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Pulmonary Edema Due to Congestive Heart Failure
- Consider Capnography
- Apply Early CPAP for an alert patient who is able to maintain a patient airway but is, or continues to be, in moderate to severe respiratory distress
- IV must be established prior to NTG administration for patients not currently prescribed and taking NTG.
- Administer 0.4 mg NTG SL. Repeat at 0.8 mg NTG q3-5". If SBP < 120 mmHg DC NTG until > 120 mmHg.
- Apply 1" NTG paste if SBP > 120 mmHg.
- -- If no improvement pt on Lasix, consider up to pt's total daily dose (max 100mg). Withhold if SBP < 120 mmHg.
- -- Contact MC to admin doses > 100 mg IV or if pt not on Lasix
- -- If daily dose of Lasix unknown, admin 40 mg Lasix IV
- Perform and interpret 12 lead EKG
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Acute Respiratory Distress
- Consider Capnography
- Consider early CPAP for an alert pt who is able to maintain a patent airway but is, or continues to be, in moderate to severe resp distress.
- If pt SOB has hx of asthma, emphysema, or is actively wheezing, administer up to 5mg albuterol via nebulizer
- Consider admin of 0.5mg nebulized ipratropium bromide (Atrovent) with albuterol.
- If wheezing continues after 1st albuterol tx is completed, you may admin 2nd dose up to 5mg of albuterol via nebulized aerosol if pt's HR remains < 150 BPM
- For Mild to Moderate resp distress, consider admin of prednisone 60mg PO in combo with Maalox 50mg or other PO fluid.
- For Severe rsp distress secondary to asthma or COPD, admin 125mg Solu-Medrol IV
- Hold all steroids for suspected pneumonia, CHF or "Metabolic Hyperventilation" (DKA, sepsis, etc.)
- Contact MC for consideration admin of 2g Mag IV over 10 min. for continuing severe resp distress secondary to asthma or COPD.
- Pts taking Xopenex via neb, this may be substituted in place of albuterol.
- Early CPAP is prefered on-scene rather than in ambulance.
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Altered Mental Status
- Obtain blood samples, check blood sugar by glucometer.
- If Blood Sugar < 60mg/dl, admin up to 25g of dextrose IV.
- If Blood Sugar < 60, no IV, admin 1mg glucagon IM, IN
- Consider admin of 0.4-2mg Narcan IV, IN, or IM to provide for a patent, self-maintained airway and adequate respirations.
- Consider alternative causes of altered mental status.
- -- Dextrose may be mixed in 100ml NSS and run wide as alternative to direct push of D50.
- -- Contact MC for NaHCO3 for tricyclic Antidepressant OD, glucagon for beta blocker OD, and CaCl for Calcium channel blocker OD.
- Consider nasal prong EtCO2 monitoring with POx to ensure proper oxygenation and ventilation.
- If glucometer fails, or not available, proceed with appropriate dose of D50 or Glucagon.
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Hypertensive Crisis
- Indications: 2 BPs measured 5 mins apart with DBP of >= 120 or a MAP >=130, associated with any of the following: N/V, HA, or visual disturbances
- Consider pain mgmt protocol for moderate-severe HA
- Contact MC for consideration of admin of 10mg Labetalol (Trandate) IV slowly over 2 min's.
- Reassess VS, if > 10mins after initial dose, diastolic BP remains >=120, contact MC for consid admin of repeat dose of 10-20mg Labetalol (Trandate) IV slowly over 2 mins.
- -- Withold Labetalol for CHF, any Heart block, brady, cocaine abuse, pt's in cardiogenic shock or asthmatics.
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Pediatric Tachycardia
- Indications: Wide Complex Tach (QRS>=0.08 secs) presumed to be VT, with a rate > 180bpm in children > 1 y/o or narrow complex tach (QRS <=0.08 secs) other than sinus tach, with a rate > 180bpm in children > 1 y/o or > 220 bpm in children < 1 y/o. There should be no evidence of trauma, hypovolemia, fever, or sepsis.
- Consider vagal maneuvers (Valsalva, ice packs to face)
- Administer fluid bolus of 20ml/kg (10ml/kg for neonates) of NSS (w/o PE)
- 12 Lead
- Contact MedComm for consideration of WCT Amiodarone IV 5mg/kg (max 150mg) infused over 10 mins.
- SVT Adenosine 0.1mg/kg IV max dose 6mg. May repeat 0.2mg/kg IV max dose of 12mg
- If the pt exhibits poor tissue perfusion, the following tx modalities should be considered -- Syncronized cardioversion 0.5 to 1 J/kg - if not effective increase to 2 J/kg. Cardioversion should only be attempted twice.
- Consider sedation bugt not to delay cardioversion, 0.2mg/kg etomidate (Amidate) to a max dose of 20mg.
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Pediatric Bradycardia
- Indication: Heart Rate < 60 with clinical evidence of shock including altered mental status, delayed cap refill, and/or absence of radial/brachial pulses b/l
- If severe cardiorespiratory compromise is present as evidenced by poor perfusion, hypotension, or clinical evidence of shock continues despite adequate ventilation and oxygenation, begin chest compressions if the heart rate remains < 60 bpm
- Administer 0.01 mg/kg epi (1:10,000) IV. Repeat q3-5 mins.
- Administer 0.02 mg/kg atropine. Min dose is 0.1mg IV. Max single dose is 0.5 mg IV. May be repeated once in 30-5 mins.
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Pediatric Asystole / PEA
- Administer 0.01 mg/kg epi (1:10,000). Repeat epi q 3-5 mins.
- Administer IV bolus up to 20 ml/kg (10ml/kg neonates) NSS boluses may be repeated at the same volume up to max of 60ml/kg (30 ml/kg for neonates)
- Compressions will not be interrupted for longer than 10 secs for intubation or other procedures. Intubation during pulse rhythm check or during compressions and should be deferred until later in the resuscitation. Consider early use of rescue airway device for anticipated difficult intubation.
- Ventilations 8-10 bpm to decrease intrathoracic pressure using one hand
- EtCO2 should be > 10mmHg with > 20mmHg desirable for ROSC
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Pediatric V-Fib / V-Tach
- In absence of effective CPR or response > 4 mins, perform 2 mins of CPR prior to 1st defibrillation or intubation
- Defib using 2J/kg
- 2 mins of CPR between each defib attempt
- Defib using 4J/kg q2 mins
- Admin 0.01 mg/kg epi (1:10,000) IV. Repeat q3-5 mins for the duration of resuscitation.
- Consider Magnesium 25mg/kg IV for Torsade de Pointes
- Admin 5mg/kg Amiodarone bolus IV (max 300mg/dose). May repeat 2x q 10 mins if VF/VT continues. Total of all doses not to exceed 450 mg.
- Follow each medication admin with single shock of 4J/kg and 2 minutes of Chest compressions
- With return of spontaneous circulation admin 5mg/kg amiodarone IV infused over 20 mins (max 300 mg). Total of all doses not to exceed 450 mg.
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Pediatric Allergic Reactions
- Indications: Moderate allergic reaction such as uticaria or hx of allergic exposure w/o airway compromise or shock. In patients >2y/o, consider admin of 12.5 to 25mg Benadryl po w/o necessity of IV access *&* consider admin of prednisone 1-2mg/kg upt to 60mg po in combo with Maalox or other po fluid
- Severe: admin 0.01 mg/kg (0.1ml/kg) of epi (1:10,000) (max 0.25mg) IV over a 1 min interval. If no IV, Admin 0.01 mg/kg epi 1:1,000 (max 0.5mg) IM
- If resp distress/shock continue and no SVT, V-ectopy, or VT; repeat 0.01 mg/kg 1:10,000 (max 0.25mg) IV over 1 min interval
- Admin 1 mg/kg Benadry IV or IM (max 50mg)
- Admin IV bolus 20ml/kg, (10 ml/kg neonates) NSS if shock persists. May repeat 2x up to 60ml/kg or 30mg/kg neonate.
- Admin 2mg/kg methylprednisolone IV up to a max dose of 125 mg.
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Pediatric Shock and Hypotension
- Indications: Clinical evidence of shock including: altered mental status, tachycardia, pale/cool/clammy skin, delayed cap refill, and/or absence of radial/brachial pulses b/l.
- For HR<60bpm refer to bradycardia protocol
- Infuse a 20 ml/kg (10ml/kg for neonates) fluid bolus of NSS
- If signs of hypovolemic shock persist, may repeat 20ml/kg (10ml/kg) up to 60ml/kg (30ml/kg)
- Contact MC for consideration of additional fluid bolus and/or a 5-20 mcg/kg/min dopamine infusion for continued hypotension not due to hypovolemia.
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Pediatric Seizures (Active)
- If BS<60mg/dl (40mg/dl newborn) via glucometer, admin 0.5g/kg Dextrose at the following dilutions (max dose 25g)
- Dextrose 25% (D25) at 2ml/kg
- Dextrose 10% (D10) at 5ml/kg for neonates
- Admin glucagon 1mg IM, IN if unable to obtain IV
- Admin 0.2 mg/kg midazolam (Versed) up to max dose of 5mg IV, IN, or IM for continued sizure activity.
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Pediatric Altered Mental Status
- If BS<60mg/dl (40mg/dl newborn) via glucometer, admin 0.5g/kg Dextrose at the following dilutions (max dose 25g)
- Dextrose 25% (D25) at 2ml/kg
- Dextrose 10% (D10) at 5ml/kg for neonates
- Admin glucagon 1mg IM, IN if unable to obtain IV
- Consider Admin 0.1mg/kg Naloxone (Narcan) IV, IN, or IM up to max dose of 2mg) for suspected Drug Overdose
- Contact MC for consideration NaHCo3 for tricyclic antidepressent OD, glucagon for beta blocker OD, and CaCl Calcium Channel Blocker OD
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Pediatric Acute Respiratory Distress
- Contact MC if pts HR > 180 bpm
- Consider Capnography
- If pt SOB has hx of asthma, or is actively wheezing, administer up to 2.5mg albuterol via nebulizer in combo with 0.5mg nebulized ipratropium bromide (Atrovent)
- .If wheezing continues after 1st albuterol tx is completed, you may admin 2nd dose up to 2.5mg of albuterol via nebulized aerosol
- Consider admin of 0.01 mg/kg epi 1:1,000 IM for pts in severe rsp distress (max dose IM 0.3mg)
- Suspected Croup consider admin of nebulized NSS for inhalation. For continued distress contact MC fpor consideration of admin of 5ml epi 1:1,000 via nebulizer
- Pt's with acute resp distress with fever, drooling, hoarseness, stridor, and sitting forward in tripod should be partial airway obstruction suspect. Keep child calm/comfortable - blow by O2. Transport ASAP, in the setting of epiglottitis, attempt airway management by BVM.
- Consider admin of prednisone 60mg PO in combo with Maalox 50mg or other PO fluid.For Severe rsp distress or 2mg/kg Solu-Medrol IV (max 125mg) for severe resp distress secondary to asthma
- Contact MC for consideration admin of 25mg/kg Mag (max 2g) IV over 10 min. for continuing severe resp distress
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