ACLS Final Comprehensive Exam Predictor

ACLS Final Comprehensive Exam Predictor ACLS Final Comprehensive Exam Predictor BLS & Chocking Relief of Adults, Children, Infants; Opioid Overdose; EKG interpretation; Cardiac anatomy; Team dynamics; BLS/Primary/Secondary Assessment; H's & T's; Airway Management; Bradycardia ACLS Algorithm; ACS ACLS Algorithm; Stroke ACLS Algorithm; Tachycardia ACLS Algorithm; Immediate Post-Cardiac Arrest Care ACLS Algorithm; Pharmacology. What is the most common cause of cardiac arrest in children? Respiratory failure or shock What is cardiac arrest? Occurs when the heart develops an abnormal rhythm and stops beating or beats too ineffectively to circulate blood to the brain and other vital organs What is heart attack? A blockage of blood flow to the heart muscle. List the eight components of high quality CPR. 1. Start compressions within 10 seconds of recognition of cardiac arrest. 2. Compress at a rate of 100-120/min with a depth of at least 2 inches in adults/children and 1 1/2 inches in infants. 3. Allow complete chest recoil after each compression. 4. Minimize interruptions in compressions (limit to 10 seconds). 5. Give effective breaths that make the chest visibly rise. 6. Switch compressors about every 2 minutes or earlier if fatigued. 7. Continue delivering chest compressions while the AED is charging. 8. Avoid prolonged rhythm analysis, frequent or inappropriate pulse checks, taking too long to give breaths to the patient, excessive ventilation, or unnecessarily moving the patient. What is the recommended compression depth for adults and children? 2 inches What is the recommended compression depth for infants? 1 1/2 inches What can result if a patient is ventilated too quickly? Hyperventilation - excessive intrathoracic pressure and gastric inflation - decreased venous return - decreased coronary and cerebral perfusion pressures - diminished cardiac output - decreased rates of survival What memory aid may be used when evaluating a patient's level of consciousness? AVPU Alert, responds to Verbal stimuli, responds to Painful stimuli, Unresponsive Upon finding an unresponsive adult patient, you verified that the scene is safe, called for help and asked that someone get an AED or defibrillator. Your next action should be to: Simultaneously look for breathing and feel for a carotid pulse for no more than 10 seconds Upon finding an unresponsive child, you verified that the scene is safe, called for help and asked that someone get an AED or defibrillator. Your next action should be to: Simultaneously look for breathing and feel for a carotid or femoral pulse for no more than 10 seconds Upon finding an unresponsive infant, you verified that the scene is safe, called for help and asked that someone get an AED or defibrillator. Your next action should be to: Simultaneously look for breathing and feel for a brachial pulse for no more than 10 seconds Upon finding an unresponsive adult patient, you verified that the scene is safe, called for help and asked that someone get an AED or defibrillator. You check for breathing and a carotid pulse simultaneously. The patient has no pulse and is not breathing normally. Your next action should be to: Begin chest compressions; remove clothing; use AED as soon as it arrives Upon finding an unresponsive adult patient, you verified that the scene is safe, called for help and asked that someone get an AED or defibrillator. You check for breathing and a carotid pulse simultaneously. The patient is breathing normally and a pulse is present. Your next action should be to: Continue to monitor until additional help arrives. Upon finding an unresponsive infant or child, you verified that the scene is safe, called for help and asked that someone get an AED or defibrillator. You check for breathing and a carotid pulse simultaneously. The patient has no pulse and is not breathing normally. The arrest was not sudden and not witnessed. Your next action should be to: begin chest compressions 30:2 (1 rescuer), 15:2 (2 rescuer); if 2 rescuers are present, one rescuer begins CPR and the other activates the ERS; use the AED as soon as it arrives; after about 2 min of CPR, if you are still alone, activate the ERS and get the AED if not already done Upon finding an unresponsive infant or child, you verified that the scene is safe, called for help and asked that someone get an AED or defibrillator. You check for breathing and a carotid pulse simultaneously. The patient has no pulse and is not breathing normally. The arrest was sudden and witnessed. Your next action should be to: Activate the emergency response system and retrieve the AED; begin chest compressions 30:2 (1 rescuer), 15:2 (2 rescuer) Upon finding an unresponsive infant or child, you verified that the scene is safe, called for help and asked that someone get an AED or defibrillator. You check for breathing and a carotid pulse simultaneously. The patient is breathing normally and a pulse is present. Your next action should be to: Activate ERS, return to victim and monitor until emergency responders arrive Upon finding an unresponsive adult patient, you verified that the scene is safe, called for help and asked that someone get an AED or defibrillator. You check for breathing and a carotid pulse simultaneously. The patient is not breathing normally but a pulse is present. Your next action should be to: Provide rescue breathing (one breath every 5-6 seconds) and recheck for a pulse every 2 minutes; be ready to perform high quality CPR if you do not feel a pulse; if opioid use is suspected, consider administering naloxone Upon finding an unresponsive infant or child, you verified that the scene is safe, called for help and asked that someone get an AED or defibrillator. You check for breathing and a carotid pulse simultaneously. The patient is not breathing normally but a pulse is present. Your next action should be to: Provide rescue breathing (one every 3-5 seconds); add compressions if pulse remains 60/min with signs of poor perfusion; activate ERS after 2 min; continue rescue breathing and check pulse about every 2 min (if no pulse begin CPR) What is the purpose of the primary survey? To detect the presence of life-threatening problems that require rapid interventions What two cardiac arrest rhythms are shockable? VF and pVT What two cardiac arrest rhythms are not shockable? Asystole and PEA During the primary survey, for what length of time should you assess for the presence of a pulse? At least 5 seconds but no more than 10 seconds What is the importance of measuring coronary perfusion pressure during CPR? Represents myocardial blood flow during chest compressions and is a key determinant of the success of resuscitation What is an adequate coronary perfusion pressure (CPP)? 15 mm Hg What is the importance of measuring waveform capnography (PETCO2) during CPR? allows for evaluation of CPR quality, optimize chest compressions, detection of ROSC during chest compressions or when a rhythm check reveals an organized rhythm, ET tube placement What is an adequate waveform capnogrpahy (PETCO2) range? 10-20 mm Hg When ROSC occurs, what happens to waveform capnography? There will be a significant increase in the ETCO2. (35-45 mmHg) This increase represents a drastic improvement in blood flow (more CO2 being dumped in the lungs by the circulation) which indicates circulation. What is chest compression fraction? The proportion of time that chest compressions are performed during a cardiac arrest What is the target goal of chest compression fraction during CPR? 60-80% What is the appropriate tidal volume for adult cardiac arrest patients? 500-600 mL (half a squeeze of an adult ventilation bag; enough to see visible chest rise) Single rescuers should use the compression-to-ventilation ratio of ____ compressions to ____ breaths when giving CPR to victims of any age. 30:2 At what rate should compressions occur? 100-120/min Interruptions in chest compressions should be limited to how many seconds? 10 Rescuers should switch compressors how often? Every 5 cycles (2 min) or sooner if fatigued What method should be utilized when opening the airway of a patient who is suspected of having a head or neck injury? Jaw thrust When communicating with a team member, the team leader communicates by taking these steps: 1. The team leader gives a message, order, or assignment to a team member. 2. By receiving a clear response and eye contact, the team leader confirms that the team member heard and understood the message. 3. The team leader listens for confirmation of task performance from the team member before assigning another task. What type of communication do these steps represent? Closed-loop communication Which pulse is palpated when performing a BLS assessment on an adult? Carotid What do agonal gasps represent? Not normal breathing; is a sign of cardiac arrest How does one palpate a carotid pulse? Locate the trachea; slide 2-3 fingers into the groove between the trachea and the muscles at the side of the neck; feel for at least 5 seconds but no more than 10 seconds When should the victim be moved during chest compressions? Never unless the victim is in a dangerous environment (such as a burning building) or if you believe you cannot perform CPR effectively in the victim's present position or location How does one properly perform chest compressions on an adult during resuscitation efforts? 1. Make sure the victim is lying face-up on a firm surface. 2. Put the heel of one hand in the center of the victim's chest, on the lower half of the sternum. 3. Put the heel of your hand on top of the first hand. 4. Straighten your arms and position your shoulders directly over your hands. 5. Rate of 100-120/min. 6. Press down at least 2 in with each compression. 7. Allow for complete chest recoil. 8. Minimize interruptions in chest compressions. How does one properly perform the head tilt-chin lift technique? 1. Place one hand on the victim's forehead and push with your palm to tilt the head back. 2. Place the fingers of the other hand under the bony part of the lower jaw near the chin. 3. Lift the jaw to bring the chin forward. How does one properly perform the jaw thrust maneuver? 1. Place one hand on each side of the victim's head. You may rest your elbows on the surface on which the victim is lying. 2. Place your fingers under the angles of the victim's lower jaw and lift with both hands, displacing the jaw forward. 3. If the lips close, push the lower lip with your thumb to open the lips. How does one properly use a pocket mask to deliver breaths using the head tilt-chin lift technique? 1. Position yourself at the victim's side. 2. Place the pocket mask on the victim's face, using the bridge of the nose as a guide for correct position. 3. Seal the pocket mask against the face. Using the hand that is closer to the top of the victim's head, place the index finger and thumb along the edge of the mask. Place the thumb of your other hand along the edge of the mask. 4. Place the remaining fingers of your second hand along the bony margin of the jaw and lift the jaw. Perform a head tilt-chin lift to open the airway. 5. While you lift the jaw, press firmly and completely around the outside edge of the mask to seal the pocket mask against the face. 6. Deliver each breath over 1 second, enough to make the victim's chest rise. How does one properly use a bag mask device to deliver breaths? 1. Position yourself directly above the victim's head. 2. Place the mask on the victim's face, using the bridge of the nose as a guide for correct position. 3. Use the E-C clamp technique to hold the mask in place while you lift the jaw to hold the airway open. 4. Squeeze the bag to give breaths (1 second each) while watching for chest rise. A 53-year-old man suddenly collapses and becomes unresponsive. You witness him collapse and are the first rescuer to arrive at the scene. You find him lying motionless on the floor. What is the first action you should take in this situation? Verify that the scene is safe for you and the victim A 53-year-old man suddenly collapses and becomes unresponsive. You witness him collapse and are the first rescuer to arrive at the scene. You find him lying motionless on the floor. The man doesn't respond when you touch his shoulder and shout, "Are you OK?" What is your best next action? Check for breathing and carotid pulse; shout for nearby help A 53-year-old man suddenly collapses and becomes unresponsive. You witness him collapse and are the first rescuer to arrive at the scene. You find him lying motionless on the floor. Several rescuers respond, and you ask them to activate the emergency response and retrieve the AED and emergency equipment. As you check for a pulse and breathing, you notice that the man is gasping for air and making "snorting" sounds. You do not feel a pulse. What is your best next action? Start high-quality CPR, beginning with chest compressions How does one properly use an AED? 1. Open the carrying case and power on the AED. 2. Attach AED pads to the victim's bare chest. 3. When the AED prompts you, clear the victim and allow the AED to analyze the rhythm. 4. Resume chest compressions while the AED is charging. 5. Clear the victim when delivering a shock; resume compressions after the shock has been delivered. 6. If no shock is needed, immediately resume CPR starting with chest compressions. What are the two correct methods for placement of AED pads? Method 1. AKA Anterolateral Placement. Place one AED pad directly below the right collarbone. Place the other pad to the right side of the left nipple, with the top edge of the pad a few inches below the arm pit. Method 2. AKA Anteroposterior Placement. Place one AED pad on the left side of the chest, between the victim's left side of the breastbone and left nipple. Place the other pad on the left side of the victim's back, next to the spine. When placing AED pads on a patient with an implanted defibrillator or pacemaker, what precautions should be taken? Avoid placing AED pad directly over the implanted device What is the most appropriate first step to take as soon as the AED arrives at the victim's side? Power on the AED What action should you take when the AED is analyzing the heart rhythm? Stand clear of the victim How does one properly palpate a brachial pulse on an infant? 1. Place 2-3 fingers on the inside of the upper arm, midway between the elbow and the shoulder. 2. Then press the fingers to attempt to feel the pulse for at least 5 seconds but no more than 10 seconds. How does one properly palpate a femoral pulse on a child? 1. Place 2 fingers in the inner thigh, midway between the hipbone and the pubic bone and just below the crease where the leg meets the torso. 2. Feel for a pulse for at least 5 but no more than 10 seconds. What pulse location should be palpated when assessing an unresponsive infant? Brachial What pulse location should be palpated when assessing an unresponsive child? Femoral or carotid What is the correct hand placement for performing high-quality chest compressions on a child? 2 hands or 1 hand (optional for small child) on the lower half of the sternum What is the correct hand placement for performing high-quality chest compressions on an infant? 1 rescuer: 2 fingers in the center of the chest, just below the nipple line 2 or more rescuers: 2 thumb-encircling hands in the center of the chest, just below the nipple line What are some signs of poor perfusion? Cool extremities, altered mental status, weak pulses, pale skin, mottling, cyanosis What is the correct compression ratio for children and infants when two rescuers are present? 15:2 How does one properly perform 2 finger compression technique on an infant? 1. Place the infant on a firm, flat surface. 2. Place 2 fingers in the center of the infant's chest, just below the nipple line, on the lower half of the breastbone. 3. Give compressions at a rate of 100-120/min. 4. Compress at least one third the AP diameter of the infant's chest (about 1 1/2 in). 5. Allow for complete chest recoil. Minimize interruptions to less than 10 seconds. 6. After every 30 compressions, open the airway using head tilt-chin lift method and deliver two breaths. 7. After about 5 cycles (2 min) of CPR, if you are alone and the ERS has not been activated, leave the infant (or carry the infant with you) and activate the ERS and retrieve the AED. 8. Continue compressions and breaths at 30:2 ratio and use the AED as soon as it arrives. Continue until advanced providers take over or the infant begins breathing or moving. How does one properly perform 2 thumb-encircling hands technique on an infant? 1. Place the infant on a firm, flat surface. 2. Place both thumbs side by side in the center of the infant's chest, on the lower half of the breastbone. Thumbs may overlap in small infants. 3. With your hands encircling the chest, use both thumbs to depress the breastbone at a rate of 100-120/min. 4. Compress at least one third the AP diameter of the infant's chest (about 1 1/2 in). 5. After each compression, completely release the pressure on the breastbone and allow the chest to recoil completely. 6. After every 15 compressions, pause briefly for the second rescuer to open the airway with a head tilt-chin lift and give 2 breaths, each over 1 sec. 7. Continue compressions and breaths in a ratio of 15:2 (2 rescuer). The rescuer providing chest compressions should switch roles with another provider about every 5 cycles (2 min). Continue CPR until the AED arrives, advanced providers take over, or the infant begins to breath/move. Why is it important to ensure that the infant's head is kept in the neutral position? if you tilt (extend) an infant's head beyond the neutral (sniffling) position, the infant's airway may become blocked; you should ensure the infant's neck is in a neutral position so that the external ear canal is level with the top of the infant's shoulder What is the correct compression-to-ventilation ratio for a single rescuer of a 3-year-old child? 30:2 What is the correct compression-to-ventilation ratio for a 7-year-old child when 2 rescuers or more are present? 15:2 Adult pads should be used on what age victim? 8 years and older; may use them on infants if you do not have child pads What are two ways to open the victim's airway? Head tilt-chin lift and jaw thrust If the chest does not rise when you give a breath, what should you do? Reposition the head and try again What are signs and symptoms of mild airway obstruction? Still has good air exchange, can cough forcefully, may wheeze between coughs What are signs and symptoms of severe airway obstruction? Clutching throat with thumb and fingers, unable to speak/cry, poor or no air exchange, weak/ineffective cough or no cough at all, high-pitched noise while inhaling or no noise at all, increased respiratory difficulty, possible cyanosis If a patient presents with signs of mild airway obstruction, what should the actions of the rescuer be? Encourage the victim to continue coughing, do not interfere with the victim's own attempts to relieve the obstruction, stay with the victim and continue to monitor, if it continues or progresses to severe airway obstruction activate the ERS If a patient presents with signs of severe airway obstruction, what should the actions of the rescuer be? ask them if they are choking (adult or child), if the victim nods "yes" and cannot talk severe airway obstruction is present, take steps to immediately relieve the obstruction, if it continues and the victim becomes unresponsive start CPR, send someone for an AED and activate the ERS, if you are alone provide 2 min of CPR before leaving the patient to activate the ERS How does one properly perform the Heimlich maneuver? 1. Stand or kneel behind the victim and wrap your arms around the victim's waist. 2. Make a fist with one hand. 3. Place the thumb side of your fist against the victim's abdomen, in the midline, slightly above the navel and well below the breastbone. 4. Grasp your fist with your other hand and press your fist into the victim's abdomen with a quick, forceful upward thrust. 5. Repeat thrusts until the object is expelled from the airway or the victim becomes unresponsive. 6. Give each new thrust with a separate, distinct movement to relieve the obstruction. When are chest thrusts used instead of abdominal thrusts to relieve airway obstruciton? Pregnant or obese victims If you are performing the Heimlich maneuver on an adult or child or infant and they become unresponsive, what steps should be taken next? 1. Shout for help and send someone for an AED. 2. Lower the patient to the ground/flat surface. 3. Begin CPR, starting with compressions. Do not check for a pulse. 4. Each time you open the airway to give breaths, open the victim's mouth wide. Look for the object. If you see an object that can be easily removed, remove it with your fingers. If you do not see an object, continue CPR. 5. After about 5 cycles (2 min) of CPR, activate the ERS if not already done. When should a blind finger sweep be performed? Why? Never; may push the foreign body back into the airway, causing further obstruction or injury You are performing abdominal thrusts on a 9-year-old child when he suddenly becomes unresponsive. After you shout for nearby help, what is the most appropriate action to take next? Begin high-quality CPR, starting with chest compressions How does one properly performing choking relief in a responsive infant? 1. Kneel or sit with the infant in your lap. 2. If it is easy to do so, remove clothing from the infant's chest. 3. Hold the infant face-down with the head slightly lower than the chest, resting on your forearm. Support the infant's head and jaw with your hand. Take care to avoid compressing the soft tissues of the infant's throat. Rest your forearm on your lap or thigh to support the infant. 4. Deliver up to 5 back slaps forcefully between the infant's shoulder blades, using the heel of your hand. 5. After delivering up to 5 back slaps, place your free hand on the infant's back, supporting the back of the infant's head with the palm of your hand. The infant will be adequately cradled between your 2 forearms, with the palm of one hand supporting the face and jaw while the palm of the other hand supports the back of the infant's head. 6. Turn the infant as a unit while carefully supporting the head and neck. Hold the infant faceup, with your forearm resting on your thigh. Keep the infant's head lower than the trunk. 7. Provide up to 5 quick downward chest thrusts in the middle of the chest, over the lower half of the breastbone. Deliver chest thrusts at a rate of about 1 per second. 8. Repeat the sequence of up to 5 back slaps and up to 5 chest thrusts until the object is removed or the infant becomes unresponsive. If you encounter an unresponsive victim and suspect opioid overdose, what medication should be given in addition to providing BLS care/assessment? Naloxone (Narcan) Your 27-year-old roommate uses opioids. You find him unresponsive with no breathing, but a strong pulse. You suspect an opioid-associated life-threatening emergency. A friend is phoning 9-1-1 and is looking for the naloxone autoinjector. What action should you take? Begin CPR, starting with chest compressions You encounter an unresponsive 56-year-old man who has been taking hydrocodone after a surgical procedure. He is not breathing and has no pulse. You notice that his medication bottle is empty. You suspect an opioid-associated life-threatening emergency. A colleague activates the emergency response system and is retrieving the AED and naloxone. What is the most appropriate action for you to take next? Begin CPR, starting with chest compressions What are some potential signs and symptoms of an opioid overdose? Coma, Pinpoint pupils, Respiratory depression, Hypotension, Hypothermia, Hyporeflexia What is the therapeutic dose of Naloxone in the treatment of suspected opioid overdose? 2 mg intranasal or 0.4 mg intramuscular What is the antidote for Acetaminophen overdose? Acetylcysteine (Mucomyst) What is the antidote for alcohol withdrawal? Librium What is the antidote for Anticholinergics overdose? Physostigmine What is the antidote for Anticoagulant overdose? Vitamin K, FFP (fresh frozen plasma) What is the antidote for aspirin overdose? Sodium bicarbonate What is the antidote for beta blocker overdose? Glucagon What is the antidote for Benzodiazepine overdose? Romazicon (Flumazenil) What is the antidote for Calcium channel blocker overdose? Calcium, Glucagon, Insulin What is the antidote for Carbon monoxide poisoning? Oxygen What is the antidote for Cholinergic overdose? Atropine, Pralidoxine (2-PAM) What is the antidote for Coumadin overdose? Vitamin K What is the antidote for Cyanide overdose? Tydroxycobalamin, Sodium thiosulfate What is the antidote for Digoxin overdose? Digoxin immune Fab (Digibind or Digifab) What is the antidote for Ethylene glycol overdose? Fomepizole, Ethanol What is the antidote for Heparin overdose? Protamine sulfate What is the antidote for heavy metal poisoning (iron, mercury, arsenic, and lead) poisoning? Chelation therapy What is the antidote for Hydrofluoric Acid overdose? Calcium gluconate What is the antidote for Insulin overdose? Glucose What is the antidote for Isoniazid overdose? Deferoxamine What is the antidote for Magnesium sulfate overdose? Calcium gluconate What is the antidote for Methanol overdose? Ethanol What is the antidote for Methemoglobin overdose? Methylene blue What is the antidote for Methotrexate overdose? Leucovorin What is the antidote for Opioid overdose? Naloxone (Narcan) What is the antidote for SSRI overdose? Cyproheptadine What is the antidote for Sulfonylurea overdose? Octreotide (Somatostatin) What is the antidote for Tricyclic antidepressants overdose? Sodium bicarbonate Which drug is described: Competitively blocks the effects of opioids, including CNS and respiratory depression, without producing any agonist (opioid-like) effects Naloxone (Narcan) The normal pacemaker of the heart is the: SA node On ECG graph paper, the horizontal axis measures: Time What are some causes of U waves? Hypokalemia, hypercalcemia, digoxin toxicity A patient presents with normal sinus rhythm on the cardiac monitor. What should be done next? Assess patient. Be sure to check pulses and electrode placement; Continue to monitor. Describe the key characteristics of normal sinus rhythm. Rhythm: Regular Rate: 60-100 beats per minute QRS Duration: Normal P wave: visible before each QRS complex P-R Interval: Normal What six questions should be asked when analyzing an ECG rhythm? 1. Determine the rhythm. 2. Determine the rate. 3. P wave present? Normal? 4. QRS duration? QRS complexes normal? 5. PR interval present? Normal? 6. T waves present? Normal? What does the P wave represent? Atrial depolarization; originates in SA node Normal duration: 0.10 seconds or less What does the PR interval represent? Represents the time from the onset of atrial depolarization to the onset of ventricular depolarization; the electrical firing of the atria and conduction of that electrical impulse through the AV node to the ventricles; includes a P wave and the short isoelectric line that follows it Normal duration: 0.12-0.20 seconds What does the QRS complex represent? Ventricular depolarization (right and left ventricles); composed of three wave deflections including the Q wave, R wave, and S wave Normal duration: 0.06-0.10 seconds What does the ST segment represent? Represents early ventricular repolarization; is the flat line between the QRS complex and the T wave Normal duration: 0.08-0.12 seconds What does the T wave represent? Ventricular repolarization; begins as the deflection gradually slops upward from the ST segment and ends when the waveform returns to baseline Normal duration: 0.01-0.25 seconds What does the QT interval represent? Represents the time between the onset of ventricular depolarization and the end of ventricular repolarization; is measured from the beginning of the QRS complex to the end of the T wave Normal duration: varies according to age, sex, and particular heart rate Can be determined by multiplying the number of small squares the the QT interval by 0.04 second The spread of the electrical stimulus through the heart muscle, producing the P wave from the atria and the QRS complex from the ventricles Depolarization The recovery of the stimulated muscle to the resting state, producing the ST segment, the T wave, and the U wave Repolarization On ECG paper, how much time is represented by one small box? 0.04 seconds On ECG paper, how much time is represented by one large box (5 small boxes)? 0.20 seconds Describe the characteristics of Premature Atrial Contractions. •Rhythm: Irregular •Rate: 60-100 bpm •P waves: Odd appearance in the ectopic beat but normal un underlying rhythm •QRS complexes: 0.12 sec •PR Interval: Variant with ectopic beat but looks normal in underlying rhythm •T waves: Usually normal but may be distorted •PACs originate outside the SA node often as an irritable focus in the atria which supersedes the SA node for 1-2 beats Describe the characteristics of Premature Ventricular Contractions. - Rhythm: Irregular - Rate: Variant - P waves: Absent in the ectopic beat - QRS complexes: Wide during the PVC but normal in underlying rhythm; Premature §PR Interval: Normal in underlying rhythm - T waves: Occur in the opposite direction of the QRS complex - PVCs are ectopic beats that originate low in the ventricles and occur earlier than expected. What are four different types of PVCs? Couplet PVCs: Two PVCs in a row Multifocal PVCs: Arise from different sites or the same site with abnormal conduction so they look different. Bigeminy PVCs: PVCs that occur every other beat. R on T Phenomenon: Refers to PVCs occurring so early that it falls on the T wave of the preceding beat. V tach or V fib could occur because the cells haven’t fully repolarized. Describe the key characteristics of sinus bradycardia. Rhythm: Regular Rate: less than 60 beats per minute QRS Duration: Normal P Wave: Visible before each QRS complex P-R Interval: Normal A patient with symptomatic sinus bradycardia at a rate of 40 beats/minute typically experiences: Hypotension and dyspnea For a patient with symptomatic sinus bradycardia, appropriate nursing interventions include establishing IV access to administer: Administer 0.5 mg Atropine IV push q 5 min until the resolved or a maximum dose of 3 mg is given. A patient that is experiencing symptomatic sinus bradycardia. Atropine has been given with no improvement. What should be the next intervention? A transcutaneous (external) or transvenous pacemaker may be needed A patient that is experiencing symptomatic sinus bradycardia. Hypotension is noted upon assessment. What two drugs may be given to reverse the hypotension? Dopamine IV infusion: usual infusion rate is 2-20 mcg/kg per min. Titrate to patient response, taper slowly. Epinephrine IV infusion: 2-10 mcg/kg per min infusion. Titrate to patient response. For a patient with asymptomatic sinus bradycardia, appropriate nursing interventions include: Monitor closely Why is mild bradycardia beneficial to some patients such as patients with acute MI? Decreases the workload on the heart What are some common causes of sinus bradycardia? Normal in athletes/sleep, hyperkalemia, hypoxia, hypoglycemia, vagal stimulation, increased intracranial pressure, drugs, etc Describe the key characteristics of first degree AV heart block. Rhythm: Regular Rate: 60-100 beats/minute P wave: normal; P-waves and R-waves; P-wave always accompanying the QRS complex PR interval: 0.20 second but constant T wave: normal QT interval: 0.40 second QRS complex will measure normal PR INTERVAL WILL BE PROLONGED (greater than 0.20 sec) Impulses from the atria are consistently delayed during conduction through the AV node so conduction takes longer than normal. No treatment is necessary if the patient has the form of AV block known as: First-degree AV block Describe the key characteristics of second degree AV block type I Wenckebach or Mobitz I. NO Pattern Missing QRS Complexes after p-waves randomly More than one P wave before each QRS complex (usually two or three, but sometimes more); Rhythm would be described as Mobitz II with 2:1 or 3:1. Non-conducted p-waves (electrical impulse conducts through the AV node but complete conduction through the ventricles is blocked, thus no QRS) P-waves are not preceded by PR prolongation as with second-degree AV block (Type 1) Fixed PR interval The QRS complex will likely be wide: The QRS on an ECG will most likely be wide because the block occurs in the His bundle or bundle branches and conduction through the ventricles is slowed. This slowing of conduction appears as a wide QRS complex on the ECG. What is the treatment plan for a patient with second degree AV block type I Wenckebach or Mobitz I? No treatment if asymptomatic; atropine to improve AV conduction; temporary pacemaker insertion In type I second-degree AV block, the PR interval: Progressively lengthens until a QRS complex is dropped Describe the key characteristics of second degree AV block type II Mobitz II. P-waves will be regular, however R-waves will NOT PR interval will measure normal (most of the time; may be prolonged) NO Pattern Missing QRS Complexes after p-waves randomly More than one P wave before each QRS complex (usually two or three, but sometimes more); Rhythm would be described as Mobitz II with 2:1 or 3:1. What is the treatment plan for a patient with second degree AV block type II Mobitz II? Temporary or permanent pacemaker insertion; atropine, dopamine, or epinephrine for symptomatic bradycardia; discontinuation of digoxin if appropriate Type II second-degree AV block is generally considered more serious than type I because in most cases of type II the: Atrial rate rises above 100 beats/min (decreased cardiac output) AV block can be caused by inadvertent damage to the heart's conduction system during cardiac surgery. Damage is most likely to occur in surgery involving which area of the heart? Mitral or tricuspid valve Describe the key characteristics of third degree AV block or Complete Heart Block. P-waves will be Regular and R-waves will be Regular P-wave will not accompany QRS complexes and vice versus, hence no relationship between the atriums and ventricles You can't measure a PR interval because the atriums and ventricles are independent What is the treatment plan for a patient with third degree or complete heart block? Correction of the underlying cause; atropine or isoproterenol to restore synchrony; pacemaker insertion Describe the key characteristics of sinus tachycardia. Rhythm: Regular Rate: Usually between 100 - 150 beats per minute QRS Duration: Normal P Wave: Visible before each QRS complex P-R Interval: Normal Persistent tachycardia in a patient who has had an MI may signal: Impending heart failure or cardiogenic shock Beta-adrenergic blockers such as metoprolol and atenolol, and calcium channel blockers, such as diltiazem may be used to treat the sinus arrythmia: Sinus tachycardia What are some common causes of sinus tachycardia? Stimulants, withdrawal, anemia, hypoxia, hypovolemia, shock, drugs, pulmonary embolism Describe the key characteristics of supraventricular tachycardia (SVT). Narrow complex tachycardia Rhythm: Regular Rate: 150 beats per minute QRS Duration: Usually normal P Wave: Often buried in preceding T wave P-R Interval: Depends on site of supraventricular pacemaker What are the interventions for the treatment of supraventricular tachycardia (SVT)? Vagal stimulation, carotid massage, Adenosine (6, 12, 12 mg) (chemical cardioversion), meds not working then try cardioversion or catheter ablation Describe the key characteristics of atrial fibrillation. Rhythm: Irregularly irregular Rate: usually 100-160 beats per minute but slower if on medication - Controlled: 60-100 bpm - Uncontrolled: 100-150 bpm - RVR: 150 bpm QRS Duration: Usually normal P Wave: Not distinguishable as the atria are firing off all over P-R Interval: Not measurable What are some complications of atrial fibrillation? Thrombus formation leading to pulmonary or systemic embolization What assessment should be performed frequently in the patient with atrial fibrillation? Neuro assessment What can be given to the patient with atrial fibrillation or atrial flutter as prophylaxis for thromboembolism? Anticoagulants What is the goal of treatment for atrial fibrillation and/or atrial flutter? Control the rate and prevent complications What are some treatment methods for controlling the rate of atrial fibrillation and/or atrial flutter? Meds (calcium channel blockers, beta blockers, etc.), cardioversion, an anti-arrhythmic such as amiodarone, catheter ablation, maze procedure If a patient presents with unstable atrial fibrillation or atrial flutter, what is the immediate treatment? Cardio version What is the treatment for a patient with stable atrial fibrillation and/or atrial flutter? TX aimed at controlling ventricular rate and providing anticoagulation; may need pacemaker Describe the key characteristics of atrial flutter. Rhythm: Atrial: regular; Ventricular: may be irregular Rate: Atrial: 250-400 bpm; Ventricular: variable QRS Duration: usually normal P Wave: Normal P waves are absent; flutter waves (f waves), (sawtooth pattern) P-R Interval: Not measurable Describe the key characteristics of ventricular tachycardia (monomorphic). Rhythm: regular Rate: 250 bpm QRS Duration: 0.16 sec P Wave: unidentified P-R Interval: not measurable What drug would be given for the treatment of stable ventricular tachycardia (monomorphic)? Amiodarone (150 mg in 100 mL D5W) is given as an IVPB bolus over 10 minutes. An additional 150 mg IVPB bolus can be repeated in 10 minutes for resistant VT. Once the rhythm converts to a stable rhythm, an amiodarone maintenance infusion should be started to prevent reoccurrence of VT. If amiodarone is not successful in the treatment of stable ventricular tachycardia (monomorphic), what is the next intervention? Sedate the patient and perform synchronized cardioversion beginning at 100 J biphasic energy dose What is the treatment for ventricular tachycardia (monomorphic) with a pulse? Give oxygen. IV x 2. Sedate patient if conscious, and perform synchronized cardioversion beginning at 100 J. Drug therapy would include amiodarone and/or lidocaine. What is the treatment for ventricular tachycardia (monomorphic) with no pulse? Begin CPR and follow ACLS protocol for Cardiac Arrest Describe the key characteristics of ventricular tachycardia (polymorphic). Ex: Torsade de Pointes Rhythm: regular Rate: 250 bpm QRS Duration: 0.12-0.16 sec or more P Wave: unidentified P-R Interval: not measurable What electrolyte imbalance is a common cause of torsade de pointes? Hypokalemia, Hypomagnesemia What is the treatment for ventricular tachycardia (polymorphic)? Isoproterenol infusion, cardiac pacing, and intravenous atropine. Intravenous magnesium sulfate, a relatively new mode of therapy for torsade de pointes, was proven to be extremely effective and is now regarded as the treatment of choice for this arrhythmia. PVCs are most dangerous if they: Are multiformed and increase in frequency The treatment of choice for a patient with ventricular fibrillation is: Defibrillation; follow ACLS protocol for Cardiac Arrest Describe the key characteristics of ventricular fibrillation. Rate: not discernible Rhythm: rapid, unorganized, not discernible QRS Duration: none P wave: Recognizable P waves are absent; wavy, irregular deflections are seen, which vary in size, shape, and height representative of quivering of the ventricles instead of contraction P-R Interval: none Describe the key characteristics of pulseless electrical activity. A clinical situation (not a specific arrhythmia) in which an organized cardiac rhythm (excluding pulseless VT) is observed on the monitor but no pulse is palpated. Rhythm: Regular Rate: 60-100 beats per minute QRS Duration: Normal P wave: visible before each QRS complex P-R Interval: Normal Signs & Symptoms: Pulselessness, Loss of consciousness, No palpable BP What is the treatment of pulseless electrical activity? Determine cause & treat CPR Epinephrine 1 mg q 3-5 min Initiate ACLS Cardiac Arrest protocol Describe the key characteristics of asystole. Rhythm: none Rate: none QRS Duration: none P Wave: none P-R Interval: none What is the treatment of asystole? Check pulse and rapidly assess the patient. Check monitor lead system (a loose electrode pad or lead wire will show a straight line). Start CPR and establish an IV line. Intubate the patient when possible. Give epinephrine 1 mg IV push and repeat every 3 to 5 minutes. Continue CPR to circulate the drug. Consider the underlying reversible causes of the rhythm (the so-called Hs and Ts) Follow ACLS Cardiac Arrest Protocol. What are the key characteristics of junctional rhythm? Rhythm: Regular Rate: 40-60 bpm P waves: Inverted in lead II and occurs immediately before the QRS complex, occurs immediately after the QRS complex, or is hidden within the QRS complex PR interval: short (0.10 second or less) QRS complex: normal (0.10 second or less) What is the treatment for symptomatic junctional rhythm? Follows the protocols for significant bradycardia (atropine, pacing, and vasopressors to increase blood pressure). Treatment should also be directed at identifying and correcting the underlying cause of the rhythm if possible. All medications should be reviewed and discontinued if indicated. Describe the key characteristics of STEMI. Tombstone appearance Elevated ST wave Progression to Q wave Full blockage of the coronary artery Describe the key characteristics of NSTEMI. Depressed ST wave or t-wave inversion No progression to Q wave Partial blockage of the coronary artery What is closed-loop communication? The team leader should call each team member by name and make eye contact when giving an instruction. They should not assign additional tasks until they are sure that the team member understands the instruction. The team leader should confirm that they understand each task to which they are assigned by verbally acknowledging the task. They should tell the team leader when they have finished a task. After performing high-quality CPR for 5 minutes, the team leader frequently interrupts chest compressions to check for a pulse even though the victim has no organized rhythm when the AED analyzes the rhythm. What action would demonstrate constructive intervention? Suggest to resume chest compressions without delay The team leader asks you to perform bag-mask ventilation during a resuscitation attempt, but you have not perfected that skill. What would be an appropriate action to acknowledge your limitations? Tell the team leader that you are not comfortable performing the task and ask for a different assignment What is the appropriate action to demonstrate closed-loop communication when the team leader assigns you a task? Repeat back to the team leader the task you were assigned Which team member is responsible for assigning roles? Team leader Which team member makes treatment decisions? Team leader Which team member provides feedback to the rest of the team as needed? Team leader Which team member assumes responsibility for roles not assigned? Team leader Which team member focuses on comprehensive patient care? Team leader Which team member is constantly reevaluating the patient’s status, interventions that have been performed, and assessment findings? Team leader Which team member opens the airway, provides bag-mask ventilation, and inserts airway adjuncts as appropriate? Airway or ventilator Which team member brings and operates the AED/monitor/defibrillator? Defibrillator Which team member alternates with compressor every 5 cycles or 2 minutes (or earlier if signs of fatigue set in), ideally during rhythm analysis? Defibrillator Which team member places the AED monitor in a position where it can be seen by the Team Leader (and most of the team)? Defibrillator Which team member assesses the patient and does 5 cycles of chest compression's? Compressor Which team member alternates with defibrillator every 5 cycles or 2 minutes (or earlier if signs of fatigue set in), ideally during rhythm analysis? Compressor Which team member initiates IV/IO access and administers medications? Medicator Which team member records the time of interventions and medications (and announces when these are next due), records the frequency and duration of interruptions in compression's, and communicates these to the Team Leader (and the rest of the team)? Recorder What should be done next if you find an unconscious victim and are unsure if a pulse is present? Begin cycles of compressions and ventilations What are the steps involved in the BLS assessment? Check responsiveness, shout for help and activate the emergency response system/get AED, check for breathing and pulse, defibrillation Interruptions in chest compressions should be limited to? Less than 10 seconds If one finds a patient that is unconscious, what assessment should be performed? BLS assessment If one finds a patient that is conscious, what assessment should be performed? Primary & Secondary assessment What mnemonic is used to remember the components of the Primary Assessment? ABCDE Airway, Breathing, Circulation, Disability, Exposure How is airway assessed during the Primary Assessment? Maintain airway patency in unconscious patients. Use advanced airway if needed. Confirm CPR/ventilation/secure device. Monitor airway placement with continuous waveform capnography How is breathing assessed during the Primary Assessment? Give supplementary oxygen as needed: - 100% oxygen for arrest patients - Titrate oxygen for stable patients (O2 sat 94%) Avoid excessive ventilation Assess chest rise, presence of cyanosis, waveform capnography, oxygen saturation. Agonal gasp are NOT signs of normal breathing (first sign of cardiac arrest). Start CPR immediately. How is circulation assessed during the Primary Assessment? Monitor CPR quality. Assess waveform capnography, intra-arterial pressure. Attach Monitor /Defibrillator/AED Using AED: o Attach pads & Turn on AED. o Continue compressions while AED is charging. o Clear patient when analyzing rhythm and when shocking. o Follow prompts. Obtain IV/IO access. Give appropriate medications and administer IV/IO fluids. Check glucose/temperature/capillary refill/perfusion issues. How is disability assessed during the Primary Assessment? Check for neurological function. Quickly assess for responsiveness (LOC, pupil dilation). AVPU (alert, voice, painful, unresponsive). How is exposure assessed during the Primary Assessment? Remove clothing: assess for obvious signs of trauma, bleeding, burns, markings, medical alert bracelets. What is the purpose of the secondary assessment? Involves the differential diagnosis, including a focused medical history and searching for and treating underlying causes (H's and T's) What mneumonic is used to remember the components of the Secondary Assessment? SAMPLE Signs and Symptoms, Allergies, Medications (including the last dose taken), Past medical history (especially relating to the current illness) & Pain characteristics (if patient is conscious), Last meal consumed and Liquids consumed, Events What are some basic questions to ask when assessing the patient? What happened? When did the symptoms start? What were you doing when the symptoms started? Do you have difficulty breathing? What other symptoms do you have? Are you allergic to anything? Do you take any medication? Do you have any medical problems? Have you had anything to eat or drink today? Have you had any of the following: a stroke, a bleeding disorder, internal bleeding, recent surgery, or trauma? Do you have any pain? Does anything lessen the pain or make you feel better? Does anything make the pain worse? Can you describe the pain? Does the pain go anywhere? On a scale of 0 to 10, how bad is the pain? Blood pressure, Pulse ox, Temperature, 12 lead ECG, Start IV, Targeted body systems assessment, Troponin test, Measure glucose, Arterial puncture, Venous blood sample What are the two most common underlying and potentially reversible causes of PEA? Hypervolemia and hypoxia What are the H's and T's? Hypervolemia, Hypoxia, Hypoglycemia, H+ Ion Excess (Acidosis), Hyper/Hypokalemia (acidosis), Hypothermia, Tension pneumothorax, Cardiac Tamponade, Thrombosis (pulmonary or coronary), Toxins, Trauma What is Hypervolemia? A sudden and significant decrease in the volume of blood and fluids in the body. What are some causes of Hypervolemia? - Loss of fluid from anywhere (thoracentesis, paracentesis, vomiting, diarrhea, hemorrhage) - Third spacing (burns, ascites) - Diseases with polyuria (diabetes mellitus) - Loss of blood (internal or external) - Inadequate fluid intake - Severe dehydration What are some signs and symptoms of Hypovolemia? - Pulse is weak/rapid/thready - Rapid, narrow complex tachycardia - Lowering BP (↑diastolic, ↓systolic) - Flat neck veins - Increased respirations (body thinks it is hypoxic) - Decreased CVP - Cool extremities (peripheral vasoconstriction in an effort to shunt blood to the vital organs) - Increased urine specific gravity What is the treatment of Hypovolemia? - Obtain IV/IO access - Administer fluids/blood products - Stop the cause What is Hypoxia? When the body is deprived of sufficient oxygen supply. What are some causes of Hypoxia? - Lack of oxygen (d/t high altitude, fire, drowning, etc.) - Lung disease - Chemical or gas poisoning What are some signs and symptoms of Hypoxia? - Early: Restlessness, Anxiety, Tachycardia, Tachypnea - Late: Bradycardia, Extreme restlessness, Dyspnea - Cyanosis - Respiratory distress What is the treatment of Hypoxia? - Monitor pulse oximetry, ET tube placement, ABGs - Ensure airway is open - Increase oxygen intake - Ventilate/intubate - Stop the cause What is Hypoglycemia? Low blood sugar (70) What are some causes of Hypoglycemia? - Drinking too much alcohol - Medications - Anorexia - Hepatitis - Adrenal/pituitary gland disorders - Kidney problems - Pancreatic tumor - Diabetes - Insulin overdose What are some signs and symptoms of Hypoglycemia? - BS 70 - Diaphoresis, tachycardia palpitations - Nervousness, shakiness, weakness - Extreme hunger, slight nausea - Dizziness, headache - Blurred vision - Fast heart rate - Slurred speech - Muscle twitching, seizures - LOC/coma - Stroke What si the treatment of Hypoglycemia? - DX bedside glucose testing - Complex carbohydrates PO - 15-15-15 Rule: 15 g glucose, wait 15 min, measure BS, repeat if hypoglycemia persists - Glucagon 1 unit IM/IV (decreases GI motility, monitor for N/V) - 50% dextrose if unable to take oral carbs (irritates veins) - Beta adrenergic blocking agents may mask signs of hypoglycemia What is Acidosis? Improper pH level caused by too much acid (lactic acidosis) in the body. What are some causes of Acidosis? - Respiratory: lung disease, pulmonary edema, pneumonia, pneumothorax, buildup of CO2 (drug overdose, airway obstruction), etc. - Metabolic: DKA/AKA, starvation, cancer, liver failure, shock, severe diarrhea, fistulas, renal failure, salicylate overdose, etc. What are some signs and symptoms of Acidosis? - Low amplitude QRS complex - ABG: ↓ pH,↑ CO2,↓ HCO3 - Respiratory: hypoventilation, hypoxia, rapid/shallow respirations, cyanotic skin, headache, hyperkalemia, drowsiness, muscle weakness, hyperreflexia - Metabolic: headache, ↓ BP, hyperkalemia, muscle twitching, warm/flushed skin, N/V, ↓ muscle tone and reflexes, Kussmaul respirations What is the treatment of Acidosis? - Respiratory: ventilate, antidote for overdose - Metabolic: sodium bicarbonate - Monitor ABGs - Stop the cause What is Hypokalemia? Too little potassium in the body What are some causes of Hypokalemia? - Vomiting, NG suction (normally have a lot of K in stomach) - Diuretics - Not eating - Cushing's disease What are some signs and symptoms of Hypokalemia? - Muscle cramps, muscle weakness - Flat T waves, U waves, Prolonged QT interval, PVCs, ventricular tachycardia - Metabolic alkalosis What is the treatment of Hypokalemia? - Potassium (never IV push, needs rapid IV infusion) - Spironolactone (aldactone) - Hypokalemia can cause digoxin toxicity What is Hyperkalemia? Too much potassium in the body. What are some causes of Hyperkalemia? - Spironolactone (aldactone) - Kidney failure - Addison's disease What are some signs and symptoms of Hyperkalemia? - Begins with muscle twitching, then proceeds to muscle weakness, then flaccid paralysis - Bradycardia, Tall, peaked T waves, flat or absent P waves, widened QRS, prolonged PR interval, ventricular fibrillation - Metabolic acidosis What is the treatment of Hyperkalemia? - Dialysis - Calcium gluconate to decrease arrythmias - Insulin (insulin carries glucose and potassium into the cells) - Sodium polystyrene sulfonate (kayexalate) What is Hypothermia? When the body loses the ability to keep itself warm. What are some causes of Hypothermia? Extreme and/or prolonged exposure to cold weather and/or water What are some signs and symptoms of Hypothermia? - Body temperature 35 degrees Celsius or 95 degrees Fahrenheit - Shivering - Sinus bradycardia, associated with progressive prolongation of the PR interval, QRS complex, and QT interval; J or Osborne waves What is the treatment for Hypothermia? - Passive and active warming measures to restore body to normal temperature - Assess core body temperature (rectal temp) - Remove any wet clothing - Keep patient horizontal - Avoid sudden movement of patient - Monitor cardiac rhythm What is tension pneumothorax? When air enters the pleural space but is unable to exit, causing a buildup in the pleural space. What are some causes of tension pneumothorax? - Chest trauma - Myocardial rupture - Pericarditis - Hemorrhage post-CABG What are some signs and symptoms of tension pneumothorax? - Subcutaneous emphysema - Diminished/absent/unequal lung sounds - Respiratory distress - Cyanosis - ↑ CVP d/t ↑ pressure in chest - Hypotension, tachycardia - Narrow QRS, T wave inversion - JVD - Tracheal deviation away from affected side (late sign) - Distended neck veins What is the treatment of tension pneumothorax? - Needle decompression/needle aspiration - Large bore needle placed into the 2nd intercostal space (by primary HCP) to allow excess air to escape - Chest tube insertion (thoracostomy) - Diagnosed by chest x-ray, ABG results, bedside ultrasound What is coronary thrombosis? Blockage of the heart's coronary artery/arteries. What are some causes of coronary thrombosis? - Blood clots - Myocardial infarction What are some signs and symptoms of coronary thrombosis? - ST elevation, Non-STEMI, T wave inversion, Q waves present - Elevated CPK-MB, Troponin, Myoglobin - Crushing chest pain - Women, diabetics, and elderly: indigestion or feeling of fullness, epigastric discomfort - Pain between shoulders, aching jaw, choking sensation, chronic fatigue - SOB - Cold/clammy skin - Hypotension - Vomiting What is the treatment of coronary thrombosis? - Administer Aspirin (160-325 mg), Oxygen (maintain O2 sat 90%), Nitroglycerin (sublingual or spray), Morphine IV if not relieved by nitro - Nitro admin teaching: take 1 every 5 min x 3 doses, chest pain is still there go to ER - Vasopressors if needed - Fibrinolytics - Percutaneous coronary intervention (PCI) - Angioplasty - Stent placement - CABG What is pulmonary thrombosis? Blockage of the lungs main artery (pulmonary artery) caused by a thrombus or blood clot, but it can be air, fat, or even amniotic fluid in the maternity client. What are some causes of pulmonary thrombosis? - Blood clots - Pulmonary embolism - Dehydration - Venous stasis from prolonged immobility or surgery - Birth control pills - Pregnancy - Clotting disorders or heart arrhythmias like A-fib What are some signs and symptoms of pulmonary thrombosis? - Rapid heart rate, Narrow QRS - Hypoxemia, Shortness of breath, Anxiety, Decreased oxygen, Decreased PaO2 - Chest pain - History of DVT or PE - Petechiae over chest - Cyanosis - Hemoptysis - Increased CVP - Atelectasis, Crackles - Pulmonary hypertension - Syncope - Low-grade fever - Respiratory alkalosis - EKG Changes: RBBB, Right axis deviation on ECG, tall peaked T waves in lead II, and Vs strain pattern, ST elevation in V1 and V2, PEA What is the treatment of pulmonary thrombosis? - Maintain airway, fluids, anticoagulation - Maintain cardiac output (inotropes, fluids) - Fibrinolytics, Thrombolytics - Embolectomy - Dopamine - rtPA - Analgesics - Diagnosis: increased d-dimer, computerized tomography angiogram (CTA), positive VQ scan, pulmonary angiography, bedside ultrasound, venous doppler - Monitor CVP d/t pulmonary HTN that leads to increased right atrial pressure leading to right HF aka cor pulmonale. What are some signs and symptoms of toxin overdose? - Neuro changes - Bradycardia, Bradypnea - Pinpoint pupils - Prolonged QT interval What is the treatment of toxin overdose? - Specific antidote based on overdose agent - Support circulation and ventilation - Vasopressors for hypotension What are some examples of advanced airways? Laryngeal mask airway, supraglottic airway device, endotracheal intubation What are some examples of non advanced airways? Mouth-to-mouth, bag mask device, pocket mask What is the compression to breath ratio for an adult with a non advanced airway? 30:2 What is the compression to breath ratio for an adult with an advanced airway? Continuous compressions without pause for breaths; 1 breath every 6 second (10 breaths per minute) What is the compression to breath ratio for a child or infant with a non advanced airway? 30 compressions to 2 breaths (1 rescuer); 15 compressions to 2 breaths (2 rescuer) What is rescue breathing? Giving breaths to an unresponsive victim who has a pulse but is not breathing What rules are applied to rescue breathing in an unresponsive adult? Give 1 breath every 5-6 seconds (about 10-12 breaths per minute); give each breath in 1 second; each breath should result in visible chest rise; check the pulse about every 2 minutes What rules are applied to rescue breathing in an unresponsive infant or child? Give 1 breath every 3-5 seconds (12-20 breaths per minute); give each breath in 1 second; each breath should result in visible chest rise; check the pulse about every 2 minutes How often should rescue breaths be given in infants and children when a pulse is present? 1 breath every 3-5 seconds What actions can rescuers perform to potentially reduce the risk of gastric inflation? Deliver each breath over 1 second, deliver just enough air to make the victim's chest rise What type of airway adjunct may be used in patients that are unconscious and have no gag reflex? Oropharyngeal airway (OPA) How does one properly measure for placement of an Oropharyngeal airway (OPA)? Place it against the patient's cheek, when the flange of the OPA is at the coroner of the mouth, the tip is at the angle of the mandible. What are the steps for properly inserting an Oropharyngeal airway (OPA)? 1. Clear the mouth and pharynx of secretions, blood, or vomit by using a rigid pharyngeal suction tip if possible. 2. Select the OPA size. 3. Insert the OPA so that it curves upward toward the hard palate as it enters the mouth. 4. As the OPA passes through the oral cavity and approaches the posterior wall of the pharynx, rotate it 180 degrees into the proper position. The OPA can also be inserted at a 90 degree angle to the mouth and then turned down toward the posterior pharynx as it is advanced. In both methods, the goal is to curve the device around the tongue so that the tongue is not inadvertently pushed back into the pharynx rather than being pulled forward by the OPA. An alternative method is to insert the OPA straight in while using a tongue depressor or similar device to hold the tongue forward as the OPA is advanced. What type of airway adjunct may be used in patients that are conscious, semiconscious, or unconscious, and present with or without a gag reflex? Nasopharyngeal airway (NPA) How does one properly measure for placement of a Nasopharyngeal airway (NPA)? Make sure the length of the NPA is the same as the distance from the tip of the patient's nose to the earlobe. What are the steps for properly inserting an Nasopharyngeal airway (NPA)? 1. Select the proper size NPA. 2. Lubricate the airway with a water-soluble lubricant or anesthetic jelly. 3. Insert the airway though the nostril in a posterior direction perpendicular to the plane of the face. Pass it gently along the floor of the nasopharynx. If you encounter resistance: • Slightly rotate the tube to facilitate insertion at the angle of the nasal passage and nasopharynx. • Attempt placement through the other nostril because patients have different-size nasal passages. What rules should be applied when suctioning a patients airway? - Suction airway immediately if there are copious secretions, blood, or vomit. - Attempts at suctioning should not exceed 10 seconds. - To avoid hypoxemia, follow suction attempts with a short period of 100% oxygen administration. - Monitor the individual's heart rate, oxygen saturation, and clinical appearance during suctioning. How can one assess for proper placement of an endotracheal tube after intubation? visualizing the passage of the tracheal tube between the vocal cords, auscultating the presence of bilateral breath sounds, confirming the absence of sounds over the epigastrium during ventilation, observing adequate chest rise with each ventilation, determining the absence of vocal sounds after the placement of the tracheal tube, measuring the level of EtCO2 (continuous waveform capnography is preferred), verifying tube placement with the use of an EDD (esophageal detector device), obtaining a chest radiograph, ultrasound imaging Give a brief summary of the steps for assisting with intubation. • Prepare for intubation by assembling the necessary equipment (IV, ECG, oximeter, BVM, suction, ETT, CO2 detector). • Place patient in sniff position, hyperventilate with O2. • Spinal motion restriction, as needed. • Give sedative: o Midazolam, 0.1-0.3 mg/kg IV/IO o Propofol, 1-2 mg/kg IV/IO o Ketamine, 1-2 mg/kg IV/IO o Etomidate, 0.3 mg/kg IV/IO o Fentanyl 2-5 mcg/kg IV/IO • If patient 2 years old, consider atropine, 0.02 mg/kg IV/IO (may block reflex bradycardia) • Give neuromuscular blocker: o Succinylcholine, 1-1.5 mg/kg IV/IO o Rocuronium, 0.6-1.2 mg/kg, IV/IO o Vecuronium, 0.1-0.2 mg/kg, IV/IO • Perform endotracheal intubation • Inflate cuff or