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ACP Directives (ADULT only) Flashcards

Includes (adult only): Tachy, Cardiogenic shock, Brady, procedural sedation, medical cardiac arrest, ROSC, hyperkalemia,intubation, naso intubation, cric, analgesia, combative, seizure, hypoglycemia, CVAD, home dialysis disconnect

1
Q

What are the indications for the tachydysrhythmia directive? (1)

A

Symptomatic tachydysrhythmia

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2
Q

List the conditions for Valsalva (5)

A
  1. At least 18 years old
  2. Unaltered
  3. HR at least 150bpm
  4. Normotensive
  5. Only for narrow complex and regular rhythms
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3
Q

Contraindications for valsalva

A

sinus tach, afib or aflutter

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4
Q

How many attempts of valsalva can you do?

A

Maximum of 2 attempts lasting 10-20 seconds duration each

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5
Q

List the conditions for Adenosine (5)

A
  1. At least 18 years old
  2. Unaltered
  3. HR at least 150bpm
  4. Normotensive
  5. Only for narrow complex and regular rhythms
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6
Q

List the contraindications for Adenosine (4)

A
  1. Allergy or sensitivity to adenosine
  2. Sinus tach, afib, or aflutter
  3. Pt taking dipyridamole or carbmazepine
  4. Bronchoconstriction on exam
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7
Q

List the route, initial dose, second dose, dosing interval and number of doses for Adenosine.

A

IV
6mg, then 12mg
2 min apart
max #2 doses

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8
Q

(Tachydysrhythmia Directive)
List the conditions for Lidocaine (5)

A
  1. At least 18 years old
  2. Unaltered
  3. HR at least 120bpm
  4. Normotensive
  5. Only for wide complex and regular rhythms
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9
Q

(Tachydysrhythmia Directive) Contraindications for lidocaine (1)

A
  1. Allergy or sensitivity to lidocaine
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10
Q

What is the route that lidocaine can be given?
(Tachydysrhythmia Directive)

A

IV only

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11
Q

What is the initial dose, subsequent dose, max single dose and dosing interval, max # of doses for lidocaine?
(Tachydysrhythmia Directive)

A

1.5mg/kg, then 0.75mg/kg
max single dose 150mg
10 minutes apart
max #3 doses

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12
Q

What is the maximum amount of lidocaine we can give a patient? (for all directives)

A

5mg/kg

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13
Q

What are patch points in the Tachydysrhythmia Directive?

A
  1. Patch to give lidocaine or amiodarone.
  2. Patch to do synchronized cardioversion.
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14
Q

(Tachydysrhythmia Directive)
List the conditions for Amiodarone (5)

A
  1. At least 18 years old
  2. Unaltered
  3. HR at least 120bpm
  4. Normotensive
  5. Wide complex and regular rhythm
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15
Q

(Tachydysrhythmia Directive)
List contraindications for amiodarone

A

Allergy or sensitivity to amiodarone

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16
Q

What is the initial dose, subsequent dose, max single dose and dosing interval, max # of doses for amiodarone?
(Tachydysrhythmia Directive)

A

standard 150mg for all doses
interval 10 minutes
max 2 doses

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17
Q

What route should amiodarone be given and how?
(Tachydysrhythmia Directive)

A

IV only
given over 10 minutes

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18
Q

Condition for synchronized cardioversion.
(Tachydysrhythmia Directive)

A
  1. At least 18 years old
  2. Altered
  3. hypotensive
  4. HR at least 120 (wide) or 150 (narrow)
  5. ongoing chest pain or other signs of shock
  6. MANDATORY PATCH POINT
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19
Q

In case of a patch failure, what are the settings for synchronized cardioversion?

A

Administer up to 3 shocks at 100J, 200J and manufacture max. (200J Zoll, 360J LP)

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20
Q

What treatments/medications are included in under the tachydysrhythmia medical directive?

A
  • valsalva
  • adenosine
  • lidocaine
  • amiodarone
  • synchronized cardioversion
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21
Q

What are the indications for the Cardiogenic shock medical directive?

A
  1. STEMI positive 12 lead ECG
    AND
  2. cardiogenic shock
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22
Q

What treatments/medications are included in under the cardiogenic shock directive?

A
  • fluid bolus
  • dopamine
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23
Q

What is the patch point under the cardiogenic shock directive?

A

If patient is also bradycardiac, patch for a consult.

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24
Q

What are the conditions for a fluid bolus?
(cardiogenic shock directive)

A
  1. At least 18 years old
  2. Hypotensive
  3. chest auscultation clear
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25
Q

What are the contraindications for a fluid bolus? (2)
(cardiogenic shock directive)

A
  1. Fluid overload
  2. SBP greater than or equal to 90
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26
Q

Which should be given first, fluid or dopamine?
(cardiogenic shock directive)

A

Fluid, then dopamine. If fluid is contraindicated consider dopamine.

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27
Q

What routes can saline bolus be given?
(cardiogenic shock directive)

A

IV, IO, or CVAD

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28
Q

How much fluid are we bolusing?
(cardiogenic shock directive)

A

10mL/kg
to a max of 1,000ml

(Patient has to be 100kg to get max)

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29
Q

What are the conditions for dopamine?
(cardiogenic shock directive)

A
  1. At least 18 years old
  2. hypotensive
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30
Q

What are the contraindications for dopamine?
(cardiogenic shock directive)

A
  1. Allergy or sensitivity to dopamine
  2. Tachydysrhythmias excluding sinus tach
  3. mechanical shock
  4. Hypovolemia
  5. Pheochromocytoma
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31
Q

What is the route dopamine can be given?
(cardiogenic shock directive)

A

IV only

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32
Q

What is the initial infusion rate for dopamine?
(cardiogenic shock directive)

A

5mcg/kg/min

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33
Q

What is the max infusion rate for dopamine?
(cardiogenic shock directive)

A

20mcg/kg/min

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34
Q

How much and how often can we increase dopamine infusion?
(cardiogenic shock directive)

A

every 5 minutes can increase by 5mcg/kg/min

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35
Q

What is the target blood pressure range for dopamine?
(cardiogenic shock directive)

A

SBP 90 to less than 110

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36
Q

What to consider when discontinuing dopamine?

A

gradually over 5-10minutes

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37
Q

What are the indications for the Symptomatic Bradycardia medical directive?

A
  1. Bradycardia
    AND
  2. Hemodynamic instability
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38
Q

What treatments/medications are included under the Symptomatic Bradycardia medical directive?

A
  1. Atropine
  2. Dopamine
  3. Transcutaneous pacing
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39
Q

What are the conditions for atropine?
(Symptomatic Bradycardia)

A
  1. At least 18 years old
  2. HR less than 50
  3. Hypotension
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40
Q

What are the contraindications for atropine?
(Symptomatic Bradycardia)

A
  1. Allergy or sensitivity to atropine
  2. Hypothermia
  3. Hx of heart transplant
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41
Q

What is the route atropine can be given?
(Symptomatic Bradycardia)

A

IV only

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42
Q

What is the initial dose, subsequent dose, number of doses and interval for atropine?
(Symptomatic Bradycardia)

A

1mg for all doses
max #2 doses
5 minutes apart

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43
Q

What are the conditions for dopamine?
(Symptomatic Bradycardia)

A
  1. At least 18 years old
  2. HR less than 50
  3. Hypotension
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44
Q

What are the contraindications for dopamine?
(Symptomatic Bradycardia)

A
  1. Allergy or sensitivity
  2. Mechanical shock
  3. Pheochromocytoma
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45
Q

What other treatments/considerations should be made?
(Symptomatic Bradycardia)

A

Consider:
- 12 lead ecg
- fluid bolus (Fluid therapy directive)

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46
Q

What is the initial infusion rate for dopamine?
(Symptomatic Bradycardia)

A

5mcg/kg/min

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47
Q

What is the max infusion rate for dopamine?
(Symptomatic Bradycardia)

A

20mcg/kg/min

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48
Q

How often and by how much can you increase dopamine?
(Symptomatic Bradycardia)

A

every 5 minutes by 5mcg/kg/min

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49
Q

What are the conditions for transcutaneous pacing?
(Symptomatic Bradycardia)

A
  1. At least 18 years old
  2. HR less than 50
  3. Hypotensive
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50
Q

What are the contraindications for pacing?
(Symptomatic Bradycardia)

A

Hypothermia

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51
Q

Not part of the medical directive: but when may pacing be ineffective?

A

hyperkalemia or other electrolyte issues

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52
Q

Not part of the medical directive: but when may cardioversion be ineffective?

A

stimulant overdose/induced tachycardia

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53
Q

What are the indications for procedural sedation?

A
  1. post-intubation OR
  2. pacing
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54
Q

What medications are options for procedural sedation?

A

Fentanyl and Midazolam

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55
Q

What are the conditions for fentanyl and midazolam under procedural sedation medical directive?

A
  1. At least 18 years old
  2. RR at least 10
  3. Normotensive
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56
Q

What are the contraindications for fentanyl and midazolam?
(procedural sedation )

A
  1. Allergy or sensitivity to respective drug
57
Q

What routes can fentanyl and midazolam be administered?
(procedural sedation)

A

IV, IO, CVAD, IN

58
Q

What is the dose, max single dose, dosing interval and max cumulative dose for fentanyl?
(procedural sedation)

A

25-75mcg
max single 75mcg
5 min interval
max 150mcg total

59
Q

What is the dose, max single dose, dosing interval and max cumulative dose for Midazolam?
(procedural sedation)

A

up to 0.1mg/kg (50kg gets max)
max single 5mg
5 min interval
Max 10 mg

60
Q

When using the procedural sedation medical directive, are you administering before or after the procedure?

A

Only after pt is tubed or after pacing started

61
Q

Conditions for epinephrine 1:10,000
(Medical cardiac arrest)

A
  1. At least 24 hours old
62
Q

What is defined as refractory Vtach or VF?

A

after 3 consecutive shocks

63
Q

What age is the adult dosing of epinephrine during a medical cardiac arrest?

A

12 years or older

64
Q

What is the dose, interval and # of doses for epi?
(Medical cardiac arrest)

A

1mg (in 10mL)
every 4 mins
no maximum

65
Q

If giving epi down the ETT tube, what is the dose?
(Medical cardiac arrest)

A

2mg
every 4 mins
no max # doses

66
Q

Contraindications for epi?
(Medical cardiac arrest)

A

allergy or sensitivity to epi

67
Q

What drugs should be considered during a medical cardiac arrest?

A
  1. Epinephrine
  2. Lidocaine (or amio)
  3. Fluid bolus
68
Q

Conditions for lidocaine (2)
(Medical cardiac arrest)

A
  1. At least 24 hours old
  2. Refractory vtach or vfib
69
Q

Contraindications for lidocaine
(Medical cardiac arrest)

A

Allergy or sensitivity to lidocaine

70
Q

Dosing for lidocaine IV,IO, CVAD
(Medical cardiac arrest)

A

1.5mg/kg
repeat dose 0.75mg/kg
every 4 mins
MAX 2 DOSES

71
Q

How does the dosing change for lidocaine down the ETT
(Medical cardiac arrest)

A

double the initial dose and second dose. Everything else is the same
(3mg/kg, 1.5mg/kg)

72
Q

Conditions for amiodarone (2)
(Medical cardiac arrest)

A
  1. at least 24 hours old
  2. refractory vtach or vfib
73
Q

Contraindications for amiodarone
(Medical cardiac arrest)

A

Allergy or sensitivity to amiodarone

74
Q

Dosing for amiodarone IV,IO, CVAD
(Medical cardiac arrest)

A

Initial dose 300mg
second dose 150mg
interval 4 minutes
MAX 2 DOSES

75
Q

Can amiodarone be given down the ETT?
(Medical cardiac arrest)

76
Q

Conditions for fluid bolus?
(Medical cardiac arrest)

A
  1. At least 24 hours old
  2. PEA OR
    any other rhythm where hypovolemia is suspected
77
Q

Contraindications for fluid bolus?
(Medical cardiac arrest)

A

Fluid overload

78
Q

How much fluid can be given?
(Medical cardiac arrest)

A

20mL/kg
max volume 2,000ml

79
Q

What treatments/medications are included under the ROSC medical directive?

A
  1. fluid bolus
  2. dopamine
80
Q

What are the conditions for dopamine? (2)
(ROSC medical directive)

A
  1. At least 8 years old
  2. hypotensive
81
Q

What are the contraindications for dopamine? (5)
(ROSC medical directive)

A
  1. Allergy or sensitivity
  2. Tachydysrhythmias (excluding sinus tach)
  3. Mechanical shock
  4. Hypovolemia
    5.Pheochromocytoma
82
Q

Does the dosing for dopamine change depending on the medical directive? Or stay the same?

A

Dosing, intervals and time stays the same for all directives.

83
Q

Conditions for fluid bolus (2)
(ROSC medical directive)

A
  1. hypotensive
  2. chest auscultation clear
84
Q

What is the adult age for fluid bolus
(ROSC medical directive)

A

At least 12 years old

85
Q

How much fluid can we give (adult)?
(ROSC medical directive)

A

10ml/kg
max 1,000ml

86
Q

What are the indications for the Hyperkalemia Medical Directive?

A

Suspected hyperkalemia
AND
- currently on dialysis, OR
- Hx end stage renal, OR
- hx prolonged crush injury
AND
Cardiac arrest, OR
Pre-arrest with 12 lead changes associated with hyperkalemia

87
Q

What are the conditions for calcium gluconate 10% and salbutamol?
(Hyperkalemia Medical Directive)

A

at least 18 years old

88
Q

What are the contraindications for calcium gluconate?
(Hyperkalemia Medical Directive)

89
Q

What are the contraindications for salbutamol?
(Hyperkalemia Medical Directive)

A

Allergy or sensitivity to salbutamol

90
Q

What routes can calcium gluconate be given?
(Hyperkalemia Medical Directive)

A

IV, IO, CVAD

91
Q

What is the dose, interval and number of repeats for calcium gluconate?
(Hyperkalemia Medical Directive)

A

1g (10ml, given over 2-3 minutes)
every 5 minutes
max 2 doses

push 2.5mL every 30 seconds

92
Q

What is the dose, interval and number of repeats for salbutamol when nebulized?
(Hyperkalemia Medical Directive)

A

10mg
can repeat immediately x 2 doses

93
Q

What is the dose, interval and number of repeats for salbutamol when MDI?
(Hyperkalemia Medical Directive)

A

1600mcg (16 puffs)
repeat immediately x 2 doses

94
Q

What are indications for a pre-arrest patient?
(Hyperkalemia Medical Directive)

A

One or more of the following:
- hypotension
- altered LOA
- symptomatic bradycardia

95
Q

What are the indications for orotracheal intubation?

A
  1. Need for ventilatory or airway control
    AND
  2. Other methods are ineffective
96
Q

Contraindications for orotracheal intubation?

A
  1. less than 50 years old
    AND
  2. current asthma flare up
    AND
  3. No in or near cardiac arrest
97
Q

Contraindications for lidocaine spray?
(orotracheal intubation)

A
  1. allergy or sensitivity
  2. unresponsive patient

keep in mind max lidocaine dose 5mg/kg if given lidocaine for vtach/vfib

98
Q

How many lidocaine sprays can a patient have?
(orotracheal intubation)

A

max 5mg/kg
and
max 20 sprays

20 sprays at 10mg/spray is 200mg, a patient would need to weigh 40kg to get the max dose

99
Q

Conditions for nasotracheal intubation?
(nasotracheal intubation)

A
  1. at least 8 years old
  2. must be spontaneously breathing
100
Q

contraindications for nasotracheal intubation?
(nasotracheal intubation)

A

Same as orotracheal intubation,
AND
1. Suspected basal skull fracture or mid face fracture
2. uncontrolled epistaxis
3. anticoagulant therapy
4. bleeding disorders

101
Q

When following our medical directives, what can we use dopamine for?

A
  • bradycardia (brady and hypotensive)
  • cardiogenic shock (hypotensive)
  • ROSC patient (hypotensive)
102
Q

If a patient is symptomatic hypotensive, but not bradycardic, can we treat with dopamine?

A

Only if they are cardiogenic shock (STEMI positive)
OR
a ROSC

103
Q

What are the indications for an SGA?
(Supraglottic Airway medical directive)

A
  1. Need for ventilatory assistance or airway control
    AND
  2. Other airway methods ineffective
104
Q

What are the conditions for an SGA?
(Supraglottic Airway medical directive)

A

absent gag reflex

105
Q

What are the contraindications for an SGA? (4)
(Supraglottic Airway medical directive)

A
  1. Airway obstructed by FBO
  2. Known esophageal disease
  3. Trauma to oropharynx
  4. Caustic ingestion
106
Q

Is vomiting a contraindication for an SGA?

A

Withhold while pt is actively vomiting, once airway is cleared, it can be placed.

However, as an ACP, it would be better to tube this patient.

107
Q

Number of attempts to place an SGA?

A

2
(per patient, not per provider)

108
Q

Indications for cricothyrotomy medical directive?

A
  1. Need for advanced airway management
    AND
  2. Intubation AND SGA unsuccessful or contraindicated
    AND
  3. unable to ventilate

Think, cant ventilate cant oxygenate, and tried everything else

109
Q

Conditions for cric?
(cricothyrotomy medical directive)

A
  1. At least 12 years old
  2. Altered
110
Q

Contraindications for cric?
(cricothyrotomy medical directive)

A
  1. suspected fractured larynx
  2. unable to landmark
111
Q

What age can be given analgesia without a patch?

A

12 or older

112
Q

Conditions for morphine?
(analgesia directive)

A
  1. at least 1 year old
  2. unaltered
  3. normotensive
113
Q

Conditions for fentanyl?
(analgesia directive)

A
  1. at least 1 year old
  2. unaltered
  3. normotensive
114
Q

Contraindications for morphine
(analgesia directive)

A
  1. Allergy or sensitivity to morphine
  2. Treatment of chronic headache
  3. Treatment of chronic pain
  4. SBP drops by 1/3 or more of it’s initial value after morphine administration
  5. Suspected cardiac ischemia
  6. active labour
115
Q

Contraindications for fentanyl
(analgesia directive)

A
  1. Allergy or sensitivity to morphine
  2. Treatment of chronic headache
  3. Treatment of chronic pain
  4. SBP drops by 1/3 or more of it’s initial value after morphine administration
  5. Suspected cardiac ischemia
  6. active labour
116
Q

What route can morphine be administered?

117
Q

What is the adult age for morphine dosing?
What is the dose and dosing interval?
Max single dose and total cumulative dose?

A

at least 18 years old
2-10mg (max 10mg single dose)
q 15 minutes
total 20mg

118
Q

What is the adult age for fentanyl dosing?
What is the dose and dosing interval?
Max single dose and total cumulative dose?

A

at least 18 years old
25-75 mcg (max 75mcg)
q 5 minutes
total 200mcg

119
Q

What route can fentanyl be administered?

120
Q

What is the indication for sedation by the combative patient directive?

A

Combative or violent or agitated behaviour that requires sedation for patient safety

121
Q

What are the conditions for midazolam?
(combative patient directive)

A
  1. at least 18 years old
122
Q

What are the conditions for ketamine?
(combative patient directive)

A
  1. at least 18 years old
  2. suspected excited delirium or severe violent psychosis
123
Q

Contraindications for midazolam
(combative patient directive)

A
  1. allergy or sensitivity to midazolam
124
Q

Contraindications for ketamine
(combative patient directive)

A
  1. allergy or sensitivity to ketamine
125
Q

What is the route, dose, max single dose, interval and total doses for midazolam?
(combative patient directive)

A

IV, IM, IN
up to 0.1mg/kg (max 5mg)
q 5 minutes
max total dose 10mg
( no limit on # of doses)

126
Q

What are the age categories for ketamine dosing?
(combative patient directive)

A

18 - 65
and older than 65

127
Q

What is the route, dose, max single dose, interval and total doses for ketamine for 18-65 year olds?
(combative patient directive)

A

IM only
5mg/kg to max of 500mg
single dose
(100kg gets max)

128
Q

What is the route, dose, max single dose, interval and total doses for ketamine 65 year old and older?
(combative patient directive)

A

IM only
3mg/kg to max of 300mg
single dose

129
Q

What dose of midazolam should be considered for combative patients if less is needed?

A

0.05mg/kg
(half of normal)

130
Q

Conditions for midazolam?
(Seizure directive)

A
  1. unresponsive
131
Q

Contraindications for midazolam?
(Seizure directive)

A
  1. allergy or sensitivity to midazolam
132
Q

What routes can midazolam be given? Which routes are in which group for dosing?
(Seizure directive)

A

IV, IO
IM, IN, buccal

133
Q

What is the IV/IO dosing, max single dose, interval for midazolam?
(Seizure directive)

A

IV, IO
0.1mg/kg (max 5mg)
q 5 minutes
max # doses 2

134
Q

What is the IM/IN dosing, max single dose, interval for midazolam?
(Seizure directive)

A

IM, IN
0.2mg/kg (max 10mg)
q 5 minutes
max # doses 2

135
Q

What is the dose, max single dose, interval, and number of doses for D10W for a patient less than 2 years old?

A

0.2g/kg (2ml/kg) –> same as adults
max 5g (50ml) (needs to be 25kg or 55lbs to get max)
q 10 mins
max 2 doses

136
Q

When can we access a CVAD?

A
  1. actual or potential need for fluid or IV medication
  2. IV access unattainable
  3. Cardiac arrest or pre-arrest
137
Q

What are the contraindications for accessing a CVAD?

A
  1. Inability to confirm patency of CVAD line.
  2. Inability to flush or aspirate
  3. injury or suspected fracture proximal to access site.
  4. swelling of involved limb
  5. bleeding at insertion site
138
Q

When can we emergency disconnect home dialysis?

A
  1. Patient is receiving home dialysis and requires transport to hospital
    AND
  2. patient is unable to disconnect
    AND
  3. there is no one else knowledgeable in dialysis disconnect

Medical directives (3 decks)

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