Exam 1 ACLS Flashcards
What HR would be considered bradyarrhythmia?
Less than 50 bpm
What is the leading cause of bradycardia?
What are other causes of bradycardia?
Hypoxia
MI/infarction
Drugs/toxicities (CCB, BB, Dig)
Hyperkalemia
What can persistent bradyarrhythmia cause?
Hypotension
Acutely altered mental status
Signs of shock
Ischemic chest discomfort
Acute HF
What do you do if someone is bradycardic but clinically stable?
Monitor and observe
What is the treatment for bradycardia?
1 mg Atropine every 3 to 5 minutes.
Max: 3 mg
What to do if atropine is ineffective for bradycardia?
Transcutaneous pacing and/or dopamine infusion or epinephrine infusion.
Dopamine infusion: 5-20 mcg/kg/min TTE
Epinephrine infusion: 2-10 mcg/min TTE
Why do you have to be cautious about when giving atropine for adult bradycardia?
A very low dose (0.1 mg) can actually worsen bradycardia. Make sure you give 1 mg.
How do you treat bradycardia secondary to calcium channel blockers?
Give Calcium
How do you treat bradycardia secondary to beta blockers?
Glucagon and give something for rate support while the glucagon kicks in
How do you treat bradycardia secondary to digoxin?
Digibind or Digifab
What is the rate for CPR?
100-120 compressions/min
Features of quality CPR?
Push hard (2 in) and fast (100-120/min)
Minimize interruptions in compressions
Avoid Excess ventilation
Change Compressors every 2 minutes or fatigued
30:2 compression: ventilation ratio if no airway
ETCO2 > 35-45 mmHg (normal)
ETCO2 of what level indicates perfusion.
15 mmHg
Shock Energy for Defibrillation
Biphasic:
Monophasic:
Shockable rhythms:
Non-shockable rhythms:
Biphasic: Manufacturer recommendation (120 to 200J)
Monophasic: 360J
Shockable rhythms: V-fib/ pulseless V-tach
Non-shockable rhythms: PEA/Asystole
Drug Therapy for Cardiac Arrest
Epinephrine IV/IO: 1mg every 3 to 5 minutes
Amiodarone IV/IO: first dose 300mg bolus, second dose 150mg
Lidocaine IV/IO: First dose 1-1.5 mg/kg, second dose: 0.5-0.75 mg/kg
Should you stop CPR to place an advanced airway?
No, oftentimes a supraglottic airway (LMA) will be placed during the code. Once the patient is stabilized, they will be intubated.
What is used to confirm and monitor ET tube placement?
Waveform capnography or capnometry
With an advanced airway, one breath will be delivered every ______ seconds.
6 seconds/ 1 breath
What are indications of Return of Spontaneous Circulation (ROSC).
Palpable Pulse
Blood Pressure, spontaneous atrial pressure wave
Abrupt sustained increase in ETCO2 (15 mmHg to 40 or 50 mmHg)
What are your reversible causes of cardiac arrest (H’s and T’s )
Hypovolemia - give blood, fluids
Hypoxia - oxygen and airway
Hydrogen Ion (acidosis)- bicarb and ventilation
Hypo/Hyperkalemia
Hypothermia- cold hearts are irritable
Tension Pneumothorax - can result in PEA, decompress chest
Tamponade, Cardiac- Pericardiocentesis
Toxins- use antidotes
Thrombosis (PE) -cannulation/ECMO/thrombectomy
Thrombosis (Coronary)-cannulation/ECMO/thrombectomy
How often do you defibrillate a shockable rhythm?
every 2 minutes
What HR is considered tachyarrhythmia?
HR greater than 150 bpm
What can persistent tachyarrhythmias cause?
Hypotension
Acutely altered mental status
Signs of shock
Ischemic chest discomfort
Acute HF
Treatment for unstable tachycardia:
Synchronized Cardioversion
-consider sedation
Difference between wide and narrow complexes in tachycardia.
Narrow complexes are supraventricular (consider adenosine)
Wide complexes are ventricular (consider ventricular antiarrhythmics )
What is the dose for adenosine for SVT?
First dose: 6 mg rapid IV push; follow with NS flush
Second dose: 12 mg
IV Amiodarone dosing for stable wide complex tachycardia.
Amiodarone: First dose 150 mg over 10 minutes followed up by 1 mg/min infusion for first 6 hours, 0.5 mg/min for the next 18 hours.
What is the IV dosing for Procainamide for stable wide tachycardia?
20 to 50 mg/min until arrhythmia suppression,
Hypotension ensues, QRS duration >50%, or max dose of 17 mg/kg.
Maintenance infusion: 1-4 mg/min. Avoid if prolonged QT or CHF.
What is the IV dosing for Sotalol for stable wide tachycardia?
100 mg (1.5 mg/kg) over 5 minutes. Avoid if prolonged QT.
Treatment for patients with stable narrow tachycardia.
Vagal maneuvers
Adenosine
Beta-blockers (esmolol)
Calcium channel blockers
Carotid sinus massage (young person)
Expert consultation
What is the first thing to do after ROSC has been obtained?
Manage the airway, with the early placement of an endotracheal tube.
Manage respiration: 10 breaths/min, SpO2 >92%, PaCO2: 35-45 mmHg
Manage hemodynamic parameters: > 90/65, MAP>65
Obtain 12 Lead
When to consider emergency cardiac intervention post ROSC?
STEMI present
Unstable cardiogenic shock
Mechanical circulatory support required (ECMO, balloon pump)
Interventions if the patient is unable to follow commands post ROSC?
Targeted temperature management
Head CT
EEG monitoring
What is the antidote for Magnesium overdose?
Calcium chloride or gluconate
This can happen in a pregnant patient receiving Magnesium for PIH
Why do you want IV access to the upper extremities for pregnant patients undergoing cardiac arrest?
The patient has uteroplacental displacement. Medication to IVs on the lower extremity might not reach the heart.
If no ROSC within _________ minutes, consider immediate perimortem c-section.
5 minutes
What are the potential etiology of maternal cardiac arrest?
Anesthetic complication - spinal
Bleeding - C-section, maternal hemorrhage-DIC
Cardiovascular - underlying issue
Drugs - meth
Embolic -amniotic fluid embolism
Fever
General (H’s and T’s)
Hypertension - Mag overdose for PIH
What meds do you give to treat amniotic fluid embolism?
Atropine
Ondansetron
Ketolorac (Tordal)
AOK
What are the biggest causes of asystole and PEA in pediatrics?
- Hypoxia
- Hypotension
How far do you compress during CPR for pediatrics?
one-third of the anteroposterior diameter of the chest.
Drug therapy during pediatric cardiac arrest.
Epinephrine: 0.01 mg/kg every 3 minutes up to a max of 1 mg.
Amiodarone: 5mg/kg bolus up to 3 doses for v-fib/pVT
Lidocaine: 1mg/kg loading dose
For pediatric patients when do you start CPR?
Start CPR if the patient is symptomatic and HR is less than 60 bpm despite oxygenation and ventilation
Meds for pediatric bradycardia.
Start with Epinephrine 0.01 mg/kg every 3-5 mins
Atropine 0.02 mg/kg, repeat once.
Minimal Atropine dose 0.1 mg
Max atropine Single dose 0.5 mg
Other interventions for pediatric bradycardia?
Transthoracic/ Transvenous pacing
ID causes (hypothermia, hypoxia, meds)
What is the most common cause of pediatric tachycardia?
Pre-existing cardiac disease rather than ischemic events.
What HR is considered tachyarrhythmia for a child and infant?
Child >180 bpm
Infant >220 bpm
What is the intervention for an unstable tachycardiac pediatric patient?
Synchronized Cardioversion
Begin with 0.5 - 1.0 J/kg; if not effective increase to 2 J/kg.
Sedate if needed, but don’t delay cardioversion
What is the medication of choice for pediatric SVT?
Adenosine
First dose 0.1 mg/kg rapid bolus (max of 6 mg)
Second dose 0.2 mg/kg rapid bolus (max of 12 mg)
When do you give adenosine for ventricular tachycardia?
If the rhythm is regular and monomorphic
What are ways to treat stable SVT in children?
Vagal maneuvers (blow up a ballon)
What is the scoring system for neonates?
APGAR score (0-2 points per category)
Score greater than 7, baby is in good health.
Activity
Pulse
Grimace
Appearance
Respiration
What to do with neonates if they are not a term gestation, do not provide good tone, and not breathing/crying immediately after birth?
Within the first minute:
Warm and maintain a normal temperature
Position Airway
Clear Secretion
Dry
Stimulate
What happens if the neonate is showing apnea or gasping after initial intervention?
Positive Pressure Ventilation
SpO2 monitor
EKG monitor
What happens if the neonate is labored breathing or presents persistent cyanosis after initial intervention?
Position and clear airway
SpO2 monitor
Supplementary O2 as needed
Consider CPAP
What happens if the neonate is bradycardic (<100 bpm) after initial intervention?
Check chest movements
Check for adequate ventilation
ETT or laryngeal mask (know where pediatric equipment is located)
What happens if neonate’s HR drops below 60 bpm?
Medications?
Intubate if not already done
CPR
Coordinate with PPV
100% O2
EKG Monitor
Consider emergency UVC (In reality, just cannulated the umbilical vein like an IV externally)
IV epinephrine (0.01 mg/kg) every 3-5 minutes
Considerations for neonate bradycardia after epinephrine and other interventions?
Consider hypovolemia
Consider pneumothorax
Check blood sugar (hypoglycemia)
Narcan
What treatment is most important to convert v-fib?
Defibrillation
What is the initial dose of lidocaine to treat v-fib?
1 to 1.5 mg/kg
