PROTOCOLS Flashcards
Rapid A-Fib and A-Flutter
Rapid atrial fibrillation and atrial flutter are defined as ventricular rates greater than 150 BPM.
ADULT
STABLE
CARDIZEM: 10mg IV/IO over 2 minutes. If no response in 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 500mL of Normal Saline and
500mg of Calcium Chloride.
UNSTABLE (HYPOTENSION)
• Normal Saline: 1-2L. Assess lung sounds every 500mL.
• If patient remains hypotensive after fluid administration: DOPAMINE: 5-20mcg/kg/min IV/IO, titrated to
maintain a SBP of 90 mmHg.
• If fluid bolus or Dopamine increases SBP greater than 90mmHg and patient has a ventricular response
greater than 150, administer Cardizem as indicated above.
PEDIATRIC
N/A
DO NOT cardiovert A-Fib/A-Flutter.
Cardioversion of A-Fib/A- Flutter may put patients at high risk for embolic stroke.
ADULT Bradycardia
S/S: Bradycardia is defined as a heart rate less than 50 BPM.
ADULT
STABLE
Monitor and transport.
UNSTABLE: (HYPOTENSION)
• Obtain a 12 LEAD ECG to rule out anMI.
• NORMAL SALINE: 1-2L. Assess lung sounds and blood pressure every 500mL.
• ATROPINE: 0.5mg IV/IO. Repeat prn every 3-5 minutes. Max dose 3mg.
• If there is no response to Atropine then begin TRANSCUTANEOUS PACING: Initial rate of 60 BPM and then
iincrease milliamps until electrical and mechanical capture is gained.
SEDATION OF TRANSCUTANEOUS PACING
• ETOMIDATE: 6mg IV/IO. May repeat 1x prn.
• If unable to establish IV/IO access, begin pacing until an acceptable blood pressure is obtained, then
administer VERSED: 2.5 mg IV/IO OR 5mg IN/IM. May repeat either route 1x prn.
• Contraindicated in hypotension.
• Monitor for respiratory depression.
IF NO RESPONSE TO ATROPINE OR TRANSCUTANEOUS PACING
DOPAMINE: 5-20mcg/kg/minute. Titrate to maintain a systolic blood pressure of 90 mmHg.
BRADYCARDIA IN THE PRESENCE OF AN MI WITH HYPOTENSION
Go directly to transcutaneous pacing as Atropine increases myocardial
ischemia and may increase the size of the infarct.
HIGH DEGREE AV BLOCKS WITH HYPOTENSION
Immediate transcutaneous pacing is acceptable when IV access is not
immediately available.
REVISION 05/2017 Bradycardia
PEDI Bradycardia
PEDIATRIC
STABLE
Monitor and transport
UNSTABLE: (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).
IF NO RESPONSE TO OXYGENATION AND VENTILATION (NO AV HEART BLOCK WITH CPRIN PROGRESS)
• EPINEPHRINE: (1:10,000) 0.01mg/kg (0.1mL/kg) IV/IO. Repeat every 3-5 minutes prn.
• If no response to Epinephrine, begin TRANSCUTANEOUS PACING. Begin pacing at 80 BPMand then iincrease
milliamps until electrical and mechanical capture is gained also increase the rate as needed until the
patient is hemodynamically stable
OR
IF NO RESPONSE TO OXYGENATION AND VENTILATION (2°OR 3°AV HEART BLOCK)
• ATROPINE: 0.02mg/kg IV/IO (Minimum single dose 0.1mg) . Max single dose 0.5mg. May repeat 1x prn.
• If no response to Atropine, EPINEPHRINE: (1:10,000) 0.01mg/kg (0.1mL/kg) IV/IO. Repeat every 3-5
minutes prn.
• 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 gained.
SEDATION FOR TRANSCUTANEOUS PACING
• D ETOMIDATE: 0.1mg/kg IV/IO over 15-30 seconds. May repeat 1x prn. Max single dose 6mg.
• D 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
5mg.
• Contraindicated in hypotension.
• Monitor for respiratory depression.
Cardiogenic Shock
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.
ADULT
LEFT VENTRICULAR FAILURE: PULMONARY EDEMA AND HYPOTENSION
DOPAMINE: 5-20mcg/kg/minute. Titrate to maintain a SBP of 90mmHg.
RIGHT VENTRICULAR FAILURE: POSITIVE V4R, CLEAR LUNG SOUNDS WITH HYPOTENSION
• NORMAL SALINE: 1-2L. Assess lung sounds and blood pressure every 500mL.
• If patient remains hypotensive after fluid administration, DOPAMINE: 5-20mcg/kg/min. Titrate to
maintain a SBP of 90 mmHg.
• Do not administer Dopamine to patients who are hypotensive secondary to blood loss.
PEDIATRIC
N/A
Cardiogenic Shock
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.
ADULT
LEFT VENTRICULAR FAILURE: PULMONARY EDEMA AND HYPOTENSION
DOPAMINE: 5-20mcg/kg/minute. Titrate to maintain a SBP of 90mmHg.
RIGHT VENTRICULAR FAILURE: POSITIVE V4R, CLEAR LUNG SOUNDS WITH HYPOTENSION
• NORMAL SALINE: 1-2L. Assess lung sounds and blood pressure every 500mL.
• If patient remains hypotensive after fluid administration, DOPAMINE: 5-20mcg/kg/min. Titrate to
maintain a SBP of 90 mmHg.
• Do not administer Dopamine to patients who are hypotensive secondary to blood loss.
PEDIATRIC
N/A
Chest Pain
ADULT
• IMMEDIATE 12 lead ECG
• ASPIRIN: Four 81mg baby aspirin (324 mg total)
• Contraindications: allergy, active GI bleeding
• Withhold if patient self-administered 324mg of aspirin within 24 hours. If patient selfadministered
less than 324mg of aspirin within 24 hours, administer full 324mg dose.
• FENTANYL: 50mcg slow IV/IO/IM OR 100mcg IN. May repeat every 5-10 minutes prn. Max total dose
200mcg IV/IO/IM/IN.
• In rare occasions, Fentanyl may cause hypotension.
• If hypotension occurs, NORMAL SALINE: 1-2L. Assess lung sounds and blood pressure every 500mL.
(Nitroglycerine may be given as a first line drug ahead of Fentanyl for stable patients with history
of opiate abuse or in whom drug seeking behavior is suspected)
IF PAIN/DISCOMFORT PERSISTS AFTER MAXIMUM FENTANYL ADMINISTRATION
NITROGLYCERINE: 0.4mg SL. May repeat every 3-5 minutes prn for pain (max 3 doses). SBP must be 90 mmHg or
greater.
• A 12 lead ECG must be obtained prior to the administration of NTG to rule out a right ventricular
infarction including V4R
• An IV must be established prior to NTG administration, even in normotensive patients.
CONTRAINDICATIONS
• SBP less than 90 mmHg
• 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).
