Bb Cpr 2

Front 1

What is a risk of isoproterenol?

Back 1

It may decrease SVR and MAP at the same time it is increasing HR, contractility and myocardial oxygen consumption

Front 2

How should you give adenosine?

Back 2

6mg then 12mg, and then another 12mg, should be administered by rapid IV push followed by 20cc

Front 3

How do you treat supraventricular arrhythmias?

Back 3

adenosine, second line is verapamil (can be lethal in VT)

Front 4

Why should you not give lidocaine when you're planning on defibrillation and cardioversion? What is this process worsened by?

Back 4

increases current and energy requirement, a process worsened by acidosis

Front 5

What is the use of lidocaine in ventricular arrhythmias?

Back 5

suppresses ventricular arrhythmias-PVCs, Vtach, Vfib; depresses automaticity without causing myocardial depression, may block chronotropy and decrease SNS outflow

Front 6

When should you use procainamide?

Back 6

when lidocaine is ineffective, suppresses ventricular ectopy

Front 7

What is the dose of procainamide?

Back 7

1.5 mg/kg over 5 min until ventricular ectopy is suppressed or QRS is widened

Front 8

What is the mechanism of action of amiodarone?

Back 8

increase refractory period and reduce membrane excitability of the heart

Front 9

What is amiodarone used for?

Back 9

antidysrhythmic used for recurrent or refractory Vtach or Vfib

Front 10

Summarize basic CPR

Back 10

-Rate of compressions - 100/min
-Compression:Ventilation - 30:2 with 2 min requirement before rhythm check
-Duration of ventilation - 1 sec
-Defibrillation - one shock followed by immediate CPR for 2 min
-Depth of compressions - 1.5-2 inches

Front 11

What can now be considered for the diagnosis and treatment of stable undifferentialed wide-complex tachycardia when the rhythm is regular and the QRS waveform is monomorphic?

Back 11

Adenosine

Front 12

Mouth to mouth resusciation delivers what FiO2?

Back 12

approx 16%

Front 13

Does sodium bicarbonate improve the ability to defibrilate and survivability?

Back 13

No

Front 14

At what pH will you begin to see a decrease in myocardial contractility and CNS depression?

Back 14

< 7.1

Front 15

What is the problem with exogenous bicarbonate?

Back 15

When it is administered during acidemia, bicarbonate reacts with H+ ions to form carbonic acid. The carbonic acid dissociates to CO2 and water and CO2 partial pressure increases. When CO2 cannot be eliminated, the pH of the system is only minimally changed or worsened.

Front 16

What is survival with VF or pulseless VT if shock is administered in <1 min?

Back 16

>70% but drops by 10% for each minute delayed

Front 17

Useful mnemonic for shockable rhythm VF/pulseless VT. Explain.

Back 17

Shock, Rock, Walk
Shock, Rock, now EVerbody, Walk
Shock, Rock, And, Lets, Moonwalk
Then back to the beginning

Shock - defibrillate
Rock - 5 cycles of CPR (C:V 30:2 over 2 mins)
Walk - check for shockable rhythm

Shock - defibrillate
Rock - Resume CPR
EVerybody - Epi 1 mg IV q3-5 min or Vasopressin 40 U IV
Walk - Check for shockable rhythm

Shock - Defibrillate
Rock - Resume CPR
And - Amiodarone 300 mg in 30cc and flush with 10-20cc NS once OR
Lets - Lidocaine 1.5 mg/kg
Moonwalk - Mg 1-2 gm IV in torsades depointes or refractory Vfib
Back to the beginning

Front 18

What are the 6 H's and 5 T's?

Back 18

Hypovolemia
Hypoxia
Hydrogen ions (acidosis)
Hypo/hyperkalemia
Hypoglycemia
Hypothermia
Toxins
Tamponade
Thrombosis (coronary or pulmonary)
Tension pneumothorax
Trauma

Front 19

What heart rate usually exists with a bradyarrhythmia?

Back 19

HR <50/min

Front 20

What could be the possible causes of a bradycardia?

Back 20

Remember: "MOOVAD"
M = Myocardial disease, ischemia, or infarction
O = O2 low
O = Overdose of anesthesia
V = Vagal phenomenon
A = acidemia
D = drugs

Front 21

Initial steps of the adult bradycardia algorithm?

Back 21

1. Assess appropriateness for clinical scenario
2. Maintain airway, give oxygen if hypoxemic, place on cardiac monitor, IV access, 12 lead EKG
3. Are they symptomatic? Yes - drugs, No - monitor and observe

Front 22

What is considered symptoms of bradycardia?

Back 22

1. hypotension
2. AMS
3. Signs of shock
4. Ischemic chest discomfort
5. acute heart failure

Front 23

How should you treat a symptomatic bradycardia?

Back 23

1. First try atropine 0.5 mg IV bolus and repeat every 3-5 minutes to a max of 3 mg (ie 6 doses)
2. If atropine is ineffective transcutaneous pace or dopamine or epi infusion.
3. Consider expert consultation and transvenous pacing

Front 24

Doses for epi and dopamine infusions in bradycardia treatment?

Back 24

Epi - 2-10 mcg/min
Dopamine 2-10 mcg/kg/min

Front 25

What is preferred when IV access is not available, IO drug injection or injection into the ETT?

Back 25

IO

Front 26

Where are the preferred IO locations?

Back 26

1. 1 cm below the tibial tuberosity medially on the tibial plateau
2. 1 cm proximal to the medial malleolus

Front 27

Describe steps of IO placement using EZ-IO kit.

Back 27

1. Anesthetize the periosteum of the bone with 2-3 cc local anesthetic
2. using a twisting action, screw the needle into the bone until a give is felt
3. Remove the trocar and the metal cannula remains standing unsupported with its tip in the bone marrow
4. aspirate bone marrow to confirm placement (might be too thick)
5. inject fluid to confirm patency - should inject easily
6. standing cannula should be taped firmly around its base with a plastic cup protecting it from accidental dislodgement

Front 28

What is the first goal with tachycardia?

Back 28

Quickly categorize it as a narrow complex (SVT) tachycardia (QRS <0.12 seconds) or wide complex tachycardia (QRS >0.12 seconds)

Front 29

What is the differential diagnosis for tachycardia?

Back 29

Remember: "How Can Every System Possibly Function Adequately?"
H = Hypovolemia, Hypoxia, Hypercarbia, Hyperthermia (malignant)
C = CHF, Catecholamines
E = Endocrine problems
S = Sepsis, Surgery
P = PE, Pneumothorax
F = Fever
A = Anemia, Anxiety, Anesthetic agents

Front 30

When HR is < ____ it is unlikely that symptoms of instability are caused primarily by the tachycardia unless there is impaired LV function.

Back 30

<150

Front 31

If not hypotensive, how should a pt with a narrow complex tachycardia be treated?

Back 31

With adenosine while preparations are made for synchronized cardioversion

Front 32

How many narrow complex tachycardias are there? Name them in order of frequency.

Back 32

1. Sinus Tach
2. Afib
3. Aflutter
4. AV nodal re-entry
5. Accessory pathway mediated tachycardia
6. Atrial or multifocal atrial tachycardia
7. Junctional tachycardia

Front 33

How many wide complex tachycardias are there? Name them in order of frequency.

Back 33

1. Vtach
2. Vfib
3. SVT with aberrancy
4. pre-excitation tachycardias (WPW)
5. Ventricular paced rhythms

Front 34

For a pt with stable, narrow complex SVTs or paroxysmal SVTs, what is the first line of defense?

Back 34

1. Vagal maneuvers - will terminate 25%
2. If ineffective, Adenosine 6 mg, followed by 12 mg if there is no response within 1-2 min
3. If this fails, reasonable to use longer acting AV nodal blocking agents, specifically CCBs such as Verapamil (2.5-5 mg) and diltiazem (15-20 mg) along with BBs such as esmolol or metoprolol

Front 35

When should adenosine NOT be used for a tachycardia?

Back 35

For a wide complex unstable, irregular, or polymorphic tachycardia since it may cause degeneration of the arrhythmia to Vfib

Front 36

What type of tachycardia is verapamil contraindicated in?

Back 36

wide complex tachycardia, unless known to be supraventricular in origin

Front 37

For pts who are stable with likely VT, what is the preferred treatment strategy?

Back 37

IV antiarrhythmic drugs or elective cardioversion is the preferred treatment strategy.
- If antiarrhythmics chosen, procainamide, amiodorone, or sotalol can be considered

Front 38

What drugs are useful for rate control for irregular tachycardias in the setting of CHF?

Back 38

Digoxin and amiodarone

Front 39

What drugs should be avoided in wide complex irregular rhythms?

Back 39

AV nodal blocking agents such as adenosine, CCBs, digoxin, and possibly even BBs since they may paradoxically increase ventricular response.

Front 40

What has been reported as effective in treating torsades de pointe?

Back 40

Magnesium, isoproterenol, and ventricular pacing

Front 41

Polymorphic Vtach in the absence of prolonged QT interval is most often due to ___.

Back 41

Myocardial ischemia

Front 42

Tachycardia with pulses algorithm

Back 42

1. ABCs, give O2
2. Stable or Unstable?
3. Unstable - perform immediate synchronized cardioversion, Stable - Is it narrow or wide complex?
4. If it's narrow is it regular or irregular?
5. If regular and narrow, attempt vagal maneuvers, if that fails give adenosine 6 mg rapid IV push, if failed give 12 mg (may repeat 12 mg once). If it converts observe for recurrence. If it recurrs tx with adenosine or longer AV nodal blocking agent (diltiazem, BBs). If it does not convert, control rate with diltiazem or BBs.
6. If irregular and narrow, control rate (diltiazem or BBs), consider expert consult
7. If it's wide complex, is it regular or irregular?
8. If regular, prepare for elective synchronized cardioversion. Give Amiodarone 150 mg IV over 10 min. Rpt as needed to max dose of 2.2g/24 hrs. If SVT w/ aberrancy give adenosine.
9. If irregular and wide, get expert consult, avoid AV nodal blocking agents, consider antiarrhythmics

Front 43

If a narrow, regular complex tachycardia converts with vagal maneuvers or adenosine, what is the likely rhythm?

Back 43

Probably reentry SVT

Front 44

If a narrow, regular complex tachycardia does not convert with vagal maneuvers or adenosine, what is the likely rhythm?

Back 44

Possibly aflutter, ectopic atrial tachycardia, or junctional tachycardia

Front 45

What is the likely rhythm if it is an irregular narrow-complex tachycardia?

Back 45

Probable afib or possible aflutter or multifocal atrial tachycardia

Front 46

What are the possible causes of an irregular wide complex tachycardia?

Back 46

AFib with aberrancy
Pre-excited afib
Recurrent polymorphic VT
Torsades de pointes

Front 47

What may improve outcomes prior to a 3rd or 4th counter-shock in refractory VF/VT?

Back 47

antiarrhythmic agents such as amiodarn one

Front 48

In the presence of VF, the beneficial effects of epi derives from...

Back 48

increased myocardial contractility, NOT increased SVR