Section 3: Cardiac Protocols

Question 1

3.01 Acute Decom Heart Failure - Pul Edema - Recognition (4/21/23)

Answer 1

Recognition:
* Respiratory distress, dyspnea on exertion, orthopnea, bilateral crackles on lung auscultation, jugular venous distention, peripheral edema, diaphoresis, hypotension, shock, chest pain or discomfort.

Question 2

3.01 Acute Decom Heart Failure - Pul Edema - Procedure (4/21/23)

Answer 2

• Routine patient care.
• Place patient in upright position as tolerated and as BP allows.
• For patients with respiratory distress, crackles on lung auscultation, or SpO2 less than 92%, if the SBP ≥ 90, provide continuous positive airway pressure (CPAP) up to 10 cmH20 as tolerated by the patient.
• ASPIRIN 81 mg x4 orally (chewed), unless allergic or unable to swallow safely.
• If the patient has chest pain or discomfort manage.
• If the patient is hypotensive or has signs of cardiogenic shock or poor perfusion,
  manage per the age appropriate General Shock and Hypotension Protocol.
• NITROGLYCERIN 0.4 mg SL (tablet or lingual spray/powder) every 5 minutes if the SBP is >100.
• If the patient is hypertensive or in severe distress, NITROGLYCERIN IV infusion starting at 100 mcg/min and titrated rapidly to symptom improvement or hemodynamics (30% reduction in MAP). Discontinue infusion if the SBP is <100.
• ENALAPRILAT 1.25 mg IV for the patient unresponsive to nitroglycerin with a SBP >140.
• MIDAZOLAM 1-2 mg IV if needed to enhance CPAP compliance.
• If the transport time is ≥ 30 minutes and the patient takes oral furosemide and the patient is normotensive (SBP ≥100), consider administering the patients daily
  dose of FUROSEMIDE (max 80 mg) IV.

Question 3

3.01 Acute Decom Heart Failure - Pul Edema - PEARLS (4/22/23)

Answer 3

PEARLS:
* The primary management of ADHF is focused on reducing cardiac afterload, increasing renal perfusion and cardiac output. This is accomplished in the filed with the early application of CPAP and the administration of vasodilators (NTG, ACEI).
* Diuretics (furosemide) and opioids (morphine sulfate) have not been shown to improve outcomes in the EMS management of patients with pulmonary edema. Furosemide should be considered a 2nd tier intervention and reserved for extenuating circumstances where transportation may be delayed.
* NTG should not be administered to patients who have used sildenafil (Viagra, Revatio) or vardenafil (Levitra) in the past 24 hours or tadalafil (Cialis, Adcirca) in the past 36 hours. Revatio is prescribed for pulmonary hypertension.
* Consider acute coronary syndrome in all patients with ADHF/pulmonary edema. Manage per the Chest Pain - Acute Coronary Syndrome - STEMI Protocol as indicated.
* If ADHF/PE is resulting from inferior wall ischemia/infarction, consider obtaining a right sided ECG to identify right ventricular (RV) infarction. NTG should be used cautiously, if at all in patients with RV infarction. If hypotension develops following the administration of NTG, the administration of an IV fluid bolus may be necessary.
* The administration of benzodiazepines to patients requiring CPAP may result in further respiratory depression, particularly in those with a history of recent drug or alcohol ingestion. All efforts at verbal coaching should be utilized to enhance CPAP compliance prior administering benzodiazepines.
* Transdermal administration of NTG (Nitropaste) has a slow onset of action and erratic absorption.
* One dose of SL NTG is equivalent to 60-80 mcg/minute.

Question 4

3.05 Adult Bradycardia - Recognition (5/9/23)

Answer 4

Recognition:
* Heart rate < 60 with a pulse and evidence of poor perfusion (hypotension, signs or symp- toms of shock, altered mental status, chest pain/discomfort, acute congestive heart failure, or syncope related to bradycardia).

Question 5

3.05 Adult Bradycardia - Procedure (5/9/23)

Answer 5

• Routine patient care.
• Assess appropriateness of heart rate for clinical situation.
• For patients without symptoms/hemodynamic instability, monitor and reassess as indicated.
• Consider treatable etiologies (hypoxia, beta blocker or calcium channel blocker
  toxicity, electrolyte imbalance) and exit to appropriate protocol if indicated.
• ATROPINE SULFATE 0.5-1.0 mg IV, repeat every 3-5 min to achieve a heart rate >60 [max dose 3 mg] or
• Transcutaneous pacing (TCP). Consider analgesia and sedation per the age appropriate Patient Comfort Protocol.
• Consider NORMAL SALINE 250-500 ml IV, repeat as needed (max 2L).
• Consider DOPAMINE HCL 2-10 mcg/kg/min IV or EPINEPHRINE 2-10 mcg/min IV for bradycardia refractory to atropine sulfate and TCP.

Question 6

3.05 Adult Bradycardia - PEARLS (5/9/23)

Answer 6

PEARLS:
* Bradycardia associated with symptoms or hemodynamic instability typically occurs with a heart rates <50. Asymptomatic or minimally symptomatic patients do not necessarily require treatment.
* Atropine sulfate should be used cautiously in the setting of myocardial ischemia/infarction as increased heart rate may worsen ischemia or infarction size.
* Atropine sulfate may be ineffective for treating bradycardia related to atrioventricular block (AVB) occurring below the AV node (type II second-degree block or third-degree [complete] block with wide QRS complex). Immediate TCP may be warranted in these patients. Atropine sulfate is also ineffective in patients who are status post cardiac transplant.
* IV fluids should be considered based on the patient’s volume status. Do not administer IV fluids to patients with clinical evidence suggesting heart failure (crackles on lung exam, shortness of breath).

Question 7

3.06 Adult Narrow Complex Tachycardia - Recognition (5/13/23)

Answer 7

Recognition:
* Narrow complex (QRS ≤ 0.12 sec) tachycardia with a rate of ≥ 150, patient with a pulse.

Question 8

3.06 Adult Narrow Complex Tachycardia - Procedure (5/13/23)

Answer 8

• Routine patient care.
• For minimally symptomatic patients, consider close observation and monitoring.
• For the unstable/pre-arrest patient, perform synchronized CARDIOVERSION 100- 200 J (biphasic) repeat as needed. Consider pre-shock sedation with MIDAZOLAM 2.5-5 mg IV [5 mg IM/IN] or DIAZEPAM 2.5-5 mg IV/IM if the SBP ≥100 or if IV
  access in unavailable, KETAMINE 2mg/kg IM.
• Vagal maneuvers (Valsalva, CSM).
• If the rhythm is regular, ADENOSINE 12 mg rapid push IV (may repeat x1).
• DILTIAZEM 0.25 mg/kg IV [max dose 20 mg], if the SBP ≥ 100 may repeat x1 at 0.35
  mg/kg IV [max dose 25 mg]. Consider a maintenance infusion at 5-15 mg/hour or METOPROLOL 2.5-5 mg IV over 2-5 min, repeat every 5 min to max of 15 mg to achieve a ventricular rate of 90-100.

Question 9

3.06 Adult Narrow Complex Tachycardia - PEARLS (5/13/23)

Answer 9

PEARLS:
* For patients with sinus tachycardia (HR ≥ 100 to 220 minus the patient’s age), search for and treat the underlying cause (anxiety, fever, pain, dehydration, hypoxia, sepsis).
* Adenosine is not the first line agent for the management of atrial fibrillation, but may considered if the patient has a history of conversion with adenosine or to aid rhythm identification.
* Consider a fluid bolus (NORMAL SALINE 500-1000 ml IV/IO) in patients with a history suggestive of dehydration and no evidence of overt heart failure/pulmonary edema.
* Consider CALCIUM CHLORIDE 1 gm SLOW IV/IO prior to administering DILTIAZEM if the BP is tenuous BP (SBP ~100)
* First line agents for rate control in irregular tachycardias (atrial fibrillation) are calcium channel blockers. As per protocol, Adenosine may be considered to assist with diagnosis or if patient has history of Adenosine conversion, but Adenosine is NOT mandated.
* CSM is contraindicated in patients with a history of TIA/stroke, known carotid atherosclerotic disease, or the presence of a carotid bruit.
* If cardioversion is needed and it is impossible to synchronize the defibrillator, deliver an unsynchronized shock (defibrillation).
* The combined use of IV nodal blocking agents (metoprolol, diltiazem) should be used requires caution and should be avoided whenever possible
* Calcium channel blockers (diltiazem, verapamil) are contraindicated in patients with a known diagnosis of or with ECGs findings consistent with Wolff-Parkinson-White (WPW) syndrome, Lown-Ganong-Levine (LGL) or other pre-excitation syndromes.
* Arrhythmias with suspicion of Wolff-Parkinson-White (WPW) syndrome should be treated with amiodarone following the dosing regimen in the wide complex tachycardia protocol.
* Adenosine administration should be followed by a 10 ml flush of NS.
* The initial dose for adenosine should be reduced to 6 mg and the repeat dose should be reduced to 12 mg in patients taking dipyridamole and those that are status post cardiac
transplant.
* Theophylline and caffeine (methylxanthines) competitively antagonize adenosine’s
effects; an increased dose of adenosine may be required.
* Adenosine is not indicated in patients with sinus tachycardia, atrial fibrillation or atrial flutter.
* Maximum dose of antiarrhythmic should be given prior to changing to another antiarrhythmic.
* The combined use of IV beta blockers and calcium channel blockers should be avoided.