21. Common Medical Emergencies

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Overview of Emergency Cardiac Care

The algorithms and guidelines of the American Heart Association (AHA) and International Liaison Committee on Cardiac Resuscitation (ILCOR) have been updated. The latest guidelines promote the use of automatic external defibrillator (AEDs) by emergency medical services (EMS), police, and the general public. The establishment of public access defibrillator (PAD) programs and continued development of EMS protocols make it necessary for receiving physicians in emergency departments to be knowledgeable in the current recommendations of the AHA regarding the use of the prehospital AEDs. These recommendations can be found in the most current Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care 2005.*

According to the latest AHA guidelines, if a person experiences witnessed sudden cardiac death (cardiac arrest) and a defibrillator or an AED is available, defibrillation should be performed as soon as possible. However, if a person is "found down" and may have been unresponsive for several minutes, 5 cycles ( 2 min) of CPR should be performed before initiation of defibrillation.

People who experience cardiac arrest and receive immediate defibrillation are more likely to be successfully defibrillated after the first shock. For every minute of circulatory arrest there is an 10% decrease in the likelihood of successful resuscitation. Patients who are subject to delays in receiving resuscitation do not fare as well, unless there has been a brief period of CPR before defibrillation.

Many communities, organizations, and EMS systems participate in PAD programs. These programs facilitate early recognition and management by the use of AEDs, and some hospitals have AEDs available, so that a patient who "arrests" can be defibrillated before the arrival of the code team.

Many patients who experience sudden cardiac death due to ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT) can be defibrillated before they arrive at the hospital. That the rescuer does not have to interpret the cardiac rhythm may increase the chance of survival by markedly decreasing time to "first shock." New guidelines for resuscitation stress timely defibrillation and early, consistent chest compressions with minimal interruption.

Children often experience VF after respiratory arrest. It is reasonable that CPR be performed (5 cycles/2 min) before defibrillation is attempted, unless the child suddenly collapses. In that case, the AED should be applied as soon as it is available.

*2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2005;112(24 suppl). Available online at: http://circ.ahajournals.org/content/vol112/24_suppl (accessed 01/04/2007).

Cardiopulmonary Resuscitation

CPR Basics: ABCs (Airway, Breathing, Circulation)

Universal precautions dictate that protective eye wear, gloves, and when necessary, water-impervious gowns and footwear be used. All patients must have a patent airway, be breathing, and have signs of spontaneous circulation. Figure 21 1 shows the basic life support (BLS) algorithm. The new guidelines differentiate resuscitation by nonprofessional rescuers from resuscitation by health care providers.

Figure 21 1.

Adult basic life support health care provider algorithm. Boxes dotted borders indicate actions or steps performed by health care providers but not the general public. ALS = advanced life support. (Reproduced with permission from Circulation 2005;112:IV-19 IV-34.)

CPR of Unresponsive Adult (Age > 8 Y): Witnessed Collapse

If a patient becomes unresponsive (no response to verbal or tactile stimuli, ie, "shake and shout"), call for help (CODE, 911). Do not move the patient unless in immediate danger.

1. Get a defibrillator or AED to the bedside stat.

2. Stand or kneel at the patient's shoulder. Position patient on back as a unit, protecting the neck.

3. Airway. Open the patient's airway. If there are signs of airway compromise (apnea, stridor, coughing, use of accessory muscles), immediately open and clear the airway using the head tilt-chin lift method (nonprofessional rescuer) or a jaw thrust (health care provider) if cervical spinal injury is suspected.

4. If a foreign body is visualized in the airway, and can easily be removed, remove it. If airway care is needed, proceed according to clinical need (see Emergency Airway and Ventilatory Support).

5. Breathing. Determine whether the patient is breathing by looking, listening, and feeling. Look at the patient's chest to determine whether there are signs of movement. Listen at the patient's mouth and nose to determine whether air is being moved through (escaping) from the upper airway. Feel for warm, moist air coming out of the mouth and nose by placing your ear close to the patient's mouth and nose.

6. If the patient is breathing, place him or her in the recovery position: a stable, side-lying position in which the tongue does not block the airway and fluid can drain from the mouth. Keep the spine straight, and position the arms so that the chest is not compressed. Continue to monitor the patient for breathing. Call for assistance!

7. If the patient is not breathing, ventilate by administering two positive-pressure breaths. Allowing 1 s per breath using either a bag valve mask or a barrier device such as a pocket mask.

8. Circulation. To determine whether there are signs of circulation, check the neck for a carotid pulse for 10 s (health care provider). However, if there is any doubt regarding the presence or absence of a pulse, start chest compressions.

9. If there is a definite pulse, give 1 breath every 5 6 s, approximately 10 12 breaths/min, rechecking for a pulse every 2 min. If an advanced airway is placed, ventilate with 8 10 breaths/min (approximately 1 breath every 6 8 s asynchronously).

10. If there are no obvious signs of circulation, begin chest compressions: Place both hands the patient's sternum, the heel of one hand on top of the heel of the other. Push fast and push hard, to a depth of 1.5 2.0 in (4 5 cm), allowing full recoil of the chest. Continue compressions until a defibrillator or an AED is brought to the patient's side. If a defibrillator is not immediately available, continue chest compressions and ventilations at a ratio of 30/2 at a rate of approximately 100 compressions/min.

11. When the defibrillator or AED arrives, attach the two pads to the patient's bare chest. Right-sided sternal pad: right superoanterior infraclavicular position; left-sided apical pad: inferolateral left side of chest lateral to the left breast. Minimize interruption of chest compressions and compress until the pads are on the chest, if possible.

12. Stop compressions. Analyze the rhythm, and if indicated (presence of VF or pulseless VT), deliver a single shock.

13. Immediately resume CPR for another 5 cycles of 30 compressions/2 breaths (2 min). Do not check for a pulse until another 5 cycles of CPR have been performed. The defibrillated, stunned myocardium may not yet be pumping efficiently.

14. If there is no pulse, resume CPR, recharge the defibrillator and administer another single shock followed by immediate CPR.

15. If unsuccessful, proceed to the advanced cardiac life support (ACLS) algorithms and guidelines.

CPR of Unconscious Adult (Age > 8 Y): Unknown Down Time

If an unconscious patient is encountered who is not breathing and has no apparent signs of circulation and the time of onset of symptoms is unknown, the situation is called unwitnessed arrest.

1. Perform CPR as described earlier (CPR of Unresponsive Adult: Witnessed Collapse) for 2 min (5 cycles of 30 compressions and 2 ventilations) before attempting defibrillation.

2. Resume CPR immediately after the first shock and reassess the patient after (2 min) or 5 cycles of 30 compressions and 2 breaths. If there are no signs of spontaneous circulation, ie, no carotid pulse, recharge the AED or defibrillator while doing CPR and administer another single shock.

3. If the defibrillation results in successful termination of VF, treat the patient supportively observing for changes in blood pressure, heart rate, and respiratory status. If unsuccessful, proceed to the ACLS algorithms and guidelines.

4. After successful defibrillation, an unstable rhythm may develop and necessitate intervention. Some patients may arrive in the emergency department with a pulseless rhythm, asystole, pulseless electrical activity, and VT or VF. Other patients may have a slow heart rate incapable of providing good perfusion pressure, ie, bradycardia (heart rate < 60 beats/min) or tachycardia (heart rate > 100 beats/min). Proceed to the appropriate ACLS algorithms and guidelines (see Figure 21 2).

Figure 21 2.

ACLS pulseless arrest algorithm. PEA = pulseless electrical activity; IO = intraosseous. (Reproduced with permission from Circulation 2005;112:IV-58 IV-66.)

CPR of Child (Age 1 8 Y): Witnessed Cardiac Arrest

If a child becomes unresponsive and experiences respiratory arrest, the approach is similar to that for an adult: ABCs and a call for help. Get a defibrillator or AED stat.

1. Airway: Open the airway with the head-tilt chin lift maneuver or, if a cervical spinal injury is a concern, a jaw thrust.

2. Breathing: Determine breathlessness: look, listen, feel. If the patient is breathing, place him or her in the recovery position. If no breathing is present, give 2 effective breaths (1 s/breath).

3. Circulation: Check for signs of circulation; carotid pulse check < 10 s (health care provider). If a pulse is obviously present, perform rescue breathing at a rate of 12 20 breaths/min (1 breath every 3 5 s) or (12 20 breaths/min). If an advanced airway is present, 8 10 breaths/min ( 1 breath/6 8 s asynchronously).

4. If no signs of circulation are present, begin chest compressions. Compress the chest with the heel of one hand at the lower half of the sternum to a depth of to of the chest. A ratio of 15 compressions/2 breaths can be assumed with two rescuers. The rate of compressions should be approximately 100/min. Avoid unnecessary interruptions in CPR.

5. As soon as a defibrillator is available, immediately apply the defibrillator or AED pads (pediatric) to the patient's bare chest with minimal interruption in chest compressions. Adult AED pads are acceptable if pediatric pads are not available; however, do not let the pads touch each other on the chest.

6. Stop CPR and allow the AED to analyze the rhythm.

7. Shock if indicated (2 J/kg if manual defibrillator).

8. Resume CPR immediately for 5 cycles and analyze the rhythm.

9. If defibrillation is unsuccessful, recharge the AED or defibrillator while resuming and continuing CPR. Reshock (4 J/kg manually) and immediately do 2 min of CPR. Reasses the patient and rhythm.

10. If unsuccessful, proceed to the pediatric advanced life support (PALS) guidelines (Table 21 1).

Table 21 1 Pediatric Advanced Life Support for Ventricular Fibrillation, Ventricular Tachycardia, and Pulseless Electrical Activity

ABCs
Airway
Breathing
Circulation
Chest Compressions/Ventilation	1 rescuer	30/2
	2 rescuers	15/2
Compress Hard and Fast	rate > 100 beats/min
Call 911/Code/EMS
AED application 2J/kg
Medications:	Epinephrine	0.01 mg/kg IV/IO VT/VF/pulseless
		OR
		0.1 mg/kg (1:1000):0.1 mL/kg per ET
		q3 5min
	Amiodarone	5 mg/kg IV/IO
	Lidocaine	1 mg/kg IV/IO
	Magnesium	25 50 mg/kg IV/IO Torsade de pointes

Consider ET tube administration if no vascular access.

Based on recommendations from Circulation 2005;112:IV-167 IV-187.

IO = intraosseous; VT = ventricular tachycardia; VF = ventricular fibrillation.

CPR of Child (Age 1 8 Y): Unwitnessed Cardiac Arrest

If a child is found to be apneic (breathless) and not showing signs of spontaneous circulation (no carotid pulse when checked by health care provider) with an unknown down time, the situation is considered unwitnessed cardiac arrest.

1. Begin CPR, as described earlier (CPR of Child: Witnessed Cardiac Arrest), for 2 min (5 cycles) before attempting defibrillation using a defibrillator or AED and pediatric pads. (Note: Adult pads can be used if pediatric pads not available. Make sure pads are not touching each other).

2. Defibrillate with AED if child's age > 1 y (2 J/kg with manual defibrillator).

3. Immediately resume CPR for 2 min.

4. Assess patient for pulse. If the defibrillation attempt was unsuccessful, resume CPR, recharge the AED or defibrillator and provide another single shock when charged. (Use 4 J/kg for second defibrillation if a manual defibrillator is used). If unsuccessful, proceed to the appropriate PALS management (Tables 21 1 and 21 2).

5. Like adults, children may present in asystole, pulseless electrical activity, or pulseless VT or VF, or these rhythms may develop after defibrillation. Furthermore, children can present with bradycardia or tachycardia. Proceed to the PALS guidelines (Tables 21 1 and 21 2, and Figure 21 2), and attempt to correct the dysrhythmia and determine the cause of the event.

Table 21 2 Pediatric Bradycardia and Tachycardia Management

Bradycardia	Tachycardia
ABCs
Epinephrine 0.01 mg/kg IV/IO (1:10,000:0.01 mL/kg)	Adenosine 0.1 mg/kg (max 6 mg)
Atropine 0.02 mg/kg IV/IO	Cardioversion 2 J/kg
	Amiodarone 5 mg/kg IV/30 min
	Procainamide 15 mg/kg/45 min

Based on recommendations from Circulation 2005; 122:IV-167 IV-187.

CPR of Unresponsive Infant (Age < 1 Y): Witnessed or Unwitnessed Cardiac Arrest

1. Airway: Head tilt-chin lift or jaw thrust.

2. Breathing: Look, listen, and feel for breathing. If absent, give 2 effective breaths at 1 s/breath.

3. Circulation: Check the brachial or femoral pulse. If no pulse is present, start chest compressions. Use 2 or 3 fingers or a thumb just below the nipple line, and press to to the depth of the chest.

4. Use 30 compressions/2 ventilations (single rescuer) or 15 compressions/2 ventilations (2 health care providers) Rate of compressions is 100/min. Rate of ventilation is 12 20 breaths/min (or 1 breath/3 5 s).

5. If an advanced airway is present, use 8 10 breaths/min ( 1 breath/6 8 s asynchronously).

6. Perform CPR for 2 min or 5 cycles, then reassess the patient. There are no recommendations regarding defibrillation in this situation. If no success, proceed to the advanced algorithms and guidelines (Tables 21 1 and 21 2, and Figure 21 2).

Neonatal Resuscitation

Immediately after delivery, a neonate begins to undergo a physiologic transition. Rapid assessment can determine the need for resuscitation:

1. Was the born baby at term?

2. Is the amniotic fluid clear and free of meconium and infection?

3. Is the baby breathing or crying?

4. Does the baby have good muscle tone?

If the answer to all these questions is yes, resuscitation probably is not needed.

It is normal for amniotic fluid to be present in the upper airways of newborns, and this fluid must be cleared. Help the neonate to breath spontaneously, maintain body temperature, and adapt to new circulatory patterns. Provide an infant warmer, oxygen, neonatal airway adjuncts, and drying materials. The sequence of basic actions is summarized in Figure 21 3.

Figure 21 3.

Neonatal resuscitation algorithm. (Based on recommendations from Circulation 2005;112:IV-188 IV-195.)

Advanced Cardiac Life Support (ACLS)

The foundation of ACLS is sound BLS. In the advanced phase (sometimes called the "D" in the ABCDs of emergency cardiac care), specific arrhythmias are managed primarily through administration of medications. Rapid reference guides to ACLS and other commonly used emergency medications are on the inside front and back covers of this book. ECG interpretation is reviewed in Chapter 19.

Cardiac Arrest

Four rhythms can produce pulseless cardiac arrest: VF, VT, pulseless electrical activity (PEA), and asystole. (See adult ACLS pulseless arrest algorithm in Figure 21 2.)

Symptomatic Bradycardia and Tachycardia

Monitor for the development of arrhythmias in any patient with chest pain or who has undergone resuscitation. In addition to the foregoing cardiac arrest arrhythmias, patients may have bradycardia or tachycardia that requires monitoring and therapy if they become symptomatic. Management of bradycardia and tachycardia based on 2005 emergency cardiac care guidelines is outlined in Table 21 3.

Table 21 3 Bradycardia and Tachycardia

Bradycardia (HR < 60 beats/min)	Tachycardia (HR > 100 beats/min)
High degree AV block II/III	Narrow complex
Transcutaneous pacing	Adenosine 6 mg, 12 mg, 12 mg IV
Atropine 0.5 mg IV (max 3 mg)	Beta blocker
Epinephrine 2 10 mcg/min IV	Wide complex
Dopamine 2 10 mcg/kg/min IV	Amiodarone 150 mg IV/10 min (max) 2.2 g/24 h
Identify and manage correctable factors
Hypovolemia	Toxins
Hypoxia	Tamponade
Hydrogen ion	Tension pneumothorax
Hypo/hyperkalemia	Thrombosis PE/CAD
Hypoglycemia	Trauma
Hypothermia

Consider ET tube administration if no IV access.

Based on recommendations from Circulation 2005;112(Suppl I):IV-6 IV-77.

Emergency Airway and Ventilatory Support

To improve oxygenation, administer 100% inspired oxygen during BLS (see also Chapter 18). Airway adjuncts are useful for this purpose and are classified as basic and advanced airway techniques. Make sure suction is readily available. Exhaled CO₂ detectors are useful for determining proper tube placement. High exhaled CO₂ levels confirm proper tube placement.

Basic Airway Management

Bag Mask Ventilation:

Can be supplied with room air or oxygen supplementation; can also be connected to an advanced airway if present. Open the airways adequately with chin lift, lifting the jaw against the mask and maintaining a tight seal. During CPR give two ventilations during a brief 3- to 4-s pause between every 30 compressions. Deliver a tidal volume sufficient to raise the chest ( 6 7 mL/kg or 500 600 mL in an adult) over 1 s. Can cause gastric inflation with subsequent complications (eg, aspiration).

Oropharyngeal Airway:

Use only if trained in the technique and only if the patient is unconscious and has no gag reflex.

Nasopharyngeal Airway:

Better tolerated by patients who are not deeply unconscious. Useful for patients with tightly clenched jaws; use with caution in craniofacial trauma.

Advanced Airways

Used only by health care providers with proper training and frequent practice. Because placement of an advanced airway may require interruption of basic CPR the risk/benefit ratio must be considered. The bag mask can be connected to an advanced airway for delivery of ventilation.

Esophagotracheal Airway (Combitube or ETC):

A multilumen airway that consists of a single, dual-lumen tube with two cuffs. After placement, port 1 (blue pilot balloon) is inflated with 100 mL air, then port 2 (white pilot balloon) is inflated with 15 mL air. Ventilate through the longer blue tube 1; if breath sounds are heard, and auscultation of gastric insufflation is negative, continue ventilation. If auscultation of breath sounds is negative and auscultation of gastric insufflation positive, ventilate through the shorter clear tube 2.

Laryngeal Mask Airway (LMA):

Inflatable silicone mask and rubber connecting tube. Inserted blindly into the pharynx, a cuff is inflated that forms a low-pressure seal around the laryngeal inlet, allowing gentle positive-pressure ventilation. Note: The black line on the airway tube must be oriented toward the upper lip, and a bite block must be in place. Aspiration may be less common with an LMA than with a bag mask.

Endotracheal Tube (ET):

Technique is reviewed in Chapter 13. Unskilled providers can cause more harm than good in attempting ET intubation during resuscitation. Indicated when the rescuer cannot ventilate an unconscious patient with a bag mask and in the absence of airway reflexes.

Automatic External Defibrillation, Defibrillation, Cardioversion

In addition to familiarizing yourself with the location of the code cart, airway supplies, emergency numbers, etc, on each new rotation, become familiar with the defibrillator and AED. AEDs are small, free-standing, battery-operated defibrillators, equipped with computer hardware and software. They are designed to "recognize" lethal, nonperfusing, "shockable" dysrhythmias such as VF and VT. More complicated AEDs can actually "cardiovert." When it recognizes lethal dysrhythmia, the AED gives visual or voice prompts for the rescuer to press a button and defibrillate the patient. Some models of AED automatically shock the patient after emitting an audible or visual warning to the rescuer to "stand clear." There are monophasic and biphasic defibrillators and AEDs in hospitals. In addition, there are biphasic, and probably some older monophasic, AEDs in public places as part of public access defibrillation programs.

General AED Instructions

1. Place the AED near the patient in such a way that access to the airway and chest is unimpeded.

2. Turn on the AED unit. Most AEDs give auditory or visual prompts such as:

• "Connect electrodes to AED."
• "Place electrodes to patient's bare chest." (Note: Do not allow the pads to touch each other.)
• "Do not touch the patient!"
• "Analyzing rhythm."
• "Shock advised Do not touch the patient!"
• "Push [flashing button] to shock patient."

3. The AED then prompts for patient evaluation, pulse check, etc. Some AEDs still have the 2000 guidelines algorithms on them. The 2005 guidelines call for delivery of only 1 shock, followed immediately by CPR for 2 min before assessment of circulation.

4. Repeat as clinically indicated.

Defibrillation

When defibrillating a patient, follow the updated algorithms.

1. Place pads securely on patient's chest: one to the right of the patient's sternum, just below the clavicle, the other on the left anterior axillary line. (Most pads and paddles are labeled to facilitate placement.) Make sure there is good contact to decrease resistance. (Most pads can be used for ECG monitoring, defibrillation, cardioversion, and pacing.)

2. If using paddles, use electrode gel or paste and use at least 25 lb of downward force to enhance contact with the chest. Most paddles can be used to "quick-look" the rhythm.

3. Charge the defibrillator to the appropriate energy (measured in joules).

4. Shout "CLEAR SHOCKING PATIENT!" Verify that no one (including yourself) is in contact with the patient.

5. Depress both buttons on the paddles to deliver the shock.

Cardioversion

There are rapid rhythms (eg, atrial fibrillation with uncontrolled rates, supraventricular tachycardia [SVT], Wolff Parkinson White [WPW]) that render a patient's condition unstable with a decrease in blood pressure, change in mentation, etc. These circumstances may necessitate that the rhythm be electrically terminated with cardioversion. For cardioversion, the control knob synchronizes the shock automatically with the peak of the R wave on the ECG strip. This step prevents shock delivery during the vulnerable period of the cardiac cycle, which can promote development of a lethal nonperfusing rhythm such as VF. The defibrillator hardware and software control the discharge of the shock after the "Shock" button is pressed. The procedure is otherwise as described for defibrillation. Because cardioversion is done with the patient conscious, consider sedation with a drug such as midazolam if clinically feasible.

Acute Coronary Syndromes and Myocardial Infarction

Perform a 12-lead ECG on any patients experiencing chest pain (see Chapters 13 and 19). If the patient has signs of ischemia or has had an AMI (shown in 2 contiguous leads), a quick decision must be made to administer thrombolytics (within 30 min of patient presentation), if appropriate. Review the contraindications. Absolute contraindications include CNS abnormalities (eg, A V malformation, tumor, history of intracranial hemorrhage, recent head trauma) and bleeding diathesis. Relative contraindications include pregnancy, history of poorly controlled hypertension, and recent (2 4 wk) internal bleeding (see source line, Table 21 1). If the patient is not a candidate for thrombolysis, prepare to take the him or her to the cardiac catheterization lab (balloon inflation within 90 min of patient presentation), if available. The appropriate sequence of acute coronary syndrome management is shown in Figure 21 4. Remember: "Time is muscle!"

Figure 21 4.

Acute coronary syndromes algorithm. STEMI = ST-elevation myocardial infarction; ED = emergency department; UFH = unfractionated heparin; PCI = percutaneous coronary intervention. (Reproduced with permission from Circulation 2005;112:IV-89 IV-110.)

Certain medications are most commonly used in emergency cardiac care. See Table Commonly Used Emergency Cardiac Care Medications.

Commonly Used Emergency Cardiac Care Medications

Medication Generic (Trade)	Adult Dose
Abciximab (ReoPro)	ACS with PCI in 24h: 0.25 mg/kg IV bolus 10 60 min before PCI, then 0.125 mcg/kg IV for 12 h; with heparin
Adenosine (Adenocard)	6 mg rapid IV push, then 20 mL NS bolus. Elevate extremity; repeat 12 mg in 1 2 min PRN
Alteplase, Recombinant (Activase)	AMI rapid inf: 15 mg bolus; then 0.75 mg/kg over 30 min (50 mg max); then 0.50 mg/kg over next 60 min (35 mg max) Acute ischemic stroke: 0.9 mg/kg IV (max 90 mg) over 60 min 10% of dose over 1 min; remaining 90% over 1 h
Amiodarone (Cordarone, Pacerone)	Cardiac arrest: 300 mg IV push; 150 mg IV push X1 in 3 5 min PRN Refractory pulseless VT, VF: 5 mg/kg rapid IV bolus. Perfusing arrhythmias: Load 5 mg/kg IV/IO over 20 60 min (repeat, max 15 mg/kg/d). Stable monomorphic VT: 150 mg IV over 10 min then 1 mg/min for 6 h then 0.5 mg/min over 18 h; repeat 150 mg bolus PRN 2.2 gmd daily max
Anistreplase (Eminase)	PE: 100 mg over 2 h. ACS: 15 mg over 1 2 min, then 50 mg over 30 min then 35 mg over 1 h, start w/heparin. If <67 kg 15 mg over 1 2 min, then 0.75 mg/kg over 30 min then 0.5 mg/kg over 60 min; w/heparin
Aspirin	160 325 mg PO ASAP (chewing preferred at ACS onset)
Atenolol (Tenormin)	5 mg IV over 5 min; in 10 min, 5 mg slow IV; if tolerated in 10 min, start 50 mg PO, then 50 mg PO BID
Atropine Sulfate	Asystole or PEA: 1 mg IV push. Repeat every 3 5 min (if asystole persists) to max of 0.03 0.04 mg/kg. Bradycardia: 0.5 1.0 mg IV q 3 5 min as needed; max 3 mg or 0.04 mg/kg: ET 2 3 mg in 10 mL NS
Calcium Choride	Hyperkalemia/hypermagnesemia/calcium channel blocker overdose: 8 16 mg/kg; 10% solution, 5 10 mL over 2 5 min
Clopidogrel	ACS: 300 mg loading dose then 75 mg/day
Diltiazem (Cardizem)	Acute rate control: 0.25 mg/kg over 2 min followed by 0.35 mg/kg over 2 min
Dobutamine (Dobutrex)	2 20 mcg/kg/min; titrate to HR not >10% of baseline
Dopamine	2 20 mcg/kg/min; Bradycardia: 2 10 mcg/kg/min; Hypotension: 10 20 mcg/kg/min
Epinephrine	1 mg IV push, repeat q 3 5 min; (0.2 mg/kg max) if 1 mg dose fails. Inf: 30 mg (30 mL of 1:1000 solution) in 250 mL NS or D5W, at 100 mL/h, titrate. ET 2.0 2.5 mg in 20 mL NS. Profound bradycardia/hypotension: 2 10 mcg/min (1 mg of 1:1000 in 500 mL NS, infuse 1 5 mL/min)
Eptifibatide (Integrillin)	ACS: 180 mcg/kg/min IV bolus over 1 2 min then 2 mcg/kg/min
Esmolol (Brevibloc)	0.5 mg/kg over 1 min, then 0.05 mg/kg/min for 4 min; if no response 2nd bolus of 0.5 mg/kg with maintenance of 0.1 mg/kg/min with maximum of 0.3 mg/kg/min
Glucagon	Beta blocker or calcium channel blocker overdose: 3 mg initially followed by 3 mg/hr
Heparin (Unfractionated)	Bolus 80 IU/kg (max 4000 IU); then 18 IU/kg/h (max 1000 IU/h for patients >70 kg) round to nearest 50 IU; keep PTT 1.5 2.0 control 48 h or until angiography. If adjunct with fibrin specific lytics then 60 IU/kg bolus then 12 IU/kg/h
Ibutilide	Adults 60 kg, 1 mg (10 mL) over 10 min; a second dose may be used; <60 kg 0.01 mg/kg
Labetalol (Trandate)	10 mg IV over 1 2 min; repeat or double dose q 10 min (150 mg max); or initial bolus, then 2 8 mcg/min
Lidocaine	Cardiac arrest from VF/VT refractory VF: Initial: 1 1.5 mg/kg IV, additional 0.5 0.75 mg/kg IV push, repeat in 5 10 min, max total 3 mg/kg. ET: 2 4 mg/kg. Perfusing stable VT, wide complex tachycardia or ectopy: 0.5 mg/kg IV push; repeat 0.5 0.75 mg/kg q 5 10 min; max total 3 mg/kg; Maint 1 4 mg/min (30 50 mcg/min)
Magnesium Sulfate	VF/pulseless VT arrest with torsades de pointes: 1 2 g IV push (2 4 mL 5% solution) in 10 mL D5W. If pulse present then 1 2 g in 50 100 mL D5W over 5 60 min
Metropolol	5 mg slow IV q 5 min, total 15 mg
Morphine	2 4 mg IV (over 1 5 min) then give 2 8 mg IV q 5 15 min as needed
Nitroglycerin	IV: infuse at 10 20 mcg/min, by 5 10 mcg/min every 3 5 min. PRN. SL: 0.3 0.4 mg, repeat q 5 min. Aerosol spray: Spray 0.5 1.0 s at 5-min intervals
Nitroprusside	0.1 5 mcg/kg/min (max dose 10 mcg/kg/min)
Procainamide	Stable monomorphic VT, HR control in a fib, AV reentrant narrow complex tachycardia: 20 mg/min IV until one of these: arrhythmia stopped, hypotension, QRS widens >50%, total 17 mg/kg; then maintenance infusion of 1 4 mg/min
Propanolol (Inderal)	0.1 mg/kg slow IV push, divided 3 equal doses q 2 3 min, max 1 mg/min; repeat in 2 min PRN
Reteplase, Recombinant (Retavase)	10 U IV bolus over 2 min; 30 min later, 10 U IV bolus over 2 min NS flush before and after each dose
Sodium Bicarbonate	1 mEq/kg IV bolus; repeat dose q 10 min PRN
Sotalol (Betropace)	1 1.5 mg/kg IV over 5 min then 10 mg/min
Streptokinase	AMI: 1.5 million IU over 1 h. PE: 3 million IU over 24 h
Tirofiban	ACS or PCI: 0.4 mcg/kg/min IV for 30 min, then 0.1 mg/kg/min
Vasopressin (Pitressin)	40 units IV; ET 40 units in 10 mL NS
Verapamil (Verapmil)	2.5 5 mg IV over 1 2 min; repeat 5 10 mg, in 15 30 min PRN max of 20 mg; or 5 mg bolus q 15 min (max 30 mg)

ACS = acute coronary syndrome; PCI = percutaneous coronary intervention; PRN = as needed; AMI = acute MI; VT = ventricular tachycardia; VF = ventricular fibrillation; PEA = pulseless electrical activity; ET = endotracheal tube; NS = normal saline; HR = heart rate; PTT = partial thromboplastin time; SL = sublingual

Stroke

Stroke is also called "brain attack." A similar caveat as for the heart holds true: "Time is brain." Signs and symptoms of a stroke include:

• Facial droop
• Change in mental status
• Pronator drift
• Unilateral motor weakness
• Slurred speech
• Syncope
• Difficulty swallowing
• Confusion

In the field, EMS personnel use the Cincinnati Prehospital Stroke Scale or the Los Angeles Prehospital Stroke Screen to determine the likelihood that a patient may have a stroke (Table 21 4). Carefully determine time of symptom onset. This step is crucial in decision making regarding the use of thrombolytics in a stroke patient without bleeding. Measure a fingerstick glucose level to detect possible hypoglycemia. If hypoglycemia is present, correct it immediately. Perform a neurologic screening exam, draw samples for lab work, order an emergency CT scan, obtain a 12-lead ECG, and take the patient to the CT suite. Activate the stroke team. The AHA stroke algorithm is in Figure 21 5.

Table 21 4 Two Systems for Field Evaluations of Stroke Risk

Cincinnati Prehospital Stroke Scale 

If any of these signs are present, the probability of a stroke is 72%:

  Facial droop: Ask patient to smile; sign is present if one side does not move as well as the other

  Arm drift: Ask patient to close eyes and hold arms out for 10 s; sign is present if one arm does not move or drifts downward

  Abnormal speech: Sign is present if the patient slurs speech or uses wrong words

Los Angeles Prehospital Stroke Screen 

If any of these factors are present, there is high likelihood of a stroke in a patient with a nontraumatic neurologic complaint:

  Age > 45 y

  No seizure or epilepsy history

  Symptoms present < 24 h

  Patient not wheelchair bound or bedridden at baseline

  Blood glucose 60 400 mg/dL

  Asymmetry of face, grip, or arm strength

Based on data from Circulation 2005;112:IV-111 IV-120.

Figure 21 5.

Algorithm for management of suspected stroke. NINDS = National Institute of Neurological Disorders and Stroke. (Reproduced with permission from Circulation 2005;112:IV-111 IV-120.)

Other Common Emergencies

Anaphylaxis

Allergic Reaction with Systolic BP < 90 mm Hg or Airway Failure

Epinephrine 

Drug of choice Dose: Adults. IV bolus: 100 mcg of 1:100,000 over 5 10 min (mix 0.1 mL of 1:1,000 epi in 10 mL NS). IV inf: 1 4 mcg/min. Peds. IV inf: 0.1 0.3 mcg/kg/min, max 1.5 mcg/kg/min

Allergic Reaction with Systolic BP > 90 mm Hg

Epinephrine

Dose: Adults. 0.3 0.5 mL (1:1000) SQ. Peds. 0.01 mL/kg (1:1000), max 0.5 mL

Supplemental drugs for anaphylaxis include:

Diphenhydramine

Dose: Adults. IV/IM/PO 50 mg. Peds. IV/IM/PO 1 mg/kg

Methylprednisolone

Dose: 1 2 mg/kg IV

Ranitidine (Zantac)

Dose: Adults. IV 50 mg over 5 min. Peds. IV 0.5 mg/kg over 5 min

Albuterol

Dose: Adults. 2.5 mg nebulized. Peds. 1.25 mg nebulized

Asthma Attack: Mild

Albuterol (Nebulized)

Dose: Adults. 2.5 5.0 mg at 20 min for up to 3 doses in first hour. Peds. 1.25 2.5 mg at 20 min for up to 3 doses in first hour. Supplemental oxygen to keep sats > 90%

Asthma Attack: Moderate to Severe

Ipratropium Bromide (Nebulized)

Dose: Adults. 0.5 mg combined with first albuterol treatment. Peds. 250 mcg with first albuterol treatment. Give continuously or every 20 min for first hour.

Levalbuterol (Xopenex)

Dose: 0.63 1.25 mg nebulized q6 8h

Methylprednisolone

Dose: Adults. 60 125 mg IV. Peds. 2 mg/kg IV Supplemental oxygen to keep sats > 90%

Asthma Attack: Severe

Administer aerosolized beta-agonists with anticholinergic continuously. Intubate and ventilate with 100% oxygen if impending or actual respiratory arrest. Administer IV corticosteroid.

Methylprednisolone

Dose: Adults. 60 125 mg IV. Peds. 2 mg/kg IV

Anticholinergic Toxicity

Usually related to drug overdose. Patients present "Hot as Hades, Blind as a Bat, Dry as a Bone, Red as a Beet, Mad as a Hatter."

Physostigmine

Controversial; use only when seizures, coma, hypotension, agitation are refractory to conventional therapy Dose: 0.5 2.0 mg IV Note: Administer S-L-O-W-L-Y (can cause seizures if given rapidly). Have cardiac monitor attached and resuscitation equipment at the bedside. Use only in consultation with the poison control center or a toxicologist

Coma

1. Establish and secure airway (protect cervical spine if trauma has occurred).

2. Assess for respiratory failure and shock; use BLS and ACLS techniques as appropriate.

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

4. Administer 1 amp (50 mL) of D₅₀ IV manually; consider checking a stat glucose first. If not hypoglycemic, can worsen stroke outcomes.

5. Administer 100 mg thiamine IV.

6. Give 0.4 mg naloxone (Narcan) IV (see Opioid Overdose).

7. Obtain fingerstick glucose, SMA, CBC, urinalysis, and ABG. Consider ECG, CT of head (see Seizures, Status Epilepticus).

Dental Emergencies

Not including facial fractures, there are generally two major categories of dental emergencies: toothaches with associated abscesses and avulsed (knocked-out) teeth. Most toothaches can be managed with antibiotics (usually penicillin-V 500 mg, q6h) and analgesics until proper dental attention can be obtained. Drain fluctuant abscesses if convenient. The exception to this rule is submandibular or infraorbital swelling. With submandibular infections, Ludwig angina, a life-threatening occurrence, can develop. Hold these patients for observation with special attention to maintaining the airway until a dental consult can be obtained. Infraorbital infections can lead to cavernous sinus thrombosis if allowed to progress.

Avulsed teeth may or may not have an associated dentoalveolar fracture. Reposition the displaced tooth in the socket within 30 min or as soon as possible. If the tooth root is dirty, wash it gently with sterile saline solution. Do not scrub or scrape the root. Obtain a dental consult to arrange to have the tooth splinted back in the socket.

Hypercalcemia

See Chapter 9, Hypercalcemia.

Hyperkalemia

See Chapter 9, Hyperkalemia.

Hypertensive Crisis

Treat only if signs of end organ damage are present.

Do not reduce MAP > 20 25% over 30 60 min.

Labetalol

Dose: 20 mg IV bolus then 2 mg/min IV to target BP or

Sodium Nitroprusside

Dose: 0.5 mcg/kg/min to max (10 mcg/kg/min)

Hypoglycemia

1. Draw a stat serum glucose. Do not wait for result before treating if hypoglycemia is 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 Adults. 1 amp of D₅₀ IV Peds. 1 mL/kg (D₁₀ for newborn).

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

Opioid Overdose

Naloxone (Narcan)

Dose: Adults. 0.4 2.0 mg IV or IM, repeat as needed. Note: If you suspect the patient is addicted to narcotics, give 0.4 mg and repeat PRN to avoid severe withdrawal. Peds. 0.01 0.02 mg/kg IV or IM, repeat PRN.

1. Observe patient for at least 6 h after treatment.

2. Manage airway by intubation if airway failure not immediately responsive to naloxone. (See Coma.)

Poisoning (Common Agents)

1. Support airway, respiration, and circulation, as needed. Note: Do not use Ipecac syrup to induce vomiting; it is no longer a recommended treatment.

2. Determine ingested substance; give specific antidote, if available. Call Regional Poison Center for assistance (1-800-222-1222). Some common poisons with their antidotes (Adult, unless specified) are in Table 21 5.

3. Prevent further absorption as described for consciousness level.

Table 21 5 Antidotes for Common Poisoning Emergencies

Acetaminophen	N-acetylcysteine, 140 mg/kg PO, then 70 mg/kg x 17
Anticholinesterases	Atropine 0.5 2 mg IV; may need up to 5 mg IV every 15 min if severe poisoning
Benzodiazepines	Flumazenil 0.2 mg IV (see Flumazenil [Romazicon])
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 or hyperbaric 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	NaHCO3 3 amps (50 mg/50 mL) in 1 L D5W at 2 3 mL/kg/h
Digoxin	Digoxin-specific Fab
	Number of vials =
Ethylene glycol	Fomepizole 15 mg/kg slow infusion
Methanol	Fomepizole (see above) or ethanol loading dose 1 g/kg of a 10% solution slowly IV, followed by an infusion of 130 mg/kg/h to keep serum level of 100 150 mg/dL
Opiates	Naloxone, see Naloxone (Narcan)

Unconscious Patient

1. Protect airway with an endotracheal tube.

2. Consider lavage with an Ewald tube or 28 Fr or larger NG tube, if ingestion has occurred within the last hour.

3. Use a series of 300-mL NS boluses through the NG or Ewald tube for adults and 20-mL/kg boluses for children.

4. Consider using activated charcoal with sorbitol unless an oral antidote is to be given.

Conscious Patient

1. Consider giving activated charcoal 1 g/kg; contraindicated for iron, lithium, lead, alkali, acid. Also give 70% sorbitol solution (2 mL/kg body weight). Monitor any patient given sorbitol for hypokalemia and hypomagnesemia.

2. Attempt to promote excretion through IV hydration.

3. Administer alkalinization (0.5 1 mEq/kg/L in IV fluids) for salicylates, barbiturates, tricyclics.

Seizures, Status Epilepticus

Status epilepticus refers to 30 min or more of continuous seizure activity or two or more seizures without recovery of consciousness between seizures.

Initial Supportive Care

1. Maintain airway with cervical spine precautions.

2. Deliver oxygen by nasal cannula.

3. Monitor ECG and blood pressure.

4. Maintain normal temperature.

Pharmacologic Therapy

1. Establish IV, administer thiamine 100 mg IV (Table 21 6).

2. Administer 1 amp of D₅₀ IV in an adult (2 mL/kg D₂₅ in children) unless obviously hyperglycemic.

3. Administer IV lorazepam or diazepam initially (midazolam 0.2 mg/kg); can be given IM in children if no IV.

4. If seizures persist, give fosphenytoin or phenytoin.

5. If seizures persist, give phenobarbital, paraldehyde.

6. If still no response, obtain emergency neurosurgery and anesthesiology consultations.

Table 21 6 Drugs for the Management of Status Epilepticus

Drug	Pediatric Dose (mg/kg)	Adult Dose	Maximum Rate (mg/min)
Diazepam (Valium)	0.10 0.20 IV	5 10 mg IV (up to 30 mg)	3 5
Fosphenytoin	NA	20 mg/kg IV	150
Paraldehydea	0.15 0.3 mL/kg PR	30 mL PR	NA
Phenytoin (Dilantin)b	15 IV	Same as for child	50
Phenobarbitalc	10 IV or IM	120 140 mg IV	100

NA = not applicable.

^aWhen given rectally, mix 2:1 with cottonseed or olive oil.

^bWhen given IV, use a maximum dose of 50 mg/min and monitor ECG and vital signs closely. Can cause severe hypotension and bradycardia. Mix with NS to prevent precipitation.

^cIndicated when the patient is allergic to phenytoin, patients may need intubation.

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