Cardiac Panel

Acute coronary syndrome with ST elevation or rising hs-cTn

Recognize: ischemic chest pain with ST elevation, or hs-cTn rising above the URL with ischemic symptoms.

1. 12-lead ECG within 10 minutes of first medical contact (Paramedic/RN/CCT)
2. Notify the receiving PCI center or STEMI system per protocol (Paramedic/RN/CCT)
3. Give aspirin and sublingual nitroglycerin per protocol (aspirin unless allergic); see nitroglycerin. Hold nitrates for SBP <90 mmHg (or a drop of 30 mmHg or more from baseline), suspected right-ventricular infarct (get a right-sided ECG in inferior STEMI), recent PDE-5 inhibitor use (sildenafil or vardenafil within 24 h, tadalafil within 48 h) or riociguat, and severe bradycardia or tachycardia per protocol.
4. High-alert Anticoagulation and fibrinolysis are decided by the receiving team; see heparin and fibrinolytics.

Hyperkalemia with ECG changes or K⁺ >6.5 mEq/L

Recognize: peaked T waves, PR prolongation, QRS widening or bradycardia, with a K⁺ above 6.5 mEq/L.

1. Stabilize the myocardium for any hyperkalemic ECG change, including isolated peaked T waves: calcium gluconate 10% 30 mL (3 g) IV over 10 min by a large peripheral vein (Paramedic/RN/CCT). Use calcium chloride 10% 10 mL (1 g) over 5 min for peri-arrest or with central or deep access. Calcium protects against arrhythmia but does not lower K⁺. Reassess the ECG about 3 min after the dose; repeat the same dose if ECG changes persist, or if K⁺ is still high after about 60 min. Calcium chloride is a vesicant: confirm IV patency and watch for extravasation.
2. High-alert Shift K⁺ into cells: regular insulin 10 units IV, mixed into the dextrose syringe and given over 5–15 min into a large vein, with dextrose 25 g IV (50 mL of D50). If pre-dose glucose is under 126 mg/dL (7.0 mmol/L), add D10 at 50 mL/hr for 5 hr. Recommended at K⁺ 6.5 or higher. Check glucose before the dose, then at 30, 60, 90, 120, 180, 240, 300 and 360 min (at least 6 hr). If K⁺ is still not below 6.0 at 2 hr, consider a second dose. Monitor for hypoglycemia, with higher risk in CKD (Paramedic/RN/CCT).
3. Add nebulized albuterol 10–20 mg as an add-on to calcium and insulin-glucose, never alone for severe hyperkalemia and not a substitute for insulin. Use 10 mg only in ischemic heart disease (Paramedic/RN/CCT).
4. Sodium bicarbonate is not routine outside arrest. Consider it only with severe metabolic acidosis (pH under 7.2) or when IV calcium is contraindicated; a wide QRS alone is not an indication. See sodium bicarbonate.
5. Repeat K⁺ on a non-hemolyzed sample and recheck the ECG after each intervention (Paramedic/RN/CCT).

Differs from FDA label: the US labels list only hypocalcemia and cap the rate (calcium gluconate 200 mg/min for adults, so 3 g takes at least 15 min; calcium chloride 1 mL/min, central or deep vein, no bolus). The rate here (gluconate 30 mL over 10 min, chloride 10 mL over 5 min) is from UKKA 2026 and is off-label.

Insulin dose: some US protocols use 5 units. UKKA 2026 states more study is needed before 5 units can be recommended, so this page uses 10 units with the glucose rules above.

Pulseless arrest from suspected hyperkalemia (2025 AHA Guidelines for CPR and ECC, Part 10, Table 3): run ACLS, then calcium chloride 10% 1 g (10 mL) IV/IO push, sodium bicarbonate 50 mEq IV/IO repeated every 5–10 min guided by blood gas, and regular insulin 10 units IV over 15–30 min with D50 50 g IV bolus. Each is COR 2b (effectiveness not well established). Differs from UKKA 2026: UKKA gives 25 g dextrose in arrest.

Albuterol: off-label dose. The label nebulized dose is 2.5 mg for asthma; 10–20 mg is from UKKA 2026. Not used in cardiac arrest from hyperkalemia (2025 AHA Guidelines for CPR and ECC, Part 10, COR 3: No Benefit, C-EO).

Torsades with QT prolongation

Recognize: polymorphic VT with QT prolongation, often with low K⁺ or Mg²⁺.

1. Defibrillate an unstable or pulseless rhythm per ACLS (Paramedic/RN/CCT)
2. High-alert Magnesium may be considered for recurrent torsades (2025 AHA Guidelines for CPR and ECC, Part 9, COR 2b, C-LD); see magnesium sulfate. Routine magnesium is not recommended for polymorphic VT with a normal QT (COR 3: No Benefit, C-LD). Monitor for hypotension, hypermagnesemia and respiratory depression, especially in renal failure; check the level before any repeat dose.
3. Correct K⁺ and Mg²⁺ together to the protocol goal; avoid drugs that prolong QT
4. Recurrent or pause-dependent torsades: refer for overdrive pacing or isoproterenol per cardiology and protocol

Acute heart failure with pulmonary edema

Recognize: dyspnea, crackles, hypoxemia and an elevated BNP or NT-proBNP with congestion.

1. Sit upright and titrate oxygen to the SpO₂ target per protocol (Paramedic/RN/CCT)
2. CPAP or BiPAP early for respiratory distress with pulmonary edema, per protocol (Paramedic/RN/CCT)
3. Nitroglycerin only for hypertensive pulmonary edema; hold for SBP <90 mmHg, PDE-5 inhibitor use within 24–48 h, or suspected RV infarct. Furosemide per protocol; its benefit is greatest with volume overload. Cardiogenic shock (hypotension with hypoperfusion) needs a different pathway, not nitrates. See nitroglycerin and furosemide
4. High-alert Morphine: not recommended routinely in acute HF or for ACS pain; use only per protocol. See morphine