Critical Care Medications Flashcards
1
Q
Primary Emphasis of BLS
A
- Removing upper airway obstruction and maintaining the patency of airway
- Eliminating respiratory arrest
- Restoring circulation
2
Q
Steps in the BLS Assessment
A
- Check for responsiveness
- Activate the emergency response system and obtain an AEB
- Circulation - check carotid pulse (for no more than 5-10 sec); if no pulse, begin CPR
- Defibrillation - AED or begin ACLS protocol
3
Q
The main focus of BLS
A
Early CPR and early difibrillation
4
Q
Effective Compression
A
Maximize compression time with no pauses longer than 10 seconds
- Not too fast
- Not too deep
- Hand placement
5
Q
How fast should compressions be?
A
Quality and effectiveness decreases with more than 120 compressions/min. The new target is 100-120 compression/min
6
Q
How deep should the compressions be?
A
Maximum compression depth 2-2.4 inches
7
Q
Describe hand placement for compressions
A
Heel of hands on lower half of sternum, fingers locked, straight arms, elbows locked, and shoulders directly over hands
8
Q
Most Commonly Abused Opiates
A
- Heroin
- Morphine
- Codeine
- Fentanyl
- Meperidine
- Oxycodone
- Hydrocodone/Hydrocodeinone
- Hydromorphone
- Oxymorphone
9
Q
Signs of Opiate Overdose
A
- Pinpoint pupils
- Breathing problems
- Dizziness
- Cold, clammy skin
- Seizures
- Skin turning blue
- Limp muscles
- Unconsciousness
- Bradycardia
- Choking sounds
- Vomiting
- Inability to talk
- Irregular breathing
10
Q
Who do we use Naloxone on?
A
- Known or suspected opioid addicts
- Patients who are not breathing normally but have a pulse
11
Q
Who can administer Naloxone?
A
Trained lay rescuers and BLS providers can administer naloxone
12
Q
Dosage for Naloxone
A
- 2 mg intranasally
- 0.4 mg IM
13
Q
If there is no response to the first dose of naloxone?
A
- The dose can be repeated after 4 minutes
- If no response after repeat dose, continue CPR and use AED
14
Q
What does ACLS stand for?
A
Advanced Cardiac Life Support
15
Q
Main goal of ACLS
A
Increase patient outcomes by sustaining life and making efforts to keep neurological function intact during a medical emergency
16
Q
ACLS Primary Survey
A
A - Airway/cervical B - Breathing C - Circulation D - Disability E - Exposure
17
Q
ABCDE ACLS: A
A
Assess airway with simultaneous cervical spine immobilization. Can the patient talk? If obstructed, consider chin lift, jaw thrust, suction, oropharyngeal airway, and intubation, all while keeping the neck immobilized
18
Q
ABCDE ACLS: B
A
Assess breathing rate, depth, effort, accessory muscle use, symmetry of chest wall movement, and bilateral breath sounds
- Close any open wounds and provide oxygen, intubation, and ventilation as needed
19
Q
ABCDE ACLS: C
A
Circulation
- Palpate central and peripheral pulses
- Assess level of consciousness
- Look for obvious signs of bleeding
- Check skin temperature and color
20
Q
ABCDE ACLS: D
A
Disability
- Perform a rapid neurological assessment
- Glasgow Coma Score
- Best eye opening
- Best verbal response
- Best motor response
21
Q
ABCDE ACLS: E
A
Exposure
- Provide exposure and environmental controls
- Remove the patient’s clothes and keep him or her warm
22
Q
ACLS: Secondary Assessment
A
S - signs and symptoms A - allergies M - medications P - past medical history L - last meal E - events leading to presentation
23
Q
Medications for Tachycardia
A
- Adenosine ***
- Procainamide ***
- Verapamil
- Diltiazem
- Amiodarone
- Digoxin
- Beta Blockers
- Magnesium sulfate
24
Q
Medications for Bradycardia
A
- Atropine ***
- Epinephrine
- Dopamine
25
Atropine Action
Increases activity in the SA node, by blocking the vagus nerve and increasing heart rate
** First line medication for bradycardia
26
Atropine IV
- 1st dose 0.5 mg bolus
- Repeat every 3-5 minutes
- Max dose: 3 mg
27
Atropine Precautions
1. MI and hypoxia: increased oxygen demand
2. Avoid hypothermia
3. Not effective in 2nd degree type II or 3rd degree heart blocks
28
What is defibrillation?
Is a non-synchronized delivery of energy during any phase of the cardiac cycle
29
What is cardioversion?
Is the delivery of energy that is synchronized to the large R waves or QRS complex
30
How is cardioversion different from defibrillation?
1. Synchronized
2. Elective procedure, need consent
3. Sedation
4. 50-200 joules
31
How is defibrillation different from cardioversion?
1. Non-synchronized
2. Emergency
3. V-fib, V-tach
4. Client unconscious
5. Begin with 200 joules up to 360
32
Adenosine Dosage
- 1st dose: 6mg rapid IV push; follow with NS flush
- 2nd dose (if required): 12 mg IV rapid push
* * Half life is very short: less than 10 seconds
33
Indications for Adenosine
1st drug of choice for stable, narrow complex, regular SVT
34
Contraindications/Precautions for Adenosine
1. Poison/drug induced tachycardia is contraindicated
2. Transient side effects; flushing, CP, asystole, brady, ectopy (random off beats)
3. If used for VT may cause worsening of clinical condition
4. Transient periods of sinus brady or ventricular ectopy common after termination of SVT
5. Safe in pregnancy
35
Procainamide: Mechanism of Action
Suppresses intraventricular conduction
36
Procainamide: Indications
Stable monomorphic v-tach with normal QT interval
37
Procainamide: Contraindications
1. Torsades de pointes
| 2. 2nd and 3rd degree AV block
38
Procainamide: Adverse Reactions
1. Confusion
2. Seizures
3. Hypotension
4. Bradycardia
39
Procainamide: Considerations
1. Pregnancy safety: Category C
| 2. Potent vasodilation and negative inotropic effects
40
Procainamide: Dosage
ACLS guidelines: infuse 20 mg/min until arrhythmia is controlled, hypotension occurs, QRS complex widens by 50% of its original width, or total of 17 mg/kg is given
41
Medications for V-fib and Pulseless V-tach
1. Epinephrine
2. Amiodarone
3. Lidocaine
4. Magnesium sulfate
42
Asystole and Pulseless Electrical Activity
Epinephrine
43
Indications for Epinephrine
1. Cardiac arrest (V-fib, V-tach, asystole, PEA)
2. Profound hypotension associated with bradycardia
3. Anaphylaxis
4. Bronchospasm and bronchoconstriction of bronchial asthma and COPD
44
Epinephrine Dosage
For V-fib, PVT, asystole, and PEA
- IV/IO: 1 mg every 3-5 minutes
- Flush with 20 mL NS (central line preferred)
- ET: 2-2.5 mg every 3-5 minutes
- Dilute in 5-10 mL SW or NS
45
Amiodarone Adverse Effects
1. Fatal pulmonary fibrosis
2. Abnormal liver function tests and hepatitis
3. Photodermatitis and gray-blue skin discoloration in sun-exposed areas
4. Corneal micro-deposits and discoloration
5. Optic neuritis: Halos develop in the peripheral visual fields, may progress to blindness
6. Hypothyroidism or hyperthyroidism
7. Bradycardia and heart block
46
Indications for Lidocaine
Alternative to amiodarone in cardiac arrest from V-fib and V-tach
47
Lidocaine: Mechanism of Action
Anti-arrhythmic, decreases depolarization and excitability of the ventricles during diastole
48
Lidocaine: Dosage
1-1.5 mg/kg q 3-5 min (Max 3 mg/kg)
49
Lidocaine: Nursing Considerations
- If received bolus, needs to receive a continuous infusion after
- Monitor for CNS effects of toxicity (drowsiness, slurred speech, seizures, respiratory depression)
50
Magnesium Sulfate: Indications
1. Torsade de pointes is suspected in cardiac arrest
| 2. Hypomagnesemia (Mg < 1.8 mg/dL)
51
Magnesium Sulfate: Dosage
1-2 grams over 5-20 minutes
52
Magnesium Sulfate: Precautions
- Fall in BP with fast administration
- Use extreme caution in renal failure
- Monitor: hypotension, respiratory, and CNS depression
53
Signs of Magnesium Sulfate Toxicity
B - blood pressure decreased
U - urine output decreased
R - respirations < 12
P - patella reflex absent
54
H's of ACLS
1. Hypovolemia
2. Hypoxia/Hypoxemia
3. Hydrogen Ion Excess (Acidosis)
4. Hypokalemia/Hyperkalemia
5. Hypothermia
55
Signs of Hypovolemia
- Rapid HR
- Narrow QRS
- Blood loss
56
Treatment of Hypovolema
- Obtain IV access
- Administer blood/fluid
- Use fluid challenge
57
Signs of Hypoxia/Hypoxemia
- Slow HR
| - Cyanosis
58
Treatment of Hypoxia/Hypoxemia
- Ensure airway is open
- Ventilate
- Ensure oxygen supply is adequate
59
Signs of Acidosis
- Low amplitude QRS complex
60
Treatment of Acidosis
- Arterial blood gas
- Provide adequate ventilations
- Sodium bicarbonate
61
Signs of Hypokalemia
Flattened T waves and a U wave
62
Signs of Hyperkalemia
Peaked T waves and a widened QRS
63
Treatment of Hypokalemia/Hyperkalemia
- Ventilate (respiratory)
| - Sodium bicarbonate (metabolic)
64
Signs of Hypothermia
- Shivering
| - Previous exposure to cold temperatures
65
Treatment of Hypothermia
- Active warming measures
| - Temperature should be above 30 degrees C
66
T's ACLS
1. Tamponade (cardiac)
2. Toxins
3. Tension pneumothorax
4. Thrombosis (pulmonary)
5. Thrombosis (coronary)
67
Signs of Cardiac Tamponade
- Rapid HR
- Narrow QRS
- JVD
- No pulse
- Muffled heart sounds
68
Treatment of Cardiac Tamponade
- Pericardiocentesis
| - Thoracotomy
69
Signs of Toxins (for T's of ACLS)
Prolonged QT interval
70
Treatment of Toxins (for T's of ACLS)
- Based on overdose agent
| - Supportive care
71
Signs of Tension Pneumothorax
- Slow HR
- Narrow QRS
- Unequal breathing
- JVD
- Tracheal deviation
72
Treatment of Tension Pneumothorax
- Needle decompression
| - Insertion of a chest tube
73
Signs of Thrombosis (Pulmonary)
- Rapid HR
- Narrow QRS
- SOB
- Decreased oxygen
- Chest pain
74
Treatment of Thrombosis (Pulmonary)
- Embolectomy
- Fibrinolytic therapy
- Anticoagulant therapy
75
Signs of Thrombosis (Coronary)
Abnormal EKG
76
Treatment of Thrombosis (Coronary)
- Angioplasty
- Stent placement
- Coronary bypass surgery
77
TTM
Targeted Temperature Management
78
TTM: Indications
1. Non-traumatic cardiac arrest with return of spontaneous circulation
2. Comatose: GCS 8 or less or no purposeful movements
3. Age 18-75 years
79
TTM: optimum temperature for therapeutic hypothermia
32-36 degrees C (89.6 - 96.8 degrees F)
80
TTN: what is temperature monitored with
Any of the following
1. Esophageal thermometer
2. Bladder catheter
3. Pulmonary artery catheter
81
TTN: Duration
A single target temperature, within this range should be selected, achieved, and maintained for at least 24 hours
82
TTN: Contraindications
1. DNR
2. Return of spontaneous circulation > 60 minutes
3. More than 6 hours since initial arrest
4. Uncontrolled arrhythmias
5. Initial temperature less than 30 degrees
6. Coagulopathy
7. Pregnancy
83
Early Coronary Reperfusion Therapy
- Initial strategy to restore blood flow to the occluded coronary arteries by two standards of care
1. Fibrinolytic therapy
2. Primary percutaneous transluminal coronary angioplasty (PTCA) stents
84
Outcomes of Reperfusion Therapy Depend on what?
- Time to treatment
| - Early and full restoration of blood flow
85
What do we give a patient who is post arrest hypotension not responsive to fluid bolus?
1. Epinephrine 0.1 - 0.5 mcg/kg/min
2. Dopamine 5 - 10 mcg/kg/min
3. Norepinephrine 0.1 - 0.5 mcg/kg/min
86
Dopamine: Indications
1. Second line drug for symptomatic bradycardia
| 2. Hypotension with signs and symptoms of shock
87
Dopamine: Precautions
1. Correct hypovolemia with volume before initializing
2. Extravasation of tissues!! Use central line!!
3. May cause tachydysrrhythmias; excessive vasoconstriction
4. If extravasation occurs: The area should be treated with phentolamine to prevent tissue necrosis in the ischemic area
5. Need to request central line insertion for infusion
88
Dopamine: IV Administration
1. Infusion at 2 - 20 mcg/kg/min
| 2. Titrate to patient response; taper slowly
89
Norepinephrine: Dosage
0.1 - 0.5 mcg/kg/min (in 70 kg patient usually 7-35 mcg/min)
90
Norepinephrine: Indications
Treatment of severe non-volume related hypotension usually after Dopamine
91
Norepinephrine: Contraindications
1. Do not give if hypotension is due to low blood volume (can lead to tissue hypoxia and decreased renal perfusion)
2. Excessive infusion rate can result in severe hypertension and tissue necrosis
3. Need to use a central line to prevent tissue damage from extravasation
4. If extravasation occurs: the area should be treated with phentolamine to prevent tissue necrosis in the ischemic area
92
Extravasation
The inadvertent administration of a vesicant solution or medication into surrounding tissue
93
Infiltration
The inadvertent administration of a non-vesicant solution/medication into a surrounding tissue
94
Vesicant
A solution or medication that causes a blistering process when inadvertently administered into the surrounding tissue
95
Hypertensive Crisis Symptoms
1. BP > 180/110
2. HA/blurred vision
3. Seizures
4. Focal neuro deficits
5. Chest pain/SOB
6. Renal failure
96
Nitroglycerin: Indications
Relief of acute angina pain and decrease hypertension
97
Nitroglycerin: Dosage
5 - 100 mcg/min as IV infusion
| ** Increase by 5 mcg/min every 5 -10 minutes based on BP
98
Nitroglycerin: Onset of Action
2 - 5 minutes
99
Nitroglycerin: Adverse Effects
1. Headache ***
2. Hypotension
3. Facial flushing
4. Tachycardia
100
Nitroglycerin: Contraindications
1. Hypotension (SBP < 90 mm Hg)
2. Bradycardia (HR < 50)
3. Tachycardia (HR > 100)
4. Patients who have taken phosphodiesterase inhibitors (vardenafil, sildenafil, tadalafil) within the past 24 hours
101
Sodium Nitroprusside: Indications
Potent vasodilator used in hypertensive emergencies (BP > 180/110)
102
Sodium Nitroprusside: Dosage and Administration
1. 0.5 mcg/kg/min (Max dose is 10 mcg/kg/min)
2. Very rapid onset of action; effects stop 3 min. after infusion discontinued
3. Given in 5% Dextrose- Must be protected from light so bag must be opaque or covered. Only good for 24 hours
4. Should be a faint brown color- is solution is red, blue, or green the medication has been inactivated with contaminants
5. DO NOT mix with any other drugs in the same line
6. Arterial line required to monitor continuous BP
7. Administered in ICU, OR, and ED
103
Sodium Nitroprusside: Side Effects
1. Byproduct of breakdown is cyanide (toxic)
2. Use only for a short period of time (< 72 hours)
3. Measure cyanide levels by measuring thiocyanate levels and lactate levels
4. Hypotension if dose is too high
