Lecture 2: What is your role in a code?

Question 1

what is defibrillation

Answer 1

• terminates VF and pulseless VT
• passage of DC of electrical shock to depolarize cells of myocardium to allow SA node to resume role of pacemaker (monophasic defibrillators deliver energy in 1 direction, biphasic defibrillators deliver energy in 2 directions)
• after the initial shock, chest compressions (CPR) should be restarted

Question 2

what is synchronized cardioversion

Answer 2

• choice of therapy for hemodynamically unstable ventricular or supraventricular tachydysrhythmias
• synchro circuit delivers counter shock on R wave of QRS complex of ECG
• synchronizer switch must be turned ON

Question 3

defibrillation vs cardioversion
(when do we do both)

Answer 3

defibrillation:
- pulseless VT
- ventricular fibrillation

cardioversion
- unstable atrial fibrillation
- unstable atrial flutter
- unstable atrial tachycardia
- unstable supraventricular tachycardia
- medication failure

Question 4

what is pacing

Answer 4

• used to pace the heart when normal conduction pathway is damaged or diseased
• pacing circuit consists of a power source, one or more conducting (pacing) leads, and the myocardium
• can be used to prevent bradycardia or tachycardia rhythms

for severe bradycardia, not for asystole, unstable

Question 5

what is a pacemaker spike + when should it be

Answer 5

The electricity the pacemaker is sending.
Should be a complex after every pacer strike

Question 6

types of pacemakers

Answer 6

• temporary transcutaneous pacemaker
• temporary transvenous pacemaker
• permanent pacemaker
• implantable cardioverter defibrillator (ICD)

Question 7

what is cab - for is my patient stable

Answer 7

1. circulation
2. airway
3. breathing

Question 8

what are we looking for in the neurological re-check

Answer 8

alert x4
any abnormalities

Question 9

tell me about glasgow coma scale

Answer 9

15 = fully alert and orientated
8 or less = endotracheal intubation to protect the airway (coma)

Question 10

potential neuro causes of unresponsiveness

Answer 10

stroke
seizure
trauma

Question 11

potential cardio causes of unresponsiveness

Answer 11

myocardial infarction
cardiac arrhythmia
cardiac arrest

Question 12

potential resp causes of unresponsiveness

Answer 12

PE
respiratory arrest

Question 13

potential endocrine causes of unresponsivenes

Answer 13

hypoglycemia

Question 14

you walk into a pt room and you have a definite pulse + normal breathing

Answer 14

1. vital signs
2. assess responsiveness
3. glasgow coma scale
4. bloodwork/imaging tests

Question 15

examples of definite pulse and normal breathing

Answer 15

• stroke/TIA
• slow brain bleed
• meds

Question 16

you walk into a pt room and you have a definite pulse + no breathing

Answer 16

• “C” check for pulse; pulse is palpable, but no breathing or breathing is not normal
• “A” (airway): open airway
• “B” (breathing): bag valve mask
• 1 breath every 5-6 sec
• pulse check every 2 min

If we don’t have oxygenated blood to circulate our organs and such will fail.

Question 17

examples of definite pulse and no breathing

Answer 17

obstruction, inadequate resp effort, meds

Question 18

you walk into a pt room and you find no pulse for cardiac arrest

Answer 18

• “C” circulation
  no pulse - IMMEDIATE CHEST COMPRESSIONS
  push hard + fast (100-120 compressions/min)
  depth of at least 2 inches (5cm)
  allow chest recoil
  minimize interruptions in compressions
• “A” airway: open airway
• “B” breathing: bag valve mask (BVM) -> 30:2

Question 19

if rhythm is shockable for cardiac arrest

Answer 19

VF/pVT - u shock then CPR for 2 min - shock - CPR and epi - until its not shockable

Question 20

if rhythm is not shockable for cardiac arrest

Answer 20

asystole/PEA

• epi asap
  then CPR (epi every 3-5 min)

Question 21

1. if YES pt has persistent tachyarrhythmia causing hypotension, ALOC, shock, chest pain, HF, etc… what do u do
2. if refractory… consider

Answer 21

synchronized cardioversion

• consider sedation
• if regular narrow complex, consider adenosine

2. • underlying cause
     - need to increase energy level for next cardioversion
     - addition of anti-arrhythmic drug
     - expert consultation

Question 22

If NO to persistent tachycardia causing etc, and no wide QRS greater than or equal to 0.12 sec…

Answer 22

• vagal maneuvers (if regular)
• adenosine (if regular)
• B blocker or calcium channel blocker
• consider expert consultation

Question 23

1. If NO to persistent tachycardia causing etc, and YES wide QRS greater than or equal to 0.12 sec…
2. if refractory… consider

Answer 23

1. consider
   - adenosine only if regular and monomorphic
   - antiarrhythmic infusion
   - expert consultation
2. • underlying cause
     - need to increase energy level for next cardioversion
     - addition of anti-arrhythmic drug
     - expert consultation

Question 24

adenosine IV dose
1st and 2nd for tachycardia

Answer 24

1st: 6 mg rapid IV push
2nd: 12 mg if required

Question 25

procainamide IV dose for antiarrhythmic IV for tachycardia

Answer 25

20-50 mg/min until better.maintanence 1-4 mg/min.

Question 26

amiodarone IV dose for antiarrhythmic IV for tachycardia

Answer 26

first dos: 150 mg over 10 min. follow by maintenance infusion 1 mg/min for 1st 6 hours.

Question 27

sotalol IV dose for antiarrhythmic IV for tachycardia

Answer 27

100 mg (1.5 mg/kg) over 5 min. avoid prolonged QT

Question 28

pt is NOT having persistent bradyarrythmia causing: hypotension, ALOC, shock, chest pain, HF...

Answer 28

monitor and observe

Question 29

pt is having persistent bradyarrhythmia causing: hypotension, ALOC, shock, chest pain, HF...

Answer 29

atropine if atropine is ineffective: transcutaneous pacing and/or dopamine or epi IV consider expert consultation and transvenous pacing

Question 30

atropine dose IV for bradyarrhythmia

Answer 30

1st dose: 1 mg bolus repeat every 3-5 min max 3 mg

Question 31

dopamine IV infusion dose for bradyarrhythmia

Answer 31

usual IV rate is 5-20 mcg/kg per min. titrate to pt response; taper slow

Question 32

epinephrine IV infusion dose for bradyarrhythmia + causes

Answer 32

2-10 mcg/min IV. causes: Myocardial ischemia/infarction, drugs/toxicologic (CCBs, digoxin), hypoxia, electrolyte abnormality (hyperkalemia)

Question 33

reversible causes of cardiac arrest

Answer 33

Hypovolemia Hypoxia Hydrogen ion (acidosis) Hypo/hyperkalemia Hypothermia Tension pneumothorax Tamponade, cardiac Toxins Thrombosis, coronary and pulmonary

Question 34

what to do with advanced airways during cardiac arrest

Answer 34

- endotracheal intubation or supraglottic advanced airway - waveform capnography or capnometry to confirm + monitor ET tube placement - once advanced airway in place, give 1 breath every 6 sec (10 breaths/min) with continuous chest compressions

Question 35

how to do good CPR quality

Answer 35

- push hard (2inch/5cm) + fast (100-120/min) - change compressor every 2 min - if no advanced airway 30:2

Question 36

shock energy for defibrillation 1. biphasic 2. monophasic

Answer 36

1. biphasic: dose of 120-200 K. subsequent doses are equivalent or higher. 2. monophasic: 360 J

Question 37

cardiac arrest epinephrine IV/IO dose

Answer 37

1 mg every 3-5 min

Question 38

cardiac arrest amiodarone IV/IO dose

Answer 38

first dose: 300 mg bolus second dose: 150 mg

Question 39

cardiac arrest lidocaine IV/IO dose

Answer 39

first dose: 1-1.5 mg/kg second dose: 0.5-0.75 mg/kg