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What rhythms require unsynchronized high-energy shocks? VF and VT
Which rhythms are not shockable? PEA and Asystole
An adult collapses from cardiac arrest. What do you do? Shout for help/Activate the Emergency Response System
Your patient is unconscious. Help is on the way. What do you do in the meantime? . Start CPR, Give oxygen, Attach monitor/defibrillator
The Rhythm is VF or pulseless VT. What do you do? Deliver shock
Give an example of how the person delivering the shock should alert team members. “Clear. I am going to shock on three.” “One, two, Three. Shocking”
One shock has been delivered. No ROSC. What’s next? CPR for 2 minutes (5 cycles) and IV/IO access. No pulse check. Then check rhythm. Deliver shock if indicated.
Two shocks have been delivered without return of ROSC. What’s next? CPR for 2 minutes. Epinephrine 1 mg every 3-5 minutes (Vasopressin 40 units can replace 1st or 2nd dose of epi) followed by 20 ml flush. Elevate limb to aid in distribution of drug. Consider advanced airway and capnography
Name and explain the relevant values when using capnography. <10mm Hg – attempt to improve CPR quality; 35-40mm Hg – target range; > 40 mm Hg sustained indicates ROSC
At what rate should breaths be delivered to the patient with an advanced airway and compressions in progress? one breath every 6-8 seconds, ideally during chest recoil, no need to interfere with compressions, to equal 8-10 breaths per minute
Two shocks have been delivered. Epinephrine has been administered. CPR is in progress. What’s next? Check Rhythm. Deliver shock if indicated.
Third shock has been delivered. Patient is in refractory VF. What’s next? Administer Amiodarone 300mg bolus followed by 20ml flush. Look for and treat reversible causes
What is the second dose of Amiodarone? 150mg
What are the H’s and T’s? Hypovolemia, Hypoxia, Hydrogen Ions (Acidosis), Hypo-HyperKalemia, Hypothermia, Tension pneumothorax, Tamponade-cardiac, Toxins, Thrombosis-pulmonary or coronary
What is the initial and following energy levels when delivering shock for VF and pulseless VT? Biphasic 120-150 j, second and third doses should be equivalent or higher; Monophasic 360 j
What energy level should be used to shock a patient who recovers from VF then goes back into the arrhythmia after displaying an organized rhythm? Deliver subsequent doses at the previously successful energy level.
What if a nonshockable rhythm is found? Give CPR for 2 minutes. Gain IV/IO access and give epinephrine 1 mg every 3-5 minutes (1st or 2nd dose may be replaced by Vasopressin 40 units) consider advanced airway and capnography
Patient is in Asystole or PEA. CPR has been in progress for 2 minutes, epinephrine administered, airway intact. What’s next? Analyze Rhythm
The rhythm remains nonshockable. What’s next? Check for and treat reversible causes. Then check for shockable rhythm.
Describe the appropriate timing for pulse checks in order to avoid prolonged interruptions in compressions. Check pulse only when an organized rhythm is observed, preferably during rhythm analysis.
What course of actions follows a palpable pulse and organized rhythm? Proceed to post cardiac arrest care.
What course of action follows a questionable pulse and organized rhythm? Immediately resume CPR
What is the appropriate dose of the antiarrhythmic amiordarone? 300mg IV/IO bolus, then consider an additional 150mg IV/IO once
If Amiodarone is not available lidocaine is an acceptable option. What is the appropriate dosing of lidocaine? 1-1.5mg/kg IV/IO first dose, then 0.5-.75mg/kg IV/IO at 5-10 minute intervals to a maximum dose of 3mg/kg
When is magnesium sulfate indicated? only for torsades de pointes associated with a long QT interval
What is the appropriate dosing for magnesium sulfate? 1-2g IV/IO diluted in 10mL of d5w given as a IV bolus typically over 5-10 minutes
What action is necessary if intra-arterial diastolic pressure is <20mm Hg? attempt to improve quality of CPR
If Petco2 is less than 10, what actions can be taken? Improve chest compressions and vasopressor therapy
What actions can be taken of arterial relaxation pressure is < 20 mm Hg? Improve chest compressions and vasopressor therapy
Describe how ACLS would differ for the hypothermic patient. Reduce the rate of drug administration to allow for slowed metabolism and avoid toxic drug levels. Vasopressors are appropriate. Antiarrhythmics have not been proven effective for hypothermia. Re-warm the patient.
Severe hypothermia is defined as 30 degrees Celsius. What’s that in Fahrenheit? 86
Describe proper drug administration using a peripheral IV during CPR. Give by bolus unless otherwise indicated, Follow with 20mL normal saline bolus, Elevate extremity for 10-20 seconds to promote delivery to central circulation
How long does it take for drugs administered via peripheral IV during CPR to take full effect? It will take several cycles of CPR for the drug to take effect.
What drugs can be given the ET tube? How are they administered? Epinephrine, Vasopressin, and Lidocaine, Dose is 2-2.5 times the IV dose, dilute the dose in 5-10 mL of sterile water or NS and inject the drug directly into the trachea
What are the limitations to drug administration via ET tube? Results are variable and unpredictable in drug absorption and blood levels.
What is the function of vasopressors in CPR? Vasopressors are used to optimize cardiac output and blood pressure
What vasopressors are utilized during CPR? Epinephrine 1 mg IV/IO q 3-5 minutes, Vasopressin 1 dose of 40 units can replace the first or second dose of epinenphrine, follow each dose with 20 ml of flush and elevation of the limb for 10-20 seconds
How does epinephrine work to improve chances of ROSC? Epinephrine acts on andrenergic receptors causing vasoconstriction resulting in increased blood pressure and heart rate and improving perfusion pressure to the heart and brain
How does vasopressin work improve the chances of ROSC? Vasopressin causes peripheral vasoconstriction and increase in arterial blood pressure
When should amiordarone be used? Consider amiordarone for VF or Pulseless VT unresponsive to shock, CPR and vasopressor.
What kind of drugs are amiodarone, lidocaine, and magnesium sulfate? antiarrhythmics
What is the proper dosing for amiodarone? 300mg IV/IO push for the first dose. If VF/VT persist consider giving a second dose of 150 mg in 3-5 minutes.
When is it advisable to use Lidocaine in CPR? when amiodarone is not available
What is the proper dosing for lidocaine? 1 -1.5 mg/kg repeat if indicated at 0.5 -0.75mg/kg over 5-10 minute intervals to a maximum dose of 3mg/kg
What is the proper dosing for lidocaine via ET? 2-4mg/kg
What are the indications for magnesium sulfate? Torsades de Pointes in which pre-arrest rhythm was associated with prolonged QT interval. Magnesium is adjunctive to primary tx of high energy shock. Malnutrition/alcoholism can lead to hypomagnesic states and may be the cause of refractory VF/VT.
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