acls team kerigan rounds ctu medicine, hgh june 20, 2007
TRANSCRIPT
ACLSACLS
Team Kerigan RoundsCTU Medicine, HGHJune 20, 2007
ACLACLSS
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ACLACLSS
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 $100
EKGs $200
WHAT IS WPW
TYPE PREEXCITATION?
EKGs $200
EKGs $300
WHAT ARE J-WAVES OR OSBORNE WAVES?
EKGs $300
EKGs $400
WHAT IS EARLY REPOLARIZATION,
NORMAL VARIANT?
EKGs $400
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.
EKGs $500
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
LIST THE INCLUSION CRITERIA (4) FOR tPA
ADMINISTRATION FOR ACUTE ISCHEMIC STROKE
STROKE $100
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
1. IF SYSTOLIC >220 OR DIASTOLIC >120
2. END-ORGAN INVOLVEMENT (AORTIC DISSECTION, ACUTE MYOCARDIAL INFARCTION, PULMONARY EDEMA, HYPERTENSIVE ENCEPHALOPATHY)
STROKE $200
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 $300
IDENTIFY
THE
LESION
STROKE $400
WHAT IS APCA STROKE?
HYPODENSE AREAS IN THE RIGHT OCCIPITAL LOBE, CONSISTENT WITH RECENT PCA
STROKE $400
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 trauma3.Recent gastrointestinal or urinary tract hemorrhage (within previous 21 days)4.Recent acute myocardial infarction (within previous 3 months)5.Post-myocardial infarction pericarditis6.Abnormal blood glucose level (<2.8 or >22.2 mmol/L]) ?
STROKE $500
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 ?
THIS IS THE TIME RANGE THAT CARDIAC
TROPONINS ARE DETECTABLE IN THE
BLOOD AFTER INFARCTION
POTPOURRI $100
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 ?
ACLACLSS
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ACLACLSS
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.• QRS width > 0.14• superior QRS axis• AV dissociation, fusion, capture beats present• 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. AFIB2. AFLUTTER W/ VARIABLE BLOCK3. MAT4. 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 m2. 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. STEMI2. Ventricular aneurysm3. Pericarditis4. Prinzmetal’s angina5. Early repolarization6. Hypothermia7. Hyperkalemia8. LVH9. LBBB10. Hypertrophic cardiomyopathies11. Artifact ?
ACS/ARREST $1000
LIST THE 5 ABSOLUTE CONTRAINDICATIONS TO FIBRINOLYTIC USE
IN STEMI
ACS/ARREST $1000
WHAT ARE (ANY 5 OF 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 ?
GOALS OF THE FIRST 6 HOURS OF
RESUSCITATIONS IN SEPSIS (4)
SEPSIS $200
WHAT ARE:1. Central venous pressure (CVP) 8 to 12
mmHg2. Mean arterial pressure (MAP) ≥ 65 mmHg3. Urine output ≥ 0.5 mL/kg/hr4. Central venous pressure (superior vena cava)
or mixed venous oxygen saturation ≥ 70% ?
SEPSIS $200
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 $400
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 OR3. sBP <90 mmHg ?
SEPSIS $600
THE 4 DETERMINANTS OF CVP
SEPSIS $800
WHAT ARE:1. Intravascular volume2. Intrathoracic pressure3. Right ventricular function4. Venous tone ?
SEPSIS $800
OUTLINE THE EGDT PROTOCOL
SEPSIS $1000
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 - 34C ?
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 HIGH-ALTIDUDE 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