ACLS

To estimate atrial rate, count number of P waves over 6s period & multiply by ________.

10

ECG should be obtained & interpreted w/in how many mins of pt arrival if suspected of ACS

10 minutes

IV nitro for pulm edema or HTN should be titrated to maintain SBP ___% < baseline if normal BP (30 below in pts w. HTN)

10%

CPR Success Rate

10% for out of hospital - 20% for in hospital

Member of resuscitation team is preparing to admin meds IV to pt in cardiac arrest. Team member follows each med admin w. bolus of fluid. How much would team member give

10-20 mL fluid bolus.

When providing high-quality CPR on adult, what is proper rate for chest compressions?

100-120 bpm

How much time from pt arrival at facility should brain imaging be ordered for pt w. suspected stroke

10m

In ventricular tachycardia, QRS complexes are wide, lasting longer than:

120 milliseconds

Nurse is preparing to defibrillate pt in cardiac arrest w. biphasic defib & needs to set energy dose according to manufacturer's recommendations, which is usually

120-200 joules

Recommended energy dose for biphasic synchronized cardioversion of AFib

120-200J

Percentage of embolic strokes associated w. AFib

15-20%

Pt w. suspected stroke arrives at 1910 & stroke team ensures comprehensive neuro assessment using NIHSS is completed & brain imaging is performed by

1930

Chemical Colorimetric Analysis

pH-sensitive paper w/in chamber placed btw tracheal tube & ventilation device - Purple, tan, or yellow

Pt w. dizziness & SOB has HR 40, initial atropine was ineffective, & monitor/defibrillator not equipped w. transcutaneous pacemaker. What is appropriate dopamine dose to give

2-10 mcg/kg/min

When providing high-quality CPR on adult, what is proper depth for chest compressions?

2-2.4"

STEMI presents at 2130 & states s/s started ~2000. After confirming dx & initiating care, PCI scheduled. Facility capable of PCI. For best outcome, PCI performed by

2300 - Reperfusion w/in 1.5h of 1st medical contact if pt doesn't need to be transferred

Pt w ischemic stroke receives fibrinolytic therapy. Anticoagulant therapy should be withheld for how long

24 hours

Gold Standard for Successful Intubation

3 ETCO2 waveforms of equal height

Troponin levels should be measured at initial presentation & then __ hours later

3-6

Fibrinolytic therapy should initiated w/in _ min of 1st medical contact if primary PCI can't be performed w/in 90m of arrival

30

Initial dose of amiodarone for pt in cardiac arrest

300 mg IVP - Subsequent doses are 150 mg IVP

When performing high-quality CPR on adult w/o advanced airway in place, what is correct ratio of compressions to ventilations?

30:2

EKG reveals following rhythm, which feature would HCP interpret as indicating AFib

Absence of discrete P waves & presence of irregularly irregular QRS complexes

Team leader instructs team member to perform intervention. To practice good communication, team member should do which of the following? (3)

Acknowledge completion of intervention, use nonverbal communication methods to indicate follow through w. intervention, & acknowledge initiation of intervention

40yo in waiting room of PCP approaches staff & says, "I'm having really severe, crushing CP that's moving to both arms." Pt diaphoretic & dyspneic. Action appropriate for staff member to take

Activate emergency medical services system

Capnogram

Actual waveform

Contraindications to therapy w. Beta Blockers in pts w. ACS

Acute HF - Recent MI - Low CO - R/O cardiogenic shock

Which non-respiratory differential dx would you consider when assessing pt w. respiratory compromise?

Acute valvular insufficiency, cardiac tamponade, cardiogenic pulmonary edema

Cardiac monitoring of pt in cardiac arrest reveals VFib. Team should immediately

Administer 1 shock

In addition to resuming CPR, what other actions should the team take at this time

Administer epinephrine. Consider establishing an advanced airway. Consider underlying causes (Hs and Ts).

Nitro Dosage

Administer nitro 0.4 mg q5m by SL tablet or spray (1-3x) to relieve ischemic CP

Initial interventions appropriate for primary assessment of pt who has achieved ROSC

Assess neuro status - Establish noninvasive BP monitoring - Assess LOC - Consider placement of ET tube to support mechanical ventilation

Actions from prehospital providers that can improve outcomes for acute stroke pts

Assigning highest priority to potential stroke calls - Notifying receiving facility in advance of pt arrival - Transporting to facility capable of assessing & treating stroke

Team Leader Responsibilities

Assigns & understands team roles - Sets clear expectations - Prioritizes, directs & acts decisively - Encourages/allows team input & interaction - Focuses on big picture - Monitors performance while providing support - Acts as role model - Coaches team - Re-evaluates & summarizes progress - Leads debriefing

Where do We Measure ETCO2

End of expiration (end of phase 3) or D in picture

Normal Respiratory Baseline

Flat & consistent from breath to breath

On capnography waveform, what finding indicates pt isn't rebreathing CO2?

Flat Baseline

Normal Capnogram Consists of:

Flat baseline, steep upstroke/downstroke, flat plateau, & ETCO2 btw 35-45 mmHg

Tamponade (Cardiac)

Fluid around heart compresses heart (can't fill or pump) - Decompress via removal of fluid in pericardium

Myocardial Stunning Tx

Fluids to optimize volume status - Dobutamine 5-10 mcg/kg per min - Mechanical augmentation (IABP)

Primary assessment

Focused assessment of airway, breathing, circulation, disability, & exposure (ABCDE) to identify potentially life-threatening conditions & address them immediately

Pt w. acute renal failure has cardiac arrest. Just before arrest, ECG had peaked T-wave. Possible cause of arrest

Hyperkalemia - Suspected in all pts w. acute/chronic renal failure w. wide-complex ventricular rhythm or tall, peaked T waves on ECG before arrest

Pt comes w. suspected stroke. Pt AxO w. family who says, "I noticed he was slurring his words & had trouble walking, like his leg was numb." What finding suggests pt is experiencing condition that mimics stroke

Hypoglycemia

Prior to cardiac arrest, EKG had flat T waves, prominent U waves & prolonged QT interval. What cause suspected

Hypokalemia

Team is providing care to pt experiencing VTach & serum electrolyte levels are contributing c/o current condition. Which electrolyte imbalance(s) would most likely be involved

Hypomagnesemia - Hypocalcemia

Which findings may suggest pt is experiencing hemodynamic compromise c/b bradyarrhythmia? (5)

Hypotension - Ischemic CP - S/S of shock - AMS - Acute HF

Physical exam findings in pts w ACS may include which conditions

Hypotension - Pulmonary edema - Crackles

Metabolic Causes for Decreased CO2

Hypothermia - Increased MM Relaxation - Increased Depth of Anesthesia

Gradual CO2 Increase C/B

Hypoventilation - Laparoscopic insufflation - Increased Metabolism - Increased Pulmonary perfusion

When a patient is in cardiac arrest, it is important to consider reversible underlying causes. What underlying causes should the team consider

Hypovolemia - Hypoxia - Hypothermia - Acidosis - Potassium imbalance - Toxins - Cardiac tamponade - Tension pneumothorax - PE - MI

EKG shows tachyarrhythmia. Pt hemodynamically stable w. HR 120-135. Based on secondary assessment, what statement by pt would team interpret as possible contributing causes

I've had a terrible cold w. horrible cough/fever over past wk - I've been anxious lately bc I just lost my job - I've been vomiting for 2d d/t a GI bug

After cardiac arrest & ROSC, pt unable to follow verbal commands so TTM initiated. Which method(s) would be appropriate

Ice-cold IVF bolus - Applying cooling blankets to pt body - Endovascular catheter

Benefits of ETCO2

Identifies early hypoventilation (dental procedures, GI procedures in morbidly obese, & PACU) - Shows effectiveness of CPR/ventilatory rate - Monitor high dose opioid/hypnotic drug - Confirm ETT placement - Guide vent mgmt

Resuscitation team responds to in-hospital arrest, immediate actions

Identify rhythm - Ensure high-quality CPR being performed

Pt w. s/s of ACS & ST elevation in II, III, aVF. Next action

If ECG = inferior wall MI, 15-lead to screen for R ventricular infarction

Inspiratory downslope

Phase of capnography waveform representing inhalation. Inhalation occurs & CO2 is rapidly purged from airways & alveoli.

Respiratory Baseline

Phase on capnography waveform representing beginning of exhalation. During phase, "dead space" air (i.e. air in airways from bronchioles to nasal cavity that doesn't contain CO2) is exhaled from body.

Respiratory upstroke

Phase on capnography waveform representing exhalation of air containing CO2 from alveoli. For most pts, respiratory upstroke should be nearly vertical.

Which diagnostic tests used for monitoring perfusion status in post-cardiac arrest pt

Serum lactate, if cells are adequately perfused and/or oxygenated it won't be produced - Start metabolizing inefficiently = Producing more acid byproducts

Pulseless VTach is Treated the Same As

VFib

Shockable Rhythms

VFib - Pulseless VTach - Don't shock asystole/PEA - As soon as shockable rhythm seen, administer defib

Pt being treated determined to have NSTE-ACS, early invasive tx planned d/t what finding

VTach

EKG shows QRS complex w. regular rhythm = Narrow-complex SVT. Pt hemodynamically stable. Tx initiated 1st

Vagal maneuvers

STEMI pt experiencing CP refractory to SL Nitro prescribed IV Nitro. When administering med, titrate to maintain SBP of

90+

Ideal time frame for performing percutaneous coronary intervention (PCI) in pt w. STEMI

90m of pt arrival at facility

In pt showing s/s of respiratory compromise, provide minimum level of supplemental O2 needed to maintain O2 saturation of at least:

94%

Provide minimal level of supplemental oxygen needed to maintain oxygen saturation of at least _____

94%.

Pt w. suspected ACS c/o SOB & given supplemental O2 - HCP determines O2 dose correct based on what SaO2 level

95%

35yo female ECG is consistent w. STEMI = New ST elevation at J point in leads V2 and V3 of at least which size

0.15 mV

Nitro dose (sublingual tablet or spray) to be administered to pt suspected of having ACS

0.4 mg q5m

Ischemic stroke pt arrives at 0200 & s/s started at ~0030. After completing necessary assessments, team dx ischemic stroke. Pt determined candidate for fibrinolytic therapy. To achieve best outcomes, team should initiate therapy no later than

0300

Pt in cardiac arrest & metabolic acidosis determined to be underlying cause, initial dose of sodium bicarb

1 mEq/kg

When advanced airway in place & pt in cardiac arrest, compressions & ventilations delivered continuously w. no interruptions. 1 provider delivers __________ q6s while 2nd provider performs compressions at rate of 100-120/min

1 ventilation

Resuscitation team debriefing following pt cardiac arrest where ACLS was initiated. Pt required placement of advanced airway to maintain patency. Statement indicates team performed high-quality CPR

1 ventilation q6s & 100-120 compressions/min

After 3 shocks, admin lidocaine for cardiac arrest. What is dose?

1-1.5 mg/kg, then 0.5-0.75 mg/kg q5-10m, max dose 3 mg/kg

Post-cardiac arrest pt has SBP < 90 mmHg. What interventions should be considered next?

1-2L IV isotonic crystalloid fluid bolus - Vasopressor infusion w. epinephrine (0.1-0.5 mcg/kg/min)

You'd expect to see ETCO2 < ___ in presence of hyperventilation

35 mmHg

HCP initiates ventilations to ensure adequate breathing/oxygenation. During ventilations, capnography established to evaluate adequacy of ventilations. HCP determines ventilations adequate based on which ETCO2 value

35-45 mmHg

What end-tidal carbon dioxide (ETCO2) value confirms adequate ventilation in intubated pt w. respiratory arrest?

35-45 mmHg

Ideal time frame for fibrinolytic therapy admin

3h from s/s onset

Reversible causes of cardiac arrest

4 H's = Hypovolemia, Hypoxia, H+ (acidosis), Hypo/hyperkalemia, Hypothermia

How much time from pt arrival at facility does brain imaging have to be interpreted

45 min

20yo man w. respiratory depression brought in by parents. Parents state, "[They] found him w. various needles & syringes around him, but have no idea what he took." Opioid OD suspected & initial dose of naloxone administered at 2200. Pt doesn't respond to initial dose. Team would expect to administer 2nd dose after how many mins

4m

Pt experiencing respiratory distress secondary to exacerbation of COPD & begins exhibiting s/s of worsening respiratory function & experiences respiratory arrest. Team intervenes, delivering ventilations via BVM delivering 1 ventilation at which interval

5-6s

Which statement about electrocardiography is true?

5-lead ECG uses 4 limb leads & 1 precordial lead to provide 7 views of electrical activity of heart

What ETCO2 value would you expect to see in presence of hypoventilation?

50 mmHg

R/O Torsades de Pointes increased when corrected QT interval (QTc) > ___ milliseconds

500

Sinus bradycardia is identical to normal sinus rhythm, except rate is less than _____ bpm

60

Ideal time frame for administration of endovascular therapy

6h from s/s onset

Bag ventalition device holds ______mL

700

About __% of pts w. ACS each yr, the arterial occlusion results in UA or NSTEMI & remaining __% result in STEMI

70; 30

Abnormal finding in 1 Cincinnati Prehospital Stroke Scale assessment areas is associated w. what stroke probability

72%

Proper ventilation rate for pt in cardiac arrest w. advanced airway in place

8-10 breaths/min

Primary Assessment

ABCDE approach & provide care PRN - Ensure patent airway - Assist ventilation PRN - Pulse ox, capnography, & cardiac monitoring - Provide minimum supplemental O2 to maintain 94% saturation (88-92% in pts who rely on hypoxic drive) - Adjust ventilations PRN to maintain ETCO2 35-45 mmHg - Establish vascular access & prepare to provide CPR/Defibrillation if condition deteriorates

Hover hands over chest but don't touch during:

AED shock (to minimize time not performing compressions)

Stroke team assessing suspected stroke, pt alert & able to carry on convo, although pt has difficulty getting words out. Testing confirms pt had ischemic stroke. Hx of which arrhythmia would alert team to pts increased r/o stroke

AFib

Synchronized cardioversion indicated for tx of which arrhythmias? (3)

AFib - Monomorphic VTach w. regular rhythm - AFlutter

During primary assessment, what tool would you use to determine pts LOC?

AVPU Model

30yo brought in cardiac arrest. Cardiac monitor shows VTach. Possible precipitating factors of VFib

Electrocution, myocardial ischemia/infarction, shock, stimulant OD, VTach

Recognize

After you gather assessment data, use critical thinking, your past clinical experience and your general knowledge to correctly interpret the meaning of the data and gain an understanding of the patient's clinical situation and care needs. This understanding enables you to determine your next steps.

NGT After Arrest or Advanced Airway Placement Rationale

Air fills in stomach & presses on lungs - Pt often recently ate/drank & at r/o aspiration

In inflammatory conditions, waveform may still be square, despite narrowing of airway, bc

Alveoli are still empty at same rate

Which anatomic landmark should be used to ensure proper placement of precordial electrodes for 12-lead ECG?

Angle of Louis (sternal angle), which is adjacent to 2nd rib. Then palpate down along sternal border to identify 4th ICS

You need to obtain intraosseous (IO) access. Identify preferred site.

Anterior proximal tibia often used bc it provides flat surface w. relatively thin outer layer of bone, large marrow cavity, & easily identifiable landmarks to facilitate placement. Proximal humerus also used.

Key questions to answer in assessment/mgmt of post-cardiac arrest pt

Any potentially reversible underlying c/o cardiac arrest that need to be addressed - Is pt candidate for TTM - Does pt require reperfusion therapy to address MI

Oxygen-hemoglobin dissociation curve depicts relationship btw partial pressure of oxygen (PaO2) & the:

Arterial oxygen saturation

Changes in what can affect rate & depth of breathing? (3)

Arterial pH - Arterial O2 levels - Arterial CO2 levels

Pt c/o SOB has long hx of COPD. Assessment reveals respiratory failure. Initial priority

Assisted ventilation w. BVM - Pts who can't ventilate adequately despite open airway or have insufficient respiratory effort require assisted ventilation initially w. BVM

In _________, atrial contraction occurs at such a rapid rate that discrete P waves separated by flat baseline can't be seen.

Atrial Flutter

In event of primary pacemaker dysfunction/failure, what part of heart's conduction system can function as backup pacemaker?

Atrioventricular (AV) Node

What part of heart's electrical conduction system helps to protect ventricles from atrial tachyarrhythmias?

Atrioventricular (AV) node

What is 1st-line therapy for unstable pt w. symptomatic bradycardia?

Atropine

Pt w. SOB/AMS arrives, team completes assessments, & cares for pt including cardiac monitoring/pulse ox, supplemental O2, ensuring adequate ventilation, & obtaining IV. Team reviews EKG (figure). Med most likely to administer

Atropine 0.5 mg q3-5m

Pt presents w. new onset of dizziness & fatigue. HR 35, BP 70/50, RR 22, & 95%. What is 1st med given

Atropine 0.5mg

O2 Warning During Defibrillation

Be sure O2 isn't blowing over pt chest during shock

Mr. Hernandez is found to be unresponsive, with no pulse and no breathing. What is the appropriate next intervention

Begin CPR and administer one shock.

Pt w. ACS is experiencing cardiogenic shock. Which adjuvant therapy would be contraindicated

Beta Blockers

Modern Defibrillators

Biphasic & 200J

Pathophysiologic SE of cardiac arrest

Brain injury - Systemic dysfunction - Myocardial Stunning (dysfunction)

Secondary assessment

Broader assessment to narrow list of differential dx & discover underlying causes. Includes focused hx, exam, & diagnostic testing

CO2 Facts

Byproduct of cellular metabolism - Transported by Hgb to lungs - Eliminated from alveoli (during ventilation)

Which blood tests are often indicated in evaluation of pts experiencing cardiovascular, cerebrovascular or respiratory emergency?

CMP, Toxicology, CBC, Cardiac markers, ABGs, Blood glucose

Flat Baseline Indicates

CO2 completely purged from airway

Bradycardia Requires Tx if

CP or SOB present - Tx = 0.5 mg Atropine q3-5m, max 3mg - Other Tx = Transcutaneous pacing, Dopamine 2-10 mcg/kg/min - Epi 2-10 mcg/min

Dx test typically obtained at presentation to r/o other c/o acute CP & to identify pulmonary congestion

CXR

Indications of Rebreathing CO2

Can occur w. faulty expiratory valve or exhausted absorber system - Inspiratory CO2 consistently > 0 - Insufflation of CO2 into airway from ENT - Will likely not see increase in 3 waveforms

Primary assessment tasks if suspected acute stroke

Cardiac monitoring - NPO - Supplemental O2 if pulse ox < 94%

The team resumes CPR, delivers a third shock and administers amiodarone, 300 mg IV push. At the next rhythm check, the monitor displays this rhythm. What action should the team take next

Check for a pulse.

Based on visual survey, pt appears to be unresponsive. What should your immediate next action be?

Check for responsiveness using shout-tap-shout sequence If they're unresponsive, call for additional resources & simultaneously check breathing/pulse for 5-10 seconds

What is the appropriate next action for the team to take at this time

Check for responsiveness, breathing and a pulse.

Which assessments would be included in primary assessment?

Checking for life-threatening injuries & checking airway patency

Team member confirms message is received & understood. What communication technique is team member using?

Closed-Loop Communication

Closed-loop communication

Communication technique used to prevent misunderstandings; receiver confirms message has been received & understood.

Flat Expiratory Plateau Indicates

Complete exhalation/emptying of CO2 from alveoli - ETCO2 reading accurate & at peak

If capnography is < 10 there may be probelm with _________

Compressions

Crew Resource Management

Concept helps to promote effective/efficient teamwork & reduce likelihood of errors. Emphasizes using all available resources (people, equipment, procedures) to reduce likelihood of human error & promote effective/efficient teamwork. Guides team members to communicate directly & effectively w. team leader about dangerous or time-critical decisions. When problem arises, team members must get attention of team leader, state concern, describe problem as they see it & suggest solution. Team leader provides direction, enabling team to work together to resolve issue.

You have just placed advanced airway. How should you verify correct placement?

Confirm initially, if pt moved & ongoing basis. Methods: Physical assessment (observing for bilateral chest rise & auscultating over lungs/epigastrium) & confirmation tool (i.e. capnography) Fogging in tube & improved O2 saturation on pulse oximetry aren't reliable methods of confirmation

Cardiac monitor indicates VTach. Pt has pulse & not showing s/s of hemodynamic compromise. ECG reveals irregular rhythm w. QRS complexes > 0.12s in duration. Which action would be appropriate

Consider antiarrhythmic infusion & expert consult

Most reliable method of confirming & monitoring correct placement of ET tube

Continuous waveform capnography

Pt has CP after Nitro x 3, cardiac biomarkers elevated, & ST-segment depression. Consider

Coronary angiography - For high-risk NSTE-ACS, early invasive strategy w/wo revascularization should be considered - Refractory ischemic CP is indication

When auscultating lung sounds in pt w. left ventricular dysfunction, you'll hear

Crackles

Important questions regarding medical hx to ask pt w. suspected stroke

Current meds & when s/s began

Which underlying mechanism can lead to hypoxia in pt w. right shift of oxygen-hemoglobin dissociation curve?

Decreased affinity for oxygen binding

Don't Intubate, Start IV, Etc. Until You

Defibrillate

Assess, Recognize & Care

Describes ongoing process of gathering data about pt condition, using data to identify problem & intervening to address problem. Acutely ill pt condition can change rapidly (for better or worse), you must continuously assess pt, recognize whats happening & provide care accordingly

Urine Output & Serum Creatinine Rationale

Detect AKI - Maintain euvolemia - Renal replacement PRN - Low output = Shock

Goals of secondary assessment in pt w. suspected arrhythmia? (2)

Determining potentially reversible causes of arrhythmia & determining the severity of s/s

Respiratory: What is body's primary muscle of inspiration?

Diaphragm

Which would be important to note when reviewing hx of pt in cardiac arrest

Disorders/Situations that could predispose pt to developing Hs/Ts - Medication use - Changes in pt clinical condition prior to arrest - R/F for cardiac or pulmonary conditions

Stroke pt is admitted to dedicated stroke unit, reflecting which 8 Ds of stroke care

Disposition

Expiratory Plateau

During this phase, the last of CO2-laden air from most distal alveoli exhaled from body. ETCO2 measured at end of exhalation (point D), representing peak level.

On capnography, absent expiratory plateau indicates:

Dynamic Hyperinflation aka auto-PEEP (auto-positive end expiratory pressure). Plateau loss produced by uneven alveolar emptying secondary to severe bronchospasm leading to air trapping.

Diagnostic study that should be delayed until ROSC

EKG

CO2 Goals

ETCO2 35-40 - ATCO2 40-45

Tan Colorimetric Analysis

ETCO2 4-15 mmHg (0.5-2% CO2)

Purple Colorimetric Analysis

ETCO2 < 4 mmHg (0.5% CO2)

Yellow Colorimetric Analysis

ETCO2 > 15 mmHg (> 2% CO2)

S/S of ROSC

ETCO2 goes up (abrupt increase, usually > 40) - HR/BP Increase - Spontaneous ventilation

Based on the primary assessment findings, what additional actions should the team take

Ensure vascular access and administer atropine. Administer supplemental oxygen.

Pt w. unstable bradyarrhythmia doesn't respond to atropine. Possible next tx

Epi/Dopamine infusion - Transcutaneous pacing

What drugs may be used as 2nd-line therapy for unstable pt w. symptomatic bradycardia?

Epinephrine - Dopamine

Absent CO2 C/B

Esophageal intubation (will see some ETCO2 initially then diminishes, why 3 equal height waveforms) - Death - Blocked sample line - Severe bronchospasm - Equipment malfunction - Hard cricoid pressure occluding tip of ETT

12-lead ECG shows wide-complex ventricular tachycardia in stable pt w. pulse. Which may be indicated in mgmt of pt?

Expert consultation and/or antiarrhythmic infusion

When providing transcutaneous pacing, appearance of wide QRS complexes & tall, broad T waves after each pacing spike confirms mechanical capture has been achieved. T/F?

False

Secondary Assessment

Goals are to discern underlying c/o respiratory compromise & evaluate severity of pt condition - Acute onset of respiratory distress is frequently pulmonary or cardiac in origin

Partial Disconnect

Gradual ETCO2 drop - Can also be from a cuff leak

Capnography

Graphic record of CO2 concentration

Team Member Responsibilities

Have necessary knowledge/skills to perform assigned role - Stay in assigned role but assist others PRN, as long as they're able to maintain own responsibilities - Communicate effectively w. team leader if they: Feel they're lacking any knowledge/skills to perform assigned roles, identify something team leader may have overlooked, or recognize dangerous situation/need for urgent action - Share info w. other team members - Focus on achieving goals - Ask pertinent questions & share pertinent observations - Participate in debriefing sessions - Crew

Capnogram Features

Height = CO2 - Frequency = RR - Normal baseline = 0 - Rhythm - Baseline - Shape

High-Risk vs Low-Intermediate Risk NSTE-ACS

High risk = Changes = Ischemia, i.e. ST depression/T-wave inversion, 2+ leads - Low/Intermediate-risk = No changes or nondiagnostic ST-segment or T-wave changes

Pt w. s/s of ACS has T-wave inversion in 2+ leads. To which clinical category should pt be assigned

High-risk NSTE-ACS

Rhythm check reveals shockable rhythm. When should chest compressions resume?

Immediately after rhythm check

Stroke S/S

Impaired balance - Sudden/Severe HA - Blurred vision

Circulatory/Respiratory Causes for Decreased CO2

Impaired peripheral circulation (insufflation, packing, positioning) - Decreased blood flow to lungs - Increased ead space - Hyperventilation (we do this to decrease ICP during neuro case & lap cases to blow off CO2)

Care

Implement appropriate care based on understanding of condition. Proper care can't be provided w/o effective assessment & accurate recognition of condition

6-Person High-Performance Resuscitation Team

Includes 3 who fulfill CPR/defib roles & 3 who perform leadership/supportive roles

How can we use PEEP to improve VQ mismatch

Increase PEEP little by little to decrease gradient as close to 1:1 as possible - Need A-line to get multiple ABGs

Equipment Causes for Increased CO2

Increased Apparatus dead space (smaller pt = bigger impact i.e. neonates) - Rebreathing - Obstruction in expiratory system (failed inspiratory/expiratory flutter valves cause us to rebreathe CO2. If inspiratory stuck open & expiratory side obstructed, exhalation can go up inspiratory side & be inhaled in next breath further increasing CO2 - If expiratory valve stuck open it allows exhalation to come back into pt when they start spontaneously breathing again

Circulatory/Respiratory Causes for Increased CO2

Increased CO - Hypoventilation - Upper airway obstruction - Rebreathing

Hyperventilation Can Cause

Increased dead space - Decreased height on capnography

Inotrope

Increases force of contraction

Therapeutic Hypothermia

Indwelling temp monitoring device - Prevent hyperpyrexia > 37.7 C - Induce if no contraindications - Cold IVF bolus 30 mL/kg - Surface/Endovascular cooling for 32-34 C x 24h - After 24h, slow rewarm 0.25 C/hr

Pt brought w. suspected opioid OD & in cardiac arrest. Priority action

Initiating high-quality CPR. arrest, Narcan is also recommended during arrest when opioid OD suspected but CPR takes priority over Narcan (Naloxone)

CP Descriptions associated w. ACS

Intermittent - Pressure/Squeezing/Tight/Aching/Heaviness - Radiates to arm(s) - Lasts > 3-5m

2 main types of strokes

Ischemic & Hemorrhagic

NIHSS Evaluates

Language deficits - Sensation & neglect - Cerebellar function - Motor & Visual Function - Level of consciousness

Equipment Causes for Decreased CO2

Leak in sample - Low sampling rate - High sampling rate - Cuff leak

Hyperventilation leads to alkalosis & a _______ shift of oxygen-hemoglobin dissociation curve.

Left

When Hgb's affinity for O2 is increased, O2 binds to Hgb easily, but offloading is difficult. This is reflected on oxygen-hemoglobin dissociation curve as shift to the _________.

Left

Pt brought in by spouse who says, "I think it's a stroke." Stroke team assesses pt using NIHSS. Area(s) included in assessment

Level of consciousness - Language deficits - Visual function

Relationship btw ETCO2 & PaCO2

Linear, ETCO2 measurement doesn't replace PaCO2 bc gradient can vary in size & direction

If Pt Isn't Perfusing

Little CO2 will be expelled & when pt starts perfusing more CO2 will be expelled (s/s of ROSC)

Normal Capnogram

Look like top hat - Y-Axis= mmHg - X-Axis= time - Phase 1= Inspiration - Phase 2= Beginning of expiration - Phase 3= Expiration - Phase 4= Beginning of inspiration

Pt has s/s suggestive of ACS has T-wave inversion < 2 mm, what category would you assign pt

Low/Intermediate-risk NSTE-ACS

Metabolic Causes for Increased CO2

MH (ETCO2 rises before temp) - Hyperthermia - Shivering/Convulsion - Pain - Catecholamines - Blood & Bicarb - Release of clamp/tourniquet - Absorption from laparoscopy - TPN

Acceptable brain imaging options for suspected acute stroke

MRI - CT w. or w/o - Diffusion-weighted MRI

What medication should be considered for Torsades de Pointes

Magnesium Sulfate

After fibrinolytic therapy pt transferred to monitored bed on stroke unit. Care focused on

Managing HTN - Controlling BG - Assessing for s/s of intracranial bleeding - Supporting airway, breathing, circulation

Capnometry

Measurement & numeric display of partial pressure or gas concentration of CO2

Increases/Decreases in ETCO2 are reliable in what pts?

Mechanically ventilated patients - Spontaneous breathing allows for changes in RR that compensate for changes in ETCO2 - Mechanically ventilated pts can't spontaneously adjust their RR

Healthcare provider conducting secondary assessment of pt w. arrhythmia. Which questions should provider seek answers to while obtaining pt hx? (3)

Meds currently being taken, what pt was doing when s/s began, & hx of pulmonary/thyroid disease

Brown lead going right side of chest in __________

Middle (~3-4th ICS)

CPR: Which statements apply to providing high-quality chest compressions? (3)

Minimize interruptions, proper depth, proper rate

Therapeutic Hypothermia Rationale

Minimizes brain injury & improves outcome (decrease brain's O2 consumption, decrease brain cell swelling)

As team leader, Dr. Hudson is responsible for monitoring CPR quality. Which of the following actions are necessary to ensure high-quality CPR

Minimizing interruptions to compressions. Providing compressions that are at least 2 inches (5 centimeters), but not more than 2.4 inches (6 centimeters), deep. Providing compressions at a rate of 100 to 120 per minute. Avoiding excessive ventilations.

What is capnography waveform graphical representation of?

Movement of CO2 through respiratory system

New ST-segment elevation in 2+ contiguous leads on 12-lead ECG suggests

Myocardial infarction

ECHO Helps Dx

Myocardial stunning - Wall-motion abnormalities - Structural problems - Cardiomyopathy - Decreased EF

Which airway device is most appropriate as initial intervention for semiconscious pt who requires ventilation w. BVM resuscitator?

NPA (nasopharyngeal airway) may be used w. conscious, semiconscious or unconscious pts

Conditions included in category of NSTE-ACS

NSTEMI & Unstable angina

Main difference btw NSTEMI & UA in NSTE-ACS

NSTEMI have elevated serum cardiac markers & pts w. UA don't

ECG finding diagnostic for STEMI in man 40+ yo

New ST elevation at J point in leads V2 & V3 that's at least 0.2 mV (≥ 2 mm)

Meds that should be administered to pt w. s/s of MI or infarction

Nitroglycerin & aspirin

Low/Intermediate-risk NSTE-ACS pt may show what ECG change

Nondiagnostic T-wave & nondiagnostic ST-segment changes

Extracorporeal cardiopulmonary resuscitation (ECPR) might help tx what c/o cardiac arrest

OD - PE - Hypothermia

Critical thinking uses

Obtaining an initial impression, determining course of action, anticipating roles & functions as part of team based on pts presentation/condition, consistently re-evaluating situation for changes, interpreting changes & applying them to pts care & tx, & modifying actions based on changes you observe.

When obtaining 12-lead ECG, where should electrodes for limb leads be placed?

On upper arms and on the thighs/calves Avoid bony areas like the ankles

STEMI mgmt focuses on early reperfusion therapy with

PCI or Fibrinolytic therapy

78yo pt who had knee replacement sx 2d ago goes into cardiac arrest. What underlying cause should be top concern

PE

ECG rhythm strip part that's time from beginning of atrial depolarization to beginning of ventricular depolarization

PR Interval

Pt in cardiac arrest experiences ROSC. As part of post-cardiac arrest care, pt is receiving mechanical ventilation. Finds that would indicate need for change in vent settings to optimize pt ventilation & oxygenation

PaCO2 35 - SaO2 92% - ETCO2 50

Don't place AED pads over___________

Pacemaker

ROSC Clinical indications

Palpable pulse, measurable BP, ETCO2 value > 40 mmHg - Regular rate/rhythm not necessarily indication

Sudden Interruption in Pulmonary Perfusion

Partial disconnect/cuff leak appearance - Cardiac arrest, massive EBL d/t surgeon cutting something big, massive PE, or surgeon compressing a major vessel

Factors to consider when determining whether to continue resuscitation effort

Physiologic data - Underlying c/o arrest - Health prior to arrest - Duration of resuscitation effort - Initial arrest rhythm (shockable rhythm = better outcome) - Witness vs unwitnessed arrest - Time to start CPR & time to defib - Pre-arrest state - Whether ROSC achieved at some point

Pt in cardiac arrest, resuscitation team initiates ventilations via BVM resuscitator. Development of which condition during provision of care would lead team to suspect that improper technique being used

Pneumothorax

Colorimetric Analysis Pros

Portability - Low cost - Applicable outside OR - No need for other equipment - Color change reversible & can change from breath to breath

Hyperventilation/Overbagging SE

Potential adverse hemodynamic effects - Increased Intrathoracic pressure - Decreased CO - Decreased Cerebral flow

Waveform indicates

Presence of CO2 - Even abnormal waveform is indication CO2 is present

Tx for pt w. imaging revealing hemorrhage depends on cause & severity of bleeding. In addition to BLS measures, care should include what else

Prevent seizures - Controlling internal bleeding - Decreasing ICP - Decreasing BP

Concept that helps to promote effective/efficient teamwork & reduces likelihood of errors is called _____.

Problem solving

Assess

Process of gathering data to help determine whats happening. To ensure most pressing problems addressed first, take phased, systematic approach to assessment: perform rapid assessment, primary assessment & when condition allows, secondary assessment. In emergency situation, assessment ongoing.

Survival advantage of providing CPR to pt in VFib

Produces small amount of blood flow to heart

Goals for Pt Mgmt During Post-Cardiac Arrest Period

Promoting neurological recovery, optimizing ventilation/oxygenation, managing hemodynamics, correcting cardiac instability, & addressing underlying c/o cardiac arrest

Resuscitation team decides to place advanced airway in pt whose in cardiac arrest. How should ventilations be provided following placement of airway?

Provide 1 ventilation q6s w/o pausing compressions

Which assessment could be made during rapid assessment?

Pt is diaphoretic

Respiratory baseline that slopes upward & increases w. each breath suggests

Pt rebreathing CO2

On rapid assessment, you note increased work of breathing, AEB tripod positioning, inability to speak > 1-2 words at a time & diaphoresis. What assessments should you obtain during primary assessment?

Pulse ox & VS

CO2 Monitor Detects Complete Airway Obstruction & Extubation Faster Than

Pulse ox & VS monitoring

Appropriate tx as part of primary assessment of pt w. suspected ACS

Pulse ox - Vascular access - EKG - Cardiac monitoring

What parts of heart's electrical conduction system play role in ventricular contraction? (3)

Purkinje fibers - Bundle of His - Bundle Branches

In 3rd-degree AV block, there is no electrical communication btw atria & ventricles, so no relationship btw P waves & the _________

QRS Complexes

What increases chance of successful conversion of VFib

Quality compressions immediately before defibrillation

What is rapid assessment?

Quick assessment to ensure safety, form initial impression of pt, & if pt appears to be unresponsive check for responsiveness/breathing/pulse

HCP is establishing cardiac monitoring w. 5 electrode system & demonstrates proper use by placing green electrode on

RLQ

Pt suddenly collapses sitting in healthcare facility. HCP sees & runs over to assess. 1st assessment performed

Rapid assessment

In 6-person high-performance resuscitation team, which tasks are responsibilities of team members? (3)

Recoding key data, sharing pertinent observations, & performing chest compressions

Which complications can occur when providing ventilations w. BVM resuscitator?

Regurgitation/Aspiration (d/t gastric insufflation) - Tension Pneumothorax (d/t barotrauma) - Decreased Cardiac Output (d/t decreased venous return)

Mr. Hernandez has a pulse and is making an effort to breathe but is still unresponsive. The monitor shows normal sinus rhythm with a rate of 80 bpm. Mr. Hernandez's vital signs are as follows:Blood pressure: 128/80 mmHgHeart rate: 80 bpm, radial pulses presentRespirations: 9 breaths/minSpO2: 90%ETCO2: 60 mmHgWhat should the team do next

Request laboratory studies to assist in evaluating perfusion status. Obtain a 12-lead ECG. Administer supplemental oxygen at a rate of 10-15 liters/min. Support ventilations at a rate of 10 to 12 breaths/min to lower the end-tidal carbon dioxide (ETCO2) level to 35-40 mmHg.

Respiratory compromise manifests along continuum. When pt is breathing but respiratory system unable to meet metabolic demands, pt is in:

Respiratory Failure

Pt in ED is in respiratory compromise. Team is monitoring pt w. capnography, ETCO2 initially 33 & later 40. From readings, team identifies pt is progressing in what stage of respiratory compromise

Respiratory distress - Capnography can objectively assess severity of respiratory distress - Early on, pt will often hyperventilate = Hypocapnia reflected by low ETCO2 (< 35) - As distress increases, & pt begins to tire ETCO2 may return to normal (35-45) - If respiratory failure, ETCO2 increases > 45 = Hypoventilation

Assessment of pt reveals respiratory compromise. From assessment, team identifies pt in earliest stage of condition. Earliest stage

Respiratory distress - Occurs along continuum - Respiratory distress Respiratory failure Respiratory arrest

Assessment shows ETCO2 55 & SaO2 88%. HCP would interpret findings as indicative of

Respiratory failure

Compressor

Responsible for chest compressions

Data Manager

Responsible for communicating & recording key data during resuscitation effort (i.e. data r/t med admin & interruptions to chest compressions)

Medication Administrator

Responsible for establishing vascular access & administering medications.

AED/Defibrillator Operator

Responsible for managing AED or defibrillator & establishing any other monitoring. Also, relieves team member performing compressions

Airway manager & ventilator

Responsible for managing airway & providing ventilations. Trained RT, if available, would fill role

Team Leader

Responsible for prioritizing & directing other team members' actions.

Colorimetric Analysis Con

Results semiquantitative, provide results for range instead of a definite number

Mr. Hernandez remains in pulseless ventricular tachycardia. What is the appropriate next intervention

Resume CPR, administer one shock and administer amiodarone.

After one shock and 2 minutes of CPR, the rhythm check reveals no change in the rhythm. What is the appropriate next intervention

Resume CPR, administer one shock and administer epinephrine.

Rapid Assessment S/S of Respiratory Compromise

Retractions - Use of accessory mm to breathe - Tripod positioning - Inability to speak in complete sentences - Pale/Ashen/Cyanotic skin - Diaphoresis - Restlessness/Agitation - Altered LOC

MI S/S

Retrosternal CP - Dyspnea - N/V - Fatigue/Weakness - Loss of Consciousness

Myocardial Stunning

Reversible reduction of function of heart contraction after reperfusion not accounted for by tissue damage or reduced blood flow - Even though heart is perfusing again, it's not working very well as pump

Part of secondary assessment of pt in cardiac arrest

Reviewing medical hx

Contraindication to Nitro for mgmt of ACS

Right ventricular infarction & dysfunction

Besides MI, what are life-threatening c/o CP

Ruptured esophagus - Perforating PUD - Pneumothorax - Aortic dissection - PE

ECG changes that suggest ischemia

ST-segment depression & T-wave inversion

ECG findings expected in pt w. high-risk NSTE-ACS

ST-segment depression & T-wave inversion in 2+ contiguous leads

ECG findings suggesting NSTE-ACS

ST-segment depression, T-wave inversion & transient T-wave elevation

12-lead ECG reveals tachyarrhythmia w. narrow QRS complexes (< 0.12s). You would classify this arrhythmia as ________.

SVT

15-lead ECG Indication

Screen for posterior MI if ACS suspected but 12-lead doesn't show ST elevation or for right ventricular infarction if 12-lead reveals evidence of inferior wall MI (II, III, aVF) - Suspicion of posterior wall/right ventricular involvement

Diagnostic studies useful for identifying c/o cardiac arrest

Serum electrolytes - Bedside US - CXR

Responsibilities of team leader? (3)

Sets clear expectations, leads debriefing, assigns roles

Bronchospasm Capnography

Shark fin wave - Asthma, blocked tube, COPD/obstructive disease, upper airway obstruction

EKG: Heart's electrical conduction system part that generates electrical impulses initiating heartbeat rhythm/rate:

Sinoatrial (SA) node

This is the rhythm that the telemetry technician observed on the cardiac monitor at the central telemetry station. What is your interpretation of the rhythm on the cardiac monitor

Sinus Bradycardia

Torsades de pointes may revert to which rhythm

Sinus Rhythm - VFib - Pulseless VTach

Arrhythmias that are narrow-complex tachyarrhythmias? (3)

Sinus tachycardia - AFlutter - AFib

What should the team do now

Stop CPR and check for a pulse.

Catastrophic Loss of Ventilation

Sudden CO2 drop - Extubation, circuit disconnect, vent failed, blocked ETT, plugged/kinked sample line, or migration to esophagus

Pt has ROSC after cardiac arrest & healthcare team is conducting secondary assessment to determine possible c/o pt arrest. Hx reveals that before arrest, pt exhibited JVD, cyanosis, apnea, & hyperresonance on percussion. Pt difficult to ventilate during response. Team most likely suspected

Tension pneumothorax

Differential dx conditions for pt w. s/s of acute stroke

Systemic infx - Seizure disorder - Hypoglycemia - Migraine

What part of ECG rhythm strip represents repolarization of ventricular myocardial cells?

T-waves

To promote neurologic recovery in comatose post-cardiac arrest pt, which tx is appropriate

TTM (targeted temperature mgmt), should be considered for any pt unable to follow verbal commands following ROSC

Mr. Hernandez remains unresponsive to verbal commands. What therapy should the team initiate to promote his neurological recovery

Targeted temperature management (TTM)

The team decides to intubate Mr. Hernandez. How does this affect compressions and ventilations

The team should provide ventilations at a rate of 1 ventilation every 6 seconds without pausing compressions.

You need to set up cardiac monitoring w. 5-electrode system. Where should you place white electrode?

Top right chest anatomically oriented

Chest Compression Fraction

Total percentage of time during resuscitation attempt in which active chest compressions are being performed. Needs to be >= 60% w. goal of 80

(T/F) Underlying c/o primary PEA can be r/t inadequate volume, impaired myocardial contractility or both

True

When assessing pt w. respiratory compromise, it's important to determine where pt is on continuum of respiratory compromise. T/F

True

Key decision point when providing care for pt w. stroke is determine

Type of stroke

Prolonged respiratory upstroke that isn't vertical indicates

Uneven alveolar emptying d/t bronchospasm

Rhythm that requires synchronized cardioversion

Unstable SVT

Pt has mild to moderate recurrent CP wo N/V. ECG shows ST depression w. transient T-wave elevation indicative of NSTE-ACS. Cardiac markers obtained & aren't elevated. Pt risk-stratification score indicates low risk. Findings suggest

Unstable angina

Three minutes after the initial dose of atropine is administered, Mr. Hernandez's heart rate has increased slightly to 34 bpm, but there is no change in his clinical condition. How should Dr. Hudson direct the team's next actions

Valerie, please administer a second dose of atropine. Haley, please attach defibrillator/pacing pads.

Defining characteristics of stroke

Vascular cause - Lasting neuro deficit - Sudden onset - Primary involvement of CNS

Conditions that contribute to pathophysiology of ACS

Vasospasm - Development of occlusive intracoronary thrombus - Transient platelet aggregation - Plaque erosion

What has the rhythm changed to

Ventricular tachycardia

EKG of pt c/o dizziness, syncope, SOB = Sinus brady. When reviewing med hx, HCP identifies what med(s) as potential cause of condition

Verapamil - Digoxin - Metoprolol - Meds associated w. sinus brady include BB (metoprolol) & CCB (verapamil/digoxin)

Pt presents to ED w. suspected ACS. EKG & cardiac biomarkers indicate a STEMI. Exam reveals s/s of left ventricular dysfunction. S/S to support this

Weak peripheral pulses - Hypotension - Crackles

Hyperkalemia suspected c/o cardiac arrest, confirmed on ECG d/t

Wide-complex ventricular rhythm & tall, peaked T waves

In 12-lead ECG, the 4 limb leads produce views in frontal plane. What are those views? (6)

aVL - I - aVR - II - III - aVF