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ACLS Guia Estudio 2006
ACLS Guia Estudio 2006
Study Guide
Mandatory pre-course test included.
0900-0910
0910-0920
0920-0940
0940-1010
EKG Review
1010-1030
1030-1040
Break
1040-1120
1120-1200
1200-1300
Lunch
1300-1335
1335-1355
1355-1455
0900-0935
0935-1035
1035-1045
Break
1045-1145
1145-1245
Lunch
1245-1345
Megacode Testing
1345-1355
ACLS Jeopardy
1355-1435
Written Exam
1435-1505
Wrap-up
0900-0910
0910-0920
0920-0940
0940-1000
1000-1010
Break
1010-1050
1050-1130
1130-1150
Stroke Video
1150-1250
Lunch
1250-1310
1310-1410
1410-1510
Megacode Testing
1510-1520
Break
1520-1530
ACLS Jeopardy
1530-1610
Written Examination
1610-1640
Wrap-up
You can access information on the warning signs of heart attack and stroke at
http://www.americanheart.org/presenter.jhtml?identifier=3053
To find any other topic, use the Heart and Stroke Encyclopedia at this link:
http://www.americanheart.org/presenter.jhtml?identifier=10000056
11/20/05
IV-68
Circulation
IV-90
Circulation
IV-112
Circulation
A L G O R I T HM R EV I EW
BRADYCARDIA
Note: Atropine is not indicated, and may actually be harmful, for 2nd #2 & 3rd degree heart blocks.
Proceed directly to pacing instead.
TACHYCARDIA
Remember: If the patient is unstable, go directly to cardioversion
Algorithm; Tachycardia With Pulses
For Regular Narrow Complex Tachycardia
1. Vagal maneuvers
2. Adenosine 6 mg rapid IV push. If no conversion, give 12 mg, then another 12, mg
3. Consider expert consultation
For Irregular Narrow Complex Tachycardia
1. Consider expert consultation
2. Control rate with Diltiazem or -blockers
1.
2.
3.
1.
2.
3.
Medication Review
The information on medications in this study guide meets the same standard set by the 2005 American Heart Association for
Advanced Cardiac Life Support. It does not supersede local protocols or medical control; consult with your medical director for
the most up-to-date guidelines on medication administration.
ADENOSINE
Class:
Endogenous nucleoside
Indicated for:
PSVT or Narrow Complex
Tachycardia
IV Bolus Dosage:
6 mg - 1st dose
12 mg 2nd dose
12 mg 3rd dose
Comments: Doses are followed by a saline flush. Two subsequent doses of 12 mg each may be administered
at 1 2 minute intervals. Use the port closest to cannulation. The AHA recommends that the dose be cut by
half if administering through a central line, or in the presence of Dipyridamole or Carbamazepine. Larger
doses are required in the presence of caffeine or Theophylline.
AMIODARONE
Class:
Indicated for:
Antiarrhythmic
Arrhythmias
Comments: Cumulative doses >2.2 g/24 hours are associated with significant hypotension. Do not
administer with other drugs that prolong QT interval (i.e., Procainamide). Terminal elimination is extremely
long half life lasts up to 40 days.
ASPIRIN
Class:
Non-steroidal anti-inflammatory
PO Dose: 160mg 325mg
Suppository Dose: 300mg
Indicated for:
Chest pain / ACS
Comments: In suspected ACS, Aspirin can block platelet aggregation, and arterial constriction. Also helps
with pain control. May cause or exacerbate GI bleeding. The goal is to give Aspirin to ACS patients within
minutes of arrival.
ATROPINE
Class:
Parasympathetic Blocker
Indicated for:
Bradycardia
PEA, Asystole
Comments: Only used in bradycardias for symptomatic patients. Only used in PEA if rate is slow. The
maximum dosage is 3mg. Doses of Atropine < .5mg may result in paradoxical slowing of the heart. Not
indicated in second degree type I or third degree heart block.
DIGOXIN
Class:
Cardiac Glycoside
Antiarrhythmic
Indicated for:
A-Fib / A-Flutter
IV Bolus Dosage:
10-15g/kg lean body weight
Comments: Reduce Digoxin dose by 50% when initiating Amiodarone due to drug interaction. Toxicity may
cause serious arrhythmias.
DILTIAZEM
Class:
Calcium Channel Blocker
Indicated for:
A-Fib / A-Flutter
IV Dosage:
15-20 mg over 2 minutes
Comments: Do not use in wide-QRS tachycardias of uncertain origin. May cause hypotension.
DOPAMINE
Class:
Catecholamine
Indicated for:
Symptomatic Bradycardia
Hypotension
IV Drip Dosage:
1-5g/kg/min - renal perfusion
5-15g/kg/min cardiac dose
10-20g/kg/min vasopressor dose
Comments: Titrate to patient response. Correct hypovolemia with volume replacement before initiating
Dopamine. May cause tachyarrhythmias. Do not mix with Sodium Bicarbonate.
EPINEPHRINE
Class:
Catecholamine
Indicated for:
V-Fib/Pulseless V-Tach
PEA, Asystole
Symptomatic Bradycardia
LIDOCAINE
Class:
Antiarrhythmic
Indicated for:
V-Fib/Pulseless V-Tach
Stable V-Tach
Infusion dosage: 1-4mg/min (30-50g/kg/min)
Comments: May repeat at 0.5-0.75mg/kg every 5-10 minutes to maximum dose 3mg/kg. Prophylactic use
in AMI is contraindicated. Use with caution in presence of impaired liver. Discontinue infusion if signs of
toxicity develop.
MAGNESIUM SULFATE
Class:
Electrolyte
Indicated for:
Cardiac arrest if torsades or
Hypomagnesemia
IV Dosage:
1-2g in 10ml D5W over 20 minutes
Comments: Occasional fall in blood pressure with rapid administration. Use with caution in renal patients.
MORPHINE SULFATE:
Class:
Opiate
Analgesic
Indicated for:
Chest pain
Pulmonary edema
IV Bolus Dosage:
2-4mg every 5-30 minutes
Comments: Administer slowly and titrate to effect. May cause respiratory depression be prepared to
support ventilations. May cause hypotension. Naloxone is reversal agent.
NALOXONE
Class:
Opiate Antagonist
Indicated for:
Narcotic overdose
Comments: If needed, can administer up to 10mg in 10 minutes. Monitor for recurrent respiratory
depression. May cause opiate withdrawal. ET route discouraged, but can be used if IV/IO access not
available.
NITROGLYCERINE
Class:
Vasodilator
Indicated for:
Chest pain/ACS
IV Bolus Dosage:
12.5-25g
Comments: Most commonly given sublingually as a tablet or spray. The dose is 0.3-0.4mg. Repeat up to 3
doses at 5 minute intervals. Hypotension or bradycardia may occur. Do not use with Viagra and similar
drugs.
NITROPRUSSIDE
Class:
Vasodilator
Indicated for:
Hypertensive crisis
IV Dosage:
0.1g/kg/min, titrate upward to effect
Comments: May cause hypotension. Use with caution with Viagra and similar drugs. Light-sensitive, bag
and tubing must be covered with opaque material.
OXYGEN
Class:
Atmospheric Gas
Indicated for:
Any cardiopulmonary
emergency
Suspected stroke
Flow
1-15 liters
Comments: Pulse oximetry provides a useful method of titrating oxygen administration; however, it may be
inaccurate in low cardiac output states.
PROCAINIMIDE
Class:
Antiarrhythmic
Indicated for:
Wide variety of arrhythmias
IV Drip Dosage:
20mg/min
SODIUM BICARBONATE
Class:
Buffer
Indicated for:
Acidosis, hyperkalemia
IV Bolus Dosage:
1 mEq/kg
Comments: Not recommended for routine use in cardiac arrest patients. If available, use arterial blood gas
analysis to guide bicarbonate therapy.
VASOPRESSIN
Class:
Hormone
Indicated for:
V-Fib/V-Tach
PEA, Asystole
Comments: Only given on time. May cause cardiac ischemia and angina. May replace first or second dose of
Epi. Not recommended for responsive patients with coronary artery disease.
VERAPAMIL
Class:
Calcium Channel Blocker
Indicated for:
A-Fib/A-Flutter
PSVT
IV Bolus Dosage:
2.5-5mg over 2-5 minutes
Comments: Alternative drug after Adenosine to terminate PSVT with adequate blood pressure and
preserved LV function. Can cause peripheral vasodilation and hypotension. Use with extreme caution in
patients receiving oral -blockers.
ELECTRICAL THERAPY
Defibrillation
Fibrillation is a disorganized rhythm that, if present in the ventricles, is life threartening. A
defibrillatory shock uses electrical current to terminate all electrical activity of the irregularly beating
heart. The hope is that following defibrillation, the heart will resume beating in a coordinated
fashion. Early delivery of electrical therapy, combined with immediate CPR following the arrest, is
critical to survival from sudden cardiac arrest.
Cardioversion
Synchronized cardioversion is a treatment option for V-Tach with a pulse, SVT, and unstable atrial
fibrillation or flutter. The shock is delivered in coordination with the QRS complex of the heart in
hopes of returning to a normal sinus rhythm. The standard sequence of energy levels for
synchronized cardioversion are as follows: 100J, 200J, 300J, & 360J monophasic energy dose (or
clinically equivalent biphasic energy dose). If the patient receiving the electrical therapy is conscious,
consider sedation prior to cardioversion.
Pacing
External cardiac pacing, or transcutaneous pacing, stimulates heart activity with an electrical impulse
delivered across the chest wall. It is a recommended therapy for symptomatic and hemodymanically
compromised bradycardias. If the patient receiving the therapy is conscious, consider sedation. The
general guideline for pacer settings is starting from zero, turn the milliamps up until capture is
achieved, then set the rate at 20 beats per minute above the monitored heart rate, with a minimum
rate of 50 bpm.
Sinus Tachycardia
(Jim never has a second cup at home
home))
Regular
Rhythm
Regular
100 - 160
Rate
60 - 100
Rate
P waves
P waves
PRI
PRI
QRS
QRS
Sinus Bradycardia
Rhythm
Regular
Rate
40 - 60
P waves
PRI
QRS
Rhythm
Rate
P waves
PRI
QRS
Sinus Arrhythmia
Supraventricular Tachycardia
Rhythm
(Regularly)
Irregular
Normal (60-100) or slow (less than
60)
Normal in configuration and direction;
one P wave precedes each QRS
Rhythm
Regular
Rate
150 - 250
P waves
PRI
PRI
Not measurable
QRS
QRS
Rate
P waves
Rhythm
Regular
Rate
150 - 250
P waves
PRI
Not measurable
QRS
ATRIAL FIBRILLATION
ATRIAL FLUTTER
Junctional Escape Rhythm
Rhythm
Regular
Rate
40-60
P waves
PRI
QRS
Rate
P waves
PRI
QRS
Rhythm
Regular
Rate
60-100
P waves
PRI
QRS
Junctional Tachycardia
Regular
Rate
P waves
PRI
QRS
Ventricular Tachycardia
Rhythm
Usually regular
Rate
Ventricular Fibrillation
Rhythm
Rate
P waves
P Waves
PRI
Not measurable
PRI
There is no PRI.
QRS
QRS
.20 Sec
ASYSTOLE
PRI
First-Degree AV Block
Rhythm
Regular
Rate
P waves
PRI
QRS
Atrial: Regular
Ventricular: Irregular
Rate
P waves
PRI
QRS
Rhythm
Atrial: Regular
Ventricular: Will be regular unless AV conduction
varies
Rate
P waves
PRI
QRS
Summary of BLS ABCD Maneuvers for Infants, Children, and Adults (Newborn Information Not Included)
MANEUVER
Adult
Lay Rescuer: 8 Years
HCP: Adolescent and older
AIRWAY
Child
Lay Rescuer: 1 to 8 Years
HCP: 1 Year to Adolescent
Infant
Under 1 Year of Age
BREATHING
(INITIAL)
2 Breaths at 1 Second/Breath
10 to 12 Breaths/Minute
(approximate)
(1 Breath Every 5-6 Seconds)
12 to 20 Breaths/Minute (approximate)
(1 Breath Every 3-5 Seconds)
8 to 10 Breaths/Minute (approximate)
(1 Breath Every 6-8 Seconds)
Abdominal Thrusts
Carotid
Brachial or Femoral
Compression Landmarks
Compression Method:
- Push Hard and Fast
- Allow Complete Recoil
Compression Depth
1 to 2 Inches
Compression Rate
Compression-Ventilation Ratio
Defibrillation AED
2 or 3 Fingers
HCP (2 Rescuer):
2 Thumb-Encircling Hands
30:2 (1 Rescuer)
HCP: 15:2 (2 Rescuer
Use AED After 5 Cycles of CPR
(out of hospital).
Use Pediatric System for Child 1 to
8 years if available.
HCP: For sudden collapse (out of
hospital) or in-hospital arrest, use
AED as soon as possible.
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ACLS Course
CPR/AED Testing Checklist
Adult 1-Rescuer CPR and AED Test
Name: ______________________________________________ Date of Test: _____________________
Skill
Step
Adult/Child CPR
With AED
if done correctly
Checks unresponsiveness
Checks breathing
Minimum 5 seconds; maximum 10 seconds
AED arrives
AED
1
Turns AED on
AED
2
AED
3
AED
4
11
The next step is done only with a manikin with a feedback device, such as a clicker or light.
If no feedback device, STOP THE TEST.
12
Test Results
NR
if done
correctly
2
Shockable
Not Shockable
Check rhythm
Shockable rhythm?
VF/VT
Asystole/PEA
4
Give 1 shock
Manual biphasic: device specific
(typically 120 to 200 J)
10
No
Check rhythm
Shockable rhythm?
Shockable
Give 5 cycles
of CPR*
11
Check rhythm
Shockable rhythm?
No
Check rhythm
Shockable rhythm?
12
If asystole, go to Box 10
If electrical activity, check
pulse. If no pulse, go to
Box 10
If pulse present, begin
postresuscitation care
Not
Shockable
13
Shockable
Go to
Box 4
Shockable
During CPR
80_
8 PM
2
Shockable
Not Shockable
Check rhythm
Shockable rhythm?
VF/VT
Asystole/PEA
4
Give 1 shock
Manual biphasic: device specific
(typically 120 to 200 J)
10
No
Check rhythm
Shockable rhythm?
Shockable
Give 5 cycles
of CPR*
Check rhythm
Shockable rhythm?
No
11
Check rhythm
Shockable rhythm?
12
If asystole, go to Box 10
If electrical activity, check
pulse. If no pulse, go to
Box 10
If pulse present, begin
postresuscitation care
Not
Shockable
13
Shockable
Go to
Box 4
Shockable
During CPR
6_Part5.indd 62
3
Signs or symptoms of poor perfusion caused by the bradycardia?
(eg, acute altered mental status, ongoing chest pain, hypotension or other signs of shock)
4A
Observe/Monitor
Adequate
Perfusion
Poor
Perfusion
Reminders
If pulseless arrest develops, go to Pulseless Arrest Algorithm
Search for and treat possible contributing factors:
Hypovolemia
Toxins
Hypoxia
Tamponade, cardiac
Hydrogen ion (acidosis) Tension pneumothorax
Hypo-/hyperkalemia
Thrombosis (coronary or pulmonary)
Hypoglycemia
Trauma (hypovolemia, increased ICP)
Hypothermia
4
Prepare for transcutaneous pacing;
use without delay for high-degree block
(type II second-degree block or
third-degree AV block)
Consider atropine 0.5 mg IV while
awaiting pacer. May repeat to a
total dose of 3 mg. If ineffective,
begin pacing
Consider epinephrine (2 to 10 g/min)
or dopamine (2 to 10 g/kg per minute)
infusion while awaiting pacer or if
pacing ineffective
5
Prepare for transvenous pacing
Treat contributing causes
Consider expert consultation
7/
TACHYCARDIA
With Pulses
Establish IV access
Obtain 12-lead ECG
(when available)
or rhythm strip
Is QRS narrow (<0.12 sec)?
Stable
Perform immediate
synchronized cardioversion
Symptoms Persist
Is patient stable?
Unstable signs include altered
mental status, ongoing chest pain,
hypotension or other signs of shock
Note: rate-related symptoms
uncommon if heart rate <150/min
Unstable
12
NARROW QRS*:
Is Rhythm Regular?
Regular
WIDE QRS*:
Is Rhythm Regular?
Expert consultation
advised
Irregular
11
Irregular Narrow-Complex
Tachycardia
Probable atrial fibrillation or
possible atrial flutter or MAT
(multifocal atrial tachycardia)
Consider expert consultation
Control rate (eg, diltiazem,
-blockers; use -blockers with
caution in pulmonary disease
or CHF)
8
Does rhythm
convert?
Note: Consider
expert consultation
Converts
9
If rhythm converts,
probable reentry SVT
(reentry supraventricular
tachycardia):
Observe for recurrence
Treat recurrence with
adenosine or longeracting AV nodal blocking
agents (eg, diltiazem,
-blockers)
Regular
13
14
If ventricular
tachycardia or
uncertain rhythm
Amiodarone
150 mg IV over 10 min
Repeat as needed
to maximum dose of
2.2 g/24 hours
Prepare for elective
synchronized
cardioversion
If SVT with aberrancy
Give adenosine
(go to Box 7)
Hypovolemia
Hypoxia
Hydrogen ion (acidosis)
Hypo-/hyperkalemia
Hypoglycemia
Hypothermia
During Evaluation
Irregular
Toxins
Tamponade, cardiac
Tension pneumothorax
Thrombosis (coronary or
pulmonary)
Trauma (hypovolemia)
Out-of-Hospital Scenario
You are a paramedic and arrive on-scene to find a 57-year-old woman complaining of indigestion. She is cold, clammy, and diaphoretic. She tells you she
is about to faint. EMS responders have obtained vital signs: HR 38, BP 70/P,
RR 16. No other assessment or management has been done. Now you assume
the role of team leader.
Initial
Assessment
Bradycardia
Algorithm
Rhythm: Sinus
Bradycardia
Pulseless Arrest
Algorithm
(VF/VT)
Pulseless Arrest
Algorithm
(Asystole)
if done correctly
Bradycardia Management
Recognizes VF
After a shock the patient becomes asystolic. The student continues to monitor high-quality CPR and follows
the asystole pathway of the Pulselss Arrest Algorithm.
If the team continues giving high-quality CPR and
appropriate drugs, you can end the case with the
patient in NSR. Otherwise you can end the case and
discuss calling the code.
Asystole Management
Recognizes asystole
Verbalizes potential reversible causes of asystole/PEA (Hs and Ts)
Administers appropriate drug(s) and doses
Test
Results
NR
Initial
Assessment
Bradycardia
Algorithm
Rhythm:
Mobitz Type II
AV Block
Pulseless Arrest
Algorithm
(VF/VT)
Pulseless
Arrest
Algorithm
(Asystole)
This woman may have an acute coronary syndrome. The case focus, however, is bradycardia.
The team leader should begin to take a history
and direct team members to start oxygen (if not
initiated) and an IV and place monitor leads.
Nitroglycerin at this point would be inappropriate
in the absence of typical ischemic-type discomfort and vital signs (severe bradycardia and hypotensioncontraindicated.)
The student is presented with bradycardia and
needs to follow the Bradycardia Algorithm. A
critical action is noting that symptoms are due to
bradycardia requiring management. Actions at this
point should include at least an initial dose of atropine and preparation for transcutaneous pacing.
Test
Results
NR
Out-of-Hospital Scenario
You are a paramedic and arrive on-scene to find a 65-year-old man complaining of palpitations and chest discomfort. He is cold, clammy, and diaphoretic. He states that he feels as if he is about to faint. EMS responders
have placed oxygen and obtained vital signs: HR 160, BP 70/P, RR 16.
if done correctly
Initial
Assessment
Tachycardia
Algorithm
Rhythm:
Regular WideComplex
Tachycardia
(VT)
Tachycardia Algorithm
VF/Pulseless VT Management
Recognizes VF
Clears before ANALYZE and SHOCK
Immediately resumes CPR after shocks
Appropriate airway management
Appropriate cycles DrugRhythm Check/ShockCPR
Administers appropriate drug(s) and doses
PEA Algorithm
Pulseless Arrest
Algorithm
(VF/VT)
Pulseless Arrest
Algorithm
(PEA)
The patient should suddenly develop VF. The student will follow the VF/VT pathway of the Pulseless
Arrest Algorithm. Now the student team leader will
assign team functions and monitor for high-quality CPR. The case should continue through safe
defibrillation, administration of a vasopressor, and
consideration of an antiarrhythmic drug.
The patient is now in PEA. The student continues to monitor high-quality CPR and follows the
PEA pathway of the Pulseless Arrest Algorithm.
Although the patient is likely in cardiogenic shock,
the student should say a differential diagnosis of
PEA. You can end the case and discuss indications
to call a code.
Recognizes PEA
Verbalizes potential reversible causes of PEA/asystole (Hs and Ts)
Administers appropriate drug(s) and doses
Immediately resumes CPR after rhythm and pulse checks
Stop the Test
Test
Results
NR
In-Hospital Scenario
Team Leader
if done correctly
Initial
Assessment
Tachycardia
Algorithm
Rhythm:
Regular NarrowComplex Stable
Tachycardia
(SVT)
Pulseless Arrest
Algorithm
(VF/VT)
Pulseless Arrest
Algorithm
(PEA)
This man has mild symptoms and is hemodynamically stable. The case focus, however, is initially a
tachycardia. The student should begin to take a
history, start oxygen and an IV, and place a monitor.
Nitroglycerin at this point would be inappropriate
because of the rapid tachycardia. Aspirin may be
given.
VF/Pulseless VT Management
During this treatment the patient suddenly develops VF. The student will follow the VF/VT pathway
of Pulseless Arrest Algorithm. Now the student
team leader will assign team functions and monitor for high-quality CPR. The case should continue
through safe defibrillation, administration of a
vasopressor, and consideration of an antiarrhythmic
drug.
After a shock the patient is now in PEA. The student
continues to monitor high-quality CPR and follow
the PEA pathway of the Pulselss Arrest Algorithm.
Although the patient is likely in cardiogenic shock,
the student should verbalize a differential diagnosis of
PEA. You can end the case and discuss indications to
call a code.
Recognizes VF
Clears before ANALYZE and SHOCK
Immediately resumes CPR after shocks
Appropriate airway management
Appropriate cycles DrugRhythm Check/ShockCPR
Administers appropriate drug(s) and doses
PEA Algorithm
Recognizes PEA
Verbalizes potential reversible causes of PEA/asystole (Hs and Ts)
Administers appropriate drug(s) and doses
Immediately resumes CPR after rhythm and pulse checks
Stop the Test
Test
Results
NR
ECC
Advanced Cardiovascular
Life Support
Written Precourse
Self-Assessment
October 2006
Date_____________________
Question
Answer
Answer
Question
1.
16.
2.
17.
3.
18.
4.
19.
5.
20.
6.
21.
7.
22.
8.
23.
9.
24.
10.
25.
11.
26.
12.
27.
13.
28.
14.
29.
15.
30.
31.
_____________________________
36.
_____________________________
32.
_____________________________
37.
_____________________________
33.
_____________________________
38.
_____________________________
34.
_____________________________
39.
_____________________________
35.
_____________________________
40.
_____________________________
Ten minutes after an 85-year-old woman collapses, paramedics arrive and start CPR for the
first time. The monitor shows fine (low-amplitude) VF. Which of the following actions should
they take next?
a. Perform at least 5 minutes of vigorous CPR before attempting defibrillation
b. Insert an endotracheal tube, administer 2 to 2.5 mg epinephrine in 10 mL NS through the tube
and then defibrillate
c. Deliver up to 3 precordial thumps while observing the patients response on the monitor
d. Deliver about 2 minutes or 5 cycles of CPR, and deliver a 360-J monophasic or equivalentcurrent biphasic shock
2.
A cardiac arrest patient arrives in the ED with PEA at 30 bpm. CPR continues, proper tube
placement is confirmed, and IV access is established. Which of the following medications is
most appropriate to give next?
a.
b.
c.
d.
3.
Which of the following actions helps deliver maximum current during defibrillation?
a.
b.
c.
d.
4.
Which of the following actions is NOT performed when you clear a patient just before
defibrillator discharge?
a. Check the person managing the airway: body not touching bag mask or tracheal tube, oxygen
not flowing directly onto chest
b. Check yourself: hands correctly placed on paddles, body not touching patient or bed
c. Check monitor leads: leads disconnected to prevent shock damage to monitor
d. Check others: no one touching patient, bed, or equipment connected to patient
5.
A woman with a history of narrow-complex PSVT arrives in the ED. She is alert and oriented
but pale. HR is 165 bpm, and the ECG documents SVT. BP is 105/70 mm Hg. Supplemental
oxygen is provided, and IV access has been established. Which of the following drug-dose
combinations is the most appropriate initial treatment?
a.
b.
c.
d.
6.
7.
9.
Endotracheal intubation has just been attempted for a patient in respiratory arrest. During
bag-mask ventilation you hear stomach gurgling over the epigastrium but no breath sounds,
and oxygen saturation (per pulse oximetry) stays very low. Which of the following is the most
likely explanation for these findings?
a.
b.
c.
d.
8.
Give epinephrine via the intracardiac route if IV access is not obtained within 3 minutes
Follow IV medications through peripheral veins with a fluid bolus
Do not follow IV medications through central veins with a fluid bolus
Run normal saline mixed with sodium bicarbonate (100 mEq/L) during continuing CPR
A 60-year-old man (weight = 50 kg) with recurrent VF has converted from VF again to a widecomplex nonperfusing rhythm after administration of epinephrine 1 mg IV and a 3rd shock.
Which of the following drug regimens is most appropriate to give next?
a.
b.
c.
d.
10. While treating a patient in persistent VF arrest after 2 shocks, you consider using
vasopressin. Which of the following guidelines for use of vasopressin is true?
a. Give vasopressin 40 U every 3 to 5 minutes
b. Give vasopressin for better vasoconstriction and -adrenergic stimulation than that provided by
epinephrine
c. Give vasopressin as an alternative to a first or second dose of epinephrine in shock-refractory
VF
d. Give vasopressin as the first-line pressor agent for clinical shock caused by hypovolemia
11. Which of the following causes of PEA is most likely to respond to immediate treatment?
a.
b.
c.
d.
12. Which of the following drug-dose combinations is recommended as the initial medication to
give a patient in asystole?
a.
b.
c.
d.
Epinephrine 3 mg IV
Atropine 3 mg IV
Epinephrine 1 mg IV
Atropine 0.5 mg IV
13. A patient with a heart rate of 40 bpm is complaining of chest pain and is confused. After
oxygen, what is the first drug you should administer to this patient while a transcutaneous
pacer is brought to the room?
a.
b.
c.
d.
Atropine 0.5 mg
Epinephrine 1 mg IV push
Isoproterenol infusion 2 to 10 g/min
Adenosine 6 mg rapid IV push
14. Which of the following statements correctly describes the ventilations that should be
provided after endotracheal tube insertion, cuff inflation, and verification of tube position?
a.
b.
c.
d.
15. A patient in the ED reports 30 minutes of severe, crushing, substernal chest pain. BP is
110/70 mm Hg, HR is 58 bpm, and the monitor shows regular sinus bradycardia. The patient
has received aspirin 325 mg PO, oxygen 4 L/min via nasal cannula, and 3 sublingual
nitroglycerin tablets 5 minutes apart, but he continues to have severe pain. Which of the
following agents should be given next?
a.
b.
c.
d.
Atropine 0.5 to 1 mg IV
Furosemide 20 to 40 mg IV
Lidocaine 1 to 1.5 mg/kg
Morphine sulfate 2 to 4 mg IV
16. Which of the following agents are used frequently in the early management of acute cardiac
ischemia?
a.
b.
c.
d.
17. A 50-year-old man who is profusely diaphoretic and hypertensive complains of crushing
substernal chest pain and severe shortness of breath. He has a history of hypertension. He
chewed 2 baby aspirins at home and is now receiving oxygen. Which of the following
treatment sequences is most appropriate at this time?
a.
b.
c.
d.
Morphine then nitroglycerin, but only if morphine fails to relieve the pain
Nitroglycerin then morphine, but only if ST elevation is >3 mm
Nitroglycerin then morphine, but only if nitroglycerin fails to relieve the pain
Nitroglycerin only, because chronic hypertension contraindicates morphine
18. A 50-year-old man has a 3-mm ST elevation in leads V2 to V4. Severe chest pain continues
despite administration of oxygen, aspirin, nitroglycerin SL 3, and morphine 4 mg IV. BP is
170/110 mm Hg; HR is 120 bpm. Which of the following treatment combinations is most
appropriate for this patient at this time (assume no contraindications to any medication)?
a.
b.
c.
d.
19. A 70-year-old woman complains of a moderate headache and trouble walking. She has a
facial droop, slurred speech, and difficulty raising her right arm. She takes several
medications for high blood pressure. Which of the following actions is most appropriate to
take at this time?
a. Activate the emergency response system; tell the dispatcher you need assistance for a woman
who is displaying signs and symptoms of an acute subarachnoid hemorrhage
b. Activate the emergency response system; tell the dispatcher you need assistance for a woman
who is displaying signs and symptoms of a stroke
c. Activate the emergency response system; have the woman take aspirin 325 mg and then have
her lie down while both of you await the arrival of emergency personnel
d. Drive the woman to the nearby ED in your car
20. Within 45 minutes of her arrival in the ED, which of the following evaluation sequences
should be performed for a 70-year-old woman with rapid onset of headache, garbled speech,
and weakness of the right arm and leg?
a. History, physical and neurologic exams, noncontrast head CT with radiologist interpretation
b. History, physical and neurologic exams, noncontrast head CT, start of fibrinolytic treatment if CT
scan is positive for stroke
c. History, physical and neurologic exams, lumbar puncture (LP), contrast head CT if LP is
negative for blood
d. History, physical and neurologic exams, contrast head CT, start fibrinolytic treatment when
improvement in neurologic signs is noted
21. Which of the following rhythms is a proper indication for transcutaneous cardiac pacing?
a.
b.
c.
d.
22. Which of the following causes of out-of-hospital asystole is most likely to respond to
treatment?
a.
b.
c.
d.
23. A 34-year-old woman with a history of mitral valve prolapse presents to the ED complaining
of palpitations. Her vital signs are as follows: HR = 165 bpm, resp = 14 per minute, BP =
118/92 mm Hg, and O2 sat = 98%. Her lungs sound clear, and she reports no shortness of
breath or dyspnea on exertion. The ECG and monitor display a narrow-complex, regular
tachycardia. Which of the following terms best describes her condition?
a.
b.
c.
d.
Stable tachycardia
Unstable tachycardia
Heart rate appropriate for clinical condition
Tachycardia secondary to poor cardiovascular function
24. A 75-year-old man presents to the ED with a 1-week history of lightheadedness, palpitations,
and mild exercise intolerance. The initial 12-lead ECG displays atrial fibrillation, which
continues to show on the monitor at an irregular HR of 120 to 150 bpm and a BP of
100/70 mm Hg. Which of the following therapies is the most appropriate next intervention?
a.
b.
c.
d.
25. You prepare to cardiovert an unstable 48-year-old woman with tachycardia. The
monitor/defibrillator is in synchronization mode. The patient suddenly becomes
unresponsive and pulseless as the rhythm changes to an irregular, chaotic, VF-like pattern.
You charge to 200 J and press the SHOCK button, but the defibrillator fails to deliver a shock.
Why?
a.
b.
c.
d.
26. Vasopressin can be recommended for which of the following arrest rhythms?
a.
b.
c.
d.
VF
Asystole
PEA
All of the above
27. Effective bag-mask ventilations are present in a patient in cardiac arrest. Now, 2 minutes after
epinephrine 1 mg IV is given, PEA continues at 30 bpm. Which of the following actions should
be done next?
a.
b.
c.
d.
Administer atropine 1 mg IV
Initiate transcutaneous pacing at a rate of 60 bpm
Start a dopamine IV infusion at 15 to 20 g/kg per minute
Give epinephrine (1 mL of 1:10 000 solution) IV bolus
28. The following patients were diagnosed with acute ischemic stroke. Which of these patients
has NO stated contraindication for IV fibrinolytic therapy?
a.
b.
c.
d.
A 65-year-old woman who lives alone and was found unresponsive by a neighbor
A 65-year-old man presenting approximately 4 hours after onset of symptoms
A 65-year-old woman presenting 1 hour after onset of symptoms
A 65-year-old man diagnosed with bleeding ulcers 1 week before onset of symptoms
29. A 25-year-old woman presents to the ED and says she is having another episode of PSVT. Her
medical history includes an electrophysiologic stimulation study (EPS) that confirmed a
reentry tachycardia, no Wolff-Parkinson-White syndrome, and no preexcitation. HR is 180
bpm. The patient reports palpitations and mild shortness of breath. Vagal maneuvers with
carotid sinus massage have no effect on HR or rhythm. Which of the following is the most
appropriate next intervention?
a.
b.
c.
d.
DC cardioversion
IV diltiazem
IV propranolol
IV adenosine
30. A patient with an HR of 30 to 40 bpm complains of dizziness, cool and clammy extremities,
and dyspnea. He is in third-degree AV block. All treatment modalities are present. What would
you do first?
a.
b.
c.
d.
Sinus Tachycardia
Sinus Bradycardia
Atrial Fibrillation
Atrial Flutter
Reentry Supraventricular Tachycardia
32.
Sinus Tachycardia
Sinus Bradycardia
Ventricular Fibrillation
Atrial Fibrillation
Atrial Flutter
33.
Sinus Tachycardia
Sinus Bradycardia
Atrial Fibrillation
Atrial Flutter
Reentry Supraventricular Tachycardia
34.
Sinus Tachycardia
Sinus Bradycardia
Ventricular Fibrillation
Atrial Fibrillation
Atrial Flutter
35.
Sinus Tachycardia
Sinus Bradycardia
Ventricular Fibrillation
Atrial Fibrillation
Atrial Flutter
10
36.
Sinus Tachycardia
Sinus Bradycardia
Ventricular Fibrillation
Atrial Fibrillation
Atrial Flutter
37.
Sinus Tachycardia
Sinus Bradycardia
Ventricular Fibrillation
Atrial Fibrillation
Atrial Flutter
11
38.
Sinus Tachycardia
Sinus Bradycardia
Ventricular Fibrillation
Atrial Fibrillation
Atrial Flutter
39.
Sinus Tachycardia
Sinus Bradycardia
Ventricular Fibrillation
Atrial Fibrillation
Atrial Flutter
12
40.
Sinus Tachycardia
Sinus Bradycardia
Ventricular Fibrillation
Atrial Fibrillation
Atrial Flutter
13
14
15
16