EMERGENCY DEPARTMENT GUIDELINES/PROTOCOLS
GENERAL ABDOMINAL PAIN
I.V - Hold blood. If severe Nausea/Vomiting Tell M.D.
RUQ Pain(Gallstones) or Severe General Upper Abdominal Pain - CMP, Amylase, CBC
Lower Quadrant Pain(suspect Possible Pregnancy, Ectopic, UTI, Atypical Appendicitis) - MP, CBC *ADD HCG and U/A (midstream or mini - cath as appropriate)*
RLQ Pain (Appendicitis) -U/A (midstream/mini-cath as appropriate) and CBC, MP
EMERGENCY DEPARTMENT GUIDELINES/PROTOCOLS
GI Cocktail Orders
Unless ordered differently a GI cocktail consists of:
10 ml of Viscous Lidocaine
10 ml of Donnatal
30 ml of Maalox/Mylanta
EMERGENCY DEPARTMENT GUIDELINES/PROTOCOLS
POSSIBLE HIP FRACTURE
IV
Chest X-Ray
X-Ray affected leg
Labs - BMP, CBC
EKG (if over 50)
Foley Catheter
EMERGENCY DEPARTMENT GUIDELINES/PROTOCOLS
LACERATION
Set up room, suture set and prep-tray
Evaluate laceration - If nerve or flexion/extension problems, STOP, refer evaluation to physician- NO problems - move on
Tetanus if needed - Td. 0.5 cc IM
Follow policy 10.R28 for prepping laceration
May use topical to wounds
X-ray as indicated for injury
IV lock PRN
Prepping Laceration (from policy 10R.28)
Prep tray - 1 section NS & 1 section 1 part betadine/9parts NS
Anesthetic:
1% Xylocaine with adrenalin (epinephrine) except on fingers, toes, penis & nose
0.25% Bupivacaine Hydorchloride(Marcaine) on fingers, toes, penis & nose
1% Xylocaine without epinephrine on dog bites
May add 1cc on Sodium Bicarb to 9cc Xyolacaine (not marcaine) to decrease sting
Maximum dose - 7ml/kg Xylocaine with Adrenalin
- 2mg/kg Marcaine
Inject anesthetic inside wound margin slowly injecting one end first then down one edge to the other end of wound & back to 2nd edge
Assess for anesthesia & repeat injection if any area not anesthetized
Shave excess hair if needed (except eyebrows)
Consult MD before shaving beards or mustaches
Place dry sterile gauze pad into wound to protect from solutions
Use betadine sol’n to clean skin around wound to include: 1) all of hand if wound involves hand
2) area large enough to avoid suture contamination, 3) may use lanolin based solvent in very dirty areas except wound bed, 4) may use toothbrush to scrub (except wound bed)
Remove soaked drapes & replace with sterile ones
When suture completed, clean wound with NS & apply antibacterial ointment (Polysporin if pt not allergic)
Apply Adaptic & dry sterile dressing
Splint in position if wound over joint
EMERGENCY DEPARTMENT GUIDELINES/PROTOCOLS
ALTERED LEVEL OF CONSCIOUSNESS/WEAKNESS
Foley catheter or mini-catheter PRN
IV Saline Lock
CBC, CMP, Blood Glucose
U/A
EKG
EMERGENCY DEPARTMENT GUIDELINES/PROTOCOLS
CONGESTIVE HEART FAILURE
IV (Saline Lock)
EKG
Portable Chest X-Ray
Foley catheter as needed
Respiratory Treatment
EMERGENCY DEPARTMENT GUIDELINES/PROTOCOLS
FLANK PAIN
I.V. - Hold Blood,
Mid-stream Urinalysis *(Mini-cath preferred if patient cannot follow detailed prep instructions)*
High Fever (Pyelonephritis) - Temp > 100 CBC, MP
Tylenol
Child Bearing Age - *ADD HCG* (Ectopic, PID)
EMERGENCY DEPARTMENT GUIDELINES/PROTOCOLS
ISOLATED EXTREMITY INJURY
Immobilize joints above and below injury
Apply ice to affected area
Elevate Extremity
Remove rings on injured extremity
If obvious fracture assessed as Type 2 or 3, consider IV Lock
ISOLATED EXTREMITY INJURY X-Ray Extremity if swelling, bruising, deformity or PRN
CXR (undress waist up)
Clavicle (undress waist up)
Elbow 4 v
Forearm 2 v
Hand 3 v (include fingers)
Humerus 2 v(undress waist up)
Shoulder 3 v(undress waist up)
Wrist 3 v
***Physician consult for C-Spine, L-Spine or infants***
Ankle 3 v
Ankle 2 v/Foot 3 v
Femur 2 v (undress waist down)
Foot 3 v (include toes) 2 v
Knee 4 v (undress waist down)
Knee/Patella 3 v (undress waist down)
Lower Leg 2 v (undress waist down)
Oscalcis (Heel) 2 v
Pelvis with Lateral Hip
EMERGENCY DEPARTMENT GUIDELINES/PROTOCOLS
VAGINAL BLEEDING
CBC & HCG (Unless fetal heart tones present)
Consider sending to Labor & Delivery if meets criteria per policy. No guidelines need implementation if sending to L&D
*RH Status* (if known pregnancy & pt. doesn’t know blood type- consider ordering old chart if previous delivery at Salem Hospital)
NPO
Consider minicath
IF Acute: In E.D. (unstable vital signs)
Type & screen
I.V Lock
Prep for Pelvic
EMERGENCY DEPARTMENTGUIDELINES/PROTOCLS CHEST PAIN
Monitor, Pulse Oximeter
O2 - @ liters or titrate
I.V. - Lock - Draw all labs
CBC, MP, CPK, Troponin
PT/PTT if on Coumadin
EKG
Portable CXR or 2 view Chest X-Ray depending on stability
Nitroglycerin SL Q 5 min. x3, maintain SBP>100
If Acute Suspicious Chest Pain Get M.D.
ASA Chewable 81 mg - 4 tabs
EMERGENCY DEPARTMENT GUIDELINES/PROTOCOLS SHORTNESS OF BREATH
Wheeze/Tightness - Albuterol 0.5cc in 2cc NS (if needed Type back)
Asthma/Wheezing/Young Healthy - if Fever & Pleuritic Pain add CXR
Monitor, Pulse Oximeter
Suspect CHF if Severe Distress(RA sats <90 with C.P)
I.V. Lock
Consider cardiac source (Draw blood & order tests if strong suspicion)
EKG; CXR
CBC; MP; CPK; Trop
Nitro SL Q 5 min X3 - maintain SBP>100
EMERGENCY DEPARTMENT GUIDELINES/PROTOCOLS
SORE THROAT (WITHOUT AIRWAY COMPRIMISE)
RAPID STREP(order if pt. has 2 out of 3 - fever, exudate, lymphadenopathy)
ACTIVE VOMITING (SEE ABD. Pain)
Start I.V.
Draw Labs
Phenergan 12.5 mg I.V or
Phenergan 25 mg I.M.
Phenergan Supp. Pediatric Dose 1 mg/kg
Type back & consider Abd. Pain Guidelines
EMERGENCY DEPARTMENT GUIDELINES/PROTOCOLS
ADULT FEVER
Tylenol 1 gm. P.O.
PEDIATRIC FEVER
Weight Based Tylenol 15 mg/kg OR
Motrin 10 mg/kg
NO MOTRIN UNDER 6 MONTHS AGE
EMERGENCY DEPARTMENT GUIDELINES/PROTOCOLS
PAIN
Protocol may be used in the following circumstances:
Patient 14 years or older
Complaints of Pain greater that 3 out of 10 on a 10 point pain measurement scale
Has not taken pain medication within past 2 hours preceding arrival to ED
Is unlikely to be NPO for tests on arrival to ED
Has NO KNOWN ALLERGIES to selected analgesia to be given
IF ALL CRITERIA MET ONE OF FOLLOWING MAY BE GIVEN:
IBUPROFEN 600 MG P.O OR TYLENOL 1000 MG P.O
EMERGENCY DEPARTMENT GUIDELINES/PROTOCOLS
PSYCHIATRIC PATIENTS
Call Social Services when on site otherwise call PCC on arrival to triage
U/A if Elderly
UDS
ETOH if visibly intoxicated. Draw and hold other tubes
If any pill ingestion known or suspected order Tylenol and ASA levels
Appropriate drug levels if on meds - ie. Depekote
EMERGENCY DEPARTMENT PAIN MANAGEMENT GUIDELINES/PROTOCOLS FOR TITRATED IV NARCOTICS
Pain Goal for each patient: Pain rated at or less that 5 on scale and/or patient reports pain tolerable
Protocol may be used in the following circumstances:
Patient has been assessed by physician & physician has ordered analgesia
Patient at least 16 years or older
Has NO KNOWN ALLERGIES to selected analgesia to be given
Morphine 2-4 mg IV every 5 minutes to maximum dose of 10 mg
Dilaudid 0.5 – 1 mg every 15 minutes to maximum dose of 2 mg
Demerol 12.5 mg every 15 minutes to maximum dose of 50 mg
IF PATIENT PAIN NOT CONTROLLED WITH MEDICATION AS GIVEN IN PROTOCOL, CHECK WITH PHYSICIAN ABOUT ADDITIONAL MEDICATIONS OR DOSAGES
Pediatric DKA Policy
Initial Approach
Do CBG – if “High” do STAT serum Glucose
LABS: Electrolytes, BUN, CBC, Venous pH, Urine for glucose & acetate
IV – 10cc/kg of NS over 30 – 60 min
NPO
After initial assessment, treatment based on degree of Acidosis
For moderate (pH 7.5-7.25) to severe (pH < 7.15) acidosis, cosnult Pediatric Enocrinologist or Ped. Critical Care Center as soon as possible
DO NOT GIVE INSULIN OR BICARB BOLUS INITIALLY
REFER TO POLICY AS SOON AS PT. DIAGNOSED
Pediatric DKA: Mild Acidosis (pH > 7.25) See Policy
Begin IV maintenance & replacement with NS (maximum 125 cc/hr – see policy for calculations)
Begin insulin drip 0.08 - 0.1 units/kg/hr if pt in ED for 2 hours
Add K+ 3mEq/kg/24 hr within 2 hrs of admission to ED or when insulin has been started
Labs: Hourly blood glucose. Venous pH or CO2 electrolytes at 2 hours & 4 hours
If blood sugar below 350mg/dl and pt. is being given insulin, add 10% dextrose to the IV solution. Maintain blood sugar between 250 and 300 mg/dl while acidosis is resolving
Pediatric DKA: Moderate Acidosis ( pH7.15-7.25) See Policy
Give bolus of 10 cc/kg of NS. This may be repeated
Use NS for maintenance and replacement fluids (see policy for chart)
Begin insulin at 0.1 mg/kg/hr if the pt. is in ED for 2 hours
Add K+ at 3 – 5 mEq/kg/24 hrs. within 2 hrs of admission to ED
Blood glucose every hour, venous pH or CO2 electrolytes at 2 and 4 hours
If blood sugar below 350mg/dl and pt. is being given insulin, add 10% dextrose to the IV solution. Maintain blood sugar between 250 and 300 mg/dl while acidosis is resolving
Pediatric DKA: Severe Acidosis (pH <7.15, CO2 <8, signs of shock) See Policy
Bolus NS at 20cc/kg. Do not give more unless there is evidence of shock
Continue NS at rate of 1 ˝ maintenance (see chart)
Monitor vital signs continuously
Arrange PICU bed as soon as possible
Begin insulin drip at 0.1 units/kg/hr within 2 hrs of admit to ED
Add K+ at 3-5 mEq/kg/24hr within 2 hrs or when insulin has been started
Obtain bedside glucose every 30 min (meter may only read high)
Blood glucose every hour, venous pH or CO2 electrolytes at 2 and 4 hours
If blood sugar below 350mg/dl and pt. is being given insulin, add 10% dextrose to the IV solution. Maintain blood sugar between 250 and 300 mg/dl while acidosis is resolving
Pediatric DKA Policy: Fluid and Insulin Dosing Chart
Trauma Team- Modified Trauma Activation
Isolated penetrating injury above base of skull
Isolated amputation above wrist or ankle
Death of same care occupant
Ejection of patient from enclosed vehicle
Extrication time > 20 min
EMT requests trauma team evaluation for high energy transfer situations or presence of co-morbid factors
Hangings*
Drownings (unwitnessed or suspect spinal cord injury)*
Pulseless extremity with traumatic injury*
Pedestrian vs. auto (especially if age>65 or on Coumadin)*
Trauma Team- Full Activation
Systolic BP < 90 mm Hg
Respiratory difficulty with rate < 10 or > 29
GCS 10 or less
Penetrating injury mid thigh to base of skull
Flail Chest
Two or more fractures of the femur or humerus
Paralysis
EMT suspects life threatening injuries
Amiodarone (Cordarone)
Rapid Infusion: Mix 150 mg in D5W 50 ml over 10 min.
Slow Infusion: Mix 900 mg in 500 ml NS
360mg/6 hr(1mg/min)= 33.3ml/hr then
540mg/18hr (0.5mg/min)=16.6 ml/hr
Dobutamine Dosing Chart 500mg/250ml (2,000 mcg/ml)
Dopamine(Inotropin) 400mg in 250ml
Integrilin (Eptifabatide)
iF YOU HAVE EMERGENCY ROOM PROTOCOLS/STANDING ORDERS/GUIDELINES........PLEASE SEND ME A COPY. THANKS.
Originally Posted by lifsavER67
Hi all,
This is my first time posting here. I am trying to do some research about Triage protocols and different ways of doing things. Any info you guys can give me would be appreciated.
I'd like to know how you determine levels of urgency, who handles ambulance arrivals, does coming by ambulance guarantee a bed or do you triage and sent nonurgent ambulance patients to the lobby?
Thanks,
lifsavER67
Would you like to comment?
Triage protocols. what does your ER use?
:hatparty: 
