BLS, ACLS & PALS

Proper compression rate for victims of all ages is at least C. 100 compressions per minute

C. 100 compressions per minute

To reduce rescuer fatigue during team CPR, compressor roles should be switched about every C. 5 cycles

C. 5 cycles

A patient is in cardiac arrest. Ventricular fibrillation has been refractory to an initial shock. What is the recommended route for drug administration during CPR? D. IV or IO

D. IV or IO

A patient w/ sinus bradycardia and a HR of 42/min has diaphoresis and a BP of 80/60 mmHG. What is the inital dose of atropine? B. 0.5 mg

B. 0.5 mg

A patient has been resuscitated from cardiac arrest and is being prepared for transport. She is intubated and is receiving 100% oxygen. BP is 80/60 mm Hg. During the resuscitation, she received 2 doses of epinephrine 1 mg and 1 dose of amiodarone 300 mg IV. You now observe the above rhythm on the cardiac monitor. The rhythm abnormality is becoming more frequent and increasing in number. You should order B. 1-2 L of normal saline

B. 1-2 L of normal saline

You are a healthcare provider responding to a call for help. You enter the hospital wing and see a 6-year-old boy lying motionless on the hallway floor. Another healthcare provider is already with the boy and explains to you that the boy has a heart condition and just collapsed. After confirming that the child is unresponsive and not breathing, he goes to activate the emergency response system and get the AED, leaving you to attend to the victim. - Your colleague arrives with the AED, and a third rescuer arrives with a bag and mask. The colleague managing the AED opens the device and begins taking out the pads. The third rescuer uses the bag and mask, and you and your colleague begin 2-rescuer child CPR with the correct compressions-to-breaths ratio of B. 15:2

B. 15:2

Recommended depth of chest compression's for an adult victim is at least B. 2 inches (5 cm)

B. 2 inches (5 cm)

More colleagues arrive at the scene, bringing the AED. You and a colleague are now ready to begin 2-rescuer while the pads are being placed. Which of the following is the preferred chest compression technique for 2-rescuer CPR in an infant? B. 2 thumb-encircling hands

B. 2 thumb-encircling hands

Bradycardia requires treatment when B. chest pain or shortness of breath is present

B. chest pain or shortness of breath is present

Best way for a rescuer to know that a rescue breath for an adult victim is effective? B. chest rises visibly

B. chest rises visibly

You are able to give breaths that produce visible chest rise for the victim of respiratory arrest (not breathing but with a pulse). Your next step is to B. continue rescue breathing, checking the pulse about every 2 minutes

B. continue rescue breathing, checking the pulse about every 2 minutes

An infant w/ a history of vomiting and diarrhea arrives by ambulance. During your primary assessment the infant responds only to painful stimulation. The upper airway is patent, the RR is 40/min w/ good bilateral breath sounds and 100% oxygen is being administered. The infant has cool extremities, weak pulses, and a capillary refill time >5sec. The infant's BP is 85/65 mm Hg and glucose conc. is 30 mg/dL (1.65 mmol/L). Which of the following is the most appropriate treatment to provide for this infant? B. establish IV or IO access and administer 20 mL/kg isotonic crystalloid over 10-20 minutes, simultaneously administer D25W 2-4 mL/kg in a separate infusion

B. establish IV or IO access and administer 20 mL/kg isotonic crystalloid over 10-20 minutes, simultaneously administer D25W 2-4 mL/kg in a separate infusion - hypotensive shock tx: first hour push repeated 20 mL/kg boluses of isotonic crystalloid - infant hypoglycemia < 60 mg/dL

When administering breaths by using a bag-mask device for a child who is not breathing but does have a pulse, the rescuer should B. give breaths at a rate of 1 breath every 3-5 seconds

B. give breaths at a rate of 1 breath every 3-5 sec - When administering breaths by using a bag-mask device for a child who is not breathing but does have a pulse, the rescuer should use the E-C clamp technique to hold the mask and should give breaths at a rate of 1 breath every 3-5 seconds or 12-20 breaths per minute

The child has a pulse and a heart rate of 64/min. Your next step is to B. give breaths without chest compressions

B. give breaths without chest compressions

This patient was admitted to the general medical ward w/ a history of alcoholism. A code is in progress, and he has recurrent episodes of his rhythm. You review his chart. Notes about the 12-lead ECG say that his baseline QT interval is high normal to slightly prolonged. he has received 2 doses of epinephrine 1 mg and 1 dose amiodarone 300 mg IV so far. What would you order for his next medication? B. give magnesium sulfate 1-2 g IV diluted in 10 mL D5W given over 5-20 minutes

B. give magnesium sulfate 1-2 g IV diluted in 10 mL D5W given over 5-20 minutes - Magnesium sulfate (2 g IV, followed by a maintenance infusion) may be used to treat polymorphic ventricular tachycardia consistent with torsade de pointes - A wide complex, irregular tachycardia may be polymorphic ventricular tachycardia (VT)/torsades de pointes. Use of atrioventricular (AV) nodal blockers in wide complex, irregular tachycardia of unclear etiology may precipitate ventricular fibrillation (VF) and patient death, and is contraindicated. Such medications include beta blockers, calcium channel blockers, digoxin, and adenosine. To avoid inappropriate and possibly dangerous treatment, the 2010 ACLS Guidelines suggest assuming that any wide complex, irregular tachycardia is caused by preexcited atrial fibrillation. - Treat polymorphic VT with emergent defibrillation. Interventions to prevent recurrent polymorphic VT include correcting underlying electrolyte abnormalities (eg, hypokalemia, hypomagnesemia) and, if a prolonged QT interval is observed or thought to exist, stopping all medications that increase the QT interval. Magnesium sulfate (2 g IV, followed by a maintenance infusion) can be given to prevent polymorphic VT associated with familial or acquired prolonged QT syndrome

Signs of a severe block in the airway in an adult or child who is responding? C. no coughing, not able to talk

C. no coughing, not able to talk

Main parts of BLS?

- Chest compressions - Airway - Breathing - Debifrillation

Initial management of shock in children

* For possible cardiogenic shock with hypovolemia, give 5 to 10 mL/kg of isotonic fluids (eg, normal saline or Ringers lactate), infused over 10 to 20 minutes. Evaluate target end points and slowly give another 5 to 10 cc/kg if there has been improvement or no change. For patients with diabetic ketoacidosis, give 10 mL/kg of isotonic fluids over one hour. • Such as inotropes or vasodilators. For newborns, prostaglandin E1. Δ For patients with DKA who do not improve with 20 mL/kg, look for another cause of shock before administering additional crystalloid. For possible cardiogenic shock, slowly give another 5 to 10 mL/kg if there has been improvement or no change. ◊ Dopamine if normotensive, norepinephrine if hypotensive and vasodilated, and epinephrine if hypotensive and vasoconstricted.

3 action steps for relieving choking in an unresponsive infant?

*do not perform blind finger sweeps in infants and children b/c may push FB back into airway 1. call for help; if someone responds send to activate ERS; place infant on firm, flat surface 2. begin CPR (C-A-B) w/ 1 extra step: each time you open airway, look for obstructing object in back of throat; if you see an object and can remove it, do so 3. after approx. 2 minutes of CPR, activate ERS if not already done

What age of a victim should you use adult AED pads?

- 8 years and older

- Can the victim be moved with AED still attached? - can the victim be analyzed while moving? why or why not?

- AED may remain attached during transport on a stretcher or in an ambulance - never push analyze button while moving victim b/c movement can interfere w/ rhythm analysis and artifacts can simulate ventricular fibrillation

Asystole

- Asystole: -- regularity: flat line -- rate: none -- P wave: none -- PRI: unmeasurable -- QRS: none - reversible causes: Hypovolemia Hypoxia Hypothermia Hypo/hyperkalemia H⁺/acidosis Toxins Tamponade Thrombosis pulmonary Thrombosis coronary Tension pneumothorax

2010 AHA BLS sequence?

- Chest compressions - Airway - Breathing

Treatable conditions associated with cardiac arrest

- Condition → Common associated clinical settings - Acidosis → Diabetes, diarrhea, drug overdose, renal dysfunction, sepsis, shock - Anemia → Gastrointestinal bleeding, nutritional deficiencies, recent trauma - Cardiac tamponade → Post-cardiac surgery, malignancy, post-myocardial infarction, pericarditis, trauma - Hyperkalemia → Drug overdose, renal dysfunction, hemolysis, excessive potassium intake, rhabdomyolysis, major soft tissue injury, tumor lysis syndrome - Hypokalemia* → Alcohol abuse, diabetes mellitus, diuretics, drug overdose, profound gastrointestinal losses - Hypothermia → Alcohol intoxication, significant burns, drowning, drug overdose, elder patient, endocrine disease, environmental exposure, spinal cord disease, trauma - Hypovolemia → Significant burns, diabetes, gastrointestinal losses, hemorrhage, malignancy, sepsis, trauma - Hypoxia → Upper airway obstruction, hypoventilation (CNS dysfunction, neuromuscular disease), pulmonary disease - Myocardial infarction → Cardiac arrest - Poisoning → History of alcohol or drug abuse, altered mental status, classic toxidrome (eg, sympathomimetic), occupational exposure, psychiatric disease - Pulmonary embolism → Immobilized patient, recent surgical procedure (eg, orthopedic), peripartum, risk factors for thromboembolic disease, recent trauma, presentation consistent with acute pulmonary embolism - Tension pneumothorax → Central venous catheter, mechanical ventilation, pulmonary disease (eg, asthma, chronic obstructive pulmonary disease), thoracentesis, thoracic trauma * Hypomagnesemia should be assumed in the setting of hypokalemia, and both should be treated.

Key principles in the performance of ACLS

- Excellent CPR is crucial. → Excellent chest compressions must be performed throughout the resuscitation without interruption, using proper timing (100 compressions per minute) and force (≥5 cm depth), and allowing for complete chest recoil. → Do not stop compressions until the defibrillator is fully charged. → Anything short of excellent CPR does not achieve adequate cerebral and coronary perfusion. → Excellent chest compressions take priority over ventilation. If a second rescuer is present, ventilations must be performed using proper timing (6 to 8 breaths per minute in the intubated patient; ratio of 30 compressions to 2 ventilations if not intubated) and force (each breath delivered over a full 1 to 2 seconds); avoid hyperventilation. - Defibrillate VF and pulseless VT as rapidly as possible. - Rapidly identify and treat causes of non-shockable arrest (PEA, asystole). → Important causes include the 5 H's and 5 T's: Hypoxia, Hypovolemia, Hydrogen ions (acidosis), Hyper/Hypo-kalemia, Hypothermia; Tension pneumothorax, Tamponade-cardiac, Toxins, Thrombosis-coronary (MI), Thrombosis-pulmonary (PE). → If reversible causes are not corrected rapidly, the patient has little chance of survival.

What is the only documented intervention that improves brain recovery after cardiac arrest?

- Hypothermia: unresponsive/comatose pts; should continue for 12-24 hrs; infused by infusing ice-cold saline or Lactated Ringer's during BP support; maintained by surface cooling devices;

ACLS: airway management - what are the steps for inserting an NPA?

- Nasopharyngeal Airway (NPA): can be used on conscious or unconscious patients 1. select an airway device that is the correct size for the patient 2. place the device at the side of the patient's face, make sure it extends from corner of mouth to earlobe; also try to use largest diameter that will fit in the nostril 3. lubricate the airway with a water-soluble lubricant or anesthetic jelly 4. insert the device slowly, moving straight into the face, not towards the brain 5. it should feel snug; do not force the device into the nostril; if it feels stuck, remove it and try the other nostril or a smaller NPA

ACLS: airway management - what are the steps for inserting an OPA?

- Oropharyngeal Airway (OPA): for unconscious patients at risk for developing airway obstruction; 1. clear mouth of blood or secretions w/ suction 2. select an airway device that is the correct size for the patient 3. place the device at the side of the patient's face - you want a device that extends from the corner of the mouth to the earlobe 4. insert the device into the mouth so the point is toward the roof of the mouth or parallel to the teeth 5. once device is almost fully inserted, turn it until the tongue is cupped by the interior curve of the device

Pulseless Electrical Activity & Asystole

- PEA & asystole: life-threatening and not shockable? - reversible causes: Hypovolemia Hypoxia Hypothermia Hypo/hyperkalemia H⁺/acidosis Toxins Tamponade Thrombosis pulmonary Thrombosis coronary Tension pneumothorax - Rx: epinephrine (1 mg every 3-5 min); vasopressin (40 units); amiodarone 300 mg bolus; 150 mg second dose

RRT/MET alert criteria?

- Rapid Response Team/ Medical Emergency Team: -- threatened airway or labored breathing -- bradycardia (<40 bpm) or tachycardia (>100 bpm) -- hypotension or symptomatic hypertension -- altered mental status -- seizure -- sudden and large decrease in urine output

2 methods for opening the airway to provide breaths?

- head tilt-chin lift: relieves airway obstruction in an unresponsive victim - jaw thrust: requires 2 rescuers; performed when suspect head or neck injury

Ventricular fibrillation & pulseless ventricular tachycardia - what are the characteristics of each form? - what is the treatment?

- VF & pulseless VT are life threatening b/c they result in ineffective ventricular contractions; despite differences get similar Tx - VF: rapid quivering of ventricles rather than forceful action; -- regularity: no regularity to the rhythm b/c there are no complexes or waves present that can be analyzed -- rate: no measurable rate -- P wave: no P waves present -- PRI: unable to be measured due to no P waves present -- QRS: no QRS complexes present - VT: regular/ rapid wide complex -- regularity: R-R intervals usually regular, not always -- rate: atrial rate cannot be determined; ventricular rate usually btw 150-250 bpm; -- P wave: QRS complexes are not preceeded by P waves; occasionally P waves in the strip, but not associated w/ ventricular rhythm -- PRI: not measured since this is a ventricular rhythm -- QRS: measures > 0.12 sec; wide and bizarre; difficult to separate QRS and T wave; - Tx: AED shocks VF & pulseless VT rhythms

VF

- VF: rapid quivering of ventricles rather than forceful action; -- regularity: no regularity to the rhythm b/c there are no complexes or waves present that can be analyzed -- rate: no measurable rate -- P wave: no P waves present -- PRI: unable to be measured due to no P waves present -- QRS: no QRS complexes present

VT

- VT: regular/ rapid wide complex -- regularity: R-R intervals usually regular, not always -- rate: atrial rate cannot be determined; ventricular rate usually btw 150-250 bpm; -- P wave: QRS complexes are not preceeded by P waves; occasionally P waves in the strip, but not associated w/ ventricular rhythm -- PRI: not measured since this is a ventricular rhythm -- QRS: measures > 0.12 sec; wide and bizarre; difficult to separate QRS and T wave;

For use with infants, what is preferred instead of an AED?

- a manual defibrillator

Percent of a rescuer's exhaled air is oxygen?

- a rescuer's exhaled air contains approximately 17% O₂ and 4% CO₂, this is enough oxygen to meet a victim's needs

BLS/CPR purposes, when is an individual considered an adult?

- adults include adolescents and older - i.e. anyone after the onset of puberty; signs of puberty include chest or underarm hair in males, and any breast development in females

Different causes of cardiac arrest in adults and children?

- adults: cardiac arrest is often sudden and results from cardiac cause - children: cardiac arrest is often secondary to respiratory failure and shock

Agonal gasps and what do they indicate?

- agonal gasps are not normal breathing and may be present in the first minutes after sudden cardiac arrest - person who gasps usually looks like he is drawing air in v. quickly; mouth may be open and jaw, head or neck may move w/ gasps - gasps may appear forceful or weak, some time may pass between gasps b/c they usually happen at a slow rate - gasp may sound like a snort, snore, groan - agonal gasps are a sign of cardiac arrest in someone who doesn't respond → activate emergency response system, check pulse, start CPR

Defines an individual as a child?

- anywhere between 1 year and puberty - signs of puberty include chest or underarm hair on mails and any breast development in females

ACLS: Principles of early defibrillation

- assure oxygen is not flowing across the patient's chest when delivering shock - do not stop chest compressions for >10sec when assessing rhythm - stay clear when delivering shock - assess pulse after the first 2 minutes of CPR - if end tidal CO₂ is <10 mmHg during CPR, consider adding a vasopressor and improve chest compressions - monophasic defibrillator: give single 360 J shock → if subsequent needed, continue w/ same dose - biphasic defibrillator: variety of waveforms; use manufacturer's recommended energy dose

Universal compression rate for all ages?

- at least 100 per minute

When are bag-mask devices used? What type of pressure ventilation do they provide?

- bag-masks are most commonly used by healthcare providers during 2-rescuer CPR and rescue breathing - they provide positive-pressure ventilation

HC providers should check victim simultaneously for both response & breathing - if the victim is not breathing normally (agonal gasps), what do you do?

- begin CPR w/ chest compressions → after first set of compressions open airway and give 2 breaths - More than half the patients in cardiac arrest gasp. Usually, this gasping or agonal breathing stops within about four minutes, which is why many experts have not recognized this phenomenon so far! Gasping is a survival reflex triggered by the brain and can increase the chances of survival for someone in cardiac arrest. - Gasping is an indication that the brain is still alive and it tells you that if you start and continue uninterrupted chest compressions, the person has a high chance of surviving. The challenge is to educate bystanders that if they are helping someone in cardiac arrest, not to mistake gasping for breathing. Contrary as it may seem, a person who is gasping is not OK - they need chest compressions. Bystander-initiated CPR has been shown to be a cardiac arrest victim's only chance of survival until an automated external defibrillator (AED) or the paramedics get to the scene

How long and where should you check for a pulse on an adult, child, and infant?

- check for no longer than 10 sec - adult: carotid a. - child: carotid or femoral aa - infant: brachial a.

Action steps for AED for adults and children 8 years of age and older?

- check for response & breathing → if none, shout for help → if someone arrives send them to activate emergency response system and get an AED → check for pulse → begin CPR 30:2 compression:breaths → power on AED, attach pads → clear victim and analyze

Steps for 2 rescuers w/ an AED?

- check for response and breathing → 1 stays w/ victim, 2nd activates emergency response system and gets AED → check pulse → remove clothing covering chest → start CPR (C-A-B) - when AED arrives place it at victim's side near rescuer who will operate it, usually opposite rescuer performing compressions → open carrying case → power on AED → attach AED pads, 1 on upper-right chest directly below clavicle, 2nd to side of left nipple w/ top edge of pad a few inches from armpit → attach cables → clear victim and analyze rhythm → follow AED prompts to either clear and shock or resume CPR → after 5 cycles (2 min) AED will analyze again

Importance of minimizing the time between last compression and shock delivery?

- if time can be kept < 10 sec the shock is much more likely to be effective (i.e. to eliminate v. fib and return spontaneous circulation)

Explain 4 key differences between child and adult BLS

- compressions-to breaths ratio for 2-rescuer child CPR 15:2 vs. 30:2 for adults - compression depth for children is at least one-third depth of chest approx 2 inches (5 cm) vs. adults at least 2 inches (5 cm) - compression technique may use 1- or 2-handed compressions for v. small children vs. adults use 2-handed - activation of emergency response system → if did not witness arrest and alone, provide 2 min CPR before leaving victim to activate emergency response system and getting AED → if arrest is sudden and witnessed, leave child to activate emergency response system and get AED then return to child

3 criteria for using an AED? What does the AED do?

- criteria: -- no response after shaking and shouting -- no breathing or ineffective breathing -- no carotid artery pulse detected - AED: resets hearts abnormal activity into a normal rhythm

When is it appropriate to move the victim?

- do not move the victim while CPR is in progress unless victim is in dangerous environment (e.g. burning building) or if you believe you cannot perform CPR effectively in victim's position or location - CPR is better and has fewer interruptions when rescuers perform resuscitation where they find victim

What is an advanced airway?

- examples include: laryngeal mask airway; supraglottic airway; or endotracheal tube - with one in place you do not need to pause compressions to provide breaths

First two steps in chest compression technique?

- first: position yourself at victim's side - second: make sure victim is lying face-up on a firm, flat surface; if victim is face-down, carefully roll him face-up; if you suspect a head or neck injury, try to keep head-neck-torso in line when rolling victim to face-up position *if a firm surface is under victim, force used is more likely to compress chest and create blood flow rather than push victim into mattress or other soft surface

Steps for rescue breathing for infants and children?

- give 1 breath every 3-5 seconds (about 12-20 breaths per minute) - give each breath in 1 second - each breath should result in visible chest rise - check pulse about every 2 minutes *in infants, if despite adequate oxygenation and ventilation, the pulse is <60/min w/ signs of poor perfusion, start CPR

What are the steps for rescue breathing for adults?

- give 1 breath every 5-6 seconds (about 10-12 breaths per minute) - give each breath in 1 second - each breath should result in visible chest rise - check pulse about every 2 minutes

Risk of giving breaths too quickly, too forcefully, or w/ too much volume?

- if you give breaths too quickly, or with too much force, air is likely to enter the stomach rather than the lungs → causes gastric inflation → serious complications such as vomiting, aspiration, or pneumonia - ↓risk of gastric inflation by taking 1 second to deliver each breath and deliver air until you make the victim's chest rise

Why is it important to keep an infant's head in a neutral position?

- if you tilt (extend) an infant's head beyond the neutral (sniffing) position, the infant's airway may become blocked - maximize airway patency by positioning the infant with the neck in a neutral position so that the external ear canal is level with the top of the infant's shoulder

5 links in the Adult Chain of Survival?

- immediate recognition of cardiac arrest and activation of emergency response system - early cardiopulmonary resuscitation (CPR) w/ an emphasis on chest compressions - rapid defibrillation - effective advanced life support - integrated post-cardiac arrest care

Signs that someone is respiratory arrest? - what is in the BLS survey? - what is in the ACLS survey?

- ineffective breathing pattern, e.g. agonal or - BLS survey: 1. check responsiveness: "are you okay?"; check breathing; continue 2. call EMS & get AED 3. circulation: check pulse for 5-10 sec → Pulse present → rescue breathing 1 breath every 5-6 sec (10-12/min) → check pulse every 2 min → No Pulse → start CPR → 30:2 → at least 100/min 4. defibrillation: if no pulse, check for shockable rhythm w/ AED; provide CPR between shocks, starting w/ chest compressions - ACLS survey: -- Airway: maintain airway in unconscious patient; consider advanced airway; monitor airway patency w/ quantitative waveform capnography -- Breathing: give 100% oxygen, keep SpO2 ≥94%; assess effective ventilation w/ quantitative waveform capnography; do not over-ventilate; -- Circulation: obtain IV/IO access; evaluate rhythm and pulse; defibrillation/cardioversion; give rhythm-specific medications; give IV/IO fluids if needed -- DDx: identify and treat reversible causes; cardiac rhythm and pt. history are keys to DDx; assess when to shock versus medicate

Infants, children, and adults what is the two rescuers compressions to breath ratio?

- infant and child 2-rescuer ratio is 15:2 - adult both 1- and 2-rescuer ratio is 30:2 → with one rescuer doing compressions and the other doing breaths

Torsades de Pointes

- irregular wide complex tachycardia

5 key differences between infant and adult CPR?

- location of the pulse check: brachial artery in infants - technique of delivery compressions: 2 fingers for single rescuer and 2 thumb-encircling hands technique for 2 rescuers - compression depth: at least one third chest depth, approx 1.5 inches (4cm) - compression-ventilation rate and ratio for 2 rescuers: same as for child at 15:2 - when to activate the emergency response system: → if did not witness arrest and alone, provide 2 min CPR before leaving infant to activate emergency response system and getting AED → if arrest is sudden and witnessed, leave infant to phone 911 and get AED then return to infant

Actions should you take as the lone rescuer, during Step 4: Begin CPR?

- lone rescuer should use universal compressions-to-breaths ratio of 30 compressions to 2 breaths when giving CPR to victims of any age - when you give compressions, it is important to push chest hard and fast, at a rate of at least 100 compressions per minute, allow the chest to recoil completely after each compression, and minimize interruptions in compressions - begin CPR w/ compressions (C-A-B sequence)

ACLS: Pharmacological Tools

- make drug flashcards

If standard AED pads need to be used for children, what precautions should be taken?

- make sure they do not touch or overlap

Preferred types of defibrillators for infants?

- manual defibrillator is preferred → if not available, use AED equipped w/ pediatric dose attenuator → if not available, use AED

- Why does the activation of the emergency response system differ between adults and children? → what is the physiologic reason for providing CPR before activation of emergency response system?

- many infants and children are thought to develop respiratory arrest and bradycardia before they develop cardiac arrest → if they receive prompt intervention before development of cardiac arrest, they have a high survival rate - if the rescuer leaves a child w/ respiratory arrest or bradycardia to phone emergency response system → child may progress to cardiac arrest → chance of survival ↓ ∴ if lone rescuer finds unresponsive child who is not breathing or only gasping w/ no pulse or bradycardia, rescuer should provide 5 cycles (~2 min) of CPR before activating emergency response system

How should an appropriately sized mask fit a victim's face?

- mask must cover victim's mouth and nose completely w/o covering eyes or overlapping chin

Can you use child AED pads on victims 8 years of age or older?

- no - why??? what if that is all you have available??

How does 2-rescuer CPR change with an advanced airway in place?

- no pauses in compressions for breaths - 1 breath every 6-8 seconds (8-10 breaths/min) *compression rate is still at least 100/min

Simultaneous actions of at least 4 rescuers in the team approach to CPR in a health care setting?

- one rescuer activates the emergency response system - a second begins chest compressions - a third is either providing ventilations or retrieving the bag-mask for rescue breathing - a fourth is retrieving a defibrillator and setting it up *communication among team members is especially important while performing chest compressions as one rescuer gets fatigued another takes over; this helps ensure proper rate and depth; counting out loud helps w/ coordination among rescuers and the ability to switch roles while minimizing interruptions in chest compressions

Steps when the AED arrives?

- one rescuer should continue chest compressions while another attaches the AED pads → power on the /AED (AED will guide you through next steps) → attach AED pads to the victim's bare chest → "clear" the victim and analyze the rhythm → if the AED advises a shock, clear and deliver a shock → if no shock is needed, resume CPR → after 5 cycles or 2 minutes the AED will repeat analysis

Can an adult AED dose be used on children an infants?

- yes, though a manual defibrillator is preferred in infants and a pediatric dose attenuator preferred in children **an adult does is better than no attempt at defibrillation

What is the recommended depth of compression for infants? - what is the 1-rescuer infant compression-to-breaths ratio?

- one-third of anterior-posterior depth of chest ~ 1.5 inches (4cm) - 30:2, the universal ratio

First step in ventilation? - what are the advanced and basic types of ventilation?

- open the airway w/ head tilt-chin lift or use jaw thrust - basic: mouth-to-mouth/nose; bag-mask ventilation; OPA; NPA - advanced: esophageal-tracheal tube; endotracheal tube (ETT); laryngeal tube; laryngeal mask airway (LMA)

Kow do you locate the brachial artery pulse in an infant?

- place 2-3 fingers on inside of upper arm, between infant's elbow and shoulder - press index and middle fingers gently on inside of upper arm for no more than 10 seconds when attempting to feel the pulse

Correct rescuer hand, arm, shoulder placement in chest compression technique?

- place heel of one hand on center of victim's chest on lower half of breastbone - place heel of other hand on top of first hand - straighten arms and position shoulders directly over your hands

Basic steps for AED operation?

- power up AED → choose adult or pediatric pads → attach the pads to chest → place pads appropriately → clear area → if no shock is advised, resume CPR → if AED indicates shock is needed, ensure patient is clear → press the "shock" button → immediately resume CPR → after 2 minutes of CPR, analyze the rhythm → continue to follow AED prompts

What is the preferred method for infant mouth-to-mouth? - what is the alternate to the preferred method? how does it differ?

- preferred is *mouth-to-mouth-and-nose: maintain a head tilt-chin lift to keep airway open → place your mouth over infant's mouth and nose to create an airtight seal → blow into infant's nose and mouth (pausing to inhale between breaths) to make chest rise w/ each breath → if chest does not rise, repeat head tilt-chin lift to reopen airway and try to give a breath that makes the chest rise → you may need to move the infant's head through a range of positions to provide optimal airway patency and effective breaths; when the airway is open, give 2 breaths that make the chest rise; you may need to try a couple of times - mouth-to-mouth: maintain a head tilt-chin lift to keep airway open → pinch victim's nose tightly w/ thumb and forefinger → make mouth-to-mouth seal → provide 2 breaths; make chest rise w/ each breath → if chest does not rise, repeat head tilt-chin lift to reopen airway and try to give a breath that makes the chest rise → you may need to move the infant's head through a range of positions to provide optimal airway patency and effective breaths; when the airway is open, give 2 breaths that make the chest rise;

ACLS: Routes of Access

- preferred routes: IV or IO - peripheral IV route best b/c does not require interruption to CPR (Peripherally Inserted Central Catheter PICC) → unless central line (central venous catheter) access already available 1. IV push bolus injection 2. flush w/ 20 mL of fluid/saline 3. raise extremity for 10-20 seconds to enhance delivery of drug circulation - Intraosseous Route (IO): 1. all age groups 2. placed in < 1min 3. has more predictable absorption than endotracheal route

5 links in the Pediatric Chain of Survival?

- prevention of arrest by identifying children at risk - early high-quality bystander CPR - rapid activation of EMS (or other emergency response system - effective advanced life support (incl. rapid stabilization and transport to definitive care and rehabilitiation) - integrated post-cardiac arrest care

If you have difficulty pushing deeply during chest compressions, what is the alternative technique? hint: it is helpful for rescuers w/ arthritis

- put one hand on breastbone to push on chest → grasp wrist of that hand w/ other hand to support first as it pushes chest

ACLS: systems of care - CPR

- rapid response team (RRT) - code team - critical care team: must be always ready + unstable patient - early detection and activation of chain of survival - post-cardiac arrest care: -- therapeutic hypothermia**: for comatose patients w/ROSC; cooled to 89.6-93.2°F -- optimization of hemodynamics and ventilation: patient pulse-ox >94%; do not over-ventilate; 10-12 bpm to achieve PETCO₂ at 35-40 mmHg -- Percutaneous Coronary Intervention (PCI): preferred over thrombolytics; transfer pt to hospital w/ PCI -- glucose control: optimal level is 144-180 mg/dL; higher than standard levels -- neurological care

Stroke chain of survival?

- recognize symptoms & call EMS → timely EMS response → transport to and notify stroke center → guideline-based stroke care → quality post-stroke care - Face drooping - Arm weakness - Speech difficulty - Time to call 911 - 8 Ds of stroke care: detection → dispatch → delivery → door → data → decision → drug → disposition (rapid admission to stroke or critical care unit)

What is respiratory arrest? What are the risks if it continues? How should healthcare providers intervene?

- respiratory arrest is the absence of respirations (i.e. apnea) - during respiratory arrest and inadequate ventilation, victim has cardiac output detectable as a palpable central pulse; HR may be slow and cardiac arrest may develop if rescue breathing is not provided - healthcare providers should be able to identify respiratory arrest → immediately open the airway and give breaths to prevent cardiac arrest and hypoxic injury to brain and other organs

What do you do if a choking victim becomes unresponsive?

- send someone to activate emergency response system - lower victim to the ground - begin CPR C-A-B sequence (do not check for pulse) - every time you open the airway to give breaths, look for the object, if you see one, remove it w/ your fingers - after 5 cycles or 2 minutes of CPR, activate emergency response system if someone has not already done so

How does the length of time compare between chest compression and chest recoil/relaxation?

- should be about equal

Actions should you take if you are alone or if there is another rescuer, during Step 2: Activate the Emergency Response System and get and AED?

- shout for help → → if another rescuer responds → send him/her to activate emergency response system & get the AED or defibrillator → if no one responds → activate the emergency response system → get the AED (or defibrillator) → return to victim to check pulse and begin CPR (C-A-B sequence)

AWhen and why should a mouth-to-barrier device be used for breaths?

- standard precautions include using barrier devices, such as face mask or bag-mask, when giving breaths - at first opportunity face shields should be replaced with mouth-to-mask or bag-mask devices b/c masks have a 1-way valve that diverts exhaled air, blood, or bodily fluids away from rescuer - risk of infection from CPR is extremely rare and limited to a few case reports, but OSHA requires healthcare workers use standard precautions in workplace, including during CPR

6 critical characteristics of high-quality CPR that improve a victim's chances of survival

- start compressions w/i 10 sec of recognition of cardiac arrest - push hard, push fast: compress at rate of at least 100/min w/ depth of at least 2" (5 cm) for adults, and at least one-third anterior-posterior diameter of chest for children (~2" or 5 cm) and infants (~1.5" or 4 cm) - allow complete chest recoil after each compression - minimize interruptions in compressions (limit to <10 sec) - give effective breaths that make chest rise - avoid excessive ventilation

ACLS: airway management - what are the steps for suctioning to maintain an airway? - what are some tips?

- suctioning steps: -- essential to maintaining an airway -- suction airway immediately if there are: secretions, blood, vomit -- attempts should not exceed 10 seconds -- to prevent hypoxemia, follow w/100% oxygen administration -- monitor HR, pulse-ox, clinical appearance -- if ∆ in monitoring parameters, interrupt and administer O₂ until HR returns to normal and clinical condition improves -- assist in ventilation as warranted - suctioning tips: -- do not insert catheter too deeply -- sterile technique should be used near bronchi -- each effort should be no longer than 10 seconds -- remember that the pt. does not get O₂ during suctioning - monitor vital signs and stop immediately if pt experiences: hypoxemia; new arrhythmia; becomes cyanotic

ACLS - resuscitation team: - team structure:

- team structure: -- team leader: organize, monitor, be able to perform all skills, direct, provide critique -- team member: understand role, be willling able and skilled, understand ACLS sequences, be committed to success 1. team leader gives clear assignment to the members 2. team member responds verbally w/ voice and eye contact 3. team leader listens for confirmation 4. team member reports when task is complete and reports the result

Purposes of BLS, what is an infant?

- the term infant means infants up to 1 year of age (12 months) **excluding newly born infants in the delivery room

How can you tell if you have successfully removed an airway obstruction in an unresponsive victim?

- you can feel air movement and see the chest rise when you give breaths - see and remove a FB from victim's throat → proceed as with any other victim: check response, breathing, pulse *if victim responds encourage the victim to seek immediate medical attention to ensure that the victim does not have a complication from abdominal thrusts

- BLS & ACLS are meant to save a pt's life, - what are the goals of post-cardiac arrest care? - what are the steps for BP support and vasopressors?

- to optimize ventilation and circulation - preserve heart and brain tissue - maintain recommended blood glucose levels 1. BP support in any patient w/ systolic BP < 90 mmHg 2. 1-2 liters of IV saline or Lactated Ringer's 3. when BP v. low, consider vasopressors; epi is first choice 4. titrate the infusion rate to maintain the desired BP - Hypothermia: unresponsive/comatose pts; should continue for 12-24 hrs; infused by infusing ice-cold saline or Lactated Ringer's during BP support; maintained by surface cooling devices; **only documented intervention that improves brain recovery after cardiac arrest

4 special situations that might require additional actions when using the AED?

- victim has a hairy chest: use pads to remove hair and /or shave chest - victim is immersed in water or water is covering victim's chest: pull victim out of water, wipe chest dry; *if victim is lying on snow or small puddle you may use the AED - victim has an implanted defibrillator or pacemaker: do not place pads over device, do not shock w/ AED if implant is shocking too - victim has a transdermal medication patch or other object on the surface of the skin where the AED pads are placed: do not place AED pads on top b/c may block transfer of energy and cause small burns to skin → remove patch → wipe clean → apply AED pad

What is rescue breathing and when is it used?

- when an adult, child, or infant has a pulse but is not breathing effectively, rescuers should give breaths w/o chest compressions; this is rescue breathing

What should change in the CPR sequence when more rescuers arrive?

- when second rescuer arrives the AED should be used as soon as available → continue to give compressions and breaths switching roles after every 5 cycles (~every 2 minutes) - as additional rescuers arrive → they can help w/ bag-mask ventilation, use of AED or defibrillator, and emergency resuscitation cart (crash cart)

Why is it important to give BOTH compressions AND breaths to infants and children in cardiac arrest when compressions along might be sufficient for adults?

- when sudden cardiac arrest occurs (i.e. typical adult cardiac arrest) the oxygen content of blood is typically normal ∴ compressions alone may maintain adequate oxygen delivery to heart and brain for first few minutes after arrest - infants & children who develop cardiac arrest often have respiratory failure or shock that ↓oxygen content of blood before onset of arrest ∴ chest compressions alone are not as effective for delivering oxygen to heart and brain as is the combination of compressions plus breaths

What is defibrillation? why is it necessary?

- when ventricular fibrillation is present, heart muscle fibers quiver and do not contract together to pump blood - a defibrillator delivers an electric shock to stop the quivering of the heart fibers - this allows the muscle fibers of the heart to "reset" so that they can begin to contract at the same time - once an organized rhythm occurs, the heart muscle may begin to contract effectively and begin to generate a pulse (called return of spontaneous circulation, or ROSC)

Can the AED be used on victims lying on snow or in small puddles?

- yes

STEMI chain of survival? - i.e. what are the goals of acute coronary syndrome treatment?

- ↓myocardial tissue necrosis to preserve heart fxn - treat ACS complications (VF, VT, shock) - prevent major adverse cardiac events (MACE) - reduce time, increase communication to improve outcome

ACLS: airway management - what are the uses for the advanced airway adjuncts? -- ET -- LMA -- laryngeal tube -- esophageal-tracheal tube (combitube)

-- Endotracheal Tube (ET): specific type of tracheal tube inserted through mouth or nose; most difficult to place, but most secure; requires use of a laryngoscope -- Laryngeal Mask Airway (LMA): comparable ventilation to ET -- Laryngeal Tube: more compact and less complicated to insert; has only 1 larger balloon to inflate; can be inserted blindly -- Esophageal-tracheal tube (combitube): provides adequate ventilation comparable to ET, has two separate balloons;

A-

-- regularity: -- rate: -- P wave: -- PRI: -- QRS:

B-

-- regularity: -- rate: -- P wave: -- PRI: -- QRS:

C-

-- regularity: -- rate: -- P wave: -- PRI: -- QRS:

Key elements in the performance of manual defibrillation

1. Attach and charge the defibrillator while continuing excellent chest compressions. 2. Stop compressions and assess rhythm (should take no more than 5 seconds). 3. If VF or VT is present, deliver shock; if non-shockable rhythm is present, resume excellent CPR. 4. Resume excellent chest compressions and CPR immediately after the shock is delivered. - Critical point: Interruptions in excellent chest compressions must be kept to a minimum: Do NOT stop compressions while defibrillator is charged.

3 actions should a rescuer perform during Step 3: Pulse Check?

1. locate trachea, using 2-3 fingers 2. slide these 2-3 fingers into groove between trachea and muscles at side of neck, where you can feel carotid pulse 3. feel for a pulse for no more than 10 seconds; if you do not definitely feel a pulse, begin CPR, starting w/ chest compressions (C-A-B sequence)

4 initial BLS steps for adults?

1. assess the victim for a response and for breathing; if there is no response and no breathing or no normal breathing (e.e. only gasping) shout for help 2. if you are alone, activate the emergency response system and get an AED (or debfibrillator) if available and return to the victim 3. check the victim's pulse (take no more than 10 seconds) 4. if you do not definitely feel a pulse w/i 10 seconds, perform 5 cycles of compression and breaths (30:2), starting with compressions (C-A-B sequence)

5 action steps for 2-rescuer infant BLS sequence?

1. check child for response and breathing 2. if no response or only gasping, send second rescuer to activate emergency response system and get the AED ( or defibrillator) 3. check infant's brachial pulse (take at least 5 and no more than 10 secs) 4. if there is no pulse or if, despite adequate oxygenation and ventilation, HR < 60/min w/ signs of poor perfusion → perform cycles of compressions and breaths (30:2) starting with compressions → when second rescuer arrives use compressions-to-breaths ratio of 15:2 5. use AED (or defibrillator) as soon as it is available

3 actions steps in 2-rescuer child BLS sequence (no AED)

1. check child for response and breathing → if none or only gasping send second rescuer to activate emergency response system 2. check child's pulse (take no more than 10 secs); you may try to feel carotid or femoral pulse 3. if w/i 10 sec you do not definitely feel a pulse or if, despite adequate oxygenation and ventilation, HR < 60/min w/ signs of poor perfusion → perform cycles of compressions and breaths (30:2) starting with compressions → when second rescuer arrives use compressions-to-breaths ratio of 15:2

5 actions steps in 1-rescuer child BLS sequence

1. check child for response and breathing → if none or only gasping shout for help 2. if someone responds, send that person to activate emergency response system and get AED → note: if child collapsed suddenly and you are alone, leave child to activate emergency response system and get AED → return to child 3. check child's pulse (take no more than 10 secs); you may try to feel carotid or femoral pulse 4. if w/i 10 sec you do not definitely feel a pulse or if, despite adequate oxygenation and ventilation, HR < 60/min w/ signs of poor perfusion → perform cycles of compressions and breaths (30:2) starting with compressions 5. after 5 cycles, if someone has not already done so, activate emergency response system and get AED (or defibrillator) → use AED as soon as available

5 actions steps in 1-rescuer infant BLS sequence?

1. check infant for response and breathing → if none or only gasping shout for help 2. if someone responds, send that person to activate emergency response system and get AED 3. check infant's brachial pulse (take no more than 10 secs) 4. if w/i 10 sec you do not definitely feel a pulse or if, despite adequate oxygenation and ventilation, HR < 60/min w/ signs of poor perfusion → perform cycles of compressions and breaths (30:2) starting with compressions 5. after 5 cycles, if someone has not already done so, activate emergency response system and get AED (or defibrillator)

7 action steps to give mouth-to-mouth breaths to a victim?

1. hold victim's airway open w/ head tilt-chin lift 2. pinch nose closed w/ your thumb and index finger (using hand on the forehead) 3. take a regular (not deep) breath and seal your lips around the victim's mouth, creating an airtight seal 4. give 1 breath (blow for about 1 second); watch for chest rise as you give the breath 5. if not chest rise → repeat head tilt-chin lift 6. give a second breath (blow fro about 1 second); watch for chest rise 7. if you are unable to ventilate the victim after 2 attempts, promptly return to chest compressions

8 action steps for relieving choking in a responsive infant?

1. kneel or sit w/ infant in your lap 2. if easy to do, remove clothing from infant's chest 3. hold infant facedown w/ head slightly lower than chest, resting on your forearm; support head and jaw in your hand; avoid compressing soft tissues of infant's throat; rest forearm on our lap or thigh to support infant 4. deliver up to 5 back slaps forecefully between infant's shoulder blades, using heel of your hand; deliver each slap with sufficient force to attempt to dislodge FB 5. after 5 back slaps, place free hand on infant's back, supporting back of head w/ palm of hand; infant cradled btw your 2 forearms 6. turn infant as a unit, carefully supporting head and neck; hold infant faceup w/ forearm resting on your thigh; keep infants head lower than trunk 7. provide 5 quick downward chest thrusts in middle of chest over lower half of breastbone; rate of 1 per second w/ enough force to dislodge FB 8 repeat sequence until object removed or infant becomes unresponsive

3 actions should the first rescuer at the scene perform during Step 1: Assessment and Scene Safety?

1. make sure scene is safe for you and victim; you do not want to become a victim yourself 2. tap victim's shoulder and shout "are you all right?" 3. check to see if victim is breathing; if a victim is not breathing or not breathing normally (i.e. only gasping), you must activate the emergency response system

How do you located the femoral pulse?

1. place 2 fingers in the inner thigh, midway btw hipbone and pubic bone, just below the crease where the abdomen meets the leg 2. feel for a pulse for no more than 10 secs → if you do not definitely feel a pulse begin COPR starting w/ chest compressions (C-A-B sequence)

7 action steps for 2-rescuer infant CPR?

1. place both thumbs side by side in **center of infant's chest on lower half of breastbone; thumbs may overlap in v. small infants 2. encircle infant's chest and support infant's back w/ fingers of both hands 3. w/ hands encircling chest, use both thumbs to depress breastbone approximately one third depth of infant's chest (approximately 1.5 inches (4cm)) 4. deliver compressions in a smooth fashion at a rate of at least 100/min 5. after each compression, completely release pressure on breastbone and chest and allow chest to recoil completely 6. after every 15 compressions*, pause briefly for the second rescuer to open the airway with a head tilt-chin lift and give 2 breaths; the chest should rise w/ each breath 7. continue compressions and breaths in a ratio of 15:2 (for 2 rescuers), switching roles every 2 minutes to avoid rescuer fatigue

5 action steps for 2-finger chest compression technique in infants?

1. place infant on a firm, flat surface 2. place 2 fingers in center of infant's chest **just below nipple line; do not press on bottom of breastbone 3. push hard and fast; to give chest compressions, press infant's breastbone down at least one third depth of chest 4. at end of each compression, make sure you allow chest to recoil (re-expand) completely; chest recoil allows blood to flow into heart and is necessary to create blood flow during chest compressions; incomplete chest recoil will reduce blood flow created by chest compressions; chest compressions and chest recoil/relaxation times should be approximately equal 5. minimize interruptions in chest compression

What are the 3 steps to perform a jaw thrust?

1. place one hand on each side of victim's head, resting your elbows on surface on which victim is lying 2. place your fingers under angles of victim's lower jaw and lift w/ both hands, displacing jaw forward 3. if lips close, push lower lip with your thumb to open lips

3 steps in performing the head tilt-chin lift? 3 things to avoid with head tilt-chin-lift?

1. place one hand on victim's forehead and push w/ your palm to tile head back 2. place fingers of other hand under bony part of lower jaw near chin 3. lift jaw to bring chin forward - do not press deeply into soft tissue under chin b/c this might block airway - do not use thumb to lift chin - do not close victim's mouth completely

7 actions for effective chest compressions?

1. position yourself at victim's side 2. make sure victim is lying face-up on firm, flat surface 3. place heel of one hand on center of victim's chest on lower half of breastbone 4. place heel of other hand on top of first hand 5. straighten your arms and position your shoulders directly over your hands 6. push hard and fast; press straight down on victim's breastbone at least 2 inches (5 cm) w/ each compression; deliver compressions at a rate of at least 100/min 7. after each compression, allow chest to recoil completely 8. minimize interruptions

6 steps for giving mouth-to-mask breaths for a lone rescuer

1. position yourself at victim's side 2. place mask on victim's face; use bridge of nose as guide for correct position 3. seal mask against face; using hand closer to top of head, place your index finger and thumb along edge of mask; place thumb of second hand along edge of mask 4. place remaining fingers of second hand along bony margin of jaw and lift jaw; perform a head tilt-chin lift to open airway 5. while you lift jaw, press firmly and completely around outside edge of mask to seal mask against face 6. deliver air over 1 second until you make victim's chest rise

4 main steps used for bag-mask during 2-rescuer CPR?

1. position yourself directly above victim's head 2. place mask on victim's face, using bridge of nose as guide for correct position 3. use E-C clamp technique to hold mask in place while you lift jaw to hold airway open → perform head tilt → place mask on face w/ narrow portion at bridge of nose → use thumb and index finger of one hand to make a "C" on side of mask, pressing edges of mask to face 4. squeeze bag to give breaths (1 second each) and watch for chest rise; deliver all breaths over 1 sec whether or not using supplementary oxygen

7 steps for two rescuer child and infant BLS?

1. shake and shout at victim to determine if they are responsive 2. assess if they are breathing - ear to mouth or watch chest 3. if child does not respond and s/he is not breathing, send second person to activate emergency response system and to get an AED 4. feel for child's carotid or femoral pulse for no more than 10 seconds 5. if no pulse, unsure, or < 60 bpm, begin 30:2 CPR - compression depth should be ∼1/3 of chest, ∼2 in. 6. when second rescuer returns, begin doing CPR by performing 15 compressions by one rescuer and 2 breaths by the second rescuer 7. use and follow AED prompts when available while continuing CPR until EMS arrives or child's condition normalizes

7 steps for one rescuer child BLS?

1. shake and shout at victim to determine if they are responsive 2. assess if they are breathing - ear to mouth or watch chest 3. if child does not respond and s/he is not breathing, yell for help - ask second person to get AED 4. feel for child's carotid or femoral pulse for no more than 10 seconds 5. if no pulse, unsure, or < 60 bpm, begin 30:2 CPR - compression depth should be ∼1/3 of chest, ∼2 in. 6. after 2 min (5 cycles) and no other help has arrived, leave child to call EMS and get an AED 7. use and follow AED prompts when available while continuing CPR until EMS arrives or child's condition normalizes

6 action steps for performing abdominal thrusts w/ victim standing or sitting? - how do these steps differ w/ pregnant and obese victims?

1. stand or kneel behind victim and wrap your arms around victim's waist 2. make a fist w/ one hand 3. place thumb side of fist against victim's abdomen, in midline, slightly above navel and well below breastbone 4. grasp your fist w/ your other hand and press your fist into victim's abdomen w/ quick, forceful upward thrust 5. repeat thrusts until object is expelled from airway or victim becomes unresponsive 6. give each new thrust w/ separate, distinct movement to relieve objstruction *if victim is pregnant or obese, perform chest thrusts instead of abdominal thrusts

Adults, children, and infants, what is the universal one rescuer compression's to breath ratio?

30:2 *adult 2-rescuer ratio is also 30:2 *excluding newly born infants in the delivery room

Definition of CARDIAC TAMPONADE

: mechanical compression of the heart by large amounts of fluid or blood within the pericardial space that limits the normal range of motion and function of the heart

each rescue breath should be delivered over a period of: A. 1 second

A. 1 second

After you identify an unresponsive victim w/ no breathing (or no normal breathing) and no pulse, chest compressions should be initiated w/i A. 10 sec

A. 10 sec

2010 AHA guidelines for CPR and ECC recommend that to identify cardiac arrest in an unresponsive victim with no breathing (or no normal breathing, only gasping), a healthcare provider should check a pulse for no more than: 10 seconds

A. 10 seconds

A patient is in refractory ventricular fibrillation and has received multiple appropriate defibrillation shocks, epinephrine 1 mg IV twice, and an initial dose of 300 mg amiodarone IV. The patient is intubated. A second dose of amiodarone is now called for. The recommended second dose of amiodarone is A. 150 mg IV push

A. 150 mg IV push

You and your partner provide 2-rescuer CPR for the infant, using a ratio of A. 15:2

A. 15:2

The victim does not answer or respond in any way and is not breathing. You would next A. activate the emergency response system and get the AED ( you can send someone to do these things)

A. activate the emergency response system and get the AED ( you can send someone to do these things)

A 1-year-old male is brought to the ED for evaluation of poor feeding, fussiness, and sweating. On initial impression he is lethargic but arousable and has labored breathing and a dusky color. Primary assessment reveals a RR of 68/min, HR 300/min that does not vary w/ activity or sleep, BP 70/45 mm Hg, weak brachial pulses and absent radial pulses, capillary refill 6 seconds, SpO2 85% in room air, and good bilateral breath sounds. You administer high-flow oxygen and place the child on a cardiac monitor. You see the above rhythm with little beat-to-beat variability of the HR. Secondary assessment reveals no history of congenital heart disease. IV access has been established. Which of the following therapies is most important for this infant? A. adenosine 0.1 mg/kg IV rapidly; if adenosine is not immedately available, perform synchronized cardioversion

A. adenosine 0.1 mg/kg IV rapidly; if adenosine is not immedately available, perform synchronized cardioversion

Why is it important to compress to the appropriate depth during CPR? A. adequate depth of compression is needed to create blood flow during compressions

A. adequate depth of compression is needed to create blood flow during compressions

A pale and obtunded 3-year-old child w/ a history of diarrhea is brought to the hospital. Primary assessment reveals RR of 45/min w/ good breath sounds bilaterally. HR is 150/min, BP is 90/64 mmHg, and SpO2 is 96% in room air. Capillary refill is 5 seconds and peripheral pulses are weak. After placing the child on a nonrebreathing face mask (10 L/min flow) w/ 100% oxygen and obtaining vascular access, which of the following is the most appropriate immediate treatment for this child? A. administer a bolus of 20 mL/kg isotonic crystalloid

A. administer a bolus of 20 mL/kg isotonic crystalloid - compensated shock

You are the code team leader and arrive to find a patient with the rhythm shown and CPR in progress. Team members report that the patient was well but reported chest pain and then collapsed. She has no pulse or respirations. Bag-mask ventilations are producing visible chest rise, high-quality CPR is in progress, and an IV has been established. What would be your next order? A. administer epinephrine 1 mg

A. administer epinephrine 1 mg - See lead II above

You enter a room to perform an initial impression of a previously stable 10-year-old male and find him unresponsive and apneic. A code is called and bag-mask ventilation is performed w/ 100% oxygen. The cardiac monitor shows a wide-complex tachycardia. The boy has no detectable pulses so compressions and ventilations are provided. As soon as the defibrillator arrives you deliver an unsynchronized shock w/ 2 J/kg. The rhythm check after 2 minutes of CPR reveals VF. you then deliver a shock of 4 J/kg and resume immediate CPR beginning w/ compressions. A team member had established IO access, so you give a dose of epinephrine, 0.01 mg/kg (0.1 mL/kg of 1:10,000 dilution) IO when CPR is restarted after the second shock. At the next rhythm check, persistent VF is present. You administer a 4 J/kg shock and resume CPR. Based on the PALS Pulseless Arrest Algorithm, what are the next drug and dose to administer when CPR is restarted? A. amiodarone 5 mg/kg IO

A. amiodarone 5 mg/kg IO

Initial impression of a 10-year-old male shows him to be unresponsive. You shout for help, check breathing or only gasping. After finding that he is pulseless, you begin cycles of compressions-to-ventilation ratio of 30:2. A colleague arrives and places the child on a cardiac monitor, revealing the above rhythm. The two of you attempt defibrillation at 2 J/kg and give 2 minutes of CPR. The rhythm persists at the second rhythm check, at which point you attempt defibrillation using 4 J/kg. A third colleague establishes IO access and administers one dose of epinephrine 0.01 mg/kg (0.1 mL/kg of 1:10,000 dilution) during the compressions following the second shock. If VF or pulseless VT persists after 2 minutes of CPR, what is the next drug/dose to administer? A. amiodarone 5 mg/kg IV

A. amiodarone 5 mg/kg IV

Recommended depth of compressions for a child is A. at least one third the depth of chest, or approximately 2 inches

A. at least one third the depth of chest, or approximately 2 inches

Proper location to perform a pulse check for a child is A. at the carotid artery of the neck or the femoral artery of the leg

A. at the carotid artery of the neck or the femoral artery of the leg

You arrive on the scene to find a 56-year-old diabetic woman w/ dizziness. She is pale and diaphoretic. Her BP is 80/60 mm Hg. The cardiac monitor documents the rhythm seen. She is receiving oxygen at 4 L/min by nasal cannula, and an IV has been established. Your next order is A. atropine 0.5 mg IV

A. atropine 0.5 mg IV

You are a healthcare provider responding to a call for help. You enter the hospital wing and see a 6-year-old boy lying motionless on the hallway floor. Another healthcare provider is already with the boy and explains to you that the boy has a heart condition and just collapsed. After confirming that the child is unresponsive and not breathing, he goes to activate the emergency response system and get the AED, leaving you to attend to the victim. - The child has no pulse. You should now A. begin cycles of chest compressions and breaths at ratio of 30:2

A. begin cycles of chest compressions and breaths at ratio of 30:2

After you perform several minutes of rescue breaths and checking for a pulse, additional help and equipment, including advanced airway management arrives. You determine that the victim no longer has a pulse and the rescuers need to begin CPR with an advanced airway in place. Which of the following options lists the correct rates for compressions-to-breaths for 2-rescuer CPR in the presence of an advanced airway? A. compress at a rate of at least 100 per minute, 1 breath every 6-8 seconds

A. compress at a rate of at least 100 per minute, 1 breath every 6-8 seconds

Which of the following most reliably delivers a high (90% or greater) concentration of inspired oxygen in a toddler or older child? A. nonrebreathing face mask w/ 12 L/min oxygen flow

A. nonrebreathing face mask w/ 12 L/min oxygen flow - maintain an O2 flow of 10-15 L/min

After 2 minutes of CPR, the AED prompts you to analyze again → next step is to A. confirm that no one is touching victim, allow AED to analyze, deliver shock if prompted by AED

A. confirm that no one is touching victim, allow AED to analyze, deliver shock if prompted by AED

Which of the following statements about the effects of epinephrine during attempted resuscitation is true? A. epinephrine improves coronary artery perfusion pressure and stimulates spontaneous contractions when asystole is present

A. epinephrine improves coronary artery perfusion pressure and stimulates spontaneous contractions when asystole is present - Administration of epinephrine is the intervention most likely to be of benefit when basic life support and volume resuscitation do not restore effective circulation ●Mechanisms - The actions of epinephrine include both alpha- and beta-adrenergic stimulation. The alpha-mediated peripheral arterial vasoconstriction is the beneficial action of epinephrine in cardiac arrest. Peripheral arterial vasoconstriction elevates systemic vascular resistance, thereby increasing the aortic-right atrial pressure gradient during the decompression phase of cardiopulmonary resuscitation (CPR). **This gradient, also called the coronary perfusion pressure, correlates directly with myocardial blood flow in animal models, and is a good predictor of return of spontaneous circulation (ROSC) in animals and humans. In addition, increased systemic vascular tone raises the arterial pressure during the compression phase of CPR, thereby raising the cerebral perfusion pressure. Thus, the administration of epinephrine increases blood flow to both the heart and the brain. Additional alpha-adrenergic vasoconstrictor effects of epinephrine include reduced blood flow to the splanchnic, renal, mucosal, and dermal vascular beds. - Beta-adrenergic stimulation increases myocardial contractility and heart rate and relaxes smooth muscle in the coronary arteries, cerebral arteries, skeletal muscle vascular beds, and bronchi. **Other effects of epinephrine include stimulation of spontaneous cardiac contraction in asystole and enhanced ability to terminate ventricular fibrillation by electrical defibrillation .

You arrive on the scene with the code team. High-quality CPR is in progress. An AED has previously advised "no shock indicated." A rhythm check now finds asystole. After resuming high-quality compressions, your next action is to A. gain IV or IO access

A. gain IV or IO access

This patient has been resuscitated from cardiac arrest. During the resuscitation, amiodarone 300 mg was administered. The patient developed severe chest discomfort with diaphoresis. He is now unresponsive. What is the next indicated action? A. give an immediate unsynchronized high-energy shock (defibrillation dose)

A. give an immediate unsynchronized high-energy shock (defibrillation dose) - b/c wide and irregular

You arrive on the scene to find CPR in progress. Nursing staff report that the patient was recovering from a pulmonary embolism and suddenly collapsed. There is no pulse or spontaneous respirations. High-quality CPR and effective bag-mask ventilation are being provided. An IV has been initiated. What would you do now? A. give epinephrine 1 mg IV

A. give epinephrine 1 mg IV

An 8-month-old male is brought to the ED for evaluation of severe diarrhea and dehydration. In the ED the child becomes unresponsive and pulseless. You should for help and start CPR at a compression rate of at least 100/min and a compression-to-ventilation ratio of 30:2. Another provider arrives, at which point you switch to 2-rescuer CPR w/ a compression-to-ventilation ratio of 15:2. The cardiac monitor shows the above rhythm. The infant is intubated and ventilated w/ 100% oxygen. An IO line is rapidly established and a dose of epinephrine is given. Of the following choices for management, which would be most appropriate to give next? A. normal saline 20 mL/kg IV rapidly

A. normal saline 20 mL/kg IV rapidly - to treat underlying issue of fluid loss

A 3-year-old boy present w/ multiple system trauma. The child was an unrestrained passenger in a MVA. On primary assessment he is unresponsive to voice or painful stimulation. His RR is <6/min, HR is 170/min, systolic BP is 60 mmHg, cap refil is 5 seconds, and SpO2 is 75% in room air. Which of the following most accurately summarizes the first interventions you should take to support this child? A. open the airway (jaw-thrust technique) while stabilizing the cervical spine, administer positive-pressure ventilation w/ 100% oxygen, and establish immediate IV/IO access.

A. open the airway (jaw-thrust technique) while stabilizing the cervical spine, administer positive-pressure ventilation w/ 100% oxygen, and establish immediate IV/IO access.

Best way to relieve severe choking in a responsive adult? A. perform abdominal thrusts

A. perform abdominal thrusts

An 8-year-old child was struck by a car. He arrives in the ED alert, anxious, and in respiratory distress. His cervical spine is immobilized and he is receiving a 10 L/min flow of 100% oxygen by nonrebreathing face mask. Primary assessment reveals RR 60/min, HR 150/min, systolic BP 70 mmHg, and SpO2 84% on supplementary oxygen. Breath sounds are absent over the right chest, and the trachea is deviated to the left. He has weak central pulses and absent distal pulses. Which of the following is the most appropriate immediate intervention for this child? A. perform needle decompression of the R. chest and assist ventilation w/ a bag and mask if necessary

A. perform needle decompression of the R. chest and assist ventilation w/ a bag and mask if necessary - Tracheal deviation is a key finding in tension pneumothorax. Air accumulation displaces the trachea to the side opposite the pneumothorax. Tracheal deviation may also be seen in patients with pulmonary emphysema, unilateral effusion, or a thoracic mass. - Tension pneumothorax or bilateral pneumothoraces may be rapidly fatal and require immediate decompression based upon clinical diagnosis. Open pneumothorax, in addition to needle decompression, requires covering the open wound to avoid re-accumulation of pleural air. Hemothorax requires immediate decompression and fluid replacement including blood products. Needle thoracostomy should be performed and followed by chest tube placement. Bedside ultrasound can be diagnostic, but should not delay needle decompression - Obstructive shock - In this form of shock, hypotension arises from obstructed blood flow to the heart or great vessels. Common causes include cardiac tamponade, tension pneumothorax, ductal dependent congenital heart lesions, and massive pulmonary embolism. ●Shock management - The approach to undifferentiated shock in children requires careful attention to history and physical examination in order to arrive at the type of shock present - Early treatment can greatly improve outcome. Goals are to improve oxygen delivery and to reduce oxygen consumption. •Reversal of identified obstructions

You are transporting a 6-year-old endotracheally intubated patient who is receiving positive-pressure mechanical ventilation. The child begins to move his head and suddenly becomes cyanotic and bradycardic. SpO2 is 65% w/ good pulse signal. You remove the child from the mechanical ventilator circuit and provide manual ventilation w/ a bag via the endotracheal tube. During manual ventilation w/ 100% oxygen, the child's color and HR improve slightly and his BP remains adequate. Breath sounds and chest expansion are present and adequate on the right side, but they are consistently diminished on the left side. The trachea is not deviated, and the neck veins are not distended. A suction catheter passes easily beyond the top of the endotracheal tube. Which of the following is the most likely cause of this child's acute deterioration? A. tracheal tube displacement into the right main bronchus

A. tracheal tube displacement into the right main bronchus - The ET tube may be advanced too far, resulting in an endobronchial intubation, most commonly right mainstem, aerating only one lung.

You are performing rescue breathing for a victim who is not breathing but has a pulse. Your initial rescue breaths did not go in. You should A. reopen the airway with the head tilt-chin lift technique and attempt additional breaths

A. reopen the airway with the head tilt-chin lift technique and attempt additional breaths

A patient's 12-lead ECG was transmitted by the paramedics and showed an acute MI. The above findings are seen on a rhythm strip when a monitor is placed in the ED. The patient had resolution of moderate (5/10) chest pain w/ 3 doses of sublingual nitroglycerin. BP is 104/70 mm Hg. Which intervention below is most important, reducing in-hospital and 30-day mortality? A. reperfusion therapy

A. reperfusion therapy

A patient has a rapid irregular wide-complex tachycardia. The ventricular rate is 138/min. He is asymptomatic, with a BP of 110/70 mm Hg. He has a history of angina. Which of the following actions is recommended? A. seeking expert consultation

A. seeking expert consultation - no adenosine b/c not regular

A patient has sinus bradycardia w/ a HR of 36/min. Atropine has been administered to a total dose of 3 mg. A transcutaneous pacemaker has failed to capture. The patient is confused, and her BP is 100/60 mmHg. Which of the following is now indicated? A. start epinephrine 2-10 mcg/min

A. start epinephrine 2-10 mcg/min

Which of the following correctly states the proper technique for delivering mouth-to-mouth breaths? A. the rescuer opens the airway, seals his or her mouth over the victim's mouth, pinches the victim's nose closed, and gives each breath for about 1 second each while watching for the chest to rise

A. the rescuer opens the airway, seals his or her mouth over the victim's mouth, pinches the victim's nose closed, and gives each breath for about 1 second each while watching for the chest to rise

2010 AHA guidelines for CPR and ECC removed the step of "look, listen, and feel" from the BLS sequence

A. true

You are working at your desk when you hear the receptionist call for help. You enter the waiting room to find a 63-year-old man slumped in a chair. When should you ensure that the scene is safe? A. when you first see the potential victim

A. when you first see the potential victim

Adult BLS algorithm for healthcare providers: 2010 guidelines

AED: automated external defibrillator; ALS: advanced life support; BLS: basic life support. * The boxes bordered with dashed lines are performed by healthcare providers and not by lay rescuers.

What do the A-B-C-D stand for in the ACLS survey? A: 3 things B: 3 things C: 5 things D: 3 things

Airway: maintain airway in unconscious patient; consider advanced airway; monitor airway patency w/ quantitative waveform capnography Breathing: give 100% oxygen, keep SpO2 ≥94%; assess effective ventilation w/ quantitative waveform capnography; do not over-ventilate; Circulation: obtain IV/IO access; evaluate rhythm and pulse; defibrillation/cardioversion; give rhythm-specific medications; give IV/IO fluids if needed DDx: identify and treat reversible causes; cardiac rhythm and pt. history are keys to DDx; assess when to shock versus medicate

Recommendations for stepwise management of hemodynamic support in infants and children with sepsis

Algorithm for time sensitive, goal-directed stepwise management of hemodynamic support in infants and children. Proceed to next step if shock persists. (1) First hour goals—Restore and maintain heart rate thresholds, capillary refill ≤2 sec, and normal blood pressure in the first hour/emergency department. Support oxygenation and ventilation as appropriate. (2) Subsequent intensive care unit goals—If shock is not reversed, intervene to restore and maintain normal perfusion pressure (mean arterial pressure [MAP]-central venous pressure [CVP]) for age, central venous O2 saturation >70 percent, and CI >3.3, <6.0 L/min/m2 in pediatric intensive care unit (PICU). Hgb: hemoglobin; PICCO: pulse contour cardiac output; FATD: femoral arterial thermodilution; ECMO: extracorporeal membrane oxygenation; CI: cardiac index; CRRT: continuous renal replacement therapy; IV: intravenous; IO: interosseous; IM: intramuscular.

You are passing by the radiology department waiting room when you hear a call for help. You enter, check the scene safety, and find an infant lying on a radiology table. A colleague in the room says the infant suddenly became limp. - There is no pulse, and your colleague has not returned with the AED. You begin chest compressions. As a lone rescuer, you start chest compressions by using the 2-finger technique, providing B. 30 compressions, just below the nipple line, at a rate of 100 compressions per minute, with a compressions-to-breaths ratio is 30:2

B. 30 compressions, just below the nipple line, at a rate of 100 compressions per minute, with a compressions-to-breaths ratio is 30:2

According to the 2010 AHA guidelines for CPR and ECC, the BLS sequence of steps is now C-A-B (chest compressions, airway, breathing)

B. C-A-B (chest compressions, airway, breathing)

You are monitoring a patient. He suddenly has this persistent rhythm. You ask about symptoms, and he reports that he has mild palpitations, but otherwise he is clinically stable with unchanged vital signs. What is your next action? B. administer adenosine 6 mg; seek expert consultation

B. administer adenosine 6 mg; seek expert consultation - Monomorphic Ventricular Tachycardia may give rise to symptoms such as palpitations, shortness of breath, or lightheadedness, depending upon the rate of the arrhythmia, its duration, and the underlying heart disease. With faster heart rates and underlying heart disease loss of consciousness (syncope) or sudden death may occur. Episodes lasting only a few beats may produce no or minimal symptoms. Tachycardia rates between 110 and 150 may be tolerated even if sustained for minutes to hours. However, faster rates (>180 beats per minute) may cause drops in arterial pressure and produce syncope. Very fast rates (>220) are imminently dangerous because they rarely terminate spontaneously and invariably cause drops in blood pressure and low cardiac output. Most commonly, sufferers of ventricular tachycardia have underlying cardiac disease. In developed countries, the majority of the patients suffer from coronary artery disease.

Complete chest recoil contributes to CPR success by B. allowing the heart to refill with blood between compressions

B. allowing the heart to refill with blood between compressions

The recommended depth of chest compressions for an infant is B. at least one third the depth of the chest, approximately 1.5 inches (4 cm)

B. at least one third the depth of the chest, approximately 1.5 inches (4 cm)

A 7-year-old boy is found unresponsive, apneic, and pulseless. CPR is ongoing. The child is intubated and vascular access is established. The ECG monitor reveals an organized rhythm, but a pulse check reveals no palpable pulses. Effective ventilations and compressions are resumed, and an initial IV dose of epinephrine is administered. Which of the following therapies should you perform next? B. attempt to identify and treat reversible causes (using the Hs and Ts as a memory aid)

B. attempt to identify and treat reversible causes (using the Hs and Ts as a memory aid) - Pulseless electrical activity (PEA) consists of any organized electrical activity observed on ECG in a patient with no central palpable pulse. Reversible conditions may underlie PEA, including: ●Hypovolemia ●Hypoxia ●Hydrogen ion (acidosis) ●Hypo-/hyperkalemia ●Hypoglycemia ●Hypothermia ●Toxins ●Tamponade, cardiac ●Tension pneumothorax ●Thrombosis (coronary or pulmonary) ●Trauma These can be remembered as the H's and T's of PEA

A choking adult becomes unresponsive while you are doing abdominal thrusts for severe choking. You ease the victim to the floor and send someone to activate your emergency response system. What should you do next? B. begin CPR w/o a pulse check; when you open the airway, look for and remove the object (if seen) before giving rescue breaths

B. begin CPR w/o a pulse check; when you open the airway, look for and remove the object (if seen) before giving rescue breaths

Best action to relieve severe choking in a responsive infant? B. begin cycles of up to 5 back slaps and up to 5 chest thrusts

B. begin cycles of up to 5 back slaps and up to 5 chest thrusts

After activating the emergency response system and sending someone to get the AED, you should B. check for a carotid pulse

B. check for a carotid pulse

You are a healthcare provider in a large hospital and you respond to a call that there is a "very sick" person in the waiting room down the hall from you. You arrive in the waiting room just as an older man slumps over in his seat - After determining that the scene is safe, you assess the victim for responsiveness and breathing. There is no response when you gently tap and speak to the victim. You note that he is not breathing. After you send someone to activate the emergency response system and get an AED, you and 2 other colleagues lower the victim gently to the floor. You would then B. check for a pulse

B. check for a pulse

As you enter the exam room, the child suspected of ingesting grandma's pills collapses. When you examine the child, you find her very limp, pale, unresponsive, and not breathing. The scene is safe, and you send your assistant to activate the emergency response system and get the AED and emergency equipment while you B. check for a pulse for no more than 10 seconds

B. check for a pulse for no more than 10 seconds

The scene is safe. You would next B. check for a response (gently tap victim and ask, "are you all right?") and check for breathing

B. check for a response (gently tap victim and ask, "are you all right?") and check for breathing

You are passing by the radiology department waiting room when you hear a call for help. You enter, check the scene safety, and find an infant lying on a radiology table. A colleague in the room says the infant suddenly became limp. - You and your colleague perform the next steps of BLS for an infant in the correct order by B. checking for both responsiveness and breathing, and then sending the colleague to activate the emergency response system and get the AED while you check for a brachial pulse and start CPR if there is no pulse

B. checking for both responsiveness and breathing, and then sending the colleague to activate the emergency response system and get the AED while you check for a brachial pulse and start CPR if there is no pulse

A patient with a possible acute coronary syndrome has ongoing chest discomfort unresponsive to 3 sublinguqal nitroglycerin tablets. There are no contraindications, and 4 mg of morphine sulfate are administered. Shortly afterward, BP falls to 88/60 mmHg, and the patient has increased chest discomfort. You should B. give normal saline 250-500 mL fluid bolus

B. give normal saline 250-500 mL fluid bolus

Gastric inflation is more likely to occur if the rescuer B. gives breaths too quickly or with too much force

B. gives breaths too quickly or with too much force

While you provide compressions and count aloud, a colleague is giving breaths; to open the airway for this victim, your colleague will use the B. head tilt-chin lift technique

B. head tilt-chin lift technique

This time, the AED advises you to shock the victim → after you clear the victim and deliver the shock, you should B. immediately restart CPR, beginning w/ chest compressions

B. immediately restart CPR, beginning w/ chest compressions

Where should a rescuer attempt to locate the brachial pulse in an infant? B. inside the upper arm, between the elbow and shoulder

B. inside the upper arm, between the elbow and shoulder

Your patient has been intubated. IV/IO access is not available. Which combination of drugs can be administered by the endotracheal route? B. lidocaine, epinephrine, vasopressin

B. lidocaine, epinephrine, vasopressin

To perform the 2-thumb-encircling technique, you wrap your fingers around the infant's chest, and place your thumbs B. on the lower half of the breastbone

B. on the lower half of the breastbone

An 18-month-old child presents with a 1-week history of cough and runny nose. You perform an initial impression, which reveals a toddler responsive only to painful stimulation w/ slow respirations and diffuse cyanosis. You begin a primary assessment and find that the child's RR has fallen from 65/min to 10.min, severe inspiratory intercostal retractions are present, HR is 160/min, SpO2 is 65% in room air, and cap refill is less than 2 secs. Which of the following is the most appropriate immediate treatment for this toddler? B. open the airway and provide positive-pressure ventilation using 100% oxygen and a bag-mask device

B. open the airway and provide positive-pressure ventilation using 100% oxygen and a bag-mask device

A 57-year-old woman has palpitations, chest discomfort, and tachycardia. The monitor shows a regular wide-complex QRS at a rate of 180/min. She becomes diaphoretic, and her blood pressure is 80/60 mm Hg. The next action is to B. perform immediate electrical cardioversion

B. perform immediate electrical cardioversion

A 35-year-old woman presents to the ED w/ a CC of palpitations. She has no chest discomfort, SOB, or light-headedness. Which of the following is indicated first? B. perform vagal maneuvers

B. perform vagal maneuvers

Which of the following statement about calcium is true? B. routine administration of calcium is not indicated during cardiac arrest

B. routine administration of calcium is not indicated during cardiac arrest - Calcium has limited uses in pediatric resuscitation which include the treatment of hypocalcemia or hypermagnesemia, hyperkalemia, or calcium channel blocker overdose. ●Mechanisms - Calcium increases cardiac inotropy. Influx and efflux of calcium ions are important for the maintenance of normal conductivity and rhythm. ●Indications and contraindications - Calcium has a very specific indication in cardiac arrests as emergency protection against the arrhythmogenic effects of hypocalcemia, hyperkalemia, hypermagnesemia, or calcium channel blocker overdose [5]. It is otherwise not recommended for pediatric cardiopulmonary arrest because of an observed association with decreased survival and poor neurologic outcomes after pediatric arrests [63]. ●Dose and administration - The optimum dose of calcium is based upon extrapolation from adult data and limited pediatric data. Calcium chloride is preferred over calcium gluconate because it provides greater bioavailability of calcium but should only be given if central venous access is available because administration through a peripheral intravenous line is associated with skin necrosis and sloughing [64]. Calcium gluconate is less irritating to the veins and may be administered by peripheral or central venous access. The recommended dose of elemental calcium is 5 to 7 mg/kg [5]. Dosing in this range can be achieved by giving 0.2 mL/kg of calcium chloride 10 percent which provides 5.4 mg/kg of elemental calcium or 0.6 mL/kg of calcium gluconate 10 percent which provides 5.6 mg/kg of elemental calciums. The maximum single dose is 540 mg of elemental calcium. Calcium chloride or calcium gluconate should be administered by slow intravenous push over 10 to 20 seconds in cardiac arrest and more slowly (eg, over 5 to 10 minutes) in perfusing patients. Rapid administration may cause bradycardia or asystole. If sodium bicarbonate is being given through the same intravenous line, the tubing must be thoroughly flushed before and after calcium administration. Otherwise an insoluble precipitate can form in the catheter lumen.

A patient is in refractory ventricular fibrillation. High-quality CPR is in progress, and shocks have been given. One dose of epinephrine was given after the second shock. An antiarrhythmic drug was given immediately after the third shock. What drug should the team leader request to be prepared for administration next? B. second dose of epinephrine 1 mg

B. second dose of epinephrine 1 mg

A child becomes unresponsive in the ED and is not breathing. You provide ventilation w/ 100% oxygen. You are uncertain if a faint pulse is present w/ the above rhythm. What is your next action? B. start high quality CPR, beginning w/ compressions

B. start high quality CPR, beginning w/ compressions

A patient in the ED develops recurrent chest discomfort (8/10) suspicious for ischemia. His monitored rhythm becomes irregular. Oxygen is being administered by nasal cannula at 4 L/min, and an IV line is in place. BP is 160/96 mm Hg. There are no allergies or contraindications to any medication. You would first order B. sublingual nitroglycerin 0.4 mg

B. sublingual nitroglycerin 0.4 mg - ECG diffuse subendocardial ischemia: manifested by prominent ST depressions in leads I, II, aVL, aVF, and V2 to V6, with ST elevation in aVR. A prolonged PR interval (0.28 sec) is also present. The findings also raise the possiblitity of severe multivessel or left main coronary artery disease.

You are a healthcare provider responding to a call for help. You enter the hospital wing and see a 6-year-old boy lying motionless on the hallway floor. Another healthcare provider is already with the boy and explains to you that the boy has a heart condition and just collapsed. After confirming that the child is unresponsive and not breathing, he goes to activate the emergency response system and get the AED, leaving you to attend to the victim. - You should now B. take no more than 10 seconds to check for a pulse

B. take no more than 10 seconds to check for a pulse

You and your partner know the rescue breaths he is delivering for the infant victim are effective when B. the chest rises visibly

B. the chest rises visibly

A patient with possible ST-segment elevation MI has ongoing chest discomfort. Which of the following would be a contraindication to the administration of nitrates? B. use of a phosphodiesterase inhibitor w/i 12 hrs

B. use of a phosphodiesterase inhibitor

You are participating in the elective intubation of a 4-year-old child w/ respiratory failure. You must select the appropriate sized uncuffed endotracheal tube. You do not have a color-coded, length-based tape to use to estimate correct endotracheal tube size. Which of the following is the most appropriate uncuffed endotracheal tube for an average 4-year-old? C. 5-mm tube

C. 5-mm tube - Age-based formula for selecting endotracheal tube size (internal diameter in mm): --> Uncuffed tube: 4 + (age in years/4) --> Cuffed tube: 3.5 + (age in years/4) - Additional tubes one size larger and one size smaller than calculated should also be available.

Which of the following victims needs CPR? C. a victim who is unresponsive w/ no breathing (or no normal breathing) and no pulse

C. a victim who is unresponsive w/ no breathing (or no normal breathing) and no pulse

A 35-year-old woman has palpitations, light-headedness, and a stable tachycardia. The monitor shows a regular narrow-complex QRS at a rate of 180/min. Vagal maneuvers have not been effective in terminating the rhythm. An IV has been established. What drug should be administered IV? C. adenosine 6 mg

C. adenosine 6 mg

Initial impression of a 2-year-old female reveals her to be alert w/ mild breathing difficulty during inspiration and pale skin color. On primary assessment, she makes high-pitched inspiratory sounds (mild stridor) when agitated; otherwise her breathing is quiet. Her SpO2 is 92% in room air, and she has mild inspiratory intercostal retractions. Lung auscultation reveals transmitted upper airway sound with adequate distal breath sounds bilaterally. Which of the following is the most appropriate initial therapeutic intervention for this child? C. administer humidified supplementary oxygen as tolerated and continue evaluation

C. administer humidified supplementary oxygen as tolerated and continue evaluation

You are caring for a 3-year-old w/ vomiting and diarrhea. You have established IV access. When you place an orogastric tube, the child begins gagging and continues to gag after the tube is placed. The child's color had deteriorated; pulses are palpable but faint and the child is now lethargic. The HR is variable (44-62/min). You begin bag-mask ventilation w/ 100% oxygen. When the HR does not improve, you begin chest compressions. The cardiac monitor shows this rhythm. Which of the following would be the most appropriate therapy to consider next? C. atropine 0.02 mg/kg IV

C. atropine 0.02 mg/kg IV - Atropine is no longer routinely recommended in patients with cardiac arrest and is primarily indicated for vasovagal induced bradycardia or the treatment of primary atrioventricular block. ●Mechanisms - Atropine is a parasympatholytic drug that increases heart rate by accelerating the sinus and atrial pacemaker and improving conduction through the AV node. Although the dominant cardiac response is tachycardia, the heart rate may decrease transiently when small doses are administered [48]. This decrease is thought to occur because atropine, at low doses, blocks the M1 muscarinic postganglionic receptors that provide feedback inhibition for synaptic acetylcholine release [49]; the resulting increase in acetylcholine inhibits spontaneous impulse generation in the SA node. ●Indications and contraindications - Atropine is indicated for the prevention of bradycardia during endotracheal intubation in infants younger than one year of age, patients younger than five years of age who also receive succinylcholine, and children older than five years of age who are administered a second dose of succinylcholine. Atropine is also recommended for children with bradycardia caused by increased vagal tone or primary atrioventricular block or unresponsive to oxygen, airway support, and administration of epinephrine (algorithm 2).

Adult tachycardia algorithm (with pulse): 2010 ACLS guidelines

CHF: congestive heart failure; ECG: electrocardiogram; IV: intravenous; J: joules; NS: normal (isotonic) saline; VT: ventricular tachycardia

A 3-year-old unresponsive, apneic child is brought to the ED. EMS personnel report that the child became unresponsive as they arrived at the hospital. The child is receiving CPR, including bag-mask ventilation w/ 100% oxygen and chest compressions at a rate of at least 100/min. Compressions and ventilations are being coordinated at a rate of 15:2. You confirm that apnea is present and that ventilation is producing bilateral breath sounds and chest expansion while a colleague confirms absent pulses. Cardiac monitor shows the above rhythm. A biphasic manual defibrillator is present. You quickly use the crown-heel length of the child on a length-based, color-coded resuscitation tape to estimate the approximate weight as 15 kg. Which of the following therapies is most appropriate for this child at this time? C. attempt defibrillation at 30 J, then resume CPR beginning w/ compressions

C. attempt defibrillation at 30 J, then resume CPR beginning w/ compressions - b/c inital shock is at 2J/kg

A patient becomes unresponsive. You are uncertain if a faint pulse is present with the above rhythm. What is your next action? C. begin CPR, starting w/ high-quality chest compressions

C. begin CPR, starting w/ high-quality chest compressions

Proper location to check for a pulse in an adult victim is at the C. carotid artery of the neck

C. carotid artery of the neck

You are evaluating an irritable 6-year-old girl w/ mottled color. On primary assessment she is febrile (temp 40C [104F]) and her extermities are cold 9despite a warm ambient temp in the room) w/ cap refill of 5 secs. Distal pulses are absent and central pulses are weak. HR is 180/min, RR is 45/min, and BP is 98/56 mmHg. Which of the following most accurately describes the categorization of this child's condition using the terminology taught in the PALS provider course? C. compensated shock associated w/ tachycardia and inadequate tissue perfusion

C. compensated shock associated w/ tachycardia and inadequate tissue perfusion

Characteristic of high-quality CPR in adults? compressing at a depth of at least 2 inches

C. compressing at a depth of at least 2 inches - high-quality CPR for adults includes starting compressions w/i 10 sec of recognizing cardiac arrest, compressing at a depth of at lest 2 inches, allowing complete chest recoil, minimizing interruptions, and giving effective but not excessive breaths

Which of the following correctly compares characteristics of chest compressions in adults with those in infants and children? C. compression depth: for adults, at least 2 inches; for infants/children, at least one third the depth of the chest

C. compression depth: for adults, at least 2 inches; for infants/children, at least one third the depth of the chest

You are called to help resuscitate an infant w/ severe symptomatic bradycardia associated w/ respiratory distress. The bradycardia persists despite establishment of an effective airway, oxygenation, and ventilation. There is no heart block present. Which of the following is the first drug you should administer? C. epinephrine

C. epinephrine

A patient is in cardiac arrest. Ventricular fibrillation has been refractory to a second shock. Of the following, which drug and dose should be administered first by the IV/IO route? C. epinephrine 1 mg

C. epinephrine 1 mg

You open the airway by using the head tilt-chin lift technique. You would now C. give 1 breath every 5-6 seconds by using a bag and mask

C. give 1 breath every 5-6 seconds by using a bag and mask

You are monitoring a patient w/ chest discomfort who suddenly becomes unresponsive. You observe the following rhythm on the cardiac monitor. A defibrillator is present. What is your first action? C. give a single shock

C. give a single shock

A patient w/ ST-segment elevation MI has ongoing chest discomfort. Fibrinolytic therapy has been ordered. Heparin 4000 units IV bolus was administered, and heparin infusion of 1000 units per hour is being administered. Aspirin was not taken by the patient because he had a history of gastritis treated 5 years ago. Your next action is to C. give aspirin 160-325 mg chewed immediately

C. give aspirin 160-325 mg chewed immediately

You are monitoring the patient and note the above rhythm on the cardiac monitor. She has dizziness, and her BP is 80/40 mm Hg. She has an IV in place. What is your next action? C. give atropine 0.5 mg IV

C. give atropine 0.5 mg IV

You are preparing to use a manual defibrillator and paddles in the pediatric setting. When would it be most appropriate to use the smaller "pediatric" sized paddles for shock delivery? C. if the patient weighs <10 kg or is less than 1 year of age

C. if the patient weighs <10 kg or is less than 1 year of age - In general, one should use the largest paddles or electrode pads that will fit on the child's chest without touching. Paddles and electrode pads designed for adults are recommended for children who weigh more than 10 kg. Of these, those 12 cm in diameter seem to be superior to those that are 8 cm in diameter [9]. Infant paddles or pads are to be used for smaller infants weighing <10 kg

A 4-year -old male is in pulseless arrest in the PICU. A code is in progress. As the on-call physician you quickly review his chart and find that his baseline corrected QT interval on a 12-lead ECG is prolonged. A glance at the monitor shows recurrent episodes of the above rhythm. The boy received one dose of epinephrine 0.01 mg/kg (0.1 mL/kg of 1:10,000 dilution) but continues to demonstrate the rhythm. If this rhythm persists at the next rhythm check, which medication would be most appropriate to administer at this time? C. magnesium sulfate 25-50 mg/kg IV

C. magnesium sulfate 25-50 mg/kg IV Magnesium sulfate — Magnesium sulfate is the primary agent recommended for the treatment of torsades de pointes. ●Mechanisms - Magnesium is a crucial cofactor in the sodium-potassium-ATPase enzyme system. It stabilizes the motor membrane by reducing the sensitivity of the motor end plate to acetylcholine. A decreased intracellular magnesium level promotes myocardial excitability but, even in the absence of a low magnesium level, a bolus of IV magnesium will suppress ectopic ventricular beats. At high levels, magnesium acts as a calcium channel blocker and can produce bradycardia with atrioventricular block and cardiac arrest. ●Indications and contraindications - Magnesium sulfate is indicated in the treatment of torsades de pointes (polymorphic VT with long QT interval) or documented hypomagnesemia. Patients with hypokalemia and arrhythmias frequently have associated hypomagnesemia. Patients who receive magnesium sulfate require monitoring of serum magnesium concentrations. Magnesium should be administered with caution to patients with myasthenia gravis or other neuromuscular disease and patients with renal impairment. ●Dose and administration - For torsades de pointes, magnesium sulfate should be diluted in 5 percent dextrose (D5W) to a 20 percent solution or less and given as an intravenous or intraosseous infusion at a dose of 25 to 50 mg/kg (maximum dose: 2 g). The rate of infusion depends upon the clinical situation: •Patients with pulseless arrest - Infuse over one to two minutes. •Perfusing patients - Infuse over 15 minutes because rapid infusion is associated with hypotension and asystole.

Which of the following statements most accurately reflects the PALS recommendations for the use of magnesium sulfate in the treatment of cardiac arrest? C. magnesium sulfate is indicated for torsades de pointes and VF/pulseless VT assoc. w/ suspected hypomagnesemia

C. magnesium sulfate is indicated for torsades de pointes and VF/pulseless VT assoc. w/ suspected hypomagnesemia - Magnesium sulfate is the primary agent recommended for the treatment of torsades de pointes. ●Mechanisms - Magnesium is a crucial cofactor in the sodium-potassium-ATPase enzyme system. It stabilizes the motor membrane by reducing the sensitivity of the motor end plate to acetylcholine. A decreased intracellular magnesium level promotes myocardial excitability but, even in the absence of a low magnesium level, a bolus of IV magnesium will suppress ectopic ventricular beats. At high levels, magnesium acts as a calcium channel blocker and can produce bradycardia with atrioventricular block and cardiac arrest. ●Indications and contraindications - Magnesium sulfate is indicated in the treatment of torsades de pointes (polymorphic VT with long QT interval) or documented hypomagnesemia. Patients with hypokalemia and arrhythmias frequently have associated hypomagnesemia. Patients who receive magnesium sulfate require monitoring of serum magnesium concentrations. Magnesium should be administered with caution to patients with myasthenia gravis or other neuromuscular disease and patients with renal impairment. ●Dose and administration - For torsades de pointes, magnesium sulfate should be diluted in 5 percent dextrose (D5W) to a 20 percent solution or less and given as an intravenous or intraosseous infusion at a dose of 25 to 50 mg/kg (maximum dose: 2 g). The rate of infusion depends upon the clinical situation: •Patients with pulseless arrest - Infuse over one to two minutes. •Perfusing patients - Infuse over 15 minutes because rapid infusion is associated with hypotension and asystole.

Parents of a 1-year old female phoned the Emergency Response System when they picked up their daughter from the baby-sitter. Paramedics perform an initial impression revealing an obtunded infant w/ irregular breathing, bruises over the abdomen, abdominal distension, and cyanosis. Assisted bag-mask ventilation with 100% oxygen is initiated. On primary assessment HR is 36/min, peripheral pulses cannot be palpated, and central pulses are barely palpable. Cardiac monitor shows sinus bradycardia. Chest compressions are started w/ a 15:2 compression-to-ventilation ratio. In the ED the infant is intubated and ventilated w/ 100% oxgyen, and IV access is established. The HR is now up to 150/min but there are weak central pulses and no distal pulses. Systolic BP is 74 mm Hg. Of the following, which would be most useful in management of this infant? C. rapid bolus of 20 mL/kg of isotonic crystalloid

C. rapid bolus of 20 mL/kg of isotonic crystalloid - Rapid intravenous administration of fluids (eg, boluses of normal saline 20 mL/kg) up to three times or more as needed for persistent hypotension. For septic shock in children in resource-rich settings, it is optimal to deliver 60 mL/kg within the first 60 minutes of management

Main benefit of changing the BLS sequence of steps is that: rescuers can start chest compressions sooner

C. rescuers can start chest compressions sooner

AED analyzes the victim's cardiac rhythm and reports "no shock advised" → victim is still unresponsive and not breathing → next, you should: C. resume CPR, beginning w/ chest compressions

C. resume CPR, beginning w/ chest compressions 30:2

You and several colleagues are w/ an adult male victim who collapsed while entering the hospital → he is unresponsive, not breathing, no pulse → you and a colleague perform 2-rescuer CPR until another arrives w/ an AED → she kneels at victim's side, places AED next to victim and opens case → what should she do next? C. turn on AED

C. turn on AED

Your colleague finds that there are only standard adult pads in the AED case. He should C. use the standard adult pads

C. use the standard adult pads - if the AED includes smaller pads, use them → if not, use standard pads **making sure they do not touch each other or overlap

You are a healthcare provider in a large hospital and you respond to a call that there is a "very sick" person in the waiting room down the hall from you. You arrive in the waiting room just as an older man slumps over in his seat - for which of the following would it be appropriate to move an adult victim who might need CPR? C. when the adult victim is in a dangerous environment

C. when the adult victim is in a dangerous environment

Adult cardiac arrest algorithm: 2010 ACLS guidelines

CPR: cardiopulmonary resuscitation; ET: endotracheal tube; EtCO2: end tidal carbon dioxide; IO: intraosseous; IV: intravenous; PEA: pulseless electrical activity; VF: ventricular fibrillation; VT: ventricular tachycardia.

Initial impression of a 9-year-old male with increased work of breathing reveals the boy to be agitated and leaning forward on the bed with obvious respiratory distress. You administer 100% oxygen by nonrebreathing mask. The patient is speaking in short phrases and tells you that he has asthma but does not carry an inhaler. He has nasal flaring, severe suprasternal and intercostal retractions, and decreased air movement w/ prolonged expiratory time and wheezing. His SpO2 is 96% (on nonrebreathing mask). What is the next medical therapy to provide to this patient? D. albuterol by nebulization

D. albuterol by nebulization

A patient is in pulseless ventricular tachycardia. Two shocks and 1 dose of epinephrine have been given. Which is the next drug/dose to anticipate to administer? D. amiodarone 300 mg

D. amiodarone 300 mg

2010 AHA guidelines for CPR and ECC, the recommended rate for performing chest compressions for victims of all ages is D. at least 100 compressions per minute

D. at least 100 compressions per minute

Victim has no pulse, you begin CPR at a compression rate of D. at least 100 per minute and a compressions-to-breaths ratio of 30:2

D. at least 100 per minute and a compressions-to-breaths ratio of 30:2

If an unresponsive infant is not breathing and has a heart rate of 53 bpm and signs of poor perfusion despite oxygenation and ventilation with a bag and mask, which of the following should you perform? D. both chest compressions and breaths

D. both chest compressions and breaths

You have just assisted w/ the elective endotracheal intubation of a child w/ respiratory failure and a perfusing rhythm. Which of the following provides the ost reliable, prompt assessment of correct endotracheal tube placement in this child? D. clinical assessment of adequate bilateral breath sounds and chest expansion plus presence of exhaled CO2 in a colorimetric detection device after delivery of 6 positive-pressure ventilations

D. clinical assessment of adequate bilateral breath sounds and chest expansion plus presence of exhaled CO2 in a colorimetric detection device after delivery of 6 positive-pressure ventilations - Confirming tube position — Immediately following intubation, placement of the endotracheal (ET) tube in the trachea must be confirmed. Clinical assessment for appropriate tube position includes: ●Visible chest wall rise ●Auscultation of breath sounds in both axillae and not heard over the stomach ●Continuous pulse oximetry should confirm adequate oxygenation ●Mist should be present in the ET tube However, because clinical evaluation is not completely accurate, confirmatory devices should be used ●End-tidal CO2 should be detected using either a colorimetric device or capnography and is the **most definitive method of confirming that the ET tube is in the trachea

A patient presents with this rhythm and reports an irregular heartbeat. She has no other symptoms. Her medical history is significant for an MI 7 years ago. BP is 110/70 mmHg. What would you do at this time? D. continue monitoring and seek expert consultation

D. continue monitoring and seek expert consultation

Which of the following statements is most accurate regarding the administration of vasopressin during cardiac arrest? D. correct dose of vasopressin is 40 units administered IV or IO

D. correct dose of vasopressin is 40 units administered IV or IO

A 62-year-old man suddenly experienced difficulty speaking and left-sided weakness. He was brought to the emergency department. He meets initial criteria for fibrinolytic therapy, and a CT scan of the brain is ordered. What are the guidelines for antiplatelet and fibrinolytic therapy? D. do not give aspirin for at least 24 hours if rtPA is administered

D. do not give aspirin for at least 24 hours if rtPA is administered

5 links in AHA adult Chain of Survival are recognition and activation, early CPR, rapid defibrillation, D. effective advanced life support, and integrated post-cardiac arrest care

D. effective advanced life support, and integrated post-cardiac arrest care

Which of the following about endotracheal drug administration is true? D. endotracheal drug administration is the least desirable route of administration b/c this route results in unpredictable drug levels and effects

D. endotracheal drug administration is the least desirable route of administration b/c this route results in unpredictable drug levels and effects - Endotracheal drug administration — Although lipid soluble drugs, such as lidocaine, epinephrine, atropine, and naloxone ("LEAN"), may be administered via endotracheal tube (ETT), the intravascular route is always preferred. Optimal drug dosing via endotracheal tube is unknown, with unpredictable drug absorption leading to lower blood levels when compared with the same dose given intravascularly.

You are supervising another healthcare provider who is inserting and IO needle into an infant's tibia. Which of the following signs should you tell the provider is the best indication of successful insertion of a needle into the bone marrow cavity? D. fluids can be administered freely w/o local soft tissue swelling

D. fluids can be administered freely w/o local soft tissue swelling

During bag-mask ventilation, which of the following is recommended to minimize the risk of gastric inflation? D. give a breath with only the force and volume needed to see the chest rise

D. give a breath with only the force and volume needed to see the chest rise

The patient suddenly becomes unconscious and has a weak carotid pulse. Cardiac monitoring, supplementary oxygen, and an IV have been initiated. The code cart with all the drugs and a transcutaneous pacer are immediately available. Next you would D. give atropine 0.5 mg IV

D. give atropine 0.5 mg IV

First link in the AHA adult Chain of Survival is

D. immediate recognition of cardiac arrest and activation of the emergency response system

Which of the following statements about the use of magnesium in cardiac arrest is most accurate? D. magnesium is indicated for VF/pulseless VT associated w/ torsades de pointes

D. magnesium is indicated for VF/pulseless VT associated w/ torsades de pointes

In 2-rescuer CPR for an adult or child 8 years of age or older, the first rescuer begins chest compressions while the second rescuer D. maintains an open airway and gives breaths

D. maintains an open airway and gives breaths

The victim has a pulse. The emergency resuscitation cart arrives. Your next step should be to D. open his airway by using the head tilt-chin lift technique

D. open his airway by using the head tilt-chin lift technique

A patient was in refractory ventricular fibrillation. A third shock has just been administered. Your team looks to you for instructions. Your immediate next order is D. resume high-quality chest compressions

D. resume high-quality chest compressions - The survival rate from cardiac arrest with asystole is dismal. During a resuscitation attempt, brief periods of an organized complex may appear on the monitor screen, but spontaneous circulation rarely emerges. As with PEA, the hope for resuscitation is to identify and treat a reversible cause. - When the rhythm check confirms asystole or PEA, resume CPR immediately. A vasopressor (epinephrine or vasopressin) may be administered at this time. Epinephrine can be administered approximately every 3 to 5 minutes during cardiac arrest; one dose of vasopressin may be substituted for either the first or second epinephrine dose. For a patient in asystole or slow PEA, consider atropine. Do not interrupt CPR to deliver any medication. Give the drug as soon as possible after the rhythm check. After drug delivery and approximately 5 cycles (or about 2 minutes) of CPR, recheck the rhythm. If a shockable rhythm is present, deliver a shock. If no rhythm is present or if there is no change in the appearance of the electrocardiogram, immediately resume CPR.

Following resuscitation with CPR and a single shock, you observe this rhythm while preparing the patient for transport. Your patient is stable, and BP is 120/80 mm Hg. She is apprehensive but has not symptoms other than palpitations. At this time you would D. seek expert consultation

D. seek expert consultation

You are a healthcare provider in a large hospital and you respond to a call that there is a "very sick" person in the waiting room down the hall from you. You arrive in the waiting room just as an older man slumps over in his seat - Several colleagues are nearby. After determining that the scene is safe, you assess the victim for responsiveness and breathing. There is no response when you gently tap and speak to the victim. You note that he is not breathing. The next thing you need to do is D. send someone to activate the emergency response system and get the AED

D. send someone to activate the emergency response system and get the AED

Initial impression of a 10-month-old male in the ED reveals a lethargic pale infant w/ slow respirations. You begin assisted ventilation w/ a bag-mask device using 100% oxygen. On primary assessment HR is 38/min, central pulses are weak but distal pulses cannot be palpated, BP is 60/40 mm Hg, and cap refill is 4 secs. During your assessment a colleague places the child on a cardiac monitor and you observe the rhythm above. The rhythm remains unchanged despite ventilation w/ 100% oxygen. What are your next management steps? D. start chest compressions and give epinephrine 0.01 mg/kg (0.1 mL/kg of 1:10,000 dilution) IV/IO

D. start chest compressions and give epinephrine 0.01 mg/kg (0.1 mL/kg of 1:10,000 dilution) IV/IO

You are evaluating a patient with chest discomfort lasting 15 minutes during transportation to the ED. He is receiving oxygen, and 2 sublingual nitroglycerin tablets have relieved his chest discomfort. He reports no other symptoms but appears anxious. BP is 130/70 mm Hg. You observe the above rhythm on the monitor. What is your next action? E. continue monitoring the patient and seek expert consultation

E. continue monitoring the patient and seek expert consultation

A patient is in cardiac arrest. High-quality chest compressions are begin given. The patient is intubated, and an IV has been started. The rhythm is asystole. Which is the first drug/dose to administer? E. epinephrine 1 mg or vasopressin 40 units IV or IO

E. epinephrine 1 mg or vasopressin 40 units IV or IO

Following initiation of CPR and 1 shock for VF, this rhythm is present on the next rhythm check. A second shock is given, and chest compressions are resumed immediately. An IV is in place, and no drugs have been given. Bag-mask ventilations are producing visible chest rise. What is your next order? E. prepare to give epinephrine 1 mg IV

E. prepare to give epinephrine 1 mg IV

A 45-year-old woman with a history of palpitations develops light-headedness and palpitations. She has received adenosine 6 mg IV for the rhythm shown w/o conversion of the rhythm. She is no extremely apprehensive. BP is 108/70 mm Hg. What is the next appropriate intervention? E. repeat adenosine 12 mg IV

E. repeat adenosine 12 mg IV

Pediatric bradycardia algorithm (with a pulse and poor perfusion): 2010 PALS guidelines

PALS: pediatric advanced life support; CPR: cardiopulmonary resuscitation; IO: intraosseous; IV: intravenous; HR: heart rate; AV: atrioventricular; ABCs: airway, breathing, circulation.

Pediatric tachycardia algorithm (with a pulse and poor perfusion): 2010 PALS guidelines

PALS: pediatric advanced life support; IO: intraosseous; IV: intravenous; ECG: electrocardiogram. * Vagal manuevers: In infants or young children, place a plastic bag filled with ice and cold water over the face for 15 to 30 seconds or stimulate the rectum with a thermometer. In older children, encourage bearing down (Valsalva maneuver) for 15 to 20 seconds. Carotid massage and orbital pressure should not be performed in children.

Pediatric cardiac arrest algorithm: 2010 PALS guidelines

PALS: pediatric advanced life support; VF: ventricular fibrillation; VT: ventricular tachycardia; PEA: pulseless electrical activity; IO: intraosseous; IV: intravenous; CPR: cardiopulmonary resuscitation; ROSC: return of spontaneous circulation.

Signs and rescuer actions during a mild airway obstruction?

Signs: - good air exchange - can cough forcefully - may wheeze between coughs - Rescuer Actions: - encourage victim to continue spontaneous coughing and breathing efforts - do not interfere but stay with victim and monitor condition - if persists, activate emergency response system

Signs and rescuer actions during a severe airway obstruction?

Signs: - poor or no air exchange - weak, ineffective cough or none at all - high-pitched noise while inhaling or none at all - ↑respiratory difficulty - possible cyanosis - unable to speak - universal choking sign - Rescuer Actions: - ask victim if choking → if nods yes → must try to relieve with abdominal thrusts in victims 1 year of age and older (not for use with infants)

if an adult is eating and suddenly coughs and cannot breathe, talk, or make any sounds, you should ask the adult if she is choking; if she nods "yes" tell her you are going to help and give abdominal thrusts a. true

a. true

Volume provided with each breath should be c. enough to cause visible chest rise

c. enough to cause visible chest rise