Protocols - Cardiac

Question 1

Adult Bradycardia Indications:

Answer 1

Slow heart rate < 60 with:
1) chest pain/shortness of breath
2) Altered/decreased level of consciousness
3) hypotension/hypoperfusion
4) CHF/pulmonary congestion
5) Acute myocardial infarction

Question 2

Adult Bradycardia Treatment (serious signs and symptoms):

Answer 2

1) Transcutaneous Pacemaker
2) Atropine 0.5-1mg IVP (repeated q 3-5mins; total 0.04mg/kg)
3) Epi Infusion 1ml/min (2-10mcg/min on IV Infusion Pump)

Question 3

Pediatric Bradycardia Treatment (serious signs and symptoms):

Answer 3

HR < 60 with poor perfusion - START CPR

1) Epi IV/IO 0.01 mg/kg q 3-5 mins
2) Atropine IV/IO 0.02 mg/kg MAX 0.5mg
repeat once

Question 4

Define Hemodynamically Unstable:

Answer 4

Systolic blood pressure less than 60 in neonates (<28 days old) 70 in infants (<1yr old) and < [70 + (2 x age)] for patients > 1 yr old

Question 5

Adult SVT Treatment (Regular narrow complex tachycardia above 150bpm):

Answer 5

1) Valsalva
2) Adenosine 6 mg rapid IVP
3) Adenosine 12 mg rapid IVP (repeat in 1-2 mins)
4) If life threatening (Synchronized Cardioversion)

Question 6

Adult V Tach w Pulse (Monomorphic wide QRS Tachycardia) Treatment:

Answer 6

1) Amiodarone 150mg IV/IO over 10 minutes (mixed in 50-100 ml approved diluent) Repeat if necessary
2) If life threatening signs and symptoms develop - Synchronized Cardioversion)

Question 7

Adult Tachycardia with history of Wolff-Parkinson White syndrome, Lown-Ganong-Levine syndrome or Mahaim type Treatment:

Answer 7

1) Monitor
2) Unstable and life-threatening (Synchronized cardioversion)

Question 8

Pediatric Narrow Complex Tachycardia (less than or equal to 0.09 seconds) Treatment

Answer 8

Sinus Tach - Identify underlying cause

SVT-
1) Vagal Maeuvers
2) Adenosine 0.01 mg/kg Max 6mg Rapid IV/IO Push
3) Adenosine 0.02mg/kg Max 12 mg Rapid IV/IO Push (x2)
4) synchronized Cardioversion 0.5 j/kg, 1 j/kg, 2 j/kg

Question 9

Pediatric V-Tach w pulse (Wide Regular) Hemodynamically Unstable Treatment:

Answer 9

1) Cardiovert 0.5 j/kg, 1 j/kg, 2 j/kg
2) Consult - Amiodarone 5mg/kg IV/IO (over 20 minutes mixed in 50-100 ml approved diluent) Obtain 12 lead prior to administration

Question 10

Pediatric V-Tach w pulse (Wide Regular) Hemodynamically Stable Treatment:

Answer 10

1) Consider Adenosine 0.01 mg/kg Max 6mg Rapid IV/IO Push
2) Adenosine 0.02mg/kg Max 12 mg Rapid IV/IO Push (x2)
3) onsult - Amiodarone 5mg/kg IV/IO (over 20 minutes mixed in 50-100 ml approved diluent) Obtain 12 lead prior to administration

Question 11

Adult Cardiac Arrest Indications:

Answer 11

Medical Arrest: 13 yoa and older
Trauma Arrest: 15 yoa and older

Patient’s are unconscious, apenic and pulseless

Question 12

Adult PEA (Narrow QRS Complex) Treatment:

Answer 12

CONSIDER SEVERE HYPOTENSION OR OBSTRUCTIVE CAUSES
High Performance CPR
Adequate Oxygenation and Ventilation
IV/IO - Wide Open
1) Epinephrine 1mg q 4 mins (Max 4 doses)
2) If Tension Pneumo - Decompress

Question 13

Adult PEA (Wide QRS Complex) Treatment:

Answer 13

CONSIDER TOXICOLOGICAL OR METABOLIC CAUSES
High Performance CPR
Adequate Oxygenation and Ventilation
IV/IO - Wide Open
1) Epinephrine 1mg q 4 mins (Max 4 doses)

IF HYPERKALEMIA:
1) Calcium Chloride 1gm IVP/IO
2) Sodium Bicarbonate 1meq/kg IV/IO

IF NA CHANNEL BLOCKER (Including tricyclic and phenobarbital overdose) or SEVERE METABOLIC ACIDOSIS
1) Sodium Bicarbonate 1meq/kg IV/IO

Question 14

Adult Asystole Treatment

Answer 14

CONSIDER HYPOXIC CAUSES
High Performance CPR
Adequate Oxygenation and Ventilation
IV/IO - Wide Open
1) Epinephrine 1mg q 4 mins (Max 4 doses)
2) If Tension Pneumo - Decompress

Question 15

Adult V-FIB/V-TACH (without pulse) Treatment:

Answer 15

High Performance CPR
Ensure Adequate Oxygenation/Ventilation
1) Defibrilate 120J
2) Defibrilate 150J
3) Amiodarone 300mg and Epinephrine 1mg
4) Defibrilate 200J
5) Epinephrine 1mg
6) Alternative Defibrillation Techniques (One defibrilator - Vector Change; Two defibrillators - Dual sequential)

If Torsades develops- Mag Sulfate 2 g IV/IO over 2 mins
**If Hyperkalemia suspected - Calcium 1 g and Sodium Bicarbonate 1 meq/kg
**If Sodium channel blocker OD suspected - Sodium Bicarbonate 1 met/kg

Question 16

Vector Change Defibrillation

Answer 16

Question 17

Dual Sequential Defibrillation

Answer 17

Question 18

Pediatric V-Fib/V-Tach Treatment:

Answer 18

1) CPR
2) Assure Adequate Oxygenation/Ventilation
3) Defibrillate 2 J/kg
4) IV/IO Access
5) Defibrillate 4 J/kg
6) Epi 1 dose q 4 minutes Max 4 doses (See Chart)
7) Defibrillate 6 J/kg
8) Amiodarone 5 mg/kg (Max 300mg) (Repeat x2 Max 15 mg/kg
9) Defibrillate 8 J/kg, 10 J/kg and Epi administration

Question 19

Pediatric Asystole/PEA Treatment:

Answer 19

1) CPR
2) Assure Adequate Oxygenation/Ventilation
3) Epi 1 dose q 4 minutes Max 4 doses (See Chart)

Question 20

Chest Pain Indications:

Answer 20

1) Angina or anginal equivalents
2) Chest pain, pressure or discomfort
3) Pain or discomfort in the upper abdomen, arm or jaw
4) Shortness of breath
5) Unexplained diaphoresis

Question 21

Chest Pain Treatment:

Answer 21

1) Perform 12 Lead EKG
2) Establish IV
3) Nitroglycerin 0.4 mg SL
4) Repeat Nitro if BP >90 mmHg and pulse is between 60-150 bpm (Max 1.2 mg)

*If no prescription or previous Nitro use, IV must be established. CONSULT for additional doses, No IV access or patient BP drops > 20 mmHg

**Nitro contraindicated in patient taking pulmonary artery hypertension drugs (Adcirca, Revatio) or ED drugs (Viagra, Levitra or Cialis) within previous 48 hrs

Question 22

STEMI Indications:

Answer 22

Patient with ACS symptoms and meets one of the following:
1) New ST elevation of 1mm (or greater) in two or more anatomically contiguous leads (Inferior, Lateral, Septal, Anterior)
2) Posterior MI - ST depression > 1mm in V1-3

Question 23

STEMI Treatment:

Answer 23

1) Aspirin 324mg
2) Nitro 0.4 mg SL (Max 1.2mg)
3) Pain Management
4) Hypotensive with clear lung sounds - 250ml LR

• If Inferior MI - Obtain V4R (If ST elevation noted withhold Nitro)
  **If Posterior MI - Obtain V7-V9
  LBB/Paced Rhythm with any of the following requires consult:
  1) Cardiogenic Shock
  2) ST Elevation > 5mm
  3) ST segment deviation (elevation or depression) in the same direction as the QRS complex
  ****Consult for Wellness Wave (Biphasic T waves or deeply inverted T waves in V2-V4)
  **Consult for ST elevation in AVR
  ****Consult for Hyperacute T Waves