Cardiovascular

2-1-a. Cardiac Arrest

Patients will be managed with ACLS and special attention to consistently doing High Performance CPR (HP-CPR), including:

1) Begin Chest Compressions

• a) Rate of 110/minute (use a metronome timer if available)

• b) Depth of 2 - 2.5 inches = 5 - 6 cm (“push hard”)

• c) Change compressors at least every 1 - 2 minutes

• d) Continuous chest compressions / minimal interruptions

2) Apply AED or Defibrillator / Monitor, then shock if a shockable rhythm or when advised by AED

3) BVM

• a) Intersperse one breath every 10 chest compressions

• b) Avoid over ventilation (10-12 breaths per minute, 6-8 cc/kg)

• c) ET intubation only if able to do so without interrupting chest compressions for more than 3-5 seconds

• d) ET intubation only if there are enough personnel to perform chest compressions and BVM properly

• e) Other options include supraglottic airway devices

• f) Do ALS when there are adequate staffing resources / personnel to provide chest compressions and ventilations properly, and then do ACLS per AHA current Guidelines

4) HP - CPR Goals:

• a) Maximize time spent on quality chest compressions (a goal is > 90% of the time). Minimize pauses and interruptions.

• b) Pauses for no more than a few seconds including for IV access and for inserting airway devices.

• c) If patient meets criteria for death, has a valid POLST form or a CCO DNR bracelet or pendent, then do not initiate HP CPR unless other circumstances warrant it.

5) Post CPA successful resuscitation cases are very unstable and the Paramedic should be vigilant for recurrent VT/ VF, and ensure adequate manpower in the ambulance before transporting.

6) Termination of Resuscitation: Field pronouncements and avoiding futile transports of clinically dead CPA cases [see 1-10. Termination of Resuscitation]

• a) If cardiac arrest patient has had ALS resuscitation for ≥ 20 minutes with no return of spontaneous circulation “ROSC” and is in asystole, the case should be considered of field pronouncement.

• b) Consider transporting patient in cardiac arrest, who are asystole, when there are concerns such as scene safety, provider safety, and CPA in a public place.

2-1-b. Chest Pain

For ongoing or recent chest discomfort suggestive of myocardial ischemia:

1) Administer O2 [see 1-4. Oxygen Administration]. No supplemental O2 is used if POX is ≥ 94%.

2) If pain persists, BP > 100 mmHg systolic and there are no contraindications, administer nitroglycerin “NTG” 0.4 mg sublingual spray or tablet.

• Contraindications include the recent use of drugs for erectile dysfunction (generic names end in “afil”) and also evidence of right ventricular infarction such as an inferior myocardial infarction “MI” with hypotension. May repeat NTG every 5 minutes if BP remains > 100 mmHg systolic.

3) Obtain 12-lead ECG. If significant ST elevations are present, notify receiving hospital as soon as possible, using the phrase “STEMI Alert”. Transport to the closest appropriate hospital, preferably one with percutaneous coronary intervention / PCI capability.

4) Whether pain persists or has resolved, administer aspirin 162 mg orally if the patient has no history of allergic reaction to aspirin. If the patient has a recent history of gastrointestinal bleeding contact the base station physician before administering the aspirin.

5) Establish IV with NS at TKO rate.

6) If chest pain is unrelieved by 3 doses of NTG, communicate for additional orders.

2-1-c. Congestive Heart Failure and Pulmonary Edema

For patients with dyspnea and rales present in both lungs, with absence of fever (<100⁰F) then:

1) Administer O2 [see 1-4. Oxygen Administration]

2) Apply continuous positive airway pressure [see 1-1. Continuous Positive Airway Pressure (CPAP)]

3) Establish IV at TKO rate

4) If BP < 90 mmHg systolic, give norepinephrine 4-12 mcg per minute via automatic IV infusion pump, adjusted to maintain BP of 100 - 110 mmHg.

To do this, put 4 mg into 500 ml of NS (= 8 mcg/ ml). Start the infusion at ½ ml/minute, and titrate rate to get desired BP ≥ 100-110 mmHg systolic.

5) If BP > 90 mmHg systolic and no contraindications (for NTG contraindications [see 2-1-b. Chest Pain]) administer nitroglycerin 0.4 mg sublingual spray or tablet. May repeat every 5 minutes up to a total of 5 doses if BP ≥ 100 mmHg systolic

2-1-d. Dysrhythmias

For all bradycardia / tachycardia / PEA / asystole patients, see the current AHA ACLS guidelines and algorithms.

2-1-e. CPA in Renal Dialysis Patient

Because a renal dialysis patient in CPA (of any type) can have profound hyperkalemia, administer these medications as soon as the IV has been established. These medications are in addition to any other applicable SO. These orders should be carried out whether or not the patient has had a recent dialysis. \

1) Calcium gluconate 10% solution, give 10 ml IV/IO push.

2) Flush IV/IO line thoroughly.

3) Sodium bicarbonate 1 mEq/kg IV/IO push.

4) If no change, flush IV line thoroughly and repeat steps 1-3, again.

CONTINUE CARDIAC ARREST STANDING ORDERS