Supraventricular Bradycardia and AV Blocks

Section 4 - CARDIAC

4.06 SUPRAVENTRICULAR BRADYCARDIA AND A.V. BLOCKS

INITIAL MEDICAL CARE (2.01) - OXYGEN @ 100% via NRB mask or assist with BVM.

STABLE:

• For 2nd Degree, Type II or 3rd Degree Heart Block, Apply transcutaneous pacemaker (TCP) on stand-by mode.

UNSTABLE:

• Apply TCP on stand-by.
• ATROPINE SULFATE 0.5 - 1.0 mg rapid IVP
• If transient increase in heart rate noted and improved patient status, Repeat ATROPINE SULFATE as needed every 3 minutes to a total dose of 3.0 mg.
• Initiate TCP. Pacemaker output may cause excessive pain / distress in the conscious patient.
• Consider administration of VERSED 2-5 mg initial dose then 2 mg every 30 seconds to 1 minute for conscious sedation.
• If mechanical capture present and symptoms unresolved, increase TCP by 10 BPM until improvement noted or TCP set at 80 BPM.
• 0.9% NaCl 200 - 300 ml fluid bolus.
• DOPAMINE 5 - 20 mcg / kg / minute titrated to systolic BP > 90 mm Hg.
• If patient exhibits acute distress, as evidenced by AMS and / or presents with a 2nd Degree, Type II or 3rd degree Heart Block, bypass ATROPINE SULFATE and proceed directly to pacing.
• If drug induced, treat as per specific drug overdose.
  • For calcium channel and beta blockers, administer GLUCAGON 2mg (may repeat x 1)
  • For calcium channel blockers, administer CALCIUM CHLORIDE 1 gram IVP. (Avoid if patient in on digoxin or lanoxin).
  • For Tricyclic (i.e.: amitriptyline [Elavil], amoxapine, imipramine [Tofranil], nortriptyline [Pamelor]) and tetracyclic (i.e.: Remeron) antidepressants OD, with wide ORS > 0.10 sec, administer SODIUM BICARBONATE, 1 mEq/kg IVP.
  • For narcotic OD, administer NALOXONE (NARCAN) 0.4 mg IVP, IO or IN start low and titrate for respiratory function improvement. Maximum total dose of 2 mg.

DO NOT GIVE LIDOCAINE TO THESE RHYTHMS

This Standing Order is divided between the care and treatment of the stable patient verses the unstable patient. As a matter of definition agreed upon by the Medical Directors, the UNSTABLE patient is one who presents with any of the following: SIGNIFICANT CARDIAC, SUSPECTED CARDIAC, SIGNIFICANT DYSPNEA, ALTERED MENTAL STATUS, OR HYPOTENSION WITH SIGNS OF DECREASED TISSUE PERFUSION, OR SIGNIFICANT COMPROMISE OF AIRWAY, BREATHING, AND/OR CIRCULATION.