Cardiac

Cardiac
• 12-Lead ECG acquisition
• Cardiac monitoring
• Coronary artery reperfusion
• Synchronised cardioversion
• Transcutaneous cardiac pacing
• Valsalva manoeuvre
Clinical Practice Procedures – Cardiac
Clinical practice procedures
12-Lead ECG acquisition
Version 1.0 – September 2011
Authorisation to practice
12-Lead ECG acquistion
The 12-lead electrocardiogram (ECG) is used to detect many
conditions affecting the heart, underlying myocardial ischaemia,
dysrrhythmias, drug toxicity and electrolyte imbalances.
Use in the pre-hospital setting is paramount to the diagnosis and
treatment of STEMI, (via the QAS cardiac reperfusion strategy).
Additional information
• The 12-Lead ECG should be acquired as part of an early
secondary assessment of the patient, especially in the
setting of suspected cardiac ischaemia or infarct.
• Electrodes should remain in their original placement
throughout management to facilitate the comparison
of serial 12-Lead ECGs.
Note: Similar complications as with cardiac monitoring,
also ensuring that:
• ECG frequency is set at 0.05 – 40 Hz, and
• paper speed is set at 25 mm/sec
These factors ensure the 12-Lead ECG printout is of
diagnostic quality.[1]
Page 1 of 2
Indications
• To aid in the identification of:
-- myocardial ischaemia or infarct
-- rhythm and conduction disturbance
-- electrolyte imbalance
-- hypertrophy of the heart
-- drug toxicity
Contraindications
• Nil in this setting
Precautions
• Nil in this setting
Procedure
• Explain to the patient what is required, ensure privacy
and obtain consent to place electrodes.
• Position the patient preferably supine or semi-recumbent,
(without arms or legs crossed).
• Attach electrodes to the snap connectors on each wire,
ensuring electrodes are in date and gel is still moist.
• Accurately position the electrodes on the patient: [2]
-- Limb electrodes
-- Limb leads can be placed on the distal location
of the inner wrists and the medial aspect of
the ankles.
-- If required, electrodes may be placed more
proximally along the limbs to reduce electrical
and mechanic artefact.
-- Chest electrodes
-- Refer to table opposite.
Procedure (continued)
PLACEMENT OF ECG CHEST ELECTRODES
Placement
order
Chest
lead
1st
V1
Anatomical position
4th Intercostal space, right of the sternum
2nd
V2
4th Intercostal space, left of the sternum
3rd
V4
5th Intercostal space, on left midclavicular
line
4th
V6
On the left mid-axillary line, level with V5
5th
V3
Midway between V3 and V4
6th
V5
Midway between V4 and V6
Optional *
V4R
5th Intercostal space, on the right
midclavicular line
* For evaluation of right ventricular involvement with inferior
STEMI, consider acquiring a 12-Lead ECG with V4 repositioned
to V4R.[3] If V4R is acquired, the 12-Lead ECG must be annotated
to indicate that V4 is now representing V4R.
• Ask the patient to breathe normally and to remain still,
without talking.
• Commence 12-Lead ECG acquisition as per specific
manufacturer’s instructions.[1]
Angle of
Louis
1 2
3
4
5
6
12-Lead electrode placement
12-Lead ECG acquisition – Page 2 of 2
Clinical practice procedures
Cardiac monitoring
Version 1.0 – September 2011
Authorisation to practice
Cardiac monitoring
Continuous cardiac monitoring records the electrical activity of the
heart as an electrocardiogram (ECG) either on the cardiac monitor
screen or via a paper print out.
Page 1 of 2
Contraindications
• Nil in this setting
Precautions
Be aware of potential artefacts in the ECG from: [1]
Cardiac monitoring is indicated for identification of potentially
lethal dysrrhythmias.
• Detached electrodes due to diaphoresis,
oily skin, or chest hair
ST segment analysis via the monitor screen is non-diagnostic.
• Patient movement, breathing, muscle tremor
or lead movement
Note: The VF/VT alarm should always be turned on.
Indications
Cardiac monitoring is essential in the following
patients’ groups, though not limited to:
• All unconscious patients or collapse patients
(or those who have recently been unconscious)
• Patients complaining of chest pain or dyspnoea
• Poisoned patients
• Patients who are poorly perfused/shocked
or hypoxic, or with abnormal vital signs
• When a medical officer requests the patient
to be monitored
• Patients in cardiac arrest are also to bemonitored
but this is done through the defibrillation pads
in anticipation of a shockable rhythm.
• AC electricity/50 hertz interference
• Broken cable tip, wire or machine malfunction
• Dry electrode conductive gel
Note: If the patient goes into cardiac arrest, any
electrodes impeding the proper application of the
defibrillator pads must be removed.
Procedure
• Explain procedure to patient and ensure privacy
where possible.
• Clean the surface of the skin to ensure monitoring
electrodes will adhere.
• It may also be necessary to:
-- Shave chest hair if necessary.
-- Inspect the monitoring electrode pad to ensure
that the surface is going to adhere and the gel
in the centre of the pad is moist.
RA/R
LA/L
• Attach the leads to the monitoring electrode pads.
• Smooth electrode pads on from one edge.
The leads primarily used in continuous cardiac monitoring
are those referred to as ‘limb leads’, identified as follows: [2]
•
•
•
•
RA = right arm
LA = left arm
RL = right leg
LL = left leg
RL/N
LL/F
The monitoring electrodes for these leads are generally
placed distally on the limbs, but to limit motion artefact
they can be applied as follows: [2]
• RA & LA placed proximally on arms, but not on torso.
Placement of limb lead monitoring electrodes
• RL & LL placed proximally, but not higher than
iliac crests.
Cardiac monitoring – Page 2 of 2
Clinical practice procedures
Coronary artery reperfusion
Version 1.2 – June 2012
Authorisation to practice
Coronary artery reperfusion
Reperfusion therapy consists of fibrinolysis ( pre-hospital or hospital
based ) or primary percutaneous coronary intervention (pPCI).
This CPP outlines the following:
• Requirements for triaging patients with acute ST elevation
myocardial infarction (STEMI) for either pre-hospital
or hospital fibrinolysis or pPCI
• Assessment of patients meeting pre-hospital fibrinolysis
and anticoagulation triage criteria
• Administration of pre-hospital fibrinolysis and anticoagulation
therapy
• Documentation for reporting patients with STEMI
• Audit and quality assurance requirements for patients with STEMI
The choice of reperfusion therapy will depend on a number
of factors, including:
• Time from the onset of symptoms
• Time of assessment and STEMI diagnosis by QAS paramedics
• Availability of pPCI and time to balloon inflation
• Time to hospital fibrinolysis
• Contraindications to pPCI or fibrinolytic therapy
• Consent to pre-hospital fibrinolysis and anticoagulation
The purpose of reperfusion is to restore blood flow through a partially
or fully obstructed coronary artery as early as possible in an attempt to
minimise the extent and duration of myocardial ischaemia.
Page 1 of 12
Indications
Reperfusion is to be considered for all patients
with classic ongoing ischaemic chest pain (atypical
ischaemic chest pain is excluded) and ECG criteria
indicating STEMI, as demonstrated on a 12-Lead ECG.
ECG criteria are:
• Persistent ST-segment elevation of ≥ 1 mm
in two contiguous limb leads AND/OR
ST-segment elevation of ≥ 2 mm in two
contiguous chest leads (V1 – V6 ).
• Normal QRS width (< 0.12 seconds) OR
right bundle branch block (RBBB) identified
on the 12-Lead ECG.
Increased scrutiny and threshold must be applied
to patients < 35 years due to the higher likelihood of
STEMI mimics in this age group such as pericarditis.
Paramedics should exercise extreme caution and
demonstrate a low threshold for waiting to gain
a second opinion at the receiving emergency
department. If doubt exists regarding the diagnosis
of STEMI, the QAS paramedic is not to administer
reperfusion therapy.
Contraindications
Pre-hospital fibrinolysis is contraindicated in the
following situations:
• Ongoing ischaemic chest pain ≥ 6 hours duration
• Patient is ≥ 75 years
• Systolic BP ≥ 180 mmHg (at any stage during
current acute episode.
• Diastolic BP ≥ 110 mmHg (at any stage during
current acute episode)
• GCS < 15
• Known allergy to tenecteplase, enoxaparin/heparin
and/or clopidogrel (as appropriate)
• Left BBB identified on 12-Lead ECG
• Current or history of thrombocytopenia
• Active tuberculosis
• Known structural nervous system disease,
in particular a malignant intracranial neoplasm
(primary or metastatic)
• Known structural cerebral vascular lesion
(e.g. arteriovenous malformation)
• Prior intracranial haemorrhage
• Ischaemic stroke or TIA within last three months
• Acute myocardial infarction in the setting
of acute trauma
• History of significant closed head or facial trauma
within last three months
• Suspected aortic dissection (including new
neurological symptoms)
• History of major trauma or surgery (including
laser eye surgery) within last six weeks
• Internal bleeding (e.g. gastrointestinal (GI)
or urinary tract bleed) within last four weeks
Contraindications (continued)
• Active bleeding or bleeding disorder
e.g. haemophilia (excluding menses)
• Current use of anticoagulants (e.g. warfarin or
dabigatran (Pradaxa® ) – excludes antiplatelet
medications e.g. aspirin AND/OR clopidogrel)
• Non-compressible vascular punctures
• Active peptic ulcers, as evidenced by recent
malaena within last six weeks, or active ongoing
symptoms prior to current cardiac event
• Prolonged (> 10 minutes) CPR.
• Known pregnancy or delivered within the last
two weeks
• History of serious systemic disease (advanced/
terminal cancer, severe liver or kidney disease)
• Resident of an aged care facility requiring significant
assistance with activities of daily living and/or
GCS < 15
Special notes:
• All STEMI patients who are contraindicated for QAS
pre-hospital fibrinolysis and who are located within
a primary pPCI catchment area are to be referred
for pPCI in accordance with the appropriate local
work instruction (LWI), except residents of an aged
care facility requiring significant assistance with
activities of daily living and/or GCS < 15.
• In patients with cardiogenic shock associated with
STEMI, there is a clear mortality benefit for pPCI over
fibrinolysis.[1] These patients should be discussed
with the receiving hospital in accordance with the LWI.
Complications
• Haemorrhage
Coronary artery reperfusion – Page 2 of 12
Clinical practice procedures
Coronary artery reperfusion
Version 1.2 – June 2012
Procedure
Advice
• All patients who are candidates for both pre-hospital
fibrinolysis or pPCI must be provided with advice
regarding the possible side effects and risks associated
with enoxaparin/heparin, tenecteplase and clopidogrel
(as appropriate) administration.
Consent
Clinicians are to:
• Read the consent section of the ‘Reperfusion checklist’
to the patient.
• If the patient consents to enoxaparin/heparin,
tenecteplase and clopidogrel (as appropriate)
administration, ensure the patient signs the consent
section of the ‘QAS Reperfusion checklist’.
Recording advice, consent and contraindications
Clinicians MUST record the following information on the eARF:
• The advice that was provided to the patient.
• Any known contraindication to enoxaparin/heparin,
tenecteplase and clopidogrel (as appropriate).
• That there were no contraindications present when
enoxaparin/heparin, tenecteplase and clopidogrel
(as appropriate) were adminisered.
• If the patient has consented, or refused enoxaparin/
heparin, tenecteplase and clopidogrel (as appropriate)
administration.
Page 3 of 12
Procedure (continued)
Drug therapy
• Whenever possible, the ACF should be avoided when
gaining IV access as this may be inaccessible during
angiography.
• If a patient is to be transported directly to a pPCI centre
then administer the following medications after aspirin
and other standard cares:
-- heparin in accordance with the QAS DTP and
-- clopidogrel in accordance with the QAS DTP
• If the patient meets the criteria for pre-hospital
fibrinolysis then administer the following medications
after aspirin and standard cares:
-- enoxaparin in accordance with the QAS DTP; and
-- tenecteplase in accordance with the QAS DTP; and
-- clopidogrel in accordance with the QAS DTP.
Transport
• Patients must be regularly reassessed and transported
to the bedside with continuous comprehensive
monitoring. All ongoing treatment must be in
accordance with the appropriate CPG.
• Where possible all thrombolysed patients should be
transported to the closest PCI capable facility, not a
Regional Hospital – as the ability to have a rescue PCI
or timely adjuvant PCI < 24 hours is required to optimise
patient outcomes.
Treatment of dysrrhythmias post fibrinolysis
• It is not uncommon to have dysrrhythmias
post-fibrinolysis.[2] Dysrrhythmias should be managed
according to their relevant CPGs.
Procedure (continued)
pPCI
• LWIs in areas with rapid access to pPCI will direct
patients to this mode of therapy in the first instance.
• This assumes rapid notification and balloon opening
time of less than 90 minutes from activation of the
process. This recognises that pPCI is of benefit if
performed within 60 minutes of potential fibrinolysis
(assuming maximum of 30 minutes to diagnose and
treat from first patient contact).[3]
Procedure (continued)
-- Complete the ‘STEMI reperfusion capture form’
and attach a copy of the 12-Lead ECG, ‘Reperfusion
checklist’ and if appropriate, the Death & Cardiac
Arrest Report Form (DCARF).
-- Forward the documentation package directly to the
Australian Centre for Pre-hospital Research.
Note: All cases are to be reviewed by the Medical Director.
Local work instruction
• LWIs have been developed outlining the local practices
for providing early reperfusion, including, but not
limited to:
-- Contraindications, accessing and availability of pPCI
-- The system for pre-alerting medical facilities
Audit
• All STEMIs are to be reported to the QAS on-call medical
officer (24/7). Cases after 12 midnight can be telephones
through the next morning if there were no complications.
• All cases of suspected Acute Myocardial Infartion
attended by the ICP where a 12-Lead ECG is acquired
(whether treated with fibrinolysis/referred for pPCI or
not) are subject to clinical review through the following
process:
-- Select final assessment as ‘Acute Myocardial
Infarction’ and complete the eARF in accordance
with current standards.
Coronary artery reperfusion – Page 4 of 12
Clinical practice procedures
Coronary artery reperfusion
Version 1.2 – June 2012
Page 5 of 12
Additional information
Fibrinolysis
Patient meets fibrinolysis criteria
pPCI
Patient meets PCI criteria according
to Local Work Instruction
Notify hospital of potential pPCI candidate
Consent given for enoxaparin and tenecleplase
and consent form signed by patient
Consent given for heparin and clopidogrel
and consent form signed by patient
Assuming standard
cares given
Assuming standard
cares given
Enoxaparin 30 mg IV
Tenecteplase
Clopidogrel 300mg
Heparin 5000 units IV
Clopidogrel 600 mg
Enoxaparin 1 mg/kg (up to max 100 mg)
subcut at 15 min post initial dose
Pre-notify as appropriate
Code 2 transport unless altered
vital signs
Code 1 transport to hospital
QAS Coronary Artery Reperfusion Check List
QAS Coronary Artery Reperfusion Check List
(back of form)
PATIENT DETAILS
Patient
Surname
Age
CONSENT
Given
Name
Date
All patients eligible for reperfusion MUST read the following and, if consent is given, the patient
must sign the bottom section of this form.
Incident
Number
INDICATIONS – if the answer is NO or UNSURE to ANY of the
following, do NOT administer any reperfusion drugs
Yes
No
Unsure
Ongoing ischaemic chest pain < 6 hours duration?
12-Lead ECG with persistent ST- elevation ≥ 1mm in at least two
contiguous limb leads AND/OR ≥ 2mm in two contiguous chest leads
V1 – V6?
Normal QRS width (< 0.12 seconds) OR right bundle branch block?
Patient is < 75 years of age?
Systolic BP < 180 (at all times during current acute episode)?
Diastolic BP < 110 (at all times during current acute episode)?
GCS = 15?
CONTRA-INDICATIONS – if the answer is YES or UNSURE to ANY
of the following questions, do NOT administer any reperfusion drugs
Known allergy to Tenecteplase, Enoxaparin / Heparin or Clopidogrel
(as appropriate)?
Left BBB identified on 12-Lead ECG?
Current or history of thrombocytopenia?
Active tuberculosis?
Known structural nervous system disease, in particular a malignant
intracranial neoplasm (primary or metastatic)?
Known structural cerebral vascular lesion (e.g. arteriovenous malformation)?
Prior intracranial haemorrhage?
Ischaemic stroke of TIA within last 3 months?
History of significant closed head / facial trauma within last 3 months?
Suspected aortic dissection (including new neurological symptoms)?
History of major trauma or surgery (including laser eye surgery)
within last 6 weeks?
Internal bleeding (e.g. GI / urinary tract bleed) within last 4 weeks?
Active bleeding or clotting problem (haemophilia etc), excluding menses?
Current use of anticoagulants (e.g. warfarin or dabigatran (Pradaxa® )
– excludes antiplatelet medications e.g. aspirin AND/OR clopidogrel)?
Non-compressible vascular punctures?
Active peptic ulcer, as evidenced by recent melaena within last 6 weeks,
or active ongoing symptoms prior to this cardic event?
Prolonged (>10 minutes) CPR?
Known to be pregnant or delivered within last 2 weeks?
It is likely that you are suffering a heart attack, and your treatment options include:
(choose one of the following as appropriate)
• a drug which reduces new clot formation called ENOXAPARIN; and
a clot dissolving drug called TENECTEPLASE; and
a drug call CLOPIDOGREL which will assist in preventing further clot formation.
(cross out if not applicable)
OR
• a drug which reduces new clot formation called HEPARIN; and
a drug called CLOPIDORGEL which will assist in keeping a stent open should a cardiologist
perform this procedure at hospital.
(cross out if not applicable)
Yes
No
Unsure
The sooner you receive these drugs, the lower the risk from the heart attack – which is why
it is recommended that the treatment is started as soon as possible. These drugs can cause
serious side affects in a small number of patients but the risks attached to this treatment are
much less then the likely benefit. I will now give you more details.
(choose the appropriate paragraph)
Enoxaparin/Tenecteplase/Clopidogrel therapy: Treatment at this stage improved the
chances or survival by 20 – 25% but it can sometimes cause serious bleeding. The biggest risk
is potentially life-threatening stroke which affects about 1 patient in every 100. Other significant
bleeding which is not normally life-threatening can occur in about 4 in 100 patients. Some patients
also have allergic reactions and other side effects that do not usually cause any
major problem.
Heparin/Clopidogrel therapy: Heparin and Clopidogrel can cause life threatening bleeding,
albeit the risk is very small. The administration of these drugs in this setting has been
recommended by national and international cardiology bodies.
Medical Records: I give permission for the QAS to access my hospital record for information
relating to this procedure.
Patient signature
X .......................................................................................................
PARAMEDIC DETAILS
I certified that I have completed and read the QAS Coronary Artery Reperfusion Check List and
the patient has given / has not given consent for the administration of the approved drugs.
(circle appropriate response)
Number
Signature
History of serious systemic disease (e.g. advanced / terminal cancer,
severe liver or kidney disease)?
Resident of an aged care facility requiring significant assistance with activities
of daily living and/or GCS < 15?
Acute myocardial infarction in the setting of acute trauma?
Coronary artery reperfusion – Page 6 of 12
Clinical practice procedures
Coronary artery reperfusion
Version 1.2 – June 2012
Page 7 of 12
-Local Work
Instruction – Far Northern Region
Introduction
This LWI sets out the procedure for triaging patients with acute ST elevation
myocardial infarction (STEMI) for Far Northern QAS region.
All public patients with acute STEMIs are to be transported to the closest
appropriate public hospital. Private patients with acute STEMI are to be
treated in accordance with this LWI, however may be considered for referral
to Cairns Private Hospital (Monday to Friday 0800 – 1600 hrs) following
pre-hospital fibrinolysis.
Procedure
ALL ACUTE STEMIs (cont.)
AFTER HOURS
AND WEEKENDS
Patient
contraindicated
for pre-hospital
fibrinolysis
OUT OF HOSPITAL
CARDIAC ARREST
WITH ROSC
ALL ACUTE STEMIs
MONDAY – FRIDAY
0800 – 1600 hrs
Patient indicated
for pre-hospital
fibrinolysis
AFTER HOURS
AND WEEKENDS
Patient indicated
for pre-hospital
fibrinolysis
MONDAY – FRIDAY
0800 – 1600 hrs
Patient
contraindicated
for pre-hospital
fibrinolysis
Public
& Private
patient
Withhold fibrinolysis and transport
Code 1 to the closest appropriate
public emergency department.
Public
& Private
patient
GCS 15
Administer pre-hospital
fibrinolysis and transport
to the closest appropriate
public emergency
department.
GCS < 15 Transport Code 1 to the
closest appropriate public
emergency department.
Public
patient
Administer pre-hospital fibrinolysis
and transport to the closest
appropriate public emergency
department.
Private
patient
Administer pre-hospital fibrinolysis
and consider referral to the Cairns
Private Hospital Rapid Cardiac
Assessment Centre 1300 264 462.
• Minimise on-scene delays.
• Treat patient in accordance with appropriate CPG.
Public
& Private
patient
Administer pre-hospital fibrinolysis
and transport to the closest
appropriate public emergency
department.
• The ICP is to make all notifications. At Cairns Private Hospital
notification is to be with the Cardiologist (who is then responsible
for all subsequent notifications). At all other hospitals the ICP will
notify the Emergency Department.
Public
patient
Private
patient
Withhold fibrinolysis and transport
Code 1 to the closest appropriate
public emergency department.
Withhold fibrinolysis and consider
referral to the Cairns Private Hospital
Rapid Cardiac Assessment Centre
1300 264 462.
All other cases
Transport to closest appropriate emergency
department.
• For patients accepted for admission at Cairns Private Hospital,
the crew are to take the patient direct to the Coronary Care Unit.
Forall other hospitals the patient will be received into the
Emergency Department.
• The receiving hospital should be notified of all relevant clinical
information as per normal communication procedures.
Local Work Instruction – Northern, Central
& South Western Regions
Introduction
This LWI sets out the procedure for triaging patients with acute ST
elevation myocardial infarction (STEMI) in the Northern, Central &
South Western regions.
Currently primary percutaneous coronary intervention (pPCI) for acute
STEMIs is not available outside of the Brisbane and South Eastern
QAS regions. The QAS continues to negotiate with major public
hospitals and private institutions regarding the availability of pPCI
in the future. Local work instructions will be released when these
services become available.
Procedure
ALL ACUTE STEMIs THAT MEET QAS REPERFUSION CRITERIA
MONDAY – SUNDAY
24 hrs
Administer pre-hospital fibrinolysis
and transport to the closest appropriate
emergency department.
OUT OF HOSPITAL
CARDIAC ARREST
WITH ROSC
GCS 15
Follow criteria above.
GCS < 15
Transport to the closest
appropriate emergency
department.
All other cases
Transport to the closest appropriate
emergency department.
• Minimise delays on-scene.
• Treat patient in accordance with appropriate CPG.
• The receiving hospital should be notified of all relevant clinical
information as per normal communication procedures.
Coronary artery reperfusion – Page 8 of 12
Clinical practice procedures
Coronary artery reperfusion
Version 1.2 – June 2012
Page 9 of 12
Local Work Instruction – North Coast Region
Procedure – Sunshine Coast Area
Introduction
ALL ACUTE STEMIs
This LWI sets out the procedure for triaging patients with acute ST
elevation myocardial infarction (STEMI) in the North Coast region.
Patients indicated
for QAS pre-hospital
fibrinolysis
Administer pre-hospital fibrinolysis and
transport to the closest appropriate
emergency department. Ensure notification
of the Clinical Deployment Supervisor (CDS)
OR Communication Centre Supervisor (CCS) who
will notify the Queensland Coordination Centre
(QCC) to initiate emergent transfer to a Brisbane
PCI centre.
Patients
contraindicated
for QAS pre-hospital
fibrinolysis and not
a resident of a care
facility (ie. requiring
assistance with
activities of daily
cares)
Transport to the closest appropriate emergency
department. Ensure notification of the
Clinical Deployment Supervisor (CDS) OR
Communication Centre Supervisor (CCS) who
will notify the Queensland Coordination Centre
(QCC) to initiate emergent transfer to a Brisbane
PCI centre.
OUT OF HOSPITAL
CARDIAC ARREST
WITH ROSC
GCS 15
Follow criteria above.
GCS < 15
Transport to the closest
appropriate emergency
department. Ensure notification
of the Clinical Deployment
Supervisor (CDS) OR
Communication Centre Supervisor
(CCS) who will notify the
Queensland Coordination Centre
(QCC) to initiate emergent transfer
to a Brisbane PCI centre.
All other cases
Transport to the closest appropriate emergency
department.
Currently primary percutaneous coronary intervention (pPCI) for acute
STEMIs is not available outside of the Brisbane and South Eastern QAS
region. The potential for direct transfer to private hospitals either post
fibrinolysis or for pPCI is currently being negotiated. Until a finalised
work instruction, paramedic should take all patients with an acute
STEMI to the closest public hospital following the listed procedure.
Procedure – Wide Bay and Cooloola Burnett Areas
ALL ACUTE STEMIs THAT MEET QAS REPERFUSION CRITERIA
Patient indicated
for QAS pre-hospital
fibrinolysis
Administer pre-hospital fibrinolysis
and transport to the closest appropriate
emergency department.
OUT OF HOSPITAL
CARDIAC ARREST
WITH ROSC
GCS 15
Follow criteria above.
GCS < 15
Transport to closest
appropriate emergency
department.
All other cases
Transport to the closest appropriate
emergency department.
• Minimise delays on-scene.
• Treat patient in accordance with appropriate CPG.
• The receiving hospital should be notified of all relevant clinical
information as per normal communication procedures.
• Minimise delays on-scene.
• Treat patient in accordance with appropriate CPG.
• The receiving hospital should be notified of all relevant clinical
information as per normal communication procedures.
Local Work Instruction
Brisbane & South Eastern Regions
This LWI sets out the procedure for triaging patients with acute ST
elevation myocardial infarction (STEMI) to primary Percutaneous
Coronary Intervention (pPCI) for the Brisbane & South Eastern QAS
regions.
All public patients with STEMI that meet the QAS reperfusion criteria
are now to be transported to the closest appropriate public hospital
pPCI facility. Private patients with acute STEMIs are to be transported
in accordance with the LWI, but every attempt should be made to refer
the patient to the private hospital of their choice that has 24/7 pPCI
capability.
These include:
• St Andrew’s Hospital (Brisbane);
• Wesley Hospital;
• Mater Private Hospital;
• Greenslopes Private Hospital;
• Holy Spirit Northside Hospital;
• Allamanda Private Hospital;
• Pindara Private Hospital; or
• John Flynn Private Hospital.
The private hospitals have no fixed geographical boundaries, but
time to reperfusion must be a priority. Therefore, the closest private
pPCI capable facility should be chosen where possible. Furthermore,
private patients should be transported to the hospital of their treating
cardiologist where possible.
Procedure
ALL ACUTE STEMIs
MONDAY – SUNDAY
24 hrs
Patient indicated for
pre-hospital fibrinolysis/
pPCI referal
MONDAY – SUNDAY
24 hrs
Patient contraindicated
for QAS pre-hospital
fibrinolysis/pPCI referral
however NOT a resident
of an aged care facility
requiring significant
assistance with daily living
and/or GCS < 15
OUT OF HOSPITAL
CARDIAC ARREST
WITH ROSC
Call appropriate interventional
cardiologist OR hospital emergency
department specialist (dependant
on receiving hospital preference)
to determine reperfusion therapy
of choice.
Call appropriate interventional
cardiologist OR hospital emergency
department specialist (dependant
on receiving hospital preference)
to determine if patient is suitable
for reperfusion therapy.
GCS 15
Follow criteria above.
GCS < 15
Call hospital agreed
contact to activate
PCI lab and transport
Code 1 to pPCI centre.
Coronary artery reperfusion – Page 10 of 12
Clinical practice procedures
Version 1.2 – June 2012
ALL ACUTE STEMIs (cont.)
• Minimise delays on-scene.
• Treat patient in accordance with appropriate CPG.
• The ICP is to make all notifications via the appropriate phone
number (see next page). At the Princess Alexandra Hospital
(PAH) and The Prince Charles Hospital (TPCH) notification is to
be with the interventional cardiologist (who is then responsible
for the subsequent notifications to the emergency department).
At all other hospitals the ICP will make notification to the
emergency department.
• When calling, the following narrative should be used:
“I am an Intensive Care Paramedic with the QAS. We have
a STEMI at [suburb], the estimated transport time to your
hospital is [minutes], is the cath lab available for emergency
Primary PCI?”
• The doctor will advise whether the patient should be
transported immediately for pPCI.
• For patients triaged to pPCI at RBWH, PAH, TPCH & GCH, the
crew will be met at the emergency department and directed to
the catheter laboratory. For all other hospitals the patient will
be received into the emergency department until the catheter
laboratory is available.
Coronary artery reperfusion
Page 11 of 12
EMERGENCY CONTACT NUMBERS (not to be disclosed to patients/public)
PUBLIC HOSPITALS
NOTIFICATION PREFERENCES
PHONE NUMBERS
Princess Alexandra
Interventional Cardiologist
1800 450 468
Royal Brisbane & Women’s
Interventional Cardiologist
3646 3434
The Prince Charles
Interventional Cardiologist
3139 4004
Gold Coast
Interventional Cardiologist
0478 324 861
PRIVATE HOSPITALS
NOTIFICATION PREFERENCE
PHONE NUMBERS
Allamanda
ED Senior Medical Officer
5591 9488 (reperfusion cases only)
Greenslopes
ED Senior Medical Officer
3397 8617
Holy Spirit Northside
ED Senior Medical Officer
3326 3303
John Flynn
ED Senior Medical Officer
5598 9005
Mater Adults
ED Senior Medical Officer
3163 1030
Pindara
ED Senior Medical Officer
5588 9000
St Andrew’s
ED Senior Medical Officer
3832 7344
Wesley
ED Senior Medical Officer
3232 7961
Additional information
• If there is a clinical concern regarding the mangement advice given by the cardiology service, please call the QAS on-call medical officer
immediately to clarify the issue.
Coronary artery reperfusion – Page 12 of 12
Clinical practice procedures
Synchronised cardioversion
Version 1.0 – September 2011
Authorisation to practice
Synchronised cardioversion
Synchronised cardioversion is a method of restoring the normal
rhythm of the heart in patients presenting with a rapid ventricular
rate associated with severely compromised cardiac output
(i.e. GCS is < 15, SBP < 90 mmHg, chest pain, heart failure).
This is achieved using a purpose modified defibrillator capable
of delivering a controlled direct current shock, synchronised
with the R-wave of the ECG. [1]
Synchronised DC shock *
Up to three attempts
Page 1 of 2
Indications
Rapid ventricular rate with severely compromised
cardiac output, in the following cardiac rhythms: [2]
• Pulsatile ventricular tachycardia
• Supra-ventricular tachycardia
• Atrial fibrillation
• Atrial flutter
CAUTION: Cardioversion of SVT including Atrial
Fibrillation and Atrial Flutter is rarely required
in the pre-hospital seting.
Contraindications
• VF/pulseless VT
• Dysrrhythmias where the patient is adequately
perfused
Complications
• Pain and discomfort
• Paradoxical asystole or VF
Procedure
• Explain the procedure to the patient.
• Establish IV access with a sodium chloride 0.9%
running line.
• Ensure resuscitative drugs are available.
• Prepare airway, suction and ventilation equipment.
• Consider sedation as per Sedation CPG.
• Position electrodes and pads as appropriate.
• Ensure that the synchroniser is on.
• Confirm synchronisation is occurring on the R wave.
Change the ECG amplitude on the monitor if necessary.
• Ensure the patient is well oxygenated/ventilated prior
to and after sedation and cardioversion.
• Perform a maximum of three attempted synchronised
cardioversions in accordance with the following joule
sequence:
100 : 150 : 200 joules
• Press and hold the shock button until the synchronised
shock is delivered.
• Assess the patient following each cardioversion attempt.
• Ensure the synchroniser button is pressed again before
each shock is delivered.
Additional information
• If synchronised cardioversion produces VF/Asystole then
immediately treat as per guidelines.
• Always consider other possible causes of the
tachyarrhythmia such as hypovolaemia.
• Should synchronised cardioversion be unsuccessful,
confirm monitoring electrodes and pads are appropriately
placed, ensure the synchroniser is on and the R wave is
being sensed, and consider alternative pad placement.
Note: The requirement for pre-hospital synchronised
cardioversion in the paediatric patient is extremely rare.
Should it be deemed as necessary, consultation with the
on-call QAS Medical Officer is required in all circumstances
with a recommended sequence at 0.5 – 1 joule/kg increasing
to 2 joules/kg if required.
Synchronised cardioversion – Page 2 of 2
Clinical practice procedures
Transcutaneous cardiac pacing
Version 1.0 – September 2011
Authorisation to practice
Transcutaneous cardiac pacing
Transcutaneous cardiac pacing (TCP) works as an artificial
pacemaker, delivering repetitive electrical currents when the
natural pacemaker has become blocked or dysfunctional.
TCP is often beneficial for patients with haemodynamically
unstable bradycardia, especially if the patient is unresponsive
to Atropine. [1]
To have effect, the myocardium must be capable of generating
cardiac output with the muscular contractions.
There are two modes of TCP: [2]
• demand pacing and
• non-demand/asynchronous pacing
Demand pacing is designed to sense the inherent QRS complex,
delivering electrical stimuli only when needed.
Note: Non-demand/asynchronous pacing is not indicated
within QAS.
Page 1 of 2
Indications
Poor perfusion resulting from significant:
• bradycardia
• heart block
Contraindications
TCP is contraindicated within the QAS for:
• asystole/PEA
• overdrive pacing of a ventricular
dysrrhythmia.
Complications
• Pain
• Discomfort
• Anxiety
Procedure
• Explain the procedure to the patient (cutaneous nerve
stimulation and/or skeletal muscle contraction).
• Establish IV access with a sodium chloride 0.9%
running line.
• Ensure adequate oxygenation and ventilation and basic
cares are completed.
• Consider sedation and/or analgesia as per the Sedation
and procedural sedation and Pain management CPG.
• Position electrodes and pads as appropriate.
• Turn pacer on and select appropriate rate
(60 – 80 in adults: rates > 90 may be associated with
worsening myocardial perfusion).
Additional information
Patients in cardiac arrest do not respond to pacing because the
heart is metabolically compromised from inadequate perfusion
and is therefore incapable of effective contractions. There is no
evidence to support routine pacing in cardiac arrest as there is
no improved return of spontaneous circulation or survival.[1]
Capture is defined as depolarisation of the heart by an artificial
electrical stimulus:
• Electrical capture is evidenced by a wide QRS complex
followed by a tall, broad T wave.
• Mechanical capture is myocardial contraction and
is evidenced by a pulse and signs of improved
cardiac output.
The most common reason for failing to achieve capture is
insufficient current.[2] Additional reasons to consider are;
• Increase current incrementally, while observing the
patient and assessing for electrical and mechanical
capture; this may change over time.
• The cause of the natural pacemaker failure and whether
the myocardium is capable of contractions (e.g. Hypoxia
and acidosis impairs cardiac contractility).
• The minimum current effective to obtain reliable
mechanical capture should be used to minimise
heart damage and patient discomfort.
• Adequate sensing of demand pacemaker by ensuring
ECG trace is properly sized
• If the patient becomes intolerant of the procedure,
consider further analgesia/sedation.
• Alternative pad placement (anterior/posterior),
pad adherence and machine and lead check
Transcutaneous cardiac pacing – Page 2 of 2
Clinical practice procedures
Valsalva manoeuvre
Version 1.0 – September 2011
Authorisation to practice
Valsalva manoeuvre
The Valsalva manoeuvre is a first line treatment for the
management of haemodynamically stable, narrow complex SVT.
The Valsalva manoeuvre has four phases: [1]
Phase one: onset of strain brings about an increase in
intrathoracic pressure. This has a compressive effect on the
aorta, resulting in a transient increase in aortic pressure.
Phase two: the end of this transient period, which results
in decreasing aortic pressure and increasing heart rate
Phase three: release of the strain leading to sudden pressure
drop within the aorta with a resultant compensatory increase
in heart rate
Phase four: increased venous return, preload and therefore
cardiac output results in an increased aortic pressure with
compensatory ‘overshoot’ of blood pressure, leading to a
reflex bradycardia
This reflex bradycardia is induced in an effort to break the pattern
of a re-entrant circuit causing the SVT.
A maximum of three attempts at the Valsalva manoeuvre is
recommended.
Page 1 of 2
Indications
• Haemodynamically stable SVT
Contraindications
• Haemodynamic compromise
Complications
• Syncope
• Prolonged hypotensive state
Procedure
• Ensure all standard cares have been performed.
• Explain the procedure to the patient.
• Obtain IV access with a one litre bag of sodium chloride 0.9%
attached.
Additional information
• Evidence suggests the following ‘gold standard’ criteria
for the Valsalva manoeuvre technique: [2]
-- minimum pressure of 40 mmHg
-- optimal duration of 15 seconds
-- supine position as an ideal posture
• Position the patient supine.
• Instruct the patient to blow into a sterile 10 mL syringe
for 15 seconds, aiming to move the plunger
up the barrel of the syringe.
• Print the ECG, indicating the start of the maneouvre.
• After 15 seconds, stop the procedure and retrieve the
syringe from the patient.
• Indicate the end of the manoeuvre on the ECG print out
and continue the print out until the ECG has stabilised.
• Ensure the patient has returned to a haemodynamically
stable SVT presentation prior to repeating the procedure.
Valsalva manoeuvre – Page 2 of 2