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Region X Cardiac SOP’sEKG Rhythms and
Interventions
Condell Medical CenterEMS System
February 2008Site Code #10-7200E1208
Prepared by: Sharon Hopkins, RN, BSN, EMT-P
ObjectivesUpon 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 SOP’s as they
relate to the patient’s presentation actively participate in case review successfully complete the quiz with a score of 80%
or greater
Introduction to Use of the SOP’s
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
Cardiac SOP’s
Obtaining a history and performing an assessment can often provide valuable information
Consider underlying causes for all situations
In the cardiac SOP’s, think of the 6 H’s and 5 T’s as possible causes of the problem as you progress through assessment & treatment for the patient
6 H’sHypovolemiaHypoxiaHydrogen ion -
acidosisHyper/hypokalemia
(high/low potassium levels)
HypothermiaHypoglycemia
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 rewarmingCheck blood glucose on all
altered mental status pts
5 T’sToxins (overdose)Tamponade, cardiacTension
pneumothorax
Thrombosis, coronary (ACS) or Thrombosis, pulmonary (embolism)
Trauma
Think “out of the box”Check for JVD, B/PCheck 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?
CPR Guidelines (2005 AHA)If witnessed arrest, CPR until defibrillator readyIf unwitnessed or >4-5 minutes, CPR for 2
minutes then defibrillate if indicated30:2 compressions to ventilations for 1 and 2
man adult CPR for 2 minute periods5 cycles of 30:2 is 2 minutesOnce intubated, compressor does not stop;
ventilator bags the patient once every 6-8 seconds via ETT
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
Securing AirwayA term used to indicate to secure the airway in
whatever manner needs to be takenInitially the airway may be secured via BVMInsert oropharyngeal airway if neededThe 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
Asystole
RegularityRateP wavesPR intervalQRS 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.
Asystole
No pulse, no breathing, no B/P!You’ve got a dead patient or a lead popped off
Asystole and DefibrillationThe 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 (they’re already there!)
The patient in PEA has electrical activity and defibrillation would interfere with the one thing that is working for them!
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 H’s and 5 T’s) as you perform CPR and administer medications
PEA <60 bpm
When the underlying rate is under 60 bpm, Atropine is indicated.
Remember “when they’re done, give them one”For asystole and slow PEA <60 give 1 mg Atropine IVP/IO
PEA >60 bpm
If the patient has no pulse, this is PEAKnowing the overall rate helps to
determine if atropine is given or notAtropine not indicated if heart rate on monitor is >60
SOP for Asystole/PEA
Begin CPRSecure airway with minimal interruptionsSearch for and treat causes (6 H’s, 5 T’s)Establish IV/IOMeds
Epinephrine 1:10,000 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
Medications - Epinephrine Stimulates vasoconstrictionSupports improved blood flow to the heart
and brainCan 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
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
Atropine in Asystole & PEA
Asystole“When they’re done, give them one”1 mg every 3-5 minutes Max total dose is 3 mg
PEA Only given if the rate is < 60
If rate >60 then you don’t need the effects of Atropine to speed up the heart rate!
“When they’re done, give them one” 1 mg every 3-5 minutes, max total 3 mg
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 treatmentcheck level of consciousnesscheck blood pressure
Sinus Bradycardia
Regularity
RateP waves
PR interval
QRS complex
Regular P to P and regular R to R
Less than 60 bpmPositive, upright,
rounded, look similar to each other
0.12-0.20 seconds and constant
<0.12 seconds
Sinus Bradycardia
Treatment indicated if the patient is symptomaticEMS needs to provide a thorough assessment
to make an accurate clinical decision
Second Degree Type I - WenckebachRegularity
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 <0.12 seconds
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”
Second Degree Type II - Classical
Regularity
Rate
P wavesPR interval
QRS complex
Atria regular, ventricular rhythm can be regular or not
Atrial rate greater than ventricular rate which is slow
Normal; more P’s than QRS’sUsually normal, constant for
the conducted beatsUsually <0.12 sec;
periodically absent after P waves
Second degree Type II - Classical
This rhythm can have a variable block or can have aset pattern (ie: 2:1; 3:1, 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 2:1” (but know block can be 3:1,etc)
3rd Degree - Complete
Regularity
Rate
P wavesPR intervalQRS 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 & sizeNone (no pattern)Narrow or wide depending on origin of
escape pacemaker
3rd degree - Complete
The patient’s 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
Patient Assessment in Bradycardia
The patient’s symptoms will depend on the ventricular rate which influences the cardiac output
Most reliable is to check the patient’s 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
SOP for Stable Bradycardia
Patient alertSkin is warm and drySystolic B/P > 100 mmHg
Transport with no further intervention
SOP for Unstable BradycardiaAltered mental statusSystolic B/P < 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 IVPMay be repeated every 3-5 minutesMax Atropine is 3 mg “When they’re alive, give 0.5”
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 firstTCP sends electrical charges thru the skinTCP 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
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 patient’s own rate may exceed the pacemaker and put the pacemaker in stand-by (function of the demand mode!)
TCP with Capture - Paced Rhythm
Observed is one to one capture.Consider sedation with Valium to make
the patient more comfortable.
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 possibleIf TCP not effective, can give Atropine 0.5
mg rapid IVP and repeat every 3-5 minutes to a max of 3 mg
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
Dangers of TachycardiaWith 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
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 lastsThe 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
Supraventricular Tachycardia - Narrow QRS
RegularityRateP wavesPR interval
QRS complex
Usually very regular150 - 200 bpmNone visibleNot measured; if P waves
seen, PR interval often abnormal
Usually <0.12 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.
Supraventricular Tachycardia - SVT
This SVT is most likely atrial tachycardiadue to shortened PR interval (abnormal PR interval). The heart rate (180) is too fast for sinus tachycardia.
The QRS is definitely narrow!
SOP for SVT (Narrow QRS)Stable patient (alert, warm & dry, B/P >100
Valsalva maneuverHave 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
Adenosine for SVT
AntiarrhythmicDecreases heart rate at SA node Slows conduction thru AV nodeDoes not convert atrial fibrillation, atrial
flutter or VTShort half life (10 seconds) so start IV in AC
area (preferably right), must be given rapidly followed immediately with saline flush
Adenosine Back-upDiltiazem/cardizem -slows heart rate
If still in stock, can give 0.25 mg/kg IVP slowly over 2 minutes
Watch for drop in blood pressureVerapamil/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 > 100 mmHg Administer fluid challenge if pt hypotensive
Diltiazem/cardizemCalcium channel blockerSlows conduction thru SA and AV nodesSlows ventricular rate for rapid atrial fib or rapid
atrial flutterDo not use in wide QRS rhythms or in WPWGive slowly to minimize side effectsWatch for drop in B/POnset in 3 minutesAs home med, treatment of chronic angina
Verapamil/IsoptinCalcium channel blockerSlows conduction thru AV nodeControls ventricular rate in rapid atrial fib or rapid
atrial flutterDo not use with wide QRS or history of WPW1st dose is 5 mg slow IVPRepeat dose in 15 minutes is 5 mg slow IVPWatch for hypotensionAs home med used for hypertension, angina
Ventricular Tachycardia - VT - This is NOT a narrow QRS!
Wide QRS tachycardia is ventricular tachycardiauntil proven otherwise. Always treat the patient
for the worst case scenario first
Atrial flutter
Regularity
Rate
P waves
PR intervalQRS 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<0.12 seconds unless abnormal
conduction
Atrial Flutter
Note key characteristics of the flutter wavesor the “saw toothed” appearance also called
the “picket fence”
Atrial Fibrillation
RegularityRate
P wavesPR intervalQRS complex
Irregularly irregularAtrial rate 400-600;
ventricular rate variableNo identifiable P wavesNone measured0.12 seconds or less unless
abnormal conduction
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.
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 VerapamilVerapamil 5 mg slow IVP over 2 minutesIf needed, may repeat Verapamil in 15
minutes if B/P remains >100 mmHg (Caution: both meds can cause in B/P)
Ventricular Fibrillation
RegularityRateP wavesPR intervalQRS 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
Ventricular Fibrillation - VF
There is no pulse, no breathing, no B/P.This patient is dead and needs immediate
CPR and defibrillation
Pulseless VT
This is not PEA!PEA does not receive defibrillationPulseless VT is treated just like VF
and requires appropriate defibrillation attempts
If pulseless VT deteriorates to VF, continue with the same SOP
SOP for VF/Pulseless VTBegin CPRIf witnessed, defibrillate ASAPIf unwitnessed, CPR for 5 cycles/2 minutesSecure airwayDefib 360 j or equivalent biphasicResume CPR immediately; 5 cycles/2 minutesEstablish IV/IOIntubateDefib 360 j or equivalent biphasic
SOP for VF/Pulseless VT cont’d
Persistent VF needs meds addedAdd meds during episodes of CPRAfter every 2 minutes of CPR, stop for
a maximum of 10 seconds to check rhythm and then proceed accordingly
Epinephrine 1:10,000 1 mg IVP/IO Repeat every 3-5 minutes for duration of
arrestAfter 2 minutes, check rhythm
Persistent VF/pulseless VT defibrillate
SOP for VF/Pulseless VT cont’dAntidysrhythmics
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 moreAmiodarone 1st dose 300 mg IVP/IOCan repeat in 5 minutes at 150 mg IVP/IOLidocaine 1.5 mg/kg IVP/IOCan repeat in 5 minutes at 0.75 mg/kg IVP
SOP for VF/Pulseless VT cont’d
Continue 2 minutes of CPRStop CPR to check rhythm (< 10 seconds)Continue defibrillation attempts
immediately resuming CPR after defibAlternate Epinephrine with the
antidysrhythmic chosen (ie: Amiodarone or Lidocaine)
Consider & treat causes (6H’s and 5 T’s) as you are progressing through treatment
Ventricular Tachycardia with Pulse
RegularityRateP waves
PR intervalQRS complex
Essentially regularGenerally over 100 bpmGenerally absent; occasionally
may be visible but have no relationship with the QRS
None measurable>0.12 seconds; often difficult
to distinguish between the QRS and T wave
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
SOP for VT with PulseThis is a tachycardiaDetermine 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 AdenosineWide QRS - consider antidysrhythmic
SOP for Stable VT with Pulse
Antidysrhythmics:Amiodarone 150 mg diluted in 100 ml
D5W IVPB over 10 minutes
ORLidocaine 0.75 mg/kg IVPContact Medical Control for further
orders after the initial bolus
Amiodarone IVPBDraw up Amiodarone 150 ml (3ml)Add to a 100 ml bag D5W and gently agitate to
mixLabel the IV bagPrime the minidrip tubing; plug into the main
IV line as close to the patient as possibleTo 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
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 joulesIf needed, synchronize cardiovert at 200 jIf needed, synchronize cardiovert at 300 jIf needed, synchronize cardiovert at 360 j
SOP for Unstable VT cont’d
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 minutesOR
Lidocaine 0.75mg/kg IVPContact Medical Control for further orders
Case Presentations
Determine an initial impressionInterpret the rhythmBased 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
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
What’s your impression & intervention?
IV, O2, monitor, pulse oxConsider 12 lead EKGEKG: 3rd degree/complete heart blockGoal 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
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-monitorYou got a 3 second glance at the monitor
when the patient grabbed their chest, their head fell back, and they became unresponsive
Case #2
What are these rhythms?What action needs to be
taken?Which SOP do you follow?
Case #2The patient was initially NSR and changed
to VT and then quickly deteriorated to VFThis was a witnessed arrest - VF SOPBegin CPR (30:2) until the defibrillator is
charged and readyAfter each defibrillation, immediately
begin CPR for 2 minutes (5 cycles)As the IV was already started, begin the
Epinephrine after the 1st shock
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?
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 defibrillationConsider the causes (6 H’s and 5 T’s) as you
are performing your interventions for PEA
Case #3Medications:
Epinephrine 1:10,000 1 mg IVP/IO every 3-5 minutes for duration of the arrest
No Atropine - the heart rate is > 60 bpmShift 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
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 rhythmIf patient remains in PEA, continue Epinephrine every 3-5
minutes; add Atropine only if the rate falls below 60 bpmrhythm checks are performed when observing a rhythm
that might generate a pulse
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?
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
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 questionsVS: 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 SVTStart with valsalva maneuvers then meds
(Adenosine)
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
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?
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 <100
Treatment goal is to convert this lethal rhythm and restore perfusion as soon as possible
Case #5
Immediate synchronized cardioversion needed If possible, sedate the patient
Cardioversion is a painful procedureVersed 2 mg IVP over 2 minutesCan 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
Case #5
Successive cardioversion energy levels100 joulesIf unsuccessful, 200 joulesIf unsuccessful, 300 joulesIf 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)
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?
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
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 NSRYou 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
Case #7
Now what!!!???You have confirmed the patient is apneic
and pulseless.Begin CPR (witnessed arrest) until
defibrillator chargedCall and look “all clear”, defibrillate at 360 j
or highest biphasic setting
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 signsB/P is rising from 0/0, P - 80, respirations
being assisted by BVM (about 4 -6/minute)
Case #7Any other medications to be given?This patient will not receive Epinephrine -
doesn’t need it nowAs 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 patient’s ventilation status
References & On-Line Review
Aehlert, B. ECG’s Made Easy. 3rd Edition. Mosby. 2006. Region X SOP Effective March 1, 2007Walraven, G. Basic Arrhythmias. 6th Edition. Brady. 2006.Www.co.livingston.mi.us/ems/ekgquiz.htmwww.ambulancetechnicianstudy.co.uk/
rhythms.html