ACLS Study Guide 8/2011 Flashcards
An endotracheal intubation attempt should be accomplished in a specific amount of time. At what point does this time interval begin and end?
The time interval begins when ventilations are ceased; it ends when the tube has been successfully placed and the ventilations are resumed.
According to AHA guidelines, when ventilating a patient during a cardia or respiratory arrest, the respiratory rate should be what?
8-10 breaths/minute
A 78 year old female has suffered a respiratory arrest. You have intubated the patient and note there is an absence of chest wall movement with bag-valve device ventilation and you are unable to auscultate breath sounds on either side of the chest. What is the most likely cause of this situation?
esophageal intubation
Which points are true about the oropharyngeal airway (OPA)? 1. Can only be used in spontaneously breathing patients 2. Is usually well tolerated in the conscious or semi conscious patient 3. should be used when possible for unconscious patients who are not intubated. 4. May result in airway obstruction if improperly inserted. 5. Should be lubricated prior to insertion.
- Not true. 2. Not true. 3. True. 4. True. 5. Not true.
You are attempting to intubate an adult patient who has suffered a respiratory arrest. A capable assistant is applying cricoid pressure. At what point should cricoid pressure be released?
It should be maintained until the endotracheal tube cuff is inflated.
Which is true about endotracheal intubation? 1. Is contraindicated in unresponsive patients 2. must be initially attempted by tactile methods 3. should be preceded by efforts to ventilate by another method. 4. when attempted, should be performed in 60 seconds or less.
- False 2. False 3. True 4. False (should be 30 seconds or less)
Which of the following are appropriate features of the bag-valve mask device? 1. it should have an oxygen inlet at the back of the bag 2. it should not have a non-rebreathing valve 3. has a pop-off valve 4. the ability to function in all environmental conditions 5. a pliable black plastic face mask
- true 2. true 3. false 4. true 5. false
When tracheal suction is performed, how/when is suction applied?
Only during withdrawal of the catheter
You have intubated a 60 year old female patient in cardiac arrest. Which of the following would indicate inadvertent esophageal intubation?
Gurgling sounds heard over the epigastrium absent lung sounds absence of condensation in ET tube No ETCO2 reading
What is tidal volume?
The volume of air exchanged in a normal breath
True or false. An endotracheal intubation attempt should not take more than 30 seconds.
True
What is the carina?
It is the point where the trachea bifurcates into the right and left mainstem bronchi
With an oxygen flow rate of 1-6 liters/minute, a nasal canula can deliver an estimated oxygen concentration of:
24-44%
Which are true about endotracheal intubation? 1. eliminates the risk of aspiration 2. should be accomplished in 30 seconds or less 3. permits tracheal suction 4. provides a route for the administration of atropine, lidocaine, and epinephrine.
- false 2. true 3. true 4. true
What is the proper flow rate to be used with a nasal canula?
1-6 liters/minute
Anatomically, where is the carina located?
In the arch of the aorta. Not at the level of the sternal angle, in the posterior oropharynx, or anterior to the epiglottis.
Inadvertent esophageal intubation with an endotracheal tube is a potentially fatal complication if it is not immediately identified. True or false?
True.
A 62 year old male has suffered a respiratory arrest and has just been intubated with an ET tube. When assessing the placement, you observe no chest wall movement with ventilations and are unable to auscultate breath sounds on either side of the chest. What will you do next?
Remove the tube and ventilate with a bag-valve device
The average tidal volume that should be delivered when ventilating and adult with a bag-valve device is:
10-15 ml/kg
When using a simple face mask, why must the oxygen flow rate be higher than 5 liters per minute?
To avoid the accumulation of exhaled air in the mask
What is the minimum oxygen flow rate that should be used with a simple face mask?
6 liters/minute
A 61 year old male has suffered a respiratory arrest. An ET tube has been correctly placed and you are preparing to ventilate the patient with a bag-valve device. What oxygen liter flow rate should be used when ventilating this patient?
At least 15 liters/minute
Which of the following is not a desirable feature of a bag-valve device? 1. Non-rebreathing valve. 2. compressible, self-refilling bag 3. pop-off (pressure release) valve 4. availability in adult and pediatric sizes
- Is desirable 2. Is desirable 3. Not desirable 4. Is desirable
What is the proper method for insertion of an oropharyngeal airway (OPA) in the adult patient?
Inserted upside down into the mouth and rotated 180 degrees when the distal tip reaches the soft palate
The tip of the straight laryngoscope blade is placed where?
Under the epiglottis
Your patient is a 67 year old male who has suffered a cardiopulmonary arrest. The preferred technique for management of this patient’s airway is what?
Insertion of an OPA and ventilating with a bag-valve device until ET intubation can be performed
You have just intubated a 68 year old male. You auscultate breath sounds on the right side of the chest and hear little, if any, sound on the left chest. What corrective action would you take?
Deflate the endotracheal tube cuff, pull back the tube slightly, re-inflate the endotracheal tube cuff, and reassess breath sounds.
Which two anatomical landmarks are used when measuring for proper OPA size?
Corner of the lips and angle of the jaw
Non-rebreathing oxygen masks with reservoirs can yield oxygen concentrations of what?
90-100%
Which of the following are possible complications of suctioning? 1. increased arterial pressure and tachycardia 2. may trigger coughing, resulting in increased intracranial pressure 3. sever hypoxia 4. bradycardia and hypotension due to vagal stimulation 5. damage to the mucosa
All are possible complications of suctioning
Which of the following, in regards to bag-valve devices, are true? 1. non-intubated patients are more effectively ventilated when two people work together 2. adult devices should not have pop-off valves 3. pediatric devices should have pop off valves 4. tidal volumes to be delivered via these units should be 10-15 ml/kg 5. should have the ability to perform adequately in all environmental temperatures.
- true 2. true 3. not true 4. true 5. true
The approximate percentage of oxygen delivered by a simple face mask at 8-10 liters/minute is:
40-60%
The tip of the curved laryngoscope blade is placed where?
In the vallecula
When the oropharyngeal airway has been properly measured and placed, the proximal end should:
Protrude approximately 1/2 inch from the patient’s lips
A bag-valve device WITHOUT an attached reservoir which does have supplemental oxygen flowing at 12-15 liters/minute provides what percentage of oxygen?
70-90%
Which is true regarding the simple face mask? 1. Provides definitive control of the airway 2. preferred device for use in COPD patients because it provides precise O2 concentrations 3. the oxygen flow rate must be greater than 5 liters/minute 4. can be used effectively to deliver high concentrations of oxygen for the apneic patient
- Not true 2. Not true 3. True - the minimum setting must be 6 liters/minute to avoid the accumulation of exhaled air 4. Not true
What is the first positive deflection seen on the ECG after the P wave?
R wave
How would you differentiate a junctional escape rhythm at 40 beats/minute from a ventricular escape rhythm at the same rate?
The junctional escape rhythm will have a narrow QRS complex while the ventricular escape rhythm will have a wide QRS complex.
Where is the positive electrode placed in lead MCL1?
Right sternal border, 4th intercostal space
The normal pacemaker of the heart is called the what? And where is it located?
the SA node, located in the right atrium
The QT interval is measured how?
The beginning of the Q wave to the beginning of the T wave
Which of the following are true of the absolute refractory period? 1. no matter how strong a stimulus, the myocardium cannot be stimulated to depolarize 2. also known as the effective refractory period 3. extends from onset of the QRS to peak of T wave 4. extends from peak of T wave to the end of T wave a very strong stimulus can stimulate a depolarization
- true 2. true 3. true 4. false 5. false
Define automaticity
The ability of cardiac cells to spontaneously initiate an electrical impulse.
Which of the following are possible causes of premature atrial complexes? 1. sympathomimetic 2. calcium channel blockers 3. digitalis toxicity 4. often the cause is unknown 5. beta adrenergic blockers
- true 2. false 3. true 4. true 5. false
If a negative P wave is found in lead II, the impulse most likely began in or near where?
The AV junction
Describe Torsades de Pointes
a gradual alteration in the amplitude and direction of the QRS; atrial rate indiscernible, ventricular rate 150-200 beats/minute.
Which is INCORRECT in regards to a complete (third-degree) AV block? 1. in complete AV block, the atrial rate is greater than the ventricular rate 2. the atria and ventricles beat independently of each other 3. the ventricular rhythm is essentially regular although the P waves occur irregularly 4. the QRS may be either wide or narrow, depending on the origin of the escape pacemaker
The incorrect statement is #3
True or False? The period of time during the cardiac cycle when cells cannot respond to a stimulus, no matter how strong, is referred to as the relative refractory period.
False
Management of unstable patients may necessitate the use of electrical therapy. Identify the correct initial and subsequent energy settings for the management of an unstable patient who presents with PSVT. 1. 100, 200, 300, 360 joules 2. 50, 100, 150, 170, 200 joules 3. 200, 200-300, 360 joules 4. 100-200-300, 360 joules
50, 100, 150, 170, 200 joules is the correct initial and subsequent energy settings for an unstable patient with PSVT
Basic EMTs responded to a 73 year old man in cardiac arrest. The patient was confirmed to be pulseless and apneic and an automated external defibrillator (AED) was applied. The AED delivered 1 shock without conversion of the rhythm. The patient has now arrived in the emergency department. The AED has delivered a second shock without conversion of the rhythm. CPR has been resumed. As an ACLS rescuer, how should you proceed?
continue CPR, place endotracheal tube, IV, and administer epinephrine.
A 52 year old female is complaining of chest pain and begins losing consciousness. Her BP is now 50 by palpitation and respirations are 12. The cardiac monitor displays a narrow QRS tachycardia at 220 beats/minute. Oxygen therapy was initiated and an IV was established prior to the patient’s collapse. You promptly deliver a synchronized countershock, however, reassessment reveals the patient to be pulseless and apneic. The cardiac monitor now reveals ventricular fibrillation. What course of action should you take at this time?
Defibrillate with 150 joules
Management of unstable patients may necessitate the use of electrical therapy. Identify the correct initial and subsequent energy settings for the management of ventricular tachycardia for an unstable patient who presents with a pulse. 1. 100, 150, 170, 200 joules 2. 50, 100, 150, 170, 200 joules 3. 200, 200-300, 360 joules 4. 100-200, 300, 360 joules
The correct electrical treatment for an unstable patient in V-tach, who presents with a pulse is 100, 150, 170, 200 joules
Emergent pacing is indicated in all of the following situations except: 1. ventricular fibrillation 2. hemodynamically compromising bradycardias 3. bradycardia with malignant escape rhythms unresponsive to pharmacologic therapy 4. overdrive pacing of tachycardia refractory to pharmacologic therapy or countershock
We do not pace ventricular fibrillation
A 73 year old male is found pulseless and apneic. CPR is initiated. The cardiac monitor shows ventricular fibrillation. The proper energy level for delivery of the initial shock to this patient would be what?
150 joules biphasic
Management of unstable patients may necessitate the use of electrical therapy. Identify the correct initial and subsequent energy settings for the management of a patient who presents with ventricular fibrillation. 1. 100, 200, 300, 360 joules 2. 50, 100, 200, 300, 360 joules 3. 150, 170, 200 joules biphasic 4. 100-200, 300, 360 joules
The correct electrical therapy for a patient who presents with ventricular fibrillation is: 150, 170, 200 joules biphasic
A 53 year old male is complaining of palpitations. He denies chest pain or difficulty breathing. His initial blood pressure is 128/64, his pulse is 88 and regular. You have attached the monitor leads to the patient’s chest and note a wide QRS complex tachycardia. Recommended treatment guidelines for this patient include what?
O2, IV, administer an IV bolus of lidocaine and reassess the patient. This is a stable patient, so medication is tried before electrical therapy.
Identify the correct initial and subsequent energy settings for the management of a patient who presents with sustained unstable Torsades de Pointes. 1. 100, 200, 300, 360 joules 2. 50, 100, 200, 300, 360 joules 3. 150, 170, 200 joules biphasic 4. 100-200, 300, 360 joules
The electrical therapy settings for Torsades de Pointe are: 150, 170, 200 joules biphasic
Which of the following factors effect transthoracic resistance? 1. electrode (paddle) size 2. phase of patient’s ventilation 3. use of interface 4. electrode (paddle) pressure
All factors listed effect transthoracic resistance
What is a synchronized counter shock?
A shock that is delivered a few milliseconds after the highest part of the R wave, as detected by the cardiac monitor.
A 56 year old male has a permanent pacemaker in place. Should it be necessary to defibrillate this patient, conventional defibrillator paddles should be placed where?
at least 5 inches from the pacemaker generator
What is the rate of 5 little boxes?
10 little boxes?
15 little boxes?
1 large box?
1 large box = 5 small boxes
A 57 year old male is apneic and pulseless
Describe critical actions for the first 10 minutes for this patient
Airway: OPA/Nonreabreather @ 15LPM O2 during CCR, then intubate after 4 rounds or 800 compressions
Breathing: During CCR, nonrebreather is sufficient. Once intubate, 8-10 breath/minute via BVM with high flow O2. Assess lung sounds
Circulation: CCR for 4 rounds or 800 total compressions at 100/minute, then swith to AHA 30:2. Establish two large bore IV’s of NS and provide a 500cc NS bolus as needed and 20cc flush p medications
Drugs: Epinepherine 1:10K / 1MG / RIVP / Q 3-5 minutes / no max dose
Lidocaine / 1-1.5mg/kg / RIVP / 1/2 initial dose q 5-10 minutes / 3mg/kg max
Successful conversion with pulse/pressure: lidocaine drip (2g in 500cc NS) / 2-4mcg/min / infusion / continuous / 4mcg/min max
Electrical: Rhythm is V-fib. Immediate shock is indicated @ 150 J biphasic. Resume CPR immediately after shock and assess for rhythm change after completing 2 minutes of CCR. Assess monitor for changes and shock again if found to be in V-fib still.
A 68 y/o F is anxious and restless. B/P is 160/90, pulse is regular/weak. Respirations are 22 and skin is W/M/P.
Describe critical actions for first 10 minutes
Airway: Patient is awake and breathing - airway is patent.
Breathing: High flow O2 via nonrebreather @ 15 LPM. Assess lung sounds. Try to calm patient and slow down respirations.
Circulation: Establish large bore IV of NS. 20cc bolus p any medications. Fluid bolus as needed.
Drugs: Consider sedation prior to Synch cardioversion with Versed / 2.5-5mg / SIVP / 1x for sedation / 5mg Max
For conversion, consider lidocaine / 1-1.5mg/kg / SIVP / repeat at 1/2 initial dose q 5-10 minutes / 3 mg Max
After conversion, lidocaine drip (2g in 500cc NS) / 2-4mcg/min / infusion / 4mcg/min Max
Electrical: For critical patient (ALOC), synch cardiovert without pretreatment of versed @ 100J biphasic. If successful, initiate lidocaine drip. If unsuccessful, patch.
A 21 year old male is unresponsive and apneic. He has overdosed on heroin. The blood pressure is 118/80, the pulse is regular, and the skin is cool/moist/cyanotic.
Describe critical actions for the first 10 minutes.
Airway: Suction if necessary. OPA if no gag reflex, NPA if gag reflex.
Breathing: BVM with 15LPM O2 at 8-10 BPM. Assess lung sounds/rise/fall of chest.
Circulation: Obtain large bore IV with NS. Provide bolus as needed. 20cc flush p medications.
Drugs: narcan / 2mg / IM-IV-Nasal (2mg each) / q 2 minutes / 6mg max (8mg is used nasally)
Electrical: Monitor rhythm for changes
A 67 year old female is apneic and pulseless. She has suffered three strokes in the last six months.
Describe critical actions for first 10 minutes.
Airway
Breathing
Circulation
Drugs
Electricity
A 55 year old male complains of “severe crushing chest pain and difficulty breathing.” The blood pressure is 142/96, the pulse is irregular, respirations are 30 per minute/labored, and the skin is cool/wet/pale.
Describe critical treatment for first 10 minutes
Airway
Breathing
Circulation
Drugs
Electricity
A 48 year old female complains of “fluttering in my chest” and being “short of breath”. The blood pressure is 156/90, the pulse is regular, respirations are 24 per minute/shallow, and the skin is warm/moist/pink.
Describe critical actions for first 10 minutes.
Airway
Breathing
Circulation
Drugs
Electricity
An 82 year old female is conscious, has spontaneous eye opening, and makes incomprehensible sounds. Her legs and feet have become edematous in the last two days. The blood pressure is 82/40, the pulse is regular, respirations are 24 per minute/shallow, and the skin is cool/moist/pale.
Describe critical actions for first 10 minutes.
Airway
Breathing
Circulation
Drugs
Electricity
A 36 year old male suffered a submersion accident when he fell through the ice cover of a lake. The blood pressure is 80/40, the pulse is regular/weak, respirations are 6 per minute/agonal, and the skin is cold/dry/cyanotic.
Describe critical actions for first 10 minutes.
Airway
Breathing
Circulation
Drugs
Electricity
A 66 year old female is apneic and pulseless. She was the driver of an automobile which ran against a red light at a high rate of speed striking another vehicle head-on. The front ends of both vehicles are severely damaged. Her steering wheel is grossly deformed.
Describe critical actions for first 10 minutes.
Airway
Breathing
Circulation
Drugs
Electricity
A 29 year old male is unresponsive and apneic after suffering an electrocution at a construction site. The blood pressure is 72/44, the pulse is regular, and the skin is warm/moist/pale. Full-thickness burns are present on both hands.
Describe 10 minutes of critical actions.
Airway
Breathing
Circulation
Drugs
Electrical
A 60 year old female is apneic and pulseless.
Describe 10 minutes of critical actions.
Airway
Breathing
Circulation
Drugs
Electical
A 73 year old male complains of being “dizzy” and “weak”. He was attempting a bowl movement and experienced a syncopal episode lasting several minutes. The blood pressure is 94/70, the pulse is regular/weak, respirations are 24 per minute, and the skin is cool/moist/pale.
Describe 10 minutes of critical actions.
Airway
Breathing
Circulation
Drugs
Electrical
A 37 year old female complains of being “extremely short of breath”. Her medical history includes “rapid heart rate”. She is prescribed Calan® (verapamil). The blood pressure is 92/66, the pulse is regular/weak, respirations are 36 per minute/labored, and the skin is cool/wet/pale.
Describe 10 minutes of critical actions.
Airway
Breathing
Circulation
Drugs
Electrical
A 75 year old male cannot move his right arm or leg. He presents with a facial droop and abnormal speech. His medical history includes hypertension. The blood pressure is 236/120, the pulse is regular, respirations are 20 per minute, and the skin is warm/dry/pink.
Describe 10 minutes of critical actions.
Airway
Breathing
Circulation
Drugs
Electrical
A 57 year old female is apneic and pulseless. She has purposefully overdosed on Elavil® (amitriptyline), a tricyclic antidepressant and alcohol.
Describe 10 minutes of critical actions.
Airway
Breathing
Circulation
Drugs
Electrical
A 97 year old male is apneic and pulseless. His medical history includes lung and esophageal cancer. An advance directive (“do not resuscitate”) form is complete and available.
Describe 10 minutes of critical actions.
Airway
Breathing
Circulation
Drugs
Electrical
