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Why is excessive ventilation harmful?
causes increased intrathoracic pressure and can decrease cerebral blood flow r/t increased CO2 in blood
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Effect of pt temp on PaCO2?
low body temp may cause PaCO2 readings to be higher than they actually are
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Optimal post-cardiac arrest BP?
unknown - maintain MAP of 65 or higher
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Survival rate of in-hospital cardiac arrests?
24%
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First step in ACLS?
determine scene is safe
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After determining scene is safe what is the next step?
LOC
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What steps should be taken based on pt LOC?
unconscious: BLS assessment then primary and secondary assessments
conscious: primary assessment is initial evalution
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Steps to BLS assessment?
- 1. Check responsiveness: "Are you OK?"
- 2. Shout for help & get AED/defibrillator
- 3. Check breathing and pulse
- 4. Defibrillation if needed
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How to check breathing?
Look at chest for 5-10 seconds
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How long to check for pulse?
5-10 seconds
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If pt has a pulse but is not breathing what should be done?
- rescue breathing 1 breath every 5-6 seconds
- and recheck pulse about every 2 minutes
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Limit interruptions in chest compressions to less than ____ seconds
10
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Compress chest at least ___ inches at a rate of ____ compressions per minute.
- 2 inches
- 100-120 compressions per minute
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Switch compressors about every ___ minutes or earlier if fatigued.
2
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Primary assessment?
ABCDE
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Airway?
- 1. patency
- 2. need for advanced airway
- 3. proper placement of airway
- 4. tube secured and placement reconfirmed frequently
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How is airway patency maintained in an unconscious patient?
head tilt chin lift and oro or naso-pharyngeal airway
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Breathing?
- 1. Assess: chest rise and fall, O2 sat, capnography
- 2. O2 and assisted breathing as needed
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Circulation?
- 1. IV/IO
- 2. fluids/BP meds
- 3. check glucose and temp
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Disability?
- 1. Check neurologic function
- 2. responsiveness, LOC, and pupil dilation
- 3. AVPU: Alert, Voice, Unresponsive
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Exposure?
Removed clothing to look for trauma, bleeding, burns, or medical alert bracelets
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Secondary assessment?
- SAMPLE & consider H's & T's
- S- signs and symptoms
- Allergies
- Medications
- Past medical Hx
- Last meal consumed
- Events
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H's and T's?
- H's:
- Hypovolemia, Hypoxia, Hydrogen ion (acidosis), Hypo/Hyperkalemia, Hypothermia
- T's:
- Tension pneumo, Tamponade, Toxins, Thrombosis (pulmonary or cardiac)
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2 most common potentially reversible causes of PEA?
hypovolemia and hypoxia
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What initially occurs in hypovolemia?
- 1. narrow complex tachycardia
- 2. increased diastolic and decreased systolic pressures
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What Tx should be considered with PEA that may be r/t hypovolemia?
volume infusion
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Common causes of hhpovolemia?
- 1. trauma
- 2. occult internal hemorrhage
- 3. severe dehydration
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When may fibrinolytics be admin?
massive/saddle PE's that obstruct flow to pulmonary vasculature and cause R heart failure
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Tx of cardiac tamponade?
- 1. volume infusion may help while definitive therapy is initiated
- 2. may need pericardiocentesis
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What test may be used to show cardiac tamponade, PE's, and tension pneumo?
ultrasound
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What should be done when pt shows s/s of ROSC?
post-cardiac arrest care should be inititiated
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Normal tidal volume?
8-10 mL/kg
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RR <___ requires assisted ventilation with bag-mask device or advanced airway with 100% O2
6
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S/S of respiratory distress?
- 1. tachypnea & tachycardia
- 2. increased respiratory effort (nasal flaring, retractions)
- 3. inadequate respiratory effort (bradypnea, hypoventilation)
- 4. abnormal airway sounds
- 5. pale, cool skin
- 6. changes in LOC
- 7. use of abd muscles to assist in breathing
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What are respiratory distress and failure?
distress: abnormal RR or effort
failure: clinical state of inadequate oxygenation, ventilation, or both (compensatory mechanisms fail)
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S/S of respiratory failure?
- 1. marked tachypnea - bradypnea and apnea are late signs
- 2. increased, decreased or no respiratory effort
- 3. poor to absent distal air movement
- 4. tachycardia (early) or bradycardia (late)
- 5. cyanosis
- 6. stupor, coma (late)
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2 common causes of respiratory arrest?
drowning, head injury
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Tidal volume that should be provided for avg adult in respiratory arrest?
500 - 600 mL (6-7mL/kg)
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What complications may be caused by excessive ventilation?
- 1. gastric inflation: regurgitation and aspiration
- 2. increased intrathoracic pressure: decreases venous return to the heart and diminishes cardiac output
- 3. cerebral vasoconstriction: decreased brain BF
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If a pt has a pulse but needs ventilations, ventilate the pt once every ___ seconds. Each breath should take __ second(s) and achieve _____.
- 5-6 seconds
- 1 second
- visible chest rise and fall
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Most reliable method of confirming and monitoring correct placement of the ET tube?
waveform capnography in addition to clinical assessment
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For patients with a perfusing rhythm ventilations should be admin every ___ seconds.
5-6
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Most common cause of upper airway obstruction in unconscious/unresponsive patient?
Intervention?
loss of tone in the throat muscles that causes tongue to fall back and occlude airway
basic airway opening techniques
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How to open airway?
- head tilt chin lift
- jaw thrust with trauma with suspected neck injury- head tilt chin lift if jaw thrust doesn't work
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What should be done in pt who are unconscious with no cough or gag reflex
OPA or NPA
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Interventions for unconscious pt that is known to have been choking?
check for FO. If no FO, start CPR. Check for FO before every set of breaths. Remove FO if it appears
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When using a bag-mask, deliver ___ mL tidal vaolume sufficient to produce chest rise over ____ second(s).
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OPA (oropharyngeal airway) should only be used in pt who are _____ with no __ or ___ reflex.
unconscious, cough or gag
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Ventilation rate with advanced airway?
one breath every 6 seconds
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When is cricoid pressure used?
NOT recommended during cardiac arrest
in nonarrest pt may help with aspiration and gastric inflation during bag-mask ventilation - can also interfere with ventilations
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___ % of pt with blunt trauma serious enough to require spinal imaging have a spinal imaging. Risk is tripled if the pt has a ___ or ____ injury
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3 precautions for pt with suspected cervical spine trauma?
- 1. open airway with jaw thrust
- 2. have someone stabilize head during
- airway manipulation - collar can interfere
- with airway
- 3. spinal immobilization during transport
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Initial Tx of ACS involves use of drugs inculding __, ___, ___, ___, ___, & ___.
- 1. morphine
- 2. oxygen
- 3. nitroglycerin
- 4. aspirin
- 5. fibrinolytics
- 6. heparin
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When is VF most likely to develop?
within 4 hours after onset of symptoms
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PCI?
performed in cath lab - balloon dilation and stent placement
percutaneous coronary intervention
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Fibrinolytics?
clot-buster drugs
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ED assessment for ACS?
Should be done in what time frame?
within 10 minutes
- 1. VS with O2 sat
- 2. IV
- 3. brief Hx and physical exam
- 4 troponin, labs, & coagulation labs
- 5. portable CXR
- 6. EKG
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O2 rate in ACS?
if O2 sat <90%, start at 4L/min and titrate
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Tx if STEMI if time from onset of Sx if <12 hours?
1. adjunctive Tx as needed
- door to balloon: 90 minutes
- door to fibrinolytics: 30 minutes
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Tx of STEMI if time from onset is > 12 hours or there is ST depression or dynamic T-wave inversion?
Consider early invasive strategy if: ischemic chest discomfort, recurrent/persistent ST deviation, ventricular tachy,
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Tx for normal/non-diagnostic ST changes in EKG with ACS
consider admission for monitoring and possible intervention
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What is the most common symptom of MI?
retrosternal chest pain
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S/S of ACS?
- 1. pressure/fullness/pain in center of chest lasting several minutes
- 2. spreading to shoulders, neck, or arm(s), or jaw
- 3. spreading into back or b/t shoulder blades
- 4. light-headedness, dizziness, fainting
- 5. diaphoresis
- 6. NV
- 7. dyspnea (usually suddenly )
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4 emergency conditions that may mimic MI?
- 1. PE
- 2. aortic dissection
- 3. pericardial effusion/tamponade
- 4. tension pneumothorax
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O2 admin for STEMI pt?
maintain O2 sat 90% or greater
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ASA admin with a STEMI?
When should asa suppository be used?
160-325mg chewed
NV, peptic ulcers, etc
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When should nitroglycerin not be given?
- SBP <90
- HR not b/t 50-100BPM
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In what type of infarcts are nitrates contraindicated?
inferior and RV infarcts
- depend on preload to maintain BP...may also
- not get morphine and other vasodilators/diuretics
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Nitrates are contraindicated if pt has used what type of medications?
phosphodiesterase inhibitors: salindafil, vardenafil, tadalafil
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4 effects of morphine that help with ACS?
- 1. CNS depression: decreased catecholemines and O2 demands
- 2. venodilation: decreased LV preload & O2 demands
- 3. decreased systemic vascular resistance: decreased LV afterload
- 4. helps redistribute BV in pt with pulmonary edema
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