MODULE 3:

CRITICAL CARE IN EMERGENCY

MEDICINE
Course/Program Title: Critical Care in Emergency Medicine

Course Description:

This module will hone the skills, enhance the knowledge and shape the right attitude of
emergency nursing staff to effectively render safe and quality critical nurse skills.

As front liners of the hospital in rendering care to life-or-death situations, the DEM
intends not only to develop its nurses’ bedside skills but to improve their character in handling
such cases. Nurses in the ED have to be able to think and make quick decisions in this fast-paced
environment. Supplemental learning with discussions and knowledge-skills checklist is aimed to
further enhance nurse’s clinical skills in the department.

Intended Audience: Nursing Staff

Teaching Strategy:

Lecture
Return Demonstration
Video Presentation

General Objective:

This module serves to guide nurses in their daily activities in the ED starting from
familiarization of the E-cart contents to their responsibilities in managing ambulatory patients
and most especially to the most critical cases needing prompt medical attention.

Specific Objectives:

After learning this module, nurses will be able to:

1. Identify contents of the Emergency Cart and Code Kit

2. Identify Emergency Drugs; its indication and method of administration
3. Properly assemble emergency equipment
4. Perform critical care skills
 3.1 EMERGENCY CART (E-CART)

Emergency Drugs

Adenosine
Stock Dose: 6mg/2ml ampule/or vial
Paroxysmal Supraventricular Tachycardia
Administration-
6 mg IVP over 1-3 seconds (maybe given IO) followed by rapid flush with 20 mL NS, if no
conversion within 1-2 minutes give 12 mg IVP, repeat a second time if necessary (30 mg total)

Dosing considerations-
When clinically advisable for PSVT, appropriate vagal maneuvers (eg, Valsalva maneuver),
should be attempted prior to adenosine administration

Amiodarone
Stock Dose: 150mg/3ml ampule
Indication-
A. Stable Monomorphic or Polymorphic Ventricular Tachycardia
150 mg IV bolus in 10 minutes; may repeat q10min as necessary, THEN
1 mg/min IV for 6 hours, THEN
0.5 mg/min IV for 18 hours; not to exceed 2.2 g/24hr
For breakthrough episodes of VF or hemodynamically unstable VT ,
repeat the initial load

B. Pulseless Ventricular Fibrillation/Ventricular Tachycardia

300 mg IV or IO push after dose epinephrine if no initial response to
defibrillation. May follow initial dose with 150 mg IV q3-5min
Administration - Rapid IV push if pulseless/no BP

Atropine SO4
Stock Dose: 1mg/ml ampule
Indication-
Sinus Bradycardia
IV: 0.5-1 mg or 0.04 mg/kg IV q5min, no more than 3 mg
ET: Some experts suggest 2-3 times IV dose diluted in 3- 5 mL sterile
water for injection/NS

Dexamethasone
Stock Dose: 5mg/ml ampule
Indication-
 Inflammation
 Cerebral Edema
 Shock
  Allergic Conditions
 Covid-19 (Off label)

Digoxin
Stock Dose: 0.5mg/2ml ampule
Indication-
 Atrial Fibrillation
 Heart Failure

Dosing Considerations- Administer slowly by direct IV injection over

minimum of 5 minutes (longer if given undiluted)

Diphenhydramine
Stock Dose: 50mg/ml ampule
Indication-
 Allergic Reaction
 Motion Sickness
 Cough
 Parkinsonism
 Insomnia
Dosing Considerations- May cause CNS depression, which can impair
driving or operating heavy machinery, check patency of IV and monitor
for irritation

Dextrose 50% 50ml/amp

Indication-
Treatment for severe hypoglycemia

Administration-
Slow intravenous push (3 to 5 minutes)
Never give via IM or SC
May cause vein irritation
 Dobutamine
Stock Dose: 250mg/5ml
Indication-
 Cardiac Decompensation
 Low Cardiac Output

Administration-
Dilute 250 mg in 250 mL of compatible solution
Infuse into large vein via infusion pump

Dopamine
Stock Dose: 200mg/5ml

Indication- Treatment of hypotension, low cardiac output, poor

perfusion of vital organs; used to increase mean arterial pressure in
septic shock patients who remain hypotensive after adequate volume
expansion

Administration-
Infuse via central line
Administer in large vein (eg, antecubital)
Use infusion pump to control flow rate; titrate dosage to desired hemodynamic values or optimal
urine flow

Epinephrine
Stock Dose: 1mg/ml
Indication-
 Cardiac Arrest
 Hypotension associated with septic shock
 Anaphylaxis
 Symptomatic Bradycardia

Administration-
 Cardiac Arrest – IV Push followed by 10 cc of saline flush
 Anaphylaxis – Inject IM or SC into the anterolateral aspect of the thigh.
Administer only in outer thigh to ensure SC or IM administration.
 Do not inject into buttock, or into digits, hands, or feet

Furosemide
Stock Dose: 20mg/2ml ampule
Indication-
 Edema associated with CHF, liver cirrhosis, renal disease
 Acute pulmonary edema / Hypertensive crisis /
Increased Intracranial Pressure

Administration-
Inject directly or into tubing of actively running IV over 1-2 minutes, check BP prior giving via
IV

Hydrocortisone
Stock Dose: Available in 100mg/2ml
vial or 250mg/2ml vial
Indication-
 Inflammation
 Status Asthmaticus
 Bronchial Asthma
 Hypersensitivity Reactions
 Covid-19 (Off label)

Isosorbide Dinitrate IV
Stock Dose: 10mg/10ml

Indication-
 Angina Pectoris

Administration-

Dilute 10 mg in compatible solution as ordered

Infuse into large vein via infusion pump

Lidocaine 2%
Stock Dose: 5ml/amp
Indication-
 Ventricular Arrhythmias or Pulseless Ventricular Tachycardia
(after defibrillation, attempts, CPR & vasopressors)
 Hemodynamically Stable Monomorphic Ventricular
Tachycardia
 Local anesthetic for minor surgeries
Administration-
IV injection or infusion; local infiltration for minor surgeries

Naloxone
Stock Dose: 400mcg/vial

Indications-
 Opioid toxicity (respiratory depression in opiod overdose)

Administration-
For infusion, dilute to 4 mcg/mL in D5W or NS
For IM/SC - Administer in anterolateral aspect of the thigh in adult and
pediatric patients

Nicardepine
Stock Dose: 10mg/10ml

Indication-
 Hypertension
 Chronic Stable Angina

Administration-
Administer via slow IV infusion or via infusion pump
May cause systemic hypotension or tachycardia; titrate slowly

Norepinephrine
Stock Dose: 4mg/4ml

Indication-
 Acute hypotension
  Cardiac Arrest
 Sepsis and Septic Shock
Administration-
Solution: 4 mg in 1000 ml D5W (4 mcg/ml); dose may be
titrated to patient response. Do not administer NaHCO3
through an IV line containing norepinephrine

Sodium Bicarbonate
Stock Dose: 84 mg/ml per 20ml ampule
Indication-
 Metabolic Acidosis
 Cardiac Arrest
 Hyperkalemia

Administration-
Monitor pH, serum potassium, and CO2
Direct IV infusion for emergencies (eg, cardiac arrest)

Tranexamic Acid
Stock Dose: 500mg/5ml
Indications-
 For prevention and reduction of haemorrhage

Administration-

100 mg or fraction thereof over at least 1 min, usually 5 minutes

Avoid rapid infusion
 Terbutaline Sulfate
Stock Dose: 500mcg/ampule

Indication-
 Bronchospasm
 Preterm Labor

Administration-
IV: Dilute as required in D5W (available form: 1 mg/mL)
Use infusion pump
Protect from light; Do not use if discoloured
May also be given via SC depending on physician’s order

Verapamil
Stock Dose: 5mg/2ml ampule

Indication-
 Angina
 Supraventricular Arrhythmias/Atrial Fibrillation/Flutter
 Hypertension

Administration-
Direct IV over at least 2 minutes (3 minutes in older patients)

Mannitol 20%
Stock Dose: 500ml vial
Indication-
 Elevated Intracranial Pressure
 Elevated Intraocular Pressure

Administration-
Infusion of hypertonic solutions through a peripheral vein, at
a concentration of 10% w/v or greater, may result in
peripheral venous irritation
Administer preferably into a large central vein; Do not mix
with blood
Hydrocyethyl Starch 6% IV (Voluven)

Indication-
Plasma volume substitute indicated for treatment and prophylaxis of
hypovolemia

Administration-
Give initial 10-20 mL by slow IV infusion and monitor for anaphylactic
reaction

Phytomenadione
Stock Dose: 10mg/ml
Indication-
 Over-anticoagulation
 Vitamin K deficiency bleeding in neonates

Administration-
Adult-Frequency and amount of subsequent doses are given
according to prothrombin time (PT) response or clinical condition
Neonate-Given as prophylaxis at birth

Diazepam
Stock Dose: 10mg/2ml ampule
Indications-
 Anti-anxiety
 Seizure Disorder / Status Epilipticus
 Alcohol Withdrawal
 Sedative
Administration- Administer over 3 min;
Monitor respiration q5-15min and before each
IV dose; Have airway support ready until
effects of IV administration are known

Ipratropium + Salbutamol (Combivent)

Stock Dose: 2.5ml Inhalation
 Indications-
 COPD
 Acute Asthma Exacerbation

Fenoterol HBr + Ipratropium Br (Berodual)

Stock Dose: 4ml, 1.25mg/0.5mg/4ml Inhalation

Indications-

 COPD
 Acute Asthma Exacerbation

Budesonide
Stock Dose: 250mcg/ml /2ml Inhalation

Indications-
 Asthma

Ipratropium Salbutamol (Duavent)

Stock Dose: 500mcg/2.5mg per 2.5ml Pulmoneb

Indications-
 COPD
 Acute Asthma Exacerbation
Lidocaine Pump Spray
Stock Dose: 10mg/dose (10%)

Indications-
Mainly performed to abolish reflexes and provide patient comfort during manipulation
and instrumentation of the airways in an awake patient during procedures such as
bronchoscopy, laryngoscopy, and intubations
Drug Computation

EPINEPHRINE
 Contents of the Code Kit

H. Electrodes

A. Bag Valve Mask D. Suction Cathether

F. Alcohol Swab

I.IV Tubing & PNSS 1L

G. IV Cannula & Start-Up Kit

B. ET Tube and KY Jelly

E. Sterile Water 1L

J. Syringe 10cc, 5 cc, 3 cc J. Syringe 10cc, 5 cc, 3 cc

C. ET Stylet

Intubation Set
 STANDARD
SHORT

MACINTOSH SIZE 3

PEDIA

MILLER SIZE 2

Left: The curved Macintosh blade and straight Miller blade in standard adult sizes (Macintosh size 3, Miller size 2), with
different handle choices available. From left to right: short, pediatric, and standard handle sizes. Each blade comes in a
variety of sizes from infant to large adult. Right: The ET holder for intubated patients in MDH-DEM.
References

Drug Computation, https://www.slideshare.net/serag35/drug-calculation-presentation

Emergency Drugs, Medscape from https://reference.medscape.com/drug

 CRITICAL CARE IN THE EMERGENCY 1
KNOWLEDGE & SKILLS CHECKLIST

INSTRUCTIONS:
Please check (√) on the space provided for whether the participant is able to perform the steps
correctly or if it is not done.
CD – Correctly done ND – Not done

*Manila Doctors Hospital Transmutation Table will be utilized for rating. (basis of 0 = 50%)
STEPS CD ND REMARKS
Check the Emergency Cart prior duty shift
Familiarize self with the contents of the Code Kit
Familiarize self with the emergency medications and its indications
Familiarize & assemble equipment included in the E-cart / stations
TOTAL

________________________ ________________________ _____________________________

Signature of Preceptee / Date Signature of Preceptor / Date _
Signature of Head Nurse/Date
3.2 EMERGENCY MEDICAL
EQUIPMENT
CBG Machine ECG Machine
Brand: Stat Strip Brand: Nihon Kohden

Cardiac Monitor Cardiac Monitor

Brand: Zoll Brand: Mindray
Infusion Pump & Syringe Pump
Brand: B.Braun

Nebulizer Vein Finder

Brand: PulmoAide Brand: AccuVein
Thermoscan Peak Flow Meter (PeFR)
Brand: Wellch Allyn Braun Brand: Philips

Monitor with SpO2, NIBP

Intraosseous Drill
and Smart Temp
Brand: Arrow® EZ-IO System
Brand: Mindray VS Monitor
Pulse Oximeter Suction Machine (Wall)
Brand: Nellcor PO2; Covidien-Nellcor Bedside
Spo2

Video Laryngoscope
Spine Board
Brand:
Intubrite
Pat Slide Trauma Stretcher
Brand: Hill-Rom