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Region X Cardiac SOP’s EKG Rhythms and Interventions. Condell Medical Center EMS System February 2008 Site Code #10-7200E1208 Prepared by: Sharon Hopkins, RN, BSN, EMT-P. Objectives. Upon successful completion of this module, the EMS provider should be able to:

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Region x cardiac sop s ekg rhythms and interventions l.jpg

Region X Cardiac SOP’sEKG Rhythms and Interventions

Condell Medical Center

EMS System

February 2008

Site Code #10-7200E1208

Prepared by: Sharon Hopkins, RN, BSN, EMT-P


Objectives l.jpg

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 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


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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


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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 s l.jpg

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 H’s


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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?

5 T’s


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CPR Guidelines (2005 AHA)

  • If witnessed arrest, CPR until defibrillator ready

  • If unwitnessed or >4-5 minutes, CPR for 2 minutes then defibrillate if indicated

  • 30:2 compressions to ventilations for 1 and 2 man adult CPR for 2 minute periods

  • 5 cycles of 30:2 is 2 minutes

  • Once intubated, compressor does not stop; ventilator bags the patient once every 6-8 seconds via ETT


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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


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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


Asystole l.jpg

Regularity

Rate

P waves

PR interval

QRS complex

There is no electrical activity; you observe a straight line

Asystole

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.


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Asystole

No pulse, no breathing, no B/P!

You’ve got a dead patient or a lead popped off


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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 (they’re already there!)

  • The patient in PEA has electrical activity and defibrillation would interfere with the one thing that is working for them!


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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


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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


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PEA >60 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 >60


Sop for asystole pea l.jpg

SOP for Asystole/PEA

  • Begin CPR

  • Secure airway with minimal interruptions

  • Search for and treat causes (6 H’s, 5 T’s)

  • Establish IV/IO

  • Meds

    • 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


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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


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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 l.jpg

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


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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


Sinus bradycardia l.jpg

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

<0.12 seconds

Sinus Bradycardia


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Sinus Bradycardia

Treatment indicated if the patient is symptomatic

EMS needs to provide a thorough assessment

to make an accurate clinical decision


Second degree type i wenckebach l.jpg

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 <0.12 seconds

Second Degree Type I - Wenckebach


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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 l.jpg

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 P’s than QRS’s

Usually normal, constant for the conducted beats

Usually <0.12 sec; periodically absent after P waves

Second Degree Type II - Classical


Second degree type ii classical26 l.jpg

Second degree Type II - Classical

This rhythm can have a variable block or can have a

set 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)


3 rd degree complete l.jpg

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

3rd Degree - Complete


3 rd degree complete28 l.jpg

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 l.jpg

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


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SOP for Stable Bradycardia

  • Patient alert

  • Skin is warm and dry

  • Systolic B/P > 100 mmHg

    Transport with no further intervention


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SOP for Unstable Bradycardia

  • Altered mental status

  • Systolic 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 IVP

      • May be repeated every 3-5 minutes

      • Max Atropine is 3 mg

      • “When they’re alive, give 0.5”


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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


Tcp and patient assessment l.jpg

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!)


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TCP with Capture - Paced Rhythm

Observed is one to one capture.

Consider sedation with Valium to make

the patient more comfortable.


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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


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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 tachycardia l.jpg

    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


    Tachycardia and the patient l.jpg

    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


    Supraventricular tachycardia narrow qrs l.jpg

    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 <0.12 seconds unless abnormal conduction

    Supraventricular Tachycardia - Narrow QRS

    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 l.jpg

    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!


    Sop for svt narrow qrs l.jpg

    SOP for SVT (Narrow QRS)

    • Stable patient (alert, warm & dry, B/P >100

      • 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


    Adenosine for svt l.jpg

    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


    Adenosine back up l.jpg

    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 > 100 mmHg

      • Administer fluid challenge if pt hypotensive


    Diltiazem cardizem l.jpg

    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


    Verapamil isoptin l.jpg

    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


    Ventricular tachycardia vt this is not a narrow qrs l.jpg

    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


    Atrial flutter l.jpg

    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

    <0.12 seconds unless abnormal conduction

    Atrial flutter


    Atrial flutter48 l.jpg

    Atrial Flutter

    Note key characteristics of the flutter waves

    or the “saw toothed” appearance also called

    the “picket fence”


    Atrial fibrillation l.jpg

    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

    Atrial Fibrillation


    Atrial fibrillation50 l.jpg

    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 l.jpg

    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 >100 mmHg

      (Caution: both meds can cause  in B/P)


    Ventricular fibrillation l.jpg

    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

    Ventricular Fibrillation


    Ventricular fibrillation vf l.jpg

    Ventricular Fibrillation - VF

    There is no pulse, no breathing, no B/P.

    This patient is dead and needs immediate

    CPR and defibrillation


    Pulseless vt l.jpg

    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


    Sop for vf pulseless vt l.jpg

    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


    Sop for vf pulseless vt cont d l.jpg

    SOP for VF/Pulseless VT cont’d

    • 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 1:10,000 1 mg IVP/IO

      • Repeat every 3-5 minutes for duration of arrest

    • After 2 minutes, check rhythm

      • Persistent VF/pulseless VT defibrillate


    Sop for vf pulseless vt cont d57 l.jpg

    SOP for VF/Pulseless VT cont’d

    • 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


    Sop for vf pulseless vt cont d58 l.jpg

    SOP for VF/Pulseless VT cont’d

    • Continue 2 minutes of CPR

    • Stop CPR to check rhythm (< 10 seconds)

    • Continue defibrillation attempts immediately resuming CPR after defib

    • Alternate 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 l.jpg

    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

    >0.12 seconds; often difficult to distinguish between the QRS and T wave

    Ventricular Tachycardia with Pulse


    Ventricular tachycardia vt l.jpg

    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 pulse l.jpg

    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


    Sop for stable vt with pulse l.jpg

    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


    Amiodarone ivpb l.jpg

    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


    Sop for unstable vt l.jpg

    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


    Sop for unstable vt cont d l.jpg

    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 minutes

        OR

      • Lidocaine 0.75mg/kg IVP

    • Contact Medical Control for further orders


    Case presentations l.jpg

    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


    Case 1 l.jpg

    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 l.jpg

    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

    What’s your impression & intervention?


    Case 2 l.jpg

    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


    Case 270 l.jpg

    What are these rhythms?

    What action needs to be taken?

    Which SOP do you follow?

    Case #2


    Case 271 l.jpg

    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 (30:2) 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


    Case 3 l.jpg

    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 373 l.jpg

    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 H’s and 5 T’s) as you are performing your interventions for PEA

    Case #3


    Case 374 l.jpg

    Case #3

    • Medications:

      • Epinephrine 1:10,000 1 mg IVP/IO every 3-5 minutes for duration of the arrest

      • No Atropine - the heart rate is > 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


    Case 375 l.jpg

    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


    Case 4 l.jpg

    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 477 l.jpg

    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


    Case 478 l.jpg

    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)


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    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


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    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?


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    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


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    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


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    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)


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    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?


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    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 #6


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    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


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    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

    Case #7


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    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)

    Case #7


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    Case #7

    • Any other medications to be given?

    • This patient will not receive Epinephrine - doesn’t 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 patient’s ventilation status


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    References & On-Line Review

    • Aehlert, B. ECG’s 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


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