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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