- 1.1 Asystole
- 1.2 Atrial Fibrillation
- 1.3 Atrial Flutter
- 1.4 Bradydysrythmias
- 1.5 Post-Resuscitation Care
- 1.6 Premature Ventricular Contractions
- 1.7 Pulseless Electrical Activity
- 1.8 Supraventricular Tachycardia
- 1.9 Ventricular Fibrillation / Pulseless Ventricular Tachycardia
- 1.10 Ventricular Tachycardia with Pulses
Asystole is defined as the complete absence of electrical activity in the myocardium. Usually this represents extensive myocardial ischemia due to prolonged periods of inadequate myocardial perfusion with a very grim prognosis. Most often, asystole represents a confirmation of death as opposed to a dysrhythmia requiring treatment. However, once asystole has been recognized, the team leader must consider the differential diagnosis while beginning and maintaining CPR, Endotracheal Intubation, Epinephrine and Atropine as one would treat PEA. In general, atropine is given to all asystolic patients but only to those patients with PEA who have bradydysrhythmias. Routine "shocking" of asystole should be discouraged. Rescuers should confirm asystole when faced with a "flat line" on the monitor. The use of transcutaneous pacing should be considered in those patients where the device can be applied very early in the course of the patient’s management: the most common salvageable situations with the use of TCP include the following: bradyasystolic arrest, Stokes-Adams attacks, asystole due to vagal discharge, or myocardial "stunning" following prompt defibrillation. One should always consider the possible causes of asystole and manage accordingly: drug overdose, hypokalemia, hypoxemia, hypothermia, pre-existing acidosis.
Note: see Appendix re: Cessation of Resuscitation in the Field.
Assessment / Treatment Priorities
1. Maintain universal blood and body fluid precautions.
2. Determine unresponsiveness, absence of breathing and pulselessness.
3. Maintain an open airway, remove secretions, vomitus, and initiate CPR with supplemental high concentration of oxygen.
4. Continually assess Level of Consciousness, ABCs and Vital Signs.
5. Obtain appropriate history related to event, including recent and Past Medical History, Medications, Drug Allergies and Substance Abuse including possible ingestion or overdose of medications, specifically calcium channel blockers, beta-blockers and / or digoxin preparations.
6. Every effort should be made to determine the possible causes of asystole in the patient.
TREATMENT
BASIC PROCEDURES
NOTE: Inasmuch as Basic-EMTs are unable to recognize the presence of Asystole, check patient for pulselessness and manage according to the following protocol:
1. Maintain universal blood and body fluid precautions.
2. Determine unresponsiveness and cardiopulmonary arrest.
3. Initiate CPR.
4. Administer high concentration of oxygen with assisted ventilations.
5. If AED / SAED credentialled:
a. Perform CPR until AED / SAED device is attached and operable.
b. Follow SAED protocol.
c. Resume CPR when appropriate.
6. Activate ALS intercept, if deemed necessary and if available.
7. Initiate transport as soon as possible with or without ALS.
8. Notify receiving Hospital.
INTERMEDIATE PROCEDURES
NOTE: Inasmuch as Intermediate-EMTs are unable to recognize the presence of Asystole, check patient for pulselessness and manage according to the following protocol:
1. Maintain universal blood and body fluid precautions.
2. Determine unresponsiveness and cardiopulmonary arrest.
3. Initiate CPR.
4. Administer high concentration of oxygen with assisted ventilations.
5. Activate Paramedic, if deemed necessary and if available.
6. If AED / SAED credentialled:
a. Perform CPR until AED / SAED device is attached and operable.
b. Follow SAED protocol.
c. Resume CPR when appropriate.
7. ALS STANDING ORDERS:
a. Provide advanced airway management.
b. Initiate IV Normal Saline KVO.
8. Initiate transport as soon as possible with or without Paramedics.
9. Notify receiving Hospital.
PARAMEDIC PROCEDURES
1. Maintain universal blood and body fluid precautions.
2. Determine unresponsiveness and cardiopulmonary arrest.
3. Initiate CPR.
4. Attach cardiac monitor and confirm asystole in 2 leads.
5. ALS STANDING ORDERS:
a. Provide advanced airway management.
b. Consider immediate Transcutaneous Pacing if asystole arrest is witnessed by EMS personnel.
c. Initiate IV Normal Saline.
d. Epinephrine (1:10,000) 1 mg IV push every 3-5 minutes. Epinephrine may be given via Endotracheal Tube if IV not yet established. (2-2.5 mg of Epinephrine 1:1,000 is preferred (ET), every 3-5 minutes)
e. Atropine 1 mg IV push every 3-5 minutes to a total of 0.04 mg / kg. Atropine may be given via Endotracheal Tube if IV not yet established (2.0 mg of Atropine via ETT is preferred; maximum dose 0.08 mg / kg).
6. Initiate transport as soon as possible.
7. Contact MEDICAL CONTROL. The following may be ordered:
a. Normal Saline fluid bolus(es).
b. Epinephrine:
- Intermediate dosing of Epinephrine: (2-5 mg) IV Push every 3-5 minutes or:
- Escalating dosing of Epinephrine (1 mg, 3 mg, or 5 mg) IV Push every 3-5 minutes or:
- High dosing of Epinephrine: (0.1 mg / kg) IV Push every 3-5 minutes.
c. Special Considerations:
- Hypothermia management per protocol.
- Drug overdose management per protocol.
- Sodium Bicarbonate 1 mEq/kg IV Push /if known pre-existing hyperkalemia or known pre-existing bicarbonate-responsive acidosis or if overdose with tricyclic antidepressants.
- Cessation of Resuscitation per protocol.
8. Notify receiving Hospital.
Atrial fibrillation is a totally chaotic activity of the atrial muscle fibers manifested by an irregularly irregular rate. In addition, since the atria are fibrillating, there is incomplete (or non-existent) emptying of these chambers and a loss of as much as 20% of the cardiac output. The rate can be variable, itself a problem, but in addition the loss of the "atrial kick" may, in and of itself, result in hypotension or other signs of cardiovascular compromise. Atrial Fibrillation is often the result of: Acute Myocardial Infarction, hypoxia, pulmonary embolus, electrolyte abnormalities, toxic effects due to medication (particularly digoxin or quinidine), and thyrotoxicosis. New onset Atrial Fibrillation can indicate a silent ischemic event, particularly in the elderly.
ASSESSMENT / TREATMENT PRIORITIES
1. Maintain universal blood and body fluid precautions.
2. Determine patient's hemodynamic stability and symptoms. Assess Level of Consciousness, ABCs, Vital Signs.
3. Maintain open airway and assist ventilations as needed.
4. Administer oxygen by nasal cannula or mask based upon patient's condition.
5. Obtain appropriate history related to event, including Past Medical History, Medications, Drug Allergies, and Substance abuse.
6. Monitor patient's EKG and vital signs.
7. Most patients tolerate Atrial Fibrillation well; however, some patients may require emergent treatment. Emergent treatment should be administered when the Atrial Fibrillation results in an unstable condition. Signs and symptoms may include: chest pain, shortness of breath, decreased level of consciousness, systolic BLOOD PRESSURE less than 90, shock, pulmonary congestion, congestive heart failure and acute myocardial infarction.
TREATMENT
BASIC PROCEDURES
NOTE: Inasmuch as Basic-EMTs are unable to recognize the presence of Atrial Fibrillation, check patient for a rapid and /or irregular pulse and possible complaint of palpitations. If present, treat according to the following Chest Pain protocol.
1. Maintain universal blood and body fluid precautions.
2. Maintain an open airway and assist ventilations as needed.
3. Administer oxygen by nasal cannula or mask based upon patient's condition.
4. Activate ALS intercept, if deemed necessary and if available.
5. Initiate transport as soon as possible with or without ALS.
6. Notify Receiving hospital.
INTERMEDIATE PROCEDURES
NOTE: Inasmuch as EMT-Intermediates are unable to recognize the presence of Atrial Fibrillation: check patient for a rapid and/or irregular pulse and possible complaint of palpitations. If present, treat according to the following Chest Pain protocol.
1. Maintain universal blood and body fluid precautions.
2. Maintain an open airway and assist ventilations as needed.
3. Administer oxygen by nasal cannula or mask based upon patient's condition.
4. Activate Paramedic intercept, if deemed necessary and if available.
5. ALS STANDING ORDERS
a. Provide advanced airway management if indicated (patient's condition deteriorates).
b. Initiate IV Normal Saline (KVO) enroute to hospital.
6. Initiate transport as soon as possible with or without Paramedics.
7. Notify receiving hospital.
PARAMEDIC PROCEDURES
1. Maintain universal blood and body fluid precautions.
2. Maintain an open airway and assist ventilations as needed.
3. Administer oxygen by nasal cannula or mask based upon patient's condition.
4. Cardiac monitor / dysrhythmia recognition.
5. ALS STANDING ORDERS
a. Provide advanced airway management if indicated (patient's condition deteriorates).
b. Initiate IV Normal Saline (KVO).
c. Vagal Maneuvers: Valsalva’s and/or cough.
d. If the patient’s Systolic BLOOD PRESSURE is unstable (less than 90): Synchronized cardioversion at 50 J, 100 J, 200 J, 300J, and 360 J. Check rhythm and pulse between each attempted cardioversion.
e. If Cardioversion is warranted, consider administration of any of the following for sedation:
- Valium: if patient < 70 kg: 2.5 mg SLOW IV Push, if patient > 70 kg: 5.0 mg SLOW IV Push or
- Versed 0.5 mg-2.5 mg SLOW IV Push or
- Morphine Sulphate 5 mg - 10 mg SLOW IV Push
6. Contact MEDICAL CONTROL. The following may be ordered.
a. Administration of CARDIZEM® (diltiazem HCL) Lyo-Ject™:
- Initial bolus: 0.25 mg/kg SLOW IV PUSH over two (2) minutes.
- If inadequate response after 15 minutes, re-bolus 0.35 mg/kg SLOW IV PUSH over two (2) minutes.
- IV Infusion 10-15 mg/hr. NOTE: 5 mg/hr may be appropriate starting infusion for some patients. CONTRAINDICATIONS: Wolff-Parkinson-White Syndrome, second or third degree heart block and sick sinus syndrome (except in the presence of a ventricular pace maker), severe hypotension or cardiogenic shock.
- Administration of Verapamil, unless contraindicated.
- Initial bolus: Verapamil 2.5 mg - 5 mg SLOW IV push. If inadequate response or after 15-30 minutes may re-bolus Verapamil at 5 mg-10 mg Slow IV push.
- CONTRAINDICATIONS : Wolff-Parkinson-White Syndrome, second or third degree heart block and sick sinus syndrome.
c. Administer IV Normal Saline 250 cc bolus(es) or titrate IV to patient’s hemodynamic status.
d. Synchronized cardioversion at 50 J, 100 J, 200 J, 300J, and 360 J. Check rhythm and pulse between each attempted cardioversion.
e. If Cardioversion is warranted, consider administration of any of the following for sedation:
- Valium if patient< 70 kg: 2.5 mg SLOW IV Push, if patient > 70 kg: 5.0 mg SLOW IV Push or
- Versed 0.5 mg-2.5 mg SLOW IV Push or
- Morphine Sulphate 5 mg - 10 mg SLOW IV Push
7. Initiate transport as soon as possible.
8. Notify receiving hospital.
Atrial Flutter is an "unstable" rhythm which will almost always deteriorate into Atrial Fibrillation or return to sinus rhythm or another form of supraventricular tachycardia. For this reason, Atrial Flutter demands close clinical attention, especially in patients with ischemic heart disease. Atrial Flutter may produce a very rapid ventricular response. The rate can be variable and may result in hypotension or other signs of cardiovascular compromise. Atrial Flutter is often the result of: Acute Myocardial Infarction, hypoxia, pulmonary embolus, electrolyte abnormalities, toxic effects due to medication (particularly digoxin or quinidine), and thyrotoxicosis. New onset Atrial Flutter can indicate a silent ischemic event, particularly in the elderly.
ASSESSMENT / TREATMENT PRIORITIES
1. Maintain universal blood and body fluid precautions.
2. Determine patient's hemodynamic stability and symptoms. Assess Level of Consciousness, ABCs, Vital Signs.
3. Maintain open airway and assist ventilations as needed.
4. Administer oxygen by nasal cannula or mask based upon patient's condition.
5. Obtain appropriate history related to event, including Past Medical History , Medications, Drug Allergies, and Substance abuse.
6. Monitor patient's EKG and vital signs.
7. Most patients tolerate Atrial Flutter well; however, some patients may require emergent treatment. Emergent treatment should be administered when the Atrial Flutter results in an unstable condition. Signs and symptoms may include: chest pain, shortness of breath, decreased level of consciousness, systolic BLOOD PRESSURE less than 90, shock, pulmonary congestion, congestive heart failure and acute myocardial infarction.
TREATMENT
BASIC PROCEDURES
NOTE: Inasmuch as Basic-EMTs are unable to recognize the presence of Atrial Flutter: check patient for a rapid and /or irregular pulse and possible complaint of palpitations. If present, treat according to the following Chest Pain protocol.
1. Maintain universal blood and body fluid precautions.
2. Maintain an open airway and assist ventilations as needed.
3. Administer oxygen by nasal cannula or mask based upon patient's condition.
4. Activate ALS intercept, if deemed necessary and if available.
5. Initiate transport as soon as possible with or without ALS.
6. Notify Receiving hospital.
INTERMEDIATE PROCEDURES
NOTE: Inasmuch as EMT-Intermediates are unable to recognize the presence of Atrial Flutter: check patient for a rapid and/or irregular pulse and possible complaint of palpitations. If present treat according to the following Chest Pain protocol.
1. Maintain universal blood and body fluid precautions.
2. Maintain an open airway and assist ventilations as needed.
3. Administer oxygen by nasal cannula or mask based upon patient's condition.
4. Activate Paramedic intercept, if deemed necessary and if available.
5. ALS STANDING ORDERS
a. Provide advanced airway management if indicated (patient's condition deteriorates).
b. Initiate IV Normal Saline (KVO) enroute to hospital.
6. Initiate transport as soon as possible with or without Paramedics.
7. Notify receiving hospital.
PARAMEDIC PROCEDURES
1. Maintain universal blood and body fluid precautions.
2. Maintain an open airway and assist ventilations as needed.
3. Administer oxygen by nasal cannula or mask based upon patient's condition.
4. Cardiac monitor / dysrhythmia recognition.
5. ALS STANDING ORDERS
a. Provide advanced airway management if indicated (patient's condition deteriorates).
b. Initiate IV Normal Saline (KVO).
c. Vagal Maneuvers: Valsalva’s and/or cough.
d. If the patient’s Systolic BLOOD PRESSURE is unstable (less than 90): Synchronized cardioversion at 50 J, 100 J, 200 J, 300J, and 360 J. Check rhythm and pulse between each attempted cardioversion.
e. If Cardioversion is warranted, consider administration of any of the following for sedation:
- Valium: if patient < 70 kg: 2.5 mg SLOW IV Push, if patient > 70 kg: 5.0 mg SLOW IV Push or
- Versed 0.5 mg - 2.5 mg SLOW IV Push or
- Morphine Sulphate 5 mg - 10 mg SLOW IV Push
6. Contact MEDICAL CONTROL. The following may be ordered.
a. Administration of CARDIZEM® (diltiazem HCL) Lyo-Ject™:
- Initial bolus: 0.25 mg/kg SLOW IV PUSH over two (2) minutes.
- If inadequate response after 15 minutes, re-bolus 0.35 mg/kg SLOW IV PUSH over two (2) minutes.
- IV Infusion 10-15 mg/hr. NOTE: 5 mg/hr may be appropriate starting infusion for some patients. CONTRAINDICATIONS: Wolff-Parkinson-White Syndrome, second or third degree heart block and sick sinus syndrome (except in the presence of a ventricular pace maker), severe hypotension or cardiogenic shock.
b. Administration of Verapamil, unless contraindicated.
- Initial bolus: 2.5 mg - 5 mg SLOW IV push. If inadequate response or after 15-30 minutes may re-bolus Verapamil at 5 mg - 10 mg Slow IV push.
- CONTRAINDICATIONS : Wolff-Parkinson-White Syndrome, second or third degree heart block and sick sinus syndrome.
c. Administer IV Normal Saline 250 cc bolus(es) or titrate IV to patient’s hemodynamic status.
d. Synchronized cardioversion at 50 J, 100 J, 200 J, 300J, and 360 J. Check rhythm and pulse between each attempted cardioversion.
e. If Cardioversion is warranted, consider administration of any of the following for sedation:
- Valium: if patient < 70 kg: 2.5 mg SLOW IV Push, if patient > 70 kg: 5.0 mg SLOW IV Push or
- Versed 0.5 mg-2.5 mg SLOW IV Push or
- Morphine Sulphate 5 mg - 10 mg SLOW IV Push
7. Initiate transport as soon as possible.
8. Notify receiving hospital.
Pathologically slow heart rates usually result from hypoxemia, acidosis, hypothermia and late shock. The following can all result in Bradycardia: vagal stimulation, intrinsic cardiac conduction system disease, acute myocardial infarction resulting in heart rates from sinus bradycardia to complete, 'third degree" heart blocks. Bradycardia may be a late finding in cases of raised intracranial pressure (ICP) due to head trauma, infection, hyperglycemia and previous neurosurgery. Rarely, an ingestion can cause bradycardia. Pre-hospital treatment is directed to the symptomatic patient only. In treating bradycardia, as in treating tachycardia the admonition "treat the patient, not the monitor" should be emphasized. REMINDER: EMS providers must be aware of the concept of "relative" bradycardia, i.e., the patient's pulse rate in relation to the patient's BLOOD PRESSURE and clinical condition.
ASSESSMENT / TREATMENT PRIORITIES
1. Maintain universal blood and body fluid precautions.
2. Maintain an open airway, remove secretions, vomitus, and assist ventilations as needed.
3. Administer high concentration of oxygen via non-rebreather mask.
4. Determine patient's hemodynamic stability and symptoms. Continually assess level of Consciousness, ABCs and Vital Signs including capillary refill.
5. Obtain appropriate history related to event, including recent and Past Medical History, Medications,
6. Drug Allergies and Substance Abuse including possible ingestion or overdose of medications, specifically calcium channel blockers, beta-blockers, and digoxin preparations.
7. Symptomatic patients will have abnormally slow heart rates accompanied by decreased level of consciousness, weak and thready pulses, delayed capillary refill, or hypotension (systolic BLOOD PRESSURE less than 90).
TREATMENT
BASIC PROCEDURES
NOTE: Inasmuch as Basic-EMTs are unable to recognize the presence of Bradydysrhythmias, check patient for a slow and /or irregular pulse. If present, treat according to the following Chest Pain protocol.
1. Maintain universal blood and body fluid precautions.
2. Maintain an open airway. This may include repositioning of the airway, suctioning to remove secretions and/or vomitus, or use of airway adjuncts as indicated. Assist ventilations as needed.
3. Administer oxygen by nasal cannula or by non-rebreather mask.
4. If pulse <60 and patient is symptomatic, place patient supine and elevate legs.
5. Activate ALS intercept, if deemed necessary and if available.
6. Initiate transport as soon as possible with or without ALS.
7. Continue to monitor vitals signs.
8. Notify receiving hospital.
INTERMEDIATE PROCEDURES
NOTE: Inasmuch as EMT-Intermediates are unable to recognize the presence of Bradydysrhythmias, check patient for a slow and/or an irregular pulse. If present, treat according to the following Chest Pain protocol.
1. Maintain universal blood and body fluid precautions.
2. Maintain an open airway. This may include repositioning of the airway, suctioning to remove secretions and/or vomitus, or use of airway adjuncts as indicated. Assist ventilations as needed.
3. Administer oxygen by nasal cannula or by non-rebreather mask.
4. If pulse <60 and patient is symptomatic, place patient supine and elevate legs.
5. Activate Paramedic intercept, if deemed necessary and if available.
6. ALS STANDING ORDERS
a. Advanced Airway Management if indicated.
b. IV Normal Saline (KVO)
7. Initiate transport as soon as possible with or without Paramedics.
8. Continue to monitor vitals signs.
9. Notify receiving hospital
PARAMEDIC PROCEDURES
1. Maintain universal blood and body fluid precautions.
2. Maintain an open airway. This may include repositioning of the airway, suctioning to remove secretions and/or vomitus, or use of airway adjuncts as indicated. Assist ventilations as needed.
3. Administer oxygen by nasal cannula or by non-rebreather mask.
4. If pulse <60 and patient is symptomatic, place patient supine and elevate legs.
5. ALS STANDING ORDERS
a. Advanced Airway Management if indicated.
b. IV Normal Saline (KVO). If hypovolemia is suspected, administer a 250 cc Normal saline Bolus and titrate IV accordingly.
c. If patient is symptomatic as defined in Assessment Priorities:
- Atropine sulfate 0.5 mg to 1.0 mg IV Push or ET every three (3) to five (5) minutes up to total dose 0.04 mg/kg. If administered via ET, 2.0 mg, followed by 2.0 ml of Normal Saline Solution.
- Transcutaneous Pacing (TCP) if indicated.
6. Continue to monitor vital signs.
7. Initiate transport as soon as possible.
8. Contact MEDICAL CONTROL. The following may be ordered:
a. Additional Fluid Boluses of Normal Saline as indicated.
b. Dopamine 5 m g/kg to 20 m g/kg per minute
P>c. Epinephrine Infusion (mix 1 mg in 250 cc Normal Saline) Administer 2 m g to 10 m g per minuted. Glucagon 1.0 to 5.0 mg IM, SC or IV for suspected beta blocker toxicity.
e. Calcium Chloride 10% 2 - 4 mg/kg IV slowly over five (5) minutes for suspected calcium channel blocker toxicity.
9. Notify receiving hospital.
The immediate goals of post resuscitation care are to (1) provide cardiorespiratory support to optimize tissue perfusion, especially to the brain; (2) transport the patient to the hospital emergency department and then to an appropriately equipped critical care unit; (3) attempt to identify the precipitating causes of the arrest and (4) institute measures such as anti-arrhythmic therapy to prevent recurrence. Determine patient's hemodynamic stability and symptoms. Patients response to resuscitation vary widely. They may range from being alert with adequate spontaneous respirations and hemodynamic stability to remaining comatose and apneic and/or having unstable circulation. Mandatory careful and frequent repeated assessments to establish cardiovascular, respiratory and neurological status are required.
ASSESSMENT / TREATMENT PRIORITIES
1. Maintain universal blood and body fluid precautions.
2. Determine patient's hemodynamic stability and symptoms. Assess Level of Consciousness, ABCs and Vital Signs.
3. Maintain an open airway and assist ventilations as needed.
4. Administer high concentration of oxygen by non rebreather mask.
5. Obtain appropriate history related to the event, including Past Medical History, Medications, Drug Allergies and Substance Abuse.
6. Monitor patient's EKG and vital signs.
7. Identification of complications, such as rib fractures, hemo-pneumothorax, pericardial tamponade, intra-abdominal trauma and improperly placed endotracheal tube.
TREATMENT
BASIC PROCEDURES
1. Maintain universal blood and body fluid precautions.
2. Maintain an open airway, assist ventilations as needed.
3. Administer high concentration of oxygen by non-rebreather mask or bag-valve-mask based upon patient's condition.
4. Consider potential need for further CPR and/or defibrillation with SAED for recurrent V-Fib/Ventricular Tachycardia.
5. Activate ALS intercept, if deemed necessary and if available.
6. Initiate transport as soon as possible, with or without ALS.
7. Notify receiving hospital.
INTERMEDIATE PROCEDURES
1. Maintain universal blood and body fluid precautions.
2. Maintain an open airway, assist ventilations as needed.
3. Administer high concentration of oxygen by non-rebreather mask or bag-valve-mask based upon patient's condition.
4. Consider potential need for further CPR and/or defibrillation with SAED for recurrent V-Fib/Ventricular Tachycardia.
5. Activate Paramedic intercept, if deemed necessary and if available.
6. ALS STANDING ORDERS
a. Provide advanced airway management if indicated.
b. Initiate/maintain IV Normal Saline (KVO).
7. Initiate transport as soon as possible with or without Paramedics.
8. Notify receiving hospital.
PARAMEDIC PROCEDURES
1. Maintain universal blood and body fluid precautions.
2. Maintain an open airway and assist ventilations as needed.
3. Administer high concentration of oxygen by non-rebreather mask or bag-valve-mask based upon patient's condition.
4. Cardiac Monitor / Dysrhythmia Recognition.
5. ALS STANDING ORDERS
a. Provide advanced airway management if indicated.
b. Initiate IV Normal Saline (KVO).
c. Consider the potential need for further CPR and/or defibrillation.
d. Manage dysrhythmias according to specific protocols.
e. If the cardiac arrest was the result of Ventricular Fibrillation or Ventricular Tachycardia and no anti-arrhythmic treatment was given, administer a Lidocaine bolus of 1.0 -1.5 mg/kg followed by maintenance infusion of 2 mg-4 mg/minute unless contraindicated. CONTRAINDICATIONS: patients with ventricular escape rhythm.
f. All other standing order treatment modalities as indicated per protocol for specific potential cause of initial cardiopulmonary arrest.
6. Initiate transport as soon as possible.
7. Contact MEDICAL CONTROL. The following may be ordered:
- All other medical control treatment modalities as indicated.
8. Notify receiving hospital.
REMEMBER: This is an extremely unstable period. The patient should be monitored closely and frequently. Recurrent dysrhythmias, hypotension and re-arrest are not uncommon occurrences.
Premature ventricular contractions (PVC's) are depolarizations that arise in either ventricle prior to the next expected sinus beat. The subsequent rhythm is irregular with a shorter than normal R-R interval separating the PVC from the preceding normal beat. P waves are absent before the PVC, and the QRS complex is distorted, wide and often bizarre in appearance. PVC's can lead to ventricular tachycardia and ventricular fibrillation. They are of particular concern in patients with chest pain of cardiac etiology.
ASSESSMENT / TREATMENT PRIORITIES
1. Maintain universal blood and body fluid precautions.
2. Maintain an open airway and assist ventilations as needed.
3. Administer oxygen by nasal cannula or mask based upon patient's condition.
4. Obtain appropriate history related to event, including Past Medical History, Medications, Drug Allergies and Substance Abuse.
5. Monitor patient's ECG and vital signs.
BASIC PROCEDURES
NOTE: Inasmuch as Basic-EMTs are unable to recognize the presence of PVCs: check patient for an irregular pulse and possible complaint of palpitations. If present treat according to the following chest pain protocol.
1. Maintain universal blood and body fluid precautions.
2. Maintain an open airway and assist ventilations as needed.
3. Administer oxygen by nasal cannula or mask based upon patient's condition.
4. Activate ALS intercept, if deemed necessary and if available.
5. Initiate transport as soon as possible with or without ALS.
6. Notify Receiving hospital.
INTERMEDIATE PROCEDURES
NOTE: Inasmuch as EMT-Intermediates are unable to recognize the presence of PVCs: check patient for an irregular pulse and possible complaint of palpitations. If present treat according to the following chest pain protocol.
1. Maintain universal blood and body fluid precautions.
2. Maintain an open airway and assist ventilations as needed.
3. Administer oxygen by nasal cannula or mask based upon patient's condition.
4. Activate Paramedic intercept, if deemed necessary and if available.
5. ALS STANDING ORDERS
a. Provide advanced airway management if indicated (patient's condition deteriorates).
b. Initiate IV Normal Saline (KVO) enroute to hospital.
6. Initiate transport as soon as possible with or without paramedics.
7. Notify receiving hospital.
PARAMEDIC PROCEDURES
1. Maintain universal blood and body fluid precautions.
2. Maintain an open airway and assist ventilations as needed.
3. Administer oxygen by nasal cannula or mask based upon patient's condition.
4. Cardiac monitor / dysrhythmia recognition.
5. Determine if PVCs are present and if patient is symptomatic:
a. related to an ongoing cardiac ischemic event (i.e., chest pain, syncope, coronary artery disease)
b. frequent (> 6/min.)
c. multifocal
d. exhibiting the R on T phenomenon
e. occurring in patterns ( e.g., bigeminy, trigeminy, etc.).
6. ALS STANDING ORDERS
a. Provide advanced airway management if indicated (patient's condition deteriorates)
b. Initiate IV Normal Saline (KVO)
c. If the heart rate is less than 50/min. not counting PVCs and accompanied by a systolic BLOOD PRESSURE less than 90 and/or other associated signs of shock or ischemia are present, administer Atropine 0.5 mg IV push and refer to Bradycardia Protocol.
d. If patient is symptomatic and is not bradycardic, the administration of Lidocaine may be considered. Lidocaine 0.5 mg/kg-1.0 mg/kg IV push; may repeat to a total dose of 3 mg/kg. NOTE: Lidocaine is not recommended as a prophylactic therapy.
e. Lidocaine Maintenance Infusion 2 mg/min.- 4 mg/min.
7. MEDICAL CONTROL may order:
a. Lidocaine 0.5 mg/kg-1.0 mg/kg IV push; may repeat to a total dose of 3 mg/kg. (if not performed on standing orders)
b. Lidocaine Infusion 2 mg/min.- 4 mg/min. (if not performed on standing orders)
c. NOTE: For those patients refractory to Lidocaine and/or in deteriorating condition: Bretylium 5 mg/kg SLOW IV push. Repeat with 10 mg/kg slow IV push every 15 minutes to maximum total dose of 30 mg/kg.
d. Bretylium Infusion 1 mg/min.-2 mg/min.
e. Atropine 0.5 mg IV push, repeat to maximum dose of 0.04 mg/kg.
8. Initiate transport as soon as possible.
9. Notify receiving hospital.
Pulseless Electrical Activity (PEA) incorporates the following rhythm disturbances: electromechanical dissociation (EMD), pseudo-EMD, idioventricular rhythms, ventricular escape rhythms, post defibrillation idioventricular rhythms, and bradyasystolic rhythms. The absence of a detectable pulse and the presence of some type of electrical activity other than Ventricular Tachycardia or Ventricular Fibrillation define this group of dysrhythmias. These rhythms can represent the last electrical activity of a dying myocardium, or they may indicate specific critical rhythm disturbances. Broad complex PEA can appear as a result of severe hyperkalemia, hypothermia, hypoxia, or preexisting acidosis. Overdoses of tricyclic antidepressant, beta blockers, calcium channel blockers and digitalis can produce PEA with specific interventions possible. The one major action that must be taken in the presence of PEA is to search for possible causes especially when you suspect the following conditions resulting in electrical activity without measurable BLOOD PRESSURE: hypovolemia, cardiac tamponade, tension pneumothorax, massive pulmonary embolism.
ASSESSMENT / TREATMENT PRIORITIES
1. Maintain universal blood and body fluid precautions.
2. Determine unresponsiveness, absence of breathing and pulselessness.
3. Maintain an open airway, remove secretions, vomitus, and initiate CPR with supplemental high concentration of oxygen.
4. Continually assess Level of Consciousness, ABCs and Vital Signs including capillary refill.
5. Obtain appropriate history related to event, including recent and Past Medical History, Medications, Drug Allergies and Substance Abuse including possible ingestion or overdose of medications, specifically calcium channel blockers, beta-blockers, and digoxin preparations.
6. Symptomatic patients may have abnormally slow or rapid heart rates accompanied by decreased level of consciousness, weak and thready pulses, delayed capillary refill, or no palpable BLOOD PRESSURE.
7. Every effort should be made to determine the possible cause(s) for PEA including medical and/or traumatic etiologies.
TREATMENT
BASIC PROCEDURES
1. Maintain universal blood and body fluid precautions.
2. Determine unresponsiveness and cardiopulmonary arrest.
3. Initiate CPR
4. Administer high concentration of oxygen with assisted ventilations.
5. Activate ALS intercept, if deemed necessary and if available.
6. Initiate transport as soon as possible with or without ALS
7. Notify receiving hospital
INTERMEDIATE PROCEDURES
1. Maintain universal blood and body fluid precautions.
2. Determine unresponsiveness and cardiopulmonary arrest.
3. Initiate CPR
4. Administer high concentration of oxygen with assisted ventilations.
5. Activate Paramedic intercept, if deemed necessary and if available.
6. ALS STANDING ORDERS
a. Provide Advanced airway management.
b. Initiate IV Normal Saline KVO.
7. Initiate transport as soon as possible with or without Paramedics.
8. Notify receiving hospital.
PARAMEDIC PROCEDURES
1. Maintain universal blood and body fluid precautions.
2. Determine unresponsiveness and cardiopulmonary arrest.
3. Initiate CPR.
4. ALS STANDING ORDERS
a. Provide advanced airway management
b. Initiate IV Normal Saline. If hypovolemia component is suspected, administer 250 cc fluid bolus and titrate IV accordingly.
c. Consider underlying causes for PEA:
- hypothermia: initiate 2 large bore IVs (warm) normal saline
- drug overdose: see specific toxicology protocol
- pneumothorax: perform needle chest decompression
d. If cause is unknown and PEA persists:
- Epinephrine 1:10,000 1 mg IV Push every 3-5 minutes. Epinephrine may be given via Endotracheal Tube if IV is not established. (2 - 2.5 mg of Epinephrine 1:1,000 is preferred (ET) every 3-5 minutes).
- If absolute bradycardia (less than 60 Beats per minute) or relative bradycardia, administer Atropine 1 mg IV Push every 3-5 minutes to a total of 0.04 mg/kg. Atropine may be given via Endotracheal Tube if IV is not established. (Atropine 2.0 mg via ET tube is preferred)
5. Initiate transport as soon as possible.
6. Contact MEDICAL CONTROL. The following may be ordered:
a. Additional Normal Saline Fluid boluses as indicated.
b. Epinephrine:
- Intermediat e dosing of Epinephrine (2-5 mg) IV Push every 3 - 5 minutes or
- Escalating dosing of Epinephrine (1 mg, 3 mg, or 5 mg) IV Push given every 3 - 5 minutes or
- High dosing of Epinephrine (0.1 mg/kg) IV Push every 3 - 5 minutes.
c. Sodium Bicarbonate 1 mEq/kg IV push
7. Notify receiving hospital.
Supraventricular Tachycardia (SVT) applies to all tachyarrhythmias in which the pacemaker site is originating above the ventricles. Examples of these are Paroxysmal Supraventricular Tachycardia (PSVT), Atrial Fibrillation, Atrial Flutter with a rapid ventricular response, and Junctional Tachycardia with a rapid ventricular response. Generally these groups of tachycardias identify narrow complex rhythm disturbances and should not be confused with Sinus Tachycardia which is treated quite differently. Narrow complex SVT with heart rates greater than 150/min. requires immediate intervention under most circumstances.
ASSESSMENT / TREATMENT PRIORITIES
1. Maintain universal blood and body fluid precautions.
2. Maintain open airway and assist ventilations as needed.
3. Determine patient's hemodynamic stability and symptoms. Assess Level of Consciousness, ABCs, Vital signs.
4. Administer oxygen by nasal cannula or mask based upon patient's condition
5. Obtain appropriate history related to event, including Past Medical History , Medications, Drug Allergies, and Substance abuse.
6. Monitor patient's EKG and vital signs.
7. Most patients tolerate SVT well, however, some patients may require emergent treatment. Emergent treatment should be administered when the SVT results in an unstable condition. Signs and symptoms may include: chest pain, palpitations, shortness of breath, decreased level of consciousness, systolic BLOOD PRESSURE less than 90, shock, pulmonary congestion, congestive heart failure and acute myocardial infarction.
TREATMENT
BASIC PROCEDURES
NOTE: Inasmuch as EMT-Basics are unable to recognize the presence of SVT: check patient for a rapid and /or irregular pulse and possible complaint of palpitations. If present treat according to the following Chest Pain protocol.
1. Maintain universal blood and body fluid precautions.
2. Maintain an open airway and assist ventilations as needed.
3. Administer oxygen by nasal cannula or mask based upon patient's condition.
4. Activate ALS intercept, if deemed necessary and if available.
5. Initiate transport as soon as possible with or without ALS.
6. Notify Receiving hospital.
INTERMEDIATE PROCEDURES
NOTE: Inasmuch as EMT-Intermediates are unable to recognize the presence of SVT: check patient for a rapid and /or irregular pulse and possible complaint of palpitations. If present treat according to the following Chest Pain protocol.
1. Maintain universal blood and body fluid precautions.
2. Maintain an open airway and assist ventilations as needed.
3. Administer oxygen by nasal cannula or mask based upon patient's condition.
4. Activate Paramedic intercept, if deemed necessary and if available.
5. ALS STANDING ORDERS
a. Provide advanced airway management if indicated (patient's condition deteriorates).
b. Initiate IV Normal Saline (KVO) enroute to hospital.
6. Initiate transport as soon as possible with or without Paramedics.
7. Notify receiving hospital.
PARAMEDIC PROCEDURES
1. Maintain universal blood and body fluid precautions.
2. Maintain an open airway and assist ventilations as needed.
3. Administer oxygen by nasal cannula or mask based upon patient's condition.
4. Cardiac monitor / dysrhythmia recognition.
5. ALS STANDING ORDERS
a. Provide advanced airway management if indicated (patient's condition deteriorates).
b. Initiate IV Normal Saline (KVO). If hypovolemia component is suspected, administer 250 cc fluid bolus(es) and titrate IV accordingly.
c. Vagal Maneuvers: Valsalva’s and/or cough.
d. If Systolic BLOOD PRESSURE is unstable (less than 90): Synchronized cardioversion at 50 J, 100 J, 200 J, 300 J and 360 J. Check rhythm and pulse between each attempted cardioversion.
e. If cardioversion is warranted, consider administration of any of the following for sedation:
- Valium: if patient < 70 kg: 2.5 mg SLOW IV Push, if patient > 70 kg: 5.0 mg SLOW IV Push or
- Versed 0.5 mg - 2.5 mg SLOW IV push or
- Morphine Sulphate 5 mg - 10 mg
f. Administer Adenosine 6 mg rapid IV push over 1-3 seconds. If previous 6 mg dose failed to resolve rhythm disturbance: Administer Adenosine 12 mg rapid IV push over 1-3 seconds. Repeat Adenosine 12 mg rapid IV push over 1-3 seconds if previous doses failed to resolve rhythm disturbance. Note: Follow all Adenosine with a 20 ml normal saline bolus and elevate extremity.
6. Contact MEDICAL CONTROL. The following may be ordered.
a. Administration of CARDIZEM® (diltiazem HCL) Lyo-Ject™:
- Initial bolus: 0.25 mg/kg SLOW IV PUSH over two (2) minutes.
- If inadequate response after 15 minutes, re-bolus 0.35 mg/kg SLOW IV PUSH over two (2) minutes.
- IV Infusion 10-15 mg/hr NOTE: 5 mg/hr may be appropriate starting infusion for some patients. CONTRAINDICATIONS: Wolff-Parkinson-White Syndrome, second or third degree heart block and sick sinus syndrome(except in the presence of a ventricular pace maker), severe hypotension or cardiogenic shock.
b. Administration of Verapamil, unless contraindicated.
- Initial bolus: 2.5 mg- 5 mg SLOW IV push. If inadequate response or after 15-30 minutes may re-bolus Verapamil at 5 mg-10 mg Slow IV push.
- CONTRAINDICATIONS : Wolff-Parkinson-White Syndrome, second or third degree heart block and sick sinus syndrome.
c. Synchronized cardioversion at 50 J, 100 J, 200 J, 300 J, and 360 J. Check rhythm and pulse between each attempted cardioversion.
d. If Cardioversion is warranted, Medical Control may order any of the following for sedation:
- Valium: if patient < 70 kg: 2.5 mg SLOW IV Push, if patient > 70 kg: 5.0 mg SLOW IV Push or
- Versed 0.5 mg-2.5 mg SLOW IV Push or
- Morphine Sulphate 5 mg - 10 mg SLOW IV Push or
e. Administer IV Normal Saline 250 cc bolus(es) or titrate IV to patient’s hemodynamic status.
7. Initiate transport as soon as possible.
8. Notify receiving hospital.
The need for early defibrillation is clear and should have the highest priority. Since these patients will all be in cardiopulmonary arrest, adjunctive equipment should not divert attention or effort from Basic Cardiac Life Support (BCLS) resuscitative measures, early defibrillation and Advanced Cardiac Life Support (ACLS). Remember: rapid defibrillation and early ACLS is the major determinant of survival.
ASSESSMENT / TREATMENT PRIORITIES
1. Maintain universal blood and body fluid precautions.
2. Determine unresponsiveness, absence of breathing and pulselessness.
3. Consider all potential non-cardiac causes (i.e. electric shock and remove from danger).
4. Begin CPR and assist ventilations while awaiting defibrillator.
5. Basic and/or Intermediate providers should activate a paramedic intercept system (ACLS) as soon as possible, if available.
TREATMENT
BASIC PROCEDURES
1. Maintain universal blood and body fluid precautions.
2. Determine unresponsiveness and cardiopulmonary arrest.
3. Initiate CPR
4. Administer high concentration of oxygen with assisted ventilations using an appropriate BLS airway adjunct.
5. Early defibrillation, if semi-automatic defibrillator is available:
a. Perform CPR until defibrillator is attached and operable.
b. Follow SAED Protocol.
c. Resume CPR when appropriate.
6. Activate ALS intercept, if deemed necessary and if available.
7. Initiate transport as soon as possible with or without ALS.
8. Notify receiving hospital.
INTERMEDIATE PROCEDURES
1. Maintain universal blood and body fluid precautions.
2. Determine unresponsiveness and cardiopulmonary arrest.
3. Initiate CPR
4. Administer high concentration of oxygen with assisted ventilations using an appropriate BLS airway adjunct.
5. Early defibrillation, if semi-automatic defibrillator is available:
a. Perform CPR until defibrillator is attached and operable.
b. Follow SAED Protocol.
c. Resume CPR when appropriate.
6. Activate paramedic intercept, if deemed necessary and available.
7. ALS STANDING ORDERS
a. Provide Advanced airway management.
b. Initiate IV Normal Saline KVO.
8. Initiate transport as soon as possible with or without Paramedics.
9. Notify receiving hospital.
PARAMEDIC PROCEDURES
1. Maintain universal blood and body fluid precautions.
2. Determine unresponsiveness and cardiopulmonary arrest.
3. Initiate CPR unless immediate defibrillation is available.
4. ALS STANDING ORDERS
a. Defibrillate up to 3 times at 200J, 200-300J and 360 J as indicated.
b. Resume CPR if indicated.
c. Provide advanced airway management.
d. Initiate IV Normal Saline KVO.
e. Administer Epinephrine (1:10,000) 1 mg IV push; repeat every 3 - 5 minutes. Epinephrine may be given via Endotracheal Tube if IV is not yet established. (2 - 2.5 mg of Epinephrine 1:1,000 is preferred (ET) every 3-5 minutes).
f. Defibrillate at 360J within 30-60 seconds If VENTRICULAR FIBRILLATION/ VENTRICULAR TACHYCARDIA is persistent:
g. Resume CPR.
h. Administer Lidocaine 1.5 mg/kg IV; subsequent dosage: 0.5 to 0.75 mg/kg IV every 3 - 5 minutes to a total dose of 3 mg/kg IV or Lidocaine ET 2 - 2.5 times the IV dose; subsequent dosage: ET 2 - 2.5 times the IV dose every 3 - 5 minutes to a total dose of 6 mg/kg ET.
i. Defibrillate 30-60 seconds after each dose of medication (pattern should be drug-shock, drug-shock). If VENTRICULAR FIBRILLATION/VENTRICULAR TACHYCARDIA is persistent:
- Administer Bretylium 5 mg/kg IV push.
- Defibrillate at 360 J.
- Resume CPR. If VENTRICULAR FIBRILLATION/VENTRICULAR TACHYCARDIA is persistent:
- Administer repeat dose(s) of Bretylium 10 mg/kg every 15 minutes IV push up to a total dose of 30 mg/kg.
- If dysrhythmia is successfully converted, consider IV infusion of Lidocaine 2-4 mg/min and follow Post-Resuscitation Care protocol.
5. Initiate transport as soon as possible.
6. MEDICAL CONTROL may order:
a. Sodium Bicarbonate 1 mEq/kg, IV push.
b. Alternative Epinephrine dosing regimes
- Intermediate dosing of Epinephrine (2-5 mg) IV Push every 5 minutes or
- Escalating dosing of Epinephrine (1 mg, 3 mg, or 5 mg) IV Push given 3 minutes apart or
- High dosing of Epinephrine (0.1 mg/kg) IV Push every 3 - 5 minutes.
c. Magnesium Sulfate 1 - 2 grams IV in Torsades de points or suspected hypomagnesemic state or severe refractory VENTRICULAR FIBRILLATION/VENTRICULAR TACHYCARDIA.
7. Notify receiving hospital.
Ventricular tachycardia (VENTRICULAR TACHYCARDIA) represents a grave, life threatening situation in which the patient requires immediate treatment. The diagnosis is suggested anytime three or more premature ventricular beats occur in succession. With ventricular tachycardia, cardiac output may drop dramatically or be absent altogether and progress into ventricular fibrillation. In VENTRICULAR TACHYCARDIA, the patient is considered to be either:
1. PULSELESS: in essence in Cardiopulmonary Arrest.
2. Stable: presents with pulses, conscious, without chest pain, Systolic BLOOD PRESSURE greater than 90.
3. Unstable: presents with pulses, but is symptomatic: chest pain, palpitations, shortness of breath (SOB), possible signs and symptoms of congestive heart failure (CHF), hypotension (systolic BLOOD PRESSURE less than 90), decreasing level of consciousness (LOC) or unresponsive.
ASSESSMENT / TREATMENT PRIORITIES
1. Maintain universal blood and body fluid precautions.
2. Determine patient's hemodynamic stability and symptoms. Assess LOC, ABCs and Vital Signs.
3. Maintain an open airway and assist ventilations as needed.
4. Administer high concentration of oxygen by non-rebreather mask.
5. Obtain appropriate history related to event, including Past Medical History, Medications, Drug Allergies and Substance Abuse.
TREATMENT
BASIC PROCEDURES
Note: Inasmuch as Basic EMTs are unable to identify the presence of V-Tach, treat patient according to the following chest pain protocol:
1. Maintain universal blood and body fluid precautions.
2. Maintain an open airway. This may include repositioning of the airway, suctioning, or use of airway adjuncts (oropharyngeal airway, nasopharyngeal airway) as indicated and assist ventilations as needed.
3. Administer high concentration of oxygen.
4. Activate ALS intercept, if deemed necessary and if available.
5. Initiate transport as soon as possible with or without ALS
6. Notify receiving hospital.
INTERMEDIATE PROCEDURES
Note: Inasmuch as Intermediate EMTs are unable to identify the presence of V-Tach, treat patient according to the following chest pain protocol:
1. Maintain universal blood and body fluid precautions.
2. Maintain an open airway. This may include repositioning of the airway, suctioning, or use of airway adjuncts (oropharyngeal airway, nasopharyngeal airway) as indicated and assist ventilations as needed.
3. Administer high concentration of oxygen.
4. Activate Paramedic intercept, if deemed necessary and if available
5. ALS STANDING ORDERS
a. Provide advanced airway management if indicated.
b. Initiate IV Normal Saline (KVO)
6. Initiate transport as soon as possible with or without Paramedics.
7. Notify receiving hospital.
PARAMEDIC PROCEDURES
1. Maintain universal blood and body fluid precautions.
2. Maintain an open airway. This may include repositioning of the airway, suctioning, or use of airway adjuncts (oropharyngeal airway, nasopharyngeal airway) as indicated and assist ventilations as needed.
3. Administer high concentration of oxygen.
4. ALS STANDING ORDERS
a. Provide advanced airway management if indicated.
b. Initiate IV Normal Saline (KVO)
c. If Systolic BLOOD PRESSURE is unstable (less than 90): Synchronized cardioversion at 100 J, 200 J, 300 J and 360 J. Check rhythm and pulse between each attempted cardioversion.
d. If cardioversion is warranted, consider administration of any of the following for sedation:
- Valium: if patient < 70 kg: 2.5 mg SLOW IV Push, if patient > 70 kg: 5.0 mg SLOW IV Push or
- Versed 0.5 mg - 2.5 mg SLOW IV push or
- Morphine Sulfate 5 mg - 10 mg
e. If Systolic BLOOD PRESSURE is stable (greater than or equal to 90), administer Lidocaine 1-1.5 mg/kg IV push.
f. Repeat Lidocaine administration 0.5-0.75 mg/kg IV push every 5-10 minutes, to a maximum total dose 3 mg/kg.
g. Administration of Bretylium 5-10 mg/kg over 8-10 minutes, to a maximum total dose of 30 mg/kg.
5. Initiate transport as soon as possible.
6. MEDICAL CONTROL may order:
a. Magnesium Sulfate 10% (for Torsades de Pointes for suspected hypomagnesemic state or severe refractory VENTRICULAR TACHYCARDIA) 1-2 grams IV Push over 1-2 minutes. CONTRAINDICATIONS: Heart Block, renal disease.
b. Further attempts at cardioversion as indicated.
7. Notify receiving hospital.
MoonDragon's EMS Index Page
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-- by Phyllis A. Balch, James F. Balch - 2nd Edition
-- by Phyllis A. Balch, James F. Balch - 4th Edition
-- by Phyllis A. Balch
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