ACLS Final Exam Review: 240 Questions and Answers, Exams of Medicine

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ACLS Final Exam 240 Questions with

Answers 2024

Dosing of epinephrine in the setting of VF/pVT and asystole/PEA ✔ 1 mg every 3-5 minutes Dosing of amiodarone (first and second dose) in the setting of cardiac arrest ✔ 300mg first dose 150mg second dose after 3-5 min Dosing of lidocaine (first and second dose) in the setting of cardiac arrest ✔ 1-1.5mg/kg first dose 0.5-0.75 mg/kg second dose, repeat in 5-10 min What is the maximum dose of lidocaine? ✔ 3 doses or 3mg/kg ROSC is typically signified by a PETCO2 of what? ✔ 40 mm Hg or more The "Hs" of reversible causes of cardiac arrest ✔ 1. Hypovolemia

2. Hypoxia
3. Hydrogen ions (acidosis)
4. Hypo/hyperkalemia
5. Hypothermia The "Ts" of reversible causes of cardiac arrest ✔ 1. Tension pneumothorax
6. Tamponade, cardiac
7. Toxins
8. Thrombosis, pulmonary
9. Thrombosis, coronary In the setting of cardiac arrest, once an advanced airway is in place, 1 breath should be given every ______ seconds. Should chest compressions be interrupted once an advanced airway is in place? ✔ 6-8 seconds (8-10 breaths/min) with continuous chest compressions If PETCO2 falls below ______, attempts should be made to improve chest compressions ✔ 10

If intra-arterial pressure monitoring is being utilized during a resuscitation attempt, if the diastolic pressure falls below ___mm Hg, attempts should be made to improve chest compressions ✔ 20 depth of adequate chest compressions ✔ 2 inches rate of adequate chest compressions ✔ 100-120/min If no advanced airway is in place, what is the ratio of chest compressions to ventilations? ✔ 30: Shock energy that should be used on a biphasic machine for defibrillation ✔ 120-200 J, if recommended setting not known, use maximum available Shock energy that should be used on a monophasic machine for defibrillation ✔ 360J In the setting of cardiac arrest, when should vasopressors be administered? ✔ after the patient has failed CPR and defibrillation (shock-refractory arrhythmias) The only vasopressor recommended in the cardiac arrest algorithm ✔ epinephrine Why is vasopressin no longer recommended in the cardiac arrest algorithm as a vasopressor? ✔ no additional benefit and may increase delays in medication administration Are higher doses of epinephrine recommended in certain situations of cardiac arrest? If so, what situations are higher doses of epinephrine recommended? ✔ no; no benefit to support use, possible harm When is endotracheal medication administration recommended? ✔ not recommended unless unable to give meds IV or IO Which medications can be administered via endotracheal tube? ✔ lidocaine, epinephrine, atropine, naloxone What is different about the dosing of medications if endotracheal medication administration is performed? ✔ Typically ETT dose 2-2.5 higher than IV due to lower absorption and dilution in 5- 10mL of fluid is recommended

When can antiarrhythmics be considered in the setting of cardiac arrest? ✔ use may be considered in patients with VF/VT who have failed high-quality CPR, shocks, and vasopressors Why must antiarrhythmics never interfere with CPR and shocks? ✔ never been shown to increase survival to discharge Antiarrhythmics that could be considered in the setting of VF/VT ✔ amiodarone and lidocaine The traditional formulation of amiodarone contains what component that may cause bradycardia and hypotension ✔ polysorbate 80 Premixed bags of amiodarone contain what component instead of polysorbate 80? ✔ captisol Are premixed bags (360mg/200mL) of amiodarone typically found in the code cart? ✔ no; used in the ICU Sodium bicarbonate is not typically used in the setting of cardiac arrest, except under what circumstances? ✔ -known preexisting hyperkalemia -known preexisiting bicarbonate-responsive acidosis such as DKA -OD of TCAs, aspirin, cocaine, or diphenhydramine -prolonged resuscitation with effective ventilation; on return of spontaneous circulation after long arrest interval Calcium is not typically used in the setting of cardiac arrest, except under what circumstances? ✔ -beta blocker or calcium channel blocker overdose -may be helpful in patients who have received high volume of blood products (citrate in transfusions may bind calcium) Is chloride salt or calcium gluconate more potent? What is the potential downside to using formulations that contain more calcium? ✔ -chloride salt is 3x more potent than gluconate -more calcium = more vascular damage Magnesium sulfate is not typically used in the setting of cardiac arrest, except under what circumstances? ✔ -torsades de pointes -suspected hypomagnesemia -life threatening ventricular arrhythmias due to digitalis toxicity Dosing of magnesium sulfate in the setting of cardiac arrest?

✔ 1-2g IV/IO bolus diluted in 10mL D5W administered via slow IV push Should magnesium sulfate be administered in a shared line? ✔ no 2015 AHA recommendation for in-hospital cardiac arrest patients regarding steroids ✔ AHA does not recommend for or against routine steroid administration for patients; further studies needed 2015 AHA recommendation for out of hospital cardiac arrest patients regarding steroids ✔ uncertain benefit; no recommendation Dosing of adenosine in the adult tachycardia algorithm ✔ first dose: 6mg second dose in 1-2 minutes if needed: 12 mg When would the initial dose of adenosine be reduced to 3 mg instead of 6mg? ✔ 1. patients receiving dipyridamole or cabamazepine

2. heart transplant patients
3. if given via central venous access Contraindications to adenosine ✔ second or third degree heart block, sick-sinus syndrome, known hypersensitivity to the drug (use caution in patients with asthma) Side effects of adenosine ✔ facial flushing, headache, SOB, dizziness, and nausea half-life of adenosine ✔ <10 seconds When is adenosine used? ✔ -stable narrow-complex SVT (terminates reentrant rhythms in SA or AV node) -does NOT convert afib/flutter or VT but may be used as a diagnostic aid (slow rate down enough to diagnose) Describe how to administer adenosine ✔ -connect drug and flush syringe(s) to patient -give medication as rapid IV injection in the port closest to patient and hold plunger down -immediately give 20mL NS IV flush Persistent tachyarrhythmias causing these symptoms should undergo synchronized cardioversion ASAP (if regular and narrow, adenosine may also be considered) ✔ -hypotension

-acutely altered mental status -signs of shock -ischemic chest discomfort -acute heart failure If your patient is not experiencing decompensating symptomatic tachycardia (hypotension, AMS, etc.) and the QRS is NOT wide (0.12 seconds or more), what is/are the next step(s). ✔ -IV access and 12 lead EKG -Vagal maneuvers -Adenosine if regular -BB or CCB -Consider expert consultation If your patient is not experiencing decompensating symptomatic tachycardia (hypotension, AMS, etc.) and the QRS is wide (0.12 seconds or more), what is/are the next step(s). ✔ -IV access and 12 lead EKG -Consider adenosine only if regular and monomorphic -consider antiarrhythmic infusion -consider expert consultation Antiarrhythmic infusion options in the tachycardia algorithm ✔ procainamide, amiodarone, sotalol Dosing of procainamide in the tachycardia algorithm ✔ 20-50mg/min until arrythmia suppressed, hypotension ensues, QRS duration increases >50%, or maximum dose of 17mg/kg is given Maximum dose of procainamide in the tachycardia algorithm ✔ 17mg/kg rate of maintenance infusion of procainamide in the tachycardia algorithm ✔ 1-4mg/min If your patient has these underlying conditions, procainamide should be avoided in the setting of tachycardia ✔ prolonged QT or CHF Dosing of amiodarone in the tachycardia algorithm ✔ first dose 150mg over 10 minutes, repeat PRN After an amiodarone infusion has been given in the setting of tachycardia, it should be followed with a maintenance infusion of 1 mg/min for the first _____ hours ✔ 6

Dosing of sotalol in the tachycardia algorithm ✔ 100mg (1.5mg/kg) over 5 mintues If you patient has this underlying condition, sotalol should be avoided in the setting of tachycardia ✔ prolonged QT Heart rates are typically _____________ if tachyarrhythmia ✔ 150 or higher Energy given for synchronized cardioversion if a narrow regular tachy rhythm is present (e.g. atrial flutter. or SVT) ✔ 50-100J Energy given for synchronized cardioversion if a narrow irregular tachy rhythm is present (e.g atrial fibrillation) ✔ 120-200 J biphasic (200J if monophasic) Energy given for synchronized cardioversion if a wide regular tachy rhythm is present (e.g. VT with a pulse) ✔ 100J Energy given if a wide irregular tachy rhythm is present (e.g. VF or pVT) ✔ defibrillation dose (not syncronized) 120-200J depending on manufacturer; 360J if monophasic Heart rate is typically _________ if bradyarrhythmia ✔ below 50 bpm If your patient is experiencing a persistent bradyarrythmia causing symptoms (hypotension, AMS, shock, etc.) what is the most appropriate next step (usually)? ✔ atropine administration When is atropine not a good choice in the setting of bradycardia? ✔ atropine is not likely to be effective for type II second or third degree AV block If atropine is ineffective in the setting of bradycardia, what are the next options for treatment? ✔ -transcutaneous pacing -dopamine infusion -epinephrine infusion Atropine dosing for bradycardia algorithm ✔ 0.5mg repeated every 3-5 min

what is the maximum dose for atropine ✔ 3 mg Dopamine dosing for the bradycardia algorithm ✔ 2-20mcg/kg/min Epinephrine dosing for the bradycardia algorithm ✔ 2-10mcg/min What is the next best step if your patient is experiencing a bradycardia that is not causing symptoms (hypotension, heart failure, AMS, etc.) ✔ monitoring and observation How often are the ACLS guidelines revised? ✔ 5 years You come across a patient who is down and no one witnessed their arrest. What is the next most appropriate step? ✔ start CPR (get help after the first round of compressions) **clarification by Sarah: "pump on their chest on speaker phone dial 911, there's no need to "leave" your patient to get help." Maximum interruption that is allowable between chest compressions ✔ 10 seconds Goal is to provide defibrillation within what timeframe of arrest outside of the hospital? ✔ 3-5 min Goal is to provide defribrillation within what timeframe of arrest in a monitored hospital setting? ✔ <3 min What should be done immediately after administering defibrillation? Why? ✔ chest compressions; improves cardiac output, even if the heart develops an organized rhythm after defibrillation, the myocardium is still not performing adequately and the patient is at risk for re-arrest When are pulse checks performed? ✔ at the end of a two minute cycle of CPR and only if there is an organized rhythm present When are medication administered during a resuscitation attempt? ✔ at any time during the 2 min cycle following defibrillation as long as the administration does not disrupt compressions or interfere with a rhythm check sudden cardiac death

✔ collapse that occurs less than one hour from the onset of symptoms (often related to cardiac arrhythmias) Most dramatic presentation of acute coronary ischemia ✔ sudden cardiac death CV disease accounts for about ________% of deaths in the country, and sudden death is the first and only symptom in _______% of patients ✔ 33 20 Most common underlying cause of sudden death ✔ atherosclerosis Coronary causes of sudden death ✔ -atherosclerosis -acute coronary syndromes -spasm (Prinzmeetal's angina) -embolism -congenital anomalies -chronic heart failure (old MI often the focus for electrical instability leading to fatal arrythmias) ROSC ✔ return of spontaneous circulation Post-ROSC care may include therapeutic hypothermia for what patients? ✔ -comatose adult patients of witnessed out-of-hospital cardiac arrest when presenting rhythm was VF -possible benefit for both in and out of hospital arrests from all other initial rhythms in adults -therapeutic hypothermia also improves neurologic survival in neonates with hypoxic- ischemic encephalopathy Adults with ROSC after out-of-hospital VF cardiac arrest should have theurapeutic hypothermia at what temperature and for what time? ✔ 32-34C (89.6-93.2F) for 12-24hours. Therapeutic hypothermia has demonstrated no role for what patients thusfar ✔ CVA What percent O2 is administered during resuscitation? ✔ 100% During the post-cardiac arrest phase, oxygen saturation should be titrated to what level? Why?

✔ at or above 94%, to avoid oxygen toxicity (don't keep administering 100% O2) Why should excessive ventilation be avoided? ✔ increases intrathroracic pressure (which lowers cardiac output) and has the potential to decrease cerebral blood flow At optimal pulmonary support, what is the goal PETCO2 and PACO2 during resuscitation? ✔ PETCO2 35- PACO2 40- MAP goal during resuscitation ✔ 65 or greater PEA ✔ organized rhythm which does not have a pulse or blood pressure Which rhythms does PEA include? Which rhythms cannot be PEA? ✔ -includes idioventricular rhythms, post-defibrillation idioventricular rhythms, sinus rhythm, ventricular escape -does NOT include VF, asystole, agonal, possibly VT (these are not perfusing rhythms) PEA used to be called..... ✔ EMD (electromechanical dissociation) Most common cause of PEA ✔ hypovolemia PEA with narrow complexes is more likely to have a ____________________cause ✔ noncardiac (e.g. hypovolemia) Consider this cause of cardiac arrest/PEA if a patient suddenly becomes combative/acute change in mental status ✔ hypoxia (AMS may precede any changes in oxygen tension) Consider this cause of cardiac arrest/PEA especially in patients with diabetes and/or renal failure ✔ acidosis (hydrogen ion excess) If PEA is caused by acidosis, what will the EKG show? ✔ small amplitude QRS complexes If PEA is caused by hypovolemia, what will the EKG show? ✔ rapid, narrow QRS complexes

Consider this cause of PEA/cardiac arrest especially if the patient has renal failure, NPO status, recent dialysis, or has an extensive medication list ✔ hypo or hyperkalemia What will the EKG most likely show in the setting of hypothermia? ✔ Osborne waves What temperature(s) is/are better to measure in the setting of suspected hypothermia? What is important to keep in mind about these temperatures during warming? ✔ better to obtain core temperature (esophagus, rectum, bladder) these temperatures may be altered during warming What signs/symptoms would make you consider a tension pneumothorax as the cause of cardiac arrest/PEA? What is the treatment for tension pneumothorax causing cardiac arrest/PEA ✔ -neck vein distention, tracheal deviation, decreased/nonexistant breath sounds, hard to ventilate patient -treat with needle decompression followed by chest tube placement What signs/symptoms would make you consider cardiac tamponade as the cause of cardiac arrest/PEA? What is the treatment of cardiac tamponade causing cardiac arrest/PEA? ✔ -neck vein distention, no pulse felt with CPR -treat with preicardiocentesis, pericardial window In the setting of a PE causing cardiac arrest/PEA, a saddle PE obstructs flow to the pulmonary vasculature and causes acute _________________ that may result in instant death if the PE is large enough ✔ right sided heart failure What can be lifesaving in the setting of cardiac arrest/PEA caused by a PE? ✔ fibrinolytics Antidote for TCAs ✔ sodium bicarbonate Antidote for CCBs and BBs ✔ calcium or glucagon Antidote for cocaine ✔ benzodiazepines What should be avoided in the setting of cocaine OD? ✔ unopposed beta blockers Antidote for local anesthetics

✔ lipid emulsions Antidote for opioids ✔ Naloxone Antidote for benzodiazepines ✔ Flumazenil Antidote for organophosphates ✔ Atropine Antidote for insecticide ✔ pralidoxine What is different about the algorithm for PEA compared to VF/pVT? ✔ no shocks are administered, only epinephrine is given (not antiarrythmics) What should be checked first when a patient suddenly "flat-lines" on the monitor ✔ the patient's leads are connected to the monitor that is being used Survival in asystole is very poor, even if everything is done. However, in what scenarios is a patient more likely to survive asystole. ✔ setting of witnessed arrest, younger age, noncardiac cause for arrest, and short interval from collapse to basic to advanced life support What is a rhythm that could look very similar to asystole that may be shockable, even though it is still not a very survivable rhythm ✔ fine VF When would CPR NOT be started in the setting of a cardiac arrest? ✔ patient has signs of irreversible death such as rigor mortis, decapitation, or dependent lividity OR if there is a threat to the safety of providers OR valid DNR status Times when epinephrine is administered ✔ -cardiac arrest, VF, pulseless VT unresponsive to initial shocks, asystole, and PEA -symptomatic bradycardia after atropine has failed (unless it is a higher degree block) -severe hypotension due to shock -anaphylaxis, severe allergic reactions What are some special circumstances in which prolonged resuscitation is appropriate? ✔ hypothermia, drowning, drug overdose, pediatric patients who primarily have respiratory arrest rather than cardiac arrest or other potentially reversible causes of arrest Factors that are typically considered when terminating resuscitation in hospital ✔ -time from collapse to CPR

-time from collapse to defibrillation -prearrest state -initial arrest arrhythmia -response to resuscitation -duration of resuscitation Resuscitation efforts out-of-hospital are continued until... ✔ -ROSC -transfer of care to senior officials -presence. of reliable criteria indicating irreversible death -exhaustion prevents continuation -valid DNR is presented -online authorization from medical control physician or by prior medical protocol for termination of life support 80% of in-patient cardiac arrests had abnormal vital signs up to _____ hours prior to arrest ✔ 8 3 core measurements of Ustein Guidelines ✔ 1. rate of bystander CPR

2. time to defibrillation
3. survival to hospital discharge After a person is found down and it is confirmed that they are unresponsive, how long should a carotid pulse be checked? ✔ 5-10 seconds How often should providers switch performing compressions? ✔ 2 min If a pulse returns during resuscitation (respiratory arrest alone), and rescue breaths are administered, how often should rescue breaths be performed? ✔ 5-6 seconds In what patients should it be assumed that a spinal injury is present until ruled out? ✔ anyone with head or facial injury If a patient has a spinal injury (or is assumed to have a spinal injury) how should their airway be opened? ✔ jaw thrust without head extension (unless this is not effective, because "dead is dead") a member of team should stabilize the head in neutral position during airway manipulation Most common reason for upper airway obstruction in an unconscious patient

✔ loss of tone in the muscles (tongue most common) If a patient was coughing prior to losing consciousness, what should be suspected as the cause of collapse, and what should be done? ✔ suspect FB and open airway wide- if FB is seen, remove it with finger. If no object is seen, begin CPR and each time respirations are given, open mouth wide and look again for foreign object and remove if seen How much air is given in order to make the chest rise over 1 second? ✔ 600mL If possible, a patient receiving bag mask ventilation should be connected to oxygen concentration of what and receive a minimal flow rate of how many liters? ✔ oxygen concentration >40% and minimal flow rate of 10-12 liters per minute This type of airway is used if the patient is at risk for developing obstruction from tongue/muscle relaxation. It is only used in unconscious patients It can be used concurrently with bag mask, can be used during suctioning of mouth and throat, and can be used in intubated patients to keep them from biting the tube ✔ OPA How is an OPA measured? ✔ tip of OPA at corner of the mouth and the flange is at the angle of mandible for proper sizing This type of airway is tolerated in a conscious or unconscious patient, and can be used when an OPA cannot be used (mandible injury, intact gag reflex, trismus, jaw wiring) ✔ NPA The outer cirumference of an NPA should be compared to what to ensure proper fit? ✔ inner aperature of nares (or diameter of patient's smallest finger) What can be performed prior to an attempted NPA insertion to remove any blockage (such as mucus, blood, or vomit) ✔ suctioning How is the NPA measured? ✔ tip of nose to earlobe What type of suctioning is best with thick secretions and/or with particles? ✔ rigid catheters (such as Yankauer) Suction time should not exceed how long? ✔ 10 seconds

What should be administered before and after suctioning? ✔ preload the patient with oxygen and 100% O2 after suctioning is done If your patient is deteriorating during suctioning, what should be done? ✔ stop at once at give 100% O2 until heart rate returns to normal and the patient clinically improves Options for advanced airway ✔ 1. endotracheal tube

2. laryngeal mask
3. laryngeal tube
4. esophageal-tracheal tube What are the pros and cons of cricoid pressure, is it typically used in the setting of cardiac arrest? ✔ could prevent gastric inflation and reduce the risk of regurgitation and aspiration during bag mask ventilation but big problem is that it can impair ventilation, not recommended in this setting (might be used during tracheal intubation to enhance visualization of vocal cords) reasons NOT to cardiovert afib ✔ -asymptomatic or minimally symptomatic, particularly those with multiple comorbidities, advanced age, or poor overall prognosis; where the risk of undergoing cardioversion and/or pharmacologic rhythm control may outweigh the benefits of restoring NSR. -low likelihood of maintaining SR, such as those with marked left atrial enlargement or dilatation, significant. mitral regurgitation, or those with florid hyperthyroidism Which patients have a low likelihood of successful cardioversion or maintenance of SR after cardioversion ✔ -Afib has been continuously present for more than one year -The left atrium is markedly enlarged -patients who had AF recurrence while taking adequate doses of appropriate antiarrythmic drugs and have recently undergone cardioversion -if the underlying precipitant has not been corrected prior to cardioversion Which arteries are affected in an inferior MI? ✔ RCA, LCx Which arteries are affected in an inferiorposterior MI? ✔ RCA, LCx Which artery is affected in an isolated RV MI? ✔ LCx Which artery is affected in an anterior MI?

✔ LAD

Which artery is affected in an inferolateral MI? ✔ LCx Which artery is affected in an anteroseptal MI? ✔ LAD Which artery is affected in a posterolateral MI? ✔ LCx Which artery is affected in an anterolateral MI? ✔ LCx If ST elevation is seen in leads II, III, and aVF; what type of MI is occurring? ✔ inferior If ST elevation is seen in leads V1 and V2, what type of MI is occurring? ✔ septal If ST elevation is seen in leads V3 and V4, what type of MI is occurring? ✔ anterior If ST elevation is seen in leads I, aVL, V5, and V6; what type of MI is occurring? ✔ lateral Criteria for right ventricular infarction ✔ 1. inferior wall MI

2. ST segment elevation greater in lead III than II
3. ST elevation in V1 (possibly extending to V5 and V6)
4. ST depression in V2 (unless elevation extends, as in #3 above)
5. ST depression in V2 cannot be more than half the ST elevation in aVF
6. More than 1mm of ST elevation in the right-sided leads If a patient has a palpable carotid pulse, their systolic BP is at least _______? ✔ 50 If a patient has a palpable radial pulse, their systolic BP is at least _____? ✔ 70 If a patient has a palpable femoral pulse, their systolic BP is at least _______? ✔ 60 What is unique about resuscitation attempts in the setting of hypothermia? ✔ single defibrillation attempt until body is rewarmed

What is unique about resuscitation attempts in the setting of drowning? ✔ 5 cycles of CPR are performed before activation of EMS What is the PDE-5 inhibitor that needs to be stopped the longest prior to nitrate administration? ✔ Tadalafil the ACLS medication most likely to lead to tachyphylaxis ✔ nitrates Most common side effects of nitrate administration ✔ headache and hypotension When is IV/IO access established (according to algorithm.. can be done as soon as possible if multiple providers are on scene) ✔ after the first shock is delivered while the patient is receiving CPR Indications for endotracheal intubation ✔ 1. Respiratory or cardiac arrest

2. Failure to protect the airway
3. Inadequate oxygenation or ventilation
4. Impending or existing airway obstruction
5. Control of airway during surgical procedures requiring general anesthesia
6. Part of care for critically ill patients with multi-system disease/injuries Which laryngoscope blade is curved? straight? ✔ Macintosh is curved; Miller is straight What size laryngoscope blade can be used in most adult patients? ✔ 3 or 4 Macintosh, 2 or 3 Miller What size endotracheal tube is appropriate for most adult patients? ✔ 7.0, 7.5, 8. When performing endotracheal intubation, the bed should be raised to what level? ✔ patient's head should be level with the lower part of your sternum If the clinical situation allows, a patient who is about to undergo endotracheal intubation should be preoxygenated with 100% oxygen for how long before the intubation? ✔ at least 3 minutes Which side of the patient's mouth should a laryngoscope blade be inserted? ✔ right side If using a curved blade for endotracheal intubation, where should the blade be placed relative to the epiglottis?

✔ place the tip of the blade into the vallecula, between the base of the tongue and the epiglottis, and lift anteriorly to expose the vocal cords If using a straight blade for endotracheal intubation, where should the blade be placed relative to the epiglottis? ✔ place the tip of the blade just past the epiglottis, and lift anteriorly to expose the vocal cords During an endotracheal intubation, when the tip of the blade is correctly positioned, the laryngoscope should be lifted up and forward at what angle? ✔ 45 degrees During an endotracheal intubation, when the tip of the blade is correctly positioned, the laryngoscope should be lifted up and forward. Where should the force of the lift be directed? ✔ along the axis of the laryngoscope handle, in the direction of the ceiling over the patient's feet (avoid bending your wrist or rocking the blade against the patient's teeth) During endotracheal intubation, why should you avoid bending your wrist or rocking the blade against the patient's teeth after the blade is positioned? ✔ this can result in soft tissue or dental injury, and will not enhance your view of the glottis If an assistant is present, what should they do to enhance the view of the glottis once the blade has been correctly positioned? ✔ gently pull on the right side of the cheek How far should the endotracheal tube be inserted past the vocal cords before the stylet is removed? After the stylet is removed? ✔ until the balloon disappears past the vocal folds into the trachea, then remove the stylet and advance the tube until the balloon is 3-4 cm beyond the vocal cords After the endotracheal tube has been properly inserted, the endotracheal balloon should be inflated to the minimum pressure required to prevent air leaks during tidal volume ventilation with a bag, which usually requires less than how many cc's of air? ✔ 10 When should the assistant stop holding cricoid pressure in the setting of control endotracheal intubation (not ACLS)? ✔ after placement of the endotracheal tube is confirmed Where should the tip of the endotracheal tube be located? ✔ mid-trachea, 3-7cm above the carina

What is a good rule of thumb to check if the endotracheal tube is in the correct position in the trachea? ✔ 22cm at the teeth for the average sized adult If using an end-tidal CO2 detector that is attached to the endotracheal tube and the ventilation bag, carbon dioxide should be detected within the first _____ breaths of an endotracheal intubation (except in some cases of cardiac arrest, when gas exchange may not be occurring properly) ✔ 6 To secondarily assess that endotracheal tube placement is correct, what areas should be auscultated with a stethoscope? ✔ -stomach during positive-pressure ventilation -both lungs in mid-axillary line What is the most serious complication of endotracheal intubation that may result in hypoxemia, hypercapnia, and death ✔ unrecognized esophageal intubation Besides esophageal intubation, what are some other complications of endotracheal intubation? ✔ -vomiting, aspiration, pneumonitis, pneumonia -bradycardia, larynogospasm, bronchospasm, apnea -trauma to teeth, lips, vocal cords -exacerbation of cervical spine injuries If you are assessing to ensure that an endotracheal tube has been properly placed, and diminished breath sounds are appreciated on the left side, what does this suggest? What should be done? ✔ -right mainstem intubation -the tube should be slowly withdrawn until symmetrical sounds are appreciated What should be used to assess the patient's pulmonary status after intubation and ensure that the tip of the endotracheal tube is well positioned ✔ chest radiograph What complication of endotracheal intubation can not be detected by chest x-ray? ✔ esophageal intubation What are the eight Ds of stroke care? ✔ 1. Detection

2. Dispatch
3. Delivery
4. Door
5. Data
6. Decision

7. Drug/Device
8. Disposition Ideally, how long should it take for a CT to be obtained in a suspected stroke patient? ✔ 25 minutes Ideally, how long should it take for a CT scan to be interpreted for a suspected stroke patient? ✔ 45 minutes Ideally, how long should it take for a ischemic stroke patient (who is candidate) to receive fibrinolytic therapy from ED arrival? ✔ 60 minutes Ideal timeframe to administer fibrinolytic therapy for a stroke patient timed from the onset of symptoms ✔ 3 hours (or 4.5 in selected patients) Major complication of fibrinolytic therapy in the setting of acute stroke ✔ intracranial hemorrhage Exclusion criteria for rtPA ✔ -significant head trauma or prior stroke in previous three months -symptoms suggestive of subarachnoid hemorrhage -arterial puncture at noncompressible site in previous 7 days -history or previous intracranial hemorrhage -elevated BP (systolic >185 or diastolic >110) -active internal bleeding -acute bleeding diathesis (platelet count <100,000; heparin in the previous 48 hours, INR >1.7 or PT>15, direct thrombin inhibitors) -blood glucose concentration < -CT showing multilobar infarction If a stroke patients SBP is >185 or DBP is >110, what antihypertensive medication is recommended? ✔ labetalol (nicradipine, or other agents such as hydralazine can also be used) BP should be kept in what range during administration of rtPA? ✔ SBP 180-230, DBP 105- Labetolol and nicardipine are typically the antihypertensives used if BP management is needed during administration of rtPA, but what antihypertensive can be considered if the diastolic BP >140 or the blood pressure is not adequately controlled on labetolol/nicardipine? ✔ sodium nitroprusside

Per guidelines, how old does a patient have to be to receive tPA? ✔ 18 or older For which patients can the window of rtPA administration NOT be extended to 4.5 hours ✔ -patients over the age of 80 -severe stroke (NIHSS >25) -taking an oral anticoagulant (even if INR normal) -history of both diabetes and prior ischemic stroke Per guidelines, what is the window of time that endovascular therapy can be administered after onset of stroke symptoms? ✔ 6 hours How often should blood pressure be checked during the administration of rtPA? ✔ monitor BP every 15 minutes for 2 hours from the start of rtPA therapy, then every 30 minutes for 6 hours, then every hour for 16 hours How much and what type of aspirin should be given in the setting of suspected MI? ✔ 160-325mg of non-enteric coated asa Ideal "door-to-balloon" time if a patient with an MI is going to receive PCI ✔ 90 minutes Ideal time to PCI if an MI patient presenting to a non-PCI capable hospital ✔ 120 minutes Ideal time to fibrinolytic therapy if this is the intended reperfusion therapy for an MI patient ✔ 30 minutes Fibrinolytics should be administered in MI patients presenting how long after symptom onset ✔ generally not recommended for patients presenting more than 12 hours after symptom onset (but may be considered if ischemic chest discomfort persists with ST- elevation) and should not be given after 24 hours unless a true posterior MI suspected 4 causes of ST segment elevation ✔ 1. STEMI

2. Prinzemetal's angina
3. Pericarditis
4. Ventricular aneurysm Expected rhythm post-MI that should never be treated ✔ idioventricular rhythm

In the setting of an idioventricular rhythm after MI, no treatment should be administered, but what medication would be deadly in this scenario ✔ lidocaine (suppresses ventricular activity) Which cardiac enzymes rise the fastest in the setting of acute MI? How long after myocardial damage do these levels rise? ✔ troponin levels, can be seen within 2 hours Which is more specific to myocardial damage, troponin I or troponin T? ✔ troponin I is without confounding variables, troponin T can only be valid in a patient with normal kidneys Most important treatment employed in PEA ✔ PEA most successfully treated by identifying and treating the underlying cause Role of Venturi mask ✔ delivers precise concentration of oxygen-prevents excessive oxygenation to patients with COPD (these patients breathe because of hypoxemia and not hypercarbia drive) Indications and contraindications for use of morphine in ACS events ✔ -used for STEMI when patient continues to have symptoms despite use of nitrates -can be used in cardiogenic pulmonary edema -avoid in unstable angina and non-STEMI because of increased mortality What will occur if more than the recommended dose of atropine is administered? What if less than 0.5mg is administered? ✔ paradoxical bradycardia (both cases) Total amount of amiodarone that can be given in 24 hours ✔ 2.2 grams After notifying 911, three initial steps for adult cardiac arrest ✔ 1. Start CPR

2. Give oxygen
3. Attach monitor/defibrillator (as soon as this is done, rhythm check should be performed) Why should nitroprusside be avoided in the setting of SAH to bring down BP? ✔ has the capability of increased intracranial pressure with its use as a blood pressure lowering medication Nitroprusside is associated with what adverse event at high doses (even though it rarely actually occurs) ✔ thiocyanate poisoning Primary contraindications for using beta blockers

✔ -reactive airway disease -peripheral vascular disease -advanced heart block (second degree type II or third degree -acute cardiogenic shock Why are right ventricular MIs treated differently? ✔ RV infarctions need volume support in order to maintain cardiac output. Other types of MIs are treated in order to unload the heart since more blood in this circumstance will result in higher oxygen demands and more stress on the heart itself A suspected stroke patient should receive general assessment by the stroke team, emergency physician, or another expert within how long of arrival? ✔ 10 minutes Maintain oxygen saturation at or above what level during post-ROSC care ✔ 94% During post-ROSC care; norepinephrine, epinephrine, and dopamine can be used to achieve a minimum SBP of greater than _____mm Hg or a MAP of greater than _____mm Hg ✔ SBP greater than 90 mm Hg MAP greater than 65 mm Hg What problem(s) can OPAs that are too large cause? ✔ may obstruct the larynx or cause trauma to the laryngeal structures What problem(s) can OPAs that are too small cause? ✔ may push the base of the tongue posteriorly and obstruct the airway How often can nitroglycerin be administered (assuming there are no contraindications present) in the setting of a patient with a suspected MI? ✔ every 3-5 minutes When administering nitroglycerin to relieve ischemic chest discomfort, it should be titrate to effect, but SBP should be keep above what? Limit the drop in SBP to how much below baseline in hypertensive patients? ✔ Keep SBP greater than 90 mm Hg Limit drop in SBP to 30 mm Hg below baseline in hypertensive patients Ideally, a stroke patient should be admitted to a monitored bed within how long of arrival to the ED? ✔ 3 hours The Cincinnati Prehospital Stroke Scale identifies stroke on the basis of what three physical findings ✔ 1. Facial droop

2. Arm drift
3. Abnormal speech