Post-ACLS Principles Care Flashcard 1
Rationale
B. Rationale: Out-of-hospital cooling is not a viable intervention during post-cardiac arrest care due to possible complications that may not be addressed in the pre-hospital setting.
Question
A 43-year-old patient with cardiac arrest secondary to a gunshot wound was revived in the out-of-hospital setting but remains unresponsive. While in transit, the patient received the following interventions: (1) massive bleeding was controlled, (2) rapid infusion therapy with cold IV fluid was applied, and (3) ventilation and oxygenation with 100% FiO2 is given via an advanced airway at a rate of 10 breaths/minute. Which of these interventions is NOT recommended in this case?
a. Bleeding control
b. Cold intravenous infusion therapy
c. Assisted ventilation via an advanced airway
d. All of the above interventions are recommended
Answer
b. Cold intravenous infusion therapy
Rationale
B. Rationale: The patient’s ETCO2 is low. Increasing ventilation to maintain an ETCO2 between 35 and 40 mm Hg is necessary.
Question
A 54-year-old post-cardiac arrest patient is being prepared for transfer to critical care. He is on a mechanical ventilator and is receiving a dopamine infusion. He has the following vital signs: HR = 72 bpm, BP = 110/60 mm Hg, ETCO2 = 29 mm Hg, oxygen saturation = 95%, T = 36.8°C. What intervention is best to optimize the patient’s post-cardiac arrest care?
a. Increase oxygen supplementation
b. Increase ventilation
c. Up titrate vasopressor infusion
d. No additional intervention needed
Answer
b. Increase ventilation
Rationale
A. Rationale: If a post-cardiac arrest patient is severely hypotensive (systolic blood pressure < 70 mm Hg) or has no response to less potent adrenergic drugs, norepinephrine is the drug of choice because it is the more potent adrenergic drug.
Question
A 67-year-old man with cardiac arrest has achieved return of spontaneous circulation. He has the following vital signs: HR = 55 bpm, BP = 60/40 mm Hg, ETCO2 = 35 mm Hg, oxygen saturation = 94%, T = 36.0°C. Which one of the following vasopressors is the more potent drug of choice?
a. Norepinephrine 0.1–0.5 mcg/kg/min IV infusion
b. Epinephrine 0.1–0.5 mcg/kg/min IV infusion
c. Dopamine 5–10 mcg/kg/min IV infusion
d. Phenylephrine 0.1–0.5 mg per dose every 10 to 15 minutes
Answer
a. Norepinephrine 0.1–0.5 mcg/kg/min IV infusion
b. Epinephrine 0.1–0.5 mcg/kg/min IV infusion
Rationale
D. Rationale: An IV bolus of 1–2 L normal saline can correct hypotension in the immediate post-cardiac arrest period.
Question
A patient in cardiac arrest secondary to an acute myocardial infarction has achieved return of spontaneous circulation and has the following vital signs: HR = 60 bpm, BP = 80/40 mm Hg, PETCO2 = 40 mm Hg, oxygen saturation = 94%, T = 36.8°C. What is the appropriate post-cardiac arrest treatment for this patient?
a. IV bolus of 2 L normal saline
b. IV bolus of atropine 1 mg
c. Increase oxygen supplementation and mechanical ventilation support
d. Percutaneous coronary intervention
Answer
d. Percutaneous coronary intervention
Rationale
D. Rationale: Following ROSC, if ventilations are optimized as in the patient in this example whose ETCO2 is within normal limits, treatment of hypotension is next in the post-cardiac arrest care algorithm. The patient has already been given a bolus of IV fluids, and thus starting an infusion of epinephrine is called for. Dopamine could also be used if preferred.
Question
A patient with refractory VF has ROSC. He is intubated, and waveform capnography is being utilized to optimize ventilations. ETCO2 is 36–38 mm Hg. He has a large-bore peripheral IV, which is patent. A 12-lead ECG shows normal sinus rhythm with premature atrial contractions and no evidence of MI. The patient’s blood pressure is 88/48 mm Hg, and he has been given a 1 L bolus of NS. The next intervention is:
A. Coronary reperfusion
B. Therapeutic hypothermia
C. Transfer to an ICU
D. Epinephrine infusion 0.1–0.5 mcg/min titrated to an SBP of > 90 mm Hg
Answer
D. Epinephrine infusion 0.1–0.5 mcg/min titrated to an SBP of > 90 mm Hg
Rationale
B. Rationale: Over-oxygenation causes toxicity-induced reperfusion injuries from too much oxygen in post-cardiac arrest patients. Over-oxygenation can produce free radicals that harm normal cells, especially in the vulnerable post-cardiac arrest patient. It is recommended to titrate oxygen supplementation to achieve an oxygen saturations of 94–99%.
Question
Adverse effects of toxicity-induced reperfusion injuries in post-cardiac arrest patients are brought about by which one of the following?
a. Overventilation
b. Over-oxygenation
c. Increased interruptions in CPR
d. Epinephrine overdose
Answer
b. Over-oxygenation
Rationale
D. Rationale: Targeted temperature management is necessary at this point. This involves lowering the patient’s body temperature with the goal of improving neurologic recovery.
Question
After 25 minutes of resuscitating a patient in cardiac arrest secondary to suspected thyroid storm, the team notices the patient has achieved return of spontaneous circulation. Ventilation, oxygenation, and circulation are managed properly during this time. Vital signs include: HR = 60 bpm, BP = 100/60 mm Hg, ETCO2 = 37 mm Hg, oxygen saturation = 96%, T = 36.8°C. A neurological assessment reveals that the patient has a Glasgow Coma Scale score of 6 and does not respond to commands. What is the next course of action for immediate post-cardiac care?
a. Percutaneous coronary intervention
b. Transfer to advanced critical care
c. Propanolol and methimazole retention enema
d. Targeted temperature management
Answer
d. Targeted temperature management
Rationale
B. Rationale: Multiple organs are affected in cardiac arrest and are subjected to ischemic injury. Because of this phenomenon, patients may develop a sepsis-like syndrome. IV fluid therapies and vasoactive drug administration, a common treatment for sepsis, may also be used during post-cardiac arrest care.
Question
Due to the susceptibility of multiple organs to ischemic injury from cardiac arrest, which of the following medical conditions may develop in cardiac arrest patients that achieve a return of spontaneous circulation?
a. Myocardial ischemia
b. Sepsis-like syndrome
c. Ebstein anomaly
d. Adult respiratory distress syndrome
Answer
b. Sepsis-like syndrome
Rationale
C. Rationale: The first step in the post-cardiac arrest rhythm is achieving a return of spontaneous circulation. This represents a perfusing rhythm with the presence of a pulse and breathing. Patients should present with a blood pressure that must be maintained at ≥ 90/60 mm Hg.
Question
Following the post-cardiac arrest algorithm, what is the first condition a patient with cardiac arrest must achieve before post-cardiac arrest care is initiated?
a. End-tidal CO2 of 20 mm Hg
b. Oxygen saturation of 93%
c. Return of spontaneous circulation
d. Terminating shockable cardiac arrest rhythm
Answer
c. Return of spontaneous circulation
Rationale
D. Rationale: Hospitals that treat a high number of cardiac arrest patients have higher rates of survival when moderate glycemic control is targeted. Therapeutic hypothermia for comatose patients with ROSC, immediate reperfusion with PCI, neurologic care, and optimization of hemodynamic and ventilatory status also lead to increased survival rates.
Question
Hospitals that treat a high number of cardiac arrest patients typically experience improved survival rates when which of the following interventions are provided?
A. Therapeutic hyperthermia
B. Delayed coronary reperfusion with PCI
C. Titration of inspired oxygen during the post-cardiac arrest phase to the minimum oxygen needed to maintain saturations > 96%
D. Glycemic control with a target of 8–10 mmol/L (144–180 mg/dL)
Answer
D. Glycemic control with a target of 8–10 mmol/L (144–180 mg/dL)