CARDIAC GUIDELINES

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Patients with narrow complex tachycardia, are often familiar with their problem and symptoms. Those who do not show evidence of hemodynamic instability require no pre-hospital medications. Patients presenting with hemodynamic instability, evidence of poor perfusion, chest pain, altered level of consciousness, shortness of breath, cyanosis or evidence of CHF are considered unstable and invasive intervention should be implemented per this protocol.\u003cbr\u003e\n\u003cbr\u003e\n\u003cbr\u003e\nEMPHASIS ON PATIENT CARE\u003cbr\u003e\nMaintain adequate perfusion, adequate oxygenation, and ALS intervention\u003cbr\u003e\n\u003cbr\u003e\n1.\tPrimary Management - Assess ABC’s and manage as indicated.\u003cbr\u003e\na.\tTitrate oxygen to maintain SpO2 \u003e92%\u003cbr\u003e\n2.\tInitiate transport to appropriate medical facility. Consider ALS intercept.\u003cbr\u003e\n3.\tSecondary Management - History, physical exam, vital signs\u003cbr\u003e\na.\tIf suspected AMI, administer ASPIRIN [325 mg PO]. Chewed then swallowed\u003cbr\u003e\n\u003cbr\u003e\nAEMT\u003cbr\u003e\n1.\tEn-route, initiate IV/IO access; if necessary, titrate isotonic solution to end organ perfusion.\u003cbr\u003e\nPARAMEDIC\u003cbr\u003e\n\u003cbr\u003e\n1.\tIf UNSTABLE (symptomatic) A-Fib/A-Flutter:\u003cbr\u003e\na.\tPatients with significant decompensation (shock, mental decompensation, severe ongoing chest pain) may require immediate Synchronized Cardioversion. If the patient is conscious, consider sedation using MIDAZOLAM [2-4 mg] IV/IO/IN/IM, prior to cardioversion, if appropriate to patient condition\u003cbr\u003e\ni.\tCardiovert at 100 joules if unsuccessful then escalate joules:\u003cbr\u003e\n•\tCardiovert at 200 J (maximum for machine). \u003cbr\u003e\nb.\tContinuously monitor patients BP\u003cbr\u003e\n\u003cbr\u003e\n2.\tIf patient’s cardiac rhythm changes during procedure, treat per applicable guidelines.\u003cbr\u003e\n3.\tUse of Nitroglycerin or Narcotic Pain Relievers for patients with this rhythm may precipitate decompensation or cardiac arrest.","adBanner":{"ad_banner_enable":0,"banner":"","redirect_url":""},"mapThirdParty":"0","MapThirdParty":"0","reviewRating":1,"attributesForList":[],"directoryInfo":[],"formIdentifier":"default","formType":"custom","widgetInfo":{"widget_enable":null,"widget_label":"Widget Label","widget_code":null},"listOwner":"","claimStatus":null,"pwaUrl":"https://www.lcfdapp.com/services_1582148118880_5/2114007/2263238/10632779"},{"listId":10632784,"catId":2263238,"dirPageId":"services_1582148118880_5","distance":"","chatUrl":"","chatType":"","header":"ASYSTOLE","summary":"","detail":"CARDIAC ARREST / ASYSTOLE\u003cbr\u003e\n\u003cbr\u003e\nALL LEVELS\u003cbr\u003e\nDesignation of Condition\u003cbr\u003e\nThe patient will be unconscious, unresponsive, pulseless, apneic, and show asystole on the monitor (confirmed with a six-second strip) in 3 leads. Patients in cardiac arrest should be managed in the field.\u003cbr\u003e\n\u003cbr\u003e\n\u003cbr\u003e\n1.\tConfirm patient is unresponsive, has apneic/agonal respirations and is pulseless.\u003cbr\u003e\na.\tBegin high quality pit crew CPR\u003cbr\u003e\nb.\tApply monitor/AED to confirm rhythm.\u003cbr\u003e\nc.\tConsider placement of Supraglottic (LMA preferred), allowing no disruption of chest compressions during placement.\u003cbr\u003e\nd.\tApply EtCO2 and SpO2\u003cbr\u003e\ne.\tCheck rhythm/pulse every 200 compressions (2 minutes).\u003cbr\u003e\nAEMT\u003cbr\u003e\n1.\tConsider placement of Supraglottic Airway (LMA preferred), allowing no disruption of chest compressions during placement.\u003cbr\u003e\n2.\tEstablish IV/IO access and administer NS\u003cbr\u003e\n3.\tAdminister Epinephrine, IV/IO See SPECIAL NOTE below.\u003cbr\u003e\n4.\tIV/IO dosage of Epinephrine: (1:10,000) 1 mg every 3-5 minutes as indicated\u003cbr\u003e\n\u003cbr\u003e\nPARAMEDIC\u003cbr\u003e\n\u003cbr\u003e\n1.\tConsider placement of SGA Airway or ETT in accordance with the corresponding Airway Placement Procedural Guidelines, allowing no disruption of chest compressions during placement.\u003cbr\u003e\n2.\tIf electrical activity returns but patient remains pulseless, proceed to PEA algorithm.\u003cbr\u003e\n3.\tIf sustained Asystole after 30 minutes consider TOR. \u003cbr\u003e\n4.\tIf no ROSC and the patient remains in asystole after 30 minutes of ALS resuscitative efforts consider TOR. See Termination of Resuscitation Guidelines.\u003cbr\u003e\n\u003cbr\u003e\nEPINEPHRINE DOSING IN CARDIAC ARREST SPECIAL NOTES\u003cbr\u003e\nShortages of EPINEPHRINE 1:10,000 are necessitating alternate dosing for cardiac arrest patients. EPINEPHRINE administration in cardiac arrest patients is associated with improved ROSC rates but no dosing regimen has been shown to be superior in terms of ultimate survival. The following dosing regimens are acceptable in cardiac arrest patients when EPINEPHRINE 1:10,000 is unavailable or rationed. ET dosing is no longer an approved route.\u003cbr\u003e\n\u003cbr\u003e\n1.\tAHA recommended dosing if EPINEPHRINE available: 1 mg. IV/IO q 3-5 minutes. No limitation on number of doses given.\u003cbr\u003e\n2.\tEPINEPHRINE 1 mg. q 5-10 minutes IV/IO. No limitation on number of doses given.\u003cbr\u003e\n3.\tEPINEPHRINE 1 mg. IV/IO followed by infusion.\u003cbr\u003e\na.\tInfusion: Mix 3 mg. (3 vials of 1 mg. 1:1,000) into a 1,000 cc bag of crystalloid solution and run so that bag is infusing throughout the 30 minute resuscitation.\u003cbr\u003e\n4.\tEPINEPHRINE infusion only.","adBanner":{"ad_banner_enable":0,"banner":"","redirect_url":""},"mapThirdParty":"0","MapThirdParty":"0","reviewRating":1,"attributesForList":[],"directoryInfo":[],"formIdentifier":"default","formType":"custom","widgetInfo":{"widget_enable":0,"widget_label":"Widget Label","widget_code":""},"listOwner":"","claimStatus":null,"pwaUrl":"https://www.lcfdapp.com/services_1582148118880_5/2114007/2263238/10632784"},{"listId":10632780,"catId":2263238,"dirPageId":"services_1582148118880_5","distance":"","chatUrl":"","chatType":"","header":"BRADYCARDIA","summary":"","detail":"BRADYCARDIA\u003cbr\u003e\n\u003cbr\u003e\nALL LEVELS\u003cbr\u003e\nDESIGNATION OF CONDITION\u003cbr\u003e\nThe patient will present with heart rate of \u003c60 bpm and be symptomatic / unstable.\u003cbr\u003e\n\u003cbr\u003e\n\u003cbr\u003e\nEMPHASIS ON PATIENT CARE\u003cbr\u003e\nMaintain adequate oxygenation and perfusion. Consider the underlying causes of bradycardia (e.g., hypoxia, hypoglycemia, toxicology and hypothermia).\u003cbr\u003e\n1.\tPrimary Management - Assess ABC’s and manage as indicated.\u003cbr\u003e\n2.\tCardiac monitoring, oxygen administration, and obtain 12 - lead ECG, if possible.\u003cbr\u003e\n3.\tCall for ALS intercept if serious signs or symptoms (hypotension, acutely altered mental status, signs of shock, ischemic chest discomfort, or acute heart failure).\u003cbr\u003e\n4.\tTransport the patient as soon as possible to the nearest medical facility.\u003cbr\u003e\n5.\tSecondary Management - History, physical exam, vital signs\u003cbr\u003e\na.\tIf suspected AMI, administer ASPIRIN [325 mg PO]. Chewed then swallowed.\u003cbr\u003e\nAEMT\u003cbr\u003e\n1.\tIn-route, initiate an IV/IO Line of isotonic solution at a flow rate determined by patient condition.\u003cbr\u003e\nPARAMEDIC\u003cbr\u003e\n\u003cbr\u003e\n1.\tIf serious signs or symptoms of hemodynamically instability (hypotension, acutely AMS, signs of shock, ischemic chest discomfort, or acute heart failure)\u003cbr\u003e\na.\tConsider cardiac pacing first.\u003cbr\u003e\ni.\tMay require sedation with MIDAZOLAM 2-4 mg IV/IO/IN/IM\u003cbr\u003e\nb.\tATROPINE 1.0 mg IV/IO to maximum of 3.0 mg. May be given simultaneously with pacing.\u003cbr\u003e\nc.\tATROPINE will not be effective in patients who have had heart transplants.\u003cbr\u003e\n2.\tRepeat set of vitals, if no change, administer a Vasopressor:\u003cbr\u003e\na.\tEPINEPHRINE drip (1 mg in 250 ml of NS = 4 mcg/ml) and start at 2 mcg/min. Titrate drip up to 10 ug/min or until an acceptable perfusing heart rate and BP are achieved.\u003cbr\u003e\n3.\tA second IV line is desired, however, do not withhold medication if second IV is unobtainable.\u003cbr\u003e\n4.\tATROPINE should be considered before TCP for suspected vagal induced bradycardia","adBanner":{"ad_banner_enable":0,"banner":"","redirect_url":""},"mapThirdParty":"0","MapThirdParty":"0","reviewRating":1,"attributesForList":[],"directoryInfo":[],"formIdentifier":"default","formType":"custom","widgetInfo":{"widget_enable":0,"widget_label":"Widget Label","widget_code":""},"listOwner":"","claimStatus":null,"pwaUrl":"https://www.lcfdapp.com/services_1582148118880_5/2114007/2263238/10632780"},{"listId":10632783,"catId":2263238,"dirPageId":"services_1582148118880_5","distance":"","chatUrl":"","chatType":"","header":"CARDIAC ARREST/MEDICAL","summary":"","detail":"CARDIAC ARREST / MEDICAL\u003cbr\u003e\nALL LEVELS\u003cbr\u003e\nDESIGNATION OF CONDITION\u003cbr\u003e\nSigns and symptoms include an unresponsive, apneic patient with absent carotid pulses. If patient does not meet Termination of Resuscitation guidelines, continue with the following protocol.\u003cbr\u003e\n\u003cbr\u003e\nEMPHASIS ON PATIENT CARE\u003cbr\u003e\n6.\tUninterrupted Effective CPR using pit crew approach if possible, defibrillation and ACLS intervention as rapidly as possible\u003cbr\u003e\na.\tApply AED and follow prompts \u003cbr\u003e\n\u003cbr\u003e\n7.\tPatients in cardiac arrest should be managed in the field; all cardiac patients not experiencing arrest require minimal scene times and expeditious transport.\u003cbr\u003e\n\u003cbr\u003e\n8.\tIf the patient has a return of spontaneous circulation (ROSC) (sustained palpable pulses and measurable blood pressure), the patient should be transported to the closest appropriate facility.\u003cbr\u003e\n\u003cbr\u003e\n9.\tAll patients in cardiac arrest require immediate CPR, airway management and ventilations with oxygen (apply NRB mask at high flow for first two cycles of CPR). CPR and initial defibrillation take precedence over advanced airway management unless the airway cannot be managed with BLS maneuvers.\u003cbr\u003e\n\u003cbr\u003e\n10.\tDefibrillation of the VF/ VT patient should occur as soon as possible\u003cbr\u003e\nAEMT\u003cbr\u003e\n11.\tEstablish IV/IO access and flush to confirm patency.\u003cbr\u003e\n\u003cbr\u003e\n12.\tAdminister Epinephrine, IV/IO. See Special Notes below for approved dosing.\u003cbr\u003e\n\u003cbr\u003e\n\u003cbr\u003e\n\u003cbr\u003e\n\u003cbr\u003e\n\u003cbr\u003e\n\u003cbr\u003e\n\u003cbr\u003e\nCARDIAC ARREST\t/ MEDICAL\u003cbr\u003e\nPARAMEDIC\u003cbr\u003e\n4.\tNotes on intubation and oxygenation:\u003cbr\u003e\na.\tApply NRB mask with high flow oxygen during first two cycles of CPR.\u003cbr\u003e\nb.\tThen place nasal cannula to patient at 15 liters/minute prior to and during intubation attempts. It may be necessary to place bilateral NPAs.\u003cbr\u003e\n5.\tAny patient who presents in cardiac arrest assumed to be from a medical cause will have CPR performed on scene for a minimum of 30 minutes. If ROSC is achieved at any time during resuscitation efforts the patient will be transported to the closest most appropriate hospital.\u003cbr\u003e\n\u003cbr\u003e\n6.\tIf after 30 Minutes the patient remains in Cardiac arrest, Medical Control should be contacted.\u003cbr\u003e\n\u003cbr\u003e\n7.\tThe following information should be collected if available, and relayed to medical control for further instructions:\u003cbr\u003e\n \u003cbr\u003e\nThe Patient’s:\u003cbr\u003e\n•\tAge\u003cbr\u003e\n•\tPMH\u003cbr\u003e\n•\tGeneral health (skin turgor, muscle tone, mobility of patient prior to arrest)\u003cbr\u003e\n•\tLast time patient was seen alive\u003cbr\u003e\n•\tWitnessed arrest\u003cbr\u003e\n•\tBystander CPR\u003cbr\u003e\n•\tPupillary Response\u003cbr\u003e\n•\tTemperature\u003cbr\u003e\n•\tInitial and current cardiac Rhythm\u003cbr\u003e\n•\tCurrent ETCO2 reading\u003cbr\u003e\n•\tFamily wishes of resuscitation efforts\u003cbr\u003e\n \u003cbr\u003e\n\u003cbr\u003e\n7.\tResuscitation efforts may be terminated in the field if the patient meets the requirements for TOR guidelines, or with medical direction approval and if ALL of the following criteria are met:\u003cbr\u003e\na.\tCPR and ALS interventions have been attempted for at least 30 minutes,\u003cbr\u003e\nb.\tNo ROSC at any time during resuscitation efforts\u003cbr\u003e\nc.\tThe arrest is not the result of hypothermia\u003cbr\u003e\nd.\tETCO2 \u003c15\u003cbr\u003e\ne.\tAbsence of Palpable Carotid/Femoral pulses\u003cbr\u003e\nf.\tFamily is accepting of the decision to terminate efforts for resuscitation.\u003cbr\u003e\ng.\tThe patient does not have an LVAD in place\u003cbr\u003e\n\u003cbr\u003e\n8.\tAll patients with a LVAD (left ventricular assist device) in cardiac arrest should be transported unless there is an active DNR.\u003cbr\u003e\n9.\tThe patient may be transported prior to reaching the 30-minute benchmark if responders feel that staying on scene does not promote good patient care or exposes them to harm or there are other mitigating circumstances. \u003cbr\u003e\n\u003cbr\u003e\nUse of NALOXONE (Narcan) in cardiac arrest. Do not routinely administer NALOXONE. Use only when strong suspicion of opioid overdose exists such as prescription opioids, paraphernalia, or history suggestive of opioid use/abuse. NALOXONE has been shown to be ineffective once there is cardiac standstill.\u003cbr\u003e\n\u003cbr\u003e\nEPINEPHRINE DOSING IN CARDIAC ARREST SPECIAL NOTES\u003cbr\u003e\nShortages of EPINEPHRINE 1:10,000 are necessitating alternate dosing for cardiac arrest patients. EPINEPHRINE administration in cardiac arrest patients is associated with improved ROSC rates but no dosing regimen has been shown to be superior in terms of ultimate survival. The following dosing regimens are acceptable in cardiac arrest patients when EPINEPHRINE 1:10,000 is unavailable or rationed. See DILUTION TECHNIQUE at the end of this section to create 1:10,000 doses.\u003cbr\u003e\n\u003cbr\u003e\n1.\tAHA recommended dosing if EPINEPHRINE available: 1 mg. IV/IO q 3-5 minutes. No limitation on number of doses given.\u003cbr\u003e\n2.\tEPINEPHRINE 1 mg. q 5-10 minutes IV/IO. No limitation on number of doses given.\u003cbr\u003e\n3.\tEPINEPHRINE 1 mg. IV/IO followed by infusion.\u003cbr\u003e\na.\tInfusion: Mix 3 mg. (3 vials of 1 mg. 1:1,000) into a 1,000 cc bag of crystalloid solution and run so that bag is infusing throughout the 30 minute resuscitation.\u003cbr\u003e\n4.\tEPINEPHRINE infusion only.\u003cbr\u003e\n\u003cbr\u003e\nEPINEPHRINE DILUTION TECHNIQUE TO ACHIEVE 1:10,000 FOR BOLUS (EMT-I, P)\u003cbr\u003e\n1.\tUse a 10 cc Flush Syringe.\u003cbr\u003e\n2.\tSquirt out 1 cc.\u003cbr\u003e\n3.\tDraw up 1 cc of EPINEPRHINE 1:1,000 into the syringe. Mix.\u003cbr\u003e\n4.\tThis renders a 1 mg dose of 1:10,000 which can be given as a bolus.\u003cbr\u003e\n5.\tIf Flush Syringe not available use 10 cc syringe and draw out 9 cc’s of NS from a bag. Then draw up the EPINEPHRINE.","adBanner":{"ad_banner_enable":0,"banner":"","redirect_url":""},"mapThirdParty":"0","MapThirdParty":"0","reviewRating":1,"attributesForList":[],"directoryInfo":[],"formIdentifier":"default","formType":"custom","widgetInfo":{"widget_enable":0,"widget_label":"Widget Label","widget_code":""},"listOwner":"","claimStatus":null,"pwaUrl":"https://www.lcfdapp.com/services_1582148118880_5/2114007/2263238/10632783"},{"listId":10632782,"catId":2263238,"dirPageId":"services_1582148118880_5","distance":"","chatUrl":"","chatType":"","header":"CHEST PAIN","summary":"","detail":"CHEST PAIN\u003cbr\u003e\nALL LEVELS\u003cbr\u003e\nDESIGNATION OF CONDITION\u003cbr\u003e\nSigns and symptoms may include any, none, or all of the following: sub-sternal chest pain, chest pressure, shortness of breath, diaphoresis, nausea, and vomiting, syncope, radiating pain to the jaw and arms, a feeling of impending doom, and history of cardiac problems.\u003cbr\u003e\n\u003cbr\u003e\n\u003cbr\u003e\nEMPHASIS ON PATIENT CARE\u003cbr\u003e\nAirway management, adequate perfusion and oxygenation, pain control and early transportation to an appropriate facility\u003cbr\u003e\n\u003cbr\u003e\n1.\tPrimary Management - Assess ABC’s and manage as indicated.\u003cbr\u003e\na.\tObtain baseline set of vital signs (HR, B/P, SpO2, BGL, etc.)\u003cbr\u003e\nb.\tCardiac monitoring, oxygen administration if SpO2 \u003c94%, and obtain a 12-lead ECG if possible.\u003cbr\u003e\n2.\tTransport the patient to an appropriate medical facility. Consider AEMT/ALS intercept.\u003cbr\u003e\n3.\tSecondary Management - History, physical exam, vital signs\u003cbr\u003e\na.\tObtain history including Thrombolytic Therapy Checklist.\u003cbr\u003e\nb.\tIf suspected AMI chest pain, administer ASPIRIN [325 mg PO]. Chewed.\u003cbr\u003e\nc.\tIf applicable, contact online medical control for administration of the patient’s own NITROGLYCERIN every 3-5 minutes up to 3 times if\u003cbr\u003e\nB/P \u003e100mmHg systolic, HR \u003e60 and \u003c 140 and relief of symptom occurs.\u003cbr\u003e\nAEMT\u003cbr\u003e\n1.\tIn route, initiate IV/IO access; consider second IV if patient condition indicates the need and time permits.\u003cbr\u003e\nA.\tIf systolic B/P \u003c90mmHg, infuse at rate to attempt to raise BP.\u003cbr\u003e\nB.\tIf 2 unsuccessful IV attempts in patients who may be candidates for thrombolytics,\u003cbr\u003e\ncontact medical control for further attempts. \u003cbr\u003e\nCHEST PAIN\t\u003cbr\u003e\nAEMT\u003cbr\u003e\n2.\tIf patient does not have nitroglycerin and is still in pain, BP \u003e 100mmHg systolic, and HR \u003e 60bpm, and \u003c140bpm, consider NITROGLYCERIN [0.4 mg SL] every 3-5 minutes up to 3 times if IV is established. If no relief after initial NTG discontinue further doses.\u003cbr\u003e\n\u003cbr\u003e\n3.\tDO NOT GIVE NITROGLYCERIN IF: patient has taken Erectile Dysfunction medications in the past 48 hours (i.e. Viagra, Cialis, Levitra, etc.).\u003cbr\u003e\n\u003cbr\u003e\n4.\tIf transport is prolonged, contact medical control for additional Nitroglycerin administration.\u003cbr\u003e\n\u003cbr\u003e\n5.\tAdminister narcotic (Fentanyl) analgesics according to PAIN MANAGEMENT GUIDELINES.\u003cbr\u003e\n\u003cbr\u003e\nPARAMEDIC\u003cbr\u003e\n1.\t12 lead ECG should be completed within the first 3-5 minutes of patient contact on chest pain patients.\u003cbr\u003e\n\u003cbr\u003e\n2.\tInterpret the 12-lead ECG and transmit per transmission protocol:\u003cbr\u003e\na.\tIf STEMI initiate transport to appropriate STEMI center and perform additional treatments in-route.\u003cbr\u003e\nb.\tHold NTG if EKG shows inferior MI pattern and consider Right sided EKG\u003cbr\u003e\n\u003cbr\u003e\n3.\tSerial 12 leads should be completed on all chest pain patients. A minimum of two 12 leads should be performed on all chest pain patients but should not delay transport to definitive care.\u003cbr\u003e\n\u003cbr\u003e\n4.\tFor pain management, Follow Pain Management Guidelines.\u003cbr\u003e\n\u003cbr\u003e\n5.\tSee appropriate guidelines for Ventricular Tachycardia (VT) with a Pulse and/or Wide Complex Tachycardias.","adBanner":{"ad_banner_enable":0,"banner":"","redirect_url":""},"mapThirdParty":"0","MapThirdParty":"0","reviewRating":1,"attributesForList":[],"directoryInfo":[],"formIdentifier":"default","formType":"custom","widgetInfo":{"widget_enable":0,"widget_label":"Widget Label","widget_code":""},"listOwner":"","claimStatus":null,"pwaUrl":"https://www.lcfdapp.com/services_1582148118880_5/2114007/2263238/10632782"},{"listId":10632785,"catId":2263238,"dirPageId":"services_1582148118880_5","distance":"","chatUrl":"","chatType":"","header":"PEA","summary":"","detail":"PULSELESS ELECTRICAL ACTIVITY / PEA\u003cbr\u003e\nALL LEVELS\u003cbr\u003e\nDESIGNATION OF CONDITION\u003cbr\u003e\nPatient presenting in cardiac arrest with organized electrical activity noted on the cardiac monitor, but without corresponding pulses palpated. Determination and correction of underlying cause of the PEA may improve outcome. Specific problems which may cause PEA:\u003cbr\u003e\n\u003cbr\u003e\nEMPHASIS ON PATIENT CARE\u003cbr\u003e\n Effective CPR, management of associated conditions\u003cbr\u003e\n\u003cbr\u003e\n1.\tPrimary Management - Assess ABC’s and manage as indicated.\u003cbr\u003e\n2.\tInitiate high quality team CPR\u003cbr\u003e\n3.\tInsert advanced airway (follow Airway Management Procedure Guidelines).\u003cbr\u003e\n4.\tApply defibrillation electrodes and begin cardiac monitoring.\u003cbr\u003e\n5.\tTransport the patient if ROSC, consider ALS intercept.\u003cbr\u003e\n6.\tSecondary Management - History, physical exam, vital signs\u003cbr\u003e\nAEMT\u003cbr\u003e\n1.\tConsider placement of Supraglottic airway (LMA preferred), allowing no disruption of chest compressions during placement.\u003cbr\u003e\n2.\tInitiate one or two large bore IV/ IO of an isotonic solution with 20mL/kg fluid bolus. Repeat as indicated.\u003cbr\u003e\n3.\tAdminister EPINEPHRINE See s\\SPECIAL NOTE below.\u003cbr\u003e\n\u003cbr\u003e\nPARAMEDIC\u003cbr\u003e\n1.\tConsider placement of SGA, ETT Airway. DO NOT STOP CPR TO INTUBATE\u003cbr\u003e\n2.\tConsider SODIUM BICARBONATE [1 mEq/kg] IV/IO, if tricyclic antidepressant overdose or metabolic acidosis is suspected.\u003cbr\u003e\n3.\tTreat for any suspected reversible causes (identified in the designation of condition) within applicable scope of practice.\u003cbr\u003e\n4.\tContact medical direction for possible TOR order if no ROSC and the patient remains in asystole after 30 minutes of ALS resuscitative efforts. See Termination of Resuscitative Efforts Treatment Guidelines\u003cbr\u003e\n5.\tIn cases of PEA with end tidal CO2 levels in the 20-30 range consider “Pseudo-PEA” and select Push Dose Epinephrine in place of Epinephrine 1:10,000 boluses. 1 mg. 1:1,000 Epinephrine in 100 ml. and draw up 10 ml. Administer 0.5-1.0 ml. per minute as needed.\u003cbr\u003e\nHypovolemia\t\t\tToxins\u003cbr\u003e\nHypoxia\t\t\t\tTamponade (cardiac)\u003cbr\u003e\nHydrogen Ion (acidosis)\tTension pneumothorax\u003cbr\u003e\nHyper-/hypokalemia\t\tThrombosis (coronary and pulmonary) \u003cbr\u003e\nHypothermia.\u003cbr\u003e\n\u003cbr\u003e\nEPINEPHRINE DOSING IN CARDIAC ARREST SPECIAL NOTES\u003cbr\u003e\nShortages of EPINEPHRINE 1:10,000 are necessitating alternate dosing for cardiac arrest patients. EPINEPHRINE administration in cardiac arrest patients is associated with improved ROSC rates but no dosing regimen has been shown to be superior in terms of ultimate survival. The following dosing regimens are acceptable in cardiac arrest patients when EPINEPHRINE 1:10,000 is unavailable or rationed. ET dosing is no longer an approved route.\u003cbr\u003e\n\u003cbr\u003e\n1.\tAHA recommended dosing if EPINEPHRINE available: 1 mg. IV/IO q 3-5 minutes. No limitation on number of doses given.\u003cbr\u003e\n2.\tEPINEPHRINE 1 mg. q 5-10 minutes IV/IO. No limitation on number of doses given.\u003cbr\u003e\n3.\tEPINEPHRINE 1 mg. IV/IO followed by infusion.\u003cbr\u003e\na.\tInfusion: Mix 3 mg. (3 vials of 1 mg. 1:1,000) into a 1,000 cc bag of crystalloid solution and run so that bag is infusing throughout the 30 minute resuscitation.\u003cbr\u003e\n4.\tEPINEPHRINE infusion only.","adBanner":{"ad_banner_enable":0,"banner":"","redirect_url":""},"mapThirdParty":"0","MapThirdParty":"0","reviewRating":1,"attributesForList":[],"directoryInfo":[],"formIdentifier":"default","formType":"custom","widgetInfo":{"widget_enable":0,"widget_label":"Widget Label","widget_code":""},"listOwner":"","claimStatus":null,"pwaUrl":"https://www.lcfdapp.com/services_1582148118880_5/2114007/2263238/10632785"},{"listId":10632789,"catId":2263238,"dirPageId":"services_1582148118880_5","distance":"","chatUrl":"","chatType":"","header":"PIT CREW CPR","summary":"","detail":"TEAM CPR GUIDELINES (pit crew CPR)\u003cbr\u003e\nALL LEVELS\u003cbr\u003e\nDESIGNATION OF CONDITION\u003cbr\u003e\nCPR performed during cardiac arrest should be a coordinated effort to maximize patient outcomes and minimize compression interruptions.\u003cbr\u003e\n\u003cbr\u003e\nEMPHASIS ON PATIENT CARE\u003cbr\u003e\nTeam approach improves CPR quality, reduces CPR pauses, and reduces confusion between providers. Metronome or similar device can help with CPR pace (≥100 compressions/minute) if available. Do not interrupt chest compressions to place airway device. If cardiac arrest due to primary respiratory cause initiate mask ventilation as soon as possible.\u003cbr\u003e\n\u003cbr\u003e\n1.\tFIRST provider to patient:\u003cbr\u003e\na.\tBegin continuous compressions hard (≥2 in.) and fast (100/min.-120/min)\u003cbr\u003e\nb.\tRecheck pulse every 2 minutes (\u003c5 seconds for each check)\u003cbr\u003e\nc.\tPlace AED or cardiac monitor at first pulse check if still alone\u003cbr\u003e\nd.\tCall for/update additional responders\u003cbr\u003e\n2.\tSECOND Provider to patient:\u003cbr\u003e\na.\tPlace AED or monitor if not already in place\u003cbr\u003e\nb.\tAppropriate guideline based on rhythm\u003cbr\u003e\nc.\tPlace high flow oxygen via non-rebreather for first TWO cycles of high CPR\u003cbr\u003e\nd.\tTake over compressions at next pulse check\u003cbr\u003e\ne.\tAlternate compressions with first provider every two minutes until more help arrives\u003cbr\u003e\ni.\tIf no additional help place airway and apply ventilator after 4 minutes of CPR\u003cbr\u003e\n3.\tTHIRD Provider to patient:\u003cbr\u003e\na.\tAssumes or assigns \"Code Command\"\u003cbr\u003e\n4.\tCODE COMMAND:\u003cbr\u003e\na.\tEnforces appropriate guideline based on rhythm\u003cbr\u003e\nb.\tEnsures compressors are rotating at 2 minute intervals \u003cbr\u003e\nc.\tEnsures CPR pauses are MINIMIZED\u003cbr\u003e\nd.\tApply ventilator if available\u003cbr\u003e\ne.\tAssigns additional tasks according to appropriate guideline\u003cbr\u003e\nf.\tTracks/records code progress\u003cbr\u003e\ng.\tResponsible for updating family and calling MCEP\u003cbr\u003e\n5.\tADDITIONAL providers to arrive:\u003cbr\u003e\na.\tPlace IV or IO\u003cbr\u003e\nb.\tMedications per appropriate guideline\u003cbr\u003e\nc.\tAirway management w/ BVM, SGA/EGA, or ETT if paramedic. Consider use of pediatric BVM for ventilation of adult patients to avoid over ventilation.\u003cbr\u003e\nd.\tAdditional tasks as assigned","adBanner":{"ad_banner_enable":0,"banner":"","redirect_url":""},"mapThirdParty":"0","MapThirdParty":"0","reviewRating":1,"attributesForList":[],"directoryInfo":[],"formIdentifier":"default","formType":"custom","widgetInfo":{"widget_enable":null,"widget_label":"Widget Label","widget_code":null},"listOwner":"","claimStatus":null,"pwaUrl":"https://www.lcfdapp.com/services_1582148118880_5/2114007/2263238/10632789"},{"listId":10632786,"catId":2263238,"dirPageId":"services_1582148118880_5","distance":"","chatUrl":"","chatType":"","header":"SHOCK/CARDIOGENIC","summary":"","detail":"SHOCK– CARDIOGENIC\u003cbr\u003e\nALL LEVELS\u003cbr\u003e\nDesignation of Condition\u003cbr\u003e\nThe patient will present with signs and symptoms of hypoperfusion usually accompanied by hypotension (BP \u003c90 mmHg), shortness of breath often secondary to pulmonary edema (wet noisy respirations/crackles and, if severe, possibly pink frothy sputum), and other indicators of\u003cbr\u003e\nhypoperfusion such as confusion, decreasing LOC and diaphoresis. These signs and symptoms are usually observed in the setting of AMI and require expeditious transport.\u003cbr\u003e\n\u003cbr\u003e\n1.\tOxygen at a flow rate sufficient to maintain SpO2 \u003e94%.\u003cbr\u003e\n2.\tMonitor ETCO2\u003cbr\u003e\n3.\tAllow the patient to seek a position of comfort (fowlers recommended if possible).\u003cbr\u003e\n4.\tManage airway and provide BVM ventilatory assistance as necessary.\u003cbr\u003e\nAEMT\u003cbr\u003e\n1.\tEstablish Vascular access IV/IO of Normal Saline or LR\u003cbr\u003e\n2.\tCheck lung sounds, If lung sounds are clear Administer a 5-10 ml/kg NS/LR bolus\u003cbr\u003e\n\u003cbr\u003e\nPARAMEDIC\u003cbr\u003e\n1.\tMonitor cardiac rhythm.\u003cbr\u003e\n2.\tMonitor Vital Signs closely\u003cbr\u003e\n3.\tObtain 12 lead ECG.\u003cbr\u003e\n4.\tIf no improvement with fluid bolus, or if fluids are contraindicated because of pulmonary edema administer a vasopressor.\u003cbr\u003e\na.\tNOREPINEPHRINE (Levophed) drip @ 2-10 mcg/min IV infusion\u003cbr\u003e\ni.\tSolution: 1 mg in 250 ml NS (4 mcg/ml); 40 ml/hr (~3 mcg/min); dose may be titrated to patient response\u003cbr\u003e\nb.\tEPINEPHRINE drip @ 2-10 ug/min\u003cbr\u003e\ni.\tEPINEPHRINE drip (1 mg in 250 ml of NS = 4 mcg/ml) and start at 2 mcg/min. Titrate drip up to 10 ug/min or until an acceptable perfusing heart rate and BP are achieved. A second IV line is desired, however, do not withhold medication if second IV is unobtainable.\u003cbr\u003e\nc.\tEPI PUSH-DOSE Inject 1 mg. (1 ml) of 1:1,000 Epinephrine into 100 ml. bag NS. \u003cbr\u003e\ni.\tPush 0.5-1 ml (5-10 mcg) q 1 min prn hypotension","adBanner":{"ad_banner_enable":0,"banner":"","redirect_url":""},"mapThirdParty":"0","MapThirdParty":"0","reviewRating":1,"attributesForList":[],"directoryInfo":[],"formIdentifier":"default","formType":"custom","widgetInfo":{"widget_enable":0,"widget_label":"Widget Label","widget_code":""},"listOwner":"","claimStatus":null,"pwaUrl":"https://www.lcfdapp.com/services_1582148118880_5/2114007/2263238/10632786"},{"listId":10632787,"catId":2263238,"dirPageId":"services_1582148118880_5","distance":"","chatUrl":"","chatType":"","header":"TACHYCARDIA/NARROW","summary":"","detail":"TACHYCARDIA / NARROW\u003cbr\u003e\nALL LEVELS\u003cbr\u003e\nDESIGNATION OF CONDITION\u003cbr\u003e\nHeart rate over 150 bpm with supraventricular focus. Patients with narrow complex tachycardia are often familiar with their problem and symptoms. Asymptomatic patients (unusual) may be comfortable with SVT and treatment is up to the discretion of the paramedic. Patients presenting with hemodynamic instability, evidence of poor perfusion, chest pain, AMS, SOB, cyanosis or evidence of CHF are considered unstable and invasive intervention should be implemented per this protocol.\u003cbr\u003e\n\u003cbr\u003e\nEMPHASIS ON PATIENT CARE\u003cbr\u003e\nMaintain adequate perfusion, adequate oxygenation, and ALS intervention\u003cbr\u003e\n\u003cbr\u003e\n1.\tPrimary Management - Assess ABC’s and manage as indicated.\u003cbr\u003e\n2.\tPerform the modified Valsalva maneuver\u003cbr\u003e\na.\tHave patient blow into 10 ml syringe for 15 seconds attempting to move plunger while sitting up, after 15 seconds have patient stop blowing and place patient supine and elevate legs to 45 degrees for 15 seconds.\u003cbr\u003e\n3.\tInitiate transport to appropriate medical facility. Consider ALS intercept.\u003cbr\u003e\n4.\tSecondary Management - History, physical exam, vital signs\u003cbr\u003e\na.\tIf suspected AMI, administer ASPIRIN [325 mg] PO. Chewed then swallowed\u003cbr\u003e\nAEMT\u003cbr\u003e\n5.\tIn-route, initiate IV/IO of an isotonic solution, titrate to maintain end organ perfusion.\u003cbr\u003e\n\u003cbr\u003e\nPARAMEDIC\u003cbr\u003e\n\u003cbr\u003e\n6.\tIf patient is hemodynamically unstable, provide the following care:\u003cbr\u003e\n\u003cbr\u003e\na.\tTrendelenberg position and fluid bolus.\u003cbr\u003e\nb.\tAdminister ADENOSINE [6 mg] rapid IV (see note below for humeral site) Draw Adenosine into 20 ml. syringe. Fill with NS. Bolus IV. \u003cbr\u003e\nc.\tIf rhythm remains after 1-2 minutes repeat adenosine 12 mg IVP times 2.\u003cbr\u003e\nd.\tIO is not recommended Route for Adenosine Administration unless humeral placement\u003cbr\u003e\n7.\tIf patient’s condition deteriorates with hemodynamic instability, perform synchronized cardioversion immediately. If the patient is conscious, consider sedation using:\u003cbr\u003e\na.\tMIDAZOLAM [2-4 mg] IV/IO/IN/IM, prior to cardioversion, if appropriate to patient condition.\u003cbr\u003e\nb.\tCardiovert at 50-100 joules. If unsuccessful escalate joules:\u003cbr\u003e\ni.\tMaximum energy is 200 joules. Any cardioversion is uncomfortable and higher joules can be painful.\u003cbr\u003e\n8.\tIf patient’s cardiac rhythm changes treat per applicable guidelines.\u003cbr\u003e\n9.\tConsider and treat potential underlying causes, e.g., hypoxemia, dehydration, fever.\u003cbr\u003e\n10.\tSigns and Symptoms of Hemodynamic instability:\u003cbr\u003e\nHypotension\u003cbr\u003e\nAcutely Altered Mental Status \u003cbr\u003e\n Signs of Shock\u003cbr\u003e\nSigns of Acute heart Failure Ischemic Chest Pain\u003cbr\u003e\n13.\tIf ventricular rate is \u003e150/min, prepare for immediate cardioversion. May give brief trial of medications based on specific arrhythmias. Immediate cardioversion is not indicated if heart rate is \u003c150.\u003cbr\u003e\n14.\tAdenosine should be administered rapidly though a proximal (e.g. antecubital) vein site. May be give IO from humeral IO site.","adBanner":{"ad_banner_enable":0,"banner":"","redirect_url":""},"mapThirdParty":"0","MapThirdParty":"0","reviewRating":1,"attributesForList":[],"directoryInfo":[],"formIdentifier":"default","formType":"custom","widgetInfo":{"widget_enable":0,"widget_label":"Widget Label","widget_code":""},"listOwner":"","claimStatus":null,"pwaUrl":"https://www.lcfdapp.com/services_1582148118880_5/2114007/2263238/10632787"},{"listId":10632788,"catId":2263238,"dirPageId":"services_1582148118880_5","distance":"","chatUrl":"","chatType":"","header":"TACHYCARDIA/WIDE","summary":"","detail":"TACHYCARDIA / WIDE\u003cbr\u003e\n\u003cbr\u003e\nALL LEVELS\u003cbr\u003e\nDESIGNATION OF CONDITION\u003cbr\u003e\nPatient who presents with sustained Ventricular Tachycardia or Wide Complex Tachycardia with pulse present. These patients may be conscious or unconscious. “Unstable” indicates symptoms such as chest pain, dyspnea, hypotension, CHF, ischemia, or unconsciousness. “Stable” patients with sustained ventricular tachycardia will not have these symptoms, but must be monitored carefully for onset of such symptoms.\u003cbr\u003e\n\u003cbr\u003e\nEMPHASIS ON PATIENT CARE\u003cbr\u003e\nMaintain adequate perfusion, adequate oxygenation, ALS intervention\u003cbr\u003e\n1.\tPrimary Management - Assess ABC’s and manage as indicated.\u003cbr\u003e\n2.\tTurn the defibrillator/monitor on and apply defibrillation electrodes.\u003cbr\u003e\n3.\tInitiate transport to an appropriate medical facility. Consider ALS intercept.\u003cbr\u003e\n4.\tSecondary Management - History, physical exam, vital signs\u003cbr\u003e\na.\tIf suspected AMI, administer ASPIRIN [325 mg PO]. Chewed then swallowed\u003cbr\u003e\n5.\tIf the patient becomes unconscious and pulseless, follow Medical Cardiac Arrest Treatment Guidelines.\u003cbr\u003e\nAEMT\u003cbr\u003e\n1.\tIn-route, initiate an IV of an isotonic solution at a TKO rate.\u003cbr\u003e\n2.\tCaution: Use of Nitroglycerin or Narcotic Pain Relievers for patients with VT rhythm may precipitate cardiac arrest\u003cbr\u003e\nPARAMEDIC\u003cbr\u003e\n1.\tIf stable wide complex tachycardia or if patient has mild symptoms of decompensation:\u003cbr\u003e\na.\tIf supraventricular tachycardia with aberrancy is suspected, consider ADENOSINE [6 mg] rapid IV/IO push (1-2 seconds) followed by a 20mL flush of Normal Saline.\u003cbr\u003e\nb.\tIf Ventricular Tachycardia consider AMIODARONE [150mg] over 10 min.\u003cbr\u003e\nc.\tMay also consider MAGNESIUM SULFATE [2 gm. diluted in 10ml over 2 min.] slow IV/IO particularly when Torsades suspected. \u003cbr\u003e\n2.\tIf hemodynamically unstable wide complex tachycardia:\u003cbr\u003e\na.\tPrepare for immediate Synchronized Cardioversion, MIDAZOLAM [2-4 mg] IV/IO/IN/IM, prior to cardioversion, if appropriate to patient condition. \u003cbr\u003e\nb.\tCardiovert at 200 joules, maximum energy.\u003cbr\u003e\nc.\tIf patient’s cardiac rhythm changes, treat per applicable guidelines.","adBanner":{"ad_banner_enable":0,"banner":"","redirect_url":""},"mapThirdParty":"0","MapThirdParty":"0","reviewRating":1,"attributesForList":[],"directoryInfo":[],"formIdentifier":"default","formType":"custom","widgetInfo":{"widget_enable":null,"widget_label":"Widget Label","widget_code":null},"listOwner":"","claimStatus":null,"pwaUrl":"https://www.lcfdapp.com/services_1582148118880_5/2114007/2263238/10632788"},{"listId":10632790,"catId":2263238,"dirPageId":"services_1582148118880_5","distance":"","chatUrl":"","chatType":"","header":"V-FIB V-TACH/PULSELESS","summary":"","detail":"V-FIB \u0026 V-TACH / NO PULSE\u003cbr\u003e\nALL LEVELS\u003cbr\u003e\nDESIGNATION OF CONDITION\u003cbr\u003e\nSigns and symptoms include an unresponsive patient with absent carotid pulses, and an ECG showing ventricular fibrillation or pulseless ventricular tachycardia.\u003cbr\u003e\nEMPHASIS ON PATIENT CARE\u003cbr\u003e\n1.\tPrimary Management - Assess ABC’s and manage as indicated.\u003cbr\u003e\n2.\tTurn the AED on and apply defibrillation electrodes following prompts.\u003cbr\u003e\n3.\tEffective pit crew CPR, defibrillation and ACLS intervention as rapidly as possible\u003cbr\u003e\n4.\tPlace NPA/OPA and provide high flow oxygen\u003cbr\u003e\nAEMT\u003cbr\u003e\n1.\tEstablish IV/IO and provide fluid bolus\u003cbr\u003e\n2.\tInitiate Epinephrine administration IV/IO immediately upon establishing vascular access.\u003cbr\u003e\na.\tEpinephrine: IV/IO dosage of Epinephrine: See SPECIAL NOTE below\u003cbr\u003e\n3.\tConsider placement of Supraglottic airway (LMA preferred), allowing no disruption of chest compressions during placement.\u003cbr\u003e\nPARAMEDIC\u003cbr\u003e\n1.\tConsider placement of Supraglottic airway or ETT in accordance with the corresponding Airway Placement Procedural Guidelines, allowing no disruption of chest compressions during placement\u003cbr\u003e\n2.\tAfter second and on third defibrillation a second set of pads should be applied to chest to change defibrillation vector. Leave initial set attached for potential DSD on 4th attempt.\u003cbr\u003e\n3.\tIn persistent or recurrent VF/VT without a pulse: initiate appropriate anti-arrhythmic therapy after 3rd defibrillation:\u003cbr\u003e\n4.\tAdminister Anti-arrhythmic\u003cbr\u003e\na.\tAMIODARONE [300mg] IV/IO followed by 10 mL saline flush. May repeat once at 150mg. If rhythm converts with Amiodarone drip at 1 mg./min.\u003cbr\u003e\nb.\tLIDOCAINE 1.5 mg./kg. IV/IO. Repeat at 0.75 mg./kg. to maximum of 3 mg./kg. (three doses). If rhythm converts with Lidocaine start drip. Mix 1 gram Lidocaine into 250 ml. (4 mg./ml.). Start drip at 2 mg./min. if loading dose \u003c2 mg./kg. 3 mg./min. if loading dose 2 mg./kg. and 4 mg./min. if loading dose 3 mg./kg.\u003cbr\u003e\nc.\tMAGNESIUM SULFATE 2 gm IV/IO (over 1-2 minutes) if continued VF/pulseless VT only if suspected pulseless Torsades De Pointes\u003cbr\u003e\n5.\tSODIUM BICARBONATE 1 mEq/kg IV/IO. Use only in cases of suspected Tricyclic Antidepressant OD. May repeat in 5 minutes to a total of 2 doses. \u003cbr\u003e\n6.\tCALCIUM GLUCONATE 10 ml 10% IV. Use only in cases of suspected hyperkalemia i.e. ESRD, dialysis. May repeat in 5 minutes to a total of 2 doses. DO NOT GIVE IN SAME IV LINE AS Sodium Bicarbonate.\u003cbr\u003e\n7.\tDouble sequential defibrillation is acceptable procedure.\u003cbr\u003e\n8.\tAll patients in V-FIB or Pulseless V-Tach at any time will be resuscitated on scene for a minimum of 30 minutes.\u003cbr\u003e\n9.\tIf sustained V-FIB or Pulseless V-Tach after 30 minutes contact Medical control for consult and TOR. See Terminal of Resuscitation Guidelines.\u003cbr\u003e\n\u003cbr\u003e\nEPINEPHRINE DOSING IN CARDIAC ARREST SPECIAL NOTES\u003cbr\u003e\nShortages of EPINEPHRINE 1:10,000 are necessitating alternate dosing for cardiac arrest patients. EPINEPHRINE administration in cardiac arrest patients is associated with improved ROSC rates but no dosing regimen has been shown to be superior in terms of ultimate survival. The following dosing regimens are acceptable in cardiac arrest patients when EPINEPHRINE 1:10,000 is unavailable or rationed. ET dosing is no longer an approved route.\u003cbr\u003e\n\u003cbr\u003e\n1.\tAHA recommended dosing if EPINEPHRINE available: 1 mg. IV/IO q 3-5 minutes. No limitation on number of doses given.\u003cbr\u003e\n2.\tEPINEPHRINE 1 mg. q 5-10 minutes IV/IO. No limitation on number of doses given.\u003cbr\u003e\n3.\tEPINEPHRINE 1 mg. IV/IO followed by infusion.\u003cbr\u003e\na.\tInfusion: Mix 3 mg. (3 vials of 1 mg. 1:1,000) into a 1,000 cc bag of crystalloid solution and run so that bag is infusing throughout the 30 minute resuscitation.\u003cbr\u003e\n4.\tEPINEPHRINE infusion only.","adBanner":{"ad_banner_enable":0,"banner":"","redirect_url":""},"mapThirdParty":"0","MapThirdParty":"0","reviewRating":1,"attributesForList":[],"directoryInfo":[],"formIdentifier":"default","formType":"custom","widgetInfo":{"widget_enable":0,"widget_label":"Widget Label","widget_code":""},"listOwner":"","claimStatus":null,"pwaUrl":"https://www.lcfdapp.com/services_1582148118880_5/2114007/2263238/10632790"}],"data":false,"categoryData":{"catName":"CARDIAC GUIDELINES","catId":2263238,"catIcon":""},"parentCategoryData":{"catId":2114007,"catName":"GUIDELINES"}}}},"page":"/[...slug]","query":{"slug":["2263238"]},"buildId":"1234567890","isFallback":false,"dynamicIds":[1204],"customServer":true,"gip":true,"scriptLoader":[]}