ACLS

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7891

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Medicine

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Feb 20, 2024

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 To minimize interruptions in chest compressions during CPR (continue CPR while the defibrillator is charging)  Indication to stop or withhold CPR efforts (safety threat to providers)  Unresponsiveness, abnormal breathing, emergency response team activated, what next. (check for pulse)  Cricoid pressure to prevent aspirations during cardiac arrest (not recommended for routine use)  Survival advantage of CPR to prevent VFIB. (produces a small amount of blood flow to the heart)  Compression rate (at least 100 per min 100- 120)  Remains in VFIB after 1 shock & 2 minutes of CPR. What next. (second shock)  Next step after defibrillation. (BEGIN CPR W/CHEST COMPRESSIONS)  1 st choice for IV access during CPR in cardiac patients (ANTECUBITAL VEIN)  Recommended 1 st IV dose of amiodarone for patient in refractory VFIB (300MG)  Drug administration during CPR is given (rapidly during compressions)  Sign of ineffective CPR (PETCO2 10MM HG)  Pulse check during BLS survey should take (5 TO 10 SEC)  Agonal breaths in unresponsive patient. (CHECK PULSE)  Treatment for asystole (EPINEPHRINE 1MG)  Pulseless V-TACH, defibrillated, what next. (CHEST COMPRESSIONS AT RATE OF 100/MIN)  Completed 1 st two min CPR & you see a non- shockable rhythm on ECG. (HAVE TEAM MEMBER CHECK PULSE)

 If you can’t get IV access (USE THE IO ROUTE)  Patient is coming to ER with possible stroke, but CT is broken (DIVERT PATIENT TO ANOTHER HOSPITAL 15MIN AWAY W/CT MACHINE READY)  SOB, CHEST PAIN, WEAKNESS, BP 102/59, HR 230/MIN & RR 16/BPM. (VAGAL MANEUVERS)  ST ELEVATION in anterior leads. First responders gave 160mg of aspirin, but still in pain after 3 doses of NITRO. (2- 4MG MORPHINE BY SLOW IV BOLUS)  Oral dose of aspirin for chest pain from ACS (160- 325mg)  SOB, BP 68/50, & HR 190/BPM, HISTORY OF CHF. (unstable SVT)  V- TACH SYNCHRONIZED CARDIOVERSION  RECOMMENDED VENTILATION RATE IN RR ARREST (10-12)  Respiratory distress with BP of 70/50 & ECG showing V-FIB/ V-TACH SYNCHRONIZED CARDIOVERSION  Pulseless V-FIB defibrillation  SYNCHRONIZED CARDIOVERSION rate 120-200 J  Sizing the OPA oropharyngeal airway (MEASURE FROM CORNER OF MOUTH TO ANGLE OF MANDIBLE)  Contraindicated for NITROGLYCERIN when treating ACS (RIGHT VENTRICULAR INFARCTION DYSFUNCTION)  Initial intervention for hypotension immediately after return of ROSC (IV or IO FLUID BOLUS)  What do ASAP after return of ROSC when not in hospital (TRANSFER PT TO FACILTY FOR PCI)  Danger of excessive ventilation during post-cardiac arrest & ROSC (DECREASED CEREBRAL BLOOD FLOW)  Target temp range for hypothermia after cardiac arrect (32- 34 Celsius)  Time of therapeutic hypothermia after reaching target temp (12-24 hours)

 Danger of giving high oxygen during post-cardiac arrest for pt with ROSC (potential oxygen toxicity)  Recommended dose of epinephrine when treating hypotension in post-cardiac arrest (0.1 – 0.5mcg/kg per min IV)  You find an unresponsive patient who is not breathing. After activating the emergency response system, you determine that there is no pulse. What is your next action? Start chest compressions at a rate of at least 100/min.  58-year-old man with chest pain. The blood pressure is 92/50 mm Hg, the heart rate is 92/min, the nonlabored respiratory rate is 14 breaths/min, and the pulse oximetry reading is 97%. What assessment step is most important now? 12 lead ECG  preferred method of access for epinephrine administration during cardiac arrest in most patients? Peripheral intravenous  An activated AED does not promptly analyze the rhythm. What is your next action? Begin chest compressions.  You have completed 2 minutes of CPR. The ECG monitor displays the lead II rhythm below, and the patient has no pulse. Another member of your team resumes chest compressions, and an IV is in place. What management step is your next priority? Administer 1 mg of epinephrine.

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 During a pause in CPR, you see this lead II ECG rhythm on the monitor. The patient has no pulse. What is the next action? Continue chest compressions.  What is a common but sometimes fatal mistake in cardiac arrest management? Prolonged interruptions in chest compressions  Which action is a component of high-quality chest compressions? 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 pulseless electrical activity? Sinus rhythm without a pulse  What is the BEST strategy for performing high- quality CPR on a patient with an advanced airway in place? Provide continuous chest compressions without pauses and 10 ventilations per minute.  Three minutes after witnessing a cardiac arrest, one member of your team inserts an endotracheal tube while another performs continuous chest compressions. During subsequent ventilation, you notice the presence of a waveform on the capnography screen and a PETCO2 level of 8 mm Hg. What is the significance of this finding? Chest compressions may not be effective.

 The use of quantitative capnography in intubated patients? allows for monitoring of CPR quality.  For the past 25 minutes, an EMS crew has attempted resuscitation of a patient who originally presented in ventricular fibrillation. After the first shock, the ECG screen displayed asystole, which has persisted despite 2 doses of epinephrine, a fluid bolus, and high-quality CPR. Consider terminating resuscitative efforts after consulting medical control.  Which is a safe and effective practice within the defibrillation sequence? Be sure oxygen is not blowing over the patient’s chest during the shock.  During your assessment, your patient suddenly loses consciousness. After calling for help and determining that the patient is not breathing, you are unsure whether the patient has a pulse. What is your next action? Begin chest compressions.  What is an advantage of using hands-free defibrillation pads instead of defibrillation paddles? Hands-free pads allow for a more rapid defibrillation.  What action is recommended to help minimize interruptions in chest compressions during CPR? Continue CPR while charging the defibrillator.  Which action is included in the BLS Survey? Early defibrillation  Which drug and dose are recommended for the management of a patient in refractory ventricular fibrillation? Amiodarone 300 mg  What is the appropriate interval for an interruption in chest compressions? 10 sec or less

 Which of the following is a sign of effective CPR? PETCO2 ≥ 10 mm Hg  What is the primary purpose of a medical emergency team (MET) or rapid response team (RRT)? Identifying and treating early clinical deterioration  Which action improves the quality of chest compressions delivered during a resuscitation attempt? Switch providers about every 2 minutes or every 5 compression cycles.  What is the appropriate ventilation strategy for an adult in respiratory arrest with a pulse rate of 80/min? 1 breath every 5 to 6 seconds  A patient presents to the emergency department with new onset of dizziness and fatigue. On examination, the patient’s heartrate is 35/min, the blood pressure is 70/50 mm Hg, the respiratory rate is 22 breaths/min, and the oxygen saturation is 95%. What is the appropriate first medication? Atropine 0.5 mg  A patient presents to the emergency department with dizziness and shortness of breath with a sinus bradycardia of 40/min. The initial atropine dose was ineffective, and your monitor/defibrillator is not equipped with a transcutaneous pacemaker. What is the appropriate dose of dopamine for this patient? 2 to 10 mcg/kg per minute  A patient has sudden onset of dizziness. The patient’s heart rate is 180/min, blood pressure is 110/70 mm Hg, respiratory rate is 18 breaths/min, and pulse oximetry reading is 98% on room air. The

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lead II ECG is shown below: What is the next appropriate intervention? Vagal maneuvers  A monitored patient in the ICU developed a sudden onset of narrow-complex tachycardia at a rate of 220/min. The patient’s blood pressure is 128/58 mm Hg, the PETCO2 is 38 mm Hg, and the pulse oximetry reading is 98%. There is vascular access at the left internal jugular vein, and the patient has not been given any vasoactive drugs. A 12-lead ECG confirms a supraventricular tachycardia with no evidence of ischemia or infarction. The heart rate has not responded to vagal maneuvers. What is the next recommended intervention? Adenosine 6 mg IV push  You are receiving a radio report from an EMS team in route with a patient who may be having an acute stroke. The hospital CT scanner is not working currently. What should you do in this situation? Divert the patient to a hospital 15 minutes away with CT capabilities.  Choose an appropriate indication to stop or withhold resuscitative efforts. Evidence of rigor mortis  A 49-year-old woman arrives in the emergency department with persistent epigastric pain. She had been taking oral antacids for the past 6 hours because she thought she had heartburn. The initial blood pressure is 118/72 mm Hg, the heart rate is 92/min and regular, the nonlabored respiratory rate is 14 breaths/min, and the pulse oximetry reading is

96%. Which is the most appropriate intervention to perform next? 12-lead ECG.  A patient in respiratory failure becomes apneic but continues to have a strong pulse. The heart rate is dropping rapidly and now shows a sinus bradycardia at a rate of 30/min. What intervention has the highest priority? Simple airway maneuvers and assisted ventilation  What is the appropriate procedure for endotracheal tube suctioning after the appropriate catheter is selected? Suction during withdrawal but for no longer than 10 seconds.  While treating a patient with dizziness, a blood pressure of 68/30 mm Hg, and cool, clammy skin, you see this lead II ECG rhythm: What is the most appropriate first intervention? Atropine  A 68-year-old woman experienced a sudden onset of right arm weakness. EMS personnel measure a blood pressure of 140/90mm Hg, a heart rate of 78/min, a nonlabored respiratory rate of 14 breaths/min, and a pulse oximetry reading of 97%. The lead II ECG displays sinus rhythm. What is the most appropriate action for the EMS team to perform next? Cincinnati Prehospital Stroke Scale assessment  EMS is transporting a patient with a positive prehospital stroke assessment. Upon arrival in the emergency department, the initial blood pressure is 138/78 mm Hg, the pulse rate is 80/min, the respiratory rate is 12 breaths/min, and the pulse

oximetry reading is 95% on room air. The lead II ECG displays sinus rhythm. The blood glucose level is within normal limits. What intervention should you perform next? Head CT scan  What is the proper ventilation rate for a patient in cardiac arrest who has an advanced airway in place? 8 to 10 breaths per minute  A 62-year-old man in the emergency department says that his heart is beating fast. He says he has no chest pain or shortness of breath. The blood pressure is 142/98 mm Hg, the pulse is 200/min, the respiratory rate is 14 breaths/min, and pulse oximetry is 95% on room air. What intervention should you perform next? 12-lead ECG.  You are evaluating a 48-year-old man with crushing substernal chest pain. The patient is pale, diaphoretic, cool to the touch, and slow to respond to your questions. The blood pressure is 58/32 mm Hg, the heart rate is 190/min, the respiratory rate is 18 breaths/min, and the pulse oximeter is unable to obtain a reading because there is no radial pulse. The lead II ECG displays a regular wide-complex tachycardia. What intervention should you perform next? Synchronized cardioversion.  What is the initial priority for an unconscious patient with any tachycardia on the monitor? Determine whether pulses are present.  Which rhythm requires synchronized cardioversion ? Unstable supraventricular tachycardia

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 What is the recommended 2 ND dose of adenosine for patients in refractory but stable narrow-complex tachycardia? 12mg  What is the usual post–cardiac arrest target range for PETCO2 when ventilating a patient who achieves return of spontaneous circulation (ROSC)? 35 to 40 mm Hg  Which condition is a hypothermia during the post–cardiac arrest period for patients who achieve return of spontaneous circulation ROSC? Responding to verbal commands  What is the potential danger of using ties that pass circumferentially around the patient’s neck when securing an advanced airway? Obstruction of venous return from the brain  What is the most reliable method of confirming and monitoring correct placement of an endotracheal tube? Continuous waveform capnography  What is the recommended IV fluid (normal saline or Ringer’s lactate) bolus dose for a patient who achieves ROSC but is hypotensive during the post– cardiac arrest period? 1 to 2 L  What is the minimum systolic blood pressure one should attempt to achieve with fluid, inotropic, or vasopressor administration in a hypotensive post– cardiac arrest patient who achieves ROSC? 90mmHg  What is the first treatment priority for a patient who achieves ROSC? Optimizing ventilation and oxygenation  Excessive ventilation causes gastric inflation, increases intrathoracic pressure, decreases venous return to

the heart, lowers cardiac output, & lowers chance of survival  BLS assessment includes checking responsiveness shout for a nearby help, activate the emergency response system, and get an AED. Check breathing and pulses and use a defibrillator.  primary assessment includes airway breathing circulation disability and exposure alert voice painful unresponsiveness.  secondary assessment includes signs and symptoms allergies medications past medical history last meal events leading to problem.  H’s & T's: H ypovolemia, H ypoxia, H ydrogen ion (acidosis), H yperkalemia, H ypokalemia, H ypothermia, T ension pneumothorax, T oxins, T amponade cardiac, T hrombosis pulmonary, T hrombosis coronary.  H’S & T’S is Mainly used to recall the major reasons for pulselessness arrest including PEA, Asystole, Ventricular Fibrillation, & Ventricular Tachycardia. Most associated with PEA.  Hypovolemia or the loss of fluid volume in the circulatory system is a major contributing cause of cardiac arrest. Look out for blood loss with pulseless arrest. After CPR IV fluid bolus is the treatment  Hypoxia is inadequate oxygen supply. Keep the patient’s airway open check for chest rise and fall and bilateral breath sounds with ventilation.  Prevent respiratory Acidosis by ventilation & prevent metabolic acidosis by giving sodium bicarbonate .

 Hyperkalemia , Major sign is tall peaked T waves, widening QRS wave . Treat with sodium bicarbonate IV, glucose/ insulin calcium chloride IV, Kayexalate, dialysis or albuterol which will help reduce the potassium level.  Hypokalemia flattened T waves, prominent U waves & possible widening QRS complex. Treated with rapid but controlled IV potassium. NEVER give UNDILUTED IV potassium.  Hypothermia from being cold treat with warming measures ASAP. This patient may be unresponsive to drug therapy, defibrillation or pacing so keep their core temperature above 30C.  Cardiac Tamponade is an emergency where fluid accumulates in the pericardium (sack around the heart) resulting in ineffective pumping of blood leading to cardiac arrest. Narrow QRS complex and rapid heart rate with JVD, NO pulse, or difficult feeling of pulse, muffled heart sounds and fluid in the pericardium. Treated by pericardiocentesis.  Tension pneumothorax is air into the pleural space preventing from escaping. Leading to cardiovascular collapse and death. Narrow QRS complexes and rapid heart rate JVD, tracheal deviation unequal breath sounds, NO pulse felt with CPR. Treat with needle decompression  Coronary thrombosis is the blockage of blood flow within the coronary artery caused by clotted blood in the vessel. Causing acute myocardial infarction leading to sudden death . ECG will show PEA, St. segment changes, T wave inversions or Q waves inversions, & elevated cardiac markers. Treat with

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fibrinolytic therapy or PCI with or without stent placement.  Ventricular fibrillation with pulse: begins CPR & defibrillate ASAP 120 to 200 jolts every two minutes. If you suspect opioid OD give naloxone 0.4 to 2.0 milligram IV or IM.  Pulseless ventricular tachycardia EPI 1mh IV push every 3 to 5 minutes. Amiodarone 300mg IV 1st dose then, 150mg for 2 nd dose or Lidocaine 1 to 1.5mg/kg IV push.  Possible heart attack outside of the hospital have them chew 160 to 325mg of aspirin while waiting for ambulance and provide oxygen if below 90% saturation get the patients history to make sure they don't have any contraindications for nitroglycerin like severe bradycardia, tachycardia, hypotension, or any erectile dysfunction medication.  Right ventricular infarction is often on the inferior wall with STEMI’s confirm its right sided with a 12 lead ECG if it is a right side then nitrates are not allowed . Treatments include LMWH, IV nitroglycerin beta blockers.  if patient is suspected of a stroke make sure you rule out hypoglycemia or a seizure and remember the 8D's detection, dispatch, delivery, door, data, decision, drug/device, disposition. Once at the hospital check blood sugar, electrolytes, CBC, get coagulation studies.  History for brain hemorrhage, prior stroke, abnormal blood vessels in brain, recent bleeding, history of

clotting problems, or any recent surgeries or accidents cannot get TPA therapy .  CPR steps : give oxygen, attach defibrillator, check rhythm, IV access, epinephrine every 3 to 5 minutes Amiodarone or Lidocaine for vfib or pulseless vtach, treat reversible causes, continue compressions, and monitor CPR quality.  Return of spontaneous circulation (ROSC) restart of a sustained heart rhythm that permeates the body after a cardiac arrest. Manage airway with endotracheal tube placement, maintain hemodynamic BP, 12 lead ECG, make sure patient can still follow commands. If they CAN and they're AWAKE continue to manage and observe them . If they CANNOT follow commands and they're COMATOSE get a brain CT, ECG, & TTM , then evaluate and treat rapidly. You can also give an IV bolus NS or LR 1-2 liters and IV Epinephrine 2-10mcg/min , Dopamine 5-20mcg/kg/min , or norepinephrine 0.1-0.5mcg/kg/min.  High performance teams include Timing (Early CPR and Defibrillation, CCF greater than 80%) Quality (rate, depth, & recoil) Coordination (team members working together and proficient with roles), Administration (leadership, assigned number of members working an arrest)

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