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ACLS Protocols
ACLS Protocols
79
Anatomy
Graduate
03/20/2012

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Term
Pt is unresponsive, and not breathing. You feel a definite pulse. What do you do now?
Definition
- Give 1 breath every 5-6 seconds
- Recheck pulse every 2 minutes
Term
High quality CPR:
Definition
- Rate of at least 100/min
- Compression depth of at least 2 inches (5 cm)
- Allow complete chest rise after each compression
- Minimize interruptions
- Avoid excessive ventilation
Term
Order of events for cardiac arrest:
Definition
1. Shout for help/activate emergency response
2. Start CPR, Give Oxygen, Attach monitor, defibrillator
3. After 2 minutes CPR> check rhythm
4. VF/VT>shock
5. Continue CPR 2 minutes> check rhythm
6. Rhythm present> Drug therapy (Epi every 3-5 minutes, Amiodarone for refractory VF/VT)
7. Consider Advanced Airway Placement (Quantitative waveform capnography)
8. Treat reversible causes
Term
If quantitative waveform capnography is less than __ mm Hg, attempt to improve CPR quality.
Definition
less than 10 mmHg
Term
If diastolic pressure is less than __mmHg, attempt to improve CPR quality.
Definition
20
Term
3 characteristics of ROSC (return to spontaneous circulation):
Definition
- Pulse and blood pressure
- Abrupt sustained increase in PETCO2 (typically > or equal to 40mmHg)
- Spontaneous arterial pressure waves with intra-aterial monitoring
Term
Biphasic shock energy:
Definition
- initial dose of 120-200 J (if unknown use maximum possible)
- second and subsequent doses should be equivalent and higher doses may be considered
Term
Monophasic shock energy for cardiac arrest:
Definition
360J
Term
For cardiac arrest what drug is given once there is a rhythm on the strip:
Definition
1 mg epinephrine every 3-5 minutes
Term
If refractory VF or VT is present on the strip, what drug is given?
Definition
300 mg bolus dose of Amiodarone
150 mg second dose
Term
what drug can replace the first or second dose of epi in cardiac arrest?
Definition
Vasopressin 40 units
Term
with advanced airway placement, how many breaths should be given per minute?
Definition
8-10 breaths/minute
Term
Reversible causes of cardiac arrest:
Definition
HHHHHTTTTT
- Hypovolemia
- Hypoxia
- Hydrogen ions (acidosis)
- Hypo/hyperkalemia
- Hypothermia
- Tension pneumothorax
- Tamponade, cardiac
- Toxins
- Thrombosis, pulmonary
- Thrombosis, coronary
Term
The heart rate is usually greater than or equal to __ bpm with tachyarrhythmias.
Definition
150
Term
You suspect pt has tachyarrhythmia b/c heart rate is greater than or equal to 150 bpm. Whats the first step?
Definition
Identify and treat underlying cause
- Maintain patent airway, assist breathing if necessary
- Oxygen if hypoxemic
- Cardiac monitor to identify rhythm
- Monitor blood pressur
- Monitor oximetry
Term
If persistent tachyarrythmia is causing any of the following, then __ __ should be considered.
Definition
- Hypotension
- Acutely altered mental status
- Signs of shock
- Ischemic chest discomfort
- Acute heart failure

Any and all of these are signs for Synchronized cardioversion
Term
With Synchronized Cardioversion for tachyarrhythmias, one should consider __. If there are regular narrow QRS complexes, consider ___.
Definition
- sedation
- adenosine
Term
regular narrow complexes with tachyarrhythmias, consider:
Definition
adenosine
Term
QRS complex is considered wide if it is greater than or equal to ___ seconds.
Definition
0.12 seconds
Term
Pt has tachyarrhythmia but does not have hypotension, acutely altered mental status, signs of shock, ischemic chest discomfort, or acute heart failure. The QRS complexes are wide and greater than 0.12 seconds. What should you do next?
Definition
- IV access
- 12 lead EKG if available
- Consider adenosine only if regular and monomorphic
- Consider antiarrhythmic infusion
- Consider expert consultation
Term
Patient has tachyarrhythmia. There is no hypotension, acutely altered mental status, signs of shock, ischemic chest discomfort, or acute heart failure. The QRS complexes are NOT wide. What should you do now?
Definition
- IV access
- 12 lead EKG if available
- Vagal maneuvers
- Adenosine if regular
- Beta blocker or CCB
- Consider expert consultation
Term
Cardioversion dose for NARROW REGULAR tachyarrhythmia:
Definition
50-100 J
Term
Cardioversion dose for NARROW IRREGULAR tachy:
Definition
120-200 J biphasic
200 J monophasic
Term
Cardioversion dose for WIDE REGULAR tachyarrhythmia:
Definition
100 J
Term
Cardioversion dose for WIDE IRREGULAR tachyarrhythmias:
Definition
defibrillation dose, NOT synchronized
Term
Adenosine IV dose for regular tachyarrhythmias:
Definition
6 mg rapid IV push, follow with NS flush
second dose 12 mg if necessary
Term
Antiarrhythmic infusions are used for __ __ ___ tachycardia.
Definition
- STABLE WIDE QRS TACHYCARDIA
Term
3 possible Antiarrhythmic infusions given to pts with stable wide QRS tachycardia:
Definition
- Procainamide
- Amiodarone
- Sotalol
Term
Procainamide IV dose is __-__mg/minute until the __ is __, __ __, the __ __ increases by __, or the __ __ of __ is given. Maintenance infusion of ___. Avoid __ __ or ___.
Definition
- 20-50mg/minute
- arrhythmia subsides
- hypotension occurs
- QRS duration increases by >50%
- maximum dose of 17mg/kg is given
- Maintenance infusion of 1-4 mg/minute
- Avoid QT prolongation and CHF
Term
The dose for procainamide with stable wide QRS tachycardia is 20-50mg/minute. When can you stop this?
Definition
- arrhythmia subsides
- hypotension occurs
- QRS duration increases by >50%
- maximum dose of 17mg/kg is given
Term
Amiodarone IV dosing for stable wide complex tachycardia:
Definition
- 150 mg over 10 minutes for first dose
- Repeat as needed if VT recurs
- Follow with maintenace of 1mg/min for first 6 hours
Term
Sotalol IV dose for stable wide complex tachycardia:
Definition
100 mg (1.5mg/kg) over 5 minutes
avoid QT prolongation
Term
Heart rate is usually less than __/minute if bradyarrhythmia.
Definition
less than 50/minute
Term
You suspect pt has bradyarrhythmia b/c heart rate is less than 50 bpm. What do you do next?
Definition
Identify and treat underlying causes
- Maintain patent airway, assist breathing as necessary
- Oxygen if hypoxemic
- Cardiac monitor to ID rhythm
- Monitor blood pressure
- Monitor oximetry
- IV access
- 12 lead EKG if possible, don't delay therapy
Term
You suspect patient is having bradyarrhythmia, but they are not hypotensive, do not have acutely altered mental status, do not show signs of shock, have no ischemic chest discomfort, and do not have acute heart failure. What do you do?
Definition
After doing all steps to id and treat underlying cause> OBSERVE
Term
Pt is having bradyarryhthmia and is hypotensive, acutely altered mental status, signs of shock, ischemic chest discomfort, or/and acute heart failure. What do you do next?
Definition
ATROPINE
If atropine does not work then do transcutaneous pacing OR dopamine OR epinephrine

Also consider transvenous pacing and expert consult
Term
first line for symptomatic bradycardia is atropine. but if this does not work, what do you do?
Definition
- transcutaneous pacing OR dopamine OR epinephrine

consider transvenous pacing and expert consult
Term
Atropine dose for bradarryhtmia:
Definition
0.5 mg bolus, repeat every 3-5 minutes

maximum of 3 mg
Term
Dopamine dose for bradyarrhythmia:
Definition
2-10 mcg/kg/minute
Term
Epinephrine dose for bradyarrhythmia:
Definition
2-10 mcg/minute
Term
After ROSC, what do you do?
Definition
Optimize ventilation and oxygenation
- Maintain oxygen saturation > or equal to 94%
- Consider advanced airway and waveform capnography
- Do NOT hyperventilate
Term
After ROSC and optimizing ventilation and oxygenation, what do you do next?
Definition
Treat hypotension (systolic < 90mmHg)
- IV/IO bolus
- Vasopressor infusion
- Consider treatable causes
- 12-lead EKG
Term
After ROSC, optimizing ventilation and oxygenation, and treating hypotension, what do you next for post cardiac arrest care?
Definition
- see if the patient can follow commands
Term
With post cardiac arrest care, you have optimized ventilation, treated hypotension, and now find that your patient cannot follow commands. What should you do next?
Definition
consider induced hypothermia
Term
With post cardiac arrest care you have optimized ventilation, treated hypotension, and now find that your patient is able to follow commands. What does this make you suspicious of?
Definition
- STEMI or AMI
Term
With post-cardiac arrest care, you have optimized ventilation, treated hypotension, found your pt able to follow commands, and found that they had a STEMI or AMI, what do you do next?
Definition
coronary reperfusion and then advanced critical care
Term
With post cardiac arrest care, you have optimized ventilation, treated hypotension, found your pt responsive to commands, but they did not have STEMI or AMI. What now?
Definition
advanced critical care
Term
Avoid exessive ventilation with post cardiac arrest care. STart at ___ bresths/minute and titrate to target PETCO2 of __ mmHg. When feasible, titrate ___ to minium necessary to accheiave SPO2 of > or equal to __.
Definition
- 10-12 breaths/minute
- target PETCO2 of 35-40mmHg
- titrate FIO2
- 94%
Term
For the IV bolus to treat hypotension in post cardiac arrest care, how much and what do you give?
Definition
1-2 Liters normal saline or lactated ringers. If inducing hypothermia, may use 4 degree C fluid.
Term
formula for converting C to F?
Definition
C= 0.556 (F-C).
Term
epinephrine dose for post-cardiac arrest care for hypotension management:
Definition
0.1-0.5 mcg/kg/minute
Term
For cardiac arrest epi is 1 mg every 3-5 minutes
For bradyarrhythmias epi is 2-10 mcg/minute
For post-cardiac arrest care epi is 0.1-0.5mcg/kg/minute
Definition
Term
Dopamine post cardiac arrest care of hypotension:
Definition
5-10 mcg/kg/minute
Term
Norepi dosage for post-cardiac arrest hypotension tmt:
Definition
0.1-0.5 mg/kg/minute
Term
vasopressors that may be used for hypotension tmt in post-cardiac arrest care:
Definition
- Epi
- Dopamine
- Norepi
Term
Immediate ED general treatment of ACS:
Definition
- If O2 sat less than 94% start oxygen at 4L/minute, titrate
- ASA 160-325 mg(if not given by EMS)
- Nitro sublingual/spray
- Morphine for discomfort
Term
Concurrent ED assessment of ACS (should be done in less than 10 minutes):
Definition
- Vitals
- Oxygen saturation
- Brief history and physical
- Fibrinolytic checklist and check CI
- Cardiac marker levels
- Electrolytes
- Coagulation studies
- Portable xray
Term
Besides checking vitals and oxygen saturation with ACS, what labs should be initally ordered (within 10 minutes of arrival to ED)?
Definition
- Cardiac markers
- Electrolytes
- Coagulation studies
- Portable chest x-ray
Term
Suspected ACS in patient. What EKG findings would make you highly suspcious of injury ST- elevation MI (STEMI)?
Definition
- ST elevation or new LBBB
Term
Suspect ACS in a patient, what EKG findings would may you highly suspicious of ischemia, high risk unstable angina, non-ST-elevation MI?
Definition
- ST depression
- dynamic T wave inversion
Term
Suspect ACS in a patient. EKG shows normal or non-diagnostic ST segment or T wave changes. What would you call this?
Definition
- Low/intermediate risk ACS
Term
If a STEMI is found on EKG, what should you do?
Definition
- Start adjunctive therapies as indicated
- Do NOT delay reperfusion
- Determine if time of onset of symptoms is less than or equal to 12 hours
Term
A STEMI if found on EKG. The time of symptom onset is less than or equal to 12 hours ago. What should you do now?
Definition
Reperfusion goals:
- Door to balloon inflation (PCI) goal of 90 minutes
- Door to needle (fibrinolysis) goal of 30 minutes
Term
EKG confirms a STEMI. The onset of symptoms was less than 12 hours ago. Your reperfusion goal from door to balloon inflation (PCI) is ___ ___. Your reperfusion goal from door to needle (fibrinolytics) is __ __.
Definition
- 90 minutes
- 30 minutes
Term
If EKG confirms UA/NSTEmI what should you do next?
Definition
- check troponin levels
- determine if pt is high risk or not
Term
With UA/NSTEMI, you should consider early invasive strategy if:
Definition
- Refractory ischemic chest discomfort
- Recurrent/persistent ST deviation
- Ventricular tachycardia
- Hemodynamic instability
- Signs of heart failure
Term
If EKG shows a STEMI and symptoms onset was greater than 12 hours ago, what should you do?
Definition
Start adjunctive treatments as indicated
- Nitroglycerin
- Heparin
- Consider po beta blockers
- Consder Clopidogrel
- Consider Glycoprotein IIb/IIIa inhibitor
Term
Possible adjunctive treatments for unstable angina/NSTEMI:
Definition
- Nitroglycerin
- Heparin
- PO Beta blockers
- PO Clopidogrel
- PO Glycoprotein IIb/IIIa inhibitor

NHBCCG
Term
Management of NSTEMI/UA:
Definition
Ajunctive tmts as indicated: Nitro, Heparin, Beta blocker po, po clopidogrel, po glycoprotein iib/iiia inhibitors
- Admit to monitored bed
- Assess risk status
- Continue ASA, Heparin and other therapies as indicated: ACE inhibitor/ARB, HMG CoA reductase inhibitor(statin)

If pt not at high risk: cardiology to risk stratify
Term
Management of a pt with suspected ACS but with normal or nondiagonstic EKG changes:
Definition
Admit to ED chest pain unit or appropriate bed and follow:
- Serial cardiac markers, including triponin
- Repeat EKG/continuous ST-segment monitoring
- Consider non-invasive dx tests
Term
You admitted an ACS patient with initial nondiagnostic/normal EKG changes. You ordered serial enzymes and another EKG. They developed one or more of the following: clinical high risk features, dynamic EKG changes consistent with ischemia, and/or elevated triponin. What do you do now?
Definition
- Start adjunctive treatment as indicated: Nitro, Heparin, BB, Clopidogrel, Glycoprotein iib or iia inhibitor
- Admit and monitor, continue ASA and heparin, other therapies as indicated: ACE inhibitor/ARB, HMG Co-A reductase inhibitor (statin)
Term
So if pt with STEMI onset of symptoms was greater than 12 hours ago, or if pts with non-diagnostic EKG changes/normal EKGs develop high risk symptoms, hve EKG changes, or elevated triponin, treat both of these pts like you would treat UA/NSTEMI.
Definition
consider early invasive strategy
Term
Immediate general assessment and stabilization of stroke pt:
Definition
- Assess ABCs, vital signs
- Oxygen if hypoxemic
- Obtain IV access and perform lab assessments
- Check glucose, treat if indicated
- Perform neuro screening and assessment
- Activate stroke team
- Order emergent CT or MRI
- Obtain 12 lead EKG
Term
NINDS time goals are for the __ algorhythm.
Definition
NINDS
Term
With the NINDS time goals, the immediate general assessment and stabilization of a stroke pt should occur when?
Definition
within first 10 minutes of ED arrival
Term
According to NINDS time goals, when should stroke team neuro assessment take place?
Definition
- be done by 25 minutes after ED arrival
Term
According to NINDS time goals, when should a stroke victim have a CT scan done?
Definition
by 45 minutes after ED arrival
Term
According to NINDS time goals, when should you be reviewing risks/benefits of fibrinolytics for ischemic stroke pt or consulting neuro for hemorrhagic stroke?
Definition
within 60 minutes after ED arrival
Term
According to NINDS time goals, when should you be administering fibrionlytics to ischemic stroke patient?
Definition
within 3 hours after arrival to ED
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