ACLS Flashcards
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 rhythm. 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 epinephrine
During a pause in CPR, you see a narrow complex rhythm on the monitor. The pt. has no pulse. What is the next action?
Resume compressions
What is a common but sometimes fatal mistake in cardiac arrest management?
Prolonged interruptions in chest compressions.
Which action is a component of high-quality chest compressions?
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 performing high-quality CPR on a pt.with an advanced airway in place?
Provide continuous chest compressions without pauses and 10 ventilations per minute.
3 min after witnessing a cardiac arrest, one member of your team inserts an ET tube while another performs continuous chest compressions. During subsequent ventilation, you notice the presence of a wavefoem on the capnography 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?
Allows for monitoring CPR quality
For the past 25 min, EMS crews have attempted resuscitation 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 interval for 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 resuscitative attempts?
Switch 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 rhythm. What is the next intervention?
Vagal maneuver.
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 indication to stop or withhold resuscitative efforts.
Evidence of rigor mortis.
A 49 y/o female arrives in the ER with persistent 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 continues to have a strong pulse. The heart rate is dropping rapidly and now shows a sinus brady rate at 30/min. What intervention has the highest priority?
Simple airway maneuvers and assisted ventilations.
What is the appropriate procedure for ET suctioning after the catheter is selected?
Suction during withdrawal, 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 rhythm 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 rhythm. What would be your next action?
Cincinnati 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 rhythm. 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, diaphoretic, 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 tachy rhythm. What intervention should be next?
Synchronized cardioversion.
What is the initial priority for an unconscious pt. with any tachycardia on the monitor?
Determine if a pulse is present.
Which rhythm requires synchronized cardioversion?
Unstable SVT
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 condition is a contraindication to therapeutic 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 circumferentially 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 monitoring 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.
What is the first drug of choice for symptomatic bradycardia? Dose?
Atropine: 0.5 mg IV bolus every 3-5 min (max 3 mg)
Which ECG rhythm is commonly associated with bradycardia?
Sinus bradycardia
First degree AV block
Second degree AV block: Mobitz I, Mobitz II
Third degree AV block
What rhythm is generally considered the most important and clinically sig degree of block?
Third degree AV block
What are the 3 drugs involved in the bradycardia algorithm? Dose?
Atropine: 0.5 mg IV bolus (repeat every 3-5 min, max 3mg)
Epinephrine: 2-10 mcg/kg/min
Dopamine: 2-10 mcg/kg/min”
True or False: Sx of bradycardia can include chest discomfort or pain, shortness of breath, decreased level of consciousness, weakness, fatigue, light-headedness, dizziness, and pre-syncope or syncope
TRUE
True or False: Signs of symptomatic bradycardia include hypotension, orthostatic hypotension, diaphoresis, pulmonary congestion, frequent PVCs or VT
TRUE
The primary decision point in the bradycardia algorithm is the determination of what?
Adequate perfusion (mental status!)
After it is determined that your patient with bradycardia does not have adequate perfusion, your first step is to:
Give atropine
The correct dose of atropine in the bradycardia algorithm is?
0.5 mg IV bolus (every 3-5 min), up to 3 mg
The correct dose or epinephrine or dopamine in the bradycardia algorithm is?
2-10 mcg/kg/min
Define the treatment sequence for bradycardia with poor perfusion?
Give atropine
Use TCP, E or Dopamine while awaiting pacemaker or if atropine is ineffective
When should TCP be immediately started?
- No response to atropine
- atropine is unlikely to be effective or IV access cannot be quickly established
- Severely symptomatic
IF TCP is ineffective for symptomatic bradycardia, the next step would be to prepare for?
Tranvenous pacing
True or False: Atropine doses of less than 0.5mg may paradoxically result in further slowing of the heart rate
TRUE
For bradycardia unresponsive to atropine what other drugs should be considered?
Epinephrine or Dopamine
Transcutaneous pacing is contraindicated in which patients?
Hypothermia
For TCP the current milliamperes output should be set at what level?
2 mA above capture dose
For transcutaneous pacing the demand rate should be set at?
60 /min adjusted based on clinical judgement
Transcutaneous pacing is not recommended for which rhythms?
Asystole
The primary ACLS tx for VF and pulseless VT is?
Unsynchorized Shocks
Drugs used in the VF/pulseless VT algorithm?
Epineprine Vasopressin Amidorane Lidocaine Magnesium Sulfate
The initial energy dose delivered in pulseless arrest (VF/VT) with a biphasic defibrillator is typically ______
120-200J
After the first shock in Pulseless VF/VT you should immediately:
resume CPR
If using a monophasic defibrillator for pulseless VF/VT, the first dose and all subsequent doses should be ____ J
360
If VF is initially terminated by a shock but recurs later in the resuscitation attempt you should:
Shock at the previously successful energy level
What is the correct sequence for VF/VT algorithm?
Give 1 shock 2 min of CPR Check rhythm Give 1 shock 2 min of CPR Check rhythm 1 mg epi IV push
The drug ______ can be used as a substitute for epi (1mg IV/IO for 3-5 min) for the first or second dose during resuscitation in VT/VF
vasopressin: 40 units IV/IO
If during VF/ VT after a shock, the rhythm check a ______ rhythm and ______, you then should proceed with the asystole/PEA pathway of ACLS pulseless arrest.
nonshockable, no pulse
The app dose of vasopressin which may be substituted for epi in the pulseless arrest algorithm is?
40 U
After the 3rd shock in the pulseless VF/VT algorithm with no change in rhythm/pulse, you should______
Consider anti-arryhtmic drugs:
- Amiodrone
- Lidocaine
- Magnesium
For the pulseless VF/VT algorithm, the proper first dose of IV amiodarone is ____
300 mg IV/IO
Second dose: 150 mg IV/IO
The most reliable method of confirming and monitoring correct placement of an ET tube?
Continuous waveform cap
The post-cardiac arrest phase, you should maintain O2 sat levels at ____
Greater than or equal of 94%
In the post-arrest hypotension is considered ____
SBP <90
What is the only post-resuscitation intervention that has been demonstrated to improve neurologic recovery after cardiac arrest?
Therapeutic Hypothermia
The treatment of hypotension during the post-cardiac arrest will often include IV bolus of fluid. What is the recommended amount of NS or lactated ringer’s that should be given?
1-2 L
3 meds recommended for the treatment of hypotension in the post-resuscitation phase are?
1) Epi: 0.1-0.5 mcg/kg/min IV
2) Norepinephrine: 5-10 mcg/kg/min IV
3) Dopamine: 0.1-0.5 mcg/kg/min IV
In the post resuscitation phase, what is the decision point for the use of therapeutic hypothermia?
Patient fails to follow commands
To induce therapeutic hypothermia, health care providers should cool patients to a target temperature of _____
32 degrees Celsius
How long should cooling measures persist during the post-arrest phase?
12-24 hours
What are adequate measures for monitoring core temp in the post-arrest phase?
Esophageal thermometer
Bladder cath
Pulmonary artery catheter
In the post-resuscitation phase when using continuous waveform capnography, you should titrate breaths/min to achieve PETCO2 of ______
35-40 mmHg
In the post resuscitation phase when evaluating an arterial blood gas, you should titrate breaths/min to achieve PaCO2 of ____
40-45 mmHg
In the post-resuscitation phase, what is a reasonable goal for MAP?
Greater than or equal to 65 mmHg
When hypoxia is the primary cause of PEA what clues may be noted on assessment?
Slow rate on ECG
During PEA, what step occurs after CPR and medication administration?
Rhythm check
What are PE signs that hypovolemia is the primary cause of PEA?
Narrow complex, rapid rate on ECG
Flat neck veins
Dropping BP prior to PEA
What is the recommended treatment to reverse PEA caused by acidosis?
Adequate ventilation
Sodium bicarbonate
PEA caused by HYPERkalemia may present with what rhythm changes?
Wide QRS complex, smaller p waves, T waves taller and peaked
What medications can be used to reverse hyperkalemia?
Sodium bicarbonate
Glucose
Insulin
Albuterol
PE caused by hypokalemia may present with which of the following symptoms?
Flattened T waves
Prominent U waves
Wide QRS
Prolonged QT
What supplement can be used to treat hypokalemia?
Magnesium
An ECG clue that PEA could be caused by drug overdose Toxins is?
Prolonged QT interval
What is the procedure that reverses PEA caused by tamponade?
Pericardiocentesis
The first drug to be used in the PEA/asystole branch is?
Epinephrine: 1 mg IV every 3-5 min
Immediate assessment and actions for a patient presenting with symptoms suggestive of ACS includes what?
O2 Aspirin Nitroglycerin Morphine 12-lead ECG
Once the patient has arrived in the ED with ACS sx, the goal is to analyzable the ECG within ___ min of arrival
10 min
What is the primary focus of treatment of a patient with ACS?
Early perfusion of the STEMI patient
Which rhythms is most commonly caused by acute MI and is the leading cause of sudden cardiac death?
VF
Re-perfusion therapy may involve which of the following?
PCI
Fibrinolytics
What is the most common sx of MI and ischemia?
Discomfort in the retrosternal chest
What rhythm is most likely to develop in the first 4 hours after onset of ACS?
VF
For patient with chest pain, nitroglycerine should be administered if the patient’s systolic blood pressure remains > ____ and heart rate is 50-100/min
90
Which pain med is indicated in STEMI when chest discomfort is unresponsive to nitrates?
Morphine
True or False: For the ACS patient, use of NSAID is contraindicated and should be discontinued.
TRUE
True or False: Response to nitroglycerine (nitrate therapy) is not dx for ACS.
TRUE
One of the goals of reperfusion therapy is to perform PCI within ___ min of arrival in the ED
90 min
What is the major contraindication to aspirin administration?
True aspirin allergy
Recent GI bleed
Fibrinolytic agents or “clot blusters” are effective in about ___% of the patient given these drugs.
50
What are the fibrin specific agents for ACS patients?
rtPA
reteplase
tenecteplase
What is the dosage for oral aspirin to be given with the ACS protocol?
160-325 mg
One goal of reperfusion therapy is to give fibrinolytic within ____ minutes of arrival
30
What is the major contraindication to the administration of nitroglycerine and morphine
Hypotension
For cases in which fibrinolytics are contraindicated, what intervention should be performed?
PCI
Indications for the use of IV nitroglycerine in STEMI are:
- Recurrent or continuing chest pain unresponsive to sublingual or spray nitroglycerine
- Pulmonary edema complicating STEMI
- HTN complicating STEMI
What are the contraindications for the use of nitroglycerin in the ACS protocol?
Right ventricular infarction
Hypotension
Recent phosphodiesterase inhibitor use
The decision point for performing immediate synchronized cardioversion is:
The patient is unstable and no other reversible causes are identified
If tachyarrhythmia is causing a patient to become unstable what is the most imp intervention?
Cardioversion
What is the correct treatment for unstable polymorphic VT?
Treat as VF w/ high energy unsynchorized shocks
What is the correct treatment of unstable monomorphic VT with a pulse?
Treat with synchronized cardioversion and an initial shock of 100J
If there is any doubt about whether an unstable patient has a monomorphic or polymorphic VT, what should you do?
Treat w/ high energy unsynchorized shocks
If the patient is unstable with a narrow-complex SVT what IV medication can be given as you prepare for immediate synchronized cardioversion?
Adenosine 6 mg IV push
