Answer Yes: If BP is low or signs of poor tissue perfusion like ongoing chest pressure, or altered LOC, then go to tx.
Tx:
*Give Atropine 1 mg IV every 3-5 minutes to a maximum dose of 3 mg.
(Avoid relying on Atropine in 2nd degree, type II and 3rd degree AV blocks with a new wide QRS complex - Go to TCP) Reference: Neumar RW, Otto CW, Link MS, et al. Part 8: adult advanced cardiovascular life support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010;122(8 Suppl 3):S729-S767. This is repeated in the 2015 provider book.
If ineffective:
*TCP (Transcutaneous Pacing) - set the rate at 60 bpm and turn up milliamps to obtain capture. Leads will need to be placed on the patient from the Pacemaker as well as the patches. Capture is when checking the patient's pulse, the pulse check number corresponds with the paced number on the monitor. If set at 60 bpm, then the pulse should be 60 bpm. If not, have not obtained capture. This is a temporary measure that can be painful. TVP (May use sedation until Transvenous Pacemaker is available through a Pulmonary Artery Catheter).
Note: Atropine will not work on denervated hearts (heart transplants). Note: If no IV or if Atropine not available, go to TCP (Transcutaneous Pacing).
Epinephrine drip IV at 2-10 mcg/min
Dopamine drip IV at 5-20 mcg/kg/min
*Isoproterenol IV 2-10 mcg/min was mentioned in the literature in 2010, but was not updated for 2015.
Note:
Heart Rate Slow = absolute bradycardia is rate < 50 bpm.
Most patients will show signs of poor perfusion with a HR < 50 bpm. Relative Bradycardia = rate less than expected, relative to underlying condition or cause (for example an athlete with a normal low heart rate does not need to be treated and an elderly person with a normal heart rate of high 80s may not tolerate one in the 60s - Treat the patient, not the
monitor).
Primary Assessment
Identify and treat underlying cause:
- Cardiac monitor to identify rhythm
- 12-Lead ECG if available, do not delay treatment
-Consider causes (Differential Diagnosis-see PEA for Hs and Ts for
some possibilities and treatments)
Ask these questions, does the patient have:
1. Hypotension? (decreased blood pressure SBP < 90
mmHg)
2. Altered mental status?
3. Signs of shock?
4. Ischemic chest discomfort?
5. Acute heart failure?
Answer No: If adequate perfusion by blood pressure and general observation of tissue perfusion, no LOC changes or ongoing chest pain.
Monitor the patient, closely.
