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WPBfire EMS Protocol > Cardiac Emergencies > Flashcards

Cardiac Emergencies Flashcards

1
Q

Rapid A-Fib & A-Flutter

A

Ventricular Rates Greater than 150 BPM

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2
Q

Stable A-Fib & A Flutter Treatment

A
  • Cardizem 10mg IV/IO Over 2 mins
    If no response in 5 minutes 2nd 15mg
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3
Q

Unstable A-Fib & A- Flutter (Hypotension)

A
  • 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
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4
Q

PEDIATRIC: Rapid A-Fib & A-Flutter

A

Call For Orders

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5
Q

Adult Bradycardia < 50 Stable and Unstabel

A

Stable
* Monitor & Transport
Unstable
* Atropine 0.5mg IV/IO repeat every 3 Minutes Max 3mg

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6
Q

IF PATIENT DETERIORATES OR HYPOTENSION PERSISTS AFTER 2 DOSES OF ATROPINE

A

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

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7
Q

SEDATION FOR TRANSCUTANEOUS PACING

A

ETOMIDATE:
6mg IV/IO
May repeat 1x prn

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8
Q

IF UNABLE TO ESTABLISH VASCULAR ACCESS AND PATIENT BECOMES NORMOTENSIVE SECONDARY TO TRANSCUTANEOUS PACING

A

VERSED:
5mg IN/IM
May repeat 1x prn, in 5 minutes

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9
Q

IF PATIENT REMAINS HYPOTENSIVE AFTER ATROPINE OR TRANSCUTANEOUS PACING

A
  • PUSH-DOSE PRESSOR EPINEPHRINE
    May repeat x2
    Max total dose 300mcg (30 mL)
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10
Q

BRADYCARDIA IN THE PRESENCE OF A MI

A

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.

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11
Q

PEDIATRIC: STABLE BRADYCARDIA

A
  • OXYGENATION:
    Ensure adequate oxygenation first, as hypoxia is most likely to be the cause of the bradycardia
  • Monitor and transport
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12
Q

PEDIATRIC: UNSTABLE (AMS AND AGE-APPROPRIATE HYPOTENSION)

A
  • VENTILATION:
  • Neonates:
    1 breath every 3 seconds for at least 30 seconds
  • Infants/Children:
    1 breath every 3 seconds for at least 1 minute
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13
Q

PEDIATRIC: (IF PATIENT REMAINS UNSTABLE AFTER VENTILATIONS AND THE HEART RATE REMAINS BELOW 60 BEATS PER MINUTE)

A

220 compressions every 2 minutes

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14
Q

PEDIATRIC: IF NO RESPONSE TO OXYGENATION, VENTILATION, AND CHEST COMPRESSIONS

A

PUSH-DOSE EPI

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15
Q

PEDIATRIC: IF BRADYCARDIC AND HYPOTENSION PERSISTS AFTER INITIAL DOSE OF EPINEPHRINE

A

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

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16
Q

PEDIATRIC: SEDATION FOR TRANSCUTANEOUS PACING

A

0.1mg/kg IV/IO, over 30 seconds, max single dose 6mg
May repeat 1x prn

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17
Q

PEDIATRIC: IF UNABLE TO ESTABLISH VASCULAR ACCESS AND PATIENT BECOMES NORMOTENSIVE SECONDARY TO TRANSCUTANEOUS PACING

A
  • VERSED
    0.2 mg/kg IN/IM, max single dose of 5mg
    May repeat either route 1x prn, in 5 minutes
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18
Q

Cardiogenic Shock

A
  • 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
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19
Q

PULMONARY EDEMA WITH HYPOTENSION ADULT AND PEDIATRIC

A
  • PUSH-DOSE PRESSOR EPINEPHRINE
  • NORMAL SALINE 1L
    Peds: 20mL/kg
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20
Q

ADULT CHEST PAIN

A
  • 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
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21
Q

ADULT CHEST PAIN TREATMENT

A
  • ASPIRIN:
    324 mg
  • FENTANYL:
    100mcg IV/IO/IN/IM (2mL)
    May repeat 2x prn, in 5 minute intervals
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22
Q

CHEST PAIN: IF PAIN/DISCOMFORT PERSISTS AFTER MAXIMUM FENTANYL ADMINISTRATION OR DRUG SEEKING BEHAVIOR IS SUSPECTED

A
  • NITROGLYCERIN:
  • 0.4mg SL
  • May repeat 2x prn, in 5 minute intervals
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23
Q

PEDIATRIC CHEST PAIN

A

Call for orders

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24
Q

STEMI SYMPTOMS

A
  • Discomfort of the chest, arm, neck, back, shoulder or jaw
  • Syncope or near syncope
  • General weakness
  • Unexplained diaphoresis
  • SOB
  • Nausea/Vomitin
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25
Q

STEMI ALERT CRITERIA

A
  • 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
26
Q

STEMI ALERT DISQUALIFIERS

A
  • 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
27
Q

CHEST PAIN: RIGHT VENTRICULAR FAILURE: POSITIVE V4R, CLEAR LUNG SOUNDS WITH HYPOTENSION

A

NORMAL SALINE:
* 1L IV/IO, titrate to desired effect
WITH OR WITHOUT CHEST PAIN
* ASPIRIN

28
Q

CHF (Pulmonary Edema) SIGNS AND SYMPTOMS

A
  • Hypertension
  • Tachycardia
  • Orthopnea (SOB while lying flat)
  • Rales
  • Pedal Edema
29
Q

CHF (Pulmonary Edema) TREATMENT

A
  • NITROGLYCERIN: 0.8mg SL (2 stacked sprays)
    May repeat with 0.4mg SL (1 spray), 2x prn, every 5 minutes
  • CPAP - (10 cm H₂O)
30
Q

PEDIATRIC: CHF (Pulmonary Edema)

A

Call for orders

31
Q

If patient is febrile or from a nursing home and pneumonia is suspected

A

Withhold nitrates

32
Q

ST VS SVT

A
  • 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
33
Q

SVT: STABLE (AAOX4 WITH OR WITHOUT HYPOTENSION)

A
  • VAGAL MANEUVERS
  • ADENOSINE: 12mg rapid IV/IO, with a 20mL NORMAL SALINE flush
  • Print ECG during administration
34
Q

SVT: IF SVT FAILS TO CONVERT/ADENOSINE IS CONTRAINDICATED OR PATIENT HAS HISTORY OF ATRIAL DYSRHYTHMIAS

A
  • CARDIZEM:
  • 10mg IV/IO, over 2 minutes
    If no response in 5 minutes, repeat with 15 mg IV/IO, over 2 minutes
35
Q

CARDIZEM-INDUCED HYPOTENSION

A
  • NORMAL SALINE: 1L IV/IO, titrate to desired effect
  • CALCIUM CHLORIDE: 500mg IV/IO, over 2 minutes
36
Q

SVT: UNSTABLE (ALTERED MENTAL STATUS WITH OR WITHOUT HYPOTENSION)

A
  • ETOMIDATE: 6mg IV/IO
    May repeat 1x prn
  • SYNCHRONIZED CARDIOVERSION:
    120j, 150j, 200j
    Repeat 360j until successfully converted
37
Q

PEDIATRIC SVT TREATMENT

A
  • 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
38
Q

PEDIATRIC SVT: UNSTABLE (ALTERED MENTAL STATUS WITH OR WITHOUT AGE-APPROPRIATE HYPOTENSION)

A
  • 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
39
Q

VENTRICULAR TACHYCARDIA (V-TACH)

A
  • 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)
40
Q

STABLE WIDE COMPLEX TACHYCARDIA (WCT) TREATMENT

A
  • 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
41
Q

WCT: UNSTABLE WCT (ANY AMIODARONE CONTRAINDICATION)

A
  • 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
42
Q

WCT PATIENTS WHO CONVERT AFTER CARDIOVERSION

A

*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

43
Q

REGULAR REALLY WIDE COMPLEX TACHYCARDIA (RRWCT)

A
  • RRWCT in adult and pediatric patients has a QRS width ≥ 0.20 (5 small boxes or 1 large box)
  • Rate usually < 120 beats per
44
Q

STABLE REGULAR REALLY WIDE COMPLEX TACHYCARDIA (RRWCT)

A
  • CALCIUM CHLORIDE:1g IV/IO, over 2 minutes
  • SODIUM BICARBONATE: 100 mEq, IV/IO, over 2 minutes
45
Q

RRWCT WITH HYPOTENSION SHALL BE TREATED AS UNSTABLE

A
  • 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
46
Q

IF UNSTABLE RRWCT FAILS TO CONVERT AFTER CARDIOVERSION OF 200J

A
  • CALCIUM CHLORIDE: as noted above
  • SODIUM BICARBONATE: as noted above
  • SYNCHRONIZED CARDIOVERSION:
  • 200j every 2 minutes prn
47
Q

PEDIATRIC: STABLE REGULAR REALLY WIDE COMPLEX TACHYCARDIA

A
  • 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
48
Q

PEDIATRIC: UNSTABLE REGULAR REALLY WIDE COMPLEX TACHYCARDIA (AGE-APPROPRIATE HYPOTENSION)

A
  • 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
49
Q

PEDIATRIC: IF UNSTABLE RRWCT FAILS TO CONVERT AFTER CARDIOVERSION

A
  • CALCIUM CHLORIDE: 20mg/kg
  • SODIUM BICARBONATE: 1mEq/kg
  • SYNCHRONIZED CARDIOVERSION: 2j/kg every 2 minutes prn
50
Q

Polymorphic V-Tach/ Torsades de Pointes: Risk factors

A
  • 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)
51
Q

STABLE POLYMORPHIC V-TACH

A
  • MAGNESIUM SULFATE:
  • Dilute: 2g of magnesium sulfate in a 50mL bag of D5W
    Administer IV/IO utilizing a 60 gtt set, run wide open
52
Q

UNSTABLE POLYMORPHIC V-TACH (HYPOTENSION)

A
  • 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
53
Q

IF UNSTABLE POLYMORPHIC V-TACH CONVERTS AFTER DEFIBRILLATION AND MAGNESIUM SULFATE HAS NOT ALREADY BEEN ADMINISTERED

A
  • 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
54
Q

PEDIATRIC: STABLE POLYMORPHIC V-TACH

A
  • 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
55
Q

PEDIATRIC: UNSTABLE POLYMORPHIC V-TACH (AGE-APPROPRIATE HYPOTENSION)

A
  • 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
56
Q

PEDIATRIC: IF UNSTABLE POLYMORPHIC V-TACH CONVERTS AFTER DEFIBRILLATION AND MAGNESIUM SULFATE HAS NOT ALREADY BEEN ADMINISTERED

A
  • 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
57
Q

Left Ventricular Assist Devices - LVADs

A

Heart Pump

58
Q

LVADs: HYPO-PERFUSION

A
  • NORMAL SALINE:
  • 1L IV/IO, titrate to desired effect. Assess lung sounds and BP frequently
    May repeat 1x, prn
59
Q

LVADs: UNRESPONSIVE PATIENTS

A
  • 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
60
Q

LVADs: TRANSPORT

A
  • 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
61
Q

Rhythms to be careful when synchronize cardiovert

A

Afib, Aflutter

62
Q

Which med can be use prior to cardioversion if you suspect the underlying rhythm to be Afib or Aflutter

A

Adenosine 12mg

WPBfire EMS Protocol (13 decks)

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