Specific to this directive, treatments do not necessarily follow the order in which they should be administered. The initial treatment choice will be based on rhythm interpretation (narrow vs. wide) and hemodynamic stability.
Early lead II and 12 lead acquisitions will prove invaluable for determining the origin of the electrical impulses, the rhythm regularity and the QRS durations.
Contraindications for Adenosine Administration:
Dipyridamole – brand name: Persantine.
Carbamazepine – brand name: Tegretol
Bronchoconstriction research has shown that inhaled adenosine provokes bronchoconstriction in asthmatic individuals (but not in the control group) and is therefore a contraindication for administration.
Adenosine Therapy:
Has changed to 6 mg and 12 mg based on AHA guideline findings that a second 12 mg dose is likely ineffective. No BHP patch is required for the administration of adenosine for narrow complex regular tachycardia.
Lidocaine Dosing:
Initial dose: 1.5 mg/kg to a max of 150 mg. The second and third doses are calculated as 0.75 mg/kg with the same maximum dose of 150 mg.
Lidocaine is limited to a maximum of 3 mg/kg total dosing via IV.
Topical doses of Lidocaine as administered in the intubation directive count towards a 5 mg/kg total dose.
In the event the patient receives the maximum dose of Lidocaine and then experiences cardiac arrest, he/she will not receive further doses of Lidocaine.
Amiodarone Dosing:
An Amiodarone infusion may be initiated following a BHP order.
FYI:
Cardioversion can be performed during pregnancy without affecting the rhythm of the fetus.
The electrode paddle (or patch) should be at least 12 cm from the pulse generator and an anteroposterior paddle position is recommended. When these precautions have been used, cardioversion with either monophasic or biphasic shocks is safe and effective in patients with an implantable device
There is currently no evidence surrounding the use of Lidocaine prehospitally for atrial fibrillation as it is only effective on ventricular arrhythmias.
If the wide complex tachycardia (WCT) recurs or persists (refractory) following initial attempts at pharmacologic interventions and electrical cardioversion, further evaluation should focus upon the presence of arrhythmia triggers (ie: ischemia, electrolyte abnormalities, and drug toxicity). Amiodarone is generally the most effective agent for treatment of recurrent or refractory WCT, particularly VT. Synchronized cardioversion or defibrillation should be repeated as necessary in patients who are hemodynamically unstable. Multiple recurrences of WCT should raise concern about cardiac ischemia, hypokalemia, digitalis toxicity, and polymorphic VT with or without QT prolongation, all of which have specific appropriate therapy.
Hemodynamic instability refers specifically to hypotension (SBP < 90 mmHg) that requires pharmacologic or electrical intervention(s).
12 lead ECG should be obtained as early as possible.
Atropine is to be administered in the setting of sinus bradycardia, junctional bradycardia, atrial fibrillation, first degree block or second degree block type I. Further, patients presenting in second degree type II or third degree block may receive a single dose of atropine while preparing pacing or if pacing is unavailable or unsuccessful.
Transcutaneous pacing should not be delayed to initiate IV access if the patient is unstable.
Transcutaneous pacing is to be initiated at a rate of 80 bpm with milliamps (mAmps) then increased to obtain electrical capture. Capture is highly variable depending on patient size, weight, pad placement, skin condition, etc. It is difficult to state the target values for capture, however 80 to 100 mAmps is common. If unable to gain capture at maximum mAmps, pacing should be discontinued. Treatment should not be discontinued if the patient responds and develops an improved blood pressure.
Pad placement for pacing should follow the cardiac monitor manufacturer’s recommendations but typically include anterior/posterior or sternum/apex.
Transcutaneous pacing is initiated when the patient is hypotensive. As the blood pressure improves, pacing is not discontinued, but the patient may be more aware of the discomfort and may require sedation.
Patients may receive multiple interventions to maintain their heart rate and blood pressure. The treatment provided must be permitted time to take effect and to be evaluated before moving on to the next treatment.
A contraindication to DOPamine administration is mechanical shock. Examples of mechanical shock include tension pneumothorax, pulmonary embolism, and cardiac tamponade.
Notify the receiving hospital staff if the DOPamine drip goes interstitial as DOPamine can cause tissue necrosis which can be mitigated by a phentolamine injection at the hospital into the affected tissue.
ETI (Endotracheal Intubation) is not mandatory. The importance of definitive airway management has given way to basic airway management and less invasive approaches.
The contraindication which references age < 50 refers specifically to patients experiencing an asthma exacerbation and who are NOT in or near cardiac arrest.
The onset of action for topical Lidocaine is within 1 minute but it may take up to 3 – 5 minutes to have full effect.
In the treatment statement, “consider intubation” is followed by “with or without facilitation devices”. This is a generic statement to address everything from the air trach, to the bougie to all things as yet undefined. The generic statement enables us to continue to use the directives despite changes in technology without being prescriptive.
The formula that is recommended for sizing a cuffed pediatric endotracheal tube is 3.5+(Age in years/4). This formula allows for a slightly smaller tube as the cuff will create the seal versus the tube only.
It is recommended that paramedics start with smaller volume of air when inflating the cuff (example 1 ml increments) and continue until no air is heard on auscultation escaping past the cuff. It is also appropriate to use a smaller syringe such a 3ml or 5ml to avoid over inflating the cuff in smaller patients.
ETI confirmation has been updated and now requires ETCO2 waveform capnography as the only primary method. It is the most reliable method to monitor placement of an advanced airway (AHA guidelines 2015, Part 7). In the event it is not available, three (3) secondary methods must be used; for example: colourmetric detector that changes color with exposure to CO2.
Definition of intubation attempt: Introducing the laryngoscope into the patient’s mouth with the intent to then insert an endotracheal tube is considered an attempt and should be documented as such including success or failure.
The number of advanced airway attempts is clearly defined as two (2) attempts per patient regardless of the route chosen.
FYI:
Nasal intubation should only be performed with the appropriate equipment. This means that the tube being used should have a trigger to curve the end.
While establishing a new peripheral IV line is preferred in the prehospital environment, central venous access devices (CVAD) offer additional parenteral routes of therapy administration should a routine IV be difficult or impossible to place and a patient has a CVAD in place.
The patient must be critically ill to access a CVAD device. This requirement is due to the associated risks involved with CVAD access including contamination of the line requiring replacement.
The steps for accessing a CVAD are very specific. Please refer to provided skill sheets.
Access must be performed with meticulous consideration of maintaining sterility, as CVAD lines carry with them an increased risk of infection. Connectors must be cleaned thoroughly before access, including all the cracks and grooves.
If unable to aspirate blood, re-clamp the lumen and attempt to use another if available. If clots are present during aspiration, do not proceed. Failure to properly aspirate can embolize microthrombi that can form around the distal tip of these catheters, bringing with them a risk of stroke, coronary event, pulmonary embolus or extremity thrombus.
If a CVAD is accidentally dislodged, place firm pressure on the insertion site for at least 10 minutes with several sterile 4x4 gauze squares or a trauma dressing to control bleeding.
The following are some examples of CVAD devices (not an exhaustive list):
Hickman: Central catheter inserted through the anterior chest wall.
Peripherally Inserted Central Catheter (PICC): Located on the patient’s upper arm, but is still direct to central circulation.
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