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:
2 2
Pulse Ox, Monitor, Med-lock, O as needed to maintain SpO > 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
Med-lock IV, If unable to obtain urine + + - 2
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
Chest Pain Monitor, Pulse ox, Stat EKG (within + + - 2
CBC, Na , K , Cl , CO , BUN, Creat, Gluc, PT, PTT, INR, CK, NTG 0.4 mg SL q 5 minutes x 3 doses CXR - PA & Lateral, Portable if pt is
2 (hold if SBP < 90) - notify physician after
10 min of arrival) , O @ 2 l/min by unstable or requires close monitoring.
concern for ACS NC, Med-lock IV CK-MB, Trop, 12-lead EKG. 1st dose Indication: Chest Pain.
ASA 325 mg PO, unless contraindicated
Monitor, Pulse ox, EKG (within 10 + + - 2
CBC, Na , K , Cl , CO , BUN, Creat, Gluc, UA, urine pregnancy CXR - PA & Lateral, Portable if pt is
2
Dyspnea min), O @ 2L /min by NC, titrate to unstable or requires close monitoring.
keep SaO2 > 95%, Med-Lock IV (if applicable), blood cultures x 2 if febrile Indication: Dyspnea
Fever & Fever w/ Adult: Temp > 38 C orally; Mask Acetaminophen 975 mg po x one dose If dialysis pt or immune
If dialysis pt or immune compromised: CBC, Na+, K+, Cl-, compromised:
immunocompromi patient if immunocompromised or if CO2, BUN, Creat, Gluc, Blood culture x 2, UA and culture
if no Acetaminophen in the last 4 hours CXR - PA & Lateral, Portable if pt is
sed patient respiratory symptoms Motrin 600mg if pt has had tylenol unstable or requires close monitoring.
Indication: Eval for infiltrate.
Flank Pain Med-Lock IV, consider request for 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 + + - 2
GI Bleed CBC, Na , K , Cl , CO , BUN, Creat, Gluc, PT/PTT, Type &
second IV site, IV NS 300 mL bolus, Screen
notify LIP. Save stool if available
+ + - 2
Hyperglycemia Med-Lock IV. Notify LIP if POC CBC, Na , K , Cl , CO , BUN, Creat, Gluc, serum acetone (if
suspecting DKA) , POC Glucose & UA, urine pregnancy (if
Glucose > 200 glucose is Critical High.
applicable).
Hypoglycemia POC glucose; Give PO sugar, juice, D50 25 Gms IV if BS < 60 mg/dl (and
cola if patient is able, Med-Lock IV. unable to take PO sugar) or
Glucose < 60 Notify LIP symptomatic
Mental Status Pulse ox, Monitor, Med-Lock IV, EKG, 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
cath applicable).
CBC, Na+, K+, Cl-, BUN, Creat, Glu, AST, ALT, ALK Phos,
Psychiatric Precaution hold if HI/SI GGT, T, Bili, Lipase, TSH, CA++, Alcohol screen, Drug levels (If
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,
Seizure Med-Lock IV Applicable drug levels (carbamazepine, phenytoin, valproic acid),
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.
Back Pain urine pregnancy test (if applicable) • 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
contraindicated cancer (immunocompromised); • Fever, chills, weight loss; • Injection drug
abuse; • Incontinence or perineal numbness.
Ankle Pain • For pain > 4/10: 600 mg Ibuprofen PO x 1, unless Order AP, lateral, mortise views of affected ankle, Indication : eval for fx.
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.
• For pain > 4/10: 600 mg Ibuprofen PO x 1, unless Order AP, lateral, oblique views of affected foot, Indication : eval for fx.
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.
Knee Pain • For pain > 4/10: 600 mg Ibuprofen PO x 1, unless Order AP, lateral views of affected knee, Indication : eval for fx.
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
Material to bedside - mayo stand, laceration tray, betadine, 500 mL normal saline, 60 mL syringe, zero- Apply LET to all FACE & SCALP wounds < 7 cm, - NEVER ears, nose, penis,
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
needle, sterile gloves effect. Room and MD should be available to suture within 30 min after
application.
Nursing LABS MEDS Radiology
BP < 90mmHg or two of the following: CBC, Na+, K+, Cl-, CO2, BUN, Creat, Gluc, Blood culture x 2,
T > 38 C or < 36 C; HR > 90; RR > 20 Acetaminophen 975 mg po x one dose CXR - PA & Lateral, Portable if pt is
Sepsis - Possible Move pt to non-hallway bed, NS 1 L IV UA, POC Loaded ABG, urine pregnancy (if applicable), & Urine
if no Acetaminophen in the last 4 hours
unstable or requires close monitoring.
bolus if no history of heart failure or on culture Indication: Eval for infiltrate.
dialysis. Notify RT to run POC blood
+ + - 2 If symptoms < 8 hours, order Stat CT
Stroke CBC, Na , K , Cl , CO , BUN, Creat, Gluc, Ca, Mg, Phos, PT,
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
Syncope EKG, orthostatics, Implement chest POC Glucose, UA with reflex culture, urine pregnancy (if
pain orders if suspicion for ACS applicable), Implement chest pain orders if suspicious for ACS

Throat Pain Rapid group a strep Acetaminophen 975 mg po or Motrin

600mg
Urinary Symptoms If unable to obtain urine sample within 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
Vomiting / Orthostatics, Med-Lock IV if symptoms POC Glucose, UA, with reflex urine pregnancy (if applicable) Ondansetron (Zofran) 4 mg IV, odt or
> 4 hours or currently vomiting, hold
Diarrhea PO
stool if obtained
Wheezing Pulse ox, Monitor if HR > 100, ask MD Albuterol 5mg with Ipratropium 500 mcg nebulizer x 1 with Pre & Post PEFR
about IV Prednisone 60 mg PO x 1
Emergency Activate Code Blue or ED code, check pulse, perform CPR, open airway, provide 2 breaths via BVM. If Atropine 0.5 MG IVP- may repeat in 5
VT or VF defibrillate at 120J as soon as possible. Resume CPR for 2 min- administer epinephrine,
Pulseless arrest identify rhythm (VT or VF- defibrillate at 150j). Continue CPR until ED or Code Blue team arrices. min; administer epinephrine

Unstable Acticate Code Blue or ED code, open airway, O2 via NRB mask or provide 2 breaths via BVM if not
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)