CLINICIAN’S POCKET REFERENCE - PART 7 pot

sta-Secondary Survey: Uses advanced medical techniques • Airway: Assess and manage with airway device eg, endotracheal intubation, etc.. ACLS protocols incorporat-ing all these emergency

TABLE 20–9

(Continued)

(CcO2− CvO 2)

Abbreviations: RAP = right atrial pressures; CVP = central venous pressure; RVP = right ventricular pressure; PAS = pulmonary artery systolic; PAD = pulmonaryartery diastolic; PCWP = pulmonary capillary wedge pressure; CO = cardiac output; CI = cadiac input; MAP = mean arterial pressure; MPAP = mean pul-monary artery pressure; SVR = systemic vascular resistance; PVR = pulmonary vascular resistance; ICP = intracranial pressure; CPP = cerebral perfusion pres-sure; BSA = body surface area; DBP = diastolic blood pressure; SBP = systolic blood pressure; FiO2= inhaled O2; Hgb = hemoglobin; SaO2= arterial oxygen,SvO2= mixed venous oxygen saturation; Qs = volume of shunted blood (ie, blood shunted past nonventilated alveoli, not participating in gas exchange); Qt =total cardiac output; CCO2= O2content of alveolar-capillary blood; CVO2= mixed venous O2content of pulmonary artery blood

Guidelines for Adult Critical Care Drug Infusions*

(Continued)

(Final Concentration)

Initially 2 mg/min

20 µg/min = 3

10 µg/min = 1.5

(Continued)

(Final Concentration)

Abbreviation: LD = loading dose; MD = maintenance dose; BP = blood pressure; PSS = physiologic saline solution; D5W = dextrose 5% in water

*These agents must be administered in the appropriately monitored clinical setting

Source: Reprinted, with permission, from Thomas Jefferson University Pharmacy and Therapeutic Committee, Philadelphia, PA.

CARDIOPULMONARY RESUSCITATION

Emergency cardiac care guidelines from the American Heart Association now recommendthat health care providers have the following items readily available: gloves, a barrier device

or bag mask, and an automated defibrillator to handle cardiac emergencies In

cardiopul-monary resuscitation, remember there are now two sets of ABCDs:

Primary Survey

• Airway: Assess and manage noninvasively.

• Breathing: Use positive pressure ventilations.

• Circulation: Perform chest compressions as needed.

• Defibrillation: Assess for VT/VF and defibrillate using an AED These are also

called PADs and are becoming widely available in public areas such as airports, diums, health clubs, and shopping malls

sta-Secondary Survey: Uses advanced medical techniques

• Airway: Assess and manage with airway device (eg, endotracheal intubation, etc).

• Breathing: Verify tube function and placement, use positive pressure ventilation

sys-tem through tube

• Circulation: Start IV, attach ECG, use rhythm-based ACLS medications.

• Differential Diagnosis: Search for, find, and treat problems according to AHA

algo-rithms presented in this chapter

Advanced Cardiac Life Support

and Emergency Cardiac Care*

Advanced Cardiac Life Support

Drugs

Electrical Defibrillation and CardioversionOther Common Emergencies

* The section on basis CPR and ACLS are based on guidelines from the American Heart Association and

the International Liaison Committee on Resuscitation [Circulation 2000;102 (Sup 1)] and the Guidelines

2000 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care by the American HeartAssocation in Collaboration with the International Liaison Committee on Resuscitation (ILCOR)

Copyright 2002 The McGraw-Hill Companies, Inc Click Here for Terms of Use

down Protect the neck.

2. Kneel at the level of the victim’s shoulder Open the airway (head-tilt, chin-lift,),

deter-mine breathlessness (“look [chest movement], listen [for air escaping], feel [for air

movement]”) for no more than 10 s In the unresponsive victim with spontaneous ration, place the victim in the recovery position Jaw thrust maneuver recommended asalternative for health care providers especially if neck injury is suspected If the victim

respi-is breathing, place in the RECOVERY POSITION (see page 449).

3. If not breathing, give patient two slow ventilations (2 s/inspiration) while maintainingairway Use pocket mask or bag mask Volume should be between 0.8–1.2 L A barrierdevice (face shield or mask with one-way valve) is recommended if mouth-to-mouth ormouth-to-nose contact is necessary Ventilate 10–12 breaths/min If unable to ventilate,

reposition head and try again If unsuccessful, perform the FOREIGN BODY STRUCTION AIRWAY SEQUENCE (see page 448).

OB-4. Check for circulation (breathing, coughing, movement) Palpate the carotid artery nomore than 10 s to determine lack of a pulse If pulse is present, perform rescue breath-ing: 1 ventilation every 5 s (10–12 ventilation/min)

5. If no pulse, use four cycles of 15 compressions and two ventilations (compression rate100/min, two ventilations 1.5–2 s each) Depth of compression 1.5–2 in or slightlygreater to generate carotid pulse Apply compressions to lower half of sternum usingthe heels of both hands placed on top of each other

6. After the four cycles (approximately 1 min of CPR), pause and check for return pulseand spontaneous respirations

7. If no pulse or respiration, resume cycles with two ventilations, then compressions, asnoted earlier

8. Incorporate appropriate ACLS management guidelines

Two-Rescuer Adult CPR

For laypersons

1. Second rescuer identifies him or herself Verify that EMS has been notified If so, ond rescuer gets into position opposite first rescuer If EMS not notified, the secondrescuer does so before assisting first rescuer

sec-2. First rescuer continues CPR

3. If and when first rescuer tires, second rescuer takes over one-person CPR as described

in the preceding section

For health care professionals

1. Sequence to continue from one-rescuer CPR as mentioned in previous section Secondrescuer identifies him or herself and gets into position for compressions

2. First rescuer completes compression and ventilation cycle (15 compression and twoventilations)

3. First rescuer then checks for spontaneous pulse and breathing, states: “No tinue CPR,” then ventilate once (1.5–2 s)

pulse con-4. Second rescuer resumes compressions at same rate of 80–100/min.(“1 & 2 & 3 & 4 & 5

& pause,” ventilate) Ratio of five compressions to one breath If airway is protected, donot pause for ventilations

5. When ready to switch, rescuer doing compressions says “switch & 2 & 3 & 4 & 5 &.”

6. Both rescuers change position simultaneously immediately after ventilation

7. Rescuer who will perform ventilations opens airway and performs a 5-s pulse check

21

9. In patient with unprotected airway, cricoid pressure may be applied (Sellick’s ver) by a third rescuer (if health care professional) to help limit gastric distention.

place in RECOVERY POSITION (see page 449).

3. If victim not breathing, give two ventilations (1–1.5 s) If unable to ventilate, perform

the FOREIGN BODY OBSTRUCTED AIRWAY SEQUENCE (see page 448).

4. Check for circulation (breathing, coughing, movement) Palpate the carotid artery for

no more than 10 s to determine presence of a pulse If pulse is present, perform rescuebreathing using pocket mask or bag-mask device (20 breaths/min)

5. If no pulse, or if pulse is <60 bpm and perfusion is poor, begin cardiac compressions atfive compressions to one ventilation at rate of 100/min Depth of compressions lessthan for an adult (1–1.5 in or one third to one half the depth of chest).Use the heel ofone hand at the lower half of the sternum Pause compressions for ventilations until pa-tient is intubated

6. Check for return of pulse and spontaneous breathing after 20 cycles (approximately

1 min)

7. Resume cycles with one ventilation (1–1.5 s each), then resume compressions

Infant CPR

(Victim’s age, ≤1 y)

1. Determine unresponsiveness, and shout for help Activate EMS system (call code or 911)

2. Open airway (head-tilt, chin-lift) Do not hyperextend head; however, create adequatehead-tilt to accomplish chest rise with breath If neck trauma suspected, use jaw thrust

If victim is breathing, place in the RECOVERY POSITION (see page 449).

3. If patient is not breathing, give two ventilations (1–1.5 s) using pocket mask or

bag-mask device If unable to ventilate, perform the FOREIGN BODY OBSTRUCTED AIRWAY SEQUENCE using back blows and chest thrusts as noted on page 448.

4. Check for circulation (breathing, coughing, movement) Palpate the femoral or brachialartery for no more than 10 s to determine presence of a pulse If pulse is present, con-tinue rescue breathing (20 breaths/min)

5. If no pulse or if pulse is <60 bpm and perfusion is poor, begin cardiac compressions.Draw an imaginary line between the nipples and identify where this line crosses thesternum (intermammary line) The site of compression is one finger breadth below thisintersection Use a compression depth of ¹₂–1 in., using the middle and ring fingers.Use five compressions to one ventilation (rate of compression is 100/min or 120 minfor newborns)

6. Use the mnemonic: (“1 & 2 & 3 & 4 & 5 & pause, head-tilt, chin-lift, ventilate−continue compressions”) When patient is intubated, no need to pause

7. Check for return of pulse and spontaneous breathing after 20 cycles (1 min)

Neonatal CPR

1. The newborn should be dried, placed head down, gently suctioned and stimulated

2. Supplemental oxygen is useful If baby is not breathing, ventilate 40–60 breaths/min

21

120/min Wrap your hands around infant’s chest and compress ¹₂–³₄ in with thumbsside by side at the midsternum.

4. The compression/ventilation ratio is 3:1 for intubated newborn with two rescuers continue compressions when rate reaches 80 bpm or greater

Dis-Foreign Body Obstructed Airway Sequence

Adult ( ≥8) and Child (1–8 y)

A Conscious victim can cough, speak, breath Do not interfere and reassure patient.

Stand by and allow patient to clear partial obstruction

B. Conscious victim cannot cough, speak, breath.

1. Ask “Are you choking” or “Can you speak?” Observe for “universal distress nal” for choking (hands clutched at neck)

sig-2. Give abdominal thrusts/Heimlich maneuver Stand behind victim Using armswrapped around victim, place thumb side of fist above umbilicus but belowxiphoid Give up to five subdiaphragmatic thrusts (Heimlich maneuver)

3. Reassess victim’s status, repeat Heimlich maneuvers as needed If not improved

by 1 min, activate EMS

C Victim becomes unconscious.

1. Place in supine (face up) position Activate EMS or if second rescuer becomesavailable have that person activate EMS

2. Open airway with tongue-jaw lift; finger sweep to clear airway, open airway(head-tilt, chin-lift)

3. Give five abdominal thrusts/Heimlich maneuver astride victim

D Victim found unconscious: Cause unknown

1. Determine unresponsiveness, call for help (activate EMS)

2. Open airway (head-tilt, chin-lift), determine breathlessness (look, listen, feel)

3. Attempt to ventilate If unsuccessful, reposition head and reattempt

4. If unsuccessful:

a. Perform up to five Heimlich maneuvers astride victim

b. Open mouth (tongue-jaw lift); finger sweep; open airway (head-tilt, chin-lift)

5. Attempt to ventilate, if unsuccessful, repeat sequence until ventilations are tive

effec-Infant

(Victim’s age, <1 y)

Victim conscious

1. Verify airway obstruction (ineffective cough, no strong cry)

2. Hold child with head lower than body, give five back blows or five gentle abdominalthrusts Repeat until victim becomes responsive

Victim becomes unconscious

1. If second rescuer is available, have that person activate EMS

2. Open airway with tongue-jaw lift, remove foreign body if visualized Attempt to late

venti-3. If still obstructed, reposition head and attempt to ventilate Give five back blows andfive abdominal thrusts Repeat step 2 until ventilation is effective

21

Recovery Position

Place an unconscious person who is still breathing and who has not suffered a traumaticneck injury in this position

1. Kneel alongside the victim and straighten the legs

2. Place victim’s arm that is closest to you in the “waving goodbye” position and place theother arm across the victim’s chest

3. Grasp the far side leg above the knee and pull the thigh up toward the body With theother hand, grasp the shoulder on the same side as the thigh

4. Gently roll the patient toward you Adjust the leg you are holding until both the thighand knee are at right angles to the body Tilt the patient’s head back and use the pa-tient’s uppermost hand to support the head and maintain a head-tilt position

5. Continue to monitor for breathing, and call for EMS

6. If patient stops breathing, roll on back and follow basic CPR guidelines

ADVANCED CARDIAC LIFE SUPPORT AND EMERGENCY

CARDIAC CARE

ACLS includes the use of advanced airway management (See Endotracheal Intubation,Chapter 13, page 268), defibrillation, and drugs along with basic CPR Most cardiac arrestsare due to VF and are unwitnessed outside the hospital setting ACLS protocols incorporat-ing all these emergency cardiac care techniques are reviewed in the following algorithms foradults:

•Universal/International ACLS algorithm (Figure 21–1)

•Comprehensive emergency cardiac care algorithm (Figure 21–2)

•Ventricular fibrillation and pulseless VT algorithm (Figure 21–3)

•Pulseless electrical activity algorithm (Figure 21–4)

•Asystole: The silent heart algorithm (Figure 21–5)

•Bradycardia algorithm (Figure 21–6)

•Tachycardia overview algorithm (Figure 21–7)

•Narrow complex SVT algorithm (Figure 21–8)

•Stable VT algorithm (Figure 21–9)

•Acute coronary syndromes algorithm (Figure 21–10)

•Acute pulmonary edema, hypotension, and shock (Figure 21–11)

Advanced Cardiac Life Support Drugs

The most commonly used agents are listed on the inside covers for quick reference

ACE Inhibitors

INDICATIONS : These agents improve the outcome in post-MI patients.

•Enalapril (Enalaprilat IV)

SUPPLIED : Tabs 2.5, 5, 10, 20 mg; IV 1.25 mg/mL (1- and 2-mL vial)

DOSAGE : 2.5 mg PO single dose, increase to 20 mg PO bid; 1.25 mg IV over 5 min, then

• Hydrogen ion — acidosis

• Hyper-/hypokalemia, other metabolic

• Hypothermia

• “Tablets” (drug OD, accidents)

• Tamponade, cardiac

• Tension pneumothorax

• Thrombosis, coronary (ACS)

• Thrombosis, pulmonary (embolism)

During CPR

• Check electrode/paddle positions and contact

• Attempt to place, confirm, secure airway

• Attempt and verify IV access

• Patients with VF/VT refractory to initial shocks:

— Epinephrine 1 mg IV, every 3 to 5 minutes

or

— Vasopressin 40 U IV, single dose, 1 time only

• Patients with non-VF/VT rhythms:

— Epinephrine 1 mg IV, every 3 to 5 minutes

• Consider: buffers, antiarrhythmics, pacing

• Search for and correct reversible causes

1

2

3

4 5,6

7

FIGURE 21–1 Universal/international advanced cardiac life support algorithm.

Abbreviations: VF = ventricular fibrillation; VT = ventricular tachycardia; BLS =

basic life support (Reproduced, with permission, from: Circulation 2000;102

supplement 1, part 6.)

• Activate emergency response system

• Call for defibrillator

• A Assess breathing (open

airway, look, listen, and feel)

Not Breathing

• B Give 2 slow breaths

• C Assess pulse, if no pulse

1 minute

Secondary ABCD Survey

• Airway: attempt to place airway device

• Breathing: confirm and secure airway device,

ventilation, oxygenation

• Circulation: gain intravenous access; give adrenergic

agent; consider antiarrhythmics, buffer agents, pacing

• Differential Diagnosis: search for and treat reversible

causes

FIGURE 21–2 Comprehensive emergency cardiac care (ECC) algorithm

Abbrevi-ations: VF = ventricular fibrillation; VT = ventricular tachycardia; BLS = basic life

sup-port; PEA = pulseless electrical activity (Reproduced, with permission, from:

Circulation 2000;102 supplement 1, part 6.)

Primary ABCD Survey

Focus: basic CPR and defibrillation

• Check responsiveness

• Activate emergency response system

• Call for defibrillator

A Airway: open the airway

B Breathing: provide positive-pressure ventilations

C Circulation: give chest compressions

D Defibrillation: assess for and shock VF/pulseless VT, up to 3 times

(200 J, 200 to 300 J, 360 J, or equivalent biphasic) if necessary

Rhythm after first 3 shocks?

Persistent or recurrent VF/VT

Secondary ABCD Survey

Focus: more advanced assessments and treatments

A Airway: place airway device as soon as possible

B Breathing: confirm airway device placement by exam plus confirmation device

B Breathing: secure airway device; purpose-made tube holders preferred

B Breathing: confirm effective oxygenation and ventilation

C Circulation: establish IV access

C Circulation: identify rhythm monitor

C Circulation: administer drug appropriate for rhythm and condition

D Differential Diagnosis: search for and treat identified reversible causes

• Epinephrine 1 mg IV push, repeat every 3 to 5 minutes

or

• Vasopressin 40 U IV, single dose, 1 time only

Resume attempts to defibrillate

1 360 J (or equivalent biphasic) within 30 to 60 seconds

Consider antiarrhythmics:

amiodarone (llb), lidocaine (Indeterminate), magnesium (llb if hypomagnesemic state), procainamide (llb for intermittent/recurrent VF/VT).

FIGURE 21–3 Ventricular fibrillation and pulseless ventricular tachycardia

algo-rithm Abbreviations: VF = ventricular fibrillation; VT = ventricular tachycardia.

(Reproduced, with permission, from: Circulation 2000;102 supplement 1, part 6.)

Primary ABCD Survey

Focus: basic CPR and defibrillation

• Check responsiveness

• Activate emergency response system

• Call for defibrillator

A Airway: open the airway

B Breathing: provide positive-pressure ventilations

C Circulation: give chest compressions

D Defibrillation: assess for and shock VF/pulseless VT

Secondary ABCD Survey

Focus: more advanced assessments and treatments

A Airway: place airway device as soon as possible

B Breathing: confirm airway device placement by exam plus confirmation device

B Breathing: secure airway device; purpose-made tube holders preferred

B Breathing: confirm effective oxygenation and ventilation

C Circulation: establish IV access

C Circulation: identify rhythm monitor

C Circulation: administer drugs appropriate for rhythm and condition

C Circulation: assess for occult blood flow (“pseudo-EMT”)

D Differential Diagnosis: search for and treat identified reversible causes

Pulseless Electrical Activity

(PEA = rhythm on monitor, without detectable pulse)

Review for most frequent causes

• Thrombosis, coronary (ACS)

• Thrombosis, pulmonary (embolism)

Epinephrine 1 mg IV push,

repeat every 3 to 5 minutes

Atropine 1 mg IV (if PEA rate is slow),

repeat every 3 to 5 minutes as needed, to a total dose of 0.04 mg/kg

1

2

3

FIGURE 21–4 Pulseless electrical activity algorithm Abbreviations: VF =

ventricu-lar fibrillation; VT = ventricuventricu-lar tachycardia; EMT = emergency medical treatment;ACS = acute coronary syndrome; PEA = pulseless electrical activity (Reproduced,

with permission, from: Circulation 2000;102 supplement 1, part 6.)

Primary ABCD Survey

Focus: basic CPR and defibrillation

• Check responsiveness

• Activate emergency response system

• Call for defibrillator

A Airway: open the airway

B Breathing: provide positive-pressure ventilations

C Circulation: give chest compressions

C Confirm true asystole

D Defibrillation: assess for VF/pulseless VT; shock if indicated

Rapid scene survey: any evidence personnel should not attempt resuscitation?

Asystole

Secondary ABCD Survey

Focus: more advanced assessments and treatments

A Airway: place airway device as soon as possible

B Breathing: confirm airway device placement by exam plus confirmation device

B Breathing: secure airway device; purpose-made tube holders preferred

B Breathing: confirm effective oxygenation and ventilation

C Circulation: confirm true asystole

C Circulation: establish IV access

C Circulation: identify rhythm monitor

C Circulation: give medications appropriate for rhythm and condition

D Differential Diagnosis: search for and treat identified reversible causes

Withhold or cease resuscitation efforts?

• Consider quality of resuscitation?

• Atypical clinical features present?

• Support for cease-efforts protocols in place?

FIGURE 21–5 Asystole: the silent heart algorithm Abbreviations: VF = ventricular

fibrillation; VT = ventricular tachycardia (Reproduced with permission from

Circula-tion 2000;102 supplement 1, part 6)

Bradycardia

• Slow (absolute bradycardia = rate <60 bpm)

or

• Relatively slow (rate less than expected

relative to underlying condition or cause)

Primary ABCD Survey

• Assess ABCs

• Secure airway noninvasively

• Ensure monitor/defibrillator is available

Secondary ABCD Survey

• Assess secondary ABCs (invasive airway management needed?)

• Oxygen–IV access–monitor–fluids

• Vital signs, pulse oximeter, monitor BP

• Obtain and review 12-lead ECG

• Obtain and review portable chest x-ray

• Problem-focused history

• Problem-focused physical examination

• Consider causes (differential diagnoses)

Serious signs or symptoms?

Due to the bradycardia?

• Transcutaneous pacing if available

• Dopamine 5 to 20 g/kg per minute

• Epinephrine 2 to 10 g/min

7

• Prepare for transvenous pacer

• If symptoms develop, use transcutaneous pacemaker until transvenous pacer placed

FIGURE 21–6 Bradycardia algorithm Abbreviations: BP = blood pressure; ECG =

electrocardiogram; AV = atrioventricular (Reproduced, with permission, from:

Circu-lation 2000;102 supplement 1, part 6.)

• Is patient stable or unstable?

• Art there serious signs or symptoms?

• Are signs and symptoms due to tachycardia?

Stable patient: no serious signs or symptoms

• Initial assessment identifies 1 of 4 types of

tachycardias

Unstable patient: serious signs or symptoms

• Establish rapid heart rate as cause of signs and symptoms

• Rate related signs and symptoms occur at many rates, seldom <150 bpm

• Prepare for immediate cardioversion

(see page 468)

1 Atrial fibrillation

Atrial flutter

2 Narrow-complex tachycardias

3 Stable wide-complex tachycardia: unknown type

4 Stable monomorphic VT

and/or polymorphic VT

Evaluation focus, 4 clinical

features:

1 Patient clinically unstable?

2 Cardiac function impaired?

3 WPW present?

4 Duration <48 or >48 hours?

Attempt to establish a specific diagnosis

2 Control the rate

3 Convert the rhythm

4 Provide anticoagulation

Diagnostic efforts yield

• Ectopic atrial tachycardia

• Multifocal atrial tachycardia

• Paroxysmal supraventricular tachycardia (PSVT)

Confirmed stable VT

Treatment of stable monomorphic and polymorphic VT

(See stable VT: monomorphic and polymorphic algorithm)

Preserved cardiac function

FIGURE 21–7 Tachycardia overview algorithm Abbreviations: VF = ventricular

fibrillation; ECG = electrocardiogram; PSVT = paroxysmal supraventricular

tachycar-dia; SVT = supraventricular tachycardia (Reproduced, with permission, from:

Circu-lation 2000;102 supplement 1, part 6.)

FIGURE 21–8 Narrow complex SVT algorithm Abbreviations: EF = ejection

frac-tion; CHF = congestive heart failure (Reproduced, with permission, from: Circulation

2000;102 supplement 1, part 6.)

Polymorphic VT

• Is QT baseline interval prolonged?

Normal function Poor ejection fraction

Normal baseline

QT interval

Prolonged baseline

QT interval (suggests torsades)

Medications: any one

Long baseline QT interval

• Correct abnormal electrolytes

Medications: any one

• Aspirin

• Other therapy as appropriate

• Patients with positive serum markers, ECG changes, or functional study: manage as high risk

Assess the initial ECG

The 12-lead ECG is central to triage of ACS in the Emergency Department.

Classify patients as being in 1 of 3 syndromes within 10 minutes of arrival.

ST-segment elevation

or new LBBB

ST-segment depression/

dynamic T-wave inversion:

strongly suspicious for ischemia

Nondiagnostic

or normal ECG

• ST elevation ≥1 mm in 2 or

more contiguous leads

• New or presumably new

• Dynamic ST-T changes with pain

• ST depression 0.5 to 1.0 mm

• T-wave inversion or flattening in leads with dominant R waves

• Normal ECG

• >90% of patients with

type chest pain and ST-segment

elevation will develop new

Q waves or positive serum

markers for AMI.

• Patients with hyperacute

T waves benefit when AMI

diagnosis is certain Repeat

ECG may be helpful.

• Patients with ST depression in

early precordial leads who have

posterior MI benefit when AMI

diagnosis is certain.

High-risk subgroup with increased mortality:

• Persistent symptoms, recurrent ischemia

• Diffuse or widespread ECG abnormalities

• Depressed LV function

• Congestive heart failure

• Serum marker release:

FIGURE 21–10 Acute coronary syndromes algorithm Abbreviations: ECG =

elec-trocardiogram; LBBB = left bundle branch block; BBB = bundle branch block; AMI =acute myocardial infarction; MI = myocardial infarction; LV = left ventricle; CK-MB+

= positive for myocardial muscle creatine kinase isoenzyme (Reproduced, with

per-mission, from: Circulation 2000;102 supplement 1, part 6.)

Clinical signs: Shock, hypoperfusion,

congestive heart failure, acute pulmonary edema

Most likely problem?

Acute pulmonary edema Volume problem Pump problem Rate problem

1st — Acute pulmonary edema

of shock

Systolic BP

70 to 100 mm Hg Signs/symptoms

• Dopamine if BP > 70 to 100 mm Hg, signs/symptoms of shock

• Dobutamine if BP >100 mm Hg, no signs/symptoms of shock

Further diagnostic/therapeutic considerations

• Pulmonary artery catheter

• Intra-aortic balloon pump

• Angiography for AMI/ischemia

• Additional diagnostic studies

FIGURE 21–11 Acute pulmonary edema, hypotension and shock Abbreviations:

BP = blood pressure; AMI = acute myocardial infarction (Reproduced, with

permis-sion, from: Circulation 2000;102 supplement 1, part 7)

DOSAGE: Adults Put patient in reverse Trendelenburg position before administering dose; initial

6 mg over 1–3 s followed by NS bolus of 20 mL, then elevate extremity Repeat 12 mg in 1–2 min

PRN A third dose of 12 mg in 1–2 min PRN Peds 0.1 mg/kg rapid IV push with continuous ECG

monitoring Follow with >5 mL NS flush May double (0.2 mg/kg for second dose) Max: firstdose: 6 mg; second dose:12 mg; single dose:12 mg

Amiodarone

INDICATIONS : Atrial and ventricular tachyarrhythmias and for rate control of rapid atrial

arrhyth-mias in patients with impaired LV function when digoxin is ineffective

SUPPLIED : 50 mg/mL in 3-mL vial

DOSAGE: Adults Max cumulative dose: 2.2 g IV/24 h Cardiac arrest 300 mg IV push Consider

repeating 150 mg IV push in 3–5 min Wide-complex tachycardia (stable): Rapid inf: 150 mg IV

over 10 min (15 mg/min), every 15 min PRN Slow inf: 360 mg IV over 6 h (1 mg/min)

Mainte-nance inf: 540 mg IV over 18 h (0.5 mg/min) Peds Refractory pulseless VT, VF: 5 mg/kg rapid IV

bolus Perfusing supraventricular and ventricular arrhythmias: Loading dose: 5 mg/kg IV/IO over

20–60 min (repeat, max 15 mg/kg/day)

Amrinone

INDICATIONS : CHF refractory to conventional agents

SUPPLIED : 0.5 mg/mL in 20-mL vial

DOSAGE: Adults 0.75 mg/kg, over 10–15 min (Do NOT mix with dextrose.) Then 5–15 µg/kg/min

titrated to effect Hemodynamic monitoring preferred Peds Loading dose: 0.75–1.0 mg/kg IV over

5 min; may repeat twice (Max: 3 mg/kg) Cont inf: 5–10 µg/kg/min IV

INDICATIONS : First drug for symptomatic bradycardia (but not Mobitz II) Second drug (after

epi-nephrine or vasopressin) for asystole or bradycardic PEA

SUPPLIED : 0.1 mg/mL in 10-mL syringe (total = 1 mg).

DOSAGE: Adults Asystole or PEA: 1 mg IV push Repeat every 3–5 min (if asystole persists) to

0.03–0.04 mg/kg max Bradycardia: 0.5–1.0 mg IV every 3–5 min as needed; max 0.03–

0.04 mg/kg Endotracheal administration: 2–3 mg in 10 mL NS Peds IV administration: 0.02

mg/kg Min single dose: 0.1 mg, max: 0.5 mg Max adolescent single dose: 1.0 mg May double forsecond IV dose Max child total dose: 1.0 mg Max adolescent total dose: 2.0 mg Endotracheal ad-ministration: 0.02 mg/kg (larger doses than IV may be required)

Beta Blockers

INDICATIONS : All patients with suspected MI; may reduce chance of VF and reduce damage.

21

ister along with calcium channel blockers due to risk of hypotension.

DOSAGE: Adults 5 mg slow IV (over 5 min) In 10 min, second dose 5 mg slow IV In 10

min, if tolerated, start 50 mg PO, then 50 mg PO bid

•Propanolol (Inderal)

SUPPLIED : 1.0 mg/mL in 1 amp, 4 mg/mL in 5-mL

DOSAGE: Adults 0.1 mg/kg slow IV push, divided 3 equal doses 2–3 min intervals, max

1 mg/min Repeat after 2 min, PRN

DOSAGE : 10 mg IV push over 1–2 min Repeat or double dose every 10 min (max:

150 mg); or initial bolus, then 2–8 µg/min

Calcium Chloride

INDICATIONS : Known/suspected hyperkalemia, hypocalcemia (eg, multiple transfusions), antidote

for calcium channel blocker overdose, prophylactically before IV calcium channel blockers vent hypotension)

(pre-SUPPLIED : 100 mg/mL in 10-mL vial (total = 1 g; 10% solution)

DOSAGE: Adults 8–16 mg/kg (usually 5–10 mL) IV slow push for hyperkalemia and calcium

channel blocker overdose 2–4 mg/kg (usually 2 mL) IV before IV calcium blockers Peds.

20 mg/kg (0.2–0.25 mL/kg) slow push Repeat PRN

Calcium Gluconate

SUPPLIED : 10% = 100 mg/10 mL = 9 mg/mL Ca

DOSAGE: Peds 60–100 mg/kg (0.6–1.0 mL/kg) IV slow push Repeat for documented conditions

Digibind

Digoxin-specific antibody therapy

INDICATIONS : Digoxin toxicity with uncontrolled life-threatening arrhythmias, shock, CHF;

hyper-kalemia >5 mEq/L with serum dig levels above 10–15 ng/mL

SUPPLIED : 40-mg vial (each vial binds about 0.6 mg digoxin)

DOSAGE: Adults Chronic intoxication: 3–5 vials may be effective Acute overdose: See Chapter

22; based on dose ingested (average dose is 10 vials (400 mg), but may require up to 20 vials (800 mg)

Digoxin

SUPPLIED : 0.15 mg/mL or 0.1 mg/mL in 1- or 2-mL amp

INDICATIONS : Slow ventricular response in AF or atrial flutter Second-line for PSVT

: Adults Loading 10–15 µg/kg Maintenance dose see Chapter 22

21

Diltiazem (Cardizem)

INDICATIONS : Control ventricular rate in AF and atrial flutter Use after adenosine to treat

refrac-tory PSVT in patients with narrow QRS complex and adequate BP

SUPPLIED : 5 mg/mL in 5- or 10-mL vial (total = 25 or 50 mg)

DOSAGE: Adults Acute rate control: 15–20 mg (0.25 mg/kg) IV over 2 min Repeat in 15 min at

20–25 mg (0.35 mg/kg) over 2 min Maintenance: 5–15 mg/h, titrated to heart rate

Dobutamine (Dobutrex)

INDICATIONS : Pump problems with BP 70–100 mm Hg and no signs of shock

SUPPLIED : 12.5 mg/mL in 20-mL vial (total = 250 mg) IV inf: Dilute 250 mg (20 mL) in 250 mL

NS or D5W

DOSAGE: Adults 2–20 µg/kg/min; titrate heart rate not >10% of baseline Hemodynamic

monitor-ing recommended Peds Cont IV inf: Titrate to effect (initial dose 5–10 µg/kg/min) Typical inf

dose: 2–20 µg/kg/min

Dopamine (Intropin)

INDICATIONS : Second line for symptomatic bradycardia Hypotension (BP <70–100 mm Hg) withsigns of symptoms of shock

SUPPLIED: 40 mg/mL or 160 mg/mL IV inf: Mix 400–800 mg in 250 mL NS or D5W

DOSAGE: Adults Titrate to response Low: 1–5 µg/kg/min (“renal doses”) Moderate: 5–

10 µg/kg/min (“cardiac doses”) High: 10–20 µg/kg/min (“vasopressor doses”) Peds Titrate to

ef-fect Initial, 5–10 µg/kg/min; typical: 2–20 µg/kg/min

Epinephrine

INDICATIONS: Cardiac arrest: VF, pulseless VT, asystole, PEA Symptomatic bradycardia: After

atropine and transcutaneous pacing Anaphylaxis, severe allergic reactions: Combine with large

fluid volumes, corticosteroids, antihistamines

SUPPLIED : 1.0 mg/10 mL in preloaded 10-mL syringe (total = 1 mg), 1 mg/mL in glass 1-mL amp

(total = 1 mg)

DOSAGE: Adults Cardiac arrest: IV dose: 1.0 mg IV push, repeat every 3–5 min; doses up to

(0.2 mg/kg) if 1 mg dose fails Inf: 30 mg epinephrine (30 mL of 1:1000 solution) to 250 mL NS or

D5W, run at 100 mL/h, titrate Endotracheal: 2.0–2.5 mg in 20 mL NS Profound

pulseless arrest: First dose: 0.1 mg/kg IV (0.1 mL/kg of 1:10,000 “standard concentration”)

Sec-ond and subsequent doses: 0.1 mg/kg IV (0.1 mL/kg of 1:1000 “High” concentration Administerevery 3–5 min during arrest; up to 0.2 mg/kg may be effective Endotracheal: 0.1 mg/kg (0.1 mL/kg

of 1:1000 [“high”] concentration) continue q3–5 min of arrest until IV access is achieved; then

begin with first IV dose Symptomatic bradycardia: 0.01 mg/kg IV (0.1 mL/kg of 1:10,000

[“stan-dard”] concentration) Endotracheal doses: 0.1 mg/kg (0.1 mL/kg of 1:1000 [“high”] tion) Cont IV inf: Begin with rapid infusion; then titrate to response Typical inf: 0.1–1.0 µg/kg/min (Higher doses may be effective)

concentra-Flumazenil (Romazicon)

INDICATIONS : Reverse benzodiazepine toxicity (do NOT use in tricyclic overdose or in unknown

poisoning)

SUPPLIED : 0.1 mg/mL in 5- and 10-mL vials

DOSAGE: Adults 0.2 mg IV over 15 s then 0.3 mg IV over 30 s, if no response, give third dose.

Third dose: 0.5 mg IV given over 30 s, repeat once per min until response, or total of 3 mg

1–2 min

Glucagon

INDICATIONS : Reverse effects of calcium channel blocker or beta-blocker

SUPPLIED : 1- and 10-mg vials

DOSAGE: Adults 1–5 mg over 2–5 min

Glucoprotein IIb/IIIa inhibitors

INDICATIONS : Acute coronary syndromes without ST elevation Do NOT use with history of active

bleeding or surgery within 30 d or if platelets <150,000/mm3 Note that optimum dosing and tion not established; check package insert

dura-•Abciximab (ReoPro)

SUPPLIED : 2 mg/mL in 5-mL vial

DOSAGE : ACS with planned PCI within 24 h: 0.25 mg/kg IV bolus up to 1 h before

proce-dure, then 0.125 µg/kg/IV; must use with heparin Platelet recovery within 48 h; redosingmay cause hypersensitivity reaction

•Eptifibatide (Integrilin)

SUPPLIED : 0.75 and 2 mg/mL in 10-mL vial

DOSAGE: ACS: 180 µg/kg IV bolus then 2 µg/kg/min infusion

PCI: 135 µg/kg IV bolus then 0.5 µg/kg/min infusion; repeat bolus in 10 min

•Tirofiban (Aggrastat)

SUPPLIED : 250 µg/mL in 50 mL or premixed 50 µg/mL

DOSAGE: ACS or PCI: 0.4 µg/kg/min IV for 30 min, then 0.1 µg/kg/min inf

Heparin (Unfractionated)

INDICATIONS : Adjuvant therapy in AMI Begin heparin with fibrinolytics.

SUPPLIED : 0.5–1.0 mL amp, vials, and prefilled syringes Multidose vials 1, 2, 5 and 30 mL

Con-centrations range from 1000 to 40,000 IU/mL

DOSAGE: Adults Bolus 60 IU/kg (max bolus: 4000 IU) Continue 12 IU/kg/h (max 1000 IU/h for

patients >70 kg) round to the nearest 50 IU Adjust to maintain PTT 1.5–2.0 × control values for

48 h or until angiography

Heparin (Low Molecular Weight) (Fragmin, Lovenox)

INDICATIONS : ACS with non-Q wave or unstable angina

SUPPLIED : Dalteparin (Fragmin), Enoxaparin (Lovenox)

DOSAGE : 1 mg/kg bid SQ for 2–8 d with aspirin

INDICATIONS : Torsades de pointes unresponsive to magnesium sulfate Temporary control of

bradycardia in heart transplant patients Class IIb at low doses for symptomatic bradycardias

SUPPLIED : 0.1 mg/mL in 1-mL vial IV inf: Mix 1 mg in 250 mL NS or D5W

: Adults 2–10 µg/min Titrate to effect

21

DOSAGE: Adults Cardiac arrest from VF/VT: Initial dose: 1.0–1.5 mg/kg IV For refractory VF

may give additional 0.5–0.75 mg/kg IV push, repeat in 5–10 min, max total dose is 3 mg/kg Asingle dose of 1.5 mg/kg IV in cardiac arrest is acceptable Endotracheal administration: 2–

4 mg/kg Perfusing arrhythmia: For stable VT, wide-complex tachycardia or uncertain type,

signifi-cant ectopy, use as follows: 1.0–1.5 mg/kg IV push Repeat 0.5–0.75 mg/kg every 5–10 min; maxtotal dose, 3 mg/kg Maintenance inf: 1–4 mg/min (30–50 µg/min)

Magnesium Sulfate

INDICATIONS : Cardiac arrest associated with torsades de pointes or suspected hypomagnesemic

state, refractory VF, life-threatening ventricular arrhythmias due to digitalis toxicity, tricyclic dose Consider prophylactic administration in hospitalized patients with AMI

over-SUPPLIED : Amps 2 and 10 mL of 50% MgSO4(total = 1 g and 5 g) 10 mL in preloaded syringe(total = 5 g/10 mL)

DOSAGE: Adults Cardiac arrest: 1–2 g IV push (2–4 mL of a 50% solution) diluted in 10 mL of

D5W AMI: Loading dose of 1–2 g, mixed in 50–100 mL of D5W, over 5–60 min IV Follow with

0.5–1.0 g/h IV for up to 24 h Torsades de pointes: Loading dose of 1–2 g mixed in 50–100 mL of

D5W, over 5–60 min IV Follow with 1–4 g/h IV (titrate dose to control the torsades)

Mannitol

INDICATIONS : Increased intracranial pressure in management of neurologic emergencies

SUPPLIED : 150-, 250-, and 1000-mL IV containers (strengths: 5%, 10%, 15%, 20%, and 25%).

DOSAGE: Adults Administer 0.5–1.0 g/kg over 5–10 min Additional doses of 0.25–2g/kg can be

given every 4–6 h as needed Use in conjugation with oxygenation and ventilation

Morphine Sulfate

INDICATIONS : Chest pain and anxiety associated with AMI or cardiac ischemia, acute cardiogenic

pulmonary edema (if blood pressure is adequate)

DOSAGE: Adults 0.4–2.0 mg IV every 2 min; up to 10 mg over <30 min Peds Bolus IV dose: For

total reversal of narcotic effects (smaller doses may be used if total reversal not required), as

fol-lows: Birth–5 y ( ≤ 10 kg): 0.1 mg/kg ≥5 y (>20 kg): 2.0 mg May be necessary to repeat doses

fre-quently Cont inf: 0.04–0.16 mg/kg/h

Nitroglycerin

INDICATIONS : Chest pain of suspected cardiac origin; unstable angina; complications of AMI,

in-cluding CHF, left ventricular failure; HTN crisis or urgency with chest pain

SUPPLIED: Parenteral: Amps: 5 mg in 10 mL, 8 mg in 10 mL, 10 mg in 10 mL, vials: 25 mg in

5 mL, 50 mg in 10 mL, 100 mg in 10 mL SL tabs: 0.3 and 0.4 mg Aerosol spray: 0.4 mg/dose

DOSAGE: Adults IV bolus: 12.5–25 µg Infuse at 10–20 µg/min Route of choice for emergencies

Use IV sets provided by manufacturer SL route: 0.3–0.4 mg, repeat every 5 min Aerosol spray:

Spray for 0.5–1.0 s at 5-min intervals

Nitroprusside (Sodium Nitroprusside, Nipride)

: HTN crisis, reduce afterload in CHF and acute PE

21

DOSAGE : 0.10 µg/kg/min, titrate up to 5.0 µg/kg/min Use infusion pump; hemodynamic ing for optimal safety

monitor-Norepinephrine

INDICATIONS : Severe cardiogenic shock and significant hypotension Last resort for ischemic heart

disease and shock

SUPPLIED : 1 mg/mL in 4-mL amp Mix 4 mg in 250 mL of D5W or D5NS

DOSAGE: Adults 0.5–1.0 µg/min titrated to 30 µg/min Peds IV inf: Initial 0.1–2 µg/kg/min to

ef-fect Do NOT administer with alkaline solutions

Procainamide (Pronestyl)

INDICATIONS : Recurrent VT not controlled by lidocaine, refractory PSVT, refractory VF/pulseless

VT, stable wide-complex tachycardia of unknown origin, AF with rapid rate in WPW

SUPPLIED : 100 mg/mL in 10-mL vial, 500 mg/mL in 2-mL vial

DOSAGE: Adults Recurrent VF/VT: 20 mg/min IV (max total 17 mg/kg) In urgent situations up to

50 mg/min to a total dose of 17 mg/kg Other indications: 20 mg/min IV until one of the following

occurs: arrhythmia suppression, hypotension, QRS widens by more than 50%, total dose of

17 mg/kg is given Maintenance: 1–4 mg/min

Sodium Bicarbonate

INDICATIONS : Specific indications for bicarbonate use are as follows: Class I (usually indicated) if

known preexisting hyperkalemia Class IIa (accepted, possibly controversial) if known preexistingbicarbonate-responsive acidosis (eg, DKA); tricyclic antidepressant overdose; alkalinize urine inaspirin overdose Class IIb (accepted, but may not help, probably not harmful) if prolonged resusci-tation with effective ventilation; on return of spontaneous circulation after long arrest interval.Class III (harmful) in hypoxic lactic acidosis (eg, cardiac arrest and CPR without intubation)

SUPPLIED : 50-mL syringe (8.4% sodium bicarbonate provides 50 mEq/50 mL)

DOSAGE: Adults IV inf: 1 mEq/kg IV bolus Repeat half this dose every 10 min thereafter If

rapidly available, use ABG analysis to guide therapy

Sodium Bicarbonate (Pediatric)

INDICATIONS : Severe metabolic acidosis (documented or following prolonged arrest) unresponsive

to oxygenation and hyperventilation, hyperkalemia, tricyclic antidepressant toxicity

DOSAGE: Adults 8.4% 1 mEq/mL in 10- or 50-mL syringe, 4.2% 0.5 mEq/mL in 10-mL syringe.

Thrombolytic Agents (Fibrinolytic Agents)

INDICATIONS: AMI in adults: ST-segment elevation of 1 mm or more in at least two contiguous

leads in the setting of AMI Adjuvant therapy: 60–325 mg aspirin chewed as soon as possible.

Begin heparin immediately and continue for 48 h if alteplase is used

•Alteplase, Recombinant

SUPPLIED : Vials 20, 50, and 100 mg, reconstituted with sterile water to 1 mg/mL

DOSAGE: Adults Recommended dose based on patient’s weight, not to exceed 100 mg.

AMI: Accelerated inf: Give 15 mg bolus Then 0.75 mg/kg over next 30 min (not to exceed

50 mg) Then 0.50 mg/kg over next 60 min (not to exceed 35 mg) 3-h inf: 60 mg in first

hour (initial 6–10 mg as a bolus) Then 20 mg/h for 2 additional hours Acute ischemic

stroke: 0.9 mg/kg (max 90 mg) infused over 60 min 10% of total dose as initial IV bolus

over 1 min Give the remaining 90% over the next 60 min

•Streptokinase

SUPPLIED : Reconstitute to 1 mg/mL

: Adults 1.5 million IU in a 1-h infusion

21

•Anistreplase APSAC

SUPPLIED : Reconstitute 30 U in 50 mL water or D5W Use two peripheral IV lines, one clusively for thrombolytic administration

ex-DOSAGE: Adults 30 IU IV over 2–5 min

•Reteplase, recombinant (Retavase)

SUPPLIED : 10-U vials reconstituted with sterile water to 1 U/mL

DOSAGE: Adults 10 U IV bolus over 2 min 30 min later, give second 10 U IV bolus over

2 min NS flush before and after each bolus

Verapamil (Colan, Isoptin)

INDICATIONS : Second line for PSVT with narrow QRS complex and adequate BP

SUPPLIED : 2.5 mg/mL in 2-, 4-, and 5-mL vials (totals = 5, 10, and 12.5 mg)

DOSAGE: Adults 2.5–5.0 mg IV over 1–2 min Repeat 5–10 mg, if needed, in 15–30 min (30 mg

max) Alternative: 5 mg bolus every 15 min to total dose of 30 mg

Electrical Defibrillation and Cardioversion

Although the defibrillator is the basic piece of equipment for both defibrillation and dioversion, they are two distinctly different procedures New devices include shock advisorydefibrillators (automated external defibrillators) The energy level is the watt-second orjoule

car-Standard Defibrillation Procedure (conventional device)

1. This is the primary therapy for VF or pulseless VT Asystole is not now routinely rillated

defib-2. Use paste or pads on skin (see step 3 for location)

3 Shout “Charging defibrillator-stand clear,” synchronization switch off (if on, the

de-fibrillator may not fire) In adults, energy levels begin at 200 J In children, use 2 J/kg

advance to 6 J/kg max

4. Place paddles as directed on the handles: one at the right upper sternum and one at theleft anterior axillary line (apex)

5. Apply paddles with firm pressure (approximately 25 lb)

6. Shout “I am going to shock on three Stand clear!” and make sure no one is touching

the patient or bed including yourself.

7. Shout “Clear,” and visually check for other team members

8. Shout three times “Everybody clear,” and press both paddle buttons simultaneously tofire the unit, and observe for any change in the dysrhythmia

9. Defibrillate up to three times with increasing joules (200, >200–300, >360) If thesefail to convert, continue full output (360 J) for all future shocks If VT recurs, shockagain at last energy level

10 If a patient is HYPOTHERMIC (Core temperature < 30 °C) shock only three times as

in step 8 Resume shocks only after temperature rises above 30 °C

11 If patient has automated implantable defibrillator and device is delivering shocks, wait

60 s for cycle to complete If defibrillation attempted, place paddles several inchesfrom the implanted pacer unit

Automated External Defibrillator (AED)

1. Familiarize yourself with the features of the unit well in advance of using it These

21

lyze” button.

3. If appropriate (VT or VF), the unit charges and the “shock” sign is given

4. Announce “Shock is indicated Stand clear,” and verify that no one is touching tient Depress “shock” button to administer shock

pa-5. Repeat until arrhythmia is cleared (“no shock indicated” signal will flash) In eral, shock in sets of three without interposing CPR After three shocks, do 1 min

1 Consider sedation because most of these patients are conscious Agents can include

diazepam, midazolam with or without a narcotic such as morphine, or fentanyl thesia support is helpful if readily available

Anes-2 Start with lower energy levels than for defibrillation Start at 100 J and increase to

200, 300, and finally 360.

3 Keep the synchronizer switch on (prevents shocking during vulnerable part of QRS

complex when shock may cause VF, so-called R-on-T phenomenon) Observe for themarkers on the R waves indicating that the synch mode is engaged

4. Place paddles, apply pressure, and verify area is cleared as for the defibrillation steps

5. Most defibrillators default back to the unsynchronized mode to allow rapid shock incase of VF Reset synch mode if multiple cardioversions needed

Transcutaneous Pacing

Primarily used for hemodynamically unstable bradycardia External pacemakers can be set

in the asynchronous (nondemand or fixed mode) or demand mode in the range of 30–180bpm with current outputs from 0–200 mA

1. Place electrode pads on chest as per unit’s instructions

2. Turn unit on and set pacer to 80 bpm initially

3. Adjust current upward until capture is achieved (ie, wide QRS after each pacer spike onECG for bradycardia

4. For asystole (not routinely used) begin at full output If capture occurs, decrease tothreshold and increase by 2 mA

OTHER COMMON EMERGENCIES

The following material gives the treatment for other common emergencies Dosages are for

adults unless stated otherwise.

Anaphylaxis

Systolic BP <90 mm Hg

Epinephrine

DOSAGE: Adults IV bolus: 100 µg of 1:10,000 over 5–10 min IV inf: 1–4 µg/min Peds IV inf:

0.1–0.3 µg/kg/min, max 1.5 µg/kg/min

21

Systolic BP >90 mm Hg

•Epinephrine

DOSAGE: 1:1000 soln SQ Adults 0.3–0.5 mL Peds 0.01 mL/kg, max 0.5 mL

Supplemental drugs for anaphylaxis include:

Ipratropium Bromide (nebulized)

DOSAGE: Adults 0.5 mg with first albuterol treatment Peds 250 µg with first albuterol treatment

NOTE : Administer as for mild to moderate cases.

Give early consideration to

DOSAGE : 0.5–2.0 mg IV

N OTE : Administer S-L-O-W-L-Y (may cause seizures if given rapidly) Have cardiac monitor

at-tached and resuscitation equipment at the bedside

Coma

1. Establish/secure airway

2. Protect cervical spine

3. Assess for respiratory failure and shock (ACLS)

4. Supply oxygen, IV access, cardiac monitor, and pulse oximetry

5. Administer 1 amp (50 mL) of D50IV manually; some recommend checking a stat cose first

glu-6. Administer 100 mg thiamine IV

7. Give naloxone (Narcan) (see following section on Narcotics Overdose)

8. Obtain fingerstick glucose, SMA, CBC, urinalysis, and ABG

Dental Emergencies

Not including facial fractures, there are generally two major categories of dental cies: toothaches with associated abscesses and avulsed (knocked-out) teeth Mosttoothaches may be managed with antibiotics (usually penicillin-V 500 mg, q6h) and anal-gesics until proper dental attention can be obtained Fluctuant abscesses may be drained ifconvenient The exception to this rule is submandibular or infraorbital swelling With sub-mandibular infections, Ludwig’s angina may develop, a life-threatening occurrence Thesepatients should be held for observation with special attention to maintaining the airway until

emergen-a dentemergen-al consult cemergen-an be obtemergen-ained Infremergen-aorbitemergen-al infections cemergen-an leemergen-ad to emergen-a cemergen-avernous sinus bosis if allowed to progress

throm-Avulsed teeth may or may not have an associated dentoalveolar fracture The best ment is to reposition the displaced tooth back in the socket within 30 min or as soon as pos-sible If the tooth root is dirty, wash it gently with sterile saline Do not scrub or scrape theroot Get a dental consult to arrange to have the tooth splinted back in the socket

1. Treat only if signs of end organ damage

2. MAP should not be reduced more than 20–25% over 30–60 min

1 Draw a STAT serum glucose Do not wait for result before treating if hypoglycemia

is strongly suspected A finger Dextro stick can usually be quickly checked.

2. Give orange juice with sugar if the patient is awake and alert; if not, give 1 amp of D50

IV (Peds 1 mL/kg).

3. If IV access is not possible, give glucagon 1 mg IM or SC

Narcotics Overdose

Naloxone (Narcan)

DOSAGE: Adults 0.4–0.8 mg IV or IM, repeat as needed (Note: if you suspect the patient is a

nar-cotic addict give 0.4 mg instead and repeat as needed to avoid precipitating severe withdrawal

Peds 0.01–0.02 mg/kg IV or IM, repeat as needed Observe patient for at least 6 h after treatment.

Poisoning

1. Support airway, respiration, and circulation, as needed

2. Determine ingested substance; give specific antidote, if available The following is a

list of some common poisons with their antidotes (Dosages for adults, unless otherwise

specified):

Acetaminophen N-acetylcysteine, 140 mg/kg

Anticholinesterases Atropine 0.5–2 mg IV; may need up to

(organophosphates, physostigmine) 5 mg IV q 15 min if severe, then 70 mg/kg

× 17 more doses; 0.05 mg/kg IV

in children

Benzodiazepines Flumazenil (see page 463)

Beta-blockers Glucagon 0.05 mg/kg IV bolus for BP

<90, then infusion of 75–150 mg/kg/h

Carbon monoxide High-flow oxygen

Calcium channel blockers Calcium chloride 10–20 mL/kg of

1% solution then 20 mg/kg/h

Cyanide Amyl nitrate pearls inhale every 2 min then

sodium nitrite 10 mL 3% IV over 3 min(0.33 mL/kg of 3% solution in children) or sodium thiosulfate 50 mL of 25% solution over 10 min or 1.65 mL/kg in children

Cyclic antidepressants NaHCO33 amps (50 mg/50 mL) in

1 L D5W @ 2–3 mL/kg/h

Methanol, ethylene glycol Loading dose 1 g/kg of a 10% solution slowly

IV, followed by an infusion of 130 mg/kg/h

If patient is on dialysis give 250–300 mg/kg/h

to maintain levels

Opiates, narcotics Naloxone see page 465

Number of vials = Serum digoxin level Patient' s weight (kg)

100

×

21

•Protect airway with an endotracheal tube.

•Lavage with an Ewald tube or 28 French or larger NG tube, if ingestion occurred,

1 h

•Use 300 mL NS boluses at a time through the NG or Ewald tube for adults and

20 mL/kg in children

•Activated charcoal can be added, unless an oral antidote is to be given

•Cathartics (sorbitol or magnesium citrate) promote GI elimination

Conscious Patient

•Activated charcoal 1 g/kg, Contraindicated for iron, lithium, lead, alkali, acid Alsogive 70% sorbitol solution (2 mL/kg body weight) Anyone given sorbitol should bemonitored for hypokalemia and hypomagnesemia

•Attempt to promote excretion through IV hydration

•Alkalinization (0.5–1 mEq/kg/L in IV fluids) for salicylates, barbiturates, tricyclics

Shock

See also Chapter 20, page 431, and this chapter, page 460

Hypovolemic: Initially, use isotonic fluids such as NS or lactated Ringer’s, blood, min, Plasmanate, or hetastarch

albu-Seizures/Status Epilepticus

Status epilepticus refers to >1 min of continuous seizure activity or back-to-back seizureswithout recovery in between

Initial Supportive Care

•Maintain airway with C-spine precautions

•Deliver oxygen by nasal cannula

•Monitor ECG and blood pressure

•Maintain normal temperature

Pharmacologic Therapy

See Table 21–1

•Establish IV

•Administer thiamine 100 mg IV

•Administer 1 amp of D50IV in an adult (2 mL/kg D25in children) unless obviouslyhyperglycemic

•Administer lorazepam or diazepam initially (see Table 21–1) (midazolam 0.2 mg/kg)can be given IM in children if no IV

•If seizures persist, give fosphenytoin or phenytoin (see Table 21–1)

•If seizures persist, administer phenobarbital, paraldehyde

•If still no response, obtain emergency neurosurgical and anesthesiology consultation

21

TABLE 21–1

Drugs for the Emergency Treatment of Seizures

Diazepam (Valium) 0.10–0.20 IV 5–10 mg IV 3–5

(up to 30 mg)Fosphenytoin N/A 20 mg/kg IV 150

Paraldehyde 0.15–0.3 30 mL PR* NA

mL/kg PR*

Phenytoin (Dilantin)† 15 IV Same as for child 50

Phenobarbital‡ 10 IV or IM 120–140 mg IV 100

*When given rectally, mix 2:1 with cottonseed or olive oil

†When given IV, use a maximum dose of 50 mg/min and monitor ECG and vital signsclosely Can cause severe hypotension and bradycardia Mix with NS to prevent precipi-tation

‡Indicated when the patient is allergic to phenytoin Patients may require intubation

This section is a quick reference of commonly used medications with selected key datalisted for each drug Be familiar with all the indications, contraindications, adverse effects,and drug interactions of any medication you prescribe Such detailed information is beyond

the scope of this manual but can be found in the package insert, the Physicians’ Desk

Refer-ence (PDR), or from the American Hospital Formulary Service.

Medications are listed by class, and then the individual medications are listed in betical order by generic name Some of the more common trade names are listed (in paren-theses after the generic name) for each medication Because many medications are used totreat various conditions based on the medical literature and not listed in their package insert,

alpha-we list common uses of the medication rather than the official “labeled indications” (FDAapproved) If no pediatric dosage is provided, we assume the agent is not well establishedfor this age group

Medications under the control of the U.S Drug Enforcement Agency (Schedule I–Vcontrolled substances) are indicated by the symbol [C] The following is a general descrip-tion for the schedules of controlled substances:

• Schedule I: All nonresearch use forbidden (eg, heroin, LSD, mescaline, etc)

• Schedule II: High addictive potential; medical use accepted No telephone call-in

prescriptions; no refills Some states require special prescription form (eg, cocaine,morphine, methadone)

• Schedule III: Low to moderate risk of physical dependence, high risk of

psycholog-ical dependence; prescription must be rewritten after 6 months or five refills (eg,

Miscellaneous AgentsGeneric Drug Listing and DataAminoglycoside DosingImmunization Schedule

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