Asystole / PEA FREDERICKSBURG EMS ACLS

FREDERICKSBURG EMS
ACLS
1
Asystole / PEA
(ADULT)




Check for Responsiveness
Check for Breathing
Check for Carotid Pulse
Initiate CPR
o As soon as a mechanical external compression device (i.e. Lucas 2)
(Procedure 12) becomes available the device can be employed as the
primary means of providing chest compressions
 Placement of AED and follow prompts as instructed
 NPA/OPA 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 (Procedure 4)
DO NOT INTERRRUPT CPR TO PLACE THE KING AIRWAY
o ETCO2 monitoring (Procedure 7)
INTERMEDIATE
 Secure airway as required by ET Intubation and confirm/secure tube
placement
 Obtain IV access – initiate fluid bolus
o IO access (immediately if available or after unable to obtain IV
access in 2 attempts)
PARAMEDIC
 Cardiac monitor
 Confirm asystole in more than one lead
 Epinephrine 1mg (1:10,000) (Rx: 13) rapid IV/IO push every 3-5
minutes
“When in doubt, do something in favor of your patient.” Jay Cloud
FREDERICKSBURG EMS
ACLS
1
Asystole / PEA
(ADULT)
 Consider TCP (Procedure 11) if a bradycardic rhythm is present
 If no rhythm change, rapid rise in ETCO2, or ROSC after 25 minutes of
aggressive CPR and ACLS therapies, consider ceasing resuscitation
efforts
 Consider Sodium Bicarbonate 1 mEq/kg (Rx: 30) IV/IO if the patient is
believed to have one of the following conditions:
o
o
o
o
Chronic Renal Failure
Hyperkalemia
Tricyclic Anti-Depressant Overdose
Suspected case of Excited Delirium
ALERTS:
Identify and treat the following contributing factors (6 H and 5 T’s):
Causes
Hypovolemia
Hypoxia
Hyperkalemia
Hypoglycemia
Hypothermia
Hydrogen Ion (acidosis)
Tension Pneumothorax
Tamponade – Cardiac
Thrombosis
Trauma
Toxins
Treatment
Normal Saline Boluses
Ventilate with 100% Oxygen
Calcium Chloride and Sodium Bicarbonate.
After administration of either medication
ensure that the IV line is completely flushed
Dextrose
Remove clothing with gradual re-warming.
Handle patient gently
Normal Saline Boluses. Sodium Bicarbonate
Needle Thoracostomy
Normal Saline Boluses and rapid transport.
In-hospital pericardiocentesis
In-hospital fibrinolysis
Provide treatment per trauma protocols
Refer to Overdose (Medical 17)
Continued
“When in doubt, do something in favor of your patient.” Jay Cloud
FREDERICKSBURG EMS
ACLS
2
Bradycardia
(ADULT)
 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 ECG, Transmit (Procedure 8)
INTERMEDIATE
 Initiate IV Normal Saline, KVO or Saline Lock
o Administer 250 ml boluses until systolic BP > 90 mmHg
o Total amount of IVF should not exceed 1000 ml
PARAMEDIC
 Cardiac monitor
 If patient has adequate perfusion – observe/monitor
 If patient has poor perfusion caused by the bradycardia with a low
degree heart block
o Consider Atropine 0.5mg (Rx: 5) IV, may repeat every 3-5 min, to a
max dose of 3mg
 If patient has poor perfusion caused by the bradycardia with a high
degree heart block
o Prepare for TCP (Procedure 11)
o Consider Versed 2-5 mg (Rx: 36) as soon as appropriate
o Consider Dopamine (5 -20 mcg/kg/min) (Rx: 12) while waiting for
TCP or if TCP not effective
Continued
“When in doubt, do something in favor of your patient.” Jay Cloud
FREDERICKSBURG EMS
ACLS
2
Bradycardia
(ADULT)
ALERTS:
 Signs/symptoms of poor perfusion primarily include hypotension
which also may include altered mental status, ongoing chest pain, or
other signs of shock
 If suspected MI with bradycardia and adequate perfusion refer to
Chest Pain (Acute Coronary Syndrome) (Medical 4)
 Consider causes (6H’s, 5T’s)
 If time permits, consider sedation with Versed 2.5-5mg IV/IN prior to
TCP
 Treatment of choice for high degree blocks (second degree type II and
third degree) is TCP (consider atropine 0.5mg IV while awaiting TCP)
“When in doubt, do something in favor of your patient.” Jay Cloud
FREDERICKSBURG EMS
ACLS
3
Narrow Complex Tachycardia PSVT / A-Fib / A-Flutter
(ADULT)
 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 ECG, Transmit (Procedure 8)
INTERMEDIATE
 Initiate IV Normal Saline, KVO or Saline Lock
o Administer 250 ml boluses until systolic BP > 90 mmHg
o Total amount of IVF should not exceed 1000 ml
PARAMEDIC
 Cardiac monitor
Unstable patient:
If time and patient condition permit, the patient should be sedated prior to the
application of electrical therapy
 Sedation
o Versed 2-5mg IV/IN (Rx: 36)
o Maximum Dose of 10mg
 Synchronized cardioversion (200 J, 300 J, & 360 J) (Procedure 10) if:
o GCS ≤14
o Appears hemodynamically unstable
o Reports active chest pain
o Exhibits significant shortness of breath
Continued
“When in doubt, do something in favor of your patient.” Jay Cloud
FREDERICKSBURG EMS
ACLS
3
Narrow Complex Tachycardia PSVT / A-Fib / A-Flutter
(ADULT)
Stable patient:
 If 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
 In the absence of A-Fib, A-Flutter or multifocal atrial tachycardia
Adenosine 6 mg (Rx: 2) rapid IV push (over 1-3 sec.), followed with 20cc NS
flush (regular & monomorphic)
Withhold Adenosine if the patient has a history of Wolff Parkinson White
Syndrome (WPW) or if delta waves are present
 Repeat Adenosine 12mg rapid IV push after 1-2 minutes, followed with
20cc NS flush
 If the Adenosine fails to slow the rate administer Cardizem IV (Rx: 9)
o Initial dose 0.25 mg/kg over 2 minutes
o Second Dose 0.35 mg/kg over 2 min q 10-15 min
Symptomatic - A-Fib, A-Flutter or multifocal atrial tachycardia:
 Cardizem IV
o Initial dose 0.25 mg/kg over 2 minutes
o Second Dose 0.35 mg/kg over 2 min q 10-15 min
 If at any time during medication administration or re-evaluation the patient
begins to deteriorate or exhibit signs of rate related cardiovascular
compromise, revert to immediate Synchronized Cardioversion in
management of the unstable patient presenting with narrow tachycardia
 If at any time after the administration of Diltiazem (Cardizem) the patient
becomes profoundly hypotensive (SBP ≤80), administer Calcium Chloride 12 gram (Rx: 8) slow IVP
Continued
“When in doubt, do something in favor of your patient.” Jay Cloud
FREDERICKSBURG EMS
ACLS
3
Narrow Complex Tachycardia PSVT / A-Fib / A-Flutter
ALERTS:
(ADULT)
 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
 If possible, establish IV access before cardioversion and give Versed 2-5 mg
slow IV push, titrated to effect, if the patient is conscious. May repeat every
5 minutes as needed for sedation. Do not delay cardioversion if the patient
is extremely unstable
 If available, obtain a 12-Lead ECG 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
Dipyridamole 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
 Patients with an atrial fibrillation duration of >48 hours are at increased risk
for cardioembolic events, although shorter durations of atrial fibrillation do
not exclude the possibility of such events. Electric or pharmacologic
cardioversion (conversion to normal sinus rhythm) should not be attempted
in these patients unless the patient is unstable
 For recurrent VT with a pulse, consider a slow infusion of 150 mg Cordarone
at 1 mg/minute IV. If Cordarone has not been given prior to conversion of
recurrent VT, administer a rapid infusion of Cordarone 150 mg IV over 10
minutes before starting the slow infusion at 1 mg/minute. Cordarone is
contraindicated if SBP <90 mm Hg
 To perform synchronized cardioversion, provide an initial shock at the
recommended energy dose. If there is no response to the first shock,
increase the dose in a stepwise fashion (e.g., 100 J, 200 J, 300 J, 360 J).
Providers should use the device-specific doses for synchronized
cardioversion, as recommended by the monitor manufacturer. Following are
the AHA recommendations
Continued
“When in doubt, do something in favor of your patient.” Jay Cloud
FREDERICKSBURG EMS
ACLS
3
Narrow Complex Tachycardia PSVT / A-Fib / A-Flutter
(ADULT)
o Atrial Fibrillation – Recommended initial biphasic energy dose
for cardioversion is 120 to 200 J. If the initial shock fails, increase
the dose in a stepwise fashion. Cardioversion with monophasic
waveforms should begin at 200 J and increase in stepwise
fashion if not successful
o SVT and Atrial Flutter – Recommended initial biphasic energy
dose for cardioversion of 50 J to 100 J is often sufficient. If the
initial 50 J shock fails, increase the dose in a stepwise fashion
o Monomorphic VT (with pulse) – Recommended initial biphasic
energy dose for cardioversion is 100 J. If there is no response to
the first shock, increase the dose in a stepwise fashion
o Polymorphic VT (such as torsades de pointes) – Treat the
rhythm as VF and
deliver high-energy unsynchronized shocks
(i.e., defibrillation doses)
 If cardioversion is needed and it is impossible to synchronize a shock (e.g.,
the patient’s rhythm is irregular), use high-energy unsynchronized shocks
 Check pulse and rhythm after each synchronized shock. Ensure monitor
remains in ““SYNC” mode for subsequent shocks
“When in doubt, do something in favor of your patient.” Jay Cloud
FREDERICKSBURG EMS
ACLS
Wide Complex Tachycardia –
4
V-Tach With A Pulse
(ADULT)
 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 ECG, Transmit (Procedure 8)
INTERMEDIATE
 Initiate IV Normal Saline, KVO or Saline Lock
o Administer 250 ml boluses until systolic BP > 90 mmHg
o Total amount of IVF should not exceed 1000 ml
PARAMEDIC
 Cardiac monitor
Unstable patient:
If time and patient condition permit, the patient should be sedated prior to the
application of electrical therapy
 Sedation
o Versed 2-5mg IV/IN (Rx: 36)
o Maximum Dose of 10mg
 Synchronized cardioversion (200 J, 300 J, & 360 J)(Procedure 10) if:
o GCS ≤14
o Appears hemodynamically unstable
o Reports active chest pain
o Exhibits significant shortness of breath
Continued
“When in doubt, do something in favor of your patient.” Jay Cloud
FREDERICKSBURG EMS
ACLS
Wide Complex Tachycardia –
4
V-Tach With A Pulse
(ADULT)
 If the rhythm converts to a non-lethal, narrow complex rhythm without the
presence of a high degree heart block then administer Cordarone
“Amiodarone” or Lidocaine:
o Cordarone 150 mg (Rx: 10) slow infusion
 Mix 150 mg in 100 ml of Normal Saline. Utilize a 10 gtts set
and infuse at 100 gtts/minute over 10 minutes
 May repeat once in 10 minutes
OR if Cordarone is not available
o Lidocaine 1 mg/kg (Rx: 22) IV/IO
 Follow by 0.5 mg/kg every 5 minutes
 Maximum total dose 3 mg/kg
Stable patient:
 If the rhythm is regular with monomorphic appearance administer
Adenosine:
o Adenosine 6mg (Rx: 2) rapid IV push (over 1-3 sec.), followed with
20cc NS flush (regular & monomorphic)
 Repeat Adenosine 12mg rapid IV push after 1-2 minutes,
followed with 20cc NS flush
 If the rhythm appears irregular or the Adenosine fails to convert the
tachycardia administer Cordarone. May repeat one time in 10 minutes:
o Cordarone 150 mg (Rx: 10) slow infusion
 Mix 150 mg in 100 ml of Normal Saline. Utilize a 10 gtts set
and infuse at 100 gtts/minute over 10 minutes
 May repeat once in 10 minutes
OR if Cordarone is not available
o Lidocaine 1 mg/kg (Rx: 22) IV/IO
 Follow by 0.5 mg/kg every 5 minutes
 Maximum total dose 3 mg/kg
 Consider continuous infusion of 2-4 mg/min (Procedure 17)
may be started following ROSC
Continued
“When in doubt, do something in favor of your patient.” Jay Cloud
FREDERICKSBURG EMS
ACLS
Wide Complex Tachycardia –
V-Tach With A Pulse
(ADULT)
 If the rhythm is polymorphic V-tach. (Torsades de Pointes) or
hypomagnesaemia is suspected administer Magnesium Sulfate:
o Magnesium Sulfate 2 gm (Rx: 23) slow IV/IO Infusion
 Mix 2 gm in 100 ml of Normal Saline. Utilize a 10 gtts set and
infuse at 50 gtts/min over 10 minutes
 If 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 (Procedure 10)
“When in doubt, do something in favor of your patient.” Jay Cloud
4
FREDERICKSBURG EMS
Wide Complex Tachycardia –
V-Tach With A Pulse
(ADULT)
Blank
“When in doubt, do something in favor of your patient.” Jay Cloud
ACLS
4
FREDERICKSBURG EMS
ACLS
5
V-Fib / Pulseless V-Tach
(ADULT)




Check for responsiveness
Check for breathing
Check for carotid pulse
Initiate CPR
o As soon as a mechanical external compression device (i.e. Lucas 2)
(Procedure 12) becomes available the device can be employed as the
primary means of providing chest compressions
 Placement of AED and follow prompts as instructed
 NPA/OPA 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 (Procedure 4)
DO NOT INTERRRUPT CPR TO PLACE THE KING AIRWAY
o ETCO2 monitoring (Procedure 7)
 12 Lead ECG, transmit if possible (Procedure 8)
INTERMEDIATE
 Secure airway as required by ET Intubation and confirm/secure tube
placement
 Obtain IV access – initiate fluid bolus
o IO access (immediately if available or after unable to obtain IV
access in 2 attempts)
Continued
“When in doubt, do something in favor of your patient.” Jay Cloud
FREDERICKSBURG EMS
ACLS
5
V-Fib / Pulseless V-Tach
(ADULT)
PARAMEDIC
 Cardiac monitor
o Confirm V-Fib / V-Tach
o Shock 360 J
o Repeat defibrillation for recurrent VF/VT after every 2 minute
cycle of quality CPR and after each drug administration is
circulated for at least 60 seconds:
 Epinephrine 1:10,000 1 mg (Rx: 13) IV/IO
o Administer Epinephrine every 3-5 minutes for the duration of the
arrest
 Administer Cordarone (PRIMARY) or Lidocaine repeat medication in 5
minutes for recurrent VF/VT:
o Cordarone (Rx: 10)
 Initial dose: 300 mg IV/IO
 Second dose: 150 mg IV/IO in 5 minutes
 Third dose: 150 mg IV/IO in 5 minutes
o Lidocaine (Rx: 22)
 Initial dose: 1 mg/kg IV/IO
 Additional dose: 1 mg/kg IV/IO, maximum total dose
3 mg/kg
 Consider Magnesium Sulfate for suspected polymorphic V-tach
(Torsades de Pointes) or hypomagnesaemia:
o Magnesium Sulfate 2 gm (Rx: 23) slow IV/IO
o Mix 2 gm in 10 ml of Normal Saline and administer over 2
minutes
 Consider Sodium Bicarbonate 1 mEq/kg (Rx: 30) IV/IO if the patient is
believed to have one of the following conditions:
o Chronic Renal Failure
o Hyperkalemia
o Tricyclic Anti-Depressant Overdose
o Suspected case of Excited Delirium
Continued
“When in doubt, do something in favor of your patient.” Jay Cloud
FREDERICKSBURG EMS
ACLS
5
V-Fib / Pulseless V-Tach
(ADULT)
 Adult patients remaining in refractory VFib / VTach after a total of four
(4) defibrillation attempts shall have Double Sequential Defibrillation
(Procedure 9) performed at 360 joules when/if a second defibrillator or
an AED becomes available
ALERTS:
• When VF/pulseless VT cardiac arrest is associated with torsades de pointes,
administer an IV/IO bolus of Magnesium Sulfate at a dose of 1 to 2 g diluted
in 6 mL Normal Saline
• The most critical interventions during the first minutes of VF or pulseless VT
are immediate CPR, with minimal interruption in chest compressions, and
defibrillation
• After an advanced airway is placed, rescuers no longer deliver “cycles” of
CPR. 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, CPR 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. Immediately after
shock delivery, resume CPR (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.
Periodic pauses in CPR 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
• “Effective” chest compressions are essential for providing blood flow
during CPR. 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 2 inches (5 cm). Allow the chest to
Continued
“When in doubt, do something in favor of your patient.” Jay Cloud
FREDERICKSBURG EMS
ACLS
5
V-Fib / Pulseless V-Tach
(ADULT)
•
•
•
•
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
CPR quality, optimize chest compressions, and detect ROSC during chest
compressions or when rhythm check reveals an organized rhythm. If ETCO2
<10 mm Hg, consider trying to improve CPR quality by optimizing chest
compression parameters. If ETCO2 abruptly increases to a normal value (35
to 40 mm Hg), it is reasonable to consider that this is an indicator of ROSC
If SVT ≥170, perform immediate synchronized cardioversion in addition to
other indicated procedures.
After conversion from shock refractory VF/VT to a perfusing rhythm,
consider a slow infusion of AMIODARONE at 1 mg/minute IV
If patient converts from shock refractory VF/VT and Amiodarone has NOT
been given during the cardiac arrest, administer a rapid infusion of
Amiodarone 150 mg IV over 10 minutes before starting the slow infusion at
1 mg/minute
“When in doubt, do something in favor of your patient.” Jay Cloud
FREDERICKSBURG EMS
ACLS
6
Return of Spontaneous
Circulation (ROSC)
(ADULT)
 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 (Procedure 4)
 ETCO2 monitoring (Procedure 7)
 Ensure that a blood glucose reading is obtained, refer to Diabetic
Emergencies (Medical 7)
 12 Lead ECG, Transmit (Procedure 8)
 Consider Air Medical (APP 1) for transport to a heart center
INTERMEDIATE
 Initiate IV Normal Saline,
o Administer 250 ml boluses to maintain or restore perfusion
o Total amount of IVF should not exceed 2000 ml
 Advanced Airway procedures as needed
PARAMEDIC
 Cardiac monitor
 If the patient was resuscitated following an episode of VF/VT and is
without profound bradycardia or high-grade heart block (2nd degree
Type II or 3rd degree or Idioventricular rhythm) administer
Cordarone Infusion (Procedure 14) or Lidocaine bolus (Procedure
17)
Note: Continue using the anti-arrhythmic medication that was administered
during resuscitation
Continued
“When in doubt, do something in favor of your patient.” Jay Cloud
FREDERICKSBURG EMS
ACLS
6
Return of Spontaneous
Circulation (ROSC)
(ADULT)
 Cordarone 150 mg (Rx: 10) slow infusion
o Mix 150 mg 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 2-4 mg/kg (Rx: 22) IV/IO
o Follow by 0.5 mg/kg every 5 minutes
o Maximum total dose 3 mg/kg
 If bradycardia persists refer to the Bradycardia Protocol (ACLS 2)
 Administer a Dopamine infusion 5-20 mcg/kg/min (Rx: 12) (Procedure 15)
for persistent hypoperfusion
 Administer an Epinephrine infusion (Rx: 13) for heart transplant recipients
or persistent hypoperfusion
o Epinephrine infusion 2-10 mcg/min
“When in doubt, do something in favor of your patient.” Jay Cloud