table of contents adult treatment guidelines A1 ADULT PATIENT CARE... 3 A2 CHEST PAIN SUSPECTED ACUTE CORONARY SYNDROME/STEMI...4 5 A3 CARDIAC ARREST INITIAL CARE AND CPR...6 7 A4 VENTRICULAR FIBRILLATION PULSELESS VENTRICULAR TACH...8 9 A5 PULSELESS ELECTRICAL ACTIVITY/ASYSTOLE... 10 11 A6 SYMPTOMATIC BRADYCARDIA... 12 13 A7 VENTRICULAR TACHYCARDIA WITH PULSES... 14 15 A8 SUPRAVENTRICULAR TACHYCARDIA... 16 17 A9 OTHER CARDIAC DYSRHYTHMIAS...18 19 A10 SHOCK/HYPOVOLEMIA...20 21 A11 POST-CARDIAC ARREST CARE...22 23 A12 PUBLIC SAFETY DEFIBRILLATION BLS/LAW ENFORCEMENT...24 25 Adult Treatment Guidelines 1
2 Adult Treatment Guidelines
A1 ADULT ADULT PATIENT CARE These basic concepts should be addressed for all adult patients (age 15 and over) SCENE SAFETY BSI SYSTEMATIC ASSESSMENT DETERMINE PRIMARY IMPRESSION BASE CONTACT TRANSPORT MONITORING DOCUMENT Use universal blood and body fluid precautions at all times Assure open and adequate airway. Management of ABCs is a priority. Place patient in position of comfort unless condition mandates other position (e.g. shock, coma) Consider spinal motion restriction if history or possibility of traumatic injury exists Apply appropriate field treatment guideline(s) Explain procedures to patient and family as appropriate Contact base hospital if any questions arise concerning treatment or if additional medication beyond dosages listed in treatment guidelines are considered Use SBAR to communicate with base Minimize scene time in critical trauma, STEMI, stroke, shock, and respiratory failure Transport patient medications or current list of patient medications to the hospital Give report to receiving facility using SBAR At a minimum, vital signs and level of consciousness should be re-assessed every 15 minutes and should be assessed after every medication administration or following any major change in the patient s condition For critical patients, more frequent vital signs should be obtained when appropriate Document patient assessment and care per policy Adult Treatment Guidelines 3
A2 ADULT OXYGEN CARDIAC MONITOR ASPIRIN CHEST PAIN SUSPECTED ACUTE CORONARY SYNDROME/STEMI BLS: Low flow unless ALOC/respiratory distress/shock ALS: Titrate to SpO 2 of at least 94% 325 mg po to be chewed by patient DO NOT administer if patient has allergies to aspirin or salicylates or has apparent active gastrointestinal bleeding 12 LEAD ECG Repeat ECGs are encouraged. Continue 12-lead monitoring. IV TKO If ECG Does Not Indicate Acute MI or STEMI NITROGLYCERIN 0.4 mg sublingual or spray May repeat every 5 minutes until pain subsides, maximum 3 doses. Contact base hospital if further dosages indicated. IV placement prior to NTG recommended for patients who have not taken NTG previously. PRECAUTIONS: Do not administer NTG if: Blood pressure below 90 systolic; Heart rate below 50; Patient has recently taken erectile dysfunction (ED) drugs: Viagra, Levitra, Staxyn or Stendra within 24 hours, or Cialis within 36 hours Consider FLUID BOLUS Consider FENTANYL 500 ml NS if BP less than 90, lungs clear and unresponsive to supine positioning with legs elevated. May repeat X 1 50 200 mcg IV titrated in 25 50 mcg increments (consider 25 mcg increments in elderly patients). Consider earlier administration to patients in severe distress from pain. Titrate to pain relief, systolic BP greater than 90, and adequate respiratory effort 4 Adult Treatment Guidelines
A2 ADULT CHEST PAIN SUSPECTED ACUTE CORONARY SYNDROME/STEMI Acute MI / STEMI Noted by 12-Lead ECG NITROGLYCERIN STEMI ALERT EARLY TRANSPORT FLUID BOLUS Consider FENTANYL Do not administer Nitroglycerin if Acute MI/STEMI noted on 12-lead ECG. Exception: Patients with suspected pulmonary edema and STEMI should receive nitroglycerin if no other contraindications (e.g. hypotension, bradycardia or use of erectile dysfunction drugs) Transmit ECG to STEMI Center and contact as soon as possible to notify facility of transport. Enter patient identifiers prior to transmission Minimize scene time 500 ml NS for Inferior MI (elevation in leads II, III, avf) if lungs clear (regardless of blood pressure) 500 ml NS if BP less than 90, lungs clear and unresponsive to positioning. May repeat up to 3 times 50 200 mcg IV in 25 50 mcg increments (consider 25 mcg increments in elderly patients). Consider earlier administration to patients in severe distress from pain. Titrate to pain relief, systolic BP greater than 90, and adequate respiratory effort. Caution: If Inferior MI suspected, use 25-50 mcg increments and observe carefully for hypotension Key Treatment Consider ations Classic symptoms: Substernal pain, discomfort or tightness with radiation to jaw, left shoulder or arm, nausea, diaphoresis, dyspnea (shortness of breath), anxiety Diabetic, female or elderly patients more frequently present atypically Atypical symptoms can include syncope, weakness or sudden onset fatigue Many STEMIs evolve during prehospital period and are not noted on initial 12-lead ECG ECG should be obtained prior to treatment for bradycardia if condition permits Transmit all 12-lead ECGs whether STEMI is detected or not detected Adult Treatment Guidelines 5
A3 ADULT ESTABLISH TEAM LEADER CONFIRM ARREST COMPRESSIONS AED or MONITOR/ DEFIBRILLATOR CARDIAC ARREST INITIAL CARE AND CPR First agency on scene assumes leadership role Leadership role can be transferred as additional personnel arrive Unresponsive, no breathing or agonal respirations, no pulse Begin Compressions: Rate 100 120 per minute. Use metronome Depth 2 inches in adults allow full recoil of chest (lift heel of hand) Rotate compressors every 2 minutes if manual compression used Minimize interruptions. If necessary to interrupt, limit to 10 seconds or less Perform CPR during charging of defibrillator Resume CPR immediately after shock (do not stop for pulse or rhythm check) Prepare mechanical compression device (if available) Apply with minimal interruption Should be placed following completion of at least one 2-minute manual CPR cycle or at end of subsequent cycle Apply pads while compressions in progress Monitor/defibrillator should be in paddle mode during resuscitation Determine rhythm and shock, if indicated Check rhythm every 2 minutes Follow specific treatment guideline based on rhythm 6 Adult Treatment Guidelines
A3 ADULT BASIC AIRWAY MANAGEMENT & VENTILATION IV/IO ACCESS ADVANCED AIRWAY TREATMENT ON SCENE CARDIAC ARREST INITIAL CARE AND CPR Open airway and provide 2 breaths after every 30 compressions Avoid excessive ventilation no more than 8 10 ventilations per minute Ventilations should be about 1 second each, enough to cause visible chest rise Use two-person BLS Airway management (one holding mask and one squeezing bag) If available, use ResQPOD with two-person BLS airway management Intraosseous or antecubital IV are preferred sites for vascular access Hand veins and other smaller veins should not be used in cardiac arrest Placement of advanced airway is not a priority during the first 5 minutes of resuscitation unless NO ventilation is occurring with basic maneuvers Exception: If ResQPOD used, early use of King Airway is appropriate Placement of King Airway or endotracheal tube should not interrupt compressions for more than 10 seconds For endotracheal intubation, position and visualize airway prior to cessation of CPR for tube passage. Immediately resume compressions after tube passage Confirm tube placement and provide on-going monitoring using end-tidal carbon dioxide monitoring Movement of a patient may interrupt CPR or prevent adequate depth and rate of compressions, which may be detrimental to patient outcome Provide resuscitative efforts on scene up to 30 minutes to maximize chances of return of spontaneous circulation (ROSC) If resuscitation does not attain ROSC, consider cessation of efforts per policy Adult Treatment Guidelines 7
A4 ADULT INITIAL CARE DEFIBRILLATION CPR VENTILATION/ AIRWAY IO or IV DEFIBRILLATION EPINEPHRINE DEFIBRILLATION AMIODARONE DEFIBRILLATION ADVANCED AIRWAY Consider repeat AMIODARONE TRANSPORT Consider SODIUM BICARBONATE VENTRICULAR FIBRILLATION PULSELESS VENTRICULAR TACHYCARDIA See Cardiac Arrest Initial Care and CPR (A3) 200 joules For 2 minutes or 5 cycles between rhythm check BLS airway is preferred method during first 5 6 minutes of CPR If no visible chest rise occurring with basic maneuvers, proceed to advanced airway TKO. Should not delay shock or interrupt CPR 300 joules 1:10,000 1 mg IV or IO every 3 5 minutes 360 joules 300 mg IV or IO 360 joules as indicated after every CPR cycle Should not interfere with initial 5 6 minutes of CPR minimize interruptions Do not interrupt compressions more than 10 seconds to obtain airway If rhythm persists, 150 mg IV or IO, 3 5 minutes after initial dose If indicated. If return of spontaneous circulation (ROSC), patient should be transported to a STEMI center. Patients without ROSC who merit transport should be transported to closest facility 1 meq/kg IV or IO for suspected hyperkalemia or pre-existing acidosis If Return of Spontaneous Circulation, see Post-Cardiac Arrest Care (A11) 8 Adult Treatment Guidelines
A4 ADULT VENTRICULAR FIBRILLATION PULSELESS VENTRICULAR TACHYCARDIA Key Treatment Consider ations Uninterrupted CPR and timely defibrillations are the keys to successful resuscitation. Their performance takes precedence over advanced airway management and administration of medications To minimize CPR interruptions, perform CPR during charging, and immediately resume CPR after shock administered (no pulse or rhythm check) Rotate compressors every 2 minutes Avoid excessive ventilation. Provide no more than 8 10 ventilations per minute. Ventilations should be about one second each, enough to cause visible chest rise If advanced airway placed, perform CPR continuously without pauses for ventilation If available, ResQPOD impedance threshold device may be used with BLS airway or King / ET tube If utilizing Endotracheal Tube, minimize CPR interruptions by positioning airway and laryngoscope, and performing airway visualization prior to cessation of CPR for tube passage. Immediately resume CPR after passage Confirm placement of advanced airway (King Airway or ET tube) with end-tidal carbon dioxide measurement. Continuous monitoring with ETCO 2 is mandatory if values less than 10 mm Hg seen, assess quality of compressions for adequate rate and depth. Rapid rise in ETCO 2 may be the earliest indicator of return of circulation Prepare drugs before rhythm check and administer during CPR Follow each drug with 20 ml NS flush Fingerstick glucose determinations are unreliable during cardiac arrest. Glucose checks should be reserved for patients with return of spontaneous circulation Transmit ALL data to the monitor site identified by your provider agency Adult Treatment Guidelines 9
A5 ADULT INITIAL CARE EPINEPHRINE PULSELESS ELECTRICAL ACTIVITY/ ASYSTOLE See Cardiac Arrest initial care and CPR (A3) 1:10,000 1 mg IV or IO every 3 5 minutes Consider Treatable Causes-treat if Applicable: Consider FLUID BOLUS VENTILATION Consider SODIUM BICARBONATE Consider CALCIUM CHLORIDE Consider WARMING MEASURES Consider NEEDLE THORACOSTOMY For hypovolemia: 500 1000 ml NS IV or IO For hypoxia: Ensure adequate ventilation (8 10 breaths per minute) For pre-existing acidosis (e.g. kidney failure), hyperkalemia, or tricyclic antidepressant overdose are suspected: 1 meq/kg IV or IO if indicated Should not be used routinely in cardiac arrest For hyperkalemia or calcium channel blocker overdose: 500 mg IV or IO may repeat in 5 10 minutes Should not be used routinely in cardiac arrest For hypothermia For tension pneumothorax If Return of Spontaneous Circulation, see Post-Cardiac Arrest Care (A11) 10 Adult Treatment Guidelines
A5 ADULT Consider TERMINATION OF RESUSCITATION TRANSPORT PULSELESS ELECTRICAL ACTIVITY/ ASYSTOLE Patients who have all of the following criteria are highly unlikely to survive: Unwitnessed Arrest and; No bystander CPR and; No shockable rhythm seen and no shocks delivered during resuscitation and; No return of spontaneous circulation (ROSC) during resuscitation Patients with asystole or PEA whose arrests are witnessed and/or who have had bystander CPR administered have a slightly higher likelihood of survival. If unresponsive to interventions these patients should be considered for termination of resuscitation. Note: These criteria should not be applied if profound hypothermia is present. If indicated. If return of spontaneous circulation (ROSC), patient should be transported to a STEMI Center. Patients without ROSC who merit transport should be transported to closest facility. Key Treatment Consider ations Atropine is no longer used in cardiac arrest Pre-existing acidosis or hyperkalemia should be suspected in patients with renal failure or dialysis or if suspected diabetic ketoacidosis In clear-cut traumatic arrest situations, epinephrine is not indicated in PEA or asystole. If any doubt as to cause of arrest, treat as a non-traumatic arrest (e.g. solo motor vehicle accident at low speed in older patients). Fingerstick glucose determinations are unreliable during cardiac arrest. Glucose checks should be reserved for patients with return of spontaneous circulation. Transmit ALL data to the monitor site identified by your provider agency Adult Treatment Guidelines 11
A6 ADULT SYMPTOMATIC BRADYCARDIA Heart rate less than 50 with signs or symptoms of poor perfusion (e.g., acute altered mental status, hypotension, other signs of shock). Correction of hypoxia should be addressed prior to other treatments. OXYGEN BLS: High flow initially ALS: Titrate to SpO 2 of at least 94% CARDIAC MONITOR 12-LEAD ECG IV TKO. If not promptly available, proceed to external cardiac pacing. Consider IO ACCESS if patient in extremis and unconscious or not responsive to painful stimuli. Consider FLUID 250 500 ml NS if clear lung sounds and no respiratory distress BOLUS TRANSCUTANEOUS PACING Consider SEDATION Consider ATROPINE Set rate at 80. Start at 10 ma, and increase in 10 ma increments until capture is achieved If pacing urgently needed, sedate after pacing initiated MIDAZOLAM initial dose 1 mg IV or IO, titrated in 1 2 mg increments (maximum dose 5 mg), and/or FENTANYL 25 100 mcg IV or IO in 25 50 mcg increments for pain relief if BP 90 systolic or greater May be used as a temporary measure while awaiting transcutaneous pacing but should not delay initiation of pacing 0.5 mg IV or IO if availability of pacing delayed or pacing ineffective Consider repeat 0.5 mg IV or IO every 3 5 minutes to maximum of 3 mg Use with caution in patients with suspected ongoing cardiac ischemia Atropine should not be used in wide-qrs second and third-degree blocks TRANSPORT Related guideline: Chest Pain/Suspected ACS/STEMI (A2) 12 Adult Treatment Guidelines
A6 ADULT SYMPTOMATIC BRADYCARDIA Key Treatment Consider ations Sinus bradycardia in the absence of key symptoms requires no specific treatment (monitor/observe) Sinus bradycardia is often seen in patients with STEMI or ischemia. Early 12-lead ECG should be obtained to assess for STEMI Fluid bolus may address hypotension and lessen need for pacing or treatment with atropine Sedation prior to starting pacing is not required. Patients with urgent need should be paced first The objective of sedation in pacing is to decrease discomfort, not to decrease level of consciousness. Patients who are in need of pacing are unstable and sedation should be done with great caution Monitor respiratory status closely and support ventilation as needed Atropine is not effective for bradycardia in heart-transplant patients (no vagus nerve innervation in these patients) Patients with wide-qrs second and third degree blocks will not have a response to atropine because these heart rates are not based on vagal tone. An increase in ventricular arrhythmias may occur Adult Treatment Guidelines 13
A7 ADULT VENTRICULAR TACHYCARDIA WITH PULSES Widened QRS Complex (greater than or equal to 0.12 sec) generally regular rhythm Initial Therapy OXYGEN BLS: Low flow unless ALOC/respiratory distress/shock ALS: Titrate to SpO 2 of at least 94% CARDIAC MONITOR 12-LEAD ECG 12 lead ECG pre-and post-treatment may be useful for comparisons at hospital. The computerized rhythm analysis on 12-lead printout should not be used for determination of rhythm. IV TKO STABLE VENTRICULAR TACHYCARDIA AMIODARONE 150 mg IV over 10 minutes (intermittent IV push or IV infusion of 15 mg/min) Consider Repeat AMIODARONE If rhythm persists and patient remains stable, 150 mg IV over 10 minutes UNSTABLE VENTRICULAR TACHYCARDIA Poor perfusion, moderate to severe chest pain, dyspnea, blood pressure less than 90 or CHF Consider SEDATION SYNCHRONIZED CARDIOVERSION Prepare for CARDIOVERSION: If awake and aware, sedate with MIDAZOLAM initial dose 1 mg IV, titrate in 1 2 mg increments (max. dose 5 mg) 100 joules 200 joules 300 joules 360 joules If VT recurs, use lowest energy level previously successful 14 Adult Treatment Guidelines
A7 ADULT VENTRICULAR TACHYCARDIA WITH PULSES Key Treatment Consider ations Document rhythm during treatment with continuous strip recording Rhythm analysis should be based on recorded strip, not monitor screen Be prepared for previously stable patient to become unstable Give AMIODARONE via Infusion or slow IV push only Caution with administration of AMIODARONE. May cause hypotension, especially if given rapidly. AMIODARONE should not be used in unstable patients. Patients with pre-existing hypotension should be considered unstable and should not receive AMIODARONE. If sedation done for cardioversion, monitor respiratory status closely and support ventilations as needed Adult Treatment Guidelines 15
A8 ADULT SUPRAVENTRICULAR TACHYCARDIA Heart rate greater than 150 beats per minute regular rhythm usually with narrow QRS complex Initial Therapy OXYGEN BLS: Low flow unless ALOC/respiratory distress/shock ALS: Titrate to SpO 2 of at least 94% CARDIAC MONITOR 12-LEAD ECG 12-lead ECG pre-and post-treatment may be useful for comparisons at hospital. The computerized rhythm analysis on 12-lead printout should not be used for determination of rhythm. IV TKO Antecubital IV needed for rapid medication administration Stable Supr aventricular Tachycardia (SVT) May have mild chest discomfort VALSALVA Consider ADENOSINE 6 mg rapid IV followed by 20 ml normal saline flush If not converted, 12 mg rapid IV 1 2 minutes after initial dose, followed by 20 ml normal saline flush 16 Adult Treatment Guidelines
A8 ADULT SUPRAVENTRICULAR TACHYCARDIA Unstable SVT May need immediate synchronized cardioversion Signs of poor perfusion include moderate to severe chest pain, dyspnea, altered mental status, blood pressure less than 90 or CHF If rhythm not regular, SVT unlikely If wide QRS complex, consider ventricular tachycardia Consider 6 mg rapid IV followed by 20 ml normal saline flush ADENOSINE If not converted, 12 mg rapid IV 1 2 minutes after initial dose, followed by 20 ml normal saline flush Consider SEDATION Prepare for CARDIOVERSION. If awake and aware, sedate with MIDAZOLAM initial dose 1 mg IV, titrate in 1 2 mg increments (max. dose 5 mg) SYNCHRONIZED CARDIOVERSION 100 joules 200 joules 300 joules 360 joules Key Treatment Consider ations Document rhythm during treatment with continuous strip recording Rhythm analysis should be based on review of P and QRS waves on printed strip, not monitor screen or computerized readout of 12-lead ECG Be prepared for previously stable patient to become unstable Proceed to cardioversion if patient becomes unstable Hypoxemia is a common cause of tachycardia. Initial evaluation should focus on determining if oxygenation is adequate. Adenosine should not be administered to patients with acute exacerbation of asthma If sedation used for cardioversion, monitor respiratory status closely and support ventilation as needed Adult Treatment Guidelines 17
A9 ADULT OTHER CARDIAC DYSRHYTHMIAS SINUS TACHYCARDIA Heart rate 100 160, regular ATRIAL FIBRILLATION Heart rate highly variable, irregular ATRIAL FLUTTER Variable rate depending on block. Atrial rate 250 350, sawtooth pattern. Initial Therapy OXYGEN BLS: Low flow unless ALOC/respiratory distress/shock ALS: Titrate to SpO 2 of at least 94% CARDIAC MONITOR Consider 12-LEAD ECG 12-lead ECG pre-and post-treatment may be useful for comparisons at hospital. The computerized rhythm analysis on 12-lead printout should not be used for determination of rhythm TKO Consider IV Unstable Atrial Fibrillation Or Atrial Flutter Ventricular rate greater than 150, and BP less than 80, or unconsciousness/ obtundation, or severe chest pain or severe dyspnea OXYGEN High flow. Be prepared to support ventilation. Consider SEDATION SYNCHRONIZED CARDIOVERSION Prepare for CARDIOVERSION. If awake and aware, sedate with MIDAZOLAM initial dose 1 mg IV, titrate in 1 2 mg increments (max. dose 5 mg) Atrial Flutter: Initial: 100 joules Subsequent: 200, 300, 360 joules Atrial Fibrillation: Initial: 200 joules Subsequent: 300, 360 joules 18 Adult Treatment Guidelines
A9 ADULT OTHER CARDIAC DYSRHYTHMIAS Key Treatment Consider ations Sinus tachycardia commonly present because of pain, fever, anemia, or hypovolemia Atrial fibrillation may be well-tolerated with moderately rapid rates (150 170) and often requires no specific treatment other than observation (oxygen, monitoring and transport) If sedation used for cardioversion, monitor respiratory status closely and support ventilation as needed Rhythm analysis should be based on review of P and QRS waves on printed strip, not monitor screen or computerized readout of 12-lead ECG Computerized analysis for Acute MI (STEMI) may be incorrect with very fast rhythms. If ***Acute MI Suspected*** or ***Meets ST-Elevation MI Criteria*** message encountered, the patient s heart rate is important information to relate to the STEMI center at time of activation. Adult Treatment Guidelines 19
A10 ADULT SHOCK/HYPOVOLEMIA HYPOVOLEMIC OR SEPTIC SHOCK Signs and symptoms of shock with dry lungs, flat neck veins May have poor skin turgor, history of GI bleeding, vomiting or diarrhea, altered level of consciousness May be warm and flushed, febrile, may have respiratory distress Sepsis patients may or may not have an associated fever CARDIOGENIC SHOCK Signs/symptoms of shock, history of CHF, chest pain, rales, shortness of breath, pedal edema HYPOVOLEMIA WITHOUT SHOCK No signs of shock, but history of poor fluid intake or fluid loss (e.g. vomiting, diarrhea). May have tachycardia, poor skin turgor. OXYGEN BLS/ALS: High flow. Be prepared to support ventilations as needed Consider CPAP If suspected pulmonary edema/cardiogenic shock ADDRESS Keep patient warm if suspected hypothermia HYPOTHERMIA CARDIAC MONITOR Treat dysrhythmias per specific treatment guideline EARLY TRANSPORT CODE 3 IV or IO TKO only if suspected pulmonary edema FLUID BOLUS For hypovolemic or septic shock, 500 ml NS bolus. May repeat once. For hypovolemia (poor intake/fluid loss), 250 ml NS bolus. May repeat once. Do not administer bolus if pulmonary edema or cardiogenic shock suspected 20 Adult Treatment Guidelines
A10 ADULT Consider 12-LEAD ECG SEPSIS SCREEN SHOCK/HYPOVOLEMIA If cardiac etiology for shock suspected Check temperature, use sepsis screening tool and advise hospital of positive sepsis screen if indicated A positive sepsis screen in adults occurs in the setting of suspected infection when 2 of 3 conditions are met: Heart rate/pulse greater than 90; Respiratory rate greater than 20; Temperature above 100.4 or below 96 BLOOD GLUCOSE Check and treat if indicated Related guidelines: Altered level of consciousness (G2), Respiratory Depression or apnea (G12) Adult Treatment Guidelines 21
A11 ADULT POST-CARDIAC ARREST CARE Following resuscitation from cardiac arrest in adults OXYGEN END-TIDAL CO2 MONITORING CARDIAC MONITOR 12-LEAD ECG TRANSPORT IV or IO FLUID BOLUS BLOOD GLUCOSE Consider THERAPEUTIC HYPOTHERMIA BLS: High flow initially ALS: Titrate to SpO 2 of at least 94% Be prepared to support ventilations as needed. Avoid excessive ventilation. If intubated, monitor and maintain respirations to keep ETCO 2 between 35 and 40 Treat dysrhythmias per specific treatment guideline Evaluate for possible STEMI. Alert STEMI center if ECG indicates ***ACUTE MI*** or equivalent STEMI message Code 3 to STEMI Receiving Center If not previously established For BP less than 90 systolic, begin infusion up to 1 liter NS Treat if indicated See Indications and contraindications below: Expose patient and apply eight (8) ice packs 2 on head, 2 on the neck over the carotid arteries, 1 on each axilla, 1 over each femoral artery Discontinue ice packs if shivering occurs or increasing level of consciousness. Advise Emergency Department that hypothermia has been initiated 22 Adult Treatment Guidelines
A11 ADULT POST-CARDIAC ARREST CARE Ther apeutic Hypothermia Indications And Contr aindications INDICATIONS All the following must be present: Must be age 18 or greater Return of spontaneous circulation for at least five minutes GCS < 8 Unresponsive without purposeful movements. Brainstem reflexes and posturing movements may be present Blood pressure 90 systolic or greater Pulse oximetry 85% or greater Blood glucose 50 or greater CONTRAINDICATIONS Traumatic cardiac arrest Responsive post-arrest with GCS 8 or greater or rapidly improving GCS Pregnancy DNR or known terminal illness Dialysis patient Uncontrolled bleeding Consider and treat other potential causes of altered level of consciousness (e.g. hypoxia or hypoglycemia) Key Treatment Consider ations Transmit ALL data to the monitor site identified by your provider agency Adult Treatment Guidelines 23
A12-ADULT SCENE SAFETY/BSI CONFIRM COMPRESSIONS AUTOMATED EXTERNAL DEFIBRILLATOR (AED) PUBLIC SAFETY DEFIBRILLATION BLS/ LAW ENFORCEMENT Use universal blood and body fluid precautions at all times Unconscious, pulseless patient with no breathing or no normal breathing Begin compressions at a rate of 100 120 per minute Compress chest at least 2 inches and allow full recoil of chest (lift heel of hand) Change compressors every 2 minutes Minimize interruptions in compressions. If necessary to interrupt, limit to 10 seconds or less. Stop compressions for analysis only resume compressions while AED is charging Resume compressions immediately after any shock If available, place mechanical compression device after first rhythm analysis or after subsequent rhythm analysis (LUCAS or Auto-Pulse) Priority of second rescuer is to apply pads while compressions are in progress With infants and children, use pediatric pads if available. Adult pads may be used with usual placement position if pads do not touch. Adult pads may be placed anteriorposterior if usual placement would cause the pads to touch. (*) Allow AED to analyze heart rhythm If the rhythm is shockable Resume compressions until charging of unit is complete Clear bystanders and crew (stop compressions) Deliver shock Resume CPR for 2 minutes, beginning with chest compressions then return to (*) If the rhythm is NOT shockable ( No Shock Advised ) Resume CPR for 2 minutes, beginning with chest compressions then return to (*) 24 Adult Treatment Guidelines
A12-ADULT BASIC AIRWAY MANAGEMENT AND VENTILATION CHECK BLOOD PRESSURE DOCUMENTATION PUBLIC SAFETY DEFIBRILLATION BLS/ LAW ENFORCEMENT Open airway and provide 2 breaths after every 30 compressions avoid excessive ventilation Provide no more than 8 10 ventilations per minute Ventilations should be about one second each, enough to cause visible chest rise. Use two-person BLS Airway management (one holding mask and one squeezing bag compressor can squeeze the bag) If patient begins to breathe or becomes responsive: Maintain airway Assist ventilations as necessary If patient begins to breathe or becomes responsive: Check blood pressure if equipment available Complete AED Use Report Forward report to EMS whenever an AED is used (whether shock administered or not) Upload AED data for EMS review if upload capability available Adult Treatment Guidelines 25
26