ACLS Prep

What is the algorithm for acute coronary syndrome?
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What is the algorithm for acute coronary syndrome?
A) Immediately - apply oxygen at 4L if O2 is less than 90%. Give Aspirin 160-325 mg if not given by EMS. Nitro then morphine if nitro doesn't work.
B) Assessment within 10 mins - vitals, insert IV, focused physical assessment, review fibrinolytic checklist, get a rainbow set of blood tubes, and a chest xray within a half hour.
C) ECG interpretation
D) STEMI - If onset of symptoms is less than 12 hours get pt to cath lab within 90 mins or fibrinolysis within 30 mins
E) High risk non-STEMI (elevated troponin) - start heparin and nitro
F) Low risk ACS - pt admission for more monitoring
What medications are indicated for ACS patients?
A) Oxygen - if O2 is less than 90% administer @ 4L and titrate up
B) Aspirin - 160-325 mg of non-enteric coated ASA for antiplatelet aggregation if they have no hx of allergy or recent GI bleed. Give 300 mg rectal ASA for pts with n/v, active peptic ulcer disease or upper GI tract disorders
C) Nitro - 1 subligual tab q3-5 mins up to 3 doses, only give if SBP is over 90 and HR is 50-100. Don't use if pt has inferior wall MI and RV infarction, have hypotension, bradycardia, or tachycardia, or recently took viagra.
D) Morphine - give if unresponsive to nitro for chest pain.
How can you tell the difference between a code STEMI, NSTE-ACS, and low/intermediate risk ACS?
A) STEMI - ST elevation in 2 or more leads. J=point greater than 2mm in lead 2 and 3 and 1 mm or more in all other leads. 2.5 mm in men under 40 and 1.5 mm in all women
B) NSTE-ACS - ST depression 0.5 mm or inverted T wave with pain. non-persistent ST elevation of 0.5 mm or more for less than 20 minutes
C) low/intermediate risk ACS - normal or nondiagnostic change in ST segment or T-wave.
What are the critical time periods for stroke patients?
10 minutes - general assessment
25 minutes - neurological assessment and head CT
45 minutes - CT interpretation
60 minutes - administration of fibrinolytic therapy, timed from ED arrival
3 hours - admission to monitored bed
3-4.5 hours - administration of fibrionlytic therapy from last known well time
6 hours - administration of endovascular therapy from last known well time in selected patients.
What is the acute stroke algorithm?
A) within 10 minutes - general assessment, VS, O2 PRN, IV access w/ labs, glucose check, neuro screening, activate stroke alert, order CT, obtain 12 lead ECG
B) within 25 minutes - review pt hx, establish last known well time, perform NIH stroke scale
C) CT shows hemorrhage - consult neurosureon and start hemorrhagic stroke pathway with admit to stoke unit or ICU
D) CT shows ischemia - check for fibrinolytic exclusions, repeat neuro exam. if pt can have TPA give it (no anticoagulants or antiplatelets within past 24 hours) then start post-TPA pathway and aggresssively monitor BP and neuro checks then get to ICU. If pt can't have TPA, give aspirin and get to ICU
What is the cardiac arrest algorithm?
A) Start CPR - give O2 and attach to monitor/defibrillator
B) Shockable rhythm - pt is in vfib/pulseless vtach so shock then start 2 mins of CPR and establish IV access. Assess for shockable rhythm again, if yes give shock and start 2 mins of CPR with 1 mg epinephrine Q3-5 minutes and consider advanced airway with capnography. Assess for shockable rhythm and shock if needed then 2 minutes of CPR. Can give 300 mg amiodarone bolus and second dose 150 mg
C) No Shockable rhythm - pt has asystole or PEA so start CPR for 2 mins, establish IV/IO access, epinephrine Q3-5 mins and consider advanecd airway with capnography. Assess for shockable rhythm, if none then continue CPR for 2 mins. Assess for shockable rhythm again, if no ROSC continue with CPR
What are the antiarrhythmic agents?
A) Amiodarone - vFib or pulseless vtach unresponsive to shock, CPR and a vasopressor. Administer 300 mg bolus then 150 mg in 3-5 minutes if arrhythmia persists
B) Lidocaine - may use when amiodarone is not available. give 1-1.5 mg/kg IV. Repeat at 0.5-0.75 mg/kg over 5-10 minute intervals to a maximum of 3 mg/kg
C) Magnesium sulfate - used for torsades
What is the algorithm for bradycardia?
A) identify and treat underlying cause - patent airway, O2 prn, cardiac monitor with BP and SpO2, IV access and 12 lead ECG
B) Symptomatic bradycardia - give atropine. if atropine doesn't work do transcutaneous pacing or dopamine or epinephrine infusion
C) Asymptomatic bradycardia - monitor
What are the medications for bradycardia?
A) atropine - 0.5 mg bolus and repeat Q3-5 min with a maximum dose of 3mg
B) dopamine infusion - usual infusion rate is 2-20 mcg/kg per minute and then titrate to pt response and taper slowly.
C) epinephrine infusion - 2-10 mcg per minute infusion and titrate to pt response.
What is the algorithm for tachycardia?
A) identify and treat underlying cause - maintain airway, O2 prn, cardiac monitor with BP and SpO2
B) Symptomatic tachycardia - do synchronized cardioversion; consider sedation for this and if there are regular but narrow complexes, consider adenosine to identify underlying rhythm.
C) Asymptomatic tachycardia if there is not a wide QRS complex - then establish IV, have pt do a vagal maneuver, administer adenosine if rhythm is regular, administer a beta blocker or calcium channel blocker and consider expert consultation. D) Asymptomatic tachycardia with a wide QRS complex - establish IV access and get 12 lead ECG, consider adenosine only if regular and monomorphic, and consider antiarrhythmic infusion and seek expert consultation.
What is the post-cardiac arrest care algorithm?1) return of spontaneous circulation (ROSC) is established 2) optimize ventilation - maintain O2 > 94%, consider advanced airway and capnography 3) treat hypotension - IV bolus, vasopressor infusion and treat reversible causes 4) 12-lead ECGWhat medications are used to treat hypotension?A) IV bolus - NS or LR B) Norepinephrine - 0.1-0.5 mcg/kg per minute, titrated to achieve a minimum CBP of more than 90 SBP or a MAP of more than 65 C) Epinehrine - 0.1-0.5 mcg/kg per minute titrated to achieve a minimum CBP of more than 90 SBP or a MAP of more than 65 D) Dopamine - 5-10 mcg/kg per minute titrated to achieve a minimum CBP of more than 90 SBP or a MAP of more than 65