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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
Indication for fibrinolytic therapy
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
26
Into which algorithm does heparin figure?
ACS
27
Which algorithms call for lidocaine?
No algorithms currently list lidocaine--listed as alternative to amiodarone for VF/pVT on acls 172
28
Indication for lidocaine
VF / Pulseless VT—second line as alternative to amiodarone--does not appear on algorithm illustration but is listed as medication 172
29
Dosing of lidocaine for cardiac arrest from VF/pVT
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)
30
Which algorithms call for magnesium?
VT associated with Torsades de Pointes Refractory VF VF with a history of alcoholism
31
Indications for magnesium
Cardiac arrest if torsades de pointes or suspected hypomagnesemia is present Life-threatening ventricular arrhythmias due to digitalis toxicity (acls 172)
32
Dosing of magnesium for cardiac arrest due to hypomagnesemia or torsades de pointes
1 to 2 g (2 to 4mL of a 50% soln diluted in 10mL [D5W, normal saline] given IV/IO (acls 172)
33
Primary assessment acls
airway/breathing/circulation/disability/exposure
34
Secondary assessment acls
Employ SAMPLE in the H/T search for underlying causes
35
SAMPLE
``` Signs/symptoms Allergies Medications (including last dose taken) Past medical history (esp related to current illness) Events leading up to current illness ```
36
Hs
``` Hypovolemia Hypoxemia Hypothermia Hypo/hyper kalmia Hydrogen ion (acidosis) ```
37
Ts
``` Tamponade (pulmonary) Tamponade (cardiac) Thrombosis (pulmonary) Thrombosis (cardiac) Toxins ```
38
ACS Algorithm: Initial 10-minute ED assessment
* 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
ACS Algorithm: Immediate ED general treatment
* 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
Fibrinolytic therapy for acute stroke is available under what time contraints?
Within three hours of symptom onset. | Within one hour of hospital arrival.
41
For STEMI patients, what is the standard for door-to-balloon inflation time for percutaneous coronary intervention?
90 minutes
42
What test should be performed for patient suspected of stroke within 25 minutes of hospital arrival?
Noncontrast CT scan
43
Amiodarone dosing for life-threatening arrhythmias
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
Therapy for symptomatic bradycardia when atropine is not effective.
``` * Transcutaneous pacing or * Dopamine infusion or * Epinephrine infusion ```
45
At what heart rate threshold is a patient likely to have a tachyarrhythmia?
150 bpm.
46
Take what initial measures upon discovery of tachycardia?
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
Persistent tachyarrhythmia: questions for assessment
* Hypotension? * Acutely altered mental status? * Signs of shock? * Ischemic chest discomfort? * Acute heart failure?
48
Unstable tachyarrhythmia: treatment
Synchronized cardioversion * Consider sedation * If regular narrow complex, consider adenosine
49
Stable narrow complex QRS tachyarrthymia: Actions
* IV access and 12-lead ECG, if available * Consider adenosine only if regular and monomorphic * Consider antiarhythmic infusion * Consider expert consultation
50
Stable wide-complex QRS tachyarrythmia: Actions
* IV access and 12-lead ECG, if available * Vagal maneuvers * Adenosine (if regular) * B-blocker or calcium channel blocker * Consider expert consultation
51
What antiarrhythmic infusions are suggested for stable wide-QRS tachycardia?
Procainamide Amiodarone Sotalol (acls algorithm 133)
52
Procainamide IV dosing for stable wide-complex tachycadia.
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
Amiodarone IV dosing for stable wide-complex tachycardia
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
Sotalol IV dosing for stable wide-complex tachycardia
``` 100 mg (1.5 mg/kg) over 5 minutes. Avoid if prolonged QT. (acls algorithm 133) ```
55
Dopamine dosing
Usual infusion rate is 2-20 mcg/kg per minute. | Titrate to patient response; taper slowly. (acls 171)
56
Dosing of epinephrine for ETT
2-2.5mg diluted in 10mL NS
57
Dosing of epinephrine for continuous infusion
0.1-0.5 mcg/kg per minute (for 70-kg patient: 7-35 mcg/min) titrate to response
58
Dosing of epinephrine for profound bradycardia or hypotension
2-10 mcg per minute infusion; titrate to patient response
59
Biphasic shock dose for defibrillation
``` Manufacturer recommendation (eg 120-200J); if unknown, use maximum available. Second and subsequent doses should be equivalent, and higher doses should be considered. ```
60
Monophasic shock dose for defibrillation
360 J
61
If patient has a-line, what diastolic pressure is marker of poor CPR?
<20 mmHg
62
How often is epinephrine given in cardiac arrest?
3-5 minutes
63
What heart rate generally indicates bradyarrhythmia?
<50/min
64
What algorithm questions determine stability of bradycardia?
``` Hypotension? Acutely altered mental status? Signs of shock? Ischemic chest discomfort? Acute heart failure? ```
65
What does one seek for symptomatic bradycardia if atropine, transcutaneous pacing and dopamine/epinephrine fail?
Expert consultation | Transvenous pacing
66
At what heart rate typically a tachyarrhythmia?
>=150/min
67
First moves when confronted with tachycardia with a pulse?
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
If tachyarrhythmia persists, what are the assessment questions?
``` Hypotension? Acutely altered mental status? Signs of shock? Ischemic chest discomfort? Acute heart failure? ```
69
Actions for unstable tachyarrhythmia.
Synchronized cardioversion * Consider sedation * If regular narrow complex, consider adenosine
70
How is wide QRS defined?
>=0.12 second
71
Actions for stable wide QRS?
IV access and 12-lead ECG if available Consider adenosine only if regular and monomorphic Consider antiarrhythmic infusion Consider expert consultation
72
Actions for stable narrow QRS?
``` IV access and 12-lead ECG if available Vagal maneuvers Adenosine (if regular) B-blocker or calcium channel blocker Consider expert consultation ```
73
Contraindications for adenosine
Atrial fibrillation Atrial flutter VT (acls 170)
74
When is atropine unlikely to be effective?
Type 2 Second-degree heart block Type 3 AV heart block Block in nonnodal tissues Routine use in PEA or asystole (acls 171)
75
When is an exceptional dose of atropine called for?
In organophosphate poisoning, extremely large doses (2 to 4 mg or higher) may be needed (acls 171)

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