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Methods of Anesthesia I > ACLS Scenarios > Flashcards

ACLS Scenarios Flashcards

1
Q

2 things for overall approach to scenario

A

arrive at scene,”universal precautions/safe”

if is awake or has pulse “monitors, iv, oxygen”

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2
Q

what are the 10 different ACLS scenarios

A 
respiratory arrest
bradycardia
supraventricular tachycardia
monomorphic vtach
vfib
polymorphic vtach (torsades)
asystole & PEA
acute coronary syndromes (ACS)
acute stroke
ROSC
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3
Q

respiratory arrest protocol 6

A 
1 responsiveness
2 activate ems/call help
3 circulation check pulse/breath
4 give 10-12 rescue breaths per min (1 per 5-6sec)
5 recheck pulse every 2 min
6 consider narcan if opiod OD suspected
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4
Q

narcan IM dose and intranasal dose

A

IM 0.4mg

intranasal 2mg

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5
Q

what rhythms fall under bradycardia

A 
sinus brady
mobitz type 1 and 2
complete heart block
afib with slow vent response
ventricular or junctional escape rhythm
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6
Q

what are the 3 bradycardia therapies

A 
drugs (epi, atropine, dopamine)
transcutaneous pacing (short to initiate)
transvenous pacing (long to initiate)
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7
Q

5 steps to perform transcutaneous pacing

A 
1 place pad posterior left anterior
2 knob to pacer
3 rate knob select HR
4 turn mA up until observe capture
5 set maintenance threshold 10% above pacing threshold
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8
Q

what are the disadvantages of transcutaneous pacing 4

A

1 only shows ventricular ECG waveform
2 doesnt produce as effective capture as transvenous pacing
3 muscle jerking may mimic carotid pulse (cant assess carotid pulse)
4 PAINFUL, sedated prior

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9
Q

pacing (stimulation) threshold

A

current when capture is observed

between 40-80mA

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10
Q

capture

A

when the heart starts beating

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11
Q

maintenance threshold

A

current which pacemaker should be maintained

10% above pacing threshold

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12
Q

stable bradycardia protocol 3

A

1 atropine
2 monitor and observe
3 SAMPLE

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13
Q

unstable bradycardia protocol 5

A 
1 monitors, iv, O2
2 atropine
3 consider if atropine ineffective: transcut pacing, epi, dopamine
4 SAMPLE
5 consider consult or transvenous pacing
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14
Q

what rhythms can be considered in the SVT scenario

A 
SVT
sinus tach
a fib
a flutter
junctional tach
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15
Q

clincal definition of SVT

A

tachycardia HR>150bpm caused by reentry

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16
Q

PSVT

A

paroxysmal SVT

begin and end abruptly (occuring in spasms)

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17
Q

Does ACLS assume that the SVT is AVNRT or AVRT?

A

AVNRT thus they recommend therapies that slow conduction through the AV node

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18
Q

what are the 4 therapies for SVT

A 
vagal maneuvers
adenosine
beta blockers
calcium channel blockers
(ineffective for afib and aflutter)
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19
Q

vagal maneuvers

A

valsalva maneuver
carotid massage
cold stimulus

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20
Q

stable SVT protocol 7

A 
1 monitors, iv, oxygen (if needed)
2 perform vagal maneuvers
3 adenosine 6mg then 12mg 
4 beta blocker or CCB
5 SAMPLE
6 consider expert consult
7 consider amiodarone or procainamide (NON ACLS)
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21
Q

unstable SVT protocol 5

A 
1 monitors, IV, o2 (if need)
2 immediate synchronized cardioversion
3 consider adenosine, vagal maneuvers, CCB, beta blockers
4 SAMPLE
5 amiodarone or procainamide (NON ACLS)
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22
Q

stable afib/aflutter protocol 3

A

1 monitors/iv/o2 (if needed)
2 consider expert consilt
3 SAMPLE

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23
Q

unstable afib/aflutter protocol 3

A

1 monitors/iv/o2 (if needed)
2 immediate synchronized cardioverson
3 SAMPLE

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24
Q

how to perform synchronized cardioverson 6

A 
1 place pads posterior anterior (right atrial, left vent)
2 knob to defib
3 press sync prior to each shock
4 select 75-120 J energy
5 charge button
6 shock button
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25
Q

therapies for ventriculare tachyarrhythmias 6

A 
1 synchronized cardioversion (pulse) or defib (no pulse)
2 epi (pulseless)
3 amiodarone
4 procainamide
5 lidocaine
5 magnesium
6 adenosine
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26
Q

what can be used to determine if rhythm is SVT or Vtach?

A

adenosine

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27
Q

stable monomorphic vtach WITH PULSE protocol 5

A 
1 monitors, IV, O2 (if needed)
2 antiarrhythmics (150 amiodarone over 10min)
3 expert consult
4 consider synchronized cardioversion
5 SAMPLE
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28
Q

unstable (WITH PULSE) monomorphic vtach protocol 3

A

1 monitors, IV, oxygen (if needed)
2 synchronized cardioversion (sedation? amiodarone?)
3 SAMPLE

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29
Q

what are the pulseless rhythms

A 
vfib (and sometimes vtach
monomorphic vtach
torsades
PEA
asystole
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30
Q

course vfib

A

higher waves

more chance of conversion

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31
Q

fine vfib

A

smaller waves
appears after course vfib
less chance of conversion

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32
Q

polymorphic vtach

A

torsades de pointes

has prolonged QT intervals

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33
Q

do you defibrillate pts in asystole?

A

no

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34
Q

what do you do when a pt is in asystole 3

A

CPR
epi
treat any reversible causes

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35
Q

PEA

A

pt has no pulse but ECG showing electrical activity

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36
Q

physiology of PEA

A

heart does not contract

insufficient CO to generate pulse and perfuse organs

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37
Q

treatment for PEA

A

1 CPR
2 epi
3 treat any reversible causes

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38
Q

do you treat PEA with defibrillation?

A

NO

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39
Q

shockable pulseless

A

vfib
vtach
torsades

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40
Q

NON shockable pulseless

A

asystole

PEA

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41
Q

what is the only effective treatment for pulseless vfib/vtach

A

defib

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42
Q

vfib and pulseless monomorphic vtach protocol 7

A 
1 CPR
2 Defib ASAP
3 resume CPR
4 analyze rhythm and check pulse
5 defib
6 resume CPR
7 analyze rhythm and check pulse
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43
Q

throughout CPR (monomorphic vtach) what should you be doing? 5

A 
1 epi 1mg every 3-5min
2 Hs and Ts of pulseless arrest
3 intubation, capnography, steroids?
4 amiodarone 300mg if epi and defib not effective (after 3rd shock) can give second dose 150 if continues
5 consider hypothermia if ROSC
44
Q

how to perform defibrillation 5

A 
1 place pads posterior anterior or anterior anterior
2 knob to defib
3 select 200J
4 charge
5 shock
45
Q

polymorphic vtach proto

A 
1 CPR
2 defib ASAP
3 resume CPR
4 analyze and check pulse 
repeat
46
Q

throughout CPR torsades what should you be doing 5

A 
1 epi 1mg every 3-5min
2 magnesium 1-2g
3 Hs and Ts
4 intubation capnog and steroids
5 hypothermia if ROSC
47
Q

asystole and PEA protocol 5

A 
1 CPR
2 epi 1mg every 3-5 min
3 Hs and Ts
4 intub capnog steroids
5 hypotherm if ROSC
48
Q

4 types of ecg in ACS

A

stemi
nstemi st depression
nstemi t inversion
normal ecg

49
Q

what is stemi caused by

A

completely blocked coronary artery

diagnosed with 12 lead ecg st elevation

50
Q

which ecg in ACS is the highest risk?

A

STEMI

51
Q

what is nstemi caused by

A

partially blocked coronary artery from platelet thrombus

ST depression or T inversion

52
Q

which is the lowest risk ecg for ACS

A

normal ecg

53
Q

why is the 12 lead ecg so important in ACLS

A

ONLY WAY of identifying STEMI

sufficient enough to start therapy without labs

54
Q

ACS etiology 6

A

1 plaque develop in coronary artery
2 plaque has inflammatory component become unstable
3 inflamed plaque ruptures
4 platelets cover surface and coag system active
5 thrombus formed
6 angina (either NSTEMI or STEMI depending on blockage)

55
Q

what is the most common cause of ACS

A

plaque rupture

56
Q

what are the possible therapies for ACS

A

MONA
Heparin
reperfusion therapy

57
Q

MONA

A

morphine
oxygen
NTG
ASA

58
Q

reperfusion therapy

A

fibrinolytics (rTPA)

percutaneous coronary intervention (PCI, balloon and stent)

59
Q

what is the goal of ACS pts?

A

relieve ischemic chest pain
NTG or morphine
only morphine when nitrates dont work

60
Q

what should you do if morphine causes hypotension

A

fluid bolus

61
Q

what pts should you use caution with morphine

A

NSTEMI bc may be associated with increase in mortality

62
Q

oxygen therapy in ACS

A

spo2<90 yes O2

SpO2 >90 may consider withholding O2

63
Q

NTG dose

A

3 sublingual NTG tabs (0.4mg) every 3-5 min

may be repeated twice (tot of 3 doses)

64
Q

when should you avoid NTG?

A

hypotensive pts SBP<90, or 30 below baseline
pts with inadequate preload (recent MI or vasodilator)
PDEi

65
Q

what should you do if pt becomes hypotensive after NTG?

A

fluid bolus

66
Q

ASA dose

A

160-325mg PO chewed

67
Q

other method for ASA administration

A

rectal

68
Q

what is the goal time to administer PCI within mins of arrival?

A

90min

door to balloon time <120min if nonPCI hosp

69
Q

what is considered if PCI cannot be initiated within 90-120 min

A

fibrinolytic therapy

only for STEMI pts

70
Q

time goal for fibrinolytic therapy

A

within 30 min of arrival

71
Q

at what time length of symptoms being present should you not administer fibrinolytics?

A

> 12hr

72
Q

contraindications fibrinolytics 6

A 
1 NSTEMI
2 hypertension 180-200 SBP or 100-110 DBP
3 head trauma or GI bleed
4 blood thinners
5 stroke symptoms >3 hr
6 symptoms >12 hr
73
Q

STEMI treatment 4

A

1 MONA
2 Start reperfusion with PCI or fibrinolytics
3 start heparin
4 consider CABG

74
Q

NSTEMI treatment 4

A

1 MONA
2 Consider reperfusion with PCI
3 Start adunctive therapies (NTG, heparin)
4 avoid fibrinolytics

75
Q

low risk normal ecg ACS treatment

A

consider admission ED chest pain unit or consult

76
Q

ACS protocol EMS

A

1 monitors, ic, o2 (12 lead)
2 MONA
3 if STEMI notify hospital (symp onset and medical contact times)
4 consider prehosp fibrinolyrics using checklist

77
Q

ACS protocol in Hospital 6

A 
1 monitors, iv, oxygen
2 MONA
3 12 lead ecg
4 IV/labs/CXR
5 PMH
6 determine treatment based on ECG
78
Q

ACS chain of survival

A

recognition and reaction to STEMI warnings
EMS dispatch and prehosp notification
assessment and diagn in ED
rapid treatment

79
Q

how many pts who die of ACS do so before reaching hospital

A

50%

80
Q

what are the 4 Ds of delay

A

door to data
data to decision
decision to drug

81
Q

ischemic stroke

A

87%

blood clot blocks flow to brain

82
Q

hemorrhagic stroke

A

10%

weakened vessel ruptures and bleeds into brain

83
Q

subarachnoid stroke

A

3%

blood vessel outside brain ruptures

84
Q

time zero

A

last time pt was seen normal

85
Q

ischemic stroke treatment

A

fibrinolytics (rTPA) or ASA if fib are not available

endovascular therapy can remove clot

86
Q

treatment for hemorrhagic or subarachnoid stroke

A

obtain STAT neurologist or neurosugeon consult

avoid fibrinolytic therapy

87
Q

what is the advantage to the CPSS

A

faster <1min

performed by EMS BEFORE hosp arrival

88
Q

CPSS findings

A

facial droop
arm weakness
abnormal speech

89
Q

1 finding of CPSS is what chance of stroke

A

72%

90
Q

3 finding of CPSS is what chance of stroke

A

85%

91
Q

NIHSS

A

NIH stroke scale performed at hosp within 10 min of arrival assess 15 items
higher score= greater impairment

92
Q

what must you do if stroke is suspected?

A

CT scan

only way to diagnose type of stroke

93
Q

3 possible treatments for ischemic stroke

A

fibrin
ASA
endovascular therapy

94
Q

fibrinolytic goal for ischemic stroke

A

within 1 hr hosp arrival

within 3-4.5 hr of symptoms

95
Q

contraindications for fibrinolytics with ischemic stroke

A 
hemorrhagic stroke
sever hypertension
stroke or MI within 3 month
hx intracranial hemorrhage
bleeding risk
96
Q

how long should providers not give ASA after rTPA is administered?

A

24 hr

97
Q

when should endovascular therapy be started for ischemic stroke

A

within 6 hr of symptom onset

98
Q

2 types of endovascular therapy

A

intraarterial rTPA

mechanical clot disruption and retrieval with stent

99
Q

stroke chain of survival

A

recognition and reaction to warning signs
EMS dispatch
EMS transport and prehosp notification
Rapid diagnosis and treatment

100
Q

out of hospital stroke care

A

rapid identification

rapid hospital transport with prehosp notification

101
Q

in hospital stroke care

A

CT scan
fibrinolytic
endovascular
initiation of stroke pathway and admission to stroke unit or ICU

102
Q

acute stroke protocol for EMS 5

A 
1 monitor, iv, oxygen
2 CPSS
3 establish time of onset
4 notify hosp and transfer
5 check glucose
103
Q

acute stroke protocol for ED 5

A 
1- first 10 min:
monitors, iv, o2
NIHSS
activate stroke team
order NON CONTRAST CT
iv/labs/tests
2- within 25 min:
obtain CT, PMH, time of symp,
3- within 45 min:
read and interpret CT
4- within 1 hr:
ischemic stroke start fibrin
hemorrhagic stroke get consult
5- within 3 hr:
begin post rtPA stroke pathway and stroke unit
6- within 6 hr:
endovascualr therapy (if applicable)
104
Q

management in stroke unit or ICU 3

A

1 frequent blood glucose
2 hypertension prevention
3 urgent CT if neurologic status deteriorates

105
Q

at what blood sugar would you give insulin

A

> 185mg/dL

106
Q

ROSC protocol 6

A

1 optimize oxygenation/ventilation
2 obtain 12 lead ecg
3 order appropriate labs
4 consider prophylactic antiarrhythmic therapy
5 maintain normal BP
6 does the pt follow commands? advanced critical care or TTM??

Methods of Anesthesia I (10 decks)

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