Saturday, June 30, 2012

Megacode Pulseless VF/VT Part 2


Continuing with the above scenario.  




6/25/12 11:26.  CPR is in progress and ventilations remain adequate with good chest rise so intubation is deferred at this time. 

11. What is the first vasoconstrictor that is administered during a pulseless arrest?

12. After the initial defibrillation, what are the subsequent joule settings in the treatment of pulseless VT/VF?
a. Monophasic
b. Biphasic

13. Name three advantage of using an oropharyngeal airway (OPA) on an unconscious victim in cardiac arrest?
a.
b.
c.
14. What are some precautions that should be observed before applying the defibrillator pads to the patient?
a.
b.
c.
d.
e.
15. During the treatment of pulseless VF/VT, how often can epinephrine be repeated?

6/25/12 11:28. Epinephrine has been given followed by a rhythm check. The patient remains in this refractory rhythm. A second defibrillation is given at 300J is given without a change in the rhythm. CPR is resumed. Ventilations remain adequate. The saline bolus is in progress.





16. What are some conditions that may predispose a patient to torsades de pointes?
a.
b.
c.
d.

17. What are the ECG characteristics of Torsades de pointes?
a.
b.
c.
d.
e.
f.
18. During CPR what is the difference in ventilation technique between an intubated patient and a non-intubated patient?


19. Name 5 medications that may be used in the treatment of pulseless VT?
a.
b.
c.
d.
e.

20. Name 4 facts related to the administration of Vasopressin
a.
b.
c.
d.

Answers to Questions


11. What is the first vasoconstrictor that is administered during a pulseless arrest?
Epinephrine 1mg IV push or Vasopressin 40 units IV push

12. After the initial defibrillation, what are the subsequent joule settings in the treatment of pulseless VT/VF?
a. 200 J or higher for biphasic defibrillators
b. 360 J for monophasic defibrillators

13. Name three advantage of using an oropharyngeal airway (OPA) on an unconscious victim in cardiac arrest?
a. The OPA holds the tongue in place and prevents it from occluding the airway
b.It may serve as a bite block in an intubated patient
c. It permits easy suctioning of the oropharynx.

14. What are some precautions that should be observed before applying the defibrillator pads to the patient?
a. Make sure the skin surface is dry
b. Avoid pacemakers and other devices
c. Avoid letting the pads touch
d. Remove medication patches
e. Remove excess chest hair if the pads do not adhere to the chest wall

15. During the treatment of pulseless VF/VT, how often can epinephrine be repeated?
Epinephrine 1mg IV every 3-5 minutes

16. What are some conditions that may predispose a patient to torsades de pointes?
a. Long QT syndrome
b. Hypomagnesaemia
c. Antiarrhythmic drug toxicity
d. Other drug toxicities: phenothiazines, tricyclic antidepressants, calcium channel blockers

17. During CPR what is the difference in ventilation technique between an intubated patient and a non-intubated patient?
With an intubated patient the rescuer gives continuous chest compressions without pauses for breaths while the person performing ventilations provides 8-10 breaths/minute.

18. What are the ECG characteristics of Torsades de pointes?
a. There are no P waves
b. There is no PR interval
c. The QRS complex appears wide, bizarre and changes from beat to beat
d. The amplitude of the QRS complex begins smaller and gets larger then begins to get smaller again.
e. The rate is usually over 150
f. The rhythm is irregular

19. Name 5 medications that may be used in the treatment of pulseless VT?
a. Epinephrine
b. Vasopressin
c. Amiodarone
d. Lidocaine
e. Magnesium

20. Name 4 facts related to the administration of Vasopressin
a. May give Vasopressin first or in place of 2nd dose of epinephrine
b. One time dose of 40 units only
c. May be given down the endotracheal tube
d. DO NOT double the dose for ET tube administration






Friday, June 29, 2012

Megacode Pulseless VF/VT Part 1


06/25/12 11:15  A 70 year old man was brought to the emergency room by his concerned neighbors who stopped by to check on him.   He is lethargic and appears malnourished and dehydrated with sunken eyes, temporomandibular wasting, and a generally thin frail appearance.  His only know medical problem is hypertension.  His neighbors have noted that he has become more reclusive since the death of his wife 8 months ago.

06/25/12 11:21  As he is being examined he loses consciousness and his breathing becomes agonal in nature.   A code blue is announced and CPR is initiated.   He is placed on the defibrillator monitor and the following rhythm is observed:







1.  Identify the following rhythm.
a.    Monmorphic VT
b.    Wide complex tachycardia
c.    Polymorphic VT
d.    Torsades de pointe

2.  What is the initial treatment of choice for this patient?
a.    CPR and early Intubation
b.    Defibrillation at 200 J (biphasic)
c.    Cardioversion at 120-200 J
d.    Epinephrine 1mg IV

3.  What are some differences between defibrillation and cardioversion?
a.    
b.   
c.    
d.    
e.    

4.  What is the correct joule setting when using a monophasic defibrillator on the above rhythm?
a.    120 J
b.    360 J
c.    300 J
d.    200 J

5.   Name 4 rhythms that can be defibrillated
a.    
b.    
c.    
d.    

Continuing with the previous scenario.  
6/25/12 11:22  CPR is in progress.  Ventilations are adequate with good chest rise.   Coworkers are attempting to establish IV access.   


6/25/12 11:23 Hands- free defibrillators pads are placed on the patient.
EKG waveform caused by cardiac compression during CPR












6/25/12 11:24.  There is no rhythm change after the initial defibrillation.   The patient remains pulseless and apneic and CPR is resumed.  An IV is established and a fluid bolus of normal saline is being infused.  Blood specimens are obtained for CBC, chemistries including Mg and Phos, PT, PTT, as well as cardiac enzymes. 

6.  What is the correct depth of compression on an adult?
a.  1-1 ½ inches
b. 1 ½- 2 inches
c. 2-3 inches
d.  2 - 2.4 inches

7..  According to the AHA was is the criteria for high quality CPR?
a.    
b.   
c.  
d.    
e.    

8.   What is the rate of compressions when performing CPR on an adult victim of cardiac arrest?
a.  80 - 100/min
b.  70 -90/min
c   60 -80/min
d.  100 -120/min

9.  The sequence for performing CPR is CAB.  What does CAB stand for?


10.  What is the ratio of compressions to ventilations when performing CPR on an adult in cardiac arrest?
a.    30:2
b.    15:2
c.    30:1
d.    15:1






Answers to questions
1.  Identify the following rhythm.
d. Torsades de pointe

2.  What is the initial treatment of choice for this patient?
b. Defibrillation at 200 J (biphasic)

3.  What are four differences between defibrillation and cardioversion?
a. Cardioversion delivers electrical current to the heart during a specific time during the cardiac cycle
b. Cardioversion can be used on a variety of rhythms including SVT, A fib, Aflutter, Stable VT, and wide complex tachycardia
c. Defibrillation does not need to be synchronized with the ECG
d. Defibrillation uses higher energy levels
e. Defibrillation is used in the treatment of pulseless VT/VF

4.  What is the correct joule setting when using a monophasic defibrillator on the above rhythm?
b. 360 J

5.   Name 4 rhythms that can be defibrillated
a. Pulseless VF
b. Pulseless VT
c.  Torsades de pointe
d. Unstable polymorphic VT

6.  What is the correct depth of compression on an adult?
d.  2 - 2.4 inches

7..  According to the AHA was is the criteria for high quality CPR?
a.  Providing chest compressions of adequate rate (at least 100/minute)
b.  Providing a compression depth of at least 2 inches (5 cm)
c.  Allowing complete chest recoil after each compression
d.  Minimizing interruptions in compressions
e. Avoiding excessive ventilation

8.   What is the rate of compressions when performing CPR on an adult victim of cardiac arrest?
a.  100 - 120/min

9.  The sequence for performing CPR is CAB.  What does CAB stand for
C- Check responsiveness and breathing.  Check for a carotid pulse.  Compressions
A-Open airway and using head-tilt chin lift or jaw thrust maneuver
B-Give two rescue breaths observing for chest rise and fall then resume compressions

10.  What is the ratio of compressions to ventilations when performing CPR on an adult in cardiac arrest?
c. 30:2


Reviewed 3/2/16

Thursday, June 28, 2012

EKG Rhythm Strip Quiz 30

Identify the  following EKG rhythm strips.

1.

a.       1st degree heart block
b.      2nd degree heart block type I
c.       2nd degree heart block type II
d.    3rd degree heart block
2.
a.       Atrial paced
b.      AV paced
c.       Biventricular paced
d.      Ventricular paced

3.







a.       Sinus rhythm with multifocal PJCs
b.      Sinus arrhythmia with PVCs
c.       Sinus tachycardia with unifocal PVCs
d.      Sinus tachycardia


4.
a.       Normal sinus rhythm
b.      Accelerated junctional rhythm
c.       Atrial flutter with variable rate
d.      2nd degree AV block type II

5.
a.       Sinus arrhythmia
b.      Accelerated Junctional rhythm
c.       Atrial fibrillation
d.      Multifocal atrial tachycardia

6.
a.       Sinus rhythm with PJCs
b.      Sinus arrhythmia with PACs
c.       Sinus rhythm with sinus arrest
d.      Sinus node exit block

7.
a.       Sinus bradycardia with T wave inversion
b.      Sinus rhythm with peaked T waves
c.       Sinus bradycardia with ST elevation
d.      Sinus rhythm with inverted T waves

8.
a.       Sinus rhythm with multifocal PVCs
b.      Wandering atrial pacemaker with ventricular paced beats
c.       Sinus arrest with multifocal PVCs
d.      Atrial fibrillation with multifocal PVCs

9.
a.       Sinus bradycardia
b.      Junctional rhythm
c.       Sinus bradycardia with PJCs
d.      Normal sinus rhythm

10.

a.       Monomorphic ventricular tachycardia
b.      Torsades de pointe
c.       Surpaventricular tachycardia
d.      Junctional  tachycardia


Answers
1.    b.      2nd degree heart block type I
2.    b.      AV paced
3.    c.       Sinus tachycardia with unifocal PVCs
4.    c.       Atrial flutter with variable rate
5.    d.      Multifocal atrial tachycardia
6.    a.       Sinus rhythm with PJCs
7.    d.      Sinus rhythm with inverted T waves
8.    a.       Sinus rhythm with multifocal PVCs
9.    d.      Normal sinus rhythm
10.  a.       Monomorphic ventricular tachycardia


Reviewed 6/4/13, 3/2/16


Wednesday, June 27, 2012

EKG Rhythm Strip Quiz 29

Identify the following EKG rhythm strips.

1.







a.       Normal sinus rhythm
b.      Accelerated junctional rhythm
c.       Atrial fibrillation with controlled rate
d.      2nd degree AV block type II

2.






a.       Atrial paced
b.      AV paced
c.       Failure to sense
d.      Failure to capture

3.






a.       Sinus bradycardia with sinus arrhythmia
b.      Atrial fibrillation with slow ventricular response
c.       Junctional rhythm
d.      Wandering atrial pacemaker

4.
   
a.       2nd degree AV block type II with unifocal PVCs
b.      Atrial flutter with variable rate and unifocal PVCs
c.       Atrial fibrillation with multiform PACs
d.      Atrial flutter with ventricular paced beats

5.






a.       Normal sinus rhythm
b.      Accelerated junctional rhythm
c.       Atrial fibrillation with controlled rate
d.      2nd degree AV block type II

6.




a.       Sinus arrhythmia with T wave inversion
b.       Sinus rhythm with peaked T waves and PVCs
c.       Sinus bradycardia with ST elevation and PJCs
d.       Sinus rhythm with inverted T waves and PACS


7.
   
a.       Sinus rhythm with unifocal PVCs
b.      Sinus rhythm with multiform PVCs
c.       Sinus bradycardia with uniform PVCs
d.      Sinus arrhythmia with multifocal PVCs

8.
   
a.       1st degree heart block
b.      2nd degree heart block type I
c.       2nd degree heart block type II
d.      3rd degree heart block 

9.
a.       Multifocoal ventricular tachycardia
b.      Accelerated idioventricular rhythm
c.       Monmorphic ventricular tachycardia
d.      Junctional tachycardia

10.






a.       Sinus arrhythmia
b.      Atrial fibrillation
c.       Accelerated Junctional rhythm
d.      Multifocal atrial tachycardia


Answers


1.     b.      Accelerated junctional rhythm
2.     b.      AV paced
3.     b.      Atrial fibrillation with slow ventricular response
4.     b.      Atrial flutter with variable rate and unifocal PVCs
5.     a.       Normal sinus rhythm
6.     d.       Sinus rhythm with inverted T waves and PACS
7.     b.      Sinus rhythm with multiform PVCs
8.     d.      3rd degree heart block 
9.     c.       Monmorphic ventricular tachycardia
10.   d.      Multifocal atrial tachycardia


Reviewed 6/4/13, 3/2/16

Tuesday, June 26, 2012

EKG Rhythm Strip Quiz 28

Identify the following EKG rhythm strips.

1.







a.       Coarse ventricular fibrillation
b.      Torsades de pointe
c.       Atrial fibrillation
d.      Artifact

2.







a.       NSR with PACs
b.      NSR with PJCs
c.       NSR with PVCs
d.      Sinus arrhythmia

3.








a.       NSR with trigeminal PVCs
b.      NSR with bigeminal PVCs
c.       NSR with  trigeminal PACs
d.      NSR with bigeminal PACs

4.







a.       NSR with trigeminal PVCs
b.      NSR with bigeminal PVCs
c.       NSR with  trigeminal PACs
d.      NSR with bigeminal PACs

5.
a.       NSR with trigeminal PVCs
b.      NSR with bigeminal PVCs
c.       NSR with  trigeminal PACs
d.      NSR with bigeminal PACs


6.










a.       1st degree heart block
b.      2nd degree heart block type I
c.       2nd degree heart block type II
d.      3rd degree heart block 

7.







a.       Monomorphic ventricular tachycardia
b.      Atrial fibrillation with wide QRS complexes
c.       Accelerated idioventricular rhythm
d.      Multifocal atrial tachycardia with wide QRS complexes

8.








a.       Multifocal Atrial tachycardia with an occasional PVC
b.      Junctional tachycardia with an occasional PVC
c.       Supraventricular tachycardia with an occasional PVC
d.      Ventricular tachycardia with an occasional PVC

9.







a.       Sinus tachycardia
b.      Atrial fibrillation with RVR
c.       Junctional tachycardia
d.      Ventricular tachycardia

10.
a.       Sinus tachycardia
b.      Atrial fibrillation with RVR
c.       Junctional tachycardia
d.      Ventricular tachycardia




Answers
1.   d.      Artifact
2.   a.       NSR with PACs
3.   b.      NSR with bigeminal PVCs
4.   a.       NSR with trigeminal PVCs
5.   c.       NSR with  trigeminal PACs
6.   b.      2nd degree heart block type I
7.   b.      Atrial fibrillation with wide QRS complexes
8.   a.       Multifocal Atrial tachycardia with an occasional PVC
9.   a.       Sinus tachycardia
10. d.      Ventricular tachycardia


Reviewed 3/2/16

Monday, June 25, 2012

EKG Rhythm Strip Quiz 27

Identify the following EKG rhythms strips.

1.







a.       Atrial paced
b.      AV paced
c.       Biventricular paced
d.      Ventricular paced

 2.







a.       Sinus arrhythmia
b.      Atrial flutter
c.       Junctional rhythm
d.      Idioventricular rhythm


3.







a.      Sinus arrhythmia with T wave inversion
b.      Sinus rhythm with peaked T waves
c.       Sinus bradycardia with ST elevation
d.      Sinus rhythm with inverted T waves

4.







a.       Sinus tachycardia
b.      Atrial flutter with RVR
c.       Junctional tachycardia
d.      Ventricular tachycardia

5.

a.       Polymorphic ventricular tachycardia
b.      Torsades de pointe
c.       Ventricular tachycardia deteriorating into VF
d.      Wide complex tachycardia


6.







a.       Sinus arrhythmia
b.      Atrial fibrillation
c.       Accelerated Junctional rhythm
d.      Multifocal atrial tachycardia


7.







a.       Coarse ventricular fibrillation
b.      Torsades de pointe
c.       Normal sinus rhythm with artifact
d.      Atrial fibrillation

8.







a.       Junctional tachycardia
b.      Sinus tachycardia
c.       Atrial fibrillation with RVR
d.      Supraventricular tachycardia

9.








a.       NSR with quadrageminal PVCs
b.      NSR with bigeminal PVCs
c.       NSR with  trigeminal PVCs
d.      NSR with pentageminal PVCs

10.

a.       1st degree heart block
b.      2nd degree heart block type I
c.       2nd degree heart block type II
d.      3rd degree heart block 



Answers


1.   a.         Atrial paced
2.   d.        Idioventricular rhythm
3.   a.        Sinus arrhythmia with T wave inversion
4.   a.         Sinus tachycardia
5.   c.         Ventricular tachycardia deteriorating into VF
6.   b.        Atrial fibrillation
7.   c.         Normal sinus rhythm with artifact
8.   d.        Supraventricular tachycardia
9.   a.         NSR with quadrageminal PVCs
10. b.        2nd degree heart block type I


Reviewed 6/4/13, 3/2/16