RCP avanzada Flashcards
dose, route and uses of adenosine in adults
use: narrow PSVT/SVT, wide QRS tachy
avoid: irregular wide QRS
dose: 6mg IV bolus (followed by flush with 20mL of saline), may repeat with 12 mg in 1-2 mins
notes: there must be continous cardiac monitoring, causes flushing and head heaviness
dose, route and uses of amiodarone in adults
use: VF / pulseless VT, VT with pulse, tachy rate control
dose: 300mg dilute in 20-30ml (may repeat 150mg in 305 mins)
notes: anticipate hipotension, bradicardia, GI toxicity. There must be continouse cardiac monitoring. Has a very long 1/2 life (up to 40 days).
DONT USE IN 2º OR 3º HEART BØ, DONT ADMIN IN ET TUBE
dose, route and uses of atropine in adults
uses:
- symptomatic bradicardia: 0.5mg IV/ET every 3-5mins, max dose 3mg
- specific toxins/overdose (ex: organophosphates): 2 - 4 mg IV/ET
notes: there must be cardiac and BP monitoring, DONT USE IN GLAUCOMA OR TACHIARRYTHMIAS, minimum dose 0.5mg
dose, route and uses of dopamine in adults
uses: shock / CHF
dose: 2 - 20 mcg/min, titrate to desired BP
notes: fluid resuscitation first, there must be cardiac and BP monitoring
dose, route and uses of epinephrine in adults
cardiac arrest:
- initial: 1mg (1:1000) or 2-2.5mg (1:1000) ETT every 3 - 5 min
- maintain: 0.1 - 0.5 mcg/min, titrate to desired BP
anaphylaxis:
- 0.3 - 0.5 IM, repeat every 5 min as needed
symptomatic bradycardia/shock:
- 2 - 10 mcg/min infusion
- titrate to response
notes: there must be continous cardiac monitoring, give via ventral line when possible
dose, route and uses of lidocaine in adults
**recommended when amiodarone isn’t available
cardiac arrest: VF/VT
- initial: 1-1.5mg/kg IV loading
- second: half of first dose in 5 - 10 min
- maintain: 1 - 4 mg/min
wide complex tachicardias with pulse:
- initial: 1 - 1.5mg/kg IV
- second: half of first dose in 5 - 10min
- maintain: 1 - 4mg/min
notes: must have cardiac and BP monitoring, rapid pulse can cause hipotension and bradicardia, use with caution in kidney failure, calcium chloried can reverse hipermagnesemia
dose, route and uses of magnesium sulfate in adults
cardiac arrest / puseless torsades: 1 - 2 gm diluted in 10ml
torsades de pointes with pulse: 1 - 2 gm IV over 5 - 60 min, maintain 0.5 - 1gm/hr IV
notes: must have cardiac and BP monitoring, rapid pulse can cause hipotension and bradicardia, use with caution in kidney failure, calcium chloried can reverse hipermagnesemia
dose, route and uses of procainamide in adults
use: wide QRS tachycardia, preferred for VT with pulse (stable)
dose: 20 - 50mg / min IV until rhythm improves, hypotension occurs, QRS widens by 50% or max dose is given
mas dose: 17mg/kg
drip: 1 - 2 gm in 250 - 500ml ate 1 - 4 mg/min
notes: must have cardiac and BP monitoring, caution with acute MI, may decrease dose with kidney failure, DONT COMBINE WITH AMIODARONE, DONT USE IN PROLONGED QT OR CHF
dose, route and uses of sotalol in adults
use: tachyarrhytmia, nomonorphic VT, 3rd line antiarrithmic
dose: 100mg (1.5mg/kg) IV over 5 min
notes: DONT USE IN PROLONGED QT
parameters that tell you oxygenation is adequate
oxygenated inspired air is best provided via a tight fitting oxygen reservoir face mask with a flow rate of at least 11 L/min
pulse oximetry must be used at all times
- doesn’t measue PaO2
- measured saturation >95% by pulse oximetry is strong coroborating evidence of adequate peripheral arterial oxygenation (PaO2 >70mmHg)
- limited usefulness in pt with severe vasoconstriction & carbon monoxide poisoning because it can’t distinguis oxyhemoglobin from carboxyhemoglobin or methemoglobin
- profound anemia (hb <5g/dl) and hypothermia (<30ºC or <86ºF) decrease the reliability of the technique
how can you tell that the ET tube is in the right place
- hearing equal breathing sounds bilaterally and detecting no borboygmi in epigastrium
the presence of CO2 in exhaled air indicates that airway has been successfully intubated, but doesn’t ensure the correct position of the tube
proper position of the tube is confirmed by chest X-ray
how many joules should a shock be admin. when using a monophasic defibrillator
360 J
must use same energy doe on subsequent shocks
which kind of defibrillator is more effective for terminating a fatal arrythmia
the biphasic defibrillator
- use the manufacturer’s recommended energy dose
what are some AED keypoints
- assure O2 isn’t following across the pts chess when delivering
- don’t stop chest compressions for more than 10 sec. when assessing the rhythm
- STAY CLEAR
- asses pulse after the 1st 2 min of CPR
- if the en tidal CO2 is <10mmHg during CPR, consider adding a vasopressor and improve chest compressions
key components of post cardiac arrest care
therapeutic hypothermia (32 - 36ºC) - recommended for commatose individuals with return of spontaneous ciculation after a cardiac arrest event
optomization of hemodynamias and ventilation
- 100% O2 is acceptable for early intervention but not for extended periods of time
- oxygen should be titrated, so that the pulse oximeter >94%
- don’t over ventilate
- ventilation rates of 10 - 12 breaths x min to achieve ETCO2 at 35 - 40mmHg
- IV fluids and vasoactive meds should be titrated for hemodyamic stability
Percutaneous Coronary Intevention (PCI):
- preferred over thrombolytics
Neurologic Care:
- neurologic assessment is key
- specialty consultation should be obtained to monitor neurologic signs and symptoms throughout the post resuscitation period
life threatening complications of ACS
ventricular fibrillation pulseless ventricular tachycardia bradyarrythmias cardiogenic shock pulmonary edema
what are the 8 D’s of stoke care
Detection: rapid detention of S&S (<10min)
Dispatch: early activation / 911
Delivery: rapid EMS 10, management and transport
Door: transport to stroke center
Data: rapid triage, eval and management
Decision: stroke expertise and therapy selection
Drug: fibrinolytics therapy, intra-arterial strategies
Disposition: rapid admit. to stroke or critical care unit
what are the stoke team alert criteria
threatened airway or labored breathing
altered mental status
bradycardia (<40BPM) or tachycardia (>100BPM)
seizure
hypotension
symptomatic hypertension
sudden and large decrease in urine output
what are the reversible causes of cardiac arrest
Hypovolemia Hypoxia Hypothermia H+ (acidosis) Hypo/Hyperkalemia
Tension Pneumothorax Tamponade Toxins Thrombosis (coronary / pulmonary) Trauma (unrecognized)
what are the most common causes of pulseless electrical activity
Hypovolemia
Hypoxia
1st line treatment of adult bradycardia with pulse (when there’s altered mental status, shock, chest pain, acute heart failure) in an emergency setting
HR <50
Atropine
- IV: 0.5mg bolus, repeat every 3 - 5 min up to 3mg max dose
if ineffective use:
- transcutaneous pacing
- dopamine infusion (2-10mg/kg/min)
- epinephrine (2 - 10mcg/min)
characteristics of a sinus bradycardia
regular
rate generally 40 - <60bpm
PR interval 0.12-0.20 sec, consistent
QRS complex <0.12 sec
characteristics of a 1ºblock
regular
rate depends on underlying rhythm
p wave >0.20sec, consistent
QRS complex <0.12sec
characteristics of a type I 2ºblock (weckenbach)
rhythm isn’t regular but does have a pattern to it, R-R interval gets longer a PR intervals get longer
ventricular rate is usually slightly higher than the atrial rate due to some atrial beats no being conducted
the atrial rate is usually normal
P wave upright and uniform, doesn’t always proceed a QRS complex
PR interval gets progressively longer until there is a dropped QRS complex
QRS complex <0.12sec
characteristics of a type II 2ºblock
the regularity depends if there is or isn’t a conduction ratio
atrial rate is normal
ventricular rate usually slower than atrial rate
P wave upright and uniform, a QRS doesn’t always follow every p wave
there is a conduction ratio (a QRS drops after “X” amount of p waves)
PR interval is constant across the strip, but not every P conducts a QRS
QRS complex <0.12 sec
characteristics of a 3º block
R-R regular, P-P wave regular but independent
atrial rate regular and normally 60 - 100bpm
rate of QRS complex is dependent on the focus
- ventricular focus: 20 - 40 bpm
- junctional focus: 40 - 60 bpm
p wave upright and regular
there isn’t a QRS following every p wave
PR interval may or may not be longer that normal
QRS complex usually prolonged
what are some of the signs and symptoms of bradycardia
low blood pressure pulmonary edema/congestion abnormal rhythm chest discomfort shortness of breath weakness/dizziness lightheadedness confusion
symptoms of tachycardia
low BP sweating pulmonary edema/congestion jugular venous distension chest pain discomfort shortness of breath weakness/diziness/lightheadedness altered mental status
how can you control the HR in an irregular narrow complex tachycardia in an emergency setting
diltiazem 15 - 20mg (0.25mg/kg) IV over 2 min or beta blockers
how can you control the HR in an regular wide complex tachycardia in an emergency setting
convert rhythm using amiodarone 150mg IV over 10 min and perform efective cardioversion
how can you control the HR in Torsades de Pointes in an emergency setting
magnesium sulfate 1 - 2 mg IV, may follow with 0.5 - 1mg over 60 min
what are the rules for a sinus tachycardia
regular ***rate >100BPM*** p wave normal PR interval normal QRS complex normal
what are the rules for atrial flutter
atrial rate 250-350
ventricular rate will only be regular if the AV node conducts the impulses in a consistent manner
p wave in a “saw-tooth” pattern
QRS normal
what are the rules for atrial fibrilation / irregular narrow complex tachycardia
R-R irregular
atrial rate usually >350
if ventricular rate is 60-100 = controlled A-fib
if ventricular rate is >100= uncontrolled A-fib
there are no obvious P waves in the rhythm*
QRS complex normal
what are some of the symptoms of an acute coronary syndrome
crushing chest pain shortness of breath pain that radiates to the jaw, arm or shoulder sweating nausea/vomiting
pt with DM or women may not present with these classic signS
KEY points in the treatment of an acute coronary syndrome in an emergency setting
Oxygen: 4L/min nasal canular; titrate as needed
Aspirin: if no allergy 160-325mg. ASA to chew. Avoid coated ASA.
Nitroglycerin: 0.3-0.4 mg SL/spray x 2 doses at 3-5 min intervals
- dont use if SBP <90mmHg
or if phosphodiesterase inhibitor (viagra) was taken within 24 hrs
Morphine: 1-5mg IV only if symptoms not relieved by nitrates or if symptoms recur. Monitor BP closely
12 lead ECG, evaluate for ST elevation/depression
IV access: large gauge
Notify hospital
once at a hospital:
- check vitals / O2 sat
- IV access
- perform targeted history / physical
- complete fibrinolytic checklist
- obtain preliminary cardiac marker, electrolytes, and coagulation studies
- obtain chest X-ray
how long is the fibronolysis window (door-to-needle)
≤ 30 min
how long is the PCI (door-to-balloon inflation) window
< 90 min
what are the symptoms of stroke
weakness in arm, face, or leg vision problems confusion // change in the level of conciousness nausea vomiting trouble speaking or forming the correct words problems walking or moving severe headache (hemorrhaigc)
**hypoglycemia can mimic stroke symptoms (which is why checking glucose level is very imp)
T/F. All acute stroke individulas are considered NPO on admission
TRUE
caracteristics of the cincinatti prehospital stroke scale
it is used to dx the presence in an individual of any of the following physical findings are seen:
- facial droop
- arm drift
- abdomal speech
if 1/3 as new event = 72% probability of ishemic stroke
if 3/3 as new event = 85% acute stroke
what is more common, ischemic or hemorrhagic stroke
ischemic stroke
what are the time goals established by the National Institute of Neurologic Disorders and Stroke when the time of onset of stroke symptoms is known
10 min of arrival: general assessment by expert, order urgent CT scan w/o contrast
25 min of arrival: perform CT scan w/o contrast, neurological assessment, seat CT scan within 45 min
60 min of arrival: evaluate criteria for use and admin fibrinolytic therapy (fibrinolytic therapy may be used within 3hrs of symptom onset)
180 min of arrival: admission to stroke unit
what are the inclusion criteria for fibrinolytic therapy criteria
symptom onset within the last 3 hrs (unless special circumstance)
≥ 18yrs
ischemic stroke with neurological deficit
what are the absolute exclusion criteria for fibrinolytic therapy criteria
head trauma in the last 3 months
stroke in the last 3 months
subarachnoid hemorrhage
arterial puncture in last 7 days
previous intracranial hemorrhage
active bleeding
heparin in the last 2 days
increased INR
Hypoglycemia
very large brain infarct (multilobal)
platelets <100,000 /mm3
what are the relative exclusion criteria for fibrinolytic therapy criteria
very minor / resolving symptoms
seizure may be affecting neurological exam
surgery or trauma in last 14 days
major hemorrhage in the last 21 days
myocardial infarction in last 3 months
