Term
| Pt is unresponsive, and not breathing. You feel a definite pulse. What do you do now? |
|
Definition
- Give 1 breath every 5-6 seconds
- Recheck pulse every 2 minutes |
|
|
Term
|
Definition
- Rate of at least 100/min
- Compression depth of at least 2 inches (5 cm)
- Allow complete chest rise after each compression
- Minimize interruptions
- Avoid excessive ventilation |
|
|
Term
| Order of events for cardiac arrest: |
|
Definition
1. Shout for help/activate emergency response
2. Start CPR, Give Oxygen, Attach monitor, defibrillator
3. After 2 minutes CPR> check rhythm
4. VF/VT>shock
5. Continue CPR 2 minutes> check rhythm
6. Rhythm present> Drug therapy (Epi every 3-5 minutes, Amiodarone for refractory VF/VT)
7. Consider Advanced Airway Placement (Quantitative waveform capnography)
8. Treat reversible causes |
|
|
Term
| If quantitative waveform capnography is less than __ mm Hg, attempt to improve CPR quality. |
|
Definition
|
|
Term
| If diastolic pressure is less than __mmHg, attempt to improve CPR quality. |
|
Definition
|
|
Term
| 3 characteristics of ROSC (return to spontaneous circulation): |
|
Definition
- Pulse and blood pressure
- Abrupt sustained increase in PETCO2 (typically > or equal to 40mmHg)
- Spontaneous arterial pressure waves with intra-aterial monitoring |
|
|
Term
|
Definition
- initial dose of 120-200 J (if unknown use maximum possible)
- second and subsequent doses should be equivalent and higher doses may be considered |
|
|
Term
| Monophasic shock energy for cardiac arrest: |
|
Definition
|
|
Term
| For cardiac arrest what drug is given once there is a rhythm on the strip: |
|
Definition
| 1 mg epinephrine every 3-5 minutes |
|
|
Term
| If refractory VF or VT is present on the strip, what drug is given? |
|
Definition
300 mg bolus dose of Amiodarone
150 mg second dose |
|
|
Term
| what drug can replace the first or second dose of epi in cardiac arrest? |
|
Definition
|
|
Term
| with advanced airway placement, how many breaths should be given per minute? |
|
Definition
|
|
Term
| Reversible causes of cardiac arrest: |
|
Definition
HHHHHTTTTT
- Hypovolemia
- Hypoxia
- Hydrogen ions (acidosis)
- Hypo/hyperkalemia
- Hypothermia
- Tension pneumothorax
- Tamponade, cardiac
- Toxins
- Thrombosis, pulmonary
- Thrombosis, coronary |
|
|
Term
| The heart rate is usually greater than or equal to __ bpm with tachyarrhythmias. |
|
Definition
|
|
Term
| You suspect pt has tachyarrhythmia b/c heart rate is greater than or equal to 150 bpm. Whats the first step? |
|
Definition
Identify and treat underlying cause
- Maintain patent airway, assist breathing if necessary
- Oxygen if hypoxemic
- Cardiac monitor to identify rhythm
- Monitor blood pressur
- Monitor oximetry |
|
|
Term
| If persistent tachyarrythmia is causing any of the following, then __ __ should be considered. |
|
Definition
- Hypotension
- Acutely altered mental status
- Signs of shock
- Ischemic chest discomfort
- Acute heart failure
Any and all of these are signs for Synchronized cardioversion |
|
|
Term
| With Synchronized Cardioversion for tachyarrhythmias, one should consider __. If there are regular narrow QRS complexes, consider ___. |
|
Definition
|
|
Term
| regular narrow complexes with tachyarrhythmias, consider: |
|
Definition
|
|
Term
| QRS complex is considered wide if it is greater than or equal to ___ seconds. |
|
Definition
|
|
Term
| Pt has tachyarrhythmia but does not have hypotension, acutely altered mental status, signs of shock, ischemic chest discomfort, or acute heart failure. The QRS complexes are wide and greater than 0.12 seconds. What should you do next? |
|
Definition
- IV access
- 12 lead EKG if available
- Consider adenosine only if regular and monomorphic
- Consider antiarrhythmic infusion
- Consider expert consultation |
|
|
Term
| Patient has tachyarrhythmia. There is no hypotension, acutely altered mental status, signs of shock, ischemic chest discomfort, or acute heart failure. The QRS complexes are NOT wide. What should you do now? |
|
Definition
- IV access
- 12 lead EKG if available
- Vagal maneuvers
- Adenosine if regular
- Beta blocker or CCB
- Consider expert consultation |
|
|
Term
| Cardioversion dose for NARROW REGULAR tachyarrhythmia: |
|
Definition
|
|
Term
| Cardioversion dose for NARROW IRREGULAR tachy: |
|
Definition
120-200 J biphasic
200 J monophasic |
|
|
Term
| Cardioversion dose for WIDE REGULAR tachyarrhythmia: |
|
Definition
|
|
Term
| Cardioversion dose for WIDE IRREGULAR tachyarrhythmias: |
|
Definition
| defibrillation dose, NOT synchronized |
|
|
Term
| Adenosine IV dose for regular tachyarrhythmias: |
|
Definition
6 mg rapid IV push, follow with NS flush
second dose 12 mg if necessary |
|
|
Term
| Antiarrhythmic infusions are used for __ __ ___ tachycardia. |
|
Definition
| - STABLE WIDE QRS TACHYCARDIA |
|
|
Term
| 3 possible Antiarrhythmic infusions given to pts with stable wide QRS tachycardia: |
|
Definition
- Procainamide
- Amiodarone
- Sotalol |
|
|
Term
| Procainamide IV dose is __-__mg/minute until the __ is __, __ __, the __ __ increases by __, or the __ __ of __ is given. Maintenance infusion of ___. Avoid __ __ or ___. |
|
Definition
- 20-50mg/minute
- arrhythmia subsides
- hypotension occurs
- QRS duration increases by >50%
- maximum dose of 17mg/kg is given
- Maintenance infusion of 1-4 mg/minute
- Avoid QT prolongation and CHF |
|
|
Term
| The dose for procainamide with stable wide QRS tachycardia is 20-50mg/minute. When can you stop this? |
|
Definition
- arrhythmia subsides
- hypotension occurs
- QRS duration increases by >50%
- maximum dose of 17mg/kg is given |
|
|
Term
| Amiodarone IV dosing for stable wide complex tachycardia: |
|
Definition
- 150 mg over 10 minutes for first dose
- Repeat as needed if VT recurs
- Follow with maintenace of 1mg/min for first 6 hours |
|
|
Term
| Sotalol IV dose for stable wide complex tachycardia: |
|
Definition
100 mg (1.5mg/kg) over 5 minutes
avoid QT prolongation |
|
|
Term
| Heart rate is usually less than __/minute if bradyarrhythmia. |
|
Definition
|
|
Term
| You suspect pt has bradyarrhythmia b/c heart rate is less than 50 bpm. What do you do next? |
|
Definition
Identify and treat underlying causes
- Maintain patent airway, assist breathing as necessary
- Oxygen if hypoxemic
- Cardiac monitor to ID rhythm
- Monitor blood pressure
- Monitor oximetry
- IV access
- 12 lead EKG if possible, don't delay therapy |
|
|
Term
| You suspect patient is having bradyarrhythmia, but they are not hypotensive, do not have acutely altered mental status, do not show signs of shock, have no ischemic chest discomfort, and do not have acute heart failure. What do you do? |
|
Definition
| After doing all steps to id and treat underlying cause> OBSERVE |
|
|
Term
| Pt is having bradyarryhthmia and is hypotensive, acutely altered mental status, signs of shock, ischemic chest discomfort, or/and acute heart failure. What do you do next? |
|
Definition
ATROPINE
If atropine does not work then do transcutaneous pacing OR dopamine OR epinephrine
Also consider transvenous pacing and expert consult |
|
|
Term
| first line for symptomatic bradycardia is atropine. but if this does not work, what do you do? |
|
Definition
- transcutaneous pacing OR dopamine OR epinephrine
consider transvenous pacing and expert consult |
|
|
Term
| Atropine dose for bradarryhtmia: |
|
Definition
0.5 mg bolus, repeat every 3-5 minutes
maximum of 3 mg |
|
|
Term
| Dopamine dose for bradyarrhythmia: |
|
Definition
|
|
Term
| Epinephrine dose for bradyarrhythmia: |
|
Definition
|
|
Term
| After ROSC, what do you do? |
|
Definition
Optimize ventilation and oxygenation
- Maintain oxygen saturation > or equal to 94%
- Consider advanced airway and waveform capnography
- Do NOT hyperventilate |
|
|
Term
| After ROSC and optimizing ventilation and oxygenation, what do you do next? |
|
Definition
Treat hypotension (systolic < 90mmHg)
- IV/IO bolus
- Vasopressor infusion
- Consider treatable causes
- 12-lead EKG |
|
|
Term
| After ROSC, optimizing ventilation and oxygenation, and treating hypotension, what do you next for post cardiac arrest care? |
|
Definition
| - see if the patient can follow commands |
|
|
Term
| With post cardiac arrest care, you have optimized ventilation, treated hypotension, and now find that your patient cannot follow commands. What should you do next? |
|
Definition
| consider induced hypothermia |
|
|
Term
| With post cardiac arrest care you have optimized ventilation, treated hypotension, and now find that your patient is able to follow commands. What does this make you suspicious of? |
|
Definition
|
|
Term
| With post-cardiac arrest care, you have optimized ventilation, treated hypotension, found your pt able to follow commands, and found that they had a STEMI or AMI, what do you do next? |
|
Definition
| coronary reperfusion and then advanced critical care |
|
|
Term
| With post cardiac arrest care, you have optimized ventilation, treated hypotension, found your pt responsive to commands, but they did not have STEMI or AMI. What now? |
|
Definition
|
|
Term
| Avoid exessive ventilation with post cardiac arrest care. STart at ___ bresths/minute and titrate to target PETCO2 of __ mmHg. When feasible, titrate ___ to minium necessary to accheiave SPO2 of > or equal to __. |
|
Definition
- 10-12 breaths/minute
- target PETCO2 of 35-40mmHg
- titrate FIO2
- 94% |
|
|
Term
| For the IV bolus to treat hypotension in post cardiac arrest care, how much and what do you give? |
|
Definition
| 1-2 Liters normal saline or lactated ringers. If inducing hypothermia, may use 4 degree C fluid. |
|
|
Term
| formula for converting C to F? |
|
Definition
|
|
Term
| epinephrine dose for post-cardiac arrest care for hypotension management: |
|
Definition
|
|
Term
For cardiac arrest epi is 1 mg every 3-5 minutes
For bradyarrhythmias epi is 2-10 mcg/minute
For post-cardiac arrest care epi is 0.1-0.5mcg/kg/minute |
|
Definition
|
|
Term
| Dopamine post cardiac arrest care of hypotension: |
|
Definition
|
|
Term
| Norepi dosage for post-cardiac arrest hypotension tmt: |
|
Definition
|
|
Term
| vasopressors that may be used for hypotension tmt in post-cardiac arrest care: |
|
Definition
|
|
Term
| Immediate ED general treatment of ACS: |
|
Definition
- If O2 sat less than 94% start oxygen at 4L/minute, titrate
- ASA 160-325 mg(if not given by EMS)
- Nitro sublingual/spray
- Morphine for discomfort |
|
|
Term
| Concurrent ED assessment of ACS (should be done in less than 10 minutes): |
|
Definition
- Vitals
- Oxygen saturation
- Brief history and physical
- Fibrinolytic checklist and check CI
- Cardiac marker levels
- Electrolytes
- Coagulation studies
- Portable xray |
|
|
Term
| Besides checking vitals and oxygen saturation with ACS, what labs should be initally ordered (within 10 minutes of arrival to ED)? |
|
Definition
- Cardiac markers
- Electrolytes
- Coagulation studies
- Portable chest x-ray |
|
|
Term
| Suspected ACS in patient. What EKG findings would make you highly suspcious of injury ST- elevation MI (STEMI)? |
|
Definition
| - ST elevation or new LBBB |
|
|
Term
| Suspect ACS in a patient, what EKG findings would may you highly suspicious of ischemia, high risk unstable angina, non-ST-elevation MI? |
|
Definition
- ST depression
- dynamic T wave inversion |
|
|
Term
| Suspect ACS in a patient. EKG shows normal or non-diagnostic ST segment or T wave changes. What would you call this? |
|
Definition
| - Low/intermediate risk ACS |
|
|
Term
| If a STEMI is found on EKG, what should you do? |
|
Definition
- Start adjunctive therapies as indicated
- Do NOT delay reperfusion
- Determine if time of onset of symptoms is less than or equal to 12 hours |
|
|
Term
| A STEMI if found on EKG. The time of symptom onset is less than or equal to 12 hours ago. What should you do now? |
|
Definition
Reperfusion goals:
- Door to balloon inflation (PCI) goal of 90 minutes
- Door to needle (fibrinolysis) goal of 30 minutes |
|
|
Term
| EKG confirms a STEMI. The onset of symptoms was less than 12 hours ago. Your reperfusion goal from door to balloon inflation (PCI) is ___ ___. Your reperfusion goal from door to needle (fibrinolytics) is __ __. |
|
Definition
|
|
Term
| If EKG confirms UA/NSTEmI what should you do next? |
|
Definition
- check troponin levels
- determine if pt is high risk or not |
|
|
Term
| With UA/NSTEMI, you should consider early invasive strategy if: |
|
Definition
- Refractory ischemic chest discomfort
- Recurrent/persistent ST deviation
- Ventricular tachycardia
- Hemodynamic instability
- Signs of heart failure |
|
|
Term
| If EKG shows a STEMI and symptoms onset was greater than 12 hours ago, what should you do? |
|
Definition
Start adjunctive treatments as indicated
- Nitroglycerin
- Heparin
- Consider po beta blockers
- Consder Clopidogrel
- Consider Glycoprotein IIb/IIIa inhibitor |
|
|
Term
| Possible adjunctive treatments for unstable angina/NSTEMI: |
|
Definition
- Nitroglycerin
- Heparin
- PO Beta blockers
- PO Clopidogrel
- PO Glycoprotein IIb/IIIa inhibitor
NHBCCG |
|
|
Term
|
Definition
Ajunctive tmts as indicated: Nitro, Heparin, Beta blocker po, po clopidogrel, po glycoprotein iib/iiia inhibitors
- Admit to monitored bed
- Assess risk status
- Continue ASA, Heparin and other therapies as indicated: ACE inhibitor/ARB, HMG CoA reductase inhibitor(statin)
If pt not at high risk: cardiology to risk stratify |
|
|
Term
| Management of a pt with suspected ACS but with normal or nondiagonstic EKG changes: |
|
Definition
Admit to ED chest pain unit or appropriate bed and follow:
- Serial cardiac markers, including triponin
- Repeat EKG/continuous ST-segment monitoring
- Consider non-invasive dx tests |
|
|
Term
| You admitted an ACS patient with initial nondiagnostic/normal EKG changes. You ordered serial enzymes and another EKG. They developed one or more of the following: clinical high risk features, dynamic EKG changes consistent with ischemia, and/or elevated triponin. What do you do now? |
|
Definition
- Start adjunctive treatment as indicated: Nitro, Heparin, BB, Clopidogrel, Glycoprotein iib or iia inhibitor
- Admit and monitor, continue ASA and heparin, other therapies as indicated: ACE inhibitor/ARB, HMG Co-A reductase inhibitor (statin) |
|
|
Term
| So if pt with STEMI onset of symptoms was greater than 12 hours ago, or if pts with non-diagnostic EKG changes/normal EKGs develop high risk symptoms, hve EKG changes, or elevated triponin, treat both of these pts like you would treat UA/NSTEMI. |
|
Definition
| consider early invasive strategy |
|
|
Term
| Immediate general assessment and stabilization of stroke pt: |
|
Definition
- Assess ABCs, vital signs
- Oxygen if hypoxemic
- Obtain IV access and perform lab assessments
- Check glucose, treat if indicated
- Perform neuro screening and assessment
- Activate stroke team
- Order emergent CT or MRI
- Obtain 12 lead EKG |
|
|
Term
| NINDS time goals are for the __ algorhythm. |
|
Definition
|
|
Term
| With the NINDS time goals, the immediate general assessment and stabilization of a stroke pt should occur when? |
|
Definition
| within first 10 minutes of ED arrival |
|
|
Term
| According to NINDS time goals, when should stroke team neuro assessment take place? |
|
Definition
| - be done by 25 minutes after ED arrival |
|
|
Term
| According to NINDS time goals, when should a stroke victim have a CT scan done? |
|
Definition
| by 45 minutes after ED arrival |
|
|
Term
| According to NINDS time goals, when should you be reviewing risks/benefits of fibrinolytics for ischemic stroke pt or consulting neuro for hemorrhagic stroke? |
|
Definition
| within 60 minutes after ED arrival |
|
|
Term
| According to NINDS time goals, when should you be administering fibrionlytics to ischemic stroke patient? |
|
Definition
| within 3 hours after arrival to ED |
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|
