Cardiac Emergencies

Question 1

Rapid A-Fib/A-flutter heart rate

Answer 1

> 150 bpm

Question 2

Adult Stable A-Fib/A-Flutter Tx

Answer 2

~Cardizem 10 mg IV/IO over 2 min
~If HR > 120 after 5 min –> Cardizem 15 mg IV/IO over 2 min

Question 3

Cardizem contraindications

Answer 3

hypotension
wide complex tachycardia (VT)
history of WPW
2nd/3rd degree AV blocks
sick sinus syndrome

Question 4

adult AFib/AFlutter:
If hypotension develops after giving cardizem….

Answer 4

1L NS
1 g CaCl

Question 5

unstable adult A-Fib/A-Flutter (hypotension)

Answer 5

1L NS
Push dose Epi

Question 6

ADULT A-FIB/A-FLUTTER:
once BP stabilizes after giving fluids & push dose Epi…

Answer 6

1) Cardizem 10 mg
2) Cardizem 15 mg after 5 min if no change

Question 7

Pedi A-Fib/A-Flutter

Answer 7

call for orders

Question 8

HR to treat bradycardia adult

Answer 8

< 50

Question 9

adult stable bradycardia tx

Answer 9

transport

Question 10

adult unstable bradycardia w/ hypotension

Answer 10

~1L NS
~Atropine 0.5 mg, repeat prn, max dose 3 mg
~Push Dose Epi
~Pacing at initial HR of 60

Question 11

pacing sedation

Answer 11

1) Ketamine 1 mg/kg IV/IO diluted (mix 9 mL NS with 100 mg Ketamine –> 10 mg/mL)
OR
2) Ketamine 3 mg/kg IM

Question 12

Adult bradycardia in presence of MI with hypotension

Answer 12

pacing (skip Atropine)

Question 13

Adult high degree AV blocks with hypotension

Answer 13

immediate pacing if IV access not immediately accessible

Question 14

Pedi stable bradycardia

Answer 14

monitor & transport

Question 15

Pedi unstable bradycardia (with AMS & poor perfusion)

Answer 15

1) oxygenation & ventilation
30 sec for neonates
1 min for infants/children
…if HR < 60 with signs poor perfusion & AMS, start compressions

2) Push dose Epi
3) Pace at HR set to 80

Question 16

Pedi pacing sedation

Answer 16

1) Ketamine 1 mg/kg IV/IO DILUTED (mix 9 mL NS with 100 mg Ketamine –> 10 mg/mL)

OR
2) Ketamine 3 mg/kg IM

Question 17

Adult chest pain

Answer 17

1) Aspirin 324 mg total
2) Nitroglycerin 0.4 mg, may repeat 3x prn, max 3 doses
3) Dilaudid
1 mg IVP if > 70 kg
0.5 mg IVP if < 70 kg
0.5 mg IVP if age > 65

Question 18

If patient took 324 mg aspirin within past 24 hours…

Answer 18

withhold giving aspirin

Question 19

if patient took < 324 mg aspirin within past 24 hours…

Answer 19

give full 324 mg dose aspirin

Question 20

contraindications for Aspirin

Answer 20

allergy
active GI bleed

Question 21

contraindications for Nitroglycerin

Answer 21

~SBP < 100
~EDD med usage within 24-48 hours
~Right Ventricular infarct (positive V4R)

Question 22

if hypotension occurs with dilaudid use…

Answer 22

1L NS

Question 23

Pedi chest pain

Answer 23

call for orders

Question 24

STEMI alert criteria

Answer 24

ST segment elevation in 2+ continguous leads:
a) CONVEX (frowny face) or “straight morphology”
2 mm or greater in V2 & V3
OR
1 mm or greater in all other
leads

b) CONCAVE (smiley face)
2 mm or greater in any lead

Question 25

STEMI mimics

Answer 25

~QRS complexes > 0.12 (LBBB, pacemaker, etc) ~left ventricular hypertrophy (LVH) ~pericarditis ~early repolarization ~ < 2 mm elevation with concave ST segment (smiley face) morphology

Question 26

determining LVH

Answer 26

1) take largest negative deflection from isoelectric line of V1 & V2 ("S" wave), whichever is larger, & count small boxes 2) take largest positive deflection of V5 or V6 ("R" wave), whichever is larger, & add it to total from V1 or V2 3) if result > 35, suspicion for LVH should be high

Question 27

S/S CHF (pulmonary edema)

Answer 27

HTN tachycardia orthopnea rales pedal edema

Question 28

Adult CHF

Answer 28

Aspirin 324 mg PO Nitroglycerin 0.4 mg SL (max 3 doses) CPAP 10 cm H2O

Question 29

Contraindications to CPAP use

Answer 29

SPB > 100 mmHg AMS (lethargic) apnea

Question 30

pedi CHF

Answer 30

call for orders

Question 31

Adult cardiogenic shock (heart failure/pulmonary edema, hypotension)

Answer 31

Push Dose Epi follow CHF protocol

Question 32

Pedi cardiogenic shock

Answer 32

call for orders

Question 33

Adult SVT (HR>150) tx

Answer 33

1) vagal maneuver 2) Adenosine 12 mg IVP + rapid 10 mL NS flush

Question 34

contraindication for Adenosine use

Answer 34

A-Fib/A-Flutter

Question 35

If adult SVT fails to convert with use of Adenosine ....

Answer 35

1) Cardizem 10 mg IVP over 2 min 2) if HR > 120 after 5 min --> Cardizem 15 mg IVP over 2 min

Question 36

what pt medication class should the paramedic be cautious of when using cardizem?

Answer 36

beta-blockers

Question 37

adult SVT: If hypotension develops after giving cardizem....

Answer 37

1L NS 1 g CaCl over 2 min

Question 38

Unstable Adult SVT (hypotension) but pt is alert

Answer 38

Adenosine 12 mg IVP + rapid 10 mL NS flush

Question 39

Unstable Adult SVT (hypotension) where pt is alert but adenosine has no effect

Answer 39

Monitor & transport

Question 40

Unstable Adult SVT (hypotension) where pt has AMS

Answer 40

synchronized cardioversion with sedation: Ketamine 1 mg/kg IV/IO diluted OR Ketamine 3 mg/kg IM SYNC 100-200-300-360 joules

Question 41

HR for SVT in children

Answer 41

> 190 bpm

Question 42

HR for SVT in infants

Answer 42

> 220 bpm

Question 43

stable pedi SVT

Answer 43

1) vagal maneuvers 2) Adenosine 0.1 mg/kg rapid IV/IO + rapid 10 mL NS flush max dose 6 mg 3) after 1 min with no change: Adenosine 0.2 mg/kg rapid IV/IO + rapid 10 mL NS flush max dose 12 mg

Question 44

unstable pedi SVT (age-appropriate hypotension) & pt is alert

Answer 44

1) Adenosine 0.1 mg/kg rapid IV/IO + rapid 10 mL NS flush max dose 6 mg 2) after 1 min with no change: Adenosine 0.2 mg/kg rapid IV/IO + rapid 10 mL NS flush max dose 12 mg

Question 45

Unstable Pedi SVT (hypotension) where pt has AMS

Answer 45

synchronized cardioversion with sedation: Ketamine 1 mg/kg IV/IO diluted OR Ketamine 3 mg/kg IM SYNC 1 J/kg, 2 J/kg

Question 46

definition of really wide complex tachycardia (think hyperkalemia)

Answer 46

1) QRS complex > 0.200 ms 2) HR = ~100-120 bpm with no discernible P waves 3) QTc > 500

Question 47

really wide complex tachycardia tx

Answer 47

1) CaCl 1 g IV/IO over 2 min 2) NaHCO3 50 mEq slow over 2 min 3) Albuterol 10 mg (4x2.5 mg) continuous treatments

Question 48

definition wide complex tachycardia

Answer 48

1) QRS > 0.12 ms (adult) OR QRS > 0.09 ms (pedi) 2) HR > 120 bpm with no discernible P waves 3) regular (think VT)

Question 49

stable adult wide complex tachycardia

Answer 49

Lidocaine bolus 1) 0.5-0.75 mg/kg up to 1-1.5 mg/kg 2) repeat 0.5-0.75 mg/kg q 5-10 min max total dose 3 mg/kg

Question 50

unstable adult wide complex tachycardia

Answer 50

synchronized cardioversion with sedation: Ketamine 1 mg/kg IV/IO diluted OR Ketamine 3 mg/kg IM SYNC 100-200-300-360 joules

Question 51

unstable adult WCT where 4 times cardioversion fails....

Answer 51

1) Lidocaine bolus 0.5-0.75 mg/kg up to 1-1.5 mg/kg 2) repeat 0.5-0.75 mg/kg q 5-10 min max total dose 3 mg/kg 3) cardioversion 360 J q 2 min prn