ACLS Heartcode 2025 Questions & Answers, 100% Correct, Latest Complete Solution

a system is a group of interdependent components that regularly interact to form a whole what is a system? -structure -processes -system -patient outcomes what are the 4 elements of an integrated system of care? the system: -provides the links for the chain of survival -determines the strength of each link and of the chain -determines the ultimate outcome -provides collective support and organization what does an integrated system of care do? system of care healthcare delivery requires structure (eg people, equipment, education) and processes (eg policies, protocols, procedures) that when integrated produce a system (eg programs, organizations, cultures) leading to outcomes (eg patient safety, quality, and satisfaction). what is this integrated response known as? -systematically evaluating care and outcome -creating benchmarks with stakeholder feedback -strategically addressing identified deficiencies the continuous quality improvement process consists of an iterative cycle of what? -people -education -equipment with the integrated system of care, what makes up the structure? -protocols -policies -procedures with the integrated system of care, what makes up the process? -programs -organization -culture with the integrated system of care, what makes up the system? -training healthcare providers to become more knowledgeable about what improves survival rates -proactive planning and simulation of cardiac arrest to provide the opportunity for the provider to practice and improve responding to cardiac arrest -rapidly recognize sudden cardiac arrest -immediately providing high-quality CPR -providing early defibrillation, as soon as a defibrillator is available -providing goal-directed, time-sensitive post-cardiac arrest care what factors have been associated with improved survival in patients with cardiac arrest? a metaphor used to organize and describe the integrated set of time-sensitive coordinated actions necessary to maximize survival what is the chain of survival? to improve patient outcomes by identifying and treating early clinical deterioration what is the purpose of a rapid response team (RRT) or medical emergency team (MET)? -event detection and response triggering arm -a planned response arm, such as RRT or MET -quality monitoring -administrative support what are the components of a rapid response system? -airway compromise -RR less than 6 breaths/min or more than 30 breaths/min -HR less than 40 bpm or greater than 140bpm -SBP less than 90 mmHg -symptomatic hypertension -unexpected decrease in level of consciousness -unexplained agitation -seizure -significant decrease in urine output -subjective concern about the patient some rapid response systems weigh, combine, and score specific physiologic criteria to determine when to act. what are the criteria for adult patients? to prevent it from happening what is the best way to improve a patient's chance of survival from an in-hospital cardiac arrest? true -teams that rapidly assess and intervene when patients have abnormal vital signs can decrease the number of in-hospital cardiac arrests, improving rates of morbidity and mortality true or false? in-hospital cardiac arrests are often preceded by changes in a patient's vital signs that are evident with routine monitoring -decreased rate of cardiac arrests after these teams intervene -decreased unplanned emergency transfers to the ICU -decreased ICU and total hospital length of stay -reduced postoperative morbidity and mortality rates -improved rates of survival from cardiac arrest what are benefits of rapid response systems? -timing -quality -coordination -administration to function effectively, what does a high-performance team need to focus on? -time to first compression -time to first shock -chest compression fraction (CCF) ideally greater than 80% -minimizing preshock pause -early EMS response time what are aspects of timing that a high-performance team needs to focus on? -rate, depth, and recoil -minimizing interruptions -switching compressors -avoiding excessive ventilation -use of a feedback device what are aspects of quality that a high-performance team needs to focus on? team members working together, proficient in their roles what are aspects of coordination that a high-performance team needs to focus on? -leadership -measurement -continuous quality improvement -number of code team members what are aspects of administration that a high-performance team needs to focus on? minimizing pauses during high-quality CPR one of the measures of a high-performance team is the ability to achieve specific performance metrics and a high chest compression fraction (CCF). you can only achieve a high CCF by doing what? -intubation -rhythm analysis -pulse checks -compressor switches -defibrillation when do pauses in high-quality CPR usually occur? -organizes the group -monitors individual performance of team members -backs up team members -models excellent team behavior -trains and coaches -facilitates understanding -focuses on comprehensive patient care -temporarily designates another team member to take over as team leader if an advanced procedure needs to be performed (eg advanced airway placement) what is the role of the team leader? comprehensive patient care while members of a high-performance team should focus on their individual tasks, what should the team leader focus on? -proficient in performing the skills in their scope of practice -clear about role assignments -prepared to fulfill their role responsibilities -well-practiced in resuscitation skills -knowledgeable about the algorithms -committed to success for a successful resuscitation attempt, what must high-performance team members be? the CPR coach supports performance of high-quality BLS skills, allowing the team leader to focus on other aspects of clinical care -the CPR coach role does not need to be a separate role but can be integrated into the current responsibilities of the monitor/defibrillator many resuscitation teams now include a CPR coach. what is the general role of the CPR coach? -coordinate initiation of CPR -coach team members to improve quality of chest compressions -coach team members to improve quality of ventilations -state guideline targets -help minimize length of pauses in compressions what are the actions a CPR coach will take? 6 when fewer than _____ people are present, team leader must prioritize these tasks and assign them to the healthcare providers present -clearly define all team member roles in the clinical setting -distribute tasks evenly to all available team members who are sure of their responsibilities what are tasks for team leaders in regards to having clear roles and responsibilities? -seek out and perform clearly defined tasks appropriate to their abilities -ask for a new task or role if an assignment is beyond their level of expertise -take only assignments that are within their level of expertise what are tasks for team members in regards to having clear roles and responsibilities? -call for assistance early rather than waiting until the patient deteriorates -seek advice from more experienced personnel when the patient's condition worsens despite primary treatment -allow others to carry out assigned tasks, especially if the task is essential to treatment what are tasks for team leaders in regards to knowing your limitations? -call for assistance early rather than waiting until the patient deteriorates -seek advice from more experienced personnel when the patient's condition worsens despite primary treatment -allow others to carry out assigned tasks, especially if the task is essential to treatment -seek advice from more experienced personnel before starting an unfamiliar treatment or therapy -accept assistance from others when it is readily available what are tasks for team members in regards to knowing your limitations? true true or false? during a resuscitation attempt, anyone on a high-performance team may need to intervene tactfully if a team member is about to take an inappropriate action true true or false? team leaders should avoid confrontation with team members and, instead, debrief afterwards if needed -ask that a different intervention be started if it has a higher priority -reassign a team member who is trying to function beyond his or her level of skill what are tasks for team leaders in regards to constructive interventions? -suggest an alternative drug or dose confidently -question a colleague who is about to make a mistake -intervene if a team member is about to administer a drug incorrectly what are tasks for team members in regards to constructive interventions? true true or false? high-performance team members should provide all available information about changes in the patient's condition to ensure that the team leader makes appropriate decisions -encourage information sharing -ask for suggestions about interventions, differential diagnoses, and possible overlooked treatments (eg intravenous access or drug treatments) -look for clinical signs that are relevant to the treatment what are tasks for team leaders in regards to knowledge sharing? -share information with each other -accept information that will improve their roles what are tasks for team members in regards to knowledge sharing? timer/recorder an essential role of the team leader is monitoring and reevaluating interventions, assessment findings, and the patient's status. team leaders should periodically state this information to the team and announce the plan for the next few steps. be flexible to changing treatment plans and ask for information and summaries from the _______ as well -continuously revisit decisions about differential diagnoses -maintain an ongoing record of treatments and the patient's response -change a treatment strategy when new information supports it -inform arriving personnel of the current status and plans for further action -note significant changes in the patient's clinical condition -increase monitoring if the patient's condition deteriorates (eg frequency of respirations, BP) what are tasks for team leaders in regards to summarizing and reevaluating? -note significant changes in the patient's clinical condition -increase monitoring if the patient's condition deteriorates (eg frequency of respirations, BP) what are tasks for team members in regards to summarizing and reevaluating? the process of verifying that the message sent was received as intended -it also verifies that any assigned tasks have been completed what is closed-loop communication? 1. give a message, order, or assignment to a team member 2. request a clear response and eye contact from the team member to ensure that he or she understood the message 3. confirm that the team member completed the task before you assign him or her another task when communicating with high-performance team members, the team leader should use what closed-loop communication steps? -always assign tasks by using closed-loop communication, such as "give 1 mg of epinephrine and let me know when it has been given" -assign additional tasks to a team member only after receiving confirmation of a completed assignment what are tasks for team leaders in regards to closed-loop communication? -after receiving a task, close the loop by informing the team leader when the task begins or ends, such as, "the IV is in" -give drugs only after verbally confirming the order with the team leader what are tasks for team members in regards to summarizing and reevaluating? concise communication spoken with a distinctive speech in a controlled voice -all healthcare providers should deliver clear messages calmly and directly, without yelling or shouting what does it mean to have clear messages? because unclear communication can delay treatment or cause medication errors -yelling or shouting can also impair effective high-performance team interaction why are distinct, concise messages crucial for communication? -repeat orders and question them if the slightest doubt exists -be careful not to mumble, yell, scream, or shout -ensure that only 1 person talks at a time what are tasks for team leaders in regards to clear messages? -encourage all team members to speak clearly and use complete sentences what are tasks for team members in regards to clear messages? -acknowledge correctly completed assignments by saying, "thanks. good job!" -show interest and listen to what others say -speak in a friendly, controlled tone of voice -avoid displaying aggression if team members do not initially understand each other -understand that when one person raises his or her voice, others will respond similarly -try not to confuse directive behavior with aggression what are tasks for team leaders in regards to mutual respect? -show interest and listen to what others say -speak in a friendly, controlled tone of voice -avoid displaying aggression if team members do not initially understand each other -understand that when one person raises his or her voice, others will respond similarly -try not to confuse directive behavior with aggression what are tasks for team members in regards to mutual respect? debriefing during and after an attempt helps individual team members perform better, and it may also bring system strengths and deficiencies to light why is debriefing as a team an important component of every resuscitation attempt? -compress the chest hard and fast at least 2 inches at a rate of 100 to 120/min (30:2 or another advanced protocol that maximize chest compression fraction) -allow the chest to completely recoil after each compression -minimize the interruption in compressions (high chest compression fraction) -switch compressors about every 2 minutes or earlier if fatigued. the switch should only take about 5 seconds -avoid excessive ventilation what should rescuers to perform high-quality CPR? because when you stop chest compressions, blood flow to the brain and heart stops why must you minimize any interruptions in chest compressions? 10 seconds -avoid prolonged rhythm analysis -avoid frequent or inappropriate pulse checks -avoid prolonged ventilation -avoid unnecessary movement of the patient you should limit interruptions in chest compressions for defibrillation or rhythm analysis to no longer than _______, unless you are moving the patient from a dangerous environment chest compression fraction- which is the proportion of time during cardiac arrest resuscitation when the rescuer is performing chest compressions what is CCF? true, CCF is a measurable goal- one that providers should strive to achieve true or false? data suggest that lower chest compression fraction (CCF) is associated with decreased ROSC and survival to hospital discharge as high as possible: at least 60% and ideally greater than 80% what should CCF (chest compression fraction) be? actual chest compression time/total code time how do you calculate chest compression fraction (CCF)? the presumed etiology of the arrest guidelines recommend that healthcare providers tailor the sequence of rescue actions based on what? -continuous chest compressions with asynchronous ventilation once every 6 seconds with the use of a bag-mask device -compression-only CPR in the first few minutes after arrest ACLS providers can choose the best approach (functioning within a 2-minute cycle) for their high-performance team to minimize interruptions in chest compressions and improve CCF including protocols such as what? coronary perfusion pressure (CPP) it is crucial to minimize interruptions in compressions to maintain adequate ______ coronary perfusion pressure- the diastolic pressure (aortic relaxation) minus right atrial diastolic pressure what is CPP (equation)? 15 mmHg during CPR, CPP correlates with both myocardial blood flow and ROSC. in 1 human study, ROSC did not occur unless a CPP of ____ or greater what achieved during CPR coronary perfusion pressure (CPP) -it takes several compressions to build enough pressure to achieve an adequate CPP necessary to get ROSC when healthcare providers interrupt chest compressions, _______ decreases dramatically and remains very low until compressions are resumed true true or false? the higher the coronary perfusion pressure during CPR, the higher the chances of survival for patients diastolic pressure (arterial relaxation) in patients with an arterial line what is a reasonable surrogate for CPP? quantitative waveform capnography using an advanced airway in place of a bag-mask device because CPP or arterial diastolic pressure measurements are not readily available during a resuscitation attempt, healthcare providers can monitor CPR quality with what? it uses ETCO2 to estimate tissue perfusion and the quality of chest compressions how does quantitative waveform capnography monitor CPR quality? true true or false? the interval from collapse to defibrillation is one of the most important determinants of survival from cardiac arrest, and early defibrillation is critical true true or false? a common initial rhythm in out-of-hospital witnessed sudden cardiac arrest is vfib true, and vfib deteriorates to asystole if not treated true or false? pulseless vtach rapidly deteriorates to vfib electrical defibrillation, and the probability of successful defibrillation decreases quickly over time what is the most effective way to treat vfib and pulseless vtach? true, when vfib is present, CPR can only provide a small amount of blood flow to the heart and brain but cannot directly restore an organized rhythm -restoring a perfusing rhythm is more likely with immediate CPR and defibrillation within a few minutes after initial arrest true or false? the earlier the defibrillation occurs, the higher the survival rate 7-10% per minute -when bystanders perform CPR, the decline in chance of survival from a witnessed vfib sudden cardiac arrest is more gradual and averages 3-4% per minute for every minute that passes between collapse and defibrillation, the chance of survival from a witnessed vfib sudden cardiac arrest declines by _________% per minute without bystander CPR true true or false? early CPR can double or triple survival from witnessed sudden cardiac arrest at most defibrillation levels true, rhythm analysis and shock administration with an AED may prolong interruptions in chest compressions true or false? the AHA does not recommend continued use of AED or automatic mode when a manual defibrillator is available and providers can adequately interpret rhythms yes, shortening the interval between the last compression and the shock by even a few seconds can improve shock success (defibrillation and ROSC), so practice efficient coordination between CPR and defibrillation -you should deliver the shock as soon as the compressor removes his or her hands from the patient's chest and all providers are clear of contact with the patient -the same compressor should resume compressions immediately after the shock is delivered while the manual defibrillator is charging, should providers resume CPR? 5 seconds to ensure safety during defibrillation, always announce the shock warning. this entire sequence should take less than __________ -warn other that you are about to deliver shocks and that everyone must stand clear of the patient -check to make sure you are clear of contact with the patient, the stretcher, or other equipment -make a visual check to ensure that no one is touching the patient or stretcher -make sure oxygen is not flowing across the patient's chest what steps should you take when about to deliver a shock to patient? face the patient to ensure coordination with the chest compressor and to verify that no one has resumed contact with the patient when pressing the shock button, should the defibrillator operator face the machine or the patient? not only does the systemic approach allow a standardized method for evaluating patients, it reduces the chances of missing or overlooking important signs and symptoms that need to be considered in treatment of all patients for optimal care, healthcare providers use a systemic approach to assess and treat acutely ill or injured patients, why? -initial impression (visualization and scene safety) -BLS assessment -primary assessment (A, B, C, D, and E) -secondary assessment (SAMPLE, Hs and Ts) what are the components of a systemic approach? rapidly survey the scene to determine if the scene is safe and that there is no threat to the provider -once you've determined the scene is safe, use the systematic approach to perform your initial impression and determine the patient's level of consciousness what should you do before you approach any patient? BLS assessment for initial evaluation -use the primary and secondary assessments for more advanced evaluation and treatment if a patient appears unconscious, what should you use for the initial evaluation? primary assessment if a patient appears conscious, what should you use for the initial evaluation? intervening and stopping a patient's downward spiral what is the ultimate goal of the BLS, primary, and secondary assessments? a systematic approach to BLS for trained healthcare providers -this approach stresses early CPR with basic airway management and defibrillation, but not advanced airway techniques or drug administration -by using the BLS assessment, any healthcare provider can support or restore effective oxygenation, ventilation, and circulation until the patient achieves ROSC or advanced providers intervene what is the BLS assessment? yes -for example, a healthcare provider who sees an adolescent suddenly collapse after a blow to the chest can assume that the patient has had a sudden cardiac arrest (he can then activate an emergency response system, get an AED and use it, and then provide CPR) -if a rescuer believes hypoxia caused the cardiac arrest (such as with drowning) they may give about 2 minutes of CPR, including breaths, before activating the emergency response system can single rescuers tailor the sequence of rescue actions to the most likely cause of arrest? 1. verify scene is safe 2. check responsiveness (are you okay?) 3. shout for nearby help/activate the emergency response system and get the AED or defibrillator 4. check for absent or abnormal breathing (scan chest for rise and fall for at least 5 but no more than 10 seconds) and pulse (feel for a pulse for 5-10 seconds). try to perform a pulse check and breathing check simultaneously. if you find a pulse, start rescue breathing at 1 breath every 6 seconds and check the pulse every 2 minutes. if you find no breathing or only gasping and no pulse, start CPR beginning with chest compressions 5. defibrillate. if pulse is not felt, check for a shockable rhythm as soon as the AED/defibrillator arrives. provide shocks as indicated. follow each shock immediately with CPR, beginning with compressions what are the steps of BLS assessment? primary and secondary assessments in some cases, BLS will result in ROSC, but sometime cardiac arrest persists, requiring you to continue with more advanced, invasive measure. this is when you should follow ________ ABCDE -keep in mind that although these steps are listed in progressive order, the resuscitation team often performs them simultaneously you can remember the steps of the primary assessment using what acronym? airway what does the A stand for in ABCDE (for the primary assessment)? breathing what does the B stand for in ABCDE (for the primary assessment)? circulation what does the C stand for in ABCDE (for the primary assessment)? disability what does the D stand for in ABCDE (for the primary assessment)? exposure what does the E stand for in ABCDE (for the primary assessment)? quantitative waveform capnography for unconscious patients, healthcare providers should maintain a patent airway and consider inserting an advanced airway device. regardless of the device chose, the resuscitation team must ensure proper placement and use _______ to monitor effectiveness true true or false? conscious patients can often maintain the integrity of their own airway, and healthcare providers need only ensure patency by providing suctioning if needed -is the patient's airway patent? -is an advanced airway indicated? -have you confirmed proper placement of the airway device? -is the tube secured, and are you reconfirming placement frequently and with every transition? what are key questions to ask for the airway portion of primary assessment? using a head tilt-chin lift, an oropharyngeal airway, or a nasopharyngeal airway *use advanced airway management if needed how should you maintain an open airway in unconscious patients? -laryngeal mask airway -laryngeal tube -esophageal-tracheal tube -endotracheal tube what are examples of advanced airway management? -laryngeal mask airway -laryngeal tube -esophageal-tracheal tube you should weigh the benefits of placing an advanced airway against the adverse effects of interrupting chest compressions. if bag-mask ventilation is adequate, you may defer inserting an advanced airway until the patient does not response to initial CPR and defibrillation or until ROSC. advanced airway devices such as what can be placed while chest compressions continue? -confirm the proper integrating of CPR and ventilation -confirm the proper placement of advanced airway devices by physical examination and quantitative waveform capnography -secure the device to prevent dislodgement -monitor airway placement, effectiveness of CPR, and ROSC what should you do if using advanced airway devices? administering oxygen as needed if a patient does not required assisted ventilation, how can healthcare providers support the patient? -are ventilation and oxygenation adequate? -are quantitative waveform capnography and oxyhemoglobin saturation monitored? what are key questions to ask with the breathing aspect of the primary assessment? 100% for cardiac arrest patients, what percent FiO2 should the oxygen administered be? as much needed to achieve oxygen saturation of 95-98% by pulse oximetry (90% for ACS and 92-98% for post-cardiac arrest care) for all other patients who are not cardiac arrest patients, what percent FiO2 should the oxygen administered be? -attached EKG leads -establish IV or IO (intraosseous) access -give appropriate drugs to manage abnormal rhythms -assess for perfusion issues *you are collecting a wide range of information including BP, HR, and cardiac rhythm. additional data, such as temperature and glucose levels may further refine the initial interventions needed how should the circulation step of primary assessment be completed? -are chest compressive effective? -what is the cardiac rhythm? -is defibrillation or cardioversion indicated? -has IV/IO access been established? -is ROSC present? -is the patient with a pulse unstable? -are medications needed for rhythm or BP? -does the patient need volume (fluid) for resuscitation? what are key questions to ask with the circulation aspect of the primary assessment? -attach monitor/defibrillator for arrhythmias or cardiac arrest rhythms (vfib, pulseless vtach, asystole, pulseless electrical activity (PEA) -provide defibrillation/cardioversion -establish IV/IO access -give appropriate drugs to manage rhythm and BP -give IV/IO fluids if needed -check glucose and temperature -check perfusion issues what are circulation interventions for primary assessment? checking for neuro function -quickly assess for responsiveness, level of consciousness, and pupil dilation what does the disability aspect of primary assessment involve? AVPU -alert -voice -painful -unresponsive what is a quick tool that can evaluated neuro status with primary assessment? -remove clothing to perform a physical examination -look for obvious signs of trauma, bleeding, burns, unusual markings, or medical alert bracelets what does the exposure aspect of primary assessment involve? differential diagnosis -this involves obtaining a focused medical history and searching for and treating reversible causes (Hs and Ts) what does the secondary assessment involve? SAMPLE S-signs and symptoms A- allergies M- medications P- past medical history L-last meal consumed E- events *the answers to these questions can help you quickly rule in or rule out suspected diagnoses what mnemonic can be used to remember the aspects of the secondary assessment? signs and symptoms -breathing difficulty -tachypnea and tachycardia -fever and headache -abdominal pain -bleeding what does the S in SAMPLE for secondary assessment stand for? allergies -medications, allergies, food, latex -associated reactions what does the A in SAMPLE for secondary assessment stand for? medications -patient medications, including over-the-counter, vitamins, inhalers, and herbal supplements -last dose and time of recent medications -medications that can be found in the patient's home what does the M in SAMPLE for secondary assessment stand for? past medical history -health history (eg previous illness, hospitalizations) -family health history (in cases of ACS or stroke) -significant underlying medical problems -past surgeries -immunization status what does the P in SAMPLE for secondary assessment stand for? last meal -time and nature of last intake of food or liquid what does the L in SAMPLE for secondary assessment stand for? events -events leading to current illness of injury (eg onset sudden or gradual, type of injury) -hazards at scene -treatment during interval from onset of disease or injury until evaluation -estimated time of onset (if out of hospital) what does the E in SAMPLE for secondary assessment stand for? look for and treat the underlying cause by considering the Hs and Ts to ensure you are not overlooking a dangerous or likely possibility after using the SAMPLE tool for secondary assessment, what is the next aspect of secondary assessment? -hypovolemia is low blood volume -hypoxia occurs when inadequate oxygen is reaching the body's tissues -hydrogen ions (acidosis) is the accumulation of acid and hydrogen ions in the blood and body tissues -hypo-/hyper-kalemia is an abnormally high or low concentration of potassium ions in the blood -hypothermia is when the body temperature drops below 95 deg F or 35 deg C. hypothermia is a potentially reversible cause of cardiac arrest and other emergency cardiopulmonary conditions what are the Hs in Hs and Ts? -tension pneumothorax results from an abnormal accumulation of air in the pleural space -tamponade (cardiac) is a condition caused by an accumulation of fluid between the heart and the pericardium -toxins may be best uncovered by a focused history -thrombosis (coronary and pulmonary) what are the Ts in Hs and Ts? -prevention of major adverse cardiovascular events (such as death, nonfatal MI, and the need for urgent post-infarction revascularization) -identification of patients with STEMI and triage for early reperfusion therapy -relief of ischemic chest discomfort -treatment of acute, life-threatening complications of ACS, such as vfib or pulseless vtach, unstable bradycardia, ventricular wall rupture, papillary muscle rupture, decompensated shock, and other unstable tachycardias what are the primary goals for ACS patients? 50% -vfib and pulseless vtach as the precipitating rhythm in the majority of cases what percent of ACS deaths occur before the patient reaches the hospital? 4 hours -so communities should develop programs to respond quickly to ACS with ACS, vfib is most likely to develop during the first _______ after onset of symptoms -recognizing symptoms of ACS -activating the emergency medical services (EMS) system, with EMS providing prehospital notification in advance -providing early CPR of cardiac arrest occurs -providing early defibrillation with AEDs available for public-access defibrillation programs and first responders -providing a coordinated system of care among the EMS system, the emergency department, and cardiac specialists what should community ACS programs focus on? similar to the chain of survival for sudden cardiac arrest, with its links indicating the actions that patients, family members, and healthcare providers can rapidly take to maximize STEMI recover: -recognition and reaction to STEMI warning signs -EMS dispatch and rapid EMS system transport and prearrival notification to the receiving hospital -assessment and diagnosis in the ED (or cath lab) -treatment what is the STEMI chain of survival? true true or false? all dispatchers and EMS providers must train to recognize ACS symptoms along with potential complications true, when authorized by medical control or protocol true or false? dispatchers should tell patients with no history of aspirin allergy or sign of active or recent GI bleeding to chew aspirin (162 to 325 mg) while they wait for EMS providers to arrive retrosternal chest discomfort what is the most common symptom of myocardial ischemia and infarction? true true or false? chest discomfort is a major symptom in most patients (both men and women) with ACS, but patients frequently deny or misinterpret this and other symptoms -elderly -women -diabetic patients -hypertensive patients *in part because they are more likely to have atypical symptoms or presentations *keep in mind, older adults and women may present without chest pain what patients are most likely to delay seeking care for MI? -uncomfortable pressure, fullness, squeezing, or pain in the center of the chest lasting several minutes (usually more than a few minutes) -chest discomfort spreading to the shoulders, neck, one or both arms, or jaw -chest discomfort spreading into the back or between the shoulder blades -light-headedness, dizziness, fainting, syncope, sweating, nausea, or vomiting -unexplained sudden shortness of breath, which may occur with or without chest discomfort -less commonly, the discomfort occurs in the epigastrium and is described as indigestions *these symptoms may also suggest other life-threatening conditions, including aortic dissection, acute PE, acute pericardial effusion with tamponade, and tension pneumothorax what are symptoms that suggest ACS? -assess ABCs. be prepared to provide CPR and defibrillation -administer aspirin and consider O2, nitroglycerin, and morphine if needed -obtain a 12-lead EKG. if there is ST elevation, notify the receiving hospital with a transmission or interpretation; note the time of onset and first medical contact -provide prehospital notification; on arrival, transport to ED/cath lab per protocol -the notified hospital should mobilize resources to respond to STEMI -if considering prehospital fibrinolysis, use a fibrinolytic checklist -if out-of-hospital providers cannot complete these initial steps before the patient arrives at the hospital, the ED provider should do so step 2 in the ACS algorithm (after symptoms) outlines EMS assessment, care, and hospital preparation. EMS responders may perform what assessments and actions as they stabilize, triage, and transport the patient to an appropriate facility? 10 minutes the ED high-performance team should quickly evaluate the patient with potential ACS on the patient's arrival. within _______ minutes, obtain a 12 lead EKG (if not obtained before arrival) and assess the patient -activated STEMI team upon EMS notification -assess ABCs, give oxygen if needed -check vital signs and evaluate oxygen saturation -establish IV acces -perform a brief, targeted history and a physical exam -review and complete the fibrinolytic checklist; check contraindications -obtain initial cardiac marker levels, complete blood counts, and coagulation studies -obtain a portable chest x-ray (in less than 30 minutes), do not delay transport to the cath lab what should initial actions for ACS patient in ED be? no, they should not unless clinically necessary, for example, in suspected aortic dissection or coagulopathy should the results of cardiac markers, chest x-ray, and laboratory studies delay reperfusion therapy for ACS patients? -chest discomfort -signs and symptoms of heart failure -cardiac history -risk factors for ACS -historical features that may preclude the use of fibrinolytics what should a target evaluation for ACS patients focus on? -first medical contact to balloon inflation within 90 minutes -door to drug (fibrinolytics) within 30 minutes of arrival what are the goals of reperfusion for patients with STEMI? 90 minutes with STEMI, first medical contact to balloon inflation should occur within __________ 30 minutes with STEMI, door to drug (fibrinolytics) should occur within _________ of arrival 12 lead EKG what is in the center of the decision pathway in managing ischemic chest discomfort? 12 lead EKG what is the only way to identify STEMI? -if O2 saturation is less than 90%, start oxygen at 4 L/min, titrate -aspirin 162 to 325 mg (if not given by EMS) -nitroglycerin sublingual or translingual -morphine IV if discomfort not relieved by nitroglycerin -consider administration of P2Y12 inhibitors *because out-of-hospital providers may have given these agents already, administer initial or supplemental doses as indicated unless allergies or contraindications exist, what 4 agents should you consider in patients with ischemic-chest discomfort? if the patient is dyspneic or hypoxemic, has obvious signs of heart failure, or as an arterial oxygen saturation that is less than 90% or unknown when should EMS providers administer oxygen? adjust to a noninvasively monitored oxyhemoglobin saturation of 90% or greater *the usefulness of supplemental oxygen therapy has not been established in normoxic patients with suspected or confirmed ACS, so providers may consider withholding it in these patients how should providers adjust oxygen therapy? 162-325 mg *this rapid platelet inhibition also reduces coronary reocclusion and other recurrent events independently and after fibrinolytic therapy a dose of ___________ non-enteric coated or chewed aspirin causes immediate and near total inhibition of thromboxane A2 production by inhibiting platelet cyclooxygenase (COX-1) chewed, particularly if the patient has received morphine in the initial hours of ACS, is aspirin better when swallowed or chewed? rectal aspirin suppositories (300 mg) what should you use instead of giving a patient aspirin if the have nausea, vomiting, active peptic ulcer disease, or other disorders of the GI tract? true true or false? aspirin is associated with a reduction in mortality for patients with ACS reduces left ventricular and right ventricular preload through peripheral arterial and venous dilation nitroglycerin effectively reduces ischemic chest discomfort, and it has beneficial hemodynamic effects. what are the physiologic effects of nitrates? -give the patient 1 sublingual table (or translingual dose) every 3 to 5 minutes for ongoing symptoms if permitted by medical control and no contraindications exist -you may repeat the dose twice (total of 3 doses) -administer only if the patient remains hemodynamically stable: SBP >90 mmHg and no lower than 30 mmHg below baseline (if known) and HR 50-100 bpm how should you administer nitroglycerin? inadequate preload because nitroglycerin is a venodilator, it should be used cautiously or not at all in patients with ________ -inferior wall MI and RV dysfunction -hypotension, bradycardia, or marked tachycardia (SBP <90 mmHg, HR <50 bpm) -recent phosphodiesterase inhibitor use in what situations should nitroglycerin be used cautiously or not at all due to patients having inadequate preload? -RV infarction may complicate an inferior wall MI -patients with acute RV infarction depend on RV filling pressures to maintain cardiac output and BP -if you cannot rule out RV infarction, use caution in administering nitrates to patients with an inferior STEMO -if you confirm RV infarction by right-sided precordial leads, or if an experienced provider confirms it through clinical findings, then nitroglycerin and other vasodilators, such as morphine, or volume-depleting drugs (diuretics) are contraindicated as well why should you be cautious about giving nitroglycerin, or not give it at all, to patients with inferior wall MI and RV infarctions? -avoid using nitroglycerin if you suspect or know that the patient has taken sildenafil or vardenafil within the previous 24 hours or tadalafil within 48 hours -these agents are generally used for erectile dysfunction or in cases of pulmonary hypertension, and in combination with nitrates may cause severe hypotension refractory to vasopressor agents why should you be cautious about giving nitroglycerin, or not give it at all, to patients with recent phosphodiesterase inhibitor use? false, routine use of IV nitroglycerin is not indicated and has not been shown to significantly reduce mortality in STEMI *however, IV nitroglycerin is indicated and widely used in ischemic syndromes and is preferred over topical or long acting forms because it can be adjusted in patients with potentially unstable hemodynamics and clinical condition true or false? routine use of IV nitroglycerin is indicated and has been shown to significantly reduce mortality in STEMI -recurrent or continuing chest discomfort unresponsive to sublingual or translingual nitroglycerin -pulmonary edema complicating STEMI -hypertension complicating STEMI what are indications for initiating IV nitroglycerin in STEMI? -for relief of ischemic chest discomfort (titrate to effect. keep SBP >90 mmHg, limit drop in SBP to 30 mmHg below baseline in hypertensive patients) -for improvement in pulmonary edema and hypertension (titrate to effect. limit drop in SBP to 10% of baseline in normotensive patients. limit drop in SBP to 30 mmHg below baseline in hypertensive patients) what are treatment goals using IV nitroglycerin? -consider administration for severe chest discomfort that does not respond to sublingual or translingual nitroglycerin, if authorized by protocol or medical control -healthcare providers can consider giving analgesics such as morphine while monitoring the patient's BP and RR -morphine is indicated in STEMI when chest discomfort does not respond to nitrates when should you consider administering morphine with ACS? there is an association with increased mortality -morphine may also mask symptoms of myocardial ischemia and decrease absorption of important orally administered drugs, such as antiplatelets (P2Y12 receptor blockers) *use morphine with caution for patients with unstable angina why should morphine be used with caution in NSTE-ACS -produces central nervous system analgesia (which reduces the adverse effects of neurohumoral activation, catecholamine release, and heightened myocardial oxygen demand) -alleviates dyspnea -produces venodilation (which reduces LV preload and oxygen requirement) -decreases systemic vascular resistance (which reduces LV afterload) -helps redistribute blood volume (in patient with acute pulmonary edema) what are the reasons morphine may be used to manage ACS? use with smaller doses and carefully monitor physiologic response before administering additional doses in patients who may be preload dependent *if hypotension develops, administer fluids as a first line of therapy because morphine is a venodilator, what should you be aware of while administering it? -non-ST segment elevation ACS (or NSTE-ACS) -STEMI *sudden cardiac death may occur with any of these syndrome patients with coronary atherosclerosis may develop a spectrum of clinical syndromes that represent varying degrees of coronary artery occlusion. what syndromes do these include? -ST segment elevation in 2 or more contiguous leads OR -new left bundle branch block (LBBB) what is STEMI characterized by? -J-point elevation greater than 2 mm (0.2 mV) in leads V2 and V3 (2.5 mm in men younger than 40 years; 1.5 mm in all women) -1 mm or more in other leads or by new or presumed new LBBB what are threshold values for ST-segment elevation consistent with STEMI? -ischemic ST-segment depression of 0.5 mm (0.05 mV) or greater OR -dynamic T-wave inversion with pain or discomfort *non-persistent or transient ST-segment elevation of 0.5mm or greater for less than 20 minutes is also included in this category what is high-risk NSTE-ACS characterized by? -normal or nondiagnostic changes in the ST segment OR -T waves that are inconclusive and require further risk stratification *this classification includes patients with normal EKGs and those with ST-segment deviation in either direction of less than 0.5 mm (0.05 mV) or T-wave inversion of 2 mm (0.2 mV) or less *serial cardiac studies and functional testing are appropriate what is low- to intermediate-risk NSTE-ACS characterized by? true true or false? patients with STEMI usually have complete occlusion of an epicardial coronary artery providing early reperfusion therapy achieved with primary PCI or fibrinolytics how should ACS be treated? opens an obstructed coronary artery with either mechanical means or drugs what does reperfusion therapy with STEMI patients do? PCI, performed in a cath lab after coronary angiography, allows balloon dilation and/or stent placement for an obstructed coronary artery what does PCI allow for? 12 hours early fibrinolytic therapy or direct catheter-based perfusion is an established standard of care for patients with STEMI who present within _________ after symptom onset with no contraindications to minimize brain injury and maximize the patient's recovery what is the goal of stroke care? the stroke chain of survival links the actions that patients, family members, and healthcare providers should take to maximize stroke recovery includes: -rapid recognition of and reaction to stroke warning signs and symptoms -rapid use of 911 and EMS dispatch -rapid EMS recognition of stroke, triage, transport, and prehospital notification to the receiving hospital -rapid diagnosis and treatment in the hospital what is the stroke chain of survival? the 8 Ds of stroke care highlight the major steps in diagnosis and treatment of stroke and key points at which delays can occur: -detection (rapid recognition of stroke signs and symptoms) -dispatch (early activation and dispatch of EMS by phoning 911) -delivery (rapid EMS stroke identification, management, triage, transport, and prehospital notification) -door (emergent ED/imaging quite triage and immediate assessment by stroke team) -data (rapid clinical evaluation, laboratory testing, and brain imaging) -decision (establishing stroke diagnosis and determining optimal therapy selection) -drug/device (administration of fibrinolytic &/or endovascular therapy if eligible) -disposition (rapid admission to a stroke unit or ICU, or emergent interfacility transfer for endovascular therapy) what are the 8 Ds of stroke care? an acute neurologic impairment that follows interruption in blood supply to a specific area of the brain what is a stroke? occurs when a blood vessel in the brain suddenly ruptures into the surrounding tissue -accounts for 13% of all strokes what is a hemorrhagic stroke? a stroke usually caused by an occlusion of an artery to a region of the brain -accounts for 87% of all strokes what is an ischemic stroke? the area surrounding the infarction in the brain that is ischemic, but not yet infarcted what is ischemic pneumbra? -sudden weakness or numbness of the face, arm, or leg (especially unilaterally) -trouble speaking or understanding -sudden trouble seeing in one or both eyes -sudden trouble walking -dizziness or loss of balance or coordination -sudden severe headache with no known cause -sudden confusion what are signs and symptoms of a stroke? cincinnati prehospital stroke scale (CPSS) or the los angeles prehospital stroke screen the AHA recommends that all EMS personnel be trained to recognize stroke by using a validated, abbreviated out-of-hospital neuro evaluation tool such as what? -facial droop (have the patient smile or try to show teeth) -arm drift (have the patient close eyes and hold both arms out, with palms up) -abnormal speech (have the patient say, "you can't teach an old dog new tricks") the cincinnati prehospital stroke scale (CPSS) identifies stroke on the basis of 3 physical findings? 72% by using the CPSS, medical personnel can evaluate a patient in less than 1 minutes. the presence of 1 finding on the CPSS has an estimated probability of stroke of ________% when scored by prehospital providers to determine if there is a large vessel occlusion (LVO) and to help identify which hospital is most appropriate for the stroke patient why should EMS perform a severity screen for stroke patients? -assess ABCs; give oxygen if needed -initiate stroke protocol -perform physical exam -perform validated prehospital stroke screen and severity tool -establish time of symptom onset (last known normal) -triage to most appropriate stroke center -check glucose; treat if indicated -provide prehospital notification on arrival, transport to brain imaging suite what should be done after recognize a stroke? for patients whose oxygen saturation is 94% or less or for patients for whom oxygen saturation is unknown when should out-of-hospital and in-hospital medical personnel should provide supplemental oxygen to hypoxemic stroke patients? 4 levels evidence indicates a benefit from triage of stroke patients directly to designated certified stroke centers. currently, ________ levels of stroke certification exist, and certification is given on the basis of a hospital's specific capabilities -acute stroke ready hospital -primary stroke center -thrombectomy-capable stroke center -comprehensive stroke center what are the 4 levels of stroke certification? -acute stroke ready hospitals typically serve rural and under-resourced areas -emergent identification and treatment of patients with alteplase, when indicated, is typically facilitated by telemedicine to provide access to acute neuro expertise -typically patients are later transferred for admission to a stroke unit or for a higher level of care, as indicated what is an acute stroke ready hospital? -the primary stroke center is the cornerstone of stroke symptoms of care -these centers compromise a wide range of hospitals able to quickly identify stroke patients, provide alterplase therapy if indicated, and admit patients to a dedicated stroke unit -roughly half of all stroke patients in the US receive care in a primary stroke center what is a primary stroke center? -the thrombectomy-capable stroke center certification was jointly created by the AHA and the joint commission to recognize stroke centers that meet the same high-quality standards as a primary stroke center but are also capable of providing endovascular therapies for patients with LVO -the thrombectomy-capable stroke center designation was created to recognize these EVT-capable facilities in areas where a comprehensive stroke center was not available what is a thrombectomy-capable stroke center? -hospitals achieving comprehensive stroke center certification are capable of managing all forms and severities of stroke, both ischemic and hemorrhagic, and can provide 24/7 access to specialty care, such as neurosurgery, endovascular therapy, and neurocritical care -a comprehensive stroke center typically serves as the hub of a regional stroke system of care, providing receiving capabilities for transferred patients and providing feedback and education for transferring sites what is a comprehensive stroke center? -identifying possible stroke patients -providing high-priority dispatch -instructing bystanders in lifesaving CPR skills or other supportive care if needed while EMS providers are on the way how do emergency medical dispatchers play a critical role in timely treatment of potential stroke? true *they can also triage to the most appropriate stroke center on the basis of a validated prehospital stroke screen, stroke severity tool, and on patient characteristics following regional destination protocols true or false? EMS can assess ABCs (and give oxygen as needed), initiate stroke protocol, perform a physical exam, establish a time of symptom onset (last known normal), and check glucose (and treat if indicated) 1. immediate general and neuro assessment by the hospital or stroke team 2. neurologic assessment by the stroke team and non-contrast CT or MRI performed within 20 mins 3. interpretation of the CT or MRI within 45 mins after ED/brain imaging suite arrival 4. initiation of fibrinolytic therapy in appropriate patients within 60 mins after hospital arrival 5. door-to-device times within 90 mins for direct arriving patients and 60 mins for transfer patients 6. door-in to door-out times for patients for patients being transferred for possible EVT within 60 mins 7. door-to-admission (stroke unit or ICU) time of 3 hours what are the key steps in the adult suspected stroke algorithm? within 10 minutes what is the critical time period for suspected stroke patient for immediate general assessment? within 20 minutes what is the critical time period for suspected stroke patient for immediate neurologic assesment? within 20 mins what is the critical time period for suspected stroke patient for acquisition of CT/MRI of the head? within 60 minutes what is the critical time period for suspected stroke patient for administration of fibrinolytic therapy, times from ED/brain imaging suite arrival? within 3 hours, or 4.5 hours in selected patients what is the critical time period for suspected stroke patient for administration of fibrinolytic therapy, timed from onset of symptoms? up to 24 hours for patients with LVO: 0-6 hours requires eligible NCCT scan; 6-24 hours requires eligible penumbral imaging what is the critical time period for suspected stroke patient for administration of endovascular therapy, times from onset of symptoms? within 3 hours what is the critical time period for suspected stroke patient for admission to monitored bed (stroke unit or ICU)? within 1 hour what is the critical time period for suspected stroke patient for interfacility transfers for EVT (door-in to door-out)? no obtaining these studies should not delay initiation of IV alteplase in eligible patients additional imaging techniques such as CT perfusion, CT angiography, or MRI scans of patients with suspected stroke should be promptly interpreted by a physician skilled in neuroimaging interpretation. is it reasonable for obtaining these studies to delay initiation of IV alteplase in eligible patients? initiate intracranial hemorrhage protocol and admit to the stroke unit or neurologic ICU (or transfer to a higher level of care) if hemorrhage is noted on the CT/MRI, the patient is not a candidate for fibrinolytics. what should the next step be? -physicians using a clearly defined institutional protocol -a knowledgeable interdisciplinary team familiar with stroke care -an institution with a commitment to quality stroke care the AHA/ASA guidelines for acute ischemic stroke recommend giving IV alteplase to patients with acute ischemic stroke who meet the current eligibility criteria if it is given by: -if the CT/MRI scan shows no hemorrhage, the probability of acute ischemic stroke remains. review inclusion and exclusion criteria for IV fibrinolytic therapy and repeat the neuro exam (NIHSS or canadian neurological scale) -if the patient's neuro function is rapidly improving to normal, fibrinolytics may not be necessary if the CT/MRI scan is negative for hemorrhage, the patient may be a candidate for fibrinolytic therapy. immediately perform what further eligibility and risk stratification? endovascular although IV alteplase remains as a first-line treatment, the AHA now recommends ________ therapy 24 hours from onset of symptoms what is the treatment window for endovascular therapy for ischemic stroke? -pre-stroke modified rankin score of 0-1 -causative LVO of the internal carotid artery or proximal middle cerebral artery demonstrated on cerebrovascular imaging -age 18 years or older -NIHSS score of 6 or greater -alberta stroke program early CT score (ASPECTS) of 6 or greater patients arriving within 6 hours after ischemic stroke symptom onset should receive endovascular therapy with a stent retriever if they meet all of what criteria? albert stroke program early CT score (ASPECTS) is an early, reliable tool that uses a 10-point quantitative topographic CT scan score to determine early ischemic changes what is ASPECTS? -begin acute stroke pathway -assess ABCs and give oxygen if needed -monitor blood glucose -monitor blood pressure -monitor temperature -perform dysphagia screening -monitor for complications of stroke and fibrinolytic therapy -transfer to a higher level of care (EVT, neuro ICU) if indicated the general care of all patients with stroke include what actions? -admit patients to a stroke unit (if available) for careful observation, including monitoring of BP and neuro status -if neuro status worsens, order an emergent CT scan. determine if cerebral edema or hemorrhage is the cause; consult neurosurgery as appropriate -additional stroke care includes support the airway, oxygenation, ventilation, and nutrition what is the beginning of the stroke pathway? approximately 75-100 ml/h if needed to maintain intravascular volume for a patient with a stroke, how much normal saline should be provided? true, but there is no direct evidence that active glucose control improves clinical outcome -there is evidence that insulin treatment of hyperglycemia in other critically ill patients improves survival rates; so consider giving IV or subcutaneous insulin to lower blood glucose with acute ischemic stroke when the serum glucose level is greater than 180 mg/dL true or false? hyperglycemia is associated with worse clinical outcome in patients with acute ischemic stroke no, but treatment of acute seizures followed by anticonvulsants to prevent further seizures is recommended is prophylaxis for seizures recommended for acute stroke patients? SBP 185 mmHg or less DBP 110 mmHg or less *because the maximum interval from the onset of stroke until effective treatment of stroke with alteplase is limited, most patients with sustained hypertension above these levels will not be eligible for IV alteplase if a patient is eligible for fibrinolytic therapy, what does BP need to be to limit the risk of bleeding complications?