A D U L T P R O T O C O L

WIDE – COMPLEX TACHYCARDIA – With Pulse

Breathing Rule out Paced /

UNIVERSAL PATIENT CARE PROTOCOL Rhythm APPLY CARDIAC MONITOR Pacer spikes may not

Airway be present with OXYGEN current pacemaker CAPNOGRAPHY PROCEDURE

technology, confirm by History / Physical IV / IO PROCEDURE Exam Shock Identify Rhythm type Regular or Irregular

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Stable / Regular Stable / Irregular Unstable / Regular or Irregular SBP < 90, No Radial Pulses, AMS, Chest Pain, Shock

Circulation 12 LEAD EKG 12 LEAD EKG Consider Sedation PROCEDURE PROCEDURE MIDAZOLAM (VERSED) 2.5 mg IV / IO or 5 mg IM / IN Attempt Vagal OR Attempt Vagal LORazepam (ATIVAN) 1 – 2 mg IV / IO / IM / IN Maneuvers Maneuvers If Midazolam (Versed) or LORazepam (Ativan) Unavailable, (NO carotid massage) (NO carotid massage) I See Medication Section for DiazePAM (Valium) I Capnography Required

Synchronized CARDIOVERSION

Cardiac MONOMORPHIC WIDE If Torsades de pointes COMPLEX TACHYCARDIA MAGNESEUM SULFATE 100 J or Device Recommendation Consider 1 ‐ 2 grams IV / IO ADENOSINE over 5 to 60 minutes I Irregular Rhythms / Afib (ADENOCARD) a Defibrillate if Torsades, do not Synchronize Cardiovert

6 mg IV push AMIODARONE followed by 20 ml (CORDARONE) No Response 1 –2 minutes Normal Saline push 150 mg IV / IO

mix in 100 ml D5W Repeat Synchronized CARDIOVERSION May consider Over 10 minutes 200, 300, 360 J or Device Recommendation ADENOSINE (ADENOCARD) I If Amiodarone (Cordarone) I Irregular Rhythms / Afib Medical 12 mg IV push Unavailable, See Medication a Defibrillate if Torsades, do not Synchronize Cardiovert Section for Lidocaine if required (Xylocaine) a Must have USEABLE 12 Lead EKG and Have Transmitted to Consider Medications if Cardioversion Unsuccessful AMIODARONE Hospital a IF PREGNANT – USE AMIODARONE (CORDARONE) (CORDARONE) LIDOCAINE, see Medication 150 mg IV / IO Section 150 mg IV / IO mix in 100 ml D5W mix in 100 ml D5W Over 10 minutes Over 10 minutes I If Amiodarone (Cordarone) Unavailable, See Medication Section for I If Amiodarone (Cordarone) Lidocaine (Xylocaine) Unavailable, See Medication a Must have USEABLE 12 Lead EKG and Have Transmitted to Hospital Trauma Section for Lidocaine a IF PREGNANT – USE LIDOCAINE, See Medication Section (Xylocaine) a Must have USEABLE 12 Lead If Torsades de pointes EKG and Have Transmitted to MAGNESEUM SULFATE Hospital 1 ‐ 2 grams IV / IO a IF PREGNANT – USE LIDOCAINE Over 5 minutes

TRANSPORT to appropriate facility CONTACT receiving facility CONSULT Medical Direction where indicated APPROPRIATE transfer of care

EMT Intervention AEMT Intervention PARAMEDIC Intervention Online Medical Control

Northeast Ohio Regional EMS Protocol ‐ 8 | 4 A D U L T P R O T O C O L Airway WIDE– COMPLEX TACHYCARDIA

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HISTORY SIGNS AND SYMPTOMS DIFFERENTIAL DIAGNOSIS Breathing  Past medical history /  Ventricular tachycardia on  Artifact / device failure medications, diet, drugs. ECG (runs or sustained)  Cardiac  Syncope / near syncope  Conscious, rapid pulse  Endocrine / metabolic   Palpitations Chest pain, shortness of  Drugs  Pacemaker breath  Pulmonary  Allergies: Amiodarone  Dizziness Circulation (Cordarone)  Rate usually 150 + bpm for sustained V‐Tach

/ Shock

Cardiac

Medical

Trauma KEY POINTS  Exam: Mental Status, Skin, Neck, Lung, Heart, Abdomen, Back, Extremities, Neuro  Polymorphic V‐Tach (Torsades de Pointes) may benefit from the administration of Magnesium Sulfate.  Polymorphic V‐Tach (Torsades de Pointes) requires defibrillation rather than synchronized cardioversion.  If the patient converts to another rhythm, refer to the appropriate protocol and treat accordingly.  If the patient relapses back into wide complex tachycardia / ventricular tachycardia, initiate synchronized cardioversion with the joules setting that previously cardioverted the patient.  Record 3 / 4 ‐ Lead EKG strips during medication administration.  Perform a 12‐ Lead EKG prior to and after medication administration, or synchronized cardioversion of wide complex tachycardia / ventricular tachycardia.  Perform a code summary and attach it to the patient run report.  Be sure to treat the patient and not the monitor.

Northeast Ohio Regional EMS Protocol ‐ 9 | 4