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Algorithms Flashcards

1
Q

What do you do for asystole?

A

-Check pulse/Confirm in 2 leads
-CPR (grab board and start compressions)
-O2 15L ambu bag
-If PEA, assess Hs & Ts
-Airway: 15L ambu bag 10 breaths/mn
-Epi 1mg ivp/io(Q3-5min)
-CPR x2 min
(repeat sequence, giving epi after every 2 cycles of CPR 2min)
-If hypovolemia suspected: 250 NS bolus (repeat after 5 min)
-Chest X-ray

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2
Q

What do you do for unstable Bradycardia? (includes heart blocks) How is Brady defined?

A

HR<50 bpm
1) O2 at 10L (min) via non-rebreather mask)
2)If transvenous leads or pacing wires, connect to pulse generator and initiate pacing
3) if above ineffective, Atropine 1mg, every 3-5 minutes (max 3mg) *20ml NS flush
4) Transcutaneous pacing asap
5) if above ineffective, dopamine 400mg/250 D5W at 5mcg/kg/min (titrate until SBP>90 or up to 20 mcg/kg/min
6) if dopa ineffective, Epinephrine 2-10mcg/min IV and titrate (up to 10) (epi 2mg/250ml)

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3
Q

Dosing of atropine (Unstable Brady)
-dose, frequency, max

A

Atropine 1mg every 3-5 minutes
max 3mg

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4
Q

Dopamine dose and titration/max (Unstable Brady)

A

Dopamine 400mg/250ml D5W at 5mcg/kg/min
Titrate: SBP>90 and/or MAP>60, up to 20mcg/kg/min

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5
Q

What do you do for PEA?

A

1) CPR and assess for causes (Hs and Ts)
2) O2 at 15L/min via ambu bag (10 breaths/min)
3) Epi 1mg ivp/io every 3-5min
4 )If hypovolemia known or suspected, infuse 250ml NS (can be LR if already infusing), repeat in 5 minutes if no improvement
5) Stat chest xray

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6
Q

What are the Hs and Ts?

A

H: hypovolemia, hypoxia, hydrogen ion (acidosis), hypo/hyperkalemia, hypoglycemia, hypothermia
T: toxins, tamponade, thrombosis, trauma, tension pneumothorax

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7
Q

What do you do for Stable V. Tach?/ what is stable v. tach?

A

Stable: pt conscious with SBP>90, no unstable signs/symptoms
1) Call physician for orders
2) O2 at 4L minimum via NC
3) 12 lead EKG
4)Draw serum K and Mag

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8
Q

What do you do for Unstable V. Tach? How is Unstable V. tach defined?

A

symptomatic (1 or more unstable symptoms), immediately cardiovert! If time permits and pt is awake and responsive, give versed

-O2 at 10L min via non-rebreather
-Pad placement
-if ventricular rate is >150, synchronized cardioversion 200 joules
-if patient awake and responsive, give Versed 0.5 (can repeat x1) total of 1 mg
-Cardiovert
-Draw K and Mag

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9
Q

What do you do for Ventricular Fibrillation/Pulseless Ventricular Tachycardia

A

(no stacked shocks), provide continuous CPR unless defibrillating, give meds during CPR
-Immediate defibrillation if witnessed arrest and defib. available
1) CPR (including board) 2 mins or until defib. arrives
2) O2 15L via ambu bag minimum
3) Place pads
4) Defib biphasic: 200j
5) CPR/Epi: 1mg
6) Check pulse/rhythm
5) Defibrillate: 200j
6) CPRx2min/amio 300mg
7) Check rhythm/pulse
8) Defibrillate 200j
9) CPR 2min/epi 1mg.
10) Check rhythm and pulse
11) Defib 200j
12) CPR 2min, amio 150mg
13)Check rhythm/pulse
14) Defib 200j–>CPR–>epi 1mg
11) If rhythm persists, defib, CPR, epi 1mg every 3-5 min

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10
Q

How many breaths per minute with ambu bag?

A

10 breaths per minute, 1 breath every 6 seconds

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11
Q

What do you do for Chest Pain?

A

1) O2 4L nasal cannula minimum
2) Nitroglycerine 0.4mg SL if SBP>90 and/or MAP>60 and HR>50; may repeat every 3-5 minutes x2 doses!
3)Morphine 2mg if SBP>90 every 5 minutes for a total of 10mg
4)Consider aspirin 325mg non-enteric coated (chewed or crushed), if no dose given on this date (and not contraindicated)
5) If hypotension and no evidence of pulmonary congestion/CHF, give 250 mL NS (or LR if already infusing)
5) 12 lead EKG

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12
Q

What is the dosing for nitro sublingual? How often?

A

0.4mg SL, may repeat every 3-5 minutes

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13
Q

What is the dosing for morphine for chest pain? max?

A

2mg IV (if BP and HR stable), repeat every 5 minutes, max 10mg

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14
Q

What do you do for Symptomatic Hypotension?

A

1) O2 at 10L/min non-rebreather
2) If hypovolemia known or suspected, 250ml NS (or LR if infusing), repeat in 5 min. if no improvement
3) If SBP<90, start dopamine 400mg/250D5W infuse at 5mcg/kg/min (titrate until SBP>90, Map>60 or up to 20mcg/kg/min)
4) Obvious blood loss: draw stat H/H and Type & Cross 2 units PRBCs
5) If suspecting sepsis, follow sepsis algorithm

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15
Q

What do you do for Increased Intracranial Pressure?

A

In the neuro impaired pt with dilated pupil associated with other signs of impending herniation (implement only in the absence of specific ICP orders)
1) Raise HOB at least 30 degrees if pt is not hypotensive; pt’s head in midline position
2)Hyperventilate the intubated pt with FiO2 100% to maintain pCO2 26-30
3) Draw baseline K, Na, BUN, Cr, Glucose (BMP), serum osmolality, and ABG

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16
Q

What do you do for respiratory depression? Associated with prior narcotic or benzodiazepine administration, RR<10

A

1) O2 at minimum 10L/min NRBM
2) Narcotic-associated respiratory depression: give naloxone (Narcan) Max dose 0.4mg
a) apnea: 0.4mg IVP once
b) RR < 10: 0.1mg IVP every 1 min, may repeat x3 (max 0.4mg)

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17
Q

Dosing for Naloxone (Narcan)? Max dose?

A

a) apnea: 0.4mg IVP once
b) RR less than 10: 0.1mg IVP every 1 min, may repeat x3
Max dose is 0.4mg

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18
Q

What do you do for respiratory distress?
Demonstrated by change in RR and/or use of accessory muscles, altered LOC, or cyanotic nail beds

A

1) O2 at 10L NRBM min.
2) Stat portable CXR
3) if bronchospasm: albuterol 0.5ml in 3ml NS aerosol inhalation
4) RRT/icu RN may obtain ABG or VBG (if unable to obtain abg)
5)RRT/ICU RN May initiate non-invasive ventilation

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19
Q

When in respiratory distress, may initiate non-invasive ventilation for the following conditions in the absence of any contraindications:

A

-exacerbation of COPD, asthma, and acute CHF
-as a bridge to mechanical ventilation

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20
Q

What are the contraindications for non-invasive ventilation?

A

respiratory arrest, inability to maintain a patent airway or clear secretions, risk for aspiration of gastric contents (n/v or bowel obstruction), pre-existing pneumothorax without chest tube or pneumomediastinum, epistaxis, recent facial, oral or skull surgery/trauma, encephalopathy/altered LOC, hypotension due to suspected intravascular depletion, unable to tolerate bipap

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21
Q

What do you do for Status Epilepticus

A

1) Protect airway, position pt in lateral decubitus position, protect from injury
2) O2 at 10L NRBM min.
3) Lorazepam (Ativan) 2mg over 1 minute
4) Draw Na, K, glucose, BUN, Cr (BMP), calcium, phosphorus, mag, and anticonvulsant levels in approp.

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22
Q

What do you do for Severe Anaphylaxis? (stridor, wheezing, respiratory distress, pallor, cyanosis, or clinical signs of shock)

A

1) O2 10L/min NRBM
2) Epi 0.3mg IM (use epi 1mg/ml) repeat in 5 min if no clinical improvement
3)place or supine and elevate lower extremities
4) infuse 250 bolus, repeat in 5 minutes if no clinical improvement (NS or LR if already infusing)
5) in the presence of bronchospasm, albuterol 0.5 ml NS aerosol inhalation
6) Benedryl 25 mg iv/io
7) hydrocortisone (solucortef) 100mg iv/io
8) Famotadine 20 mg iv
9) If no response and pt still showing s/s of shock, give epi. 0.1 mg IV SLOWLY over 3 minutes (epi 0.1mg/ml)
10) if no response, RRT/icu RN May start epi infusion 2mg/250ml NS at 1mcg/min (max 10 mcg/min)

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23
Q

What is the suspected sepsis algorithm?

A

1) If hypovolemia known or suspected, infuse 250ml NS (or LR), repeat in 5 min if no improvement
2) Evaluate if pt meets at least 2 SIRS criteria
3) If pt meets 2 SIRS criteria, assess for infection (confirmed or suspected) and organ dysfunction
4) if criteria in #3 met, then obtain lactate (if not done within 6 hours; repeat in 4 hours if initial level >2); obtain blood cultures x2, consult RRT and call physician
5) if RRT/ICU if SBP <90, 250 boules times 2, start levo
6) LR or NS bolus order of 30ml/kg at 126ml/hr

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24
Q

What are the SIRS criteria?

A

a) WBC count >12,000 or less than 4,000 or greater than 10% bands
b) HR greater than 90bpm
c) Respiratory rate greater than 20 per minute
d) Temp >38.3 or <36

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25
Q

What are some examples s/s of organ dysfunction?

A

a) SBP <90, MAP<65, or decrease in SBP>40
b) Lactate >2
c) Creatinine >2 or UOP <0.5ml/kg/hr
d) Bili >2
e) Platelet <100,000
f) INR >1.5, aPTT>60 seconds
g) New onset respiratory failure requiring BIPAP or intubation
H) new mental status change

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26
Q

BS level indicating hypoglycemia?

A

<70 or <60 in obstetric pt (up to 6 weeks postpartum)

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27
Q

Hypoglycemia: patient conditions to notify physician?

A

1) Stat if there is deterioration in vital signs or LOC
2) Stat if second treatment does not result in BG>70
3) Prior to resuming insulin or oral hypoglycemic agents after 1st treatment of hypoglycemia results in BG >70mg

28
Q

Know rhythms, heart blocks (1-3), pacemakers (failure to capture and failure to pace) and what they look like

A

https://www.skillstat.com/tools/ecg-simulator
The link above is great practice for EKGs

29
Q

When do you do synchronized cardioversion?

A

unstable tachycardias with ventricular rate >150bpm

30
Q

When do you do immediate unsynchronized cardioversion?

A

pt with Unstable pulseless V.tach ( or v.fib)

31
Q

Dosing for epi (unstable brady)

A

2-10 mcg/min
-bag is 2mg/250mL NS

32
Q

What are the 5 steps to Transcutaneous Pacing?

A

-Pad placement
-Stimulation Threshold 40-80 mA
-Achieved 100% consistent capture
-Safety margin 10% above threshold
-Assess effectiveness of transcutaneous pacing

33
Q

What are 3 ways to assess effectiveness of transcutaneous pacing?

A

Pulse, BP, and LOC

34
Q

–Simplified: Unstable Brady algorithm

A

AATDE
Airway: 10L NRBM
Atropine: 1mg Q3-5min
Transcutaneous pacing
Dopamine 5-20mcg/kg/min
Epinephrine 2-10 mcg/min

35
Q

Rate of compressions?

A

-30:2 if no advanced airway placed
-Continuous if advanced airway in place; 100-120/min x2 min

36
Q

Steps for cardioversion:

A

-Press SYNC button
-State and select approp. level (75j)
-State “Charging” and charge it
-State “All clear” when fully charged
-State “Press and HOLD” discharge button
-Repeat sequence with 120j, repeat with 150j
[If ventricular rate >150: biphasic: synchronized cardioversion per approved energy dose listed on defibrillator]

37
Q

General procedure for all life-threatening patient conditions

A

-IV/IO access
-Begin NS TKO
-Flush lines with 20ml NS flush after each medication

38
Q

If IV access is unavailable, which medications can you give via ET tube? What dose?

A

Narcan, atropine, and epinephrine. 2-2 1/2 times the IV dose diluted in 10ml NS flush

39
Q

All external electrical therapy will use ____ monitors using appropriate energy dose

A

biphasic

40
Q

What concentration of epi do you use for asystole? mg/ml

A

-0.1 mg/ml
-give 1 mg epi

41
Q

Dose for epi and titration (Unstable Brady)

A

2mg/250ml NS at 2mcg.min, max 10 mcg/min

42
Q

What are the only 2 algorithm(s) that call for 4L nasal cannula?

A

STABLE V. Tach and chest pain

43
Q

If you over sedate your patient with versed (midazolam) or other benzo, what is the reversal drug? What is the dosing and max?

A

O2 10L NRBM
Romazicon/Flumazenil
0.2 mg IVP/IO over 15 seconds, may repeat in 45 seconds if required, max 0.6mg
*if patient receives reversal agent, complete an RL and consider continuous capnography monitoring

44
Q

What do you do for symptomatic hypotension for immediate post anesthesia patients?

A

if O2 and bolus are not effective,
-Ephedrine 5mg IVP/IO
-if no improvement within 3 minutes, repeat ephedrine 10mg IVP/IO
-if obvious blood loss, stat H/H, Type and cross 2 units PRBCs

45
Q

Which labs would you draw for increased ICP its?

A

Draw baseline K, Na, BUN, Cr, Glucose (BMP), serum osmolality, and ABG

46
Q

If pt is having bronchospasm, what medication and what dosing?

A

Albuterol 0.5mL in 3mL NS

47
Q

What labs do you draw for status epilepticus?

A

K, Na, glucose, BUN, Cr, and anticonvulsant levels if appropriate

48
Q

What is the dosing and titration for dopamine?

A

400 mg/250 mL D5W
5-20 mcg/kg/min

49
Q

What is the dosing and titration for epi?

A

2 mg/250mL NS
2-10 mcg/min

50
Q

Define ESO:

A

Pre-established medical orders approved by appropriate medical staff to be administered in the absence of a physician. These orders specify EMERGENT treatment
interventions for life-threatening conditions.

51
Q

Define Unstable:

A

Serious signs and symptoms related to the life-threatening rhythm or condition(s) which
may include:
Signs: Tachypnea, apnea, respiratory depression, tachycardia, bradycardia, arrhythmias, hypotension,
decreased O2 saturation, dyspnea, change in level of consciousness, increased intracranial pressure
(ICP), status epilepticus
Symptoms: Dizziness, lightheadedness, shortness of breath (SOB), chest pain, weakness, cold,
diaphoretic, heart palpitations, anxiousness

52
Q

go back to ESO study guide

A

review blocks and maybe make cards for defining the rhythm

53
Q

How is STEMI defined/diagnosed? What is the goal when STEMI diagnosed?

A

12 lead EKG, ST elevation >2mm in 2 contiguous leads or the onset of a new BBB (suggests stemi)
Goal: PCI or thrombolytics in <90 minutes// call RRT (STEMI algorithm)

54
Q

s/s of symptomatic hypotension?

A

cool/clammy skin, oliguria, increased HR, impaired sensorium (decreased LOC/confusion)

55
Q

First sign of increased ICP? later signs?
increased ICP is defined by?

A

first signs: decreased LOC
later signs: hemiparesis, posturing, signs of herniation (unilateral or bilateral fixed and dilated pupils)
-increased ICP >15mmHg (or as specified by MD)
Patients must be neurologically impaired with dilating pupil (associated with other signs of impending herniation without specific ICP physician orders)

56
Q

Define status epilepticus

A

Generalized tonic-clonic (grand mal) movements lasting more than 5 minutes or recurrent seizures without return of consciousness

57
Q

What can cause status epilepticus?

A

Withdrawal from anticonvulsant meds, acute alcohol withdrawal, cns infections, brain tumors, metabolic disorders, or cerebral edema

58
Q

A sudden increase of ETCO2 of ____ could indicate ROSC

A

typically> 40 mmHg

59
Q

Define first degree AV heart block

A

This block is caused by a delay in the passage of the impulse anywhere from the
atria to the ventricles. It is characterized by a long PR interval (> 0.20 seconds) that is constant

60
Q

Which block is Wenckebach?

A

second degree type 1

61
Q

Define second degree AV block type I

A

This block occurs when some impulses are conducted
and others are blocked. It is characterized by progressive prolongation of the PR interval until a p wave is
not conducted. This pattern is repetitive and results in “group beating” e.g. three conducted p waves with
progressively lengthening PR intervals and a fourth p wave that is not followed by a QRS. ( Wenckebach)

62
Q

Define second degree heart block type II

A

It is characterized by constant
PR intervals in conducted beats and more than one non-conducted p waves. This block, when associated
with an acute myocardial infarction (AMI), carries a high risk of progressing to a complete heart block.

63
Q

Describe third degree heart block (complete heart block)

A

There are no consistent PR
intervals.

64
Q

What is the goal for STEMI to PCI or thrombolytics?

A

<90 minutes

65
Q

Increased ICP is defined as ICP> _____

A

15 (or as specified by MD)

ESO (1 decks)

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