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Terms in this set (128)
• What rhythm most commonly follows a cardiac arrest in adults?
o VF (V-FIB)
• Because pulseless VT (V-Tach) often rapidly deteriorates to VF (V-Fib) Adult patients with ROSC (return of spontaneous circulation), therapeutic hypothermia is recommended. What is the goal body temp and length of time of the cooling?
o 32-34 C (89.6-93.2F)
o for 12 to 24 hrs
IF during CPR (cardiopulmonary resusciation), the waveform capnography is < 10 mmHg. What would you consider?
o The quality of CPR in inadequate; attempt to improve it
• If PETCO2 abruptly increases to a normal value of 35-40 mmHg, what would you consider?
ROSC: (return of spontaneous circulation)
• Synchronized cardioversion is the treatment of choice for what condition?
o unstable SVT
o unstable AFIB
o unstable A-Flutter
o unstable regular monomorphic tachycardia w/ a pulse
• While performing synchronized cardioversion, your pt suddenly develops V-FIB, what do you do??
o Immediately attempt to defibrillate the patient.
o Most defibs will revert back to unsynchronized mode after a synchronized cardioversion due to this
What four initial drugs should be considered for suspected MI?
1. Morphine Sulfate
4. ASA (asprin)
How long should you check for a pulse?
o 5 seconds but no longer than 10 seconds
• If chest compressions must be interrupted, how long is the recommended limit?
o 10 seconds or less
• What is the first step in any emergency before ABCD's?
o ABCD'S is the ACLS survey....
o BLS survey comes first
For a patient in respiratory arrest with a pulse, how often do you give a breath?
o ventilation every 5-6 seconds (10-12 bpm)
• For a patient in respiratory arrest with a pulse, how often do you recheck the pulse?
o every 2 minutes
What harm can be caused by hyperventilation?
o increase of intrathoracic pressure→decrease venous return to the heart→ dec cardiac output
o Can also cause gastric inflation and pre-dispose pt to vomiting and aspiration of gastric contents.
With a suspected neck injury, how would you open the airway?
o Jaw thrust WITHOUT head extension
• If the jaw thrust in a suspected neck injury pt was not effective, how would you open the airway with a suspected neck injury?
o head tilt chin lift as ventilation is priority
Why is an OPA (oropharyngeal airway) NOT used on a conscious victim?
o Conscious victims have a cough an gag reflex - OPA can stimulate vomiting and laryngospasm.
How do you measure for proper sizing of the OPA (oropharyngeal airway)?
o Place on side of face, when tip of OPA is at the corner of the mouth, the flange is at the angle of the mandible.
Properly sized OPA results in proper alignment with the glottic opening.
What could happen if the OPA (oropharyngeal airway) is too large?
o May obstruct the larynx or could cause trauma to the laryngeal structures.
• What could happen if the OPA (oropharyngeal airway) is too small or incorrectly placed?
o It could push the base of the tongue posteriorly and obstruct the airway.
• When would you use an NPA (nasopharyngeal airway)?
o It can be used in consciouse or semi-conscious patients. Or used when OPA is technically difficult or dangerous as with pt with gag reflex, trismus, massive trauma around mouth, or wiring of the jaw.
• How do you correctly size the NPA (nasopharyngeal airway)?
o Outer circumference of the NPA should compare with the INNER aperture of the nares.
o Length of the NPA should be the same as the distance from the tip of the nose to the earlobe.
What do you check immediately after insertion of an OPA or NPA?
o Check spontaneous respirations....if respirations are absent or inadequate, start positive pressure ventilations at once with an appropriate device.
o If not available use mouth to mouth w/barrier device for ventilation.
If routine use of circoid pressure indicated?
Coricoid in non arrest patient offer protection to airway from aspiration and gastric insulation. BUT, may impede with ventilation and interfere with placement of supraglottic airway or intubation.
How often are breaths given when an advanced airway is in place?
o 1 breath every 6-8 seconds (8-10 bpm) without regard to compressions.
o If NO compressions, 1 breath every 5-6 seconds (10-12 bpm)
• When suctioning with ETT (endotracheal tube), how long would you apply suction?
o no longer than 10 seconds
• If you were not sure if the patient has a pulse, would you begin compressions?
How does defibrillation affect the viable heart in V-tach or V-Fib?
o Stuns and briefly terminates all electrical activity including VT and VF, when viable, the hearts normal pacemakers may eventually resume electrical activity.
• Prior to shocking, is it important to be sure oxygen is NOT flowing across the victim's chest?
o YES!! COULD CAUSE EXPLOSION
Waveform capnography monitor ETT placement but can it also monitor CPR quality?
o YES, PETCO<10 mmHg suggests poor quality of CPR,
o If arterial relaxation is <20 mmHg attempt to improve chest compressions,
o If ScvO2 is <30% try to improve
Why is CPR needed immediately following defibrillation?
o Immediately after successful defib, any spontaneous rhythm is typically slow and does not create pulses or adequate perfusion.
• What should you do if the AED does not function properly?
o NEVER delay chest compressions to troubleshoot AED
o Resume compressions and ventilations
o Check all connections between the AED and the patient.
What would you do when applying the AED pads on a hairy chest?
o Press down firmly on the pads;
o If the AED continues to prompt you to check pads/electrodes quickly pull off the pads as this will remove much of the hair.
o If still too much hair, shave with razor in the AED carrying case if available and put new set of AED pads on pt.
What would you do if your victum is in water and you needed to defibrillate him?
o DO NOT USE IN WATER - pull pt out of water
o If water on patient's chest, wipe off
o Lying on snow or ice or in a small puddle - ok to use AED
• What would you do if your victim needed a shock but was lying in the snow?
o USE THE AED
• Could you utilize an AED if the victim has an implanted defib/pacemaker?
o YES - place the pads on either side of device (not directly on top) & follow normal steps.
o Occasionally the analysis & shock cycles of implanted defib & AEDs will conflict- if you notice pt's muscles contracting like with shock AED/defib shocking, wait 30-60 sec for internal defib to finish cycle before delivering shock via AED
Is it acceptable to place pads over medication patches?
o NO - may block transfer of energy or cause burns on skin
o Remove medication patches and wipe skin.
• What is done IMMEDIATELY post-shock?
o Restart of compressions
How long should compressions be held for rhythm checks?
o Less than 10 seconds.
• What vasopressor and dose will you give your patient in VF?
o Epinephrine 1 mg q 3-5 min OR
o Vasopressor 40 units
If IV access is not available what is the next best-preferred route for medication adminstration?
o IO (intraosseous or directly into the bone marrow)
At what SBP would you consider treatment for hypotension?
o <90 SBP
What is recommended IV fluid bolus and amount to treat hypotension?
o 1-2 L NS or LR
What is the second does of amiodarone in VF?
o 150 mg (first is 300mg)
During a code, are drug administrations and advances airway a primary importance?
o NO - compressions are priority!
What is the energy level for biphasic cardioversion of unstable A-FIB?
What is the energy level for biphasic cardioversion of unstable monorphic VT?
Supraventricular tachy cadrioverson(narrow regular)
Wide complex tachy=cardioversion
Irregular narrow complex tachy that is unstable
What is the energy level for biphasic cardioversion of unstable SVT or A-flutter
What is the energy level for biphasic cardioversion of unstable polymorphic VT (irregular form and rate)?
Treat as VF with high-energy shock
• Why is the IO route considered over the ETT route for medication administration?
o Increased absorption via IO route - higher doses of medications and unknown absorption rates via ETT
Can IO access be established in the elderly?
o YES - all age groups
• What drugs can be administered via the IO route?
o ANY ACLS drug or fluid that is administered IV can be done via IO
• When would you NOT consider therapeutic hypothermia after ROSC (return of spontaneous circulation)?
o WhEn pt is following compands
If necessary, what drugs can be given via the ETT route?
...o Lidocaine, epinephrine, vasopressin...ett=elv
• How would you administer drugs via the ETT route?
o Dilute the dose in 5-10 mls sterile water or NS and inject the drug directly into the trachea
o Dose is 2 - 2 1/2 x the IV dose
• What is the definistion of PEA? (pulseless electrical activity)
o Any organized rhythm without a pulse
For PEA (pulseless electrical activity), what dose would you give?
o Epinephrine 1mg q3-5 min or vasopressin 40 units
• What is the maximum total dose of atropine?
o 0.04 mg/kg or 3 mg total=bradycardia
• What would be two acceptable reasons to stop or withold CPR?
o pulse / rhythm check and to defib
After giving a drug, how long do you provide CPR?
o 2 minutes
What are the 6 H's?
o hydrogen ion (acidosis),
• What are the 5 T's?
o tension pneumothorax,
o thrombosis (cardiac or pulmonary)
Would you give NTG to a patient with an inferior wall MI or with right ventricular infarction?
o NO - due to dependence on RV filling to maintain CO and BP
o Other vasodilators (morphine) or volume-depleting drugs drugs (morphine) are contraindicated as well
• Is asystole truly a "rhythm"?
• Symptomatic bradycardia exists when what criteria are present?
o AMS change,
o signs of shock,
o ischemic chest discomfort,
o acute heart failure.
• What is the key critical concept to consider in treating bradycardia?
o Determination of adequate perfusion
If atropine is ineffective for symptomatic bradycardia, what will you do next?
o Transcutaneous pacing,
o Dopamine or epinephrine infusion.
• Is pacing recommended for asystole?
How would you treat stable regular tachycardia with wide complexes?
o Adenosine - if regular or monomorphic
o anti-arrhythmic infusion
o expert consultation
• How would you treat stable narrow QRS complex trachycardia,?
o IV access w/ 12 lead EKG,
o vagal maneuvers,
o BB or CCB,
o adnosine (if regular),
o expert consultation
What are the key questions to ask when evaluating a patient with tachycardia?
o Unstable with s/sx a result of tachycardia -
• Hypotension ,
• Signs of shock,
• Ischemic chest discomfort,
• Why is it important to synchronize cardioversion?
o Sync with the rhythm to defib in the peak of the R wave instead of shocking during the repolarization period which can percipitate VF
• Why is a CT scan critical to determine treatment for a stroke?
o To determine hemorrhagic VS ischemic stroke
Why is it best to call EMS vs driving someone to the ER?
o Delays access to treament and diagnosis
• What is the correct order for AED use?
o Power on AED
o Attach electrode pads
o Analyze rhythm
• if AED advises shock, be sure to clear the patient
• How many times will you shock a patient VF?
o Until perusing rhythm, ROSC, or deteriorates to asystole (unless hypothermia or drug overdose)
You find an unresponsive pt. who is not breathing. After activating the emergency response system, you determine there is no pulse. What is your next action?
o Start chest compressions of at least 100 per min.
You are evaluating a 58 year old man with chest pain. The BP is 92/50 and a heart rate of 92/min, non-labored respiratory rate is 14 breaths/min and the pulse O2 is 97%. What assessment step is most important now?
o Obtaining a 12 lead ECG.
• What is the preferred method of access for epi administration during cardiac arrest in most pts?
o Peripheral IV
• An AED does not promptly analyze a rythm. What is your next step?
o Begin chest compressions.
You have completed 2 min of CPR. The ECG monitor displays the lead below (PEA) and the pt. has no pulse. You partner resumes chest compressions and an IV is in place. What management step is your next priority?
o Administer 1mg of epinepherine
• During a pause in CPR, you see a narrow complex rythm on the monitor. The pt. has no pulse. What is the next action?
o Resume compressions
What is a common but sometimes fatal mistake in cardiac arrest management?
o Prolonged interruptions in chest compressions.
• Which action is a component of high-quality chest comressions?
Allowing complete chest recoil
Which action increases the chance of successful conversion of ventricular fibrillation?
Providing quality compressions immediately before a defibrillation attempt.
Which situation BEST describes PEA?
o Sinus rhythm without a pulse
• What is the best strategy for performing high-quality CPR on a pt.with an advanced airway in place?
o Provide continuous chest compressionswithout pauses and 10 ventilations per minute.
• 3 min after witnessing a cardiac arrest, one member of your team inserts an ET tube while another performs continuous chest compressions. During subsequent ventilation, you notice the presence of a waveform on the capnography screen and a PETCO2 of 8 mm Hg. What is the significance of this finding?
o Chest compressions may not be effective.
The use of quantitative capnography in intubated pt's does what?
o Allows for monitoring CPR quality
For the past 25 min, EMS crews have attempted resuscitation of a pt who originally presented with V-FIB. After the 1st shock, the ECG screen displayed asystole which has persisted despite 2 doses of epi, a fluid bolus, and high quality CPR. What is your next treatment?
o Consider terminating resuscitative efforts after consulting medical control.
Which is a safe and effective practice within the defibrillation sequence?
o Be sure O2 is NOT blowing over the pt's chest during shock.
During your assessment, your pt suddenly loses consciousness. After calling for help and determining that the pt. is not breathing, you are unsure whether the pt. has a pulse. What is your next action?
o Begin chest compressions.
• What is an advantage of using hands-free d-fib pads instead of d-fib paddles?
o Hands-free allows for more rapid d-fib.
What action is recommended to help minimize interruptions in chest compressions during CPR
o Continue CPR while charging the defibrillator.
Which action is included in the BLS survey?
o Early defibrillation
Which drug and dose are recommended for the management of a pt. in refractory V-FIB?
o Amioderone 300mg
• What is the appropriate interval for an interruption in chest compressions?
o 10 seconds or less
Which of the following is a sign of effective CPR?
o PETCO2 = or > 10mm Hg
• What is the primary purpose of a medical emergency team or rapid response team?
o Identifying and treating early clinical deterioration.
Which action improves the quality of chest compressions delivered during resuscitave attemepts?
o Switch providers about every 2 min or every 5 compression cycles.
• What is the appropriate ventilation strategy for an adult in respiratory arrest with a pulse of 80 beats/min?
o 1 breath every 5-6 seconds
• A pt. presents to the ER with a new onset of dizziness and fatugue. Onexamination, the pt's heart rate is 35 beats/min, BP is 70/50, resp. rate is 22 per min, O2 sat is 95%. What is the appropriate 1st medication?
o Atropine 0.5mg
• A pt. presents to the ER with dizziness and SOB with a sinus brady of 40/min. The initial atropine dose was ineffective and your monitor does not provide TCP. What is the appropriate dose of Dopamine for this pt?
• A pt. has an onset of dizziness. The pt.s heart rate is 180, BP is 110/70, resp. rate is 18, O2 sat is 98%. This is a reg narrow complex tach rhythm. What is the next intervention?
o Vagal maneuver.
• A monitored pt. in the ICU developed a sudden onset of narrow complex tach at a rate of 220/min. The pt's BP is 128/58, the PETCO2 is 38mm Hg, and the O2 sat is 98%. There is an EJ established for vascular access. The pt. denies taking any vasodilators. A 12 lead shows no ischemia or infarction. Vagal maneuvers are ineffective. What is the next intervention?
o Adenosine 12mg IV
You receiving a radio report from an EMS team enroute with a pt. who may be having a stroke. The hospital CT scanner is broken. What should you do?
Divert the pt. to a hospital 15 min away with CT capabilities.
• Choose an appropriate indication to stop or withhold resuscitative efforts.
Evidence of rigor mortis.
• A 49 y/of male arrives in the ER with persistent epigastric pain. She has been taking antacids PO for the past 6 hours because she had heartburn. BP is 118/72, heart rate is 92/min, resp. rate is 14 non-labored and O2 sat is 96%. What is the most appropriate next action?
o Obtain a 12 lead ECG.
• A pt. in respiratory failure becomes apneic but continues to have a strong pulse. The heart rate is dropping rapidly and now shows a sinus brady rate at 30/min. What intervention has the highest priority?
o Simple airway maneuvers and assisted ventilations.
What is the appropriate procedure for ET suctioning after the catheter is selected?
o Suction during withdrawal, but not for longer than 10 seconds.
While treating a stable pt for dizziness, a BP of 68/30, cool and clammy, you see a brady rhythm on the ECG. How do you treat this?
o Atropine 0.5mg
A 68 y/o female pt. experienced a sudden onset of right arm weakness. BP is 140/90, pulse is 78/min, resp rate is non-labored 14/min, 02 sat is 97%. Lead 2 in the ECG shows a sinus rhythm. What would be your next action?
o Cinncinati Stroke Scale
• You are transporting a pt. with a positive stroke assessment. BP is 138, pulse is 80/min, resp rate is 12/min, 02 sat is 95% room air. Glucose levels are normal and the ECG shows a sinus rhythm. What is next.
o Head CT scan
• What is the proper ventilation rate for a pt. in cardiac arrest who has an advanced airway in place?
8-10 breaths per minute
• A 62 y/o male pt. in the ER says his heart is beating fast. No chest pain or SOB. BP is 142/98, pulse rate is 200/min, reps rate is 14/min, O2 sats are 95 at room air. What should be the next evaluation?
Obtain a 12 lead ECG
• You are evaluating a 48 y/o male with crushing sub-sternal pain. He is cool, pale, diaphoretic, and slow to respond to your questions. BP is 58/32, pulse is 190/min, resp rate is 18, and you are unable to obtain an 02 sat due to no radial pulse. The ECG shows a wide complex tach rhythm. What intervention should be next?
o Synchronized cardioversion.
• What is the initial priority for an unconscious pt. with any tachycardia on the monitor?
o Determine if a pulse is present.
Which rhythm requires synchronized cardioversion?
o Unstable SVT
What is the recommended dose for adenosine for pt's in refractory, but stable narrow complex tachycardia?
What is the usual post-cardiac arrest target range for PETCO2 who achieves return of spontaneous circulation (ROSC)?
o 35-40mm Hg
• Which condition is a contraindication to therapeutic hypothermia during the post-cardiac arrest period for pt's who achieve return of spontaneous circulation (ROSC)?
o Responding to verbal commands
What is the potential danger to using ties that pass circumferentially around the pt's neck when securing an advanced airway?
o Obstruction of venous return from the brain
• What is the most reliable method of confirming and monitoring correct placement of an ET tube?
o Continuous waveform capnography
• What is the recommended IV fluid (NS or LR) bolus dose for a pt. who achieves ROSC but is hypotensive during the post-cardiac arrest period?
o 1 to 2 Liters
What is the minimum systolic BP one should attempt to achieve with fluid, Inotropic, or vasopressor administration in a hypotensive post-cardiac arrest who achieves ROSC?
o 90mm Hg
What is the 1st treatment priority for a pt. who achieves ROSC?
o Optimizing ventilation and oxygenation.
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