OMFS Secrets, Ch14, BLS, ACLS, AND ATLS
What are the four life-threatening conditions that may mimic acute MI and lead to cardiovascular collapse?
1. Massive pulmonary embolism 2. Cardiac tamponade 3. Hypovolemic and septic shock 4. Aortic dissection
How is a patient with a bradyarrhythmia initially managed according to AHA protocol?
1. Supportive actions: • Assess ABCs • Chest X-ray • Oxygen, IV, monitors, and pulse oximetry • Brief history and targeted physical exam • 12-lead ECG 2. Determine if bradycardia is hemodynamically significant. • Monitor patient. • Be prepared to begin transcutaneous pacing (TCP) on standby. If the patient is hemodynamically unstable: • Atropine, 0.5 to 1.0 mg IV • Epinephrine infusion, 2 to 10 mg/min • TCP • Isoproterenol infusion, 2 to 10 mg/min • Dopamine infusion, 5 to 20 mg/kg/min
When a child or infant has a pulse but is breathless, what is the recommended rate of rescue breathing?
Once every 3 seconds (20 breaths/min). Add compressions if the pulse remains <60 with signs of poor perfusion.
Where is the correct location for applying pressure for external chest compressions in adult and children victims?
The center of the chest, between the nipples (lower half of the sternum). In adults, use the heels of both hands, with one stacked on the other to perform the compressions. In children ages 1 to 8 years, use the heel of one hand.
What is the recommended initial management for a stable adult patient with chest pain that is suggestive of ischemia?
1. Call for help. 2. Perform immediate assessment including: • Vital signs and SaO2 monitoring • IV access and electrocardiogram (ECG) • Targeted history and physical exam • Initial serum cardiac marker levels, electrolytes, and coagulation studies • Portable chest X-ray 3. Immediate general treatment: Morphine (pain) Oxygen (4L/min to start) Nitroglycerin (sublingual/spray) Aspirin (160-325mg chew) Beta Blocker ACE inhibitor/ARB Statin Heparin
What are the four steps of basic life support (BLS)?
1. Check responsiveness (also check for absent or abnormal breathing by scanning the chest for movement). 2. Activate the emergency response system/get automated external defibrillator (AED). 3. Circulation (check the carotid pulse): if no pulse within 10 seconds, start CPR. 4. Defibrillate.
According to AHA protocol, how is PEA treated?
1. Continue CPR. 2. Intubate/establish IV access. 3. Assess blood flow using Doppler. 4. Consider and treat underlying causes. 5. Epinephrine, 1 mg IV/IO. Repeat every 3 to 5 minutes, or you may give one dose of vasopressin 40 U IV/IO to replace the first or second dose of epinephrine. 6. Atropine, 1 mg IV push if pulse is present and absolute bradycardia is <60 beats/min. Repeat every 3 to 5 minutes (up to three doses).
What four conditions other than asystole can lead to a flat-line tracing on ECG?
1. Fine V-fib 2. No power 3. Loose electrode leads 4. Signal gain is turned down.
What are the major updates for ACLS based on the 2010 AHA guidelines?
1. For the cardiac arrest algorithm, emphasis is centered on a 2-minute cycle of chest compressions. 2. Continued emphasis for vasopressors to be used every 3 to 5 minutes. This may be either epinephrine or vasopressin. 3. Administer amiodarone for refractory ventricular fibrillation or ventricular tachycardia. 4. Atropine is no longer recommended for use in pulseless electrical activity or asystole.
What is the American Heart Association (AHA) Emergency Cardiovascular Care Adult Chain of Survival?
1. Immediate recognition of cardiac arrest and initiation of the emergency response system 2. Early CPR (emphasizing chest compressions) 3. Rapid defibrillation 4. Effective advanced life support 5. Integrated post-cardiac arrest care
What are the four universal steps of AED operation?
1. Power on AED. 2. Attach AED pads to victim's chest (use adult pads for victims >8 years old). 3. Clear victim and analyze heart rhythm. 4. Clear victim and deliver shock if indicated. Directly after the shock is delivered (or if no shock is needed), immediately resume chest compressions.
What length of time is used when assessing for a pulse?
<10 seconds. If a pulse is not felt within 10 seconds, begin CPR. Assess the carotid pulse in children and adult. Assess the brachial pulse in infants.
What is the rate of external chest compressions for adults, children, and infants?
>100/min. The number of chest compressions delivered per minute is determined not only by the rate of compressions, but also by the frequency and duration of interruptions. You must provide an adequate compression rate and minimize interruptions to provide for adequate compressions.
What is the recommended method of clearing foreign body airway obstructions in infants?
A combination of back slaps and chest thrusts: five back slaps followed by five chest thrusts, repeated until the object is dislodged. Do not use the Heimlich maneuver because an infant's liver is not well protected by the ribs and is at risk for injury with this technique. If the infant becomes unresponsive, begin CPR.
When does sinus bradycardia need treatment?
A patient with a slow heart rate needs treatment only if there are serious signs or symptoms associated with the slow heart rate that indicate the patient is already or is becoming hemodynamically unstable. These signs and symptoms include: • Signs: hypotension, congestive heart failure, pulmonary congestion, and acute MI • Symptoms: chest pain, shortness of breath, and decreased level of consciousness
What is the depth of external chest compressions in children?
At least one-third the depth of the child's chest (about 2 inches).
After successful resuscitation (ROSC), what is done with the patient?
If signs of circulation and breathing return, place the patient in the recovery position. Continue to monitor pulse and blood pressure. Leave the AED in place and turned on while monitoring the patient. The patient should be transported to the appropriate hospital or critical care unit. Multidisciplinary care is vital.
Which tachyarrhythmias are supraventricular?
If the QRS complex is narrow, then the tachyarrhythmia is supraventricular. This means the arrhythmia is originating at or above the level of the atrioventricular (AV) node: • Sinus tachycardia • A-flutter • A-fib • PSVT If the QRS complex is wide, then the tachycardia is of ventricular origin: • Wide-complex tachycardia of uncertain type • VT
At what point should EMS be activated with an infant or child victim?
If the arrest was not witnessed, call EMS after five cycles (approx. 2 minutes) of CPR. It is believed that many children develop respiratory arrest and bradycardia prior to cardiac arrest. During this time (prior to progression to cardiac arrest), these younger victims have a higher survival rate if CPR is started. Once a child progresses to cardiac arrest, his or her chance of survival is much lower. If the arrest is sudden and witnessed, call EMS first.
What is the rate of ventilation in a patient with an advanced airway?
One breath every 6 to 8 seconds (8 to 10 breaths/min). These breaths are not synchronous with chest compressions.
Where is the ideal location for applying pressure for external chest compressions in infants?
One finger width below the nipple line, with care being taken to stay off the xiphoid process. Use two fingers to perform the compressions or use the two thumb encircling hand technique if two rescuers are available.
Why do we need to avoid excessive ventilation during CPR?
Over-ventilation during CPR means too much volume is forcefully delivered into the patient. This causes multiple problems including gastric distention, which is caused when pressure overcomes the esophageal sphincters. This may lead to increased risk of aspiration. Over-ventilation also increases intrathoracic pressure, which decreases venous return and decreases chances of survival.
What is the pathophysiology of PSVT?
PSVT is a distinct clinical syndrome characterized by repeated episodes of tachycardia with abrupt onset lasting a few seconds to many hours. PSVT is due to a reentry mechanism involving the AV node alone or automatic focus.
What are the current guidelines for cricoid pressure?
Per the 2010 guidelines, the AHA states one should not routinely use cricoid pressure during cardiac arrest. Cricoid pressure is a maneuver that is difficult to master, may not prevent aspiration as once thought, and may delay or prevent placement of advanced airway.
What are some of the complications of external chest compression?
Rib and sternal fractures are the most common iatrogenic injuries. Other complications include cardiac or pericardial injuries (hematomas, lacerations, ruptures) and damage to other adjacent structures (e.g., pneumothorax, GI laceration), but these injuries are rare. The number of iatrogenic injuries increases when the compression depths exceed 6 cm (2.3 inches), but these injuries are rarely fatal. Do not let fear of complications interfere with effective chest compression.
What is the best indicator of effective ventilation?
Seeing the chest rise when delivering breaths.
In the initial assessment, when is breathing assessed?
When assessing the patient for responsiveness, also check for normal breathing. Scan the chest for movement (for 5 to 10 seconds). If the patient is not breathing or is not breathing normally, begin chest compressions. After 30 chest compressions, open the airway and deliver two breaths. Abnormal breathing includes gasping for air or agonal breathing. "Look, listen, and feel" was removed from the 2010 AHA guidelines as a way to assess breathing due to excess delay and confusion when patients exhibited agonal gasping.
Why is it important to allow for full chest recoil?
When the chest recoils (re-expands) after each compression, it allows blood to flow into the heart. This allows for the next chest compression to create blood flow because compressions pump the blood in the heart into the rest of the body. If the chest does not completely recoil, it decreases the blood flow created by each chest compression.
What are the major differences between initial resuscitation efforts for pediatric patients vs. adult patients?
With a child or infant victim, CPR should be started promptly prior to EMS activation if the arrest is not witnessed. EMS should be called after five cycles (approx. 2 minutes) of CPR have been performed. In adults, EMS should be activated immediately. Another major difference is, when two rescuers are available, the compression to breath ratio for children and infants should be 15:2 (compared to adults, for whom the ratio stays at 30:2).
Can you use an AED in children and infants?
Yes. Ideally, in children from 1 to 8 years of age an AED should be used with a dose attenuator if available. If not available, a standard AED may be used. For infants (<1 year old), a manual defibrillator is preferred. If not available, then an AED with a pediatric dose attenuator would be the next choice, but if neither is available a standard AED may be used.
What are the signs and symptoms of hypovolemic shock?
• Cardiac output will be low due to inadequate left ventricular filling. • Hypotension may lead to changes in the ECG.
How can one monitor the quality of CPR?
• End-tidal CO2 of less than 10 mm Hg will not achieve ROSC. • Intra-arterial relaxation pressures of less than 20 mm Hg will not achieve ROSC. • The team leader should also monitor the quality of the compressions and instruct another provider to switch if unable to provide high-quality compressions.
What are the signs of mild versus severe airway obstruction?
• Mild: good air exchange, forceful cough, possible wheezing • Severe: poor to no air exchange, weak or absent cough, high-pitched noises during inhalation, no noises, respiratory difficulty, unable to speak, cyanosis (turning blue), universal choking sign
How much oxygen does mouth-to-mouth deliver compared to other techniques?
• Mouth-to-mouth ventilation delivers Approximately 17% inspired oxygen and 4% carbon dioxide. • Bag-mask ventilation delivers 21% oxygen. • Bag-mask ventilation with an oxygen supply can deliver close to 100% oxygen.
What is the rate of external chest compressions to breaths for one or two rescuers with a child or infant?
• One rescuer: 30:2 (30 compressions for every two breaths). • Two rescuer: 15:2 (15 compressions for every two breaths).
What are the types of narrow-complex tachycardia?
• PSVT: caused by a reentry circuit mechanism • Ectopic or multifocal atrial tachycardia: caused by an automatic focus • Junctional tachycardia: caused by automatic focus that originates within or near the AV node Reentry tachycardia responds well to antiarrhythmic medications and electrical cardioversion. Automatic focus tachycardias do not respond to electrical cardioversion and should be treated with medications that suppress the ectopic foci.
What are the signs and symptoms of cardiac tamponade?
• Persistent tachycardia with falling blood pressure • Pulsus paradoxus • Pulsatile neck veins • Enlarging heart shadow on chest X-ray
What is the initial assessment of a 12-lead ECG in patients with cardiac ischemia?
• ST-segment elevation or new-onset left bundle branch block (LBBB) strongly suggests a myocardial injury. New LBBB is caused by occlusion of the left anterior descending (LAD) branch of the left coronary artery. LAD occlusion causes a loss of a large amount of myocardium. • ST-segment depression or T-wave inversion (ischemia) • Non-diagnostic or normal ECG
What are the indicators of effective CPR?
• Seeing the chest rise when rescue breathing is delivered • Presence of a pulse during chest compressions (Intra-arterial relaxation pressures of less than 20 mm Hg will not achieve return of spontaneous circulation [ROSC].) • Capnography (end-tidal CO2) >10 to 15 mm Hg (End-tidal CO2 of less than 10 mm Hg will not achieve ROSC.) The team leader should also monitor the quality of the compressions and instruct another provider to switch if unable to provide high-quality compressions.
What are the principal types of bradyarrhythmias?
• Sinus bradycardia • A-fib with slow ventricular response • AV block: • First-degree heart block • Second-degree heart block, types I and II • Third-degree heart block • Relative bradycardia Other rhythms that may also be considered bradyarrhythmias are: • Pulseless electrical activity • Asystole
When is synchronized cardioversion used?
• Tachycardia • A-fib • PSVT • A-flutter
How is a flat-line rhythm verified to be asystole?
• The patient is pulseless. • The patient is unresponsive. • The monitoring leads are correctly hooked up. • There is a flat-line recording in more than one lead.
Which types of chest pain suggest cardiac ischemia?
• Uncomfortable squeezing pressure, fullness, or pain in the center of the chest lasting longer than 15 minutes • Pain that radiates to the shoulder, neck, arm, and jaws • Pain between the shoulder blades • Chest discomfort with light-headedness, fainting, sweating, and nausea • A feeling of distress, anxiety, or impending doom
How is hypovolemic shock treated?
• Volume loss can be diagnosed through history and clinical evaluation. • Replace volume with crystalloid or colloid solution when the hematocrit is normal. • With active bleeding, hemostasis must be achieved first. If the hematocrit is dangerously low, transfusion of whole blood or packed red blood cells is indicated.
What are the signs and symptoms of A-fib and A-flutter?
A-fib may result from multiple areas of reentry within the atria or from multiple ectopic foci. A-fib may be associated with sick sinus syndrome, hypoxia, increased atrial pressure, and pericarditis. Because there is no uniform atrial depolarization, no P-wave will be seen on ECG. Hypotension may result from A-fib. A-flutter is the result of a reentry circuit within the atria. A-flutter rarely occurs in the absence of organic disease. It is seen in association with mitral or tricuspid valvular disease, acute cor pulmonale, and coronary artery disease. Signs and symptoms include hypotension, ischemic pain, and severe congestive heart failure.
What are the components of high-quality CPR?
According to the advanced cardiac life support (ACLS) guidelines, the following are components of high-quality CPR: 1. Rate ≥100/min 2. Compression depth of ≥2 inches in adults 3. Complete chest recoil after each compression 4. Minimize interruptions in compressions. 5. Switch providers every 2 minutes to prevent fatigue. 6. Avoid excessive ventilations; one should only provide 500 to 600 ml of tidal volume per breath, which correlates to half a bag squeeze on the AMBU bag.
When should a responder alter the CAB and utilize the ABC algorithm for resuscitation?
Airway and Breathing algorithm components should be emphasized when the clinical scenario justifies their use, such as a patient in cardiac arrest secondary to drowning or asphyxiation. For a drowned patient, clearing the airway and providing rescue breaths will allow increased oxygen delivery. Patients with airway obstruction and the resulting hypoxia benefit from efficient maneuvers to clear the airway. To put it another way, if the patient's heart started beating again, but he had a collapsed airway, no oxygen would be delivered and resuscitation would be futile.
What does an AED/defibrillator do?
An AED/defibrillator delivers an electric shock to the heart that stops the movement of the heart muscle fibers and allows the electrical system to reset itself. It does not restart the heart, but it resets it, hopefully allowing an organized rhythm to take over. If an organized rhythm occurs and the heart starts contracting effectively, a pulse will be generated, indicating ROSC.
What age ranges delineate infants and children?
An infant is younger than age 1, and a child is age 1 year old to puberty
What is the depth of external chest compressions in adults?
At least 2 inches.
What is the depth of external chest compressions in infants?
At least one-third the depth of the infant's chest (about 1.5 inches).
In a victim with a pulse, how often should the pulse be checked during rescue breathing?
Once every 2 minutes.
What is the ratio of external chest compressions to breaths for one or two rescuers with an adult victim?
30 compressions for every two breaths (30:2) for both one- and two-rescuer CPR.
When an adult victim has a pulse but is breathless, what is the recommended rate of rescue breathing?
Once every 5 to 6 seconds (10 to 12 breaths/min).
How is V-fib/pulseless VT treated initially according to the AHA recommendations?
1. The initial treatment for V-fib is always defibrillation. 2. Begin with the universal algorithm: • Assess the airway, breathing, and circulation (ABCs). • Ascertain that the patient is in cardiac arrest. • Begin CPR with cycles of 30 compressions and two breaths until defibrillator is attached, and confirm V-fib. 3. Give one shock: • Manual biphasic: device specific (120 to 200 J) • AED: device specific • Monophasic: 360 J 4. If V-fib persists: • Resume CPR immediately, intubate, and establish IV access. • Administer epinephrine 1 mg IV/IO (intraosseous) and repeat every 3 to 5 minutes 5. Give five cycles of CPR. 6. Give one shock if the rhythm is shockable. 7. Resume CPR immediately after the shock. 8. Consider antiarrhythmic medications.
What are the types of wide-complex tachycardias and their AHA treatment recommendations?
1. Unknown type: • Attempt to identify and distinguish between VT and SVT with aberrant conduction due to the different treatment options for SVT that might compromise a patient with VT. • Always assume that any wide-complex tachycardia is VT until proven otherwise, because there is little danger in treating a wide-complex SVT as if it were VT. • Treatment: DC cardioversion, procainamide, or amiodarone for preserved cardiac function. Treat with DC cardioversion or amiodarone for impaired cardiac function. 2. Monomorphic VT: • QRS complexes appear identical in shape. • Treatment: procainamide, amiodarone, lidocaine, or sotalol with normal cardiac function. Lidocaine or amiodarone should be given to patients with impaired cardiac function. 3. Polymorphic VT: • QRS complexes are subdivided into normal baseline QT and prolonged baseline QT interval. • Associated with metabolic derangement such as electrolyte abnormalities or drug toxicities. • Treatment: search for the metabolic derangement. Use DC cardioversion, procainamide, amiodarone, or beta blockers. • Torsades de pointes is an example of this VT with a unique rhythm strip. The drug of choice for torsades associated with hypomagnesemia is magnesium sulfate.
What are the three mechanisms of cardiac arrest? Which is most commonly during the first minute following onset of cardiac arrest?
1. V-fib/pulseless VT 2. Pulseless electrical activity 3. Asystole V-fib is most commonly present during the first minute following the onset of cardiac arrest.
What are four conditions that require you to change how you use an AED?
1. Victim is in water (remove to dry area and dry off chest) 2. Victim has implanted pacemaker or defibrillator (place electrodes away from device) 3. Victim has transdermal patch (remove and clean area) 4. Victim has a hairy chest (quickly pull pads to remove hair and replace pads)
What is the length of time recommended to deliver each breath to an adult victim?
About 1 second/breath. You should see visible chest rise. Allow for full exhalation between breaths.
What is agonal breathing?
Absent breathing or nonfunctional breathing. This includes gasping, which does not move oxygen. Agonal gasps are not effective breathing. One should not be fooled into a false sense of security with agonal breathing; respiratory arrest is occurring and treatment should commence.
How are A-fib and A-flutter treated?
According to the AHA, the protocol for treatment of A-fib and A-flutter is: 1. Rule out precipitating causes for A-fib and A-flutter: • Heart failure • Pulmonary embolism • Acute MI/substance abuse • Hyperthyroidism • Hypokalemia • Hypoxia • Hypomagnesemia 2. Control the rate: • Preserved heart function: diltiazem (or another calcium channel blocker) or metoprolol (or another beta blocker), flecainide, propafenone, procainamide, amiodarone, or digoxin • Impaired heart function: diltiazem, digoxin, or amiodarone • Patients with Wolff-Parkinson-White (WPW) syndrome: Avoid adenosine, calcium channel blockers, beta blockers, and digoxin to control the rate. Convert the rhythm (electrical cardioversion if drug therapy is unsuccessful) if the duration is 48 hours or less. • Preserved heart function: DC cardioversion, amiodarone, ibutilide, flecainide, propafenone, procainamide • Impaired heart function: DC cardioversion, amiodarone 3. Convert the rhythm if the duration is >48 hours. 4. Urgent cardioversion: begins with IV heparin, followed by transesophageal echocardiogram to exclude atrial clot. Then cardiovert within 24 hours and give anticoagulation for 4 weeks. 5. Delayed cardioversion: anticoagulation for 3 weeks; then cardiovert and anticoagulate for 4 more weeks.
How is the diagnosis of cardiac arrest established?
By definition, the patient is in full cardiac arrest if he or she: • Is not responsive • Is not breathing • Has no pulse
What is the new sequence of CPR?
CABD: Chest compressions, airway, breathing, defibrillation. The 2010 guidelines emphasize chest compressions for both trained and untrained rescuers. Chest compressions should be initiated prior to ventilation. If a person is not CPR trained, he or she should provide Hands-Only (compression-only) CPR. This change of sequence allows for chest compressions to be initiated sooner, increasing the patient's chance of survival.
What is the relationship between 12-lead EGC findings and coronary artery disease?
ECG relationship: • Anterior myocardium injury/infarct: V3 and V4 • Septal myocardium injury/infarct: V1 and V2 • Lateral myocardium injury/infarct: I, aVL, V5, V6 • Inferior myocardium injury or infarct: II, III, aVF Coronary artery branches relationship: • LAD artery occlusion: V1 through V6 • Circumflex artery occlusion: I, aVL, +/- V5, V6 • Right coronary artery occlusion: II, III, aVF
In a pulseless victim, how often should the pulse/rhythm be checked during CPR?
Every 2 minutes. The goal is to minimize interruption during compressions. Do not take longer than 10 seconds to assess the pulse.
What are the effects of excessive ventilation?
Excessive ventilation (giving breaths too rapidly or with too much force) may decrease cardiac output and increase the risk of regurgitation and aspiration. Excessive ventilation increases intrathoracic pressure, decreasing venous return to the heart and in turn diminishing cardiac output. It increases the risk of regurgitation and aspiration by forcing air into the stomach, causing gastric inflation once the esophageal opening pressure is exceeded. To reduce the risk of aspiration, you should deliver air until you make the victim's chest rise and take 1 second to deliver the breath. You should also watch the victim's chest fall as you allow time for the lungs to empty.
What is first-degree heart block?
First-degree heart block is the prolonged delay in conduction at the AV node or the bundle of His. The diagnosis of first-degree heart block is based on the PR interval. First-degree heart block exists when the PR interval is longer than 0.2 seconds.
What is meant by the term heart block?
Heart block is used interchangeably with the correct term, atrioventricular (AV) block. AV block describes a delay or interruption in conduction between the atria and the ventricles, which may be caused by one or more of the following: • Lesion in the conduction pathway • Prolonged refractory period along the conduction pathway • Supraventricular heart rates that surpass the refractory period of the AV node
What is WPW syndrome? Which drugs can be harmful in the treatment of A-fib or A-flutter associated with WPW syndrome?
If there is an extra conduction pathway, the electrical signal may arrive at the ventricles too soon. This condition is called Wolff-Parkinson-White (WPW) syndrome. It is in a category of electrical abnormalities called pre-excitation syndromes. It is recognized by certain changes on the ECG, which is a graphical record of the heart's electrical activity. The ECG will show that an extra pathway or shortcut exists from the atria to the ventricles. Many people with WPW syndrome who have symptoms or episodes of tachycardia (rapid heart rhythm) may have dizziness, chest palpitations, fainting, or, rarely, cardiac arrest. Other people with WPW syndrome never have tachycardia or other symptoms. About 80% of people with symptoms first have them between the ages of 11 and 50. Drugs that selectively block the AV node without also blocking coexisting accessory conduction pathways (e.g., adenosine, calcium channel blockers, beta blockers, and digoxin) are contraindicated when pre-excitation syndromes are present. These medications can increase conduction through the accessory pathway and paradoxically increase the heart rate. For patients with A-fib or A-flutter, this poses severe risks and is associated with a very high incidence of clinical deterioration.
At what point should EMS be activated with an adult victim?
Immediately upon finding an unresponsive adult. The victim should be checked for responsiveness and breathing, and then the emergency response system should be activated and an AED should be retrieved, if available. Return to the victim to check a pulse and begin CPR. Most adults in cardiac arrest are in ventricular fibrillation (V-fib); therefore the time from collapse until defibrillation is the single greatest factor in survival.
What maneuver should the rescuer first use to open the airway in an otherwise uninjured patient? What if the patient has a suspected neck injury?
In an uninjured patient, perform the head tilt with chin lift maneuver to open the airway. In an unconscious patient with a suspected neck injury, the jaw thrust should be performed. The jaw thrust pulls the mandible forward, which pulls the tongue and epiglottis anteriorly off the upper airway (with minimal cervical hyperextension). This is only possible with two rescuers.
Where are the sites that intraosseous access can be achieved?
In general, the anatomic sites that are common include sternum, humeral head, anterior superior iliac spine, medial malleolus, distal radius, distal femur, and proximal tibia. Certain devices are site specific, so one should be familiar with the specific device at one's institution. Similar to with all ACLS medications, one should flush the meds with normal saline to propel the medication into the central circulation.
What is second-degree heart block?
In second-degree heart block, not every atrial impulse is able to pass through the AV node into the ventricles. The atrial impulses that are conducted to the ventricle will stimulate ventricular contraction. Therefore the ratio of P to QRS will be >1:1. Type I second-degree heart block (Wenckebach): • Occurs at the level of the AV node • Is usually due to increased parasympathetic tone or drug effects • Is characterized by progressive elongation of the PR interval • Conduction velocity through the AV node gradually decreases until the impulse is blocked, resulting in a skipped ventricular beat. Type II second-degree heart block: • Occurs below the level of the AV node, uncommonly at the bundle of His • Is usually due to a lesion along the pathway • Has a PR interval that does not lengthen before a skipped ventricular beat • May have more than one skipped ventricular beat in a row • Has a poorer prognosis than type I second-degree heart block • Is more likely to progress to complete heart block than type I
What drugs can be administered through the endotracheal tube?
L-E-A-N (Lidocaine, Atropine, Epinephrine, Narcan). Administer all tracheal medications at 2 to 2.5 times the recommended IV dosage, diluted in 10 mL of normal saline or distilled water. Tracheal absorption is greater with the distilled water as the diluent than with normal saline, but distilled water has a greater adverse effect on PaO2.
What is the goal for when a shock should be delivered after a victim collapses?
Less than 3 minutes. Early defibrillation results in better outcomes, and the goal is shock delivery within 3 minutes from the time of collapse.
What are each of the meds in MONA BASH used for?
Morphine = pain/anxiety O2 = up to 70% of pt demonstrate hypoxemia; O2 may limit ischemic myocardial damage Nitroglycerin = reduce angina, dilate coronary vessels (inc blood flow), reduce preload Aspirin = inhibit platelet aggregation (stop thrombus) and stabilize plaque, reduce mortality Beta blocker = reduce mortality, slow HR, lower BP ACEI/ARB = dec remodeling/scar tissue, dec mortality, lower BP Statins = decrease cholesterol (LDL), plaque stabilization, dec mortality Heparin = decrease mortality, inhibit thrombus formation https://quizlet.com/17429375/acute-coronary-syndrome-flash-cards/
What is tachycardia?
Tachycardia means that there is a rapid heart rate. The normal adult heart rate is considered by most to be between 60 and 100 beats/min. Thus a heart rate of >100 beats/min can be classified as tachycardia. Not all patients with a heart rate of 100 beats/min or more will require treatment. The following cardiac rhythms are considered tachyarrhythmias: 1. Atrial flutter (A-flutter)/atrial fibrillation (A-fib) 2. Narrow-complex tachycardia: • Junctional tachycardia • Paroxysmal supraventricular tachycardia (PSVT) • Multifocal or ectopic atrial tachycardia 3. Wide-complex tachycardia: • SVT with aberrant conduction • Stable monomorphic VT • Stable polymorphic VT (with and without normal baseline QT interval) • Torsades de pointes A patient with tachycardia or tachyarrhythmia needs treatment when there are signs and symptoms associated with the rapid heart rate. The following signs and symptoms indicate that the patient is already or is becoming hemodynamically unstable: • Symptoms: shortness of breath, chest pain, dyspnea on exertion, and altered mental status • Signs: pulmonary edema, rales, rhonchi, hypotension, orthostasis, jugular vein distention, peripheral edema, ischemic ECG changes, ventricular rate >150 beats/min
What is the recommended method of clearing foreign body airway obstructions in responsive children and adults? What do you do if the victim is unresponsive?
The Heimlich maneuver (abdominal thrusts) is used in responsive victims. If the victim is pregnant or obese, perform chest thrusts instead of abdominal thrusts. If the victim becomes unresponsive, activate EMS and begin CPR, starting with compressions.
Where should you check for a pulse in an infant? In a child?
The brachial pulse in an infant and the carotid or femoral pulse in a child.
When should hypothermia be considered in the ACLS protocol?
The goal of controlled hypothermia is to optimize survival and neurologic function when brain injury is suspected. Hypothermia is the only intervention shown to improve neurologic recovery. This intervention should be considered for any patient who is comatose after ROSC and V-fib was the presenting rhythm. Multiple studies have demonstrated improved outcomes for patients whose temperature was decreased to 32-34° C for 12 to 24 hours.
What is the most common arrhythmia following electrical shock?
The most common arrhythmia caused by electrocution is V-fib; hence cardiac arrest is the primary cause of death from electrical shock. Other rhythms that may occur following electrical shock are VT progressing to V-fib and asystole. Electrical shock is the cause of more than 1000 deaths/year in the United States. It results in injuries ranging from unpleasant sensation to instant cardiac death. Exposure to high-tension current (>1000 V) is more likely to produce serious injury. However, death can result from exposure to relatively low voltage (100 V) household currents. Alternating current (AC) is more dangerous than direct current (DC). AC produces muscle tetany, which may prevent the victim from releasing the electrical source and thus prolong the contact.
Why should blind finger sweeps not be used in children and infants?
The object may be pushed deeper in the airway. Only attempt to remove the object if you can see it and it can be easily removed with your fingers.
What is asystole?
The term asystole indicates the absence of ventricular activity. The patient will be without a pulse. ECG will show characteristic flat-line tracing without P-waves and QRS complexes. The underlying causes of asystole can be remembered using the mnemonic PHD: Preexisting acidosis Hypoxia, hyperkalemia, hypokalemia, hypothermia Drug overdose
What is bradycardia?
The term bradycardia simply means that the heart rate is slow. Normal adult heart rate is considered by most to be 60 to 100 beats/min. According to this definition, every patient with a heart rate <60 beats/min is bradycardic. Not all patients with a heart rate <60 beats/min will need treatment. Autonomic influence or intrinsic disease affecting the cardiac conduction system most often causes bradycardia. A patient may have a relative bradycardia. An example is the patient with severe hypotension but with a heart rate of 70 beats/min; the heart rate of 70 in a hypotensive patient may not sustain the cardiac output.
What is shock?
The term shock denotes a clinical syndrome in which there is inadequate cellular perfusion and inadequate oxygen delivery for the metabolic demands of the tissues. Types of shock include: • Cardiogenic shock • Neurogenic shock • Hypovolemic shock • Flow disruption shock • Septic shock • Anaphylactic shock In general, shock is characterized by: • Increased vascular resistance • Anxiety • Cool mottled skin • Vomiting • Oliguria • Diarrhea • Tachycardia • Myocardial ischemia • Adrenergic response • Mental status changes • Diaphoresis
What is the most frequent cause of airway obstruction in an unconscious person?
The tongue.
According to AHA protocol, what is the treatment for asystole?
The treatment sequence for asystole is virtually the same algorithm for PEA: 1. Continue CPR. 2. Intubate/establish IV access. 3. Confirm asystole. 4. Consider and treat underlying causes. 5. TCP only if started early. 6. Epinephrine, 1 mg IV/IO. Repeat every 3 to 5 minutes, or you may give one dose of vasopressin 40 U IV/IO to replace the first or second dose of epinephrine. 7. Atropine, 1 mg IV/IO. Repeat every 3 to 5 minutes (up to three doses).
How do you open an airway? What do you do differently if the victim is an infant?
The two basic maneuvers to open an airway are head tilt with chin lift and jaw thrust. If the victim is an infant, do not extend the head beyond the neutral position because it may block the airway.
Why the change from ABC to CAB?
When an adult suffers from cardiac arrest, it is most often caused by ventricular fibrillation or ventricular tachycardia. The heart is quivering but fails to effectively deliver blood to the heart and other organs. By initiating chest compressions, the responder serves to pump blood and deliver oxygen to organs. By bypassing the "Airway and Breathing" part of the algorithm, one can deliver oxygen without additional delays and increase the chance of survival. Chest compressions will generate negative pressure upon recoil that will allow ambient air to be entrained into the pulmonary system.
What are the causes of PEA?
The underlying causes of PEA can be remembered easily using the mnemonic 5 H's and 5 T's. Five causes that start with H: Hypovolemia Hypoxia Hydrogen ion (acidosis) Hyperkalemia/hypokalemia Hypothermia Five causes that start with T: Table (ABCDs): antidepressants, beta blockers, calcium channel blocker, and digitalis Tamponade (cardiac) Tension pneumothorax Thrombosis (coronary) Thrombosis (pulmonary) Alternatively, the causes of PEA can be divided into three basic categories: 1. Inadequate ventilation: • Intubation of right main stem bronchus • Tension pneumothorax • Bilateral pneumothorax 2. Inadequate circulation: • Pericardial effusion with tamponade • Myocardial rupture • Ruptured aortic aneurysm • Massive pulmonary embolus • Hypovolemia 3. Metabolic disorder: • Electrolyte disturbances (hyperkalemia or hypokalemia, hypomagnesemia) • Persistent severe acidosis (diabetic ketoacidosis or lactic acidosis) • Tricyclic overdose • Hypothermia
What four conditions are pulseless?
There are four conditions in which the patient will present without a pulse and which are therefore considered nonperfusing conditions: 1. V-fib 2. Pulseless VT 3. PEA: • Electromechanical dissociation • Pseudo-EMD (pulse will be very faint and evident only by Doppler) • Ventricular escape rhythms • Postdefibrillation idioventricular rhythms 4. Asystole
What happens if chest compressions are interrupted?
There will be a decreased organ perfusion. During CPR, blood flow is completely dependent on chest compressions. Any interruption in CPR results in a lack of blood flow during that time.
According to AHA protocol, how is third-degree heart block treated?
Third-degree heart block is treated only if there are signs and symptoms that the patient is or is becoming hemodynamically unstable. Recommended treatment for third-degree heart block is: • Atropine, 0.5 to 1.0 mg • Epinephrine infusion, 1 to 2 mg/min • TCP • Fluid challenge if appropriate • Dopamine infusion beginning with 5 μg/kg/min
What is third-degree heart block?
Third-degree heart block occurs when no atrial impulses are transmitted to the ventricles. The atrial rate will be equal to or greater than the ventricular rate. If block occurs at the AV node, a junctional pacemaker may initiate ventricular depolarizations at a regular rate of 40 to 60 beats/min. If the block is infranodal, usually both bundle branches are blocked and there is significant disease of the conduction pathway.
What is pulseless electrical activity (PEA)?
This term is used to describe a group of diverse ECG rhythms that manifest electrical activity but are similar in that the patient will be without a pulse. Therefore the PEA is a nonperfusing rhythm. The types of rhythms included in the PEA group are: • EMD: organized ECG rhythm present, no pulse • Pseudo-EMD: as above, but with some meaningful cardiac contraction • Idioventricular, ventricular escape: wide-QRS, no atrial activity, and no pulse • Bradyasystolic: profound bradycardia with periods of asystole, no pulse PEA is almost always a secondary disorder resulting from some underlying condition.
What is the predominant determinant of successful CPR?
Time to restoration of spontaneous circulation, which itself is a function of the time to effective chest compression and time to defibrillation in ventricular fibrillation. Early CPR, minimizing interruptions, and reducing the time from collapse to defibrillation can result in quicker restoration of spontaneous circulation, which improves survival in hospital and nonhospital settings.
According to AHA protocol, how is type I second-degree heart block treated?
Type I second-degree heart block rarely requires treatment unless symptoms associated with bradycardia develop. Treatment should be directed at addressing the underlying cause of the block, such as: • Decreased parasympathetic tone • Propranolol toxicity/overdose • Digitalis toxicity • Verapamil toxicity/overdose If serious symptoms occur, then the following treatment is recommended: • Atropine, 0.5 to 1.0 mg • Epinephrine infusion, 1 to 2 μg/min • TCP • Fluid challenge if appropriate • Dopamine infusion, beginning with 5 μg/kg/min
According to AHA protocol, how is type II second-degree heart block treated?
Type II second-degree heart block requires no treatment unless symptoms associated with bradycardia develop. If serious symptoms develop, then the following treatment is recommended: • Atropine, 0.5 to 1.0 mg • Epinephrine infusion, 1 to 2 μg/min • TCP • Fluid challenge if appropriate • Dopamine beginning with 5 μg/kg/min
What is V-fib?
V-fib is a cardiac dysrhythmia that occurs when multiple areas within the ventricles display unsynchronized depolarization and repolarization. As a result, the ventricles do not contract as a unit. Instead, the ventricles appear to quiver, or fibrillate, as multiple areas of the ventricle are contracting and relaxing in a disorganized fashion. The net result is no cardiac output and no pulse.
What is the function and significance of waveform capnography?
Waveform capnography is a measure of CO2 with respiration. The waveform rises with expiration and returns to zero upon inhalation. It serves as the most reliable indicator of endotracheal tube position after intubation. It also serves as a monitor for effectiveness of chest compressions.
