Michigan Adult Cardiac Protocols TABLE OF CONTENTS

Transcription

1 Date: November 15, 2012 Page 1 of 1 TABLE OF CONTENTS Asystole Section 2-1 Bradycardia Section 2-2 Cardiac Arrest General Section 2-3 Cardiac Arrest ROSC Section 2-4 Chest Pain Acute Coronary Syndrome Section 2-5 Nitroglycerin Drip Supplement (Optional) Section 2-5(S) Hypothermia Cardiac Arrest Section 2-6 Pulmonary Edema/CHF Section 2-7 Tachycardia Section 2-8 V-Fib Pulseless Tachycardia Section 2-9 Section 2 MCA Implementation Date

2 ASYSTOLE / PULSELESS ELECTRICAL ACTIVITY (PEA) Date: May 31, 2012 Page 1 of 2 Asystole / Pulseless Electrical Activity During CPR, consider reversible causes of Asystole/PEA and treat as indicated. Causes and efforts to correct them include but are not limited to: Hypovolemia give NS IV/IO fluid bolus up to 1 liter, wide open. Hypoxia reassess airway and ventilate with high flow oxygen Tension pneumothorax see Pleural Decompression Procedure Hypothermia follow Hypothermia Cardiac Arrest Protocol rapid transport Hyperkalemia (history of renal failure) see #5 below. Pre-Medical Control PARAMEDIC 1. Follow the Cardiac Arrest - General Protocol. 2. Confirm that patient is in asystole by evaluating more than one lead. 3. Administer Epinephrine 1:10,000, 1 mg (10 ml) IV/IO, repeat every 3-5 minutes. 4. Per MCA selection, administer Vasopressin 40 Units IV/IO in place of second dose of Epinephrine. Vasopressin 40 Units IV/IO Included Not Included 5. In a dialysis patient hyperkalemia is likely. Administer Calcium Chloride 1gm IV/IO and Sodium Bicarbonate 1 meq/kg IV/IO with 20 ml NS flush in between medications. 6. Continue CPR and reassess rhythm every 2 minutes. Section 2-1 MDCH Approval Date MCA Implementation Date

3 ASYSTOLE / PULSELESS ELECTRICAL ACTIVITY (PEA) Date: May 31, 2012 Page 2 of 2 During CPR, consider reversible causes of Asystole/PEA and treat as indicated. Causes and efforts to correct them include but are not limited to: Hypovolemia give NS IV/IO fluid bolus up to 1 liter, wide open. Hypoxia reassess airway and ventilate with high flow oxygen Tension pneumothorax See Pleural Decompression Procedure Hypothermia follow Hypothermia Cardiac Arrest Protocol rapid transport Hyperkalemia (history of renal failure) see below Vasopressin 40 Units IV/IO Included Not Included Follow Cardiac Arrest General Protocol. Confirm that patient is in asystole by evaluating more than one lead. Administer Epinephrine 1:10,000, 1 mg (10 ml) IV/IO, repeat every 3-5 minutes. Per MCA selection, administer Vasopressin 40 units IV/IO in place of second dose of Epinephrine In a dialysis patient hyperkalemia is likely. Administer Calcium Chloride 1 gm IV/IO and Sodium Bicarbonate 1 meq/kg IV/IO with 20 ml NS flush in between medications. Continue CPR, reassess rhythm every 2 minutes. Contact Medical Control Section 2-1 MDCH Approval Date MCA Implementation Date

4 BRADYCARDIA Date: November 15, 2012 Page 1 of 3 Bradycardia This is a protocol for patients with serious symptomatic bradycardia. Serious symptomatic bradycardia may be defined as patients with heart rate less than 50 bpm and hypotension, or shock. Titrate treatments to a heart rate above 50 bpm. If the patient remains hypotensive refer to the Shock Protocol. Pre-Medical Control MFR/EMT/SPECIALIST/PARAMEDIC 1. Follow the General Pre-Hospital Care Protocol. PARAMEDIC 2. Administer Atropine 0.5 mg IV/IO repeating every 3-5 minutes to a total dose of 3 mg IV/IO, until a heart rate of greater than 50 /minute is reached. 3. Transcutaneous pacing (TCP) when available may be initiated prior to establishment of IV access and/or before Atropine begins to take effect. Pacing is the treatment of choice for high degree A-V block. Follow the Electrical Therapy Procedure. 4. Per MCA selection, provide sedation per Patient Sedation Procedure. Post-Medical Control 1. Consider Dopamine Drip 2-10 mcg/kg/min IV/IO. Mix drip by putting Dopamine 400 mg in 250 ml NS. 2. Consider Epinephrine Drip 2-10 mcg/min IV/IO. Mix drip by putting Epinephrine 1:1,000, 1 mg (1 ml) in 250 ml NS. Notes: 1. Some patients may not tolerate the pacing stimulus to the skin and chest wall that occurs with transcutaneous pacing. In these cases, consider sedation if SBP > 100. (See box) 2. Consider possible etiologies: A. Hyper/hypokalemia, other metabolic disorders B. Hypothermia C. Hypovolemia (including vomiting/diarrhea) D. Hypoxia E. Toxins/ overdose (e.g. beta-blocker or calcium channel-blocker) F. Tamponade G. Tension pneumothorax 3. Transcutaneous pacemaker electrode pads may be applied to these patients without initiating pacing so that the pacemaker is ready if patient condition deteriorates. 4. For symptomatic high-degree (second-degree or third-degree) AV block, begin pacing without delay. 5. Atropine 0.5 mg should be administered by rapid IV/IO push and may be repeated every 3-5 minutes, to a maximum dose of 3 mg. Atropine is ineffective and should be avoided in heart transplant patients. Northwest Regional MCA MCA Implementation Date MCA Name Section 2-2

5 BRADYCARDIA Date: November 15, 2012 Page 2 of 3 This is a protocol for patients with serious symptomatic bradycardia. Serious symptomatic bradycardia may be defined as patients with heart rate less than 50 bpm and hypotension, or shock. Titrate treatments to a heart rate above 50 bpm. If the patient remains hypotensive refer to the Shock Protocol. Follow the General Pre-Hospital Care Protocol Administer Atropine 0.5 mg IV/IO repeating every 3-5 minutes to a total dose of 3 mg IV/IO, until a heart rate of greater than 50 / minute is reached. Transcutaneous pacing (TCP) when available may be initiated prior to establishment of IV access and/or before Atropine begins to take effect. Pacing is the treatment of choice for high degree A-V block. Follow the Electrical Therapy Procedure. Per MCA selection, provide sedation per Patient Sedation Procedure. Contact Medical Control Consider Dopamine Drip 2-10 mcg/kg/min IV/IO. Mix drip by putting Dopaimine 400 mg in 250 ml NS. Consider Epinephrine Drip 2-10 mcg/min IV/IO. Mix drip by putting Epinephrine 1:1,000; 1 mg (1 ml) in 250 ml NS. Northwest Regional MCA MCA Implementation Date MCA Name Section 2-2

6 BRADYCARDIA Date: November 15, 2012 Page 3 of 3 Notes: 1. Some patients may not tolerate the pacing stimulus to the skin and chest wall that occurs with transcutaneous pacing. In these cases, consider sedation if SBP > 100. (See box) 2. Consider possible etiologies: A. Hyper/hypokalemia, other metabolic disorders B. Hypothermia C. Hypovolemia (including vomiting/diarrhea) D. Hypoxia E. Toxins/ overdose (e.g. beta-blocker or calcium channel-blocker) F. Tamponade G. Tension pneumothorax 3. Transcutaneous pacemaker electrode pads may be applied to these patients without initiating pacing so that the pacemaker is ready if patient condition deteriorates. 4. For symptomatic high-degree (second-degree or third-degree) AV block, begin pacing without delay. 5. Atropine 0.5 mg should be administered by rapid IV/IO push and may be repeated every 3-5 minutes, to a maximum dose of 3 mg. Atropine is ineffective and should be avoided in heart transplant patients. Northwest Regional MCA MCA Implementation Date MCA Name Section 2-2

7 CARDIAC ARREST GENERAL Date: November 15, 2012 Page 1 of 5 Cardiac Arrest General This protocol should be followed for all adult cardiac arrests. Medical cardiac arrest patients undergoing attempted resuscitation should not be transported unless return of spontaneous circulation (ROSC) is achieved or transport is ordered by medical control or otherwise specified in protocol. If an arrest is of a known traumatic origin refer to the Dead on Scene Protocol. If it is unknown whether the arrest is traumatic or medical, continue with this protocol. Patients displaying a Do Not Resuscitate order or bracelet follow DNR Protocol. When an ALS unit is present, follow this general cardiac arrest protocol in conjunction with the protocol that addresses the indentified rhythm. Once arrest is confirmed, emphasis should be on avoiding interruptions in CPR. CPR should be done in accordance with current guidelines established by the American Heart Association. Pre-Medical Control MFR/EMT/SPECIALIST 1. Confirm Arrest A. Assess for signs of normal breathing. B. Check a carotid pulse for not more than 10 seconds. 2. Initiate CPR or continue CPR if already in progress and apply and use AED as soon as available. 3. Ensure CPR quality A. Compressions at least 2 in depth for adults. B. Compression rate at least 100 per minute. C. Avoid excessive ventilation (volume and rate). 4. Continue CPR with minimal interruptions, changing the rescuer doing compressions every 2 minutes, when possible. 5. Initiate ALS response if available. 6. Establish a patent airway, maintaining C-Spine precaution if indicated, using appropriate airway adjuncts and high flow oxygen. See Emergency Airway Procedure. EMT 7. Establish a patent airway with a supraglottic airway. After insertion, provide continuous CPR without pauses for ventilation. Ventilations should be delivered at 8-10 breaths per minute or 1 breath every 5 to 6 seconds. See Emergency Airway Procedure. 8. Verify CPR quality frequently and anytime the rescuer providing compressions or ventilations changes. 9. If Return of Spontaneous Circulation (ROSC) has not been achieved after three, two minute cycles of CPR and ALS is not available or delayed, contact medical control, initiate transport. Section 2-3 MCA Board Approval Date MDCH Approval Date MCA Implementation Date

8 CARDIAC ARREST GENERAL Date: November 15, 2012 Page 2 of 5 SPECIALIST 10. If Return of Spontaneous Circulation (ROSC) has not been achieved after three, two minute cycles of CPR and ALS is not available or delayed, contact medical control prior to initiating transport. 11. Start an IV/IO NS KVO. If IV is attempted and is unsuccessful, after 2 attempts start an IO line per Vascular Access & IV Fluid Therapy Procedure. IO may be first line choice. 12. Establish a patent airway, maintaining C-Spine precaution if indicated, using appropriate airway adjuncts and high flow oxygen. See Emergency Airway Procedure. A. Minimize interruptions in compressions during airway placement to less than 10 seconds. PARAMEDIC 13. Confirm Arrest if not previously done. A. Assess for signs of normal breathing. B. Check a carotid pulse for not more than 10 seconds. 14. Initiate CPR, or continue CPR if already in progress and apply cardiac monitor. 15. Check rhythm, shock if indicated and continue CPR. 16. Ensure CPR quality A. Compressions at least 2 in depth for adults. B. Compression rate at least 100 per minute. C. Avoid excessive ventilation (volume and rate). D. Continue CPR with minimal interruptions, changing rescuer doing compressions every 2 minutes, when possible. E. Apply waveform capnography, if available. 17. Start an IV/IO NS KVO. If IV is attempted and is unsuccessful after 2 attempts start an IO line per Vascular Access & IV Fluid Therapy Procedure. IO may be first line choice. 18. Administer Medications consistent with appropriate protocol. 19. Establish a patent airway, maintaining C-Spine precaution if indicated, using appropriate airway adjuncts and high flow oxygen. See Emergency Airway Procedure. A. Minimize interruptions in compressions during airway placement to less than 10 seconds. B. Supraglottic airways are an acceptable alternative for endotracheal intubation. 20. If quantitative waveform capnography is available and PETCO 2 is < 10 mm Hg attempt to improve CPR quality. 21. Reassess ABC s as indicated by rhythm or patient condition change. Pulse checks should take no more than 10 seconds. If no pulse after 10 seconds, assume pulselessness, continue CPR. 22. Prior to advanced airway placement, utilize ventilation periods to visualize the ECG rhythm without compression artifact, this will allow you to plan ahead for the assessment period at the end of the two minute CPR cycle. 23. After insertion of advanced airway, monitor capnography to confirm appropriate tube placement and deliver continuous CPR, without pauses for ventilation. Ventilations delivered at 8-10 breaths per minute or 1 breath every 6-8 seconds. Section 2-3 MCA Board Approval Date MDCH Approval Date MCA Implementation Date

9 CARDIAC ARREST GENERAL Date: November 15, 2012 Page 3 of 5 Post-Medical Control MFR/EMT/SPECIALIST/PARAMEDIC 24. Additional basic and/or advanced life support care as appropriate. 25. Consider termination of resuscitation per Termination of Resuscitation Protocol. Notes: 1. Excellent CPR is a priority: A. 30 compressions: 2 ventilations in groups of 5 cycles, over 2 minutes. B. Push hard and fast (100/min) and allow full recoil of chest during compressions. C. Change rescuer doing compressions every 2 minutes to avoid fatigue or utilize automated mechanical CPR devices, if available. D. Restart CPR immediately after any defibrillation attempts. E. Keep pauses in CPR to a minimum by checking rhythm when rotating rescuer doing compressions and by avoiding pauses in CPR during airway management and other interventions. 2. If AED has been applied by BLS personnel, skip to appropriate place in protocol that incorporates previous care. ALS personnel should switch to manual defibrillator after initial AED shock or place AED in manual mode. 3. For Biphasic devices shock with energy levels following manufacturers recommendations ( J). If unknown use the maximum available. For monophasic devices use 360 J. 4. Confirm and document tube placement by physical exam, measurement of exhaled CO 2 and/or use of other MCA approved secondary confirmation device. 5. If possible, contact medical control prior to moving or transporting patient. 6. Continue resuscitation attempts and initiate transport, unless field termination is ordered by Medical Control. 7. An impedance threshold device may be utilized during CPR, if available. Device should be discontinued immediately upon return of spontaneous circulation. 8. Treat reversible causes. Northwest Regional MCA MCA Implementation Date MCA Name Section 2-3

10 CARDIAC ARREST GENERAL Date: November 15, 2012 Page 4 of 5 This protocol should be followed for all adult cardiac arrests. Medical cardiac arrest patients undergoing attempted resuscitation should not be transported unless return of spontaneous circulation (ROSC) is achieved or transport is ordered by medical control or otherwise specified in protocol. If an arrest is of a known traumatic origin refer to the Dead on Scene Protocol. If it is unknown whether the arrest is traumatic or medical, continue with this protocol. Patients displaying a Do Not Resuscitate order or bracelet follow DNR Protocol. When an ALS unit is present, follow this general cardiac arrest protocol in conjunction with the protocol that addresses the indentified rhythm. Once arrest is confirmed, emphasis should be on avoiding interruptions in CPR. CPR should be done in accordance with current guidelines established by the American Heart Association. Confirm Arrest Assess for normal breathing. Check a carotid pulse for not more than 10 seconds. Initiate CPR or Continue CPR if already in progress. Apply cardiac monitor. Check rhythm, shock if indicated and continue CPR. Ensure CPR quality Compressions at least 2" in depth for adults Compression rate at least 100 per minute Avoid excessive ventilations (volume & rate) Continue CPR with minimal interruptions, changing rescuer doing compressions every 2 minutes, when possible. Apply waveform capnography, if available Start an IV/IO NS KVO If IV is attempted and is unsuccessful after 2 attempts start an IO line per Vascular Access & IV Fluid Therapy Procedure. IO may be first line of choice. Administer medications consistent with appropriate protocol Establish a patent airway, maintaining C-Spine precaution if indicated, using appropriate airway adjuncts & high flow oxygen. See Emergency Airway Procedure. Minimize interruptions in compressions during airway placement to less than 10 seconds. Supraglottic airways are an acceptable alternative for endotracheal intubation. If quantitative Waveform Capnography is available and PETCO2 is < 10 mm Hg, attempt to improve CPR quality. Reassess ABC s as indicated by rhythm or patient condition change. Pulse checks should take no more than 10 seconds. If no pulse after 10 seconds, assume pulselessness, continue CPR. Prior to advanced airway placement, utilize periods to visualize ECG rhythm without compression artifact, this allows you to plan ahead for assessment period at end of 2 minute CPR cycle. After insertion of advanced airway, monitor capnography to confirm appropriate tube placement and deliver continuous CPR. Ventilations delivered at 8-10 per minute or 1 breath every 6 8 seconds. Contact Medical Control Additional basic and/or advanced life support care as appropriate Consider termination of resuscitation per Termination of Resuscitation Protocol Section 2-3 MCA Board Approval Date MDCH Approval Date MCA Implementation Date

11 CARDIAC ARREST GENERAL Date: November 15, 2012 Page 5 of 5 Notes: 1. Excellent CPR is a priority: A. 30 compressions: 2 ventilations in groups of 5 cycles, over 2 minutes. B. Push hard and fast (100/min) and allow full recoil of chest during compressions. C. Change rescuer doing compressions every 2 minutes to avoid fatigue or utilize automated mechanical CPR devices, if available. D. Restart CPR immediately after any defibrillation attempts. E. Keep pauses in CPR to a minimum by checking rhythm when rotating rescuer doing compressions and by avoiding pauses in CPR during airway management and other interventions. 2. If AED has been applied by BLS personnel, skip to appropriate place in protocol that incorporates previous care. ALS personnel should switch to manual defibrillator after initial AED shock or place AED in manual mode. 3. For Biphasic devices shock with energy levels following manufacturers recommendations ( J). If unknown use the maximum available. For monophasic devices use 360 J. 4. Confirm and document tube placement by physical exam, measurement of exhaled CO 2 and/or use of other MCA approved secondary confirmation device. 5. If possible, contact medical control prior to moving or transporting patient. 6. Continue resuscitation attempts and initiate transport, unless field termination is ordered by Medical Control. 7. An impedance threshold device may be utilized during CPR, if available. Device should be discontinued immediately upon return of spontaneous circulation. 8. Treat reversible causes. Section 2-3 MCA Board Approval Date MDCH Approval Date MCA Implementation Date

12 CARDIAC ARREST ROSC Date: May 31, 2012 Page 1 of 2 Cardiac Arrest Return of Spontaneous Circulation (ROSC) This protocol should be followed for all adult cardiac arrests with ROSC. If an arrest is of a known traumatic origin refer to the Trauma Protocol and MCA Transport Protocol. If it is unknown whether the arrest is traumatic or medical, continue with this protocol. Pre-Medical Control MFR/EMT/SPECIALIST 1. If ventilation assistance is required, ventilate at breaths per minute. Do not hyperventilate. 2. Reassess patient, if patient becomes pulseless begin CPR and follow Adult or Pediatric Cardiac Arrest General Protocol. 3. Monitor vital signs. 4. Initiate ALS response if available. SPECIALIST 5. Start an IV/IO NS KVO. 6. Treat hypotension (SBP less than 90 mm/hg) with an IV/IO fluid bolus consistent with Shock Protocol. PARAMEDIC 7. Perform 12- lead ECG 8. Consider treatable causes 9. If ventilation assistance is required with an advanced airway in place and quantitative waveform capnography is available target PETCO2 of mm Hg. 10. Transport to a facility capable of Percutaneous Coronary Intervention (PCI) and therapeutic hypothermia where available per MCA protocol. Post-Medical Control PARAMEDIC 11. If hypotension persists after IV/IO fluid bolus, administer Dopamine 5-20 mcg/kg/min. Mix drip by putting Dopamine 400 mg in 250 ml NS. Notes: If a mechanical ventilator is available or there are spontaneous respirations in the nonintubated patient titrate inspired oxygen on the basis of monitored oxyhemoglobin saturation to maintain a saturation of. Section 2-4 MCA Implementation Date

13 CARDIAC ARREST ROSC Date: May 31, 2012 Page 2 of 2 This protocol should be followed for all adult cardiac arrest patients with ROSC. If an arrest is if a known traumatic origin, refer to the Trauma Protocol and MCA Transport Protocol. If it is unknown whether the arrest is traumatic or medical, continue with this protocol. If the patient becomes pulseless, begin CPR and follow the Adult or Pediatric Cardiac Arrest - General Protocol. Perform 12 lead ECG Consider treatable causes. If ventilation assistance is required with an advanced airway in place and quantitative waveform capnography if available, target PETCO2 of mm Hg. Transport to a facility capable of Percutaneous Coronary Intervention (PCI) and theraputic hypothermia where available per MCA protocol. CONTACT MEDICAL CONTROL If hypotension persists after IV/IO fluid bolus administer Dopamine 5-20 mcg/kg/min. Mix drip by putting Dopamine 400 mg in 250 ml NS Notes: If a mechanical ventilator is available or there are spontaneous respirations in the non-intubated patient titrate inspired oxygen on the basis of monitored 94% but <100%. Section 2-4 MCA Implementation Date

14 CHEST PAIN/ACUTE CORONARY SYNDROME Date: November 15, 2012 Page 1 of 3 Chest Pain/Acute Coronary Syndrome The goal is to reduce cardiac workload and to maximize myocardial oxygen delivery by reducing anxiety, appropriately oxygenating and relieving pain. For non-cardiac causes of chest pain refer to appropriate protocol which may include Pain Management Procedure. Pre-Medical Control MFR/EMT/SPECIALIST/PARAMEDIC 1. Follow General Pre-Hospital Care Protocol. 2. A oximetry is not available administer oxygen at 4 L/min per nasal cannula. MFR 3. Assist patient in the use of their own aspirin, chew and swallow if no aspirin or suspected insufficient dose since the onset of chest pain. EMT 4. Assist patient in the use of their own aspirin, or administer up to 324 mg if available, chew and swallow if no aspirin or suspected insufficient dose since the onset of chest pain. 5. Inquire of all patients (male and female) if they have taken Viagra (sildenafil citrate) or similar erectile dysfunction medications or medications used to treat pulmonary hypertension in the last 48 hours. If yes, DO NOT ADMINISTER NITROGLYCERIN AND CONTACT MEDICAL CONTROL. 6. Assist patient in the use of their own Nitroglycerin sublingual tabs (check expiration date), if available, and if the patient s systolic BP is above 120 mmhg, for a maximum of 3 doses. SPECIALIST 7. Start an IV NS KVO. If the patient has a BP of less than 100 mmhg, administer an IV/IO NS fluid bolus up to 1 liter wide open, in 250 ml increments and reassess. 8. Administer oxygen 4 L/min per nasal cannula; titrate to main oximetry is not available administer oxygen at 4 L/min per nasal cannula. 9. Administer aspirin 324 mg PO, chew and swallow if no aspirin or suspected insufficient dose since the onset of chest pain. 10. Inquire of all patients (male and female) if they have taken Viagra (sildenafil citrate) or similar erectile dysfunction medications or medications used to treat pulmonary hypertension in the last 48 hours. If yes, DO NOT ADMINISTER NITROGLYCERIN AND CONTACT MEDICAL CONTROL. 11. Administer nitroglycerin 0.4 mg sublingual if BP is above 100 mmhg. Dose may be repeated at 3 to 5 minute intervals if chest pain persists and BP remains above 100 mmhg. Nitroglycerin may be administered prior to IV placement if the BP is above 120 mmhg. 12. Contact Medical Control. PARAMEDIC 1. Start an IV NS KVO. If the patient has a BP of less than 100 mmhg, administer an IV/IO NS fluid bolus up to 1 liter wide open, in 250 ml increments and reassess. 2. Administer oxygen 4 L/min per nasal cannula; titrate to maintain SaO2 oximetry is not available administer oxygen at 4 L/min per nasal cannula. Section 2-5 MCA Implementation Date

15 CHEST PAIN/ACUTE CORONARY SYNDROME Date: November 15, 2012 Page 2 of 3 3. Administer aspirin 324 mg PO, chew and swallow if no aspirin or suspected insufficient dose since the onset of chest pain. 4. Obtain 12-lead ECG if available. Follow local MCA transport protocol if ECG is positive for acute ST Elevation Myocardial Infarction (STEMI) and alert the hospital as soon as possible. 5. Do not delay transport. 6. Inquire of all patients (male and female) if they have taken Viagra (sildenafil citrate) or similar erectile dysfunction medications or medications used to treat pulmonary hypertension in the last 48 hours. If yes, DO NOT ADMINISTER NITROGLYCERIN AND CONTACT MEDICAL CONTROL. 7. Administer nitroglycerin 0.4 mg sublingual if BP is above 100 mmhg. Dose may be repeated at 3 to 5 minute intervals if chest pain persists and BP remains above 100 mmhg. Nitroglycerin may be administered prior to IV placement if the BP is above 120 mmhg. 8. If pain persists after up to 3 doses of nitroglycerin, and BP is greater than 100 mmhg, administer narcotic analgesic per MCA selection per Pain Management Procedure. 9. Contact Medical Control. Section 2-5 MCA Implementation Date

16 CHEST PAIN/ACUTE CORONARY SYNDROME Date: November 15, 2012 Page 3 of 3 The goal is to reduce cardiac workload and to maximize myocardial oxygen delivery by reducing anxiety, appropriately oxygenating and relieving pain. For non-cardiac causes of chest pain refer to appropriate protocol which may include Pain Management Procedure. Follow General Pre-hospital Care Protocol Administer oxygen 4 L/min per nasal cannula; titrate to maintain SaO2 > 94 %. If pulse oximetry is not available administer oxygen at 4 L/min per nasal cannula. Start an IV NS KVO, if the patient has a BP is less than 100 mmhg, administer IV/IO NS fluid bolus up to 1 liter wide open, in 250 ml increments & reassess. Administer oxygen 4 L/min per nasal cannula; titrate to maintain SaO2 > 94 %. If pulse oximetry is not available administer oxygen at 4 L/min per nasal cannula. Administer aspirin 324 mg PO, chew and swallow if no aspirin or suspected insufficient dose since the onset of chest pain. Obtain 12-lead ECG, if available. Follow local MCA transport protocol if ECG is positive for acute ST Elevation Myocardial Infarction (STEMI) and alert the hospital as soon as possible. Do not delay transport. YES Inquire of all patients (male and female) if they have taken Viagra (sildenafil citrate) or similar erectile dysfunction medications or medications used to treat pulmonary hypertension within last 48 hours. NO DO NOT ADMINISTER NITROGLYCERIN Contact Medical Control Administer Nitroglycerin 0.4 mg sublingual if BP is above 100 mmhg. Dose may be repeated at 3-5 minute intervals if chest pain persists and BP remains above 100 mmhg. Nitroglycerin may be administered prior to IV placement if the BP is above 120 mmhg. If pain persists after up to 3 doses of nitroglycerin, & BP is greater than 100 mmhg, administer narcotic analgesic per MCA selection per Pain Management Procedure. Contact Medical Control Section 2-5 MDCH Approval Date MCA Implementation Date

17 1 Michigan HYPOTHERMIA CARDIAC ARREST Date: May 31, 2012 Page 1 of 2 Hypothermia Cardiac Arrest Pre-Medical Control MFR/EMT/SPECIALIST/PARAMEDIC 1. Follow General Pre-hospital Care Protocol. 2. Assess body temperature. If temperature is greater than 30 C (86 F), follow Cardiac Arrest General Protocol 3. If pulseless, begin CPR. 4. Protect against heat loss. 5. Apply heat packs, if available, to axillae, groin, and neck. 6. Administer warmed humidified oxygen, if possible. SPECIALIST/PARAMEDIC 7. Administer warmed NS IV/IO, if possible. PARAMEDIC 8. Follow appropriate VF/VT or Asystole/PEA Protocols EXCEPT: A. Limit defibrillation to a single attempt. B. Medication Administration: follow appropriate cardiac arrhythmia treatment protocol with 1 round of medication. EMT/SPECIALIST/PARAMEDIC 9. Initiate transport and contact Medical Control. Section 2-6 MCA Implementation Date

18 1 Michigan HYPOTHERMIA CARDIAC ARREST Date: May 31, 2012 Page 2 of 2 Follow General Pre-hospital Care Protocol Assess body temperature If temperature is greater than 30 C (86 F), follow Cardiac Arrest General Protocol If pulseless, Or begin CPR Protect against heat loss Apply heat packs, if available, to axillae, groin and neck Administer warmed humidified oxygen, if possible Administer warmed NS IV/IO, if possible Follow appropriate VF/VT or Asystole/PEA Protocols EXCEPT: Limit defibrillation to a single attempt Medication administration: follow appropriate cardiac arrhythmia treatment protocol with 1 round of medication. Initiate transport Contact Medical Control Section 2-6 MCA Implementation Date

19 NITROGLYCERIN DRIP SUPPLEMENT TO CHEST PAIN / ACUTE CORONARY SYNDROME Date: May 31, 2012 Page 1 of 4 Nitroglycerin Drip Supplement to Chest Pain / Acute Coronary Syndrome MCA Name MCA Approval Date MDCH Approval Date MCA Implementation Date Medical Control Authorities choosing to adopt this supplement may do so by selecting this check box. Adopting this supplement changes or clarifies the referenced protocol or procedure in some way. This supplement supersedes, clarifies, or has authority over the referenced protocol. Post-Medical Control This protocol provides for the use of a Nitroglycerin Drip in the pre-hospital setting for systems that can justify the use based on long transport times. Implementation of the protocol requires additional paramedic training approved by the Medical Control Authority and Department. A suggested training outline is included in this protocol. Indications for Nitroglycerin Drip 1. Chest pain secondary to presumed cardiac ischemia, acute coronary syndrome or acute myocardial infarction. The nitroglycerin drip may be used after failure of SL nitroglycerin and narcotic administration to relieve cardiac chest pain treated using the Chest Pain / Acute Coronary Syndrome protocol. 2. Acute pulmonary edema / CHF. The nitroglycerin drip may be used as a supplement to SL nitroglycerin treatment using the Acute Pulmonary Edema / CHF protocol. 3. Continued as a maintenance drip for patients during inter-facility transfers. Equipment 1. At least one functioning IV. A second IV preferable to allow additional IV fluid or medication administration. 2. Pump and tubing supplied by the ambulance service. The pump may also be supplied by the hospital provided the paramedics have been previously trained in the use of the hospital pump. 3. Nitroglycerin drip, supplied by the sending facility. Insure sufficient volume is taken to complete the transport. Administrations Guidelines 1. Dosing A. Nitroglycerin may be mixed in D5W or NS. Dosing chart: see Table I. B. For pre-hospital use begin the nitroglycerin drip at 10 mcg/min and increase by 10 mcg/min at 5 minute intervals if chest pain persists and systolic blood pressure remains above 100 mmhg. C. If titrating nitroglycerin for Pulmonary Edema / CHF, titrate until systolic BP is 120 mmhg or below. D. For inter-hospital patient transfers a nitroglycerin drip may be continued at the rate begun at the transferring hospital. Titrate the drip as above to relieve chest pain or per sending facility orders. Northwest Regional MCA Section 2-5 (S)

20 NITROGLYCERIN DRIP SUPPLEMENT TO CHEST PAIN / ACUTE CORONARY SYNDROME Date: May 31, 2012 Page 2 of 4 2. Patient monitoring A. If pain resolves completely, maintain drip at current rate of administration. B. If pain continues, increase the drip rate by 10 mcg/min every 5 minutes until pain resolves or systolic BP falls below 100 mmhg. C. Maximum dose is 200 mcg/min. D. If systolic BP falls below 90 mmhg during titration, decrease the drip rate by 10 mcg/min and give a NS IV/IO fluid bolus up to 1 liter, wide open. If BP remains below 90 mmhg, discontinue drip. Table I. Dosing Chart for Nitroglycerin Dose (mcg/min) Amount to infuse in ml/hr 50 mg/250 ml 100 mg/500 ml (200 mcg/ml) 100 mg/250 ml 200 mg/500 ml (400 mcg/ml) Northwest Regional MCA MCA Name MCA Approval Date MDCH Approval Date MCA Implementation Date Section 2-5 (S)

21 NITROGLYCERIN DRIP SUPPLEMENT TO CHEST PAIN / ACUTE CORONARY SYNDROME Date: May 31, 2012 Page 3 of 4 Nitroglycerin Drip Training Guidelines Suggested Training Requirements for Paramedics 1. Training requirements for paramedics = 2 hours A. Nitroglycerin training = 1 hour B. Pump training = 1 hour 2. Pharmacology and actions of nitroglycerin A. Cardiovascular effects a. Decreases preload: reduces venous tone, decreasing venous load on the heart. b. Decreases afterload: reduces peripheral vascular resistance. c. Increases myocardial oxygen supply: causes dilatation of coronary arteries and relief of coronary artery spasm. B. Generalized effect: causes generalized smooth muscle relaxation 3. Administrations Guidelines A. Dosing a. Nitroglycerin may be mixed in D5W or NS. Dosing chart: see Table I. b. For pre-hospital use begin the nitroglycerin drip at 10 mcg/min and increase by 10 mcg/min at 5 minute intervals if chest pain persists and systolic blood pressure remains above 100 mmhg. c. If titrating nitroglycerin for Pulmonary Edema / CHF, titrate until systolic BP is 120 mmhg or below. d. For inter-hospital patient transfers a nitroglycerin drip may be continued at the rate begun at the transferring hospital. Titrate the drip as above to relieve chest pain or per sending facility orders. 4. Patient monitoring and titration of nitroglycerin drip A. Patient should be have continuous cardiac rhythm monitoring and frequent blood pressure monitoring. Blood pressure should be rechecked after each dosing change. B. If pain resolves completely, maintain drip at current rate of administration. C. If pain continues, increase the drip rate by 10 mcg/min every 5 minutes until pain resolves or systolic BP falls below 100 mmhg. D. Maximum dose is 200 mcg/min. E. If systolic BP falls below 90 mmhg during titration, decrease the drip rate by 10 mcg/min and give a NS IV/IO fluid bolus up to 1 liter, wide open. If BP remains below 90 mmhg, discontinue drip. 5. Side effects and special notes A. Peripheral vasodilatation can cause profound hypotension and reflex tachycardia. B. Common side effects: throbbing headaches, flushing, dizziness Northwest Regional MCA MCA Name MCA Approval Date MDCH Approval Date MCA Implementation Date Section 2-5 (S)

22 NITROGLYCERIN DRIP SUPPLEMENT TO CHEST PAIN / ACUTE CORONARY SYNDROME Date: May 31, 2012 Page 4 of 4 C. Less common: orthostatic hypotension, sometimes marked. Nitroglycerin does not provide controlled hypotension. D. Because nitroglycerin causes generalized smooth muscle relaxation, it may be effective in relieving chest pain caused by esophageal spasm. Table I. Dosing Chart for Nitroglycerin Dose (mcg/min) Amount to infuse in ml/hr 50 mg/250 ml 100 mg/500 ml (200 mcg/ml) 100 mg/250 ml 200 mg/500 ml (400 mcg/ml) Northwest Regional MCA MCA Name MCA Approval Date MDCH Approval Date MCA Implementation Date Section 2-5 (S)

23 PULMONARY EDEMA/CHF Date: November 15, 2012 Page 1 of 2 Pulmonary Edema / CHF This protocol is to be followed for patients in acute respiratory distress situations, not chronic. Pre-Medical Control MFR/EMT/SPECIALIST/PARAMEDIC 1. Follow General Pre-Hospital Care Protocol. 2. Initiate supplemental oxygen by non-rebreather mask. 3. Position patient upright with legs dependent, if possible. EMT/SPECIALIST 4. Consider CPAP (if available) per CPAP/BiPAP Procedure. SPECIALIST 5. Inquire of all patients (male and female) if they have taken Viagra (sildenafil citrate) or similar erectile dysfunction medications or medications used to treat pulmonary hypertension in the last 48 hours. If yes, DO NOT ADMINISTER NITROGLYCERIN AND CONTACT MEDICAL CONTROL. 6. If BP above 100 mmhg, administer Nitroglycerin 0.4 mg SL. Repeat every 3-5 minutes if BP above 100 mmhg. Nitroglycerin may be administered prior to IV placement if the BP is above 120 mmhg. 7. If wheezing or bronchial constriction administer nebulized Albuterol 2.5 mg/3ml. PARAMEDIC 8. Consider CPAP / Bi-PAP (if available) or if indicated, an advanced airway. 9. Obtain 12-lead ECG if available. Follow local MCA transport protocol if ECG is positive for ST segment elevation myocardial infarction (STEMI) and alert hospital as soon as possible. 10. Inquire of all patients (male and female) if they have taken Viagra (sildenafil citrate) or similar erectile dysfunction medications or medications used to treat pulmonary hypertension in the last 48 hours. If yes, DO NOT ADMINISTER NITROGLYCERIN AND CONTACT MEDICAL CONTROL. 11. If BP above 100 mmhg, administer Nitroglycerin 0.4 mg SL. Repeat every 3-5 minutes if BP above 100 mmhg. Nitroglycerin may be administered prior to IV placement if the BP is above 120 mmhg. 12. If wheezing or bronchial constriction administer nebulized Albuterol 2.5 mg/3ml. Post-Medical Control 13. If BP is less than 100 mmhg and signs/symptoms of shock, administer Dopamine 5 20 mcg/kg/min. Generally start at 5 mcg/kg/min, and increase every 10 minutes by an additional 5 mcg/kg/min until BP is greater than 100 mmhg. DO NOT exceed 20 mcg/kg/min unless ordered by medical control. Section 2-7 MCA Board Approval Date MDCH Approval Date MCA Implementation Date

24 PULMONARY EDEMA/CHF Date: November 15, 2012 Page 2 of 2 This protocol is to be followed for patients in acute respiratory distress situations, not chronic. Follow General Pre-hospital Care Protocol Initiate supplemental oxygen by non-re-breather mask Position patient upright with legs dependent, if possible Consider CPAP/Bi-PAP (if available) or if indicated, an advanced airway. Obtain 12-lead ECG if available. Follow local MCA transport protocol if ECG is positive for ST segment elevation myocardial infarction (STEMI) and alert hospital as soon as possible. Inquire of all patients (male & female) if they have taken Viagra (sildenafil citrate) or a similar erectile dysfunction medications or medications used to treat pulmomary hypertension in the last 48 hrs., if yes DO NOT ADMINISTER NITROGYCERIN AND CONTACT MEDICAL CONTROL. Blood Pressure greater than 100 mmhg YES NO Administer Nitroglycerin 0.4 mg SL Repeat every 3-5 minutes if BP above100 mmhg. Nitroglycerin may be administered prior to IV placement if the BP is above 120 mmhg. Contact Medical Control If wheezing or bronchial constriction, administer nebulized Albuterol 2.5 mg/3ml Contact Medical Control If BP less than100 mmhg and signs/symptoms of shock administer Dopamine at 5-20 mcg/kg/min Generally start at 5 mcg/kg/min, and increase every 10 minutes by an additional 5 mcg/kg/min until BP greater than100 mmhg. DO NOT exceed 20 mcg/kg/min unless ordered by medical control. Section 2-7 MCA Board Approval Date MDCH Approval Date MCA Implementation Date

25 TACHYCARDIA Date: August 15, 2013 Page 1 of 4 Tachycardia This protocol is used for the care of patients with persistent tachycardia (ventricular rate greater than 150/minute) where the tachycardia is believed to be the primary cause of the patient s symptoms. It is not intended to treat tachycardia that is secondary to underlying conditions (i.e., dehydration, trauma toxins). Consultation with online medical control should be considered for complex patients in whom the cause of the arrhythmia is not obvious. SYNCHRONIZED CARDIOVERSION PRECEDES DRUG THERAPY FOR UNSTABLE PATIENTS. Unstable patients may be defined as those suffering a tachycardia with: hypotension, acutely altered mental status, signs of shock, significant ischemic chest discomfort, shortness of breath, or pulmonary edema that is likely due to the arrhythmia. Adenosine is only used for regular monomorphic rhythm tachycardia. Pre-Medical Control PARAMEDIC 1. Follow the General Pre-Hospital Care Protocol. 2. Identify and treat reversible causes. 3. Determine if patient is stable or unstable. UNSTABLE 4. If time and condition allow prior to cardioversion, sedate per MCA selection. Refer to Patient Sedation Procedure. 5. For unstable patients with a REGULAR NARROW OR WIDE rhythm, cardiovert beginning at 100 J, increasing to 200 J, 300 J, 360 J. (Use manufacturers suggested biphasic energy dose, 100 J). 6. For unstable patients with an IRREGULAR NARROW rhythm, cardiovert beginning at 200 J, increasing to 300 J, 360 J. (Use manufacturers suggested biphasic energy dose, J). 7. For patients that are unstable with an IRREGULAR WIDE rhythm, cardiovert beginning at 200 J, increasing to 300 J, 360 J. (Use manufacturers suggested biphasic energy dose J). STABLE 8. DO NOT USE CAROTID MASSAGE. Have the patient attempt to bear down (a valsalva maneuver). 9. Start an IV NS KVO. A large bore antecubital IV should be secured whenever possible. 10. If the rhythm is regular, consider Adenosine 6 mg rapid IV push through the most proximal injection site. This should be followed immediately with 20 ml NS flush. 11. If conversion does not occur, administer Adenosine 12 mg IV using the same technique as stated above. 12. If rhythm is stable with narrow QRS contact medical control for possible orders. 13. If rhythm is stable with wide QRS administer Amiodarone OR Lidocaine per MCA Selection Medication Options (Choose One) Amiodarone mg IV over 10 minutes OR Lidocaine 1 mg/kg IV Section 2-8 MCA Board Approval Date MCA Implementation Date

26 TACHYCARDIA Date: August 15, 2013 Page 2 of If at any point a patient becomes unstable proceed to cardioversion. 15. Administer Magnesium Sulfate 2 gm IV/IO for suspected torsades de pointes. 16. Contact Medical Control Post-Medical Control 17. Per MCA selection, administer additional Amiodarone 150 mg IV over 10 minutes as needed to a maximum of 450 mg OR Lidocaine mg/kg IV push every 5-10 minutes to a maximum of 3 mg/kg. NOTES: 1. Administration of Amiodarone is best accomplished by adding Amiodarone 150 mg to 50, 100 or 250 ml of NS and infusing over approximately 10 minutes. 2. Administration of Magnesium Sulfate is best accomplished by adding Magnesium Sulfate 2gm to 50, 100 or 250 ml of NS and infusing over approximately 10 minutes. Section 2-8 MCA Board Approval Date MCA Implementation Date

27 TACHYCARDIA Date: August 15, 2013 Page 3 of 4 This protocol is used for the care of patients with persistent tachycardia (with a ventricular rate greater than 150/minute) where the tachycardia is believed to be the primary cause of the patient s symptoms. It is not intended to treat tachycardia that is secondary to underlying conditions (i.e., dehydration, trauma toxins). Consultation with online medical control should be considered for complex patients in whom the cause of the arrhythmia is not obvious. SYNCHRONIZED CARDIOVERSION PRECEDES DRUG THERAPY FOR UNSTABLE PATIENTS. Unstable patients may be defined as those suffering a tachycardia with: hypotension, acutely altered mental status, signs of shock, significant ischemic chest discomfort, shortness of breath, or pulmonary edema that is likely due to the arrhythmia. Adenosine is only used for regular monomorphic rhythm tachycardia. Follow General Pre-hospital Care Protocol Identify and treat reversible causes STABLE DETERMINE STABILITY UNSTABLE DO NOT USE CAROTID MASSAGE. Have patient attempt to bear down (a valsalva maneuver). Start an IV NS KVO. A large bore antecubital IV should be secured whenever possible. Consider Adenosine 6 mg rapid IV push through the most proximal injection site, followed immediately with a 20 ml NS flush. If conversion does not occur, administer Adenosine 12 mg IV using same technique as stated above. Regular Rhythm? REGULAR RHYTHM NARROW OR WIDE REGULAR NARROW QRS WIDE Contact Medical Control Administer Amiodarone or Lidocaine per MCA selection If at any point a patient becomes unstable proceed to cardioversion. Administer Magnesium Sulfate 2 g IV/IO for suspected torsades de pointes. If time and condition allow prior to cardioversion, sedate per MCA selection. Refer to Patient Sedation Procedure. For unstable patients with a REGULAR NARROW or WIDE rhythm, cardiovert beginning at 100 J, increasing to 200 J, 300 J, then 360 J. (Use manufacturers suggested biphasic energy dose, 100 J). For unstable patients with an IRREGULAR NARROW rhythm, cardiovert beginning at 200 J, increasing to 300 J then 360 J. (Use manufacturers suggested biphasic energy dose, J). For unstable patients with an IRREGULAR WIDE rhythm, cardiovert beginning at 200 J, increasing to 300 J then 360 J. (Use manufacturers suggested biphasic energy dose, J). Medication Options: (Choose One) Amiodarone 150 mg IV over 10 minutes OR Lidocaine 1 mg/kg IV Contact Medical Control Per MCA selection, administer additional Amiodarone 150 mg IV over 10 minutes as needed to a max of 450 mg OR Lidocaine mg/kg IV push every 5-10 minutes to a max of 3 mg/kg Section 2-8 MCA Board Approval Date MCA Implementation Date

28 TACHYCARDIA Date: August 15, 2013 Page 4 of 4 NOTES: 1. Administration of Amiodarone is best accomplished by adding Amiodarone 150 mg to 50, 100 or 250 ml of NS and infusing over approximately 10 minutes. 2. Administration of Magnesium Sulfate is best accomplished by adding Magnesium Sulfate 2gm to 50, 100 or 250 ml of NS and infusing over approximately 10 minutes. Section 2-8 MCA Board Approval Date MCA Implementation Date

29 VENTRICULAR FIBRILLATION / PULSELESS VT Date: May 31, 2012 Page 1 of 2 Ventricular Fibrillation / Pulseless Ventricular Tachycardia If AED is applied prior to ALS arrival, perform CPR and reassess the rhythm as indicated. After each intervention resume CPR immediately and reassess the rhythm after each 2 minute or 5 cycle interval. For Biphasic devices shock with energy levels following manufacturers recommendations ( J). If unknown use the maximum available. For monophasic devices use 360 J. Pre-Medical Control PARAMEDIC 1. Follow the Cardiac Arrest General Protocol. 2. Defibrillate and then continue CPR for 2 minutes. 3. Repeat defibrillation every 2 minutes as indicated with immediate resumption of compressions. If rhythm changes go to appropriate protocol. 4. Start an IV/IO NS KVO. If IV is unsuccessful after 2 attempts, start an IO line per Vascular Access & IV Fluid Therapy Procedure. IO may be first line choice. 5. Administer Epinephrine 1:10,000, 1 mg (10 ml) IV/IO. Repeat every 3-5 minutes. May be administered before or after defibrillations. Vasopressin 40 Units IV/IO Included Not Included 6. Per MCA selection, administer Vasopressin 40 units IV/IO in place of the second dose of Epinephrine. 7. Establish an advanced airway. Avoid significant interruptions in CPR. See Emergency Airway Procedure. 8. For persistent or recurrent Ventricular Fibrillation / Pulseless Ventricular Tachycardia, administer Amiodarone 300 mg IV/IO. May be administered before or after defibrillations. 9. In a dialysis patient hyperkalemia is likely. Administer Calcium Chloride 1g IV/IO and Sodium Bicarbonate 1 meq/kg IV/IO with 20 ml NS flush in between medications. 10. For persistent or recurrent Ventricular Fibrillation / Pulseless Ventricular Tachycardia, administer additional Amiodarone 150 mg IV/IO. May be administered before or after defibrillations. 11. If patient is in Torsades de Pointes administer Magnesium Sulfate 2 grams IV/IO. Section 2-9 MCA Implementation Date

30 VENTRICULAR FIBRILLATION / PULSELESS VT Date: May 31, 2012 Page 2 of 2 If AED is applied prior to ALS arrival, perform CPR and reassess the rhythm as indicated. After each intervention resume CPR immediately and reassess the rhythm after each 2 minute or 5 cycle interval. For Biphasic devices, shock with energy levels following manufacturers recommendations ( J). If unknown use the maximum available. For monophasic devices use 360 J. Follow Cardiac Arrest General Protocol Defibrillate and then continue CPR for 2 minutes. Repeat defibrillation every 2 minutes as indicated with immediate resumption of compressions. If rhythm changes go to appropriate protocol. Vasopressin 40 Units IV/IO Included Not Included Start an IV/IO NS KVO. If IV is unsuccessful after 2 attempts start an IO line per Vascular Access & IV Fluid Therapy Procedure. IO may be first line choice. Administer Epinephrine 1:10,000, 1 mg (10 ml) IV/IO. Repeat every 3-5 minutes. May be administered before or after defibrillations. Per MCA selection, administer Vasopressin 40 units IV/IO in place of the second dose of Epinephrine. Establish an advanced airway. Avoid significant interruptions in CPR. See Emergency Airway Procedure. For persistent or recurrent VF / Pulseless VT, administer Amiodarone 300 mg IV/IO. May be administered before or after defibrillations. In a dialysis patient hyperkalemia is likely. Administer Calcium Chloride 1g IV/IO and Sodium Bicarbonate 1 meq/kg IV/IO with 20 ml NS flush in between medications. For persistent or recurrent VF/ Pulseless VT, administer additional Amiodarone 150 mg IV/IO. May be administered before or after defibrillations. If patient is in Torsades de Pointes administer Magnesium Sulfate 2 grams IV/IO. Section 2-9 MCA Implementation Date