1. Clinical condition of bradycardia
    HR typically less than 50 bpm
  2. What is first step (bradycardia with pulse)
    • ID and treat underlying cause:
    • maintain airway, assist breathing if needed
    • O2, if hypoxemic
    • Cardiac monitor to ID rhythm
    • Monitor BP & pulse ox
    • Iv access
    • 12 lead ECG if avaliable
  3. If bradycardia is not causing any problems...
    Monitor and observe
  4. What can s/s can bradycardia cause?
    • Hypotension
    • Acutely altered mental status
    • signs of shock
    • Ischemic chest discomfort
    • Acute heart failure
  5. What step to take if bradycardia causing s/s
    What drugs are used for Bradycardia
    • Administer Atropine
    • If uneffective:
    • Transcutaneous pacing
    • OR Dopamine infusion
    • OR epi infusion

    *Consider expert consultation
  6. Transcutaneous pacing
    • a temporary means of pacing a patient's heart during a medical emergency.
    • It is accomplished by delivering pulses of electric current through the patient's chest, which stimulates the heart to contract.
    • Alternative is drug therapy
  7. Dose/details for atropine (bradycardia)
    • Atropine Iv doses:
    • First dose 0.5 mg bolus
    • Repeat every 3-5 mins
    • Max 3 mg.

    *is the first drug of choice for bradycardia. Increases heart rate
  8. Dose/details for Dopamine (bradycardia)
    • second-line drug for bradycardia when atropine is ineffective
    • IV infusion:
    • Usual infusion rate is 2-20 mcg/kg per min
    • Titrate to pt response

    • *Causes increased HR 
    • also used to treat hypotension
  9. Dose for epi (bradycardia)
    • Alternative drug for bradycardia if atropine don't work
    • 2-10 mcg per minute infusion via IV
    • Titrate to pt response
  10. What's first the cardiac arrest algorithm
    • Start CPR & attach monitor/defib
    • Analyze rhythm
  11. What drugs are used for cardiac arrest
    • Epi
    • Amiodarone
  12. Dose/details for epi FOR CARDIAC ARREST
    • EPI given via IV/IO
    • 1 mg every 3-5 min

    Is a vasopressor... causes vasoconstriction and increase cardiac output
  13. Dose/details for Amiodarone for cardiac arrest
    • Given IV/IO
    • First dose: 300 mg bolus
    • 2nd dose: 150 mg

    antiarrhythmic medication
  14. In cardiac arrest algorithm, what if rhythm is NOT shockable???
    • It's Asystole/PEA
    • Continue CPR for 2 min
    • Gain IV/IO access
    • Give EPI every 3-5 min 
    • Consider advanced airway & capnography

    *after 2 mins, reanalyze
  15. You reanalyze cardiac arrest that was not shockable... it's still not shockable. What do you do?
    • Continue CPR
    • Treat reversible causes
    • Reanalyze after 2 mins
  16. You reanalyze cardiac arrest that was not shockable... it's still not shockable. What do you do?
    • *If no s/s of ROSC, continue w cpr, epi, etc.
    • *If ROSC, follow Post-cardiac arrest care algorithm
  17. You reanalyze a cardiac arrest that was not shockable... it is now shockable. What do you do?
    • Shock!
    • Give epi every 3-5 min (or amiodarone, depending on where you are with drugs)
    • If haven't done so yet, consider airway and capnography
    • reanalyze rhythm after 2 mins of CPR
  18. You reanalyze a cardiac arrest that was at first not shockable. At the first rhythm reassess, it was shockable. You shocked, gave epi and considered an airway. When you reanalyze, your able to shock again. What do you do now?
    • Shock
    • continue CPR
    • Give Amiodarone
    • Treat reversible causes

    *continue cycles of CPR and shock until ROSC
  19. For cardiac arrest, what is epi dose?
    • IV/IO
    • 1 mg every 3-5 mins
  20. For cardiac arrest, what is amiodarone dose?
    • IV/IO
    • First dose: 300 mg bolus
    • Second dose: 150 mg

    *antiarrhythmic medication used to treat v-tach or v-fib
  21. Synchronized cardioversion, initial recommended doses
    • Narrow regular: 50-100 J
    • Narrow irregular: 120-200 J for biphasic OR 200 J monophasic
    • Wide regular: 100 J
    • Wide irregular:  defib dose (not synchronized)
  22. Biphasic vs monophasic defib
    Monophasic Waveforms: A type of defibrillation waveform where a shock is delivered to the heart from one vector

    Biphasic Waveforms: A type of defibrillation waveform where a shock is delivered to the heart via two vectors.
  23. Clinical condition for pt w tachycardia w pulse
    First steps in treatment
    • Heart rate typically ≥ 150 bpm
    • Maintain airway
    • O2 if hypoxic
    • Obtain cardiac moniter to ID rhythm
    • monitor vitals
  24. What to if tachycardia is causing:
    Acutely altered LOC
    Signs of shock
    Ischemic chest discomfort
    Acute heart failure
    • Synchronized cardioversion
    • Consider sedation
  25. What is tachycardia isn't causing:
    altered LOC
    Signs of shock
    Ischemic chest discomfort
    acute heart failure
    • Look at rhythm, specifically QRS
    • Is it Wide?
    • Is it ≥ 0.12 seconds?
  26. With tachycardia, that isn't causing hypotension, altered LOC, sx of shock, chest discomfort of acute heart failure...
    You have looked at the rhythm on the monitor.  The QRS wave is wide, ≥ 0.12 sec. What do you do?
    • Obtain IV access & 12 lead ECG (if available)
    • Consider adenosine (only if regular and monomorphic
    • Consider antiarrhythmic infusion
  27. With tachycardia, when should you consider using adenosine?
    • With wide QRS, ≥ 0.12 sec
    • ONLY if reg and monomorphic

    • *Adenosine is an antiarrhythmic that works by  slowing the electrical conduction in the heart, slowing heart rate, or normalizing heart rhythm.
    • *Is the scariest drug you'll push. Monitor will show flat line, then should allow electrical component of heart to realine
  28. Dose info for adenosine with tachycardia
    • IV
    • First dose: 6 mg rapid IV push, followed by NS flush

    • Second dose: 12 mg, if required
    • Very short half life (2 secs)
    • Will stop heart, allow it to reset. Scary drug!
  29. How would you administer an antiarrhythmic infusion for a stable wide QRS tachycardic pt
    • With Procainamide via IV dose:
    • 20-50 mg/min until arrhythmia suppressed, hypotension ensues, QRS duration increases >50% OR MAX dose of 17 mg/kg
    • Maintenance infusion: 1-4 mg/min

    *Avoid if prolonged QT or CHF
  30. Your pt is tachycardic with a pulse. Not causing hypotension, altered LOC, shock, chest discomfort, or acute heart failure. After looking at rhythm, the QRS is NOT wide and is ≤ 0.12 sec. What do you do?
    • Obtain IV access & 12 lead, if available
    • Do vagal maneuvers
    • Give Adenosine (IF REGULAR)
    • Give Beta-blocker or calcium channel blocker
  31. What dose would you use of Amiodarone for a tachycardic pt
    • First dose: 150 mg over 10 mins
    • Repeat as needed if VT recurs
    • Follow by maintenance infusion of 1 mg/min for first 6 hours
  32. What dose of Sotalol can be used for tachycardic pt
    • Sotalol is beta blocker
    • 100 mg (1.5 mg/kg) over 5 mins
    • *Avoid if QT prolonged!
  33. ROSC
    • Return of Spontaneous Circulation.. pulse and BP
    • Abrupt sustained increase in PETCO2 (typically ≥40 mm Hg)
    • Spontaneous arterial pressure waves with intra arterial monitoring
  34. After cardiac arrest, you pt finally experiences ROSC. What now
    • Optimize ventilation and oxygenation:
    • Maintain o2 sat ≥94%
    • Consider airway/waveform capnography
  35. How to treat for hypotension after cardiac arrest?
    Give IV/IO bolus: approx 1-2 L NS or lactated Ringer

    Vasopressor infusion: either epi, dopamine, or norephiniphrine
  36. Dose for epi in post-cardiac arrest
    • IV infusion
    • 0.1 - 0.5 mcg/kg per min
  37. Dose for dopamine in post-cardiac arrest
    5-10 mcg/kg per min IV
  38. Dose for Norepinephrine in post-cardiac arrest
    • IV infusion
    • 0.1-0.5 mcg/kg per min
  39. Acute coronary syndromes
    Any condition brought on by a sudden reduction or blockage of blood flow to the heart.
  40. For EMS, what do you do if symptoms suggest ischemia or infaction
    • Monitor and support ABCs
    • Be prepared to provide CPR & defib
    • MONA
    • Obtain 12 lead; 

    • Notify hospital w transmission, note time of onset & first med contact
    • Notified hospital should mobilize resources
    • to respond to STEMI
  41. What are the 3 groups hospital personnel should categorize pt's according to ST segment or presence of LBBB (left bundle branch block)
    • STEMI
    • NSTE-ASC
    • Low/intermediate-risk ACS
  42. What does STEMI look like on ECG interpretation
    *a full-blown heart attack caused by the complete blockage of a heart artery. 

    • ST elevation
    • New or presumably new LBBB
    • strongly suspicious for injury

    Start adjunctive therapies, do not delay reperfusion
  43. LBBB
    • Left bundle branch block
    • A delay or blockage of electrical impulses to the left side of the heart.
  44. What is NSTE-ACS
    • High-risk Non-ST Elevation ACS
    • Encompass NSTE myocardial infarction (NSTEMI) and unstable angina
    • Lack the declarative electrocardiographic findings that readily identify patients with STEMI
  45. Aspirin dose for ACS
    160 - 325 mg
  46. Cautions on taking Nitro (besides viagra)
    • SBP is greater than 90 
    • HR is greater than 50 - 100/min
  47. What 2 contradictions in first part of algorithm would there be for fibrinolytic tx
    • Don't give if:
    • Pt has experienced chest discomfort for greater than 15 mins but less than 12 hrs
    • ECG shows pt has NOT had STEMI or new LBBB
  48. List contraindications for fibrinolysis for STEMI
    • SBP >180 or DBP >100
    • R vs L are BP shows difference of 15mmHg
    • Hx of central nervous system dx
    • Sig head/facial trauma within last 3 months
    • Stroke >3 hrs or <3 months
    • Any hx of intracranial hemorrhage
    • Bleeding, clotting prob, blood thinners
    • Preg female
  49. Critical EMS assessment for suspected stroke
    • Support ABC's, give O2 if needed
    • Perform prehospital stroke assess
    • Establish time last normal
    • Triage to stroke center
    • Alert hospital
    • Check glucose!
  50. What is the stroke assessment
    • Cincinnati prehospital stroke scale:
    • Facial droop
    • Arm drift
    • Abnormal speech
  51. Ischemic vs hemorrhagic stroke
    Ischemic involves occlusion of artery to region of brain. Involves 87% of all strokes

    Hemorrhagic involves sudden rupture of blood vessel. Consists of 13% of all strokes
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