ACLS Cases Flashcards
Assess Airway
is the airway patent?
is an advanced airway indicated?
is proper placement of airway device confirmed?
is tube secured and placement reconfirmed frequently?
What advanced airways can be placed WHILE chest compressions are happening?
laryngeal mask airway, laryngeal tube, or esophageal-tracheal tube
Assess Breathing
are ventilation and oxygenation adequate?
are quantitative waveform capnography and oxyhemoglobin saturation monitored?
For cardiac patients, how much oxygen do you give?
100%
for non-cardiac arrest patients, how much oxygen do you give?
titrate oxygen to achieve o2 sats greater than 94%
Assess circulation
what is the cardiac rhythm? is the patient with a pulse unstable? is defib or cardioversion indicated? are chest compressions effective? Is ROSC present? has IV/IO access been established? Are meds needed for rhythm or BP? Does the patient need fluids?
What PETCO2 indicates CPR is inadequate?
< 20 mm Hg
what is PETCO2?
the partial pressure of end-tidal CO2, a measure of the amount of CO2 present in the expired air.
Why is excessive ventilation bad?
increases intrathoracic pressure, decreases venous return to the heart, and diminishes cardiac output. It may also cause gastric inflation and predispose the patient to vomiting and aspiration of gastric contents.
what is the most common cause of upper airway obstruction?
loss of tone in the throat muscles, allowing the tongue t fall back and occlude the airway
when do you insert a OPA or NPA?
when patient is unconscious with no cough or gag reflex
When DONT you use an OPA?
if the patient is conscious or semiconscious because it may induce choking or laryngospasm
When do you use an NPA?
may be used when gag/cough reflexes are intact (conscious or semi-conscious). The NPA is indicated when insertion of an OPA is technically difficult or dangerous. Often can use the pinky finger to determine proper size of NPA to use.
Suctioning
should not exceed 10 seconds, hyperventilate before and after
when do you use laryngeal mask airway?
it is an advanced airway alternative to ET intubation.
NAVEL
Meds that can be administered with ET tube: Naloxone Atropine Vasopressin Epinephrine Lidocaine
What rhythms are shockable?
VF and pulseless VT
What do you do if the AED says the rhythm is NOT shockable?
resume CPR immediately for two minutes if still no pulse. Check rhythm q2mins
What is the purpose of defibrillation?
Defibrillation does not restart the heart. Defibrillation stuns the heart and briefly terminates all electrical activity. If the heart is still viable, its normal pacemaker may resume electrical activity (return of spontaneous rhythm) that ultimately results in a perfusing rhythm.
Cardiac Arrest
a nonresponsive patient with agonal gasping who has no pulse is in cardiac arrest
Epinephrine
after second VF/VT shock; 1 mg q3-5 mins, Vasopressin IV/IO 40 units can replace first or second dose of EPI
Amiodarone
Give after third VF/VT shock (EPI 1 mg already given); first dose is 300 mg bolus, second dose is 150 mg
Asystole/PEA drugs
EPI 1mgq3-5 mins
Adult Cardiac Arrest Flow Chart
Start CPR (start oxygen, set up defibrillator)
Shockable rhythm? shock or don’t
CPR 2 mins, IV/IO access (if no shock, consider EPI 1mg and need for advanced airway with capnography)
Shockable rhythm?
Give EPI 1 mg, CPR 2 mins, consider airway/capnography
Shockable rhythm?
CPR, amiodarone (300 mg bolus first dose/150 mg second dose)
reversible causes of cardiac arrest (5H5T)
hypovolemia: fluids (and oxygen and vent if hypoxic too)
hypoxia: oxygen and ventilation
hydrogen ion (acidosis): oxygen and vent
hypo/hyperkalemia: tall peaked T wave vs flat T wave
hypo/hyperthermia
hypoglycemia: check sugars once vascular access
Tension pneumo
tamponade
tablets/toxins
Thrombosis pulmonary: get an early 12 lead
Thrombosis coronary: get an early 12 lead
What PETCO2 indicates ROSC?
> 40 mm Hg
Biphasic Shock Energy
first shock should be 120-200J, use maximum available. Subsequent shocks should be equivalent and higher doses may be considered
Monophasic shock energy
360J
If the initial shock terminates VF, but the arrhythmia recurs later in the resuscitation attempt, what shock strength do you then deliver?
the shock strength previously successful
how many cycles of CPR are typically performed in two minutes?
5 cycles
If a nonshockable rhythm is present and the rhythm is organized, what do you do next?
check for a pulse. If there is any doubt about the presence of a pulse, resume CPR immediately, consider EPI 1 mg and investigate need for advanced airway. If there is a pulse with an organized rhythm, proceed to post cardiac care
What if amiodarone is unavailable during a persistent VF/ pulseless VT code?
use lidocaine 1-1.5 mg/kg IV/IO first dose, then 0.5-0.75 mg/kg IV/IO at 5-10 minute intervals. Max dose of 3 mg/kg
Torsades des pointes (long QT interval)
mag sulfate 1-2 g IV/IO diluted in 10 mL D5W or NS over 5-20 mins if asymptomatic. If symptomatic, defib at 200J
Central Venous Oxygen Saturation (SCVO2)
should be 60-80%; if less than 30%, try to improve compressions and vasopressor (EPI) therapy
the typical dose of drugs delivered via endotracheal tube is
2-2.5 times greater than the IV route dose. DIlute the doses in 5-10 mL of sterile water or NS
what do you do after each peripheral dose of a rescue med is delivered?
flush with 20 mL NS and elevate extremity for 10 seconds.
diminished/absent lung sounds; look at chest rise: is it symmetric or asymetric? Person venting should say, “Im meeting resistance.”
tension pneumo: tracheal deviation are late/ominous signs
no reversal agents for
meth and cocaine
3 attempts at a PIV within 90 s
if unsuccessful, go to IO
IO is designed for
short duration-only 24 hours
hesitate to run what through an IO?
adenosine: half life is too short. If IO is in LE, it wont be active by the time the drug circulates to the heart.
0.5 mg with a max of 3 mg for bradycardia
atropine for bradycardia: reassess q 3-5 mins; consider pacing or dopamine or EPI infusion (EPI 2-10 mcg for initial dose. Dopamine is weight-based 2-10 mcg/kg/min)
sinus tachy 100-150 bpm
treat underlying causes, but not the rhythm
Vtach
tombstone. No vagals. regular/monomorphic: give 6 mg adenosine (if it works, SVT with a aberancy) If that doesn’t work, try amiodarone drip 150 mg over 10 min follow by maintenance infusion of 1mg/min for first 6 hours. If symptoms appear–> cardioversion.
5 things that can make a person SYMPTOMMATIC
chest pain diaphoresis SOB altered LOC hypotension
narrow
QRS complex less than 3 boxes (.12mm); indicates an atrial issue
wide
QRS complex greater than .12 mm. wide indicates a vertricular issue
unstable AF
monophasic cardiovert @ 200 J
unstable monomorphic VT
monophasic cardiovert @ 100 J
Other unstable SVT/Atrial flutter
monophasic cardiovert @ 50-100 J
polymorphic VT
monophasic debrillate
no adenosine for
patients with a Hx of asthma
Post cardiac arrest care (what you do once you have ROSC)
optimize hemodynamic and vent status initiate therapeutic hypothermia provide immediate PCI for coronary reperfusion (STEMI or AMI) institute glycemic control provide neuro interventions
how do you induce hypothermia?
use 4 degree C fluids such as LR or NS
what is the EPI flow rate for treating hypotension once you have ROSC?
0.1-0.5 mcg/kg/min titrated to SBP >90 mm Hg or MAP > 65
what is dopamine flow rate for treating hypotension on you have ROSC?
5-10 mcg/kg/min until 90>SBP or MAP >65
What is NE flow rate for treating hypotension if you have ROSC?
0.1-0.5 mcg/kg/min until SBP > 90 or MAP > 65
Once you have ROSC, and your patient fails to follow commands, the HCP should consider implementing
therapeutic hypothermia to protect the brain and other organs. Target temp is 32-34 degrees C for 12-24 hours.
hypovolemia
narrow complex, rapid rate
signs of dehydration
volume infusion
Hypoxia
slow rate
cyanosis, ABG’s, airway probs
vent, oxygenation, advanced airway
Hydrogen ion (acidosis)
smaller amplitude QRS
Hx diabetes, renal failure
vent, give sodium bicarb
Hyperkalemia
Tall, peaked T waves, smaller P waves, wide QRS
Hx renal failure, diabetes, recent dialysis, dialysis fistulas, meds
give calcium chloride, sodium bicarb, glucose with insulin, possibly albuterol
Hypokalemia
T waves flatten, Prominent U waves, wide QRS, QT prolongs, wide complex tachycardia
diuretic use, n/v
add mag sulfate if in cardiac arrest
Hypothermia
J or Osborne waves (camel hump)
cold exposure, core body temp decreased
rewarm according to protocol
tension pneumo
narrow complex, slow rate
no pulse, neck vein distention, tracheal deviation, unequal breath sounds, difficult to vent pt
needle decompression, tube thoracostomy
Tamponade, cardiac
narrow complex, rapid rate
no pulse, vein distention
pericardiocentesis
Toxins
prolonged QT interval
bradycardia, empty bottles at the scene, pupils, neuro exam
intubation, specific antidotes and agents per toxidrome
Thrombosis, lungs; massive pulmonary embolism
narrow complex, rapid rate
no pulse, distended neck veins, prior + test for DVT or PE
surgical embolectomy, fibrinolytics
Thrombosis, heart; acute, massive MI
Abnormal 12 lead EKG
cardiac markers, good pulse with CPR
PEA with narrow complexes is more likely to have a
noncardiac cause: consider volume infusion
STEMI
current injury
ST depression
indicates ischemia
PCI
balloon dilation or stent placement for an occluded coronary artery
ACS ED assessment
VS, O2 sat, 12 Lead EKG (within 10 mins of arrival) Establish IV access physical assessment fibrinolytic checklist labs (cardiac markers, electrolytes, coags) CXR If O2 sat < 94%, O2 via NC @ 4L/min ASA 160-325 mg (fi not given by EMS) Nitro Morphine
Chest pain may indicate
AMI, Aortic Dissection, PE, pericardial effusion with tamponade, and tension pneumo
STEMI Treatment
give fibrinolytics within 30 mins of arrival to ED and perform PCI within 90 mins
contraindications to ASA
allergy and active/recent GI bleed
What rhythms result in bradycardia?
Sinus brady, AV Blocks
block most likely to cause cardiovascular collapse and require immediate pacing
third degree or complete AV block
STEMI and NSTEMI heparin dosing
Bonus 60 Units/kg IV not to exceed 4,000 units
Infusion 12 Units/kg/hr not to exceed 1,000 units
STEMI and NSTEMI lovenox dosing
Lovenox 1mg/kg sub cut round down!!
