Studying ACLS

List 4 advanced airway pieces of equipment

* laryngeal mask airway *the laryngeal tube *the esophageal-tracheal tube *ET tube

To ensure the success of post-cardiac arrest care, healthcare providers must do what?

* optimize the patient's hemodynamic and ventilation status * initiate therapeutic hypothermia * provide immediate coronary reperfusion with PCI * institute glycemic control * provide neurologic care and prognostication and other structured interventions

What vasopressors used during cardiac arrest?

*Epinephrine: 1 mg IV/IO (repeat every 3 to 5 minutes) *Vasopressin: 1 dose of 40 units IV/IO may replace either the first or second dose of epinephrine

What are the important points about using the IO route for delivery of drugs

*IO access can be established in all age groups *IO access often can be achieved in 30 to 60 seconds *the IO route of administration is preferred over the endotracheal route *any ACLS drug or fluid that is administered IV can be given IO

When an IV is established, how should hypotension be treated?

*IV bolus - 1-2 L normal saline or lactated Ringer's. If therapeutic hypothermia is indicated or will be performed, you may use 4 degree C fluids *Epinephrine .1-.5 mcg/kg per minute IV infusion titrated to achieve a minimum SBP of >90mmHg or a mean arterial pressure of >65mmHg *Dopamine 5-10 mcg/kg per minute IV infusion titrated to achieve a minimum SBP of >90mmHG or a mean arterial pressure of >65mmHG *Norepinephrine .1-.5 mcg/kg per minute IV infusion titrated to achieve a minimum SPC of >90 mmHg or a mean arterial pressure of >65mmHg

What type of rhythms might be seen in a case of VF/Pulseless VT

*VF *VT *Artifact that looks line VF *New left bundle branch block

When assessing breathing using the ACLS survey what questions are you asking yourself?

*are ventilation and oxygenation adequate? *are quantitative waveform capnography and oxyhemoglobin saturation monitored?

What are the steps of an adult in cardiac arrest using an AED and drugs when rhythm is not shockable?

*before beginning - shout for help/activate emergency response 1) Start CPR - give oxygen, attach monitor/defibrillator 2) No shockable rhythm - Asystole/PEA 3) CPR 2 minutes - IV/IO access, Epinephrine every 3-5 minutes, consider advanced airway, capnography 4) No shockable rhythm 5) CPR 2 minutes - treat reversible causes

What are the first 8 steps of an adult in cardiac arrest using an AED and drugs when rhythm is shockable?

*before beginning - shout for help/activate emergency response 1) Start CPR - give oxygen, attach monitor/defibrillator 2) Yes rhythm is shockable - VF/VT 3) Deliver shock 4) CPR 2 minutes - IV/IO access 5) Yes, rhythm is shockable - deliver shock 6) CPR 2 minutes - Epinephrine every 3-5 min, consider advanced airway, capnography 7) Yes, rhythm is shockable - deliver shock 8) CPR 2 minutes - amiodarone - treat reversible causes

What is the role of the team member?

*clear about role assignments *prepared to fulfill their role responsibilities *well practiced in resuscitation skills *knowledgeable about the algorithms *committed to success

What are drugs use if VF/Pulseless VT

*epinephrine *norepinephrine *vasopressin *amiodarone *lidocaine *magnesium sulfate *dopamine *oxygen

What are 3 common types of fixation errors?

*everything is okay *this and only this is the correct path *anything but this

What is the guidelines when administering a drug by peripheral venous route

*give the drug by bolus infection unless otherwise specified *follow with a 20mL bolus of IV fluid *evaluate the extremity for about 10 to 20 seconds to facilitate delivery of the drug to the central circulation

When assessing Airway in the ACLS survey what questions are you asking yourself?

*is the airway paten? *is an advanced airway indicated? *is proper placement of airway device confirmed? *is tube secured and placement reconfirmed frequently?

What does the team leader do?

*organizes the group *monitors individual performance of team members *backs up team members *models excellent team behavior *trains and coaches *facilitates understanding *focuses on comprehensive patient care

What is an essential role of the team leader is monitoring and reevaluating what?

*the patient's status *interventions that have been performed *assessment findings

What is the physiologic criteria for adult patinets to activate a RRT

*threatened airway *respiratory rate <6 or >30 breaths per minute * HR <40/min or >140/min *systolic BP <90mmHG *symptomatic HTN *unexpected decrease in LOC *unexplained agitation *seizure *significant fall in urine output *subjective concern about the patient

What are the questions to ask when assessing for circulation in the ACLS survey

*what is the cardiac rhythm *is the patient with a pulse unstable? *is defibrillation or cardioversion indicated? *are chest compression effective? *is ROSC present? *has IV/IO access been established? *are medications needed for rhythm or BP *does the patient need volume (fluid) for resuscitation

What question should be asked if thinking about the differential diagnosis

*why did this patient develop symptoms or arrest? *is there a reversible cause that can be treated?

How much Epinephrine should you give during CPR

1 mg IV/IO - repeat every 3 to 5 minutes

How much and how is lidocaine administered

1 to 1.5 mg/kg IV/IO first does, then .5-.75 mg/kg IV/IO at 5 to 10 minute intervals, to a maximum dose of 3 mg/kg

What are ventilations during a respiratory arrest with bag mask or advanced airway

1 ventilation every 5 to 6 seconds (10 to 12 breaths per minute)

What are the steps of action for a person in respiratory arrest?

1) Check responsiveness - :"are you okay?" and scanning the chest for movement (5-10second) 2)Activate the emergency response system/get AED 3)Circulation - check the carotid pulse (5-10seconds) - if no pulse start with chest compressions (30:2) 4)Defibrillation - if no pulse check for shockable rhythm

what are the 4 universal steps to starting the AED?

1) Power on the AED 2) Attach electrode pads 3) Analyze rhythm 4) be sure to clear the patient (DO NOT TOUCH the patient)

List the steps of adult immediate post cardiac arrest care

1) Return of spontaneous Circulation (ROSC) 2) Optimize ventilation and oxygenation 3) Treat hypotension (SBP ,90mmHg) 4) Follow commands? If yes -- STEMI or suspicion of AMI If No -> 5) consider induced hypothermia 6) STEMI or suspicion of AMI If yes, 7) Coronary reperfusion --> 8) Advanced Critical care If no, -- 8) Andvanced Critical Care

What are the simplified steps for Adult BLS HCP?

1) unresponsive (no breathing or no normal breathing) 2) activate emergency response --> send someone to get AED 3) check pulse 4) start CPR 5) check rhythm/shock if indicated (repeated every 2 minutes)

What 3 ways can you monitor the adequacy of ventilation and oxygenation

1)clinical criteria (chest rise and cyanosis) 2)quantitative waveform capnography 3)oxygen saturation

List the 6 action as appropriate during the circulation assessment

1)monitor CPR quality 2)attach monitor/defibrillator for arrhythmias or cardiac arrest rhythms 3) defibrillation/cardioversion 4)obtain IV/IO access 5)give appropriate drugs to manage rhythm and BP 6)give IV/IO fluids if needed

To pause in CPR to conduct a rhythm check should not exceed how many seconds?

10 seconds

How much and how is amiodarone administered

300mg IV/IO bolus, then consider and additional 150mg IV/IO once

What is the target temperature of cooling patients?

32 to 34 degrees Celsius for 12 to 24 hours

How much Vasopressin should you give during CPR

40 units IV/IO - may substitute for the first or second dose of epinephrine

Which drug has been shown to increase short-term survival to hospital admission?

Amiodarone

What is an very important saying to remember when performing the BLS survey

Assess....then perform appropriate action

What does VF deteriorate to?

Asystole

What is the most effective way to treat VF

Electrical defibrillation - delivery of a shock to stop the VF

What are the most common causes of PEA starting with the letter H?

Hypovolemia Hypoxia Hydrogen ion (acidosis) Hyper-/Hypokalemia Hypothermia

What rhythms are included to define PEA?

Idoventricular rhythms ventricular escape rhythms postdefibrillation idoventricular rhythms sinus rhythm

Does vasopressin have an alpha-adrenegic effect as well?

NO, it is a nonadrenergic peripheral vasoconstrictor

Dopamine is a chemical precursor to what drug

Norepinephrine that stimulates the heart through both alpha- and beta- adrenergic receptors

What is the preferred route of drug and fluid administration

Peripheral IV

What does PEA stand for?

Pulseless Electrical Activity - any organized rhythm without a pulse

What does ROSC stand for?

Return Of Spontaneous Circulation

What does pulseless VT rapidly deteriorates to?

V-Fib

what is the common initial rhythm witnessed out of hospital sudden cardiac arrest?

V-Fib

Can you administer drugs during CPR and/or should you stop CPR to administer drugs?

Yes administer drugs during CPR and DO NOT STOP CPR to administer drugs

If amiodarone is not available, then what

administer lidocaine

What is epinephrine thought to stimulate during cardiac arrest?

adrenegric receptors, producing vasoconstriction, increasing BP, and HR, and improving perfusion pressure to the brain and heart

What does amiodarone affect on cellular level?

affects sodium, potassium and calcium channels. it also has alpha- and beta-adrenergic blocking properties

When should you conduct a rhythm check?

after 2 minutes of CPR or 5 cycles

Where is the NPA placed?

airflow between the nares and the pharynx

What drug is the first line drug given as a antiarrhythmic drug during cardiac arrest

amiodarone

Name 3 Antiarrhytmic agents commonly used

amiodarone lidocaine magnesium sulfate

Remember that pulseless VT is treated with-----

an immediate high-energy shock, where as magnesium is an adjunctive agent used to prevent recurrent or treat persistent VT associated with torsades de pointes

What is the key assessment to check in order to use the OPA?

an intact cough or gag reflex

What does vasopressin increase?

arterial blood pressure because it is a nonadrenergic peripheral vasoconstrictor

What is something you want to avoid while helping deliver oxygen

avoid excessive ventilation

why is excessive ventilations harmful

because it increases intra-thoracic pressure, decreases venous return to the heart, and diminishes cardiac output. it may also cause gastric inflation and predispose the patient to vomiting and aspiration of gastric contents

What is the major determinant of CO2 delivery to the lungs?

cardiac output

What do vasopressors optimize

cardiac output and blood pressure

What are 2 vasopressors you can give during CPR?

epinephrine and vasopressin

How should you monitor the patient's core temperature during induced hypothermia?

esophageal thermometer, a bladder catheter in nonanuric patients, or a pulmonaryartery catheter

When giving a dose of drugs peripherally what should you remember to do?

follow each dose given by peripheral injection with a 20mL flush of IV fluid and elevate the extremity above the level of the heart for 10 to 20 seconds

How much and how should magnesium sulfate be administered

for tosades de pointes, loading dose 1 to 2g IV/IO diluted in 10mL (D5W, normal saline) given as IV/IO bolus, typically over 5 to 20 minutes

When should you consider using amiodarone?

for treatment of VF or pulseless VT unresponsive to shock delivery, CPR, and a vasopressor

What is rescue breathing amount for someone in respiratory arrest with pulse

give 1 breath every 5 to 6 seconds (10 to 12 breaths per minute)

If an advanced airway is in place and compressions are being performed, what is the rate of ventilating?

give 1 breath every 6-8 seconds (~8 to 10 breaths per minute)

what are the priorities during cardiac arrest

high quality CPR and early defibrillation

What should the quantitative waveform capnography look like

if PETCO2 is <10mmHG, attempt to improve CPR quality

When should CPR be improved when looking at intra-arterial pressure

if the relaxation phase [diastolic] pressure is <20mmHG

when is an OPA used?

in patients who are at risk for developing airway obstruction form the tongue or from relaxed upper airway muscles

When should the OPA not be used?

in the conscious or semiconscious patient

What does vasoconstriction do during CPR

increases cerebral and coronary blood flow by increasing mean arterial pressure and aortic diastolic pressure

What are secondary importance during a cardiac arrest

insertion of an advanced airway and drug administration

What is PETCO2?

is the partial pressure of end-tidal CO2, a measure of the amount of carbon dioxide present in the exhaled air

what question will the AED answer?

is the rhythm shockable? VF or pulseless VT

What is amiodarone given first during a cardiac arrest

it has been clinically demonstrated that it improves the rate of ROSC and hospital admission in adults with refractory VF/pulseless VT

What is meant by comatose?

lack of meaningful response to verbal commands

What is another name of norepinephrine?

levaraterenol

What drug is given if amiodarone is not available?

lidocaine

what is the most common cause of upper airway obstruction in the unconscious/unresponsive patient

loss of tone in the throat muscles

What medication to consider if torsades de pointes associated with a long QT interval

magnesium sulfate

What kind of patient can the NPAs be used in

may be used in conscious or semiconscious patients

What does NPA stand for?

nasopharyngeal airway

What will hypothermia help improve physically or neurologically

neurologic recovery after cardiac arrest

what does OPA stand for

oropharyngeal airway

What is the main drug to use for respiratory arrest?

oxygen

Why is epinephrine used during resuscitation?

primarily for its alpha-adrenergic effects (vasoconstriction)

When should you recheck the patient in respiratory arrest?

recheck the pulse every 2 minutes

what does rtPA represent?

recombinant tissue plasminogen activator

What might magnesium sulfate terminate or prevent?

recurrent torsades de pointes in patients who have a prolonged QT interval during a normal sinus rhythm

What is respiratory arrest?

respirations are completely absent or clearly inadequate to maintain effective oxygenation and ventilation. A pulse is present

what should you assume if you have a patient with multiple trauma, head injury, and facial trauma

spine injury

How long should you take to check for a pulse when rescue breathing?

take at least 5 seconds but no more than 10 seconds for a pulse check

What is "fixation error"

team leaders may become trapped in a specific treatment or diagnostic approach

What is end tidal CO2 (PETCO2)?

the concentration of carbon dioxide in exhaled air at the end of expiration

What does the heart do when VF is present?

the heart quivers and does not pump blood

What is a good practice for the team leader?

to summarize the patient's status, interventions, and assessment findings out loud in a periodic update to the team.

Can you place an advanced airway while chest compressions are going on?

yes

Do you give supplementary oxygen for cardiac or other types of patients?

yes - 100% oxygen for cardiac arrest patients and other to titrate to achieve >94% O2 pulse ox