This document summarizes changes made to the Rhode Island Emergency Medical Services Statewide EMS Protocols for October 2016. Key points include: - The Cardiac Protocols section was expanded from 8 to 10 protocols, with 2 new Post Cardiac Arrest Care protocols added for adults and pediatrics. - Many of the previous protocols were reorganized and renamed for clarity. - The protocols provide standing orders and guidelines for emergency responders at different certification levels to manage cardiac emergencies, cardiac arrest, dysrhythmias, and post-resuscitation care for both adults and pediatrics. - The protocols detail treatments and interventions that can be performed at each response level, from basic

2. Rhode Island
Emergency Medical Services
Statewide EMS Protocols
October 2016
Rhode Island Department of Health

3. Cardiac Protocols
Section 3

5. Cardiac Protocols
General Changes and Additions
• This section was previously titled Cardiac Emergencies.
• This section has 8 protocols.
• READ PEARLS – Pearls contain critical educational information to understand protocol
management and may contain care direction.

6. Cardiac Protocols
New Protocol Previous Protocol
Previous Protocol
Section
3.01 Acute Decompensated Heart Failure/Pulmonary Edema 2.6 Congestive Heart Failure (Pulmonary Edema) Cardiac Emergencies
3.02 Chest Pain - Acute Coronary Syndrome - STEMI
2.5 Chest Pain - 2.8 ST-Elevation Myocardial Infarction (STEMI)
[ALS] Cardiac Emergencies
03.03A Cardiac Arrest - Adult
2.1 Cardiac Arrest 2.7 Pulseless Electrical Activity 2.13
Ventricular Fibrillation and Pulseless Ventricular Tachycardia Cardiac Emergencies
03.03P Cardiac Arrest - Pediatric 2.1 Cardiac Arrest Cardiac Emergencies
03.04A Post Cardiac Arrest Care - Adult New – did not exist in previous version Cardiac Emergencies
03.04P Post Cardiac Arrest Care - Pediatric New – did not exist in previous version Cardiac Emergencies
03.05A Cardiac Dysrhythmia - Bradycardia - Adult 2.3 Bradycardia (Adult, Symptomatic) [ALS] Cardiac Emergencies
03.05P Cardiac Dysrhythmia - Bradycardia - Pediatric 2.4 Bradycardia (Pediatric, Symptomatic) [ALS] Cardiac Emergencies
03.06A Cardiac Dysrhythmia - Narrow Complex Tachycardia - Adult 2.9 - 2.10 Supraventricular Tachycardia Cardiac Emergencies
03.06P Cardiac Dysrhythmia - Narrow Complex Tachycardia -
Pediatric 2.11-2.12 Supraventricular Tachycardia Cardiac Emergencies
03.07A Cardiac Dysrhythmia - Wide Complex Tachycardia - Adult 2.14 – 2.15 Ventricular Tachycardia (Stable/Unstable) Cardiac Emergencies
03.07P Cardiac Dysrhythmia - Wide Complex Tachycardia -
Pediatric New – did not exist in previous version
3.08 Care of the Patient with a Ventricular Assist Device (VAD) New – did not exist in previous version

7. 3.01 Acute Decompensated Heart Failure
- Pulmonary Edema
Protocol Summary
• Previously protocol 2.6 Congestive Heart Failure (Pulmonary Edema).
• This protocol recognizes and provides standing orders for patients with
respiratory distress, dyspnea on exertion, orthopnea, bilateral crackles on
lung auscultation, jugular venous distention, peripheral edema, diaphoresis,
hypotension, shock, chest pain/discomfort.
• This protocol is divided into different levels of care.
• Routine Patient Care.
• Continuous Positive Airway Pressure.
• Manage as per Chest Pain – Acute Coronary Syndrome – STEMI
protocol.
• Manage as per General Shock and Hypotension Protocol.
• CONSIDER ALS INTERCEPT.
• Advanced EMT Cardiac may treat with NITROGLICERIN 0.4 mg SL.
• Consider FUROSEMIDE 10-80 mg IV if transport time is ≥ 30 min and
patient is normotensive.
• MEDICAL CONTROL for MIDAZOLAM 1-2 mg IV for mask compliance.
• NITROGLYCERIN 0.4 mg SL (tablet or lingual spray).
• NITROGLYCERIN IV.
• ENALAPRILAT 1.25 mg IV/IO for the patient unresponsive to nitroglycerin
with a SBP >140.
• Consider MIDAZOLAM 1-2 mg IV if needed for mask compliance.
• Consider FUROSEMIDE 10-80 mg IV if the transport time is ≥ 30 min and
the patient takes oral furosemide and the patient has SBP≥100.

8. 3.02 Chest Pain - Acute Coronary
Syndrome - STEMI
Protocol Summary
• Previously protocol 2.5 Chest Pain and 2.8 ST-Elevation Myocardial Infarction (STEMI)
[ALS].
• This protocol recognizes and provides standing orders for patients with complaints of chest
pain/discomfort consistent with a cardiac etiology or other known or suspected anginal
equivalents, patients with STEMI including posterior MI, and patient with new onset left
bundle branch block (must be evaluated in context with symptoms).
• This protocol is divided into different levels of care.
• Routine Patient Care.
• ASPIRIN 81 mg.
• Prescribed NITROGLYCERIN.
• Multi-lead ECG.
• CODE STEMI.
• NITROGLYCERIN 0.4 mg SL.
• Manage as per Patient Comfort Protocol/ General Shock and
Hypotension Protocol/ Cardiac Dysrhythmia protocols.
• SAME MANAGEMENT AS
Advanced EMT Cardiac .
• + IV Nitroglycerin by IV infusion.

9. 3.03 Adult - Cardiac Arrest
Protocol Summary
• Previously protocol 2.1 Cardiac Arrest.
• This protocol recognizes and provides
standing orders for patients in Cardiac
Arrest.
• This protocol is divided into different
levels of care.
All Providers:
• Routine Patient Care.
• CONTINUE or BEGIN HIGH QUALITY CPR IMMEDIATELY.
• Limit interruptions/pauses.
• RESUSCITATIVE EFFORTS SHOULD CONTINUE FOR A MINIMUM OF 30 MINUTES
PRIOR TO MOVING THE PATIENT UNLESS TRAUMA OR UNSAFE LOCATION.
• See Reversible Causes of Cardiac Arrest.
• If ROSC, then manage per Post Cardiac Arrest Care Protocol.
Advanced EMT Cardiacs
• Early Interosseous Placement above
diaphragm.
• EPINEPHRINE (1:10,000) 1 mg IV/IO.
• AMIODARONE 300 mg IV/IO and/or
Lidocaine 100 mg IV/IO for VF/PVT.
• DSED for refractory VF/PVT.
• Fluid bolus for PEA Arrest and
suspected hypovolemia.
Paramedics
• Same as Advanced EMT Cardiac.
• + Procainamide and Metoprolol for
refractory or recurrent VF/PVT.
• +Needle thoracostomy for PEA arrest
with suspected tension pneumothorax.
• + Magnesium for Torsades de Pointes
or hypomagnesemia.

10. 3.03 Pediatric - Cardiac Arrest
Protocol Summary
• Previously integrated in protocol 2.1 Cardiac Arrest.
• This protocol delineates care for pediatric patients in Cardiac Arrest.
• This protocol is divided into different levels of care.
Advanced EMT Cardiacs
• Early Interosseous Placement above
diaphragm if age appropriate.
• EPINEPHRINE (1:10,000) 0.01 mg/kg IV/IO.
• AMIODARONE and/or LIDOCAINE for
VF/PVT.
• Refractory VF/PVT change pads or site.
• Fluid bolus for PEA Arrest.
• Note that Naloxone is not indicated for
cardiac arrest.
Paramedics
• Early IO placement above diaphragm if age appropriate.
• EPINEPHRINE (1:10,000) 0.01 mg/kg IV/IO.
• AMIODARONE and/or LIDOCAINE for VF/PVT.
• Refractory VF/PVT change pads or site.
• Needle thoracostomy for PEA arrest with suspected tension pneumothorax.
• Fluid bolus for PEA Arrest.
• Magnesium sulfate 40mg/kg for Torsades de Pointes.
• Gastric tube placement for distention.
All Providers:
• Routine Patient Care.
• CONTINUE or BEGIN HIGH QUALITY CPR IMMEDIATELY .
• Limit interruptions/pauses.
• RESUSCITATIVE EFFORTS SHOULD CONTINUE FOR A MINIMUM OF 30 MINUTES PRIOR TO
MOVING THE PATIENT UNLESS TRAUMA OR UNSAFE LOCATION.
• REQUEST ALS, if available.
• See Reversible Causes of Cardiac Arrest.
• If ROSC, then manage per Post Cardiac Arrest Care Protocol.

11. 3.04Adult - Post Cardiac Arrest Care
Protocol Summary
• This is a new protocol.
• This protocol recognizes and provides standing orders for patients who
need post Cardiac Arrest Care.
• This protocol is divided into different levels of care.
All Providers:
• Routine Patient Care.
• Once ROSC is achieved, do not move patient for 10 minutes unless trauma
or danger. Maintain constant palpation of pulse during this period.
• Provide airway and ventilator management as needed.
• Manage hypotension/shock.
• Perform blood glucose analysis.
• Transport to PCI capable facility if indicated.
Advanced EMT Cardiac:
• Waveform Capnography.
• Acquire multi-lead ECG.
• Manage cardiac dysrhythmias.
Paramedic:
• Manage as for Advanced EMT Cardiac.
• Consider AMIODARONE or LIDOCAINE infusion.
• Consider gastric tube placement.
• Consider sedation and analgesia.

12. 3.04 Pediatric - Post Cardiac Arrest Care
Protocol Summary
• This is a new protocol.
• This protocol recognizes and provides standing orders for
pediatric patients who need post Cardiac Arrest care.
• This protocol is divided into different levels of care.
All Providers:
• Routine Patient Care.
• Once ROSC is achieved, do not move patient for 10
minutes. Maintain constant palpation of pulse during this
period.
• Provide airway management.
• Manage hypotension/shock.
• Perform blood glucose analysis.
• Transport patient (consider transport to a pediatric
specialty care facility).
Advanced EMT Cardiac:
• Waveform capnography.
• Acquire multi-lead ECG.
• Manage cardiac dysrhythmias.
Paramedic:
• Manage as per Advanced EMT Cardiac.
• Consider gastric tube placement.
• Consider sedation and analgesia.

13. 3.05 Adult - Bradycardia - Cardiac
Dysrhythmia
Protocol Summary
• Previously protocol 2.3 Bradycardia (Adult, Symptomatic) [ALS].
• This protocol recognizes and provides standing orders for adult
patients with heart rate < 60 with a pulse and evidence of poor
perfusion.
• This protocol is divided into different levels of care.
All Providers:
• Routine Patient Care
• Assess
• Unstable patients - monitor and reassess
• Consider treatable etiologies
• Transport
Advanced EMT Cardiac:
• ATROPINE SULFATE 0.5-0.1 mg IV/IO
• Transcutaneous pacing (TCP) [manage as per Patient
Comfort Protocol if sedation or analgesia are required]
• NORMAL SALINE 250-500 ml IV/IO
Paramedic:
• Manage as per Advanced EMT Cardiac
• Consider DOPAMINE HCL 2-10 mcg/kg/min or EPINEPHRINE
2-10 mcg/min IV/IO if refractory to TCP

14. 3.05Pediatric - Bradycardia - Cardiac
Dysrhythmia
Protocol Summary
• Previously protocol 2.4 Bradycardia (Adult, Symptomatic) [ALS].
• This protocol recognizes and provides standing orders for
pediatric patients with heart rate < 60 with a pulse and evidence
of poor perfusion.
• This protocol is divided into different levels of care.
All Providers:
• Routine Patient Care
• Assess appropriateness of heart rate for clinical situation
• Maintain adequate oxygenation and ventilation
• Consider treatable etiologies
• Transport
Advanced EMT Cardiac:
• NORMAL SALINE 20 ml/kg IV/IO
• EPINEPHRINE (1:10,000) 0.01 mg/kg IV/IO
• ATROPINE SULFATE 0.02 mg/kg IV/IO
• Transcutaneous Pacing (TCP) [manage as per Patient
Comfort Protocol if sedation or analgesia are required]
Paramedic:
• Manage as per Advanced EMT Cardiac
• If no IV/IO access is available for ATROPINE, consider 0.04-
0.06 mg/kg via ETT
• Consider DOPAMINE 2-10 mcg/kg/min if refractory to TCP.

15. 3.06 Adult - Narrow Complex Tachycardia
- Cardiac Dysrhythmia
Protocol Summary
• Previously protocols 2.9 and 2.10 Supraventricular Tachycardia.
• This protocol recognizes and provides standing orders for adult patients
with a narrow complex QRS (≤0.12 sec) and a pulse.
• This protocol is divided into different levels of care.
All Providers:
• Routine Patient Care.
• Transport.
Advanced EMT Cardiac:
• Observe minimally symptomatic
patients.
• Treat unstable/pre arrest patients
o Synchronized CARDIOVERSION
o Pre-shock sedation
• If Regular Rhythm
o VAGAL maneuvers
o ADENOSINE 12 mg IV PUSH, may repeat
X1
o Contact MEDICAL CONTROL for
DILTIAZEM 0.25 mg/kg IV/IO, may
repeat 0.35 mg/kg IV/IO
Paramedic:
• Unstable/Pre Arrest Patient
o Synchronized CARDIOVERSION and pre-shock sedation
• Regular Rhythm
o Vagal maneuvers
o ADENOSINE 12 mg, may repeat X1
o DILTIAZEM 0.25 mg/kg IV/IO, may repeat 0.35 mg/kg IV/IO
o METOPROLOL 2.5-5 mg IV, may repeat to a max of 15 mg

16. 3.06 Pediatric - Narrow Complex
Tachycardia - Cardiac Dysrhythmia
Protocol Summary
• Previously integrated in Protocols 2.9 and 2.10 Supraventricular Tachycardia.
• This protocol recognizes and provides standing orders for pediatric patients
with a narrow complex QRS (≤0.12 sec) and a pulse.
• This protocol is divided into different levels of care.
All Providers:
• Routine Patient Care
• Transport
Advanced EMT Cardiac:
• Unstable/pre arrest patient
o Synchronized CARDIOVERSION
o Pre-shock sedation
• Sinus Tachycardia consider
underlying etiologies
• Observe minimally symptomatic
patients
• For Stable patients obtain multi-
lead ECG
• Vagal maneuvers
• Contact MEDICAL CONTROL for
ADENOSINE 0.1 mg/kg rapid
IV/IO, may repeat X1
Paramedic:
• Unstable/pre arrest patient: synchronized CARDIOVERSION, consider pre-
shock sedation
• For sinus tachycardia consider underlying etiologies
• Observe minimally symptomatic patients
• For stable patients obtain multi-lead ECG
• Vagal maneuvers
• ADENOSINE 0.1 mg/kg rapid IV/IO push (may repeat X1), if ineffective,
AMIODARONE 5 mg/kg IV/IO

17. 3.07 Adult - Wide Complex Tachycardia -
Cardiac Dysrhythmia
Protocol Summary
• Previously protocols 2.14 – 2.15 Ventricular Tachycardia (Stable/Unstable).
• This protocol recognizes and provides standing orders for adult patients
with a wide complex QRS (≥0.12 sec) tachycardia and a pulse.
• This protocol is divided into different levels of care.
All Providers:
• Routine Patient Care
• Transport
Advanced EMT Cardiac:
• Unstable/pre arrest patient, synchronized CARDIOVERSION (consider
pre-shock sedation).
• If rhythm is regular with monomorphic complexes, ADENOSINE 12
mg IV/IO, may repeat X1.
• Contact MEDICAL CONTROL for:
o AMIODARONE 150 mg IV/IO or
o LIDOCANE 1-1.5 mg/kg IV/IO
Paramedic:
• Unstable/pre arrest patient, synchronized CARDIOVERSION (consider pre-shock sedation)
• If rhythm is regular with monomorphic complexes, ADENOSINE 12 mg IV/IO, may repeat X1.
• AMIODARONE 150 mg IV/IO or
• PROCAINAMIDE 25- 50 mg/min or
• LIDOCAINE 1- 1.5 mg/kg
• Polymorphic ventricular tachycardia/Torsades de Pointes, MAGNESIUM SULFATE 1-2 gm IV/IO

18. 3.07 Pediatric - Wide Complex
Tachycardia - Cardiac Dysrhythmia
Protocol Summary
• Previously protocols 2.14-2.15 Ventricular Tachycardia
(Stable/Unstable).
• This protocol recognizes and provides standing orders for
pediatric patients with a wide complex QRS (≥0.09 sec)
tachycardia and a pulse.
• This protocol is divided into different levels of care.
All Providers:
• Routine Patient Care.
• Transport (consider transport to a pediatric specialty
care facility).
Advanced EMT Cardiac:
• Unstable/pre arrest patient, synchronized
CARDIOVERSION (consider preshock sedation)
• Stable patient, obtain multi-lead ECG
• Contact MEDICAL CONTROL for:
o AMIODARONE 5 mg/kg
o LIDOCANE 1 mg/kg IV/IO
Paramedic:
• Unstable/prearrest Patient, synchronized CARDIOVERSION
(consider pre-shock sedation)
• Stable Patient, obtain a multi-lead ECG
• Consider AMIODARONE 5 mg/kg or LIDOCANE 1 mg/kg
IV/IO
• Polymorphic ventricular tachycardia/Torsades de Pointes,
MAGNESIUM SULFATE 1-2 gm IV/IO

19. 3.08 Patient with a Ventricular Assist
Device (VAD)
Protocol Summary
• This is a new protocol.
• This protocol recognizes and provides standing orders for patients with a
ventricular assist device.
• This protocol is for all levels of care.
All Providers:
• Routine Patient Care
• Assess the patient
• Assess the VAD
• Usually there is no palpable pulse
or measurable blood pressure
unless a pulsatile flow device
• If indication of possible device
malfunction or failure, contact
coordinator.
• If patient is unresponsive, pulseless
(no signs of life) with non-
functioning pump troubleshoot
pump before compressions.
• Transport patient with a VAD
problem to their VAD hospital
• Bring all resources (batteries etc.)

20. Continue on to RI EMS
Protocol Education
Modules
Section 4