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Methods of Anesthesia > ACLS > Flashcards

ACLS Flashcards

1
Q

Average survival rate for IHCA (in hospital cardiac arrest)

A

24%

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2
Q

Causes for more than half IHCAs

A

Respiratory failure or hypovolemic shock

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3
Q

Most common cause of out of hospital cardiac arrest

A

Ischemia coronary artery disease

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4
Q

Possible first indicators of cardiac arrest in adult patients

A

Generalized seizures

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5
Q

ROSC occurs when an arrested patient comes out of cardiac arrest and displays one of the following

A
  1. Pulse & adequate blood pressure
  2. Abrupt increase in EtCO2 (>40 mmHg)
  3. Spontaneous arterial blood pressure waves with intra-arterial monitoring
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6
Q

When do most deaths occur after ROSC?

A

Within 24 hours

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7
Q

What should you do when you notice agonal breathing?

A

Start CPR

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8
Q

Do agonal breaths provide adequate oxygenation?

A

No

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9
Q

Slow, complex rhythms immediately preceding asystole

A

Agonal rhythms

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10
Q

Normal capillary refill time

A

<2 seconds

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11
Q

Prolonged capillary refill time

A

> 5 seconds

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12
Q

Common causes of prolonged capillary refill time

A
  1. Dehydration
  2. Shock
  3. Hypothermia
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13
Q

The proportion of time spent performing chest compressions in a cardiac arrest

A

Chest compression fraction

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14
Q

Ideal chest compression fraction

A

at least 60% and ideally occupy >80% of resuscitation attempt

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15
Q

1st 28 days of life

A

Neonate

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16
Q

1 month-1 year of age

A

Infant

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17
Q

1 year to onset of puberty

A

Child

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18
Q

Puberty or older

A

Adult

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19
Q

Person who does not have specialized or professional knowledge of a subject

A

Lay person or lay provider

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20
Q

Description of respiratory distress

A
  1. Increased respiratory rate and effort, but able to move air
  2. Potential abnormal airway sounds and pallor
  3. Tachycardia and anxiety
  4. Pt improves with initial therapy
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21
Q

Description of respiratory failure

A
  1. Labored breathing accompanied by signs of shock (cyanosis, lethargy, bradycardia)
  2. Requires intervention/assistance
  3. May not respond to initial breathing treatments & interventions
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22
Q

Definition of stable

A
  1. Normal BP
  2. Signs of good perfusion
  3. Awake/alert
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23
Q

Definition of unstable

A
  1. Hypotension
  2. Signs of poor perfusion
  3. Altered or depressed consciousness, or the pt is sick
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24
Q

Process of deciding which patients should be treated first, where they should go based on how sick or seriously injured they are

A

Triage!!!!

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25
Q

Teams roles (6)

A
  1. Team leader
  2. Compressor (1st priority)
  3. AED/monitor/defibrillator (2nd priority)
  4. Airway (3rd priority)
  5. IV/IO/meds
  6. Timer/recorder
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26
Q

Purpose of code team

A

Respond AFTER an arrest has occured

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27
Q

Purpose of rapid response team

A

Identify and treat early clinical deterioration BEFORE the arrest

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28
Q

Team dynamics (8)

A
  1. Have clear roles
  2. Know your limits
  3. Have constructive interference
  4. Share knowledge
  5. Summarize and reevaluate
  6. Have closed loop communication
  7. Give clear messages
  8. Have mutual respect
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29
Q

Systems of care

A
  1. Community- lay providers
  2. Out of hospital- EMS
  3. In hospital - Code teams, rapid response, critical care, stroke
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30
Q

Description of OHCA

A
  1. Lay providers witness the arrest and activate EMS
  2. CPR is started
  3. Defibrillation is performed as soon as an AED is available
  4. EMS arrives, resuscitates and transports
  5. ACLS and post arrest care
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31
Q

IHCA description

A
  1. Hospital providers monitor and prevent arrest
  2. If an arrest is witnessed, EMS is activated
  3. CPR is started
  4. Defib is performed as soon as an AED is available
  5. ACLS and post arrest care
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32
Q

ABCDEs of ACLS

A 
Airway
Breathing
Circulation
Disability
Exposure
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33
Q

Airway suction pressure

A

-80-120 mmHg

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34
Q

Suction attempts

A
  • No more than 10 seconds
  • Limited to less than 10 at a time
  • Follow attempts with a short period of 100% O2 administration
  • Squirt 1-2 ml NS before suctioning thick material
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35
Q

Suction catheter appropriate for thin secretions

A

Soft suction for tracheal

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36
Q

Suction catheter for thick secretions

A

Rigid suction catheter

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37
Q

How do you open the airway for trauma patients?

A

With a jaw thrust, unless that does not work, then chin lift

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38
Q

C spine restrictions for trauma patients

A

Manual spinal motion restriction rather than cervical collars bc cervical collars complicate airway management

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39
Q

Management for severe choking in responsive adults

A

-Perform the Heimlich maneuver

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40
Q

Management for severe choking in responsive children

A

Heimlich maneuver or abdominal thrusts below xyphoid process

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41
Q

Management for severe choking in responsive infants

A
  1. Place pt prone in one arm and deliver 5 back slaps
  2. Flip the pt supine in other arm and deliver 5 downward chest thrusts with two fingers
  3. Continue until obstruction is relieved or pt loses consciousness
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42
Q

Severe choking management in unresponsive patients

A

Immediately start CPR and look for object in mouth each time you deliver breaths

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43
Q

What do you do after an airway obstruction is relieved?

A

Place the patient in recovery position

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44
Q

Most important factor to influence survival in drowning

A

Immediate, high quality CPR

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45
Q

Airway management for foreign body airway obstruction

A
  1. The pt needs to stay calm
  2. Pt should remain spontaneously breathing if possible
  3. Use mask induction or cautious IV induction with maintenance of spontaneous ventilation
  4. Anesthetize the pharynx and vocal cords
  5. Maintenance with propofol-remifentanil based TIVA with maintenance of spontaneous ventilation
  6. Use of jet ventilation and/or oxygen insufflation through the bronchoscope may help prevent hypoxia
  7. Steroids can be used
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46
Q

When CPR is not being administered, oxygen should be administered and titrated to an SpO2 of

A
  1. 94-99% for all non-ACS cases

2. >90% for ACS syndrome cases

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47
Q

Oxygen administration during CPR

A

100%

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48
Q

Mouth to mouth breathing in adults

A
  1. Pinch nose
  2. Perform head tilt chin lift
    or use pocket mask
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49
Q

Pt’s FiO2 from mouth to mouth ventilation

A

17% oxygen and 4% CO2

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50
Q

Mouth to mouth in infants/neonates/children

A

Mouth over victim’s mouth and nose or use peds pocket mask

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51
Q

When is bag mask ventilation used?

A

With 2 rescuer ventilation

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52
Q

When is mouth to mouth used?

A

With single rescuer ventilation

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53
Q

Correct hand placement for bag mask according to ACLS test

A

E-C technique (not C-E)

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54
Q

Provides more effective ventilation and more accurate EtCO2 in cardiac arrest

A

Intubation

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55
Q

Disadvantages to excessive ventilation

A
  1. Creates gastric inflation
  2. Decreases venous return and cardiac output
  3. Decreases cerebral blood flow
  4. Lowers survival
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56
Q

Best way to avoid excessive ventilation

A

Give a breath when chest rise is observed

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57
Q

Goal tidal volume for adults during arrest

A

500-600 mL

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58
Q

Preferred method for confirming effective ventilation and correct endotracheal tube placement

A

Continuous waveform

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59
Q

What color of the colorimetric capnography indicates EtCO2

A

Yellow

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60
Q

If compressions are required, what breathing rate is suggested

A

Lower, 10 breaths/min or 1 breath every 6 seconds

-Improves venous return

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61
Q

If compressions are not required, what breathing rate is suggested

A

10-12 breaths/min or 1 breath every 5-6 seconds

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62
Q

Breathing rate in intubated patients

A

10 breaths/min

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63
Q

Breathing rate in mask ventilated patients

A

10-12 breaths/min

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64
Q

Breathing protocol

A
  1. R- Check responsiveness
  2. A-Activate EMS/call
  3. C-Circulation; check pulse and breathing
  4. If not breathing, but still a pulse, give 10-12 rescue breaths per minute
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65
Q

Vascular access priority

A
  1. IV
  2. IO if IV not possible
  3. ETT if IO and IV are not possible
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66
Q

Best IO access

A

Anterior tibia

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67
Q

How do you administer drugs via the ETT?

A
  1. Inject the drug
  2. Follow w/5-10 ml NS
  3. Provide 5 rapid positive pressure ventilations
  4. Stop compressions to prevent regurgitations
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68
Q

ETT epi dose in adults

A

2-3 times the IV dose

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69
Q

ETT epi dose in children

A

10x the IV dose

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70
Q

ETT epi dose in neonates

A

same as IV dose

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71
Q

Problems with lower concentration of epi via ETT

A

May produce beta 2 effects which can cause hypotension and decrease chances of ROSC

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72
Q

Drugs that can be given via ETT in adults

A 
NAVEL
Narcan
Atropine
Vasopressin
Epi
Lidocaine
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73
Q

Drugs that can be delivered via ETT in pediatrics

A 
LEAN
Lidocaine
Epinephrine
Atropine
Narcan
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74
Q

If there is no pulse, or you are unsure of whether or not there is a pulse after checking for 10 seconds, what should you do?

A

Begin compressions

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75
Q

If there is no breathing but there is a pulse, what should you do?

A

Give 10-12 rescue breaths per minute (1 breath every 5-6 seconds, each breath over 1 second)

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76
Q

Where do you look for a pulse in adults and children >1 year old?

A

Carotid or femoral pulse

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77
Q

Where do you look for a pulse in children <1 year old

A

Brachial pulse

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78
Q

How long are pulse checks?

A

Less than 10 seconds

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79
Q

What should you do if you are not sure if a pulse exists?

A

Do not delay chest compressions

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80
Q

Indications for compressions in adults

A

If there is no pulse

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81
Q

Indications for compressions in children

A

If the HR is less than 60 bpm

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82
Q

Indications for compressions in older children

A

If the HR is less than 40 bpm

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83
Q

Rate for compressions

A

100-120 per minute

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84
Q

How many compressions does it take before getting good blood flow?

A

20-25

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85
Q

Chest compression technique

A
  1. Use a hard, flat surface
  2. Press down on lower half of the breastbone
  3. Push to an adequate depth
  4. Allow complete chest recoil
  5. Switch providers every 2 minutes (or 5 cycles)
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86
Q

What is an adequate chest compression depth for adults and adolescents?

A

2-2.4 inches

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87
Q

What is an adequate chest compression depth for children?

A

2 inches

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88
Q

What is an adequate chest compression depth for infants?

A

1/3 to 1/2 depth of chest, or 1.5 inches

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89
Q

High quality CPR Pneumonic

A

Chest recoil
Push hard, push fast
Rotate rescuers

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90
Q

CPR technique used for adults and adolescents

A

2 handed technique

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91
Q

CPR technique used for 1-8 year old children

A

One handed or 2 handed

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92
Q

CPR technique indicated for infants when only one responder is available

A

2 finger technique

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93
Q

CPR technique indicated for infants when 2 responders are available

A

Thumb encircling technique

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94
Q

CPR on mask ventilated patients

A
  1. Compressions are interrupted when performing breaths

2. CPR is performed in 5 cycles (or over a 2 minute period)

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95
Q

CPR cycle for mask ventilated adults

A

30 compressions and 2 breaths

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96
Q

CPR cycle for mask ventilated infants with 1 provider

A

30:2

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97
Q

CPR cycle for mask ventilated infants with 2 providers

A

15:2 bc kids require faster respiratory rates

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98
Q

CPR cycle for mask ventilated neonates for a respiratory arrest

A

3:1

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99
Q

CPR cycle for mask ventilated neonates for cardiac arrest

A

15:2

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100
Q

CPR in intubated patients

A
  1. Chest compressions are NOT interrupted during breaths

2. CPR is performed in 2 minute increments (not in cycles)

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101
Q

CPR in intubated adults

A

Compression rate is 100-120 /min

breathing rate is 10 breaths/min

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102
Q

CPR in intubated kids

A

100-120 compressions/min

Faster breathing rate

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103
Q

Goals for chest compressions

A
  1. EtCO2 of at least 20 mmHg
  2. Diastolic BP on an arterial line of at least 20 mmHg
  3. Coronary perfusion pressure of at least 10 mmHg
  4. Mixed venous SaO2 of at least 30%
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104
Q

Chest compressions take priority over everything except:

A
  1. Calling for help

2. Defibrillating when pads are on and ready to go

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105
Q

What are continuous chest compressions?

A
  • Done by EMS
  • 3 periods of 200 compressions each
  • Passive oxygen insufflation
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106
Q

When is CPR stopped/withheld

A
  1. DNR requests
  2. Threat to the safety of rescuers
  3. Rigor mortis
  4. Lividity
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107
Q

CPR protocol when using a defibrillator

A
  1. Check the pulse
  2. Perform CPR until an AED arrives
  3. Defibrillate ASAP
  4. Resume 2 minutes of CPR before re-analyzing the rhythm
  5. Re-analyze rhythm and check the pulse
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108
Q

When are IV/IO meds given with defibrillation?

A

Immediately before or immediately after shock delivery

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109
Q

4 ways neurologic function is assessed

A
  1. Checking the patient’s blood sugar
  2. Pupil response to light
  3. AVPU pediatric response scale
  4. GCS (Glasgow Coma Scale)
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110
Q

What is assessed when examining the pupils with light?

A
  1. Pupil size (in mm)
  2. Equality of pupil size
  3. Constriction in response to light
    PERRL
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111
Q

What is the AVPU scale?

A

Alert
Responsive to Voice
Responsive to Pain
Unresponsive

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112
Q

What is measured with the GCS?

A

Eye opening
Verbal
Motor

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113
Q

When is intubation indicated with the GCS?

A

When it is less than or equal to 8

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114
Q

What happens in the exposure step of ACLS?

A

The providers does a quick physical exam to assess for signs of trauma, bleeding, burns, unusual markings, or medical alert bracelets

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115
Q

What can an AED do?

A
  1. Sense and analyze vfib/vtach

2. Can defibrillate

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116
Q

Limitations of the AED

A
  1. Does not produce an ECG rhythm strip/cannot sense other arrhythmias outside of vfib/vtach
  2. Cannot pace
  3. Cannot perform synchronized cardioversion
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117
Q

When should a shock be delivered when the AED advises? (time frame)

A

Within 10 seconds

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118
Q

What is the difference between semi-automated and fully automated AEDs?

A

Semi-automated only ADVISES a shock, the provider must push the button
Fully automated shocks for you if indicated

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119
Q

AED protocol

A
  1. Power on the AED
  2. Attach the electrode pads
  3. Clear the victim
  4. Analyze the rhythm
  5. Charge and shock if advised
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120
Q

What can a manual defibrillator do?

A

Same as AED, analyze and shock, but also show ECG rhythm strip, perform synchronized cardioversion, and perform transcutaneous pacing

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121
Q

How long should the entire clear and shock process take with a manual defibrillator?

A

<5 seconds

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122
Q

Reason most defibrillators are biphasic

A

They allow the maximum efficiency delivered with the smallest possible amount of energy

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123
Q

Means the shock will be delivered during the R wave

A

Synchronized cardioversion

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124
Q

What happens if the shock is delivered during the T wave?

A

It could cause an “R on T phenomenon,” which could precipitate vtach or vfib

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125
Q

Indications for synchronized cardioversion

A
  1. Unstable SVTs (SVT, afib, aflutter)

2. Unstable monomorphic vtach with a pulse

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126
Q

How to perform a synchronized cardioversion

A
  1. Place pads in a posterior, left anterior fashion
  2. Turn knob to defib
  3. Press sync prior to each shock attempts
  4. Select energy to be delivered (75-120J)
  5. Hit the charge button
  6. Hit the shock button
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127
Q

If you are synchronized cardioverting an atrial rhythm, where does the anterior pad go?

A

On the R chest

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128
Q

If you are synchronized cardioverting a ventricular rhythm, where does the anterior pad go?

A

On the L chest

129
Q

Energy to be delivered during synchronized cardioversion

A

75-120 J

130
Q

Delivery of a shock at the precise moment the shock button is pressed

A

Defibrillation

131
Q

When is defibrillation indicated?

A

For all ventricular rhythms that are pulseless and/or irregular (vfib, pulseless vtach, torsades de pointes)

132
Q

When is defibrillation NOT indicated?

A
  1. SVT
  2. Asystole
  3. PEA
133
Q

How to perform defibrillation

A
  1. Place pads in either a posterior-anterior or anterior-anterior fashion
  2. Turn knob to defib
  3. Select the amount of energy to be delivered (200J)
  4. Charge
  5. Shock
134
Q

Amount of energy delivered with defibrillation in adults (biphasic)

A

120-200J

use manufacturer’s recommended first dose, or maximum dose on machine

135
Q

Amount of energy delivered with defibrillation in pediatrics

A

1st dose 2J/kg
2nd dose 4J/kg
Up to 10J/kg

136
Q

Amount of energy delivered with synchronized cardioversion irregular SVT (afib)

A

120-200 J biphasic

137
Q

Amount of energy delivered with synchronized cardioversion regular SVT

A

50-100 J

138
Q

Amount of energy delivered with synchronized cardioversion monomorphic vtach

A

100 J

139
Q

Amount of energy used with transcutaneous pacing capture

A

40-80 mA

140
Q

How does pacing work?

A

Pads deliver energy to the heart that causes the heart to depolarize and contract, taking over the job of the SA node

141
Q

Indications for transcutaneous pacing

A

Severe bradycardia that is unresponsive to drug therapy (atropine or epi)

142
Q

How to perform transcutaneous pacing

A
  1. Place pads on patient, posterior, left anterior
  2. Turn knob to pacer
  3. Select HR you want to pace with
  4. Turn current up until you observe capture
  5. Set maintenance threshold 10% above pacing threshold
143
Q

Disadvantages of transcutaneous pacing

A
  1. It only shows a ventricular EKG waveform
  2. Does not produce effective capture as transvenous pacing
  3. Causes muscle jerking, which may mimic a carotid pulse
  4. It is painful, pt needs sedation if stable enough
144
Q

The current at which “capture” is observed

A

Pacing (stimulation) threshold, usually occurs between 40-80 mA

145
Q

What is capture?

A

When the heart starts beating

146
Q

Current at which the pacemaker should be maintained, 10% above stimulation threshold

A

Maintenance threshold

147
Q

Where is the anterior-anterior pad placement?

A
  1. Upper R chest above nipple

2. L anterior or mid axillary line of 5th intercostal space

148
Q

Posterior, left anterior pad placement

A
  1. Posterior under L scapula

2. Anterior to the L of the sternum under L breast

149
Q

Posterior, R anterior pad placement

A
  1. Posterior under L scapula

2. Anterior to the R of sternum above R breast

150
Q

Most common and recommended placement for AED pads

A

Anterior-anterior

151
Q

Less common placement for AED pads

A

Posterior, left anterior

152
Q

Recommended pad placement for transcutaneous pacing

A

Posterior, left anterior

153
Q

Less common pad placement for transcutaneous pacing

A

Anterior-anterior

154
Q

Preferred pad placement for defibrillation and cardioversion of vtach

A

Posterior, left anterior

155
Q

Less common pad placement for defibrillation and cardioversion of vtach

A

Anterior-anterior

156
Q

Recommended pad placement for cardioversion of atrial rhythms

A

Posterior, R anterior

157
Q

Less common pad placement for cardioversion of atrial rhythms

A

Anterior-anterior

158
Q

Most common and recommended paddle placement on adults

A

Anterior-anterior

159
Q

Less common paddle placement on adults

A

Posterior, L anterior

160
Q

Recommended paddle placement for infants

A

Anterior-anterior

161
Q

Recommended paddle placement for small children

A

Anterior-anterior or anterior-posterior

162
Q

Purpose of conducting gel between paddles and pt’s chest

A

Reduces transthoracic impedance

163
Q

What age range are pediatric AED pads used on?

A

Children 1-8 years old

164
Q

What should you remember with pediatric AED pads?

A

They should not touch each other

165
Q

True/false. You can place the defib pads directly on top of any medication patch, pacemaker, or implantable cardioverter defibrillator

A

False

166
Q

True/false. It is safe and reasonable to perform multiple defibrillation attempts in hypothermic patients

A

True, although intervals between shocks may need to be longer

167
Q

True/false. Oxygen can blow across the chest during defibrillation

A

False

168
Q

True/false. The defibrillator still works if the patient is covered in water or sweat

A

False. Water conducts the shock across the skin of the chest and prevents adequate shock

169
Q

True/false. Defibrillator pads should not touch each other

A

True

170
Q

True/false. Pads should be placed flat on the skin and at least 2 inches apart to reduce the risk of current arcing

A

True

171
Q

True/false. Paddles carry a lower risk of current arcing than pads

A

False

172
Q

True/false. Pads provide a more rapid defibrillation

A

True, they are already connected in case the need for a shock arises

173
Q

Time from arrival to first shock

A

<90 seconds

174
Q

When should medications be given?

A

During compressions, immediately before or after shock delivery

175
Q

What should a lone rescuer do when encountering a hypoxic arrest?

A

Provide 2 minutes of CPR BEFORE activating EMS

176
Q

What should a lone rescuer do if they witness a sudden collapse?

A

Call for help or leave pt to get AED BEFORE initiating chest compressions

177
Q

What should a lone rescuer do if they do NOT witness a sudden collapse?

A

Perform 2 minutes of CPR BEFORE calling for help

178
Q

Possible airway/breathing interventions in ACLS (7)

A
  1. Check breath sounds, airway patency (& pulse)
  2. Open airway with jaw thrusts, chin lift or oral/nasal airways
  3. Provide rescue breaths and/or assist ventilation
  4. Supplementary oxygen
  5. Auscultate breath sounds
  6. Suction the airway
    7 Avoid excessive ventilation
179
Q

Possible circulation interventions in ACLS

A
  1. Start an IV and administer drugs
  2. Place monitors on the patient (ECG, BP)
  3. Perform CPR on unconscious patients
  4. Use an AED or manual defibrillator
180
Q

Initial ABCDEs in ACLS if the patient is unconscious/unresponsive

A
  1. Check for a pulse and breath sounds
  2. Call for help, start CPR and get defibrillator if there is no pulse
  3. Provide rescue breaths, place monitors if there is a pulse but the pt is not breathing
181
Q

Initial ABCDEs in ACLS if the patient is conscious/responsive

A
  1. Place monitors on the patient
  2. Start IV
  3. Place oxygen
182
Q

For unconscious/unresponsive patients, both ACLS and PALS recommend that the ABC steps be done in what order?

A

C-A-B

check pulse and start compressions before checking breathing/rescue breaths

183
Q

What should you do before approaching a patient in an ACLS scenario?

A
  1. Use universal precautions (gloves)

2. Make sure the scene is safe

184
Q

What is the first thing an ACLS provider should do when approaching a patient?

A

Check the level of responsiveness to see if they are conscious or not

185
Q

What should you do if a patient is not responsive and the pulse cannot be palpated?

A

Start CPR

186
Q

What should you do if a patient is not responsive, the pulse can be palpated, but the pt is not breathing?

A

Administer rescue breaths

187
Q

What is the BLS assessment?

A

In unconscious patients, RACD

  • Responsiveness
  • Activate EMS and get -AED (before CPR)
  • Check circulation and breathing simultaneously
  • Defibrillation
188
Q

How should you approach a conscious/responsive patient in ACLS?

A
  1. Place monitors (C)
  2. IV (C)
  3. O2 (A/B)
189
Q

What is the primary assessment in ACLS?

A

For conscious patients

  1. Monitors, IV, oxygen
  2. Diagnosing and intervening to treat the patient
  3. Performing D & E after initial intervention
190
Q

What is secondary assessment in ACLS?

A

SAMPLE, H’s and T’s

191
Q

What does SAMPLE stand for in ACLS?

A 
Signs and symptoms
Allergies
Medications
PMHx
Last meal consumed
Events
192
Q

What are the 7 H’s of pulseless arrest?

A
  1. Hypovolemia
  2. Hypoxia
  3. Hypothermia
  4. Hypoglycemia
  5. Hypokalemia
  6. Hyperkalemia
  7. Acidosis
193
Q

What are the 5 T’s of pulseless arrest?

A
  1. Tamponade
  2. Thrombosis
  3. Tension PNX
  4. Trauma
  5. Toxins
194
Q

Treatment for tension PNX

A
  1. Needle decompression at 2nd intercostal space/mid clavicular line
  2. Chest tube second (6th intercostal space/midaxillary line)
195
Q

What are the symptoms of post-cardiac arrest syndrome?

A
  1. Post arrest brain injury
  2. Post arrest myocardial dysfunction
  3. Systemic ischemia
  4. Reperfusion response
  5. Pathology that might have precipitated the cardiac arrest
196
Q

4 goals of post resuscitation care

A
  1. Optimize ventilation and hemodynamic status (BP)
  2. Initiate targeted temperature management
  3. Immediate coronary reperfusion with PCI
  4. Neurologic care and prognostication and other structured interventions
197
Q

The only intervention demonstrated to improve neurologic recovery

A

Targeted temperature management

198
Q

The first priority in someone who achieves ROSC

A

Oxygenation and ventilation

199
Q

When is targeted temperature management indicated?

A

To any patient who is comatose and unresponsive to verbal commands after ROSC

200
Q

Goal temperature for comatose patients

A

32-36 C for at least 24 hours

201
Q

For pts not treated with TTM, the earliest time for neurologic assessment is

A

72 hours after cardiac arrest (or longer if sedatives were used)

202
Q

For pts treated with TTM, wait ___ before assessing neurologic status

A

72 hours after return to normothermia

203
Q

Methods of initiating TTM

A
  1. Rapid infusion of ice cold, isotonic, non-glucose containing fluid (30mL/kg)
  2. Surface cooling devices
  3. Ice bags
204
Q

How do you keep SpO2 > 94% post resuscitation?

A

Titrate the FiO2 to the lowest level

205
Q

EtCO2 and PaCO2 goals post resusciation

A

Ventilation should be started at 10 breaths per minute to achieve an EtCO2 of 35-40 mmHg and PaCO2 of 40-45 mmHg

206
Q

EKG post resuscitation guidelines

A

12 lead ASAP

Consider reperfusion therapy if STEMI or AMI is suspected

207
Q

Blood pressure goals post resuscitation

A

MAP >65 mmHg

Systolic >90 mmHg

208
Q

Temperature control goals post resuscitation

A

32-36 C for 24 hours should be considered only for unconscious patients

209
Q

Prophylactic Antiarrhythmic therapy after ROSC

A
  1. Consider beta blockers

2. Consider lidocaine

210
Q

When to consider terminating resuscitation efforts

A
  1. Providers are unable to get EtCO2 >10 mmHg after 20 minutes of CPR in intubated patients
  2. A valid DNR is presented
  3. The resuscitation is taking place in dangerous environmental hazards
211
Q

When to consider prolonging resuscitation efforts (>20 minutes)

A
  1. If the cause of cardiac arrest is reversible

2. If return of spontaneous circulation occurred at any time during the resuscitation attempt

212
Q

Protocol for defib and drug dosing in severe hypothermic patients

A

<30 C

  • Perform a single defib attempt
  • subsequent defib attempts and drug therapy should be delayed until temperature is >30C
213
Q

Protocol for defib and drug dosing in mildly hypothermic patients

A

<34 C

-Provider can defib as normal, but should wait longer intervals between drug doses

214
Q

The most rapid and effective technique for rewarming severely hypothermic patients

A

Extracorporeal circulation

215
Q

“What to say once a patient achieves ROSC”

A
  1. Order a 12-lead EKG
  2. Consider hypothermia
  3. Maintain normal BP
  4. Get frequent lab work
  5. Maintain SpO2 of 94-99%
  6. Consider intubation and maintain EtCO2 of 25-40 mmHg
  7. Consider lidocaine or beta blockers
216
Q

Bradycardia therapies

A
  1. Atropine (0.5mg, repeated every 3-5 min)
  2. Epinephrine 2-10 mcg/min
  3. Dopamine 2-20 mcg/kg/min
217
Q

Adenosine dose

A

Initial 6mg bolus, NS flush

up to 2 additional doses of 12 mg

218
Q

Beta blocker that slows conduction/increases refractoriness in the AV node

A

Sotalol

219
Q

Sotalol dose

A

100 mg, or 1.5 mg/kg

220
Q

When should sotalol be avoided?

A

In patients with prolonged QT syndrome

221
Q

Dose of epi in cardiac arrest

A

1mg every 3-5 minutes

222
Q

Indications for amiodarone

A

For patients with monomorphic vtach (w/ or w/out a pulse) and/or vfib

223
Q

When is amiodarone contraindicated?

A

In patients with prolonged QT intervals

224
Q

First-line antiarrhythmic agent for shockable rhythms refractory to CPR, defibrillation and vasopressor therapy based on short term survival advantages

A

Amiodarone

225
Q

Amiodarone dose for a patient with monomorphic vtach that is awake or still has a pulse

A

150mg over 10 minutes (repeat as needed)

226
Q

Amiodarone dose for a patient in vfib/pulseless vtach

A

300mg bolus for the first dose, 150 mg for the second dose

227
Q

Amiodarone dose for a post-resuscitation infusion

A

1 mg/min for 1st 6 hours and 0.5 mg/min for the next 18 hours
-Loading dose of 150 mg is given if not given during arrest

228
Q

When is procainamide indicated?

A

Vfib or monomorphic vtach

229
Q

Dose of procainamide

A
  • 20-50 mg/min until the arrhythmia is gone, hypotension ensues or QRS duration decreases 50%
  • Maintenance infusion 1-4 mg/min
  • max dose 27 mg/kg
230
Q

When is procainamide contraindicated?

A

With prolonged QT syndrome or CHF

231
Q

When are amiodarone and procainamide used in ACLS?

A

Only with vfib/vtach

232
Q

When are amiodarone and procainamide used in the real world?

A

SVT, Afib/atrial flutter, vfib/vtach

233
Q

When is magnesium indicated in ACLS?

A

For polymorphic vtach

234
Q

Dose of magnesium

A

1-2g

235
Q

ACLS approach to respiratory arrest

A
  1. Check responsiveness
  2. Call for help
  3. Check pulse and breathing
236
Q

If pt is in respiratory arrest and has a pulse, but agonal breathing, what should you do?

A

Give 2 rescue breaths and 10-12 breaths/min

237
Q

If a patient is in respiratory arrest and has no pulse, what should you do?

A

Begin 5 cycles of CPR

238
Q

What to do if a patient is unresponsive

A

Check pulse, activate EMS and start CPR

239
Q

What to do if a patient is responsive

A

Start primary assessment by verbalizing “monitors, IV, oxygen”

240
Q

Steps to follow in each ACLS scenario

A
  1. Check responsiveness and start initial therapy
  2. Perform an initial diagnosis based on what the monitors say
  3. Intervene again
  4. Perform secondary and diagnostic assessments while initial intervention is going on
  5. Intervene again
  6. Frequently reassess the patient and continue to intervene
241
Q

Respiratory arrest protocol

A
  1. Check responsiveness
  2. Activate EMS/call for help
  3. Circulation; check pulse and breathing
  4. Give 10-12 rescue breaths per min (1 breath every 5-6 seconds)
  5. Re-check the pulse every 2 minutes
  6. Consider narcan
242
Q

Dose of Narcan

A

0.4 mg IM and intranasal dose 2mg

may be repeated every 4 minutes

243
Q

Rhythms that fall under bradycardia algorithm

A
  1. Sinus bradycardia
  2. Mobitz Type I and II block
  3. Complete 3rd degree heart block
  4. Afib with slow ventricular response
  5. Ventricular or junction escape rhythm
244
Q

Bradycardia therapies

A
  1. Drugs (epi for peds, atropine, dopamine)
  2. Transcutaneous pacing
  3. Transvenous pacing
245
Q

Protocol for stable bradycardia

A
  1. Atropine
  2. Monitor and observe
  3. SAMPLE
246
Q

Protocol for unstable bradycardia

A
  1. Monitors, IV and Oxygen
  2. Atropine
  3. Transcutaneous pacing, epi, dopamine
  4. SAMPLE
  5. Consult or transvenous pacing
247
Q

Narrow, complex tachycardia

A

Supraventricular

248
Q

Wide complex tachycardia

A

Ventricular

249
Q

When tachycardia usually causes symptoms

A

when HR >150 bpm

250
Q

The big difference between SVT and afib/a flutter

A

the AV node is USUALLY part of the SVT reentry circuit, but is not part of the afib/a flutter ectopic pathways

251
Q

Treatment for obvious, stable SVT

A
  1. Monitors, IV and oxygen
  2. vagal maneuvers
  3. adenosine
  4. Beta blocker or CCB
  5. SAMPLE
  6. Consider expert consult
  7. Consider amiodarone or procainamide (not officially ACLS)
252
Q

Treatment for obvious , stable afib or atrial flutter

A
  1. Monitors, IV, oxygen
  2. Consider expert consult
  3. SAMPLE
253
Q

Treatment for unstable SVT

A
  1. Monitors, IV and oxygen
  2. Immediate synchronized cardioversion
  3. Consider adenosine, vagal maneuvers, CCB, B blockers
  4. SAMPLE
  5. Consider amiodarone or procainamide (not officially ACLS)
254
Q

Treatment for unstable afib/aflutter

A
  1. Monitors, IV, oxygen
  2. Immediate synchronized cardioverison
  3. SAMPLE
  4. While waiting for defibrillator, consider adenosine, vagal maneuvers or CCB
  5. Consider amiodarone/procainamide (not officially ACLS)
255
Q

Therapies for ventricular tachyarrhythmias

A
  1. Synchronized cardioversion or defibrillation
  2. Epi (if pulseless)
  3. Amiodarone
  4. Procainamide
  5. Lidocaine
  6. Magnesium (only torsades)
  7. Adenosine (used for diagnostics)
256
Q

Protocol for stable monomorphic vtach with a pulse

A
  1. Monitors, IV, oxygen
  2. Give antiarrhythmics
  3. Expert consult
  4. Synchronized cardioversion
  5. SAMPLE
257
Q

Protocol for unstable monomorphic vtach with a pulse

A
  1. Monitors, IV, oxygen
  2. Synchronized cardioversion
  3. SAMPLE
258
Q

Pulseless rhythms

A
  1. Vfib and sometimes vtach
  2. Monomorphic vtach sometimes
  3. Torsades de Pointes
  4. PEA
  5. Asystole
259
Q

Type of vfib with higher waves and more chance of conversion

A

Course vfib

260
Q

Type of vfib with smaller waves, appears after course vfib, less chance of conversion

A

Fine vfib

261
Q

Treatment for asystole

A

CPR, epi, treat reversible causes

262
Q

Treatment for PEA

A

CPR, epi, treat reversible causes

263
Q

Most common potentially reversible causes of PEA

A

Hypovolemia and hypoxia

264
Q

What rhythms is CPR used for?

A
  • Vfib/pulseless vtach
  • Polymorphic vtach
  • Asystole
  • PEA
265
Q

What rhythms is epi used for?

A
  • Vfib/pulseless vtach
  • Polymorphic vtach
  • Asystole
  • PEA
266
Q

What rhythms is defib used for?

A
  • Vfib/pulseless vtach

- Polymorphic vtach

267
Q

What rhythms is amiodarone used for?

A

–Vfib/pulseless vtach

268
Q

What rhythms is magnesium used for?

A

-Polymorphic vtach

269
Q

What rhythms is lidocaine used for?

A

-Vfib/pulseless vtach

270
Q

Most common initial rhythm in sudden cardiac arrest

A

Vfib

271
Q

The only effective treatment for pulseless vfib/vtach

A

Defibrillation

272
Q

Vfib and pulseless monomorphic vtach protocol

A
  1. Start CPR
  2. Defib ASAP
  3. Resume CPR
  4. Analyze
  5. Repeat
273
Q

vfib and pulseless monomorphic vtach protocol throughout CPR

A
  1. Give epi 1mg every 3-5 minutes
  2. Consider H&T’s of pulseless arrest
  3. Consider intubation, capnography and steroids
  4. Give amiodarone 300 mg if epi and defib are not effective after 3rd shock attempt
  5. Consider hypothermia if pt achieves ROSC
274
Q

Polymorphic vtach protocol

A
  1. Start CPR
  2. Defib
  3. Resume CPR
  4. Analyze rhythm & check pulse
  5. Repeat
275
Q

Polymorphic vtach protocol throughout CPR

A
  1. Give epi 1mg every 3-5 minutes
  2. Give magnesium 1-2 mg
  3. Consider H&T’s of pulseless arrest
  4. Consider intubation, capnography, and steroids
  5. Consider hypothermia if the patient achieves ROSC
276
Q

Asystole protocol

A
  1. CPR

2. Epi 1mg every 3-5 minutes

277
Q

Asystole protocol throughout CPR

A
  1. Consider 7 H’s and 5 T’s of pulseless arrest
  2. Consider intubation, capnography, & steroids
  3. Consider hypothermia if pt achieves ROSC
278
Q

The only way of identifying a STEMI

A

EKG

279
Q

Possible therapy for ACS in ACLS

A
  1. Oxygen, ASA, NTG, morphine
  2. Heparin
  3. Reperfusion therapy
280
Q

When is morphine indicated with ACS?

A

In STEMI patients who are unresponsive to nitrates

281
Q

When is oxygen therapy needed with ACS?

A

If the SpO2 < 90%

282
Q

ACLS dose of NTG

A

3 sublingual NTG tablets (0.4mg) every 3-5 min and may be repeated twice (total of 3 doses)

283
Q

When should NTG be avoided

A
  1. Hypotensive patients (SBP <90mmHg or 30 mmHg below baseline)
  2. Patients with inadequate preload (recent MI, vasodilator)
284
Q

ASA dose

A

160-325 mg PO

285
Q

When should rectal administration be considered for ASA, and what is the dose?

A

300mg if the pt has N/V, PUD or other upper GI disorders

286
Q

When should PCI be administered?

A

Within 90 minutes of arrival

287
Q

Treatment of choice in ACS patients

A

PCI

288
Q

When are fibrinolytics indicated?

A

For STEMI patients only, within 30 minutes of arrival

289
Q

Contraindications to fibrinolytics

A
  1. If ACS symptoms have been present for >12 hours
  2. NSTEMI
  3. Hypertension (>180-200 SBP or 100-110mmHg DBP)
  4. Recent head trauma or GI bleed
  5. Pts on blood thinners
  6. Pts with stroke symptoms present >3 hours
290
Q

When should you choose PCI over fibrinolytics?

A
  1. If you are confident that door to balloon time with be <90 minutes
  2. Fibrinolytics are contraindicated
  3. Symptoms have been present >12 hours
291
Q

When should you choose fibrinolytics over PCI?

A

If initiation of PCI would take longer than 90-120 minutes

292
Q

When should fibrinolytics be started

A

Within 30 minutes of hospital arrival

293
Q

STEMI treatment protocol

A
  1. Oxygen, ASA, NTG, morphine
  2. Reperfusion with PCI or fibrinolytics
  3. Heparin
  4. CABG
294
Q

NSTEMI treatment protocol

A
  1. Oxygen, NTG, ASA
  2. Reperfusion with PCI
  3. Heparin
  4. CABG
295
Q

ACS protocol for EMS

A
  1. Monitors, IV, oxygen
  2. Immediate ONA (maybe M)
  3. If STEMI present, notify hospital
  4. Consider prehospital fibrinolytics using checklist
296
Q

ACS protocol for in hospital

A
  1. Monitors, IV, oxygen
  2. Immediate MONA
  3. 12 lead EKG
  4. IV/labs/CXR
  5. Obtain quick PMH
  6. Determine treatment based on EKG
297
Q

4 D’s of delay (3 points)

A
  1. Door to data
  2. Data to decision
  3. Decision to drug
298
Q

Most common type of stroke

A

Ischemic stroke

299
Q

Ischemic stroke primary treatment

A

Fibrinolytics, rTPA

300
Q

Management for hemorrhagic stroke

A
  1. Obtain a STAT neuro consult

2. Avoid fibrinolytic therapy

301
Q

Management for subarachnoid stroke

A
  1. Obtain a STAT neuro consult

2. Avoid fibrinolytic therapy

302
Q

Cincinnati Prehospital stroke scale

A
  1. Facial droop
  2. Arm weakness
  3. Abnormal speech
303
Q

Chance of stroke with 1 finding on CPSS

A

72%

304
Q

Chance of stroke with 3 findings on CPSS

A

> 85%

305
Q

Time frame to perform NIH stroke scale

A

within 10 minutes of ED arrival after the CPSS

306
Q

True/false. Providers can give ASA after rTPA administration

A

False, wait at least 24 hours after rTPA administration to give ASA

307
Q

When should fibrinolytics be given after a stroke?

A

Within 1 hour of hospital arrival or within 3 hours of symptoms onset (or 4.5 hours for <80 years old and NIH score <25)

308
Q

Treatments for ischemic stroke

A
  1. Fibrinolytics
  2. ASA if fibrinolytics are contraindicated
  3. Endovascular therapy
309
Q

What is endovascular therapy?

A
  1. Intra-arterial rtPA within 6 hours of symptom onset (not approved by FDA)
  2. Mechanical clot disruption and retrieval with a stent

used in addition to IV rtPA

310
Q

ACLS stroke protocol for EMS

A
  1. Monitors, IV, oxygen
  2. Perform CPSS
  3. Establish time of onset
  4. Notify hospital and transfer to stroke center
  5. Check glucose
311
Q

ACLS protocol for ED in first 10 minutes

A
  1. Monitors, IV, oxygen
  2. Perform neurologic screening assessment and activate the stroke team
  3. Order an urgent, non contrast CT scan
  4. Get IV/labs/tests
312
Q

ACLS protocol for ED within 25 minutes

A
  1. Obtain CT scan
  2. Perform NIHSS
  3. Obtain PMH
313
Q

ACLS protocol for ED within 45 minutes

A

Read and interpret CT scan

314
Q

ACLS protocol for ED within 1 hour

A

-For ischemic stroke: administer fibrinolytics
administer ASA if fibrinolytics are contraindicated
-For hemorrhagic stroke: consult, admit to stroke unit or ICU and begin stroke or hemorrhage pathway

315
Q

ACLS protocol for ED within 3 hours

A

Begin post rtPA stroke pathway by admitting to the stroke unit or ICU

316
Q

ACLS protocol for ED within 6 hours

A

Initiate endovascular therapy if applicable

317
Q

Post rtPA stroke pathway

A
  1. Frequently check blood glucose levels
  2. Prevent hypertension
  3. Order urgent CT scan if neurologic status deteriorates
318
Q

When should blood sugars be treated with insulin after a stroke?

A

When they are >185 mg/dl

319
Q

ROSC protocol

A
  1. Optimize oxygenation/ventilation
  2. Obtain 12 lead EKG
  3. Order appropriate labs
  4. Consider prophylactic antiarrhythmic therapy
  5. Maintain normal BP
  6. Does the patient follow commands?

Methods of Anesthesia (20 decks)

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