10 Scenario's Flashcards
Respiratory Arrest
Not breathing, has pulse
- Responsiveness
- Acvitvate EMS / Get AED
- Check Circulaiton and Breathing
- Give 10 breaths/min
- Consider Naloxone if OD suspected
Naloxone: 0.4mg IM or 2/4mg intranasal
Bradycardia
* Stable BP
3
- Consider atropine
- Monitor and observe
- SAMPLE
Bradycardia
* Unstable BP
4
- Atropine
- If atropine ineffective consider Epi or Dopamine infusion / Transcutaneous Pacing
- SAMPLE
- Consider expert consult or transvenous pacing
Atropine: 1mg every 3-5 min (Max 3mg)
Epi: 2-10 mcg/min
Dopamine: 5-20mcg/kg/min
Pacing: 40-80mA
SVT
* Stable BP
5
- Vagal Maneuvers
- Adenosine
- BB or CCB
- SAMPLE
- Consider expert consult
Adenosin: 6mg then 12mg
SVT
* Unstable BP
2
- Prompt synchronized cardioversion
- Consider adenosine, BB, CCB
Adenosin: 6mg then 12mg(x2)
Sotalol: 100mg or 1.5mg/kg
Cardioversion:
Adult = 50-100 J
Pedi:
1st shock = 0.5-1 J/kg
2nd shock = 2 J/kg
Afib / A flutter
* Stable BP
3
- Consider expert consult
- SAMPLE
- Can give adenosin to diagnose between SVT
Adenosin: 6mg then 12mg(x2)
Afib / A flutter
* Unstable BP
3
- Prompt synchronozed cardio version
- SAMPLE
- Can give adenosin to diagnose between SVT
Cardioversion:
Adult = 120-200 J
Pedi:
1st shock = 0.5-1 J/kg
2nd shock = 2 J/kg
Monomorphic Vtach with Pulse
* Stable BP
4
- Antiarrhythmics
* Amiodarone
* Lidocaine
* Sotalol (only if there is a pulse!)
* Procainamide - Expert consult before cardioversion
- Consider cardioversion
- SAMPLE
Amiodarone: 150mg/10 min
Lido: 1.5mg/kg
Sotalol: 100mg
Procainamide: 20-50mg/min
Cardioversion:
Adult = 100 J
Pedi:
1st shock = 0.5-1 J/kg
2nd shock = 2 J/kg
Monomorphic Vtach with a Pulse
* Unstable BP
- Synchronized cardioversion
- SAMPLE
Cardioversion:
Adult = 100 J
Pedi:
1st shock = 0.5-1 J/kg
2nd shock = 2 J/kg
Consider sedation and antiarrythmics:
Amiodarone: 150mg/10 min
Lido: 1/5mg/kg
Sotalol: 100mg
Procainamide: 20-50mg/min
Vfib / Monomorphic Vtach
* Pulseless
CPR / Shock Routine (8 steps)
- Start CPR
- Defib ASAP
- Resume CPR
- Analyze rhythm / check pulse
- Defib
- Resume CPR
- Analyze rhythm / check pulse
- Repeat cycle: Defib-CPR-Analyze
Adult = 120-200 J
Pedi:
1st shock = 2J/kg
2nd shock = 4 J/kg
Subsequent = up to 10J/kg
Vfib / Monomorphic Vtach
* Pulseless
During CPR
- Epi (after 2nd shock)
- Consider H’s & T’s
- Consider intubation, capnography, and steroids
- Give amiodarone or Lido if Epi and defib are ineffective (after 3rd shock)
- Consider hypothermia if patient achieves ROSC
Epi: 1mg every 3-5 mins
Amiodarone: 300mg
Lido: 1-1.5mg/kg
H’s
7
- Hypovolemia
- Hypoxia
- Hypothermia
- Hypoglycemia
- Hypokalemia
- Hyperkalemia
- H+ (acidosis)
T’s
5
- Cardiab Tamponade
- Thrombosis (coronary or pulmonary)
- Tension pneumothorax
- Toxins
- Trauma
Asystole / PEA
2
CPR steps / DO NOT SHOCK
- CPR
- Epi ASAP
1mg every 3-5 min
DO NOT SHOCK
Asystole / PEA
3
During CPR / DO NOT SHOCK
- Consider H’s and T’s
- Consider intubation, capnography, and steroids
- Consider hypothermia if patient achieves ROSC
DO NOT SHOCK
Polymorphic Vtach
“Torsades de Pointes”
Same as pulseless Monomorphic Vtach / Vfib
CPR / Shock Routine (8 steps)
- Start CPR
- Defib ASAP
- Resume CPR
- Analyze rhythm / check pulse
- Defib
- Resume CPR
- Analyze rhythm / check pulse
- Repeat cycle: Defib-CPR-Analyze
Adult = 120-200 J
Pedi:
1st shock = 2J/kg
2nd shock = 4 J/kg
Subsequent = up to 10J/kg
Polymorphic Vtach
“Torsades de Pointes”
During CPR
- Epi (after 2nd shock)
- Give magnesium and/or Lido
- Consider H’s & T’s
- Consider intubation, capnography, and steroids
- Consider hypothermia if patient achieves ROSC
Mono / Vfib is amiodarone, this is magnesium!
Epi: 1mg every 3-5 mins
Magnesium: 1-2g
Lido: 1-1.5mg/kg
ROSC Protocol
* Airway / Breathing
- SpO2: 92-98%
- Consider intubation
- Target PaCO2: 35-45 mmHg
ROSC Protocol
* Circulation
- 12 lead ECG ASAP
- Coronary reperfusion if STEMI or AMI susptected
- MAP ≥ 65mmHg
- Systolic ≥ 90mmHg
- Consider prophylatic antiarrythmics
- Consider H’s and T’s
Norepi: 0.1-0.5mcg/kg/min
Epi: 2-10mcg/kg/min
Dopamine: 5-20mcg/kg/min
ROSC Protocol
* Disability / Exposure
- If comatose consider TTM, brain CT, start EEG monitoring
- If awake start critical care management
- Draw labs (Blood sugar, ABG’s, BMP). Treat hypoglycemia if applicable
- Neurological care and prognostication
Acute Coronary Syndrome
EMS
- 12 lead EKG, IV, O2
- OAN-M
- STEMI, notify hospital in route
- Consider fibrinolytic. Use checklist
Acute Coronary Syndrome
In Hospital
- 12 lead EKG, IV, O2
- Activate STEMI team (if STEMI present)
- Immediate OAN-M
- Fibrinolytic checklist and past medical history
- Obtain labs and chest x-ray (in 30 mins)
- Decide on PCI or fibrinolytics
Acute stroke
EMS
- 12 lead EKG, IV, O2
- FAST / CPSS / NIHSS
- Time of symptom onset
- Notify hospital and transfer to stroke center (skip ED, go to brain scan)
- Check glucose and treat if needed
Acute Stroke
In Hospital
- Skip ED, go to brain scan
- 12 lead EKG, IV, O2 (assess withing 10 mins)
* CPSS / NIHSS
* Quick history - Neurlogical assesment and CT scan (within 20 mins)
- Labs (within 30 mins)
- Interpret CT (within 45 mins)
If Hemorrhagic stroke
- get consult
- admit to stroke unit or ICU
patient should be admitted to a monitored bed within 3 hours
If Ischemic Stroke
- Administer fibrinolytics (alteplase) (within 60 mins of arrival or 3-4.5 hours of symptom onset)
- Administer aspirin if alteplase contraindicated
- Consider endovascular therapy
1. Door to device: 90 mins
2. Ideally within 6 hours (up to 24 hours if penumbral imaging has been done)
3. Interfacility transfer: 60 mins
patient should be admitted to a monitored bed within 3 hours