Cardiac Emergencies Flashcards
Rapid A-Fib & A-Flutter
Ventricular Rates Greater than 150 BPM
Stable A-Fib & A Flutter Treatment
- Cardizem 10mg IV/IO Over 2 mins
If no response in 5 minutes 2nd 15mg
Unstable A-Fib & A- Flutter (Hypotension)
- Normal Saline 1L x1
If pt remains hypotensive: - Push-dose Epi
If Pt Becomes Normotensive Switch to Cardizem
Cardizem Induced Hypotension:
Calcium chloride
500mg IV/IO Over 2 Minutes
PEDIATRIC: Rapid A-Fib & A-Flutter
Call For Orders
Adult Bradycardia < 50 Stable and Unstabel
Stable
* Monitor & Transport
Unstable
* Atropine 0.5mg IV/IO repeat every 3 Minutes Max 3mg
IF PATIENT DETERIORATES OR HYPOTENSION PERSISTS AFTER 2 DOSES OF ATROPINE
TRANSCUTANEOUS PACING:
* Initial rate of 60 beats per minute and increase milliamps until capture is gained
* Increase the rate as needed until the patient is hemodynamically stable
SEDATION FOR TRANSCUTANEOUS PACING
ETOMIDATE:
6mg IV/IO
May repeat 1x prn
IF UNABLE TO ESTABLISH VASCULAR ACCESS AND PATIENT BECOMES NORMOTENSIVE SECONDARY TO TRANSCUTANEOUS PACING
VERSED:
5mg IN/IM
May repeat 1x prn, in 5 minutes
IF PATIENT REMAINS HYPOTENSIVE AFTER ATROPINE OR TRANSCUTANEOUS PACING
- PUSH-DOSE PRESSOR EPINEPHRINE
May repeat x2
Max total dose 300mcg (30 mL)
BRADYCARDIA IN THE PRESENCE OF A MI
Go directly to transcutaneous pacing for unstable bradycardia in the presence of a myocardial infarction as ATROPINE increases myocardial ischemia and may increase the size of the infarct.
PEDIATRIC: STABLE BRADYCARDIA
- OXYGENATION:
Ensure adequate oxygenation first, as hypoxia is most likely to be the cause of the bradycardia - Monitor and transport
PEDIATRIC: UNSTABLE (AMS AND AGE-APPROPRIATE HYPOTENSION)
- VENTILATION:
- Neonates:
1 breath every 3 seconds for at least 30 seconds - Infants/Children:
1 breath every 3 seconds for at least 1 minute
PEDIATRIC: (IF PATIENT REMAINS UNSTABLE AFTER VENTILATIONS AND THE HEART RATE REMAINS BELOW 60 BEATS PER MINUTE)
220 compressions every 2 minutes
PEDIATRIC: IF NO RESPONSE TO OXYGENATION, VENTILATION, AND CHEST COMPRESSIONS
PUSH-DOSE EPI
PEDIATRIC: IF BRADYCARDIC AND HYPOTENSION PERSISTS AFTER INITIAL DOSE OF EPINEPHRINE
TRANSCUTANEOUS PACING:
* Initial rate of 80 beats per minute and increase milliamps until capture is gained
* Increase the rate as needed until the patient is hemodynamically stable
PEDIATRIC: SEDATION FOR TRANSCUTANEOUS PACING
0.1mg/kg IV/IO, over 30 seconds, max single dose 6mg
May repeat 1x prn
PEDIATRIC: IF UNABLE TO ESTABLISH VASCULAR ACCESS AND PATIENT BECOMES NORMOTENSIVE SECONDARY TO TRANSCUTANEOUS PACING
- VERSED
0.2 mg/kg IN/IM, max single dose of 5mg
May repeat either route 1x prn, in 5 minutes
Cardiogenic Shock
- A condition in which the heart suddenly can’t pump enough blood to meet the body’s needs
- Most often caused by a severe heart attack
- Rare, but often fatal if not treated immediately
PULMONARY EDEMA WITH HYPOTENSION ADULT AND PEDIATRIC
- PUSH-DOSE PRESSOR EPINEPHRINE
- NORMAL SALINE 1L
Peds: 20mL/kg
ADULT CHEST PAIN
- Obtain 12 and 15 lead ECGs and leave cables connected
- The right hand and right wrist should be avoided for vascular access if at all possible. These sites may be utilized for cardiac catheterization.
- The right AC and anywhere on the left is acceptable
ADULT CHEST PAIN TREATMENT
- ASPIRIN:
324 mg - FENTANYL:
100mcg IV/IO/IN/IM (2mL)
May repeat 2x prn, in 5 minute intervals
CHEST PAIN: IF PAIN/DISCOMFORT PERSISTS AFTER MAXIMUM FENTANYL ADMINISTRATION OR DRUG SEEKING BEHAVIOR IS SUSPECTED
- NITROGLYCERIN:
- 0.4mg SL
- May repeat 2x prn, in 5 minute intervals
PEDIATRIC CHEST PAIN
Call for orders
STEMI SYMPTOMS
- Discomfort of the chest, arm, neck, back, shoulder or jaw
- Syncope or near syncope
- General weakness
- Unexplained diaphoresis
- SOB
- Nausea/Vomitin
STEMI ALERT CRITERIA
- ST-Segment Elevation in 2 or more contiguous leads:
- Convex (frown face) (Sad Face)
2mm or greater in V2 and V3 - 1mm or greater in all other leads
- Concave (smiley face)
2mm or greater in any lead - All STEMI Alerts shall be transported as priority 2
STEMI ALERT DISQUALIFIERS
- Left Bundle Branch Block (QRS complexes > 0.12)
- Pacemaker with QRS complexes > 0.12
- Left Ventricular Hypertrophy (LVH)
- Early repolarization
- < 2mm of elevation with a concave (smiley face) morphology
- Patient presentations indicative of myocardial ischemia that DO NOT meet “STEMI Alert Criteria”
should still be transported Priority 2 to a STEMI facilit
CHEST PAIN: RIGHT VENTRICULAR FAILURE: POSITIVE V4R, CLEAR LUNG SOUNDS WITH HYPOTENSION
NORMAL SALINE:
* 1L IV/IO, titrate to desired effect
WITH OR WITHOUT CHEST PAIN
* ASPIRIN
CHF (Pulmonary Edema) SIGNS AND SYMPTOMS
- Hypertension
- Tachycardia
- Orthopnea (SOB while lying flat)
- Rales
- Pedal Edema
CHF (Pulmonary Edema) TREATMENT
- NITROGLYCERIN: 0.8mg SL (2 stacked sprays)
May repeat with 0.4mg SL (1 spray), 2x prn, every 5 minutes - CPAP - (10 cm H₂O)
PEDIATRIC: CHF (Pulmonary Edema)
Call for orders
If patient is febrile or from a nursing home and pneumonia is suspected
Withhold nitrates
ST VS SVT
- SVT will generally have no discernible P-waves or there may be P-waves just after the QRS complex
- History that favors ST (e.g., dehydration, fever, pain, anxiety, physical activity, exertional heat
stroke, etc.) - Vagal maneuvers may gently slow down ST but will either not affect SVT OR abruptly break the SVT (SVT shouldn’t gently terminate)
- Adult:
QRS width < 0.12 (3 small boxes)
Rate: > 150 beats per minute after ST has been ruled out - Pediatric:
QRS width < 0.09 (2 small boxes)
Rate: SVT in pediatrics is considered > 180 beats per minute - SVT in infants: Considered > 220 beats per minute
SVT: STABLE (AAOX4 WITH OR WITHOUT HYPOTENSION)
- VAGAL MANEUVERS
- ADENOSINE: 12mg rapid IV/IO, with a 20mL NORMAL SALINE flush
- Print ECG during administration
SVT: IF SVT FAILS TO CONVERT/ADENOSINE IS CONTRAINDICATED OR PATIENT HAS HISTORY OF ATRIAL DYSRHYTHMIAS
- CARDIZEM:
- 10mg IV/IO, over 2 minutes
If no response in 5 minutes, repeat with 15 mg IV/IO, over 2 minutes
CARDIZEM-INDUCED HYPOTENSION
- NORMAL SALINE: 1L IV/IO, titrate to desired effect
- CALCIUM CHLORIDE: 500mg IV/IO, over 2 minutes
SVT: UNSTABLE (ALTERED MENTAL STATUS WITH OR WITHOUT HYPOTENSION)
- ETOMIDATE: 6mg IV/IO
May repeat 1x prn - SYNCHRONIZED CARDIOVERSION:
120j, 150j, 200j
Repeat 360j until successfully converted
PEDIATRIC SVT TREATMENT
- VAGAL MANEUVERS
- ADENOSINE: 0.2mg/kg rapid IV/IO, with a simultaneous 10mL NORMAL SALINE flush
Max single dose 12mg
If no change in 1 minute: - Repeat 0.2mg/kg rapid IV/IO, with a simultaneous 10mL NORMAL
- Print ECG during administration
PEDIATRIC SVT: UNSTABLE (ALTERED MENTAL STATUS WITH OR WITHOUT AGE-APPROPRIATE HYPOTENSION)
- ETOMIDATE (consider for sedation): 0.1mg/kg IV/IO, over 30 seconds, max single dose 6mg
May repeat 1x prn, max total dose 12mg - SYNCHRONIZED CARDIOVERSION: 0.5j/kg
If not effective, increase to 2j/kg - Repeat 2j/kg until successfully converted
VENTRICULAR TACHYCARDIA (V-TACH)
- V-TACH has no discernible P waves
- Precordial concordance: All chest leads point in the same direction (either positive OR negative)
- Negative Lead V6
- Backward frontal plane axis: II, III, and aVF are negative; aVL and aVR are positive
- Presence of capture beats or fusion beats (sinus beats that interrupt the WCT)
- Rate usually > 120 beats per minute
- QRS width > 0.12 (3 small boxes)
STABLE WIDE COMPLEX TACHYCARDIA (WCT) TREATMENT
- AMIODARONE INFUSION: Dilute 150mg of in a 50mL bag of D5W
Administer over 10 minutes IV/IO by utilizing a 10 gtt set delivering 1 gtt/sec - Administer all 150mg, even if the WCT terminates
May repeat 1x prn
WCT: UNSTABLE WCT (ANY AMIODARONE CONTRAINDICATION)
- ETOMIDATE: 6mg IV/IO
May repeat 1x prn - SYNCHRONIZED CARDIOVERSION:
120j, 150j, 200j
Repeat 200j until successfully converted - If a WCT converts with cardioversion and later returns to a WCT, use the last successful energy setting and increase as needed
WCT PATIENTS WHO CONVERT AFTER CARDIOVERSION
*12-lead and 15-lead
* Rule out any contraindications to AMIODARONE
* AMIODARONE INFUSION: If not already administer
Only for patients who convert after (any of the following):
* 2 cardioversions by Fire Department
* 2 or more shocks by their Implantable Cardioverter (ICD)
* DO NOT administer amiodarone if the patient has already received amiodarone
REGULAR REALLY WIDE COMPLEX TACHYCARDIA (RRWCT)
- RRWCT in adult and pediatric patients has a QRS width ≥ 0.20 (5 small boxes or 1 large box)
- Rate usually < 120 beats per
STABLE REGULAR REALLY WIDE COMPLEX TACHYCARDIA (RRWCT)
- CALCIUM CHLORIDE:1g IV/IO, over 2 minutes
- SODIUM BICARBONATE: 100 mEq, IV/IO, over 2 minutes
RRWCT WITH HYPOTENSION SHALL BE TREATED AS UNSTABLE
- ETOMIDATE (consider for sedation): 6mg IV/IO
May repeat 1x prn - SYNCHRONIZED CARDIOVERSION:
120j, 150j, 200j - If a RRWCT converts with cardioversion and later returns to a WCT, use the last successful energy setting and increase as needed
IF UNSTABLE RRWCT FAILS TO CONVERT AFTER CARDIOVERSION OF 200J
- CALCIUM CHLORIDE: as noted above
- SODIUM BICARBONATE: as noted above
- SYNCHRONIZED CARDIOVERSION:
- 200j every 2 minutes prn
PEDIATRIC: STABLE REGULAR REALLY WIDE COMPLEX TACHYCARDIA
- CALCIUM CHLORIDE: 20mg/kg IV/IO, over 2 minutes
- SODIUM BICARBONATE: 1mEq/kg IV/IO, over 2 minutes
Max single dose 50mEq
May repeat 1x prn, in 5 minutes. Max total dose 100mEq
PEDIATRIC: UNSTABLE REGULAR REALLY WIDE COMPLEX TACHYCARDIA (AGE-APPROPRIATE HYPOTENSION)
- ETOMIDATE:
- 0.1mg/kg IV/IO, over 30 seconds, max single dose 6mg
- May repeat 1x prn
- SYNCHRONIZED CARDIOVERSION:
- 0.5j/kg
- If no response, increase to 2j/kg
- If a WCT converts with cardioversion and later returns to a WCT, use the last successful energy setting and increase as needed
- Contraindications - WCTs that are irregularly-irregular
PEDIATRIC: IF UNSTABLE RRWCT FAILS TO CONVERT AFTER CARDIOVERSION
- CALCIUM CHLORIDE: 20mg/kg
- SODIUM BICARBONATE: 1mEq/kg
- SYNCHRONIZED CARDIOVERSION: 2j/kg every 2 minutes prn
Polymorphic V-Tach/ Torsades de Pointes: Risk factors
- Congenital long QT syndrome
- Female gender
- Renal/liver failure
- Medications that cause QT interval prolongation (e.g., anti-dysrhythmics, calcium channel
blockers, psychiatric drugs, antihistamines)
STABLE POLYMORPHIC V-TACH
- MAGNESIUM SULFATE:
- Dilute: 2g of magnesium sulfate in a 50mL bag of D5W
Administer IV/IO utilizing a 60 gtt set, run wide open
UNSTABLE POLYMORPHIC V-TACH (HYPOTENSION)
- ETOMIDATE (consider for sedation):
- 6mg IV/IO
- May repeat 1x prn
- DEFIBRILLATION:
- 120j, 150j, 200j
- If a PVT converts with defibrillation and later returns to a PVT, use the last successful energy setting and increase as needed
IF UNSTABLE POLYMORPHIC V-TACH CONVERTS AFTER DEFIBRILLATION AND MAGNESIUM SULFATE HAS NOT ALREADY BEEN ADMINISTERED
- MAGNESIUM SULFATE:
- Dilute: 2g of magnesium sulfate in a 50mL bag of D5W
- Administer over 10 minutes IV/IO by utilizing a 10 gtt set delivering 1 gtt/sec
PEDIATRIC: STABLE POLYMORPHIC V-TACH
- MAGNESIUM SULFATE:
- Dilute: 40mg/kg in a 50mL bag of D5W
- Administer over 10 minutes IV/IO by utilizing a 10 gtt set delivering 1 gtt/sec
Max dose 2g
PEDIATRIC: UNSTABLE POLYMORPHIC V-TACH (AGE-APPROPRIATE HYPOTENSION)
- ETOMIDATE (consider for sedation):
- 0.1mg/kg IV/IO, over 30 seconds, max single dose 6mg
- May repeat 1x prn
- DEFIBRILLATION:
- 2j/kg, 4j/kg
- If a PVT converts with defibrillation and later returns to a PVT, use the last successful energy setting and increase as needed
PEDIATRIC: IF UNSTABLE POLYMORPHIC V-TACH CONVERTS AFTER DEFIBRILLATION AND MAGNESIUM SULFATE HAS NOT ALREADY BEEN ADMINISTERED
- MAGNESIUM SULFATE:
- Dilute: 40mg/kg in a 50mL bag of D5W
- Administer over 10 minutes IV/IO by utilizing a 10 gtt set delivering 1 gtt/sec
Max dose 2g
Left Ventricular Assist Devices - LVADs
Heart Pump
LVADs: HYPO-PERFUSION
- NORMAL SALINE:
- 1L IV/IO, titrate to desired effect. Assess lung sounds and BP frequently
May repeat 1x, prn
LVADs: UNRESPONSIVE PATIENTS
- ONLY perform chest compressions when the patient’s LVAD is not working and no other options exist to restart the LVAD
- Evaluate unresponsive patients carefully for reversible causes by assessing:
- A.E.I.O.U.-T.I.P.S.
- H’s & T’s
- CHECK BGL
CHEST COMPRESSIONS: - Position hands to the right of the sternum to avoid LVAD dislodgement
Contraindication: - DO NOT use the AutoPulse
Precaution - Performing chest compressions risks rupturing of the ventricular wall leading, to fatal hemorrhage
LVADs: TRANSPORT
- Non-LVAD chief complaints should be transported according to the “Transport Destinations” protocol
- If there are any questions regarding this, contact the EMS Captain and LVAD Coordinator
- JFK MEDICAL CENTER LVAD COORDINATOR:
- (561) 548-5823. Any LVAD issue should be transported to JFK Medical Center
Rhythms to be careful when synchronize cardiovert
Afib, Aflutter
Which med can be use prior to cardioversion if you suspect the underlying rhythm to be Afib or Aflutter
Adenosine 12mg
