Region X Cardiac SOPs EKG Rhythms and Interventions

1
Region X Cardiac SOPsEKG Rhythms and
Interventions

• Condell Medical Center
• EMS System
• February 2008
• Site Code 10-7200E1208
• Prepared by Sharon Hopkins, RN, BSN, EMT-P

2
Objectives

• Upon successful completion of this module, the
  EMS provider should be able to
• review identification of a variety of EKG rhythms
• relate the dysrhythmia to the presentation of the
  patient
• comprehend the Region X cardiac SOPs as they
  relate to the patients presentation
• actively participate in case review
• successfully complete the quiz with a score of
  80 or greater

3
Introduction to Use of the SOPs

• Care is initiated for all patients based on your
  assessment
• A pediatric patient is considered under the age
  of 16 (15 and less)
• Do not delay care to contact Medical control
• But, prompt communication is encouraged

4
Cardiac SOPs

• Obtaining a history and performing an assessment
  can often provide valuable information
• Consider underlying causes for all situations
• In the cardiac SOPs, think of the 6 Hs and 5
  Ts as possible causes of the problem as you
  progress through assessment treatment for the
  patient

5
6 Hs

• Hypovolemia
• Hypoxia
• Hydrogen ion - acidosis
• Hyper/hypokalemia (high/low potassium levels)
• Hypothermia
• Hypoglycemia

• Give fluids (20 ml/kg)
• Provide supplemental O2
• Ventilate to blow off retained CO2
• Difficult to determine in the field consider in
  diabetic ketoacidosis renal dialysis
• Attempt rewarming
• Check blood glucose on all altered mental status
  pts

6
5 Ts

• Toxins (overdose)
• Tamponade, cardiac
• Tension pneumothorax
• Thrombosis, coronary (ACS) or Thrombosis,
  pulmonary (embolism)
• Trauma

• Think out of the box
• Check for JVD, ? B/P
• Check for JVD, ? B/P, absent/decreased breath
  sounds, difficulty bagging
• Obtain 12 lead when applicable good history
  taking to lead to suspicions (travel, surgery,
  immobility)
• What is history of current status?

7
CPR Guidelines (2005 AHA)

• If witnessed arrest, CPR until defibrillator
  ready
• If unwitnessed or gt4-5 minutes, CPR for 2 minutes
  then defibrillate if indicated
• 302 compressions to ventilations for 1 and 2 man
  adult CPR for 2 minute periods
• 5 cycles of 302 is 2 minutes
• Once intubated, compressor does not stop
  ventilator bags the patient once every 6-8
  seconds via ETT

8
AHA 2005 Guidelines

• After each defibrillation attempt, immediately
  resume CPR
• Do not look to check the rhythm
• Do not stop to check for a pulse
• After 5 cycles (2 minutes), stop CPR (no longer
  than 10 seconds) to reevaluate the rhythm
• Meds are administered during cycles of CPR

9
Securing Airway

• A term used to indicate to secure the airway in
  whatever manner needs to be taken
• Initially the airway may be secured via BVM
• Insert oropharyngeal airway if needed
• The patient can be intubated when time and
  personnel are available and after defibrillation
  has been performed
• Whatever method is used, limit interruption of
  CPR to a maximum of 10 seconds when possible

10
Asystole

• Regularity
• Rate
• P waves
• PR interval
• QRS complex

• There is no electrical activity you observe a
  straight line

There is no pulse, no perfusion, no blood
pressure. Survival from this dysrhythmia
is extremely slim. CPR is initiated in the
absence of a State of Illinois DNR form.
11
Asystole
No pulse, no breathing, no B/P! Youve got a dead
patient or a lead popped off
12
Asystole and Defibrillation

• The goal in defibrillation is trying to allow the
  dominant pacemaker (preferably the SA node) to
  take over pacemaker duties
• When you defibrillate a patient, you place them
  into asystole
• So, the patient in asystole does not need
  defibrillation (theyre already there!)
• The patient in PEA has electrical activity and
  defibrillation would interfere with the one thing
  that is working for them!

13
PEA

• A clinical situation in which there is organized
  electrical activity (other than VT) viewed on the
  monitor but there is no palpable pulse no
  breathing
• In the absence of a palpable pulse, the patient
  needs high quality CPR
• Focus on the causes (6 Hs and 5 Ts) as you
  perform CPR and administer medications

14
PEA lt60 bpm
When the underlying rate is under 60 bpm,
Atropine is indicated. Remember when theyre
done, give them one For asystole and slow PEA
lt60 give 1 mg Atropine IVP/IO
15
PEA gt60 bpm
If the patient has no pulse, this is PEA Knowing
the overall rate helps to determine if atropine
is given or not Atropine not indicated if heart
rate on monitor is gt60
16
SOP for Asystole/PEA

• Begin CPR
• Secure airway with minimal interruptions
• Search for and treat causes (6 Hs, 5 Ts)
• Establish IV/IO
• Meds
• Epinephrine 110,000 1 mg IVP/IO every 3-5
  minutes alternated with Atropine if indicated
• Asystole slow PEA Atropine 1 mg IVP/IO every
  3-5 minutes to maximum total dose 3mg

17
Medications - Epinephrine

• Stimulates vasoconstriction
• Supports improved blood flow to the heart and
  brain
• Can place a strain on the heart (this is
  adrenaline!) by ? heart rate and ? strength of
  contractility (more blood squeezed out)
• Relatively short half-life so needs to be
  repeated frequently (every 3-5 minutes)
• There is no maximum

18
Medications - Atropine

• Blocks effects of the parasympathetic nervous
  system that may be exerting a negative influence
  (decreasing heart rate)
• Increases rate of discharge of impulses at the SA
  node
• Decreases the amount of block at the AV node
  (lets more impulses travel through to the
  ventricles)
• Attempts to increase the heart rate

19
Atropine in Asystole PEA

• Asystole
• When theyre done, give them one
• 1 mg every 3-5 minutes
• Max total dose is 3 mg
• PEA
• Only given if the rate is lt 60
• If rate gt60 then you dont need the effects of
  Atropine to speed up the heart rate!
• When theyre done, give them one
• 1 mg every 3-5 minutes, max total 3 mg

20
Bradycardia and Heart Blocks

• When the heart rate falls, the cardiac output is
  affected.
• The patient becomes symptomatic when the cardiac
  output cannot keep up with the demands of the
  body
• Determine if the patient is symptomatic or not
  before administering treatment
• check level of consciousness
• check blood pressure

21
Sinus Bradycardia

• Regularity
• Rate
• P waves
• PR interval
• QRS complex

• Regular P to P and regular R to R
• Less than 60 bpm
• Positive, upright, rounded, look similar to each
  other
• 0.12-0.20 seconds and constant
• lt0.12 seconds

22
Sinus Bradycardia
Treatment indicated if the patient is
symptomatic EMS needs to provide a thorough
assessment to make an accurate clinical decision
23
Second Degree Type I - Wenckebach

• Regularity
• Rate
• P waves
• PR interval
• QRS complex

• Atria are regular, ventricular rhythm is
  irregular
• Atrial rate greater than ventricular rate
• Normal in shape not all followed by QRS
• PR gets progressively longer until dropped QRS
  complex
• Normally lt0.12 seconds

24
Second Degree Type I - Wenckebach
Note characteristics of irregular rhythm, grouped
beating, lengthening PR intervals, periodically
dropped QRS. The P to P interval is regular and
measures out in all blocks! Type I drops one
Wenckebach winks at you
25
Second Degree Type II - Classical

• Regularity
• Rate
• P waves
• PR interval
• QRS complex

• Atria regular, ventricular rhythm can be regular
  or not
• Atrial rate greater than ventricular rate which
  is slow
• Normal more Ps than QRSs
• Usually normal, constant for the conducted beats
• Usually lt0.12 sec periodically absent after P
  waves

26
Second degree Type II - Classical
This rhythm can have a variable block or can have
a set pattern (ie 21 31, etc). The slower the
heart rate, the more symptomatic the patient.
Treatment with Atropine versus TCP based on
width of QRS. Think Type II is 21 (but know
block can be 31,etc)
27
3rd Degree - Complete

• Regularity
• Rate
• P waves
• PR interval
• QRS complex

• Atria regular, ventricular rhythm regular but
  independent of each other
• Atrial rate greater than ventricular ventricular
  rate determined by origin of escape rhythm (can
  be slow or normal)
• Normal in shape size
• None (no pattern)
• Narrow or wide depending on origin of escape
  pacemaker

28
3rd degree - Complete
The patients symptoms are based on the
ventricular heart rate - the slower the heart
rate the more symptomatic the patient will be.
Again, P to P marches right through. Treatment
with TCP versus Atropine based on width of QRS
29
Patient Assessment in Bradycardia

• The patients symptoms will depend on the
  ventricular rate which influences the cardiac
  output
• Most reliable is to check the patients level of
  consciousness and blood pressure to help
  determine stability
• If interventions are necessary, the goal will be
  to improve the heart rate to improve the cardiac
  output

30
SOP for Stable Bradycardia

• Patient alert
• Skin is warm and dry
• Systolic B/P gt 100 mmHg
• Transport with no further intervention

31
SOP for Unstable Bradycardia

• Altered mental status
• Systolic B/P lt 100 mm Hg
• Bradycardia or Type I second degree heart block
• Includes all narrow QRS complex bradycardias
• Goal to speed up the heart rate
• Atropine 0.5 mg rapid IVP
• May be repeated every 3-5 minutes
• Max Atropine is 3 mg
• When theyre alive, give 0.5

32
Transcutaneous Pacemaker (TCP)

• TCP when Atropine is ineffective
• Narrow QRS bradycardia not responding to dose(s)
  of Atropine
• Wide QRS bradycardia where Atropine is not
  expected to be effective, TCP is tried first
• TCP sends electrical charges thru the skin
• TCP is uncomfortable
• Valium 2 mg slow IVP over 2 minutes
• May repeat Valium 2 mg slow IVP every 2 minutes
  to max of 10 mg for comfort

33
TCP and Patient Assessment

• Increase mA from lowest output setting until
  consistent capture noted on the monitor
• Document settings (rate, mA) on the patient care
  run report
• In the demand mode, if Atropine was administered
  and now kicks in, the patients own rate may
  exceed the pacemaker and put the pacemaker in
  stand-by (function of the demand mode!)

34
TCP with Capture - Paced Rhythm
Observed is one to one capture. Consider sedation
with Valium to make the patient more comfortable.
35
SOP for Wide QRS Bradycardia

• Typically refers to Type II second degree heart
  block and 3rd degree (complete)
• Atropine is not effective in wide QRS complex
  bradycardia (origin most likely below bundle of
  His if QRS is wide)
• Begin TCP as soon as possible
• If TCP not effective, can give Atropine 0.5 mg
  rapid IVP and repeat every 3-5 minutes to a max
  of 3 mg

36
Tachycardia and 2 Questions to Ask
During Assessment

• 1 - Is the patient stable or unstable?
• What is the level of consciousness?
• What is the blood pressure?
• If patient is unstable, needs emergent
  cardioversion
• If patient is stable, get to question 2
• 2 - Is the QRS narrow or wide?
• If narrow QRS think SVT
• If wide QRS think VT until proven otherwise

37
Dangers of Tachycardia

• With a rapid heart beat, the heart performs
  inefficiently
• There is not enough filling time for the
  ventricles
• Blood flow and B/P drop
• With a rapid heart beat, the work load/demand
  increases on the heart
• Increased requirement for more oxygen with
  reduced blood flow to myocardium increases risk
  of ischemia and potential MI

38
Tachycardia and the Patient

• Signs and symptoms often depend on
• Ventricular rate
• The faster the rate, the less filling time for
  the heart, the more symptomatic the patient is
• How long the tachycardia lasts
• The longer the tachycardia, the less reserve
  there is left and the more symptomatic the
  patient tends to be
• General health and presence of underlying heart
  disease

39
Supraventricular Tachycardia - Narrow QRS

• Regularity
• Rate
• P waves
• PR interval
• QRS complex

• Usually very regular
• 150 - 200 bpm
• None visible
• Not measured if P waves seen, PR interval often
  abnormal
• Usually lt0.12 seconds unless abnormal conduction

SVT is a term used to describe a category of
rapid rhythms that cannot be further defined
because of indistinguishable P waves.
40
Supraventricular Tachycardia - SVT
This SVT is most likely atrial tachycardia due to
shortened PR interval (abnormal PR interval).
The heart rate (180) is too fast for sinus
tachycardia. The QRS is definitely narrow!
41
SOP for SVT (Narrow QRS)

• Stable patient (alert, warm dry, B/P gt100
• Valsalva maneuver
• Have patient hold breath and bear down for 10
  seconds (or try to blow up a balloon or blow
  through a straw)
• Patient at home may have tried to make self gag
• Adenosine 6 mg rapid IVP
• Followed immediately by rapid flush of 20 ml NS
• If no response in 2 minutes, repeat Adenosine at
  12 mg rapid IVP again with 20 ml flush

42
Adenosine for SVT

• Antiarrhythmic
• Decreases heart rate at SA node
• Slows conduction thru AV node
• Does not convert atrial fibrillation, atrial
  flutter or VT
• Short half life (10 seconds) so start IV in AC
  area (preferably right), must be given rapidly
  followed immediately with saline flush

43
Adenosine Back-up

• Diltiazem/cardizem -slows heart rate
• If still in stock, can give 0.25 mg/kg IVP slowly
  over 2 minutes
• Watch for drop in blood pressure
• Verapamil/isoptin - slows heart rate
• 5 mg IVP slowly over 2 minutes
• Watch for drop in blood pressure
• If necessary, can repeat 5 mg slow IVP in 15
  minutes if B/P gt 100 mmHg
• Administer fluid challenge if pt hypotensive

44
Diltiazem/cardizem

• Calcium channel blocker
• Slows conduction thru SA and AV nodes
• Slows ventricular rate for rapid atrial fib or
  rapid atrial flutter
• Do not use in wide QRS rhythms or in WPW
• Give slowly to minimize side effects
• Watch for drop in B/P
• Onset in 3 minutes
• As home med, treatment of chronic angina

45
Verapamil/Isoptin

• Calcium channel blocker
• Slows conduction thru AV node
• Controls ventricular rate in rapid atrial fib or
  rapid atrial flutter
• Do not use with wide QRS or history of WPW
• 1st dose is 5 mg slow IVP
• Repeat dose in 15 minutes is 5 mg slow IVP
• Watch for hypotension
• As home med used for hypertension, angina

46
Ventricular Tachycardia - VT - This is NOT a
narrow QRS!
Wide QRS tachycardia is ventricular
tachycardia until proven otherwise. Always treat
the patient for the worst case scenario first
47
Atrial flutter

• Regularity
• Rate
• P waves
• PR interval
• QRS complex

• Atria regular ventricular rhythm can be regular
  or irregular
• Atrial rate 250, ventricular rate variable
• No identifiable P waves saw tooth or picket
  fence pattern noted
• Not measurable
• lt0.12 seconds unless abnormal conduction

48
Atrial Flutter
Note key characteristics of the flutter waves or
the saw toothed appearance also called the
picket fence
49
Atrial Fibrillation

• Regularity
• Rate
• P waves
• PR interval
• QRS complex

• Irregularly irregular
• Atrial rate 400-600 ventricular rate variable
• No identifiable P waves
• None measured
• 0.12 seconds or less unless abnormal conduction

50
Atrial Fibrillation
Rhythm is irregularly irregular. Check for
medication history of blood thinner (ie
coumadin)and digoxin (strengthens cardiac
contractions). When obtaining pulse, some
impulses stronger than others.
51
SOP for Atrial Fib/flutter

• If patient stable, need to slow accelerated
  ventricular rate
• Diltiazem/cardizem 0.25 mg/kg IVP slowly over 2
  minutes
• In absence of Diltiazem, use Verapamil
• Verapamil 5 mg slow IVP over 2 minutes
• If needed, may repeat Verapamil in 15 minutes if
  B/P remains gt100 mmHg
• (Caution both meds can cause ? in B/P)

52
Ventricular Fibrillation

• Regularity
• Rate
• P waves
• PR interval
• QRS complex

• No discernible wave forms to be identified or
  measured
• Course Vfib stands up taller from the baseline
  and is thought to be more receptive to
  defibrillation
• Fine Vfib is flatter and less likely to
  respond to defibrillation

53
Ventricular Fibrillation - VF
There is no pulse, no breathing, no B/P. This
patient is dead and needs immediate CPR and
defibrillation
54
Pulseless VT

• This is not PEA!
• PEA does not receive defibrillation
• Pulseless VT is treated just like VF and requires
  appropriate defibrillation attempts
• If pulseless VT deteriorates to VF, continue with
  the same SOP

55
SOP for VF/Pulseless VT

• Begin CPR
• If witnessed, defibrillate ASAP
• If unwitnessed, CPR for 5 cycles/2 minutes
• Secure airway
• Defib 360 j or equivalent biphasic
• Resume CPR immediately 5 cycles/2 minutes
• Establish IV/IO
• Intubate
• Defib 360 j or equivalent biphasic

56
SOP for VF/Pulseless VT contd

• Persistent VF needs meds added
• Add meds during episodes of CPR
• After every 2 minutes of CPR, stop for a maximum
  of 10 seconds to check rhythm and then proceed
  accordingly
• Epinephrine 110,000 1 mg IVP/IO
• Repeat every 3-5 minutes for duration of arrest
• After 2 minutes, check rhythm
• Persistent VF/pulseless VT ? defibrillate

57
SOP for VF/Pulseless VT contd

• Antidysrhythmics
• Choose one Amiodarone or Lidocaine
• Do not mix use of these drugs - heart becomes
  more irritable
• After a repeat dose of antidysrhythmic, need
  medical control orders for more
• Amiodarone 1st dose 300 mg IVP/IO
• Can repeat in 5 minutes at 150 mg IVP/IO
• Lidocaine 1.5 mg/kg IVP/IO
• Can repeat in 5 minutes at 0.75 mg/kg IVP

58
SOP for VF/Pulseless VT contd

• Continue 2 minutes of CPR
• Stop CPR to check rhythm (lt 10 seconds)
• Continue defibrillation attempts immediately
  resuming CPR after defib
• Alternate Epinephrine with the antidysrhythmic
  chosen (ie Amiodarone or Lidocaine)
• Consider treat causes (6Hs and 5 Ts) as you
  are progressing through treatment

59
Ventricular Tachycardia with Pulse

• Regularity
• Rate
• P waves
• PR interval
• QRS complex

• Essentially regular
• Generally over 100 bpm
• Generally absent occasionally may be visible but
  have no relationship with the QRS
• None measurable
• gt0.12 seconds often difficult to distinguish
  between the QRS and T wave

60
Ventricular Tachycardia - VT
Regular rhythm with wide QRS complex. You can
basically stack the complexes one on top of the
other - they will fit like stacking blocks
61
SOP for VT with Pulse

• This is a tachycardia
• Determine the answer to 2 questions
• 1 - Is the patient stable?
• Stable patients treated conservatively (meds)
• Unstable patients need immediate cardioversion
• 2 - If the patient is stable, then you get to
  this next question - 2 -Is the QRS narrow or
  wide?
• Narrow QRS - consider Adenosine
• Wide QRS - consider antidysrhythmic

62
SOP for Stable VT with Pulse

• Antidysrhythmics
• Amiodarone 150 mg diluted in 100 ml D5W IVPB over
  10 minutes
• OR
• Lidocaine 0.75 mg/kg IVP
• Contact Medical Control for further orders
• after the initial bolus

63
Amiodarone IVPB

• Draw up Amiodarone 150 ml (3ml)
• Add to a 100 ml bag D5W and gently agitate to mix
• Label the IV bag
• Prime the minidrip tubing plug into the main IV
  line as close to the patient as possible
• To infuse over 10 minutes, the minidrip tubing
  needs to drip at a rate just below wide open
  slow down or stop if B/P drops

64
SOP for Unstable VT

• Sedate the conscious patient with Versed 2 mg IVP
  over 2 minutes
• Repeat Versed 1mg as needed to sedate up to 10 mg
• Synchronize cardiovert at 100 joules
• If needed, synchronize cardiovert at 200 j
• If needed, synchronize cardiovert at 300 j
• If needed, synchronize cardiovert at 360 j

65
SOP for Unstable VT contd

• If VT recurs, synchronize cardiovert at energy
  level that was previously successful
• If VT recurs, then begin antidysrhythmic bolus
• Amiodarone 150 mg diluted in 100 ml D5W IVPB run
  over 10 minutes
• OR
• Lidocaine 0.75mg/kg IVP
• Contact Medical Control for further orders

66
Case Presentations

• Determine an initial impression
• Interpret the rhythm
• Based on your patient assessment and
  interpretation of data gathered, determine the
  appropriate intervention
• Discuss the steps in the appropriate SOP and
  understand why the intervention is necessary

67
Case 1

• 72 year old female presents with feeling
  lightheaded, weak and dizzy for one week getting
  progressively worse especially today
• Assessment
• Skin pale, slightly moist responsive to
  questions lungs with slight rales in bases
• VS 89/40 P-36 R-28 SaO2 96
• Meds Plavix, lisinopril, Coreg
• No allergies
• Hx ? B/P, CVA (no residual effects), angina

68
Whats your impression intervention?

• IV, O2, monitor, pulse ox
• Consider 12 lead EKG
• EKG 3rd degree/complete heart block
• Goal of therapy increase heart rate
• Intervention Bradycardia SOP
• QRS narrow so start with Atropine 0.5 mg IVP
• Prepare to attach TCP in case atropine not
  effective

69
Case 2

• You were called to the scene for a 66 year old
  patient with complaints of chest pain, chest
  pounding, and a feeling like they were going to
  pass out.
• You had just initiated IV-O2-monitor
• You got a 3 second glance at the monitor when the
  patient grabbed their chest, their head fell
  back, and they became unresponsive

70
Case 2

• What are these rhythms?
• What action needs to be taken?
• Which SOP do you follow?

71
Case 2

• The patient was initially NSR and changed to VT
  and then quickly deteriorated to VF
• This was a witnessed arrest - VF SOP
• Begin CPR (302) until the defibrillator is
  charged and ready
• After each defibrillation, immediately begin CPR
  for 2 minutes (5 cycles)
• As the IV was already started, begin the
  Epinephrine after the 1st shock

72
Case 3

• A car drove past your station and dropped off a
  passenger
• Your patient is a 25 year old male with multiple
  bruising about the chest and abdomen who is
  apneic and pulseless
• There are no witnesses and no history can be
  obtained there is evidence of trauma
• What is the rhythm?
• What is your impression?

73
Case 3

• THERE IS NO PULSE!!!
• The rhythm is PEA
• Important to note the rate (determines if
  Atropine is given or not)
• This patient needs CPR, no defibrillation
• Consider the causes (6 Hs and 5 Ts) as you are
  performing your interventions for PEA

74
Case 3

• Medications
• Epinephrine 110,000 1 mg IVP/IO every 3-5
  minutes for duration of the arrest
• No Atropine - the heart rate is gt 60 bpm
• Shift to thinking most likely causes in this
  young patient with evidence of trauma
• Hypovolemia - fluid bolus 200 ml at a time
• Hypoxia acidosis-ventilate with supplemental O2
• Tension pneumothorax - check breath sounds
• Tamponade - rapid transport

75
Case 3

• To consider
• Is this a traumatic arrest?
• If you answer yes, then consider bilateral chest
  decompression with evidence of chest trauma
• Transport is to the highest level trauma center
  within 25 minutes
• After every 5 cycles (2 minutes) of CPR, stop for
  10 seconds to evaluate the EKG rhythm
• If patient remains in PEA, continue Epinephrine
  every 3-5 minutes add Atropine only if the rate
  falls below 60 bpm
• rhythm checks are performed when observing a
  rhythm that might generate a pulse

76
Case 4

• Your patient is a 72 year old female who has
  called you due to feeling short of breath and has
  a pounding in her chest after shoveling snow.
• What is the rhythm?
• What is your general impression?
• What SOP will be followed and what interventions
  are necessary?

77
Case 4

• Upon 1st contact with your patients, get into the
  habit of feeling for a pulse while introducing
  yourself.
• Is the pulse slow, normal, or fast?
• Is the pulse regular or irregular?
• This first pulse can give you an idea of how
  critical the situation might be and a clue to
  what you might find once the monitor is hooked up

78
Case 4

• Rhythm has a narrow complex, no visible P waves,
  rate over 150 - SVT
• 1st question - is the patient stable?
• This patient is responding to your questions
• VS 102/58 P-140 R-22 SaO2 97
• Yes, the patient is stable
• 2nd question - is the QRS narrow or wide?
• QRS is narrow so treat as SVT
• Start with valsalva maneuvers then meds
  (Adenosine)

79
Case 4 - What is unique about giving Adenosine?

• Start the IV in the AC, preferably right
• Give the drug as a quick flush immediately
  followed by a 20 ml saline flush
• After 2 minutes and reassessment of the patient
  (B/P, rhythm check), if the 1st dose (6mg) was
  not effective, repeat Adenosine with 12 mg again
  as a rapid IVP immediately followed with a 20 ml
  saline flush
• Transient side effects to warn the patient about
  include chest tightness, shortness of breath, and
  a flushed hot feeling

80
Case 5

• You are called to a patient who is passing out
  but is still breathing.
• Upon arrival, you have a 65 year-old male who is
  supine, breathing, looks pale, is diaphoretic,
  and responds to pain.
• They have a carotid pulse but a very faint radial
  pulse if at all
• VS 88/52 P - 190 R - 12 SaO2 94
• What is the rhythm and your impression?

81
Case 5

• The rhythm is VT (wide QRS until proven
  otherwise)
• The patient is unstable
• Responds only to pain, ? respirations, poor skin
  parameters, possibly non-palpable radial pulse,
  B/P lt100
• Treatment goal is to convert this lethal rhythm
  and restore perfusion as soon as possible

82
Case 5

• Immediate synchronized cardioversion needed
• If possible, sedate the patient
• Cardioversion is a painful procedure
• Versed 2 mg IVP over 2 minutes
• Can repeat Versed 1 mg as needed to sedate to a
  max of 10 mg
• Appropriate pads or conductive material is
  applied - no air bubbles under the pads
• Practice safety - look around and call out all
  clear have BVM reached out in case of need from
  sedation with Versed

83
Case 5

• Successive cardioversion energy levels
• 100 joules
• If unsuccessful, 200 joules
• If unsuccessful, 300 joules
• If unsuccessful, 360 joules
• If cardioversion is successful and VT recurs,
  cardiovert at previously successful level
• If VT recurs, then begin bolus of antidysrhythmic
  of your choice (Amiodarone 300mg or Lidocaine
  0.75mg/kg)

84
Case 6

• Your 58 year-old fell and has a deformed wrist.
• Upon assessment EMS notes an irregular pulse.
• The patient meds include insulin, a B/P med,
  multiple vitamins
• What points are important to include during your
  assessment?

85
Case 6

• What is the rhythm?
• Second degree Type I - Wenckebach
• The overall heart rate runs low but patients are
  generally not symptomatic due to the heart rate
• What is important to know during this assessment?
• Why did the patient fall?
• If the patient tripped (he did), this is a trauma
  call
• This patient has no problem related to his
  diabetes so a blood sugar level is not indicated

86
Case 7

• You were called to the scene of a 48 year-old
  patient with chest pain for 1 hour.
• VS 110/72 P - 78 R - 18 SaO2 99
• Monitor was NSR
• You had the patient begin chewing Aspirin, you
  had administered a nitroglycerin tablet after
  establishing an IV and have just completed
  sending a 12 lead EKG.
• The patient suddenly becomes unresponsive

87
Case 7

• Now what!!!???
• You have confirmed the patient is apneic and
  pulseless.
• Begin CPR (witnessed arrest) until defibrillator
  charged
• Call and look all clear, defibrillate at 360 j
  or highest biphasic setting

88
Case 7

• After 2 minutes of immediate CPR following the
  defibrillation, you stop CPR and check the rhythm
• Rhythm looks like NSR, now you can check for a
  pulse - there is a pulse!!!
• Stop CPR, reassess vital signs
• B/P is rising from 0/0, P - 80, respirations
  being assisted by BVM (about 4 -6/minute)

89
Case 7

• Any other medications to be given?
• This patient will not receive Epinephrine -
  doesnt need it now
• As no antidysrhythmic was administered to the
  patient, EMS must call Medical Control for orders
• If the B/P does not come up, consider a Dopamine
  drip and fluid bolus
• Continue to support and monitor patients
  ventilation status

90
References On-Line Review

• Aehlert, B. ECGs Made Easy. 3rd Edition.
• Mosby. 2006.
• Region X SOP Effective March 1, 2007
• Walraven, G. Basic Arrhythmias. 6th
• Edition. Brady. 2006.
• Www.co.livingston.mi.us/ems/ekgquiz.htm
• www.ambulancetechnicianstudy.co.uk/ rhythms.html