Clinical Operating Guidelines

Transcription

1 History Hypertension Hyperlipidemia Viagra, Levitra, Cialis ast medical history (, Angina, Diabetes, ost enopausal) Family HX cardiovascular disease Recent physical exertion moker timulants igns & ymptoms C (pain, pressure, aching, vice-like tightness) Nausea, vomiting, dizziness hortness of breath ale, diaphoresis Location (substernal, epigastric, arm, jaw, neck, shoulder) Radiation of pain Obesity Differential Trauma vs. edical Angina vs. yocardial infarction ericarditis ulmonary embolism Asthma / COD neumothorax Aortic dissection or aneurysm G reflux or Hiatal hernia Esophageal spasm Chest wall injury or pain leural pain Overdose (Cocaine) Universal atient Care rotocol (U-01) Aspirin 324 mg O X1 Oxygen Titrate to ao2 >95% but <100% 12-Lead ECG Acquisition Acquire within 5 inutes of atient Contact ystem ET - ET- ET- TE nterpret edical Control Declare a TE Alert nitiate transport to appropriate TE Center. Transmit 12-Lead f Able atient Assist NTG L 0.4 mg q 5min if 100 until patient is pain free NTG L 0.4 mg q 5min until pain free Hold if < 100 nferior wall consider: rmal aline ml ay repeat x 1 V/O Access UT be established prior to second dose of NTG. orphine ulfate 5-20 mg V/O (ax 5 mg increments) Hold if < 100 -OR- Fentanyl 1-3 mcg/kg V//N/O er Dose Titrate to Effect (ax total 400 mcg) Diazepam 5-20 mg V/O ax 5 mg increments for ignificant Anxiety Consider: Hypotension rotocol (-11) Nausea/Vomiting rotocol (-13) Dysrhythmia rotocols (C) tify Destination Early earls: Do not administer Nitroglycerin in any patient who has used Viagra (sildenafil) or Levitra (vardenafil) in the past 24 hours or Cialis (tadalafil) in the past 48 hours due to potential severe hypotension. Declare TE Alert if symptomatic with T elevation 1mm in two contiguous leads and transmit 12 lead.ekg Contact receiving facility for AC Consult if asymptomatic with EKG meeting TE criteria -or- symptomatic patient with new L f patient has ECG changes, or is going directly to cardiac cath lab, establish a second V but do NOT delay transport. onitor for hypotension and respiratory depression after administration of nitroglycerin and morphine. Diabetics and geriatric patients often have atypical pain, or only generalized complaints. Hypersympathetic state from stimulant abuse usually presents with sustained HR >120 bpm and HTN. f chest pain occurs in setting of stimulants utilize benzodiazepine per Overdose/Toxic ngestion rotocol in addition to above. C-01

2 History ast edical History edications eta lockers Calcium Channel lockers Digoxin Cholineregics Clonidine acemaker Events Leading to Current tatus igns & ymptoms HR <60/min with: Hypotension, Acute altered LOC, Chest pain, CHF, Z, yncope or shock Differential Acute acemaker Failure Hypothermia inus radycardia Electrolyte Abnormality (K+) CVA, increased C, Head njury pinal Cord Lesion ick inus yndrome AV locks OD onitor and reassess Universal atient Care rotocol (U-01) HR < 60 with symptoms: hypotension, acute altered LOC, chest pain, acute CHF, shock secondary to bradycardia? ystem ET - ET- ET- edical Control YE uspected Ca Channel /eta locker OD? eta locker overdose: Glucagon 1 mg V/O Calcium Channel locker OD: Calcium Chloride 1 gram V/O -or- Calcium Gluconate 1 gram V/O V N 500mL olus ay repeat RN to 100 mmhg (max. 2 Liters) External Transcutaneous 80bpm Consider sedation with idazolam mg V/O Consider Atropine 0.5 mg V/O q 3 minutes ax of 3mg if TC not immediately available Dopamine 5-20 mcg/kg/min Epinephrine 2-10 mcg/min edical Control earls: The use of lidocaine in heart block can worsen bradycardia and lead to asystole and death. Treatment of bradycardia is based on the presence of symptoms. f asymptomatic, monitor only. Remember: The use of Atropine for bradycardia in the presence of an may worsen ischemia. Consider treatable causes for bradycardia (eta blocker OD, Calcium channel blocker OD, etc.) - treat appropriately e sure to aggressively oxygenate the patient and support respiratory effort. f wide complex bradycardia consider hyperkalemia. C-02

3 edications (Aminophylline, Diet pills, Thyroid supplements, Decongestants, Digoxin) Diet (caffeine, chocolate) Drugs (nicotine, cocaine) ast medical history History of palpitations / heart racing Alcohol igns and ymptoms: HR > 150/in QR less than 0.12 sec QR greater than 0.12 sec or history of WW go to V-Tach with pulse rotocol Dizziness, C, O yncope / near syncope Heart disease (WW, Valvular) ick sinus syndrome yocardial infarction Electrolyte imbalance Exertion, ain, Emotional stress Fever Hypovolemia or Anemia Drug effect / Overdose (see Hx) Hyperthyroidism ulmonary embolus Wide Complex Tachycardia rotocol (C-05) Universal atient Care rotocol (U-01) table QR greater than 0.12 sec OR History of WW re-arrest (everely altered or palpable ) ystem ET - ET- ET- edical Control Consider sedation for Cardioversion with idazolam mg V/O Diltiazem 0.25 mg/kg V/O over 2 minutes (ax = 20 mg) f unsuccessful after 15 min. Diltiazem 0.35 mg/kg V/O over 2 minutes (ax = 25 mg) ynchronized Cardioversion 120J x 1, then 360J Repeat RN Diltiazem 0.25 mg/kg V/O over 2 minutes (ax = 20 mg) f unsuccessful after 15 min. Diltiazem 0.35 mg/kg V/O over 2 minutes (ax = 25 mg) after rate control or conversion edical Control earls: f patient has history of or reveals Wolfe arkinson White (WW), DO NOT administer Diltiazem. Adenosine may not be effective in identifiable atrial flutter/fibrillation, but is not harmful. onitor for hypotension after administration of Diltiazem. onitor for respiratory depression and hypotension associated with idazolam. Document all rhythm changes with monitor strips and obtain monitor strips with each therapeutic intervention. Continuous pulse oximetry is required for all Atrial Fibrillation atients. aximum HR calculation 220 minus (-) age in years = ax HR Rapid ventricular response is defined as rate > 100 however rate related signs and symptoms are uncommon with HR 150/min in patients with healthy heart. Consider rate control at lower heart rates if symptomatic,. C-03

4 edications (Aminophylline, Diet pills, Thyroid supplements, Decongestants, Digoxin) Diet (caffeine, chocolate) Drugs (nicotine, cocaine) ast medical history History of palpitations / heart racing yncope / near syncope igns and ymptoms: HR greater than 150/in QR less than 0.12 ec (QR greater than 0.12 sec go to V-Tach rotocol) f history of WW, go to V-Tach rotocol Dizziness, C, O otential presenting rhythm inus tachycardia Atrial fibrillation / flutter ultifocal atrial tachycardia Heart disease (WW, Valvular) ick sinus syndrome yocardial infarction Electrolyte imbalance Exertion, ain, Emotional stress Fever Hypovolemia or Anemia Drug effect / Overdose (see Hx) Hyperthyroidism ulmonary embolus Wide Complex Tachycardia with ulse rotocol (C-05) Universal atient Care rotocol (U-01) table QR > 0.12 sec OR History of WW re-arrest everely altered or no palpable radial pulse ystem ET - ET- ET- edical Control Valsalva's maneuver initially and after each drug administration Adenosine 12 mg rapid V/O ay repeat x 1 Use 10 ml flush after each dose f readily available Consider Adenosine 12 mg rapid V/O 10 ml flush after each dose Consider sedation for Cardioversion with idazolam mg V/O ynchronized Cardioversion 100J x1 then 360J Repeat RN Any change in rhythm, go to appropriate rotocol Diltiazem 0.25 mg/kg V/O over 2 minutes (ax dose 20 mg) Diltiazem ay repeat 0.35 x1 mg/kg at 0.35mg/kg V over 2 V/O minutes (ax after = min mg) (ax dose 25mg) Hold if < 100 mmhg edical Control for assistance earls: f patient has history of or reveals Wolfe arkinson White (WW), DO NOT administer Diltiazem, go to VT with ulse. f patient requires multiple conversion attempts without resolution consider alternative cause of dysrhythmia Adenosine may not be effective in identifiable atrial flutter/fibrillation, but is not harmful. onitor for respiratory depression and hypotension associated with idazolam. Document all rhythm changes with monitor strips and obtain monitor strips with each therapeutic intervention. Continuous pulse oximetry is required for all VT atients. erious / are uncommon with HR < 150. atients with impaired cardiac function may become symptomatic at lower HR. aximum physiologic heart rate (inus Tachycardia) is 220 bpm minus age in years. C-04

5 ast medical history / medications, diet, drugs yncope / Near syncope alpitations acemaker Allergies: Lidocaine / vocaine Appropriate rotocol f Regular and onomorphic: Adenosine 12mg Rapid V/O ay repeat x 1 Use 10 ml flush after each dose igns and ymptoms: Ventricular Tachycardia on ECG (Runs or ustained) Conscious, rapid pulse Chest ain, hortness of reath Dizziness Rate usually bpm for sustained V- Tach QR > 0.12 sec Universal atient Care rotocol (U-01) alpable ulse and QR >0.12 sec? table Amiodarone 150mg V/O over 10 minutes Repeat q10 min (max. dose of 450 mg) Yes Unstable/re-Arrest everely altered or no palpable radial pulse Artifact / Device Failure Endocrine/Electrolyte Drugs/Toxic exposure ulmonary disease Consider sedation idazolam 2.5-5mg V/O ynchronized Cardioversion 120J x1 then 360J Repeat RN ystem ET - ET- ET- edical Control f refractory to initial therapy initiate transport Amiodarone 150mg V/O over 10 min Repeat q10 min (max. dose of 450 mg) ATENT TALE? Yes Consider: (Torsades de ointes) agnesium ulfate 50% 2 grams low V/O over 5 min 12 lead ECG after conversion Contact Destination or edical Control earls: For witnessed / monitored ventricular tachycardia, try having patient cough f torsades de pointes: agnesium ulfate 50% 2 grams slow V /O push over 5 minutes. aximum dose of antiarrhythmic should be given before changing antiarrhythmic. f hyperkalemia or tricyclic OD consider odium icarbonate 1 meq/kg early in intervention. C-05