REMAC of N.Y.C. - A.L.S. Protocols

Regional Emergency Medical Advisory Committee of New York City
Prehospital Advanced Life Support Protocols
Copyright January 1996 (12/96)

505 CARDIAC DYSRHYTHMIAS

Begin appropriate Basic Life Support Procedures.
Begin Cardiac Monitoring, record and evaluate EKG strip.
Begin an IV infusion of Normal Saline (0.9 NS) to keep vein open, or a Saline Lock.
Monitor blood pressure every 2-3 minutes.

Sub-Protocols

505-A Supraventricular Tachycardia

505-B Ventricular Tachycardia with a Pulse/Wide Complex Tachycardia of Uncertain Type

505-C Bradydysrhythmias/Complete Heart Block

505-A SUPRAVENTRICULAR TACHYCARDIA

In unconscious patients with unstable Supraventricular tachycardia, perform Synchronized Cardioversion using 50 joules. If this fails to convert the dysrhythmia and the patient still has a pulse, Synchronized Cardioversion may be repeated as necessary, using 100, 200, 300 and 360 joules.
In conscious patients with stable and symptomatic Supraventricular tachycardia administer Adenosine as follows:

a. Administer Adenosine 6.0 mg, IV/Saline Lock bolus, rapidly, followed by a Normal Saline (0.9 NS) flush.

b. Observe EKG monitor for 1 - 2 minutes for evidence of cardioversion.

c. If there is no evidence of cardioversion, administer Adenosine 12 mg, IV/Saline Lock bolus, rapidly, followed by a Normal Saline (0.9 NS) flush.

d. If there is still no evidence of cardioversion, repeat Adenosine 12 mg IV/Saline Lock bolus, rapidly, followed by a Normal Saline (0.9 NS) flush.

3.
If Adenosine fails to convert the dysrhythmia or the patient has evidence of low cardiac output, contact Medical Control for implementation of one or more of the following MEDICAL CONTROL OPTIONS:

MEDICAL CONTROL OPTIONS:

OPTION A:

OR If complex width is narrow and blood pressure is normal or elevated:

Administer Verapamil 2.5-5.0 mg, IV/Saline Lock bolus, slowly, over 2 minutes, monitoring blood pressure continuously.
Administer Diltiazem 0.25 mg/kg, IV/Saline Lock bonus, slowly over 2 minutes, monitoring blood pressure continuously.

OPTION B:
If complex width is narrow and blood pressure is low or unstable, perform Synchronized Cardioversion* using 50 joules. If this fails to convert the dysrhythmia and the patient still has a pulse, Synchronized Cardioversion may be repeated as necessary using 100, 200, 300, and 360 joules.

*
If the patient is alert prior to performing Synchronized Cardioversion, the patient must first be sedated as follows:

a. Administer Diazepam 5.0-10 mg, IV/Saline Lock bolus. Repeat doses of Diazepam 5.0-10 mg, IV/Saline Lock bolus, may be given as necessary. (Maximum total dosage is 20 mg.)

OR

b. Administer Midazolam 1.0-2.0 mg, IV/Saline Lock bolus. Repeat doses of Midazolam 1.0 mg, IV/Saline Lock bolus, may be given as necessary. (Maximum total dosage is 5.0 mg.)

OR

c. AdministerMorphine Sulfate 2.0-5.0 mg, IV/Saline Lock bolus. Repeat doses of Morphine Sulfate 2.0-5.0 mg, IV/Saline Lock bolus, may be given as necessary. (Maximum total dosage is 15 mg.)

NOTE: IF HYPOTENSION, HYPOVENTILATION, OR STUPOR DEVELOPS OR PERSISTS DURING ADMINISTRATION OF MORPHINE SULFATE , WITHHOLD MORPHINE SULFATE, ELEVATE THE LEGS, AND ADMINISTER NALOXONE 2.0 mg, IV/SALINE LOCK BOLUS.

OPTION C: Transportation decision

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505-B VENTRICULAR TACHYCARDIA WITH A PULSE/WIDE COMPLEX TACHYCARDIA OF UNCERTAIN TYPE

MEDICAL CONTROL OPTIONS:TREATMENT ALGORITHMS

NOTE: IN PATIENTS WITH PULSELESS VENTRICULAR TACHYCARDIA, SEE SUB-PROTOCOL 503-B.

In unconscious patient with unstable ventricular tachycardia with a pulse, perform Synchronized Cardioversion using 100 joules. If this fails to convert the dysrhythmia and the patient still has a pulse, Synchronized Cardioversion may be repeated as necessary using 200, 300 and 360 joules.
Administer Lidocaine 1.5 mg/kg, IV/Saline Lock bolus. Repeat doses of Lidocaine 0.75 mg/kg, IV/Saline Lock bolus, may be given every 5 minutes. (Maximum individual dose is 1.5 mg/kg and maximum total dosage is 3.0 mg/kg).
If Lidocaine converts the dysrhythmia, administer Lidocaine 1.0-4.0 mg/min, IV/Saline Lock drip.
If Lidocaine fails to convert the dysrhythmia, contact Medical Control for implementation of one or more of the following MEDICAL CONTROL OPTIONS:

MEDICAL CONTROL OPTIONS

OPTION A: Perform Synchronized Cardioversion* using 100 joules. If this fails to convert the arrhythmia and the patient still has a pulse, Synchronized Cardioversion may be repeated as necessary using 200, 300, and 360 joules.

* If the patient is alert prior to performing Synchronized Cardioversion, the patient must first be sedated as follows:

a. Administer Diazepam 5.0-10 mg, IV/Saline Lock bolus. Repeat doses of Diazepam 5.0-10 mg, IV/Saline Lock bolus, may be given as necessary. (Maximum total dosage is 20 mg.)

OR

b. Administer Midazolam 1.0-2.0 mg IV/Saline Lock bolus. Repeat doses of Midazolam 1.0 mg, IV/Saline Lock bolus, may be given as necessary. (Maximum total dosage 5.0 mg.)

OR

c. Administer Morphine Sulfate 2.0-5.0 mg, IV/Saline Lock bolus. Repeat doses of Morphine Sulfate 2.0-5.0 mg, IV/Saline Lock bolus, may be given as necessary. (Maximum total dosage is 15 mg.)

NOTE: IF HYPOTENSION, HYPOVENTILATION, OR STUPOR DEVELOPS OR PERSISTS DURING ADMINISTRATION OF MORPHINE SULFATE, WITHHOLD MORPHINE SULFATE , ELEVATE THE LEGS, AND ADMINISTER NALOXONE 2.0 MG, IV/SALINE LOCK BOLUS.

OPTION B: 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.)

OPTION C: Administer Adenosine as follows:

a. Administer Adenosine 6.0 mg, IV/Saline Lock bolus, rapidly, followed by a Normal saline (0.9 NS) flush.

b. Observe EKG monitor for 1-2 minutes for evidence of cardioversion.

c. If there is no evidence of cardioversion, administer Adenosine 12 mg, IV/Saline Lock bolus, rapidly, followed by a Normal Saline (0.9 NS) flush.

d. If there is still no evidence of cardioversion, repeat Adenosine 12 mg, IV/Saline Lock bolus, rapidly, followed by a Normal Saline (0.9 NS) flush.

OPTION D: Administer Magnesium Sulfate 2.0 gm, IV/Saline Lock bolus, diluted in 10 ml of Normal Saline (0.9 NS), over 2 minutes

OPTION E: Transportation Decision.

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505-C BRADY DYSRHYTHMIAS and COMPLETE HEART BLOCK

If the patient has a ventricular rate of less than 60 beats/min and signs of decompensated shock, administer Atropine Sulfate 0.5-1.0 mg, IV/Saline Lock bolus.
Begin Transcutaneous Pacing (if available).
NOTE: IF THE PATIENT IS ALERT PRIOR TO BEGINNING TRANSCUTANEOUS PACING AND REQUIRES SEDATION, PROCEED TO MEDICAL CONTROL OPTIONS.
If there is insufficient improvement in cardiac status, contact Medical Control for implementation of one or more of the following MEDICAL CONTROL OPTIONS:

MEDICAL CONTROL OPTIONS:

OPTION A: Repeat Atropine Sulfate 0.5 mg, IV/Saline Lock bolus. (Maximum total dosage is 3.0 mg.)

OPTION B:

a. Administer Diazepam 5.0-10 mg, IV/Saline Lock bolus. Repeat doses of Diazepam 5.0-10 mg, IV/Saline Lock bolus, may be given as necessary. (Maximum total dosage is 20 mg.)

OR

b. Administer Midazolam 1.0-2.0 mg IV/Saline Lock bolus. Repeat doses of Midazolam 1.0 mg, IV/Saline Lock bolus, may be given as necessary. (Maximum total dosage 5.0 mg.)

OR

c. Administer Morphine Sulfate 2.0-5.0 mg, IV/Saline Lock bolus. Repeat doses of Morphine Sulfate 2.0-5.0 mg, IV/Saline Lock bolus, may be given as necessary. (Maximum total dosage is 15 mg.)

NOTE: IF HYPOTENSION, HYPOVENTILATION, OR STUPOR DEVELOPS OR PERSISTS DURING ADMINISTRATION OF MORPHINE SULFATE, WITHHOLD MORPHINE SULFATE , ELEVATE THE LEGS, AND ADMINISTER NALOXONE 2.0 MG, IV/SALINE LOCK BOLUS.

OPTION C:
Administer Dopamine 5 ug/kg/min, IV/Saline Lock drip. If there is insufficient improvement in hemodynamic status, the infusion may be increased until the desired therapeutic effects are achieved or adverse affects appear. (Maximum dosage is 20 ug/kg/min, IV/Saline Lock drip.)

OPTION D:

Administer Epinephrine 1.0 ug/min, IV/Saline Lock drip. Prepare infusion by adding 1.0 mg of Epinephrine (1.0 ml of a 1:1,000 solution) to 250 ml of Normal Saline (0.9 NS) (1 ug/min = 15 ml/hr = 15 gtts/min) If there is insufficient improvement in hemodynamic status, the infusion may be increased until the desired therapeutic effects are achieved or adverse affects appear. (Maximum dosage is 10 ug/min, IV/Saline Lock drip.)

OPTION E:
Transportation decision.

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	a.	Administer Adenosine 6.0 mg, IV/Saline Lock bolus, rapidly, followed by a Normal Saline (0.9 NS) flush.
	b.	Observe EKG monitor for 1 - 2 minutes for evidence of cardioversion.
	c.	If there is no evidence of cardioversion, administer Adenosine 12 mg, IV/Saline Lock bolus, rapidly, followed by a Normal Saline (0.9 NS) flush.
	d.	If there is still no evidence of cardioversion, repeat Adenosine 12 mg IV/Saline Lock bolus, rapidly, followed by a Normal Saline (0.9 NS) flush.
3.	If Adenosine fails to convert the dysrhythmia or the patient has evidence of low cardiac output, contact Medical Control for implementation of one or more of the following MEDICAL CONTROL OPTIONS:

OPTION A: OR	If complex width is narrow and blood pressure is normal or elevated: Administer Verapamil 2.5-5.0 mg, IV/Saline Lock bolus, slowly, over 2 minutes, monitoring blood pressure continuously. Administer Diltiazem 0.25 mg/kg, IV/Saline Lock bonus, slowly over 2 minutes, monitoring blood pressure continuously.
OPTION B:	If complex width is narrow and blood pressure is low or unstable, perform Synchronized Cardioversion* using 50 joules. If this fails to convert the dysrhythmia and the patient still has a pulse, Synchronized Cardioversion may be repeated as necessary using 100, 200, 300, and 360 joules.
*	If the patient is alert prior to performing Synchronized Cardioversion, the patient must first be sedated as follows:
	a.	Administer Diazepam 5.0-10 mg, IV/Saline Lock bolus. Repeat doses of Diazepam 5.0-10 mg, IV/Saline Lock bolus, may be given as necessary. (Maximum total dosage is 20 mg.)
OR
	b.	Administer Midazolam 1.0-2.0 mg, IV/Saline Lock bolus. Repeat doses of Midazolam 1.0 mg, IV/Saline Lock bolus, may be given as necessary. (Maximum total dosage is 5.0 mg.)
OR
	c.	AdministerMorphine Sulfate 2.0-5.0 mg, IV/Saline Lock bolus. Repeat doses of Morphine Sulfate 2.0-5.0 mg, IV/Saline Lock bolus, may be given as necessary. (Maximum total dosage is 15 mg.)
NOTE:		IF HYPOTENSION, HYPOVENTILATION, OR STUPOR DEVELOPS OR PERSISTS DURING ADMINISTRATION OF MORPHINE SULFATE , WITHHOLD MORPHINE SULFATE, ELEVATE THE LEGS, AND ADMINISTER NALOXONE 2.0 mg, IV/SALINE LOCK BOLUS.
OPTION C:	Transportation decision

OPTION A:	Perform Synchronized Cardioversion* using 100 joules. If this fails to convert the arrhythmia and the patient still has a pulse, Synchronized Cardioversion may be repeated as necessary using 200, 300, and 360 joules.
*	If the patient is alert prior to performing Synchronized Cardioversion, the patient must first be sedated as follows:
	a.	Administer Diazepam 5.0-10 mg, IV/Saline Lock bolus. Repeat doses of Diazepam 5.0-10 mg, IV/Saline Lock bolus, may be given as necessary. (Maximum total dosage is 20 mg.)
OR
	b.	Administer Midazolam 1.0-2.0 mg IV/Saline Lock bolus. Repeat doses of Midazolam 1.0 mg, IV/Saline Lock bolus, may be given as necessary. (Maximum total dosage 5.0 mg.)
OR
	c.	Administer Morphine Sulfate 2.0-5.0 mg, IV/Saline Lock bolus. Repeat doses of Morphine Sulfate 2.0-5.0 mg, IV/Saline Lock bolus, may be given as necessary. (Maximum total dosage is 15 mg.)