Section 3: Cardiac Protocols (2024.01 Done)

Question 1

3.01 Acute Decompensated Heart Failure - Pulmonary Edema Recognition/BLS

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.
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* 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 per the Chest Pain-Acute Coronary Syndrome-STEMI Protocol.
* If the patient is hypotensive or has signs of cardiogenic shock or poor perfusion, manage per the age appropriate General Shock and Hypotension Protocol.
* Transport the patient to the nearest appropriate Hospital Emergency Facility, consider ALS intercept if available.

Question 2

3.01 Acute Decompensated Heart Failure - Pulmonary Edema Treatment

Answer 2

• 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 (and SBP is >100), NITROGLYCERIN IV infusion starting at 100 mcg/minute and titrated rapidly downward as symptoms improvement or MAP decreased by 30%. Discontinue infusion if the SBP is <100.
• ENALAPRILAT 1.25 mg IV for patients unresponsive to nitroglycerin with a SBP >140.
• If necessary for CPAP mask compliance administer MIDAZOLAM 1-2 mg IV.
• If the transport time is ≥ 30 minutes and the patient takes oral furosemide and the patient is normotensive (SBP ≥100), consider administering the patient’s daily dose of FUROSEMIDE (maximum 80 mg) IV instead of PO as usually taken.

Question 3

3.01 Acute Decompensated Heart Failure - Pulmonary Edema Notes

Answer 3

• The primary management of ADHF is focused on reducing cardiac afterload, increasing renal perfusion and cardiac output. This is accomplished in the field 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 outcome 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 and further NTG should be held.
• 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, and should avoided in favor of the oral or IV route.
• One dose of SL NTG is briefly equivalent to a 60-80 mcg/minute infusion.

Question 4

3.02 Chest Pain - Acute Coronary Syndrome - STEMI Recognition/BLS

Answer 4

Recognition:
* Patient with a complaint of chest pain/discomfort consistent with a cardiac etiology or other known or suspected anginal equivalent including fatigue, nausea, dyspnea, dizziness (common symptoms in women).
* STEMI: ST elevation in ≥2 contiguous leads of ≥ 2mm in males or ≥ 1.5mm in females in leads V2-V3 and/or of ≥1 mm in other contiguous chest leads or the limb leads.
* Posterior MI: ST depression >1mm in V1-V3 with a dominant R wave (R/S ratio >1) in V2 and upright T waves.
* New onset left bundle branch block (must be evaluated in context).
* Routine patient care.
* ASPIRIN 81 mg x4 orally (chewed), unless allergic or unable to swallow safely.
* For patients prescribed NITROGLYCERIN with a SBP ≥ 100 mmHg, administer 0.3/0.4 mg SL (tabs or lingual spray/powder) of their own medication, may repeat every 5 minutes to a maximum of 3 doses if the SBP remains ≥ 100.
* If equipment resources are available, acquire a multi-lead (≥ 12 lead) ECG and transmit ECG to MEDICAL CONTROL at the nearest PCI capable facility for assistance with interpretation (see Table 2 Point of Entry - Specialized Hospital Emergency Facilities in Routine Patient Care).
* Transport the patient to the nearest appropriate Hospital Emergency Facility.

Question 5

3.02 Chest Pain - Acute Coronary Syndrome - STEMI Treatment

Answer 5

• Acquire a multi-lead (≥ 12 lead) ECG; if the ECG is suggestive of STEMI:
  
  • Limit on scene time to ≤ 10 minutes.
  • Triage patient to the nearest PCI capable facility (see Table 2 Point of Entry Specialized Hospital Emergency Facilities in Routine Patient Care).
  • Consider consulting MEDICAL CONTROL if assistance with ECG interpretation is needed.
  • Provide immediate notification/CODE STEMI to the receiving facility (to expedite registration, provide the patient’s name, DOB and if available, patient ID number).
• If initial ECG is not diagnostic but suspicion for STEMI is high, obtain serial ECGs at 5-10 minutes intervals.
• Consider NITROGLYCERIN 0.4 mg SL (tablet or lingual spray/powder) every 5 minutes, if the SBP is >100 and ECG does not show inferior or posterior STEMI.
• Consider NITROGYLCERIN by IV infusion starting at 5 to 10 μg/minutes and increase while titrating to effect if the SBP is >100 and ECG does not show inferior or posterior STEMI.
• Analgesia as indicated per the age appropriate Patient Comfort Protocol.
• If patient is hypotensive or has signs of cardiogenic shock/poor perfusion, also manage per the age appropriate General Shock and Hypotension Protocol.
• Manage dysrhythmias per the age appropriate Cardiac Dysrhythmia Protocol.

Question 6

3.02 Chest Pain - Acute Coronary Syndrome - STEMI Notes

Answer 6

NOTES:
* Oral agents, other than aspirin, and IV Ketorolac are not indicated for the management of chest pain/discomfort of suspected cardiac etiology.
* Patients without STEMI should be transported to the nearest appropriate Hospital Facility.
* A copy of all acquired multi-lead ECGs must be provided to the receiving facility as part of the prehospital medical record. Additionally, a copy must be maintained as part of the EMS medical record by the licensed ambulance service.
* EMS healthcare professionals should maintain a low threshold for acquiring a multi-lead ECG in geriatric, female or diabetic patients with vague/non-specific or upper GI (nausea, GI distress etc.) complaints such as weakness, dizziness, fatigue, or indigestion. A low threshold also applies to patients with a history of coronary artery disease, HTN, smoking and other cardiac risk factors.
* Reperfusion is time-critical for STEMI patients, with a linear relationship between time to reperfusion and mortality.
* Posterior infarction accompanies 15-20% of STEMIs, usually occurring in the context of an inferior or lateral infarction.
* While not meeting the criteria for STEMI, ST elevation in lead aVR with global ST depression is concerning for a high risk proximal LAD or left main lesion.
* Right ventricular infarction (RVI) complicates up to 40% of inferior wall STEMI. Consider performing a right sided ECG in patients with ECG findings suggestive of inferior wall STEMI.
* The following are suggestive of RVI: STE in V1, STE in lead III > lead II, STE in V4R.
* STE in V4R has a sensitivity of 88%, specificity of 78% and diagnostic accuracy of 83% in the diagnosis of RVI.
* Patients with RVI are very preload sensitive and can develop severe hypotension in response to nitrates or other preload-reducing agents. If hypotension develops following the administration of NTG, stop NTG administration and treat hypotension with an IV fluid bolus. NTG should not be used in patients with RV infarction.
* 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.
* Unless there is a known history of coronary disease, NTG should not be administered to patients < 16 y.o. without consultation of medical control.

Question 7

3.03 Adult Cardiac Arrest - Recognition/BLS

Answer 7

• Routine patient care.
• In situations where adequate bystander cardiopulmonary resuscitation (CPR) [good quality compressions/other care] is ongoing upon EMS arrival, proceed with BLS or ALS assistance as below. If no bystander care is in progress, begin CPR following current AHA ECC Guidelines.
• A defibrillator (AED or manual) should be applied as soon as available and ECG rhythm analysis should immediately follow. If indicated (VF/VT), electrical therapy should be delivered without delay. The initial shock should be delivered at the defibrillator manufacture’s recommended energy dose. Subsequent shocks should be administered as indicated every 2 minutes, interposed between two minute CPR duty cycles.
• Continuous compressions and delivery of electrical therapy should take priority over other care.
• Maintain good quality continuous compressions by switching healthcare professionals every 2 minutes. Rhythm checks should occur at this time and pauses should be limited to ≤ 5 seconds.
• Pre-charge the defibrillator at 1:45 seconds of each duty cycle to minimize pre-shock pauses if electrical therapy is indicated.
• CPR should be resumed immediately following the delivery of electrical therapy without a pulse check.
• If an automated CPR device (load-distributing or piston) is used, the time for application should be minimized.
• Continuous inline waveform capnography may be helpful in determining the quality of chest compressions identifying return of spontaneous circulation (ROSC).
• If the EtCO2 is < 10 mmHg, attempt to improve CPR quality.
• For patients with shockable rhythm (VT/VT), the first 4 cycles of CPR should include passive ventilation with a non-rebreather mask or BVM. Subsequently, avoid over-ventilation; ventilate at a rate of 10 bpm. Advanced airway management should not occur until after the 4th cycle of CPR and should not result in interruption of chest compressions.
• For patients with non-shockable rhythm (no shock advised), initiate airway management and artificial ventilation as soon as possible while providing continuous compressions and prompt epinephrine every 5 minutes to a maximum of 5 doses.
• A blindly inserted airway device (BIAD) [e.g., i-Gel®, King® airway, laryngeal mask airway, etc.) shall be the initial advanced airway of choice in all patients in cardiac
  arrest. The use of continuous waveform capnography confirming advanced airway placement is MANDATORY and must be monitored and documented.
• Regardless of proximity to a receiving facility, absent concern for EMS healthcare professional’s safety, confirmed pregnancy >20 weeks gestation or traumatic
  etiology for cardiac arrest, continue resuscitative efforts for a minimum of 30 minutes prior to moving the patient to the ambulance or transporting the patient. BLS EMS healthcare professionals should request ALS, if available.
• If, after 30 minutes of resuscitation at the scene, the patient has organized electrical activity or a shockable rhythm or an EtCO2 ≥ 20 mmHg or signs of life (purposeful motor movement, eye opening) during CPR, consideration should be given to continuing resuscitative efforts at the scene.
• If return of spontaneous circulation (ROSC) is achieved, manage patient per age appropriate Post Cardiac Arrest Care Protocol.
• Transport the patient to the nearest appropriate Hospital Emergency Facility. Per the Post Cardiac Arrest Care Protocol, patients with STEMI or hemodynamic
  instability (MAP <65 or SBP <90, electrical instability (recurrent VF/VT, bradycardia recurring with TCP or pharmacologic therapy) should be transported to PCI capable facility (see Routine Patient Care Protocol - Table 2 - Point of Entry - Specialized Hospital Emergency Facilities).
• Identify possible treatable etiology of cardiac arrest and manage per appropriate protocol(s) as indicated.

Question 8

3.03 Adult Cardiac Arrest - Treatment

Answer 8

• Orotracheal intubation shall only be performed if the use a BIAD is insufficient to facilitate adequate ventilation. In cardiac arrest, studies indicate that orotracheal intubation offers no appreciable benefit to patient outcome when a BIAD is providing adequate ventilation. Additionally, interruptions in the delivery of chest compressions during attempts at orotracheal intubation may be harmful.
• Consider early IV placement (preferred) in a site above the diaphragm. If attempts at IV access are unsuccessful or not feasible, IO access (if available) may be attempted, preferably using a site above the diaphragm in age-appropriate patients (adolescents [age => 12] and adults).
• For non-shockable rhythms, administer EPINEPHRINE (1 mg/10 ml) 1 mg IV/IO every 5 minutes to a maximum of 5 doses.
• For shockable rhythms, administer EPINEPHRINE (1 mg/10 ml) 1 mg IV/IO every 5 minutes, to a maximum of 3 doses, after three cycles of CPR and electrical therapy ; followed by first dose of AMIODARONE or LIDOCAINE.
• Consider EPINEPHRINE by IV infusion at 0.5 mcg/kg/minutes in place of EPINEPHRINE by IV bolus. For ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT):
  
  • AMIODARONE 300 mg IV, repeat 150 mg for VF/VT refractory to the first dose and at least one defibrillation attempt.
  • As alternative to amiodarone or for VF/VT refractory to amiodarone, LIDOCAINE 100 mg IV, repeat every 10 minutes x2.
• For recurrent VF/VT:
  
  • PROCAINAMIDE 1.5 gm IV infused over 15 minutes.
  • METOPROLOL 5 mg IV over 1 minute (may repeat every 5 minutes x3).
• For refractory VF/VT:
  
  • Change defibrillator pads and apply a 2nd set of pads to a new site.
  • PROCAINAMIDE 1.5 gm IV infused over 15 minutes.
  • METOPROLOL 5 mg IV over 1 minute (may repeat every 5 minutes x3).
  • Consider Double Sequential External Defibrillation Procedure Protocol if resources allow.
• For pulseless electrical activity (PEA) arrest:
  
  • LACTATED RINGER’S or NORMAL SALINE 500-1000 ml IV (may repeat x1).
  • Perform needle thoracostomy for suspected tension pneumothorax.
• For polymorphic ventricular tachycardia (Torsades de Pointes) or suspected hypomagnesemia, MAGNESIUM SULFATE 2 gm IV.
• For patients with CPR induced consciousness, consider KETAMINE 0.5-1 mg/kg IV or MIDAZOLAM 5mg IV (may repeat every 5-10 minutes as required up to 20mg).
• Consider placement of a gastric tube to address gastric distention.

Question 9

3.03 Adult Cardiac Arrest - Notes

Answer 9

• The focus of resuscitative efforts should be centered on high quality and continuous chest compressions (rate, depth, recoil) with limited interruptions. “Hands on chest time” should be maximized. Peri-shock pauses should minimized. CPR should not be interrupted for placement of a BIAD or endotracheal intubation.
• Absent a traumatic etiology, confirmed pregnancy >20 weeks gestation, or concerns for EMS healthcare professional safety, continue resuscitative efforts at the scene of the cardiac arrest for a period of not less than 30 minutes. Unless for environmental conditions, the
  patient should not be moved to the ambulance during this time (a definitive airway is not required as long as oxygen delivery and ventilation are achievable utilizing a bag-valve-mask device).
• Prompt peri-mortem C-section is beneficial to both mother and baby, and therefore prompt transport with high quality CPR is recommended.
• Some evidence suggests that in non-shockable rhythms, epinephrine is most beneficial when administered very early in cardiac arrest, and there is minimal benefit after 5 doses.
• Attention should be paid to the ventilation rate. Do not hyperventilate, ventilation should occur at a rate of 10 bpm, EtCO2 should be used to guide ventilation.
• In one study, pre-shock pauses >20 seconds had a 53% lower chance of survival compared to those with pre-shock pauses less than 10 seconds. For every 5 second increase in shock pause, the chance of survival decreased by 18%.
• Consider possible treatable causes for cardiac arrest. Use relevant protocols in conjunction with this protocol when indicated.
• Naloxone has no utility in cardiac arrest, even if secondary to opioid ingestion/overdose. Naloxone reverses respiratory depression, but during CPR respiration is artificially supported.
• For patients with VF/PVT, antiarrhythmic agents (amiodarone, lidocaine) should be administered after at least one attempt at defibrillation.
• Recurrent VF/VT is defined as VF/VT successfully terminated by conventional electrical therapy, but subsequently returns. It should be treated with conventional electrical therapy and antiarrhythmics.
• Refractory VF/VT is not responsive to conventional electrical therapy. It should be treated with conventional electrical therapy, antiarrhythmics and, if resources allow, DSED. In patients with refractory VF/VT, consider replacing defibrillator pads and changing their location.
• New evidence suggests some uncertainty about the efficacy of the IO route compared with IV. Therefore, it is reasonable for practitioners to first attempt establishing iv access for drug administration in cardiac arrest. Additionally, there is strong evidence that IV or IO access
  above the diaphragm, when possible, is preferable during cardiac arrest.

Question 10

3.03 Pediatric Cardiac Arrest - Recognition/BLS

Answer 10

• Routine patient care.
• In situations where adequate bystander cardiopulmonary resuscitation (CPR) [good quality compressions/other care] is ongoing upon EMS arrival, proceed with BLS or ALS assistance as below. If no bystander care is in progress, begin CPR following current age appropriate AHA ECC Guidelines.
• A defibrillator (AED or manual) should be applied as soon as available and ECG rhythm analysis should immediately follow. If indicated (VF/VT), electrical therapy should be delivered without delay:
• The initial shock should be delivered at 2J/kg.
• The second shock should be delivered at 4J/kg.
• Subsequent shocks should delivered at ≥4J/kg (maximum 10J/kg or adult dose).
• Shocks should be administered as indicated every 2 minutes, interposed between two minute CPR duty cycles.
• Continuous compressions and delivery of electrical therapy, when indicated, should take priority over other care.
• Maintain good quality continuous compressions by switching EMS Healthcare Professionals every 2 minutes. Rhythm checks should occur at this time and pauses should be limited to ≤ 5 seconds.
• Pre-charge the defibrillator at 1:45 sec of each duty cycles to minimize pre-shock pauses if electrical therapy is indicated.
• CPR should be resumed immediately following the delivery of electrical therapy without a pulse check.
• If there is no shock advised, continue quality compressions and begin ventilation / airway management promptly.
• Continuous inline waveform capnography may be helpful in determining the quality of chest compressions identifying return of spontaneous circulation (ROSC). If the EtCO2 is < 10 mmHg, attempt to improve CPR quality.
• Avoid over-ventilation; ventilation should occur at a rate of 12-20 bpm.
• Advanced airway management (placement of a BIAD) should not result in interruption of chest compressions. A blindly inserted airway device (BIAD) [e.g., i-Gel®, King® airway, laryngeal mask airway, etc.] shall be the initial advanced airway of choice in all patients in cardiac arrest. Orotracheal intubation shall only be performed if the use a BIAD is insufficient to facilitate adequate ventilation.
• Regardless of proximity to a receiving facility, absent concern for EMS healthcare professional’s safety or a traumatic etiology for cardiac arrest, resuscitative efforts should continue for a minimum of 30 minutes prior to moving the patient to the ambulance or transporting the patient. BLS healthcare professionals should request ALS, if available.
• Provide the receiving facility with early entry notification.
• Identify possible treatable etiology of cardiac arrest and manage per appropriate
  protocol(s) as indicated.
• If return of spontaneous circulation (ROSC) is achieved, manage patient per age appropriate Post Cardiac Arrest Care Protocol.
• Transport the patient to the nearest appropriate Hospital Emergency Facility.

Question 11

3.03 Pediatric Cardiac Arrest - Treatment

Answer 11

• Orotracheal or nasotracheal intubation shall only be performed if the use a BIAD is insufficient to facilitate adequate ventilation. In cardiac arrest, studies indicate that orotracheal intubation offers no appreciable benefit to patient outcome when a BIAD is providing adequate ventilation. Additionally, interruptions in the delivery of chest compressions during attempts at orotracheal intubation may be harmful.
• Consider early IV placement (preferred) in a site above the diaphragm. If attempts at IV access are unsuccessful or not feasible, IO access (if available) may be attempted, preferably using a site above the diaphragm in age-appropriate patients (adolescents [age => 12]).
• EPINEPHRINE (1:10,000) 0.01 mg (10 mcg/0.1 ml)/kg IV every 3-5 minutes.
• For ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT) unresponsive to initial electrical therapy and one dose of epinephrine:
  
  • AMIODARONE 5 mg/kg IV (may repeat x2).
  • An alternative to amiodarone or for VF/VT refractory to amiodarone, LIDOCAINE 1 mg/kg IV [100 mg maximum] (may repeat x1 inon 10 minutes).
  • For refractory VF/VT, change defibrillator pads and apply 2nd set of pads at a new site.
• For pulseless electrical activity (PEA) arrest:
  
  • Consider LACTATED RINGER’S or NORMAL SALINE 20 ml/kg IV [10 ml/kg for patients ≤ 3 months] (may repeat x1).
  • Perform needle thoracostomy for suspected tension pneumothorax.
• For polymorphic ventricular tachycardia (Torsades de Pointes), consider MAGNESIUM SULFATE 40 mg/kg IV (may repeat every 5 minutes, 2 gm maximum).
• Consider placement of a gastric tube to address gastric distention.

Question 12

3.03 Pediatric Cardiac Arrest - Notes

Answer 12

• Most pediatric cardiac arrests are the result of respiratory arrest. The focus of resuscitative efforts should be centered on high quality and continuous chest compressions (rate, depth, chest recoil) with limited interruptions and early ventilation/ airway management unless a shockable rhythm is noted. “Hands on chest time” should be maximized.
• Peri-shock pauses should minimized.
• CPR should not be interrupted for endotracheal intubation.
• For patients with VF/VT, antiarrhythmic agents (amiodarone, lidocaine) should be administered after at least one attempt at defibrillation and after the first dose of epinephrine.
• The bG should be checked in all critically ill pediatric patients.
• Do not hyperventilate, ventilation should occur at a rate of 12-20. EtCO2 should be used to guide ventilation.
• Consider possible treatable causes for cardiac arrest. Use relevant protocols in conjunction with this protocol when indicated.

Question 13

3.04 Adult Post Cardiac Arrest Care Recognition/BLS

Answer 13

• Routine patient care.
• Identify pulse and continuously palpate for 10 minutes. Absent concern for EMS healthcare professional safety, confirmed pregnancy >20 weeks gestation, or a traumatic etiology for the cardiac arrest, the patient should not be moved during this time.
• Repeat primary assessment including vital signs.
• Continue to address specific differentials associated with original dysrhythmia/ etiology of arrest.
• Provide airway management as indicated per the age appropriate Airway Management Protocol.
• Continue ventilatory support as indicated; do not hyperventilate.
• Decrease and titrate oxygen concentration to maintain SpO2 94-99%.
• Manage hypotension/shock per the age appropriate General Shock and Hypotension Protocol.
• If equipment resources are available, acquire a multi-lead (≥ 12 lead) ECG and transmit ECG to MEDICAL CONTROL for interpretation. Manage as indicated per the Chest Pain-Acute Coronary Syndrome-STEMI Protocol.
• Perform blood glucose analysis; manage per the age appropriate Diabetic Emergencies Protocol as indicated.
• Transport patient to the nearest appropriate Hospital Emergency Facility. Patients with hemodynamic instability (SBP <90 or MAP <65 or requiring vasopressors), electrical instability (recurrent VF/VT, complex ectopy or bradycardia requiring TCP or pharmacologic therapy) or STEMI should be transported to a PCI capable facility.

Question 14

3.04 Adult Post Cardiac Arrest Care Treatment

Answer 14

• Utilize waveform capnography to guide ventilation (maintain normocarbia [EtCO2 35-45 mmHg]).
• Perform multi-lead ECG (≥ 12 lead), manage as indicated per the Chest Pain-Acute Coronary Syndrome-STEMI Protocol.
• Manage cardiac dysrhythmias per the age appropriate Cardiac Dysrhythmia Protocol.
• If either agent was effective, consider maintenance infusions of AMIODARONE at 1 mg/minutes or LIDOCAINE at 2-4 mg/minutes.
• Consider placement of a gastric tube to address gastric distention.
• For patients with an advanced airway in place, consider sedation and analgesia as indicated per age appropriate Patient Comfort Protocol.

Question 15

3.04 Adult Post Cardiac Arrest Care Notes

Answer 15

• During any movement of patient, perform a continuous pulse check and continuous ECG monitoring. DO NOT discontinue ECG monitoring at any time (i.e., transfer from ambulance to, etc.).
• Reassess breath sounds, EtCO2 and ECG rhythm after every patient move.
• Hyperventilation can cause significant hypotension and re-arrest during the post resuscitation phase and therefore should be avoided.
• The initial EtCO2 may be elevated immediately post-resuscitation, but will usually normalize. Do not hyperventilate the patient to achieve a normal EtCO2 (35-45 mmHg).
• Titrate vasopressors as needed to maintain a SBP ≥90 or MAP ≥65. Consider treatable etiologies (pneumothorax, hypovolemia, hyperventilation) for post-resuscitation hypotension.
• Patient with long standing hypertension may require a higher MAP to maintain adequate perfusion.
• Both hypoglycemia and hyperglycemia are deleterious during the post-resuscitation phase. Hypoglycemia should be recognized and treated accordingly and hyperglycemia from indiscriminate glucose administration should be avoided.
• Pre-mix vasopressors in anticipation of hypotension.

Question 16

3.04 Pediatric Post Cardiac Arrest Care Recognition/BLS

Answer 16

• Routine patient care.
• Identify pulse and continuously palpate for 10 minutes. Absent concern for EMS healthcare professional safety, confirmed pregnancy >20 weeks gestation or a traumatic etiology for the cardiac arrest, the patient should not be moved during this time.
• Repeat primary assessment including vital signs.
• Continue to address specific differentials associated with original dysrhythmia/ etiology of arrest.
• Provide airway management as indicated per age appropriate Airway Management Protocol.
• Continue ventilatory support as indicated, do not hyperventilate.
• Decrease and titrate oxygen concentration to maintain SpO2 94-99%.
• Manage hypotension/shock per the age appropriate General Shock and Hypotension Protocol.
• If equipment resources are available, acquire a multi-lead (≥ 12 lead) ECG and transmit ECG to MEDICAL CONTROL for interpretation. Manage as indicated per the Chest Pain-Acute Coronary Syndrome-STEMI Protocol.
• Perform blood glucose analysis, manage per the age appropriate Diabetic Emergencies Protocol as indicated.
• Transport the patient to the nearest appropriate Hospital Emergency Facility. Consider transportation to a Pediatric Specialty Care Facility.

Question 17

3.04 Pediatric Post Cardiac Arrest Care Treatment

Answer 17

• Utilize waveform capnography to guide ventilation (maintain normocarbia [EtCO2 35-45 mmHg]).
• Acquire a multi-lead ECG (≥ 12 lead), manage per the Chest Pain - Acute Coronary Syndrome -STEMI Protocol if indicated.
• Manage cardiac dysrhythmias per the age appropriate Cardiac Dysrhythmia Protocol
• Consider placement of a gastric tube to address gastric distention.
• For patients with an advanced airway in place, consider sedation and analgesia as indicated per the age appropriate Patient Comfort Protocol.

Question 18

3.04 Pediatric Post Cardiac Arrest Care Notes

Answer 18

• During any movement of patient, perform a continuous pulse check and continuous ECG monitoring. DO NOT discontinue ECG monitoring at any time (i.e., transfer from ambulance to ED, etc.).
• Reassess breath sounds, EtCO2 and ECG rhythm after every patient move.
• Hyperventilation can cause significant hypotension and re-arrest during the post resuscitation phase and therefore should be avoided.
• The initial EtCO2 may be elevated immediately post-resuscitation, but will usually normalize. Do not hyperventilate the patient to achieve a normal EtCO2 (35-45 mmHg).
• Titrate vasopressors as needed to maintain a SBP ≥ 90 or MAP ≥65.
• Consider treatable etiologies (pneumothorax, hypovolemia, hyperventilation) for post- resuscitation hypotension.
• Check and document bG and temperature in all critically ill pediatric patients.
• Patient with long standing hypertension may require a higher MAP to maintain adequate perfusion.
• Both hypoglycemia and hyperglycemia are deleterious during the post-resuscitation phase. Hypoglycemia should be recognized and treated accordingly and hyperglycemia from indiscriminate glucose administration should be avoided.

Question 19

3.05 Adult Bradycardia - Cardiac Dysrhythmia Recognition/BLS

Answer 19

Recognition:
* Symptomatic Bradycardia: heart rate < 60 with a pulse and evidence of poor perfusion (hypotension, signs or symptoms of shock, altered mental status, chest pain/discomfort, acute congestive heart failure, or syncope related to bradycardia).
E
* 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.
* Transport the patient to the nearest appropriate Hospital Emergency Facility.

Question 20

3.05 Adult Bradycardia - Cardiac Dysrhythmia Treatment

Answer 20

• ATROPINE SULFATE 0.5-1.0 mg IV, repeat every 3-5 minutes to achieve a heart rate >60 [maximum 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 (maximum 2L).
• Consider DOPAMINE HCL 2-10 mcg/kg/minute IV or EPINEPHRINE 2-10 mcg/minute IV for bradycardia refractory to atropine sulfate and TCP.

Question 21

3.05 Adult Bradycardia - Cardiac Dysrhythmia Notes

Answer 21

• Bradycardia associated with symptoms or hemodynamic instability typically occurs with a 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 suggestive of heart failure (crackles on lung or shortness of breath).

Question 22

3.05 Pediatric Bradycardia - Cardiac Dysrhythmia Recognition/BLS

Answer 22

• Symptomatic Bradycardia: heart rate < 60 with a pulse and evidence of poor perfusion (hypotension, signs or symptoms of shock, altered mental status, chest pain/discomfort,
  congestive heart failure, or syncope related to bradycardia).
  E
• Routine patient care.
• Assess appropriateness of heart rate for clinical situation. For patients without symptoms/hemodynamic instability, monitor and reassess as indicated.
• If HR is < 60 with poor perfusion despite oxygenation and ventilation, initiate external chest compressions and continued ventilation, reevaluate after 2 minutes. If after 2 minutes bradycardia and signs of hemodynamic compromise persist, verify that support is adequate (airway, oxygen source, ventilation). Continue chest compressions and ventilation if bradycardia with poor perfusion persist.
• Continue to ensure adequate oxygenation and ventilation.
• Consider treatable etiologies (hypoxia, beta blocker or calcium channel blocker toxicity, electrolyte imbalance) and exit to appropriate protocol if indicated.
• Transport the patient to the nearest appropriate Hospital Emergency Facility.

Question 23

3.05 Pediatric Bradycardia - Cardiac Dysrhythmia Treatment

Answer 23

• Consider NORMAL SALINE 20 ml/kg IV (may repeat x2).
• EPINEPHRINE (10 mcg/ml) 10 mcg IV every 3-5 minutes.
• For bradycardia believed to be related to increased vagal tone or primary AV conduction block, ATROPINE SULFATE 0.02 mg/kg IV [minimum dose 0.1 mg and maximum single dose 0.5 mg] (may repeat x1). If no IV access is available, consider 0.04-0.06 mg/kg via ETT (may repeat x1).
• If epinephrine or atropine are ineffective, start transcutaneous pacing (TCP). Consider analgesia and sedation per the age appropriate Patient Comfort Protocol.
• Consider DOPAMINE 2-10 mcg/kg/minute for bradycardia refractory to atropine and TCP.

Question 24

3.05 Pediatric Bradycardia - Cardiac Dysrhythmia Notes

Answer 24

• Bradycardia is commonly a pre terminal physiologic response to hypoxia in the pediatric patient. Initial management should focus on restoring adequate oxygenation and ventilation.
• If pulseless arrest develops manage as per Pediatric Cardiac Arrest Protocol.
• 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.
• Heart rates of 50-60 are not uncommon in asymptomatic athletic adolescents
• Significant bradycardia (<40-60) may be seen in patients with eating disorders (marker of severity), in these patients fluid boluses should be avoided.

Question 25

3.06 Adult Narrow Complex Tachycardia - Cardiac Dysrhythmia Recognition/BLS

Answer 25

Recognition: * Symptomatic narrow complex (QRS ≤ 0.12 sec) tachycardia: heart rate of ≥ 150, patient with a pulse and symptoms (weakness, dizziness, diaphoresis, chest pain, dyspnea, palpitations). * Routine patient care. * Transport the patient to nearest appropriate Hospital Emergency Facility.

Question 26

3.06 Adult Narrow Complex Tachycardia - Cardiac Dysrhythmia Treatment

Answer 26

* For minimally symptomatic patients, consider close observation and monitoring. Identify underlying causes for tachycardia (sepsis, anemia, dehydration, etc.). * 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 is unavailable, administer KETAMINE 1-2mg/kg IM. * For stable patients, attempt vagal maneuvers (Valsalva, CSM). * If the rhythm is regular, ADENOSINE 12 mg rapid push IV (may repeat x1). * DILTIAZEM 0.25 mg/kg IV [maximum dose 20 mg], if the SBP ≥ 100 may repeat x1 at 0.35 mg/kg IV [maximum dose 25 mg]. Consider a maintenance infusion at 5-15 mg/hour or METOPROLOL 2.5-5 mg IV over 2-5 minutes, repeat every 5 minutes to maximum of 15 mg to achieve a ventricular rate of 90-100. * For patients with an irregular rhythm/atrial fibrillation, consider administration of AMIODARONE 150 mg IV over 20 minutes instead of calcium channel or beta blocker. * Consider administration of MAGNESIUM 2g IV over 15 minutes. * Consult MEDICAL CONTROL to discuss complex cases.

Question 27

3.06 Adult Narrow Complex Tachycardia - Cardiac Dysrhythmia Notes

Answer 27

* 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, emotional stress, recent exercise, drug use, hypoxia, sepsis). Avoid using medication to slow tachycardia in patients with a treatable underlying cause (sepsis, dehydration, hypoxia, etc.). * Adenosine is not the first line agent for the management of atrial fibrillation, but may be 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) 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 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.

Question 28

3.06 Pediatric Narrow Complex Tachycardia - Cardiac Dysrhythmia Recognition/BLS

Answer 28

* Symptomatic narrow complex (QRS ≤0.12 sec) tachycardia: Age-appropriate elevated heart rate (typically ≥150), patient with a pulse and symptoms (weakness, dizziness, diaphoresis, chest pain, dyspnea, palpitation). E * Routine patient care. * Transport the patient to nearest appropriate Hospital Emergency Facility. * For minimally symptomatic patients, consider close observation and monitoring. * For the stable patient, obtain a multi-lead (≥ 12) ECG and transmit to MEDICAL CONTROL for interpretation.

Question 29

3.06 Pediatric Narrow Complex Tachycardia - Cardiac Dysrhythmia Treatment

Answer 29

* For the unstable/pre-arrest patient, perform SYNCHRONIZED CARDIOVERSION 1 J/kg, may repeat and increase subsequent energy to 2 J/kg. Consider pre-shock sedation with MIDAZOLAM 0.1 mg/kg [2.5 mg maximum] IV/IM/IN (may repeat x1) [do not administer if <5kg] or FENTANYL 2 mcg/kg [75 mcg maximum] IV/IM/IN or if IV access is unavailable, KETAMINE 2 mg/kg IM. * For patients with sinus tachycardia (infants usually HR <220, children HR < 180), consider possible underlying etiologies (fever, pain, volume depletion etc.) and manage per the appropriate protocol(s). * For minimally symptomatic patients, consider close observation and monitoring. * For the stable patient, obtain a multi-lead (≥ 12) ECG (repeat if conversion occurs). * Vagal maneuvers (Valsalva). * ADENOSINE 0.2 mg/kg rapid IV push [maximum 12 mg], may repeat x1. * If adenosine is ineffective, consider AMIODARONE 5 mg/kg (maximum 150 mg) IV over 20 minutes.

Question 30

3.06 Pediatric Narrow Complex Tachycardia - Cardiac Dysrhythmia Notes

Answer 30

* 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). * Consider a fluid bolus (normal saline 20 ml/kg [10 ml/kg in the neonate] IV) in patients with a history suggestive of sepsis or dehydration and no evidence of overt heart failure/pulmonary edema. * If cardioversion is needed and it is impossible to synchronize the defibrillator, deliver an unsynchronized shock (defibrillation). * Obtaining a continuous running ECG strip during conversion will help aid in the diagnosis of the type of tachyarrhythmia. * Utilize pediatric defibrillation/multifunction electrical therapy pads for patients <10 kg. * Vagal maneuvers for infants and small children consist of applying ice or cold water to the face without occluding the airway for a period of 30-60 seconds. For older children, utilize the Valsalva maneuver or have the patient blow through a narrow straw. * Paramedics may perform carotid sinus massage in children ≥8 yo. * Adenosine should be administered via a proximal vein and should be followed by a rapid flush of 5 ml normal saline. * The dose for adenosine should be reduced in patients taking dipyridomole 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 contraindicated in patients with sinus tachycardia, atrial fibrillation or atrial flutter. * The maximum dose of an antiarrhythmic should be given prior to changing to another antiarrhythmic.

Question 31

3.07 Adult Wide Complex Tachycardia - Cardiac Dysrhythmia Recognition/BLS

Answer 31

Recognition: * Tachycardia with a wide complex QRS (≥ 0.12 sec), patient with a pulse. * Routine patient care. * Transport the patient to the nearest appropriate Hospital Emergency Facility.

Question 32

3.07 Adult Wide Complex Tachycardia - Cardiac Dysrhythmia Treatment

Answer 32

* For the unstable/pre-arrest patient, perform SYNCHRONIZED CARDIOVERSION 100-200 J (biphasic) [if the rhythm is wide and irregular, perform unsynchronized cardioversion], repeat as indicated. 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 ≥ or if IV access in unavailable, KETAMINE 2mg/kg IM. * If the rhythm is regular with monomorphic complexes, consider ADENOSINE 12 mg rapid IV push (may repeat x1). * Consider: * AMIODARONE 150 mg IV over 10 minutes (may repeat x1 in 10 minutes). If amiodarone is effective in terminating the arrhythmia, consider a maintenance infusion of 1 mg/minutes or * PROCAINAMIDE 25-50 mg/minutes until the arrhythmia is suppressed, hypotension ensues, QRS duration increased by 50%, or a cumulative dose of 17 mg/kg is administered or * LIDOCAINE 1-1.5 mg/kg IV (may repeat x1 in 5 minutes). If lidocaine is effective in terminating the arrhythmia, consider a maintenance infusion of 2-4 mg/minutes. * For polymorphic ventricular tachycardia / Torsades de Pointes, consider MAGNESIUM SULFATE 1-2 gm IV over 5 minutes.

Question 33

3.07 Adult Wide Complex Tachycardia - Cardiac Dysrhythmia Notes

Answer 33

* 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). * Consider a fluid bolus (NORMAL SALINE 500-1000 ml IV) in patients with a history suggestive of sepsis or dehydration and no evidence of overt heart failure/pulmonary edema. * If cardioversion is needed and it is impossible to synchronize the defibrillator, deliver an unsynchronized shock (defibrillation). * 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. Arrhythmias with suspicion of Wolff-Parkinson-White (WPW) syndrome should be treated with amiodarone. * 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. * Maximum dose of antiarrhythmic should be given prior to changing to another antiarrhythmic. * Theophylline and caffeine (methylxanthines) competitively antagonize adenosine's effects; an increased dose of adenosine may be required. * Adenosine is contraindicated in patients with sinus tachycardia, atrial fibrillation or atrial flutter. * The presence of the following factors increase the likelihood of ventricular tachycardia in the patient with a wide complex tachycardia: age > 35 y.o., history of ischemic heart disease/MI, history of structural heart disease, CHF, cardiomyopathy or a family history of sudden cardiac death. * If the rhythm is regular with monomorphic QRS complexes, consider VT or SVT. * If the rhythm is irregular with monomorphic complexes, consider pre-excitation or atrial fibrillation with aberrancy.

Question 34

3.07 Pediatric Wide Complex Tachycardia - Cardiac Dysrhythmia Recognition/BLS

Answer 34

Recognition: * Tachycardia with a wide complex QRS (≥ 0.09 sec), patient with a pulse. E * Routine patient care. * Transport patient to nearest appropriate Hospital Emergency Facility.

Question 35

3.07 Pediatric Wide Complex Tachycardia - Cardiac Dysrhythmia Treatment

Answer 35

* For the unstable/pre-arrest patient, perform SYNCHRONIZED CARDIOVERSION 1 J/ kg, may repeat and increase subsequent energy to 2 J/kg. Consider pre-shock sedation with MIDAZOLAM 0.1 mg/kg [2.5 mg maximum] IV/IM/IN (may repeat x1) [do not administer if <5kg] or FENTANYL 2 mcg/kg [75 mcg maximum] IV/IM/IN or if IV access is unavailable, KETAMINE 2 mg/kg IM. * For the stable patient, acquire a multi-lead (≥12) ECG (repeat if conversion occurs). * Consider: * AMIODARONE 5 mg/kg (maximum dose 150 mg) IV over 20 minutes (may repeat x1 in 10 minutes) * Initiating transport if refractory to initial therapy. * LIDOCAINE 1 mg/kg IV (may repeat every 10 minutes x2, maximum cumulative dose 3 mg/kg). If effective, consider an infusion at 20-50 mcg/kg/minutes. * For polymorphic ventricular tachycardia / Torsades de Pointes, consider MAGNESIUM SULFATE 50 mg/kg IV (maximum 2 gm) over 20 minutes.

Question 36

3.07 Pediatric Wide Complex Tachycardia - Cardiac Dysrhythmia Notes

Answer 36

* If cardioversion is needed and it is impossible to synchronize the defibrillator, deliver an unsynchronized shock (defibrillation). * Utilize pediatric defibrillation/multifunction electrical therapy pads for patients <10 kg. * For witnessed/monitored VT, try “cough” cardioversion if patient is able to comply. * Maximum dose of antiarrhythmic should be given prior to changing antiarrhythmic. * Place 50 mg/kg magnesium sulfate 50% into 50 ml NS and infuse over 20 minutes.

Question 37

3.08 Patient with a Ventricular Assist Device (VAD) Recognition

Answer 37

* Patient who has a ventricular assist device.

Question 38

3.08 Patient with a Ventricular Assist Device (VAD) Treatment

Answer 38

* Routine patient care. * Determine if you have a patient with a VAD problem or a patient with a VAD that has a medical problem not caused by the VAD. * Assess the patient, keeping in mind the following: * Skin color and mental status are the best indicators of stability in the VAD patient. * A pulse is usually not palpable in the VAD patient. Nearly all VADs are continuous flow devices and there is no rhythmic pumping as there is with a functioning ventricle. If the device is a pulsatile flow device, a pulse should be palpable. * Blood pressure may or may not be obtainable and auscultated readings are usually unreliable. In a continuous flow device, mean arterial blood pressure (MAP) can be obtained by auscultating with a Doppler. The first sound heard during auscultation in a VAD patient reflects the MAP. The MAP displayed by an automated non-invasive measurement may also be used. A normal MAP is 60- 70 mmHg. If the device is a pulsatile flow device, a blood pressure should be measurable. * Data suggest that pulse oximetry readings seem to be accurate, despite the manufacturer stating otherwise. * Quantitative waveform capnography should be accurate and can be reflective of pump function (cardiac output). An EtCO2 of < 30 mmHg can be indicative of low perfusion secondary to poor pump function. * Temperature should be measured as infection and sepsis are common in VAD patients. * Assess the VAD: * Auscultate over the VAD pump location (this should be just to the left of the epigastrium, immediately below the base of the heart). If the pump is functioning, a low hum should be audible. Do not assume that the pump is functioning just because the control unit looks ok. * Palpate the control unit. A hot control unit indicates the pump may be working harder than it should be and often indicates a pump problem such as a thrombosis. * Look at the alarms on the control panel. Trouble with the VAD will usually be identified by an alarm. The patient will usually have a resource guide to direct alarm troubleshooting. * The patient and family members are generally very knowledgeable about the VAD and troubleshooting problems. Inquire about DNR status. Ask if the device is a continuous or pulsatile flow device. Ask if the patient can receive electrical therapy. Ask if chest compressions can be performed in the event of pump failure. * If there is no indication of possible VAD malfunction or failure, exit to appropriate protocols. Only symptomatic dysrhythmias that are not the patient’s baseline should be treated. If indicated, place electrical therapy/defibrillation pads away from VAD site and AICD. Call the VAD coordinator and discuss plan with caregivers. * If the device is a pulsatile flow device and there is no palpable pulse or detectable blood pressure, the EMS healthcare professional should use the device’s hand pump to maintain perfusion (family members should be familiar with this). * If there is indication of possible device malfunction or failure, contact the VAD coordinator. Discuss the plan with caregivers. * In the event the patient is unresponsive, has no signs of life, and has a non-functioning pump, deciding when to initiate chest compressions is very difficult. Chest compressions may cause death by exsanguination if the device becomes dislodged. However, if the pump has stopped, the native heart will not be able to maintain perfusion and the patient will likely die. If a VAD patient is unresponsive with no signs of life, has a non-functioning VAD and has previously indicated a desire for resuscitative efforts, begin chest compressions and resuscitative efforts. Ensure that all troubleshooting efforts (reconnecting wires, changing batteries, replacing the control unit) have failed prior to starting chest compressions. Contact the VAD Coordinator and MEDICAL CONTROL. * When transporting a VAD patient: * Patients without a VAD problem should be transported to the nearest appropriate Hospital Emergency Facility for their condition. * Patients with a VAD problem should be transported to their VAD hospital when possible. EMS healthcare professionals can utilize available resources (private service, etc.) to facilitate transportation to the patient’s VAD hospital. * Always bring the patient’s resource bag with you. It should contain spare batteries, +/- a spare control unit, contact information for the VAD coordinator, and directions for equipment and alarm troubleshooting. * Always bring spare batteries for the VAD with the patient, even if it is not a VAD related problem. Fresh batteries last 3-5 hours. * If the transport is going to be prolonged or it is expected that the patient will be away for a while, try to bring the VAD base power unit with you. Alternately, you can ask the patient’s family/caregiver to bring it to the hospital. There may be times when you may need to bring it in the ambulance with the patient and plug it into an inverter to utilize it.

Question 39

3.08 Patient with a Ventricular Assist Device (VAD) Notes

Answer 39

* Utilize the patient and family as a resource. * Always contact the VAD coordinator if there is a VAD related problem or question. * Common complications in VAD patients include CVA and TIA (incidence up to 25%), bleeding, dysrhythmias, and infection. * The most common causes of death in VAD patients are sepsis and CVA. Keep these in mind when evaluating a VAD patient with altered mental status. * VAD patients are preload dependent. Consider that a fluid bolus can often reverse hypoperfusion.