Standardized Procedure- Emergency
Standing Orders at Sharp Healthcare Exam
General Procedure for all Life-Threatening Patient Conditions- what kind of access should a nurse
obtain?
a. Obtain IV/intraosseous (IO) access (large bore cannula in the antecubital vein should be the first
target for IV access if a central line is not present)
General Procedure for all Life-Threatening Patient Conditions- what kind of fluid should be started to
KVO?
b. Begin IV infusion of Normal Saline (NS) to keep vein open (KVO)
General Procedure for all Life-Threatening Patient Conditions- If IV access is not available what
medications can be given and how is it administered?
c. If IV access is not available: Narcan, Atropine, and Epinephrine may be administered via
endotracheal route at doses of 2 times the IV dose diluted in 10ml NS flush
General Procedure for all Life-Threatening Patient Conditions- what's the process after giving each
medication?
d. Flush IV line with 20ml of NS after each IV medication given and elevate extremity if applicable.
General Procedure for all Life-Threatening Patient Conditions- In applicable situations, what should be
readily available?
e. Oxygen
What's the proper techniques using circulation, airway, and breathing?
1. Compressions should be performed at a rate of 100/min for two minutes "push hard,push fast"
allowing full chest recoil, and minimize interruptions in chest compressions after each intervention.
2. All external electrical therapy will be cardioverted/defibrillated with biphasic monitors using
appropriate energy dose as designated by condition.
True/False
In most cases, treatment (e.g. O2 administration) is administered concurrently.
TRUE
True/False
Stickers with appropriate energy levels of cardioversion/defibrillation should be placed on all
defibrillators for quick reference.
TRUE
ASYSTOLE
1. CPR (2 min)
2. O2 at 15ml/min ambu bag (8-10 breaths/min)
3. Epinephrine (1:10,000) 1mg IVP/IO, repeat q3-5 min as long as asystole persists.
BRADYCARDIA UNSTABLE (Heart Rate <60bpm)
1. O2 at minimum 10ml/mim NRBM
, 2. If transvenous leads or epicardial pacing wires present, connect to a pulse generator and initiate
pacing control.
3. Atropine 0.5mg IVP/IO, repeat q3-5min up to a total of 0.04mg/kg (or 3mg)
4. Transcutaneous pacing as soon as available
5. If above algorithm is ineffective, start dopamine 400mg/250ml D5W infusion at 5mcg/kg/minute.
Titrate until SBP =/> 90mmHg and/or MAP >60mmHg up to 20mcg/kg/min.
6. If no response from above algorithm, initiate Isuprel infusion 1-10mcg/min IV/IO)
PULSELESS ELECTRICAL ACTIVITY (PEA)
1. CPR (2min) and assess for possible causes.
2. O2 at 15ml/min ambubag (8-10breaths/min)
3. Epinephrine (1:10,000) 1mg IVP/IO, repeat q3-5mim
4. If hypovolemia known or suspected, infuse 250ml LR or NS. Repeat in 5 minutes if no clinical
improvement.
5. Stat CXR
What are the 7 H's possible causes of PEA?
1. Hypovolemia
2. Hypoxia
3. Hydrogen Ion (acidosis)
4. Hypokalemia
5. Hyperkalemia
6. Hypoglycemia
7. Hypothermia
What are the 5 T'# possible causes of PEA?
1. Toxins
2. Tamponade
3. Thrombosis
4. Trauma
5. Tension pneumothorax
VENTRICULAR TACHYCARDIA (Wide Complex) STABLE
1. Call the physician for orders
IN ADDITION TO CALLING THE MD PERFORM THE FF:
a. O2 at minimum 4L/min NC and adjust per patient status
b. Obtain 12 Lead EKG
c. Draw serum K, Mg
VENTRICULAR TACHYCARDIA (Wide Complex) UNSTABLE
1. O2 at minimum 10ml NRBM
2. If ventricular rate is >150: BIPHASIC- Synchronized cardioversion per approved energy dose listed
on defibrillator
3. If patient is awake and responsive, give Midazolam (versed) 0.5mg IVP/IO prior to cardioversion.
May repeat to a total of 1mg to achieve sedation.
4. Draw serum K, Mg
What's the reversal agent for midazolam (Versed) and when can you give it?
Romazicon 0.1mg IVP/IO over 15sec. May repeat in 45sec based on patient's response, not to exceed
0.6mg- requires a physician order for over sedation (decreased level of consciousness, RR <10min)
Standing Orders at Sharp Healthcare Exam
General Procedure for all Life-Threatening Patient Conditions- what kind of access should a nurse
obtain?
a. Obtain IV/intraosseous (IO) access (large bore cannula in the antecubital vein should be the first
target for IV access if a central line is not present)
General Procedure for all Life-Threatening Patient Conditions- what kind of fluid should be started to
KVO?
b. Begin IV infusion of Normal Saline (NS) to keep vein open (KVO)
General Procedure for all Life-Threatening Patient Conditions- If IV access is not available what
medications can be given and how is it administered?
c. If IV access is not available: Narcan, Atropine, and Epinephrine may be administered via
endotracheal route at doses of 2 times the IV dose diluted in 10ml NS flush
General Procedure for all Life-Threatening Patient Conditions- what's the process after giving each
medication?
d. Flush IV line with 20ml of NS after each IV medication given and elevate extremity if applicable.
General Procedure for all Life-Threatening Patient Conditions- In applicable situations, what should be
readily available?
e. Oxygen
What's the proper techniques using circulation, airway, and breathing?
1. Compressions should be performed at a rate of 100/min for two minutes "push hard,push fast"
allowing full chest recoil, and minimize interruptions in chest compressions after each intervention.
2. All external electrical therapy will be cardioverted/defibrillated with biphasic monitors using
appropriate energy dose as designated by condition.
True/False
In most cases, treatment (e.g. O2 administration) is administered concurrently.
TRUE
True/False
Stickers with appropriate energy levels of cardioversion/defibrillation should be placed on all
defibrillators for quick reference.
TRUE
ASYSTOLE
1. CPR (2 min)
2. O2 at 15ml/min ambu bag (8-10 breaths/min)
3. Epinephrine (1:10,000) 1mg IVP/IO, repeat q3-5 min as long as asystole persists.
BRADYCARDIA UNSTABLE (Heart Rate <60bpm)
1. O2 at minimum 10ml/mim NRBM
, 2. If transvenous leads or epicardial pacing wires present, connect to a pulse generator and initiate
pacing control.
3. Atropine 0.5mg IVP/IO, repeat q3-5min up to a total of 0.04mg/kg (or 3mg)
4. Transcutaneous pacing as soon as available
5. If above algorithm is ineffective, start dopamine 400mg/250ml D5W infusion at 5mcg/kg/minute.
Titrate until SBP =/> 90mmHg and/or MAP >60mmHg up to 20mcg/kg/min.
6. If no response from above algorithm, initiate Isuprel infusion 1-10mcg/min IV/IO)
PULSELESS ELECTRICAL ACTIVITY (PEA)
1. CPR (2min) and assess for possible causes.
2. O2 at 15ml/min ambubag (8-10breaths/min)
3. Epinephrine (1:10,000) 1mg IVP/IO, repeat q3-5mim
4. If hypovolemia known or suspected, infuse 250ml LR or NS. Repeat in 5 minutes if no clinical
improvement.
5. Stat CXR
What are the 7 H's possible causes of PEA?
1. Hypovolemia
2. Hypoxia
3. Hydrogen Ion (acidosis)
4. Hypokalemia
5. Hyperkalemia
6. Hypoglycemia
7. Hypothermia
What are the 5 T'# possible causes of PEA?
1. Toxins
2. Tamponade
3. Thrombosis
4. Trauma
5. Tension pneumothorax
VENTRICULAR TACHYCARDIA (Wide Complex) STABLE
1. Call the physician for orders
IN ADDITION TO CALLING THE MD PERFORM THE FF:
a. O2 at minimum 4L/min NC and adjust per patient status
b. Obtain 12 Lead EKG
c. Draw serum K, Mg
VENTRICULAR TACHYCARDIA (Wide Complex) UNSTABLE
1. O2 at minimum 10ml NRBM
2. If ventricular rate is >150: BIPHASIC- Synchronized cardioversion per approved energy dose listed
on defibrillator
3. If patient is awake and responsive, give Midazolam (versed) 0.5mg IVP/IO prior to cardioversion.
May repeat to a total of 1mg to achieve sedation.
4. Draw serum K, Mg
What's the reversal agent for midazolam (Versed) and when can you give it?
Romazicon 0.1mg IVP/IO over 15sec. May repeat in 45sec based on patient's response, not to exceed
0.6mg- requires a physician order for over sedation (decreased level of consciousness, RR <10min)
