.Emergent Interventions (Adult)

Intubation:

RSI

• • Etomidate 20mg (0.3mg/kg)
  • Sux 100mg (1.5mg/kg) – starts 45 sec, lasts 6-10 min. 
  • Rocuronium 80mg (1.2mg/kg). 75 sec onset. lasts 33 min. sugammadex, 16 mg/kg IV reversal. 
  • ketamin IM 5mg/kg for immediate sedation (be prepared to manage airway)
  • propofol inducation 1.5-2 mg/kg (avoid w/ soy and egg allergy)
  • 1/2 dose sedatives in hemodynamically unstable patient.
  • If IM:
    • succinylcholine 4 mg/kg IM with 2-4 min onset (4-5 min children)
    • ketamine 4 mg/kg IM OR midazolam 0.1-0.3 mg/kg IM
• Push dose pressors
  • Rules of 10s: take 10cc flush, squirt out 1 cc, fill with 1 cc of 1/10k epi. = 10mcg/cc of epi. So pushing 1 cc’s every 1 min would be about 10mcg/min. Dose of gtt is 0.1 to 1 mcg/min/kg. So for 100kg person, 1 cc per min is the lowest (0.1mcg/min/kg) and pushing all 10 cc per min would be max (1mcg/min/kg). So basically pushing anywhere from 1 to 10 cc/min is equivalent to the normal range. 
  • Epi: 1/1000 is IM form. 1/10,000 is IV form (for ACS)
  • Quick epi gtt:    ^{Take your code-cart epi (it doesn’t matter if it’s 1:1,000 or 1:10,000) and inject 1mg into a liter bag of NS. Final concentration is 1mcg/ml. Run at 1cc/min and titrate to effect” Run side open which will be with an 18 gauge IV about 20cc/min which is 20mcg/min. 20 drops is 1 cc. quoted from WikEM. Also article on ALiEM.} 
  •  
• Drips
  • Norepinephrine 10mcg/min (max 30) then second line pressor.
  • Dobutamine first line if CHF. Start 2.5 mcg/kg/min. Range 10-40.
  • Propofol for maintenance intubation: 5 mcg/kg/min.
  • 0.001mg=1mg (3 decimal places)

• Imaging (Clinical Decision Rules, Courtesy of WikEM)
  • Canadian C-Spine (GCS 15, Hemodynamically stable, Age <16)
    • High Risk Rhyme
    • Sixty five,
    • Fast drive (dangerous mechanism), Sense deprive (Image if alive), Low Risk Rhyme, Slow wreck, Slow neck, Sitting down, Walking around, C-spine fine
      (Range the spine)
    • No High Risk Factors
      • Age >65
      • Dangerous mechanism
      • Parasthesias in extremities
      • ANY Low Risk Factor
      • Simple rear end MVC
      • Delayed onset of pain
      • Sitting position in ED
      • Ambulatory at any time
      • Absence of midline C-spine tenderness
      • ROM
      • Rotates neck 45 degrees to left and right
      • C-spine can be cleared clinically if above criteria met[3] [4]
  • Canadian Head CT
    • Inclusion Criteria
    • GCS 13-15
    • Age ≥ 16yr
    • No coagulopathy nor on anti-coagulation
    • No obvious open skull fx
    • Rule
      • Head CT not required if NONE of the following are present
      • Age ≥ 65 years
      • Vomiting > 2 time
      • Suspected open or depressed Skull Fracture
      • Signs suggesting basal skull fracture:
      • Hemotympanum
      • Racoon eyes
      • CSF otorrhea or rhinorrhea
      • Battle’s sign (bruising around mastoid process)
      • GCS < 15 at 2 hours post injury
      • Retrograde Amnesia > 30min
      • Dangerous mechanism
      • Pedestrian struck by vehicle
      • Ejection from motor vehicle
      • Fall from elevation >3 feet or 5 stairs

• AHA
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*This information is intended for educational purposes only and not intended for use in patient care (which requires a trained credentialed attending physician and individualization of the medical care plan to the specific patient).