PEA and Asystole Test 1
hypovolemia hypoxia hypo/hyperkalemia hydrogen ions (acidosis) hypoglycemia hypothermia
6 H's of asystole/ PEA??
lung base
A nurse is listening to a patient w/ suspected tension pneumothorax. Where should he expect absent breath sounds?
narrow QRS complex, narrow neck veins ... VERY COMMON CAUSE OF PEA
A pt with hypovolemia will present with what physical assessment findings and what ECG characteristic?
slow HR,cyanosis, airway problems! VERY COMMON CAUSE OF PEA
A pt with hypoxia will present with what physical assessment findings:
1. Start CPR 2. Give O2 3. Attach monitor/defibrillator 4. shockable rhythm...shock 5. CPR 2 min 6. IV/IO access 7. Shock 8. CPR 2 min 9. Epinephrine every 3-5 min 10. Consider advanced airway, capnography 11. Shock 12. CPR 2 min 13. Amiodarone or Lidocaine 14. Treat Reversible causes
Algorithm of VF or PVT
1. CPR 2. Give O2 3. Attach monitor/defibrillator 4. NO SHOCK since it is asystole 5. CPR 2 min 6. IV/IO access 7. Epinephrine every 3-5 min 8. Consider advanced airway, capnography 9. DO NOT SHOCK and check rhythm 10. CPR 2 min 11. Treat reversible causes 12. check rhythm after 2 min. CPR and epi...nothing...post arrest care
Asystole Algorithm.
power; connections
Asystole Flatline Protocol: Check ____ to both monitor and defibrillator-check pads and proper connection! Check ALL _____ and check lead select, gain, and sensitivity paddles. FIRST CHECK THE PATIENT, then check the monitor
advanced; conduction; hyperkalemia; acidosis
Asystole clinical associations are ____ cardiac disease, severe cardiac ____ system, advanced heart failure, severe _____, _____.
flatine; reverse
Asystole is a ____ and there is nothing really happening in the heart. It can look like little waves (not always just a flat line). This is hard to ____ once it happens!
sandstill; negative; survive
Asystole is sometimes call ventricular ____! It is rarely associated with a positive outcome! It is usually a ____ outcome where a large percentage do NOT ____!
advanced; end; cannot;
Asystole is usually a result of ____ heart disease, a severe cardiac conduction system disturbance, or ____-stage HF. Generally the patient with asystole has end-stage heart disease or has a prolonged arrest and ____ be resuscitated.
full; absence
Asystole physical assessment: patients are in ___ arrest with a loss of conscious, ____ of pulse, respirations, and blood pressure. These patients are dead pretty much!
total; depolarization
Asystole represents the ____ absence of ANY electrical activity! There is NO ventricular contraction that occurs because ______ does not occur!
total; P; ventricular; apneic; VF; more
Asystole represents the ____ absence of ventricular electrical activity. Occasionally, ____ waves are seen. No _____ contraction occurs because depolarization does not occur. Patients are unresponsive, pulseless, and ____. Asystole is a LETHAL dysrhythmia that requires immediate treatment. ___ may masquerade as asystole. Always assess the rhythm in ____ than one lead. The prognosis of a patient with asystole is extremely poor.
CPR; epinephrine
Asystole treatment consists of ____ with initiation of ACLS measures. These include definitive drug therapy with ____ and/or vasopressin, and intubation.
epinephrine; vasoconstriction; hyperkalemia; pull
Asystole treatment! ____: 1 mg IV push, repeat every 3 to 5 minutes. Epinephrine produces _____ and increases diastolic blood pressure, blood flow to the brain, and some blood flow to the heart, specifically the coronary arteries. May give sodium bicarbonate equal to 1 mEq/kg. This is helpful if known to have _____ or a known drug overdose with tricyclic antidepressants. If lots of epi has been given and lots of CPR, you may ____ out the bicarb
electrical
Asystole=A cardiac arrest rhythm associated with no discernable ____ activity on the monitor.
epinephrine; 1
Asysytole drugs=_____ at ___mg IV repeat every 3-5 minutes
PEA; asystole
Do Not Shock ____ or _____!!!!
shock; stunned
Do not ____ asystole!!! Some clinicians argue that "shocking asystole cannot make the rhythm any worse" or "if you administer a shock you may convert the patient into VF and give them a chance to survive." But shocks can be harmful. Can produce a ____ heart which would eliminate any possibility of the return of spontaneous cardiac activity.
flush; lighter; fast
Epi is the only drug for asystole! There is no calculation and you just prime the med and ____ it into the patient! Slamming the epi and slowly putting the epi in does not give the same impact. Epi is like ____ fluid! Epi is trying to blow the heart up so you want to flush/slam it as ____ as possible.
presence; positive; broken
Family presence: An emerging clinical practice is allowing or encouraging family ____ at resuscitation attempts. Sometimes it is good or bad to have a family member in the room (it depends on the situation). Interviews conducted with family members indicate this to be a ____ experience. It allowed closure for the loved one. Research shows a strong therapeutic effect. Codes are super hard on the patient. Patients can have ____ ribs or collapsed lungs if compressions are done well enough.
every 2 min
How often should you switch people for compressions?
smaller; diabetes; renal; sodium bicarbonate; insulin; ketoacidosis; respiratory
Hydrogen Ions (acidosis): Features of electrical activity: ____ QRS complexes. Physical assessment: history of _____, _____ failure. Treatment: _____ _____, _____, hyperventilation. Hx of diabetes and renal failure contribute to acidosis. Renal regulates your base and you are at risk for acidosis from diabetes due to _____! Hyperventilate these people bc they are blowing off the acid (____ is quickest way to treat acidosis)
higher; flat; U; renal; dialysis; diuretic
Hyperkalemia or hypokalemia: Features of electrical activity: Hyperkalemia will have _____ T waves and peaked. Hypokalemia will have ____ T waves with prominent ____ waves. Physical assessment of hyperkalemia: history of _____ failure, diabetes, _____, medications Physical assessment of hypokalemia: abnormal loss of potassium, _____ use. Low potassium can be from Lasix and you are dumping the potassium! High potassium can be from too much supplements and not aware of how much potassium they are intaking, renal issues bc you are not filtering out the potassium (potassium does not come out unless you have dialysis from renal issues)
sodium bicarbonate; calcium; Kayexalate
Hyperkalemia treatment is _____ _____, glucose plus insulin, _____ chloride, ______ (poop out all their potassium), dialysis (long term).
dextrose 50; routine
Hypoglycemia: Check blood glucose, administer _____ ____ if necessary. Check history of patient. Check _____ blood sugars! If patient does not eat or bottoms out before they eat...check the sugar and treat it accordingly
infusion; burns
Hypokalemia treatment is rapid but controlled _____ of potassium. Potassium infusion takes about a couple of hours bc it _____ and you will kill them if you give it too fast. NEVER push potassium.
central; warm; heated
Hypothermia: Physical assessment: History of exposure to cold, ____ body temperature. Treatment: Bear Hugger, _____ blankets, _____ IV fluids
hypoxia; reversible; temporary
Hypovolemia and _____ are the two most common and easily _____ causes of PEA. Cardiac toxicity from drug overdose is a common cause of PEA. In these situations the myocardium is healthy, but a _____ cardiac disturbance has caused clinical death. A healthy heart and you fix the problem, the person will be fine. But if MI is happening it is harder for the patient to be fine once problem is fixed
narrow; rapid; narrow; epi, CPR; infusion
Hypovolemia: features of electrical activity is a ____ QRS complex and a _____ rate BUT there is NO pulse! The patient will have ____ neck veins! Treatment is ____,____, and dump a ____ infusion (500 mL NS as quickly as possible!) Fluid resuscitation with hypovolemia! Dehydration (burns, excessive vomiting, trauma causing blood loss)
slow; blood gases; oxygenation
Hypoxia: features of electrical activity is a ____ rate! Physical assessment is cyanosis, _____ _____, airway problems! Treatment is _____, ventilation! Pt is blue, blood gases are crap, soo reverse hypoxia by giving oxygen
distended... the heart is so constricted that it can't pump... meaning it can't receive blood correctly either so blood backs up into periphery
If a patient has cardiac tamponade, the neck veins will be __________.
doctor's; quality;
If asystole persists after multiple days of epi: Ask these Questions ~Withhold or cease resuscitative efforts? NO this is the _____ say and not a nurse's ~Consider _____ of resuscitation? Is my IV good enough to get where it needs to go, are chest compressions good ~Support for cease-efforts protocols in place? Are protocols in place if you end it
P; immediate
In asystole, you may see a ___ wave BUT NO QRS complex! The sinoatrial node may continue to fire and depolarize the atria, but it requires _____ attention
epinephrine
PEA drug is ______! 1 mg IV/IO repeat every 3-5 minutes! This drug is where you slam it
History Physical Exam 6 H's 5 T's
PEA-How do we search for causes of PEA?
Epinephrine; push
PEA: _____ 1 mg IV/IO ____, repeat every 3 to 5 minutes.
rapid; clinical; CPR
PEA= ____ assessment and aggressive management offer the best chance of success. PEA is often associated with a reversible _____ state. Need to search for a reversible cause (remember the 6 H's and 5 T's)!!!!! Try to find a reversible cause in addition to the _____ and epi! A lot of people will be doing a lot of things to find the cause-foley in to check renal, iv, cxr, vital signs, ekg...
reversible; electrical
Pulseless Electrical Activity is where you focus on assessing and treating patients. Search for the _____ cause, which is the key to treating these patients. Many conditions may cause PEA. PEA displays ____ activity but produces no clinically detectable pulse.
match
Pulseless Electrical Activity is where you got something on the monitor like a normal sinus rhythm, but the patient is dead! The monitor does not _____ the patient
contraction; ineffective; identify; CPR; muscle
Pulseless Electrical Activity patho is cardiac conduction impulses occur in organized pattern, but this fails to produce myocardial ____; or insufficient ventricular filling during diastole; or _____ contractions. Key treatment for this rhythm is to _____ and treat reversible causes and to provide effective _____. Everything is happening electrically (so this is why it shows up on the monitor) but the _____ is not responding to the electrical impulses
electrical; pulse
Pulseless Electrical Activity refers to an semiorganized or organized _____ activity that can be seen on the monitor although the patient LACKS a palpable _____! Prognosis is POOR unless the underlying cause can be identified and corrected!
electrical; defibrillation; poor
Pulseless electrical activity (PEA) is a situation in which organized _____ activity is seen on the ECG, but there is NO mechanical heart activity and the patient has no pulse. It is the most common dysrhythmia seen after ____. Prognosis is ____ unless the underlying cause is quickly identified and treated.
FALSE DO NOT SHOCK
T/F: Asystole is a shockable rhythm??
False...most do not survive
T/F: most patients who are in true asystole usually make it
TRUE!!!! MUST be able to distinguish the two rhythms
T/F: the treatment for V-fib and asystole is different?
False! Do not shock either
T/F: while you can't shock asystole, you can shock PEA?
bradycardia; neurologic; charcoal; narcaine
Tablets: Features of electrical activity: various effects on EKG. Physical assessment: _____, history of ingestion, pupils, _____ exam Treatment: drug screens, lavage, activated _____ absorbs drugs in the GI tract, specific antidotes, lactulose. Drug overdose! SO know what they overdosed on because not everything is ingested orally!! Some people will put alcohol on tampons and get overdosed on that. _____ IV will reverse and work quickly on an overdose.
pressure; beat; narrow; rapid; pericardiocentesis
Tamponade: is where there is _____ on the heart bc there is either blood or fluid around the heart. The heart wont ____ right d/t the pressure: Features of electrical activity -____ complex, ____ rate. Physical assessment - history, neck vein distention! Treatment - ______-put needle to drain the fluid and take pressure off the heart
collapsed; narrow; slow; pulse; deviation; unequal; decompression
Tension Pneumothorax: _____ lung: Features of electrical activity - _____ complex _____ rate. Physical assessment - history, no ____, neck vein distention, tracheal _____ and trachea will push over to the side that is NOT collapsed-so if left is collapsed the trachea deviation is on the right, ____ breath sounds. Treatment - needle _____. Usually they put in a chest tube on that side to reinflate the lung and get air in that space
tablets; tamponade; tension pneumothorax; thrombosis; thrombosis
The 5 T's ______ (drug overdose) ______ _____ _____ ______ (heart like MI) ______(lungs, like a pulmonary embolus)
hypovolemia; hypoxia; hydrogen ions; hyperkalemia/hypokalemia; hypothermia; hypoglycemia
The 6 H's of Asystole= _____=maybe they bled out, severely dehydrated _____=not breathing well enough _____ ion (acidosis)=too many hydrogen ions _____/________ ______=temp drops _______ *If you can fix these reasons, you can REVERSE the cardiac arrest!
hypovolemia; hypothermia; thrombosis; CPR; intubation
The most common causes of PEA include ____, hypoxia, metabolic acidosis, hyperkalemia, hypokalemia, hypoglycemia, ____, toxins (e.g., drug overdose), cardiac tamponade, ____ (e.g., MI, pulmonary embolus), tension pneumothorax, and trauma. Treatment begins with ____ followed by drug therapy (e.g., epinephrine) and _____. Correcting the underlying cause is critical to prognosis.
narrow; rapid; embolectomy; fibrinolytics
Thrombosis (airway): Features of electrical activity - ____ complex, _____ rate. Physical assessment - history, distended neck veins. Treatment - surgical ______ (go in and get it out), ______. *reestablish perfusion to where you are not getting perfusion in
ST; Fibrinolytic
Thrombosis (coronary, MI): Features of electrical activity - Abnormal EKG, Q wave, ___ changes. Physical assessment - history, EKG, enzymes. Treatment - _____ agents. Eliminate thrombosis and reestablish circulation
another
Ventricular fibrillation may masquerade as asystole! The nurse must assess the rhythm in ____ lead for accurate interpretation! Treatment for these two rhythms (VF, asystole) differs greatly, the nurse must be familiar with the treatment
diabetes; renal failure
What are common patient histories of acidosis?
hyperkalemia- tall, peaked T wave hypokalemia- flat T wave w/ U wave
What are prominent ECG characteristics associated with hyperkalemia and hypokalemia?
-open chest wound (acts as a 1 way valve letting air in on inspiration but it can't escape) -clamped/blocked chest tubes -mechanical ventilation -resuscitation
What are some causes of tension pneumothorax?
tachycardia and eventually asystole JVD tracheal deviation unequal breath sounds cyanosis extreme agitation profuse diaphoresis MEDICAL EMERGENCY!
What are some physical assessment findings for a tension pneumothorax?
sodium bicarbonate glucose and insulin calcium chloride kayexalate dialysis
What are some treatments for hyperkalemia?
tablets tamponade tension pneumothorax thrombosis (heart) thrombosis (lungs)
What are the 5 T's for causes of asystole/PEA?
tablets tamponade tension pneumothorax thrombosis (heart) thrombosis (lungs)
What are the 5 T's of asystole/ PEA causes???
hypovolemia hypoxia hypo/hyperkalemia hydrogen ion (acidosis) hypothermia hypoglycemia
What are the 6 h's for causes of asystole/PEA?
Hypovolemia, hypoxia
What are the two MOST common causes of PEA?
V-fibrillation
What can asystole be occasionally mistaken for?
narrow complex, slow rate
What does a tension pneumothorax show on an ECG?
narrow complex, rapid rate
What does cardiac tamponade show on an ECG?
it produces vasoconstriction and increases diastolic blood pressure, blood flow to the brain, and coronary blood flow
What effect does epinephrine have on the cardiovascular system?
rapid but controlled potassium infusion *** DON'T BE STUPID AND GIVE IT TOO FAST
What is a treatment for hypokalemia?
a semiorganized/organized electrical activity that can be seen on the monitor although the patient lacks a palpable pulse
What is defined as PEA?
1 mg Q3 minHARD AND FAST FLUSH HARD AND FAST
What is the dosage for epinephrine in asystole Tx?
ID and treat reversible causes and provide effective CPR
What is the key in treating PEA?
Circulation AirwayBreathing MEDS (NOT DEFIB!!!)
What is the order of priority for asystole treatment?
poor
What is the prognosis for PEA?
sodium bicarbonate insulin if diabetic hyperventilation to blow off CO2
What is the treatment for acidosis?
pericardiocentesis
What is the treatment for cardiac tamponade?
needle decompression (followed by chest tube insertion w/ drainage system)
What is the treatment for tension pneumothorax?
epinephrine 1 mg every 3-5 mins
What meds do you give for PEA?
-renal failure pts -diabetes pts -dialysis pts -heart patients taking certain meds like potassium-sparing diuretics and regular diuretics
What type of patients would typically hint to issues with potassium balance?
small
What will the QRS complex look like in acidosis?
Q wave changes, ST changes, T wave changes
What would an ECG show for MI?
tablets (drug OD w/ tricyclic antidepressants), hyperkalemia, acidosis
When can sodium bicarbonate be helpful in asystole/ PEA?
bradycardia history of ingestion pupil size neurologic exam
When performing a physical assessment for drug overdose, what are some things to assess for?
it can produce a stunned heart and eliminate any possibility of the return of spontaneous cardiac activity
Why should you not shock asystole?
circulation; CPR
With asystole, no matter how dead the patient is, check ____, Airway/Breathing, Diagnosis/Meds (BLS)! Start ____/compressions and until that happens nothing else matters
assess patient! .. check in 2 leads.. don't waste time obviously but don't call code for disconnected leads
prior to freaking out, what should be done if asystole is seen on the monitor?
