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Flashcards in ACLS Scenarios Deck (115)
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1

When is Narcan used in ACLS?

When respiratory distress or cardiac arrest from opioid overdose is suspected

2

What are 2 ways Narcan can be administered?

What are the doses of each?

intramuscular: 0.4 mg

intranasal: 2 mg

*doses can be repeated after 4 minutes

3

3 drugs used for bradycardia

1. epi
2. atropine
3. dopamine

4

What is the disadvantage of transcutaneous pacing?

does not produce as effective capture as trans venous pacing

5

What is the preferred method of pacing for emergent, unstable bradycardia?

transcutaneous pacing

6

What is the better pacing option for stable bradycardia?

transvenous pacing

7

What is the 3 step protocol for stable bradycardia?

1. atropine
2. monitor and observe
3. SAMPLE

8

What is the 5 step protocol for unstable bradycardia?

1. Monitors, IV, Oxygen
2. Atropine
3. consider transcutaneous pacing, epi, dopamine
*if atropine is ineffective
4. SAMPLE
5. consult or transvenous pacing

9

Clinically, a HR is considered SVT when:
1. the HR is ____
2. the QRS complex is _____
3. difficult to differentiate between _____ and _____

1. >150 bpm
2. normal width
3. sinus tach and junctional tach (p waves may or may not be present)

10

is SVT an emergency?

yes,
ventricular filling time is greatly reduced and this reduces cardiac output

11

What is paroxysmal SVT?

SVT that begins and ends abruptly (occurs in spasms)
-need to witness the stopping/starting on ECG

12

What is the BIG difference between SVT and afib/flutter?

AV node is part of the SVT re-entrant circuit, but NOT part of afib/flutter pathway

13

most types of SVT occur within the _____

AV node

14

For SVT, recommended therapies will ______ conduction through the _____

slow, AV node

15

What are 5 treatment options for SVT

1. Vagal maneuvers
-carotid massage
-cold stimulus to the face
-valsalva maneuver

2. Adenosine

3. Beta blockers (sotalol)

4. Ca2+ channel blockers (cardizem)

5. synchronized cardioversion

16

What is the treatment for afib/flutter?

synchronized cardioversion

17

What are 2 other drugs that can treat SVT that are not part of the ACLS protocol?

1. amiodarone
2. Procainamide

18

What type of patients should a carotid massage be avoided?

geriatric patients or patients with hx of stroke or high cholesterol

19

SVT usually refers to a (narrow/wide) tachycardia with a more (regular/irregular) rhythm

narrow
regular

20

Afib usually manifests as a (narrow/wide) tachycardia with a more (regular/irregular) rhythm

narrow
irregular

21

atrial flutter can be (regular, irregular, both) rhythm

both

22

What is the only reason to use AV nodal blockers in Afib/flutter?

to slow down the HR in SVT to better diagnose the arrhythmia (SVT, Afib, Aflutter)

23

What is the only difference in treatment for stable vs unstable SVT?

in unstable SVT you perform immediate synchronized cardioversion before administration of adenosine

In stable SVT you will try vagal maneuvers first

24

What is the first thing you should do when you encounter a patient in SVT? (stable or unstable)

monitors, IV, oxygen

25

What is the dose of adenosine for SVT

1st dose of 6mg
then 2nd dose of 12mg if needed

26

What is the main difference in treatment for stable vs unstable afib/flutter

in stable afib/flutter you just consider expert consult

in unstable afib/flutter you will do immediate synchronized cardioversion

27

What is the therapy for ventricular tachyarrhythmias when the patient is pulseless?

defibrillation

28

What is the therapy for ventricular tachyarrhythmias when the patient has a pulse?

synchronized cardioversion

29

What are the 4 drugs used to treat ventricular tachyarrhythmias and what are the doses?

1. epi (if pt is pulseless)

2. Amiodarone

3. Procainamide

4. Lidocaine

30

What is the dose of epi for a pulseless ventricular tachyarrhythmia?

1 mg every 3-5 minutes

31

What is the dose of amiodarone for a patient that is pulseless?

300 mg bolus

32

what is the dose of amiodarone for a patient that has a pulse?

150 mg over 10 minutes

33

What is the dose of Procainamide for ventricular tachyarrhythmias?

20-50 mg/ min

34

What is the dose of lidocaine for ventricular tachyarrhythmias?

100 mg IV

35

What is the drug used for Torsades de Pointes and what is the dose?

1-2 g Magnesium IV

36

What is adenosine used for in ventricular tachyarrhythmias?

diagnose what type of arrhythmia it is

If adenosine converts the rhythm, it was likely SVT

If the rhythm doesn’t convert after adenosine, Vtach is more likely

37

What is the main difference in treatment for Stable Monomorphic Vtach with a pulse VS Unstable Monomorphic Vtach (but not pulseless)?

In stable Monomorphic Vtach, administer antiarrhythmics (150 mg of amiodarone over 10 minutes) and expert consult

in Unstable (with a pulse) Monomorphic Vtach, perform synchronized cardioversion

38

Course Vfib has (higher/ lower) waves and a (more/less) chance of conversion

higher
more

39

fine Vfib has (higher/lower) waves and a (more/less) chance of conversion

lower
less

appears after course Vfib

40

If a patient is in asystole, what are the 3 treatments we can perform?

1. CPR
2. Epi
3. treat any reversible causes

41

What are the non-shockable pulseless rhythms?

asystole, PEA

42

What is PEA?

when the patient has no pulse but the ECG is showing an organized electrical rhythm

43

What are the 2 most common reversible causes of PEA?

1. Hypoxia

2. Hypovolemia

44

What are the 3 shockable pulseless rhythms?

Vfib
Vtach
Torsades de Pointes

45

can procainamide be used in pulseless rhythms?

no

46

What is the most common initial rhythm in sudden cardiac arrest?

Vfib

47

What is the only effective treatment for pulseless Vfib/ Vtach?

defibrillation

48

What is the main reason we use Epi in cardiac arrest?

to increase myocardial blood flow

49

What is the 1st step and the repeat cycle used for pulseless Vfib and pulseless monomorphic Vtach?

1. CPR
2. then defibrillate, CPR, analyze

50

When is Epi given in Vfib and pulseless monomorphic Vtach?

after the 2nd shock attempt

51

If Epi and defibrillation are not effective in Vfib and pulseless monomorphic Vtach, what is the next therapy considered?

300 mg Amiodarone bolus given after the 3rd shock attempt

* can give a second dose of 150 mg if code continues

52

If a patient achieves ROSC after Vfib and pulseless monomorphic Vtach, what therapy should be considered?

hypothermia

53

What is the only difference in the treatment protocol for vfib/ monomorphic Vtach VS polymorphic Vtach?

in polymorphic Vtach, we administer 1-2 g of Magnesium instead of amiodarone after the administration of Epi

54

Which ECG is the highest risk in acute coronary syndrome?

STEMI

55

What are the 2 types of NSTEMI ECGs in acute coronary syndrome?

1. Non ST elevation with T-wave inversion

2. Non ST elevation with ST depression

56

acute coronary syndrome that is diagnosed by either ST depression or T wave inversion

NSTEMI

57

Which ECG is caused by a partially blocked coronary artery?

NSTEMI

58

Which ECG is caused by a completely blocked coronary artery that leads to a heart attack, and is considered the highest risk ECG (because cardiac arrest can occur at any time)

STEMI

59

this is considered the lowest risk out of the different types of ECGs found in ACS

unstable angina with a normal ECG

60

What type of ECG is needed for detecting a STEMI?

12 -lead ECG

61

What is the most common cause of ACS?

When an inflamed plaque weakens and ruptures

62

What are the 3 therapies for ACS in ACLS?

1. MONA
2. Heparin
3. Reperfusion therapy

63

What does MONA stand for in ACS?

and how should it be prioritized?

Morphine
Oxygen
Nitrates
Aspirin

Prioritized as OANM

64

When should morphine be considered in ACS?

for STEMI only
-when unresponsive to nitrates

65

What are the 2 types of reperfusion therapy in ACS?

1. PCI (treatment of choice)
-balloon angioplasty/stent

2. Fibrinolytic Therapy (anticoagulation)
-streptokinase, recombinant tissue, plasminogen activator (rTPA)

66

When are fibrinolytics considered in ACS?

for STEMI only

67

At what SpO2 should the provider consider withholding oxygen in ACS?

when the SpO2 is ≥ 90%,

68

What is the ACLS dose of Nitroglycerin

3 sublingual tablets (0.4 mg) every 3-5 min
-dose may be repeated twice for a total of 3 doses

69

When should nitroglycerin be avoided?

1. Hypotensive patients (SBP ≤90 mmHg or 30mmHg below baseline)

2. Patients with inadequate preload
Recent MI, recent vasodilator (ex: PDEi) use

70

If the patient becomes hypotensive after NTG administration, what should you do?

fluid bolus

71

What is the PO dose of aspirin?

160-325 mg
-absorbed better when chewed and not swallowed

72

If the patient has a hx of current N/V, PUD, or other upper GI disorders, what is the preferred route and dose of aspirin?

rectal administration of 300 mg

73

What is the only NSAID allowed for ACS syndromes?

Aspirin

74

What is commonly given early (as an adjunct to PCI and fibrinolytic therapy) in STEMI patients

Heparin
-unfractioned or low molecular weight

75

What is the goal time to administer PCI?

within 90 minutes of arrival

76

What is the goal time to administer time when the patient needs to be transferred from a "non-PCI" hospital to a "PCI" hospital?

“door to balloon” time can be ≤ 120 minutes

77

When are fibrinolytics most often considered in STEMI patients?

if it is anticipated that PCI will not be able to be initiated within 90-120 minutes

78

Fibrinolytics are ONLY considered for (NSTEMI /STEMI / both)

STEMI

79

if choosing a fibrinolytic therapy, what is the goal time for administration?

within 30 minutes of arrival

80

Fibrinolytics should not be administered if ACS symptoms have been present for ______

≥12 hours

81

6 contraindications for Fibrinolytics

1. NSTE ACS (NSTEMI) patients

2. Hypertension
(>180-200mmHg SBP or 100-110mmHg DBP)

3. patients with recent head trauma or GI bleed

4. Patients taking blood thinners

5. Patients with stroke symptoms > 3 hours

6. if symptoms have been present for >12 hours

82

What type of stroke occurs when a blood clot blocks blood flow to the brain?

Ischemic stroke

83

What type of stroke occurs when a weakened vessel ruptures and bleeds into the surrounding brain

hemorrhagic stroke

84

What type of stroke occurs when a blood vessel just outside the brain ruptures

subarachnoid stroke

85

This is the last time the patient was seen normal

Time Zero

86

How is an ischemic stroke primarily treated?

fibrinolytics (rtPA)
*aspirin can be given if these are not available
*clot can be removed with endovascular therapy

87

What are the 2 management points for hemorrhagic stroke?

1. STAT neurologist or neurosurgeon consult

2. avoid fibrinolytic therapy

88

What is the management for subarachnoid stroke?

the same as hemorrhagic stroke

89

What are the 3 physical findings on the Cincinnati Prehospital Stroke Scale?

1. Facial droop
2. arm weakness
3. abnormal speech

90

______ is a prehospital stroke scale performed by EMS, so it should be performed by EMS BEFORE hospital arrival

Cincinnati Prehospital Stroke Scale (CPSS)

91

the _____ is an “in hospital” stroke scaled used to quantify the level of impairment caused by a stroke

NIH stroke scale (NIHSS)

92

in the NIHSS, (higher/lower) scores indicate greater level of impairment

higher

93

When should the NIHSS be performed?

within 10 minutes of arriving at the ED
*after the CPSS

94

What is the only way that we can diagnose whether or not the stroke is ischemic or hemorrhagic?

obtaining a CT scan
-cannot treat a stroke until the CT scan is obtained

95

What is the preferred drug therapy for ischemic stroke?

fibrinolytics

96

The goal for ischemic stroke is to give fibrinolytics:
1. within ______ of hospital arrival
2. within _____ of symptom onset

1 hour
3 hours (3-4.5 hours)

97

providers should not give ASA for at least ____ after rtPA is administered

24 hours

98

If fibrinolytics are contraindicated, what is an alternative drug option for ischemic stroke?

aspirin (ASA)
*perform swallowing screen before administration and if it fails, give rectally

99

What is a type of therapy used for ischemic stroke if fibrinolytics are contraindicated?

endovascular therapy

1. intra-arterial rtPA
2. mechanical clot disruption and retrieval with a stent

100

When should endovascular therapy be started for ischemic stroke?

within 6 hours of symptom onset

101

What is the main lab that should be ordered in an acute stroke protocol within the first 10 minutes?

glucose test
-hypoglycemia

102

What are the 4 things that should be done within 10 minutes of an acute stroke?

1. monitors, IV, oxygen
2. Perform neurologic screening assessment (CPSS or NIHSS) and activate the stroke team
3. Order an urgent non-contrast CT scan
4. Get IV labs/tests (glucose and 12 lead ECG to rule out Afib)

103

What are the 3 things that should be done within 25 minutes of an acute stroke?

1. Obtain the CT scan
2. Perform NIHSS or Canadian stroke scale
3. obtain a past medical hx

104

What should you do within 45 minutes of an acute stroke?

Read and interpret the CT scan

105

What should you do within 1 hour of an ischemic stroke?

1. administer fibrinolytics
2. administer ASA if fibrinolytics are contraindicated

106

What should you do within 1 hour of a hemorrhagic stroke?

get a consult, admit to ICU or stroke unit and begin stroke/hemorrhage pathway

107

What should be done within the first 3 hours of an acute stroke?

Begin the post rtPA stroke pathway by admitting to the stroke unit or ICU

108

What should be done within 6 hours of an acute stroke?

Initiate endovascular therapy

109

What are the 3 items that make up the Post rtPA stroke pathway?

1. frequently check blood glucose levels
-blood sugars should be treated with insulin if glucose is > 185mg/dL

2. avoid hypertension in patients who have received rtPA in order to reduce the risk of intracerebral hemorrhage

3. an urgent CT scan should be ordered if neurologic status deteriorates

110

in ROSC, what should the SpO2 be?

94-99%

111

In ROSC, how should the patient be ventilated if unconscious?

intubate and use capnography
-avoid hyperventilation

112

In ROSC, what should the capnography EtCO2 be maintained at?

35-40 mmHg

113

What antiarrythmics should be used in ROSC?

lidocaine
beta blockers
amiodarone

114

How should you treat hypotension in ROSC?

1. 1-2 L fluid bolus

2. Vasopressors
Epi (0.1-0.5mcg/kg/min), Dopamine (5-10mcg/kg/min), or Norepinephrine (0.1-0.5mcg/kg/min)

115

If the patient does not follow commands in ROSC, what should be initiated?

TTM (target temperature management)