ACLS Review Questions

A 55 year old male arrives to the ER with complaints of weakness, nausea, and difficulty breathing that began an hour ago.  His skin appears pale, cool and clammy.   Although he is alert, he is mildly confused and appears anxious and has difficulty concentrating.   He is taken immediately to the triage area where his vital signs are obtained:  97.6-200-24.  BP 88/54.   SPO2 92%.   A 12 lead EKG is obtained and the following rhythm is noted.

1.  Identify the above rhythm

a.   Sinus tachycardia

b.   Wandering atrial pacemaker with RVR

c.   Supraventricular tachycardia

d.  Atrial tachycardia

 2.  Based upon the patient’s symptoms what is the recommended treatment for this patient?

a.  Immediate defibrillation at 200 J

b.  Adenosine 6mg IV given rapid push

c.  Diltiazim 0.35mg/kg IV push over 5 minutes

d.  Synchronized cardioversion

 3.  Oxygen at 2L/min is placed on the patient and an IV is quickly established and the patient is placed on the monitor/defibrillator.   As this is occurring, the doctor asks the patient to take 3 forceful coughs.  What is the doctor’s rationale for asking the patient to cough?

a.  The doctor is ensuring that the patient’s airway is patient prior to the administration of conscious sedation

b.  The doctor knows that forceful coughing may depress conduction through the AV node and may terminate the rhythm

c.  The doctor is aware that Selleck’s maneuvers may help clarify the underlying rhythms and terminate the reentry tachycardia

d.  The doctor is assessing the patient’s ability to follow directions

4.   Give four examples of vagal maneuvers

a.

b.

c.

d.

When the defibrillator monitor is placed in the “synch” mode the following rhythm is observed.

5.  What is your assessment of the rhythm?

a.  The monitor had failed to capture and the mAs should be increased

b.  The monitor has correctly synchronized with the R waves of the rhythm

c.  The monitor is ready for immediate defibrillation

d.  The monitor has failed to sense the patient’s underlying rhythm

6.  Synchronized cardioversion may be used on all of the following rhythms EXCEPT:

a.  Atrial flutter

b.  Monomorphic ventricular tachycardia

c.  Mutltifocal atrial tachycardia

d.  New onset atrial fibrillation with rapid ventricular response

After administering the patient an analgesic and appropriate conscious sedation, the patient is then cardioverted at 50 J.   Afterwards the following rhythm is observed.

7.  What is the next appropriate step?

a.  Deliver an unsynchronized shock at 200 Joules for refractory SVT

b.  Place the monitor back in the synch mode and deliver another synchronized shock

c.  Administer adensosine 6mg rapid IV push

d.  Have the patient perform vagal maneuvers

8.  What are four differences between cardioversion and defibrillation?

a.

b.

c.

d.

After placing the monitor/defibrillator in the synch mode, the joule setting on the above patient in increased to 100 joules and a synchronized shock is delivered.   Afterwards, the following rhythm is observed.

9.  What is the next appropriate intervention for this patient?

a.  Discharge the patient home

b.  Continue to monitor the patient’s vital signs and for refractory SVT

c.  Administer Amiodarone 300mg IV push for recurrent SVT

d.  Remind the doctor to write the patient a prescription for oral adenosine to be used on a prn basis

10.  Match the following medications with their correct corresponding dosages.

a. 1st dose of Diltiazem                                  5mg

b. 2^nd dose of Adenosine                              0.25mg/kg

c. 1^st dose of Verapamil                                12mg

d. 1^st dose of Metoprolol                              2.5-5mg

Answers

1.   c.  Supraventricular tachycardia.
The rhythm has the appearance of WPW with delta waves forming the base of the QRS complex.   A 12 lead EKG would be indicated to differentiate the rhythm.  

2.   d.  Synchronized cardioversion.
When the patient is unstable, think electrical interventions first.  In reality, the MD may try some adenosine as the patient is being prepared for cardioversion.

3.   b.  The doctor knows that forceful coughing will depress conduction through the AV node and may terminate the rhythm

4.   Valsalva maneuver, coughing, ice water application to the face, blowing through a straw, carotid sinus massage

5.   b.  The monitor has correctly synchronized with the R waves of the rhythm

6.   c.  Mutltifocal atrial tachycardia

7.   b.  Place the monitor back in the synch mode and deliver another synchronized shock.
As soon as the refractory rhythm is recognized then increase the joule setting, re-synch the defibrillator, and deliver another shock.  

8.   Cardioversion synchronizes with the patient’s heart rhythm; defibrillation is given anytime during the cardiac cycle.   Cardioversion begins at a lower joule setting; defibrillation uses higher energy settings.   Cardioversion is used on profusing rhythms; defibrillation is primary used on non-profusing rhythms (exception is polymorphic VT with a pulse).  Cardioversion is used on patients who are alive.   Defibrillation is used on all others. LOL

9.   b.  Continue to monitor the patient’s vital signs and for refractory SVT.

10.

a. 1st dose of Diltiazem                         0.25mg/kg

b. 2^nd dose of Adenosine                     12mg

c. 1^st dose of Verapamil                               2.5-5mg
d. 1^st dose of Metoprolol                     5mg

Reviewed 3/2/16