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