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Flashcards in Cardiovascular Protocols Deck (85):
1

ACLS Treatment for Asystole (adult)

EPINEPHRINE
* IV/IO 1 mg q 4 minutes
* ET 2 mg f q 4 minutes

2

ACLS Treatment for Asystole (pediatric/adolescent)

EPINEPHRINE
* IV/IO 0.01 mg/kg (1:10,000 0.1 ml/kg) q 4 minutes
* ET 0.1 mg/kg (1:1,000 0.1 ml/kg) q 4 minutes

3

How long to do CPR before first rhythm analysis.

If unwitnessed cardiac arrest, and no CPR initiated, perform 2 minutes of CPR before rhythm analysis.

4

Process for ET administration of epinephrine.

In situations where an intravenous or intraosseous line cannot be established and the patient is intubated, EPINEPHRINE may be injected directly into the endotracheal tube. The dose of EPINEPHRINE should be diluted to a volume of 10 ml using normal saline.

5

H's and T's

oHypovolemia
oHypoxia
oHydrogen ion (acidosis)
oHyper-/hypokalemia
oHypothermia
oToxins
oTamponade, cardiac
oTension pneumothorax
oThrombosis (pulmonary)
oThrombosis (coronary)

6

Treatments for dialysis cardiac arrest

In conjunction with appropriate cardiac arrest protocol:
¤ Use fistula if no IV access obtained
¤ CALCIUM GLUCONATE (10%) 10 cc or 1 amp IV/IO
¤ SODIUM BICARBONATE 50 mEq IV/IO
¤ [D50W] IV/IO 50 cc or 1 amp
¤ INSULIN R IV/IO 10 units

7

Purpose of "dialysis cocktail"

Ninety percent of dialysis patients arrest because of hyperkalemia. Therefore, measures to correct hyperkalemia should be started simultaneously with standard cardiac arrest protocols.

8

Which type of dialysis patients will have a fistula?

Hemodialysis

9

ACLS treatment for PEA (adult)

1. volume load with 1-2 L N/S
2. EPINEPHRINE
* IV/IO 1 mg q 4 minutes
* ET 2 mg f q 4 minutes

10

ACLS treatment for PEA (pediatric/adolescent)

1. volume load with 20ml/kg N/S
2. EPINEPHRINE
* IV/IO 0.01 mg/kg (1:10,000 0.1 ml/kg) q 4 minutes
* ET 0.1 mg/kg (1:1,000 0.1 ml/kg) q 4 minutes

11

Defibrillation dose (Zoll) for adults in pVT/VF

200J

12

Defibrillation dose (Zoll) for pediatrics or adolescents in pVT/VF

first shock: 2J/kg
subsequent shocks: 4J/kg

13

Two provider CPR ratio for adult patients with no advanced airway.

30 compressions : 2 ventilations

14

Two provider CPR ratio for adolescent patients with no advanced airway.

30 compressions : 2 ventilations

15

Two provider CPR ratio for pediatric patients with no advanced airway.

15 compressions : 2 ventilations

16

Amiodarone dosing for adults in VF/pVT arrest.

AMIODARONE 300 mg IV/IO
¤ If VF / pulseless VT persists or recurs then administer second dose of AMIODARONE 150 mg IV/IO in 4 minutes

17

Amiodarone dosing for pediatric or adolescent in VF/pVT arrest

AMIODARONE 5 mg/kg IV/IO (max dose 300 mg)
¤ If VF / pulseless VT persists or recurs then administer second dose of AMIODARONE 5 mg/kg IV/IO (max dose 150 mg) in 4 minutes

18

Lidocaine dosing for adults in VF/pVT arrest.

If second dose of AMIODARONE is ineffective, proceed to LIDOCAINE
* LIDOCAINE IV/IO 1.5 mg/kg first dose, then if persistent VF/VT reduce to 0.75 mg/kg q4 min. (to max. total dose of 3 mg/kg)

OR

ET: 3 mg/kg (diluted to 10mL in NS) (max 2 doses)

19

Lidocaine dosing for pediatric or adolescent in VF/pVT arrest

If second dose of AMIODARONE is ineffective, proceed to LIDOCAINE
¤ LIDOCAINE IV/IO 1 mg/kg first dose, then if persistent VF/VT repeat 1 mg/kg q4 min. (to max. total dose of 3 mg/kg)

OR

ET: 2 mg/kg (diluted to 5mL/10mL in NS) (max 2 doses)

20

Initial treatment and assessment of suspected ACS.

¤ Low dose ASA b 160 mg PO
¤ If discomfort consistent with ACS and blood pressure greater than 100 systolic:
- NITROGLYCERIN SPRAY 0.4 mg SL q5 min (with patient supine or sitting with legs elevated)
- Apply NITRO PATCH 0.2 mg/hour with 2nd NITRO SPRAY
¤ 12 lead ECG
- Repeat ECG q15 min. if persistent ACS symptoms

21

¤ If only PCP crew on scene AND confirmed STEMI

¤ Call for closest ACP or MS to attend the call
Complete STEMI reperfusion checklist and go to STEMI protocol if both of the following criteria are met:
¤ Discomfort consistent with ACS ≤12 hours
¤ No significant dementia

22

When is a 15 lead ECG indicated?

oAcute inferior MI on 12 lead ECG
oST depression in V1 and V2 with prominent R waves on 12 lead ECG
oNormal 12 lead ECG
It is important to note that the ECG recordings for V4R, V8, and V9 are in diagnostic mode but the interpretative diagnosis is not valid.

23

Criteria to move to STEMI reperfusion checklist and STEMI protocol

Are all of the following criteria met?
¤ STEMI
¤ No LBBB
¤ Discomfort consistent with ACS ≤12 hours
¤ No significant dementia

24

ACS criteria and dosing for Fentanyl

¤ If chest discomfort continues, blood pressure greater than 100 systolic and Sa02 greater than or equal to 95%:
* Administer FENTANYL 25 mcg IV q 5 minutes (max 200 mcg)

25

Prior to treating ACS symptoms, rule out:

Tachycardic or bradycardic dysrhythmia

26

Contraindications to ASA administration

- Allergy to ASA
- Symptoms / signs of upper GI bleeding

27

Treatment implications of V4R ST elevation

In patients with ECG evidence of right ventricular infarct (ST elevation in lead V4R), drugs that reduce preload such as NITROGLYCERIN SPRAY and FENTANYL must not be used.

28

Drugs that potentiate hypotensive effects of nitroglycerin.

Sildenafil (Viagra), Vardenafil (Levitra) and Tadalafil (Cialis)

29

Treatment for systolic blood pressure drop below 100 after treatment with nitroglycerin or fentanyl.

The patient's legs should be elevated and vital signs re-checked and meds discontinued. If blood pressure
remains less than 100 systolic and there is no evidence of CHF, a fluid challenge of 500 cc N/S should be given. In the event of a right ventricular infarct and continued hypotension despite 500 cc N/S, a second bolus of 500 cc N/S can be administered as long as the lung sounds are clear.

30

When is ST elevation considered significant?

oThere is ST elevation greater than 1 mm on a 12 lead ECG (in diagnostic mode) calibrated to 10 mm/1 mV
oThe ST elevation is present in at least 2 limb leads or in 2 or more contiguous precordial leads (in
diagnostic mode)

31

Absolute contraindications for PCI

1. Active internal bleeding (except menstruation)
2. Suspected aortic dissection
3. Acute stroke, significant head trauma or other acute intracerebral pathology

32

Relative contraindications for PCI

Previous CABG

33

Three STEMI protocol options

1. Closest hospital
2. Thrombolytics
3. Cath Lab

34

Two considerations for selecting drug dosage for thrombolytics and their basic implications.

1. History of renal failure (if so, use unfractionated heparin instead of enoxaparin)
2. Age
<75: clopidogrel 300mg po
>=75: clopidogrel 75mg po

35

Drug dosing for PCI candidate being transported to Cath Lab.

¤ TICAGRELOR 180 mg PO
¤ UNFRACTIONATED HEPARIN 70 U/kg IV (max. 10000 U)

36

Considerations for communication with on call cardiologist

Care should be discussed by paramedic via phone with on-call STEMI physician using *closed-loop communication. Paramedic should be prepared to discuss: present history, past history, medications, allergies, content of Reperfusion checklist, vital signs
and findings of physical exam. (closed-loop communication: sender gives message, receiver repeats back)

37

If crew is unable to contact the on-call STEMI physician after two attempts, they should:

1) Attempt to contact WFPS Medical Director or Associate Medical Director. Contact numbers available through Comm. Centre.
2) If unable to contact WFPS Medical Director or Associate Medical Director AND automated ECG interpretation states:
** ** ** ** * Acute MI * ** ** ** ** (E-Series)
or
*** STEMI *** (X-Series)
then patient should be transported to St. Boniface Emergency.

38

Considerations for transporting to Cath Lab

EMS crew must stay with patient until at least the
physician and 2 cath lab staff members are present to assume care of the patient. EMS crew should be prepared to manage these cases in the same manner as a primary 911 call in the community. They should bring all necessary equipment and medications with them at the patient’s side.

39

Management of post thrombolysis reperfusion dysrhythmias

Reperfusion dysrhythmias are common after the administration of thrombolytic agents. These
dysrhythmias are usually brief in duration and self-resolving. The key to management is to ensure
the patient remains stable ( ie. maintain adequate BP, mentation, etc.)

40

Management of inappropriate shocks delivered by ICD.

If inappropriate shocks delivered by ICD place magnet over pulse generator

41

Placement of defib pads relative to ICD.

Defibrillator pads should be placed a minimum of 2.5 cm or 1 inch from the pulse generator. Failure to do
so may damage the pulse generator. If external defibrillation in the anterior-lateral position does not convert ventricular dysrhythmia, the pad position should be changed to anterior-posterior placement because the patient may have epicardial patches that insulate the heart and deflect the shock.

42

ICD deployment during CPR.

If a rescuer is performing CPR while the ICD is delivering shock therapy to the patient, the rescuer may feel a tingling sensation. The ICD shocks are not dangerous to the rescuer.

43

Transport of patients with ICD related issue.

All patients with an ICD and a problem related to the ICD, that are not in cardiac arrest, should be
transported to SBGH.

44

Criteria for discontinuation of resuscitation in the field.

1. Age greater than or equal to 18 years.
2. Arrest is unwitnessed (no one hears or sees the patient collapse).
3. Initial monitored rhythm is asystole.
4. No evidence of major trauma, hypothermia (T < 30°C), or drowning.
5. Rhythm remains asystole throughout field resuscitative steps.
6. No return of spontaneous pulse at any time during field resuscitative steps.
7. Field resuscitative steps must be the completed Advanced Life Support protocol for asystolic cardiac arrest and include:
- adequate ventilation of patient with 100% oxygen via Combitube, endotracheal tube or bag-valve mask & oropharyngeal airway
- IV/IO establishment
- IV/IO drug administration of EPINEPHRINE (1 mg x 3 doses) ensuring each dose is circulated with 2 minutes of CPR

45

Documentation of code black.

The patient care report must be completed by the ICP/ ACP / Medical Supervisor and
must include documentation that all criteria for discontinuation of resuscitation have
been met (including time of death). A copy of the patient care report must be sent to
the Medical Examiner’s office (In TabletPCR select Discontinuation of Resucitation as Outcome, then select the Medical Examiner Office as a Destination Facility).

46

Symptomatic Bradycardia (adolescent or adult)

Not hypothermic

AND

Blood pressure less than 90 systolic with signs of poor perfusion

AND

One of the following present:
- Decreased level of consciousness
- Chest pain
- Pulmonary edema
- Ventricular escape rhythm

47

Atropine dosing for adult symptomatic bradycardia

¤ ATROPINE 0.5 - 1.0 mg IV
If responsive to ATROPINE continue administration q3 minutes, as necessary, to a max of 0.04 mg/kg (not to exceed a max of 3 mg.)

48

Atropine dosing for adolescent symptomatic bradycardia

¤ ATROPINE 0.02 mg/kg IV (single dose max. of 1 mg)
If responsive to ATROPINE continue administration q3 minutes to a max of 0.04 mg/kg (not
to exceed a max. of 3 mg)

49

Management of discomfort in adult patients receiving transcutaneous pacing

If pacing causing patient discomfort, and Sa02 greater than 95% and BP greater than 90 systolic, consider analgesia FENTANYL 25 mcg q 5 min for the first 3 doses then subsequent doses q 10 min and / or sedation MIDAZOLAM 1 – 2.5 mg q 5 min for the first 3 doses then subsequent doses q 10 min.

50

Management of discomfort in adolescent patients receiving transcutaneous pacing

If pacing causing patient discomfort, and Sa02 greater than 95% and BP greater than 90 systolic, consider analgesia FENTANYL 0.5 mcg/kg (single dose max. of 25 mcg) q5 min for the first 3 doses then subsequent doses q10 min. and / or sedation MIDAZOLAM 0.05 mg/kg (single dose max. of 1 mg) q 5 min for the first 3 doses then subsequent doses q 10 min.

51

Common causes of bradycardia

Hypoxemia, acidosis, and hypotension interfere with normal sinus node function and slow conduction.
Excess vagal stimulation may also produce bradycardia.

52

Primary contraindication for drug therapy and pacing in a bradycardic patient.

Hypothermia (<= 30C)

53

A case for skipping atropine in the symptomatic bradycardic patient.

Denervated transplanted hearts will not respond to ATROPINE. Go at once to pacing.

54

Initial management of the pediatric bradycardic patient.

Ensure adequate ventilation and oxygenation.
If they remain bradycardic, begin CPR.

55

PALS management of the pediatric bradycardic patient.

EPINEPHRINE
* IV 0.01 mg/kg (1:10,000 0.1 ml/kg) q 4 minutes
* ET 0.1 mg/kg (1:1,000 0.1 ml/kg) q 4 minutes

If increased vagal tone or primary AV block:
¤ ATROPINE
* IV 0.02 mg/kg (minimum single dose 0.1 mg and max. single dose 0.5 mg)
* ET 0.04 mg/kg (minimum single dose 0.2 mg and max. single dose 1.0 mg)
If responsive to ATROPINE may repeat dose once at 4 minutes.

If no response to ATROPINE at any point or max dose achieved and patient remains symptomatic
¤ Establish TRANSCUTANEOUS PACING

56

Management of discomfort in pediatric patients receiving transcutaneous pacing

If pacing causing patient discomfort, and Sa02 greater than 95% and SBP greater than 70 + 2x age in
years consider:
¤ FENTANYL IV 0.5 mcg/kg (single dose max. of 25 mcg) q5 min for the first 3 doses then subsequent
doses q10 min.
¤ MIDAZOLAM IV 0.05 mg/kg (single dose max. of 1 mg) q10 min.

57

Criteria for Symptomatic narrow complex tachycardia with a pulse, regular

Confirm :
¤ Adult patient
¤ Narrow complex tachycardia with ventricular rate greater than 150 bpm
¤ QRS complex less than 0.12 seconds
¤ Paroxysmal in nature (abrupt onset and cessation)

AND

Are any of the following present?
1) Blood pressure less than 90 systolic with
signs of poor perfusion
2) Decreased level of consciousness
3) Pulmonary edema
4) Cardiac chest pain

58

Treatment for symptomatic narrow complex tachycardia with a pulse, regular

If patient conscious, blood pressure greater than
90 systolic and Sa02 greater than 95%
¤ Establish IV d N/S TKVO
¤ consider MIDAZOLAM 1-2.5 mg IV

¤ Synchronized cardioversion 50 joules
¤ Repeat synchronized cardioversion 100 joules if necessary

59

Sinus Tachycardia

Sinus tachycardia has a gradual onset and generally has a rate of less than 150 bpm. Management of
sinus tachycardia includes identification and treatment of the underlying conditions, such as anxiety, fever,
blood loss, thyrotoxicosis.

60

Valsalva maneuver

To be used in asymptomatic narrow complex tachycardia with a pulse, regular

The Valsalva maneuver should be performed by asking the patient to exhale against a closed glottis.
This may slow the rate of an ectopic rhythm, allowing a more accurate interpretation of the rhythm and
might rarely convert the patient to a normal sinus rhythm. The Valsalva maneuver is of no therapeutic
benefit in patients with rapid atrial fibrillation and should not be performed in these patients.

61

Criteria for Symptomatic narrow complex tachycardia with a pulse, irregular

Confirm :
¤ Adult patient
¤ Narrow complex tachycardia irregular with ventricular rate greater than 150 bpm
¤ QRS complex less than 0.12 seconds
¤ Paroxysmal in nature (abrupt onset and cessation)

AND

Blood pressure less than 90 systolic

AND

One of the following:
1) Decreased level of consciousness
2) Pulmonary edema
3) Cardiac chest pain

62

Treatment for symptomatic narrow complex tachycardia with a pulse, irregular

¤ Synchronized cardioversion 200 joules
¤ Dose to be maintained for all subsequent shocks

Ideally egress should occur after 2 shocks on scene with subsequent shocks given enroute

63

Considerations for synchronized cardioversion of an irregular tachycardia

Atrial fibrillation is irregularly irregular. Cardioversion of a patient that has been in atrial fibrillation for >/=
to 48 hours introduces a significant risk of stroke. If such a patient is grossly unstable, atrial cardioversion
is still indicated.

64

Criteria for Symptomatic wide complex tachycardia with a pulse

Confirm:
¤ Ventricular rate greater than 150 bpm, and regular rate
¤ QRS complex greater than 0.12 seconds
¤ P waves, if apparent, are independent of the ventricular rate

AND

Are any of the following present?
1) Blood pressure less than 90 systolic with signs of poor perfusion
2) Decreased level of consciousness
3) Pulmonary edema
4) Cardiac chest pain

65

Treatment for asymptomatic wide complex tachycardia with a pulse (adults)

¤ LIDOCAINE 1.5 mg/kg IV

If no change in rhythm after 3 minutes:
¤ MIDAZOLAM 2.5 mg IV if Sa02 greater than 95%
¤ Synchronized cardioversion 100 joules
¤ Repeat synchronized cardioversion 200 joules if necessary

66

Treatment for symptomatic wide complex tachycardia with a pulse (adults)

If patient conscious, blood pressure greater than 90 systolic and Sa02 greater than 95%
¤ consider MIDAZOLAM 2.5 mg IV

¤ Synchronized cardioversion 100 joules
¤ Repeat synchronized cardioversion 200
joules if necessary

If wide complex tachycardia with a pulse persists:
¤ LIDOCAINE 1.5 mg/kg IV, may be repeated in 10 min. if required

67

Treatment for asymptomatic wide complex tachycardia with a pulse (adolescents)

¤ LIDOCAINE 1 mg/kg IV, may be repeated in 10 minutes if required

If no change in rhythm after 3 minutes:
¤ MIDAZOLAM 0.05 mg/kg IV if Sa02 greater than 95%
¤ Synchronized cardioversion 1 joule/kg
¤ Repeat synchronized cardioversion 2 joules/kg if necessary

68

Treatment for symptomatic wide complex tachycardia with a pulse (adolescents)

If patient conscious, blood pressure greater than 90 systolic and Sa02 greater than 95%
¤ consider MIDAZOLAM 0.05 mg/kg IV

¤ Synchronized cardioversion 1 joule/kg
¤ Repeat synchronized cardioversion 2 joules/kg if necessary

If wide complex tachycardia with a pulse persists:
¤ LIDOCAINE 1 mg/kg IV , may be repeated in 10 min, if required

69

Criteria for wide complex tachycardia with a pulse in pediatric patients

Confirm:
¤ Wide complex tachycardia with a pulse and poor perfusion
¤ a heart rate that is fast compared with normal heart rates for patient age
¤ QRS complex greater than 0.08 seconds
¤ P waves, if apparent, are independent of the ventricular rate

70

Treatment for symptomatic wide complex tachycardia with a pulse (pediatric)

¤ Synchronized cardioversion 1 joule/kg
¤ Repeat synchronized cardioversion 2 joules/kg if necessary

If wide complex tachycardia with a pulse and poor perfusion persists:
¤ LIDOCAINE 1 mg/kg IV/IO
¤ LIDOCAINE dose may be repeated x1 in 10 min. if required

71

Common causes of non-traumatic shock

Hypovolemia
Sepsis
Pulmonary embolism
Cardiac tamponade
Myocardial infarction
Arrhythmia
Anaphylaxis

72

Size of fluid boluses in non-traumatic shock (adults)

250mL in adults, max 2L

Target of fluid resuscitation is to maintain a systolic blood pressure of 90 mmHG.

73

Size of fluid boluses in non-traumatic shock (adolescents)

10mL/kg with Class II shock
20mL/kg with Class III or IV shock

Repeat bolus as needed based on class of shock

Target of fluid resuscitation is to maintain a systolic blood pressure of 90 mmHG.

74

Management of shock secondary to DKA in pediatric or adolescent patients.

If signs and/or symptoms of DKA and pt is in class II shock, volume load 10 ml/kg N/S over 20 minutes.

75

Signs of DKA in pediatric or adolescent patients

DKA should be suspected in adolescent patients with acute hyperglycemia or a known history of diabetes and hyperglycemia combined with the following symptoms:
- tachypnea or Kussmaul respirations
- tachycardia
- polyuria
- polydypsia
- altered level of consciousness
- hypotension

76

Pediatric management consideration for Class IV shock

If intravenous access not available AND class IV shock then establish IO

77

Ventilation of pediatric patient.

Parameters for adequate ventilation in a pediatric patient without an advanced airway in place are adequate chest rise and a rate of 12-20 breaths/min. (1 breath every 3-5 seconds).

78

Criteria for determination of death.

Resuscitative steps may be withheld a if ANY of the following criteria are met:
1. Decapitation or displaced brain matter
2. Complete transection of torso (chest or abdomen)
3. Gross/advanced decomposition
4. Incineration (whole body charring)
5. Continuous Liquid submersion > 90 minutes (with or without hypothermia)
6. Found in a warm environment with ALL of the following:
- Rigor Mortis
- Lividity
- Confirmed asystole in 2 leads

79

Troubleshooting an LVAD

Ensure the following:
- Pump is connected to controller
- Controller is connected to power
- Green power light is on
- Batteries are not depleted
OR
- Power base unit and power module are plugged into a working outlet.

80

Treatment of a responsive patient with an LVAD

Follow all applicable WFPS Protocols and
Procedures EXCEPT:
No Cardioversion
No Pacing

Transport Amber or Red to SBGH.

81

Treatment of an unresponsive patient with an LVAD

Cardiac arrest protocol. Transport Amber or Red to SBGH.

82

Considerations for assessing a patient with an LVAD

Proper functioning of LVAD pump can be confirmed by auscultation of the left upper abdominal quadrant confirming a continuous humming sound.

The patient may not have a palpable pulse, measureable BP or pulse oximeter readings even if pump is functional.

Cardiac arrest is determined by the combination of an unresponsive patient and a nonfunctioning
LVAD pump.

If conducting a 12-lead, do not place V5 and V6 to eliminate 60 cycle interference.

83

Treatment of cardiac arrest with suspected opioid ingestion.

In conjunction with appropriate cardiac arrest protocol:
¤ NALOXONE 2mg q4 min. IM/IV/IO
¤ ET 4mg (diluted to 10mL in NS) q4 min.

(Note: dosing can be changed to PRN based on appropriate clinical response)

84

Clinical presentation of acute opioid overdose.

Pinpoint pupils, stupor or coma, and hypoventilation. In severe overdose, hypotension, respiratory and cardiac arrest may occur.

85

Role of Naloxone in opioid overdose.

NALOXONE can rapidly reverse the CNS and respiratory depression of an opioid overdose.
In patients that have progressed from respiratory depression to cardiopulmonary arrest , clinical
improvement may be delayed.