acls team kerigan rounds ctu medicine, hgh june 20, 2007

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