PWC Protocols

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PWC Protocols

• Protocol 5B
• Cardiac Emergencies
• Bradycardia

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Bradycardia

• Defined as
• Formally
• A heart rate below 60 BPM, when related to atrial
  and sinus rhythms
• Informally
• A slow heart rate (below 60 BPM)
• For PWC purposes

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Bradycardia

• Can be a normal variant
• People in good shape
• Can result from many physiologic conditions
• AMI, SSS, increased vagal tone, hypoxia,
  hypothermia, hypothyroidism (Myxedema),
  hyperkalemia, glaucoma, medications, organic
  heart disease, etc.

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Non-symptomatic

• Pt is hemodynamically stable and does not have
  cardiac related complaints
• Not unusual
• May be normal
• Seen with people in good physical condition while
  at rest

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Symptomatic

• Chest Pain
• SOB
• PVCs
• Particularly ventricular escape beats
• Altered mental status
• Hypotension
• BP lt 90 mm/Hg systolic

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Dont Forget The Basics

• Maintain a patent airway
• O2, ventilatory assistance if needed
• Shock position if hypotensive and not
  contraindicated by respiratory compromise
• Perform a rapid focused history and physical exam

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• IV
• Normal Saline, KVO
• Standard Administration Set

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IF Symptomatic And Normotensive

• Atropine
• 0.5 mg Rapid IV
• If no change, repeat q 3 5 minutes up to a
  total dosage of 3 mg
• Note
• Atropine is contraindicated in cases where 2nd
  degree type II HB or 3rd degree HB exist

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IF Symptomatic Hypotensive(BP lt 90 mm/Hg)

• Pace
• May be initiated prior to administration of
  Atropine
• Note if mechanical capture is obtained prior to
  giving Atropine, withhold the Atropine
• Consider the administration of Versed
• Up to 2.5 mg slow IVP

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Medical Control Only

• Dopamine infusion of 400 ug/min
• 400 mg in 500 ml of Normal Saline
• 30 gtts/min using a minidrip set titrate to
  desired effect
• Epinephrine infusion of 2 10 ug/min
• 2 mg in 500 ml of Normal Saline
• 2 ug/min 30 gtts/min using a minidrip set
• Further pacing as directed
• Other pharmacologic therapy as directed

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PWC Protocols

• Protocol 5C D
• Cardiac Emergencies
• Narrow Complex Tachycardia

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Narrow Complex Tachycardia

• Defined as
• A rapid dysrhythmia with no visible P waves, a
  regular rhythm, and rates generally greater than
  150
• If QRS is greater than .12 seconds, use Wide
  Complex Tachycardia protocol
• Includes
• Atrial flutter /c 11 response
• Atrial tachycardia
• Junctional tachycardia
• Sinus tachycardia
• Rarely has rates greater than 150

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Narrow Complex Tachycardia

• Is most often the result of
• Reentry
• Increased automanticity
• Accessory pathways
• Can lead to myocardial ischemia and necrosis
• Oxygenation/perfusion mismatch

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Classifications of Narrow Complex Tachycardias

• Stable (Protocol 5C)
• Patients who may have a fluttering in their
  chest, feel anxious, are lightheaded, etc.
• Unstable (Protocol 5D)
• Patients who experience serious cardiovascular
  S/S
• Chest pain, SOB, pulmonary edema, hypotension (BP
  lt 90), altered LOC
• Significantly unstable (Protocol 5D)
• Patients who exhibit hypotension (BP lt 90), and
  have an altered LOC

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All Narrow Complex Tachycardias

• IV
• Normal Saline, KVO
• Standard Administration Set
• An A/C IV site or higher is prefered

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Stable Patients (5C)

• Valsalva Maneuver
• 10 15 seconds while monitoring ECG
• May repeat twice
• Adenosine
• 6 mg rapid IVP
• Follow with a 20 ml Normal Saline flush
• If no change in 1 2 minutes
• Repeat Adenosine at 12 mg followed by a 20 ml
  Normal Saline flush
• May repeat procedure once in 1 2 minutes if
  indicated

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Medical Control OnlyStable Patients (5C)

• Cardizem 0.25 mg/kg over two minutes
• Patient must not be hypotensive
• Elicit a history of WPW or Beta-blocker use prior
  to administering Cardizem
• If no change after 15 minutes
• Repeat Cardizem at 0.35 mg/kg over 2 minutes
• Amiodarone 150 mg over ten minutes
• 150 mg diluted in a 20 in a 20 cc/syringe of
  Normal Saline
• 2 cc per minute
• 150 mg in 100 ml of Normal Saline
• Using a 10 gtt set 100 gtts/min
• Using a 20 gtt set 200 gtts/min
• Other pharmacologic or electric therapy as
  directed

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Unstable Patients (5D)

• No Valsalva
• Adenosine
• 6 mg rapid IVP
• 20 ml Normal Saline flush
• If no change in 1 2 minutes
• Repeat Adenosine at 12 mg followed by a 20 ml
  Normal Saline flush
• May be repeated if necessary

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Unstable Patients (5D)

• If significantly unstable, prior to administering
  Adenosine
• If indicated, administer Versed, up to 2.5 mg
  slow IVP
• Cardiovert _at_ 50 joules
• If necessary repeat _at_ 100, 200, 300, 360 joules

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Medical Control OnlyUnstable Patients (5D)

• Cardizem 0.25 mg/kg over two minutes
• Patient must not be hypotensive
• Elicit a history of WPW or Beta-blocker use prior
  to administering Cardizem
• If no change after 15 minutes
• Repeat Cardizem at 0.35 mg/kg over 2 minutes
• Amiodarone 150 mg over ten minutes
• 150 mg diluted in a 20 in a 20 cc/syringe of
  Normal Saline
• 2 cc per minute
• 150 mg in 100 ml of Normal Saline
• Using a 10 gtt set 100 gtts/min
• Using a 20 gtt set 200 gtts/min
• Other pharmacologic or electric therapy as
  directed

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Atrial Fibrillation Can Be Dangerous To Cardiovert

• Atrial fibrillation will cause blood to pool and
  clot within the atria
• Should NSR be restored by cardioversion, these
  clots may pass to the lungs and/or the brain

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PWC Protocols

• Protocol 5E F
• Cardiac Emergencies
• Wide Complex Tachycardia

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Wide Complex Tachycardia

• Defined as
• A rapid dysrhythmia that displays no visible P
  waves, has a regular rhythm, QRS complexes
  measure gt .12 seconds, and has rates generally
  greater than 150
• Includes
• Ventricular Tachycardia
• Runs of Ventricular Tachycardia (3 PVCs or more
  in a row)
• Bundle Branch Blocks

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Classifications of Wide Complex Tachycardias

• Stable (Protocol 5E)
• Patients who may have a fluttering in their
  chest, feel anxious, are lightheaded, weak, etc.
• Unstable (Protocol 5F)
• Patients who experience serious cardiovascular
  S/S
• Chest pain, SOB, pulmonary edema, hypotension (BP
  lt 90), altered LOC
• Significantly unstable (Protocol 5F)
• Patients who exhibit hypotension (BP lt 90), and
  have an altered LOC

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All Wide Complex Tachycardias

• IV
• Normal Saline, KVO
• Standard Administration Set

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Stable Patients (5E)

• Amiodarone 150 mg over ten minutes
• Using a 20 cc syringe dilute with Normal Saline
  and administer 2 ml/min
• If arrhythmia is suppressed, initiate an
• Amiodarone Drip 1 mg/min
• 100 mg into 100 ml NS
• Using a minidrip
• 60 gtts/min

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Stable Patients (5E)

• If dysrhythmia is not suppressed, administer
• Adenosine
• 6 mg rapid IVP
• 20 ml Normal Saline flush
• If no change in 1 2 minutes
• Repeat Adenosine at 12 mg followed by a 20 ml
  Normal Saline flush
• May be repeated if necessary
• If no change, contact Medical Control for other
  pharmacologic or electrical therapies

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Unstable Patients (5F)

• Amiodarone 150 mg over ten minutes
• Using a 20 cc syringe dilute with Normal Saline
  and administer 2 ml/min
• If Rhythm is suppressed
• Amiodarone Drip 1 mg/min
• 100 mg into 100 ml NS
• Using a minidrip
• 60 gtts/min

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Unstable Patients (5F)

• If significantly unstable
• If indicated, administer Versed, up to 2.5 mg
  slow IVP
• Cardiovert _at_ 50 joules
• If necessary repeat _at_ 100, 200, 300, 360 joules
• If no change, contact Medical Control for other
  pharmacologic or electrical therapies

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