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Flashcards in Cardiac Emergencies Deck (40)
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1

Rapid A Fib & A Flutter
Information

Rapid atrial fibrillation and atrial flutter are defined as ventricular rates greater than 150 BPM.

2

Rapid A Fib & A Flutter
Adult- Stable

CARDIZEM: 10mg IV/IO over 2 minutes. If HR > 120 after 5 minutes, repeat with 15mg IV/IO over 2 minutes.
• Contraindicated for hypotension, wide complex QRS, history of WPW or sick sinus syndrome.
• Use with caution for patients taking beta blockers.
• If hypotension develops after Cardizem administration, administer
1L of Normal Saline and 1 gram of Calcium Chloride.

3

Rapid A Fib & A Flutter
Adult- Unstable (Hypotension)

• Normal Saline: 1L. Assess lung sounds every 500mL.
• If patient remains hypotensive after fluid administration:
• If blood pressure stabilizes then administer Cardizem as indicated above.
• DO NOT cardiovert A-Fib/A-Flutter.
Cardioversion of A-Fib/A- Flutter may put patients at high risk for embolic stroke.

4

Rapid A Fib & A Flutter
Pediatric

Call for orders

5

Bradycardia
Information

S/S: Bradycardia is defined as a heart rate less than 50 BPM.

6

Bradycardia
Adult- Stable

Monitor and transport

7

Bradycardia
Adult- Unstable

(HYPOTENSION) SBP < 100
• Obtain a 12 LEAD ECG to rule out an MI.
• NORMAL SALINE: 1L .Assess lung sounds and blood pressure every 500mL.
• ATROPINE: 0.5mg IV/IO. Repeat prn every 3-5 minutes. Max dose 3mg.
• Push Dose EPINEPHRINE
• TRANSCUTANEOUS PACING: Initial rate of 60 BPM and then increase milliamps until electrical and mechanical capture is gained.

8

Bradycardia
SEDATION OF TRANSCUTANEOUS PACING

• ETOMIDATE: 10mg IV/IO. May repeat 1x prn.
• If unable to establish IV/IO access, begin pacing until an acceptable blood pressure is obtained, then administer VERSED 5mg IN/IM. May repeat either route 1x prn.
• Contraindicated in hypotension.
• Monitor for respiratory depression.

BRADYCARDIA IN THE PRESENCE OF AN MI WITH HYPOTENSION Go directly to transcutaneous pacing as Atropine increases myocardial ischemia and may increase the size of the infarct.

HIGH DEGREE AV BLOCKS WITH HYPOTENSION
Immediate transcutaneous pacing is acceptable when IV access is not immediately available.

9

Bradycardia
Pediatric- Stable

Monitor and transport

10

Bradycardia
Pediatric- Unstable

(Defined as a child with AMS and poor perfusion)
• OXYGENATION & VENTILATION: Ensure adequate oxygenation and ventilation first, as hypoxia is most likely to be the cause of the bradycardia.
• After oxygenation and ventilation of 1 minute for infants/children and 30 seconds for neonates (birth to1month), begin chest compressions if the heart rate remains below 60 BPM with signs of poor perfusion (AMS).
• Push Dose EPINEPHRINE
• If no response to Epinephrine, begin TRANSCUTANEOUS PACING. Begin pacing at 80 BPM and increase the rate as needed until the patient is hemodynamically stable. Start at 30 milliamps and Increase milliamps until electrical and mechanical capture is achieved.

11

Bradycardia
Pediatric
Sedation for Transcutaneous Pacing

• ETOMIDATE: 0.15 MG/KG-SEE PEDIATRIC MED TOOL
• If unable to obtain IV/IO access, begin pacing until an acceptable blood pressure is obtained, then administer VERSED 0.2mg/kg IN/IM. Max single dose 5mg. May repeat 1x in 3 minutes prn. Max total dose 5 mg.
• Contraindicated in hypotension.
• Monitor for respiratory depression.

12

Chest Pain
INFORMATION

For STEMI Alerts or suspected STEMI Alerts, the right hand and wrist should be avoided (DUE TO CATH ACCESS) if at all possible for IV ACCESS.The right AC and anywhere on the left is acceptable.

13

Chest Pain
Adult

• IMMEDIATE 12lead ECG
• ASPIRIN: Four 81mg baby aspirin (324 mg total) chewed and swallowed.
• Contraindications: allergy, active GI bleeding
• Withhold if patient self-administered 324mg of aspirin within 24 hours. If patient self- administered less than 324mg of aspirin within 24 hours, administer full 324mg dose.
• FENTANYL: 100 mcg slow IV/IO/IM OR 100 mcg IN. May repeat once in 5-10 minutes. Max total dose 200mcg IV/IO/IM/IN.
• In rare occasions, Fentanyl may cause hypotension.
• If hypotension occurs, NORMAL SALINE: 1L. Assess lung sounds and
blood pressure every 500mL.
NITROGLYCERINE: 0.4mg SL. May repeat every 3-5 minutes prn for pain (max 3 doses). SBP must be 100 mmHg or greater.
Nitroglycerine may be given as a first line drug ahead of FENTANYL
CONTRAINDICATIONS
• SBPlessthan100mmHg
• EDD (Viagra and Levitra within 24 hours and Cialis within 48 hours)
• Right Ventricular Infarction. Positive V4R (in this case, follow the CARDIOGENIC SHOCK: RIGHT VENTRICULAR FAILURE protocol).

Patients without pain/discomfort who have ST segment elevation are treated with aspirin only. Fentanyl and NTG are only given to relieve ischemic pain/discomfort.

14

Chest Pain
Pediatric

Call for orders

15

STEMI Alert
Information

STEMI Symptoms can be variable and include discomfort of the chest, arm, neck, back, shoulder or jaw and also can be painless with syncope/near syncope (lightheadedness), general weakness/fatigue, unexplained diaphoresis, SOB, or nausea/vomiting.

16

STEMI Alert
Adult

• IMMEDIATE 12 LEAD ECG WITH IMMEDIATE NOTIFICATION TO PCI FACILITY INCLUDING ECG TRANSMISSION.
• ASPIRIN: Four 81mg baby aspirin (324mg total) chewed and swallowed, if not already administered.
• Contraindications: allergy, active GI bleeding
• Withhold if patient self-administered 324mg of aspirin within 24 hours. If patient self- administered less than 324 mg of aspirin within 24 hours, administer full 324mg dose.
• This protocol may be run concurrent with the Chest Pain Protocol as applicable for ischemic chest pain.

17

STEMI Alert Criteria

• ST-Segment Elevation in two or more contiguous leads (2mm or greater in V2 and V3 or 1mm or greater in all other leads) with a “convex” (frown face) or “straight” morphology.
• ST-Segment Elevation in two or more contiguous leads of 2mm or greater in any lead with a“concave” (smiley face).
• Consider 15 LEAD EKG

18

STEMI Alert Disqualifiers

The following are STEMI mimics:
• QRS complexes greater than 0.12 (LBBB, Pacemaker, etc.)
• Left Ventricular Hypertrophy (LVH)
• Pericarditis
• EarlyRepolarization
• Less than 2mm of elevation with a Concave ST Segment (Smiley Face) Morphology

Left Ventricular Hypertrophy (LVH)
Take the largest negative deflection from the isoelectric line of VI and V2 (“S” wave), whichever is larger, and count the small boxes. Then take the largest positive deflection of V5 or V6 (“R” wave), whichever is larger, and add it to the total from VI or V2. If the result is greater than 35, your suspicion for LVH should be high.

19

CHF (Pulmonary Edema)
Information

• S/S: Hypertension, Tachycardia, Orthopnea, Rales, Pedal Edema

20

CHF (Pulmonary Edema)
Adult

• 12LEADECG
• ASPIRIN: Four 81mg baby aspirin (324 mg total) chewed and swallowed.
• Contraindications: allergy, active GI bleeding
• Withhold if patient self-administered 324mg of aspirin within 24 hours. If patient self- administered less than 324mg of aspirin within 24 hours, administer full 324mg dose.
• SL NTG (0.4mg) Repeat every 5 minutes-Max3doses
• CPAP (10cmH2O)

CONTRAINDICATIONS: CPAP
• SBPlessthan100mmHg
• AMS (Lethargic)
• Apnea: you shouldn’t even consider
• NITRO-PASTE: apply 1” to the anterior upper chest.
• The SL and paste (NTG) may be given concurrently for SBPgreater than 100
mmHg.

CONTRAINDICATIONS: NTG
• SBPlessthan100mmHg
• EDD (Viagra and Levitra within 24 hours and Cialis within 48 hours)
• Right Ventricular Infarction
• Place an advanced airway for patients with a decreasing level of consciousness.

21

Cardiogenic Shock
Information

Cardiogenic shock is a condition in which the heart suddenly can’t pump enough blood to meet the body’s needs. This condition is most often caused by a severe heart attack. Cardiogenic shock is rare, but often fatal if not treated immediately.

22

Cardigenic Shock
Adult

HEART FAILURE: PULMONARY EDEMA AND HYPOTENSION • FollowCHFProtocol
• Hypotension: Push Dose EPINEPHRINE

Once SBP is 100 mmHg or greater, treat CHF/Pulmonary Edema and/or Chest Pain as applicable.

23

Cardiogenic Shock
Pediatric

Call for orders

24

Supraventricular Tachycardia
Information

SVT is defined as a regular, narrow complex tachycardia of 150 BPM or greater without discernible P- waves and/or flutter waves.

25

Supraventricular Tachycardia
Adult- Stable

CAUTION: DO NOT administer Adenosine to patients with a history of a heart transplant or with history of WPW

12 LEAD ECG

• VAGAL MANEUVERS (The REVERT Trial-Lancet)
• ADENOSINE: 12mg rapid IVP, with a simultaneous 10mL Normal Saline flush.
• If rhythm fails to convert, CARDIZEM: 10mg IVP over 2 minutes. If HR>120 after 5 minutes, administer CARDIZEM: 15mg IVP over 2 minutes.
• Contraindicated for hypotension, wide complex QRS, patients with a history of WPW. SEE DIAGRAM BELOW for example of WPW
• Use with caution for patients taking beta blockers.
• If hypotension develops after Cardizem administration, NORMAL SALINE: 1L then
Calcium Chloride : 1 gram IV/IO over 2 min

26

Supraventricular Tachycardia
Adult- Unstable (Hypotension)

IF PATIENT IS ALERT

• ADENOSINE: 12mg rapid IVP, with a simultaneous 10mL Normal Saline flush.
• If no change after Adenosine, monitor patient throughout transport for changes in
mental status.

IF PATIENT HAS AN ALTERED MENTAL STATUS
• Consider sedation prior to cardioversion. ETOMIDATE: 10mg IV/IO. May repeat 1x prn.
• SYNCHRONIZED CARDIOVERSION: (200J ZOLL), (360 LP)

27

Supraventricular Tachycardia
Pediatric- Stable

• SVT in children is considered greater than 180 BPM.
• SVT in infants is considered greater than 220 BPM.
• VAGAL MANEUVERS: For young children, place a bag of ice water on the child's face completely obstructing their nose and mouth for 15 seconds.
• ADENOSINE: 0.1mg/kg rapid IV/IO SEE PED MED TOOL, with a simultaneous 10mL flush. Max dose 6mg.
• If no change in one minute, ADENOSINE: 0.2 mg/kg rapid IV/IO, with a simultaneous 10mL flush. Max dose 12mg. SEE PED MED TOOL

28

Supraventricular Tachycardia
Pediatric- Unstable (age appropriate hypotension)

• SVT in children is considered greater than 180 BPM.
• SVT in infants is considered greater than 220 BPM.

IF PATIENT IS ALERT
ADENOSINE: Administer as noted above.

IF PATIENT HAS AN ALTERED MENTAL STATUS
• Consider sedation prior to cardioversion
• ETOMIDATE: 0.15mg/kg IV/IO over 15-30 seconds. Max single dose of 10mg.
May repeat 1x prn SEE PED MED TOOL
• SYNCHRONIZED CARDIOVERSION: 1j/kg. If not effective, increase to 2j/kg.

29

Wide Complex Tachycardia
Information

Wide complex tachycardia (WCT) has a QRS greater than or equal to 0.12 (0.09 for pediatrics) and a heart rate greater than 120 BPM without discernible P waves.

CAUTION: DO NOT cardiovert wide complex tachycardias that are irregularly/irregular, as they are most likely to be A-Fib/A-Flutter with an aberrancy and would put the patient at risk for an embolic stroke.

ECG features that favor a diagnosis of Ventricular Tachycardia
• Precordial concordance –all chest leads point in the same direction (either positive OR negative)
• Presence of capture beats or fusion beats
• Absence of RS in all precordial leads
• R to S > 100 ms in one precordial lead
ECG features that favor a diagnosis of supraventricular origin
• Normal Rwave progression in the chest leads
• Left bundle branch block or right bundle branch block pattern
• Only slight widening of the QRS
• Irregularly-irregular rhythm

ALL REGULAR WCTs SHOULD BE TREATED AS V-TACH UNLESS PROVEN TO BE SUPRAVENTRICULAR!

30

Really Wide Complex Tachycardia
Information

Very Wide complex tachycardia (WCT) with a QRS greater than 0.200 and a heart rate approx. 100 -120 BPM without discernible P waves is likely HYPERKALEMIA and NOT V TACH

REALLY WIDE COMPLEX TACYCARDIA stable:
• QRS IS greater than .200ms.,
• QTc > 500
• Rate less than 120

TREATMENT
• DO NOT GIVE AMIODARONE!!!
•Calcium Chloride: 1 gram IV/IO over 2 min
• SODIUM BICARBONATE: 50mEq, slow IV/IO each amp over 2 minutes.