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Chest Pain/Acute Coronary Syndrome (ACS) with or w/o pain; Time sensitive ST-segment Elevation Myocardial Infarction (ST...

Chest Pain/Acute Coronary Syndrome (ACS) with or w/o pain; Time sensitive ST-segment Elevation Myocardial Infarction (STEMI) pt Typical S&S: Pain, discomfort or tightness in the chest, neck, jaw, teeth, back, arm, or abdomen of suspected cardiac origin. May also present w/ dyspnea, sweating, nausea, vomiting, dizziness, fatigue, or weakness and may be associated with presyncope, syncope, acute HF, or shock = medical emergency. Populations with atypical S&S: Elderly, women, diabetics, recent thoracic surgery or trauma Defer ASA and NTG and use PAIN MGT SOP in pts w/ thoracic trauma or surgery within last 72 hours unless 12-L ECG changes suggest acute ischemia 1. Begin immediate IMC BLS Decrease O2 demand - limit activity, do not allow to walk; sit up, loosen tight clothing If dyspnea, hypoxemia, or obvious signs of HF, titrate O2 to achieve SpO2 of 94% Cardiac monitor; assess for rate, rhythm, pump, or volume problem; hypoperfusion & CR compromise Rx per appropriate SOP. Obtain medication Hx; Is pt taking beta-or calcium channel blockers, clonidine, digoxin, anticoagulants, or meds for erectile dysfunction or pulmonary HTN (vasodilators) 2. ASPIRIN 324 mg (4 tabs 81 mg) chewed and swallowed while prepping for 12 L ECG Indication: Cardiac ischemia due to suspected ACS regardless of chest pain Contraindications: Drug appendix + confirmed adequate dose taken after symptom onset; chest pain after trauma 4. 12-L ECG w/in 5 min of pt contact | Ensure good skin prep & interface | Correct lead placement Clear tracing w/o artifact: capture while stationary - may transmit while moving Call STEMI alert ASAP if + 12 L ECG changes present (See appendix) Communicate & document: Clinical S&S (OPQRST) Pt age, gender, DNR status PCP/cardiologist if known Meds PMH of AMI, PCI/stent/CABG, chronic kidney disease, or contrast allergy (GWTG) ECG rhythm and 12 L findings (transmit/download tracing; if unable - read interpretation to OLMC) Repeat 12 L ECG every 10 min if ongoing pain/symptoms Provide ECGs to treating personnel at receiving hospital NONE to MILD CR compromise + EMERGENT: Moderate CR compromise + pain/discomfort present pain/discomfort present Alert, oriented, well-perfused & SBP > 100 Alert, oriented, perfused & SBP 90-100 4. NITROGLYCERIN (NTG) 0.4 mg SL [BLS] 4. Complete IMC: (unless contraindicated – see drug appendix) IV NS 200 mL fluid challenge if lungs clear 5. Complete IMC: IV NS TKO 5. NITROGLYCERIN 0.4 mg SL (unless contraindicated) [BLS] 6. Pain persists | SBP ≥100 (MAP ≥65): Repeat NTG 0.4 mg SL every 3-5 min X 2; monitor for SE [BLS] 7. Pain persists | SBP ≥90 (MAP ≥65) after NTG or NTG contraindicated: Rx per PAIN Mgt. SOP 8. Transport to primary PCI hospital/STEMI-Receiving Center if transport time ≤ 30 min Goal: First EMS contact to balloon inflation (initial device used) within 90 min (or current AHA guidelines) Monitor closely | Clinical deterioration may be rapid: dysrhythmias, chest pain, SOB, decreased LOC syncope, shock/hypotension | Prepare for CPR and defibrillation CRITICAL (Severe CR compromise): AMS + S&S hypoperfusion; SBP < 90 (MAP 150, AMS, SBP < 90 (MAP < 65), SOB, ongoing chest pain, shock, pulmonary edema, HF or ACS sensitive Immediate cardioversion is seldom needed for HR 0.10 sec): Refer to Wide Complex Tachycardia with a Pulse SOP (next page) DC cardioversion is ineffective in junctional and ectopic atrial tachycardias *PSVT & A-flutter often respond to lower energy levels, start with 50 J NWC EMSS 2022 SOP 19 Rev. 3-11-24  WIDE COMPLEX TACHYCARDIA with a PULSE (QRS 0.12 sec or wider) – VT; SVT with aberrancy, WPW; Torsades de pointes 1. Assess for hypoperfusion, cardiorespiratory compromise, acidosis 2. IMC: Support ABCs as needed Obtain, review and transmit 12-L ECG per ACS SOP if available | Determine rhythm & stability ASAP If unconscious: defer vascular access until after cardioversion 3. If possible ACS & alert with gag reflex: ASPIRIN per ACS SOP Time Low Acuity to EMERGENT: None to moderate cardiorespiratory/perfusion compromise sensitive Alert, HR > 150, SBP > 90 (MAP> 65), no evidence of tissue hypoperfusion or shock pt Regular Monomorphic VT; polymorphic VT w/ normal QT interval; WPW; Polymorphic VT w/ prolonged QT (Torsades de points): Irregular wide complex tachycardia; AF w/ aberrancy; AF w/ WPW (short PR, delta wave) 4. AMIODARONE 150 mg mixed with 7 mL NS slow IVP 5. MAGNESIUM (50%) 2 g in16 mL NS (slow IVP) or in or in 50 mL NS IVPB over 10 min. May repeat. 50 mL NS (IVPB) | Give over 10 min - Max 1 g / 5 min. Complete dose even if rhythm converts. Cover IV site with cold moist gauze or cold pack to 5. OLMC only: ADENOSINE 6 mg rapid IVP + 10 mL NS relieve burning flush | Contraindication: polymorphic, irregular rhythm Chest pain: NTG per ACS SOP if HR drops to ≤ 100 | If pain persists: Rx per PAIN Mgt. SOP CRITICAL: Severe cardiorespiratory/perfusion compromise (unstable) Time Instability must be related to HR > 150 + one or more of these: Altered sensorium, SBP < 90 (MAP 10 min) phases CPR If indicated, start high quality, minimally interrupted MANUAL CPR w/in 10 seconds of arrest recognition. Use audible prompt for correct rate + real-time CPR feedback device until a mechanical CPR device is deployed 13+ yrs/no contraindications after manual CPR started: Deploy Mechanical CPR device ASAP (if available and meets protocol) to maintain uninterrupted chest compressions | Pause compressions < 5 sec to place device No CPR device or contraindicated: Continue 2 person manual CPR (adult, child, infant) CPR caveats: - DNR status unclear: Start CPR; stop if valid POLST/DNR order is presented or per OLMC order - LifeVest® on: Disconnect batteries | remove vest | resuscitate per SOP - Pulseless & VAD placed: SpO2 | DO NOT disconnect batteries | See VAD SOP; call VAD Coord for instructions - Pregnant & fundus at navel or higher: CPR + manual left lateral uterine displacement; stop magnesium if running GIVE OXYGEN: BLS airways: Maintain manual airway positioning + NPA/OPA | O2 15 L/ NC EtCO2 sensor Hold BV mask over EtCO2 NC w/ tight mask seal to reduce O2 leak 13+ yrs: Add RQP above mask to maintain negative intrathoracic pressure unless contraindicated Contraindications: Flail chest, pulse present; children ≤12 years Place SpO2 central sensor; observe (trend) reading and pleth waveform Immediate vs. Delayed BLS Positive Pressure VENTILATIONS (PPV) Ventilate immediately: Cardiac arrest caused by hypoxic event (asthma, anaphylaxis, O2 w/o ventilations (ApOx): submersion, drug OD etc.), unwitnessed arrest; pregnant, peds ≤12 years EMS witnessed arrest and/or Adult 10 BPM (asthma 6-8 BPM) | child (1 breath q. 6 sec) each over 1 second; see found in a shockable rhythm: visible chest rise (adult: 500-600 mL) + bilateral breath sounds midaxillary lines Manual airways + O2 as above Avoid hyperventilation, high airway pressure (≥25 cm H2O) & gastric distention No ventilations for first 3 mins. EARLY DEFIBRILLATION (VF & Pulseless VT) APPLY DEFIB PADS on exposed chest w/o interrupting compressions (anterolateral or anteroposterior) Connect to cardiac monitor [ALS] / AED [BLS] (See Peds IMC p. 72 for peds pad sizes) RHYTHM: Does monitor sense native rhythm with CPR in progress? CPR device + monitor senses ECG: No pause in compressions to ID rhythm NO CPR device/monitor does not sense ECG: Palpate femoral pulse for 5 sec with compressions in progress | pause compressions ≤ 5 sec. to check rhythm | Resume compressions immediately Can’t ID rhythm: Print strip during pause; resume compressions; read ECG from printed strip Not shockable: Continue compressions Shockable: DEFIBRILLATE immediately JOULES (rapidly measure child with length-based tape) Adult and peds ≥ 50 kg: Monitor-specific joules (see bottom of next page) Peds < 50 kg: 2 J/kg then 4 J/kg | subsequent shocks ≥ 4 J/kg not to exceed 10 J/kg or adult max Defibrillation caveats - Perishock pause: With CPR device: None | NO CPR device: ≤ 5 sec (Pre-charge w/ compressions ongoing) | Discharge current after a compression - not a ventilation | Immediately resume compressions - NO CPR device: Change compressors q. 2 min (immediately after defib or sooner if fatigued) - NO rhythm/pulse check until after 2 min of CPR unless evidence of ROSC - Continue to defibrillate shockable rhythms per above procedure in 2 minute cycles - If very fine VF and/or EtCO2 low or decreasing: CPR quality – attempt to improve perfusion/ventilation - Persistent/refractory VF: Change defib pad location if possible NWC EMSS 2022 SOP 21 Rev. 3-11-24  ALS interventions: Priority order – IV/IO access | EPINEPHRINE | Adv. airway 1. VASCULAR ACCESS: 3. Consider ADVANCED Airway 3 min after preox May consider IO (approved site) if attempts at IV ETI (preferred in adults) limit 2 attempts per DAI SOP/BIAD (adults & peds) access are unsuccessful or not feasible. Place w/o pausing CPR | Cont. O2 15 L/EtCO2 NC until placed NS TKO unless IVF indicated per condition Keep head of bed flat if using CPR device When placed, give meds w/o CPR interruption Confirm correct placement & secure / ADV airway SOP 2. Early EPINEPHRINE (Non-shockable rhythm: as Tower of Power: Airway | EtCO2 | HEPA filter (product- soon as feasible | Shockable: after initial defibs) dependent) | ITD (RQP) | Zoll Accu-vent | BVM (D/C NC EtCO2) EPINEPHRINE (1 mg/10 mL) IVP / IO Repeat every 6 min as long as CPR continues PPV: O2 15 L/BVM at 10 BPM with continuous chest Adult: 1 mg (each dose) compressions. Volume only to see visible chest rise and Peds: 0.01 mg/kg (0.1 mL/kg) (max 1 mg/dose) bilateral breath sounds at midaxillary lines. May adjust peds to Use dosing chart in Appendix 20 BPM based on SpO2 / EtCO2. Don’t over ventilate. Antidysrhythmic agent only if SHOCKABLE RHYTHM AMIODARONE IVP/IO Adult: 300 mg Peds: 5 mg/kg (Max 300 mg) Rhythm persists after 5 min: Adult: 150 mg Peds: 5 mg/kg (May repeat up to 3 total doses) Consider & Rx reversible causes: Hs & Ts (May use ultrasound to ID reversible causes or ROSC) Hypoxia (ventilate/O2) Tamponade, cardiac Hypothermia (core rewarm) Thrombosis (coronary/pulmonary) Hypovolemia/dehydration (IVF boluses) Tension pneumothorax (pleural decompression) Hypo/hyperkalemia (bicarb-responsive acidosis (DKA; TCA /ASA OD, cocaine, diphenhydramine): Toxins Opioid OD: NALOXONE SODIUM BICARB 1 mEq/kg (max 50 mEq) IVP/IO Adult: 1 mg IVP/IO; repeat q. 2 min. up to 4 mg from EMS (routine use of sodium bicarb in an undifferentiated Peds 0.1 mg/kg IVP/IO (max 1 mg); repeat as above cardiac arrest is not recommended) Additional doses: OLMC Return of spontaneous circulation (ROSC): Rapid, sustained rise in EtCO2 (≥40); pt moves; wakes up Time- FOCUS: Oxygenation, circulatory support, lung-protective ventilation, adequate sedation; 12 L ECG sensitive pt Remove RQP | Assess VS + SpO2 & EtCO2: palpate pulse & watch SpO2 pleth for 5 min to detect PEA Support ABCs; Target SpO2 (92-98%), EtCO2 (35-45) | Adult SBP > 90 (MAP > 65) | Child SBP >70 + (2 X age) PPV prn 10 BPM w/ visible chest rise; do not hyperventilate even if ↑ EtCO2 If ETI/BIAD placed and pt remains unconscious: Assess need for pain mgt/sedation (RASS score) per DAI SOP Obtain12 L ECG (as soon as feasible - target within 8 min) after ROSC (call alert if STEMI) Emergent Rx if hypotensive | cardiogenic shock | mechanical circulatory support needed If lungs clear: IV NS 20 mL/kg up to 1 L while prepping… NOREPINEPHRINE drip (IV/IO) Concentration: 4 mg in 1,000 mL NS (4 mcg/mL) | Use of IV pump preferred Adult: Initial dose: 8 mcg/min (2 mL/min) titrated to reach SBP ≥ 90 (MAP ≥ 65) Peds: Initial dose: 0.1 mcg/kg/min (max 1 mcg/kg/min up to 8 mcg/min) titrated to SBP >70 + (2 X age in yrs) Higher doses (10 mcg/min) RARELY needed – contact OLMC. Assess BP (MAP) q. 2 min until target BP is reached (don’t overshoot) | Then reduce drip rate incrementally to maintain at BP targets Maintenance: 2 to 4 mcg/min (0.5 mL to 1 mL/min) or less | Continue to reassess BP q. 5 min. Monitor for SEIZURES: Rx per SOP | GLUCOSE level: Rx HYPERGLYCEMIA SOP; avoid hyperglycemia Determination of Death | TERMINATION OF RESUSCITATION (TOR) | Must be approved by OLMC physician BLS TOR Rule: Arrest Unwitnessed by EMS/1st responders | No ROSC before transport | no AED shocks (intentionally) delivered ALS TOR Rule: Arrest unwitnessed by anyone | No bystander CPR | No ROSC after full ALS | No defib before transport Addtl. Considerations: Normothermic pt. remains in persistent monitored asystole for ≥ 30 min despite resuscitation | EtCO2 remains ≤ 10 mmHg for 20 min in pts with advanced airways & no reversible causes of arrest identified If TOR denied: Transport with CPR in progress after 30 min of resuscitation on scene If TOR granted: Note time resuscitation was terminated | Follow System policy for patient disposition Adult Defibrillator Joule recommendations If ICD is delivering shocks, wait 30-60 sec. for cycle to complete. LifePak 200 – 300 - 360 Place pads at least 1” from implanted device. Philips 150 – 170 - 200 Zoll all series 120 – 150 - 200 NWC EMSS 2022 SOP 22 Rev. 3-11-24  HEART FAILURE | PULMONARY EDEMA | CARDIOGENIC SHOCK HF: Structural or functional impairment of ventricular filling or ejection of blood. Assess for hypoperfusion and cardiorespiratory (CR) compromise. Obtain PMH/comorbidities: CAD/ACS/AMI, HTN, valvular heart disease, rhythm-related (tachycardia, PVCs, RV pacing); cardiomyopathies, infiltrative disease (amyloid/sarcoid/excess iron); rheumatic or autoimmune /endocrine or metabolic causes; myocarditis (infectious, toxin or medication, immunological, hypersensitivity); cardiotoxicity with cancer; SUD (alcohol, cocaine, and methamphetamine); or pregnancy-related. Consider pulmonary embolism. Assess for clinical congestion: JVD, orthopnea, peripheral edema; auscultate lung sounds all lobes, front & back; report timing/location of wheezes/crackles | Differentiate HF from COPD/asthma by PMH, meds, S&S, EtCO2 PULMONARY EDEMA: Low Acuity to Emergent | Mild to moderate CR compromise | Alert, (SBP ≥ 90 & DBP ≥ 60) (MAP ≥ 65) 1. IMC special considerations: BLS Position patient sitting upright at 90˚ (if tolerated); dangle legs over sides of stretcher C-PAP 5-10 cm PEEP | If SBP < 90 (MAP < 65): Titrate PEEP down to 5 cm; remove if MAP < 60 If resp. distress & CPAP contraindicated/not tolerated: Assess need for ADV airway [ALS]; O2 15 L/NRM 2. 12-L ECG & ASPIRIN 324 mg (4 tabs 81 mg) PO per ACS SOP unless contraindicated 3. NITROGLYCERIN 0.4 mg SL | If SBP ≥ 90 (MAP ≥ 65): Repeat NTG 0.4 mg SL q. 3-5 min – no dose limit May be given if HR > 100 in pulmonary edema | monitor BP closely 4. Severe anxiety: MIDAZOLAM (standard dose) per ACS SOP ALS CARDIOGENIC SHOCK (CRITICAL): Pump failure due to PMH above &/or drugs with Time SBP < 90; MAP < 65 + S&S hypoperfusion sensitive pt 1. IMC special considerations: Assess need for advanced airway to ↓ WOB, protect airway, or if PPV indicated Assess for hypovolemia / dehydration 2. If hypovolemic and/or dehydrated - lungs clear + ventilations unlabored: NS IVF in 200 mL increments up to 1 L; attempt to achieve SBP ≥ 90 (MAP ≥ 65) | Frequently reassess lung sounds 3. NOREPINEPHRINE 8 mcg/min (2 mL/min) IVPB/IO per inopressor SOP | Use of IV pump preferred 4. If possible ACS: (alert with gag reflex): ASPIRIN 324 mg (4 tabs 81 mg) PO per ACS SOP [BLS] Sampling of drugs prescribed for patients with CV disease/Heart Failure ACE Inhibitors (ACEi): Benzapril (Lotensin), captopril (Capoten), enalapril (Vasotec), fosinopril, monopril, lisinopril (Prinivil/Zestril), moesipril (Univasc), perindopril (Aceon), quinapril, accupril, Ramipril (Altace), trandolapril (Mavik) Angiotensin Receptor Blockers (ARB): candesartan (Atacand), eprosartan (Teveten), irbesartan (Avapro), losartan (Cozaar), olmesartan (Benicar), telmisartan (Micardis), valsartan (Diovan) Angiotensin Receptor-Neprilysin Inhibition (ARNi): Sacubitril-valsartan HCN Channel blocker: Ivabradine (Colanor, Lancora, Procoralan) Anticoagulants: apixaban (Eliquis), aspirin, argatroban, bivalirudin (Angiomax), clopidogrel (Plavix ), dabigatran (Pradaxa), endoxaban (Savaysa/Lixiana), eptifibatide (Integrilin), lepirudin (Refludan), presugrel (Effient), rivaroxaban (Xarelto), ticagrelor (Brilinta), ticlodipine (Ticlid), warfarin (Coumadin, Jantoven); SUBQ route: dalteparin (Fragmin), enoxaparin (Lovenox), fondaparinux (Arixtra), tinzaparin (Innohep); Heparin (IV & SUBQ) Beta Blockers: acebutolol (Sectral), atenolol (Tenormin), betaxolol (Betopic,Kerlone), bisoprolol (Zebeta), carvedilol (Coreg), esmolol (Brevibloc), labetalol (Normodyne, Trandate), levobunolol (Betagan), metoprolol (Lopressor/Toprol), Kapspargo Sprinkle (metoprolol succinate extended-release), nadolol (Corgard), pembutolol, pindolol (Visken), propranolol (Inderal), timolol (Blocadren, Timoptic), sotalol (Betapace) Calcium channel blockers: amlodipine (Norvasc), felodipine, diltiazem (Cardizem), nicardipene (Cardene), nifedipine (Procardia, Adalat), verapamil (Calan, Isoptin) Diuretics: amiloride (Midamor), bumetanide (Bumex), chlorothiazide (Diuril), diazide, furosemide (Lasix), hydrochlorothiazide (Hydrodiuril), indapamide (Lozol), metolazone (Zaroxolyn), Polythiazide, torsemide Mineralocorticoid Receptor Antagonists (MRAs): spironolactone (Aldactone); eplerenone (Inspra); finerenone (Kerendia) Sodium-glucose cotransporter-2 inhibitors: canagliflozin (Invokana); dapagliflozin (Farxiga); empagliflozin (Jardiance) Vasodilators: hydralazine (Apresoline), isosorbide dinitrate (Isordil), minoxidil (Loniten), nesiride (Natrecor), Nitrates/NTG Aldosterone antagonists: (K sparing diuretics) Eplerenone, spironolactone (Aldactone); triamterene (Dyrenium) NWC EMSS 2022 SOP 23 Rev. 3-11-24  Ventricular Assist Device (VAD) Purpose: Improve survival and minimize morbidity in patients with end stage heart failure (HF). The current generation of VADs have a number of components in common: an inflow cannula is inserted in the left ventricular (LV) apex that drains blood from the LV to the pump; an electrically actuated continuous-flow (CF) pump with a single rotating impeller suspended within a tube propels blood forward by spinning at high speeds; and an outflow cannula carries blood back to the arterial circulation, typically by way of the ascending aorta. The power supply for the VAD is a percutaneous lead that traverses the skin and connects the external power system with the internal pump. The external components generally consist of a power source (i.e., batteries or an alternating current power unit) and a small portable controller that controls pump speed and monitors device function. 1. CALL VAD Coordinator listed on patient information sheet for instructions EMS personnel are authorized to follow directions of the VAD Coordinator 2. Patient may/may not have a peripheral pulse or normal BP at any time; SpO2 registers if perfusion is present 3. Evaluate perfusion based on mental status, skin signs 4. CHEST COMPRESSIONS ARE ALLOWED if patient is unconscious and non-breathing - see below. Follow all other BLS and ALS protocols. 5. Patients with VADs may tolerate sustained ventricular arrhythmias with minimal hemodynamic instability because the VAD maintains cardiac output during arrhythmic events. Patient may be defibrillated, as necessary for V-fib with loss of consciousness, without disconnecting the pump. 6. Do not defibrillate over the pump; defibrillate at nipple line or above. Anterior-posterior pad placement preferred. 7. ECG waveforms may have a lot of artifact due to the device. 8. Patients will often have pacemakers and/or Internal Cardioverter Devices (ICDs). 9. Waveforms may be flat; without amplitude in spite of accurate readings – i.e. pulse ox. 10. Patient should have a binder with record of daily VAD parameters. 11. Patients will be on anticoagulation medications and are at risk for thromboembolic events. 12. NO MRIs - CT Scans are ok; avoid water submersion; avoid contact with strong magnets or magnetic fields 13. Never remove both sources of power (batteries) at the same time! NWC EMSS 2022 SOP 24 Rev. 3-11-24