Download Cardiac Emergencies and Running the Code

Cardiac Emergencies
Running the Code
November 2013 CE
Condell Medical Center
EMS System
Site Code: 107200E-1213
Prepared by: Sharon Hopkins, RN, BSN, EMT-P
Rev 11.18.13
1
Objectives
Upon successful completion of this module, the
EMS provider will be able to:
Discuss cardiac rhythms that may be too fast,
too slow, or too bad.
Describe signs and symptoms of impaired
cardiac output related to a variety of cardiac
rhythms.
Review properties of medications used in
cardiac situations in Region X SOP’s.
Review identification of cardiac rhythms
2
Objectives cont’d
Review Region X SOP treatment and
interventions for a variety of cardiac rhythms
Actively participate in case scenario
discussion.
Actively participate in a mock code situation
including medication preparation.
Successfully complete the post quiz with a score
of 80% or better.
3
Lethal Cardiac Rhythms
Rhythms that cannot sustain perfusion and
therefore life
Evaluate rhythms:



Too slow
Too fast
Too bad
What does the patient look like?
How is the patient handling that rhythm?
4
Signs & Symptoms
Signs and symptoms generated based on
status of perfusion
Cardiac output (CO) =

stroke volume x heart rate
Cardiac output – total volume of blood
pumped out of heart in one minute
Stroke volume – amount of blood pumped
out of ventricle with each contraction
Heart rate – pulse rate over one minute
5
Symptoms Impaired Cardiac
Output
Anxiety
Chest pain
Shortness of breath
Lightheadedness
Near syncope
“Something is not right”
6
Signs Impaired Cardiac Output
Dyspnea
Diaphoresis
Hypotension
Cool, clammy skin
Cyanosis
Syncopal episode
Decreased level of consciousness
7
Cardiac Medications in SOP
You are responsible for knowing






Why a medication would be used
When the medication would be used
How much to administer
What route to use for the medication
What side effects to monitor for
How to document the medication given
8
6 Rights of Medication
Administration
These are checked each & every time you
administer medications






Right patient
Right time
Right medication – always triple checked
Right dosage
Right route
Right documentation
You need to know “ml” when drawing up the syringe
volume; you need “mg” when documenting
9
Epinephrine
Trade name - Adrenaline®
Sympathomimetic - Mimics sympathetic nervous
system (Fight or Flight)


Increases heart rate
Increases automaticity
Ability to initiate an impulse

Increases contractile forces
Stimulates alpha and beta receptors



Stimulates vasoconstriction
Stimulates the heart
Causes bronchodilation
10
Epinephrine cont’d
Used as initial drug in cardiac arrest


First drug used following defibrillation
Improves perfusion to the heart and brain
Dose is 1 mg IVP/IO


Relatively short acting so dose repeated
every 3 - 5 minutes
No max
11
Amiodarone
Trade name Cordarone®
Antidysrhythmic
Relaxes vascular smooth muscle
Decreases peripheral vascular resistance
Increase coronary blood flow
12
Amiodarone cont’d
Used in variety of ventricular irritability




Stable monomorphic VT after failure to
respond to Adenosine
Stable polymorphic wide complex VT
Unstable VT not responsive to cardioversion
VF/Pulseless VT not responsive to
defibrillation and Epinephrine
13
Amiodarone cont’d
Dosing

Patient with pulse
150 mg diluted in 100 ml D5W
 IVPB run over 10 minutes

Patient without pulse
Initial dose 300 mg diluted with 20 ml NS or D5W
 Given rapid IVP/IO
May be repeated in 5 minutes at 150 mg IVP/IO if
needed
Watch out in patients with pulses

Causes hypotension –must be administered
slowly!!!
14
Atropine
Parasympatholytic blocker



Blocks parasympathetic nervous system
Increases heart rate at SA node
Decreases degree of block at AV node
Anticholinergic

Decreases secretions
15
Atropine cont’d
Administered only if patient is symptomatic

What is the level of consciousness?
First indicator to change when perfusion altered

What is the blood pressure?
Last indicator to change when perfusion altered
Only dosing used is 0.5 mg rapid IVP/IO



May be repeated every 5 minutes
Max dose is 3 mg
Should be in process of applying TCP as first
dose is being delivered
16
Atropine cont’d
Side effects to expect



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Dry mouth
Dilated pupils
Tachycardia
Ringing in the ears
Did you know…

To transplant a heart, the vagus nerve is cut
This patient will no longer respond to Atropine
Immediately apply the TCP
17
Atropine cont’d
Why don’t we use Atropine in the pediatric
patient with bradycardia???

Peds brady usually result of insult to the
respiratory system and not due to a diseased
heart
Most often need to fix the airway to fix the heart rate
Why give the peds patient Atropine as a premed in drug assisted intubation???

Peds patient sensitive to reflexively brady down
with stimulation of the airway
18
Dopamine
Trade name Intropin®
Sympathomimetic

Mimics sympathetic system
Used to treat hemodynamically significant
hypotension in absence of fluid deficit
Effects dosage dependent


Used to increase/improve contractile force to
improve cardiac output
Minimal effect on increasing heart rate
19
Dopamine cont’d
Medium dose 5 – 20 mcg/kg/min


Recommend EMS to start at 5 mcg/kg/min
Can increase dosing if needed
Wait 5 minutes to see effects of medication
Watch for extravasation
 Dumps a concentrated dose in one area
 Causes excessive vasoconstriction that can
lead to tissue sloughing
20
Dopamine cont’d
How fast do you drip in Dopamine?
Chart listed in SOP’s

Ranges provided from 5 – 20 mcg/kg/min
Quick method for drip rate



Calculate patient’s weight in pounds
Take first 2 numbers of 3 digit weight
Drop 2 points and have starting rate for drip
Example: 160 pound patient

Take 16, minus 2; start drip at 14 minidrips/min
21
Adenosine
Trade name Adenocard®
Antidysrhythmic




Slows conduction time thru AV node
No effect on contractility
Blocks reentry pathways thru AV node
Decreases heart rate at SA node
22
Adenosine cont’d
Used to treat relatively stable
tachydysrhythmias


Stable narrow complex SVT
Stable monomorphic VT
On the suspicion that this might be SVT with
aberrancy
 Aberrancy means conduction will take another
route thru the conduction system
 Any time there is a detour in conduction, the
complexes widen
23
Adenosine cont’d
Caution:

May cause an increase in heart rate for the
patient with WPW (Wolff Parkinson White)
syndrome
Medication blocks AV node conduction but not
accessory pathways

Medication must be administered as quickly
as possible
Half-life is only 10 seconds
Start IV in AC, preferably right
24
Adenosine cont’d
Dosing


Initial is 6 mg followed immediately with 20 ml
NS flush
Warn patient they may feel “funny” for few
minutes
Monitor for chest pressure, hot feeling, shortness
of breath

After 1-2 minutes, repeat dosage, if needed,
12 mg immediately followed with 20 ml NS
flush
Run strips for documentation while
administering medication
25
Verapamil
Trade name Calan®
Calcium channel blocker


Slows AV conduction
Moderately decreases contractility and
peripheral vascular resistance (afterload)
Onset 3- 5 minutes
26
Verapamil cont’d
First line medication for relatively stable
atrial fibrillation and atrial flutter
Used as backup to Adenosine resistant
stable narrow complex tachycardia
Should NEVER be administered in the
presence of a ventricular dysrhythmia

May precipitate hemodynamic deterioration
and lead into ventricular fibrillation
DO NOT USE in WPW

May cause ventricular fibrillation
27
Verapamil cont’d
Dosing

5 mg IVP SLOWLY over 2 minutes
Watch for hypotension

May repeat dosage in 15 minutes if necessary
Most common side effect

Hypotension – watch patient carefully
NEVER administer in VT
Common medication used at home for control of
hypertension

Reduces afterload – pressure heart pumps against
28
Additional Medication Support
For critical interventions, additional
medication s may be added


Benzodiazepines
Opioid narcotics
To be used to relax, sedate, and make
patients more comfortable
The above can cause respiratory
depression

Monitor airway when using these meds
29
Valium®
Generic name Diazepam
A benzodiazepine
Relatively short acting sedative, hypnotic, and
anticonvulsant
Induces amnesia
Onset 2 - 3 minutes IVP route
Peak effects 3 – 5 minutes
Duration 4 - 6 hours

Longer acting than Versed
30
Valium® cont’d
In cardiac setting, used for to help “take
the edge off” if using TCP
Dosage


2 mg IVP/IO over 2 minutes
May repeat 2 mg every 2 minutes to max of
10 mg as needed
Watch for respiratory depression
For pain control, need to add Fentanyl
31
Valium® cont’d
Use



Longer acting sedation for use of the TCP
To prevent shivering when cooling a patient
with heat stroke
Back up to Versed when Versed ® dose has
been maxed in behavioral emergencies
32
Versed®
Generic is Midazolam
A benzodiazepine
Useful as a short acting sedative
Onset – fast – 1 - 2 minutes
Peak 3 – 5 minutes
Duration – 15 – 80 minutes; relatively
short
33
Versed ® cont’d
Dosage


2 mg IVP/IO every 2 minutes titrated
Max 10 mg
Used:



Drug Assisted Intubation – post sedation
Sedation for synchronized cardioversion
First drug for seizure control
IN route avoids exposure to needle risk

Behavioral emergency
IN route avoids exposure to needle risk
34
Fentanyl
Synthetic opioid narcotic – analgesic
Similar to morphine but quicker and shorter in
duration
Less hemodynamic changes than morphine
Dosing





0.5 mcg/kg IVP/IO/IN over 2 minutes
IN used if no IV access
Onset 1 – 2 minutes
Peak effect 3 – 5 minutes
Duration 30 -60 minutes
35
Rhythm Strip ID and Intervention
What’s this rhythm and how do you decide
on intervention?
SVT

Narrow QRS with rapid (>100 ) ventricular
response; no discernable rounded P waves
First identify & find a T wave; if no “bumps/waves”
left over to be P waves then rhythm is not sinus
Treatment based on stability
36
Tachycardia Decision Tree
Using words “bradycardia” and
“tachycardia” just describe a rate

Does not indicate what the rhythm is!
Critical thinking skills with tachycardia

Your assessment and EKG interpretation will
drive the decision over which pathway to
follow for intervention
37
Decision Tree cont’d
1st question – Is patient stable or
unstable?
A tachycardic patient should have some
signs and symptoms


You would with a sinus tachycardia!!!
Having symptoms DOES NOT make a patient
unstable; just symptomatic
If unstable, patient requires immediate and
more aggressive intervention

Consider synchronized cardioversion
38
Determining Stability
2 components will quickly provide this answer

Check level of consciousness
First thing to change when perfusion drops
How well does patient communicate when spoken to?

Palpate a radial pulse
If you can palpate a radial pulse, blood pressure is
present to perfuse to a distant part of the body
 Blood pressure last indicator to drop when
compensation has been exhausted
Stability must be measured for each
individual and may be unique to them
39
Decision Tree cont’d
If patient relatively stable, can take more
time for conservative intervention
If patient relatively stable, determine width
of QRS
If narrow, consider SVT
If wide QRS, need to determine if
monomorphic or polymorphic


Monomorphic – complexes relatively alike;
complexes could stack one on top of each
other
Polymorphic – more disorganization
40
Rhythm Strip ID and Intervention
What’s this rhythm and how do you decide on
intervention?
Monomorphic VT
Wide QRS, no normal P wave with PR intervals
Wide complex is VT until proven otherwise
Treatment depends on type of VT (monomorphic
vs polymorphic) and patient stability
41
Rhythm Strip ID and Intervention
What is this rhythm and what do you do?
Torsades de Pointes
If pulseless, treat like VF and defibrillate
If alive, assess stability


If stable treat with Amiodarone
If unstable cardiovert
42
Case Scenario #1
Group Discussion
Patient 70 y/o who is pale and feeling
weak; has had episodes of diarrhea today
Hx: throat cancer, hypertension, PEG tube
VS: B/P 104/50; P 78; R 18; SpO2 98%
Monitor applied due to patient’s age
What is your interpretation of the monitor?
43
Case Scenario #1
Patient had no cardiac complaints at all
Rhythm is

Sinus
When you note ST elevation, what is your
next action?

Obtain a 12 lead EKG
Can you determine presence /absence of
acute MI based on 1 lead view?

No; you can be suspicious though
44
Case Scenario #1
EMS 12 lead – what is your interpretation?
ST elevation II, III, aVF
45
Case Scenario #1
12 lead taken upon ED arrival – what do
you think? No ST elevation
46
Case Scenario #1
Good example why serial EKG’s are
important
Patient was taken to cath lab based on
EMS 12 lead EKG
Patient had 99% blockage of RAD
coronary artery


Blockage opened with stent
Patient did well
47
Active Case Scenario Practice
For the following cases, respond as if the
call just came in
Do what you would do on a real call
Working in groups, progress through the
call and perform as many of the skills as
possible
Take time to discuss and critique the call
before moving on
Lessons learned are valuable
48
Case Scenario #2
EMS responds to a 56 year old found
unresponsive in the locker room of a gym
Patient appears unconscious
What are your initial assessment steps?


Check responsiveness – no response
Check for signs of life; presence of breathing
Agonal breathing

Check carotid pulse for 5 – 10 seconds
Carotid pulse of 30/minute; no radial pulse
49
Case Scenario #2
What early intervention is necessary for
the agonal breathing?

Supportive ventilations
BVM 1 breath every 5 - 6 seconds

If DAI is considered, what medications would
be used?
Etomidate 0.3 mg/kg IVP/IO (maximum 20 mg)
Post-intubation sedation Versed 2 mg IVP/IO every
2 minutes titrated to effect; max 20 mg
50
Case Scenario #2
Monitor is applied
What is this rhythm?
Second degree Type II – Classical


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Regular R to R
More P waves than QRS
Consistent PR interval
51
Case Scenario #2
Vital signs: B/P cannot obtain; P – 30;
R – 10 – 12 per minute assisted
Do you consider patient to be
symptomatic?

YES!!!
Altered level of consciousness
Decreased blood pressure
Most likely cold and clammy
Might have altered skin color
52
Case Scenario #2
What additional interventions are now
required?


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Atropine 0.5 mg rapid IVP/IO
Prepare TCP if medication is ineffective
If TCP used, pre-medicate
Valium 2 mg IVP/IO over 2 minutes
May repeat 2 mg every 2 minutes as needed; max
10 mg

For pain control
Fentanyl 0.5 mcg/kg IVP/IO/IN

May repeat dose in 5 minutes if needed
53
Case Scenario #2
What are the settings for TCP?


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Rate - 80/minute
Sensitivity – auto
Output – start mA at “0”
Increase to lowest setting that delivers consistent
capture
Evaluate need for Valium and Fentanyl
54
Case Scenario #2
EMS notes a rhythm change
What is the rhythm?

VF
What do you do?

Immediately defibrillate followed by CPR
55
Case Scenario #2
What is your next action (an IV has
already been established)

Administer Epinephrine 1 mg IVP during CPR
After 2 minutes of CPR pause for up to
10 seconds to evaluate the rhythm
What do you do now?
Check a pulse; there is no pulse; continue CPR for PEA56
Case Scenario #2
What is your next action after CPR
resumed?


Administer Epinephrine 1 mg 3 – 5 minutes
after 1st dose and during CPR
When able, can secure airway with advanced
device (i.e.: ETT or King)
When do you stop to check rhythms?


After 2 minutes of CPR
No pulse check unless you view a rhythm that
should generate a pulse
57
Case Scenario #2
Early in critical situations consider the H’s
and T’s as cause
H’s

Hypovolemia, hypoxia, hydrogen ion acidosis,
hyper/hypokalemia, hypothermia
T’s

Toxins, tamponade, tension pneumothorax,
thrombosis (coronary or pulmonary)
58
Case Scenario #2
Next 10 second pause, you note this:
Pulse felt; sinus rhythm
What is your immediate action?

Check a pulse
If no pulse, PEA and resume CPR
If pulse, then evaluate ventilations
 Then check full vital signs
59
Case Scenario #2
What do you do if patient remains
unresponsive after return of spontaneous
circulation (ROSC)?


Begin ROSC therapy (hypothermia induction)
as long as ROSC is present at least 5 minutes
Place ice packs in axilla, neck, and groin
Place ice pack over IV insertion site
60
Case Scenario #2
ROSC indications



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

Adult or pediatric patient resuscitated after out
of hospital cardiac arrest
Remains unconscious and unresponsive
Return of spontaneous circulation (ROSC)
greater than 5 minutes
Able to maintain systolic B/P >90 with or
without vasopressors
Airway secured
Presumed cardiac etiology
61
Case Scenario #3
EMS is called for a 45 year old patient with
flu-like symptoms for past 24 hours
Patient pale, dry, warm
VS: B/P 100/70; P – 170; R 18; SpO2 92%
What does the monitor display?
Monomorphic ventricular tachycardia (VT)
62
Case Scenario #3
Is your patient stable or unstable?

Relatively stable – awake, talking, B/P OK
Is rhythm narrow or wide?

Wide, regular, complexes similar
Note: Wide rhythms should be considered VT
until proven otherwise
What medication is tried/attempted initially?

Adenosine 6 mg rapid IVP immediately followed with
20 ML saline flush
If this is not successful, what’s next?

Amiodarone 150 mg
63
Case Scenario #3
How do you administer Amiodarone in
relatively stable VT?





Draw up and place 150 mg Amiodarone in
100 ml D5W
Run through mini-drip IV tubing
Connect IV drug line into main IV line
Adjust flow rate so individual drips are visible
Piggy back needs to run in over 10 minutes
64
Case Scenario #3
During preparation of IVPB, patient loses
consciousness
What is the rhythm?
VF – what do you do?
Immediately defibrillate patient
Why not start CPR first?

Do not want to delay defibrillation if ready to be used 65
Case Scenario #3
What do you do after each defibrillation?

Resume CPR starting with compressions
What medications would be given for VF
unresponsive to defibrillation?

Epinephrine 1:10,000 – 1 mg IVP/IO
Repeated every 3 – 5 minutes

Alternated with Amiodarone 300 mg IVP/IO
Repeat dosage in 3 – 5 minutes is 150 mg IVP/IO
 May be given rapid – no worry of hypotension
66
Case Scenario #3
After several minutes and rounds of
defibrillation and medication, this rhythm is
noted:
Asystole
Now what?

Resume CPR
Do you do a pulse check?

No, only if the rhythm should generate a pulse
67
Case Scenario #3
What medications are used for asystole?

Epinephrine 1:10,000 - 1mg
Repeated every 3 – 5 minutes
Only medication used in asystole and PEA
Need to be considering the H’s and T’s
Evaluate effectiveness of compressions and
ventilations



Check capnography – should be at least
10mmHg during compressions
Is ETCO2 indicator yellow?
Is chest rising and falling; breath sounds
bilateral?
68
Case Scenario #3
After several rounds of Epinephrine and
on one of the rhythm checks you notice
this rhythm
What is the rhythm?
What do you do now?

Check a pulse; And yes, there is one!!!
69
Case Scenario #3
Now what do you do???

Evaluate the patient
Start with ventilation status
Then obtain vital signs

Activate the ROSC protocol (cool patient)
based on level of consciousness
Patient remains unconscious and unresponsive
Systolic B/P >90 with/without vasopressors
Presumed cardiac etiology

Cooling preserves neurological function
70
Case Scenario #4
EMS is called to the scene for a 30 year
old patient who complains of a rapid heart
rate for one hour after playing sports
The patient now has chest pain and is
weak
What is the rhythm?
SVT with rapid ventricular response
71
Case Scenario #4
VS: B/P 70/palpable; P -240; R – 28; SpO2 93%
Chest pressure 7/10
Patient becoming less responsive
What should EMS do?

Prepare to synchronize cardiovert patient
Patient becoming less tolerant of rapid rhythm
Cardiac output is falling and patient is considered
symptomatic
72
Case Scenario #4
What are the steps to cardiovert a patient?

If able to, sedate patient
Versed 2 mg IVP/IO over 2 minutes
May repeat to desired effect and max of 10 mg

Prepare monitor in sync mode
Activate sync button
Set energy joules starting at 100 j
 May increase as needed to 200j, 300j, 360j
Observe safety precautions
 Look and call all clear before discharging
energy buttons
73
Case Scenario #4
After cardioversion, you observe this on
the monitor – what do you do?
Check a pulse!!!

There is no pulse
Begin CPR with compressions
 The rhythm is PEA
74
Case Scenario #4
What is your next intervention/medication?


Administer Epinephrine 1 mg 1:10,000
Deliver medications during 2 minute rounds of CPR
After 2 minutes of CPR evaluate the rhythm
What do you do?

Check a pulse! Yes – there is a pulse
75
Case Scenario #4
Evaluate quality of ventilations

If supportive ventilations required, avoid
hyperventilation
If using BVM – 1 breath every 5 – 6 seconds
If ventilating via advanced airway, 1 breath every
6 – 8 seconds
Consider activating ROSC after return of
spontaneous circulation and continued
unresponsiveness

Evaluate for relative exclusions
76
Case Scenario #4
Relative exclusions ROSC hypothermia
induction







Major head trauma or traumatic cardiac arrest
Recent major surgery within 14 days
Systemic infection
Coma from other causes such as drug induced or
overdose
Active bleeding
Hypothermia not recommended in isolated respiratory
arrest
Suspected hypothermia already present
(93.20F/340C)
77
Case Scenario #5
EMS is called for a 55 year-old patient with
weakness
Complains of fluttering in the chest
Skin is pale and dry
Patient is alert and oriented; B/P 110/70
What is the rhythm?
Sinus tachycardia
78
Case Scenario #5
Sinus tachycardia

NO MEDICATION TREATMENT!!!
Rhythm generated in response to a
situation
Find the cause and treat the cause; not
the rhythm




Fever
Pain
Shock
Anxiety
79
Case Scenario #5
Patient continues to complain of
increasing episodes of chest fluttering
You notice the monitor
What is this rhythm?

VT – monomorphic
Complexes fit stacked one on top of each other
80
Case Scenario #5
What question/assessment is important to
decide what treatment path to follow?

Is patient stable or unstable???
VS: B/P 110/70 – P 110 – R 20; SpO2 99%
Remains alert and oriented
VT is in brief runs and then returns to sinus tach

Patient should be considered relatively stable
at this time
81
Case Scenario #5
Sustained VT is now noted
The patient has a pulse
Now what assessment is necessary?


Is patient stable or unstable?
Has a palpable radial pulse and answers all
questions
Patient remains relatively stable
What intervention is required now?
82
Case Scenario #5
Treatment for stable monomorphic VT




Adenosine 6 mg rapid IVP followed
immediately with 20 ml NS flush
There is no response to Adenosine
Now what???
Amiodarone 150 mg IVPB
Diluted in 100 ml D5W and run over 10 minutes
What side effect do you need to monitor
for when infusing Amiodarone?

Hypotension
83
Case Scenario #5 - What if???
IF patient unstable VT and sync required:
If first sync attempt is unsuccessful, begin
to initiate an Amiodarone drip



Do not want to delay time to begin medication
Want to allow medication to start to work while
continuing electrical therapy
Mix 150 mg Amiodarone with 100 ml D5W
Spike bag with mini drip tubing
Piggy back into primary line
Run fast enough to still be able to count individual
drips
84
Case Scenario #5
After infusion of Amiodarone, you observe
the following
What does the monitor show?

Sinus rhythm
What assessment should be done?

Peripheral pulses, rest of vital signs
85
Case Scenario #5
Patient’s B/P remains 72/40
The patient is symptomatic
What interventions would be appropriate
to treat hypotension?

Following Cardiogenic Shock SOP
IV/IO fluid challenge
 Assess lung sounds first to make sure patient
can tolerate an increased amount of fluids
 Infuse 200 ml in increments
Dopamine drip
 Begin at 5 mcg/kg/min (weight 185#)
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Case Scenario #6
EMS called for a patient with complaints of
fluttering in their chest for past several
hours
Patient awake, cooperative, answering all
questions, pale, slightly diaphoretic, radial
pulse rapid and weak
What’s rhythm?
Rapid atrial fibrillation
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Case Scenario #6
This is a tachycardia
What is your first question?




Is the patient stable or unstable?
Awake, talking, pale, slightly clammy
C/O being lightheaded
VS: B/P 96/70; P – 190; R – 24; SpO2 97%
Patient is relatively stable

Of course they have some symptoms with a
heart rate of 190!!!
88
Case Scenario #6
Stable Rapid Atrial Fibrillation
Valsalva maneuver


Have patient bear down for 10 seconds
Run monitor strip during maneuver
Administer Verapamil 5 mg SLOW IVP
over 2 minutes

Watch blood pressure!!!
If no response in 15 minutes AND B/P >90

Repeat Verapamil 5 mg SLOW IVP over 2
minutes
89
Bibliography
Aehlert, B. ECG’s Made Easy. 4th Edition. Mosby
Jems. 2011.
Bledsoe, B., Porter, R., Cherry, R. Paramedic
Care Principles & Practices, 4th edition. Brady.
2013.
Region X SOP’s; IDPH Approved January 6,
2012.
http://www.sgna.org/issues/sedationfactsorg/me
dications.aspx
Rnceus.com
resuscitationcentral.com
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