Transcript February 2008 - Advocate Health Care

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:
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’s
Hypovolemia
 Give fluids (20 ml/kg)
Hypoxia
 Provide supplemental O2
Hydrogen ion  Ventilate to blow off
acidosis
retained CO2
Hyper/hypokalemia  Difficult to determine in the
(high/low potassium field; consider in diabetic
levels)
ketoacidosis & renal dialysis
Hypothermia
 Attempt rewarming
Hypoglycemia
 Check blood glucose on all
altered mental status pts
5 T’s
Toxins (overdose)
 Think “out of the box”
Tamponade, cardiac  Check for JVD,  B/P
 Check for JVD,  B/P,
Tension
pneumothorax
absent/decreased breath
sounds, difficulty bagging
Thrombosis, coronary  Obtain 12 lead when
(ACS) or Thrombosis, applicable; good history
pulmonary
taking to lead to suspicions
(embolism)
(travel, surgery, immobility)
Trauma
 What is history of current
status?
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
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 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
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.
Asystole
No pulse, no breathing, no B/P!
You’ve got a dead patient or a lead popped off
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!
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 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
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
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
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 treatment
check level of consciousness
check blood pressure
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
 <0.12 seconds
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
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
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 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
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)
3rd Degree - Complete
 Atria regular, ventricular rhythm
regular but independent of each
other
 Atrial rate greater than ventricular;
Rate
ventricular rate determined by origin
of escape rhythm (can be slow or
normal)
 Normal in shape & size
P waves
PR interval  None (no pattern)
QRS complex  Narrow or wide depending on origin
of escape pacemaker
Regularity
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 alert
Skin is warm and dry
Systolic B/P > 100 mmHg
Transport with no further intervention
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”
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
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 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
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
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
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
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
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 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)
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
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
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
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
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!
Wide QRS tachycardia is ventricular tachycardia
until proven otherwise. Always treat the patient
for the worst case scenario first
Atrial flutter
 Atria regular; ventricular rhythm
can be regular or irregular
Rate
 Atrial rate 250+, ventricular rate
variable
 No identifiable P waves; saw
P waves
tooth or picket fence pattern
noted
PR interval
 Not measurable
QRS complex  <0.12 seconds unless abnormal
conduction
Regularity
Atrial Flutter
Note key characteristics of the flutter waves
or the “saw toothed” appearance also called
the “picket fence”
Atrial Fibrillation
 Irregularly irregular
 Atrial rate 400-600; ventricular
rate variable
 No identifiable P waves
P waves
 None measured
PR interval
QRS complex  0.12 seconds or less unless
abnormal conduction
Regularity
Rate
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 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
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 - 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 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
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
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’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’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
 Essentially regular
 Generally over 100 bpm
 Generally absent; occasionally
may be visible but have no
relationship with the QRS
PR interval
 None measurable
QRS complex  >0.12 seconds; often difficult to
distinguish between the QRS and
T wave
Regularity
Rate
P waves
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
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
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
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
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
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
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
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 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
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 #2
What are these rhythms?
What action needs to be taken?
Which SOP do you follow?
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
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 defibrillation
Consider the causes (6 H’s and 5 T’s) as you are
performing your interventions for PEA
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 #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
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 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)
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 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
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)
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 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
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
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)
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
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