UNC Hospitals- Emergency Department Adult Emergency Care Protocols Revised March 2013

for Patients >18yrs of age

Universal Standards: For any vital signs outside of normal limits or on Registered Nurse judgement:
Pulse Ox, Monitor, Med-lock, O2 as needed to maintain SpO2 > 92%, immediate MD contact
Adult Tdap (or equivalent) for patients <65 years old with last immunization > 5 years ago - if no contraindications
For any known or newly-diagnosed pregnant patient, obtain OB/Gyn consultation prior to any operative or interventional procedure.
Nursing LABS MEDS Radiology
+ + - 2
Med-lock IV, If unable to obtain urine CBC, Na , K , Cl , CO , BUN, Creat, Gluc, PT/PTT, AST, ALT,
Abdominal Pain sample within 30 minutes, then in & Alk Phos, GGT, T. Bili, Lipase, UA, serum BHCG (for females),
out cath any applicable drug levels (digoxin, seizure meds, etc…)
Diphenhydramine 50 mg IV x 1 or PO
Allergic Reaction Med-Lock IV Prednisone 60 mg PO x 1 OR
Solumedrol 125mg IV
NTG 0.4 mg SL q 5 minutes x 3 doses
Monitor, Pulse ox, Stat EKG (within CXR - PA & Lateral, Portable if pt is
Chest Pain CBC, Na+, K+, Cl-, CO2, BUN, Creat, Gluc, PT, PTT, INR, CK, (hold if SBP < 90) - notify physician after
10 min of arrival) , O2 @ 2 l/min by unstable or requires close monitoring.
concern for ACS CK-MB, Trop, 12-lead EKG. 1st dose
NC, Med-lock IV Indication: Chest Pain.
ASA 325 mg PO, unless contraindicated
Monitor, Pulse ox, EKG (within 10 CXR - PA & Lateral, Portable if pt is
CBC, Na+, K+, Cl-, CO2, BUN, Creat, Gluc, UA, urine pregnancy
Dyspnea min), O2 @ 2L /min by NC, titrate to unstable or requires close monitoring.
(if applicable), blood cultures x 2 if febrile
keep SaO2 > 95%, Med-Lock IV Indication: Dyspnea
If dialysis pt or immune
Fever & Fever w/ Adult: Temp > 38 C orally; Mask Acetaminophen 975 mg po x one dose compromised:
If dialysis pt or immune compromised: CBC, Na+, K+, Cl-,
immunocompromi patient if immunocompromised or if if no Acetaminophen in the last 4 hours CXR - PA & Lateral, Portable if pt is
CO2, BUN, Creat, Gluc, Blood culture x 2, UA and culture
sed patient respiratory symptoms Motrin 600mg if pt has had tylenol unstable or requires close monitoring.
Indication: Eval for infiltrate.
Med-Lock IV, consider request for
Flank Pain BUN, Creat, UA with reflex cx,Serum BHCG
analgesia (contact physician)
Flu-Like s/s Mask patient/droplet precaution Rapid Influenza PCR

Orthostatics VS, Med-Lock IV. If

Tachycardiac or Hypotensive start CBC, Na+, K+, Cl-, CO2, BUN, Creat, Gluc, PT/PTT, Type &
GI Bleed
second IV site, IV NS 300 mL bolus, Screen
notify LIP. Save stool if available
CBC, Na+, K+, Cl-, CO2, BUN, Creat, Gluc, serum acetone (if
Hyperglycemia Med-Lock IV. Notify LIP if POC
suspecting DKA) , POC Glucose & UA, urine pregnancy (if
Glucose > 200 glucose is Critical High.
applicable).
POC glucose; Give PO sugar, juice, D50 25 Gms IV if BS < 60 mg/dl (and
Hypoglycemia
cola if patient is able, Med-Lock IV. unable to take PO sugar) or
Glucose < 60 Notify LIP symptomatic
Pulse ox, Monitor, Med-Lock IV, EKG,
Mental Status CBC, Na+, K+, Cl-, CO2, BUN, Creat, Gluc, Mg, Drug Levels (If
notify LIP. If unable to obtain urine
applicable), POC Glucose, UA with reflex cx, urine pregnancy (if
Change sample within 30 minutes then in & out
applicable).
cath
CBC, Na+, K+, Cl-, BUN, Creat, Glu, AST, ALT, ALK Phos,
Psychiatric GGT, T, Bili, Lipase, TSH, CA++, Alcohol screen, Drug levels (If
Precaution hold if HI/SI
Complaint applicable) UA, Urine Tox, urine pregnancy for females 18-65. If
overdose suspected: Acetaminophen & Salicylate level
CBC, Na+, K+, Cl-, CO2, BUN, Creat, Glu, Ca, Mg, Phos,
Applicable drug levels (carbamazepine, phenytoin, valproic acid),
Seizure Med-Lock IV
POC glucose, EKG, UA with reflex cx, urine pregnancy (if
applicable).
Musculoskeletal Nursing MEDS Radiology
 UNC Hospitals- Emergency Department Adult Emergency Care Protocols Revised March 2013
for Patients >18yrs of age
Order AP, Lateral lumbar spine series, Indication :eval for fracture.
• For pain > 4/10: 600 mg Ibuprofen PO x 1, unless If any of the following are present: • Age > 50; • History of trauma; • History of
Back Pain urine pregnancy test (if applicable)
cancer (immunocompromised); • Fever, chills, weight loss; • Injection drug
contraindicated
abuse; • Incontinence or perineal numbness.
Order AP, lateral, mortise views of affected ankle, Indication : eval for fx.
• For pain > 4/10: 600 mg Ibuprofen PO x 1, unless
Ankle Pain Ice and elevate If pt has bone tenderness at A or B (on Ottawa diagram) or inability to bear
contraindicated
weight both immediately and in the ED.
Order AP, lateral, oblique views of affected foot, Indication : eval for fx.
• For pain > 4/10: 600 mg Ibuprofen PO x 1, unless
Foot Pain Ice and elevate If pt has bone tenderness at C or D (on Ottawa diagram) or inability to bear
contraindicated
weight both immediately and in the ED.
Order AP, lateral views of affected knee, Indication : eval for fx.
• For pain > 4/10: 600 mg Ibuprofen PO x 1, unless
Knee Pain Ice and elevate If any of the following are present: • Age >55; Tenderness at head of fibula; •
contraindicated
Tenderness on patella;• Inability to bear weight both immediately & in ED.
Extremity Pain
• For pain > 4/10: 600 mg Ibuprofen PO x 1, unless Order AP, lateral, oblique views of affected extremity (shoulder, hand, wrist)
w/ suspected Ice and elevate
contraindicated Indication : eval for fx
fracture
Apply LET to all FACE & SCALP wounds < 7 cm, - NEVER ears, nose, penis,
Material to bedside - mayo stand, laceration tray, betadine, 500 mL normal saline, 60 mL syringe, zero-
finger, toes. Ask MD for other areas. Requires a MINIMUM of 20 minutes for
Laceration wet, sterile bowl, 4x4 boat, 1% lidocaine, antibiotic ointment,10 mL syringe, 25 gauge needle, 18 gauge
effect. Room and MD should be available to suture within 30 min after
needle, sterile gloves
application.
Nursing LABS MEDS Radiology
BP < 90mmHg or two of the following:
T > 38 C or < 36 C; HR > 90; RR > 20 CBC, Na+, K+, Cl-, CO2, BUN, Creat, Gluc, Blood culture x 2, CXR - PA & Lateral, Portable if pt is
Acetaminophen 975 mg po x one dose
Sepsis - Possible Move pt to non-hallway bed, NS 1 L IV UA, POC Loaded ABG, urine pregnancy (if applicable), & Urine unstable or requires close monitoring.
if no Acetaminophen in the last 4 hours
bolus if no history of heart failure or on culture Indication: Eval for infiltrate.
dialysis. Notify RT to run POC blood
CBC, Na+, K+, Cl-, CO2, BUN, Creat, Gluc, Ca, Mg, Phos, PT, If symptoms < 8 hours, order Stat CT
Stroke Monitor, Pulse ox, Med-Lock IV, EKG PTT, INR, CK, CK-MB, Trop, T & S, POC glucose, UA, urine Head - non-contrast
pregnancy (if applicable). Indication: Acute Stroke Protocol
EKG, orthostatics, Implement chest POC Glucose, UA with reflex culture, urine pregnancy (if
Syncope
pain orders if suspicion for ACS applicable), Implement chest pain orders if suspicious for ACS
Acetaminophen 975 mg po or Motrin
Throat Pain Rapid group a strep
600mg
If unable to obtain urine sample within
Urinary Symptoms UA with reflex culture, urine pregnancy (if applicable)
30 minutes thenconsider in & out cath
Orthostatics, Med-Lock IV if significant
Vaginal Bleeding bleeding (>1pad/hour), Place pt in CBC, Type & Screen, Serum BHCG, UA
pelvic room, set up for pelvic exam
Orthostatics, Med-Lock IV if symptoms
Vomiting / Ondansetron (Zofran) 4 mg IV, odt or
> 4 hours or currently vomiting, hold POC Glucose, UA, with reflex urine pregnancy (if applicable)
Diarrhea PO
stool if obtained
Pulse ox, Monitor if HR > 100, ask MD Albuterol 5mg with Ipratropium 500 mcg nebulizer x 1 with Pre & Post PEFR
Wheezing Prednisone 60 mg PO x 1
about IV
Activate Code Blue or ED code, check pulse, perform CPR, open airway, provide 2 breaths via BVM. If
Emergency VT or VF defibrillate at 120J as soon as possible. Resume CPR for 2 min- administer epinephrine, Atropine 0.5 MG IVP- may repeat in 5
Pulseless arrest identify rhythm (VT or VF- defibrillate at 150j). Continue CPR until ED or Code Blue team arrices. min; administer epinephrine
Emergency- Acticate Code Blue or ED code, open airway, O2 via NRB mask or provide 2 breaths via BVM if not
Unstable breathing, check pulse, identify rhythm & sx that make pt unstable. Prepare for trancutaneous pacing and Atropine 0.5 MG IVP- may repeat in 5
Bradycardia w/ initiate at rate of 70 BPM if patient remian unstable min
pulse (HR <60)