Arkansas EMS protocols,
in your pocket.

• Point-of-care troponin testing
• ✓ Serial prehospital 12-lead electrocardiograms
• Continuous pulse oximetry monitoring
• Prehospital echocardiography

The protocol references Verbeek et al. (2012), which found that serial prehospital 12-lead ECGs increase identification of STEMI, making repeated 12-lead acquisition a key prehospital intervention for these patients.

• Allow him to refuse transport since he has fully recovered and has no cardiac history.
• ✓ Transport to the emergency department, as syncope during exercise often indicates an ominous cardiac cause.
• Consult medical direction for a delayed or non-transport decision, as vasovagal syncope is most likely in a young, healthy patient.
• Administer a fluid bolus and reassess; transport only if he does not improve.

The protocol states that syncope occurring with strenuous exercise, notably in the young and seemingly healthy, often indicates an ominous cardiac cause, and that such patients should be evaluated in the emergency department. Vasovagal/lower-risk etiology considerations and delayed transport only apply where a lower-risk cause is suspected — exertional syncope is explicitly flagged as high-risk.

• Administer a third dose of atropine 1 mg IV immediately
• ✓ Initiate vasopressor therapy (e.g., epinephrine IV drip 0.02–0.2 mcg/kg/min) or transcutaneous pacing
• Administer dopamine as the first-line vasopressor
• Withhold further treatment and monitor the patient closely

The protocol states that if bradycardia and symptoms or hemodynamic instability continue after atropine (max total dose 3 mg, given 1 mg q 3–5 min), the next step is vasopressor medications or transcutaneous pacing. Epinephrine IV drip is listed as the first vasopressor of preference. Dopamine is not listed as a preferred first-line agent in this context, and a third dose of atropine would be premature here as only 2 mg has been given but escalation is warranted given no improvement.

• The patient has no palpable pulse AND ventricular fibrillation is confirmed on the cardiac monitor
• ✓ The pump has stopped AND troubleshooting efforts to restart it have failed
• The VAD coordinator has been contacted AND has given verbal authorization for CPR
• The patient is unresponsive AND the VAD travel bag with spare controller is unavailable

The protocol states CPR may be initiated only where: (i) you have confirmed the pump has stopped and troubleshooting efforts to restart it have failed, AND (ii) the patient is unresponsive and has no detectable signs of life. Both conditions must be met. VAD coordinator authorization is recommended guidance but is not listed as a required condition to initiate CPR.

• Treat hypertension before transport to reduce hemorrhagic conversion risk
• ✓ Elevate the head of the stretcher 15–30 degrees and provide early hospital notification including suspected LVO
• Withhold oxygen because his SpO2 is 96%
• Delay transport to obtain a second 12-lead EKG on scene

The protocol directs providers to prevent aspiration by elevating the head of the stretcher 15–30 degrees when systolic BP is greater than 100 mmHg, and to provide early hospital notification per the local stroke plan including any suspected LVO. Hypertension should NOT be treated per the protocol's key considerations, and oxygen is administered to target 94–98% saturation (not withheld if within range, but withholding is not the primary actionable step here). Delaying transport for additional EKGs is not supported.

• Wait for the defibrillator to be ready before touching the patient
• ✓ Initiate chest compressions immediately while your partner sets up the defibrillator
• Perform a detailed history and physical exam before starting compressions
• Apply a non-rebreather mask and begin passive ventilation before compressions

The protocol states that EMS clinicians should initiate chest compressions in cases with no bystander CPR, or take over from bystanders, while a second rescuer sets up the AED or defibrillator. Compressions are the most rapidly applied therapy and should begin as soon as pulselessness is confirmed.