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Exam 5
ACLS, Shock, Arrhythmia, Stroke
306
Pharmacology
Graduate
03/24/2011

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Term
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Definition
Term
3 primary origins of stroke
Definition
1)Cerebral atherosclerosis
2) Penetrating artery disease (Lacune)
3) Cardiogenic
Term
Describe Strokes of cerebral athersclerotic origins
Definition
Atherosclerotic lesions cause ischemia in the brain
Term
What is the etiology of Lacunar/Penetrating stroke?
Definition
Poorly managed HTN. This occures in the terminal portion of blood vessels burried in the brain, hard to find
Term
Describe how a cardiogenic stroke occures
Definition
Cardiac origin, clot forms in the heart, leaves the ehart and migrates to the brain causing a stroke. This is more common with afib or abnormal/synthetic heart valve
Term
What are the two types of stroke?
Definition
Hemorragic stroke
Ischemic Stroke
Term
What is the difference in a stroke and a TIA?
Definition
Strokes are permanent/residual deficit, TIA is like brain angina
Term
How many hours might a TIA event last?
Definition
24h, anything longer is considered a stroke
Term
What are the symptoms of stroke?
Definition
Aphagia, dysphagia, numbness, visual defects, paralysis
Term
Name 3 non-modifiable risk factors for stroke
Definition
1) Age
2) Gender
3) Race
Term
Name 6 modifiable risk factors for stroke
Definition
1) blood pressure 2) cardiac disease 3) lipids 4) afib 5) alcohol consuption 6) smoking
Term
What are the two primary diagnostic tests done in stroke?
Definition
CT and MRI
Term
What does a CT or MRI look for in stroke and what is it's significance?
Definition
Bleeding, if there's bleeding you need a neurosurgeon, if it's a clot causing the stroke you need drug therapy
Term
What drug would you use for post-stroke HTN long term?
Definition
Labatolol
Term
What might you use post-HEMORHAGIC stroke for HTN?
Definition
Nimodapine for 21 days (short term only)
Term
How would you treat an ischemic stroke?
Definition
TPA/alteplase is 1st choice
Term
What disqualifies someone from TPA/alteplase treatment?
Definition
Ptlts <100,000
High BP (185/110)
Hemorhage/major bleed
Surgery/trauma
Term
What is the dose for TPA/alteplase?
Definition
0.9mg/kg first portion given as bolus the rest over the next hr
Term
What are the treatment options for Cerebrovascular disease?
Definition
Drug- Antiplatelet drugs
Surgery- Carotid endartectomy or stent
Term
Which is better for cerebrovascular disease endarderectomy or stent?
Definition
It don't make no nevermind
Term
What are the three main stroke types that might be able to be prevented by drug therapy?
Definition
HTN, Afib, Cerebrovascular disease
Term
How good is ASA at stroke prevention?
Definition
Prevents stroke 25% of the time. Lower doses (50mg) are better because the same positive outcomes with fewer bleeds
Term
Which should be used in stroke pt antiplatelet or anticoags?
Definition
Antiplatelet, anticoags have to much bleed risk
Term
What is the problematic side effect of Ticlopidine?
Definition
TTP- not common, but fatal.
Term
The CAPPRIE trial reviled what?
Definition
That Clopedigrel is better than ASA but not by much, price may out-weigh benefit
Term
Should ASA and plavix be used together for stroke?
Definition
NO! The MATCH trial showed that this only increases ADE/bleeds
Term
What is the minimum diparydamol dose for antiplatelet effects?
Definition
400mg/day
Term
Why can't regular release diparidamol be givent at doses of 400mg/day?
Definition
Headaches (main SE) are too severe. MUST USE ER dipydridamol
Term
What is the most common side effect of dipyridamol or Aggrenox?
Definition
Headache
Term
What did the profess trial revile?
Definition
Aggrenox and Plavix are similar in action, but aggrenox has more bleeds
Term
What is the best means of secondary stroke prevention?
Definition
ANTIPLATELET therapy. 1A rec. AHA 2010 guidelines.
Term
Would enteric coating help prevent ASA induced GI ulcers?
Definition
NO! It's a systemic prostaglandin effect
Term
What are the major manifestations of CVD (cerebrovascular disease)
Definition
Ischemic stroke, TIA
Term
Which is more prevalent, Ischemic stroke or hemorrhagic stroke?
Definition
Ischemic (88%)
Term
A pt has had a non-cardioembolic stroke and has ACS (or stent) what medication should he be on?
Definition
Clopidogrel 75mg qd PLUS ASA 81mg (Grade 1A ACCP/Chest)
Term
What are the AHA/ASA/ACCP/CHEST guidelines for stroke?
Definition
ASA 50-325mg, clopidogrel 75mg, Aggrenox 200/50 BID is grade 1A
Term
Name 4 types of shock
Definition
1) Hypovolemic
2) Cardiogenic
3) Distributive/vasodilatory
4) Anaphylactic
Term
First line treatment for Hypovolemic shock
Definition
Volume resuscitation
Term
Primary alternative treatments for Hypovolemic shock
Definition
Norepinephrine
Dopamine
Term
First line treatment for Cardiogenic shock
Definition
Dobutamine
Term
Primary alternative treatments for Cardiogenic shock
Definition
Dopamine
Norepinephrine
Term
First line treatment for Distributive/Vasodilatory shock
Definition
Norepinephrine and/or Dopamine
Term
Primary alternatives treatments for Distributive/vasodilatory shock
Definition
Vasopressin, Phenylephrine, epinephrine, dobutamine
Term
First line treatment for anaphylactic shock
Definition
Epinephrine
Term
Primary alternative treatment for Anaphylactic shock
Definition
Norepinephrine
Term
Common causes of hypovolemic shock
Definition
haemorrhage
vomiting
diarrhoea
dehydration
third-space losses during major operations
Term
Common causes of Cardiogenic shock
Definition
blood flow decreased due to an intrinsic heart muscle, or the valves are dysfunctional. often related to acute MI
Term
Common causes of Vasodilatory/Distributive shock
Definition
septic shock
anaphylactic shock
acute adrenal insufficiency
neurogenic shock
Term
Common causes of Anaphylactic shock
Definition
Allergy
Term
What class of drug used in shock must be weaned to avoid worsening hemodynamics?
Definition
All Vasopressors EXCEPT vasopressin!
Term
Excess peripheral vasoconstriction may cause what?
Definition
Ischemia to extremities/poorly perfused areas
Term
Describe the hemodynamic features of hypovolemic or cardiogenic shock
Definition
SBP <90 or >40mmHg decrease from baseline
Term
Describe the metabolic abnormalities seen in hypovolemic or cardiogenic shock
Definition
Oliguria, lacticacidemia
Term
What are the compensatory responses to hypovolemic shock?
Definition
Vasoconstriction, tachycardia, tachypnea and oliguria
Term
What are the signs of hypovolemic shock?
Definition
Decrease urine output, skin tuger, tachycardia, cold, modeling/poor perfusion, BP change
Term
Clinically, what is the most siginicant indicator of hypovolemic shock?
Definition
Light headedness, blood is being shunted else where, there is less blood and therefore less oxygent
Term
What is shock?
Definition
When the body loses it's ability to compensate for volume loss so the body loses it's ability to properly circulate blood
Term
Hypovolemic shock treatment
Definition
1) Rehydrate with NS 20ml/kg
2) Look for offending drugs- Manitol and Lasix
3) Is there profuse bleeding?- admin blood
Term
When do you consider a transfusion?
Definition
Profuse bleeding causing Hg<7 or <10 in recent MI/stroke Pt
Whole Blood is drug of choice for this!
Term
Is there any compensatory response from the kidneys in shock?
Definition
No, they are slow to respond acutely. They respond in days.
Term
What is the treatment for bleeding disorders?
Definition
FFP (composed primarily of clotting factors)
Term
What receptors does Norepinephrine stimulate?
Definition
Alpha 1 and Alpha 2 with some Beta 1
POST SYNAPTIC (in periphery)
MOST POTENT VASOCONSTRICTOR
Term
What drug is the most potent vasoconstrictor?
Definition
Norepinephrine
Term
What is beta 1 agonists effect?
Definition
Chronotrope (HR) and inotrope (contactility) both increase
Term
What is beta 1 agonists effect?
Definition
Chronotrope (HR) and inotrope (contactility) both increase
Term
What does Alpha1 and Alpha2 agonists do?
Definition
Vasoconstriction
Term
What receptors does Dopamine act at?
Definition
Alpha1 and Alpha2 post synaptically
Beta1 stronger than with NE
Term
Epinephrine acts at what receptors?
Definition
Alpha1 and Alpha2 to vasoconstrict
Beta 1 AND beta2 to increase HR and contractility
DON"T USE IN HYPOVOLEMIC SHOCK
Term
What receptors does Phenylephrine work at?
Definition
PURE ALPHA1 and ALPHA2 nooooo beta, good because it won't effect the HR
Term
Where are alpha 1 and 2 recepotrs found and what is the significance?
Definition
The heart, this is why many of the alpha drugs cause arrhythmias
Term
What class of drug is Dobutamine?
Definition
Sympathomimetic
Term
What receptors does Dobutamine work at?
Definition
Beta 1 (inotropic), beta2 is weak and selective Alpha 1. Less likely to induce HTN
Term
Generally speaking what effects does Beta1 agonists have?
Definition
Inotropic effects (increased contractility)
Term
What specific types of shock events is Dobutamine useful in?
Definition
Stun, MI and contusions
Term
What drug is the most potent alpha1/alpha2 stimulator?
Definition
Norepinephrine
Term
List shock drugs (5) from greatest to least beta agonist
Definition
Dobutamine
Epinephrine
Dopamine
Norepinephrine
Phenylephrine
Term
Which shock drug is pure alpha with no beta?
Definition
Phenylephrine
Term
What is the biggest problem with Beta agonists?
Definition
Arrhythmia
Term
What drug is good for refractory shock patients?
Definition
Epinephrine
Term
Generally speaking what side effects do you see with shock-related drugs?
Definition
Arrhythmia (Beta stimulation), Anxiety, Headache, Necrosis (extravasion), SOB/Resp distress, HTN, anginal pain
Term
What shock drugs cause bradycardia?
Definition
Phenylephrine and Norepinephrine
Term
What shock drugs cause tachycardia?
Definition
Epinephrine, Dobutamine, Dopamine
Term
What shock drug is least likely to cause arrhythmia?
Definition
Phenylephrine, it's pure alpha stimulation
Term
What side effects are specific to Phenlyephrine?
Definition
Decreased cardiac output, metabolic acidosis, reduced urine output
Term
What two shock drugs can cause paresthesia?
Definition
Dobutamine and Phenylephrine
Term
What side effects are specific to Dopamine?
Definition
Hypotension, inc glucose, azotemia, polyuria, hair to stand up (piloerection)
Term
What shock drug might cause hypotension?
Definition
Dopamine
Term
Specific reactions to Norepinephrine
Definition
Bradycardia which is shared with Phenylephrine
Term
What side effects are specific to Dobutamine?
Definition
paresthesia, Sr potassium decrease, thrombocytopenia, leg cramps
Term
Side effects specific to Epinephrine
Definition
Cerebral hemorrhage, tremor/weakness, pulmonary edema, diaphoresis and inc intraocular pressure
Term
How are shock drugs dosed?
Definition
To effect via continuouse IV infusion, very short halflife
Term
What effects does Beta 1 and beta 2 have?
Definition
Vasodilation and cardiac (inotropic/chronotropic)
Term
What effect does Alpha1 and Alpha2 have?
Definition
Vasoconstriction (normally arteriole)
Term
What is a Schuanzgans cath?
Definition
Right heart cath used to measure capilary pressure etc
Term
How might you prevent necrosis with vasopressors?
Definition
Central line
Term
What two shock drugs might DECREASE cardiac output
Definition
Phenylephrine, vasopressin
Term
Which drug is more preffered Norepinephrine or Epinephrine?
Definition
Norepi, fewer advers effects
Term
Shock might present with perfusion abnormailities despite adequate fluid resucitation
Definition
Term
What are the three main components of the cardiovascular system?
Definition
Pump- heart
Tubing- vasculature
Fluid- Blood
Term
What is the amount of blood ejected during a single contraction called?
Definition
Stroke Volume
Term
What is preload?
Definition
The amount of blood in the heart before it starts to contract (End Diastolic volume)
Term
What is afterload?
Definition
The force required to overcome resistance to ejection
Term
What is the formula for CO?
Definition
CO = SV x HR
Term
What three systems maintain circulating volume and where are they located?
Definition
1) Baroreceptors- Carotids and aortic arch
2) Sr Osmolality- Brain and kidneys
3) RAAS- Kidneys
Term
Eitiology of shock- One of the three regulatory systems of BP have failed and the other two have lost the ability to compensate
Definition
Term
When does hypotension become shock?
Definition
When evidence of end organ insufficency (confusion, oliguria, lactic acidemia)
Term
What are the two cornerstone components of shock
Definition
1) failure of circulation
2) failure to compensate
Term
Can shock be due to more than one cardiovascular system failure?
Definition
Certainly!
Term
What are the three primary/general compensatory mechanisms?
Definition
1) SV- starlings law
2) HR
3) Vasoconstriction
Term
What can cause hypovolemic shock?
Definition
Hemorrhage, third spacing (severe burn), fluid loss
Term
What can cause cardiogenic shock?
Definition
Pumpfailure (MI, cardiac hypertrophy, BB/CCB, bacterial toxin)
Term
Causes of distributive shock
Definition
Vasodilation, anaphylaxis, neurogenic, septic, drug induced
Term
What type of shock can be drug induced?
Definition
Distributive shock
Term
What type of shock does septicemia cause?
Definition
Distributive shock predomniently and some cardiogenic
Term
What type of shock does anaphylaxis cause?
Definition
Distributive shock and hypovolemic shock
Term
What is generally the problem in Distributive shock?
Definition
Vasodilation
Term
What kind of shock might cardiac arrest create?
Definition
Distributive, hypovolemic and cardiogenic shock! ALL THREE TYPES
Term
What kind of shock might cardiac arrest create?
Definition
Distributive, hypovolemic and cardiogenic shock! ALL THREE TYPES
Term
What are the ABC's of shock?
Definition
Airway, breathing, circulation
Term
What is the rule of thumb for shock fluid resucitation?
Definition
3:1, every 1ml blood lost replace w/ 3ml NS
Term
What vasopressor is the drug of choice for most shock?
Definition
Norepinephrine
Term
What vasopressor isn't recomended for kidney protection in sepsis?
Definition
Dopamine!
Term
What is the drug of choice for anaphylaxis?
Definition
Epinephrine
Term
What affects the dosing of Norepinephrine and how?
Definition
Sepsis and acidosis cause downregulation so you need to have higher doses of Norepinephrine
Term
What drug is first line for Septic shock?
Definition
Dopamine
Term
What decreases the effectiveness of Dopamine?
Definition
Term
Are there any ABSOLUTE contraindications for Epi in lifethreatening situations?
Definition
NO
Term
Which drug is tachycardia more likely assocaited with Norepinephrine, Phenylephrine or Epinephrine
Definition
Epinephrine
Term
What drug for shock is primarily and inotrope?
Definition
Dobutamine
Term
What does synchronized cardioversion require?
Definition
A pulse with which to synchronize
Term
What does the AED "capture" in synchronized cardioversion?
Definition
QRS complex
Term
When do you use desynchronized cardioversion?
Definition
When HR is to fast to capture (Vfib/Vtach)
Term
When does the AED shock a person with desynchronized cardioversion?
Definition
on demand
Term
What is one of the most important things in ACLS?
Definition
GOOD CPR
Term
What do you need to remeber about drug aministration in ACLS?
Definition
10ml NS flush after EVERY drug
Term
What do you do if someone has a pulseless arest?
Definition
Check for shockable rhythm
Term
What rhythms are shockable?
Definition
VF/VT
Term
What are non-shockable rhythms?
Definition
Asystole and pulseless electrical activity (PEA)
Term
What is the first things you do for VT/VF?
Definition
1)give 1 shock
2)resume CPR
Term
With VT/VF after initial shock and 5 cycles of CPR whad do you do?
Definition
Check and make sure they have a shockable rhythm and shock them then admin 1mg IV Epinephrine
Term
After the first two shocks and administration of epinephrine with continouse CPR what do you do?
Definition
1) check for shockable rhythm
2) Shock
3) Amiodarone (300mg IV once + 150mg)
4) Consider Mg (1-2gm IV) for torsades
Term
What do you do if a pulseless arrest is asystole/pea
Definition
1) not a shockable rhythm
2) CPR for 5 cycles
3) Epinephrine 1mg IV q 3-5min
(Vasopressin 40 might replace epi 1st or 2nd dose)
4) Consider atropine 1mg IV q 3-5min 3 doses
Term
What do you do with Asystole/PEA after the first round of CPR and medication?
Definition
Repeate! Same step over and over until you get a shockable rhythm or they are declared dead
Term
What is the drug of choice for cardiac arrest?
Definition
Early Electricity
Term
Possible causes of pulseless cardiac arrest
Definition
Hypoxia, hyperkalemia, hypothermia, durg OD (tricylcis), MI
Term
What is the first thing you would do in Tachycardia WITH a pulse?
Definition
1)ABC's
2) Oxygen
3) Monitor ECG
4) Identify/treat reversible causes
Term
What do you do if symptoms persist in Tachycardia after initial treatment/monitoring?
Definition
Establish if the patient is stable
Term
What are signs of instability in a shock patient?
Definition
Altered mental status, chest pain, hypyotension
Term
What do you do for a Tachy patient that is determined to be stable?
Definition
1) Establish IV access
2) Put on ECG and check QRS (Wide or narow)
Term
What is considered a wide QRS and a Narrow QRS?
Definition
Wide- >0.12s
Narrow- <0.12s
Term
What do you do for a Tachycardic shock patient that proves to be unstable when assesed?
Definition
Immediate SYNCRHONIZED cadioversion
Term
What do you do for a tachy shock patient that has been deemed unstable and has been shocked?
Definition
1) Establish IV access
2) ECG and determine if Narrow or Wide QRS
Term
What do you do in Tachycardic shock for wide QRS?
Definition
Expert consultation
Determine if regular or irregular
Term
What do you do for Tachycardic shock pt with Wide regular QRS?
Definition
1) Amiodarone 150mg IV
2) Synchronized cardioversion
Term
What do you do for a tachycardic shock patient determined to have an irregular and wide QRS?
Definition
1)Amiodarone 150mg IV
2) Mg 1-2gm for torsades
Term
What do you do for a tachycardic shock patient with Narrow QRS and regular ryhthm
Definition
Give adenosine 6mg then 12mg and may repeast 12mg once
Term
What do you do for a tachycardic shock patient with irregular rythm and narrow QRS?
Definition
Probably Afib- rate control w/ Dilt or BB
Term
What do you do if you have a tachycardic shock patient that has a narrow, regular QRS that doesn't convert when treated with adenosine
Definition
Consider Aflutter and try to rate control w/ BB or Dilt
Term
What do you do if you have a tachycardic shock patient with narrow QRS and regular rhythm that converts when given Adenosine?
Definition
Monitor for reentry and use adenosine for reocurance. BB or Dilt for longer acting control
Term
slide 10
Definition
Term
What is the first thing you do for a bradycardic patient?
Definition
1) Airway, breathing, oxygen
2) Monitor ECG and identify rhythm
3) Establish IV access
Term
What do you do for a bradycardic patient after you have done the initial airway treatment and ECG monitoring?
Definition
Asses if they have adequate prefusion
Term
What do you do for a Bradycardic patient after initial Airway and ECG Tx/monitoring and they prove to have adequate perfusion?
Definition
Observe/monitor
Term
What do you do for a bradycardic patient after initial airway/ECG treatment/monitoring and they prove to have poor perfusion?
Definition
1) prep for II or III AV heart block
2) Consider Atropine 0.5mg IV up to 3mg max. If ineffective begine pacing (heart block)
3) Consider Epi or dopamine (2-10ug/kg) while waiting for pacer or if pacing is ineffective
Term
What do you do for a bradycardic patient after initial airway and ECG monitoring if they are poorly perfused and atropine and epi/dopamine fail to pace
Definition
Transvenous pacing (Pace maker)
Term
What method other than IV can you do on a patient that is having a code?
Definition
Endotracheal
Term
What 4 drugs can be given endotreachealy?
Definition
LEAN
L- Lidocain
E- Epinephrine
A- Atropine
N- Narcan (narc OD suspected)
Term
What do you do for Paroxysmal Supraventricular tachycadia (PSVT) and a low EF (<40%)
Definition
No cardioversion
Dig or Amio or Dilt
Term
What do you do in paroxysmal supraventricular tachycardia with a normal EF?
Definition
CCB>bb>dig>DC cardioversion consider procainamide, sotalol, amio
Term
What is the pharmacists role in a code/cardiac arrest?
Definition
Call for help, medication managemnt (order and prep), documentation
Term
What are the symptoms of cardiac arrest
Definition
arm pain, jaw pain, INSTANT DEATH (50%) of the time.
Term
How do you dose endotracheal drugs?
Definition
IV dose x 2
Term
What should you stop while administering endotracheal drugs?
Definition
CPR
Term
When do you anticoagulate in relationship to cardioversion
Definition
Pre AND postcardioversion
Term
What drugs might you use to chemically cardiovert someone?
Definition
Amiodarone, dofetalide, ibutalide, propafenone, flecanide
Term
What drugs might you use for cardioversion in a HF pt?
Definition
Dofetalide, ibutalide, amiodarone
Term
What drugs might you use in a non-HF pt?
Definition
Dofetalide, ibutalide, propafenone, flecanide
Term
Vaughn Williams classification of antiarrhythmics
Definition
I = sodium channel blockers
Ia = moderate
Ib = weak
Ic = strong
II = BB
III = K channel blocker
IV = CCB
Term
What portion of the ECG represents atrial fxn?
Definition
P wave
Term
What does the ECG of Afib lack?
Definition
Pwave
Term
What is the corrected QTc formula?
Definition
QT/ Sqrt(RR) where RR is the length of time it takes for 1 heart beat (Milisec)
Term
What is the relationship between QT and heart rate?
Definition
As HR increase QT shortens. This is solved by the QTc formula using RR
Term
Is all sinus bradycardia abnormal?
Definition
No, often people that exercise frequently have a sinus bradycardia
Term
When do you treat sinus bradycardia?
Definition
when it's symptomatic
Term
What do you do if bradycardia is drug related?
Definition
DC drug and wait 5 halflives to see if it fixes HR, if not it wasn't the offending agent and can be restarted
Term
When might you consider a pacemaker in bradycardia?
Definition
one major area is a person who NEEDS a BB (post MI etc) and has bradycardia
Term
How might you best treat a patient with bradycardia and no identifiable eitiology?
Definition
Atropine (or epi or dopamine)
Term
What might you look for in labs for a pt with bradycardia?
Definition
Thyroid levels (hypothyroidism) and electrolyte abnormalities
Term
How do you detect hypothyroidism and what can it cause?
Definition
TSH- elevated above normal (Norm 0.5-5)
Causes bradycardia
Term
What is another name for sinus bradycardia?
Definition
SSS (Sick sinus syndrome)
Term
What is 1st degree AV nodal blockade?
Definition
asymptomatic, not Tx, just monitor with routein ECG
Term
What is 2nd degree AV nodal blockade?
Definition
Impulses by AV not conducted to ventricle properly. Look for underlyign causes
Term
Where does Mobitz 1/Wenchebach's occure?
Definition
Slightly further down the AV node than 1st degree. Electrical impulses slowed with each beat until it skips a beat. Not very serious
Term
Where does Mobitz II occure?
Definition
same skipped impulse pattern but below the bundle of hiss. Electrical impulses can't reach ventricles. More serious
Term
What are two types of 2nd degree AV block?
Definition
Mobitz I / wenchebachs
Mobitz II
Term
What is 3rd degree heart block?
Definition
Total heartblock, signal doesn't pass from upper chambers to lower so independant paceing centers take control (AV and SA node)
Term
What causes afib?
Definition
Abnormal formation of signal/conduction of signal
Term
Doing what will help Afib?
Definition
Slow down ventricular rate
Term
What are the three types of afib?
Definition
Paroxmismal
Persistent
Permanent
Term
What is paroxmismal afib?
Definition
You go in and out of afib on your own
Term
What is persistent afib?
Definition
Afib can be cardioverted and there's hope of staying in rhythm
Term
What is permanent Afib?
Definition
irreverible afib, failed therapy
Term
What are afib pt at high risk of?
Definition
STROKE, both ischemic (clot) AND hemorrhagic (due to warfarin)
Term
Why is lifelong anticoagulation often needed with afib?
Definition
Once a patient goes into afib they will likely have another episode, anticoag decreases the stroke risk associated with afib episodes
Term
What is goal INR? What is target INR?
Definition
2-3
2.5
Term
What are some benefits of Dabigatran?
Definition
Fewer INR monitoring/needle pokes, once daily, no vit K diet modification
Term
What is the biggest draw back of Dabigatran?
Definition
Cost
Term
Which works better Dabigatran or warfarin?
Definition
They work the same for efficacy and side effects (bleeding)
Term
What state might Afib lead to?
Definition
Heart failure due to uncontroled tachycardia
Term
How do you identify hemodynamic instability?
Definition
Mental status changes, BP <90 (hypotension), shock, ventricular rate of 150, crushing chest pain
Term
What do you do for hemodynamicaly unstable afib?
Definition
Synchronized cardioversion, 100-200-300-360J
Usually doesn't feel good so give anasthesia
Term
Which is more effective in hemodynamically unstable patients, chemical cardioversion or electrical cardioversion?
Definition
Electrical
Term
If possible how should DCC (DC cardioversion) be carried out?
Definition
1) First 12h 2)TEE 3)Heparin 4) Anasthesia 5) Cardiovert 6) warfarin for atleast 4wks
Term
What are the goals of therapy for afib?
Definition
1) Rate control
2)stroke prevention
3)restore normal sinus rhythm
4)Decrease episodes
Term
What does a TEE look for?
Definition
Thrombus
Term
If a TEE reviels a clot what do you do?
Definition
Anticoagulate and re-evaluate in 3 weeks with another TEE
Term
What must be administered
Definition
Term
What are the rate controlers for Afib WITHOUT HF
Definition
BB, CCB pirmarily. Also Dig or Amio
Term
What drugs can be used as rate controlers for Afib WITH HF
Definition
Dig and Amio
Term
What is the goal for rate redxn in Afib pt?
Definition
HR <100 or 20% rdxn from baseline
Term
Can rate controling drugs be added together to help lower HR?
Definition
Absolutely
Term
What drug should be used for long-term rate control?
Definition
What ever they cardioverted on if it's available PO
Term
What is an odd side effect of amio?
Definition
Blueman synd/smurf synd
Term
What are some side effects of amio?
Definition
(thyroid effecs due to iodide component), blueman/smurf synd, corneal microposits/ophthalmic monitoring, pulmonary fibrosis, A LOT of monitoring is needed. HIGH DOSES LONG TIME. Monitor liver. Photosysativity.
Term
What are usual side effects of Dig/dig toxicity?
Definition
Nausa, vomiting, seeing green/yellow halos around light, Does NOT rate control active persons
Term
Why might you use amiodarone over dig?
Definition
Because it will rate control in active people
Term
What is important to know about dronederone?
Definition
1) related to amio
2) less side effects than amio (no iodo grp)
3) Doesn't cardiovert, merely maintains
4) EXACERBATES HF
Term
What drugs might you use to cardiovert a patient with heart failure?
Definition
Dofetalide
Ibutalide
Amiodarone
Term
What drugs might be used to cardiovert a pt w/o HF?
Definition
Dofetalide
Ibutalide
Propafenon
Flecanide
Term
What chemical cardioversion drugs are also available PO?
Definition
Flecanide, Propafenone, Amiodarone
Term
What is an important monitoring parameter of Dofetalide?
Definition
Renal fxn and CrCl, must be dosed acordingly
Term
What is more important rate control or rhythm control?
Definition
Mortality: they are equal
morbidity/hospitalization/SE: Rate control
Term
What does CHADS stand for?
Definition
C= CHF
H= HTN
A= Age
D= Diabetes
S= Stroke
Term
What is the CHADS treatment protocol?
Definition
0 = ASA 325
1 = ASA 325 OR Warfarin
2 = Warfarin
Term
What is the halflife of Amio?
Definition
50-60days
Term
How often might you check the INR in a warfarin pt started on Amio?
Definition
weekly for 3 months
Term
Is INR monitoring a problem with dronedarone like it is with amiodarone?
Definition
No
Term
What are some other names for Ventricular premature depolarization (VPD)? (Vtach)
Definition
PVC, VPB, VPC
(VTach)
Term
What is a VPD?
Definition
electrical impulse orginating in ventricular tissue with wide QRS
Term
Who has gerater risk for VPD?
Definition
Men, CAD, LVF, HD/HF
Term
What is the biggest risk of VPD?
Definition
It's biggest symptom is often sudden death
Term
How do you treat an asymptomatic Vtach patient?
Definition
You don't treat it! ESPECIALLY don't use incanide or flecanide they cause more deaths
Term
What does treating asymptomatic Vtach patients improve?
Definition
Mortality rate!
Term
What might symptomatic Vtach pt benefit from?
Definition
BB, most of these pt have CAD and BB are beneficial for that aswell
Term
Define sustained VTach
Definition
Lasts longer than 30s
Requires intervtion to terminate
Term
Define Non-sustained Vtach
Definition
Lasts less than 30s
Terminates spontaniously
Term
What causes VT/VF?
Definition
CAD, MI, HF, electrolyte abnormalities (ESP Mg or K), anti-arrhythmics
Term
How might you treat VT with ischemia unrelated to MI?
Definition
Procainamide
Term
What are two ways to cardiovert Vfib?
Definition
1) DCC 100-200-360J (start at 200 for PEA)
2) Procainamide (drug of choice)
Term
What is important to remeber about chemical cardioversion?
Definition
Pt must be hemodynamically stable to do chemical cardioversion
Term
What might you use in a pt w/ VF and ischemia due to MI?
Definition
Lidocain, procainamide or Amio
Term
When should you start to worry about your QT?
Definition
500ms
Term
What is a normal QT interval?
Definition
<440
Term
What is a supra therapeutic level of dig?
Definition
>2.2
Term
What does Afib lack on an ECG?
Definition
Has no P wave
Term
Can an AICD (implatable cardioverter) be used in conjunction with drugs?
Definition
Yes
Term
What is most effective in reducing cardiac death in VF?
Definition
AICD
Term
What does uncontrolled Vtach normally do?
Definition
Turn into Vfib
Term
Is VFib a sustainable rhythm?
Definition
Nope, means you'll die if nothing happens soon
Term
Vfib cardioversion for hermodynamically unstable patietns
Definition
200J then 360J then give Epinephrine or vasopressin if no respsone and Defibrilate again
Term
What is the role of drug therapy in hemodynamically unstable VF
Definition
augmentation of electrical cadrioversion
Term
What is motion artifact?
Definition
When a person wearing ECG monitor partakes in activity that might make ECG appear to show VFib such as brushing the teeth.
Term
What is the VT amio dosing?
Definition
150mg/10min then 1mg/min for 6h
Term
What is the VF dosing for amio?
Definition
300mg IV then 150mg IV
Term
Does VT and VF amio dosing differ?
Definition
YES
VT- 150mg/10min 1mg/min for 6h
VF- 300mg then 150mg
Term
What might you do if you have shocked the Pt and administered epi and shocked again with no results?
Definition
Try Amio or lido
Term
Is torsades life threatening?
Definition
Yes
Term
Torsades is related to Vtach, Vtach is the precursor to Vfib and Vfib is unsustainable = death
Definition
Term
What are some risk factors for Torsades?
Definition
Age (>65), QT >500 or Inc by 60ms, female, HF, hypokalemia, hypomagnesimia, bradycardia, elevetaed concentration of QT prolonging drugs or rapid infusion
Term
Where might you go to access good information on torsades?
Definition
torsades.org hosted online by the university of arizona
Term
What two drugs have an important reaction for torsades?
Definition
Terfinidine and fexofenodine had addative effects and caused alot of torsades
Term
What is the drug of choice for hemodynamically stable Torsades?
Definition
Magnessium 1-2gm in D5w up to 12gm
Term
Do you use Mg to treat torsades after Mg levels have been corrected?
Definition
Yes
Term
What do you do to treat hemodynamically unstable Torsades?
Definition
DCC
Term
What are second and third line for cardioversion in hemodynamically stable torsades?
Definition
Isoperterinol, lidocain, phenotoin
Term
How do you determine if a pt has HF?
Definition
LVEF < 40%
Term
What are the most common shock heart rhythms/beats
Definition
Unstable VT/VF
Asystole
Afib/Aflutter
Bradycardia
Narrow-complex SVT
Tachycardia
PSVT
Stable VT
PEA
Term
What do you do for PEA?
Definition
1) Fluid challenge
2) DEAD: Double check rhythm
3) Epinephrine 1mg IV q 3-5min
2) Atropine if bradycardic 1mg q 3-5min
3) Determine underlying cause
Term
what are some underying causes of PEA?
Definition
Hypovolemia, tamponade (fluid in paricardium), tension pnemothorax, PE, hypoxia, hypothermia, acidosis, MI, hyPERkalemia, drug overdose
Term
Stable VT treatment
Definition
1) cardioversion
2) procainabimide (drug of choice), sotalol (both 2a) or amiodarone, lidocaine (both 2b)
Term
What do you do for PSVT with normal EF?
Definition
1) CCB>BB>dig>DCC
2) consider procainamide, sotalol or amio
3) proceed to cardioversion if unstable
Term
PSVT treatment w/ HF
Definition
1) no DCC, use dig, amio or dilt
2) If unstable proceed to cardioversion
Term
What is MAT in reference to PSVT?
Definition
Multi-focal Atrial Tachycardia
Term
How do you treat MAT PSVT?
Definition
Normal EF= CCB, BB, amio
EF<40 = amio and dilt
NO DCC
Term
How do you treat junctional PSVT?
Definition
EF normal = amio, bb, ccb
EF <40% = amio
Term
What is junctional PSVT?
Definition
atrial nodal reentry trachycardia
Term
What treatment might you use to treat narrow-complex SVT
Definition
1) Vagal stimulation (cough)
2) Adenosine
3) Dilt
4) Metoprolol
Term
What is the dosing for Adenosine in SVT?
Definition
Adenosine 6mg-12mg-12mg
Term
Tachycardia treatment
Definition
HR <150 do nothing
HR >150 Immediate DCC, medicate if possible
Term
What is the drug of choice in VT w/o pulse and VF
Definition
Early electricity
Term
What are the 4 non-perfusing rhythms? (you'll use CPR for them)
Definition
PEA, VT w/o pulse, VF, Asystole
Term
What if you have an asystole Pt and it's possible they are in a fine VFib?
Definition
Move the leads and check the heart from another angle, important because shocking VFib is good, shocking asystole is useless
Term
What do you do for asystole?
Definition
1) double check not Vfib
2) give epi
3) do CPR
Term
Asystole is DEAD
Definition
D- double check
E- Epinephrine
A- Atropine
D- do it again
Term
Is Vfib w/o pulse shockable?
Definition
Yest
Term
What do you use desynchronized cardioversion for?
Definition
Vfib
Term
What do you do for Vfib?
Definition
Shock, Epi, CPR, Recheck pulse, Shock, Amio, Epi
Term
What are comon causes of Vfib?
Definition
Electrolytes and heart attack
Term
Is VTach w/o pulse shockable?
Definition
Yes
Term
Is VTach w/ a pulse shockable?
Definition
Yes- use SYNCHRONIZED cardioversion
Term
What type of DCC is used for Vtach w/o pulse?
Definition
Desynchronized
Term
What drugs can be used in VF?
Definition
Epinephrine, vasopressin, amiodarone, lidocain, magnesium, hypothermia?
Term
What drugs can be used in PVT?
Definition
Epinephrine, vasopressin, amiodarone, lidocaine, Mg
Term
What drugs do you use for PEA?
Definition
Epinephrine, atropine
Term
What drugs might you use for asystole?
Definition
Epinephrine, vasopressin, Atropine
Term
what drug might you give when PE is suspected?
Definition
Fibrinolytics
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