ACLS

Question 1

4 elements of integrated system of care

Answer 1

• Structure: people, education, equipment
• Process: protocols, policies, procedures
• System: programs, organizations, culture
• Patient Outcome: balance of satisfaction, safety, quality

Question 2

Factors associated w/ improved survival in pts with cardiac arrest:

Answer 2

• training HCP to be more knowledgeable about what improves survival rates
• proactive planning & simulation of cardiac arrest to provide opportunity for HCP to practice/improve responding to cardiac arrest
• rapidly recognizing sudden cardiac arrest
• immediately providing high quality CPR
• providing early defibrilation
• providing goal oriented, time sensitive, post-cardiac arrest care

Question 3

Chain of Survival

Answer 3

• early recognition & prevention
• activation of emergency response
• high quality CPR
• defibrillation
• post-cardiac arrest care
• recovery

Question 4

Rapid response system

Answer 4

purpose of a rapid response team (RRT) or medical emergency team (MET) is to improve patient outcomes by identifying & treating early clinical deterioration.
* event detection & response triggering arm
* planned response arm (such as RRT/MET)
* quality monitoring
* administrative support

Question 5

Signs of clinical deterioration for adult patients:

8

Answer 5

• airway compromise
• RR < 6/min or > 30/min
• HR < 40/min or > 140/min
• Systolic BP: < 90mmHg
• Symptomatic Hypertension
• Unexpected decrease in LOC
• Unexplained agitation
• Seizure

Question 6

How does rapid response prevent in-hospital cardiac arrests?

Answer 6

• best way to improve survival chance is to prevent IHCA from ever occuring
• teams rapidly assess and intervene when patients have abnormal vital signs which reduces # of IHCAs and improves morbidity & mortality

Question 7

Impact of RRTs/METs

Answer 7

ideal composition of METs and RRTs not known, but many published before/after studies have reported a drop in rate of cardiac arrests after these teams intervene. Findings:
* reduced unplanned emergency transfers to the ICU
* decreased ICU and total hospital length of stay
* reduced postoperative morbidity and mortality rates
* improved rates of survival from cardiac arrest

Question 8

Key components of an effective high performance team

Answer 8

Timing
* time to first compression
* time to first shock
* CCF ideally greater than 80%
* minimizing preshock pause
* early EMS response time

Quality
* rate, depth, and recoil
* minimizing interrupt
* switching compressors
* avoiding excessive ventilation
* use of feedback device

Coordination
* team members working together, proficient in their roles

Administration
* leadership
* measurement
* continuous quality improvement
* number of code team members

Question 9

Key Components of an Effective High Performance Team

Answer 9

Successful high-performance teams not only have medical expertise and mastery of resuscitation skills but also demonstrate effective communication & team dynamics

One of the measures of a high-performance team is the ability to achieve performance metrics and a high chest compression fraction (CCF). You can only achieve high CCF by minimizing pauses during high quality CPR.
* The Resuscitation Outcomes Consortium (ROC) trials showed an 11% increase in CCF is roughly equal to a 10% increase in survival.
* Pauses can occur during intubation, rhythm analysis, pulse checks, compressor switches, and defibrillation.

Recommendations
* Hover over the chest: whenever compressions are paused, compressors should hover over the chest (not touching it) to prepare to resume compressions
* Before pausing compressions: 15s before pausing compressions at the end of each 2 min cycle, high-performance teams should check for a pulse, pre-charge the defibrillator, and be prepared to deliver a shock in 10s or less.
* Switch Compressors: switch with the second compressor coming in from behind the first (this allows the 2nd to have the same view of the team). Seamless transitions = switching every 2 minutes
* Real Time Feedback Devices: practice w/ real time feedback devices during CPR

Question 10

Roles of High Performance Team Members

Answer 10

Team Leader
* organize group
* monitor individual performance, back up team members
* train/coach, facilitate understanding
* models excellent team behavior
* focuses on comprehensive patient care

Team Member Roles
* proficient in performing the skills in their scope of practice
* clear about role assignments
* prepared to fulfill their role responsibilities
* well practiced in resuscitation skills
* knowledgeable about algorithms
* committed to success

CPR Coach
* coordinate initiation of CPR
* coach team members to improve quality of chest compressions
* coach team members to improve quality of ventilations

Question 11

Elements of Effective Team Dynamics

Clear Roles/Responsibilities

Answer 11

• Leader: clearly define all team member roles in clinical setting; distribute tasks evenly to all available team members
• Members: seek out & perform clearly defined tasks appropriate to their abilities; ask for new task/role if assignment is beyond their level of expertise; take only assignments w/in level of expertise

Question 12

Elements of Effective Team Dynamics

knowing limitations

Answer 12

• Leaders + Members: call for assistance early rather than waiting until pt deteriorates; seek advice from more experienced personnel when pt’s condiiton worsens despite primary tx; allow others to carry out assigned tasks (esp if task is essential to tx)
• Members: seek advice from more experienced personnel before starting an unfamiliar tx; accept assistance from others when it is readily available

Question 13

elements of effective team dynamics

Answer 13

• Leaders: ask that a different intervention be started if it has a higher priority; reassign a team member who is trying to function beyond their skill
• Members: suggest alternative drug/dose confidently; question colleague who is going to make an error; intervene if drug admin is incorrect

Question 14

What to Communicate

knowledge sharing

Answer 14

sharing info is critical to effective team performance
* Leader: encourage info sharing, ask for suggestions about interventions, differential diagnoses, and possible overlooked tx, look for clinical signs that are relevant to tx
* Members: share info w/ each other, accept info that will improve their roles

Question 15

what to communicate

summarizing & re-evaluating

Answer 15

an essential role of the team leader is monitoring & re-evaluating interventions, assessment findings, and pt status.
* leaders: continuously re-visit decisions about ddx; maintain ongoing record of tx and pt’s response; change tx strategy if new info supports it; inform arriving personnel of the current status & plans for further action
* Members: note significant changes in pt’s clinical condition; increase monitoring pt’s condition deteriorates

Question 16

how to communicate

closed loop communication

Answer 16

closed loop communication is process of verifying that the message sent was received as intended. It also verifies that assigned tasks have been completed.
1. give message, order, or assignment to team member
2. request clear response/eye contact to ensure that he/she understood the message
3. confirm that the team member completed the task before you assign them another task

• Members: after receiving a task, close loop by informing the task leader when the task begins/ends; give drugs only after verbally confirming the order w/ the team leader
• Leaders: assign tasks via closed-loop communication; assign additional tasks to a team member only after receiving confirmation of a completed assignment

Question 17

how to communicate

clear messages

Answer 17

clear messages mean concise communication spoken w/ distinctive speech in a controlled voice. All HCP should deliver clear messages calmly and directly. Distinct, concise messages are crucial for clear communication because unclear communication can delay tx or cause med errors.

• Leaders: encourage all team members to speak clearly & use complete sentences
• Members + Leaders: repeat orders & question them if doubt exists; be careful not to mumble/yell/scream/shout; ensure only 1 person talks at a time

Question 18

how to communicate

mutual respect

Answer 18

speak to each other in a professional manner, regardless of scope of practice/expertise. Resuscitation events are stressful and emotions can run high.

• Leaders: acknowledge completed assignments
• Both: listen to others; speak in a friendly way; avoid displaying frustration/aggression; understand that when one person raises their voice, others will respond similarly; try not to confuse directive behavior w/ aggression

Question 19

communicating

the debrief

Answer 19

debrief as a team to improve subsequent performance

Question 20

components of high quality CPR

Answer 20

• compress chest hard & fast at least 2in at a rate of 100-120/min (30:2 ratio)
• allow chest to completely recoil after each compression
• minimize interruption in compressions
• switch compressors about every 2 min or earlier if fatigued (switch in < 5 min)
• avoid excessive ventilation

Question 21

high-quality cpr

minimizing interruptions

Answer 21

when you stop compressions, blood flow to the brain/heart stops, so you should minimize interruptions
* AVOID: prolonged rhythm analysis, frequent/inappropriate pulse checks, prolonged ventilation, unnecessary movement of pt
* CCF= chest compression fraction; proportion of time during cardiac arrest when the rescuer is performing compressions (minimal is 60%; ideal is > 80%)

CCF = actual chest compression time/total code tide

Question 22

high quality CPR

tailoring sequence of rescue actions

Answer 22

guidelines recommend that CHP tailor the sequence of rescue actions based on presumed etiology of the arrest. ACLS providers can choose the best approach for their high-performance team to minimize interruptions in chest compression & improve CCF including:
* continuous chest compressions w/ asynch ventilation Q6 s with use of bag mask device
* compression only CPR in the first few min after arrest

Question 23

Coronary Perfusion Pressure (CPP)

Answer 23

crucial to minimize interruptions in compressions to maintain adequate CPP
* CPP = aortic diastolic pressure - right atrial diastolic pressure

Info
* during CRP, CPP correlates w/ myocardial blood flow and ROSC
* when HCP interrupt chest compressions, coronary perfusion pressure decreases dramatically and remains low until compressions are resumed
* the higher the coronary perfusion pressure during CPR, the higher the chances of survival for patients
* surein a patient w/ an arterial line, a reasonable surrogate for CPP is arterial relaxation or diastolic pressure

Question 24

Interruptions in chest compressions

quantitative waveform capnography

Answer 24

because CPP or arterial diastolic pressure measurements are not readily available during a resuscitation attempt, HCP can monitor CPR quality w/ quantitative waveform capnography using advanced airway in place of a bag-masked device.
* this used ETCO2 to estimate tissue perfusion and the quality of chest compressions

Question 25

defib + survival | early defibrillation

Answer 25

the interval from collapse to defibrillation is one of the most important determinants of survival from cardiac arrest (early defib = vital) * common rhythm in out-of hospital witnessed sudden cardiac arrest= v fib * pulseless ventricular tachycardia (pVT) rapidly can deteriorate to VF (heart quivers & does not pump blood) * electrical defibrillation is most effective tx of VF & pVT * probability of successful defibrillation decreases over time * VF deteriorates to asystole if no tx

Question 26

Defib + survival | minimizing interruptions in compressions during defibrillation

Answer 26

* AHA does not recommend continued use of an AED or automatic mode when manual defibrillator is available & providers can adequately interpret rhythms * rhythm analysis & shock admin w/ AED can prolong interruptions in chest compressions * while manual defib is charging, resume CPR (shortens interval between last compression + shock, even a few seconds improves success) * return to CPR as soon as shock is delivered

Question 27

Defib + Survival | safe defibrillation

Answer 27

defibrillation should take fewer than 5s * "CLEAR. SHOCKING": check to make sure everyone is clear of contact w/ patient, stretcher, or other equipment; make visual check to ensure that no one is touching pt or stretcher; make sure O2 not flowing across pt's chest * when pressing the shock button, the defib operator should face the patient, not the machine. This helps to ensure coordination w/ the chest compressor & to verify that no one has resumed contact w/ the patient

Question 28

systematic approach

Answer 28

for optimal care, HCP use systematic approach to assess & tx acutely ill or injured patients. Not only does the systematic approach allow a standardized emthod for evaluating pts, it reduces the chances of missing/overlooking important signs and sx that should be considered. Components * initial impression (visualization, scene safety) * BLS assessment * Primary Assessment (ABCDE) * Secondary Assessment (SAMPLE, H's and T's)

Question 29

Systematic Approach | Initial Impression

Answer 29

* rapidly survey scene to determine if it is safe/no threat to provider * then determine patient's LOC * if unconscious: BLS assessment * if conscious: primary assessment --> secondary assessment

Question 30

BLS Assessment

Answer 30

* early CPR w/ basic airway management & defibrillation (but not advanced airway techniques or drug administration) * by using BLS assessment, any HCP can support or restore effective oxygenation, ventilation, and circulation until patient achieves ROSC or advanced providers intervene. Tailoring Sequence of Rescue Actions * single rescuers may tailor the sequence of resuce actions to the most likely cause of arrest STEPS 1. check for responsiveness (tap/shout "are you ok?") 2. shout for nearby help/activate emergency response system & get the AED/defib 3. check for breathing/pulse (check for absent/abnormal breathing (assess for at least 5s max 10s), feel for a pulse 5-10s, should do them simultaneously; IF you find a pulse do rescue breaths Q6s and check pulse Q2 min; no breath = CPR & begin w/ chest compressions 4. defib (check for shockable rhythm, provide as advised)

Question 31

Primary Assessment

Answer 31

* A: airway; maintain/establish airway; can maintain using head tilt-chin lift, oropharyngeal airway, or nasopharyngeal airway * B: breathing; assist w/ ventilation Q6s if pt needs ventilation. supplement O2 PRN; 100% O2 for cardiac arrest patients, others give O2 for oxygen saturation of 95-98% * C: circulation; attach EKG leads and establish IV/IO access; give appropriate drugs to manage abnormal rhythms & assess for perfusion issues; monitor w/ quantitative waveform capnography, if intra-arterial pressure monitoring is available, strive to optimize blood pressure * D: disability: check for neuro functioning; assess for responsiveness, LOC, pupil dilation; AVPU (alert, voice, painful, unresponsive) * E: exposure; remove clothing to perform PE looking for signs of trauma, bleeding, burns, unusual markings, or medical alert bracelets.

Question 32

Secondary Assessment

Answer 32

SAMPLE (s/sx, allergies, meds, PMHx, last meal, events) * S: breathing difficulty, tachypnea, tachycardia, fever, HA, abd pain, bleeding * A: meds, foods, latex; associated rxns * M: pt meds including OTCs, vitamins, inhalers, herbals; last dose/time of recent meds * P: health hx, family hx, significant med problems, past surgeries, immunization status * L: time/nature of last intake of liquid or food * E: events leading to current illness/injury; hazards at scene; tx during interval from onset of disease or injury until evaluation; estimated time of onset (if out of hospital)

Question 33

secondary assessment | H&T

Answer 33

* H's: hypovolemia, hypoxia, hydrogen (acidosis), hypo/hyper kalemia, hypothermia * T's: tension pneumothorax, tamponade (cardiac), toxins, thrombosis (PE), thrombosis (coronary)

Question 34

Acute Coronary Syndromes Intro | Goals for ACS patients

Answer 34

* prevention of major adverse CV events such as death, non-fatal MI, and need for urgent post-infarction revascularization * identification of patients w/ STEMI and triage for early reperfusion therapy * relief of ischemic chest discomfort * tx of acute, life-threatening complications of ACS (such as VF, pVT, unstable bradycardias, ventricular wall rupture, papillary msk rupture, decompensated shock, unstable tachycardias)

Question 35

acute coronary syndrome introduction | OHCA response

Answer 35

* half of ACS deaths occur before the patient reaches the hospital w/ VF or pVT as the precipitating rhythm in a majority of cases * CF most likely to develop during first 4 hrs after sx onset * programs should focus on: recognizing sx of ACS; activating EMS; early CPR; early AED use; coordinating care w/ EMS, ED, and Cardiology

Question 36

Acute Coronary Syndrome Intro | STEMI Chain of Survival

Answer 36

* recognition and rxn to STEMI warning signs * EMS dispatch & rapid EMS system transport (notify hosp in advance) * assessment & dx in ED (or cath lab) * tx Dispatch Instructions * dispatch can tell patients w/ no hx of aspirin allergy or signs of active or recent GI bleeding sohuld chew aspirin (162-325mg) while they wait for EMS providers to arrive

Question 37

s/sx of ACS

Answer 37

* retrosternal chest discomfort (pressure/tightness vs actual pain) * delayed pain onset most common in elderly, women, diabetic pt, HTN pt * other sx: dizzy, light headed, diaphoresis, n/v, SOB, pain rad to shoulder/back/jaw/arms/neck

Question 38

EMS Assessment, Care, & Hospital Prep

Answer 38

EMS responders may do the following: * assess ABC/provide CPR and defibrillation * administer aspirin; consider oxygen, nitro, morphine * obtain 12 lead EKG (if there is ST elevation notify hosp) * provide prehospital notification; transport to ED/cath lab per protocol * hosp will mobilize resources to respond to STEMI * use fibrinolytic checklist as appropriate

Question 39

ED/Cath Lab Assessment

Answer 39

* hosp will mobilize resources to respond to STEMI * assess ABC/provide CPR and defibrillation * establish IV access * check vitals & eval O2 sat * obtain initial cardiac marker levels, CBCs, coag studies * portable CXR * review/complete fibrinolytic checklist (check contraindications) * 12 lead EKG Reperfusion Goals (STEMI) * first medical contact to balloon inflation w/in 90 min * door to drug (fibrinolytics) w/in 30 min arrival

Question 40

Concurrent ED or Cath Lab Assessment | patient general tx

Answer 40

give these meds unless allergies/contraindications exist * if O2 saturation < 90%; start oxygen at 4L/min (titrate) * Aspirin 162-325mg * Nitroglycerin sublingual/translingual * morphine IV if not relieved by nitroglycerin * consider administration of P2Y 12 inhibitors

Question 41

administering O2

Answer 41

Indications * EMS providers should administer O2 if pt is dyspneic or hypoxemic, has obvious signs of heart failure, or has an arterial O2 sat < 90% or unknown Oxygen Therapy * adjust until > 90% O2

Question 42

Administering Aspirin (acetylsalicylic acid)

Answer 42

* dose of 162-325mg * near total inhibition of thromboxane A2 production by inhibiting platelet cyyclooxygenase (COX-1) * rapid inhibition of platelets reduces coronary reocclusion * give if no hx of allergy, no evidence of recent GI bleed * chew

Question 42

Administerin Nitroglycerin (glyceryl trinitrate)

Answer 42

* reduces ischemic chest discomfort * reduces LV and RV preload via peripheral arterial and venous dilation * give 1 sublingual tablet Q3-5 min for sx if no contraindications (max of 3 doses) * admin only if hemodynamically stable (SBP > 90mmg and no lower than 30 mmHG below baseline if known; HR 50-100) CONTAINDICATIONS * inferior wall MI, RV infarction (b/c pt w/ inferior wall MI depend on RV filling pressure to maintain cardiac output & BP) * hypotension, bradycardia, marked tachycardia * recent phosphodiesterase inhibitor use (sildenafil, vardenafil) w/in 24-48 hrs When to use IV * recurrent or continuing chest discomfort unresponsive to sublingual/translingual nitroglycerin * pulmonary edema complicating STEMI * HTN complicating STEMI

Question 43

administering morphine

Answer 43

INDICATIONS * consider if pain is severe and not responsive to nitroglycerin PHYSIOLOGIC EFFECTS * produces CNS analgesia, which reduces adverse effects of neurohumoral activation, catecholamine release, andd heightened myocardial oxygen demand * alleviates dyspnea * produces venodilation, which reduces LV preload and O2 requirement * decreases systemic vascular resistence which reduces LV afterload * helps redistribute blood volume in pts w/ acute pulmonary edema * VENODILATOR MISC * fucks w/ anti-platelets

Question 44

pathway of occlusion

Answer 44

1. unstable plauqe 2. plaque rupture 3. unstable angina 4. microemboli 5. occlusive thrombus

Question 45

STEMI vs NSTEMI

Answer 45

STEMI * characterized by ST segment elevation in 2+ contiguous leads or new LBBB * threshold values: J-point elevation > 2mm in leads V2/3; > 1mm in all other leads NSTEMI (NSTE-ACS) * High Risk: ST depression of > 0.5mm or dynamic TWI w/ pain * Low/Mod Risk: normal or non-diagnostic changes in the ST segment or T waves that are inconclusive & require further risk stratification

Question 46

Tx strategies for ACS patients

Answer 46

* pts w/ STEMI usually have complete occlusion of an epicardial coronary artery; treat STEMI bby providing early reperfusion therapy achieved w/ primary percutaneous coronary intervention (PCI) or fibrinolytics. * Reperfusion therapy opens an obstructed coronary artery Info * PCI allows balloon dilation and/or stent placement for an obstructed coronary artery * early fibrinolytic therapy or direct catheter based reperfusion is an established standard of care for pt w/ STEMI who present w/in 12 hrs after sx osnet no contraindications

Question 47

Timeframes for ACS pts & reperfusion therapies

Answer 47

* PCI: 90 min or less * non-PCI capable hosp: first medical contact to device < 120 min when considering primary PCI * Fibrinolysis: door to needle 30 min * door to door departure time of < 30 min

Question 48

choosing PCI

Answer 48

* primary PCI: pt taken to cath lab for immediate PCI after hospital preesntation * rescue PCI: pt initially tx w/ fibrinolytic therapy; pt does not show signs of reperfusion (lack of ST resolution more than 50% after 1 hr of fibrinolytic therapy administration) and referred for rescue PCI * Pharmacoinvasive: pt tx initially w/ fibrinolytics and intention of performing coronary angiography and PCI as appropriate

Question 49

choosing fibrinolytics

Answer 49

* admin fibrinolytic agent to pt w/ ST segement elevation > 2mm in leads V2/3 or > 1mm in all other leads, or by new LBBB * fibrin specific agents achieve normal flow in ~50% of patients CONTRAINDICATIONS * > 24 hrs after onset of sx * those w/ ST segment depression (unless true posterior MI is suspected)

Question 50

Stroke chain of survival

Answer 50

* rapid recognition of and rxn to stroke warning s/sx * rapid use of 911 and EMS * rapid EMS recognition * rapid dx and tx in hospital

Question 51

8 D's of stroke

Answer 51

* detection: rapid recognition of stroke s/sx * dispatch: early activation & dispatch of EMS by phoning 911 * Delivery: rapid EMS stroke identification, management, triage, transport, prehosp notificaiton * Door: emergent ED/imaging suite triage, immediate assessment by stroke team * Data: rapid clinical evaluation, lab testing, brain imaging * Decision: establishing stroke dx, determine therapy * Drug/Device: admin fibrinolytics, endovascular therapy as eligible * Disposition: rapid admission to stroke unit or CCU

Question 52

types of strokes

Answer 52

* **Hemorrhagic**: 13% all strokes; occurs when blood vessel in brian suddenly ruptures into surrounding tissue * **Ischemic**: accounts for 87% of all strokes; occlusion of artery

Question 53

warning s/sx of ischemic stroke

Answer 53

* sudden weakness/numbness of face/arm/leg * trouble speaking/understanding * sudden trouble seeing in one or both eyes * sudden trouble walking * dizziness or loss of balance or coordination * sudden severe HA w/ no known cause * sudden confusion

Question 54

stroke assessment tools for EMS

Answer 54

CPSS identifies stroke on basis of 3 physical findings * facial droop * arm drift * abnormal speech can evaluate pt in less than 1 min

Question 55

steps after recognizing stroke

Answer 55

* assess ABCs (O2 PRN) * initiate stroke protocol * PE * perform validated prehospital stroke screen & severity tool * establish time os sx onset * triage to most appropriate stroke center * check glucose (tx if indicated) * provide prehospital notification on arrival; transport to brain imaging suite providing supplemental O2 for all hypoxemic stroke pts (O2 sat < 94%) or for those whose O2 unknown

Question 56

assessing for stroke

Answer 56

Stroke Assessment Tools * CPSS/FAST (cincinnati) * LAPSS (Los Angeles Prehosp Stroke Screen) * MASS (Melbourne Ambulance Stroke Screen) * MENDS (miamia emergency neurologic deficit score) * ROSIER (recognition of stroke in ER) Stroke Severity Score * NIHSS * shortened NIHSS * CPSSS * FAST-ED * LAMS * RACE

Question 57

Levels of Stroke Certifications

Answer 57

* Acute Stroke Ready Hospital: typically serve rural and under-resourced areas; emergent ID & tx w/ alteplase; ultimate txfr * Primary Stroke Center: quickly ID & tx pts; admit to stroke unit; 1/2 of stroke pt receive care in this level center * Thrombectomy Capable Stroke Center: above + can provide endovascular therapies * Comprehensive: manage all forms + severities of strokes

Question 58

Advantages of EMS Transport

Answer 58

* EMS play critical role in timely tx of potential stroke by identifying possible stroke pts, providing high priority dispatch, instructing bystanders in livesaving CPR skills or supportive care * responding providers can assess ABCs/give O2 as needed * EMS personnel can initiate stroke protocol, check glucose, establish time of sx onset * EMS can triage most appropriate stroke center on bases of validated prehospital stroke screen, severity tool * EMS can provide prehospital notification, enabling the hosp to prepare to evaluate & manage pt more efficiently

Question 59

Tx goals for ischemic stroke

Answer 59

1. immediate general and neurologic assessment by hospital or stroke team, ED physician, or another expert, ideally w/in 10 min after arrival; activate stroke team upon EMS notification, prep for emergent CT/MRI; assess ABCs, O2, IV access, labs (glucose); review pt hx/meds;sx onset; perform PE, neuro exam 2. Neuro Assessment + NCCT or MRI w/in 20 min 3. Interpret NCCT/MRI w/in 45 min 4. fibrinolytics w/in 45 min 5. door to device time w/in 90 min of direct arrival or 60 min for txfr 6. door in to door out for txfr pt win 60 min 7. door to admit w/in 3 hrs

Question 60

Eligibility for Alteplase Therapy

Answer 60

greater likelihood of good/excellent functional outcome when alteplase is given to adults with acute ischemic stroke w/in 3 hrs after sx onset or w/in 4.5 hrs after sx onset in certain pts EVALUATING * if CT/MRI is negative for hemorrhage, pt can be candidate for fibrinolytic therapy * if CT/MRI scan shows no hemorrahge, the probability of acute ischemic stroke remains; review inclusion/exclusion criteria * if pt's neurologic function is rapidly improving to normal, fibrinolytics may be unnecessary

Question 61

criteria for endovascular therapy

Answer 61

* pt arrives w/in 6 hrs sx onset * prestroke modified rankin score 0-1 * causative LVO of the internal carotid artery or proximal middle cerebral artery * > 18 yrs * NIHSS score >6 * ASPECTS 6+

Question 62

general stroke care

Answer 62

includes the following actions: * begin acute stroke pathway * assess ABCs, give O2 * monitor blood glucose, BP, temp * perform dysphagia screening * monitor for complications of stroke and fibrinolytic therapy * txfr to a higher level of care if indicated

Question 63

general stroke care | begin stroke pathway

Answer 63

* admit pt to stroke unit for observation, monitoring of BP/neuro status * if neuro status worsens, order an emergent Ct scan * determine if cerebral edema or hermorrhage; consult neurosurgery PRN * support: airway, oxygenation, ventilation, nutrition; provide normal saline to maintain intravascular volume (75-100mL/hr)

Question 64

general stroke care | monitor blood glucose

Answer 64

* monitor glucose: hyperglycemia associated w/ worse clinical outcomes; give insulin is glucose > 180 * monitor for complications of stroke/fibrinolytics: increased intracranial pressure; BP monitoring; seizure watch * HTN management: if give alteplase; to get fibrinolytic BP should be < 185mmHg systolic or < 110 mmHg diastolic

Question 65

RR + TV

Answer 65

* RR: 12-20 min * TV: 6ml/kg (500mL) * RR < 6/min: assisted ventilation

Question 66

sx respiratory distress

Answer 66

* tachypnea * increased/inadequate resp effort * abnormal airway sounds * tachycardia * pale/cool skin * changes in LOC/agitation * use of abd msk to help breathe

Question 67

sx respiratory failure

Answer 67

* marked tachypnea OR bradypnea/apnea * no resp effort * poor to absent distal air movement * bradycardia * cyanosis * stupor/coma can result from upper or lower airway obstruction, lung tissue disease, disordered control of breathing

Question 68

general resp arrest

Answer 68

* TV approx 500-600 mL to produce visible chest rise * if obstruction or poor lung compliance may need higher pressure to produce visible chest rise Avoid Excessive Ventilation * can increase thoracic pressure * decreases venous return to heart * diminished cardiac output + survival * may cause cerebral vasoconstriction reducing blood flow to the brain

Question 69

describe oropharyngeal airway (OPA) as adjunct airway

Answer 69

* J shaped, single use, disposable plastic device * fits over tongue to hold both it and soft hypopharyngeal structures away from posterior wall of pharynx * adult sizes range from 8-10 USE FOR: * pts at risk of developing airway obstruction from tongue or relaxed upper airway msk * unconscious patients when other procedures fail * faciltating suctioning of intubated pt mouth/throat * preventing pt from biting/obstructing ET tube

Question 70

describe use of nasopharyngeal airway (NPA) as adjunct

Answer 70

* alternate to OPA * soft rubber/plastic uncuffed tube that provides conduit for airflow between nostrils & pharynx * can be used in conscious, semiconscious, or unconscious pts * can be used in pt with difficulties inserting OPA or those with neruologic impairments

Question 71

atropine for bradycardia

Answer 71

* first line drug for acute stable bradycardia * acts by reversing cholinergic mediated decreases in HR & AV node conduction * 1mg IV Q3-5 min (max dose 3mg IV) * giving doses < 0.5mg can slow heart rate

Question 72

epinephrine & dopamine for bradycardia

Answer 72

* B adrenergic infusion not first line for unstable bradycardia but can be used as an alternative when a bradycardia is unresponsive to tx w/ atropine * epinephrine dose at 2-10 mcg/min and titrate to pt response * dopamine: 5-20mcg/kg/min and titrate to pt response; at lower doses, dopamine has a more selective effect on inotropy & HR; at higher doses (> 10 mcg/kg/min) has vasoconstrictive effects

Question 73

how to perform transcutaneous pacing

Answer 73

1. place pacing electrodes on chest according to instructions 2. turn pacer on 3. set demand rate to 6-80/min (adjust up or down) 4. set current milliamperes output 2mA above dose at which consistent capture is observed