Adult Cardiogenic Shock Designation of Condition: The patient will present with signs and symptoms of hypoperfusion usually accompanied by hypotension (BP <90 mmHg), shortness of breath often secondary to pulmonary edema (wet noisy respirations/crackles and, if severe, possibly pink frothy sputum), and other indicators of hypoperfusion such as confusion, decreasing LOC and diaphoresis. These signs and symptoms are usually observed in the setting of AMI and require expeditious transport Oxygen at a flow rate sufficient to maintain SpO2 >90% Allow the patient to seek a position of comfort (Fowler’s recommended if possible) Obtain a complete set of vital signs B Manage airway and provide BVM ventilatory assistance as necessary Consider CPAP if noted pulmonary edema If patient complains of chest pain, consider Cardiac and STEMI guidelines IV/IO NS TKO or saline lock I If lung sounds are clear, administer a 5-10 ml/kg NS bolus repeat to effect, SBP >90 mmHG, max 2L Monitor cardiac rhythm Obtain 12 lead ECG, STEMI ALERT if indicated Caution with excess fluids in cardiogenic shock; consider the presence of pulmonary edema; utilize pressors early If no improvement with fluid bolus, or if fluids are contraindicated because of pulmonary P edema: Epinephrine Drip of 2 mcg/min IV/IO, increase 2mcg/min to max of 10mcg/min or Norepinephrine drip of 4 mcg/min IV/IO, increase 2 mcg/min to a max of 10 mcg/min or Epinephrine mini-bolus of 0.5 to 1 cc of 1:100,000 IV/IO q 1 min PRN To a goal SBP > 90 mmHg ***KEY POINTS*** Remember this is a primary pump failure with decreased cardiac output ETCO2 reading of <25mmHg may be sign of poor perfusion Continuous Central Line Infusion Pump Designation of Condition: A patient being treated with a continuous central line infusion If patient is conscious: • Perform primary and secondary surveys and provide care as appropriate • If a problem exists with the patient’s central IV line that compromises the continuous infusion, initiate a peripheral IV/IO and connect the tubing directly to the peripheral IV catheter after ensuring patency of the peripheral line • Utilize patient’s expertise to ensure patient’s ambulatory pump is working properly and is infusing at the correct rate If the patient is unconscious: • Perform primary and secondary surveys and provide care as appropriate • Evaluate whether the medication is infusing properly via the patient’s central IV line by inspecting the patient’s ambulatory pump for signs of proper operation • If it is infusing properly, leave infusion as is and allow patient’s ambulatory pump to control the infusion en route to the hospital P • If the medication is not infusing properly via the patient’s central IV line and you determine it is due to occlusion of the central IV line, initiate a peripheral IV/IO and connect the medication tubing directly to the peripheral IV/IO catheter after ensuring patency of the peripheral line • If patient’s ambulatory pump is alarming another type of failure, troubleshoot as possible, gather all materials necessary and transport patient emergently to the hospital If the patient is in cardiac arrest: • Perform a primary survey and treat the cardiac arrest per guideline • Ensure the continuous infusion is either through the patient’s central IV line or through a designated peripheral IV/IO line. Remember, ACLS drugs must be administered through a SEPARATE IV/IO. In all cases, upon arrival at the hospital, ensure the staff is informed of the patient’s condition and of the need for the continuous infusion Adult Narrow Complex Tachycardia Irregular Rhythm Designation of Condition: The patient will have a rapid heart rate (often greater than 150 bpm) with Atrial Flutter or Atrial Fibrillation on the ECG or 12 Lead ECG (if available) with a QRS < 0.11 sec ABC’s, Vital signs Apply cardiac monitor Acquire 12 lead in first 5 minutes O2 to maintain an SpO2 of >90% Capnography B If patient is hemodynamically stable but has severe chest pain administer: Administer ASA 324 PO refer to ACS guideline If patient is significantly SOB with rales on auscultation refer to Pulmonary Edema / Congestive Heart Failure IV/IO Consider fluid bolus of 500ml to rule out hypovolemia/dehydration as cause of tachycardia Repeat as patient condition requires I OR If patient is significantly SOB with rales on auscultation do not give fluid bolus Narrow Irregular Stable Narrow Irregular Unstable (A-fib, WPW, MAT) Hypotension/weak or no radial pulse, acute AMS, ischemic chest pain, acute CHF, syncope, s/sx of cardiogenic shock Obtain 12 lead ECG Supportive care Consider sedation with Treatment of symptoms Midazolam 1-5mg P Close observation IV/IO/IM/IN Consider placing the pads on the Synchronized Cardioversion patient and prep medications for LP15: 100J, 200J, 300J, 360J decompensation Zoll: 75J, 120J, 150J, 200J P If time permits: sedate prior to cardioversion If unable to sedate, treat post cardioversion pain per pain control guideline DO NOT GIVE BOTH NARCOTICS AND BENZODIAZEPINES ***KEY POINTS*** Be aware that cardioversion of the patient who has not been adequately anti-coagulated carries a significant risk of embolic stroke and pulmonary embolism. Patients with symptoms >48 hours are at greatest risk. Consider rapid transport and MCEP consultation prior to cardioversion if time permits. If cardioversion cannot be delayed, assess post cardioversion for possible stroke/PE symptoms Adult Narrow Complex Tachycardia Regular Rhythm Designation of Condition: The patient will have a regular heart rate greater than 150 bpm with a supraventricular focus. P-waves will not be present. QRS complexes are most often narrow (<0.11 sec), but may be wide if patient has pre-existing ventricular conduction defect or reentrant conduction via accessory pathway ABC’s, Vital signs Apply cardiac monitor Acquire 12 lead in first 5 minutes B O2 to maintain an SpO2 of >90% Capnography Administer ASA 324 PO IV/IO Consider fluid bolus of 500ml to rule out hypovolemia/ I dehydration as cause of tachycardia Repeat as patient condition requires Narrow Regular Stable Narrow Regular Rhythm Unstable (SVT. A-Flutter, PAT) Hypotension/weak or no radial pulse, acute AMS, ischemic chest pain, acute CHF, syncope, s/sx of cardiogenic shock Attempt vagal maneuvers (NO carotid massage) or modified Valsalva Consider sedation with Midazolam 1-5mg Consider placing the P IV/IO/IM/IN pads on the patient and prep medications for Synchronized Cardioversion decompensation LP15: 100J, 200J, 300J, 360J Zoll: 75J, 120J, 150J, 200J P If time permits: sedate prior to cardioversion If unable to sedate, treat post cardioversion pain per pain control Adenosine 6mg RIVP preferably guideline in a proximal IV followed by a 20ml flush DO NOT GIVE BOTH NARCOTICS AND A 2nd dose of 12mg may be P BENZODIAZEPINES given after 1-2 min if no change Contraindicated in WPW ***KEY POINTS*** Be aware that cardioversion of the patient who has not been adequately anti-coagulated carries a significant risk of embolic stroke and pulmonary embolism. Patients with symptoms >48 hours are at greatest risk. Consider rapid transport and MCEP consultation prior to cardioversion if time permits. If cardioversion cannot be delayed, assess post cardioversion for possible stroke/PE symptoms Adult Symptomatic Bradycardia Designation of Condition: The patient will present with a heart rate typically <50bpm with associated signs and symptoms of hypoperfusion (decreased or altered LOC, chest pain, lightheadedness/dizziness, shortness of breath, acute heart failure or other SxS of shock) ABC’s Vital signs to include BGL Apply cardiac monitor B Acquire 12 lead in irst 5 minutes O2 to maintain an SpO2 of >90% Capnography Administer ASA 324 PO if C/O chest pain I IV/IO Stable Unstable (SBP >90mmHg / NO Altered Mental Status) (SBP <90mmHg / Altered Mental Status) Consider placing the pads on the patient and P prep medications for decompensation P Monitor and reevaluate the patient’s condition Transport to the appropriate facility Administer narcotics per the Pain Management guideline If narcotic administration is contraindicated P (e.g., patient allergy, hypotension, etc.), sedation may be utilized instead of analgesia: Administer Benzodiazepine OR Atropine 0.5mg IV/IO q 3-5 min to a max of 3mg The goal is a heart rate of at least 60 bpm and a blood pressure of 90 mmHg systolic (^LOC, ^hemodynamics). P In the setting of acute MI, cardiac transplant patients, third degree heart block or Mobitz type II second-degree heart block, Atropine is not effective, and should be used only after attempts at transcutaneous pacing have failed Epinephrine Drip of 2 mcg/min IV/IO, increase 2mcg/min to max of 10mcg/min or Norepinephrine drip of 4 mcg/min IV/IO, increase 2 mcg/min to a max of 10 mcg/min If Atropine and TCP P or are NOT successful Epinephrine mini-bolus of 0.5 to 1 cc of with signs and 1:100,000 IV/IO q 1 min PRN symptoms of To a goal SBP > 90 mmHg profound shock or hypotension Maintain BP of >90mmHg Adult Wide Complex Tachycardia Irregular Rhythm Designation of Condition: Sustained ventricular tachycardia (broad QRS > 0.11ms) will be present on the monitor with an irregular pattern. The patient will have a pulse and may present with hypotension (SP <90mmHg), chest pain, shortness of breath, or diaphoresis ABC’s, Vital signs Apply cardiac monitor Obtain 12 lead ECG B O2 to maintain an SpO2 of >90% Capnography IV/IO Fluid bolus of 500ml, repeated as needed to a max of I 20ml/kg, to rule out hypovolemia or dehydrtation Is the patient stable? Unstable signs: Hypotension/weak or no radial pulse, acute AMS, ischemic chest pain, acute CHF, syncope, s/sx of cardiogenic shock YES NO Wide Polymorphic Stable Wide Polymorphic Unstable DO NOT GIVE ADENOSINE Consider sedation with Midazolam 1-5mg IV/IO/IM/IN If it is believed to be Torsades de to max of 10mg P Pointes: Magnesium Sulfate 2 grams IV/ Attempt to sync: IO push.