Maryland EMS protocols,
in your pocket.

• Start at 200 m.a. and titrate down until capture is lost
• ✓ Start as low as possible and gradually increase until a palpable pulse confirms capture, up to 200 m.a. maximum
• Start at 100 m.a. and hold steady regardless of palpable pulse
• Start at 50 m.a. and increase in 50 m.a. increments every 2 minutes

The Clinical Pearls section of the Adult Bradycardia Algorithm (3.2-A) states: 'Start current (m.a.) as low as possible and gradually increase current until a palpable pulse is present to confirm capture or to a maximum of 200 m.a.'

• Administer 100% oxygen and obtain vital signs
• ✓ Begin HPCPR and attach an AED as soon as possible
• Support ventilation and call for ALS transport
• Analyze the cardiac rhythm and defibrillate immediately

According to the Universal Algorithm for Adult Emergency Cardiac Care for BLS (Protocol 3.1-A), when a patient is unresponsive, not breathing, and has no pulse, the BLS crew must Begin HPCPR and Attach AED ASAP simultaneously as the first steps in the no-pulse branch of the algorithm.

• Three doses of epinephrine administered by ALS
• ✓ Five two-minute cycles of chest compressions and rhythm interpretation
• Two shocks delivered and one dose of epinephrine
• Placement of a mechanical CPR device and advanced airway

Per the BLS section of the Adult Cardiac Arrest protocol (3.4-A), patients attended to by BLS clinicians with a medical etiology must be resuscitated in place until 'the patient has received a minimum of five two-minute cycles of chest compressions and rhythm interpretation' before transport is considered.

• Provide supportive care only, including oxygen via nasal cannula, but withhold intubation and cardiac monitoring
• ✓ Provide the full scope of interventions including intubation, CPAP/BiPAP, cardiac monitoring, cardioversion, and medications
• Provide comprehensive care excluding intubation, as intubation is never permitted under any MOLST option
• Withhold all treatment and contact medical direction before initiating any interventions

The protocol states that for MOLST A-1 (Maximal Restorative Care, including intubation), prior to respiratory or cardiac arrest, the patient shall receive the full scope of interventions permissible under the Maryland Medical Protocols, including intubation, CPAP/BiPAP, cardiac monitoring, cardioversion, cardiac pacing, IVs, and medications in an attempt to forestall cardiac or respiratory arrest.

• Continue resuscitation and reevaluate at the next rhythm check, as PEA never qualifies for TOR
• Immediately transport to the nearest emergency department
• ✓ May terminate resuscitation, as the rhythm is PEA with ETCO2 less than 15 mmHg after the minimum required HPCPR cycles
• Terminate resuscitation only if the rhythm converts to asystole

Per the Adult TOR – Medical Arrest protocol (3.6-A), after a minimum of 15 two-minute cycles of HPCPR without ROSC, if the rhythm is asystole OR VF/Pulseless VT/PEA with ETCO2 less than 15 mmHg, the crew MAY terminate resuscitation. This patient meets both criteria (PEA and ETCO2 of 12 mmHg).

• Administer midazolam 0.1 mg/kg IV immediately and monitor
• ✓ Place a donut magnet directly over the device and tape it firmly in place
• Apply the AED pads and override the ICD manually
• Perform synchronized cardioversion using the manual defibrillator

Per Protocol 3.10, ALS providers should place a donut magnet directly over the ICD to deactivate the device, preventing further shocks. After deactivation, the magnet should be taped firmly in place and the cardiac rhythm treated per the appropriate algorithm. Medications for comfort are reserved for when deactivation is questionable, unsuccessful, or a magnet is unavailable.