FRRCKSBURG MS Asystole / A (ATRC) 1 Check for Responsiveness Check for Breathing Check for Carotid ulse nitiate CR o As soon as a mechanical external compression device (i.e. Lucas 2) (rocedure 11) becomes available the device can be employed as the primary means of providing chest compressions lacement of A and follow prompts as instructed NA/OA with assisted ventilations via BVM as soon as possible, priorities should be on compressions, then airway o No gag reflex consider the insertion of the King Airway (rocedure 4) O NOT NTRRRUT CR TO LAC TH KNG ARWAY o TCO2 monitoring (rocedure 7) NTRMAT Secure airway as required by T ntubation and confirm/secure tube placement Obtain V access initiate fluid bolus o O access (immediately if available or after unable to obtain V access in 2 attempts) ARAMC Cardiac monitor Confirm asystole in more than one lead pinephrine 0.1 mg/kg (1:10,000) (Rx: 13) rapid V/O push every 3-5 minutes
FRRCKSBURG MS Asystole / A (ATRC) 1 Consider TC if a bradycardic rhythm f no rhythm change, rapid rise in TCo2, or ROSC after 25 minutes of aggressive CR and ACLS therapies, consider ceasing resuscitation efforts Consider Sodium Bicarbonate 1 mq/kg (Rx: 30) V/O if the patient is believed to have one of the following conditions: o Chronic Renal Failure o Hyperkalemia o Tricyclic Anti-epressant Overdose o Suspected case of xcited elirium ALRTS: Causes dentify and treat the following contributing factors (6 H and 5 T s): Treatment Hypovolemia Normal Saline Boluses Hypoxia Ventilate with 100% Oxygen Hyperkalemia Calcium Chloride and Sodium Bicarbonate. After administration of either medication ensure that the V line is completely flushed Hypoglycemia extrose Hypothermia Remove clothing with gradual re-warming. Handle patient gently Hydrogen on (acidosis) Normal Saline Boluses. Sodium Bicarbonate Tension neumothorax Needle Thoracostomy Tamponade Cardiac Normal Saline Boluses and rapid transport. n-hospital pericardiocentesis Thrombosis n-hospital fibrinolysis Trauma rovide treatment per trauma protocols Toxins Refer to Overdose (edi Medical 13)
FRRCKSBURG MS Bradycardia (ATRC) 2 ABC s o Monitor Vital Signs o Support life-threatening problems associated with airway, breathing, and circulation Support airway and provide supplemental Oxygen if Oxygen Saturation by pulse oximetry is less than 94% 12 Lead CG, Transmit (rocedure 8) NTRMAT nitiate V Normal Saline, KVO or Saline Lock o 20 ml/kg as needed to maintain or restore perfusion. o Repeat once for a total of 40 ml/kg ARAMC Cardiac monitor f patient has adequate perfusion observe/monitor f patient has poor perfusion caused by the bradycardia with a low degree heart block Consider pinephrine 1:10,000 0.01 mg/kg V/O (Rx: 13) o f bradycardia is due to increased vagal tone or primary AV block administer Atropine 0.02 mg/kg V/O (Rx: 5) Minimum dose: 0.1 mg Maximum dose: 0.5 mg f patient has poor perfusion caused by the bradycardia with a high degree heart block o repare for TC (Rate 100, 5 ma increase at 5 ma increments until capture)
FRRCKSBURG MS Bradycardia (ATRC) o Consider Versed 0.1 mg/kg V/O/N (Rx: 36) as soon as appropriate Consider pinephrine infusion for persistent hypoperfusion and/or Bradycardia: o pinephrine infusion 0.1-1 mcg/kg/min (Rx: 13) o f <10 kg mix 0.4 mg 1:1,000 in a 100 ml NS for a concentration of 4 mcg/ml. nfuse with a 60 gtts set for the desired dose. f >10 kg mix 0.8 mg 1:1,000 in a 100 ml NS for a concentration of 8 mcg/ml. nfuse with a 60 gtts set for the desired dose. ALRTS: Causes Signs/symptoms of poor perfusion primarily include hypotension which also may include altered mental status, ongoing chest pain, or other signs of shock f time permits, consider sedation with Versed 0.1mg/kg V/N prior to TC Treatment of choice for high degree blocks (second degree type and third degree) is TC (consider atropine 0.5mg V while awaiting TC) Consider causes (6H s, 5T s) Treatment Hypovolemia Normal Saline Boluses Hypoxia Ventilate with 100% Oxygen Hyperkalemia Calcium Chloride and Sodium Bicarbonate. After administration of either medication ensure that the V line is completely flushed Hypoglycemia extrose Hypothermia Remove clothing with gradual re-warming. Handle patient gently Hydrogen on (acidosis) Normal Saline Boluses. Sodium Bicarbonate Tension neumothorax Needle Thoracostomy Tamponade Cardiac Normal Saline Boluses and rapid transport. n-hospital pericardiocentesis Thrombosis n-hospital fibrinolysis Trauma rovide treatment per trauma protocols Toxins Refer to Overdose (edi Medical 13) 2
FRRCKSBURG MS Narrow Complex Tachycardia - SVT (ATRC) 3 ABC s Monitor Vital Signs Support life-threatening problems associated with airway, breathing, and circulation Support airway and provide supplemental Oxygen if Oxygen Saturation by pulse oximetry is less than 94% 12 Lead CG, Transmit (rocedure 8) NTRMAT nitiate V Normal Saline, KVO or Saline Lock o Administer 250 ml boluses until systolic B > 90 mmhg o Total amount of VF should not exceed 1000 ml ARAMC Cardiac monitor Unstable patient: f time and patient condition permit, the patient should be sedated prior to the application of electrical therapy Sedation o Versed 0.1 mg/kg V/N (Rx: 36) o Maximum Single ose of 5 mg Synchronized cardioversion (0.5 J/kg, 1 J/kg, & 2 J/kg)(rocedure 10) if: o GCS 14 o Appears hemodynamically unstable o Reports active chest pain o xhibits significant shortness of breath
FRRCKSBURG MS Narrow Complex Tachycardia - SVT (ATRC) Stable patient: f the patient is in a narrow complex tachycardia (<0.12) without evidence of A-Fib / A-Flutter and is hemodynamically stable without critical signs and symptoms attempt vagal maneuvers first n the absence of A-Fib, A-Flutter or multifocal atrial tachycardia Adenosine 0.1 mg/kg (Rx: 2) rapid V push (over 1-3 sec.), followed with 20cc NS flush (regular & monomorphic) Withhold Adenosine if the patient has a history of Wolff arkinson White Syndrome (WW) or if delta waves are present Repeat Adenosine 0.2 mg/kg rapid V push after 1-2 minutes, followed with 20cc NS flush ALRTS: Give Adenosine rapidly over 1 to 3 seconds through a large (e.g., antecubital) vein followed by a 10 ml Normal Saline flush and elevation of the arm f possible, establish V access before cardioversion and give Versed 0.1 mg/kg slow V push, titrated to effect, if the patient is conscious. May repeat every 5 minutes as needed for sedation. o not delay cardioversion if the patient is extremely unstable f available, obtain a 12-Lead CG to better define the rhythm, but this should not delay immediate cardioversion if the patient is unstable Adenosine is safe and effective in pregnancy. However, Adenosine does have several important drug interactions. Larger doses may be required for patients with a significant blood level of Theophylline, Caffeine, or Theobromine. The initial dose should be reduced to 3 mg in patients taking ipyridamole or Carbamazepine or those with transplanted hearts Adenosine should not be given for unstable or for irregular or polymorphic wide-complex tachycardias, as it may cause degeneration of the arrhythmia to VF 3
FRRCKSBURG MS Wide Complex Tachycardia V-Tach With A ulse (ATRC) 4 ABC s Monitor Vital Signs Support life-threatening problems associated with airway, breathing, and circulation Support airway and provide supplemental Oxygen if Oxygen Saturation by pulse oximetry is less than 94% 12 Lead CG, Transmit (rocedure 8) NTRMAT nitiate V Normal Saline, KVO or Saline Lock o Administer 250 ml boluses until systolic B > 90 mmhg o Total amount of VF should not exceed 1000 ml ARAMC Cardiac monitor Unstable patient: f time and patient condition permit, the patient should be sedated prior to the application of electrical therapy Sedation o Versed 0.1 mg/kg V/N (Rx: 36) o Maximum ose of 5 mg Synchronized cardioversion (0.5 J/kg, 1 J/kg, & 2 J/kg)(rocedure 10) if: o GCS 14 o Appears hemodynamically unstable o Reports active chest pain o xhibits significant shortness of breath
FRRCKSBURG MS Wide Complex Tachycardia V-Tach With A ulse (ATRC) 4 f the rhythm converts to a non-lethal, narrow complex rhythm without the presence of a high degree heart block then administer Lidocaine: o Lidocaine 1 mg/kg (Rx: 22) V/O Follow by 0.5 mg/kg every 5 minutes Maximum total dose 3 mg/kg Stable patient: f the rhythm is regular with monomorphic appearance consult with the on duty physician about the use of Adenosine: o Recommended dosage for ediatric atient: o Adenosine initial dose: 0.1 mg/kg rapid V/O o if required second dose: 0.2 mg/kg rapid V/O f the rhythm appears irregular or the o Lidocaine 1 mg/kg (Rx: 22) V/O Follow by 0.5 mg/kg every 5 minutes Maximum total dose 3 mg/kg f the rhythm is polymorphic V-tach. (Torsades de ointes) or hypomagnesaemia is suspected consult with the on duty physician about the use of Magnesium Sulfate: Magnesium Sulfate 25-50 mg/kg (Rx: 23) V over 20 minutes Mix 2 gm in 100 ml of Normal Saline. Utilize a 10 gtts set and infuse at 20 gtts/min over 20 minutes Max single does of 2 gm f at any time during the administration of a medication infusion or reevaluation, the patient begins to deteriorate or exhibit signs of tachycardia related cardiovascular compromise, revert to immediate Synchronized Cardioversion (rocedure 10)
FRRCKSBURG MS V-Fib / ulseless V-Tach (ATRC) 5 Check for responsiveness Check for breathing Check for carotid pulse nitiate CR o As soon as a mechanical external compression device (i.e. Lucas 2) (rocedure 12) becomes available the device can be employed as the primary means of providing chest compressions lacement of A and follow prompts as instructed NA/OA with assisted ventilations via BVM as soon as possible, priorities should be on compressions, then airway o f unable to provide adequate ventilations with BVM, consider the insertion of the King Airway (rocedure 4) O NOT NTRRRUT CR TO LAC TH KNG ARWAY o TCO2 monitoring (rocedure 7) 12 Lead CG, transmit if possible (rocedure 8) NTRMAT Secure airway as required by T ntubation and confirm/secure tube placement Obtain V access initiate fluid bolus o O access (immediately if available or after unable to obtain V access in 2 attempts)
FRRCKSBURG MS V-Fib / ulseless V-Tach (ATRC) 5 ARAMC Cardiac monitor o ConfirmV-Fib / V-Tach o Shock 2 J/kg o Repeat defibrillation for recurrent VF/VT after every 2 minute cycle of quality CR and after each drug administration is circulated for at least 60 seconds: pinephrine 1:10,000 0.01 mg/kg (Rx: 13) V/O o Administer pinephrine every 3-5 minutes for the duration of the arrest Administer Cordarone (RMARY) or Lidocaine repeat medication in 5 minutes for recurrent VF/VT: o Cordarone (Rx: 10) nitial dose: 5 mg/kg V/O Additional doses: 5 mg/kg V/O Maximum total dose: 15 mg/kg V/O OR o Lidocaine (Rx: 22) nitial dose: 1 mg/kg V/O Additional dose: 1 mg/kg V/O, maximum total dose 3 mg/kg Consider Magnesium Sulfate for suspected polymorphic V-tach (Torsades de ointes) or hypomagnesaemia: o Magnesium Sulfate 25-50 mg/kg (Rx: 23) slow V/O o Mix 2 gm in 10 ml of Normal Saline and administer over 2 minutes o Maximum single dose of 2 gm Consider Sodium Bicarbonate 1 mq/kg (Rx: 30) V/O if the patient is believed to have one of the following conditions: o Chronic Renal Failure o Hyperkalemia
FRRCKSBURG MS V-Fib / ulseless V-Tach (ATRC) 5 o Tricyclic Anti-epressant Overdose o Suspected case of xcited elirium ALRTS: When VF/pulseless VT cardiac arrest is associated with torsades de pointes, administer an V/O bolus of Magnesium Sulfate at a dose of 25-50 mg/kg diluted in 6 ml Normal Saline The most critical interventions during the first minutes of VF or pulseless VT are immediate CR, with minimal interruption in chest compressions, and defibrillation After an advanced airway is placed, rescuers no longer deliver cycles of CR. Give continuous chest compressions without pauses for breaths. Give 8 to 10 breaths/minute. Check rhythm every 2 minutes When a rhythm check reveals VF/VT, CR should be provided while the defibrillator charges (when possible), until it is time to clear the victim for shock delivery. Give the shock as quickly as possible. mmediately after shock delivery, resume CR (beginning with chest compressions) without delay and continue for 5 cycles (or about 2 minutes if an advanced airway is in place), and then check the rhythm Minimize the number of times that chest compressions are interrupted. eriodic pauses in CR should be as brief as possible and only as necessary to assess rhythm, shock VF/VT, perform a pulse check when an organized rhythm is detected, or place an advanced airway
FRRCKSBURG MS V-Fib / ulseless V-Tach (ATRC) ffective chest compressions are essential for providing blood flow during CR. To give effective chest compressions, push hard and push fast. Compress the adult chest at a rate of at least 100 compressions per minute, with a compression depth of 1/2 chest depth. Allow the chest to recoil completely after each compression, and allow approximately equal compression and relaxation times Continuous waveform capnography is required, if available, in addition to clinical assessment to confirm and monitor correct placement of an endotracheal tube Use quantitative waveform capnography in intubated patients to monitor CR quality, optimize chest compressions, and detect ROSC during chest compressions or when rhythm check reveals an organized rhythm. f TCO2 <10 mm Hg, consider trying to improve CR quality by optimizing chest compression parameters. f TCO2 abruptly increases to a normal value (35 to 40 mm Hg), it is reasonable to consider that this is an indicator of ROSC f SVT 170, perform immediate synchronized cardioversion in addition to other indicated procedures. 5
FRRCKSBURG MS Return of Spontaneous Circulation (ROSC) (ATRC) 6 ABC s Support airway and provide supplemental Oxygen if Oxygen Saturation by pulse oximetry is less than 94% o No gag reflex consider the insertion of the King Airway (rocedure 4) TCO2 monitoring (rocedure 7) o nsure that a blood glucose reading is obtained, refer to iabetic mergencies (edi Medical 5) 12 Lead CG, Transmit (rocedure 8) Consider Air Medical for transport to a heart center NTRMAT nitiate V Normal Saline, o Administer 20 ml/kg boluses to maintain or restore perfusion o Repeat once for a total of 40 ml/kg Advanced Airway procedures as needed ARAMC Cardiac monitor f the patient was resuscitated following an episode of VF/VT and is without profound bradycardia or high-grade heart block (2nd degree Type or 3rd degree or dioventricular rhythm) administer Cordarone nfusion (rocedure 14) or Lidocaine bolus Note: Continue using the anti-arrhythmic medication that was administered during resuscitation
FRRCKSBURG MS Return of Spontaneous Circulation (ROSC) (ATRC) 6 Cordarone 5 mg/kg (Rx: 10) slow infusion o Mix dose in 100 ml of Normal Saline. Utilize a 10 gtts set and infuse at 100 gtts/minute over 10 minutes o May repeat once in 10 minutes OR if Cordarone is not available Lidocaine 0.5 mg/kg (Rx: 22) V/O o Follow by 0.5 mg/kg every 5 minutes o Maximum total dose 3 mg/kg f bradycardia persists refer to the Bradycardia rotocol ( 2) Administer a opamine infusion 5-20 mcg/kg/min (Rx: 12) for persistent hypoperfusion Administer an pinephrine infusion (Rx: 13) for heart transplant recipients or persistent hypoperfusion: o pinephrine infusion 0.1-1 mcg/kg/min