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Emergency Medicine Clerkship > BLS/ACLS/PALS/ATLS > Flashcards

BLS/ACLS/PALS/ATLS Flashcards

1
Q

Adult BLS Algorithm for Healthcare Providers

A
  1. Unresponsive (No breathing or no normal breathing, ie, only gasping)
  2. Activate emergency response system, get AED/defibrillator
  3. Check pulse - definite pulse within 10 seconds?
    3A. Definite pulse - give 1 breath every 5 to 6 seconds, recheck pulse every 2 minutes
    3B. No pulse -> 4.
  4. Begin cycles of 30 compressions and 2 breaths
  5. AED/Defibrillator arrives
  6. Check rhythm - shockable?
  7. If shockable, give 1 shock and resume CPR immediately for 2 minutes, then check rhythm again
  8. If not shockable, resume CPR immediately for 2 minutes. Check rhythm every 2 minutes and continue until ALS providers take over or victim starts to move
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2
Q

Define high-quality CPR

A

Rate at least 100/min and not faster than 120/min
Compression depth at least 2” (5cm) but no more than 2.5” (6cm)
Allow complete chest recoil after each compression
Minimize interruptions in chest compression (10 seconds or less)
Avoid excessive ventilation
Rotate compressor every 2 minutes, or sooner if fatigued
If no advanced airway, 30:2 compression-ventilation ratio. If advanced airway, give 1 breath every 6 seconds (10 breaths/min) with continuous chest compressions
If using quantitative waveform capnography - if PETCo2 <10 mmHg, attempt to improve CPR quality
If relaxation phase (diastolic pressure) <20 mmHg, attempt to improve CPR quality

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3
Q

Adult Cardiac Arrest Algorithm

A
  1. Start CPR (give O2, attach monitor/defibrillator) - is rhythm shockable?
  2. VF/pVT (yes) [if no, #9]
  3. Shock
  4. CPR for 2 minutes, obtain IV/IO access. Assess rhythm.
  5. If shockable, shock.
  6. CPR for 2 minutes. Give epinephrine every 3-5 minutes. Consider advanced airway/capnography. Assess rhythm.
  7. If shockable, shock.
  8. CPR for 2 minutes. Give amiodarone. Treat reversible causes.
  9. Asystole/PEA
  10. CPR for 2 minutes, obtain IV/IO access, epinephrine every 3-5 minutes, consider advanced airway, capnography. Check rhythm.
  11. If not shockable, CPR for 2 minutes, treat reversible causes. Check rhythm.

If at any point rhythm is shockable, go to #5 or #7.

If ROSC, go to post-cardiac arrest care.

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4
Q

Shock energy for defibrillation?

A

Biphasic - manufacturer recommendation (eg, initial dose of 120-200 J). If unknown, use maximum available. Second and subsequent doses should be equivalent, and higher doses may be considered.

Monophasic - 360 J

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5
Q

Dose of epinephrine (IV/IO)?

A

1 mg every 3-5 minutes

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6
Q

Dose of amiodarone (IV/IO)?

A

First dose - 300 mg bolus

Second dose - 150 mg bolus

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7
Q

Define ROSC?

A

Pulse and blood pressure
Abrupt sustained increase in PETCO2 (typically 40+ mmHg)
Spontaneous arterial pressure waves with intra-arterial monitoring

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8
Q

Reversible causes?

A 
Hypovolemia
Hypoxia
Hydrogen ions (acidosis)
Hypo/hyperkalemia
Hypothermia
(Hypoglycemia)
Tension pneumothorax
Tamponade (cardiac)
Toxins
Thrombosis (pulmonary)
Thrombosis (coronary)
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9
Q

Adult Bradycardia with a Pulse Algorithm

A
  1. Assess appropriateness of clinical condition. HR typically <50/min if bradyarrhythmia
  2. Identify and treat underlying cause. Maintain patent airway; assist breathing as necessary. O2 if hypoxemic. Cardiac monitor to identify rhythm. Monitor blood pressure and oximetry. IV access. 12-lead ECG if available; don’t delay therapy.
  3. Persistent bradyarrhythmia causing hypotension? Acutely AMS? Signs of shock? Ischemic chest discomfort? Acute heart failure?
  4. If no, monitor and observe.
  5. If yes, give atropine. If ineffective, move to transcutaneous pacing OR dopamine infusion OR epinephrine infusion
  6. Consider expert consultation or transvenous pacing
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10
Q

Atropine IV doses?

A

First dose: 0.5 mg bolus
Repeat every 3-5 minutes
Maximum 3 mg

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11
Q

Dopamine IV infusion?

A

Usual rate is 2-20 mcg/kg per minute. Titrate to patient response; taper slowly.

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12
Q

Epinephrine IV infusion?

A

2-10 mcg/minute infusion. Titrate to patient response

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13
Q

Adult tachycardia algorithim?

A
  1. Assess appropriateness for clinical condition. HR typically 150+/min in tachyarrhythmia
  2. Identify and treat underlying cause. Maintain patient airway; assist breathing as necessary. O2 if hypoxemia. Cardiac monitor to identify rhythm; monitor BP and oximetry
  3. Persistent tachyarrhythmia causing hypotension? Acutely AMS? Signs of shock? Ischemic chest discomfort? Acute heart failure?
  4. If yes, synchronized cardioversion (consider sedation. If regular narrow complex, consider adenosine while preparing for cardioversion)
  5. If no, is the QRS wide? (0.12+ seconds)
  6. If yes, get IV access and 12-lead EKG if available. Consider adenosine only if regular and monomorphic. Consider antiarrhythmic infusion. Consider expert consultation.
  7. If no, IV access and 12-lead EKG if available. Vagal maneuvers. Adenosine if regular. Beta-blocker or CCB. Consider expert consultation
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14
Q

Initial recommended doses for synchronized cardioversion?

A

Narrow regular: 50-100 J
Narrow irregular: 120-200 J biphasic or 200 J monophasic
Wide regular: 100 J
Wide irregular: defibrillation dose (not synchronized)

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15
Q

Adenosine IV doses for synchronized cardioversion?

A

First dose: 6 mg rapid IV push followed by NS flush

Second dose: 12 mg if required

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16
Q

Antiarrhythmic infusion options for stable wide-QRS tachycardia?

A

Procainamide IV
Amiodarone IV
Sotalol IV

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17
Q

Procainamide IV dose?

A

20-50 mg/minute until arrhythmia suppressed, hypotension ensues, QRS duration increases >50%, or maximum dose 17 mg/kg given

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18
Q

Amiodarone IV dose?

A

First dose: 150 mg over 10 minutes, repeat as needed if VT recurs
Follow by maintenance infusion of 1 mg/minute for first 6 hours

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19
Q

Sotalol IV dose?

A

100 mg (1.5 mg/kg) over 5 minutes. Avoid if prolonged QTc

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20
Q

What tasks should be assigned during a code?

A 
Compressions
Airway/BVM
Defibrillator
IV insertion and medications
Recorder
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21
Q

Team leader tasks?

A

Ensure high quality CPR at all times
Analyze rhythm while chest compressions are held
Recognize rhythm

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22
Q

Duration of resuscitation?

A

No evidence for a “correct” duration of resuscitation; after 20-30 minutes, possibility of ROSC becomes extremely small

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23
Q

After achieving ROSC, what should be considered?

A

Therapeutic hypothermia

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24
Q

Proper positioning for chest compressions?

A

Fingers interlaced, elbows locked, heal of hand between nipples on mid-sternum

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25
Q

Primary actions in cardiopulmonary arrest?

A
  1. Perform BLS primary survey
  2. Obtain finger stick blood sugar
  3. Perform ACLS secondary survey
26
Q

Aspects of BLS primary survey?

A
  1. Is the airway open? Head tilt-chin lift or jaw thrust (if trauma is suspected)
  2. Initiate rescue breathing with BVM ventilation if not adequately breathing
  3. Check carotid pulse for at least 5 seconds (max 10 seconds). If no pulse, initiate CPR.
  4. Defibrillation
27
Q

Aspects of ACLS secondary survey?

A
  1. Airway - head tilt-chin lift, jaw thrust, oropharyngeal airway, or nasopharyngeal airway; endotracheal intubation if indicated (do not delay defibrillation)
  2. Breathing - adequacy of oxygenation and ventilation should be confirmed by assessing rise and fall of the chest, auscultation of equal breath sounds, absence of breath sounds over the epigastrum, monitoring end-tidal CO2 using capnometry or capnography, secure ET tube and confirm position with CXR, monitor pulse ox
  3. Circulation - IV or IO access, monitor, appropriate drugs per ACLS guidelines
28
Q

Optimal dosing of drugs administered endotracheally has not been established, but ___x the IV route is generally accepted.

A

2-2.5

29
Q

ACLS drugs safe for endotracheal administration?

A 
NAVEL
Naloxone
Atropine
Vasopressin
Epinephrine
Lidocaine
30
Q

DDx for cardiac arrest

A 
Hypovolemia
Hypoxia
H+ (Acidosis)
Hypothermia
Hyperkalemia (or other electrolyte abnormality)
Tension pneumothorax
Tamponade (cardiac)
Toxins (OD)
Trauma
Thrombosis (ACS or PE)
31
Q

Work-up of cardiac arrest?

A 
H&amp;P
EKG
ABG
Lytes
CXR
US
32
Q

Initiation of mild hypothermia (cooling to 32-34 C) has been demonstrated to decrease the 6 month mortality rate and lead to improved functional recovery at hospital discharge. What are the inclusion criteria for therapeutic hypothermia?

A

Patient resuscitated after out-of-hospital witnessed arrest with VT/VF as initial rhythm

Resuscitation initiated by EMS within 5-15 minutes of arrest

No more than 60 minutes from collapse to ROSC

Persistent coma after ROSC

Adult age

Endotracheal intubation and MV

33
Q

Contraindications to therapeutic hypothermia?

A 
Severe cardiogenic shock (SBP<90) despite fluids and inotropes
Cause of coma other than cardiac arrest (OD, CVA)
Pregnancy
Known coagulopathy
Life-threatening arrhythmias
Initial temperature <30C
Pre-existing DNR status
Pediatric patients
34
Q

Initial actions in trauma patient?

A
  1. Assess primary survey with focus on ABCDEs
  2. Address problems with any portion of the survey before moving on
  3. Log roll the patient
  4. XR (AP chest, AP pelvis) and FAST
  5. Secondary survey
  6. Resuscitation and stabilization
35
Q

Primary survey in trauma patient?

A

Airway maintenance with C-Spine protection
Breathing and ventilation
Circulation with hemorrhage control/shock assessment
Disability (neuro status)
Exposure/Environmental control

36
Q

Airway management in trauma patient?

A
  1. Judge the airway - have the patient speak to you to establish patency and to evaluate for voice change and stridor. Is there evidence of pooling secretions or cyanosis?
  2. If intact, look for problems which may cause the patient to lose the airway in the near future -> facial injury causing obstruction or bleeding, laryngeal fractures, expanding hematomas, GCS of 9 or less (requires intubation)
  3. If not intact -> act
    - Always maintain C-spine immobilization
    - Jaw thrust to establish patency
    - Consider NP or OP airway during BVM
    - Rapid sequence intubation
    - Evaluate neck for landmarks associated with cricothyroidotomy and for SubQ emphysema or tracheal deviation
37
Q

Breathing in trauma patient?

A

Patent airway DOES NOT mean adequate ventilation, which requires functioning lungs, chest wall, and diaphragm

Inspect - look for cyanosis, JVD (tension PT, cardiac tamponade), asymmetric movement of the chest (flail chest), accessory muscle use (tension PT), or open chest wounds (open PT)

Auscultate - listen for stridor (upper airway injury), lung breath sounds (PT or hemothorax)

Percuss - hyperresonance (PT) or dullness (hemothorax), subQ emphysema (airway injury), paradoxical movements (flail chest), crepitence and point tenderness (rib fractures), bruising (pulmonary contusion)

38
Q

Why is tension pneumothorax so serious?

A

Formation of one-way valve at point of rupture in the lung -> air becomes trapped in the pleural cavity between the chest wall and lung, builds up, puts pressure on the lung, prevents full inflation

Hypotension develops due to increased intrathoracic pressure decreasing preload, loss of L heart blood flow due to loss of pulmonary vasculature to affected lung, compression of mediastinum

39
Q

Rx tension pneumothorax?

A

14-16 gauge long angiocath inserted at midclavicular line in the second intercostal space over the 3rd rib to avoid the neurovascular bundle

40
Q

Presentation of massive hemothorax?

A

Systemic or pulmonary vessel disruption leads to >1500 mL blood loss initially and 400 cc/hr for 2 hours

Neck veins expected to be flat but may be full due to supine position or associated tension PT or tamponade. Consider in those in sohck with no breath sounds and/or percussion dullness

41
Q

Rx massive hemothorax?

A

Place large (36 F) chest tube and possible trip to OR for hemorrhage control

42
Q

Circulation management in trauma?

A

Establish that the patient is getting adequate tissue perfusion and oxygenation

Control any active hemorrhage with direct pressure

Feel for pulses

43
Q

If a radial pulse is palpable, it suggests a systolic BP of at least ___. If the femoral or carotid is palpable, these suggest a systolic BP of at least ___.

A

80; 60

44
Q

What types of patients may not mount a tachycardic response to shock?

A

Neurogenic shock
Beta-blockers, CCBs
Elderly, children, young adults
Conditioned athletes start with a lower basal level (doubled resting heart rate of 45-50 shows a falsely reassuring HR of 90-100)

45
Q

ATLS classifications of hemorrhagic shock (define by HR, BP, findings)

A

Class I: normal to fast HR, normal BP, no specific findings

Class II: normal to fast HR, normal to low BP, narrowed pulse pressure

Class III: fast HR, low BP, altered mentation

Class IV: fast HR, low BP, obtunded

46
Q

ATLS classifications of hemorrhagic shock (blood loss and treatment)?

A

Class I: <15% blood loss, NS

Clas II: 15-30% blood loss, NS

Class III: 30-40% blood loss, NS + blood products

Class IV: >40% blood loss, NS + blood products

47
Q

Disability assessment in trauma?

A

Quick check of neuro status - use the AVPU scale

Alert - fully awake
Voice - responds when verbally addressed (response can be verbal, motor, or with eyes)
Pain - makes a response on any of the three component measurements only when pain stimuli is delivered
Unresponsive - no eye, motor, or voice response to voice or painful stimuli

Gross motor/sensory exam to determine if CNS is intact (simple, not a full neuro exam)

Assess pupils (uncal herniation - blown pupil)

Log roll patient using spinal immobilization to palpate spine for step-offs or pain

48
Q

GCS?

A

Eyes: Spontaneous (4), loud voice (3), pain (2), none (1)

Verbal: Oriented (5), Confused (4), Inappropriate words (3), Incomprehensible sounds (2), no sounds (1)

Motor: Obeys (6), Localizes to pain (5), Withdraws to pain (4), Abnormal flexion posturing (3), Abnormal extension posturing (2), None (1)

49
Q

Assess Exposure/Environment in trauma patient?

A

Completely disrobe patient to assess for any hidden injury

Keep patient warm to prevent coagulopathy

50
Q

Secondary Survey - history?

A 
AMPLE history:
Allergies
Medications
Past illnesses
Last meal
Events/environment/mechanism of injury
51
Q

Secondary survey - physical?

A

Head to toe directed assessment focusing on:

  • Head/CNS Trauma
  • Motor Strength/Grading
  • Facial Trauma
  • C-spine/Neck exam
  • Chest
  • Abdomen
  • Pelvis
  • Perineum, Rectum, and Genital Exam
  • MSK
52
Q

Head/CNS trauma physical exam?

A 
Skull fractures
Axonal injuries
Contusion
Concussion
Hemorrhage

Battle’s sign (ecchymosis behind ear, indicates basilar skull fracture)

Raccoon eyes (periorbital ecchymosis without edema, indicates skull fracture)

53
Q

Cervical spine/neck trauma patient exam?

A

Blunt trauma - crushed larynx, tracheal disruption, expanding hematoma, esophageal leak

Penetrating trauma - injury to major vascular structures, pharynx, larynx, trachea, esophagus

Flexion, extension, rotational injuries may injur spine

Obstruction 2/2 trauma may be due to direct trauma to larynx or neck - may have inspiratory stridor (supraglottic) or expiratory stridor (subglottic), muffled voice, difficulty handling secretions

54
Q

What must be done to clear the C-spine and remove the collar?

A 
Alert and not intoxicated
Absence of neck pain
Absence of midline neck tenderness
Absence of distracting injury
Absence of sensory or motor complaint
55
Q

Chest trauma patient physical exam?

A

Inspect for obvious injuries with consideration for mechanism
Palpate for subcutaneous emphysema and chest wall stability
Percuss for dullness or hyperresonance
Auscultate for diminished breath sounds

56
Q

Some life threatening conditions to the chest in a trauma patient?

A

Tracheobronchial tree disruption (subQ emphysema) -> chest tube with failure of lung to inflate (persistent air leak), may need 2nd tube or OR

Pulmonary contusion (mild hypoxia that worsens after fluid resuscitation) -> Dx on CXR or CT, Rx by proper O2, ventilation, normovolemia

Blunt cardiac injury - abnormal EKG, echo with hypokentic heart; medicate dysrhythmias

Traumatic aortic disruption - rapid acceleration or deceleration injury, may be immediately fatal, widened mediastinum on CXR, confirm with CT or CTA, surgery

Flail chest - moves in opposite direction, disrupts normal negative-pressure ventilatory mechanisms

57
Q

Abdomen trauma patient exam?

A

Bruising patterns (Cullen’s sign of periumbilical bruising, Grey-Turner’s sign of blank bruising, both associated with retroperitoneal hemorrhage, or seat belt sign)

Auscultate for absent or tympanic bowel sounds

Palpate and percuss for rebound tenderness, guarding, or diffuse dullness

Re-evaluate frequently

58
Q

Pelvic trauma patient exam?

A

Pain/instability on palpation, unequal leg lengths

Can hide severe hemorrhage

Rx - stabilize by wrapping a sheet around it (compress), longitudinal traction, pelvic binders

59
Q

GU exam in trauma patient?`

A

Examine perineum for contusions, scrotal hematomas, lacerations, or blood at the meatus

Rectal exam - diminished tone

Prostate - high-riding can be a sign of a pelvic fracture or urethral injury

Rectal wall integrity, gross blood

60
Q

MSK trauma patient exam

A

Distal perfusion and neurovascular status (worry about compartment syndrome - pallor, pain, paresthesia, poikilothermia, pulselessness)

61
Q

Diagnostic studies in trauma?

A 
Tye and crossmatch
CBC
ABG and lactate
BMP
UA
EtOH
EKG if indicated
AP chest and pelvic XR
C-spine XR (lateral, AP, odontoid, oblique views)
CT
FAST
XR
EKG
Retrograde urethrogram if concern for urethral injury

Emergency Medicine Clerkship (18 decks)

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