Download dysrhythmias

PUEBLO COUNTY MEDICAL
TREATMENT
PROTOCOL S
DYSRHYTHMIAS
U P D A T E D :
K .
W E B E R ,
M D
3/08/2012
D .
W I L S O N ,
M D
Specific information needed
1. Present symptoms -- sudden or gradual onset, palpitations.
2. Associated symptoms -- chest pain, dizziness or fainting, trouble breathing, abdominal
pain, fever.
3. Prior history -- angina, dysrhythmias, cardiac disease, exercise level, pacemaker.
4. Current medications, particularly cardiac.
Specific objective findings
1. Vital signs.
2. Signs of poor cardiac output:
a. Altered level of consciousness.
b. "Shocky" appearance -- cold clammy skin, pallor.
c. Blood pressure < 90 systolic.
3. Signs of cardiac failure (increased back-up pressure):
a. Neck vein distention.
b. Lung congestion, crackles (rales).
c. Peripheral edema -- sign of chronic failure, not acute.
4. Signs of hypovolemia:
a. Sinus tachycardia, 100 -- 150 (usually).
b. Flat neck veins.
c. Poor peripheral perfusion.
d. Evidence of blood loss (see Shock - Medical.)
e. Evidence of dehydration (dry mouth, tenting skin, etc.)
5. Signs of hypoxia: marked respiratory distress, cyanosis, tachycardia.
6. Signs of hypothermia: cold skin, decreased level of consciousness.
Treatment
1. O2, high flow (10-15 L/min). Titrate to pulse oximetry > 90% if possible. Place in
position of comfort.
2. IV -- NS, TKO.
3. Evaluate the patient: IS THE PATIENT PERFUSING ADEQUATELY OR ARE THERE
SIGNS OF INADEQUATE PERFUSION?
4. Apply cardiac monitor and evaluate rhythm:
a. Is there a pulse corresponding to the monitor rhythm?
b. Rate -- tachycardia, bradycardia, normal?
c. Are the ventricular complexes wide or narrow?
d. What is the relationship between atrial activity (P waves) and ventricular activity
(QRS-T complexes)?
e. IS THE DYSRHYTHMIA POTENTIALLY DANGEROUS ELECTRICALLY TO THE PATIENT?
(See Note below.)
5. Document the rhythm by recording the ECG.
6. Treat if needed according to pulse rate (see protocols) or as directed by base physician.
7. Document results of treatment (or lack thereof) by checking pulse and recording the
ECG.
8. Transport non-emergency if patient is stable. Monitor condition enroute.
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PUEBLO COUNTY MEDICAL
TREATMENT
PROTOCOL S
DYSRHYTHMIAS
U P D A T E D :
K .
W E B E R ,
M D
3/08/2012
D .
W I L S O N ,
M D
Specific precautions
1. TREAT THE PATIENT NOT THE DYSRHYTHMIA! If the patient is perfusing adequately,
he does not need emergency treatment. This is true of bradyrhythms as well as
tachyrhythms. What is normal for one person may be fatal to another.
2. Documentation of dysrhythmias is extremely important. Field treatment of a
dysrhythmia may be life-saving, but long-term treatment requires knowing what the
problem was. Documentation also allows for learning and discussion after the case.
These cases are not common, and should be reviewed and used as learning tools by as
many prehospital personnel as possible.
3. Correct dysrhythmia diagnosis based only on monitor strip recordings is difficult and
often not possible. Treatment must be based on observable parameters: rate, patient
condition and distance from the hospital. Whenever possible, treatment in the field
should be undertaken only after consultation with base physician.
4. Electrically "dangerous" rhythms are those which do not necessarily cause poor
perfusion, but are likely to deteriorate. They require recognition and treatment to
prevent degeneration to mechanically significant dysrhythmias. Among the electrically
dangerous rhythms are: multiple and multifocal PVCs, ventricular tachycardia, and
Mobitz II 2nd degree block.
5. Cardiac arrest and life-threatening dysrhythmias can be successfully treated in the field,
and show the benefits of "stabilization prior to transport" in prehospital care. The
patient is better off when the duration of arrest or poor perfusion is minimized.
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PUEBLO COUNTY MEDICAL
TREATMENT
PROTOCOL S
DYSRHYTHMIAS
U P D A T E D :
K .
W E B E R ,
3/08/2012
M D
D .
W I L S O N ,
M D
BRADYCARDIC DYSRHYTHMIAS
Rhythm strip assessment
1. Rate.
2. Relation of P waves to ventricular complexes.
3. Irregular ventricular complexes (block or atrial fibrillation)?
4. Ectopic beats -- premature or late?
Indications for treatment
1. Signs of poor perfusion -- BP < 90 systolic, diaphoresis, dizziness, confusion, chest pain.
2. Pulse < 60 in patient > 40 years old.
3. Presence of premature ventricular contractions or ventricular escape beats.
4. Relative contraindication to aggressive treatment -- atrial fibrillation.
Treatment
1. O2, high flow (10-15 L/min). Titrate to pulse oximetry > 90% if possible.
2. Patient in position of comfort.
3. Apply ECG monitor and obtain a 12 lead if possible.
4. IV -- volume expander large bore, TKO or as needed based on patient condition.
5. If signs of poor perfusion with hypotension:
6. Consider atropine (see atropine protocol).
7. Consider external pacing and sedation (see pacing and diazapam protocols).
8. Consider dopamine for hypotension (see dopamine protocol).
9. Consider options with base physician and transport rapidly if transvenous pacemaker
indicated.
10. If pulses disappear, initiate CPR and treat as PEA.
Specific precautions
1. If patient in atrial fibrillation, do not use atropine or dopamine unless absolutely
necessary (to avoid provoking uncontrolled ventricular response).
2. Pain from injury can occasionally cause marked vagal stimulation, with bradycardia and
hypotension. This will respond to positioning with legs elevated or administration of
atropine or fluids. Pain control may also be helpful.
3. Well-conditioned athletes may normally be bradycardic, with pulses equal to or less than
40 beats/minute; ask your patient what is normal for him or her. In the setting of chest
pain or possible acute MI, sinus bradycardia under 60 beats/minute should be treated
when it is associated with hypotension or ectopy.
4. Second or third degree heart block should not be treated if the patient is doing well.
Chronic 3rd degree block is often well tolerated, particularly when the ventricular rate is
50 or above. Symptoms most often occur when the block develops acutely.
5. Differentiate premature ventricular beats from escape beats, which are wide complexes
occurring late after the preceding beat as a lower pacemaker cell takes over. Escape
beats are beneficial to the patient and should be treated by increasing the underlying
rate and conduction; not by suppressing the escape beat. Premature beats associated
with a bradycardia also may respond to increasing rate.
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PUEBLO COUNTY MEDICAL
TREATMENT
PROTOCOL S
DYSRHYTHMIAS
U P D A T E D :
K .
W E B E R ,
3/08/2012
M D
D .
W I L S O N ,
M D
NORMAL RATE DYSRHYTHMIAS
Rhythm strip assessment
1. Rate.
2. Regularity, evidence of atrial fibrillation, A-V block.
3. P waves -- relationship to ventricular complexes.
4. Ectopic beats -- wide or narrow?
Indications for treatment
1. Premature wide complex beats (presumed PVCs) in presence of chest pain which occur:
2. Multiformed.
3. Couplets or salvos.
4. R on T
Treatment
1. If no pulse, initiate CPR and treat according to PEA protocol. Otherwise:
2. O2, high flow (10-15 L/min). Titrate to pulse oximetry > 90% if possible.
3. Patient in position of comfort.
4. Apply ECG monitor and obtain a 12 lead if possible.
5. IV -- volume expander, large bore, TKO or as needed based on patient condition.
6. If BP < 90 systolic -- treat for Shock, Medical.
7. If BP > 90, determine if atrial fibrillation or any conduction block exists (1st, 2nd, or 3rd
degree). If so, avoid treatment and discuss options with base. Monitor these patients
closely to detect deterioration of rhythm.
8. If BP > 90 and patient in normal sinus rhythm, treat significant PVCs in presence of chest
pain with:
a. Lidocaine (see lidocaine protocol).
b. Consider nitroglycerin (see nitroglycerine protocol).
c. Consider magnesium sulfate (see magnesium sulfate protocol).
Specific precautions
1. PVCs are common in elderly patients who are seen for any reason. They should only be
treated in the presence of acute cardiac symptoms. Discuss any other indications with
base before treatment.
2. Atrial fibrillation is commonly complicated by wide complex beats. Many of these are not
ventricular, despite their looks. In addition, lidocaine can cause uncontrolled ventricular
rates. Avoid treatment when not essential.
3. Propranolol and other beta-blockers can prevent the tachycardic response to pain,
hypoxia, or hypovolemia. Look carefully for hidden problems in patients on these
medications.
4. Acute atrial fibrillation may cause hypotension because the atrial "kick" is lost and
ventricular filling suddenly becomes less adequate. Acutely, it is usually accompanied by
a ventricular response > 150/minute. If the ventricular rate is in the normal range, the
rhythm is most likely chronic. Look for other causes of patient deterioration.
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PUEBLO COUNTY MEDICAL
TREATMENT
PROTOCOL S
DYSRHYTHMIAS
U P D A T E D :
K .
W E B E R ,
3/08/2012
M D
D .
W I L S O N ,
M D
TACHYCARDIC DYSRHYTHMIAS
Rhythm strip assessment
1. Rate, regularity of complexes.
2. Ventricular complexes -- wide (QRS > .12) or narrow.
3. P waves if detectable and relation to QRS.
Indications for treatment
1. Signs of poor perfusion -- BP < 90 systolic, diaphoresis, confusion, dizziness.
2. Chest pain.
3. Signs of hypovolemia (poor perfusion plus low venous pressure).
4. Pulmonary edema.
Treatment
1. O2, high flow (10-15 L/min). Titrate to pulse oximetry > 90% if possible.
2. IV -- volume expander TKO or as directed.
3. If pulse >100 AND < 150, look for signs of hypovolemia and treat according to Medical
Shock Protocol.
4. Narrow complex tachycardia, regular rhythm, pulse > 150 (Except atrial flutter or atrial
fibrillation):
a. Good perfusion -- observe.
b. Conscious but signs of poor perfusion:
i. Consider Valsalva and observe monitor for gradual or abrupt slowing.
ii. Consider carotid sinus massage (see carotid sinus massage protocol).
iii. Consider adenosine (see adenosine protocol).
c. Unconscious:
i. Cardiovert (see cardioversion protocol).
5. Narrow complex atrial flutter or atrial fibrillation, pulse > 150 (atrial fibrillation):
a. Good perfusion and no other complications -- observe.
b. Good perfusion, but complicating factors such as pulmonary edema
i. Conscious but signs of poor perfusion or unconscious:
ii. Cardiovert (see cardioversion protocol).
6. Wide complex tachycardia, pulse > 150:
a. Good perfusion:
i. Amiodarone (see amiodarone protocol).
ii. If no response -- observe, transport.
b. Conscious but signs of poor perfusion:
i. Amiodarone (see amoidarone protocol).
ii. Consider adenosine (see adenosine protocol).
iii. Consider magnesium sulfate (see magnesium sulfate protocol).
iv. Consider cardioversion with sedation (see cardioversion and specific
benzodiazapine protocol).
c. Unconscious with ventricular rate > 150:
i. Cardiovert (see cardioversion protocol).
ii. After conversion, administer amiodarone (see amiodarone protocol).
Specific precautions
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PUEBLO COUNTY MEDICAL
TREATMENT
PROTOCOL S
DYSRHYTHMIAS
U P D A T E D :
K .
W E B E R ,
M D
3/08/2012
D .
W I L S O N ,
M D
1. Wide complex tachycardias may be ventricular or supraventricular in origin. Treatment
should be based on adequacy of perfusion. Assume ventricular tachycardia in the
emergency care setting if the patient is symptomatic.
2. It is most difficult to know how aggressive to be in treating the patient in the "grey"
zone: symptomatic but conscious. Discuss with base, consider transport time, patient
complaints, and vital signs.
3. Tachycardia is most likely a secondary problem with rate variation over time or when the
pulse < 150. Treat hypoxia, hypovolemia, pain and other problems first.
4. Unconscious patients (from CVA or other causes) may present with a secondary
tachycardia. Unconsciousness due to the tachycardia is usually associated with a rate
greater than 180 and poor peripheral pulses.
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