Cardiac Non-Arrest

Tachycardia (Unstable)

  • 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


  • 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
  • CONTACT RECEIVING FACILITY to alert Cardiac Cath Lab team