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Methods II > ACLS Scenarios > Flashcards

ACLS Scenarios Flashcards

1
Q

When is Narcan used in ACLS?

A

When respiratory distress or cardiac arrest from opioid overdose is suspected

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2
Q

What are 2 ways Narcan can be administered?

What are the doses of each?

A

intramuscular: 0.4 mg
intranasal: 2 mg
* doses can be repeated after 4 minutes

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3
Q

3 drugs used for bradycardia

A
  1. epi
  2. atropine
  3. dopamine
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4
Q

What is the disadvantage of transcutaneous pacing?

A

does not produce as effective capture as trans venous pacing

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5
Q

What is the preferred method of pacing for emergent, unstable bradycardia?

A

transcutaneous pacing

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6
Q

What is the better pacing option for stable bradycardia?

A

transvenous pacing

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7
Q

What is the 3 step protocol for stable bradycardia?

A
  1. atropine
  2. monitor and observe
  3. SAMPLE
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8
Q

What is the 5 step protocol for unstable bradycardia?

A
  1. Monitors, IV, Oxygen
  2. Atropine
  3. consider transcutaneous pacing, epi, dopamine
    * if atropine is ineffective
  4. SAMPLE
  5. consult or transvenous pacing
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9
Q

Clinically, a HR is considered SVT when:

  1. the HR is ____
  2. the QRS complex is _____
  3. difficult to differentiate between _____ and _____
A
  1. > 150 bpm
  2. normal width
  3. sinus tach and junctional tach (p waves may or may not be present)
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10
Q

is SVT an emergency?

A

yes,

ventricular filling time is greatly reduced and this reduces cardiac output

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11
Q

What is paroxysmal SVT?

A

SVT that begins and ends abruptly (occurs in spasms)

-need to witness the stopping/starting on ECG

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12
Q

What is the BIG difference between SVT and afib/flutter?

A

AV node is part of the SVT re-entrant circuit, but NOT part of afib/flutter pathway

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13
Q

most types of SVT occur within the _____

A

AV node

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14
Q

For SVT, recommended therapies will ______ conduction through the _____

A

slow, AV node

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15
Q

What are 5 treatment options for SVT

A
  1. Vagal maneuvers
    - carotid massage
    - cold stimulus to the face
    - valsalva maneuver
  2. Adenosine
  3. Beta blockers (sotalol)
  4. Ca2+ channel blockers (cardizem)
  5. synchronized cardioversion
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16
Q

What is the treatment for afib/flutter?

A

synchronized cardioversion

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17
Q

What are 2 other drugs that can treat SVT that are not part of the ACLS protocol?

A
  1. amiodarone

2. Procainamide

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18
Q

What type of patients should a carotid massage be avoided?

A

geriatric patients or patients with hx of stroke or high cholesterol

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19
Q

SVT usually refers to a (narrow/wide) tachycardia with a more (regular/irregular) rhythm

A

narrow

regular

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20
Q

Afib usually manifests as a (narrow/wide) tachycardia with a more (regular/irregular) rhythm

A

narrow

irregular

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21
Q

atrial flutter can be (regular, irregular, both) rhythm

A

both

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22
Q

What is the only reason to use AV nodal blockers in Afib/flutter?

A

to slow down the HR in SVT to better diagnose the arrhythmia (SVT, Afib, Aflutter)

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23
Q

What is the only difference in treatment for stable vs unstable SVT?

A

in unstable SVT you perform immediate synchronized cardioversion before administration of adenosine

In stable SVT you will try vagal maneuvers first

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24
Q

What is the first thing you should do when you encounter a patient in SVT? (stable or unstable)

A

monitors, IV, oxygen

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25
Q

What is the dose of adenosine for SVT

A

1st dose of 6mg

then 2nd dose of 12mg if needed

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26
Q

What is the main difference in treatment for stable vs unstable afib/flutter

A

in stable afib/flutter you just consider expert consult

in unstable afib/flutter you will do immediate synchronized cardioversion

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27
Q

What is the therapy for ventricular tachyarrhythmias when the patient is pulseless?

A

defibrillation

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28
Q

What is the therapy for ventricular tachyarrhythmias when the patient has a pulse?

A

synchronized cardioversion

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29
Q

What are the 4 drugs used to treat ventricular tachyarrhythmias and what are the doses?

A
  1. epi (if pt is pulseless)
  2. Amiodarone
  3. Procainamide
  4. Lidocaine
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30
Q

What is the dose of epi for a pulseless ventricular tachyarrhythmia?

A

1 mg every 3-5 minutes

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31
Q

What is the dose of amiodarone for a patient that is pulseless?

A

300 mg bolus

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32
Q

what is the dose of amiodarone for a patient that has a pulse?

A

150 mg over 10 minutes

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33
Q

What is the dose of Procainamide for ventricular tachyarrhythmias?

A

20-50 mg/ min

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34
Q

What is the dose of lidocaine for ventricular tachyarrhythmias?

A

100 mg IV

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35
Q

What is the drug used for Torsades de Pointes and what is the dose?

A

1-2 g Magnesium IV

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36
Q

What is adenosine used for in ventricular tachyarrhythmias?

A

diagnose what type of arrhythmia it is

If adenosine converts the rhythm, it was likely SVT

If the rhythm doesn’t convert after adenosine, Vtach is more likely

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37
Q

What is the main difference in treatment for Stable Monomorphic Vtach with a pulse VS Unstable Monomorphic Vtach (but not pulseless)?

A

In stable Monomorphic Vtach, administer antiarrhythmics (150 mg of amiodarone over 10 minutes) and expert consult

in Unstable (with a pulse) Monomorphic Vtach, perform synchronized cardioversion

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38
Q

Course Vfib has (higher/ lower) waves and a (more/less) chance of conversion

A

higher

more

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39
Q

fine Vfib has (higher/lower) waves and a (more/less) chance of conversion

A

lower
less

appears after course Vfib

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40
Q

If a patient is in asystole, what are the 3 treatments we can perform?

A
  1. CPR
  2. Epi
  3. treat any reversible causes
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41
Q

What are the non-shockable pulseless rhythms?

A

asystole, PEA

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42
Q

What is PEA?

A

when the patient has no pulse but the ECG is showing an organized electrical rhythm

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43
Q

What are the 2 most common reversible causes of PEA?

A
  1. Hypoxia

2. Hypovolemia

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44
Q

What are the 3 shockable pulseless rhythms?

A

Vfib
Vtach
Torsades de Pointes

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45
Q

can procainamide be used in pulseless rhythms?

A

no

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46
Q

What is the most common initial rhythm in sudden cardiac arrest?

A

Vfib

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47
Q

What is the only effective treatment for pulseless Vfib/ Vtach?

A

defibrillation

48
Q

What is the main reason we use Epi in cardiac arrest?

A

to increase myocardial blood flow

49
Q

What is the 1st step and the repeat cycle used for pulseless Vfib and pulseless monomorphic Vtach?

A
  1. CPR

2. then defibrillate, CPR, analyze

50
Q

When is Epi given in Vfib and pulseless monomorphic Vtach?

A

after the 2nd shock attempt

51
Q

If Epi and defibrillation are not effective in Vfib and pulseless monomorphic Vtach, what is the next therapy considered?

A

300 mg Amiodarone bolus given after the 3rd shock attempt

  • can give a second dose of 150 mg if code continues
52
Q

If a patient achieves ROSC after Vfib and pulseless monomorphic Vtach, what therapy should be considered?

A

hypothermia

53
Q

What is the only difference in the treatment protocol for vfib/ monomorphic Vtach VS polymorphic Vtach?

A

in polymorphic Vtach, we administer 1-2 g of Magnesium instead of amiodarone after the administration of Epi

54
Q

Which ECG is the highest risk in acute coronary syndrome?

A

STEMI

55
Q

What are the 2 types of NSTEMI ECGs in acute coronary syndrome?

A
  1. Non ST elevation with T-wave inversion

2. Non ST elevation with ST depression

56
Q

acute coronary syndrome that is diagnosed by either ST depression or T wave inversion

A

NSTEMI

57
Q

Which ECG is caused by a partially blocked coronary artery?

A

NSTEMI

58
Q

Which ECG is caused by a completely blocked coronary artery that leads to a heart attack, and is considered the highest risk ECG (because cardiac arrest can occur at any time)

A

STEMI

59
Q

this is considered the lowest risk out of the different types of ECGs found in ACS

A

unstable angina with a normal ECG

60
Q

What type of ECG is needed for detecting a STEMI?

A

12 -lead ECG

61
Q

What is the most common cause of ACS?

A

When an inflamed plaque weakens and ruptures

62
Q

What are the 3 therapies for ACS in ACLS?

A
  1. MONA
  2. Heparin
  3. Reperfusion therapy
63
Q

What does MONA stand for in ACS?

and how should it be prioritized?

A

Morphine
Oxygen
Nitrates
Aspirin

Prioritized as OANM

64
Q

When should morphine be considered in ACS?

A

for STEMI only

-when unresponsive to nitrates

65
Q

What are the 2 types of reperfusion therapy in ACS?

A
  1. PCI (treatment of choice)
    - balloon angioplasty/stent
  2. Fibrinolytic Therapy (anticoagulation)
    - streptokinase, recombinant tissue, plasminogen activator (rTPA)
66
Q

When are fibrinolytics considered in ACS?

A

for STEMI only

67
Q

At what SpO2 should the provider consider withholding oxygen in ACS?

A

when the SpO2 is ≥ 90%,

68
Q

What is the ACLS dose of Nitroglycerin

A

3 sublingual tablets (0.4 mg) every 3-5 min

-dose may be repeated twice for a total of 3 doses

69
Q

When should nitroglycerin be avoided?

A
  1. Hypotensive patients (SBP ≤90 mmHg or 30mmHg below baseline)
  2. Patients with inadequate preload
    Recent MI, recent vasodilator (ex: PDEi) use
70
Q

If the patient becomes hypotensive after NTG administration, what should you do?

A

fluid bolus

71
Q

What is the PO dose of aspirin?

A

160-325 mg

-absorbed better when chewed and not swallowed

72
Q

If the patient has a hx of current N/V, PUD, or other upper GI disorders, what is the preferred route and dose of aspirin?

A

rectal administration of 300 mg

73
Q

What is the only NSAID allowed for ACS syndromes?

A

Aspirin

74
Q

What is commonly given early (as an adjunct to PCI and fibrinolytic therapy) in STEMI patients

A

Heparin

-unfractioned or low molecular weight

75
Q

What is the goal time to administer PCI?

A

within 90 minutes of arrival

76
Q

What is the goal time to administer time when the patient needs to be transferred from a “non-PCI” hospital to a “PCI” hospital?

A

“door to balloon” time can be ≤ 120 minutes

77
Q

When are fibrinolytics most often considered in STEMI patients?

A

if it is anticipated that PCI will not be able to be initiated within 90-120 minutes

78
Q

Fibrinolytics are ONLY considered for (NSTEMI /STEMI / both)

A

STEMI

79
Q

if choosing a fibrinolytic therapy, what is the goal time for administration?

A

within 30 minutes of arrival

80
Q

Fibrinolytics should not be administered if ACS symptoms have been present for ______

A

≥12 hours

81
Q

6 contraindications for Fibrinolytics

A
  1. NSTE ACS (NSTEMI) patients
  2. Hypertension
    (>180-200mmHg SBP or 100-110mmHg DBP)
  3. patients with recent head trauma or GI bleed
  4. Patients taking blood thinners
  5. Patients with stroke symptoms > 3 hours
  6. if symptoms have been present for >12 hours
82
Q

What type of stroke occurs when a blood clot blocks blood flow to the brain?

A

Ischemic stroke

83
Q

What type of stroke occurs when a weakened vessel ruptures and bleeds into the surrounding brain

A

hemorrhagic stroke

84
Q

What type of stroke occurs when a blood vessel just outside the brain ruptures

A

subarachnoid stroke

85
Q

This is the last time the patient was seen normal

A

Time Zero

86
Q

How is an ischemic stroke primarily treated?

A

fibrinolytics (rtPA)

  • aspirin can be given if these are not available
  • clot can be removed with endovascular therapy
87
Q

What are the 2 management points for hemorrhagic stroke?

A
  1. STAT neurologist or neurosurgeon consult

2. avoid fibrinolytic therapy

88
Q

What is the management for subarachnoid stroke?

A

the same as hemorrhagic stroke

89
Q

What are the 3 physical findings on the Cincinnati Prehospital Stroke Scale?

A
  1. Facial droop
  2. arm weakness
  3. abnormal speech
90
Q

______ is a prehospital stroke scale performed by EMS, so it should be performed by EMS BEFORE hospital arrival

A

Cincinnati Prehospital Stroke Scale (CPSS)

91
Q

the _____ is an “in hospital” stroke scaled used to quantify the level of impairment caused by a stroke

A

NIH stroke scale (NIHSS)

92
Q

in the NIHSS, (higher/lower) scores indicate greater level of impairment

A

higher

93
Q

When should the NIHSS be performed?

A

within 10 minutes of arriving at the ED

*after the CPSS

94
Q

What is the only way that we can diagnose whether or not the stroke is ischemic or hemorrhagic?

A

obtaining a CT scan

-cannot treat a stroke until the CT scan is obtained

95
Q

What is the preferred drug therapy for ischemic stroke?

A

fibrinolytics

96
Q

The goal for ischemic stroke is to give fibrinolytics:

  1. within ______ of hospital arrival
  2. within _____ of symptom onset
A 
1 hour
3 hours (3-4.5 hours)
97
Q

providers should not give ASA for at least ____ after rtPA is administered

A

24 hours

98
Q

If fibrinolytics are contraindicated, what is an alternative drug option for ischemic stroke?

A

aspirin (ASA)

*perform swallowing screen before administration and if it fails, give rectally

99
Q

What is a type of therapy used for ischemic stroke if fibrinolytics are contraindicated?

A

endovascular therapy

  1. intra-arterial rtPA
  2. mechanical clot disruption and retrieval with a stent
100
Q

When should endovascular therapy be started for ischemic stroke?

A

within 6 hours of symptom onset

101
Q

What is the main lab that should be ordered in an acute stroke protocol within the first 10 minutes?

A

glucose test

-hypoglycemia

102
Q

What are the 4 things that should be done within 10 minutes of an acute stroke?

A
  1. monitors, IV, oxygen
  2. Perform neurologic screening assessment (CPSS or NIHSS) and activate the stroke team
  3. Order an urgent non-contrast CT scan
  4. Get IV labs/tests (glucose and 12 lead ECG to rule out Afib)
103
Q

What are the 3 things that should be done within 25 minutes of an acute stroke?

A
  1. Obtain the CT scan
  2. Perform NIHSS or Canadian stroke scale
  3. obtain a past medical hx
104
Q

What should you do within 45 minutes of an acute stroke?

A

Read and interpret the CT scan

105
Q

What should you do within 1 hour of an ischemic stroke?

A
  1. administer fibrinolytics

2. administer ASA if fibrinolytics are contraindicated

106
Q

What should you do within 1 hour of a hemorrhagic stroke?

A

get a consult, admit to ICU or stroke unit and begin stroke/hemorrhage pathway

107
Q

What should be done within the first 3 hours of an acute stroke?

A

Begin the post rtPA stroke pathway by admitting to the stroke unit or ICU

108
Q

What should be done within 6 hours of an acute stroke?

A

Initiate endovascular therapy

109
Q

What are the 3 items that make up the Post rtPA stroke pathway?

A
  1. frequently check blood glucose levels
    - blood sugars should be treated with insulin if glucose is > 185mg/dL
  2. avoid hypertension in patients who have received rtPA in order to reduce the risk of intracerebral hemorrhage
  3. an urgent CT scan should be ordered if neurologic status deteriorates
110
Q

in ROSC, what should the SpO2 be?

A

94-99%

111
Q

In ROSC, how should the patient be ventilated if unconscious?

A

intubate and use capnography

-avoid hyperventilation

112
Q

In ROSC, what should the capnography EtCO2 be maintained at?

A

35-40 mmHg

113
Q

What antiarrythmics should be used in ROSC?

A

lidocaine
beta blockers
amiodarone

114
Q

How should you treat hypotension in ROSC?

A
  1. 1-2 L fluid bolus
  2. Vasopressors
    Epi (0.1-0.5mcg/kg/min), Dopamine (5-10mcg/kg/min), or Norepinephrine (0.1-0.5mcg/kg/min)
115
Q

If the patient does not follow commands in ROSC, what should be initiated?

A

TTM (target temperature management)

Methods II (11 decks)

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