and color change cannot be maintained on end tidal CO2 detector, discuss with Medical Command going to the nearest facility with available airway stabilizing assistance. Contraindications to LMA placement: Patients not sufficiently unconscious as demonstrated by intact gag reflex or resistance to insertion. Unconscious patients unable to open mouth sufficiently. Suspected epiglottitis or upper airway obstruction due to other causes. Key Points: Do not force the LMA. Refer to Pediatric Failed Airway guidelines for infants weighing more than 6.5 kg. Quality Indicators: Use of appropriate mode for rescue airway. Obtains additional assistance when available. Documentation of confirmation of LMA placement. U H C r i t i c a l C a r e P r o t o c o l P a g e 28 | 20 NEONATAL CRITICAL CARE PROTOCOL NEONATAL GASTROSCHISIS AND OMPHALOCELE Verify bowel is well perfused, cover exposed bowel, and initiate antibiotics Indications: Gastroschisis Omphalocele Treatment: If the cord has not already been cut prior to arrival, maintain at least 10cm of cord proximal to the clamp. Insert a 10 Fr Replogle tube nasally or orally if a not already in place. Attach to low intermittent suction. Examine any exposed bowel for evidence of adequate perfusion. In the case of gastroschisis, place the lower half of infant into sterile bowel bag and pour warm saline into bag to keep exposed intestines wet, cinch bowel bag closed around the upper abdomen to prevent excessive insensible water loss. If a bowel bag is not available, can wrap the exposed use sterile, saline-soaked, non-stick, non- adherent, gauze such as tefla or saline soaked sterile towels. Ensure that the environment inside the bowel bag, or the gauze in contact with the exposed bowel if

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