EMT STANDING ORDERS

• Routine Patient Care.
• Place patient in position of comfort and loosen restrictive clothing.
• Provide oxygen via appropriate oxygen delivery device to maintain saturation 94-98%.
• Administer aspirin 324 mg PO (chewable). (Note: If patient has taken a partial dose (81 mg), administer remaining 243 mg.)
• Facilitate administration of the patient's own nitroglycerin every 3 - 5 minutes while symptoms persist and systolic BP remains ≥100 mmHg, to a total of 3 doses.
• Obtain 3 lead ECG if available.
• Establish IV access KVO.
• Consider expert consultation.
• Call for AEMT / Paramedic intercept. & Assists AEMT / Paramedic in patient care.

AEMT/PARAMEDIC STANDING ORDER:

• Acquire and transmit 12-lead ECG.
• Administer medications if not administered yet.
• Provide oxygen via appropriate oxygen delivery device to maintain saturation 94-98%.
  • Administer nitroglycerin 0.4 mg SL/ spray every 5 min, to total
  • dose of 1.2 mg (3 sprays).
  • Consider morphine 2 - 4 mg IV/IO every 5 minutes to a maximum of 10 mg titrated to pain and systolic BP remains ≥ 100 mmHg. Monitor BP OR
  • Consider fentanyl 25 - 50 mcg slow IV push every 5 minutes up to 100 mcg and systolic BP remains ≥ 100 mmHg.
  • Phenergan 12.5-25 mg IV/IO slowly to control nausea if the patient is not allergic to it.
• Treat dysrhythmias as needed; refer to the appropriate protocol. Notify the receiving hospital with transmission or interpretation and note the time of onset and first medical contact.

AEMT/PARAMEDIC STANDING ORDERS

• Establish IV/IO access.
• Administer 500 mL bolus 0.9% NaCl IV/IO. (Pediatrics: 20 mL/kg bolus 0.9% NaCl IV/IO. May repeat to a maximum of 60 mL/kg.).

Acute Coronary Syndrom (Chest Pain / MI):

• Avoid nitroglycerin in any patient who has used a phosphodiesterase inhibitor for erectile dysfunction and pulmonary hypertension, such as sildenafil (Viagra, Revatio) or vardenafil (Levitra, Staxyn) within 24 hours, or tadalafil (Cialis, Adcirca) within 48 hours. Also, avoid use in patients receiving intravenous prostacyclins for pulmonary hypertension.
• Administer nitrates with extreme caution, if at all, to patients with inferior-wall STEMI or suspected right ventricular (RV) involvement because these patients require adequate RV preload.
• Morphine should be used with caution due to an increased association with mortality.

IMPORTANT:

• Transmission of 12-lead ECG and/or communication with the receiving facility is critical to the activation of a STEMI system.
• If Paramedic interpretation or automated interpretation states: "Acute MI" or "Meets ST Elevation MI Criteria," notify the receiving facility of a "STEMI ALERT."
• Obtain 12-lead ECG in all patients with the following signs and symptoms:
  • Chest, jaw or arm discomfort.
  • Shortness of breath.
  • Epigastric discomfort.
  • Syncope, general malaise, or palpitations.
  • Self-administered nitroglycerin.
  • After sudden cardiac arrest with the return of cardiac activity.
• Administration of aspirin has been shown to decrease mortality in Acute Coronary Syndrome.
• Administer aspirin to every patient with suspected acute coronary syndrome unless they have:
  • History of anaphylaxis to aspirin, NSAIDs, or
  • Evidence of active gastrointestinal or other internal bleeding.
• Any patient with acute coronary syndrome (especially women, patients with a history of diabetes, and the elderly) may present with signs and symptoms other than chest pain including diaphoresis, shortness of breath, weakness, syncope and nausea.