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Flashcards in ACLS Deck (76):
1

Post-Cardiac Arrest Cara

Temperature Management : between 32-36Celcius 89.6-95.2Farenheit for at least 24 hours
Oxygen: should titration of oxygen to lowest level possible to avoid oxygen toxicity. Approximately 94% oxygen or greater
Ventilation: start at 10/min and ventilate for capnography at around 35-45mmHg
Pressure: mean arterial pressure of at least 65mmHg is reasonable

2

Roles of Arrest

Airway
Compressor
Defibrillator
Team Leader
Medications
Time/Recorder

3

Team Member

Ask for new task or role if unable to perform assigned task because it is beyond level of experience
Suggest an alternative drug dose in a confident manner
Question a colleague who is about to make a mistake

4

Team Leader

Clearly define roles for each person
Ask new intervention be done if it is higher priority
Ask for ideas of diagnoses
Confirm what members do and be clear about instructions

5

If Unsure about a Pulse

Start CPR because it can be more harmful to not do it if it is needed

6

BLS Assesment

Check Respnsiveness
Shout for Help
Check Breathing and Pulse
Start CPR and Rescue Breathing
Attach Defibrilator

7

Coronary Perfusion pressure

Aortic relaxation "diastolic"
-relates with both myocardial blood flow and ROSC
-one study showed that ROSC did not occur unless a CPP 15mmHg or greater was achieved

8

Quality Compresion

At least 2 inches
Rate of 100-120
Allow full chest recoil

9

Depth of Compressions

More often too shallow but too deep >2.4 inches has shown to decrease survival rate in cardiac arrest due to injuries

10

High Quality CPR

Compress chest hard and fast
Allow complete chest recoil
Minimize interruptions less than 10 seconds
Avoid excessive ventilations
Switch compressor every two minutes

11

Capnography

If less than 10mmHg then reasses quality of CPR

12

H's and T's

Hypovolemia
Hypoxia
Hydrogen Ion
Hypo/hyperkalemia
Hypothermia
Tension Pneumo
Tamponade
Toxins
Thrombosis (coronary and PE)

13

Tidal Volume of Adult

8-10ml/kg

14

Respiratory

Respiratory Rate below 6/min is considered hypoventilation and requires ventilation assistance

15

Resp Distress

Abnormal Respiratory Rate

16

Resp Failure

Inadequate Oxygenation

17

Resp Arrest

Absent Breathing

18

Tidal Volume for Patient not breathing

6-7ml/kg will suffice enough to rise the chest

19

BVM

If ventilations are being properly delivered and are adequate, providers may differ from an advanced airway

20

Excessive Ventilation

Can increase thoracic pressure, decreases venous return to the heart and diminishes cardiac output

21

Common Airway Obstruction

Loss of tone in the throats muscles. When the tounge falls to the back of the throat

22

Airway Obstruction

If obstructed and resp arrest occurs, start CPR and check mouth after every two minutes when going to give ventilations and remove with fingers if clearly visible

23

BVM device

Delivers approximately 600ml of volume and should see chest rise over 1 second

24

Suctioning

Suction force of 80-120mmHg is nescessary
Soft: used for mouth or nose and et deep suction
Ridged: suction oropharynx and thick secretions

25

Suction Measure

Ridged is the same as an OPA and the Soft is measured from nose, around ear to xiphoid process
Should not exceed more than 15 seconds

26

ACS Algorithm

Symptoms of ischemia=> abc's 12 lead => titration oxygen if less than 90%, give 160-325 aspirin, nitoglycerine, morphine if pain not relieved by nitro

27

Reperfusion Goals

Door to Ballon 90minutes
Door to Needle (fibronolysis) 30 minutes

28

Chest Discomfort of Ischemia

-Uncomfortable Pressure, fullness, squeezing, pain in center of chest lasting several minutes
-Chest discomfort spreading to shoulders, neck, one or both arms or jaw
-Chest discomfort spreading to back or between shoulder blades
-Unexplained SOB with or without chest discomfort

29

Aspirin

Dose: 160-325mg causes near immediate and total inhibition of thromboxone
IF Pt has not taken aspirin, has allergies, or recent GI bleed

30

Nitroglycerine

Reduces ischemic chest discomfort
Cause reduction in LV and RV preload through peripheral arterial and venous dilation
1 spray, or dose, 400mcg every 3-5 minutes for ongoing symptoms
Total of three doses
BP > 90mmHg Systolic and HR IS 50-100/min

31

Inferior Wall MI

RV infarction may complicate an inferior wall MI because RV infarction rely heavily on RV filling pressures to maintain cardiac output
-Should not be given nitroglycerine or other Volume depleting drugs such as morphine or diuretics

32

Recent Phosphodiesterase Inhibitor Use

Avoid using nitroglycerine is suspected or known that patient has taken ED medications with 24-48 hours because may cause severe hypotension

33

Morphine

Opiate given for chest discomfort unresponsive to sublingual or nitro spray with medical control

34

PreHsopital notification of Stemi

Decreases time to treatment by 10-60 minutes

35

NonStemi

ST depression indicating injury or dynamic t wave inversion

36

Heparin

Given as adjunct to PCI therapy

37

Streptokinase

Fribronolytic drug used in MI in hospital

38

Stroke

87% ischemic
10% intracerebral
3% subarachnoid

39

Fibronolytic Therapy

Within 1 hour of hospital arrival time

40

Stroke Symtpoms

Confusion
Trouble Speaking
Sudden Weakness
Dizziness
Trouble Walking
Severe Headache

41

Cincinnati

Facial Droop
Arm Drift
Abnormal Speech
If identified one of three signs then 72% chance is having a stroke

42

Establish Information

Last known normal time or seen
Bring a witness
Check BGL

43

Provide Oxygen to Stroke

If oxygen saturation is less than 94%

44

rTPA

Alteplase is a clot buster for stroke patients
Inclusion: onset within 4.5 hours and neurological deficit
Exclusion: age>80years old, taking anticoagulant, severe stroke, Hx of diabetes and stroke

45

Cardiac Arrest Algorithm

Start CPR
Rhythm Shockable ?
No, CPR 2 min, IO, Epi
Yes, Shock, CPR 2 min, IO
Rhythm? Shock, CPR 2 mins, Epi
Rhythm? Shock, CPR 2 mins, ami
Rhythm? Shock, CPR 2 mins, Epi

46

Shock Dosage

200j for defibrillator dose

47

Drug Therapy

Epinephrine 1mg Q 3-5mins
Amiodarone 300mg bolus and 150mg bolus

48

Shocking a Heart

Does not restart Heart. It temporarily stuns the heart and briefly terminates all electrical activity and if the heart is still viable, the heart will resume with its normal pacemaker

49

Rate Of Decline

For every minute of no CPR to cardiac arrest survival chances decrease by 7-10%
-with bystander CPR chances decline slower at 3-4%/minute

50

End Tidal Co2

Measure of blood delivered to lungs and readings less than 10mmHg mean ROSC is unlikely

51

Amiodarone

Vf/Vt
Blocks sodium and potassium channels

52

Lidocaine

No proven short term or long term benefits
- 1-1.5mg/kg bolus then consider .5-.75mg/kg to max of 3mg/kg

53

Mag Sulfate

Terminate torsades in patients with long QT interval
Loading dose of 1-2 G /5 minutes

54

Cardiac Arrest PEA

Consider H's and T's and focus on epi and compressions

55

Terminate CPR

If etco2 less than 10 after 20 minutes
Down time

56

Bradycardia

Bradycardia and heart blocks
Rhythm less than 60/min

57

Symptomatic Bradycardia Unstable

Hypotension?

58

Symptomatic Bradycardia Symptoms

Dizziness, weakness, fatigues, light headed, syncope

59

Bradycardia Algorithm

Oxygen, 12 lead, vitals, history
- hypotension? AMA? Shock? Ischemic chest discomfort? Acute heart failure?
Yes:
Atropine
Dopamine infusion
Epinephrine infusion
No effect consider pacing at 70bpm until mechanical and electrical capture on patient and monitor

Atropine .5mg Q3-5minutes max of 3mg
Dopamine 2-20mcg/kg/min titration
Epinephrine 2-10mcg/min

60

Transcutaneous Pacing

Indications: hypotension, ams, Shock, ischemic chest discomfort, acute heart failure (hemodynamically unstable)
Heart blocks, ventricular escape rhythms, new BBB
Contraindicated: severe hypothermia or asystole
-Conscious use analgesics for pain
-assess radial pulses and NOT carotid for mechanical capture
-once electrical captured set 2ma higher
-set rate 60-70bpm
-alternative is a chronotropic drug infusion (dopamine, epinephrine)

61

Tachycardia

Heart beating so fast cardiac output is reduced

62

Indications for Cardioversion

Sinus Tachycardia
Atrial Flutter
Atrial Fin RVR
V tach

63

Unstable

Have to use synchronized cardioversion
-hypotension
-ams
-Shock
-ischemic chest discomfort
-acute heart failure
-IF unstable do not waste time obtaining 12 lead to verify rhythm

64

Wide QRS stable

Without unstable then consider adenosine if regular and monomorphic, antiarrhythmic infusion
150mg/10min
Peds: 5mg/kg/20-30minutea

65

Polymorphic V Tach

Monitor will not allow synchronization of rhythm due to polymorphic and have to defibrillate at 200j dose

66

Synchronized

Synchronized to the highest point of the R wave to inhibit shocking the patient during an absolute refractory period causing possible asystole or other deadly rhythms

67

Doses

Narrow Regular 50-100j
Narrow Irregular 120-200j
Wide Regular 100j

Adenosine 6mg 12mg 12mg

Amiodarone 150mg/10mins with maintanence infusion of 1mg/min
Procainamide 20-50mg/min with maintanence infusion of 1-4mg/min

68

Wide Regular Tachycardiac

Vtach with pulse, if stable, medications, unstable, cardiovert

69

Synchronized with Monitor

Make sure to reset "synchronized mode" after shock. Some monitors reset to unsynchronized in case lethal rhythm is produced from shock

70

SvT

Stable : make sure pathological, vagal maneuvers, adenosine, amiodarone, Shock if unstable

71

Adenosine

Contraindications:
A fib or flutter may accelerate rhythm

72

A fib RVR

Stable: vagal, .25 mg/kg bolus Cardiazem then .35mg/kg bolus and maintenance infusion of 5-15mg/HR

73

Post Cardiac Arrest Care

*Avoid Excessive ventilation start at 10 breaths a minute and titration 35-40 mmHg
-Maintain oxygen saturation above 94%*
-Consider Advanced Airway and Capnograhy
*Treat hypotension <90mmHg*
-IV IO bolus 1-2L fluid
-Vasopressor Infusion
-Consider treatable causes
*12 Lead*
*Temperature Management*
-32-36degrees Celsius (no contraindications for temperature management)
-ice packs in junctional spaces

74

Post Arrest Vasopressor infusion

Epi: .1-.5mcg/kg/min
Dopamine: 5-10mcg/kg/min

75

Epi Bradycardia

2-10mcg/min

76

Epi Hypotension

.1-.5 mcg/kg/min