Resp Emergencies

Respiratory Emergencies:

CHF, Pulmonary Edema, COPD, Asthma CPAP & Albuterol NebulizerCondell Medical Center EMS SystemSeptember, 2007Site Code#10-7200E1207Prepared by: Sharon Hopkins, RN, BSN, EMT-P

ObjectivesUpon successful completion of this program, the EMS provider should be able to:review the presentation and intervention for the patient presenting with CHF, pulmonary edema, COPD, and asthma.review criteria for the use of CPAP.discuss the set-up for CPAP.review the SOP for Acute Pulmonary edema, Asthma/COPD with Wheezing, and Conscious Sedation

Objectives contdreview the Whisperflow patient circuit for CPAP.actively participate in return-demonstration of the albuterol nebulizer and in-line set-up.successfully complete the quiz with a score of 80% or better.

Heart FailureA clinical syndrome where the hearts mechanical performance is compromised and the cardiac output cannot meet the demands of the bodyConsidered a cardiac problem with great implications to the respiratory systemHeart failure is generally divided into right heart failure and left heart failure

Heart FailureEtiologies are variedvalve problems, coronary disease, heart diseasedysrhythmias can aggravate heart failureVariety of contributing factors to developing heart diseaseexcess fluid or salt intake, fever (sepsis), history of hypertension, pulmonary embolism, excessive alcohol or drug usage

Deoxygenated Blood Flow Through The HeartDeoxygenated blood returns to the right heart via inferior and superior vena cavasBlood flow thru the right side of the heartright atriumright ventriclepulmonary artery to the lungsarteries always carry blood away from the heartpumped to the lungs to be oxygenated

Oxygenated Blood Flow Through The HeartOxygenated blood from the lungs returns to the heart via the pulmonary veins to the left atriumBlood flow thru the left side of the heartleft atriumleft ventriclethru aortic valve to the aortato aorta for distribution to the body

Left Side of the HeartHigh pressure systemBlood needs to be pumped to the entire bodyLeft ventricular muscle needs to be significant in size to act as a strong pumpLeft sided failure results in backup of blood into the lungs

Right Side of the HeartLow pressure systemBlood needs to be pumped to the lungs right next to the heartRight ventricle is smaller than the left and does not need to be as developedRight sided failure results in back pressure of blood in the systemic venous system (the periphery)

Left Ventricular Heart FailureCausesfailure of effective forward pumpback pressure of blood into pulmonary circulationheart diseaseMIvalvular diseasechronic hypertensiondysrhythmias

Left Ventricular FailurePressure in left atrium risesincreasing pressure is transmitted to the pulmonary veins and capillariesincreasing pressure in the capillaries forces blood plasma into alveoli causing pulmonary edemaincreasing fluid in the alveoli decreases the lungs oxygenation capacity and increases patient hypoxia

As MI is a common cause of left ventricular failure:

Until proven otherwise, assume all patients exhibiting signs and symptoms of pulmonary edema are also experiencing an acute MI

Right Ventricular Heart FailureCausesfailure of the right ventricle to work as an effective forward pumpback pressure of blood into the systemic venous circulation causes venous congestionmost common cause is left ventricular failuresystemic hypertensionpulmonary embolism

Congestive Heart FailureA condition where the hearts reduced stroke volume causes an overload of fluid in the bodys other tissuesCan present as edemapulmonaryperipheralsacralascites (peritoneal edema)

Compensatory Measures - Starlings LawThe more the myocardium is stretched, the greater the force of contraction and the greater the cardiac outputThe greater the preload (amount of blood returning to the heart), the farther the myocardial muscle stretches, the more forceful the cardiac contractionAfter time or with too much resistance the heart has to pump against, the compensation methods fail to work

Acute Congestive Heart FailureOften presenting in the field as:Pulmonary edemaPulmonary hypertensionMyocardial infarction

Chronic Congestive Heart FailureOften presenting in the field as:Cardiomegaly - enlargement of the heartLeft ventricular failureRight ventricular failure

Patient AssessmentScene size-upInitial assessmentairwaybreathingcirculationdisabilityAVPUGCSexpose to finish examining

Identify priority patients, make transport decisionsAdditional assessmentvital signs, pain scaledetermine weightroom air pulse ox, if possible, and oxygen PRNcardiac monitor; 12 lead ECG if applicableestablish 0.9 NS IV, TKOdetermine blood glucose if indicatedunconscious, altered level of consciousness, known diabetic with diabetic related callreassess initial assessment findings and interventions started

Closest Appropriate Hospital

Hospital of patients choice within the departments transport areaThe patient who is alert and oriented has the right to request their hospital of choiceEMS can have the patient sign the release for transport to a farther hospitalIf EMS does not feel comfortable transporting farther away, you can communicate this to the patient to get your point across in a diplomatic manner (ie: Im very concerned about your condition and I would feel more comfortable taking you to the closest hospital)

RefusalsA conscious and alert patient has the right to refuse care and/or transportationA refusal, though, with a patient in CHF might prove devastatingworsening of signs and symptomsincreased and unnecessary myocardial damagesevere pulmonary edema deathAvoid refusals in these patients at all costsDocument well the efforts taken to encourage transportation

Signs and Symptoms CHFProgressive or acute shortness of breathLabored breathing especially during exertion (ie: standing up, walking a few steps)Awakened from sleep with shortness of breath (paroxysmal nocturnal dyspnea)increasing episodes usually indicate the disease is worseningPositioningtripod - resting arms on thighs, leaning forwardinability to recline in bed without multiple pillowsusing more pillows to be comfortable in bed

Changes in skin parameterspale, diaphoretic, cyanoticmottling present in severe CHF Increasing edema or weight gain over a short timeearly edema in most dependent parts of the body first (ie: feet, presacral area)Generalized weaknessMild chest pain or pressureElevated blood pressure sometimesto compensate for decreased cardiac output

Typical home medication profilediuretic - to remove excess fluidshypertension medications - to treat a typical co-morbid factordigoxin - to increase the contractile strength of the heartoxygenWorst of the worst complications - pulmonary edema

Progression of Acute CHFLeft ventricle fails as a forward pumpPulmonary venous pressure risesFluid is forced from the pulmonary capillaries into the interstitial spaces between the capillaries and the alveoliFluid will eventually enter & fill the alveoliPulmonary gas exchange is decreased leading to hypoxemia ( oxygen in blood) & hypercarbia ( carbon dioxide in blood)

Progression of CHF contdHypercarbia ( carbon dioxide retained in the blood) can cause CNS depressionslowing of the respiratory driveslowing of the respiratory rate

Wheezes heard in any geriatric patient should be considered pulmonary edema until proven otherwise (especially in the absence of any history of COPD or asthma)

Progression of Pulmonary EdemaUntreated, leads to respiratory failureOxygen exchange inhibited due to excess serum fluid in alveoli hypoxia deathPresentationtachypneaabnormal breath soundscrackles (rales) at both basesrhonchi - fluid in larger airways of the lungswheezing - lungs protective mechanismsbronchioles constrict to keep additional fluid from entering the airway

Acute Pulmonary Edema SOPRoutine medical carepatient assessmentIV-O2-monitorcautiously monitor IV fluid flow ratesPlace patient in position of comfortoften patient will choose to sit uprightdangle the feet off the cart to promote venous poolingDetermine if the patient is stable or unstableevaluate mental status, skin parameters, and blood pressure

Stable Acute Pulmonary EdemaPatient alertSkin warm & drySystolic B/P > 100 mmHgNitroglycerin 0.4 mg sl - maximum 3 dosesConsider CPAPLasix 40 mg IVP (80 mg if already taking)If systolic B/P remains >100 mm Hg give Morphine Sulfate 2 mg IVP slowlyIf wheezing, obtain order from Medical Control for Albuterol nebulizer

Pulmonary Edema MedicationsNitroglycerinvenodilator; reduces cardiac workload and dilates coronary vesselsdo not use in the presence of hypotension or if Viagra or Viagra-type drug has been taken in the past 24 hourscan repeat the drug (0.4 mg sl) every 5 minutes up to 3 doses total if blood pressure remains > 100 mmHgonset 1 - 3 minutes sl (mouth needs to be moist for the tablet to dissolve & be absorbed)

Lasix (Furosemide)diuretic; causes venous dilation which decreases venous return to the heartavoid in sulfa allergies & in the presence of hypotensiondose 40 mg IVP (80 mg IVP if the patient is taking the drug at home)vascular effect onset within 5 minutes; diuretic effects within 15 - 20 minutes

Morphine sulfatenarcotic analgesic (opioid)causes CNS depression; causes euphoria increases venous capacity and decreases venous return to the heart by dilating blood vesselsused to decrease anxiety and to decrease venous return to the heart in pulmonary edemagive 2 mg slow IVP; titrate to response and vital signs and give 2 mg every 2 minutes to a maximum of 10 mg IVPeffects could be increased in the presence of other depressant drugs (ie: alcohol)

Albuterolbronchodilatorreverses bronchospasm associated with COPDdose is 2.5 mg in 3 ml solution administered in the nebulizerthe patient may be aware of tachycardia and tremors following a doseAlbuterol must be ordered by Medical Control for the acute pulmonary edema patient

Using CPAP With MedicationsMedications and CPAP are to be administered simultaneouslyThe use of CPAP buys time for the medications to exert their effect CPAP and medications used (Nitroglycerin, Lasix, and Morphine) can all cause a drop in blood pressure CPAP and medications must be discontinued if the blood pressure falls < 100 mmHg

Case Scenario #1A 68 year-old female calls 911 due to severe respiratory distress which suddenly woke her up from sleep. She is unable to speak in complete sentences and is using accessory muscles to breathe. Lips and nail beds are cyanotic; ankles are swollen.B/P 186/100; P - 124; R - 34; SaO2 - 88%Crackles are auscultated in the lower half of the lung fields.

Case Scenario #1History: angina and hypertension; smokes 1 pack per day for the past 30 yearsMeds: Cardizem, nitroglycerin PRN; 1 baby aspirin daily; furosemide, Atrovent inhaler as neededRhythm:

Case Scenario #1What is your impression?What will be your intervention(s)?What is the rationale for your interventions?What is this patients rhythm and do you need to administer any medications for the rhythm?

Case Scenario #1Impression: congestive heart failure with pulmonary edemaparoxysmal nocturnal dyspnea (sudden shortness of breath at night)bilateral crackles in the lungsperipheral edemacardiac history - hypertension and anginaRhythm - sinus tachycardiado not treat this rhythm with medicationdetermine and treat the underlying cause

Case Scenario #1InterventionsSit the patient upright, have their feet dangle off the sides of the cartpromotes venous pooling of blood and decreases the volume of return to the heartOxygen via non-rebreather face maskPrepare to assist breathing via BVMhave BVM reached out and ready for useIV-O2-monitorMeds: NTG, Lasix, Morphine, consider CPAP

Unstable Acute Pulmonary EdemaAltered mental statusSystolic B/P < 100 mmHgContact Medical Controlmedications given in the stable patient are now contraindicated due to a lowered blood pressureCPAP on orders of Medical ControlConsider Cardiogenic Shock protocolTreat dysrhythmia as they are presentedContact Medical Control for Albuterol if wheezing; possibly in-line with intubation

CPAP ContinuousPositiveAirway PressureA means of providing high flow, low pressure oxygenation to the patient in pulmonary edema

CPAPCPAP, if applied early enough, is an effective way to treat pulmonary edema and a means to prevent the need to intubate the patientCPAP increases the airway pressures allowing for better gas diffusion & for reexpansion of collapsed alveoliCPAP allows the refilling of collapsed, airless alveoli CPAP allows/buys time for administered medications to be able to work

CPAP expands the surface area of the collapsed alveoli allowing more surface area to be in contact with capillaries for gas exchangeWith CPAPBefore CPAP

CPAP is applied during the entire respiratory cycle (inhalation & exhalation) via a tight fitting mask applied over the nose and mouthThe patient is assisted into an upright positionThe lowest possible pressure should be usedthe higher the pressure, the risk of barotrauma (pneumothorax, pneumomediastinum) risesincreased pressures in the chest decrease ventricular filling worsening cardiac output (less coming into the heart, less going out of the heart)

Goal of Therapy With CPAPIncrease the amount of inspired oxygenDecrease the work load of breathing In turn to:Decrease the need for intubationDecrease the hospital stayDecrease the mortality rate

Indications & Criteria for CPAP Use Patient identified with signs & symptoms of pulmonary edema or, in consultation with Medical Control, exacerbation of COPD with wheezingPatient must be alert & cooperativeSystolic B/P >100 mmHgNo presence of nausea or vomiting; absence of facial or chest trauma

Patient Monitoring During CPAP UsePatient tolerance; mental statusRespiratory patternrate, depth, subjective feeling of improvementB/P, pulse rate & quality, SaO2, EKG patternIndications the patient is improving (can be noted in as little as 5 minutes after beginning)reduced effort & work of breathingincreased ease in speakingslowing of respiratory and pulse ratesincreased SaO2

Discontinuation of CPAPHemodynamic instability B/P drops below 100 mmHgThe positive pressures exerted during the use of CPAP can negatively affect the return of blood flow to the heartInability of the patient to tolerate the tight fitting maskEmergent need to intubate the patient

Patient CircuitsComplete package includesmask tubinghead strapWhisperflow CPAP valvecorrugated tubingair entrapment filter

Patient Circuit

Oxygen Tank DurationD sized tank - 30 minutes*typical small portable tank kept on patient cartH sized tank - 508 minutes* (8+ hours)typical large tank kept in locker on rigOther tank sizes:E sized tank - 50 minutes* typically used in hospitals during patient transportsM sized tank - 253 minutes** Based on 50 psi output & approx 30% FIO2

Case Scenario #2You have initiated CPAP and simultaneous medication administration (NTG, Lasix and Morphine) to a 76 year-old patient who EMS has assessed to be in acute pulmonary edemaThe patient begins to lose consciousness and the blood pressure has fallen to 86/60.What is the appropriate response for EMS to take?

Case Scenario #2This patient is showing signs of deteriorationThe CPAP needs to be discontinuedNo further medications (NTG, Lasix, Morphine) can be administered due to the lowered B/PPrepare to intubate the patient following the Conscious Sedation SOPsupport ventilations with BVM prior to intubation attempt

COPDChronic obstructive pulmonary disease - a progressive and debilitating collection of diseases with airflow obstruction and abnormal ventilation with irreversible components (emphysema & chronic bronchitis)Exacerbation of COPD is an increase in symptoms with worsening of the patients condition due to hypoxia that deprives tissue of oxygen and hypercapnia (retention of CO2) that causes an acid-base imbalance

Obstructive Lung Disease - COPD & AsthmaAbnormal ventilation usually from obstruction in the bronchiolesCommon changes noted in the airwaysbronchospasm - smooth muscle contractionincreased mucous production lining the respiratory treedestruction of the cilia lining resulting in poor clearance of excess mucusinflammation of bronchial passages resulting in accumulation of fluid and inflammatory cells

The Ventilation ProcessNormal inspiration - the working phasebronchioles naturally dilateNormal exhalation - the relaxation phasebronchioles constrictExhalation with obstructive airway diseaseexhalation is a laborous process and not efficient or effectiveair trapping occurs due to bronchospasm, increased mucous production, and inflammation

EmphysemaGradual destruction of the alveolar walls distal to the terminal bronchiolesLess area available for gas exchangeSmall bronchiole walls weaken, lungs cannot recoil as efficiently, air is trapped in number of pulmonary capillaries which resistance to pulmonary blood flow which leads to pulmonary hypertensionmay lead to right heart failure & cor pulmonale (disease of the heart because of diseased lungs)

Alveolar Sac and Capillaries

Emphysema in PaO2 leads to in red blood cell production (to carry more oxygen)Develop chronically elevated PaCO2 from retained carbon dioxideLoss of elasticity/recoil; alveoli dilatedMore common in men; major contributing factor is cigarette smoking; another contributing factor is environmental exposuresPatients more susceptible to acute respiratory infections and cardiac dysrhythmias

Assessment of EmphysemaPink puffer - due to excess red blood cellsRecent weight loss; thin bodiedIncreased dyspnea on exertionProgressive limitation of physical activityBarrel chest (increased chest diameter)Prolonged expiratory phase (usually pursed lip breathing noted on exhalation)Rapid resting respiratory rateClubbing of fingers

Diminished breath soundsUse of accessory musclesOne-to-two word dyspneaWheezes and rhonchi depending on amount of obstruction to air flowMay have signs & symptoms of right heart failure jugular vein distentionperipheral edemaliver congestion

Case Scenario #3The patient is a conscious, restless, and anxious 68 year-old male with respiratory distress that has progressively worsened during the past 2 days.The patient has cyanosis of the lips and nail bedsB/P 138/70; P - 116 & irregular; R - 26; SaO2 82% Rhonchi and rales are auscultated in the lower right lung field; patient feels warm to the touchThe patient has had a cold for 1 week with a productive cough of yellow-green sputumHx: emphysema, angina, osteoarthritis

Case Scenario

What is this patients rhythm? What influence would this rhythm have on this patients health history & current condition? Do you need to intervene?

Case Scenario #3

Atrial fibrillation diminishes the efficiency of the pumping of the heart which can further compromise the cardiac output

Case Scenario #3Impression & intervention?The patient has COPD most likely complicated by pneumonia a cold over the last weekproductive cough of yellow-green sputumwarm to the touch (temperature 100.60F)rhonchi & rales in the right lung field baseRoutine medical caresupplemental oxygen heart rate most likely due to pneumonia and does not need specific treatment

Chronic BronchitisAn increase in the number of mucous-secreting cells in the respiratory treeLarge production of sputum with productive coughDiffusion remains normal because alveoli not severely affectedGas exchange decreased due to lowered alveolar ventilation which creates hypoxia and hypercarbia

Assessment of Chronic BronchitisBlue bloater - tends to be cyanoticTends to be overweightBreath sounds reveal rhonchi (course gurgling sound) due to blockage of large airways with mucous plugsSigns & symptoms of right heart failurejugular vein distentionankle edemaliver congestion

Drive to Breath & COPD Normal driving force to breathedecreased oxygen (O2) levelincreased carbon dioxide (CO2) levelChemoreceptors sense:too little O2 ( resp rate to improve) or too much CO2 ( resp rate to blow off more CO2)Patients with COPD have retained excess CO2 for so long that their chemoreceptors are no longer sensitive to the elevated CO2 levelsCOPD patients breathe to pull in O2

O2 Administration & COPDNever withhold oxygen therapy from a patient who clinically needs it

Monitor all patients receiving O2 but especially the patient with COPDNormal O2 sat for COPD patient is around 90%If the patient with COPD is supplied all the oxygen they need, this might trigger them not to work at breathing anymore and may result in hypoventilation and/or respiratory arrest

AsthmaChronic inflammatory disorder of the airwaysAirflow obstruction and hyperresponsiveness are often reversible with treatmentTriggers vary from individual environmental allergenscold air; other irritantsexercise; stressfood; certain medications

Asthmas Two-Phase ReactionPhase one - within minutesRelease of chemical mediators (ie: histamine)contraction of bronchial smooth muscle (bronchoconstriction)leakage of fluid from bronchial capillaries (bronchial edema)Phase two - in 6-8 hoursInflammation of the bronchioles from invasion of the mucosa of the respiratory tract from the immune system cellsadditional swelling & edema of bronchioles

Assessment of AsthmaPresentationDyspneaWheezing - initially heard at end of exhalationCough - unproductive, persistent may be the only presenting symptomHyperinflation of chest - trapped airTachypnea - an early warning sign of a respiratory problemUse of accessory muscles

Severe Asthma AttackOne and two word dyspneaTachycardiaDecreased oxygen saturation on pulse oximetryAgitation & anxiety with increasing hypoxia

Obtaining a HistoryVery helpful in forming an accurate impressionWill have a history of asthmaHome medications indicate asthmaA prior history of hospitalization with intubation makes this a high-risk patient for significant deteriorationNote: unilateral wheezing is more likely an aspirated foreign body or a pneumothorax than an asthma attack

Treatment Goals -COPD & AsthmaRelieve and correct hypoxiaReverse any bronchospasm or bronchoconstriction

Asthma/COPD with Wheezing SOPRoutine medical carePulse oximetry (on room air if possible)Albuterol 2.5 mg / 3ml with oxygen adjusted to 6 l/minuteMay repeat Albuterol treatments if neededMay need to consider intubation with in-line administration of Albuterol based on the patients conditionContact Medical Control for possible CPAP in patient with COPD

Albuterol Nebulizer ProcedureMedication is added to the chamber which must be kept uprightThe T-piece is assembled over the chamberThe patient needs to be coached to breath slowly and as deeply as possiblethis will take time and several breathes before the patient can slow down and start breathing deeper; the patient needs a good coach to talk them through the slower/deeper breathingthe medication needs to be inhaled into the lungs to be effectivethe patient should be sitting upright

Add medication to the chamber

Connect the mouthpiece to the T-piece

Connect the corrugated tubing to the T-pieceKit connected to oxygen and run at 6 l/minute (enough to create a mist)

Encourage slow, deep breathing

Albuterol Nebulizer Mask For the patient who is unable to keep their lips sealed around the mouthpiece, take the top T-piece off the kit and replace with an adult or pediatric nebulizer mask

Pediatric patient using nebulizer mask.Caregiver may assist in holding the mask.

Case Scenario #47 year-old with history of asthma has sudden onset of difficulty breathing and wheezing while playing outsidePatient has an increased respiratory rate and is using accessory musclesB/P - 108/70; P - 90; R - 20; SaO2 - 97%Upon auscultation, left lung is clear and wheezing is present on the right sideImpression and intervention?

Case Scenario #4Sounds like asthma, looks like asthma, has a history of asthma but why should you not suspect asthma?Asthma is not a selective disease - the patient will have widespread, not localized, bronchoconstriction and have bilateral wheezing, not unilateralDig into the history more - what was the patient doing prior to the development of symptoms?

Case Scenario #4This patient was playing with friends, running around while eating foodPossibly aspirated a foreign bodysudden onset of unilateral wheezingAlbuterol would not be indicated in this situationTransport with supplemental oxygen if indicated, position of comfort, reassessment watching for increase in airway obstruction

Aerosol Medication via BVM or ETT with BVM (In-line)

Place Albuterol in the chamber as usualConnect the chamber to the T-pieceOnce the nebulizer kit is assembled and the clear adaptor(s) are in place, you may begin to bag the patient prior to completion of intubationthe clear adaptor on the corrugated tubing is attached to the BVMs maskany medication that can be delivered as soon as possible to the target organ (the lungs) will be helpful in promoting bronchodilation

Nebulizer with white T-piece (CMC pyxis)Remove the white mouth piece; the BVM will be connected to this portAdd a clear adaptor to the distal end of the corrugated tubingIntubate the patient as usual and connect the clear adaptor on the corrugated tubing to the proximal end of the ETT placed in the patientBegin to bag the patientSupplemental oxygen must be connected to the nebulizer and the BVM

Nebulizer with blue T-pieceRemove the mouthpiece from the T-piece and connect a clear adaptor in its placeThe BVM will attach to the clear adaptor on the T-pieceAdd a second clear adaptor to the distal end of the corrugated tubingThis clear adaptor will be connected to the proximal end of the ETT after intubation is performed in the usual mannerSupplemental oxygen must be connected to the nebulizer and the BVM

Remove mouthpiece from T-piece and replace with BVM Connect nebulizer to oxygen sourcePlace clear adaptor at distal end of corrugated tubing (to connect to ETT)

Intubate the patientConnect the clear adaptor on the distal end of the corrugated tubing to the proximal end of the ETTConfirm placement in the usual mannervisualizationchest rise & fall5 point auscultationETCO2 detector

Case Scenario #5EMS has responded to a 14 year-old child in severe respiratory distress with audible wheezing. The complaints have been present for the past 3 hours. Inhalers used have not been effective.B/P - 112/60; P - 120; R - 32; SaO2 - 89%Patient is very anxious, pale, cool, and diaphoretic. The lips and nail beds are cyanotic.What is your impression?What is your greatest concern?

Case Scenario #5This patient is experiencing a severe asthma attack that is not responding to medication - status asthmaticusThis patient is in danger of going into respiratory arrest due to exhaustionBegin supportive oxygen therapySet up the albuterol nebulizer kit and simultaneously the BVMAnticipate intubation with administration of Albuterol via the in-line method

Case Scenario #5Patients experiencing an asthma attack are in need of bronchodilators (Albuterol) and IV fluids (they are usually dry from the rapid respirations and inability to have been taking in fluids)If the patient is losing consciousness, you may need to follow the Conscious Sedation SOP to intubate and administer Albuterol via in-line

Conscious Sedation Would Lidocaine bolus be indicated?What is the dose of Versed and the purpose of Versed?What would be the effects of Morphine?How do you know if the patient needs Benzocaine (Hurricaine, Cetacaine)?

Conscious SedationLidocaine is not indicated there is no presence of head injury or insultVersed is an amnesic and will relax the patientVersed does not take away any painThe dose of Versed is 5 mg slow IVPIf not sedated within 60 seconds, Versed 2 mg slow IVP every minutes until sedatedFollowing sedation, may give Versed 1 mg IVP every 5 minutes for agitation (total dose 15 mg)

BibliographyBledsoe, B., Porter, R., Cherry, R. Essentials of Paramedic Care. Brady. 2007.Kohlstedt, D. Sales Representative. Tri-Anim.Region X SOPs, March 1, 2007.Sanders, M. Mosbys Paramedic Textbook, Revised Third Edition. 2007.Via Google: Respiratory Module Part IVia Google: Respiratory Module Part II