Emergency Cardiac Care for BLS Algorithm

Adult Emergency Cardiac Care for BLS – Algorithm

• Indications for adult emergency cardiac care include slow heart rate, bradycardic patients, and patients with serious signs and symptoms such as chest pain, shortness of breath, and hypotension.
• Assess and treat for shock, if indicated, and continuously monitor airway and reassess vital signs every 5 minutes.
• Begin CPR if HR is less than 60 with signs of poor perfusion despite oxygenation and ventilation.

Pediatric Emergency Cardiac Care for BLS – Algorithm

• Indications for pediatric emergency cardiac care include slow heart rate, bradycardia, and patients with serious signs and symptoms such as chest pain, shortness of breath, and hypotension.
• If less than 1 hour old, refer to the Newly Born Protocol.
• Oxygen as needed, ventilate as needed, target ventilation rate to 20 bpm, and attach AED with pediatric capability.
• Defibrillate one time and resume CPR immediately for 2 minutes.

Adult Bradycardia Algorithm

• Indications for adult bradycardia include slow heart rate, less than 60 bpm, and patients with serious signs and symptoms such as chest pain, shortness of breath, and hypotension.
• Assess and treat for shock, if indicated, and continuously monitor airway and reassess vital signs every 5 minutes.
• Begin CPR if HR is less than 60 with signs of poor perfusion despite oxygenation and ventilation.

Pediatric Bradycardia Algorithm

• Indications for pediatric bradycardia include slow heart rate, less than 60 bpm, and patients with serious signs and symptoms such as chest pain, shortness of breath, and hypotension.
• If less than 1 hour old, refer to the Newly Born Protocol.
• Assess and treat for shock, if indicated, and continuously monitor airway and reassess vital signs every 5 minutes.
• Begin CPR if HR is less than 60 with signs of poor perfusion despite oxygenation and ventilation.

Adult Tachycardia Algorithm – Irregular Rhythm

• Indications for adult tachycardia include irregular heart rhythm, more than 100 bpm, and patients with serious signs and symptoms such as chest pain, shortness of breath, and hypotension.
• Place patient in a position of comfort, assess and treat for shock, if indicated, and continuously monitor airway and reassess vital signs every 5 minutes.

Adult Tachycardia Algorithm – Regular Rhythm

• Indications for adult tachycardia include regular heart rhythm, more than 100 bpm, and patients with serious signs and symptoms such as chest pain, shortness of breath, and hypotension.
• Place patient in a position of comfort, assess and treat for shock, if indicated, and continuously monitor airway and reassess vital signs every 5 minutes.

Pediatric Tachycardia Algorithm

• Indications for pediatric tachycardia include irregular heart rhythm, more than 100 bpm, and patients with serious signs and symptoms such as chest pain, shortness of breath, and hypotension.
• If less than 1 hour old, refer to the Newly Born Protocol.
• Assess and treat for shock, if indicated, and continuously monitor airway and reassess vital signs every 5 minutes.

Cardiac Arrest – Adult

• Indications for adult cardiac arrest include unconsciousness, apnea, and pulselessness.
• Perform high-quality uninterrupted chest compressions, apply AED as soon as available, and follow machine prompts regarding rhythm analyses and shocks.
• Limit breaks in compressions to 10 seconds or less for rhythm analysis periods and during shocks.

Cardiac Arrest – Pediatric

• Indications for pediatric cardiac arrest include unconsciousness, apnea, and pulselessness.
• If less than 1 hour old, refer to the Newly Born Protocol.
• Perform high-quality uninterrupted chest compressions, apply AED as soon as available, and follow machine prompts regarding rhythm analyses and shocks.
• Limit breaks in compressions to 10 seconds or less for rhythm analysis periods and during shocks.

Return of Spontaneous Circulation (ROSC) – Adult

• Indications for ROSC include patients 18 years and older who have been revived from cardiac arrest.
• Verify presence of a carotid pulse, and if apneic or with inadequate respirations, continue to support ventilations.
• Frequently reassess vital signs, treat any abnormalities, and rendezvous with ALS or transport to the closest ED.

Return of Spontaneous Circulation (ROSC) – Pediatric

• Indications for ROSC include pediatric patients less than 18 years old who have been revived from cardiac arrest.
• Verify presence of a carotid pulse, and if apneic or with inadequate respirations, continue to support ventilations.
• Frequently reassess vital signs, treat any abnormalities, and rendezvous with ALS or transport to the closest ED.

Termination of Resuscitation – Adult

• Indications for termination of resuscitation include patients who are in cardiac arrest due to medical or traumatic etiology.
• If the patient meets the criteria listed in the Pronouncement of Death in the Field protocol, EMS clinicians should terminate resuscitation efforts.

Termination of Resuscitation – Pediatric

• Indications for termination of resuscitation include patients who are in cardiac arrest due to medical or traumatic etiology.
• If the patient meets the criteria listed in the Pronouncement of Death in the Field protocol, EMS clinicians should terminate resuscitation efforts.

Pronouncement of Death in the Field

• Indications for pronouncement of death in the field include patients who have met the criteria for termination of resuscitation.
• Confirm that the patient is unresponsive, pulseless, and apneic, and document the exact time and location of the pronouncement of death.

EMS DNR/MOLST

• Indications for EMS DNR/MOLST include patients who have a valid DNR order or MOLST form.
• Resuscitation status is determined by the MOLST form or DNR order, and EMS clinicians must follow the instructions on the form or order.
• If the patient is conscious and able to communicate directly to EMS clinicians, they may revoke the DNR order or MOLST form verbally.### MOLST and DNR Orders
• If a patient has a MOLST or DNR order, do not initiate CPR or resuscitative efforts if the patient experiences respiratory or cardiac arrest
• If resuscitative efforts were already in progress, withdraw them upon discovery of the MOLST or DNR order

MOLST A-1 – Comprehensive Efforts

• Prior to respiratory or cardiac arrest: provide full resuscitative efforts, including intubation
• If respiratory or cardiac arrest occurs: do not attempt resuscitation

MOLST A-2 – Comprehensive Efforts, excluding intubation

• Prior to respiratory or cardiac arrest: provide full resuscitative efforts, excluding intubation
• If respiratory or cardiac arrest occurs: do not attempt resuscitation

MOLST B – Palliative Care

• Prior to respiratory or cardiac arrest: provide supportive treatment, including:
  • Respiratory support: maintain airway, provide oxygen, and use suction as necessary
  • Cardiac support: continue ventilator support, and allow patient-controlled analgesia
  • Pain management: allow patient to receive pain medication, and initiate pain management protocol if necessary
  • Immobilize fractures and control bleeding
  • Transport to a specified inpatient hospice facility if requested

DNR Flowchart

• If a patient has a DNR order and is not in cardiac arrest, provide supportive care
• If a patient is in cardiac arrest, do not attempt resuscitation
• If a patient has a DNR order and is experiencing symptoms of a medical emergency, treat according to Maryland Protocols

Cardiac Arrest

• If a patient is in cardiac arrest, do not attempt resuscitation if a DNR order is present
• If a patient is in cardiac arrest and no DNR order is present, provide CPR and use an AED as appropriate

Chest Pain/Acute Coronary Syndrome

• Indications: angina, chest pain, pressure or discomfort, pain or discomfort in the upper abdomen, arm, or jaw, shortness of breath, unexplained diaphoresis
• Treatment: provide oxygen, administer aspirin, assist with administration of patient-prescribed nitroglycerin, and assess for shock

Cardiac Emergencies: Implantable Cardioverter Defibrillator (ICD) Malfunction

• Indications: three or more distinct ICD shocks, and obvious device malfunction with at least one EMS clinician-witnessed inappropriate shock
• Treatment: provide supportive care, and assess for shock

ST Elevation Myocardial Infarction (STEMI)

• Indications: patient with acute coronary syndrome symptoms, and either new ST elevation or posterior MI
• Treatment: not applicable; ALS protocol only

Ventricular Assist Device (VAD) Protocol

• Indications: adult patients with an implantable VAD, and symptoms of cardiovascular compromise or cardiac arrest
• Treatment: assess level of consciousness and vitals, check for breathing and assist ventilation if necessary, and assess for perfusion

Abuse/Neglect

• Indications: injuries or burns in a pattern suggesting intentional infliction, injuries in various stages of healing, or malnutrition or extreme lack of cleanliness
• Treatment: stabilize and treat injuries, document the situation, and report to the police or social service agency

Agitation

• Indications: mild, moderate, or severe symptoms of agitation
• Treatment: maintain scene safety, assess patient's capacity and risk for self-harm, and attempt verbal de-escalation

Allergic Reaction

• Indications: mild, moderate, or severe symptoms of an allergic reaction
• Treatment: provide epinephrine, albuterol, and additional doses as needed, and consult with a medical professional

Altered Mental Status

• Indications: acute onset of altered mental status, with or without a history of seizures
• Treatment: assess vital signs, perform a physical exam, and check for signs of trauma, fever, or low blood pressure

Anaphylaxis

• Indications: acute onset of severe illness after exposure to a known allergen, with two or more symptoms

• Treatment: provide epinephrine, albuterol, and additional doses as needed, and consult with a medical professional### Anaphylaxis - Adult

• Indications: acute onset of severe illness after exposure to a known allergen with two or more of the following:

  • Urticaria (hives) or acute swelling of the mucosa (e.g., tongue, airway, stridor, lips)
  • Respiratory compromise
  • Hypotension
  • GI symptoms (e.g., persistent nausea/vomiting, abdominal pain, or diarrhea)

• Indications: acute onset of severe illness after exposure to a known allergen with hypotension

Anaphylaxis - Pediatric (4.5-P)

• Indications: same as adult, with two or more of the following:
  • Urticaria (hives) or acute swelling of the mucosa (e.g., tongue, airway, stridor, lips)
  • Respiratory compromise
  • Hypotension
  • GI symptoms (e.g., persistent nausea/vomiting, abdominal pain, or diarrhea)

Epinephrine (BLS) Administration

• Less than 5 years of age: 0.15 mg IM in the lateral thigh
• 5 years of age or greater: 0.3 mg IM in the lateral thigh
• Alternative: BLS epinephrine OSP approved, epinephrine (BLS) (1 mg/mL) 0.15 mg IM in the lateral thigh (less than 5 years) or 0.5 mg IM in the lateral thigh (5 years or greater)

Albuterol (BLS) Administration

• Less than 2 years of age: albuterol (BLS) inhaler (2 puffs) inhaled or 1.25 mg nebulized
• 2 years of age or greater: albuterol (BLS) inhaler (2 puffs) inhaled or 2.5 mg nebulized

Additional Considerations

• Additional doses of pediatric epinephrine auto-injector, epinephrine, albuterol, ipratropium, diphenhydramine beyond those listed above require medical consultation
• Consider pediatric epinephrine infusion for refractory anaphylactic shock
• Clinical Pearls:
  • Re-check dosing and concentration of epinephrine prior to administration
  • Epinephrine 1 mg/mL (previously known as 1:1,000) is appropriate for the IM route only
  • Epinephrine should never be given by IV route, except for an epinephrine infusion for patients in anaphylaxis or for patients in cardiac arrest

Apparent Life-Threatening Event/Brief Resolved Unexplained Event (ALTE/BRUE)

• Indications: infant or child less than 2 years of age, with an episode that is frightening to the observer, including:
  • Apnea
  • Skin color change (cyanosis, pallor, erythema)
  • Marked change in muscle tone
  • Choking or gagging not associated with feeding or witnessing foreign body aspiration
• Assessment:
  • Perform assessment using the Pediatric Assessment Triangle
  • Obtain a description of the event, including nature, duration, and severity
  • Assess the environment for possible causes
  • When obtaining the medical history, include questions to identify any:
    • Current medications
    • Chronic diseases
    • Current or recent infections
    • Evidence of seizure activity
    • Gastro-esophageal reflux
    • Recent trauma
• Clinical Pearls:
  • Most patients will appear stable upon assessment
  • This episode may be a sign of serious underlying illness or injury
  • All suspected ALTE/BRUE patients should be transported for further medical evaluation