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==Section 4 - CARDIAC 4.02==
==Section 4 - CARDIAC==
=== ASYSTOLE ===
===4.02 ASYSTOLE===
====CONSIDER MEDICAL ETIOLOGY OF ASYSTOLE AND REFER TO APPROPRIATE PRACTICE PARAMETER:====
* Hypoxia / acidosis, [[Initial Medical Assessment and Care|INITIAL MEDICAL CARE]] (2.01).
* Drug overdose, [[Drug Overdose Poisoning|DRUG OVERDOSE / POISONING]] (5.05).
* Vagal Stimuli


Asystole is a terminal condition identified by an absence of any cardiac electrical activity. It is important to CONFIRM true asystole early in the management of the case. Consider all possible reversible causes for Asystole utilizing a national recommended mnemonic of “H’s and T’s”:


====When the Patient found in Asystole:====
{| class="wikitable"
* Initiate 5 cycles of CPR (30:2) for approximately 2 minutes to allow blood to circulate and continue throughout resuscitation, minimizing interruptions. Assist ventilations with OXYGEN @ 100% via BVM. '''DO NOT HYPERVENTILATE'''.
|-
* Reassess for circulation. Establish IV or IO.
! H’s !! T’s
* If HYPOTHERMIC, also follow [[Environmental Cold Emergencies|HYPOTHERMIC PARAMETERS]] (5.06).
|-
* Consider securing the airway king tube / intubation. Confirm tube placement with EtCO2. (a range 5-20 mmHg is indicative of low cardiac output)
| Hypovolemia|| Tension Pneumothorax
* [[Hormones Vitamins|VASOPRESSIN]] 20 units IV / IO. (Alternate with) [[Adrenergics|EPINEPHRINE]] 1:10,000 1 mg IV / IO (Vasopressin may be given twice) Continue [[Adrenergics|EPINEPHRINE]] ever 3-5 minutes of arrest.
|-
* [[Antiarrhythmics|ATROPINE SULFATE]] 1 mg rapid IVP or IORepeat every 3 - 5 minutes up to a total of .04 mg/kg.
| Hypoxia|| Tamponade, cardiac
* Apply TCP, set at maximum M-amp. If pulse generated, decrease dosage to setting which still  maintains a palpable pulse. If unsuccessful, reattempt capture every 3 - 5 minutes as above.
|-
'''Check for pulse and rhythm change after all interventions.'''  
| Hydrogen Ion (acidosis)|| Toxins or Tablets (overdose)
|-
| Hypo/hyperkalemia|| Thrombosis, pulmonary
|-
| Hypothermia|| Thrombosis, cardiac
|}
In addition, also consider the following:
{| class="wikitable"
|-
| Hypoglycemia|| Trauma
|}
 
 
Check proper lead placement – confirm that a “flat line” is not an equipment or operator error
'''BASED ON MEDICAL ETIOLOGY OF ASYSTOLE - REFER TO APPROPRIATE PRACTICE PARAMETER:'''
* Hypoxia / acidosis, [[Initial Medical Assessment and Care|INITIAL MEDICAL CARE (2.01)]].
* Drug overdose, [[Drug Overdose Poisoning|DRUG OVERDOSE / POISONING (5.05)]].
 
====When the Patient found in True Asystole:====
* Initiate 5 cycles of high quality CPR (push hard/push fast)
** Minimum of 100 compressions per minute, minimize interruptions
** Compression rate of 30:2 for approximately 2 minutes
** Depth of compression of at least 2 inches
** Initiate the use of a mechanical compression device if available
* Assist ventilations with OXYGEN @ 100% via BVM - DO NOT HYPERVENTILATE
* Establish intravenous access via IV or IO
* Reassess for circulation every two minutes
** If a shockable rhythm is identified proceed to [[Ventricular Fibrillation Pulseless Ventricular Tachycardia|VF/VT PARAMETER (4.08)]]
* If HYPOTHERMIC, also follow [[Cold Emergencies|HYPOTHERMIC PARAMETER (5.06)]]
* Consider advanced airway procedure using supraglottic airway (king tube) or endotracheal intubation
** Do not interrupt compressions to place an advanced airway
** Confirm tube placement with capnography (a range 5-20 mmHg is indicative of low cardiac output)
 
====Pharmacologic Therapy:====
* Administer [[Epinephrine|EPINEPHRINE 1:10,000]] (0.1 mg/ml) 1 mg IV / IO – repeat every 3-5 minutes of arrest
 
{| class="wikitable"
|-
! The current national guidelines do not include [[Atropine|ATROPINE]] for treatment of TRUE ASYSTOLE as there is no proof it has a therapeutic benefit. <br />
Under the Seminole County Practice Parameters the use of [[Atropine|ATROPINE SULFATE]] is indicated in cardiac arrest that may be caused by extreme bradycardia/hypotension.
<br />
The Paramedic may use [[Atropine|ATROPINE SULFATE]] based on clinical impression where there is a possibility that its use will have a positive therapeutic benefit. <br />
If ATROPINE SULFATE is used, the recommended dose is: [[Atropine|ATROPINE SULFATE]] 1 mg rapid IVP or IO Repeat every 3 - 5 minutes up to a total of .04 mg/kg
|}
 
{| class="wikitable"
|-
! Electrical Therapy/Pacing is no longer recommended
|}
 
''Check for pulse and rhythm change after all interventions.''


====If suspected DRUG OVERDOSE (5.05)====
====If suspected DRUG OVERDOSE (5.05)====
* For calcium channel and beta-blockers, administer [[Antidiabetics|GLUCAGON]] 2 mg IVP, IN or IO May repeat x 1
* For calcium channel and beta-blockers
* For calcium channel blockers, administer [[Electrolytes|CALCIUM CHLORIDE]] 1 gram IVP or IO.
** Administer [[Glucagon|GLUCAGON]] 2 mg IVP, IN or IO May repeat x 1
** Avoid if patient is on digoxin or lanoxin.
* For calcium channel blockers
* For tricyclic antidepressants (amitriptyline [Elavil], amoxapine, imipramine [Tofranil ], nortriptyline [Pamelor] and tetracyclic antidepressants (Remeron) OD, with wide QRS> 0.10 sec, administer [[Electrolytes|SODIUM BICARBONATE]] 1 mEq/kg IVP. Repeat in 5-10 mins.
** Administer [[Calcium Chloride|CALCIUM CHLORIDE]] 1 gram IVP or IO
* For narcotic OD, Administer [[Antagonists|NALOXONE (NARCAN)]] 1 mg IVP, IN or IO  
** Avoid if patient is on digoxin or lanoxin
* For tricyclic antidepressants (amitriptyline [Elavil], amoxapine, imipramine [Tofranil ], nortriptyline [Pamelor] and tetracyclic antidepressants (Remeron) OD, with wide QRS> 0.10 sec
** Administer [[Sodium Bicarbonate|SODIUM BICARBONATE]] 1 mEq/kg IVP. Repeat in 5-10 mins.
* For narcotic OD
** Administer [[Naloxone|NALOXONE (NARCAN)]] 1 mg IVP, IN or IO


====For patients with HYPERKALEMIA:====
====For patients with HYPERKALEMIA:====
Suspect hyperkalemia in patients with any of the following: Diagnosis of Renal Failure or any form of kidney insufficiency, widening QRS, increased K+ in diet (excessive consumption of cherries, bananas, melons or citrus), acidosis, or shock. Note last dialysis TX.
Suspect hyperkalemia in patients with any of the following: Diagnosis of Renal Failure or any form of kidney insufficiency, widening QRS, increased K+ in diet (excessive consumption of cherries, bananas, melons or citrus), acidosis, or shock. Note last dialysis TX.
* Administer [[Electrolytes|CALCIUM CHLORIDE]] 1 gram IVP or IO. Avoid if patient is on digoxin or lanoxin.
* Administer [[Calcium Chloride|CALCIUM CHLORIDE]] 1 gram IVP or IO. Avoid if patient is on digoxin or lanoxin
* Administer [[Electrolytes|SODIUM BICARBONATE]] 1 mEq/kg IVP or IO
* Administer [[Sodium Bicarbonate|SODIUM BICARBONATE]] 1 mEq/kg IVP or IO
 


====Termination of efforts====
====Termination of Resuscitation:====
In Medical Related Cardiac Arrests, the paramedic may terminate resuscitative efforts in Non-Hypothermic Adults provided all of the following criteria have been provided and established:
In Medical Related Cardiac Arrests, the paramedic may terminate resuscitative efforts in Non-Hypothermic Adults provided all of the following criteria have been provided and established:
* Patient initially presents and maintains in Asystole. (Verified in 2 leads)
* Patient initially presents and maintains in True Asystole (verified in 2 leads)
* Airway has been successfully controlled. (Not necessarily intubated)
* Airway has been successfully controlled (not necessarily intubated)
* External pacing has been attempted and no palpable pulse was generated.
* EPINEPHRINE 1:10,000 (0.1 mg/ml) 1 mg IVP or IO has been administered & allowed time to circulate x1
* [[Hormones Vitamins|VASOPRESSIN]] 20 units IVP has been administered and allowed time to circulate. x1
* EtCO2 is (less than) < 20 mm Hg
* [[Antiarrhythmics|ATROPINE SULFATE]] 1.0 mg rapid IVP/ IO has been administered and allowed time to circulate x1.
* If clinically indicated - ATROPINE SULFATE 1.0 mg rapid IVP/ IO has been administered and allowed time to circulate x1.
* [[Adrenergics|EPINEPHRINE]] 1:10,000 1 mg IVP or IO has been administered & allowed time to circulate x1
'''OR'''
* EtCO2 is (less than) < 20 mm Hg.
* After 15 minutes of ALS procedures without any response or return of spontaneous circulation
OR
'''OR'''
* After 15 minutes of ALS with never having return of spontaneous circulation.
* After the patient’s personal medical doctor agrees to sign the death certificate
OR
'''''Contact will be made in conjunction and compliance with Federal, State, Local, and Agency Laws and Policies regarding patient body care and removal.'''''
* After the patients personal medical doctor agrees to sign the death certificate.
<br />


====Contact will be made in conjunction and compliance with Federal, State, Local, and Agency Laws and Policies regarding patient body care and removal.====
'''''A paramedic may decide to continue resuscitation efforts as outlined in these Practice Parameters. Reasons to continue may include scene safety, location, and input from present family members.'''''


====A paramedic may decide to continue resuscitation efforts as outlined in these Practice Parameters. Reasons to continue may include scene safety, location, and input from present family members.====
'''If patient combative post resuscitation, refer to [[Analgesia and Sedation|ANALGESIA / SEDATION PARAMETER (2.04)]]'''


====If patient combative post resuscitation, refer to [[Analgesia and Sedation|ANALGESIA / SEDATION PARAMETER]] (2.04)====
[[Category:Cardiac|0402]]

Latest revision as of 15:00, 12 December 2022

Section 4 - CARDIAC

4.02 ASYSTOLE

Asystole is a terminal condition identified by an absence of any cardiac electrical activity. It is important to CONFIRM true asystole early in the management of the case. Consider all possible reversible causes for Asystole utilizing a national recommended mnemonic of “H’s and T’s”:

H’s T’s
Hypovolemia Tension Pneumothorax
Hypoxia Tamponade, cardiac
Hydrogen Ion (acidosis) Toxins or Tablets (overdose)
Hypo/hyperkalemia Thrombosis, pulmonary
Hypothermia Thrombosis, cardiac

In addition, also consider the following:

Hypoglycemia Trauma


Check proper lead placement – confirm that a “flat line” is not an equipment or operator error BASED ON MEDICAL ETIOLOGY OF ASYSTOLE - REFER TO APPROPRIATE PRACTICE PARAMETER:

When the Patient found in True Asystole:

  • Initiate 5 cycles of high quality CPR (push hard/push fast)
    • Minimum of 100 compressions per minute, minimize interruptions
    • Compression rate of 30:2 for approximately 2 minutes
    • Depth of compression of at least 2 inches
    • Initiate the use of a mechanical compression device if available
  • Assist ventilations with OXYGEN @ 100% via BVM - DO NOT HYPERVENTILATE
  • Establish intravenous access via IV or IO
  • Reassess for circulation every two minutes
  • If HYPOTHERMIC, also follow HYPOTHERMIC PARAMETER (5.06)
  • Consider advanced airway procedure using supraglottic airway (king tube) or endotracheal intubation
    • Do not interrupt compressions to place an advanced airway
    • Confirm tube placement with capnography (a range 5-20 mmHg is indicative of low cardiac output)

Pharmacologic Therapy:

The current national guidelines do not include ATROPINE for treatment of TRUE ASYSTOLE as there is no proof it has a therapeutic benefit.

Under the Seminole County Practice Parameters the use of ATROPINE SULFATE is indicated in cardiac arrest that may be caused by extreme bradycardia/hypotension.
The Paramedic may use ATROPINE SULFATE based on clinical impression where there is a possibility that its use will have a positive therapeutic benefit.
If ATROPINE SULFATE is used, the recommended dose is: ATROPINE SULFATE 1 mg rapid IVP or IO Repeat every 3 - 5 minutes up to a total of .04 mg/kg

Electrical Therapy/Pacing is no longer recommended

Check for pulse and rhythm change after all interventions.

If suspected DRUG OVERDOSE (5.05)

  • For calcium channel and beta-blockers
    • Administer GLUCAGON 2 mg IVP, IN or IO May repeat x 1
  • For calcium channel blockers
    • Administer CALCIUM CHLORIDE 1 gram IVP or IO
    • Avoid if patient is on digoxin or lanoxin
  • For tricyclic antidepressants (amitriptyline [Elavil], amoxapine, imipramine [Tofranil ], nortriptyline [Pamelor] and tetracyclic antidepressants (Remeron) OD, with wide QRS> 0.10 sec
  • For narcotic OD

For patients with HYPERKALEMIA:

Suspect hyperkalemia in patients with any of the following: Diagnosis of Renal Failure or any form of kidney insufficiency, widening QRS, increased K+ in diet (excessive consumption of cherries, bananas, melons or citrus), acidosis, or shock. Note last dialysis TX.


Termination of Resuscitation:

In Medical Related Cardiac Arrests, the paramedic may terminate resuscitative efforts in Non-Hypothermic Adults provided all of the following criteria have been provided and established:

  • Patient initially presents and maintains in True Asystole (verified in 2 leads)
  • Airway has been successfully controlled (not necessarily intubated)
  • EPINEPHRINE 1:10,000 (0.1 mg/ml) 1 mg IVP or IO has been administered & allowed time to circulate x1
  • EtCO2 is (less than) < 20 mm Hg
  • If clinically indicated - ATROPINE SULFATE 1.0 mg rapid IVP/ IO has been administered and allowed time to circulate x1.

OR

  • After 15 minutes of ALS procedures without any response or return of spontaneous circulation

OR

  • After the patient’s personal medical doctor agrees to sign the death certificate

Contact will be made in conjunction and compliance with Federal, State, Local, and Agency Laws and Policies regarding patient body care and removal.

A paramedic may decide to continue resuscitation efforts as outlined in these Practice Parameters. Reasons to continue may include scene safety, location, and input from present family members.

If patient combative post resuscitation, refer to ANALGESIA / SEDATION PARAMETER (2.04)