Adult Cardiac Protocols

Question 1

Acute Coronary Syndromes

Include

Answer 1

♦ ACS includes

♦ Unstable Angina,

♦ ST Elevation MI (STEMI),

♦ Non ST Elevation MI,

♦ Silent MI

Question 2

ACS Interventions

(Initial)

Answer 2

Follow Airway Management Protocol.

→ 12 lead EKG within 5 minutes of arrival.

Maintain saturations between 94% – 99%.

→ Aspirin 324 mg PO.

Establish IV at KVO rate – follow Circulation: Intravenous Infusion Procedure.

Question 3

ACS Interventions

(meds)

Answer 3

• *Nitroglycerin 0.4 mg** SL. (SB/P > 90)
• *q 5-minute intervals** (no max as long as blood pressure stays above 90 mm Hg.
• Consider NTG infusion for extended transports.*
• *Suspected Right Ventricular Infarct**, Ntg may be administered in stable patients (B/P >120) after an IV established.

No NTG -Viagra or Levitra within 24 hrs; or Cialis within 36hrs) potential severe hypotension.

Zofran (Ondanestron) 4 mg IM/IO/IV for nausea. May repeat once.

Question 4

ACS Medications / Interventions

(STEMI)

Answer 4

♦ Heparin 5,000 units IV/IO (Adults only and requires OLMD).
♦ Analgesia per Pain Management protocol.
Consider a Normal Saline bolus
♦ Metoprolol (Lopressor) 5 mg IO/IV. _May be repeated 2 times_ while monitoring BP, heart rate, and EKG. May especially benefit anterior and lateral wall myocardial infarction.

• *Notes:**
• *DO NOT** administer Aspirin or Heparin if patient has an ACS in the presence of other etiology such as CVA or trauma.

Question 5

ACS STEMI

(Pain Management)

Answer 5

• *a**. Morphine 0.1 mg/kg (up to 5 mg) IM/IO/IV. SBP must be > 90 mm Hg. May repeat dose once to a max of 10 mg.
• *b**. Fentanyl (Sublimaze) 1 mcg/kg IM/IO/IV/IN. May repeat at 1 mcg/kg. Max single dose 100mcg.
• *c**. Ketamine 0.1-0.5 mg/kg IV/IO if opoids are not managing pain, may repeat every 10 minutes.
• *d**. If pain not relieved by the above doses, may contact OLMD for further dosing.
• *4**. Zofran (Ondansetron) 4 mg IM/IO/IV as needed.

Question 6

Adult Cardiac

(Asystole)

Answer 6

• *Assessment:**
• *♦** Asystole is to be confirmed and documented in three different EKG leads.

♦ If rhythm is unclear and is possibly fine ventricular fibrillation, follow Ventricular Fibrillation and Pulseless Ventricular Tachycardia Protocol

Question 7

Adult Cardiac

(Asystole Interventions)

Answer 7

• *1**. Immediate CPR for 2 minutes (5 cycles of 30 compressions: 2 ventilations)
• *2**. Check rhythm / pulse
• *3**. Immediate CPR for 2 minutes (5 cycles of 30 compressions: 2 ventilations); continue CPR / rhythm-pulse check cycle throughout Asystole / PEA.
• *4**. Establish IV/IO at KVO rate – follow Circulation: Intravenous Infusion Procedure.
• *5**. Administer Epinephrine (Adrenalin) 1:10,000 solution 1 mg IO/IV, repeat every 3 to 5 minutes until rhythm changes.

6. Secure airway & confirm placement – follow Airway: Airway Management Protocol.

Question 8

Adult Cardiac

(Asystole w/ Suspected Hemodialysis/Hyperkalemia)

Answer 8

If hemodialysis patient and hyperkalemia is suspected, administer

♦ Calcium Gluconate (Kalcinate) 1 -2 grams IO/IV or

Calcium Chloride 1 gram IO/IV or

♦ Sodium Bicarbonate 1 mEq/kg IO/IV to a max of 50 mEq, albuterol.

Question 9

Adult Cardiac

(Asystole - H’s and T’s)

Answer 9

• *** Hypovolemia
• *** Hypoxia
• *** Hypo/Hyperkalemia
• *** Hypothermia
• *** Hydrogen Ion (acidosis)
• *** Toxins
• *** Tamponade, cardiac
• *** Tension pneumothorax
• *** Thrombosis coronary
• *** Thrombosis pulmonary

Question 10

Adult Cardiac

(A-fib / A-flutter - Stable)

Assessment

Answer 10

Perform patient assessment – Heart rate > 150 bpm (not due to hypovolemia)

Question 11

Adult Cardiac

(A-fib / A-flutter - Stable)

Interventions

Answer 11

12 lead EKG; → if STEMI follow ACS Protocol → IV at KVO rate

► Attempt Valsalva maneuvers.

► Diltiazem (Cardizem) 0.25 mg/kg IO/IV over 2 minutes if systolic BP > 90.

If patient remains in uncontrolled Atrial Fibrillation, after 15 minutes, administer 0.35 mg/kg IO/IV over 2 minutes.

►Repeat 12 lead EKG.

Question 12

Adult Cardiac

(A-fib - Unstable)

Assessment

Answer 12

• Heart rate > 150 bpm (not due to hypovolemia).
• Signs and symptoms of poor perfusion or the patient is hemodynamically unstable.

Question 13

Adult Cardiac

(A-fib - Unstable)

Interventions

Answer 13

Follow Airway Management Protocol.

• *1**. 12 lead EKG; if STEMI → ACS Protocol.
• *2**. Establish IV at KVO rate
• *3**. Consider sedation – follow the Disability: Conscious Sedation Procedure.:
• *4**. Follow Cardiac: Cardioversion Procedure.
• *i**. 120 joules
• *ii**. 150 joules
• *iii**. 200 joules; repeat shocks at 200 joules
• *5**. Consider Diltiazem (Cardizem) 0.25 mg/kg IO/IV over 2 minutes if systolic BP > 90.
• *6**. Repeat 12 lead EKG.

Question 14

Adult Cardiac

(A-fib - Unstable)

Conscious Sedation

Answer 14

i. Lorazepam (Ativan) 1 – 2 mg IM/IO/IV/IN repeated up to 4 mg max OR
ii. Midazolam (Versed) 1 – 2 mg IM/IO/IV/IN repeated up to 5 mg max OR
iii. Diazepam (Valium) 5-10 mg IO/IV or 0.2 mg/kg rectal up to 20 mg max

Question 15

Adult Cardiac

(Bradycardia)

Interventions

Answer 15

12 lead EKG; if STEMI → ACS Protocol.
Establish IV at KVO rate
S/S of poor perfusion =
♦ Atropine 0.5 mg IO/IV as initial therapy, may repeat every 3-5 mins for a max of 3 mg total.

b. If ineffective:

i. Begin Transcutaneous Pacing – follow the Cardiac: External Pacing Procedure.
ii. Consider sedation
iii. Dopamine (Intropin) 5-20 mcg/kg/min IO/IV. Alternatively, consider Epinephrine (Adrenalin) drip at 0.5-10 mcg/min IO/IV

Question 16

Adult Cardiac

(Bradycardia w/ Beta Blockers)

Answer 16

Glucagon 1-4 mg IO/IV/IN if patient is still bradycardic after:

Atropine** → **Pacing** → **Dopamine** → **Epi drip

Question 17

Adult Cardiac

(Bradycardia w/ Calcium Channel Blockers)

Answer 17

Calcium Gluconate : 1-2 gram IO/IV

OR

Calcium Chloride 1 gram IO/IV

if patient is still bradycardic after

*Atropine → Pacing → Dopamine → Epi drip*

Question 18

Adult Cardiac

(CHF / Pulmonary Edema)

Assessment

Answer 18

Significant findings:

Severe shortness of breath, air hunger, tachypnea, tachycardia, elevated blood pressure,

bi-lateral rales, neck vein distention, edema,

pink frothy sputum, and diaphoresis.

Question 19

Adult Cardiac

(CHF / Pulmonary Edema)

Interventions

Answer 19

Nitroglycerin 0.4 mg SL - SB/P > 90mmHg

• *q**. 5 minute intervals SB/P >90 mm Hg.
• *Withhold Nitroglycerin** due ED medication (i.e., Viagra or Levitra within 24 hours; or Cialis within 36 hours)

Consider Nitroglycerin infusion for extended transports.

Morphine sulfate 3 mg (reduce myocardial oxygen demand, preload, anxiety)

Consider Furosemide 40-80mg
Consider bronchodilators
Consider C-PAP

Question 20

Adult Cardiac

(Post Resuscitation)

Answer 20

Normal Saline bolus - hemodynamically unstable

+ Ventricular ectopy- Amiodarone 150 mg IO/IV _over 10 minutes_

Dopamine 5-20 mcg/kg/min IO/IV. or

Norepinephrine (Levophed) 2-20 mcg/min IO/IV or

Epinephrine (Adrenalin) at 0.5-10 mcg/min IV/IO or

Dobutamine (Dobutrex) 2-20 mcg/kg/min IO/IV

Question 21

Adult Cardiac

(SVT - Stable)

Interventions

Answer 21

12 lead EKG → IV at KVO → vagal maneuvers

Adenosine 6 mg followed by 20 ml flush.

No change → Adenosine 12 mg followed by 20 ml flush.

Alternatively, consider Metoprolol (Lopressor) 5 mg IO/IV. May be repeated 2 times

If no change in patient condition, consider following Atrial Fibrillation/Atrial Flutter (Stable) protocol

Question 22

Adult Cardiac

(SVT - Unstable)

Interventions

Answer 22

Heart rate > 150 bpm QRS < .12 Seconds

Perform 12 lead → IV → Consider sedation

Cardiovert (synchronized)

i. 100 joules
ii. 120 joules
iii. 150 joules
iv. 200 joules; repeat shocks at 200 joules

Repeat 12 lead EKG.

Question 23

Adult Cardiac

(V-Tach Stable)

Answer 23

12 lead EKG → Establish IV

Consider a one-time dose of Adenosine 6 mg for stable monomorphic, regular wide-complex tachycardia that may be SVT with aberrancy.

Amiodarone 150 mg over 10 minutes.

*May repeat in 10 minutes if patient remains in stable ventricular tachycardia.*

Question 24

Adult Cardiac

(V-Tach Unstable)

Answer 24

An unstable patient is defined as:
► Heart rate > 150 beats per minute
►Signs or symptoms of poor perfusion or the patient is hemodynamically unstable

12 lead EKG → Establish IV → Consider sedation

Cardiovert (synchronized)
♦ 100 joules (If Torsades de Pointes, begin at 120 joules unsynchronized)
♦ 120 joules → iii. 150 joules → 200 joules; repeat shocks at 200 joules

Amiodarone 150 mg over 10 minutes. May repeat in 10 minutes if patient remains in unstable VT

Consider Magnesium Sulfate 2 grams slow IO/IV push over 5 - 20 minutes if patient is in refractory VT unresponsive to Amiodarone, or if patient is in Torsades de Pointes.