68 Questions
What should you do if the calculated joules setting is lower than the cardioversion device can deliver?
Use the lowest joules setting possible or obtain medical consultation
What medication may be considered for pre-procedural sedation or analgesia?
Midazolam, ketamine, or opioid with medical consultation
What is the maximum dose of adenosine for pediatric patients?
12 mg
How long does the administration of amiodarone take?
20 minutes
What medication is administered for torsades de pointes?
Magnesium sulfate
What is the maximum dose of magnesium sulfate for torsades de pointes?
2 grams
What is the maximum number of doses of Amiodarone that can be administered?
2
How long should CPR be resumed after defibrillation?
2 minutes
What is the initial dose of Amiodarone administered?
300 mg IV/IO push
How many times should defibrillation be performed?
Until ROSC or TOR
What is the purpose of defibrillation?
To treat cardiac arrest
What should be done after defibrillation?
Resume CPR immediately
What is the repeated dose of Amiodarone?
150 mg IV/IO push
When can additional doses of Amiodarone be administered?
After ROSC
What is the first step in managing a patient with cardiac arrest?
Confirm asystole in more than one lead
What is the recommended volume of lactated Ringer's solution for volume infusion in cardiac arrest?
20 mL/kg
When is epinephrine indicated in cardiac arrest?
Never in cardiac arrest
What is the treatment for severe metabolic acidosis in cardiac arrest?
Give sodium bicarbonate 1 mEq/kg IV/IO
What is the next step when the patient's condition changes during cardiac arrest?
Transition to a new treatment algorithm, considering prior therapy
What is the treatment for hypothermic patients in cardiac arrest?
Rewarming
What is the indication for administering calcium chloride 1 gram IVP/IO in cardiac arrest?
Hyperkalemia
What is the treatment for needle decompression in cardiac arrest?
NA channel blocker overdose treatment
What is the maximum compression depth for an adult during CPR?
2.4 inches (6 cm)
How should you assess for bleeding in a patient with cardiac arrest?
Use a method appropriate for the patient's injuries, such as direct pressure or wound packing
What should you do after assessing a patient's skin color, temperature, and capillary refill?
Initiate cardiac monitoring as appropriate
How many hands should be used for chest compressions on a very small child?
1 hand or 2 hands (optional)
Where should you place your hands for chest compressions on an adult?
On the lower half of the breastbone (sternum)
What is the recommended anterior-posterior diameter of the chest for a child?
About 1½ inches (3.8 cm)
What is the recommended rate of chest compressions in cardiac arrest?
100-120 per minute
What should you do after managing profuse bleeding in a patient with cardiac arrest?
Initiate cardiac monitoring as appropriate
How many fingers should be used for chest compressions on a very small child?
2 fingers
What is the recommended compression depth for children less than 1 year old?
1 ½ inches (4 cm)
What is the recommended ventilation ratio in cardiac arrest?
2 breaths:15 compressions
What is the goal of minimizing interruptions in cardiac arrest?
Less than 10 second pause
What is the role of Clinician #2 in cardiac arrest?
AED operator
What is the goal of coordinating 2-minute cycles in cardiac arrest?
To ensure efficient team performance
What is the primary goal of stabilizing the cervical spine during airway management?
To prevent further injury to the patient's spine
What should EMS clinicians do if a patent airway cannot be established in a patient?
Transport the patient to the closest appropriate hospital-based emergency department
What is an indication of upper airway foreign body or partial airway obstruction in infants and young children?
Inspiratory stridor
What is the primary goal of assessing mental status in a patient?
To assess the patient's level of consciousness
What should be done in case of an infant or young child with inspiratory stridor?
Request ALS rendezvous and transport the patient rapidly
What is the primary goal of establishing an airway in a patient?
To facilitate breathing and improve ventilation
What should EMS clinicians do after establishing an airway in a patient?
Suction the airway as needed
What is the primary goal of assessing circulation in a patient?
To assess the patient's skin perfusion
What is the definition of hemodynamically unstable in a patient less than 1 year old?
Systolic blood pressure less than 70
What is the initial step in managing a patient with tachycardia?
Identify and treat the underlying cause
What is the recommended energy dose for cardioversion in a pediatric patient?
0.5 J/kg
What is the definition of tachycardia in a pediatric patient?
Heart rate greater than 180 bpm
What is the recommended next step after administering adenosine?
Assess the patient's response
What is the purpose of vagal maneuvers in tachycardia management?
To slow down the heart rate
What is the recommended treatment for tachycardia in a hemodynamically unstable patient?
Cardiovert the patient
What is the goal of managing tachycardia?
To slow down the heart rate
What is the recommended dose of diltiazem for patients older than 50 years of age with SBP 100-120, known renal failure or CHF?
5-10 mg SLOW IV bolus over 2 minutes
What should be done if the rate does not slow down in 15 minutes?
Administer a second dose of diltiazem
What rhythms include Wolff-Parkinson White (WPW) syndrome, Lown-Ganong-Levine syndrome (LGL), and Mahaim type?
Regular narrow complex tachycardias
What should be done while continuously monitoring airway and reassessing vital signs every 5 minutes?
Place patient in position of comfort
What signs and symptoms are related to tachycardia?
Hypotension, acutely altered mental status, and signs of shock
How long should clinicians be prepared for asystole during a procedure?
Up to 40 seconds
What should be assessed and treated, if indicated, in adult tachycardia algorithm?
Shock
Why might clinicians consider pre-procedural sedation or analgesia?
To reduce patient discomfort
What is the primary goal of treating a patient with irregular rhythm and HR greater than 130?
To alleviate symptoms related to tachycardia
What should be considered when deciding to administer sedative or analgesia to a patient with irregular rhythm?
The patient's overall status, including BP
What medication may be administered to treat hypotension induced by diltiazem?
Calcium chloride
What is the recommended approach for managing a patient with discomfort during TCP?
Administer opioid or ketamine per Pain Management protocol
What is the primary goal of continuously monitoring airway and reassessing vital signs every 5 minutes in a patient with irregular rhythm?
To assess for changes in the patient's condition
What should be done initially when managing a patient with cardiac arrest?
Assess and treat for shock, if indicated
What is the primary goal of treating a patient with irregular rhythm and SBP greater than 100?
To alleviate symptoms related to tachycardia
What should be considered when deciding to administer midazolam to a patient with discomfort during TCP?
The patient's overall status, including BP
Study Notes
Cardiac Arrest Management
- Confirm asystole in more than one lead
- Wide-open fluids and high-performance CPR are essential
- Epinephrine is not indicated in adult traumatic cardiac arrest
- For hypothermic patients in cardiac arrest, rewarmed; see exclusions to Termination of Resuscitation
Treatment Algorithm
- If tension pneumothorax, perform needle decompression
- For hyperkalemia, severe metabolic acidosis, and calcium channel blocker overdose (including tricyclic antidepressants and phenobarbital), administer:
- Calcium Chloride 1 gram IVP/IO
- Sodium bicarbonate 1 mEq/kg IV/IO
Post-ROSC Management
- When patient's condition changes, new treatment considers prior therapy (e.g., previously administered medications)
- If arrest occurs after ROSC, an additional 2 doses of medication may be administered
Defibrillation and Rhythm Management
- Defibrillate 1 time, then resume CPR immediately for 2 minutes
- Amiodarone administration:
- Initial dose: 300 mg IV/IO push
- May repeat once: 150 mg IV/IO push
- For shockable rhythms, repeat CPR and defibrillation until ROSC or Termination of Resuscitation (TOR)
Special Considerations
- If calculated joules setting is lower than cardioversion device can deliver, use lowest joules setting possible or obtain medical consultation
- Consider pre-procedural sedation or analgesia (midazolam, ketamine, or opioid with medical consultation)
- Adenosine administration:
- Initial dose: 0.1 mg/kg rapid IV/IO, maximum 6 mg
- Second and third doses: 0.2 mg/kg rapid IV/IO, maximum single dose 12 mg
- Amiodarone administration:
- 5 mg/kg IV/IO over 20 minutes (mixed in 50-100 mL of approved diluent)
- Obtain 12-lead EKG prior to administration
- If torsades de pointes, administer magnesium sulfate (25 mg/kg IV/IO to a maximum of 2 grams over 2 minutes)
Chest Compression
- Compression depth should be no more than 2.4 inches (6 cm) for adults and about 1½ inches (3.8 cm) for children.
- Hand placement for chest compression: 2 hands on the lower half of the breastbone (sternum) for adults, and 2 hands or 1 hand on the lower half of the breastbone for very small children.
- For 2 or more rescuers, use 2 thumb-encircling hands in the center of the chest, just below the nipple line.
General Patient Care
- Assess for and manage profuse bleeding using appropriate methods: direct pressure, wound packing, hemostatic gauze, or tourniquet/junctional tourniquet (with jurisdictional training).
- Assess skin color, temperature, and capillary refill.
- Initiate cardiac monitoring as appropriate.
- Ensure proper chest compression rate: 100-120 compressions per minute.
- Ensure proper compression depth: less than 1 year – 1 ½ inches (4 cm), greater than or equal to 1 year – 2 inches (5 cm).
Breathing and Circulation
- Ventilate at 2 breaths:15 compressions.
- Minimize interruptions (less than 10-second pause).
- Ensure full chest recoil.
- Coordinate 2-minute cycles.
Airway and Breathing
- Assess mental status: alert, responds to verbal stimuli, responds to painful stimuli, or unresponsive.
- Stabilize cervical spine when appropriate.
- Open and establish airway using appropriate adjunct.
- Place patient in appropriate position.
- Suction airway as needed, including tracheostomy tubes.
- If a patent airway cannot be established, transport the patient to the closest appropriate hospital-based emergency department or designated free-standing emergency medical facility.
- In infants and young children, inspiratory stridor is an indication of upper airway foreign body or partial airway obstruction. Request ALS rendezvous and transport the patient rapidly and with caution.
Tachycardia Algorithm
- Tachycardia is defined as ventricular heart rates exceeding 220 bpm in infants and 180 bpm in pediatrics.
Identification and Treatment
- Identify and treat underlying causes of tachycardia.
- Consider vagal maneuvers, cardioversion, and adenosine administration.
Hemodynamic Instability
- Hemodynamic instability is defined as systolic blood pressure: • Less than 60 mmHg in neonates (0-28 days). • Less than 70 mmHg in infants (less than 1 year). • Less than [70 + (2 x years)] in patients over 1 year old. • Altered mental status with hypoperfusion.
Adenosine Administration
- Initial dose: 0.5 mg/kg rapid IV push.
- If rate does not slow in 15 minutes, administer a second dose of 0.35 mg/kg over 2 minutes.
Cardioversion
- Synchronized cardioversion: 0.5 J/kg, 1 J/kg, or 2 J/kg.
Amiodarone Administration
- Use amiodarone if cardioversion is not successful.
Other Considerations
- Consider pre-procedural sedation or analgesia (midazolam, ketamine, or opioid).
- Be prepared for up to 40 seconds of asystole during cardioversion.
- Administer opioids or ketamine for discomfort during TCP.
Test your knowledge of emergency medical procedures, including CPR, epinephrine, and tension pneumothorax treatment.
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