ACLS Team Kerigan Rounds CTU Medicine HGH June

ACLS Team Kerigan Rounds CTU Medicine, HGH June 20, 2007

ACLS

ACLS $100 $200 $200 $300 $300 $400 $400 $500 $500 $100

EKGs $100

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 $200

EKGs $200 WHAT IS WPW TYPE PREEXCITATION?

EKGs $300

EKGs $300 WHAT ARE J-WAVES OR OSBORNE WAVES?

EKGs $400

EKGs $400 WHAT IS EARLY REPOLARIZATION, NORMAL VARIANT?

EKGs $500

EKGs $500 WHAT IS RBBB PLUS MOBITZ II 2 ND DEGREE AV BLOCK? THE CLASSIC RSR' IN V 1 IS RBBB. MOBITZ II 2 ND DEGREE AV BLOCK IS PRESENT BECAUSE THE PR INTERVALS ARE CONSTANT.

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

STROKE $100 LIST THE INCLUSION CRITERIA (4) FOR t. PA ADMINISTRATION FOR ACUTE ISCHEMIC STROKE

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

STROKE $200 1. IF SYSTOLIC >220 OR DIASTOLIC >120 2. END-ORGAN INVOLVEMENT (AORTIC DISSECTION, ACUTE MYOCARDIAL INFARCTION, PULMONARY EDEMA, HYPERTENSIVE ENCEPHALOPATHY)

STROKE $300 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 $400 IDENTIFY THE LESION

STROKE $400 WHAT IS A PCA STROKE? HYPODENSE AREAS IN THE RIGHT OCCIPITAL LOBE, CONSISTENT WITH RECENT PCA

STROKE $500 3 OF THE 6 RELATIVE CONTRAINDICATIONS FOR t. PA 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 trauma 3. Recent gastrointestinal or urinary tract hemorrhage (within previous 21 days) 4. Recent acute myocardial infarction (within previous 3 months) 5. Post-myocardial infarction pericarditis 6. Abnormal blood glucose level (<2. 8 or >22. 2 mmol/L]) ?

DRUGS $100 4 FIBRINOLYTIC AGENTS

DRUGS $100 WHAT ARE: • ALTEPLASE (t. PA) • 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 300 MG IV/ ONCE, THEN CONSIDER ADDITIONAL 150 MG IV ONCE OR 2. LIDOCAINE 1 -1. 5 MG/KG FIRST DOSE THEN 0. 5 -0. 75 MG/KG IV, MAXIMUM 3 DOSES OR 3 MG/KG ?

POTPOURRI $100 THIS IS THE TIME RANGE THAT CARDIAC TROPONINS ARE DETECTABLE IN THE BLOOD AFTER INFARCTION

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 ?

ACLS

ACLS $200 $400 $400 $600 $600 $800 $200 $800 $1000 $1000

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 > 100 ms 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 V 1 and V 6. • QRS width > 0. 14 • superior QRS axis • AV dissociation, fusion, capture beats present • Morphology in precordial lead V 1 = 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. AFIB 2. AFLUTTER W/ VARIABLE BLOCK 3. MAT 4. 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 m 2. 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. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. STEMI Ventricular aneurysm Pericarditis Prinzmetal’s angina Early repolarization Hypothermia Hyperkalemia LVH LBBB Hypertrophic cardiomyopathies Artifact ?

ACS/ARREST $1000 LIST THE 5 ABSOLUTE CONTRAINDICATIONS TO FIBRINOLYTIC USE IN STEMI

ACS/ARREST $1000 WHAT ARE (ANY 5 OF 7): 1. 2. 3. 4. 5. 6. 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 ?

SEPSIS $200 GOALS OF THE FIRST 6 HOURS OF RESUSCITATIONS IN SEPSIS (4)

SEPSIS $200 WHAT ARE: 1. Central venous pressure (CVP) 8 to 12 mm. Hg 2. Mean arterial pressure (MAP) ≥ 65 mm. Hg 3. Urine output ≥ 0. 5 m. L/kg/hr 4. Central venous pressure (superior vena cava) or mixed venous oxygen saturation ≥ 70% ?

SEPSIS $400 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 $600 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 m. M OR 3. s. BP <90 mm. Hg ?

SEPSIS $800 THE 4 DETERMINANTS OF CVP

SEPSIS $800 WHAT ARE: 1. Intravascular volume 2. Intrathoracic pressure 3. Right ventricular function 4. Venous tone ?

SEPSIS $1000 OUTLINE THE EGDT PROTOCOL

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 - 34 C ?

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 HIGHALTIDUDE 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