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OVERVIEW OF EMERGENCY CARDIAC CARE

The algorithms and guidelines of the American Heart Association (AHA) and International Liaison Committee on Cardiac
Resuscitation (ILCOR) have been updated. The latest guidelines promote the use of automatic external defibrillator
(AEDs) by emergency medical services (EMS), police, and the general public. The establishment of public access
defibrillator (PAD) programs and continued development of EMS protocols make it necessary for receiving physicians in
emergency departments to be knowledgeable in the current recommendations of the AHA regarding the use of the
prehospital AEDs. These recommendations can be found in the most current Guidelines for Cardiopulmonary
Resuscitation and Emergency Cardiovascular Care 2005.*
According to the latest AHA guidelines, if a person experiences witnessed sudden cardiac death (cardiac arrest) and a
defibrillator or an AED is available, defibrillation should be performed as soon as possible. However, if a person is "found
down" and may have been unresponsive for several minutes, 5 cycles ( 2 min) of CPR should be performed before
initiation of defibrillation.
People who experience cardiac arrest and receive immediate defibrillation are more likely to be successfully defibrillated
after the first shock. For every minute of circulatory arrest there is an 10% decrease in the likelihood of successful
resuscitation. Patients who are subject to delays in receiving resuscitation do not fare as well, unless there has been a
brief period of CPR before defibrillation.
Many communities, organizations, and EMS systems participate in PAD programs. These programs facilitate early
recognition and management by the use of AEDs, and some hospitals have AEDs available, so that a patient who
"arrests" can be defibrillated before the arrival of the code team.
Many patients who experience sudden cardiac death due to ventricular fibrillation (VF) or pulseless ventricular
tachycardia (VT) can be defibrillated before they arrive at the hospital. That the rescuer does not have to interpret the
cardiac rhythm may increase the chance of survival by markedly decreasing time to "first shock." New guidelines for
resuscitation stress timely defibrillation and early, consistent chest compressions with minimal interruption.
Children often experience VF after respiratory arrest. It is reasonable that CPR be performed (5 cycles/2 min) before
defibrillation is attempted, unless the child suddenly collapses. In that case, the AED should be applied as soon as it is
available.
*2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.
Circulation 2005;112(24 suppl). Available online at: http://circ.ahajournals.org/content/vol112/24_suppl (accessed
01/04/2007).
CARDIOPULMONARY RESUSCITATION
CPR Basics: ABCs (Airway, Breathing, Circulation)
Universal precautions dictate that protective eye wear, gloves, and when necessary, water-impervious gowns and
footwear be used. All patients must have a patent airway, be breathing, and have signs of spontaneous
circulation. Figure 21–1 shows the basic life support (BLS) algorithm. The new guidelines differentiate resuscitation by
nonprofessional rescuers from resuscitation by health care providers.
Figure 21–1.
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Adult basic life support health care provider algorithm. Boxes dotted borders indicate actions or steps performed by health care
providers but not the general public. ALS = advanced life support. (Reproduced with permission from Circulation 2005;112:IV
IV-34.)
CPR of Unresponsive Adult (Age > 8 Y): Witnessed Collapse
If a patient becomes unresponsive (no response to verbal or tactile stimuli, ie, "shake and shout"), call for help (CODE,
911). Do not move the patient unless in immediate danger.
1. Get a defibrillator or AED to the bedside stat.
2. Stand or kneel at the patient's shoulder. Position patient on back as a unit, protecting the neck.
3. Airway. Open the patient's airway. If there are signs of airway compromise (apnea, stridor, coughing, use of
accessory muscles), immediately open and clear the airway using the head tilt-chin lift method (nonprofessional
rescuer) or a jaw thrust (health care provider) if cervical spinal injury is suspected.
4. If a foreign body is visualized in the airway, and can easily be removed, remove it. If airway care is needed,
proceed according to clinical need (see Emergency Airway and Ventilatory Support).
5. Breathing. Determine whether the patient is breathing by looking, listening, and feeling. Look at the patient'
chest to determine whether there are signs of movement. Listen at the patient's mouth and nose to determine
whether air is being moved through (escaping) from the upper airway. Feel for warm, moist air coming out of the
mouth and nose by placing your ear close to the patient's mouth and nose.
6. If the patient is breathing, place him or her in the recovery position: a stable, side-lying position in which the
tongue does not block the airway and fluid can drain from the mouth. Keep the spine straight, and position the arms
so that the chest is not compressed. Continue to monitor the patient for breathing. Call for assistance!
7. If the patient is not breathing, ventilate by administering two positive-pressure breaths. Allowing 1 s per breath
using either a bag valve mask or a barrier device such as a pocket mask.
8. Circulation. To determine whether there are signs of circulation, check the neck for a carotid pulse for
(health care provider). However, if there is any doubt regarding the presence or absence of a pulse, start chest
compressions.
9. If there is a definite pulse, give 1 breath every 5–6 s, approximately 10–12 breaths/min, rechecking for a pulse
every 2 min. If an advanced airway is placed, ventilate with 8–10 breaths/min (approximately 1 breath every 6
asynchronously).
10. If there are no obvious signs of circulation, begin chest compressions: Place both hands the patient's sternum, th
heel of one hand on top of the heel of the other. Push fast and push hard, to a depth of 1.5–2.0 in (4–5 cm), allowi
full recoil of the chest. Continue compressions until a defibrillator or an AED is brought to the patient's side. If a
defibrillator is not immediately available, continue chest compressions and ventilations at a ratio of 30/2 at a rate of
approximately 100 compressions/min.
11. When the defibrillator or AED arrives, attach the two pads to the patient's bare chest. Right-sided sternal pad:
right superoanterior infraclavicular position; left-sided apical pad: inferolateral left side of chest lateral to the left
breast. Minimize interruption of chest compressions and compress until the pads are on the chest, if possible.
12. Stop compressions. Analyze the rhythm, and if indicated (presence of VF or pulseless VT), deliver a single shock
13. Immediately resume CPR for another 5 cycles of 30 compressions/2 breaths (2 min). Do not check for a pulse
until another 5 cycles of CPR have been performed. The defibrillated, stunned myocardium may not yet be pumping
efficiently.
14. If there is no pulse, resume CPR, recharge the defibrillator and administer another single shock followed by
immediate CPR.
15. If unsuccessful, proceed to the advanced cardiac life support (ACLS) algorithms and guidelines.
CPR of Unconscious Adult (Age > 8 Y): Unknown Down Time

If an unconscious patient is encountered who is not breathing and has no apparent signs of circulation and the time of
onset of symptoms is unknown, the situation is called unwitnessed arrest.
1. Perform CPR as described earlier (CPR of Unresponsive Adult: Witnessed Collapse) for 2 min (5 cycles of 30
compressions and 2 ventilations) before attempting defibrillation.
2. Resume CPR immediately after the first shock and reassess the patient after (2 min) or 5 cycles of 30 compressio
and 2 breaths. If there are no signs of spontaneous circulation, ie, no carotid pulse, recharge the AED or defibrillator
while doing CPR and administer another single shock.
3. If the defibrillation results in successful termination of VF, treat the patient supportively observing for changes in
blood pressure, heart rate, and respiratory status. If unsuccessful, proceed to the ACLS algorithms and guidelines.
4. After successful defibrillation, an unstable rhythm may develop and necessitate intervention. Some patients may
arrive in the emergency department with a pulseless rhythm, asystole, pulseless electrical activity, and VT or VF.
Other patients may have a slow heart rate incapable of providing good perfusion pressure, ie, bradycardia (heart rat
< 60 beats/min) or tachycardia (heart rate > 100 beats/min). Proceed to the appropriate ACLS algorithms and
guidelines (see Figure 21–2).
Figure 21–2.
ACLS pulseless arrest algorithm. PEA = pulseless electrical activity; IO = intraosseous. (Reproduced with permission from
Circulation 2005;112:IV-58–IV-66.)
CPR of Child (Age 1–8 Y): Witnessed Cardiac Arrest

If a child becomes unresponsive and experiences respiratory arrest, the approach is similar to that for an adult: ABCs an
a call for help. Get a defibrillator or AED stat.
1. Airway: Open the airway with the head-tilt chin lift maneuver or, if a cervical spinal injury is a concern, a jaw
thrust.
2. Breathing: Determine breathlessness: look, listen, feel. If the patient is breathing, place him or her in the
recovery position. If no breathing is present, give 2 effective breaths (1 s/breath).
3. Circulation: Check for signs of circulation; carotid pulse check < 10 s (health care provider). If a pulse is obvious
present, perform rescue breathing at a rate of 12–20 breaths/min (1 breath every 3–5 s) or (12–20 breaths/min). If
an advanced airway is present, 8–10 breaths/min ( 1 breath/6–8 s asynchronously).
4. If no signs of circulation are present, begin chest compressions. Compress the chest with the heel of one hand at
the lower half of the sternum to a depth of ⅓ to ½ of the chest. A ratio of 15 compressions/2 breaths can be assume
with two rescuers. The rate of compressions should be approximately 100/min. Avoid unnecessary interruptions in
CPR.
5. As soon as a defibrillator is available, immediately apply the defibrillator or AED pads (pediatric) to the patient's
bare chest with minimal interruption in chest compressions. Adult AED pads are acceptable if pediatric pads are not
available; however, do not let the pads touch each other on the chest.
6. Stop CPR and allow the AED to analyze the rhythm.
7. Shock if indicated (2 J/kg if manual defibrillator).
8. Resume CPR immediately for 5 cycles and analyze the rhythm.
9. If defibrillation is unsuccessful, recharge the AED or defibrillator while resuming and continuing CPR. Reshock (4
J/kg manually) and immediately do 2 min of CPR. Reasses the patient and rhythm.
10. If unsuccessful, proceed to the pediatric advanced life support (PALS) guidelines (Table 21–1).
Table 21–1 Pediatric Advanced Life Support for Ventricular Fibrillation, Ventricular
Tachycardia, and Pulseless Electrical Activity
ABCs
Airway
Breathing
Circulation
Chest Compressions/Ventilation 1 rescuer 30/2
2 rescuers 15/2
Compress Hard and Fast rate > 100 beats/min
Call 911/Code/EMS
AED application 2J/kg
Medications: Epinephrine 0.01 mg/kg IV/IO VT/VF/pulseless

OR
0.1 mg/kg (1:1000):0.1 mL/kg per ET
q3–5min
Amiodarone 5 mg/kg IV/IO

Lidocaine 1 mg/kg IV/IO
Magnesium 25–50 mg/kg IV/IO Torsade de pointes
Consider ET tube administration if no vascular access.
Based on recommendations from Circulation 2005;112:IV-167–IV-187.
IO = intraosseous; VT = ventricular tachycardia; VF = ventricular fibrillation.

CPR of Child (Age 1–8 Y): Unwitnessed Cardiac Arrest
If a child is found to be apneic (breathless) and not showing signs of spontaneous circulation (no carotid pulse when
checked by health care provider) with an unknown down time, the situation is considered unwitnessed cardiac arrest.
1. Begin CPR, as described earlier (CPR of Child: Witnessed Cardiac Arrest), for 2 min (5 cycles) before attempting
defibrillation using a defibrillator or AED and pediatric pads. (Note: Adult pads can be used if pediatric pads not
available. Make sure pads are not touching each other).
2. Defibrillate with AED if child's age > 1 y (2 J/kg with manual defibrillator).
3. Immediately resume CPR for 2 min.
4. Assess patient for pulse. If the defibrillation attempt was unsuccessful, resume CPR, recharge the AED or
defibrillator and provide another single shock when charged. (Use 4 J/kg for second defibrillation if a manual
defibrillator is used). If unsuccessful, proceed to the appropriate PALS management (Tables 21–1 and 21
5. Like adults, children may present in asystole, pulseless electrical activity, or pulseless VT or VF, or these rhythms
may develop after defibrillation. Furthermore, children can present with bradycardia or tachycardia. Proceed to the
PALS guidelines (Tables 21–1 and 21–2, and Figure 21–2), and attempt to correct the dysrhythmia and determine th
cause of the event.
Table 21–2 Pediatric Bradycardia and Tachycardia Management
Bradycardia Tachycardia
ABCs
Epinephrine 0.01 mg/kg IV/IO (1:10,000:0.01 mL/kg) Adenosine 0.1 mg/kg (max 6 mg)
Atropine 0.02 mg/kg IV/IO Cardioversion 2 J/kg

Amiodarone 5 mg/kg IV/30 min
Procainamide 15 mg/kg/45 min
Based on recommendations from Circulation 2005; 122:IV-167–IV-187.

CPR of Unresponsive Infant (Age < 1 Y): Witnessed or Unwitnessed Cardiac
Arrest
1. Airway: Head tilt-chin lift or jaw thrust.
2. Breathing: Look, listen, and feel for breathing. If absent, give 2 effective breaths at 1 s/breath.
3. Circulation: Check the brachial or femoral pulse. If no pulse is present, start chest compressions. Use 2 or 3
fingers or a thumb just below the nipple line, and press to ½ to ⅓ the depth of the chest.
4. Use 30 compressions/2 ventilations (single rescuer) or 15 compressions/2 ventilations (2 health care providers)
Rate of compressions is 100/min. Rate of ventilation is 12–20 breaths/min (or 1 breath/3–5 s).
5. If an advanced airway is present, use 8–10 breaths/min ( 1 breath/6–8 s asynchronously).
6. Perform CPR for 2 min or 5 cycles, then reassess the patient. There are no recommendations regarding
defibrillation in this situation. If no success, proceed to the advanced algorithms and guidelines (Tables 21
2, and Figure 21–2).
Neonatal Resuscitation
Immediately after delivery, a neonate begins to undergo a physiologic transition. Rapid assessment can determine the
need for resuscitation:
1. Was the born baby at term?
2. Is the amniotic fluid clear and free of meconium and infection?
3. Is the baby breathing or crying?
4. Does the baby have good muscle tone?
If the answer to all these questions is yes, resuscitation probably is not needed.
It is normal for amniotic fluid to be present in the upper airways of newborns, and this fluid must be cleared. Help the
neonate to breath spontaneously, maintain body temperature, and adapt to new circulatory patterns. Provide an infant
warmer, oxygen, neonatal airway adjuncts, and drying materials. The sequence of basic actions is summarized in Figure
21–3.
Figure 21–3.
Neonatal resuscitation algorithm. (Based on recommendations from Circulation 2005;112:IV-188–IV-195.)
ADVANCED CARDIAC LIFE SUPPORT (ACLS)

The foundation of ACLS is sound BLS. In the advanced phase (sometimes called the "D" in the ABCDs of emergency
cardiac care), specific arrhythmias are managed primarily through administration of medications. Rapid reference guide
to ACLS and other commonly used emergency medications are on the inside front and back covers of this book. ECG
interpretation is reviewed in Chapter 19.
Cardiac Arrest
Four rhythms can produce pulseless cardiac arrest: VF, VT, pulseless electrical activity (PEA), and asystole. (See adult
ACLS pulseless arrest algorithm in Figure 21–2.)
Symptomatic Bradycardia and Tachycardia

Monitor for the development of arrhythmias in any patient with chest pain or who has undergone resuscitation. In
addition to the foregoing cardiac arrest arrhythmias, patients may have bradycardia or tachycardia that requires
monitoring and therapy if they become symptomatic. Management of bradycardia and tachycardia based on 2005
emergency cardiac care guidelines is outlined in Table 21–3.
Table 21–3 Bradycardia and Tachycardia
Bradycardia (HR < 60 beats/min) Tachycardia (HR > 100 beats/min)

High degree AV block II/III Narrow complex
Transcutaneous pacing Adenosine 6 mg, 12 mg, 12 mg IV

Atropine 0.5 mg IV (max 3 mg) Beta blocker
Epinephrine 2–10 mcg/min IV Wide complex

Dopamine 2–10 mcg/kg/min IV Amiodarone 150 mg IV/10 min (max) 2.2 g/24 h
Identify and manage correctable factors
Hypovolemia Toxins
Hypoxia Tamponade
Hydrogen ion Tension pneumothorax

Hypo/hyperkalemia Thrombosis PE/CAD
Hypoglycemia Trauma
Hypothermia
Consider ET tube administration if no IV access.
Based on recommendations from Circulation 2005;112(Suppl I):IV-6–IV-77.

EMERGENCY AIRWAY AND VENTILATORY SUPPORT
To improve oxygenation, administer 100% inspired oxygen during BLS (see also Chapter 18). Airway adjuncts are usefu
for this purpose and are classified as basic and advanced airway techniques. Make sure suction is readily available.
Exhaled CO2 detectors are useful for determining proper tube placement. High exhaled CO2 levels confirm proper tube
placement.
Basic Airway Management

BAG MASK VENTILATION:
Can be supplied with room air or oxygen supplementation; can also be connected to an advanced airway if present. Ope
the airways adequately with chin lift, lifting the jaw against the mask and maintaining a tight seal. During CPR give two
ventilations during a brief 3- to 4-s pause between every 30 compressions. Deliver a tidal volume sufficient to raise the
chest ( 6–7 mL/kg or 500–600 mL in an adult) over 1 s. Can cause gastric inflation with subsequent complications (eg
aspiration).
OROPHARYNGEAL AIRWAY:
Use only if trained in the technique and only if the patient is unconscious and has no gag reflex.
NASOPHARYNGEAL AIRWAY:
Better tolerated by patients who are not deeply unconscious. Useful for patients with tightly clenched jaws; use with
caution in craniofacial trauma.
Advanced Airways
Used only by health care providers with proper training and frequent practice. Because placement of an advanced airwa
may require interruption of basic CPR the risk/benefit ratio must be considered. The bag mask can be connected to an
advanced airway for delivery of ventilation.
ESOPHAGOTRACHEAL AIRWAY (COMBITUBE OR ETC):

A multilumen airway that consists of a single, dual-lumen tube with two cuffs. After placement, port 1 (blue pilot balloon
is inflated with 100 mL air, then port 2 (white pilot balloon) is inflated with 15 mL air. Ventilate through the longer blue
tube 1; if breath sounds are heard, and auscultation of gastric insufflation is negative, continue ventilation. If
auscultation of breath sounds is negative and auscultation of gastric insufflation positive, ventilate through the shorter
clear tube 2.
LARYNGEAL MASK AIRWAY (LMA):

Inflatable silicone mask and rubber connecting tube. Inserted blindly into the pharynx, a cuff is inflated that forms a low
pressure seal around the laryngeal inlet, allowing gentle positive-pressure ventilation. Note: The black line on the airwa
tube must be oriented toward the upper lip, and a bite block must be in place. Aspiration may be less common with an
LMA than with a bag mask.
ENDOTRACHEAL TUBE (ET):

Technique is reviewed in Chapter 13. Unskilled providers can cause more harm than good in attempting ET intubation
during resuscitation. Indicated when the rescuer cannot ventilate an unconscious patient with a bag mask and in the
absence of airway reflexes.
AUTOMATIC EXTERNAL DEFIBRILLATION, DEFIBRILLATION,
CARDIOVERSION
In addition to familiarizing yourself with the location of the code cart, airway supplies, emergency numbers, etc, on each
new rotation, become familiar with the defibrillator and AED. AEDs are small, free-standing, battery-operated
defibrillators, equipped with computer hardware and software. They are designed to "recognize" lethal, nonperfusing,
"shockable" dysrhythmias such as VF and VT. More complicated AEDs can actually "cardiovert." When it recognizes letha
dysrhythmia, the AED gives visual or voice prompts for the rescuer to press a button and defibrillate the patient. Some
models of AED automatically shock the patient after emitting an audible or visual warning to the rescuer to "stand clear
There are monophasic and biphasic defibrillators and AEDs in hospitals. In addition, there are biphasic, and probably
some older monophasic, AEDs in public places as part of public access defibrillation programs.
General AED Instructions
1. Place the AED near the patient in such a way that access to the airway and chest is unimpeded.
2. Turn on the AED unit. Most AEDs give auditory or visual prompts such as:
"Connect electrodes to AED."
"Place electrodes to patient's bare chest." (Note: Do not allow the pads to touch each other.)
"Do not touch the patient!"
"Analyzing rhythm."
"Shock advised—Do not touch the patient!"
"Push [flashing button] to shock patient."
3. The AED then prompts for patient evaluation, pulse check, etc. Some AEDs still have the 2000 guidelines
algorithms on them. The 2005 guidelines call for delivery of only 1 shock, followed immediately by CPR for
min before assessment of circulation.
4. Repeat as clinically indicated.
Defibrillation
When defibrillating a patient, follow the updated algorithms.
1. Place pads securely on patient's chest: one to the right of the patient's sternum, just below the clavicle, the other
on the left anterior axillary line. (Most pads and paddles are labeled to facilitate placement.) Make sure there is good
contact to decrease resistance. (Most pads can be used for ECG monitoring, defibrillation, cardioversion, and pacing.
2. If using paddles, use electrode gel or paste and use at least 25 lb of downward force to enhance contact with the
chest. Most paddles can be used to "quick-look" the rhythm.
3. Charge the defibrillator to the appropriate energy (measured in joules).
4. Shout "CLEAR—SHOCKING PATIENT!" Verify that no one (including yourself) is in contact with the patient.
5. Depress both buttons on the paddles to deliver the shock.
Cardioversion
There are rapid rhythms (eg, atrial fibrillation with uncontrolled rates, supraventricular tachycardia [SVT], Wolff
Parkinson–White [WPW]) that render a patient's condition unstable with a decrease in blood pressure, change in
mentation, etc. These circumstances may necessitate that the rhythm be electrically terminated with cardioversion. For
cardioversion, the control knob synchronizes the shock automatically with the peak of the R wave on the ECG strip.
This step prevents shock delivery during the vulnerable period of the cardiac cycle, which can promote development of a
lethal nonperfusing rhythm such as VF. The defibrillator hardware and software control the discharge of the shock after
the "Shock" button is pressed. The procedure is otherwise as described for defibrillation. Because cardioversion is done
with the patient conscious, consider sedation with a drug such as midazolam if clinically feasible.
ACUTE CORONARY SYNDROMES AND MYOCARDIAL INFARCTION
Perform a 12-lead ECG on any patients experiencing chest pain (see Chapters 13 and 19). If the patient has signs of
ischemia or has had an AMI (shown in 2 contiguous leads), a quick decision must be made to administer thrombolytics
(within 30 min of patient presentation), if appropriate. Review the contraindications. Absolute contraindications include
CNS abnormalities (eg, A–V malformation, tumor, history of intracranial hemorrhage, recent head trauma) and bleeding
diathesis. Relative contraindications include pregnancy, history of poorly controlled hypertension, and recent (2
internal bleeding (see source line, Table 21–1). If the patient is not a candidate for thrombolysis, prepare to take the hi
or her to the cardiac catheterization lab (balloon inflation within 90 min of patient presentation), if available. The
appropriate sequence of acute coronary syndrome management is shown in Figure 21–4. Remember: "Time is
muscle!"
Figure 21–4.
Acute coronary syndromes algorithm. STEMI = ST-elevation myocardial infarction; ED = emergency department; UFH =
unfractionated heparin; PCI = percutaneous coronary intervention. (Reproduced with permission from Circulation 2005;112:IV
89–IV-110.)
Certain medications are most commonly used in emergency cardiac care. See Table Commonly Used Emergency Cardia
Care Medications.
Commonly Used Emergency Cardiac Care Medications
Medication Adult Dose

Generic (Trade)
Abciximab (ReoPro) ACS with PCI in 24h: 0.25 mg/kg IV bolus 10–60 min before PCI, then 0.125 mcg/kg IV for 12 h
with heparin
Adenosine 6 mg rapid IV push, then 20 mL NS bolus. Elevate extremity; repeat 12 mg in 1–2 min PRN
(Adenocard)
Alteplase, AMI rapid inf: 15 mg bolus; then 0.75 mg/kg over 30 min (50 mg max); then 0.50 mg/kg over
Recombinant next 60 min (35 mg max) Acute ischemic stroke: 0.9 mg/kg IV (max 90 mg) over 60 min 10%
(Activase) of dose over 1 min; remaining 90% over 1 h
Amiodarone Cardiac arrest: 300 mg IV push; 150 mg IV push X1 in 3–5 min PRN Refractory pulseless VT,
(Cordarone, VF: 5 mg/kg rapid IV bolus. Perfusing arrhythmias: Load 5 mg/kg IV/IO over 20–60 min
Pacerone) (repeat, max 15 mg/kg/d). Stable monomorphic VT: 150 mg IV over 10 min then 1 mg/min for
6 h then 0.5 mg/min over 18 h; repeat 150 mg bolus PRN 2.2 gmd daily max
Anistreplase PE: 100 mg over 2 h. ACS: 15 mg over 1–2 min, then 50 mg over 30 min then 35 mg over 1 h,
(Eminase) start w/heparin. If <67 kg 15 mg over 1–2 min, then 0.75 mg/kg over 30 min then 0.5 mg/kg ove
60 min; w/heparin
Aspirin 160–325 mg PO ASAP (chewing preferred at ACS onset)
Atenolol 5 mg IV over 5 min; in 10 min, 5 mg slow IV; if tolerated in 10 min, start 50 mg PO, then 50 mg
(Tenormin) PO BID
Atropine Sulfate Asystole or PEA: 1 mg IV push. Repeat every 3–5 min (if asystole persists) to max of 0.03
mg/kg. Bradycardia: 0.5–1.0 mg IV q 3–5 min as needed; max 3 mg or 0.04 mg/kg: ET 2
in 10 mL NS
Calcium Choride Hyperkalemia/hypermagnesemia/calcium channel blocker overdose: 8–16 mg/kg; 10% solution, 5
10 mL over 2–5 min
Clopidogrel ACS: 300 mg loading dose then 75 mg/day
Diltiazem Acute rate control: 0.25 mg/kg over 2 min followed by 0.35 mg/kg over 2 min
(Cardizem)
Dobutamine 2–20 mcg/kg/min; titrate to HR not >10% of baseline
(Dobutrex)
Dopamine 2–20 mcg/kg/min; Bradycardia: 2–10 mcg/kg/min; Hypotension: 10–20 mcg/kg/min
Epinephrine 1 mg IV push, repeat q 3–5 min; (0.2 mg/kg max) if 1 mg dose fails. Inf: 30 mg (30 mL of 1:1000
solution) in 250 mL NS or D5W, at 100 mL/h, titrate. ET 2.0–2.5 mg in 20 mL NS. Profound
bradycardia/hypotension: 2–10 mcg/min (1 mg of 1:1000 in 500 mL NS, infuse 1–
Eptifibatide ACS: 180 mcg/kg/min IV bolus over 1–2 min then 2 mcg/kg/min
(Integrillin)
Esmolol (Brevibloc) 0.5 mg/kg over 1 min, then 0.05 mg/kg/min for 4 min; if no response 2nd bolus of 0.5 mg/kg with
maintenance of 0.1 mg/kg/min with maximum of 0.3 mg/kg/min
Glucagon Beta blocker or calcium channel blocker overdose: 3 mg initially followed by 3 mg/hr
Heparin Bolus 80 IU/kg (max 4000 IU); then 18 IU/kg/h (max 1000 IU/h for patients >70 kg) round to
(Unfractionated) nearest 50 IU; keep PTT 1.5–2.0 ¥ control 48 h or until angiography. If adjunct with fibrin specific
lytics then 60 IU/kg bolus then 12 IU/kg/h
Ibutilide Adults 60 kg, 1 mg (10 mL) over 10 min; a second dose may be used; <60 kg 0.01 mg/kg
Labetalol 10 mg IV over 1–2 min; repeat or double dose q 10 min (150 mg max); or initial bolus, then 2
(Trandate) mcg/min
Lidocaine Cardiac arrest from VF/VT refractory VF: Initial: 1–1.5 mg/kg IV, additional 0.5–0.75 mg/kg
IV push, repeat in 5–10 min, max total 3 mg/kg. ET: 2–4 mg/kg. Perfusing stable VT, wide
complex tachycardia or ectopy: 0.5 mg/kg IV push; repeat 0.5–0.75 mg/kg q 5–10 min; max
total 3 mg/kg; Maint 1–4 mg/min (30–50 mcg/min)
Magnesium Sulfate VF/pulseless VT arrest with torsades de pointes: 1–2 g IV push (2–4 mL 5% solution) in 10
mL D5W. If pulse present then 1–2 g in 50–100 mL D5W over 5–60 min
Metropolol 5 mg slow IV q 5 min, total 15 mg
Morphine 2–4 mg IV (over 1–5 min) then give 2–8 mg IV q 5–15 min as needed
Nitroglycerin IV: infuse at 10–20 mcg/min, by 5–10 mcg/min every 3–5 min. PRN. SL: 0.3–0.4 mg, repeat q 5
min. Aerosol spray: Spray 0.5–1.0 s at 5-min intervals
Nitroprusside 0.1–5 mcg/kg/min (max dose 10 mcg/kg/min)
Procainamide Stable monomorphic VT, HR control in a fib, AV reentrant narrow complex tachycardia:
20 mg/min IV until one of these: arrhythmia stopped, hypotension, QRS widens >50%, total 17
mg/kg; then maintenance infusion of 1–4 mg/min
Propanolol 0.1 mg/kg slow IV push, divided 3 equal doses q 2–3 min, max 1 mg/min; repeat in 2 min PRN
(Inderal)
Reteplase, 10 U IV bolus over 2 min; 30 min later, 10 U IV bolus over 2 min NS flush before and after each
Recombinant dose
(Retavase)
Sodium 1 mEq/kg IV bolus; repeat ½ dose q 10 min PRN
Bicarbonate
Sotalol (Betropace) 1–1.5 mg/kg IV over 5 min then 10 mg/min
Streptokinase AMI: 1.5 million IU over 1 h. PE: 3 million IU over 24 h
Tirofiban ACS or PCI: 0.4 mcg/kg/min IV for 30 min, then 0.1 mg/kg/min
Vasopressin 40 units IV; ET 40 units in 10 mL NS

(Pitressin)
Verapamil 2.5–5 mg IV over 1–2 min; repeat 5–10 mg, in 15–30 min PRN max of 20 mg; or 5 mg bolus q 15
(Verapmil) min (max 30 mg)
ACS = acute coronary syndrome; PCI = percutaneous coronary intervention; PRN = as needed; AMI = acute MI; VT =
ventricular tachycardia; VF = ventricular fibrillation; PEA = pulseless electrical activity; ET = endotracheal tube; NS =
normal saline; HR = heart rate; PTT = partial thromboplastin time; SL = sublingual
STROKE
Stroke is also called "brain attack." A similar caveat as for the heart holds true: "Time is brain." Signs and symptoms
a stroke include:
Facial droop
Change in mental status
Pronator drift
Unilateral motor weakness
Slurred speech
Syncope
Difficulty swallowing
Confusion
In the field, EMS personnel use the Cincinnati Prehospital Stroke Scale or the Los Angeles Prehospital Stroke Screen to
determine the likelihood that a patient may have a stroke (Table 21–4). Carefully determine time of symptom onset. Th
step is crucial in decision making regarding the use of thrombolytics in a stroke patient without bleeding. Measure a
fingerstick glucose level to detect possible hypoglycemia. If hypoglycemia is present, correct it immediately. Perform a
neurologic screening exam, draw samples for lab work, order an emergency CT scan, obtain a 12-lead ECG, and take th
patient to the CT suite. Activate the stroke team. The AHA stroke algorithm is in Figure 21–5.
Table 21–4 Two Systems for Field Evaluations of Stroke Risk
Cincinnati Prehospital Stroke Scale
If any of these signs are present, the probability of a stroke is 72%:

Facial droop: Ask patient to smile; sign is present if one side does not move as well as the other
Arm drift: Ask patient to close eyes and hold arms out for 10 s; sign is present if one arm does not move or drifts
downward
Abnormal speech: Sign is present if the patient slurs speech or uses wrong words
Los Angeles Prehospital Stroke Screen

If any of these factors are present, there is high likelihood of a stroke in a patient with a nontraumatic neurologic
complaint:
Age > 45 y
No seizure or epilepsy history

Symptoms present < 24 h
Patient not wheelchair bound or bedridden at baseline
Blood glucose 60–400 mg/dL
Asymmetry of face, grip, or arm strength
Based on data from Circulation 2005;112:IV-111–IV-120.
Figure 21–5.
Algorithm for management of suspected stroke. NINDS = National Institute of Neurological Disorders and Stroke. (Reproduced
with permission from Circulation 2005;112:IV-111–IV-120.)
OTHER COMMON EMERGENCIES

Anaphylaxis
ALLERGIC REACTION WITH SYSTOLIC BP < 90 MM HG OR AIRWAY FAILURE
Epinephrine
Drug of choice Dose: Adults. IV bolus: 100 mcg of 1:100,000 over 5–10 min (mix 0.1 mL of 1:1,000 epi in 10 mL NS)
IV inf: 1–4 mcg/min. Peds. IV inf: 0.1–0.3 mcg/kg/min, max 1.5 mcg/kg/min
ALLERGIC REACTION WITH SYSTOLIC BP > 90 MM HG

Epinephrine
Dose: Adults. 0.3–0.5 mL (1:1000) SQ. Peds. 0.01 mL/kg (1:1000), max 0.5 mL
Supplemental drugs for anaphylaxis include:
Diphenhydramine
Dose: Adults. IV/IM/PO 50 mg. Peds. IV/IM/PO 1 mg/kg
Methylprednisolone
Dose: 1–2 mg/kg IV
Ranitidine (Zantac)
Dose: Adults. IV 50 mg over 5 min. Peds. IV 0.5 mg/kg over 5 min
Albuterol
Dose: Adults. 2.5 mg nebulized. Peds. 1.25 mg nebulized
Asthma Attack: Mild

Albuterol (Nebulized)
Dose: Adults. 2.5–5.0 mg at 20 min for up to 3 doses in first hour. Peds. 1.25–2.5 mg at 20 min for up to 3 doses in
first hour. Supplemental oxygen to keep sats > 90%
Asthma Attack: Moderate to Severe

Ipratropium Bromide (Nebulized)
Dose: Adults. 0.5 mg combined with first albuterol treatment. Peds. 250 mcg with first albuterol treatment. Give
continuously or every 20 min for first hour.
Levalbuterol (Xopenex)
Dose: 0.63–1.25 mg nebulized q6–8h
Methylprednisolone
Dose: Adults. 60–125 mg IV. Peds. 2 mg/kg IV Supplemental oxygen to keep sats > 90%
Asthma Attack: Severe

Administer aerosolized beta-agonists with anticholinergic continuously. Intubate and ventilate with 100% oxygen if
impending or actual respiratory arrest. Administer IV corticosteroid.
Methylprednisolone
Dose: Adults. 60–125 mg IV. Peds. 2 mg/kg IV
Anticholinergic Toxicity
Usually related to drug overdose. Patients present "Hot as Hades, Blind as a Bat, Dry as a Bone, Red as a Beet, Mad as
Hatter."
Physostigmine
Controversial; use only when seizures, coma, hypotension, agitation are refractory to conventional therapy
2.0 mg IV Note: Administer S-L-O-W-L-Y (can cause seizures if given rapidly). Have cardiac monitor attached and
resuscitation equipment at the bedside. Use only in consultation with the poison control center or a toxicologist
Coma
1. Establish and secure airway (protect cervical spine if trauma has occurred).
2. Assess for respiratory failure and shock; use BLS and ACLS techniques as appropriate.
3. Supply oxygen, IV access, cardiac monitor, and pulse oximetry.
4. Administer 1 amp (50 mL) of D50 IV manually; consider checking a stat glucose first. If not hypoglycemic, can
worsen stroke outcomes.
5. Administer 100 mg thiamine IV.
6. Give 0.4 mg naloxone (Narcan) IV (see Opioid Overdose).
7. Obtain fingerstick glucose, SMA, CBC, urinalysis, and ABG. Consider ECG, CT of head (see Seizures, Status
Epilepticus).
Dental Emergencies
Not including facial fractures, there are generally two major categories of dental emergencies: toothaches with associat
abscesses and avulsed (knocked-out) teeth. Most toothaches can be managed with antibiotics (usually penicillin
mg, q6h) and analgesics until proper dental attention can be obtained. Drain fluctuant abscesses if convenient. The
exception to this rule is submandibular or infraorbital swelling. With submandibular infections, Ludwig angina, a life
threatening occurrence, can develop. Hold these patients for observation with special attention to maintaining the airwa
until a dental consult can be obtained. Infraorbital infections can lead to cavernous sinus thrombosis if allowed to
progress.
Avulsed teeth may or may not have an associated dentoalveolar fracture. Reposition the displaced tooth in the socket
within 30 min or as soon as possible. If the tooth root is dirty, wash it gently with sterile saline solution. Do not scrub or
scrape the root. Obtain a dental consult to arrange to have the tooth splinted back in the socket.
Hypercalcemia
See Chapter 9, Hypercalcemia.
Hyperkalemia
See Chapter 9, Hyperkalemia.
Hypertensive Crisis
Treat only if signs of end organ damage are present.
Do not reduce MAP > 20–25% over 30–60 min.
Labetalol
Dose: 20 mg IV bolus then 2 mg/min IV to target BP or
Sodium Nitroprusside
Dose: 0.5 mcg/kg/min to max (10 mcg/kg/min)
Hypoglycemia
1. Draw a stat serum glucose. Do not wait for result before treating if hypoglycemia is suspected.
Dextro stick can usually be quickly checked.
2. Give orange juice with sugar if the patient is awake and alert; if not, give Adults. 1 amp of D50 IV Peds.
(D10 for newborn).
3. If IV access is not possible, give glucagon 1 mg IM or SC.
Opioid Overdose
Naloxone (Narcan)
Dose: Adults. 0.4–2.0 mg IV or IM, repeat as needed. Note: If you suspect the patient is addicted to narcotics, give 0.
mg and repeat PRN to avoid severe withdrawal. Peds. 0.01–0.02 mg/kg IV or IM, repeat PRN.
1. Observe patient for at least 6 h after treatment.
2. Manage airway by intubation if airway failure not immediately responsive to naloxone. (See Coma.)
Poisoning (Common Agents)

1. Support airway, respiration, and circulation, as needed. Note: Do not use Ipecac syrup to induce vomiting; it is no
longer a recommended treatment.
2. Determine ingested substance; give specific antidote, if available. Call Regional Poison Center for assistance
(1-800-222-1222). Some common poisons with their antidotes (Adult, unless specified) are in Table 21
3. Prevent further absorption as described for consciousness level.
Table 21–5 Antidotes for Common Poisoning Emergencies
Acetaminophen N-acetylcysteine, 140 mg/kg PO, then 70 mg/kg x 17
Anticholinesterases Atropine 0.5–2 mg IV; may need up to 5 mg IV every 15 min if severe poisoning
Benzodiazepines Flumazenil 0.2 mg IV (see Flumazenil [Romazicon])
Beta-blockers Glucagon 0.05 mg/kg IV bolus for BP <90, then infusion of 75–150 mg/kg/h
Carbon monoxide High-flow oxygen or hyperbaric oxygen

Calcium channel Calcium chloride 10–20 mL/kg of 1% solution then 20 mg/kg/h
blockers
Cyanide Amyl nitrate pearls, inhale every 2 min then sodium nitrite 10 mL 3% IV over 3 min (0.33 mL/kg
of 3% solution in children) or sodium thiosulfate 50 mL of 25% solution over 10 min or 1.65
mL/kg in children
Cyclic NaHCO3 3 amps (50 mg/50 mL) in 1 L D5W at 2–3 mL/kg/h
antidepressants
Digoxin Digoxin-specific Fab
Number of vials =
Ethylene glycol Fomepizole 15 mg/kg slow infusion

Methanol Fomepizole (see above) or ethanol–loading dose 1 g/kg of a 10% solution slowly IV, followed by
an infusion of 130 mg/kg/h to keep serum level of 100–150 mg/dL
Opiates Naloxone, see Naloxone (Narcan)
UNCONSCIOUS PATIENT
1. Protect airway with an endotracheal tube.
2. Consider lavage with an Ewald tube or 28 Fr or larger NG tube, if ingestion has occurred within the last hour.
3. Use a series of 300-mL NS boluses through the NG or Ewald tube for adults and 20-mL/kg boluses for children.
4. Consider using activated charcoal with sorbitol unless an oral antidote is to be given.
CONSCIOUS PATIENT
1. Consider giving activated charcoal 1 g/kg; contraindicated for iron, lithium, lead, alkali, acid. Also give 70% sorbit
solution (2 mL/kg body weight). Monitor any patient given sorbitol for hypokalemia and hypomagnesemia.
2. Attempt to promote excretion through IV hydration.
3. Administer alkalinization (0.5–1 mEq/kg/L in IV fluids) for salicylates, barbiturates, tricyclics.
Seizures, Status Epilepticus

Status epilepticus refers to 30 min or more of continuous seizure activity or two or more seizures without recovery of
consciousness between seizures.
INITIAL SUPPORTIVE CARE

1. Maintain airway with cervical spine precautions.
2. Deliver oxygen by nasal cannula.
3. Monitor ECG and blood pressure.
4. Maintain normal temperature.
PHARMACOLOGIC THERAPY
1. Establish IV, administer thiamine 100 mg IV (Table 21–6).
2. Administer 1 amp of D50 IV in an adult (2 mL/kg D25 in children) unless obviously hyperglycemic.
3. Administer IV lorazepam or diazepam initially (midazolam 0.2 mg/kg); can be given IM in children if no IV.
4. If seizures persist, give fosphenytoin or phenytoin.
5. If seizures persist, give phenobarbital, paraldehyde.
6. If still no response, obtain emergency neurosurgery and anesthesiology consultations.
Table 21–6 Drugs for the Management of Status Epilepticus
Drug Pediatric Dose (mg/kg) Adult Dose Maximum Rate (mg/min)
Diazepam (Valium) 0.10–0.20 IV 5–10 mg IV (up to 30 mg) 3–5

Fosphenytoin NA 20 mg/kg IV 150
Paraldehydea 0.15–0.3 mL/kg PR 30 mL PR NA
Phenytoin (Dilantin)b 15 IV Same as for child 50
Phenobarbitalc 10 IV or IM 120–140 mg IV 100
NA = not applicable.
a
When given rectally, mix 2:1 with cottonseed or olive oil.
b
When given IV, use a maximum dose of 50 mg/min and monitor ECG and vital signs closely. Can cause severe
hypotension and bradycardia. Mix with NS to prevent precipitation.
c
Indicated when the patient is allergic to phenytoin, patients may need intubation.
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Common Medical Emergencies Page 1 of 28

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OVERVIEW OF EMERGENCY CARDIAC CARE

CPR of Unresponsive Adult (Age > 8 Y): Witnessed Collapse

1. Get a defibrillator or AED to the bedside stat.

CPR of Unconscious Adult (Age > 8 Y): Unknown Down Time

CPR of Child (Age 1–8 Y): Witnessed Cardiac Arrest

6. Stop CPR and allow the AED to analyze the rhythm.

7. Shock if indicated (2 J/kg if manual defibrillator).

8. Resume CPR immediately for 5 cycles and analyze the rhythm.

Medications: Epinephrine 0.01 mg/kg IV/IO VT/VF/pulseless

Amiodarone 5 mg/kg IV/IO

Consider ET tube administration if no vascular access.

Based on recommendations from Circulation 2005;112:IV-167–IV-187.

IO = intraosseous; VT = ventricular tachycardia; VF = ventricular fibrillation.

3. Immediately resume CPR for 2 min.

Table 21–2 Pediatric Bradycardia and Tachycardia Management

Atropine 0.02 mg/kg IV/IO Cardioversion 2 J/kg

Based on recommendations from Circulation 2005; 122:IV-167–IV-187.

5. If an advanced airway is present, use 8–10 breaths/min ( 1 breath/6–8 s asynchronously).

1. Was the born baby at term?

2. Is the amniotic fluid clear and free of meconium and infection?

3. Is the baby breathing or crying?

4. Does the baby have good muscle tone?

Neonatal resuscitation algorithm. (Based on recommendations from Circulation 2005;112:IV-188–IV-195.)

ADVANCED CARDIAC LIFE SUPPORT (ACLS)

Symptomatic Bradycardia and Tachycardia

Table 21–3 Bradycardia and Tachycardia

Bradycardia (HR < 60 beats/min) Tachycardia (HR > 100 beats/min)

Transcutaneous pacing Adenosine 6 mg, 12 mg, 12 mg IV

Epinephrine 2–10 mcg/min IV Wide complex

Identify and manage correctable factors

Hydrogen ion Tension pneumothorax

Consider ET tube administration if no IV access.

Based on recommendations from Circulation 2005;112(Suppl I):IV-6–IV-77.

Basic Airway Management

ESOPHAGOTRACHEAL AIRWAY (COMBITUBE OR ETC):

LARYNGEAL MASK AIRWAY (LMA):

ENDOTRACHEAL TUBE (ET):

General AED Instructions

"Connect electrodes to AED."

"Do not touch the patient!"

"Shock advised—Do not touch the patient!"

"Push [flashing button] to shock patient."

4. Repeat as clinically indicated.

3. Charge the defibrillator to the appropriate energy (measured in joules).

5. Depress both buttons on the paddles to deliver the shock.

Commonly Used Emergency Cardiac Care Medications

Medication Adult Dose

Vasopressin 40 units IV; ET 40 units in 10 mL NS

Change in mental status

Unilateral motor weakness

Table 21–4 Two Systems for Field Evaluations of Stroke Risk

Cincinnati Prehospital Stroke Scale

If any of these signs are present, the probability of a stroke is 72%:

Los Angeles Prehospital Stroke Screen

No seizure or epilepsy history

Blood glucose 60–400 mg/dL

Asymmetry of face, grip, or arm strength

Based on data from Circulation 2005;112:IV-111–IV-120.