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Pulseless VT/VF Algorithm First Impression: Sick or not sick? Primary survey Unresponsive? Open airway, give 2 breaths Give oxygen when available If no pulse, 30 compressions/2 breaths Attach AED or monitor/defibrillator Assess ECG rhythm Shockable? YES Shock (defibrillate) 1 Resume CPR—5 cycles (about 2 minutes) Without interrupting CPR, start IV/IO During CPR, give vasopressor Epinephrine 1 mg every 3-5 min OR Vasopressin 40 U 1 in place of first or second epinephrine dose NO Asystole? Go to asystole algorithm Electrical activity present? Check pulse No pulse, go to PEA algorithm Pulse present? Assess vital signs, begin postresuscitation care REASSESS/MONITOR • Airway • Oxygenation/ventilation • Paddle/pad position/contact • Effectiveness of CPR • No O2 flowing over patient during shocks Attempt/verify: • Advanced airway placement • Vascular access Monitor and treat: • Glucose • Electrolytes • Temperature • CO2 SHOCKS Defibrillation • Monophasic: 360J all shocks • AED: Per manufacturer • Biphasic: Per manufacturer • Biphasic unknown: 200J initially, then same or higher as first shock REVERSIBLE CAUSES NO Assess ECG rhythm Shockable? YES Shock (defibrillate) 1 Resume CPR—5 cycles (about 2 minutes) During CPR, consider antiarrhythmic Amiodarone 300 mg IV/IO initial dose; consider repeat dose of 150 mg 1 in 5 min OR Lidocaine 1-1.5 mg/kg IV/IO initial dose (if amiodarone not available), then 0.5-0.75 mg/kg prn every 5-10 min; max cumulative dose 3 mg/kg Consider magnesium 1-2 g IV/IO for torsades de pointes Consider reversible causes of arrest • Pulmonary embolism— anticoagulants? surgery? • Acidosis—give oxygen, ensure adequate ventilation • Tension pneumothorax— needle decompression • Cardiac tamponade— pericardiocentesis • Hypovolemia—replace volume • Hypoxia—give oxygen, ensure adequate ventilation • Heat/cold—cooling/warming measures • Hypo—hyperkalemia (and other electrolytes)— correct electrolyte abnormalities • Myocardial infarction— fibrinolytics? • Drug overdose/accidents— antidote/specific therapy Algorithm assumes scene safety has been assured, personal protective equipment is used, no signs of obvious death or presence of do not resuscitate order, and previous step was unsuccessful Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Asystole/Pulseless Electrical Activity Algorithm First Impression: Sick or not sick? Primary survey Unresponsive? Open airway, give 2 breaths Give oxygen when available If no pulse, 30 compressions/2 breaths Attach AED or monitor/defibrillator Assess ECG rhythm Shockable? NO YES Go to pulseless VT/VF algorithm Resume CPR for about 2 min Without interrupting CPR, start IV/IO During CPR, give vasopressor Epinephrine 1 mg every 3-5 min or Vasopressin 40 U 1 in place of first or second epinephrine dose -----------If asystole or slow PEA, consider atropine 1 mg every 3-5 min; maximum total dose 3 mg YES Assess ECG rhythm Shockable? Algorithm assumes scene safety has been assured, personal protective equipment is used, no signs of obvious death or presence of do not resuscitate order, and previous step was unsuccessful REASSESS/MONITOR • Airway • Oxygenation/ventilation • Paddle/pad position/contact • Effectiveness of CPR Attempt/verify: • Advanced airway placement • Vascular access Monitor and treat: • Glucose • Electrolytes • Temperature • CO2 NO Resume CPR 5 cycles (about 2 minutes) REVERSIBLE CAUSES • Pulmonary embolism— anticoagulants? surgery? • Acidosis—give oxygen, ensure adequate ventilation • Tension pneumothorax— needle decompression • Cardiac tamponade— pericardiocentesis • Hypovolemia—replace volume • Hypoxia—give oxygen, ensure adequate ventilation • Heat/cold—cooling/warming measures • Hypo—hyperkalemia (and other electrolytes)— correct electrolyte abnormalities • Myocardial infarction— fibrinolytics? • Drug overdose/accidents— antidote/specific therapy Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Symptomatic Bradycardia Serious signs/symptoms due to the bradycardia (heart rate 60 bpm)? Hypotension Pulmonary congestion Dizziness Shock Ongoing chest pain Shortness of breath CHF Weakness/fatigue Acute altered mental status ABCs, O2, IV, monitor Is QRS narrow or wide? Narrow QRS (0.10 sec) Atropine 0.5 mg IV Repeat pm every 3 to 5 min Maximum total dose 3 mg Wide QRS (0.10 sec) Prepare for transvenous pacing CONSIDER CONTRIBUTING CAUSES Transcutaneous pacing Dopamine infusion 2 to 10 mcg/kg/min or Epinephrine infusion 2 to 10 mcg/min • Pulmonary embolism— anticoagulants? surgery? • Acidosis—give oxygen, ensure adequate ventilation • Tension pneumothorax— needle decompression • Cardiac tamponade— pericardiocentesis • Hypovolemia—replace volume • Hypoxia—give oxygen, ensure adequate ventilation • Heat/cold—cooling/warming measures • Hypo—hyperkalemia (and other electrolytes)— correct electrolyte abnormalities • Myocardial infarction— fibrinolytics? • Drug overdose/accidents— antidote/specific therapy Transcutaneous pacing Dopamine infusion 2 to 10 mcg/kg/min or Epinephrine infusion 2 to 10 mcg/min Algorithm assumes scene safety has been assured, personal protective equipment is used, and previous step was unsuccessful. Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Narrow-QRS Tachycardia (Regular ventricular rhythm) Serious signs/symptoms due to the tachycardia (heart rate 150 bpm)? Hypotension Pulmonary congestion Dizziness Shock Ongoing chest pain Shortness of breath CHF Weakness/fatigue Acute altered mental status ABCs, O2, IV, monitor, 12-lead ECG Three important questions: 1. Patient stable or unstable? 2. QRS narrow or wide? 3. Rhythm regular or irregular? Stable or unstable? Stable Unstable Vagal maneuvers Adenosine 6 mg rapid IV push If no conversion, give 12 mg rapid IV push after 1-2 min May repeat 12 mg dose once in 1-2 min Follow each dose with 20 mL normal saline IV flush If no conversion, consider calcium channel blocker (verapamil, diltiazem) or beta-blocker CONSIDER CONTRIBUTING CAUSES • Pulmonary embolism— anticoagulants? surgery? • Acidosis—give oxygen, ensure adequate ventilation • Tension pneumothorax— needle decompression • Cardiac tamponade— pericardiocentesis • Hypovolemia—replace volume • Hypoxia—give oxygen, ensure adequate ventilation • Heat/cold—cooling/warming measures • Hypo—hyperkalemia (and other electrolytes)— correct electrolyte abnormalities • Myocardial infarction— fibrinolytics? • Drug overdose/accidents— antidote/specific therapy Consider medications (adenosine) while preparing for cardioversion Do not delay cardioversion -----------If serious signs and symptoms, prepare for immediate synchronized cardioversion with 50, 100, 200, 300, 360 J (or biphasic equivalent) Give sedation if possible Algorithm assumes scene safety has been assured, personal protective equipment is used, and previous step was unsuccessful. Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Wide-QRS Tachycardia (Regular ventricular rhythm) Serious signs/symptoms due to the tachycardia (heart rate 150 bpm)? Hypotension Pulmonary congestion Dizziness Shock Ongoing chest pain Shortness of breath CHF Weakness/fatigue Acute altered mental status ABCs, O2, IV, monitor, 12-lead ECG Three important questions: 1. Patient stable or unstable? 2. QRS narrow or wide? 3. Rhythm regular or irregular? Stable or unstable? Stable Unstable If possible SVT with aberrancy, give adenosine as for narrow-QRS tachycardia. If monomorphic VT or wide-QRS tachycardia of unknown origin, give amiodarone 150 mg IV over 10 min Repeat prn to max dose of 2.2 g/24 hr Alternative drugs: procainamide, sotalol CONSIDER CONTRIBUTING CAUSES • Pulmonary embolism— anticoagulants? surgery? • Acidosis—give oxygen, ensure adequate ventilation • Tension pneumothorax— needle decompression • Cardiac tamponade— pericardiocentesis • Hypovolemia—replace volume • Hypoxia—give oxygen, ensure adequate ventilation • Heat/cold—cooling/warming measures • Hypo—hyperkalemia (and other electrolytes)— correct electrolyte abnormalities • Myocardial infarction— fibrinolytics? • Drug overdose/accidents— antidote/specific therapy If serious signs and symptoms, prepare for immediate synchronized cardioversion. Give sedation if possible Ventricular tachycardia (with pulse) synchronized cardioversion with 100, 200, 300, 360 J (or biphasic equivalent) Algorithm assumes scene safety has been assured, personal protective equipment is used, and previous step was unsuccessful. Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Irregular Tachycardia Serious signs/symptoms due to the tachycardia (heart rate 150 bpm)? Hypotension Pulmonary congestion Dizziness Shock Ongoing chest pain Shortness of breath CHF Weakness/fatigue Acute altered mental status ABCs, O2, IV, monitor, 12-lead ECG Three important questions: 1. Patient stable or unstable? 2. QRS narrow or wide? 3. Rhythm regular or irregular? Stable or unstable? Stable Cardiology consult advised • Atrial Fib with rapid ventricular response: magnesium, diltiazem, beta-blockers effective • Atrial Fib WPW: consider amiodarone 150 mg IV over 10 min; avoid adenosine, digoxin, diltiazem, verapamil • Atrial flutter: beta-blocker • Polymorphic VT with normal QT interval: amiodarone may be effective • Polymorphic VT with prolonged QT interval (torsades de pointes): magnesium sulfate 1–2 g IV in 50 to 100 mL over 5 to 60 min Unstable CONSIDER CONTRIBUTING CAUSES • Pulmonary embolism— anticoagulants? surgery? • Acidosis—give oxygen, ensure adequate ventilation • Tension pneumothorax— needle decompression • Cardiac tamponade— pericardiocentesis • Hypovolemia—replace volume • Hypoxia—give oxygen, ensure adequate ventilation • Heat/cold—cooling/warming measures • Hypo—hyperkalemia (and other electrolytes)— correct electrolyte abnormalities • Myocardial infarction— fibrinolytics? • Drug overdose/accidents— antidote/specific therapy If serious signs and symptoms, prepare for immediate synchronized cardioversion. Give sedation if possible. -----------Synchronized cardioversion: Atrial flutter: 50, 100, 200, 300, 360 J* Atrial Fib: 100, 200, 300, 360 J* *or biphasic equivalent -----------Sustained polymorphic VT: treat as VF with defibrillation Algorithm assumes scene safety has been assured, personal protective equipment is used, and previous step was unsuccessful. Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Ischemic Chest Pain/Discomfort Algorithm ABC’s, O2, IV, monitor Vital signs, pulse oximeter, blood pressure monitor SAMPLE history, assess discomfort (0 to 10 scale) Obtain 12-lead ECG Begin reperfusion checklist Give aspirin, nitroglycerin, morphine as indicated (if no contraindications) Evaluate 12-lead ECG Complete reperfusion checklist Get baseline cardiac biomarker levels, electrolytes, coagulation studies, chest x-ray Evaluate initial interventions, pain management Evaluate initial 12-lead ECG INJURY ISCHEMIA NORMAL ST-segment elevation or new left bundle branch block? ST-segment depression or transient ST/T wave changes? Normal ECG or nonspecific ST/T wave changes? ST-elevation MI High-risk unstable angina/ Non–ST-Elevation MI Intermediate/low-risk unstable angina STEMI UA/NSTEMI UA Determine reperfusion strategy Beta-blockers Clopidogrel Heparin ACE inhibitors (oral) Statins Nitroglycerin Beta-blockers Clopidogrel Heparin Glycoprotein IIb/IIIa inhibitor ACE inhibitors (oral) Statins Aspirin Additional therapy as appropriate Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Acute Pulmonary Edema ABC’s, O2, IV, monitor Assess blood pressure INITIAL ACTIONS If feasible and BP permits, place patient in sitting position with feet dependent • Increases lung volume and vital capacity • Decreases work of respiration • Decreases venous return, decreases preload -----Nitroglycerin sublingual if systolic BP 100 mm Hg -----Morphine 2 to 4 mg IV -----Furosemide 0.5 to 1 mg/kg IV* *Use less than 0.5 mg/kg for new onset acute pulmonary edema without hypovolemia. Use 1 mg/kg for acute or chronic volume overload, renal insufficiency. ADDITIONAL ACTIONS Intubate if needed -----Nitroglycerin IV infusion at 10 to 20 mcg/min if systolic BP 100 mm Hg -----Dopamine 5 to 15 mcg/kg/min if systolic BP 70 to 100 mm Hg with signs/symptoms of shock -----Dobutamine 2 to 20 mcg/kg/min if systolic BP 70 to 100 mm Hg with no signs/symptoms of shock Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Cardiogenic Shock ABC’s, O2, IV, monitor Assess blood pressure BP 70 If systolic BP 70 to 100 mm Hg with signs/ symptoms of shock: Norepinephrine IV infusion 0.5 to 30 mcg/min BP 70 to 100 If systolic BP 70 to 100 mm Hg with signs/ symptoms of shock: Dopamine IV infusion 5 to 15 mcg/kg/min BP 70 to 100 If systolic BP 70 to 100 mm Hg with no signs/ symptoms of shock: Dobutamine IV infusion 2 to 20 mcg/kg/min BP 100 If systolic BP 100 mm Hg: Nitroglycerin IV infusion 10 to 20 mcg/min Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
