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Protocol
ADULT CARDIAC / RESPIRATORY ARREST
C-1
ADULT CARDIAC/ RESPIRATORY ARREST
October 1, 2013
BLS-Specific Care
# For unwitnessed arrest: Consider 2 minutes of good, sustained, and
effective CPR prior to defibrillation or AED attachment.
# For witnessed arrest, or after 2 minutes of good, effective and sustained
CPR use the AED
% Single shocks are recommended to reduce interruption of CPR.
#
Reduce interruptions of chest compression. Compressions should be
interrupted for the following only:
% Rhythm check
% Delivering a shock
% Moving the patient from the floor to the cot
#
When VF/pulseless ventricular tachycardia (VT) is present, deliver 1 shock
and immediately resume CPR, beginning with chest compressions. Do
not delay resumption of chest compressions to recheck the rhythm
or pulse.
After 5 cycles (about 2 minutes) of CPR, analyze the cardiac rhythm and
deliver another shock if indicated. If a non-shockable rhythm is detected,
resume CPR immediately.
Change personnel performing chest compressions every 2 minutes during
rhythm check if feasible
Avoid hyperventilation/hyperinflation through careful use of BVM, airway
adjuncts. Ventilations should occur over 1-2 seconds.
Oxygen-Administer 100% initially until ROSC then titrate down to a goal of
>94%
Notify responding ALS unit ASAP
Obtain BG
#
#
#
#
#
#
ILS-Specific Care
# LMA or other supraglottic airway as appropriate.
# IV access (to a max of three attempts)
# IO access if needed due to severity of underlying injury or illness
% IV: Crystalloid solution at a TKO rate. May administer 200-500 cc
if S/S of dehydration are present, repeat as needed
% Withhold fluids and maintain IV at TKO rate if patient is
hemodynamically stable or signs and symptoms of fluid overload
are present. Use caution in patients with a history of CHF
ALS-Specific Care
# Advanced airway management as appropriate.
% Consider supraglottic airway placement until ROSC obtained
% Compressions should not be stopped for ETT placement
% Goal is attempt to take <20 seconds
Protocol
#
#
#
Consider underlying causes of cardiac arrest and treat as well
% & % # % $ % hyper/hypokalemia, hypothermia, hyper/hypoglycemia
% & ! $ ! ! " ! $ ! thromboembolism, trauma
Rhythm-specific therapy (see appropriate protocols).
The precordial thump may be considered for patients with witnessed,
monitored, unstable VT (including pulseless VT) if a defibrillator is not
immediately ready for use, but it should not delay CPR and shock delivery.
# Epinephrine
% IV/IO: 1 mg (1:10,000) every 3-5 minutes
% ET: 2-2.5 x IV dose (1:1,000 diluted to a volume of 8-10 cc)
#
Consider underlying causes of cardiac arrest and treat accordingly.
#
Consider as appropriate:
# Sodium bicarbonate for known hyperkalemia, bicarb acidosis (DKA,
TCA), prolonged resuscitation after ROSC.
% IV/IO: 1 mEq/kg bolus, may repeat ½ dose 5-10 minutes
thereafter.
% Minimum initial dose 50 mEq
% Follow TCA recommendations if TCA overdose is suspected.
# Calcium chloride for suspected hyperkalemia, calcium channel
blocker OD, or suspected hypocalcemia.
%
#
#
IV/IO 500-1000 mg slow push
% Max: 1 g/dose
% Also administer sodium bicarbonate at 1 mEq/kg afterward.
Use a separate IV line for administration.
Albuterol sulfate (high dose) for suspected hyperkalemia.
% ETT: 10 mg (4 unit-doses) directly instilled into the ETT,
followed by brief hyperventilation.
Narcan (naloxone) for suspected narcotic overdose.
IV/IO: 2 mg repeat every 2-3 minutes PRN
IM: 2 mg repeat every 2-3 minutes PRN
IN: 2 mg split (1 mg each nare) repeat every 2-3 minutes PRN
% Max single dose 2 mg
%
%
%
#
% Failure to obtain reversal after 10 mg usually indicates
another disease process or overdose on non-opioid drugs.
Dextrose 50% for hypoglycemia.
% IV/IO: 6.25-25g slow IV push may repeat once
ADULT CARDIAC / RESPIRATORY ARREST
C-1
Protocol
C-2
ADULT CARDIOPULMONARY ARREST
October 1, 2013
ADULT CARDIOPULMONARY ARREST
Box #1:
#
#
#
#
If adequate CPR is being performed upon arrival:
Confirm cardiopulmonary arrest and, if necessary, continue CPR.
Apply defibrillation pads and cardiac monitor without cessation of CPR.
Move on to, Check for DNR/POST
Box #2:
Sudden, witnessed arrest in the presence of EMS:
Perform CPR only long enough to apply defibrillation pads and cardiac monitor.
Move on to, Check for DNR/POST
Box #3:
#
#
#
#
#
If inadequate CPR, or no CPR at all, is being performed upon arrival:
Initiate CPR
Check for DNR/POST
5 cycles 30 compressions to 2 ventilations (approximately 2 minutes)
Consider placement of supraglottic airway
During CPR:
%
Apply defibrillation pads and cardiac monitor.
%
Prepare for endotracheal intubation.
%
Prepare IV/IO equipment.
%
Move on to, Box #4:
Rhythm Check
Check Blood Glucose
VF/Pulseless VT:
Continue CPR while defibrillator
charges.
Shock @ manuf !
recommendation.
Immediately resume CPR without
pause for rhythm check.
Perform 5 cycles 30:2 (approx. 2
min)
Intubate without cessation of
compressions.
Asystole/PEA:
No shock indicated.
Immediately resume CPR.
5 cycles 30:2 (approx. 2 min)
Intubate without cessation of
compressions.
Protocol
Box #5:
Rhythm Check
VF/Pulseless VT:
Shock @ manuf !
recommendation. (ZOLL-200J)
#
Continue CPR while defibrillator
charges.
Immediately administer 2 minutes
of asynchronous CPR without
pause for rhythm check.
Obtain IV/IO access without
cessation of compression
Assess BG
MEDICATION ADMINISTRATION
DURING CPR:
IV/IO 1:10,000 epinephrine:
%
1 mg with 20 ml NS flush.
%
Repeat every 3-5 minutes as
needed
OR:
ETT 1:1,000 epinephrine:
%
If unable to obtain IV/IO
access.
%
2-2.5 mg diluted to 10 ml with
NS.
%
Repeat every 3-5 minutes as
needed.
Asystole/PEA:
No shock indicated.
Immediately administer 2 minutes
of asynchronous CPR without
pause for rhythm check.
Obtain IV/IO access.
Assess BG
MEDICATION ADMINISTRATION
DURING CPR:
Epinephrine (1:10,000):
% IV/IO: 1 mg (1:10,000) every
3-5 minutes
OR:
Epinephrine (1:1,000):
% If unable to obtain IV/IO
access.
% ETT: 2-2.5 mg diluted to 10 ml
with NS.
% Repeat every 3-5 minutes as
needed.
ADULT CARDIOPULMONARY ARREST
C-2
Protocol
C-2
ADULT CARDIOPULMONARY ARREST
Box #6:
Rhythm Check
VF/Pulseless VT:
!
recommendation. (ZOLL-200J)
% Continue CPR while defibrillator
charges.
Immediately administer 2 minutes of
asynchronous CPR without pause
for rhythm check.
MEDICATION ADMINISTRATION
DURING CPR:
st
Amiodarone 1 Line
antiarrrhythmic
% IV/IO: 300 mg (diluted in 2030cc of NS)
% Follow with a 150 mg dose after
3-5 minutes
Asystole/ PEA
#
#
#
#
#
#
#
#
Push hard & fast (100/min)
Ensure full chest recoil
Try to eliminate interruptions in
chest compressions
One cycle of CPR: 30 compressions
the 2 breaths; 5 cycles ' 2 min
Do Not hyperventilation
Secure airway & confirm placement
Rotate compressions every 2 minutes
with rhythm checks
Search for & treat possible
contribution factors:
#
#
Lidocaine 2%: (Refactory VF/VT)
% IV/IO: 1 mg/kg bolus, can
repeat in 3-5 minutes followed
by additional doses of 0.5
mg/kg
% Max: 3 mg/kg
% ETT Administration32 mg/kg (2
times the IV dose) every 3-5
minutes PRN
% Max: 3 mg/kg
Lidocaine maintenance
infusion:***
% 1 g in 250 ml of NS yields 4
mg/ml ran at 2-4 mg/min (Start
@ 2 mg/min & add 1 mg/min for
each additional 1 mg/kg IV
bolus)
% 1 mg/kg bolus = 2 mg/min.
% 1.5-2 mg/kg total bolus = 3
mg/min.
% 2.5-3 mg/kg total bolus = 4
mg/min.
IV/IO Magnesium Sulfate:
st
% IV: 2 g every 5 minutes, 1 line
for Torsades or refractory VFib/Pulseless V-Tach. Take 2 g
(4cc), dilute to a total of 20 cc to
make 10% solution. Do not
give faster than 1 g/minute.
#
#
#
#
#
#
#
Hypovolemia
Hypoxia
Hydrogen ion (acidosis)
Hypo-/hyperkalemia
Hypothermia
Toxins
Tamponade, cardiac
Tension Pneumothorax
Thrombosis (coronary or
pulmonary)
* After an advanced airway is placed,
CPR.
Give continuous chest compressions without
pauses for breaths. Give 8 to 10
breaths/minutes. Check rhythm every 2
minutes.
Protocol
C-2
- - # % (( '+ * " #$ # '#$$ )& ' " '! (
- # #% # ) - Sequence until:
# Transport/transfer of care is complete.
# Resuscitative efforts are terminated
# A rhythm change occurs.
If a rhythm change occurs, treat according to its respective algorithm, starting at
the top of that algorithm.
Additional pharmacologic therapies:
Sodium bicarbonate:
% IV/IO: 1 mEq/kg bolus, may repeat ½ dose 5-10 minutes thereafter.
% Minimum initial dose 50 mEq
Amiodarone:
% Post conversion IV/IO infusion of 1mg/min
Calcium chloride: For suspected arrest due to hyperkalemia
or calcium channel blocker overdose.
% IV/IO: 500-1000 mg. Flush line thoroughly before and
after administration.
Albuterol: For suspected hyperkalemia.
% ETT: 10 mg (4 unit doses) directly instilled into the ETT followed by
brief hyperventilation.
#
Narcan (Naloxone): suspected opiate overdose
% IV/IO/ETT/IN/IM 2 mg repeat every 2-3 minutes PRN
% Max single dose 2 mg
Dextrose:
% IV/IO: 6.25-25g slow IV push may repeat once
ADULT CARDIOPULMONARY ARREST
Continue the following:
Protocol
GENERAL CARDIAC CARE/A.C.S.
C-3
GENERAL CARDIAC CARE/ACS
October 1, 2013
BLS SPECIFIC CARE:
# Basic BLS care and assessments including oxygen administration and v/s
every 5 minutes
# AED at patient side; Pads may be placed (but do not turn AED on unless
pulses are lost) if patient appears in extreme distress
# Consider assisted ventilations with signs of severe respiratory distress
# Assistance ublingual
nitroglycerin (NTG.):
% Determine how many doses the patient has already selfadministered
% If the patient has not already administered/received a total of 3
doses, licensed EMTs may assist patient with sublingual
administration of up to a total of 3 doses
% DO NOT administer if:
# $ # $ " # The p $ ! # The patient has taken a total of 3 doses prior to EMS arrival
# The patient presents with altered mental status
# The patient has taken medications for erectile dysfunction in
the preceding 24 hours
#
Pharmacologic:
% Aspirin:
# Four (4) 81 mg chewable tabs (324 mg total.)
# Administer even if patient has received normal daily dose within the
past 24 hours
# Do not administer if patient is taking other anticoagulants/platelet
aggregation inhibitors
# Do not administer if:
% Patient history of aspirin allergy
% Recent history of GI or other internal bleeding/disorders
Protocol
ILS SPECIFIC CARE:
# IV access (to a max of three attempts) only if needed due to severity of
underlying injury or illness, otherwise defer until arrival of ALS providers
# Limit fluid administration unless symptomatic, hypotensive, and with clear
lung sounds
# An end goal of 2 IV lines is a desirable goal to facilitate cath
lab/thrombolytic care
ALS SPECIFIC CARE:
# EKG Must be obtained prior to Nitrates
# Use caution if EKG indicates inferior MI obtain a right sided EKG.
% Do Not use Nitrates on right sided MI
# Nitrates:
% Tablet?One tablet (0.4 mg) sublingual, may be repeated every 3-5
minutes, (Hold for systolic <90)
% Spray?1 spray (0.4 mg) under tongue, may be repeated every 3-5
minutes, (Hold for systolic <90)
% Infusion: Start with 10 mcg\min. Increase until desired response is
obtained, (after SL NTG has been initiated)
(maintaining systolic B/P > 90 mmHg)
#
Analgesics and/or sedatives:
% Discontinue or do not administer if:
# Signs and symptoms of hypoperfusion are present or develop
# Respiratory rate, SpO2 and/or mental status diminishes
# Contact OLMC to exceed maximum doses
# The Paramedic MAY reduce the dose of any analgesic/sedative to
achieve needed results
% Fentanyl: To be used if allergic to morphine
# IV/IN/IO: 25-50 mcg slow push
# MAX of 100 mcg for ACS/ischemic chest pain
#
Anti-emetics:
% Zofran (Ondansetron)
# IV/IO: 4 mg, repeated once in 10 minutes PRN
# ODT: 4 mg, repeated once in 10 minutes PRN
% Benadryl (Diphenhydramine)
# IV/IM/IO: 25-50 mg may repeat in 10-15 minutes PRN
# Max single dose: 50 mg
# Max total: 100 mg
GENERAL CARDIAC CARE/A.C.S.
C-3
Protocol
STEMI PROTOCOLS
C-4
STEMI PROTOCOLS/FLOW CHART
October 1, 2013
BLS SPECIFIC CARE:
# General Cardiac/ACS protocols C-3
# Obtain the following information for data transmission
% Pt Last Name
% Pt First Name
% Pt DOB (mm/dd/yyyy)
% % Pt Age
% Pt Sex
# Patients PMH including but not limited to:
% Meds
% Allergies
% POST/DNR/DNI status
ILS SPECIFIC CARE:
# IV Access (to a max of three attempts)
# Avoid use of Right hand and wrist
# End goal of 2 IV lines for cath lab/thrombolytic care
# IO access if needed due to severity of underlying injury or illness
% IV: Crystalloid solution at a TKO rate. May administer 200-500cc if
S/S of dehydration are present, repeat as needed
% Withhold fluids and maintain IV at TKO rate if patient is
hemodynamically stable or signs and symptoms of fluid overload
are present. Use caution in patients with a history of CHF
PECIFIC CARE:
ALS SPECIFIC CARE:
# Confirm STEMI with 12-lead
and transmit to receiving
facility
% Unit ID
% Stable vs Unstable
(hemodynamic)
% Age
% Gender
% Post/DNR/DNI
#
GOAL is less 10 minute scene time
% Name of Cardiologist (if
available)
% ETA
% Stay on Hospital
frequency
STEMI PROTOCOLS
Protocol
C-4
Protocol
ADULT WIDE-COMPLEX TACHYCARDIA
C-5
ADULT WIDE-COMPLEX TACHYCARDIA
October 1, 2013
BLS-Specific Care See General Cardiac Care and ACS Protocol C-3
ILS-Specific Care See General Cardiac Care and ACS Protocol C-3
# IV access (to a max of three attempts)
# IO access if needed due to severity of underlying injury or illness
% IV: Crystalloid solution at a TKO rate. May administer 200-500cc if
S/S of dehydration are present, repeat as needed
% Withhold fluids and maintain IV at TKO rate if patient is
hemodynamically stable or signs and symptoms of fluid overload
are present. Use caution in patients with a history of CHF.
ALS-Specific Care See General Cardiac Care and ACS Protocol C-3
Cardioversion for hemodynamically UNSTABLE patients
# Electrical Therapy is the primary treatment for ALL hemodynamically
UNSTABLE patients
# Synchronized cardioversion per manufacturer recommendation
# Polymorphic VT (torsades de Pointes) will usually not permit synchronized
cardioversion. Proceed with high energy unsynchronized shocks. (120200j)
# Sedation/Analgesia prior to cardioversion is highly desirable, but not
mandatory. If IV access cannot be obtained for prompt sedation, then
cardioversion may be performed without sedation.
% See the Adult Pain Control and Sedation Protocol M-11 for
medications and doses.
% Use Versed (Midazolam) for sedation in cardioversion.
#
Antiarrhythmics for hemodynamically STABLE patients
% Lidocaine (Xylocaine)
#
IV: 1 mg/kg slow bolus followed by additional doses of 0.5 mg/kg every 5-10
minutes. If ectopy resolves, can set up a continuous infusion. (Be sure to
rebolus @ 0.5-0.75 mg/kg in 8-10 minutes to maintain therapeutic levels of
lidocaine if infusion not set up)
Max: 3 mg/kg or 300 mg in 30 minutes (not including infusion)
#
Continuous infusion
#
% 1 g in 250 ml of NS yields 4 mg/ml ran at 2-4 mg/min (Start @ 2
mg/min & add 1 mg/min for each additional 1 mg/kg IV bolus)
% 1 mg/kg bolus = 2 mg/min.
% 1.5-2 mg/kg total bolus = 3 mg/min.
% 2.5-3 mg/kg total bolus = 4 mg/min.
Protocol
% Amiodarone
# IV/IO: 150 mg over 10-15 minutes (15mg/min)
# May repeat in 10 minutes as needed
# Post conversion infusion of 1mg/min
% Magnesium sulfate:
# First line agent in treatment of hemodynamically stable polymorphic
wide complex tachycardia (torsades de pointes.)
# Also indicated in treatment of refractory VF, wide complex tachycardia
in the presence of suspected hypomagnesemia and life threatening
ventricular dysrhythmias due to suspected digitalis toxicity.
% IV: 2 g over 5 minutes,
% Take 2 g (4cc), dilute to a total of 20 cc to make 10% solution.
% Do not give faster than 1 g/minute
% Adenosine (Adenocard): Consider for suspected SVT with aberrancy or
wide, regularly monomorphic tachycardia. Use Lidocaine or
Amiodarone instead of Adenosine in cases of known VT.
% 6 mg rapid IV bolus followed by 20 ml flush
% No response in 1-2 minutes'12 mg
#
Sedation
Consider sedation prior to cardioversion if it will not cause unnecessary
delays.
% DO NOT administer if:
# Systolic BP < 90 mmHg.
# Low respiratory rate, SpO2 and/or diminished mental status.
% Versed (Midazolzam):
# IV/IO: 0.5-5 mg, repeat every 5-10 minutes PRN
# IM: 5 mg repeat every 10-15 minutes PRN
# IN: 5 mg repeat every 5-10 minutes PRN (divided between nostrils)
# Max: 10 mg
ADULT WIDE-COMPLEX TACHYCARDIA
C-5
Protocol
ADULT NARROW COMPLEX TACHYCARDIA
C-6
ADULT NARROW COMPLEX TACHYCARDIA
October 1, 2013
BLS SPECIFIC CARE: See General Cardiac Care/ACS Protocol C-3
ILS SPECIFIC CARE: See General Cardiac Care/ACS Protocol C-3
# IV access (to a max of three attempts)
# IO access if needed due to severity of underlying injury or illness
% IV: Crystalloid solution at a TKO rate. May administer 200-500cc if
S/S of dehydration are present, repeat as needed
% Withhold fluids and maintain IV at TKO rate if patient is
hemodynamically stable or signs and symptoms of fluid overload
are present. Use caution in patients with a history of CHF.
ALS SPECIFIC CARE: See General Cardiac Care/ACS Protocol C-3
Vagal Manuevers
# Valsalva Manuever
# Carotid Sinus Massage (CSM) or Carotid Sinus Pressure (CSP)
Cardioversion for Unstable patients in A-Flutter & -Fib
# Synchronized cardioversion per manufacturer recommendation
# If synchronization is not obtained, proceed with unsynchronized
cardioversion at the same settings
Cardioversion for Unstable patients in A-Fibrillation:
% 120-200j unsynchronized
#
Sedation
Consider sedation prior to cardioversion if it will not cause unnecessary
delay.
% DO NOT administer if:
# Systolic BP < 90mmHg
# Low respiratory rate, Spo2 and/or diminished mental
status.
% Versed (Midazolam)
#
#
#
#
#
IV/IO: 0.5-5 mg slow push, repeat every 10 minutes PRN
IM: 5 mg slow push repeat every 15 minutes PRN
IN: 2.5-5 mg slow push repeat every 10 minutes PRN (divided
between nostrils)
Max: 10 mg
Obtain pre and post conversion 12-Leads if appropriate (time)
Protocol
#
Antiarrhythmics:
% Adenosine (Adenocard): Use Lidocaine or Amiodarone instead if
KNOWN VT. DO NOT administer to irregular or polymorphic
# 6 mg rapid IV bolus followed by 20 ml flush
# No response in 1-2 minutes/12 mg rapid IV push followed by a
20ml flush
% Cardizem (Diltiazem):
# Bolus: 0.25 mg/kg IV/IO over 2 minutes (Usual dose about 20 mg).
# May repeat in 15 minutes @ 0.35 mg/kg IV over 2 minutes
# Infusion: initial dose of 5mg/hr, may increase 5mg/hr increments
# MAX Infusion: 15mg/hr
# Hold for WPW
ADULT NARROW COMPLEX TACHYCARDIA
C-6
Protocol
ADULT BRADYCARDIA
C-7
ADULT BRADYCARDIA
October 1, 2013
BLS-SPECIFIC CARE: See General Cardiac Care/ACS Protocol C-3
# Obtain BG
ILS-SPECIFIC CARE: See General Cardiac Care/ACS Protocol C-3
# IV access (to a max of three attempts)
# IO access if needed due to severity of underlying injury or illness
% IV: Crystalloid solution at a TKO rate. May administer 200-500cc if
S/S of dehydration are present, repeat as needed
% Withhold fluids and maintain IV at TKO rate if patient is
hemodynamically stable or sign and symptoms of fluid overload are
present. Use caution in patients with a history of CHF
ALS-SPECIFIC CARE: See General Cardiac Care/ACS Protocol C-3
Atropine is the first line treatment for all symptomatic bradycardias.
For second-degree type ll or third-degree AV blocks consider immediate TCP
and/or vasopressor support.
# Consider sedation/analgesia with transcutaneous pacing if it will not
cause unnecessary delays.
# Transcutaneous pacing:
% Start at 80 ppm and 80 mA.
# Consider giving Atropine while preparing TCP if it does not delay
TCP
# Sedation:
% DO NOT administer if:
# Systolic BP < 90 mmHg
# Low respiratory rate, SpO2 and/or diminished mental status.
# Start at a lower dose if any of the above are present
#
% Versed (Midazolam):
# IV/IO: 0.5-5 mg, repeat every 10 minutes PRN
# IM: 5 mg repeat every 15 minutes PRN
# IN: 2.5-5 mg repeat every 10 minutes PRN (divided between
nostrils)
# Max: 10 mg
Analgesia:
%
Caution with administration if:
# Systolic BP < 90 mmHg
# Respiratory rate, SpO2 and/or mental status diminishes.
# Start at a lower dose if any of the above are present
Protocol
C-7
#
#
Pain Control/ Sedation/ Intubation
% IV/IM/IN/IO: 25-50 mcg slow push repeat every 5-10 minutes PRN
% Max: 200 mcg
ACS/ ischemic chest pain
% IV/IM/IN/IO: 25-50 mcg slow push repeat every 5-10 minutes PRN
% MAX of 100 mcg for ACS/ischemic chest pain
% Morphine:
# IV/IM/IO: 2-5 mg, repeated every 15 minutes PRN
# Max: 20 mg for severe pain
# Max: 10 mg for ischemic chest pain
# Hold for systolic BP <90
%
#
% Atropine sulfate:
# IV/IO: 0.5 mg every 3-5 min PRN
# Maximum total dose 3 mg.
# Maximum total dose of 0.04 mg/kg for morbidly obese patients.
#
Vasopressors:
For bradycardia or hypotension unresponsive to other therapies.
% Dopamine infusion:
# IV/IO 5-20 mcg/kg/min
# Titrated to adequate heart rate and/or blood pressure response.
# Max 20 mcg/kg/min
% Epinephrine infusion:
#
IV/IO Infusion: 2-10 mcg/min IV Infusion (requires medical control
authorization)
#
#
Titrated to adequate heart rate and/or blood pressure response.
ADULT BRADYCARDIA
% Fentanyl:
Protocol
CONGESTIVE HEART FAILURE/
PULMONARY EDEMA
CONGESTIVE HEART FAILURE/PULMONARY EDEMA
C-8
October 1, 2013
BLS SPECIFIC CARE: See General Cardiac Care/ACS Protocol C-3
ILS SPECIFIC CARE: See General Cardiac Care/ACS Protocol C-3
# IV access (to a max of three attempts)
# IO access if needed due to severity of underlying injury or illness
% IV: Crystalloid solution at a TKO rate. May administer 200-500cc if
S/S of dehydration are present, repeat as needed
% Withhold fluids and maintain IV at TKO rate if patient is
hemodynamically stable or signs and symptoms of fluid overload
are present. Use caution in patients with a history of CHF.
ALS SPECIFIC CARE: See General Cardiac Care/ACS Protocol C-3
# NTG
% SL: 0.4 mg SL spray/tab
% If SBP >180 mmHg initial dose up to 3 sprays/tabs
% If SBP 140-180 mmHg initial dose up to 2 sprays/tabs
% If SBP 90-140 mmHg initial dose of 1 spray/tab
% Infusion:
# Start with 10 mcg/min. Titrate up 5-10 mcg/min every 5-10 minutes
# SL NTG should be initiated first
# Max 200 mcg/min
% Hold for B/P <90, Viagra use (or similar drug) within previous 24 hours,
or suspected right-sided MI.
#
CPAP: See also Appendix A-6
% Medical Control required if BP less than 90 systolic.
% Initial setting at 2-5 cmH2O,
% Titrate upward for effect. MAX: 10 cmH2O
% Coaching will be required to reduce anxiety.
#
If coaching is unsuccessful, then consider low dose sedation
% Ativan (Lorazepam)
#
#
#
IV/IO: 1-2 mg slow push. repeat every 5-10 minutes PRN
IM: 1-2 mg slow push repeat every 10-15 minutes PRN
Max: 8 mg
% Valium (Diazepam)
# IV/IO: 2-5 mg slow push every 5-10 minutes
# Max: 10 mg
Protocol
% Versed (Midazolam)
#
#
#
#
IV/IO: 0.5-5 mg slow push, repeat every 10 minutes PRN
IM: 5 mg slow push repeat every 15 minutes PRN
IN: 2.5-5 mg slow push repeat every 10 minutes PRN (divided
between nostrils)
Max: 10 mg
CONGESTIVE HEART FAILURE/PULMONARY EDEMA
C-8
Protocol
C-9
INDUCED HYPOTHERMIA
October 1, 2013
INDUCED HYPOTHERMIA
BLS SPECIFIC CARE: See General Cardiac Care/ACS Protocol C-3
ILS SPECIFIC CARE: See General Cardiac Care/ACS Protocol C-3
# IV access (to a max of three attempts)
# IO access if needed due to severity of underlying injury or illness
% IV: Crystalloid solution at a TKO rate. May administer 200-500cc if
S/S of dehydration are present, repeat as needed
% Withhold fluids and maintain IV at TKO rate if patient is
hemodynamically stable or signs and symptoms of fluid overload are
present. Use caution patients with a history of CHF.
ALS SPECIFIC CARE: See General Cardiac Care/ACS Protocol C-3
INCLUSION CRITERIA:
ROSC
Age >16 (Adult)
Temp > 34 C / 93 F
SBP > 90mmHg or MAP >60 mmHg
EXCLUSION CRITERIA:
DNR/POST, or other Advanced
Directive
Obvious Terminal Illness
PROCEDURE:
Assess and Document:
Pupil Response
Neuro assessment
#
Neuro exam 5 minutes after ROSC
shows NO purposeful pain response
ETT, LMA secured and confirmed
Obvious Pregnancy
Obvious Traumatic Arrest
Airway Control:
Intubate as indicated
Ventilate to an ETCO2 of 35mmHg.
Do not hyperventilate.
Sedation and Paralytics:
% Versed (Midazolam): may be used to prevent shivering
# IV/IO: 0.5-5 mg, repeat every 10 minutes PRN
# Max: 10 mg
% Vecuronium (Norcuron): Use only when patient shivering is witnessed (to
prevent heat production) ADMINISTER ONLY AFTER ENDOTRACHEAL
TUBE type airway is SECURED and placement confirmed with SPO2 and
CONTINUOUS ETCO2
# IV: 0.1 mg/kg, repeated PRN.
Induced Hypothermia
% Establish a second IV/IO if possible.
% Expose the patient while protecting modesty.
% Cold Packs to Groin, Axilla, and Neck (if accessible).
% Saline/Water soaked Sheet applied to trunk
% Chilled Crystalloid
# IV: 30 cc/kg fluid bolus to max of 2 liters
Protocol
Target Systolic Blood Pressure: 90 mmHg
Vasopressors: titrate to a blood pressure of 90 mmHg systolic if chilled
saline does not maintain
Cold saline is a strong vasoconstrictor. Watch blood pressures closely!
% Dopamine infusion
# IV/IO 5-20 mcg/kg/min
# Not to exceed 20 mcg/kg/min without medical control
% Epinephrine infusion
# IV Infusion: 2-10 mcg/min IV Infusion (requires medical control
authorization)
Ensure early notification to receiving facility for expeditious coordination
of care.
INDUCED HYPOTHERMIA
C-9
Protocol
C-10
Left Ventricular Assist Device (LVAD)
Heartmate II
October 1, 2013
BLS-Specific Care
LVAD
Initiate ALS response if cardiopulmonary complaint or ACLS is indicated
Listen with stethoscope for the the LVAD
If LVAD is runningInitiate transport immediately per protocol
If LVAD not runningDedicate one person on scene to immediately call LVAD
coordinator- contact on tag of emergency bag
Check all connections
Follow instructions of LVAD coordinator for changing batteries
and/or system driver
Chest compressions '&%) if all attempts to start LVAD fail
Check blood glucose
Respiratory assistance per protocol
ILS-Specific Care
# IV access (to a max of three attempts)
# IO access if needed due to severity of underlying injury or illness
% IV: Crystalloid solution at a TKO rate. May administer 200500cc if S/S of dehydration are present, repeat as needed
% Withhold fluids and maintain IV at TKO rate if patient is
hemodynamically stable or signs and symptoms of fluid
overload are present. Use caution in patients with a history of
CHF.
ALS-Specific Care
Obtain HR from ECG monitor
ACLS medications per ACLS protocol
Defibrillate only if unresponsive
Cardioversion with sedation if indicated
Protocol
C-10
LVAD
Family will be specifically trained on LVAD- listen to the family on scene; assist
family with trouble shooting LVAD, transport trained family members with
patient when possible
Patients will be on Coumadin to prevent clots within system- higher risk for:
# Intracranial/internal bleeding with falls/trauma
Most patients will not have palpable pulse
BP may be difficult to obtain and will have a narrow pulse pressure
Oximetery will be accurate but HR off oximeter may not be accurate
Chest compressions need to be done slightly higher on the sternum to avoid
dislodging pump from the left ventricle.
Patient may be in VT/V-fib but still have adequate profusion due to pump
running.
Transport LVAD patients to St. Lukes Boise