Original Effective Date: 01/01/2001 | Revised Date: 01/25/2010
CARDIAC EMERGENCIES / MEDICAL CARDIAC ARREST
DESIGNATION OF CONDITION
Signs and symptoms include an unresponsive patient with absent carotid pulses.
EMPHASIS ON PATIENT CARE
CPR, defibrillation, and ACLS intervention as rapidly as possible.
FIRST RESPONDER AND BASIC PRE-HOSPITAL MANAGEMENT
1. Initial Management – Defibrillation, assess airway, breathing and circulation and manage as indicated.
2. Contact Medical Control for transport or termination of resuscitation instructions.
3. Rapidly transport the patient as soon as possible to the nearest medical facility, and consider ALS intercept.
INTERMEDIATE PRE-HOSPITAL MANAGEMENT
4. Initiate an IV of an isotonic solution.
5. Defibrillation is the most effective means of terminating Ventricular Fibrillation (VF) and pulseless Ventricular Tachycardia (VT). Following defibrillation attempts, consider:
Adult:
Administer 1 mg EPINEPHRINE 1: 10,000 [1.0 mg] every 3-5 minutes for duration of resuscitation until pulses return or the arrival of ALS. If indicated, defibrillate between drug administrations.
Pediatric:
Administer EPINEPHRINE 1:10,000 0.01mg/kg every 3-5 minutes.
PARAMEDIC PRE-HOSPITAL MANAGEMENT
6. See specific Cardiac Protocols.
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CARDIAC EMERGENCIES / VF & VT (without a pulse)
DESIGNATION OF CONDITION
Signs and symptoms include an unresponsive patient with absent carotid pulses and an EKG showing ventricular fibrillation or pulseless ventricular tachycardia.
EMPHASIS ON PATIENT CARE
CPR, defibrillation and ACLS intervention as rapidly as possible.
FIRST RESPONDER AND BASIC PRE-HOSPITAL MANAGEMENT
Note: After the initial defibrillation; if transport time to the nearest ACLS provider is < 20 minutes away, initiate transport, defibrillate enroute as needed. If transport time to the nearest ACLS provider is > 20 minutes away, contact Medical Control for instructions and consideration of terminating resuscitation.
INTERMEDIATE PRE-HOSPITAL MANAGEMENT
2. Initiate an IV of an isotonic solution.
3. After the initial defibrillation, administer EPINEPHRINE 1: 10,000 [1.0 mg] every 3-5 minutes for duration of resuscitation until pulses return or the arrival of ALS. If indicated, defibrillate between drug administrations.
PARAMEDIC PRE-HOSPITAL MANAGEMENT
4. After initial defibrillation (joule setting per manufacturer recommendation), with CPR in progress, intubate the patient with ET tube (if patient is not adequately ventilated with advanced airway device).
Note: Bicarbonate has been de-emphasized in ACLS. Acidosis should be managed by insuring that the patient has adequate ventilations and perfusion.
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CARDIAC EMERGENCIES / ASYSTOLE (witnessed rhythm deterioration)
DESIGNATION OF CONDITION
The patient will be unconscious, unresponsive, pulseless, apneic, and show no electrical activity on the monitor (confirmed by 10-second strips in at least two consecutive leads, when possible). This protocol is considered for a normo-thermic patient.
EMPHASIS ON PATIENT CARE
CPR, ACLS intervention, possible decision to terminate resuscitation
FIRST RESPONDER AND BASIC PRE-HOSPITAL MANAGEMENT
1. Initial Management - Assess airway, breathing and circulation and manage as indicated.
2. Consult with Medical Control for transport or termination of resuscitation orders.
3 Consider inserting advanced airway (follow Airway Management Protocols).
4. If indicated, initiate rapid transport with ALS intercept.
INTERMEDIATE PRE-HOSPITAL MANAGEMENT
5. Initiate an IV of an isotonic solution at a TKO rate.
6. Administer EPINEPHRINE 1: 10,000 [1 mg] every 3-5 minutes for duration of resuscitation until pulses return or the arrival of ALS.
PARAMEDIC PRE-HOSPITAL MANAGEMENT
7. Intubate the patient with ET tube (if patient is not adequately ventilated with basic airway management).
8. Consider possible underlying treatable causes of asystolic cardiac arrest and treat accordingly:
9. Repeat EPINEPHRINE 1:10,000 [1 mg] IVP or IO, [2-2.5 mg (1:1,000 in 10ml saline)] ET, every 3-5 minutes.
10. Administer ATROPINE SULFATE [1 mg] IVP or IO, [2-2.5 mg] ET, every 3-5 minutes to a maximum dose of 0.04 mg/kg (3mg).
11. Consider SODIUM BICARBONATE [1.0 mEq/kg] IVP if down time longer than 15 min.
12. Contact Medical Control for transport or termination of resuscitation instructions.
Note: Bicarbonate has been de-emphasized in ACLS. Acidosis should be managed by insuring that the patient has adequate ventilations and perfusion.
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CARDIAC EMERGENCIES / TRAUMATIC CARDIAC ARREST
DESIGNATION OF CONDITION
Signs and symptoms include an unresponsive patient with absent carotid pulses with a high suspicion of traumatic origin.
EMPHASIS ON PATIENT CARE
CPR, ACLS intervention, possible decision to terminate resuscitation. Verify that the mechanism of injury is consistent with the patient presentation and cause of arrest.
FIRST RESPONDER AND BASIC PRE-HOSPITAL MANAGEMENT
1. Initial Management - Assess airway, breathing and circulation and manage as indicated.
a. C- spine precautions.
b. Initiate CPR, ventilate with 100% OXYGEN.
2. Contact Medical Control for transport and/or termination of resuscitation orders.
3. Transport the patient as soon as possible to the nearest medical facility, consider ALS intercept if transport time > 10 minutes.
a. Insert advanced airway (follow Airway Management Protocols).
b. Turn the defibrillator/monitor on and apply defibrillation electrodes.
c. Analyze the EKG rhythm.
d. If patient is in V-Fib or Pulseless V-Tach., follow Medical Cardiac Arrest Protocols if arrest is not due to obvious trauma. Remember the arrest may have preceded trauma and be the underlying cause.
INTERMEDIATE PRE-HOSPITAL MANAGEMENT
4. En route, initiate two large bore IVs of an isotonic solution wide open.
PARAMEDIC PRE-HOSPITAL MANAGEMENT
5. Intubate the patient with an ET tube (if patient has not already been intubated with a multi-lumen airway or laryngeal device).
6. If patient is in Pulseless Electrical Activity (PEA) follow PEA Protocols, consider cause, and treat accordingly:
a. Tension pneumothorax
b. Cardiac tamponade
c. Hypovolemia
d. Acidosis
e. Overdose
f. Hypoxia
g. Pulmonary emboli
h. AMI
i. Traumatic asphyxia
7. If not already done, contact Medical Control for transport or termination of resuscitation orders.
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CARDIAC EMERGENCIES / BRADYCARDIA-SYMPTOMATIC
DESIGNATION OF CONDITION
The patient will present with a hemodynamically unstable bradycardia (BP <90mmHg systolic, decreased LOC, and a heart rate of < 60 bpm with associated signs and symptoms including: chest pain, shortness of breath, etc).
EMPHASIS ON PATIENT CARE
Maintain adequate oxygenation and perfusion, ALS intervention.
FIRST RESPONER AND BASIC PRE-HOSPITAL MANAGEMENT
1. Initial Management - Assess airway, breathing and circulation and manage as indicated.
a. Cardiac monitoring, and obtain a 12 - lead EKG, if possible for documentation.
2. Transport the patient as soon as possible to the nearest medical facility, consider ALS intercept.
3. Focused H&P - History, physical exam, vital signs
a. If suspected AMI, administer ASPIRIN [162-324 mg PO].
INTERMEDIATE PRE-HOSPITAL MANAGEMENT
4. En-route, initiate an IV of isotonic solution at a flow rate determined by patient condition.
PARAMEDIC PRE-HOSPITAL MANAGEMENT
5. If the patient is symptomatic, consider TRANSCUTANEOUS PACING at a rate of 60 bpm, assess for electrical and mechanical capture. If patient is showing a Second Degree Type II or Third Degree block, TRANSCUTANEOUS PACING is the treatment of choice.
6. Consider sedation with DIAZEPAM [2-10 mg] or MIDAZOLAM [1-5 mg] in conjunction with TRANSCUTANEOUS PACING.
7. Consider ATROPINE SULFATE [0.5 mg] IVP, repeated every 3-5 minutes up to .04 mg/kg (3mg).
NOTE: ATROPINE may be harmful in Second Degree Type II or wide Third Degree blocks. ATROPINE should be considered before pacing for suspected vagal induced bradycardias. ATROPINE will not be effective in patients who have had heart transplants.
8. Consider DOPAMINE [2-20 mcg/kg/min.], or EPINEPHRINE [2-10 mcg/min.]: titrate to effect.
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CARDIAC EMERGENCIES / HYPERTENSION (EMERGENT)
DESIGNATION OF CONDITION
The patient may be experiencing hypertension sufficient to produce clinical end organ dysfunction most commonly in the cardiovascular system, CNS, and kidneys. Diastolic pressure usually exceeds 130 mmHg. Common presentations may include: severe headache, chest pain, CHF, blurred vision, and confusion.
EMPHASIS ON PATIENT CARE
Airway management, adequate oxygenation and perfusion, and transport
FIRST RESPONDER AND BASIC PRE-HOSPITAL MANAGEMENT
1. Initial Management - Assess airway, breathing and circulation and manage as indicated.
2. Initiate transport to appropriate medical facility. Consider ALS intercept.
3. Focused H&P - History, physical exam, vital signs.
INTERMEDIATE and PARAMEDIC PRE-HOSPITAL MANAGEMENT
4. En-route, initiate an IV of isotonic solution at a TKO rate.
5. Treat other findings (chest pain, CHF) according to the appropriate protocols.
Note: Most patients with hypertension are asymptomatic and do not require pre-hospital lowering of blood pressure.
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CARDIAC EMERGENCIES / PULSELESS ELECTRICAL ACTIVITY (PEA)
DESIGNATION OF CONDITION
Patient presenting in cardiac arrest with organized electrical activity noted on the cardiac monitor, but without corresponding pulses palpated. Determination and correction of underlying cause of the PEA may improve outcome. Specific problems which may cause PEA:
Tension pneumothorax · Hypothermia · Hypovolemia · Hyperkalemia · Cardiac tamponade · Pulmonary embolism · Acidosis · Drug overdose · AMI
EMPHASIS ON PATIENT CARE
CPR, rapid transport, management of associated conditions.
FIRST RESPONDER AND BASIC PRE-HOSPITAL MANAGEMENT
1. Initial Management - Assess airway, breathing and circulation and manage as indicated.
a. Initiate CPR.
b. Insert advanced airway (follow Airway Management Protocols).
c. Apply defibrillation electrodes and begin cardiac monitoring for documentation.
2. Transport the patient as soon as possible to the nearest medical facility, consider ALS intercept.
3. Focused H&P - History, physical exam, vital signs.
INTERMEDIATE PRE-HOSPITAL MANAGEMENT
4. En-route, initiate one or two large bore IVs of an isotonic solution with 20cc/kg fluid bolus. Repeat as indicated.
5. Administer EPINEPHRINE 1:10,000 [1.0 mg] IVP every 3-5 minutes as long as the patient remains pulseless.
PARAMEDIC PRE-HOSPITAL MANAGEMENT
6. Intubate, if advanced airway has not been placed or if airway management is ineffective.
7. Repeat EPINEPHRINE 1:10,000 [1.0 mg] IVP or IO, [2.0-2.5 mg (1:1,000 in 10ml saline)] ET, every 3-5 minutes.
8. If patient is bradycardic (heart rate < 60 bpm), administer ATROPINE SULFATE [1.0 mg] IVP or IO, [2.0-2.5 mg] ET, every 3-5 minutes to a maximum dose of 0.04 mg/kg.
9. Consider SODIUM BICARBONATE [1 mEq/kg] IVP, especially if hyperkalemia, tricyclic antidepressant overdose or metabolic acidosis is suspected.
10. Treat for any suspected reversible causes (identified in the designation of condition) within applicable scope of practice.
11. Contact Medical Control for transport or termination of resuscitation orders.
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CARDIAC EMERGENCIES / NARROW COMPLEX TACHYCARDIAS
DESIGNATION OF CONDITION
Patient presentation with heart rate over 150 with supraventricular focus. Patients with narrow complex tachycardia, are often familiar with their problem and symptoms. Those who do not show evidence of hemodynamic instability require no pre-hospital medications. Patients presenting with hemodynamic instability, evidence of poor perfusion, chest pain, and altered level of consciousness, shortness of breath, cyanosis or evidence of congestive heart failure are considered unstable and invasive intervention should be implemented per this protocol.
EMPHASIS ON PATIENT CARE
Maintain adequate perfusion, adequate oxygenation, and ALS intervention.
FIRST RESPONDER AND BASIC PRE-HOSPITAL MANAGEMENT
1. Initial Management - Assess airway, breathing and circulation and manage as indicated.
2. Initiate transport to appropriate medical facility. Consider ALS intercept.
3. Focused H&P - History, physical exam, vital signs
a. If suspected AMI, administer ASPIRIN [162-324 mg PO].
INTERMEDIATE PRE-HOSPITAL MANAGEMENT
4. En-route, initiate an IV of an isotonic solution, titrate to maintain adequate vital signs.
PARAMEDIC PRE-HOSPITAL MANAGEMENT
5. If STABLE Narrow Complex Tachycardia
a. Trendelenberg position and Valsalva maneuvers may be attempted.
6. If UNSTABLE Narrow Complex Tachycardia:
a. Patients with significant decompensation may require immediate Synchronized Cardioversion. If the patient is conscious, consider sedation using DIAZEPAM [2-10 mg] or MIDAZOLAM [1-5 mg] IVP, prior to cardioversion, if appropriate to patient condition.
i. Cardiovert at 50-100 joules, or biphasic equivalent.
ii. Cardiovert at 200 joules, or biphasic equivalent.
iii. Cardiovert at 300 joules, or biphasic equivalent.
iv. Cardiovert at 360 joules, or biphasic equivalent.
b. In patients with mild to moderate decompensation:
i. Administer ADENOSINE [12.0 mg] rapid IV push (1-2 seconds) followed by a 20 cc flush of Normal Saline.
ii. Repeat ADENOSINE [12.0 mg] rapid IV push (1-2 seconds) followed by a 20 cc flush of Normal Saline, after 1-2 minutes, if indicated.
iii. Repeat ADENOSINE [12.0 mg] rapid IV push (1-2 seconds) followed by a 20 cc flush of Normal Saline, after 1-2 minutes, if indicated.
iv. If patient’s condition deteriorates, perform synchronized cardioversion
immediately.
c. If patient’s cardiac rhythm changes during procedure, treat per applicable protocols.
Caution: Use of Nitroglycerine or Morphine Sulfate for patients with this rhythm may precipitate cardiac arrest or decompensation.
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CARDIAC EMERGENCIES / WIDE COMPLEX TACHYCARDIA (with a pulse)
DESIGNATION OF CONDITION
Patient who presents with sustained Ventricular Tachycardia or Wide Complex Tachycardia with pulse present. These patients may be conscious or unconscious. “Unstable” indicates symptoms such as chest pain, dyspnea, hypotension, CHF, ischemia, or unconsciousness. “Stable” patients with sustained ventricular tachycardia will not have these symptoms, but must be monitored carefully for onset of such symptoms.
EMPHASIS ON PATIENT CARE
Maintain adequate perfusion, adequate oxygenation, and ALS intervention.
FIRST RESPONDER AND BASIC PRE-HOSPITAL MANAGEMENT
1. Initial Management - Assess airway, breathing and circulation and manage as indicated.
2. Turn the defibrillator/monitor on and apply defibrillation electrodes.
3. Record the EKG rhythm.
4. Initiate transport to an appropriate medical facility. Consider ALS intercept.
5. Focused H&P - History, physical exam, vital signs
a. If suspected AMI, administer ASPIRIN [162-324 mg PO].
b. If the patient becomes unconscious and pulseless, follow Cardiac Arrest Protocols.
INTERMEDIATE PRE-HOSPITAL MANAGEMENT
6. En-route, initiate an IV of an isotonic solution at a TKO rate.
Caution: Use of Nitroglycerine or Morphine Sulfate for patients with this rhythm may precipitate cardiac arrest or decompensation.
PARAMEDIC PRE-HOSPITAL MANAGEMENT
7. If stable wide complex tachycardia or if patient has mild symptoms of decompensation:
a. Administer LIDOCAINE [1.0 mg/kg] IVP or AMIODARONE [150mg] over 10 min.
b. If tachycardia does not resolve, repeat antidysrhythmic.
c. If tachycardia is resolved, start continuous infusion.
d. If no response to antidysrhythmic, and supraventricular tachycardia with aberrancy is suspected, consider ADENOSINE [6.0 mg] rapid IV push (1-2 seconds) followed by a 20 cc flush of Normal Saline.
e. May also consider MAGNESIUM SULFATE [1-2g diluted in 10ml of D5W over 1-2 min.] slow IVP. For Torsades de Pointes, Magnesium Sulfate is the drug of choice and may require doses up to 5-10 g administered slow IVP.
8. If hemodynamically unstable wide complex tachycardia:
a. Prepare for immediate Synchronized Cardioversion and may give brief trial of LIDOCAINE [1.0 mg/kg] IVP. If the patient is conscious, consider sedation using DIAZEPAM [2-10 mg] or MIDAZOLAM [1-5 mg] IVP, prior to cardioversion, if appropriate to patient condition.
i. Cardiovert at 100 joules, or biphasic equivalent.
ii. Cardiovert at 200 joules, or biphasic equivalent.
iii. Cardiovert at 300 joules, or biphasic equivalent.
iv. Cardiovert at 360 joules, or biphasic equivalent.
b. If patient’s cardiac rhythm changes during procedure, treat per applicable protocols.