Cardiac Arrest: Asystole –
Key Points/Considerations
• Do not interrupt compressions for placement of an advanced airway during the first
4 minutes of CPR
• Check asystole in more than 1 lead
• Refer to the Termination of Resuscitation Protocol as needed
• Consider and treat causes that EMS can manage: Hypoglycemia, Hypovolemia,
Hypoxia, Hydrogen ion (acidosis), Hyperkalemia, Toxins, Tension pneumoThorax,
Trauma
Cardiac Arrest: PEA –
Key Points/Considerations
• Do not interrupt compressions for placement of an advanced airway during the first
4 minutes of CPR
• Refer to the Termination of Resuscitation Protocol as needed
• Consider and treat causes that EMS can manage: Hypoglycemia, Hypovolemia,
Hypoxia, Hydrogen ion (acidosis), Hyperkalemia, Toxins, Tension pneumoThorax,
Trauma
Cardiac Arrest – Termination of Resuscitation
Resuscitative efforts for patients in cardiac arrest should not be initiated if:
• The patient presents with significant dependent lividity, rigor mortis, decomposition
and/or injuries incompatible with life (such as decapitation)
• There is a signed NYS Out-of-Hospital DNR (Do Not Resuscitate) Order Form
DOH #3474 or MOLST form indicating DNR
• The patient is in a health care facility (as defined in NYS Public Health Law Article
28) and has a DNR order appropriate to that facility
For all other patients in respiratory or cardiac arrest, the EMS provider MUST initiate
‘General Cardiac Arrest Care’ and consult physician for termination order
Key Points/Considerations
• Resuscitative efforts must be initiated while attempting to contact a Physician. If
there is an extended time required to contact a Physician, try another facility
• Health Care Facilities (as defined in NYS Public Health Law Article 28) may have
DNR forms appropriate to the level of facility. If identified by the facility staff as
correct, these forms should be honored
• If a patient presents in respiratory or cardiopulmonary arrest and there is any other
form of advanced directive, the EMS Provider must start BLS care (including
Defibrillation), and contact Medical Control
• Other forms of advanced directives include: Living Wills, Health Care Proxies, and
In-Hospital Do Not Resuscitate orders
• Copies of the MOLST form should be honored
• If a patient with a DNR is a resident of a Nursing Home and expires during
transport contact the receiving facility to determine if they are willing to accept the
patient. If not, return the patient to the sending facility. A copy of the DNR must
be attached to the PCR and retained by the agency
V-Fib/V-Tach
Key Points/Considerations
• Do not interrupt compressions for placement of an advanced airway during the first
4 minutes of CPR
• Consult physician if patient has return of pulses (even transiently)
• Maximize dose of each antiarrythmic before considering using another
• Refer to the Termination of Resuscitation Protocol as needed
Cardiac Arrest: ROSC
Key Points/Considerations
• Treatment for presenting rhythm should include antiarrythmic to any patient who
has been in a shockable rhythm.
• Care and transport must be performed with on-line medical control from receiving
facility as soon as possible after ROSC
• ALL patients with STEMI and ROSC should be transported to a receiving hospital
capable of primary angioplasty, if feasible, as long as transport time is projected to
be less than 60 minutes
• Patients who are in recurrent cardiac arrest should be transported to the closest
hospital
• Documentation must include accurate pupillary exam, and initial GCS recorded by
element, not as a total: Eyes _/4, Verbal _/5, Motor _/6
Cardiac: ACS – Suspected
Key Points/Considerations
• Focus on rapid identification, notification and transport to appropriate facility
• 12 Lead EKG should be transmitted to receiving facility, if possible
• Vitals, including 12 Lead EKG, should be monitored frequently during transport
• Caution with Nitroglycerin in inferior wall MI for bradycardia and hypotension
Cardiac: Cardiogenic Shock
Key Points/Considerations
• UNSTABLE is defined as MAP < 65 or SBP < 100 mmHg and/or decreased level
of consciousness
• Refer to Dysrhythmia protocols as needed
Cardiac: Ventricular Assist Device
Key Points/Considerations
• Community patients are entirely mobile and independent
• Keep device and components dry
• Batteries and the emergency power pack can provide 24-36 hours of power
• Trained support members include family and caregivers who have extensive
knowledge of the device, its function, and its battery units and are a resource to the
EMS provider when caring for a VAD patient
• Patients are frequently on three different anticoagulants and are prone to bleeding
complications
• Patient may have VF/VT and be asymptomatic. Contact Medical Control for
treatment instructions
Cardiac: Wide Complex Tachycardia with a Pulse
Key Points/Considerations
• If no pulse treat as V-Fib
• UNSTABLE is defined as ventricular rate > 150 bpm with symptoms of chest pain,
dyspnea, altered mental status, pulmonary edema, ischemia, infarction or
hypotension (MAP < 65 or SBP < 90 mmHg)
• Wide Complex is defined as a QRS complex > 0.12 sec/ 120 msec / 3 small boxes
Cardiac: Narrow Complex Tachycardia
Key Points/Considerations
• Do NOT use carotid sinus massage as vagal maneuver
• UNSTABLE is defined as ventricular rate > 150 bpm with symptoms of chest pain,
dyspnea, altered mental status, pulmonary edema, ischemia, infarction or
hypotension (MAP < 65 or SBP < 90 mmHg)
• If Diltiazem is not available, contact physician for medication choice
Cardiac: Symptomatic Bradycardia/Heart Blocks
Key Points/Considerations
• Only treat bradycardia if patient is symptomatic
• Symptomatic presentation includes chest pain, dyspnea, altered mental status,
pulmonary edema, ischemia, infarction or hypotension (MAP < 65 or SBP < 90
mmHg)
