Regional Emergency Medical Advisory Committee of New York City
Prehospital Advanced Life Support Protocols
Copyright January 1996 (8/96)

503 NON-TRAUMATIC CARDIAC ARREST

  1. Begin Basic Life Support Non-traumatic Cardiac Arrest procedures.
  2. Begin Cardiac Monitoring, record and evaluate EKG strip, preferably using quick-look paddles.

Sub-Protocols*

503-A Asystole

503-B Ventricular Fibrillation/Pulseless Ventricular Tachycardia

503-C Pulseless Electrical Activity/Electro-Mechanical Dissociation /Agonal Idioventricular Rhythm

* In the event that initial EKG rhythm changes, refer to the appropriate cardiac arrest sub-protocol. Complete Standing Orders without repetition of previously administered drugs and contact Medical Control for further orders.

503-A ASYSTOLE

  1. Perform Endotracheal Intubation.
  2. In monitored asystolic arrests, begin Transcutaneous Pacing (if available).
  3. Begin an IV infusion of Normal Saline (0.9 NS) to keep vein open, or Saline Lock.
  4. Administer Epinephrine 1.0 mg (10 ml of a 1:10,000 solution), IV/Saline Lock bolus. If there is no change in the rhythm within 3-5 minutes, repeat Epinephrine 1.0 mg (10 ml of a 1:10,000 solution), IV/Saline Lock bolus, every 3-5 minutes.
  5. Administer Atropine Sulfate 1.0 mg, IV/Saline Lock bolus. If there is no change in the rhythm within 3-5 minutes, repeat Atropine Sulfate 1.0 mg, IV/Saline Lock bolus, every 3-5 minutes. (Maximum total dosage is 3.0 mg.)
  6. Contact Medical Control for implementation of one or more of the following MEDICAL CONTROL OPTIONS:

MEDICAL CONTROL OPTIONS:

OPTION A:
If there is no change in the rhythm, repeat Epinephrine 3.0 mg (3 ml of a 1:1000 solution), IV/Saline Lock bolus, 3 minutes after the initial dose. If there is still no change in the rhythm, administerEpinephrine 5.0 mg (5.0ml of a 1:1,000 solution), IV/Saline Lock bolus, 3 minutes after the previous dose. Subsequent doses of Epinephrine 5.0 mg (5.0 ml of a 1:1,000 solution), IV/Saline Lock bolus, should be given every 3 - 5 minutes for the duration of treatment.

OPTION B:
Begin Transcutaneous Pacing (if available).

OPTION C:
Administer Sodium Bicarbonate 44 - 88 mEq, IV/Saline Lock bolus, for pre-existing acidosis. Repeat doses of Sodium Bicarbonate 44 mEq, IV/Saline Lock bolus, may be given every 10 minutes.

OPTION D:
Defibrillate* using 200 joules. If this fails to convert the dysrhythmia, Defibrillation may be repeated as necessary, using 300 and 360 joules. (See Protocol #503-B.)

OPTION E:
Administer Dextrose 25 gm (50 ml of a 50% solution), IV/Saline Lock bolus.

OPTION F:
Administer Naloxone 2.0 mg, IV/Saline Lock bolus. Repeat doses of Naloxone 2.0 mg, IV/Saline Lock bolus, may be given as necessary. (Maximum total dosage is 10 mg.)

OPTION G:
Transportation decision.

* Immediately following conversion to a supraventricular rhythm (even of a short duration), administer Lidocaine 1.5 mg/kg, IV/Saline Lock bolus. Repeat doses of Lidocaine .75 mg/kg, IV/Saline Lock bolus may be given every 5 minutes, and may be followed by Lidocaine 1.0-4.0 mg/min, IV/Saline Lock drip. (Maximum individual dose is 1.5 mg/kg and maximum total dosage is 3.0 mg/kg.)

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503-B VENTRICULAR FIBRILLATION/ PULSELESS VENTRICULAR TACHYCARDIA

NOTE:IF PATIENT HAS A PERMANENT PACEMAKER IN PLACE, POSITION THE PADDLES OR SEMI-AUTOMATIC DEFIBRILLATOR PADS AT LEAST FIVE (5) INCHES AWAY FROM THE PACEMAKER DEVICE.

  1. Immediately Defibrillate* using 200 joules.
  2. If there is no change in the rhythm, Defibrillate* using 300 joules.
  3. If there is still no change in the rhythm, Defibrillate* using 360 joules.
  4. Perform Endotracheal Intubation.
  5. Begin an IV infusion of Normal Saline (0.9 NS) to keep vein open, or a Saline Lock.
  6. Administer Epinephrine 1.0 mg (10 ml of a 1:10,000 solution), IV/Saline Lock bolus, every 3-5 minutes.
  7. If there is still no change in the rhythm, Defibrillate* using 360 joules.
  8. Administer Lidocaine 1.5 mg/kg, IV/Saline Lock bolus. (Maximum individual dose is 1.5 mg/kg and maximum total dosage is 3.0 mg/kg.)
  9. If there is still no change in the rhythm, Defibrillate*. using 360 joules
  10. RepeatLidocaine 1.5 mg/kg, IV/Saline Lock bolus after 5 minutes. (Maximum individual dose is 1.5 mg/kg and maximum total dosage is 3.0 mg/kg.
  11. If there is still no change in the rhythm Defibrillate* using 360 joules.
  12. Administer Bretylium Tosylate 5.0 mg/kg, IV/Saline Lock bolus, slowly.
  13. If there is still no change in the rhythm Defibrillate* using 360 joules.
  14. Administer Bretylium Tosylate 10 mg/kg, IV/Saline Lock bolus, slowly.
  15. If there is still no change in the rhythm, Defibrillate* using 360 joules.
  16. If there is insufficient improvement in hemodynamic status, contact Medical Control for implementation of one or more of the following MEDICAL CONTROL OPTIONS:

* Immediately following conversion to a supraventricular rhythm (even if only of a short duration), administer Lidocaine 1.5 mg/kg, IV/Saline Lock bolus (Maximum individual dose is 1.5 mg/kg and maximum total dosage is 3.0 mg/kg.)

MEDICAL CONTROL OPTIONS:

OPTION A:Repeat any of the above Standing Orders.

OPTION B:
If there is no change in the rhythm, administer Epinephrine 3.0 mg (3.0 ml of 1:1,000 solution), IV/Saline Lock bolus, 3-5 minutes after the initial dose. If there is still no change in the rhythm, administer Epinephrine 5.0 mg (5.0 ml of 1:1,000 solution), IV/Saline Lock bolus, 3-5 minutes after the previous dose. Subsequent doses of Epinephrine 5.0 mg, (5.0 ml of a 1:1,000 solution), IV/Saline Lock bolus, should be given every 3 - 5 minutes for the duration of treatment.

OPTION C:
Administer Sodium Bicarbonate 44 -88 mEq, IV/Saline Lock bolus. Repeat doses of Sodium Bicarbonate 44 mEq, IV/Saline Lock bolus, may be given every 10 minutes.

OPTION D:
Administer Dextrose 25 gm (50 ml of a 50% solution), IV/Saline Lock bolus.

OPTION E:
AdministerMagnesium Sulfate 2 gm, IV/Saline Lock bolus, diluted in 10 ml of Normal Saline (0.9 NS), over 2 minutes.

OPTION F:
Transportation decision.

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503-C PULSELESS ELECTRICAL ACTIVITY (PEA)/ ELECTRO-MECHANICAL DISSOCIATION (EMD)/ AGONAL IDIOVENTRICULAR RHYTHM

NOTE:CONSIDER THE POSSIBILITY OF CONDITIONS MASQUERADING AS PEA/EMD WHICH REQUIRE IMMEDIATE IN-HOSPITAL TREATMENT SUCH AS SEVERE SHOCK, TRAUMATIC CARDIAC ARREST, PERICARDIAL TAMPONADE, HYPOVOLEMIA, TENSION PNEUMOTHORAX, ETC.

  1. If a Tension pneumothorax is suspected, perform Needle Decompression. (See Appendix O.)
  2. Perform Endotracheal Intubation.
  3. Begin an IV infusion of Normal Saline (0.9 NS) to keep vein open, or a Saline Lock.
  4. Administer Epinephrine 1.0 mg (10 ml of a 1:10,000 solution), IV/Saline Lock bolus. If there is no change in the rhythm within 3-5 minutes, repeat Epinephrine 1.0 mg (10 ml of a 1:10,000 solution), IV/Saline Lock bolus, every 3-5 minutes.
  5. If the patient has a heart rate (based on rhythm strip) less than 60 beats/min, administer Atropine Sulfate 0.5 mg, IV/Saline Lock bolus. If there is no change in the heart rate within 3-5 minutes, repeat Atropine Sulfate 0.5 mg, IV/Saline Lock bolus, every 3-5 minutes. (Maximum total dosage is 3.0 mg.)
  6. If there is insufficient improvement in hemodynamic status, contact Medical Control for implementation of one or more of the following MEDICAL CONTROL OPTIONS:

MEDICAL CONTROL OPTIONS:

OPTION A:Repeat any of the above Standing Orders.

OPTION B:
If there is no change in the rhythm, administer Epinephrine 3.0 mg (3.0 ml of a 1:1,000 solution), IV/Saline Lock bolus, 3-5 minutes after the initial dose. If there is still no change in the rhythm, administer Epinephrine 5.0 mg (5.0 ml of a 1:1,000 solution), IV/Saline Lock bolus, 3-5 minutes after the previous dose. Subsequent doses of Epinephrine 5.0 mg (5.0 ml of a 1:1,000 solution), IV/Saline Lock bolus, should be given every 3-5 minutes for the duration of treatment.

OPTION C:
Administer Sodium Bicarbonate 44-88mEq, IV/Saline Lock bolus. Repeat doses of Sodium Bicarbonate 44 mEq, IV/Saline Lock bolus, may be given every 10 minutes.

OPTION D:
Administer Dextrose 25 gm (50 ml of a 50% solution), IV/Saline Lock bolus.

OPTION E:
Administer Naloxone 2.0 mg, IV/Saline Lock bolus. Repeat doses of Naloxone 2.0 mg, IV/Saline Lock bolus, may be given as necessary. (Maximum total dosage is 10 mg.)

OPTION F:
Begin rapid IV/Saline Lock infusion of Normal Saline (0.9 NS), up to 3.0 liters.

OPTION G:
Begin Transcutaneous Pacing (if available).

OPTION H:
Administer Dopamine 5.0 ug/kg/min, IV/Saline Lock drip. If there is insufficient improvement in hemodynamic status, the infusion rate may be increased until desired therapeutic effects are achieved or adverse effects appear. (Maximum dosage is 20 ug/kg/min, IV/Saline Lock drip.)

OPTION I:
Transportation decision

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