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Bradycardic Disrhythmias
(Symptomatic)
- Sinus Bradycardia
- 2nd Degree Type I HB
- 2nd Degree Type II HB
- 3rd Degree HB
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Bradycardic Disrhythmias
Symptomatic & STABLE
- BSI
- Scene Safety
- ABC's
- O2 PRN
- 12 Leak EKG
- IV Access
- 0.5 mg Atropine: every 3 - 5 minutes, up to max of 3.0 mg
- Consider:
- Epi drip - 2 - 10 mcg/min OR
- Dopamine drip - 2 - 10 mcg/kg/min
- Consider pacing
- Expert Consultation
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Bradycardic Disrhythmias
Symptomatic & UNSTABLE
- BSI
- Scene Safety
- ABC's
- O2 PRN: NRB or BVM
- IV Access
- 0.5 mg Atropine IV (1 dose only)
- Place pacing pads on the patient
- Pace: Turn up energy (60 - 70) until you reach capture, select rate, make sure that you have mechanical & electrical capture.
- Consider:
- Dopamine drip: 2 - 10 mcg/kg/min
- OR
- Epinephrine drip: 2 - 10 mcg/min
- Expert Consultation
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Tachycardic Disrhythmias
Narrow & Regular
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SVT & A-Flutter
STABLE
- BSI
- Scene Safety
- Assess ABC's
- O2 via NRB or BVM
- 12 Lead EKG
- IV/IO Access
- Vagal Maneuvers
- 6 mg Adenosine: rapid push w/flush
- Reassess - BP
- 12 mg Adenosine: rapid push w/flush
- 0.25 mg/kg Cardizem: IV over 2 minutes
- 0.35 mg/kg Cardizem: IV over 2 minutes (after 3-5 min)
- Consider a Beta Blocker (Sotolol 1.5 mg/kg over 5 minutes - avoid if prolonged QT)
- Expert Consultation
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SVT & A-Flutter
UNSTABLE
- BSI
- Scene Safety
- Assess the ABC's
- O2 via NRB or BVM
- IV/IO access
- Consider sedation
- Synchronized Cardioversion: 50 - 100 Joules, repeated incrementally
- Expert Consultation
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Tachycardic Dysrhymias
Narrow & Irregular
A-Fib
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A-Fib
STABLE
- BSI
- Scene Safety
- ABC's
- O2 PRN
- 12 Lead EKG
- IV/IO Access
- 0.25 mg/kg Cardizem: over 2 minutes
- 0.35 mg/kg Cardizem: over 2 minutes (3-5 minutes after first dose)
- Consider Synchronized Cardioversion (120J - 200J)
- Expert Consultation
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A-Fib
UNSTABLE
- BSI
- Scene Safety
- ABC's
- O2 PRN: NRB or BVM
- Cardioversion: 120 - 200 Joules
- Expert Consultation
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Tachycardic Disrhythmias
Wide Complex Tachycardia
V-Tach with a pulse
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V-Tach with a pulse
STABLE
- BSI
- Scene Safety
- ABC's
- O2 PRN
- 12 Lead EKG
- IV/IO Access
- 6 mg Adenosine: rapid IV w/flush
- 12 mg Adenosine: rapid IV w/flush
- 150 mg Amiodarone: over 10 minutes, diluted in 250 mL D5W wide open)
- Expert Consultation
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V-Tach with a pulse
UNSTABLE
- BSI
- Scene Safety
- ABC's
- O2 PRN
- IV access
- Cardioversion: 100 Joules
- Repeat incrementally to 200 Joules or manufacturer's specifications
- Consider: Amiodarone (150 mg over 10 min)
- OR Procainamide (20-50 mg/min) or
- Expert Consultation
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V-Fib / Pulseless V-Tach
- CPR: 2 min/30:2/At least 2 inches/Full recoil
- *Attach monitor and pads
- *OPA & Ventilate - with BVM @ 15 lpm
- *Rhythm / Pulse Check
- SHOCK - 200J monophasic / 120J biphasic
- CPR: 2 min/30:2/At least 2 inches/Full recoil
- *Obtain IV/IO access
- *Prepare 1.0 mg Epinephrine 1:10,000
- *Rhythm / Pulse Check
- SHOCK - 300J monophasic / 150J biphasic
- CPR: 2 min/30:2/At least 2 inches/Full recoil
- *Administer 1.0 mg Epi (every 3 - 5 min)
- *Consider an advanced airway with ETC02
- *Prepare 300 mg Amiodarone
- *Rhythm / Pulse Check
- SHOCK - 300J monophasic / 150J biphasic
- CPR: 2 min/30:2/At least 2 inches/Full recoil
- *Administer 300 mg Amiodarone IV/IO bolus (2nd bolus of 150 mg may be given in 3 - 5 min)
- *Continue administering Epi every 3 - 5 min
- *Consider reversible causes (H's & T's)
- *After 20 minutes consider Expert Consultation
- **Lidocaine may be used if Amiodarone is unavailable:
- 1.0 - 1.5 mg/kg IV/IO - first dose
- 0.5 - 0.75 mg/kg IV/IO - second dose (5-10 min after 1st dose)
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Asystole / PEA
- CPR: 2 min/30:2/At least 2 inches/Full recoil
- *Attach monitor & pads
- *OPA & Ventilate with BVM @ 15 lpm
- *Rhythm / Pulse Check
- CPR: 2 min/30:2/At least 2 inches/Full recoil
- *Obtain IV/IO access
- *Prepare 1.0 mg Epinephrine (1:10,000)
- *Rhythm / Pulse Check
- CPR: switch compressors, monitor quality
- *Administer 1.0 mg Epinephrine
- *Readminister Epi every 3 - 5 min
- *Consider an advanced airway with ETC02
- *Consider reversible causes (H's & T's)
- *After 20 min, consider Expert Consultation
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Return of Spontanious Circulation
ROSC
- *Assess ABC
- *Maintain Sp02 94% - 99%
- *Advanced airway & ETC02
- *IV/IO access - 2 large bore
- *Fluid bolus - 1 - 2 liters
- *Vasopressor infusion:
- Dopamine 5 - 10 mcg/kg/min
- Epinephrine 0.1 - 0.5 mc/kg/min
- *12 Lead EKG
- *Consider reversible causes:
- Hypovolemia
- Hypoxia
- Hydrogen ion (acidosis)
- Hypo/Hyperthermia
- Hypo/Hyperkalemia
- Tension Pneumothorax
- Tamponade - cardiac
- Toxins
- Thrombus - P.E.
- Thrombus - Coronary
- Spontaneous Movement / Commands?
If no: consider Induced Hypothermia
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H's & T's
H
- Hypovolemia - Fluid infusion
- *Narrow-complex, rapid rate
- *Flat neck veins
- Hypoxia - Oxygen/Ventilation/Intubation
- *Slow HR
- *Cyanosis
- *Airway problems
- Hydrogen Ion (acidosis) - Ventilation /
- Sodium Bicarb (1 mEq/kg IV/IO)
- *Small QRS complexes
- *Hx of Diabetes
- *Renal failure
- Hyperkalemia - Calcium Chloride / Sodium Bicarb / Glucose & Insulin / Albuterol
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*Tall, peaked T waves / small P waves - *QRS widens
- *Hx of renal failure
- *Hx of Diabetes / recent dialysis
- HypoKalemia - Magnesium Sulfate
- *Flattened T waves / Prominent U waves
- *QRS widens / QT prolongs
- *Wide-complex Tachy
- *Diuretic usage
- *Abnormal loss of potassium
- Hypothermia - Warm / Treat for Shock
- *J or Osborne waves
- *Hx of exposure to cold
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H's & T's
T
- Tension Pneumo - Needle Decompression
- *Narrow complex & Slow Rate
- *Hx of pneumo
- *No pulse felt during CPR
- *JVD and/or Tracheal deviation
- *Unequal breath sounds
- *Dificult to ventilate
- Tamaponade (Cardiac) - Pericardiocentesis
- *Narrow complex & Rapid Rate
- *Hx of tamponade
- *JVD
- *No pulse felt during CPR
- Toxins - Intubation / Specific antidotes
- *Bradycardias / Pupils
- *Various effects
- Thrombus (Lungs - PE) - Fibrinolytics / Surgery
- *Narrow complex & Rapid Rate
- *Hx of thrombus, PE, or DVT
- Thrombus (Heart - MI)
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*Abnormal 12-lead - *Good pulse during CPR
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