2010 Aha Cpr/ecc Guidelines Part 8: Acls

Front 1

Define the ABCDs of ACLS:

Back 1

Airway
Breathing
Circulation
Differential Diagnosis

Front 2

What is the O2 saturation goal for cardiac arrest patients? For others?

Back 2

100%
>94%

Front 3

Describe effective closed-loop communication for ACLS team leaders:

Back 3

1. give a message, order, or assignment to a team member
2. confirm message received by listening for a clear response and making eye contact
3. receive confirmation of completion before assigning the next task

Front 4

List the Dos and Don'ts of "clear messages"

Back 4

Do:
-encourage team to speak clearly
-repeat the medication order
-question an order if the slightest doubt exists

Don't
-mumble
-give unclear orders
-yell, scream, or shout
-feel patronized by distinct and concise messages

Front 5

List the six main roles played by members of the ACLS team:

Back 5

-team leader
-observer/recorder
-compressor
-airway
-IV/IO/meds
-monitor/defibrillator

Front 6

List the Dos and Don'ts of "Reevaluation and summarizing"

Back 6

Do:
-draw continuous attention to decisions about differential diagnoses
-review or maintain an ongoing record of drugs and treatments administered and patient's response
-clearly draw attention to significant changes in the patient's clinical condition
-incraese monitoring when the patient's condition deteriorates

Don't
-fail to chagne a treatment strategy when new information supports such a change
-fail to inform arriving personnel of the current status and plans for further action

Front 7

What is the purpose of ventilation during CPR?

Back 7

maintain adequate oxygenation and sufficient elimination of carbon dioxide

Front 8

Why is a lower-than-normal respiratory rate preferred during CPR?

Back 8

easy to hyperventilate because systemic and pulmonary perfusion are substantially reduced

Front 9

What is the rate limiting step of oxygen deligery to the brain and heart during the first few minutes of CPR: oxygen content of blood or blood flow?

Back 9

blood flow (therefore CPR more important than rescue breaths)

Front 10

Should ACLS providers skip ventilations and do chest compression only CPR?

Back 10

No. Not enough evidence to support this at this time. Passive ventilation (inhalation and exhalation due to chest compressions likely enough with open airway but not enough evidence yet.)

Front 11

Which ventilation methods are preferred for the lone rescuer?

Back 11

mouth-to-mouth or mouth-to-mask preferred over bag-mask ventilation

Front 12

What are possible complications of bag-mask ventilation?

Back 12

gastric inflation (regurgitation, aspiration, pneumonia, elevated diaphragm, restricted lung movement, decrease respiratory compliance)

Front 13

What is the role of cricoid pressure in nonarrest patients?

Back 13

May help protect the airway from aspiration and gastric insufflation during bag-mask ventilation. May also impede ventilation, however, Routine use is not recommended in cardiac arrest.

Front 14

How important is advanced airway placement during CPR (timing, etc.)?

Back 14

Minimal interruptions in CPR appears more valuable. Earlier time to invasive airway (<5 min) in hospital was not assoc with incr ROSC but did incr 24 hours survival. Intubation outside of hospital in <12 min was associated with better survival than >13 min. Defer insertion of advanced airway until the patient fails to respond to initial CPR and defib attempts or demonstrates ROSC.

Front 15

What monitoring should occur during intubation for patients with perfusing rhythms?

Back 15

pulse oximetry and ECG, with interruptions in intubation as needed to correct changes

Front 16

What physical exam steps should be performed to ensure proper placement of advanced airway?

Back 16

visualize chest expansion bilaterally and listening over the epigastrium (no breath sounds) and the lungs bilaterally (breath sounds equal and adequate)

Front 17

What form of continuous monitoring should be used to ensure advanced airways remain in correct place?

Back 17

continuous waveform capnography (should be assessed in the field, in the transport vehicle, on arrival at the hospital, after any patient transfer; helps reduce unrecognized tube misplacement)

Front 18

What is the proper rate of ventilation and chest compression once an advanced airway has been placed?

Back 18

1 breath every 6-8 seconds (faster can increase intrathoracic pressure and worsen hemodynamics), 100 compressions per minute, only pause to switch positions (every 2 min)

Front 19

List a few examples of supraglottic airways (do not require glottis visualization during placement):

Back 19

laryngeal mask airway, esophageal-tracheal tube (Combitube), and laryngeal tube (King LT)

Front 20

List advantages and disadvantages of a Combitube:

Back 20

advantages (easy to place, similar efficacy to endotracheal intubation) & disadvantages (identification of which tube is in the trachea vs esophagus is critical, mistakes can be fatal; can also cause esophageal trauma including lacerations, bruising, and emphysema)

Front 21

List advantages and disadvantages of a King LT (laryngeal tube):

Back 21

Advantages (easy to place and can only go into esophagus which may help with less aspiration) & disadvantages (less well studied)

Front 22

List advantages and disadvantages of a laryngeal mask airway:

Back 22

Advantages (easy to place, reduces risk of aspiration compared to bag-mask, provides similar ventilation to endotracheal intubation) & disadvantages (does not work for every patient, must have a backup tube option)

Front 23

List advantages and disadvantages of endotracheal intubation:

Back 23

Advantages (keeps airway patent, permits suctioning of airways, enablies high flow of oxygen, alternate route of drug delivery, can help prevent aspiration when used with a cough) & disadvantages (difficult to perform and must maintain competency, can cause trauma to oropharynx, interrupts compressions, difficult to detect tube misplacement)

Front 24

List two indications for endotracheal intubation:

Back 24

1. inability of provider to ventilate unconscious patient adequately with a bag and mask & 2. absence of airway pretective reflexes (coma or cardiac arrest patients)

Front 25

How much time should be allowed for an intubation attempt:

Back 25

10 seconds, everyone should be prepped before stopping compressions, and everyone should resume compressions ASAP; consider supraglottic airway with unsuccessful intubation attempts

Front 26

When is advanced airway displacement most common?

Back 26

during patient transfers

Front 27

List methods for determining proper tube placement:

Back 27

1. continuous waveform capnography 2. CO2 exhalation detectors (can give false positives if patient just swallowed carbonated beverages and tube is in esophagus; false negatives can occur with PEs) 3. color-imetric device (false reading if contaminated with acidic drugs (epi) or stomach contents) 4. esophageal detector devices (bulb or syringe used to pull back on tube; placement in esophagus will collapse tube and make it difficult to draw back; trachea can collapse, however, with obesity, pregnancy, or status asthmaticus, or excessive endotracheal secretions)

Front 28

Describe postintubation airway management:

Back 28

1. record depth of tube placement to the teeth or gums 2. secure tube with tape or other device without compressing neck 3. capnography 4. cxr to check tube placement

Front 29

What is the recommended compression-ventilation ratio for HCPs when an advanced airway has not been placed?

Back 29

30 to 2

Front 30

Adult Cardiac Arrest algorithm: outline VF/VT pathway

Back 30

1. activate emergency response 2. start CPR, give oxygen, and prep defibrillator 3. give one shock ASAP 4. cpr for 2 minutes 5. shock again if still VF/VT 6. cpr for 2 minutes and give epi 1 mg q3-5 min, consider advanced airway 7. shock again if still vf/vt 8. cpr for 2 minutes, give amio 300 mg bolus, and treat reversible causes 9. continue to shock if able, epi q3-5 min (or vasopression 40 units x1), second dose amio (150 mg bolus), continue until ROSC

Front 31

Adult Cardiac Arrest algorithm: outline PEA/asystole pathway

Back 31

1. activate emergency response 2. start CPR, give oxygen, and prep defibrillator 3. no shocks advised, continue cpr for 2 min, epi 1 mg q3-5 min, consider advanced airway 4. reassess need for shock every 2 min, continue CPR, continue epi 1 mg q3-5 min (or vasopression 40 units x1)

Front 32

Adult Cardiac Arrest algorith: describe CPR quality

Back 32

1. push hard (>=2 in) and fast (>100/min) and allow chest recoil 2. minimize interruptions 3. avoid excessive ventillation (8-10 vents per minute) 4. rotate compressor every 2 minutes 5. 30:2 ratio if no advanced airway 6. quantitative waveform capnography (improve CPR quality if PETCO2 <10 mmHG) 7. improve CPR if intra-arterial pressure (diastolic) <20 mmHg

Front 33

Adult Cardiac Arrest algorith: define return of spontaneous circulation (ROSC):

Back 33

1. pulse and blood pressure 2. abrupt sustained increase in PETCO2 (usually >40 mmHg), 3. spontaneous arterial pressure waves with intra-arterial monitoring

Front 34

Adult Cardiac Arrest algorithm: describe electrical shock settings

Back 34

biphasic (follow manufacturer recommendation (usually 120-200 J, use max if unknown), consider higher and equivalent doses for second and subsequent doses) & monophasic (360 J)

Front 35

Adult Cardiac Arrest algorithm: list doses for three drugs listed on algorithm

Back 35

Epi (IV/IO 1 mg q3-5 min), Vaso (IV/IO 40 units can replace 1st or 2nd epi dose), Amio (IV/IO 300 mg bolus first dose, 150 mg bolus second dose)

Front 36

Adult Cardiac Arrest algorithm: list 5 Hs and 5 Ts

Back 36

Hs (hypovolemia, hypoxia, hydrogen ion [acidosis], hypo/hyperkalemia, hypothermia) & Ts (tension pneumothorax, cardiac tamponade, toxins, pulmonary thrombosis, coronary thrombosis)

Front 37

Adult Cardiac Arrest algorithm: which interventions increases survival to hospital discharge

Back 37

high-quality CPR and shocks for VF/VT

Front 38

Adult Cardiac Arrest algorithm: where should defib pads be placed

Back 38

anterior-lateral (front right chest and left side); alternatives include anterior-posterior, anterior-left infrascapular, anterior-right infrasapular

Front 39

Adult Cardiac Arrest algorithm: what should also be checked during a postive rhythm check?

Back 39

pulse

Front 40

Adult Cardiac Arrest algorithm: if a shock is successful but then the bad rhythm returns, how should the shock energy change?

Back 40

shouldn't change, keep the same as previous successful shock

Front 41

Adult Cardiac Arrest algorithm: what are the immediate steps after giving a shock

Back 41

resume CPR immediately with compressions (without a rhythm or pulse check) for 2 minutes, then check rhythm and repeat sequence

Front 42

Adult Cardiac Arrest algorithm: describe the importance of minimizing time between shocks and compressions

Back 42

When VF is present for a few minutes, myocardium is depleted of oxygen and metabolic substrates. Compressions help deliver oxygen and substrates and "unload" the volume-overloaded right ventricle. This increases the likelihood of a shock being successful. Minimizing the time between compressions and shock also helps increase.

Front 43

Adult Cardiac Arrest algorithm: is there benefit in delaying defib to allow compressions?

Back 43

unclear at this time, perhaps

Front 44

Adult Cardiac Arrest algorithm: describe the pros and cons of giving a vasopressor immediately after a shock

Back 44

doing so allows serum drug levels to be elevated enough to help the next shock work better (2-3 min later); if first shock works, however, giving a vasopressor could be detrimental to hemodynamics (decrease myocardial perfusion)

Front 45

Adult Cardiac Arrest algorithm: describe evidence for amio vs lido in refractory VF/VT

Back 45

amio has been proven to improve rate of ROSC and hospital admission; lido does not

Front 46

Adult Cardiac Arrest algorithm: when should you consider magnesium?

Back 46

TdP with prolonged QT only

Front 47

Adult Cardiac Arrest algorithm: what is a common cause of refractory VF/pulseless VT?

Back 47

acute coronary ischemia/myocardial infarction (consider PCI, CABG; fibrinolytic therapy during CPR for ACS has not been shown to improve outcomes)

Front 48

Adult Cardiac Arrest algorithm: list next steps after AED reveals a nonshockable rhythm

Back 48

CPR resumed immediately x2 min; repeat rhythm check; if organized rhythm found, check pulse; if no pulse (PEA), resume CPR

Front 49

Adult Cardiac Arrest algorithm: which drugs are given in PEA/asystole

Back 49

vasopressor (epi/vasopressin); no benefit to giving atropine (no harm either)

Front 50

Adult Cardiac Arrest algorithm: list common causes of PEA/asystole and how to manage

Back 50

hypoxemia (advanced airway); volume loss/sepsis (IV/IO crystalloid); blood loos (blood transfusion); PE (consider fibrinolytic); tension pneumothorax (needle decompression)

Front 51

Adult Cardiac Arrest algorithm: what is the prognosis for asystole

Back 51

not good. Generally in end-stage after prolonged VF/PEA

Front 52

Adult Cardiac Arrest algorithm: list three physiologic paramters that can be used to detect ROSC w/o stopping compressions

Back 52

end-tidaly CO2 production (PETCO2: normally 35-40, less without delivery of CO2 to lungs; use if patients are intubated), coronary perfusion pressure (CPP should be >15; or aortic relaxation "diastolic" pressure > 17), central venous oxygen saturation (SCVO2; 60-80% normal)

Front 53

Adult Cardiac Arrest algorithm: is there benefit in checking for pulses during CPR?

Back 53

no studies demonstrate value; retrograde blood flow into venous system can produce femoral pulses; carotid pulsations do not correlate with coronary and cerebral perfusion; palpation of pulses when compressions are stopped can be an indicator of ROSC (do not take more than 10 sec to do though)

Front 54

Adult Cardiac Arrest algorithm: explain two drug therapies that can falsely alter PETCO2 levels

Back 54

bicarb therapy increases CO2 in body (false elevation), vasopressors increase BP but decrease cardiac output (can lower PETCO2)

Front 55

Adult Cardiac Arrest algorithm: describe steps to make peripheral IV drug delivery more effective

Back 55

administer drug by bolus infection and follow with a 20 ml bolus of IV fluid; brief elevation of the extremity can also help

Front 56

Adult Cardiac Arrest algorithm: pros/cons of central line placement

Back 56

allows faster drug delivery, can be used to measure SCVO2 and estimate CPP; relative contraindication to fibrinolytic therapy

Front 57

Adult Cardiac Arrest algorithm: which drugs can be given down the ET tube

Back 57

naloxone, atropine, vasopression, epi, lidocaine; doses should be 2-2.5x IV dose (epi doses may need to be 3-10x higher); dilute with 5-10 ml of sterile water or NS, sterile water may have better absorption

Front 58

Adult Cardiac Arrest algorithm: amio dosing

Back 58

300 mg iv/io for first dose, 150 mg for second dose

Front 59

Adult Cardiac Arrest algorithm: lidocaine dosing

Back 59

1-1.5 mg/kg IV for first dose; 0.5-0.75 mg/kg IV push for subsequent doses at 5-10 minute intervals; maximum of 3 mg/kg total

Front 60

Adult Cardiac Arrest algorithm: recommended mag sulfate dose for TdP

Back 60

1-2 g diluted in 10 ml D5W

Front 61

Adult Cardiac Arrest algorithm: pros/cons of bicarb therapy

Back 61

can help correct acidemia (two studies show improved outcomes); most studies, however, show harm (reduced systemic vascular resistance, extracellular alkalosis that shifts oxyhemoglobin saturation curve and inhibits oxygen release, hypernatremia (hyperosmolarity), paradoxical increase in myocardial intracellular acidosis, may inactivate catecholamines

Front 62

Adult Cardiac Arrest algorithm: situations when bicarb might be useful and list dose

Back 62

preexisting metabolic acidosis, hyperkalemia, TCA poisoning; dose is 1mEq/kg

Front 63

Adult Cardiac Arrest algorithm: pros/cons of fibrinolytics

Back 63

initial studies showed promising outcomes for ACS/PE but larger studies have since shown no benefit of giving during CPR; not recommended for ACS during CPR; consider if PE presumed/known to be cause

Front 64

Adult Cardiac Arrest Algorithm: s/sx of hypovolemia and tx

Back 64

narrow QRS complex w/ rapid rate; hx suggests dehydration, flat neck veins; treat with fluids

Front 65

Adult Cardiac Arrest Algorithm: s/sx of hypoxia and tx

Back 65

slow rate (hypoxia); cyanosis, blood gases, airway problems; oxygenation, ventilation, advanced airway

Front 66

Adult Cardiac Arrest Algorithm: s/sx of acidosis (H ion) and tx

Back 66

smaller-amplitude QRS complexes; hx of dm, bicarb responsive preexisting acidosis, renal failure; ventilation, sodium bicarb

Front 67

Adult Cardiac Arrest Algorithm: s/sx of hyperkalemia and tx

Back 67

high-potassium EKG: t waves taller and peaked, P waves smaller, QRS widens, sine-wave PEA; hx of renal failure, diabetes, recent dialysis, dialysis fistulas, medications; tx hyperK with CaCl, bicarb, glucose+insulin, albuterol

Front 68

Adult Cardiac Arrest Algorithm: s/sx of hypokalemia and tx

Back 68

low-potassium EKG: t waves flatten, prominent U waves, QRS widens, QT prolongs, wide complex tachycardia; abnormal K loss, diuretic use; tx with potassium AND magnesium if cardiac arrest

Front 69

Adult Cardiac Arrest Algorithm: s/sx of hypothermia and tx

Back 69

J or Osborne waves, h/o exposure to cold, central body temp; hypothermia algorithm

Front 70

Adult Cardiac Arrest Algorithm: s/sx of tension pneumothorax and tx

Back 70

narrow complex w/ slow rate (hypoxia); hx, no pulse with CPR, neck vein distension, tracheal deviation, unequal breath sounds, difficult to ventilate patient; needle decompression and tube thoracostomy

Front 71

Adult Cardiac Arrest Algorithm: s/sx of cardiac tamponade and tx

Back 71

narrow complex w/ rapid rate; hx, no pulse felt with CPR, vein distention; pericardiocentesis

Front 72

Adult Cardiac Arrest Algorithm: s/sx of toxins and tx

Back 72

various EKG effects; bradycardia, pupils, neuro exam, empty drug bottles; intubation, antidotes

Front 73

Adult Cardiac Arrest Algorithm: s/sx of MI and tx

Back 73

12 lead EKG: Q waves, ST segment changes, inverted T waves; hx, cardiac enzymes, good pulses with CPR; see algorithm

Front 74

Adult Cardiac Arrest Algorithm: s/sx of PE and tx

Back 74

narrow complex w/ rapid rate; hx, no pulse felt with CPR, vein distension, h/o PE/DVT; surgical embolectomy, fibrinolytics

Front 75

What is true-asystole?

Back 75

actually asystole; not another rhythm (fine VF) or due to operator error

Front 76

Which is more severe: unstable or symptomatic brady/tachycardia?

Back 76

unstable indicates vital organ function impaired or cardiac arrest is iminent

Front 77

Adult Bradycardia Algorithm: s/sx of bradycardia

Back 77

chest discomfort/pain, SOB, decr LOC, weakness, fatigue, light-headedness, dizziness, syncope; hypotension, orthostatic hypotension, sweating, pulm congestion, CHF, frequent PVCs

Front 78

Adult Bradycardia Algorithm: define bradycardia

Back 78

HR < 60 bpm (usually <50 bpm if symptomatic)

Front 79

Adult Bradycardia Algorithm: describe a common cause of bradycardia and how to assess

Back 79

hypoxemia: focus on signs of increased work of breathing (tachypnea, intercostal retractions, suprasternal retractions, paradoxical abdominal breathing, pulse oximetry); provide supplemental oxygen as needed

Front 80

Adult Bradycardia Algorithm: list the initial steps in the workup of bradycardia

Back 80

assess oxygen status, evaluate BP, establish IV access, obtain a 12 lead EKG to better define the rhythm, identify potential reversible causes

Front 81

Adult Bradycardia Algorithm: list the indications for starting drug therapy

Back 81

symptomatic bradycardia (acute mental status changes, ischemic chest discomfort, acute heart failure, hypotension, signs of shock)

Front 82

Adult Bradycardia Algorithm: name and describe the different types of AV blocks

Back 82

1st degree AV block (prolonged PR interval >0.20 sec; generally benign); 2nd degree AV block Mobitz type 1 (block is at AV node; PR interval gets longer and longer, QRS complexes get bunched into sets with gaps in between; usually transient/asx); 2nd degree AV block Mobitz type II (block is in His-Purkinje system; normal looking but then there will be a P wave without a QRS complex; often sx and progresses to 3rd degree); 3rd degree AV block (AV node, bundle of His, or bundle braches; no connection between atria and ventricles; atria beat at 100 bmp and ventricles beat at 40 bpm; can be permanent or transient)

Front 83

Adult Bradycardia Algorithm: describe first line (temporary) therapy while waiting for pacing

Back 83

atropine 0.5 mg q3-5 minutes for a max of 3 mg (do not give doses <0.5 mg); caution in ACS or MI as incr HR may worsen ischemia; likely ineffective if vagal innervation is absent from heart (s/p heart transplant); avoid in type II 2nd degree AV block and 3rd degree AV block (use beta agonists and pacing instead)

Front 84

Adult Bradycardia Algorithm: when should transcutaenous pacing be used?

Back 84

unstable patients who do not respond to atropine and need temp tx until transvenous pacing (minimize use b/c it is painful for conscious patients)

Front 85

Adult Bradycardia Algorithm: list second line drug therapy

Back 85

dopamine (start at 2-10 mcg/kg/min for HR, can incr >10 mcg/kg/min for BP, assess fluid status); epinephrine (2-10 mcg/min); isoproterenol (B1/B2 agonist, 2-10 mcg/min)

Front 86

Adult Tachycardia Algorithm: List 8 types of narrow-QRS-complex tachycardias (QRS<0.12s)

Back 86

sinus tachycardia, atrial fibrillation, atrial flutter, AV nodal reentry, accessory pathway-mediated tachycardia, atrial tachycardia (automatic and reentry forms), multifocal atrial tachycardia, junctional tachycardia

Front 87

Adult Tachycardia Algorithm: List four types of wide-QRS-complex tachycardias (QRS>0.12s)

Back 87

VF/VF, SVT with aberrancy, pre-excited tachycardias (WPW syndrome), ventricular paced rhythms

Front 88

Adult Tachycardia Algorithm: define tachycardia

Back 88

HR>100, usually >150 when symptomatic; upper rate of sinus tachycardia is age-related (220-age for approx upper end of normal)

Front 89

Adult Tachycardia Algorithm: list the initial steps in the workup of tachycardia

Back 89

check for a pulse, assess oxygen status, evaluate BP, establish IV access, obtain a 12 lead EKG to better define the rhythm, identify potential reversible causes

Front 90

Adult Tachycardia Algorithm: list the indications for cardioversion

Back 90

rate-related cardiovascular compromise, symptomatic tachycardia (acute mental status changes, ischemic chest discomfort, acute heart failure, hypotension, signs of shock); if HR < 150, unlikely to be primary cause of instability

Front 91

Adult Tachycardia Algorithm: when can adenosine be used?

Back 91

if not hypotensive, can use adenosine for regular narrow-complex SVT (likely due to suspected reentry, paroxysmal SVT) while preparing for cardioversion

Front 92

Adult Tachycardia Algorithm: next step if tachycardia is stable

Back 92

obtain 12 lead EKG and determine if QRS complex is >= 0.12 sec

Front 93

Adult Tachycardia Algorithm: list differences between and benefits of synchronized vs unsynchronized cardioversion

Back 93

synchronized cardioversion avoids shocking the patient during the relative refractory period of the cardiac cycle when a shock could product VF

Front 94

Adult Tachycardia Algorithm: which rhythms is synchronized cardioversion recommended for?

Back 94

unstable SVT, unstable afib, unstable aflutter, unstable monomorphic (regular) VT; works by interrupting the reentrant pathway

Front 95

Adult Tachycardia Algorithm: list the recommended energy doses for cardioversion

Back 95

afib (120-200 J biphasic), aflutter/other SVTs (50-100 J biphasic, 200 J monophasic), regular/monomorphic VT w/ a pulse (100 J biphasic/monophasic), polymorphic VT rhythms (TdP) or unclear unstable VT: use unsynchronized defibrillation doses)

Front 96

Adult Tachycardia Algorithm: list common physiologic stimuli for sinus tachycardia

Back 96

fever, anemia, hypotension/shock

Front 97

Adult Tachycardia Algorithm: list drug therapy for sinus tachycardia

Back 97

nothing specific (treat underlying causes, slowing the heart rate can decrease cardiac output)

Front 98

Adult Tachycardia Algorithm: when is a tachyarhythmia considered to be of supraventricular origin

Back 98

(QRS is narrow or if the QRS is wide and pre-existing BBB or rate-dependent aberrancy is KNOWN to be present)

Front 99

Adult Tachycardia Algorithm: where can reentry circuits reside and which arrhythmias do they produce?

Back 99

atrial myocardium (afib, aflutter, some atrial tachycardias), both limbs in AV nodal tissue (AV nodal reentry tachycardia), one limb in AV nodal tissue and an accessory pathway (AV reentry tachycardia); AVNRT and AVRT are characterized by abrupt onset and termination and a regular rate that exceeds the upper limit of sinus tachycardia, often lose p waves

Front 100

Adult Tachycardia Algorithm: describe SVTs that are automatic tachycardias

Back 100

gradual onset and termination, due to an excited automatic electrical focus (ectopic atrial tachycardia, MAT, junctional tachycardia)

Front 101

Adult Tachycardia Algorithm: describe the role of vagal maneuvers

Back 101

along with adenosine, preferred initial treatment for stable PSVT; vagal maneuvers can stop up to 25% of PSVTs; may also help slow other PSVTs to aid in rhythm analysis

Front 102

Adult Tachycardia Algorithm: describe the use of adenosine for PSVT

Back 102

if PSVT does not respond to vagal maneuvers, give 6 mg IV adenosine as rapid IV push through a large vein followed by a 20 ml saline flush; give a 12 mg dose in 1-2 minutes if rhythm does not convert; be prepared with defibrillator b/c adenosine can convert rhythm to afib with RVR; adenosine has similar efficacy to verapamil w/o as many side effects; faster onset than amio and less proarrhythmic properties

Front 103

Adult Tachycardia Algorithm: can adenosine be given in pregnancy?

Back 103

yes

Front 104

Adult Tachycardia Algorithm: when are higher doses of adenosine needed?

Back 104

patients with high blood levels of theophylline, caffeine, theobromine

Front 105

Adult Tachycardia Algorithm: when should the theophylline dose be decreased?

Back 105

patients taking dipyridamole or carbamazepine, heart transplants, or if given via central access

Front 106

Adult Tachycardia Algorithm: what are the side effects of adenosine?

Back 106

flushing, dyspnea, chest discomfort

Front 107

Adult Tachycardia Algorithm: which patient group should not receive adenosine?

Back 107

asthmatic patients

Front 108

Adult Tachycardia Algorithm: list two classes of drugs that are longer acting alternatives to adenosine for AV node blocking

Back 108

diltiazem and beta blockers

Front 109

Adult Tachycardia Algorithm: list dosing for verapamil

Back 109

2.5-5 mg IV bolus over 2 minutes (3 min in elderly), if no response and no toxicity may give repeat dose of 5-10 mg q15-30 min to max of 20 mg or give 5 mg q15 min to a total of 30 mg; only give to patients with known SVTs, do not give to patients with wide-complex tachycardias, impaired ventricular function, or heart failure

Front 110

Adult Tachycardia Algorithm: list dosing for diltiazem

Back 110

15-20 mg IV over 2 minutes (0.25 mg/kg); repeat dose of 20-25 mg in 15 minutes (0.35 mg/kg); maintenance infusion is 5-15 mg/hr titrated based on HR

Front 111

Adult Tachycardia Algorithm: what is the caution for pre-excited atrial fibrillation/flutter that conducts to the ventricles via the AV node and an accessory pathway

Back 111

treatment with AV nodal agent (adenosine, CCB, BB, digoxin) is unlikely to slow the ventricular rate and may actually incr rate

Front 112

Adult Tachycardia Algorithm: what is the concern with using antiarrhythmic medications (amio, procainamide, sotalol) for SVTs

Back 112

higher toxicity, risk of proarrhythmia; exception is in patients with pre-excited atrial arrhythmias (anti-arrhythmics can convert rhythm), be prepared for thromboembolic complications

Front 113

Adult Tachycardia Algorithm: in an unstable patient with a wide-complex tachycardia, which rhythm should be presumed?

Back 113

VT, immediate cardioversion

Front 114

Adult Tachycardia Algorithm: next step after determining a stable patient has wide complex tachycardia

Back 114

12 lead EKG to evaluate the rhythm; synchronized cardioversion; unsynchronized if detioriates to VF or polymorphic VT

Front 115

Adult Tachycardia Algorithm: outline the regular wide-complex tachcardias and the irregular wide-complex tachycardias

Back 115

regular (VT or SVT w/ aberrancy); irregular (afib with aberrancy, pre-excited afib with accessory pathway for antegrade conduction); polymorphic VT/TdP

Front 116

Adult Tachycardia Algorithm: when can adenosine be used for wide-complex tachycardias and describe the outcomes/management

Back 116

stable undifferentiated wide complex tachycardia when the rhythm cannot be determined, the rate is regular and QRS is monomorphic (do NOT use for unstable, irregular, or polymorphic wide-complex tachy since it may lead to VF); adenosine will slow SVT with aberrancy; it will not slow VT and therefore can be used for diagnosis/treatment; continuous EKG monitoring recommended

Front 117

Adult Tachycardia Algorithm: can verapamil be used for wide-complex tachycardias?

Back 117

no, unless known to be of supraventricular origin; can cause severe hypotension

Front 118

Adult Tachycardia Algorithm: treatment of choice for stable likely VT

Back 118

antiarrhythmic drugs (procainamide, amiodarone, sotalol) or elective cardioversion

Front 119

Adult Tachycardia Algorithm: describe procainamide usage

Back 119

termination of hemodynamically stable monomorphic VT; 20-50 mc/min until arrhythmia is suppressed, hypotension ensures, QRS duration increases >50%, or max dose of 17 mg/kg is given; maintenance dose is 1-4 mg/min; avoid prolonged QT and CHF

Front 120

Adult Tachycardia Algorithm: describe sotalol usage

Back 120

termination of hemodynamically stable monomorphic VT; 1-1.5 mg/kg over <= 5 minutes (slow infusion recommended in insert, but can be given faster); avoid in prolonged QT

Front 121

Adult Tachycardia Algorithm: describe amiodarone usage

Back 121

used to prevent recurrent monomorphic VT or treating refractory ventricular arrhythmias; 150 mg IV over 10 minutes (max dose of 2.2 g per 24hours; higher doses associated with an increased frequency of hypotension? Maybe just due to solvent in old formulation)

Front 122

Adult Tachycardia Algorithm: describe lidocaine usage

Back 122

second line agent behind amio/procain/sotalol b/c less effective; dose is 1-1.5 mg/kg IV bolus; infusion is 1-4 mg/min (30-50 mcg/kg/min)

Front 123

Adult Tachycardia Algorithm: what are the three treatment focuses for afib

Back 123

rate control, rhythm control if unstable, anticoagulation if afib >48 hrs (or give heparin and perform TEE to preclude thrombus on left atria)

Front 124

Adult Tachycardia Algorithm: when is electric cardioversion used for afib patients

Back 124

when they are unstable

Front 125

Adult Tachycardia Algorithm: which drugs can be used for rate control?

Back 125

Bblockers, diltiazem; digoxin and amio in CHF (caution conversion is using amio, anticoagulate?)

Front 126

Adult Tachycardia Algorithm: How should a wide-complex irregular rhythm be treated?

Back 126

consider to be pre-excited atrial fibrillation; avoid AV nodal blocking agents like adenosine, CCB, digoxin, Bblockers (may actually incr ventric rate); typically require electric cardioversion and/or antiarrhythmics

Front 127

Adult Tachycardia Algorithm: describe treatment of polymorphic VT

Back 127

requires immediate defibrillation like VF; use pharmacologic treatment to prevent recurrence

Front 128

Adult Tachycardia Algorithm: first steps if long QT interval is observed during sinus rhythm

Back 128

TdP; stop meds known to prolong QT interval, correct electrolyte imbalances and other acute precipitants (poisoning)

Front 129

Adult Tachycardia Algorithm: treatment options for drug-induced TdP

Back 129

magnesium; isoproterenol and ventricular pacing if associated with bradycardia and drug-induced QT prolongation

Front 130

Adult Tachycardia Algorithm: treatment options for familial long QT syndrome

Back 130

iV magnesium, pacing, and/or bblockers; avoid isoproterenol

Front 131

Adult Tachycardia Algorithm: treatment options for acquired long QT syndrome

Back 131

IV magnesium; consider adding pacing or IV isoproterenol when accompanied by bradycardia or is precipitated by pauses in rhythm

Front 132

Adult Tachycardia Algorithm: most common cause of polymorphic VT in the absence of prolonged QT

Back 132

myocardial ischemia; can use IV amiodarone and bblockers to prevent recurrence; magnesium of limited benefit

Front 133

Adult Tachycardia Algorithm: list two rare causes of polymorphic VT and their treatments

Back 133

catecholaminergic VT (Bblockers) and Brugada syndrome (isoproterenol)