When is Narcan used in ACLS?
When respiratory distress or cardiac arrest from opioid overdose is suspected
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 drugs used for bradycardia
- epi
- atropine
- dopamine
What is the disadvantage of transcutaneous pacing?
does not produce as effective capture as trans venous pacing
What is the preferred method of pacing for emergent, unstable bradycardia?
transcutaneous pacing
What is the better pacing option for stable bradycardia?
transvenous pacing
What is the 3 step protocol for stable bradycardia?
- atropine
- monitor and observe
- SAMPLE
What is the 5 step protocol for unstable bradycardia?
- Monitors, IV, Oxygen
- Atropine
- consider transcutaneous pacing, epi, dopamine
* if atropine is ineffective - SAMPLE
- consult or transvenous pacing
Clinically, a HR is considered SVT when:
- the HR is ____
- the QRS complex is _____
- difficult to differentiate between _____ and _____
- > 150 bpm
- normal width
- sinus tach and junctional tach (p waves may or may not be present)
is SVT an emergency?
yes,
ventricular filling time is greatly reduced and this reduces cardiac output
What is paroxysmal SVT?
SVT that begins and ends abruptly (occurs in spasms)
-need to witness the stopping/starting on ECG
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
most types of SVT occur within the _____
AV node
For SVT, recommended therapies will ______ conduction through the _____
slow, AV node
What are 5 treatment options for SVT
- Vagal maneuvers
- carotid massage
- cold stimulus to the face
- valsalva maneuver - Adenosine
- Beta blockers (sotalol)
- Ca2+ channel blockers (cardizem)
- synchronized cardioversion
What is the treatment for afib/flutter?
synchronized cardioversion
What are 2 other drugs that can treat SVT that are not part of the ACLS protocol?
- amiodarone
2. Procainamide
What type of patients should a carotid massage be avoided?
geriatric patients or patients with hx of stroke or high cholesterol
SVT usually refers to a (narrow/wide) tachycardia with a more (regular/irregular) rhythm
narrow
regular
Afib usually manifests as a (narrow/wide) tachycardia with a more (regular/irregular) rhythm
narrow
irregular
atrial flutter can be (regular, irregular, both) rhythm
both
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)
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
What is the first thing you should do when you encounter a patient in SVT? (stable or unstable)
monitors, IV, oxygen
What is the dose of adenosine for SVT
1st dose of 6mg
then 2nd dose of 12mg if needed
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
What is the therapy for ventricular tachyarrhythmias when the patient is pulseless?
defibrillation
What is the therapy for ventricular tachyarrhythmias when the patient has a pulse?
synchronized cardioversion
What are the 4 drugs used to treat ventricular tachyarrhythmias and what are the doses?
- epi (if pt is pulseless)
- Amiodarone
- Procainamide
- Lidocaine
What is the dose of epi for a pulseless ventricular tachyarrhythmia?
1 mg every 3-5 minutes
What is the dose of amiodarone for a patient that is pulseless?
300 mg bolus
what is the dose of amiodarone for a patient that has a pulse?
150 mg over 10 minutes
What is the dose of Procainamide for ventricular tachyarrhythmias?
20-50 mg/ min
What is the dose of lidocaine for ventricular tachyarrhythmias?
100 mg IV
What is the drug used for Torsades de Pointes and what is the dose?
1-2 g Magnesium IV
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
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
Course Vfib has (higher/ lower) waves and a (more/less) chance of conversion
higher
more
fine Vfib has (higher/lower) waves and a (more/less) chance of conversion
lower
less
appears after course Vfib
If a patient is in asystole, what are the 3 treatments we can perform?
- CPR
- Epi
- treat any reversible causes
What are the non-shockable pulseless rhythms?
asystole, PEA
What is PEA?
when the patient has no pulse but the ECG is showing an organized electrical rhythm
What are the 2 most common reversible causes of PEA?
- Hypoxia
2. Hypovolemia
What are the 3 shockable pulseless rhythms?
Vfib
Vtach
Torsades de Pointes
can procainamide be used in pulseless rhythms?
no
What is the most common initial rhythm in sudden cardiac arrest?
Vfib
What is the only effective treatment for pulseless Vfib/ Vtach?
defibrillation
What is the main reason we use Epi in cardiac arrest?
to increase myocardial blood flow
What is the 1st step and the repeat cycle used for pulseless Vfib and pulseless monomorphic Vtach?
- CPR
2. then defibrillate, CPR, analyze
When is Epi given in Vfib and pulseless monomorphic Vtach?
after the 2nd shock attempt
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
If a patient achieves ROSC after Vfib and pulseless monomorphic Vtach, what therapy should be considered?
hypothermia
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
Which ECG is the highest risk in acute coronary syndrome?
STEMI
What are the 2 types of NSTEMI ECGs in acute coronary syndrome?
- Non ST elevation with T-wave inversion
2. Non ST elevation with ST depression
acute coronary syndrome that is diagnosed by either ST depression or T wave inversion
NSTEMI
Which ECG is caused by a partially blocked coronary artery?
NSTEMI
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
this is considered the lowest risk out of the different types of ECGs found in ACS
unstable angina with a normal ECG
What type of ECG is needed for detecting a STEMI?
12 -lead ECG
What is the most common cause of ACS?
When an inflamed plaque weakens and ruptures
What are the 3 therapies for ACS in ACLS?
- MONA
- Heparin
- Reperfusion therapy
What does MONA stand for in ACS?
and how should it be prioritized?
Morphine
Oxygen
Nitrates
Aspirin
Prioritized as OANM
When should morphine be considered in ACS?
for STEMI only
-when unresponsive to nitrates
What are the 2 types of reperfusion therapy in ACS?
- PCI (treatment of choice)
- balloon angioplasty/stent - Fibrinolytic Therapy (anticoagulation)
- streptokinase, recombinant tissue, plasminogen activator (rTPA)
When are fibrinolytics considered in ACS?
for STEMI only
At what SpO2 should the provider consider withholding oxygen in ACS?
when the SpO2 is ≥ 90%,
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
When should nitroglycerin be avoided?
- Hypotensive patients (SBP ≤90 mmHg or 30mmHg below baseline)
- Patients with inadequate preload
Recent MI, recent vasodilator (ex: PDEi) use
If the patient becomes hypotensive after NTG administration, what should you do?
fluid bolus
What is the PO dose of aspirin?
160-325 mg
-absorbed better when chewed and not swallowed
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
What is the only NSAID allowed for ACS syndromes?
Aspirin
What is commonly given early (as an adjunct to PCI and fibrinolytic therapy) in STEMI patients
Heparin
-unfractioned or low molecular weight
What is the goal time to administer PCI?
within 90 minutes of arrival
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
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
Fibrinolytics are ONLY considered for (NSTEMI /STEMI / both)
STEMI
if choosing a fibrinolytic therapy, what is the goal time for administration?
within 30 minutes of arrival
Fibrinolytics should not be administered if ACS symptoms have been present for ______
≥12 hours
6 contraindications for Fibrinolytics
- NSTE ACS (NSTEMI) patients
- Hypertension
(>180-200mmHg SBP or 100-110mmHg DBP) - patients with recent head trauma or GI bleed
- Patients taking blood thinners
- Patients with stroke symptoms > 3 hours
- if symptoms have been present for >12 hours
What type of stroke occurs when a blood clot blocks blood flow to the brain?
Ischemic stroke
What type of stroke occurs when a weakened vessel ruptures and bleeds into the surrounding brain
hemorrhagic stroke
What type of stroke occurs when a blood vessel just outside the brain ruptures
subarachnoid stroke
This is the last time the patient was seen normal
Time Zero
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
What are the 2 management points for hemorrhagic stroke?
- STAT neurologist or neurosurgeon consult
2. avoid fibrinolytic therapy
What is the management for subarachnoid stroke?
the same as hemorrhagic stroke
What are the 3 physical findings on the Cincinnati Prehospital Stroke Scale?
- Facial droop
- arm weakness
- abnormal speech
______ is a prehospital stroke scale performed by EMS, so it should be performed by EMS BEFORE hospital arrival
Cincinnati Prehospital Stroke Scale (CPSS)
the _____ is an “in hospital” stroke scaled used to quantify the level of impairment caused by a stroke
NIH stroke scale (NIHSS)
in the NIHSS, (higher/lower) scores indicate greater level of impairment
higher
When should the NIHSS be performed?
within 10 minutes of arriving at the ED
*after the CPSS
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
What is the preferred drug therapy for ischemic stroke?
fibrinolytics
The goal for ischemic stroke is to give fibrinolytics:
- within ______ of hospital arrival
- within _____ of symptom onset
1 hour 3 hours (3-4.5 hours)
providers should not give ASA for at least ____ after rtPA is administered
24 hours
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
What is a type of therapy used for ischemic stroke if fibrinolytics are contraindicated?
endovascular therapy
- intra-arterial rtPA
- mechanical clot disruption and retrieval with a stent
When should endovascular therapy be started for ischemic stroke?
within 6 hours of symptom onset
What is the main lab that should be ordered in an acute stroke protocol within the first 10 minutes?
glucose test
-hypoglycemia
What are the 4 things that should be done within 10 minutes of an acute stroke?
- monitors, IV, oxygen
- Perform neurologic screening assessment (CPSS or NIHSS) and activate the stroke team
- Order an urgent non-contrast CT scan
- Get IV labs/tests (glucose and 12 lead ECG to rule out Afib)
What are the 3 things that should be done within 25 minutes of an acute stroke?
- Obtain the CT scan
- Perform NIHSS or Canadian stroke scale
- obtain a past medical hx
What should you do within 45 minutes of an acute stroke?
Read and interpret the CT scan
What should you do within 1 hour of an ischemic stroke?
- administer fibrinolytics
2. administer ASA if fibrinolytics are contraindicated
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
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
What should be done within 6 hours of an acute stroke?
Initiate endovascular therapy
What are the 3 items that make up the Post rtPA stroke pathway?
- frequently check blood glucose levels
- blood sugars should be treated with insulin if glucose is > 185mg/dL - avoid hypertension in patients who have received rtPA in order to reduce the risk of intracerebral hemorrhage
- an urgent CT scan should be ordered if neurologic status deteriorates
in ROSC, what should the SpO2 be?
94-99%
In ROSC, how should the patient be ventilated if unconscious?
intubate and use capnography
-avoid hyperventilation
In ROSC, what should the capnography EtCO2 be maintained at?
35-40 mmHg
What antiarrythmics should be used in ROSC?
lidocaine
beta blockers
amiodarone
How should you treat hypotension in ROSC?
- 1-2 L fluid bolus
- Vasopressors
Epi (0.1-0.5mcg/kg/min), Dopamine (5-10mcg/kg/min), or Norepinephrine (0.1-0.5mcg/kg/min)
If the patient does not follow commands in ROSC, what should be initiated?
TTM (target temperature management)
