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”
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
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
4
Q
narcan IM dose and intranasal dose
A
IM 0.4mg
intranasal 2mg
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
6
Q
what are the 3 bradycardia therapies
A
drugs (epi, atropine, dopamine) transcutaneous pacing (short to initiate) transvenous pacing (long to initiate)
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
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
9
Q
pacing (stimulation) threshold
A
current when capture is observed
between 40-80mA
10
Q
capture
A
when the heart starts beating
11
Q
maintenance threshold
A
current which pacemaker should be maintained
10% above pacing threshold
12
Q
stable bradycardia protocol 3
A
1 atropine
2 monitor and observe
3 SAMPLE
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
14
Q
what rhythms can be considered in the SVT scenario
A
SVT sinus tach a fib a flutter junctional tach
15
Q
clincal definition of SVT
A
tachycardia HR>150bpm caused by reentry
16
Q
PSVT
A
paroxysmal SVT
begin and end abruptly (occuring in spasms)
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
18
Q
what are the 4 therapies for SVT
A
vagal maneuvers adenosine beta blockers calcium channel blockers (ineffective for afib and aflutter)
19
Q
vagal maneuvers
A
valsalva maneuver
carotid massage
cold stimulus
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)
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)
22
Q
stable afib/aflutter protocol 3
A
1 monitors/iv/o2 (if needed)
2 consider expert consilt
3 SAMPLE
23
Q
unstable afib/aflutter protocol 3
A
1 monitors/iv/o2 (if needed)
2 immediate synchronized cardioverson
3 SAMPLE
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
25
therapies for ventriculare tachyarrhythmias 6
```
1 synchronized cardioversion (pulse) or defib (no pulse)
2 epi (pulseless)
3 amiodarone
4 procainamide
5 lidocaine
5 magnesium
6 adenosine
```
26
what can be used to determine if rhythm is SVT or Vtach?
adenosine
27
stable monomorphic vtach WITH PULSE protocol 5
```
1 monitors, IV, O2 (if needed)
2 antiarrhythmics (150 amiodarone over 10min)
3 expert consult
4 consider synchronized cardioversion
5 SAMPLE
```
28
unstable (WITH PULSE) monomorphic vtach protocol 3
1 monitors, IV, oxygen (if needed)
2 synchronized cardioversion (sedation? amiodarone?)
3 SAMPLE
29
what are the pulseless rhythms
```
vfib (and sometimes vtach
monomorphic vtach
torsades
PEA
asystole
```
30
course vfib
higher waves
| more chance of conversion
31
fine vfib
smaller waves
appears after course vfib
less chance of conversion
32
polymorphic vtach
torsades de pointes
| has prolonged QT intervals
33
do you defibrillate pts in asystole?
no
34
what do you do when a pt is in asystole 3
CPR
epi
treat any reversible causes
35
PEA
pt has no pulse but ECG showing electrical activity
36
physiology of PEA
heart does not contract
| insufficient CO to generate pulse and perfuse organs
37
treatment for PEA
1 CPR
2 epi
3 treat any reversible causes
38
do you treat PEA with defibrillation?
NO
39
shockable pulseless
vfib
vtach
torsades
40
NON shockable pulseless
asystole
| PEA
41
what is the only effective treatment for pulseless vfib/vtach
defib
42
vfib and pulseless monomorphic vtach protocol 7
```
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
```
43
throughout CPR (monomorphic vtach) what should you be doing? 5
```
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
how to perform defibrillation 5
```
1 place pads posterior anterior or anterior anterior
2 knob to defib
3 select 200J
4 charge
5 shock
```
45
polymorphic vtach proto
```
1 CPR
2 defib ASAP
3 resume CPR
4 analyze and check pulse
repeat
```
46
throughout CPR torsades what should you be doing 5
```
1 epi 1mg every 3-5min
2 magnesium 1-2g
3 Hs and Ts
4 intubation capnog and steroids
5 hypothermia if ROSC
```
47
asystole and PEA protocol 5
```
1 CPR
2 epi 1mg every 3-5 min
3 Hs and Ts
4 intub capnog steroids
5 hypotherm if ROSC
```
48
4 types of ecg in ACS
stemi
nstemi st depression
nstemi t inversion
normal ecg
49
what is stemi caused by
completely blocked coronary artery
| diagnosed with 12 lead ecg st elevation
50
which ecg in ACS is the highest risk?
STEMI
51
what is nstemi caused by
partially blocked coronary artery from platelet thrombus
| ST depression or T inversion
52
which is the lowest risk ecg for ACS
normal ecg
53
why is the 12 lead ecg so important in ACLS
ONLY WAY of identifying STEMI
| sufficient enough to start therapy without labs
54
ACS etiology 6
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
what is the most common cause of ACS
plaque rupture
56
what are the possible therapies for ACS
MONA
Heparin
reperfusion therapy
57
MONA
morphine
oxygen
NTG
ASA
58
reperfusion therapy
fibrinolytics (rTPA)
| percutaneous coronary intervention (PCI, balloon and stent)
59
what is the goal of ACS pts?
relieve ischemic chest pain
NTG or morphine
only morphine when nitrates dont work
60
what should you do if morphine causes hypotension
fluid bolus
61
what pts should you use caution with morphine
NSTEMI bc may be associated with increase in mortality
62
oxygen therapy in ACS
spo2<90 yes O2
| SpO2 >90 may consider withholding O2
63
NTG dose
3 sublingual NTG tabs (0.4mg) every 3-5 min
| may be repeated twice (tot of 3 doses)
64
when should you avoid NTG?
hypotensive pts SBP<90, or 30 below baseline
pts with inadequate preload (recent MI or vasodilator)
PDEi
65
what should you do if pt becomes hypotensive after NTG?
fluid bolus
66
ASA dose
160-325mg PO chewed
67
other method for ASA administration
rectal
68
what is the goal time to administer PCI within mins of arrival?
90min
| door to balloon time <120min if nonPCI hosp
69
what is considered if PCI cannot be initiated within 90-120 min
fibrinolytic therapy
| only for STEMI pts
70
time goal for fibrinolytic therapy
within 30 min of arrival
71
at what time length of symptoms being present should you not administer fibrinolytics?
>12hr
72
contraindications fibrinolytics 6
```
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
STEMI treatment 4
1 MONA
2 Start reperfusion with PCI or fibrinolytics
3 start heparin
4 consider CABG
74
NSTEMI treatment 4
1 MONA
2 Consider reperfusion with PCI
3 Start adunctive therapies (NTG, heparin)
4 avoid fibrinolytics
75
low risk normal ecg ACS treatment
consider admission ED chest pain unit or consult
76
ACS protocol EMS
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
ACS protocol in Hospital 6
```
1 monitors, iv, oxygen
2 MONA
3 12 lead ecg
4 IV/labs/CXR
5 PMH
6 determine treatment based on ECG
```
78
ACS chain of survival
recognition and reaction to STEMI warnings
EMS dispatch and prehosp notification
assessment and diagn in ED
rapid treatment
79
how many pts who die of ACS do so before reaching hospital
50%
80
what are the 4 Ds of delay
door to data
data to decision
decision to drug
81
ischemic stroke
87%
| blood clot blocks flow to brain
82
hemorrhagic stroke
10%
| weakened vessel ruptures and bleeds into brain
83
subarachnoid stroke
3%
| blood vessel outside brain ruptures
84
time zero
last time pt was seen normal
85
ischemic stroke treatment
fibrinolytics (rTPA) or ASA if fib are not available
| endovascular therapy can remove clot
86
treatment for hemorrhagic or subarachnoid stroke
obtain STAT neurologist or neurosugeon consult
| avoid fibrinolytic therapy
87
what is the advantage to the CPSS
faster <1min
| performed by EMS BEFORE hosp arrival
88
CPSS findings
facial droop
arm weakness
abnormal speech
89
1 finding of CPSS is what chance of stroke
72%
90
3 finding of CPSS is what chance of stroke
85%
91
NIHSS
NIH stroke scale performed at hosp within 10 min of arrival assess 15 items
higher score= greater impairment
92
what must you do if stroke is suspected?
CT scan
| only way to diagnose type of stroke
93
3 possible treatments for ischemic stroke
fibrin
ASA
endovascular therapy
94
fibrinolytic goal for ischemic stroke
within 1 hr hosp arrival
| within 3-4.5 hr of symptoms
95
contraindications for fibrinolytics with ischemic stroke
```
hemorrhagic stroke
sever hypertension
stroke or MI within 3 month
hx intracranial hemorrhage
bleeding risk
```
96
how long should providers not give ASA after rTPA is administered?
24 hr
97
when should endovascular therapy be started for ischemic stroke
within 6 hr of symptom onset
98
2 types of endovascular therapy
intraarterial rTPA
| mechanical clot disruption and retrieval with stent
99
stroke chain of survival
recognition and reaction to warning signs
EMS dispatch
EMS transport and prehosp notification
Rapid diagnosis and treatment
100
out of hospital stroke care
rapid identification
| rapid hospital transport with prehosp notification
101
in hospital stroke care
CT scan
fibrinolytic
endovascular
initiation of stroke pathway and admission to stroke unit or ICU
102
acute stroke protocol for EMS 5
```
1 monitor, iv, oxygen
2 CPSS
3 establish time of onset
4 notify hosp and transfer
5 check glucose
```
103
acute stroke protocol for ED 5
```
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
management in stroke unit or ICU 3
1 frequent blood glucose
2 hypertension prevention
3 urgent CT if neurologic status deteriorates
105
at what blood sugar would you give insulin
>185mg/dL
106
ROSC protocol 6
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??
