Montana EMS protocols,
in your pocket.

• Whether out-of-hospital 12-lead EKG eliminates the need for in-hospital cardiac catheterization
• ✓ The benefits of out-of-hospital 12-lead EKG and advance notification in STEMI patients
• Whether out-of-hospital 12-lead EKG replaces serial EKGs in the prehospital setting
• Whether out-of-hospital 12-lead EKG is beneficial only for anterior STEMI

The guideline references Nam et al. (2014), 'Systematic review and meta-analysis of the benefits of out-of-hospital 12-lead EKG and advance notification in ST-segment elevation myocardial infarction patients' (Ann Emerg Med).

• The patient's VAD coordinator has given verbal authorization
• ✓ The patient is unresponsive and has no detectable signs of life
• A 12-lead EKG confirms ventricular fibrillation
• You have disconnected the controller and batteries from the device

CPR may be initiated only where (1) you have confirmed the pump has stopped and troubleshooting efforts to restart it have failed, and (2) the patient is unresponsive and has no detectable signs of life. CPR should not be performed if there is any evidence the pump is still functioning; the decision whether to perform CPR should be made based upon best clinical judgment in consultation with the patient's VAD-trained companion and the VAD coordinator (or direct medical oversight if VAD coordinator unavailable). Disconnecting the controller is not required.

• Likely vasovagal syncope; consult medical direction regarding non-transport
• ✓ An ominous cardiac cause; the patient should be evaluated in the emergency department
• Dehydration-related syncope; administer a fluid bolus and reassess on scene
• A seizure disorder; refer to the Altered Mental Status Guideline

The protocol states that 'syncope that occurs during exercise often indicates an ominous cardiac cause' and that 'patients should be evaluated in the emergency department,' noting this in the young and seemingly healthy.

• Immediately perform synchronized cardioversion
• ✓ Administer adenosine 12 mg IV
• Administer diltiazem 0.35 mg/kg IV over 2 minutes
• Administer amiodarone 150 mg IV over 10 minutes

Under Regular Narrow Complex Tachycardia – Stable (SVT), after vagal maneuvers adenosine 6 mg IV (proximal site) followed by a 10 mL fluid bolus is given; if tachycardia continues, give adenosine 12 mg IV, and a third dose of 12 mg IV can be given. Synchronized shock is listed under the Unstable branch.

• SVT, Atrial Fibrillation, Atrial Flutter, and Heart Block
• ✓ VF, VT, Asystole, and PEA
• Bradycardia, Tachycardia, Heart Block, and WPW
• VF, SVT, Asystole, and Sinus Arrest

The protocol is explicitly titled 'Cardiac Arrest (VF/VT/Asystole/PEA),' indicating that ventricular fibrillation (VF), ventricular tachycardia (VT), asystole, and pulseless electrical activity (PEA) are the four rhythm categories covered.

• Wait for the defibrillator to arrive before initiating any intervention.
• ✓ Begin chest compressions immediately while your partner sets up the defibrillator.
• Establish IV access and administer epinephrine before starting compressions.
• Place an advanced airway first to ensure oxygenation prior to compressions.

The guideline states to initiate chest compressions in cases with no bystander chest compressions or take over compressions from bystanders while a second rescuer is setting up the AED or defibrillator. It names prompt defibrillation for shockable rhythms and minimally interrupted effective chest compressions as the most important therapies, and says an adult's airway management is of secondary importance and should not interfere with compressions and defibrillation.