Pulseless VT/VF Algorithm First Impression: Sick or not sick? Primary survey Unresponsive?

Open airway, give 2 breaths Give oxygen when available If no pulse, 30 compressions/2 breaths Attach AED or monitor/defibrillator

Assess ECG rhythm Shockable?

YES Shock (defibrillate) 1 Resume CPR5 cycles (about 2 minutes) Without interrupting CPR, start IV/IO During CPR, give vasopressor Epinephrine 1 mg every 3-5 min OR Vasopressin 40 U 1 in place of first or second epinephrine dose SHOCKS Defibrillation Monophasic: 360J all shocks AED: Per manufacturer Biphasic: Per manufacturer Biphasic unknown: 200J initially, then same or higher as first shock REVERSIBLE CAUSES NO Assess ECG rhythm Shockable? Pulmonary embolism anticoagulants? surgery? Acidosisgive oxygen, ensure adequate ventilation Tension pneumothorax needle decompression Cardiac tamponade pericardiocentesis Hypovolemiareplace volume Hypoxiagive oxygen, ensure adequate ventilation Heat/coldcooling/warming measures Hypohyperkalemia (and other electrolytes) correct electrolyte abnormalities Myocardial infarction fibrinolytics? Drug overdose/accidents antidote/specific therapy

NO Asystole? Go to asystole algorithm Electrical activity present? Check pulse No pulse, go to PEA algorithm Pulse present? Assess vital signs, begin postresuscitation care

REASSESS/MONITOR Airway Oxygenation/ventilation Paddle/pad position/contact Effectiveness of CPR No O2 flowing over patient during shocks Attempt/verify: Advanced airway placement Vascular access Monitor and treat: Glucose Electrolytes Temperature CO2

YES Shock (defibrillate) 1 Resume CPR5 cycles (about 2 minutes) During CPR, consider antiarrhythmic Amiodarone 300 mg IV/IO initial dose; consider repeat dose of 150 mg 1 in 5 min OR Lidocaine 1-1.5 mg/kg IV/IO initial dose (if amiodarone not available), then 0.5-0.75 mg/kg prn every 5-10 min; max cumulative dose 3 mg/kg Consider magnesium 1-2 g IV/IO for torsades de pointes Consider reversible causes of arrest

Algorithm assumes scene safety has been assured, personal protective equipment is used, no signs of obvious death or presence of do not resuscitate order, and previous step was unsuccessful

Copyright 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Asystole/Pulseless Electrical Activity Algorithm First Impression: Sick or not sick? Primary survey Unresponsive? Open airway, give 2 breaths Give oxygen when available If no pulse, 30 compressions/2 breaths Attach AED or monitor/defibrillator

Assess ECG rhythm Shockable?

NO Resume CPR for about 2 min Without interrupting CPR, start IV/IO During CPR, give vasopressor Epinephrine 1 mg every 3-5 min or Vasopressin 40 U 1 in place of first or second epinephrine dose -----------If asystole or slow PEA, consider atropine 1 mg every 3-5 min; maximum total dose 3 mg

YES Go to pulseless VT/VF algorithm YES

Assess ECG rhythm Shockable?

Algorithm assumes scene safety has been assured, personal protective equipment is used, no signs of obvious death or presence of do not resuscitate order, and previous step was unsuccessful REASSESS/MONITOR Airway Oxygenation/ventilation Paddle/pad position/contact Effectiveness of CPR Attempt/verify: Advanced airway placement Vascular access Monitor and treat: Glucose Electrolytes Temperature CO2

NO Resume CPR 5 cycles (about 2 minutes) REVERSIBLE CAUSES Pulmonary embolism anticoagulants? surgery? Acidosisgive oxygen, ensure adequate ventilation Tension pneumothorax needle decompression Cardiac tamponade pericardiocentesis Hypovolemiareplace volume Hypoxiagive oxygen, ensure adequate ventilation Heat/coldcooling/warming measures Hypohyperkalemia (and other electrolytes) correct electrolyte abnormalities Myocardial infarction fibrinolytics? Drug overdose/accidents antidote/specific therapy

Copyright 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Symptomatic Bradycardia Serious signs/symptoms due to the bradycardia (heart rate 60 bpm)? Hypotension Pulmonary congestion Dizziness Shock Ongoing chest pain Shortness of breath CHF Weakness/fatigue Acute altered mental status

ABCs, O2, IV, monitor

Is QRS narrow or wide? Narrow QRS (0.10 sec) Prepare for transvenous pacing Wide QRS (0.10 sec)

Atropine 0.5 mg IV Repeat pm every 3 to 5 min Maximum total dose 3 mg

Transcutaneous pacing

CONSIDER CONTRIBUTING CAUSES Transcutaneous pacing Pulmonary embolism anticoagulants? surgery? Acidosisgive oxygen, ensure adequate ventilation Tension pneumothorax needle decompression Cardiac tamponade pericardiocentesis Hypovolemiareplace volume Hypoxiagive oxygen, ensure adequate ventilation Heat/coldcooling/warming measures Hypohyperkalemia (and other electrolytes) correct electrolyte abnormalities Myocardial infarction fibrinolytics? Drug overdose/accidents antidote/specific therapy

Dopamine infusion 2 to 10 mcg/kg/min or Epinephrine infusion 2 to 10 mcg/min

Dopamine infusion 2 to 10 mcg/kg/min or Epinephrine infusion 2 to 10 mcg/min

Algorithm assumes scene safety has been assured, personal protective equipment is used, and previous step was unsuccessful.

Copyright 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Narrow-QRS Tachycardia (Regular ventricular rhythm) Serious signs/symptoms due to the tachycardia (heart rate 150 bpm)? Hypotension Pulmonary congestion Dizziness Shock Ongoing chest pain Shortness of breath CHF Weakness/fatigue Acute altered mental status

ABCs, O2, IV, monitor, 12-lead ECG Three important questions: 1. Patient stable or unstable? 2. QRS narrow or wide? 3. Rhythm regular or irregular? Stable or unstable? Stable Vagal maneuvers CONSIDER CONTRIBUTING CAUSES Pulmonary embolism anticoagulants? surgery? Acidosisgive oxygen, ensure adequate ventilation Tension pneumothorax needle decompression Cardiac tamponade pericardiocentesis Hypovolemiareplace volume Hypoxiagive oxygen, ensure adequate ventilation Heat/coldcooling/warming measures Hypohyperkalemia (and other electrolytes) correct electrolyte abnormalities Myocardial infarction fibrinolytics? Drug overdose/accidents antidote/specific therapy Unstable Consider medications (adenosine) while preparing for cardioversion Do not delay cardioversion -----------If serious signs and symptoms, prepare for immediate synchronized cardioversion with 50, 100, 200, 300, 360 J (or biphasic equivalent) Give sedation if possible

Adenosine 6 mg rapid IV push If no conversion, give 12 mg rapid IV push after 1-2 min May repeat 12 mg dose once in 1-2 min Follow each dose with 20 mL normal saline IV flush

If no conversion, consider calcium channel blocker (verapamil, diltiazem) or beta-blocker

Algorithm assumes scene safety has been assured, personal protective equipment is used, and previous step was unsuccessful.

Copyright 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Wide-QRS Tachycardia (Regular ventricular rhythm) Serious signs/symptoms due to the tachycardia (heart rate 150 bpm)? Hypotension Pulmonary congestion Dizziness Shock Ongoing chest pain Shortness of breath CHF Weakness/fatigue Acute altered mental status

ABCs, O2, IV, monitor, 12-lead ECG Three important questions: 1. Patient stable or unstable? 2. QRS narrow or wide? 3. Rhythm regular or irregular? Stable or unstable? Stable If possible SVT with aberrancy, give adenosine as for narrow-QRS tachycardia. If monomorphic VT or wide-QRS tachycardia of unknown origin, give amiodarone 150 mg IV over 10 min Repeat prn to max dose of 2.2 g/24 hr CONSIDER CONTRIBUTING CAUSES Pulmonary embolism anticoagulants? surgery? Acidosisgive oxygen, ensure adequate ventilation Tension pneumothorax needle decompression Cardiac tamponade pericardiocentesis Hypovolemiareplace volume Hypoxiagive oxygen, ensure adequate ventilation Heat/coldcooling/warming measures Hypohyperkalemia (and other electrolytes) correct electrolyte abnormalities Myocardial infarction fibrinolytics? Drug overdose/accidents antidote/specific therapy Unstable If serious signs and symptoms, prepare for immediate synchronized cardioversion. Give sedation if possible Ventricular tachycardia (with pulse) synchronized cardioversion with 100, 200, 300, 360 J (or biphasic equivalent)

Alternative drugs: procainamide, sotalol

Algorithm assumes scene safety has been assured, personal protective equipment is used, and previous step was unsuccessful.

Copyright 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Irregular Tachycardia Serious signs/symptoms due to the tachycardia (heart rate 150 bpm)? Hypotension Pulmonary congestion Dizziness Shock Ongoing chest pain Shortness of breath CHF Weakness/fatigue Acute altered mental status

ABCs, O2, IV, monitor, 12-lead ECG Three important questions: 1. Patient stable or unstable? 2. QRS narrow or wide? 3. Rhythm regular or irregular? Stable or unstable? Stable CONSIDER CONTRIBUTING CAUSES Pulmonary embolism anticoagulants? surgery? Acidosisgive oxygen, ensure adequate ventilation Tension pneumothorax needle decompression Cardiac tamponade pericardiocentesis Hypovolemiareplace volume Hypoxiagive oxygen, ensure adequate ventilation Heat/coldcooling/warming measures Hypohyperkalemia (and other electrolytes) correct electrolyte abnormalities Myocardial infarction fibrinolytics? Drug overdose/accidents antidote/specific therapy Unstable If serious signs and symptoms, prepare for immediate synchronized cardioversion. Give sedation if possible. -----------Synchronized cardioversion: Atrial flutter: 50, 100, 200, 300, 360 J* Atrial Fib: 100, 200, 300, 360 J* *or biphasic equivalent -----------Sustained polymorphic VT: treat as VF with defibrillation

Cardiology consult advised Atrial Fib with rapid ventricular response: magnesium, diltiazem, beta-blockers effective Atrial Fib WPW: consider amiodarone 150 mg IV over 10 min; avoid adenosine, digoxin, diltiazem, verapamil Atrial flutter: beta-blocker Polymorphic VT with normal QT interval: amiodarone may be effective Polymorphic VT with prolonged QT interval (torsades de pointes): magnesium sulfate 12 g IV in 50 to 100 mL over 5 to 60 min

Algorithm assumes scene safety has been assured, personal protective equipment is used, and previous step was unsuccessful.

Copyright 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Ischemic Chest Pain/Discomfort Algorithm ABCs, O2, IV, monitor Vital signs, pulse oximeter, blood pressure monitor SAMPLE history, assess discomfort (0 to 10 scale) Obtain 12-lead ECG Begin reperfusion checklist Give aspirin, nitroglycerin, morphine as indicated (if no contraindications)

Evaluate 12-lead ECG Complete reperfusion checklist Get baseline cardiac biomarker levels, electrolytes, coagulation studies, chest x-ray Evaluate initial interventions, pain management

Evaluate initial 12-lead ECG

INJURY ST-segment elevation or new left bundle branch block?

ISCHEMIA ST-segment depression or transient ST/T wave changes?

NORMAL Normal ECG or nonspecific ST/T wave changes?

ST-elevation MI

High-risk unstable angina/ NonST-Elevation MI

Intermediate/low-risk unstable angina

STEMI Determine reperfusion strategy Beta-blockers Clopidogrel Heparin ACE inhibitors (oral) Statins

UA/NSTEMI Nitroglycerin Beta-blockers Clopidogrel Heparin Glycoprotein IIb/IIIa inhibitor ACE inhibitors (oral) Statins

UA Aspirin Additional therapy as appropriate

Copyright 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Acute Pulmonary Edema ABCs, O2, IV, monitor

Assess blood pressure

INITIAL ACTIONS If feasible and BP permits, place patient in sitting position with feet dependent Increases lung volume and vital capacity Decreases work of respiration Decreases venous return, decreases preload -----Nitroglycerin sublingual if systolic BP 100 mm Hg -----Morphine 2 to 4 mg IV -----Furosemide 0.5 to 1 mg/kg IV* *Use less than 0.5 mg/kg for new onset acute pulmonary edema without hypovolemia. Use 1 mg/kg for acute or chronic volume overload, renal insufficiency.

ADDITIONAL ACTIONS Intubate if needed -----Nitroglycerin IV infusion at 10 to 20 mcg/min if systolic BP 100 mm Hg -----Dopamine 5 to 15 mcg/kg/min if systolic BP 70 to 100 mm Hg with signs/symptoms of shock -----Dobutamine 2 to 20 mcg/kg/min if systolic BP 70 to 100 mm Hg with no signs/symptoms of shock

Copyright 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Cardiogenic Shock ABCs, O2, IV, monitor BP 70 If systolic BP 70 to 100 mm Hg with signs/ symptoms of shock: Norepinephrine IV infusion 0.5 to 30 mcg/min BP 70 to 100 If systolic BP 70 to 100 mm Hg with signs/ symptoms of shock: Dopamine IV infusion 5 to 15 mcg/kg/min BP 70 to 100 If systolic BP 70 to 100 mm Hg with no signs/ symptoms of shock: Dobutamine IV infusion 2 to 20 mcg/kg/min BP 100 If systolic BP 100 mm Hg: Nitroglycerin IV infusion 10 to 20 mcg/min

Assess blood pressure

Copyright 2007 by Mosby, Inc., an affiliate of Elsevier Inc.