ACLS

Question 1

ventilation:compression ratio- CA (bag-mask)

Answer 1

30:2

Question 2

ventilation in RA

Answer 2

10-12 per minute (1 ventilation every 5-6 seconds ). True with advanced airway or bag-mask

Question 3

ventilation in CA with advanced airway

Answer 3

8-10 breaths per minute (1 every 6-8 seconds)

Question 4

Steps of ACLS survey when pt is in cardiac arrest (VF or pulseless VT)

Answer 4

1. BLS survey (check responsivness/breathing, activate emergency response, assess pulse, CPR, defibrillation)
2. Give oxygen, attach monitor
3. Reassess rhythm (VF/VT)
   SHOCK!
4. CPR 2 mins + Establish IV/IO access
5. Recheck rhythm (VF/VT)
   SHOCK!
6. CPR 2 mins + Epinephrine (every 3-5 mins)- capnography? airway?
7. Assess rhythm (VF/VT)
   SHOCK!
8. CPR 2 min + Amiodarone + find reversible causes

Question 5

How much Epinephrine?

Answer 5

1 mg (1:10) every 3-5 mins

Question 6

How much Amiodarone?

Answer 6

300 mg IV bolus (over 
2nd dose (3-5 mins later)- 150 mg (bolus)

Question 7

How do you follow administration of peripheral meds?

Answer 7

with 20 mL flush of IV saline and elevate extremity above heart for 10-20 seconds

Question 8

When should you give Mg Sulfate?

Answer 8

torsades de pointes (VT following prolonged QT)

Question 9

What is ROSC?

Answer 9

Pulse and BP or
PETCO2 > 35-40 or
spontaneous arterial pressure waves are seen

Question 10

What are two indications of BAD chest compressions?

Answer 10

PETCO2 < 10 or

“diastolic” pressure <20 mmHg

Question 11

What if the patient is in VF AND hypothermic?

Answer 11

Proceed as usual, but allow MORE time between medication admin and engage in active reheating simultaneously

Question 12

How long should a rhythm check take?

Answer 12

5-10 seconds

Question 13

What are the steps after ROSC?

Answer 13

1. Optimize ventilation (>=94%)- consider advanced airway and capnography
2. Treat hypotension (SBP90 (or >65 MAP), consider treatable causes, 12-lead EKG
3. Can pt. follow commands? - if Yes, either STEMI or critical care, if NO consider induced hypothermia, then STEMI or critical care

Question 14

How do you “optimize” ventilation?

Answer 14

begin ventilator with 10-12 breaths per min and titrate up until patients oxyHg is >94% OR PETCO2 of 35-40%

Question 15

and how are you treating hypertension after ROSC?

Answer 15

1. bolus 1-2 L NS or Ringer’s

2. Epinephrine (0.1-0.5 mcg/kg per minute)

Question 16

When do you use Norepinephrine?

Answer 16

if SBP < 70 and low total peripheral resistance that failes to respond to dopamine, phenylephrine, or mehtoxamine (so basically never, I guess)

Question 17

When do you use Dopamine?

Answer 17

Patient has low BP that cannot be corrected with Epinephrine and bolus alone

Question 18

One of the interns collapses in the trauma bay and you don’t find a pulse or breathing. On rhythm check you find asystole, what now?

Answer 18

1. CPR, dummy - 2 minutes!
2. IV/IO access»advanced airway (unless bag-mask is ineffective)
3. Epinephrine (1 mg every 3-5)
4. Rhythm, CPR, Epi, over and over. unless ROSC or shockable rhythm appear…unless you discover the cause!

Question 19

What are the reversible causes of PEA and Asystole (Hs and Ts)? How does each look on EKG?

Answer 19

Hypovolemia- narrow comples
Hypoxia- slow rate
Hydrogen ion (acidosis)- small amplitude QRS
Hyperkalemia- Peaked T waves, smaller Ps. Sine wave PEA
Hypokalemia- Flat T waves, prominant U waves, wide QRS, long QT
Hypothermia
Tension pneumothorax (hypoxic)
Tamponade (narrow complex)
Toxins
Thrombosis- lungs (narrow complex, rapid rate)
Thrombosis-heart (Q waves, ST changes, T wave inversions)

Question 20

What do you give to all patients you suspect of ACS (before EKG interpretation)?

Answer 20

Obtain EKG - (EMS will have notified you of STEMI and may have sent this over already)
Oxygen (4L/min) if O2 sat is <94%
Aspirin
Nitroglycerin (sublingual or spray)
Morphine (if still in pain)

Question 21

If EKG reveals STEMI…

Answer 21

Suggests acute injury- If time from onset <= 12 hrs, PCI or Fibrinolysis. Goal time from door-to-balloon is 90 mins, and from door-to-needle is 30 mins.

Question 22

how frequently should the team member delivering chest compressions be switched?

Answer 22

About every 2 minutes or 5 CPR cycles.

Question 23

What is the AHA definition of hypotension?

Answer 23

SBP < 90

Question 24

When should chewable aspirin be deferred in suspected ACS?

Answer 24

True aspirin allergy, no evidence of recent GI bleed.

Use rectal suppository (300 mg) for patients with nausea, vomiting, active peptic ulcer, or other upper GI disease.

Never give aspirin <24 hours after heparin thrombolysis.

Question 25

when is nitroglycerine contraindicated?

Answer 25

Hemodynamically unstable (SBP100; Inferior MI or RV MI; recent use of PDE inhibitor (sildenifil, vardenifil- 24 hours, tadalafil within 48 hrs).

Question 26

When should Morphine be used with caution?

Answer 26

NSTEMI or UA- associated with increased mortality

Question 27

what are the next steps for a suspected ACS patient who has had a 12 lead suggesting unstable angina or NSTEMI? What would this look like?

Answer 27

ST depressions and T wave inversions. Determine whether patient is “high” or “low” risk. Send high risk

High-risk = Elevated troponin or 1. Refractory anginal pain, 2. persistent ST deviation (>0.5mm); 3. VT; 4. hemodynamic instability; or 5. signs of heart failure

Low risk: ST segment deviation <=2mm.