Lisbon Fire Department Standard Operating Guidelines and Policies
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DRUG ACTION: Nonsteroid anti-inflammatory, analgesic, antipyretic INDICATIONS FOR USE Mild to moderate pain CONTRAINDICATIONS Allergy to NSAIDS or aspirin Possibility of surgery in near future (increases bleeding) Head injuries Renal insufficiency
SPECIAL NOTES: Pregnancy category C USUAL DOSE: Adult: 30 mg IV, 60 mg IM Geriatric, known renal failure: 15 mg IV, 30 mg IM
Vital signs, response to medication END DRUG PROFILE
The following is the basic information and guideline for use of: LORAZEPAM (ATIVAN)
DRUG ACTION: Sedative, anticonvulsant (benzodiazepine) INDICATIONS FOR USE Seizures
Status epilepticus Premedication for cardioversion Sedation Chemical restraint CONTRAINDICATIONS Allergy to the drug Glaucoma
SPECIAL NOTES: Can be reversed with flumazenil Can be given rectally if IV access is not available Short shelf life if not refrigerated Pregnancy category D
0.5-2 mg IV bolus (adult) 0.05 – 0.1 mg/kg (pediatric)
Vital signs, response to medication END DRUG PROFILE
The following is the basic information and guideline for use of: MEPERIDINE (DEMEROL)
DRUG ACTION: Narcotic analgesic, central nervous system depressant INDICATIONS FOR USE Moderate to severe pain CONTRAINDICATIONS Allergy to the drug Head, chest or abdominal trauma Undiagnosed abdominal pain MAO inhibitors
SPECIAL NOTES: Addictive Can be reversed with naloxone Pregnancy category B (D at term) USUAL DOSE: 25-50 mg IV MONITOR, REPORT, DOCUMENT Vital signs, response to medication END DRUG PROFILE
The following is the basic information and guideline for use of: NALBUPHINE (NUBAIN)
DRUG ACTION: Synthetic narcotic analgesic INDICATIONS FOR USE Moderate to severe pain CONTRAINDICATIONS Allergy to the drug Head, chest or abdominal trauma Undiagnosed abdominal pain SIDE EFFECTS Respiratory depression Headache Hypotension Bradycardia Nausea, vomiting Blurred vision Altered level of consciousness SPECIAL NOTES: May precipitate withdrawal in addicts Can be reversed with naloxone (see drug profile 014) Pregnancy category C USUAL DOSE: 2-5 mg IV MONITOR, REPORT, DOCUMENT Vital signs, response to medication END DRUG PROFILE
The following is the basic information and guideline for use of: NITROUS OXIDE* *Currently under pilot project study for use in 9-1-1 services
DRUG ACTION: Analgesic and anesthetic gas, central nervous system depressant INDICATIONS FOR USE Moderate to severe pain Reduction of anxiety, particularly in pediatric patients
Allergy to the drug Head, chest or abdominal trauma Unable to follow simple directions Pneumothorax Abdominal distention/bowel obstruction Altered level of consciousness or unable to understand instructions Decompression sickness (bends) SIDE EFFECTS Dizzy Nausea, vomiting Altered level of consciousness Hallucinations SPECIAL NOTES: Self administered by inhalation Mixed 50:50 with oxygen Inhalation is associated with spontaneous abortion (consideration for both patient and rescuer who may be pregnant) Be sure the driver and patient compartments are well ventilation USUAL DOSE: Inhalation until pain is relieved or patient drops mask MONITOR, REPORT, DOCUMENT Vital signs, response to medication END DRUG PROFILE
The following is the basic information and guideline for use of: PROMETHAZINE (Phenergan)
DRUG ACTION: Antihistamine, Antiemetic INDICATIONS FOR USE: Nausea and Vomiting Motion sickness
Allergy to the drug Comatose states Patients with history of dystonic reactions (Excessive muscle tone, muscle spasm and postural abnormalities after taking certain medications) Seizure disorders Hypotension Current bronchospasm secondary to asthma or COPD Concomitant use of other anticholinergic drugs (Atropine, Monoamine Oxidase Inhibitors, etc.) Patient with history of Neuroleptic Malignant Syndrome (NMS) Patients who are CNS depressed (alcohol, barbiturates, narcotics) Children with unknown etiology for vomiting
Sedation & Respiratory depression May impair mental and physical ability Allergic reaction Dysrhythmias (tachycardia. bradycardia) Blurred vision (dilated pupils) Dystonic reactions (muscle spasm, fixed postures, strange movement patterns) Lower seizure threshold SPECIAL NOTES: Use with caution in patients who are using other sedating medications Use precaution in patients with asthma, peptic ulcer, and bone marrow depression IM injection is the preferred route (take care to avoid intra-arterial injection) Dystonic reactions can be treated with Diphenhydramine (Benadryl) 25-50mg IVP Pregnancy Safety - Category C (generally considered safe for use during labor) (? Breast milk) USUAL DOSE: Adult: 12.5 – 25mg IM Pediatric: 0.5 – 1mg/kg IM, Not for younger than 2 y/o
Vital signs within 5 min of administration, Altered LOC, Drowsiness, Dysrhythmias, effectiveness END DRUG PROFILE
The following is the basic information and guideline for use of: SUCCINYLCHOLINE
DRUG ACTION: Depolarizing neuromuscular blocker, onset of action 60-90 seconds, duration 4-5 minutes INDICATIONS FOR USE Skeletal muscle paralytic used to facilitate endotracheal intubation CONTRAINDICATIONS Allergy to the drug Penetrating eye injuries Narrow angle glaucoma History of malignant hyperthermia
SPECIAL NOTES: Should not be administered unless personnel are confident they will be able to intubate An alternative airway should be immediately available in case you are unable to intubate. Lidocaine, beta blockers, magnesium sulfate and other neuromuscular blockers enhance the blocking action Paralytic action does not affect the level of consciousness or pain sensation, patients receiving the drug must also receive sedation Paralysis starts in the eyelids and jaw, progresses to extremities, abdomen and finally diaphragm and intercostals Pregnancy category C USUAL DOSE: 1-1.5 mg/kg IV MONITOR, REPORT, DOCUMENT Vital signs, pulse oximetry, respiratory and cardiovascular status END DRUG PROFILE
The following is the basic information and guideline for use of: VECURONIUM
DRUG ACTION: Nondepolarizing neuromuscular blocker, paralysis of muscle fibers INDICATIONS FOR USE Muscle relaxation to facilitate endotracheal intubation when succinylcholine is contraindicated To extend period of paralysis after intubation with succinylcholine
Allergy to the drug SIDE EFFECTS Wheezing Respiratory depression Apnea Arrhythmias (bradycardia, sinus arrest) Hypertension or hypotension Increased intraocular pressure Increased intracranial pressure SPECIAL NOTES: Should not be administered unless personnel are confident they will be able to intubate An alternative airway should be immediately available in case you are unable to intubate Lidocaine, beta blockers, magnesium sulfate and other neuromuscular blockers enhance the blocking action Paralytic action does not affect the level of consciousness nor pain sensation, patients receiving the drug must also receive sedation Pregnancy category C
0.08-0.1 mg/kg IV Onset of paralysis in 1 minutes, lasts 25-30 minutes
Vital signs, pulse oximetry, respiratory and cardiovascular status END DRUG PROFILE
The following is the basic information and guideline for use of: MARK-1 AUTO-INJECTORS (aka DuoDote®)
*Requires Operational Plan DRUG ACTION: Reverses toxic effects of chemical nerve agents (Sarin, Soman, Tabun, VX) or organophosphates (pesticides) in Weapons of Mass Destruction situations INDICATIONS FOR USE Mark 1 kit use is strictly intended for personal protection. Mark 1 auto-injectors may be used if signs and symptoms of poisoning by one of the above agents is present or if known exposure has occurred prior to signs or symptoms. CONTRAINDICATIONS Allergy to atropine or pralidoxime SIDE EFFECTS Atropine: blurred vision, increased blood pressure, palpitations, tachycardia Pralidoxime: Tachycardia, nausea, vomiting, visual disturbances, hypertension
Mark 1 kits may be self-administered or administered by another EMT Immediately evacuate the contaminated area. If dermal (skin) exposure has occurred, decontamination is critical and should be done with standard decontamination procedures. Consider request for ALS transport or intercept. Intermediate(99) and Paramedic level providers carry Atropine as one of their standard medications. Continued pre-hospital treatment with Atropine is essential to survival. Mark-1 kits are not intended for treatment of patients. Mark-1 kits are for “rescue” of EMS providers. HazMat or Disaster stockpile Mark-1 kits may be used to treat any victim per local HazMat guidelines. USUAL DOSE Adult EMS personnel: 1 atropine auto-injector, followed by 1 pralidoxime auto-injector (Note: Mark 1 kits are now marked as DuoDote® and contain both medications in a single syringe) MONITOR, REPORT, DOCUMENT Respiratory rate and quality of respirations Changes in level of consciousness Vital signs within 5 minutes after administration Decontamination procedures
The following is the basic information and guideline for use of: ONDANSETRON HYDROCHLORIDE (ZOFRAN)
DRUG ACTION: Antiemetic INDICATIONS FOR USE Nausea and vomiting CONTRAINDICATIONS Known hypersensitivity to the drug Use with caution in patients on Selective Serotonin Reuptake Inhibitors (SSRIs: i.e. Paxil, etc), Those on multiple SSRIs, or those who may have overdosed on a SSRI medication SIDE EFFECTS Headache Constipation Sensation of flushing or warmth SPECIAL NOTES: Zofran is not effective in preventing motion-induced nausea and vomiting Pregnancy category B
0.1 slow mg/kg IV bolus for patient less than 40 kg (pediatric) 4 mg slow IV bolus for patient greater than 40 kg (pediatric)
Continuous ECG Vital Signs before and within 5 minutes after administration
DRUG PROFILE
The following is the basic information and guideline for use of: NITROGLYCERIN DRIP
DRUG ACTION: Vasodilator Decreased venous return
Chest pain of cardiac origin (ischemic), angina unrelieved with at least three sublingual nitroglycerin sprays/tablets Acute Congestive Heart Failure/Pulmonary Edema requiring careful blood pressure control Angina with systolic blood pressures less than120 but greater than 100 who may not tolerate sublingual administration Angina with right ventricular myocardial infarction who may not tolerate larger doses of nitrates
Hypotension (systolic pressure less than100 mmHg) Use of sildenafil (Viagra) within the past 24 hours Use of tadalafil (Cialis), vardenafil (Levitra) within the past 48 hours SIDE EFFECTS Headache Hypotension (systolic pressure less than100 mmHg) Tachycardia Use with caution in patients with inferior AMI SPECIAL NOTES: Drug is sensitive to light and moisture Medication is stored in a glass bottle Medication must be administered with approved nitroglycerin IV tubing Medication must be administered with infusion pump to ensure precise flow rates Pregnancy Category C USUAL DOSE: Adults:
Infusion 50 mg in 250 ml (200 micrograms per ml) Angina: Start infusion rate of 3-6 ml/hour (10-20 micrograms/min) and increase this infusion rate by 3-6 ml/hour (10-20 micrograms/min) every 3-5 minutes up to a rate of 12 ml/hour is reached (40 micrograms) If systolic blood pressure drops quickly, is below 90 mmHg, or patient becomes hemodynamically unstable, decrease drip rate or stop administration accordingly. If chest pain/discomfort is relieved and blood pressure is stable, maintain current drip rate. If higher doses are needed, contact medical control Hypertensive emergencies with CHF/pulmonary edema: Blood pressure greater than 180/100, start infusion at 12 ml/hour (40 micrograms/min) and contact medical control
MONITOR, REPORT, DOCUMENT Continuous ECG Vital Signs and pain assessment every 3-5 minutes during administration Blood pressure before and after increases in medication dose END DRUG PROFILE
The following is the basic information and guideline for use of: LEVALBUTEROL HYDROCHLORIDE (XOPENEX)
DRUG ACTION: Bronchodilator INDICATIONS FOR USE Treat or prevent bronchospasms of bronchial asthma CONTRAINDICATIONS Hypersensitivity to the drug or to albuterol Children less than 6 years of age unless specific physician prescription Women who are breast feeding SIDE EFFECTS Headache
Dizziness Tremors
Tachycardia SPECIAL NOTES: Use with caution in patients with cardiovascular disease, seizure disorders or diabetes mellitus Pregnancy category C
Adult: 0.63 – 1.25 mg by nebulizer Pediatrics (6-11 years old): 0.31 mg by nebulizer
Vital signs before and within 5 minutes of administration Breath sounds and respiratory effort Monitor ECG in adults over 40 years of age or with cardiac history END DRUG PROFILE
The following is the basic information and guideline for use of: ZIPRASIDONE HYDROCHLORIDE (GEODON)
DRUG ACTION: Antipsychotic INDICATIONS FOR USE Patients suspected to be experiencing excited delirium CONTRAINDICATIONS Hypersensitivity to Geodon Known history of : QT prolongation, Acute MI (within 3 months), Uncompensated Heart failure Known current use of other agents that prolong QT (ie. Sotalol, Quinidine, Risperidone, Haloperidol, etc.. ) Known history of Neuroleptic Malignant Syndrome or Tardive Dyskinesia Known current use of other agents that cause dystonia (ie. Compazine, Phenergan, Reglan, etc. ) Bradycardia or heart block
Orthostatic Hypotension, Seizures, Hyperthermia SPECIAL NOTES: Consider 10mg dosage for those greater than 65 years of age or those less then 120 pounds Pregnancy category C Onset time 10-20 min. Should be avoided in patients known to be currently (within last 3 days) using Geodon When used with benzodiazepines may cause significant hypotension and respiratory depression May precipitate extrapyramidal or dystonic reaction
Adult (post puberty): 10 – 20 mg IM (not approved IV) Reconstitute vial with 1.2ml of Sterile Water (20mg / ml) Pediatric: Not approved MONITOR, REPORT, DOCUMENT Continuous ECG and Oxygen Saturation monitoring as soon as practical Closely monitor airway and manage/support accordingly Vital signs and behavior before if possible and every 5 minutes after administration if possible. Document details demonstrating high likelihood of excited delirium
DRUG PROFILE
The following is the basic information and guideline for use of: PROPOFOL (DIPRIVAN)* *For Interfacility Services with Approved Training Plan and competency components
DRUG ACTION: Rapid acting hypnotic Decreases vascular resistance
Sedation
Induction and maintenance of anesthesia CONTRAINDICATIONS Increased intracranial pressure Impaired cerebral circulation Children less than 3 years of age SIDE EFFECTS Involuntary muscle movements Apnea (common during induction Hypotension Nausea and vomiting Burning/stinging at the IV site SPECIAL NOTES: Rapid onset (40 sec), lasts 3-12 hours Lower dose for elderly Use with caution in the debilitated, those with cardiovascular, respiratory or renal disease Rapid administration produced severe hypotension and respiratory depression Pregnancy category B USUAL DOSE 5 micrograms/kg/min for 5 minutes until peak effect reached MONITOR, REPORT, DOCUMENT Vital signs before administration and every 3-5 minutes during administration END DRUG PROFILE
The following is the basic information and guideline for use of: Metoprolol (Lopressor)
DRUG ACTION: Beta-adrenergic blocker (predominately cardioselective – Beta 1) INDICATIONS FOR USE Acute Coronary Syndrome (ST Elevation MI – STEMI) Rare pre-hospital use (only with specific on-line medical control): Narrow complex SVT, A Fib with RVR, Hypertension
Bradycardia (HR less then 50) AV Blocks (except 1st degree) Hypotension (BPs less then 100 mmHg) Acute CHF COPD
Asthma Concurrent allergic reaction from any cause Raynaud’s disease Cocaine use Known allergy
Bradycardia, hypotension, precipitation or exacerbation of CHF, peripheral vasospasm, Bronchial Spasm SPECIAL NOTES: Use caution in patients with inferior wall MI (prone to bradycardia and hypotension) It is not unusual to increase time between doses if concern for bradycardia or hypotension Not an ideal beta-blocker for treatment of hypertension Any administration of Metoprolol requires on-line medical control USUAL DOSE Preparation: 1mg/ml in 5 ml syringe Adults: 5mg slow IV push – Dose may be repeated every 5 minutes to max of 15mg total infused (it is very uncommon for more then 2 doses to be administered in the prehospital setting) MONITOR, REPORT, DOCUMENT Continuous ECG monitoring Vital signs every 5 minutes after administration and between doses. Be sure to include as part of verbal and written report DRUG PROFILE
The following is the basic information and guideline for use of: KETAMINE (KETALAR, KETANEST, KETASET)
DRUG ACTION: Dissociative anaesthetic with hypnotic, analgesic and amnesic effects, stimulates central nervous system, INDICATIONS FOR USE 1) Sedation of a violent individual, particularly after “Taser” use to subdue the person (suspected excited delirium) {Recognize off label use – can not be routinely supported as general practice} 2) Pain management for extremely painful condition that will not be effectively treated with opiates (ie. Entrapment and crush with need for rapid extrication) 3) Sedative / induction agent for asthmatic requiring intubation
SIDE EFFECTS Tachycardia Hypertension Decreased level of consciousness Respiratory depression, short period of apnea following administration if administered IV rapidly Hallucinations (as drug is wearing off) Salivation SPECIAL NOTES: Medical control contact required for on line orders Psychological dependence common, illicit use common, Schedule III drug Pregnancy : Category D
3-5 mg/kg IM MONITOR, REPORT, DOCUMENT END DRUG PROFILE
The following is the basic information and guideline for use of: Enalapril (Vasotec)
DRUG ACTION: Angiotension Converting Enzyme Inhibitor (ACE inhibitor) INDICATIONS FOR USE 1) Hypertensive emergency (ie. BPs greater than 180, BPd greater than 110) with CHF / Pulmonary Edema CONTRAINDICATIONS
SIDE EFFECTS Hyperkalemia (chronic use) Renal failure (chronic use) SPECIAL NOTES: Medical control contact required for on line orders Third line agent and should not be considered until NTG and CPAP have been used Pregnancy category : D
The following is the basic information and guideline for use of: Hydroxocobalamin (Cyanokit)
DRUG ACTION: Hydroxocobalamin binds to cyanide molecules and is converted to cyanocobalamin, which is then eliminated from the body in the urine. INDICATIONS FOR USE Known or suspected cyanide poisoning. To be administered only after consultation with medical control. CONTRAINDICATIONS Known allergy to hydroxocobalamin. SIDE EFFECTS Elevated blood pressure. Headache. Nausea and vomiting. Infusion site reaction, generalized rash and or ‘flushing’ reaction. Potential for anaphylactic type reactions. SPECIAL NOTES: Hydroxocobalamin is incompatible for administration in the same IV with numerous medications, including dopamine, dobutamine, fentanyl, and nitroglycerine. Initiate a second IV exclusively for administration of hydroxocobalamin. Hydroxocobalamin interferes with numerous laboratory tests. If possible, draw a ‘rainbow’ of blood tubes prior to administration to facilitate further evaluation of the patient upon arrival to the ED (1 dark green, 1 mint green, 2 lavender, 1 gold top, and 1 blue top).
Cyanokit contains: Two 250 ml glass vials, each containing 2.5 grams hydroxocobalamin for injection. Two sterile transfer spikes. One sterile IV infusion set. One quick use reference guide. One package insert. Diluent (normal saline) is not included. Once reconstituted in normal saline, hydroxocobalamin must be stored at a temperature above freezing and less than 104F and discarded if not used within 6 hours.
*Example: 10 kg child would receive 70 mg/kg x 10kg = 700mg dose. 700 mg dose / (25 mg / ml of solution) = 28 ml dose administered over 15 minutes.
Vital signs every 10 to 15 minutes. Report and document any adverse reactions or significant change in patient clinical status, or, significant deviations in vital signs or cardiac rhythm. END
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