Sharp ESO
3 types of Ventricular Tachycardia: - ANS - 1. Stable
2. Unstable
3. Pulseless
antecubital vein - ANS - First target for IV access if a central line is not present
Asystole - ANS - i. CPR (2 min.)
ii. O2 at 15 L/min. ambu bag
iii. Epinephrine 1 mg IVP/IO (use epinephrine 0.1 mg/ml), repeat every 3-5 minutes
iv. Repeat CPR and epinephrine administration if no signs of ROSC
Asystole treatment - ANS - Asystole represents total absence of ventricular activity/contraction.
There is no pulse associated with this rhythm. Initiate CPR immedicately.
a. CPR for 2 minutes
b. O2 at 15ml/min. ambu bag (10 breaths per minute)
c. Epinephrine 1mg IVP/IO (Use Epinephrine 0.1mg/ml) repeat every 3-5 minutes
d. Repeat CPR and Epinephrine administrations if not signs of ROSC
-NO defibrillation
-Transcutaneous pacing for asystole is not recommended as it is ineffective
Asystole treatment - ANS - i. CPR (2 min.)
ii. O2 at 15 L/min. ambu bag
iii. Epinephrine 1 mg IVP/IO (use epinephrine 0.1 mg/ml), repeat q 3-5 minutes
iv. Repeat CPR and Epinephrine administration if no signs of ROSC
Availability of medications required for ESOs: - ANS - Medications that are part of an ESO
must be readily available for administration to the patient
Bradycardia unstable (Heart Rate less than 50bpm) - ANS - i. O2 at minimum 10L/min.
non-rebreather mask
ii. If transvenous leads or epicardia pacing wires present, connect to a pulse generator and
initiate pacing per protocol.
If no response, perform the following:
iii. Atropine 1mg IVP/IO, repeat every 3-5 minutes (max 3 mg)
iv. Transcutaneous pacing as soon as possible.
v. If above algorithm is ineffective, start dopamine 400mg/250ml D5W infusion at
5mcg/kg/minute. Titrate to patient response up to 20mcg/kg/minute.
,vi. If above is ineffective, start epinephrine 2mg/250ml NS at 2mcg/min., titrate to patient
reponse up to 10mcg/minute
NOTE: Assess patient for adequate intravascular volume and volume status when using
vasoconstrictors.)
Bradycardia-Unstable (includes heart blocks) - ANS - 1. Bradycardia is defined as heart rate
less than 50 beats per minute. This rhythm is too slow to maintain an adequate blood pressure.
2. The patient must be symptomatic, exhibiting one or more of the "unstable" signs/symptoms
related to the slow rate.
3. Bradycardias range from sinus bradycardia to complete, third degree heart block.
Chest Pain - ANS - i. O2 start at minimum 4L/min. NC and titrate to maintain SPO2 greater
than or equal to 94%.
ii. Nitroglycerin 0.4mg sublingual if SBP greater than or equal to 90 mmHg and HR greater than
50. May repeat every 3-5 minutes x2.
iii. Morphine sulfate 2mg IVP/IO, if SBP greater than or equal to 90 mmHg every 5 minutes up to
a total of 10mg.
iv. Give aspirin 325 mg non-enteric coated, chewed or crushed. If not contraindicated and no
dose give on this date.
v. If hypotension develops and no evidence of pulmonary congestion, give 250ml NS IV/IO (may
be substituted with LR if currently infusing) and resume treatment for chest pain if not relieved.
vi. 12 lead EKG
Chest pain - ANS - The most common presentation of an acute coronary syndrome (ex:
unstable angina; non-Q wave MI; Q-wave MI
Chest pain suggestive of ischemia may be described as: - ANS - a. Uncomfortable pressure,
fullness, squeezing, or pain in the center of the chest lasting several minutes (usually more than
15 minutes)
b. Pain spreading to the shoulders, neck, arms, jaw; or pain in the back or between the shoulder
blades
c. Chest discomfort with light-headedness, fainting, sweating, nausea, or shortness of breath
d. A global feeling of distress, anxiety or impending doom
It is important to respond immediately when symptoms of myocardial ischemia are present. A
high priority is to provide pain relief.
Circumstance under which an ESO Competent RN may perform ESO standarized procedures: -
ANS - Emergency standing orders will be initiated by ESO competency-validated RNs in the
absense of a physician.
Coarse and fine V Fib - ANS - Used to describe the amplitude of the rhythm
Coarse VFib - ANS - Usually indicates a recent onset of V-Fib that may be corrected with
immediate defibrillation
, Comatose Adult - ANS - No eye opening to pain and no purposeful motor response
CPR (cardiopulmonary resuscitation) - ANS - Includes circulation with compressions, airway
assessment and breathing (C-A-B)
Documentation for nurse instituting ESO - ANS - a. Life threatening condition
b. Precipitating factors
c. Specific ESO implemented (medication and/or treatment)
d. Patient's response
e. When and which physician was notified
Emergency Standing Orders (ESO) - ANS - Pre-established medical orders, approved by
appropriate medical staff to be administered in the absence of a physician. Orders specify
emergent treatment interventions for life-threatening conditions.
End Tidal CO2 - ANS - the maximum CO2 concentration at the end of each tidal breath, which
can be used to assess disease severity and response to treatment. Reflects cardiac output
during CPR. Can be used to measure the effectiveness of cardiac compressions and
assessment of return of spontaneous circulation (ROSC) after cardiac event
Epinephrine Severe Anaphylaxis - ANS - Considered to be the most important drug for any
severe anaphylactic reaction. It works best when given early after the onset of reaction. Adverse
effects are rare when given IM. Antihistamines and coritcosteroids are used adjunctively in the
management of anaphylaxis. The former helps counter histamine release and the latter helps
avert late sequelae.
ESO Competent Nurse - ANS - RN who had successfully demonstrated the knowledge and
skills in identification and treatment of life-threatening conditions
ESO Documentation - ANS - a. Interdisciplinary note
b. Provider communication note
c. Code Blue record and critique form-- for respiratory and cardiopulmonary arrest
d. Rapid Response Team record will be completed for all RRT events that utilize ESOs
Fine VFib - ANS - Indicates a more prolonged VFib that is approaching asystole. Successful
resuscitation is more difficult at this stage
First-Degree AV Block - ANS - This block is caused by a delay in the passage of the impulse
anywhere from the atria to the ventricles. It is characterized by a long PR interval (more than
0.20 seconds) that is constant.
Flumazenil (Romazicon) - ANS - 0.2 mg IVP over 15 seconds is the reversal agent for
benzodiazepines
3 types of Ventricular Tachycardia: - ANS - 1. Stable
2. Unstable
3. Pulseless
antecubital vein - ANS - First target for IV access if a central line is not present
Asystole - ANS - i. CPR (2 min.)
ii. O2 at 15 L/min. ambu bag
iii. Epinephrine 1 mg IVP/IO (use epinephrine 0.1 mg/ml), repeat every 3-5 minutes
iv. Repeat CPR and epinephrine administration if no signs of ROSC
Asystole treatment - ANS - Asystole represents total absence of ventricular activity/contraction.
There is no pulse associated with this rhythm. Initiate CPR immedicately.
a. CPR for 2 minutes
b. O2 at 15ml/min. ambu bag (10 breaths per minute)
c. Epinephrine 1mg IVP/IO (Use Epinephrine 0.1mg/ml) repeat every 3-5 minutes
d. Repeat CPR and Epinephrine administrations if not signs of ROSC
-NO defibrillation
-Transcutaneous pacing for asystole is not recommended as it is ineffective
Asystole treatment - ANS - i. CPR (2 min.)
ii. O2 at 15 L/min. ambu bag
iii. Epinephrine 1 mg IVP/IO (use epinephrine 0.1 mg/ml), repeat q 3-5 minutes
iv. Repeat CPR and Epinephrine administration if no signs of ROSC
Availability of medications required for ESOs: - ANS - Medications that are part of an ESO
must be readily available for administration to the patient
Bradycardia unstable (Heart Rate less than 50bpm) - ANS - i. O2 at minimum 10L/min.
non-rebreather mask
ii. If transvenous leads or epicardia pacing wires present, connect to a pulse generator and
initiate pacing per protocol.
If no response, perform the following:
iii. Atropine 1mg IVP/IO, repeat every 3-5 minutes (max 3 mg)
iv. Transcutaneous pacing as soon as possible.
v. If above algorithm is ineffective, start dopamine 400mg/250ml D5W infusion at
5mcg/kg/minute. Titrate to patient response up to 20mcg/kg/minute.
,vi. If above is ineffective, start epinephrine 2mg/250ml NS at 2mcg/min., titrate to patient
reponse up to 10mcg/minute
NOTE: Assess patient for adequate intravascular volume and volume status when using
vasoconstrictors.)
Bradycardia-Unstable (includes heart blocks) - ANS - 1. Bradycardia is defined as heart rate
less than 50 beats per minute. This rhythm is too slow to maintain an adequate blood pressure.
2. The patient must be symptomatic, exhibiting one or more of the "unstable" signs/symptoms
related to the slow rate.
3. Bradycardias range from sinus bradycardia to complete, third degree heart block.
Chest Pain - ANS - i. O2 start at minimum 4L/min. NC and titrate to maintain SPO2 greater
than or equal to 94%.
ii. Nitroglycerin 0.4mg sublingual if SBP greater than or equal to 90 mmHg and HR greater than
50. May repeat every 3-5 minutes x2.
iii. Morphine sulfate 2mg IVP/IO, if SBP greater than or equal to 90 mmHg every 5 minutes up to
a total of 10mg.
iv. Give aspirin 325 mg non-enteric coated, chewed or crushed. If not contraindicated and no
dose give on this date.
v. If hypotension develops and no evidence of pulmonary congestion, give 250ml NS IV/IO (may
be substituted with LR if currently infusing) and resume treatment for chest pain if not relieved.
vi. 12 lead EKG
Chest pain - ANS - The most common presentation of an acute coronary syndrome (ex:
unstable angina; non-Q wave MI; Q-wave MI
Chest pain suggestive of ischemia may be described as: - ANS - a. Uncomfortable pressure,
fullness, squeezing, or pain in the center of the chest lasting several minutes (usually more than
15 minutes)
b. Pain spreading to the shoulders, neck, arms, jaw; or pain in the back or between the shoulder
blades
c. Chest discomfort with light-headedness, fainting, sweating, nausea, or shortness of breath
d. A global feeling of distress, anxiety or impending doom
It is important to respond immediately when symptoms of myocardial ischemia are present. A
high priority is to provide pain relief.
Circumstance under which an ESO Competent RN may perform ESO standarized procedures: -
ANS - Emergency standing orders will be initiated by ESO competency-validated RNs in the
absense of a physician.
Coarse and fine V Fib - ANS - Used to describe the amplitude of the rhythm
Coarse VFib - ANS - Usually indicates a recent onset of V-Fib that may be corrected with
immediate defibrillation
, Comatose Adult - ANS - No eye opening to pain and no purposeful motor response
CPR (cardiopulmonary resuscitation) - ANS - Includes circulation with compressions, airway
assessment and breathing (C-A-B)
Documentation for nurse instituting ESO - ANS - a. Life threatening condition
b. Precipitating factors
c. Specific ESO implemented (medication and/or treatment)
d. Patient's response
e. When and which physician was notified
Emergency Standing Orders (ESO) - ANS - Pre-established medical orders, approved by
appropriate medical staff to be administered in the absence of a physician. Orders specify
emergent treatment interventions for life-threatening conditions.
End Tidal CO2 - ANS - the maximum CO2 concentration at the end of each tidal breath, which
can be used to assess disease severity and response to treatment. Reflects cardiac output
during CPR. Can be used to measure the effectiveness of cardiac compressions and
assessment of return of spontaneous circulation (ROSC) after cardiac event
Epinephrine Severe Anaphylaxis - ANS - Considered to be the most important drug for any
severe anaphylactic reaction. It works best when given early after the onset of reaction. Adverse
effects are rare when given IM. Antihistamines and coritcosteroids are used adjunctively in the
management of anaphylaxis. The former helps counter histamine release and the latter helps
avert late sequelae.
ESO Competent Nurse - ANS - RN who had successfully demonstrated the knowledge and
skills in identification and treatment of life-threatening conditions
ESO Documentation - ANS - a. Interdisciplinary note
b. Provider communication note
c. Code Blue record and critique form-- for respiratory and cardiopulmonary arrest
d. Rapid Response Team record will be completed for all RRT events that utilize ESOs
Fine VFib - ANS - Indicates a more prolonged VFib that is approaching asystole. Successful
resuscitation is more difficult at this stage
First-Degree AV Block - ANS - This block is caused by a delay in the passage of the impulse
anywhere from the atria to the ventricles. It is characterized by a long PR interval (more than
0.20 seconds) that is constant.
Flumazenil (Romazicon) - ANS - 0.2 mg IVP over 15 seconds is the reversal agent for
benzodiazepines
