Asystole / PEA FREDERICKSBURG EMS ACLS

FREDERICKSBURG EMS ACLS 1

Asystole / PEA

(ADULT )

 Check for Responsiveness  Check for Breathing  Check for Carotid Pulse  Initiate CPR o As soon as a mechanical external compression device (i.e. Lucas 2) (Procedure 12) becomes available the device can be employed as the primary means of providing chest compressions  Placement of AED and follow prompts as instructed  NPA/OPA with assisted ventilations via BVM as soon as possible, priorities should be on compressions, then airway o No gag reflex consider the insertion of the King Airway (Procedure 4) DO NOT INTERRRUPT CPR TO PLACE THE KING AIRWAY o ETCO2 monitoring (Procedure 7)

INTERMEDIATE

 Secure airway as required by ET Intubation and confirm/secure tube placement  Obtain IV access – initiate fluid bolus o IO access (immediately if available or after unable to obtain IV access in 2 attempts)

PARAMEDIC

 Cardiac monitor  Confirm asystole in more than one lead  Epinephrine 1mg (1:10,000) (Rx: 13) rapid IV/IO push every 3-5 minutes

“When in doubt, do something in favor of your patient.” Jay Cloud FREDERICKSBURG EMS ACLS 1 Asystole / PEA

(ADULT)  Consider TCP (Procedure 11) if a bradycardic rhythm is present  If no rhythm change, rapid rise in ETCO2, or ROSC after 25 minutes of aggressive CPR and ACLS therapies, consider ceasing resuscitation efforts  Consider Sodium Bicarbonate 1 mEq/kg (Rx: 30) IV/IO if the patient is believed to have one of the following conditions: o Chronic Renal Failure o Hyperkalemia o Tricyclic Anti-Depressant Overdose o Suspected case of Excited Delirium ALERTS: Identify and treat the following contributing factors (6 H and 5 T’s):

Causes Treatment Hypovolemia Normal Saline Boluses Hypoxia Ventilate with 100% Oxygen Hyperkalemia Calcium Chloride and Sodium Bicarbonate. After administration of either medication ensure that the IV line is completely flushed Hypoglycemia Dextrose Hypothermia Remove clothing with gradual re-warming. Handle patient gently Hydrogen Ion (acidosis) Normal Saline Boluses. Sodium Bicarbonate Tension Pneumothorax Needle Thoracostomy Tamponade – Cardiac Normal Saline Boluses and rapid transport. In-hospital pericardiocentesis Thrombosis In-hospital fibrinolysis Trauma Provide treatment per trauma protocols Toxins Refer to Overdose (Medical 17)

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“When in doubt, do something in favor of your patient.” Jay Cloud FREDERICKSBURG EMS ACLS 2

Bradycardia

(ADULT)

 ABC’s o Monitor Vital Signs o Support life-threatening problems associated with airway, breathing, and circulation  Support airway and provide supplemental Oxygen if Oxygen Saturation by pulse oximetry is less than 94%  12 Lead ECG, Transmit (Procedure 8)

INTERMEDIATE

 Initiate IV Normal Saline, KVO or Saline Lock o Administer 250 ml boluses until systolic BP > 90 mmHg o Total amount of IVF should not exceed 1000 ml PARAMEDIC

 Cardiac monitor  If patient has adequate perfusion – observe/monitor  If patient has poor perfusion caused by the bradycardia with a low degree heart block o Consider Atropine 0.5mg (Rx: 5) IV, may repeat every 3-5 min, to a max dose of 3mg  If patient has poor perfusion caused by the bradycardia with a high degree heart block o Prepare for TCP (Procedure 11) o Consider Versed 2-5 mg (Rx: 36) as soon as appropriate o Consider Dopamine (5 -20 mcg/kg/min) (Rx: 12) while waiting for TCP or if TCP not effective

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“When in doubt, do something in favor of your patient.” Jay Cloud FREDERICKSBURG EMS ACLS 2 Bradycardia

(ADULT)

ALERTS:  Signs/symptoms of poor perfusion primarily include hypotension which also may include altered mental status, ongoing chest pain, or other signs of shock  If suspected MI with bradycardia and adequate perfusion refer to Chest Pain (Acute Coronary Syndrome) (Medical 4)  Consider causes (6H’s, 5T’s)  If time permits, consider sedation with Versed 2.5-5mg IV/IN prior to TCP  Treatment of choice for high degree blocks (second degree type II and third degree) is TCP (consider atropine 0.5mg IV while awaiting TCP)

“When in doubt, do something in favor of your patient.” Jay Cloud FREDERICKSBURG EMS ACLS 3

Narrow Complex Tachycardia -

PSVT / A-Fib / A-Flutter

(ADULT)

 ABC’s  Monitor Vital Signs  Support life-threatening problems associated with airway, breathing, and circulation  Support airway and provide supplemental Oxygen if Oxygen Saturation by pulse oximetry is less than 94%  12 Lead ECG, Transmit (Procedure 8)

INTERMEDIATE

 Initiate IV Normal Saline, KVO or Saline Lock o Administer 250 ml boluses until systolic BP > 90 mmHg o Total amount of IVF should not exceed 1000 ml PARAMEDIC

 Cardiac monitor Unstable patient: If time and patient condition permit, the patient should be sedated prior to the application of electrical therapy  Sedation o Versed 2-5mg IV/IN (Rx: 36) o Maximum Dose of 10mg  Synchronized cardioversion (200 J, 300 J, & 360 J) (Procedure 10) if: o GCS ≤14 o Appears hemodynamically unstable o Reports active chest pain o Exhibits significant shortness of breath

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“When in doubt, do something in favor of your patient.” Jay Cloud FREDERICKSBURG EMS ACLS 3 Narrow Complex Tachycardia -

PSVT / A-Fib / A-Flutter

(ADULT)

Stable patient:  If the patient is in a narrow complex tachycardia (<0.12) without evidence of A-Fib / A-Flutter and is hemodynamically stable without critical signs and symptoms attempt vagal maneuvers first  In the absence of A-Fib, A-Flutter or multifocal atrial tachycardia Adenosine 6 mg (Rx: 2) rapid IV push (over 1-3 sec.), followed with 20cc NS flush (regular & monomorphic) Withhold Adenosine if the patient has a history of Wolff Parkinson White Syndrome (WPW) or if delta waves are present  Repeat Adenosine 12mg rapid IV push after 1-2 minutes, followed with 20cc NS flush  If the Adenosine fails to slow the rate administer Cardizem IV (Rx: 9) o Initial dose 0.25 mg/kg over 2 minutes o Second Dose 0.35 mg/kg over 2 min q 10-15 min

Symptomatic - A-Fib, A-Flutter or multifocal atrial tachycardia:  Cardizem IV o Initial dose 0.25 mg/kg over 2 minutes o Second Dose 0.35 mg/kg over 2 min q 10-15 min  If at any time during medication administration or re-evaluation the patient begins to deteriorate or exhibit signs of rate related cardiovascular compromise, revert to immediate Synchronized Cardioversion in management of the unstable patient presenting with narrow tachycardia  If at any time after the administration of Diltiazem (Cardizem) the patient becomes profoundly hypotensive (SBP ≤80), administer Calcium Chloride 1- 2 gram (Rx: 8) slow IVP

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“When in doubt, do something in favor of your patient.” Jay Cloud FREDERICKSBURG EMS ACLS 3 Narrow Complex Tachycardia -

PSVT / A-Fib / A-Flutter ALERTS: (ADULT)  Give Adenosine rapidly over 1 to 3 seconds through a large (e.g., antecubital) vein followed by a 10 mL Normal Saline flush and elevation of the arm  If possible, establish IV access before cardioversion and give Versed 2-5 mg slow IV push, titrated to effect, if the patient is conscious. May repeat every 5 minutes as needed for sedation. Do not delay cardioversion if the patient is extremely unstable  If available, obtain a 12-Lead ECG to better define the rhythm, but this should not delay immediate cardioversion if the patient is unstable  Adenosine is safe and effective in pregnancy. However, Adenosine does have several important drug interactions. Larger doses may be required for patients with a significant blood level of Theophylline, Caffeine, or Theobromine. The initial dose should be reduced to 3 mg in patients taking Dipyridamole or Carbamazepine or those with transplanted hearts  Adenosine should not be given for unstable or for irregular or polymorphic wide-complex tachycardias, as it may cause degeneration of the arrhythmia to VF  Patients with an atrial fibrillation duration of >48 hours are at increased risk for cardioembolic events, although shorter durations of atrial fibrillation do not exclude the possibility of such events. Electric or pharmacologic cardioversion (conversion to normal sinus rhythm) should not be attempted in these patients unless the patient is unstable  For recurrent VT with a pulse, consider a slow infusion of 150 mg Cordarone at 1 mg/minute IV. If Cordarone has not been given prior to conversion of recurrent VT, administer a rapid infusion of Cordarone 150 mg IV over 10 minutes before starting the slow infusion at 1 mg/minute. Cordarone is contraindicated if SBP <90 mm Hg  To perform synchronized cardioversion, provide an initial shock at the recommended energy dose. If there is no response to the first shock, increase the dose in a stepwise fashion (e.g., 100 J, 200 J, 300 J, 360 J). Providers should use the device-specific doses for synchronized cardioversion, as recommended by the monitor manufacturer. Following are the AHA recommendations

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“When in doubt, do something in favor of your patient.” Jay Cloud FREDERICKSBURG EMS ACLS 3 Narrow Complex Tachycardia -

PSVT / A-Fib / A-Flutter

(ADULT)

o Atrial Fibrillation – Recommended initial biphasic energy dose for cardioversion is 120 to 200 J. If the initial shock fails, increase the dose in a stepwise fashion. Cardioversion with monophasic waveforms should begin at 200 J and increase in stepwise fashion if not successful o SVT and Atrial Flutter – Recommended initial biphasic energy dose for cardioversion of 50 J to 100 J is often sufficient. If the initial 50 J shock fails, increase the dose in a stepwise fashion o Monomorphic VT (with pulse) – Recommended initial biphasic energy dose for cardioversion is 100 J. If there is no response to the first shock, increase the dose in a stepwise fashion o Polymorphic VT (such as torsades de pointes) – Treat the rhythm as VF and deliver high-energy unsynchronized shocks (i.e., defibrillation doses)  If cardioversion is needed and it is impossible to synchronize a shock (e.g., the patient’s rhythm is irregular), use high-energy unsynchronized shocks  Check pulse and rhythm after each synchronized shock. Ensure monitor remains in ““SYNC” mode for subsequent shocks

“When in doubt, do something in favor of your patient.” Jay Cloud FREDERICKSBURG EMS ACLS 4

Wide Complex Tachycardia –

V-Tach With A Pulse

(ADULT)

INTERMEDIATE

 Initiate IV Normal Saline, KVO or Saline Lock o Administer 250 ml boluses until systolic BP > 90 mmHg o Total amount of IVF should not exceed 1000 ml PARAMEDIC

 Cardiac monitor Unstable patient: If time and patient condition permit, the patient should be sedated prior to the application of electrical therapy  Sedation o Versed 2-5mg IV/IN (Rx: 36) o Maximum Dose of 10mg  Synchronized cardioversion (200 J, 300 J, & 360 J)(Procedure 10) if: o GCS ≤14 o Appears hemodynamically unstable o Reports active chest pain o Exhibits significant shortness of breath

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“When in doubt, do something in favor of your patient.” Jay Cloud FREDERICKSBURG EMS ACLS 4 Wide Complex Tachycardia –

V-Tach With A Pulse

(ADULT)

 If the rhythm converts to a non -lethal, narrow complex rhythm without the presence of a high degree heart block then administer Cordarone “Amiodarone” or Lidocaine: o Cordarone 150 mg (Rx: 10) slow infusion . Mix 150 mg in 100 ml of Normal Saline. Utilize a 10 gtts set and infuse at 100 gtts/minute over 10 minutes . May repeat once in 10 minutes OR if Cordarone is not available o Lidocaine 1 mg/kg (Rx: 22) IV/IO . Follow by 0.5 mg/kg every 5 minutes . Maximum total dose 3 mg/kg

Stable patient:  If the rhythm is regular with monomorphic appearance administer Adenosine: o Adenosine 6mg (Rx: 2) rapid IV push (over 1-3 sec.), followed with 20cc NS flush (regular & monomorphic) . Repeat Adenosine 12mg rapid IV push after 1-2 minutes, followed with 20cc NS flush  If the rhythm appears irregular or the Adenosine fails to convert the tachycardia administer Cordarone. May repeat one time in 10 minutes: o Cordarone 150 mg (Rx: 10) slow infusion . Mix 150 mg in 100 ml of Normal Saline. Utilize a 10 gtts set and infuse at 100 gtts/minute over 10 minutes . May repeat once in 10 minutes OR if Cordarone is not available o Lidocaine 1 mg/kg (Rx: 22) IV/IO . Follow by 0.5 mg/kg every 5 minutes . Maximum total dose 3 mg/kg . Consider continuous infusion of 2-4 mg/min (Procedure 17) may be started following ROSC

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“When in doubt, do something in favor of your patient.” Jay Cloud FREDERICKSBURG EMS ACLS 4 Wide Complex Tachycardia –

V-Tach With A Pulse (ADULT)

 If the rhythm is polymorphic V-tach. (Torsades de Pointes) or hypomagnesaemia is suspected administer Magnesium Sulfate: o Magnesium Sulfate 2 gm (Rx: 23) slow IV/IO Infusion . Mix 2 gm in 100 ml of Normal Saline. Utilize a 10 gtts set and infuse at 50 gtts/min over 10 minutes  If at any time during the administration of a medication infusion or reevaluation, the patient begins to deteriorate or exhibit signs of tachycardia related cardiovascular compromise, revert to immediate Synchronized Cardioversion (Procedure 10)

“When in doubt, do something in favor of your patient.” Jay Cloud FREDERICKSBURG EMS ACLS 4 Wide Complex Tachycardia – V-Tach With A Pulse (ADULT)

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“When in doubt, do something in favor of your patient.” Jay Cloud FREDERICKSBURG EMS ACLS 5

V-Fib / Pulseless V-Tach

(ADULT)

 Check for responsiveness  Check for breathing  Check for carotid pulse  Initiate CPR o As soon as a mechanical external compression device (i.e. Lucas 2) (Procedure 12) becomes available the device can be employed as the primary means of providing chest compressions  Placement of AED and follow prompts as instructed  NPA/OPA with assisted ventilations via BVM as soon as possible, priorities should be on compressions, then airway o No gag reflex consider the insertion of the King Airway (Procedure 4) DO NOT INTERRRUPT CPR TO PLACE THE KING AIRWAY o ETCO2 monitoring (Procedure 7)  12 Lead ECG, transmit if possible (Procedure 8)

INTERMEDIATE

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“When in doubt, do something in favor of your patient.” Jay Cloud FREDERICKSBURG EMS ACLS 5 V-Fib / Pulseless V-Tach

(ADULT) PARAMEDIC

 Cardiac monitor o Confirm V-Fib / V-Tach o Shock 360 J o Repeat defibrillation for recurrent VF/VT after every 2 minute cycle of quality CPR and after each drug administration is circulated for at least 60 seconds:  Epinephrine 1:10,000 1 mg (Rx: 13) IV/IO o Administer Epinephrine every 3-5 minutes for the duration of the arrest  Administer Cordarone (PRIMARY) or Lidocaine repeat medication in 5 minutes for recurrent VF/VT: o Cordarone (Rx: 10) . Initial dose: 300 mg IV/IO . Second dose: 150 mg IV/IO in 5 minutes . Third dose: 150 mg IV/IO in 5 minutes o Lidocaine (Rx: 22) . Initial dose: 1 mg/kg IV/IO . Additional dose: 1 mg/kg IV/IO, maximum total dose 3 mg/kg  Consider Magnesium Sulfate for suspected polymorphic V-tach (Torsades de Pointes) or hypomagnesaemia: o Magnesium Sulfate 2 gm (Rx: 23) slow IV/IO o Mix 2 gm in 10 ml of Normal Saline and administer over 2 minutes  Consider Sodium Bicarbonate 1 mEq/kg (Rx: 30) IV/IO if the patient is believed to have one of the following conditions: o Chronic Renal Failure o Hyperkalemia o Tricyclic Anti-Depressant Overdose o Suspected case of Excited Delirium

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“When in doubt, do something in favor of your patient.” Jay Cloud FREDERICKSBURG EMS ACLS 5 V-Fib / Pulseless V-Tach

(ADULT)

 Adult patients remaining in refractory VFib / VTach after a total of four (4) defibrillation attempts shall have Double Sequential Defibrillation (Procedure 9) performed at 360 joules when/if a second defibrillator or an AED becomes available

ALERTS: • When VF/pulseless VT cardiac arrest is associated with torsades de pointes, administer an IV/IO bolus of Magnesium Sulfate at a dose of 1 to 2 g diluted in 6 mL Normal Saline • The most critical interventions during the first minutes of VF or pulseless VT are immediate CPR, with minimal interruption in chest compressions, and defibrillation • After an advanced airway is placed, rescuers no longer deliver “cycles” of CPR. Give continuous chest compressions without pauses for breaths. Give 8 to 10 breaths/minute. Check rhythm every 2 minutes • When a rhythm check reveals VF/VT, CPR should be provided while the defibrillator charges (when possible), until it is time to “clear” the victim for shock delivery. Give the shock as quickly as possible. Immediately after shock delivery, resume CPR (beginning with chest compressions) without delay and continue for 5 cycles (or about 2 minutes if an advanced airway is in place), and then check the rhythm • Minimize the number of times that chest compressions are interrupted. Periodic pauses in CPR should be as brief as possible and only as necessary to assess rhythm, shock VF/VT, perform a pulse check when an organized rhythm is detected, or place an advanced airway • “Effective” chest compressions are essential for providing blood flow during CPR. To give “effective” chest compressions, “push hard and push fast.” Compress the adult chest at a rate of at least 100 compressions per minute, with a compression depth of 2 inches (5 cm). Allow the chest to

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“When in doubt, do something in favor of your patient.” Jay Cloud FREDERICKSBURG EMS ACLS 5 V-Fib / Pulseless V-Tach

(ADULT)

recoil completely after each compression, and allow approximately equal compression and relaxation times • Continuous waveform capnography is required, if available, in addition to clinical assessment to confirm and monitor correct placement of an endotracheal tube • Use quantitative waveform capnography in intubated patients to monitor CPR quality, optimize chest compressions, and detect ROSC during chest compressions or when rhythm check reveals an organized rhythm. If ETCO2 <10 mm Hg, consider trying to improve CPR quality by optimizing chest compression parameters. If ETCO2 abruptly increases to a normal value (35 to 40 mm Hg), it is reasonable to consider that this is an indicator of ROSC • If SVT ≥170, perform immediate synchronized cardioversion in addition to other indicated procedures. • After conversion from shock refractory VF/VT to a perfusing rhythm, consider a slow infusion of AMIODARONE at 1 mg/minute IV • If patient converts from shock refractory VF/VT and Amiodarone has NOT been given during the cardiac arrest, administer a rapid infusion of Amiodarone 150 mg IV over 10 minutes before starting the slow infusion at 1 mg/minute

“When in doubt, do something in favor of your patient.” Jay Cloud FREDERICKSBURG EMS ACLS 6

Return of Spontaneous

Circulation (ROSC)

(ADULT)

 ABC’s  Support airway and provide supplemental Oxygen if Oxygen Saturation by pulse oximetry is less than 94% o No gag reflex consider the insertion of the King Airway (Procedure 4)  ETCO2 monitoring (Procedure 7)  Ensure that a blood glucose reading is obtained, refer to Diabetic Emergencies (Medical 7)  12 Lead ECG, Transmit (Procedure 8)  Consider Air Medical (APP 1) for transport to a heart center

INTERMEDIATE

 Initiate IV Normal Saline, o Administer 250 ml boluses to maintain or restore perfusion o Total amount of IVF should not exceed 2000 ml  Advanced Airway procedures as needed

PARAMEDIC

 Cardiac monitor  If the patient was resuscitated following an episode of VF/VT and is without profound bradycardia or high-grade heart block (2nd degree Type II or 3rd degree or Idioventricular rhythm) administer Cordarone Infusion (Procedure 14) or Lidocaine bolus (Procedure 17) Note: Continue using the anti-arrhythmic medication that was administered during resuscitation

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“When in doubt, do something in favor of your patient.” Jay Cloud FREDERICKSBURG EMS ACLS 6 Return of Spontaneous

Circulation (ROSC)

(ADULT)

 Cordarone 150 mg (Rx: 10) slow infusion o Mix 150 mg in 100 ml of Normal Saline. Utilize a 10 gtts set and infuse at 100 gtts/minute over 10 minutes o May repeat once in 10 minutes OR if Cordarone is not available  Lidocaine 2-4 mg/kg (Rx: 22) IV/IO o Follow by 0.5 mg/kg every 5 minutes o Maximum total dose 3 mg/kg  If bradycardia persists refer to the Bradycardia Protocol (ACLS 2)  Administer a Dopamine infusion 5-20 mcg/kg/min (Rx: 12) (Procedure 15) for persistent hypoperfusion  Administer an Epinephrine infusion (Rx: 13) for heart transplant recipients or persistent hypoperfusion o Epinephrine infusion 2-10 mcg/min

“When in doubt, do something in favor of your patient.” Jay Cloud