LifeMed Alaska 2017 CARDIAC DYSRHYTHMIAS SCOPE Any patient with impaired cardiac function and presenting with cardiac dysrhythmias. PROCEDURE Oxygen at 6-­‐‑10 L/minute via NC if patient is stable. If patient unstable or planned sedation for cardioversion, then give 15 lpm oxygen by NRB. (May give in addition to NC). Follow ACLS guidelines, consult medical control for any clarification. A. Bradycardia: Rate < 60 (absolute) or relative. 1. If systolic BP is > 90, no treatment is necessary. 2. If systolic BP is < 90 (with signs / symptoms of compromise). ATROPINE 0.5 -­‐‑ 1 mg IV. Repeat at 3-­‐‑5 minute intervals up to total of 0.04 mg/kg. Transcutaneous Pacemaker Consider a DOPAMINE (5-­‐‑20 mcg/Kg/min) or EPINEPHRINE infusion (2-­‐‑10 mcg/min.). B. Supraventricular Tachyarrhythmias (SVT) 1. Paroxysmal Supraventricular Tachycardia (PSVT) Attempt carotid sinus massage (avoid in elderly or those with peripheral vascular disease) or valsalva. ADENOSINE 6 mg IVP as rapidly as possible. May repeat 12 mg after 1 minute. May repeat a 3rd time with 12 mg after 2 more minutes. If ADENOSINE does not work and continue to have a narrow complex use DILTIAZEM bolus dose of 0.25mg/kg actual body weight or 20 mg IV), with a repeat dose of 0.35mg/kg (or 25 mg IV) in 15 minutes, if needed. Continuous infusions of 10mg/hour IV (range: 5 to 15mg/hour) may be instituted after bolus dose to maintain heart rate less than 150 or Lower if needed. If wider complex follow procedure for "wide-­‐‑complex PSVT". Synchronized cardioversion at 50 joules if the patient has inadequate BP, angina, or CHF. If unsuccessful, increase the joules to 100, 200, 300, 360 (max for Zoll = 200j). Consider Midazolam 2 -­‐‑3 mg IV for sedation prior to cardioversion if appropriate for patient’s condition. Consider fentanyl and/or midazolam. 2. Wide Complex PSVT (History of Bundle Branch Block or indication of aberrant conduction). 23 LifeMed Alaska 2017 If SVT complex is wide, you may consider; 3. a. LIDOCAINE 1mg/kg IVP, repeat in 5-­‐‑10 minutes with 0.5 mg/kg until total of 3 mg/kg. b. ADENOSINE 6mg IVP as rapidly as possible. May repeat 12mg after 2 minutes. May repeat a 3rd time with 12 mg after 2 minutes. c. Synchronized cardioversion at 50 joules if the patient has inadequate BP, angina, or CHF. If unsuccessful, increase the joules to 100, 200, 300, 360 (Zoll max = 200j.). Consider Midazolam 2-­‐‑3 mg IV for sedation prior to cardioversion if appropriate for patients condition. Atrial Fibrillation / Atrial flutter a. DILITAZEM bolus dose of 0.25mg/kg actual body weight (or 20 mg IV), with a repeat dose of 0.35mg/kg (or 25 mg IV) in 15 minutes if needed. Continuous infusions of 10mg/hour IV (range: 5 to 15 mg.hour) may be instituted after bolus dose to maintain heart rate less than 150 or lower if needed. b. C. Synchronized Cardioversion at 50-­‐‑100 Joules if the patient has an inadequate BP, angina, or CHF. If unsuccessful, increase the joules to 200, 300, 360 (start at 50J for atrial flutter, Zoll max = 200j). Consider MIDAZOLAM 1-­‐‑2 mg and/or FENTANYL 250 micrograms IV for sedation prior to cardioversion if appropriate for patient’s condition. Always preoxygenate with 100% O2 Ventricular Dysrhythmias 1. PVCs (> 6 per minute or pt. is symptomatic) LIDOCAINE 1.0 mg/kg IV bolus and start a LIDOCAINE infusion at 2-­‐‑4 mg/min If continued suppression of PVCs is necessary, give 2nd bolus of 0.5 mg/kg after 5-­‐‑10 min. (Total = 3 mg/kg) OR AMIODARONE 150 mg over10 minutes, then 1mg/min IV infusion for 6 hours, followed by 0.5 mg/min IV infusion for 18 hours. 2. Ventricular Tachycardia a. Inadequate BP i. Oxygen 100% NRB ii. Cardioversion (synchronize if time allows Biphasic 100 -­‐‑ 120 joules/ Monophasic 100-­‐‑200J ). Consider sedation. iii. AMIODARONE 300 mg IVP, may repeat 150 mg in 3-­‐‑5 minutes for persistent V. Tach. When rhythm converts start IV infusion at 1 mg/min for 6 hours, followed by 0.5 mg/min IV infusion for 18 hours. 24 LifeMed Alaska 2017 OR iv. LIDOCAINE 1.0 mg/kg IV bolus. May repeat at 0.5 mg/kg IVP every 5 -­‐‑ 10 minutes to total of 3 mg/kg. If rhythm converts start a continuous infusion of 2 – 4 mg/min. v. Consider MAGNESIUM SULFATE 1 -­‐‑ 2 gm IV in Torsades or suspected hypomagnesemia. b. Adequate BP i. AMIODARONE 150 mg IV over 10 min. May repeat PRN every 10 minutes to maximum dose of 450 mg. When rhythm converts start IV infusion at 1 mg/min for 6 hours, followed by 0.5 mg/min IV infusion for 18 hours. OR ii. LIDOCAINE 1.0 mg/kg IV bolus. May repeat at 0.5 mg/kg IVP every 5 -­‐‑ 10 minutes for total of 3 mg/kg. When rhythm converts start IV infusion at 2 -­‐‑ 4 mg/min. iii. Cardioversion (synchronized) 50 -­‐‑ 100 joules. Consider sedation, Midazolam 2-­‐‑3 mg IV. NOTE: In Torsades de Pointes, consider overdrive pacing and/or MAGNESIUM SULFATE 1 -­‐‑ 2 Gm IV over 1 -­‐‑ 2 minutes. If SVT with aberrancy give ADENOSINE 6 mg IVP if no response 12 mg IVP may repeat x 1. If A-­‐‑fib with aberrancy consider rate control or cardioversion. 3. Ventricular Fibrillation: See cardiac arrest protocol. 4. Asystole / PEA: See cardiac arrest protocol. 25