Frequently Asked Questions - Emergency Medical Services Administrative Guidelines

The management of a cardiac arrest in trauma differs from the care of medical cardia arrest as the underlying pathophysiology is different. Cardiac arrest caused by severe blunt or penetrating trauma is commonly due to exsanguination or anatomic barriers. Individuals in traumatic arrest often present in PEA and have functional hearts that are impeded by severe blood loss or obstructions, like a pneumothorax or pericardial tamponade. Life-saving interventions such as bleeding control, fluid administration, and needle thoracostomy should be the priority. Ideally, we would replace the lost blood volume with blood products, but we utilize available crystalloids in our region. In contrast, epinephrine is a powerful vasopressor that stimulates the heart to beat faster and causes blood vessels to vasoconstrict; usually, this improves cardiac output, but in a patient with severe blood loss and an already maximally vasoconstricted vasculature, epinephrine has little or no benefit. Instead, prioritize airway support, fluid administration, reversal of suspected pneumothorax with needle decompression, Tranexamic Acid (TXA) administration, and transport to a Level 1 trauma hospital.

The fear of giving epinephrine to a patient experiencing a myocardial infarction is that the effects of the epinephrine will increase the oxygen demand of an already ischemic heart. While this is true, there are situations where the benefits outweigh the risks. We would prefer the use of IV fluids in these patients unless profoundly hypotensive or if there is a contraindication to fluids, such as signs of volume overload. If IV fluids are contraindicated, fail, or if the patient is profoundly hypotensive (SBP <70), then push-dose epinephrine should be considered. While the use of epinephrine may increase myocardial oxygen demand, hypotension results in under-perfused coronary arteries which also worsens myocardial ischemia. This is a situation where there is a potential for harm either way, but we feel the benefit of correcting hypotension likely outweighs the risk of increased cardiac oxygen demand. As such, we do not recommend against the use of push-dose epinephrine in STEMI patients, but instead suggest it be used with caution when fluids have failed or if the hypotension is severe, per the Shock/Crashing Medical Patient AG.

Facilitated intubation is the use of sedative medications to assist in the placement of an advanced airway such as an endotracheal tube. Facilitated intubation is a very high-risk procedure and when performed in the prehospital environment is associated with a doubling of mortality. As intubation is a difficult procedure best done in a controlled environment with multiple backup tools, facilitated intubation is not appropriate in the pre-hospital setting.

This is a very medicolegally complicated issue. As pre-hospital providers in Arizona, you are only required to interpret a signed and valid DNR form on orange paper. If there is no valid DNR physically present, the crew may call for online medical control to discuss request for termination.

No. Although intubating laryngeal mask airways (iLMAs) exist and are fairly successful in enabling intubation (approximately 80% success rate), data on the use of iGels in this fashion is not yet established in patients. Studies are ongoing in this application of iGels.

The 2025 medical cardiac arrest guidelines were updated to include early administration of amiodarone in patients with Ventricular Tachycardia (VTach) and Ventricular Fibrillation (VFib) and to delay the administration of epinephrine in these patients as epinephrine can potentiate these shockable rhythms.If, on your first look, the patient is in VTach or VFib, you should defibrillate, give amiodarone, and delay giving epinephrine until the third shock. If on your next rhythm check, you encounter Pulseless Electrical Activity (PEA) or Asystole, then the strategy should be switched, and epinephrine should be given immediately. You may end up switching back and forth between epinephrine and amiodarone depending on the changes in the patient’s rhythm.

All patients with capacity have the right to make their own medical decisions, whether it is in their best interest or not. When a patient is incapacitated or is unable to express their wishes, then Arizona follows a hierarchy of surrogate decision makers: the first is the patient’s designated medical power of attorney, followed by a spouse, then child or children’s consensus, then parent, then domestic partner, then sibling, and then close friend. In circumstances where capacity is uncertain, we encourage you to contact medical control.

A surrogate decision maker cannot make medical decisions on behalf of the patient when the patient has the capacity to make their own decisions.Similarly, the surrogate should not be signing refusal documentation for patients with capacity to make their own medical decisions.

We do not have a preference in cardiac monitor pad placement. We recommend placing pads in the configuration recommended by the defibrillator and pad manufacturer.

The second dose, 150mg of Amiodarone, should be given if a patient is not successfully cardioverted after 4 attempts or 8 minutes after the first dose.