14 / 70
The Valley Hospital Mobile ICU
Standing Orders / Communications Failure Orders
14
3. Establish vascular access;
i. If vascular access cannot be established, proceed directly to transcutaneous pacing;
4. If the patient does not have signs or symptoms of an acute myocardial infarction,
administer Atropine Sulfate 0.5 mg via vascular access; May be repeated every three to
five minutes to a maximum of 3 mg;
ii. Note: De-enervated hearts (i.e. heart transplants) and patients with high degree
heart blocks will not respond to Atropine Sulfate. In such cases, initiate external
cardiac pacing.
5. If there is no response to the Atropine Sulfate or the patient is having signs or symptoms of
an acute myocardial infarction, administer transcutaneous pacing at a rate of 70, at the
lowest amount of energy necessary to obtain capture; and
6. Contact medical command.
(b) In stable patients with Type II second degree or third degree AV block, transcutaneous pacemaker
pads should be applied as a precaution.
Communications Failure Orders for bradycardia
(a) If the patient is having signs or symptoms of, or the electrocardiogram suggests, an acute
myocardial infarction, administer Acetylsalicylic Acid by mouth to make the total dose received by
the patient to a maximum dose of 324 mg; this includes any aspirin already taken by the patient
prior to ALS encounter.
(b) If the EKG is consistent with hyperkalemia or the patient is known to be on dialysis or has
evidence of dialysis or fistula, administer Calcium Chloride 1 gram IV/IO push followed by a 20 ml
fluid bolus. Then administer Sodium Bicarbonate 50 mEq IV/IO push. If patient is conscious, also
administer Albuterol 7.5mg via nebulizer. If patient is bradycardic due to hyperkalemia, atropine
and pacing will not be effective.
(c) If the patient requires pain control during transcutaneous pacing, administer Morphine Sulfate 0.1
mg/kg to a maximum of 10mg per dose or administer Fentanyl 1mcg/kg to a maximum of 100 mcg
per dose. These may be and repeated every 10 minutes as long as the systolic blood pressure is
at least 90 mmHg.
(d) If patient requires sedation during transcutaneous pacing, administer Midazolam 2mg IV/IO push.
This may be repeated one time as needed as long as the systolic blood pressure is at least 90
mmHg.
(e) If the patient does not respond to Atropine or transcutaneous pacing, administer Dopamine
5 mcg/kg/min IV/IO drip titrated to a maximum dose of 10 mcg/kg/min.