Cardiac Arrest and Chest Pain (Emerg flash cards)

Question 1

What are the indications for electrical cardioversion?

Answer 1

“Paroxysmal SVT
Atrial fibrillation/Atrial flutter
Ventricular tachycardia”

Question 2

What are the pre-medication options before electrical cardioversion?

Answer 2

“Midazolam 1-5mg (+/- fentanyl 50-200mcg)
Propofol 50-150mg IV
Ketamine 0.25-1.5mg/kg IV
Etomidate 20mg IV”

Question 3

What is synchronized cardioversion?

Answer 3

Delivery of a low-energy shock that is timed with the patient’s cardiac cycle (synchronized with the peak of the QRS complex)

Question 4

What is unsynchronized cardioversion?

Answer 4

Delivery of a high-energy shock, with no time delay (delivered as soon as button is pressed on defibrillator)

Question 5

What can happen if a low-energy shock is delivered at the wrong point in the cycle?

Answer 5

If the shock occurs on the t-wave (during repolarization), there is a high likelihood that the shock can precipitate VF (Ventricular Fibrillation)

Question 6

What are the indications for synchronized cardioversion?

Answer 6

“unstable atrial fibrillation
atrial flutter
atrial tachycardia
supraventricular tachycardias”

Question 7

When is unsynchronized cardioversion used?

Answer 7

• there is no coordinated intrinsic electrical activity in the heart (pulseless VT/VF), or
• the defibrillator fails to synchronize in an unstable patient

Question 8

What “dose” of electricity is given in synchronized cardioversion?

Answer 8

pSVT/Aflutter: 150J biphasic or 300J monophasic

Vtach/Afib: 200J biphasic or 360J monophasic

Question 9

What is the management of stable atrial fibrillation or flutter?

Answer 9

If HR > 120: rate control

Then consider rhythm control

Question 10

What are the medical management options for acute narrow complex afib with HR >120?

Answer 10

"Diltiazem 20mg IV
Verapamil 2.5-4mg IV
Metoprolol 5mg IV
Amiodarone 150mg over 10min
Digoxin 0.5mg IV"

Question 11

What are the medical management options for acute wide complex afib with HR >120?

Answer 11

“Procainamide 30mg/min to 17mg/kg

Amiodarone 150mg over 10min”

Question 12

What is the general initial management of Vfib or pulseless vtach?

Answer 12

“Intubate, ventilate, early IV/IO access (med admin)

Treat reversible causes”

Question 13

Name 7 reversible causes of Vfib/Vtach

Answer 13

"Hypovolemia
Hypoxia
Acidosis
Hyper/o kalemia
Hypothermia
Toxins
Ischemia"

Question 14

Should you start CPR or shock first?

Answer 14

Shock first if defibrillator is immediately available; if not start CPR and interrupt for defibrillator

Question 15

Describe key features of high-quality CPR

Answer 15

5cm compression, 100-120/min, with complete chest recoil. Change compressors q2min.
Minimize interruptions, avoid ventilation >10/min, monitor end-tidal CO2

Question 16

For what ECG findings do you initiate CPR?

Answer 16

VFib and pulseless VTach

Question 17

What are the two preferred medications that can be provided during CPR?

Answer 17

Epinephrine: 1mg IV q3-5min
Amiodarone: 300mg IV bolus, can add 150mg IV (2nd dose)

Question 18

What alternate medications can be provided during CPR?

Answer 18

“Refractory VFib: lidocaine, 1.5mg/kg IV, q3-5min (max 3mg/kg)
Polymorphic VTach: Magnesium sulfate, 2g IV”

Question 19

What “dose” of electricity is given for vfib or pulseless vtach?

Answer 19

200J biphasic or 360J monophasic

Question 20

What “dose” of electricity is given for unstable afib?

Answer 20

200J biphasic or 360J monophasic

Question 21

For wide-complex tachycardia, when should you consider synchronized cardioversion?

Answer 21

Early: meds only revert VT 30% of the time

Question 22

What medications can be used for wide-complex tachycardia?

Answer 22

“Procainamide 30mg/min (max 17mg/kg)

Amiodarone 150mg over 10min (repeat x2 PRN)”

Question 23

What is the next step after one antidysrhythmic fails?

Answer 23

Electric cardioversion: multiple antidysrhythmics can have proarrythmogenic effects

Question 24

What is the first step for a stable patient in paroxysmal supraventricular tachycardia (pSVT)?

Answer 24

Vagal manoeuvres

Question 25

What vagal maneouvres can stop SVT?

Answer 25

"Bearing down Carotid massage Cold wet face towel (cold face stimulus) Coughing, gagging"

Question 26

What are the medication options for pSVT?

Answer 26

"Adenosine: 6mg IV over 3 secs (1st dose), 12mg IV (2nd dose) Diltiazem: 20mg IV over 2 min (1st dose), 25mg IV (2nd dose) Metoprolol: 5mg IV (max 15mg) Verapamil: 2.5-5mg IV over 2 min, repeat 5-10mg in 10 mins"

Question 27

What is the stepwise treatment progression for pSVT?

Answer 27

"Vagal manoeuvres Medication Synchronized cardioversion (if unstable)"

Question 28

What are the "5Hs and 5Ts" used to remember?

Answer 28

Reversible causes of Pulseless Electrical Activity, Asystole

Question 29

What are the 5 Hs?

Answer 29

``` "Hypovolemia Hypoxia Hydrogen (Acidosis) Hyper/o kalemia Hypothermia" ```

Question 30

What are the 5 Ts?

Answer 30

``` "Toxins Tamponade Tension pneumo Thrombosis: coronary (MI) Thrombosis: pulmonary (PE)" ```

Question 31

What is the management of PEA/Asystole?

Answer 31

"Ongoing CPR Treat reversible causes Epinephrine 1mg IV q3-5min Re-evaluate for shockable rhythm Until ROSC or it's called"

Question 32

What is the management of stable bradycardia due to first degree block or type I second degree block?

Answer 32

Observe

Question 33

What is the management of stable bradycardia due to type II second degree block or third degree block?

Answer 33

Transcutaneous pacing --> transvenous pacing

Question 34

What is the management of unstable bradycardia?

Answer 34

"Atropine 0.5mg q3-5min (max 3mg) If not effective consider one of: - transcutaneous pacing - dopamine 2-10 mcg/kg/min - epinephrine 2-10 mcg/min"

Question 35

What are the signs of cardiac instability (for ACLS)?

Answer 35

``` "Chest pain Shortness of breath Loss of consciousness Low BP CHF Acute MI" ```