Stanford Emergency Manual

For adults. pick up w/bronchospasm, pg 6

When doing CPR, what are you goal end tidal CO2 and diastolic BP measurements?

ETCO2 > 10

DBP > 20 mmHg

In adults, if you have a shockable rhythm, what is your monophasic and biphasic dose for defribrilation?

Mono - 360 J

Bi - 200 J

In adults, what is the atropine dose for bradycardia?

0.5-1mg, q3minutes

max 3 mg

What is the next step after atropine for bradycardia? Dose?

Epinephrine, 5-10mcg

What infusions would you consider for refractory or persistent bradycardia?

Epinephrine 0.02-0.3 mcg/kg/min

Dopamine 5-20 mcg/kg/min

If pacing for bradycardia, what settings do you use?

Rate minimum 80 bpm

Increase current (mA) by 10 until you have capture (confirm w/pulse)

Set pacer output to 10 mA above mechanical capture

What is the electrical dose for unstable SVT with that is narrow complex with regular rhythm?

Synchronous 50-100 J biphasic

What is the electrical dose for unstable SVT with that is narrow complex with irregular rhythm?

Synchronous 120-200 J

What is the electrical dose for unstable SVT with that is wide complex with regular rhythm?

Synchronous 150J biphasic

What is the electrical dose for unstable SVT with that is wide complex with irregular rhythm?

Unsynchronous 200 J biphasic

What steps should you take if a pt has stable SVT that is wide complex and irregular?

Likely polymorphic SVT, consult cardiology STAT and start magnesium infusion

What medications should you consider for a pt with stable SVT that is narrow complex with regular rhythm?

Adenosine

Esmolol

Metoprolol

Diltiazem

Adenosine dose and contraindications for SVT

6mg followed by 12mg

Avoid in WPW or asthma

Esmolol dose and contraindications for stable SVT

0.5mg/kg, repeat in 1min

Infusion of 50-300mcg/kg/min

Avoid in WPW, pts with reduced EF, &/or asthma

Metoprolol dose and contraindications for stable SVT

1-2.5mg, can repeat or double in 3-5 minutes

Avoid in WPW, pts with reduced EF, &/or asthma

Diltiazem dose and contraindications for stable SVT

10-20mg over 2 minutes. Can repeat in 5 minutes

Infusion 5-10 mg/hr

What medications should you consider for a stable pt with SVT that is wide complexed and regular?

If h/o CAD/MI, likely CT, amiodarone

Adenosine

Procainamide

Procainamide dosing and contraindications in SVT

20-50mg/min (max 17mg/kg) until arrhythmia is suppressed

Infusion 1-4 mg/min

Avoid if pt has reduced EF, prolonged QT

What medications should you consider for a stable pt with narrow complex and irregular rhythm?

Esmolol

Metoprolol

Diltiazem

Amiodarone

What is amiodarone’s infusion rate?

1 mg/min, then can go to 0.5mg/min after 6(?) hours

When do you start amiodarone for a pt in cardiac arrest with VF/pVT?

After the 3rd shock

What is the magnesium dose for a pt in torsades or with hypomagnesemia?

1-2g

Why do we give epineprhine in anaphylaxis?

To prevent mast cell degranulation

What is the dose of epinephrine in anaphylaxis?

IV: 10-100mcg, increase q2min if no response. May need >1mg. Early infusion

IM: 500mcg

What should be on your differential for anaphylaxis?

Anesthetic overdose

Aspiration

Distributive or obstructive shock

Hemorrhage

Sepsis

Pneumothorax

MI

Hypotension

Embolism

What are the signs/symptoms of anaphylaxis?

Severe hypotension

Cardiac arrest

Wheezing

Bronchospasm

High inspiratory pressures

Angioedema

Airway swelling

Tachycardia

Arrhythmia

Itching

Rash

Flushing

Hives

If your patient has angioedema, what should you consider?

Early intubation

If persistent hypotension in anaphylaxis, what infusions should you consider?

Epinephrine, then vasopressin or norepinephrine

How do you treat bronchospasm in anaphylaxis if unable to ventilate?

IV Epinephrine 5-10mcg (or 200mcg subq)

IV Ketamine 10-50mg (40mg IM)

IV Magnesium 1-2g

How do you treat bronchospasm in anaphylaxis when you can ventilate?

Albuterol 4-8 puffs MDI or 2.5mg nebulized

Sevoflurane at 1 MAC

How do you treat persistent bronchospasm?

IV H1 antagonist - diphenhydramine 25-50mg

IV H2 antagonist - famotidine 20mg

IV Corticosteroids - hydrocortisone 100mg or methylprednisolone 125mg

What labs should you draw specifically for anaphylaxis?

Serum tryptase level 2hrs after onset

What should dispo be after anaphylaxis and shock?

Monitor at least 6 hrs after. If severe, then a biphasic response is more likely, should be in ICU