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ACP Directives (ADULT only) Flashcards

Includes (adult only): Tachy, Cardiogenic shock, Brady, procedural sedation, medical cardiac arrest, ROSC, hyperkalemia,intubation, naso intubation, cric, analgesia, combative, seizure, hypoglycemia, CVAD, home dialysis disconnect (138 cards)

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1
Q

What are the indications for the tachydysrhythmia directive? (1)

A

Symptomatic tachydysrhythmia

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2
Q

List the conditions for Valsalva (5)

A
  1. At least 18 years old
  2. Unaltered
  3. HR at least 150bpm
  4. Normotensive
  5. Only for narrow complex and regular rhythms
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3
Q

Contraindications for valsalva

A

sinus tach, afib or aflutter

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4
Q

How many attempts of valsalva can you do?

A

Maximum of 2 attempts lasting 10-20 seconds duration each

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5
Q

List the conditions for Adenosine (5)

A
  1. At least 18 years old
  2. Unaltered
  3. HR at least 150bpm
  4. Normotensive
  5. Only for narrow complex and regular rhythms
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6
Q

List the contraindications for Adenosine (4)

A
  1. Allergy or sensitivity to adenosine
  2. Sinus tach, afib, or aflutter
  3. Pt taking dipyridamole or carbmazepine
  4. Bronchoconstriction on exam
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7
Q

List the route, initial dose, second dose, dosing interval and number of doses for Adenosine.

A

IV
6mg, then 12mg
2 min apart
max #2 doses

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8
Q

(Tachydysrhythmia Directive)
List the conditions for Lidocaine (5)

A
  1. At least 18 years old
  2. Unaltered
  3. HR at least 120bpm
  4. Normotensive
  5. Only for wide complex and regular rhythms
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9
Q

(Tachydysrhythmia Directive) Contraindications for lidocaine (1)

A
  1. Allergy or sensitivity to lidocaine
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10
Q

What is the route that lidocaine can be given?
(Tachydysrhythmia Directive)

A

IV only

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11
Q

What is the initial dose, subsequent dose, max single dose and dosing interval, max # of doses for lidocaine?
(Tachydysrhythmia Directive)

A

1.5mg/kg, then 0.75mg/kg
max single dose 150mg
10 minutes apart
max #3 doses

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12
Q

What is the maximum amount of lidocaine we can give a patient? (for all directives)

A

5mg/kg

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13
Q

What are patch points in the Tachydysrhythmia Directive?

A
  1. Patch to give lidocaine or amiodarone.
  2. Patch to do synchronized cardioversion.
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14
Q

(Tachydysrhythmia Directive)
List the conditions for Amiodarone (5)

A
  1. At least 18 years old
  2. Unaltered
  3. HR at least 120bpm
  4. Normotensive
  5. Wide complex and regular rhythm
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15
Q

(Tachydysrhythmia Directive)
List contraindications for amiodarone

A

Allergy or sensitivity to amiodarone

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16
Q

What is the initial dose, subsequent dose, max single dose and dosing interval, max # of doses for amiodarone?
(Tachydysrhythmia Directive)

A

standard 150mg for all doses
interval 10 minutes
max 2 doses

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17
Q

What route should amiodarone be given and how?
(Tachydysrhythmia Directive)

A

IV only
given over 10 minutes

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18
Q

Condition for synchronized cardioversion.
(Tachydysrhythmia Directive)

A
  1. At least 18 years old
  2. Altered
  3. hypotensive
  4. HR at least 120 (wide) or 150 (narrow)
  5. ongoing chest pain or other signs of shock
  6. MANDATORY PATCH POINT
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19
Q

In case of a patch failure, what are the settings for synchronized cardioversion?

A

Administer up to 3 shocks at 100J, 200J and manufacture max. (200J Zoll, 360J LP)

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20
Q

What treatments/medications are included in under the tachydysrhythmia medical directive?

A
  • valsalva
  • adenosine
  • lidocaine
  • amiodarone
  • synchronized cardioversion
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21
Q

What are the indications for the Cardiogenic shock medical directive?

A
  1. STEMI positive 12 lead ECG
    AND
  2. cardiogenic shock
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22
Q

What treatments/medications are included in under the cardiogenic shock directive?

A
  • fluid bolus
  • dopamine
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23
Q

What is the patch point under the cardiogenic shock directive?

A

If patient is also bradycardiac, patch for a consult.

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24
Q

What are the conditions for a fluid bolus?
(cardiogenic shock directive)

A
  1. At least 18 years old
  2. Hypotensive
  3. chest auscultation clear
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25
What are the contraindications for a fluid bolus? (2) (cardiogenic shock directive)
1. Fluid overload 2. SBP greater than or equal to 90
26
Which should be given first, fluid or dopamine? (cardiogenic shock directive)
Fluid, then dopamine. If fluid is contraindicated consider dopamine.
27
What routes can saline bolus be given? (cardiogenic shock directive)
IV, IO, or CVAD
28
How much fluid are we bolusing? (cardiogenic shock directive)
10mL/kg to a max of 1,000ml (Patient has to be 100kg to get max)
29
What are the conditions for dopamine? (cardiogenic shock directive)
1. At least 18 years old 2. hypotensive
30
What are the contraindications for dopamine? (cardiogenic shock directive)
1. Allergy or sensitivity to dopamine 2. Tachydysrhythmias excluding sinus tach 3. mechanical shock 4. Hypovolemia 5. Pheochromocytoma
31
What is the route dopamine can be given? (cardiogenic shock directive)
IV only
32
What is the initial infusion rate for dopamine? (cardiogenic shock directive)
5mcg/kg/min
33
What is the max infusion rate for dopamine? (cardiogenic shock directive)
20mcg/kg/min
34
How much and how often can we increase dopamine infusion? (cardiogenic shock directive)
every 5 minutes can increase by 5mcg/kg/min
35
What is the target blood pressure range for dopamine? (cardiogenic shock directive)
SBP 90 to less than 110
36
What to consider when discontinuing dopamine?
gradually over 5-10minutes
37
What are the indications for the Symptomatic Bradycardia medical directive?
1. Bradycardia AND 2. Hemodynamic instability
38
What treatments/medications are included under the Symptomatic Bradycardia medical directive?
1. Atropine 2. Dopamine 3. Transcutaneous pacing
39
What are the conditions for atropine? (Symptomatic Bradycardia)
1. At least 18 years old 2. HR less than 50 3. Hypotension
40
What are the contraindications for atropine? (Symptomatic Bradycardia)
1. Allergy or sensitivity to atropine 2. Hypothermia 3. Hx of heart transplant
41
What is the route atropine can be given? (Symptomatic Bradycardia)
IV only
42
What is the initial dose, subsequent dose, number of doses and interval for atropine? (Symptomatic Bradycardia)
1mg for all doses max #2 doses 5 minutes apart
43
What are the conditions for dopamine? (Symptomatic Bradycardia)
1. At least 18 years old 2. HR less than 50 3. Hypotension
44
What are the contraindications for dopamine? (Symptomatic Bradycardia)
1. Allergy or sensitivity 2. Mechanical shock 3. Pheochromocytoma
45
What other treatments/considerations should be made? (Symptomatic Bradycardia)
Consider: - 12 lead ecg - fluid bolus (Fluid therapy directive)
46
What is the initial infusion rate for dopamine? (Symptomatic Bradycardia)
5mcg/kg/min
47
What is the max infusion rate for dopamine? (Symptomatic Bradycardia)
20mcg/kg/min
48
How often and by how much can you increase dopamine? (Symptomatic Bradycardia)
every 5 minutes by 5mcg/kg/min
49
What are the conditions for transcutaneous pacing? (Symptomatic Bradycardia)
1. At least 18 years old 2. HR less than 50 3. Hypotensive
50
What are the contraindications for pacing? (Symptomatic Bradycardia)
Hypothermia
51
Not part of the medical directive: but when may pacing be ineffective?
hyperkalemia or other electrolyte issues
52
Not part of the medical directive: but when may cardioversion be ineffective?
stimulant overdose/induced tachycardia
53
What are the indications for procedural sedation?
1. post-intubation OR 2. pacing
54
What medications are options for procedural sedation?
Fentanyl and Midazolam
55
What are the conditions for fentanyl and midazolam under procedural sedation medical directive?
1. At least 18 years old 2. RR at least 10 3. Normotensive
56
What are the contraindications for fentanyl and midazolam? (procedural sedation )
1. Allergy or sensitivity to respective drug
57
What routes can fentanyl and midazolam be administered? (procedural sedation)
IV, IO, CVAD, IN
58
What is the dose, max single dose, dosing interval and max cumulative dose for fentanyl? (procedural sedation)
25-75mcg max single 75mcg 5 min interval max 150mcg total
59
What is the dose, max single dose, dosing interval and max cumulative dose for Midazolam? (procedural sedation)
up to 0.1mg/kg (50kg gets max) max single 5mg 5 min interval Max 10 mg
60
When using the procedural sedation medical directive, are you administering before or after the procedure?
Only after pt is tubed or after pacing started
61
Conditions for epinephrine 1:10,000 (Medical cardiac arrest)
1. At least 24 hours old
62
What is defined as refractory Vtach or VF?
after 3 consecutive shocks
63
What age is the adult dosing of epinephrine during a medical cardiac arrest?
12 years or older
64
What is the dose, interval and # of doses for epi? (Medical cardiac arrest)
1mg (in 10mL) every 4 mins no maximum
65
If giving epi down the ETT tube, what is the dose? (Medical cardiac arrest)
2mg every 4 mins no max # doses
66
Contraindications for epi? (Medical cardiac arrest)
allergy or sensitivity to epi
67
What drugs should be considered during a medical cardiac arrest?
1. Epinephrine 2. Lidocaine (or amio) 3. Fluid bolus
68
Conditions for lidocaine (2) (Medical cardiac arrest)
1. At least 24 hours old 2. Refractory vtach or vfib
69
Contraindications for lidocaine (Medical cardiac arrest)
Allergy or sensitivity to lidocaine
70
Dosing for lidocaine IV,IO, CVAD (Medical cardiac arrest)
1.5mg/kg repeat dose 0.75mg/kg every 4 mins MAX 2 DOSES
71
How does the dosing change for lidocaine down the ETT (Medical cardiac arrest)
double the initial dose and second dose. Everything else is the same (3mg/kg, 1.5mg/kg)
72
Conditions for amiodarone (2) (Medical cardiac arrest)
1. at least 24 hours old 2. refractory vtach or vfib
73
Contraindications for amiodarone (Medical cardiac arrest)
Allergy or sensitivity to amiodarone
74
Dosing for amiodarone IV,IO, CVAD (Medical cardiac arrest)
Initial dose 300mg second dose 150mg interval 4 minutes MAX 2 DOSES
75
Can amiodarone be given down the ETT? (Medical cardiac arrest)
No
76
Conditions for fluid bolus? (Medical cardiac arrest)
1. At least 24 hours old 2. PEA OR any other rhythm where hypovolemia is suspected
77
Contraindications for fluid bolus? (Medical cardiac arrest)
Fluid overload
78
How much fluid can be given? (Medical cardiac arrest)
20mL/kg max volume 2,000ml
79
What treatments/medications are included under the ROSC medical directive?
1. fluid bolus 2. dopamine
80
What are the conditions for dopamine? (2) (ROSC medical directive)
1. At least 8 years old 2. hypotensive
81
What are the contraindications for dopamine? (5) (ROSC medical directive)
1. Allergy or sensitivity 2. Tachydysrhythmias (excluding sinus tach) 3. Mechanical shock 4. Hypovolemia 5.Pheochromocytoma
82
Does the dosing for dopamine change depending on the medical directive? Or stay the same?
Dosing, intervals and time stays the same for all directives.
83
Conditions for fluid bolus (2) (ROSC medical directive)
1. hypotensive 2. chest auscultation clear
84
What is the adult age for fluid bolus (ROSC medical directive)
At least 12 years old
85
How much fluid can we give (adult)? (ROSC medical directive)
10ml/kg max 1,000ml
86
What are the indications for the Hyperkalemia Medical Directive?
Suspected hyperkalemia AND - currently on dialysis, OR - Hx end stage renal, OR - hx prolonged crush injury AND Cardiac arrest, OR Pre-arrest with 12 lead changes associated with hyperkalemia
87
What are the conditions for calcium gluconate 10% and salbutamol? (Hyperkalemia Medical Directive)
at least 18 years old
88
What are the contraindications for calcium gluconate? (Hyperkalemia Medical Directive)
None
89
What are the contraindications for salbutamol? (Hyperkalemia Medical Directive)
Allergy or sensitivity to salbutamol
90
What routes can calcium gluconate be given? (Hyperkalemia Medical Directive)
IV, IO, CVAD
91
What is the dose, interval and number of repeats for calcium gluconate? (Hyperkalemia Medical Directive)
1g (10ml, given over 2-3 minutes) every 5 minutes max 2 doses push 2.5mL every 30 seconds
92
What is the dose, interval and number of repeats for salbutamol when nebulized? (Hyperkalemia Medical Directive)
10mg can repeat immediately x 2 doses
93
What is the dose, interval and number of repeats for salbutamol when MDI? (Hyperkalemia Medical Directive)
1600mcg (16 puffs) repeat immediately x 2 doses
94
What are indications for a pre-arrest patient? (Hyperkalemia Medical Directive)
One or more of the following: - hypotension - altered LOA - symptomatic bradycardia
95
What are the indications for orotracheal intubation?
1. Need for ventilatory or airway control AND 2. Other methods are ineffective
96
Contraindications for orotracheal intubation?
1. less than 50 years old AND 2. current asthma flare up AND 3. No in or near cardiac arrest
97
Contraindications for lidocaine spray? (orotracheal intubation)
1. allergy or sensitivity 2. unresponsive patient keep in mind max lidocaine dose 5mg/kg if given lidocaine for vtach/vfib
98
How many lidocaine sprays can a patient have? (orotracheal intubation)
max 5mg/kg and max 20 sprays 20 sprays at 10mg/spray is 200mg, a patient would need to weigh 40kg to get the max dose
99
Conditions for nasotracheal intubation? (nasotracheal intubation)
1. at least 8 years old 2. must be spontaneously breathing
100
contraindications for nasotracheal intubation? (nasotracheal intubation)
Same as orotracheal intubation, AND 1. Suspected basal skull fracture or mid face fracture 2. uncontrolled epistaxis 3. anticoagulant therapy 4. bleeding disorders
101
When following our medical directives, what can we use dopamine for?
- bradycardia (brady and hypotensive) - cardiogenic shock (hypotensive) - ROSC patient (hypotensive)
102
If a patient is symptomatic hypotensive, but not bradycardic, can we treat with dopamine?
Only if they are cardiogenic shock (STEMI positive) OR a ROSC
103
What are the indications for an SGA? (Supraglottic Airway medical directive)
1. Need for ventilatory assistance or airway control AND 2. Other airway methods ineffective
104
What are the conditions for an SGA? (Supraglottic Airway medical directive)
absent gag reflex
105
What are the contraindications for an SGA? (4) (Supraglottic Airway medical directive)
1. Airway obstructed by FBO 2. Known esophageal disease 3. Trauma to oropharynx 4. Caustic ingestion
106
Is vomiting a contraindication for an SGA?
Withhold while pt is actively vomiting, once airway is cleared, it can be placed. However, as an ACP, it would be better to tube this patient.
107
Number of attempts to place an SGA?
2 (per patient, not per provider)
108
Indications for cricothyrotomy medical directive?
1. Need for advanced airway management AND 2. Intubation AND SGA unsuccessful or contraindicated AND 3. unable to ventilate Think, cant ventilate cant oxygenate, and tried everything else
109
Conditions for cric? (cricothyrotomy medical directive)
1. At least 12 years old 2. Altered
110
Contraindications for cric? (cricothyrotomy medical directive)
1. suspected fractured larynx 2. unable to landmark
111
What age can be given analgesia without a patch?
12 or older
112
Conditions for morphine? (analgesia directive)
1. at least 1 year old 2. unaltered 3. normotensive
113
Conditions for fentanyl? (analgesia directive)
1. at least 1 year old 2. unaltered 3. normotensive
114
Contraindications for morphine (analgesia directive)
1. Allergy or sensitivity to morphine 2. Treatment of chronic headache 3. Treatment of chronic pain 4. SBP drops by 1/3 or more of it's initial value after morphine administration 5. Suspected cardiac ischemia 6. active labour
115
Contraindications for fentanyl (analgesia directive)
1. Allergy or sensitivity to morphine 2. Treatment of chronic headache 3. Treatment of chronic pain 4. SBP drops by 1/3 or more of it's initial value after morphine administration 5. Suspected cardiac ischemia 6. active labour
116
What route can morphine be administered?
IV or Sc
117
What is the adult age for morphine dosing? What is the dose and dosing interval? Max single dose and total cumulative dose?
at least 18 years old 2-10mg (max 10mg single dose) q 15 minutes total 20mg
118
What is the adult age for fentanyl dosing? What is the dose and dosing interval? Max single dose and total cumulative dose?
at least 18 years old 25-75 mcg (max 75mcg) q 5 minutes total 200mcg
119
What route can fentanyl be administered?
IV or IN
120
What is the indication for sedation by the combative patient directive?
Combative or violent or agitated behaviour that requires sedation for patient safety
121
What are the conditions for midazolam? (combative patient directive)
1. at least 18 years old
122
What are the conditions for ketamine? (combative patient directive)
1. at least 18 years old 2. suspected excited delirium or severe violent psychosis
123
Contraindications for midazolam (combative patient directive)
1. allergy or sensitivity to midazolam
124
Contraindications for ketamine (combative patient directive)
1. allergy or sensitivity to ketamine
125
What is the route, dose, max single dose, interval and total doses for midazolam? (combative patient directive)
IV, IM, IN up to 0.1mg/kg (max 5mg) q 5 minutes max total dose 10mg ( no limit on # of doses)
126
What are the age categories for ketamine dosing? (combative patient directive)
18 - 65 and older than 65
127
What is the route, dose, max single dose, interval and total doses for ketamine for 18-65 year olds? (combative patient directive)
IM only 5mg/kg to max of 500mg single dose (100kg gets max)
128
What is the route, dose, max single dose, interval and total doses for ketamine 65 year old and older? (combative patient directive)
IM only 3mg/kg to max of 300mg single dose
129
What dose of midazolam should be considered for combative patients if less is needed?
0.05mg/kg (half of normal)
130
Conditions for midazolam? (Seizure directive)
1. unresponsive
131
Contraindications for midazolam? (Seizure directive)
1. allergy or sensitivity to midazolam
132
What routes can midazolam be given? Which routes are in which group for dosing? (Seizure directive)
IV, IO IM, IN, buccal
133
What is the IV/IO dosing, max single dose, interval for midazolam? (Seizure directive)
IV, IO 0.1mg/kg (max 5mg) q 5 minutes max # doses 2
134
What is the IM/IN dosing, max single dose, interval for midazolam? (Seizure directive)
IM, IN 0.2mg/kg (max 10mg) q 5 minutes max # doses 2
135
What is the dose, max single dose, interval, and number of doses for D10W for a patient less than 2 years old?
0.2g/kg (2ml/kg) --> same as adults max 5g (50ml) (needs to be 25kg or 55lbs to get max) q 10 mins max 2 doses
136
When can we access a CVAD?
1. actual or potential need for fluid or IV medication 2. IV access unattainable 3. Cardiac arrest or pre-arrest
137
What are the contraindications for accessing a CVAD?
1. Inability to confirm patency of CVAD line. 2. Inability to flush or aspirate 3. injury or suspected fracture proximal to access site. 4. swelling of involved limb 5. bleeding at insertion site
138
When can we emergency disconnect home dialysis?
1. Patient is receiving home dialysis and requires transport to hospital AND 2. patient is unable to disconnect AND 3. there is no one else knowledgeable in dialysis disconnect

Medical directives (4 decks)

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