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acls Flashcards

1
Q

Adenosine dosing

A
  • Place patient in mild reverse Trendelenburg position before administration of drug.
  • Initial bolus of 6mg given rapidly over 1 to 3 seconds followed by NS bolus of 20mL; then elevate the extremity
  • A second bolus (12mg) can be given in 1 to 2 minutes if needed. (ACLS 170)
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2
Q

Indications for adenosine

A
  • Most forms of stable narrow-complex SVT (after vagal maneuvers fail to terminate rhythm)
  • Unstable narrow-complex reentry tachycardia when preparations being made for cardioversion
  • Regular and monomorphic wide-complex tachycardia thought to be previously defined to be reentry SVT (ACLS 170)
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3
Q

Amiodarone dosing for VF/pVT

A

–only after cpr, shock, vasopressor have failed

300 mg IV/IO push

Second dose (if needed): 150mg IV/IO push (acls algorithm 94)

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4
Q

Aspirin dosing

A

Chew and swallow 160-325mg. (acls algorithm 62, 65)

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5
Q

Which algorithm uses aspirin?

A

ACS (acls algorithm 62, 65)

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6
Q

Which algorithms use atropine?

A
  • Bradycardia (acls algorithm 123)

* Formerly: Asystole / bradycardic PEA

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7
Q

Indications for atropine.

A
  • Symptomatic sinus bradycardia (first-line)

* AV nodal block (“may be” beneficial). (acls 171)

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8
Q

Dosing atropine

A
  • 0.5 mg IV every 3-5 minutes as needed, not to exceed total dose of 0.04 mg/kg (total 3 mg)
  • Use shorter dosing interval (3 minutes) and higher doses in severe clinical conditions (acls 171)
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9
Q

Which algorithms use beta blockers?

A
  • Adult Tachycardia with a Pulse (acls algorithm 133)
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10
Q

ACLS beta blocker dosing.

A

Metoprolol IV dosing: 5mg IV slowly over 2-5 minutes repeated q5 minutes for a total of 15mg.

Labetalol IV dosing: 10mg IV push slowly over 2-5 minutes. Repeat every 10 minutes to a maximum dose of 150mg. The maximum effect of each injection usually occurs within 5 minutes. Avoid rapid or excessive falls in blood pressure. (tachycardia algorithm 133–where dosing?)

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11
Q

Which algorithm calls for dopamine?

A

Bradycardia

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12
Q

Indication for dopamine.

A

Symptomatic bradycardia after atropine has failed.

Hypotension (SBP < 70-100 mmHg) with signs and symptoms of shock.

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13
Q

Dopamine dosing effects–from app

A

Most common starting dose 2-10mcg/kg/min–optimal range for inotropic effects.
At higher doses, 10-20mcg/kg/min dopamine exhibits mostly vasoconstrictor effects. (App)

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14
Q

What does PCI stand for again?

A

Percutaneous coronary intervention

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15
Q

Algorithms for diltiazem

A

SVTs

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16
Q

Indications for diltiazem

A

Stable narrow-complex refractory PSVT–second line after adenosine
Aflutter, Afib–first-line agent for control of ventricular rate (app)

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17
Q

Class of medication for diltiazem

A

calcium channel blocker

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18
Q

Precautions/contraindications for diltiazem

A

–Patient with WFW plus rapid Aflutter/Afib
—Sick sinus syndrome
—AV block (app)

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19
Q

Dosing of diltiazem

A

IV Dosing: 15-20mg (0.25mg/kg) IV bolus over 2 minutes. May repeat for 2nd dose in 15 minutes at 20-25mg (0.35mg/kg) over 2min again
Infusion: 5-15mg/hr titrate to rate control heart rate (app)

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20
Q

Algorithms for epinephrine

A

VF / Pulseless VT
Asystole / PEA
Symptomatic Bradycardia

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21
Q

Indications for epinephrine

A
  • Cardiac arrest: VF, pulseless VT, asystole, PEA
  • Symptomatic bradycardia: Can be considered after atropine as an alternative infusion to dopamine.
  • Severe hypotension: Can be used when pacing and atropine fail, when hypotension accompanies bradycardia, or with phosphodiesterase enzyme inhibitor
  • Anaphylaxis, severe allergic reactions: Combine with large fluid volume, corticosteroids, antihistamines. (ACLS 171)
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22
Q

Class of medication for epinephrine

A

catecholamine – acting on alpha and beta adrenergic receptors (app)

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23
Q

Epinephrine dose for cardiac arrest

A

1 mg (10mL of 1:10,000 soln) administered every 3-5 minutes during resuscitation. Follow each dose with 20 mL flush, elevate arm for 10-20 seconds after dose

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24
Q

Fibrinolytic therapy figures into which algorithms

A

ACS

Stroke

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25
Q

Indication for fibrinolytic therapy

A

ACS:
—Within 12 hours of onset of symptoms
—Meets definition for cut ST elevation MI
Stroke:
—Less than 3 hours of onset of stroke symptoms

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26
Q

Into which algorithm does heparin figure?

A

ACS

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27
Q

Which algorithms call for lidocaine?

A

No algorithms currently list lidocaine–listed as alternative to amiodarone for VF/pVT on acls 172

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28
Q

Indication for lidocaine

A

VF / Pulseless VT—second line as alternative to amiodarone–does not appear on algorithm illustration but is listed as medication 172

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29
Q

Dosing of lidocaine for cardiac arrest from VF/pVT

A

Initial dose: 1 to 1.5 mg/g IV/IO
For refractory VF, may give additional 0.5 to 0.75 mg/kg IV push, repeat in 5 to 10 minutes; maximum 3 doses or total of 3 mg/kg
(acls 172)

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30
Q

Which algorithms call for magnesium?

A

VT associated with Torsades de Pointes
Refractory VF
VF with a history of alcoholism

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31
Q

Indications for magnesium

A

Cardiac arrest if torsades de pointes or suspected hypomagnesemia is present
Life-threatening ventricular arrhythmias due to digitalis toxicity (acls 172)

32
Q

Dosing of magnesium for cardiac arrest due to hypomagnesemia or torsades de pointes

A

1 to 2 g (2 to 4mL of a 50% soln diluted in 10mL [D5W, normal saline] given IV/IO (acls 172)

33
Q

Primary assessment acls

A

airway/breathing/circulation/disability/exposure

34
Q

Secondary assessment acls

A

Employ SAMPLE in the H/T search for underlying causes

35
Q

SAMPLE

A 
Signs/symptoms
Allergies
Medications (including last dose taken)
Past medical history (esp related to current illness)
Events leading up to current illness
36
Q

Hs

A 
Hypovolemia
Hypoxemia
Hypothermia
Hypo/hyper kalmia
Hydrogen ion (acidosis)
37
Q

Ts

A 
Tamponade (pulmonary)
Tamponade (cardiac)
Thrombosis (pulmonary)
Thrombosis (cardiac)
Toxins
38
Q

ACS Algorithm: Initial 10-minute ED assessment

A
  • Check vital signs; evaluate oxygen saturation
  • Establish IV access
  • Perform brief, targeted history, physical exam
  • Review/complete fibrinolytic checklist; check contraindications
  • Obtain initial cardiac marker levels
  • Obtain portable chest x-ray (< 30 minutes)
39
Q

ACS Algorithm: Immediate ED general treatment

A
  • If O2 sat <90%, start oxygen at 4Lpm, titrate
  • Aspirin 160-325 mg (if not given by EMS)
  • Nitroglycerin sublingual or spray
  • Morphine IV if discomfort not relieved by nitroglycerin
40
Q

Fibrinolytic therapy for acute stroke is available under what time contraints?

A

Within three hours of symptom onset.

Within one hour of hospital arrival.

41
Q

For STEMI patients, what is the standard for door-to-balloon inflation time for percutaneous coronary intervention?

A

90 minutes

42
Q

What test should be performed for patient suspected of stroke within 25 minutes of hospital arrival?

A

Noncontrast CT scan

43
Q

Amiodarone dosing for life-threatening arrhythmias

A

Stable VT: 150 mg IV infusion over 10 minutes.
May repeat 150 mg IV every 10 min to maximal cumulative dose.

Maximum cumulative dose: 2.2 g IV over 24 hours.

  • Rapid infusion: 150 mg IV over first 10 minutes (15 mg/minute). May repeat rapid infusion (150 mg IV) every 10 minutes as needed.
  • Slow infusion: 360 mg IV over 6 hours (1 mg per minute)
  • Maintenance infusion: 540 mg IV over 18 hours (0.5 mg per minute) (acls 170)
44
Q

Therapy for symptomatic bradycardia when atropine is not effective.

A 
* Transcutaneous pacing
or
* Dopamine infusion
or
* Epinephrine infusion
45
Q

At what heart rate threshold is a patient likely to have a tachyarrhythmia?

46
Q

Take what initial measures upon discovery of tachycardia?

A

Identify and treat underlying cause.

  • Maintain patent airway; assist with breathing as necessary
  • Oxygen (if hypoxemic)
  • Cardiac monitor to identify rhythm; monitor blood pressure and oximetry
47
Q

Persistent tachyarrhythmia: questions for assessment

A
  • Hypotension?
  • Acutely altered mental status?
  • Signs of shock?
  • Ischemic chest discomfort?
  • Acute heart failure?
48
Q

Unstable tachyarrhythmia: treatment

A

Synchronized cardioversion

  • Consider sedation
  • If regular narrow complex, consider adenosine
49
Q

Stable narrow complex QRS tachyarrthymia: Actions

A
  • IV access and 12-lead ECG, if available
  • Consider adenosine only if regular and monomorphic
  • Consider antiarhythmic infusion
  • Consider expert consultation
50
Q

Stable wide-complex QRS tachyarrythmia: Actions

A
  • IV access and 12-lead ECG, if available
  • Vagal maneuvers
  • Adenosine (if regular)
  • B-blocker or calcium channel blocker
  • Consider expert consultation
51
Q

What antiarrhythmic infusions are suggested for stable wide-QRS tachycardia?

A

Procainamide
Amiodarone
Sotalol (acls algorithm 133)

52
Q

Procainamide IV dosing for stable wide-complex tachycadia.

A

20-50 mg/min until arrhythmia supressed, hypotension ensues, QRS duration increases >50%, or maximum does 17 mg/kg given.

Maintenance infusion: 1-4 mg/min.

Avoid if prolonged QT or CHF. (acls algorithm 133)

53
Q

Amiodarone IV dosing for stable wide-complex tachycardia

A

First dose: 150 mg over 10 minutes.
Repeat as needed if VT recurs.
Follow by maintenance infusion of 1 mg/min for first 6 hours. (acls algorithm 133)

54
Q

Sotalol IV dosing for stable wide-complex tachycardia

A 
100 mg (1.5 mg/kg) over 5 minutes.
Avoid if prolonged QT. (acls algorithm 133)
55
Q

Dopamine dosing

A

Usual infusion rate is 2-20 mcg/kg per minute.

Titrate to patient response; taper slowly. (acls 171)

56
Q

Dosing of epinephrine for ETT

A

2-2.5mg diluted in 10mL NS

57
Q

Dosing of epinephrine for continuous infusion

A

0.1-0.5 mcg/kg per minute
(for 70-kg patient: 7-35 mcg/min)
titrate to response

58
Q

Dosing of epinephrine for profound bradycardia or hypotension

A

2-10 mcg per minute infusion; titrate to patient response

59
Q

Biphasic shock dose for defibrillation

A 
Manufacturer recommendation (eg 120-200J); if unknown, use maximum available. 
Second and subsequent doses should be equivalent, and higher doses should be considered.
60
Q

Monophasic shock dose for defibrillation

61
Q

If patient has a-line, what diastolic pressure is marker of poor CPR?

62
Q

How often is epinephrine given in cardiac arrest?

A

3-5 minutes

63
Q

What heart rate generally indicates bradyarrhythmia?

64
Q

What algorithm questions determine stability of bradycardia?

A 
Hypotension?
Acutely altered mental status?
Signs of shock?
Ischemic chest discomfort?
Acute heart failure?
65
Q

What does one seek for symptomatic bradycardia if atropine, transcutaneous pacing and dopamine/epinephrine fail?

A

Expert consultation

Transvenous pacing

66
Q

At what heart rate typically a tachyarrhythmia?

A

> =150/min

67
Q

First moves when confronted with tachycardia with a pulse?

A

Identify and treat reversible causes

  • Maintain patent airway; assist breathing if necessary*
  • Oxygen (if hypoxemic)
  • Cardiac monitor to identify rhythm; monitor blood pressure and oximetry.
68
Q

If tachyarrhythmia persists, what are the assessment questions?

A 
Hypotension?
Acutely altered mental status?
Signs of shock?
Ischemic chest discomfort?
Acute heart failure?
69
Q

Actions for unstable tachyarrhythmia.

A

Synchronized cardioversion

  • Consider sedation
  • If regular narrow complex, consider adenosine
70
Q

How is wide QRS defined?

A

> =0.12 second

71
Q

Actions for stable wide QRS?

A

IV access and 12-lead ECG if available
Consider adenosine only if regular and monomorphic
Consider antiarrhythmic infusion
Consider expert consultation

72
Q

Actions for stable narrow QRS?

A 
IV access and 12-lead ECG if available
Vagal maneuvers
Adenosine (if regular)
B-blocker or calcium channel blocker
Consider expert consultation
73
Q

Contraindications for adenosine

A

Atrial fibrillation
Atrial flutter
VT (acls 170)

74
Q

When is atropine unlikely to be effective?

A

Type 2 Second-degree heart block
Type 3 AV heart block
Block in nonnodal tissues
Routine use in PEA or asystole (acls 171)

75
Q

When is an exceptional dose of atropine called for?

A

In organophosphate poisoning, extremely large doses (2 to 4 mg or higher) may be needed (acls 171)

accs (13 decks)

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