Hypotension, altered mental status, signs of poor perfusion
Synchronized cardioversion
V-tach, A-fib, PSVT: 100j, 200j, 300j, 360j
A-flutter: 50j, 100j, 200j, 300j, 360j
Polymorphic V-tach: 200j, 300j, 360j or biphasic equivalents, based on manufacturers recommendations
Consider procedural sedation if practical (Midazolam 2.5 mg IV or Diazepam 5 mg IV)
Tachycardia (Stable)
PSVT or narrow complex tach consistently >140-150, consider vagal maneuvers. If unsuccessful, adenosine 6 mg rapid IVP; repeat dose of 12 mg x2 as needed
For all others, monitor and transport
Congestive Heart Failure
Consider Nitroglyerin 0.4 mg SL if SBP ≥ 90 if patient has not taken any erectile dysfunction drugs: sildenafil (Viagra), vardenafil (Levitra), or tadalafil (Cialis) in the previous 24- 72 hrs
Consider Lasix (furosemide) 0.5-1.0 mg/kg IV or Bumex (bumetanide) 1 mg IV
Consider Morphine Sulfate 1-5 mg slow x1
Consider CPAP if not improving with above measures and SBP ≥ 90
Bradycardia
Atropine 0.5 IV/IO q 3-5 min (3 mg max)
Consider pacing – preferable to atropine for patients with Mobitz II or 3rd degree HB with wide QRS – Consider sedation – Versed 2-4 mg/min IV/IM until patient’s speech slurs or a total of 8 mg. Lorazepam (Ativan™) 1 mg IV or 2 mg IM, repeatable x1 in 5 mins OR Midazolam (Versed) 2.5 mg IV, repeatable x1 in 5 mins
Dopamine drip (5-10 ug/kg/min) Epinephrine (2-10 ug/min) if pacing is ineffective
Consider fluid bolus
Consider Glucagon 2-5 mg IV, IM or SQ over 2-5 minutes in adults for suspected overdose of a beta-blocker or calcium channel blocker
Acute Coronary Syndrome
12-lead ECG
324 mg baby aspirin (chewable). If patient states they cannot take ASA due to “stomach problems” or “doctor’s orders”, call medical control for guidance
Nitroglycerin 0.4 mg SL every 5 minutes while symptoms persist if SBP >90. Avoid this for patients who take Sildenafil, tadalafil, or vardenafil in past 48 hours
If ECG suggests AMI, consider Morphine Sulfate 2 mg IVP every 5 minutes up to 10 mg if pain persists and SBP >90
Consider Fentanyl 25-50 mcg for patients with a morphine allergy or know right ventricular infarction