ACLS

Adenosine 6 mg

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?

(Reentry Supraventricular Tachycardia) Perform vagal maneuvers.

A 35-year-old woman presents to the emergency department with a chief compliant of palpitations. She has no chest discomfort, shortness of breath, or light-headedness. Which of the following is indicated first?

(reentry SVT) Repeat adenosine 12 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 above without conversion of the rhythm. She is now extremely apprehensive. Blood pressure is 108/70 mm Hg. What is the next appropriate intervention?

Obtain a 12 lead ECG

A 49 y/of male arrives in the ER with persistent epigastric pain. She has been taking antacids PO for the past 6 hours because she she had heartburn. BP is 118/72, heart rate is 92/min, resp. rate is 14 non-labored and O2 sat is 96%. What is the most appropriate next action?

Perform immediate electrical cardioversion.

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:

Obtain a 12 lead ECG.

A 62 y/o male pt. in the ER says his heart is beating fast. No chest pain or SOB. BP is 142/98, pulse rate is 200/min, reps rate is 14/min, O2 sats are 95 at room air. What should be the next evaluation?

Do not give aspirin for at least 24 hours if tPA is administered.

A 62-year-old man suddenly experienced difficulty speaking and left-side 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 (ASA)?

Cinncinati Stroke Scale

A 68 y/o female pt. experienced a sudden onset of right arm weakness. BP is 140/90, pulse is 78/min, resp rate is non-labored 14/min, 02 sat is 97%. Lead 2 in the ECG shows a sinus rhythm. What would be your next action?

Seeking expert consultation.

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

Start epinephrine 2 to 10 mcg/min.

A patient has sinus bradycardia with a heart rate of 36/min. Atropine has been administered to a total of 3 mg. A transcutaneous pacemaker has failed to capture. The patient is confused, and her blood pressure is 110/60 mm Hg. Which of the following is now indicated?

Epinephrine 1 mg or vasopressin 40 units IV or IO.

A patient is in cardiac arrest. High-quality chest compressions are being given. The patient is intubated and an IV has been started. The rhythm is asystole. Which is the first drug/dose to administer?

Epinephrine 1 mg

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?

IV or IO

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?

Amiodarone 300 mg

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?

150 mg IV push.

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:

Second dose of epinephrine 1 mg

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?

(Atrial Fibrillation) Continue monitoring and seek expert consultation.

A patient presents with the rhythm below and reports an irregular heartbeat. She has no other symptoms. Her medical history is significant for a myocardial infarction 7 years ago. Blood pressure is 110/70 mm Hg. What would you do at this time?

Resume high-quality chest compressions.

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:

Give aspirin 160 to 325 mg chewed immediately.

A patient with ST-segment elevation MI has ongoing chest discomfort. Fibrinolytic therapy has been ordered. Heparin 4000 units IV bolus was administered, and a 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:

Give normal saline 250 mL to 500 mL fluid bolus.

A patient with a possible acute coronary syndrome has ongoing chest discomfort unresponsive to 3 sublingual nitroglycerin tablets. There are no contraindications, and 4 mg of morphine sulfate was administered. Shortly afterward, blood pressure falls to 88/60 mm Hg, and the patient has increased chest discomfort. You should:

Use of a phosphodiesterase inhibitor within 12 hours

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?

0.5 mg

A patient with sinus bradycardia and heart rate of 42/min has diaphoresis and a blood pressure of 80/60 mm Hg. What is the initial dose of atropine?

Vagal maneuver.

A pt. has an onset of dizziness. The pt.s heart rate is 180, BP is 110/70, resp. rate is 18, O2 sat is 98%. This is a reg narrow complex tach rhythm. What is the next intervention?

Simple airway maneuvers and assisted ventilation.

A pt. in respiratory failure becomes apneic but continues to have a strong pulse. The heart rate is dropping rapidly and now shows a sinus brady rate at 30/min. What intervention has the highest priority?

Atropine 0.5mg

A pt. presents to the ER with a new onset of dizziness and fatigue. On examination, the pt's heart rate is 35 beats/min, BP is 70/50, resp. rate is 22 per min, O2 sat is 95%. What is the appropriate 1st medication?

Sinus Tachycardia

A pt. with *regular* narrow-complex QRS at a rate >150bpm in which vagal maneuvers are ineffective should be given 6mg adenosine IV Synchronized cardioversion is indicated if the pt. is hypotensive, AMS, shock, ischemic CP, or acute HF. dx rhythm?

Indication: life threatening arrhythmia such as VF, pulse-less VT, unresponsive to shock delivery, CPR, and vasopressin Precaution: Rapid infusion can lead to hypotension Route: IV. Dosage: 300 mg, second dose of 150 mg

Amiodarone

Begin chest compression.

An AED does not promptly analyze a rhythm. What is your next step?

Indication: any person with symptom of ischemic pain such as crushing, pressure Precaution: known hypersenisivity to aspirin Route: PO Dosage: 160 mg-*325 mg* nonenteric tablet

Aspirin

Indication: use in sinus symptomatic bradycardia. Precaution: avoid hypothermic bradycardia. Route: IV. *Dosage: 0.5 mg (every 3-5 min) max 3 mg.*

Atropine

Chest pain or shortness of breath is present.

Bradycardia requires treatment when:

Indication:second line of drug for bradycardia. Precaution: do not mix with sodium bicarbonate. Route: IV. *Dosage:2-20 mcg/kg/mi*

Dopamine

Resume compressions

During a pause in CPR, you see a narrow complex rythm on the monitor. The pt. has no pulse. What is the next action?

Indication: cardiac arrest: VF, pulse-less VT, asystole, PEA. Precaution: higher dosage needed to treat poison/drug induce shock. Route: IV. Dosage: 1mg every 3-5 min followed by a 20mL of NS raised extremity

Epinephrine

Prepare to give epinephrine 1 mg IV.

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?

Seek expert consultation.

Following resuscitation with CPR and a single shock, you observe this rhythm while preparing the patient for transport. Your patient is stable and blood pressure is 120/80 mm Hg. She is apprehensive but has no symptoms other than palpitations. At this time you would:

Adenosine

Indication: stable narrow complex SVT Precaution: posion/drug induce tachycardia or 2 or 3 degree heart block. Route: IV rapid push Dosage: 6 mg follow by a 20mL of NS raise extremity, second dosage of 12 mg if needed, 1-2min

Indication: Alternative use for amiodarone in cardiac arrest: VF/VT. Precaution: discontinue if toxicity develop. Route: IV. Dosage: 1-1.5 mg max 3mg.

Lidocaine note: Lidocaine not a correct question choice on test

Indication: cardiac arrest only if *torsades de pointes* or hypomagnesemia is present. Precaution: caution in renal failure. Route:IV. Dosage:1-2 mg diluted in a 10ml of D5W

Magnesium Sulfate

Indication: acute cardogenic pulmonary edema. Precaution: respiratory depression. Route:IV. Dosage:2-4mg IV

Morphine Sulfate

Indication: hypertensive urgency with ACS. Precaution: hypotension. Route:IV. Dosage:12.5-25 UG

Nitroglycerin

*Question 46* (Polymorphic Ventricular Tachycardia) Give an immediate unsynchronized high-energy shock (defibrillation dose). *Question 53*(torsades) Give magnesium sulfate 1 to 2 g IV diluted in 10 mL D5W given over 5 to 20 minutes

Question 46: 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? Question 53: This patient was admitted to the general medical ward with a history of alcoholism. A code is in progress and he has recurrent episodes of this 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 of amiodarone 300 mg IV so far. What would you order for his next medication?

Continue CPR while charging the defibrillator.

What action is recommended to help minimize interruptions in chest compressions during CPR?

Prolonged interruptions in chest compressions.

What is a common but sometimes fatal mistake in cardiac arrest management?

Optimizing ventilation and oxygenation.

What is the 1st treatment priority for a pt. who achieves ROSC?

90mm Hg

What is the minimum systolic BP one should attempt to achieve with fluid, Inotropic, or vasopressor administration in a hypotensive post-cardiac arrest who achieves ROSC?

Continuous waveform capnography

What is the most reliable method of confirming and monitoring correct placement of an ET tube?

Obstruction of veneous return from the brain

What is the potential danger to using ties that pass circumferential around the pt's neck when securing an advanced airway?

Peripheral IV

What is the preferred method of access for epi administration during cardiac arrest in most pts?

1 to 2 Liters

What is the recommended IV fluid (NS or LR) bolus dose for a pt. who achieves ROSC but is hypotensive during the post-cardiac arrest period?

12mg

What is the recommended dose for adenosine for pt's in refractory, but stable narrow complex tachycardia?

35-40mm Hg

What is the usual post-cardiac arrest target range for PETCO2 who achieves return of spontaneous circulation (ROSC)?

Allowing complete chest recoil

Which action is a component of high-quality chest compressions?

Early defibrillation

Which action is included in the BLS survey?

Responding to verbal commands

Which condition is a contraindication to therapeutic hypothermia during the post-cardiac arrest period for pt's who achieve return of spontaneous circulation (ROSC)?

PETCO2 = or > 10mm Hg

Which of the following is a sign of effective CPR?

Magnesium is indicated for VF/pulseless VT associated with torsades de pointes.

Which of the following statements about the use of magnesium in cardiac arrest is most accurate?

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

Which of the following statements is most accurate regarding the administration of vasopressin during cardiac arrest?

Unstable SVT

Which rhythm requires synchronized cardioversion?

Syncronized cardioversion.

You are evaluating a 48 y/o male with crushing sub-sternal pain. He is cool, pale, diaphoretic, and slow to respond to your questions. BP is 58/32, pulse is 190/min, resp rate is 18, and you are unable to obtain an 02 sat due to no radial pulse. The ECG shows a wide complex tach rhythm. What intervention should be next?

Obtaining a 12 lead ECG.

You are evaluating a 58 year old man with chest pain. The BP is 92/50 and a heart rate of 92/min, non-labored respiratory rate is 14 breaths/min and the pulse O2 is 97%. What assessment step is most important now?

[Second Degree Heart Block (Mobitz I); note prolonged PR int until dropped beat] Continue monitoring the patient and seek expert consultation.

You are evaluating a patient with chest discomfort lasting 15 minutes during transportation to the emergency department. He is receiving oxygen and 2 sublingual nitroglycerin tablets have relieved his chest discomfort. He reports no other symptoms but appears anxious. Blood pressure is 130/70 mm Hg. You observe the rhythm below on the monitor. What is your next action?

(Coarse Ventricular Fibrillation) Give a single shock

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

(Monomorphic Ventricular Tachycardia) Administer adenosine 6 mg; seek expert consultation.

You are monitoring a patient. He suddenly has the persistent rhythm shown below. 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?

Give atropine 0.5 mg IV.

You are monitoring the patient and note the rhythm below on the cardiac monitor. She has dizziness and her blood pressure is 80/40 mm Hg. She has an IV in place. What is your next action?

Atropine 0.5 mg IV.

You arrive on the scene to find a 56-year-old diabetic woman with dizziness. She is pale and diaphoretic. Her blood pressure is 80/60 mm Hg. The cardiac monitor documents the rhythm below. She is receiving oxygen at 4 L/min by nasal cannula and an IV has been established. Your next order is:

Gain IV or IO access.

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:

Start chest compression of at least 100 per min.

You find an unresponsive pt. who is not breathing. After activating the emergency response system, you determine there is no pulse. What is your next action?

Administer 1mg of epinepherine

You have completed 2 min of CPR. The ECG monitor displays the lead below (PEA) and the pt. has no pulse. You partner resumes chest compressions and an IV is in place. What management step is your next priority?

Divert the pt. to a hospital 15 min away with CT capabilities.

You receiving a radio report from an EMS team enroute with a pt. who may be having a stroke. The hospital CT scanner is broken. What should you do?

Lidocaine, epinephrine, vasopressin

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

Sinus Bradycardia Sinus bradycardia can be treated with atropine at an initial dose of 0.5mg *Not ALL cases of sinus brady needed to be treated with atropine! If pt. is symptomatic (chest pain, SOB) it requires treatment.

dx rhythm?

Agonal Rhythm/Asystole Asystole is treated with high quality CPR and epi 1mg or vasopressin 40mg IV/IO

dx?

Fine Ventricular Fibrillation... VFib should be treated with defibrillation followed by 1mg epi if necessary...and of course CPR

dx?

Sinus Bradycardia Sinus bradycardia can be treated with atropine at an initial dose of 0.5mg *Not ALL cases of sinus brady needed to be treated with atropine! If pt. is symptomatic (chest pain, SOB) it requires treatment.

dx?

120 - 200 J biphasic OR 200 J monophasic

energy shock for narrow irregular QRS? (afib)

50 -100J

energy shock for regular narrow QRS? (a flutter, SVT)

100 J

energy shock for wide regular QRS? (VT)

answer B. amiodarone

on test, if given choice between lidocaine, amiodarone, mag. what would you choose?

Indication: for patient suspected of stoke and hypoxemia, or unknown oxyhemoglobin saturation. Precaution: monitor closely in patient that are dependent of their hypoxic drive

oxygen

Indication: alternative to epinephrine in asystole, PEA. Precaution: not recommended for responsive patient with coronary artery disease. route:IV. dose: *one dose of 40 units*

vasopressin