Chest Pain (Revised 11/29/04)

Chest Trauma

Dysrythmia

Asystole

Bradycardia (symptomatic) revised 12-12-03

PVC's

PEA

Tachycardia (narrow)

Tachycardia (wide)

V-Fib

 

SECTION 2

ADULT CARDIAC CARE

ACLS ALGORITHMS

SECTION

CHEST PAIN  revised 2-3-04

 

 

GUIDELINES FOR CARE

  1. ASSURE ABC’S
  2. PULSE OXIMETRY
  3. APPLY OXYGEN (4 LPM BY NASAL CANNULA, UNLESS PATIENT IS SHORT OF BREATH, HYPOXIC BY PULSE OXIMETRY, HAVING OBVIOUS RESPIRATORY COMPROMISE, OR ALTER LEVEL OF CONSCIOUSNESS)
  4. APPLY CARDIAC MONITOR
  5. IF PATIENT IS LESS THAN 30 YEARS OLD AND DEEMED STABLE BY THE PARAMEDIC, SKIP TO 11
  6. ADMINISTER 2 TO 4 CHEWABLE 81 MG ASPIRIN. NOTE: IF PT. IS ON BLOOD THINNERS, I.E. "COUMADIN AND HEPARIN" SKIP THIS ORDER
  7. START IV OF NORMAL SALINE AT KVO
  8. *(see precautions below regarding possible medications taken in past 48 hours) ADMINISTER NITROGLYCERIN X ONE METERED DOSE (OR ONE TABLET) SUBLINGUAL IF B/P IS GREATER THAN 100 SYSTOLIC. MAY BE REPEATED EVERY 5 MINUTES UNTIL:
    1. THREE (3) METERED DOSE SPRAYS (OR 3 TABLETS) HAVE BEEN GIVEN
    2. PAIN IS RELIEVED
    3. B/P FALLS BELOW 100 SYSTOLIC

*PRECAUTIONS: Lavitra (Vardenafil) and Cialis (Tadalafil) are in the same class of drug as Viagra (Sildenafil). Nitroglycerin interacts with all 3 to cause life-threatening hypotension. The difference is that Levitra and Cialis are much longer acting drugs.

Some patients may forget to to tell health care professionals about a medications taken 2 days prior, therefore, it is imperative that you inquire about these medications.

*IF PATIENT HAS TAKEN THE DRUG VIAGRA WITHIN THE PAST 12 HOURS, DO NOT GIVE NTG

*IF PATIENT HAS TAKEN THE DRUG LEVITRA WITHIN THE PAST 24 HOURS, DO NOT GIVE NTG

*IF PATIENT HAS TAKEN THE DRUG CIALIS WITHIN THE PAST 48 HOURS, DO NOT GIVE NTG
  1. IF NOT FREE OF PAIN AFTER 3 NTG, TITRATE MORPHINE SULFATE IN 2 MG INCREMENTS IV TO EFFECT, UP TO A MAXIMUM DOSE OF 10 MG.
  2. CHECK B/P BEFORE EACH DOSE AND HOLD IF SYSTOLIC B/P IS <100.
  3. TREAT ANY DYSRHYTHMIAS PER PROTOCOLS
  4. TRANSPORT AS INDICATED

 

CHEST TRAUMA

GUIDELINES FOR CARE

  1. ASSURE ABC’S
  2. PULSE OXIMETRY
  3. OXYGEN
  4. CARDIAC MONITOR
  5. INITIATE IV (OPTIONAL)
  6. IF OPEN PNEUMOTHORAX
    1. PLACE OCCLUSIVE DRESSING OVER THE WOUND AND SEAL ON THREE SIDES
    2. MONITOR FOR THE DEVELOPMENT OF TENSION PNEUMOTHORAX
  7. IF TENSION PNEUMOTHORAX IS DEVELOPED OR DISCOVERED
    1. UNDO DRESSING TO RELIEVE TENSION
    2. PERFORM DECOMPRESSION AT SITE OF CHOICE
  8. IF FLAIL SEGMENT IS FOUND STABILIZE WITH BULKY DRESSING
  9. INTUBATE AND VENTILATE AS INDICATED
  10. TRANSPORT AS INDICATED

 

DYSRHYTHMIA GUIDELINES

  1. ALWAYS TREAT THE PATIENT AND NOT THE MONITOR
    2.
  2. CARDIAC ARREST CAUSED BY TRAUMA IS TREATED BY FIXING THE UNDERLINE PROBLEM
  3. PROTOCOLS FOR CARDIAC ARREST SITUATIONS PRESUMES THAT THE CONDITION UNDER DISCUSSION CONTINUALLY PERSISTS, THAT THE PATIENT IS BEING CARDIAC MONITORED, REMAINS IN CARDIAC ARREST AND THAT CPR IS BEING PERFORMED
  4. ADEQUATE AIRWAY, VENTILATION, OXYGENATION, CHEST COMPRESSIONS AND DEFIBRILLATION ARE MORE IMPORTANT THAN THE ADMINISTRATION OF MEDICATIONS AND TAKE PRECEDENT OVER INITIATING AN IV OR INJECTING MEDICATION
  5. REMEMBER, NARCAN, ATROPINE, VALIUM, EPINEPHRINE AND LIDOCAINE (NAVEL) CAN BE ADMINISTERED VIA THE ENDOTRACHEAL TUBE AT 2 TO 2 ˝ TIMES THEIR REGULAR DOSES. This should be followed by a 10 CC flush of NS. THIS, ALONG WITH HYPERVENTILATING THE PATIENT AFTER EACH DRUG ADMINISTRATION VIA THE ET TUBE, WILL AID IN GETTING THE DRUG INTO THE BLOOD STREAM CIRCULATION AND HELP PREVENT CAPILLARY CONSTRICTION IN THE ALVEOLI.
  6. AFTER EACH INTRAVENOUS MEDICATION, GIVE A 20 TO 30 ML BOLUS OF INTRAVENOUS FLUID AND ELEVATE THE EXTREMITY
  7. THE FLUID OF CHOICE FOR THE PATIENT IN CARDIAC ARREST IS NORMAL SALINE

 

ASYSTOLE

GUIDELINES FOR CARE

  1. ASSURE ABC’S
  2. INITIATE AND CONTINUE CPR, VENTILATING WITH 100% OXYGEN
  3. CONFIRM ASYSTOLE IN TWO LEADS
  4. PULSE OXIMETRY
  5. INTUBATE AT ONCE, 100% OXYGEN VENTILATIONS CONTINUED
  6. INITIATE IV
  7. IF WITHIN 10 MINUTES OF ARREST, CONSIDER PACING
  8. ADMINISTER 1 MG OF EPINEPHRINE 1:10,000 EVERY 3-5 MINUTES IV (*OR VIA ET TUBE AT 2 TO 2 ˝ TIMES THEIR REGULAR DOSE IF NO LINE PRESENT)
  9. ADMINISTER ATROPINE 1 MG IV (*OR VIA ET TUBE AT 2 TO 2 ˝ TIMES THEIR REGULAR DOSE IF NO LINE PRESENT). MAY REPEAT
  10. TREAT POSSIBLE CAUSES
    1. IF RENAL PATIENT, CONSIDER CALCIUM CHLORIDE 10 CC GIVEN IV
    2. IF POSSIBLE PRE-EXISTING ACIDOSOS, CONSIDER SODIUM BICARBONATE
  1. TRANSPORT AS INDICATED

* REMEMBER, NARCAN, ATROPINE, VALIUM, EPINEPHRINE AND LIDOCAINE (NAVEL) CAN BE ADMINISTERED VIA THE ENDOTRACHEAL TUBE AT 2 TO 2 ˝ TIMES THEIR REGULAR DOSES. This should be followed by a 10 CC flush of NS. THIS, ALONG WITH HYPERVENTILATING THE PATIENT AFTER EACH DRUG ADMINISTRATION VIA THE ET TUBE, WILL AID IN GETTING THE DRUG INTO THE BLOOD STREAM CIRCULATION AND HELP PREVENT CAPILLARY CONSTRICTION IN THE ALVEOLI.

 

BRADYCARDIA (SYMPTOMATIC) •revised 10-25-05

 

GUIDELINES FOR CARE

  1. ASSURE ABC’S
  2. PULSE OXIMETRY
  3. ADMINISTER OXYGEN VIA NRB
  4. CARDIAC MONITOR
  5. INITIATE IV
  6. IF PATIENT EXHIBITS ANY OF THE FOLLOWING ADMINISTER 0.5 MG ATROPINE SULFATE IV:
    1. SHORTNESS OF BREATH
    2. DECREASED LEVEL OF CONSCIOUSNESS
    3. HYPOTENSION
    4. PULMONARY EDEMA
    5. CHEST PAIN •(Precaution: NTG should be used with caution in bradycardia <60 because of possible R ventricular infarct in leads II, III and AVF)
  1. A REPEAT DOSE OF ATROPINE 0.5 MG MAY BE GIVEN IF DESIRED AFFECT IS NOT REACHED
  2. CONSIDER PACING IF NO RESPONSE TO ATROPINE
  3. TRANSPORT AS INDICATED
  4. NOTE: IF ORGANOPHOSPHATE POISONING IS SUSPECTED TO BE THE CAUSE OF THE BRADYCARDIA, ADMINISTER 2 MG ATROPINE SULFATE IV PUSH Q 5-15 MIN TO DRY SECRETIONS.

PVC’S

 

GUIDELINES FOR CARE

  1. ASSURE ABC’S
  2. PULSE OXIMETRY
  3. OXYGEN VIA NRB OR NC AS INDICATED
  4. CARDIAC MONITOR
  5. INITIATE IV
  6. VERIFY PVC’S PRESENT AFTER OXYGENATION
  7. IF PT. IS ASYMPTOMATIC, TRANSPORT WITH CONTINUOUS MONITORING ENROUTE
  8. IF PT. EXHIBITS ANY OF THE FOLLOWING SIGNS OR SYMPTOMS, GO TO STEP 10:
    1. CHEST PAIN
    2. DIZZINESS
    3. SYMPTOMS OF ACUTE MI
  9. IF PVC’S ARE MALIGNANT, GO TO STEP 10
    1. >6 PER MINUTE
    2. MULTI-FOCAL
    3. OCCURRING IN COUPLETS OR SALVOS
    4. RUNS OF V-TACH
    5. EXHIBITING "R ON T PHENOMENON"
  10. ADMINISTER 1.0 MG/KG LIDOCAINE
  11. REPEAT LIDOCAINE AT HALF THE INITIAL DOSAGE IF PVC’S PERSIST
  12. BEGIN LIDOCAINE DRIP AT 2-4 MG/MIN IF PVC’S BECOME SUPPRESSED (REDUCE THE DOSAGE BY HALF IF PATIENT IS OVER 70 YEARS OF AGE OR HAS A KNOWN LIVER DISEASE
  13. TRANSPORT AS INDICATED

 

 

PULSELESS ELECTRICAL ACTIVITY (PEA)

 

 

GUIDELINES FOR CARE

 

  1. ASSURE ABC’S
  2. INITIATE AND CONTINUE CPR
  3. PULSE OXIMETRY
  4. CARDIAC MONITOR
  5. INTUBATE AND VENTILATE WITH 100% OXYGEN
  6. INITIATE IV

 

 

  1. ADMINISTER 1 MG EPINEPHRINE 1:10,000 IV (*OR VIA ET TUBE AT 2 TO 2 ˝ TIMES THEIR REGULAR DOSE IF NO LINE PRESENT) EVERY 3 TO 5 MINUTES
  2. IF BRADYCARDIA, ADMINISTER ATROPINE SULFATE 1 MG IV (*OR VIA ET TUBE AT 2 TO 2 ˝ TIMES THEIR REGULAR DOSE IF NO LINE PRESENT) AND REPEAT AS NEEDED UNTIL A MAXIMUM OF 0.04 MG/KG IS GIVEN

 

  1. CONSIDER POSSIBLE CAUSES AND PROVIDE SPECIFIC THERAPY
    1. IF POSSIBLE PRE-EXISTING ACIDOSIS, GIVE SODIUM BICARBONATE
    2. IF RENAL FAILURE WITH POSSIBLE INCREASED POTASSIUM, GIVE CALCIUM CHLORIDE
    3. IF TENSION PNEUMOTHORAX, NEEDLE DECOMPRESSION
    4. IF HYPOVOLEMIA, GIVE NS WIDE OPEN
    5. IF TRICYCLIC OVERDOSE, GIVE SODIUM BICARBONATE

 

 

  1. TRANSPORT AS INDICATED

 

* REMEMBER, NARCAN, ATROPINE, VALIUM, EPINEPHRINE AND LIDOCAINE (NAVEL) CAN BE ADMINISTERED VIA THE ENDOTRACHEAL TUBE AT 2 TO 2 ˝ TIMES THEIR REGULAR DOSES. This should be followed by a 10 CC flush of NS. THIS, ALONG WITH HYPERVENTILATING THE PATIENT AFTER EACH DRUG ADMINISTRATION VIA THE ET TUBE, WILL AID IN GETTING THE DRUG INTO THE BLOOD STREAM CIRCULATION AND HELP PREVENT CAPILLARY CONSTRICTION IN THE ALVEOLI.

 

 

TACHYCARDIA (NARROW COMPLEX)

 

 

GUIDELINES FOR CARE

 

  1. ASSURE ABC’S
  2. PULSE OXIMETRY
  3. OXYGEN
  4. CARDIAC MONITOR
  5. INITIATE IV NORMAL SALINE AT KVO
  6. IF THE PT. EXHIBITS ANY OF THE FOLLOWING TREAT THE PT. AS UNSTABLE AND *CARDIOVERT (FO TO STEP 7). IF PT IS STABLE GO TO STEP 9

    7. *IF PATIENT PRESENTS WITH HISTORY OF ATRIAL FIB WITHIN LAST 72 HOURS OR GREATER - CONTACT MEDICAL CONTROL BEFORE CARDIOVERSION  

    1. SHORTNESS OF BREATH
    2. ALTERED LEVEL OF CONSCIOUSNESS
    3. PULMONARY EDEMA
    4. SEVERE CHEST PAIN
  7. PREMEDICATE WITH VALIUM 10 MG IV
  8. PLACE DEFIBRILLATOR IN SYNCHRONIZED MODE AND SHOCK IN THE FOLLOWING SEQUENCE UNTIL PATIENT CONVERTS, THEN GO TO STEP 13
  9. IF PATIENT IS STABLE, AND RHYTHM IS SVT, ATTEMPT VAGAL MANEUVERS
  10. IF SVT AND NO RESPONSE TO ABOVE, GIVE ADENOSINE 6 MG IVP WITH RAPID FLUSH
  11. IF SVT AND NO RESPONSE TO ABOVE, GIVE ADENOSINE 12 MG IVP WITH RAPID FLUSH. MAY REPEAT X 1 IF NO CONVERSION.
  12. CARDIOVERT IF PATIENT BECOMES UNSTABLE
  13. TRANSPORT AS INDICATED

 

 

TACHYCARDIA (WIDE COMPLEX)

 

 

GUIDELINES FOR CARE

 

  1. ASSURE ABC’S
    1. VERIFY PULSE, IF NONE, TREAT AS V-FIB
  2. PULSE OXIMETRY
  3. OXYGEN VIA NRB
  4. CARDIAC MONITOR
    1. IF OF UNKNOWN ORIGIN GO TO STEP 5
  5. INITIATE IV
  6. IF THE PATIENT EXHIBITS ANY OF THE FOLLOWING TREAT THE PATIENT AS UNSTABLE AND CARDIOVERT. IF THE PATIENT IS STABLE GO TO STEP 8
    1. SHORTNESS OF BREATH
    2. DECREASED LEVEL OF CONSCIOUSNESS
    3. HYPOTENSION
    4. PULMONARY EDEMA
    5. CHEST PAIN
  7. IF PATIENT IS CONSCIOUS GIVE 10 MG VALIUM PRIOR TO CARDIOVERSION
  8. ADMINISTER 1.5 MG/KG LIDOCAINE AND REPEAT UP TO A MAXIMUM OF 3 MG/KG
  9. IF NO RESPONSE TO LIDOCAINE, ADMINISTER 6 MG ADENOSINE RAPID IVP
  10. REPEAT ADENOSINE 12 MG RAPID IVP TWICE AS NEEDED
  11. CARDIOVERT IF PT. BECOMES UNSTABLE AT ANY TIME
  12. TRANSPORT AS INDICATED

 

 

VENTRICULAR FIBRILLATION

AND

PULSLESS VENTRICULAR TACHYCARDIA

 

 

GUIDELINES FOR CARE

 

  1. ASSURE ABC’S
  2. INITIATE AND CONTINUE CPR WITH 100% OXYGEN UNTIL DEFIBRILLATOR IS READY
  3. AS SOON AS DEFIBRILLATOR IS AVAILABLE, DEFIBRILATE UP TO THREE TIMES AT THE SETTINGS BELOW: (REMEMBER, DEFIBRILLATION IS OR MOST EFFECTIVE INTERVENTION IN THIS ARRHYTHMIA, AND SHOULD BE PERFORMED AS SOON AS AVAILABLE WITHOUT DELAY FOR IV LINES, MEDS OR OTHER INTERVENTIONS)
    1. (200 JOULES)
    2. (300 JOULES)
    3. (360 JOULES)
  4. ATTACH CARDIAC MONITOR (IF NOT ALREADY DONE)
  5. INTUBATE
  6. INITIATE IV WITH NORMAL SALINE

 

 

  1. ADMINISTER EPINEPHRINE 1:10,000 1MG IV (*OR VIA ET TUBE AT 2 TO 2 ˝ TIMES THEIR REGULAR DOSE IF NO LINE PRESENT) EVERY 3 TO 5 MINUTES

 

 

  1. DEFIBRILLATE AT 360 JOULES
  2. ADMINISTER AMIODARONE 300 MG IV (DO NOT REPEAT DOSE)
  3. DEFIBRILLATE AT 360 JOULES
  4. ADMINISTER SECOND ANTIARRHYTHMIC

11.0 LIDOCAINE 1.5 MG/KG IV (*OR VIA ET TUBE AT 2 TO 2 ˝

TIMES THEIR REGULAR DOSE IF NO LINE PRESENT), REPEAT ONCE (IF PATIENT CONVERTS AFTER LIDOCAINE BOLUS, HANG LIDOCAINE DRIP AT 2 MG/MIN)

    1. MAGNESIUM SULFATE 2 GM (RECOMMENDED IF TORSADES OR PATIENT IS MALNOURISHED)

 

 

  1. ALTERNATE DRUG-SHOCK-DRUG UNTIL RHYTHM CONVERTS
  2. TRANSPORT 10-33 TRAFFIC TO NEAREST FACILITY

 

 

* REMEMBER, NARCAN, ATROPINE, VALIUM, EPINEPHRINE AND LIDOCAINE (NAVEL) CAN BE ADMINISTERED VIA THE ENDOTRACHEAL TUBE AT 2 TO 2 ˝ TIMES THEIR REGULAR DOSES. This should be followed by a 10 CC flush of NS. THIS, ALONG WITH HYPERVENTILATING THE PATIENT AFTER EACH DRUG ADMINISTRATION VIA THE ET TUBE, WILL AID IN GETTING THE DRUG INTO THE BLOOD STREAM CIRCULATION AND HELP PREVENT CAPILLARY CONSTRICTION IN THE ALVEOLI.