Part 8: Adult Advanced Cardiovascular Life Support Flashcards
1
Q
Why can a normal ventilation-perfusion relationship be
maintained with a minute ventilation that is much lower
than normal during CPR?
A
- Because both systemic and pulmonary perfusion are substantially reduced during CPR.
1
Q
When should an advanced airway be placed during CPR?
A
- There is inadequate evidence to define the optimal timing of advanced airway placement in relation to other interventions during resuscitation from cardiac arrest.
1
Q
During CPR and after placement of ETT the provider
delivering ventilation should provide 1 breath every _ to _
seconds?
A
6 to 8 seconds (8 to 10 breaths per minute)
1
Q
What does it mean when a CO2 detector shows a false-negative reading?
A
- Failure to detect CO2 despite tube placement in the trachea.
1
Q
Name the T’s that a provider should consider to identify
during management of cardiac arrest.
A
- Toxins
- Tamponade(cardiac)
- Tension pneumothorax
- Thrombosis, pulmonary
- Thrombosis, coronary
1
Q
How can IV sodium bicarbonate during CPR alter the
correlation between PETCO2 and cardiac output?
A
- The bicarbonate is converted to water and CO2
- causing a transient increase in delivery of CO2 to the lungs.
1
Q
What change in PETCO2 can be expected following
administration of IV sodium bicarbonate during CPR? (Increase or decrease)
A
- Increase
1
Q
What are the side effects of Amiodarone according to AHA2010?
A
- Bradycardia
- Hypotension
- Phlebitis
1
Q
What are the side effects of Magnesium according to AHA2010?
A
- Hypotension
- CNS toxicity
- Respiratory depression
1
Q
Is third degree AV block permanent or transient?
A
Can be either depending on the underlying cause
1
Q
When should you avoid relying on Atropine in a
bradycardia?
A
- In type II second degree or
- third degree AV block or
- in patients with third-degree AV block with a new wide-QRS complex where the location of block is likely to be in non-nodal tissue (such as in the bundle of His or more distal conduction system)
1
Q
At what rate does a tachycardia have a clinical
significance and is more attributable to the arrhythmia?
A
>=150b/min
2
Q
What are the indications for ETT according to AHA2010?
A
- The inability of the provider to ventilate the unconscious patient adequately with a bag and mask
- Absence of airway protective reflexes (coma or cardiac arrest)
3
Q
What are the advantages of IO cannulation?
A
- Access to a noncollapsible venous plexus
- Enables drug delivery similar to that achieved by peripheral venous access at comparable doses
- Can be established efficiently;
- Is safe and effective for fluid resuscitation drug delivery blood sampling
- Attainable in all age groups
4
Q
When should 2 providers change compressor and
ventilator roles to prevent fatigue during CPR?
A
- Every 2 minutes
5
Q
Where in the myocardium does the Mobitz type II block
usually occur?
A
- Usually below the AV node, within the His-Purkinje system
6
Q
What are the possible reasons for a false-negative reading
during cardiac arrest?
A
- Low blood flow and delivery of CO2 to the lungs
- Pulmonary embolus
- Detector contaminated with gastric contents or acidic drugs (eg endotracheally administered adrenaline)
- Severe airway obstruction
- Ppulmonary oedema
6
Q
Why is Amiodarone the first-line antiarrhythmic agent
given during cardiac arrest?
A
Because it has been clinically demonstrated to improve
the rate of ROSC and hospital admission in adults with
refractory VF/pulseless VT.
7
Q
When is the bag-mask ventilation particularly helpful
during CPR?
A
- When placement of an advanced airway is
- delayed or
- unsuccessful.
8
Q
What are the possible complications with insertion of a
nasopharyngeal airway during CPR and what are the
related precautions?
A
- Airway bleeding
- NPA should be used with caution in patients with severe craniofacial injury.
9
Q
What are the advantages of the ETT according to
AHA2010?
A
- Keeps the airway patent
- Permits suctioning of airway secretions
- Enables delivery of a high concentration of oxygen
- Provides an alternative route for the administration of some drugs
- Facilitates delivery of a selected tidal volume
- With use of cuff, may protect the airway from aspiration
9
Q
Which tachyarrhythmias fall under narrow-QRS-complex (SVT) tachycardias classification?
A
- Sinus tachycardia
- Atrial fibrillation
- Atrial flutter
- AV nodal reentry
- Accessory pathway-mediated tachycardia
- Atrial tachycardia (including automatic and reentry forms)
- Multifocal atrial tachycardia (MAT)
- Junctional tachycardia (rare in adults)
10
Q
What is a synchronized cardioversion?
A
- Shock delivery that is limited (synchronized) with the QRS complex
11
Q
Is it true that during CPR performed by providers trained in
its use, the supraglottic airway is a reasonable alternative
to bag-mask ventilation and endotracheal intubation?
A
Yes (Class IIa, LOE B)
11
What methods can be used in addition to clinical
assessment as the initial method for confirming correct
tube placement in a patient in cardiac arrest when
waveform capnography is not available?
* Colorimetric CO2 detectors and
* nonwaveform exhaled CO2 detectors.
11
Is Adenosine administration in Pregnancy safe and
effective?
Yes, however adenosine does have several important drug interactions
12
Should cricoid pressure be applied routinely during CPR?
No, routine use of cricoid pressure in cardiac arrest is not recommended.
13
What is the classification of tachycardias based on?
* Appearance of the QRS complex
* Heart rate
* Regularity
15
What drug is Dopamine?
Dopamine hydrochloride is a catecholamine with both
Alpha and Beta adrenergic actions.
16
What is the definition of tachycardia according to AHA2010?
* Arrhythmia with a rate of \>100 b/min
18
What is the expert opinion on initial energy settings for a
monomorphic VT (regular form and rate) with a pulse?
* 100J for initial shock
* If there is no response to the first shock, it may be reasonable to increase the dose in a stepwise fashion
19
What can a dose of
It may paradoxically result in further slowing of the heart rate
21
What are the key principles of arrhythmia (tachycardia)
recognition and management in adult?
* If the tachycardic patient is unstable with severe signs and symptoms related to a suspected arrhythmia,
* immediate cardioversion should be performed (with prior sedation for conscious patients)
* If the tachycardic patient is stable, determine if
* the pt has a narrow-complex or
* wide-complex tachycardia, whether the rhythm is regular or
* irregular, and for wide complexes whether the QRS morphology is monomorphic or polymorphic
* Know when to call for expert consultation regarding complicated rhythm interpretation, drugs, or management decisions
22
What should the adenosine initial dose be reduced to in
patients taking dipyridamole or carbamazepine, those with
transplanted hearts, or if given by central venous access?
* 3 mg
23
What does 'unstable' refers to, according to AHA2010?
* Refers to a condition in which vital organ function is
* acutely impaired or
* cardiac arrest is ongoing or imminent
24
Which tachyarrhtymias fall under the classification of
wide-QRS-complex tachycardias?
* Ventricular tachycardia (VT)
* Ventricular fibrillation (VF)
* SVT with aberrancy
* Pre-excited tachycardias (Wolf-Parkinson-White [WPW] syndrome)
* Ventricular paced rhythms
26
What are the main signs and symptoms of cardiovascular
compromise due to tachycardia?
* Acute altered mental status
* Ischemic chest discomfort
* Acute heart failure
* Hypotension
27
What does it mean when CO2 detector shows false
positive reading?
CO2 is detected but the tube is in the esophagus.
28
Under what condition can a patient with a regular narrow-
complex SVT be treated with adenosine while preparing
for synchronized cardioversion?
* If not hypotensive
29
Besides affecting protein channels, what other properties
does IV amiodarone have?
* Alpha and
* Beta-adrenergic blocking properties
30
Is the EDD accurate for the continued monitoring of ETT
placement?
* No, there is no evidence that the EDD is accurate for the continued monitoring of ETT placement.
32
What does an assessment by physical examination
consist of once an advanced airway is inserted?
* Visualising chest expansion bilaterally and
* listening over the epigastrium.
34
How is a first-degree AV block defined?
(on the basis of ECG interpretation)
Prolonged PR interval (\>0.20 second)
35
What is the most common mechanism of SVTs?
* Reentry Abnormal rhythm circuit that allows a wave of depolarization to repeatedly travel in a circle in cardiac tissue
36
What is the optimal timing of vasopressor administration
during the 2 minute period of uninterrupted CPR?
The optimal timing has not been established
37
What are the side effects of Lidocaine according to AHA2010?
* Slurred speech
* Altered consciousness
* Seizures Bradycardia
38
What is the primary goal of giving a vasopressor during CPR?
To increase myocardial blood flow and achieving ROSC
40
What are the key principles of arrhythmia (bradycardia)
recognition and management in adult?
* Recognition of signs and symptoms of instability
* initial treatment is atropine.
* If bradycardia is unresponsive to atropine, IV infusion of beta-adrenergic agonists with rate-accelerating effects (adrenaline) or
* transcutanous pacing can be effective
41
When is bag-mask ventilation most effective during CPR?
When performed by 2 trained and experienced providers
42
How can you determine/calculate the upper rate of age
related sinus tachycardia?
Approximately 220b/min - patient's age in years
43
When are periodic pauses in CPR permitted?
* To assess rhythm
* Shock VF/VT
* Perform a pulse check when organised rhythm is detected
* To place an advanced airway
45
What are the three classes of AV blocks?
First, second, and third degree
47
When can the compressions be interrupted and for how
long during CPR?
* For the time required by the intubating provider to visualise the vocal cords and insert the tube
* This is ideally less then 10 seconds.
49
What are the signs and symptoms of poor perfusion?
* Hypotension
* Acutely altered mental status
* Signs of shock Ischemic chest discomfort
* Acute heart failure
50
What are the most common forms of wide-complex
tachycardia according to AHA 2010?
* VT or VF SVT with aberrancy
* Pre-excited tachycardias (associated with or mediated by an accessory pathway)
* Ventricular paced rhythms
51
What are the precautions or special considerations
according to AHA2010 for Adenosine?
* Contraindicated in patients with asthma
* May precipitate atrial fibrillation, which may be very rapid in patients with WPW, thus defibrillator should be readily available
* Reduce dose in post-cardiac transplant patients, those taking dipyridamole or carbamezapine and when administered via central vein
52
What is a common cause of bradycardia?
* Hypoxemia
53
What treatment may be considered for patients with
witnessed, monitored, unstable ventricular tachycardia if a
defibrillator is not immediately ready for use?
* Precordial thump
54
What are the general causes of AV blocks?
* Medications
* Electrolyte disturbances
* Structural problems resulting form AMI or
* other myocardial disease
55
What is the purpose of ventilation during CPR?
* To maintain adequate oxygenation and
* sufficient elimination of carbon dioxide.
56
What do the AHA guidelines 2010 say about
administration of vasopressor following shock which
results in a perfusion rhythm during the subsequent 2
minute period of CPR? (before rhythm check)?
It could theoretically have detrimental effects on
cardiovascular stability.
58
What does 'symptomatic' imply according to AHA2010?
* Symptomatic implies that arrthythmia is causing symptoms, such as
* palpitations,
* lightheadedness, or
* dyspnea, but the patient is stable and not in imminent danger.
59
Give three examples of automatic arrhythmias
* Ectopic Atrial tachycardia
* Multifocal atrial tachycardia (MAT)
* Junctional tachycardia
61
Why may checking for a pulse in the femoral triangle
indicate venous rather than arterial blood flow?
* There are no valves in the inferior vena cava, therefore
* retrograde blood flow into the venous system may produce femoral vein pulsations.
62
Why can 'normalizing' of heart rate be detrimental in a
patient with poor cardiac function with compensatory
tachycardias?
* The cardiac output can be dependent on a rapid heart rate or
* compensatory tachycardia, whereby the stroke volume is limited.
63
When can a vasopressor be given during CPR with
persistant VF/pulseless VT?
* When VF/pulseless VT persists after at
* least 1 shock and a 2 minute CPR period
64
What is the cause of automatic tachycardias?
An excited automatic focus
65
What is the benefit of synchronized cardioversion?
Synchronization avoids shock delivery during the relative refractory period of the cardiac cycle when a shock could produce VF.
66
What is the recommended initial energy for cardioversion of SVTs for biphasic and monophasic defibrilator?
* Initial energy of 50J to 100J
* If initial 50J shock fails, the provider should increase the dose in a stepwise fashion
* Cardioversion with monophasic waveforms should begin at 200J and increase in stepwise fashion if not successful
67
What is the primary treatment of polymorphic VT?
Immediate defibrilation
68
What channels does amiodarone affect?
* Sodium,
* Potassium, and
* Calcium channels
69
When is synchronized cardioversion recommended
according to AHA2010?
* Unstable SVT
* Unstable atrial fibrillation
* Unstable atrial flutter
* Unstable monomorphic (regular)VT
70
In which patients is magnesium sulphate no likely to be
effective in terminating irregular/polymorphic VT? (looking at ECG)
* In patients with normal QT interval
71
How does Epinephrine produce beneficial effects (alpha and beta-adrenergic stimulation) in
patients during cardiac arrest?
* Primarily because of its alpha-adrenergic receptor-stimulating (ie, vasoconstrictor) properties.
* The alpha-adrenergic effects of epinephrine can increase CPP and cerebral perfusion pressure during CPR.
* The value and safety of the Beta-adrenergic effects of epinephrine are controversial because they may increase myocardial work and reduce subendocardial perfusion
72
When is Atropine most likely to be ineffective and why?
In patients who have undergone cardiac transplantation
because transplanted heart lacks vagal innervation
73
What are the common side effects of adenosine according
to AHA2010?
* Flushing,
* Dyspnea, and
* Chest discomfort
74
What should the initial evaluation of any patient with
tachycardia focus on?
* Signs of increased work of breathing
* Tachypnea
* Intercostal retractions
* Suprasternal retractions
* Paradoxical abdominal breathing
* Oxyhemoglobin saturation (pulse oximetry)
75
Where can a third degree AV block occur?
* AV node
* Bundle of His bundle branches
75
What is the most likely arrhythmia with irregular narow-
complex or wide-complex tachycardia
* Atrial fibrillation with an uncontrolled ventricular response
77
Where in the heart can reentry circuits occur, resulting in SVT?
* Atrial myocardium
* Whole or in part in the AV node itself
78
When using BVMR during CPR what tidal volume should
the provider deliver?
* Approximately 600ml of TV
* sufficient to produce chest rise
* over 1 second.
79
What is the value of monitoring of PETCO2 trends during
CPR?
* Optimisation of compression depth and rate
* Detect fatigue in the provider performing compressions
* Abrupt sustained increase in PETCO2 during CPR is an indicator of ROSC.
80
What are patients with atrial fibrillation and duration \>48
hours at risk for ?
They are at increased risk for cardioembolic events
81
When is a rhythm considered to be supraventricular?
If the QRS complex is narrow (
82
What is the role of precardial thump according to AHA 2010?
* The precordial thump may be considered for
* termination of witnessed monitored unstable ventricular tachyarrhythmias
* when defibrillator is not immediately ready for use, but
* should not delay CPR and shock delivery.
83
What is bradycardia defined as?
Any rhythm disorder with a heart rate \< 60b/min
84
What is the primary drug commonly used to treat torsades de pointes VT?
Magnesium Sulphate
86
What do the guidelines AHA 2010 say about intentionally
delaying defibrillation to perform CPR?
The value of intentionally delaying defibrillation to perform
CPR is less clear.
87
What should the initial evaluation of any patient with
bradycardia focus on?
* Signs of increased work of breathing
* Tachypnea
* Intercostal retractions
* Suprasternal retractions
* Paradoxical abdominal breathing
* Oxyhemoglobin saturation as determined by pulse oximetry
88
When may the EDD yield misleading results?
* In patients with:
* Morbid obesity
* Late pregnancy
* Status asthmaticus copious endotracheal secretions
89
What is the most common cause of polymorphic VT in the
absence of a prolonged QT interval?
Myocardial ischemia
91
Name the H's that a provider should consider to identify
during management of cardiac arrest.
* Hypoxia
* Hypovolemia
* Hydrogen ion(acidosis)
* Hypo-/hyperkalemia
* Hypothermia
92
When should a pulse check be performed during CPR?
If an organised rhythm is observed
93
When can immediate pacing be considered?
* In unstable patients with high-degree AV block when IV access is not available
95
What should be monitored continuously in a patient with
perfusing rhythm who requires intubation?
* Pulse oximetry
* Electrocardiographic (ECG) status
96
What complications can be produced when using bag-mask ventilation?
* Gastric inflation with complications including:
* regurgitation
* aspiration pneumonia
* elevation of diaphragm, which can restrict lung movement and
* decrease respiratory system compliance
97
What other most reliable method of confirming and
monitoring correct placement of ETT is recommended?
Continuous waveform capnography
