ADULT TREATMENT GUIDELINES

A1 Adult Patient Care A2 Chest Pain / Suspected ACS A3 Cardiac Arrest Initial Care and CPR A4 Ventricular Fibrillation / Ventricular Tachycardia A5 PEA / Asystole A6 Symptomatic Bradycardia A7 Ventricular Tachycardia with Pulses A8 Supraventricular Tachycardia A9 Other Dysrhythmias A10 Shock A11 Post-Cardiac Arrest Care A12 Public Safety Defibrillation ADULT TREATMENT GUIDELINES

A1 ADULT ADULT PATIENT CARE These basic concepts should be addressed for all adult patients (age 15 and over) Scene Safety Body Substance Use universal blood and body fluid precautions at all times Isolation Systematic Assessment Determine Primary Impression Base Contact Transport Document Assure open and adequate airway. Management of ABC s is a priority. Place patient in position of comfort unless condition mandates other position (e.g. shock, coma) spinal immobilization 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 Document patient assessment and care per policy

A2 ADULT CHEST PAIN SUSPECTED ACUTE CORONARY SYNDROME OXYGEN Low flow Caution: Do not administer or allow patient to take Nitroglycerin if patient has taken PRECAUTION erectile dysfunction meds Viagra or Levitra within 24 hrs or Cialis within 36 hrs. In these situations, severe hypotension may occur as a result of NTG administration. Nitroglycerin BLS Personnel: Allow patient to take own if BP greater than 90 CARDIAC MONITOR 12 LEAD ECG ASPIRIN IV NITROGLYCERIN MORPHINE SULFATE FLUID BOLUS If transmission available, transmit ECG. If STEMI detected, alert STEMI Center. Perform right-sided lead (V4R) if inferior MI noted. Repeat ECGs are encouraged. 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 TKO 0.4 mg sl if systolic BP above 90. May repeat every 5 minutes until pain subsides, maximum 6 doses or BP less than 90 systolic. Do not administer Nitroglycerin if Right Ventricular MI suspected 2-20 mg IV in 2-4 mg increments for pain relief if BP greater than 90 and NTG not effective. earlier administration to patients in severe distress from pain. Titrate to pain relief, systolic BP greater than 90, and adequate respiratory effort. If persistent pain, continue NITROGLYCERIN to maximum of 6 doses. Do not administer Morphine Sulfate if Right Ventricular MI suspected 250 ml NS if BP less than 90, lungs clear and unresponsive to positioning. May repeat X 1. Patients with Right Ventricular MI may require multiple fluid boluses.

Key Treatment 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 frequently present atypically Atypical symptoms can include syncope, weakness or sudden onset fatigue Rapid identification of STEMI to speed intervention is the goal of 12-lead ECG 12-lead ECG should be acquired as soon as possible after arrival (ideally within 5 minutes) 12-lead ECG should be acquired before initial NTG administration 12-lead ECG should be acquired prior to treatments for bradycardia if condition permits Minimize scene time in STEMI patients If STEMI noted and ST elevation is noted in inferior distribution (leads II, III, and avf), the possibility for right ventricular MI (RVMI) exists o Perform ECG with right-sided lead (V4R) mirrored in the same orientation as V4. RVMI should be suspected if ST elevation of 1 mm or greater in V4R. o Patients with RVMI may present with shock or poor perfusion in the presence of clear lungs and may have jugular venous distention. o Nitroglycerin and Morphine should not be administered in the setting of RVMI. Trendelenburg positioning and fluid bolus is appropriate treatment for shock in this setting. If STEMI noted and ST elevation is noted in anterior distribution (V1-V4), patient is at higher risk for pump failure and CHF on presentation Many STEMI s evolve during prehospital period and are not noted during first ECG, so repeat 12-lead ECGs are encouraged (avoid artifact by patient or vehicle movement) IV placement prior to NTG recommended in patients who have not taken NTG previously

A3 ADULT ESTABLISH TEAM LEADER CARDIAC ARREST INITIAL CARE AND CPR First agency on scene assumes leadership role Leadership role can be transferred as additional personnel arrive CONFIRM ARREST Unresponsive, no breathing or agonal respirations, no pulse Begin Compressions: Rate at least 100/minute 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. COMPRESSIONS 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 AED or MONITOR/ Determine rhythm and shock, if indicated DEFIBRILLATOR Follow specific treatment guideline based on rhythm BASIC AIRWAY MANAGEMENT and VENTILATION 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

IV / IO ACCESS IO access is preferred unless no suitable site is available If IV used (no IO access), antecubital vein is preferred. Hand veins and other smaller veins should not be used in cardiac arrest ADVANCED AIRWAY TREATMENT ON SCENE Placement of advanced airway is not a priority during the first 5 minutes of resuscitation unless no ventilation is occurring with basic maneuvers. o 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

A4 ADULT INITIAL CARE DEFIBRILLATION CPR VENTILATION/AIRWAY IO or IV DEFIBRILLATION EPINEPHRINE DEFIBRILLATION AMIODARONE DEFIBRILLATION ADVANCED AIRWAY repeat AMIODARONE TRANSPORT SODIUM BICARBONATE VENTRICULAR FIBRILLATION PULSELESS VENTRICULAR TACHYCARDIA See Cardiac Arrest Initial Care and CPR (A3) 200 joules (low energy 120 joules) For 2 minutes or 5 cycles between rhythm check BLS airway is preferred method during first 5-6 minutes of CPR If no ventilation occurring with basic maneuvers, proceed to advanced airway TKO. Should not delay shock or interrupt CPR 300 joules (low energy 150 joules) 1:10,000-1 mg IV or IO every 3-5 minutes 360 joules (low energy 200 joules) 300 mg IV or IO 360 joules (low energy 200 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 1 meq/kg IV or IO for suspected hyperkalemia or pre-existing acidosis If Return of Spontaneous Circulation, see Post-Cardiac Arrest Care (A11)

Key Treatment 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 ETCO2 is mandatory if values less than 10 mm Hg seen, assess quality of compressions for adequate rate and depth. Rapid rise in ETCO2 may be the earlist indicator of return of circulation. Prepare drugs before rhythm check and administer during CPR Follow each drug with 20 ml NS flush

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 treatable causes treat if applicable: FLUID BOLUS VENTILATION For hypovolemia: 500-1000 ml NS IV or IO For hypoxia: Ensure adequate ventilation (8-10 breaths per minute) SODIUM BICARBONATE CALCIUM CHLORIDE WARMING MEASURES 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 NEEDLE THORACOSTOMY For tension pneumothorax If Return of Spontaneous Circulation, see Post-Cardiac Arrest Care (A11)

Patients who have all of the following criteria are highly unlikely to survive: TERMINATION OF RESUSCITATION 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. Key Treatment 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

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 High flow. Be prepared to support ventilation as needed CARDIAC MONITOR TKO. If not promptly available, proceed to external cardiac pacing. IO IV ACCESS if patient in extremis and unconscious or not responsive to painful stimuli. 12-LEAD ECG pre- and post-treatment if condition permits TRANSCUTANEOUS Set rate at 80 PACING Start at 10 ma, and increase in 10 ma increments until capture is achieved SEDATION ATROPINE TRANSPORT FLUID BOLUS DOPAMINE 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 MORPHINE SULFATE 1-5 mg IV or IO in 1 mg 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 onset of pacing. 0.5 mg IV or IO if availability of pacing delayed or pacing ineffective 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. 250-500 ml NS if clear lung sounds and no respiratory distress Begin infusion at 5 mcg/kg/min if not responsive to pacing or atropine (see table)

Key Treatment ations Sinus bradycardia in the absence of key symptoms requires no specific treatment (monitor / observe) 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.

A7 ADULT VENTRICULAR TACHYCARDIA WITH PULSES Widened QRS Complex (greater than or equal to 0.12 sec) generally regular rhythm INITIAL THERAPY OXYGEN High flow. Be prepared to support ventilation as needed. CARDIAC MONITOR 12-LEAD ECG IV AMIODARONE pre- and post treatment if condition permits TKO STABLE VENTRICULAR TACHYCARDIA 150 mg IV over 10 minutes (intermittent IV push or IV infusion of 15 mg/min) repeat If rhythm persists and patient remains stable, 150 mg IV over 10 minutes AMIODARONE UNSTABLE VENTRICULAR TACHYCARDIA Poor perfusion, moderate to severe chest pain, dyspnea, blood pressure less than 90 or CHF 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 (low energy setting 75 W/S) 200 joules (low energy setting 120 W/S) 300 joules (low energy setting 150 W/S) 360 joules (low energy setting 200 W/S) If VT recurs, use lowest energy level previously successful

Key Treatment 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

A8 ADULT SUPRAVENTRICULAR TACHYCARDIA Heart rate greater than 150 beats per minute regular rhythm usually with narrow QRS complex OXYGEN CARDIAC MONITOR 12-LEAD ECG IV May have mild chest discomfort VALSALVA ADENOSINE INITIAL THERAPY High flow. Be prepared to support ventilation as needed. pre- and post-treatment if condition permits TKO Antecubital IV needed for rapid medication administration STABLE SUPRAVENTRICULAR TACHYCARDIA (SVT) 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.

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 ADENOSINE SEDATION SYNCHRONIZED CARDIOVERSION 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. 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 (low energy setting 75 W/S) 200 joules (low energy setting 120 W/S) 300 joules (low energy setting 150 W/S) 360 joules (low energy setting 200 W/S) Key Treatment 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 Proceed to cardioversion if patient becomes unstable Adenosine should not be administered to patients with acute exacerbation of asthma Hypoxemia is a common cause of tachycardia. Initial evaluation should focus on determining if oxygenation is adequate. If sedation used for cardioversion, monitor respiratory status closely and support ventilation as needed

A9 OTHER CARDIAC DYSRHYTHMIAS ADULT 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, saw-tooth pattern INITIAL THERAPY OXYGEN Low flow. High flow if unstable. CARDIAC MONITOR 12-lead ECG pre- and post-treatment if patient symptomatic and condition permits 12-LEAD ECG IV TKO 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. 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 (low energy setting 75 joules) Subsequent: 200, 300, 360 joules (low energy settings 120, 150, 200 joules) Atrial Fibrillation Initial: 200 joules (low energy setting 120 joules) Subsequent: 300, 360 joules (low energy settings 150, 200 joules)

Key Treatment 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 Computerized rhythm analysis on 12-lead ECG is frequently incorrect and requires review of the ECG to verify rhythm Computerized analysis for Acute MI (STEMI) may be incorrect with very fast rhythms. If ***Acute MI***, ***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.

A10 ADULT SHOCK 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 May be warm and flushed, febrile May have history of high fever (sepsis) OXYGEN Keep patient warm CARDIAC MONITOR EARLY TRANSPORT CODE 3 IV or IO FLUID BOLUS BLOOD GLUCOSE DOPAMINE SHOCK (NOT CARDIOGENIC) High flow. Be prepared to support ventilations as needed. Treat dysrhythmias per specific treatment guideline 250-500 ml NS Recheck vitals every 250 ml to a maximum of 1 liter Check and treat if indicated Begin infusion at 5 mcg/kg/min if hypotension persists (see table) Related guidelines: Altered level of consciousness (G2), Respiratory Depression or apnea (G12)

CARDIOGENIC SHOCK Signs and symptoms of shock, history of CHF, chest pain, rales, shortness of breath, pedal edema OXYGEN High flow. Be prepared to support ventilations as needed. Keep patient warm CARDIAC MONITOR Treat dysrhythmias per specific treatment guideline EARLY TRANSPORT CODE 3 IV or IO TKO BLOOD GLUCOSE Check and treat if indicated DOPAMINE Begin infusion at 5 mcg/kg/min if hypotension persists (see table) 12 LEAD ECG Perform if time and condition permits Related guideline: Altered Level of Consciousness (G2)

A11 ADULT Following resuscitation from cardiac arrest in adults OXYGEN END-TIDAL CO2 MONITORING CARDIAC MONITOR 12-LEAD ECG TRANSPORT CODE 3 IV or IO BLOOD GLUCOSE FLUID BOLUS DOPAMINE THERAPEUTIC HYPOTHERMIA POST-CARDIAC ARREST CARE Titrate to keep oxygen saturation above or equal to 94%. Be prepared to support ventilations as needed. Avoid excessive ventilation. If intubated, monitor and maintain respirations to keep ETCO2 between 35 and 40 Treat dysrhythmias per specific treatment guideline Evaluate for possible STEMI. Alert and transport to STEMI center if ECG indicates ***ACUTE MI*** or equivalent STEMI message If not previously established Treat if indicated For BP less than 90 systolic, begin infusion up to 1 liter NS Begin infusion at 5 mcg/kg/min if hypotension persists after fluid bolus (see table) 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.

THERAPEUTIC HYPOTHERMIA INDICATIONS AND CONTRAINDICATIONS All the following must be present: Must be age 18 or greater Return of spontaneous circulation for at least five minutes GCS < 8 INDICATIONS 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 Traumatic cardiac arrest Responsive post-arrest with GCS 8 or greater or rapidly improving GCS Pregnancy CONTRAINDICATIONS DNR or known terminal illness Dialysis patient Uncontrolled bleeding and treat other potential causes of altered level of consciousness (e.g. hypoxia or hypoglycemia)

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 at least 100 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 If less than 8 years of age, attach pediatric electrodes, if available. If not, attach adult electrodes with anterior-posterior placement (pads should not touch) (*) Allow AED to analyze heart rhythm o 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 (*) o If the rhythm is NOT shockable ( No Shock Advised ) Resume CPR for 2 minutes, beginning with chest compressions then return to (*)

BASIC AIRWAY MANAGEMENT AND VENTILATION If patient begins to breathe or becomes responsive 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) Maintain airway Assist ventilations, as necessary Check blood pressure, if equipment available