CLASS 2 TICKET ALGORITHM ACTIVITY

A client presents to the emergency department with a “racing heartbeat” that started two hours ago while doing yard work. Client denies syncope, exertional chest pain or dyspnea. This is the first time the client has experienced this sensation.

VS 98.8 F / BP 124/82 / HR 158 / RR 14 / SaO2 98%

On exam, the client appears comfortable and in no acute distress. Client is awake and oriented x3. Cardiovascular exam reveals a rapid rate with regular rhythm. No murmurs, rubs or gallops are appreciated. Distal pulses +2 with normal capillary refill. Breathing is unlabored without accessory muscle use. Lungs are clear to auscultation bilaterally. No pedal edema. A 12-lead EKG reveals a narrow complex, regular monomorphic tachycardia with a rate of 158. Bilateral IV access has been obtained. Which of the following is the priority?

• Vagal maneuvers

• Sedation and Intubation

• Synchronized cardioversion

• Procainamide infusion at 60 mg/min until arrhythmia is suppressed

Answer explanation

This client is stable and most likely has supraventricular tachycardia, a common form of tachycardia typically caused by a reentry circuit in the conduction system. This condition most commonly presents with a narrow QRS, however the QRS interval can be >120 ms in cases associated with aberrant conduction. Vagal maneuvers disrupt the reentry system Note:.nurses CANNOT perform carotid massage and if a provider does it, be cautious as it could cause potential blood clots to travel); the patient in this case is experiencing SVT, but is stable (steps 3, 6, and 8)

The client's rhythm does not change. Which of the following is the priority?

• 12 mg rapid IV push of Adenosine, followed by NS flush

• IV infusion of 12 mg Adenosine over 1 hour

• IV infusion of 6 mg Adenosine over 1 hour

• 6 mg rapid IV push of Adenosine, followed by NS flush

Answer explanation

SVT that is refractive to vagal maneuvers should be treated with adenosine. Adenosine has an extremely short half-life of less than 10 seconds. It should be administered via rapid injection into a large proximal vein, followed by a normal saline flush of 20 mL and extremity elevation. Patients should be on continuous EKG monitoring during administration (step 8)

6 mg of Adenosine is administered via rapid IV push. The client reports feeling very hot and flushed, clutching chest due to discomfort. The symptoms resolve spontaneously after just 30 seconds. There is still no change in the rhythm seen on the EKG. Vitals are otherwise stable. The client is mildly perturbed, but is in no acute distress. Which of the following is the priority

• Repeat rapid IV push of 6 mg

• Increase dose to 12 mg rapid IV push of Adenosine

• Immediate defibrillation

• Retry vagal maneuvers

Answer explanation

As seen here, it’s essential that clients are warned of the significant albeit transient side effects prior to adenosine injection, which include flushing , chest pain and difficulty breathing. If the initial 6 mg dose is ineffective, it is appropriate to give a 2nd dose at 12 mg (step 8)

After administering a second dose of Adenosine at 12 mg, the patient experiences severe chest pain and becomes acutely confused. Blood pressure quickly becomes unobtainable; however, a weak pulse is palpable. EKG exhibits a major change in rhythm, now displaying a regular, wide (>0.12 s) complex monomorphic ventricular tachycardia at a rate of 220. Which of the following is the priority?

• Give third dose of 12 mg rapid IV push of Adenosine

• Immediately perform synchronized cardioversion

• Start a beta-blocker

• Immediately perform defibrillation

Answer explanation

This patient has become acutely unstable, with conversion of his rhythm to a ventricular tachycardia (VT). Patients with regular, wide complex monomorphic VT and a palpable pulse should be immediately treated with synchronized cardioversion (step 4)

Synchronized cardioversion is performed, with no change to the rhythm on EKG. The client rapidly loses consciousness. Pulse is no longer palpable. Which of the following is the priority?

• Go to the supply room and retrieve an arterial line kit

• Immediately perform defibrillation

• Pronounce the patient dead

• Immediately perform synchronized cardioversion

Answer explanation

The client has continued to deteriorate, now exhibiting a pulseless VT. The best initial treatment for a witnessed cardiac arrest is delivery of an unsynchronized shock, also known as defibrillation. This should be performed as soon as possible, as decreased time to defibrillation has been shown to improve the odds for return of perfusion and survival (steps 2 and 3). If there is a delay in charging the defibrillator, good quality CPR should be done (step 1)

After two minutes, there is still no pulse. Rhythm analysis reveals no change. Which of the following is the priority?

• Deliver 2nd unsynchronized shock

• Give 1 mg IV push of Epinephrine

• Start amiodarone

• Find another EKG machine to recheck rhythm

Answer explanation

If after two minutes of CPR, rhythm analysis reveals ongoing pulseless VT, a second shock should be delivered (step 5)

A second unsynchronized biphasic shock is delivered. CPR is resumed. Which of the following is the priority?

• 0.5 mg IV push of Epinephrine every 3-5 minutes

• Alternating 1 mg IV Epinephrine and 40 U Vasopressin every 3-5 minutes

• 1 mg IV push of Epinephrine every 3-5 minutes

• 40 U IV push of Vasopressin every 3-5 minutes

Answer explanation

After a second shock is delivered, the ACLS algorithm allows for initiation of 1 mg Epinephrine given intravenously every 3-5 minutes (step 6)

Epinephrine is given at 1 mg intravenously. After two minutes, reanalysis of the rhythm reveals the patient remains in pulseless VT. A third unsynchronized shock is delivered and CPR is resumed. Which of the following is the priority?

• 2 g IV Magnesium sulfate

• 800 mg IV Dopamine

• 300 mg IV Amiodarone

• 3 g IV Metoprolol

Answer explanation

After delivery of a third shock, administer amiodarone 300 mg (step 8) or lidocaine at a dose of 1-1.5 mg/kg for the first dose. It is not advised to mix amiodarone and lidocaine. Whatever the patient received in the field should be given in the hospital. A repeat dose of either amiodarone 150 mg or lidocaine 0.5-0.75 mg/kg may be considered if necessary.

A client presents to the emergency department with new onset altered mental status. Client's family reports that the client complained of dizziness in the morning, but has subsequently become more confused throughout the day.

VS: 98.6 F / BP 84/58 / HR 44 / RR 18 / SaO2 90% On exam, the client is oriented to person and place only. Cardiovascular exam reveals a slow rhythm with occasional skipped beats. No murmurs, rubs or gallops are appreciated. Distal pulses are weak. Lungs are clear to auscultation bilaterally. No pedal edema. A 12-lead EKG reveals a gradually progressive prolongation of the PR interval leading up to a blocked sinus impulse.

• Endotracheal intubation

• 2L of O2 via nasal cannula

• Initiate CPAP

• Initiate BiPAP

Answer explanation

Remember, you do NOT have to identify the types of heart blocks. Longer, longer, longest drop now you have a Wenkebach-Mobitz type I second degree AV block can occur due to a variety of both pathologic and iatrogenic factors. Common pathologies include acute or chronic ischemia, infiltrative myocardial diseases, myocarditis, and hyperkalemia. hypoxemia is a common cause of symptomatic bradycardia (step 3)

Bilateral IV access has been obtained. Which of the following is the priority?

• 0.5 mg bolus IV atropine

• 1 mg bolus IV atropine

• 0.5 mg bolus norepinephrine

• 5 mg bolus norepinephrine

Answer explanation

The client is unstable and 1 mg of atropine should be administered (step 5)