ft - lmher.com guidelines october 2015.doc · web viewgout 21 head injury/concussion 22...

ER ‘Guidelines’Shane Barclay MD, Revised October 2015

PageAcute Chest pain, STEMI, NSTEMI (TNK) 2 - 3ACS Admission orders – post ER 4 - 5Acute Pulmonary Edema (CHF) 6Airway Management (Rapid Sequence Induction) 7Analgesics/Anesthetic – Conscious Sedation, 8Anaphylaxis 9Asthma 10Atrial Fibrillation – decompensated 11Bites – Human and Animal 12Bronchiolitis 13Burns 14 – 15Burn management/dressing using Aquacel Ag 16Coma 17Croup 18Diabetic Ketoacidosis 19Frostbite 20Gout 21Head Injury/Concussion 22Hypertensive Emergencies/Urgencies 23Hypoglycemia 24Hypothermia 25Intravenous Lipid Emulsion therapy (ILT) 26Migraine Headaches 27Overdose – Benzodiazepine 28

- Misc. (other alcohols, cocaine, opioid, TCA, PCP) 29-31 - Acetaminophen 32Pediatric analgesia and conscious sedation 33Post Cardiac Arrest Care 34Sedation for Severe Agitation/Alcohol Withdrawal 35Seizures – Adult 36Seizures – Pediatric 37Shock / Hypotension 38-40Spinal Cord Injury 41Ventilator Support (settings) 42-44ATLS Protocol 45-47Glasgow Coma Scales (Adult and Pediatric) 47Procedures: Chest tube, Tick removal, Zipper injury, ABI 48-55 Subungual hematoma, Fishhook removal, Priapism,

Shoulder DislocationIV drugs in the ER 56-59

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Acute Chest Pain – Management1. Oxygen to maintain O2sats > 90%2. Cardiac Monitor (on LifePac), BP, HR, SaO2. RR.3. Aspirin – ASA 160. Have patient chew and swallow. 4. Nitrospray: 1 spray q 10 minutes x 3, prn (check no recent Viagra, Cialis, etc.)

5. IV access – 2 or 3 lines preferably, above diaphragm. May start 2 lines in one arm.

6. ECG should be done ASAP. 7. If pain persists, Morphine 2.5 – 5 mg IV q 5 min. As long as systolic

BP > 100. NB Caution with Inferior MI’s.8. If pain still persists, consider Nitro drip IV. Start at 10 mcq/min or 3

drops/min. See page 21. (caution with Inferior MI’s)9. Draw blood for CBC, CPK, LDH, BUN, Creat, Lytes, PT, PTT, and

Troponin. CK/CK-MB if previous MI within 14 days.10. Beta-blocker – if systolic BP > 100, HR >50, no Rt. heart failure

(Caution with COPD, ASTHMA)Metoprolol 50 mg orally Or if uncontrolled HTN, ongoing angina, use Metoprolol 5 mg IV slowly q 5 min x 3 doses (total 15 mg), then in 1 hour give 50 mg PO

11. Atorvostatin 80 mg po stat 12. Ramipril 1.25 mg PO up to 5 mg PO13. CXR if possible (supine if necessary)If STEMI (acute MI) 14. Consider Thrombolytic Therapy (TNKase)

Patient Weight Pt. Weight TNKase Reconstituted Kg Lbs TNKase (ml/cc)< 60 < 132 30 6< 60 - < 70 > 132 - < 154 35 7> 60 - < 80 > 155 - < 176 40 8> 80 - < 90 > 177 - < 198 45 9> 90 > 199 50 10

15. Age < 75 yrs.: Clopidogrel 300 mg-600 PO stat. Enoxaparin 30 mg IV after TNK plus 1 mg/Kg s.c. (Max s.c. dose is 100 mg) Caution in renal insufficiency (see page 4). Continue with Enoxaparin 1mg/Kg s.c. q 12hrs. Age > 75 yrs.: Clopidogrel 300 mg stat

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Unfractionated Heparin Patient Weight Heparin I.V. Bolus Initial Heparin Infusion

41-50 kg 2700 units 550 units/hr. = 11ml/hr.51-60 kg 3300 units 650 units/hr. = 13ml/hr.61-70 kg 3900 units 750 units/hr. = 15ml/hr. 71-80 kg 4000 units 900 units/hr. = 18ml/hr.

>80 kg 4000 units 1000unit/hr. = 20ml/hr.

If NSTEMI or Unstable angina Do 1 – 13 above 16. Clopidogrel 600 mg Stat 17. If GFR > 30 Fondaparinux 2.5 mg SC (and then daily x 2 days)

If GFR < 30 Unfractionated Heparin – bolus then infusion. Patient Weight Heparin I.V. Bolus Initial Heparin Infusion

41-50 kg 2700 units 550 units/hr. = 11ml/hr.51-60 kg 3300 units 650 units/hr. = 13ml/hr.61-70 kg 3900 units 750 units/hr. = 15ml/hr. 71-80 kg 4000 units 900 units/hr. = 18ml/hr.


Inclusion/Exclusion Criteria for TNKaseExclusion Criteria:Absolute Yes No1. Active internal bleeding (except menses)< 10days ___ ___2. Suspected aortic dissection ___ ___3. Previous hemorrhagic stroke at any time,

Other strokes or CVA within 2 – 6 months. ___ ___4. Known intra-cranial neoplasm, AVM, aneurysm ___ ___5. Intra-spinal surgery or trauma within 2 months ___ ___6. Known bleeding diathesis ___ ___Relative 7. Severe uncontrolled hypertension at

presentation (BP> 200/>120) ___ ___8. Other intracranial pathology ___ ___9. Current use of warfarin (INR >2-3) ___ ___10. Recent trauma (2-4 wks.), including head trauma ___ ___11. Prolonged (>10 min), potentially traumatic CPR ___ ___12. Major surgery (< 3wks prior) ___ ___13. Non compressible vascular bleeding ___ ___14. Pregnancy, post-partum < 6 weeks ___ ___15. Active peptic ulcer. ___ ___

16. Diabetic retinopathy, history of laser Sx. ___ ___ 17. Allergic reaction to Thrombolytic ___ ___ 18. Advanced Liver disease, with INR > 2-3 ___ ___ 19. Acute Pericarditis ___ ___Inclusion Criteria: (acute MI1. Chest pain consistent with MI (onset within

6 hrs. or presented to clinic after 6 hours, with onset of pain equal to or less than 12 hours) ___ ___

2. Evidence of MI ___ ___- anterior: > or = to 2 mm ST elevation in 2 contiguous leads (V1-V6)- inferior: > or = to 1 mm ST elevation in 2 inf Leads (II, III, AVF)- lateral: > or = 1 mm ST elevation in 2 lateral leads (V5, V6, I, AVL) or new Left Bundle Branch block.

3. Lack of ST normalization and pain after s.l. nitro ___ ___

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Admission orders: ACS – post ERMRP ________________________________________Patient AGE______, WT ________kg, GFR ________.Code Status ______________________________Diet: Healthy heart, Diabetes, NPO, Other ______________________.Activity: Bed rest, Commode, Activity as tolerated, Advance activity prn ASA 325 mg po daily Oxygen @ ___ Liters/min, or to maintain Oxygen Sats > 90%ECG Daily x _____ daysUrinary catheter - In and Out catheterization for retention PRNLab: Fasting lipid profile x 1, Fasting glucose x 1Daily: CBC, GFR, Na, Cl, K, CO2. Repeat troponin at _____________ hrs. IV normal saline lock or ___________________________Nitroglycerin 0.4 mg sublingual q 5 min PRN for chest pain is systolic BP > 90 Nitroglycerin patch _____mg/hr. at ____h and off at ___ h. Keep on overnight first night.Acetaminophen 500-1000 mg q 6 h PRN for mild pain or fever. Clopidogrel 75 mg po daily Morphine ________ mg IV q 5 min PRN if systolic BP > 90. Metoprolol 25 mg po BID or Metoprolol ______ mg po BID Atorvostatin 80 mg po daily or _______________________________Ramipril 5 mg po daily or _______________________________Dimenhydrinate 12.5 – 25 mg IV q 4 h PRNPantoprazole 40 mg PO daily or, Ranitidine 150 mg PO BIDLorazepam 1 mg hs PRN or _______________________________Zoplicone 7.5 mg hs PRN Laxatives as indicated by RN, PRN

STEMI patients – post thrombolysis in ER. Age < 75 years

Enoxaparin: GFR > 30: 1 mg/Kg S.C. q 12 h for 48 hours. GFR < 30: 1 mg/Kg S.C. q 24 h for 48 hours.

Age > 75 years Enoxaparin: GFR > 30: 1 mg/Kg S.C. q 12 h for 48 hours. GFR < 30: 1 mg/Kg S.C. q 24 h for 48 hours. Unfractionated Heparin x 48 hours

Patient Weight Heparin I.V. Bolus Initial Heparin Infusion41-50 kg 2700 units 550 units/hr. = 11ml/hr.51-60 kg 3300 units 650 units/hr. = 13ml/hr.61-70 kg 3900 units 750 units/hr. = 15ml/hr. 71-80 kg 4000 units 900 units/hr. = 18ml/hr.


Be Be Be BeBe Be Be

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NSTEMI patients/Unstable Angina – no thrombolysis.GFR > 30: Fondaparinux 2.5 mg S.C. daily.GFR < 30 unfractionated heparin x 48 hrs.

Patient Weight Heparin I.V. Bolus Initial Heparin Infusion41-50 kg 2700 units 550 units/hr. = 11ml/hr.51-60 kg 3300 units 650 units/hr. = 13ml/hr.61-70 kg 3900 units 750 units/hr. = 15ml/hr. 71-80 kg 4000 units 900 units/hr. = 18ml/hr.


____________________ _______________ ______________ ______________Signature, Designation College License# Date Time

Inferior MI 1. If suspect inferior MI or if ST depression V1-3, do 15 lead ECG r/o

posterior MI2. IVs, monitor, labs, ECG3. 15 lead ECG4. TNK – if severely hypotensive (MAP < 65), consider pressors (below)

before giving TNK. i.e. there may not be enough perfusion for the TNK to work.

5. Have patient on Lifepak and have amp of Atropine handy6. If hypotensive, give small fluid boluses to maximum 1 liter7. If still hypotensive, consider Norepinephrine drip – start 5-8 mcg/min8. If still hypotensive, consider adding Dobutamine Start 2 mcg/kg/min9. Fentanyl for pain – 25 mcg aliquots and consider infusion.

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Acute Pulmonary EdemaIF Adequate Perfusion (i.e. MAP > 65 and warm extremities)1. Oxygen only if hypoxic. Position patient upright. 2. Non-invasive ventilation (NIV), PEEP 6-8, titrate up to 10-12 as needed.3. Search for causes (ACS, HTN, arrhythmia, acute aortic or mitral valve regurgitation, aortic

dissection, sepsis, renal failure or anemia) and treat appropriately. (see Vent support page 42)

4. Intubate ONLY if apneic/agonal respirations.5. Vasodilators – Nitrogylcerin S/L x 4 puffs, then IV infusion starting at 40

mcg/min, increase by 50 mcg/min q 2-4 min up to 200 mcg/min.6. If Pt in extremis, bolus Nitro loading dose of 400mcg/min x 2 min, then

then drop to 100 mcg/min. Titrate up prn (Take 200mcg/ml mixture, set pump rate to 120cc/hr. Set volume to be infused 4 ml – will give 400 mcg/min x 2 min. Or you can take 4 ml nitro and 6 ml NS and give IV over 2 minutes)

7. +/- ACE Inhibitor – SL Captopril 12.5 – 25 mg 8. Fentanyl 20-25 mcg IV for ‘mask anxiety’ 9. Labs, CXR, ECG

IF Hypotensive (decompensated CHF) (Cardiogenic shock MAP < 65)1. Oxygen, vital signs and monitor. 2 IVs large bore. 2. Order ECG, CXR, Labs Search for causes (ACS, PCE, PE, arrhythmia, acute aortic

or mitral valve regurgitation, aortic dissection or sepsis) and treat appropriately.3. Most of these Pts are complex, consider call to ICU on call physician. 4. Provide non-invasive ventilation (NIV) unless immediate intubation is

needed. NIV will often increase BP.5. Consider Fluid challenge, 250 – 500 cc N/S over 5 minutes.(Rt HF)6. Lasix 40 mg IV7. If known systolic heart failure - Use Inotrope: Dobutamine 2 mcg/Kg/min

and increase to a maximum 20 mcg/Kg/min.8. If known diastolic heart failure with signs of hypotension– Use IV

Vasopressor - Phenylephrine 0.5mcg/kg/min and titrate. (NO inotropes) 9. If unknown cardiac status and signs of hypotension/shock –

Use Inotrope – Dobutamine 2 mcg/Kg/min and titrate up.10. If refractory, can add pressor – Norepinephrine start 2 mcg/kg/min 11. Once BP established start low dose Nitro drip and titrate.12. Fentanyl 20-25 mcg IV prn for anxiety.

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Airway Management – RSI Protocols1. Check neck for potential cric, have cric kit.2. Positioning – sniffing position, ideally head up 30 degrees 3. Check for dentures – in for bag mask, out for intubation. 4. Preoxygenation – 100% NRB mask or BVM at 15 lpm x 4 minutes.5. Attach in line EtCO2 monitor to BVM6. Have OPA and NPA available in proper size if not already in use. 7. Have proper size LMA available with syringe and lubricant. 8. Pick ET tube. Check balloon with 10 cc air, leave syringe attached. Place stylet or have bougie

handy. 9. +/-‘Lube the tube’ – put small amount of sterile lube jelly on ETT tip10. Choice of laryngoscope. Check bulb working. Have spare laryngoscope handy. 11. Suction – turn on, place handle under right shoulder of patient or under pillow.12. Have Epinephrine push dose on hand – 5-10 mcg/kg IV (or Phenylnephrine 100 mcg/ml)13. Designate someone to watch monitor. Announce if Sats < 90% or MAP < 65 mmHg. Normotensive, neurologically stable patient: 14. Pretreatment agent? – Fentanyl 3 mcg/kg 15. Induction agents – Ketamine 2 mg/kg or Propofol 1.5 – 3 mg/kg (or Midazolam 0.3 mg/kg TBW) 16. Neuromuscular blocking agents – Succinylcholine 2 mg/kg or Rocuronium 1.2 mg/kgHypotensive/Shock patient 14. Consider Scopolamine 0.4 mg IV 15. Induction agents – Ketamine 0.25 mg/kg or Propofol 0.1 – 0.15 mg/kg 16. Neuromuscular blocking agents – Succinylcholine 2 – 2.5 mg/kgElevated ICP/Traumatic head injury patient 14. Have Labetalol 20-25 mg IV on hand for elevated systolic pressure. 15. Induction agents – Ketamine 2 mg/kg 16. Neuromuscular blocking agents – Succinylcholine 2 mg/kg

Asthmatic patient 14. If time permits can give Lidocaine 1.5 mg/kg 3 minutes prior 15. Induction agents – Ketamine 2 mg/kg 16. Neuromuscular blocking agents – Rocuronium 1.2 mg/kg or Succinylcholine 2 mg/kg

17. Cricoid pressure – BURP18. Intubate – place ETT 23 cm to lips for males, 21 cm to lips for females. Inflate balloon.

Secure tube.19. Confirm – listen to chest, check EtCO2 (or colorimetric after 8 breaths)20. Order CXR to confirm ETT depth21. Post intubation medications – Fentanyl or morphine infusion. +/- sedation 22. Place NG tube, in line suction23. Head of bed up 30-45 degrees. 24. Foley catheter. 25. Ventilator settings.

Mode: ACFiO2 100%RR 10-14 bpm for Normotensive or Hypotensive.

14 - 18 bpm for ICP 6 - 10 bpm for Asthmatic Tidal Volume 8 cc/kg IBW for all patients (except pneumonia, may be less: 6-8)

PEEP 5 or as needed for all except asthmatics. 0 for asthmatics initially. Give bronchodilators continuously for asthmatics.

26. Foley catheter. 27. ABG within 30 minutes post intubation.

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Analgesia/Anesthetic for Minor Procedures“Conscious Sedation”

Resuscitation Setup1. Oxygen (prongs or mask)2. Atropine 0.4 –0.6 mg amp3. Ephedrine 50 mg/cc diluted with N/S in 5 cc syringe to strength of 10mg/cc. Give 1 cc to

increase BP and HR)4. Narcan 0.4 mg. Can dilute in 5 cc syringe N/S. Give 1 – 2 cc (80-160 mcg or 1-2 mcg/kg)

to reverse respiratory depression. 5. Anexate

Monitors: BP, O2 Sats, 3 lead ECG and if available, End Tidal C02 monitorSuction:

IV: one 22 or larger.Airway: Working Laryngoscope, Oral airway, ET tube on introducer or LMA with Ambubag.Drugs for Conscious Sedation:

1. Midazolam: 0.02 mg/kg to maximum 2 mg IV slowly over 5 minutes. A drop of BP is often best indicator of sedation. NB: obese/sleep apneic patients are very sensitive to Midazolam and may be sedated with as little as 1 mg of Versed

Or 1a Propofol: dose 0.5 – 2 mg/kg. Synergistic effect if used with Midazolam so may have possible apnea.

+ 2. Fentanyl: Initial dose is 0.5 mcg/kg (50-100mcg for average adult). Time of onset is 3–4 minutes and lasts 45 minutes.

If respiratory depression, can reverse with Narcan, but Narcan may wear off before Fentanyl so may need second dose.

Or 3. Ketamine 1-2 mg/kg over 1-2 minutes. May repeat 0.25-0.5 mg/kg

Have on hand:4. Succinylcholine: Dose 1 mg/kg (comes in 20 mg/cc (have on hand in case patient becomes apneic and

you need to intubate.)5. Narcan: have drawn up or ready. Use to reverse narcotics (fentanyl)6. Anexate: have drawn up or ready. Use to reverse benzodiazepines (midazolam)7. Ephedrine: have on hand for hypotension, highly recommended.8. Atropine: have on hand for bradycardia, highly recommended.

Oral Sedation for Pediatrics: (setting fractures, LPs, suturing etc)1. Midazolam (Versed) 0.25 - 0.5 mg/kg up to maximum 8 mg. (tastes awful) 2. Mix with Tylenol 20 mg/kg.3. can add artificial food tastes

Onset is about 10 – 15 minutes and lasts ~ 30 minutes.

“Quick” Estimate/Calculation of Pediatric Weight< 8 yr. old = (age x 2) + 8 ~ ____kg

>9 yr. old = (age x 3) ~ ____kg

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AnaphylaxisClinical Presentation

1. Respiratory compromise. Wheezing, dyspnea, stridor2. Hypotension – Systolic < 90 mmHg. 3. Skin/mucosal involvement – hives, itch, flushing, swollen lips /tongue/uvula,

pilar erection 4. Persistent gastrointestinal symptoms – cramps, abdominal pain, vomiting.5. Anxiety, apprehension, sense of impending doom. 6. Seizures, headache.7. Uterine cramping and/or bleeding.

NB: often anaphylaxis may present as a mild reaction, but can turn into a severe reaction within minutes… be prepared!Beware of biphasic anaphylaxis -25% pts have recurrence of symptoms 8-72 hrs. after initial reaction. Treatment:1. Epinephrine 0.3 -0.5 mg of 1:1,000 IM q 5 min. (Peds: 0.15 mg of

1:1,000 IM) (there are NO absolute contraindications to epi)2. If no response, start epi infusion. Start 1-5 mcg/min then titrate 3. Antihistamines: Benadryl 2 mg/Kg up to 50 mg IM, PO, IM – help with

itch and hives but do not treat bronchospasm. 4. Oxygen, 10 – 15 L/min.5. IV volume resuscitation as needed. 6. Ranitidine 50 mg IV – helps with itch, but not anaphylaxis 7. Consider Methylprednisolone 125 mg IV or 1-2 mg/kg PO daily – may

prevent biphasic reaction only. 8. Ventolin 5 mg via nebulizer for bronchospasm9. Consider Glucagon 1-5 mg IV q 5 min if Pt on beta blockers. Then

infusion of 5-15 mcg per minute.

NB: most common contributor to anaphylaxis related death is not identifying anaphylaxis and/or delaying treatment with epinephrine

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Asthma

Adult Treatment 1. Oxygen 2. Ventolin 2 puffs MDI via aero chamber q 5 min up to 12-15 puffs3. Or Ventolin 2.5 – 5 mg in 3 cc N/S via neb, q 5 - 10 min.4. Add Atrovent aqueous 250 – 500 ug to Ventolin. 5. If severe, try Epinephrine 0.3 of 1/1,000 S.C. or 2 – 10 ml of 1:10,000 IV

q 20min x 3.6. Steroids: Prednisone 40 – 60 mg PO daily x 7 – 10 days, or

Methyprednisolone 125 mg IV x 1 dose, or Hydrocortisone 200 – 500 mg IV x 1 dose.

7. Mg Sulfate 2 gms IV over 20 mins (if status asthmaticus)8. Consider IV hydration (Normal saline), as often these patients are

dehydrated.

Pediatric Treatment1. Oxygen2. Ventolin 2 puffs via aero chamber, q 5 minutes up to 12 puffs.

Or Ventolin 0.1 mg/Kg (ie 2 – 5 mg) in 2 – 3 cc N/S via neb.3. Atrovent 250 ug via neb (can mix with Ventolin)4. Epinephrine 0.01 mg/Kg of 1:1,100 (up to 0.3 mg) S.C.

Repeat prn q 5 – 10 minutes x 3 doses.5. If no response after 1 hour (as per Peek Flow) give:

Prednisone 1- 2 mg/Kg PO daily x 3 – 5 daysor Methylprednisolone 1 – 2 mg/Kg q 6 h x 24 hours, then 1 mg/Kg q 12 hours.

6. Consider IV hydration.7. MgSo4 30-70 mg/kg (max 2 gms) over 20 min for status.

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Atrial Fibrillation – Decompensated

This section deals only with decompensated A Fib. Hypotensive.

1. Cardioversion – 360 J. with sedation (ketamine?). Usually doesn’t work2. Screen for WPW. If wide QRS and Rate 250-300 – Cardioversion+.3. Phenylephrine take 1 cc from vial (10 mg/ml) add to 100 ml N/S

minibag. Draw up some in syringe – 100mcg/ml. Give .5 - 1 cc q 1-5 min. until diastolic above 60.

4. Amiodarone 150 mg bolus and then drip 5. Or Diltiazem 2.5 mg/min until HR <100 or maximum 50 mg. 6. If still tachycardic, consider MgSO4, re-shock and consult cardiology.

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Bites – Animal and Human

1. All wounds should have vigorous cleaning. Use lidocaine for freezing, clean surface with 1% Povidone iodine, then copious saline in the wound. Avoid high pressure irrigation into the wound.

2. X-ray all ‘closed fist’ hand bite injuries. (i.e. cut over knuckles from hitting other person’s teeth)

3. Cultures of non-infected wounds are of no valueWound Infection Risk Factors

“High Risk” “Low Risk”Bite from: Cat, human dog, rodentWound on: hand, below knee, face, scalp, mucosal

over joint, thru & thru oralWound type: puncture (deep), extensive large, superficial, clean, crush, contaminated,

recent (< 24 hrs)old (> 24 hrs)

Patient: elderly, diabetic, alcoholic

Wound Care and Prophylactic Antibiotics Suture Proph. Antibiotic? Antibiotic. PCN allergyDog yes if high risk Clavulin or Doxy + Clinda

Clinda + CiproCat Face only all Clavulin Doxy + Clinda

or Doxy + ClindaHuman No all Clavulin Doxy + Clinda(on hand)Human Yes high risk Clox, Keflex Doxy + Clinda(not hand)Self inflictedIntraoral Yes No - -Self inflictedThru & thru oral Yes Yes Pen V ClindamycinFor all wounds: check for Tetanus immunization status.Suture only if 1. Uninfected, 2. < 12 hours old (< 24 hrs. on face), 3. NOT on the hands or feet. Indications for Hospital Admission for Human Bites1. Wound > 24 hours old2. Established infection3. Penetration of joint or tendon sheath4. Bone involvement5. Foreign body6. Diabetic7. Unreliable patient, poor home situation

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Bronchiolitis

Clinical: Usually infants < 2 years old, acute onset cough, fever and runny nose for 1 – 2 days, followed by expiratory wheezing, tachypnea, and respiratory distress. If severe, may have nasal flaring, intercostal retractions subcostal in-drawing and cyanosis. Has a variable course and lasts usually a week but can last 3 – 4 weeks.Most common cause is Respiratory Syncytial virus (RSV). Treatments:Do RSV swabsMild: Resp. Rate < 40 breaths/min, Sp02 > 92%Treatment: hydrate, symptomatic (humidified air)Moderate: Resp. Rate 40 – 60/min, moderate in-drawing, nasal flaring, wheezes/rales, costal retractions. Treatment: Oxygen to maintain SpO2 > 90%. (NB O2 is mainstay of Trt! In fact the only treatment that has been shown to consistently help!)

Saline via nebulization PRNWait 1 hour – if improved (Sa02 > 92%) discharge

- if not improved, try Epinephrine 0.05 ml/Kg 3-5 mL of 2.25% solution in 3 ml NS; administer with jet nebulizer over ~15 minutes every 3-4 hours

- Try? Ventolin 0.03 ml/Kg (.15 mg/Kg/dose) in 2 cc N/SWait one hour as above. If no improvement, consider admission.

Severe: As for Moderate + Resp. Rate > 60/min, cyanosis, apneic spells.Treatment: as above, transfer.Note: Transfer any patient < 3 months old or who has congenital cardiopulmonary

disease (of any age).Corticosteroids have been shown to decrease recurrence of bronchiolitis. Not recommended in healthy infants or for first episode of bronchiolitis. Inhaled steroids are ineffective. When indicated, usual dose is Dexamethasone 1 mg/Kg IM daily x 3 days.

Ribavirin, which inhibits RSV, is for children with proven RSV and who are at risk for severe infections (ie underlying cardiac or pulmonary disease, < 6 weeks old, metabolic disease, etc.)

Discharge when:1. Respiratory rate < 602. Caretaker can clear infant’s airway using bulb suctioning3. Patient is stable without supplemental oxygen. 4. Patient has adequate oral intake to prevent dehydration.

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5. Caretakers are confident they can provide care at home.

Burns – Thermal1st Degree Burn - Superficial

Minor epithelial damage, no blistering.2nd Degree Burn – Partial thickness

a) Superficial partial thickness – thin walled, fluid filled blister, tender, heal in 2 – 3 weeks.

b) Deep partial thickness – thick walled, commonly rupture, and heal in 3 – 6 weeks.

3rd Degree BurnFull thickness, white leathery appearance, no pain sensation.If > 1 cm in diameter, usually need skin grafting.

4th Degree BurnFull thickness with underlying fascia, muscle, bone etc. involved.

AssessmentPatients palm is approximately 0.5% Body Surface Area (BSA), palm and fingers (ie hand) is 1%Use burn sheets with diagrams.

Minor Burns- 1st or 2nd Degree Burn- < 10% BSA child or < 20% BSA adult.- Not over palms, fingers, feet, joints, genitalia or head.

1. If burn occurred within 30 minutes, immerse in cold water for 30 min.If burn < 9% BSA, may use local cooling for more than 30 minutes.

2. Remove any local jewelry and burned clothing.3. Leave blisters on palms and soles intact.4. Blisters elsewhere, aspirate sterilely or remove surface with scalpel.5. Tetanus shot if indicated.6. Topical antibiotics of little or no benefit.7. Prophylactic antibiotics NOT indicated.8. After cleaning/debriding, apply strips of sterile, fine mesh gauze soaked in

saline. Cover with Flamazine and Telfa dressings. May need to secure in place with elastic roller gauze.

9. Elevate injured part if possible.10. Analgesics as necessary.11. Mobilize injured part after 24 hours.12. Follow up in 48 hours. Remove outer gauze, if inner gauze adherent to

dry pink wound, simply cover with new 4x4 gauze.

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13. Follow up in 4- 5 days. Follow as in 12 above. Because most superficial partial thickness burns heal in 10-14 days, spontaneous separation of gauze from burn will occur.

14. If burn exhibits purulent discharge at any time, remove fine mesh, cleanse with saline. Apply Flamazine and apply Telfa dressing. Remove cream completely with saline and reapply BID.

15. Encourage use of sun block when necessary over burn x 6 months.

Major Burns – Need Transfer to Burn Center Transfer if 1st or 2nd Degree Burn and:

- > 10% BSA if < 10 or > 50 years old- > 20% BSA adult- Head, feet, hands, genitalia, major joints.- Inhalation injury known or suspected.3rd Degree Burn- > 5% BSA- Inhalation injury

1. ABC’s, 2. Humidified oxygen @ 10-12 L/min.3. Elevate legs if hypotensive.4. Remove all burned clothing and jewelry.5. Immerse burn in cool water or gauze (12 degrees) for 15 min if burn is

less than 30 minutes old and < 20% BSA. Applying cool water to large BSA can cause hypothermia. DO NOT APLY ICE. Monitor core temp.

6. If transferring to burn center, do not dress burns, just cover in dry sheets.7. IV – Ringers lactate at 2 – 4 ml/BSA/24 hrs. Give ½ in first 8 hours.8. Foley9. Maintain urine output at 30 – 50 ml/hr adults, 1 ml/Kg/hr children.10. Blood for CBC, LFT, lytes, GFR, carboxyhemoglobin, ABGs.11. CXR and ECG. 12. If nausea, vomiting insert NG tube.13. IV narcotics for pain (morphine 5 – 15 mg prn)14. Cover burn with clean linen. DO NOT APPLY ICE.15. Do NOT give prophylactic antibiotics.

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Burn Care using Aquacel Ag

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Coma Management

1. ABC’s with C-Spine control if indicated.2. Glasgow coma scale. 3. IV’s and Oxygen4. ECG, Temp5. Do finger prick glucose6. Draw blood for CBC, hepatic panel, lytes, Ca, CK, Mg, blood cultures7. Urine for drug screen 8. If blood glucose < 3, give 50 mls of 50% glucose (25 gms) over 3 – 4

minutes IV9. Thiamine 100 mg IV10. Narcan 2 mg IV bolus11. If febrile (meningitis?) draw blood for blood cultures, then start empiric

antibiotic. Ceftriaxone 2 gm IV (it crosses the blood brain barrier)This will NOT affect a lumbar puncture test if done within the next 60 hours.

“DONT” Coma Cocktail1. Dextrose2. Oxygen3. Narcan 0.4 mg4. Thiamine 100 mg IV/IM

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Croup

Clinical: usually 2 – 3 days of URTI, low grade fever, runny nose, then ‘seal bark’ coughs – usually at night. Cough lasts 3 – 4 nights and is usually fine during the day.

Treatment: Cool mist – ie advice parents to take child in bathroom and put on cold shower to fill room with cool mist.

In ER:Mild/Moderate: Sa02 > 93%, Resp. Rate < 60/min, may

have retractions with crying.- N/S 3 – 5 cc via nebulizer- If no change/improvement - Epinephrine 5 ml of 1:1,000 via neb.

Repeat q 20 min.- Dexamethasone 0.6mg/kg PO (or IM/IV) x 1 dose- + Pulmicort 2 mg (2 ml) via nebulizer may help if not improving.

Severe: Sa02 < 93%, R.R. > 60/min, stridor & retractions at rest- 1/1,000 Epinephrine as above.- Pulmicort 2 mg via neb x 1 dose.- Dexamethasone 0.6mg/Kg IM or IV

Or Prednisone 1 mg/Kg PO. Controversy whether steroids actually help.

Consider admission if:1. Moderate symptoms (stridor at rest, retractions) persisting after more

than 4 hours from corticosteroid dose. 2. Moderate symptoms persist after more than 2 hours from epinephrine

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Adult Diabetic Ketoacidosis

For Pediatric Diabetic Ketoacidosis – call Pediatrician!

Laboratory Signs/Diagnosis:1. Hyperglycemia (serum glucose > 14 mmol/L)2. Low bicarbonate (HCO < 18 mmol/L)3. Low pH ( pH < 7.3) 4. Ketones on dipstick – absence almost excludes Dx DKA5. Anion gap > 10DDx: Hyperosmolar Hyperglycemic state: glucose > 30, pH>7.3, small or negative urine ketones,

Treatment1. Draw serum glucose, K, Cl, BUN, Creat, CBC. LFT, HgA1c PO4, ABG2. Urine 3. ECG4. CXR5. Start IV replacement with N/S at 1 – 1.5 liters/hr. for 1 hour

Then if severe dehydration, start N/S at 1 liter/hr.If mild dehydration and normal Na, use .45% NS at 250-500 ml/hr.If mild dehydration and low Na, use 0.9% NS at 250-500 ml/hr.

6. Blood glucose should drop by 2.5 – 3 mmol/L over the first hour and about 3 – 5 mmol/L thereafter.

7. Do hourly glucose.8. Potassium replacement. If K result not available wait for urine output

then give 20 – 40 mEq/l in IV fluid. If K result is available then if K normal, give 20 – 40 mEq/L, if K < 3, give 40 mEq/L and withhold insulin for first 1 – 2 hours. Maintain K between 4 – 5 mEq/l.

9. Regular insulin 0.1 units/Kg IV. Then start insulin infusion 0.1 units/kg/hour.

10. If serum glucose does not fall by 10% in first hour, give Regular insulin 0.14 units/kg IV bolus, and then continue infusion.

11. Once serum glucose falls to 11 mmol/L, reduce infusion to 0.02-0.05 units/kg/hr and change IV to 5% dextrose with 0.45% NS at 150-250ml/hr

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12. Bicarbonate 100 mmol over 2 hrs. only if pH < 6.913. Maintain glucose 8-11 until resolution DKA.

Frostbite

Prethaw1. Protect part2. Stabilize core temperature3. IV rehydration (R/L, N/S)4. Avoid friction massage

Thaw1. Re-warm part in circulating water (or large tub) at 40 – 42 degrees C. (no

more, no less) with active motion, until distal flush in skin occurs (usually 10 – 30 minutes). Use thermometer to monitor water temperature.

2. IV analgesics (morphine) as necessary (5 – 10 mg to start then titrate)

Post-Thaw1. Debride clear vesicles (see below)2. Leave hemorrhagic vesicles alone.3. If available, apply topical Aloe Vera q 6 h.4. Give Ibuprofen (Motrin) 400 mg q 12 h.5. Analgesics as needed. 6. Elevate involved parts7. Place cotton pledges/balls between frozen toes8. Cover with loose clean sheets. No compressive dressings9. If sever, give strep. Prophylaxis, Pen G, x 48 hours.10. Avoid nicotine or other vasoconstrictive medications, x 72 hours.

“Progressive Dermal Ischemia” = In clear vesicles with frostbite, arachidonic acid breakdown products are released forming prostaglandins and thromboxanes which cause vasoconstriction and further tissue damage under the blister. Thus debride clear blisters and apply topical aloe vera (Dermaide) and oral Motrin which both minimize arachidonic acid production. Leave hemorrhagic blisters to prevent tissue desiccation.

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GOUT“A red joint is septic or crystals – or both”

“No touch Gout Diagnosis” Score

Male 2Previous patient reported gout/arthritis attack 2Onset within 1 day 0.5Joint redness 1Involvement of 1st MTP 2.5Hypertension or CVD 1.5Serum uric acid > 350 3.5

Score of 4 or less – not goutScore of 4-8 – possible gout (~30% chance)Score > 8 probable gout

Note: uric acid levels usually fall into low/normal range during an acute attack and return to normal or elevated only often 2 weeks after the gouty attack.

Treatment options1. Ice, rest and elevation 2. NSAIDS high dose or Indomethacin 25-50 tid 3. Colchicine 1.2 mg stat then 0.6 mg daily for 5-7 days +/- NSAIDs4. Prednisone 50 mg daily for 3-5 days 5. Intra-articular cortisone injection

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Head Injury/ConcussionMajor Head Trauma 1. ABCDE’s as per ATLS2. Consider intubation if GCS < 83. IV N/S or R/L, NOT D5W4. Mild Hyperventilation or normal rates if intubated.5. Consult Neurosurgeon 6. ? Mannitol 1 g/Kg IV for worsening neurological condition (ie decreasing GCS) (consult

Neurosurgeon)7. ? Lasix 0.3 – 0.5 mg/Kg IV (i.e. 20 – 40 mg)8. Steroids NOT recommended9. Barbiturates NOT recommended (unless ordered by neurosurgeon)10. Watch for cardiac dysrhythmias (especially PSVT)11. Control seizures with Ativan 2 – 4 mg IV or Valium 5 – 10 mg IV12. Seizure prophylaxis if:

- Depressed skull fracture- Paralyzed and intubated (i.e. unable to assess for seizures)- GCS < 8- Penetrating brain injuryUse Dilantin 15 mg/Kg IV over 20 – 30 min. Watch BP.

Concussion“Mild” if GCS 13-15 at 30 minutes post injury Hallmark signs are confusion and amnesia with or without preceding loss of consciousness.

Westmead Post-concussion Assessment Tool: (one mistake indicates cognitive impairment)1. What is your name? 2. What is the name of this place? 3. Why are you here?4. What month are we in? 5. What year are we in? 6. In what town/city are you in? 7. How old are you? 8. What is your date of birth? 9. What time of the day is it?10. 3 pictures are presented for subsequent recall.

‘Guidelines’ for Sending Patient for CT scan:CT is usually only required for patients with a history of mild head injury within the previous 24 hours and any one of the following high risk factors:

1. GCS < 15 at two hours after injury2. Suspected open or depressed skull fracture3. Any sign of basal skull fracture (blood behind ear drum, ‘raccoon eyes’, CSF from

nose/ears, ‘Battle’s’ Sign.4. Vomiting > 2 episodes5. Age > 656. Amnesia before impact of 30 or more minutes. 7. Dangerous mechanism (struck by vehicle, fall > 3 ft. or 5 stairs. 8. Neurological deficit

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9. Seizure10. Presence of bleeding diathesis or oral anticoagulant use.

Hypertensive Urgencies and EmergenciesDefinitions:Hypertensive Urgencies: diastolic > 115 mmHg without evidence of end organ damage.Hypertensive Crisis/Emergency: diastolic > 115 with evidence of end organ damage.

“End organ damage”: renal (increase creatinine, BUN, hematuria or proteinuria), cardiac hypertrophy/failure (ECG changes of LVH, CXR changes of CHF) or eye damage (cotton wool spots, retinal hemorrhages).

There is no solid clinical evidence that rapid reduction of asymptomatic sever hypertension is of clinical benefit. In fact may increase risk.

Elevated BP without evidence of end organ damage rarely requires urgent antihypertensive therapy. ie look for end organ damage.

The most common cause of hypertensive emergencies/urgencies is inadequately treated essential hypertension. Other causes are renal and renovascular.

Hypertensive Urgencies: Treatment can be: watch and wait or ONE or more of the following:

1. Furosemide 20 mg PO2. Clonidine 0.2 mg PO3. Captopril 6.25 or 12.5 mg PO

Hypertensive Crisis/Emergencies: 1. Hypertensive Encephalopathy – extremely rare.

Symptoms are severe headache, vomiting, drowsiness, confusionRx: Nitroprusside IV drip – 0.25 – 0.5 mcg/kg per min, titrate to max 10 mcg/kg/minMalignant Hypertension – diastolic > 130mmHg. Is hypertension with evidence of end organ damage? (see Urgencies above).Need one or more of the following for diagnosis:

i. retinal changes (cotton wool spots, hemorrhages)ii. elevated BUN/Creat with Hematuria &/or proteinuriaiii. Left Ventricular Hypertrophy + strain on ECGiv. Congestive Heart Failure on CXR

Rx: Nitroprusside dripLabetalol 20 mg IV push over 2 minutes. Max 40-80 mg. Infusion 2 mg/min titrate.

2. Hypertension with Pulmonary EdemaRx: Nitroglycerin or Nitroprusside - treat for CHF as per guideline above

3. Hypertension in Pregnancy = > 30 mm systolic rise or > 15 mm Diastolic or > 130/90Pre-eclampsia: systolic > 160, diastolic > 110 with a) 24 hr urine < 400c or b) proteinuria > 5 gm/24 hrs or c) visual disturbances.Eclampsia = pre-eclampsia as above with seizures.Rx: discuss with Obstetrician – usually use hydralazine or labetalol.

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Hypoglycemia

Definition = Blood sugar < 3.0 and symptomatic

1. Have patient ingest 10 – 20 gms of glucose10 gm glucose is in:

- ½ cup orange juice, soft drink- 1/3 cup apple juice- 2 packets or 2 tsp table sugar

2. Follow by starch and protein if next meal is going to be more than 1 hour away.

- 6 soda crackers and 1 ounce of cheese or- 1 slice of bread and 1 tbsp peanut butter.

3. If unable to give oral glucose, then use one of the following:- Glucagon 1 mg S.C. or I.M.

(0.5 mg in children under 5 years old)- 25 gms glucose (50 ml of D5W) IV - Glucose gel (Instaglucose) inserted into mouth.

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Hypothermia

Measure CORE (Rectal) temperature using rectal hypothermia thermometer (in hypothermia box in Trauma Room)Clinical:Mild: 35 – 33

35 – Maximum shivering34 – Amnesia, dysarthria, normal BP, increase resp. rate.33 – Ataxia, apathy

Moderate: 32 – 2832 – Stupor31 – No shivering any more30 – Atrial fibrillation, dysrhythmia, decrease BP29 – Deep loss of consciousness, pupils dilated28 – Ventricular fibrillation

Severe: 27 – 1027 – Lost knee jerk (often first thing to return in re-warming)26 – No pain response25 – Pulmonary edema24 – Significant hypotension23 - No corneal reflex19 – Flat ECG18 – Asystole

Management:1. Avoid excessive movement of patient (may precipitate V. Fib)2. Avoid pharmacological manipulations of BP (ie no dopamine etc)3. Treat arrhythmias as per ACLS protocol.4. Try to re-warm to 35 degrees before pronouncing dead.5. Give empiric 250 – 500 ml HEATED (40-42 deg.) D5W (NOT R/L)

Microwave 1 liter on high for 2 minutes, shake bag when done)6. Oropharyngeal intubation is not harmful, nor rhythmogenic7. Place NG tube8. ECG monitor

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9. Do active external re-warming of THORAX only. Heated pads, bear hugger, blankets etc.

10. Use heated, humidified Oxygen (42 – 45 degrees)

Intravenous Lipid Emulsion Therapy (ILT)

- ILE is an oil and water microemulsion, soya bean extract. pH 8.0- Probably works as a ‘lipid sink’ (sequestration) attracting and

binding lipophilic drugsIndications:

1. Local anesthetic overdose 2. Tricyclic antidepressants, Wellbutrin overdose3. Calcium channel, beta blocker overdose4. Antipsychotic overdose (Haldol)

Dosage:1.5 ml/Kg (ideal body wt) bolus followed by0.25 ml/Kg/min for 30-60 minutesBolus can be repeated 1-2 times for persistent asystole.

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Migraine Headache

Beware of Patient with ‘first migraine headache” ie needs Neuro assessment to R/O other causes.

1. “Classic” (10% Patients)- preceded by 1 or more reversible aura symptoms (last < 1 hr)- unilateral (usually)- photophobia- Pt should have at least 2 attacks before Diagnosis.

2. “Common” (80% Patients)- no aura, ½ are bilateral- aggravated by physical activity- pulsating- photophobia, phonophobia- Pt should have at least 5 attacks before diagnosis

Treatment Options:1. DHE (dihydroergotamine) 0.5 – 1 mg IM, IV, SC2. Prochlorperazine 5 – 10 mg IM3. Metoclopramide (Maxeran) 10 mg IV 4. Toradol 30 mg IV/IM and Maxeran 10 mg IV and 1 liter fluids IV

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Overdose – Benzodiazepine(Ativan, Valium, Propofol, Versed, Serax)

1. ABCD – maintain oxygenation2. IV access3. Flumazenil (Anexate)

- 0.3 mg IV over 30 seconds – wait 1 minute- Then if no response, repeat 0.3 mg IV over 30 seconds.- May repeat up to maximum 2 mg.- If no improvement in respirations or level of consciousness, consider

other causes.- If response, but patient later becomes drowsy again (i.e. ½ life of

Anexate around 45 minutes) may start infusion at 0.1 – 0.4 mg/hr.- Titrate to response.

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Overdoses – Misc.(Isopropyl Alcohol, Ethylene, Methanol, Cocaine, PCP. TCA, Opioids)

These are ‘some’ of the overdoses, other than alcohol, that one can see in Emergency settings. Often the patient will not, or can not, give you the information that they have taken a particular drug or substance. The following are ‘clues’ of various signs/symptoms that might warn you of a particular overdose and some first line treatment.

Isopropyl Alcohol (in rubbing alcohol, antifreeze)Lethal dose is 150 – 250 ml or 2 – 4 ml/KgSigns and symptoms- Headache, dizzy, ataxia (stumbling gait), confused, nausea, vomiting, abdominal pain, no odor of alcohol on

breath, Miosis (pinpoint pupils), sudden respiratory arrest.Lab: no ketones in urineTreatment- no lavage or activated charcoal (absorption is too rapid)- monitor breathing, give Oxygen- +/- vasopressors (dopamine) for hypotension- +/- dialysis (i.e. all need to be medevac’d)

Ethylene Glycol (motor coolant, detergents, antifreeze)Lethal dose ~ 60 mlsSigns and Symptoms- ‘drunk’ appearing, elevated BP, congestive heart failure, flank pain, oliguria, acute respiratory distress syndrome

(respiratory failure)Lab: often elevated WBCTreatment:- +/- Lavage stomach if less than 2 hours post ingestion- NO activated charcoal (absorption too fast)- +/- Narcan 0.4 – 1.4 mg IV- Thiamine 100 mg IV- IV fluids (R/L or N/S)- Consider IV Lasix if signs of CHF- +/- IV Bicarb (40 mEq) if you know serum pH < 7.2- Ethanol – can be given PO or IV, but need to measure Ethanol level first.- +/- dialysis – ie all Pts need to be medevac’d

Methanol (antifreeze, window washing fluid)Lethal dose ~ 30 mls (0.4 ml/Kg of 40% methanol)As little as 4 ml can cause blindnessSigns and Symptoms- “walking in a snowstorm”. Pts will complain that their vision is often blurred and it is like walking in a

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- “yellow spots” in from of eyes. Decreased light perception, headache, dizzy, malaise, dilated sluggish pupils, (opposite to Isopropyl alcohol ingestion), abdominal tenderness, abrupt respiratory arrest.

Treatment: same as for Ethylene GlycolCocaine, ‘Ecstasy’ (MDMA), Amphetamines (‘speed’, diet pills)Note: Risk of sudden death increases 25 times if cocaine is used with alcohol.Intoxication Signs and Symptoms:- euphoria, stimulated, decrease appetite, mydriasis (large sluggish pupils)- increase BP, HR, RR, Temp- Chest Pain, angina, acute MIOverdose Signs and Symptoms- as above except more so- Bruxism (grinding teeth – esp. with Ecstasy), picking at face, repetitive movements, toxic psychosis,

hallucinations (paranoid)- Chest pain, cough, SOB, hemoptysis, wheeze (‘crack lung’)- Bronchitis, pulmonary embolus- Headache, TIA, CVA, Subdural hemorrhage, spinal cord infarct- GI ulcers- Acute renal failure- Nose bleeds, septal perforationTreatment:Pulmonary – Oxygen, +/- intubateAtrial Tachycardia – beta blockers unless chest painWide QRS Tachycardia – Na Bicarb 40 mEq IV, NO lidocaineChest Pain – rule out MI, treat as for angina, but NO Beta BlockersSeizures/Agitation – IV Ativan, or Haldol (see page 34)

PCP (“Angel Dust”, Hog, PeaCe, WOW…..)Signs and Symptoms- bizarre behavior, agitated lethargic, confused, can be extremely violent, marked strength, blank stare,

nystagmus, increase BP/HR/Temp, muscle rigidityTreatment- Ativan 2 – 4 mg IV, may repeat q 10 – 15 minutes- Restraints- Haldol 5 mg IM q 20 min x 3 or until settled. (if given IV watch for hypotension)- Watch for acute renal failure- Try to keep temperature down (can develop dangerous hyperthermia)

NOTE: If ordering a toxicology urine screen, if you suspect PCP or Ecstasy, they must be specifically asked for, as ‘routine tox. screen’ will not detect these.

There is NO drug screen for LSD.

For Treating Major Drug Withdrawal or Agitation see ER Protocol for “Sedation for SevereAgitation” page 38.

Anticholinergic (Benadryl, Atropine, Cogentin, Atrovent, most older antihistamines)Signs and Symptoms

Pupil Size in Different OverdosesMiosis (Pinpoint) Mydriasis (Dilated)Heroin CocaineMorphine Anticholinergic (Benadryl, older antihistamines)Ethylene glycol LSD, Mescaline

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- “hot as a hare, red as a beet, blind as a bat, dry as a bone and mad as a hen”- Increased temp, flushed skin, mydriasis (dilated pupils – blurred vision), dry mouth, low blood sugar,

bladder distention, silly/agitated, violent behavior, visual hallucinationsTreatment:- Ativan 2 – 4 mg IV or Valium 5 – 10 mg IV- No physical restraints if possible, as it may increase temperature- Stomach lavage if ingestion < 1 – 2 hours- Activated charcoal 1 mg/Kg

Tri-Cyclic Antidepressants (Elavil, Desyrel, Desipramine etc)Signs and Symptoms- 4 C’s – convulsions, coma and cardiovascular collapse- On ECG, will often see ever widening QRS complex until total CV collapseTreatment:- maintain airway- Activated charcoal 1 mg/Kg- NO diuresis (i.e. no Lasix) or dialysis- Bicarb if wide QRS or pH < 7.2

SSRI Antidepressants (Prozac, Zoloft, Paxil etc)Signs and Symptoms- drowsy, increase heart rate, ECG changes, nausea, vomiting, tremorTreatment:- none really, observe, treat symptoms

Opioids (Morphine, Codeine, Demerol, Fentanyl, Heroine, Lomotil)Signs and Symptoms:- Note: if addict, there is tolerance built up to all of the following except miosis (small pupils) so the

following really only applies to acute, non addict ingestions.- Decrease Respiratory rate- Pulmonary Edema (can have pink frothy sputum)- Miosis (small pinpoint pupils)- Nausea and vomiting- Seizures, twitchy, increase deep tendon reflexes, rigidity- Usually little on no effect on BP, HR, or heart rhythmTreatment:- oxygen- if oral ingestion, activated charcoal (1 mg/Kg)- Narcan – use only if sever OD. If used in codeine OD may need large dose of Narcan. Watch for vomiting

if using Narcan, ie protect airway. May need up to 10 mg Narcan.- If seizures, use IV Ativan 2 – 4 mg - If pulmonary edema, use oxygen but no? diuretics as that may bottom out BP.

Note: Lomotil OD in children. If child < 5 yrs old, they ALL need hospital admission regardless of dose. They can develop sudden respiratory arrest.

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Overdose - AcetaminophenToxic Dose > 140 mg/Kg

(i.e. average 60 Kg adult that is ~ 25 Plain Tylenol tablets)If Toxic Dose:1. Obtain a 4 hour ingestion acetaminophen level. If > 150 micrograms/ml,

or above toxic level on graph initiate N-Acetyl cysteine (Mucomyst) therapy.

2. Do baseline AST, SGOT, LDH, PT, PTT, CBC, Lytes, BUN, Creat.3. Mucomyst (Acetyl cysteine Therapy)

Give within 12 – 16 hours, preferably < 8 hours ingestion.Oral: (preferred route)

- 140 mg/Kg orally in 20% solution diluted with 4 parts citric juice or soda.- Follow with 70 mg/Kg orally q 4 hours for 17 additional doses,

or serum Acetam. level 0.- If patient vomits within 1 hour of dose, repeat that dose.

Intravenous (use if unable to give orally)- Loading dose of 150 mg/Kg in 200 ml D5W over 15 min.- Then 50 mg/Kg in 500 ml D5W over 4 hours- Then 100 mg/Kg in 1000 ml D5W over 16 hours.

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Pediatric Analgesia and Conscious Sedation

LET (lidocaine-epinephrine-tetracaine). It provides adequate local anesthesia for wound closure in 75 to 90 percent of scalp and facial lacerations in a manner that is equivalent to tetracaine, adrenaline, and cocaine (TAC) topical solution. LET is less effective on extremity or truncal woundsAcetaminophen: Oral - 10-15 mg/kg q 3-4 hIbuprofen: Oral - 10-15 mg/kg q 6 h Nitrous Oxide: 25-50% concentration with oxygen. Morphine: Oral - 0.3 mg/kg PO q 3-4 h

0.1 mg/kg IV q 2-4 hHydromorphone: 0.04 – 0.08 mg/kg ORALLY q 3-4 h 0.015 mg/kg IV q 2-4 h

Ketamine: Oral: 6-10 mg/kg (mix with cola or sweet beverage) – give 30 min prior to procedure.IM: 3-7 mg/kgIV: 0.5 – 1 mg/kg for sedation

Midazolam: 0.25 -0.5 mg/kg PO/SL Mix with liquid Tylenol, cola etc (has bitter taste) (note: only 15-35% bioavailable orally. Intranasal, buccal and sublingual has 70-80 % bioavailability)(onset 20-30 min, duration 30-60 min)

0.2-0.3 mg/kg Intranasal 0.2-0.3 mg/kg Buccal

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Children undergoing fracture reduction or other painful procedures have been shown to have good analgesia with combination of Ketamine and Midazolam, with less side effects with regard to respiratory depression but had slightly higher vomiting rates than when using Midazolam and Fentanyl.

Post Cardiac Arrest Care Objectives

1. Control body temperature to optimize neurological recovery and survival.2. Identify and treat acute coronary syndromes 3. Optimize ventilation 4. Reduce risk of multi-organ injury and support organ function5. Objectively assess prognosis for recovery 6. Assist survivors with rehab services when required. 7. Involve family members in prognosis and treatment issues.

Treatment 1. Maintain Oxygen saturations >94% but less than 100%2. Avoid hyperventilation 3. Continuous ECG monitoring 4. Consider therapeutic hypothermia in any patient unable to follow verbal

commands after return of spontaneous circulation (ROSC)5. Consider sedation/analgesia and even neuromuscular blockade for agitated

patients or who may need induced hypothermia and to control shivering. 6. Consider Vasoactive drugs for sustained hypotension (epinephrine,

norepinephrine, dopamine, dobutamine – consult cardiology/ICU)7. 12 Lead ECG – if suggestive of ACS treat as per ACS protocol (note: comatose

patients can receive TNK/PCI safely)8. Maintain blood glucose between 8 – 10 mmol/L. 9. No literature to support use of steroids. 10.Transfer to Tertiary care facility as soon as possible

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Therapeutic Hypothermia1. Goal core temp is 34-36 degrees Celsius for 12 – 24 hours.2. Place cool wet sheet over patient3. Ice bags in axilla groin and neck. 4. Wrap hands and feet in dry towels to prevent shivering. 5. Can give ice cold IV fluids (N/S or R/L) 500 ml IV. 6. Monitor core temperature with esophageal (or bladder- less accurate) probes. Not

rectal temp nor axillary. 7. Watch for complications – coagulopathy, arrhythmias, hyperglycemia.

Sedation for Severe Agitation/Psychosis

Droperidol 5 mg with Midazolam 5 mg IM.orHaloperidol 5 mg with Lorazepam 2 mg IM or if IV established:Time Haldol IV + Ativan IV0 min 3 mg 0.5 – 1 mg20 min 5 mg 0.5 – 2 mg40 10 mg 0.5 – 10 mgEvery hour 10 mg 0.5 – 10 mg

Alcohol Withdrawal4 Components:

1. Early withdrawal – usually occur 6-8 hrs. after last drink2. Withdrawal seizures – usu. 6-48 hrs. after last drink, can last 2-3 days.

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3. Alcoholic hallucinations – occurs 12-48 hrs. after last drink, last 1-2 days

4. Delirium tremens (DTs) occur in 5%, have 5-15% mortality. Can last up to 5 days, not necessarily preceded by hallucinosis or seizures.

1. Lab: CBC, alcohol level, urine drug screen, u/a, CXR/blood/urine culture if infection suspected.

2. CT head only if altered mental status or clinical suspicion3. IV and monitor PRN. 4. Ativan 2 mg PO/IV repeat q 2-4 PRN5. Or Valium 5-20 mg PO/IV PRN6. Or Phenobarbital 30-60 mg PO for mild symptoms or 15-20 mg/kg

slow IV for severe symptoms or seizures7. Or Propofol 25-75 mcg/kg/min then titrate as necessary. 8. Dilantin NOT indicated for alcoholic withdrawal seizures.

Seizures – Adult1. ABCDE’s2. IV lines3. Do finger prick glucose4. Draw blood for CBC, LFT, Calcium, Magnesium5. If glucose < 3, give Glucose 50 ml of 50% (25 gms)over 5 minutes IV6. Thiamine 100 mg IV, IM7. Ativan 2 – 4 mg IV or Valium 2 – 10 mg IV or Midazolam 0.1 – 0.2

mg/kg IV (5 – 10 mg) 8. If unable to establish IV, may use Midazolam 0.05 – 0.2mg/Kg IM

(10 mg IM may be more effective than Ativan)9. For Status Epilepticus:

A. Phenytoin (Dilantin) 20-30 mg/Kg IV at max. 50 mg/minPatient should be on cardiac monitor to watch for QRS width. Stop drug is QRS > 50% baseline width. Watch also for hypotension. May repeat 10 min after loading dose. Not for use in alcohol withdrawal seizures. (see Alcohol Withdrawal page 36)

B. Valproic Acid 20-60 mg/kg IV bolus at 2 mg/min. May repeat 10 Min. after loading dose

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C. Phenobarbital 20-30 mg/Kg IV at no faster than 60 mg/min. D. Propofol 1-2 mg/kg at 20 mcg/kg/min, followed by infusion at 30-200mcg/kg/min (requires mechanical ventilation)

Antiepileptic Drugs

Onset Peak Action Half lifeAtivan: 2 – 3 min. 45 – 60 min 6 – 8 hrs.

Valium: 1 – 3 min. 15 – 30 min 3 – 4 hrs. Midazolam: 1 –5 min. 4 hrs.

Seizures – Pediatric

1. ABCDE’s: oxygen, suction secretions, recovery position2. IV line/intraosseous access.3. glucose, CBC, lytes4. If glucose < 3, give 25% glucose 2 – 4 ml/Kg IV.5. Lorazepam 0.1 mg/kg (max 4 mg/dose) IV/IO/IN 6. Or Diazepam 0.2 mg/kg IV/IO/PR (max 10 mg/dose) or

Midazolam 0.1 – 0.2 mg/kg IV/IO/IM/IN 7. Phenytoin (Dilantin) 20 mg/kg IV/IO at 50 mg/min (max 1000mg)

Have patient on cardiac monitor, watch BP. 8. Phenobarbital 20 mg/kg IV/IO/IM (note IM takes 2 hours for onset)

For Refractory Status Epilepticus:9. For Status Epilepticus: A. Phenytoin (Dilantin) 20-30 mg/Kg IV at max. 50 mg/min

Patient should be on cardiac monitor to watch for QRS width. Stop drug is QRS > 50% baseline width. Watch also for hypotension.

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May repeat 10 min after loading dose. Not for use in alcohol withdrawal seizures.

B. Valproic Acid 20-60 mg/kg IV bolus at 2 mg/min. May repeat 10 Min. after loading dose C. Phenobarbital 20-30 mg/Kg IV at no faster than 60 mg/min. D. Propofol 1-2 mg/kg at 20 mcg/kg/min, followed by infusion at 30-200mcg/kg/min (requires mechanical ventilation)

Shock / HypotensionThink of the cause of shock: (i.e. treat the cause if possible)

1. Hemorrhage 2. Cardiogenic 3. Distributive/Sepsis4. Neurogenic

Hemorrhagic Shock Class- Class I : (blood loss up to 15%, < 750 cc)

Vital Signs: normal- Class II : (blood loss 15-30%, 750-1500 cc)

HR , BP normal, + RR, urine output normal- Class III : (blood loss 30-40%, 1500-2000 cc)

HR , BP , RR , urine output- Class IV : (blood loss > 40%, > 2 liters)

HR , BP , RR , urine output.

Consider Etiology of Pediatric Seizures:Infectious (febrile, meningitis, abscess..)Traumatic (cerebral contusion, epidural/subdural hematoma)Vascular (AVM, subarachnoid/subdural hematoma, migraine)Metabolic (hypoglycemia, lytes, hypoxia, hepatic and renal failure)Neoplastic (primary and metastatic tumors)Toxic (intoxication, withdrawal)

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Rx: Class I and II: 2 IV (18 gauge or larger) N/S or Ringers lactate 500 cc bolus, reassess, bolus again prn up to 2 liters.

Class III and IV: as above, N/S or Ringers and packed red cells.Hemorrhagic Shock

1. Look for cause, CXR, FAST, C-spine and pelvic x-ray. 2. 3 Goals: restore fluid volume, maintain oxygenation, limit ongoing

blood loss3. IV access – 16g x 2 in antecubital fossa or intraosseous. 4. 2 liters N/S. If further fluids needed use Ringer’s lactate. Goal is MAP

65 (Goal in traumatic brain injury or blunt abdominal injury is MAP > 105

5. Blood transfusion: If no change in MAP after 2-3 liters fluid give 2 units PRC. If uncontrolled bleeding requiring > 4 units PRC over one hour, use PRC, FFP and platelets in 1:1:1 ration (if in a center with these products)

6. No role for vasopressors.

Cardiogenic Shock1. IV N/S 500 ml aliquots and monitor MAP (goal is > 65 and warm

extremities). 2. Causes: Arrhythmia, PE, PCE, OD, STEMI (note: if STEMI don’t thrombolyse

as there is not enough perfusion to work)3. Inotropes:

Dobutamine (use if SBP > 80). May cause Tachyc. Start 2 mcg/kg/min. or Dopamine (improves myocardial contractility). Start 5-10 mcg/kg/min If MAP still not up to 65 can then add Norepinephrine 0.5 mcg/kg/min

4. Consider Calcium Chloride 1 gm IV thru central line or good AC line (or Ca Gluconate 3 gm IV through peripheral line).

5. Lasix 40 mg IV6. Consider NIPPV if pulmonary edema (see Acute Pulm. Edema pg 6)7. Often will need intubation. 8. CXR, EXG, CBC, Lactate, BNP, lytes, Creat., Ca, Trop, ABG9. Fentanyl 20-25 mcg IV for anxiety

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Distributive/Septic Shock 1. Diagnosis sepsis: documented or suspected infection, Temp > 38.3

or < 36, HR > 90, tachypnea >20/min, altered mental status, edema, hyperglycemia in absence of diabetes, WBC > 12,000, elevated lactate > 1 mmol/L, mottling or decreased cap refill.

2. Oxygen. May need intubation 3. Labs: Blood cultures, CBC, lactate, Creat, lytes, CRP, MSU, CXR.4. Antibiotics – based on suspected source or empirical. See below5. 2 IVs - N/S bolus 2 liters, then give Ringer’s lactate. Goal is MAP >

65, IVP EDE. 6. If MAP > 65 not achieved, vasopressors – Norepinephrine start 0.5

mcg/kg/min7. Add Epinephrine drip if low cardiac output. Start 2 mcg/min 8. If refractory shock and decreased cardiac output – Dobutamine start

2 mcg/kg/min 9. If refractory consider IV Hydrocortisone 50 mg q 6 hr (200 mg/day) 10. Insulin infusion for hyperglycemia. Monitor blood glu. q1-2 hrs. 11. Repeat lactate after 6 hours, should be lowered by 10%.

Empiric Antibiotics for SepsisPneumonia – Ceftriaxone 2 g IV and azithromycin 500 mg IVSkin/soft Tissue – Cefazolin 2 g IV and clindamycin 900 IV GI – Pip/Taz 4.5 g, +/- Metronidazole 500 mg IV and Gentamicin GU/Pyelo – Pip/Taz 4.5 gCNS – Ceftriaxone 2 g IV and Vancomycin 25 mg/kUnknown Source – Pip/Taz 4.5 g IV and Vancomycin 25mg/k and Gentamicin (as per GFR. > 60 7 mg/k, GFR < 60 or unknown, 2 mg/k)

Neurogenic/Spinal ShockOnly occurs in cord lesions above T8. Will have hypotension but also bradycardia or normal HR. Can have warm extremities and good urine output. Always look for other causes of hypotension.

1. Management is ABCD of trauma 2. Stabilize spinal injury3. Fluids, pressors to maintain MAP > 1054. Insert Foley early as bladder distention may occur

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5. Severe bradycardia (lesionsC1-5) may require atropine or external pacing.

6. Watch temperature, may lose temperature regulation.7. ? Methylprednisolone – ask neurosurgeon

Spinal Cord Injury

1. ABCDE’s 2. A c-spine can be “cleared” if the patient is not drunk, obtunded and able to

cooperate. The 4 criteria for a ‘clear’ c-spine are1) Patient does not complain of any neck pain2) No pain on palpation of spinous processes.3) Normal neurological exam, i.e. no sensory or motor deficits in

extremities4) Take collar off and have patient first rotate neck and then flex and

extend neck. If no pain, neck is cleared. If there is pain on any motion, put back collar.

If there is any question of c-spine injury, obtain lateral, AP and open-mouth neck x-rays and more likely CT neck. If cleared by physician, remove collar.If you suspect injury, with or without normal x-ray series then:

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3. Consult Neurosurgeon4. Remember – lying on a backboard more than 2 hours leads to high risk of

decubitus ulcers.5. Neurosurgeon may order Methylprednisolone Sodium Succinate 30

mg/Kg IV followed by 5.4 mg/Kg per hour over the next 23 hours. If used in non-penetrating spinal cord injury, it should be stated within 8 hours of injury. NOTE: Some Neurosurgeons do not advocate corticosteroid use so check with them before administering.

Ventilator SupportVentilator Settings for Philips Trilogy 202

Ideal Body Weight

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NIV/BPAPMode: S/TPEEP: 5 cm H20 (max 15)IPAP: 10 cm H20 (max 20)Fi02: 100% initialRate (Backup): 14Inspiratory time: 1 sec

Mode: A/C Volume Tidal Volume (Vt): 8 cc/kgResp. Rate: 10 bpmPEEP: O cm H2OFiO2: 40 %

Goal: Keep pH above 7.1

Mode: A/C VolumeTidal Volume (Vt): 6-8 cc/kg IBWResp. Rate: 18 bpmPEEP: 5 cm H2OFiO2: 100% initially

After 5 min, do ABG, follow ARDSnet chartGoal: PaO2 55-85 mmHg or SaO2 90%

Asthma/COPD

Type 2

CO2 +/ - O2

Pulm Edema, Pneumonia, OD…Everything except Asthma/COPD

Type 1

O2 +/- CO2 Mode: S/TPEEP: O – 5 cm H20IPAP: 10-15 cm H2O (max 20)FiO2: 100% initially, usually 40%Rate (Backup): 14Inspiratory time: 1 sec

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Height 5’ 5’1” 5’2” 5’3” 5’4” 5’5” 5’6” 5’7” 5’8” 5’9” 5’10” 5’11” 6’ 6’1” 6’2” 6’3” 6’4” 6’5” 6’6” 6’7” Male-kg 52 53 55 57 59 61 63 65 66 68 70 72 74 76 78 79 81 83 85 87Female-kg 49 50 52 54 55 57 59 60 62 64 65 67 68 70 72 73 75 77

FiO2/PEEP Chart (ARDSnet Chart)FiO2 0.3 0.4 0.4 0.5 0.5 0.6 0.7 0.7 0.7 0.8 0.9 0.9 0.9 1.0PEEP 5 5 8 8 10 10 10 12 14 14 14 16 18 18-24

Points to RememberNon-Invasive Ventilation (NIV)

1. Never hesitate to call for help from the RT. 2. Be cautious using NIV on patients with pneumonia or excessive secretions3. Contraindicated with obtunded, respiratory arrest, pH < 7.2, or facial deformity.4. EtCO2 does NOT equal PaCO25. For COPD/Asthma, if following CO2, can use venous blood gases.6. For COPD/Asthma remember to continue to give nebulizers. 7. Mode can be S/T for all respiratory failure types.8. Be aware of AutoPEEP in asthmatics/COPD.9. Pulse Oximetry lags behind present patient condition by at least 30-60 seconds. 10.Never hesitate to call for help from the RT.

Mechanical Ventilation1. Never hesitate to call for help from the RT2. Use Assist/Control mode for all types of respiratory failure. 3. For Pulm Edema and other Type 1 failure, use FiO2 100%, at least initially4. For Asthma/COPD use FiO2 40%5. Use ‘Ideal Body Wt” for tidal volume, NOT the patient’s actual weight. 6. Respiratory Rate is what controls CO2 levels7. FiO2 and PEEP control Oxygenation 8. Don’t change Tidal Volume unless concern about barotrauma. Especially don’t

change it to effect the CO2 levels. 9. In CHF and other Type 1’s, goal is to keep PaO2 ~ 80 mmHg or SpO2 90%10.In Asthma/COPD, goal is to keep pH > 7.1. 11.In Asthma/COPD remember to continue to give nebulizers. 12.In CHF and other Type 1’s, the worse the CXR, the smaller the tidal volume.13.If PaO2 is too low – increase PEEP and/or FiO214.If PaCO2 is too high – increase the respiratory rate. 15.If PaCO2 is too low – decrease the respiratory rate. 16.If all the alarms are going off, BP dropping etc, disconnect the vent and bag the

patient. Then check for blockage, pneumothorax,…

17.Never hesitate to call for help from the RT.

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Settings for LTV 1000 Ventilator

Ideal Body Weight

Pulm Edema, Pneumonia, OD….Everything except Asthma/COPD

Type 1

O2 +/-

CO2NIV/BPAP

Asthma/COPD

Type 2

CO2 +/ -

O2

Mechanical Ventilation

Mode: SIMV/CPAPSet Breath rate to - - (or will be in SIMV)PEEP: 5 cm H20 (max 15) (*)PSV (IPAP): 10 cm H20 (max 20)Fi02: 100% initial

Mode: SIMV/CPAPPEEP: O – 5 cm H20PSV (IPAP): 10-15 cm H2O (max 20)FiO2: 100% initially

Mode: A/C VolumeSet “Sensitivity” to 3 (**)Tidal Volume (Vt): 6-8 cc/kg IBWResp. Rate: 18 bpmPEEP: 5 cm H2OFiO2: 100% initialIFR: 60-80 lpmAfter 5 min, do ABG, follow ARDSnet chartGoal: PaO2 55-85 mmHg or SaO2 90%Check Plateau Pressure – push the ‘inspiratory hold’ button. Keep lowering Vt until Plat pressure < 30Don’t go below 4 cc/kg IBW

Mode: A/C Volume Tidal Volume (Vt): 8 cc/kg (***)Resp. Rate: 10 bpmPEEP: O cm H2OFiO2: 40 %IFR: 80 – 100 lpmGoal: Keep pH above 7.1

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Height 5’ 5’1” 5’2” 5’3” 5’4” 5’5” 5’6” 5’7” 5’8” 5’9” 5’10” 5’11” 6’ 6’1” 6’2” 6’3” 6’4” 6’5” 6’6” 6’7” Male-kg 52 53 55 57 59 61 63 65 66 68 70 72 74 76 78 79 81 83 85 87Female-kg 49 50 52 54 55 57 59 60 62 64 65 67 68 70 72 73 75 77

FiO2/PEEP Chart (ARDSnet Chart)FiO2 0.3 0.4 0.4 0.5 0.5 0.6 0.7 0.7 0.7 0.8 0.9 0.9 0.9 1.0PEEP 5 5 8 8 10 10 10 12 14 14 14 16 18 18-24

(*) Remember: On the LTV 1000, CPAP is set using the valve located at the terminal end of the circuit (tubing)Because the CPAP is not set internally, the LTV is not ‘PEEP compensated’. Thus if you give ‘Pressure Support’ (PSV) of 5 and PEEP of 5, the amount of pressure delivered on inspiration will be 0. PSV 12 and PEEP 5, pressure delivered will be 7. (**) in A/C mode, if the sensitivity is set to zero (- -) the mode will be ‘Assist’. If the sensitivity is anywhere from 1-9, the mode will be A/C. (***) for COPD/Asthma, use as large an ET as possible (ie 8)

ATLS ProtocolAre you protected?? Gloves, gown and goggles?

Airway with C-Spine ControlLook, Listen & Feel for breath sounds. Suction if necessaryChin lift, jaw thrust, oral airwayProblem? Consider Intubation

Breathing. Listen to chest, look for JVD,Trachea midline?Problem? Consider need for chest tube/pericardiocentesis?

Circulation.BP, skin color, capillary refillLook for obvious bleeding, apply pressureStart 2 IV’s (Ringers), blood for CBC, lytes, Blood type and x-match

Disability.AVPU: (Alert, Verbal Response, Pain Response, Unconscious)

A

B

C

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Glasgow Coma Scale

Expose and EnvironmentRemove ALL clothing, cover with warm blanketLog Roll (protecting spine) and inspect back.

If possible hypothermia, do rectal/core temperature.

Secondary Survey – “Head to Toe”Light in ears, eyes, mouthPalpate scalp, facial bones, +/- C-spine and collar bones.If OK, insert NG tube.Listen to heart.Listen to chest; look at neck for JVD and tracheal deviation.Palpate abdomen.Palpate pelvic bones (down, out and distract legs).Rectal exam, any blood at meatus?If normal, insert Foley – do urine preg test on females.Palpate arms for pain, have patient move feet, bend knees, assess foot planar/dorsi flexion, assess sensation and reflexes, plantar responses.EDE FAST scan

Clear C-Spine?If patient is alert, sober and cooperative to exam:1) Patient complains of NO pain in neck2) No pain on palpation of spinous processes.3) No abnormality on sensory or motor exam of extremities

NB: If any of the above positive, leave c-spine collar on and neck must be cleared with C-spine x- rays/CT scan by physician.

4) Remove collar5) Have patient slowly rotate neck, then flex neck and finally extend

neck. Stop if pain at any point, return collar. If no pain, C-Spine can be clinically cleared and collar left off.

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Radiology “Trauma Series”1. CXR2. Pelvis3. C-Spine

“AMPLE History”AllergiesMedications, Drugs/Alcohol Ingestion Past Medical/Surgical historyLast meal, LMP/PregnantEvents: History of accident and mechanism.

Glasgow Coma ScaleADULT Eye Response Score Motor ResponseSpontaneous 4 Obey command 6To Voice 3 Localizes pain 5To Pain 2 Withdraws from pain 4None 1 Flexes to pain 3Verbal Response Extension to pain 2Oriented 5 None 1Confused 4Inappropriate 3 SCORE /15Incomprehensible 2None 1

PEDIATRICBest Eye ResponseEyes open spontaneously 4Eye opening to speech 3Eye opening to pain 2No eye opening or response 1Best Verbal ResponseSmiles, oriented to sounds, follows objects, interacts 5Cries but consolable, inappropriate interactions 4Inconsistently inconsolable, moaning 3

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Inconsolable, agitated 2No verbal response 1Best Motor Response Infant moves spontaneously or purposefully 6Infant withdraws from touch 5Infant withdraws from pain 4Abnormal flexion to pain for an infant (decorticate) 3Extension to pain (decerebrate) 2No motor response 1

SCORE /15

PROCEDURES:Chest Tube Insertion

Equipment Needed:BetadineSterile field drapeLocal anesthetic (1 or 2% lidocaine with epi)10 ml syringe, 18 gauge needle, 25 gauge needle#10 scalpelChest tube (Adult 28-32 Fr., Child 20-24 Fr., Infant 18 Fr.)2 Large Curved Kelly clampsPlastic connecting tubingPleurovac Adequate suction (ideal is wall suction of 60 cm H2O) Needle holderSuture scissors0-silkSterile 4x4 spongesAntibiotic ointmentOrange Elastoplast tape

Procedure:6. Select site, fourth intercostal space in the mid-axillary line. (this corresponds to a

line drawn from the nipple to underneath the middle of the armpit) Fig 4.25

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7. Prep skin with betadine or antiseptic. Note this is a sterile procedure, so wear sterile gloves and mask.

8. Infiltrate skin with 2% lidocaine along site of incision, subcutaneous tissue and along anterior rib margin.

9. Make a linear incision along the rib, one interspace below the site of insertion.10.Insert curved Kelly clamp and tunnel superiorly to the interspace that is to be

entered. Remain on the upper border of the rib to avoid the neurovascular bundle. Fig 4.27

11.Gently but forcibly enter the thoracic cage by advancing the closed curved clamp through the pleura. A gush of air or blood will usually escape out the hole. Open the curved clamps to enlarge the opening. Do not advance the tips of the clamps any further than is necessary to avoid damage to the lungs. Fig 4.28

12.Insert a sterile gloved finger into the pleural space to prevent inadvertent passage of the tube into the lung should unsuspected pleural adhesions be present. If adhesions are felt, they should be separated away from the lung with the finger before chest tube insertion. Fig 4.29

13.Cover the pleural opening with the hand before the tube is placed. With a curved clamp, grasp the tip of the chest tube and advance it through the skin and into the intercostal space. Fig 4.30

14.Secure the tube to the skin with 0 – silk as in diagram. Close remaining incision site opening with sutures. Fig 4.31, 4.32

15.Apply antibacterial ointment followed by 4x4 gauze. Secure the dressing with orange waterproof tape.

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Note: A simple underwater seal (3 bottles or Pleurovac) is usually adequate for draining fluid (blood) from the chest cavity. If air only (ie a pneumothorax) then it is best to add some suction if possible, if only 20 cm of water.

Tick Removal

1. Clean around the area with povidone-iodine.

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2. With blunt forceps, tweezers or gloved fingers, grasp the tick as close to the skin surface as possible and pull upward with steady pressure. Do NOT twist or jerk the tick as the mouthparts may break off.

3. Never squeeze, crush or puncture the body as fluids contain infectious products. 4. Disinfect the bite site.

If the tick is too embedded 1. Disinfect the area as above2. Apply a punch biopsy so that it encompasses the tick. 3. Advance the punch biopsy down to the dermis. 4. Remove punch, then cut the pedicle with scissors or scalpel. 5. Suture or apply pressure to punch site after disinfecting.

Zipper InjuryFor Penis/scrotum caught in zipper:

1. If it is a child you may need to use oral sedation (see page 8)2. Can also infiltrate skin with local Xylocaine3. Paint the area with povidone-iodine.4. Cover the area with liberal amounts of mineral oil. Leave this in place for 15-

20 minutes. This lubricates the moving parts and often frees the skin. 5. If mineral oil doesn’t work, there are two techniques to try. 6. First method is to grasp the zipper with fingers or Kelly forceps and while

gently pulling apart twist your wrists in opposite directions (supination), which can sometimes separate the two halves of the zipper

7. The second method is to cut the metal bar at the bottom of the zipper with wire cutters, tin snips or a small hack saw. This then releases the zipper.

8. Assess need for tetanus vaccination9. Clean the skin and if necessary suture or steristip any laceration.

Ankle Brachial Index (ABI)

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-The Ankle Brachial Index (ABI) is the systolic pressure at the ankle, divided by the systolic pressure at the arm. -It has been shown to be a specific and sensitive metric for the diagnosis of Peripheral Arterial Disease. -Additionally, the ABI has been shown to predict mortality and adverse cardiovascular events independent of traditional CV risk factors. -The major cardiovascular societies advise measuring an ABI in every smoker over 50 years old, every diabetic over 50, all patients over 70 and ANY patient you are considering using venous compression stockings on. Method:-The ABI is performed by measuring the systolic blood pressure from both brachial arteries and from both the dorsalis pedis and posterior tibial arteries after the patient has been at rest in the supine position for 10 minutes. -The systolic pressures are recorded with a handheld 5- or 10-mHz Doppler instrument. Usually a standard blood pressure cuff can be used at the ankle. It is recommended to begin with the right arm, then the right leg, then the left leg, and finally the left arm, as the blood pressure may drift during the exam, and the two arm pressures at the beginning and end of the exam provide for some quality control.-An ABI is calculated for each leg. The ABI value is determined by taking the higher pressure of the 2 arteries at the ankle, divided by the brachial arterial systolic pressure. -In calculating the ABI, the higher of the two brachial systolic pressure measurements is used. In normal individuals, there should be a minimal (less than 10 mm Hg) interarm systolic pressure gradient during a routine examination. A consistent difference in pressure between the arms greater than 10mmHg is suggestive of (and greater than 20mmHg is diagnostic of) subclavian or axillary arterial stenosis, which may be observed in individuals at risk for atherosclerosis.

Eg: Right ABI = Highest pressure in Right foot (post tib or dorsalis) Highest pressure in Both arms

>1.4 can be seen in diabetics and elderly patients.

0.8-0.9 should only use compression stockings with caution.

< 0.8 and lower should NOT have compression stockings applied.

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Subungual Hematoma EvacuationIndications:

1. Painful Subungual hematoma with nail edges intact. Not necessary if the nail is not painful.

Contraindications: 1. Crushed or fractured nail bed. 2. Nail edges are disrupted by a deep laceration. However most nail bed lacerations

do not need repair. In the past hematomas over 50% of the nail bed were thought to indicate laceration of underlying nail bed – which some experts said required removal of the whole nail and repair of the laceration to avoid post traumatic nail bed deformity – this has been shown to NOT be the case.

Technique:1. Consider x-ray for fracture distal phalanx, may need splint for comfort. 2. Clean nail. 3. Heated paper clip (use lamp bulb to heat), or 4. Battery operated Cautery unit (caution with acrylic nails – flammable!), or 5. 18 gauge needle – twirl needle between your fingers to drill hole. 6. Assess for Td vaccination. 7. Keep finger elevated, cool compresses for 12 hours. Avoid soaking and keep dry

for 2 days. 8. Advise patient the nail may fall off in the following week but should regrow

providing the nail matrix is intact. Also advise patient this procedure will not hasten healing or prevent infection.

Fishhook Removal

1. Freeze skin with lidocaine2. Using an 18 gauge needle, advance down the shaft

to cover the barb. 3. Advance hook slightly to dislodge the barb, then

back the hook and needle out

1. Freeze the skin2. Advance hook up through skin, and

then clip off with wire cutters. 3. Back out hook.

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Priapism All cases should be discussed with urologist.

Causes: Drugs (anticoagulants, antihypertensives, antidepressants, ED treatments, blockers, cocaine, alcohol, testosterone, haematological disorders, metabolic disorders, trauma, neurological disorders etc)Identify if priapism is: “High flow” – painless and usually caused by blunt tramua to penis or perineum.

Treatment is often just observation, but if unsuccessful, then surgery done by urology, identifying fistulas etc. In young children with high flow priapism, perineal compression with the thumb will cause prompt detumescence, called Piesis sign

“Low Flow”- painful, most commonly seen due to ED medications.Treatment:

- Can try oral pseudoephedrine or oral beta-agonists such as terbutaline. - Intracavernosal phenylephrine (Neo-Synephrine) is the drug of choice and first-line

treatment of low-flow priapism because the drug has almost pure alpha-agonist effects and minimal beta activity. In short-term priapism (< 6 h), especially for drug-induced priapism, intracavernosal injection of phenylephrine alone may result in detumescence. Use a mixture of 1 ampule of phenylephrine (1 mL: 1000 mcg) and dilute it with an additional 9 mL of normal saline. Using a 29-gauge needle, inject 0.3-0.5 mL into the corpora cavernosa, waiting 10-15 minutes between injections. Vital signs should be monitored, and compression should be applied to the area of injection to help prevent hematoma formation. This is found to be almost 100% effective, if done within 12 hours of onset.

- The next step in the treatment of low-flow priapism is aspiration of the corpora cavernosa followed by saline irrigation and, if necessary, injection of an alpha-adrenergic agonist (eg, phenylephrine). Placement of a penile nerve block with a long-acting local anesthetic such as bupivacaine (Sensorcaine) without epinephrine increases patient comfort and improves patient cooperation with the sometimes-painful penile aspiration procedure.

- Aspiration is best performed by placing a large-bore intravenous catheter (ie, 16- to 18-gauge) into the lateral aspect of the corpus cavernosum. A unilateral approach is adequate because of the vascular channels between the 2 corpora cavernosa. Local lidocaine or a penile ring block may be used for anesthesia. Aspiration may be difficult because of the sludging of blood within the corpus cavernosum.

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Shoulder Dislocation

There are at least 8 maneuvers for reducing a shoulder dislocation. They all work!Below are ones I have found to be effective.

Before attempting a reduction. 1. Check for axillary nerve compromise – (ie check for intact sensation over the

deltoid muscle area)2. Always obtain xrays to ensure no fracture.

If you have no access to IV sedation/analgesia the following can be used. Hennipen and modified Kocher Technique.

1. Pt is seated upright or at 45 degrees. MD stabilizes the elbow and wrist. 2. Slowly externally rotate the Pt’s elbow until 90 degrees. It may have to be in

steps to let muscle spasm and pain subside. 3. Ususally reduction occurs by 90 degrees, but if not, then slowly elevate the

arm. (modified Kocher)

If you have IV sedation then either of the following can be usedStimson Technique

1. Pt is placed in prone position on a stretcher. 2. A rolled up towel is then placed under the coracoid process. 3. A weight is affixed to the wrist (wts or a bucket of water). Use gauze roll not

tape. 4. If necessary the MD can facilitate by gently internally/externally rotating the

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Milch-Cooper Technique 1. Pt is supine on stretcher. 2. With the arm slightly abducted and with forward traction, start to bring the

arm up until it is directly overhead. 3. Often reduction will occur at this point. If not one can slowly

internally/externally rotate the arm. 4. If step 3 is ineffective,using outward traction and abduction bring the arm

slowly through a full lateral downward arc.

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IV Drugs in the Emergency Department Drug Indication Dosage

Adenosine PSVT Conversion 6 mg IV push, may repeat 12 mg IV q 1-2 min x 1-2 doses

Amiodarone VF/Pulseless VT 300 mg IV/IOWide Complex Tach 150 mg IV x 1 over 10 min

Then 1 mg/min x 6 hrsAtropine ACLS Brady 0.5 mg IV/IO q 3-5 min, to max 3 mg

ACLS Asystole 1 mg IV/IO q 3-5 min Cardiogenic shock/brady 0.5 mg IV/IO q 3-5 minOrganophosphate poison 2 mg IV/IO q 5 min

Calcium ChlorideHypocalcaemia .5- 1gm IV over 10 min use central line if CCB overdose 1-2 g IV over 10 min, repeat possible

Q 20 min x 5 doses prn Calcium Gluconate Hypocalcaemia 1.5-3 gm IV over 10 min (may use peripheral IV)

CCB overdose 3-6 g IV over 15-20 minDexamethasone Croup 0.6 mg/kg PO x 1Diazepam Seizure 5-10 mg IV q 5-10 min, max 30 mgDiltiazem AF/Flutter/PSVT 0.25 mg/kg IV, 5-15 mg/hr infusionDigoxin CHF/AF/PSVT 2.4-3.6 mcg/kg IVDobutamine Cardiac decompensation 2-20 mcg/kg/min. Start 2 mcg/kg/minEphedrine Hypotension 5-25 mg IV q 5 minEpinephrine ACLS-VT/Vib/PEA 1 mg (1:10,000)IV q 3-5 min

Brady/cardiac output maint. 2-10 mcg/min Anaphylaxis 0.1-0.5 mg (1:1000) IM/SC, max 1 mg‘Push Dose’ 1 cc 1:10,000 Epi in 9 cc N/S (10mcg/ml) 0.5-1 ml

q 5 minFentanyl Sedation/pain 25-50 mcg IV, infusion 25mcg/hr titrate

RSI 50-100mcg IVFlumazenil Benzodiaz OD 0.2-0.5 mg IV q min x 5 doses max,

Infusion 0.1-0.4 mg/hrGlucagon Hypoglycemia 1 mg SC/IM/IV

Beta Blocker OD 3-5 mg IV, 1-5 mg/hr IV infusionHaloperidol Acute psychosis 5-10 mg IVHydralazine HTN crisis 10-20 mg IV q 2-4 hrHydrocortisone Status asthmaticus 300-400 mg/day IV divided q 6 (Solu-cortef) Septic Shock 200-300 mg/day IV divided q 6Isoproterenol Shock/Hypotension 0.5-30 mcg/min IV

Brady due to 2-10 mcg.minCCB/BBlocker OD

Ketamine Anesth induction/Proc Sed 1-4 mg/kg IV over 1 minPeds Proc. Sedation 0.5- 1.5 mg/kg IV over 1 min

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Drug Indication Dosage Labetalol HTN emerg start 20 mg IV, max 300 mg total

2 mg/min IVLipid Emulsion Local Anesth/TCA/BBlocker,1.5 ml/kg bolus, then 0.25 ml/kg/min for

!st Gen antipsychotic OD 30-60 min. Repeat bolus for persistent asystoleLorazepam Seizure/Status 3-4 mg IV/IO. Repeat x 1 q 10 minMannitol Cerebral Edema 0.25 – 1 gm/kg IVMagnesium Sulfate Symptom. HypoMg 1-4 gm IV

Seizure/Preeclampsia 1-2 gm/hr IV, start 4 gm IVVent. Arrhyth/Torsades 2 gm IV

Metoprolol Acute MI 5 mg IV q 2 min x 3 dosesAfter 15 min give 50 mg po q 6 h

Midazolam Proc. Sedation 1-2 mg IV q 2-3 min, max 5 mgRSI 0.1 mg/kg IV Agitation, violent behavior 5 -10 mg IM

Morphine Analgesic 2-5 mg IV prnNaloxone Opioid OD 0.4-2 mg IV

0.0025 0 o.16 mg/kg/hr IVNitroglycerin Angina start 5 mcg/min

Acute Pulm Edema 50 mcg/min to max 200 mcg/minNorepinephrine Hypotension 0.1 – 0.5 mcg/kg/minPhenobarbital Seizure 10-20 mg.kg IV x1

May repeat 10 mg.kg Phenylephrine Shock 50-100 mcg/min IV

Mild hypotension 10 – 150 mcg IV q 10 min onset 1 min, duration 15-20 min

“Push Dose” mix 10 mg (1ml) in 100 ml N/S = 100mcg/mlPropofol Procedural Sedation 1-2 mg/kg IVRanitidine Anaphylaxis 50 mg IVRocuronium Intubation 0.6 – 1 mg/kg IVSuccinylcholine RSI paralysis 1-2 mg/kg IV premedicate with atropine Sotalol VT/VF 75- 100 mg IV q 12 hTNKase STEMI <60 kg = 30 mg IV 60-69=35 mg

70-79=40 mg 80-89=45 mg >90 kg=50 mg

Vasopressin VF/VT/Asystole/PEA 40 units IV/IOVerapamil PSVT conversion 2.5-10 mg IV

Atr. Fib/Flutter 2.5-10 mg IVXylocaine Status Seizure 1 mg/kg IV bolus

VF/VT 0.5-0.75 mg/kg IV q 5-10 min, Then 1-4 mg/min

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Cardiovascular Effects of IV ER DrugsAlpha 1 – Agonists cause vasoconstriction. Antagonists cause vasodilationAlpha 2 – CNS mediated, agonists cause hypotension, sedation. Beta 1 – heart effects: inotropic (strength of contraction), chronotropic (heart rate), dromotrophic (‘conduction’)Beta 2 – Lung effects: agonists cause bronchodilation, antagonists cause bronchoconstriction 1 1 Drug &2 Inotr Chron Dromo 2 V/C V/D

Phenylephrine +++

Epinephrine +++ +++ ++ ++ ++

Norepinephrine +++ ++ ++ ++ o

Dobutamine o/+ +++ ++ o +Dopamine0.5-2mcg/k/min5-1010-20

o + ++

+ ++ ++

o o o

o SVR/CO SVR

Digoxin + _

Amiodarone + -SA/-AV

Atropine + +SA/AV

Ca Chloride/Gluconate +Dihydropyridone –

Amlodipine (Nifedipine) Arterial V/DNo venous V/D

_ _ _ +

Non-dihyd - Phenylakytlamine

VerapamilMin. Art V/D _ _ _ _ 0

Non-dihyd. - Benzothiazepine

DiltiazemArterial V/D _ _ +

Beta Blockers _ _ _ _ -SA/AV +

Nitroglycerine Low dose ven V/DHigh dose art V/D

+ +

ACE Inhibitors - +Mg Sulfate +Isoproterenol + V/D via B2

receptors + + + + SBP

-DBP +

Ketamine * _ +

Fentanyl ** _ +

Morphine *** _ ++

Propofol **** ++

Midazolam #

of 60

* Ketamine – negative inotrope but due to secondary CNS simulation causes increase in pulmonary BP, heart rate, cardiac output and myocardial O2 demand. Usually there will be no changed in systemic vascular resistance. ** Fentanyl – Usually has minimal or no effect on BP, LV Pressure and cardiac output. Initial boluses can decrease MAP. May have some negative Chronotropy (decrease HR) that can be treated with atropine.*** Morphine – lowers BP via decreasing alpha adrenergic tone mediated through the CNS.****Propofol – can cause large reduction in MAP via venous and arterial vasodilation. It also blocks normal baroreceptor mediated tachycardia which would normally counteract these changes. # Midazolam – has minimal CV effects.

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