V-FIB & V-TACH / NO PULSE
ALL LEVELS
DESIGNATION OF CONDITION
Signs and symptoms include an unresponsive patient with absent carotid pulses, and an ECG showing ventricular fibrillation or pulseless ventricular tachycardia.
EMPHASIS ON PATIENT CARE
1. Primary Management - Assess ABC’s and manage as indicated.
2. Turn the AED on and apply defibrillation electrodes following prompts.
3. Effective pit crew CPR, defibrillation and ACLS intervention as rapidly as possible
4. Place NPA/OPA and provide high flow oxygen
AEMT
1. Establish IV/IO and provide fluid bolus
2. Initiate Epinephrine administration IV/IO immediately upon establishing vascular access.
a. Epinephrine: IV/IO dosage of Epinephrine: See SPECIAL NOTE below
3. Consider placement of Supraglottic airway (LMA preferred), allowing no disruption of chest compressions during placement.
PARAMEDIC
1. Consider placement of Supraglottic airway or ETT in accordance with the corresponding Airway Placement Procedural Guidelines, allowing no disruption of chest compressions during placement
2. After second and on third defibrillation a second set of pads should be applied to chest to change defibrillation vector. Leave initial set attached for potential DSD on 4th attempt.
3. In persistent or recurrent VF/VT without a pulse: initiate appropriate anti-arrhythmic therapy after 3rd defibrillation:
4. Administer Anti-arrhythmic
a. AMIODARONE [300mg] IV/IO followed by 10 mL saline flush. May repeat once at 150mg. If rhythm converts with Amiodarone drip at 1 mg./min.
b. LIDOCAINE 1.5 mg./kg. IV/IO. Repeat at 0.75 mg./kg. to maximum of 3 mg./kg. (three doses). If rhythm converts with Lidocaine start drip. Mix 1 gram Lidocaine into 250 ml. (4 mg./ml.). Start drip at 2 mg./min. if loading dose <2 mg./kg. 3 mg./min. if loading dose 2 mg./kg. and 4 mg./min. if loading dose 3 mg./kg.
c. MAGNESIUM SULFATE 2 gm IV/IO (over 1-2 minutes) if continued VF/pulseless VT only if suspected pulseless Torsades De Pointes
5. SODIUM BICARBONATE 1 mEq/kg IV/IO. Use only in cases of suspected Tricyclic Antidepressant OD. May repeat in 5 minutes to a total of 2 doses.
6. CALCIUM GLUCONATE 10 ml 10% IV. Use only in cases of suspected hyperkalemia i.e. ESRD, dialysis. May repeat in 5 minutes to a total of 2 doses. DO NOT GIVE IN SAME IV LINE AS Sodium Bicarbonate.
7. Double sequential defibrillation is acceptable procedure.
8. All patients in V-FIB or Pulseless V-Tach at any time will be resuscitated on scene for a minimum of 30 minutes.
9. If sustained V-FIB or Pulseless V-Tach after 30 minutes contact Medical control for consult and TOR. See Terminal of Resuscitation Guidelines.
EPINEPHRINE DOSING IN CARDIAC ARREST SPECIAL NOTES
Shortages of EPINEPHRINE 1:10,000 are necessitating alternate dosing for cardiac arrest patients. EPINEPHRINE administration in cardiac arrest patients is associated with improved ROSC rates but no dosing regimen has been shown to be superior in terms of ultimate survival. The following dosing regimens are acceptable in cardiac arrest patients when EPINEPHRINE 1:10,000 is unavailable or rationed. ET dosing is no longer an approved route.
1. AHA recommended dosing if EPINEPHRINE available: 1 mg. IV/IO q 3-5 minutes. No limitation on number of doses given.
2. EPINEPHRINE 1 mg. q 5-10 minutes IV/IO. No limitation on number of doses given.
3. EPINEPHRINE 1 mg. IV/IO followed by infusion.
a. Infusion: Mix 3 mg. (3 vials of 1 mg. 1:1,000) into a 1,000 cc bag of crystalloid solution and run so that bag is infusing throughout the 30 minute resuscitation.
4. EPINEPHRINE infusion only.
ALL LEVELS
DESIGNATION OF CONDITION
Signs and symptoms include an unresponsive patient with absent carotid pulses, and an ECG showing ventricular fibrillation or pulseless ventricular tachycardia.
EMPHASIS ON PATIENT CARE
1. Primary Management - Assess ABC’s and manage as indicated.
2. Turn the AED on and apply defibrillation electrodes following prompts.
3. Effective pit crew CPR, defibrillation and ACLS intervention as rapidly as possible
4. Place NPA/OPA and provide high flow oxygen
AEMT
1. Establish IV/IO and provide fluid bolus
2. Initiate Epinephrine administration IV/IO immediately upon establishing vascular access.
a. Epinephrine: IV/IO dosage of Epinephrine: See SPECIAL NOTE below
3. Consider placement of Supraglottic airway (LMA preferred), allowing no disruption of chest compressions during placement.
PARAMEDIC
1. Consider placement of Supraglottic airway or ETT in accordance with the corresponding Airway Placement Procedural Guidelines, allowing no disruption of chest compressions during placement
2. After second and on third defibrillation a second set of pads should be applied to chest to change defibrillation vector. Leave initial set attached for potential DSD on 4th attempt.
3. In persistent or recurrent VF/VT without a pulse: initiate appropriate anti-arrhythmic therapy after 3rd defibrillation:
4. Administer Anti-arrhythmic
a. AMIODARONE [300mg] IV/IO followed by 10 mL saline flush. May repeat once at 150mg. If rhythm converts with Amiodarone drip at 1 mg./min.
b. LIDOCAINE 1.5 mg./kg. IV/IO. Repeat at 0.75 mg./kg. to maximum of 3 mg./kg. (three doses). If rhythm converts with Lidocaine start drip. Mix 1 gram Lidocaine into 250 ml. (4 mg./ml.). Start drip at 2 mg./min. if loading dose <2 mg./kg. 3 mg./min. if loading dose 2 mg./kg. and 4 mg./min. if loading dose 3 mg./kg.
c. MAGNESIUM SULFATE 2 gm IV/IO (over 1-2 minutes) if continued VF/pulseless VT only if suspected pulseless Torsades De Pointes
5. SODIUM BICARBONATE 1 mEq/kg IV/IO. Use only in cases of suspected Tricyclic Antidepressant OD. May repeat in 5 minutes to a total of 2 doses.
6. CALCIUM GLUCONATE 10 ml 10% IV. Use only in cases of suspected hyperkalemia i.e. ESRD, dialysis. May repeat in 5 minutes to a total of 2 doses. DO NOT GIVE IN SAME IV LINE AS Sodium Bicarbonate.
7. Double sequential defibrillation is acceptable procedure.
8. All patients in V-FIB or Pulseless V-Tach at any time will be resuscitated on scene for a minimum of 30 minutes.
9. If sustained V-FIB or Pulseless V-Tach after 30 minutes contact Medical control for consult and TOR. See Terminal of Resuscitation Guidelines.
EPINEPHRINE DOSING IN CARDIAC ARREST SPECIAL NOTES
Shortages of EPINEPHRINE 1:10,000 are necessitating alternate dosing for cardiac arrest patients. EPINEPHRINE administration in cardiac arrest patients is associated with improved ROSC rates but no dosing regimen has been shown to be superior in terms of ultimate survival. The following dosing regimens are acceptable in cardiac arrest patients when EPINEPHRINE 1:10,000 is unavailable or rationed. ET dosing is no longer an approved route.
1. AHA recommended dosing if EPINEPHRINE available: 1 mg. IV/IO q 3-5 minutes. No limitation on number of doses given.
2. EPINEPHRINE 1 mg. q 5-10 minutes IV/IO. No limitation on number of doses given.
3. EPINEPHRINE 1 mg. IV/IO followed by infusion.
a. Infusion: Mix 3 mg. (3 vials of 1 mg. 1:1,000) into a 1,000 cc bag of crystalloid solution and run so that bag is infusing throughout the 30 minute resuscitation.
4. EPINEPHRINE infusion only.