LF Protocols

STEMI

1. 12-lead confirmation (15-lead if inf)

2. 324 mg ASA

3. 0.4 mg NTG q 5 min max 3 

4. Fent/Morphine for pain 

5. Brilinta 180 mg (if not given full dose of plavix 600 mg or going to a GMC or St Lukes facility) 

6. Heparin 60 units/kg (4000 units max)

7. Discontinue all drips 

Rupture or Leaking AAA

1. x2 large bore IVs 

2. perfusion of extremities? 

3. Obtain imaging 

4. Fent/morphine for pain

5. Give blood! Use sending facilities if possible 

6. permissive hypotension (90 SBP) 

7. < 80 SBP bolus of 250 ml of NSS to be >80 

8. SBP > 140 = contact MC for nicardipine 

9. On blood thinner? Think of reversal agents 

10. Document onset of symptoms 

Aortic Dissection

1. x2 large bore IVs 

2. Perfusion to extremities? 

3. Obtain imaging 

4. Fent/morphine for pain 

5. Goals: HR < 60; SBP < 120

6. Labetolol first (10 mg pushes over 2 min q 10 min until goal or max 40 mg met) 

7. Esmolol - titrate by 25-50 mcg/kg/min until goal met (max 300) 

8. Goals not met? Nicardipine (tell me how to set up and titrate) 

Airway Management - Indications/Preoxygenate

- Indications: decrease MS, airway obstruction/impending one, inhalation burns, s/s of respiratory failure, inadequate ventilatory effort

-Preoxygenate: 15 lpm NC and NRB (or CPAP/BVM) 

Airway Management - PICA Criteria

Adult: SBP < 90, SI > 0.9, SPO2 < 94%, Age > 70, morbidly obese

Peds (6-11): SIPA >1.0 

Peds (1-5): SIPA > 1.2 

If the patient has positive PICA criteria, what do you do? 

Identify the problem and attempt to fix the problem 

What is the number one important thing to have prepared prior to intubation?

Suction

Airway Management - Standard RSI

Sedative for induction:

• Etomidate: 0.3 mg/kg (Max 30 mg)

• Ketamine 2 mg/kg (Max 200 mg)

• Versed 0.1 mg/kg (Max 10 mg)

Paralytic

• Succinylcholine 2 mg/kg (Max 200 mg)

• Rocuronium 1 mg/kg (Max 100 mg)

Airway Management - Modified RSI

Sedative for induction

• Ketamine 1 mg/kg (Max 100 mg)

• Etomidate 0.15 mg/kg (Max 15 mg) 

HAVE PUSH DOSE READY 

• Epi 10-20 mcg 

• Neo 50-100 mcg 

• Peds: Epi 1 mcg/kg (max 20) 

Paralytic For Induction 

• Succinylcholine 2 mg/kg (Max 200 mg) 

• Roccuronium 1 mg/kg (Max 100 mg) 

Airway Management - Analgesia and Sedation

Analgesia:

• Fentanyl 0.5-1 mcg/kg (Max 100 mcg/dose)

• Morphine: 2-5 mg (max 10 mg)

Sedation:

• Versed 0.05 mg/kg (Max 5 mg)

• Ketamine 1 mg/kg (max 100 mg)

• Propofol 25 -150 mcg/kg/min (tritrate for RASS)

*if hypotensive use ketamine and fentanyl

Contraindications for Succ

• suspected hyperkalemia or known hyperkalemia (>5.5)

• burns > 24 hours

• neuromuscular disorders

• globe injuries

• crush injuries

• PMH of Malignant hyperthermia

• PMH of spinal cord injury

Contraindications for Ketamine 

• schizo 

• heart disease (HTN risk) 

Airway Management - Long Term Neuromuscular Blockade

• only given after adequate sedation and analgesia

• indications: failure to properly ventilate, excessive patient movement and poses a risk to crew or indwelling catheters

• Rocc 1 mg/kg (Max 100 mg)

What is FloLan?

Epoprostenol

• used to treat pulmonary HTN in severe patients with heart failure

Transport Ventilator Ops - Adult NIV-ST

• BiPAP 

• PIP (IPAP): 15 

• PEEP (EPAP): 5 

• FIO2: 100% titrate 

Transport Ventilator Ops - Adult NFNC 

• Flow: 40-50 lpm 

• FiO2: 100% - titrate

Transport Vent Ops - APVcmv

• tidal volume 6-8 ml/kg/IBW

• rate: 12-15

• flow trigger: 5

• FiO2: 100% titrate

• PEEP: 6

• PIP: <30

• Pplat: <30

Transport Vent Ops - ASV

• minute ventilation: 100%

• FiO2: 100% titrate

• PEEP: 6

• PIP: <30

• Pplat: <30

Transport Vent Ops - Peds APVcmv

• Tidal Volume: 7mL/kg 

• Vent rate: 18-25 bpm depending on age 

• Flow trigger: 5

• FiO2: 100% titrate 

• PEEP: 5 

Transport Vent Ops -Infant (non-NICU) APVcmv

• Tidal volume: 7 mL/kg

• Ventilation rate: 20-40 bpm

• Flow trigger: 5

• FiO2: 100% titrate

• PEEP: 5

• I:E: 1:4

Restraint and Sedation

• used for anxious patients on the helicopter

• as well as combative patients

• standing orders for soft restraints

• Versed 0.1 mg/kg IM (max 10 mg)

• Versed 0.05 mg/kg IV (max 5 mg)

• Droperidol 5 mg IM or 1.25 mg IV

  • only for patients >14 yrs old

  • avoid in pts with TBI or PMH of seizures

SIRS criteria

Temp > 38.3 C or < 36

HR > 90

RR > 20 or PaCO2 < 32

WBC > 12,000 or < 4,000 or >10% bands

Sepsis Criteria (& Severe)

• Presence of SIRS criteria

• Suspicion of infection or proven infection

Severe:

• Lactate > 4

• Hypotension

• UOP < 0.5 mL/kg/hr for more than 2 hours despite adequate resus

Adult Sepsis Treatment 

1. fluids (30mL/kg) - can give additional if improvement in vitals from initial 

2. Vasopressors 

   1. Norepinephrine 8-12 mcg/min (max 40 mcg)

   2. Epinephrine 2-10 mcg/min (max 20 mcg)

   3. Phenelyephrine 100-180 mcg/min (max of 350)

   4. Vasopression 0.03 u/min

3. Corticosteroids 

   1. Decadron 4 mg IVP

4. Additional considerations 

   1. Antibiotics given?

   2. Tylenol? 

ICH Protocol

• isotonic fluids only 

• on a blood thinner? reverse that as long as it does not delay transport significantly 

• HOB > 30 degrees

• Seizures? Versed

• SEDATION AND ANALGESIA

• No evidence of ICP 

  • SBP 140-160

  • No lower!

• Evidence of ICP 

  • SBP 160-180

  • ICP monitoring? CPP 60-95

• Signs of impending herniation? 

  • 3% hypertonic saline 3 mL/kg (max of 300 mL) over 20 min

  • hyperventilation ETCO2 30-35

Ischemic Stroke Protocol

• exclusion: signs of trauma or radiographic signs of ICH 

• MRACE > 5 = LVO, need thrombectomy 

• Noted LTKN and Time of Onset 

• HOB < 30 

• HAVE received reperfusion therapy 

  • 180/105

• SUSPECTED/EXPECTED reperfusion therapy 

  • 185/110

• NO REPERFUSION

  • <220/120

Antihypertensive: Labetolol & Nicardipine

Re-implantation centers with neurovascular microsurgery

• Hershey Medical Center 

• Jefferson University Hosp

• University of Pitt 

If your patient is < 1 month and has a tension pneumothorax, what needle are you using?

2.5 cm 21-23 g butterfly

If your patient is 1 month - 12 yrs and has a tension pneumothorax, what size needle are you using?

1.5” 14-16g angiocath

If your patient is > 13 yrs old and has a tension pneumothorax, what size needle should you use?

Spear needle

Pericardiocentesis Indications

• Radiographically confirmed pericardial tamponade of a symptomatic patient

• traumatic cardiac arrest

• orders given by medical command

Beck’s triad 

• JVD 

• Muffled heart tones 

• Hypotension

Cushing’s triad

• bradycardia

• hypertension

• tachypnea (abnormal Resp pattern)

TXA indications & dose

• > 15 yrs old

• evidence of hemorrhagic shock

• SI > 0.9

• Hypotension (SBP > 90)

• initial injury < 3 hrs ago

• Post-partum hemorrhage

• Dose:

  • 2 g bolus IVP

TXA contraindications

• isolated head injury or spinal injury 

• time of injury onset > 3 hours 

• known sensitivity 

• non-hemorrhagic shock

Blood protocol 

Indictions: 

• Pts > 1 yr of age w/ blunt or penetrating trauma 

• AAA 

• GI bleed 

• Post-partum hemorrhage 

Exclusion: 

• Patient < 1 yr of age 

• hypovolemic/hemorragic shock not due to indications 

Order: 

• WB then Frozen Plasma then pRBCs 

Ages > 12 = SBP < 90 and SI > 0.9

Ages 1-11 = 10 mL/kg and can repeat once 

• SIPA 1-5: >1.2 

• SIPA 6-11: >1 

Considerations: 

• Giving more than 2 units? Calcium Chloride 1 amp over 10 min 

• X2 large bore IVs 

• TXA 

• Reversal of blood thinner

• Transfusion RXN (need temp before and 15 min after blood admin) 

Antibiotics for Open Fractures

• > 15 yrs old

• No allergies to other antibiotics

• Zosyn: 4.5 g over 30 min