Hypothermia
– re-warming
(see Hypothermia protocol)
Treatment protocols for cardiac emergencies are based on current American Heart Association Emergency Cardiovascular Care Standards.
A.
Talk to patient and reassure to decrease anxiety. Place at rest on
stretcher with head elevated 30-40 degrees or in position of comfort.
B.
Elicit patient history*, i.e., chief complaint, history of present
illness, pertinent past medical history, medications, allergies, pacemaker or
automatic implantable cardiac defibrillator (ICD).
* History-taking to be done concurrently with the
following steps:
C.
Begin oxygen therapy per general guidelines
D.
Perform the following expeditiously:
1. Obtain vital signs and estimate of patient's weight;
2. Perform appropriate physical exam to include lung auscultation and observation for jugular vein distention and dependent edema.
3. Establish IV access using intracath needle connected to either a saline lock or normal saline with IV drip tubing, run to keep vein open (TKO). If IV cannot be started after two attempts, begin transport.
4.
Attach ECG chest leads and obtain tracing of initial rhythm.
E.
If indicated, assess patient for proper functioning of pacemaker or ICD.
F.
Obtain 12-lead EKGf available and transmit to receiving hospital if indicated. Other
patient treatments and transport should not be significantly delayed in order to
obtain a 12-lead EKG.
G. When medical control is indicated, establish ASAP.
Patients with any of the following chief complaints or presenting problems should be treated as a suspected MI unless ordered otherwise. If in doubt, contact physician and discuss case:
Chest pain or pressure in any patient over age 30
Syncopal episode in any patient over age 50 (without suspicion of stroke)
Atypical cardiac pain, i.e., shoulder, arm, or jaw pain in absence of chest pain (especially in patient with past cardiac history)
Acute onset fatigue, SOB or diaphoresis in a patient with past cardiac history (especially elderly)
Unexplained respiratory distress
Standing Orders
1. Begin standing orders for cardiac problems. Do not delay nitroor aspirinto establish IV access.
2. For cardiac pain, administer nitroglycerin 0.4 mg SL tablet or one metered dose spray if patient's systolic BP ³ 110 (Consult with medical control physician if SBP <110). Check BP immediately prior to and after administration.
3. For any suspected MI, even in absence of chest pain, administer 324 mg aspirin PO if no history of allergy.
4. Establish IV access. If patient has been loaded in the ambulance without IV access, begin transport promptly, with IV and all other interventions performed en route.
5. If no relief and patient’s SBP remains 110 or greater may repeat nitroevery five minutes. Recheck BP before and after administration.
6. If pain persists after 3 nitroand SBP remains 110 or greater may give morphinesulfate 2-10 mg IV titrated to obtain pain relief. (Use caution in presence of COPD).
a. If patient is allergic to MorphineSulfate may use Dilaudid1-2 mg IV/IM.
7. Monitor vital signs. If respiratory depression or hypotension occurs after administration of Morphine Sulfateor Dilaudidventilate patient as necessary and administer Narcan0.4 - 2 mg IV. Notify a medical control physician.
8.
After administration of at least 3 nitroif authorized and transport
time is greater than 10 minutes, consider administration of nitro drip
Chest Pain - Suggestive of Ischemia (continued)
9. If patient is a potential candidate for reperfusion therapy, assure following info has been communicated to receiving E.D. prior to arrival:
a. Patient age/sex
b. Vital signs
c. Pain - time of onset & response to nitro
d. Dosage and response to Morphine Sulfateif given
e. Any Hx recent surgery or trauma
f. Any Hx bleeding problems
g. Any CNS disease
h. Hx of previous lytic therapy
i. Pregnancy
j. Results of 12-lead EKG if available
Consider requesting diversionif difference in transport times to requested hospital vs. closest hospital is >30 minutes.
After Obtaining Verbal Orders
10. If patient potential candidate for reperfusion therapy, consider diversionif difference in transport times to requested hospital vs. closest hospital is > 30 minutes.
Standing Orders
1. Begin standing orders for cardiac problems. Do not delay nitroto establish IV access.
2. Keep head elevated at all times. Begin oxygen therapy. If respiratory distress severe; consider positive pressure ventilatory assist if patient able to tolerate. Consider ET intubation, if authorized, if patient's ventilations ineffective or Glasgow Coma Score < 8.
3. Monitor ECG closely for dysrhythmias secondary to hypoxia.
4. Give nitroglycerin SL 0.4 mg tablet x2 or metered dose spray x2 if systolic BP 140 or greater.
a. 2 minutes after initial dose repeat nitroglycerin 0.4 mg SL or 1 metered dose spray if patient still has signs of pulmonary edemaand systolic BP remains 140 or greater.
b. 5 minutes after second dose repeat nitroglycerin 0.4 mg SL or 1 metered dose spray if patient still has signs of pulmonary edemaand systolic BP 140 or greater.
5. Give Aspirin324mg PO if no history of allergy.
6. If no relief and patient’s SBP remains 140 or greater:
a. May repeat nitroevery three to five minutes. Recheck BP before and after administration. Or
b. After administration of at least 3 nitroif authorized and transport time is greater than 10 minutes, consider administration of nitro drip.
7.
Contact medical control physician for further orders.
After Obtaining Verbal Orders
8. Consider Lasix40 mg IV (use with caution).
Standing Orders
1. Suspect when myocardial ischemia symptoms accompanied by hypotension/shocksymptoms in the absence of major dysrhythmias.
2. Begin standing orders for cardiac problems.
3. Contact medical control physician for orders.
After Obtaining Verbal Orders
4. Treatment based on patient history and physical exam findings.
Standing Orders
1. Establish ABC's, oxygen, IV access, vital signs, pulse oximetry and 12-lead ECG if available.
2. Consider treatable causes for bradycardic rhythms (e.g. hypoxia, AMI)
3. Assess for serious signs or symptoms due to bradycardia:
· Shortness of breath
· Chest pain
· CHF
· Decreased level of consciousness
· Hypotension
· PVC's in setting of AMI
a. If serious signs or symptoms present:
- Give atropine0.5 mg IV
- Begin transcutaneous pacingconsider sedation
b. If no serious signs or symptoms present and ECG rhythm is Type II second-degree AV block or Third-degree AV block:
- Prepare transcutaneous pacer
- If symptoms develop, begin transcutaneous pacingconsider sedation.
c. If no serious signs or symptoms and bradycardic rhythm is NOT Type II second-degree AV block or Third-degree AV block:
- Monitor patient closely
d. Contact a medical control physician for further orders if necessary.
See ALS algorithm for Bradycardia
Standing Orders
1. No serious signs or symptoms (shortness of breath, chest pain, dyspnea on exertion, altered mental status, pulmonary edema, rales, rhonchi, hypotension, orthostasis, JVD, peripheral edema, and/or ischemic ECG changes)
2. Initial assessment identifies 1 of 4 types of tachycardias:
1) Atrial Fibrillation/Atrial Flutter;
2) Stable Wide Complex;
3) Tachycardia: Unknown Type,
Stable Monomorphic and/or Polymorphic VT
a. Monitor vital signs and ECG closely
b. Obtain 12-lead ECG if available
c. Treat changes in patient condition as appropriate
4) Narrow Complex Tachycardias
- 12-lead ECG if available
- Attempt Valsalvamaneuver
- Adenosine6 mg rapid IV push (over 1-3 seconds) followed by 20 ml normal saline flush. May repeat 12 mg dose in 3-5 minutes if necessary.
3. Contact medical control physician for further orders if necessary
See ALS algorithm for Tachycardias
Standing Orders
1.
Establish rapid heart rate as cause of serious signs and symptoms
(shortness of breath, chest pain, dyspnea on exertion, altered mental status,
pulmonary edema, rales, rhonchi,
hypotension, orthostasis, JVD, peripheral edema, and/or ischemic ECG changes)
Rate related signs and symptoms occur at many heart rates but seldom <150 bpm.
2. If ventricular rate is > 150 bpm, prepare for immediate cardioversion.
3. Have available:
a. Oxygen saturation monitor
b. Suction
c. IV line
d. Intubation equipment
4. Premedicate patient whenever possible, effective regimes include:
Sedative:
a. Midazolam2mg slow IV (up to total of 5mg)
with or without an Analgesic:
b. Morphine2-10 mg IM/IV
5. Synchronized cardioversion (energy rates as prescribed by current AHA ACLS guidelines e.g., 100 J, 200 J., 300 J., 360 J. or biphasic equivalent) for:
a. Ventricular Tachycardia
b. PSVT
c. Atrial Fibrillation
d. Atrial Flutter
6. Contact medical control physician for further orders if necessary.
See ALS algorithm for Tachycardias
Standing Orders
1. Institute or continue CPR.
2. Assess and confirm Pulseless VT/VF then defibrillate up to 3 times (stacked), if necessary (energy rates as prescribed by current AHA ACLS guidelines; e.g. 200 J, 200 to 300 J, 360 J, or equivalent biphasic).
3. Reassess rhythm, if defibrillation results in a change in rhythm proceed to the appropriate protocol. If rhythm remains unchanged or recurs continue this protocol.
4. Secure airway; confirm tube placement by exam plus confirmation device (End-Tidal Carbon Dioxide Detection Device or Endotracheal Tube Locator).
5. Obtain IV access
6. Administer Epinephrine1 mg every 3-5 min.
7. Defibrillate up to 3 times (stacked), (energy rates as prescribed by current AHA ACLS guidelines; e.g. 200 J, 200 to 300 J, 360 J, or equivalent biphasic).
8. Consider Lidocaine100 mg IV may repeat in 3-5 min. (max. total 3 mg/kg).
9. Defibrillate up to 3 times (stacked) after each drug dose.
10. Consider Sodium Bicarbonate1 amp (50mEq) IV.
11. Consider magnesiumsulfate 1-2 g IV
12. Contact medical control physician for further orders.
After Obtaining Verbal Orders
13. Consider additional doses of initial antiarrhythmic.
14. After successful resuscitation from V-Tach or V-Fib, begin prophylactic lidocaine. If defibrillation alone lead to a restored circulation, give lidocaine 1 mg/kg as a loading dose followed by 2 mg/min continuous drip. If lidocaine was given during the initial resuscitation, the loading dose is not needed.
15. If no response, consider termination of resuscitative efforts.
See ALS algorithm for VF/Pulseless VT
Standing Orders
1. Institute or continue CPR.
2. Rapid scene survey: Is there any evidence that resuscitation should not be attempted (e.g., DNRorders, conditions incompatible with life)
3. Secure airway; confirm tube placement, effective ventilation and oxygenation.
4. Assess and confirm asystole (check second lead to verify)
5. Obtain IV access.
6. Administer Epinephrine1 mg, repeat q 3-5 min.
7. Administer Atropine1 mg, repeat q 3-5 min (up to total of 3 mg)
8. May consider transcutaneous pacing;f considered, perform immediately.
9. Contact medical control physician for further orders.
After Obtaining Verbal Orders
10. If no response consider termination of resuscitative efforts.
See ALS algorithm for Asystole
Standing Orders
1. Institute or continue CPR.
2. Secure airway; confirm tube placement, effective ventilation and oxygenation.
3. Assess and confirm rhythm as PEA (rhythm on monitor without detectable pulse)
4. Review the most frequent causes of PEA, treat according to protocols if present:
· Hypovolemia – fluids, PCT
· Hypoxia – ventilation and oxygenation
·
Hypothermia
– re-warming
(see Hypothermia protocol)
5. Obtain IV access.
6. Administer Epinephrine1 mg, repeat every 3-5 min.
7. If PEA rate is slow (<60 bpm) administer Atropine1 mg, repeat every 3-5 min (up to total of 3 mg)
8. Contact medical control physician for further orders.
After Obtaining Verbal Orders
9. If no response consider termination of resuscitative efforts.
See ALS algorithm for PEA
Standing Orders
1.
For
renal patients in cardiac arrest contact a medical control physician for
consideration of treatment of hyperkalemia