Transcript ACLS Jeopordy

ACLS
Team Kerigan Rounds
CTU Medicine, HGH
June 20, 2007
ACLS
ACLS
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EKGs $100
EKGs $100
WHAT IS HYPERKALEMIA?
Marked widenening of the QRS duration combined with tall,
peaked T waves are suggestive of advanced hyperkalemia. Note
the absence of P waves, suggesting a junctional rhythm, but in
hyperkalemia the atrial muscle may be paralyzed while still in
sinus rhythm. The sinus impulse conducts to the AV node through
internodal tracts without activating the atrial muscle.
EKGs $200
EKGs $200
WHAT IS WPW
TYPE PREEXCITATION?
EKGs $300
EKGs $300
WHAT ARE J-WAVES OR
OSBORNE WAVES?
EKGs $400
EKGs $400
WHAT IS EARLY
REPOLARIZATION,
NORMAL VARIANT?
EKGs $500
EKGs $500
WHAT IS RBBB PLUS MOBITZ II
2ND DEGREE AV BLOCK?
THE CLASSIC RSR' IN V1 IS RBBB. MOBITZ II 2ND DEGREE AV BLOCK
IS PRESENT BECAUSE THE PR INTERVALS ARE CONSTANT.
ANDTIDOTES $100
OPIATES
ANDTIDOTES $100
NALOXONE
ANDTIDOTES $200
DIGOXIN
ANDTIDOTES $200
DIGIBIND
ANDTIDOTES $300
BETA-BLOCKERS
ANDTIDOTES $300
GLUCAGON
ANDTIDOTES $400
BENZOS
ANDTIDOTES $400
FLUMAZENIL
ANDTIDOTES $500
TCAs
ANDTIDOTES $500
Sodium Bicarbonate
STROKE $100
LIST THE INCLUSION
CRITERIA (4) FOR tPA
ADMINISTRATION FOR ACUTE
ISCHEMIC STROKE
STROKE $100
WHAT ARE:
•Age 18 years or older
•Clinical diagnosis of ischemic stroke with a measurable
neurologic deficit
•No evidence of intracranial hemorrhage on
pretreatment non-contrast CT head
•Time of symptom onset (when patient was last seen
normal) well established as < 180 minutes (3 hours)
before treatment would begin?
STROKE $200
INDICATIONS TO LOWER BP
IN AN ACUTE ISCHEMIC
STROKE
STROKE $200
1. IF SYSTOLIC >220 OR DIASTOLIC >120
2. END-ORGAN INVOLVEMENT (AORTIC
DISSECTION, ACUTE MYOCARDIAL
INFARCTION, PULMONARY EDEMA,
HYPERTENSIVE ENCEPHALOPATHY)
STROKE $300
ELEVATED BODY TEMPERATURE IN
THE SETTING OF ACUTE CEREBRAL
ISCHEMIA IS ASSOCIATED WITH
INCREASED MORBIDITY AND
MORTALITY. THIS IS WHEN YOU
SHOULD TREAT A FEVER
STROKE $300
WHAT IS
T>37.5?
STROKE $400
IDENTIFY
THE
LESION
STROKE $400
WHAT IS A
PCA STROKE?
HYPODENSE AREAS IN THE RIGHT OCCIPITAL
LOBE, CONSISTENT WITH RECENT PCA
STROKE $500
3 OF THE 6 RELATIVE
CONTRAINDICATIONS FOR
tPA ADMINISTRATION FOR
ACUTE ISCHEMIC STROKE
STROKE $500
WHAT ARE:
1.Only minor or rapidly improving stroke symptoms
(clearing spontaneously)
2.Within 14 days of major surgery or serious trauma
3.Recent gastrointestinal or urinary tract hemorrhage
(within previous 21 days)
4.Recent acute myocardial infarction (within previous 3
months)
5.Post-myocardial infarction pericarditis
6.Abnormal blood glucose level (<2.8 or >22.2
mmol/L]) ?
DRUGS $100
4 FIBRINOLYTIC AGENTS
DRUGS $100
WHAT ARE:
•ALTEPLASE (tPA)
•RETEPLASE (RETAVASE)
•TENECTEPLASE (TNK)
•STREPTOKINASE (STREPTASE) ?
DRUGS $200
CONSIDER GIVING THIS DRUG IF YOU SEE THIS EKG
DRUGS $200
WHAT IS MAGNESIUM,
LOADING DOSE 1-2 G IV?
DRUGS $300
THIS IS THE NNT WITH
ASA THERAPY IN SETTING
OF ACS TO SAVE ONE LIFE
AT 30 DAYS.
DRUGS $300
WHAT IS NNT OF 19?
DRUGS $400
AMIODARONE BELONGS
TO THIS CLASS OF
ANTIARRYTHMICS
DRUGS $400
WHAT IS CLASS III?
DRUGS $500
IN THE SETTING OF VENTRICULAR
FIBRILLATION/PULSELESS VT, THESE
TWO ANTI-ARRYTHMICS SHOULD BE
CONSIDERED (INCLUDE DOSES)
DRUGS $500
WHAT ARE:
1. AMIODARONE 300MG IV/ ONCE, THEN
CONSIDER ADDITIONAL 150MG IV ONCE
OR
2. LIDOCAINE 1-1.5MG/KG FIRST DOSE
THEN 0.5-0.75 MG/KG IV, MAXIMUM 3
DOSES OR 3MG/KG ?
POTPOURRI $100
THIS IS THE TIME RANGE
THAT CARDIAC TROPONINS
ARE DETECTABLE IN THE
BLOOD AFTER INFARCTION
POTPOURRI $100
WHAT IS 3-12 HOURS?
POTPOURRI $200
MAX. SETTING FOR
MONOPHASIC
DEFIBRILLATION
POTPOURRI $200
WHAT IS 360 J?
POTPOURRI $300
3 METHODS TO
SHIFT K+ INTO
CELLS
POTPOURRI $300
WHAT ARE:
•SODIUM BICARBONATE
•INSULIN PLUS GLUCOSE
(2 U PER 5 G)
•VENTOLIN?
POTPOURRI $400
THESE DRUGS
CAN BE GIVEN
VIA ET TUBE
POTPOURRI $400
WHAT ARE:
•NALOXONE
•ATROPINE
•VENTOLIN
•EPINEPHRINE
•LIDOCAINE?
POTPOURRI $500
THE STEPS OF
RAPID
SEQUENCE
INTUBATION
POTPOURRI $500
WHAT ARE:
•PREOXYGENATE
•PREMEDICATE
•PARALYZE AFTER SEDATION
•PLACEMENT OF TUBE
•PRIMARY CONFIMRATION
•SECONDARY CONFIRMATION
•SECURE TUBE ?
ACLS
ACLS
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DYSRHYTHMIAS $200
ATROPINE WILL NOT BE
EFFECTIVE IN PATIENTS
WITH NEW THIRD-DEGREE
BLOCK WITH WIDE QRS
COMPLEXES AND THIS TYPE
OF AV BLOCK
DYSRHYTHMIAS $200
WHAT IS MOBITZ TYPE II
BLOCK (INFRANODAL
BLOCK)?
IT MAY CAUSE PARADOXICAL SLOWING
DYSRHYTHMIAS $400
IN PATIENTS WITH STABLE
REENTRY SUPERVENTRICULAR
TACHYCARDIA, THESE ARE THE
2 INITIAL THERAPEUTIC
CHOICES
DYSRHYTHMIAS $400
WHAT ARE VAGAL
STIMULATION AND
ADENOSINE?
DYSRHYTHMIAS $600
THIS SET OF CRITERIA IS
USED TO DISTINGUISH
VT AND VT WITH
ABBERANCY
DYSRHYTHMIAS $600
WHAT IS BRUGADA’S CRITERIA?
Step 1: Absence of RS complex in all the precordial leads?
Step 2: R to S interval > 100ms in any 1 precordial lead?
Step 3: More QRS Complexes than P waves? - AV dissociation?
Step 4: Look for Morphological features for VT in leads V1 and V6.
1. QRS width > 0.14
2. superior QRS axis
3. AV dissociation, fusion, capture beats present
4. Morphology in precordial lead V1 = RBBB like pattern
DYSRHYTHMIAS $800
THE USE OF CARDIOVERSION
FOR THE TREATMENT OF
JUNCTIONAL TACHYCARDIAS,
ECTOPIC, OR MULTIFOCAL
ATRIAL TACHYCARDIAS ARE
LIKELY TO RESULT IN THIS
DYSRHYTHMIAS $800
WHAT IS INCREASE THE
RATE OF THE
TACHYARRYTHMIA?
THESE RHYTHMS HAVE AN AUTOMATIC FOCUS, ARISING IN CELLS
THAT ARE SPONTANEOUSLY DEPOLARIZING AT A RAPID RATE
DYSRHYTHMIAS $1000
THE DIFFERENTIAL
DIAGNOSIS (4) OF A PATIENT
WITH A NARROW QRS
COMPLEX AND AN
IRREGULAR TACHYCARDIA
DYSRHYTHMIAS $1000
WHAT IS:
1. AFIB
2. AFLUTTER W/ VARIABLE BLOCK
3. MAT
4. SINUS TACHYCARDIA WITH
FREQUENT PACs ?
ACS/ARREST $200
THESE ARE THE
REPERFUSION GOALS WITH
PCI AND FIBRINOLYTICS IN
PATIENTS PRESENTING TO
THE ER WITH STEMI
ACS/ARREST $200
WHAT ARE:
1. Door-to-balloon (PCI) goal of 90 m
2. Door-to-needle (fibrinolysis) goal of 30 m ?
ACS/ARREST $400
IN PEA ARREST,
THESE ARE THE 6
H’S TO THINK
ABOUT
ACS/ARREST $400
WHAT ARE:
•HYPOVOLEMIA
•HYPOXEMIA
•HYDROGEN ION (ACIDOSIS)
•HYPO-/HYPERKALEMIA
•HYPOGLYCEMIA
•HYPOTHERMIA ?
ACS/ARREST $600
IN PEA ARREST,
THESE ARE THE 6
T’S TO THINK
ABOUT
ACS/ARREST $600
WHAT ARE:
•TOXINS
•TAMPONADE
•TENSION PNEUMOTHORAX
•THROMBOSIS - CORONARY
•THROMBOSIS - PULMONARY
•TRAUMA ?
ACS/ARREST $800
NAME 6 CAUSES OF
ST ELEVATION
ACS/ARREST $800
WHAT ARE (ANY 6 OF):
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
STEMI
Ventricular aneurysm
Pericarditis
Prinzmetal’s angina
Early repolarization
Hypothermia
Hyperkalemia
LVH
LBBB
Hypertrophic cardiomyopathies
Artifact ?
ACS/ARREST $1000
LIST THE 5 ABSOLUTE
CONTRAINDICATIONS
TO FIBRINOLYTIC USE
IN STEMI
ACS/ARREST $1000
WHAT ARE (ANY 5 OF 7):
1.
2.
3.
4.
5.
6.
7.
Any prior ICH
Known structural cerebral vascular lesion (e.g. AVM)
Known malignant intracranial neoplasm (primary or mets)
Ischemic stroke within 3 months EXCEPT acute ischemic
stroke within 3 hours
Aortic dissection
Active bleeding or bleeding diathesis
Significant close head trauma or facial trauma within 3
months ?
SEPSIS $200
GOALS OF THE FIRST 6
HOURS OF
RESUSCITATIONS IN
SEPSIS (4)
SEPSIS $200
WHAT ARE:
1. Central venous pressure (CVP) 8 to 12
mmHg
2. Mean arterial pressure (MAP) ≥ 65 mmHg
3. Urine output ≥ 0.5 mL/kg/hr
4. Central venous pressure (superior vena cava)
or mixed venous oxygen saturation ≥ 70% ?
SEPSIS $400
5 NON-INFECTIOUS
MIMICS OF SEPSIS
SEPSIS $400
WHAT ARE (ANY 5 OF):
•
•
•
•
•
•
•
•
•
•
•
Acute myocardial infarction
Acute pulmonary embolus
Acute pancreatitis
Fat emboli syndrome
Acute adrenal insufficiency
Acute gastrointestinal hemorrhage
Overzealous diuresis
Transfusion reactions
Adverse drug reactions
Procedure-related transient bacteremia
Amniotic fluid embolism?
SEPSIS $600
THE INCLUSION
CRITERIA FOR EGDT
SEPSIS $600
WHAT ARE:
1. 2 of 4 SIRS criteria:
• Temp >38° C or <36° C
• HR >90 bpm
• RR >20/min
• WBC >12,000 or <4,000 or bands
>10%
2. Lactate >4 mM OR
3. sBP <90 mmHg ?
SEPSIS $800
THE 4 DETERMINANTS OF
CVP
SEPSIS $800
WHAT ARE:
1. Intravascular volume
2. Intrathoracic pressure
3. Right ventricular function
4. Venous tone ?
SEPSIS $1000
OUTLINE THE EGDT
PROTOCOL
SEPSIS $1000
ENVIRONMENT $200
BASELINE
CARBOXYHEMOGLOBIN
LEVELS IN SMOKERS MAY
BE AS HIGH AS…
ENVIRONMENT $200
WHAT IS 10% ?
ENVIRONMENT $400
TEMPARATURE RANGE
ASSOCIATED WITH
MODERATE HYPOTHERMIA
ENVIRONMENT $400
WHAT IS 30 - 34C ?
ENVIRONMENT $600
4 METHODS OF
ACTIVE INTERNAL
REWARMING
ENVIRONMENT $600
WHAT ARE (ANY 4 OF):
•Warm IV Fluids (43 C)
•Warm, humid oxygen (42-46 C)
•Peritoneal lavage (KCl-free fluid)
•Extracorporeal warming
•Esophageal rewarming tubes ?
ENVIRONMENT $800
THESE ECG CHANGES
ARE ASSOCIATED
WITH HYPOTHERMIA
ENVIRONMENT $800
WHAT ARE :
•TACHYCARDIA - BRADYCARDIA - A
FIB - SLOW V RATE - V FIB - ASYSTOLE
•PROLONGED PR
•PROLONGED QRS
•PROLONGED QT
•OSBORN J WAVES ?
ENVIRONMENT $1000
THIS EXTREME
PROGRESSION OF ACUTE
MOUNTAIN SICKNESS MAY
PRESENT WITH FOCAL
NEURO DEFICITS
ENVIRONMENT $1000
WHAT IS HIGHALTIDUDE CEREBRAL
EDEMA (HACE)?
SHOCKING $200
THE FIRST STEP IN
USING AN AED
SHOCKING $200
WHAT IS TURN THE
POWER ON?
SHOCKING $400
SHOCK OR NO SHOCK:
PULSELESS VT
SHOCKING $400
WHAT IS SHOCK?
SHOCKING $600
SYNC OR NO SYNC:
ATRIAL FIBRILLATION
(PULSE PRESENT)
SHOCKING $600
WHAT IS SYNC?
SHOCKING $800
YOU SHOULD BE SAYING
THIS AS YOU COUNT
DOWN TO A SHOCK
SHOCKING $800
WHAT IS “I AM GOING TO
SHOCK ON THREE. ONE,
I’M CLEAR. TWO, YOU’RE
CLEAR. THREE,
EVERYBODY’S CLEAR?
SHOCKING $1000
THE WEIGHT THAT
SHOULD BE PUT ON
THE PADDLES WHIEN
DEFIBRILLATING
SHOCKING $1000
WHAT IS 25 POUNDS?
HOUSESTAFF
HOW MANY CUPS
OF COFFEE A DAY
DOES LAMIA
DRINK