ACLS Flashcards
in cardiac arrest when do you first introduce medical intervention? which drug?
after 2 rounds of CPR/shock
after 2nd shock give 1 mg epinephrine every 3-5 minutes
when do you introduce amiodarone during cardiac arrest?
after the 3rd shock give 300 mg bolus of amiodarone
if second dose is needed give 150mg as second dose
what rhythms are shockable in cardiac arrest
VF VT
what rhythms are not shockable in cardiac arrest
asystole PEA
if you are in an unshockable rhythm arrest when do you give epi
1mg epi every 3-5 minutes after 1st round of CPR
what do you do after return of spontaneous circulation
maintain O2 sat at 94% treat hypotension (fluids vasopressor) 12 lead EKG if in coma consider hypothermia if not in coma and ekg shows STEMI or AMI consider re-perfusion
how do you treat non-symptomatic bradycardia
monitor and observe
what constitutes symptomatic bradycardia
hypotension altered mental status signs of shock chest pain acute heart failure
how do you treat symptomatic bradycardia
- give 0.5mg atropine every 3-5 mins to max of 3mg
if that doesn’t work try one of the following:
transcutaneous pacing
2-10mcg/kg / minute dopamine infusion
2-10mcg/minute epinephrine infusion
what is considered a tachycardia requiring treatment
over 150 per minute
when do you consider cardioversion
if persistent tachycardia is causing: hypotension altered mental status signs of shock chest pain acute heart failure
if persistent tachycardia does not present with symptoms what do you need to consider
wide QRS?
greater than 0.12 seconds
If persistent tachycardia without symptoms DOES have a wide QRS what to do you do?
IV access and 12 lead if available
6mg adenosine followed by NS flush only IF regular and monomorphic
consider anti-arrhythmic infusion:
- 20-50mg/min procainamide (max 17mg/kg)
- 150mg amiodarone over 10 minutes
- 100mg sotalol over 5 minutes
which anti-arrhythmic drugs can be used if prolonged QT
only amiodarone
150mg over 10 minutes, repeat if VT occurs
follow by maintenance infusion 1mg/min for first 6 hours
if persistent tachycardia without symptoms and without wide QRS what do you do
IV access and 12 lead EKG if available
vagal maneuvers
6mg adenosine followed by NS flush only IF regular
Beta blocker or calcium channel blocker
patient comes in with symptoms of ACS what do you do first
chew 325mg aspirin
O2
nitro
morphine
get 12 lead EKG
IV access
IF ACS patient has EKG showing ST elevation and symptoms are less than 12 hours then what
re-perfusion
door to balloon 90 minutes
door to needle 30 minutes
If ACS patient has EKG showing non ST elevation MI or high risk unstable angina then what
early invasive strategy? adjunctive treatment? -nitroglycerin -heparin -beta blockers -clopidogrel -glycoprotein IIb / IIIa inhibitor
what are the contraindications to fibrinolytics in ACS treatment
systolic > 180
diastolic > 100
right arm left arm systolic difference > 15
history of structural central nervous system disease
recent head/facial trauma
stroke more than 3 hours or less then 3 months ago
recent trauma, surgery or bleed
any history of intracranial hemorrhage
bleeding, clotting problem or on blood thinners
serious systemic disease
adenosine
used in tachy
6mg bolus followed by 20mL normal saline
12mg can be used after 1-2 minutes
amiodirone
In VF/VT arrest AFTER trying CPR shock and epi/vasopressin:
300mg then 150mg
In life threatening arrhythmias:
150mg over 10 minute infusion, every 10 minutes as needed
atropine sulfate
use as first line defense in sinus bradycardia
0.5mg every 3-5 minutes as needed MAX is 3mg ( think alive gets 0.5)
do not use if hypothermia
dopamine
2nd line drug for symptomatic bradycardia
use for hypotension with signs of shock
2-20 mcg/kg per minute
epinephrine
in cardiac arrest:
1mg every 3-5 minutes
in bradycardia or hypotension:
2-10mcg/minute infusion
lidocaine
alternative to amiodirone in cardiac arrest:
1-1.5 mg/kg IV
for stable VT, wide complex VT:
0.5 - 0.75 mg.kg every 5-10 minutes max of 3mg/kg
magnesium sulfate
use in cardiac arrest only if hypomagnesemia or torsades:
1-2g diluted in 10mL of D5W
use in torsades with a pulse or AMI with hypomagnesia:
1-2g in 50 to 100 mL of D5W
maintenance with 0.5g per hour infusion
vasopressin
cardiac arrest:
40 units can replace either 1st or 2nd dose of epi
what meds can go down the endotrachial tube
atropine
epinephrine
lidocaine
vasopressin
hyperkalemia
1mEq of sodium bicarb
hypokalemia
10-20 mEq of potassium
hypomagnesemia
give mag sulfate 1-2g
Treating Sinus Bradycardia
Atropine .5 mg q 3-5 minutes (max 3 g)
max dose of atropine
3 mg
How do we treat the three forms of tachycardia with a pulse
Sinus Tachycardia
Stable (narrow QRS complex) → vagal maneuvers → adenosine (if regular) → beta-blocker/calcium channel blocker → get an expert
Stable (wide/regular/monomorphic) → adenosine → consider antiarrhythmic infusion → get an expert
Unstable- Cardiovert
Causes of tachycardia
Fever, sepsis, pain, hypovolemia, anxiety, drugs, asthma, hypotension
SVT Supraventricular Tachycardia on EKG
> 150 and no p waves
Treating SVT
stabe:
Vagal manuevers
Adenosine 6 mg rapid IVP
2nd dose: 12 mg rapid IVP
unstable:
Sedate
Immediate synchronized cardioversion 100 joules
Treating Ventricular Fibrillation
TXN:
Shock 200 J (Debrillation)
CPR 30 x2 (2 minutes)
Meds- Epi x 1 mg
Amiodarone 200 mg 1st/ 150 mg 2nd
Treating pulseless V-Tach
TXN: Pulseless
Shock 200 J, CPR 30 x 2 (2 minutes)
Epi 1 mg; amiodarone 300 mg 1st, 150 mg 2nd
What causes PEA?
Sinus brady
normal sinus rhythm
Sinus tach
Treats:
Stable SVT
Symptomatic/ HR increase to 150
Slows down a fast rate
Adenosine 6mg then 12mg
Symptomatic Bradycardia
Speeds up slow rate
Atropine 0.5mg
Give to pulseless patient treats: VF VT Asystole PEA
1mg Epi
Used to treat:
VF
VT (Pulselness)
Amioderone 300mg then 150mg
1st degree HB
Normal PR interval = .12-.20
PR interval is dealed, greater than .20 seconds
Treating 3rd Degree Heart Block
TXN:
Consider TCP
Increase milliamp until you gain full capture
If TCP ineffective, Dopamine 2-10 mcg/kg/min
3rd degree HB
total disasscoation w/ P wave and QRS complex; QRS will contract on regular interval
You find an unresponsive pt. who is not breathing. After activating the emergency response system, you determine there is no pulse. What is your next action?
Start chest compressions of at least 100 per min.
You are evaluating a 58 year old man with chest pain. The BP is 92/50 and a heart rate of 92/min, non-labored respiratory rate is 14 breaths/min and the pulse O2 is 97%. What assessment step is most important now?
Obtaining a 12 lead ECG.
What is the preferred method of access for epi administration during cardiac arrest in most pts?
Peripheral IV
An AED does not promptly analyze a rythm. What is your next step?
Begin chest compressions.
You have completed 2 min of CPR. The ECG monitor displays the lead below (PEA) and the pt. has no pulse. You partner resumes chest compressions and an IV is in place. What management step is your next priority?
Administer 1mg of epinepherine
During a pause in CPR, you see a narrow complex rythm on the monitor. The pt. has no pulse. What is the next action?
Resume compressions
What is acommon but sometimes fatal mistake in cardiac arrest management?
Prolonged interruptions in chest compressions.
Which action is a componant of high-quality chest comressions?
Allowing complete chest recoil
Which action increases the chance of successful conversion of ventricular fibrillation?
Providing quality compressions immediately before a defibrillation attempt.
Which situation BEST describes PEA?
Sinus rythm without a pulse
What is the best strategy for perfoming high-quality CPR on a pt.with an advanced airway in place?
Provide continuous chest compressionswithout pauses and 10 ventilations per minute.
3 min after witnessing a cardiac arrest, one memeber of your team inserts an ET tube while another performs continuous chest comressions. During subsequent bentilation, you notice the presence of a wavefom on the capnogrophy screen and a PETCO2 of 8 mm Hg. What is the significance of this finding?
Chest compressions may not be effective.
The use of quantitative capnography in intubated pt’s does what?
Allowsfor monitoring CPR quality
For the past 25 min, EMS crews have attemptedresuscitation of a pt who originally presented with V-FIB. After the 1st shock, the ECG screen displayed asystole which has persisted despite 2 doses of epi, a fluid bolus, and high quality CPR. What is your next treatment?
Consider terminating resuscitive efforts after consulting medical control.
Which is a safe and effective practice within the defibrillation sequence?
Be sure O2 is NOT blowing over the pt’s chest during shock.
During your assessment, your pt suddenly loses consciousness. After calling for help and determining that the pt. is not breathing, you are unsure whether the pt. has a pulse. What is your next action?
Begin chest compressions.
What is an advantage of using hands-free d-fib pads instead of d-fib paddles?
Hands-free allows for more rapid d-fib.
What action is recommended to help minimize interruptions in chest compressions during CPR?
Continue CPR while charging the defibrillator.
Which action is included in the BLS survey?
Early defibrillation
Which drug and dose are recommended for the management of a pt. in refractory V-FIB?
Amioderone 300mg
What is the appropriate intervalfor an interruption in chest compressions?
10 seconds or less
Which of the following is a sign of effective CPR?
PETCO2 = or > 10mm Hg
What is the primary purpose of a medical emergency team or rapid response team?
Identifying and treating early clinical deterioration.
Which action improves the quality of chest compressions delivered during resuscitave attemepts?
Shitch providers about every 2 min or every 5 compression cycles.
What is the appropriate ventilation strategy for an adult in respiratory arrest with a pulse of 80 beats/min?
1 breath every 5-6 seconds
A pt. presents to the ER with a new onset of dizziness and fatugue. Onexamination, the pt’s heart rate is 35 beats/min, BP is 70/50, resp. rate is 22 per min, O2 sat is 95%. What is the appropriate 1st medication?
Atropine 0.5mg
A pt. presents to the ER with dizziness and SOB with a sinus brady of 40/min. The initial atropine dose was ineffective and your monitor does not provide TCP. What is the appropriate dose of Dopamine for this pt?
2-10mcg/kg/min
A pt. has an onset of dizziness. The pt.s heart rate is 180, BP is 110/70, resp. rate is 18, O2 sat is 98%. This is a reg narrow complex tach rythm. What is the next intervention?
Vagal manuever.
A monitored pt. in the ICU developed a suddent onset of narrow complex tach at a rate of 220/min. The pt’s BP is 128/58, the PETCO2 is 38mm Hg, and the O2 sat is 98%. There is an EJ established for vascular access. The pt. denies taking any vasodialators. A 12 lead shows no ischemia or infarction. Vagal manuevers are ineffective. What is the next intervention?
Adenosine 12mg IV
You receiving a radio report from an EMS team enroute with a pt. who may be having a stroke. The hospital CT scanner is broken. What should you do?
Divert the pt. to a hospital 15 min away with CT capabilities.
Choose an appropriate inidication to stop or withhold resuscitive efforts.
Evidence of rigor mortis.
A 49 y/ofmaile arrives in the ER with persistant epigastric pain. She has been taking antacids PO for the past 6 hours because she she had heartburn. BP is 118/72, heart rate is 92/min, resp. rate is 14 non-labored and O2 sat is 96%. What is the most appropriate next action?
Obtain a 12 lead ECG.
A pt. in respiratory failure becomes apneic but contineues to have a strong pulse. The heart rate is dropping paridly and now shows a sinus brady rate at 30/min. What intervention has the highest priority?
Simple airway manuevers and assisted ventilations.
What is the appropriate procedure for ET suctioning after the catheter is selected?
Suction during withdrawl, but not for longer than 10 seconds.
While treating a stable pt for dizziness, a BP of 68/30, cool and clammy, you see a brady rythm on the ECG. How do you treat this?
Atropine 0.5mg
A 68 y/o female pt. experienced a sudden onset of right arm weakness. BP is 140/90, pulse is 78/min, resp rate is non-labored 14/min, 02 sat is 97%. Lead 2 in the ECG shows a sinus rythm. What would be your next action?
Cinncinati Stroke Scale
You are transporting a pt. with a positive stroke assessment. BP is 138, pulse is 80/min, resp rate is 12/min, 02 sat is 95% room air. Glucose levels are normal and the ECG shows a sinus rythm. What is next.
Head CT scan
What is the proper ventilation rate for a pt. in cardiac arrest who has an advanced airway in place?
8-10 breaths per minute
A 62 y/o male pt. in the ER says his heart is beating fast. No chest pain or SOB. BP is 142/98, pulse rate is 200/min, reps rate is 14/min, O2 sats are 95 at room air. What should be the next evaluation?
Obtain a 12 lead ECG.
You are evaluating a 48 y/o male with crushing sub-sternal pain. He is cool, pale, diaphretic, and slow to respond to your questions. BP is 58/32, pulse is 190/min, resp rate is 18, and you are unable to obtain an 02 sat due to no radial pulse. The ECG shows a wide complex tach rythm. What intervention should be next?
Syncronized cardioversion.
What is the initial priority for an unconscious pt. with any tachycardia on the monitor?
Determine if a pulse is present.
What is the recommended dose for adenosine for pt’s in refractory, but stable narrow complex tachycardia?
12mg
What is the usual post-cardiac arrest target range for PETCO2 who achieves return of spontaneous circulation (ROSC)?
35-40mm Hg
Which conditionis a contraindication to theraputic hypothermia during the post-cardiac arrest period for pt’s who achieve return of spontaneous circulation (ROSC)?
Responding to verbal commands
What is the potential danger to using ties that pass circumfrentially around the pt’s neck when securing an advanced airway?
Obstruction of veneous return from the brain
What is the most reliable method of confirming and montioring correct placement of an ET tube?
Continuous waveform capnography
What is the recommended IV fluid (NS or LR) bolus dose for a pt. who achieves ROSC but is hypotensive during the post-cardiac arrest period?
1 to 2 Liters
What is the minimum systolic BP one should attempt to achieve with fluid, Inotropic, or vasopressor administration in a hypotensive post-cardiac arrest who achieves ROSC?
90mm Hg
What is the 1st treatment priority for a pt. who achieves ROSC?
Optimizing ventilation and oxygenation.
