Ottawa Ems Cardiac Related Directives

Front 1

Cardiac ischemia ASA conditions

Back 1

Over 18 years old
Unaltered
Able to chew and swallow

Front 2

Cardiac ischemia ASA contraindications

Back 2

Allergy or sensitivity to ASA or NSAIDS
If asthmatic, no prior use of ASA
Current active bleeding
CVA or TBI in the previous 24 hours

Front 3

Cardiac ischemia ASA dose

Back 3

160-162mg dose
So usually two 80mg chewable tablets
Max dose of 162mg

Front 4

Cardiac ischemia Nitro conditions

Back 4

Over 18 years old
Unaltered
Heart rate between 60-159
Normotensive
Prior Nitro hx OR IV obtained

Front 5

Cardiac ischemia Nitro contraindications

Back 5

Phosphodiesterase inhibitor use within 48 hours
SBP drops by one third or more of its initial value after nitroglycerin is administered
12‐lead ECG compatible with Right Ventricular infarct
SPB under 100mmhg

Front 6

Cardiac ischemia Nitro dose

Back 6

0.3-0.4mg spray sublingual
Q 5 minutes
Max 6 doses

Front 7

Cardiac ischemia Morphine indications

Back 7

Over 18 years old
Normotensive
Unaltered

Front 8

Cardiac ischemia Morphine contraindications

Back 8

Allergy or sensitivity to morphine
Injury to the head or chest or abdomen OR pelvis
SBP drops by one‐third or more of its initial value after morphine is administered

Front 9

Cardiac ischemia Morphine dose

Back 9

2mg
Q 5 minutes
Max 5 doses

Front 10

Cardiac ischemia Morphine considerations

Back 10

Consider morphine after the third dose of nitroglycerin or if nitroglycerin is contraindicated

Front 11

Acute cardiogenic pulmonary edema indications

Back 11

Moderate to severe respiratory distress
AND
Suspected acute cardiogenic pulmonary edema

Front 12

Acute cardiogenic pulmonary edema Nitro conditions

Back 12

Over 18 years old
Normotensive
Heart rate between 60-159
Prior history of nitroglycerin use OR establish IV access

Front 13

Acute cardiogenic pulmonary edema Nitro contraindications

Back 13

Phosphodiesterase inhibitor use within the previous 48 hours
SBP drops by one third or more of its initial value after nitroglycerin is administered

Front 14

Acute cardiogenic pulmonary edema Nitro dose for SBP 100 mmHg to under 140 mmHg

Back 14

0.3-0.4mg spray
Q 5 minutes
Max 6 doses

Front 15

Acute cardiogenic pulmonary edema Nitro dose for SBP over 140 mmHg and a Hx of Nitro use OR an IV is established

Back 15

0.6-0.8mg spray
Q 5 minutes
Max 6 doses

Front 16

Acute cardiogenic pulmonary edema Nitro dose for SBP over 140 mmHg and NO Hx of Nitro use and no IV is established

Back 16

0.3-0.4mg spray
Q 5 minutes
Max 6 doses

Front 17

Cardiogenic shock indications

Back 17

STEMI‐positive ECG
AND
Cardiogenic shock

Front 18

Cardiogenic shock N/S conditions
(When do we/can we use it)

Back 18

Clear chest
Hypotensive

Front 19

Cardiogenic shock N/S dose, over 18 years old

Back 19

10ml/kg
Reassess every 250mls
Max dose of 10ml/kg

Front 20

Cardiogenic shock Dopamine considerations
(What are we trying to achieve)

Back 20

Titrate dopamine to achieve a systolic BP of 90‐110 mmHg.
If discontinuing dopamine electively, do so gradually over 5‐10 minutes

Front 21

Cardiogenic shock Dopamine conditions
(Why do we use it)

Back 21

Hypotensive

Front 22

Cardiogenic shock Dopamine contraindications

Back 22

Allergy or sensitivity to dopamine
Tachydysrhythmias excluding sinus tachycardia
Mechanical shock states
Pheochromocytoma

Front 23

Cardiogenic shock Dopamine dose

Back 23

5mcg/kg/min
Titrate by 5mcg/kg/min every 5 minutes
Max 20mcg/kg/min

Front 24

Symptomatic Bradycardia indications

Back 24

Bradycardia
AND
Hemodynamic instability

Front 25

Symptomatic Bradycardia Atropine conditions
(when can we use it)

Back 25

Over 18 years old
Hypotensive
Heart rate under 50

Front 26

Symptomatic Bradycardia Atropine contraindications
(when we cannot use it)

Back 26

Allergy or sensitivity to atropine
Hemodynamic stability
Hypothermia
History of heart transplant

Front 27

Symptomatic Bradycardia Atropine dose

Back 27

0.5mg
Q 5 minutes
Max 2 doses

Front 28

Symptomatic Bradycardia Dopamine conditions
(When we use it)

Back 28

Over 18 years old
Hypotensive
Heart rate under 50

Front 29

Symptomatic Bradycardia Dopamine contraindications
(When we cannot use it)

Back 29

Allergy or hypersensitivity to dopamine
Hemodynamic stability
Pheochromocytoma

Front 30

Symptomatic Bradycardia Dopamine dose

Back 30

5mcg/kg/min
Titrate by 5mcg/kg/min every 5 minutes
Max 20mcg/kg/min

Front 31

Symptomatic Bradycardia Dopamine considerations
(What are we trying to achieve)

Back 31

Titrate dopamine to achieve a systolic BP of 90‐110 mmHg. If discontinuing dopamine electively, do so gradually over 5‐10 minutes

Front 32

Symptomatic Bradycardia mandatory patch points

Back 32

Patch to BHP for authorization to proceed with transcutaneous pacing and/or a dopamine infusion

Front 33

Symptomatic Bradycardia pacing conditions

Back 33

Over 18 years old
Hypotensive
Heart rate under 50

Front 34

Symptomatic Bradycardia pacing contraindications

Back 34

Hemodynamic stability
Hypothermia

Front 35

Symptomatic Bradycardia pacing/atropine consideration

Back 35

A single dose of atropine should be considered for second degree Type II or third degree AV blocks with fluid bolus while preparing for TCP OR if there is a delay in implementing TCP OR if TCP is unsuccessful

Front 36

Symptomatic Bradycardia Atropine consideration

Back 36

Atropine may be beneficial in the setting of sinus bradycardia, atrial fibrillation, first degree AV block, or second‐degree Type I AV block

Front 37

Symptomatic Tachydysrhythmia valsalva conditions

Back 37

Over 18 years old
Unaltered
HR over 150
Normotension
Narrow complex and regular rhythm

Front 38

Symptomatic Tachydysrhythmia valsalva contraindications

Back 38

Sinus tachycardia
Atrial fibrillation
Atrial flutter

Front 39

Symptomatic Tachydysrhythmia valsalva dose

Back 39

Perform a maximum of two attempts lasting 10 to 20 seconds duration each

Front 40

Symptomatic Tachydysrhythmia Adenosine conditions

Back 40

Over 18 years old
Unaltered
HR over 150
Normotensive
Narrow complex and regular rhythm

Front 41

Symptomatic Tachydysrhythmia Adenosine contraindications

Back 41

Allergy or sensitivity to adenosine
Sinus tachycardia or atrial fibrillation or atrial flutter
Patient taking dipyridamole or carbamazepine
Bronchoconstriction on exam

Front 42

Symptomatic Tachydysrhythmia Adenosine dose

Back 42

6mg rapid IV push
Q 5 minutes
Second dose is 12 mg rapid IV push
Max 2 doses

Front 43

Symptomatic Tachydysrhythmia cardioversion indications

Back 43

Over 18 years old
HR over 120 (wide) or over150 (narrow)
Hypotension
Altered mental status, ongoing chest pain, other signs of shock

Front 44

Symptomatic Tachydysrhythmia cardioversion dose

Back 44

Administer up to three synchronized shocks in accordance with BHP direction and energy settings. (In the setting of a patch failure, the energy settings to be used are 100 J, 200 J and the maximum manufacturer setting.)

Front 45

Symptomatic Tachydysrhythmia Patch points

Back 45

Synchronized cardioversion
Lidocaine for wide complex
Adenosine for monomorphic wide complex
regular rhythm

Front 46

Symptomatic Tachydysrhythmia Lido conditions

Back 46

Over 18 years old
HR over 120 and wide and regular
Normotensive

Front 47

Symptomatic Tachydysrhythmia Lido dose

Back 47

1.5mg/kg
Q 10 minutes
Next dose is half so 0.75mg/kg
Max # of doses is 3
Max single dose of 150mg