What are the treatment protocols with specific doses and potential contraindications for acute medical emergencies, including cardiovascular, respiratory, and neurological conditions?

Treatment Protocols for Acute Medical Emergencies

The most effective treatment protocols for acute medical emergencies require specific medication dosages, administration routes, and awareness of contraindications to optimize patient outcomes and reduce mortality. 1

Cardiovascular Emergencies

Cardiac Arrest Management

• Begin high-quality CPR immediately with chest compressions at 100-120/min, pushing hard (2½ of anteroposterior diameter of chest) and allowing complete chest recoil while minimizing interruptions 1
• Avoid excessive ventilation as it can impair cardiac output 1
• Administer epinephrine 0.01 mg/kg (0.1 mL/kg of 1:10,000 concentration) IV/IO every 3-5 minutes 1
• If IV/IO access is unavailable, consider endotracheal administration at 0.1 mL/kg of 1:1000 concentration 1

Ventricular Fibrillation/Pulseless Ventricular Tachycardia

• For refractory VF/pulseless VT, administer amiodarone 5 mg/kg IV/IO bolus 1
• Alternative: lidocaine IV/IO at initial dose of 1 mg/kg, with maintenance dose of 20-50 mcg/kg per minute 1
• Repeat lidocaine bolus if infusion initiated >15 minutes after initial bolus therapy 1

Anticoagulation for Thromboembolism

• For therapeutic anticoagulation with heparin, administer initial IV bolus of 5,000 units followed by continuous infusion of 20,000-40,000 units/24 hours in 1,000 mL of 0.9% sodium chloride 2
• Alternative intermittent IV dosing: initial 10,000 units followed by 5,000-10,000 units every 4-6 hours 2
• Contraindications: history of heparin-induced thrombocytopenia, known hypersensitivity to heparin or pork products, uncontrolled bleeding state (except when due to disseminated intravascular coagulation) 2
• Monitor aPTT, platelet count, hematocrit, and occult blood in stool during therapy 2

Respiratory Emergencies

Advanced Airway Management

• Use highest possible inspired oxygen concentration during CPR to correct tissue hypoxia 1
• Secure airway via endotracheal intubation or supraglottic airway device 1
• Confirm proper tube placement using waveform capnography or capnometry 1
• Once advanced airway is placed, deliver 10 breaths/minute with continuous chest compressions 1
• Monitor for signs of respiratory distress including facial expressions, which can provide valuable information about respiratory status 3

Pulmonary Hypertension Crisis

• If intravenous or inhaled therapy to decrease pulmonary hypertension has been interrupted, reinstitute it immediately 1
• Consider hypoventilation in patients with Fontan or hemi-Fontan/bidirectional Glenn physiology as it may improve oxygen delivery 1
• Negative-pressure ventilation may improve cardiac output in patients with single ventricle physiology 1

Neurological Emergencies

Status Epilepticus

• Administer lorazepam 0.05-0.10 mg/kg IV (maximum 4 mg per dose), which may be repeated every 10-15 minutes if needed 4
• Monitor oxygen saturation closely due to increased risk of apnea, especially when combined with other sedative agents 4
• Have flumazenil available to reverse life-threatening respiratory depression, but be aware it will also counteract anticonvulsant effects and may precipitate seizures 4

Muscle Spasticity/Agitation

• For muscle relaxation, diazepam may be administered IV with careful monitoring for respiratory depression 5
• Avoid rapid administration of IV diazepam as it can cause pain at injection site, hypotension, and increased risk of respiratory depression 5
• Be aware that paradoxical excitement or agitation may occur with benzodiazepines, especially in younger patients 5

Special Considerations

Intra-hospital Transport of Critically Ill Patients

• Be aware that adverse events during transport can occur in up to 68% of cases, with serious events requiring intervention in 4.2-8.9% 1
• Cardiac arrest during transport ranges from 0.34% to 1.6% 1
• Major risk factors during transport include management of mechanical ventilation, number of infusion lines, and sedation 1
• Ensure adequate oxygen reserves, appropriate ventilator settings, and secure airway position before and during transport 1

Cardiac-Neurological Interactions

• Recognize that heart disease frequently causes cerebral complications including embolic stroke, syncope, and intracerebral bleeding 6
• Cardiac emboli can originate from the left atrium, left atrial appendage, left ventricle, or the mitral/aortic valves 6
• Arrhythmias like atrial fibrillation not only increase thrombus formation risk but can lead to low output failure causing watershed infarction, vertigo, or syncope 6
• Consider extracorporeal membrane oxygenation (ECMO) for cardiac arrest in patients with Fontan physiology 1

Contraindications and Cautions

• Heparin is contraindicated in patients with history of heparin-induced thrombocytopenia, hypersensitivity to heparin or pork products, and uncontrolled bleeding states 2
• Benzodiazepines should be used cautiously in patients with respiratory compromise, as they can cause respiratory depression, especially when combined with other sedative agents 4, 5
• Avoid intramuscular administration of heparin due to frequent occurrence of hematoma at injection site 2
• Rapid administration of IV diazepam increases risk of hypotension and respiratory depression 5
• Be cautious with fluid resuscitation volumes in certain conditions where restrictive fluid strategies may be beneficial 1