Follow General Medical Protocol.
Mandatory interventions:
a. Cardiac monitoring
b. Oxygen
c. IV access
d. 12 lead EKG
Assess for the following signs or symptoms of distress. If any are present, treat per appropriate protocol.
a. Shortness of breath
b. Chest pain
c. Acute CHF
d. Hypotension
e. Altered mental of status
BRADYCARDIA / HEART BLOCKS (including 2nd & 3rd degree blocks)
If the any of the above symptoms are present AND the patient’s heart rate (HR) < 55 bpm AND SBP < 90 mm Hg:
a. Administer ATROPINE 0.5 – 1 mg IV every 5 minutes as needed until either SBP > 100 OR HR > 55 (maximum 3 mg). (Remember - 3rd degree heart blocks seldom respond to atropine administration.)
b. If no response to atropine after a total 3 mg given AND patient is symptomatic, initiate transcutaneous pacing. (Anticipate need for pain control and/or sedation. Contact Medical Control.)
If patient is on chronic beta blocker therapy and:
a. STABLE
i. No therapy is needed.
b. UNSTABLE
i. Follow the Poisoning / Overdose Protocol subsection Beta blocker.
NEVER administer lidocaine or amiodarone for PVC’s associated with a HR < 55. Treat the bradycardia with atropine as above.
TACHYCARDIA
Assess wave formation and treat based on stability of patient:
a. NARROW-COMPLEX
i. Sinus tachycardia (treat underlying condition)
ii. Supraventricular tachycardia [REGULAR]
iii. Atrial fibrillation/flutter [REGULAR or IRREGULAR]
b. WIDE-COMPLEX
i. Atrial fibrillation/flutter [REGULAR or IRREGULAR]
ii. Monomorphic ventricular tachycardia
iii. Polymorphic ventricular tachycardia (“Torsades”)
Only patients who are STABLE should be treated with the following drugs. If, at any time, the patient becomes UNSTABLE, immediate cardioversion should be performed (see Cardioversion Protocol).
UNSTABLE is defined as SBP < 80, severe chest pain, respiratory distress, NEW altered mental status, or worsening condition.
SUPRAVENTRICULAR TACHYCARDIA (NO P waves)
a. Administer ADENOSINE (Adenocard) 6 mg rapid IV followed by 10 mL saline flush. If transient or no response after 1 minute, administer ADENOSINE (Adenocard) 12 mg rapid IV followed by 10 mL saline flush.
ATRIAL FIBRILLATION / FLUTTER with Rapid Ventricular Rate (RVR)
a. Administer DILTIAZEM (Cardizem) 20 mg IV over 2 minutes. This dose (20 mg) may be repeated after 15 minutes if HR > 140.
IF DILTIAZEM (Cardizem) IS NOT AVAILABLE
b. Administer AMIODARONE 150 mg (mixed in 100 mL D5W) IV over 10 minutes. This may be repeated once at same dose in 10 – 30 minutes if patient remains in this rhythm.
WIDE-COMPLEX TACHYDYSRHYTHMIA
a. Administer AMIODARONE 150 mg (mixed in 100 mL D5W) IV over 10 minutes. This may be repeated once at same dose in 10 – 30 minutes if patient remains in this rhythm.
b. If rhythm does not respond to amiodarone, you may administer LIDOCAINE (Xylocaine) 100 mg IV and begin LIDOCAINE DRIP at 2 mg/min.
POLYMORPHIC VENTRICULAR TACHYCARDIA (“Torsades”)
a. Administer MAGNESIUM SULFATE 50% 2 grams IV over 2 minutes.
b. If inadequate response, administer AMIODARONE 150 mg IV over 10 minutes.
c. If the patient deteriorates into pulseless ventricular tachycardia or ventricular tachycardia, immediately defibrillate as per Cardiac Arrest Protocol.