1
Q
Average survival rate for IHCA (in hospital cardiac arrest)
A
24%
2
Q
Causes for more than half IHCAs
A
Respiratory failure or hypovolemic shock
3
Q
Most common cause of out of hospital cardiac arrest
A
Ischemia coronary artery disease
4
Q
Possible first indicators of cardiac arrest in adult patients
A
Generalized seizures
5
Q
ROSC occurs when an arrested patient comes out of cardiac arrest and displays one of the following
A
- Pulse & adequate blood pressure
- Abrupt increase in EtCO2 (>40 mmHg)
- Spontaneous arterial blood pressure waves with intra-arterial monitoring
6
Q
When do most deaths occur after ROSC?
A
Within 24 hours
7
Q
What should you do when you notice agonal breathing?
A
Start CPR
8
Q
Do agonal breaths provide adequate oxygenation?
A
No
9
Q
Slow, complex rhythms immediately preceding asystole
A
Agonal rhythms
10
Q
Normal capillary refill time
A
<2 seconds
11
Q
Prolonged capillary refill time
A
> 5 seconds
12
Q
Common causes of prolonged capillary refill time
A
- Dehydration
- Shock
- Hypothermia
13
Q
The proportion of time spent performing chest compressions in a cardiac arrest
A
Chest compression fraction
14
Q
Ideal chest compression fraction
A
at least 60% and ideally occupy >80% of resuscitation attempt
15
Q
1st 28 days of life
A
Neonate
16
Q
1 month-1 year of age
A
Infant
17
Q
1 year to onset of puberty
A
Child
18
Q
Puberty or older
A
Adult
19
Q
Person who does not have specialized or professional knowledge of a subject
A
Lay person or lay provider
20
Q
Description of respiratory distress
A
- Increased respiratory rate and effort, but able to move air
- Potential abnormal airway sounds and pallor
- Tachycardia and anxiety
- Pt improves with initial therapy
21
Q
Description of respiratory failure
A
- Labored breathing accompanied by signs of shock (cyanosis, lethargy, bradycardia)
- Requires intervention/assistance
- May not respond to initial breathing treatments & interventions
22
Q
Definition of stable
A
- Normal BP
- Signs of good perfusion
- Awake/alert
23
Q
Definition of unstable
A
- Hypotension
- Signs of poor perfusion
- Altered or depressed consciousness, or the pt is sick
24
Q
Process of deciding which patients should be treated first, where they should go based on how sick or seriously injured they are
A
Triage!!!!
25
Teams roles (6)
1. Team leader
2. Compressor (1st priority)
3. AED/monitor/defibrillator (2nd priority)
4. Airway (3rd priority)
5. IV/IO/meds
6. Timer/recorder
26
Purpose of code team
Respond AFTER an arrest has occured
27
Purpose of rapid response team
Identify and treat early clinical deterioration BEFORE the arrest
28
Team dynamics (8)
1. Have clear roles
2. Know your limits
3. Have constructive interference
4. Share knowledge
5. Summarize and reevaluate
6. Have closed loop communication
7. Give clear messages
8. Have mutual respect
29
Systems of care
1. Community- lay providers
2. Out of hospital- EMS
3. In hospital - Code teams, rapid response, critical care, stroke
30
Description of OHCA
1. Lay providers witness the arrest and activate EMS
2. CPR is started
3. Defibrillation is performed as soon as an AED is available
4. EMS arrives, resuscitates and transports
5. ACLS and post arrest care
31
IHCA description
1. Hospital providers monitor and prevent arrest
2. If an arrest is witnessed, EMS is activated
3. CPR is started
4. Defib is performed as soon as an AED is available
5. ACLS and post arrest care
32
ABCDEs of ACLS
```
Airway
Breathing
Circulation
Disability
Exposure
```
33
Airway suction pressure
-80-120 mmHg
34
Suction attempts
- No more than 10 seconds
- Limited to less than 10 at a time
- Follow attempts with a short period of 100% O2 administration
- Squirt 1-2 ml NS before suctioning thick material
35
Suction catheter appropriate for thin secretions
Soft suction for tracheal
36
Suction catheter for thick secretions
Rigid suction catheter
37
How do you open the airway for trauma patients?
With a jaw thrust, unless that does not work, then chin lift
38
C spine restrictions for trauma patients
Manual spinal motion restriction rather than cervical collars bc cervical collars complicate airway management
39
Management for severe choking in responsive adults
-Perform the Heimlich maneuver
40
Management for severe choking in responsive children
Heimlich maneuver or abdominal thrusts below xyphoid process
41
Management for severe choking in responsive infants
1. Place pt prone in one arm and deliver 5 back slaps
2. Flip the pt supine in other arm and deliver 5 downward chest thrusts with two fingers
3. Continue until obstruction is relieved or pt loses consciousness
42
Severe choking management in unresponsive patients
Immediately start CPR and look for object in mouth each time you deliver breaths
43
What do you do after an airway obstruction is relieved?
Place the patient in recovery position
44
Most important factor to influence survival in drowning
Immediate, high quality CPR
45
Airway management for foreign body airway obstruction
1. The pt needs to stay calm
2. Pt should remain spontaneously breathing if possible
3. Use mask induction or cautious IV induction with maintenance of spontaneous ventilation
4. Anesthetize the pharynx and vocal cords
5. Maintenance with propofol-remifentanil based TIVA with maintenance of spontaneous ventilation
6. Use of jet ventilation and/or oxygen insufflation through the bronchoscope may help prevent hypoxia
7. Steroids can be used
46
When CPR is not being administered, oxygen should be administered and titrated to an SpO2 of
1. 94-99% for all non-ACS cases
| 2. >90% for ACS syndrome cases
47
Oxygen administration during CPR
100%
48
Mouth to mouth breathing in adults
1. Pinch nose
2. Perform head tilt chin lift
or use pocket mask
49
Pt's FiO2 from mouth to mouth ventilation
17% oxygen and 4% CO2
50
Mouth to mouth in infants/neonates/children
Mouth over victim's mouth and nose or use peds pocket mask
51
When is bag mask ventilation used?
With 2 rescuer ventilation
52
When is mouth to mouth used?
With single rescuer ventilation
53
Correct hand placement for bag mask according to ACLS test
E-C technique (not C-E)
54
Provides more effective ventilation and more accurate EtCO2 in cardiac arrest
Intubation
55
Disadvantages to excessive ventilation
1. Creates gastric inflation
2. Decreases venous return and cardiac output
3. Decreases cerebral blood flow
4. Lowers survival
56
Best way to avoid excessive ventilation
Give a breath when chest rise is observed
57
Goal tidal volume for adults during arrest
500-600 mL
58
Preferred method for confirming effective ventilation and correct endotracheal tube placement
Continuous waveform
59
What color of the colorimetric capnography indicates EtCO2
Yellow
60
If compressions are required, what breathing rate is suggested
Lower, 10 breaths/min or 1 breath every 6 seconds
| -Improves venous return
61
If compressions are not required, what breathing rate is suggested
10-12 breaths/min or 1 breath every 5-6 seconds
62
Breathing rate in intubated patients
10 breaths/min
63
Breathing rate in mask ventilated patients
10-12 breaths/min
64
Breathing protocol
1. R- Check responsiveness
2. A-Activate EMS/call
3. C-Circulation; check pulse and breathing
4. If not breathing, but still a pulse, give 10-12 rescue breaths per minute
65
Vascular access priority
1. IV
2. IO if IV not possible
3. ETT if IO and IV are not possible
66
Best IO access
Anterior tibia
67
How do you administer drugs via the ETT?
1. Inject the drug
2. Follow w/5-10 ml NS
3. Provide 5 rapid positive pressure ventilations
4. Stop compressions to prevent regurgitations
68
ETT epi dose in adults
2-3 times the IV dose
69
ETT epi dose in children
10x the IV dose
70
ETT epi dose in neonates
same as IV dose
71
Problems with lower concentration of epi via ETT
May produce beta 2 effects which can cause hypotension and decrease chances of ROSC
72
Drugs that can be given via ETT in adults
```
NAVEL
Narcan
Atropine
Vasopressin
Epi
Lidocaine
```
73
Drugs that can be delivered via ETT in pediatrics
```
LEAN
Lidocaine
Epinephrine
Atropine
Narcan
```
74
If there is no pulse, or you are unsure of whether or not there is a pulse after checking for 10 seconds, what should you do?
Begin compressions
75
If there is no breathing but there is a pulse, what should you do?
Give 10-12 rescue breaths per minute (1 breath every 5-6 seconds, each breath over 1 second)
76
Where do you look for a pulse in adults and children >1 year old?
Carotid or femoral pulse
77
Where do you look for a pulse in children <1 year old
Brachial pulse
78
How long are pulse checks?
Less than 10 seconds
79
What should you do if you are not sure if a pulse exists?
Do not delay chest compressions
80
Indications for compressions in adults
If there is no pulse
81
Indications for compressions in children
If the HR is less than 60 bpm
82
Indications for compressions in older children
If the HR is less than 40 bpm
83
Rate for compressions
100-120 per minute
84
How many compressions does it take before getting good blood flow?
20-25
85
Chest compression technique
1. Use a hard, flat surface
2. Press down on lower half of the breastbone
3. Push to an adequate depth
4. Allow complete chest recoil
5. Switch providers every 2 minutes (or 5 cycles)
86
What is an adequate chest compression depth for adults and adolescents?
2-2.4 inches
87
What is an adequate chest compression depth for children?
2 inches
88
What is an adequate chest compression depth for infants?
1/3 to 1/2 depth of chest, or 1.5 inches
89
High quality CPR Pneumonic
Chest recoil
Push hard, push fast
Rotate rescuers
90
CPR technique used for adults and adolescents
2 handed technique
91
CPR technique used for 1-8 year old children
One handed or 2 handed
92
CPR technique indicated for infants when only one responder is available
2 finger technique
93
CPR technique indicated for infants when 2 responders are available
Thumb encircling technique
94
CPR on mask ventilated patients
1. Compressions are interrupted when performing breaths
| 2. CPR is performed in 5 cycles (or over a 2 minute period)
95
CPR cycle for mask ventilated adults
30 compressions and 2 breaths
96
CPR cycle for mask ventilated infants with 1 provider
30:2
97
CPR cycle for mask ventilated infants with 2 providers
15:2 bc kids require faster respiratory rates
98
CPR cycle for mask ventilated neonates for a respiratory arrest
3:1
99
CPR cycle for mask ventilated neonates for cardiac arrest
15:2
100
CPR in intubated patients
1. Chest compressions are NOT interrupted during breaths
| 2. CPR is performed in 2 minute increments (not in cycles)
101
CPR in intubated adults
Compression rate is 100-120 /min
| breathing rate is 10 breaths/min
102
CPR in intubated kids
100-120 compressions/min
| Faster breathing rate
103
Goals for chest compressions
1. EtCO2 of at least 20 mmHg
2. Diastolic BP on an arterial line of at least 20 mmHg
3. Coronary perfusion pressure of at least 10 mmHg
4. Mixed venous SaO2 of at least 30%
104
Chest compressions take priority over everything except:
1. Calling for help
| 2. Defibrillating when pads are on and ready to go
105
What are continuous chest compressions?
- Done by EMS
- 3 periods of 200 compressions each
- Passive oxygen insufflation
106
When is CPR stopped/withheld
1. DNR requests
2. Threat to the safety of rescuers
3. Rigor mortis
4. Lividity
107
CPR protocol when using a defibrillator
1. Check the pulse
2. Perform CPR until an AED arrives
3. Defibrillate ASAP
4. Resume 2 minutes of CPR before re-analyzing the rhythm
5. Re-analyze rhythm and check the pulse
108
When are IV/IO meds given with defibrillation?
Immediately before or immediately after shock delivery
109
4 ways neurologic function is assessed
1. Checking the patient's blood sugar
2. Pupil response to light
3. AVPU pediatric response scale
4. GCS (Glasgow Coma Scale)
110
What is assessed when examining the pupils with light?
1. Pupil size (in mm)
2. Equality of pupil size
3. Constriction in response to light
PERRL
111
What is the AVPU scale?
Alert
Responsive to Voice
Responsive to Pain
Unresponsive
112
What is measured with the GCS?
Eye opening
Verbal
Motor
113
When is intubation indicated with the GCS?
When it is less than or equal to 8
114
What happens in the exposure step of ACLS?
The providers does a quick physical exam to assess for signs of trauma, bleeding, burns, unusual markings, or medical alert bracelets
115
What can an AED do?
1. Sense and analyze vfib/vtach
| 2. Can defibrillate
116
Limitations of the AED
1. Does not produce an ECG rhythm strip/cannot sense other arrhythmias outside of vfib/vtach
2. Cannot pace
3. Cannot perform synchronized cardioversion
117
When should a shock be delivered when the AED advises? (time frame)
Within 10 seconds
118
What is the difference between semi-automated and fully automated AEDs?
Semi-automated only ADVISES a shock, the provider must push the button
Fully automated shocks for you if indicated
119
AED protocol
1. Power on the AED
2. Attach the electrode pads
3. Clear the victim
4. Analyze the rhythm
5. Charge and shock if advised
120
What can a manual defibrillator do?
Same as AED, analyze and shock, but also show ECG rhythm strip, perform synchronized cardioversion, and perform transcutaneous pacing
121
How long should the entire clear and shock process take with a manual defibrillator?
<5 seconds
122
Reason most defibrillators are biphasic
They allow the maximum efficiency delivered with the smallest possible amount of energy
123
Means the shock will be delivered during the R wave
Synchronized cardioversion
124
What happens if the shock is delivered during the T wave?
It could cause an "R on T phenomenon," which could precipitate vtach or vfib
125
Indications for synchronized cardioversion
1. Unstable SVTs (SVT, afib, aflutter)
| 2. Unstable monomorphic vtach with a pulse
126
How to perform a synchronized cardioversion
1. Place pads in a posterior, left anterior fashion
2. Turn knob to defib
3. Press sync prior to each shock attempts
4. Select energy to be delivered (75-120J)
5. Hit the charge button
6. Hit the shock button
127
If you are synchronized cardioverting an atrial rhythm, where does the anterior pad go?
On the R chest
128
If you are synchronized cardioverting a ventricular rhythm, where does the anterior pad go?
On the L chest
129
Energy to be delivered during synchronized cardioversion
75-120 J
130
Delivery of a shock at the precise moment the shock button is pressed
Defibrillation
131
When is defibrillation indicated?
For all ventricular rhythms that are pulseless and/or irregular (vfib, pulseless vtach, torsades de pointes)
132
When is defibrillation NOT indicated?
1. SVT
2. Asystole
3. PEA
133
How to perform defibrillation
1. Place pads in either a posterior-anterior or anterior-anterior fashion
2. Turn knob to defib
3. Select the amount of energy to be delivered (200J)
4. Charge
5. Shock
134
Amount of energy delivered with defibrillation in adults (biphasic)
120-200J
| use manufacturer's recommended first dose, or maximum dose on machine
135
Amount of energy delivered with defibrillation in pediatrics
1st dose 2J/kg
2nd dose 4J/kg
Up to 10J/kg
136
Amount of energy delivered with synchronized cardioversion irregular SVT (afib)
120-200 J biphasic
137
Amount of energy delivered with synchronized cardioversion regular SVT
50-100 J
138
Amount of energy delivered with synchronized cardioversion monomorphic vtach
100 J
139
Amount of energy used with transcutaneous pacing capture
40-80 mA
140
How does pacing work?
Pads deliver energy to the heart that causes the heart to depolarize and contract, taking over the job of the SA node
141
Indications for transcutaneous pacing
Severe bradycardia that is unresponsive to drug therapy (atropine or epi)
142
How to perform transcutaneous pacing
1. Place pads on patient, posterior, left anterior
2. Turn knob to pacer
3. Select HR you want to pace with
4. Turn current up until you observe capture
5. Set maintenance threshold 10% above pacing threshold
143
Disadvantages of transcutaneous pacing
1. It only shows a ventricular EKG waveform
2. Does not produce effective capture as transvenous pacing
3. Causes muscle jerking, which may mimic a carotid pulse
4. It is painful, pt needs sedation if stable enough
144
The current at which "capture" is observed
Pacing (stimulation) threshold, usually occurs between 40-80 mA
145
What is capture?
When the heart starts beating
146
Current at which the pacemaker should be maintained, 10% above stimulation threshold
Maintenance threshold
147
Where is the anterior-anterior pad placement?
1. Upper R chest above nipple
| 2. L anterior or mid axillary line of 5th intercostal space
148
Posterior, left anterior pad placement
1. Posterior under L scapula
| 2. Anterior to the L of the sternum under L breast
149
Posterior, R anterior pad placement
1. Posterior under L scapula
| 2. Anterior to the R of sternum above R breast
150
Most common and recommended placement for AED pads
Anterior-anterior
151
Less common placement for AED pads
Posterior, left anterior
152
Recommended pad placement for transcutaneous pacing
Posterior, left anterior
153
Less common pad placement for transcutaneous pacing
Anterior-anterior
154
Preferred pad placement for defibrillation and cardioversion of vtach
Posterior, left anterior
155
Less common pad placement for defibrillation and cardioversion of vtach
Anterior-anterior
156
Recommended pad placement for cardioversion of atrial rhythms
Posterior, R anterior
157
Less common pad placement for cardioversion of atrial rhythms
Anterior-anterior
158
Most common and recommended paddle placement on adults
Anterior-anterior
159
Less common paddle placement on adults
Posterior, L anterior
160
Recommended paddle placement for infants
Anterior-anterior
161
Recommended paddle placement for small children
Anterior-anterior or anterior-posterior
162
Purpose of conducting gel between paddles and pt's chest
Reduces transthoracic impedance
163
What age range are pediatric AED pads used on?
Children 1-8 years old
164
What should you remember with pediatric AED pads?
They should not touch each other
165
True/false. You can place the defib pads directly on top of any medication patch, pacemaker, or implantable cardioverter defibrillator
False
166
True/false. It is safe and reasonable to perform multiple defibrillation attempts in hypothermic patients
True, although intervals between shocks may need to be longer
167
True/false. Oxygen can blow across the chest during defibrillation
False
168
True/false. The defibrillator still works if the patient is covered in water or sweat
False. Water conducts the shock across the skin of the chest and prevents adequate shock
169
True/false. Defibrillator pads should not touch each other
True
170
True/false. Pads should be placed flat on the skin and at least 2 inches apart to reduce the risk of current arcing
True
171
True/false. Paddles carry a lower risk of current arcing than pads
False
172
True/false. Pads provide a more rapid defibrillation
True, they are already connected in case the need for a shock arises
173
Time from arrival to first shock
<90 seconds
174
When should medications be given?
During compressions, immediately before or after shock delivery
175
What should a lone rescuer do when encountering a hypoxic arrest?
Provide 2 minutes of CPR BEFORE activating EMS
176
What should a lone rescuer do if they witness a sudden collapse?
Call for help or leave pt to get AED BEFORE initiating chest compressions
177
What should a lone rescuer do if they do NOT witness a sudden collapse?
Perform 2 minutes of CPR BEFORE calling for help
178
Possible airway/breathing interventions in ACLS (7)
1. Check breath sounds, airway patency (& pulse)
2. Open airway with jaw thrusts, chin lift or oral/nasal airways
3. Provide rescue breaths and/or assist ventilation
4. Supplementary oxygen
5. Auscultate breath sounds
6. Suction the airway
7 Avoid excessive ventilation
179
Possible circulation interventions in ACLS
1. Start an IV and administer drugs
2. Place monitors on the patient (ECG, BP)
3. Perform CPR on unconscious patients
4. Use an AED or manual defibrillator
180
Initial ABCDEs in ACLS if the patient is unconscious/unresponsive
1. Check for a pulse and breath sounds
2. Call for help, start CPR and get defibrillator if there is no pulse
3. Provide rescue breaths, place monitors if there is a pulse but the pt is not breathing
181
Initial ABCDEs in ACLS if the patient is conscious/responsive
1. Place monitors on the patient
2. Start IV
3. Place oxygen
182
For unconscious/unresponsive patients, both ACLS and PALS recommend that the ABC steps be done in what order?
C-A-B
| check pulse and start compressions before checking breathing/rescue breaths
183
What should you do before approaching a patient in an ACLS scenario?
1. Use universal precautions (gloves)
| 2. Make sure the scene is safe
184
What is the first thing an ACLS provider should do when approaching a patient?
Check the level of responsiveness to see if they are conscious or not
185
What should you do if a patient is not responsive and the pulse cannot be palpated?
Start CPR
186
What should you do if a patient is not responsive, the pulse can be palpated, but the pt is not breathing?
Administer rescue breaths
187
What is the BLS assessment?
In unconscious patients, RACD
- Responsiveness
- Activate EMS and get -AED (before CPR)
- Check circulation and breathing simultaneously
- Defibrillation
188
How should you approach a conscious/responsive patient in ACLS?
1. Place monitors (C)
2. IV (C)
3. O2 (A/B)
189
What is the primary assessment in ACLS?
For conscious patients
1. Monitors, IV, oxygen
2. Diagnosing and intervening to treat the patient
3. Performing D & E after initial intervention
190
What is secondary assessment in ACLS?
SAMPLE, H's and T's
191
What does SAMPLE stand for in ACLS?
```
Signs and symptoms
Allergies
Medications
PMHx
Last meal consumed
Events
```
192
What are the 7 H's of pulseless arrest?
1. Hypovolemia
2. Hypoxia
3. Hypothermia
4. Hypoglycemia
5. Hypokalemia
6. Hyperkalemia
7. Acidosis
193
What are the 5 T's of pulseless arrest?
1. Tamponade
2. Thrombosis
3. Tension PNX
4. Trauma
5. Toxins
194
Treatment for tension PNX
1. Needle decompression at 2nd intercostal space/mid clavicular line
2. Chest tube second (6th intercostal space/midaxillary line)
195
What are the symptoms of post-cardiac arrest syndrome?
1. Post arrest brain injury
2. Post arrest myocardial dysfunction
3. Systemic ischemia
4. Reperfusion response
5. Pathology that might have precipitated the cardiac arrest
196
4 goals of post resuscitation care
1. Optimize ventilation and hemodynamic status (BP)
2. Initiate targeted temperature management
3. Immediate coronary reperfusion with PCI
4. Neurologic care and prognostication and other structured interventions
197
The only intervention demonstrated to improve neurologic recovery
Targeted temperature management
198
The first priority in someone who achieves ROSC
Oxygenation and ventilation
199
When is targeted temperature management indicated?
To any patient who is comatose and unresponsive to verbal commands after ROSC
200
Goal temperature for comatose patients
32-36 C for at least 24 hours
201
For pts not treated with TTM, the earliest time for neurologic assessment is
72 hours after cardiac arrest (or longer if sedatives were used)
202
For pts treated with TTM, wait ___ before assessing neurologic status
72 hours after return to normothermia
203
Methods of initiating TTM
1. Rapid infusion of ice cold, isotonic, non-glucose containing fluid (30mL/kg)
2. Surface cooling devices
3. Ice bags
204
How do you keep SpO2 > 94% post resuscitation?
Titrate the FiO2 to the lowest level
205
EtCO2 and PaCO2 goals post resusciation
Ventilation should be started at 10 breaths per minute to achieve an EtCO2 of 35-40 mmHg and PaCO2 of 40-45 mmHg
206
EKG post resuscitation guidelines
12 lead ASAP
| Consider reperfusion therapy if STEMI or AMI is suspected
207
Blood pressure goals post resuscitation
MAP >65 mmHg
| Systolic >90 mmHg
208
Temperature control goals post resuscitation
32-36 C for 24 hours should be considered only for unconscious patients
209
Prophylactic Antiarrhythmic therapy after ROSC
1. Consider beta blockers
| 2. Consider lidocaine
210
When to consider terminating resuscitation efforts
1. Providers are unable to get EtCO2 >10 mmHg after 20 minutes of CPR in intubated patients
2. A valid DNR is presented
3. The resuscitation is taking place in dangerous environmental hazards
211
When to consider prolonging resuscitation efforts (>20 minutes)
1. If the cause of cardiac arrest is reversible
| 2. If return of spontaneous circulation occurred at any time during the resuscitation attempt
212
Protocol for defib and drug dosing in severe hypothermic patients
<30 C
- Perform a single defib attempt
- subsequent defib attempts and drug therapy should be delayed until temperature is >30C
213
Protocol for defib and drug dosing in mildly hypothermic patients
<34 C
| -Provider can defib as normal, but should wait longer intervals between drug doses
214
The most rapid and effective technique for rewarming severely hypothermic patients
Extracorporeal circulation
215
"What to say once a patient achieves ROSC"
1. Order a 12-lead EKG
2. Consider hypothermia
3. Maintain normal BP
4. Get frequent lab work
5. Maintain SpO2 of 94-99%
6. Consider intubation and maintain EtCO2 of 25-40 mmHg
7. Consider lidocaine or beta blockers
216
Bradycardia therapies
1. Atropine (0.5mg, repeated every 3-5 min)
2. Epinephrine 2-10 mcg/min
3. Dopamine 2-20 mcg/kg/min
217
Adenosine dose
Initial 6mg bolus, NS flush
| up to 2 additional doses of 12 mg
218
Beta blocker that slows conduction/increases refractoriness in the AV node
Sotalol
219
Sotalol dose
100 mg, or 1.5 mg/kg
220
When should sotalol be avoided?
In patients with prolonged QT syndrome
221
Dose of epi in cardiac arrest
1mg every 3-5 minutes
222
Indications for amiodarone
For patients with monomorphic vtach (w/ or w/out a pulse) and/or vfib
223
When is amiodarone contraindicated?
In patients with prolonged QT intervals
224
First-line antiarrhythmic agent for shockable rhythms refractory to CPR, defibrillation and vasopressor therapy based on short term survival advantages
Amiodarone
225
Amiodarone dose for a patient with monomorphic vtach that is awake or still has a pulse
150mg over 10 minutes (repeat as needed)
226
Amiodarone dose for a patient in vfib/pulseless vtach
300mg bolus for the first dose, 150 mg for the second dose
227
Amiodarone dose for a post-resuscitation infusion
1 mg/min for 1st 6 hours and 0.5 mg/min for the next 18 hours
-Loading dose of 150 mg is given if not given during arrest
228
When is procainamide indicated?
Vfib or monomorphic vtach
229
Dose of procainamide
- 20-50 mg/min until the arrhythmia is gone, hypotension ensues or QRS duration decreases 50%
- Maintenance infusion 1-4 mg/min
- max dose 27 mg/kg
230
When is procainamide contraindicated?
With prolonged QT syndrome or CHF
231
When are amiodarone and procainamide used in ACLS?
Only with vfib/vtach
232
When are amiodarone and procainamide used in the real world?
SVT, Afib/atrial flutter, vfib/vtach
233
When is magnesium indicated in ACLS?
For polymorphic vtach
234
Dose of magnesium
1-2g
235
ACLS approach to respiratory arrest
1. Check responsiveness
2. Call for help
3. Check pulse and breathing
236
If pt is in respiratory arrest and has a pulse, but agonal breathing, what should you do?
Give 2 rescue breaths and 10-12 breaths/min
237
If a patient is in respiratory arrest and has no pulse, what should you do?
Begin 5 cycles of CPR
238
What to do if a patient is unresponsive
Check pulse, activate EMS and start CPR
239
What to do if a patient is responsive
Start primary assessment by verbalizing "monitors, IV, oxygen"
240
Steps to follow in each ACLS scenario
1. Check responsiveness and start initial therapy
2. Perform an initial diagnosis based on what the monitors say
3. Intervene again
4. Perform secondary and diagnostic assessments while initial intervention is going on
5. Intervene again
6. Frequently reassess the patient and continue to intervene
241
Respiratory arrest protocol
1. Check responsiveness
2. Activate EMS/call for help
3. Circulation; check pulse and breathing
4. Give 10-12 rescue breaths per min (1 breath every 5-6 seconds)
5. Re-check the pulse every 2 minutes
6. Consider narcan
242
Dose of Narcan
0.4 mg IM and intranasal dose 2mg
| may be repeated every 4 minutes
243
Rhythms that fall under bradycardia algorithm
1. Sinus bradycardia
2. Mobitz Type I and II block
3. Complete 3rd degree heart block
4. Afib with slow ventricular response
5. Ventricular or junction escape rhythm
244
Bradycardia therapies
1. Drugs (epi for peds, atropine, dopamine)
2. Transcutaneous pacing
3. Transvenous pacing
245
Protocol for stable bradycardia
1. Atropine
2. Monitor and observe
3. SAMPLE
246
Protocol for unstable bradycardia
1. Monitors, IV and Oxygen
2. Atropine
3. Transcutaneous pacing, epi, dopamine
4. SAMPLE
5. Consult or transvenous pacing
247
Narrow, complex tachycardia
Supraventricular
248
Wide complex tachycardia
Ventricular
249
When tachycardia usually causes symptoms
when HR >150 bpm
250
The big difference between SVT and afib/a flutter
the AV node is USUALLY part of the SVT reentry circuit, but is not part of the afib/a flutter ectopic pathways
251
Treatment for obvious, stable SVT
1. Monitors, IV and oxygen
2. vagal maneuvers
3. adenosine
4. Beta blocker or CCB
5. SAMPLE
6. Consider expert consult
7. Consider amiodarone or procainamide (not officially ACLS)
252
Treatment for obvious , stable afib or atrial flutter
1. Monitors, IV, oxygen
2. Consider expert consult
3. SAMPLE
253
Treatment for unstable SVT
1. Monitors, IV and oxygen
2. Immediate synchronized cardioversion
3. Consider adenosine, vagal maneuvers, CCB, B blockers
4. SAMPLE
5. Consider amiodarone or procainamide (not officially ACLS)
254
Treatment for unstable afib/aflutter
1. Monitors, IV, oxygen
2. Immediate synchronized cardioverison
3. SAMPLE
4. While waiting for defibrillator, consider adenosine, vagal maneuvers or CCB
5. Consider amiodarone/procainamide (not officially ACLS)
255
Therapies for ventricular tachyarrhythmias
1. Synchronized cardioversion or defibrillation
2. Epi (if pulseless)
3. Amiodarone
4. Procainamide
5. Lidocaine
6. Magnesium (only torsades)
7. Adenosine (used for diagnostics)
256
Protocol for stable monomorphic vtach with a pulse
1. Monitors, IV, oxygen
2. Give antiarrhythmics
3. Expert consult
4. Synchronized cardioversion
5. SAMPLE
257
Protocol for unstable monomorphic vtach with a pulse
1. Monitors, IV, oxygen
2. Synchronized cardioversion
3. SAMPLE
258
Pulseless rhythms
1. Vfib and sometimes vtach
2. Monomorphic vtach sometimes
3. Torsades de Pointes
4. PEA
5. Asystole
259
Type of vfib with higher waves and more chance of conversion
Course vfib
260
Type of vfib with smaller waves, appears after course vfib, less chance of conversion
Fine vfib
261
Treatment for asystole
CPR, epi, treat reversible causes
262
Treatment for PEA
CPR, epi, treat reversible causes
263
Most common potentially reversible causes of PEA
Hypovolemia and hypoxia
264
What rhythms is CPR used for?
- Vfib/pulseless vtach
- Polymorphic vtach
- Asystole
- PEA
265
What rhythms is epi used for?
- Vfib/pulseless vtach
- Polymorphic vtach
- Asystole
- PEA
266
What rhythms is defib used for?
- Vfib/pulseless vtach
| - Polymorphic vtach
267
What rhythms is amiodarone used for?
--Vfib/pulseless vtach
268
What rhythms is magnesium used for?
-Polymorphic vtach
269
What rhythms is lidocaine used for?
-Vfib/pulseless vtach
270
Most common initial rhythm in sudden cardiac arrest
Vfib
271
The only effective treatment for pulseless vfib/vtach
Defibrillation
272
Vfib and pulseless monomorphic vtach protocol
1. Start CPR
2. Defib ASAP
3. Resume CPR
4. Analyze
5. Repeat
273
vfib and pulseless monomorphic vtach protocol throughout CPR
1. Give epi 1mg every 3-5 minutes
2. Consider H&T's of pulseless arrest
3. Consider intubation, capnography and steroids
4. Give amiodarone 300 mg if epi and defib are not effective after 3rd shock attempt
5. Consider hypothermia if pt achieves ROSC
274
Polymorphic vtach protocol
1. Start CPR
2. Defib
3. Resume CPR
4. Analyze rhythm & check pulse
5. Repeat
275
Polymorphic vtach protocol throughout CPR
1. Give epi 1mg every 3-5 minutes
2. Give magnesium 1-2 mg
3. Consider H&T's of pulseless arrest
4. Consider intubation, capnography, and steroids
5. Consider hypothermia if the patient achieves ROSC
276
Asystole protocol
1. CPR
| 2. Epi 1mg every 3-5 minutes
277
Asystole protocol throughout CPR
1. Consider 7 H's and 5 T's of pulseless arrest
2. Consider intubation, capnography, & steroids
3. Consider hypothermia if pt achieves ROSC
278
The only way of identifying a STEMI
EKG
279
Possible therapy for ACS in ACLS
1. Oxygen, ASA, NTG, morphine
2. Heparin
3. Reperfusion therapy
280
When is morphine indicated with ACS?
In STEMI patients who are unresponsive to nitrates
281
When is oxygen therapy needed with ACS?
If the SpO2 < 90%
282
ACLS dose of NTG
3 sublingual NTG tablets (0.4mg) every 3-5 min and may be repeated twice (total of 3 doses)
283
When should NTG be avoided
1. Hypotensive patients (SBP <90mmHg or 30 mmHg below baseline)
2. Patients with inadequate preload (recent MI, vasodilator)
284
ASA dose
160-325 mg PO
285
When should rectal administration be considered for ASA, and what is the dose?
300mg if the pt has N/V, PUD or other upper GI disorders
286
When should PCI be administered?
Within 90 minutes of arrival
287
Treatment of choice in ACS patients
PCI
288
When are fibrinolytics indicated?
For STEMI patients only, within 30 minutes of arrival
289
Contraindications to fibrinolytics
1. If ACS symptoms have been present for >12 hours
2. NSTEMI
3. Hypertension (>180-200 SBP or 100-110mmHg DBP)
4. Recent head trauma or GI bleed
5. Pts on blood thinners
6. Pts with stroke symptoms present >3 hours
290
When should you choose PCI over fibrinolytics?
1. If you are confident that door to balloon time with be <90 minutes
2. Fibrinolytics are contraindicated
3. Symptoms have been present >12 hours
291
When should you choose fibrinolytics over PCI?
If initiation of PCI would take longer than 90-120 minutes
292
When should fibrinolytics be started
Within 30 minutes of hospital arrival
293
STEMI treatment protocol
1. Oxygen, ASA, NTG, morphine
2. Reperfusion with PCI or fibrinolytics
3. Heparin
4. CABG
294
NSTEMI treatment protocol
1. Oxygen, NTG, ASA
2. Reperfusion with PCI
3. Heparin
4. CABG
295
ACS protocol for EMS
1. Monitors, IV, oxygen
2. Immediate ONA (maybe M)
3. If STEMI present, notify hospital
4. Consider prehospital fibrinolytics using checklist
296
ACS protocol for in hospital
1. Monitors, IV, oxygen
2. Immediate MONA
3. 12 lead EKG
4. IV/labs/CXR
5. Obtain quick PMH
6. Determine treatment based on EKG
297
4 D's of delay (3 points)
1. Door to data
2. Data to decision
3. Decision to drug
298
Most common type of stroke
Ischemic stroke
299
Ischemic stroke primary treatment
Fibrinolytics, rTPA
300
Management for hemorrhagic stroke
1. Obtain a STAT neuro consult
| 2. Avoid fibrinolytic therapy
301
Management for subarachnoid stroke
1. Obtain a STAT neuro consult
| 2. Avoid fibrinolytic therapy
302
Cincinnati Prehospital stroke scale
1. Facial droop
2. Arm weakness
3. Abnormal speech
303
Chance of stroke with 1 finding on CPSS
72%
304
Chance of stroke with 3 findings on CPSS
>85%
305
Time frame to perform NIH stroke scale
within 10 minutes of ED arrival after the CPSS
306
True/false. Providers can give ASA after rTPA administration
False, wait at least 24 hours after rTPA administration to give ASA
307
When should fibrinolytics be given after a stroke?
Within 1 hour of hospital arrival or within 3 hours of symptoms onset (or 4.5 hours for <80 years old and NIH score <25)
308
Treatments for ischemic stroke
1. Fibrinolytics
2. ASA if fibrinolytics are contraindicated
3. Endovascular therapy
309
What is endovascular therapy?
1. Intra-arterial rtPA within 6 hours of symptom onset (not approved by FDA)
2. Mechanical clot disruption and retrieval with a stent
used in addition to IV rtPA
310
ACLS stroke protocol for EMS
1. Monitors, IV, oxygen
2. Perform CPSS
3. Establish time of onset
4. Notify hospital and transfer to stroke center
5. Check glucose
311
ACLS protocol for ED in first 10 minutes
1. Monitors, IV, oxygen
2. Perform neurologic screening assessment and activate the stroke team
3. Order an urgent, non contrast CT scan
4. Get IV/labs/tests
312
ACLS protocol for ED within 25 minutes
1. Obtain CT scan
2. Perform NIHSS
3. Obtain PMH
313
ACLS protocol for ED within 45 minutes
Read and interpret CT scan
314
ACLS protocol for ED within 1 hour
-For ischemic stroke: administer fibrinolytics
administer ASA if fibrinolytics are contraindicated
-For hemorrhagic stroke: consult, admit to stroke unit or ICU and begin stroke or hemorrhage pathway
315
ACLS protocol for ED within 3 hours
Begin post rtPA stroke pathway by admitting to the stroke unit or ICU
316
ACLS protocol for ED within 6 hours
Initiate endovascular therapy if applicable
317
Post rtPA stroke pathway
1. Frequently check blood glucose levels
2. Prevent hypertension
3. Order urgent CT scan if neurologic status deteriorates
318
When should blood sugars be treated with insulin after a stroke?
When they are >185 mg/dl
319
ROSC protocol
1. Optimize oxygenation/ventilation
2. Obtain 12 lead EKG
3. Order appropriate labs
4. Consider prophylactic antiarrhythmic therapy
5. Maintain normal BP
6. Does the patient follow commands?
Methods of Anesthesia
flashcards
Decks in class (20)
# Cards
-
Cardiac Surgery Concepts198
-
On Pump vs Off Pump97
-
Anesthesia for Cardiothoracic Procedures115
-
Cardiac Assist Devices37
-
Preexcitation & SVT52
-
Acid/Base190
-
Cardiac Drug Card67
-
Neuraxial Drug Card34
-
ACLS319
-
Pacemakers108
-
Neuraxial Anesthesia252
-
Epidural Placement14
-
Spinal and CSE placement6
-
Maternal & Fetal Physiology56
-
OB142
-
Congenital Heart Disease157
-
PALS375
-
Advanced Fluid Management95
-
Electrolyte Abnormality96
-
Advanced EKG34
