Special Information.pdf

Notes on Drug Routes: IN generally preferred prior to IM unless contraindicated IN or NAS: nostrils for secretions/obstructions; suction; remove NPA; max 1 IM preferred site: Vastus Lateralus muscle mid-anterolateral thigh mL/nostril; if tota...

Notes on Drug Routes: IN generally preferred prior to IM unless contraindicated IN or NAS: nostrils for secretions/obstructions; suction; remove NPA; max 1 IM preferred site: Vastus Lateralus muscle mid-anterolateral thigh mL/nostril; if total volume > 0.4 mL, divide dose into 2 syringes; BRISKLY depress IO approved sites: syringe plunger to atomize medication. DO NOT have pt inhale while giving. Adult ≥ 22 yrs: Proximal humerus; proximal tibia; distal tibia IV: Select site based on vein condition, purpose (fluid/drugs to be infused); pt. age/ Peds & up to 21 yrs: Proximal humerus; proximal tibia; distal tibia; distal femur size, clinical status and presence of special vein & skin problems (elderly, peds, IO contraindications: Fx in same extremity; infection at insertion site, significant previous obese pts; those with AV shunts or grafts; and previous mastectomies). Maintain orthopedic procedure at the site (IO in past 48 hrs; local vascular compromise; prosthetic limb or joint aseptic technique; confirm line patency, flush tubing after drug delivery; use arm IO in responsive pt: Flush w/ lidocaine per Drug Appendix (adult & peds doses) board if access near point of flexion. Consider saline lock if IVF not indicated. All IO: put IV bag into pressure infuser 7 RIGHTS of medication administration - RIGHT Patient: Confirm absence of allergy Drug package/drug container for name, concentration, integrity/sterility of parenteral medication, expiration date (do not use if expired unless authorized in writing by EMS MD/FDA) | Prepare dose in compliance with SOP/OLMC | Controlled substances, IV inopressors; and high risk meds (peds dosing/others Dose per protocol) require a Medication Administration Cross-check Procedure (MACC) with another qualified practitioner before giving. Timing of administration: See drug profile or individual SOP Route & site: See above Reason: Must be indicated and not contraindicated for patient | Risk : benefit analysis Documentation: Must note drug, concentration if epinephrine, dose, route; time of administration, and patient response for each individual dose Medication Administration Cross Check procedure: Two-person verbal procedure using intentional steps to find and prevent drug errors in high-risk situations. 1. Person preparing dose: Confirm that all “Rights” of medication administration above have been followed 2. Whenever possible: Verify with 2nd practitioner authorized to give that drug: Verbally alert partner to Medication Cross Check – receive affirmation they are ready to participate State indication for drug and lack of contraindications – receive affirmation that drug is indicated Show packaging to confirm medication name, concentration – receive affirmation of correct drug Both do dose calculation (independently using SOP, dosing charts, or electronic dose calculator) Mutually verify that correct dose (amount of drug and volume of solution) has been prepared and syringe or IV container is labeled correctly Mutually confirm route and rate of administration Weight estimation: Accurate measurement and/or estimation in kg is important for many drugs and EMS interventions | EMS estimations are highly variable Approved options: 1. Direct measurement using a scale (often not available) | Pt or caregiver self-report (consider accuracy) 2. Peds pts ≤12: Length-based tape (Broselow) or approved equivalent - measure head to heel If child cannot lie flat, est. using Broselow age: wt table or Pedi Wheel. Note: Age-based formulas and length- based methods without habitus adjustment tend to predict ideal (not actual) body weight. 3. Child taller than tape & adults (may not be valid in elderly): Mid-upper arm circumference (MUAC) formula: Wt in kg = 4 X MUAC (in cm) – 50. Use left upper arm; measure at mid-point between tip of shoulder & elbow. NWC EMSS 2022 SOP 106 Rev. 3-11-24  ACETAMINOPHEN IV ADENOSINE AMIODARONE ATROPINE DIPHENHYRAMINE EPINEPHRINE Peds Doses 15 mg/kg 0.1 mg/kg 5 mg/kg 0.02 mg/kg 1 mg/kg (max 50 mg) 1 mg/1 mL Round up to next closest (1,000 mg/100 mL) (1 mg/10 mL) 50 mg/mL (6 mg/2 ml) (150 mg/3 mL) 0.01 mg/kg IM dose that can be given Max dose: 750 mg Min 0.1 mg; Max child IVP/IO over 2 min Max daily : 3750 mg Max: 6 mg 1st dose VT: max 150; VF 300 0.5 mg | Adoles 1 mg (no IV/IO give IM) max 0.3 mg Weight Dose mg / mL Dose mg / mL Dose mg / mL Dose mg / mL Dose mg / ml Dose mg / mL 6.6 lbs = 3 kg 45 mg = 4.5 mL 0.3 mg = 0.1 mL 15 mg = 0.3 mL 0.06 mg = 0.6 mL 8.8 lbs = 4 kg 60 mg = 6 mL 20 mg = 0.4 mL 0.08 mg = 0.8 mL 11 lbs = 5 kg 75 mg = 7.5 mL 0.5 mg = 0.2 mL 25 mg =0.5 mL 0.1 mg = 1 mL 5 mg = 0.1 mL 13 lbs = 6 kg 90 mg = 9 mL 30 mg = 0.6 mL 0.12 mg = 1.2 mL 15.4 lbs= 7 kg 105 mg = 10.5 mL 35 mg =0.7 mL 0.14 mg = 1.4 mL 17.6 lbs = 8 kg 120 mg = 12 mL 0.8 mg = 0.3 mL 40 mg =0.8 mL 0.16 mg = 1.6 mL 19.8 lbs = 9 kg 135 mg = 13.5 mL 45 mg =0.9 mL 0.18 mg = 1.8 mL 22 lbs = 10 kg 150 mg = 15 mL 50 mg = 1 mL 0.2 mg = 2 mL 10 mg = 0.2 mL 0.1 mg = 0.1 mL 24.2 lbs = 11 kg 165 mg = 16.5 mL 1.1 mg = 0.4 mL 55 mg = 1.1 mL 0.22 mg – 2.2 mL 26.4 lbs = 12 kg 180 mg = 18 mL 60 mg = 1.2 mL 0.24 mg = 2.4 mL 28.6 lbs – 13 kg 195 mg = 19.5 mL 67.5 mg = 1.3 mL 0.26 mg = 2.6 mL 30 lbs = 14 kg 210 mg = 21 mL 1.4 mg = 0.5 mL 70 mg = 1.4 mL 0.28 mg = 2.8 mL 33 lbs = 15 kg 225 mg = 22.5 mL 75 mg =1.5 mL 0.3 mg = 0.3 mL 15 mg = 0.30 mL 0.15 mg – 0.15 mL 35 lbs = 16 kg 240 mg = 24 mL 80 mg = 1.6 mL 0.32 mg = 3.2 mL 40 lbs = 18 kg 270 mg = 27 mL 1.8 mg = 0.6 mL 90 mg = 1.8 mL 0.36 mg = 3.6 mL 44 lbs = 20 kg 300 mg = 30 mL 2 mg = 0.7 mL 100 mg = 2 mL 0.4 mg = 4 mL 20 mg = 0.40 mL 0.2 mg = 0.2 mL 48 lbs = 22 kg 330 mg = 33 mL 110 mg = 2.3 mL 0.44 mg = 4.4 mL 53 lbs = 24 kg 360 mg = 36 mL 2.4 mg = 0.8 mL 120 mg = 2.4 mL 0.48 mg = 4.8 mL 55 lbs = 25 kg 375 mg = 37.5 mL 125 mg = 2.5 mL 0.5 mg – 5 mL 25 mg = 0.5 mL 57 lbs = 26 kg 390 mg = 39 mL 2.6 mg = 0.9 mL 130 mg = 2.6 mL 0.52 mg = 5.2 mL 62 lbs = 28 kg 420 mg = 42 mL 140 mg = 2.8 mL 0.56 mg = 5.6 mL 66 lbs = 30 kg 450 mg = 45 mL 3 mg = 1.0 mL 150 mg = 3 mL 0.6 mg = 6 mL 30 mg = 0.6 mL 0.3 mg = 0.3 mL 70 lbs = 32 kg 480 mg = 48 mL 3.2 mg = 1.1 mL 160 mg = 3.2 mL 0.64 mg = 6.4 mL Max Single Dose 75 lbs = 34 kg 510 mg = 51 mL 3.4 mg = 1.1 mL 170 mg = 3.4 mL 0.68 mg = 6.8 mL 34 mg = 0.7 mL 79 lbs = 36 kg 540 mg = 54 mL 3.6 mg = 1.2 mL 180 mg = 3.6 mL 0.72 mg = 7.2 mL 84 lbs = 38 kg 570 mg = 57 mL 3.8 mg = 1.3 mL 190 mg = 3.8 mL 0.76 mg = 7.6 mL 88 lbs = 40 kg 600 mg = 60 mL 4 mg = 1.3 mL 200 mg = 4 mL 0.8 mg = 8 mL 40 mg = 0.8 mL 99 lbs = 45 kg 675 mg = 67.5 mL 4.5 mg = 1.5 mL 225 mg = 4.5 mL 0.9 mg = 9 mL 45 mg = 0.9 mL 110-128 lbs / 50-58 kg 750 mg = 75 mL 5 mg = 1.7 mL 250 mg = 5 mL 1 mg = 10 mL 50 mg = 1 mL NWC EMSS 2022 SOP 107 Rev. 3-11-24  FENTANYL ONDANSETRON MIDAZOLAM MIDAZOLAM NALAXONE Peds Doses 1 mcg/kg EPINEPHRINE MAGNESIUM 0.1 mg/kg IVP/IO 0.15 mg/kg 0.2 mg/kg IM/IN 0.1 mg/kg Round up to next (100 mcg / 2 mL) 1 mg/10 mL 25 mg/kg (10 mg/ 2 mL) (4 mg/2 mL) (10 mg/ 2 mL) (2 mg/ 2 mL) closest dose that can (max 100 mcg); 0.01 mg/kg (up to 2 g) repeat 0.5 mcg/kg in 5 Max total 1 mm from prior baseline Men < 40: 2.5 mm STE in V2 or V3; 1 mm in any other lead | Men ≥ 40: 2 mm STE in V2 or V3; 1 mm in any other lead Women: ≥ 1.5 mm STE in V2 or V3, 1 mm in any other lead Posterior STEMI ST depression in leads V1, V2, V3 (V4?) | Tall, broad R waves (dominant in V2) | Upright T waves ST elevation of ≥0.5 mm in any posterior (V7, V8, V9) lead is recommended as the cut-off point. STE ≥1 mm has increased specificity and is recommended as the cut-off point in men aged 3 is specific for MI in patients with LBBB Concordant ST elevation ≥ 1 mm any leads with a positive QRS = 5 points Concordant ST depression ≥ 1 mm in V1, V2, V3 = 3 points Excessive discordant ST elevation ≥ 5 mm in leads with a negative QRS complex = 2 points Smith criteria Replaced the 3rd item in Sgarbossa’s to improve accuracy Discordance should be proportional to the QRS with an ST-QRS ratio no greater than 0.20; anything > 0.25 is STEMI Removed the point system making all 3 criteria equal. The presence of any single criteria is deemed 80% sensitive and 99% specific in identifying acute MI in known LBBB. Rule of appropriate discordance: ST segments in all leads should be discordant to the majority direction of the QRS Concordance: ST segment is in the same direction as the QRS Discordance: ST segment is in the opposite direction to the QRS | Excessive ST discordance – not normal RBBB + Fascicular block Bi-fascicular block – New RBBB w/ Left anterior/Posterior fascicular block Indicates high-grade LAD or RCA occlusion | Decompensates quickly Left Main Disease ST elevation in aVR assoc. w/ ≥ 1 mm ST depression in multiple leads may suggest left main CA stenosis or occlusion NWC EMSS 2022 SOP 112 Rev. 3-11-24  Differential for SOB S&S HF/PE AMI COPD Pneumonia SOB + + + + Cough -/+ - + / early am + Sputum Frothy (pink) - Clear Yellow/green Fever - - - + Sweats + Cold/moist + Cold/moist - + / Hot Chest pain - +/-; heavy/tight - +/-; sharp/pleuritic Varies; Gradually worsening, Chest pain duration - usually > 20 min - then constant Hypertension + Risk + Risk - - Cyanosis +/- +/- + +/- Air entry to lungs Good upper/worse at bases Good Poor Patchy Wheezing +/- +/- Must have air entry to wheeze +/- patchy Crackles + + w/ HF/otherwise clear - isolated to infected lobes ↑ is a risk factor; ↑ is a risk factor; Usually unaffected; BP Usually unaffected ↓ if severe S&S ↓ if severe S&S ↓ if severe S&S Tachycardia +/- +/- + + Heart Failure COPD / Asthma PMH/meds for: CVD, CAD, MI, Wt. gain (tight shoes, belt, watch, rings) PMH/meds for: asthma, COPD, HF, HTN, cardiomyopathy, high Fatigue chronic bronchitis, emphysema, cholesterol; ICD, pacing, DM, renal Crackles or wheezes smoking (steroids, bronchodilators, failure, smoking, alcoholism Capnograph: square waveform anticholinergics) Meds: See list on HF SOP p. 22 12-L abnormal (acute MI, AF, Cough: productive yellow/green Paroxysmal nocturnal dyspnea LVH, ischemia, BBB, “age- S/S respiratory infection: fever, Orthopnea (multiple pillows to sleep) undetermined infarct) chills, rhinorrhea, sore throat Dyspnea on exertion S3 (3rd heart sound, after lub-dub, Exposure to known allergen Cough: (non-productive or best heard at apex) Capnograph: “sharkfin” waveform productive; frothy, clear, white, pink) JVD, pedal edema (RHF) Wheezes (initially expiratory) Non-invasive positive-pressure ventilation (NIPPV) / CPAP – per procedure Primary functions: Provides high flow O2 and constant positive airway pressures throughout inspiration and expiration Improves pulmonary compliance, keeps distal airways open longer to reduce hypercarbia and breath stacking Improves alveoli aeration by recruiting and stabilizing collapsed alveoli: ↑ alveolar pressures reverses microatelectasis ↑ in oxygen driving pressure facilitates diffusion and improves gas exchange Reduces inspiratory work and relieves respiratory muscle fatigue ↑ Intrathoracic pressure reduces venous return (preload), transmural pressure, and afterload; ↑alveolar pressures stop further fluid movement into alveoli. Together, these enhance cardiac function and reduce pulmonary edema. Indications: 18 yrs; alert, can consent, understand & cooperate | intact airway, can clear secretions, good ventilatory effort throughout respiratory cycle | MAP ≥ 60 | Significant distress / Needs NIPPV but NO immediate ADV airway DNR/POLST order (advanced disease/terminal illnesses) declining advanced airway Elderly if O2 via NC or NRM is ineffective | Severely obese w/ hypoxia/hypercarbia (obesity hypovent. syndrome) Preoxygenation prior to DAI | Post-extubation rescue/acute ventilatory failure COPD, asthma | Acute bronchitis; or pneumonia HF/cardiogenic pulmonary edema | Post-submersion congestion / ↑ WOB Inhalation injury/burn | Toxic inhalation (chlorine High SCI with diaphragmatic weakness | Blunt chest wall trauma (flail chest w/o pneumothorax) Absolute Contraindications: 40 yrs in soil 5-60 days Brucellosis No (usually 1-2 m) Weeks to months