ACLS EHS2
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| name parts of BLS 1ry survey | **1st check responsiveness, activate EMS, get AED, then go back to pt and Airway, Breathing, Circulation, Defib
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| Name steps of ea part of BLS 1ry survey | Airway: head tilt-chin lift or jaw thrust w/o head extension if trauma; Breath: look chest rise/fall, listen/feel for air moving, 2 rescue breaths >1sec; Circul: pulse check 5-10sec…CPR until AED; Defib: if rhythm shockable->shock immed CPR starting w CC
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| Name steps of ACLS 2ry survey | A: advanced airway needed? Placed&secured; Breath: assess oxygenation and vent w O2 sat, capnometry/capnography, give O2; Circul: assess rhythm, vol resusc nec? BP mgmt? Action: IV access, ECG leads, Rx, IVF; DDx: find underlying causes and treat
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| in respiratory arrest go through steps thru end of BLS 1ry | check pt responsive, activate emergency response, get AED, then BLS 1ry: A=open airway; B=look chest rise, listen/feel air mvmt; 2 breaths ea 1 sec; C=feel carotid 5-10 sec; give 10-12 breaths/min and recheck pulse q2min
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| when use or when NOT use OPA | OPA only for unconscious/no gag, so check for gag
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| sizing of OPA | should reach edge of mandible
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| how insert OPA | insert upside down and twist 180 as put in
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| NPA when to use | can be used in semi-conscious (ie gag reflex), if trauma around mouth but be careful bc cribiform plate fx can go to brain
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| length and size of NPA | dia should be that of smallest finger or small enough so doesn't blanche nares going in; length=nares to earlobe
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| when/how to Yankauer | give O2 before suction and after, suction for <10sec, don't insert further than nose to earlobe distance.
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| ET suction, before, after, how to | give 100% O2 before hand, then 1-2ml NS and positive pressure to disperse NS, don't insert catheter beyond ET and only occlude side opening while wdrawing c rotation
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| describe CPR when pt intubated or advanced airway | give 8-10 breaths/min and don't need to synchronize w CC but ideally give during chest recoil;
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| describe breaths if pulse and no advanced airway | rescue breathing if pulse and no advanced airway 10-12 breaths/min
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| when assume spine injury | if mltpl traumas, head/facial traumas, fallen from hgt, or MVA
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| why don't use cervical collars | may complicate airway mgmt, interfere w airway patency, and incrs ICP
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| how handle possible spinal injury incl during transport | during transport should immobilize, otherwise use manual spinal restriction (Safer) and have someone stbilize during any manipulation of airway
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| describe BLS 1ry survey if unsure pulse | already opened airway, checked breathing and given 2 rescue breaths if nec, if uncertain during 5-10 sec pulse check start CC ((30:2 w ventilations) until AED pads placed
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| describe proper CC | 1.5-2 inches in depth, 100/min, allowing complete recoil
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| describe using AEDs | power on, wipe sweat/water put white pad above R chest, red pad L side, what left to L shoulder (white to right, red to ribs, what's left to L shoulder); make sure NO ONE touching pt and analyze rhythm, if tells you to shock say I'm going to shock on 3,
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| what happens if AED says rhythm nonshockable | it will say CPR immed
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| describe algorithm for shockable VF/VT | CPR until Shock1, 5 cycles of CPR, check rhythm; shock2 w epi 1mg q3-5min or 40U vasopressin 5 cycles CPR and check rhythm; shock3 w anti arrhyth (amio 300, 150 or lido 1-1.5mg/kg x1, 0.5-0.7 mg/kg (or Mg) 5 cycles; check rhythm; go back shock2 (w epi)
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| if ever get asystole or PEA during cardiac arrest, what are the steps | 5 cycles CPR and when avail epi 1mg q3-5min or vasopressin 40U; consider atropine 1mg for asysteole or slow rate PEA q3-5min, max 3 doses.
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| what do if hypothermia and cardiac arrest | defibx1, if doesn't work wait until greater than 30 C; if just moderate hypothermia just need to space out Rx bc slower metabolism (worried abt toxicity)
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| what priority for access | IV, then IO (venous plexus of the marrow), then ET
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| what procedure for giving Rx via IV | follow ea bolue w 20cc and elevate exremities (will take 1-2 min to reach central circulation)
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| how give Rx via ET, incl how you adjust dose | dose is usu 2-2.5x IV dose, dilute in 5-10cc NS and give directly into trachea
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| what Rx can you give via ET | epi, vaso, atropine, lido [amio and Mg not listed]
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| when think abt giving Mg | if saw QT prolongation in pre-arrest EKG, or ppl w low Mg (ie ETOH, malnutrition)
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| dose amio given in CPR | 300, then 150 after 3-5min
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| dose lidocaine CPR | 1-1.5mg/kg, then repeat 0.5-0.75 over 5-10min
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| postresuscitation treatment | infusion of anti-arrhythmic, amio: bolus 150 over 10min then 1mg/min for 6hrs and 0.5mg/min for next 18hrs (if already got during arrest just start infusion); lidocaine loading 1-1.5mg/kg, then 0.5-0.75 mg/kq q 5-10min; infusion 1-4mg/min
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| max dose of amio and lido post resuscitation | amio: 2.2g/24hr; lido max 3mg/kg
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| what to watch for w amio | hypotension, bradycardia, GI toxicity
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| when should lido be reduced | elderly and liver dz
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| causes of PEA (5H's, 5T's) | Hypovol, hypoxia, H ion, hyper/hypoK, hypogly, hypothermia; toxins, tamponade, tension PTX, thrombosis (heart, lung), trauma
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| EKG of the 6 Hs | hypovol: narrow tachycard; hypoxia: slow rate; H: small QRS h/o DM, CRF; hyperK: pkd T, wide QRS; hypoK flat T, U waves, wide QRS long QT; hypothermia J or Osborne waves
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| EKG of 5 Ts | toxins: various, tamponade: tachyvardia w JVD; t PTX: narrow complex w slow rate (hypoxia); AMI; PE: tachycardia
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| when can d/c resuscitation | no ROSC at anytime >20min BLS/ACLS
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| tx ACS | O2 for 6hrs, ASA chewed, NG, morphine
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| indications O2 for ACS | O2 for 6hrs (and then only continue if CP, hemo instability, Sat<90, pul congestion)
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| specifics of NG in ACS | up to 3 tablets 3-5min apart, only is SBP>90, HR 50-100
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| what don't do in RV infarct | not NG or morphine (preload dependent)
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| when don't give NG | RV infarct or recent PDE use incl sildanefil 24hr, vardenafil 48h
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| goal tx of ACS | fibrinolytics <30min, PCI<90min
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| how STEMI defined | 1mm in 2 contig leads (precordial or limb) or new LBBB
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| ST depression or T wave inversion is what in ACS | high risk unstable angina or NSTEMI
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| when can fibrinolytics be used after symptoms | 12hrs (not effective >24hrs)
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| name 4 fibrinolytics | tPA, reteplase, tenectaplase, steptokinase (but that's not fibrin specific)
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| how does PCI compare to fibrinolytics | superior
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| when can PCI be used | symptoms 3-12 hrs
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| when IV NG used | if CP unresponsive to SL NG, pul edema +STEMI, HTN + STEMI. Only use if SBP>90 and limit drop 30
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| when should bradycardia be treated | if symptoms due to bradycardia, ie inadequate perfusion as in CP, SOB, lightheaded, decrs LOC, wknss, dizzy, syncope, hypotension
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| tx brady cardia | prepare for TCP, atropine 0.5mg IV while awaitng pacer q 3-5 min, max 3mg (if atropine ineffective TCP), consider epi or dopa 2-10ug/min
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| when TCP used | immed if unstable, Mobitz II or 3rd degree, also if atropine ineffective
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| how set TCP | sedate pt first if time; initial rate 60, set to 2mA >capture (if ACS want lowest rate possible to not incrs ischemia)
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| how sedate pt before TCP | benzo, narcotic
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| tx unstable tachycardia | immed cardiovert
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| how define unstable tachycardia, how high is HR usu | AMS, CP, hypotension, presyncope (usu HR >150)
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| if stable tachy what do you do | get ECG and IV access
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| tx narrow, regular tachy | vagal, then adenomsine 6mg, then 12mg
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| if narrow, regular tachy converted w adenosine what was it | reentry SVT
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| how tx pt after conversion of narrow, reg tachy | adenosine for future occurrences or longer acting AV node blcokers, ie dilt and b blocker
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| if narrow, regular tachy didn't convert w adenosine what could it be, what should you do | A flutter, jxnl tachy, ectopic atrial tachy--just control rate w dilt or b blocker
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| when be careful w b blocker | pul dz and CHF
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| narrow irreg QRS could be, how treat? | A fib, or MAT; want to rate control
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| regular wide QRS is ; tx | VT (monomorphic or polymorph); tx amio 150 over 10min and repeat as nec max 2.2g/24hr
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| how does SVT w aberrancy look? Tx? | regular wide QRS, tx w adenosine
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| if wide complex and unstable think | VT
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| how tx VT | monomorphic if unstable w pulse then 100J synch, then step wise 200, 300, 360; polymorphic high energy unsynch
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| if unsure monomorph v polymorph VT how tx | unsynch shock
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| when use unsynch shock? | pulseless VT, deteriorating (polymorph) VT, if unsure monomorph v polymorph
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| when use syn shock | VT w pulse, unstable tachy w pulse (incl A fib or flutter)
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| shock dose for A fib | 100-200 if monophasic, 100-120 if biphasic and escalate
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| Dose shock A flutter; mono VT | 50-100; 100
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| goals for acute stroke | CT within 25min and interpret within 45 and fibrinolytics within 1hr (<3hr symptoms)
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| tx of stroke after CT done and other than fibrinolytics | O2 if Sat <92, tx hypo and hypergly, 12 lead EKG (to see if embolic), IVF 75-100ml/hr, tx fever, CT if change in MS, BP control
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| after fibrinolytics when can you give tpa or anticoag | >24 until f/u CT shows no hemorrhage
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| BP control before fibrinolytics | for >185/110 give labetalol 10-20mg, can repeat 1x or nitropaste
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| during/after fibrinolytics BP control | labetalol 10mg q 10min, max 300 or infusion 2-8mg/min OR nicardipine 5mg/hr can incrs q5min to 15mg/hr
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| BP control for pp not on fibrinolytics | tx if >220/120-140 w labetalol or nicardipine w goal 10-15% reduction BP (same doses as above), if diastolic >140 use nitroprusside 0.5ug/kg/min
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| when start tx BP for those on fibrinolytics | >180/105
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| other than intracranial bldg, what are risks of fibrinolytics | angioedema or transient hypotension
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| how freq check BP stroke | q15min 2hrs, q30min 6hrs, q1hr 16hrs
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| if not candidate for fibrinolytics what Rx give | ASA
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