‘Give 1 ehook * Manual biphasic; device spastic {yplealy 120 0200s) + AED: device spostie * Monoptasi: 360 J FRecume CPR immediately ‘Resume CPR immediately for 6 cycles Wher 10 avaable, gia vasoproacor = Epinephrine tm Mio Repeat every 3to 5 min + May ave T dose of vasopressin 40 U 110 to teplace ator second dose of epinephvine CConsier atropine 1 mg VIO. {or asystole oF Sow PEA rato Pepeat avery 0'3 min (opto 9 cose) Continue GPR whie detbaators eheging ‘Give t shook * Manuel biphasie: doves specio (eeme as fat shock or higher dose) ‘AED: device specito + Monophasc: 360 J Resume CPR immediatly ater the shock ‘nen NO avd, ge vasopressor dng GPR (belo or aftr tha shock) Epinephrine 1g MIO Repeat every 3 to 5 min + May give 1 de of vasopressin 40 U I/O to replace frat or sacond dose of epinephrine +H asystote, goto Box 10 4 tretectrical activity, check pulse. i no pulse, Go to Box to + Hulse present, begin postresuscitation care uring CPR + Push hard and fact (100!mis) + Rotate compressce avery Soha hil che esol 2rinvts win yh checks Mn aa + Search fran teat posse Minne wmupon incest Tes + One cjla of CPR 20 compressions than 2 eats 8 ool "2 min + Avoid mparventtion + Secure alway and corm placement Continue CPR while defbittoris charging ‘Give # shook * Manuel biasl: deve specic feame a8 fat shook or igh dose) + AED: device spec + Monophase: 360.5 Resume CPR immediately ater the shock Conse anariytinics: ve dung GPR (betes o afer the seh) amiodarone (0 ma NO one, hen ‘Snel ation 150 mg W/O once oF lidocaine (to 15 mg/h rst dose, ten 0. to 1,75 mph NAO, maximum 3 doses er mea) Conse magnesium, losing dose "t02g W/O fr torsades de portes [After 5 cycles of CPR,” got to Box 5 above * heron nana ore en. SFSte Gee cise har com Pressone without pauses fortran. Eve to 10 beaten Cred hm every 2s+ Eetablieh WV access: + Obtain 12-ead ECG. (nen avaiabie) cor yt sitio 4s ORS narrow (0.1200)? + Atempt vagal maneuvers + Gwe adenasine 6 mg pid IV push. tno conversion. ‘ive 12 mg api IV push: may repeal 12 mg dose once Whythm converts, probable reontry SVT (reentry supraventricul tachycardia) *Obeare fr reeurence + Troat recurrence with adenosine longer ‘acting AV nodal locking ‘gens (eg, litlazem, Blockers) Wide (20.12 sec), Irregular Narrow-Compiex TTachycarcia Probabie atrial tbeitation or possible arial ltter or MAT (rulbocal aa! tachyeara * Consider expert consuation * Control at (eg, aitiazem, Brblockor; use Bosker with ‘saubon in pulmonary cisoase orcHF) rhythm does NOT convert, possible atrial flutter ‘ectopic atrial tachycardia, fr junctional tachyeardi "Control at (og, itazom, Blocker; use icckers with ‘caution in pulmonary dleease or CHF + Treal underying cause + Consider export consultation tachycardia or tincertaln shyt ‘amiodarone 180 ma IV over 10 min FRopoat as needed tomeximum dose of 22 gi2s hours + Prepare for elective ‘synchronizod ‘cardioversion W SVT with sberrancy "Give adenosine (goto Box7) * See iegular Nao CComplox Tachyearcia ox) It pre-oxcted atrial Aiilation (AF + WPW) + Exper consutaton advaed + Avoid AV nada locking agents og, adenosine, digon dlitiazem, verapamil) + Consider antarthyth 19, amiodarone 150 mg lV over 10 min) recurrent polymer hie VF, cook oxport oneutation torsades de pointes, ‘give magnesium (lose witn 1-2 g over 5-60 min, then ks)Adult Bradycar (With Pulse) Identity and treat underlying cause ‘+ Maintain patent airway; assist breathing as necessary ‘Oxygen (f hypoxemic) Waccess ‘ 12-Lead ECG if avalable; don't delay therapy Persistent bradyarrhythmia 5 ay Iypsenrt ee eer ent Seta ++ Ischemic chest discomfort? + Acute heart falure? Atropine If atropine ineffective: + Transcutaneous pacing ‘OR ‘+ Dopamine infusion OR, ‘+ Epinephrine infusion Consider: + Expert consultation * Tranevenous pacing (© 2010 american Hest Assocation ‘Assess appropriateness for clinical condition. Heart rate typically <60/min if bradyarrhiythm ‘Cardiac monitor to identify rythm; monitor blood pressure and oximetry Doses/Detaile ‘Atropine IV Dose: First dose: 0.5 mg bolus Repeat every 3-5 minutes Maximum: 3 mg Dopamine IV Infusion: 2-10 mogfkg per minute Epinephrine IV infusion: 2-40 meg per minuteBRADYCARDIA Heart rate <60 bpm and inadequate for clinical condition + Prepare for transvenous pacing * TWeat contributing causes ‘= Consider expert consultationCilical EMS assessments and actions + Support ABCs; give oxygen if needed : prehoaptal soe ascosement (Tables 1 and 2) + Establish timo when patent ast known roma (Noo: therapies may be avalable beyond 3 hous from onset) wos + Transpor:; conser tiage toa canter witha stoke Unt ‘Me 4 appropiate; consider bringing a witness, family cous irember ox careaver + Check glucose if possible Ey aval Immediate general assessment and stabilization + Assess ABCs, vital signs + Provide oxygen if hypoxemic + Obtain IV access and blood samples + Check glucose; treat it indicated + Perform neurologic screening assessment + Activate stroke team + Order emergent CT scan of brain + Obtain 12-l¢ad ECG oS: 0 aia Immediate neurologic assessment by stroke team or designee + Review patient history | + Estabish symptom onset mn + Perform neurologic examination (NIH Stroke Scale or Canadian Neurologic Scale) 0 atv ‘Consult neurologist or neurosurgeon; consider transer it nat available Probable acute ischemic stroke; consider fibrinolytic therapy + Check for frinohtic exclusions (Table 3) ara 60min Review risks/benefits with patient and family: + Begin stroke pathway C) Wecceptable — Acmnitto stoke unt # avaiable 5 Monitor SP: teat f indicated (Table 4) ee + Monitor neurologic status; emergent CT + No anticoagulants or antplatelet treatment for Deheue I dotercration. + Monitor blood glucose; treet f needed + Intiate supportive therapy; teat comartiditiesEMS assessment and care and hospital preparation: + Monto, support ABCs, Be prepared to provide CPR and defiortaton + Administer exygen, aspin, nltroglyeenn, arc) morphine reas | Hfavalabl,oblan 12-ead ECG; Stevan: = Netty recaving hosptal with ranamission or nterprtation = Begin nbenojti ehecKist Figur 2) + Notte hospital shoud mobilize hospital resources to respond to STEM Trimedlate ED assessment (<10 min) ‘Chock itl sign value oxygen saturation Estalsh IV access Cbtanvreviaw 12d ECG {Part bit, targeted history, physical exam Trimediate ED goneral woatmont "Star oxygen st 4 Linn: maintain O st 909 ‘Aspirin 160 t0 325 ma not aven by EMS) ‘aroglycern sublingual spray, or {+ Morpie Vif pain not reteved by nitoaycerin * Roviewioompletofevinchytis check (Figure 2) check contrandeatons (able 1) + Obtain tal cardiac mark lve, ‘tal elscrots and cosguation susan + Obtain portable chee ray (<20 min) ‘F deapression or dynamic ‘Ewave Inversion; etonghy Suspicious fo ischemia High Risk Unstable Angina Non-ST-Etvation Ml (UAINSTEMI) Normal or nondiagnostio changes In ST segment or T wave IntermedtaterLow Risk UA Start adjunctive treatments 2s Ingato (ae text for containcations) De not eel repertuson + BrAdronerge receptor blockers + Clopidogrel 1 Heparin (UFH or Ltr) Start adjunctive treatments 35 indented (ae tot for conandleatons) { Nitrogiyeerin + BrAdrenorgic receptor blockars $ Clopidogrel 1 Heparin (UFH or Usir + clyeoprotein bla inhibitor ‘Consider admission to ED chest pain unit orto ‘monitored bea in ED Fotew: *Seral cordac markers {cluding troponin) + Ropoat ECGIeonnuous STeegment mena + Consider sree te ‘igh-vsk pation (Tables 3, 4 for ‘isk strateation: Fetractery ischemic chest pan + Recurrenvperestert ST devation 1 Nentsclertachyearie + Homodyramio nstabity * Sigs of pump falre Repertusion strategy: “Terepy defined by patent and center ctr abe 2) *'Bo aware of reportusion goats: = Deor-to-balloon inflation PCI) {goal of 90 min ‘Eat invasive strategy, ncuding = Doorsto-neede (rinoiyss) ‘catnetrzaion and revaculazation {geal of 90min for shock wit 48 hours of an AMI + Continue adjunctive therapies and SiACE inhibtors/engiotesin, ‘receptor blockor ARB) win 24 hours of symptom onset = HMG CoA reductase inhibitor (atin nerapy Continue ASA, oparin, and other therapies as indicated. "ACE nhbitor/ARB 1 HMG-CoA reductase inhibitor tain therapy) Not thigh rise cardiology to rak-tratty