ACLS Concepts Flashcards
ACS
acute coronary syndrome
ALS
advanced life support
AMI
acute myocardial infarction
CCF
chest compression fraction
CPSS
cincinnati prehospital stroke scale
CQI
continued quality improvement
CT
computed tomography
DNAR
do not attempt resuscitation
ECC
emergency cardiovascular care
ED
emergency departement
EMS
emergency medical services
IHCA
in hospital cardiac arrest
what is the average survival rate for an in hospital cardiac arrest?
24%
what are more than half of IHCA due to?
respiratory failure or hypovolemic shock
MACE
major adverse cardiac events
- death
- nonfatal MI
- need for urgent revascularization
MET
medical emergency team
NIH
national institutes of health
NINDS
national institute of neurological disorders and stroke
NSTE-ACS
non-ST elevation acute coronary syndrome or NSTEMI
OHCA
out of hospital cardiac arrest
what is the most common cause of cardiac arrest?
ischemia from CAD
what may be the first indicator of cardiac arrest?
brief generalized seizures
PCI
percutaneous coronary intervention
ROSC
return of spontaneous circulation
pts that display one of what have ROSC? 3
1 pulse and adequate BP
2 abrupt increase in etCO2 >40mmHg
3 spontaneous arteral BP waves via aline
RRT
rapid response team
rtPA
recombinant tissue plasminogen activator
what is rtPA used for?
fibrinolytic used to treat pts with STEMI
STEMI
st elevation MI
TCP
transcutaneous pacing
TTM
targeted temperature management
UA
unstable angina
agonal breathing
more than half cardiac arrest pts experience “gasps”, gurgling, moaning, snorting, or labored breathing
agonal rhythm
slow complex rhythms that immediately precede asystole
what should be initiated when agonal rhythms are incountered?
chest compressions bc agonal rhythms do not produce life sustaining cardiac output
what is the definition of CCF and what is the correct fraction
proportion of time spent performing chest compressions
at least 60% but ideally >80%
neonate
0-28 days
infant
1 month-1 year
child
1 year to puberty (breast development or axillary hair in males)
adult
puberty or older
lay person or lay provider definition
no specialized/professional knowledge of a subject
mild respiratory distress
change in airway sounds
severe respiratory distress
deterioration in color
changes in mental status
hypoventilation RR
<6
bradypnea RR
<12
normal RR
12-16
tachypnea RR
> 20
stable
normal BP and signs of good perfusion
what are the signs of good perfusion
good color good pulse good capillary refill warm awake and alert
unstable
hypotension and signs of poor perfusion
what are the signs of poor perfusion
blue or pale weak pulse delayed capillary refill cold altered or depressed consciousness sick
triage
process of deciding which pt should be treated first and where they should go based on how sick they are
name the 6 person high performance teams (in order)
1- team leader 2- compressor 3- AED/monitor/defibrillator 4- airway 5- IV/IO/Medication 6- timer/recorder
what does the team leader do
assigns roles to team members, makes decisions, provides feedback and responsible for unassigned roles
how often does the compressor alternate? and with who do they alternate with?
alternates with AED person every 5 cycles (2min) or when fatigue sets in
what does the AED/monitor/defibrillator person do?
obtains and operates defib and places monitor so team leader can see
rotates with compressor
what does the airway person do?
ventilates and intubates if necessary
what team member establishes access and pushes drugs?
IV/IO/medications member
what does the timer/recorder do?
records times of interventions/medications
announces when next drug is due
records frequency and duration of interruptions in compressions
what if you have less than 6 people?
multiple providers can take higher priority tasks
at what number of providers should there be a team leader?
2 or more
cardiac arrest teams
code blue teams
do NOT prevent, only respond after arrest has occured
RRT or METS purpose
identify and treat early clinical deterioration BEFORE arrest
what percent of IHCA pts have abnormal vitals documented for up to 8 hours?
80%
what are the three components of a rapid response team?
1 -event detection and activating response (by nurse, family, doc)
2- planned response arm (RRT) (hosp sets criteria as trigger)
3- quality monitoring and administrative support
8 steps to successful team dynamics
1- have clear roles 2- know your limits 3- have constructive intervention 4- share knowledge 5- summarize and re-evaluate 6 have a closed loop communication 7- give clear messages 8- have mutual respect
what is the most important role of a team member?
being proficient in skills according to your scope of practice
what should you do if you are assigned a task you do not feel proficient in?
ask for a new task
what are the 3 steps to knowing your limits
1- call for assistance EARLY
2- don’t initiate unfamiliar therapy without advice
3- don’t take on too many tasks
should you suggest an alternative drug, dose or question someone if they are about to make a mistake?
YES but do so tactfully so it is a CONSTRUCTIVE INTERVENTION
how do you share knowledge 3
1 avoid fixation error (fixating on one thing when there are more important ones)
2 encourage environment of sharing
3 ask if anything has been overlooked
how do you summarize and re-evaluate during a code? 3
- keep records of drugs/therapy
- monitor and reassess after treatments
- inform arriving personnel of status/plans
can you give a drug without confirming verbally with your team leader?
NO
explain closed loop communication
team leader gives order
confirms it was heard
listens to confirmation from team member before assigning another task
3 steps to giving clear messages during a code
speak clearly no shout/mumble
repeat if necessary
question if there is any doubt
what are examples of systems of care
community (lay providers)
out of hospital (EMS)
hospital systems (code team, RRT, CCT, stroke team)
OCHA chain of survival 5
1- recognition/ activation of emergency response
2- immediate CPR
3- rapid defibrillation
4- basic and advanced EMS/transport
5- advanced life support and postarrest care
IHCA chain of survival 5
1- hosp providers monitor/prevent arrest 2- arrest witnessed EMS activated 3- CPR started 4- Defibrillation ASAP 5- ACLS and postarrest care
what two things should you do before approaching the pt?
use universal precautions (gloves)
make sure scene is safe (if in field)
what assessment do you do if the pt is unconscious?
BLS RACD
RACD
- Responsiveness
- Activate EMS and get AED
- Circulation check (pulse and breathing simutaneously)(CPR)
- Defibrillation
during RACD you check the circulation and there is no pulse what do you do?
begin chest compressions
during RACD you check the circulation and there is a pulse but no breathing what do you do?
give two rescue breaths
does BLS assessment include intubation or starting an IV?
no
what is probable if you see a patient collapse
sudden cardiac arrest
what is probably if you see a patient drown
hypoxic cause of arrest
what do you do if you are lone rescuer and pt with hypoxic arrest
2 min CPR
then activate EMS
what do you do if you are lone rescuer and pt with probable cardiac arrest
activate EMS and get AED
then start CPR
bc defibrillation is needed to treat
what assessment should you do if the patient is conscious?
primary assessment (ABCDEs)
what if you are unsure if the patient is conscious?
start RACD (check responsiveness)
what is ABCDEs?
PRIMARY ASSESSMENT airway breathing circulation disability exposure
A of primary assessment
airway
check patency and consider advanced airway placement
B of primary assessment
breathing
consider supplementary oxygen and advanced airway placement, monitor oxygenation and ventilation
C of primary assessment
circulation
assessing pulse, EKG, BP (stable vs unstable), CPR effectiveness, temp and glucose, need for fluid or drugs, need for cardioversion/defib
D of primary assessment
disability
check neurologic function (responsive, conscious level, pupil dilation)
AVPU
AVPU
alert, voice, painful, unresponsive
E of primary assessment
exposure
remove clothing to perform quick physical exam
look for signs of trauma, bleeding, burns, medical alert bracelet
initial steps on conscious pt what things do you want to verbilize?
1- oxygen placed on pt (A and B)
2- monitors placed, 12 lead ECG, SpO2, BP (C)
3- IV placed (C)
once you have a SpO2 monitor on what do you want to titrate the SpO2 to?
94-99%
after you verbilize the first 3 steps what should you do?
auscultation and check patency of airway
check BP/pulse (stable?)
check ECG (rhythm?)
neurologic fxn and physical exam
what makes up the secondary assessment?
SAMPLE and H’s & T’s
searches for cause of problem
SAMPLE
signs and symptoms allergies medications past medical history last meal events
when should you verbalize SAMPLE?
conscious pt
when should you verbalize Hs and Ts
unconscious pt
how many hypos, hypers and H+ are in the H’s?
5 hypos
1 hyper
1 H+
what are the 7 H’s of pulseless arrest?
hypovolemia hypoxemia hypothermia hypoglycemia hypokalemia hyperkalemia acidosis (H+)
what are the 5 T’s of pulseless arrest?
tamponade thrombosis (coronary/pulm) tension pneumothorax trauma toxins
how is cardiac tamponade diagnosed and treated
diagnosed with ultrasound
treated with pericardiocentesis
in pts with cardiac arrest due to presumed or known PE what is it reasonable to do?
administer fibrinolytics
what is the diagnosis for a tension pneumothorax
unilateral absent breath sounds deviated trachea hypotension CXR bedside ultrasound
treatment for tension pneumo
needle decompression
then chest tube
needle decompression
2nd intercostal space
mid clavicular line
chest tube
6th intercostal space
mid axillary line
what can toxins or drug overdose lead to? ECG
prolonged QT on ECG
how do you treat toxins or drug OD?
monitor blood sugar (beta blocker or alcohol can lead to hypoglycemia) gastric lavage (wash out stomach) charcoal tablets
what should wall suction be capable of ?
-80 to -120 mmHg
usually >-300
effective suction technique
<10 sec, <10 attempts
follow with short period of O2
what should you do if suctioning thick material?
squirt 1-2cc N/S before suctioning
what type of suction goes down ETT and is better for thin secretions
soft suction catheter
in trauma pts how should the airway be opened? what should be avoided and why
jaw thrust
avoid chin lift bc of potential cervical instability
for trauma pts should manual spinal motion restriction or immobilization devices be used?
manual spinal motion restriction bc the collars can complicate airway management
mild choking classification
pt can cough
good air exchange
NO HEIMLICH
activate EMS if obstruction persists
severe choking classification
pt canNOT cough
unable to speak
treatment differs
severe choking in responsive adult protocol
heimlich (above navel below breastbone)
examined post heimlich to rule out damage
severe choking in responsive child protocol
heimlich maneuver or abdominal thrusts below xyphoid
severe choking in responsive infant protocol
prone in one arm and 5 back blows
flip supine in other arm and 5 downward chest thrust two fingers (exactly where compressions would be)
severe choking in unresponsive pts protocol
immediately start CPR (even if pulse palpable)
each time you open airway for breaths look for object in mouth
choking pt after the obstruction is relieved protocol
place in recovery position (on side)
drowning protocol
immediate CPR
if in icy water then rewarming core temp to at least 30C is recommended before abandoning CPR
what is the most rapid and effective technique for rewarming hypothermic cardiac arrest
extracorporeal circulation
what should your caution be when securing the ETT?
potential danger of obstructing venous return from brain with tube tie
is cricoid recommended in ACLS?
not recommended
what is the preferred method of confirming ETT placement
etCo2 continuous waveform
as in exact co2
what is used if continuous etco2 waveform is not available?
colorimetric capnography
what type of capnography is colorimetric
semi-qualitiative
confirms there is etco2 but not exactly what it is
may fail to detect co2 when ETT is correctly placed
purple colorimetric capnography
<2.28mmHg
beige colorimetric capnography
3.8-7.6mmHg
yellow colorimetric capnography
> 15.2mmHg
GOLD=GOOD
should an advanced airway be placed?
AHA recommends that rescuers provide assisted ventilation with BVM or advanced airway
oxygen therapy during arrest and initial resuscitation
high flow oxygen 100%
oxygen therapy after ROSC
titrated to spo2 of 94=99 for non ACS
>90% fot ACS
mouth to mouth breathing adults protocol
pinch nose chin lift
what is the FiO2 of mouth to mouth? CO2?
17% fiO2
4% CO2
mouth to mouth breathing kids protocol
place mouth over victims mouth and nose
which should be performed with one rescuer? two rescuer?
mouth to mouth
bag mask
one= mouth to mouth two= bag mask
what are the 4 disadvantages to excessive ventilation
1 gastric inflation (regurg/aspiration)
2 decreases venous return and CO (increased intrathor pressure)
3 decreases cerebral BF
4 lowers survival
what is the best way to avoid excessive ventilation?
give breath until chest rise is observed
what is the goal tidal volume for adults during arrest
500-600mL
what is the breathing rate if compressions are required? (cardiac arrest)
LOWER 10 breaths/min
venous return more important
what is the breathing rate if compressions are not required?(resp arrest)
HIGHER 10-12 breaths/min
venous return less important
what is the breathing rate for mask ventilated pts (resp arrest)?
10-12 breaths/min (every 5-6 sec)
bc breath not as effective
what is the breathing rate for intubated pt? (resp or cardiac arrest)
10breath/min
bc breaths are more effective
what should agonal breaths be treated the same as?
apnea
ratio of compressions to breath mask ventilation cardiac arrest
30:2
when you check pulse and breathing for RACD how long should you do it?
5-10 sec and recheck every 2 min
if there is no breathing but there is a pulse how many breaths per minute?
10-12 breaths/min
every 5-6 sec
each breath over 1 sec
what is the priority for establishing vascular access?
IV first
OP (intraosseous) second
ETT last resort
what should you do when injecting medication IV during code?
dose followed by N/S bolus 5 mL for peds 20mL for adults
extremity elevated for 10-20 sec
how fast can IO access be achieved?
30-60 sec
is dosing in the IO the same as IV?
yes
where is the best IO access? confirmation?
anterior tibia
fluids can flow freely without local soft tissue swelling
ETT access for meds protocol
inject drug in ETT
5-10mL N/S flush
5 rapid PP ventilations
compressions temporarily interrupted to avoid regurg of drug
what can low dose epo via ETT cause?
beta 2 effects
hypotension
decrease chance for ROSC
ETT access dose epi adults
2-3 times IV
ETT access dose epi children
10 times IV
ETT access dose epi neonates
same as IV
what is the acronym for possible ETT drugs adults
NAVEL narcan atropine vasopressin epi lidocaine
what is the acronym for possible ETT drugs peds
LEAN lidocain epi atropine narcan
what is the indication for compressions adults
no pulse
what is the indication for compressions children up to puberty
HR<60
what is the indication for compression “larger children”
HR<40
what is the rate for compressions
100-120 per min
how many compressions does it take before good blood flow?
20-25
how will you know if you are pushing too fast for compressions?
special monitors are available to alert you
5 steps for chest compression technique
1 use hard flat surface 2 press down on lower half of breastbone 3 push to adequate depth 4 allow complete chest recoil 5 switch providers every 2 min( or 5 cycles)
adequate compression depth adults? children?
adult 2-2.4 inches
child 1/3 to 1/2 depth of chest or 1.5 inches
high quality CPR pneumonic
CPR
Chest recoil
Push hard/fast
Rotate rescuer
when do you use a two hand CPR technique?
adults and adolescents
when do you use a one hand CPR technique
alternative to two hand for children 1-8 yrs
when do you use 2 finger CPR technique
?
infants with one responder
two finger CPR technique
2 fingers below nipples above xyphoid
when do you use thumb encircling CPR technique?
neonates and infants when 2 responders
CPR in mask ventilated pts
compressions are interrupted when performing breaths
CPR in 5 cycles over 2 min
cycle ratio of CPR mask vent adults
30:2
cycle ratio of CPR mask vent infant/children
1 provider
30:2
2 provider
15:2
cycle ratio of CPR mask vent neonate
respiratory arrest
3:1
cardiac arrest
15:2
CPR in intubated pts
chest compressions are not interrupted during breaths
CPR performed in two min increments NOT cycles
CPR intubated adults
100-120 compressions/min
10 breaths/min
CPR intubated kids
100-120 compressions/min
breathing rate is faster depending on age
4 goals for chest compressions
1 etco2 of at least 20mmHg
2 diastolic BP on aline of at least 20mmHg
3 mixed venous saO2 of at least 30% (norm is 60-80%)
4 coronary perfusion pressure of 10mmHg
starting compressions takes priority over everything except
calling for help
defibrillating vfib/vtach when pads are on and ready
can chest compreswsions continue when defib is charging
yes
what is continuous chest compressions?
EMS setting
3 periods of 200 chest compressions (2 min each period)
advanced airway is postponed
passive oxygen insufflation replaces positive pressure until 3 periods are done
are the compressions in continuous chest compressions interrupted for anything?
yes rhythm analysis and defibrillation
4 times to withhold CPR?
DNR request
threat to safety of rescuers
rigor mortis (stiffening of limbs)
lividity (black and blue discoloration)
CPR protocol when defibrillating 6
1 check the pulse (no longer than 10 sec)
2 perform CPR until AED arrives
3 defib ASAP
4 resume 2 min of CPR
5 reanalyze rhythm (and check pulse if organized rhythm present) within 10sec
6 repeat cycle as needed
where do you check the pulse adults? infants?
adult carotid
infant brachial
why do we continue CPR for 2 min before reanalyzing
be rhythms dont usually create perfusion in the first few min
when should IV/IO meds be given during CPR protocol/defib
immediately before or after shock delivery, so there is time to circulate before next check
ECMO for arrest?
may be considered in select cardiac arrest pts who havent responded to conventional CPR
abilities of the AED/AED pads
sense and analyze vfib/vtach can defibrillate (auto energy dose)
limitations of AED/AED pads
does not produce ECG strip (cannot sense anything except vfib/vtach
cannot pace
cannot perform synchronized cardioversion
automated external defibrillator (AED)
automated means semi or fully
semi= advises if shock is indicated and provider pushes button
fully= shocks for you if indicated
AED protocol
power on AED attach electrode pads clear the victim analyze rhythm charge and shock if advised
manual defibrillator extra abilities on top of AED
show ECG strip
can perform synchronized cardioversion
can perform transcutaneous pacing
manual defib vs AED
manual defib is preferred if the providers skills are adequate
when is the analyze button used on a defibrillator
when BLS provider cannot analyze rhythm
energy select button on defib
adjusts the energy you shock with
how long should the clear and shock process take
<5 sec
knob set to monitor
3 tracing screens
knob set to defib
allows defib and synchronized cardioversion
knob set to pacer
allows the defib to pace
pacing with manual defib
output button controls current delivered
rate button controls heart rate
4:1 button causes 3 of 4 pacer impulses to be suppressed so we can analyze the rhythm
are most defib today mono or bi phasic?
biphasic
they are more effective at defibrillating
waveform is up and down
sync button for synchronized cardioversion does what
ensures shock wave occurs during R wave not during T wave
indications for synchronized cardioversion
unstable supraventricular rhythms (SVT, afib, aflutter
unstable monomorphic vtach with pulse
how to perform synchronized cardioversion 6
1 place pads in posterior, left anterior (ventricular) right anterior (atrial)
2 knob to defib
3 sync button prior to each shock attempt
4 select 75-120 J energy
5 hit charge
6 hit shock
when is defibrillation indicated?
all ventricular rhythms that are pulseless and/or irregular (vfib, vtach, torsades)
when is defibrillation NOT indicated
supraventricular rhythms
asystole
pulseless electrical activity (PEA)
is sedation necessary with defibrillation
no
how to perform defibrillation 5
1 place pads posterior-anterior or anterior-anterior 2 knob to defib 3 select 200J energy 4 charge 5 shock
adult defib biphasic energy dose
120-200 J
adult defib monophasic energy dose
360J
pediatric defib biphasic 1st,2nd,up-to doses
2J/kg
4J/kg
up to 10J/kg
synchonized cardioversion biphasic irregular SVT (afib) energy dose?
monophasic?
120-200J
mono= 200J
synchronized cardioversion biphasic regular SVT energy dose
50-100J
synchronized cardioversion biphasic monomorphic vtach energy dose
100J
transcutaneous pacing biphasic energy dose
40-80mA
anterior/anterior pad placement
anterior upper right chest above nip
apex/lateral pad left anterior mid axillary of 5th intercostal space
posterior, left anterior pad placement
posterior pad under left scapula
anterior pad left of sternum under left breast
posterior, right anterior pad placement
posterior pad under left scapula
anterior pad right of sernum above right breast
what is the pad placement for AED
anterior- anterior (most common)
posterior and left anterior
pad placement for transcutaneous pacing
posterior, left anterior (under left breast) {most common}
anterior, anterior
placement for defibrillation and cardioversion of vtach
posterior, left anterior (best)
anterior, anterior
pad placement for cardioversion of atrial rhythms
posterior, right anterior (recommended)
anterior, anterior
what is the most common paddle placement adult
anterior, anterior
post, ant can be used but harder to clear and takes longer
paddle placement for infant
anterior anterior
paddle placement for children over 1 year
anterior anterior OR
posterior anterior
what is needed if you are using defibrillation paddles?
conducting gel
anterior anterior placement is recommended for:
AED
defib paddles
posterior left anterior placement is recommended for:
pacing
defib/ syn CV of ventricular rhythms
posterior right anterior placement is recommended for:
atrial rhyhtms
anterior anterior placement can also be used for (second choice):
defib with defib pads
syn cardioversion of atrial rhythm
pacing
posterior left anterior placement can also be used for (second choice)
AED pads
Defib paddles
what are pediatric manual defibrillator pads
used on children less 1 year old
bc can use lower energy doses than AED
pediatric AED pads
used on 1-8 yr old
placed so they dont touch eachother
does the AED automatically deliver pediatric dose
some have a key or switch that can deliver a child shock dose
adult AED pads
used on kids >8 yr
acceptable in infants if no peds are available
defibrillator safety 6
1 do not place pads on top of medication patch or pacemaker
2 it is safe to perform multiple defib attempts in hypothermic pts
3 make sure oxygen is not blowing across chest during defib
4 dry chest if sweat or water
5 pads placed flat at least 2 inches apart
6 do not allow pads to touch
if the pt has a ICD how far away should you place the pad?
1 inch to the side
if the pt is laying in water can you shock them
move to dry area then shock
electrical arcing
flow of current through air between electrodes can induce fire, explosion, and thermal injury
how many shocks are given at once?
1 shock at a time
how long should the time from arrival to first shock be?
<90sec
what is priming the pump
when EMS performs a period of CPR before defib, not recommended
post cardiac arrest syndrome includes
postarrest brain injury postarrest myocardial dysfunction systemic ischemia reperfusion response pathology that might have precipitated the arrest
4 goals of post resuscitation care
optimize ventilation and hemodynamic status
initiate targeted temperature management (TTM)
provide immediate coronary reperfusion with PCI
provide neurologic care and prognostication and other structured interventions
what is the first priority for someone who achieves ROSC?
oxygenation and ventilation
airway management for unconscious pt with ROSC
advanced airway usually
potentially head at 30 degrees to decrease cerebral edema, aspiration, and vent pneumonia
what is the only post ROSC intervention demonstrated to improve neurologic recoveru?
TTM
are TTM and PCI at the same time safe?
yes feasible and safe
when should TTM be administered
comatose and unresponsive after ROSC
what is the goal temp for TTM
32-36 C for 24 hr
bleeding risk may not tolerate
seizures and cerebral edema have worse outcomes with higher temsp
what sites should be used for core temp measurement
esophageal
bladder
earliest neurologic status check not treated with TTM
72 hr
earliest neurologic status check with TTM
72 hr after return of normothermia
methods of initiating TTM
rapid infusion of ice cold isotonic non glucose fluid (30mL/kg) =best for fast not for targeted temp
surface cooling devices
ice bags
spO2 after ROSC
titrate Fio2 to lowest level to maintain spo2 >94%
capnography after ROSC
ventilation 10breaths per min
etCO2 35-40mmHg
cardiovascular care after ROSC
12 lead ECG ASAP
consider coronary reperfusion therapy if stemi or AMI
goal BP after ROSC
MAP > 65
Sys P>90
hypotension treated with fluids or pressor
is TTM considered in conscious pts?
no
post ROSC lab and diagnositic tests
`look for electrolyte abnormalities
look for pulm,cariac, or neurologic precipitants of arrest
prophylactic antiarrhythmic therapy after ROSC
following vtach/vfib
consider beta blockers
consider lidocaine
when can you consider terminating resuscitative efforts?
unable to get etCO2 >10mmHg after 20 min of CPR in intubated pts
DNAR order presented
dangerous environment
when should you consider prolonging resuscitative efforts? >20min
cause of cardiac arrest is reversible (hypotherm, drugs)
ROSC at any time throughout attempt
why is resuscitation in hypothermic pts different?
may be unresponsive to drugs, defib and pacing (drugs could accumulate)
should concentrate on rewarming (extracorporeal circulation)
protocol for severe <30C hypothermic vfib/vtach
single defib then hold until >30C
protocol for moderate <34C hypothermic vfib/vtach
defib but wait longer intervals
when should termination of resuscutative efforts happen for hypothermic pts?
core temp is at least 30C before terminate
7 things you must say to do after ROSC
1- 12 lead EKG
2- consider hypothermia
3- maintain normal BP (1-2L crystalloid bolus)
4- frequent lab work
5- maintain spO2 94-99%
6- consider intubation and maintain etCo2
7- consider lidocaine or BB
bradycardia therapy
atropine
epi
dopamine
atropine dose
0.5mg every 3-5 min
max 3mg
epi dose
2-10mcg/min
dopamine dose
2-20mcg/kg/min
SVT therapy
adenosine (slowing AV node)
sotalol (slowing AV node)
calcium channel blockers (“)
adenosine dose
6mg bolus (N/S flush) 2 additional dose of 12mg
sotalol dose
100mg or 1.5mg/kg
when should sotalol be avoided?
QT syndrome
treatment for afib/aflutter
unstable synchronized cardioversion
stable= consult
why would you use adenosine for afib/aflutter
when you need to slow the HR so you can diagnose the rhythm
when do you give epi
(vtach/vfib,PEA,asystole)
pulseless rhythms 1 mg every 3-5min
does not fix the problem, keeps alive so defib can fix
indications for amiodarone
monomorphic vtach (with or without a pulse) or vfib
when is amiodarone avoided?
pts with prolonged QT interval or torsades
amiodarone monomorphic vtach awake or still has pulse dose
150mg over 10min
amiodarone vfab/pulseless vtach dose
300mg bolus
150mg second dose
post resuscitation infusion dose amiodarone
1mg/min 1st 6 hr
0.5mg /min next 18 hr
loading dose of 150mg if not already given
when is procainamide used? dose?
vfib or monomorphic vtach
20-50mg/min until:
arrhythmia gone, hypotension ensues, or QRS duration decreases 50%
maintenance infusion procainamide
1-4mg/min
procainamide max dose
27mg/kg
when is procainamide avoided?
prolonged QT or CHF
when is magnesium indicated? dose
torsades
1-2g
steroids and arrest
use of methylprednisolone during arrest and
hydrocortisone after ROSC has shown improved survival
