Signs of rising intracranial pressure (Cushing’s Reflex)
(1) Bradycardia (slowing heart rate)
(2) Systolic hypertension (rising systolic BP / widening pulse pressure)
(3) Erratic respirations
Signs of pericardial tamponade (Beck’s triad)
(1) Narrowed pulse pressure (narrowing difference between systolic and diastolic
(2) Muffled heart tones
(3) JVD
Pediatric assessment triangle
(1) Appearance (tone, interactiveness, consolability, gaze, speech)
(2)Work of breathing (sounds, position, retractions, flaring, gasping)
(3) Circulation to skin (pallor, mottling, cyanosis)
Reversible causes of cardiac arrest
per CAREMS (5)
Hypothermia
Hyperkalemia
Hypovolemia
Overdose
Tension pneumo
Chest Pain / STEMI algorithm
- 12 lead and transmit to receiving facility
- O2 if less than 94%
- 324 mg ASPIRIN
- NITRO 0.4 mg for chest pain if SBP>100 (may repeat every 3-5 minutes as pain continues and BP allows)
- for STEMI chest pain unresponsive to nitro: FENTANYL 0.5 mcg/kg IN/IV/IO; max initial dose 50 mcg; max total dose 200 mcg
Bradycardia algorithm (adults)
< 60 and symptomatic
- 12 lead
- unstable & conscious: pacing & PUSH DOSE EPI 10-20 mcg (1-2 mL) every 2 min
- unconscious: start CPR and work as a code
- stable & symptomatic: PUSH DOSE EPI or ATROPINE (1mg every 3-5 min)
Bradycardia algorithm (peds)
ages < or equal to 6 months and heart rate <60 (oxygenate and ventilate) and initiate chest compressions
otherwise:
CODE EPI (1:10,000): 0.01mg/kg every 3-5 min
ATROPINE: 0.02 mg/kg max initial dose 0.5mg
Supraventricular Tachycardia (adult) algorithm
unstable: sync cardiovert 70J/120J/150J/200J
(with FENTANYL if possible: 1mcg/kg)
stable & symptomatic (need medical direction if known WPW):
(1) vagal maneuvers
(2) ADENOSINE: 6mg fast bolus
ADENOSINE 2nd dose:12mg fast bolus
(3) CARDIZEM: 0.125 mg/kg max 12.5 slow push (max 10 mg if over 65 years old)
CARDIZEM 2nd dose: after 10 minutes as needed (same dose)
A-fib / A-flutter / multifocal atrial tachycardia algorithm
unstable: sync cardiovert
70J/120J/150J/200J
(with FENTANYL if possible: 1mcg/kg)
stable & symptomatic:
(1) CARDIZEM: 0.125 mg/kg max 12.5 mg slow push (max 10 mg if over 65 years old)
CARDIZEM 2nd dose: after 10 minutes as needed (same dose)
V-Tach with a pulse algorithm
(regular, wide)
unstable: sync cardiovert
70J/120J/150J/200J
(with FENTANYL if possible: 1mcg/kg)
stable:
(1) AMIODARONE: 150 mg over 10 minutes; repeat once as needed if VT recurs
Torsades algorithm
unstable: Defib
120J/150J/200J/200J
stable:
(1) MAGNESIUM SULFATE: 50mg/kg over 5-10 minutes, max 2g
Seizure algorithm
- ongoing when we arrive or lasting >5 minutes; or more than 2 in one hour
- pregnancy / postpartum: manage with mag
- check blood sugar
- manage airway (suction / ventilate as needed)
- administer benzos:
VERSED 0.2mg/kg IM/IN (max 5mg if <40kg; max 10mg if >40kg)
ATIVAN or VERSED 0.1mg/kg IV/IO (slow push; max single dose 4mg) - monitor ETCO2
no ketamine for postictal patients
Syncope / Presyncope algorithm
- includes both LOC and presyncope or “nearly blacking out”
- check blood sugar
- 12 lead
- 500 mL fluid bolus if symptoms of poor perfusion; repeat as necessary
Sepsis algorithm
- check blood sugar
- ETCO2 and SPO2
- 12 lead
- 30 ml/kg fluid bolus (consider LR)
- treat per “shock” algorithm as indicated
- CN “sepsis alert”
Indicators for sepsis
- SUSPECTED INFECTION OR IMMUNOSUPPRESSION(open wounds / UTI / pneumonia / meningitis / indwelling medical device / vomiting or diarrhea / recent surgery or procedure / chronic steroid use)
=> high risk: chemotherapy / sickle cell / bone marrow or organ transplant / severe intellectual disability
AND
- 2 OR MORE MARKERS OF SYSTEMIC INFLAMMATORY RESPONSE SYNDROME –Temp > 100 or < 97
- HR > 90
- RR > 20
- glucose > 140 in non-diabetic
- altered
(3. findings of shock)
Hypoglycemia algorithm
- less than 60 mg/dL
- ORAL GLUCOSE 15g PO; may repeat x1 as needed
- DEXTROSE (D10) IV; 1ml/kg max 250mL (25g); titrate to effect
or
-GLUCAGON 1mg IM/IN (may repeat) - reassess blood sugar
** patients with insulin pump: if altered: stop insulin pump or disconnect at insertion site; if GCS 15 leave connected with pump running
Hyperkalemia algorithm (a reversible cause of cardiac arrest)
If findings are present:
- Peaked T waves progressing to sine waves
-wide QRS
- Pt: renal failure / Addison’s / crush syndrome / rhabdo
- administer fluids
- CALCIUM CHLORIDE 20mg/kg over 5 min
Most Common Blood Thinners (7)
Aspirin (salicylate)
Plavix (clopidogrel)
Pradaxa (dabigatran)
Xarelto (rivaroxaban)
Eliquis (apixaban)
Coumadin (warfarin)
Heparin
General Trauma Management algorithm
Hemorrhage control
Airway control / O2
ETCO2
Spinal precautions
Blood thinners?
TBI?
- FLUID THERAPY: If SBP <90 or HR >120; give 1L bolus
- manage pain
- consider TXA if hemorrhagic shock potential (and w/n 3 hours of injury): 1 g
- absent/diminished lung sounds in hypotensive pt: tension pneumo? … needle decompress
- avoid hypothermia
Crashing Medical Patient algorithm
(new onset altered LOC, airway issues, signs of shock …)
- do not initiate movement of patient until tx is optimized
- need trending vital signs
- initiate cardiac monitoring and ETCO2
- BLS AIRWAY: NPA/OPA; NRB; BVM
- ALS AIRWAY: NRB or CPAP; i-gel or intubate
- CIRCULATION: unstable brady –> (see algorithm); unstable tach –> (see algorithm); cardiogenic: 30 ml/Kg fluid bolus
- SHOCK unresponsive to fluids: push dose EPI
TBI algorithm
(Consider mechanism, GCS, exam)
avoid the H bombs
- HYPOTENSION for SBP approaching 100mmHG: aggressive fluids (1 L bolus)
- HYPOXIA high flow O2: target 100% // aggressively prevent desat below 90%
- HYPERVENTILATION BVM at 10 breaths/min
- trend vital signs/GCS/ and monitor for shock (tachy, falling SBP
- blood sugar / C-Spine / control bleeding with direct pressure if no open skull injury
- IV/IO
- monitor for hypoventilation/apnea (target ETCO2 40mmHg)
- consider advanced airway if O2<90%
H Bombs in TBI
- **HYPERventilation
- **HYPOtension
- **HYPOxia
(HYPOglycemia)
(HYPOthermia)
GCS
(4) EYE
- 4: spontaneous
- 3: to sound
- 2: to pressure
- 1: none
(5) VERBAL
- 5: oriented
- 4: confused
- 3: words
- 2: sounds
- 1: none
(6) MOTOR
- 6: obeys commands
- 5: localizes pain
- 4: withdraws from pain
- 3: flexion (decorticate posturing)
- 2: extension (decerebrate posturing)
- 1: none
Neuro Assessment
AVPU
- wrist/hand/finger extension
- foot push/pulls (plantar/dorsiflexion)
- gross sensation in all extremities
- any numbness/tingling in any extremities (paresthesias)
