ACLS—Preventing Arrest Flashcards
Name S/S of an adult pt who is deteriorating
-Airway compromise
-RR <6 or >30
-HR <40 or >140
-SBP <90
-Symptomatic Hypertension
-Unexpected decrease in LOC
-Symptomatic Hypertension
-Unexplained Agitation
-Seizure
-Significant decrease in urine output
-Subjective concern about the pt
What 2 ECG categories are outlined int he ACS algorithm?
-STEMI
-NSTEMI ACS (NSTE-ACS)
What can be seen on the EKG of the pt w/ NSTEMI?
-ST segment depression, T wave inversion, Transient ST Segment Elevation
-Nondiagnostic or normal EKG
What are the primary goals for ACS patients?
-Prevention of major adverse cardiovascular events such as Death, Nonfatal MI and the need for urgent Post Infarction Revascularization
-Identification of pts w/ STEMI & triage for early reperfusion therapy
-Relief of ischemic chest discomfort
-Tx of acute, life-threatening complications of ACS, such as VF/pVT, Unstable Bradycardia, Ventricular Wall Rupture, Decompensated Shock & other Unstable Tachycardias
What rhythms should be anticipated for ACS w/ acute ischemia?
-Sudden Cardiac Death
-Ventricular Tachycardias
-Hypotensive Bradycardia
What drugs are used to treat ACS?
-O2
-Aspirin
-Nitroglycerin
-Opiates (Morphine)
-Fibrinolytic Therapy
-Heparin
When is Nitroglycerin contraindicated?
-Inferior Wall MI w/ RV Infarction
-Hypotension, Bradycardia & Tachycardias
-Recent Phosphodiesterace Inhibitor use (drugs for ED)
When is Morphine indicated for STEMI?
-When chest discomfort does not respond to Ntg.
What are the benefits of using Morphine to manage ACS?
-CNS analgesia
-Reduces O2 demand
-Alleviates Dyspnea
-Produces venodilation which reduces LV preload & O2 requirements
-Decreases SVR which reduces LV after load
-Helps redistribute blood volume in pts w/ acute pulmonary edema
If hypotension develops after Morphine is given, what should be done?
IV Fluids
Why is pain relief after Ntg administration not useful in diagnosis the cause of chest pain or discomfort?
Because GI & other causes of chest discomfort can also improve after Ntg.
Why are coronary arteries also called epicardial arteries?
Because they run along the outer surface of the heart on the epicardium. The main coronary/epicardia arteries and the Left Coronary and the R Coronary arteries.
When STEMI is seen on the EKG there is usually a complete occlusion of what artery/arteries?
Left or Right Coronary artery.
What is the most commonly occluded of the coronary arteries and what is a nickname given to ST elevation of this artery?
Left Anterior Descending—“Widow Maker”
D’s of in-hospital STEMI therapy?
Door
Data
Decision
Drug
What leads are affected w/ ST elevation >2.0 mm for presumed “New LBBB”?
III, aVF, V3, V4, I & aVL
EKG findings of an acute posterior wall MI include the following:
ST segment depression (not elevation) in the early precordial leads V1-V4 (anterior & septal leads). This occurs because the EKG leads will see the MI backwards: the leads are placed anteriorly but the myocardial injury is posterior.
Posterior wall
Name the 2 different types of strokes and the common percentage each occur:
Ischemic—87%
Hemorrhagic—13%
What are the 3 physical findings assessed on the Cincinnati Prehospital Stroke Scale?
Facial Droop—smile or show teeth
Arm Drift—close eyes and hold out both arms palms up
Abnormal speech—have pt say “You can’t teach an old dog new tricks.”
What is the goal of B/P management in order to give TPA?
</= 180/105
Name the rhythms for Bradycardia:
Sinus Bradycardia
1st degree AV Block
2nd degree AV Block
-Mobitz Type I or Wenkebach
-Mobitz Type II
3rd degree AV Block
What drugs are used to treat Bradycardia?
Atropine
Dopamine (infusion)
Epinephrine (infusion)
Describe the second degree AV block.
There is a block of some, but not all, atrial impulses before they reach the ventricles.
Describe the 2nd degree Mobitz type one or Wenkebach rhythm
Block typically occurs at the AV w/ successive prolongation of the PR interval until an atrial impulse is not conducted to the ventricles (there will not be a QRS following the last P wave). The cycle of progressive lengthening of the PRI until failure of conduction of the atrial impulse often repeats.
Describe the 2nd Degree Mobitz Type II block.
Block occurs below the level of the AV node and is characterized by intermittent nonconducting of P Waves (atrial impulses) to the ventricles w/ constant PR interval or conducted beats. There can be a consistent ration of atrial to ventricular depolarizations
Describe the 3rd Degree AV Block:
Atria and ventricles beat independently of each other. No atrial beats are conducted to the ventricles.
What AV Block is the most clinically significant?
3rd Degree or Complete Heart Block because it is the most likely to cause cardiovascular collapse and require immediate pacing.
Describe 3rd degree or Complete Heart Block:
Altria and ventricles beat independently of each other. No atrial beats are conducted to the ventricles.
When would Atropine be given for an AV Block?
If the pt has S/S of poor perfusion caused by the Bradycardia
If Atropine is ineffective for the symptomatic pt w/ an AV Block what other actions can be taken?
-Dopamine infusion
-Epinephrine infusion
-Transcutaneous pacing
Bradycardia can be a S/O life-threatening Hypoxia.
Give O2!!
***Bradycardia associated w/ Hypertension can be a S/O life-threatening increase in ICP, especially in the setting of stroke or brain injury.
***When assessing the pt w/ Bradycardia, the key clinical question is whether the bradycardia is causing the pt’s symptoms or some other illness is causing the bradycardia.
What are some symptoms of Bradycardia?
-Altered mental status
-Shock
-Ischemic chest discomfort
What are some symptoms of bradycardia?
-Hypotension
-Acuter heart failure
What is the the first drug given to the pt w/ poor perfusion secondary to bradycardia?
Atropine (but not for pt w/ heart transplant)
If Atropine is ineffective for symptomatic bradycardia what treatment should be considered next?
Transcutaneous pacing and/or Dopamine @ 5-20mcg/kg/min infusion (Chronotropic or HR dose) or epinephrine @ 2-10 mcg/min infusion
How often can Atropine be given?
1 mg Q3-5 minutes to max of 3 mg total
Atropine < 0.5 mg IV may further slow the HR.
How does Atropine work?
Atropine works by reversing cholinergic-mediated decreases in HR.
What medication is used to treat Beta-Blocker induces bradycardias or hypotension?
Glucagon
What type of drug is Atropine and how does it work?
-Atropine is an antimuscarinic
-Atropine increases parasympathetic inhibition & allow for pre-existing sympathetic stimulation to predominate, creating increased cardiac output
What heart blocks will not likely respond to Atropine?
-2nd degree Mobitz Type II
-3rd degree AV Block
-3rd degree AV Block w/ new wide QRS
What beta adrenergic drugs can be used as an alternative treatment for bradycardias not responsive to Atropine?
-Dopamine
-Epinephrine
What can happen if Atropine is given to a heart transplant pt?
-Increased likelihood of VF
-Instead treat these pts w/ pacing and/or dopamine or epinephrine.
What is the dose of epinephrine for bradycardia?
2-10 mcg/min & titrate to pt response
What is the dose of dopamine for bradycardia?
-5-20 mcg/kg/min & titrate to pt response.
-At lower doses, dopamine has a more selective effect on inotropy & HR; at doses >10 mcg/kg/min dopamine also has vasoconstrictive effects.
Patients w/ ACS should be paced at the lowest HR that allows clinical stability—Why?
Higher HR can worsen ischemia because HR is a major determinant of myocardial O2 demand & ischemia can precipitate arrhythmias.
