Cardiac Non-Arrest

Tachycardias – Wide Complex w/ pulse (Unstable) Tachycardias – Wide Complex (Stable) Tachycardias – Narrow Complex w/ pulse (Unstable) Tachycardias – Narrow Complex (Stable) Congestive Heart Failure Cardiogenic Shock Bradycardia Acute Coronary Syndrome

Tachycardias – Wide Complex w/ pulse (Unstable)

C303

  • If rhythm is Torsades de Pointes- Mag Sulfate 1 gram
  • If patient is to be cardioverted and does not have an altered LOC, consider sedation- Versed 2-4 mg IV/IM until patient’s speech slurs or a total of 8 mg
  • Synchronized cardioversion at 100 joules (or biphasic equiv.)
  • If no change, repeat synchronized cardioversion at 200/300/360 (or biphasic equiv.)
  • Obtain 12-lead EKG after successful conversion
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Tachycardias – Wide Complex (Stable)

C304

  • Obtain 12-lead EKG of initial rhythm
  • If rhythm is Torsades de Pointes, Mag Sulfate 1 gram
  • Consider Adenosine 6/12 if rhythm is regular
  • Amiodarone 150 mg IV/IO over 10 minutes
  • If wide complex tach persists, may repeat Amiodarone 150 mg IV/IO over 10 minutes
  • Obtain a 12-lead EKG after any rhythm change
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Tachycardias – Narrow Complex w/ pulse (Unstable)

C306

  • Obtain 12-Lead EKG of initial rhythm
  • If patient is to be cardioverted and does not have an altered LOC, consider sedation- Versed 2-4 mg IV/IO/IM until patient’s speech slurs or a total of 8 mg
  • Atrial fibrillation: synchronized cardioversion at initial energy of 120-200 joules biphasic
  • Atrial flutter and all other SVTs: synchronized cardioversion at initial energy of 50-100 joules biphasic
  • If initial energy level fails, increase energy stepwise 100/ 200/ 300/ 360
  • If no change from above, contact medical control
  • If patient converts, obtain 12-lead EKG
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Tachycardias – Narrow Complex (Stable)

C305

  • Valsalva maneuver and note changes (or absence of)
  • Obtain a 12-lead EKG after Valsalva maneuver
  • Adenosine 6 mg with immediate 10 ml NaCl 0.9% flush
  • Adenosine 12 mg with immediate 10 ml NaCl 0.9% flush
  • Adenosine 12 mg with immediate 10 ml NaCl 0.9% flush
  • Obtain a 12-lead EKG after any rhythm change
  • Notify receiving hospital if patient fails to convert
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Congestive Heart Failure

M404

  • CPAP if available
  • Evaluate for contraindications to nitroglycerin:
    • Systolic BP <100 mmHg
    • Viagra/sildenafil in the last 24 hours
    • Levitra/vardenafil in the last 48 hours
    • Cialis/tadalafil in the last 72 hours
    • Medications for pulmonary hypertension (ex: Flolan, Revatio, Adcirca)
  • Assess vitals, acquire 12-lead ECG and establish IV
  • Consider Nitroglycerin administration as described below (If inferior MI evident on ECG, contact medical control prior to Nitroglycerin administration):
  • 0.4 mg SL every 5 min X3 for MILD symptoms (HR<100, SBP 100-150, RR<25) or;
  • 0.8 mg SL every 5 min X3 for MODERATE or SEVERE symptoms (HR>100, SBP >150, RR>25) or;
  • Topical Nitroglycerin:
  • 1″ for SBP 100-150
  • 1.5″ for SBP 150-200
  • 2″ for SBP >200
  • Reassess blood pressure after each Nitroglycerin dose; do not readminister if SBP<100 mmHg
  • Monitor LOC & respiratory status; do not readminister if status changes that cause concern for aspiration based on patient’s clinical status
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Cardiogenic Shock

M401

  • 500 ml bolus of 0.9 NS fluid challenge if lungs are clear, otherwise TKO
  • Consider push dose Epinephrine 0.5-2 ml of a 10 mcg/ml solution every 2-5 min (5-20 mcg)
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Bradycardia

C302

  • 12-lead ECG
  • Atropine 0.5 IV/IO
  • Consider external pacing
  • If pacing, consider sedation – Versed 2-5 mg/min IV/IM until patient’s speech slurs or a total of 8 mg.
  • If no response to initial measures, repeat Atropine 0.5 mg IV/IO push every 3-5 min to max 3.0 mg
  • If bradycardia and hypotension continue, consider push dose epinephrine 0.5-2 ml of a 10 mcg/ml solution every 2-5 min (5-20 mcg)
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Acute Coronary Syndrome

M400

  • 12 lead ECG ASAP (<10 min) and transmit or relay findings
  • 324 mg baby aspirin (chewable) if not contraindicated
  • Determine erectile dysfunction or pulmonary hypertension drug use
  • Nitroglycerin 0.4 mg SL q 5 min X 3 or 1″ topical Nitroglycerin
  • Morphine Sulfate 1-5 mg (10 mg total) or Fentanyl 25-50 mcg IV/IO (200 mcg total) if BP>100mm Hg and pain persists
  • If medic interprets rhythm as STEMI, minimize on-scene time to <15 min, treat during transport, and request cath lab activation
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