Cardiac Emergencies

  • Chest Pain
  • STEMI
  • Bradycardia - Adult
  • Bradycardia - Pediatric
  • Narrow Complex Tachycardia
    Adult
  • Narrow Complex Tachycardia
    Pediatric
  • Wide Complex Tachycardia
    Adult
  • Wide Complex Tachycardia
    Pediatric
  • Cardiogenic Shock
  • Non-Cardiogenic Shock
    Adult
  • Non-Cardiogenic Shock
    Pediatric
  • Cardiac Arrest
  • Pediatric Cardiac Arrest
  • Pit Crew CPR
  • Pediatric Pit Crew CPR
  • Cardiac Arrest VF/VT
    Adult
  • Cardiac Arrest VF/VT
    Pediatric
  • Cardiac Arrest PEA/Asystole
    Adult
  • Cardiac Arrest PEA/Asystole
    Pediatric
  • Post Cardiac Arrest Care - Adult
  • Post Cardiac Arrest Care - Pediatric
  • Left Ventricular Assist Device

Chest Pain

All patients complaining of chest pain should be treated as having a myocardial infarction, unless other signs indicate pain is obviously from another origin.

 

The combination of nitroglycerin and Viagra®, Revatio® (sildenafil), Levitra® (vardenafil), or Cialis® (tadalafil) have been found to cause precipitous and irreversible hypotension.

 

Ask every chest pain patient whether or not he/she has been on Viagra, etc. and, if so, when was the last dose? Document this on every run sheet involving the cardiac chest pain patient (even those who deny using Viagra or similar medications).

DO NOT automatically administer nitroglycerin to any patient who has had Viagra, etc. within the past week. Consult with the receiving physician for appropriateness.

 

BLS

 

  1. Administer oxygen if necessary. (See Oxygen Administration Protocol)
  2.  

  3. If pain is suspected to be cardiac in origin and if no significant allergy to aspirin exists, administer 324 mg aspirin PO and have the patient chew them if not already taken within the previous 12 hours.
  4.  

  5. Request ALS if not already en route. If the BLS crew is able to deliver the patient to an emergency room within the same time it would take for the ALS crew to respond to the scene, the BLS crew should transport the patient.
  6.  

  7. If systolic BP is at or above 90 mm Hg and the patient has their own nitroglycerin prescription, assist the patient with taking one dose of his/her nitroglycerin. Nitroglycerin may be administered up to 3 times (every 3-5 minutes) as long as pain is not completely resolved and systolic BP remains above 90 mm Hg.
  8.  

  9. Contact receiving facility for further consultation if ALS is not on the scene. Initiate transport.

 

ALS

 

  1. Administer ASA 324 mg PO if not already taken within the previous 12 hours.
  2.  

  3. Apply the cardiac monitor. If dysrhythmias are present, refer to the appropriate protocol. Obtain a 12-lead EKG as soon as possible, and with any significant change in patient condition.
  4.  

    1. Time permitting, obtain a repeat the 12-lead EKG en route and present both with patient.
    2.  

    3. If the patient’s 12-lead EKG demonstrates an acute inferior STEMI, consider obtaining another 12-lead with V4R but do not delay transport to obtain.
    4.  

    5. If ST segment depressions in V1-V3 with no confirmed STEMI, consider posterior ECG

     

  5. If systolic BP is at or above 90 mm Hg, administer a 0.4 mg dose of nitroglycerin sublingually. Nitroglycerin may be administered every 3 – 5 minutes as long as pain is not completely resolved and systolic BP remains at or above 90.
  6.  

  7. Initiate an IV
  8.  

  9. Scene time should be kept to a minimum, as this is a time-critical condition. Contact the intended receiving facility and alert them of a potential myocardial infarction (Medical Alert).

STEMI

Patients with a STEMI or patients with chest pain thought to be due to myocardial ischemia and a left bundle branch block (LBBB) will be transported to a receiving facility with a cardiac catheterization laboratory (cath lab) available.

 

 

  1. Call the intended receiving facility as early as possible to activate the cath lab process. Inform the receiving facility that you are bringing in a “STEMI Alert”
  2.  

    1. Patients who are hemodynamically stable will be transported to an appropriate hospital of their choice.
    2.  

    3. Patients who are hypotensive (systolic BP < 90 mm Hg) despite fluids or who have persistent life-threatening dysrhythmias will be transported to the closest hospital with cath lab availability.
    4.  

    5. Current cath lab availability will be displayed on the IndyTrac system.

 

The combination of nitroglycerin and Viagra®, Revatio® (sildenafil), Levitra® (vardenafil), or Cialis® (tadalafil) have been found to cause precipitous and irreversible hypotension.
 

    Ask every chest pain patient whether or not he/she has been on Viagra, etc. and, if so, when was the last dose? Document this on every run sheet involving the cardiac chest pain patient (even those who deny using Viagra or similar medications).

     

    DO NOT automatically administer nitroglycerin to any patient who has had Viagra, etc. within the past week. Consult with the receiving physician for appropriateness.

     

 

12 Lead Cheat Sheet

I (Lateral)

aVR

V1 (Septal)

V4 (Anterior)

II (Inferior)

aVL (Lateral)

V2 (Septal)

V5 (Lateral)

III (Inferior)

aVF (Inferior)

V3 (Anterior)

V6 (Lateral)

Adult
Bradycardia

BLS

 

BRADYCARDIA CRITERIA: Heart rate < 60/minute for children (1-15) and adults; < 80/minute in infants. Bradycardia with hemodynamic compromise is an ominous sign of impending cardiac arrest in infants and children.

 

SYMPTOMATIC CRITERIA: Bradycardia with signs of poor perfusion and altered mentation, chest pain or dyspnea with associated hypotension.

 

  1. Begin Initial Medical Care.
  2.  

  3. Follow Airway Management protocol.
  4.  

  5. Follow Oxygen Administration protocol.
  6.  

  7. If patient is symptomatic, call for ALS unit. If the BLS crew is able to deliver the patient to an emergency room within the same time it would take the ALS crew to respond to the scene, the BLS crew should emergently transport the patient.

 

ALS

 

  1. Apply cardiac monitor and obtain 12-lead EKG
  2.  

  3. If patient is symptomatic, establish a saline lock or IV with 0.9% NaCl. If an IV cannot be established and an urgent need for vascular access exists, establish IO access.
  4.  

  5. If patient remains symptomatic, perform the following in a step-wise fashion. Reassess after each step and proceed to the next step if there is no improvement.
  6.  

  7. Administer atropine 0.5 mg every 3-5 minutes until pulse rate is greater than 60 beats per minutes or a total dose of 3 mg is given.
  8.  

    1. Atropine administration should not delay pacing in peri-arrest situations.

    2. Second Degree Type II and wide complex Third Degree blocks should prompt aggressive use of external pacing.

     

  9. Implement pacing procedures:
  10.  

    1. Set rate at 70 bpm
    2.  

    3. Start mA at 10 and gradually increase until the point of electrical capture
    4.  

    5. Verify mechanical capture by feeling for a femoral or radial pulse. Muscle contractures initiated by the pacemaker make a carotid pulse unreliable while externally pacing.
    6.  

    7. If sedation or analgesia is indicated during the pacing procedure, Versed 2.5mg SIVP may be administered. Repeat x 1 as necessary to maintain an adequate level of sedation. Use capnography if given.

Pediatric
Bradycardia

BLS

 

BRADYCARDIA CRITERIA: Heart rate < 60/minute for children (1-15) and adults; < 80/minute in infants. Bradycardia with hemodynamic compromise is an ominous sign of impending cardiac arrest in infants and children.

 

SYMPTOMATIC CRITERIA: Bradycardia with signs of poor perfusion and altered mentation, chest pain or dyspnea with associated hypotension.

 

  1. Begin Initial Medical Care.
  2.  

  3. Follow Airway Management protocol.
  4.  

  5. Follow Oxygen Administration protocol.
  6.  

  7. If patient is symptomatic, call for ALS unit. If the BLS crew is able to deliver the patient to an emergency room within the same time it would take the ALS crew to respond to the scene, the BLS crew should emergently transport the patient.

 

ALS

 

  1. Perform CPR if clinically indicated
  2.  

  3. Intubate only if BVM ventilations/oxygenation is inadequate
  4.  

  5. Administer epinephrine 0.01 mg/kg (1:10,000, 0.1 mL/kg) IV or IO every 3-5 minutes.
  6.  

  7. For increased vagal tone or primary AV block administer atropine 0.02 mg/kg (min. dose 0.1 mg, max single dose 0.5 mg) IV or IO; may repeat one time 3-5 minutes after initial dose.
  8.  

  9. Continue searching for possible reversible causes of hypoxia

Adult
Narrow Complex Tachycardia QRS < 0.12 sec

BLS

 

  1. Begin Initial Medical Care.
  2.  

  3. Follow Airway Management protocol.
  4.  

  5. Follow Oxygen Administration protocol.
  6.  

  7. If patient is symptomatic, call for ALS

 

ALS

 

  1. Apply cardiac monitor and obtain 12-lead EKG
  2.  

  3. If patient is symptomatic, establish a saline lock or IV with 0.9% NaCl. If an IV cannot be established and an urgent need for vascular access exists, establish IO access.
  4.  

  5. If the patient has no signs or symptoms of pulmonary edema, administer 250 mL bolus of 0.9% NaCl solution. Repeat 250 mL boluses every 5 minutes as long as SBP remains below 90 mmHg and no signs of pulmonary edema exist. (For peds, 20 mL/kg boluses)
  6.  

  7. If patient remains symptomatic, perform the following in a step-wise fashion. Reassess after each step and proceed to the next step if there is no improvement.
  8.  

  9. For pediatric patients, refer to Pediatric Emergency weight/length-based tape
  10.  

    Urgent:
    angina chest pain, hypotenstion, and/or pulmonary edema

     

    1. Have patient perform Valsalva maneuver using the REVERT method.
    2.  

        Have patient blow into 10ml syringe to slowly move the plunger (~15 seconds); then quickly position patient supine with legs lifted >45 degrees

       

    3. If rhythm has not converted to a sinus rhythm, and in your judgment the rhythm is believed to be SVT, administer:
    4.  

      1. Adenosine, 12 mg RIVP, followed with 10 mL fluid flush
      2.  

        1. Observe and anticipate AV block(s) and/or transient asystole

         

      3. If, after 1-2 minutes, the rhythm does not convert, or no AV block/transient asystole has occurred, repeat adenosine at 12 mg RIVP, followed with 10 mL fluid flush

       

    5. If unable to rapidly establish IV access, or if no response to adenosine, or a rhythm other than SVT is observed, transport.

     

    Emergent:
    Unconscious, SBP < 90 mmHg or no obtainable BP

     

    Perform synchronous cardioversion in an escalating fashion at dosages recommended by the manufacturer.

     

    If still conscious, consider 2.5 mg IV midazolam before cardioversion. Use capnography if given.

     

    Narrow Tachycardia
    50J → 100J → 150J → 200J

     

    Atrial Fibrillation
    120J →150J → 200J

Pediatric
Narrow Complex Tachycardia QRS < 0.12 sec

BLS

 

  1. Begin Initial Medical Care.
  2.  

  3. Follow Airway Management protocol.
  4.  

  5. Follow Oxygen Administration protocol.
  6.  

  7. If patient is symptomatic, call for ALS

 

ALS

 

  1. Apply cardiac monitor and obtain 12-lead EKG
  2.  

  3. If patient is symptomatic, establish a saline lock or IV with 0.9% NaCl. If an IV cannot be established and an urgent need for vascular access exists, establish IO access.
  4.  

  5. If the patient has no signs or symptoms of pulmonary edema, administer 20 mL/kg bolus of 0.9% NaCl solution. Repeat 20 mL/kg boluses every 5 minutes as long as SBP remains below 90 mmHg and no signs of pulmonary edema exist.
  6.  

  7. If patient remains symptomatic, perform the following in a step-wise fashion. Reassess after each step and proceed to the next step if there is no improvement.
  8.  

  9. For pediatric patients, refer to Pediatric Emergency weight/length-based tape
  10.  

    Urgent:
    Infants - rate usually > 220/min
    Children - rate usually > 180/min

     

    1. Have patient perform Valsalva maneuver using the REVERT method.
    2.  

        Have patient blow into 10ml syringe to slowly move the plunger (~15 seconds); then quickly position patient supine with legs lifted >45 degrees

       

    3. If rhythm has not converted to a sinus rhythm, and in your judgment the rhythm is believed to be SVT, administer:
    4.  

      1. Adenosine 0.1 mg/kg (max 6 mg) RIVP, followed with 10 mL fluid flush.
      2.  

      3. Second dose of adenosine, 0.2 mg/kg (max 12 mg) RIVP, followed by 10 mL fluid flush.

     

    Emergent:
    Hypotension, acutely altered mentation, signs of shock

     

    Perform synchronous cardioversion in an escalating fashion. Start at 0.5-1 Joules/kg then 2 J/kg

    If still conscious, consider 0.1mg/kg (max 2.5 mg) IV midazolam or 0.2mg/kg IN (max 2.5mg) before cardioversion. Use capnography if given

Adult
Wide Complex Tachycardia QRS > 0.12 sec

BLS

 

  1. Begin Initial Medical Care.
  2.  

  3. Follow Airway Management protocol.
  4.  

  5. Follow Oxygen Administration protocol.
  6.  

  7. If patient is symptomatic, call for ALS

 

ALS

 

  1. Apply cardiac monitor and obtain 12-lead EKG
  2.  

  3. If patient is symptomatic, establish a saline lock or IV with 0.9% NaCl. If an IV cannot be established and an urgent need for vascular access exists, establish IO access.
  4.  

  5. If the patient has no signs or symptoms of pulmonary edema, administer 250 mL bolus of 0.9% NaCl solution. Repeat 250 mL boluses every 5 minutes as long as SBP remains below 90 mmHg and no signs of pulmonary edema exist. (For peds, 20 mL/kg boluses)
  6.  

  7. If patient remains symptomatic, perform the following in a step-wise fashion. Reassess after each step and proceed to the next step if there is no improvement.
  8.  

  9. For pediatric patients, refer to Pediatric Emergency weight/length-based tape
  10.  

    Asymptomatic

     

    1. Establish IV access and monitor patient for changes.

     

    Mild Symptoms
    Chest pain or dyspnea

     

    1. If regular/monomorphic administer adenosine 12 mg RIVP; immediately follow with 10 mL fluid flush.
    2.  

    3. If irregular or VT does not resolve, administer amiodarone 150 mg IV over 10 minutes
    4.  

    5. Do not delay emergent transport
    6.  

    7. If VT does not resolve, an additional 150 mg amiodarone may be administered over 10 minutes
    8.  

    9. If VT persists, contact medical control regarding additional doses of amiodarone

     

    Serious Symptoms
    pulmonary edema, SBP<90, or unconscious with pulse

     

    1. Perform synchronous cardioversion in an escalating fashion at dosages recommended by the manufacturer.
      If still conscious, consider 2.5 mg IV midazolam before cardioversion Use capnography if given.
    2.  

      100J → 150J → 200J

       

    3. Administer amiodarone 150 mg IV over 10 minutes
    4.  

    5. If VT persists, cardiovert with maximum electrical output
    6.  

    7. If VT recurs, administer additional amiodarone 150 mg IV over 10 minutes and cardiovert at the energy level that was previously successful
    8.  

    9. If VT persists, contact medical control regarding additional doses of amiodarone

     

    Unconscious without Pulses

     

    Treat as Cardiac Arrest, VF/VT

Pediatric
Wide Complex Tachycardia QRS > 0.12 sec

BLS

 

  1. Begin Initial Medical Care.
  2.  

  3. Follow Airway Management protocol.
  4.  

  5. Follow Oxygen Administration protocol.
  6.  

  7. If patient is symptomatic, call for ALS

 

ALS

 

  1. Apply cardiac monitor and obtain 12-lead EKG
  2.  

  3. If patient is symptomatic, establish a saline lock or IV with 0.9% NaCl. If an IV cannot be established and an urgent need for vascular access exists, establish IO access.
  4.  

  5. If the patient has no signs or symptoms of pulmonary edema, administer 250 mL bolus of 0.9% NaCl solution. Repeat 250 mL boluses every 5 minutes as long as SBP remains below 90 mmHg and no signs of pulmonary edema exist. (For peds, 20 mL/kg boluses)
  6.  

  7. If patient remains symptomatic, perform the following in a step-wise fashion. Reassess after each step and proceed to the next step if there is no improvement.
  8.  

  9. For pediatric patients, refer to Pediatric Emergency weight/length-based tape
  10.  

    Asymptomatic

     

    1. Establish IV access and contact medical control for further instructions

     

    Mild Symptoms
    Chest pain or dyspnea

     

    1. Contact medical control for further instructions

     

    Serious Symptoms
    Hypotension, acutely altered mentation, signs of shock

     

    1. Perform synchronous cardioversion beginning with 0.5-1 j/kg; if not effective, increase to 2 j/kg
      If still conscious, consider 0.1mg/kg (max 2.5 mg) IV midazolam or 0.2mg/kg IN (max 2.5mg) before cardioversion. Use capnography if given.
    2.  

    3. Contact medical control for further instructions
    4.  

    Unconscious without Pulses

     

    Treat as Cardiac Arrest, VF/VT

Cardiogenic Shock

Criteria: Symptomatic hypotension due to a suspected cardiac event with heart rate between 60-150 per minute.

 

BLS

 

  1. Begin Initial Medical Care.
  2.  

  3. Follow Airway Management protocol.
  4.  

  5. Follow Oxygen Administration protocol.
  6.  

  7. Request ALS if not already en route. If the BLS crew is able to deliver the patient to an emergency room within the same time it would take for the ALS crew to respond to the scene, the BLS crew should transport the patient.

 

ALS

 

  1. Apply cardiac monitor and obtain 12-lead EKG; if dysrhythmias are present, treat according to the appropriate protocol. If STEMI is suspected, notify the intended receiving facility
  2.  

  3. Establish an IV with 0.9% NaCl. If an IV cannot be established and an urgent need for vascular access exists, establish IO access.
  4.  

  5. If the patient has no signs or symptoms of pulmonary edema, administer 500 mL bolus of 0.9% NaCl solution (20ml/Kg in pediatrics).
  6.  

  7. Contact medical control at the intended receiving facility to discuss additional fluid boluses and/or a levophed infusion (typically beginning at 2-4 mcg/min and titrated to a systolic BP of 90 mm Hg. Max infusion 12 mcg/min).  Consider epinephrine drip starting at 5mcg/min as an alternative agent if norepinephrine infusion unavailable.

Adult
Non-Cardiogenic Shock

BLS

 

  1. Begin Initial Medical Care.
  2.  

  3. Follow Airway Management protocol.
  4.  

  5. Follow Oxygen Administration protocol.
  6.  

  7. Request ALS if not already en route. If the BLS crew is able to deliver the patient to an emergency room within the same time it would take for the ALS crew to respond to the scene, the BLS crew should transport the patient.
  8.  

  9. If evidence of trauma or hemorrhage present see Initial Trauma Care Protocol
  10.  

  11. Consider other causes of shock

 

ALS

 

  1. Apply cardiac monitor
  2.  

  3. Initiate two large bore IVs (or IO, if IV access in not available) of NaCl and titrate to a systolic BP of 90 mm Hg if patient has no signs or symptoms of fluid overload
  4.  

  5. Reassess vital signs and peripheral perfusion; reassess for signs of pulmonary edema.

Pediatric
Non-Cardiogenic Shock

BLS

 

  1. Begin Initial Medical Care.
  2.  

  3. Follow Airway Management protocol.
  4.  

  5. Follow Oxygen Administration protocol.
  6.  

  7. Request ALS if not already en route. If the BLS crew is able to deliver the patient to an emergency room within the same time it would take for the ALS crew to respond to the scene, the BLS crew should transport the patient.
  8.  

  9. If evidence of trauma or hemorrhage present see Initial Trauma Care Protocol
  10.  

  11. Consider other causes of shock

 

ALS

 

  1. Administer 20 mL/kg IV or IO NaCl solution as rapidly as possible.
  2.  

  3. Reassess vital signs and peripheral perfusion; reassess for signs of pulmonary edema.
  4.  

  5. If no improvement in vital signs, peripheral perfusion, and no indication of pulmonary edema is present, repeat NaCl bolus of 20 mL/kg
  6.  

  7. In cases of hypotension involving infants, perform glucose analysis. If blood glucose suggest hypoglycemia administer 4 mL/kg D25
    If hypoglycemic, see hypoglycemia in ALOC protocol.

Cardiac Arrest
General Care

For EMS witnessed cardiac arrest, quick defibrillation is key – do not delay defibrillation!

 

Pediatric/Infant/Neonate:
Oxygenation and ventilation is of utmost importance in cardiac arrest care! Use the Broselow® tape (or appropriate equivalent) to assess and determine correct dosing regimen. Note that pediatric patients ALWAYS requires respiratory support with BVM during cardiac arrest.

 

High Performance CPR – KEEP HANDS ON THE CHEST!

Avoid interruptions to chest compressions.
Ensure full chest recoil
During charging of manual defibrillator, provide chest compressions.
Do not use a long clearing chant before delivering defibrillation.
Immediately resume chest compressions after shock delivered.
Keep interruptions to less than 10 seconds.

 

BLS

 

  1. Follow established AHA BLS guidelines for cardiac arrest

 

ALS

 

  1. Rapid defibrillation and high-quality uninterrupted CPR takes priority over any ALS intervention.
  2. Do not hyperventilate once advanced airway is in place. Ventilate at a rate of 10 breaths/minute (1 breath every 6 seconds). Ensure ETCO2 capnography is used.
  3. Establish an IV/IO with 0.9% NaCl
  4. Follow appropriate Cardiac Arrest Dysrhythmia protocol
  5. Treatment of hypoglycemia from blood testing identified during cardiac arrest is not recommended.
  6.  

      Defibrillate at setting recommended by the manufacturer.

       

      Displace the uterus to the left for the obvious pregnant female (palpable uterus above the umbilicus)

Pediatric
Cardiac Arrest, General Care

Prior to transport, the patient should receive 15 minutes of high quality CPR OR have received at least 3 doses of Epinephrine administered according to the appropriate cardiac arrest protocol.

 

Oxygenation and ventilation are of utmost importance in pediatric cardiac arrest care! Most pediatric cardiac arrests are secondary to a primary respiratory arrest.

 

Use the Broselow® tape (or appropriate equivalent) to obtain approximate weight and determine correct dosing regimen.

 

For EMS witnessed cardiac arrest, quick defibrillation is key – do not delay defibrillation!

 

BLS

 

  1. Follow established AHA BLS guidelines for pediatric cardiac arrest
  2.  

  3. Attach AED and follow prompts.
  4.  

    1. Utilize pediatric pads or pediatric key as appropriate to the AED for children < 8 years old or < 25 kg. The use of an adult AED is acceptable if pediatric supplies are not available

    2. Pads should be placed in the anterior-posterior position.

    3. If "no shock advised," perform CPR for 2 minutes, then check pulse. Re-analyze rhythm if no pulse is found.

     

  5. Initial airway management
  6.  

    1. OP/NP - Only if gag reflex absent

    2. Provide good bag valve mask ventilation with mask that forms an adequate seal around the mouth.

     

  7. If the patient regains a pulse, follow Peds - Post Cardiac Arrest Care Protocol.

 

ALS

 

  1. Establish an IV/IO with 0.9% NaCl
  2.  

  3. Apply cardiac monitor and follow appropriate Cardiac Arrest Dysrhythmia protocol
  4.  

  5. Defibrillation is the treatment priority when advised by the AED. Bare and dry chest. Place patient on hard surface.
  6.  

    1. Defibrillate as described in the appropriate protoco

     

  7. Try to minimize interruptions in chest compressions
  8.  

  9. Respiratory rate of 10 breaths/minute (1 breath every 6 seconds) is adequate for patients in cardiac arrest when an advanced airway is in place – do not hyperventilate.

  10. Place ETCO2 in line with the bag.

Pit Crew CPR

Pit crew CPR is a high performance model of CPR that maximizes compressions and minimizes interruptions by pre-assigning provider roles based on order of arrival to the patient. Below is a description of the positions that are to be assumed by those arriving on scene to a cardiac arrest.

 

  1. Pit Crew CPR applies to all cardiac arrest patients (VT, VF, PEA and asystole)
  2.  

  3. Positions:
  4.  

    1. Position #1: (Patient’s right hand side)
    2.  

      1. Check pulses and initiate first 2 minutes of compressions
      2. When not performing compressions, assist position #3 with BVM if indicated

       

    3. Position #2: (Patient’s left hand side)
    4.  

      1. Attach AED and follow prompts
      2. Alternate compressions with position #1 on 2 minute intervals
      3. When not performing compressions, assist position #3 with BVM if indicated

       

    5. Position #3: (Patient’s head)
    6.  

      1. Initiate airway management as per protocol
      2. Alternate with position #1/#2 for compressions

       

    7. Position #4: First arriving EMT-P after Positions 1-3 are filled.
    8.  

      1. Obtain IV/IO access and administer medications as per ACLS protocol
      2. Temporarily slide to position #3 if advanced airway required
      3. Directs ACLS interventions based on rhythm, EtCO2 and pulse

       

    9. Position #5: “Quality Assurance”
    10.  

      1. Utilizes checklist (see appendix) to verify positions are appropriately filled and performing required interventions
      2. Records rhythm and if shock delivered every 2 minutes
      3. Records time of administration of ACLS medications
      4. IF ROSC OBTAINED – Utilizes Checklist to verify all tasks have been completed.

       

    11. Position #6: “Liaison”
    12.  

      1. Liaisons with family, bystanders and maintains scene safety.

Pediatric
Pit Crew CPR

Pit crew CPR is a high performance model of CPR that maximizes compressions and minimizes interruptions by pre-assigning provider roles based on order of arrival to the patient. Below is a description of the positions that are to be assumed by those arriving on scene to a cardiac arrest.

 

NOTE: The positions for Pediatric Pit Crew CPR are slightly different to emphasize the importance of Oxygenation and Ventilation
  1. Pit Crew CPR applies to all cardiac arrest patients (VT, VF, PEA and asystole)
  2.  

  3. Positions:
  4.  

    1. Position #1: (Patient’s right hand side)
    2.  

      1. Check pulses and initiate first 2 minutes of compressions
      2. Alternate compressions with Position #4 on 2 minute interval
      3. Compressions should be continuous until BVM is set up then switch to ratio of 15 compressions:2 breaths

       

    3. Position #2: (Patient’s head)
    4.  

      1. Initiate BVM with 100% Oxygen
      2. Focus on achieving and maintaining an excellent seal with 2 handed technique

       

    5. Position #3: (Patient’s head right/left)
    6.  

      1. Assist Position #2 with BVM and airway management
      2. Maintain quality CPR with 15:2 ratio
      3. Alternate with Position #2 holding the mask in case of fatigue

       

    7. Position #4: (Patient’s left hand side)
    8.  

      1. Attach AED and follow prompts
      2. Alternate compressions with Position #1 on 2 minute intervals

       

    9. Position #5: First arriving EMT-P after Positions 1-4 are filled.
    10.  

      1. Obtain IV/IO access and administer medications as per current Indianapolis Metropolitan Area EMS Protocols
      2. Directs PALS interventions based on rhythm, EtCO2 and pulse
      3. Temporarily slide to position #3 if advanced airway required

       

    11. Position #6: “Quality Assurance”
    12.  

      1. Utilizes checklist (see appendix) to verify positions are appropriately filled and performing required interventions
      2. Records rhythm and if shock delivered every 2 minutes
      3. Records time of administration of PALS medications
      4. IF ROSC OBTAINED – Utilizes Checklist to verify all tasks have been completed.

       

    13. Position #7: “Liaison” (if available)
    14.  

      1. Liaisons with family, bystanders and maintains scene safety.

Adult
Cardiac Arrest - VF/VT

BLS

 

  1. Perform chest compressions until defibrillator is attached. (Provide 2 minutes of chest compressions prior to defibrillation for unwitnessed arrest.) Compressions should be performed at a rate of 100-120/minute.
  2.  

  3. Refer to Cardiac Arrest General Care guidelines

 

ALS

 

 

Persistent or Recurrent VF/VT

 

  1. Apply pads and defibrillate at maximum settings as recommended by the manufacturer.
  2.  

  3. Immediately resume CPR for 2 minutes. Minimize CPR interruptions to any placement of advanced airway. Use in-line ETCO2.
  4.  

  5. ASAP administer 1 mg epinephrine 1:10,000 IV or IO push and repeat every 3-5 min.
  6.  

  7. Check for an organized rhythm at 2-minute intervals. Shock if indicated. Immediately resume CPR.
  8.  

  9. If persistent VF/VT after first epinephrine dose and subsequent shock, administer 300 mg amiodarone IV or IO. May repeat one time at half dose (150 mg)
  10.  

  11. Resuscitative efforts should rotate on 2 minute cycles. Pattern should be shock, CPR, drug.
  12.  

  13. If no response to amiodarone, consider 2 grams magnesium sulfate IV or IO. May repeat one time in 3-5 mins.

 

Once VF/VT has Resolved

 

  1. Administer amiodarone if the 300 mg bolus was not given previously:
  2.  

    1. Add 150 mg amiodarone to a 50 mL 5% dextrose IV bag
    2. Infuse over 10 minutes
    3.  

      100 gtt/min using 20 gtt/mL drip set
      75 gtt/min using 15 gtt/mL drip set

     

  3. Begin a magnesium IV infusion at 33 mg/min (2 g/h) if the 2 g magnesium bolus was used
  4.  

    1. Add 2 g magnesium sulfate to a 50 mL 0.9% saline or 5% dextrose IV bag
    2. Infuse at 50 gtt/min using the 60 gtt/mL drip set.

 

If VF/VT has NOT Resolved

 

  1. Consider Alternate Vector Defibrillation then Double Sequential External Defibrillation if second defibrillator is available and:
  2.  

    1. Refractory to ≥ 3 standard defibrillations AND
    2. Has already received 300 mg amiodarone AND
    3. Ventricular fibrillation/pulseless ventricular tachycardia NEVER converted

     

  3. Refer to Procedures section for further instruction on Alternate Vector/Double Sequential External Defibrillation.

Pediatric
Cardiac Arrest - VF/VT

BLS

 

  1. Perform chest compressions until defibrillator is attached. (Provide 2 minutes of chest compressions prior to defibrillation for unwitnessed arrest.) Compressions should be performed at a rate of 100-120/minute.
  2.  

  3. Refer to Cardiac Arrest General Care guidelines

 

ALS

 

 

Persistent or Recurrent VF/VT

 

  1. Defibrillate, if indicated at 2 J/Kg. Subsequent shocks should be at 4 J/Kg.
  2.  

      The use of pediatric defibrillation pads is preferred if age < 8 or < 25 kg. If adult pads are used, they should be placed in an anterior-posterior configuration.

     

  3. Defibrillate, immediately resume CPR for 2 minutes. Establish an IV (or an IO line, if IV access is not available).
  4.  

  5. BVM is the preferred method of ventilation. Proceed to advanced airway only if BVM ventilation/oxygenation is inadequate. Use in-line ETCO2.
  6.  

  7. Administer 0.01 mg/Kg (0.1 mL/Kg) 1:10,000 epinephrine IV or IO every 3-5 minutes (max dose is 1mg)
  8.  

  9. Check for an organized rhythm at 2-minute intervals. Shock if indicated. Immediately resume CPR.
  10.  

  11. If persistent VF/VT after first epinephrine dose and subsequent shock, administer amiodarone 5 mg/Kg IV or IO (max dose is 300 mg).
  12.  

  13. Resuscitative efforts should rotate on 2 minute cycles. Pattern should be shock, CPR, drug.

 

Once VF/VT has Resolved

 

  1. Contact medical control for further instructions.
  2.  

Adult
Cardiac Arrest - PEA/Asystole

Consider possible reversible causes of PEA such as hypovolemia, hypoxia, tension pneumothorax, cardiac tamponade, hypothermia, acidosis, drug overdose, hyperkalemia, massive acute MI, or pulmonary embolism

 

Consider possible reversible causes of Asystole such as hypoxia, preexisting acidosis, drug overdose, or hypothermia.

 

ALS

 

  1. High quality CPR has priority over any ALS intervention.
  2.  

  3. If the rhythm is unclear and possibly ventricular fibrillation, defibrillate as for VF.
  4.  

  5. Minimize CPR interruptions to any placement of advanced airway. Use in-line ETCO2.
  6.  

  7. Establish IV/IO
  8.  

  9. Administer 1 mg epinephrine 1:10,000 IV or IO push and repeat every 3-5 min.
  10.  

  11. Check for an organized rhythm at 2-minute intervals. Shock if indicated. Immediately resume CPR.
  12.  

  13. Continue resuscitative efforts for 30 minutes total. Contact receiving facility for further consultation as needed.

Pediatric
Cardiac Arrest - PEA/Asystole

Consider possible reversible causes of PEA such as hypovolemia, hypoxia, tension pneumothorax, cardiac tamponade, hypothermia, acidosis, drug overdose, hyperkalemia, massive acute MI, or pulmonary embolism

 

Consider possible reversible causes of Asystole such as hypoxia, preexisting acidosis, drug overdose, or hypothermia.

 

ALS

 

  1. High quality CPR has priority over any ALS intervention.
  2.  

  3. If the rhythm is unclear and possibly ventricular fibrillation, defibrillate as for VF.
  4.  

  5. BVM is the preferred method of ventilation. Proceed to advanced airway only if BVM ventilation/oxygenation is inadequate. Use in-line ETCO2.
  6.  

  7. Establish IV (or an IO line, if IV access is not available)
  8.  

  9. Administer 0.01 mg/kg epinephrine: (1:10,000, 0.1 mL/Kg) IV or IO every 3-5 minutes (max dose is 1 mg).

Adult
Post Cardiac Arrest Care

  1. Applies to patients resuscitated from cardio-respiratory arrest who have a perfusing rhythm and pulse, and who remain unresponsive.
  2.  

  3. Secure the airway. If not previously accomplished, the airway should be secured with an ET tube or a non-visualized airway.
  4.  

  5. Maintain normoventilation. Initially, ventilate at 10-12 breaths per minutes. Do NOT hyperventilate. If end-tidal capnography is available, titrate ventilation to an EtCO2 of 35-40 mm Hg. All advanced airways require confirmation/monitoring with waveform capnography.
  6.  

  7. If patient has an advanced airway in place and patient starts to regain consciousness, administer midazolam 2.5 mg IV/IO or ketamine 1 mg/kg IV/IO. Can repeat once as necessary to maintain an adequate level of sedation.
  8.  

  9. Stabilize dysrhythmias:
  10.  

    1. Unstable tachydysrhythmias – treat with cardioversion
    2. Unstable bradydysrhythmias – consider external pacing
    3. Stable tachycardia or bradycardia – treat per protocols

     

  11. If initial arrest rhythm was v-fib or v-tach, give amiodarone 150 mg IV over 10 minutes if not already given during resuscitation. If significant ventricular ectopy persists, repeat amiodarone per protocol.
  12.  

  13. Support blood pressure
  14.  

    1. Administer 500 mL boluses of 0.9 NS to maintain SBP between 110 and 140 mm Hg

    2. If the patient’s SBP is less than 90 mm Hg after 500 mL of fluid consider norepinephrine drip (starting at 2-4 mcg/min) or epinephrine drip (starting at 5 mcg/min, mix 1 mg 1:1,000 epi in 1L saline infuse at 5 ml/min ). Titrate to a SBP >110 and < 140.

     

  15. Obtain a 12-lead EKG and transmit, if possible. Notify the receiving facility as soon as a STEMI is suspected.
  16.  

  17. Check glucose and treat per protocol
  18.  

  19. Seizure activity – monitor for seizure activity and treat per protocol.

Pediatric
Post Cardiac Arrest Care

  1. Applies to pediatric patients resuscitated from cardio-respiratory arrest who have a perfusing rhythm and pulse, and who remain unresponsive.
  2.  

  3. Continue to support respirations with BVM, attempting to time support with the patients own respirations
  4.  

  5. ETCO2 should be used in line with bag during BVM. If the patient is breathing and BVM is not necessary then nasal cannula ETCO2 should be placed on the patient.
  6.  

  7. Maintain normal ventilation. Initially, ventilate at 10 breaths per minute (1 breath every 6 seconds). Do NOT hyperventilate or hypoventilate.
  8.  

  9. Stabilize dysrhythmias:
  10.  

    1. Stable tachycardia or bradycardia – treat per protocols
    2. If initial arrest rhythm was v-fib or v-tach, give Amiodarone 5 mg/kg (max 300 mg) IV/IO over 10 minutes if not already given during resuscitation. If significant ventricular ectopy persists, repeat amiodarone per protocol

     

  11. Support blood pressure
  12.  

    1. Administer 10 mL/kg boluses of 0.9 NS to maintain adequate blood pressure for age (70 + 2xPatient Age)

    2. If the patient’s SBP is less than lower limit based on the above equation after first 10 ml/kg of fluid, call medical control for further instructions

     

  13. Obtain a 12-lead EKG.
  14.  

  15. Check glucose and treat per protocol
  16.  

  17. Seizure activity – monitor for seizure activity and treat per protocol.
  18.  

  19. Monitor for fever.

Left Ventricular Assist Device (LVAD)

  1. The most valuable resource for the LVAD patient is their caregiver. They are trained and familiar with all of the LVAD equipment. The caregiver will be transported with the patient to the Emergency department.
  2.  

  3. Contact VAD coordinator (found on card the patient will give you) for additional guidance.
  4.  

  5. All ALS and BLS protocols are valid for the LVAD patient.
  6.  

  7. You must use clinical judgment to determine the need for CPR. (warm, pink, with good capillary refill)
  8.  

    1. Peripheral pulses may not be present.
    2. BP can only be measured with a Doppler ultrasound or automated blood pressure cuff.
    3. Pulse oximetry may not be reliable (if there is no pulse).
    4. Listen over the pump for a mechanical whirring sound.
    5.  

      1. If the patient is unconscious and there is no whirling sound, start CPR.
      2. If there is a whirling sound, but the patient is unconscious and has delayed capillary refill or ETCO2 <20 mmHg after advanced airway placement, start CPR.

       

    6. If CPR is initiated transport patient to the hospital.

     

  9. CPR is performed in the usual manner.
  10.  

  11. Defibrillation and cardioversion are performed in the usual manner.
  12.  

    1. Not all dysrhythmias need to be treated.
    2.  

      1. If the patient is warm, pink with good capillary refill, CPR is not necessary

       

    3. Do not place defibrillator pads over the “pump”

     

  13. If the pump is not working (no mechanical whirring sound):
  14.  

    1. Check System control panel for alarms.
    2. Check Power Supply connection.
    3. Never disconnect both batteries at the same time.
    4. Contact VAD coordinator (found on card the patient will give you) for additional guidance.

     

  15. Always transport patient with Travel Bag containing extra controller, batteries and cables and if stable transport to a VAD center.
  16.  

  17. Most patients are on sildenafil (Viagra®, Revatio®) and nitrates should not be administered.