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525 Cards in this Set

  • Front
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What comes after the BLS primary survey?

ACLS secondary survey

During the primary BLS survey, how many rescue breaths should be given?
During the primary BLS survey, give each rescue breath over ___ second(s)?
1 second
During the primary BLS survey, check the carotid pulse for at least ___ but no loger than ___ seconds.

During the primary BLS survey, follow each shock immediately with CPR, beginning with ______.
chest compressions
Try to limit interruptions to chest compressions to no longer than ___ seconds.
Step 4 in the BLS survey is ______.
The "D" in the ACLS secondary survey stands for ______.
differential diagnosis
Use of OPA and NPA is considered in the ______ survey.
ACLS secondary survey
During the ACLS secondary survey, name three ways to assess the adequacy of oxygenation and ventillation.
(1) Clinical criteria (chest rise)
(2) O2 saturation
(3) Capnography
Name three ways to confirm proper placement of advanced airway devices.
(1) Physical Examination
(2) Measurement of exhaled CO2
(3) Use of esophageal detector device
The first three steps in treating any cardiac emergency before ABCDs are:
(1) Scene safety
(2) Check responsiveness
(3) Get help/AED/return
If trauma is suspected, the proper method for opening the airway is the ______.
jaw lift without head extension
If trauma is NOT suspected, the proper method for opening the airway is the ______.
head tilt-chin lift
You check for a pulse and there is none. AED is on the way. What is the next step?
Begin CPR until AED arrives.
You check for a pulse and there is none. AED is beside the patient. What is the next step.
Immediately connect AED and analyze.
Remember: assess... then ______.
perform appropriate action
For rescue breathing without chest compressions, give bag-mask ventillations every ___ to ___ seconds.
5 to 6
For rescue breathing without chest compressions, give bag-mask ventillations at a rate of ___ to ___ breaths per minute.
10 to 12
During the differential diagnosis, you search for, find, and treat ______.
reversible causes
During rescue breathing, each breath should take ____ second(s) and achieve visible ______.
1 second

chest rise
Be careful to avoid ______ breaths per minute or ______ a volume per breath.
too many

too large
Name four ways in which hyperventillation can be harmful.
(1) increases intrathoracic pressure
(2) decreases venous return to the heart
(3) diminishes cardiac output
(4) may cause distention, vomiting, and aspiration
Administer oxygen continuously if saturation is less than ______.
Four steps for instering an OPA
(1) Suction as needed
(2) Measure (corner mouth/angle jaw)
(3) Insert backward
(4) Rotate 180% on insertion
Too large of an OPA may ______.
damage or obstruct larynx
Too small of an OPA may ______.
push down tongue/obstruct airway
Three steps for inserting an NPA
(1) Measure (tip nose/earlobe)
(2) lubricate with KY
(3) insert along floor, rotate/switch nostrils if resistance
compications of NPA insertion
(1) Bleeding
(2) Esophageal entry (too long)
(3) larygospams/vomiting
(4) cranial cannulation (w/trauma)
Always check for _______ immediately after insertion of either an OPA or an NPA.
spontaneous respirations
Portable suction may be inadequate, as a suction force of ______ to ______ is generally necessary to properly suction.
-80 to -120 mm Hg
A wall-mounted suction unit should be capable of suction force exceeding ______.
-300 mm Hg
A ______ is a type of suction catheder that can be used for thin secretions in the mouth or nose.
soft flexible catheter
A ______ is a type of suction catheder that can be used for thick secretions in the oropharynx.
rigid (Yankauer) catheter
Do not insert an oropharyngeal suction catheter any further than the distance from the ______ to the ______.
tip of nose

To apply oropharygeal suction, ______ side opening of catheder and ______ while withdrawing.

Typically limit suction attempts to ___ seconds or less.
What four things should be monitored during suctioning?
(1) heart rate
(2) pulse
(3) O2 saturation
(4) clinical appearance
If ______ developes or ______ deteriorates, interrupt suctioning.

clinical appearance
If bradycardia developes during suctioning, ______ until the heart rate returns to normal.
administer high flow 02
three steps to perform ET (sterile) suctioning
(1) use sterile technique
(2) insert with side opening open; do not pass tip of ET tube
(3) Occlude opening & withdraw while rotating
Precede and follow suction attempts with a short period of ______.
100% O2 administration
List three advanced airways.
(1) Laryngeal mask airway (LMA)
(2) Laryngeal tube
(3) ET Tube
The ______ and ______ are advanced airway alternatives to endotracheal intubation.

What does LMA stand for?
larygeal mask airway.
Seven steps for performing ET intubation
(1) assemble equipment
(2) intubate
(3) inflate cuff
(4) attach bag
(5) confirm placement
(6) secure the tube
(7) monitor for displacement

(routine use of cricoid pressure no longer recommended)
Use cricoid pressure during intubation only if the patient is ______.
few special circumstances

(routine use of cricoid pressure no longer recommended)
What is the correct CPR ventillation to compression cycle once an advanced airway is placed?
There is no cycle.
(Chest compressions are no longer interrupted for ventillations.)
With an advanced airway in place and CPR in progress, give 1 breath every ___ to ___ seconds.
6 to 8
With an advanced airway in place and CPR in progress, give ___ to ___ breaths per minute.
8 to 10
In a full cardiac arrest, what is the rate of breaths per minute for basic versus advanced airways?
basic airway: 2 ventilation after every 30 compressions

advanced airway w/CPR: 8-10 breaths/min
In a full cardiac arrest, how many seconds between breaths for basic versus advanced airways?
basic airway: 2 ventilation after every 30 compressions

advanced airway w/CPR: every 6-8 secs
With an advanced airway in place in a patient with a pulse and no compressions needed, give 1 breath every ___ to ___ seconds.
5 to 6
With an advanced airway in place in a patient with a pulse and no compressions needed, give ___ to ___ breaths per minute.
10 to 12
In a respiratory arrest, what is the difference in the rate of breaths delivered per minute for basic versus advanced airways?
Nothing. In both cases, deliver 10-12 breaths per minute.

(The recommended rate is different only for full cardiac arrest when an advanced airway is in place.)
In a respiratory arrest, what is the difference in the number of seconds between breaths for basic versus advanced airways?
Nothing. In both cases, administer 1 breath every 5-6 seconds.

(The recommended rate is different only for full cardiac arrest when an advanced airway is in place.)
Rescue breaths for CPR with an advanced airway in place are ___ to ___ breaths per minute.
8 to 10
Rescue breaths for CPR with an advanced airway in place are 1 breath every ___ to ___ seconds.
6 to 8
In a patient requiring resuscitation, the use of ______ spinal immobilization is preferred over _______, as the latter may complicate airway management. (However, always use the latter during transport.)
manual (spinal stabilization is preferred over..)

immobilization devices
If breathing is inadequate, give rescue breaths using a ______ if available.
barrier device
Take between ___ and ___ seconds to check breathing.
5 - 10
Take between ___ and ___ seconds to check pulse.
5 - 10
Complete this sentence:
Peform high quality CPR until the AED...
pads are placed and ready to analyze.
Complete this sentence:
Follow each shock immediately with...
CPR, beginning with chest compressions.
If you are unsure of whether the patient has a pulse or not, you should ______.
begin CPR
In the first few minutes after successful defribrillation, any spontaneous rhythm is typically ______ and does not create ______ or ______.

pulses (or) perfusion
What is the rationale for resuming immediate chest compressions after every shock.
Even successful defibrillations do not typically produce an adequately perfusing rhythm instantly.
CPR in the patient with a pulse ______ harmful.

(is/is not)
It is not harmful.
The interval from ______ to ______ is one of the most important determinants of survival from cardiac arrest.

Name the four reasons early defibrillation is critical for victims of sudden cardiac arrest.
(1) VF is a common sudden arrest rhythm
(2) VF responds best to defibrillation
(3) chances of successful defib decrease over time
(4) Untreated VF becomes asystole
For every minute that passes between collapse and defibrillation, VF survival declines by ____ percent if NO bystander CPR is provided.
For every minute that passes between collapse and defibrillation, VF survival declines by ____ percent if bystander CPR is provided.
Use AEDs only when patients have the following 3 clinical findings.
(1) No response
(2) No breathing
(3) No pulse
Remember that ______ are not adequate breathing.
agonal gasps
List the 4 universal steps for operating an AED.
(1) Power on
(2) Attach pads
(3) Clear and Analyze
(4) Clear and Shock
What is the correct pad placement for an AED.
pad 1 - upper right chest
pad 2 - left side below nipple line
Expect the AED analysis to take about ___ to ___ seconds.
5 to 15
As soon as the shock is delivered by the AED, do NOT ______, but instead immediately ______.
check pulse

resume high-quality CPR
After a shock is delivered, and after about ___ minutes of CPR, the AED will prompt you to analyze rhythm again.
Never delay ______ to troubleshoot an AED!
chest compressions (CPR)
When you witness an out-of-hospital adult arrest and an AED is immediately available, should you use the AED or first perform 2 full minutes of CPR?
If you witness an arrest, use AED immediately or as soon as available.
When you witness an in-hospital adult arrest as a healthcare provider and an AED is nearby, should you use the AED immediately or first perform 2 full minutes of CPR?
In this case, use AED immediately or as soon as it's available, meanwhile perform CPR until it is attached.
If you did NOT witness an out of hospital arrest as an EMS provider, or if your response time to an arrest was longer than four to five minutes, should you defibrillate immediately or first perform 2 full minutes of CPR?
If the arrest was not witnessed and it took you a while to get there, first consider performing two full minutes of CPR, then attempt defibrillation.
When should you consider witholding the AED in favor of two minutes of CPR?
An EMS response to a non-witnessed out-of-hospital arrest.
When should you use the AED as soon as it's available?
(1) witnessed out-of-hospital arrests

(2) in hospital arrests
four situations that may require extra care in placing electrodes
(1) hairy chest
(2) immersed in water
(3) implanted pacemaker
(4) transdermal med patch
four steps for dealing with a hairy chest
(1) press pads firmly
(2) quickly pull off pads
(3) shave if needed/available
(4) replace with new pads
With AED, if patient is in water, _____.
pull him out!
With AED, if patient's chest is wet, _____.
dry it!
With AED, if patient is in snow or small puddle, _____.
you can use the AED.
What do you do with the AED electrode if you find a an implanted pacemaker (a hard lump) on the patients chest?
Place electrode at least one inch from pacemaker, and use AED normally.
What should you do to prevent a medication patch from blocking shocks from an electrode?
Remove the patch and wipe the area clean before applying electrode.
ACLS drugs for VF/Pulselsess VT case
(1) Epinephrine
(2) Norepinephrine
(3) Vasopressin
(4) Amiodarone
(5) Lidocaine
(6) Magnesium Sulfate
(7) Dopamine
(8) Oxygen
The ACLS ______ Algorithm is the most important algorithm to know for adult resuscitation.
Pulseless Arrest
Name the two pathways for pulseless arrest established in the ACLS Pulseless Arrest Algorithm.
(1) VF/VT (shockable rhythms)
(2) Asystole/PEA (nonshockable rhythms)
V-fib and pulseless V-tach are ______ rhythms.

PEA and asystole are ______ rhythms.

Name the two most critical interventions in a VF/VT arrest.
(1) CPR with minimal interruption
(2) defib within 5 minutes
Continued use of an AED ______ recommended if a manual defibrillator is available.

(is/is not)
it is NOT recommended

(AED may result in unecessary prolonged interruptions as compared to manual defib.)
Chest compressions should ideally only be interruped for (1)______ (unless an advanced airway is in place), (2)______, and (3)______.
(1) ventillation
(2) rhythm checks
(3) shock delivery
Even a _____ second pause in chest compressions reduces the chance that a shock will terminate VF.
If a charging defibrillator takes more than ___ seconds to charge, resume compressions while charging.
Wherease previous ACLS guidelines recommended three stacked shocks, the current guidelines recommend ______.
one shock
The energy dose is determined by whether the defibrillator is ______ or ______.

If you are using a monophasic defibrillator, give a single ______-J (joules) shock.
With a biphasic truncated exponential waveform, it is reasonable to used selected energies of ______-J to ______-J.
120 to 200 (the manufacturer's recommended dose, if unknown, use the max)
For biphasic defibrillators, the effective biphasic waveform dose range should be displayed ______.
on the face of the device
If you do not know the effective dose range for a particular biphasic defibrillator, deliver ______ for the first shock and ______ for subsequent shocks.
the maximum energy

the same
Immediately after a shock, resume CPR, beginning with ______.
chest compressions
Clearing the patient prior to a shock should take no more than ___ seconds.
The pause in chest compressions to check rhythm ideally should not exceed ___ seconds.
Perform a pulse check -- preferrably during rhythm analysis -- ONLY if a ______ is present.
organized rhythm
(complexes regular and narrow)
If there is EVER any doubt about the presence of a pulse... (complete this sentence).
immediately resume CPR
For an arrest that was initially shockable, if the monitor reveals a nonshockable and pulseless rhythm, you should... (complete this sentence).
proceed along the asystole/PEA pathway of the ACLS Pulseless Arrest Algorithm.
The use of ______ for defibrillation reduces the risk of arching over paddles.
self-adhesive pads
Immediately after a shock, give ___ minutes, or about ___ cycles of CPR.

A cycle of CPR consists of ___ compressions followed by ___ ventillations.

List the two "either-or" vasopressors given during CPR for a shockable arrest, either before or after the shock.
Epinephrine (1 mg IV/IO)


Vasopressin (40 U IV/IO)
Epinephrine is used during resuscitation primarily for its ______ effects, ie, vasoconstriction.
α-adrenergic (alpha)

(ie vasoconstriction)
Epinephrine induced vasoconstriction increases ______ and ______ bloodflow during CPR as mean arterial pressure and aortic diastolic pressure are increased.

The full name of the ACLS drug Epinephrine is ______.
epinephrine hydrochloride
Vasopressin is a ______ peripheral vasoconstrictor.
Vasopressin is a nonadrenergic ______.
peripheral vasoconstrictor
What is a significant difference between the effects of vasopressin and epinephrine.
Overall, the effects of the two have not been shown to differ for ROSC or survival rates.
What is ROSC?
return of spontaneous circulation
Who is responsible for team safety while compressions are being performed and the defibrillator is charging?
the team leader
Interruption in CPR to conduct a rhythm analysis ideally should not exceed ___ seconds.
"Give one shock and ______ immediately after the shock."
resume CPR
List three "either-or" antiarrhythmic drugs given during CPR of a shockable arrest, either before or after the shock.
(1) Amiodarone


(2) Lidocaine


(3) Magnesium (for Torsades)
How is Amiodarone given during a shockable arrest? (doses, route, etc.)

300 mg IV/IO once.
Consider additional
150 mg IV/IO once.
How is Lidocaine given during a shockable arrest? (doses, route, etc.)
Lidocaine (if amiodarone is unavailable)

1 to 1.5 mg/kg IV/IO first dose,
then 0.5 to 0.75 mg/kg every 5-10 mins,
maximum dose 3 mg/kg
How is Magnesium given during a shockable arrest? (doses, route, etc.)
Magnesium Sulfate
(only for torsades de pointe associated with long QT interval)

Loading dose 1 to 2 g IV/IO in 10 mL D5W,
IV/IO bolus over 5 to 20 minutes
In a shockable arrest, Magnesium is typically given by IV bolus over ______ minutes.
5 to 20
Magnesium Sulfate is typically used to treat the rhythm ______.
torsades de pointes
In a shockable arrest, Lidocaine is administered every ______ minutes.
5 to 10
In a shockable arrest, rhythm checks and shocks are organized around ______ cycles of CPR.
two minute cycles
(five 30:2 cycles)
At what point should you administer a drug once a rhythm is identified?
As soon as possible, but do not delay shocks or CPR.
In hypothermic patients with a body temp <86F (<30C), how many times should you attempt defibrillation?
Once. If initial shock is ineffective, perform additional defib attempts along BLS guidelines but withhold drugs.
In hypothermic patients with a body temp <86F (<30C), what is the concern with ACLS drug administration?
Drug metabolism is reduced, and drugs may accumulate to toxic levels. Withhold drugs until the temp rises if there is no response to the first shock.
What is the recommended approach to an arrest patient with MODERATE hypothermia (30C to 34C [86F to 93.2F])?
attempt defibrillation and give ACLS meds spaced at longer intervals
ACLS treatment of in-hospital cardiac arrest victims suffering from SEVERE hypothermia should be aimed at _______.
rapid core rewarming
What two classes of pharmacologic agents are used in a resuscitation of VT/VF?
(1) vasopressor agents
(2) antiarrhythmic agents
In what treatment sequence are the two drug classes used in shockable rhythms initially administered?
Vasopressors first,
Antiarrhythmics second.
Name the two vasopressors used in VF/VT arrest.
Name the three antiarrhythmics used in VF/VT arrest.
Priorities during cardiac arrest are ______ and ______, whereas ______ and ______ are of secondary importance.
quality CPR
early defibrillation

advanced airways
drug administration
Which drugs have be shown to improve survival to hospital discharge in cardiac arrest patients?
None. Not a one. That is why high-quality CPR and early defibrillation take precedence to ACLS.
ET absorption of drugs is generally ______.

Prioritize the three routes of vascular access.
(1) IV route
(2) IO route
(3) ET route
Which vascular route is preferred for drug and fluid administration?
peripheral IV
Insertion of a ______ may cause delays and complicate CPR, and it is a relative contraindication to fibrinolytic therapy; therefore, it is undesirable and in most cases unecessary for resuscitations.
central line
Drugs administered by peripheral line with CPR in progress typically take how long to reach central circulation?
1 to 2 minutes
Typically, the IV drug you give based on a rhythm check will not take effect until....
completion of the next cycle of CPR.
three steps for administering an IV drug to an arrest victim
(1) Give by bolus unless specified
(2) Follow with a 20 ml fluid bolus
(3) Elevate extremity for 10 to 20 seconds
Amiodarone is a complex drug that affects (1)_____, (2)_____, and (3)_____ channels.
(1) sodium
(2) potassium
(3) calcium
If IV access is not available, drugs and fluids can be delivered effectively via the ____ route.
four important points about IO access
(1) can be established in all age groups
(2) achievable in 30 to 60 secs
(3) preferred over the ET route
(4) any IV drug/fluid can be given IO
For vascular access, _____ and _____ are preferred over the ET route.
IV and IO
IO cannulation provides access to a _______.
noncollapsible marrow venous plexus
two points to bear in ming with respect to ET drug access
(1) optimal ET dose remains unknown
(2) typical dose is 2-2.5 times that of IV
Name the drugs that can be administered via the ET route.

Describe the method of administration for drugs administered via the ET route.
Dilute the dose in 5 to 10 ml of water or normal saline and inject directly into the trachea.
True or False:
There is no evidence to date that routine use of any vasopressor at any stage during management of pulseless VT, VF or asystole increases survival to discharge.
True or Fales:
There is no evidence to date that routine use of any vasopressor at any stage during management of pulseless VT, VF or asystole favors initial resuscitation with ROSC.
There is evidence that vasopressors aid in initial resuscitation and ROSC, but there is no evidence the improve survivability to discharge.
Vasopressors optimize ______ and ______.
cardiac output

blood pressure
Name the vasopressors used during cardiac arrest.
How is Epinephrine given during a cardiac arrest? (doses, route, etc.)
Epinephrine Hydrochloride

1 mg IV/IO (repeat every 3-5 mins)
How is Vasopressin given during a cardiac arrest? (doses, route, etc.)
1 dose of 40 Units IV/IO
may replace 1st or 2nd dose of EPI
How is Epinephrine given down the endotracheal tube during a cardiac arrest? (doses, route, etc.)
ET Epinephrine

1:1000 solution, 2 to 2.5 mg
diluted in 5 to 10 ml water or NS
(results will be variable and unpredictable)
Low EPI concetrations by ET administration may produce transient ______ effects (vasodilation), which may be detrimental to an arrest victim.
β-adrenergin (beta)
Vasopressin is a nonadrenergic vasoconstrictor that causes ______ and ______ vasoconstriction.

Because the efficacy is no different, a single dose of vasopressin may replace the ______ or ______ dose of EPI.
first or second
When VF/pulsless VT persists after a total of 2 or 3 shocks separated by cycles of CPR, consider ______.
These agents can be used for postresuscitation maintenance therapy.

(amiodarone, lidocaine, magnesium)
Consider antiarrhythmics in a shockable arrest if the rhythm is refractory after ______ shocks separated by cycles of CPR.
Amiodarone is more effective that ______ for short-term survival, but may not improve chances to hospital discharge.
Amiodarone has both ______ and ______ adrenergic blocking properties.
alpha and beta
Name the ACLS antiarrhythmic that is both an alpha and beta blocker.
The second does of amiodarone, which is exactly half of the first dose, is typically given after _______ minutes.
3 to 5
The antiarrhythmic ______ is an old and familiar drug with no proven efficacy in cardiac arrest, given when amiodarone is not available.
At what dose is Lidocaine given down the endotracheal tube during a cardiac arrest?
2 to 4 mg/kg
How is Amiodarone given down the endotracheal tube during a cardiac arrest?
WATCH IT! Amiodarone is NOT given down the tube.
IV Magnesium may terminate or prevent recurrence of ______ in patients who have a ______ interval during NSR.
torsades de pointes

prolonged QT interval
In addition to torsades de points, magnesium is useful for arrested patients with a history of alcoholism or other conditions associated with ______ abnormality.
After conversion of VF/pulseless VT to a perfusing rhythm, consider a ______ for maintenance therapy.
After conversion of a shockable rhythm with the administration of antiarrhythic drugs, it is usual to administer a post arrest maintenance dose of ______ antiarrhythmic.

(the same/a different)
the same
(typically use the one that was successful in resuscitation)
After successful conversion from a shockable rhythm, you would consider ______ or ______ for post arrest maintenance therapy.
amiodarone or lidocaine
Prophylactic administration of lidocaine to patients with acute coronary syndromes ______ recommended.

(is/is not)
It is NOT recommended.
Maximum 24 hour dose of maintenance therapy Amiodarone based on cumulative toxicity.
2.2 g over 24 hours
Post-arrest maintenance therapy dosages for Amiodarone.
(1) 150 mg IVB over 10 mins (skip if given during arrest)

(2) follow by IV infusion of 360 mg over 6 hours

(3) then maintain with 540 mg over next 18 hours
In post-arrest maintenance therapy with amiodarone, monitor the patient for these three things.
(1) hypotension
(2) bradycardia
(3) GI toxicity
Post-arrest maintenance therapy dosages for Lidocaine.
(1) 1 to 1.5 mg/kg loading, then 0.75 mg/kg every 5 to 10 minutes if needed to a total of 3 mg/kg (skip if done during arrest)

(2) Follow with a continuous infusion of 1 to 4 mg/min
With a lidocaine maintenance drip, a reduced dose may be needed for ______ and those with ______.
the elderly

liver disease
Correction of an underlying cause of the rhythm ______ is especially critical to patient outcome.
In PEA arrests, the team leader should verbalize the ______ in the search for treatment and reversible causes.
Differential Diagnosis
The target of PEA treatment is the ______, not the ______.

List the drugs for the ACLS PEA case.
acronym "EVA-O"

Others (depending on cause)
Name four common underlying rhythms associated with PEA.
(1) idioventricular
(2) ventricular escape
(3) postdefibrillatory idioventricular
(4) bradyasystolic
An organized rhythm without a pulse is defined as ______.

(pulseless electrical activity)
Previous (now obsolete) term for PEA.

(electromechanical dissociation)
In fact, most patients with PEA have weak contractile cardiac function that does not generate a pulse, called ______.
What is the most common rhythm present following defibrillation?
In ACLS management of the patient with PEA, ______ is a priority over ______.
IV/IO access

advanced airway management
In PEA cases, all team members must search for ______ in addition to performing their assigned roles.
underlying cause
For PEA, continue high-quality CPR, and as soon as IV/IO access is available, administer ______.
a vasopressor
What class of drugs are the first line of treatment for PEA?
What two vasopressors are used in the treatment of PEA?
EPI (1 mg IV/IO every 3-5 min)

Vasopressin (40 U IV/IO in place of 1st or 2nd EPI)
How many times can you give Vasopressin in an arrest?
Only once. Use it in place of the first or second EPI dose (there is no efficacy difference to date).
Which vasopressor has been shown to increase survival from PEA.
None. But because of their perfusion pressure effects, they continue to be recommended.
If the PEA rate is ______, consider giving atropine.
IF the PEA rate is slow, consider giving ______.
atropine (1 mg every 3-5 min)

up to 3 doses
You would administer atropine in PEA if the rate is ______.
You can give up to ___ doses of atropine in a PEA arrest.
Atropine is given at ___ mg every _____ minutes, up to 3 doses.

A ______ dosing interval for atropine (every ___ minutes) is possibly helpful in cardiac arrest.

Administer drugs during _____. DO NOT STOP _____ to administer drugs.
If organized electrical activity is present during a monitor rhythm check, you would ______.
check pulse
"Resume CPR starting with ______."
chest compressions
If a previously non-shockable rhythm has converted to a shockable rhythm...
resume CPR immediately (if possible) and charge defibrillator to deliver shock.
Patients with PEA generally have ______ outcomes.

It is critically important to quickly identify the underlying cause, as PEA may be caused by a ______ problem.
The ______ is of paramount importance in cases of PEA and asystole.
underlying cause
You would consider the following four things in the search for underlying causes of PEA.
(1) Recall your "H's and T's" (causes of PEA)
(2) Analyze the ECG for clues
(3) Recognize hypovolemia
(4) Recognize ODs/poisonings
In the treatment sequence of asystole/PEA, prepare the next drug prior to the ______.
rhythm check
The most common causes of PEA are best memorized by thinking of the "____ and ____."
"H's and T's"
How many "H's" are there in the "H's and T's."
How many "T's" are there in the "H's and T's"
The "H's and T's" consist of ___ H's and ___ T's. (the numbers)
6 H's
5 T's
List the six "H's" of PEA common causes.
(1) Hypovolemia
(2) Hypoxia
(3) Hydrogen ion (acidosis)
(4) Hyper/Hypokalemia
(5) Hypoglycemia
(6) Hypothermia
List the five "T's" of PEA common causes.
(1) Toxins
(2) Tamponade (cardiac)
(3) Tension Pneumothorax
(4) Thrombosis (coronary/pulmonary)
(5) Trauma
PEA from Hypovolemia

(1) monitor clues?
(2) clinical/Hx clues?
(3) recommended treatment?

(1) monitor: rapid, narrow complex
(2) clinical: flat neck veins
(3) treatment: fluid infusion
PEA from Hypoxia

(1) monitor clues?
(2) clinical/Hx clues?
(3) recommended treatment?

(1) monitor: slow rate (hypoxia)
(2) clinical: cyanosis, blood gasses, airway problems
(3) treatment: O2, ventillation
PEA from Hydrogen ions (acidosis)

(1) monitor clues?
(2) clinical/Hx clues?
(3) recommended treatment?

(1) monitor: small amplitude QRS
(2) Hx: diabetes, renal, acidosis
(3) treatment: bicarb, hyperventillation
PEA from Hyperkalemia

(1) monitor clues?
(2) clinical/Hx clues?
(3) recommended treatment?

(1) monitor: wide QRS, peaked T, small P, sine waves
(2) Hx: renal, diabetes, dialysis, meds
(3) treatment: bicarb, calcium, glucose/insulin, kayexalate/sorbitol, dialysis, albuterol
PEA from Hypokalemia

(1) monitor clues?
(2) clinical/Hx clues?
(3) recommended treatment?

(1) monitor: flat T, prominent U, wide QRS, long QT, wide-complex tach
(2) Hx: diuretics, potassium loss
(3) treatment: infusion of potassium and magnesium
PEA from Hypothermia

(1) monitor clues?
(2) clinical/Hx clues?
(3) recommended treatment?

(1) monitor: J or Osborne waves
(2) clinical: cold exposure, body temp
(3) treatment: hypothermia algorithm (ECG handbook)
PEA from overdose

(1) monitor clues?
(2) clinical/Hx clues?
(3) recommended treatment?

(1) monitor: prolonged QT, various effects
(2) clinical: bradycardic, bottles on scene, pupils, neuro exam
(3) treatment: intubation, lavage, charcoal, drug screens, antidotes
PEA from tamponade

(1) monitor clues?
(2) clinical/Hx clues?
(3) recommended treatment?

(1) monitor: narrow complex, rapid rate
(2) clinical: no pulse with CPR, vein distention
(3) treatment: pericardiocentesis
PEA from tension pneumo

(1) monitor clues?
(2) clinical/Hx clues?
(3) recommended treatment?
PEA/Tension pneumo

(1) monitor: narrow compex, slow rate (hypoxia)
(2) clinical: history, no pulse with CPR, vein distention, tracheal deviation, unequal breath sounds, difficulty ventillating
(3) treatment: needle decompression
PEA from cardiac thrombosis

(1) monitor clues?
(2) clinical/Hx clues?
(3) recommended treatment?

(1) monitor: abnormal 12-lead, Q-waves, ST changes, T inversions
(2) clinical: history, cardiac markers
(3) treatment: fibrinolytic agents
PEA from pulmonary thrombosis

(1) monitor clues?
(2) clinical/Hx clues?
(3) recommended treatment?
PEA/pulmonary embolism

(1) monitor: narrow complex, rapid rate
(2) clinical: history, no pulse with CPR, distended neck veins, prior DVT or PE
(3) treatment: surgical embolectomy, fibrinolytics
In PEA, obtain a rapid _____ EKG, if possible, without interrupting CPR for more than 10 seconds.
______ complex PEAs are more likely to have a non-cardiac cause; low volume, low vascular tone.
______ complex PEAs are more often due to cardiac cause; also drug and electrolyte toxicities.
A common cause of PEA, ______, initially produces the classic physiological response of rapid, sinus-tach.
Sinus tach that deteriorates into PEA after increased systolic and decreased diastolic pressures is most likely caused by ______.
Consider ______ for PEA associated with a narrow-complex tachycardia.
volume infusion
Heart muscle failure and pulmonary vasculature obstructions can frequently present as a ____ arrest.
For cardiac tamponade PEA, ______ may help until definitive therapy is initiated.
volume infusion
Drug overdoses that cause peripheral vascular dilation and/or myocardial dysfunction may cause a ______ arrest.
The two most common and easily reversible causes of PEA are ______ and ______.

The two most common and easily reversible causes of PEA are ______ and ______.

In ACLS management of the patient with asystole, ______ is a priority over ______.
IV/IO access

advanced airway management
In an asystole arrest, it is imperative to look for ______.
an underlying cause
Survival from asystole is ______, and asystole may represent a(n) ______ rhythm.

agonal (end-stage)
A slow PEA may ultimately terminate in a ______ rhythm.
Name the three drugs used for the ACLS asystole case.
(1) Atropine
(2) Epinephrine
(3) Vasopressin
Confirm that "flat-line" on the monitor is not _____ or _____.
VF or a technical error
three technical difficulties that can mimick asystole
(1) loose/disconnected leads
(2) no power
(3) low signal gain
four reasons to stop or withhold CPR
(1) rigor mortis
(2) DNAR
(3) living will
(4) threat to safety
In cases of asystole, prolonged resuscitation is not necessary unless special situations exist, such as ______ or _____.

drug overdose
three components of managing asystole
(1) implement resuscitative steps
(2) identify/correct underlying causes
(3) terminate efforts as appropriate
The causative "H's and T's" apply not only to PEA, but also to ______.
After seeing asystole on the monitor, you immediately resume compressions, and at the same time you begin the all-important search for ______.
the underlying cause
After rapidly determining that you are dealing with PEA, you immediately resume compressions, and at the same time you begin the all-important search for ______.
the underlying cause
For asystole, give priority to ______, and do not routinely insert ______ unless ventillation with bag valve mask is ineffective.
IV/IO access

advanced airways
Your first drugs in the treatment of asystole should be the _______ class.
What are the two vasopressors used to treat asystole?
(1) Epinephrine (1 mg IV/IO every 5 min)

(2) Vasopressin (40 U IV/IO to replace 1st or 2nd dose of EPI)
Remember, vasopressin can only be given ______.
True or False.
Vasopressin was shown in a post-hoc analysis to slightly improve asystole survival over EPI.
True, but with no improvement in neurological outcome.
What is the full name of the ACLS drug Atropine?
Atropine Sulfate
Atropine reverses cholinergic-mediated decreases in (1)_____, (2)_____, and (3)_____.
(1) heart rate
(2) systemic vascular resistance
(3) blood pressure
Asystole can be exacerbate/precipitated by vagal tone, so it is logical to use a vagolytic drug like ______.
atropine sulfate
When is Atropine typically administered for asystole?
after vasopressors
How is Atropine administered in asystole? (dose, route, etc.)
Atropine Sulfate

1 mg IV/IO - repeat every 5 mins
(up to three doses)
What is the maximum number of atropine doses given to an asystole patient?
In asystole, attempting transcutaneous pacing is ______.

(recommended/not recommended)
not recommended
There is usually ______ for delivering a shock to patients with clear asystole.

(justification/no justification)
no justification
If it is unclear whether the rhythm is asystole or V-fib, you should ______.
defibrillate once
Decision to terminate CPR may include the following six factors.
(1) Time to CPR
(2) Time to defibrillation
(3) Comorbid disease
(4) Prearrest state
(5) Initial arrest rhythm
(6) Response to resuscitation
Studies have shown that survival is highly unlikely if there is no response to BLS/ACLS in the first within the first __ minutes.
Name the two situations in which you are most likely to see asystole.
(1) as a terminal rhythm in an unsuccessful resuscitation

(2) as a first rhythm in unwitnessed, prolonged arrest
Persistent aystole represents extensive ______ from prolonged inadequate coronary perfusion.
myocardial damage
Rescuers must make an effort to give asystole patients a ______.
"trial of CPR and ACLS"
To begin compressions on an adult, put the heel of one hand... (where)
on the center of the victim's bare chest between the nipples
"Push ______ and ______."
hard and fast
When doing compressions on an adult, push down ______ inches with each compression.
1.5 to 2 inches
At the end of each compression, make sure you allow the chest to ______.
Deliver compressions on an adult at a rate of ______ compressions per minute.
Steps for performing head-tilt chin-lift.
(1) one hand, palm and forehead
(2) other hand, fingers under jaw
(3) bring chin forward
One-rescuer universal compression-ventillation ratio on all victims except neonates.

30 compressions
2 breaths
One-rescuer universal compression-ventillation ratio on all victims except neonates.

30 compressions
2 breaths
Two-rescuer compression-ventillation ratio for children and infants.

15 compressions
2 breaths
Two-rescuer compression-ventillation ratio for children and infants.

15 compressions
2 breaths
Check breathing. If none, give ______, then check pulse.
2 breaths
Check breathing. If none, give ______, then check pulse.
2 breaths
If a victim is unresponsive, prior to opening the airway, you should...
call for help
activate EMS
get AED and return
Healthcare providers should use child CPR guidelines for children from age ___ to ___.
"1 to puberty"
When giving rescue breaths, blow for ___ seconds(s).
A rescuer's exhaled air contains ___% O2 and ___% carbon dioxide.
17% O2

4% CO2
If breath does not make the chest rise on the first attempt you should ______.
reposition the airway and try again
For children (1 to puberty) how deeply should you press for each compression.
1/3 to 1/2 the depth of chest
If a child's heart rate is less than ______ with ______, start CPR

signs of poor perfusion
If a child's heart rate is less than 60 with signs of poor perfusion, you should ______.
start CPR
True or False:
It may be appropriate to perform CPR on an unresponsive child with a very slow pulse.
If there are signs of poor perfusing, begin CPR.
Should you use an AED on a child as soon as it arrives or should you perform 2 full minutes of CPR?
for children out-of-hospital, perform 2 full minutes of CPR prior to defibrillation
Should you use an AED on a an adult as soon as it arrives or should you perform 2 full minutes of CPR?
defibrillate as soon as you can with an adult, unless the arrest was not-witnessed and down time without CPR was extended
When should a lone rescuer leave an arrested child to call EMS and get an AED?
only after completing two full minutes of IMMEDIATE CPR
(unless it is a sudden collapse)
True or false:
As with an adult, a lone rescuer should leave an unresponsive child to retrieve an AED and call for help prior to starting CPR.
In the case of a lone rescuer with a child, IMMEDIATE CPR for two minutes is indicated prior to calling for help or getting an AED.
The correct rate for giving compressions to a child is ______ compressions a minute.
The correct compression-ventillation ratio for 1-rescuer CPR for a child is ______ compressions and ______ breaths.
What artery is appropriate for checking pulse on:

(1) adults
(2) children
(3) infants
(1) carotid
(2) carotid
(3) brachial
What are the next steps in the order you would perform them after finding an unresponsive...

(1) adult
(2) child
(3) infant
(1) adult - EMS/AED/CPR
(2) child - CPR2min/EMS/AED
(3) infant - CPR2min/EMS/AED
EMS and AED are on the way. You check pulse. What is your next step for...

(1) adults
(2) children
(3) infants
(1) adult - no pulse=CPR
(2) child - rate<60 poor perfustion=CPR
(3) child - rate<60 poor perfustion=CPR
What is the correct compression location for...

(1) adults
(2) children
(3) infants
(1) adult - between nipples
(2) children - between nipples
(3) infants - just below nipples
Everyone gets 30:2 compressions EXCEPT _____.
infants and children
compression/ventillation ratio for adult 2-rescuer CPR
compression/ventillation ratio for adult 1-rescuer CPR
True or False:
The compression/ventillation ratio for adult 1-rescuer and 2-rescuer CPR is the same.
True or False:
The compression/ventillation ratio for child 1-rescuer and 2-rescuer CPR is the same.
For children...
1-rescuer gives 30:2
2-rescuers give 15:2
True or False:
The compression/ventillation ratio for infant 1-rescuer and 2-rescuer CPR is the same.
For infants...
1-rescuer gives 30:2
2-rescuers give 15:2
compression depth for infants
1/2 to 1/3 depth of chest
compression rate per minute for infants
True or False:
The compression rate per minute for infants, children, and adults is the same.
True. 100.
Only neonates require a faster compression rate.
Describe the correct compression position for infants...

(1) 1-rescuer
(2) 2-rescuer
(1) 2 fingers
(2) 2 thumbs/encircling hands
A stable, modified lateral position that maintains alignment of the back and allows for the drainage of fluid.
recovery position
Use the ______ position to manage unresponsive victims who have adequate breathing.
What is ACS?
acute coronary syndrome
The initial ______ is used in all ACS cases to classify patients into one of three EKG categories.
12-lead EKG
Name the three ACLS designated EKG categories for ACS.
(1) ST-segment elevation
(2) ST-segment depression
(3) undiagnostic or normal
Sudden death due to ______ and hypotensive ______ occur with acute ischemia.

Treatment of ACS involved drugs that do what three principal things?
(1) relieve discomfort
(2) dissolve clots
(3) inhibit thrombin and platelets
Name six initial drugs used to treat ACS.
(1) Oxygen
(2) Aspirin
(3) Nitroglycerin
(4) Morphine
(5) Fibrinolytic therapy
(6) Heparin
Name 4 adjunct drugs that may be used for therapy of ACS, but are not a part of ACLS treatment.
(1) Beta-blockers
(2) Clopidogrel
(3) ACE inhibitors
(4) HMG-CoA reductase inhibitors (statins)
The primary goal for patients with ACS is identification of ______ and triage for early reperfusion therapy.

(ST-elevated Myocardial Infarction)
therapy that opens an occluded coronary artery with either drugs or mechanical means
reperfusion therapy
What is PCI?
percutaneous coronary intervention
(balloon angioplasty/stent)
What is a STEMI?
ST-elevated MI
What is a NSTEMI?
Non-ST-elevated MI
What is UA?
Unstable angina
List five varying degrees of coronary artery occlusion
(1) unstable plaque (it ruptures)
(2) plaque rupture (platelets gather)
(3) unstable angina (partial occlusion)
(4) microemboli (microvascular occlusions)
(5) occlusive thrombus (full blown STEMI)
Based on 12 EKG findings, EMS may notify the receiving ED of...
a potential AMI-STEMI.
In a possible STEMI, the goal is for a physician to evaluate 12-lead EKG within ___ minutes of ED arrival.
The ______ is central to the inital risk and treatment stratification of STEMI.
12-lead EKG
Elevated cardiac enzymes _____ necessary for a decision to administer fibrolynic therapy or PCI.

(are/are not)
are not
five basic steps to assessment and treatment of ACS
(1) identify ischemic chest pain
(2) EMS care and ED notification
(3) Immediate ED assessment/treatment
(4) Classification by ST-segment
(5) STEMI treatment
The most common symptom of myocardial ischemia and infarction is _______.
retrosternal chest discomfort
Dispatchers should tell patients with no known allergies or GI bleeding to ______ while waiting for EMS.
chew on aspirin
List the four drugs used in the ACLS Acute Coronary Syndrom case.
(1) Oxygen
(2) Aspirin
(3) Nitroglycerin
(4) Morphine
Studies have shown that O2 can reduce ST-elevation in ______.
anterior infarctions
Oxygen administration is probably most beneficial for the first ___ hours of AMI therapy.
After the initial six hours following a STEMI, there is no clinical benefit for continued oxygen administration EXCEPT in these three circumstance.
(1) continued chest pain w/ hemodynamic instability
(2) overt pulmonary congestion
(3) O2 saturation below 90%
Give the ACS patient aspirin to chew only if (1)______, (2)______, and (3)______.
(1) the patient has not already taken aspirin
(2) there is no allergy to aspirin
(3) there is no Hx of GI bleeding
Give the ACS patient _______ mg of aspirin to chew.
160-325 mg
In the initial hours of an ACS, aspirin is absorbed better when ______, particularly when ______ is given.

Use a ______ to administer aspirin to ACS patients with nausea or upper GI disorders.
rectal aspirin suppository
Give the ACS patient up to ___ sublingual nitro tablet for ______ symptoms, at intervals of ___ minutes.


Administer nitro only to patients with a systolic pressure above ___ mmHg, or ___ mmHg below a known baseline, and a heart rate of ___ per minute.


Nirtoglycerin is a ______ and needs to be used cautiously or not at all in patients with inadequate ventricular ______.

As examples of preload-dependent ACS cases, you should avoid giving Nitro in the following three situations.
(1) Inferior MI and RV infarction
(2) Hypotension, Bradycardia, Tachycardia
(3) Viagra use (phosphodiesterase inhibitors)
Patients with acute RV infarction are very dependent on ______ to maintain cardiac output and blood pressure, therefore nitrates and vasodilators are contraindicated in these patients.
RV filling pressures
True or False.
You should avoid using Nitroglycerine in patients with tachycardia (>100 pulse).
You should avoid using nitro in patient with a marked bradycardia, ie below this rate: _____.
In addition to pain management, Morphine is an important treatment for ACS for these four reasons.
(1) CNS analgesia suppresses catecholamines and cardiac 02 demand
(2) reduces LV preload and 02 demand through venodilation
(3) decreases systemic resistance/afterload
(4) redistributes blood in APE cases
Since morphine is a ______ like Nitro, use morphine with caution on ______-dependant ACS patients.

If hypotension developes with Morphine, administer ______ as a first line of therapy.
In ACS cases, EMS providers should obtain a ______ EKG if available.
EMS prearrival notification to a STEMI center _____ treatment and reperfusion therapy.
If STEMI is identified on the 12-lead EKG, EMS should complete a ______ if appropriate.
fibrinolytic checklist
_____ is critical for myocardial salvage in STEMI patients.
In clinical studies, EMS prenotification of STEMI centers has been shown to shorten time to reperfusion therapy by ___ to ___ minutes.
10 to 60
Prior STEMI notification by EMS may reduce ______ and minimize ______ injury.

In the ED, a 12-lead should be performed and assessed within ___ minutes of arrival, if not already performed before arrival.
The ______ is at the center of the decision pathway in the management of ischemic chest pain and is the only means of identifying STEMI.
12-lead EKG
For the patient with STEMI, the goals of reperfusion are to give fibrinolytics within ___ minutes of ED arrival or provide PCI within ___ minutes.

ACS patient assessment <10 minutes
(list the 7 steps)
(1) Vitals & O2 sat.
(2) IV
(3) 12-lead
(4) history/phys.exam
(5) fibrinolytic checklist
(6) draw blood
(7) chest x-ray
Name the 4 agents routinely recommended for the treatment of patients with ischemic chest pain.
(1) Oxygen
(2) Aspirin
(3) Nitroglycerin
(4) Morphine
Unless contraindicated, the following agents are recommended for initial therapy of ALL patients suspected of having ischemic chest discomfort.
(1) Oxygen
(2) Aspirin
(3) Nitroglycerin
(4) Morphine
The major contraindication to nitroglycerin and morphine is ______.
The major contraindications to aspirin are ______ and ______.
true aspirin allergy

Hx GI bleeding
List the three classifications of ACS based on ST-segment deviation.
(2) High Risk UA/NSTEMI
(3) Intermediate/Low Risk UA
What is the criterion for ACS catagorization as STEMI (or category 1)?
ST elevation
What is the criterion for ACS categorization as NSTEMI/High Risk UA (or category 2)?
ST depression
or T inversion
What is the criterion for ACS catagorization as Intermediate/Low Risk UA (or category 3)?
Normal or nondiagnostic EKG
STEMI is characterized by ST elevation greater than ___ mm in ___ or more contiguous precordial leads or ___ or more limb leads or by a presumed new ______.
High risk unstable angina or non-ST elevation MI is characterized by ischemic ST depression of ___ mm or greater or dynamic ______ with pain or discomfort, or transient ______ for less than 20 minutes.
T-wave inversion
ST elevation
Intermediate or low risk angina is characterized by ______ or ______ EKG.

Count the boxes between the J-point and the baseline to measure ______.
ST-segment deviation
Patients with STEMI usually have complete occlusion of an ______.
epicardial coronary artery
______ in STEMI is perhaps the most important advancement in treatment of cardiovascular disease in recent years.
Reperfusion therapy
Reperfusion has been established as a standard of care for patients with STEMI who present within ___ hours of onset of symptoms with no contraindications.
A ___ percent reduction in mortality was noted when fibrinolytic therapy was provided in within ____ after onset.

1 hour
The mainstain treatment for STEMI is early reperfusion therapy achieved with ______ or ______.

primary PCI
aka "clot-buster"
fibrinolytic agent
Fibrin-specific agents are effective in achieving normal flow in about ______ of patients given these drugs.
In a posterior wall MI, ______ in the early precordial leads is equal to ______ in others, which is suggestive of a "STEMI" on the posterior wall of the heart.

Fibrinolytics are generally not recommended for patients presenting more than ___ hours after onset of symptoms.
The most commonly used form of PCI is ______.
coronary angioplasty
Primarily PCI is used as an alternative to ______.
______ is used early after fibrinolytics in patients who may have persistent occlusion.
Rescue PCI
Adjunct treatments for ACS (in addition to the core recommended drugs) may include the following six agents.
(1) IV Nitro
(2) Heparin
(3) Clopidogrel
(4) Beta Blockers
(5) ACE Inhibitors
(6) HMG coenzyme inhibitors (statin)
As adjunct therapies (in addition to the core recommended ACLS therapies), ______ and ______ are commonly used in early in the management of STEMI.
IV Nitro
Indications for IV Nitro in STEMI are these three situations.
(1) recurrent chest pain
(2) pulmonary edema
(3) hypertension
List the two treatment goals of IV Nitroglycerin.
(1) Relief of chest pain
(2) Improvement in pulmonary edema and hypertension
The inappropriate dosing and monitoring of ______ therapy has caused excess intracerebral bleeding and major hemorrhage in STEMI patients.
After manual defibrillation, a rhythm and pulse check ______ performed.

(is/ is not)
is NOT

(IMMEDIATELY resume compressions. Check for conversion only after two full minutes of CPR.)
Under what two circumstances is the consideration of atropine recommended for cardiac arrest?
(1) asystole
(2) bradycardic PEA
Consider administering fluids to treat cardiac arrests with...
(1) any suspected hypovolemia
(2) narrow-complex tachy PEA
Name three conditions that might cause a narrow-complex tachycardic PEA.
(1) Hypovolemia
(2) Cardiac Tamponade
(3) Pulmonary Embolism
the 5 cornerstones for managing bradycardia
(1) differentiate bet. related and unrelated symptoms
(2) diagnose AV Block
(3) atropine first? decision
(4) transcutaneous pacing (TCP)? decision
(5) EPI or Dopamine? decision
four rhythms in the ACLS bradycardia case
(1) sinus bradycardia
(2) 1st degree AV block
(3) 2nd degree AV blocks I & II
(4) 3rd degree AV block
The most important and clinically siginificant heart block is a ______ degree AV block.
(complete heart block)
Which heart block is most likely to cause cardiovascular collapse and require pacing?
3rd degree
(complete heart block)
Name the primary and secondary goals of dealing with bradycardia.
primary: recognize symptomatic bradycardia due to AV block
secondary: recognize type of block
Name the three drugs used in the ACLS bradycardia case.
(1) Atropine
(2) Dopamine (infusion)
(3) Epinephrine (infusion)
define bradyarrhythmia/bradycardia
any rhythm disorder with a heart rate less than 60
define symptomatic bradyarrhythmia
signs and symptoms that are due to the slow heart rate
A well-trained athlete may have a heart rate in the ____ - ____ range or occasionally lower.
A heart rate in the normal sinus range that is lower than expected for the condition (eg 70 bpm in septic shock) is termed ______ or ______ bradycardia.
functional or relative
A symptomatic bradycardia exists when these 3 criteria are present.
(1) heart rate is slow
(2) patient has symptoms
(3) symptoms are due to rate
You must perform a ______ and ______ to identify symptomatic bradycardia.
focused history

physical examination
Symptomatic bradycardia symptoms may include these eight.
(1) chest discomfort/pain
(2) shortness of breath
(3) decreased LOC
(4) weakness
(5) fatigue
(6) lightheadedness
(7) dizzyness
(8) syncope/presyncope
Symptomatic bradycardia signs may include these six.
(1) hypotension
(2) orthostatic hypotension
(3) diaphoresis
(4) pulmonary congestion
(5) CHF/pulmonary edema
(6) ventricular escapes
In the bradycardia case, the primary decision point in the algorithm is the determination of ______.
adequate perfusion
In the bradycardia case, if the patient has adequate perfusion, you would ______.
In the bradycardia case, if the patient has inadequate perfusion, you would...
prepare for TCP and consider administration of drugs.
At the same time you are conducting assessment and interventions of symptomatic bradycardia, you should be searching for and treating ______.
underlying cause
two steps to identifying bradycardia
(1) is heart rate less than 60?
(2) is it functional/relative?
In ______ bradycardia, the pulse rate is less than expected in relation to the underlying condition or cause.
Perform a ______ EKG in bradycardia patients.
two key questions when assessing signs/symptoms in bradycardic patients
(1) are signs/symptoms "serious"?
(2) are they related to the slow heart rate?
The "D" in the ABC's of Bradycardia represent...
Differential Diagnosis
(conduct a problem-focused history and exam)
In bradycardia, the key clinical question is whether the bradycardia is causing the patient's symptoms or some other illness is causing the ______.
If the patient has poor pefusion secondary to bradycardia, the 1-2-3 treatment sequence is...
(1) prepare for pacing
(2) consider atropine while awaiting pacer
(3) consider EPI and dopamine
Severe symptomatic bradycardia may require ______ interventions.
multiple simultaneous interventions.
In bradycardia cases, TCP should be started immediately for symptomatic patients who are unstable, particularly those with a ______.
high degree AV block
What is TCP?
transcutaneous pacing
In bradycardia, start TCP immediately in theses three situations.
(1) no response to atropine
(2) atropine unlikely to work
(3) severely symptomatic
Following initiation of pacing in a bradycardic patient, confirm that there is...
electrical and mechanical capture
Following TCP for bradycardia, reassess patient for...
symptomatic improvement and hemodynamic stability
Following the initiation of emergency TCP for bradycardia, give the patient...
analgesics and sedatives for pain control
Before and after the situation has been brought under control, alway stive to identify and corrent the ______ of bradycardia.
underlying cause
In the bradycardic patient, if TCP is ineffective (eg, inconsistent capture)...
prepare for transvenous pacing and obtain expert consultation
In bradycardia, atropine doses of less that ____ may paradoxically result in further slowing of the heart rate.
0.5 mg
DO NOT RELY ON ATROPINE in bradycardic patients with ______ heart block or ______ heart block -- instead, go straight to ______.
2nd degree type II
3rd degree (complete)

Hemodynamically unstable or rapidly deteriorating patients require ______ pacing with ______. In all other awake patients, ______ before pacing.
no prior sedation

Most awake patients should be given ______ before TCP.
For bradycardia unresponsive to atropine, consider titrated ______ or ______ infusion as a temporary measure until pacing is started.
epinephrine (or) dopamine
In cases of bradycardia unresponsive to atropine, an epinephrine infusion may be given at a dose of ______ per minute titrated to the patient's response.
2-10 mcg/min
In cases of bradycardia unresponsive to atropine, a dopamine infusion may be given at a dose of ______ per minute titrated to the patient's response.
2-10 mcg/kg/min
True or false:
Both Epinephrine and Dopamine can be simultaneously administered to a bradycardic patient.
The ______ dose of dopamine will likely be lower than the ______ dose.
chronotropic (heart rate)

inotropic (vasoconstrictor)
Dopamine hydrochloride has both ______ and ______ actions.
alpha (and) beta
After transcutaneous pacing is in place, you may need to consider expert consultation and other treatments such ______.
transvenous pacing
______ is the treatment of choice when the a patient has a symptomatic bradycardia with signs of poor perfusion.
Transcutaneous pacing (TCP)
The ability to perform ______ is now often as close as the nearest defibrillator.

(transcutaneous pacing)
Give four examples of situations that would indicate a "hemodynamically unstable" bradycardia.
(1) blood pressure changes
(2) altered mental status
(3) angina
(4) pulmonary edema
Give 5 TCP indicators.
(1) hemodynamically unstable bradycardia
(2) unstable clinical condition from brady
(3) readiness in brady/block/BBB AMIs
(4) Bradycardia w/symptomatic Ventricular escape
(5) Overdrive pacing of refractory tachycardia
Give 3 precautions of TCP.
(1) contraindicated: hypothermia / not recommended: asystole
(2) most conscious patients require sedation unless unstable
(3) do not assess capture on carotid due to false jerking
List the four steps of performing transcutaneous pacing.
(1) place electrodes on chest
(2) turn pacer on
(3) set 60/min demand, adjust to clinical response
(4) set output 2 mA higher than observed capture dose
External pacers have either ______ rates or ______ rates.
List three recommended uses of TCP.
(1) symptomatic bradycardia
(2) bradycardia with escape
(3) standby pacing
Rather than target a precise heart rate, the goal of TCP is to ensure improvement in ______.
clinical status
Start pacing at a rate of ___ beats per minute.
Once pacing is initiated, adjust the rate based on the patient's ______.
clinical response
With TCP, most patients will improve with a rate of ______ to ______ if the symptoms are primarily due to bradycardia.
60 - 70 bpm
Consider giving ______ to increase the heart rate before pacing in mildly symptomatic patients.
Do not delay pacing for unstable patients, particularly those with ______.
high degree AV block
True or false.
Atropine may eliminate the need for pacing.
When TCS is indicated, patients with ACS should be paced at...
the lowest heart rate that allows clinical stability.
Higher that necessary pacer rates in MI patients can worsen ______ and cause ______.

If pacing is not immediately available and symptomatic bradycardia is unresponsive to atropine, consider ______ class drugs in doses that stimulate ______.

An accelerated ______ rhythm may occur in the setting of an inferior wall MI, which is a rhythm that is usually stable and does not require pacing.
With sever bradycardia, some patients may develop wide-complex ventricular beats that can precipitate ____ or ____.
VT or VF
Pacing may increase heart rate and eliminate ______ ventricular rhythms.
In standby pacing, you place TCP electrode on clinically stable but ______ patients in anticipation of sudden deterioration.
acutely ischemic
Name the four rhythms in which standy pacing is appropriate.
(1)symptomatic sinus bradycardia
(2) asymptomatic Mobitz II
(3) asysptomatic 3rd degree block
(4) new LBBB, RBBB or bifascicular block in MI
two keys questions in the management of tachycardia
(1) pulses present?
(2) if yes, stable or unstable?
Ventricular rates of less than 150 usually ______ cause serious signs and symptoms.(do/do not)
do not
Tachycardia intervention is determined by the presence of ______ or by an ______ resulting from the tachycardia.
significant symptoms

unstable condition
Serious signs and symptoms of tachycardia and include these five.
(1) altered mental status
(2) chest discomfort/short Breath
(3) presyncope/syncope

In unstable patients:
(4) hypotension
(5) signs of shock
Assessment and management of tachycardia are guided by these four key questions.
(1) symptoms present or absent?
(2) patient stable or unstable?
(3) QRS narrow or wide?
(4) rhythm regular or irregular?
Under the BLS primary & ACLS secondary surveys, you would do these four things first in treating a tachycardia patient with a pulse.
(1) ABCs
(2) O2 admin, pulse oximetry
(3) identify EKG rhythm/check BP
(4) identify and treat reversible causes
In cases of tachycardia with a pulse, it is important to evaluate the patient to determine whether the rhythm is ______ or ______.

If a tachycardia patient is unstable with signs and symptoms, you would...
perform immediate synchronized cardoversion.
Once you determine that a patient with tachycardia is stable, you should proceed with the following 3 steps.
(1) establish IV
(2) obtain 12 lead EKG
(3) determine if QRS is narrow or wide
True or False:
You may not always be able to distinguish between supraventricular and ventricular rhythms.
If the patient has a wide complex tachycardia and is unstable, assume it is ______ until proven otherwise.
V-Tach (VT)
The amount of energy required for cardioversion of VT is determined by ______.
A regular uniform wide-complex VT is called ______ VT.
An unstable, monomorphic VT with a pulse should be treated this way.
synchronized cardioversion
(stepped-up monophasic energy)
100 J x1
200 J x1
300 J x1
360 J x1
An unstable, polymorphic VT with a pulse should be treated this way.
high energy unsynchronized shocks
(defibrillate as with VF)
If there is any doubt as to whether an unstable patient with a pulse has polymorphic or monomorphic VT, do not delay but immediately...
provide high-energy, unsynchronized shocks
True or False.
According to ACLS guidelines, it is sometimes necessary to defibrillate (unsynchronized) an unstable patient with a pulse.
Unstable polymorphic VT with a pulse should be treated with immediate high-energy defibrillation.
Provide sedation prior to cardioversion ______.

(always/if possible)
if possible
If a tachycardia patient is unstable with a narrow-complex SVT, give ______ while preparing for ______.

Do not delay cardioversion in extremely unstable patients for administration of ______ or ______.

Before cardioversion, establish an IV and ______ the patient if possible, but do not delay cardioversion in an ______ patient.

What two types of shocks are modern defibrillator/cardioverters capable of administering?
(1) unsynchronized shocks
(2) synchronized shocks
Unsynchronized shocks should use ______ energy levels than synchronized shocks.
Synchronized cardioversion uses a sensor to deliver a shock that is synchronized with...
the peak of a QRS complex.
There will likely be a ______ when delivering a synchronized shock as the machine synchronizes with the QRS complexes.
Synchonization avoids the delivery of a shock during _____, which can precipitate VF.
repolarization (T-wave)
Synchronized cardioversion uses a ______ energy level than attempted defibrillation.
Low-evergy shocks should always be delivered as _____ shocks to avoid precipitating VF.
Delivery of low-energy shocks as unsynchronized shocks is likely to induce.
If cardioversion is needed and it is not possible to synchronize the shocks, use _____ doses.
high energy/defibrillation
two types of patients that synchronized shocks are recommended for
(1)symptomatic stable tachycardia
(2) unstable tachycardia with pulses
three types of patients that unsynchronized shocks are recommended for
(1) pulseless arrest
(2) prearrest/polymorphic w/ pulse
(3) unsure if mono or polymorphic
Should an unsynchronized shock could VF in a tachycardic patient, immediately _____.
defibrillate (again)
VF occurs as a result of administration of a unsychronized high-energy shock to unstable tachycardia patients...
only in a very small minority of patients, despite the theoritical risk.
Cardioversion of SVT and A-flutter generally requires ______ energy than with A-fib.

A-fib generally requires ______ energy to cardiovert than SVT.

What is the recommended initial monophasic dose for cardioversion of atrial fibrillation?
100J - 200J
What is the recommended initial biphasic dose for cardioversion of atrial fibrillation?
100J - 120J
What is the recommended initial monophasic dose for cardioversion of atrial flutter and SVT?
50J - 100J
(monophasic damped sinusoidal)
What is the treatment of choice when a patient has a symptomatic (unstable) reentry SVT or VT with pulses?
synchronized cardioversion
______ is unlikely to be effective for treatment of junctional tachycardia or ectopic or multifocal atrial tachycardia because these rhythms have an automatic focus arising from cells that are spontaneously depolarazing at a rapid rate.
snychronized cardioversion
The sync mode of cardioverters is designed to delivery energy just after the ___ wave of the QRS complex.
Imagine and recite the 13 steps for synchronized cardioversion.
(1) sedate if possible
(2) turn on defibrillator
(3) attach to patient
(4) press SYNCH
(5) look for flagging
(6) adjust gain until flags appear
(7) select energy level
(8) annouce: "Charging!"
(9) press charge
(10) announce: "CLEAR!"
(11) press to shock
(12) check monitor/increase energy PRN
(13) activate synch after EACH shock
After synchonized cardioversion, the monitor returns to unsynchronized mode by default. Why?
In case you need to defibrillate immediately after cardioversion.
monophasic energy levels for
A-fib cardioversion
100-200J, 300J, 360J
monophasic energy levels for
stable monomorphic VT cardioversion
100-200J, 300J, 360J
monophasic energy levels for
SVT and A-flutter cardioversion
50J, 100J, 200J, 300J, 360J
monophasic energy levels for
Polymorhpic VT w/pulse cardioversion
360J unsynchronized
(defibrillation dose)