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EMERGENCYPROTOCOLS

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SY MP TOMS and PROTOCOLS

Anaphylaxis

Bradycardia

CardiacChestPain

HighSpinalBlock

OpiateRespiratoryDepression

Seizure


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AnaphylaxisSymptoms

Symptomsinclude(byorgansystem):Skin

• Hives,itching,flushing,swellingoflips,throatortongue,cyanosisRespiratory

• Shortnessoffbreath,wheezing,stridor,hoarseness,changeinphonation,difficultyswallowing,cough

Cardiac• CoronaryarteryspasmleadingtoMI,dysrhythmia,andarrestloweringofBPassociatedwithfastHR

• Shockandlossofconsciousness

Other• GI-abdpain,cramping,n/v/d• GU-lossofbladdercontrol• Neuro-headaches• Generalanxietyandfeelingofimpendingdoom


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AnaphylaxisProtocolCallforhelp:

• Callcodeinfacility• Call911ifneeded-useclinicaljudgment• AEDandcrashcartbroughttoroom

Removeanytriggeringagent

Establishairway:• Positionpatientsupine• Openairwaywithhead-tilt,chinlift• Insertairwaydevise(oralornasal)asneeded

Start100%O2viamask(nonrebreather)

Giveepinephrine0.3-0.5mlof1:1000IM• Note---thiscomesinapre-filledsyringereadyforadministrationcalledan

Epipen.o Thisisusefulbecauseitdoesnothavetobedrawnup.o CanbeadministeredASAPthroughclothing.

Checkbreathing:• Watchforchestrise,feelforbreath,listenforbreathsounds• Assistventilationwithambubagifneeded

Ifneeded,basedonclinicaljudgment,establishartificialairwayviaintubationwithETTorLMAbasedonskilllevel

• Verifytubeposition• Chestmovementvs.abddistension• Breathsoundsvs.gastricgurgle• CO2monitorinlinewithtube

Checkcirculation• CheckPulse• Ifnopulse,gotoCardiacArrestProtocol


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AnaphylaxisProtocolcont.Ifpatienthasapulse,placeinTrendelenburgifhypotensiveStartlargeboreIV-bolusIliterNSasneededTitratetostablebloodpressureRepeateqiq5minutesasneededtitratedtoeffectsCheckvitalsignsq2minutes:

• Bloodpressure• Heartrate• Respiratoryrate• O2saturation

Ifdeterioratingorneardeath:• Give10mlorEpi1:10,000IVslowlyover10minutes• Titratetoeffects• Repeatasnecessary

AdministerBenadryl50mgIVorIMStartsecondlargeboreIVandgiveanotherfluidbolusof1000ccofNS

Ranitidine50mgIVor150mgpo

Transporttoemergencydepartment(ED)byEMT's

ModifiedfromImmunologyandAllergyClinicsofNorthAmerica;Vol.25No.2.May2005Rosen,P.Rosen’sEmergencyMedicine.7thedition.Mosby2009


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BradycardiaSymptomsSymptomsinclude:

• Light---headedness• Nausea• Diaphoresis• Tinnitus• Confusion• Weakness• Visualdisturbance• Lossofconsciousness

Mostcommonseenbyspinalinjectionists–vasovagalsyncope

Symptomsusuallyproceededbytriggeringevent(pain)

BradycardiaProtocolAssessappropriatenessforclinicalcondition:

o Heartratetypically<50/minifbradyarrhythmiaIdentifyandtreatunderlyingcause:

o Maintainpatentairway;assistbreathingasnecessaryo Oxygen(ifhypoxemic)o Cardiacmonitortoidentifyrhythm;monitorbloodpressureandoximetryo IVaccesso 12---LeadECGifavailable;don'tdelaytherapy

Persistentbradyarrhythmiacausing:o Hypotension?o Acutelyalteredmentalstatus?o Signsofshock?o Ischemicchestdiscomfort?o Acuteheartfailure?

IfNo:Monitorandobserve


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BradycardiaProtocolcont.IfYes:AtropineAtropineIVDose:Firstdose:0.5mgbolusRepeatevery3-5minutesMaximum:3mg

Ifatropineineffective:TranscutaneouspacingORDopamineinfusionDopamineIVInfusion:2-10mcg/kgperminuteOREpinephrineinfusionEpinephrineIVInfusion:2-10mcgperminute

Consider:ExpertconsultationTransvenouspacing

FromtheAmericanHeartAssociation---May2011:“BradycardiawithaPulseAlgorithm”


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CardiacChestPainSymptomsSymptomsinclude:

• Chestpainradiatingtoleft>rightarm,jaw,epigastriumpaindescribedastightness,squeezingorpressure,

• SOB,dyspneaonexertion,diaphoresis,weakness,lightheadedness,n/v,palpitations

• Lossofconsciousnessandsuddendeathcanoccur

Symptomsinwomenmaybeatypical:• MostcommonsymptomsofMIinwomenareSOB,weaknessandfatigue

• Inwomen,chestpainmaybelesspredictiveofcoronaryischemia

• Atleast25%(range22-64%)ofallmyocardialinfarctionsaresilent(asymptomatic)andarediscoveredlateronEKG,autopsy,etc.

CardiacChestPainProtocolCheckresponsiveness:"Areyouokay?"

• Ifunresponsive,callforhelp• Callcodeinfacility(PICS)• Call911

RecommendreviewingACLSAlgorithmCallforhelp:



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CardiacChestPainProtocolcont.Checkairway:

• Positionpatientsupine• Openairwaywithhead-tilt,chinlift• Insertairwaydeviseisneeded

Checkforbreathing:

• Watchforchestrise,feelforbreath,listenforbreathsounds

Administer100%oxygenviamaskCheckcirculation:• Checkpulse• Ifnopulse,startchestcompressionsat100/minuteuntilAEDarrives• WhenAEDarrives,attachandfollowinstructions

Ifstillnopulse,proceedtoCardiacArrestProtocolIfpatienthaspulse:• Administeraspirin325mgpo,chewedorsuppository• AdministernitroglycerineifSBP>90o Give0.4mgsublingualq5minuteso Repeatadministrationtwotimes

• Start20gIV

o Administermorphine2-5mgIVq5-30minutesasnecessaryifnopainrelieffromnitroglycerineadministeredthreetimes

• Checkvitalsignsq2minuteso bloodpressureo heartrateo respiratoryrateo oxygensaturation

• Monitorforrespiratorydepression,hypotensionandlethargy

• TransporttoEDviaEMT’s


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HighSpinalBlockSymptomsSymptomsinclude:• Respiratory

o Difficultybreathingorapneao Difficultyspeaking,cougho ReducedO2saturation,respiratoryarrest

• Cardiaco Hypotensiono Bradycardiao Cardiacarrest(asystole)

• Neurologicalo Anxietyo Paralysisofupper/lowerextremityo Highsensorylevelo Lossofconsciousness

• Othero GU-lossofbladdercontrol

HighSpinalBlockProtocolCallforhelp:


Checkairway:• Positionpatientsupine• Openairwaywithhead-tilt,chinlift• Insertairwaydeviceasneeded


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HighSpinalBlockProtocolcont.Checkforbreathing:

• Watchforchestrise,feelforbreath,listenforbreathsoundsAdminister100%oxygenviamaskBepreparedtoassistrespirationswithanambubagifshowingsignsofpoorrespiratoryeffort,whispering,paradoxylrespirations,oranxiety

Ifapneic,decreasingLOCorrespirations<6/min,and/orsat<90%on100%oxygen:

• PrepareforintubationIfneeded,basedonclinicaljudgment,establishairwayviaintubationwithETTorLMAbasedonskilllevel

• Verifytubeposition• Chestmovementvs.abddistension• Breathsoundsvs.gastricgurgle• CO2monitorinlinewithtube

Checkcirculation:• Checkpulse• Ifnopulse,gotoCardiacArrestProtocol

ModifiedfromWorldAnesthesia.UpdateinAnesthesia.Issue14Article14.CaseReport-TotalSpinalAnesthesiaDijkemaL.,HaismaH.DepartmentofAnesthesiology.UniversityHospitalGroningen.TheNetherlands


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OpiateRespiratoryDepressionSymptoms

Symptomsinclude:• Sedation• Pupillaryconstriction• Hypoxia• Slowingorcessationofrespiration

OpiateRespiratoryDepressionProtocol

Checkresponsiveness-"Areyouokay?"Ifnoresponse:

• Callcodeinfacility• Call911ifneeded---useclinicaljudgment• AEDandcrashcartbroughttoroom

Ifunresponsive---checkairway:• Positionpatientsupine• Openairwaywithhead-tilt,chinlift• Insertairwaydeviseasneeded

Checkforbreathing:• Watchforchestrise,feelforbreath,listenforbreathsounds

Ifbreathing:

• Administer100%OxygenviamaskandmonitorO2saturationviapulseoxIfpatientissnoring,insertnasalairwayandassistwithbreathingwithambubagasnecessaryIfrespirations<6/min,and/orsat<90%on100%oxygen:

• Insertoral/nasalairwayastolerated• Assistventilationwithambubag/mask

EstablishairwayviaintubationwithETTorLMAbasedonskilllevel• Verifytubeposition• Chestmovementvs.abddistension• Breathsoundsvs.gastricgurgle• CO2monitorinlinewithtube


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OpiateRespiratoryDepressionProtocolcont.Start20gIV

CheckvitalssignsandO2satq2minutesCirculation

Checkpulse:• Ifnopulse,gotocardiacarrestprotocol• WhenAEDarrives,attachandfollowinstructions

ConsideruseofNarcan:

o Note:Narcanmustbeusedwithextremecautioninpatientstakingopioidsonaroutineorchronicbasis

IfthedecisionismadetoadministerNarcan:• Dilute1ml(0.4mg/ml)in9mlofsterilesalineandgive1-2mlIVq2-5xminutes• Titrateun=lsaturation>90%onroomair

Oncepatientisrevived,mix4vialsNarcanin1000mlofsalineandrunIVat50-200ml/hr-titratetoeffectIfpatientshowssignsofagitation,sniffling,orothersignsofwithdrawal,decreaseinfusionrateContinuetomonitorvitalsignsq2minutesTransporttoEDincareofEMT’s


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SeizureSymptomsSymptomsinclude:

o Suddeninvoluntarycontractionofmusclesandlossofconsciousness

SeizureProtocolsCheckresponsiveness-"Areyouokay?"Ifunresponsive,callforhelp

• Callcodeinfacility• Call911

HaveAEDbroughttoroomandattachtopatient

ASAPcheckairway:• Positionpatientleftlateraldecubitus• Openairwaywithheadtilt---chinlift• Removedenturesifpresent• Insertnasopharyngealairwayifobstructionnoisesheard

Checkforbreathing:• Watchforchestrise,feelforbreath,listenforbreathsounds

o Ifbreathing-administer100%oxygenviafacemasko Ifnotbreathing-gotorespiratoryarrestprotocol

Checkcirculation:• Checkpulse• Ifabsent,proceedtoCardiacArrestProtocol

ConsiderpossibilityofreactiveseizureMostcommoncauseishypoglycemia


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SeizureProtocolscont.

StartIVandadministerMidazolam0.2mg/kgIVbolus,which,in75kg(165lb.)individual=15mg

o Note-maybegivenintranasallyatidenticaldoseMonitorlevelofconsciousness,oxygensaturationandvitalsignsevery2minutesBepreparedtomanageairwayandbreathingafteradministrationofVersedIfbreathing:

• Administer100%oxygenviamaskandmonitorO2saturationviapulseoxIfpatientissnoring,insertnasalairwayandassistwithbreathingwithambubagasnecessary

Ifrespirations<6/min,and/orsat<90%on100%oxygen:• Insertoralornasalairwayastolerated• Assistventilationwithambubag/mask

EstablishairwayviaintubationwithETTorLMAbasedonskilllevel• Verifytubeposition• Chestmovementvs.abddistension• Breathsoundsvs.gastricgurgle• CO2monitorinlinewithtube

TransporttoEDincareofEMT’s

ModifiedfromMARX:Rosen'sEmergencyMedicine:ConceptsandClinicalPractice,7thEd.

Copyright2009;Duviver,E.Pollack,C.Chapter100-SeizuresMosby


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AdditionalResourcesACLSAlgorithm1. Checkresponsiveness:"Areyouokay?"

• Ifunresponsive,callforhelp• Callcodeinfacility• Call911

2. StartCPR• GiveOxygen• Attachmonitor/defibrillator

Rhythmshockable?

Yes?Gotostep3

No?Gotostep10


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6. Shock

7. CPR2min• Epinephrineevery3-5min• Consideradvancedairwaycapnography

Rhythmshockable?

Yes?Gotostep8

No?Gotostep13


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10. Asystole/PEA

11. CPR2min• IV/IOaccess• Epinephrineevery3-5min• Consideradvancedairway,capnography

Rhythmshockable?

Yes?Gotostep6orstep8

No?Gotostep12


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12. CPR2min• Treatreversiblecauses

Rhythmshockable?

Yes?Gotostep6orstep8

No?Gotostep13

13. Ifnosignsofreturnofspontaneouscirculation(ROSC),gotostep11orstep12

IfROSC,followPost-CardiacArrestCare


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ReturnofSpontaneousCirculation(ROSC)• Pulseandbloodpressure

• AbruptsustainedincreaseinPETCO2(typically~40mmHg)

• Spontaneousarterialpressurewaveswithintra-arterialmonitoring

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