Rhode Island Emergency Medical Services Statewide EMS ProtocolsOctober 2016Rhode Island Department of Health

Cardiac ProtocolsSection 3

Cardiac ProtocolsGeneral Changes and Additions• This section was previously titled Cardiac Emergencies. • This section has 8 protocols. • READ PEARLS – Pearls contain critical educational information to

understand protocol management and may contain care direction.

Cardiac ProtocolsNew Protocol Previous Protocol

Previous Protocol Section

3.01 Acute Decompensated Heart Failure/Pulmonary Edema 2.6 Congestive Heart Failure (Pulmonary Edema)

Cardiac Emergencies

3.02 Chest Pain - Acute Coronary Syndrome - STEMI2.5 Chest Pain - 2.8 ST-Elevation Myocardial Infarction (STEMI) [ALS]

Cardiac Emergencies

03.03A Cardiac Arrest - Adult

2.1 Cardiac Arrest 2.7 Pulseless Electrical Activity 2.13 Ventricular Fibrillation and Pulseless Ventricular Tachycardia

Cardiac Emergencies

03.03P Cardiac Arrest - Pediatric 2.1 Cardiac ArrestCardiac Emergencies

03.04A Post Cardiac Arrest Care - Adult New – did not exist in previous versionCardiac Emergencies

03.04P Post Cardiac Arrest Care - Pediatric New – did not exist in previous versionCardiac Emergencies

03.05A Cardiac Dysrhythmia - Bradycardia - Adult 2.3 Bradycardia (Adult, Symptomatic) [ALS]Cardiac Emergencies

03.05P Cardiac Dysrhythmia - Bradycardia - Pediatric 2.4 Bradycardia (Pediatric, Symptomatic) [ALS]Cardiac Emergencies

03.06A Cardiac Dysrhythmia - Narrow Complex Tachycardia - Adult 2.9 - 2.10 Supraventricular Tachycardia

Cardiac Emergencies

03.06P Cardiac Dysrhythmia - Narrow Complex Tachycardia - Pediatric 2.11-2.12 Supraventricular Tachycardia

Cardiac Emergencies

03.07A Cardiac Dysrhythmia - Wide Complex Tachycardia - Adult

2.14 – 2.15 Ventricular Tachycardia (Stable/Unstable)

Cardiac Emergencies

03.07P Cardiac Dysrhythmia - Wide Complex Tachycardia - Pediatric New – did not exist in previous version3.08 Care of the Patient with a Ventricular Assist Device (VAD) New – did not exist in previous version

3.01 Acute Decompensated Heart Failure - Pulmonary EdemaProtocol Summary

• Previously protocol 2.6 Congestive Heart Failure (Pulmonary Edema).

• This protocol recognizes and provides standing orders for patients with respiratory distress, dyspnea on exertion, orthopnea, bilateral crackles on lung auscultation, jugular venous distention, peripheral edema, diaphoresis, hypotension, shock, chest pain/discomfort.

• This protocol is divided into different levels of care.• Routine Patient Care.• Continuous Positive Airway Pressure.• Manage as per Chest Pain – Acute Coronary Syndrome –

STEMI protocol. • Manage as per General Shock and Hypotension Protocol. • CONSIDER ALS INTERCEPT.• Advanced EMT Cardiac may treat with NITROGLICERIN

0.4 mg SL.• Consider FUROSEMIDE 10-80 mg IV if transport time

is ≥ 30 min and patient is normotensive.• MEDICAL CONTROL for MIDAZOLAM 1-2 mg IV for

mask compliance. • NITROGLYCERIN 0.4 mg SL (tablet or lingual spray).

• NITROGLYCERIN IV.• ENALAPRILAT 1.25 mg IV/IO for the patient

unresponsive to nitroglycerin with a SBP >140. • Consider MIDAZOLAM 1-2 mg IV if needed for

mask compliance.• Consider FUROSEMIDE 10-80 mg IV if the transport

time is ≥ 30 min and the patient takes oral furosemide and the patient has SBP≥100.

3.02 Chest Pain - Acute Coronary Syndrome - STEMI

Protocol Summary • Previously protocol 2.5 Chest Pain and 2.8 ST-Elevation Myocardial

Infarction (STEMI) [ALS].• This protocol recognizes and provides standing orders for patients with

complaints of chest pain/discomfort consistent with a cardiac etiology or other known or suspected anginal equivalents, patients with STEMI including posterior MI, and patient with new onset left bundle branch block (must be evaluated in context with symptoms).

• This protocol is divided into different levels of care.• Routine Patient Care.• ASPIRIN 81 mg. • Prescribed NITROGLYCERIN. • Multi-lead ECG.• CODE STEMI.• NITROGLYCERIN 0.4 mg SL.• Manage as per Patient Comfort Protocol/ General Shock

and Hypotension Protocol/ Cardiac Dysrhythmia protocols.

• SAME MANAGEMENT AS Advanced EMT Cardiac .

• + IV Nitroglycerin by IV infusion.

3.03 Adult - Cardiac ArrestProtocol Summary • Previously protocol 2.1 Cardiac

Arrest.• This protocol recognizes and

provides standing orders for patients in Cardiac Arrest.

• This protocol is divided into different levels of care.

All Providers: • Routine Patient Care.• CONTINUE or BEGIN HIGH QUALITY CPR IMMEDIATELY.• Limit interruptions/pauses. • RESUSCITATIVE EFFORTS SHOULD CONTINUE FOR A

MINIMUM OF 30 MINUTES PRIOR TO MOVING THE PATIENT UNLESS TRAUMA OR UNSAFE LOCATION.

• See Reversible Causes of Cardiac Arrest.• If ROSC, then manage per Post Cardiac Arrest Care Protocol.

Advanced EMT Cardiacs• Early Interosseous Placement

above diaphragm.• EPINEPHRINE (1:10,000) 1 mg

IV/IO.• AMIODARONE 300 mg IV/IO

and/or Lidocaine 100 mg IV/IO for VF/PVT.

• DSED for refractory VF/PVT.• Fluid bolus for PEA Arrest and

suspected hypovolemia. Paramedics• Same as Advanced EMT

Cardiac. • + Procainamide and

Metoprolol for refractory or recurrent VF/PVT.

• +Needle thoracostomy for PEA arrest with suspected tension pneumothorax.

• + Magnesium for Torsades de Pointes or hypomagnesemia.

3.03 Pediatric - Cardiac Arrest

Protocol Summary • Previously integrated in protocol 2.1 Cardiac Arrest.• This protocol delineates care for pediatric patients in Cardiac Arrest.• This protocol is divided into different levels of care.

Advanced EMT Cardiacs• Early Interosseous Placement

above diaphragm if age appropriate.

• EPINEPHRINE (1:10,000) 0.01 mg/kg IV/IO.

• AMIODARONE and/or LIDOCAINE for VF/PVT.

• Refractory VF/PVT change pads or site.

• Fluid bolus for PEA Arrest.• Note that Naloxone is not

indicated for cardiac arrest.Paramedics• Early IO placement above diaphragm if age appropriate.• EPINEPHRINE (1:10,000) 0.01 mg/kg IV/IO.• AMIODARONE and/or LIDOCAINE for VF/PVT.• Refractory VF/PVT change pads or site.• Needle thoracostomy for PEA arrest with suspected tension

pneumothorax. • Fluid bolus for PEA Arrest.• Magnesium sulfate 40mg/kg for Torsades de Pointes.• Gastric tube placement for distention.

All Providers: • Routine Patient Care.• CONTINUE or BEGIN HIGH QUALITY CPR IMMEDIATELY .• Limit interruptions/pauses.• RESUSCITATIVE EFFORTS SHOULD CONTINUE FOR A MINIMUM OF

30 MINUTES PRIOR TO MOVING THE PATIENT UNLESS TRAUMA OR UNSAFE LOCATION.

• REQUEST ALS, if available.• See Reversible Causes of Cardiac Arrest.• If ROSC, then manage per Post Cardiac Arrest Care Protocol.

3.04Adult - Post Cardiac Arrest Care

Protocol Summary • This is a new protocol.• This protocol recognizes and provides standing orders for

patients who need post Cardiac Arrest Care.• This protocol is divided into different levels of care.All Providers: • Routine Patient Care.• Once ROSC is achieved, do not move patient for 10

minutes unless trauma or danger. Maintain constant palpation of pulse during this period.

• Provide airway and ventilator management as needed.• Manage hypotension/shock.• Perform blood glucose analysis.• Transport to PCI capable facility if indicated.

Advanced EMT Cardiac:• Waveform Capnography.• Acquire multi-lead ECG.• Manage cardiac dysrhythmias.

Paramedic:• Manage as for Advanced EMT Cardiac.• Consider AMIODARONE or LIDOCAINE infusion.• Consider gastric tube placement.• Consider sedation and analgesia.

3.04 Pediatric - Post Cardiac Arrest Care

Protocol Summary • This is a new protocol.• This protocol recognizes and provides

standing orders for pediatric patients who need post Cardiac Arrest care.

• This protocol is divided into different levels of care.All Providers:

• Routine Patient Care.• Once ROSC is achieved, do not move patient

for 10 minutes. Maintain constant palpation of pulse during this period.

• Provide airway management.• Manage hypotension/shock.• Perform blood glucose analysis.• Transport patient (consider transport to a

pediatric specialty care facility).

Advanced EMT Cardiac:• Waveform capnography.• Acquire multi-lead ECG.• Manage cardiac dysrhythmias.

Paramedic:• Manage as per Advanced EMT Cardiac.• Consider gastric tube placement.• Consider sedation and analgesia.

3.05 Adult - Bradycardia - Cardiac Dysrhythmia

Protocol Summary • Previously protocol 2.3 Bradycardia (Adult,

Symptomatic) [ALS].• This protocol recognizes and provides standing

orders for adult patients with heart rate < 60 with a pulse and evidence of poor perfusion.

• This protocol is divided into different levels of care.

All Providers: • Routine Patient Care• Assess• Unstable patients - monitor and reassess• Consider treatable etiologies• TransportAdvanced EMT Cardiac:• ATROPINE SULFATE 0.5-0.1 mg IV/IO• Transcutaneous pacing (TCP) [manage as per

Patient Comfort Protocol if sedation or analgesia are required]

• NORMAL SALINE 250-500 ml IV/IOParamedic:• Manage as per Advanced EMT Cardiac• Consider DOPAMINE HCL 2-10 mcg/kg/min or

EPINEPHRINE 2-10 mcg/min IV/IO if refractory to TCP

3.05Pediatric - Bradycardia - Cardiac Dysrhythmia

Protocol Summary • Previously protocol 2.4 Bradycardia (Adult,

Symptomatic) [ALS].• This protocol recognizes and provides standing

orders for pediatric patients with heart rate < 60 with a pulse and evidence of poor perfusion.

• This protocol is divided into different levels of care.

All Providers: • Routine Patient Care• Assess appropriateness of heart rate for

clinical situation • Maintain adequate oxygenation and

ventilation• Consider treatable etiologies• TransportAdvanced EMT Cardiac:• NORMAL SALINE 20 ml/kg IV/IO• EPINEPHRINE (1:10,000) 0.01 mg/kg IV/IO• ATROPINE SULFATE 0.02 mg/kg IV/IO• Transcutaneous Pacing (TCP) [manage as per

Patient Comfort Protocol if sedation or analgesia are required]

Paramedic:• Manage as per Advanced EMT Cardiac• If no IV/IO access is available for ATROPINE,

consider 0.04- 0.06 mg/kg via ETT• Consider DOPAMINE 2-10 mcg/kg/min if

refractory to TCP.

3.06 Adult - Narrow Complex Tachycardia - Cardiac Dysrhythmia

Protocol Summary • Previously protocols 2.9 and 2.10 Supraventricular

Tachycardia.• This protocol recognizes and provides standing orders for

adult patients with a narrow complex QRS (≤0.12 sec) and a pulse.

• This protocol is divided into different levels of care.All Providers: • Routine Patient Care.• Transport.Advanced EMT Cardiac:• Observe minimally

symptomatic patients.• Treat unstable/pre arrest

patientso Synchronized

CARDIOVERSION o Pre-shock sedation

• If Regular Rhythm o VAGAL maneuverso ADENOSINE 12 mg IV PUSH,

may repeat X1o Contact MEDICAL CONTROL

for DILTIAZEM 0.25 mg/kg IV/IO, may repeat 0.35 mg/kg IV/IO

Paramedic:• Unstable/Pre Arrest Patient

o Synchronized CARDIOVERSION and pre-shock sedation • Regular Rhythm

o Vagal maneuverso ADENOSINE 12 mg, may repeat X1o DILTIAZEM 0.25 mg/kg IV/IO, may repeat 0.35 mg/kg IV/IOo METOPROLOL 2.5-5 mg IV, may repeat to a max of 15 mg

3.06 Pediatric - Narrow Complex Tachycardia - Cardiac Dysrhythmia

Protocol Summary • Previously integrated in Protocols 2.9 and 2.10

Supraventricular Tachycardia.• This protocol recognizes and provides standing orders for

pediatric patients with a narrow complex QRS (≤0.12 sec) and a pulse.

• This protocol is divided into different levels of care.All Providers: • Routine Patient Care• TransportAdvanced EMT Cardiac:• Unstable/pre arrest patient

o Synchronized CARDIOVERSION

o Pre-shock sedation • Sinus Tachycardia consider

underlying etiologies• Observe minimally

symptomatic patients• For Stable patients obtain

multi-lead ECG• Vagal maneuvers• Contact MEDICAL

CONTROL for ADENOSINE 0.1 mg/kg rapid IV/IO, may repeat X1 Paramedic:

• Unstable/pre arrest patient: synchronized CARDIOVERSION, consider pre-shock sedation

• For sinus tachycardia consider underlying etiologies• Observe minimally symptomatic patients• For stable patients obtain multi-lead ECG• Vagal maneuvers• ADENOSINE 0.1 mg/kg rapid IV/IO push (may repeat X1), if

ineffective, AMIODARONE 5 mg/kg IV/IO

3.07 Adult - Wide Complex Tachycardia - Cardiac Dysrhythmia

Protocol Summary • Previously protocols 2.14 – 2.15 Ventricular Tachycardia

(Stable/Unstable).• This protocol recognizes and provides standing orders for

adult patients with a wide complex QRS (≥0.12 sec) tachycardia and a pulse.

• This protocol is divided into different levels of care.All Providers: • Routine Patient Care• TransportAdvanced EMT Cardiac:• Unstable/pre arrest patient, synchronized

CARDIOVERSION (consider pre-shock sedation). • If rhythm is regular with monomorphic complexes,

ADENOSINE 12 mg IV/IO, may repeat X1.• Contact MEDICAL CONTROL for:

o AMIODARONE 150 mg IV/IO oro LIDOCANE 1-1.5 mg/kg IV/IO

Paramedic:• Unstable/pre arrest patient, synchronized CARDIOVERSION (consider pre-

shock sedation) • If rhythm is regular with monomorphic complexes, ADENOSINE 12 mg IV/IO,

may repeat X1.• AMIODARONE 150 mg IV/IO or• PROCAINAMIDE 25- 50 mg/min or• LIDOCAINE 1- 1.5 mg/kg• Polymorphic ventricular tachycardia/Torsades de Pointes, MAGNESIUM

SULFATE 1-2 gm IV/IO

3.07 Pediatric - Wide Complex Tachycardia - Cardiac Dysrhythmia

Protocol Summary • Previously protocols 2.14-2.15 Ventricular

Tachycardia (Stable/Unstable).• This protocol recognizes and provides

standing orders for pediatric patients with a wide complex QRS (≥0.09 sec) tachycardia and a pulse.

• This protocol is divided into different levels of care.All Providers:

• Routine Patient Care.• Transport (consider transport to a pediatric

specialty care facility).Advanced EMT Cardiac:• Unstable/pre arrest patient, synchronized

CARDIOVERSION (consider preshock sedation) • Stable patient, obtain multi-lead ECG• Contact MEDICAL CONTROL for:

o AMIODARONE 5 mg/kgo LIDOCANE 1 mg/kg IV/IO

Paramedic:• Unstable/prearrest Patient, synchronized

CARDIOVERSION (consider pre-shock sedation)

• Stable Patient, obtain a multi-lead ECG• Consider AMIODARONE 5 mg/kg or LIDOCANE

1 mg/kg IV/IO• Polymorphic ventricular tachycardia/Torsades

de Pointes, MAGNESIUM SULFATE 1-2 gm IV/IO

3.08 Patient with a Ventricular Assist Device (VAD)

Protocol Summary • This is a new protocol.• This protocol recognizes and provides standing orders for

patients with a ventricular assist device.• This protocol is for all levels of care.

All Providers: • Routine Patient Care• Assess the patient• Assess the VAD• Usually there is no palpable

pulse or measurable blood pressure unless a pulsatile flow device

• If indication of possible device malfunction or failure, contact coordinator.

• If patient is unresponsive, pulseless (no signs of life) with non-functioning pump troubleshoot pump before compressions.

• Transport patient with a VAD problem to their VAD hospital

• Bring all resources (batteries etc.)

Continue on to RI EMS Protocol Education ModulesSection 4