Exam 1 ACLS Flashcards by Joshua Martinez

What HR would be considered bradyarrhythmia?

Less than 50 bpm

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What is the leading cause of bradycardia?

What are other causes of bradycardia?

Hypoxia

MI/infarction
Drugs/toxicities (CCB, BB, Dig)
Hyperkalemia

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What can persistent bradyarrhythmia cause?

Hypotension
Acutely altered mental status
Signs of shock
Ischemic chest discomfort
Acute HF

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What do you do if someone is bradycardic but clinically stable?

Monitor and observe

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What is the treatment for bradycardia?

1 mg Atropine every 3 to 5 minutes.
Max: 3 mg

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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

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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.

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How do you treat bradycardia secondary to calcium channel blockers?

Give Calcium

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How do you treat bradycardia secondary to beta blockers?

Glucagon and give something for rate support while the glucagon kicks in

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How do you treat bradycardia secondary to digoxin?

Digibind or Digifab

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What is the rate for CPR?

100-120 compressions/min

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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)

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ETCO2 of what level indicates perfusion.

15 mmHg

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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

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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

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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.

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What is used to confirm and monitor ET tube placement?

Waveform capnography or capnometry

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With an advanced airway, one breath will be delivered every ______ seconds.

6 seconds/ 1 breath

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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)

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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

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How often do you defibrillate a shockable rhythm?

every 2 minutes

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What HR is considered tachyarrhythmia?

HR greater than 150 bpm

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What can persistent tachyarrhythmias cause?

Hypotension
Acutely altered mental status
Signs of shock
Ischemic chest discomfort
Acute HF

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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?

1. Hypoxia 2. 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