Medical Emergencies Adults

Allergic Reaction Anaphylaxis

Clinical Findings

Neuro: Anxiety, restlessness

Resp: Dyspnea, bronchospasm, wheezing, stridor, swelling of

tongue or throat, respiratory arrest

CV: Hypotension, localized or systemic edema, CV collapse/arrest

Skin: Urticaria, itching, hives, coolness, pallor, cyanosis, diaphoresis

Emergency Management (may need MD order)

■ Remove source of allergy. Remove stinger by scraping only! Do not use tweezers (squeezing venom sac will inject more venom)!

■ Establish and manage ABCs and intubate if indicated.

■ Administer 100% oxygen via NRB mask or use BVM if indicated.

■ Obtain IV access and titrate to hemodynamic status.

■ Attach ECG monitor and manage dysrhythmias per advanced cardiac life support (ACLS).

■ Administer prescribed medications which may include epinephrine 1:1,000 0.3–0.5 mg SC, albuterol 2.5 mg in 3 mL NS nebulized, diphenhydramine 25–50 mg IV or IM, dexamethasone 10 mg IV, and a dopamine infusion starting at 10 mcg/kg/min.

Drug Overdose Poisoning

Clinical Findings

Varies depending on type of substance Pt has overdosed on.

Emergency Management (may need MD order)

■ Establish and manage ABCs as indicated.

■ Protect airway by placing Pt into a lateral-lying position and suctioning airway as needed. Insert an oropharyngeal airway (OPA), or, if Pt has a gag reflex and there is no evidence of facial trauma, use a nasopharyngeal airway (NPA).

■ Intubate if indicated and confirm tube placement.

■ Administer supplemental oxygen titrated to vital signs (VS).

■ Contact MD, poison control stat (USA: 1-800-222-1222).

■ If substance known, see Antidotes for specific reversal agents.

■ Continue to monitor and manage ABCs, LOC, VS, and ECG. CNS stimulants or hallucinogens: Minimize sensory stimulation. Orogastric Lavage: May be done in ED airway must be protected. Activated Charcoal: 1 gram/kg PO or NG. Mix with 250 mL water to make a slurry. Caution: Ineffective for treating OD of heavy metals, alcohols, caustics, hydrocarbons, potassium, or potassium cyanide. Caution: Avoid the use of Ipecac because vomiting may complicate or worsen clinical management of OD or poisoning.

Antidotes

NOTE: This is strictly a reference! It is intended to provide quick information about antidotes commonly used to reverse or remove common biological or pharmacological agents from the body. It is not intended to replace nor dictate hospital protocol!

Acetaminophen . . . . . . . . . . . . .acetylcysteine or mucomyst

Anticholinesterase . . . . . . . . . . .atropine or pralidoxime

Anticholinergics . . . . . . . . . . . . .physostigmine

Antifreeze . . . . . . . . . . . . . . . . .fomepizole, ethanol

Benzodiazepines . . . . . . . . . . . .Romazicon (flumazenil)

Beta-Blocking Agents . . . . . . . .Glucagon, epinephrine

Ca__ Channel Blockers . . . . . . .Ca_ chloride, glucagon

Carbon Monoxide (CO) . . . . . . .hyperbaric, oxygen

Coumadin . . . . . . . . . . . . . . . . .phytonadione or vitamin K

Cyanide . . . . . . . . . . . . . . . . . . .amyl nitrite, sodium nitrite, or

sodium thiosulfate

Cyclophosphamide . . . . . . . . . .mesna

Digoxin . . . . . . . . . . . . . . . . . . . .Digibind or Digoxin Immune Fab

Dopamine . . . . . . . . . . . . . . . . .Rigitine

EPS . . . . . . . . . . . . . . . . . . . . . . .Benadryl (diphenhydramine)

(Extra Pyramidal Symptoms)

Ethylene Glycol . . . . . . . . . . . . .fomepizole

Fluorouracil . . . . . . . . . . . . . . . .leucovorin calcium

Heroin . . . . . . . . . . . . . . . . . . . .Narcan (naloxone) or nalmefene

Heparin . . . . . . . . . . . . . . . . . . .protamine sulfate

Insulin Reaction . . . . . . . . . . . . .IV glucose (D50)

Iron (Fe) . . . . . . . . . . . . . . . . . . .deferoxamine

Lead . . . . . . . . . . . . . . . . . . . . . .edetate calcium disodium,

dimercaprol, or succimer

Malignant Hyperthermia (MH) .dantrolene

Methanol . . . . . . . . . . . . . . . . . .ethanol

Methotrexate . . . . . . . . . . . . . . .leucovorin calcium

Narcotics . . . . . . . . . . . . . . . . . .Narcan (naloxone) or nalmefene

Opioid Analgesics . . . . . . . . . . .Narcan (naloxone) or nalmefene

Organophosphate (OPP) . . . . . .atropine, pralidoxime

Potassium (K) . . . . . . . . . . . . . .Insulin and glucose, NaHCO3, albuterol inhaler, or Kayexalate (sodium polystyrene sulfonate)

Rohypnol . . . . . . . . . . . . . . . . . .Romazicon (flumazenyl)

TCA (tricyclic antidepressants) .physostigmine or NaHCO3

Tranquilizers—EPS symptoms .Benadryl (diphenhydramine)

Tylenol . . . . . . . . . . . . . . . . . . . .acetylcysteine

Warfarin . . . . . . . . . . . . . . . . . . .phytonadione or vitamin K

Hyperglycemia (DKA, diabetic ketoacidosis)

Clinical Findings

■ See Comparing Hypoglycemia & Hyperglycemia following

Emergency Management (may need MD order)

■ Establish and manage ABCs as indicated.

■ Administer 100% oxygen via NRB mask or use BVM if indicated.

■ Obtain stat blood glucose level and manage as indicated.

■ Attach ECG monitor and manage dysrhythmias per ACLS.

■ Obtain IV access and infuse 0.9% NS _ 2 liters, then switch to 0.45% sodium chloride solution (may need up to 10 liters).

■ Administer regular insulin (High-Alert Rx) 5–10 IU/hr IV infusion.

■ Administer sodium bicarbonate 1–2 mEq/kg IV for pH _ 7.0.

■ Administer potassium (High-Alert Rx) added to IV until serum potassium repleted to _ 4.0 mEq/L.

■ Document assessment, interventions, and outcome.

Special Considerations

■ Average fluid volume deficit in DKA is 5–10 liters.

■ The goal of therapy is to lower the blood glucose by 100 mg/dL/hr.

■ Switch to glucose-containing IV solution once blood glucose falls to 250 mg/dL.

Hypoglycemia (Diabetic Coma, Insulin Shock)

Clinical Findings

■ See Comparing Hypoglycemia & Hyperglycemia following

Emergency Management (may need MD order)

■ Establish and manage ABCs as indicated.

■ Administer 100% oxygen via NRB mask or use BVM if indicated.

■ Obtain stat blood glucose level and manage as indicated.

■ Attach ECG monitor and manage dysrhythmias per ACLS.

■ Administer oral glucose 20 g PO (Pt MUST be alert and oriented).

■ Obtain IV access and titrate to hemodynamic status.

■ Administer dextrose (D50) 25 gram IV only.

■ Administer glucagon 1–2 mg IM if IV access delayed or unavailable.

■ Monitor blood glucose level every hour until stable.

■ Document assessment, interventions, and outcome.

Special Considerations

■ Known history of adrenal insufficiency: hydrocortisone 100 mg IV with glucagon 1 mg IV.

■ Resistant hypoglycemia due to sulfonylureas: diazoxide 300 mg IV infusion over 30 minutes q 4 hr PRN (may cause hypotension).