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Paramedic Protocol 2018-CHEST PAIN/ACUTE CORONARY SYNDROME-What is the maximum time to obtain a 12-lead ECG?*** Pg 26
Do not delay treatment or transport beyond 2-3 minutes to obtain 12-lead ECG***
Paramedic Protocol 2018-CHEST PAIN/ACUTE CORONARY SYNDROME-If the patient has not taken aspirin? Pg 26
If the patient has not taken aspirin and has no history of aspirin allergy or evidence of recent GI bleeding, administer ASPIRIN (325mg) to chew.
Paramedic Protocol 2018-CHEST PAIN/ACUTE CORONARY SYNDROME-If the patient has taken there own aspirin and still are having Chest Pain, can you give them aspirin?**
Yes (325mg) to chew.
Paramedic Protocol 2018-CHEST PAIN/ACUTE CORONARY SYNDROME-Sublingual nitroglycerin contraindications? Pg 26
- Suspected or known that the patient has taken sildenafil (Viagra) or vardenafil (Levitra) within the previous 24 hours or tadalafil (Cialis) within the previous 48 hours.
- Systolic blood pressure less than 90 mm Hg or heart rate less than 50 beats per minute.
- ST Elevation in lead II,III, or AVF.
Paramedic Protocol 2018-CHEST PAIN/ACUTE CORONARY SYNDROME-What do you administer if unresponsive to nitroglycerin? Pg 26
- Fentanyl 50mcg slow IV/IM/IO/atomized, repeat 50mcg increments to max dose of 200mcg unless contraindicated by B/P or HR
- 5 mg of morphine, slow IV push, to relieve persistent chest pain/discomfort.
- Repeat in 2-3 minutes until pain relieved or to a total of 20 mg
- (Max doses are no longer stated in protocol* MAX DOSE IS STATED IN PAIN CONTROL PROTOCOL)
Paramedic Protocol 2018-TACHYCARDIA WITH A PULSE-What is the treatment sequence for a stable patient with a wide QRS and a regular rate?*** Pg 21
GIVE AMIODARONE 150 MG IN 100 ML OF NS IV/IO OVER 10 MIN, MAX DOSE 450MG***
Paramedic Protocol 2018-TACHYCARDIA WITH A PULSE-What is the treatment sequence for a stable patient with a narrow QRS *** Pg 21
Vagal maneuver then Adenosine 6mg, 12mg,12mg max of 30mg.
Paramedic Protocol 2018-TACHYCARDIA WITH A PULSE-What should you do if the patient is unstable and conscious and you need to cardiovert?*** Pg 21
Provide sedation to a conscious patient if possible, but do not delay cardioversion if the patient is unstable.***
Paramedic Protocol 2018-BRADYCARDIA-What should you do after TCP? Pg 24
- Assess electrical and mechanical capture.
- Reassess patient perfusion.
- Give analgesics and sedatives for pain control if not done before TCP.
Paramedic Protocol 2018-BRADYCARDIA-What medications should you consider if you are going to pace a patient? Pg 24
- Versed 1mg slow IV push and
- Fentanyl 50mcg IV or Morphine 5mg IV, titrated to patient comfort.
- Contact base hospital for further orders if additional sedation/pain relief is required.
Paramedic Protocol 2018-BRADYCARDIA-What dose of Atropine should you give?*** Pg 23
0.5MG IV. MAY REPEAT TO A TOTAL DOSE OF 3 MG
Paramedic Protocol 2018-BRADYCARDIA-When should you start TCP immediately?*** Pg 24
- No response to atropine***
- Atropine unlikely to be effective (second degree block-type II or third degree block)
- IV access cannot be quickly established
- Patient is severely symptomatic
Paramedic Protocol 2018-BRADYCARDIA-What should you do if the patient fails to respond to TCP or Atropine? Pg 24
- EPINEPHRINE infusion 2-8mcg/min, titrated to patient response, or
- DOPAMINE infusion 2-10mcg/kg/min, titrated to patient response.
Paramedic Protocol 2018-BRADYCARDIA-What should the starting pace rate be?*** Pg 24
Paramedic Protocol 2018-PEDIATRIC TACHYCARDIA-What is the key to proper treatment? Pg 39
Is to differentiate whether the tachycardia is the primary cause of the patient's symptoms, or if the tachycardia is a compensatory response to a separate medical issue.
Paramedic Protocol 2018-PEDIATRIC TACHYCARDIA-What is the joules setting for Synchronized Cardioversion? Pg 38
0.5-1J/KG;IF NOT EFFECTIVE INCREASE TO 2J/KG.
Paramedic Protocol 2018-PEDIATRIC TACHYCARDIA-What are common causes of sinus tachycardia? Pg 39
- Metabolic Stress
Paramedic Protocol 2018-PEDIATRIC BRADYCARDIA-What are the most common pre-arrest rhythms in children? Pg 41
Bradyarrythmias and are often associated with hypoxia, hypotension, and acidosis.
Paramedic Protocol 2018-PEDIATRIC BRADYCARDIA-What medication is indicated for persistant symptomatic bradycardia not responding to oxygenation and ventilation? Pg 41
Epinephrine 0.1-1mcg/kg/min IV drip with base hospital order.
Paramedic Protocol 2018-PEDIATRIC BRADYCARDIA-What medication is indicated as first medication intervention for bradycardia secondary to increased vagal tone, cholinergic drug toxicity (eg, organophosphates), or AV block?
Atropine first 0.02mg/kg (minimum dose 0.1mg) may repeat to MAXIMUM total dose of 1mg.
Paramedic Protocol 2018-Comments Transcutaneous Cardiac Pacing (TCP)***
For symptomatic bradycardia****
What patients can receive transcutaneous cardiac pacing?
What is the rate for external cardiac pacing?
- Rate = 80
- Ma= 50-90 adjust until capture
Is it Ok to stay on-scene with a patient with a suspected MI to obtain a 12-lead?
The Chest Pain protocol states, do not delay treatment or transport beyond 2-3 minutes to obtain a 12-lead ECG.
Paramedic Protocol 2018-PREMATURE VENTRICULAR CONTRACTIONS-PVCs in bradycardia or heart blocks?***
PVCs should not be suppressed in bradycardic rhythms***
Paramedic Protocol 2018-CPR-The pause in chest compressions to check the rhythm and pulse should not exceed?*** Pg 18
Paramedic Protocol 2018-CPR-For a cardiac arrest patient in VF/VT who has a body temperature of (<86oF), How many defibrillation(s) attempt are appropriate?*** Pg 18
Paramedic Protocol 2018-CPR-What hospital(s) would you transport to for therapeutic hypothermia treatment?*** Pg 18
Bakersfield Memorial or San Joaquin Community Hospital
Paramedic Protocol 2018-CPR-For therapeutic hypothermia what is the inclusion criteria?
- Age 18-75
- There is restoration of spontaneous circulation (ROSC)
- Comatose after ROSC: Unresponsive to verbal stimuli and no purposeful movement to pain
- CPR initiated within 15 minutes of collapse
- An interval not exceeding 60 minutes from collapse to ROSC
Paramedic Protocol 2018-CPR/PEA-Patients with PEA have poor outcomes. The most common and easily reversible causes of PEA? Pg 18
hypovolemia and hypoxia
Paramedic Protocol 2018-CPR/PEA What are the Hs and Ts in PEA?*** Pg 20
- Hypovolemia(most common)***
- Hydrogen ion (acidosis)
- Tamponade (cardiac)
- Tension Pneumothorax
- Thrombosis (coronary and pulmonary)
Paramedic Protocol 2018-PEDIATRIC PULSELESS ARREST/ENTRY-ALGORHITHM-What are the most common causes of cardiac arrest in children? Pg 32
Respiratory failure and hypotension
Paramedic Protocol 2018-PEDIATRIC PULSELESS ARREST/ENTRY-ALGORHITHM-Should you allow the family to remain present during resuscitation?*** Pg 32
Consider allowing the family to remain present during resuscitation. Studies show that family members who were present believe their presence was beneficial to the patient. Studies also suggest that family members present during resuscitations have less anxiety and depression and more constructive grieving behavior.***
Paramedic Protocol 2018-PEDIATRIC POST RESUSCITATION CARE-Why should you not provide excessive ventilation or hyperventilation? Pg 48
Hyperventilation may impair neurologic outcome by adversely affecting cardiac output and cerebral perfusion.
Paramedic Protocol 2018-PEDIATRIC POST RESUSCITATION CARE-What are the signs of impending cranial hemorrhage? Pg 48
- Dilated pupils(s) not responsive to light
Paramedic Protocol 2018-PEDIATRIC POST RESUSCITATION CARE-What is the transcutaneous oxygen saturation level that should be maintained? Pg 48
At least 94%
Paramedic Protocol 2018-PEDIATRIC VF/PULSLESS VT-What is the joule setting for the initial and subsequent shocks? Pg 34
2 J/KG then 4 J/KG
Paramedic Protocol 2018-PEDIATRIC VF/PULSELESS VT-The pause in chest compressions to check the rhythm and pulse should not exceed how many seconds?*** Pg 45
Paramedic Protocol 2018-PEDIATRIC VF/PULSELESS VT- What should you do for a cardiac arrest patient in VF/VT who has a body temperature of <30oC (<86oF)?*** Pg 35
A single defibrillation attempt is appropriate. If the patient fails to respond to the initial defibrillation attempt, defer subsequent attempts and drug therapy until the core temperature rises above 30oC (86oF).***
Paramedic Protocol 2018-PEDIATRIC ASYSTOLE-What medication and dose is given for asystole? Pg 36
Epinephrine 0.01 mg/kg IV/IO
When can you discontinue CPR in a cardiac arrest pt.?
- When information comes available that would have prevented you from starting CPR (DNR found, etc.), after 10 minutes of failure to respond to ALS procedures (ET, defib, appropriate meds), successful chest decompression of trauma pts. If indicated. In trauma pts. If transport To ED or Trauma Center is greater than 15 minutes.
- Pt. is to be left at scene w/ ET, IV, electrodes etc. left in place.
You are working up a cardiac arrest patient in the back of the ambulance at the scene and have not began transport, base physician advises to discontinue resuscitation, what do you do?
Discontinue CPR, remain at scene with patient in your ambulance until released by law enforcement agency with investigative authority or coroner.
You receive base orders to discontinue CPR while enroute to the hospital, what do you do?
Stop CPR, continue Code 2 to the closest most appropriate receiving hospital or base hospital.
You're in the East Kern and receive orders from a base hospital in the Bakersfield area to discontinue CPR, what do you do?
Discontinue CPR, proceed Code 2 to the closest most appropriate receiving facility. Make contact with that facility ASAP and inform the ED of the situation. In this situation youre going to transport to either, AVH, RCH or KVH and contact them with the situation.
Ped/Infant cardiac asystole treatment sequence?
- CPR IMMEDIATELY FOR 5 CYCLES
- EPINEPHRINE 0.01 MG/KG IV/IO REPEAT EVERY 3-5 MINUTES
- Look for reversible causes
Paramedic Protocol 2018-How should you deliver low energy shocks during cardioversion? Pg 22
Low energy shocks should always be delivered as synchronized shocks. Low energy unsynchronized shocks (defibrillation) are likely to induce VF. If cardioversion is needed and it is not possible to synchronize a shock, use unsynchronized shocks (defibrillation) at defibrillation doses.
Paramedic Protocol 2018-Comments Synchronized Cardioversion***
50-100 J, 200 J, 300 J, 360 J or equivalent bi-phasic delivered (Do Not Use Quick-Look Paddles).***
Paramedic Protocol 2018-Comments Defibrillation***
Adult: 360 J or equivalent bi-phasic delivered***Pediatric: 2 J/kg or equivalent bi-phasic delivered, repeat at 4 J/kg or equivalent bi-phasic
Paramedic Protocol 2018-When preparing for TCP, What order of drugs do you consider? Pg 25
- Atropine- 0.5mg IV
- Epinephrine Drip- 2-8MCG/Min
- Dopamine Drip- 2-10MCG/KG/Min