Wednesday, August 31, 2011

ACLS review: Pulseless Electrical Activity- part 5

Drug therapy
Epinephrine

Note:  Available evidence suggests that the routine use of atropine during PEA or asystole is unlikely to have a therapeutic benefit. For this reason, atropine has been removed from the Cardiac Arrest Algorithm.

To date no placebo-controlled trials have shown that administration of any vasopressor agent at any stage during management of VF, pulseless VT, PEA, or asystole increases the rate of neurologically intact survival to hospital discharge. There is evidence, however, that the use of vasopressor agents is associated with an increased rate of ROSC.


Drug Therapy: Epinephrine

·         Epinephrine 1mg (1:10,000 solution) IV/IO q3-5min

·         ETT dose 2mg diluted in 10cc of NS

·         Increases systemic vascular resistance (vasoconstriction)

·         Increase coronary and cerebral perfusion pressures during CPR

·         Escalating or high doses without demonstrable benefit

·         After drug delivery and approximately 5 cycles (or about 2 minutes) of CPR then recheck the rhythm 



Vasopressin has been removed from the 2015 AHA Adult Cardiac Arrest Algorithms.

Reviewed 2/28/16

Tuesday, August 30, 2011

ACLS review: Pulseless Electrical Activity- part 4

Peripheral IV Drug Delivery
·         Adults peak drug concentrations are lower and circulation times longer
·         Does not require interruption of CPR
·         Administer the drug by bolus injection and follow with a 20-mL bolus of IV fluid
·         Elevate the extremity for 10 to 20 seconds to facilitate drug delivery to the central circulation.

Endotracheal Drug Delivery
·         Results in lower blood concentrations than the same dose given intravascularly.
·         Give 2 to 2½ times the recommended IV dose.
·         Providers should dilute the recommended dose in 5 to 10 ml of water or normal saline and inject the drug directly into the endotracheal tube

Intraosseous Drug Delivery
·         Enables drug delivery similar to that achieved by peripheral venous access at comparable doses.
·         Is safe and effective for fluid resuscitation, drug delivery, and  blood sampling
·         Is attainable in all age groups.

Central IV Drug Delivery
·         Peak drug concentrations are higher and drug circulation times shorter
·         Central line placement can interrupt CPR.
·         A central line extending into the superior vena cava can be used to monitor SCVO2 and estimate CPP during CPR, both of which are predictive of ROSC


Reviewed 2/28/16

Monday, August 29, 2011

ACLS review: Pulseless Electrical Activity- part 3

Methods of Confirming ET tube Placement
Direct cord visualization
End-tidal CO2 monitor
Yellow- yes, tube is correctly placed
Tan- think about it
Purple- problem with tube placement
Bilateral breath sounds
CXR
Continuous waveform capnography

Note:  Continuous waveform capnography is recommended in addition to clinical assessment as the most reliable method of confirming and monitoring correct placement of an endotracheal tube (Class I, LOE A). Providers should observe a persistent capnographic waveform with ventilation to confirm and monitor endotracheal tube placement in the field, in the transport vehicle, on arrival at the hospital, and after any patient transfer to reduce the risk of unrecognized tube misplacement or displacement

Continuous Waveform Capnography
Persistently low PETCO2 values (<10 mm Hg) during CPR in intubated patients suggest that ROSC is unlikely
If PETCO2 is <10 mm Hg, it is reasonable to consider trying to improve CPR quality by optimizing chest compression parameters

Note:  Although a PETCO2 value of <10 mm Hg in intubated patients indicates that cardiac output is inadequate to achieve ROSC, a specific target PETCO2 value that optimizes the chance of ROSC has not been established. Monitoring PETCO2 trends during CPR has the potential to guide individual optimization of compression depth and rate and to detect fatigue in the provider performing compressions


Reviewed 2/28/16

Sunday, August 28, 2011

ACLS review: Pulseless Electrical Activity- part 2


Primary Survey- Assess CABs

·         Assess responsiveness and pulse

·         Active EMS system

·         Call for defibrillator/monitor


Note:  If a rhythm is present on the monitor but the pulse is absent (eg,PEA), CPR should be started immediately, beginning with chest compressions, and should continue for 2 minutes before the rhythm check is repeated.


Primary Survey- Assess CABs

·         Circulation- give uninterrupted chest compressions for two minutes

·         Airway- Open airway

·         Breathing- give positive pressure ventilation

·         Defibrillator- attach and assess rhythm

·         Look for pulse using doppler


Look for Pulse Using Doppler

·         A doppler will help distinguish between a pulseless state and profoundly weak cardiac contractions with a low cardiac output (pseudo-PEA).

·         True PEA:  no pulse and no perfusion

·         Pseudo-PEA: weak pulse detected doppler or echocardiography and severely compromised perfusion


Secondary Survey

·         Intubate and secure airway device.

·         Oxygenate with 100% O2.

·         IV access



Note: Given the potential association of PEA with hypoxemia, placement of an advanced airway is theoretically more important than during VF/pulseless VT and might be necessary to achieve adequate oxygenation or ventilation.


Reviewed 2/28/16

Saturday, August 27, 2011

ACLS review: Pulseless Electrical Activity- part 1

PEA
Displays a rhythm on the monitor
Lacks a palpable pulse
Patients with PEA have poor outcomes
Need to find underlying cause ASAP
No pulse = no perfusion
PEA
Patients who have PEA will not benefit from defibrillation attempts.
The focus of resuscitation is to perform high-quality CPR with minimal interruptions and 
to identify reversible causes or complicating factors

PEA Rhythms

Bradycardia






Idioventricular rhythm





Tachycardia





Reviewed 2/28/16



Friday, August 26, 2011

ACLS review: asystole part 5

Assess Reversible Causes: 5Hs & 5Ts

·         Hypoxia
·         Hypovolemia
·         Hyper/hypokalemia
·         Hydrogen ions (acidosis)
·         Hypothermia

Assess Reversible Causes: 5Hs & 5Ts

·         Tension pneumothorax
·         Thrombosis: cardiac
·         Thrombosis: lungs
·         Tables/toxins
·         Tamponade, cardiac

Consider Termination of Efforts

The final decision to stop can never rest on a single parameter, such as duration of resuscitative efforts. Rather, clinical judgment and respect for human dignity must enter
into decision making. In the out-of-hospital setting, cessation of resuscitative efforts in adults should follow system specific criteria under direct medical control.



References


Aehlert, Barbara. ACLS Quick Review Study Guide, 2nd edition.  Mosby, inc.  St. Louis, Mo. 1994.

Neumar RW, Otto CW, Link MS, Kronick SL, Shuster M, Callaway CW, Kudenchuk PJ, Ornato JP, McNally B, Silvers SM, Passman RS, White RD, Hess EP, Tang W, Davis D, Sinz E, Morrison LJ. Part 8: adult advanced cardiovascular life support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010;122(suppl 3):S729–S767


Reviewed 2/28/16

Thursday, August 25, 2011

ACLS review: asystole part 4

Drug therapy 
Epinephrine
Note: Available evidence suggests that the routine use of atropine during PEA or asystole is unlikely to have a therapeutic benefit. For this reason, atropine has been removed from the Cardiac Arrest Algorithm.
To date no placebo-controlled trials have shown that administration of any vasopressor agent at any stage during management of VF, pulseless VT, PEA, or asystole increases the rate of neurologically intact survival to hospital discharge. There is evidence, however, that the use of vasopressor agents is associated with an increased rate of ROSC.
Drug Therapy: Epinephrine
· Epinephrine 1mg (1:10,000 solution) IV/IO q3-5min
· ETT dose 2mg diluted in 10cc of NS
· Increases systemic vascular resistance (vasoconstriction)
· Increase coronary and cerebral perfusion pressures during CPR
· Escalating or high doses without demonstrable benefit
· After drug delivery and approximately 5 cycles (or about 2 minutes) of CPR then recheck the rhythm 
Vasopressin is no longer recommended

Reviewed 2/28/16


Wednesday, August 24, 2011

ACLS review: asystole part 3

Peripheral IV Drug Delivery
·         Adults peak drug concentrations are lower and circulation times longer
·         Does not require interruption of CPR
·         Administer the drug by bolus injection and follow with a 20-mL bolus of IV fluid
·         Elevate the extremity for 10 to 20 seconds to facilitate drug delivery to the central circulation.

Endotracheal Drug Delivery
·         Results in lower blood concentrations than the same dose given intravascularly.
·         Give 2 to 2½ times the recommended IV dose.
·         Providers should dilute the recommended dose in 5 to 10 ml of water or normal saline and inject the drug directly into the endotracheal tube

Intraosseous Drug Delivery
·         Enables drug delivery similar to that achieved by peripheral venous access at comparable doses.
·         Is safe and effective for fluid resuscitation, drug delivery, and  blood sampling
·         Is attainable in all age groups.

Central IV Drug Delivery
·         Peak drug concentrations are higher and drug circulation times shorter
·         Central line placement can interrupt CPR.
·         Central line extending into the superior vena cava can be used to monitor ScvO2 and estimate CPP during CPR, both of which are predictive of ROSC


Reviewed 2/28/16

Tuesday, August 23, 2011

ACLS review: asystole part 2

Primary Survey- ABCs
·         Assess responsiveness and breathing
·         Active EMS system
·         Check pulse
·         Perform chest compressions
·         Open Airway
·         Give two slow breaths
·         Attach Defibrillator/monitor

Note:  If the rhythm is asystole or the pulse is absent (eg,PEA), CPR should be resumed immediately, beginning with chest compressions, and should continue for 2 minutes before the rhythm check is repeated.

Confirm Presence of Asystole

·         Confirm asystole in another lead
·         Make sure correct lead is displayed on the monitor
·         Make sure cables are connected to the monitor
·         Check gain on monitor
·         Check for loose leads


Secondary Survey
·         Intubate and secure airway device.
·         Oxygenate with 100% O2.
·         Confirm ET tube placement
           Direct cord visualization
           End-tidal CO2 monitor
           Bilateral breath sounds
           CXR
           Continuous waveform capnography
·       IV access

Note:  Continuous waveform capnography is recommended in addition to clinical assessment as the most reliable method of confirming and monitoring correct placement of an endotracheal tube (Class I, LOE A). Providers should observe a persistent capnographic waveform with ventilation to confirm and monitor endotracheal tube placement in the field, in the transport vehicle, on arrival at the hospital, and after any patient transfer to reduce the risk of unrecognized tube misplacement or displacement.


Reviewed 2/28/16

Monday, August 22, 2011

ACLS review: asystole part 1

Asystole· A-(without) Systole- (contraction)
· No discernible electrical activity, no cardiac output
· Very poor outcomes
· Terminal rhythm of patient whose clinical condition has deteriorated
· Often a confirmation of death rather than a rhythm

Asystolic Rhythms· “Flat line”








P wave asystole- atrial activity without ventricular activity





Agonal or idioventricular rhythms at a rate less than 6 per minute










Reviewed 2/28/16

ACLS review


296. In order to successfully treat a patient in PEA, it is important to look for possible causes.  If a pulseless patient in PEA is found to  have absent breath sounds on the right with a deviated trachea, the rescuer should evaluate the patient for which of the following:
a.            Tension pneumothorax,
b.            Tablets/toxins
c.             Thrombosis pulmonary/Thrombosis     coronary
d.            Tamponade

297. PEA is often caused by reversible conditions and can be treated if those conditions are identified and corrected.
a.            True
b.            False

299.  All of the follow are true regarding Vasopressin when being used to treat PEA and asystole EXCEPT:
a.            It is administered either as first dose before epinephrine
b.            It can be administered as a second dose of epinephrine
c.             If no physiologic effects are noted, it may be repeated in 3-5 minutes
d.            It is a noradrenergic vasoconstrictor

300.  What is the maximum cumulative dose of Lidocaine?
a.            1mg/kg
b.            2mg/kg
c.             3mg/kg
d.            4mg/kg


Reviewed 2/28/16

Friday, August 19, 2011

ACLS review


291.        A 45 year old woman is brought to the hospital for nausea, vomiting, and diarrhea x 4 days.  Her heart rate is 180 and her BP is 84/40. She complains of feeling weak and dizzy.  A saline lock has been inserted and a liter fluid bolus has been ordered.  She has been placed on telemetry.  As you begin to assess her she suddenly vomits and loses consciousness.  What would be the next appropriate step for this patient?
a.   Administer a precordial thump
b.   Shock the patient at 200J
c.   Call respiratory therapy
d.   Assess her responsiveness, respirations, and check a pulse

292.  For this patient, the cardiac monitor reveals a regular, narrow complex tachycardic rhythm.  However, a pulse check reveals that the patient is pulseless.  What would be the next appropriate intervention?
a.  Administer a precordial thump
b.  Cardiovert at 50 J
c.  Begin CPR
d.  Defibrillate at 200 J

293.  Based upon the above information about this patient, you would follow which AHA algorithm in treating this patient:
a.  Unstable tachycardia
b.  Pulseless VF/VT
c.  Unstable bradycardia
d.  PEA

294. In order to confirm pulselessness in a patient with PEA, you should
a.  Confirm pulselessness with a doppler
b.  Check a femoral pulse over 2 minutes
c.  Order a stat echocardiogram
d.  Insert an arterial line and assess the waveform

295.  For the above patient, CPR is in progress.   IV access had been obtained and now the patient has just been intubated.  What would be the next appropriate step?
a.  Suction the patient
b.  Administer Epinephrine 
c.  Confirm ET tube placement
d.  Reassess the rhythm on the monitor

Answers 291 - 295
291.  d
292.  c
293.  d
294.  a
295.  c


Reviewed 2/28/16

Thursday, August 18, 2011

ACLS review


286 Name the drug: Stimulates alpha and beta adrenergic receptors, produces bronchodilation and increases heart rate and force of contractions. 
a.            Epinephrine
b.            Dopamine
c.            Sodium Bicarbonate
d.            Atropine

287. Name the drug: Neutralizes excess buildup of acid caused by severe hypoxic states, helps restore normal pH
a.            Epinephrine
b.            Dopamine
c.            Sodium Bicarbonate
d.            Atropine

288.  When treating a patient for PEA and asystole it is important to look for underlying problems that may have triggered the cardiac event.  The most common problems are called the 6Hs and the 6Ts.  Name the 6 Hs.
A.            _________________
B.            _________________
C.            _________________
D.            _________________
E.            _________________


289.  When treating a patient for PEA and asystole it is important to look for underlying problems that may have triggered the cardiac event.  The most common problems are called the 6Hs and the 6Ts.  Name the 6 Ts.
A.            _________________
B.            _________________
C.            _________________
D.            _________________
E.            _________________

290. Patients who have either asystole or PEA will benefit from defibrillation attempts.
a.            True
b.            False


Answers 286-290
286.  a
287.  c
288.  Hypoxia, Hypovolemia,Hypothermia, Hydrogen ions, Hyperkalemia, Hypokalemia
289.  Toxins, Tension pneumothorax, Thrombosis coronary, Thrombosis pulmonary, Trauma, Tamponade
290.  a


Reviewed 2/28/16

Wednesday, August 17, 2011

ACLS review


281.  When initially assessing the patient for PEA, it is important to do the following:
a.  Give epinephrine 0.5mg IV push
b.  Assess pulselessness with Doppler
c.   Give atropine 0.5mg IV push
d.  Begin early transcutaneous pacing

282. All of the following are beneficial effects of epinephrine EXCEPT:
a. Increases myocardial contraction
b. Increases peripheral vascular vasoconstriction
c. Increases myocardial oxygen consumption
d.  Increases heart rate

283. What is the correct dosing interval for intravenous Epinephrine?
a. 1mg q10 minutes
b. 1mg q3-5 minutes
c.  2mg q10 minutes
d.  2mg q3-5 minutes

284. A patient weighting 100kg is being treated for PEA.  What is the maximum initial dose of epinephrine that can be given?
a.  1.5mg/kg  = 150mg IV/IO
b.  1 mg only
c.  1mg/kg = 100mg IV/IO
d.  0.75mg/kg  = 75mg/kg

285. Name the drug: Exerts direct vagolytic action on the SA and AV nodes and causes increased sinus node automaticity and AV conduction
a.  Epinephrine
b.  Dopamine
c.  Sodium Bicarbonate
d.  Atropine

Answers 281 -285
281.  b
282.  c
283.  b
284.  b
285.  d


Reviewed 2/28/16

Tuesday, August 16, 2011

ACLS review


276. What is the correct dose of Atropine when treating PEA
a.  none, no longer recommended
b.  2mg
c.  1.5mg
d.  0.5mg

277. Sodium Bicarbonate is indicated for all of the following except
a.   Tricyclic antidepressant overdose
b.   Known hyperkalemia
c.   Alkalinize urine in aspirin overdose
d.   Prexisting hypokalemia

278. During asystole, transcutaneous pacing may be used
a.  As a last ditch effort
b.  After giving both epinephrine and atropine
c.  Useful with first few minutes of arrest
d.  It is not recommended for asystole

279. To verify presence of asystole you do would which of the following?
a.  Confirm asystole in another lead
b.  Make sure the correct lead is displayed on the monitor
c.  Make sure all cables are connected to the monitor
d.  All of the above


Answers  276-280
276.  a
277.  d
278.  d
279. d


Reviewed 2/28/16

Monday, August 15, 2011

ACLS review

271. What is the initial dose of atropine in an asystole?
a.  1.0mg/kg
b. .04mg/kg/min
c.  0.5mg
d.  none, no longer recommended

272. What is the initial IV/IO dose of epinephrine for a patient in PEA
a.  1mg/kg of a 1:1000 solution
b.  1mg of a 1:1000 solution
c.  1mg/kg of a 1:10,000 solution
d.  1mg of a 1:10,000 solution

273. When used to treat asystole and PEA, all of the following are true regarding epinephrine except?
a.  Must be given slowly over 2 minutes
b.  May be given every 3-5 minutes
c.  May be given via an endotracheal tube at 2-2.5mg
d.  It may increase the heart rate and BP

274. What is the recommended second dose of epinephrine in treating a patient in pulseless arrest?
a.  1mg
b.  2mg
c.  3mg
d.  4mg

275. Under current AHA guidelines you may defibrillate asystole immediately.
a.  True
b.  False

Answers  271-275
271.  d
272.  d
273.  a
274.  a
275.  b

Sunday, August 14, 2011

ACLS review


266.   Epinephrine may be used in treating all of the following EXCEPT?
a. Asystole
b. Ventricular fibrillation
c. Supraventricular tachycardia
d. Bradycardia pulseless electrical activity

267.  A 62 year old female arrives to the ER complaining of chest pain radiating to her neck and back. Her BP 156/87, Temp 98.0, respirations 20, pulse 115.  The initial management of this patient might include:
a. Oxygen, vagal maneuvers, adenosine 6mg rapid IV push
b. Oxygen, EKG, IV, nitro, aspirin, morphine
c. Oxygen, IV, epinephrine 1mg IV bolus
d. Oxygen, IV, nitro, morphine, defibrillation

268.  What is the recommended maximum dose of adenosine?
a. 0.5 mg
b. 1.5mg/kg
c. 300mg
d. 12mg

269.  All are correct about using an oropharyngeal airway EXCEPT:
a. It is measured from corner of mouth to ear lobe
b. It facilitates oral suctioning of the patient
c. It reduces the risk of aspiration of gastric contents
d. It should be removed when a gag reflex is present

270. What treatment is preferred for unstable bradycardia?
a. Unsynchronized shocks
b. Pacing
c. Immediate defibrillation
d. Cardioversion 50-100 joules

Answers 266-270
266.  c
267.  b
268.  d
269.  c
270.  b


Reviewed 2/28/16

Saturday, August 13, 2011

ACLS review


261.  What is the initial dose of atropine in symptomatic bradycardia?
a. 0.5mg/kg
b. .04mg/kg
c. 0.5mg
d. 1.5mg

262.   A 30 year old male is admitted to the ER complaining of heart palpitations and dizziness.  He is alert and oriented, denies dyspnea or chest pain.  BP 104/54, respirations 20, heart rate 188. The EKG showed a rhythm that is regular with a narrow complex.  Which of the following medications would be considered?
a. Amiodarone
b. Atropine
c. Adenosine
d. Epinephrine

263.  A 72 year old female is in respiratory arrest. You have intubated the patient and note that breath sounds are present on the right but diminished on the left.  What is the most likely the cause?
a. Left main stem intubation
b. Gastric intubation
c. Right main stem intubation
d. Esophageal intubation

264.  A 35 year old female is brought in to the ER by EMS with decreased level of consciousness.  She has no obvious signs of trauma. Her skin is cool and clammy.   She has some crackles in both bases.   BP 88/40, respirations 28 and shallow, heart rate 186.  A 12 lead EKG shows a narrow complex tachycardia that has regular rhythm.  What is the treatment of choice for unstable tachycardia?
a. Defibrillate at 200 J
b. Cardiovert at 50 J
c. Administer Amiodarone 150mg IV over 10 minutes
d. Administer Epinephrine 1 mg IV push

265.  What is the maximum cumulative dose of Lidocaine?
a. 2mg/kg
b. 5mg/kg  
c. 4mg/kg
d. 3mg/kg

Answers 261-265
261.  a
262.  c
263.  c
264.  b
265.  d


Reviewed 2/28/16

Friday, August 12, 2011

ACLS review


256.  When ventilating an intubated patient the rate should be?
a. 10 per minute
b. 12  per minute
c. 24 per minute
d. at least 40 per minute

257. What is the dose of magnesium when given for a ventricular tachycardic rhythm?
a. 40 units
b. 1-2 grams
c. 300mg
d. 1 mg

258. When ventilating an intubated patient the ventilation rate should be?
a. Once every 2 seconds
b. Once every 4 seconds
c. Once every 6 seconds
d. Once every 10 seconds

259. What is the dose of procainamide in ventricular rhythms?
a. 20-50mg/kg/min
b. 17mg/kg
c. 20-30mg/min
d. 1-4mg/min

260.  What is the dose of vasopressin in the ventricular fibrillation algorithm?
a. Vasopressin is no longer recommended
b. 40 Units once
c. 40mg/kg as a second dose to epinephrine
d. 40 Units repeated every 3-5minutes

Correct answers 256-260
256 a
257 b
258 c
259 a
260 a


Reviewed 2/28/16

ACLS review


251.  Which of the following factors are least likely to reduce transthoracic resistance during defibrillation?
a.  Use of a conduction gel or gel pads
b. Administration of epinephrine before the defibrillation attempts
c. Application of firm paddle pressure or use of hands-free defibrillation pads

252. Which one of the following rhythms is seen most commonly in the first few minutes of cardiac arrest?
a. Asystole
b. Idioventricular
c. Ventricular fibrillation
d. Third degree heart block

253. All of the following are correct concerning the use of epinephrine during adult cardiac arrest EXCEPT
a. May be replaced by vasopressin
b. Given every 3-5 minutes
c. Given via an endotracheal tube at 2mg
d. Given at doses of 0.1mg/kg

254. What is the recommended dose of epinephrine 1:10000 IV/IO?
a. 1mg
b. 1mg/kg
c. 0.1mg
d. 0.1mg/kg

255. What is the recommended initial dose of Lidocaine in pulseless VF/VT?
a. 0.5-.75mg/kg
b. 1-2mg/kg
c. 1-1.5mg/kg
d. 3mg/kg

Answers 251-255
251 b
252 c
253 d
254 a
255 c


Reviewed 2/28/16