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BSO EMS Protocols > Cardiac Emergencies > Flashcards

Cardiac Emergencies Flashcards

1
Q

Rapid A Fib & A Flutter

Information

A

Rapid atrial fibrillation and atrial flutter are defined as ventricular rates greater than 120 BPM.

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2
Q

Rapid A Fib & A Flutter

Adult- Stable

A
  • CARDIZEM: 10mg IV/IO over 2 minutes. If HR > 120 after 5 minutes, repeat with
  • 15mg IV/IO over 2 minutes.
  • Contraindicated for hypotension, wide complex QRS, history of WPW or sick sinus syndrome.
  • Use with caution for patients taking beta blockers.

• If hypotension develops after Cardizem administration, administer
* 1L of Normal Saline
and
* 1 gram of Calcium Chloride.

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3
Q

Rapid A Fib & A Flutter

Adult- Unstable (Hypotension)

A
  • Normal Saline: 1L. Assess lung sounds every 500mL.
  • If blood pressure stabilizes then administer Cardizem as indicated above.

• DO NOT cardiovert A-Fib/A-Flutter.
Cardioversion of A-Fib/A- Flutter may put patients at high risk for embolic stroke.

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4
Q

Rapid A Fib & A Flutter

Pediatric

A

Call for orders

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5
Q

Bradycardia

Information

A

S/S: Bradycardia is defined as a heart rate less than 50 BPM.

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6
Q

Bradycardia

Adult- Stable

A

Monitor and transport

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7
Q

Bradycardia

Adult- Unstable

A

(HYPOTENSION) SBP < 100
• Obtain a 12 LEAD ECG to rule out an MI.
• NORMAL SALINE: 1L .Assess lung sounds and blood pressure every 500mL.
• ATROPINE: 0.5mg IV/IO. Repeat prn every 3-5 minutes. Max dose 3mg.
• Push Dose EPINEPHRINE
• TRANSCUTANEOUS PACING: Initial rate of 60 BPM and then increase milliamps until electrical and mechanical capture is gained.

In the presence of chest pain or a high degree of AV blocks with hypotension

  • Go directly to transcutaneous pacing
  • Immediate transcutaneous pacing is acceptable when IV access is not immediately available.
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8
Q

Bradycardia

SEDATION OF TRANSCUTANEOUS PACING

A

• ETOMIDATE: 10mg IV/IO. May repeat 1x prn.

Or

  • VERSED 5mg IN/IM. May repeat either route 1x prn.
  • If unable to establish IV/IO access, begin pacing until an acceptable blood pressure is obtained, then administer
  • Contraindicated in hypotension.
  • Monitor for respiratory depression.
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9
Q

Bradycardia

Pediatric- Stable

A

Monitor and transport

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10
Q

Bradycardia

Pediatric- Unstable

A

(Defined as a child with AMS and poor perfusion)
• OXYGENATION & VENTILATION: Ensure adequate oxygenation and ventilation first, as hypoxia is most likely to be the cause of the bradycardia.
• After oxygenation and ventilation of 1 minute for infants/children and 30 seconds for neonates (birth to 1 month), begin chest compressions if the heart rate remains below 60 BPM with signs of poor perfusion (AMS).
• Push Dose EPINEPHRINE
• If no response to Epinephrine, begin TRANSCUTANEOUS PACING. Begin pacing at 80 BPM and increase the rate as needed until the patient is hemodynamically stable. Start at 30 milliamps and Increase milliamps until electrical and mechanical capture is achieved.

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11
Q

Bradycardia
Pediatric
Sedation for Transcutaneous Pacing

A

• ETOMIDATE: 0.15 MG/KG-SEE PEDIATRIC MED TOOL

Or

  • Versed: 0.1mg/kg - See Pediatric Med tool.
  • If unable to obtain IV/IO access, begin pacing until an acceptable blood pressure is obtained, then administer VERSED 0.2mg/kg IN/IM. Max single dose 5mg. May repeat 1x in 3 minutes prn. Max total dose 5 mg
  • Contraindicated in hypotension.
  • Monitor for respiratory depression.
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12
Q

Chest Pain

INFORMATION

A

For STEMI Alerts or suspected STEMI Alerts, the right hand and wrist should be avoided (DUE TO CATH ACCESS) if at all possible for IV ACCESS.The right AC and anywhere on the left is acceptable.

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13
Q

Chest Pain

Adult

A

• IMMEDIATE 12 lead ECG
• ASPIRIN: Four 81mg baby aspirin (324 mg total) chewed and swallowed.
- Contraindications: allergy, active GI bleeding
- Withhold if patient self-administered 324mg of aspirin within 24 hours. If patient self- administered less than 324mg of aspirin within 24 hours, administer full 324mg dose.
• FENTANYL: 100 mcg slow IV/IO/IM OR 100 mcg IN. May repeat once in 5-10 minutes. Max total dose 200mcg IV/IO/IM/IN.
- In rare occasions, Fentanyl may cause hypotension.
- If hypotension occurs, NORMAL SALINE: 1L. Assess lung sounds and
blood pressure every 500mL.

  • NITROGLYCERINE: 0.4mg SL. May repeat every 3-5 minutes prn for pain (max 3 doses).
  • SBP must be 100 mmHg or greater.
  • Nitroglycerine may be given as a first line drug ahead of Fentanyl
  • Nitro no mortality or morbidity benefit in ACS
  • Nitro can cause significant harm if given with contraindications present.

Nitro CONTRAINDICATIONS

  • SBP less than 100mmHg
  • EDD (Viagra and Levitra within 24 hours and Cialis within 48 hours)
  • Right Ventricular Infarction. Positive V4R (in this case, follow the CARDIOGENIC SHOCK: RIGHT VENTRICULAR FAILURE protocol).

Patients without pain/discomfort who have ST segment elevation are treated with aspirin only. Fentanyl and NTG are only given to relieve ischemic pain/discomfort.

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14
Q

Chest Pain

Pediatric

A

Call for orders

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15
Q

STEMI Alert

Information

A

STEMI Symptoms can be variable and include discomfort of the chest, arm, neck, back, shoulder or jaw and also can be painless with syncope/near syncope (lightheadedness), general weakness/fatigue, unexplained diaphoresis, SOB, or nausea/vomiting.

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16
Q

STEMI Alert

Adult

A

• IMMEDIATE 12 LEAD ECG WITH IMMEDIATE NOTIFICATION TO PCI FACILITY INCLUDING ECG TRANSMISSION.
• ASPIRIN: Four 81mg baby aspirin (324mg total) chewed and swallowed, if not already administered.
- Contraindications: allergy, active GI bleeding
- Withhold if patient self-administered 324mg of aspirin within 24 hours. If patient self- administered less than 324 mg of aspirin within 24 hours, administer full 324mg dose.
• This protocol may be run concurrent with the Chest Pain Protocol as applicable for ischemic chest pain.

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17
Q

STEMI Alert Criteria

A
  • ST-Segment Elevation in two or more contiguous leads (2mm or greater in V2 and V3 or 1mm or greater in all other leads) with a “convex” (frown face) or “straight” morphology.
  • ST-Segment Elevation in two or more contiguous leads of 2mm or greater in any lead with a“concave” (smiley face).
  • Consider 15 LEAD EKG
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18
Q

STEMI Alert Disqualifiers

A

The following are STEMI mimics:
• QRS complexes greater than 0.12 (LBBB, Pacemaker, etc.)
• Left Ventricular Hypertrophy (LVH)
• Pericarditis
• Early Repolarization
• Less than 2mm of elevation with a Concave ST Segment (Smiley Face) Morphology

Left Ventricular Hypertrophy (LVH)
Take the largest negative deflection from the isoelectric line of VI and V2 (“S” wave), whichever is larger, and count the small boxes. Then take the largest positive deflection of V5 or V6 (“R” wave), whichever is larger, and add it to the total from VI or V2. If the result is greater than 35, your suspicion for LVH should be high.

19
Q

CHF (Pulmonary Edema)

Information

A

• S/S: Hypertension, Tachycardia, Orthopnea, Rales, Pedal Edema

20
Q

CHF (Pulmonary Edema)

Adult

A

• 12 LEAD ECG
• ASPIRIN: Four 81mg baby aspirin (324 mg total) chewed and swallowed.
- Contraindications: allergy, active GI bleeding
- Withhold if patient self-administered 324mg of aspirin within 24 hours. If patient self- administered less than 324mg of aspirin within 24 hours, administer full 324mg dose.

  • SL NTG (0.4mg) Repeat every 5 minutes-Max3doses
  • CPAP (10cmH2O)

CONTRAINDICATIONS: CPAP

  • SBP less than 100mmHg
  • AMS (Lethargic)
  • Apnea: you shouldn’t even consider

• NITRO-PASTE: apply 1” to the anterior upper chest.
- The SL and paste (NTG) may be given concurrently for SBPgreater than 100
mmHg.

CONTRAINDICATIONS: NTG

  • SBPless than 100mmHg
  • EDD (Viagra and Levitra within 24 hours and Cialis within 48 hours)
  • Right Ventricular Infarction

• Place an advanced airway for patients with a decreasing level of consciousness.

21
Q

Cardiogenic Shock

Information

A

Cardiogenic shock is a condition in which the heart suddenly can’t pump enough blood to meet the body’s needs. This condition is most often caused by a severe heart attack. Cardiogenic shock is rare, but often fatal if not treated immediately.

22
Q

Cardigenic Shock

Adult

A

HEART FAILURE: PULMONARY EDEMA AND HYPOTENSION
• FollowCHFProtocol

• Hypotension: Push Dose EPINEPHRINE

Once SBP is 100 mmHg or greater, treat CHF/Pulmonary Edema and/or Chest Pain as applicable.

23
Q

Cardiogenic Shock

Pediatric

A

Call for orders

24
Q

Supraventricular Tachycardia

Information

A

SVT is defined as a regular, narrow complex tachycardia of 150 BPM or greater without discernible P- waves and/or flutter waves.

25
Q

Supraventricular Tachycardia

Adult- Stable

A

CAUTION: DO NOT administer Adenosine to patients with a history of a heart transplant or with history of WPW

12 LEAD ECG

• VAGAL MANEUVERS (The REVERT Trial-Lancet)
• ADENOSINE: 12mg rapid IVP, with a simultaneous 10mL Normal Saline flush.
• If rhythm fails to convert, CARDIZEM: 10mg IVP over 2 minutes. If HR>120 after 5 minutes, administer CARDIZEM: 15mg IVP over 2 minutes.
- Contraindicated for hypotension, wide complex QRS, patients with a history of WPW. SEE DIAGRAM BELOW for example of WPW
- Use with caution for patients taking beta blockers.
- If hypotension develops after Cardizem administration,
* NORMAL SALINE: 1L
then
* Calcium Chloride : 1 gram IV/IO over 2 min

26
Q

Supraventricular Tachycardia

Adult- Unstable (Hypotension)

A

IF PATIENT IS ALERT

• ADENOSINE: 12mg rapid IVP, with a simultaneous 10mL Normal Saline flush.
• If no change after Adenosine, monitor patient throughout transport for changes in
mental status.

IF PATIENT HAS AN ALTERED MENTAL STATUS
• Consider sedation prior to cardioversion. ETOMIDATE: 10mg IV/IO. May repeat 1x prn.
• SYNCHRONIZED CARDIOVERSION: (200J ZOLL), (360 LP)

27
Q

Supraventricular Tachycardia

Pediatric- Stable

A
  • SVT in children is considered greater than 180 BPM.
  • SVT in infants is considered greater than 220 BPM.
  • VAGAL MANEUVERS: For young children, place a bag of ice water on the child’s face completely obstructing their nose and mouth for 15 seconds.
  • ADENOSINE: 0.1mg/kg rapid IV/IO SEE PED MED TOOL, with a simultaneous 10mL flush. Max dose 6mg.
  • If no change in one minute, ADENOSINE: 0.2 mg/kg rapid IV/IO, with a simultaneous 10mL flush. Max dose 12mg. SEE PED MED TOOL
28
Q

Supraventricular Tachycardia

Pediatric- Unstable (age appropriate hypotension)

A
  • SVT in children is considered greater than 180 BPM.
  • SVT in infants is considered greater than 220 BPM.

IF PATIENT IS ALERT
ADENOSINE: Administer as noted above.

IF PATIENT HAS AN ALTERED MENTAL STATUS
• Consider sedation prior to cardioversion
• ETOMIDATE: 0.15mg/kg IV/IO over 15-30 seconds. Max single dose of 10mg.
May repeat 1x prn SEE PED MED TOOL
• SYNCHRONIZED CARDIOVERSION: 1j/kg. If not effective, increase to 2j/kg.

29
Q

Wide Complex Tachycardia

Information

A

Wide complex tachycardia (WCT) has a QRS greater than or equal to 0.12 (0.09 for pediatrics) and a heart rate greater than 120 BPM without discernible P waves.

CAUTION: DO NOT cardiovert wide complex tachycardias that are irregularly/irregular, as they are most likely to be A-Fib/A-Flutter with an aberrancy and would put the patient at risk for an embolic stroke.

ECG features that favor a diagnosis of Ventricular Tachycardia
• Precordial concordance –all chest leads point in the same direction (either positive OR negative)
• Presence of capture beats or fusion beats
• Absence of RS in all precordial leads
• R to S > 100 ms in one precordial lead

ECG features that favor a diagnosis of supraventricular origin
• Normal R wave progression in the chest leads
• Left bundle branch block or right bundle branch block pattern
• Only slight widening of the QRS
• Irregularly-irregular rhythm

ALL REGULAR WCTs SHOULD BE TREATED AS V-TACH UNLESS PROVEN TO BE SUPRAVENTRICULAR!

30
Q

Really Wide Complex Tachycardia

Information

A

Very Wide complex tachycardia (WCT) with a QRS greater than 0.200 and a heart rate approx. 100 -120 BPM without discernible P waves is likely HYPERKALEMIA and NOT V TACH

REALLY WIDE COMPLEX TACYCARDIA stable:
• QRS IS greater than .200ms.,
• QTc > 500
• Rate less than 120

TREATMENT
• DO NOT GIVE AMIODARONE!!!
•Calcium Chloride: 1 gram IV/IO over 2 min
• SODIUM BICARBONATE: 50mEq, slow IV/IO each amp over 2 minutes.

31
Q

Wide Complex Tachycardia

Adult: Stable

A

AMIODARONE INFUSION: 150mg IV/IO (150mg into 50mL of Normal Saline) over 10 minutes. May repeat 1x prn.
• Administer all 150mg, even if the VT terminates.

32
Q

Wide Complex Tachycardia

Adult: Unstable (hypotension)

A
  • DO NOT DELAY CARDIOVERSION TO ESTABLISH IV ACCESS!
  • Consider sedation prior to cardioversion. ETOMIDATE: 10 mg IV/IO. May repeat 1x prn.
  • SYNCHRONIZED CARDIOVERSION: 200J (ZOLL) 360J (LP)
  • If unstable WCT fails to convert, AMIODARONE INFUSION: 150mg IV (150mg into 50mL of Normal Saline) infuse over 10 minutes. After the 150mg has been infused and the patient remains unstable, cardiovert with 200J (ZOLL) 360J (LP) every 2 minutes prn.
33
Q

Ventricular Tachycardia

Pediatric

A

STABLE

  • AMIODARONE INFUSION: PEDIATRIC MEDICATION TOOL
  • Ok to substitute Lidocaine when Amiodarone is not available
  • Lidocaine 1mg/kg IV/IO push (max dose 100mg). Repeat once after 5 minutes if no effect.

UNSTABLE (AGE APPROPRIATE HYPOTENSION)
Consider sedation prior to cardioversion. : ETOMIDATE 0.15 mg/kg SEE PED MED TOOL
SYNCHRONIZED CARDIOVERSION: 1J/kg. If no response, increase to 2J/kg, then 4J/Kg
• For patient’s who convert after two cardioversions
OR
after two or more shocks by their Implantable Cardioverter (ICD) administer AMIODARONE INFUSION: SEE INFUSION PROTOCOL

34
Q

Polymorphic Ventricular Tachycardia

Information

A

Torsades de Pointes is an uncommon form of V-Tach characterized by a changing in amplitude or “twisting” of the QRS complexes.

35
Q

Polymorphic Ventricular Tachycardia

Adult

A

12 LEAD ECG

STABLE PVT
* MAG SULFATE: 2g IV/IO, in 50 mL of Normal Saline - as per infusion protocol

Unstable PVT
* DO NOT DELAY DEFIBRILLATION TO ESTABLISH IV ACCESS!
Sedation
• ETOMIDATE: 10mg IV/IO.
• DEFIBRILLATION: 200j ZOLL 360j LP
• Magnesium Sulfate Infusion regardless of conversion.

CAUTION: DO NOT cardiovert wide complex tachycardias that are irregularly irregular, as they are most likely to be A-Fib/A-Flutter with an aberrancy and would put the patient at risk for an embolic stroke.

If defibrillation terminates the PVT and the patient returns to PVT, begin defibrillation at the last successful energy setting and increase as needed.

36
Q

Polymorphic Ventricular Tachycardia

Pediatric

A

Stable PVT
* MAG SULFATE: administered as per PEDIATRIC MEDICATION TOOL

UNSTABLE PVT
• DO NOT DELAY DEFIBRILLATION TO ESTABLISH IV ACCESS!
• Consider sedation prior to DEFIBRILLATION.
• ETOMIDATE: 0.15mg/kg max of 10mg IV/IO. SEE PEDIATRIC MEDICATION TOOL
• DEFIBRILLATION: 2J/kg, 4J/kg, 10J/kg
• Magnesium Sulfate: administered as per infusion protocol

CAUTION: DO NOT cardiovert wide complex tachycardias that are irregularly irregular, as they are most likely to be A-Fib/A-Flutter with an aberrancy and would put the patient at risk for an embolic stroke.

If defibrillation terminates the PVT and the patient returns to PVT, begin defibrillation at the last successful energy setting and increase as needed.

37
Q

Ventricular Assist Devices

Information

A

Ventricular Assist Devices (VADs), also known as Heart Pumps, are surgically implanted circulatory support devices designed to assist the pumping action of the heart. Caring for these patients is complicated and every effort should be made to contact the patient’s primary caretaker (spouse, guardian etc.) and the VAD coordinator during your evaluation. Patients with a properly functioning VAD may NOT have a detectable pulse, measurable blood pressure or accurate oxygen saturation.

38
Q

Ventricular Assist Devices

Adult

A
  • Contact the VAD coordinator immediately; the phone number will be on the device and the equipment carrying bag. Take all equipment associated with the VAD system to the ED.
  • Locate patient’s emergency “bag” with backup equipment.
  • Treat Non–VAD associated conditions in accordance with the appropriate protocol.
  • Determine the type of device, assess alarms, auscultate for pump sounds. if needed, assist patient (caretaker) in replacing the device’s batteries or cables.
  • Locate the driveline site on the patient’s abdomen. BE CAREFUL not to cause any trauma to the site or driveline (wires).
  • If signs of hypo-perfusion, administer NORMAL SALINE: 1L
  • If there is bleeding at the site, apply direct pressure.

AUSCULTATION FOR PUMP FUNCTION:
Auscultate chest and upper abdominal quadrants – Continuous humming sound = pump is working.

39
Q

Ventricular Assist Device

Unresponsive Patients

A
  • EVALUATE UNRESPONSIVE PATIENTS CAREFULLY FOR REVERSIBLE CAUSES!
  • Perform a blood glucose level, if blood glucose is less than 60 mg/dl administer D10: 100mL. Refer to the hypoglycemia protocol.
  • Performing Chest Compressions risks rupturing of the ventricular wall leading to fatal hemorrhage. ONLY perform chest compressions when the patient’s VAD has no hand pump, the pump is not working and no other options exist to restart the VAD.
40
Q

Ventricular Assist Device

Transport

A

Transport to the closest appropriate facility based on the patient’s chief complaint. There are two centers in Broward County.
Cleveland Clinic 954-226-9196,
Memorial Regional 954-232-5049

PACKAGING AN VAD PATIENT: Be aware of the cables, controller, and
batteries. It may be best to place the stretcher straps under the LVAD cables so you are not creating any torque on the device. At a minimum, be aware of this extra hardware.

41
Q

Patient presentations indicative of myocardial ischemia that do not meet
“STEMI Alert Criteria”

A

should still be transported a STEMI facility.

42
Q

CHF Pediatric

A

Call for orders

43
Q

SPECIAL CONSIDERATIONS AFTER CARDIOVERSION

For patient’s who convert after two cardioversions OR after two or more shocks by their Implantable Cardioverter (ICD)

A

administer. AMIODARONE INFUSION: 150mg IV/IO (150mg into 50mL of Normal Saline) over 10 minutes (if Amiodarone has not already been administered).

BSO EMS Protocols (13 decks)

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