EMT STANDING ORDERS:

• Routine Patient Care.
• If serious signs or symptoms (hypotension, acutely altered mental status, signs of shock, ischemic chest discomfort, or acute heart failure); Call for Paramedic intercept, if available.
• Obtain 3 lead ECG if available.
• Establish IV access to KVO.
• Call for AEMT/Paramedic intercept. & Assists AEMT/Paramedic in patient care.

AEMT/PARAMEDIC STANDING ORDER:

• Follow ACLS guidelines as trained and credentialed.
• Acquire and transmit 12-lead ECG, if available.
• If symptomatic and hemodynamically unstable:
  • Consider cardioversion immediately.
  • Consider procedural sedation prior to or during pacing:
    • Midazolam 2-5 mg slow IV/IO, may repeat once in 5 minutes OR
    • Diazepam  5 mg slow IV/IO, may repeat 5 mg once in 5 minutes.
  • Use the following initial energy doses, then escalate to the next higher energy level if no conversion. (follow manufacturer's recommendations for dosing).
    • For narrow regular rhythm: 50 - 100J Biphasic or 200J monophasic.
    • For narrow irregular rhythm: 120 - 200J Biphasic or 200J Monophasic.
    • For wide regular rhythm: 100J Biphasic or Monophasic.
    • For wide irregular/polymorphic VT: 200J Biphasic or 360 Monophasic, using unsynchronized defibrillation doses.
  • If hemodynamically stable:
    • For narrow complex tachycardia (with a heart rate persistently > 150 bpm):
    • Attempt Vagal Maneuver, for regular rhythms.

      If Vagal Maneuvers fail and the rhythm is regular:

      • Adenosine 6 mg rapid IV/IO, followed by a rapid flush. May repeated once at a dose of 12 mg if no conversion.
    • If irregular rhythm, to control ventricular rate:
      • Diltiazem 0.25 mg/kg IV/IO (Maximum dose 20 mg) over 2 minutes. (Consider 10 mg maximum dose for elderly patient or patient with low BP.) May repeat dose in 15 minutes at 0.35 mg/kg (Maximum dose 25 mg), if necessary.
      • Sotalol 100 mg (1.5 mg/kg) IV/IO over 5 minutes. Avoid if prolonged QT.
    • For wide complex tachycardia:
      • Only for regular rhythm with monomorphic QRS:
        • Consider: adenosine 6 mg rapid IV/IO, followed by rapid flush.
        • Amiodarone 150 mg IV/IO over 10 minutes. May repeat once in 10 minutes. If successful, consider a maintenance infusion of 1 mg/min OR
        • Procainamide 20-50 mg/min IV/IO until arrhythmia suppressed. Maintenance infusion 1-4 mg/min. avoid if prolonged QT or CHF.
    • For polymorphic Ventricular Tachycardia/Torsade de Pointes: If pulse is present, consider magnesium sulfate1- 2 gm IV/IO diluted in 10 mL D5W or 0.9% NaCl over 10 minutes.
    • Consider expert consultation.