ACLS Scenarios Flashcards
Taylor Brundage
2 things for overall approach to scenario
arrive at scene,”universal precautions/safe”
if is awake or has pulse “monitors, iv, oxygen”
what are the 10 different ACLS scenarios
respiratory arrest bradycardia supraventricular tachycardia monomorphic vtach vfib polymorphic vtach (torsades) asystole & PEA acute coronary syndromes (ACS) acute stroke ROSC
respiratory arrest protocol 6
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
narcan IM dose and intranasal dose
IM 0.4mg
intranasal 2mg
what rhythms fall under bradycardia
sinus brady mobitz type 1 and 2 complete heart block afib with slow vent response ventricular or junctional escape rhythm
what are the 3 bradycardia therapies
drugs (epi, atropine, dopamine) transcutaneous pacing (short to initiate) transvenous pacing (long to initiate)
5 steps to perform transcutaneous pacing
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
what are the disadvantages of transcutaneous pacing 4
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
pacing (stimulation) threshold
current when capture is observed
between 40-80mA
capture
when the heart starts beating
maintenance threshold
current which pacemaker should be maintained
10% above pacing threshold
stable bradycardia protocol 3
1 atropine
2 monitor and observe
3 SAMPLE
unstable bradycardia protocol 5
1 monitors, iv, O2 2 atropine 3 consider if atropine ineffective: transcut pacing, epi, dopamine 4 SAMPLE 5 consider consult or transvenous pacing
what rhythms can be considered in the SVT scenario
SVT sinus tach a fib a flutter junctional tach
clincal definition of SVT
tachycardia HR>150bpm caused by reentry
PSVT
paroxysmal SVT
begin and end abruptly (occuring in spasms)
Does ACLS assume that the SVT is AVNRT or AVRT?
AVNRT thus they recommend therapies that slow conduction through the AV node
what are the 4 therapies for SVT
vagal maneuvers adenosine beta blockers calcium channel blockers (ineffective for afib and aflutter)
vagal maneuvers
valsalva maneuver
carotid massage
cold stimulus
stable SVT protocol 7
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)
unstable SVT protocol 5
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)
stable afib/aflutter protocol 3
1 monitors/iv/o2 (if needed)
2 consider expert consilt
3 SAMPLE
unstable afib/aflutter protocol 3
1 monitors/iv/o2 (if needed)
2 immediate synchronized cardioverson
3 SAMPLE
how to perform synchronized cardioverson 6
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
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
what can be used to determine if rhythm is SVT or Vtach?
adenosine
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
unstable (WITH PULSE) monomorphic vtach protocol 3
1 monitors, IV, oxygen (if needed)
2 synchronized cardioversion (sedation? amiodarone?)
3 SAMPLE
what are the pulseless rhythms
vfib (and sometimes vtach monomorphic vtach torsades PEA asystole
course vfib
higher waves
more chance of conversion
fine vfib
smaller waves
appears after course vfib
less chance of conversion
polymorphic vtach
torsades de pointes
has prolonged QT intervals
do you defibrillate pts in asystole?
no
what do you do when a pt is in asystole 3
CPR
epi
treat any reversible causes
PEA
pt has no pulse but ECG showing electrical activity
physiology of PEA
heart does not contract
insufficient CO to generate pulse and perfuse organs
treatment for PEA
1 CPR
2 epi
3 treat any reversible causes
do you treat PEA with defibrillation?
NO
shockable pulseless
vfib
vtach
torsades
NON shockable pulseless
asystole
PEA
what is the only effective treatment for pulseless vfib/vtach
defib
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
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
how to perform defibrillation 5
1 place pads posterior anterior or anterior anterior 2 knob to defib 3 select 200J 4 charge 5 shock
polymorphic vtach proto
1 CPR 2 defib ASAP 3 resume CPR 4 analyze and check pulse repeat
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
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
4 types of ecg in ACS
stemi
nstemi st depression
nstemi t inversion
normal ecg
what is stemi caused by
completely blocked coronary artery
diagnosed with 12 lead ecg st elevation
which ecg in ACS is the highest risk?
STEMI
what is nstemi caused by
partially blocked coronary artery from platelet thrombus
ST depression or T inversion
which is the lowest risk ecg for ACS
normal ecg
why is the 12 lead ecg so important in ACLS
ONLY WAY of identifying STEMI
sufficient enough to start therapy without labs
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)
what is the most common cause of ACS
plaque rupture
what are the possible therapies for ACS
MONA
Heparin
reperfusion therapy
MONA
morphine
oxygen
NTG
ASA
reperfusion therapy
fibrinolytics (rTPA)
percutaneous coronary intervention (PCI, balloon and stent)
what is the goal of ACS pts?
relieve ischemic chest pain
NTG or morphine
only morphine when nitrates dont work
what should you do if morphine causes hypotension
fluid bolus
what pts should you use caution with morphine
NSTEMI bc may be associated with increase in mortality
oxygen therapy in ACS
spo2<90 yes O2
SpO2 >90 may consider withholding O2
NTG dose
3 sublingual NTG tabs (0.4mg) every 3-5 min
may be repeated twice (tot of 3 doses)
when should you avoid NTG?
hypotensive pts SBP<90, or 30 below baseline
pts with inadequate preload (recent MI or vasodilator)
PDEi
what should you do if pt becomes hypotensive after NTG?
fluid bolus
ASA dose
160-325mg PO chewed
other method for ASA administration
rectal
what is the goal time to administer PCI within mins of arrival?
90min
door to balloon time <120min if nonPCI hosp
what is considered if PCI cannot be initiated within 90-120 min
fibrinolytic therapy
only for STEMI pts
time goal for fibrinolytic therapy
within 30 min of arrival
at what time length of symptoms being present should you not administer fibrinolytics?
> 12hr
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
STEMI treatment 4
1 MONA
2 Start reperfusion with PCI or fibrinolytics
3 start heparin
4 consider CABG
NSTEMI treatment 4
1 MONA
2 Consider reperfusion with PCI
3 Start adunctive therapies (NTG, heparin)
4 avoid fibrinolytics
low risk normal ecg ACS treatment
consider admission ED chest pain unit or consult
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
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
ACS chain of survival
recognition and reaction to STEMI warnings
EMS dispatch and prehosp notification
assessment and diagn in ED
rapid treatment
how many pts who die of ACS do so before reaching hospital
50%
what are the 4 Ds of delay
door to data
data to decision
decision to drug
ischemic stroke
87%
blood clot blocks flow to brain
hemorrhagic stroke
10%
weakened vessel ruptures and bleeds into brain
subarachnoid stroke
3%
blood vessel outside brain ruptures
time zero
last time pt was seen normal
ischemic stroke treatment
fibrinolytics (rTPA) or ASA if fib are not available
endovascular therapy can remove clot
treatment for hemorrhagic or subarachnoid stroke
obtain STAT neurologist or neurosugeon consult
avoid fibrinolytic therapy
what is the advantage to the CPSS
faster <1min
performed by EMS BEFORE hosp arrival
CPSS findings
facial droop
arm weakness
abnormal speech
1 finding of CPSS is what chance of stroke
72%
3 finding of CPSS is what chance of stroke
85%
NIHSS
NIH stroke scale performed at hosp within 10 min of arrival assess 15 items
higher score= greater impairment
what must you do if stroke is suspected?
CT scan
only way to diagnose type of stroke
3 possible treatments for ischemic stroke
fibrin
ASA
endovascular therapy
fibrinolytic goal for ischemic stroke
within 1 hr hosp arrival
within 3-4.5 hr of symptoms
contraindications for fibrinolytics with ischemic stroke
hemorrhagic stroke sever hypertension stroke or MI within 3 month hx intracranial hemorrhage bleeding risk
how long should providers not give ASA after rTPA is administered?
24 hr
when should endovascular therapy be started for ischemic stroke
within 6 hr of symptom onset
2 types of endovascular therapy
intraarterial rTPA
mechanical clot disruption and retrieval with stent
stroke chain of survival
recognition and reaction to warning signs
EMS dispatch
EMS transport and prehosp notification
Rapid diagnosis and treatment
out of hospital stroke care
rapid identification
rapid hospital transport with prehosp notification
in hospital stroke care
CT scan
fibrinolytic
endovascular
initiation of stroke pathway and admission to stroke unit or ICU
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
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)
management in stroke unit or ICU 3
1 frequent blood glucose
2 hypertension prevention
3 urgent CT if neurologic status deteriorates
at what blood sugar would you give insulin
> 185mg/dL
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??
