Given the current shortage of Diltiazem: In cases of rapid atrial fibrillation that require rate control per protocol, please consider there is a standing order to use Metoprolol instead. Dosing is 2.5-5 mg per protocol, often the 5 mg is the most appropriate dose.
Note that rate control per protocolis only appropriate when:
1) rates are above 150
2) patients are symptomatic from this (but also stable; unstable patients get cardioverted)
Protocol does not specify this, but please remember that rate control (with either diltiazem or metoprolol) is not first-line for patients who have rapid heart rates from an obvious underlying cause– for example a patient having a large GI bleed, or a fever/sepsis picture. In those patients, the heart rate is actually compensating for a problem, and blocking the AV node is potentially harmful.
Protocol also mentions Amiodarone as a med control call option for rapid AFib. It should remain a med control call option only.
Given the current shortage of Dextrose 50%, cases of hypoglycemia can be treated as per a standing order with Dextrose 10%.
For a hypoglycemic emergency, the standard initial dose of dextrose is 12.5 mg.
This would be “half an amp of D50” or 25 mLs from a standard 50 mL ampule of 50% Dextrose.
The 12.5 mg dose, if given in 10% Dextrose equivalents, would be 125 mL.
Whether giving dextrose as 50% or 10% solutions, a second dose of 12.5 mg of dextrose is allowed per protocol for persistent hypoglycemia and altered mental status.
Patients with left ventricular assist devices (LVADs) are becoming more common in our area and are uniquely challenging.
A patient with an LVAD will often not have a detectable pulse or blood pressure: the device provides non-pulsatile flow. Unless the patient exhibits other clinical signs of cardiovascular collapse, they do not need CPR.
However, a patient with an LVAD who has no pulse, no pressure and other signs of cardiovascular collapse (i.e., unresponsiveness, agonal respirations, poorly perfused extremities), should still have CPR and be treated per all ACLS protocols.
LVAD patients can be transported to all usual points of entry, including those with STEMIs or polytrauma. If the EMS provider feels it is warranted, the patient’s LVAD cardiologist can be called from the field for advice; this advice, including any suggestions for where to take the patient, should be confirmed with on-line medical control before making final decisions.
On-line medical control will be the final arbiter of any disputes about best disposition for the patient.