ACLS

List three advanced airways.

(1) Combitube (2) LMA (3) ET Tube

Unless contraindicated, the following agents are recommended for initial therapy of ALL patients suspected of having ischemic chest discomfort.

(1) Oxygen (2) Aspirin (3) Nitroglycerin (4) Morphine

Name six initial drugs used to treat ACS.

(1) Oxygen (2) Aspirin (3) Nitroglycerin (4) Morphine (5) Fibrinolytic therapy (6) Heparin

Name three ways to confirm proper placement of advanced airway devices.

(1) Physical Examination (2) Measurement of exhaled CO2 (3) Use of esophageal detector device

Name the three ACLS designated EKG categories for ACS.

(1) ST-segment elevation (2) ST-segment depression (3) undiagnostic or normal

List the three classifications of ACS based on ST-segment deviation.

(1) STEMI (2) High Risk UA/NSTEMI (3) Intermediate/Low Risk UA

The first three steps in treating any cardiac emergency before ABCDs are:

(1) Scene safety (2) Check responsiveness (3) Get help/AED/return

Four steps for instering an OPA

(1) Suction as needed (2) Measure (corner mouth/angle jaw) (3) Insert backward (4) Rotate 180% on insertion

Name the two pathways for pulseless arrest established in the ACLS Pulseless Arrest Algorithm.

(1) VF/VT (shockable rhythms) (2) Asystole/PEA (nonshockable rhythms)

ACS patient assessment <10 minutes (list the 7 steps)

(1) Vitals & O2 sat. (2) IV (3) 12-lead (4) history/phys.exam (5) fibrinolytic checklist (6) draw blood (7) chest x-ray

two key questions when assessing signs/symptoms in bradycardic patients

(1) are signs/symptoms "serious"? (2) are they related to the slow heart rate?

Give 3 precautions of TCP.

(1) contraindicated: hypothermia / not recommended: asystole (2) most conscious patients require sedation unless unstable (3) do not assess capture on carotid due to false jerking

Name four common underlying rhythms associated with PEA.

(1) idioventricular (2) ventricular escape (3) postdefibrillatory idioventricular (4) bradyasystolic

two points to bear in ming with respect to ET drug access

(1) optimal ET dose remains unknown (2) typical dose is 2-2.5 times that of IV

two keys questions in the management of tachycardia

(1) pulses present? (2) if yes, stable or unstable?

Imagine and recite the 13 steps for synchronized cardioversion.

(1) sedate if possible (2) turn on defibrillator (3) attach to patient (4) press SYNCH (5) look for flagging (6) adjust gain until flags appear (7) select energy level (8) annouce: "Charging!" (9) press charge (10) announce: "CLEAR!" (11) press to shock (12) check monitor/increase energy PRN (13) activate synch after EACH shock

four rhythms in the ACLS bradycardia case

(1) sinus bradycardia (2) 1st degree AV block (3) 2nd degree AV blocks I & II (4) 3rd degree AV block

Amiodarone is a complex drug that affects (1)_____, (2)_____, and (3)_____ channels.

(1) sodium (2) potassium (3) calcium

Give the ACS patient aspirin to chew only if (1)______, (2)______, and (3)______.

(1) the patient has not already taken aspirin (2) there is no allergy to aspirin (3) there is no Hx of GI bleeding

What two types of shocks are modern defibrillator/cardioverters capable of administering?

(1) unsynchronized shocks (2) synchronized shocks

Portable suction may be inadequate, as a suction force of ______ to ______ is generally necessary to properly suction.

-80 to -120 mm Hg

To help remove thick mucus secretions, instill ______ into the airway before suctioning and ______ to disperse.

1 to 2 ml saline ventilate

In a possible STEMI, the goal is for a physician to evaluate 12-lead EKG within ___ minutes of ED arrival.

10

For rescue breathing without chest compressions, give bag-mask ventillations at a rate of ___ to ___ breaths per minute.

10 to 12

monophasic energy levels for A-fib cardioversion

100-200J, 300J, 360J

Reperfusion has been established as a standard of care for patients with STEMI who present within ___ hours of onset of symptoms with no contraindications.

12

In ACS cases, EMS providers should obtain a ______ EKG if available.

12-lead

In PEA, obtain a rapid _____ EKG, if possible, without interrupting CPR for more than 10 seconds.

12-lead

The ______ is at the center of the decision pathway in the management of ischemic chest pain and is the only means of identifying STEMI.

12-lead EKG

With a biphasic truncated exponential waveform, it is reasonable to used selected energies of ______-J to ______-J.

150 to 200

In cases of bradycardia unresponsive to atropine, a dopamine infusion may be given at a dose of ______ per minute titrated to the patient's response.

2-10 mcg/kg/min

DO NOT RELY ON ATROPINE in bradycardic patients with ______ heart block or ______ heart block -- instead, go straight to ______.

2nd degree type II 3rd degree (complete) TCP

Give the ACS patient up to ___ sublingual nitro tablet for ______ symptoms, at intervals of ___ minutes.

3 ongoing 3-5

For the patient with STEMI, the goals of reperfusion are to give fibrinolytics within ___ minutes of ED arrival or provide PCI within ___ minutes.

30 90

Which heart block is most likely to cause cardiovascular collapse and require pacing?

3rd degree (complete heart block)

In a shockable arrest, Lidocaine is administered every ______ minutes.

5 to 10

Fibrin-specific agents are effective in achieving normal flow in about ______ of patients given these drugs.

50%

monophasic energy levels for SVT and A-flutter cardioversion

50J, 100J, 200J, 300J, 360J

Oxygen administration is probably most beneficial for the first ___ hours of AMI therapy.

6

The "H's and T's" consist of ___ H's and ___ T's. (the numbers)

6 H's 5 T's

With an advanced airway in place and CPR in progress, give 1 breath every ___ to ___ seconds.

6 to 8

With TCP, most patients will improve with a rate of ______ to ______ if the symptoms are primarily due to bradycardia.

60 - 70 bpm

Use of OPA and NPA is considered in the ______ survey.

ACLS secondary survey

How is Amiodarone given during a shockable arrest? (doses, route, etc.)

Amiodarone 300 mg IV/IO once. Consider additional 150 mg IV/IO once.

How is Epinephrine given during a cardiac arrest? (doses, route, etc.)

Epinephrine Hydrochloride 1 mg IV/IO (repeat every 3-5 mins)

True or Fales: There is no evidence to date that routine use of any vasopressor at any stage during management of pulseless VT, VF or asystole favors initial resuscitation with ROSC.

False. There is evidence that vasopressors aid in initial resuscitation and ROSC, but there is no evidence the improve survivability to discharge.

As adjunct therapies (in addition to the core recommended ACLS therapies), ______ and ______ are commonly used in early in the management of STEMI.

IV Nitro Heparin

Which vasopressor has been shown to increase survival from PEA.

None. But because of their perfusion pressure effects, they continue to be recommended.

What is a significant difference between the effects of vasopressin and epinephrine.

Overall, the effects of the two have not been shown to differ for ROSC or survival rates.

Drug overdoses that cause peripheral vascular dilation and/or myocardial dysfunction may cause a ______ arrest.

PEA

PEA from cardiac thrombosis (1) monitor clues? (2) clinical/Hx clues? (3) recommended treatment?

PEA/AMI (1) monitor: abnormal 12-lead, Q-waves, ST changes, T inversions (2) clinical: history, cardiac markers (3) treatment: fibrinolytic agents

PEA from Hydrogen ions (acidosis) (1) monitor clues? (2) clinical/Hx clues? (3) recommended treatment?

PEA/acidosis (1) monitor: small amplitude QRS (2) Hx: diabetes, renal, acidosis (3) treatment: bicarb, hyperventillation

What is the most common rhythm present following defibrillation?

PEA/pseudo-PEA

What should you do to prevent a medication patch from blocking shocks from an electrode?

Remove the patch and wipe the area clean before applying electrode.

In a posterior wall MI, ______ in the early precordial leads is equal to ______ in others, which is suggestive of a "STEMI" on the posterior wall of the heart.

ST-depression ST-elevation

The primary goal for patients with ACS is identification of ______ and triage for early reperfusion therapy.

STEMI (ST-elevated Myocardial Infarction)

______ is the treatment of choice when the a patient has a symptomatic bradycardia with signs of poor perfusion.

Transcutaneous pacing (TCP)

True or False. You should avoid using Nitroglycerine in patients with tachycardia (>100 pulse).

True.

True or false. Atropine may eliminate the need for pacing.

True.

In what treatment sequence are the two drug classes used in shockable rhythms initially administered?

Vasopressors first, Antiarrhythmics second.

Do not delay cardioversion in extremely unstable patients for administration of ______ or ______.

adenosine sedation

In the bradycardia case, the primary decision point in the algorithm is the determination of ______.

adequate perfusion

Name the ACLS antiarrhythmic that is both an alpha and beta blocker.

amiodarone

After conversion of VF/pulseless VT to a perfusing rhythm, consider a ______ for maintenance therapy.

antiarrhythmic

define bradyarrhythmia/bradycardia

any rhythm disorder with a heart rate less than 60

The causative "H's and T's" apply not only to PEA, but also to ______.

asystole

Consider giving ______ to increase the heart rate before pacing in mildly symptomatic patients.

atropine

In a full cardiac arrest, what is the rate of breaths per minute for basic versus advanced airways?

basic airway: 10-12 breaths/min advanced airway w/CPR: 8-10 breaths/min

Pacing may increase heart rate and eliminate ______ ventricular rhythms.

bradycardia-dependent

If pacing is not immediately available and symptomatic bradycardia is unresponsive to atropine, consider ______ class drugs in doses that stimulate ______.

catecholamine chronotropy

In the initial hours of an ACS, aspirin is absorbed better when ______, particularly when ______ is given.

chewed morphine

The ______ dose of dopamine will likely be lower than the ______ dose.

chronotropic (heart rate) inotropic (vasoconstrictor)

The "D" in the ACLS secondary survey stands for ______.

differential diagnosis

In addition to torsades de points, magnesium is useful for arrested patients with a history of alcoholism or other conditions associated with ______ abnormality.

electrolyte

If STEMI is identified on the 12-lead EKG, EMS should complete a ______ if appropriate.

fibrinolytic checklist

If hypotension developes with Morphine, administer ______ as a first line of therapy.

fluid

A heart rate in the normal sinus range that is lower than expected for the condition (eg 70 bpm in septic shock) is termed ______ or ______ bradycardia.

functional or relative

The inappropriate dosing and monitoring of ______ therapy has caused excess intracerebral bleeding and major hemorrhage in STEMI patients.

heparin

Do not delay pacing for unstable patients, particularly those with ______.

high degree AV block

Hemodynamically unstable or rapidly deteriorating patients require ______ pacing with ______. In all other awake patients, ______ before pacing.

immediate no prior sedation sedate.

Persistent aystole represents extensive ______ from prolonged inadequate coronary perfusion.

myocardial damage

In asystole, attempting transcutaneous pacing is ______. (recommended/not recommended)

not recommended

Perform a pulse check -- preferrably during rhythm analysis -- ONLY if a ______ is present.

organized rhythm (complexes regular and narrow)

For an arrest that was initially shockable, if the monitor reveals a nonshockable and pulseless rhythm, you should... (complete this sentence).

proceed along the asystole/PEA pathway of the ACLS Pulseless Arrest Algorithm.

If there is any doubt as to whether an unstable patient with a pulse has polymorphic or monomorphic VT, do not delay but immediately...

provide high-energy, unsynchronized shocks (defebrillate)

Use a ______ to administer aspirin to ACS patients with nausea or upper GI disorders.

rectal aspirin suppository

If a previously non-shockable rhythm has converted to a shockable rhythm...

resume CPR immediately (if possible) and charge defibrillator to deliver shock.

You would administer atropine in PEA if the rate is ______.

slow

Always check for _______ immediately after insertion of either an OPA or an NPA.

spontaneous respirations

Following TCP for bradycardia, reassess patient for...

symptomatic improvement and hemodynamic stability

An unstable, monomorphic VT with a pulse should be treated this way.

synchronized cardioversion (stepped-up monophasic energy) 100 J x1 200 J x1 300 J x1 360 J x1

When TCS is indicated, patients with ACS should be paced at...

the lowest heart rate that allows clinical stability.

IV Magnesium may terminate or prevent recurrence of ______ in patients who have a ______ interval during NSR.

torsades de pointes prolonged QT interval

What is TCP?

transcutaneous pacing

After transcutaneous pacing is in place, you may need to consider expert consultation and other treatments such ______.

transvenous pacing

What class of drugs are the first line of treatment for PEA?

vasopressors

Epinephrine is used during resuscitation primarily for its ______ effects, ie, vasoconstriction.

α-adrenergic (alpha)

Low EPI concetrations by ET administration may produce transient ______ effects (vasodilation), which may be detrimental to an arrest victim.

β-adrenergin (beta)